Urgent Care Flashcards
1
Q
Placental abruption
A
- separation of placenta from implantation site before delivery of baby
- RF: preeclampsia, chronic HTN, smoking, cocaine, thrombophilia, prior abruption, AMA, multiparity, multifetal gestation, prior uterine surgery, polyhydraminos, fibroid, PPROM
- sxs: painful vaginal bleeding, uterine tenderness, frequent contractions
- signs: uterine tenderness (“woody”), fetal distress, shock, dilated cervix
- dx: clinical dx - US, CBC, coags, fibrinogen, type and screen BUN/Cr, tocodynamometry (FHR monitoring), urine output
- tx: immediate delivery due to high risk of fetal death
- preterm/no distress (34-37): induce labor
- term/no distress: vaginal delivery
- fetal distress: emergent CS regarless of age
- fetal demise: vaginal delivery, induction, D&E if 2nd trim.
- complications: life-threatening PPH and increased need for emergent hysterectomy
2
Q
Placenta previa
A
- placenta implants over internal cervical os; most common abnormality of placental implantation
- RF: AMPS (AMA, multiparity, multiple gestation, prior previa, c-section, D&C, smoking)
- sxs: painless vaginal bleeding, nontender uterus, breech/transverse lie common
- consequences: PPH, required C-section, placenta accreta, increta, or percreta, abruption, and growth restriction
- dx: if dx in first or second trim., repeat US; on TVUS, placenta is low; CBC, coags, type and screen; fetal HR monitoring; DO NOT PERFORM DIGITAL EXAM
- tx: hospitalization for evaluation, if 37+ wks - delivery, if <36wks - expectant management (asx or preterm = close observation and steroids; mature fetus+/- contractions = base on fetal testing, document lung maturity, schedule 36-38wk)
- delivery regardless of gest age if: severe fetal status, life threatening hemorrhage, bleeding after 34wk
3
Q
orbital cellulitis
A
- MC in children
- median age 7-12yo
- associated: sinusitis
- causes: dental infxn, facial infxn, infxn of globe or eyelids or lacrimal system, trauam
- MC bugs → S. pneumo, S. aureus, H. flu, gram neg, MRSA
- sxs: ptosis, eyelid edema, exophthalmos, purulent dc, conjunctivitis, fever, restricted ROM of eyes, sluggish pupillary response, edema and erythema of lids
- dx: CBC< blood cx, cx of drainage → high WBC; CT scan → broad infiltration of orbital soft tissue
- tx: medical emergency requiring hospitalization, IV abx (broad until fever subsides, then 2-3wks PO; nafcillin and flagyl, or clinda, 2nd or 3rd gen ceph, and FQs; I and D, if MRSA suspected → vanco
4
Q
allergic rxn
A
- nonimmun rxn to food MC than true food allergies
- food allergy is dt abnl immune response following ingestion (exposure)
- non-IgE mediated allergy isolated to GI tract and/or skin manifestations
- sxs: more suacute and/or chronic, V/D, itching and/or burning
- signs: vesicular eruption (symmetrical on extensor surfaces of elbows, knees, buttocks, sacrum, face, neck, trunck, and occasionally w/in the mouth
- tx: stop transfusion if med related, tx with antihistamines
5
Q
foreign body aspiration
A
- asp of gastric contents, inert material, toxic material, or poorly chewed food, degree of injury depends on substance
- sxs: choking and coughing, wheezing or hemoptysis
- complications: asphyxia, PNA, acute gastric aspiration
- dx: CXR (regional hyperinflation dt check valve effect, cx if postobstructive PNA suspected
tx: heimlich maneuver, bronchoscopy → dxic ant txic
6
Q
anaphylactic rxn
A
- gen allergic rxn that is rapid and may cause death
- Immunoglobulin E (IgE), MCC in children = food, MCC in adultes = insect stings and meds
- RF: asthma, CV dz, resp dx, acute infxn (URI, fever), emotional stress, exercise, disruption of routine, premenstrual status
- sxs: difficulty breathing, LOC, flushing, swollen lips, tongue, or uvula, nasal dc or congestion, change in voice quality, sensation of choking or closing throat, SOB, cough, N/V/D, abd pain
- signs: hives, pruritis, periorb edema, conjunctival swelling, wheezing stridor, hypotonia, syncope, incontinence, dizziness, tachy, hypotension
- tx: ABCs, recumbent, NS bolus, albuterol
- 1ml IM epi to mid-outer thigh, repeat q5-15min PRN, NO absolute contraindications
- adjunct: diphenhydramine, ranitidine, methylprednisolone
- if refract: epi IV 0.1mcg/kg/min
7
Q
Burns
A
- first degree → MCC is overexposure to sunlight and breief scalding, only involves epidermis, painful but doesnt blister (resolves in 48-72hrs), erythema and minor micro changes
- tx: heals uneventfully, damaged skin peels off in 5-10d, no scarring
- second degree (partial thickness) → involves all of epidermis and some corium or dermis, extremely painful with weeping and blisters
- superficial → blister formation (increase in size)
- tx: most heal with expectant management w/ minimal scarring in 10-14d
- deep → reddish appearance or layer of whitish, nonviable dermis firmly adherent to remaining viable tissue
- tx: excise and graft (heal over 4-8wks)
- complications: conversion to full thickness burn by infxn
- third degree (full thickness) → prolonged exposure to heat, involvement of fat and underlying tissue; leathery, painless, nonblanching (white, dry, waxy)
- dx: lack of sensation in burned skin, lack of cap refill, leathery texture
