LMCC II Flashcards
Pregnancy Hx
-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
Gestational Age
weeks from the first day of last menstrual period
Estimated date conception (date when will give birth)
LMP + 7 days - 3 months
MSIGECAPS
- Mood (depressed)
- sleep (increased, decreased, early morning awakening)
- Interest
- Guilt/ worthlessness
- Energy
- concentration/ difficulty making decisions
- appetite/weight
- psychomotor activity
- suicidal ideation
MDD
- Requires 5 of MSIGECAPS over 2 week period
- 1/5 must be loss of interest or depressed mood
Health tips while pregnant
- abstinence from eton, smoking, drugs
- use of meds only after consulting MD
- healthy eating
Abortion age limits
- Latest in Canada is at 20 weeks
- preferably earlier at 16 weeks
Abortion medical options
<12 weeks: 12 weeks: prostaglandins (intra or extra amniotic) OR misoprostol
Surgical abortions
16 weeks: dilatation and evacuation, early induction of labour
Complications of abortion
- pain + discomfort commonly
- hemorrhage
- perforation of uterus
- laceration of cervix
- risk of infection/endometritis
- retained products of conceptions
Risk factors for breast cancer
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
preconception counselling supplementation
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
preconception counselling: risk modification
- lifestyle: balanced nutrition and physical fitness
- infection screening: toxo, rubella, CMV, hepatitis B, VDRL, Pap smear, gon/chlam, HIV, TB, varicella
Investigation first pregnancy visit
CBC,blood group and type, Rh antibodies
Infectious screening
Urine C and S, screen proteinuria
Pelvic exam; Pap smear, chlam/gono, bacterial vaginosis
Air travel when pregnant
Allowed into second trimmest, discouraged after 36 weeks
Exercise during pregnancy absolute contraindications
- 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
Pre-natal visit: asess at every visit
- 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
Symphysis pubic height
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
Fetal movements
First noticed at 18-20 weeks
Prenatal screening: high risk population screening test
- Thalassemia (mediterranean, south east asian)
- Sickle cell (african, caribbean)
- Cystic fibrosis
- Tay Sachs
- Fragile X syndrome
T2DM in pregnancy fact sheet
- 2-4% pregnancies complicated by diabetes
- diagnosed 24-28 weeks
Treatment for pregnancy induced DM
- 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
T2DM and labour
- monitor glucose q1hr
- pt should be on insulin and dextrose drip
- 3.5-6.5
Risk factors for gestational diabetes
- age >25
- obesity
- ethnicity (aboriginal, hispanic, asian, african)
- Fhx of DM
- previous hx GDM
- previous child with birthweight > 4 kg
GDM and long term prognosis
-50% risk of developing DM in next 20 yrs
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
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)
PET investigations
MAHA picture (CBC, D-dimer, fibrinogen, blood smear, hap to, bill)
LFT
Creat
Thrombocytopenia < 100
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
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
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
Eclampsia defn
PET + CNS involvement (decreased LOC and seizures)
HELLP syndrome
variant of PET
- hemolysis
- elevated LFT
- low platelets
4 types of pregnancy-related hypertensive disorders
- preeclampsia/eclampsia/hellp
- Chronic/pre-existing htn
- pre-eclampsia superimposed upon chronic/pre-existing htn
- gestational hypertension
chronic pre-existing htn
- > 140/90
- pre-dates pregnancy OR present before 20 weeks and persists longer than 12 weeks post partum
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
Gestational htn
-htn without proteinuria or signs of PET that develops > 20 weeks and should resolve within 12 weeks post partum
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
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
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
PET increases fetal risk of
- malnutrition
- hypoxia
- IUGR
- prematurity
- death
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
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
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
PE on EKG
S1Q3T3
Deep S in lead I
Q wave lead III
T wave lead III
Hampton hump
Peripheral wedge shaped opacity
Westermark sign
Focus of oligemia; secondary to proximal pulmonary artery dilatation and peripheral vasoconstriction (hypoxic)
Life threatening causes of CP
MI Tamponade Tension pneumothorax Aortic dissection PE Esophageal rupture
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
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
MMR
12, 18 months
Pneumo-C
pneumococcal 7 valent conjugated vaccine
2, 4, 6, 15
Men-C
Meningococcal C conjugate vaccine
2, 4, 6, OR 12
Var
15 months
Hep B
0, 1, 6 months
Vaccines at 2, 4, 6
DTaP-IPV + 18 + teens + adult
Men-C (6 or 12)
Pneu-C + 15 months
HiB + 18
Hib
2, 4, 6, 18
Live vaccines
MMR
Varicella
**can give to pts with CD4 > 200
Contraindications to all vaccines
moderate to severe illness +/- fever (common URTI fine)
allergy to vaccine component (yeast or gelatin?)
