midterm Flashcards

Question

myocarditis

Answer 1

-assoc with pericarditis -usually viral cause -> cruzii aka CHAGAS MCC) -drugs, toxins, immune, idiopathic -myalgias, joint pain -chest pain -HF sx -fever, tachy -dysrhythmias -sudden death

Answer 2

-Becks triad- muffled heart sounds, JVD, hypotension -pulsus paradoxus -CXR- water bottle heart (chronic) -> normal if acute -300ml until you see on CXR -ECG- low voltage, electrical alternans -US- swinging heart, effusion, RV diastolic collapse!!! -Acute tamponade tx: -ABCs, IV, monitor, ECG, O2 -FLUIDS! -> preload dependent (avoid ventilation bc of this) -Emergent pericardiocentesis- unstable -stable- guided pericardiocentesis or pericardial window

Answer 3

-Nonruptured: -50% Asymptomatic! -> Incidental finding -pulsatile mass -lower back pain -Ruptured: -!!!ABDOMEN (80%) BACK & FLANK (60%), OR GROIN (22%) -Triad (<50%) -!Sudden Abdominal/back pain + Hypotension + Pulsatile abdominal mass!! -syncope alone (rare) -Lightheadedness or dizziness, Sweating, Clammy skin -Rare- pulse deficit, or lower limb ischemia -US: -dilated aorta - measure from outside wall to outside wall (avoids false lumen) -cant tell you if ruptured or not bc blood goes retroperitoneal -> cant detect dissection -diameter >=3cm or >50% aortic diameter proximal to dilation -Tx: -3-5cm - serial US ->5cm - referral to repair w/ open surgery or endovascular repair within 3-5 days -SUSPECTED RUPTURE: -RESUSCITATE -!!!surgical consult!!!!, 2 IV, fluids, type and cross, EKG -massive transfusion protocol

Answer 4

-!!Periumbilical or epigastric pain initially -> 4-48 hrs -> RLQ -!Fever (low grade) -N/V (typically after pain started!!!!)!*- GASTRITIS IS BEFORE -Pain !worse w/ movement! -CHILDREN: Diarrhea, Limp, Anorexia, nausea -ELDERLY: late presentation masking of VS -Retrocecal appendix -> right flank / low back -Retroileal appendix -> testicle, suprapubic area, or cause dysuria -Low appendix -> left sided or rectal pain -Pregnant -> RLQ or RUQ pain -> due to enlarged uterus -significant pain -> decreased pain -> perforation -US- 1st choice for kids and pregnant- >6mm or >2mm wall -!!CTAP w/ IV contrast- >7mm, mural enhancement, stranding - best

Answer 5

-Typically normal -Possible findings: -Mild pyuria (WBCs in urine) -Mild hematuria -due to irritation of right ureter, especially if retrocecal -differentiates from UTI and nephrolithiasis -Culture- Not typically needed

Answer 6

-appendicitis -ectopic pregnancy -ovarian torsion -testicular torsion -diverticulitis -meckels diverticulum -inguinal hernia -ovarian cyst rupture -PID -psoas abscess -TOA -ureteral calculi

Answer 7

-Biliary colic- <6hrs and less severe -intermittent -no fever, normal labs, gallstones with no inflammation -pain control, elective cholecystectomy -CHOLECYSTITIS: -Fat, female, fertile, forty -pain after eating >6 hrs -± Kehr’s sign -Fever, N/V, RUQ TTP -!Murphy’s sign -Voluntary guarding -stones + inflammation -Dx- -Labs: High WBC, ALP -US 1st line: -Gallstone w/ shadowing -Pericholecystic fluid -!GB wall >3mm -Sonographic murphys sign -GB distension (diameter >5cm, length >10cm) *if dilated CBD, consider choledocholithiasis* -Tx: -analgesics -IV antibiotics -Lap cholecystectomy

Answer 8

-gallstones in CBD -post prandial, N/V -!AND EXTRAHEPATIC CHOLESTASIS: -jaundice and itching -pale stool/dark urine -Dx: LFTs, RUQ US -high bilirubin, ALP, GGT, AST/ALT -Tx: MRCP -> ERCP, cholecystectomy

Answer 9

-ABNORMAL LIPASE/AMPLYASE -gallstone obstructs ampulla of vater -> inflammation of pancreas -epigastric pain radiating to back -maybe jaundice -Dx: -US- pancreatic inflammation -Tx: supportive -ERCP if needed

