Cdem Cases Svt

Front 1

age>50, sudden onset abdominal pain severe and diffuse without localization, +N/V/D, abd soft, no rebound or guarding

Back 1

Mesenteric Ischemia, before bowel infarction

Front 2

4 mechanisms of mesenteric ischemia

Back 2

1. Mesenteric artery embolus (most common), 2. mesenteric artery thrombosis, 3. mesenteric vein thrombosis, 4. non-occlusive ischemia

Front 3

Risk Factors for Mesenteric artery embolus

Back 3

arrhythmias, post-MI w/ mural thrombi, valvular heart disease, structural heart defects (R->L shunts)

Front 4

What are the differences between SMA blockage by embolus and thrombus?

Back 4

Embolus lodges distal to middle colic artery - spares duodenum and proximal jejunum.

 

Thrombus causes a more proximal blockage and more extensive bowel ischemia

Front 5

History of abdominal angina and fear of food suggest which mechanism of mesenteric ischemia?

Back 5

mesenteric artery thrombosis

Front 6

Risk factors for mesenteric vein thrombosis

Back 6

hypercoaguable states, recent surgery, malignancy, cirrhosis, h/o DVT

Front 7

Risk factors for non-occlusive mesenteric ischemia

Back 7

cardiogenic shock, CHF, arrhythmias, sepsis, hypotensive states, drugs causing mesenteric vasoconstriction (digoxin, cocaine, alpha-agonists, beta blockers)

Front 8

Gold standard test for diagnosis of mesenteric ischemia?

Back 8

angiography (however, CTA a good alternative bc fast, less invasive, and more readily available in many hospitals)

Front 9

Lab tests to order if you suspect mesenteric ischemia?

Back 9

Lactic acid - may not be elevated until late in disease (after bowel infarcted, sensitive not specific)

WBC commonly elevated

Front 10

Treatment for mesenteric ischemia

Back 10

2 large bore IVs, triple lumen, broad spectrum abx, d/c vasoconstrictive meds, if think thrombus start heparin drip to prevent expansion, 

Papaverine during angiography to increase blood flow

Front 11

signs and symptoms of perforated viscus

Back 11

generalized peritonities, board like rigidity, involuntary guarding, diffuse rebound tenderness, acutely toxic appearing, SIRS syndrome

Front 12

Imaging required to evaluate for perforated viscus

Back 12

upright CXR and/or left lateral decubitus abdominal x-ray

CT scan if x-ray negative (CT is most sensitive and specific)

Front 13

Pneumoperitoneum on upright CXR

Back 13

perforated viscus, call surgeon

Front 14

Labs to order if suspect perforated viscus

Back 14

type and screen/cross, H&H, platelet and coags, WBC, ABG, lactic acid, BUN/Cr, LFTs, lipase/amylase, U/A

Front 15

ABX for perforated viscus

Back 15

Want to cover Gram neg, Gram pos, and anaerobics:

Cipro and Flagyl, Zosyn, or imipenem

Front 16

Viperidae

Back 16

largest family of venomous snakes

pit vipers, rattlesnakes, copperheads, and cottonmouths

Front 17

Elapidae

Back 17

other venomous snake family, cobras and coral snakes (red on yellow kill a fellow) + Aussie snakes

Front 18

Latrodectus

Back 18

black widows

Front 19

loxosceles

Back 19

brown recluse

Front 20

coral snake venom effects

Back 20

block neuromuscular transmision at ACh sites

 

Front 21

Signs of bite by coral snake

Back 21

ptosis followed by progressive neuromuscular weakness - slurred speech, fasiculations, drowsiness, weakness, dyspnea

Front 22

signs of bite by pit vipor

Back 22

localized edema and pain, spreads proximally and involves entire extremity. Vesicular lesions and bullae may develop. Systemic effects after a few hours (nausea, weakness, metallic taste, fasiculations, sensory changes, pulmonary edema and refractory shock

Front 23

Which snake venom disrupts coagulation cascade and alters vascular permeability?

Back 23

Pit vipers

Front 24

pain that increases over an hour and radiate proximally along limb. Muscles spasms, systemic effects less common (may include hypertension, agitation, fever, paresthesias, and cardiac effects)

Back 24

S/Sx of lactrodectism

Front 25

cytotoxic or necrotic venom

Back 25

venom of brown recluse

Front 26

Local effects - range from mild self-limiting erythema to large necrotis ulcerations. local pain and burning

Systemic effects - hemolysis, DIC, renal failure

Back 26

S/Sx of loxoscelism

Front 27

Lab tests needed for snake bite

Back 27

CBC, CMP, coags (including fibrinogen, PT, aPTT), and CPK

Monitor UOP, check U/A for myoglobin

Front 28

Treatment for envenomations

Back 28

remove spines/stingers, wash, monitor for s/sx compartment syndrome, monitor hemodynamic status, parenteral analgesia, tetanus ppx