MMR contraindications
- allergy egg or neomycin
- pregnancy
- immunocompromised (except healthy HIV positive children)
Varicella contraindications
- Pregnancy or planning to get pregnant within 3 months
- anaphylaxis
HPV
between age 9-26 at 0, 2, 6 months
Contraindications to pertussis component
Hx of progression neuro disorder or epilepsy
Somatoform disorder (diseases)
Conversion Somatization Pain disorder Hypochondriasis Body dysmorphic disorder
Malingering
Intentional production of false or grossly exaggerated physical or psych symptoms motivated by external reward (missing work)
Factitious disorder
intention production or feigning of physical or psych signs or symptoms to assume the sick role where external incentives are absent
Conversion disorder
symptoms affecting voluntary motor or sensory function that mimic neuro disorder
-symptoms preceded by stress or conflict
(blindness, inability to speak, numbness)
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
Pain disorder
pain as primary symptom
Hypochondriasis
- preoccupation with fear of having serious disease based on misinterpretation of bodily signs or symptoms
- belief is not delusional
Body dysmorphic disorder
preoccupation with imagined defect in appearance or excess concern around slight anomaly; usually related to face
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
Joints of ankle
Tibio-talar: dorsi and plantar flex
Subtalar: talar-calcenal joint
Transverse tarsal: forefoot
Talar drawer sign
laxity indicates anterior talo-fibular ligament rupture
talar tilt
transverse tarsal joint; laxity indicates tear in medial or lateral tendons (calcaneo-fibular or deltoid)
Treatment of sprains
RICE: Rest Ice Compression Elevation
Grading ankle sprain
1: stretched ligament fiber
2: partial tear with pain and swelling
3: complete ligament separation
CAGE questionnaire
Cut back
people Annoyed
Guilty
Eye-opener
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
Special test for appendicitis
Psoas sign
Obturator sign
Rosving’s
Obturator sign (appendicitis)
hips and knees flexed
hold ankle and knee
internal rotation
-to identify a pelvic appendix
Psoas sign
raise leg against resistance
Rosving’s sign
palpate LLQ which produces RLQ pain
Approach to neonatal jaundice
Conjugated vs Unconjugated
Hemolysis vs no hemolysis
If hemolysis; Coombs + or negative
Conjugated Hyperbilli is ALWAYS PATHOLOGICAL
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
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
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
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
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
Txt of hyperbillirubinemia
If unconjugated
- phototherapy
- exchange RBC
W/U of hyperbilli
- LFT
- neonatal and maternal blood type
- Coombs
- Blood smear
- CBC+ retics
- septic w/u +/- CSF
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
Differential for microscopic hematuria in adults
CA Stones Infection GN BPH
Psych history
Past psychiatric hx -suicide attempts -hospitalizations -pharmacology/ECT Past medical/surgical hx (head trauma, seizures) Family psychiatric hx
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
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)
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)
Yeast infection
- cottage cheese d/c
- erythematous/pruritic
- high pH R/O yeast infection
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
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
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
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
Reflex grading
0-no reflex 1-trace reflex 2-normal reflex 3-very brisk 4-clonus
Hoffman reflex
Upper motor Babinski
Flick index finger downwards and watch for reflex flexion of thumb
C4 dermatome
below mandible to clavicle (neck anterior and posterior)
C5 dermatome
Strip on medial arm not including hand
C6 dermatome
Strip on external arm (lateral to C5) including thumb
C7 dermatome
Strip on outer arm including index and middle finger
C8 dermatome
trip on lateral arm including elbow and ring and pinky fingers
muscles innervated T1
Hand intrinsics
Adduction of fingers
Adduction/abduction of thumb (involves T1 and C8)