Answer 10

-obstruction with bacterial infection (usually CBD) -MCC- gallstones, ERCP, cholangiocarcinoma -Charcots triad- RUQ pain, fever, jaundice -Reynold pentad- charcots + AMS and shock -Dx: -Labs- high WBC, ALP, ALT/AST, GGT, bilirubin -blood cultures -US- dilated CBD, +/- pus -Tx: -ASAP tx- IV fluids, NPO -IV antibiotics!, pressors if hypotension -!ERCP (suction vs stent) -percutaneous cholecystostomy if cant get ERCP -call critical care + surgery

Answer 11

-CHOLECYSTITIS: -murpheys and kernh -high WBC -mild ALP/AST/ALT -US- wall thickening, pericholecystic fluid, distention CHOLEDOCHOLITHIASIS: -fever -jaundice -Labs: high bilirubin, ALP, GGT, AST/ALT -US- CBD dilation, stone

Answer 12

-Mallory Weiss: -partial thickness at the gastroesophageal junction -BLEEDING!!!!! -vomiting with blood in it -pain is mild -normal PE -EGD -Esophageal rupture: -NO BLEEDING -transmural rupture due to increased intrathoracic pressure -sever retrosternal or epigastric pain -CT, x-ray -emergent surgery, IV antibiotics

Answer 13

-RF: 50% have cirrhosis -Tx in brisk bleed: -OCTREOTIDE -PPI -Broad spectrum antibiotics -unstable -> !Balloon tamponade!- Sengstaken-Blakemore -> do ET tube first -stable- Endoscopic variceal ligation -TIPS procedure

Answer 14

-Embolism- sudden diffuse abdominal pain, N/V, +/- GI bleeding or (bloody) diarrhea -Chronic- postprandial pain -Venous thrombosis- gradual onset -pain out of proportion to exam!! -non-specific sx -> difficult to dx -soft abdomen although extreme pain -MC- SMA -RF: afib, endocarditis (murmur), hypotensive, dehydration, shock, hemorrhage, CHF, vasopressor use, hypercoaguable states, PVD -Labs: -WBC (25+) -Blood gas- high lactate, lactic acidosis -Def dx: CT angiography -cutoff sign in vessel or filling defects -ascites, wall thickening, edema -> gas (pneumatosis portalis), pneumoperitoneum after perf, intramural gas (intestinal pneumatosis)

Answer 15

-MCC- spontaneous bacterial peritonitis (SBP) -MC- e.coli translocation -RF- cirrhosis with ASCITES, portal HTN, perforation (surgery, PUD), dialysis, hepatic encephalopathy -S&S: -severe, diffuse pain -distention -rebound tenderness -involuntary guarding -rigidity -absent or hypoactive bowel sounds -fever, chills, tachy, tachypnea, hypotension, shock -N/V -ileus

Answer 16

-crampy, colicky, N/V -distention, tympanic -obstipation -early diarrhea -> late constipation -peritoneal signs if perf -dehydration -> hypotensive, tachy -RF- past surgery, IBD, obesity, radiation, opioids, anticholinergics, FB -Causes: ADHESIONS,HERNIA (esp testicular), neoplasm, strictures, intussusception, IBD -Imaging: -CXR- air under diaphragm -Abdominal XR- air fluid levels, string of pearls, plicae circulares/valvular coniventes -Supine XR- distended loops of bowel >3cm, no gas in rectum -!CTAP- find transition point, pneumatosis intestinalis +/-

Answer 17

-1. SIGMOID (MC): Abdominal XR- coffee bean sign -2. CECAL -CT- best test -> whirl sign -3. MIDGUT (infants)- Upper GI series is gold standard in stable, barium enema (bird beak), US,

Answer 18

-OBTRUCTED: -can be manually reduced at bedside -pain meds to relax surrounding musculature -ice packs to reduce swelling -URGENT -SBO sx -If suspicion of strangulation -> DONT attempt reduction -STRANGULATED: -non-reducable-> compromised blood supply and necrosis -tender, red, warm, fever, sepsis -reducing -> reintroduces ischemic/necrotic bowel -> perf and sepsis -contact surgery ASAP - EMERGENCY -begin broad spectrum antibiotics -pre op labs, control pain, and resuscitate if needed

Answer 19

-Conservatively: -meat <12hrs -removal w/o complication -blunt, short, narrow -non-toxic -EGD within 24hrs -Emergently: -respiratory sx, drooling -complete obstruction -button battery -persistent/severe sx -multiple magnets, or single with metallic object ->24hrs w/o passing pylorus -sharp -> that can perf -large (>2.5cm width or >6cm length) -multiple objects -coin @ criopharyngeous -past LES (stomach)- observe -past the pylorus -> let them pass it bc it will require surgery if it perfs anyways

