midterm Flashcards
Asthma triggers
-Environment: Pollen, dust mites, molds, animal dander, cockroaches
-URI (MC)
-Aspirin-exacerbated respiratory disease (AERD)
-some NSAIDs
-!!Cold environments
-Exercise
-GERD
-Emotional stress
-Hormonal fluxes: Pregnancy, menstrual cycle
-!!BB (even eye drops)
Asthma sx and tx
-worse at night
-sx during childhood
-family hx
-hx of allergic rhinitis/eczema
-tripoding
-speaking in phrases
->40 RR, >120 HR
-SpO2 <90%
-peak flow < 40-50% of predicted
-AMS/agitation
-SILENT CHEST ≠ Reassurance
-BAD sx:
-decrease expiratory flow
-air trapping -> PTX
-decrease venous return -> hypotension, pulsus paradoxus
-Initial tx:
->92%
-1-2L normal saline
-MDI +- spacer, nebulizer
-SABA- albuterol
-Anticholinergic- ipratropium bromide WITH SABA
-Steroids (except mild)
-Magnesium sulfate- severe/impending failure
-Discharge tx:
-albuterol MDI +/- steroids (5 days)
-consider ICS
BiPAP
-INDICATIONS:
-stay on for at least 72 hrs
-MC- pulmonary edema
-COPD exacerbation (respiratory acidosis)
-PNA- be careful of hypotension
-burns
-flail chest
-post op deterioration
-CONTRAINDICATION:
-AMS
-no gag reflex
-upper airway obstruction
-facial trauma, burns
-gastric distention -> abdominal compartment syndrome
-GI bleed
-aspiration pneumonia
-respiratory arrest
-anxiety/agitation
-severe hypotension/shock/arrythmias
COPD exacerbation
-hyperresonant chest
-sputum color change
-viral or bacterial infection?
-EKG- tachycardia, MAT, cardiac mimics (STEMI)
-X-ray- flat diaphragm, vertical heart, increase AP diameter, bullae, RVH, large pulmonary artery
-right HF -> edema/ascites/hepatomegaly/JVD
-1. nasal cannula -> BiPAP! -> intubation
-88-92%
-IV, monitor
-2. bronchodilators (beta agonist)- SABA
-3. steroids- mainstay but not fast
-4. antibiotics- ceftriaxone
Acute CHF
-MC sx- dyspnea
-IV, vitals, monitor, ECG, CXR, POCUS
-POCUS-
-CXR- cardiomegaly, pulmonary edema, pleural effusion, kerley B lines, dilated vessels
-US- 3+ B-lines, EF, walls, IVC
-Tx:
-100% NRB -> !NIPPV! -> intubate
-!!Nitroglycerin = 1st line if w/o shock -> decrease pre/afterload
-IV diuretics
-IF SHOCK…
-BiPAP
-vasopressors- norepinephrine, dopamine
-MAP 65-80
-Inotropes- dobutamine
-fluids or diuretics depending
Understand the risk stratification scores for PE (Wells, or Geneva, and PERC)
-Risk stratification with:
-Well’s score (classic)
-OR
-Revised Geneva score (more objective)
-YEARS score (pregnancy)
-If low risk on well or geneva -> r/o PE with PERC score
Pulmonary embolism and DVT
-RF- trauma to LE or pelvis in last 3mo, malignancy, venous FB (central line, PPM)
-JVD, S3/4
-rales, wheezing, dullness to percussion, fremitus, dec breath sounds
-flank/upper abd pain -> pulmonary infarct/pleuritis
-ECG- tachy, RBBB, S1Q3T3, deep TWI V1-V4, rightward axis
-CXR- atelectasis, effusion, elevated hemidiaphragm, hampton hump, westermarks sign
-U/S- right heart strain -> D-sign -> shifts the LV making it D shaped
-Doppler US for DVT
-CTA!!- BEST TEST
-Pregnant/contrast allergy- V/Q scan -> PERFUSION SCAN ONLY -> ventilation w/o perfusion
-Tx:
-UNSTABLE- thrombolysis and/or embolectomy
-STABLE- anticoagulation for 3mo with DOAC (preferred) or bridge to warfarin with UFH/LMWH
- (i.e. when is heparin used versus thrombolytics)?
