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231 Cards in this Set
- Front
- Back
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Unmyleninated fibers that innervate the capsules or walls of organs results in ____ pain and pts are often unable to lie still.
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Visceral pain
pg 519 |
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Myelinated fibers innervate the abdominal wall resulting in ___ pain and pts often prefer to remain immobile.
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Parietal pain
pg 519 |
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Which type of abdominal pain is easier to localize, parietal or visceral?
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Parietal pain can be localized to the dermatone superficial to the site of the painful stimuli.
pg 519 |
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Critically ill pts should be stabilized before attempting diagnosis. What are some red flags for identifying the critically ill?
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extremes of age, severe pain of rapid onset, abnormal vitals, dehydration, evidence of visceral involvement (pallor, diaphoresis, vomiting)
pg 519 |
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Intravascular volume depletion. About 20% blood loss is suspected when the pulse rate increases ___bpm after standing for 1 minute.
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30bpm increase equals about 1L of blood loss or 20%
pg 519 |
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Describe the physical exam of the acute abdomen.
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Inspection -distention, masses, ecchymosies
Auscultation - BS Percussion - HSM, fluid wave Palpation- guarding, rigidity, rebound, AAA, pelvic & rectal exam pg 520 |
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T/F: Opioid analgesia obscures abdominal findings for acute abdomen.
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False
pg 520 |
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What population is more likely to develop appendicitis?
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Young adults
pg 521 |
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Who is more likely to develop bowel obstruction, biliary disease, and diverticulitis?
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Older adults
pg 521 |
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T/F: A normal WBC excludes a surgical emergency.
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False: CANNOT exclude surgical disease
pg 522 |
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What percent of pts with a perforation will not demonstrate free air on acute abdomen series?
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20%
pg 522 |
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Name some high risk groups that make it difficult to identify a critical illness.
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AMS,
cognitive impairment, elderly, transplant pts, immunocompromised (DM, HIV, pregs, CA, malnurished) pg 522 |
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What is the most common surgical cause of abdominal pain in the elderly?
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Cholecystitis
pg 523 |
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What is the leading cause of maternal death in the first trimester?
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Hemorrhage from an ectopic gestation.
pg 525 |
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If no allergies, what is the first line category of antibiotics for severely sick, elderly, or immunocompromised pts with intra-abdominal infections?
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Aminoglycosides:
Gentimicin 1.5mg/kg q 8h or Tobramycin 1.5mg/kg q 8h or Amikacin 5mg/kg q 8h pg 525 |
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What is the first test in a woman who presents with abdominal pain or abnormal vaginal bleeding?
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screening hCG
pg 526 |
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Common causes of ab/pelvic pain in the female.
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Adnexal torsion,
Endometriosis, PID, Ectopic pregnancy, Ovarian Cyst, Tubo-ovarian abscess pg 526 |
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T/F: Fever is not a reliable marker for surgical disease in the elderly b/c they tend to be hyporthermic in the presence of serious abdominal infections.
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True
pg 526 |
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Bariatric pts can have complications such as anastomotic leak, dumping syndrome, metabolic absorption complications, and _____.
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Bowel obstruction
pg 526 |
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45yo M with constant LLQ and intermittent RLQ pain for 1 day. Recently lost 30lbs with exercise and diet. BMI - 30. +N/V/D, no fever. CT shows fatty mass with hyperdense rim and surrounding messenteric stranding. Appendectomy at 22yo. What is the concern for?
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Epiploic Appendagitis - self limiting, resolves in 1-2 weeks, no antibiotics indicated, provide pain control
pg 527 |
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50yo F c/o N/V, ab distention, cramps, and unable to pass gas or stool (obstipation). Pt recently had an open abdominal nephrectomy 3 days ago. What is the concern for?
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Ileus and Postop Bowel Obstruction, plain films show diffusely dilated bowel loops with air present in the colon
pg 527 |
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65yo M with profuse, foul smelling watery diarrhea for 1 week. Pt denies bloody stool, minimal tenderness of abdomen, and stable VS. ALTHA shows recent URI treated with Levoquin for 2 weeks by PCM. What is the concern for?
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Clostridium Difficile, WBCs may be elevated, Stool cultures take 72hrs (not helpful in ED).
pg 527 |
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Treatment of C. Difficile consists of what?
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Stopping inciting antibiotic therapy, NO antiperistaltic meds, Metronidizole 500mg TID x 10days,
Severe dz - Vanco and Metro IV pg 527 |
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What is the most common cause of N/V in the U.S.?
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1. Gastroenteritis,
2. Drugs (in adults), and 3. Pregnancy (women) pg 528 |
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What are the three stages of vomiting?
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1. Nausea (hypersalivation, repetitive swallowing, tachycardia)
2. Retching (gastric relaxation, diaphragm contractions) 3. Vomiting (retrograde expulsion of gastric contents) pg 529 |
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The type of vomitus can clue you in to the location of the obstruction. Match.
Bilious Esophageal Undigested food Large Bowel Fecal material Small Bowel |
Undigested Food - Esophageal
Bilious - Small Bowel Fecal Material - Large Bowel pg 529 |
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The DDX is broad for Nausea and Vomiting. What are some of the labs to order during the workup?
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CBC, BMP, hCG, LFTs, Lipase, TSH, APAP, ASA, ETOH, UDS, UA, ESR
pg 530 |
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What are the four mechanisms for diarrhea?
