Set the Language

We weren't able to detect the audio language on your flashcards. Please select the correct language below.

Front

Back

Related Flashcards

Flashcards
»
Tiny Tips - BoringEM

Tiny Tips - Boringem

by siewertj, Jan. 2015

Favorite

Add to folder

Flag

Shuffle
Toggle On

Toggle Off
Alphabetize
Toggle On

Toggle Off
Front First
Toggle On

Toggle Off
Both Sides
Toggle On

Toggle Off
Read
Toggle On

Toggle Off

Reading...

Front

Card Range To Study

through

Play button

Progress

1/430

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

430 Cards in this Set

Front
Back

	DDx for delirium / AMS	IS IT / MEATS INTRACRANIAL I nfection S tructural/S eizure/S troke I CH/I schemia T rauma/T hrombus _______________________ EXTRACRANIAL M etabolic E ndocrine/E nvironment A noxia/A bnormal pCO2 T oxins/T ablets/T oo little (withdrawal) pS ychiatric
	Intubation preparation	STOP I C BARS Suction Tubes Oxygenate Prepare with Preload, Position, Pharmacy (drugs), Post-intubation plan IV's CO2 monitoring Bougie & Blades Alternate airway Rescue airway Surgical airway
	Diagnosing the cause of an alarming ventilator	D - Dislodged tube O - Obstructed tube (mucous plug, blood, kink) P - Pneumothorax E - Equipment failure (ventilator, tubing, etc) S - Breath Stacking [breath] (Auto-PEEP)
	CHF treatment	POND Positive-pressure ventilation Oxygen Nitroglycerine Diuretics
	Ingestions that are not absorbed by activated charcoal	PHAILS Pesticides Hydrocarbons Acids/Alkalis/Alcohols Iron Lead/Lithium Solvents
	Causes of anion-gap metabolic acidosis	KULT Ketones Uremia Lactate Toxins
	Hydrocarbon additives that require GI decontamination	CHAMP Camphor - seizures Halogenated HC - dysrhythmias/hepatotoxicity Aromatic HC - bone marrow suppression/cancer Metals (arsenic, murcury & lead) Pesticides - cholinergic crises/seizures/resp depression
	Mass casualty triage protocol	Use the START (Simple Triage And Rapid Treatment) Protocol Remember with ABCD
	PERC Rule	Apply if clinical gestalt = low risk for PE HAD CLOTS H - Hormone (estrogen) use A - Age > 50 D - DVT or PE history (have they HAD CLOTS?) C - Coughing blood L - Leg swelling disparity O - O2 sats < 95% T - Tachycardia (>100bpm) S - Surgery or Trauma (recent)
	CATCH Rule - High Risk Criteria	WIGS W - Worsening Headache I - Irritability G - GCS <15 2 hours after the injury S - Suspected open/depressed skull #
	CATCH Rule - Medium Risk Criteria	SDH S - Skull # D - Dangerous mechanism (MVC, fall >3ft or 5 stairs, bike accident without helmet) H - Hematoma (boggy)
	Causes of Seizure	STATUS EPILEPsy S - alicylates / S eizure med noncompliance / S trychnine T - ricyclic Antidepressants A - VM / A cute hydrocephalus / A nticholinergics T - rauma / T raumatic bleed (ICH, SDH) U - remia (Renal Failure) S - trychnine / S ugar (low glucose) / S epsis (meningitis) E - lectrolytes (Hyponatremia, Hypocalcemia) P - esticides I - ctogenic foci (e.g. post TBI, post stroke) L - ithium / L idocaine intoxication E - clampsia / E tOH withdrawal Psy - Psy chogenic Non-Epileptic Seizures (formerly known as ‘pseudo seizures’)
	Signs of Delirium (for Confusion Assessment Method, CAM)	AIDA A - cute and fluctuating I - nattention D - isorganized thinking - incoherent, rambling A - ltered LOC - stuperous, agitated, hyper-alert, lethargic, drowsy
	What is needed for a safe discharge plan?	No RISKS R - oaming/wandering I - mminent danger (falls/fire setting) S - uicidal ideation K - inship and relationship (abuse and/or supports) S - afe driving, S ubstance misuse, S elf neglect
	Diagnostic criteria of major depressive disorder	MDD classified as 5 or more of these symptoms occurring most days over a 2 week period along with a change in function. MUST have depressed mood or loss of interest/function. SIGECAPS S - leep I - nterest G - uilt E - nergy C - oncentration A - ppetite P - sychomotor slowing S - uicidal ideation Not a mixed episode, due to anxiety, caused by a general medical condition, or consistent with bereavement (<2 months from loss)
	Approach to the Alarming Ventilator	D - Disconnect the patient from the ventilator +/- provide gentle pressure to the chest (assess for and treat breath Stacking and Equipment failure) O - Oxygen (100%) and manual ventilation with a bag (check compliance by squeezing the bag: difficult bagging suggests Pneumothorax or Obstructed tube, very easy bagging suggests Dislodged tube or Equipment failure due to a deflated cuff) T - Tube position/function (see if the tube has migrated to assess for Dislodged tube; pass a bougie or suction catheter through to see if the tube is Obstructed) T - Tweak the vent (prevents breath Stacking by decreasing respiratory rate, decreasing tidal volume or decreasing inspiratory time) S - Sonography (assess for pneumothorax, mainstem intubation, plugging)
	Ottawa SAH Rule	A - Age > 40y N - Neck pain/stiffness T - Thunderclap onset L - LOC E - Exertion onset a F - Flexion decreased
	Ring enhancing lesions on Head CT	MAGICAL DR M - Metastatic lesions A - Abscess / Parasite (Neurocysticercosis, Tapeworm) G - GBM I - Infarction C - Contusion A - Acute Disseminated Encephalomyelitis L - Lymphoma D - Demyelinating disease R - Radiation necrosis
	Anterior cord syndrome	Like a car - if it smashes the front the engine won't work (paralysis) but instruments/GPS will (soft touch and proprioception)
	What are the NEXUS Criteria?	2 Exam -Neurologic deficit -Midline cervical tenderness 3 Credibility -Normal GCS -Not intoxicated -No distracting injuries
	Unstable C-Spine Fractures	Jefferson Bit Off A Hangman's Tit And Pinky J efferson fracture (burst fracture of C1 seen on odontoid view) B ilateral Facet Joint Dislocation (look for a step on the lateral, FLEXion mechanism) O dontoid 2 or 3 (odontoid view neck or body fracture) A tlanto-occipital / A xial dissociation (head detached with wide spinous process separation) H angman's fracture (see break around the spinolaminar line at C2. HyperEXTENSION) T eardrop (break of anteroinferior part of the spinal body, most often HyperFLEXion) A ny fracture-dislocation P osterior neural arch of C1
	Approach to bradycardia	DIE! Drugs (BB, CCB, Dig) Infarction Electrolytes (especially K!)
	Rashes that start on the palms	Sifting Rocks Scabbed Emma's Hands Siphylis RMSF Scabies EM Hand/foot/mouth (Coxsackie)
	Rashes with a + Nikolsky sign	Stevie got scalded by TEN PV'd nickels Steven-Johnson Syndrome Staph Scalded Skin Syndrome Toxic Epidermal Necrolisis (TEN) Pemphigus vulgaruS (PV) Nikolsky
	Rashes with vesicle / bullae	Old man with BPPV fell into a pool of necrotizing gonorrhea Bullous Pemphigoid / Pemphigus Vulgarus Necrotizing fasciitis (hemmorhagic) Gonorrhea (disseminated)
	Rashes with petechiae / purpura	Henoch the Tick gave Meningitis to DICk the purple drug addict Ricketsia (RMSF) Meningococcemia DIC (purpural fulminans) Endocarditis
	Exam findings of serotonin syndrome	CHARM CNS dysffunction Hyperthermia/Hyperreflexia Autonomic dysfunction Rigidity Myoclonus NOTE: NMS does NOT have myoclonus or hyperreflexia!!!
	Depression symptoms	SIGECAPS Sleep Interest Guilt Energy Concentration Appetite Psychomotor slowing Suicidal Ideation
	Suicidal ideation assessment	SADPERSONS scale correlates with the decision to admit to psychiatry. Does not predict risk of future suicidality. S ex (male) - 1 A ge - 1 D epressed - 2 P revious attempt or psych care - 1 E thanol abuse or street drugs - 1 R ational thought (not) - 2 S eparated, widowed, divorced - 1 O rganized plan or serious attempt - 2 N o social support - 1 S tated future intent - 2 <6 - Outpatient >6 - ED psych evaluation >9 - Psych admission
	Major and minor criteria for Rheumatic Fever. Treatment.	Jones criteria (requires evidence of strep infection + 2 major or 1 major/1 minor) MAJOR J - oints - polyarthritis of large joints (knees, elbows, wrist, ankles) <3 - carditis (murmurs, effusions, cardiomegaly, CHF) N - Nodules - subcutaneous on extensor surfaces (wrist, elbow, knees, spine) E - Erythema marginatum (painless, non-pruritic) S - Sydenham's Chorea MINOR F - Fever A - Arthralgias C - CRP E - ESR P - PR interval increased Treatment -Penicillin x 10 days or Benzathine penicillin 1million units IM; long-term prophylactic antibiotics -Aspirin -IVIg
	Criteria for diagnosing Endocarditis	Duke's criteria () BE FIVER (+ if 2 major, 1 major 2 minor, 5 minor) B - Blood cultures (2 positive with typical pathogens) E - Echo lesions (vegetation, perivalve abscess, prosthetic valve dehisence, new regurgitation) F - Fever (>38) I - Immunologic (Roth, Osler, rheumatoid factor) V - Vascular (Janeway, septic emboli, conjunctival hemorrhage) E - eccentric blood culture (single positive culture unless organism does not cause IE) and echo (consistent with IE but do not meet criteria) R - risk factors (IVDU, prosthetic valve)
	San Francisco Syncope Rule	CHESS CHF Hematocrit <30% ECG SOB Systolic BP <90
	Dangerous ECG findings on an ECG of a patient with syncope	Prolonged QT WPW Brugada HOCM Ischemia
	Causes of hyperacute T waves	Ischemia Hyperkalemia Pericarditis LVH LBBB Benign early repolarization
	Causes of tall R wave in v1	Posterior MI RBBB RVH WPW type A Children and adolescents Dextrocardia
	Causes of ST elevation on ECG	STEMI Printzmetal's LBBB LVH Pericarditis Hyperkalemia Brugada PE Celebral hemorrhage Pacing BER
	How can VT be distinguished from SVT with aberrancy?	Brugada criteria (note: not good enough to use in real life): 1. Absence of any RS complexes in the chest leads 2. RS duration (measured from beginning of R to deepest part of S wave) greater than 100 msec 3. AV dissociation (often present but overlooked; may be best appreciated in inferior limb leads and V1-2) 4. Specific VT morphologic criteria
	What are the common pacemaker malfunctions?	Failure to capture - lead displacement or break, block or battery Oversensing - sensing T waves or extracardiac stimulus Undersensing - poor lead connection or break, small amplitude, poor contact Inappropriate rate - battery, response to atrial dysrhytmias
	What is the code for pacemaker type?	Chamber paced - A, V, D Champer sensed - A, V, D Response to sensing - Inhibit pacing (V or A and V) or Trigger pacing (old) Programming - simple, programmable, rate adaptive, communicating, none Antitachy response - pace or shock
	Complications of ICD and pacemaker placement	Infection of wound Infection of pouch Thrombophlebitics Chronic thrombosis
	Indications for a pacemaker	High level block: -And symptomatic brady -And asystole >3s (AFib pauses >5s) -Following AV ablation -With neuromuscular disease -Intermittently with bi or trifascicular block -With exercise
	Indications for an ICD	1. Cardiac arrest from VF or VT not caused by a reversible event 2. Spontaneous sustained VT 3. Syncope of undetermined origin with inducable sustained VT or VF 4. Nonsustained VT with coronary artery disease, prior myocardial infarction, left ventricular dysfunction, and inducible VF
	Etiology of Pericarditis	-Infectious (Viral, Bacterial, Fungal, Parasite, Rickettsia) -Postinjury (Trauma, Surgery, Myocardial infarction, Radiation) -Metabolic diseases (Uremia, Medications) -Systemic diseases (Rheumatoid arthritis, Systemic lupus erythematosus, Sarcoidosis, Scleroderma, Dermatomyositis, Amyloidosis) Tumors Aortic dissection
	List the hypertensive emergencies and their ideal treatment.	ACS - nitroglycerine, labetolol Heart failure - nitroglycerine, furosemide Dissection - esmolol & nitroprusside OR labetolol Ischemic stroke - nicardipine, labetolol Intracerebral hemorrhage - nicardipine, labetolol Hypertensive encephalopathy - nicardipine, labetolol Kidney injury - fenoldopam, nicardipine Preeclampsia - magnesium and labetolol Sympathetic crisis - phentolamine
	What features distinguish orbital cellulitis from periorbital cellulitis?	Proptosis, opthalmoplegia, and visual changes (look for afferent pupillary defect secondary to increased IOP).
	Differential diagnosis for a NAGMA	HARDUPS Hyperalimentation / TPN Acetazolamide RTA Diarrhea Ureteral diversion Pancreas Spironolactone
	Niacin deficiency	aka Vitamin B3 and results in Pellagra 4D’s: Diarrhea Dermatitis Dementia Death
	Thiamine deficiency	aka vitamin B1 Wernicke's Encephalopathy- WACO: ataxia, confusion, opthalmoplegia Korsakoff's Psychosis - irreversible short-term memory loss Beri-beri - high output heart failure secondary to vasodilation and fistula formation
	Cobalamin deficiency	aka vitamin B12 Megaloblastic anemia Neurologic changes (paresthesias, ataxia, clonus, memory loss) Psychiatric (depression, psychosis) Folate looks the same except NO neurologic changes and it happens faster.
	Causes of non-cardiogenic pulmonary edema	IS NOT THE HEART I nhaled Toxins (Ammonia, Chlorine, Phosgene, Nitrous oxide) S IRS / Sepsis / Septic Shock N eurogenic (seizure, strangulation, trauma) O verdose (Heroin, methadone, cocaine) T hyrotoxicosis T rauma H eat (Smoke! Remember to also consider carbon monoxide!) E lectrocution H igh altitude pulmonary edema E mbolism (Pulmonary Embolism, Acute Gas Embolism, Amniotic Fluid Embolism) A SA toxicity R eperfusion or Re-expansion pulmonary edema (or Rocky Mountain Spotted Fever*) T ransfusion
	Diagnostic criteria of Multiple Myeloma	-Monoclonal plasma cells or plasmacytoma in the bone marrow -Monoclonal protein in blood or urine -Organ dysfunction (CRAB criteria) C - HyperCalcemia R - Renal failure A - Anemia B - Bone damage (lesions or osteoporosis)
	What cancers cause bone mets?	Painful Bones Kill These Suckers Prostate Breast Kidney Thyroid Skin Also Lungs
	Hard signs of vascular injury	HARD Bruit Hypotension Arterial Bleed Rapidly expanding hematoma Deficit (pulse/neuro) Bruit/thrill
	Criteria to call a febrile seizure simple	6 months to 6 years 1 episode in 24 hours Duration <15 minutes Generalized No neurological history
	HELLP Syndrome	Hemolysis Elevated Liver enzymes Low Platelets
	Kawasaki Disease criteria	Warm CREAM Warm - fever >5 days C - Conjunctivitis R - Rash (erythematous, maculopapular, morbilliform) E - Erythema of palms/soles with swelling A - Adenopathy (cervical) M - Mucous membranes (dry, red, strawberry tongue)
	Tetrology of Fallot cardiac anomolies	-Boot shaped heart (Fall over your own Boots) -Pulmonary hypertension, VSD, RVH, Overriding Aorta -Ductal dependent lesion that crash after PDA closes (2-10 days, treat with PGE1 0.1mcg/kg/m) Tet spells (knees to chest to increase SVR and O2 to decrease PVR)
	Congenital Adrenal Hyperplasia abnormalities	21-hydroxylase deficiency Low Na and High K Virulized females, small penis in boys Treat with glucose and hydrocortisone
	Abuse fracture patterns	ANY in a child <1yo Bucket Corner Diaphysis of humerus, radius, femur, tibia (especially <3yo) Rib Scapular Spinous process Sternum** Skull (stellate)* Vertebral* Digits* Multiple* or Bilateral Different stages of healing*
	Psychological signs of child sexual abuse	Very broad definition Regression Acting out Sexualized behavior Disclosure
	The crashing neonate	THE MISFITS T rauma / abuse H eart disease / H ypothermia / H ypoxia E ndocrine (CAH, hyperthyroid) M etabolic (hypoglycemia, hyponatremia, hypocalcemia) I nborn errors (ammonia) S epsis (most common!) F ormula mishaps I ntestinal catastrophes (volvulus, NEC, diaphragmatic hernia) T oxins (home remedies) S eizures
	Cyanotic heart disease	Increased lung markings 1-Truncus arteriosis 2-Transposition of the great arteries 5-Total anomalous venous return Decreased lung markings 3-Tricuspid atresia / pulmonary atresia 4-Tetrology of Fallot
	Congenital heart disease: Obstructive Lesions	Also happen with closure of the duct, but NOT cyanotic. Give them 0.1mcg/kg/m of PGE1 Coarctation of the aorta Hypoplastic left heart syndrome Interrupted aortic arch Aortic stenosis (critical)
	List some symptoms of lead poisoning	L - Lead lines E - Encephalopathy A - Anemia with basophilic stippling D - Drop (wrist)
	Outline the phases of iron poisoning	I GI effects (hemorrhagic GI effects) x 6 hours II Quiscient x 12 hours III Systemic (vasodilatory shock; hepatorenal dysfunction) IV Liver failure V Resolution (GI scarring, stomach obstruction)
	Pelvic avulsion fractures (muscle attachments and bony anatomy)
	Anticholinergic Toxidrome	Blind as a bat (Mydriasis) Mad as a hatter (Altered mental status) Red as a beet (vasodilation, flushed) Hot as a hare (febrile) Dry as a bone (no secretions/diaphoresis) Bowel and bladder lose their tone Heart runs alone (tachycardia) Atropine, antihistamines, scopalamine, antipsychotics
	Cholinergic Toxidrome	SLUDGE and the killer B's Salivation Lacrimation Urination Defication Gastro upset Emesis Bradycardia, Bronchorrhea, Bronchospasm Also mioisis and lethargy Organophosphates, carbamates, mushrooms
	Approach to CT Head	Blood Can Be Very Bad Blood Cisterns Brain Ventricles Bone
	Approach to CXR	ABCS Airway Breathing (lungs) Cardiac (heart) Skeleton and Soft tissues
	Substances that are radioopaque on x-ray	CHIPES Chloral hydrate Hydrocarbons (especially halogenated ones) Iron Phenothiazines Enteric coated Solvents (some of them)
	Associations with Ciguatera toxicity	Big fish (grouper, barracuda) -Anticholinesterase (cholinergic) effects -Gastroenteritis -Hot/cold reversal of sensation or cold allodynia -Teeth feel loose -Brady / resp arrest Treat with antihistamines (treat the itch), atropine, amitryptaline (allodynia), mannitol (controversial)
