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247 Cards in this Set
- Front
- Back
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What organism causes an external hordeolum?
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S. aureus
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What do you call an infection of an oil gland at the lash line?
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external hordeolum (stye)
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What is another name for an internal hordeolum?
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chalazion
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What is a mebomian gland blockage at the tarsal plate?
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chalazion (internal hordeolum)
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Tx for a refractory hordeolum?
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doxycycline 14-21 days
possible surgical removal |
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clinical findings of bacterial conjunctivitis?
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*can be monocular or binocular
*matting, mucopurulent discharge *conjunctival inflammation *flourescein staining may reveal abrasions ulcers, dendritic lesions |
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What are indications for use of flourescein staining?
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Hx of trauma, contact lens use, herpes like lesions, rashes
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Tx of bacterial conjunctivitis?
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Broad spectrum antibiotic drops x 5-7 days or E-mycin ointment. For contact lens wearers cover pseudomonas with cipro, floxin, or tobramycin. For patients <2 months old give sulfacetamide 10% 1gtt qid
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What do you do for severe purulent ophthalamic discharge with hyperacute onset? What is the possible Dx?
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*consult ophthalmology
*gram stain & culture *rocephin 1g IM or cipro 1gtt q2h *if corneal involvement - rocephin IV, tobramycin, or doxycycline Possible gonococcal conjunctivitis |
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What are clinical findings of viral conjunctivitis?
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*can be monocular or binocular
*watery dc, chemosis, conjunctival inflammation *often follows URI, adenovirus *palpable preauricular adenopathy - differentiates from bacterial *flourescein staining shows superficial punctate keratitis- otherwise clear |
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Tx for viral conjunctivitis?
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symptomatic - cool compresses qid, naphazoline/pheniramine prn
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What is the characteristic feature of allergic conjunctivitis?
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severe itching
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SSx of corneal abrasion?
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tearing, photophobia, blepharospasm, pain
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Tx for corneal abrasion?
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topical antibiotics, cycloplegics, (flouroquinolones for contact wearers), narcotic analgesics for severe pain, tetanus update, no patching, reexamine in 24hrs
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What is a corneal ulcer?
Who is at highest risk of developing a corneal ulcer |
*severe infection of the corneal stroma
*contact lens wearers |
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SSx of corneal ulcer?
Slit lamp exam findings? |
*often assoc. with trauma - pain redness, tearing, photophobia
*staining corneal defect with surrounding white hazy infiltrate |
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Tx for corneal ulcer?
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topical ofloxacin or cipro qh, cycloplegics, no eye patching
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What is pathognomic for HSV of the eye?
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dendrite on flourescein staining
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Tx for HSV of eye?
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If no corneal involvement - antiviral, topical E-mycin
With corneal involvement - increase antiviral, add cycloplegic |
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Can you use topical steroids in the eye?
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NO NOT EVER!! UNDIAGNOSED HSV IN THE EYE WITH CORTICOSTEROIDS WILL LEAD TO BLINDNESS
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What does a positive Hutchinson's sign indicate?
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involvement of nasociliary nerve
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Tx for herpes zoster ophthalmicus?
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antivirals if <3 days prior onset, E-mycin ointment, warm compresses, oral narcotics, cycloplegics, ophthalmology consult if significant ocular involvement
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Differentiate between periorbital cellulitis and orbital cellulitis.
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periorbital is more superficial and does not extend beyond the orbital septum the way orbital cellulitis does. Periorbital cellulitis does not cause pain with movement, orbital does. Orbital cellulitis also causes fever and proptosis. They both show warm, indurated, erythematous eyelids.
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Tx for periorbital cellulitis?
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>5y.o. - augmentin
<5y.o., comorbidities, or toxicities in adults - hospital admission for IV rocephin and vancomycin |
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Tx for orbital cellulitis?
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emergent CT of orbits and sinuses, consult ophthalmology, admission for IV cefuroxime
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Tx for hyphema?
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place upright with protective shield, no strenuous activity, exclude ruptured globe, dilate pupil with atropine, measure IOP - if >30mmHg give timolol .5% 1gtt, emergent ophthalmologic consult
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If a patient with an orbital blowout fracture presents with restriction of upward gaze and diplopia and paresthesia along distribution of infraorbital nerve is it more likely to be medial or inferior?
