Emergency Medicine 1b

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Emergency Medicine 1b
2011-05-18 16:23:09
DPAP2012 Emergency Medicine

Emergency Medicine 1 questions made by previous students
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  1. Definition of acute renal failure
    Rapidly deteriorating kidney function (accumulation of nitrogenous waste)
  2. Urine output less than 0.5-1cc/kg/hr (400cc/day in adults)
  3. Most common cause of acute renal failure
  4. No urine output
  5. Prerenal cause of ARF
    • Hypovolemia, ineffective circulating volumes (sepsis, anaphylaxis, third spacing),
    • decreased cardiac output (CHF, mi)
  6. What can cause dehydration?
    • Vomiting and diarrhea,
    • diuretics,
    • skin losses (burns)
  7. Renal origins of ARF
    • Tubulointerstitial,
    • glomerular,
    • vascular
  8. Postrenal origins of ARF
    • Ureteral or bladder obstruction,
    • urethral obstruction
  9. Causes of ureteral or bladder obstruction
    • Kidney stones,
    • blood clots,
    • malignancies,
    • prostatic hypertrophy
  10. Urethral obstructions
    • Strictures,
    • phimosis,
    • meatal stenosis
  11. What lab are you looking at to determine ARF?
    Creatinine >1.4
  12. Treatment for prerenal ARF
    • Volume replacement,
    • maximize cardiac output
  13. Treatment for renal ARF
    • Low dose dopamine,
    • mannitol in early rhabdomyolysis,
    • dialysis
  14. Treatment for postrenal ARF
    Relieve obstruction (Foley, ureteral stent, nephrostomy)
  15. Signs and symptoms of UTI
    • Dysuria,
    • frequency,
    • urgency,
    • hematuria,
    • urethral discharge,
    • pain (suprapubic, rectal, costovertebral)
  16. Most common UTI pathogen
  17. Safe UTI treatments during pregnancy
  18. Duration of treatment for uncomplicated UTI’s
    3 days
  19. Duration of treatment of pyelonephritis, pregnant patients with utis, complicated/frequent utis/prior treatment failure
    7-14 days
  20. Treatment for GC
    Ceftriaxone (Rocephin) IM
  21. Treatment for Chlamydia
    Azithromycin or doxycycline
  22. Treatment for trichomonas
    Metronidazole (Flagyl)
  23. Presentation of acute prostatitis
    • Fever,
    • malaise,
    • back or rectal pain,
    • rectal exam reveals swollen/firm/painful prostate
  24. Source of acute prostatitis in males<35 yo
    GC, chlamydia
  25. Source of acute prostatitis in males>35
    E-coli, klebsiella, Enterobacter, proteus
  26. Treatments for acute prostatitis
    Quinolone, Bactrim
  27. Presentation of urolithiasis
    • Flank pain (abrupt onset, severe, colicky, may radiate to scrotum),
    • N/V,
    • previous episodes,
    • CVA tenderness,
    • LQ pain
  28. What are some deadly diseases that can mimic presentation for kidney stones?
    • AAA,
    • appendicitis,
    • tuboovarian abscess,
    • ectopic pregnancy
  29. Any female of childbearing age with abdominal pain gets a work up for what
  30. Modality of choice for evaluation of urolithiasis in pregnant females
  31. Presentation of testicular torsion
    • Young men,
    • pain with abrupt onset (after exertion, or during sleep),
    • severe low abdominal/inguinal canal/scrotum,
    • N/V,
    • horizontal lie of testicle,
    • absence of cremasteric reflex
  32. Testicular torsion must be detorsed within __ for salvage
  33. Blue dot sign on translumination of testes is pathognomonic for what
    Testicular appendage torsion
  34. What is Prehn’s sign and what is it a sign of
    • Pain relief with elevation of testicle,
    • epididymo-orchitis
  35. Treatment for priapism
    • Subcutaneous terbutaline/phenylephrine,
    • Surgery
  36. Inability to retract the foreskin due to fibrous constriction or scar
  37. Inability to reduce retracted foreskin over the glans
  38. What is essential in the immediate treatment of chemical burns to the eye?
  39. When should treatment of a chemical burn to the eye begin?
    Before arrival at the emergency center
  40. If a patient has a chemical burn to the eye with an acidic substance should an attempt be made to neutralized it by adding an alkaline substance
  41. What should be done after 30 min of irrigation of an eye with a chemical burn?
    Check tear ph, if not 7, continue irrigation
  42. Bleeding in the anterior chamber of the eye
  43. What are some of the general guidelines in the treatment of hyphema?
    • Shield eye (no patch),
    • bedrest (with b/r privileges),
    • elevate head of bed to 30 degrees,
    • topical atropine, no aspirin/NSAIDs,
    • consider topical steroids,
    • monitor intraocular pressure
  44. What are some signs and symptoms of a corneal abrasion?
    • Sharp pain/foreign body sensation,
    • photophobia,
    • tearing,
    • fluorescein staining,
    • conjunctival injection,
    • swollen lid
  45. When considering a corneal abrasion what should be in your differential?
    • Dry eye/recurrent erosion syndrome,
    • infectious keratitis (bacterial ulcer, HSV, acanthamoeba, fungal ulcer)