Answer 20

-chronic liver disease or cirrhotic pts -portal HTN -> bowel edema -> transmigration of enteric bacteria -consider in any pt with ascites AND hepatic encephalopathy, abd pain, fever, leukocytosis, renal failure -DX- PARACENTESIS -> neutrophils >250 -+grain stain

Answer 21

-looking for intraperitoneal fluid -4 places: -epigastric- subxiphoid -RUQ -LUQ -suprapubic

Answer 22

-transvaginal US- >1,500 -you can see an ectopic earlier so order it anyway -abdominal US- 6,000

Answer 23

PRE-ECLAMPSIA: -20wks-6wks postpartum ->140/>90 on 2 readings at least 4hrs apart -PLUS 1: -proteinuria -thrombocytopenia- <100,000 -creatinine >1.1 -elevated LFT (2x) -pulmonary edema -HA, visual changes, epigastric pain -ECLAMPSIA: -generalized tonic-clonic seizure in pt who has pre-eclampsia -Definitive tx: delivery of fetus and placenta (34wks rec for pre-) -> betamethasone to help fetus lung maturity -SEIZURE: -Magnesium sulfate 2-4mg IV -after 3rd convulsion consider: -Lorazepam (Ativan) -Diazepam (Valium) -HTN: -1. LABETOLOL** -20mg IV over 2 minutes -> double -> double -> after 3 doses still >160/ >110 -> hydralazine 10mg IV -2. HYDRALAZINE -3. NIFEDIPINE

Answer 24

-Unruptured ectopic- light bleeding, tender, adnexal mass -Ruptured ectopic- peritoneal signs, cool, pale, syncope, severe pain, hypotension, tachy, N/V -Unruptured US- yolk sac and embryo outside uterus, empty uterus, thickened endometrial lining -hcg >1500 and IUP not seen -> high risk -Ruptured POCUS/FAST- intraperitoneal fluid, collapsed gestation sac Tx: -Unruptured- methotrexate until HCG is 0 -only if stable, no cardiac activity, <3.5cm, <5000 hcg, normal kidney/liver -Laparoscopy if methotrexate is CI -Ruptured- -ABCs, IVF, transfusion -RhoGAM if Rh- -salpingotomy/ectomy

Answer 25

-ovary and fallopian tube twists on its own bloody supply -young (cysts), infertility -sudden, severe stabbing unilateral pain -N/V, radiation to groin -bimanual- tender, mass (rare) -peritoneal signs -> necrosis :( -def dx- laparoscopy -ovarian salvage time is 36hrs

Answer 26

-mild to severe -MC- midline lower pain -!vaginal discharge, dysuria, dyspareunia -abn bleeding, fever, N/V, malaise -cervical motion tenderness (CMT) -adnexal tenderness -friable cervix -cervical discharge, purulent -Tuboovarian abscess (TOA)- severe pain/fullness worse on one side (bimanual) -Causes- POLYMICROBIAL, STI, anaerobes (BV), enteric (ascending tract infection -> endometritis, salpingitis, oophoritis, myometritis) -US- possible TOA -> complex thick walled adnexal structure -R/o ruptured cyst, ovarian torsion -Tx: -PID: Cefoxitin or ceftriaxone, doxycycline, and metronidazole -TOA: Even though abscess -> same tx as PID ->IV antibiotics and pain control -if persistent, or very large -> surgically drained

Answer 27

-CHLAMYDIA TX: -Doxycycline 100 mg PO BID x 7 days - tx of choice OR -Azithromycin 1g PO 1x (pregnancy) -GONORRHEA TX: -Ceftriaxone 500mg IM once (1g if >150kg) -If allergy: Gentamicin 240mg IM x 1 dose + Azithromycin 2g PO x 1 dose -Expedited partner therapy (EPT): Cefixime 800mg PO once

Answer 28

-Chlamydia trachomatis serotypes L1-L3 -MC- rectal -1. small painless genital ulcers -> heal -2. painful swelling of inguinal lymph nodes

Answer 29

->500mL of bleeding -> hemorrhage -Causes: -MC- Uterine atony (80%)- no contraction -Undiagnosed/unrepaired lacerations -Retained POC -Coagulopathies -boggy uterus -lacerations or uterine inversion -previous venipuncture sites for bleeding -> DIC -Emergency tx: -ABCs, IV x 2 -O-neg to start -Call OBGYN early! -Oxytocin or misoprostol (immediately after birth to prevent) -Fundal massage