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inferior - medial typically presents with subcutaneous emphysema (rice krispies under the skin)
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Tx for orbital blowout fracture/
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CT of orbit, r/o ocular injury, Keflex X 10days, refer to ophthalmology
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SSx of acute angle closure glaucoma?
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eye pain, HA, cloudy vision, colored halos around lights, conjunctival injection, fixed mid-dilated pupil, hazy cornea, increased IOP of 40-70mmHg, N/V common, narrow anterior chamber angles
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Tx of AACG?
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timolol .5% 1gtt, apraclonidine .5% 1gtt, prenisolone 1% 1gtt q15min x 4 then qh. Diamox if IOP >50 or if vision loss is severe, Mannitol if IOP doesn't decrease in 1hr. Once IOP <40 - pilocarpine, treat pain and nausea, consult ophthalmology
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SSx of optic neuritis? Tx?
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acute vision loss esp. color.
Tx with IV steroids |
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SSc of central retinal artery occlusion?
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sudden painless monocular loss of vision, amaurosis fugax, retina will be pale, less transparent, edematous, cherry red spot on macula is characteristic finding
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Tx for CRAO?
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consult ophthalmology, pressure on globe to dislodge the embolus, diamox or timoptic to decrease IOP
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SSx of central retinal vein occlusion?
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acute painless monocular vision loss, optic disc edema, cotton wool spots, diffuse retinal hemorrhages. Pt will prob. have Hx of HTN, hypercoagulability, vasculitis, glaucoma
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Tx for CRVO?
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measure IOP, ASA, DC predisposing drugs or diuretics
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SSx of retinal detachment? Tx?
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acute decrease in visual acuity, flashing lights, floaters
Consult ophthalmology |
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If a pt presents with unilateral sensorineural hearing loss, what should you do first?
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Obtain MRI to r/o acoustic neuroma
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Who is most at risk for DRSP with otitis media?
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<2y.o., day care attendance, antibiotics in past 3 months, immunocompromised
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What is Tx algorithm for acute otitis media?
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1st line - amoxicillin 45-60mg/kg/d divided BID-TID
risk factors for DRSP - amoxicillin 80-90mg/kg/d divided BID also for DRSP - augmentin, vantin, ceftin, omnicef, rocephin if PCN allergy: zithromax |
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Complications of AOM?
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TM perforation, conductive hearing loss, acute serous labyrinthitis, facial nerve paralysis, acute mastoiditis, lateral sinus thrombosis, cholesteatoma, intracranial complications.
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Does otitis media with effusion cause pain or other signs of infection? How is it treated?
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NO. observation for resolution, ENT referral if persistent
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What pathogen causes bullous myringitis? Tx?
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Mycoplasma pneumoniae is MC. Tx with E-mycin if effusion is present
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SSx of acute mastoiditis?
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otalgia, fever, postauricular erythema, swelling, and tenderness, protrusion of auricle, patients appear systemically ill
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Tx of acute mastoiditis?
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CT, ENT consult for possible surgical drainage, IV cefotaxime, hospital admission,
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Causative organisms of otitis externa?
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psuedomonas (MC), staph, bacteroides, polymicrobial, fungi, candida
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Tx of otitis externa?
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ear wick if edema and exudate obstructing EAC, cipro HC 3gtt BID, Floxin 10gtt BID if TM is ruptured, analgesics, oral antibiotics if auricular cellulits
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Who is at risk for malignant otitis externa?
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DM, immunocompromised
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SSx of malignant otitis externa? Tx?
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systemic sx and auricular cellulitis
CT, ENT consult, admission, aminoglycoside and anti-pseud. PCN, ceph., or flouroquinolone |
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What size sutures do you use on the ear?
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5-0 or 6-0 absorbable
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How do you treat a hematoma onn the ear?
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immediate I&D with compressive dressing
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How do you determine if epistaxis is anterior or posterior?
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it is posterior if: anterior source not visualized, bleeding from both nares, blood in post. pharynx after anterior source is controlled
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What is MC type of epistaxis?
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bleeding from Kiesselbach's plexus on anterior septum
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Tx of anterior epistaxis?
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topical anesthetic and vasoconstrictor (lidocaine and oxymetolazine), direct pressure, anterior nasal packing (remove in 2-3 days), if visible - cautery with AgNO3
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Tx of posterior epistaxis?
