Adult EM Flashcards
(41 cards)
1
Q
Differential for Lower Quadrant Pain
A
- Pregnancy
- Appendicitis
- UTI
- Nephrolithiasis
- Bowel obstruction
- Ovarian torsion
- PID or TOA
- Ectopic
- Cecal volvulus
2
Q
3 Appendicitis Signs
A
- Rovsing - RLQ pain with LLQ palpation
- Psoas - RLQ pain with hip extension in lateral decubitus position
- Obturator - RLQ pain with internal rotation of hip
3
Q
What imaging should you choose if you suspect appendicitis?
A
- US in young females or if pregnant
* CT if older adult or male
4
Q
Tx of Appendicitis
A
NPO, IV abx, IVF, zofran or reglan and pain meds; SURGICAL
5
Q
Differential for SOB and Chest Pain
A
- Coronary
- A fib
- CHF
- Pericarditis
- Anxiety
- Cardiomyopathy
- Pleural effusion
- Pneumonia
- COPD
- Restrictive Lung Disease
- Cor pulmonale
- Pneumothorax
- PE
6
Q
Pathophysiology of PE
A
- Causes increase in pulmonary vascular resistance –> less LV preload –> R heart failure
- Inc in dead space (blood not reaching alveoli)
- Improves with administration of O2 unlike a shunt
7
Q
Classic PE EKG Finding
A
S1Q3T3 (inverted t wave in lead III)
8
Q
Imaging Choices for PE
A
CT pulmonary angio - unless pregnant or allergic to contrast
If pregnant use US of lower extremities
If allergic use VQ scan
9
Q
PE Tx
A
- If stable … heparin bridge to coumadin
* If unstable … embolectomy or TPA
10
Q
UFH v. LMWH
A
- Unfractionated (IV) - must monitor PTT q 6 hr
* LMWH (subQ) - no monitoring but must have good renal function
11
Q
Tx of Spontaneous v. Tension Pneumothorax
A
- Spontaneous …
- If >15% of lung field then place chest tube (b/n 4th and 5th rain in nipple line) + observe
- If < 15% of lung field and stable then dispo home
- Tension …
- Usually traumatic and unstable
- Use needle decompression at 2nd intercostal space in mid-clavicular line
12
Q
Causes of A Fib
A
- Cardiac - MV regurgitation, MI, WPW, conduction problem, pericardial pathology
- Hyperthyroid
- Hypothermia
- Pulmonary - PE, pneumonia, hypoxia, COPD
- Alcohol
- Infection
- Renal failure
- DM
- Obesity
- Digoxin
- Electrolytes abnormalities
- Cardiac or pulmonary surgery
13
Q
Tx of A fib
A
If stable … Ca ++ channel blocker (diltiazem) and usually convert on own
If unstable (hypotension and altered) … immediate cardio version and IV heparin –> Coumadin
14
Q
CHADS2 Score
A
- **0 is low, 1 moderate, 2 high so give med
- C - CHF
- H - HTN
- A - age > 75
- D - DM
- S - stroke (prior TIA or thromboembolism)
15
Q
Has-Bled Score
A
- **if greater than CHADS2 score then do not give med
- H - HTN
- A - abnormal liver or renal function (1 pt ea)
- S - stroke
- B - bleed hx or predisposition
- L - labile INRs
- E - elderly (> 65)
- D - drugs or alcohol (1 pt ea)
16
Q
Testicular Torsion v Epididymitis
A
Torsion
- neg cremasteric reflex
- high lie or horizontal lie
- no flow on US
- bimodal distribution (childhood and pre-adolescence)
- EMERGENT urology consult + detorsion (rotate medial to lateral “open the book”)
Epididymitis
-point tenderness at head of epididymis and at superior
pole
-most commonly secondary to STDs in adolescence
-Tx = IM ceftriaxone and oral doxy
17
Q
What is the #1 sign of a torsed appendage testis?
A
- blue dot sign; self-resolving
18
Q
What are possible etiologies of a R sided varicocele?