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1)increased intestinal secretions
2)decreased intestinal absorption 3)increased osmotic load 4) and abnormal intestinal motility |
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What percent of diarrhea is infectious?
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85%
pg 531 |
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Most common cause of diarrhea in the US?
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Noroviruses (50-80%) or Rotaviruses
pg 531 |
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Common symptoms with infectious causes of diarrhea. Match.
1) reverse temp sensation 2) heat intolerance and anxiety 3) seizures a) Shigellosis b) Ciguatera c) Thyrotoxicosis |
Ciguatera - reverse temp sensation
Thyrotoxicosis - heat intol and anxiety Shigellosis - seizures pg 531 |
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Important questions to ask regarding diarrhea.
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Recent travel? Medications? Rural hiking? Anal sex? Fevers? Length of diarrhea?
pg 531 |
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T/F: Diarrhea rules out fecal impaction.
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False: diarrhea/ liquid stool may pass around the impaction.
pg 531 |
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Diarrhea with severe ab pain, fever, and purulent/bloody diarrhea needs what lab test?
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Ova and parasite.
pg 532 |
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Treatment for diarrhea includes what?
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1) ABCs, 2) oral rehydration (gluose containing beverages - unaffected by enterotoxins), 3) BRAT diet, 4) Infectious vs other causes (antibiotics vs. antimotility agents)
pg 532-533 |
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T/F: Antibiotic-associated diarrhea is usually mild without cramps, fevers, or fecal leukocytes.
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False: usually Moderate to Severe
pg 532 |
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Diarrhea as a result of foreign travel is related to ___ % of infectious causes.
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80% - what was the destination? E. coli - south amer, Shigella, Salmonella - Asia
pg 533 |
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Are antimotility agents indicated in infectious diarrhea for pt relief?
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No. Risk of prolonged fever, toxic megacolon in C. diff
pg 534 |
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Fluoroquinoles: Cipro 500mg PO BID 1-3 days is indicated for which two infectious processes?
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Shigella and E. coli
pg 534 |
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Most common cause of infectious diarrhea in the hospitalized setting in North America?
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Clostridium Difficile
pg 535 |
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Treatment for mild, moderate and severe C. difficile infections are?
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Mild - d/c offending antibiotic
Moderate - Metronidazole 500mg q6h PO 10-14 days Severe - admission, Vanc 125-250mg q6h PO 10 days, rarely a colectomy pg 535 |
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Indications for a Colectomy in the severe C. difficile pt?
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Leukocytosis >20x10^9, Lactate >5, Age >75, immunosuppressed, shock, perforation, organ failure
pg 535 |
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62yo F c/o chronic but worsening intermittent RLQ ab pain, fever, diarrhea. Pain is crampy. Perianal exam + fissures. CT shows bowel wall thickening, mesenteric edema, and local abscess formation near the illeum. Possible cause?
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Crohns Disease
pg 537 |
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Where can Crohn's dz affect in the GI tract?
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mouth to anus
pg 536 |
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Most common location of Crohn's dz affecting?
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Illeum
pg 536 |
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Two distinguishing pathological factors of Crohn's dz are?
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1) skip areas
2) involvement of all layers of the bowel, to include extension in to mesenteric lymph nodes, fistulas pg 536 |
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What dermatological symptoms can be associated with Crohn's dz? (4)
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1) perianal fistulas
2) perianal fissures 3) erythema nodosum 4) pyoderma gangrenosum pg 537 |
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ED treatment of Crohns should involve r/o what (4) life threatening conditions?
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1)Obstruction,
2)lntra-abdominal abscess, 3)hemorrhage, or 4)toxic megacolon pg 538 |
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ED treatment of acute inflammatory bowel disease includes? (think txmt not dx)
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1)restore fluids,
2)NPO, 3)Pain control, 4)antibiotics, 5)nasogastric suction pg 538 |
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Outpt treatments med options for inflammatory bowel dz. (big general pic)
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Sulfasalazine (anti-inflam), Steroids (anti-inflam), azathioprine (fistual healing), methotrexate (immunsup), Antibiotics, Remicade **consult GI for medication changes
pg 538 |
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60yo M c/o 3 month hx of profuse mucoid diarrhea on and off, fatigue, weight loss, abdominal cramps. PCM work up - NEG O&P or heme. CT - rectosigmoid colon thickening. DDX?
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DDX:
1) Cancer 2) Crohns, 3) Ulcerative Colitis - most likely with just rectosigmoid involvement pg539 |
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Pt with new onset dx of Ulcerative Colitis has been taking anti-diarrheals for symptoms. 10+ BMs per day. temp-101, HR-115, BP 100/70, PE- ab distention, tender diffusely, and tympanic. Plain film - long continous segment of air filled colon >6cm in diameter. concern?
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Toxic megacolon
pg 540 |
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Toxic Megacolon treatment?
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Surgical consult - colectomy if improvement not seen in 24-48hrs
pg 540 |
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Common causes of constipation to r/o in ED (5)?
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1)tumor
2)strictures 3)hernia 4)adhesions 5)volvulus pg 541 |
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Labs to consider in the case of constipation in the ED?
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CBC, CMP, Ca+, Thyroid panel, Lead, Iron
pg 542 |
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Treatment of choice for most cases of constipation will include (no quick fix)?
