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LMCC II Flashcards

1
Q

Pregnancy Hx

A 
-Previous pregnancies:
GPA 
Mode of delivery
Sex
weight
length of labour
complications
-Hx present pregnancy
GA, EDC
Bleeding, N/V
-Past medical history
(DM, thyroid, htn, coagulopathy)
-Past gene hx
-Medications
Prescription and no
-Family hx
genetic disease, birth defects, multiple gestations
-Social
Smoking, ETOH, drugs
Domestic violence (50% begin in pregnancy)
Social support, employment/finances, hx abuse, is mother prepared to raise a child
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2
Q

Gestational Age

A

weeks from the first day of last menstrual period

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3
Q

Estimated date conception (date when will give birth)

A

LMP + 7 days - 3 months

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4
Q

MSIGECAPS

A
  • Mood (depressed)
  • sleep (increased, decreased, early morning awakening)
  • Interest
  • Guilt/ worthlessness
  • Energy
  • concentration/ difficulty making decisions
  • appetite/weight
  • psychomotor activity
  • suicidal ideation
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5
Q

MDD

A
  • Requires 5 of MSIGECAPS over 2 week period

- 1/5 must be loss of interest or depressed mood

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6
Q

Health tips while pregnant

A
  • abstinence from eton, smoking, drugs
  • use of meds only after consulting MD
  • healthy eating
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7
Q

Abortion age limits

A
  • Latest in Canada is at 20 weeks

- preferably earlier at 16 weeks

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8
Q

Abortion medical options

A

<12 weeks: 12 weeks: prostaglandins (intra or extra amniotic) OR misoprostol

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9
Q

Surgical abortions

A

16 weeks: dilatation and evacuation, early induction of labour

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10
Q

Complications of abortion

A
  • pain + discomfort commonly
  • hemorrhage
  • perforation of uterus
  • laceration of cervix
  • risk of infection/endometritis
  • retained products of conceptions
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11
Q

Risk factors for breast cancer

A 
Age over 50
Sex f over m
Estrogen exposure
Post menopausal
In utero exposure to des
Hrt
Early menarche
Nulliparity
Pregnancy at older age
Personal history of breast cancer
Family history
Genetics: brca
Lifestyle; etoh, smoking, 
Exposure to chest radiation
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12
Q

preconception counselling supplementation

A

Folic acid within 8-12 weeks of conception (0.4-1 mg daily, 5 mg if previous NTD, anti-epileptic meds, DM or BMI > 35) and continue for T1
Iron supplementation
Prenatal vitamins
Ensure adequate calcium/ Vit D

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13
Q

preconception counselling: risk modification

A
  • lifestyle: balanced nutrition and physical fitness

- infection screening: toxo, rubella, CMV, hepatitis B, VDRL, Pap smear, gon/chlam, HIV, TB, varicella

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14
Q

Investigation first pregnancy visit

A

CBC,blood group and type, Rh antibodies
Infectious screening
Urine C and S, screen proteinuria
Pelvic exam; Pap smear, chlam/gono, bacterial vaginosis

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15
Q

Air travel when pregnant

A

Allowed into second trimmest, discouraged after 36 weeks

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16
Q

Exercise during pregnancy absolute contraindications

A
  • ruptured membranes
  • pre-term labour
  • hypertensive disorders of pregnancy
  • incompetent cervix
  • IUGR
  • multiple gestation (>3)
  • placenta previa >28 weeks
  • persistent 2/3 trimester bleeding
  • uncontrolled T1DM, thyroid disease
  • other serious cardiovascular, respiratory or systemic disorder
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17
Q

Pre-natal visit: asess at every visit

A
  • fetal movements
  • uterine bleeding
  • leaking
  • cramping

P/E
-BP
-weight gain
-fundal height
Investigations
-urinanalysis for glucosuria, ketones, proteinuria
-fetal heart tones starting at 12 weeks using doppler

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18
Q

Symphysis pubic height

A

12 weeks: uteirne fundus at pubic symphysis
20 weeks: fundus at umbilicus, SFH should be within 2 cm of GA btw 20-36 weeks
37 weeks: fundus at sternum

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19
Q

Fetal movements

A

First noticed at 18-20 weeks

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20
Q

Prenatal screening: high risk population screening test

A
  • Thalassemia (mediterranean, south east asian)
  • Sickle cell (african, caribbean)
  • Cystic fibrosis
  • Tay Sachs
  • Fragile X syndrome
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21
Q

T2DM in pregnancy fact sheet

A
  • 2-4% pregnancies complicated by diabetes

- diagnosed 24-28 weeks

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22
Q

Treatment for pregnancy induced DM

A
  • lifestyle modifications
  • insulin (OHG controversial)
  • tight glycemic control: post-prandial blood glucose
  • 1 hr post prandial <5.3,
  • monitor 24 hour urine protein and creat clearance, retinal exam, hga1c
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23
Q

T2DM and labour

A
  • monitor glucose q1hr
  • pt should be on insulin and dextrose drip
  • 3.5-6.5
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24
Q

