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144 Cards in this Set
- Front
- Back
What should be the primary survey of a patient with AMS
|
Oxygen, Monitor, IV access
Dexistick-->administer glucose Narcan |
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When dealing with AMS, before dx established, what can you give
|
COMA Cocktail: D.O.N.T.
Dextrose ~ 1 amp D50 IV Oxygen ~ 100% non-rebreather Naloxone ~ 2 mg IV THiamine (B1) ~ 100 mg IV |
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acute mental status changes differential
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1) defect in glucose control or other electrolyte abnormality
2) increased ICP 3) poisoning 4) infection 5) hypoxia/ hypercarbia 6) environmental exposure (hypo-hyperthermia) |
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what is difference between AVPU and GCS
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GCS is for trauma patients and AVPU describes patients level of consciousness during primary survey
do full neuro on non-trauma patient |
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What does AVPU stand for?
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A = awake and alert
V = responds to verbal stimuli P = responds to painful stimuli U = unresponsive |
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GCS
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Eye Opening:
~spontaneous = 4 ~to voice = 3 ~to pain = 2 ~none = 1 Best Verbal Response ~oriented = 5 ~confused = 4 ~ innapropriate words = 3 ~incomprehensible words = 2 ~none = 1 Best Motor Response ~obeys commands = 6 ~localizes pain = 5 ~withdraws to pain = 4 ~flexion to pain = 3 ~extension to pain = 2 ~none = 1 |
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Coma
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neither arousal nor awareness is present
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delirium
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increased alertness, confused, disoriented
but with psychomotor agitation, and hallucinations |
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Characteristics of a metabolic etiology of AMS
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-rapid deterioration over a few hours
-metabolic and drug-related causes are most common for acute changes (70-80%) -no focal neuro deficits -reactive and equal pupils usually point to a metabolic cause |
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Asymmetric reactive pupils
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Normal variant
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One pupil fixed and dilated
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Acute hemorrhage
|
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Both pupils pinpoint and minimally reactive
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-exposure to insecticides
-heroin overdose |
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Efferent parasympathetic fibers travel with which nerve
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CN III (oculomotor)
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Afferent limb of pupillary reflex arc
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CNII (optic)
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Efferent sympathetic fibers travel with which nerves
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superior cervical ganglion via the carotid sympathetic plexus
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How does a mass effect pupil size
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Compression on the third nerve will cause loss of parasympathetic input-->unopposed sympathetic input-->pupillary dilatation
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What do lesions at the level of the pons do to pupillary size?
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interrupt sympathetic fibers as they pass through MLF on their way to cervical sympathetic plexus-->unopposed parasympathetic input-->pinpoint pupil
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5 general indications for head CT in patients with AMS
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1) Trauma
2) SAH 3) Focal Neuro deficits 4) Papilledema 5) Other causes are ruled out |
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Retinal hemorrhage
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Subarachnoid hemorrhage
|
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hemotympanum
Battle's sign |
basilar skull fracture
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Pupil dilatation and contralateral hemiparesis
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Impending uncal herniation
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Absence of Doll's eyes
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Brainstem dysfunction
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Oculocephalic reflex
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Doll's eyes (normal)- eyes will remain looking straight ahead
Painted on pathologic Requires intact CN III (oculomotor) and CN VIII (vestibular) |
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Oculovestibular
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Cold water calorics
COWS (intact cortex) ->cold-water causes fast nystagmus opposite the stimulus, warm water will cause movement towards the stimulus Barbituates and sedatives may abolish this |
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Immediate management of patient with possible incranial process
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ABC OMI
1) mannitol 1 gm/kg IV 2) head CT 3) immediate neurosurg consult 4) endotracheal intubation and hyperventilation |
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Syncope
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Sudden, temporary loss of conciousness and loss of postural tone with spontaneous recovery
-fall in BP leading to impairment of cerebral perfusion that cannot be overcome by autoregulatory mechanisms |
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What drop in % of cardiac output is necessary to cause unconciousness in healthy adult
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Systolic BP <50
-cardiac output has to drop to 50% |
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What type of mechanical or obstructive cardiac disease can cause syncope
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1) IHSS
2) CHF 3) PE 4) Cardiac Tamponade |
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historical features of seizure
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Pre-seizure:
1) aura or prodrome 2) precipitants 3) Hx of seizures At time of Seizure: 1) tonic-clonic activity 2) tongue biting 3) incontinence Post-seizure: 1) Incontinence 2) post-ictal confusion 3) gradual recovery of MS |
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3 primary cardiac etiologies that would cause syncope due to bradycardia
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1) sick sinus (tachy-brady) syndrome
2) 2nd or 3rd degree heart block 3) pacemaker malfunction |
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What should you do in every patient with orthostatics?
