Emergency Medicine Exam 3 Flashcards
(113 cards)
1
Q
Erysipelas organism
A
Strep
2
Q
Cellculitis organism
A
Staph
3
Q
Erysipelas v. Cellulitis presentation
A
Both warm to touch - erysipelas has more well defined borders
4
Q
Eval for Cellulitis or erysipelas
A
Only need labs if there are systemic symptoms, immune suppressed, failed outpatient therapy
5
Q
Workup with concern for abcess
A
Use a bedside US
6
Q
Outpatient management for erysipelas/cellulitis
A
No RF for MRSA keflex, ALT: clinda
MRSA risk: Bactrim, Doxy, Clinda
7
Q
When to return for cellulitis/erysipelas
A
Follow up with PCP in 2-3 days
ED if expands, or septic, abcess
8
Q
Inpatient management for cellulitis/erysipelas
A
If meets sepsis criteria or systemic toxicity
Rocephin, Cefzolin, or Clinda IV for MSSA
MRSA risk -Vanc or Daptomycin
9
Q
3 MRSA risk factor groups
A
Recent major or invasive healthcare interaction (surgery, hospitalization, dialysis, nursing home)
IV drug or Abx use
Close quarters - military, prison, sports
10
Q
Presentation of cutaneous abcess
A
Fluctuant, tender, painful nodule - softens over time
May start draining on its own - rupture
Systemic symptoms are rare
11
Q
Dx for abcess
A
US for pus
XR for foreign body
12
Q
Management of abcess
A
I&D with anesthesia around the wound lidocaine with epi
Culture of pus
Irrigate and pack with iodoform packing - one long piece
13
Q
Abx prophylaxis for abcess
A
Clinda or Vanc 30-60 minutes before
14
Q
4 Risk factors for endocarditis to consider before I&D of abcess
A
Prosthetic valves
Previous endocarditis
Congenital heart isease
Cardiac transplant with regurg
15
Q
Abx management for abcess tx
A
Mild may not need abx
Bactrim, doxy, or clinda PO for moderate
IV Vanc, linezolid, or clinda for severe
16
Q
5 Indications for abcess abx (usually we just give anyways)
A
Lesion over 2cm
Multiple abcesses
Extensive surrounding cellulitis
Immune suppression
Signs of systemic illness
17
Q
Abx we add for severe abcess tx if septic
A
Meropenem OR Zosyn (pip and taz)
18
Q
Presentation of DVT
A
Unilateral swelling, pain, cramping, red, warmth
Homans sign
19
Q
Measuring for DVT
A
Diffierence over 2cm in diameter in indicative
20
Q
Phlegmasia alba/cerula dolens
A
Large proximal DVT extending proximally - emergent
21
Q
8 Wells criteria
A
Active cancer
Paralysis
Bedridden
Localized tenderness
Swollen leg
Calf swelling unilateral
Pitting edema Unilateral
Collateral superficial veins
Prev hx
1 point each!
22
Q
Wells interpretation
A
0 or less - D dimer
1-2 high sensitivity d dimer
3+ US
23
Q
Management of DVT
A
Step 1 - Determine distal or proximal (larger than distal)
Step 2 - Determine risk of bleeding
Step 3 - Determine a treatment plan
24
Q
of risk factors for moderate risk of bleeding
A
1 risk factor
25
Management of proximal DVT without limb ischemia and with high bleeding risk
IVC filter
26
Management for proximal DVT without ischemia with mild/moderate bleed risk
DOAC - preferred
LMHW - ALT
27
Management of DVT with ischemia and high bleed risk
Surgical thrombectomy with IVC filter
28
Management for proximal DVT with ischemia and moderate/low risk
Catheter directed thrombolysis - followed by anticoagulant
29
Management for distal DVT patient with high bleed risk
IVC filter placement
30
Management for symptomatic distal DVT with Low/Moderate bleed risk
DOAC - preferred
LMWH - ALT
31
Management for asymptomatic distal DVT with Low/moderate bleed risk
Treat as symptomatic if extension suspected
Serial US for 2-4 weeks if extension not suspected
32
Admission criteria for DVT - 4
Proximal DVT
PE symptoms
High risk of bleeding
Comirbidities
33
Discharge criteria for a DVT - 3
Hemodynamically stable
Non renal insufficiency
No social concerns
34
Presentation of arterial limb ischemia - chronic
Classic claudication - only in 30% of patients
Atypical leg pain (at rest
Chronic non-healing wounds
Hair loss and muscle atrophy
35
Presentation of acute arterial oclusion
Sudden onset of severe constant pain
6 Ps. -Pallor, Pulseless, Paresthesia, Poikilothermia, Paralysis, Pain
36
Progession of arterial limb ischemia skin changes
Skin Pallor then Mottling/Cyanosis then Petechiae/Blisters then Necrosis
37
Diagnostics for arterial limb ischemia
Bedside doppler followed by ABI if flow is present
Doppler US for extent of occlusion
CTA/MRA may also be ordered
38
Management for rutherford I or IIa arterial limb ischemia
Get CT or MRA or US to determine level of severity
39
Management for rutherford stage IIb arterial limb ischemia
Immediate surgical consult for attempted revascularization
40
Management for stage III arterial limb ischemia
Amputation usually indicated
41
Pharm for arterial limb ischemia
Use UFH while waiting for surgery
Pain medication
42
6 things that go into rutherford score
Pain
Cap refill
Motor deficit
Sensory deficit
Venous doppler
Arterial doppler
43
Presentation of testicular torsion
Consider in abdominal pain complaints
Sudden onset - exercise, etc.
