Neuro/Heet Flashcards
Sign: Bilateral/vice-like,
Duration: Daily
Exacerbated: stress, fatigue, glare.
Associated: hypertonicity of neck muscle.
Tension Headache:
Treatment: Ibuprofen or Naproxen (NSAIDS), Tylenon 325-1000mg PO q4-6
Sign: Unilateral/start temple or eye
Duration: 15 mins to 3 hours
Exacerbated:
Associated: congestion/rhinorrhea, lacrimation, Horner syndrome (ptosis, miosis, anhidrosis)
Cluster Headache:
Treatment: Initial 100% oxygen for 15 mins.
Sumatrip
Sign: Gradual build-up of a throbbing headache
Duration: several hours
Aura: star, light slashes, zigzag, aphasia or numbness, tingling, weakness.
Associated: Nausea and Vomtiting
Migraines
Treatment: Avoidance of precipitating factor.
chronic pain, complaints of headache unresponsive to medication.
History of analgesics reveal.
Medication Overuse Headache
Withdraw med, improvement in months, not days
Symptoms Occur within 1-2 days of injury, and subside with 7-10 days.
Associated: impaired memory, poor concentration, emotional instability.
Post-Traumatic Headache
Treatment: Simple analgesics first line therapy
(a) Hallmark “Thunder clap headache” or “worse headache of my life”
(b) Headache onset is sudden and may have meningeal irritation
Drug use (cocaine, amphetamines), smoking, hypertension, alcohol use
Analgesia with Tylenol
Intracerebral hemorrhage:(SAH)
Analgesia with Tylenol, Referral
Sudden onset focal neurological deficit. Faster – face, arm, steadiness, talking, eyes, react.
Cerebral Vascular Accident (CVA) Transient Ischemic Attack(TIA)
Don’t lower B/P acutely unless 220/120 above, lower pressure by 15%.
Lab
RLS is an uncomfortable “creeping, crawling” sensation or “pins and needles feeling” in the limbs, especially in the legs. The uncomfortable sensations are temporarily relieved by limb movement
Restless Leg Syndrome.
Low iron
Immediate loss of conciousness after significant head trauma
“Lucid interval” with recovery of consciousness
May also see seizure, coma, anisocoria, respiratory collapse
Epidural hemorrhage presentation
Referral
(1) Pain, numbness, or tingling in the lower back and spreading down 1 or both legs
(2) Leg weakness or a problem called “foot drop,” which is when you cannot seem to hold
your foot up (for example, while walking)
(3) Problems with bowel or bladder control
Cauda Equina Syndrome
Referral
Pain, burning, and tingling in the distribution of the median nerve.
(a) Median nerve innervates thumb, pointer, middle and half of the ring finger
Pos for Tinel or phalen’s sign exacerbates neuropathic symptoms
Carpal Tunnel Syndrome.
Patient should modify their hand activities and the affected wrist shoul
b) Nuchal rigidity
(c) Change in mental status
(a) Brudzinski sign – spontaneous flexion of hips during passive flexion of the neck
(b) Kernig sign – inability or reluctance to allow full extension of knee when hip is flexed at 90 degrees
Meningitis
Ceftriaxone (rocephin) 2g IV q12h
Dexamethasone 0.15mg/kg IV Q6Hr
Exposed crew – Ciprofloxacin (Cipro) - is a Fluoroquinolone antibiotic
(1) Abrupt onset of unilateral facial paralysis
(1) In a stroke, there is NO paralysis of the forehead
(2) Intact forehead muscle tone suggests STROKE not BELL’s Pals
Bell’s Palsy.
Prednisone, Immediate referral/MEDEVAC
- Usually, asymptomatic.
- Epigastric pain, Nausea and vomiting.
- Upper GI bleeding with “coffee grounds” hematemesis (Most common presentation).
Gastritis
NSASIDS gastritis: reduce to lowest dosage or with food. Proton pump inhibitor 2-4 weeks. Alcoholic gastritis: D/C alcohol use, H@ receptor antagonists, proton pump inhibitors or sucralfate for 2-4 week. Helicobacter Pylori: spiral gram-negative rod: PPI, AMOX, Clarithromycin (sub metronidazole for AMOX if PCN allegery)
* PPI, levofloxacin, Amox(sub metronidazole for AMOX if PCN allegery)
If bleeding occurs
* PPI 80 mg IV blous, then 8mg/h
* Sucralfate suspension.