PNA types
-strep pneumoniae- rusty
-haemophilus influenzae- COPD
-staph aureus- post viral
-klebsiella pneumoniae- alc
-pseudomonas and enterobacter- HAP
-anaerobes- foul smell, poor dentition, alc
-atypical: productive
-Mycoplasma pneumoniae- bullous myringitis
-chlamydia pneumoniae
-legionella pneumophilia- GI
-HIV:
-PCP
-TB
-histoplasmosis
CURB-65
-CURB-65-
-Confusion
-Uremia (BUN >20)
-RR >30
-BP (<90/<60)
-age > 65
-PORT-
-Demographics- age, sex, nursing home
-Comorbidities- neoplasia, chronic liver ds, CHF, CVA, renal ds
-Presentation- AMS, RR>30, SBP <90, temp <95 or >103, HR >125
-Labs/imaging- pH<7.35, BUN >30, sodium <130, glucose > 250, hematocrit <30, PaO2<60, pleural effusion
PNA tx
-OUTPT- NO CO-MORBIDITIES (CHOOSE ONE):
-1. Amoxicillin
-2. Azithromycin
-3. Clarithromycin
-4. Doxycycline
-OUTPT CO-MORBIDITIES (CHOOSE ONE):
-1a. Amoxicillin-clavulanateAND
-1b. AzithromycinOr Doxycycline
-2a. Cefpodoximeproxetil or Cefuroxime axetilAND
-2b. Azithromycinor Doxycycline
-3. Levofloxacin -> Monotherapy fluoroquinolone not first line recommendation!!!!
-NON-SEVERE INPATIENT:
-beta-lactam- Ceftriaxone IV OR Ampicillin + sulbactam (Unasyn) OR cefotaxime
-PLUS Azithromycin
-OR monotherapy- fluoroquinolone: Levofloxacin
-SEVERE:
-Beta-lactam- ceftriaxone
-IF PSEUDOMONAS- piperacillin-tazobactam or cefepime
-atypical coverage (always)- azithromycin or doxycycline
-PLUS MRSA- vancomycin or linezolid if post-influenza
pneumothorax
-CXR upright- collapse usually at apex, deep sulcus sign if severe
-CXR supine- deep sulcus sign- air goes anteriorly and basally
-POCUS- pleural slide -> ants on log and M-Mode (Seashore)
-M-mode barcode -> BAD, no slide
-Tx:
-small (simple)- <20% or apical <1-2cm from chest wall -> observation w/ 100% nasal O2 -> repeat CXR in 6 hrs
-Large/symptomatic- chest tube
-Tension- >20% -> needle decompression in 2nd ICS MCL -> chest tube 5th ICS anterior axillary line
asthma vs COPD vs CHF
6 you cant miss
-ACS
-PE
-dissection
-tension ptx
-tamponade
-esophageal rupture
Typical vs atypical sx, UA/NSTEMI/STEMI
-UNSTABLE ANGINA:
-negative troponins
-nonspecific ECG
-tx with meds and consider cath in 1-2 days
-NSTEMI:
-ECG- ischemia
-positive cardiac enzymes
-tx medically and cath within 1-2 days
-STEMI:
-ECG- ST elevations
-positive positive enzymes
-STAT tx
-atypical- elderly, female, DM
-short term pain
-pain with movement
-24 hour pain
-RF- >40yo, HIV + HAART
posterior MI
-reciprocal changes in anterior leads (V1-V3) -> depressions
-V7-V9- ST elevation
-tall R waves
-no nitro for posterior and inferior! infarcts
-RV dysfunction
-brady
ACS management
-ABCs, IV, monitoring, serial ECG (10), CXR, troponin (30)
-O2 if <90%
-!Nitroglycerin- ↓ preload
-Avoid w/ sildenafil in past 24-48 hrs
-ANTIPLATELETS:
-!Aspirin 162-325mg -> Reduces mortality by 23%
-P2Y12 inhibitor:
-ASAP or at the time of PCI
-Clopidogrel (Plavix)
-ASA+ clopidogrel -> reduce MACE in pts with NSTEMI
-Ticagrelor (Brilinta)- ?better than clopidogrel-> but higher chance of bleeding
-Prasugrel (Effient)
-ANTICOAGULANTS:
-LMWH/UFH- controversial
-STEMI getting PCI: UFH
-STEMI getting fibrinolysis: LMWH, UFH, or Fondaparinux
-BB and statins- start but not in ER
PCI VS Thrombolytics
-!!PCI- within 90 minutes
-120 for non-PCI facilities
-Sx <12 hrs, Sx 12-24 hrs with ongoing ischemia, or if signs of cardiogenic shock and severe acute HF regardless of time
-!!Thrombolytic tx within 30 mins
-Inferior to PCI
-Best reduction in M&M if within 12 hrs of sx
-4 agents: Tenecteplase (tPA), reteplase, alteplase
-Transfer to PCI facility after!!!!