  46. What do you include in the work-up of a corneal abrasion?
    • Slit lamp exam with fluorescein,
    • evert lids to rule out foreign body
  47. What is the treatment for a corneal abrasion in a non-contact lens wearer?
    • Erythromycin or Polytrim drops,
    • cycloplegic agent,
    • consider patch
  48. What is the treatment for a corneal abrasion in a contact lens wearer?
    • Must cover pseudomonas (tobramycin ointment, fluoroquinolone drop),
    • cycloplegic agent,
    • consider patch
  49. When should a corneal abrasion be referred to an ophthalmologist?
    • If not healed in 24 hours,
    • abrasion related to contact lens wear,
    • white corneal infiltrate develops
  50. Focal loss of corneal stroma with overlying epithelial defect
    Corneal ulcer
  51. What is the number one risk factor for corneal infection?
    Contact lens wear (overnight, swimming)
  52. What is the #2 risk factor for corneal infection?
    Trauma, corneal abrasion
  53. What should you do if you suspect infectious keratitis?
    Call an ophthalmologist
  54. What is the treatment for infectious keratitis?
    Broad spectrum antibiotic drops
  55. What should be included in the workup for central retinal artery occlusion?
    ESR for temporal arteritis
  56. What is the treatment for central retinal artery occlusion?
    Although no treatment has been proven to improve outcome you can try, lowering IOP with topicals, Diamox, anterior chamber paracentesis
  57. The immediate treatment for angle closure glaucoma is to lower eye pressure, how is this done?
    • Drops (timolol, dorzolamide, brimonidine),
    • oral agents (Diamox, isosorbide),
    • IV agents (mannitol), h
    • old pilocarpine until seen by an ophthalmologist
  58. What is endophthalmitis?
    • Inflammation of the tissue inside the eye caused by bacteria (coag neg staph, SA, gram -),
    • fungi, rarely viruses (Herpes simplex/zoster),
    • or protozoa (acanth, toxplasafi),
    • and is usually associated with eye surgery
  59. What are the symptoms of endophthalmitis?
    • Decreased vision,
    • pain,
    • redness (especially after eye surgery),
    • blurred vision (pretty generic)
  60. What is the treatment of endophthalmitis?
    Injection of intravitreal antibiotics or surgery ASAP
  61. What is the most common etiologic agent of viral conjunctivitis?
  62. What is the treatment for viral conjunctivitis?
    • Supportive,
    • throw out contact lens/case/solution,
    • wash sheets/towels,
    • wash hands religiously
  63. For how long is viral conjunctivitis contagious?
    2 weeks
  64. Conjunctivitis in an infant, assume what organisms?
    Chlamydia and or gonorrhea
  65. Gonococcal conjunctivitis requires __ treatment
  66. Acute, often red, infection of the sebaceous glands at the base of the eyelashes
  67. Chronic, often fibrotic, infection of the sebaceous glands at the base of the eyelashes
  68. Treatment for hordeolum/chalazion
    • Start conservatively,
    • warm compresses,
    • erythromycin ointment,
    • consider I&D,
    • steroids sometimes injected to prevent recurrence
  69. Inflammation along the eyelashes/meibomian glands (gritty burning eyes)
  70. Treatment of blepharitis
    Warm compresses, lid scrubs, consider erythromycin ointment or doxycycline
  71. Blepharitis with ulceration or lash loss consider __
  72. What are risk factors for retinal detachment?
    Myopia, trauma, family history, cataract surgery, detachment in the other eye
  73. What will happen to the pressure in an eye affected with a retinal detachment?
    May be lower
  74. What is significant in the history of a retinal detachment?
    Flashes or floaters
  75. What is the treatment for periorbital cellulitis?
    PO or IV antibiotics
  76. Elderly man with history of monocular vision loss, jaw pain, and recent weight loss, what are you suspicious for?
    Giant cell/temporal arteritis
  77. 29 year old woman with multiple sclerosis presents with acute loss of central vision in one eye, and pain with eye movements. What are you suspicious for?
    Optic neuritis
  78. What is a stye
    Acute infection of the oil gland at the lash line that appears as a pustule (aka external hordeolum)
  79. Treatment for stye (external hordeolum)
    • Warm wet compresses 4x day,
    • erythromycin ointment 2x/day for 7-10 days
  80. Acute or chronic noninfectious inflammation of the eyelid secondary to meibomian gland blockage in the tarsal plate
    Chalazion (internal hordeolum)
  81. Why has gentamicin fallen out of favor for the treatment of bacterial conjunctivitis?
    High incidence of ocular irritation
  82. Presents as monocular or binocular eyelash matting, mild to moderate mucopurulent discharge, and conjunctival inflammation
    Bacterial conjunctivitis
  83. Presents as a monocular or binocular watery discharge, chemosis, and conjunctival inflammation
    Viral conjunctivitis
  84. Treatment of viral conjunctivitis
    Cool compresses 4x/day, naphazoline/pheniramine drops for conjunctival congestion or itching. Follow up in 7-14 days
  85. Endophthalmos is a true __
    Ocular emergency
  86. How do patients with endophthalmos present?
    Pain and visual loss
  87. What is the initial empiric treatment for endophthalmos?
    Vancomycin and ceftazidime
  88. Periorbital cellulitis (preseptal cellulitis)
    A superficial infection of the eyelids that does not extend past the orbital septum. The eyelids become warm indurated and erythematous but he eye itself is not involved
  89. Orbital cellulitis (postseptal cellulitis)
    A potentially sight and life threatening ocular infection deep to the orbital septum, typically as a result of spread from the ethmoid sinuses
  90. How should superficial conjunctival abrasions be treated?
    • Erythromycin ointment 2x/day for 2-3 days,
    • ocular foreign body should be excluded
  91. What is the preferred topical ocular anesthetic used when assessing a corneal abrasion?
  92. How will a corneal abrasion appear during fluorescein stain when using cobalt blue light on slit lamp?
    It will fluoresce green
  93. What is the treatment for a simple corneal abrasion?
    • A cycloplegic (cyclopentolate, homatropine) for the pain,
    • and a topical antibiotic (tobramycin, erythromycin, bacitracin/polymyxin)
  94. What is the antibiotic treatment for a corneal abrasion for a person with contact lenses?
    Should include coverage for pseudomonas (ofloxacin or ciprofloxacin)
  95. How are superficial corneal foreign bodies removed?
    Under slit lamp microscopy with a fine needle, eye spud, or ophthalmic burr. Proparacaine is used (also instilled in the unaffected eye to depress reflex blinking)
  96. Who should remove a corneal foreign body deep within the corneal stroma, or in the central visual axis?
    An ophthalmologist
  97. What do you do for a high risk lid laceration if an ophthalmologist is not immediately available to evaluate and treat?
