LE pain quiz readings Flashcards
Homen’s sign
pain in the calf with forced dorsiflexion of the foot (Homans’ sign) is neither sensitive nor specific for DVT.
when do you order a D dimer for sus of DVT?
low or intermediate risk (2 or less points)
ULN of D dimer calculation?
age x 10 ng/mL
What do you get if you have a high pretest probability wells score DVT OR a positive D dimer?
US of LE
treatment of DVT
O2 if needed
fluids if needed
UFH, LMWH (preferred over UFH), or DOAC
what can a severe, non-PE DVT lead to?
phlegmasia cerulea dolens can lead to loss of limb and requires immediate treatment.
treatment of phlegmasia cerulea dolens
affected limb should be maintained at neutral level, constrictive clothing, casts, or dressings should be removed, and anticoagulation should be initiated. Catheter- based thrombectomy or thrombolysis should be discussed with an interventional radiologist, peripheral interventional cardiologist, or vascular surgeon. If this service is not available, consider intravenous thrombolysis.
t/f low risk DVT patients can be discharged with a DOAC
true
what is Peripheral arterial disease (PAD)
ABI of <0.9
high risk individuals for ABI
> 70
50 with DM or other RF
these people should be worked up
when does irreversible changes of peripheral nerves happen in PAD?
4-6 hours
MC diseased arteries in PAD
Femoropopliteal, tibial, aortoiliac, and brachiocephalic.
Femoropopliteal (MC)
Clinical features of arterial limb ischemia
1+ of the six Ps:
Pallor, poikilothermia (coldness), pulseless- ness, paresthesias, and paralysis
what is the earliest symptom of PAD
Pain
When is pain worsened for PAD
elevation of the limb (because you are getting even less of a blood supply)
when is a decreased pulse distal to a vascular obstruction NOT reliable finding
early ischemia, especially in patients with chronic peripheral vascular disease and well-developed collateral circulation
t/f intermittent claudication is a really common finding in late PAD
false
more of an early sign - but as the disease progresses, you lose feeling
what symptoms suggests an arterial embolus in PAD
abruptly ischemic limb in a patient with atrial fibrillation or recent myocardial infarction is strongly sugges- tive of an embolus
what do you exam in PE for PAD
differences in peripheral pulses, capillary refill, and skin findings on the extremities.
what do you order to confirm a PAD in ER setting
Objective bedside testing with a handheld Doppler can document the presence or absence of blood flow in an affected limb.
Duplex ultrasonog- raphy can further be used to detect an obstruction to flow with sensitivity greater than 85%.
Doppler US
peripheral vascular disease, and a ratio lower than ____ is concerning for critical limb ischemia.
0:41:1
gold standard for diagnosing PAD
arteriogram
can define the anatomy of the obstruction and direct treatment of the limb.
what is the managmenet of PAD with potential limb threat
stablize
EKG
UFH followed by IV fluids
vascular surgeon referral
telemetry bed or ICU
if a patient with chronic peripheral arterial disease who lack comorbidities and have no immediate limb threat can be discharged on ____
aspirin 81 mg
325 mg PO before discharge
what criteria do you use to grade the severity of acute limb ischemia?
Rutherford criteria
what are the categories of Rutherford criteria and how does that change managment
- Patients that meet criteria I (Viable) to IIa (Marginally Threatened) may have diagnostic testing before definitive treatment.
- Patients with criteria IIb (Immediately Threatened) need immediate consultation and intervention. Patients that meet criteria III (Irreversible) may require limb amputation.
what are the soft tissue infections commonly seen in an ER setting
MRSA
Necrotizing
Cellulitis
Erysipelas
Abscess
Sporotrichosis
What is often mistaken for a spider bite
MRSA and abscess
What imaging can you use for a sus MRSA abscess that is not definitive on PE in the ER
US
What is the initial treatment of MRSA
I&D (often do not need ABX)
when would you need ABX for MRSA
immunocompromise, systemic illness, surrounding cellulitis, or other characteristics prompting antibiotic treatment, con- sider antibiotics effective against MRSA when appropriate.
what are the ABX you can use for MRSA
clinda
Bactrim
cefalxin
vanc
parental if extreme ends of age
how does necrotizing appear at first
benign
what is tachycardia with necroizing?
out of proportion compared to the fever
what imaging can you order for necrotizing if you like
plain film radiographs
treatment of necrotizing
- IV ABX:
vanc PLUS meropenom OR pip/taz. Can consider clinda - IV cryastaloid fluids to help tachy
- Tetanus prophylaxis
- surg asap for debridement, fasciotomy, or even amputation.
t/f you should routinely order a CBC in patients with cellulitis
false
does not change management
typically dx with just HnP
treatment of cellulitis where MRSA is not sys
cephalexin
dicloxaccin
clinda
skin markers
if there is severe non MRSA cellulitis, what do you do?
IV ABX
clindamycin
cefazolin
nafcillin
what differs erysipeals from cellulitis
lympathic involvement with a portal of entry and SHARP borders of erythema
more likely to have systemic symptoms
how to treat erysipeals?
same as cellulitis
Bartholin gland abscess treatment
unilateral painful swelling of the labia with a fluctuant 1 to 2 cm mass.
NO ABX
I&D followed by word catheter
Hidradenitis suppurativa abscess treatment
s a recurrent chronic infection involving the apocrine sweat glands and commonly occurs in the axilla and groin. Acute abscesses can be treated with incision and drainage. Refer patients with recurrent disease to a surgeon for definitive treatment.
Infected epidermoid and pilar cysts treatment
are erythematous, tender, cutaneous nodules that are often fluctuant. Perform a simple incision and drainage and recommend wound rechecks in 2 to 3 days. The cyst contains a capsule that must be removed to prevent recurrence, and this capsule excision is typically done at a later follow-up visit.
Pilonidal abscess
presents as a tender, swollen, and fluctuant mass along the superior gluteal fold. Treatment in the acute care setting includes incision and drainage and the patient should be rechecked in 2 to 3 days. Surgical referral is usually necessary for definitive treatment.
Folliculitis
is characterized by pruritic erythematous lesions that are usually <5 mm in diameter, with pustules sometimes present at the centers. These inflamed hair follicles are usually caused by bacterial invasion with S. aureus. The lesions usually resolve spontaneously with symptomatic care, but can be treated with warm compresses or topical antibiotics such as bacitracin. For painful or more extensive cases, oral antibiotics such as cephalexin, dicloxacillin, or azithromycin are recommended.
etiology of SpOROTRICHOSIS
Sporotrichosis is caused by traumatic inoculation of the fungus Sporothrix
schenckii, which is commonly found on plants and in the soil.
3 week incubation period
treatment of sporotrichosis
Itraconazole OP if mild
amphotericin IP if severe