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packing, O2, narcotic analgesics, ENT consult for possible hospital admission - ligation of nasal arterial supply (internal maxillary a. and ethmoid aa.) or endovascularembolization of internal maxillary artery
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Tx of nasal fractures?
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non-displaced - no Tx
displaced - consult ENT |
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What is a complication of an untreated septal hematoma? Tx?
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abscess or necrosis of septum
Tx with I&D and anterior nasal packing |
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What is a complication of a fracture of the cribriform plate?
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may violate subarachnoid space and cause CSF rhinorrhea - get CT and neuro consult
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What is the MC cause of pharyngitis?
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viruses
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SSx of GABHS pharyngitis?
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sore throat, fever, HA, abdominal pain, absence of cough, anterior cervical adenopathy, palatal petechiae, tonsillar hypertrophy, scarlatina-form rash
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SSx of EBV pharyngitis?
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fever, sore throat, malaise, anterior and posterior cervical adenopathy, hepatosplenomegaly
maintain a high suspicion with a sore throat that will not resolve |
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Tx of GABHS pharyngitis?
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*benzathine PCn
*amoxicillin 60mg/kg/d *E-mycin ethylsuccinate *cefzil or ceftin *zithromax *if sx are severe - dexamethasone to reduce inflammation |
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complications of GABHS pharyngitis (suppurative and non-suppurative)
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suppurative: cervical lymphadenitis, PTA, retropharyngeal abscess, sinusitis, AOM
non-suppurative: acute rheumatic fever, poststreptococcal glomerulonephritis |
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Tx for GC pharyngitis?
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rocephin + zithromax or spectinomycin + doxycycline
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Tx for EBV pharyngitis?
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supportive, treat airway obstruction with steroids if necessary
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What is MC cause of PTA?
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GABHS
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SSx of PTA?
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fever, malaise, sore throat, odynophagia, dysphagia, hot potato voice, otalgia, +/- trismus, unilateral tonsilar enlargement, palatal and uvular edema, contralateral deflection of uvula, tender ipsilateral anterior lymphadenopathy, drooling, dehydration
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Tx of PTA?
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aspiration of purulent material, PCN V, if PCN allergy give clindamycin. can also give augmentin or cefuroxime plus flagyl
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who gets a retropharyngeal abscess most often?
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children <5y.o.
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What are diagnostic findings in a retropharyngeal abscess?
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neck slightly extended in supine position, torticollis, pain with tracheal movement, lateral soft tissue xray will show thickening in prevertebral space
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Tx for retropharyngeal abscess?
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airway management, ENT consult, clindamycin or ampicillin/sulbactam
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SSx of Ludwig's angina? Tx?
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edema and erythema of sublingual region, tongue displaced up and back, fever, dysarthria, drooling
Tx - possible intubation, IV ampicillin/sulbactam or high dose amoxicillin plus flagyl, C&S, surgical consult |
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Tx for necrotizing ulcerative gingivitis?
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debridement, flagyl, clindamycin, warm 1/2 strength peroxide rinses
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What is the MC cause of upper GI bleeding?
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PUD
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What is MC cause of appearant lower GI bleed?
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upper GI bleed
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What is MC cause of lower GI bleed?
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hemorrhoids
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What is suggested if a pt presents with coffee ground emesis or hematemesis?
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source is proximal to R colon
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What should you suspect if pt presents with hematochezia or melena?
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distal colorectal lesion
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What is suggested by spider angiomata, palmar erythema, jaundice, and gynecomastia?
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underlying liver disease
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What are essentials to Dx GI bleeding?
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careful ENT exam, NG tube placement and aspiration, rectal exam, type and cross match, CBC, CMP, PT/INR
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What is emergency Tx of esophageal varices?
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octreotide IV
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If a pt has transport dysphagia for solids only, is this mechanical, obstructive, or motility d/o?
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mechanical or obstructive
motility will have dysphagia for liquids also |
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Essential for dx of esophageal emergencies?
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history - most important, AP/lat neck and CXR, barium swallow, direct laryngoscopy to identify structural lesions
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How do you tell if a swallowed coin is in the esophagus or the trachea?
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esophagus - lie in frontal plane
trachea - lie in saggital plane |
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Tx for appendicitis?
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NPO, IV access, analgesia (fentanyl), piperacillin/tazobactam or ampicillin/sulbactam, surgical consult
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What is a classic sign of intestinal obstruction?
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active high pitched bowel sounds
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If intestinal obstruction is suspected, what studies should be ordered?