	Associations with Scombroid	Poorly refrigerated fish (Tuna, mahi mahi) Histidine in decomposing fish gets broken down into histamine -Rapid flushing to head/face/torso -Gastroenteritis
	What is VATER Syndrome?	AKA VACTERAL Association, these conditions occur together more commonly than would be expected otherwise Vertebral anomolies Anal atresia Cardiac defects Tracheo-esophogeal fistula Esophageal atresia Renal anomolies Limb defects
	DDx for febrile and altered mental status patients	SWEAT Sepsis Withdrawal Endocrine (thyroid) & Environment (heat stroke) Agitated delirium Toxidromes (sympathimetic, anticholinergic, amphetamines, salicylates, SS, NMS, MH, strychnine, hallucinogens)
	General approach to the intoxicated patient	ABCDDDEF Airway Breathing Circulation Dextrose Decontamination Diagnosis (ECG, VBG, acetaminophen, ASA, osmolality, EtOH) Exposure (features of toxidrome) Elimination (enhance it) Find an antidote
	TCA mechanisms of action	TCA Thinker 1 – Indirect GABA antagonism (seizures) 2 – Serotonin reuptake inhibition (serotonin syndrome and agitated delirium) 3 – Norepinephrine reuptake inhibition (initial hypertension and agitated delirium) Cardiac 4 - Na channel blockade in phase 0 of cardiac depolarization (wide QRS, impaired inotropy) 5 – K efflux blockade prolonging phase 3 of cardiac repolarization (long QT) 6 – Alpha-1 adrenergic blockade causing vasodilation (hypotension) Anti 7 – Anticholinergic (delirium, seizures, sedation, coma, prolonged gastric emptying) 8 – Antihistamine (I don’t believe this causes any problems in OD) 9 – Antidepressant (this actually results from the Norepi/Serotonin reuptake inhibition, but it balances out the acronym!)
	Sternbach's criteria for serotonin syndrome	Recent serotonergic med/med increase, no recent neuroleptics, no other cause, and 3 CAN features Cognitive -Agitation, Confusion, Delirium, Hypomania Autonomic instability -Tachy, HTN, shiver, diaphoresis, mydriasis, diarrhea Neuromuscular activity Fever, ataxia, tremor, hyperreflexia, myoclonus, muscular rigidity
	Plants and animals containing cardiac glycosides	FLOWeRY BF Foxglove Lily of the valley white Oleander Weed of milk Red squill Yellow oleander Bofo toad Firefly
	What are the indications for monitoring/admission after electrical injury?	Clinical -Cardiac arrest, LOC, hypoxia, chest pain, suspected conductive injury, other injury requiring admission ECG -Abnormal or dysrhythmia has occurred Risk factors -Known CAD -Risk factors for CAD
	What is the feathering cutaneous burn caused by a lightning strike called?	Lictenburg figure
	How do high voltage electrical injuries differ lightning injuries?	More often, high voltage electrical injury causes -Muscle necrosis -Rhabdomyolysis -Compartment syndrome -Kissing burns -Mouth burns But does not cause -Lictenburg figures -Karaunoparalysis
	How do humans transfer heat?	Conduction - from a warmer to cooler object through direct physical contact Convection - loss to circulating air and water molecules Radiation - transferred by electromagnetic waves Evaporation - conversion of liquid to gas
	Contrast heat cramps, heat edema, heat syncope, prickly heat	Cramps - due to fluid replacement with hyptonic fluids Edema - vasodilation causes pooling which leads to swelling Syncope - vasodilation and dehydration lead to decreased CO and fainting Prickly heat - obstruct the sweat pores, staph infection, vesicular rash - treat with chlorhexidine cream
	What is the difference between classic and exertional heatstroke?	Classic is in older people with chronic disease in high temperatures, sweating is absent, rhabdo and ARF are rare, lactate is BAD Exertional is in young people exerting themselves, sweating is common, rhabdo and ARF are common, and lactate is less bad
	List the ways that a patient can be rewarmed from hypothemic states	Active external: -Bair hugger, AV anastomosis, hot water immersion, heating pads, hot water bottles, radiant heat lamp, negative pressure rewarming Active internal -Humidified ventilation, warm IVF, thoracic bladder gastric myocardial or colonic lavage, peritoneal dialysis, ECMO +/- diathermy
	Causes of syncope	P ressure (hypotensive causes) A rrhythmias - Bradyarrhythmias, Tachyarrhythmia's (SVT, NSVT, A.F.), pacemaker malfunctions S eizures S ugar (hypo / hyperglycemia) O utput (cardiac) - AS, PS, MS, IHSS, Cardiomyopathies, Atrial Myxoma, Cardiac Tamponade, Aortic Dissection, MI, CHF O 2 (hypoxia) - PE, Pulm HTN, COPD exacerbation, CO poisoning U nusual causes - Anxiety, Major depressive disorder, Panic disorder, Hyperventilation syndrome, Somatization disorder T ransient Ischemic Attacks & Strokes, CNS dz's
	Describe the Haddon matrix	Matrix to assess and modify factors related to injury HAVE Host Agent Vector/Environment Before, during, and after injury
	List 3 strategies used to decrease injuries	The E's Education - teaching at risk populations how to prevent injury Engineering - design safety into the environment (e.g. highway design) Enforcement - of laws requiring safer behavior (e.g. seatbelts)
	Hemiparesis ipsilateral to a pupil blown secondary to increased ICP	Kernohan's notch syndrome secondary to uncal herniation compressing the contralateral cerebral peduncle. It results in 'false localization'
	Layers of the scalp and associated hemorrhage	SCALP Skin Connective Tissue (Caput succedaneum) Aponeurosis galea Loose areolar tissue (Subgaleal hematoma) Periosteum (Cephalohematoma limited by sutures)
	How can we assess for pseudosubluxation on pediatric c-spine x-rays?	Most commonly C2-C3 Look at spinolaminar (Swischuk's) line drawn from anterior cortex of the C1 to C3 spinous process. If the line is >2mm anterior to the anterior cortex of C2 suspect a posterior element fracture.
	Differences in the pediatric versus adult airway
	Anatomic differences in pediatric patients that change response to trauma	-Small size = more multitrauma -Less protective fat/muscles = more internal organ injuries (liver, spleen, kidneys) -Elastic chest wall = lung injury without # -Open growth plates = different fracture patterns -Large surface area = quicker hypothermia -Faster metabolic rate = quicker desat, hypoglycemia -Better at maintaining BP = tachy as only sign of shock -Bigger head-to-body, thin skull, less myelin = more head injuries -More elastic vertebral column = more SCIWORA -Bigger head = higher fulcrum = C2-3 versus C6 injuries more common
	Anatomic difference in pregnant patients that change response in trauma	Airway - more friable and edematous mucosa, lower esophageal sphincter tone, increased abdominal girth Respiratory - higher RR = greater minute ventilation and lower CO2; higher diaphragm = lower FRC (quicker desat) and req's higher chest tube Cardiac - Increased blood volume, tachycardia, decreased PVR, increased venous congestion/pressures, lots of blood to uterus, aortocaval compression when supine Heme - dilutional and Fe-deficiency anemia; hypercoaguable Abdomen - displaced contents; decreased sensitivity of exam for peritonitis; ALP doubles; decreased GB contractility (increased gallstones; weight gain Nephro - bladder is extrapulvic after 12 weeks; decreased GFR; polyuria and hydropnephrosis due to bladder compression MSK - widened pubic symphesis (4 -> 8mm)
	How can we assess for atlanto-occipital dislocation on pediatric c-spine x-rays?	Use power's ratio (should be <1): Basion to anterior cortex of C1 spinous process Opisthion to posterior cortex of dens Also Basion-Dens & Basion to posterior axillary line should be <12mm
	Tube sizes in pediatrics	Broselow tape ETT = (age/4) + 4 (uncuffed - drop 0.5-1 size for a cuffed tube) Chest tube = ETT size x 4 Foley / NG tube = ETT size x 2
	Anatomic difference in elderly patients that change response in trauma	General - on medications Cardiac - decreased reserve, can't increase HR Pulmonary - decreased compliance and increased chest wall rigidity, brittle bones Neurologic - brain atrophy increases mobility and shearing of bridging veins (SDH); dura is fused so less EDH Derm - skin is thin and brittle, easier to lacerate and tear, forms ulcers quicker MSK - osteopenia so increased fractures, decreased joint mobility, spinal stenosis
	Approach to hyponatremia
	Effects of typical antipsychotics	HOT DAMN Fever Dopamine receptor blockade Alpha blockade Muscarinic blockade Na/K channel blockade (wide QRS and long QTc)
	Addictions that can kill in withdrawl	ABBA Alpha blockers (clonidine) Benzo's Barbiturates Alcohol
	Nicotinic stimulation effects	Monday - mydriasis Tuesday - tachycardia Wednesday - weakness tHursday - hypertension Friday - fasciculations Saturday - seizures
	Oxygen toxicity symptoms	VENTIAC V ertigo E uphoria N ausea T innitus I mpaired judgement A LOC (Altered LOC) C onvulsions
	Lake Louise criteria for AMS
	Lake Louise criteria for HACE
	Lake Louise criteria for HAPE
	The TIMI Score	2 or more episodes of angina in past 24h 7 days history of ASA use C AD (known and >50%) A ge > 65 R isk factors (>3) T roponin S T changes
	Predictors of difficult BVM	B eard O bstructed / O bese / O SA N eck stiffness / N eck mass E xpecting (pregnant) S tridor / S nores
	Predictors of difficult intubation	L ook externally E valuate 3-3-2 M allampati O bstruction / O besity N eck mobility (decreased)
	Predictors of difficult cric	S urgery H ematoma / H ave infection (abscess) O besity R adiation T rauma / T umor
	Predictors of difficult LMA	R estricted mouth opening O bstruction D istored airway anatomy S tiff lungs / Neck
	What are the lines of the cervical spine?
	How do you assess for pseudosubluxation in the pediatric C-spine?	Swischuk's line (anterior arch of C1-C3 is within 2mm of C2)
	Cervical spine fracture mechanisms	All are flexion, except: Vertical Compression - Burst & Jefferson Extension - C1 neural arch, Hangman, Extension teardrop Flexion-rotation - Unilateral facet, Rotary atlantoaxial
	Sensory spinal levels
	Motor spinal levels
	Reflex spinal levels
	Describe the motor deficit in central cord syndrome	It is MUDdy! Motor > sensory Upper > lower Distal > proximal
	Signs of aortic dissection on CXR	Wide CHAPPLA1N Wide mediastinum (8cm AP, 6cm PA, >25% chest width at aortic knob) C alcium sign H emothorax A ortic knob obscured P aratracheal stripe widened P leural cap L eft mainstem bronchus depressed A ortic window lost 1 st rib fracture N G deviates to the right along with trachea
	Occlusive and nonocclusive arterial injuries	Occlusive -Transection -Thrombosis -Arterial spasm (reversible) Nonocclusive -Intimal flap -Pseudoaneurysm -AVM -Compartment syndrome
	Diagnostic aid for a migraine	Migraine is likely with two or more of the POUND criteria: -P ounding -hO urs lasts (4-72) -U nilateral -N ausea and vomiting -D ebilitating
	International Headache Society Migraine Definition	1 --> 4 to 72 hours 2 --> At least two of the following: -Aggravation by or causing avoidance of routine physical activity -Moderate or severe pain intensity -Pulsating quality -Unilateral location 3 --> During headache, at least one of the following: -Nausea and/or vomiting -Photophobia and phonophobia 4 --> Not attributed to another disorder 5 --> History of at least five attacks fulfilling above criteria
	Causes of pancreatitis	I GET SMASHED I diopathic G allstones E thanol T umors (pancreas, ampula, choledochal) S corpion stings M icro - Bacterial (Mycoplasma, Camylobacter, TB), Viral (Mumps, Coxsackie, Rubella, Varicella, CMV, hepatitis, EBV), Parasites (ascaris, echinococcus) A utoimmune (SLE, PAN, Crohn's) S urgery / trauma H yperlipidemia / H ypercalcemia (hyperparathyroid) E mboli / ischemia D rugs / toxins (azathioprine, estrogen, lasix, valproic acid, APAP, ASA, sulfonamides)
	Types/causes of diarrhea	MMISO M alabsorption (short gut, CF, IBD, celiac, lactose intolerant) M otility (DM, neuromuscular, scleroderma) I nflammatory - cellular damage causing secretion; can be hemorrhagic (enterohemorrhagic E Coli, Salmonella) or IBD, autoimmune, chemo S ecretory (Toxin-mediated chloride secretion: Enterotoxic E Coli, Shigella, Salmonella, Vibrio, C Diff; does not decrease with fasting) O smotic (altered gut flora from Noro or Rotavirus; ingestion of sorbitol or lactulose; decreases with fasting)
	Top 5 causes of occult irritability in children	FAT SHIC F racture A buse T esticular torsion S urgical abdomen H air tourniquet I mproper feeding C orneal abrasion / C olic
	Dermatologic findings in pediatric seizures due to neurocutaneous disorders	Cafe au lait - Neurofibromatosis Ash leave - Tuberous sclerosis Port au Wine Staine - Sturge-Weber
	Appearance assessment of the pediatric assessment triad	TICLS Tone Interactivity Consolability Look/gaze Speech/cry
	Lateral soft tissue x-ray findings of epiglottitis	AAA PBL on TV A ir fluid level A ryepiglottic fold swelling A rytenoid swelling P revertebral tissue swelling B allooning of the hypopharynx L oss of L ordosis T humbprint epiglottis V allecula obliteration
	Approach to the striderous child	Supraglottic -Congenital (Micrognathia, Macroglossia, Choanal atresia) -Acquired (Retropharyngeal abscess, Epiglottitis) Glottic -Congenital (Laryngeal web, Vocal cord paralysis, Laryngeomalacia) -Acquired (Laryngeal papilloma) Subglottic -Congenital (Subglottic stenosis, Hemangioma) -Acquired (Croup, Subglottic stenosis) Tracheal -Congenital (Tracheomalacia, Tracheal stenosis, vascular ring) -Acquired (Bacterial tracheitis, Foreign body)
	Signs of retrobulbar hemorrhage and indications for lateral canthotomy	DIP A CONE (DIP is primary indications; A CONE is secondary) D ecreased VA I ncreased IOP (>40) P roptosis A fferent pupillary defect C herry red macula O pthalmoplegia N erve head pallor E ye pain
	Medical treatment of increased IOP	ABCDPS A lpha 2 agonist (Apraclonidine 1% - decrease production and increase outflow) B eta blocker (Timolol 0.5% - decrease humor production) C holinergic (Pilocarpine 1% - constricts pupil and opens trabecular meshwork) D iuretic (Mannitol & Acetazolamide - decrease production) P rostaglandins (Latanoprost - increase outflow) S teroids (Prednisone acetate 1% - decrease inflammation)
	Indications for referral to opthalmology of an eyelid laceration	The 5 L's L id margin L acrimal system L evator or canthal tendons L oss of tissue L eaking of fat
	DDx for sudden visual loss	Anatomic Anterior chamber - hyphema, hypopiom, glaucoma Iris/lens - lens dislocation, iritis Posterior chamber - posterior vitreous detachment or hemorrhage Retina - Retinal detachment, central venous occlusion, central arterial occlusion Neuro-opthalmologic - pre-chiasm (optic neuritis due to ischemia/compression/toxin), chiasmal (tumor), post-chiasm (CVA, tumor, AVM, migraine), visual cortex (CVA)
	Kanavel signs of flexor tenosynovitis	Fingers held in slight flexion Fusiform (symmetrical) swelling Pain to palpation of flexor tendon Pain on passive extension
	Hand motor testing	Radial nerve - wrist extension (triceps) Posterior interosseous branch of the radial nerve - thumb extension Median nerve - thumb opposition to fingers Anterior interosseous branch of the median nerve - OK sign Ulnar nerve - Froment's paper sign; finger abduction and adduction
	Hand sensation testing	Radial nerve - dorsal 1st web space Median nerve - volar tip of D2 Ulnar nerve - volar tip of D5
	Back pain red flags	Infectious - fever, IVDU Fracture - history of trauma Cancer - weight loss, history of cancer Cauda equina - urinary retention, fecal incontinence, saddle anesthesia Nocturnal pain
	Indications for lumbar spine x-rays	M alignancy A ge (<18 or >50) F ever I mmunocompromised N euro deficits (progressive) D uration (>4-6 weeks) W eight loss I VDU T rauma
	Lines of the pelvis x-ray
	One pill can kill	Alpha blocker (clonidine) Antihyperglycemic agents BB Barbiturates CCB Digoxin MAO-I Methadone Theophylline TCA Methyl salicylate Toxic alcohol Iron Camphor Lomotil
	Drugs that cause seizures	WITH LA COPS W ithdrawal / Wellbutrin I NH T heophylline / TCA H ypoglycemic agents L ithium / L ocal anesthetics / L ead A nticholinergics C holinergics / C amphor O rganophosphates P CP S alicylates / Sympathomimetics
	Drugs MDAC is appropriate for	Please Quit Drinking the AC Dummy Phenobarb Quinine Dapsone Theophylline / TCA (maybe) ASA Carbamezapine Digoxin (maybe) / Dilantin (maybe)
	Dialyzable drugs	BIT SLIME B arbiturates I soniazid T heophylline S alicylates L ithium I ctogenic drugs (Tegetrol, Valproate, Phenobarb) M ethanol E thylene glycol D abigitran
	Indications for reduction of a distal radius fracture	Step >1mm Radial inclination <15 degrees (normal 22) Volar tilt less than 0 degrees (normal 10-25) Decreased radial height (normal 11mm, loss of 2mm relative to other side is short)
	Clavicle fracture's requiring orthopedic consultation	The rule of 2's >2 cm displacement 2 or more pieces <2cm from either end of the clavicle >2cm of shortening 2 good 2 be true
	Shoulder dislocation techniques	Stimson - prone, arm hanging with weight x 20 minutes Traction-countertraction - sheet under arm for countertraction, abducted arm FARES - supine, slow abduction with flexion/extension until 90 degrees then external rotation Milch - supine at 45 degrees, external rotation and abduction to 90/90 then longitudinal traction Scapular manipulation - can be added to traction/countertraction and Stimson, rotate inferior tip medially Cunningham - seated, shoulders adducted, elbow flexed with shoulder on provider shoulder, massage of bicep at mid-humeral level
