Final review Flashcards
Abx you can and cannot give for OM with perforation or tympanostomy tube
Avoid eardrops containing aminoglycosides
-Avoid gentamicin, neomycin sulfate, or tobramycin in the presence of TM perf
-Results in sensorineural hearing loss
If pt has a perf
-PO abx: amoxicillin, bactrim, cefixime, augmentin
-Topical: Ofloxacin gtts
What object inserted into the nose would be concerning?
Button batteries, magnets anywhere in the body are of particular concern
Electrical current has the potential to necrose tissue
Unilateral rhinorrhea usually indicates mechanical nasal obstruction
Most common site for anterior nosebleed
Kiesselbach’s plexus
DDx for exudate on surface of tonsils
Strep and mono
-Mono: posterior lymph nodes and splenomegaly
Most cases of pharyngitis are viral in origin but MC bacterial: GABHS (strep pyogenes)
-Tx for GABS: PCN
-If allergic: erythromycin or 1st gen cephalosporin
Modified Centor criteria: age
+1: 3-14
0: 15-44
- 1: >45
Modified Centor criteria: exudates/tonsillar swelling
+1: positive
0: none
Modified Centor criteria: temp >38 (100.4)
+1: yes
0: no
Modified Centor criteria: cough
+1: absent
0: present
Modified Centor criteria: total score
-1 to 1: no Cx or abx
2-3: Cx and tx
+4-5: no cx needed, tx
DDx for pseudomembrane on tonsils
Diphtheria
High propensity to obstruct airway
Sx: high fever, dysphagia, drooling, respiratory distress
Tx: diphtheria antitoxin. Abx: 1st line erythomycin 2nd line: Pen G
What to do in epiglottitis in peds
O2
Keep child calm
Ensure an adequate airway (immediate airway management)
Not stable or has signs of resp distress or pending respiratory arrest: first attempt ventilation with BVM, with correct positioning, correct size face mask, and adequate ventilation with use of end-tidal CO2
What not to do with a child with epiglottitis
Oral airway should NOT be placed
Unnecessary blood tests, IV access, and tongue depression with a tongue blade should be avoided
Visualization of the epiglottis should not be performed unless staff members capable of securing an airway are present
What is the best abx to use for facial swelling
Clindamycin
How to calculate body surface area
Total head 9% (back or front of head: 4.5% each)
Front side of each arm: 4.5%, back side of each arm: 4.5% (ENTIRE arm 9%)
Each half of torso: 18% each
Front of each leg: 9%, back side of each leg 9%
Genitals/perineum: 1%
Parkland formula for fluid resuscitation in adult burn pts
4 mL lactated ringers x weight (kg) x TBSA (%) over initial 24 hrs
- 50% in 1st 8 hrs from time of burn
- 50% over remaining 16 hrs
First-degree burn
Epidermis only
Erythema; blanches with pressure
Sensation: intact; mild to moderate pain
Healing: 3-6 days without scarring
Superficial second degree burn
Epidermis and superficial dermis; skin appendages intact
Erythema, blisters, moist, elastic; blanches with pressure
Sensation: intact; severe pain
Healing: 1-3 wks; scarring unusual
Deep second degree burn
Epidermis and most dermis; most skin appendages destroyed
White appearing with erythematous areas, dry, waxy, less elastic; reduced blanching to pressure
Sensation decreased; may be less painful
Healing > 3 weeks; often with scarring and contractures
Third degree burn
Epidermis and all of dermis; destruction of all skin appendages
White, charred, tan, thrombosed vessels; dry and leathery; does not blanch
Sensation: anesthetic; not painful (although surrounding areas of second-degree burns are painful)
Healing: does not heal, severe scarring and contractures
Burn unit referral criteria
Partial-thickness burns >10% TBSA
Burns that involve face, hands, feet, genitalia, perineum or major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in pts with preexisting medical d/os that could complicate management, prolong recovery or affect mortality
Any pts with burns and concomitant trauma (such as fxs) in which the burn injury poses the greatest risk of morbidity and mortality
Burned children in hospitals without qualified personnel or equipment for the care of children