    As long as all sight-threatening lesions have been excluded prescribe oral and topical antibiotics and gentle cold compresses with referral to an ophthalmologist in 24 hours
  98. A hyphema should be dilated with __ to prevent pupillary movement from tearing damaged blood vessels
    Atropine 1%
  99. What orbital walls do blowout fractures commonly involve?
    Inferior and medial
  100. Which muscle is usually entrapped in a blowout fracture, and what does it cause?
    • Inferior rectus muscle.
    • May cause restricted movement, resulting in diplopia on upward gaze
  101. What must be avoided once a globe injury is suspected?
    Any further manipulation or examination of the eye
  102. Severe subconjunctival hemorrhage, shallow or deep anterior chamber, hyphema, teardrop-shaped pupil, limited extraocular motility, extrusion of globe contents, reduction in visual acuity can all mean what?
    Ruptured globe
  103. A bright green streaming appearance to fluorescein instilled into the tear layer (Seidel test) is pathognomonic for what?
    Penetrating trauma or ruptured globe
  104. Treatment for ruptured globe
    • Call ophthalmologist immediately.
    • Metallic eye shield,
    • first gen cephalosporin,
    • antiemetic (prevent Valsalva),
    • tetanus update,
    • CT to look for foreign body.
  105. How long after the first 2L of irrigation fluid should you wait to check the ph in an eye that has suffered a chemical burn?
    5-10 minutes
  106. What should you do for an eye that has been chemically burned and continues to have an abnormal ph despite being irrigated with 8-10 L of fluid?
    The fornices should be inspected thoroughly and re-swept with a moistened tip applicator
  107. What ocular condition classically presents with eye pain or headache, cloudy vision, colored halos around lights, conjunctival injection, a fixed mid-dilated pupil and increased IOP of 40-70 mmhg?
    Acute angle closure glaucoma
  108. What is a normal range for IOP?
    10-20 mm Hg
  109. What can precipitate an attack of acute angle closure glaucoma in a patient with narrow anterior chamber angles?
    • Movie theaters,
    • reading,
    • ill-advised use of dilatory agents or inhaled anticholinergics
  110. What are some treatments used to reduce IOP?
    • Timolol,
    • apraclonidine,
    • prednisolone acetate drops
  111. What can you use to decrease pressure if the IOP is greater than 50 mmhg?
    Acetazolamide IV
  112. What can you use to decrease IOP if it does not do so with first line agents after 1 hour?
    Give 1-2g/kg mannitol IV
  113. Once IOP is below 40 mmhg in acute angle closure glaucoma, what can be given as long as the patient has an intact lens in place?
    Pilocarpine drops
  114. Presents with acute vision loss with a particular reduction in color vision (red desaturation test), often painful especially with eoms
    Optic neuritis
  115. What can often be detected in Optic Neuritis?
    Afferent pupillary defect
  116. Presents as a sudden painless, severe monocular loss of vision, often associated with a history of amaurosis fugax
    Central retinal artery occlusion
  117. Causes acute, painless monocular vision loss. Examination shows optic disc edema, cotton wool spots, and retinal hemorrhages in all quadrants (blood and thunder fundus)
    Central retinal vein occlusion
  118. A systemic vasculitis that can cause a painless ischemic optic neuropathy?
    Giant cell arteritis
  119. Who is the typical patient with giant cell arteritis?
    Women older than 50 years, often with a history of polymyalgia rheumatica
  120. What are associated symptoms of giant cell arteritis?
    • Headache,
    • jaw claudication,
    • scalp or temporal artery tenderness,
    • fatigue,
    • fever,
    • anorexia
  121. What is may be seen on funduscopic exam with giant cell arteritis?
    Flame hemorrhages
  122. What labs should be ordered when giant cell arteritis is suspected?
    • Sed rate,
    • c-reactive protein
  123. What should be done if there is a strong suspicion of giant cell arteritis?
    The patient should be admitted for methylprednisolone 250 mg IV every 6 hours
  124. What may be done if there is a low suspicion for giant cell arteritis?
    The patient may be discharged with prednisone with close follow up
  125. Hyphema work-up
    • Assume open globe;
    • poss CT (if suspect blow out fx);
    • poss US to r/o vitreous hemo or retinal detach;
    • SPE (pts w/SCD)
  126. What is the most life threatening gynecologic cause of acute abdomen in the female patient?
    Ectopic pregnancy
  127. Amylase is elevated in __
    • Pronounced: acute pancreatitis;
    • moderate: small bowel obstruction, salivary gland infxn/inflam, mumps, panc ca, perf'd peptic ulcer
  128. ALT/AST is elevated in __
  129. Bilirubin/Alk Phosphatase is elevated in __
    Common bile duct obstruction
  130. Never place __ above an obstruction
  131. Indications for barium studies
    Volvulus, colon cancer, mucosal detail
  132. Barium studies are not only useless for evaluation of __ they are dangerous
  133. For what disease process are the five F’s used for
    Acute cholecystis
  134. Five F’s of acute cholecystis
    • Female,
    • Fertile,
    • Forty,
    • Fat,
    • Flatulent
  135. Murphy’s sign is used to help diagnose __
    Acute cholecystitis
  136. Periumbilical pain that migrates to RLQ, anorexia is a possible history of __
    Acute appendicitis
  137. Obturator sign/psoas sign is used to help diagnose __
    Acute appendicitis
  138. __ hours after acute appendicitis symptom onset there is a >95% perforation rate
