ER Flashcards
1
Q
PET MAC
A
6 deadly causes of chest pain PE Esophageal rupture (Boerhaave syndrome) Tension pneumo MI Aortic dissection Cardiac tamponade
2
Q
Who gets admitted for syncope?
A
San Fran Syncope Rule (CHESS) CHF (hx or suspicion) Hematocrit <30% EKG abnormalities SOB w/ syncope episode Systolic BP <90 post arrival to ED
3
Q
What is the treatment for HTN emergency in the ER?
A
amlodipine (CCB), nicardipine (CCB) or clonidine (alpha 2 blocker)
4
Q
What are the most common causes of acute pancreatitis?
A
alcohol abuse and cholelithiasis
5
Q
Abdominal pain that is relieved by leaning forward?
A
acute pancreatitis
other sxs also include: N/V, epigastric pain that radiates to the back diminished bowel sounds fever Grey Turner sign, Cullen sign
DDx: hepatitis, AAA, GERD, MI, cholelithiasis
6
Q
What is the treatment for PID?
A
ceftriazone 250mg IM in a single dose + doxycycline 100mg PO bid for 14 days +/- metronidazole 500mg PO bid for 14d
7
Q
What is the definition of orthostatic hypotension?
A
decrease in systolic BP by 20mmHg or diastolic BP drop by 10mmHg
8
Q
In a pt who comes in for hypertensive emergency, we don’t normally want to lower their BP too fast, except with what condition?
A
aortic dissection
via nicardipine
9
Q
What is the initial test of choice for someone with heart failure?
A
TTE - transthoracic echo
10
Q
NYHA class 1
A
sxs only occur with vigorous activities, such as playing a sport
pts are nearly asymptomatic
11
Q
NYHA class 4
A
symptoms occur at rest. incapacitating
12
Q
What is the treatment for CHF in the ER?
A
sodium restriction
Lasix (furosemide - loop diuretic)
ACEI
13
Q
What are risk factors of nephrolithiasis?
A
gout hyperparathyroidism PUD crohn's disease IBD family or personal hx
14
Q
What are concerning sxs suggestive of MI?
A
diaphoresis and vomiting
15
Q
What are the components are heart score?
A
story EKG changes age risk factors (DM, HTN, obesity, family hx) troponin
16
Q
What PE needs to be done for someone who had a syncopal episode?
A
Neuro
orthostatic
possible rectal for occult blood
17
Q
What specifically should you look for on EKG for pts who had a syncopal episode?
A
BLOW Hard Brugada LOng QT WPW HOCM
18
Q
What is the most common chronic arrhythmia?
A
A. fib
19
Q
Describe what A. fib looks like
A
irregularly irregular rhythm ww/ narrow QRS, no P waves, just fib waves at 350-600 bpm w/ ventricular rate of 80-140
20
Q
What are possible complications of a. fib?
A
hypoTN, decreased CO, thromboembolism, cardiomyopathy
21
Q
What is the difference between stable and unstable a.fib?
A
unstable: hypoTN, AMS, refractory CP, acute HF
22
Q
What is the difference in treatment between stable and unstable a.fib?
A
both: CHADS-VASc2 - to determine the need for
unstable: synchronized cardioversion
stable: rate control: BB, CCB
if young w/ long afib: synchronized cardioversion perferred (after 3-4 weeks on anticoags)
23
Q
Describe what A. flutter looks like
A
regular rhythm
saw tooth waves at 250-350 bpm
24
Q
What is the difference in treatment between stable and unstable a. flutter?
A
Stable: vagal, BB, CCBs (or cardiovert if <48 hours)
Unstable: synchronized cardioversion
ultimate: radiofrequency ablation
IV ibutilide is good for converting flutter to sinus in acute cases
Amiodarone can be used post cardioversion for chronic management
everyone gets warfarin anticoagulation? keeping INR between 2-3
25
What is SVT?
regular rapid rhythm of >150
| MC d/t impulse re-entry or ectopic pacemaker above bundle of his
26
What is the treatment for SVT?
Unstable: cardiovert
Stable: vagal maneuvers first; then 6mg adenosine
if no response in 2 min, give 12mg adenosine
if wide complex SVT, treat as if VTach unless known WPW: procainamide
27
What does V. Tach look like?
3+ PVCs >100bpm
prolonged QT predisposes to V.Tach
28
Torsades de Pointes is most commonly caused by what?
hypomagnesemia or hypokalemia
29
What are the two shockable rhythms?
pulseless v. tach and v. fib
30
What defines a HTN emergency?
diastolic BP >115 mmHg with evidence of end organ damage
31
What are some causes of HTN emergency in pts without hx of HTN?
eclampsia - pregnancy
| acute glomerulonephritis
32
What is the treatment in the ER for HTN emergency?
amlodipine (CCB) or clonidine (alpha 2 agonist)
MAP should be gradually reduced by 10 - 20% in the first hour
the only time you rapidly reduce BP is for pts with aortic dissection
33
How does pulmonary HTN affect the heart?
decrease preload and decrease CO
34
What is the pathophys of cardiogenic shock?
decreased CO with adequate volume but evidence of tissue hypoxia
d/t MI, myocardiditis, valve dysfunction, cardiomyopathy, arrhythmias
35
What is the most common chronic arrhythmia?
A. fib
36
What is CHESS used for?
to determine if someone w/ syncope needs to be admitted
37
What is the first line treatment for stable a. fib?
rate control
BB - metoprolol
or
CCB - diltaizem
38
What is the first line treatment for unstable a. fib?
synchronized cardioversion
39
What are the components of CHADSVASC2?
```
CHF
HTN
Age > 75 (2 points)
DM
Stroke (2 points)
Vascular dz
Age 65-74
Sex - female
```
40
What is the first line therapy for an unstable bradyarrythmia?
unstable: AMS, hypotension, acute heart failure, refractory CP
atropine
41
What is the first line treatment for unstable tachy arrythmia?
synchornized cardioversion
42
What is the first line treatment for stable, wide tachy arrythmia?
amiodarone
narrow QRS? vagal --? adenosine
43
How do you treat HTN emergency?
amlodipine (CCB - 2.5mg)
| clonidine (alpha 2 - 0.2mg)
44
What is the initial tx for most symptomatic pts with CHF?
ACEI + diuretic
45
What is the initial test of choice for heart failure?
TTE (echo) - noninvasive assessment of anatomy and function
46
What % occlusion causes angina?
@ rest 90%
| w/ exercise 75%
47
What is the treatment for variant angina?
CCB + nitrate
48
What is the treatment for acute bronchitis?
symptomatic, bronchodilators
49
What is the treatment for acute bronchiolitis?
humidified O2
50
What is the treatment for epiglottis?
2nd/3rd gen cephalosporins
| Ceftriaxone/ceftaxrine
51
What is the treatment for croup?
dexamethasone (0.6mg/kg po x 1) + humidified O2
max of 10 or 20mg total?
52
What is the treatment for pertussis?
Macrolide (erythromycin)
53
What is the treatment for acute pericarditis?
NSAIDs
54
What causes aortic regurgitation?
```
Rheumatic heart disease, endocarditis
Marfans syndrome
syphilis
SLE
ankylosing spondylitis (bamboo spine)
```
55
What is the pathophysiology of aortic regurgitation?
Aortic valve fails to close during diastole which leads to blood flow back into LV from aorta at the same time that blood is flowing from LA to LV -- this leads to LV volume overload --> LVH --> CHF
56
What are the signs and sxs of aortic regurgitation?
diastolic decrescendo blowing murmur heard at the LUSB
widened pulse pressures
57
What increases the intensity of the aortic regurgitation murmur?
squatting, sitting forward, hand grip (think anything straining)
58
What decreases the intensity of the aortic regurgitation murmur?
decrease venous return: valsalva
inspiration
nitrates
59
What is the Austin Flint murmur and what is it associated with?
associated with aortic regurg
mid-late diastolic rumble at the apex secondary to retrograde regurgitation jet competing with antegrade flow from LA into LV (functional mitral stenosis)
60
How is aortic regurgitation diagnosed?