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dietary changes, exercise, adequate fluid intake (1.5L), fiber (10g/day)
pg542 |
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Medical adjuncts to treatment for constipation?
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Colace, Glycerin suppository, Sorbitol, Polyethylene glycol, mineral oil
pg 542 |
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Most common cause (80%) of upper GI bleed?
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Peptic ulcer disease (gastric, duodenal, esophageal and stomal ulcers) - 80%
pg 543 |
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Second leading causes of upper GI bleed?
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Erosive gastritis (esophagitis, NSAIDs, duodenitis, alcohol) - 13%
pg 543 |
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Third cause of UGI bleeds?
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Esophageal and gastric varices (related to alcoholic liver dz)- 7%
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Pt c/o hematemesis x4 for 1 day. reports cough fits and n/v before hematemesis. blood is bright red. What must be r/o?
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Mallory-Weiss syndrome - longitudinal tear in the cardioesophageal region
pg 543 |
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If only one test could be ordered for UGI bleed what would it be?
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Type and Cross-match
pg 543 |
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What happens to the BUN/Creatinine ratio in a UGI bleed?
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elevates. typically over 30:1 ratio is indicative of UGI bleed
pg 544 |
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Diagnostic study of choice for UGI bleed is _______.
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UGI endoscopy
pg 544 |
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What are the three causes of pancreatitis?
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gallstone - most common 40%
alcohol hypertrigylceridemia (4%) pg 558 |
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What is the pathophysiology behind acute pancreatitis?
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unregulated activation of trypsin w/in the acinar cells and lack of elimination. Trypsin causes autodigestion by activating digestive enzymes.
pg 558 |
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At what stage in the disease would you expect to see the Cullen or Gray-Turners sign; acute, middle or late stage? and what are they?
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Late Stage
Cullen -periumbilical ecchymoses Gray-Turner- Flank ecchymoses pg 559 |
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T/F: Dx of acute pancreatitis is w/ 2/3 features: 1) epigastric ab pain, 2)serum amylase/lipase +10IU/L than normal, 3) US or CT with peripancreatic stranding and fluid collections.
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False: Aymlase/ Lipase should be 3x greater than normal (raised up to 1000IU/L)
pg 559 |
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What other processes can elevate amylase?
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appendicitis, cholecystitis, intestinal obstruction or ischemia, and GYN dz
pg 599 |
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T/F: Normal Lipase and Amylase help r/o pancreatic disorders.
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False: Due to the poor sensitivity of Amylase (65%) and normal Lipase levels in chronic pancreatitis.
pg 559 |
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When is an ERCP uselful?
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if a stone is suspected as the cause for the obstruction, then it is both diagnostic and therapeutic
pg 559 |
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In the ED management of the acute pancreatitis, when should either Ranson's criteria or an APACHE score be determined?
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Should not in the ED. Limited value and poor sensitivity (65%) and specificity (76%).
pg 560 |
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Txmt of acute pancreatitis includes?
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Vital Sign monitoring q 2h
Fluid therapy - maintain urine output at 0.5ml/kg Pain, N/V control Monitor H&H, ionized Ca+, Albumin Abx - if moderate to severe case pg 562 |
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54yo F c/o ab diffuse upper abdominal pain x 5hrs. Usually starts in the RUQ but radiates to the epigastrum, waist, and left upper back. started about 1am and woke her up. +N/V, diaphoresis. Has had this a couple times before but usually resolves on its own in couple hours.
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Acute Cholecystitis - classic presentation of RUQ w/ rad to R scapula after fatty meals is not necessarily accurate
pg 563 |
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Most common cause of cholecystitis?
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Gallstones
pg 562 |
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What is cholangitis?
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ascending infection to the gallbladder due to partial or complete obstruction of the bile duct.
pg 562 |
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What is the clinical finding or symptoms has the highest positive Likelyhood Ratio for cholecystitis?
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Murphey's sign - sens 65% spec 87%, LR+ 2.8; though + US and elevated CRP gives sens 97% and spec 95%
pg 563 |
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What are considered positive US findings of cholecystitis?
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Thickened anterior wall >3mm
Pericholecystic fluid Biliary duct diameter >7mm |
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Definitive treatment for cholecystitis is _____.
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laparoscopic cholecystectomy
pg 565 |
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ED treatment for cholecystitis includes (6).
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1)Pain control (narcotics - no neg studies, consider Ketorolac)
2)N/V control 3)NPO 4)IV Fluid therapy 5)antibiotics (ceftriaxone 1g IV and metro) 6)surgical consult pg 565 |
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What physical exam findings can be used to sufficiently r/o appendicitis?
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None
pg 574 |
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When should appendicitis be considered?
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atraumatic right-sided ab, periumbilical, or flank pain in pt w/ remaining appendix
pg 575 |
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What does an elevated WBC indicate in the evaluation of possible appendicitis?
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No clear consensus on it's usefulness
pg 575 |
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T/F: Surgical consult after the appy is confirmed by CT is the most effective method.
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False: Early Surgical consult should be obtained before imaging on straightforward cases of suspected appy.
pg 575 |
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What is the imaging of choice in pregnant women and children for suspected appy?
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Ultrasound with graded compression
pg 575 |
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What is the characteristic finding on US of acute appy?