Muscles innervated by C5
Deltoids
Biceps
Weakness
- shoulder abduction
- elbow flexion
Muscles innervated C6
Biceps
Wrist extensors
Weakness
- flexion
- wrist extension
Muscles innervated C7
Triceps
Wrist flexors
Finger extension
Weakness
- triceps
- wrist flexion
Muscles innervated C8
Finger intrinsics
Thumb ad/abduction (C8/T1)
Weakness hand grip
Thumb abd/adduction
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
Radial nerve sensory innervation
Dorsal aspect of hand including thumb and proximal 1/2 index and middle
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
Motor innervation median nerve
thenar muscle
flex at metacarpophalangeal joints of index and middle finger
motor innervation of ulnar nerve
flexion/adduction wrist
flexion fingers
intrinsic muscles of fingers
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
Tinel’s sign
tap on palmar surface of wrist + if elicits shooting parasthesias in median nerve distn
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
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
Blood tests Thrombocytopenia
R/O plt clumping CBC, coags, LFT Blood smear Hemolytic w/u R/O infection (HIV, Hep)
TXT of BPH
Proscar (finasteride) (5 alpha reductase blocker)
Flomax (alpha blocker)
Referral to urology for TURP
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
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
Simple febrile seizures
- last less than 15 minutes
- have no focal features
- occur once in a 24-hour period.
Complex febrile seizures
- last >30 mins
- focal neuro symptoms
- occur >1 in 24 hours
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
W/U febrile seizures
- Chem 7/CBGM
- CBC
- Cultures
- imaging with CT/EEG indicated only in specific situations
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
Dysphagia solids vs liquids
Solids indicate mechanical obstruction
Liquids indicate neuromuscular dysfunction (often occurs swallowing either liquids or solids)
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
W/U esophageal dysphagia
Barium swallow (diagnose stricture or achalasia) Manometry if concern re achalasia Endoscopy
Secondary causes of Htn
Primary renal disease Vascular -Renovascular disease (RAS) -Coarctation aorta Endo -Renin/Aldo -Hypercortisolism -Pheochromocytoma -Hyperthyroidism
Test coarctation aorta
BP UE>LE
brachial-femoral delay
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
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
Diagnosis HTN on ABPM
awake BP >135/85
OR
mean 24 hour BP >130/80
Examples of target organ damage in HTN
- CVA
- Vascular dementia
- htn retinopathy
- LV dysfunction/hypertrophy
- CAD/angina/CHF
- renal disease/albuminuria
- PAD/claudication
Hx of extra-intestinal manifestations of IBD
- iritis/uveitis
- arthritis
- mouth ulcers
- anal ulcers
- skin lesions
- kidney stones
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
Arcus senilis
evidence of familial hypercholesterolemia in the eyes
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
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)
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
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
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
Continuous murmur
begins in systole and continues through diastole without interruption, encompassing S2
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
Diff’ll holosystolic murmur
MR
TR
VSD
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
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)
VSD
holosystolic
loud, can be associated with thrill
LL sternal border
Late systolic murmur
MVP
TVP
Ischemic MR
MVP
- late systolic
- diaphragm
- apex
- -usually preceded by single or multiple clicks
- murmur increases with increasing preload (squatting, elevation legs, hand grip)
early diastolic murmur
AR
Pulmonic regurgitation
Mid diastolic murmur
MS
TS
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
Abrupt standing as it portends to heart murmurs
Decreases venous return to heart
Decrease intensity AS
Decrease MR/TR
Increases HCM
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)
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
Valsalva
Decreases venous return to both right and left ventricle