Answer 30

-Fever, tachycardia, tachypnea, +/- hypotension, with delirium -Sepsis = 2+ SIRS + infection -SIRS criteria: -temp >38 (100.4) or <36 (96.8) -HR > 90 -RR > 20 or CO2 < 32 -WBC > 12,000 or < 4,000 or >10% bands -qSOFA score: -systolic BP <= 100 -RR >= 22 -GCS <15 -Dx: -central venous cath and arterial line -CXR -ECG if tachy -CBC, CMP, UA, VBG (for lactate), cultures (blood + urine) -As indicated -> CT, CSF, SSTI wound cultures, joint cx -Serial- vitals, PE, urine output, lactate -Tx in 1st 3 hrs: -Lactated ringers @ 30ml/kg -Empiric antibiotics -Vasopressors- MAP >65: Norepinephrine -> vasopressin or epinephrine once norepi dose >15 -remove any sources of infection -What if this doesnt work?: -

Answer 31

-red, warm, tender, FIRM -fevers, chills, sweats, lymph nodes, streaking (ascending lymphangitis) -US- cobblestoning -Stasis dermatitis: MC misdiagnosis as cellulitis! -!bilateral and chronic! -telangiectasia, varicose veins, hyperpigmentation, edema subsides with laying -> wound clinic, elevate -> NO antibiotics -Contact dermatitis – itchy! -Allergic reactions – itchy! -PAD -DVT: venous cord, can check Homan’s sign (pain behind knee with dorsiflexion) -> duplex US -Mono-arthritis (septic/gout): suspect when cellulitis overlies a joint

Answer 32

CELLULITIS: -unilateral -pain, red, swelling, warm, tender, streaking (ascending lymphangitis) -firm -systemic sx -ABSCESS: -fluctuant -surrounding induration! -pain, tender, red -NECROTIZING FASCIITIS: -swelling, severe pain -> out of proportion -poorly define margins -bullae -gangrenous skin -crepitus -wooden feel

Answer 33

-MCC- s. pneum -triad: Fever, neck stiffness, AMS -HA (MC) -Seizures -!Kernigs: Hip is flexed, but knee cannot be straightened -!Brudinski’s: Flexion of the neck (by you) leads to flexion of the hip (by the patient) -Head jolt sign -Do not delay ANTIBIOTICS for CT/ LP/blood cultures! Goal < 60 mins -CT before LP if: ->60yo -Hx of CNS ds -Immunocompromised state -Seizure <1 week before -AMS -Focal neuro deficits -CSF testing = Gold standard -CSF opening pressure -Gram stain -Cell count -Glucose level -Protein level -Tx: -Empiric: !Vancomycin + Ceftriaxone! -!Add ampicillin for listeria if >50yo -!Add acyclovir IV if HSV -Neonates: ampicillin + gentamicin -Consider !dexamethasone! to decrease M&M (controversial)

Answer 34

-bite or trauma prior -Kanavel signs: -Fusiform digit swelling (entire thing) -Finger held in passive flexion (contracted) -Pain with extension -Tender over the flexor tendon sheath

Answer 35

-Augmentin!!! -If severely infected +/- sepsis -> IV antibiotics -PEP: -anytime bat involvement -if you catch the animal wait and test it -high risk animals -Human rabies immune globulin (HRIG) IM into wound and then rest into deltoid or thigh -dont need HRIG if previous vaccine -Vaccine IM in CONTRALATERAL deltoid -> days 0,3,7,14 (+28 if immunocompromised)

Answer 36

-ALWAYS consider in child with prolonged fever and rash -VASCULITIS -MC- 6mo–5yo -high risk for aneurysm -Dx criteria: -5 days of fever (can be shorter if high suspicion) PLUS -B/L conjunctivitis -Cervical lymph node >1.5CM -Polymorphous exanthem -Cracked lips or strawberry tongue -Erythema, edema, cracking or peeling of the hands/feet -NONBLANCHING rash -Echo- inflammation of coronary arteries -Tx- high dose ASA, IVIG, PPI

Answer 37

-meningococcal -lyme -RMSF -necrotizing fasciitis -toxic shock syndrome -endocarditis -kawasaki -HIV -dengue -chikungunya

Answer 38

-MC intrascrotal infection -posterior pain + swelling -<35yo - STI ->25yo- E.coli UTI -dysuria, frequency, discharge, pyruria -NO N/V or fever -+Prehn's sign- decreased pain with lifting of scrotum -US- increased blood flow + inflammation -Tx- -STI- ceftriaxone, doxycycline -Enteric- fluoroquinolone -Admit if signs of systemic infection