  139. What is the rule of 2’s for Meckel’s diverticulitis?
    • 2% of the pop,
    • 2 feet proximal to the ileocecal valve,
    • 2 types of mucosa,
    • 2 years of age,
    • 2:1 M:F ratio
  140. What is the treatment for Meckel’s diverticulitis?
  141. Severe epigastric pain radiating to the back, often associated with ETOH, usually elevated amylase/lipase
    Acute pancreatitis
  142. Distended abdomen, surgical scars, high pitched bowel sounds, tympanic to percussion, nausea w/ bilious vomiting, constipation, often severely dehydrated
    Small bowel obstruction
  143. Non-operative treatment for small bowel obstruction
    • NPO,
    • NGT (decompression),
    • IV fluids
  144. Most common causes of large bowel obstruction
    • Diverticulitis,
    • cancer,
    • volvulus
  145. LLQ pain, fever
  146. Sudden onset of sharp ab pain, N/V, diarrhea, GI bleeding, pain out of proportion to physical exam, may have history of angina, atherosclerosis, smoking
    Mesenteric ischemia
  147. Midline ab pain with tearing sensation to the back, patients often present in shock, exam reveals pulsatile mass
    Ruptured AAA
  148. >__ cm AAA has an increased risk of rupture 20-30% within 5 years
  149. Patients with __ pain tend to lie still
  150. Patients with __ pain tend to move about
  151. __ should be considered in any patient older than 50 with ab pain out of proportion to physical findings
    Mesenteric ischemia
  152. CT is the preferred imaging modality for what emergencies
    Pancreatitis, biliary obstruction, aortic aneurysm, appendicitis, and urolithiasis
  153. __ in appropriate doses may decrease guarding and improve localization of abdominal pain
  154. Antiemetics such as __ increase patients comfort and facilitate assessment of S/S
  155. What is the most reliable symptom of appendicitis?
    Abdominal pain
  156. Palpation of the LLQ quadrant with pain referred to the RLQ is referred to as the __ and is indicative of __
    Rovsing’s sign, acute appendicitis
  157. The diagnosis of acute appendicitis is generally __
  158. The most significant predictors of acute appendicitis in the elderly are __
    Tenderness, rigidity, pain at diagnosis, fever, and previous abdominal surgery
  159. What are the main features of intestinal obstruction?
    Crampy, intermittent, progressive ab pain
  160. What causes the pseudoobstruction that commonly occurs in the low colonic region?
    Depression of intestinal motility from medications such as anticholinergic agents, or tricyclic antidepressants
  161. In the case of pseudoobstruction what is diagnostic as well as therapeutic
  162. Predominant means of diagnosis for hernias
    Physical examination
  163. Should you attempt hernia reduction if there is a question about the duration of the incarceration?
  164. __ hernias in children are common
  165. When should a child with an umbilical hernia be referred for surgical evaluation?
    Children older than 4 or with hernias greater than 2cm in diameter
  166. R/LLQ pain, purulent cervical dc, CMT, adnexal tenderness =
    Tubo-ovarian abscess
  167. AAA risk factors
    • Atherosclerosis,
    • elderly,
    • HTN,
    • smoking,
    • CTD/Marfan,
    • +FH,
    • hyperlipidemia
  168. S/S in abd trauma
    • Seat belt sx;
    • Chance fx;
    • Grey Turner sx;
    • Cullen sx
  169. Chance fx
    Ecchymosis across lower abd 2/2 seat belt, assoc L-spine fx
  170. Grey Turner sx
    • Ecchymosis over flanks,
    • usu dev after 12 hrs = retroperitoneal hemo
  171. Cullen sx
    • Ecchymosis over umbilicus,
    • usu dev after 12 hrs = retroperitoneal hemo
  172. Mesenteric ischemia: cause
    Embolus to SMA 2/2 intracardiac thrombus 2/2 A-fib
  173. Pancreatitis s/s
    • Fever,
    • tachy;
    • poss tachypnea,
    • hypoxia,
    • dec breath sounds if pleural effusion;
    • hypoactive BS,
    • guarding,
    • TTP;
    • abd distension if ileus;
    • Cullen & Gray Turner sxs if hemo
  174. Pancreatitis tx
    • Supportive: IVF 2/2 n/v;
    • NPO, poss NG tube;
    • pain ctrl
  175. SBO tx
    • NGT for bowel decompression;
    • surg;
    • IVF 2/2 n/v;
    • broad abx (Flagyl, amp/ gent)
  176. SBO s/s
    • Colicky abd pain in waves, n/v, obstipation;
    • tachy, hypotension;
    • no peritoneal sxs;
    • early: Distended tympanitic;
    • later: tinkling BS
  177. Tx for diarrhea 2/2 Shigella, Yersinia, ETEC, V cholerae
    Oral quinolone
  178. Infxs diarrhea: no abx for:
    • SA,
    • B cereus;