- Decreases AS, MR and TR
- increases HCM (decrease LVOT with decrease venous return)
hand grip
increase SVR, increase LV volume
Most useful to differentiate AS v MR
AS: decrease
MR: increase
AS
- systolic
- RUSB
- harsh
- crescendo/decrescendo
- radiates carotids/clavicle
- musical radiation to apex (gallaverdin)
OPQRST hx
Onset Progression/provoking Quality Radiation Severity Timing Relieving/exacerbating
Hx of spinal stenosis
Pain worse with activity, resolves with rest
Pain worse lying down
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
Low back pain history
- OPQRST
- Neuro sx: weakness, parasthesias
- bladder/bowel incontinence
- B symptoms
- Infectious sx
- trauma
- arthralgias, skin lesions
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
Quads
L234
Hamstrings
L4L5S1S2
plantar flexion: Anterior tibili
L4L5
Toe extension
extensor hallucis longus
L5
Ankle eversion
S1
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
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)
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
Back surface anatomy
PSIS (posterior, superior iliac spine) corresponds L4L5
Of NOTE: cord ends at L1; below is caudal equine
Benign causes LBP
Irritation paraspinal muscles, ligaments or vertebral body articulations
Characterized by no radiation, worse with activity, improving with rest
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
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
Walking on toes mediated by
S1 root
L5 radiculopathy sx
Radiation from buttock to lateral calf
Numbness medial dorsum of foot (including web of great toe)
-weakness ankle dorsiflexion
S1 radiculopathy Sx
Radiation posteriorly down leg to heel (lateral)
Lateral foot numbness
Ankle plantar flexion weakness
Decreased ankle jerk
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
Pain on flexion of back indicates
discogenic pain
Pain on extension of back indicates
facet joint pain
When to suspect malingering with LBP
pt claims to be unable to bend from standing position but able to extend knees from sitting position
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
Brudzinski sign
Pt supine
Lift head off examining table
Positive if pt flexes hip and/or knees
Developmental milestones
2 months
- smiles
- coos
- recognizes parents
- track
- when prone can extend arms forward +/- hold head up
Developmental milestones
4 months
- laughs
- rolls over
- responds to voice
- reaches and grabs stuff and puts in mouth
Developmental milestones
6 months
- tripod sit
- babbles
- stranger anxiety/object permanence
- ulnar grasp
Developmental milestones
9 months
- Pulls to stand, crawls
- mama/dada
- finger-thumb grasp
- peek-a-boo
Developmental milestones
12 months
- walks
- pincer grasp
- 2 words
Developmental milestones
15 months
- walks without support
- draws line
- jargon
Developmental milestones
-18 months
- climbs steps
- follows simple commands (sit down)
- drinks from cup, eats with spoon
Developmental milestones
24 months
- 2 word sentences
- understands 2 step commands
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
Birth weight
Loss up to 10% in first 7 days normal
Neonate should regain all of birth weight by day 10
Hip flexors
L2 largely
Amenorrhea, types
Primary
Secondary; most common
Primary amenorrhea defn
Absence of menses AND secondary sexual characteristics by age 14
OR
absence of menses by age 16 if sex characteristics present
Secondary amenorrhea definition
Absence of menses for >3 cycles (or >6 months) after menarche
- more common
- most common case: pregnancy
Oligomenorrhea
vaginal bleeding is irregular and light at intervals > 35 days
PCOS common cause
GTPAL
gravita (#pregnancies) Term Pre-term Abortions Living
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
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
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
Oligomenorrhea, differential (similar to secondary amenorrhea)
Thyroid
PCOS
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
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)
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)
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))
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