Echo
| CXR might show cardiomegaly and some pulmonary congestion if bad
61
What is the treatment for aortic regurg?
We want to decrease afterload (in hopes that this will decrease the back flow into LV?)
This is done with nitrates, ACEI, hydralazine (vasodilator)
(NOT BB--> they decrease HR and thus increase the amount of time in diastole)
surgery for those pts with LV decompensation: decreased EF
62
What causes mitral stenosis?
rheumatic heart disease MC
63
What is the pathophysiology of mitral stenosis?
obstruction of flow from LA to LV causing blood to back up in LA leading to pressure and volume overload --> pulmonary congestion/HTN
64
What is the clinical manifestation of mitral stenosis?
dyspnea MC sx
hemoptysis
a. fib
dysphagia (d/t esophageal compression from enlarged LA)
opening snap, early diastolic rumble at apex (low-pitched)
65
What age group presents with mitral stenosis?
since the MC cause is rheumatic heart disease the mean age is 30s-40s
66
What increases the intensity of mitral stenosis?
increasing venous return via squatting or left lateral decubitus position
67
What decreases the intensity of mitral stenosis?
decrease venous return by valsalva or inspiration
68
What is the treatment for mitral stenosis?
percutaneous balloon valvuloplasty/valvotomy
loop diuretics and Na+ restriction if congestion sxs
69
What is the most common valvular disease?
Aortic stenosis
70
What is the pathophysiology of aortic stenosis?
normal area: 3-4 cm2
sxs: <1cm2
stenosis leads to LV outflow obstruction --> fixed CO --> increases afterload (pressure overload) --> LVH
71
What is the clinical manifestations of aortic stenosis?
dyspnea (mc sxs)
Angina
Syncope (exertional)
CHF (worst prognosis)
narrowed pulse pressures (the opposite of aortic regurg)
once pts start having sxs their life span decreases dramatically if valve replacement not done
72
What is the murmur for aortic stenosis?
systolic ejection crescendo-decrescendo murmur at RUSB that radiates to carotid
73
What decreases murmur intensity in aortic stenosis?
decrease in venous return (valsalva, standing) handgrip
74
What increases murmur intensity in aortic stenosis?
increase in venous return: squatting, leg raise, leaning forward
75
How is aortic stenosis dx?
Echo
| LVH on EKG
76
What is the treatment for aortic stenosis?
```
no medication treatment
surgery is the only effective treatment
valve replacement for those sx pts
percutaneous aortic valvuloplasty
intraortic balloon pump
```
77
What is the MC cause of mitral regurg?
mitral valve prolapse
78
What is the pathophys of mitral regurg?
blood flows from LV to LA -- LV volume overload --> dilation --> decrease CO
79
What are the clinical manifestations of mitral regurg?
pulmonary edema
hypotension
dyspnea
chronic: a. fib
80
What is the murmur associated with mitral regurg?
blowing, holosystolic murmur @ apex with radiation
81
Humeral head fracture can cause what nerve damage?
brachial plexus or axillary nerve
82
Humeral shaft fracture can cause which nerve damage?
radial nerve --> wrist drop
83
Claw hand is which nerve damage?
ulnar nerve
84
Navicular fracture
anatomical snuff box tenderness
85
Which elbow dislocation is most common?
posterior MC
86
Which shoulder dislocation is most common?
anterior
| posterior is much less common and typically from muscle spasms d/t seizures, getting struck by lightening, and some MCVs
87
Monteggia fx
proximal ulnar fx with radial head dislocation at elbow
88
Galeazzi fx
distal radial shaft fx + dislocation of distal ulna
89
Beck's Triad
JVD
hypotension
muffled heart sounds
90
What is the treatment for asthma?
albuterol 2.5mg q 20-30 min
| albuterol, beta agonist, will increase HR
91
Which ABX should be given to a pt with COPD flare?
azithromycin (Z-pack)
92
A pts CXR shows PNA, when do you admit them?
CURB65
| Age >/=65, SBP <90 or DBP <60, confusion, BUN >19, RR >/=30
93
What is the PNA tx for an inpt?
azithromycin + ceftriaxone
94
What is the MC cause of hemoptysis?
bronchitis
95
What is the treatment for croup?
dexamethasone 0.6mg/kg po x 1 (max dose 20 mg)
96
Who gets tested for influenza?
<2yo, >/=65, pregnant, other underlying heart or lung dz)
97
What is the treatment for influenza?
tamiflu (oseltamivir) or relenza (zanamivir)
| only treat in sxs started <72 hours ago
98
What is the cause of whooping cough?
bordetella pertussis (there's a vaccine for it)
99
What is the treatment for pertussis?
o2, neb,
| abx only to decrease contagiousness (macrolides)
100
What pathogens cause CAP?
community acquired PNA
| s. pneumo (MC), mycoplasma (MC atypical "walking" PNA), h. flu
101
What is the common pathogen of PNA in alcoholics?
klebsiella
102
RSV
respiratory syncytial virus
common lung and URI in children <2 yo
tx: supportive treatment
103
What is one important assessment question you must ask pts in the ED with asthma or COPD exacerbation?
Have you ever been intubated before?
| *always ask triggers -- what were they doing when this began
104
How does albuterol work in asthma?
binds to beta receptors that activates to cAMP and decreased Ca2+ release --> smooth muscle relaxation
105
What are the most common causes of pleural effusion?
CHF, PNA, CA, PE
106
Transudate
```
typically bilateral (unlike exudate)
low protein
```
107
Exudate
typically unilateral
| high in protein
108
What is the treatment for pleural effusion?
thoracentesis (typically done by IR)
| or chest tube if large
109
How is pleural effusion dx?
pleural friction rub to auscultation
| blunting of the costophrenic angles (seen when fluid is >250ml)
110
What are the signs and sxs of tension pneumothorax?
increased JVP, pulsus paradoxus, hypoTN
unilateral pleuritic CP, decreased breath sound
decreased lung markings on CXR w/ respiratory view
111
What is the treatment for pneumothorax?
tension: needle decompression in the 2nd ICS at MCL (heaven is above and hell is below a rib)
chest tube for other pneumothorax that are >15% of diameter of hemithorax (2-3cm)
112
What questions must you ask when you assessing risk of PE?
```
hemoptysis
O2 sat
Hormone use
age >50
hx DVT or PE
surgery or trauma within last 4 weeks
```
tachy?
travel within the last 3 months
113
What is the treatment for PE?
Anticoagulation --> LMWH (Lovenox or enoxaparin)
IVC filters only for pts who are stable but can not have anticoagulation treatment
TPA only considered for pts who are hemodynamically unstable
114
White out on CXR
ARDS
| spares the costophrenic angles
115
How is ARDS dx?
white out on CXR
ABG PaCO2/FIO2 <200 refractory to 100% oxygen
catheter wedge pressure <18 (>18 = cardiogenic pulmonary edema)
116
What is the treatment for ARDS?