call poison control about antivenom 

Front 29

causative organisms of typical PNA

Back 29

strep pneumo, H. influenza, moraxella catarrhalis, and viruses

Front 30

presentation of atypical pna

Back 30

insidious onsent, mild respiratory sx, low grade fevers, little to no sputum

Front 31

criteria for nosocomial pna

Back 31

pna > 48 hrs after admission, >3 mo in nursing home

Front 32

nosocomial organisms

Back 32

Pseudomonas aeruginosa, MRST, Klebsiella, E. coli

Front 33

fever, tachypnea, and irritability in <6mo old

Back 33

consider PNA

Front 34

etiology of PNA <1 month old

Back 34

GBS, E. coli, Klebsiella, Eneterobacter, Listeria

Front 35

etiology of PNA 1-3 months old

Back 35

Viruses (RSV), chlamydia, pertussis, ureaplasma

Front 36

etiology of PNA 3mo-5yo

Back 36

viruses, pneumococcus, hemophilius, mycoplasma, chlaymdia

Front 37

etiology of PNA 6-18 yo

Back 37

viruses, mycoplasma, pneumococcus, chlamydia, hemophilus

Front 38

Empiric ABX for CAP

Back 38

Doxycycline, Macrolides, Sulfonamides, Fluroquinolones

Front 39

Empiric ABX for aspiration PNA

Back 39

Augmentin or (Clinda + aminoglycoside)

Front 40

Empiric ABX for nosocomial PNA

Back 40

Zosyn + (Aminoglycoside or Fluoroquinolone)

Front 41

Empiric ABX for PNA in children

Back 41

Amoxicillin, Macrolide

Front 42

Can PNA patient go home?

Back 42

If Pneumonia severity index is <70, reliable f/u, able to get abx, don't require O2

Front 43

classic patient with primary ptx

Back 43

thin, young males who use tobacco

Front 44

distressed patient, tachycardic, tachypneic, hypotensive, hypoxic

Back 44

tension ptx

Front 45

Treatment for PTX

Back 45

tension - immediate needle decompression, then chest tube immediately after

Large PTX (>20%) - chest tube

Small - repeat CXR for spontanous resolution, needle decompression, or small pigtail catheter

Front 46

most common time for PID 

Back 46

shortly after start of menstrual cycle - fewer defenses by servical musocal barrier to ascending infections

Front 47

risk factors for PID

Back 47

h/o STDs, multiple sexual partners, IUD, age 15-25, sexual intercourse at an early age, recent instrumentation of uterine cavity`

Front 48

common exam findings of PID

Back 48

b/l adnexal tenderness, purulent cervical discharge, cervical motion tenderness, uterine and lower abdominal tenderness

unilateral adnexal tenderness - TOA

RUQ tenderness - Fitz-Hugh-Curtis

Front 49

Labs/tests to order for PID

Back 49

U/A, hcg, CDC w/ diff, LFTs (if FHC suspected), gc/chl PCR on urine or cervical secretions, gram stain cervical secretions, Pelvic u/s if suspect TOA

Front 50

Complications of PID

Back 50

chronic pelvic pain, dyspareunia, infertility, ectopic, TOA, FHC syndrome

Front 51

Bacteria causing PID

Back 51

Gonorrhea, Chlamydia, E. coli, multiple anaerobic bacteria...often polymicrobial

Front 52

treatment for PID

Back 52

Inpatient:

2nd/3rd gen cephalosporin + Doxy

If allergic to cephalosporin, Clinda+Gent

Outpatient:

Ceftriaxone, probenecid, Doxy, +/- Metro

Front 53

Indications for admission for PID

Back 53

suspected TOA or FHC, intractable vomiting, septic, peritonitis, prepubertal children, indwelling IUD, pregnant, comorbidities (DM, AIDS), nulliparous (to preserve fertility)

Front 54

Female, sudden onset unilateral lower abdominal pain, initially visceral, +/- N/V, possibly radiation to groin or flank

Back 54

ovarian torsion

Front 55

w/u for ovarian torsion

Back 55

pregnancy test (concern is ectopic), u/a, WBC, u/s w/ doppler flow

Front 56

ED treatment for ovarian torsion

Back 56

IV access, treat pain, NPO, get to surgery

Front 57

Deep veins

Back 57

calf veins, popliteal, femoral (including superficial femoral), and external iliac

Front 58

mild SOB, chest pain, fatigue

Back 58

beware of PE

Front 59

"Classic" EKG finding of PE

Back 59

S1Q3T3

Front 60

Most common EKG finding of PE

Back 60

sinus tachycardia

Front 61

Risk factors for PE

Back 61

active cancer treatments past 6 months, recent immobilization, DVT or h/o DVT, hormone therapy

Front 62

S/Sx of PE

Back 62

SOB, CP, malaise, pleuritic CP, DVT symptoms, RHF, new oxygen requirement

Front 63

Point of PERC rules

Back 63

if low risk clinically, and PERC negative, don't need further testing

If not lowest risk, and not PERC negative, then use Wells Criteria

Front 64

Function of Wells Criteria

Back 64

If determined low risk by Wells, then a negative d-dimer will essentially rule out PE

Front 65

Test to order for PE

Back 65

CTA!, V/Q scan (old, but maybe if CKD), U/S Duplex (look for DVT), CXR (nonspecific)

Front 66

Treatment for PE

Back 66

heparin or enoxaparin (start before imaging if high pre-test probability), admit to hospital

Front 67

Pain

Hypotension

Pulsatile abdominal mass

Back 67

ruptured AAA

Front 68

Initial treatment for suspected ruptured AAA

Back 68

Manage airway and breathing, 2 large bore IVs, type and cross match blood, target SBP 90-100 mmHg

Front 69

Lab tests for ruptured AAA

Back 69

(only if stable, otherwise to OR)

H&H, coags, electrolytes and U/A

U/S - extremely sensitive

CT - extremely accurate, can see other diagnoses, can indicate intact AAA --> consider imminent rupture if symptoms fit