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PEM > Gen ER > Flashcards

Gen ER Flashcards

1
Q

What are three categories of stridor and at least three causes in each?

A

1) Supraglottic
(epiglottitis, peri/retro-pharyngeal abscess, adenotonsillar hypertrophy, craniofacial abN)

2) Glottic
(laryngomalacia, laryngospasm, VC paresis/paralysis/dysfunction, VC nodule/mass)

3) Subglottic
(laryngotracheobronchitis, anaphylaxis, bacterial tracheitis, subglottic stenosis, subglottic web, subglottic hemangioma, tracheomalacia)

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2
Q

What are the two categories of causes of epistaxis?

List five in each

A

LOCAL

  • trauma
  • inflammation (URTI, staph)
  • congenital syphilis
  • foreign body
  • allergic rhinitis
  • telangiectasia (Osler-W-R)
  • juvenile angiofibroma
  • nasopharyngeal lymphoepithelioma
  • rhinitis sicca

SYSTEMIC

  • hematologic (platelet or hemophilias ie ITP, leuk, aplastic anemia, vWD, DIC, vitK, ASA, VPA, NSAIDs)
  • hypertension (arterial, superior vena cava syndrome, CF)
  • vicarious menstruation
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3
Q

How to manage epistaxis?

A 
- pressure, lean forward
consider:
- dental roll under front gums
- gauze soaked with epi 1:1000
- nasal packing, tampons
- cautery with silver nitrate stick
home therapies:
humidifier
petroleum jelly
consider antibiotic ointment
consider nasal decongestants
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4
Q

For nasal cauterization, name the indications, contraindications (2) and complications (3) of the procedure.

A

indications: failure to control bleed with pressure and topical vasoconstrictor
contraindications: bleeding diathesis (hemophilia, ITP) or previous cauterization within 6 weeks
complications: septal perforation, staining of the upper lip or nares, bacterial superinfection or the cauterized area
* refrain from cauterizing both sides of the nasal septum

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5
Q

For nasal packing, name indications and complications of the procedure.

A

indications: bleeding that cannot be controlled with pressure and topical vasoconstrictor, with a contraindication to or failure of cauterization

complications:

1) bacterial rhinosinusitis
2) toxic shock syndrome
3) nasal alar or columnar necrosis
4) septal ulceration or perforation
5) synechiae formation
6) hypoxemia or resp distress from nasal obstruction

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6
Q

Name the components of the GCS score

A

Eyes Verbal Motor

Eyes
4-open spontaneously
3-closed and open with voice
2-close and open with pain
1-closed 
Verbal
5- coherent
4- confused
3- garbled
2- moans
1- nil
Motor
6- command
5- localizes
4- withdraws
3- decorticate
2- decerebrate
1- flaccid
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7
Q

Describe AVPU method of assessing level of consciousness

A

Alert
Voice
Painful
Unresponsive

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8
Q

Name the components of the pediatric trauma score and describe its relevance in practice

A 
Size 
Airway
Systolic blood pressure
Central nervous system
Skeletal
Cutaneous

The PTS emphasizes the importance of patient size and ability to maintain the airway. Studies have confirmed its use as a predictor of outcome: 9% mortality for PTS >8, 100% mortality for PTS <0 and a directly linear correlation between 0-8.

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9
Q

Name physical exam findings that would suggest a difficult airway

A
  • small mouth
  • inability to open the mouth
  • TMJ abnormalities
  • narrow receding mandible
  • protuberant maxillae
  • large tongue
  • distance <6cm between mandible and thyroid prominence
  • inability to place in the sniffing position
  • short, full or bull necks
  • neck mass
  • significant penetrating trauma to face or neck
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10
Q

Describe ECG changes seen with hypothermia with a core temperature <32C

A
  • marked sinus bradycardia
  • 1st degree AV block
  • Osborn or J waves
  • Ass’ w/ long QT
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11
Q

Describe changes seen in hypothermia with temperatures:
31-32C
28-31C
<28

A

31-32C: normal vitals, loss of shivering
28-31C: decreased HR and BP, afib, dilated pupils
<28C: absent pulse and BP, Vfic, coma, fixed pupils