CPAP or mechanical ventilation (tx underlying condition)
keep O2 >90%
PEEP prevents airway collapse
117
How does someone with an anterior shoulder dislocation present?
arm abducted, externally rotated with loss of deltoid contour
118
What is the work up and treatment for anterior shoulder dislocation?
rule out axillary nerve injury
reduction with use of propofol +/- ketamine
inferior --> external rotation --> abduction of the shoulder
119
Light bulb or ice cream cone shape to shoulder xray
posterior shoulder dislocation
120
Proximal humerus fracture
FOOSH or direct blow
*common side of fx with breast ca metastasis
risk of brachial plexus or axillary nerve injury
121
What splint would you do for a humeral shaft fracture?
sugar tong
122
Humeral shaft fx
FOOSH or direct trauma
radial nerve injury risk --> wrist drop
tx: sugar tong splint
123
Supracondylar humerus fracture
FOOSH with hyperextended elbow, MC kids 5-10yo
risk of medial nerve and brachial artery injury
+ fat pads on elbow xray
tx: displaced: ORIF, nondisplaced: posterior splint
124
What is the MC bone fx in kids?
clavicle fracture
risk of brachial plexus injury or PTX
tx: mid 1/3: sling 4-6 weeks
proximal 1/3: ortho consult
125
Radial head fracture
FOOSH
posterior fat pad sign or displaced anterior fat pad
tx: sling if nondisplaced
126
Olecranon fracture
direct blow
risk of ulnar nerve damage
tx: reduction
127
Galeazzi fx
mid-distal radial shaft fx + dislocation of distal ulna
FOOSH
tx: ORIF
128
Monteggia fx
proximal ulnar fracture + anterior dislocation of radial head
direct blow to arm
tx: ORIF
129
What is the MC dislocation in kids?
elbow (posterior)
130
What is the MC carpal fracture?
scaphoid fracture (snuff box tenderness --> thumb spica splint)
131
Colles fracture
distal radius fracture w/ dorsal/posterior angulation
FOOSH w/ wrist extension (increase incidence post menopausal)
tx: sugar tong splint
132
Smiths Fracture
the opposite to colles fx
fall oto a flexed wrist
distal radius fx + anterior dislocation
133
Barton fracture
intra-articular distal radius fracture w/ carpal dislocation
134
perilunate dislocation
lunate and capitate no longer articular
| but lunate still articulates with radius
135
Lunate dislocation
lunate doesnt articulate w/ either radius or capitate --> emergency
"piece of pie" sign AP
"spilled teacup" lateral xray
136
Lunate fx
most emergent carpal fracture
avascular necrosis of this bone can lead to Kienbocks disease
tx: immobilize (refer to ortho?)
137
Boxers fracuter
fracture to the neck of the 5th metacarpal bone
communicated transverse fracture +/- loss of knuckle on exam
also check for bites (from fight --> tx: augmentin)
reduction
ulnar gutter splint
138
Bennett Fracutre
intra-articular fracture through base of 1st metacarpal bone with distal fragment dislocated radially and dorsally d/t abductor pollicus longus
ORIF
thumb spica for temporary stabilization
139
Acetabular fracture
MC pelvic fracture
| d/t high-impact injury
140
Hip dislocations
emergencies
MC posterior
Trauma MC cause
complications: avascular necrosis, sciatic nerve injury, DVT, bleeding
141
Shortened leg, internally rotated and adducted
hip dislocation
142
hip pain with shortened leg, externally rotated and abducted
hip fx
143
Legg Calve Perthes
idiopathic avascular necrosis of femoral head in kids d/t ischemia of capital femoral epiphysis
MC 4-10yo
M>F
painless limping
144
Slipped Capital femoral epiphysis
femoral head slips posterior and inferior at growth plate
MC age 7-16yo d/t growth spurt
tx: non-weight bearing
ORIF
145
Cauda eqine
EMERGENCY
nerve root compression of L4-L5 or L5-S1
urinary retention, loss of bladder/bowel control (decreased rectal tone)
tx: immediate surgical decompression
146
Saddle Anesthesia
loss of sensation in butt, inner thigh, perineum
147
Who is at increased risk of osteomyelitis?
IVDU, DM/immunocomp, children, sickle cell
| overlying infection or open fracture
148
Which bone fractures are more likely to spread infection throughout the blood?
pelvis, vertebrae, clavicles/sternum
149
What is the treatment for osteomyelitis?
need for tissue cultures for sensitivity
MSSA: nafcillin 2g IV q4h, cefazolin 2gIV q8h
MRSA: vancomycin 30mg/kg IV q24h (divided into 2-3 doses/day)
150
Monoarticular joint swelling
septic joint until proven otherwise
>10,000 WBC with a left shift is dx on arthrocentesis
knee is MC
151
What is the treatment for septic arthritis?
depends on the type of bacteria --> arthrocentesis, send for gram stain and culture
Gram + cocci: nafcillin
Gram - cocci or gonococcus: ceftriaxone
Gram - rods: ceftriaxone + anti-pseudomonal aminoglycoside (gentamicin)
No organism seen: nafcillin or vanc + ceftriaxone
152
How is osteomyelitis dx?
bone aspiration = gold standard
elevated ESR
periosteal reaction on xray
153
Costochondritis
acute inflammation of rib, clavicle, and/or sternal joints d/t viral infection
substernal pleuritic CP thats worse with arm movement
TTP and pinpoint pain to 2nd-5th costochondral junctions
154
What is the treatment for bursitis?
inflammation of bursa over bony prominence commonly d/t gout, inflammation, trauma, infections
limited ROM with flexion
tx: NSAIDs, local steroid injections
rest
155
Podagra
the 1st MTP joint that is the MC involved with gout
156
How can you tell gout from psuedogout?
gout: negative birefringent needle shaped crystals on arthrocentesis
157
Gout
uric acid depostion in soft tissue, joints, and bone
| MC d/t underexcretion of uric acid
158
What foods should be avoided in pts with gout?
high purine rich foods like alcohol, liver, seafood, yeast
159
What meds should be avoided in pts with gout?
diuretics, ACEI, ARB, ethambutol, aspirin
160
Punches out lesions or mouse bites on xray
gout
161
What is the treatment of gout?
acute: NSAIDS (not ASA), + colchicine
chronic: allopurinol (increases uric acid excretion
162
A pulled muscle is also called....
strain
163
Epigastric abdominal pain DDx
pancreatitis, PUD, MI, aortic aneurysms, gastritis
164
LLQ abdominal pain DDx
diverticulitis, ischemic colitis, appendicitis, gynecologic disorders
165
RLQ abdominal pain DDx
appendicitis, crohns disease, diverticulitis, ovarian torsion, gynecologic disorders
166
Abrupt vs waxing and waning abdominal pain
abrupt: perforation of a hollow viscus
| waxing and waning: colicky, suggests obstruction
167
Esophagitis
pill vs infection induced
Pill: doxyxycline, NSAIDs, bisphoshonates, KCl, quinidine
Infectious: MC in immunocompromised: candida, HSV, CMV
168
Odynophagia
painful swallowing
169
How is esophagitis dx?
esophagoscopy with biopsy and culture
candida: air contrast barium swallow shows ulceration and plaques
170
What is the treatment for infectious esophagitis?
candida: ketoconazole or fluconazole
HSV: acyclovir
171
How is pill esophagitis avoided?
take pill with lots of water and sit upright for 30min after taking pill
172
Mallory Weiss tear
partial thickness lacerations of the gastroesophageal junction caused by forceful emesis
self limiting in most people
more worrisome in alcoholic pts d/t risk of ruptured vericies
Dx: EGD
Tx: assess hemodynamics
173
PUD
erosion of mucosa that produce pain and can perforate into a blood vessel or into the peritoneal cavity
common cause of upper GI bleed
commonly d/t H. pylor
RF: smoking, alcohol, asa/nsaid use, fam hx
174
CP of PUD
burning/gnawing pain in epigastric region relieved by antacids, H2 blockers or PPIs
gastric ulcers: worse after eating
Duodenal: relieved with eating
175
PUD perforation presenstation
abrupt onset of epigastric pain w/ vomiting and diaphoresis
| diffuse abdomen with rigidity and guarding
176
Work up for PUD
CBC (H&H)
type and cross
PT/PTT
xray (free air = perforation)
177
What is the treatment for PUD?
uncomplicated H.pylori: clarithromycin, amoxicillin, PPI (avoid EtOH, caffeine, NSAIDs)
Hemorrhage: fluids, packed RBCs, IV PPI
perforation: NG suction, IV fluids, Cefoxitin, surgery
178
4Fs
```
risk factors for acute cholecystitis
female
fat
forty
fertile
```
179
How do pts with cholecystitis present?
constant, cramping RUQ or epigastric pain
+/- radiation to scapula
N/V
worse postprandial with fatty foods
RUQ tenderness --> Murphy's sign
+/- fever, jaundice
DDx: biliary colic
180
How is cholecystitis dx?
elevated WBC
+/- elevation in LFTs and bilirubin (esp if stone in common bile duct vs cystic duct)
US
HIDA - outpt
181
What is the treatment for cholecystitis?
