Urgent Care + Heme/Onc

Question 1

MCC of RUQ pain (biliary vs hepatic)

Answer 1

Biliary - Biliary colic, acute cholecystitis, acute cholangitis, sphincter of oddi dysfunction

Hepatic - Fitz hugh curtis, liver abscess, budd-chiari, portal vein thrombosis

Question 2

MCC of epigastric pain

Answer 2

Acute MI, acute or chronic pancreatitis (pain radiating to back) , Peptic ulcer dz, GERD, gastritis, dyspepsia, gastroparesis

Question 3

MCC of left upper quadrant pain

Answer 3

Splenomegaly, splenic infarct, splenic abscess, splenic rupture

Question 4

MCC of lower abdominal pain

Answer 4

Apendicitis, diverticulitis, nephrolithiasis, pyelonephritis, acute urinary retention, cystitis, infectious colitis,

Question 5

Brown recluse spider bite sx

Answer 5

• Brown violin on the abdomen
• Necrotic wound - Local tissue reaction causes local burning at the site for 3-4 hours → blanched area (due to vasoconstriction) → central necrosis erythematous margin around an ischemic center “red halo” → 24-7 hours after hemorrhagic bullae that undergoes Eschar formation → necrosis

Question 6

Tx for brown recluse bite

Answer 6

For brown spider bites, use wound care, local symptomatic measures, and sometimes delayed excision

Question 7

Sx of black widow spider bite

Answer 7

• Red hourglass on the abdomen
• Neurologic manifestations - You may not see much at bite site: toxic reaction: nausea, vomiting, HA, fever, syncope, and convulsions

Question 8

Tx of black widow bite

Answer 8

anti-venom available for elderly and kids

Question 9

Burns - 1-4th degree, how are they described

Answer 9

• 1st degree (sunburn): Erythema of involved tissue, skin blanches with pressure, the skin may be tender
• 2nd degree (partial thickness): Skin is red and blistered, the skin is very tender
• 3rd degree (full thickness): Burned skin is tough and leathery, skin non-tender
• 4th degree: Into the bone and muscle

Question 10

Tx of major burns involves what total body %

Answer 10

Major: >25% TBSA adults, >20% TBSA young/old, >10% full-thickness burn, burns involving the face, hands, perineum, feet, cross major joints/circumferential

Question 11

Tx of major burns

Answer 11

Treatment: monitor ABCs, fluid repletion, topical antibiotic

• Cleans with mild soap and water, don’t apply ice directly; irrigate chemical burns with running water x 20 min, topical antibiotic cream to superficial burns, fingers and toes wrapped individually to prevent maceration and gauze placed between them
• Children with > 10% total body surface area and adults with > 15% need fluid resuscitation ⇒ LR IV x 24 hrs (1/2 in first 8 hrs; ½ in remaining 16)

Question 12

3 specific beta blockers used in heart failure

Answer 12

Bisoprolol

Carvedilol

Metoprolol succinate

Question 13

What heart sound is heard with systolic heart failure

Answer 13

S3 (Rapid ventricular filling during early diastole is the mechanism responsible for the S3)

Question 14

Diastolic left heart failure, what is usually normal?

Answer 14

• Ejection fraction is usually normal

Question 15

Causes of altered levels of consciousness - AEIOU TIPS

Answer 15

• Alcohol or AAA
• Electrolytes, endocrine
• Insulin
• Opiates
• Uremia
• Trauma, temperature or toxemia
• Infections – sepsis, meningitis
• Psychogenic or pulmonary embolus
• Space occupying lesions, strokes, shock, seizure

Question 16

Decreased extraocular movement, pain with movement of the eye and proptosis, signs of infection

Answer 16

Orbital cellulitis

Question 17

Dx of orbital cellulitis

Answer 17

CT scan

Question 18

Tx of orbital cellulitis

Answer 18

Hospitalization and IV broad-spectrum antibiotics (vancomycin)

Question 19

Absence of breath sounds and hyperresonance to percussion with tracheal deviation

Answer 19

Pneumothorax

Question 20

2 types of pneumothorax

Answer 20

• Primary spontaneous pneumothorax occurs in the absence of underlying disease - tall, thin males between 10 and 30 years of age are at the greatest risk of primary pneumothorax
  
  • Secondary spontaneous pneumothorax occurs in the presence of underlying disease - asthma, COPD, cystic fibrosis, interstitial lung disease

Question 21

Tx of pneumothorax

Answer 21

<15% of the diameter of the hemithorax will resolve spontaneously without the need for chest tube placement

• For large, > 15% of the diameter of hemithorax, and symptomatic pneumothoraces, chest tube placement is performed
• Patients should be followed with serial CXR every 24 hours until resolved

Question 22

Virchows triad in PE

Answer 22

• Virchow’s triad: hypercoagulable state, venous stasis, vascular injury

Question 23

Dx of PE

Answer 23

• Spiral CT: Best initial test
• Gold Standard is pulmonary arteriography

Question 24

Tx of PE

Answer 24

Heparin to Coumadin bridge. 3-6 mo treatment

Question 25

Etiology of acute resp distress

Answer 25

Etiology: Sepsis, severe trauma, aspiration of gastric contents, near-drowning * Rapid onset of profound dyspnea occurring **12-24 hours after the precipitating event.** * Tachypnea, **pink frothy sputum,** crackles

Question 26

Dx study for resp failure/distress

Answer 26

* Chest radiograph: **air bronchograms** and **bilaterally fluffy infiltrate** * Normal BNP, pulmonary wedge pressure, left ventricle function and echocardiogram Treatment: Underlying cause and intubation positive pressure oxygen