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thickened, noncompressible appendix >6mm in diameter
pg 576 |
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T/F: Noncontrast CT imaging is acceptable method for the dx of appy and results in faster imaging.
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True: Noncontrast CT shows sens 93% and spec 96%
pg 576 |
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Important treatment of acute appy includes NPO, pain control, IV fluids, anntiemetics, _____, and surgical consult.
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abx - Ampicillin 3g IV q6h or Ertapenem 1g IV or Metronidazole 500mg IV q 6h and...Cipro or Levofloxacin
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What type of patient is the most likely to perforate their acute appy?
|
the uninsured
pg 578 |
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What is the most common surgical emergency in pregnant patients?
|
Acute Appy
pg 578 |
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Two most common causes of small bowel obstruction (SBO) are?
|
1) adhesions after ab surgery
2) incarceration of a groin hernia pg 581 |
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This cause of SBO in children is from a blunt trauma (ie seat belt injury in MVA)?
|
duodenal hematoma
pg 581 |
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Most common causes of large bowel obstructions are?
|
1) Neoplasms
2) Diverticulitis 3) Sigmoid Volvulus 4) Fecal Impaction (elderly) pg 581-82 |
|
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Diagnostic method of choice in the ED for suspicion of obstruction is ____?
|
CT w/ oral and IV contrast
pg 583 |
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ED treatment of obstruction includes (5).
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1) Pain control
2) IV fluids 3) Nasogastric tube - if distended 4) Abx - tazobactam 3.375mg IV q6h 5) Surgical consult |
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Name the three categories of causes for renal failure.
|
1) Prerenal - decreased perfusion
2) Renal /Intrinsic - pathologic changes 3) Postrenal - obstruction pg 615 |
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Most common cause of community acquired acute renal failure is Prerenal, with ___% of it due to dehydration.
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90%
pg 615 |
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Most common cause of intrinsic renal failure is______?
|
ischemia (traditionally know as acute tubular necrosis)
pg 615 |
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|
Examples of causes of intrinsic renal failure are?
|
Nephrolithiasis, Rhabdo, glomerulonephritis, interstitial nephritis, renal artery occlusion, Goodpasture's
pg 616 |
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Postrenal obstruction: how long before permanent loss of kidney function?
|
10-14 days
pg 617 |
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|
How do NSAIDs cause renal failure?
|
They inhibit vasodilatory prostoglandins.
pg 618 |
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What is the BUN/Cr ratio in a dehydrated person with normal concentrating ability?
|
> 20:1
pg 619 |
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T/F: A large postvoid bladder residual >125ml on catheterization suggests obstruction below the bladder.
|
True
pg 621 |
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|
What is the medication of choice for severe hypertensive emergencies resulting in renal dysfunction?
|
Fenoldopam
pg 621 |
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|
Why is dopamine no longer used for renal recovery?
|
increases urinary output at the cost of increased medullary oxygen consumption.
pg 621 |
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|
What is the best treatment for postrenal obstruction volume overload?
|
Nitrates and dialysis
pg 621 |
|
|
Indication for emergent hemodialysis for acute renal failure?
|
uncontrolled hyperkalemia (>6.5)
fluid overload progressive uremia Serum Na+ <115 or >165 Metabolic acidosis unresponsive to Bicarb pg 621 |
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|
Radiocontrast-induced nephropathy begins to be a concern at what GFR level?
|
<60 in CT
pg 621 |
|
|
This polymicrobial, infective necrotizing fasciitis occurs in the perianal or genital area. Typically seen in diabetics and alcoholics males. Cause and treatment?
|
Fournier Gangrene - txmt is fluid therapy, broad spec abx (imipenem 1g IV) and wide surgical debridement
pg 646 |
|
|
This recurrent inflammation of the glans penis can be the sole presenting sign of Diabetes.
|
Balanoposthitis
pg 647 |
|
|
Phimosis is inability to retract foreskin over the glans penis and Paraphimosis is inability to reduce the foreskin distall over the glans penis. Which is the surgical emergency?
|
Paraphimosis- the foreskin can become edematous and strangle local blood supply.
pg 647 |
|
|
This urologic process has thickened plaque on the dorsum of the penile shaft making erections painful. related to Dupuytren's contractures.
|
Peyronie's Dz.
pg 648 |
|
|
Commonly seen in sickle cell pt's this urologic emergency presents with persistent painful erections. What is the treatment?
|
Priapism-
Narcotics for pain, Terbutaline 0.25-0.5mg SC q 20min prn and Corporal aspiration with phenylephrine irrigation. pg 648 |
|
|
17yo M c/o severe scrotal pain that woke him in the middle of the night. Right testicle is firm, tender, and elevated higher than Left. What is the dx and what is the most sensitive finding on exam?
|
Testicular Torsion and unilateral absence of the Cremasteric reflex
pg 649 |
|
|
How else can torsion present that could mislead or cause a misdiagnosis?
|
nonspecific abdominal pain in young boy
pg 649 |
|
|
Treatment for epididymitis in males >40yo and <40yo?
|
>40yo - txmt for Gram Neg - Cipro 500mg BID 10-14 days or Levoquin 250mg qd 10-14 days
<40yo - txmt for G/C - Rocephin 250mg IM + doxy 100mg BID 10days pg 650 |
|
|
What is the top differential for a firm testicular mass that is painless?