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12
Q

Name 5 management pearls of hypothermia resuscitation

A 
Warm fluids to 43C
Correct hypoglycemia
Watch for coagulopathy
If VF defib no more than three times until temp >30C
Drugs rarely effective until T>30C
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13
Q

What are the stages of frostbite

A
  • initial stinging
  • cold, pale, decreased sensation
  • blotchy and painful areas
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14
Q

Describe features of heat stroke

A 
core temp >41C
dry, hot, ashen skin
ARF
rhabdo
headache, disorientation -> coma, weakness, gait disturbance
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15
Q

Describe features of heat exhaustion (or water depletion)

A 
T <40C
lethargy
nausea, vomiting
heaadches
BP, incr HR
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16
Q

Name good and poor prognostic features with regards to submersion injury prognosis

A

Good:
ROSC <10 minutes
Submersion <5 minutes
PERL, NSR at scene

Poor:
Delayed CPR
ROSC >25 minutes
Submersion >10 minutes

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17
Q

Describe features of high voltage injuries

A

tetany *can prevent grip release, arching
muscle damage -> compartment syndrome -> rhabdo
CNS injury
VF / cardiac arrest
Monitor heart, urinanalysis

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18
Q

What are the features of a brown recluse spider bite?

A

local pain -> central blister -> subcutaneous discoloration ->ulcer
systemic reactions develop in small children: fever, n&v, joint pain, hematuria
treat with analgesia and local care, excision and grafting if severe

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19
Q

What snakes do you have to worry about in Canada?

A

Massasauga and Western rattlesnake

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20
Q

Name indications for admission in anorexia nervosa (8)

A 
systolic <90
HR<45 bpm (some <40 bpm)
orthostatic changes of 30 bpm
systolic 20 mmHg
temp <35.5C
75% of goal weight
support and comorbidity
failure of outpatient
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21
Q

What is the management of neonatal mastitis?

A

Treat as a potentially severe infection in infants <2 months of age with septic work-up (use low risk criteria to determine LP or not in >1 month), IV antibiotics and admit.

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22
Q

What inborn error of metabolism should you suspect if there is hypoglycemia, hyperammonemia and metabolic acidosis?

What if there are urine ketones as well?

A

Fatty acid oxidation disorder

Organic aciduria

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23
Q

What inborn error of metabolism should you suspect with neonatal hypoglycemia and lactic acidosis?

A

Glycogen storage disease

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24
Q

What inborn error of metabolism should you suspect with very high serum ammonia?

A

Urea cycle defect

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25
Q

What are BRUE low risk criteria?

A
  • age >60 days
  • born at >/= 32wks and CGA >/=45wks
  • no CPR by trained medical professional
  • event lasted <1 minute
  • first event
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26
Q

What investigations may you consider in a low-risk BRUE patient?

A

ECG
pertussis
brief monitoring with continuous O2 and rechecks

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27
Q

What is an oral ranula and how do you treat?

A

A ranula is a mucus extravasation cyst involving a sublingual gland and is a type of mucocele found on the floor of the mouth.

Self resolve in 3-6 weeks

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28
Q

What are risk factors for SCFE?

A 
obesity
steroid use
Down's syndrome
endocrinopathy
osteodystrophy
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29
Q

What are the P’s of compartment syndrome?

A 
pain out of proportion to PE findings
passive stretch exacerbation
paresthesias
point discrimination loss
paresis
pallor
pulselessness
30
Q

Name medications which may cause methhemoglobinemia?

A 
dapsone
benzocaine
sodium nitrate
sulfonamides
quinones
well water
phenozopiridine
31
Q

How does macrophage activation syndrome or reactive hemophagocytic lymphohistiocytosis present and who is at risk?

A

Presentation with fever, HSM, rash and liver dysfunction.

  • cytopenias >2 cell lines
  • hypertriglyceridemia
  • hypofibrinogenemia
  • elevated ferritin

Varios auto-immune disorders are at risk

32
Q

What is the most specific test for SLE?

