Shared Flashcard Set

Details

Clinical Applications Exam
n/a
314
Medical
Graduate
06/10/2010

Additional Medical Flashcards

 


 

Cards

Term

Methods of Engineering Control 

(Standard Precautions)

Definition

Meant to reduce employee exposure by either removing the hazard or isolating the worker

 

sharps disposal container

self-sheathing needles

safer medical devices

Term

Work Practice Controls

(Standard Precautions)

Definition

Meant to reduce the likelihood of exposure by altering how a task is performed

 

Wash hands after removing gloves

Do not bend or break sharps

No food or smoking in work areas

Do not recap needles

Term

Average Risks with needle sticks and general procedure...

 

HIV

HBV
HCV

Definition

HIV: 0.3% - prophylaxis within 24 hours

 

HBV: 1-6% (with vaccination) - give passive and active immunization upon exposure

 

HCV: 1.8% - hope and pray

Term
GWU PA Program Needlestick Procedure
Definition

On Campus:

Between 8 - 4p M-F: Report to GW Employee Health Services

Off hours: Report to GW ER

 

Off Campus:

Follow site's reporting procedures

Notify preceptor, GW PA Program

Term
RBC Indices
Definition

MCV: size of RBC
MCH: color of RBC

MCHC: concentration of RBC

Term
RDW
Definition

Red Cell Distribution Width

 

"Anisocytosis"

 

Indicates ongoing anemia, such that new RBCs are being actively introduced into the blood stream

Term
Reticulocyte Count
Definition

Immature RBCs that are larger and bluer than mature RBCs

They contain nuclear remnants

 

"Polychromasia"

 

SHOULD be high in anemia 

Term
WBC with Differential
Definition

Polys/PMN/Neutrophils: contain segmented nuclei, indicate bacterial infection

Lymphs: contain very large nuclei, indicate viral infection, lymphocytic anemia
Monocytes/Macrophages: infection

Eosinophils: contain red granules, indicate allergy, parasite

Basophils: contain purple granules, indicate histamine rxn (IgE)

Bands: immature polys with horseshoe nucleus, indicates severe infection

Term

Intrinsic Pathway

 

Factors

Diseases

Labs

Definition

Factors: 12, 11, 9, 8

Hemophilia

Monitor PTT when on Heparin

Term

Extrinsic Pathway

 

Factors

Diseases 

Labs

Definition

Factors: TF, 7 (Vitamin K dependent)

Vitamin K deficiencies and chronic liver disease

Monitor PT and INR when on Coumadin

Term
Anxious, Agitated, or Acutely Psychotic Patient
Definition

Presentation:

Psychosis is a disturbance of reality, evidenced by hallucinations, delusions, or thought disorganization

 

Evaluation:

Ensure that everyone is safe!

Assess for hallucinations, delusions, ADLs, cognitive loss, and diminished verbal communication

 

Management:

Immediate hospitalization

Calm the pt with verbal reassurance

Haloperidol

Lorezepam

Term
Depressed or Suicidal Patient
Definition

Presentation:
Variable 

 

Evaluation:
You must ask pt if they have a suicide plan

Assess means, availability, lethality, and likelihood of rescue

 

Management:

72 hour hold with constant guard

Intensive therapy

Anti-depressants

Assess for co-morbidities

Remember to plan for discharge the minute you admit them

Term
Alcohol Intoxication
Definition

Presentation:

Smell of EtOH, slurred speech, ataxia, confusion

Inappropriate behavior, loss of consciousness

 

Evaluation:

Level of consciousness, injuries, evidence of chronic abuse, BAC

 

Management:

Banana Bag (Thiamine, Mg, MVI, Folate, NS)

Tx injuries

Prevent withdrawal with oral benzo 
Always offer detox

Term
Opiate Abuse
Definition

Presentation:

Pinpoint pupils (miosis), slurred speech, ataxia, confusion, somnolence, respiratory depression, loss of consciousness

 

Evaluation:

level of consciousness, respiratory rate and depth

Pupillary size and reactivity, injuries

Urine toxicology

 

Management:

No respiratory distress: ride the high
Respiratory distress: Naloxone IM, IV, SC, NG

Repeat over 20 hours

Always offer detox

Term
Cocaine Abuse
Definition

Presentation:

Usually present with complications - chest pain, stroke, spontaneous abortion, asthma sx

 

Evaluation:

Urine toxicology

EKG, cardiac enzymes, CXR, CT

 

Management:

Do not give Beta Blockers!