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
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
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
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
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
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
Protective factors for breast cancer
Brast feeding
Physical activity
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
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
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
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)
Asthma triggers
URTI Pets Smoker/smoke in house cold weather? (helps in assessment of whether asthma on differential)
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
Diagnosis asthma on PFT
FEV1/FVC (actual ratio, not predicted)
<0.7 means obstruction
FEV1 percent predicted indicates severity of asthma
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
Treatment of atopic dermatitis
steroid cream +/- referral to derm
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)
Pyramid treatment asthma
SABA PRN
ICS + SABA PRN
LABA + ICS + SABA PRN
then could add leukotriene receptor antagonist (montelukast) then eventually oral glucocorticoids
Psychosis differential
- Schizophreniform disorders
- Affective disorders
- Personality disorders
- general medical condition (hypercalcemia, delirium, glucocorticoids)
- intoxication
Schizophreniform disorders
- schizophrenia
- schizoaffective disorder
- delusional disorder
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
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
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
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)
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
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
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)
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
Consequences of PID
Hydrosalpinx (damage fallopian tubes)
Chronic pelvic pain (30%)
infertility
ectopic pregnancy
Causes of pelvic pain in pregnancy
Spontaneous abortion
Ruptured ectopic
Risk factors for spontaneous abortion
Increasing maternal age
Previous spontaneous abortion (risk of miscarriage in future pregnancy 43% after >3 consecutive miscarriages)
Maternal smoking
Classic presentation spontaneous abortion
Amenorrhea
Vaginal bleeding
Pelvic pain
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
Ruptured ectopic classic symptoms
6-8 weeks after last normal menses
abdo pain/amenorrhea/vaginal bleeding
normal pregnancy discomforts
Breast tenderness
frequent urination
nausea
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)
bhcg must be what to visualize gestational sac by TV U/S
1500-2000
Can be seen as early as GA 5 weeks
Post menopausal bleeding
Endometrial atrophy
Endometrial carcinoma
Meds (HRT)
When NOT to perform a vaginal exam
women in 3rd trimester of pregnancy: risk of causing separation of placental previa
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
W/U bleeding pregnant patient
CBC (hg, plt)
Blood type + X match, Rh status
R/O coagulopathy: Coags, D-Dimer, Fibrinogen, blood smear
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
Risk factors for endometrial cancer
Increasing age Tamoxifen therapy Early menarche Late menopause Nulliparity PCOS Obesity DM Estrogen secreting tumor Family history
Irregular bleeding suggests
ovulatory dysfunction
Often extremes of reproductive age
PCOS
Endocrine disorder (thyroid, hyper prolactinoma)
Intermenstrual bleeding
Endometrial polyps
Contraception
Endometrial hyperplasia/CA
Endometritis or PID
Heavy menstrual bleeding
Uterine leiomyas
Adenomyosis
Related to CSection
Bleeding disorder
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
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
Tox history
How much
***WHEN
WHAT
Suicidal intention (will need psych consult after)
Universal toxidrome antidote
TONG Thiamine Oxygen Naloxone Glucose
Things to not forget in overdose pts
R/O hypoxia R/O hypoglycemia Consider Cspine trauma Consider meningitis R/O brain bleed (pupils, DTR)
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
Anticholinergic OD substances
TCA
Antipsychotics