- Sense of incomplete evacuation, excessive straining, infrequent stool.
Constipation
- Psych issue identified and addressed.
- First line: diet and exercise. Increase water and fiber supplementation (no immediate response).
- Second line: stool softening or laxative use. Docusate sodium (Colace), Bisacodyl (Dulcolax), Magnesium hydroxide (milk of magnesia), Magnesium citrate:
- Third line: Suppository, Enemas. Fecal disimpaction.
- Initial care: treat empirically in acute phase, start less invasive, lifestyle change, monitor for improvement.
Internal Hemorrhoid: Above dentate line, subepithelial cushions. Not painful when present. External Hemorrhoid: below dentate line, Arise from inferior hemorrhoidal vein. Painful when thrombose. Tense blush perianal nodule covered with skins. Tender to palpation.
Hemorrhoids:
Internal: Hemorrhoidectomy: chronic stage 3< and stage 4.
Definitive treatment: surgical banding (rubber band ligation). External Hemorrhoid: Warm sitz baths, analgesics and ointments. First 24-48hr, removal clot may relief.
- Sever tearing pain during defecation, followed by throbbing discomfort may lead to constipation due to fear of recurrent pain.
- Bright red blood, confirmed by visual inspection of anal verge.
Anal Fissure
- Directed at promoting effortless, painless bowel movement.
fiber supplement sitz baths - Topical anesthetics Lido (temporary relief), Oral analgesics (Tylenol, NSAIDS)
- Initial care: promoting effortless, painless bowel movement (stool softener), keep the area clean,
- Dull, aching, or throbbing pain worse immediately before defecation, lessened after defecation, but persists between bowel movements.
- Pain is aggravated by straining, coughing, or sneezing. pain and tenderness interfere with walking or sitting
Anorectal Abscess
- Treatment is surgical and should be performed as soon as the diagnosis is made.
- All perirectal abscesses (supralevator, intersphincteric, and complicated ischiorectal) should be drained in the operating room.
Initial Care:
Perianal and deep postanal: Incision and drainage, perirectal (supralevator, intersphincteric, and complicated ischiorectal): refer to general surgery.
- “nonhealing” anorectal abscess following drainage, chronic purulent drainage and a pustule-like lesion.
- intermittent and malodorous perianal drainage and pruritu
Anorectal Fistula
- Require higher echelon care, stabilized and prepare for MEDEVAC.
Initial Care - Initial care will be based on vital signs and patient stability.
- If patient presents in pain, consider MEDEVAC and treat pain.
- Inflammation in the midline of the gluteal crease. Swelling, pain, persistent discharge.
Pilonidal Disease
- Initial care: Simple I&D with suction in clinical setting recurrent are common. Antibiotic (cephalexin, doxycycline) if cellulites present.
- Definitive treatment: surgical excision in OR.
- Bloody diarrhea (hellmark), Fecal urgency
- Diffuse or lower crampy abdominal pain,
- Tenesmus (consistent feeling of needing to defecate).
- Mild: gradual onset of infrequent dirrhea, less than 5, LLQ cramp relived by defecation.
- Moderate: severe diarrhea with frequent bleeding, abdominal pain low.
- Severe: bloody diarrhea more than 6, abdominal pain high
Ulcerative colitis
Mild to moderate colitis:
1) Treatment as recommended by GI
2) May eat a regular diet but limit their intake of caffeine and gas-producing
vegetable
4) All opioid or anticholinergic agents should be discontinued.
5) Restore circulating volume with fluids, correct electrolyte abnormalities, and
consider transfusion for significant anemia (hematocrit 25-28%).
LAB: CBC, CPR, ESR, Stool Bacterial culture, C dif, GI CT scan/ Colonsocpy.
- Illeitis or ileo-clitis
- Non-bloody diarrhea,
- Lower-grade fever, malaise, weight loss,
- cramping abdominal pain: diffuse, RLQ or peri-umbilical pain.
- Possible intra-abdominal Abscess: tender mass.
Crohn’s Disease.
Endoscopy/Colonsocopy, CT scan of the abdomen
HALLMARK: abdominal discomfort is relieved immediately after defecation
Abdominal discomfort or pain that has at least 2 of the 3 features:
* Relieved with defecation
* Onset associated with a change in frequency of stool
* Onset associated with a change in form of stool
Irritable Bowel Syndrome
- Important to establish a therapeutic relationship with validate the patient’s symptoms.