    • salmonella,
    • EHEC
  179. Ranson's criteria predict M&M for:
  180. What is the suspensory ligament of the duodenum?
    Ligament of Treitz
  181. What is the most common cause of lower GI bleeding?
  182. Common, painless and can be massive, caused from an erosion into penetrating artery from the diverticulum
  183. What is the most common cause of upper GI bleed?
    Peptic ulcer disease
  184. Cause of esophageal and gastric varices
    Portal hypertension
  185. Longitudinal mucosal tear in the cardioesophageal region, caused by repeated retching
    Mallory-Weiss syndrome
  186. Common cause of lower GI bleeding, seen in people with hypertension and aortic stenosis
    Arteriovenous malformations
  187. Spider angiomata, palmer erythema, jaundice, and gynecomastia are seen in __
    Liver disease
  188. Petechiae and purpura seen in __
  189. Why would you do a careful ENT exam on a patient suspected of GI bleed?
    Rule out causes that can mimic GI bleed such as epistaxis
  190. Can be diagnostic and therapeutic but requires a brisk bleed at .5-2ml/min
  191. Can only be diagnostic but are more sensitive than angiography and require a bleeding rate of only .1ml/min
    Bleeding scans
  192. Is diagnostic and therapeutic and more accurate than bleeding scans and angiography
  193. Class __ bleed replace volume with crystalloid
    I and II
  194. Class __ bleed replace volume with crystalloid and blood
    III and IV
  195. Hemorrhaging is broken down into how many categories by the ACS
  196. Class __ hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary
  197. Class _ hemorrhage involves 15-30% of total blood volume. A patient is often tachy, narrowed pulse pressure. Peripheral vasoconstriction, pale cool skin, slight changes in behavior, volume resuscitation with crystalloids
  198. Class __ hemorrhage involves loss of 30-40% of blood volume; pt’s BP drops, HR increases, peripheral perfusion decreases (prolonged cap refill), mental status worsens; crystalloid & blood transfusions usually necessary
  199. Class __ hemorrhage involves loss of >40% of blood volume; limit of body’s compensation is reached and aggressive resuscitation is required to prevent death
  200. __ ulcers do not extend through the muscularis mucosa
  201. Only __ % of patients who are infected with H. Pylori will develop ulcers
  202. Inhibits bicarbonate ion production and increases gastric emptying
    Cigarette smoking
  203. Main complaint of gastric ulcer
    Gnawing, aching or burning epigastric pain
  204. Physical exam of uncomplicated PUD, there may be a finding of __
    Epigastric tenderness
  205. Inhibit gastric acid secretion, equally as effective as antacids with better compliance due to decreased frequency of doses
    H2 antagonists
  206. Inhibits gastric acid secretions, heals ulcers faster than H2-antagonists and antacids
  207. Locally binds to the base of the ulcer and therefore protects it from acid
  208. Prostaglandin E1 analogue which acts as natural prostaglandin in the body
  209. Vomiting and diarrhea is most often __
  210. Which is more common: upper or lower GI bleeding?
  211. What is the most common cause of acute lower GI bleeding?
    Hemorrhoids, followed by diverticular disease
  212. What is the most important lab test for a patient with a significant GI bleed?
    Type and crossmatch
  213. When is surgical treatment for hemorrhoids indicated?
    Severe, intractable pain, continued bleeding, incarceration, or strangulation
  214. Treatment of choice for patients with pseudomembranous colitis
    Metronidazole for mild to moderate disease in patients who do not respond to supportive measures
  215. __ should be reserved for patients with pseudomembranous colitis who have not responded to or are intolerant of metronidazole and for children and pregnant patients
  216. For patients with pseudomembranous colitis __ may prolong or worsen symptoms and should be avoided
    Antidiarrheal agents
  217. Mackler triad
    Sx of esophageal perf: vomiting, chest pain, subq emphysema
  218. Oliguria =
    Output <400 cc/day (or 0.5-1.0 cc/kg/hr)
  219. Pre-renal ARF: ineffective circulating volumes; may be due to:
    • Sepsis (early);
    • Anaphylaxis;
    • 3rd space sequestration (pancreatitis, peritonitis, ischemic bowel)
  220. Renal ARF: glomerular causes
    Post-infective glomerulonephritis (GAS, after 1-3 wks; pneumococcus, staph); SLE; Vasculitis; H-S purpura
  221. Renal ARF: vascular causes
    • Thrombosis;
    • TTP/ DIC;
    • NSAID OD;
    • Severe HTN;
    • HUS
  222. Renal ARF: tx
    • LD dopamine;
    • Mannitol in early rhabdomyolysis;
    • Dialysis
  223. UTI tx
    • Sulfonamides;
    • FQ;
    • Nitrofurantoin (safe in pregnancy);
    • use 3 days;
    • 7 days if: Pyelonephritis; PG; complicated, frequent utis / Prior tx failure
  224. UTI: cx if:
    • Pyelonephritis;
    • Resistant or recurrent utis;
    • Men
  225. 90% of stones are:
  226. Calcium oxalate or phosphate stones
    • 75%;
    • occasionally with chronic hypercalcemia (hyperparathyroidism)
  227. Magnesium – ammonium – phosphate (struvite) stones
    • 15%;
    • secondary to recurrent infection (urease producing bacteria)
  228. Uric Acid / cystine stones
    History of gout
  229. Stones: ddx
    • AAA;
    • Appendicitis;
    • Tuboovarian Abscess (TOA);
    • Ectopic Pregnancy
  230. Urolithiasis: dx imaging
    • Noncontrast CT (high sensitivity);
    • US (hydronephrosis; good for PG);
    • KUB (less specific)
  231. Urolithiasis admit criteria
    • Infection / Sepsis;
    • Complete Obstruction;
    • Deteriorating renal fn;
    • Intractable N/V;
    • Solitary kidney;
    • Very large or proximal stones
  232. Epididymitis has a _______ onset
  233. Spermatocele
    • Asx;
    • separate from & superior to testicle;
    • aspiration: white cloudy fluid
  234. Testicular tumor
    • Firm, nontender mass;
    • does not transilluminate
  235. Treatment priorities for sepsis
    • Oxygen,
    • aggressive fluid replacement,
    • vasopressors (dopamine, dobutamine, norepi, vasopressin)
  236. Empiric broad spectrum antibiotics used in sepsis
    • 3rd gen cephalosporins + aminoglycoside (ceftazidime and gentamicin),
    • +/- vancomycin (MRSA)/clindamycin (anaerobes)
  237. Recombinant human activated protein C, only FDA approved drug used solely for the treatment of sepsis in the adult patient with high risk of death. Only for use in the ICU
  238. Empiric treatment for bacterial meningitis
    • Begin antibiotics immediately (ceftriaxone or cefotaxime 2 g IV and vanc.