Can use nitro or ASA for chest pain/vasospasm

Benzo if HTN or tachycardia

Term
Hyponatremia
Definition

Presentation:

apathy, agitation, HA, altered mental status

Seizures, coma, weakness, N/V

Signs of cerebral edema

 

Evaluation:

Serum Na < 136 (< 125)

Electrolytes, BUN, Cr, Glucose

Urine Na, OSM

EKG, CXR

 

Management:

Hospitalize if clinically significant

Restrict water intake to 1/2 - 1/3 

Increase Na 1 mEq/hr for 4 hours using 3% NaCl

Term
Hypernatremia
Definition

Presentation:

confusion, weakness, tremulousness, seizures, coma, hypotension, tachycardia, thirst, fatigue, lightheadedness

 

Evaluation:

Serum Na > 145

ALWAYS ASSESS VOLUME STATUS

CBC, electrolytes, glucose, BUN, Cr

Urine Na and OSM, EKG

 

Management:

Give NS

Term
Hypokalemia
Definition

Presentation: progressively worse symptoms 

Generalized weakness, fatigue, lassitude, constipation, leg cramps, muscle breakdown, paralytic ileus, bowel obstruction, ascending paralysis, impaired respiration, arrhythmias

 

Evaluation:
Serum K < 3.0 

Electrolytes, BUN, Cr, CPK (muscles), P, Mg, Glucose

 

EKG: prominent P waves, flat T waves, U waves

Wide QRS, Torsades, Arrhythmias, PEA, asystole

 

Management:

Give 20 mEq of K, oral preferred

Rapid correction only for highly unstable pts

Limit replacement 10-20 mEq/hr

Term
Hyperkalemia
Definition

Presentation:

weakness, hypotension, paresthesia, ascending paralysis, confusion, areflexia, ileus, respiratory insufficiency, cardiac arrest

 

Evaluation:

Serum > 5.5 

Electrolytes, BUN, Cr, Glucose, Mg

 

EKG: Peaked T waves, PEA, VF, VT, asystole

 

Management (in order of severity):

Furosemide, Kayexalate

NaHCO3, glucose/insulin, albuterol

Dialysis

Term
Hypocalcemia
Definition

Presentation:

Paresthesias of face, extremities, fatigue, muscle cramps, carpopedal spasms, stridor, tetany, seizures, confusion, impaired memory

Hyperreflexia, Chvostek's sign (CN VII twitch), Trousseau's sign (carpal spasm), decreased contractility, hypotension, heart failure

 

Evaluation:

Serum Ca < 8.5

Albumin, Ca, Mg, P, BUN, Cr, Liver studies

Amylase, Lipase, Electrolytes, CBC, ABG

 

EKG: QT prolongation, Terminal T wave inversion, Bradycardia, Heart block, VT or Torsades

 

Management:

Oral supplementation for asymptomatic

Ca gluconate, Ca chloride IV

Always correct hyperphosphatemia before the hypocalcemia

Term
Hypercalcemia
Definition

Presentation:

Depression, weakness, fatigue, confusion, lethargic, hallucinations, disorientation, hypotonicity, comatose, cardiac depression, arrhythmias

Constipation, Peptic ulcers, pancreatitis, polyuria, renal lithiasis, abdominal pain (moans and groans)

 

EKG: short QT interval, flat T wave, AV block

 

Management:

Tx if clinically significant

Restore volume rapid NaCl

Furosemide

Zolendronate 

Calcitonin

Glucocorticoids

Term
Hypomagnesemia
Definition

Presentation:

muscular tremors, fasciculations, vertigo, ataxia, altered mental status, Chvostek's sign, Trousseau's sign, paresthesia, ocular nystagmus, tetany, dysphagia, seizures

