Urgent Care

Question 1

Anaphylaxis
Path:
Pt:
Tx:

Answer 1

Path: Preexisting IgE antibodies -> mast cell degranulation -> shock, airway compromise

Pt:
Respiratory compromise
Hypotension
Angioedema
Urticaria
MC trigger-> food allergy  

Tx: IM epinephrine (adults: 0.3-0.5mg 1:1000; children 0.01mg/kg 1:1000)
Refractory hypotension for beta-blocker-> glucagon

Question 2

Pneumothorax 
Path:
Pt:
Dx:
Tx:

Answer 2

Path:
Spontaneous
Primary: no clinically apparent lung disease; tall, thin males
Secondary: pts w/ underlying lung disease; COPD, TB
Iatrogenic: thoracentesis, central venous line placement
Traumatic: blunt/penetrating trauma

Pt:
Dyspnea, cough, chest pain, anxiety, shock, tracheal deviation, JVD, cardiovascular collapse
PE: Dec BS, dec fremitus, hyperresonance to percussion

Dx: CXR- absent lung markings along lung periphery

Tx:
Small ( <20%): conservative + oxygen may inc rate of gas resorption
Large/ significant sx ( >20%): needle aspiration, thoracostomy

Question 3

Foreign Body Aspiration
Pt:
Dx:
Tx:

Answer 3

Pt: Asx
Coughing, choking, wheezing, hemoptysis, excessive drooling, stridor
Aspiration pneumonia
Gastric aspiration may cause ARDS/hyaline membrane disease

Dx: Bronchoscopy- direct visualization
CXR- regional hyperinflation
CT if high suspicion and negative CXR

Tx:
Button battery ingestion-> emergent removal (sharp objects or signs of obstruction)
Bronchoscopy- removal of foreign object
Blunt objects, coins-> monitor patient for 24 hours

Question 4

Third trimester bleeding

Answer 4

Placenta abruption: Separation of placenta from its site of implantation before delivery of the fetus
Visible if blood between membranes and uterus escapes through cervix
Concealed if blood is retained between detached placenta and uterus
Dx: Clx
Complications:
Consumptive coagulopathy -> DIC
Renal failure
Fetal demise
Couvelaire uterus: widespread extravasation of blood into the uterine musculature beneath uterine serosa
Tx: Maternal resuscitation w/ blood and crystalloid
Delivery
For viable fetus: cesarean section if vaginal delivery is not imminent

Placenta Previa: placenta is located over/very near internal os
Dx:
Doppler TV U/S @20w (early in pregnancy may resolve by term from placental migration)
Speculum exam visualize bleeding is from above the os
Tx:
Ideal: term fetus or fetus w/ documented lung maturity can be scheduled for routine cesarean
Less ideal: pt w/ known previa presents in labor and receives emergent cesarean
Least ideal: severe hemorrhage preterm mandating stat cesarean