	Open fracture classification	Gustillo classification system I - <1cm, clean, tx with 1st gen cephalosporin II - >1cm, minimal soft tissue damage, tx with 1st gen cephalosporin IIIa - significant soft tissue damage with adequate coverage, 1st gen cephalosporin and aminoglycoside (gentamicin) IIIb - significant soft tissue damage with INadequate coverage, same tx as IIIa IIIc - open # with vascular injury , same tx as IIIa Add Pen G or Clinda if concern for anaerobes (farm injury) and Cipro if concern for salt water (pseudomonas)
	Femoral nerve injury	Motor - weak knee extension, can't climb stairs or get up from sitting Sensory - varies, most reliable superomedial to patella Reflex - decreased patellar
	Sciatic nerve injury	Motor - paralysis of hamstring (knee flexion) and all muscles below the knee Sensory - posterior thigh and below the knee Reflex - decreased Achilles tendon
	Hip reduction techniques	Allis - patient supine with hip and knee flexed to 90 degrees, get on bed and provide vertical upward traction while someone holds the pelvis to the bed. Works for posterior and anterior-obturator (femoral head seen over obturator foramen). Stimson - patient prone with one leg hanging off of the bed, flex hip and knee to 90 degrees, vertical downward traction while someone holds the pelvis/pushes down on the femoral head. Whistler - patient supine, arm under knee of dislocated hip with arm on opposite knee (both legs flexed at the hip/knee) to use opposite leg as a fulcrum. A modification of this is the Captain Morgan with your leg under the patient's knee instead of your hand.
	Kocher criteria to distinguish septic arthritis from transient synovitis	With 0-4 criteria the likelihood is: 2%, 9.5%, 35%, 73%, 93% -Non weight bearing -ESR >40 -WBC >12 -Fever > 38.5 CRP >20 is also predictive
	Ottawa Knee Rule	Get x-rays if: Age >55 Inability to transfer weight 4 times at time of injury OR in ED Inability to flex to 90 degrees Patellar tenderness Fibular head tenderness
	How do you assess for patella alta / baja?	Blumensaat's line or Insall-Salvati ratio (patella length should be <0.8 of patellar tendon length; if not patella alta)
	Ottawa Ankle Rule	Applied to acute ankle injuries with malleolar pain (not hindfoot, forefoot, upper fibula) -Pain to posterior edge of the lateral malleolus from its distal part and 6cm proximal -Pain to the posterior edge of the medial malleolus from its distal part and 6cm proximal -Unable to weight bear 4 steps immediately after the injury and in the ED
	Ottawa Foot Rule	-Pain over the navicular bone -Pain to the base of the 5th metatarsal -Unable to weight bear 4 steps immediately after the injury and in the ED
	How do you calculate Boehler's angle?	A = Posterior tuberosity B = Apex of posterior facet C = Apex of anterior process
	Bones at high risk of AVN	-Head of femur (Legg-Calve-Perthes syndrome in children generally 4-10yo) -Scaphoid -Lunate (Kienbock's disease) -Talus -Navicular (Kohler's disease) -Second metatarsal
	DDx for non-accidental trauma in children (fractures and bruising)	-Osteogenesis Imperfecta -Rickets -Scurvy -Menkes' Kinky Hair Syndrome -Hypervitaminosis A -Hypoparathyroidism -Congenital Syphilis -Pathologic fractures -Birth fractures -Metaphyseal cupping & spurring (normal variant - bilateral, diaphyseal, smooth) -Periosteal new bone formation (normal variant - especially to the femur) -Cultural practices (Cupping, Coining, Spooning) -Bleeding disorders (hemophilia, vWD, HSP) -Mongolian spots -Hemangioma -'Tattooing' -ITP -HSP -Secondary syphilis
	Diagnostic criteria for staph toxic shock syndrome	DR FrOH (NO culture needed) D esquamation of the skin (begins during recovery phase after 1-2 weeks; R ash (blanching, macular, erythematous, NOT itchy, fades before desquamation) F ever (>38.9) r O rgan systems (>3/7 involved: CNS, mucous membranes, GI, renal, hepatic, heme, MSK) H ypotension (sBP < 90 or < 5th percentile in children)
	Diagnostic criteria for strep toxic shock syndrome	You going to the strep SHO? S erology (isolation from a sterile [definite] or nonsterile [non-definite] site) H ypotension (sBP<90 or <5th percentile) O rgan systems (>2/6 involved: Renal, Heme, Liver, Lung, Rash, Soft tissue necrosis)
	Determining capacity	C ommunication U nderstanding R easoning V alues E mergency S urrogate
	When can implied consent be assumed	-Patient is unable to express their preferences (CURV) -Immediate action is required (E) -No surrogate decision maker (S)
	Signs of Lithium toxicity	SNAP MUD S eizures N /V/D A taxia P arkinsonian M yoclonus U MN D elirium/D ecreased LOC
	Infections requiring airborne precautions	Respiratory TB Varicella (chickenpox and disseminated zoster) Measles SARS Smallpox +/- Ebola and TB (during aerosolizing procedures)
	AIDS-defining illnesses	Heme -CD4<200 Malignancies -Kaposi's Sarcoma -Lymphoma -Cervical cancer (invasive) Neuro -HIV-associated encephalopathy -Progressive multifocal leukoencephalopathy -Toxoplasmosis of brain Fungal infection -Candida (esophageal or pulmonary) -Histoplasmosis -Cryptococcus -Coccidiomycosis Protozoa infection -PJP pneumonia -Isosporiasis -Toxoplasma gondii -Cryptosporidium Viral -HSV (persistent, pneumonia, esophagitis) -CMV (except spleen/liver/lymphatics) Bacterial infection -Tuberculosis -Mycobacterium avium complex -Salmonella sepsis -Recurrent bacterial infections
	SIRS	HR > 90 RR < 20 OR PaCO2 <32 T < 36 OR > 38 WBC <4 OR >12 OR >10% bands
	Definition of ARDS	As per the 2012 Berlin Definition -Respiratory symptoms started or worsened acutely with the last week -PaCO2 / FiO2 ratio 200-300 = mild, 100-200 = moderate, <100 = severe -Bilateral pulmonary infiltrates (CXR or CT) -Not in cardiac failure / no fluid overload
	Malaria: Organism, Vector, Incubation, Presentation, Complications, Diagnosis, Treatment	-Organism: Plasmodium Falciparum is most dangerous (also Ovale, Vivax, Malariae) -Vector: Female anopheles mosquito -Incubation: 8-28 days -Presentation: Fever in the returning traveler, anemia, constitutional (weak, dizzy, N/V/D, lethargy, myalgia, arthralgia, CP, abd pain, SOB) -Complications: cerebral/seizures, ARDS, ARI, DIC, anemia, acidosis, hypoglycemia -Diagnosis: Thin and thick peripheral blood smears q8-12h x 3d -Treatment: Chloroquine if sensitive; otherwise quinine & doxycycline
	Lyme disease: Organism, Vector, Incubation, Presentation, Diagnosis, Complications, Treatment	-Organism: Borrelia Borgdorferi (spirochete) -Vector: Ixodes Tick -Incubation: Tick must attach long enough to become engorged (>48 hours) -Presentation: 1st stage erythema migrans & flu-like symptoms/HA; 2nd stage 4 weeks later with fluctuating meningoencephalitis/bilat Bells palsy, conduction block/pericarditis, arthritis, eye inflammation; 3rd stage lasting >1y with fatigue syndrome and arthritis -Diagnosis: Tick bite, IgM+ from 3-6 weeks, IgG+ >1 month (send both) -Complications: Can get Jarisch-Herxheimer reaction when tx started -Treatment: prophylax within 72h in endemic areas if adult tick on for >36h - use Doxy 200mg x1; treat with Doxy 200mg BID x 28d
	Rocky-Mountain Spotted Fever: Organism, Vector, Incubation, Presentation, Diagnosis, Complications, Treatment	-Organism: Rickettsia Rickettsii -Vector: Rocky Mountain Wood Tick -Presentation: Sudden onset fever followed by N/V/abd pain/HA. Gets into vessels and releases tPA & vWF causing microthrombi and vascular permeability. Petechiae develop on wrists/hands then spread inward. Also cardiac (AVB, myocarditis), pulmonary (ARDS), neurologic (meningismis, transient deficits due to microinfarcts), renal (microinfarcts), heme (DIC). -Diagnosis: Serology not positive for 1/52 but req'd for conclusive Dx. Skin bx at 4-10 days. -Complications: Death due to renal failure then ARDS/DIC in 25% if not treated -Treatment: Doxycycline
	Things that shift the oxygen-hemoglobin dissociation curve	CADETS turn right and fall down (right shift and decreased oxygen affinity) C - CO2 A - Acid D - 2,3 DPG E - Exercise T - Temperature S - Sickled Hb S
	Diagnostic criteria for delerium	4 criteria: -Inability to focus/Inattention -Fluctuating course -Cognitive deficit (memory, disorientation, language) or perceptual disturbance not caused by dementia -Evidence that it is caused by a medical condition, ingestion, or withdrawl
	Diagnostic criteria for dementia	1 - Memory impairment AND 2 - One of aphasia, apraxia, agnosia, impairment in executive functioning -Causing significant impairment -NOT due to delerium
	Treatment of active TB	RIPE (side effects) x 9 months! R ifampin (orange body fluid) I soniazid (INH injures nerves and hepatocytes) P yrazinomide E thambutol (E=eyes - optic neuritis; can't distinguish red/green)
	Treatment for hyperkalemia	C BIG K Drop C alcium B eta agonist / B icarbonate I nsulin G lucose K ayexalate D iuretics (Furosemide) R - R enal dialysis o p
	GBS: Cause, Presentation, Diagnosis, Complications, Treatment	Cause: idiopathic, often secondary to Campylobacter, Mycoplasma, CMV or EBV - results in antibodies to nerves Presentation: progressive ascending symmetric weakness and areflexia; Miller-Fischer variant starts centrally (areflexia, ataxia, opthalmoplegia with III/IV/VI affected). Also has autonomic dysfunction (tx brady with atropine; use short acting for hypertension, fluids for hypotension) Diagnosis: CSF elevated protein, normal glucose and WBC Complications: respiratory compromise req'ing intubation if FVC <20ml/kg or NIF <30mL/kg Treatment: IVIg or plasmaphoresis
	Myasthenia Gravis: Cause, Presentation, Diagnosis, Complications, Treatment	Cause: Antibodies to post-synaptic ACh receptors (take spots & destroy them) Presentation: Ptosis, Diplopia, Dysarthria, Dysphagia, Blurred vision with spared pupils, resp failure. Treated patients can present with cholinergic crisis. Diagnosis: Tensilon test, ice to eyes, NIF (<15 intubate)/FVC (<15 intubate); check for anti-AChR antibodies Treatment: Plasma exchange or IVIg (neostigmine and/or thymectomy for chronic); intubate with cisatracurium (Hoffman degradation)
	DDx of bulbar neuropathy	-Myasthenia gravis -Lambert-Eaton myasthenic syndrome -ALS -Miller-Fisher variant GBS -Elapidae (coral snake) or Hydraphidae (sea snake) envenomation -Botulism -Lyme disease -Organophosphate poisoning -Congenital syndrome -Penicillamine toxicity
	How can Tick Paralysis and GBS be distinguished?	-Both generally ascending paralysis -Finding/not finding an Ixodes tick attached -Tick paralysis has pupillary dilation while GBS does not
	Gram stain results of bacteria	Staph: Gram+ cocci in singles, doubles, tetrads or clusters Strep: Gram+ paired diplococci (other strep in pairs/chains) Listeria: Gram+ single or chains Moraxella caterrhalis: Gram- diplococci Neisseria: Gram- paired diplococci H Flu: Gram- coccobacilli E Coli: Gram- rods Pseudomonas: Gram- rods
	Angina Classification	Canadian Cardiovascular Society I - No limitation of ordinary activity II - Mild limitation. Symptoms at >1-2 blocks or >1 flight of stairs. III - Moderate limitation. Symptoms at <1-2 blocks or <1 flight of stairs. IV - Severe limitation. Symptoms at rest.
	Definition of stable angina	Predictable Transient (<15m) Reproducible with activity Relieved with rest/nitro
	Definition of acute MI	-Rise and fall of troponin with: ischemic symptoms, Q waves, ST/T changes, coronary artery intervention -Pathological evidence
	Types of myocardial infarction	I - ischemia due to a primary coronary event (plaque rupture or dissection) II - supply-demand ischemia III - sudden cardiac death with symptoms of MI IV - MI with coronary instrumentation V - MI with CABG
	At risk for an atypical presentation of MI	Aunt Jemima with dementia -Elderly -Diabetic (from all the syrup) -Non-white -Female -Dementia -Hyperlipidemia (from all the sausages) Also: No prior history of MI, history of stroke, /CHF, no family history
	Liver transplant criteria in acetaminophen-induced and non-acetaminophen-induced fulminant hepatic failure (King's College criteria)	Acetaminophen induced pH <7.3 or lactate >3 after 12h of resuscitation Lactate >3.5 after 4h of resuscitation OR all 3 of: -Cr >300 -INR >6.5 -Grade 3-4 hepatic encephalopathy Non-acetaminophen induced INR >6.5 OR 3/5 of: J aundice >1 week prior to encephalopathy A ge <10 or >40 N on-A non-B hepatitis E tiology: indeterminate or drug reaction B ilirubin >300mmol/L I NR >3.5
	Sgarbossa Criteria	In setting of LBBB, the criteria for calling AMI is >3 points: >1mm concordant STE (OR 25, 5 points) >1mm STD in v1, v2, v3 (OR 6, 3 points) >5mm discordant STE (OR 4.3, 2 points) Also look at ST (baseline to T) / S (top of S to baseline) ratio <-0.25
	Classification of AMI severity	Killip classes 1 no failure 2 crackles, S3, elevated JVP 3 frank pulmonary edema 4 cardiogenic shock, hypotension, vasoconstriction (oligurea & cyanosis)
	What are the target times for ACS?	Door Data (10m) Decision Drug (lytic 30m, PCI 90m in center)
	What is the Ashman phenomenom?	-Seen in supraventricular tachyarrhythmias (generally AFib) -Long R-R interval (has long refractory period) followed by a short R-R interval results in part of the right bundle being refractory -Get a RBBB waveform that looks like a PVC
	Mechanisms for arrhythmias	-Increased automaticity (ischemia, electrolytes, drugs) -Reentry (req's 2 conduction pathways with different responsiveness and conduction speed) -Triggered (early afterpolarizations in brady/long QTc; treat by increasing HR vs late afterpolarizations in tachy/increased Ca; treat by slowing HR and decreasing Ca)
	Antiarrhythmic types/actions	Some Buggers Kill Cats S odium channel blocker (a block fast, b block inactivated phase, c block both) - procainamide/TCA/cocaine, lidocaine/phenytoin, flecainide/dilantin B eta blocker - propranolol/esmolol K potassium channel blocker - amiodarone/sotalol C alcium channel blocker (slow) - verapamil/diltiazam
	How does Digoxin work?	1 - Blocks Na/K ATPase leading to increased intracellular Ca++ (increased inotropy, tachyarrhythmias) 2 - Increases vagal tone (anti-arrhythmic, bradyarrhythmias)
	Non-compensatory pause vs compensatory pause	Non-compensatory pause: sinus node is reset and beat following the aberrant beat occurs at the same R-R interval as it would have if it came after a regular beat. Compensatory pause: sinus node is NOT reset. One sinus beat is not conducted (meets refractory AVN) and the next is. The next beat comes after exactly 2x the standard R-R interval.
	DDx for irregular SVT	-AFib -MAT -Atrial flutter/tachy with variable conduction -Parasystole -Extrasystoles
	Contraindications to ED Cardioversion of AFib	1 - Lasted > 48 hours 2 - Rheumatic heart disease 3 - Mechanical valve 4 - History of stroke/TIA
	Risk stratification for AFib - who needs anticoagulation?	CHADS2 C HF H ypertension A ge > 75 D iabetes S troke before (worth 2 points) 0 = ASA; 1 = ASA or anticoagulant (anticoagulant preferred); 2 = anticoagulant
	Strong predictors of VT in a rapid wide-complex tachycardia	-AV Dissociation -Fusion beats -Capture beats -QRS >0.14 -Extreme left axis Brugada and Griffith criteria are too unreliable for use and likely cause harm
	Congenital vs Adult Torsades	Congenital: precipitated by tachycardia, catacholamine excess, and delayed afterpolarization, treat with beta blockers, associated with Romano-Ward syndrome and Jervall & Lange Nielson syndrome Adult: precipitated by bradycardia, early afterpolarization, treat with beta agonists, associated with drugs
	Drugs that prolong QT	Antidysrhythmics Ia, Ic, III: procainamide, propafenone, amiodarone Antibiotics: azithromycin, ciprofloxacin Antipsychotics: haloperidol Antiemetics: ondansetron, metoclopramide Anticonvulsants: Antihistamines: Antifungals: Antimalarials: chloroquine Antidepressants: TCA, citalopram Analgesia: Methadone Also, hypoCa, hypoMg, hypoK
	Effect and indications for use of a magnet on a pacemaker	Changes a standard pacemaker to VOO mode and turns off defibrillation in an ICD/pacemaker -Atrial tachycardia with rapid ventricular rate -Runaway pacemaker (re-entry tachycardia) -Bradycardia due to oversensing
	Causes of ICD malfunction	Frequent shocks -Shocking SVT -Oversensing T waves -Having frequent VF/VT (hypoK, hypoMg, Ischemia, drug-induced) Inadequate shocks (dizzy/syncope) -Undersensing VT -Shocks not strong enough -Inadequate backup pacing for brady Cardiac arrest -Likely VF did not respond to defibrillation -May have not detected VF (change parameters)
	Anemia differential approach	Decreased production -Lack of stimulation (renal disease, chronic disease) -Unfunctional marrow (infiltrative disease: amyloid, metastasis; marrow disorders: aplastic, myelofibrosis; blood cancers: lymphoma, leukemia; tox: heavy metals, clozapine) -Lack components (B12, Folate, Fe) Increased destruction -Intravascular (mechanical: prosthetics and microangiopathic DIC/TTP; transfusion reaction: ABO, antibodies; defects: G6PD, sickling) -Extravascular (abnormal RBC: spherocytosis, thalassemia)