Antiparkinsonian
Cholinergic toxidrome
Lacrimation Salivation Sweating Urination Diarrhea Bradycardia
Cholinergic OD substances
organophosphate insecticides
Sarin nerve gas
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
neuroleptic malignant syndrome signs and symptoms
Cognitive
-AMS; delirium progressing to lethargy, stupor, coma
Neuromuscular
- tremor
- rigidity
- shuffling gait
Autonomic
- labile BP
- hyperthermia
- tachycardia
Malignant hyperthermia
appears after general anasthesia with inhaled anesthetic OR Succinylcholine
Serotonin syndrome drug causes
SSRI
TCA
MAOIs
NMS causes
Antipsychotics (typical and atypical)
Withdrawal from parkinsonian meds (dopamine agonists; withdrawal results in acute depletion of dopamine)
Blood tests in NMS
Muscle damage and necrosis
- CK
- LDH
- AST
- ALT
Cell necrosis
- hyperkalemia
- hyperphosphatemia
- hyperuricemia
- hypocalcemia
- myoglobulinuria can lead to renal failure
Txt NMS
supportive cooling blankets Antipyretics Aggressive fluid resuscitation Alkalinization of urine can help ARF and enhance excretion myoglobulinuria
Tylenol toxicity
clinically silent within first 24 hours then evidence of hepatic toxicity
ASA toxicity
Hyperventilation (deep, rapid) Hyperthermia Tinnitis AMS ABG; metabolic acidosis with respiratory alkalosisexamp
Acute toxidrome labs
pregnanc test EKG Chem 7 ABG + Lactate Tox screen serum osmolality CK Ketone CT head
Management Anticholinergic toxidrome
Cardiac monitor (arrhythmias!) Activated charcoal Call poison control Benzos to control agitation If asymptomatic monitor for at least 6 hours
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
Tylenol toxicity treatment
Normogram (*time of ingestion crucial)
activated charcoal if within 4 hours
NAC
Prophylax with anti-nausea meds
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)
Acute dystonic reaction Txt
Benzaprine 2 mg PO/IV daily
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)
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
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
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
ATLS approach
ABCDE Airway Breathing Circulation Disability (GCS + pupils) Exposure and environmental control
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
Airway assessment trauma
Look incr WOB, cyanosis, secretions
Assess difficulty of airway (teeth, deformities, edema)
Trachea midline
Feel subcutaneous emphysema
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
GCS components
Eye opening (4) Verbal response (5) Motor response (6) Total score out of 15
GCS eye opening
spontaneous 4
To speech 3
To pain 2
No response 1
GCS verbal response
oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1
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
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
Disability (as part of ATLS)
GCS + pupils
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
Get CT C spine if any of five are present
- Neuro deficits, focal
- spine tenderness, midline
- AMS
- intoxication
- distracting injury
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
Contraindications to NGT in trauma
Basal skull fracture
Esophageal stricture or bleeding diathesis
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
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
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
Fever in <1 month yr old
Blood Cx
Urine Cx
CSF cx (LP!)
If 30 days to 3 months w/u for fever
Blood cx, urine cx but only LP if looks toxic
Txt Meningitis
3 months
Strep pneumo, Neisseria, Hib; Ceftriaxone + vanco +/- Ampi for Listeria if over 50
Fever <1 month
Ampi + cefotaxime
OR
Ampi + gent
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)
Chronic diarrhea without FTT diff’ll
Lactose intolerance Osmotic diarrhea (fructose intolerance, fruit juice diarrhea) Cow's milk intolerance
Chronic diarrhea with FTT diff’ll
Celiacs (>3 months) IBD (>3 yrs) Pancreatic insufficiency (Cystic fibrosis) Milk protein allergy Laxative abuse
Acute diarrhea diff’ll
Infectious (viral/bacterial)
R/O surgical problems
-appendicitis
-intussussuption (<1 yr)
Diagnosis lactose intolerance
>6 yrs: hydrogen breath test ellimination diet (use soy based infant formula)
