Rosh Flashcards
most appropriate first-line treatment for minor bleeding in patients with von Willebrand disease.
Desmopressin is the most appropriate first-line treatment for minor bleeding in patients with von Willebrand disease.
lab findings in VOn Willebrand
Patients may present with an prolonged activated partial thromboplastin time (seen in patients with low factor VIII levels) but will have normal platelet levels and prothrombin time.
In this cancer patient with a new diagnosis of DVT without other complicating factors the best treatment option is?
low molecular weight heparin therapy and discharge her to follow up with her primary doctor.
An ECG with a small positive deflection buried in the end of the QRS complex?? Disease associated? Imaging?
epsilon wave, (terminal positive deflection in QRS) is characteristic for arrhythmogenic right ventricular cardiomyopathy (formerly called right ventricular dysplasia)
Cardiac MRI and place defibrillator
Pemhigus? Disease of what?
Diagnosis?
tx?
Pemphigus is an autoimmune disorder characterized by bullae and blisters that develop from deposition of immunoglobulin G autoantibodies in the epithelial cell surface. Biopsy is required to make an official diagnosis. Treatment includes management of volume depletion and electrolyte disarray, typically in a burn unit
Infantile SPasm Triad?
infantile spasms or West syndrome. Infantile spasms are defined by the triad of findings: (1) clusters of myoclonic seizures on awakening, (2) hypsarrhythmia pattern on EEG, and (3) developmental delay.
HypoK EKG findings
Flattened or inverted T
U wave
Numbers for compartment syndrome. TWO
- Direct compartment pressures over 30 mm Hg
- the difference of diastolic blood pressure compartment pressure (known as the delta pressure) less than 30 mm Hg are indicative of compartment syndrome, with the latter being more accurate.
POst viral PNA?
Staph aureus
bullous pemphigoid
Tx?
Etiology?
bullous pemphiGoid (igG). Bullous pemphigoid is a chronic bullous disease that involves IgG autoantibodies against the basement membrane (subepidermal).
Tx- doxy and wound care. If severe immunomodulators.
Nikolsky NEGATIVE
Age >60
Most commo area of clavicle fractures
What vessels/nerve at risk with any clavicle fracture
Middle 1/3 (80%)
A careful neurovascular assessment should be performed since the subclavian vessels and brachial plexus run in close proximity to the clavicle
BRUE??
What makes them low risk
Breief unexplained unexplained event.
Infants are considered low risk for having serious underlying pathology or recurrence of episodes if they meet all of the following criteria:
- age greater than 60 days
- gestational age ≥ 32 weeks and postconceptional age ≥ 45 weeks
- occurrence of only one BRUE
- duration of event less than one minute and no cardiopulmonary resuscitation was required by a trained professional.
Erythema multiforme lesion looks like?
Associated with which two viruses
Erythema multiforme is characterized by a rash of “target lesions” that typically have a dark red center and are surrounded by a pale ring and sometimes another red outer ring.
HSV and Mycoplasma PNA
Bacterial tracheitis
Which bugs? How does the kid good look? How
Bacterial Tracheitis
Patient will be 3–5 years old
Complaining of high fever, barky cough, stridor
Treat as airway emergency!
Comments: Patient will look like croup but toxic appearing
Most common staph aureus.
Borad IV ABx
which typical asthma med should be avoided in prengancy
Acute asthma exacerbations should be treated in the ED as in any nonpregnant patient. Epinephrine may also cause uterine vasoconstriction and reduced fetal oxygenation.
What is the most common cause of acute mesenteric ischemia?
Cardiac emboli to the superior mesenteric artery.
What bacterial infection should be considered as the cause of flexor tenosynovitis in sexually active patients?
Answer: Disseminated gonorrhea.
What is the role of dexamethasone in a child presenting with a high-risk for H. influenzae meningitis?
Answer: Treatment with dexamethasone has been shown to decrease hearing loss associated with H. influenzae meningitis in children.
Presentation of neonatal seizures?
Dx of chose?
lip smacking, eye deviation, staring, rhythmic blinking, and bicycling movements.
Phenobarbital
malrotation mid gut
Test? Finding?
When and age?
1 week of life- surgical emergency
The classic presentation is an infant with bilious vomiting. The child may initially appear well, but as gut ischemia occurs, abdominal pain, distention, hematochezia, and shock develop.
An upper GI study is the gold standard for diagnosis of malrotation with midgut volvulus, showing characteristic corkscrew appearance of the jejunum.
Commonalities of Taco and Trali
Big difference
- Pulm edema, hypoxia in both
- Hypotension and FEver in TRALI
Hypertension in TACO
-
What is the most common organism associated with bacterial tracheitis?
Staph Aureus
Skiers thumb
MO injury?
tx?
What’s injuried?