Risk factors for gestational diabetes

A
  • age >25
  • obesity
  • ethnicity (aboriginal, hispanic, asian, african)
  • Fhx of DM
  • previous hx GDM
  • previous child with birthweight > 4 kg
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25
GDM and long term prognosis
-50% risk of developing DM in next 20 yrs
26
Complications of DM
- Obstetric: htn/PET, polyhydramnios, pre-term, stillbirth - Fetal: macrosomia OR IUGR, RDS (hyperglycemia interferes with surfactant synthesis), congenital abnormalities - Mom: hypoglycemia, DKA
27
Defn pre-eclampsia, criteria for diagnosis
- Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, and - Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein:creatinine ratio ≥0.3, or - Signs of end-organ dysfunction (platelet count 1.1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration)
28
PET investigations
MAHA picture (CBC, D-dimer, fibrinogen, blood smear, hap to, bill) LFT Creat Thrombocytopenia < 100
29
Labour management PET
-hourly ins and outs -urine dip q12 -hourly Neuro vitals -continuous FHR monitoring -anticonvulsant therapy: mag sulfate -anti-hypertensive therapy: hydralazine 5-10 mg IV bolus over 5 mins q 15-30 mins labetolol 20-50 mg IV q 10 mins 2nd line: nifedipine 10-20 mg PO q 20-60 mins ACEi contraindicated
30
Post partum management PET
- early admission (36 weeks) - mag sulfate (continue mg sulfate in first 12-24 hours post partum: seizure risk increased) - IV hydralazine - 2nd line: labetolol - 3rd line: nifedipine - vitals q 1h - most return normotensive in 2 weeks
31
PET symptoms P/E
- persistent headache - sudden weight gain over 1-2 days/edema - RUQ pain - Persistent and/or severe headache - Visual abnormalities (scotomata, photophobia, blurred vision, or temporary blindness) - Nausea, vomiting - Dyspnea - decreased urination
32
Eclampsia defn
PET + CNS involvement (decreased LOC and seizures)
33
HELLP syndrome
variant of PET - hemolysis - elevated LFT - low platelets
34
4 types of pregnancy-related hypertensive disorders
- preeclampsia/eclampsia/hellp - Chronic/pre-existing htn - pre-eclampsia superimposed upon chronic/pre-existing htn - gestational hypertension
35
chronic pre-existing htn
- >140/90 | - pre-dates pregnancy OR present before 20 weeks and persists longer than 12 weeks post partum
36
pre-eclampsia superimposed upon chronic preexisting htn
- new onset proteinuria or other end organ dysfunction after 20 weeks - if had proteinuria + htn before pregnancy then defined by worsening or resistant htn in last half pregnancy or development os S and S of severe spectrum of disease
37
Gestational htn
-htn without proteinuria or signs of PET that develops > 20 weeks and should resolve within 12 weeks post partum
38
Prevalence PET
7.5% pregnancies worlwide more prevalent in first pregnancies Late onset (>34 weeks) more common than early onset <34 weeks 10-15% of direct maternal deaths are associated with PET/clampsia
39
PET increased maternal risk for
- progession to eclampsia=> seizures - stroke (hemorrhagic) - pulmonary edema - AKI - hepatic failure or rupture - DIC (bleeding problems) - placental abruption - maternal and fetal death (rarely) - fetal risks: prematurity, IUGR, hypoxia
40
Risk factors for PET
- hx PET - first pregnancy - fam hx PET - pre-existing medical conditions including DM, htn, antiphospholipid antibodies, high BMI, CKD - twin pregnancies - advanced maternal age
41
PET increases fetal risk of
- malnutrition - hypoxia - IUGR - prematurity - death
42
treatment PET
- delivery is curative! - no use of antihypertensives unless BP >150/100 or symptomatic - admit hospital 36 weeks for monitoring; may need to admit earlier with steroids and earlier delivery
43
Management of pregnancy induced hypertension (severe)
- control BP with IV labetolol or hydrazine (target BP <160/110) - prevent seizures with mg so4 - delivery by induction or C section when stable with prophylaxis 24 hours post partum
44
Eclampsia
``` ABC + supplemental O2 Mg SO4 g over 20 mins then drip -If seizures occur use IV diazepam -control BP with labetolol/hydralazine -initiate delivery when mother stable ```
45
PE on EKG
S1Q3T3 Deep S in lead I Q wave lead III T wave lead III
46
Hampton hump
Peripheral wedge shaped opacity
47
Westermark sign
Focus of oligemia; secondary to proximal pulmonary artery dilatation and peripheral vasoconstriction (hypoxic)
48
Life threatening causes of CP
``` MI Tamponade Tension pneumothorax Aortic dissection PE Esophageal rupture ```
49
Nasal prong L translated into FiO2
``` 2L=> 26% 3L=> 30% 4L=> 35% 6L=> 40% 40% considered maximum inspired oxygen obtainable without high flow mask such as ventimask ```
50
``` DTaP-IPV Diptheria Tetanus acellular Pertussis Inactivated Polio vaccine ```
2, 4, 6 months 18 months DTap at 14-16 yrs Tetanus and diptheria q 10 yrs
51
MMR
12, 18 months
52
Pneumo-C | pneumococcal 7 valent conjugated vaccine
2, 4, 6, 15
53
Men-C | Meningococcal C conjugate vaccine
2, 4, 6, OR 12
54
Var
15 months
55
Hep B
0, 1, 6 months
56
Vaccines at 2, 4, 6
DTaP-IPV + 18 + teens + adult Men-C (6 or 12) Pneu-C + 15 months HiB + 18
57
Hib
2, 4, 6, 18
58
Live vaccines
MMR Varicella **can give to pts with CD4 > 200
59
Contraindications to all vaccines
moderate to severe illness +/- fever (common URTI fine) | allergy to vaccine component (yeast or gelatin?)
60
MMR contraindications
- allergy egg or neomycin - pregnancy - immunocompromised (except healthy HIV positive children)
61
Varicella contraindications
- Pregnancy or planning to get pregnant within 3 months | - anaphylaxis
62
HPV
between age 9-26 at 0, 2, 6 months
63
Contraindications to pertussis component
Hx of progression neuro disorder or epilepsy
64
Somatoform disorder (diseases)
``` Conversion Somatization Pain disorder Hypochondriasis Body dysmorphic disorder ```
65
Malingering
Intentional production of false or grossly exaggerated physical or psych symptoms motivated by external reward (missing work)
66
Factitious disorder
intention production or feigning of physical or psych signs or symptoms to assume the sick role where external incentives are absent
67
Conversion disorder
symptoms affecting voluntary motor or sensory function that mimic neuro disorder -symptoms preceded by stress or conflict (blindness, inability to speak, numbness)
68
Somatization disorder
recurrent multiple clinically significant complaints which result in pt seeking txt or having impaired functioning - 4 pain sx to four different sites - 2 GI sx (not including pain) - 1 sexual - 1 pseudo-neural
69
Pain disorder
pain as primary symptom
70
Hypochondriasis
- preoccupation with fear of having serious disease based on misinterpretation of bodily signs or symptoms - belief is not delusional
71
Body dysmorphic disorder
preoccupation with imagined defect in appearance or excess concern around slight anomaly; usually related to face
72
Treatment of somatoform disorders
- brief frequent visits - focus psychological not physical symptoms - minimize medical investigations - minimize psychotropic drugs; anxiolytics in short term only, antidepressants for depressive symptoms - attend to transference and countertransference
73
Joints of ankle
Tibio-talar: dorsi and plantar flex Subtalar: talar-calcenal joint Transverse tarsal: forefoot
74
Talar drawer sign
laxity indicates anterior talo-fibular ligament rupture
75
talar tilt
transverse tarsal joint; laxity indicates tear in medial or lateral tendons (calcaneo-fibular or deltoid)
76
Treatment of sprains
``` RICE: Rest Ice Compression Elevation ```
77
Grading ankle sprain
1: stretched ligament fiber 2: partial tear with pain and swelling 3: complete ligament separation
78
CAGE questionnaire
Cut back people Annoyed Guilty Eye-opener
79
HEEADSS
``` Home -where, with who, relations with family, recent moves, ever run away? Education -attending school? grades? failures? suspensions? future plans, goals Eating -habits, hx AN, obesity Activities -extracuricular, sports, work -best friends -social clubs -car -gangs Drugs -types/amount -with friends or alone Sexuality -dating, types experiences -contraception, pregnancies, STD -sexual abuse Suicide -self harm thoughts -prior attempts -depression ```
80
Special test for appendicitis
Psoas sign Obturator sign Rosving's
81
Obturator sign (appendicitis)
hips and knees flexed hold ankle and knee internal rotation -to identify a pelvic appendix
82
Psoas sign
raise leg against resistance
83
Rosving's sign
palpate LLQ which produces RLQ pain
84
Approach to neonatal jaundice
Conjugated vs Unconjugated Hemolysis vs no hemolysis If hemolysis; Coombs + or negative Conjugated Hyperbilli is ALWAYS PATHOLOGICAL
85
Causes of conjugated hyperbilli
Hepatic; - infectious (TORCH) - metabolic (lipid storage, galactosemia, hypothyroid) - drugs - TPN Post hepatic - biliary atresia - choledochal cysts - sepsis - UTI Work-up U/S +/- HIDA scan ALWAYS PATHOLOGIC
86
Causes unconjugated hyperbilli
Hemolysis Coombs + - ABO incompatibility - SLE - drug induced - idiopathic Coombs- RBC defects: G6PD, hemoglobinopathy, hereditary spherocytosis, HUS No hemolysis - physiologic jaundice of newborn - breast milk jaundice - breast feeding jaundice - Gilbert/crigler-najjar - hypothyroid - pyloric stenosis - sepsis
87
Physiologic jaundice of newborn
- occurs at day 2-3 NEVER ON DAY 1 - resolves by 1 week (but could last a bit longer if premature) - diagnosis of exclusion
88
Breast milk jaundice
- 5-7 days into breast feeding, peaks at 3 weeks - mild unconj hyperbilli - considered normal - substances in breast milk increase enterohepatic circulation
89
Breast feeding jaundice
- failure to breast feed - caused by decreased intake with excessive weight and fluid loss - nutritional inadequacy causes increases EHC of bill - change to formula, frequent feeding * *take good breast feeding history
90
Txt of hyperbillirubinemia
If unconjugated - phototherapy - exchange RBC
91
W/U of hyperbilli
- LFT - neonatal and maternal blood type - Coombs - Blood smear - CBC+ retics - septic w/u +/- CSF
92
Acute billirubin encephalopathy
acute rise in bill in CNS lethargy, decreased feeding, hypotonic, high pitched cry Kernicterus is the chronic sequelae of acute bill encephalopathy
93
Differential for microscopic hematuria in adults
``` CA Stones Infection GN BPH ```
94
Psych history
``` Past psychiatric hx -suicide attempts -hospitalizations -pharmacology/ECT Past medical/surgical hx (head trauma, seizures) Family psychiatric hx ```
95
Mental status exam: ASEPTIC