	Causes of sideroblastic anemia	Impaired production of porphoryn; leads to anemia and excess Fe in RBC's (Fe ring in sideroblasts) -Toxins: Lead, Alcohol & INH -Premalignant condition in elderly (often get AML) -Malignancy -RA -Pyridoxime deficiency
	Paroxysmal nocturnal hemglobinuria	Definition - Stem cell defect with abnormal sensitivity of RBCs, neutrophils and platelets to complement Diagnosis - Get hemosiderinurea, low RBC/Plt/Neutrophils, chronic hemolysis -Luekocyte alkanine phosphatase levels are elevated -Complications: thrombosis of arteries and hepatic vein. Also MUST transfuse with WASHED RBC's or compliment on them will lead to lysis.
	Encapsulated bacteria	SSome Nasty Killers Have Capsular Protection S trep pneumoniae S almonella typhi N eisseria meningitidis K lebsiella pneumoniae H aemophilus influenzae C ryptococcus neoformans P seudomonas aeruginosa
	Equipment required for a neonatal resuscitation	Be prepared for baby WOBLIS W armer / polyethylene bag - all babies O xygen (blended) - for persistent hypoxia B ag and mask - if HR<100, gasping, apnea give 40-60 bpm with PPV L aryngoscope and ETT - for meconium suctioning, ineffective/prolonged BVM, chest compressions I ncubator for transport S uction
	Does the baby need resuscitation?	Term? Breathing or crying? Muscle tone? If yes, no resuscitation needed
	Neonatal CPR	CPR is indicated if the infant's HR is <60bpm despite 30s of adequate PPV. Chest compression rate is 90/minute Breathing rate is 30/minute (q 3 chest compressions) Epinephrine is used if HR <60bpm after 30s of CPR (dose 0.1-0.3mL/kg of 1:10,000 epi IV)
	When should an infant not be resuscitated?	-<23 weeks -<400g birth weight -Anencephaly -Known chromosomal abnormalities incompatible with life (trisomy 13 or 18) -Stop resuscitation at 10m if there has been no HR or respiratory effort
	Causes of ascending paralysis	Goes BOTTOM VP G BS B uckthorn / B-virus (Herpes Simiae) O rganophosphate T ick paralysis T oxic neuropathies (DM, EtOH, B-vitamin deficiencies, Buckthorn) M etabolic (hyperkalemic periodic paralysis) V iral (Rabies, CNS VZV/CMV, West Nile) P olio
	Causes of hemolytic anemia (low haptoglobin, high LDH)	Intrinsic: -Enzymes (Pyruvate Kinase or G6PD) -Membrane (Spherocytosis, Elliptocytosis, PNH) -Heme (Thallasemia, Sickle Cell) Extrinsic -Mechanical (Microangiopathic - DIC/TTP/HUS/Vasculitis/Preeclampsia) -Other (valves, march) -Immunologic --> Alloimmune (ABO IgM intravasc / Rh IgG extravasc) --> Autoimmune (Reticular neoplasms [CML, CLL, lymphoma, myeloma], Inflammatory (SLE/RA/PAN/UC), Drugs (quinine, quinidine, methyldopa, PCN/cephalosporins, sulfa), Infectious (CMV/EBV/Mycoplasma/Coxsackie/Hepatitis), Thyroid, Environmental (hyperthermia, brown recluse bites, freshwater drowning, burns, snakes, malaria) Abnormal sequestration (hypersplenism)
	Pentad of TTP	CRAFTY C NS changes (fluctuating seizures, paresthesias, altered LOC) R enal failure (ARI, hematuria, proteinuria) A nemia (microangiopathic hemolytic with schistocytes) F ever T hrombocytopenia (Plts 10-50)
	Erythema nodosum	BELTY SLIPS B ehcets E strogen L ofgran's T B Y = V iral (#2) S trep (#1) L ymphoma (NHL) and Leukemia I BD P CN S ulpha
	Define and give a DDx for ALTE	ALTE is an acute, unexpected change in an infant's breathing (apnea or gagging), appearance (color change), or behavior (loss of muscle tone) that frightens the observer. Prevalence peaks at 10-12 weeks but can occur in children <1yo. -Neuro - Seizures/Hydrocephalus -Cardiac - Arrhythmia, Congenital heart disease -Respiratory tract infection (Pertussis, RSV) -GI - GERD (Sandifer syndrome) -Metabolic - Hypoglycemia, inborn errors of metabolism, hyponatremia -Sepsis - pneumonia, UTI -Heme - anemia -NAT -Factitious illness -Toxins
	HUS vs TTP vs DIC	HUS -Caused by Shiga toxin of O157:H7 -Renal symptoms predominate -Consumptive (elevated DDimer decreased haptoglobin but normal LDH) -Children with bloody diarrhea -Plasmapheresis ineffective TTP -Caused by lack of ADAMTS13 (? autoimmune) not cleaving vWF precursor -Neuro symptoms predominate -Adults -Non-consumptive (normal DDimer/Haptoglobin/fibrinogen but elevated LDH) -Schistocytes -Treat with plasmaphoresis or plasma exchange DIC -Consumptive: low fibrinogin and fibrin levels; high DDimer -Bleeding and clotting at the same time; ultimately bleed when factors gone -Schistocytes, anemia, thrombocytopenia -Caused by multiple underlying disorders
	Treatment options in patients with vWD	1 - Tranexamic acid or Aminocaproic acid (plasmin inhibitors - 5g po/iv) 2 - DDAVP (releases vWF and F8 from endothelium - 0.3mcg/kg SC/IV or 1.5mg nasal spray x 2) 3 - Humate-P F8 concentrate (need to ensure it has enough vWF) 4 - Cryoprecipitate (not recommended due to potential for viral transmission)
	Describe how factors should be replaced in Hemophilia A and B	Can empirically use 15-20mL/kg FFP (40mL/kg replaces 100% of all factors). -Cryo contains F8. DDAVP releases F8 -Cryo-poor plasma contains F9. -aF7 bypasses both Generally use F8 & F9 concentrate, respectively. Give 0.5IU/kg/% activity needed for F8 Give 1IU/kg/% activity needed for F9 INITIAL goals: Mild ~30%, Moderate ~50%, Life-threatening >90%; repeat dosing needed for F8 (q8-12h) and F9 (q18-24h) -Minor bruising/lacerations - 40% -Dental work /severe epistaxis/renal/deep lac - 50% -Deep muscle (e.g. iliopsoas)/CNS/Throat/GI/major surgery - 80-100%
	Bleeding reversal agents for Aspirin, Clopidogrel, Ticegralor, Warfarin, UFH, LMWH, Dabigatran, Rivaroxaban, Apixaban, t-PA/lytic	Aspirin: DDAVP for minor, platelets for major Clopidogrel/Ticegralor: DDAVP for minor, platelets for major Warfarin: Depends. Hold if not bleeding. Hold + vit K po if have time. Hold + vit K IV + FFP (15mL/kg or 2-4U) OR PCC 50IU/kg UFH: Protamine sulfate 1mg per 100U LMWH: Protamine sulfate 1mg per 1mg Dabigatran: PCC 50IU/kg, try FEIBA, vitamin K, Tranexamic acid (1g IV), dialysis (only 33% protein bound); send TT (thrombin time to confirm cause) Rivaroxaban/Apixaban: PCC 50IU/kg; try tranexamic acid (1g IV), NO dialysis; send anti-Xa level to confirm cause t-PA/thrombolytic: FFP 2U q6h x 4; Cryoprecipitate x 10U; Tranexamic Acid 1g; Platelets 1 adult; DDAVP 0.3mcg/kg IV; Protamine to reverse any heparin; treat ICP; be prepared to treat seizures
	Causes of heart failure	HEART FAILED H ypertension E ndocarditis / E nvironment (heat wave A nemia R heumatic heart disease T hyrotoxicosis F ailure to take meds A rrhythmia I nfection / I schemia / I nfarction L ung (COPD, PE, Pneumonia) E ndocrine (Pheochromocytoma / Hyperaldosteronism) D ietary indiscretions (salt / fluid)
	Heart failure classes	NYHA Functional classes for CHF I - Asymptomatic with ordinary physical activity II - Symptomatic with ordinary physical activity III - Symptomatic with less than ordinary physical activity IV - Symptomatic at rest
	Organisms responsible for endocarditis	Staph aureus (especially in right sided / IVDU) Strep viridans Strep bovis (association with GI malignancies) Enterococcus (add vanco and watch for resistance) HACEK - haemophilus atrophilus, actinobacilus, cardiobacterium hominus, eikenella corrdons, kingella kingae (often chronic IE, hard to culture) Immunocompromised fungal - Candida/Aspirgillus
	ECG changes of pericarditis and how are they different than MI	1 - PR depression and diffuse STE (hours to days) 2 - Normalization of ST segments and flattening of T waves 3 - Deep, symmetrical T wave inversion 4 - ECG reverts to normal (sometimes T waves remain inverted) Different than MI: non-anatomic pattern, concave up, no Q waves, no dynamic worsening
	Distinguishing murmur of AS vs HOCM	AS is more likely to have insufficiency on top of other findings. Valsalva (increased intrathoracic pressure decreases pre and afterload) - HCM louder and AS quieter Squat (increased SVR increases pre and afterload) - HCM quieter and AS louder
	Prognostic factors for pancreatitis	Ranson criteria (on admission) - mortality for 1-2 = 1%; 3-4 = 15%; 5 = 50% Non-gallstone / Gallstone A GALL A ge >55yo / >70yo G lucose >11 / >12 A ST >250 / >250 L DH >350 / >400 L eukocytes >16 / >18 BISAP score Urea > 8.92 Impaired mental status >2 SIRS criteria Age >60 Pleural effusion
	Transfer to a burn center	-Partial thickness burn 10% BSA (2nd degree) -Any 3rd degree burn -Burns to face, hands, feet, genitalia, perinium, joints -Electrical burn (including lightning) -Chemical burn -Inhalational burn -Pre-existing medical conditions that complicate management -Children at a location that can not care for children -Cocomitent burn and trauma where the burn is the greatest danger -Burn injury in patients requiring social, emotional, rehabilitative intervention
	Dive injuries	On descent -Ear barotrauma (inner, middle, external) -Mask squeeze (facial barotrauma) -Sinus barotrauma At depth -Oxygen toxicity -Contaminated gases -Hypothermia -Nitrogen narcosis On ascent -Alternobaric vertigo -AGE -Pneumothorax/ Pneumomediastinum/ Pulmonary hemorrhage -GI barotrauma -Barodontalgia
	Dive injuries requiring a recompression chamber	-AGE -DCS I and II -Contaminated gases (CO)
	Arterial embolism vs thrombosis	Embolism -Source of emboli -Sharp demarcation (no collaterals) Thrombosis -History of claudication -Contralateral findings of partial occlusion -Diffuse atherosclerosis (lots of collaterals)
	Causes of CVL obstruction	Complete -Clots -Precipitant -Mechanical obstruction Withdrawl -Against vessel wall -Vein thrombosis -Fibrin sheath -Ball-valve thrombus Intermittent -Pinching between clavicle and 1st rib
	Well's DVT Criteria	DImPLES and the 3 C's (-2 points if an alternative diagnosis is as likely) - Likely if 2 or more D VT previously I mmobilization (paralysis, plaster) P ain (along deep venous system) L eg swelling (entire leg) P itting edema (to only the affected leg) S urgery (last 3m) C ancer (palliative or treated in past 6m) C alf swelling (>3cm circumference difference C ollateral veins (visible and nonvaricose)
	Well's PE Criteria	Likely if 4 or more D VT signs and symptoms A lternative less likely M alignancy P revious P E/DVT H emoptysis I mmobilization hR > 100
	Contraindications for fibrinolytic in STEMI and PE	1-Dissection? Stroke 2-Prior ICH? 3-Ischemic stroke in last 3m? Bleed 4-Known vascular lesion? (AVM) 5-Known intracelebral neoplasm? 6-Significant head/facial trauma in last 3m? Can't Clot 7-Active bleeding 8-Bleeding diatheses?
	Gas laws (Pascal, Boyle, Charles, Dalton, Henry)	Pascal - Pressure on a fluid is transmitted equally throughout Boyle - P1V2 = P2V2 Charles - V1/T1 = V2/T2 Dalton - Pt = P1 + P2 + P3 ... Henry - The amount of gas dissolved in a liquid (solubility) is proportional to the partial pressure of that gas above the liquid
	Reasons to modify the dose of adenosine	-Patient weight (obese, pediatrics), need more or less -Heart transplant (don't use it) -Methylxanthines (theophylline) stimulates receptors, need more -Carbamezapine, needs less -Dipyradamole prevents breakdown, needs less -CVL delivery, need less
	Causes of priapism	Medical conditions -Sickle cell -Leukemia -Spinal cord injury -G6PD deficiency -Thalassemia Medications -ED - papaverine and PGE-1 -Phosphodiesterase inhibitors - sildenafil -Antipsychotics - chlorpromazine, clozapine -Antidepressants - SSRI's - trazodone -HTN - HCTZ -Mood/convulsant - Valproic acid -Recreational - alcohol, cocaine, amphetamines, heroin
	Toxic levels: ASA, APAP, Iron, Digoxin, Lithium, Methanol, Ethylene Glycol, TCA	ASA Dose: 200mg/kg dose Level: Acute >7mmol/L; Chronic >3.5mmol/L APAP Dose: 200mg/kg/24h dose; >150mg/kg/d for 48h; >100mg/kg/d for 72h Level: >1000mmol/L Iron Dose: 20-40mg/kg (mild); 40-60mg/kg (mod); >60mg/kg (severe) Level: >90mmol/L Digoxin Dose: 0.1mg/kg Level: >19mmol/L acute; >12mmol/L chronic Lithium Level: >4mmoL/L acute; >2.5mmoL/L chronic Methanol Dose: 0.15mL/kg Level: >6mmol/L toxic; >15mmol/L HD Ethylene Glycol Dose: 0.2mL/kg Level: >3mmol/L toxic; >8mmol/L HD TCA Dose: >5mg/kg
	Contrast Dilated, Hypertrophic, Restrictive, Takotsubo, Peripartum Cardiomyopathies (cause, treatment)	Dilated: Mostly idiopathic but caused by ethanol, smoking, HTN, pregnancy, infection (myocarditis). Treated with pre and afterload reduction (ACEi, diuretics, PPV) Hypertrophic: Caused by HOCM, AS, CAD, HTN. Treated with afterload reduction (BB). Must maintain preload! Restrictive: Caused by amyloidosis, sarcoidosis, hemochromatosis, scleroderma, radiation, glycoven-storage diseases (Fabry/Gaucher). Treat underlying cause. Optimize preload (fluids). Takotsubo: Caused by ? stress hormones. Treat as MI (indistinguishable from anterior STEMI) then BB and ACEi until recovery. Peripartum: Caused by pregnancy (3 months before delivery to 6 months after). Treat afterload (hydralazine/labetolol until delivery, ACEi/BB after), preload (nitro), and contractility (digoxin) until recovery.
	Arteriosclerosis obliterans vs Thromboangiitis obliterans	Arteriosclerosis: blue toe syndrome, claudication, ischemic rest pain in an elderly (>50) vasculopath (DM, smoker, HTN, cholesterol). Requires intervention if they have pain at rest. Can have distal ulcers. Thromboangiitis: aka Buerger's disease, get painful erythematous nodules and decreased pulse in peripheral arteries. Only most commonly in male smokers 20-40yo and cure is stopping smoking completely.
	Distinguish vasogenic skin ulcers	Arterial - distal to ankle, shiny, hairless, unswollen skin and thick nails. Less painful when dependent. Venous - proximal to ankle, ++ swelling, weaping. Less painful when elevated. Neurotrophic - sites of repeated trauma that they don't feel. Heels, toes, plantar surface. Not painful. Hypertensive - on lateral malleolus, hemorrhagic bleb becomes an ulcer. Very painful.
	Vascular complications of IV drug use	AV fistula and pseudoaneurysms (from 'hitting pink') Unilateral hand edema (obliteration of superficial venous circulation) Distal ischemia (severe burning pain distal to injections; possibly FB, talc, precipitate - nothing works to fix it; can need amputation) Infected pseudoaneurysm (infected mass after hitting artery, reason that we assess abcesses for pulsatility)
	Extensive ileofemoral DVT: Names and diagnosis	Phlegmasia Cerulia Dolens - swollen, congested, painful, cyanotic leg due to iliofemoral occlusion. Treat with thrombectomy. Phlegmasia Alba Dolens - painful white leg secondary to arterial spasm that results from iliofemoral occlusion. Looks like arterial occlusion. Worse then cerulia. Treat with thrombectomy.
	APGAR Score	A ppearance (pink, acrocyanosis, cyanosis) P ulse (>100, <100, absent) G rimace (sneeze/cough/pull away, grimace, no response) A ctivity (active, arms/legs flexed, limp) R espirations (good crying, weak cry, absent)
	Diagnosis and management of oncologic emergencies: febrile neutropenia, SVC syndrome, Tumor lysis syndrome, Hyperviscosity syndrome, Hypercalcemia	Febrile neutropenia: Temp >38.3 (x1) or 38.0 (x1h) with ANC<1 or expected <0.5 (biggest drop 5-10 days post chemo). NO rectal temps. Treat with Tazocin x 14d if stable + vanco/gent if not stable. SVC syndrome: Present with periorbital edema, plethora, facial swelling, arm swelling, dyspnea. Diagnose with CT. Treat with radiation/chemo or stent (stent best). Tumor lysis syndrome: See hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia. Treat with IVF +/- urinary alkalinization if acidic +/- dialysis. Can also try rasburicase with consultations. Allopurinol can prevent but not treat. Hyperviscosity syndrome: Lab can't run tests. Happens with MM, Waldenstrom's Macroglobulinemia, Leukemia. Present with CNS/vision changes. Treat with exchange transfusion, plasma/leukopheresis. Hypercalcemia: Due to mets or parthyroid-like hormone. Treat with hydration, furosemide, bisphosphonates, calcitonin.
	Indications for dialysis in tumor lysis syndrome	Phosphate >3.2 Potassium >6 Uric acid >590 Creatinine >880 Volume overload Symptomatic hypocalcemia
	Synovial fluid interpretation (Color, Viscosity, WBC/mm3, Differential, Culture)
	Special tests for the shoulder (Jobe, Drop arm, Neer's, Hawkin's, Painful arc, Lift off, Lift off lag, Yergason's, Speed's)	Supraspinatus Jobe's: 90 degrees abd, 30 degrees anterior to coronal plane, internally rotated/pronated - weakness or pain = supraspinatus involvement. Drop arm test: passive abduction to 90 degrees. If can't be maintained, possible large supraspinatus tear. Supraspinatus/Impingement Neer's: Hand stabilizing scapula, passive flexion to 180 degrees. Pain towards 180 degrees indicates impingement. Hawkin's: imagine a hawk being held on an arm (90-90 flexion at shoulder/elbow) then internally rotate and see if there is pain. Indicates impingement. Subacromial bursitis Painful arc: Abduction with pain from 70-100 degrees indicates subacromial bursitis. Subscapularis Lift off test: assess for tear by putting internally rotated hand on back, holding elbow, and getting patient to lift off. Lift off lag: assess for rupture by doing same but passively lifting off and seeing if patient can maintain. Biceps Yergason's sign: Flex elbow to 90 and have patient try to supinate against resistance. Pain is positive. Speed's test: Extend elbow and supinate forearm. Flex shoulder against resistance. Pain is positive.