    • Add ampicillin for pts <3months/>55 and or immunocompromised
  239. What do you add to empiric therapy for meningitis if HSV is suspected?
  240. What do you give concurrently with empiric antibiotics when treating bacterial meningitis?
    Dexamethasone, continue for 4 days
  241. Supportive care for bacterial meningitis
    Hydration, pain meds, anticonv, antiemetics
  242. Outpatient antibiotics for pneumonia
    • Azithro,
    • doxy,
    • levo,
    • cefpodoxime+azithro
  243. Inpatient regimens for pneumonia
    • Ceftriaxone+azithro,
    • resp fluoroq,
    • +/- vanc
  244. Duration of tx for uncomplicated cystitis in non-pregnant women/men
    3-5 days
  245. What is the duration of treatment for uncomplicated cystitis in children, preg women, and complicated infections in everyone else?
    7-10 days
  246. Antibiotics for cystitis
    • Tmp/smz,
    • nitrofurantoin,
    • quinolones,
    • cephalexin
  247. Treatment for pyelonephritis
    • Cipro 7-10 days,
    • levo for 7 days,
    • Augmentin 10 days,
    • cephalexin 10 days
  248. Treatment of impetigo
    • Cephalexin,
    • diclox,
    • mupirocin,
    • retapamulin
  249. Outpatient treatment for cellulitis
    • Cephalexin,
    • diclox,
    • augmentin,
    • doxy,
    • minocycline,
    • (MRSA) tmp/smx-bactrim or clinda
  250. Inpatient treatment for cellulitis
    • IV clinda,
    • IV vanc +/- cefazolin
  251. Treatment of a fresh bite <24 hours old
    • Exploration/irrigation/immobilization,
    • primary closure if face/head/neck,
    • tetanus/rabies prophylaxis
  252. Prophylactic antibiotics for fresh bite
    • Augmentin,
    • moxifloxacin,
    • clindamycin + ciprofloxacin
  253. Incubation of malaria in returning travelers
    Varies from <2 weeks to >6 weeks
  254. PID tx
    Ceftriaxone + azithromycin OR doxycycline + metronidazole (outpatient)
  255. Chancroid tx
    Ceftriaxone or zithro (1 dose)
  256. Meningitis bugs: neonates
    • GBS, E coli, listeria;
    • tx = amp & cefotaxime (Claforan)
  257. Meningitis bugs: 1 mo - 50 yo
    SP, Neisseria, H flu
  258. Meningitis bugs: >50 yo / etoh
    • SP, listeria;
    • tx = amp + rocephin + dex
  259. Meningitis tx: 1 - 3 mos
    Amp + (rocephin or cefotaxime) + Dex
  260. Meningitis tx: 3 mos - 50 yo
    (rocephin or cefotaxime) + vanc + Dex
  261. PEP for meningitis
    • Post exposure prophylaxis = rifampin for household contacts/droplet exp only;
    • alts = cipro or rocephin
  262. Labs to get in the w/u of sepsis
    • CBC,
    • chems (lfts, bicarb, creatinine),
    • PT/PTT,
    • Lactate
  263. An important marker of global tissue hypoxia
  264. Additional labs to evaluate source of sepsis
    • Blood cultures,
    • UA,
    • urine C & S,
    • CXR,
    • discharge from lesions,
    • sterile fluids if suspected
  265. CSF tube 1 is used for what purpose
    Appearance; cell count/diff
  266. CSF tube 2 is used for what purpose
    Glucose and protein
  267. CSF tube 3 is used for what purpose
    Gram stain and culture
  268. CSF tube 4 is used for what purpose
    Cell count with differential
  269. What patients with cystitis should get a urine culture?
    Anyone who is not a healthy young female
  270. Pneumonia labs
    • CBC;
    • CXR;
    • sputum gr stain/cx;
    • Blood cx;
    • Pulse ox,
    • ABG;
    • Urine for streptococcal and Legionella antigen;
    • PCR assays;
    • Serologies;
    • Influenza rapid antigen
  271. Septic arthritis: Joint fluid analysis
    • Cell count/diff (WBC <200 normal; septic >50-60K);
    • Diff: <25% PMN normal;
    • >50% PMN infxs/inflam;
    • Gr stain/cx;
    • Crystals
  272. What should be included in the workup for central retinal artery occlusion?
    ESR for temporal arteritis
  273. What should be done in the case of orbital cellulitis?
    Emergent CT of the orbits and sinuses, ophthalmologic consultation and admission for cefuroxime IV
  274. What is the preferred topical ocular anesthetic used when assessing a corneal abrasion
  275. How will a corneal abrasion appear during fluorescein stain when using cobalt blue light on slit lamp
    It will fluoresce green
  276. A hyphema should be dilated with __ to prevent pupillary movement from tearing damaged blood vessels
    Atropine 1%
  277. A bright green streaming appearance to fluorescein instilled into the tear layer (Seidel test) is pathognomonic for what