Answer 39

-1st year of life- undescended testicle -Puberty/adolescence- rapid increase in testicular size -MCC- testicle not strongly attached to scrotum at birth -other causes- minor trauma around scrotum, vigorous physical activity or during sleep -Sudden onset -hours after exercise -!!N/V -swollen, tender UNILATERAL -transverse lie of testicle- bell clapper -ABSENT CREMASTERIC REFLEX -US- -Hyperechoic enlarged testicle -False negatives- Early in ds, Degree of twisting, Intermittent torsion -False positives- Prepubertal patients have decreased or absent testicular blood flow at baseline -blue dot sign- torsion of the appendix -Tx: -manual detorsion- opening the book -surgical detorsion + orchiopexy

Answer 40

-transillumination- hydrocele -bag of worms that increases valsalva maneuvers- varicocele -reducable- hernia

Answer 41

-PHIMOSIS -foreskin stuck in distal -> cant retract -cant void -> EMERGENCY -<5yo -> if no urgency -> grow out of it -> DO NOT RETRACT ->5yo -> topical steroids (hydrocortisone), gentle retraction -PARAPHIMOSIS -EMERGENCY -swelling + pain in glans in uncircumcised male -vascular compromise possible -call urology -> manual reduction, prepuce injection, puncture technique, or dorsal slit

Answer 42

-high riding prostate or blood at urethral meatus -BLOOD AT URETHRAL MEATUS INDICATES ANTERIOR URETHRAL INJURY

Answer 43

-MC- E.coli -Pyelonephritis/ascending infection sx: -CVAT or flank tenderness -FEVER -chills -N/V -flank pain (CVAT) -Tx- nitrofurantoin, trimethoprim-suldamethoxazole, fosfomycin, beta-lactam e.g. cefpodoxime -Tx for pyelo- fluoroquinoloes: cipro, levo OR -ceftriaxone IV and send home with trimethoprim-sulfamethoxazole -ADMIT PYELO IF...intractable N/V, sepsis/shock, obstruction, emphysematous pyelo, pregnancy, immunocompromised, foley, failed outpt, poor social support -INPT- ceftriazone or piperacillin-tazobactam, IV fluoroquinolone

Answer 44

-consider this in pts who dont respond to tx for cystitis -fever -flu like- n/v, chills -urge incontinence, RETENTION!! -boggy, tender prostate -edema

Answer 45

-colic, radiates to groin -N/V, dysuria, hematuria -proximal ureter or renal pelvis -> radiation to ipsilateral testicle, flank region -middle third of ureter -> lower and anterior flank -level of ureterovesical junction -> lower flank radiates to scrotal or vulvar skin -fever, hypotensive, AMS- infection -US- hydronephrosis, renal abscess, distal hydroureter -CT scan- spiral non-contrast!- renal calculi, hydroureter, hydronephrosis, gas and renal abscess -Tx- -<5mm -> discharge ->5mm -> expulsive therapy- tamsulosin (alpha-1 blocker) >7-10mm -> surgery, shock wave lithotripsy, ureteroscopy

Answer 46

-10-12hrs -may have AKI -may have overflow incontinence -Causes- BPH!, Ca, mass, stone, prolapse, fibroid, constipation, stricture, UTI, prostatitis!, abscess, HSV, meningitis, cauda equina!, antihistamines!, anti-cholinergics! ->100mL post-void residual -> rules in retention -1st line relief -> urethral foley catheter -correct size, coude tip in BPH, small tip in strictures -never FORCE -> can cause urethral damage (bleeding) -> suprapubic foley catheter is indicated

Answer 47

-s. aureus > viridians strep > HAECK -FEVER! -murmur, HF -glomerulonephritis -osler nodes- painful nodules on fingers -roth spots -janeway lesions- painless spots on palms -Dx: -Echo- vegetation, abscess, new regurgitation, dehiscence of prosthetic valves -TEE -Blood culture -Duke criteria -Tx: -antibiotics for 6 wks -!Vancomycin PLUS gram neg coverage (cefazolin) -> no drug use -!prosthetic -> vancomycin PLUS gentamycin PLUS cefepime/cipro -> surgical intervention!

Answer 48

-PCP- CD4 <200 -TB- CD4 <500 -toxoplasmosis- CD4 <100 -cryptococcus- CD4 <100 -CMV, TB colitis- CD4 <50 -esophagitis (CMV, HSV, candida)- CD4 <100 -HAART can cause diarrhea

Answer 49

-URI -nasal, sinus, pharynx, larynx -virus -low grade fever -lung sounds/xray are normal -supportive tx -BRONCHITIS -virus -NO fever -persistent cough -ronchi -peribronchial thickening -supportive tx -PNA -alveoli -DYSPNEA -bacteria MC -high fever -purulent sputum -crackles -CXR- consolidation, air bronchograms -Antibiotics for tx