What labs would be helpful |
rectal and orthostatics
CBC and BUN/Cr |
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Differential Diagnosis of AMS and Coma
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AEIOU TIPS
A = Alch and other toxins E = endocrine, electrolytes I = insulin (DM) O = oxygen/opiates U = uremia T = trauma, temperature changes I = Infection P = psychiatric/ porphyria S = SAH/ space-occupying lesion |
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With acute STEMI, what does evidence support
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1) call cath
2) ASA 3) One dose of LMWH, followed by unfractionated heparin IV 4) If going to cath, then IIb/IIIa inhibitor is beneficial -can add O2 and give morphine -If give Plavix-->irreversible platelet inhib, so cannot do CABG during this time -Beta-blocker are contraindicated in patients with: hypotension bradycardia asthma/copd acute CHF |
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What percentage of patients with MI have chest wall tenderness
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15%
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What are the most common sx of PE:
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-pleuritic chest pain (88%)
-dyspnea (84%) -cough (50%) -hemoptysis (30%) massive PE (>60% pulmonary capillary bed) -syncope, hypotension, RHF |
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How do you calculate A-a gradient?
What is normal |
A-a gradient = 150 - [PaO2 + (1.2 x PCO2)]
nl is <15mmHg |
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What is the value of EKG in "ruling out" MI as cause of chest pain
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-only has PPD; only helpful if shows new changes
-can only be used to rule in ischemia, not rule out -20-50% patients with acute MI have NL or non-specific EKG on presentation to ED |
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Immediate tx of PE
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supportive therapy, oxygen, and heparin anticoagulation
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What is use of ELISA D-Dimer for PE
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Very high sensitivity and NLR
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Patient with chest pain and bradycardia/ hypotension
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1) atropine 0.5mg IV
2) Fluid bolus of 250 cc NS 3) IV morphine for pain relief when BP imporved 4) serial repeat vitals |
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Therapy for tension Pneumothorax
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needle decompression followed by
tube thoracostomy |
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Dissection of the thoracic aorta
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control hypertension with sodium nitroprusside and beta-blocker
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Unstable angina
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Give sublingual nitro and beta-blocker to maximize myocardial oxygen delivery and minimize demand
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Treatment for inferior MI with posterior infarction
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-Oxygen
-Fluid bolus with normal saline prior to nitro administration -Nitro sublingual followed by IV nitro if pain continues -**ASA 325mg po -Beta-blocker IV -**heparin IV bolus then maintenance drip -Morphine IV as needed for pain -Immediate catheterization or thrombolytic therapy -IV GP IIb/IIIa inhib if going to cath lab -cath -admit to CCU or ICU |
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changes on EKG with unstable angina
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ST-T changes
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describe how the results of CPK with MB influence therapy and dispo.
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MB fraction is more specific for myocardial damage, but it takes 6 hrs from time of infarction to begin to see rise in CKMB or troponin
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What do you do if a patient with acute MI cannot go to cath lab for >1 hr
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give thrombolytics
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What are some signs that a patient may need active airway management
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-tolerating oropharyngeal airway (loss of gag reflex)
-breathing shallowly-->hypoventilation -s/p blunt head injury with persistent depressed mental status--> may indicate intracranial process--> needing hyperventilation to decrease intracranial pressure |
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How do you estimate ET tube size in infants and children?
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up to age 15:
16 + age (in yrs)/ 4 = ET tube size for those >15 yrs of age -->7.5 - 8 cm |
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What blade do you use to intubate
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#3 or #4 Miller or Macintosh
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What do you do if you cannot visualize cords while intubating, despite using various laryngoscope blades and repositioning techniques
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1) Use LMA (laryngeal mask airway)
2) Intubate over a bronchoscope 3) Intra-oral palpation and intubation over a lighted stylet |
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Name the 4 life-threatening Gynecologic emergencies
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-Toxic Shock
-Ruptured hemorrhagic cyst -Ruptured ectopic -ruptured TOA |
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What are importnat parts of GYN hx
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-LMP and timing of 2 or more immediate past menstrual periods
-changes in recent menstrual patterns -amount of bleeding |
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If LMP is normal and patient is <4wks passed LMP....