|
Cancer
pg 650 |
|
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54yo M c/o low back pain, difficulty voiding, dysuria, and fever x 7 days. Workup, Dx, and Txmt?
|
consider urethral cultures for G/C, UA not helpful (can be normal), Pain medication and antibiotics (initial txmt is fluoroquinolone x 30days.)
pg 650 |
|
|
Urethral strictures are a common side effect of STDs and rising in young adults. This commonly presents as difficulty voiding or increased pressure or frequency. Most urologist think ___ to ___mL is abnormal residual urine volume.
|
150-200mLs
pg 651 |
|
|
If a catheter cannot be passed by 2-3 attempts in a urethral stricture contact urology or emergently you can decompress the bladder with a ______?
|
suprapubic cystostomy.
pg 651 |
|
|
Should the parents be present when interviewing the adolescent girl especially about sexual activity and STDs?
|
No. ALWAYS interview the pt w/out parents present to assure pt of confidentiality.
pg 665 |
|
|
What is the most common cause of abnormal bleeding in women of reproductive years?
|
Pregnancy related complications
pg 667 |
|
|
Leiomyomas, Adenomyosis, and Endometriosis are all causes of vaginal bleeding, but what must be r/o in women > 35yo w/ negative hCG?
|
Endometrial CA
pg 668 |
|
|
If the pt is hemodynamically stable, not pregnant what else needs to be r/o concerning vag bleeding?
|
Trauma (sexual assault/abuse), foreign body, infection, bleeding disorders
pg 670 |
|
|
Female with left sided pelvic pain and pressure. Hx of bilateral tubal surgery. + Vaginal bleeding. What is next step?
|
urine hCG. r/o ectopic.
pg 676 |
|
|
T/F: Missed menses occurs in 15% of the ectopic pregnancy cases.
|
False: 85%
pg 676 |
|
|
What level can serum and urine tests detect hCG at?
|
Urine - >=20mIU/mL
Serum - >=10mIU/mL pg 677 |
|
|
T/F: Doubling time occurs every two days in a normal pregnancy and every 1 day in an ectopic.
|
False: Ectopic are slower to double 677
|
|
|
According to ACEP policy, is it recommended as a Level A, B, or C for transvaginal US for confirmation of IUP or ectopic w/ a B hCG level <1000?
|
Level C recommendation - conflicting evidence
pg 678 |
|
|
24yo F c/o ab/pevlic pressure, N/V and missed menses x 1 month. Pt and husband have been trying to get pregnant. She is taking Clomid x 5 months. Abdomen US shows IUP. but left adnexus is unclear. Next step?
|
Ectopic must be r/o. Pts taking fertility medications have a 1/3000 risk of IUP and ectopic risk.
pg 678 |
|
|
Define viable pregnancy.
|
IUP w/ cardiac activity and a closed cervical os.
pg 679 |
|
|
What level hCG is generally when transabdominal US able to pick up an IUP?
|
6000mIU/mL
pg 679 |
|
|
T/F: Laproscopy is diagnostic and therapeutic for suspected ectopic and a nondiagnostic US.
|
True
pg 680 |
|
|
Treatment options for the confirmed ectopic pregnancy are (2)
|
Surgical (laproscopic), Medical (methotrexate)
pg 680 |
|
|
What is a vital lab to obtain with an ectopic pregnancy?
|
type and screen / ABO to determine Rh + or -
pg 681 |
|
|
What is the ACEP recommendation for Rh- mothers?
|
Rhogam 50mcgs
pg 681 |
|
|
Other common causes of first trimester bleeding, DDX?
|
Abortion, Ectopic, Molar Pregnancy (gestational trophoblastic dz), and Implantation bleeding
pg 682 |
|
|
23yo F with vag bleeding. 5 weeks pregnant. denies pain. serum hCG is 1500mIU/mL. IUP on transvag US. Pelvic shows dilated cervical os without tissue. what is the dx and txmt?
|
Inevitable abortion. Pt should have OB/GYN consult for uterine evacuation. RhoGAM 150mcg given
pg 682 |
|
|
Pt reports 4 weeks since LMP and positive at home urine test. serum hCG is 50,000. uterus is larger than expected for dates. US shows cluster of grapes. What is dx and txmt?
|
Molar pregnancy (Gestational Trophoblastic Dz) and suction curettage. Serial hCGs (persistent elevation can be metastatic dz)
pg 682 |
|
|
What antiemetic is safe in pregnancy?
|
Zofran (Ondansetron) Class B, Reglan (metoclopramide) Class B, Benadryl Class B
pg 683 |
|
|
30yo F, 30 weeks pregnant, G1P0, c/o radiating dull left low back, left groin and left thigh pain. denies fevers, edema, or injury. No recent travel. DDX?
|
1) DVT
2) Sciatica 3) LBP |
|
|
PE treatment in the prego 20+ weeks is ____.
|
Heparin or Low molecular weight Heprin until delivery. Coumadin can be started for 6 months post delivery.
pg 696 |
|
|
Why do you not start coumadin for DVT/ PE prevention in pregos?
|
Coumadin crosses the placental barrier and is teratogenic.
pg 696 |
|
|
Difference btwn chronic and gestational hypertension?
|
Chronic HTN occurs before pregnancy and lasts up to 6 weeks after delivery.
pg 696 |
|
|
Which antihypertensive does not cross the placenta barrier?