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)
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
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
FTT defn
-weight <80% expected weight for heigh and age
Peds hx
PMHX
- pregnancy hx
- APGAR scores
- milestones
- growth curve
- med condition
Fam Hx
- short stature
- genetic diseases
Social
- parents/siblings
- stressors/coping
Adult vaccines
Strep pneumo >65 q 5 yrs if many med comorbidities
Zoster vaccine >65 (pay)
Influenza Q winter >65, all pregnant women
C5 radiculopathy
Motor: weakness shoulder abduction
Reflex
Bicep
Sensory
lateral shoulder
lateral neck
scapula
Axillary nerve damage
C5C6 root
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
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
C8 radiculopathy
Motor:
Intrinsics of hand
Abd/add thumb
Reflex
Finger jerk
Sensory:
-ulnar forearm +ring/pinky
(spares upper arm)
Ulnar nerve
C8T1
Radiculopathy vs Neuropathy
Radiculopathy
- painful
- parasthesia
- sensory loss mild or absent
Neuropathy
- NOT painful
- parasthesias not as common
- sensory loss in patch area
Causes of radiculopathy
Disc herniation
Meningioma
L
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
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
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)
Diff’ll for neck pain
Neck strain
Spondylosis
Discogenic nerve entrapment
Whiplash syndrome
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
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
CN II
Visual acuity
Pupils
Visual fields
Fundoscopy
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
Trigeminal nerve CN V
- Sensory V1-V3, afferent limb corneal reflex
- Motor: temporalis, masseter, petygoids, jaw jerk reflex
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
Vestibulococchlear CN VIII
Whiper baseball into ears and ask to repeat
Rinne
Weber
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
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
Glossopharyngeal (CN IX)
Vagus CN X
Palatal elevation
gag reflex
vocal cord function
swallowing
Hypoglossal CN XII
tongue muscle
Tongue deviates to side of the lesion
Accessory (CN XI)
Sternocleidomastoid: left SCM turns head right
Trapezius
C7 nerve root encompasses which peripheral nerves
Radial nerve
Posterior interosseos
Radial nerve innervates which muscle
Triceps: Elbow extension
Posterior interosseus innervates which muscle
Extensor digitorum communis: finger extension
C8T1 nerve root encompasses which peripheral nerve
Median
Ulnar
Median nerve innervates which muscle
Flexor pollicis longus: thumb flexion
**look for thenar wasting
Abductor policis brevis: thumb abduction
Opponens pollicis: opposition
Ulnar nerve innervates which muscle
First dorsal interosseus: finger abduction
***wasting in first dorsal webbed space
L2L3L4 nerve roots innervate which peripheral nerve
- Femoral nerve
- Obturator nerve
Femoral nerve responsible for what muscle movement
-Iliopsoas: hip flexion
Quadriceps: Knee extension (L3L4)
Obturator nerve responsible for what muscle movement
-Adductor muscles: hip adduction
L3L4 nerve roots innervate which peripheral nerve
- femoral (L3L4)
- Deep peroneal (L4)
Deep peroneal nerve responsible what muscle movement
L4
-Tibialis anterior: Dorsiflexion
L5 nerve root innervates which nerves
Sciatic (L5S1)
Tibial
Superficial peroneal
Deep peroneal
Sciatic nerve responsible what muscle movement
Gluteus maximus: hip extension (L5)
Hamstring muscles: knee flexion (S1)
Tibial nerve responsible what muscle movement
Tibialis posterior: ankle inversion (L5)
Plantarflexion (gastroc and soleus), S1
Superfical peroneal responsible what muscle movement
Peroneal muscles: ankle eversion
Deep perineal responsible what muscle movement
big toe extension
S1 nerve root innervates which peripheral nerve
Sciatic
Tibial
Sciatic nerve responsible what muscle movement
Hamstring: Knee flexion
Gluteus maximus : hip extension
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
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)
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)
Common disc herniations
L5S1 > L4L5
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)
Social aspects of back pain
- disability compensation?