A: Appearance -dress, posture, stated age, psychomotor agitation/depressionm attentive, eye contact S: Speech -rate (pressured or slow), rhythm, volume, tone, articulation E: Emotions -Mood (how do you feel?) -Affect (how do they seem; range of expression, flattened affect) P: Perception -illusions (misperception of real stimulus) -hallucination: perception in absence of stimulus -derealization, depersonalization T: thought process and content -coherent, tangential, loose association -content: suicidality/homicidality, obsessions, delusions I: insight and judgement -Judgement: dr's own of patient C: Cognition -MMSE, intellect
96
Bacterial vaginosis
- grayish/white fishy discharge - clue cells - +whiff test (also sometimes positive in trichomonas) - NOT sexually transmitted - can cause PID - Treat with metronidazole or clinda (Amox in pregnancy) - High pH (>5)
97
Trichomonas
-motile trichomonads on microscopy -STI yellow/green frothy discharge -Motile flagellated organisms on microscopy -treat partner -can cause PID -treat with flagyl ->pH (>5)
98
Yeast infection
- cottage cheese d/c - erythematous/pruritic - high pH R/O yeast infection
99
Chlamydia
- Asymptomatic in 80% of women - Muco-purulent endocervical discharge/urinary sx/pelvic pain/post coital bleeding - Test with cervical culture/PCR/urine test - Reportable disease - Treat with doxy X 7 days OR azithro X 1 (safe in pregnancy) - In pregnancy=> re-test for cleared infection 3-4 weeks after txt
100
Gonorrhea
- Can infect cervix, oropharynx (sore throat), anorectal area - Txt: ceftriaxone IM or cefixime OR cipro - if pregnant: use cephalosporins (avoid quinolones) - treat co-infection with chlam - Re-test in pregnancy
101
HSV of vulva
classically HSV-1 above belt HSV-2 below belt -presents 2-21 days following contact -prodromal sx: burning, tingling, pruritus -multiple painful shallow ulcerations with vesicles appear 7-10 days after initial infection -lesions are infectious -treat first episode of acyclovir 7-10 days, second episode for 3-5 days -can use suppressive therapy if 6-8 recurrences/year -C-section if active genital lesion -suppression therapy for pregnant women with first episode or hx HSV from 36 weeks on
102
Grading muscle strength
0-no contraction 1-visible muscle twitch but no movement of joint 2-weak contraction insufficient to overcome gravity 3-weak contraction able to overcome gravity with no additional resistance 4-weak contraction able to overcome some resistance but not full resistance 5-normal able to overcome full resistance
103
Reflex grading
``` 0-no reflex 1-trace reflex 2-normal reflex 3-very brisk 4-clonus ```
104
Hoffman reflex
Upper motor Babinski | Flick index finger downwards and watch for reflex flexion of thumb
105
C4 dermatome
below mandible to clavicle (neck anterior and posterior)
106
C5 dermatome
Strip on medial arm not including hand
107
C6 dermatome
Strip on external arm (lateral to C5) including thumb
108
C7 dermatome
Strip on outer arm including index and middle finger
109
C8 dermatome
trip on lateral arm including elbow and ring and pinky fingers
110
muscles innervated T1
Hand intrinsics Adduction of fingers Adduction/abduction of thumb (involves T1 and C8)
111
Muscles innervated by C5
Deltoids Biceps Weakness - shoulder abduction - elbow flexion
112
Muscles innervated C6
Biceps Wrist extensors Weakness - flexion - wrist extension
113
Muscles innervated C7
Triceps Wrist flexors Finger extension Weakness - triceps - wrist flexion
114
Muscles innervated C8
Finger intrinsics Thumb ad/abduction (C8/T1) Weakness hand grip Thumb abd/adduction
115
Median nerve sensory innervation
Palmar aspect: thumb, indexm, middle and medial half of ring | Dorsal aspect: distal half of index, middle fingers and medial half of distal ring
116
Radial nerve sensory innervation
Dorsal aspect of hand including thumb and proximal 1/2 index and middle
117
Ulnar nerve sensory innervation
Palmar aspect: hypothenar eminence, pinky and distal half of ring finger Dorsal aspect: proximal half/lateral half middle finger, wring finger and pinky
118
Motor innervation median nerve
thenar muscle | flex at metacarpophalangeal joints of index and middle finger
119
motor innervation of ulnar nerve
flexion/adduction wrist flexion fingers intrinsic muscles of fingers
120
Damaging ulnar nerve
commonly occurs with medial epicondyle fracture | Classic sign: can flex wrist but is accompanied by abduction, cannot abduct fingers, cannot grip pager
121
Tinel's sign
tap on palmar surface of wrist + if elicits shooting parasthesias in median nerve distn
122
Phalen's sign
maximally flex both wrists but pushing the dorsi of hands together for 30-60 sec+ if elicits median nerve distribution numbness/paresthesias
123
Exam for pt with new petecchiae
``` Skin, nails for nutritional status Stigmata liver disease Liver/spleen size/tenderness Lymphadenopathy Lungs for effusions Thyroid exam (high association with ITP) ``` NO RECTAL EXAM GIVEN RISK OF BLEEDING
124
Blood tests Thrombocytopenia
``` R/O plt clumping CBC, coags, LFT Blood smear Hemolytic w/u R/O infection (HIV, Hep) ```
125
TXT of BPH
Proscar (finasteride) (5 alpha reductase blocker) Flomax (alpha blocker) Referral to urology for TURP
126
When should an LP be performed in the setting of a febrile seizure
- if meningeal signs on exam - if vaccination status of strep pneumo of Hib uncertain - if on antibiotics since can mask signs and symptoms of meningitis
127
Defn Febrile seizure
- age 6 months -18 months (typically btw 12-18) - convulsions associated with T >38 - no CNS infection/inflammation, no metabolic cause - no hx of afebrile seizures
128
Simple febrile seizures
- last less than 15 minutes - have no focal features - occur once in a 24-hour period.
129
Complex febrile seizures
- last >30 mins - focal neuro symptoms - occur >1 in 24 hours
130
Prognosis febrile seizure
- 2/3 never have another febrile seizures - 1/3 will have further febrile seizures - 3% will go on to have seizures without fever - 2% develop lifelong epilepsy
131
W/U febrile seizures
- Chem 7/CBGM - CBC - Cultures - imaging with CT/EEG indicated only in specific situations
132
Txt febrile seizures
- treat seizure lasting > 5 mins with lorazepam (0.05-0.1 mg/kg) - Tylenol - use of anti epileptics for complex seizures should be individualized
133
Dysphagia solids vs liquids
Solids indicate mechanical obstruction | Liquids indicate neuromuscular dysfunction (often occurs swallowing either liquids or solids)
134
Approach to esophageal dysphagia
Solids - mechanical obstruction - intermittent: esophageal ring - Progressive: if chronic heartburn indicates peptic sricture, if B sx malignant Liquids/Solids - suggests motor dysfunction - Intermittent: DES - Progressive: scleroderma, achalasia
135
W/U esophageal dysphagia
``` Barium swallow (diagnose stricture or achalasia) Manometry if concern re achalasia Endoscopy ```
136
Secondary causes of Htn
``` Primary renal disease Vascular -Renovascular disease (RAS) -Coarctation aorta Endo -Renin/Aldo -Hypercortisolism -Pheochromocytoma -Hyperthyroidism ```
137
Test coarctation aorta
BP UE>LE | brachial-femoral delay
138
Diagnosis of HTN
1) First visit: - take three readings, discard first and average 2/3 - If BP >140/90: schedule visit two within 1 month 2) 2nd Visit - If BP >180/110 diagnose HTN - If BP > 140/90 AND evidence of macro vascular target organ damage, DM, CKD diagnose HTN Diagnose HTN if -BP >160/100 averaged across first three visits OR -BP>140/90 averaged across five visits ABPM - if mean awake SBP >135, DBP >85 - mean 24 hours SBP >130/80 Home BP measurement - >135/85 average
139
Htn urgency
BP >180/110 often with mild headache No signs of acute end organ damage -reduction of BP gradually over hours to days -can use Acei, Lasix, clonidine acc uptodate -rapid BP lowering not recommended in pts with known aortic or intracranial aneurysm (BP lowering over course of hours); arguably pts high risk for stroke or MI also
140
Diagnosis HTN on ABPM
awake BP >135/85 OR mean 24 hour BP >130/80
141
Examples of target organ damage in HTN
- CVA - Vascular dementia - htn retinopathy - LV dysfunction/hypertrophy - CAD/angina/CHF - renal disease/albuminuria - PAD/claudication
142
Hx of extra-intestinal manifestations of IBD
- iritis/uveitis - arthritis - mouth ulcers - anal ulcers - skin lesions - kidney stones
143
HTN emergency
``` BP >180/110 with evidence of end organ damage; Cerebrovascular -Htn encephalopathy, ICH/SAH Cardiac -acute aortic dissection/LV failure/MI/after CABG Renal -Acute GN, post kidney transplant, MAHA Eclampsia ```
144
Arcus senilis
evidence of familial hypercholesterolemia in the eyes
145
Guidelines to ECHO pts with a symptomatic heart murmurs
- diastolic murmur - continuous - late systolic murmur - murmurs associated with ejection clicks - murmurs that radiate to the neck or back - grade 3 or louder mid peaking systolic murmurs - Other indications (class IIa): associated with abnormal physical findings, associated with abnormal ECG or CXR
146
Qualifying heart murmurs
Intensity (grade I-VI) Pitch (high or low, rumbling, blowing, musical) Configuration (shape; cresc/decresc) Location Timing (midsystolic, holosystolic, early or late systolic, continuous)
147
Grading murmur
I: faint, heard with difficulty II: faint III: moderate IV: associated with palpable thrill V: loud but cannot be heard without stethoscope VI: loud and can be heard without stethescope
148
Timing of systolic murmurs
Midsystolic: begins after S1 and ends before S2 (both S1S2 audible) Holosystolic: obscures both S1S2 Early systolic: obscures S1, audible S2 Late systolic: starts after S1, obscures S2
149
Timing of diastolic murmurs
``` Early diastolic: begins with A2/P2 and extends into diastole for variable duration Mid diastolic: starts after S2 terminates before S1 Late diastolic (presystolic) starts well after S2 and extends to S1 ```
150
Continuous murmur
begins in systole and continues through diastole without interruption, encompassing S2
151
Mid systolic murmurs, causes
Most often benign -Flow murmurs: increased flow rate across normal semilunar valve (thyrotoxicosis, pregnancy, anemia) or aortic valve sclerosis -ASD with left to right shunting Benign if NOT associated with other cardiac signs
152
Diff'll holosystolic murmur
MR TR VSD
153
MR
``` Holosystolic best heard in left lateral decubitus with bell stethoscope Blowing/high pitch Apex Radiate to axilla/scapula Increases with manoeuvres that increase LV volume ex leg raising or when after load increases (squatting, handgrip) Decreases with valsalva or with standing little respiratory variation ```
154
TR