Question 27

3rd trimester bleeding MCC

Answer 27

Placental abrution vs placenta previa(painless)

Question 28

Anemia of chronic dz labs show elevated

Answer 28

Normal or ↓ MCV, ↓ TIBC, **_↑ Ferritin (high iron stores)_** ↓ serum erythropoietin

Question 29

Which cell lines are decreased in aplastic anemia

Answer 29

All The only anemia where all three cell lines are decreased **↓ WBC ↓ RBC ↓ Platelets - will have normal MCV and ↓ Retic**

Question 30

**After infection or medication** (oxidative stress) in an **African American male (x-linked)** + **Heinz Bodies** and **Bite Cells** on smear

Answer 30

G6PD def

Question 31

Diagnostic studies for G6PD

Answer 31

* Diagnostic studies: **Heinz Bodies** and **Bite Cells** on smear

Question 32

**Red blood cells are destroyed faster than they can be made.** The destruction of red blood cells is called hemolysis.

Answer 32

Hemolytic anemia

Question 33

5 types of hemolytic anemia

Answer 33

1. [**Autoimmune Hemolytic anemia**](https://smartypance.com/lessons/anemias/hemolytic-anemia/) (+ Direct Coombs Test) - **↑ Retic, ↑ LDH, ↓ Haptoglobin, and ↑ Bilirubin (indirect)** 2. **Hereditary Spherocytosis** **(+) osmotic fragility test.** ↑ **Retic, ↑ LDH, ↓ Haptoglobin, and ↑ Bilirubin (indirect)** and the presence of **spherocytes** 3. [**G6PD deficiency**](https://smartypance.com/lessons/anemias/g6pd-deficiency/) **after infection or medication** (oxidative stress) in an African American male (x-linked) + **Heinz Bodies and Bite Cells** on a smear (damaged hemoglobin - G6PD protects RBC membrane) 4. [**Sickle Cell Anemia**](https://smartypance.com/lessons/anemias/sickle-cell-anemia-reeldx354/) (**Very ↑ Retic count** + Pain in African American male, Hemoglobin electrophoresis: Hemoglobin S, Blood smear: Sickled RBCs, Howell-Jolly bodies, target cells) 5. [**Thalassemia**](https://smartypance.com/lessons/anemias/thalassemia/) Very ↓ MCV (microcytic and hypochromic) with a normal TIBC and Ferritin, elevated iron and family history of blood cell disorder

Question 34

**African American, pain, family history of blood disorder, Hemoglobin electrophoresis: Hemoglobin S, Blood smear: Sickled RBCs, Howell-Jolly bodies, target cells**

Answer 34

Sickle cell

Question 35

Tx of sickle cell

Answer 35

Hydroxyurea

Question 36

Family history of blood cell disorder, **Microcytic hypochromic**, Elevated iron

Answer 36

Thalassemia

Question 37

Hbg electophoresis for beta thal will show

Answer 37

* Hemoglobin electrophoresis: **Hemoglobin A2 and F**

Question 38

2 types of hemophilia and the clotting factors they affect

Answer 38

* [**The Hemophilias**](https://smartypance.com/lessons/coagulation-disorders/clotting-factor-disorders/#hemophilia) * **Hemophilia A** ↓ clotting factor VIII * **Hemophilia B** ↓ clotting factor IX

Question 39

* Most common genetic bleeding disorder, autosomal dominant

Answer 39

Von wille

Question 40

Tx of von wille

Answer 40

DDVAP

Question 41

MC type of hemophilia

Answer 41

* **Hemophilia A,** which accounts for about **80% of all cases**, is a deficiency in **clotting factor VIII** **("Aight")**

Question 42

**CHILD** + **Lymphadenopathy + bone pain + bleeding + fever in a CHILD,** bone marrow **\> 20% blasts in bone marrow**

Answer 42

Acute lymph leukemia

Question 43

**Middle age patient**, often asymptomatic (seen on blood tests), fatigue, lymphadenopathy, splenomegaly

Answer 43

Chronic lymph leukemia

Question 44

Strikingly Increased WBC count \> 100,000 + hyperuricemia + Adult patient (usually \> 50 years old)

Answer 44

Chronic myeloid * 70% asymptomatic until the patient has **a blastic crisis (acute leukemia)** * Diagnostic studies: **Philadelphia chromosome** (translocation of chromosome 9 and 22) - "**Philadelphia C**rea**M** cheese", splenomegaly

Question 45

Aur rods

Answer 45

AML

Question 46

**Reed-Sternberg Cells are pathognomonic** - B cell proliferation with bilobed or multilobed nucleus "owl eye"

Answer 46

Hodgkins

Question 47

**malignancy** of the **bone marrow** that results in the overproduction of **red blood cells (primarily)** but also can affect **platelets**, and **white blood cells**

Answer 47

Polycythemia

Question 48

Sx of polycythemia

Answer 48

**pruritus after hot baths**, as well as swelling, burning pain, and rubor of the hands and feet (erythromelalgia)

Question 49

4 H's of polycythemia

Answer 49

**The 4 H's**: **H**ypervolemia (**↑ RBC), H**istaminemia (↑ histamine due to release from mast cells), **H**yperviscosity (**↑** hematocrit = **↑** viscosity), and **H**yperuricemia (**↑**uric acid)

Question 50

Tx of polycythemia

Answer 50

Treatment consists of **repeated phlebotomy** to lower hematocrit to **≤ 42%**