Burn injury in pts who will require special social, emotional, or long-term rehabilitative intervention
Erlichiosis
Caused by erlichia species- amblyomma americanum (Lone Star tick)
Found in southeast, south central, and mid-Atlantic US, 1-21 day incubation
Sx of erlichiosis
High fever HA N/V Malaise Abd pain Anorexia Myalgias Occasional rash
Erlichiosis triad
WBC: low
Platelets: low
LFTs elevated: (2-3x nl)
Tx of erlichiosis
7-14 day doxycycline in adults and children
Rifampin in pregnancy
Appendicitis
Periumbilical pain that radiates of RLQ
MCC: fecalith
For kids they can have pain anywhere on the abdomen
PE findings for appendicitis
Pos McBurney’s, Rovsing’s, Psoas, obturator, bump sign
Early: vague periumbilical pain, anorexia, n/v
Later: classic presentation- pain migrates to RLQ, fever if late finding
-If sudden decrease in pain, consider perforation
Labs for appendicitis
CBC
UA
Urine hcG
Nl WBC does not r/o appendicitis
Imaging for appendicitis
CT with IV and oral contrast is study of choice, u/s
-Pericecal inflammation, abscess, periappendicular phlegm or fluid collections
Tx for appendicitis
Surgery
Abx- Pip-TZ, ampicillin/sulbactam
Diverticulitis sx
LLQ abdominal pain Steady discomfort Tenesmus- the urgency equivalent of poop Change in BM N/V Low-grade fever
Labs for diverticulitis
CBC
CMP
UA
Hemoccult may be pos
Imaging for diverticulitis
CT abd/pelvis with IV and oral contrast
Tx for diverticulitis
IV fluids
Abx- cipro + metronidazole
Clear liquid diet
Surgery if complicated
Acute cholecystitis
RUQ or epigastric pain >5 hrs Fat Female Forty Fertile
Sx of acute cholecystitis
Colicky pain that becomes steady and increases in intensity
N/V
Low fever
Anorexia
PE of acute cholecystitis
Pos Murphys. Pain radiation to R shoulder or subscapula
Pain worse after eating, esp high fat meal
Labs of acute cholecystitis
CBC
CMP
UA
Increased WBCs, LFTs, bilirubin (BR increases after 24 hrs)
Imaging of acute cholecystitis
U/s is study of choice, CT
Pos sonographic Murphy’s sign
Other indicators on u/s- thickened GB wall, gallstones, GB distention, pericholecystic fluid
Tx of acute cholecystitis
Cholecystectomy
Abx- ceftriaxone + metronidazole
Ascending cholangitis
EMERGENCY
Complete biliary obstruction + bacterial superinfection
Presentation of ascending cholangitis
Charcot’s triad: fever + jaundice + RUQ abdominal pain
Reynold’s pentad: Charcot’s + hypotension + AMS (indicated sepsis)
Labs for ascending cholangitis
Leukocytosis and elevated bili
Alk phos increased
Imaging for ascending cholangitis
U/s, ERCP is optimal (diagnostic and therapeutic)
Tx of ascending cholangitis
Triple coverage
-Ampicillin, gentamicin, clinda
IMMEDIATE surgical consult
Spontaneous bacterial peritonitis presentation
Ascites + fever= SBP until proven otherwise
Abd pain, ascites, fever, usually confusion/AMS
MC in pts with portal HTN (EtOH)
Diagnosis of spontaneous bacterial peritonitis
Diagnostic paracentesis
250+ neutrophil count of ascitic fluid OR if <250, positive ascitic fluid cultures (do not delay abx)
Tx of spontaneous bacterial peritonitis
3rd gen cephalosporin (i.e., cefotaxime) is preferred
MC organisms of spontaneous bacterial peritonitis
E. coli + Klebsiella
Presentation of intestinal obstruction
Result of mechanical blockage or loss of nl peristalsis
Crampy, intermittent progressive abdominal pain with inability to have a BM or pass flatus
Vomiting
Bilious in proximal obstructions, feculent in distal obstructions
Abd distention
May have surgical scars, hernia or masses on exam that can provide clues to site of obstruction
Localized to generalized tenderness
Active, high pitched BS that later become absent
Tympany with percussion
Workup for intestinal obstruction
Rectal exam and hemoccult: stool in rectum does not exclude obstruction
CBC and CMP
Imaging of intestinal obstruction
Abd series (plain films) may show air fluid levels and multiple dilated loops of bowel CT scan abd/pelvis (with IV contrast) is diagnostic