    Penetrating trauma or ruptured globe
  278. What is a normal range for IOP?
    10-20 mm Hg
  279. What may be seen on funduscopic exam with giant cell arteritis?
    Flame hemorrhages
  280. What labs should be ordered when giant cell arteritis is suspected?
    Sed rate,c-reactive protein
  281. Hyphema work-up
    • Assume open globe;
    • poss CT (if suspect blow out fx);
    • poss US to r/o vitreous hemo or retinal detach;
    • SPE (pts w/SCD)
  282. MI labs
    Troponin, CKMB
  283. AAA imaging
    Xray: calcified arch or paravert ST mass; u/s accurate for dx/measuring diameter; CT most sensitive for ruptured AAA
  284. Imaging modality of choice for acute pancreatitis
  285. Imaging modality of choice for aortic aneurysm
  286. Imaging modality of choice for acute appy
    CT w/contrast: shows walls >2mm, abscess, free fluid, RLQ fat stranding, appendicolith
  287. Imaging modality of choice for biliary obstruction
    U/s is definitive initial test for GS; u/s or HIDA for cholecystitis; xray/CT for porcelain; u/s or ERCP for choledocho
  288. GI bleed labs
    CMP, CBC (H&H), type & cross, coags; BUN often elevated 2/2 GI blood breakdown; ECG; poss NG tube to distinguish upper/lower
  289. GIB: angiography requires bleeding rates of:
    0.5 - 2.0 ml/min
  290. Imaging TOC for upper GIB =
  291. GIB IVF resuscitation
    3:1 rule - 3L crystalloid per 1L blood lost
  292. GIB rfs
    • ETOH,
    • NSAIDs,
    • steroids,
    • anticoag meds
  293. Mesenteric ischemia TOC
    • Angio/CTA;
    • abd xray/CT shows wall thickening / pneumatosis intestinalis
  294. Biliary labs
    • ECG,
    • CBC,
    • lytes,
    • LFTs,
    • bili, amylase,
    • lipase,
    • UA,
    • bhCG
  295. Appendicitis labs
    • UA,
    • CBC,
    • bhCG
  296. What radiographs should be obtained to assess for intestinal obstruction
    Flat and upright abdominal, and upright chest
  297. Pancreatitis labs
    • Elev WBC,
    • hypocalcemia;
    • Sens/Sens: lipase > amylase (both high in acute)
  298. Fever, all peds:
    • Ua/ucc;
    • poss cxr
  299. Fever (>38C), <28 days old
    • Admit;
    • ucc,
    • blood cx,
    • LP,
    • poss cxr;
    • IV amp/gent
  300. Fever (>38C), 28 day - 3 mos
    • Ucc,
    • blood cx,
    • LP,
    • poss cxr;
    • Rocephin 50 mg/kg;
    • dc if cxs neg;
    • f/u in 24hr
  301. Fever (>39C), 3 mos - 3 yo
    • Ucc,
    • poss cxr,
    • stool cx; close f/u
  302. Imaging TOC for pyloric stenosis
    • U/S;
    • spec, not always sensitive;
    • 2nd line: upper GI series: shows string sign
  303. Imaging TOC for PE
    • ECG, CXR (atelectasis, pl effusion, elev hemidiaphragm); gold std = pulmonary angiogram, but
    • Invasive (mort = 1-5%), so most 1st order V/Q scan
  304. Testing for suspected stroke
    • Glucose,
    • EKG,
    • lytes,
    • CBC,
    • coag
  305. Imaging tests for stroke
    • CT: noncontrast detects hemo, ischemic visible after 6 hrs;
    • MRI sensitive for posterior fossa or <6 hr;
    • gold std: angio
  306. Meningitis testing
    • CBC,
    • coag,
    • blood cx;
    • CT (r/o mass lesion) before LP;
    • empiric abx
  307. CSF, viral meningitis
    • Opening pressure <200,
    • WBC <1000 & <50% PMN,
    • glucose >40,
    • pro <200,
    • neg Gr Stain / cx
  308. CSF, bacterial meningitis
    • Opening pressure >300,
    • WBC >1000 & >80% PMN,
    • glu <40,
    • pro >200,
    • pos Gr Stain / Cx
  309. Seizure labs
    • Anticonvulsant levels;
    • lytes,
    • glu,
    • tox screen,
    • poss CK;
    • poss LP
  310. Seizure tx
    • 1stline: benzos (versed, Ativan, valium),
    • poss phenobarb;
    • 2ndline: Dilantin, Depakote;
    • Mg sulfate: eclampsia
  311. Status epilepticus tx
    • Pentobarb infusion (coma),
    • isoflurane aesthesia
  312. SAH testing
    • CT 90% sensitive, esp within 12 hrs;
    • LP 98%, esp >12 hrs, when xanthochromia present
  313. AMI labs: troponin
    Troponin rises first & stays high 5 to 14 days, and is most sensitive/specific for MI
  314. AMI labs: CK-MB
    CKMB rises within 4 hours and peaks at 24 hrs
  315. CHF xray
    • Cardiomegaly,
    • pulmo edema (plump vessels, interstitial / alveolar edema, Kerley B lines)
  316. Imaging for aortic dissection
    • CXR: widened mediastinum, poss tracheal deviation to right, left hemothorax;
    • CT contrast;
    • TEE to ID type & valvular involvement;