|
none...all cross
pg 696 |
|
|
Which are the two preferred anti-HTN meds in pregos?
|
methyldopa 250mg PO q 6h titrated to effect (max 3 grams) or...
labetalol 100mg PO BID. consider Hydralazine, Nifedipine, or Nitropusside pg 696-97 |
|
|
Which class is absolutely contraindicated for HTN in pregos?
|
ACE-I and ARBs - toxic effects on fetal scalp, heart, lungs, and kidneys
pg 697 |
|
|
New diagnostic criteria for preeclampsia?
|
systolic >140 or diastolic >90
and proteinuria >0.3g (24h collection) and 20+ weeks gestation pg 697 |
|
|
Definitive treatment for preeclampsia is ?
|
delivery of fetus
pg 697 |
|
|
Define eclampsia and txmt?
|
Eclampsia= Preeclampsia + seizures
Txmt: mag sulfate 4-6mg IB |
|
|
This syndrome is a clinical variant of preeclampsia and seen more in multigravid pts. presents with RUQ pain. easily missed. need to check coags is key.
|
HELLP syndrome (Hemolysis, Elevated Liver enzymes, and low Platelets)
pg 698 |
|
|
Management of HELLP (Hemolysis, Elevated Liver enzymes, and low Platelets) in ED?
|
BP control, Stabilize electrolytes, correct coagulopathy. Delivery of fetus is definitive.
pg 698 |
|
|
T/F: A bimanual exam should not be performed in a second half pregnancy with bleeding.
|
True
pg 698 |
|
|
Likely causes of vaginal bleeding in the 20+ weeks of pregnancy.
|
1) Placentae Abruptio (bad prognosis)
2) Placenta Previa 3) Premature Labor 4) Vaginal laceration pg 698 |
|
|
If Abruptio is considered what are the initial steps of care?
|
- two large bore IVs
-blood type and cross -call for emergency release -CBC, Coag -fetal monitoring pg 699 |
|
|
Medication consideration in Premature Rupture of Membranes before 34 weeks should include?
|
steroids - betamethasone 12mg IM or dexamethasone 6mg IM q 12h for fetal lung maturity
pg 700 |
|
|
3 most common causes of maternal death in US.
|
1) thromboembolism
2) HTN 3) Postpartum hemorrhage pg 701 |
|
|
Pharmcologic treatment of postpartum hemorrhage is aimed at promoting ____ and correcting coagulopathies.
|
uterine contractions
pg 701 |
|
|
First line medication for Postpartum hemorrhage?
|
Oxytocin 10mg IM or slow IV push
|
|
|
28yo F postpartum 3 days with fever 103, HR - 116, lethargy, pelvic pain and foul smelling discharge. suspect and txmt?
|
Postpartum Endometritis
Txmt: outpt - Clindamycin 300mg TID x 10days or inpt: Clindamycin 500mg IV q6h + gentamicin 4.2mg/kg IV/daily pg 702 |
|
|
Diverticular bleeding is responsible for what % of Lower GI bleeds?
|
23%
pg 581 |
|
|
Hinchey classification scheme is to categorized complicated diverticulitis complications. Describe the four stages.
|
Stage 1- small abscess, Stage 2- large abscess contained in the pelvis, Stage 3- perforated diverticulitis, Stage 4- free perforation w/ fecal contamination
pg 580 |
|
|
Surgical consult is the treatment difference for what two types of diverticulitis?
|
Uncomplicated and Complicated.
Both are treated with NPO, Pain control, Abx pg 579 |
|
|
What is the most common form of hernia?
|
inguinal hernias 75%
pg 584 |
|
|
Which type of inguinal hernia is most common?
|
indirect hernias are most common inguinal hernia 67%
pg 584 |
|
|
This type of hernia is a result of excess wall tension or inadequate wound healing after surgery. Recurrence rate up to 50%.
|
Incisional hernia
pg 584 |
|
|
This hernia is more likely to occur in women (10:1), more likely to result in complications (strangulation), and occurs below the inguinal ring.
|
Femoral hernia
pg 584 |
|
|
This form of hernia is typically seen in older frail women and nearly always present as partial or complete bowel obstruction.
|
Obturator hernia
pg 586 |
|
|
What is the best imaging for diagnosis of hernias?
|
CT is best and can diagnose the uncommon types of hernias. US is operator dependent but useful in pregos and kids.
pg 587 |
|
|
What is the next step in the septic/ toxic looking pt with a identified exquisitely tender hernia.
|
Consult general surg immediately. IV Abx (cefoxitin), fluids, pain meds, preop labs
pg 587 |
|
|
Steps for reducing a hernia are?
|
1) NPO
2) IV pain meds 3) Cold packs to reduce swelling 4) Traction on the hernia neck 5) Pressure on the distal hernia 1-2 attempts then consult surgery pg 587 |
|
|
What nerve root innervates the internal anal sphincter (check rectal tone)?
|
L1-L3
pg 588 |
|
|
What must the pt do during the anoscope exam to reveal a rectal prolapse?
|
Bear down
pg 588 |
|
|
T/F: Internal hemorrhoids are easily palpabe and visible w/ anoscope at the 1, 5, 9 o'clock position.
|
False: difficult to palpate and located the 2, 5, and 9 o'clock position of the rectum
pg 589 |
|
|
What process should be considered in a pt with external hemorrhoids and frequent bouts of diarrhea/constipation?
|
Inflammatory Bowel Dz
pg 589 |
|
|
What is the most common cause of rectal bleeding?
|
hemorrhoids
pg 590 |
|
|
What typically causes the pain associated with hemorrhoids, both internal and external?
|
1) Thrombosis
2) abscess 3) fissure pg 590 |
|
|
Describe the grading scale for internal hemorrhoids.
|
Grade 1-painless bleeding, no prolapse
Grade 2- prolapse w/ straining- spontaneous reduction Grade 3- prolapse needing manual reduction Grade 4-prolapse non-reducible pg 590 |
|
|
Txmt for Grades 1-3 is the same and is ?