- Counseled that although IBS does not increase their risk of malignancy (cancer).
- Establish realistic expectations and involve patient in treatment decisions.
- Diet: FODMAPs, fermentable oligo-, di-, and monosaccharides and polyols. Low fatty and caffeine intake.
- Antidiarrheal: Lopermide (Imodium). IBS-D
- Anti-constipation agents: Osmotic Laxatives (milk of magnesia or polyethylene) IBS-C
- Antispasmodic agent: Hyoscyamine (Levsin), Methscopolamine, Dicyclomine (Bentyl)
- Psychotropic agents: Tricyclic Antidepressants (TCA). IBS-D
- 30-60 mins after meals upon reclining. Dysphagia 1/3 patient due to erosive esophagitis, esophageal stricture.
Gastroesophageal Reflux Disease (GERD)
Mild, intermittent symptoms:
* Lifestyle change: eat small meals, acidic foods, weight loss.
* Advised to avoid lying down within 3 hrs after meals and to elevate the head of the bed on 6 inch blocks or a foam wedge to reduce reflux and enhance esophageal clearance.
* Antacids: not prevent GERD, relief of mild GERD symptoms, , short duration of effect of 30 to 60 minutes. Ranitidine, Famotidine.
Troublesome symptoms
* Proton Pump Inhibitors (PPI): heartburn relief for up to 8 hours, delay on sent 30 mins Omeprazole (Prilosec), Pantoprazole (Protonix), Esomeprazole (Nexium)
- Medication-induced: retrosternal pain or heart burn (60 percent), odynophagia (50 percent), and dysphagia (40 percent). swallowing a pill without water, commonly at bedtime. *Antibiotics: Tetracycline, Doxycycline, Clindamycin, Anti-inflammatory medications: Asprin
- Candida Esophagitis-Symptoms: hallmark of Candida esophagitis is odynophagia, or pain on swallowing. mucosal plaque-like lesions are noted on endoscopy. common in HIV-infected patients
Esophagitis
RAD: Consider Endoscopy
(1) Treat the underlying cause
(a) Pill induced
1) Stop taking offensive medication
2) Take with water
(2) Candida Esophagitis
(a) Evaluate for immunocompromised conditions: HIV, Cancer, Diabetes
(1) Localized substernal chest pain
(2) Heartburn
(3) Dysphagia is the cardinal feature of esophageal stricture
Esophageal Stricture
- Mild: treat for GERD
- Severe Symptoms: MEDEVAC for potential surgery
- Refer all patients for Gastroenterology for dilation and evaluation.
- Gradual onset of dysphagia with solid foods and some liquids.
- Substernal discomfort/ fullness.
- Lifting neck or throwing shoulders back to enhance gastric emptying.
- Regurgitation is common.
Esophageal Spams:
PPI medication if GERD
Symptom reduction, eat small bites,
Endoscopic injection of botulinum toxin.
Initial care: treat symptoms associated with spams, underlying cause
- Chronic NSAIDs use
Pain is typically well localized to the epigastrium and not severe. It is
described as gnawing, dull, aching, or “hunger-like.”
Epigastric pain (dyspepsia), the hallmark of peptic ulcer disease - Chronic H pylori infection: Upper endoscopy with gastric biopsy for H pylori is the diagnostic procedure of choice in most patients.
- Acid hypersecretory states:
Peptic Ulcer Disease.
Smoking retards the rate of ulcer healing and increases the frequency of recurrences and should be discouraged.
Initial: d/c causative agent, treatment H pllori.
Treat with anti-H pylori regimen for 10-14 days:
* Proton pump inhibitor PO BID
* Clarithromycin 500 mg PO BID
* Amoxicillin 1 g PO BID (OR metronidazole 500 mg PO BID, if penicillin allergic)
- Microperforation: localized paracolic inflammation
- Macroperforation: either abscess or generalized peritonitis
- Acute abdominal pain and fever. LLQ
- Left lower abdominal tenderness and possible mass.
- Leukocytosis
- Occult blood is common, hematochezia is rare
Diverticulitis
- Mild symptoms and no peritoneal signs: managed with conservative measures, clear liquid diet and broad-spectrum oral antibiotics
- Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) and
- patients who are elderly or immunosuppressed: hospitalization, NPO, Intravenous antibiotics, Recurrent attacks warrant elective surgical resection.