Severe and unilateral pain
N/V
Position has no effect
44
PE for testicular torsion
Transvere testicle
Absent cremasteric reflex
Anterior Epididymis
Firm and tender testicle
45
Bell clapper deformity
Positional deformity of testicle - RF for torsion
46
Dx for testicular torsion
Color flow duplex US of scrotum
May see pyuria on UA
47
Treatment for testicular torsion
Refer to urology
Goal to detorse in 6 hours - amputate after
Medial to lateral detorsion manually - 360 degree rotation
48
Testicular appendage torsion
Pain with blue dot sign - non emergent
US to r/o TT
Pain medicine and rest
49
Epididymitis and Orchitis pathogenesis
Think mumps with orchitis if unvaccinated
Think syphillis if vaccinated
Think STI under 35, Think E coli/Klebsiella over 35
50
Presentation of epididymitis and orchitis
Gradual onset of unilateral testicular pain
Affected testes hangs lower
Normal cremasteric reflex
Pain relieved by elevation (Prehn's +)
51
Dx for Epididymitis/Orchitis
UA with C&S
Catch very first bit of urine
PCR or DNA for GC or chlamydia
52
Tx for orchitis/epididymitis - 4 cases
Levaquin for E coli
Rocephin - GC
Doxy - for chlamydia
Rocephin and levofloxacin for anal intercourse
53
Presentation of scrotal abcess
Superficial and intrascrotal are possible
Unilateral scrotal pain and swelling
Penile discharge
54
Dx for scrotal abcess
US to determine superficial or deep
55
Management for superficial scrotal abcess
I&D at bedside and discharge
Sitz bath
56
Management for intrascrotal (deep) abcess
Don't I&D
Urology consult for surgery
Zosyn for immune compromised
57
Fourniers gangrene
Necrotizing fasciitis of perineal genital or perianal anatomy
MC in females
Polymicrobial
Deadly
58
Presentation/Progression of fournier's gangrene
Pain out of proportion followed by
Prodromal fever and lethargy
Intense genital edema and erythema
Dusky appearance gangrene then frank necrosis
59
Dx for fournier's gangrene
Look for air on a CT scan with contrast
60
Management of fournier's gangrene
Aggressive IV fluids
NPO
IV Zosyn
Opiate
Septic workup
61
Presentation of balanoposthitis
Hx of lack of hygeine
Purulent glans with foul odor
Satellite lesions for candida
62
Management of fungal balanoposthitis
Clinical dx
Topical nystatin/clotrimazole
PO fluconazole for severe
63
Management of bacterial balanoposthitis
Bacitracin or Mupirocin for mild - topical
PO Clinda or Flagyl for severe
64
When to swab for balanoposthitis
Recurrent - may consider circumcision
65
Management for paraphimosis - 3 options
Dorsal block of the penis
Compress the glans for 5-10 minutes to reduce
Needle aspiration via small puncture wounds if that fails
Dorsal slit last restort
66
Management of phimosis
Emergency if can't pee
Topical lidocaine with stretching to releive urinary retention
May do dorsal slit if needed
67
Presentation of priapism
Painful erection lasting over 4 hours at which point tissue damage occures
Irreversible damage after 24 hours
68
Ischemic priapism
Low flow - blood can't get out
Often an underlying condition
Low O2 high CO2
69
Non-ischmic priapism
Fistula from artery to vein
Non-painful
Normal ABG
70
Management of priapism
Dorsal block of penis
Two needles to aspirate corpora cavernosa - saline then pull
Phenylephrine ONLY in ischemic to cause vasoconstriction
71
2 diseases to think about for priapsim in a preadolescent
Sickle cell
ALL
72
Management of penile entrapment
Cooling/Compression followed by string technique or 18G needle aspiration
May also cut or surgically remove
Retrograde urethrogram afterwards and doppler US for blood supply
73
Presentation of penile fracture
Blunt trauma, snap and flaccid penis that becomes ecchymotic
74
Management of penile fracture
Urgent urologic consult
Preoperative retrograde urethrogram
Analgesics and antipyretics
75