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flat & upright abdomen and CXR, CBC, CMP, amylase, UA, sigmoidoscopy and barium enema, contrast enhanced CT
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Tx of intestinal obstruction?
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surgical consult, NG tube decompression, IV fluids (monitor response), broad spectrum antibiotics,
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What are risk factors for hernias?
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family Hx, lack of developmental maturity, undescended testes, GU abnormalities, conditions with increased abdominal pressure (ascites, pregnancy), COPD, surgical incision sites
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Tx of reducible hernia?
incarcerated? strangulated? |
reducible - outpt surgical eval. & repair, avoid heavy lifting, return if not reducible or signs of obstruction
incarcerated - if recent: attempt to reduce, if duration unknown: do not attempt reduction. Possibly strangulated if no bowel sounds. surgical consult, NPO, IV fluids, NG tube, broad spectrum antibiotics |
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MC cause of intestinal obstruction in children 3months - 6yrs?
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intussusception
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SSx of intussusception?
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male>females, currant jelly stools, colicky epigastric pain, sausage shaped mass in R abdomen
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T or F? pyloric stenosis occurs more frequently in males.
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true
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What finding is diagnostic of pyloric stenosis?
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olive shaped mass in LUQ - US will aid in Dx
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What are extraintestinal findings of Crohn's disease?
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arthritis, uveitis, liver, or skin disease(erythema nodosum or pyoderma gangrenosum), hepatobiliary disease, kidney stones, thromboembolism.
also assoc. with perianal fissures or fistulas, abscesses, or rectal prolapse |
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Definition of toxic megacolon?
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long, continuous segment of air-filled colon >6cm diam.
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Define diverticulitis?
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bacterial proliferation in an existing colonic diverticulum
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SSx of diverticulitis?
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steady, deep discomfort in LLQ, tenesmus, change in bowel habits, irritation of urinary tract (fistula b/t colon and bladder, recurrent UTI), paralytic ileus (abdominal distention, n/v), SBO and perforation, RLQ pain with ascending colon involvement, fullness or mass over affected area, low grade fever, rebound tenderness, occult blood
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Is it OK to perform a barium enema or colonoscopy in acute diverticulitis?
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no - risk of perforation
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What are indications for admission for diverticulitis?
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systemic ssx, failed outpt therapy, signs of peritonitis
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outpt tx for diverticulitis?
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cipro and flagyl as well as liquid diet for 48hrs then low residue diet
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inpt tx for diverticulitis?
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gentamycin or tobramycin + flagyl or clindamycin, NPO, NG suction
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What is the MC cause of painful rectal bleeding?
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anal fissures
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If an anal fissure is not located in the midline posteriorly, what should you suspect?
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crohn's, UC, carcinoma, lymphoma, STD's
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What are possible underlying causes of anal fistulas? Tx?
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crohn's, UC, TB, gonococcal proctitis, carcinoma
Tx with surgical excision |
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Can a perirectal abscess be drained in ED?
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NO - must be done in OR
Perianal abscess is only anorectal abscess that can be drained in ED |
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Give GASTROENTERITIS acronym for Dx of vomiting and diarrhea.
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G -GI disease
A - appendicitis or aorta S - specific dz (glaucoma) T - trauma R - Rx (meds) O - OB/GYN d/o E - endocrine N - neuro T - toxicology E - environmental R - renal dz I - infection T - tumors I - ischemia S - supratentorial |
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What antibiotics are used to treat severe prolonged diarrhea or in pts with Hx of travel to third world countries?
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cipro 500mg BID x 3days or bactrim x 3 days for children and nursing mothers
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What is the MC digestive complaint in the US?
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constipation
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What bilirubin levels produce clinically evident jaundice?
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2-2.5mg/dl
(normal is .5-1mg/dl) |
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What does direct hyperbilirubinemia suggest?
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liver disease
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What does indirect hyperbilirubinemia suggest?
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hemolytic anemia, sepsis, CHF
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What do you suspect when a pt presents with sudden onset jaundice, fever, malaise, myalgia, and tender enlarged liver?
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viral hepatitis
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Pt presents with hepatomegaly, pedal edema, and JVD. What do you suspect?
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CHF
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When do you admit a pt for acute viral hepatitis?
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any changes in mental status (encephalopathy, prolonged PT, intractable vomiting, hypoglycemia, bilirubin >20, >45y.o., immunosuppression, suspected toxin induced
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What are MC causes of cirrhosis?