IV fluids and bowel rest
surgical consult
*if stones are found coincidentally on scan, no tx required
182
How is biliary colic different from cholecystitis?
severe colicky pain that lasts several hours without fever or elevation in WBC, LFTS or bilirubin
tx: antispasmoidcs (dicyclomine)
183
Cholangitis
bacterial infection of the biliary system d/t impaction of gallstone in the common bile duct
Charcot's triad: RUQ pain, fever, jaundice
Reynold's Pentad: + hypotension, AMS
184
Charcot's triad
seen with cholangitis
RUQ pain, fever, jaundice
Ryenold's pentad: + hypotension, AMS
185
How is cholangitis dx:
RUQ US
AST/ALT 2-3x normal
total bil >3mg/dL
186
What is the tx for cholangitis?
ampicillin + gentamicin or ceftriaxone + metronidazole
+
urgent endoscopic cholangiogram (endoscopic sphincterotomy) with drainage of infected bile
removal of gallbladder 2 weeks later
187
Acute pancreatitis
inflammation fo the pancrease d/t inappropriate intrapancreatic activation of enzymes
MC cause: EtOH, followed by gallstones
CP: N/T, epigastric pain that radiates to the back, relieved by leaning forward
epigastric tenderness, diminished bowel sounds, fever, jaundice
Grey-Turners: flank ecchymosis
Cullen Sign: periumbilical ecchymosis
188
CP of acute pancreatitis
CP: N/T, epigastric pain that radiates to the back, relieved by leaning forward
epigastric tenderness, diminished bowel sounds, fever, jaundice
Grey-Turners: flank ecchymosis
Cullen Sign: periumbilical ecchymosis
189
Grey Turner sign vs Cullen sign
Grey Turner: flank ecchymosis
| Cullens: periumbilical ecchymosis
190
Acute pancreatitis labs
amylase (rises first)
lipase (more specific)
CT
US only used to r/o gallstone cause
191
Rnson criteria
and apache 2
| clinical prediction rules for severity (mortality) of acute pancreatitis
192
What is the treatment for acute pancreatitis?
IV fluids (250-500mL/h)
Fentanyl/hydromorphone (or meperidine) preferred over morphine (d/t sphincter of Oddi spasm)
NG tube for decompression
admission: severe pancreatitis w/ instability or end organ damage
193
What is the DDx of acute pancreatitis?
perforated duodenal ulcer, acute cholecystitis, acute SBO, leaking AAA, renal colic, acute mesenteric ischemia
194
Which age is most likely to get appendicitis?
10-19 yo
195
CP of acute appendicitis?
periumbilical pain that moves to RLQ
McBurnery point tenderness, rebound tenderness
Rovsing sign
Anorexia, N/V, +/- fever
196
What is the treatment for appendicitis?
ABX while waiting for surgery
| Ceftraizone (Rocefin) or Pip/Tazo (Zosyn)
197
Toxic megacolon
```
nonobstructive dilation (>6cm) of colon + signs of systemic toxicity
etiology: UC, chorhns, C. diff, infectious, radiation, ischemia
```
CP: fever, N/V?D, adb. pain, rectal bleeding, tenesmus
tachycardia, hypotension, AMS
Dx: xray
Tx: bowel decompression, bowel rest, NG tube, ABX?
198
What causes toxic megacolon?
UC, chorhns, C. diff, infectious, radiation, ischemia
199
How is toxic megacolon dx?
xray
200
What is the tx for toxic megacolon?
bowel decompression, bowel rest, NG tube, ABX?
| if refractory: colostomy
201
SBO
surgical adhesions MC > tumors> hernias> strictures, crohns
CP: cramping, inability to pass stool or gas, vomiting, abd distension
high pitched bowel sounds
Dx: Xray - air fluid levels (free air under the diaphragm = perf)
Tx: NG tube, NPO, IV hydration +/- surgery if no improvement in 12-24 h
202
How is SBO dx?
xray - air fluid levels
203
How is SBO tx?
NG tube, NPO, IV hydration, +/- surgery
204
Large bowel obstruction
MC colorectal carcinoma > volvulus > diverticular disease > hernia, foregin body, IBD
CP: distention, postprandial cramping/bloating, bowel habit changes, vomiting
Dx: Xray - haustral markings seen
Tx: NG tube, NPO, IV hydration --> surgery
205
Voluvulus
twisting of bowel more than 180 degrees at mesenteric attachment site
MC sigmoid colon
tx: endoscopic decompression
206
Anal fissure
linear tears distal to the dentate line
usually in the posterior midline
MC cause of anal pain
can be associated with Crohn's or UC
burning and stinging during defecation, minimal rectal bleeding
tx: high fiber diet, sitz bath after BM
207
Anal fistula
abnormal tracts from the anal canal, most often d/t external damage of an anorectal abscess, but can also come from diverticulitis, appendicitis, or IBD
CP: bloody or foul smelling discharge, recurrent inflammation
Tx: surgery
208
Anal abscess
often d/t bacterial infection of anal duct/glands
MC s. aureus, e. coli
anorectal swelling, pain worse with sitting, coughing, defecation
Tx: I&D followed by WASH: warm water, analgesics, sitz baths, high fiber diet
209
What is the difference between internal and external hemorrhoids?
dentate line
internal = above, painless rectal bleeding
external = below, painful bleeding
210
how can you tell the difference between thrombosed and not thrombosed hemorrhoids?
thrombosed are hard masses on exam
| not thrombosed are cushion like
211
What are the different classifications of hemorrhoids?
1st degree = simple internal
2nd degree = prolapsed internal that reduce spontaneously
3rd degree = prolapsed internal must be reduced manually
4th degree = can not be reduced
212
How do you dx internal hemorrhoids?
anoscopy or flexible endoscopy
213
What is the treatment for hemorrhoids?
conservative: high fiber diet, fluids, stool softener, sitz bath, topical analgesic ointment, hydrocortisone cream
External thrombosed hemorrhoid can be resected in the ED
internal: refer to colorectal surgeon
214
Gastroparesis
slowed gastric emptying
MC risk factors: DM, smoking mary jane
215
Gastritis
superfical inflammation/irritation of stomach mucosa
MC cause: H. pylori
NSAIDS/ASA: second MC d/t decrease in prostaglandin production
CP: epigastric pain, N/V, anorexia
Dx: endoscopy is gold standard
Tx: CAP (triple therapy) Clarithromycin + amoxicillin + PPI
216
What is the CP for gastritis?
epigastric pain, N/V, anorexia
217
What is the gold standard for dx of gastritis?
endoscopy
218
What is the treatment for gastritis?