Gamekeeper’s Thumb - Skier’s Thumb
Patient with a history of skiing
Complaining of pain, swelling, and tenderness on the ulnar side of the metacarpophalangeal joint of the thumb
Most commonly caused by the forceful radial abduction of the thumb
Treatment is thumb spica splint
PArkland formula
4 mL x Patient’s kg x % BSA, giving half in the first eight hours and the remaining half in the next 16 hours
Cause of HyperCalcemia in Sarcoid
hypercalcemia (due to macrophage production of calcitriol),
What does positive pressure do in asthma (non invasive)
Noninvasive positive pressure ventilation applies a consistently positive airway pressure to increase laminar flow. This leads to airway stenting, elimination of dead space through alveolar recruitment, and an increase in tidal volumes and minute ventilation.
When do you use ACoagulation in superficial venous thrombosis
found to have thrombus within 5 cm to the deep venous system (e.g., near the saphenofemoral or saphenopopliteal junction) or an affected vein segment that is greater than 5 cm are at increased risk for thromboembolism and should be anticoagulated. Options for anticoagulation include rivaroxaban, low-molecular-weight heparin, or fondaparinux.
When do you give steroids in PJP
Patients with arterial partial pressure of oxygen less than 70 mm Hg or an alveolar-arterial gradient greater than 35 mm Hg should also be treated with corticosteroids
How do hematocrit levels change in hypothermic patients?
2% increase in hematocrit for every 1°C drop in temperature.
Ammonia: Chlorine: Hydrocarbons: Hydrogen sulfide: Nitrogen oxides: Phosgene: Pulmonary edema
Ammonia: cleaning product odor, fertilizers
Chlorine: swimming pool odor
Hydrocarbons: fuels
Hydrogen sulfide: rotten egg odor, cyanide like effect
Nitrogen oxides: combustion
Phosgene: hay odor, plastics/textiles
Pulmonary edema
Contraindications to LPs (5)
- Infection over site
- Fracture
- Cardiopulm instability
- Bleeding Diathesis
- Increased intracranial pressure
5 parts of ottawa critrea
tenderness over the posterior lateral malleolus, tenderness over the posterior medial malleolus, tenderness over the navicular bone, tenderness over the base of the fifth metatarsal, and inability to bear weight for four steps
Flexion teardrop fracture
- Hyperflexion
- ## stable fracture of the antero-inferior aspect of the vertebral body that occurs due to hyper-flexion. . The vertebral body is divided into three columns: the anterior, middle, and posterior columns and unstable bc it fractures through all.
Jefferson Fracture
ABC
Axial load (diving, head on football) Burst C1 rfactrue
Unstable
Jefferson fracture is a burst fracture of the lateral masses of C1.
Ankle Arthrocentesis Location
medial to the tibialis anterior tendon and directed toward the anterior edge of the medial malleolus
Most common cause of SVC?
Clinical signs and symtoms
SVC via compression, infiltration, or thrombosis. The most common etiology of this disorder is squamous cell carcinoma of the lung, which causes 65% of all cases of SVC syndrome. Signs and symptoms are typically caused by venous hypertension in the head, neck, and chest. These include dyspnea, periorbital edema and facial swelling,
Lymphogrganulum
Population at risk?
- Initial presentation and timeline
- Secondary presentation
Lymphogranuloma Venereum
Primarily seen in men who have sex with other men
With a history of recent travel to tropical and subtropical areas of the world
Incubation period- 3-21 days Complaining of small, shallow painless genital ulcer
Secondary- 3-20 days after ulcers resolve- PE will show tender inguinal/femoral lymphadenopathy
Most commonly caused by Chlamydia trachomatis
Treatment is doxycycline
Carcinoid Syndrome
Symtoms?
Treatment?
Carcinoid Syndrome
Patient presents with skin flushing, wheezing, and diarrhea
Diagnosis is made by 24-hour excretion of 5-hydroxy-indoleacetic acid (5-HIAA) in the patient’s urine
Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)
Octrotide
In submersion/drowning, The degree of pulmonary insult is ultimately determined by ?
the quantity of liquid aspirated.
7 steps of catching a baby
engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.
Infantile Spasm Triad?
Infantile spasms are defined by the triad of findings: (1) clusters of myoclonic seizures on awakening, (2) hypsarrhythmia pattern on electroencephalogram, and (3) developmental delay.
Septic thombophlebitis-other name?
Define?
triad?
Septic thrombophlebitis (i.e. Lemierre syndrome) is an infected clot of the jugular vein caused by local invasion from bacterial pharyngitis.
Traid- 1. ancedent pharyngitis
- Fever not breaking with Abx
- Septic pulm emboli
These patients are described as toxic in appearance with fever, anterior neck pain and stiffness, as well as possible respiratory distress from septic pulmonary emboli. Treatment is with admission for intravenous antibiotic therapy.
Indication of Left Main on EKG?
ST segment elevation in lead aVR greater than 1 mm or greater than the elevation seen in the ST segment of V1 should prompt concern for occlusion of the left main coronary artery
Most common cause of acute mesenteric isshemia
ost common cause of acute mesenteric ischemia is from arterial embolism that often originates from the left atrium, left ventricle, cardiac valves, or proximal aorta. Atrial fibrillation, especially if not on anticoagulation, places the patient at high risk for distal embolization.