A

dsDNA

33
Q

Which populations is ARF most common in?

A

Fiji, Tonga, India, Pakistan, Turkey, Mozambique

34
Q

Dermatomyositis is complicated by what deficiencies?

A

complicated by velopalatine muscle weakness

  • cough, nasal voice, difficulty handling secretions
  • PTX, ILD, GI hemorrhage & perf, soft tissue calcinosis
35
Q

How does juvenile dermatomyositis present?

A

5-10yoM with proximal muscle weakness
photosensitive rash involving nasolabial folds
Gottron papules
lab abnormalities (aldolase, AST, ALT, LDH, CPK)

36
Q

What should you suspect with high fever, salmon rash, leukocytosis, anemia and thrombocytosis?

A

JIA

37
Q

If a Kawasaki patient is on aspirin therapy and you suspect that they have the flu, what should you do?

A

Don’t stop treatment! Start tamiflu!

38
Q

Name three possible treatments for hereditary angioedema? What to send to confirm?

A

icabitant
ecallantide
recombinant C-1 inhibitor

send serum complement factor 4
C1 inhibitor level

39
Q

What to consider in a patient with fever, urticaria and arthritis?

A

Serum sickness!
1-2 weeks post offending agent
type III hypersensitivity reaction, immune-complex mediated

40
Q

What is the classic presentation of DRESS?

A

2-6 weeks post medication (antiseizure)

morbilliform rash -> exfoliative -> fever, liver, LADN, edema, mucosal involvement in 50%

41
Q

What is the mode of inheritance and classic presentation of Wiskott Aldrich?
What is most lethal?

A

eczema, thrombocytopenia, recurrent infections
x-linked
susceptibility to infxns with S. pneumo, N. meningitides, H. influenza
bleeding risk is deadly! ICH, massive GI

42
Q

What is the risk of anaphylaxis with Ceftriaxone in a penicillin-allergic patient?

A

<1%

43
Q

How can you manage an accidental epipen auto-injection?

A
  • observation
  • soaking in warm water
  • topical nitroglycerin
  • phentolamine injection (reversible alpha agonist)
44
Q

What inborn error of metabolism presents with intermittent encephalopathy, ataxia, confusion, coma and hyperammonemia?

A

Ornithine transcarbamylase deficiency, a urea cycle defect
x-linked dominant
female heterozygotes have a milder episode presentation exacerbated by a high protein diet and stress

45
Q

A failure to thrive baby with jaundice and an E. coli UTI should be suspected of what condition?

A

galactosemia!
lethargy, poor feeding, FTT, hypoglycemia, eventually direct hyperbilirubinemia
galactose deposition in liver = HSM, eyes = cataracts, heart = MR

46
Q

An 18mo presents with hypoglycemia in the context of a gastrointestinal illness, no ketones are present in their urine. What diagnosis should you suspect? How to confirm?`

A

MCAD (AR)

order urine organic acids and acylcarnitine profile

47
Q

What to suspect with lethargy, vomiting, seizures, acidosis, hyperammonemia and ketones?

A

Maple syrup urine disease

aka methylmalonic acidemia = organic aciduria

48
Q

What is the best way to confirm the appropriate location of an IUD?

A

pelvic ultrasound
then AXR
then CT / MRI

49
Q

What is the presentation of a septic abortion?

How to manage?

A

abdominal pain
foul-smelling discharge
chills or fever
(can be seen post-misoprostol)

Rx Genta & Clinda, U/S +/- D&C

50
Q

If a subdermal implant is suspected to have been broken, what is the best way to evaluate it?

A

Ultrasound

51
Q

If a young girl presents with painful vaginal ulcers in the context of diarrhea, what should you suspect?

A

shigella vaginitis
culture to rule-out sexual abuse
treat with azithro

52
Q

How do you treat phimosis? labial adhesion?

A

phimosis: reassurance mostly, topical steroids

labial adhesions: topical estrogen

53
Q

What testing should you consider for abnormal uterine bleeding?
Management?