Holosystolic Diaphragm Left lower sternal border Murmur increases with increased venous return; inspiration, leg raising Decreases with standing (decreasing venous return) c-v wave JVP, pulsatile, increase with inspiration due to increased in venous return (Kussmaul)
155
VSD
holosystolic loud, can be associated with thrill LL sternal border
156
Late systolic murmur
MVP TVP Ischemic MR
157
MVP
- late systolic - diaphragm - apex - -usually preceded by single or multiple clicks - murmur increases with increasing preload (squatting, elevation legs, hand grip)
158
early diastolic murmur
AR | Pulmonic regurgitation
159
Mid diastolic murmur
MS | TS
160
Inspiration as it portends to right and left sided venous return
Increases right sided and decrease left sided venous return Increases right sided murmurs (TR, PR) Decreases murmur of MVP
161
Abrupt standing as it portends to heart murmurs
Decreases venous return to heart Decrease intensity AS Decrease MR/TR Increases HCM
162
Squatting as it portends to heart murmurs
Increase venous return (preload) with increased after load - Increases MR (after load) - Increases VSD - decreases HCM (after load increases effective orifice size of outflow tract)
163
HCM
crescendo-decrescendo murmur apex and LLSB radiate axilla and base, usually not to neck Increases by increasing obstruction; squatting to standing, valsalva Decreases by attenuation of obstruction; handgrip, passive elevation of legs
164
Valsalva
Decreases venous return to both right and left ventricle - Decreases AS, MR and TR - increases HCM (decrease LVOT with decrease venous return)
165
hand grip
increase SVR, increase LV volume Most useful to differentiate AS v MR AS: decrease MR: increase
166
AS
- systolic - RUSB - harsh - crescendo/decrescendo - radiates carotids/clavicle - musical radiation to apex (gallaverdin)
167
OPQRST hx
``` Onset Progression/provoking Quality Radiation Severity Timing Relieving/exacerbating ```
168
Hx of spinal stenosis
Pain worse with activity, resolves with rest | Pain worse lying down
169
Lower extremity dermatomes
``` L2-L1 Upper thigh Inner lower leg L3: Inner thighs over medial knee L4: Medial to calf L5: dorsal foot (plantar foot) S1: outer foot ```
170
Low back pain history
- OPQRST - Neuro sx: weakness, parasthesias - bladder/bowel incontinence - B symptoms - Infectious sx - trauma - arthralgias, skin lesions
171
LBP exam
Observation: - Gait, toe walk (S1), heel walk (L4L5 weakness) - observe back for scoliosis, kyphosis Palpate: spinuous processes, paraspinals, deeper into facet joint areas - PSIS: transition lumbar to S1 joint - sacroiliac joint Passive ROM: - forward bending/extension - lateral flexion - straight leg raise Motor - Hip flexors (flex/ex/int/ext rotation) - Knees - Ankle Neuro - reflexes - sensory (test dermatomes) - Babinski - Ankle clonus - saddle anasthesia - rectal tone Vascular Peripheral pulses
172
Quads
L234
173
Hamstrings
L4L5S1S2
174
plantar flexion: Anterior tibili
L4L5
175
Toe extension
extensor hallucis longus | L5
176
Ankle eversion
S1
177
Indications for early imaging of LBP
- neuro findings - constitutional symptoms - hx traumatic onset - Hx malignancy - Age >50 - Osteoperosis (increased risk of compression fracture, W>M) - Infection risk: steroids, IVDU
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Diff'll LBP
- Degenerative (90%); mechanical, spinal stenosis, peripheral nerve compression (herniated disk) - Trauma - Inflammatory (ank spond) - Infectious (epidural abscess, osteo, discitis) - CA - Referred (AAA, pyelo, stones, pancreas)
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Red flags back pain
``` BACKPAIN Bowel/bladder dysfunction Anasthesias (saddle) Constitutional sx K for chronic disease Pain > 1 month and/or at night AGE > 50 IVDU Neuromotor deficits ``` Others; - unexplained decr weight - CORT use - Osteoperosis - Prior surgery - cumulative trauma
180
Back surface anatomy
PSIS (posterior, superior iliac spine) corresponds L4L5 | Of NOTE: cord ends at L1; below is caudal equine
181
Benign causes LBP
Irritation paraspinal muscles, ligaments or vertebral body articulations Characterized by no radiation, worse with activity, improving with rest
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Sciatica
Typically L5-S1 -burning/electric shock starts in LB travelling down buttocks and along back of legs, radiates below knees Causes: irritation of nerve root as it exits spinal column due to compromised neuroforamina (bony osteophyte) OR herniated disc
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Spinal stenosis
Pain starts in LB and radiates down buttocks bilaterally continuing along backs of both legs -sx usually worse with walking, relieved when patient bends forward (neurogenic claudication) Pain quickly resolves when stops walking unlike PAD takes longer to resolve -Normal peripheral pulses
184
Walking on toes mediated by
S1 root
185
L5 radiculopathy sx
Radiation from buttock to lateral calf Numbness medial dorsum of foot (including web of great toe) -weakness ankle dorsiflexion
186
S1 radiculopathy Sx
Radiation posteriorly down leg to heel (lateral) Lateral foot numbness Ankle plantar flexion weakness Decreased ankle jerk
187
Ankylosing spondylitis history
- AM Stiffness that improves during day - recurrent and nocturnal back pain - Associated: weight loss, fever, fatigue, anemia - ask joint pains (typically large joints) - uveitis (occurs in 1.3 of cases) - Family hx
188
Pain on flexion of back indicates
discogenic pain
189
Pain on extension of back indicates
facet joint pain
190
When to suspect malingering with LBP
pt claims to be unable to bend from standing position but able to extend knees from sitting position
191
kernig sign
- pt supine, flex hip with knee flexed - while hip flexed try to extend knee - positive if resistance to knee extension or back pain - if bilaterally + more suggestive meningeal irritation
192
Brudzinski sign
Pt supine Lift head off examining table Positive if pt flexes hip and/or knees
193
Developmental milestones | 2 months
- smiles - coos - recognizes parents - track - when prone can extend arms forward +/- hold head up
194
Developmental milestones | 4 months
- laughs - rolls over - responds to voice - reaches and grabs stuff and puts in mouth
195
Developmental milestones | 6 months
- tripod sit - babbles - stranger anxiety/object permanence - ulnar grasp
196
Developmental milestones | 9 months
- Pulls to stand, crawls - mama/dada - finger-thumb grasp - peek-a-boo
197
Developmental milestones | 12 months
- walks - pincer grasp - 2 words
198
Developmental milestones | 15 months
- walks without support - draws line - jargon
199
Developmental milestones | -18 months
- climbs steps - follows simple commands (sit down) - drinks from cup, eats with spoon
200
Developmental milestones | 24 months
- 2 word sentences | - understands 2 step commands
201
Developmental red flags
``` Gross motor: not walking at 18 months Fine motor: handedness at < 10 months Speech < 3 words at 18 months Social: not smiling at 3 months Cognitive: no peak a boo at 9 months ```
202
Birth weight
Loss up to 10% in first 7 days normal | Neonate should regain all of birth weight by day 10
203
Hip flexors
L2 largely
204
Amenorrhea, types
Primary | Secondary; most common
205
Primary amenorrhea defn
Absence of menses AND secondary sexual characteristics by age 14 OR absence of menses by age 16 if sex characteristics present
206
Secondary amenorrhea definition
Absence of menses for >3 cycles (or >6 months) after menarche - more common - most common case: pregnancy
207
Oligomenorrhea
vaginal bleeding is irregular and light at intervals > 35 days PCOS common cause
208
GTPAL
``` gravita (#pregnancies) Term Pre-term Abortions Living ```
209
Primary amenorrhea history
- pregnancy history - developmental history (secondary sexual characteristics) - family hx: age menarche of mother, family history of delayed puberty or absent puberty - Cushingoid features (striae, puffiness), ACTH excess (change skin colour); may indicate possible 21 hydoxylase deficiency
210
Secondary amenorrhea history
Gyne hx - GTPA, type abortions - menses history - family hx early menopause - sexual hx ?pregnancy - sx of menopause: hot flashes, night sweats, decreased libido, vaginal dryness) for premature ovarian failure - signs virilization (hair growth, voice changes) Endo hx - signs of prolactinoma: galactorrhea, visual changes (loss peripheral vision), chronic headache - Thyroid dysfunction (T, mood, GI, skin/hair changes) - hypothalamic amenorrhea (exercise, weight loss, fasting, stress) GI hx -Celiacs (bloating, dyspepsia, diarrhea)-association btw celiacs and amenorrhea
211
Differential for secondary amenorrhea
Gyne - PREGNANCY - Premature ovarian failure - PCOS - menopause - hypothalamic amenorrhea (stress, exercise) - uterine or vaginal defect (structural; atrophy...) Endo - Thyroid - Prolactinoma - other tumours
212
Oligomenorrhea, differential (similar to secondary amenorrhea)
Thyroid | PCOS
213
PCOS diagnosis
2/3 - oligmenorrhea/irregular menses for 6 months - clinical or lab evidence of hyperandrogenism - PCOS on U/S W/U - LH>FSH - high DHEA, testosterone, androstenedione - decr sex hormone binding globulin Txt - Lifestyle (lose weight) - OCP - metformin - clominphene citrate to induce ovulation - 5 alpha reductase to reduce hirsutism
214
Exam amenorrhea
GA - BMI - Skin; darkening, cushingoid, easy bruising (CAH) - galactorrhea; if suspect do visual fields - parotid hyperplasia, eroded dental enamel (bulimia) - eval for tanner staging, turner sydrome (neck web, wide spaced nipples, low hairline) Gyne - vaginal atrophy, dryness (estrogen deficiency) - careful genital exam (primary amenorrhea)
215
W/U for amenorrhea-labs
- hcg - FSH (central or gonadal) - LH - TSH - Total testosterone (secreted by gonads) if suspect virilization - 17 hydroxyprogesterone to R/O classic 21 hydroxylase deficiency - DHEA-to R/O adrenal source of androgens (androgens produced in adrenals)
216
W/U amenorrhea-imagine
-transvaginal U/S to image ovaries (R/O PCOS, absence of usual uterine stripe in ashermans syndrome), normal anatomy (R/O structural esp in primary amenorrhea))
217
Primary amenorrhea plan
``` get FSH and refer! 50% from chromosomal abnormalities 25% functional hypothalamic ameorrhea vs tumor 20% anatomic abnormalities PCOS (more rare) **will need specialists ```
218
Secondary amenorrhea trial of progesterone challenge (this may be in the real of specialists aka refer to gyny)