- screening for depression
Key points for history back pain
- R/O red flags
- Asess social factors (compensation, depression)
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
L4L5 radiculopathy
need to find
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
Suspect hyperaldosteronism if
- Spontaneously Hypokalemia
- diuretic induced hypoK
- resistant htn (>3 drugs)
- concomitant incidentaloma
- W/U: AM renin and aldosterone levels
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)
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
Dysphagia PMHx
DM Autoimmune -sjogren Neuromuscular -PD -MG -Muscular dystrophy -MS Malignancy Surgery
Dysphagia
Difficulty swallowing, sensation food getting stuck after swallowing
Odynophagia
Pain on swallowing
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
Diff’ll dysphagia
Neuromuscular
- DES
- Scleroderma
- Achalasia
Mechanical
- carcinoma
- stricture/heartburn
- lower esophageal ring
Odynophagia diff’ll
Neuromuscular
- CVA
- MG
- muscular dystrophy
- Polymyositis
Mechanical
- tumors
- Zenker’s diverticulum
- peritonsillar abscess/pharyngitis
Functional
-Xerostomia (dry mouth)
Progressive dysphagia solids + liquids
Scleroderma (if reflux symptoms)
Achalasia
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
Corkscrew on Ba swallow
Diffuse esophageal spasm
Progressive dysphagia solids
CA (Adeno vs SCC)
if >50, wt loss
Peptic stricture
(heartburn)
Intermittent dysphagia solids
Lower esophageal ring
Eosinophilic esphagitis
Intermittent dysphagia solids and liquids
DES (chest pain)
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)
Lifestyle modifications GERD
- weight loss
- decreased spicy food/coffee
- avoid eating before bed
- Stop smoking/drinking
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)
Dementia diagnostic criteria
Memory impairment +
- aphasia
- agnosia
- apraxia
- disturbed executive function
Sign decline from previous level functioning
-R/O GMC, depression/pseudodementia
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
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)
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)
W/U acute urinary retention
-Chem 7 CBC U/A Cytology PSA
Imaging: renal U/S R/O hydronephrosis
PVR
+/- CT abdo/pelvis
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
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
Cause of febrile fever
Convulsion associated T>38
Recent infx (viral or bact)
Recent immunization esp MMR, DTP
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
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
Manic episode
DIG FAST Distractibility Insomnia Grandiosity Flight of ideas Activity/agitation (increased goal directed activity, sexual) Speech Thoughtlessness (buying sprees, sexual indiscretions)
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
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
Risk factors for child abuse
First time mother
Young Mom
Difficult child
Lack of social/family support
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
Investigations for ALL pts with HTN
- CBC
- electrolytes (including creat, K, Ca)
- Fasting glucose
- Lipid profile
- 12 lead ECG
- U/A
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
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
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
Cervical spine XR views
-lateral (most important)
-Antero-posterior view
-Odontoid peg view (open mouth view)
+/- Swimmer’s view if don’t see T1
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
-
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
Cervical spine XR Odontoid/peg view high points
- need to see C1C2
- distance between peg (odontoid) and lateral edge of C1 should be equal
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)
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
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
L234 radiculopathy
Sensory: anterior thigh and course medially over lower leg with pain
Reflex: patellar
Motor: weakness hip ADduction, flexion and knee extension
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
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)
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
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)
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.
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?
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
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
Medications which cause complete heart block
Digitalis OD
TCA OD
b blocker
CCB
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?
Counselling pt with preeclampsia re worsening symptoms
Worsening signs
- rapid weigjt gain
- liver pain
- visual disturbance
- persistent headache/drowsiness
- seizures
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
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
Quantifying fetal hemoglobin in third trimester hemorrhage
Apt test
Kleihauer-Betke (quantifies amount of fetal blood to guide amt of Rhogram to give)
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
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)
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
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
Ankylosing spondylitis test
Schober
Lateral flexion
Skin sutures:
Non-Absorbable sutures
Non braided
Prolene
Silk
Nylon
To use on skin for removal within 10 days (body) 7 days on face
Pap test
Start age 21 OR when sexually active
Screen Q2-3 years
GST PAID
Grandiosity Sleep (decreased need) Talkativeness Pleasurable activities, painful consequences Activities (goal directed) Irritability Distractibility
