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68 Cards in this Set
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WHAT: |
Strep pyogenes (Group A beta-hemolytic strep)
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LIST:
Symptoms of a patient with pharyngitis that would indicate impending disaster |
stridorous breathing
air hunger toxic appearance drooling inability to swallow |
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LIST:
Classic presentation of strep throat |
1. <15 yrs of age
2. fever 3. absence of cough 4. tonsillar exudate 5. tender anterior cervical adenopathy 6. age >45 is actually a NEGATIVE predictor These are the CENTOR Criteria for Predicting Strep Pharyngitis |
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NAME:
Two additional DDx that would be important to identify but can present similarly to strep throat |
DDx of Pharyngitis includes many bacteria and viral agents
Consider: Primary HIV! - identify to initiate anti retrovirals Consider: Mononucleosis - identify to prevent splenic rupture |
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GIVE:
The algorithm Dx/Tx of Step Pharyngitis with a RAT |
1. Centor Criteria
4 points = empiric ABx Tx, no testing 2-3 points = RAT --> Tx if +, Cx if - 0-1 points = no testing, no Abx |
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WHY:
Give antibiotics in Strep Pharyngitis |
There are the major and feared complications - BUT there is debatable evidence that antibiotics actually help prevent ... rheumatic fever, streptococcal toxic shock, poststreptococcal glomerulonephritis
May help (and therefore indicated) in preventing: --tonsillopharyngeal cellulitis --abscesses --sinusitis --meningitis --streptococcal bacteremia |
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HOW:
Tx Strep Pharyngitis |
Penicillin V PO 500 mg BID x 10 days
vs Penicillin G IM 1.2 million units |
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DIAGNOSE:
1. Sudden fever, drooling, stridor, tachypneic 2. Fever, sore throat, stiff neck, no trismus, adult w h/o trauma 3. sublingual submental mass with elevation of tongue, jaw swelling, fever, chills, trismus 4. Swelling pushing uvula aside, fever, sore throat, dysphagia, trismus |
1. epiglottitis
2. retropharyngeal abscess 3. Ludwig angina 4. peritonsillar abscess ***NOTE: these oral abscesses should be treated with both penicillin and metronidazole (why not clindamycin?) |
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LIST:
Labs and Diagnostics in Probable MI |
Diagnostics:
ECG CXR - r/o dissection before thrombolytics Cardiac Monitor - watch for arrhythmias Labs: Trops Electrolytes Renal Function PT/PTT CBC |
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DDx:
5 life-threatening conditions that can present with chest pain |
1. MI
2. Aortic Dissection 3. Embolism 4. Pneumothorax 5. Esophageal Rupture (Boerhaave syndrome) |
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WHAT:
Population is known to have atypical chest pain presentations during MI |
Diabetics - why???
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HOW:
Sensitive is an ECG in MI |
Unfortunately:
Non-diagnostic in 50% Completely normal in 8% ***thus must always consider a patient's pretest probability |
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NAME:
Major components of treatment of an MI |
E-Med favors MONA:
-morphine sulfate -oxygen -nitroglycerine -ASPIRIN (162 mg chewable) Also give: -beta blocker STEMI Tx: -PCI (note: transfer to a neighoring facility for primary PCI is superior to thrombolysis if transfer accomplished within 2 hours as PCI window is preferable within 90 minutes but possible up to 6 hours of presentation) -give LMWH -give glycoprotein IIB/IIIA inhibitor -potential benefit to giving thrombolytics at the time of PCI! NSTEMI/UA -medications, and eventual cath?? |
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DX/TX:
Cardiac Pain presenting with Hypotension and WITHOUT Pulmonary Congestion |
Right ventricular infarction - a complication of an inferior MI
Confirm with ST elevation of V4 in a RIGHT SIDED ECG Tx = aggressive volume loading |
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LIST:
Common contributing factors to atrial fibrillation |
1. Underlying cardiopulmonary disease
2. Age 3. Hypertension 4. Hyperthyroidism 5. Pulmonary embolism 6. Electrolyte abnormalities |
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WHAT:
Are the two most important complications of atrial fibrillation and HOW: Could we evaluate them in the ED |
1. Thromboembolism
2. Cardiomyopathy Dx: TTE ***can also see low cardiac output as there is impaired "atrial kick" from the AFib and impaired filling time from the RVR |
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SUMMARIZE:
Once again, the immediate treatment of patients with atrial fibrillation |
Rate Control > Rhythm Control
--consider DILTIAZEM acutely as has efficacy in moderate to severe cases, without huge risk of HoTN --consider VERAPAMIL or BETA BLOCKER as super effective negative inotrops, BUT! Increased risk of HoTN in pts with low BPs or poor LV function Cardioversion <48 hrs and NO Hx of stroke? --> immediate cardioversion >48 hours (or RF+), then anticoagulation, either ... 1.) 3 wks coumadin --> convert --> 4 more wks 2.) negative echo + heparin --> allowing immediate cardioversion + wks coumadin after ****patients should be given AMIODARONE or PROPAFENONE after cardioversion to help maintain normal sinus rhythm |
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HOW:
Treat an unstable patient with 72 hours of atrial fibrillation? |
Immediate cardioversion
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NAME:
Additional (non classically diabetic) symptoms that accompany a presentation of DKA |
Dyspnea - from the metabolic acidosis
Severe Abdominal Pain - idiopathic Altered Sensorium Nausea/Vomiting |
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NAME:
Potentially precipitating causes of DKA that should be evaluated for as patient is stablized |
1. INFECTION!!! - pneumonia vs. UTI are super common, also consider cellulitis (particularly unusual locations like perineum)
2. MI |
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DDX:
Patient with ketosis but normal glucose levels Acidosis without hyperglycemia or ketones |
1. Starvation vs Pregnancy (also starving lolz) vs. Alcoholic Ketoacidosis (also starving lolz) vs. Isopropyl Alcohol Ingestion (= why bro???)
2. Hyperchloremic acidosis vs. Salicylate Poisoning vs. uremia, vs. Lactic Acidosis vs. other drugs |
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DESCRIBE:
Treatment of DKA |
Normal Saline - Correct hypovolemic shock - pt may be down 10L! 2L bolus appropriate, continue aggressive fluids
Insulin - fast acting, IV (IM risky in hypovolemic), continued until anion gap has normalized (NOTE: this may mean adding dextrose to insulin infusion if serum glucose <200 but anion gap not resolved) **typical insulin dose = 0.1 U/kg/h ... so 75 kg adult gets 7.5 U/hour Replace electrolytes - POTASSIUM!!!! also commonly sodium, magnesium, phosphate |
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HOW:
Much is serum sodium lowered by elevated glucose |
Sodium drops 1.6 mEq/L for every 100 mg/dL glucose
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DESCRIBE:
Potassium supplementation in patients presenting with DKA |
While serum levels may be temporarily high, expect total body levels to be down
NOTE: do NOT give potassium before insulin, do NOT give potassium until levels are actually dropping ... you do NOT want to precipitate hyperkalemia |
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NAME:
The most common sources of sepsis in the elderly |
UTI and Pneumonia
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DESCRIBE:
The two phases of sepsis |
1 = hyperdynamic = compensated? getting a distributive shock picture but CO increased to the point that body remains warm (pt will be warm but with tachycardia/tachypnea)
2 = hypodynamic = dysregulation of homeostatic mechanisms and full septic shock ... impaired myocardial function results in decreased CO - get a lactic metabolic acidosis |
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DESCRIBE:
Treatment of sepsis |
1. Resuscitation focused on organ perfusion
-fluids -vasopressors if refractory to fluids (think DOPAMINE 2. Infection source control 3. Human recombinant activated protein C -if severe sepsis with multi-organ dysfunction refractory to all previous treatments 4. Early goal directed therapy?????? --ask about this one 5. Intensive glucose control (80-110) 6. Controversial role of low dose corticosteroids |
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WHAT:
Is Morrison pouch |
= hepatorenal recess of subhepatic space = the potential space between liver and right kidney where fluid can accumulate
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WHAT:
Are the five areas that should be assessed for bleeding in a trauma patient |