How to treat bad pulm contusions
Exceptions
“Good lung” should be positioned down (good to ground) to improve V/Q matching and oxygenation
Exceptions: “bad lung” is in the dependent position (down) include massive hemoptysis (to prevent blood from filling the good lung), large pulmonary abscesses (to prevent pus from filling the good lung), and unilateral emphysema (to prevent hyperinflation)
Ethylene Glycol lab findings??
Markers of intoxication with ethylene glycol include high anion gap metabolic acidosis with an absence of significant lactate or ketone concentrations, and calcium oxalate formation leading to acute renal failure.
Mortality in myxedema coma is proportional to the severity of the patient’s …?
Hypothermia
As with other causes of hypothyroidism, the TSH is typically high while T4 and T3 are low. Definitive therapy for patients with myxedema coma is with the administration of intravenous thyroxine.
What is the Star sign? Caused by?
classic “star sign” of hyperechoic blood in the basal cisterns, consistent with a subarachnoid hemorrhage. Most of these cases are caused by rupture of a cerebral aneurysm (75%). less commong cuases arteriovenous malformations (B), vertebral artery dissection (D)
L3 and L4 radiculopathy findings
Compression of L3 (A) results in weakness with hip flexion and adduction with decreased sensation of the anterior thigh. L4 (
B) radiculopathy presents with weakness with knee extension, and decreased sensation of the lateral thigh, anterior knee and medial leg
Most common complicatoin of HELLP
Other complications?
Patients with HELLP syndrome are at risk for bleeding complications, including disseminated vascular coagulation (DIC), intracranial hemorrhage, placental abruption, and spontaneous hepatic or splenic hemorrhage. Hepatic hemorrhage can progress to hepatic rupture, which is associated with a maternal and fetal mortality rate of over 50%.
HgSS with hyphema- avoid which med group? Why?
However, carbonic anhydrase inhibitors are contraindicated in patients with sickle cell disease because the lower aqueous pH induces sickling of red blood cells, occludes the trabecular meshwork and leads to increased intraocular pressure
Which med in RIPE should be avoided in pregnancy?
pyrazinamide- tetargenic
Latent TB tx?
Latent TB, first line: Isoniazid with B6
Acute interstitial nephritis
Cause?
Presentation?
UA findings?
Acute interstitial nephritis (AIN), most often due to a hypersensitivity drug reaction, presents abruptly with signs and symptoms of acute kidney injury. Patients may have malaise, nausea and vomiting, and oliguria. Classic symptoms of rash, fever, and eosinophilia can be seen in cases due to drug reaction, although most patients do not have all three cardinal symptoms. Cases caused by nonsteroidal anti-inflammatory drugs are also less likely to present with classic symptoms compared with other agents. Urinalysis findings include pyuria, microscopic or gross hematuria, eosinophiluria, and mild proteinuria.
Severe DIsease? What is it? What test? Tx? Risk factors?
Sever Disease - Apophysitis Of The Calcaneus
Overuse injury in children + wearing cleats
Heel pain
(+) Calcaneal compression test
Manage with supportive care (ice, pain medication, reduced activity)
Cuff size formula estimate?
Formula: cuffed ETT size = (age/4) + 3.5 and uncuffed ETT size = (age/4) + 4.
Neuro deficit in lightening strike
Other indications of a lightning injury include keraunoparalysis, a temporary paralysis of the extremities which may appear blue, mottled and cold. Due to transient vascular spasm and sympathetic nervous system instability, this is more commonly seen in the lower extremities and often resolves in a few hours.
Shoulder Impingement Syndrome (SIS)
cause
test
tx
Shoulder Impingement Syndrome (SIS) Repetitive motion Neer/Hawkins-Kennedy tests Ice, rest, pain control, PT referral Orthopedic evaluation
Indications for CT before LP
- AMS
- Hx of intracranial mass
- Immunocompromised
- Focal deficits
- New onset seizre the week prior
Failure to capture?
Spikes ut no QRS after
Failure to capture can range from complete absence of pacemaker activity to pacemaker spikes being seen but not resulting in depolarization of the myocardium. Complete absence of activity can be due to battery depletion, fracture of the pacemaker lead (which is uncommon with today’s technology) or disconnection of the lead from the generator. Intermittent failure to capture is commonly due to lead displacement and is most likely to happen within the first month of placement.
IgG autoantibodies against the desmosomes
IgG autoantibodies against the desmosomes (C) is an example of type II or cytotoxic hypersensitivity reactions and is the mechanism by which pemphigus vulgaris occurs.
IgG autoantibodies against the basement membrane (subepidermal)
Bullous pemphigoid is a chronic bullous disease that involves IgG autoantibodies against the basement membrane (subepidermal)
CI TO handling splenic infarcts non-op?
Realtive CI?
Contraindications to nonoperative management include persistent hemodynamic instability, generalized peritonitis, inability to follow clinically with serial abdominal examinations (due to lack of resources or altered mental status), high-grade splenic injury (grade IV or higher), or need for operative management of other intra-abdominal injuries.
Another relative contraindication would be age > 55 years as these patients are at higher risk for failure of nonoperative management, including embolization.
SBP labs?
Labs will show PMNs > 250/µL, WBC > 1,000/µL, pH < 7.34