Tx of intestinal obstruction
Hospitalize IV fluids Nasogastric decompression NPO Surgery
Criteria for dx of PID
Laparoscopy is the criterion standard, but the dx of PID in EDs is often based on clinical criteria
Minimal criteria needed to diagnose PID
Pelvic or lower abd pain
No other cause other than PID can be identified
One or more of the following:
-Cervical motion tenderness (chandelier test)
-Uterine tenderness
-Adnexal tenderness
Additional criteria that improve diagnostic specificity include:
Oral temp > 38.3 (101)
Abundant cervical or vaginal mucopurulent d/c
Abundant WBCs on saline microscopy of vaginal secretions
Elevated ESR
Elevated CRP
Lab evidence of cervical infection with N. gonorrhoeae or C. trachomatis (via culture or DNA probe)
MC organisms responsible for bronchitis in adults
Viruses (60%)-MC: influenza A + B or parainfluenza
Mycoplasma species, Chlamydia pneumoniae, S. pneumoniae, M. catarrhalis, H. flu
Intermittent asthma
Nighttime awakenings less than or equal to 2/mo
Less than or equal to 2 days/wk SABA use for symptom control
No interference with nl activity
Nl FEV1 during exacerbations; FEV1 >80% predicted; FEV1/FVC nl
Mild persistent asthma
Sx >2 days/wk Nighttime awakenings 3-4/mo >2 days/wk but not daily; not >1x on any day SABA use for symptom control Minor limitation with nl activity FEV1>80% predicted; FEV1/FVC nl
Moderate persistent asthma
Daily sx
>1x/wk but not nightly nighttime awakenings
Daily SABA use for symptom control
Some limitation with nl activity
FEV1 60-80% predicted; FEV1/FVC reduced 5%
Severe persistent asthma
Sx throughout the day
Nightly nighttime awakenings
Several times/day SABA use for symptom control
Extreme limitation with nl activity
FEV1 <60% predicted; FEV1/FVC reduced >5%
Clinical presentation of respiratory failure
Tachypnea and dyspnea; crackles upon auscultation
Clinical setting of resp failure
Direct insult (aspiration) or systemic process causing lung injury (sepsis)
Radiologic appearance and lung mechanics of resp failuare
Radiologic: 3-quadrant or 4-quadrant alveolar flooding- “white out”
Lung mechanics- diminished compliance
MC pathogen with cat bites
Pasturella multocida
Infection <24 hrs: P. multocida, 10-14 days amox-clav, cefuroxime axetil, doxycycline
If >24 hrs: strep- irrigate all penetrating wounds
-LAD- Bactrim (TMP-SMX), Rifampin
S/sx of cat bites
Progressively growing red, swollen area. Hand is MC location. Will see puncture wound and lacerations
What is P. multocida resistant to?
Dicloxacillin
Cephalexin
Clindamycin
Some to erythromycin
NSTEMI characteristic findings on EKG
ST depression
Transient ST elevation (absence of persistent ST elevation)
New T-wave inversion
Positive troponins
What is the MCC of syncope
Vasovagal
Potential causes of syncope
Sick sinus syndrome PE Anaphylaxis Severe aortic stenosis MVP Pulm HTN Sudden cardiac arrest HCM Cor pulmonale Orthostatic hypotension Hypoglycemia QT prolongation
What are meds that can cause QT prolongation?
Azithromycin
TCAs
Zofran
Others
BV typical organism
Gardnerella vaginalis
BV presentation
Fishy smell on KOH prep and increased pH
D/c in BV
Fishy, watery, and grayish
Microscopy in BV
Clue cells
Tx of BV
Metronidazole or clindamycin
Tx of male partner not indicated
Typical organism for trich
Trichomonas vaginalis
Presentation of trich
Severe itching and increased pH
Strawberry cervix and petechiae
D/c of trich
Yellow and green
Microscopy of trich
Motile trichomonads
Tx of trich
Metronidazole for pt and partner
Typical organism of yeast
Candida albicans
Presentation of yeast
Itching, burning, erythema, and decreased pH
D/c of yeast
Cottage cheese
Microscopy of yeast
Pseudohyphae- more pronounced with KOH prep
Tx of yeast
Fluconazole or nystatin
Tx of male partner not indicated
In pregnancy, treat with topical miconazole
Abortive treatment for migraine
NSAIDs
Acetaminophen
Triptans and ergot alkaloids
Prophylactic tx for migraine
BBs
TCAs
Divalproex
CCBs
Lyme dz is usually diganosed through what?