CAP (triple therapy) Clarithromycin + amoxicillin + PPI
| since H. pylori is the MC cause
219
Colitis
same inflammation/irritation of superficial mucosa as in gastritis but specifically at to colon
tx: ciprofloxacin or metronidazole
cipro: risk of C. diff (consider augmentin)
220
What is the treatment for colitis?
ciprofloxacin or metronidazole
| cipro: risk of C. diff (consider augmentin)
221
Gastroenteritis
Viral( norovirus in adults, rotavirus in kids)
| Bacterial (salmonella, shigella, campy)
222
What is the treatment for gastroenteritis?
rehydrate, antiemetic, BRAT diet
| PO challenge prior to d/c
223
Gut motility is affected by what?
diet, activity level, anatomic lesions, neurologic conditions, medications, toxins, hormones, rheumatologic conditions, infection, psych
224
Acute constipation
SBO until proven otherwise
| keep suspicion high tho, don't just assume constipation d.t hx of constipation
225
What tests must your run for a pt with constipation?
CBC, electrolytes (BMP), thyroid panel
hypothyroidism or hyperparathryoidism can cause constipation
increase CA2+, decrease Mg2+, decrease K+
226
What is the treatment for constipation?
metamucil (psyllium)
milk of magnesia
manual fecal disimpaction
227
Diarrhea
3+ watery stools per day
85% have infectious etiologies
228
Crohn's disease
part of IBD
segmental ulceration of the GI tract ANYWHERE
"skip lesions"
cobblestoning
no blood
diarrhea for several years, anorexia, weight loss
229
What is the treatment for Crohn's disease?
ED: IVF, parenteral analgesia (viscus lidocaine), bowel rest, correct electrolyte abnormalities if present
prednisone gives sx relief but doesnt alter dz
labs: CBC, type and cross, plain filsm for poss obstruction or toxic megacolon
230
What are some complications of Crohns disease?
intra abdominal abscess, fissures, fistulas, toxic megacolon, malnutrition, anemia
Extrainestinal: arthritis, uveitis, nephrolithiasis, hepatobiliary dz, thromboemolic dx, skin disease
231
Ulcerative colitis
ALWYAS includes the rectum
continues proximally up the colon
+ bloody diarrhea
complete remission between flares
232
What is the treatment for ulcerative colitis?
IVF, parenteral analgesia, bowel rest, correction of electrolyte abnormalities
avoid anti-diarrheals d/t risk of toxic megacolon
233
What are possible complications of ulcerative colitis?
MC GI hemorrhage, perforation
higher risk of colon CA
extraintestinal: ankylosing spondylitis, peripheral arthritis, uveitis, hepatobiliary dz, erythema nodosum, episcleritis
234
Recent travel to mexico or asia and now has diarrhea
enterotoxigenic e. coli (same with undercooked beef)
235
What is the treatment for C. diff?
mild: metronidazole 500mg PO for 10-14 days
Severe: PO vancomycin 125-250mg
236
Potato salad and now has diarrhea
staph aureus or salmonella (d/t mayo)
237
What is the most common cause of upper GI bleed?
PUD (50%)
| gastritis, mallory weiss tear, esophgeal varices
238
What is the most common cause of lower GI bleed?
Young children: Meckles diverticulum, IBD, polyps
Adults: diverticulosis, IBD, neoplasma
60+: diverticulosis, neoplasms, angiodysplasia
239
Diverticular disease
herniations of the colonic mucoas through the muscularis propria
thought to be caused by a low fiber diet
leads to less stool mass and constipation --> higher intracolonic pressures --> muscular hypertrophy --> promotes herniation
sigmoid colon (LLQ) MC
increasing incidence with age
only a problem if it causes pain, bleeding, diverticulitis
MC cause of lower GI bleed
240
Where is divertiuclar disease most common?
LLQ - sigmoid colon
241
Diverticulitis
inflammatory condition (d/t infection/obstruction) leading to microperforation of the diverticulum which is usually d/t the lodging of feces in the pouch --> LLQ pain worse with BM, fever, dysuria
242
What is the test of choice for diverticular disease?
CT
243
What is the treatment for diverticulitis?
clear liquid diet
| Ciprfloxacin or Bactrim + Metronidazole
244
What is the treatment for diverticula?
high fiber diet
| bleeding: fluids, blood products, octreotide (to reduce bleeding?)
245
Ischemic colitis
MC type of bowel ischemia (vs mesenteric ischemia)
| inflammation and injury of the large intestine d/t insufficient blood supply
246
How is ischemic colitis dx?
CT most commonly used
colonoscopy, barium enema
heme + stool
247
What is the treatment for ischemic colitis?
IV fluids, ABX, admit
248
Mesenteric ischemia
DANGEROUS - 80% mortality rate
etiology: embolism, thrombosis or low flow states
embolism obstruction most commonly occurs in superior mesenteric artery
249
What are risk factors for mesenteric ischemia?
old age, afib, atheroscleorsis
250
How do pts with mesenteric ischemia present?
pain out of proportion to exam in the periumbilical region
251
Hemo-concentration
increased HgB that is actually false
| d/t dehydration or bleed?
252
How is mesenteric ischemia dx?
CTA
253
What is the treatment for mesenteric ischemia?
IVNS and immediate surgery consult
254
What is the classic symptom of PVD?
peripheral vascular disease
intermittent claudication - reproducible pain in LE during exercise that is relieved with rest
255
Hyperbilirubinemia
jaundice
typically presents in sclera first - around 2 - 2.5mg/dL
256
Excess levels of Unconjugated vs conjugated bilirubin
unconjugated: hemolysis: increased production of bilirubin; or liver defect in the conjugation of bilirubin
conjugated: decreased excretion of conjugated bilirubin via intestinal tract
257
Hepatitis A
RNA virus
fecal oral transmission
self limited
no chronic form or carrier state
258
Hepatitis B
DNA virus
spread via IVdrugs or sex
incubation 1 - 6 months
10% develop chronic or carrier
259
Hepatitis C
```
DNA virus
spread IV drugs
incubation 2 weeks - 6 months
Milder than HBV
50% develop chronic
```
260
Hepatitis D
can only replicate in the presence of HBV (acute or chornic)
261
Hepatitis E
waterborne RNA virus endemic to Mexico, Asia, Africa
| tends to cause fulminant hepatitis in pregnant women
262
How do pts with hepatitis present?
jaundice, dark urine, pale stools
liver is usually enlarged and tender
=
icteric phase
263
What labs can you expect for a pt with hepatitis?
AST and ALT >10x normal limit
elevations 2-3x with AST > ALT = alcohol-induced liver damage
Alk phos elevation = biliary obstruction or gallbladder dz
low serum albumin, glucose and prolonged PT
264
What is the treatment for hepatitis?
IV fluids, antiemetic, VitK for elevated PT
prophylaxis for household and sexual partners for HepA/B pts
Hep C: sofosbuvir and simprevir
most pts can be treated outpt
265
What is the treatment for alcoholic hepatitis?
fluids with D5W
thiamine 100mg w/ banana bag
correction of electrolytes (esp. Mg, K)
paracentesis for symptomatic ascites
266
What is a hernia?
protrusion of a viscus through an opening into an abnormal location
267
What are the different types of hernias?
Inguinal (75%): indirect are m/c --> bowel travels down a patent processes vaginalis into inguinal canal, can progress into scrotum
direct --> bowel protrudes through a defect in the abdominal wall in Hesselbach triangle
increase with age and physical exertion
Incisional (10%): occur at sites of previous abdominal surgery
Umbilical (5%): mostly in women
Femoral (5%): almost half of these become incarcerated or strangulated
268
Infectious diarrhea is most commonly what?