Txmt for Grade 4 is? |
Grade 1-3: Sitz bath, topical steroids, bulk laxatives, stool softeners, high fiber
Grade 4: emergent surgical consult pg 591 |
|
|
Anal fissures are the most common cause of PAINFUL rectal bleeding. Common among infants and children and typically present ___% occur in the midline posterior.
|
90%
pg 592 |
|
|
What should be suspected in an anal fissure in the anterior midline when fetal delivery is not involved?
|
Sexual assault.
pg 592 |
|
|
How do anal fistulas typically form?
|
infected anal glands at the dentate line.
pg 593 |
|
|
What disease should be considered in pt w/ fistuals and fissures?
|
Crohns Dz
pg 593 |
|
|
Txmt of perianal fistula includes IV fluids, pain meds, surgical consult and what abx?
|
cirpo 750mg po bid + metro 500mg po qid
pg 594 |
|
|
T/F: Perianal and perirectal abscesses are the only type of anorectal abscesses that can be adequately treated in the ED.
|
False: Perianal only. Perirectal abscess need to be drained in the OR.
pg 596 |
|
|
Proctitis is the inflammation of the rectal mucosa and typically develops how?
|
Autoimmune disorder, vasculitis, ischemia, and STDs
pg 596 |
|
|
Txmt of Condlomata acuminata?
|
HPV, laser ablation, cyrotherapy, exicision
pg 596 |
|
|
Txmt of Gonorrhea?
|
Ceftriaxone 125mg IM + azithro 2g PO
pg 596 |
|
|
Txmt of Chlamydia?
|
azithro 2g PO or Doxy 100mg BID x 7 days
pg 597 |
|
|
Txmt Syphilis?
|
Penicillin-G 2.4million units IM or
doxy 100mg BID x 14days pg 597 |
|
|
Txmt of Herpes?
|
Acyclovir 400mg PO x 10 days initial episode or
Acyclovir 800mg PO TID x 2 days recurrent episode pg 597 |
|
|
Name the three types of rectal prolapses.
|
1) rectal mucosa only
2) prolapse of all layers (complete) 3) intussusception of upper rectum thru lower rectum pg 597 |
|
|
What is complete rectal prolapse associated with?
|
Elderly women and chronic constipation
pg 597 |
|
|
Rectal prolapse in children should prompt the provider to eval for possible underlying conditions such as malnutrition, diarrhea, and ____?
|
Cystic fibrosis
pg 598 |
|
|
What is a technique to decrease an edematous rectal prolapse that was original used in veterinary medicine?
|
granulated sugar 15mins reduces edema
pg 598 |
|
|
What is the most common cause of pruritus ani in children?
|
Pinworms
|
|
|
This inflamed painful lesion occurs in the midline upper gluteal cleft. What is the dz, imaging needed and txmt?
|
Pilonidal Cyst
Imaging: US Txmt: abx (cellulitis), incision and drainage and refer to surgeon for further exploration pg 601 |
|
|
Painful nodules around the perianal surface that are indurated also seen in the axilla. Dz and txmt?
|
Hidradenitis Suppurativa
topical clindamycin 1% or oral pg 601 |
|
|
Define uremia and azotemia.
|
Uremia - build up of urine in the blood
Azotemia - build up of nitrogen in the blood pg 624 |
|
|
What are some indications for emergent dialysis in Uremia?
|
Hyperkalemia, severe acid-base disturbances, and pulmonary edema resistant to txmt
pg 625 |
|
|
76yo M presents by EMS with AMS according to spouse. Pt has hx of ESRD and is on dialysis. Pt missed last session due to being sick. No focal deficits. What is the concern?
|
Bilateral Subdural Hematomas - 10x more likely in dialysis pts
pg 625 |
|
|
Why are cardiac markers not effective with End Stage Renal Disease pts?
|
regular dialysis filters markers out, no elevation occurs
pg 626 |
|
|
How do you treat pulmonary edema in a ESRD?
|
O2, nitrates, CPAP, ACE-I, morphine, and diuretics (Furosemide 60-100mg IV)
|
|
|
Why is Furosemide 60-100mg IV effective in Pulmonary Edema in ESRD?
|
increases pulmonary vasodilatation.
pg 626 |
|
|
Beck's triad (hypotension, JVD, and muffled heart sounds) are rarely present in ESRD pts. How do they typically present for cardiac tamponade?
|
Hypotension, SOB, and AMS.
pg 626 |
|
|
What is the difference btwn uermic pericarditis and infectious pericarditis?
|
No related EKG changes in Uremic Pericarditis (global ST changes)
pg 626 |
|
|
How is anemia treated in ESRD pts?