1. External - scalp/extremity lacs
2. Pleural Cavity - hemothorax 3. Peritoneal Cavity - intraabdominal injury 4. Pelvic Girdle - fractures 5. Soft Tissue Compartments - long bone fractures |
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HOW:
Much blood is associated with different types of fractures |
Humerus or Tibia = 750 mL = 1.5 units
Femur = 1.5 L = 3 units Pelvis = 3 L = 6 units |
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WHAT:
Are the classes of hemorrhagic shock? |
I = <750, see no changes in pt vitals
II = 750-1500 mL = now tachy, but normal blood pressure III = 1.5-2 L = HR >120 RR >30 and DECREASED blood pressure IV = >2.0 L = 40% blood loss = crashing |
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WHY:
Do hemoglobin and hematocrit NOT change in early hemorrhage? |
because they reflect concentrations ... not total body amounts
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WHAT:
Populations do the normal manifestations of shock NOT apply |
Pregnant women
Athletes Anyone w/ altered autonomic nervous system --elderly --pts on beta blockers |
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DDX:
Acute symptoms of involuntary motor deficits |
Stroke (ischemic vs hemorrhagic)
Seizure w/ Todd paralysis Non-convulsive status epilepticus Migraine Hypoglycemia Hematoma Spinal Cord Injury Drug Overdose Conversion reaction **most important - stat blood glucose and CT |
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WHAT:
Are the consequences of a stroke that occurs in a patient's dominant vs non-dominant hemisphere? |
Dominant - basic contralateral numbness/weakness/visual field cut ... BUT also APHASIA
Nondominant - basic basic contralateral numbness/weakness/visual field cut ... BUT also CONTRALATERAL NEGLECT |
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WHAT:
Are the effects of a ... 1. Lacunar infarct 2. Basilar artery occlusion 3. Vertebrobasilar syndrome |
1. pure motor or sensory deficit
2. quadripledia, coma, locked-in syndrome 3. dizziness, vertigo, diplopia, dysphagia, ataxia |
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DX:
Sudden onset dizziness, vomiting, gaze palsies, truncal instability, stupor |
Cerebellar hemorrhage = serious
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GIVE:
Indications for thrombolysis in ischemic stroke |
>18 yrs old
Clinical criteria of ischemic stroke (NOT hemorrhagic) Well-established time of onset <3 hrs (or is it) give rt-PA = recombiant tissue plasminogen activator |
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GIVE:
Contraindications to thrombolysis in ischemic stroke |
SBP >185
Super severe stroke (NIH >22) Minor symptoms Rapidly improving symptoms Hemorrhage Recent stroke Intracranial neoplasm Recent GI bleeding, head injury, major surgery, anticoagulation, thrombocytopenia |
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LIST:
General categories of syncopal etiologies |
Cardiac
Reflex mediated Orthostatic Medication Psychiatric Hormonal Neurologic Idiopathic |
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LIST:
Sources of cardiac syncope |
Bradydysrhytmias = sinus node dz, heart block, long-QT, pacemaker malfunction
Tachydysthythmias = ventricular tachycardia, ventricular fibrillation, WPW, tosade de pointes, supraventricular tachycardia Mechanical = aortic stenosis, hypertrophic cardiomyopathy, PE? **all disrupt outflow or preload causing inadequate brain perfusion |
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LIST:
Sources of reflex-mediated syncope |
Vasovagal
Cough Micturition Defecation Emesis Swallow??? Valsalva Emotional Carotid Sinus/Tight Collar **early pregnancy/ectopic pregnancy ***all stimulate a "vagal reflex" causing bradycardia and HoTN ***associated with warmth, nausea, lightheadedness, and impending sense |
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LIST:
Symptoms associated with orthostatic HoTN |
Diaphoresis
Lightheadedness Graying of Vision |
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LIST:
Common medications causing QT prolongation |
Erythromycin
Clarithromycin Haloperidol Amiodarone Droperidol??? Zofran |
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WHAT:
Syncope patients should be admitted (vs d/c) |
Any obvious pt - unstable/active medical problem
But also: pts >60, pts w/ known cardiovascular dz, pts w/out a reassuring prodrome or situational cause |
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WHAT:
Are causes of a PE besides a blood clot? |
**all rare, but ...
Air bubbles Fat droplets Amniotic fluid Clumps of parasites Tumor cells |
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WHAT:
Is D-dimer, and what are reasons it would be positive |
= compound released into circulation from degradation (by pasmin) of cross-linked fibrin, thus indicating presence of concurrent thrombus formation and degradation
Other conditions that can cause elevation = Sepsis Recent MI/Stroke (<10 days) Recent surgery Recent trauma DIC Collagen vascular disease Metastatic cancer Liver disease |
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WHAT:
Types/locations of vein thrombus formation should be treated? How treated acutely? |
Deep veins
At or above the popliteal level Acute Management = anticoagulation --unfractionated heparin --LMWH = ENOXAPARIN @ 1 mg/kg BID Followed by Coumadin/Warfarin **thombolytics are used in pts with serious PE resulting in HoTN, but no study has proven a survival advantage |
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LIST:
Components of a Wells Score Cut-offs of low medium high pretest probability |
Active cancer
Paralysis of lower extremities Recent bedridden vs recent surgery Tenderness along distribution of deep vein Entire leg swelling Calf swelling >3 cm compared to other leg Pitting edema > other leg Collateral superficial veins? -2 for alternative Dx more likely than DVT 0 = low pretest 1-2 = medium pretest 3+ = high pretest probability |
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LIST:
Classic triad of Sx for PE, and some additional Sx that can be seen |
Triad (true in <20%) = hemoptysis + chest pain + dyspnea
Sx = cough, DOE or at rest, diaphoresis, tachypnea, tachycardia, rales/crackles, low-grade fever |
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WHAT:
Sign of a PE can be seen in CXR |
Hampton's hump
= wedge-shaped pleural-based density |
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WHAT:
Are the limitations of CTA for PE |
Great = at large, central PEs
Misses = central clots in middle (right) and lingular (left) pulmonary arteries, peripheral clots **thus a negative CT does NOT r/o PE in a high probability patient **Pulmonary Angiography = gold standard |
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WHAT:
Is the role of D-dimer in evaluating for PE |
Can r/o PE in a low-risk patient
**negative D-dimer alone cannot rule out PE in high-risk pt **only has significant NPV (no PPV given many things can make it positive) |
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WHERE:
Do 80% of DVTs come from |
Iliac
Popliteal Femoral (including superficial femoral, which counts as a deep vein despite its name!) |
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DISCUSS:
Presentation, pathophysiology, management of preeclampsia |
= HTN dz unique to pregnancy, with HTN + Proteinuria (>300 mg/24 hrs) + Peripheral/Facial Edema ... must be past 20 wks
= from vasospasm and capillary leakage = tx with blood pressure lowering agents safe in pregnancy (IV hydralazine, labetalol) ... goal is DBP <115 ... and ... magnesium sulfate for SEIZURE PROPHYLAXIS definitive tx is to induce labor |
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LIST:
End organ effects of preeclampsia |
Pretty much everything!
HA / vision changes / SEIZURES / blindness PROTEINURIA / oliguria / elevated Cr level PULMONARY EDEMA thrombocytopenia / hemoconcentration / coagulopathy SEVERE HTN IUGR / decreased uterine perfusion increased liver enzymes |
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WHAT:
Is the difference between preeclampsia and malignant hypertension |
preeclampsia has proteinuria
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WHAT:
Is the initial goal in treating a hypertensive crisis Agents would you use |
Lower DBP to about 100-105 w/in 2-6 hrs
BUT - not by more than 25% the presenting value Agents with immediate results: --sodium nitroprusside --nitroglycerin --diazoxide --trimethaphan Long-term control: --hydralazine --beta blocker --enalapril (captopril) --nifedipine |
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WHAT:
ECG finding is associated with PE |
Tachycardia |
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WHAT:
Findings would suggest perforation of a swallowed foreign body |
Fever
Subcutaneous air Peritoneal signs ***indicates prompt surgical management needed |
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WHAT:
Conditions could predispose an adult to a swallowed/retained foreign body |
Stricture
Malignancy Scleroderma Achalasia ***in general adults tend to get objects stuck in the distal esophagus (vs proximal in kids) |
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WHAT:
To do if patient swallows a cocaine body package whole |
**rupture can be fatal
--avoid endoscopy as high risk of rupture --attempt whole-bowel irrigation vs surgery |
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WHAT:
Are the top causes of small bowel vs. large bowel obstruction Are the major symptoms of each |
Small = ADHESIONS (post-surgical?) vs malignancy vs. hernias vs volvulus
Small = vomiting + crampy pain + some distention Large = carcinoma vs. volvulus vs diverticular disease vs everything else (fecal impaction, ischemic colitis, IBD) Large = DISTENSION, postprandial cramps, bowel habit changes |
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WHAT:
Is the preferred imaging modality for initial evaluation of bowel obstruction |
Apparently an abdominal series
**tells you partial from high-grade/complete obstruction ... partial is consistent with stool or air in the rectal vault ... air fluid levels in the small bowel with an absence of rectal vault findings consistent with a complete obstruction |
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DESCRIBE:
Management of Small Bowel Obstruction |
NPO |
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DESCRIBE:
Management of Large Bowel Obstruction |
NPO |
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LIST:
Components of the trauma survey related to the face |
Check the eyelids Check inside the nose (septal hematoma can lead to necrosis of the septum!) Check for lacs across the vermillion border Check for raccoon eyes Check for damage inside of the ear |
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NAME:
Classic risk factors for DVT |
Factor V Leiden Antithrombin III vs Protein C vs Protein S deficiency Old age (>60) Obesity Pregnancy/Postpartum Prior thromboembolism Smoking Antiphospholipid Syndrome Immobilization Malignancy Medical illness (CHF, MI) Surgery Trauma **IBD |