	Types of hypersensitivity reactions	ACID I A naphylaxis - IgE-mediated degranulation of mast cells and basophils II C ytotoxic - IgG mediated complex fixation III I mmune complex - IgG or IgM antigen-antibody complex deposition IV D elayed - T cell mediated
	Causes of cavitating lesions	CAVITY C ancer (metastasis) A utoimmune (Wegener's granulomatosis, Rheumatoid Arthritis) V ascular (emboli, infarction) I nfection (TB, MRSA, SA, Klebsiella, Fungal) T rauma (pneumatocele) Y outh (congenital things; bronchogenic cyst)
	Treatment of common Tinea (capitis/barbae, kereon, versicolour, unguinum, pedis, other)	Tinea capitis/barbae: Itraconazole 250mg po od x 4/52; Selenium Sulphide shampoo 2x weekly Kerion: As per tinea, plus Keflex 500mg po qid (if infected) and Prednisone 1mg/kg/d x 1/52 Tinea versicolour (Malassezia Furfur): Selenium Suphide shampoo (q monthly for prophylaxis) +/- Fluconazole 400mg po x 1 Tinea unguinum: Penlac (antifungal painted on nail) trial; Ketoconazole 200mg po od x 6 months +/- surgical nail removal Tinea pedis: Clotrimazole 1% bid x 6 weeks Tinea (other areas): Clotrimazole 1% bid x 3 weeks
	Treatment of candidiasis (Thrush, Cutaneous, Vulvovaginal)	Thrush: Adults Nystatin (100,000U/kg) swish and spit 5mL po qid until resolved x 1/52. Infants the same but 'paint the mouth' qid x 7 days. Fluconazole if immunocompromised. Cutaneous: Dry regularly, zinc oxide prn, 1% hydrocortisone prn, Nystatin (100,000U/kg) cream bid-qid OR Clotrimazole 1% qid x 6/52. Can also use Fluconazole 100mg od x 2/52. Vulvovaginal: Clotrimazole intravaginal OTC. Can also use Fluconazole 150mg po x 1.
	Indications for emergent decompression of a subdural hematoma	-Midline shift >5mm ->1cm thick -GCS decreased by 2 or more since the time of the injury -Fixed dilated pupils -ICP >20mmHg
	Define SIDS, apnea, pathological apnea, apnea of infancy, apnea of prematurity, periodic breathing	SIDS: sudden infant death in a child without historical, physical, laboratory, or postmortem findings that explain the death. Peaks at 3-5 months (90% <6 months) Apnea: cessation of air flow (central, obstructive, mixed) Pathologic apnea: apnea lasting >20s with bradycardia, cyanosis, hypotonia Apnea of infancy: pathologic apnea with no identifiable cause Apnea of prematurity: pathologic apnea associated with pre-term delivery (generally resolves by 37 weeks) Periodic breathing: breathing pattern with 3 or more pauses each lasting >3s with 20s of normal breathing surrounding them.
	Gout vs Pseudogout (crystals, risks, treatment)	Gout -Negatively birefringent needle urate crystals -Risks: obesity, DM, HTN, diuretics, alcohol, meat, seafood, beer, legumes -Treat: allopurinal (production), probenacid (excretion) chronically; colchicine 1.2/0.6/0.6, NSAIDS, steroids acutely Pseudogout -Positively birefringent rhomboid calcium pyrophosphate crystals -Risks: hyperparathyroid, hypothyroid, hypoMg, hypoPO4, Wilson's, Hemochromatosis -Treat: As for gout except steroids > NSAIDs/Colchicine; also treat underlying cause but does not affect course.
	What is Still's disease? Treatment?	Multisystem inflammatory disorder characterized by fever, arthritis, sore throat, myalgias, pericarditis, hepatitis, splenomegaly, and salmon colored rash that occurs ONLY with the fever. Treat with NSAIDs, Steroids, IVIg
	What are the seronegative spondyloarthropathies?	-They are RF NEGATIVE and HLA B27 POSITIVE . Generally involve the axial skeleton (not extremities) PAIRS - P soriatic arthritis (affects smaller joints, sausage fingers and psoriasis) A nkylising spondylitis (males, back pain, sacroiliitis, bamboo spine) I nflammatory bowel disease R eiters syndrome / reactive arthritis (post GU chlamydia or GI shigella, salmonella, campylobacter, yersinia infection)
	Medial and lateral epicondylitis	Medial - Pitcher's/Golfer's Elbow -Flex wrist then try to pronate against resistance - pain to medial epicondyle Lateral - Tennis -Extend and supinate wrist then try to flex against resistance - pain to the lateral epicondyle (Cozun test) Both - treat with rest, RICE, PT
	Criteria for the diagnosis of lupus	Require 4/11 ANA is quite sensitive (good rule-out); anti-DS-DNA & anti-Sm are quite specific (good rule-in) -Malar rash -Discoid rash -Oral ulcers -Photosensitivity -Nonerosive polyarthritis -Serositis (pericardial or pleural effusion) -Renal disorder (nephrotic or nephritic) -Neurologic disorder (seizures or psychosis nos) Hematologic disorder (low Hb, WBC, platelets) -Immunologic disorder (anti-dsdna, anti-sm, LAC, anticardiolpin, false + syphilis serology) -Positive ANA
	Drugs that cause drug-induced lupus	Cardiac: procainamide, amiodarone HTN: hydralazine, methyldopa Antimalarial: quinidine Antimicrobial: nitrofurantoin, penicillin, INH, sulfonamides, tetracycline Anticonvulsant: phenytoin Antithyroid: PTU Antipsychotic: lithium, chlorpromazine Gout: allopurinol
	Diagnostic criteria for giant cell arteritis	If you have 2 treat and get biopsy, if you have 3 just treat. 1 - >50yo 2 - new onset localized headache 3 - ESR >50 4 - abnormal biopsy with mononuclear infiltration or granulomatous inflammation
	Vasculitis classification and key features	Large vessel: -Takasayu's - pulseless disease, renovascular hypertension -Giant cell - temporal artery headache, amaerosus fugax Medium vessel: -Polyarteritis nodosa - mostly CNS/GI necrotizing arteritis, no venous involvement, non-granulomatous, palpable purpura, hypergammaglobulinemia, ANCA negative -Buerger's disease - aka thromboangiitis obliterans, 20-40yo male smokers, painful dark phlebitis migrans nodules -Kawasaki disease - Warm CREAM, pediatrics Small vessel -Goodpasture's - anti-GBM antibody +, alveolar hemorrhage, glomerulonephritis (RPGN). c-ANCA negative (unlike Wegener's) -Microscopic polyangitis - alveolar hemorrhage, glomerulonephritis, nerve involvement. NOT granulomatous (unlike Wegener's). p-ANCA+ (unlike Goodpasture's) -Wegener's granulomatosis - necrotizing granulomatous with upper resp (sinusitis, otitis, ulcers, tracheal stenosis), lower resp (bilat nodular infiltrates with cavitation), renal (RPGN), can have multiple other sx's, c-ANCA + -Churg-Strauss - asthma attacks, allergic rhinitis, eosinophilia. Constrictive pericarditis. -Behcet's - uveitis (also optic neuritis, iritis), apthous ulcers, genital ulcers. -HSP - IgA mediated hypersensitivity vasculitis mostly in <20yo. Fever, lower extremity palpable purpura, abd pain (occasionally intussusception), glomerulonephritis, arthralgias. Treatment for all is a combo of steroids, plasmapheresis, cyclophosphamide
	What is serum sickness (pathophys, cause, presentation, treatment)?	-Type III hypersensitivity response with immune-complex complement fixation in vessel walls. -Associated with penicillin, sulpha, NSAIDs -Get erythema to fingers/toes, then urticaria, lymphadenopathy, arthralgias, constitutional symptoms 7-21 days after exposure. -Give steroids if severe
	DDx for target lesions	Pityriasis rosea (herald patch with salmon colored central clearing) Tinea corporis (very well defined) Erythema multiforme (dark center, clearing, dark halo) Urticaria (raised, migratory) Erythema marginatum (dark center, clearing, dark halo similar to multiforme but there is only 1 and it is much bigger) Secondary syphilis
	MRSA risk factors	J ail S ports H omeless / H ealthcare I VDU R esidence C rowded
	Antibiotics effective against MRSA	Clindamycin Septra Doxycycline Vancomycin Linezolid Cefepime Ceftobiprole Daptomycin Tigecycline
	Measles vs Rubella	Both present with viral exanthems and should get MMR -Measles is highly contagious and classically presents with cough, coryza, conjunctivitis, and Koplic spots. Treat with Ig. Measles rash starts on hand and feet. -Rubella presents with rash, fever and lymphadenopathy with a rash that goes face to trunk.
	Treatment of pediculitis (lice) and scabies	Both -Simultaneously treat the patient, sexual partners, family members, clothing, furniture and homes -Clothes should be washed in hot water and dried in a hot dryer. Other things can be frozen for 5 days. Lice -Permethrin (Nix) 1% shampoo for 10m on day 1 and 8 while avoiding conditioner for 2 weeks Scabies -Permethrin 5% cream applied for 8-14h on day 1 and 8
	Syphilis (Stages, Diagnosis, Treatment)	Stages -Primary - painless chancre (papule -> 1cm ulcer) with painless lymphadenopathy -Secondary - 6 weeks to 6 months post-exposure, symmetrical non-pruritic macular/papular rash to palms and soles, can have condyloma lata around genitals, fatigue, lymphadenopathy, exanthem, myalgia, pharyngitis -Latent - Nil -Tertiary - gummas, granulomatous ulcerative lesions on skin, liver, bones, brain Treatment -VDRL is positive after primary syphilis. Used for screening (false positives in SLE, thyroiditis, lymphoma, post-vaccine, mycoplasma, mono, hepatitis, measles, malaria, pregnancy) -FTA used for diagnosis (flouresence treponomal antibody test) Treatment -Primary & secondary: Benzathine penicillin 2.4 million U IM; VDRL goes non-reactive after ~12 months -Persistent or tertiary: treat weekly -Watch for Jerisch Herscheimer reaction
	Pemphigus vulgaris vs bullous pemphigoid	PV -Autoimmune reaction affecting patients 50-60yo generally on penicillamine, captopril or rifampim -Present with oral bullae -> painful ulcers then skin bullae -> painful ulcers -Diagnose with history, + Nikolski sign, + Tzank smear -Treat with high dose prednisone (100-300mg/d), immunosuppresants, plasmapheresis BP -IgG autoimmune reaction of those ~65yo. Less sick than PV. -Present with tense, fluid-filled blisters and a negative Nikolski sign. Mucous membrane involvement is possible but less frequent than PV. -Treat with prednisone and other immunosuppresants for 2-5 years and it generally resolves.
	Canadian C-Spine Rule
	Indications for dialysis in renal failure	AEIOU A cidosis / A lkalosis (note: HCO3 can precipitate tetany/convulsions in the setting of hypoCa) E lectrolyte abnormalities (HyperK, HyperMg, HyperCa - MM) I ngestions that are dialyzable O verload of fluid (CHF, pulmonary edema, severe HTN) U remia (pericarditis, N/V, lethargy)
	Bacteria causing UTI's	KEEPPSSS K lebsiella (institutionalized, newborns) E nterococcus (institutionalized) E coli (>80% of UTI's) P roteus (3-11yo) P seudomonas S taphylococcus saprophyticus (can be normal skin flora in perineum) S erratia S almonella
	UTI treatment length	Uncomplicated lower tract - 3 days with nitrofurantoin, cefixime, cipro, septra Complicated lower tract - 7 days (diabetes, sickle cell, immunocompromised) with cefixime, cipro, septra Pregnancy lower tract - 10 days with cefixime or nitrofurantoin (avoid near term due to hemolytic anemia) or septra (avoid near term due to hemolytic anemia, jaundice, kernicterus) Upper tract - 10-14 days with cefixime or ceftriaxone
	Types of kidney stones and causes	Calcium oxalate 75% - excess calcium (milk alkali syndrome, high dietary intake, antacids, increased PTH). Oxalate increases in radiation enteritis, IBD, and ethylene glycol ingestion. Struvite 15% - infection with urea-splitting organisms (pseudomonas, proteus, klebsiella, staph) Hyperuricemia 10% - gout, tumor lysis syndrome, hematologic malignancies. they are radioluscent. Cysteine 1% - inborn error of metabolism Struvite, urate, and cysteine stones can form staghorn calculi.
	5 locations of urinary obstruction	Renal calyx UPJ (uretopelvic junction) Pelvic brim UVJ (uretovesicular junction) Vesicular orifice
	Acute scrotal pain / swelling differential and physical exam features	Pain -Testicular torsion - negative cremasteric reflex -Torsion of the testicular appendage (appendix testis or appendix epididymis) - blue dot sign -Epididymitis - Prehn's sign -Trauma -Orchitis -Testicular tumor WITH hemorrhage (normally tumor is not painful) -Inguinal hernia (if incarcerated/strangulated) Swelling -Varicocele (bag of worms) -Ideopathic scrotal edema -Hydrocele
	Causes of varicocele	Venous varicocities of spermatic veins (bag of worms) -Right spermatic vein -> IVC - generally caused by IVC compression or thrombosis -Left spermatic vein -> left renal vein - generally caused by RCC
	Approach to priapism	Determine low (painful) or high (not painful) flow Treatment of low flow ->4h duration requires treatment -Noninvasive tx - walk up stairs (decrease flow to penis), ice packs, compress -PO treatment - terbutaline 5-10mg PO (beta agonist) -Analgesia with dorsal nerve block -Aspiration of cavernosum -Injection of alpha agonist (phenylephrine) or methylene blue -Sicklers get O2 and hydration as well Treatment of high flow -Angiography, surgical shunt, if painful can do block
	Causes of false positive hematuria	Myoglobin Porphyria Bilirubinuria Meds -Nitrofurantoin -Rifampin -Chloroquine/Hydroxychloroquine -Iodine bromide Foods -Food coloring -Beets -Rhubarb -Berries
	Nephrotic vs Nephritic syndrome	Nephrotic - HALEH H ypoalbuminea A lbuminurea (>3.5g/d proteinuria) L ipiduria E dema H yperlipidemia (and clotting - produce increased clotting factors) Nephritic - PHAROH P roteinuria (<3.5g/d) H ematuria (micro or macroscopic) A zotemia (increased urea/Cr) R BC casts O liguria (<400mL/d) H ypertension
	Causes of amenorrhea	-Hypothalamic - exercise, stress, anorexia, hypothalamic tumor, GnRH deficiency -Pituitary - primary hypopituitarism, Sheehan syndrome, pituitary tumor -Ovarian dysfunction - PCOS, gonadal dysgenesis (Turner's), menopause, radiation/chemo -Endocrine - Hyperprolactinemia, hyper/hypothyroidism, Cushing's, hyperandrogenism (PCOS) -Obstruction - imperforate hymen, cervical stenosis
	Definition and causes of menorrhagia and metrorrhagia	Menorrhagia is prolonged (>7d) or heavy (>80cc) bleeding Metrorrhagia is bleeding at irregular intervals (e.g. between periods Non-structural (COTIPE) C oagulopathy O vulatory dysfunction (ovulation, anovulation, exogenous steroids) I atrogenic (OCP) / I nfectious (endometritis, cervicitis, vaginitis) P regnancy (implantation, ectopic, abortion, molar) E ndometriosis E ndocrine (Cushing's) Structural (PLAMT) P olyps L eiomyoma A denomyosis M alignancy (Endometrial / Cervical / Ovarian cancer) T rauma (sexual abuse, foreign body)
	Treatment of unstable (stable) uterine bleeding	-Premarin 25mg IV q4-6h until bleeding stops along with an antiemetic (2.5mg PO bid-qid - follow up with progesterone for normal withdrawal bleeding OR 5-4-3-2-1 regular OCP's/day then 1 pill x 7 days, then 4 day period and restart) -Tranexamic acid 1g IV (1g PO tid-qid while menstrating) -Intrauterine foley to tamponade bleeding -OR - D&C / Hysterectomy
	Causes of false BhCG test	False positive -Post-menopausal (usually <10) -Abortion (x 60 days) -BhCG secreting tumor (hydratiform mole) -Exogenous source (e.g. to induce ovulation) -Incomplete abortion, abortion with 2nd fetus, abortion with heterotopic ectopic False negative -Dilute urine early in gestation
	DDx for hematuria (>5RBC / hpf)	Hematological/Cardiac -Sickle cell (infarcts) -Coagulopathy -Endocarditis Renal -Glomerular - primary glomerulonephritis (post-strep) or secondary glomerulonephritis (HUS, TTP, SLE, PAN, PAN, Wegener's, Goodpastures) -Nonglomerular - trauma, pyelonephritis, AIN, RCC, infarct, AVM, Polycystic Kidneys, Exercise Postrenal -Ureter - stone, TCC -Bladder - trauma, TCC, cystitis -Prostate - prostatitis, BPH, prostate cancer -Urethra - Foley, urethritis False -Myoglobin -Menstration -Traumatic cath -Drugs (rifampin, nitrofurantoin, chloroquine/hydroxychloroquine) -Feeds (beets, berries, food coloring)
	DDx for proteinuria	Glomerular (can be >10g/d) -Nephrotic syndrome, minimal change disease, membranous GN, focal segmental glomerulosclerosis, Post-strep GN, IgA nephropathy Tubular (generally <2g/d) -UTI -AIN -Sickle cell Overflow -Multiple myeloma, Waldenstrom's macroglobulinemia, Amyloidosis Other -Orthostatic proteinuria -Pregnancy -Exertion, stress
	What is ATN and its diagnostic criteria?	Acute Tubular Necrosis -Death of the tubular epithelium of the kidney -Generally caused by toxins (HHS, rhabdo, hemolysis, aminoglycosides, contrast) and hypoperfusion (shock) -See FENa >1%, Urine Na >40
	Requirements for the use of methotrexate in an ectopic pregnancy	-Patient is hemodynamically stable -Tubal mass is <3.5cm -No FHR -No signs of rupture (FF) -BhCG <1200-5000
	Shoulder dystocia: problem, risk factors, diagnosis, treatment	Problem: vertical (rather than oblique) shoulder orientation of fetus (sacropubic) Risk factors: maternal obesity, DM; fetal macrosomia; pregnancy post-date, prolonged 2nd stage Diagnosis: can not deliver either shoulder, turtle sign Treatment: HELPER H elp (obs, anesthesia, neonatal) E pisiotomy (oblique) / E mpty bladder L egs flexed (McRoberts maneuver) P ressure suprapublically to push the anterior shoulder down and to the side E nter vagina (Rubin - post most accessible shoulder toward fetal chest; Woods - rotate 180 degrees Rubin plus spin the opposite hip the other direction) R emove posterior arm (grab hand and sweep arm across the chest and deliver it with the shoulder; can have humerus and brachial plexus injury) Other: -Break the babies clavicle -Symphesotomy
	BLS Termination of Resuscitation	No defibrillation by AED No ROSC prehospital Not witnessed by EMS
	ALS Termination of Resuscitation	No defibrillation No ROSC prehodpitsl Not witnessed by EMS Not witnessed by bystanders No bystander CPR