- If get a withdrawal bleed considered positive test - indicates have enough estrogen on board to thicken endometrium - Diff'll: anovulation - if no bleeding may be inadequatee estrogen or excessive androgens - Diff'll: ovarian dysfunction, premature ovarian failure, PCOS, hypothalamic dysfunction
219
If find premature ovarian failure
High FSH/LH, normal testosterone/androgens - <40 - screen for autoimmune adrenal insufficiency (anti-adrenal antibody, anti-21 hydroxylase antibody), R/O hypothyroid - discuss need for HRT, adequate cal/vit D, protection bone density loss - continue HRT until natural age of menopause (50) to avoid risk of increased CV and CA complications
220
Diagnostic criteria for premenstrual syndrome
-at least 1 of following during 5 days preceding menses during last 3 cycles -affective sx: depression, angry burst, irritability, anxiety, confusion, social withdrawal -physical: breast tenderness, abdo bloating, HA, peripheral edema -sx must be relieved within 4 days of onset of menses -not due to eton/drugs/rx sx result in dysfunction -must occur through 2 cycles of recording R/O hypothyroidism, depression Ask to keep symptom diary to better diagnose
221
Abnormal LFTs overview
``` Infectious hx (RF for hepatitis) Habits (IVDU/etoh) Drugs (including OTC, *tylenol) Nash (HTN/DM) Fam Hx (Wilson's, hemochromatosis, Gilbert, HBV vertical transmission) Hemolysis Gallstones (jaundice) Developmental history ```
222
Liver disease P/E
Hands: palmar erythema, deputryan's contracture, Terry's nailes Face: temporal muscle wasting, telangiectasias, scleral icterus Abdomen: caput medusae, liver space, liver edge, splenomegaly, ascites, hemorrhoids
223
W/U liver dysfunction
``` Hepatitis IGM (only in acute jaundice) HBV (surface ag-active infection, surface ab-immunization or past exposure, core ab-previous exposure with cleared virus) HCV ab Iron profile + ferritin Ceruloplasmin level ANA, anti-sm antibodies U/S R/O thrombosis and ischemia Hemolysis work up ```
224
Protective factors for breast cancer
Brast feeding | Physical activity
225
Red flag for familial breast cancer
Breast cancer in young women Multiple relatives with breast or ovarian Bilateral breast cancers Family hx of male cancers
226
Breast exam
``` Seated -observe -raise both arms upwards -arms on waist with contraction of pecs -cervical and axillary node exam Supine -use pads of first three fingers -imagine wheel with spokes radiating from nipple -feel all quadrants, including towards axilla -feel around nipple -squeeze nipple for discharge ```
227
If breast mass found on exam
Women under 30: send for ultrasound Women over 30: mammogram even if recently had a normal study 10-20% clinically palpable masses will be missed on mammography If large palpable mass can refer directly to surgeon for biopsy
228
Triad asthma
Asthma Allergic rhinitis; - Atopic dermatitis; hx rash (infancy; red, scaly itchy crusted lesions on extensor surfaces, cheeks or scalp) (child; rash less exudative, lichenification on lexical surfaces like antecubital and popliteal fossa) (adults: lichenified skin and excoriated papules on hands and feet)
229
Asthma triggers
``` URTI Pets Smoker/smoke in house cold weather? (helps in assessment of whether asthma on differential) ```
230
Asthma symptom control
- how many days of week do they have sx/use PRN puffer (< 4 ok) - how many times/week SOB/cough (90% of best value and that varies by <15% adequate
231
Diagnosis asthma on PFT
FEV1/FVC (actual ratio, not predicted) <0.7 means obstruction FEV1 percent predicted indicates severity of asthma
232
Post-nasal drip (cause of childhood dry cough)
if allergic rhinitis prescribe intra-nasal topica glucocorticoid spray (budenoside, mometasone) especially if suspect asthma/known asthmatic as will worsen symptoms +/- referral to ENT
233
Treatment of atopic dermatitis
steroid cream +/- referral to derm
234
Treatment asthma general principles
Pyramid approach Controllers and relievers Action plan (written document telling them how often to monitor, how to maintain good control (avoidance triggers, med regularly) and when to seek help (If taking a lot of Ventolin)
235
Pyramid treatment asthma
SABA PRN ICS + SABA PRN LABA + ICS + SABA PRN then could add leukotriene receptor antagonist (montelukast) then eventually oral glucocorticoids
236
Psychosis differential
- Schizophreniform disorders - Affective disorders - Personality disorders - general medical condition (hypercalcemia, delirium, glucocorticoids) - intoxication
237
Schizophreniform disorders
- schizophrenia - schizoaffective disorder - delusional disorder
238
Schizophrenia diagnostic criteria
>2 of following OR only 1 if sx is a first rank (voices minting running commentary OR two voices talking to each other) - delusions - hallucinations - disorganized speech - negative symptoms Marked decline in functioning At least 1 month Not schizoaffective OR affective disorder Not general medical condition
239
Schizoaffective disorder
- Meets criteria for schizophrenia BUT concurrent affective episode (mania/MDE/mixed) - In same period del/hall last at least 2 weeks in absence of mood symptoms - affective sx present for substantial portion of whole episode - Not due to into or GMC
240
Psych hx
Age Occupation Social structure/support Living situation PMHx - psych - past suicide attempts - hospitaliaiton - treatments - legal Habits -substance abuse Fam Hx - psych problems or psychosis - family structure, relationships Meds
241
gynaecological causes of pelvic pain
``` Acute -Adnexal Mittelschmerz, ruptured ovarian cyst, ruptured ectopic pregnancy, ovarian/tubal torsion -Uterine Fibroids -Infectious Acute PID, endometritis ``` Chronic - Chronic PID - Endometriosis - Adenomyosis - adhesions - ovarian cyst - Fibroids (rare)
242
Vaginal bleeding (Gyne) history
``` Age Obs hx (GPA, pregnancy complications) Menstrual history (date started menstruating, frequency, quality, pain, date last menstrual bleeding, episodes similar bleeding) Gyne hx (pelvic infections) OCP history (barrier method, IUD, tampon, foreign bodies) ``` PMHx - bleeding diathesis - endocrine dysfunction (PCOS, thyroid) - surgery (C/S) Meds - hormones - anticoagulants - chemo - steroids Fam Hx - bleeding disease - vaginal bleeding Habits - sexually active, contraception, possibility of pregnancy - inter menstrual bleeding - Menorrheagia - Dyspareunia - infectious
243
Quantifying vaginal bleeding
``` # tamponds changed/24 hours -if changing q3 hours=> heavy bleeding ``` Passing clots -clot >1cm associated with 80 ml blood loss 80cc normal for period loss
244
Reproductive age vaginal bleeding diff'll
- structural (uterine fibroids, endometrial polyps, adenomyosis) - Anovulation (PCOS, thyroid, hyperPRL) - Disorders of hemostasis - Neoplasia - Drugs (HRT, progestin only contraceptives) - Infection (endometritits, PID)
245
Dysfunctional uterine bleeding
Irregular uterine bleeding that occurs in absence of recognizable pelvic pathology, general medical diseases or pregnancy Disruption in normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining Bleeding may be heavy/light/prolonged/frequent/random Diagnosis of exclusion Common cause is anovulation (weight changes, eating disorder, stress
246
Consequences of PID
Hydrosalpinx (damage fallopian tubes) Chronic pelvic pain (30%) infertility ectopic pregnancy
247
Causes of pelvic pain in pregnancy
Spontaneous abortion | Ruptured ectopic
248
Risk factors for spontaneous abortion
Increasing maternal age Previous spontaneous abortion (risk of miscarriage in future pregnancy 43% after >3 consecutive miscarriages) Maternal smoking
249
Classic presentation spontaneous abortion
Amenorrhea Vaginal bleeding Pelvic pain
250
Pelvic exam for spontaneous abortion
``` source of bleeding is uterus Volume bleeding Uterine size products of conception at cervic/in vagina open cervix ***R/O ectopic ```
251
Ruptured ectopic classic symptoms
6-8 weeks after last normal menses | abdo pain/amenorrhea/vaginal bleeding
252
normal pregnancy discomforts
Breast tenderness frequent urination nausea
253
bhcg and pregnancy
doubles Q48 hours Failure of bhcg to rise consistent with failed pregnancy (arrested pregnancy, tubal abortion, spontaneous resolving ectopic, complete or incomplete abortion)
254
bhcg must be what to visualize gestational sac by TV U/S
1500-2000 | Can be seen as early as GA 5 weeks
255
Post menopausal bleeding
Endometrial atrophy Endometrial carcinoma Meds (HRT)
256
When NOT to perform a vaginal exam
women in 3rd trimester of pregnancy: risk of causing separation of placental previa
257
Rhogam; when to give, dose
Give to pts with any bleeding during pregnancy (miscarriage, ectopic, blunt abdo trauma, antepartum bleeding, fetal death) who are RH- to prevent RhD alloimmunization -300 mcg
258
W/U bleeding pregnant patient
CBC (hg, plt) Blood type + X match, Rh status R/O coagulopathy: Coags, D-Dimer, Fibrinogen, blood smear
259
Fast facts uterine bleeding
Estrogen-progestin contraceptives: unschedulled bleeding Progestin-only: irregular uterine beleding or amenorrhea Copper IUD: increases menstrual flow Ask about Trauma Dysmenorrhea, dyspareunia, or infertility suggest endometriosis Change in bowel/bladder dysfnx suggests mass effect Galactorrhea, heat or cold intolerance, hirsutism or hot flashes suggests endocrinologic issue Recent illness, stress, excessive exercise or possible eating disorder suggests hypothalamic dysfunction Endometrial polyps, endometritis or PID may present with heavy or prolong menses but intermenstrual bleeding most common
260
Risk factors for endometrial cancer
``` Increasing age Tamoxifen therapy Early menarche Late menopause Nulliparity PCOS Obesity DM Estrogen secreting tumor Family history ```
261
Irregular bleeding suggests
ovulatory dysfunction Often extremes of reproductive age PCOS Endocrine disorder (thyroid, hyper prolactinoma)
262
Intermenstrual bleeding
Endometrial polyps Contraception Endometrial hyperplasia/CA Endometritis or PID
263
Heavy menstrual bleeding
Uterine leiomyas Adenomyosis Related to CSection Bleeding disorder
264
VBAC counselling on risks
- Avoid induction of labour - In-hospital birth so uterine rupture can be managed expectantly and quickly - having more than 1 C/S increases risk - having one VBAC increases chances of safe delivery
265
Risks of VBAC
-uterine rupture (0.5-1%) -risks of uterine rupture increases with: classical incision, 2+ C/S, single layer closure, induction of labor, use PG, short inter pregnancy interval, infx at prior C/S
266
Tox history
How much ***WHEN WHAT Suicidal intention (will need psych consult after)
267
Universal toxidrome antidote
``` TONG Thiamine Oxygen Naloxone Glucose ```