70% - viral
24% - bacterial
6% - parasitic (think chronic diarrhea, travel hx, immunocompromised)
269
Dysenteric vs nondysenteric pathogens causing diarrhea
nondysenteric: viral, s.aureus, b.cereus, ETEC, botulism, cholera, giardia
no mucus, no blood, no colon involvement, +/- fever
dysteteric: salmonella, shigella, campy, yersinia, C. diff
+mucus, + blood, + colon, + fever
270
B. Cereus
Fried rice
271
ETEC
travelers diarrhea
tx: supportive, cipro x 5 days
272
Cholerae
rice water stools
gulf coast of texas and louisianna
single dose of cipro may shorten course
273
Giardia
MC intestinal parasite in US
tx: metronidazole x 7 days
274
Salmonella
dysentery
very common
treat sever illness or immunocompromised
Cipro x 7d
275
Shigella
dysentery
very common, esp in kids
"sheets" of WBC in stool
tx: cipro x 3-5d
276
Campylobacter
dysentery
backpackers diarrhea
tx: cipro for high risk pts
277
Which dysentery infection mimics appendicitis?
yersinia
tx: cipro for at risk pts
278
EHEC
grossly bloody diarrhea that mimic GI bleed or mesenteric ischemia
ABX will increase risk of complications
279
C. Diff
dysentery
hx of clindamycin, PCN, or cephalopsorin use
tx: metronidazole or vancomycin x 14 days
280
Entamoeba histolytica
dysentery
may develop hepatic abscess
tx: metro x 10 days followed by iodoquinol x 20 days
281
What are the different antiemetics used in the ED?
prochlorperazine (compazine): 5-10mg IV in adults
odansetron (zofran): 4-8mg IV adults
Promethazine (phenergan): 12.5-25mg IV (use with caution in elderly, can lead to AMS)
Metoclopramide (Reglan): 5-10mg IV in adults
282
What is the risk of using antidiarrheals?
such as loperamide (imodium), bismuth (pepto-bismol)
risk of toxic megacolon or colitis
283
What is the most common GI complaint in the US?
constipation
acute is much more concerning than chronic (but don't get anchored just because they have a hx of constipation)
284
What is the work up for someone with constipation?
CBC (r/o anemia)
thyroid panel (r/o hypothyroid or hyperparathyroid)
CMP (r/o electrolyte issues - hypokalemia, hypercalcemia)
abdominal xray - obstruction
285
What are the treatment options for chronic constipation?
milk of magnesia
mag citrate
lactulose
sorbitol
286
What is the most common cause of cirrhosis?
chronic viral hepatitis
| alcoholism
287
How to pts with cirrhosis present?
typically in the ED d/t worsening ascites or edema or bleeds or encephalopathy
common s/s: anorexia, muscle loss, fatigue, n/v, ascites, low grade fever
288
What is the treatment for spontaneous bacterial peritonitis?
cefotaxime 2mg IV
289
What fluids can you give a pt you suspect has encephalopathy?
D5W
290
Ascariasis
parasitic infection that travels through bloodstream to lungs
cough, fever, hemoptysis, eosinophilia
tx: pyrantel pamoate
291
Pinworm
intense pruritus around anus at night
tx: pyrantel pamoate
292
Hookworm
chronic anemia, cough, fever, diarrhea, weakness, eosinophilia
tx: pyrantel pamoate
293
Threadworm
rash, cough, dyspnea, PNA , bloody mucoid diarrhea
tx: thiabendazole
294
Whipworm
anorexia, diarrhea, rectal prolapse in peds
tx: mebendazole
295
Schistosomiasis
hepatosplenomegaly, ascites, liver failure
296
Tapeworm
fish: MC - pernicious anemia
Beef
Pork
297
Trypanosomiasis
can cause Chagas dz, CHF, myocarditis, megacolon
298
What is the most common cause of vertigo?
BPPV
d/t canalithiasis in the semicircular canals
299
How is BPPV dx?
dix-hallpike test
300
How is BPPV tx:
Epley maneuver
301
Blepharitis
inflammation of eyelid margin
d/t staph, chronic inflammation, lid gland dysfunction
tx: warm compresses + erythromycin cream
302
Conjunctivitis
viral: adenovirus, coxsackievirus, enterovirus, herpesvirus
bacterial: staph, strep, gonorrhoaea
allergic
itching, tearing, redness, sensation of FB
303
What is the tx for conjunctivitis?
erythromycin (length of eyelid every 6 hours)
alt: polymixin-trimethoprim
FQ (preferred for contact lens wearers)
304
What is a blow out fx?
fx to orbital floor d/t trauma
tear drop sign on CT
decreased visual acuity, diplopia that is worse with upward gaze
tx: AVOID blowing nose, corticosteroids reduce edema, ABX (d/t sinus exposure to eye cavity)
surgery consult with ENT
305
"Blood and thunder" fundus
hyphema
pooling of blood in the anterior chamber
photophobia + anisocoria
tx: emergency referral for associated ocular trauma
elevation of head to 30 degrees
bilateral patching
306
Acute angle glaucoma
ocular ischemia/infarction d/t intraocular HTN d/t aqueous outflow obstruction
s/s: mid-dilated fixed pupil w/ sluggish light reflex, photophobia, HA, N
*HA in older pts could be first sign of glaucoma
tunnel vision, "steamy" cornea
307
How is acute angle closure glaucoma dx?
applanation tonometry
(>21mmHg)
gonioscopy >40mmHg
308
How is glaucoma tx?
- Acetazolamide (first line) to decrease intraocular pressure by decreasing aqueous humor production
- topical BB (timolol) to reduce IOP without affecting visual acuity
- miotics/cholinergics (pilocarpine, carbachol) to induce papillary constriction
309
AMD
age related macular degeneration
central portion of the retina degenerates -- central vision loss
dry: atrophic
wet: neovascular or exudative
amsler grid given to dry AMD to monitor progression of dz
inhibit VEGF reduces neovascularization in wet AMD (bevacizumab)
310
What is the treatment for wet macular degeneration?
reduce neovasularization by inhibiting VEGF with intravitreal anti-angiogenics like bevacizumab
311
Optic Neuritis
acute inflammation and demyelination fo optic nerve
MS is MC cause (ethambutol tx for TB can also cause this)
loss of color vision
unilateral vision loss after a few days
pain with eye movement
tx: IV methylprednison followed by PO steriods
312
What is the treatment for optic neuritis?
IV methylprednisone followed by PO steroids
313
Papilledema
usually bilaterally optic nerve swelling secondary to increased ICP
HA, N/V, enlarged blind spot in vision (negative Marcus Gunn pupil 0 see in optic neuritis)
dx: swollen optic disc on fundoscopy
CT to r/o mass then LP to determine if increased CSF pressure
tx: diuretics (Acetazolamide to decrease prodcution of CSF and aaqueous humor)
314
What medication decreases the production of aqueous humor and CSF?
acetazolamide
315
Retinal detachment
separation of neurosensory retina from pigmented retinal epithelium; d/t vitreous contraction/liquification
s/s: painLESS monocular vision loss preced by floaters
dx: bedside US, indirect ophthalmoscopy
tx: emergent referral for surgical photocoagulation, cryotherapy, vitrectomy, scleral buckle insertion
316
What is the treatment for retinal vein occlusion?
urgen intravitreal VEGF inhibitor
s/s: painLESS sudden monocular visual blurring
dx: dilated fundoscopy, retinal angiography
317
What is the treatment for barotrauma?
open eustachian tube (chew gum, valsalva, yawn)
antihistamines (benadryl)
decongestantns (sudafed, mucinex)
318
What is barotrauma?
abrupt onset of conductive HL
| dizziness, tinnitus, vertigo, N/V, TM rupture
319
Labyrinthitis
peripheral vertigo
dizzy, fluctuating hearing loss, N/V, tinnitus, malaise, nystagmus
320
Mastoidisits
usually extension of AOM or AOE (s. pneumo, s. pyogens, s aureus)
fever, chills, erythema of mastoid process
post auricular pian
fluctuant mass
tx: ENT referral
admission
cefotaxime or ceftriaxone
321
What is the treatment for mastoiditis?