	Risk factors for death due to asthma	Asthma history -Intubation/ICU admission for asthma -Hospitalized 2 or more times in past year -To ED 3 or more times in past year -Hospitilization/ED visit in past month ->2 MDI canisters of B-agonist/month -Using or withdrawing from corticosteroids -Difficulty perceiving asthma severity/symptoms Social history -Low socioeconomic status -Psychosocial problems -Illicit drug use (especially cocaine/heroin) Comorbidities -Cardiovascular disease -Chronic lung disease -Psychiatric disease
	Definition and classification of COPD	Irreversible, progressive airway destruction secondary to an abnormal inflammatory response. Chronic bronchitis: productive cough for >3 months in the past 2 years; high pCO2 Emphysema: destruction of the lung parenchyma due to imbalance of elastase/antielastase from inflammation; low pCO2 (breath a lot to maintain pO2) 4 classes in the Gold Classification - all have FEV1/FVC < 70% I Mild FEV1>80%; no symptoms II Moderate FEV1<80%; AECOPD and SOBOE III Severe FEV1 <50%; affects QoL IV Very Severe FEV1 <30%; R heart failure 4
	Define AECOPD. What decreases mortality in COPD?	An acute Exacerbation of COPD is characterized by the Antonisen criteria: 1) increased dyspnea, 2) sputum production, or 3) sputum purulence. Generally need 2/3 to treat. Mortality in COPD is decreased by 1) quitting smoking and 2) chronic oxygen therapy
	Indications for intubation and mechanical ventilation?	-Respiratory arrest -Decreased LOC despite maximal therapy -Cardiovascular instability -NIPPV failure or unable to use (exclusion criteria) -Severe dyspnea -Severe tachypnea -Life-threatening hypoxia -Severe acidosis / hypercapnea -Severe illness requiring respiratory support
	Complications of posterior nasal packing	B radycardia A sphyxia / Aspiration / Arrest D ysrhythmia N ecrosis of mucosa, palate / Nasorespiratory reflex O titis Media S hock (Toxic Shock) E ustachian tube dysfunction
	Distinguish epiglottitis, peritonsillar abscess, retropharyngeal abscess	Lingual tonsillitis - hot potato voice, pain on tongue depression, scalloped anterior valecula Epiglottitis - hyoid tenderness and muffled (not hoarse) voice, sniffing position Peritonsillar abscess - hot potato voice, drooling, hallitosis, trismus, inferomedially displaced tonsil Parapharyngeal abscess - same as peritonsillar except can have Horner's and oral/nasal/aural bleeding from carotid. Retropharyngeal abscess - supine with head extended, neck pain, meningismus, cri du canard (duck quack voice)
	Complications of deep space infections of the posterior pharynx	Airway compromise Mediastinitis Pericarditis Pneumonia Empyema Lemierre's syndrome (jugular vein thrombophlebitis) Horner's (sympathetic chain) Carotid artery erosion or pseudoaneurysm Cavernous sinus thrombosis Mastoiditis Otitis Meningitis Brain abscess
	How does O2 increase the speed of PTx resolution?	Decreases the partial pressure in the blood and as per Henry's gas law this results in the N2 from the PTx being resorbed more quickly into circulation. It increases resorbtion from 1-2%/d to 4-8%/d
	How do you calculate the size of a PTx in %?	((A + B + C)/3) x 10%
	What are light's criteria?	Distinguishes between exudative and transudative effusion Exudative have at least one of: Pleural fluid >2/3 of upper level of normal serum LDH Pleural LDH/serum LDH >0.6 Pleural protein/serum protein >0.5 Highly sensitive, less specific for exudate
	Causes of miscarraige	Two main: -Chromosomal anomolies -Uterine malformations (leiomyoma, bifid uterus, uterine scarring, cervical incompetence) Other: -Increased maternal/paternal age -Low pre-pregnancy BMI -History of miscarriage -History of vaginal bleeding -Maternal stress -Increased parity -Autoimmune disease -Endocrine disorders (DM) -Maternal infections -Maternal toxin ingestion (cocaine, EtOH)
	Categories of hypertension in pregnancy	Hypertension in pregnancy: >140/90 Preeclampsia: A disorder of pregnancy characterized by hypertension and proteinuria during pregnancy that is thought to be due to endothelial dysfunction Types of hypertension in pregnancy Chronic hypertension: dx'd before 20 weeks Gestational hypertension: dx'd after 20 weeks and no proteinuria Pre-eclampsia with chronic hypertension: proteinuria (>300mg/24h) and BP >160/110 in a patient with known hypertension Pre-eclampsia: proteinuria (>300mg/24h) and BP >140/90
	Amniotic fluid embolism: pathophysiology, major causes, presentation	Pathophysiology: release of amniotic fluid into the circulation causing an anaphylactoid reaction Causes: labor, amniocentesis, uterine manipulation (version), placental separation. Can also occur during miscarriage/abortion and spontaneously. Presentation: hypoxemia due to plugging of pulmonary vessels, cardiovascular collapse, non-cardiogenic pulmonary edema, DIC Treatment: aggressive ventilatory and hemodynamic support. Plasma exchange to remove cytokines. Delivery of fetus.
	Diagnostic algorithm for PE in pregnancy	If leg symptoms -> compression U/S (treat if pos) If no leg symptoms or U/S neg -> CXR If CXR clear -> V/Q scan If V/Q inconclusive -> CTPE If CXR abnormal -> CTPE If CTPE neg -> stop
	Hyperemesis gravidarum: definition, onset,	Definition: emesis that causes starvation metabolism with weight loss, dehydration, ketonuria, and ketonemia Onset: 6-20 weeks Pathyphys: unsure, associated with increased B-hCG, molar pregnancy, and multiple gestation Management: fluid rehydration, enteral nutrition, diclectin (doxylamine and B6) up to 8 tabs/d then gravol then zofran/maxeran then methylprednisone
	What is a teratogen? What characteristics of a drug increase its ability to cross the placenta?	Any chemical, pharmacologic, environmental or mechanical agent that can cause deviant or disruptive development of the conceptus Characteristics that increase crossing the placenta Size (small), ionization (uncharged), protein binding (free drug), pKa (weak organic acids get caught in fetal base-ness), lipid solubility (more soluble)
	List 10 teratogens	Heavy metals/toxins: Lead, CO, Iodine Anticoagulant: Warfarin Antiarrhythmics: Amiodarone, Quinine Anti-inflammatories: NSAIDs, misoprostol Antiepileptics: Phenytoin, VPA, carbamazepine Chemotherapeutics Busulfan, methotrexate, thalidomide Anti-hypertensives: ACEI, ARBs Dermatologic: Retinoic acid derivatives Androgens/Estrogens: OCP, HRT, diethylstilbestrol Antipsychotics: Lithium Drugs of Abuse: EtOH, cocaine Antibiotics: Erythromycin, tetracycline, aminoglycosides
	Distinguish true labor from false labor	True labor -cyclic uterine contractions of increasing frequency, duration, and strength -cervical dilation -bloody show False labor (Braxton-Hicks contractions) -no cervical dilation or effacement -intact membranes -do not escalate in frequency, duration or strength -not sensed by external monitors
	What is assessed on pelvic exam in true labor? How can fontanelles be distinguished?	Cervical dilation, cervical effacement, presenting part, station of presenting part, orientation of presenting part The anterior fontanelle has 4 sutures while the posterior fontanelle has 3. OA is the most common presentation.
	Steps to breech delivery	-Get a C-section instead -Call obstetrics -Monitors -Rule-out prolapsed cord -Open pelvis (knees wide) -Episiotomy -When abdomen is through pull out 10-15cm of cord to try to avoid it getting trapped -Grasp neonate by the pelvis and direct face/abdomen away from the symphysis -Keep the next flexed forward (do not let it extend!! Causes spinal cord injury)
	Umbilical cord prolapse: diagnosis and treatment	Diagnosis: see the cord on pelvic, suddenly non-reassuring FHR Treatment: emergency C-section, mother in knee to chest position with head down, fingers elevate presenting part, Foley to install 500-750 cc of fluid into bladder, replace cord above the presenting part
	Uterine prolapse: risk factors, diagnosis and treatment	Risk factors: -Primip -Oxytocin use -fundal implantation -forceful traction on umbilical cord -MgSO4 use Diagnosis -Severe abdominal pain -Visualization of the uterus at the os or in the introitus Treatment -Do NOT remove the placenta while the uterus is out -Give tocolytics (terbutaline, MgSO4, halogenated anesthetics to relax the uterine ring -Replace uterus -Then start oxytocin
	DDx for diffuse wheeze	Pulmonary -Lower airway o Congenital: CF, Bronchopulmonary dysplasia o Trauma: FB, Aspiration o Infectious: Pneumonia, Bronchiolitis, COPD o Inflammatory: Anaphylaxis o Vascular: PE o Degenerative: Sarcoidosis -Upper airway o Congenital: Vascular ring o Trauma: FB, Caustic ingestion o Infectious: Epiglottitis, Croup, Retropharyngeal abscess o Inflammatory: Anaphylaxis, Angioedema o Neoplastic o Vascular ring Extra-pulmonary -CHF -ARDS
	Asthma severity classifications	PEFR Mild >70% predicted Moderate 40-70% predicted Severe <40% predicted Life threatening <25%
	Side effects of steroids	SHORT TERM o Insomnia o Mood alterations or Psychosis o GI upset o Increased appetite/weight gain o Fluid retention o Hyperglycemia o Hypokalemia LONG TERM o Hyperglycemia o Osteoporosis o Thin skin, easy bruising, poor wound healing o Rare: HTN, PUD, AVN, Allergic reaction o Adrenal suppression if > 4 courses/year
	Soft signs of arterial injury in neck trauma	FOAHHDDS F ocal neuro deficit O ropharnygeal blood A irleak from chest tube Hemoptysis / Hematemesis H ematoma (non-expansive) D ysphagia / Dysphonia D yspnea Subcutaneous Air (or mediastinal Air)
	Risk factors for primary and secondary PTx	Primary: -Tall, skinny, male smokers with Marfan's and Mitral valve prolapse at altitude Secondary: -Airway: cystic fibrosis, asthma, COPD -Infectious: TB, PJP, lung abscess, necrotizing -Interstitial: sarcoid, fibrosis, pneumoconioses, tuberous sclerosis -Neoplasm: primary or metastatic -Miscellaneous: endometriosis, pulmonary infarction
	When is a diagnostic thoracentesis indicated?	Unexplained pleural effusions Pneumonic and parapneumonic effusions -Pneumonia with a parapneumonic effusion >10mm wide on decubitus films -Loculated pleural effusion -Thickened pleural core Diagnosis of a possible malignancy
	Indications for bicarbonate therapy	-pH <7.1 -HCO3 <12 -Refractory hypotension (to pressors) -TCA toxicity -ASA toxicity -Phenobarb overdose -Ethylene glycol and methanol ingestion Empiric dose is 1 mEq/kg with 1/2 as a bolus and 1/2 over 4 hours
	How can bicarbonate cause a paradoxical intracranial acidosis? Other complications?	Paradoxical CNS acidosis -HCO3 diffuses over the BBB slowly -HCO3 in the plasma is converted by carbonic anhydrase to CO2 which is then blown off to decrease pH -This CO2 can diffuse quickly over the BBB decreasing the CNS pH -With the improved pH the RR is decreased increasing CO2 which again crosses the BBB Other complications -Hypernatremia -Hyperosmolarity -Hypocalcemia -Hypokalemia
	Metabolic alkalosis: causes	Causes: hypovolemia, hypokalemia, hypochloremia DDx: -Volume contracted (saline responsive, urine Cl<10): Vomiting, diarrhea, NG suction, diuretics -Normal or expanded volume (saline unresponsive, urine Cl>10): primary hyperaldosteronism (Conn's, CAH), secondary hyperaldosteronism (CHF, cirrhosis, nephrotic syndrome, Cushing's, Barter's, Licorice, ectopic ACTH) -Other: milk-alkali syndrome, citrate, nonparathyroid hypercalcemia Treatment -Saline responsive: fluid and acetazolamide -Saline resistant: replace K and spironolactone (aldosterone antagonist)
	K - symptoms of hyperkalemia and hypokalemia	Hyperkalemia: -CVS: dysrhythmias (heart block, WCT, sine wave pattern) -CNS: muscle cramps, weakness, paralysis, paresthesias Hypokalemia (sloooow muscles): -CNS: lethargy, depression, irratibility, confusion, paresthesias, decreased reflexes, weakness -CVS: dysrhythmias (heart blocks, AF) -GI: N/V, ileus -MSK: myalgias, rhabdo, weakness
	Na - symptoms of hypernatremia and hyponatremia	Hypernatremia: -General: fatigue, malaise, anorexia, N/V -CNS: seizures, AMS, coma -MSK: twitching, hyperreflexia, clonus, tremor -Skin: dry and doughy Hyponatremia: -Nonspecific: nausea, malaise, anorexia -CNS: HA, AMS, decreased LOC, seizures, focal neural deficits -MSK: cramps, weakness
	Definition of DKA	Due to a lack of insulin and increase in glucagon leading to hyperglycemia, osmotic diuresis, and ketoacidosis. Glucose >13.9mmol/L (peds <11) pH <7.3 HCO3 <18 (peds <15) Serum or urine ketones
	How does iodide bolus affect thyroid hormone production?	2 possible effects: Wolff-Chaikoff effect: excess iodide inhibits ion trapping, thyroglobin iodination, and blocks the release of thyroid hormone Jod-Basedow effect: in patients with Graves or multinodular goiter who are iodine deficient it can induce hyperthyroidism
	Thyroid storm: cause, precipitants, and treatment	Cause: increased T3/T4 over a prolonged period of time increases B receptors and sympathetic surge activates them all at once. Precipitants: -Trauma (burns, surgery, thyroid trauma) -Vascular (MI, CVA, PE, CHF) -Toxicologic (Iodine, radiocontrast, hormone ingestion, amiodarone, stopping therapy, ASA, chemo, pseudoephedrine, OP's) -Sepsis -Metabolic: hypo or hyperglycemia -Pregnancy -Psych: mania, emotional crisis Treatment: -Decrease hormone production with PTU 1g po -Decrease release of preformed hormone with Saturated Solution of Potassium Iodide (SSKI) 5 drops 1h after PTU; Li works too -Beta blockade with propranolol 1-2mg IV q15m -Prevent T4->T3 conversion with hydrocortisone 100mg IV -Prevent enterohepatic circulation with cholestyramine -Prevent entry of thyroid hormone into cell with L-Carnitine -Supportive care with cooling, benzos, acetaminophen -Remove thyroid hormones with plasmapheresis, dialysis, plasma exchange -Treat precipitant -Admit to ICU -Thyroid surgery or ablation
	Myxedema coma: cause, precipitants, and treatment	Cause: severe longstanding hypothyroidism with a precipitant Precipitants: -Trauma, burns -Vascular: CVA, GIB, MI -Toxicologic: lithium/iodide (decrease release), narcotics, benzo's, barbiturates -Metabolic: hypoglycemia, hyponatremia, hypoxia, DKA, hypercapnea -Cold exposure Treatment -ABC's - note macroglossia/mucosal swelling -IVF - watch Na and glucose (often need to be added) -Thyroid hormone - T4 if old/cardiac hx (T4 300-500ug IV bolus); T3 if young (T3 10-20ug IV bolus). Can also give a bit of each. -Hydrocortisone 100mg IV -Rewarming -Treat precipitant
	Treatment of upper and lower esophageal foreign body	Upper: -Magill forceps / Glidescope -Foley -Bougienage -Endoscopy Lower: -Pop -Glucagon -Maxeran -Nifedipine -SL nitro -Midazolam sedation -Endoscopy
	Indications for immediate endoscopy of an esophageal foreign body	-Complete obstruction (unable to handle secretions) -Respiratory distress (FB in esophagus can compress trachea) -Sharp objects -Impacted for 24 hours -Coins in the proximal esophagus -Alkaline button batteries -Failure of medical treatment -Coins in children <2yo (relative)
	Complications of esophageal FB's	-Abscess -Tracheo-esophageal fistula -Aorto-enteric fistula -Perforation and mediastinitis / pneumothorax / pneumomediastinum
	Indications for immediate removal of a foreign body in the stomach	>2.5cm wide >5cm long Sharp Toxic (e.g. lead) >3-4 weeks impaction 90% of objects that make it to the stomach make it all the way through. If past the pylorus things can generally be left alone (then require surgery rather than endoscopy). Remove if hasn't moved in 3-4 weeks.
	Indications for surgery to remove a foreign body in the small intestines	>99% of these pass without problem -Hasn't moved for >7 days -Hasn't passed in >4 weeks ->1 industrial strength magnet (not a fridge magnet)
	Grades and treatment of hepatic encephalopathy	Grades I - Depression, irritability, disordered sleep, mild cognitive dysfunction II - Lethargy, disorientation, asterixis III - Somnolence, disorientation, confused speech IV - Coma Treatment -Stop all sedatives / CNS depressants -Correct hypokalemia (allows ammonia to be excreted renally) -Remove GI protein (treat bleed, decrease protein intake, treat constipation) -Give lactulose 30mL qid (becomes lactic acid and traps NH4+ and decreases transport time) -Flagyl or Clarithromycin to kill NH3 producing gut flora -Acarbose to decrease NH3 production -MARS
	How does lactulose correct hepatic encephalopathy? What are other treatments?	Lactulose is converted to lactic acid, acidifying the bowel contents. This converts ammonia (NH3) to ammonium (NH4+) and its positive charge keeps it trapped in the lumen. Remove other sources of protein (e.g. NG for GIB, protein-restricted diet) Clarithromycin or Flagyl (alter gut flora to decrease ammonia production) Acarbose (changes bacterial activity to decrease ammonia)
	What is the SAAG? How is it interpreted?	SAAG = serum-ascites albumin gradient (serum albumin - ascites albumin) This replaces the distinction between transudate/exudate SAAG<11 = inflammation or decreased oncotic pressure (Carcinomatosis, TB, Pancreatic or biliary ascites, nephrotic syndrome) SAAG>11 = portal hypertension (Cirrhosis, Alcoholic hepatitis, portal-vein thrombosis, Budd Chiari, liver mets)
	Diagnosis of SBP. Differentiating primary versus secondary bacterial peritonitis	Diagnosis: -PMN >250 cells/mm3 -Positive culture -Ascites fluid pH <7.34 or a gap between blood pH of >0.10 Primary: -Protein <10 -Prior SBP -Bili >42mmol/L -Platelets <98 -Single bacteria cultured Secondary: -Protein >10 -Glucose <2.8 -LDH > upper limit of normal serum LDH -Multiple types of bacteria cultured