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alcohol abuse, Hep C, obesity with non-alcoholic fatty liver disease
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What is the MC complication of cirrhotic ascites?
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spontaneous bacterial peritonitis
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SSx of spontaneous bacterial peritonitis?
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fever, abdominal pain/tenderness, worsening ascites, encephalopathy, decreasing renal function, hypothermia, diarrhea
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What is diagnostic of SBP?
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WBC >1000 or PMN>250 from paracentesis fluid
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Tx of SBP?
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cefotaxime, p/t, a/s, t-c, or rocephin, albumin to stabilize intravascular volume
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What is hepatorenal syndrome? Causes?
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functional renal failure in cirrhotic pts in absence of intrinsic renal disease
can be caused by overzealous diuresis, sepsis, dehydration, high volume paracentesis |
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Tx for alcoholic hepatitis?
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IV fluids with dextrose, thiamine, MVI, electrolyte replacement, avoid hepatotoxic drugs, identify infections
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Tx for encephalopathy?
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O2, dextrose in IV fluids, support respiration, manage precipitating factors, lactulose, neomycin if lactulose fails, if one or the other is unsuccessful use both
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SSx of biliary colic?
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epigastric or RUQ pain that is intermittent, colicky, or constant, n/v, referred to R shoulder or L upper back, pain after fatty meals, duration 2-6hrs and recur at intervals >1week
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Difference b/t biliary colic and acute cholecystitis?
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Acute cholecystitis persists longer than 6 hrs
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Unique SSx of acute cholecystitis?
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anorexia, abdominal distention, hypoactive bowel sounds, + Murphy's sign,
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What is Charcot's triad for ascending cholangitis?
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fever, jaundice, RUQ pain
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Which biliary tract emergencies require hospitalization and surgical consultation?
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acute cholecystitis, gallstone pancreatitis, ascending cholangitis
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General management of biliary tract emergencies?
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IV fluids (isotonic), phenergan, NG tube if vomiting is intractable, demerol, if no cholecystitis - toradol, with cholecystitis or ascending cholangitis - antibiotics: no sepsis - 3rd gen. Ceph
with sepsis - ampicillin, gentamycin, and clindamycin |
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What is the #1 cause of acute pancreatitis?
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alcohol abuse
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Tx of acute pancreatitis?
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fluid resusitation, prevention or tx of vomiting (antiemetics or NG tube), pain mgmt., NPO, O2, prophylaxis for EtOH withdrawal
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Give Ranson's Criteria for acute pancreatitis.
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AT ADMISSION:
age >55 WBC >16000 LDH >350 AST >250 Glucose >200 DURING 1ST 48HRS: Hct decrease >10 BUN increase >5 Ca <8 PaO2 <60 Base deficit >4 Fluid sequestration >6L |
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If you suspect a leg fracture in a child, do you have to xray the entire leg?
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yes
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Name the components of a fracture description.
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*open or closed?
*location *orientation of fracture line *displacement *separation *shortening *angulation *rotational deformity *fracture combined with dislocation or subluxation? |
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What are the general management guidelines for all fractures and dislocations in the ED?
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cold packs, elevation, analgesics, NPO, reduction of fracture deformity, postreduction xrays, antibiotics for open fractures (1st gen. Ceph. and aminoglycoside), immobilize the joint, crutches for lower extremity injuries
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Tx guidelines for flexor tendon repair?
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close skin and splint - refer
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Tx guidelines for extensor tendon repair?
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often can be done in ER
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What is gamekeepers thumb? Tx?
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forced radial abduction at the MCP joint - injury to UCL of thumb
thumb spica splint - refer for surgical repair |
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Tx of a Boutonniere deformity due to traumatic injury?
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splint PIP joint in extension and allow DIP motion for 4-6 weeks
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What is mallet finger? Tx?
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DIP flexion deformity - stretching or rupture of tendon of extensor digitorum profundus or avulsion of part of the distal phalanx with tendon attached. Extension not possible
splint finger in extension across the DIP joint leaving PIP joint free for 6-12 weeks - may need operative repair |
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What causes PIP joint dislocations? Tx?
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rupture of volar plate
Tx - xray, digital block, splint and refer |
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MC direction of MCP joint dislocations? Tx?
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dorsal - require surgical reduction
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What is the MC distal phalanx fracture? Tx?