- Initial care: stabilize and prepare for MEDEVAC
Caused by a sudden increase in transabdominal pressure, E.g. lifting, retching or Alcohol use, vomiting. S/S of upper GI bleed, heavy alcohol user, Hematemesis with or without melena.
Mallory-Weiss: non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction.
- Self-limiting, NPO, IV PPI, IV/IM Antiemetic
- Surgical Evaluation. MEDEVAC
Hartman’s sign: “Crunching” sound heard on auscultation of the mediastinum
Boerhaave’s Syndrome: full perforation of the esophagus into the mediastinum.
- Gradual onset (12-24 hr), periumbilical abdominal pain to RLQ.
Appendicitis
Gram negative and anaerobic bacteria:
* Metronidazole (Flagyl) AND ciprofloxacin (cipro)
* Gold Standard Definitive Treatment: Appendectomy
* Symptom Management: NPO, Morphine, 2 IV, IV fluid monitoring urine output.
Perforation can escalate quickly in some individuals (within 6 hours), however, it usually takes 24-36 hours.
CBC: Leukocytosis
UA: Proteinuria, granular casts, glycosuria (10% of cases)
* Abrupt onset (within minutes) epigastric abdominal pain
* Steady, ‘boring’, severe abdominal pain radiates to the back, that is made worse with walking and lying supine. Relief with sitting upright and leaning forward. Mild jaundice is commom. Weakness, fever and anxiety
(i) Grey-Tuner and Cullen’s sign in severe disease
Pancreatitis
CT scan is useful
Lab
(a) CBC: Leukocytosis (10,000-30,000/mcL)
(b) Gold Standard: Elevated serum Lipase is diagnostic, UA
- NPO + aggressive fluid resuscitation is the gold-standard for uncomplicated pancreatitis.
- Fluid Resuscitation (hallmark of therapy): 5-10mL/kg/hr initially.
- targeted to adequate urinary output (0.5-1.0 ml/kg/hr), stabilization of BP and HR.
- Pain Control: Ketorolac, Morphine, or Hydrocodone
- NPO: resumed when no pain, Clear liquids are given first, then low fat,
last > 6 hours
“6 F’s” Fat, Fertile, 40, Female, Flatulence, Fever.
RUQ Pain after eating a meal high in fat.
Cholecystitis
MEDEVAC
1) NPO
2) Antibiotic therapy
(2 Or Ceftriaxone: 2 grams IV qD
Analgesia:
1) Start with NSAIDs Ketorolac 15-30mg IV q6hrs PRN
- Abdominal pain: crampy, intermittent. Cause by peristalsis passing over obstruction.
- Urge to move, unable to find a comfortable position.
- Abdominal distention, constipation, bloating common.
- Mechanical obstructions: active, high-pitched bowel sounds with “rushes”.
- Paralytic Ileus: less intense pain more constant, diminished bowel sounds.
Small Bowel/Intestinal Obstruction
NPO, D/C med inhibit bowel motility (opiods), Nasogastric tube insertion decompress proximal GI track.
* Two IV access: aggressive fluid resuscitation.
* Mechanical obstructions: IV antibiotics. Medevac for all Mechanical obstructions,
* general surgery if: gangrene or necrosis (WBC>20,000), mechanical (carcinoma), failure of conservative.
- Constant aching diffuses lower abdominal pain, bloating, distention, constipations and inability to pass flatus. Possible feculent vomitus.
Large Bowel Obstruction (LBO)
NPO, D/C med inhibit bowel motility (opiods), Nasogastric tube insertion decompress proximal GI track.
* Two IV access: aggressive fluid resuscitation.
* Mechanical obstructions: IV antibiotics. Medevac for all Mechanical obstructions,
* general surgery if: gangrene or necrosis (WBC>20,000), mechanical (carcinoma), failure of conservative.
- very ill appearing, unstable vital signs.
- Fetal position or supine with legs bent.
- Patients typically do NOT want to move.
- Absence of dullness over the liver suggests free air/perforation.
- board-like abdomen is unmistakable and indicates obvious peritonitis
Secondary Peritonitis
- IV antibiotic: Ertapenem 1gram IV q24 hours
- diffuse peritonitis: NPO, IV, pain control (morphine).
- specific disease process treatment algorithms
- General Surgery consultation