```
cefotaxime or ceftriazone
ENT referral (inpt)
```
322
PTA
peritonsillar abscess
occurs when acute pharyngitis or tonsillitis spreads to the surrounding tissue in the pharynx causing collection of pus
B - hemolytic strep
hot potato voice
odynophagia x 2-3d
trismus
+/- CT w/ contrast
Tx: I&D - refer to ENT
ABX: augmentin or clindamycin (PO)
Unasyn (amp-sulbactam) IV
323
What is the treatment for PTA?
```
augmentin or clindamycin PO
IV unasyn (amp - silbactam)
```
324
Dental abscess treatment
drainge with scalpel
PCN VK or clindamycin
augmentin for dental pain?
325
Thumb print sign
epiglotitis
sudden onset fever, drooling, tripoding, tachypnea, stridor, toxic appearing
dx: lateral cervical x-ray
tx: Urgent ENT consult for airway management
heliox _ cefuroxime
326
What is the treatment for epiglotitis?
Urgent ENT consult for airway management
| heliox _ cefuroxime
327
Anterior vs posterior epistaxis
anterior: Kiesselbach plexus
posterior: sphenopalatine artery (behind septum)
328
What is the the treatment algorithm for epistaxis?
1) pinch nose fo 15-20min + afrin (vasoconstriction)
2) look for site of bleeding - cautery with silver nitrate
3) packing with rhinorocket
ABX - augmentin
F/U with ENT in 48hours
329
Centor Criteria
used to determine if you need to screen and treat strep
tonsillar exudate
fever of hx of fever >38
tender anterior cervical lymphadenopahty
absence of cough
3+ = consider ABX
330
What is the ABX treatment for strep?
PCN g single dose
alternatives: PCN V 250mg q6h x 10d
first and second gen cephalosporins
erythromycin
331
Fe deficiency anemia
increase transferrin
increase TIBC
decrease ferritin (Fe stores)
332
Pernicious anmeia
B12 deficiency
autoimmune destruction/loss of gastric parietal cells that secrete intrinsic factor --> leads to B12 deficiency
333
Hypersegmented neutrophils
b12 deficiency - macrocytic anemia
334
swimmers ear
otitis externa
MC is pseudomonas
S/S: ear pain, swelling of ear canal, purulent exudate
tx: otic drops - aminoglycosides or FQ
335
Acute OM
MC in infants and children
s. peunoma, H. flu
amoxicillin if <2
watch and wait if >2
336
Acute laryngitis
usually viral following URI
if bacterial: M. catarrhalis or H. flu
s/s: hoarseness
tx: vocal rest
bacterial: erythromycin or augmentin
337
What causes tympanic membrane perforation?
rupture can occur for infection (AOM) or trauma
tx: avoid moisture, most resolve on their own
338
Acute sinusitis
S. pneumo, H. flue, M catarrhalis, s aureus
TTP over affected sinus
complications: orbital cellulitis, osteomyelitis
tx: NSAIDs for pain + saline washes
if sxs >14 days tx: amoxicillin
339
Sickle cell has what type of inheritence pattern?
autosomal recessive
340
Howell - Jolly bodies
can be seen with sickle cell anemia
| as well as nucleated RBCs and target cells
341
What is the treatment for sickle cell anemia?
hydroxyurea
PCN daily until 6yo
blood transfussions
342
AML vs ALL age distribution
```
ALL = kids 3-7yo
AML = adulthood
```
343
S/S of leukemia
thrombocytopenia
neutropenia
lymphadenopathy and hepatsplenomegaly = ALL
Pancytopenia w/ blasts
Auer rods in AML for bone marrow biopsy
344
Auer rods
AML
345
JAK2 mutation
diagnostic for polycythemia
+ high Hct >50%
346
Tx for polycythemia
serial phlebotomy
| hydoxyurea
347
Epi of pilonidal cysts?
M > F
15-30
hair follicles become infected
I&D
348
Pressure sore stages
1: non-blanching redness; skin intact
2: open ulcer
3: full thickness - visible subq fat
4: full thickness - exposed muscle or bone
349
Dacyoadenitis
lacrimal gland disorder
usually sterile inflammation (infectious rare - G+)
S/S: tenderness, swelling
Tx: steroids; chronic condition is less responsive to steroids
350
What is the plan for a pt who comes in with hematoma of the external ear that began 7 days ago?
referred to ENT/surgery
best time to I&D is within first 24 hours --> ENT consult if longer than 24 hours
351
Hodgkin's lymphoma
lymphocyte neoplasm
bimodal distribution 20s and > 50s
painless lymphadenopathy --upper body with contiguous spread
EtOH can cause lymph node pain
*mediastinal lymphadenopathy
B-sxs
Dx: excisional biopsy - Reed Sternberg Cells - owl-eye appearance
Tx: local radiation
+/- chemo depending on stage
352
Reed Sternberg Cells
Hodgkin's lymphoma
owl eye appearance on biopsy
353
Painless lymphadenopathy or the upper body
Hodgkin's lymphoma
| mediastinal lymphadenopathy
354
Non-Hodgkin's lymphoma
lymphocyte neoplasm with diffuse B cells and T cells
peripheral lymph nodes MC
S/S: painless lymphadenopathy
tx: Rituximab?
355
What is the distribution of non-hodgins lymphoma?
peripheral lymph node
356
What is the most common cause of cellulitis?
S. aureus
357
Whatis the treatment for Cellulitis?
Keflex PO outpt
| IV Vanco inpt
358
How is DM dx?
if 2 fast glucose (greater than 8 hours apart) are 126+
if hemoglobin A1C is 6.5%+
if any random glucose test is 200+
359
What is the difference between SJS and TENS?
```
SJS = <10% body surface area sloughing
TENs = >30% bsa sloughing
```
+Nikolsky sign
360
Which drugs are known for causing SJS or TENs?
```
SATAn
sufla
allopurinol
tetracyclines
anticonvulsants
NSAIDs
```
361
What is the treatment for lice?
pediculosis
Nix (permethrin)
head: 10 minutes
body/pubic: 8-10h
PO ivermectin if refractory
362
Scabies
```
Type 4 hypersensitivity reaction
mites transmitted via prolonged close skin to skin contact or fomites
takes 3-6 weeks to develop sxs
spares neck and face/scalp
intense pruritis that is worse at night
```
dx: clinicla, skin scrappings, felt pen
tx: permethrin (nix) applied full body for 8-14hours
repeat in 7 days
treat family members and sexual contacts
may return to work/school after on tx for 24 hours
363
How can you tell RSV from asthma or reactive airway disease?
RSV will not improve with albuterol tx
364
Bronchioloitis
MC lower resp infection in pts <2 yo caused by RSV
rhinorrhea, cough, low grade fever, tachy
self limited, typically improves in 2-5 days
365
What does the EKG of someone with pericardial effusion look like?
low voltage
electrical alternans
sinus tachy
366
What is the treatment for an EKG with tachycardia, no P waves, and narrow QRS waves?
plus its an irregularly irregular rhythm
A. fib: rate control = diltiazem or metoprolol
if this was just tachycardia and not a.fib then the treatment would be adenosine
you can tell the different by whether or not the rhythm is regular
367
What is the first line treatment for someone with aortic dissection?
Esmolol
we want to control the rate before we control the vasodilation to prevent reflex tachycardia and thus more shearing (nitroprusside)
368
Type A vs Type B aortic dissections
Type A = ascending = immediate surgery
| Type B = descending = medical management
369
What medication is classically implicated in causing nephrogenic diabetes insipidus?
lithium
370
Myxedema coma is seen with which thyroid condition?
hypothyroidism
371
Osteomyelitis in children is dx how?