Urethral foreign boies
Dx with an XR
Do not try to pull out
Consult Urology
Pain control
76
Urethral stricture presentation
Decrease in stream with spraying or unable to peeMa
77
Management of urethral stricture
Foley catheter insertion, suprapubic catherter if that does not work
78
Workup for urinary retention
Look for signs of stricture
Prostate exam
Neuro exam
GU and Pelvic exam
79
Best dx for urinary retention
Post void residual - stuff left over is indicative
80
Management for urinary retention
12-14G Foley catheter
Urgent consult if unable to pass
Irrigate with 3 port catheter if hematuria
81
Complications of urinary retention
Post obstructive diuresis - will develop electrolyte abnormalities, observe and admit if they have more than 200cc per hour after therapy
82
F/u for urinary retention
Admit if renal failure or post obstructive diuresis
All others follow up in 3-7 days
83
Confusion, Delerium, Dementia
Confusion - Alters from societal norms
Delerium - Acute change in mental ststus
Dementia - Chronic change in mental status
84
Alertness
Reponsive - can maintain arousal independantly
85
Lethargic
Fall asleep without verbal stimulus - can stay awake
86
Obtundation
Need physical (non painful) stimulus to be aroused
87
Stuporous
Need painful stimuli to be aroused
88
Lab to consider for hypoxic patients
ABG
89
IV access for AMS patients
2 large bore IVs for all patients
90
3 meds safe in all patients
Naloxone, Thiamine, Glucose
91
Giving thiamine and glucose
Give thiamine before glucose
92
GCS eye responses
Open spontaneously - 4
Open to verbal command - 3
Open to pain - 2
Do not open - 1
93
GCS Verbal responses
Oriented - 5
Confused conversation - 4
Inapropriate but words - 3
Incomprehensible sounds - 2
No verbal response - 1
94
GCS Motor responses
Obeys commands - 6
Purposeful movement to pain - 5
Withdrawal from pain - 4
Decorticate - 3
Decerebrate - 2
No motor response - 1
95
Six item screen for mental status
3 item memory
Day of week, Month, Year
96
Indications for a lumbar puncture
Suspicion of meningitis
Suspicion of subarachnoid hemorrhage (SAH)
Suspicion of nervous system diseases such as Guillain-Barré syndrome [6] and carcinomatous meningitis
Therapeutic relief of pseudotumor cerebri
97
Absolute CI to lumbar puncture
Midline shift - increased ICP
98
Management of delerium
Lower doses in older adults
Haldol - QT prolongation and extrapyramidal
Lorazepam - Respiratory depression
99
Observation for narcotic overdose
Observe for 1-1.5 hours before discharge - Narcan will wear off
100
Hypoglycemia in children
Under 45 with symptoms
Under 35 without symptoms
101
Management of hypoglycemia in children
Give oral sugar then IV
102
Neonate dextrose dose
D10W over 3-5 minutes
103
Infants and older children dextrose dose
D25W over 3-5 minutes
104
Disposition of children given IV dextrose
Admit all
105
Management of hypoglycemia in adults
D50W over 3-5 minutes
Continuous infusion to maintain over 100mg/dL may be needed
IM glucagon if no IV
106
Management for refractory hypoglycemia due to sulfonylureas
Octreotide
107
Hypoglycemia in adults with insulin pump
DO NOT remove insulin pump
Refer
108
Adults to admit for hypoglycemia
Related to long acting agents: Sulfonylureas, long acting insulin, Meglitinides
109
5 Actions of insulin
Glucose into cells
Potassium into cells
Anabolic environment
Inhibits breakdown of fat
Blocks breakdown of proteins
110
6 causes of DKA - 6 I's
Infection
Infarction
Insult
Infant - Pregnant
Indiscretion
Insulin - Not taking
111
Presentation of DKA - 3 main umbrellas
Hyperglycemia - Polydipsia, Polyuria
Volume Depletion - Orthostasis, Hypotension
Acidosis - Tachypnea, Fruity breath
112
Diagnostic criteria for DKA
Glucose over 250
Anion gap over 10-12
Bicarb under 15
pH under 7.3
113
Management of DKA - Step 1