 

Evaluation:

Serum Mg < 1.0 

Mg, Ca, BUN, Cr, Glucose, Electrolytes

 

EKG: prolonged QT, T wave inversion, Torsades, VFib

 

Management:

Mild: Oral replacement Mg oxide, sulfate

Moderate/Severe: IV Mg sulfate

Term
ABGs of Respiratory Acidosis
Definition

Primary abnormality: inc PCO2

Compensation: inc HCO3

pH < 7.4

Term
Hypermagnesemia
Definition

Presentation:

muscle weakness, paralysis, ataxia, drowsiness, confusion, N/V, hypoventilation, cardiac arrest, respiratory arrest

 

Evaluation:
Serum Mg > 2.5

Ca, BUN, Cr, Electrolytes

 

EKG: prolonged PR, QT intervals, complete AV block, asystole

 

Management:

IV fluids

Ca gluconate or Ca chloride (antagonize Mg)

NS and Furosemide

Dialysis

Term
Respiratory Acidosis
Definition

Presentation:

HA, blurred vision, restlessness, tremor, delirium, sleepiness, arrhythmias, peripheral vasodilation, hypotension

 

Evaluation:

ABG - pCO > 45, pH < 7.40

 

Management:

relieve airway obstruction

bronchodilators and abx for COPD

bronchodilators for asthma

diuretics, inotropes for pulmonary edema

chest tube for pneumothorax

NGT for abdominal distension

Term
Respiratory Alkalosis
Definition

Presentation:
Tetany, lightheadedness, seizures, arrhythmias, vasoconstriction

 

Evaluation:

pCO < 35 

pH > 7.40

 

Management:

Correct hypoxemia, supportive care

Remove stimulating agents

Decrease minute ventilation

Term
Metabolic Acidosis
Definition

Presentation:

hyperventilation, tachycardia, arrhythmias, altered mental status

 

Evaluation:

HCO3 < 24

pH < 7.40

 

Management:

Exogenous HCO3- 

Term
Metabolic Alkalosis
Definition

Presentation:

Confusion, lethargy, coma, seizure, hypokalemia, arrhythmias, hypoventilation

 

Evaluation:

HCO3- > 26

pH > 7.40

 

Management:

Replace gastric losses

H2 blockers

NS

Term
Volume Depletion
Definition

Presentation: 

Thirst weakness, anorexia, apathy, syncope, tachycardia, weight loss, dry mucous membranes, ileus, weakness, decreased turgor, decreased IOP, orthostatic changes, tachycardia

 

Evaluation:

Increase urine osm, increased urine SG

BUN out of proportion to Cr (> 20:1)

Increased Hct, increased serum protein

 

Management:

Bolus NS

Maintain urine at 0.5 - 1.0 ml/kg/hr

Replace blood loss with crystalloid 3:1

Term
Volume Excess
Definition

Presentation:

Weight gain, edema, dyspnea, tachycardia, JVD, pulmonary congestion, ascites

 

Management:

fluid resuscitation, diuresis, monitor urine output and daily weights

Term
ABGs of Respiratory Alkalosis
Definition

Primary abnormality: dec PCO2

Compensation: dec HCO3

pH > 7.4

Term
AGBs of Metabolic Acidosis
Definition

 

Primary abnormality: dec HCO3

Compensation: dec PCO2

pH < 7.4

 

Term
ABGs of Metabolic Alkalosis
Definition

 

Primary abnormality: inc HCO3

Compensation: inc PCO2

pH > 7.4

 

Term
Differential Diagnosis of dyspnea
Definition

MI, COPD, CHF, pulmonary edema

PE, Pneumonia, Cor pulmonale

Pneumothorax, renal failure, sepsis

Epiglottitis, anaphylaxis, ARDS

Anemia, Bleed, Upper airway obstruction

Asthma, Toxin exposure

Metabolic electrolytes, neurologic

Term
Triage, Stabilization, Evaluation and Management of Dyspneic Patient
Definition