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tuft fracture
Tx - <1/3 articular surface involved - dorsal extension splint >1/3 articular surface involved - internal fixation |
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What do you suspect if the fingertips of a closed hand do not all point to the same spot on wrist?
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middle or proximal phalanx fracture
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Tx of middle or proximal phalanx fracture?
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non-displaced - gutter splint in position of function and referral
displaced - surgical intervention |
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What is the MC metacarpal fracture?
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4th or 5th neck fracture (Boxer's)
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How do you treat a fracture of the 2nd or 3rd metacarpal with angulation >15 degrees?
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reduction
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How do you treat a Boxer's fracture with >20 degrees angulation?
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reduction
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What is the MC carpal fracture?
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scaphoid
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What is a colle's fracture?
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distal radius is dorsally displaced - dinner fork deformity
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What is a smith's fracture?
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distal radius is volarly displaced - garden spade deformity
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what direction are most elbow dislocations?
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posterior due to FOOSH
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What structures are most prone to injury from an elbow dislocation?
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brachial artery and ulnar nerve
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Tx for elbow dislocation?
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sedation, reduce by gentle traction on wrist and forearm, reasses neurovascular status, postreduction films, long arm splint in 90 degrees flexion, close ortho f/u
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What is the MC elbow fracture?
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radial head due to FOOSH
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If a patient recieves direct force to the elbow, what is the most likely location of the fracture?
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intercondylar
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Who is more prone to supracondylar fractures? Cause?
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children - extension force causes posterior displacement
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clinical presentation of radial head fracture?
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lateral elbow pain/tenderness, inability to fully extend elbow
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clinical presentation of intercondylar and olecranon fractures?
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swelling, tenderness, limited ROM
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What structures are most at risk for injury in a supracondylar fracture? How do you asses damage to this structure?
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anterior interosseus nerve
OK sign |
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What might you find on xray of a radial head fracture?
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posterior fat pad sign
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What might you find on xray of a supracondylar fracture?
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AP shows transverse fx line, lateral shows oblique line and displacement of distal fragment proximally and posteriorly - post. and ant. fat pad sign
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Tx for non-displaced/minimally displaced elbow fractures?
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immobiliize in splint and refer
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Define Monteggia fracture-dislocation
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fx of proximal ulna shaft with a radial head dislocation
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define galeazzi fx-dislocation.
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fx of distal radius with associated distal radioulnar joint dislocation
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Tx of forearm fractures?
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non-displaced: immobilize in long arm cast, refer
displaced: ortho consult, open reduction and internal fixation in adults. In children, closed reduction can be done |
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SSx of distal biceps tendon rupture?
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strength in flexion and supination is weaker, swelling, ecchymosis, and tenderness in antecubital fossa, biceps tendon not palpable in antecubital fossa
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SSx of proximal biceps tendon rupture?
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swelling, tenderness, and crepitus over bicipital groove, ball in mid-arm when elbow is flexed, minimal loss of strength in elbow flexion
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SSx of triceps tendon rupture?
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swelling and tenderness proximal to olecranon, extension of forearm is weak
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Tx of biceps and triceps tendon rupture?
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sling, ice, analgesia, ortho referral for surgical repair
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What is the first priority when evaluating d/o of the shoulder?
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determine if pain is result of another d/o.
c-spine, TOS, pancoasts tumor, ACS, GI |
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name the four joints of the shoulder
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sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
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What is the best test to differentiate b/t an anterior and posterior sternoclavicular joint dislocation?
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CT
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What is the MC fracture in children?
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clavicle
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Who MC receives acromioclavicular joint injuries?
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young males - sports related
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Name the five classifications of AC joint injuries and their Tx.
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I - AC lig. sprain or partial tear, tenderness with little or no deformity. Tx: rest, ice, analgesics, immobilization X 1-3 weeks. Once pain free do ROM exercises.
II - disruption of AC lig. Tx: same as Type I. III - disruption of AC and CC. Tx: can be conservative or operative IV-VI - complete AC and CC disruption with different orientations of displaced clavicle. Tx: operative |
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What is the MC major joint dislocation? MC direction?
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glenohumeral joint - anterior
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Clinical presentation of anterior glenohumeral joint dislocation?
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pt holds arm in slight abduction and external rotation, shoulder with a squared off appearance
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What structure is most likely to be injured with a glenohumeral joint dislocation? How do you test for this injury?