MC sxs: fever + joint pain
elevated ESR and CRP are 98% sensitive for osteomyelitis in peds
gold standard: bone biopsy + culture
xray: periosteal elevation or bony erosions
372
What are the back pain red flags?
weight loss, night pain (tumor)
fever, chills, sweats (infection)
acute bony tenderness (fracture)
morning stiffness >30min in young pt (seronegative spondyloarthropathy)
373
Steeple sign
croup
| subglottic tracheal narrowing
374
Testicular torsion
young male with intense scrotal pain
no cremasteric reflex
dx: doppler US
375
"Machine-like" murmur
PDA
pulmonary artery to descending aorta
bounding pulse
poor feeding
tx: IV indomethacin
this is why pregnant pts can NOT take NSAIDs --> premature closure of PDA
376
What is a common side effect of lithium?
nephrogenic diabetes insipidus
377
Horner's Syndrome
ptosis, miosis, anhydrosis
seen in cluster HA - unilateral
nasal congestion, lacrimation, conjunctivitis
378
What is the first line treatment for cluster HA?
100% oxygen
| prophylaxis: verapamil
379
What is the treatment for migraines?
MC in women
```
triptans or ergotamines (5HT1 agonists)
DA antagonist (compazine, metoclopramde)
```
toradol 30mg IV
380
What is the most common type of HA overall?
tension HA
381
Middle meningeal artery bleed?
epidural hematoma
lucid interval
balloon shape on CT - does not cross suture lines
382
Tearing of the bridging veins
subdural hematoma
crescent moon shaped - crosses suture lines
neurologic emergency - surgical intervention to decrease ICP
surgery within 2-4h
383
Status epilepticus treatment
Lowestein algorithm
lorazepam 2mg IV (or diazepam)
Phenytoin 20mg/kg IV
Phenobarbital
384
What is the treatment for Bell's Palsy?
UNABLE to raise eye brows
prednisone 60-80mg/day x 1 week + patching of eye
+/- acyclovir
385
What is the treatment for Guilain Barre?
IVIg or plasmaphoresis
diminished deep tendon reflexes
386
Where does scabies avoid?
neck and face
387
What is the treatment for impetigo?
topical mupirocin (bactroban)
388
What is the most common type of kidney stone?
calcium oxalate or calcium phosphate
389
What is the treatment for epididymitis for a pt <30 yo?
assume STD related
ceftriaxone 250mg IM + doxycycline 100mg BID x 10 days
390
What is the treatment for epididymitis for a pt >30 yo?
Bactrim 160/800mg or cipro 500mg BID x 10-14d
391
What is the treatment for nephrolithiasis?
IV hydration
NSAIDs (tordol?)
zofran
ceftriazone if infx
392
What is the treatment of cellulitis?
outpt: keflex PO
inpt: IV vanco
393
What is the treatment for prostatisis?
tender boggy prostate
>35yo: FQ or bactrim x 4-6 weeks
<35yo: ceftraixone, or doxycycline, or oflaxacin
394
Orchitis
occurs only if post-pubertal pts
usually associated with systemic infection - mumps esp
Tx: bed rest, heat application, oral analgesia
395
When are urine cultures ordered for poss cystitis?
immunocompromised
suspected pyelonephritis
indwelling catheters
396
What is the treatment for cystitis?
UA (>/= 10 leuks)
Nitrofurantoin 100mg PO BID x 5d
bactrim or ciprofloxacin alternatives
pregnancy: nitrofurantoin or amoxicillin
Men: consider STD treatment (250 ceftriaxone + 1g azithromycin)
397
What is the treatment for pyelonephritis?
use urine culture and susceptibility test
levofloxacin, cipro, bactrim, amoxicillin
398
BUN:Cr >20:1
Pre-renal AKI
399
BUN:Cr <10:1
post-reanl AKI
400
What is the treatment for AKI?
if acidosis, hyperkalemia or volume overload: dialysis
treat underlying causes:
prerenal: five fluids
postrenal: foley to eliminate obstruction
401
What is the treatment for corneal ulcer?
topical ciprofloxacin
| covering psudomonas
402
What is the treatment for PID for inpt?
cefotetan or cefoxitin IV + doxy IV
inpt:
ill-appearing (septic)
pregnant
tubo-ovarian abscess
403
Bones, stones, groans, psych overtones
hypercalcemia
MC d/t maligancy or primary hyperparathyroidism
groans: abdominal pain (N, cramping, constipation)
404
MAT
mutlifocal atrial tachycarida
irregular rhythm with P waves --at least 2 different P waves
etiology: COPD, hypoxia, pulmonary HTN
405
What is the most sensitive finding of cauda equina?
urinary retention (100-200ml post void residual volume)
lumbarsacral nerve root compression
eti: herniated disk
dx: MRI
tx: surgical decompression
406
Leading cause of sudden cardiac death in young athletes?
hypetrophic cardiomyopathy
407
What is the MC cardiomyopathy?
dilated
idopathic
familial pattern, EtOH, meds (chemo), infections, postpartum
408
What is the treatment of pertussis?
Macrolides (azithromycin, clarithromycin, erythromycin) or bactrim
409
Which ABX are contrainidcated in pts with G6PD deficiency?
sufla drugs like bactrim
410
What are the components of the Ranson criteria?
acute pancreatitis
at admission:
```
age >55yo
WBCs >16,000
Blood glucose >200
LDH >350
AST >250
```
411
What does the LP for a pt with Guillain-Barre show?
elevated proteins
| few cells
412
What is the first line treatment for trigeminal nueralgia?
carbamazepine 100mg BID
alt: gabapentin
413
Parkland formula
used in 2nd-4th degree burns to determine how much fluid resuscitation to give in first 24 hours
(4x weight in kg) x (TBSA of 2nd-4th degree burns)
first 50% given in first 8 hours
414
What is the leading cause of sudden cardiac death in young athletes?
hypertrophic cardiomyopathy
415
What is the treatment for H. pylori infection?
triple therapy CAP
| clarithromycin, amoxicillin (or metro), PPI
416
Butterfly rash on the face
erisipelas
well demarcated (unlike celluitis)
prodrome: fever, chills, malaise
tx: amoxicillin
butterfly rash is also seen with Lupus (malar rash)
417
Optic neuritis
MC in MS pts
loss of color vision in one eye
pain with eye movement
tx: IV steroids (methylprednisone)
418
What is the name for an intra-articular fracture at the base of the thumb metacarpal with associated dislocation or subluxation at the carpometacarpal joint?
Bennett fx
419
What is the treatment for absence seizures?
Ethosuximide first line
420
What is the treatment for Lyme disease?
doxycycline
pedis/pregnant: amoxicillin 14d
421
Smudge cells
CLL
422
What is the treatment for myasthenia gravis?
Acetylcholinesterase inhibitors
pyridostigmine or neostigmine
IVIG or plasmapheresis for rapid response
423
What is the treatment for Parkinson's?
Levodopa/Carbidopa
dz:
lewy bodies at substantia nigra
depletion of dopamine
424
Charcot's Neuro Triad
seen with MS
| Nystagmus, Staccato speech, Intentional tremor
425
What is the first line treatment for acute exacerbations of MS?
IV steroids
B-interferon or glatiramer acetate for replasing remitting
426
What is the treatment for Meningitis?
Ceftraixone and vanc +/- ampicillin if elderly
427
What is the treatment for pemphigus?
Either pemphigus vulgaris or vullous pemphigoid, the treatment is steroids x 5-10 weeks
recall that PV is found in the mucosa and has + Nikolsky sign
while Bp is more old people boils that does not have + Nikolsky sign
428
SIRS cirteria
HR >90
RR >20 or PaCO2 <32
WBC >12,000 or <4,000 or >10% bandemia
Temp >38 or <36
429
Free water deficit
Used in pts with hypernatremia
0.6(kg)x(((Na+)-145)/145)