268
Things to not forget in overdose pts
``` R/O hypoxia R/O hypoglycemia Consider Cspine trauma Consider meningitis R/O brain bleed (pupils, DTR) ```
269
Anticholinergic toxidrome
``` Hot at a hare Blind as a bat Dry as a bone Red as a beet Mad as a hatter ``` ``` Hyperthermic Dilated pupils No sweat Flushing Confusion Urinary retention Ileus tachycardia ```
270
Anticholinergic OD substances
TCA Antipsychotics Antiparkinsonian
271
Cholinergic toxidrome
``` Lacrimation Salivation Sweating Urination Diarrhea Bradycardia ```
272
Cholinergic OD substances
organophosphate insecticides | Sarin nerve gas
273
Serotonin syndrome signs and symptoms | cognitive, neuromuscular, autonomic
Cognitive: - confusion - agitation - reduced LOC - seizures Neuromuscular - myoclonus/clonus - hyperreflexia - tremors - muscle rigidity Autonomic - Hyperthermia - htn - tachycardia - diaphoresis - shivering
274
neuroleptic malignant syndrome signs and symptoms
Cognitive -AMS; delirium progressing to lethargy, stupor, coma Neuromuscular - tremor - rigidity - shuffling gait Autonomic - labile BP - hyperthermia - tachycardia
275
Malignant hyperthermia
appears after general anasthesia with inhaled anesthetic OR Succinylcholine
276
Serotonin syndrome drug causes
SSRI TCA MAOIs
277
NMS causes
Antipsychotics (typical and atypical) | Withdrawal from parkinsonian meds (dopamine agonists; withdrawal results in acute depletion of dopamine)
278
Blood tests in NMS
Muscle damage and necrosis - CK - LDH - AST - ALT Cell necrosis - hyperkalemia - hyperphosphatemia - hyperuricemia - hypocalcemia - myoglobulinuria can lead to renal failure
279
Txt NMS
``` supportive cooling blankets Antipyretics Aggressive fluid resuscitation Alkalinization of urine can help ARF and enhance excretion myoglobulinuria ```
280
Tylenol toxicity
clinically silent within first 24 hours then evidence of hepatic toxicity
281
ASA toxicity
``` Hyperventilation (deep, rapid) Hyperthermia Tinnitis AMS ABG; metabolic acidosis with respiratory alkalosisexamp ```
282
Acute toxidrome labs
``` pregnanc test EKG Chem 7 ABG + Lactate Tox screen serum osmolality CK Ketone CT head ```
283
Management Anticholinergic toxidrome
``` Cardiac monitor (arrhythmias!) Activated charcoal Call poison control Benzos to control agitation If asymptomatic monitor for at least 6 hours ```
284
Cholinergic poisoning management
Intubate pt early (death by resp failure if you don't) If skink ontact, remove clothes and irrigate DO NOT GIVE CHARCOAL Benzos Poison control Atropine 2 mg IV double dose q5 mins until resp status improves
285
Tylenol toxicity treatment
Normogram (*time of ingestion crucial) activated charcoal if within 4 hours NAC Prophylax with anti-nausea meds
286
ASA toxicity treatment
do not intubate unless hypo ventilate (hyperventilation is protective; apneic periods increases ASA toxicity) IVF Bicarb Glucose (ASA selectively decreases cerebral glucose concentration, so give it even if glucose is normal)
287
Acute dystonic reaction Txt
Benzaprine 2 mg PO/IV daily
288
Contraindications for fibrinolysis
- suspected aortic dissection - Stroke >3 hours or < 3 months ago - Hx ICH/mass - Hypertensive emergency - Surgery within 2-4 weeks - Unstable (shock, pulmonary edema, required CPR)
289
ACS initial management
``` ABC IV access Cardiac monitor VS CBGM EKG MONA (ASA 325 mg chewed stat unless allergy) R/O phosphodiesterase inhibitor (viagra) prior to Nitro -Atorvastatin 80 -MT 25 PO BID unless in heart failure ```
290
STEMI cath vs fibrinolysis
PCI preferred IF cannot do PCI, pain < 12 hours and no contraindications to fibronolysis=> LYSE If lyse, can still use ASA/plavix/heparin
291
TIMI score
4 points hx - age >65 - 3 cardiac risk factors (Htn, DLP, smoking, DM, dam hx MI < 65) - known high grade stenosis (>50%) - on ASA 3 points ACS diagnosis - ST change admission EKG - CP (>2 episodes in last 24 hours) - Trops TIMI 3-4 indicates increased chance of bad outcome with medical management alone
292
ATLS approach
``` ABCDE Airway Breathing Circulation Disability (GCS + pupils) Exposure and environmental control ```
293
Trauma general guidelines
``` Universal precautions gloves and gown Vitals + cardiac monitor ABCDE primary and secondary survey AMPLE hx Transfer pt to trauma centre when stabilized ```
294
Airway assessment trauma
Look incr WOB, cyanosis, secretions Assess difficulty of airway (teeth, deformities, edema) Trachea midline Feel subcutaneous emphysema
295
Doses of intubation agents
``` Etomidate 0.3 mg/kg IV push Propofol 1-1.5 mg/kg Ketamine 1-1.5 mg/kg Fentanyl 50-100 mcg Succinylcholine 1-1.5 mg/kg ```
296
GCS components
``` Eye opening (4) Verbal response (5) Motor response (6) Total score out of 15 ```
297
GCS eye opening
spontaneous 4 To speech 3 To pain 2 No response 1
298
GCS verbal response
``` oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1 ```
299
GCS motor response
``` Obeys commands 6 Moves to localized pain 5 Flexion withdrawal from pain 4 Abnormal flexion (decorticate) 3 Abnormal extension (decerebrate) 2 No response 1 ```
300
Basilar skull fracture
occurs most commonly through temporal bone Increased risk of ICH Battle sign (retroauricular and mastoid ecchymosis) Periorbital ecchymosis (Raccoon eye) CSF rhinorrhea or otorrhea Hemotympanum
301
Disability (as part of ATLS)
GCS + pupils
302
Exposure and Environment (as part of ATLS)
``` Remove clothes Cover with warm dry blankets to prevent hypothermia Log Roll Palpate C Spine R/O CSpine injury Pelvic exam -DRE -R/O blood at meatus -R/O high-riding/non palpable prostate -check anal sphincter tone -Foley catheter if no contraindications ```
303
Get CT C spine if any of five are present
- Neuro deficits, focal - spine tenderness, midline - AMS - intoxication - distracting injury
304
Radiology for trauma
``` CXR; lungs + ETT placement Spine: entire C spine (C7-T1) Pelvic XR (R/O pelvic fracture) Abdo XR R/O free air Any other areas including joints above and below ```
305
Contraindications to NGT in trauma
Basal skull fracture | Esophageal stricture or bleeding diathesis
306
4:2:1 rule
4 cc/kg/hr for first 10 kg 2 cc/kg/hr for next 10 kg 1 cc/kg/hr for subsequent kg
307
intussuseption
``` Air contrast barium enema diagnostic and therapeutic (do if high clinical suspicion) U/S Most common cause Colicky abdo pain bloody mucus Currant jelly stools vomitting ```
308
Pyloric stenosis
In first 3 weeks of life Palpable olive shaped epigastric mass Visible gastric peristaltic wave Diagnosed by ultrasound Non biliary vomitus Hypochloremic hypokalemic metabolic alkalosis
309
Fever in <1 month yr old
Blood Cx Urine Cx CSF cx (LP!)
310
If 30 days to 3 months w/u for fever
Blood cx, urine cx but only LP if looks toxic
311
Txt Meningitis
3 months | Strep pneumo, Neisseria, Hib; Ceftriaxone + vanco +/- Ampi for Listeria if over 50
312
Fever <1 month
Ampi + cefotaxime OR Ampi + gent
313
Red flags for pediatric diarrhea
``` <6 months Fever Blood in stool High vol diarrhea OR clinical signs of diarrhea Change in MS Recent antibiotic use (C Diff) ```
314
Chronic diarrhea without FTT diff'll
``` Lactose intolerance Osmotic diarrhea (fructose intolerance, fruit juice diarrhea) Cow's milk intolerance ```
315
Chronic diarrhea with FTT diff'll
``` Celiacs (>3 months) IBD (>3 yrs) Pancreatic insufficiency (Cystic fibrosis) Milk protein allergy Laxative abuse ```
316
Acute diarrhea diff'll
Infectious (viral/bacterial) R/O surgical problems -appendicitis -intussussuption (<1 yr)
317
Diagnosis lactose intolerance
``` >6 yrs: hydrogen breath test ellimination diet (use soy based infant formula) ```
318
General w/u diarrhea
``` Stool O/P Fat content C Diff Anti-TTG, IgA Sweat test Lactose breath test +/- upper GI series, small bowel follow-up/endoscopy (usually for chronic diarrhea) ```
319
When to use antibiotics in acute diarrhea (in immunocompetent pts)
Severe illness Persistent diarrhea with specific pathogen isolated on cx Do NOT use even if bloody stool and fever Most can be managed as outpatients in normal vitals and little danger of dehydration
320
Toddler's diarrhea txt
benign self limiting osmotic diarrhea due to malabsorption of disaccharides Four Fs: -adequate fiber -normal fluid intake -forty % dietary fat -no fruit juice Dx of exclusion if no evidence weight loss/electrolyte probe
321
FTT defn
-weight <80% expected weight for heigh and age
322
Peds hx
PMHX - pregnancy hx - APGAR scores - milestones - growth curve - med condition Fam Hx - short stature - genetic diseases Social - parents/siblings - stressors/coping
323
Adult vaccines
Strep pneumo >65 q 5 yrs if many med comorbidities Zoster vaccine >65 (pay) Influenza Q winter >65, all pregnant women
324
C5 radiculopathy
Motor: weakness shoulder abduction Reflex Bicep Sensory lateral shoulder lateral neck scapula
325
Axillary nerve damage
C5C6 root
326
C6 Root encompasses which peripheral nerves
Musculocutaneous (C5C6) Radial C5 Musculocutaneous nerve C5, C6 -innervates biceps; responsible elbow flexion Radial nerve C6 - innervates brachioradialis: elbow flexion - innervates extensor carpi radialis longus: wrist extension
327
Median nerve - nerve root - motor innervation - sensory innervation
Nerve root: C7-8, T1 Motor: weakness intrinsics of hands + thumb Wrist extension ``` Sensory: -Palmar surface: Index finger Middle finger radial 1/2 ring finger -Dorsal surface DIP index, middle and radial half ring ```
328
C8 radiculopathy
Motor: Intrinsics of hand Abd/add thumb Reflex Finger jerk Sensory: -ulnar forearm +ring/pinky (spares upper arm)
329
Ulnar nerve
C8T1
330
Radiculopathy vs Neuropathy
Radiculopathy - painful - parasthesia - sensory loss mild or absent Neuropathy - NOT painful - parasthesias not as common - sensory loss in patch area
331
Causes of radiculopathy
Disc herniation Meningioma L
332
Red flags neck pain
- neck pain associated with H/A, shoulder or hip girdle pain or visual symptoms in older pts (PMR vs GCA) - Fever/chills - weight loss - immunosuppression - Hx CA - IVDU
333
Diagnosis of cervical strain
Nonspecific diagnosis to describe injury to cervical paraspinal muscles, ligaments and spasm of neck and back muscles neck and trapezius pain No neuro symptoms <6 weeks duration
334
cervical spondylosis
***most common cause of acute and chronic neck pain - includes soft tissue, disk and degenerative bony lesions - changes in facet joints and laminal arches - can identify on plain radiograph (disk space narrowing, osteophytes)
335
Diff'll for neck pain
Neck strain Spondylosis Discogenic nerve entrapment Whiplash syndrome
336
Presentations of cervical spondylotic myelopathy