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axillary nerve - pinprick over lateral shoulder
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What is a Hill-Sach's lesion?
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compression fracture of humeral head
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What is a Bankard lesion?
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fracture of anterior glenoid rim
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Clinical presentation of posterior glenohumeral joint dislocation?
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pt holds arm in internal rotation and adduction, coracoid process may appear prominent
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Clinical presentation of inferior glenohumeral joint dislocation?
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pt holds arm overhead
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What structures are most likely to be injured with a proximal humerus fracture?
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axillary nerve, axillary artery, or brachial plexus
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What structures are most likely to be injured in a humeral shaft fracture?
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brachial artery or vein, or to radial, ulnar, or median nerve
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Tx of humerus fractures?
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immobilization (sling and swath or shoulder immobilizer), ice, analgesics, ortho referral
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SSx of radial head subluxation?
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arm held flexed, close to body, and forearm pronated - no pain on palpation, but pain with ROM, x-ray will be normal. Tx is closed reduction
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Red flags for acute back pain?
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incontinence, saddle anesthesia, B neurologic deficits-->possible cauda equina syndrom
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causes of cauda equina syndrome?
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large central disc herniation, tumors, trauma, epidural abscess, hematoma
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More red flags for acute back pain?
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wt loss, night pain, fever/chills, hx of Ca, IV drug use
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Indications of herniated disc?
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decreased reflexes, + straight leg and crossed straight leg raise
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SSx of cauda equina syndrome?
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decreased rectal tone, saddle anesthesia, motor weakness, absent reflexes
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How do you r/o cauda equina syndrome?
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urinary post void residual <50-100 mL
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Tx for lumbosacral strain and chronic DDD?
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analgesics - NSAIDS or Tylenol +/- muscle relaxants
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Tx for herniated disc/sciatica?
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same as for lumbosacral strain, however opiods may be required short term
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Tx for cauda equina syndrome?
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true emergency - dexamethasone IV, consult neuro while awaiting MRI
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Tx of pelvic avulsion fractures?
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analgesia, rest, crutches, f/u 1-2 weeks
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What should you suspect if a patient has pain with wt bearing & a negative xray?
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acetabular fracture - get CT or MRI
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Clinical presentation of hip fractures?
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affected leg shortened & externally rotated
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Complications of hip fractures?
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high morbidity and mortality, infection, VTE, avascular necrosis, nonunion
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Tx of non-displaced fx of femoral neck?
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pin fixation
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Tx of displaced fx of femoral neck?
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open reduction or prosthesis
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What is MC direction of hip dislocations?
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posterior
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Tx of hip dislocations?
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early closed reduction to reduce risk of avascular necrosis
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Clinical presentation of posterior hip dislocation?
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leg shortened, internally rotated and adducted
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Clinical presentation of anterior hip dislocation?
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abduction and external rotation
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Who gets an xray for a knee injury?
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*any blunt trauma
*<12y.o. *>50y.o. *inability to walk 4 wt bearing steps |
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What is the best film to obtain when a patellar fx is suspected?
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sunrise view - plain films
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Tx of patellar fx?
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non-displaced - immobilize, ice, analgesics, elevation, referral
displaced >3mm or disruption of extension - operative repair |
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What are some injuries/structures associated with femoral condyle fx?
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popliteal artery, hip dislocation/fx, quadriceps injury, neurologic injury (deep perineal nerve)
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Tx of femoral condyle fx?
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ortho consult - most require operative repair
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What complication is most concerning with a tibial fx?
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compartment syndrome
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What is MC direction of knee dislocation?
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posterior
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What structures are MC injured due to knee dislocation?
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popliteal artery and peroneal nerve
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Who is more susceptible to patellar tendon rupture?
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<40y.o. with hx of patellar tendonitis or steroid injections
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Who is more susceptible to quadriceps tendon rupture?
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older patients after sudden forceful contraction of quads
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Who is most at risk for achilles tendon rupture?
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RA, lupus, quinolones, previous steroid injection of achilles tendon, poor athletic conditioning
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How do you dx achilles tendon rupture?
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Thompson test
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Tx of achilles tendon rupture?
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splint in plantar flexion, non-wt bearing, analgesics, elevation, referral to ortho
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What is the MC ligamentous knee injury?
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ACL - due to deceleration, hyperextension, or internal rotation of the tibia on the femur
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what is most sensitive test for dx of ACL injury?