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...low chances of pregnancy complications since spontaneous abortions and ectopics do not occur before first missed period
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When can urine enzyme immunoassay be used to detect pregnancy
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2-4 wks after conception
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When can serum enzyme immunoassay be used to detect pregnancy
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1 wk after conception
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3 most common presenting sx of ectopic
incidence |
abdominal pain, amenorrhea, vaginal bleeding
20/1000 |
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Pregnant patient with abdominal pain:
-what are the 7 serious causes of abdominal pain |
1) ECTOPIC
2) THREATENED Ab 3) Inevitable/incomplete Ab 4) Complete Ab 5) Ruptured Corpus Luteum ( can exist up to 8th wk of pregnancy) 6) Molar Preg 7) Non-gyn (appendicitis) |
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Common serious gynecologic conditions causing abdominal pain in non-preg patient
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1) PID
2) Ovarian torsion 3) Mittelschmerz: in patients with regular 28-33 day cycle; occurs at days 14-16 with pain lasting <1 day 4) Ruptured corpus luteum cyst |
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What test COULD be ordered on patient with + pregnancy test and abd. pain to confirm dx
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1) quant: increases 66% every 2 days
(15% ectopics have nl incr,10% nl preg have abnl incr) 2) US 3) culdocentestis |
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when can US be used to visualize pregnancy?
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Abd US: (>6500 hCG)
-5th wk: gestational sac -6th wk: fetal pole -7th wk: fetal heart motion Vaginal US: (>2000 hCG) -can detect IUP @ 3 wks |
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tx of ectopic
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1) O2
2) Type and screen 3) RhoGam testing 4) Surgery |
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tx of threatened Ab
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1) bed rest
2) vaginal rest 3) RhoGam test 4) return if worsening sx (incr pain, bleeding, lightheadedness) 5)f/u with OB/GYN next 2 days |
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tx of inevitable/incomplete Ab
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-D + C
-RhoGam |
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tx Ruptured Corpus Luteum
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-surgical intervention with ovarian cystectomy
-outpatient tx contraindicated unless approved by OB |
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Differential for vaginal DC
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1) vulvovaginitis
2) cervicitis 3) PID |
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How dx PID
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Clinically:
~Abd pain ~adnexal pain ~cervical motion tenderness ~purulent cervical dc ~fever onset is usually shortly after menstrual flow |
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What lab test should you order with a suspected dx of PID
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1) preg. test
2) gram stain of DC (N. gon are g- diplococci 3) Culture of DC: for N. gon and C. trach 4) CBC: WBC 5) UA: if cystitis suspected |
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How distinguish TOA from PID
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TOA will have adnexal mass on exam or patient returning after 2 days of outpatient tx has failed to improve sx
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Outpatient Tx of PID
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Ceftriaxone 250mg IM and doxycycline 100mg bid for 10-14 days
-reevaluate in 2 days |
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Admission criteria for PID
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1) TOA
2) temp > 100.4 3) pregnancy 4) poor po tolerance 5) IUD in place 6) failure to respond to ABx after 48 hrs 7) uncertain dx 8) upper peritoneal signs (F-H-C syndrome) 9) WBC > 12,000 |
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If patient only has STD exposure, what is tx
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Ceftriaxone 125mg IM
and Azithromycin 1 gm PO |
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Admission criteria for pyelo:
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If elderly, debilitated, serious underlying dz, too toxic, -->admit
Rule of 2s: Young, healthy female with uncomplicated pyelo: give: -2 liters IV fluid -2 Tylenol #3 -2nd gen quinolone IV -2hrs of obs -If during 2 hr obs time, patient has 2glasses of water 2 degree decrease in fever can be dc'd with: -2 wks of levaquin po -2 day f/u to ensure improvement |
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4 major types of kidney stones
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1) Ca (oxalate or Phos) 75%
2) Mg-Amm-Phos 10% 3) Uric Acid 10% 4) Cystine/other 5% |
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When admit with kidney stone
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1) infxn with obstruction
2) One kidney with obstr 3) undontrolled pain 4) intractable emesis 5) large stone (>6mm only 10% chance of passing) |
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order of appearance of sx in appendicitis
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Pain, anorexia, n/v, change in bowel habits, fever
|
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Dz that can give elevated amylase
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-Peptic ulceration
-Liver dz -SBO -Common duct stones -Bowel infarction -ectopic -acute ethanol intox |
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Differential in acute appendicitis
|
acute chole
UTI or pyelo ureteral stone Yersinia enterocolitica PID Ectopic Mesenteric Lymphadentitis |
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Management of appendicitis
|
Fluids
Abx: Single dose of cefoxitin Pain meds: Morphine sulfate 5-10mg IV |
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How to stabilize for AAA
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-2 large bore IVs
-crystalloid bolus of 1-2liters -Type and cross 4 units PRBCs -STA call to vascular surg |
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Tx of perforated gastric ulcer
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-volume repletion with isotonic crystalloids