tPA contraindications
-ABSOLUTE
-PCI immediately available
-History of !intracranial hemorrhage!
-Known !intracranial neoplasm or vascular lesions!
-Intracranial or intraspinal surgery within !3 months!
-Active internal bleeding (except menses) or known bleeding disorder
-!Embolic stroke within 3 months! (exception: embolic stroke within 3 hours)
-Suspected !aortic dissection!
-Significant facial or head trauma within !3 months!
-RELATIVE
-Uncontrolled severe hypertension(>180 systolic, >110 diastolic)!!!
-Prolonged cardiopulmonary resuscitation (>10minutes) or recent surgery (<3 weeks) or non-compressible vascular puncture
-Recent internal bleeding or active peptic ulcer disease
-Pregnancy
-Current anticoagulation with high international normalized ratio (INR)
-For streptokinase: prior exposure to the drug or history of allergic reaction
pericarditis ECG and tx
-fever, malaise
-lasts 2-4wks
-pulsus paradoxus
-can have pericardial effusion
-ECG:
-Diffuse STE (not in V1 or aVR, that makes pericarditis unlikely)
-<1 week- widespread ST elevation and PR depression -> aVR and V1- ST depression and PR elevation
-stage 2- normal
-stage 3- widespread T wave inversion
-4- normal
-spodicks sign- downsloping TP segments in 2, V4-V6
-Tx:
-NSAIDs , ASA or steroids
brugada
-inherited arrhythmia -> sudden death
-adults
-incidental
-syncope
-VT, VF
-ST elevation >2mm in >1 of V1-V3 followed by neg T wave
wellens syndrome
-unstable angina
-strongly associated with proximal stenosis of LAD
-Pts walk around with these
-often found incidentally or during a pain-free period
-troponins are often normal (or only slightly elevated)
-High risk for large anterior wall acute MI
-As soon as its dx -> interventional cardiologist consulted for definitive tx with cardiac catheterization with PCI
-ECG- deep wide symmetrical T wave inversion in V2-V3
sgarbossa’s criteria
-In pts with LBBB or VENTRICULAR PACED RHYTHYM
-can be difficult to dx an infarct (bc T-wave inversions are expected)
-can help dx infarction in setting of LBBB
esophageal rupture
-RF- alcoholic, iatrogenic, vomiting, coughing, childbirth, seizures, weightlifting, Ca, trauma, caustic, FB
-MACKLER TRIAD (Boerhaave):
-vomiting followed by
-severe retrosternal chest pain
-subcutaneous emphysema
-neck/thoracic pain, SOB, abdominal pain (if lower), fever
-crepitus- Hamman’s crunch
-diaphoretic
-reduced breath sounds on side of perforation
-DX:
-cervical XRAY- subq emphysema
-chest XRAY- pneumomediastinum, pneumopericardium, PTX, pleural effusion, widened mediastinum, subdiaphragmatic air
-CT esophagram with water soluble contrast (gastrografin)- TEST OF CHOICE- -Extravasated contrast/air, Free air/fluid, wall thickening, Pneumomediastinum, Pneumopericardium, PTX, Widened mediastinum
-TX:
-ABCDE
-NPO
-broad spectrum IV antibiotics
-IV analgesic
-IV PPI
-parenteral nutrition
-cardiothoracic surgical consult
aortic dissection
-widen mediastinum
-aortic insufficiency murmur
-pulse deficit
-can cause tamponade
-Dx:
-CT angiography- IV contrast
-Tx:
-Stanford A - Emergency SURGERY (CT surgery)
-Stanford B - Endovascular stenting and Medical management
-!GOAL: HR < 60 & SBP <120
-HR is more important -> every beat pumps more blood into it
-IV agents
-!!First line: BB!!!!!