    • aortography is gold std but invasive
  317. Feeling of difficult, labored or uncomfortable breathing
  318. Rapid physical exam for respiratory distress
    • Oropharynx,
    • neck,
    • cardiac,
    • chest exam,
    • pulmonary,
    • skin
  319. What do you look for in the oropharynx in the setting of respiratory distress?
    Appearance of uvula, foreign body
  320. What do you look for in the neck exam in the setting of respiratory distress?
    Tracheal deviation, distended neck veins, stridor
  321. What do you look for in the cardiac exam in the setting of respiratory distress?
    Rate and rhythm
  322. What do you look for in the chest exam in the setting of respiratory distress?
    Equal rise, trauma
  323. What do you look for in the pulmonary exam in the setting of respiratory distress?
    Rales, crackles, wheezing, equal breath sounds
  324. What do you look for in the skin exam in the setting of respiratory distress?
    Color, temperature, diaphoresis
  325. Arbitrarily defined as a Pao2<60mmhg, correlates with O2 sat 90%
  326. Segmental fracture of 3 or more adjacent ribs in two or more places of each individual rib, results in paradoxical respiration
    Flail chest
  327. Tall lanky guy who smokes, with sudden onset of dyspnea, what is it?
    Tension pneumothorax
  328. Chest pain worse on breathing in, leaning forward, and on palpation
    Pleuritic chest pain
  329. Accumulation of fluid in alveoli resulting in impaired gas exchanged and subsequent hypoxia
    Pulmonary edema
  330. Characterized by inflamed airway tissue and excessive mucus production
  331. COPD treatment
    Steroids, use of NIPPV:CPAP or bipap, careful use of O2 (goal of pao2 at least 60mmhg), broad spectrum antibiotics
  332. History: pleuritic chest pain, dyspnea (may be intermittent), cough, hemoptysis, anxiety. Physical findings: tachypnea, tachycardia, fever, hypotension, signs of DVT. What is it
    Pulmonary embolism
  333. Do you get a d-dimer on patients who you have a high suspicion or low suspicion for pulmonary embolism
  334. Cornerstone of treatment for pulmonary embolism
    LMWH, heparin, Coumadin
  335. Biggest reason to perform the Sellick maneuver
    To prevent aspiration
  336. Flail chest: indicators for early intubation include
    Persistent arterial Po2<80, shock, age>65, severe head injury, comorbid pulmonary disease
  337. What should be done immediately for the patient with a tension pneumo?
    14-16 ga catheter should be inserted into anterior chest wall (2nd intercostal space at midclavicular line)
  338. What is the definitive treatment for a tension pneumo?
    Inflation of affected lung with evacuation of pleural air via a chest tube
  339. Who is at risk for aspiration pneumonia?
    Nursing home patients, alcoholics, patients on sedatives, narcotics users, patients with GERD
  340. What are some causes of non-cardiogenic pulmonary edema?
    Drug overdose, sepsis, pulmonary contusion
  341. Treatment for pulmonary edema
    • 100% O2,
    • noninvasive positive pressure vent CPAP or bipap (consider intubation for obtunded patients),
    • NTG,
    • morphine,
    • diuretics (Lasix),
    • Foley (for the Lasix you just gave),
    • treat underlying cause
  342. What are the two phases of asthma?
    • Acute bronchoconstriction,
    • sub-acute airway inflammation and mucous plugging
  343. What are some ominous signs of impending respiratory failure in someone with asthma?
    A quiet chest, agitation or confusion
  344. What are red flags in an asthma patient?
    Fever, productive cough, immunosuppression, elderly or very young
  345. Asthma treatment
    • Supplemental oxygen,
    • beta agonist (albuterol/smooth muscle relaxation),
    • anticholinergic (Atrovent/decreased mucous production),
    • epinephrine (if impending resp failure),
    • steroids (treat late phase and prevent rebound)
  346. Characterized by inflamed airway tissue and excessive mucus production. Coughing on most days for 3 month in 2 consecutive years
  347. Alveoli loose ability to stretch and thus become weak, and break resulting in inability of the lung to exchange CO2 and O2
  348. What is the treatment goal of COPD?
    Pao2 of at least 60mmhg
  349. What are some hypercoagulable states (in PE)?
    Malignancy, pregnancy, postpartum, estrogen use, genetic mutations, Pro C/S deficiency
  350. Risk factors for pulmonary embolism
    Hyper-coagulable state, vascular injury, venous stasis
  351. Bed rest > __ hours can lead to venous stasis and put the patient at risk for PE
  352. Gold standard for the diagnosis of PE
    Pulmonary angiography
  353. Causes of cardiogenic pulmonary edema
    • H/O CHF or ESRD,
    • new onset arrhythmia,
    • medication noncompliance,
    • dietary indiscretion
  354. Pulmonary edema: ancillary tests
    • Pulse Ox,
    • blood gas,
    • BNP,
    • chemistry,
    • cardiac markers,
    • EKG;
    • Urine/Serum,
    • toxicology screen
  355. Pulmonary embolism: ancillary imaging tests
    • Doppler US;
    • CT (may miss small peripheral PE);
    • V/Q scan;
    • pulmonary angiography
  356. Pulmonary embolism: tx
    • Anticoagulation (cornerstone of tx; LMWH, hep, warfarin);
    • thrombolysis (for pts in extremes);
    • embolectomy (rare);
    • IVC filter (recurrent DVT/PE pt on anticoag)
  357. Miller laryngoscope blade
    • Straight;
    • Lifts epiglottis directly
  358. Macintosh laryngoscope blade
    • Curved;
    • Lifts vallecula (indirectly lifting epiglottis)
  359. ET tube sizes
    • M 8.0-8.5;
    • F 7.0-7.5;
    • infants/kids: estimate by diameter of pinky finger
  360. LEMON
    • Look externally;
    • Evaluate 3-3-2;
    • Mallampati;
    • Obstruction;
    • Neck mobility
  361. BURP
    • Backward,
    • Upward,
    • Rightward,
    • Pressure on thyroid cartilage (studies don't support benefit of either maneuver)