A 
CBC &amp; iron studies
STI testing
pregnancy
trauma
TSH, testo, LH, FSH
vWF
head imaging if neuro findings, galactorrhea

Consider TXA, monophasic combined OCP BID x 7 days

54
Q

How do you manage a urethral prolapse?

A

confirm with catheter if doubt
surgery if necrosed
otherwise topical estrogen cream and sitz baths

55
Q

What are the diagnostic criteria for bacterial vaginosis and treatment options?

A

3/4 of

1) homogeneous, thin, grayish-white discharge adherent to vaginal walls
2) vaginal pH >4.5
3) positive whiff test after KOH prep
4) >20% clue cells on wet prep

treat with Metronidazole or Clinda

56
Q

What is a grape-like mass near the vaginal introitus?

A

rule-out sarcoma botryoides

57
Q

Name causes of vaginal bleeding in a premenarchal girl

A
  • nonhormonal: trauma, tumour, urethral prolapse, infectious vaginitis, intravaginal foreign body, genital warts
  • hormonal: neonatal bleeding, exogenous estrogen, precocious puberty
58
Q

Name causes of vaginal bleeding in a post-menarchal girl

A 
menses
hormonal contraception
endometritis
dysfunctional uterine bleeding
bleeding diathesis
complications of pregnancy
59
Q

With a chemical injury to the eye, when do you stop irrigating?

A

stop irrigating when the pH of the affected eye is comparable to the unaffected eye (a little while after finishing, normal is 6.5-7.5, otherwise pH 5.5 = NS)
20 minutes minimum or 2L of fluid
sedate if they won’t cooperate!

60
Q

What is Brown-Sequard syndrome?

A

a hemisection of the spinal cord:

ipsilateral loss of motor, proprioception, vibratory sensation
contralateral loss of pain and temperature

61
Q

What is central cord syndrome?

A

bilateral motor paresis, upper > lower, distal > proximal

62
Q

What is anterior cord syndrome?

A

paralysis below the level with loss of pain and temp

63
Q

What is posterior cord syndrome?

A

loss of proprioception and vibration

64
Q

What are the four types of hypersensitivity reactions and how are they mediated?

A

1: anaphylaxis, IgE
2: cytotoxic, IgG/IgM binds to host cell
3: immune complex, IgG with soluble antigen
4: cell mediated, T-cells

65
Q

What elements of the CATCH CT head rule suggest a CT scan is indicated?

A

GCS <15 2hrs after injury
Suspected open or depressed skull fracture
Worsening headache
Irritability
Basal skull fracture
Boggy scalp hematoma
Dangerous mechanism (>3ft, MVC, bike without helmet)

66
Q

What are the PECARN indications to absolutely do a non-contrast head CT?

A

GCS =14
Altered mental status
Palpable skull fracture <2
Signs of basilar skull fracture >2

67
Q

What are the PECARN indications to consider doing a head CT vs observation?

A 
<2:
Non-frontal scalp hematoma
LOC ≥ 5 seconds
Severe injury mechanism
head struck by high-impact object
Abnormal activity per parents
>2-18:
History of vomiting^
LOC
Severe injury mechanism
Head struck by high-impact object
Severe headache
68
Q

For air transport considerations, what two laws do you need to take into account and what do they imply clinically?

A

Boyle’s law: as pressure decreases, volume increases
significant considerations for pneumothoraces
Dalton’s law: at higher altitudes, the concentration of gas decreases
hypoxia increases at higher altitudes

69
Q

With the following WBC counts following knee aspiration, what is your suspected diagnosis?
<2000
2-50,000
>50,000

A

<2,000 non-inflammatory (PMN <25%)
2-50,000 inflammatory (PMN 50%)
>50,000 infectious (PMN >75%)

70
Q

What are the 5 layers of the scalp?

A 
SCALP
Skin
Dense Connective Tissue
Epicranial Aponeurosis
Loose Areolar Connective Tissue 
Periosteum
71
Q

What are the three reportable STIs in Canada?

A

chlamydia
gonorrhea
syphilis

PEM (14 decks)

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