A
retroperitoneal tumor, RCC, renal vein thrombosis
19
Q
Differential for Flank Pain
A
- AAA
- PE
- Appendicitis
- Renal vein thrombosis
- Renal tumor
- Ectopic
- Bowel obstruction
- Pancreatitis
- Cholecystitis
- MSK
- Zoster
- Renal cyst
- Pyelonephritis
- Nephrolithiasis
- Hepatitis
- Peptic ulcer
- Diverticulitis
20
Q
3 Most Common Locations of Kidney Stones
A
ureteropelvic junction
iliac vessels
ureterovesicular junction
21
Q
Mgt of Kidney Stones
A
- CBC, CMP, UA
- pain meds, zofran, Flomax, IVF
- Imaging = US in pregnant women or kids; non-enhanced CT in adults
- Dispo - > 7 mm need surgical correction
22
Q
Differential for Sore Throat
A
- Strep throat (GBS) - treat w/ PCN; only steroids to lessen tonsil swelling
- EBV
- PTA/retropharyngeal abscess
- Epiglossitis
- Lemieres
23
Q
Centor Criteria
A
(if 2 then do rapid strep - specific so if pos then no culture, if negative but high suspicion get culture)
- No cough
- Fever
- Tonsilar exudate
- Cervical LN
24
Q
SIRS
Sepsis
Severe Sepsis
Septic Shock
A
- SIRS (2+)
- Temp > 38 or < 36
- HR > 90
- RR > 20 or PaCO2 < 32
- WBC > 12,000 or < 4,000 or >10% bands
- Sepsis
- SIRS + infection
- Severe Sepsis
- Septic + end organ damage
- Septic Shock
- Severe sepsis + hypotension
- Systolic < 90
- Drop >40 from baseline
- Refractory to IVF
- Severe sepsis + hypotension
25
Differential for Acute Abdomen
* Renal Colic
* Pancreatitis
* Mesenteric ischemia
* Diverticulitis
* Cholecystitis
* Appendicitis
* Perforation
* Bowel obstruction
* AAA
26
What is the most common AAA location?
Infra-renal
27
When do you treat a AAA?
5. 5 cm in males
5. 0 cm in females
OR if symptomatic
28
AAA Mgt
* US first
* Then ... CBC, BMP, CXR, EKG, type + screen, CT abdomen and pelvis w/ contrast
* Call vascular surgery
* 2 large bore IVs for hypotension
29
EKG Findings for STEMI Locations
* Inferior - II, III, aVF
* Lateral - V5, V6
* Anterior wall - V2, V3, V4
30
MI Mgt
* First - ASPIRIN
* Meds - MONA + beta + anti-coagulation
* Morphine, oxygen, nitrates, aspirin, beta blocker
* Dual anti-platelet if STEMI
31
Differential for RUQ Pain
* Gallstones / cholecystitis
* Hepatitis
* Gastritis / PUD
* Pancreatitis
* Pulmonary (RLL pneumonia)
* Fitz-Hugh-Curtis (PID)
32
Cholelithiasis
Cholecystitis
Choledocholithiasis
Cholangitis
* Cholelithiasis - stones
* Cholecystitis - stone in cystic duct
* Choledocholithiasis - stone in common bile duct (jaundice)
* Cholangitis - stone in biliary tree + bacterial infection (sepsis)
33
Tx of Cholecystitits
* abx, pain and nausea meds +/- GB removal
34
Charcot's Triad and Reynold's Pentad
* Charcot's triad
* 1- fever
* 2- RUQ pain
* 3- jaundice
* Reynolds Pentad
* 4- hypotension
* 5- altered mental status
35
Cholesterol v Pigmented Gallstones
Cholesterol
- Inc cholesterol and dec bile acids
- Fat, female, fertile, forty
- CF, family hx
- do not see on Xray
Pigmented
- black = hemolysis
- brown = bacterial or parasite infection
- sickle cell
- can be radio-opaque
36
Seizure
* Meningitis
* Known seizure disorder
* Anoxic brain injury
* Hypoglycemia
* Metabolic disorder
* Na problem
* Actually syncope
* Toxin or withdrawal
* Pregnancy
* Intracranial hemorrhage or other intracranial pathology
37
Generalized Sz
Simple Partial Sz
Complex Sz
Status Epilepticus
* Generalized = whole brain
* Simple partial = no altered mental status
* Complex = altered mental status
* Status epilepticus = 5 min continuous sz activity OR 2+ episodes without return to baseline between
38
Important Questions to Ask in Sz History
* ASK FOR WITNESS
* Any prodrome? Palpitations? Aura?
* Were they back to baseline immediately after?
* Movements? Length?
* Urinary incontinence or tongue biting?
* Did someone check blood glucose?
39
3 Lines of Tx for Status Epilepticus
* 1 - benzo (ativan) q 2 min X 5
* 2- phenytoin or phosphenytoin
* 3- phenobarbital OR levetiracetam OR valproic acid
40
PERC Rules
If none present then r/o DVT, pre-test probability < 15%, if any positive then do work-up w/ D dimer or imaging depending on risk
* Age > 50
* HR > 100
* SaO2 < 95% on RA
* Unilateral leg swelling
* Hemoptysis
* Recent surgery (requiring GA) or trauma in last 4 wks
* Prior PE or DVT
* Hormone Use - OCPs, estrogen replacement
41
Well's Criteria
* Clinical signs and sx DVT - 3 pt
* PE is #1 diagnosis or equally likely - 3 pt
* HR > 100 - 1.5 pt
* Immobilization for 3+ days or surgery in last 4 wks - 1.5 pt
* Previous DVT or PE - 1.5 pt
* Hemoptysis - 1 pt
* Cancer treated in last 6 mo or palliative - 1 pt
POINT SYSTEM
* < 2 pt - low risk (consider D dimer or PERC, if D dimer negative STOP)
* 2-6 pt - moderate risk (high sensitivity D dimer or CTA)
* > 6 pt - high risk (no D-dimer - right to CTA)