- pain in neck, subscapular, shoulder radiates to arm - lhermitte's sign: electric shock like sensation in neck radiating down spine into arms, produced by forward flexion of neck (could indicate myelopathy (herniation) OR MS) - numbness/parasthesias in arms - weakness
337
Non-spinal causes of neck pain
- inflammatory arthritis (ank spond) - infections; meningitis, pharyngeal abscess, herpes zoster - CA - CV; thoracic outlet obstruction, vertebral/carotid artery dissection, ACS - diabetic neuropathy
338
CN II
Visual acuity Pupils Visual fields Fundoscopy
339
Oculomotor nerves
``` CN III -levator palpebrae superioris -Medial rectus -superior rectus -inferior rectus: extorsion, elevates eye while in adducted position -inferior oblique CN IV (trochlear) --superior oblique: intorsion, depresses eye while in adducted position CN VI (abducens) -lateral rectus ```
340
Trigeminal nerve CN V
- Sensory V1-V3, afferent limb corneal reflex | - Motor: temporalis, masseter, petygoids, jaw jerk reflex
341
Facial nerve CN VII
Sensorimotor: muscles of facial expression, hyperacussis (stapedius), corneal reflex (efferent) Visceral sensory: taste anterior 2/3 Visceral motor: salivary and lacrimal glands
342
Vestibulococchlear CN VIII
Whiper baseball into ears and ask to repeat Rinne Weber
343
Rinne
Tuning fork against mastoid bone then in front of external ear Normal: continue to hear in front of ear indicating intact conductive hearing Abnormal: don't hear it in front of ear indicating problem with conductive hearing loss Air conduction = sensorineural hearing loss Bone conduction = conduction hearing loss
344
Weber
- Tuning fork in middle of head - A normal result is when the sound is the same in both ears - If the sound is louder in one ear, it is indicative of conductive hearing loss (CHL) in that ear or sensorineural hearing loss (SNHL) in the opposite ear. - if sensorineural hearing loss is preserved (i.e. bone conduction is preserved), then only conduction hearing -The reverse is also true. If the sound is quieter in one ear, it is indicative of SNHL in that ear or CHL in the opposite ear. If bone conduction is intact on both sides (therefore no SNHL), the patient will report a louder sound in the ear with CHL. This is because the ear with the CHL is only receiving input from the bone conduction and no air conduction, and the sound is perceived as louder in that ear. If air conduction is intact on both sides (therefore no CHL), the patient will report a quieter sound in the ear with the SNHL. This is because the ear with the SNHL is not receiving input from the bone conduction, and the sound is perceived as louder in the normal ear. Air conduction = sensorineural hearing loss Bone conduction = conduction hearing loss
345
Glossopharyngeal (CN IX) | Vagus CN X
Palatal elevation gag reflex vocal cord function swallowing
346
Hypoglossal CN XII
tongue muscle | Tongue deviates to side of the lesion
347
Accessory (CN XI)
Sternocleidomastoid: left SCM turns head right | Trapezius
348
C7 nerve root encompasses which peripheral nerves
Radial nerve | Posterior interosseos
349
Radial nerve innervates which muscle
Triceps: Elbow extension
350
Posterior interosseus innervates which muscle
Extensor digitorum communis: finger extension
351
C8T1 nerve root encompasses which peripheral nerve
Median | Ulnar
352
Median nerve innervates which muscle
Flexor pollicis longus: thumb flexion **look for thenar wasting Abductor policis brevis: thumb abduction Opponens pollicis: opposition
353
Ulnar nerve innervates which muscle
First dorsal interosseus: finger abduction | ***wasting in first dorsal webbed space
354
L2L3L4 nerve roots innervate which peripheral nerve
- Femoral nerve | - Obturator nerve
355
Femoral nerve responsible for what muscle movement
-Iliopsoas: hip flexion | Quadriceps: Knee extension (L3L4)
356
Obturator nerve responsible for what muscle movement
-Adductor muscles: hip adduction
357
L3L4 nerve roots innervate which peripheral nerve
- femoral (L3L4) | - Deep peroneal (L4)
358
Deep peroneal nerve responsible what muscle movement
L4 | -Tibialis anterior: Dorsiflexion
359
L5 nerve root innervates which nerves
Sciatic (L5S1) Tibial Superficial peroneal Deep peroneal
360
Sciatic nerve responsible what muscle movement
Gluteus maximus: hip extension (L5) | Hamstring muscles: knee flexion (S1)
361
Tibial nerve responsible what muscle movement
Tibialis posterior: ankle inversion (L5) | Plantarflexion (gastroc and soleus), S1
362
Superfical peroneal responsible what muscle movement
Peroneal muscles: ankle eversion
363
Deep perineal responsible what muscle movement
big toe extension
364
S1 nerve root innervates which peripheral nerve
Sciatic | Tibial
365
Sciatic nerve responsible what muscle movement
Hamstring: Knee flexion | Gluteus maximus : hip extension
366
Cauda Equina symptoms
``` Bowel or bladder dysfunction (overflow incontinence typically present) saddle anasthesia areflexia bilat sciatica leg weakness ``` Most commonly caused by tumor or massive midline disk herniation
367
Physical exam for sciatica
Straight leg raise Crossed straight leg raise Seated straight leg test (seated, knees flexed 90, leg is slowly raised extending knee; positive if symptoms distal to knee OR if symptoms abolished with knee flexion)
368
Diff'll back pain
-Lumbar strain -Degenerative = spondylosis -osteoperosis -Disc herniation (radiculopathy) -Spondylolisthesis -Spinal stenosis -Trauma/fractures -Congenital diseases (kyphosis, lordosis, scoliosis) -Malignant (MM, leuk/lymp, mets) -Infectious (abscess, osteomyelitis) -Inflammatory (ank spond, psoriatic spondylitis, IBD) -Referred pain (pelvic organs: prostatitis, endometriosis, chronic PID), renal pain (nephrolithiasis, pyelo), AAA, GI (pancreatitis, chole, perf ulcer)
369
Common disc herniations
L5S1 > L4L5
370
Spinal stenosis symptoms
Back pain transient parasthesias (tingling) in legs Ambulation induced pain localized to calf and distal lower extremity, resolving with rest (sitting or spine flexion)=neurogenic claudication **differentiate from vascular claudication by presence of good pulses)
371
Social aspects of back pain
- disability compensation? | - screening for depression
372
Key points for history back pain
- R/O red flags | - Asess social factors (compensation, depression)
373
P/E back pain
Inspection: -back, posture ROM -flex/ex Palpate -spinuous process, soft tissue Motor -strength legs Sensory -legs Vascular -pulses DRE/sphincter tone
374
L4L5 radiculopathy
need to find
375
Pheochromocytoma should be suspected in pts with...
Paroxysmal htn self-limited episodes of nonexertional palpitations, diaphoresis, headache, tremor or pallor -Htn triggered by beta blockers, MAOI -pts with adrenal incidentalomas, MEN, NF, vHL -W/U: urine metanephrines and abdo MRI
376
Suspect hyperaldosteronism if
- Spontaneously Hypokalemia - diuretic induced hypoK - resistant htn (>3 drugs) - concomitant incidentaloma - W/U: AM renin and aldosterone levels
377
W/U for pt presenting with htn
CBC (wbc infx, hg chronic disease) CHEM 7 (glucose DM, K, Creat) EKG (R/O end organ damage) Lipid profile (metabolic syndrome)
378
Medication that can increase BP
``` NSAIDS CORT/anabolic steroids Vasoconstricting/sympathomimetic decongestants Calcineuron inhibitors (cyclosporin, tacrolimus) EPO Antidepressants: MAOI, SSRI, SNRI Drugs (cocains, ETOH) Salt ```
379
Dysphagia PMHx
``` DM Autoimmune -sjogren Neuromuscular -PD -MG -Muscular dystrophy -MS Malignancy Surgery ```
380
Dysphagia
Difficulty swallowing, sensation food getting stuck after swallowing
381
Odynophagia
Pain on swallowing
382
Key questions for dysphagia
- Difficulty in initiating swallow (odynophagia) vs food getting stuck - Associated sx: choking, coughing, nasal regurgitation, change voice pitch - Solids, liquids, both - Intermittent vs progressive - Hx heartburn - Change in eating habits/diet
383
Diff'll dysphagia
Neuromuscular - DES - Scleroderma - Achalasia Mechanical - carcinoma - stricture/heartburn - lower esophageal ring
384
Odynophagia diff'll
Neuromuscular - CVA - MG - muscular dystrophy - Polymyositis Mechanical - tumors - Zenker's diverticulum - peritonsillar abscess/pharyngitis Functional -Xerostomia (dry mouth)
385
Progressive dysphagia solids + liquids
Scleroderma (if reflux symptoms) | Achalasia
386
Bird's beak on Ba swallow
Achalasia: failure of lower LES to relax (hiccups)=> obstruction distal esophagus Need endoscopy to R/O malignancy Motility studies for definitive diagnosis
387
Corkscrew on Ba swallow
Diffuse esophageal spasm
388
Progressive dysphagia solids
CA (Adeno vs SCC) if >50, wt loss Peptic stricture (heartburn)
389
Intermittent dysphagia solids
Lower esophageal ring | Eosinophilic esphagitis
390
Intermittent dysphagia solids and liquids
DES (chest pain)
391
GERD S and S
Non-esophageal - Chronic cough - wheezing - aspiration pneumonia - sore throat - Hoarseness - dental erosions Esophageal - heartburn - acid reflux - chest pain - dysphagia - odynophagia (rare)
392
Lifestyle modifications GERD
- weight loss - decreased spicy food/coffee - avoid eating before bed - Stop smoking/drinking
393
Diagnostic criteria for delirium (and qs to ask on hx)
-Disturbed consciousness (distractibility, inattention) -Change in cognition (memory deficits, language disturbance, disorientation, perceptual disturbance ex hall) -acute onset with fluctuating course -concomitant GMC (infx, ingestion/intox, metabolic endocrine/etc)
394
Dementia diagnostic criteria
Memory impairment + - aphasia - agnosia - apraxia - disturbed executive function Sign decline from previous level functioning -R/O GMC, depression/pseudodementia
395
Lab W/U delirium
``` CBC CHEM 10 LFT TSH Folate/B12 Tox screen U/A Blood cx +/- LP (may need CT head before) CXR CT head ```
396
Medications for dementia
Cholinesterase inhibitors -indicated for mild-mod AD Memantine (GABA antagonist) -mild symptomatic improvement severe dementia Antidepressants may be useful Antipsychotics to control sx (black box warning)
397
Acute urinary retention diff'll
Infex/Inflammation - Cystitis - prostatitis Structural - BPH - constipation - Tumors (bladder, pelvic mass) - urethral strictures - prolapse - stones Neuro - DM with peripheral neuropathy - MS/Parkinsons - Cauda equina Meds - anticholinergic - post op (opioids)
398
W/U acute urinary retention
``` -Chem 7 CBC U/A Cytology PSA ``` Imaging: renal U/S R/O hydronephrosis PVR +/- CT abdo/pelvis
399
When to refer to urologist for acute urinary retention