|
Erythropoietin replacement therapy.
pg 626 |
|
|
If time is critical for bleeding time (ie subdural hematoma, GI tract bleed etc) what other options can be used in the ESRD pt?
|
Desmopressin (1h), Cryopercipitate (4h), and conjugated estrogens (6h)
pg 626 |
|
|
Why does the ESRD pt have a higher mortality rate due to a calcium-phosphate product >72?
|
Metastatic calcifications in cardiac and pulmonary systems occurs due to falling GFR and increasing Phosphate levels
pg 627 |
|
|
78yo M presents by EMS for AMS, fever, hypotension. WBC > 12. BP 80/40. HR 120, RR 24. Pt is a ESRD and started dialysis 6 months ago. Pt is septic. What is the source likely due to?
|
infected dialysis catheter. 48% pt will develop and often overlooked is the erythema, swelling and pain at the catheter site. Draw cultures from cath and another site.
pg 627 |
|
|
What is most likely organism to cause dialysis catheter related infection and txmt?
|
Staph aureus
Vancomycin 1g IV (add aminoglycoside if gram - suspected) pg 628 |
|
|
What is the concern for the repeat intradialytic hypotensive pt?
|
Acute MI or pericardial tamponade
pg 629 |
|
|
Most common cause of UTI (organism)?
|
Escherichia coli
pg 631 |
|
|
Most common cause of complicated UTIs?
|
Pseudomonas or Enterococcus
pg 631 |
|
|
T/F: Frequent and complete voiding is associated with an increased risk of UTIs?
|
False: Reduction in UTIs. This allows the bladder wall to remove organisms
pg 631 |
|
|
34yo F c/o dysuria, increased frequency, bladder pressure and fever, chills, and N/V is at risk for?
|
Acute Pyelonephritis
pg 632 |
|
|
What is the urine nitrite sensitivity and specificity?
|
Nitrites Sensitivity - 50%
Specificity -90% pg 634 |
|
|
What is the urine leukocyte esterase sensitivity and specificity?
|
LE sensitivity - 48%
specificity -93% pg 634 |
|
|
Uncomplicated UTI txmt in female and male?
|
Female - Bactrim DS 160/800mg BID x 3-5 days (less effective at 3 days), Cipro 250mg BID x 3d, Macrobid 100mg QID x 5d
Males - Cipro 500mg BID x 10-14d, Levofloxacin 500mg QD x 10-14d pg 635 |
|
|
65yo M c/o left flank and ab pain, hematuria and CVA tenderness. KUB negative. What is in the differential?
|
1) AAA rupturing or expanding
2) nephrolithasis - * most common misdiagnosis given to pt's with AAA pg 652 |
|
|
Pt has flank pain and hematuria. What is the likelihood of radiographic evidence of ureterolithiasis?
|
75%
pg 653 |
|
|
What is the recommended txmt for ureterolithiasis?
|
IV fluids, N/V meds (Reglan 10mg IV), Pain control (NSAIDS > Narcotics), Alpha Blockers - Flomax
NSAIDs- Keterolac 30mg IV pg 655 |
|
|
This ischemic condition can be intermittent severe pelvic pain but is a surgical emergency to preserve ovarian fxn. 50%+ occur on the right side.
|
Ovarian / Adnexal Torsion
pg 675 |
|
|
Perihepatitis secondary to PID is ?
|
Fitz-Hugh-Curtis syndrome. RUQ pain, get CT and txmt the PID (ceftriaxone 250mg IM, doxy 100mg BID and metro 500mg BID x 14d.
pg 676 |
|
|
Pregnant diabetic presents appearing ill, N/V and a d-stick of 190. What is the concern, workup and txmt?
|
DKA in pregos 180+ glucose, get urine ketones, and serum ketones.
Txmt: fluids and left lat decub to improve uterine circulation pg 684 |
|
|
Pregnant diabetic presents with sweating, tremors, blurry vision, weakness, nausea and HA. Concern? Txmt for alert pts vs AMS pts?
|
Hypoglycemia
Txmt alert: low fat milk (doesn't over shoot glucose_ AMS - 1 amp D50% in water IV bolus, Glucagon 1-2mg IM pg 685 |
|
|
28yo F G1P0 18 weeks along presents with anxiety, nervousness, inability to gain weight (despite good appetite), palpatations, heat intolerance is and what txmt?
|
Thyrotoxicosis
Txmt: PTU 50-200mg PO TID, Iodine 1g in 500mL water, cool patient (APAP), Propanolol 40mg PO 6 h, and O2, Fluids pg 685 |
|
|
What reverses Heparin or LMWH in pregos for DVT/ PE prevention?
|
Protamine Sulfate providers rapid reversal
pg 686 |
|
|
What is the most common MEDICAL disease in pregos?
|
Asthma
pg 686 |
|
|
How do you treat acute exacerbation of asthma in pregos?
|
O2 (>95%), Albuterol (add Ipratropium if severe), Steroids
Epinephrine if critically ill but can cause potent vasoconstriction in placental circulation pg 687 |
|
|
Lower ab pain, adnexal tenderness, and cervical motion tenderness is ______ and is treated how?
|
PID- Ceftriaxone 250mg IM, Doxy 100mg PO BID x 14 d and Metro 500mg PO BID x 14d
*get partner treated! pg 719-20 |