Hx
Most are unaware of bite, late spring-early fall, outdoor activity
Organism of Lyme dz
Borrelia burgdorferi
Stage I Lyme dz
Target lesion/erythema migrans 2-20 days after bite
Stage II Lyme dz
Multiple lesions Fever LAD Arthralgias Splenomegaly Cardiac abnormalities Flu-like sx May develop into neurologic dz
Stage III Lyme dz
Chronic arthritis Myocarditis Subacute encephalopathy Axonal polyneuropathy Leukoencephalopathy
Tx of Lyme dz
21 days of doxycycline, amoxicillin, cefuroxime, clarithromycin, azithromycine or ceftriaxone
Classic findings of Rocky Mountain Spotted Fever
Rickettsia rickettsii bacteria
Sx: HA and high fever, rash on wrist/ankles then spreads (little red spots of over)
Tx of Rocky Mountain Spotted Fever
Doxy x7-14 days BID
Alternative: Chloramphenical QID x 7-14 days
Post-streptococcal glomerulonephritis
Seen most commonly following GABHS infection and occurring on average 7-10 days after initial infection
Abrupt onset of nephritic symptoms and AKI
Post-streptococcal glomerulonephritis
HTN Dark-reddish brown urine Decreased urine output Facial swelling Protein in urine RBC casts
Lab findings in post-streptococcal glomerulonephritis
UA: hematuria, proteinuria, RBCs, RBC casts
Tx of post-streptococcal glomerulonephritis
Supportive
High-dose steroids
Hand foot mouth dz
Coxsackie A16 virus
Common in kids during summer and fall
S/sx and tx hand foot mouth dz
Low-grade fever
Painful mouth ulcers
Flat-reddish-gray vesicles on hands and feet
Tx: supportive
Rabies vaccine schedule
For immunocompetent: 0, 3, 7, 14 days following injury
Immunocompromised: 0, 3, 7, 14, and 21 days following injury
Ovarian cysts
MC ovarian mass in women of reproductive age
Tx:
Large (>5 cm) or symptomatic may undergo surgical resection
Small asymptomatic cysts managed conservatively
Ovarian torsion
An emergency
Colicky pain and N/V more likely to be torsion, pain that radiates to groin
Worse with menstrual cycle is more likely to be cysts
If a cyst ruptures, emergency
Get an u/s with doppler
Ectopic pregnancy
Should be suspected in any woman in reproductive age with:
Abd/pelvic pain (referred shoulder pain may be present)
Irregular bleeding
Amenorrhea
Temp >38 C is unusual (look for infectious cause)
PE of ectopic pregnancy
Cervical motion tenderness
Adnexal mass
Presentation of ruptured ectopic pregnancy
Hypotension
Signs of shock
Workup for ectopic pregnancy
Pelvic u/s
Elevate b-hcG with no signs of uterine gestational sac by u/s is highly suspicious
Tx of ectopic pregnancy
Methotrexate or surgery
How does tooth numbering work?
Starts at upper right, goes to upper left
Then lower left to lower right
Wisdom teeth are 1, 16, 17, 32
Tooth numbering types from “inside out”
Medial incisors Lateral incisors Canines 1st and 2nd premolars 1st and 2nd molars 8 incisors, 4 canines, 8 premolars, 12 molars (including wisdom teeth)
Ludwig’s angina
MC presentation is elderly debilitated man
Most disease spread from infected mandibular teeth
PE of retropharyngeal abscess
Woody induration
TTP on submandibular space
S/sx of retropharyngeal abscess
Difficulty speaking
Muffled voice
Constitutional sx
Open mouth
Tx for retropharyngeal abscess
I and D STAT- Unasyn or Pen G + metro or clinda
Imunnocompromised: Cefepime, Zosyn