Quick Assessment:
ABCs - do they look well? vitals

 

Begin forming differential

 

Get a Hx and Physical Exam

 

ED Interventions: O2, cardiac monitor, IV access

 

Labs: ABG, CBC, Chemistries, Cardiac enzymes, Mg, D-dimer (PE), BNP (CHF), EKG, CXR

Term
Acute Respiratory Distress
Definition

Presentation:

dyspnea, tachypnea, tachycardia, hypoxemia

 

History/Risk:

Sepsis, drugs, aspiration, trauma, pancreatitis

 

Diagnosis:

CXR shows bilateral diffuse infiltrates

ABGs show PCO2 < 60

PCWP helps distinguish from pulm edema (< 18)

Bronchoscopy with lavage

 

Management:

Hypoxemia will not improve with 100% O2

Mechanical ventilation

Fluid management (prevent overload)

Tx underlying cause

Term
Foreign Body Aspiration
Definition

Presentation:
stridor, wheezing

 

History/Risk:
witness

 

Diagnosis:

Decubitus expiratory CXR - one lung will expand and the other won't

X-ray for AP and lateral soft tissue

Fiberoptic scope

 

Management:

Assess spontaneous breathing

If none, do Heimlich and prep for surgical airway

If foreign body inferior to vocal cords, it can be pushed into mainstem bronchus with Ambo bag or ET tube to allow one lung to ventilate until surgery

Term
Pulmonary Embolism
Definition

Presentation:

tachypnea, tachycardia, hypoxia, rales

wheezes, fever (though not common), LE erythema, swelling, redness (signs of DVT)

Variable BP

 

History/Risk:
DVT, prolonged immobilization, malignancy, hypercoaguable, OCP, smoking, recent surgery, IVDU, nursing home

 

Evaluation:

Triad: hemoptysis, dyspnea, chest pain

Most common symptoms: SOB, chest pain, anxiety

Most common sign: tachypnea, rales, fever

D-dimer - negative predictive value (helps r/o)

PT/PTT, bHCG

EKG - RBBB, AFib

CVR: Westermark, elevated hemidiaphragm

CT with IV contrast is the standard of care

 

Management:

Manage airway

Tx shock with IV fluids if no pulmonary edema

Pressors

Anticoagulation (Heparin)

Thrombolysis 

Embolectomy

 

Term
DVT
Definition

Presentation:
LE erythma, swelling, redness

 

History/Risk:
Virchow's Triad: endothelial injury, venous stasis, hypercoaguability

 

Evaluation:

LE doppler ultrasound

80% PE on autopsy have concurrent DVT

CT of bilateral thighs

 

Management: see PE

Term

Generalized Seizures

Definitions

Definition

Tonic Clonic: convulsions that are bilaterally symmetric and without focal onset

Consciousness is imparied

 

Absence: brief, sudden, impaired consciousness without motor abnormalities and no post-ictal period

 

Term

Partial Seizures

Definitions

Definition

Simple Partial:

consciousness remains intact, and the seizure is localized. May evolve into complex partial

 

Complex Partial:
consciousness is impaired, with automatisms, olfactory, and gustatory hallucinations

Term

Status Epileptics

Definition

Definition

Ongoing seizure for 10 minutes or more

OR

2 or more sequential seizures within < 30 min

 

Term
Tonic Clonic Seizures
Definition

Presentation:
often post-ictal state, are at risk for seizing again

 

Evaluation:

Get detailed hx from witnesses

Is there a known cause?

Focus PE on acute injuries - make sure to check for increased ICP

D-stick for glucose, CMP, CBC, alcohol, drug screen, phenytoin/carbamazepine levels

CT if suspect stroke, tumor, or trauma

 

Management:
Tx the cause if known

Give D50

If pt known to be on Dilantin (Phenytoin) or Tegretol (Carbamazepine), give IV meds

IV Lorazepam for subsequent seizures

Neuro consult

Term
Status Epilepticus
Definition

Presentation:
unresponsive or tonic clonic seizures

Small jerking movements

Possible non-convulsive status epilepticus

 

Evaluation:

Continually assess as treatment occurs with hx, PE, labs

 

Management:

Secure airway, give high flow O2

Give glucose if blood sugar is low

Consider thiamine and Mg if known alcoholic or malnutrition

Lorazepam 

Phenytoin

Phenobarbital/General anesthesia

Admit to hospital with neuro care

EEG and consults

Consider CT/MRI

Term
Guillan Barre Syndrome
Definition

Presentation:
progressive weakness in arms/legs

areflexia

history of cold/infection in previous weeks

 

Assessment:
Can they breathe? Can they walk?