-!Esmolol
-Labetolol
-Nicardipine
-Vasodilators (2nd line)
-Nitroprusside
-No nitrates by themselves! -> Reflex tachycardia
myocarditis
-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
tamponade
-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
AAA
-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
appendicitis
-!!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
urine analysis/culture in appendicitis
-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
RLQ
-appendicitis
-ectopic pregnancy
-ovarian torsion
-testicular torsion
-diverticulitis
-meckels diverticulum
-inguinal hernia
-ovarian cyst rupture
-PID
-psoas abscess
-TOA
-ureteral calculi
biliary colic/cholelithiasis VS cholecystitis
-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
choledocholithiasis
-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
gallstone pancreatitis
-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
ascending cholangitis
-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
What lab results and U/S imaging findings help you differentiate a cholecystitis vs. a choledocholithiasis?
-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
Mallory Weiss tear (AKA esophageal laceration or gastroesophageal mucosal tear) vs. esophageal perforation (AKA Booerhaeve’s or esophageal rupture)
-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
esophageal varices
-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
Mesenteric ischemia
-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)
peritonitis
-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
SBO
-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 +/-
LBO volvulus imaging
-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,
hernias
-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
Swallowed foreign body
-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
spontaneous bacterial peritonitis
-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
FAST exam
-looking for intraperitoneal fluid
-4 places:
-epigastric- subxiphoid
-RUQ
-LUQ
-suprapubic
beta-HCG
-transvaginal US- >1,500
-you can see an ectopic earlier so order it anyway
-abdominal US- 6,000
Pre-eclampsia (PEC) & eclampsia
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
ectopic pregnancy
-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
ovarian torsion
-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
PID
-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
empiric tx for possible infection with gonorrhea and chlamydia?
-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
LVG- lymphogranuloma venereum
-Chlamydia trachomatis serotypes L1-L3
-MC- rectal
-1. small painless genital ulcers -> heal
-2. painful swelling of inguinal lymph nodes
post partum hemorrhage
->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
Sepsis
-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
Cellulitis vs DVT, stasis dermatitis, PAD, allergic rx
-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
PE: cellulitis vs abscess vs Necrotizing fasciitis
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
Meningitis
-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)
flexor tenosynovitis
-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
Bites
-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)
kawasakis disease
-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
fever and rash
-meningococcal
-lyme
-RMSF
-necrotizing fasciitis
-toxic shock syndrome
-endocarditis
-kawasaki
-HIV
-dengue
-chikungunya
epididymitis
-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
testicular torsion
-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
non painful scrotal mass
-transillumination- hydrocele
-bag of worms that increases valsalva maneuvers- varicocele
-reducable- hernia
phimosis VS paraphimosis
-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
blunt penile trauma
-high riding prostate or blood at urethral meatus
-BLOOD AT URETHRAL MEATUS INDICATES ANTERIOR URETHRAL INJURY
UTI/pyelonephritis
-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
prostatitis
-consider this in pts who dont respond to tx for cystitis
-fever
-flu like- n/v, chills
-urge incontinence, RETENTION!!
-boggy, tender prostate
-edema
kidney stones
-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
acute urinary retention
-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
endocarditis
-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!
Opportunistic infections at different CD4 levels
-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
Differentiate between simple URI vs. bronchitis vs. pneumonia
-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