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Lachman test - can also do anterior drawer and lateral pivot shift
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Tx of ACL injury?
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knee immobilization, ice,elevation, analgesics, and ortho referral
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What is the MC direction of ankle sprains?
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inversion injuries
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MC injured structured in the ankle?
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lateral ankle, anterior talofibular ligament
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Tx of following:
stable ankle sprain (wt bearing) stable ankle sprain (no wt bearing) unstable ankle sprain |
stable wb - RICE
stable nwb - ankle brace unstable - posterior short leg splint and ortho f/u |
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Tx for ankle fractures?
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unimalleolar - post. splint, nwb, ortho f/u
bi/tri malleolar - open reduction and internal fixation, splint and get ortho CONSULT |
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Tx for small (<3mm) avulsion fractures of fibula?
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treat like a sprain - RICE x 72 hrs
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Tx for open ankle fx?
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wet sterile dressing over wound, splint, tetanus update, cefazolin 1g IV, if obvious gross contamination, add aminoglycoside
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Pt presents with absence of pulse and a cool dusky foot - what do you do?
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immediate reduction by orthopedist
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What is a Jones fracture?
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transverse fracture at 5th metatarsal base
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What is a pseudo Jones fracture?
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avulsion fracture at tuberosity of 5th metatarsal base
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What can cause compartment syndrome?
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decreased compartment size or distensability due to constrictive dressing, casts, decreased tissue compliance due to thermal injuries or frostbite
increased compartment volume due to edema, hemorrhage within the compartment after blunt or penetrating injury can also be both |
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Where is compartment syndrome MC?
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anterior and lateral leg compartments
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What are the five classic signs of compartment syndrome?
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pain, pallor, paresthesias, pulselessness,and paralysis
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Tx for compartment syndrome?
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Based on pressure:
<10 - none 15-20 - reevaluate in 12-24hrs >20 - hospital admission and/or surg. consult >30-40 - immediate fasciotomy |
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What is rhabdomyolysis MC assoc. with?
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EtOH, drug use, toxic ingestion, trauma, certain infections, strenuous physical activity, heat related illness
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Risk factors for rhabdo?
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recent immobility with muscle compression, increased muscle activity due to drug intoxication, unaccustomed muscle activity, electrical injury, injuries, heat stroke, sickle cell disease, dermatomyositis, polymyositis
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What mm. are MC involved in rhabdomyolysis?
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postural mm. of calves, thighs, and lower back
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what is most serious complication of rhabdomyolysis?
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ARF
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What is the hallmark of dx of rhadbomylysis?
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5 fold increase in CPK
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Tx of rhabdomyolysis?
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rehydration (mainstay), cardiac monitoring, serial: urinary pH, venous pH, electrolytes, CPK, Ca, pH, BUN/Cr
Also give sodium bicarb, diuresis with 20% mannitol, treat electrolyte imbalance and underlying etiology |
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Describe Salter Harris Classification.
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I - epiphysis seperates from metaphysis but no bony fragments, no disruption in bone growth, xray may only show joint effusion. Tx: splint & refer
II - (MC physeal fx) fx through physis and out through metaphysis, periosteum intact over metaphyseal fragment but torn on opposite side, growth preserved. Tx: closed reduction -->cast immobilization III - intraarticular fx of epiphysis with cleavage plane cont. over physis. MC proximal or distal fibula. Bone growth usually favorable and depends on circulation. Tx - often open reduction IV - fracture line through articular surface, epiphysis, physis, and metaphysis. MC distal humerus. Tx - open reduction to reduce risk of premature bone growth arrest V - usually ankle or knee, physis crushed, no epiphyseal displacement. May have growth arrest. Tx - cast immobilization, nwb, close ortho f/u |
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define dyspnea
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subjective feeling of difficult, labored, or uncomfortable breathing
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Tx algorithm for resp. distress?
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O2, if no improvement - C-PAP-->Bi-PAP-->mechanical ventilation
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Define hypoxia.
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inadequate delivery of oxygen to the tissues - PaO2<60
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SSx of hypoxia?
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tachypnea, tachycardia, changes in mental status
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SSx of chronic hypoxia?
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clubbing, polycythemia, cor pulmonale, changes in body habitus
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Define hypercapnia
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PaCO2 > 45 (doesn't apply to COPD pts who may stay @ 60-70)
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