-transfusion of PRBCs prn -NG tube to empty stomach -pain relief (5-10mg morphine sulfate IV) -IV H2 blockers or PPIs -IV ABx and surg |
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If patient only has STD exposure, what is tx
|
Ceftriaxone 125mg IM
and Azithromycin 1 gm PO |
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Admission criteria for pyelo:
|
If elderly, debilitated, serious underlying dz, too toxic, -->admit
Rule of 2s: Young, healthy female with uncomplicated pyelo: give: -2 liters IV fluid -2 Tylenol #3 -2nd gen quinolone IV -2hrs of obs -If during 2 hr obs time, patient has 2glasses of water 2 degree decrease in fever can be dc'd with: -2 wks of levaquin po -2 day f/u to ensure improvement |
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4 major types of kidney stones
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1) Ca (oxalate or Phos) 75%
2) Mg-Amm-Phos 10% 3) Uric Acid 10% 4) Cystine/other 5% |
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When admit with kidney stone
|
1) infxn with obstruction
2) One kidney with obstr 3) undontrolled pain 4) intractable emesis 5) large stone (>6mm only 10% chance of passing) |
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order of appearance of sx in appendicitis
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Pain, anorexia, n/v, change in bowel habits, fever
|
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Dz that can give elevated amylase
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-Peptic ulceration
-Liver dz -SBO -Common duct stones -Bowel infarction -ectopic -acute ethanol intox |
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Differential in acute appendicitis
|
acute chole
UTI or pyelo ureteral stone Yersinia enterocolitica PID Ectopic Mesenteric Lymphadentitis |
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Management of appendicitis
|
Fluids
Abx: Single dose of cefoxitin Pain meds: Morphine sulfate 5-10mg IV |
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How to stabilize for AAA
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-2 large bore IVs
-crystalloid bolus of 1-2liters -Type and cross 4 units PRBCs -STA call to vascular surg |
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Tx of perforated gastric ulcer
|
-volume repletion with isotonic crystalloids
-transfusion of PRBCs prn -NG tube to empty stomach -pain relief (5-10mg morphine sulfate IV) -IV H2 blockers or PPIs -IV ABx and surg |
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narcotic toxidrome
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-constipated
-bradycardic -lethargic -miosis -coma |
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Anticholinergic toxidrome
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-dry as a bone
-mad as a hatter -red as a beet -hot as a hare -blind as a bat |
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Cholinergic toxidrome
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-salivation
-lacrimation -urination -defecation |
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sympathetic toxidrome
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tachycardic, increased bowel sounds, diaphoretic
|
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tx of anticholinergic syndrome
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physostigmine
supportive care -benzos |
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tx of cholinergic syndrome
|
pralidoxime
|
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TCA overdose
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QRS prolongation, inhibition of norepi and serotonin, alpha-blockade
tx with sodium bicarb and MG for torsades obs 6 hrs |
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Common precipitants of asthma
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1) PE
2) CHF 3) Mold 4) URI |
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Most common complication in pregnant asthmatic
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undertreatment by physician
|
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Differential dx of Wheezing
|
Asthma
Stasis/PE Toxin Heart/CHF Mechanical: foreign body Allergy Tumor Infection Congen |
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When should CXR be ordered in an asthmatic with wheezing
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Chest pain, fever, productive cough
|
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How treat CHF exacerbation
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1) NO
2) NO 3) NO 4) Lasix 5) Morphine 2mg IV |
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How do you tell if a patient has a pure respiratory acidosis
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change in pH of 0.08 for every change in pCO2 of 10
|
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Wheezes, tachycardia, pleuritic chest pain
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PE
|
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JVD, wheezes, rales, peripheral edema
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CHF
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Inspiratory wheezing, fever, sore throat
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epiglotitis
|
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wheezing, non-productive cough, irritant exposure
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asthma
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When should intubation be considered in asthmatics
|
confused or rising CO2;
pO2 on 100% O2 = <50 pCO2 > 50 |
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absolute contraindications to DPL
|
entry and exit wounds
|
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When agitated, what fluids should a patient be resusitated with
|
blood
and NS |
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How do you resuscitate during hemorrhagic shock
|
2L NS--> 2L NS-->Blood 2U-->Blood 2U
|
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How do you resuscitate during AOS
|
1L NS-->1L NS-->pressors (dopamine/Norepi)
|
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How do you resusitate kids in hem. shock
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20cc/kg-->20cc/kg-->10cc/kg PRBCs
|
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Where perform needle decompression
|
mid-clavicular line, 2nd intercostal
|
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Where perform chest tube
|
mid-axillary 5th intercostal
|
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Beck's triad is WHAT?