- pelvic radiation or surgery - pelvic pain - severe incontinence - severe LUTS - recurrent uro infx - neuro disease - abnormal prostate exam - hematuria - elevated PSA
400
Febrile seizure hx
``` NO CNS infx No systemic metabolic abnormality No hx previous afebrile seizures No development delay Normal head circumference No neuro abnormalities Normal vaccinations ```
401
Cause of febrile fever
Convulsion associated T>38 Recent infx (viral or bact) Recent immunization esp MMR, DTP
402
Polymyalgia rheumatica Dx
- Age > 50 - F>M - pain > 1 month in 2/3 areas: neck, shoulders, pelvic girdle - High index suspicion for development temporal arteritis (1/4 pts, examine temporal artery and retinal fundus) - High ESR/CRP - responds well low dose pred
403
Fibromyalgia
Pain 11/18 trigger points lasting at least 3 months in all four quadrants of body Suggest conservative therapy with physical activity, stress reduction, sleep improvement Low dose TCA OR pregabalin
404
Manic episode
``` DIG FAST Distractibility Insomnia Grandiosity Flight of ideas Activity/agitation (increased goal directed activity, sexual) Speech Thoughtlessness (buying sprees, sexual indiscretions) ```
405
Infantile colic
- Unexplained irritability and crying >3 hours/day and > 3 days/week for > 3 weeks in otherwise healthy well fed baby - 10% infants - etiology: lag in normal peristalsis, lack self soothing mechanisms - baby may be crying due to gas pains, too hot/cold, overstimulated, need to suck or be held - 10 days to 3 months of age;peaks 6-8 weeks - child may cry and pull legs up and passes gas after feeding - Management: parental relief and reassurance, hold baby, music, check diaper, car ride - meds don't work - in small percentage of cases elimination cow's milk from mother's diet useful - try casein hydroxylates formula
406
Schizophreniform disorder
- Same symptoms as schizophrenia but: - duration>1 month < 6 months - level of functioning may not be affected - onset may be more rapid than schizophrenia (which can be months) - prognosis overall better than Sz
407
Risk factors for child abuse
First time mother Young Mom Difficult child Lack of social/family support
408
CAP treatment
Healthy ppl, no antibiotics in previous 3 months -Clarithromycin (biaxin) 500-1000 mg PO x 7 days OR -Azithromycin (7 days) Presence comorbidities or antibiotics past 3 months - Levaquin 500 DIE 7-14 days OE 750 x 5 days - Moxi 400 mg DIE X 10 days OR -Amoxicillin or Amox-clav AND Clarithro/azithro
409
Investigations for ALL pts with HTN
- CBC - electrolytes (including creat, K, Ca) - Fasting glucose - Lipid profile - 12 lead ECG - U/A
410
Older lady with urinary incontinence; | history
Stress vs Urge incontinence ``` Stress; -pelvic prolapse/surgery -vaginal delivery -hypoestrogenic state -age -smoking Txt: -kegel -local estrogen vaginal therapy -vaginal pessary ``` Urge - urine loss associated with sudden urge to void "OAB" - R/O neuro causes (MS, DM, slipped disc) - frequency/urgency/nocturia/leakage - txt - lifestyle: caffeine, smoking cessation, regular coding schedules - Kegel - Meds: anticholinergics, TCA * **multichannel urodynamics gold standard but most cases can be diagnosed on history alone * **typical investigations: UA, Cx
411
ASCUS on Pap smear
if < 30, no HPV testing available - repeat cytology in 6 months - if Negative: repeat 6 months with routine testing - if ASCUS again => colposcopy If > 30 HPV-DNA testing -if Negative; routine testing -If positive: colposcopy
412
Anything above ASCUS - ASC-H (atypical squamous cell cannot exclude HSIL) - LSIL (low grade sq intraepithelial lesions) - HSIL (high grade sq intraepithelial lesions)
LSIL=CINI -observe with regular cytology Q 6 months Colposcopy if 2X positive Other lesions: Go straight to colposcopy
413
Cervical spine XR views
-lateral (most important) -Antero-posterior view -Odontoid peg view (open mouth view) +/- Swimmer's view if don't see T1
414
Cervical spine XR Lateral view; high points
-all vertebrae visible from T1-C1 -aligment; anterior line, posterior line, spinolaminar line -trace cortical outline of all bones to check for fractures -disc spaces (should be equal height) -prevertebral hematoma -
415
Cervical spine XR AP view; high points
- Aligment; lateral edges of Cspine are aligned - fractures less well seen on this view than lateral - spacing of spinuous processes (should be even) - surgical emphysema - pneumothorax
416
Cervical spine XR Odontoid/peg view high points
- need to see C1C2 | - distance between peg (odontoid) and lateral edge of C1 should be equal
417
Canadian CT head rules
Ct head required in pts with minor head injury if any one of findings present: -GCS < 15 at 2 hours after injury -suspected open or depressed skull fracture -signs of basal skull fracture (hemotympanum, racoon eyes, CSF otorrhea/rhinorrhea, Battle sign) -vomitting > 2 episodes Age > 65 Medium risk for brain injury on CT - amnesia before impact > 30 min - dangerous mechanism (pedestrian, occupant ejected, fall from elevation)
418
Ottawa ankle rules for ankle XR
Ankle XR required if there is pain in malleolar zone and any of the following - bone tenderness at posterior tip of medial OR lateral malleolus - inability bear weight both immediately AND in ED
419
Ottawa ankle rules for foot XR
Pain in midfoot zone and any of these findings - bone tenderness at base of 5th metatarsal OR navicular - inability to bear weight both immediately after AND in ED
420
L234 radiculopathy
Sensory: anterior thigh and course medially over lower leg with pain Reflex: patellar Motor: weakness hip ADduction, flexion and knee extension
421
L5 radiculopathy
MOST COMMON Sensory: lateral leg curving over dorsum of foot and first toe Motor: weakness ABDuction hip, dorsiflexion, inversion, eversion but preserved plantar fexion
422
S1 radiculopathy
Sensory: shooting pain to foot with sensory deficit along entire posterior leg and lateral foot Motor: weakness plantar flexion (but also hip extension and knee flexion)
423
S2S3S4 radiculopathy
Sensory: deficits straight down back of leg, perianal, perineal and radiating to back of leg sometimes Motor: weakness anal tone, urinary retention sexual dyfunction Reflex: bulbocavernosus reflexes diminished
424
capacity vs consent
Capacity = the degree to which one is able to understand the information relevant to a treatment decision and appreciate the reasonably foreseeable consequences of a decision or lack of a decision. (a question of degree) Competence = being able to understand information relevant to a treatment decision and to appreciate the reasonably foreseeable consequences of a decision or lack of a decision. (all or nothing)
425
Components of competence
four specific abilities should be assessed: 1) the ability to understand information about treatment; 2) the ability to appreciate how that information applies to their situation; 3) the ability to reason with that information; 4) and the ability to make a choice and express it.
426
somatoform disorders screen
How has your health been for most of your life? How have your pains affected your job, social life, relationships, and your life generally? Are you often unwell, how often do you visit the doctor? Do you worry that you have a serious illness? If a doctor tells you that there is nothing wrong, how does that make you feel? Do you believe him or her?
427
Physical exam consolidation
Consoildation increases transmission of sounds voice transmission - egophany (ee to ay) - bronchophony (enhanced transmission of spoken word 99) - whispered pectoriloquy (whisper 99 and heard well through stethoscope) Also increases - tactile femitus (99) - bronchial BS - crackles - dullness to percussion
428
TCA overdose medical management
- typically see QRS > 100; if so give bicarb amps/drips and aim for alkalemic blood gases - activated charcoal IF pt presents within 2 hour of ingestion AND can protect airway (do not intubate to give activated charcoal) - intubate if indicated - monitoring for first 24 hours - treat seizures with benzos NOT dilantin
429
Medications which cause complete heart block
Digitalis OD TCA OD b blocker CCB
430
Suicide attempt: is the pt safe to go home?
Is pt remorseful? Is there support network? What kind of attempt; cry for help or honest suicide attempt? Is the pt actively suicde/plan/means to accomplish? How many previous attempts Can proper follow-up be arranged?
431
Counselling pt with preeclampsia re worsening symptoms
Worsening signs - rapid weigjt gain - liver pain - visual disturbance - persistent headache/drowsiness - seizures
432
Differential for 3rd trimester vaginal bleeding
- placenta previa - bloody show - abruptio placenta - vasa previa (fetal bleed due to root vessels of umbilical cord overlying the cervical os; very dangerous to fetus Ask about - sex - trauma to abdomen (car accident) or sexual abuse
433
third trimmest vaginal bleeding; rule of thumb re vaginal exam
DO NOT DO VAGINAL EXAM until placenta previa has been ruled our by U/S
434
Quantifying fetal hemoglobin in third trimester hemorrhage
Apt test | Kleihauer-Betke (quantifies amount of fetal blood to guide amt of Rhogram to give)
435
Solitary pulmonary nodule
defined as < 3 cm (mass > 3 cm) Bottom line: if < 8 mm can watch and wait with serial scans If > 8 mm should do PET scan
436
Risk factors for child abuse
Environmental: social isolation, poverty, domestic violence Caregiver: substance abuse, parents abused, mental illness, poor social/vocational skills/below avg IQ Child factors: disability, difficult child (temperament, premature)
437
Clearing C spine
If high risk => radiography - age > 65 - dangerous mechanism - parasthesias If low risk factors AND able to rotate neck 45 degrees => no radiography (if any low risk factors are present OR if unable to move neck 45 degrees=> radiography) -simple rear end MVC -sitting in ER -ambulatory at any time -delayed onset back pain -absence of midline c spine tenderness
438
Sacroilitis test
``` Faber test (leg crossed and press down on crossed legs bilat) Compression test (pt on side with pillow between leg and press on hip joint) ``` If positive: pressure applied reproduces pain
439
Ankylosing spondylitis test
Schober | Lateral flexion
440
Skin sutures: Non-Absorbable sutures Non braided
Prolene Silk Nylon To use on skin for removal within 10 days (body) 7 days on face
441
Pap test
Start age 21 OR when sexually active | Screen Q2-3 years
442
GST PAID
``` Grandiosity Sleep (decreased need) Talkativeness Pleasurable activities, painful consequences Activities (goal directed) Irritability Distractibility ```

LMCC II (1 decks)

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