	The triad and tetrad of ascending cholangitis	Charcot's triad: -Fever -Jaundice -RUQ pain Raynaud's pentad: -Charcot's triad plus altered mental status and shock (hypotension/tachycardia)
	Sonographic findings of an abnormal TV ultrasound	-BhCG >3000 and no gestational sac -Gestational sac >13mm and no yolk sac ->5mm crown rump length and no fetal heart tones -No fetal heart tones after 10-12 weeks -Gestational sac >25mm and no fetus
	Risk factors for ectopic pregnancy	PMHx - PID, previous ectopic or abortion, tubal surgery, infertility, abnormal anatomy Patient factors - smoker, age Pregnancy factors - has IUD, embryo transfer fertility treatments
	What is a molar pregnancy? What are the types? How does it present	-Disordered proliferation of chorionic villi Two types: -Complete hydatidiform mole: absence of fetal tissue -Incomplete hydatidiform mole (much less common): fetal tissue with focal trophoblastic hyperplasia -Can also get choriocarcinoma (responds well to chemo, can metastasize) Presentation -Hyperemesis gravidarum -Crazy high BhCG -Snowstorm U/S
	Numbness or pain to the outer side of the thigh associated with pregnancy or obesity	-Meralgia paresthetica -Due to compression of the lateral femoral cutaneous nerve of the thigh as it passes the inguinal ligament
	Cause and treatment of postpartum hemorrhage	Cause: Tissue - retained products, accreta (placental villi adhere to myometrium) / increta (enter the myometrium) /percreta (through the myometrium) make more likely Tone - diagnosis of exclusion Trauma - perineal tears, vulva/vaginal epithelium trauma Thrombin - vWD, coagulopathy, DIC Treatment Uterine massage Repair lacerations Remove products of conception Oxytocin - run 40U/1L fast; 10U IM Misoprostol (PGE1) - 800-1000mcg PR Hemabate (PGFalpha) - 250mcg IM Pack uterus Foley in uterus Embolize vessels D&C Hysterectomy
	Types of lactic acidosis	A - tissue hypoxia B1 - systemic disorders (DM, renal insufficiency, leukemia, sepsis) B2 - substance associated (biguanides, methanol, salicylates, INH) B3 - heritable metabolic disease
	Risk factors, presentation, and treatment of cerebral edema in DKA	Risk factors -New onset diabetes -Children <5yo -Extremely ill on presentation -Treated with HCO3 -Excessive fluid replacement -Rapidly dropping serum osmolality Presentation -HA -Behavioral changes -Incontinence -Seizures -Autonomic (BP and temp) Then coma, respiratory arrest, death Treatment -Mannitol 1-2g/kg over 15m -Decrease IVF and insulin rate -Intubate, hyperventilate, CT head NB - cause is unknown - ? idiogenic osmoles
	4 characteristics that determine the toxicity of a hydrocarbon	•Viscosity •Volatility •Side chains (halogenated) •Surface tension
	Diagnostic criteria of HHS	Glucose >33 Sosm >320 pH >7.3 HCO3 >15
	Complications of long-term DM	Infection (immunocompromised secondary to decreased neutrophil and lymphocyte activity) Diabetic foot Insulin allergy (must go desensitization or change type) Cutaneous manifestations (diabetic dermopathy, dermal hypersensitivity at injection sites as well as hypo or hypertrophy, acanthosis nigrans, necrobiosis lipoidica diabeticoricum, xanthoma diabeticorum) Macrovascular complications (CAD, CVD, PVD) Microvascular complications (Nephropathy, Retinopathy, Neuropathy)
	Causes of rhabdomyolysis	Traumatic -Crush -Compartment syndrome -Excessive exertion Non-traumatic (relate to lack of ATP) -Electrolytes (HypoK or HypoP) -Ischemia -Congenital ATP deficiency due to inborn errors of metabolism -Environmental (electrical injury, heat stroke, hypothermia, rattle snake bite) -Endocrine (pheochromocytoma, DKA, HHS, hypo/hyperthermia) -Toxin (SS, NMS, statins, alcohol) -Infections (all types) -Seizures -Rheumatic (polymyositis, dermatomyositis, Sjogren's)
	Thyroid diseases	Hyperthyroid -Graves (TSH receptor antibodies) -Toxic multinodular goiter (multiple overactive and big areas, can cause SVC syndrome) -Toxic adenoma -Acute thyroiditis (gland is tender) --> Autoimmune (Hashimoto's antibody to thyroid peroxidase; Postpartum; Sporadic) --> Infectious (De Quervian's viral; suppurative bacterial) --> Drug induced (amiodarone, iodine, interferon, lithium) -Pituitary adenoma -Gestational trophoblastic / germ cell tumors (create TSH-like hormone) Hypothyroid -Hypothalamic and pituitary underactivity (tumors, Sheehan's, amyloidosis, sarcoidosis, radiation) -Late thyroiditis (as per above) -Iatrogenic (thyroidectomy, ablation, lithium, iodine, amiodarone) -Congenital (causes cretinism)
	Primary versus secondary adrenal dysfunciton	Primary is a disease of the gland itself and affects all 3 functions (glucocorticoids, mineralocorticoids, androgens) -See hyperpigmentation, hyperkalemia, hyponatremia, salt craving, and acidosis from the lack of aldosterone / excess ACTH Secondary is a disease of the pituitary and does NOT affect mineralocorticoids (regulated by the RAAS) -Still get hyponatremia, but it is due to increased ADH Both -Hypotension -Depression, delerium, HA, abdominal pain, emesis, hypoglycemia, hyponatremia (differnet reasons), hypercalcemia, fevers, ARF
	Steroid equivalency (hydrocortisone, prednisone, methylprednisolone, dexamethasone)	Hydrocortisone = 1 Prednisone/Prednisolone = 4 Methylprednisolone = 5 Dexamethasone = 25
	Esophageal narrowings and risk factors for obstruction / dysphagia	Narrowings -Upper esophageal sphincter (cricopharyngeus) -Aortic arch -Left mainstem bronchus -Lower esophageal sphincter Causes of obstruction / dysphagia Poor dentition (they don't chew) Intrinsic -Esophageal carcinoma -Shatzki's ring -Peptic stricture -Esophageal web Extrinsic -Cardiomegaly -Aortic aneurysms or anomylous right subclavian -Goiter -Mediastinal tumor -Enlarged lymph nodes -Zenker's diverticulum Neuromuscular (Neuro - head trauma, brain tumor, CVA, Alzheimer's, Parkinsons, MS, ALS, Myesthenia; Muscular - achalasia, scleroderma) Toxic (Lead or EtOH) Infectious (Bacteria - diptheria, botulism, syphilis, tetany OR Viral - rabies, polio)
	What is Mackler's triad? How can the problem be diagnosed?	Suggests esophageal rupture -Subcutaneous emphysema -Chest pain -Vomiting Diagnose with contrast study. Use gastrograffin if no risk of aspiration (safer but less sensitive test; pneumonitis if aspirated) THEN barium (worse inflammatory response through perforation). Try CT if normal or unsafe to do.
	Contributors to thte development of GERD and evidence-based ways to get rid of it	-Decreased sphincter tone (anticholinergics, caffeine, benzo's, nicotine, nitrates, peppermint, chocolate, estrogen, progesterone) -Decreased esophageal motility (DM, achalasia, scleroderma) -Increased intraabdominal pressure (pregnancy, obesity) -Decreased gastric emptying (anticholinergic, diabetic gastroparesis, outlet obstruction) Evidence-based treatments: weight loss and bed elevation
	Eradication treatment for H Pylori	Triple: Clarithromycin 500bid / Amoxicillin 1000bid OR Metronidazole 500bid/ PPI x 10-14d OR Quadruple: Bismuth subsalicylate (pepto-bismol) 525qid / metronidazole 250qid / Tetracycline 500qid / PPI x 10-14d
	Poor predictors of outcome in upper esophageal bleed	Components of the Rockall score Age >60 Heart failure Ischemic heart disease Renal failure Liver failure Metastatic cancer Gastric cancer Vigorous bleeding
	DDx for transaminitis	-Structural: o Inflammatory/ Autoimmune/ Infiltrative: autoimmune hepatitis (PBS, PSC), NASH (? d/t insulin resistance), amyloid o Vascular: Budd-Chiari (thrombosis of hepatic veins or IVC/SVC), portal vein thrombosis, ischemia, CHF o Congen/Degen: neonatal hepatitis -Toxicology: acetaminophen, EtOH, INH, iron, phenytoin, ecstasy (autoimmune hepatitis) -Infection: o Viral: HAV, HBV, HCV, HDV, HGV, EBV, CMV o Protazoan: amoeba o Toxoplasmosis o Associated with bacterial sepsis -Metabolic: Wilson’s disease (copper overload), Reye’s syndrome, hemochromatosis -Pregnancy: Fatty liver of pregnancy -GI: gallstones, strictures, cholangitis, biliary/pancreatic cancer, annular pancreas (obstructive causes)
	Hepatitis serology	Hep A -For acute infection send HAV IgM -For chronic infection send HAV IgG Hep B -For acute infection send HBV sAg and HBV cAb IgM -For chronic infection send HBV cAb IgG -For vaccine immunity send HBV sAb Hep C -HCV Ab
	Hepatitis post-exposure prophylaxis	A: HAIg to unvaccinated close personal contacts, childcare workers/attendees (people who wipe their bum), similar food-borne source in last 2/52 B: HBIg to: -unvaccinated / low titer recipients exposed to source that is HBV sAg + OR high risk -neonates with HBV sAg + mothers C: N/A
	Signs of cholecystitis on ultrasound	-Stones / biliary sludge -Wall thickening (2-4mm) -Distension of GB (>4cm wide or 10cm long) -Pericholecystic fluid -Air in the GB wall (emphysematous or gangrenous cholecystitis) -Murphy's sign (sonographic)
	Treatment of hyponatremia with focal neurologic symptoms, seizure, or coma. Complication of rapid correction.	Hypertonic (3%) saline 100mL over 10m then 100mL over the next hour (approximately 3mL/kg total) After this aim to correct by 0.5mEq/L/h if chronic, 1mEq/L/h is okay if acute Complication: central pontine myelinolysis
	Causes, diagnosis and treatment of SIADH	Lung masses -Cancer, pneumonia, TB, abscess CNS disorders -Infection (meningitis, abscess), mass (subdural, postop, CVA) Drugs -Thiazides, narcotics, oral hypoglycemic agents, barbiturates, neoplastic agents, vasopressin Diagnosis - low Sosm (<280), high Uosm (>100) with no other explanation Treatment - water restriction, treat cause
	Causes of hypercalcemia and hypocalcemia	Hypercalcemia -Increased intake (Ca supplements, milk-alkali) -Decreased losses (HCTZ) -Bone resorption (primary hyperparathyroidism, parathyroid-like hormone from small cell lung tumor, lytic bone lesions) -OD - estrogens, vitamin A, vitamin D, Lithium -Endocrine - hyperthyroid, adrenal insufficiency -Granulomatous disorders (activate macrophages that convert vit D to make active) - sarcoid, TB, coccidiomycosis, histoplasmosis Hypocalcemia -Hypoparathyroidism (congenital, maternal, thyroid surgery) -Tox (EtOH, chemo) -Hyperphosphatemia, tumor-lysis syndrome
	Ca - symptoms and treatment of hypercalcemia and hypocalcemia	Hypercalcemia -CNS - AMS, ataxia, fatigue -CVS - HTN, short QT, brady, STE -GI - N/V, anorexia, ileus, constipation -Renal - polyuria, dehydration, nephrolithiasis Treatment - IVF, zaledronic acid, calcitonin, steroids, lasix, underlying cause Hypocalcemia -Neuromuscular - paresthesias, tetany (Chvostek's, Trousseau's) -CV - long QT, hypotension, brady, arrest -Resp - bronchspasm, laryngospasm -Psych/CNS - confusion, psychosis, dementia, depression, anxiety, irritability Treatment - asymptomatic CaCO3 1-4g/d po, stable CaGluc 10mL IV, unstable CaCl4 10mL IV
	Conditions that can cause a false positive lipase result (not pancreatitis)	Many false positives at standard cutoff. Quite specific at 5x standard level, but down to 60% sensitivity. 2x cutoff is best for maximal sensitivity/specificity. -Cholecystitis -Bowel obstruction -Peritonitis -Duodenal ulcer -DKA -Trauma -Post ERCP -Idiopathic
	x-ray and ultrasound findings of pancreatitis	x-ray -Pleural effusion -Pancreatic calcification -Free air (? due to perf'd something) -Ileus -ARDS Ultrasound -Occasionally can see CBD stone and/or enlarged hepatic duct (suggesting distal obstruction)
	Causes of simple and closed loop SBO	Top 3: -Adhesions -Hernias -Cancer Intrinsic - congenital, IBD, radiation enteritis, cancer, intussusception, hematoma Extrinsic - hernias, adhesions, volvulus, compressing tumors, abscesses, hematomas Intraluminal - FB, gallstones, bezoar, barium, ascaris
	X-ray signs of intussusception	Crescent sign Target sign Abdominal mass (no air in one area - usually RUQ) / No liver edge sign Air fluid levels (SBO) Dilated loops of bowel (SBO) NOTE: In adults (as opposed to children) you do not want to reduce this with enema as it is often caused by cancer and this can result in seeding
	X-ray signs of mechanical SBO, closed loop obstruction, ileus. Normal measurements of bowel.	Mechanical -Dilated proximal loops and flattened distal loops -Sharply angulated or step-ladder loops of small bowel -Multiple air-fluid levels -'String of pearls' (pockets of gas trapped in the plicae semicircularis when the bowel is full of fluid) Closed-loop -Coffee bean sign (U-shaped bowel loop also seen in sigmoid volvulus) -Pseudotumor sign (fluid filled loop resembling a mass) Ileus -Dilated loops throughout the entire bowel including the colon -Dilation less prominent -Air fluid levels less prominent Bowel measurements: -Small 3cm -Large 6cm -Cecum 9cm
	Causes of mesenteric ischemia and risk factors	-Arterial embolism ~50% - mostly SMA (CAD, valvular disease, AF, aneurysms, dissections, coronary angiography) - needs embolectomy -Arterial thrombosis >15% - mostly SMA and have h/o abdominal angina (elderly, PVD, hypertension) - needs revascularization, heparin -Venous thrombosis <15% (same risk factors as DVT/hypercoaguability; Factor V Leiden most common) - needs heparain, thromboplasty -Non-occlusive - 20% (all shock states, cocaine, vasopressors; >50yo) Lactate is highly sensitive CT angiography is most helpful diagnostic test; Angiography is gold standard and early angiography decreases death
	Modified Alverado score, WBC/CRP, U/S and CT for Appy	Alverado score History: Migratory RLQ pain, Anorexia, N/V PE: T>37.5, RLQ tender (2 points), Rebound tenderness, Leukocytosis (2 points) WBC<10 and CRP<12 have a -LR of 0.09 (very sensitive) but less helpful in peds. U/S 75-95% sensitive, 85-95% specific - operator dependent but 1st choice for kids/women - see non-compressible, thick-walled (>2mm), dilated (>6mm), thickened mesentary, pain with compression, appendicolith CT 95% sensitivity and specificity
	Rome III criteria for IBD	Recurrent abdominal pain/discomfort for at least 3d in the past 3m associated with 2/3 of: -Improvement with defecation -Onset associated with a change in stool frequency -Onset associated with a change in stool appearance
	Causes of large bowel obstruction	1 - Colorectal cancer 2 - Volvulus 3 - Diverticulitis 4 - Extrinsic compression from mets Also: Abscess, stricture due to chronic ischemia, fecal impaction, IBD, CF, Hirschsprung's, body packers/stuffers, Ogilvie's (pseudo-obstruction)
	AXR findings of large bowel obstruction	Distended colon Air-fluid levels Cecal dilation >12cm has increased risk of perforation
	Volvulus types, risk factors, x-ray findings	Gastric: hiatal hernia, either between 40 and 50yo or <1yo. Often have diaphragmatic defects, gastric ulcer or cancer, adhesions, paralyzed diaphragm. Can't pass NG tube!! Cecal: pregnancy, 'coffee bean sign' pointing to LUQ, also can have air-fluid levels in the small bowel, paucity of colonic gas. Treatment surgical. Sigmoid: elderly, psych/neuro disease, institutionalized, constipation, high fiber diet, 'coffee bean sign' pointing to RUQ, bird's beak contrast. Treatment endoscopic detorsion or surgery.
	Crohn's versus colitis	Crohn's affects mouth to anus / Colitis large colon and rectum only Crohn's commonly found in terminal ileum and colon / Colitis starts at rectum and moves proximally Crohn's is transmural / Colitis is superficial mucosa Crohn's has skip lesions / Colitis is continuous Crohn's gets primary sclerosing cholangitis / Colitis gets colon cancer
	Extra-intestinal manifestations of IBD	ULCERATIVE U rinary stones L iver cirrhosis / sclerosing cholangitis C holelithiasis E rythema nodosum / erythema multiforme / pyoderma gangrenosum R etardation of growth A rthralgias / arthritis / ankylosing spondylitis T hrombophlebitis I atrogenic (steroids) V itamin deficiency E yes (uveitis, episcleritis) Also pulmonary fibrosis
	Intestinal manifestations of IBD	COLITIS C ancer O bstruction L eakage / perf I ron deficiency T oxic megacolon I nanition (wasting) S tricture Also: abscess, fistula
	What is toxic megacolon? What causes it? What's the treatment?	Inflammation of the smooth muscles of the colon leads to dilation and perforation if untreated. Patients look toxic and have dilated colon on AXR (>6cm). Often due to infection (C Diff gets po vanco or po/iv flagyl; other gets ceftriaxone/flagyl), IBD (gets tazo and steroids), antimotility agents (anticholinergic or opioid - stop them). May need OR.
	What is required to prove negligence in a malpractice suit?	-Health care provider has a duty of care -That duty of care is breached by breaking the standard of care -The patient is harmed -There is a direct link between the breach and the harm
	Mimics appendicitis Backpacker's diarrhea Raw/undercooked poultry Associated with GBS Diarrhea and seizures Associated with Reiter's Raw oysters/shellfish Prolonged diarrhea Dysentry without fever Fried rice GI and neuro Cold allodynia / hot/cold reversal Worse after EtOH ingestion Mayo/potato salad Eggs	Mimics appendicitis: campylobacter and yersinia Backpacker's diarrhea: giardia lamblia, campylobacter Raw/undercooked poultry: campylobacter Associated with GBS: campylobacter Diarrhea and seizures: shigella Associated with Reiter's: salmonella Raw oysters/shellfish: vibrio parahemolyticus, plesiomonas Prolonged diarrhea: yersinia, aeromonas, parasite Dysentry without fever: e coli O157:H7 Fried rice: bacillus cereus (toxin mediated) GI and neuro: ciguatera toxin Cold allodynia / hot/cold reversal: ciguatera toxin Worse after EtOH ingestion: ciguatera toxin Mayo/potato salad: staph aureus Eggs: salmonella