- tx: requires skin grafting and escharotomy, no potential for reepithelialization
- fourth degree → affects underlying soft tissue
- Rule of nine: ant and post trunk each are 18%, each lower extrem is 18%, each upper extrem is 9%, head is 9%
- parkland or baxeter formula → 3-4ml/Kg/% burn of lactated ringers (half given during first 8 hrs, remaining half given over subsequent 16hrs)
8
Q
pneumothorax
A
- air in the pleural space (spontaneous primary (simple) w/o underlying dz (healthy), spontaneous reupture of subpleural blebs, MC in tall, lean men, 50% recurrence in 2y
- secondary (complicated) → underlying lung dz (MC COPD), asthma, ILD, neoplasm, CF, TB, life threateing
- traumatic - iatrogenic
- sxs: ipsilateral chest pain, sudden onset, dyspnea, cough, dec/absent tactile fremitus, mediastinal shift toward affected side, dec breaht sounds over affected side, hyperresonance
- dx: CXR confirms dx, visceral-pleural line
- tx: if small and asxatic, observe 10d +/- small chest tube; large +/- sxs → O2 w/ chest tube; secondary → chest tube drainage; repeat CXR daily until resolved
9
Q
tension pneumo
A
- air in pleural space; tissue surrounding opening acts as valve, air can enter but not leave; accum of air under + pressure → collapse of ipsilateral lung, shifts mediastinum away from affected side
- causes: mechanical vent, CPR, trauma
- sxs: hyTN, distended neck veins, shift of trachea away from affected side, dec breath sounds, hyperresonance
- dx: XR not necessary as this is a medical emergency
- tx: chest decompression with large-bore beedle (2nd or 2rd ICL MCL) followed by chest tube placement
10
Q
pulmonary embolism RF and sxs
A
- thrombus embolizes to pulm vasc tree via RV and pulm artery → causes cor pulmonale (severe)
- MC site → distal to bifurcation of main pulm artery in main lobar, segmental, or subsegmental branches of pulm a; saddle → bifurcation of main pulm a
- incidence = M>F
- RF: age >60y, malig, prior hx, hypercoag, prolonged immobilization or bed rest, long-distance travel, cardiac dz, obesity, nephrotic syndrome, major surg or major trauma, preg, E use (OCP)
- Virchows triad: hypercoag, venous stasis, endothelial injury
- sxs: dysp (at rest or with exert), pleuritic chest pain (worse with insp), cough, calf or thigh pain or swelling, wheezing, hemoptysis, syncope
- signs: tachypnea, tachycardia, rales, dec breath sounds, accentuated pulm component of S2, JVD, fever
- signs of RVHF: hypoTN and JVD, R-sided S3, parasternal lift, cyanosis
11
Q
pulmonary embolism diagnostics and tx
A
- dx: CXR, D dimer (if low clinical suspicion - do first), EKG (tachy and non specific ST and T wave changes - <10% shows S1Q3T3), + CT pulm angiogram w/ contrast (GOLD STANDARD), VQ scan, normal CXR required prior → test of choice in pregnancy, contrast allergy, and pts with renall insuff, doppler US of lower extrem, Increased A-a gradient, ABG shows resp alkalosis
- tx: O2, hemodynamically unstable (IVF, vasopressors: NE), anticoag
- prognosis: recurrenc common
- poor prognostic factors: hyponNa, elevated lactate, leukocytosis, age >65
12
Q
hydrocarbons, bases ingestion or poisoning
A
- hydrocarbons → mucosal irritation, V/bloody D, Cyanosis, resp distress, fever tachycardia
- dx: CXR, UA, EKG
- tx: O2, abx if PNA develops, avoid emetics and lavage
- bases (clorox, drano) → irritated mucous membranes, stomach perf, hepatotox, resp distress
- dx: EGD to determine degree of damage to larynx, esophagus, stomach
- tx: small amnts of water (diluent) avoid vomiting, supportive care
13
Q
Acetaminophen and ASA ingestion
A
- acetaminophen: especially in depressed pts → converts to free radicals → liver necrosis (occurs in hypoxic area around central veins called zone III)
- sxs: hepatic failure
- tx: gastric lavage (w/in 1st hr), charcoal (w/in 2 hrs), N-acetylcysteine (antidote)
- Aspirin (salicylates): V, hyperpnea, pulm edema, fever, encephalopathy, convulsions, coma, renal failure
- tx: induce emesis, charcoal to bind drug, correct dehydration with IVF, hemodialysis
14
Q
organophosphates (chlorthion, diazinon) and Iron ingestion and tx
A
- Organophosphates: salivation, lacrimation, sweating, urination, D, pulm congest, twitching, vonculsions, coma, miosis
- dx: measure red cell cholinesterase levels, blood glucose levels
- tx: ABCs, decontamination of skin, atropine + pralidozime
- Iron: itestinal bleeding, impaired coag, shock, coma, red urine
- dx: blood indices, met panel (acidosis), UOP, type and screen, LFTs
- tx: evoke emesis, gastric lavage, whole-bowel irrigation, desferoxamine, dialysis
15
Q
Mercury, lead, arsenic ingestion and tx
A
- mercury: overconsumption of fish; diarrhea, constricted visual fields, periph neuropathy, hyperhidrosis (sweating), renal fialure, tachycardia, HTN
- tx: chelating agents (succimer dimercaprol, penicillamine)
- Lead: ingestion lead-based paint, working with batteries or working with lead-based casting materials
- sxs: neuropathy and renal failure
- tx: chelating agents (succimer, dimercaprol
- Arsenic: pesticides or contaminated ground water; severe HA, abd pain, D, delirium, convulsions, and breath that smellslike garlic
- tx: chelating agents (succimer, dimercaptrol)