|
JVD; hypotension; decreased heart sounds
how treat? U/S guided needle decompression of pericardial tamponade |
|
WHat do you do when a patient's status acutely changes
|
ABC
|
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What if a stab wound occurs under the nipple line
|
Abd U/S
|
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How do you calculate fluid replacement for burn victims
|
TSA x Wt X 4 = 24hrs + maintanence
|
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A patient's hand equals what percent of BSA
|
1%
|
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what does each area of the body correspond to in BSA for burns
Infant? |
head: 9%
each arm: 9% front torsoe: 18% back torsoe: 18% penis: 1% Each leg" 18% Infant: legs are 13.5% each; head is 18% |
|
When does a patient have to be transferred to burn center
|
>20% second degreee burns
>3% third degree burns |
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WHat are the 1/2 lives of CO
|
RA = 4hrs
100% O2 = 40 min HBO2 = 4 min |
|
How do you treat burns
|
1) Pain meds (Morphine)
2) clean sheets 3) IV NS |
|
What are the 5 P's of Rapid Sequence Intubation
|
Preparation (Et tube, blade, suction)
Preoxygenation Pretreatment Paralysis (SUCCS for defascifculations + atomadate for sedation) Pass the Tube |
|
What is a septic workup for a child
|
1) UA
2) Blood cx 3) CXR 4) CBC 5) lytes 6) Consider LP If 2 mo and under do everything and admit |
|
Most common organisms for 0-2month old meningitis and tx
|
1) GBS
2) E. Coli 3) Listeria Ceftriaxone and Ampicillin with steroids at or before abx |
|
3mo --> 103 y/old
|
1) S. Pneumo
2) H. flu 3) N. Mening Ceftriaxone and Vanco + steroids |
|
Most common causes of seizures at 6mo - 3 yrs:
|
1) febrile seizures
2) meningitis 3) tauma 4) tox 5) space-occupying |
|
Most common 0-6mo
|
1) congen
2) metabolic 3) meningitis 4) hypocalc 5) hypoxemia 6) SIDS |
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tx for seizures
|
1) ativan 1mg
2) ativan 1mg 3) ativan 1mg 4) ativan 1mg 5) phosphenytoin 6) phenobarb 7) intubate |
|
common causes of stridor in children
|
1) retropharyngeal abscess
2) croup 3) foreign body |
|
tx of acute-angle glaucoma
|
-timolol
-acetazolamide -->decreases production by ciliary body -pilocarpine-->causes miosis |
|
Class I hem shock
|
(0-15%) volume
-bolus of 2L NS |
|
Class II hem shock
|
(16-30%) volume
-incr HR -bolus 2L NS |
|
Class III hem
|
cerebral hypoxia-->agitation
NS + blood (31-40%) |
|
Suture used with face
|
6.0 or 7.0
|
|
Suture used with scalp/extensor surfaces
|
3.0 - 4.0
|
|
Human bite
|
Augmentin 20 - 40 mg/kg daily dividded TID for 7 days
|
|
Fracture of proximal phalanx of 4th and 5th digits (boxer's)
|
short ulnar gutter
|
|
Fracture of first and second digits (proximal phalanx) and metacarpals
|
radial gutter
|
|
fractures of scaphoid and proximal phalanx and metacarpal of thumb
|
thumb spica splint
|
|
AMPLE Hx
|
Allergies
Medications PMH Last Meal Event |