	Bacterial causes of diarrhea; antibiotic treatment	CSS Yalk Constantly - So Believe Every Child Vomiting And Pooping C ampylobacter S higella - treat dysenteriae for public health S almonella - treat typhi and all food handlers for public health Y ersinia C lostridium jejuni S taph aureus (toxins) B acillus cereus (toxins) E coli (toxins) C difficile and perfringins (toxins) V ibrio cholera (toxins) and parahemolyticus A eromonas P lesiomonas Toxin-producing generally do not respond to antibiotics Antibiotics for severe infectious diarrhea with no evidence of HUS with cultures pending - children cefixime/azithro x 3-14d; adults cipro x 3-14d
	Causes of free fluid in the abdomen	-Blood -Urine -Peritoneal dialysis fluid -Ascites > Liver disease - cirrhosis, alcoholic hepatitis, portal vein thrombosis, Budd-Chiari, liver mets (SAAG>11) > Abdominal or ovarian malignancies / carcinomatosis (SAAG<11) > TB peritonitis (SAAG<11) > Pancreatitis (SAAG<11) > Nephrotic syndrome (SAAG<11) > CHF > Hemodialysis
	Internal hemorrhoid classification and treatment	1st degree - sense of fullness, no prolapse, medical management 2nd degree - prolapse during defecation and spontaneously reduce, medical management 3rd degree - prolapse spontaneously and during bowel movement, reduce spontaneously, medical or surgical management 4th degree - permanent prolapse with risk of thrombosis, surgical repair
	Medical and surgical hemorrhoid treatment	Medical: WASH W arm water A nalgesia (topical nifedipine, lidocaine for external; internal controversial) S tool softeners H igh fiber diet Surgical: sclerotherapy, hemorrhoidectomy, banding
	What is the anal fissure triad? Treatment?	Deep ulcer Sentinal pile (hypertrophic edematous skin tag) Enlarged anal papilla Treatment with WASH (warm water, analgesia with nitro/lidocaine/nifedepine, stool softeners, high fiber diet) as per hemorrhoids.
	Types of rectal abscess	-Supralevator (high and deep) -Intersphincteric (internal, above pectinate line) -Ischiorectal (lateral; may be able to drain in ED - controversial) -Perianal and Perirectal (only ones we'd drain in ED) Always tx with tetanus; Abx if DM/ immunocompromised/ valvular disease
	Causes of fecal incontinence	Pediatric -Congenital (meningocele, myelomeningocele, spina bifida) -Post-op imperforate anus -Sexual abuse -Neuro (demential, spinal cord injury, autonomic neuropathy from DM, pedental nerve damage from surgery/obstetrics, Hirshsprung's) -Trauma to sphincter -Mass (colorectal cancer, foreign body, hemorrhoids, fecal impaction) -Medical (rectal prolapse, diarrhea, IBD, laxatives)
	Gastroenteritis bugs that require treatment	1) Culture positive, 2) immunocompromised, and 3) not improving Also: -Shigella dysentariae (even if asymptomatic - public health) -Yersinia (even if asymptomatic - public health) -Salmonella typhi in food handlers, healthcare workers, severe colitis, <3m/o, >50yo -Bacillus anthracis -C difficile -Giardia Lambia -Entamoeba histolytica
	When can anti-diarrheal medications be given?	AVOID in <2yo and those with fever or dysentery (blood +/- pus or mucous) Consider in patients with severe symptoms along with antibiotics
	Diarrhea history - key questions	Travel - parasites Antibiotics - c diff Ingestions - food poisoning Well-water - parasites Infectious contacts - virulent bacteria Pets at home - salmonella
	DDx for bilateral CNVII palsy	Gosh, bilateral CNVII isn't just B2E2LLS3 GBS (Millar-Fischer variant) Basilar Skull # / Bacterial Meningitis EBV / CMV Ethylene glycol toxicity Lyme Leukemia Sarcoidosis / Syphillis / Sarcoma, Kaposi’s
	Characteristics of self-induced knife wounds	-Multiple superficial incisions to trunk/arms/face -Multiple superficial stabs to trunk/arms/face -Parallel incisions on the non-dominant side of the body in close proximety to each other -Sparing of sensitive areas -Linear or curved incisions toward the hand inflicting the wound -Intact clothing covering the wound -Evidence of similar prior wounds
	Types of abuse	3 categories: -Domestic -Institutional -Self Multiple types -Physical -Emotional -Sexual -Neglect -Abandonment -Financial -Factitious disease (Munchausen's by proxy)
	Risk factors for child abuse	Child -Premature -Difficult temperament -Developmental delay or chronic medical condition -Social isolation Caregiver -EtOH or substance abuse*** -Abused as a child -Intimate partner violence -Mental illness -Single parent Demographic -Low SES -Ethnic minority
	Shaken baby syndrome; imaging studies	-Generally <1yo; can be <3yo -No evidence of impact -SDH and SAH -On fundoscopy see retinal hemorrhages (>75%), papilledema due to increased ICP CT is better for SAH, imaging of intracranial injuries, easier to perform. MRI is better if subacute/chronic, deel cerebral injuries, extraaxial fluid, smaller SDH's
	Historical indicators of child abuse	-Magical injuries -Inconsistent story -Inconsistent with childhood development (can't bruise if can't cruise; 3 week-old 'rolling' off of a table) -Unexplained delay in seeking care -History does not explain the injury
	Risk factors for HIV transmission via sexual intercourse	Victim -Anal > vaginal -Coexisting STD's or genital lesions -Trauma evident -Ejaculate on mucous membranes -Cervical ectopy -Active menstration -Currently pregnant Assailant -Foreskin -Primary infection -Late stage infection -Viral load in genital tract -STI's or genital lesions -Not on HAART -Multiple offenders -Incarcerated, homosexual, bisexual
	Risk factors for interpersonal violence	Victim -Demographics (<35yo, female, immigrant, separated or divorced) -Environment (low SES, homeless, previous exposure to violent caretakers) -History (disabled, previous physical or sexual assault) Perpetrator -Demographics (young) -Societal (low income, unemployed, low SES, low academic achievement, criminal behavior) -Psych (low self-esteem, personality disorder, emotional dependence, insecure) -Substance abuse -History (abused as a child, violence in family of origin, history of TBI)
	Medical problems on DDx with interperesonal violence	-Depression, PTSD, suicidal ideation -Headaches -Stress-related illnesses -EtOH / substance abuse -Trauma in pregnancy -Chronic pain -STI/HIV
	Historical indicators of elder abuse	Implausible mechanism of injury Inconsistent history between patient and caregiver Delay to presentation Unexplained injuries Elder being called 'accident prone' Past history of frequent injuries Noncompliance with meds, appointments, directions Caregiver does not know patient's history/meds Caregiver answers all questions Caregiver/patient reluctant to give answers Strained patient/caregiver interactions Poor living situation
	Diagnostic criteria for a manic episode	Manic episodes are characterized by a >2 week period with elevated/irritable mood and >3 of the following GST PAID G randiosity S leep (decreased) T alkative P leasurable activities / P ainful consequences A ctivity I deas (flight of) D istractable Is not mixed, causes marked impairment or requires hospitalization, not due to a general medical condition.
	Anxiety definitions: Anxiety, Panic attack, Agoraphobia, Social phobia, Phobia, OCD, Generalized anxiety, PTSD, acute stress disorder	-Anxiety: a specific unpleasurable state of tension that forewarns the presence of danger (uneasiness stems from the anticipation of some imminent danger, the source of which is unknown or unrecognized) -Panic attack: discrete period of sudden onset of intense apprehension, often associated with feelings of impending doom -Agoraphobia: Anxiety about place or situations from which escape might be difficult (fear of being along in public places). -Panic disorder with agoraphobia: Pts have recurrent unexpected panic attack and become fearful of situations where they might occur -Specific phobia: irrational fear of something that is perceived as dangerous (normal in children) -Social phobia: anxiety d/t social or performance situations -Obsessive-Compulsive Disorder: Obsessions → stress or anxiety which is relieved by a compulsive behaviour -Generalized anxiety disorder: persistent, excessive anxiety or worry for > 6 months -Post-traumatic stress disorder: Heightened arousal and avoidance of stimulus following a significant traumatic exposure -Acute stress disorder: similar to PTSD occurring immediately in the aftermath of an extremely traumatic event
	Predictors of organic anxiety disorders	Predictors -Onset after 35yo -Lack of childhood, personal, or family history of anxiety/phobias -Lack of avoidance behavior -Absence of live events that would exacerbate anxiety -Poor response to anxiolyticsiD
	Disorders that can manifest as anxiety	Substance abuse: sympathomimetics (caffeine, amphetamine, cocaine), hallucinogens (LSD, PCP, Ecstasy, marijuana) Withdrawl: depressants (benzos, barbiturates, EtOH) Cardiac: arrhythmias, mitral valve prolapse Endocrine: hypo/hyperthyroid, hypoglycemia, pheochromocytoma, hyperadrenocortism Resp: asthma, PE Medications: alpha agonists, theophylline, corticosteroids, thyroid hormone
	What is somatization disorder?	Somatization disorder -Unexplained physical symptoms beginning before 30yo -At least 4 sites of pain, 2 GI symptoms, 1 reproductive/sexual symptom, 1 neurologic symptom -Not explained by another medical condition -Not intentionally feigned/produced Risk factors -Women, low SES, alcoholism, addictions, poor education, interpersonal problems
	What is conversion disorder?	-A somatoform disorder -Sudden onset of a single symptom not under the patient's control and often associated with la belle indifference -Generally neurological (motor: tremors, paralysis, pseudoseizures, aphonia, ataxia; sensory: anesthesia, blindness, tunnel vision) -Often a psychiatric coping mechanism
	What is somatization? List the somatoform disorders.	Somatization The unconscious experience and communication of psychological distress through physical symptoms. -Somatization disorder -Conversion disorder -Pain disorder -Hypochondriasis
	What is hypochondriasis? DDx for it? Treatment?	4 key features: -Symptoms are more than the organic disease that is evident -Fear of disease and conviction that one is sick -Preoccupied with their body -Persistent and unsatisfying pursuit of medical care DDx -Endocrine (hyperparathyroid, thyroid disorders, Addison's, insulinoma, panhypuitarism), MS, porphyria, Lupus, Wilson's disease, Myesthenia Gravis, GBS, Uremia Treatment -Reassurance, legitimize, share diagnostic uncertianty, assure ongoing care, avoid drugs that cause dependency, come up with realistic treatment goals focused on symptom control, arrange single-physician follow-up
	Compare factitious disorder, Munchausen's Syndrome, Munchausen's syndrome by proxy, Malingering,	Factitious disorder: symptoms and signs produced or feigned in the absence of external symptoms to take on the sick role, IS a mental disorder, unmarried educated women <40yo with healthcare background. Munchausen's: a form of factitious disorder, wide variety of illnesses with intent of gaining hospital admission, hospital shoppers, believe they are very important, initially praise care -> become disruptive -> rage and AMA Munchausen's by proxy: a form of factitious disorder where illness produced/feigned in a child. Persistent presentations with symptoms that stop when perperator is removed. Parents work in healthcare. Notify protective services and consult psych for mother. Malingering: Malingerers ARE motivated by external incentives! Assume somatization unless otherwise proven. Often medicolegal context, discrepancy between findings and disability, poor cooperation, antisocial behavior. Don't want to get better; gaming the system.
	Diagnosis of schizophrenia	>2 of these symptoms for >1 month -Delusions (if delusions bizarre counts as 2) -Hallucinations (if running commentary counts as 2) -Disorganized speech -Disorganized or catatonic behavior -Negative features (avolition, poverty of speech, flat affect) As well as: -Sharp deterioration -Disturbance for >6 months (with prodrome) -Other causes ruled out
	Complications of neuroleptic use and treatment	-Orthostatic hypotension - alpha blockade, give fluids -Acute dystonia - cholinergic, treat with anticholinergic benztropine (cogentin) 1-2mg IV/IM +/- benadryl -Akathisia - motor restlessness, decrease dose or try beta-blocker -Parkinsonism - can be indistinguishable from Parkinson's, tends to resolve over time, decrease dose or start parkinson's meds -Tardive dyskinesia - occurs over years, bad, choreathetoid movements (tongue, grimace, writhing), no known treatments, try switching to atypical or benzo's -NMS
	Symptoms (in order) of NMS, medications that cause it, treatment	MR HA altered M ental status (agitated or catatonic) R igidity (lead pipe, tremor) H yperthermia A utonomic instability Medications: typical and atypical antipsychotics, lithium, Parkinson's medications, maxeran Treatment: Benzo's, stop neuroleptics, bromocriptine/dantroline/amantidine, cool, ICU, electroconvulsive therapy (Seriously? Seriously??)
	Simple vs complex skull fracture	Simple: -Linear not crossing suture lines -<2mm of separation Complex: -Linear crossing suture lines ->2mm of separation -Stellate -Comminuted -Depressed -Compound -Diastatic
	Triad of shaken baby syndrome	-Subdural hematoma -Cerebral edema -Retinal hemorrhages
	DDx for retinal hemorrhages	-Vaginal delivery (resolve in 10-14 days) -Bleeding disorders -AV malformations -Meningitis -Severe accidental head injury
	Physical exam signs of sexual abuse	-Unexplained vulvar bruising -Hemorrhage -Hymenal or vulvar tears -Loss of hymen out to the margin of the vagina -Signs of STI's (gonorrhea, chlamydia, hsv2, syphilis, trichomonas) Can get HPV, HSV1, Gardnerella vaginosis, Hepatitis B/D and AIDS without assault.
	Bronchiolitis treatments	-Oxygen - yes if hypoxic -IVF - yes if dehydrated -Beta agonists - not generally recommended (perhaps 10% responders, atopic people more likely) -Steroids - no -Epinephrine - some bad evidence that it can help prevent hospitalization, but not enough evidence to use it -Epi and steroids together - may be a synergistic response, but more evidence needed. NOT recommended. -Nebulized hypertonic saline - evidence moving towards its use, but it is still not in the guidelines
	Inadequate view of prevertebral soft tissue in children	-View taken on EXpiration -Flexed or neutral (rather than extended) neck
	Esophageal button battery - mechanisms of injury	-Current from the battery forming a circuit -Release of hydroxide -Pressure necrosis due to esophageal foreign body
	What are the goals / indications of PSA?	Analgesia Anxiolysis Sedation Immobility Amnesia
	Crisis vs psychiatric emergency	Crisis: acute emotional upset arising from situational or developmental problems that results in temporary inability to cope Psychiatric emergency: acute behavioral disturbance related to severe mental or emotional instability or dysfunction requiring medical intervention
	HEADSS social history	H ome E ducation A fter school D rugs S exual history S uicidal thoughts/attempts
	Mental status exam	Appearance Attitude Behavior Mood Affect (appropriateness, lability, eye contact) Orientation (date/time/place) Speech Thought process (disorganized) Thought content (delusions) Perceptions (hallucinations) Cognition (memory, content of thought, preoccupations, coherent speech, ability to reason, insight, judgement) Insight Judgement Suicidal ideation Homicidal ideation Capacity (CURVES)
	Substance dependence	WITHDraw IT W ithdrawal I nterest or Important activities neglected T olerance H arm to physical and psychosocial are known but they continue to use D esire to cut down, control it I ntended time, amount exceeded T ime spent too much
	Pediatric vs adult bones	-Thicker and more stable periosteum -Faster healing with less immobilization -Better remodeling capability and vascularity -Growth plates weaker than ligaments -More porous and pliable
	Toddler's fracture characteristics	-Minimal or no history of trauma -Red flags for NAT are: more transverse fracture with an associated fibular injury -Generally 9m to 3y of age -On physical exam spiral oblique axial load provokes pain (put axial load and twist ankle) -Generally treat with an above knee backslab - sometimes don't need anything.
	Seven pulmonary complications of pneumonia	-Pleural effusion / empyema -Pneumothorax -Lung abscess -Bronchopleural fistula -Necrotizing pneumonia -Pneumatocele -Acute respiratory failure
	How long are these pediatric rashes congagious for? (varicella, rubella, measles, parvovirus)	-Varicella - 2 days before until lesions are all crusted over -Rubella - 1-2 weeks before they present with rash -Measles - 5 days before and 4 days after -Parvovirus - a week before until the rash starts

Share This Flashcard Set

Set the Language

Related Flashcards

Tiny Tips - Boringem

Add to Folders

Upgrade to Cram Premium

Card Range To Study

430 Cards in this Set