CBC, CMP, coags, serial pulm function tests

LP would show elevated proteins but few cells

EMG/NCV

Tests to r/o other ddx

 

Management:

Admit to hospital with neuro care

IVIG or plasmapheresis

Cardiac monitorings

Pain control (gabapentin, opioids)

PT to avoid contractures

Psych support for family

Term

Presentations of Specific Ischemic Stroke Syndromes

 

Anterior Cerebral Artery

Definition
Contralateral leg weakness > arm weakness
Term

Presentations of Specific Ischemic Stroke Syndromes

 

Posterior Cerebral Artery

Definition

Light touch and pinprick sensation markedly decreased

 

Visual cortex defects

Term

Presentations of Specific Ischemic Stroke Syndromes

 

Middle Cerebral Artery

Definition

If in dominant hemisphere (usually left), may have aphasia

Homonymous hemianopsia

Arm weakness > Leg weakness

Term

Presentations of Specific Ischemic Stroke Syndromes

 

Vertebrobasilar Artery Stroke

Definition

Hx of head/neck trauma

CN deficits on one side of face

Contralateral motor weakness

Term
Ischemic Stroke 
Definition

Presentation:

dependent on specific locations

 

Assessment:

When exactly did the symptoms start?

Thrombotic: DM, cholesterol, PVD

Embolic: AFib, valve replacemetn, carotid stenosis, MI

Hypoperfusion: heart failure, decreasing BP too fast (iatrogenic)

Assess level of consciousness, facial drop, flat nasolabial fold, motor abilities, speech, sensation, visual fields, neglect

CT to look for blood - if you don't see blood, you can r/o ICH

Most acute ischemic strokes will not show on

non-contrast CT for 3-6 hours

If they do show up, you see hypodensity (dark) infarct

If you see blood --> ICH

If you see nothing --> ischemic

If you see dark --> ischemic

Coags, CBC, CMP, D-stick, EKG

 

Management:

Within 3 hours onset of sx: tPA

If > 3 hours, supportive care with O2, NS, intensive monitoring

Tx identifiable causes of stroke

Consider ASA, Plavix

Term

Intracranial Hemorrhage

(Hemorrhagic Strokes)

Definition

Presentation:
Often indistinguishable from ischemic stroke in same vascular region (refer to specific stroke syndromes)

 

Evaluation:

Hx of HTN

CT - will see bood

Shows up as bright white in known vascular distribution

 

Management:
Neurolosurgery consult

Mannitol if increased ICP

Gradually lower BP if it is elevated

Supportive care and rehab

Term

Subarachnoid Hemorrhage 

(Hemorrhagic Strokes)

 

Definition

Presentation:

Abrupt onset WHOL (back of head and upper neck)

Photophobia, N/V, altered MS

Nuchal rigidity

Hx of sentinel bleed

 

Evaluation:

Neurosurgery consult

Surgical decompression if large

Avoid increased ICP with anti-emetics, anti-tussives, anti-convulsants

Manage HTN

Nimodipine to decrease vasospasm

Term
Emergency Stroke Treatment Algorithm
Definition

Patient should be on CT scanner within 25 min of arrival to hospital

Should be read by radiologist within 45 min

 

Contraindications to tPA:

bleed anywhere in body

onset of sx > 3 hours ago

time of onset of sx is unknown

pt on anticoagulant therapy

suspected SAH

abnormal coags, platelets

hx of hemorrhagic stroke

acute HTN

 

Term

Subdural Hemorrhage 

(Intracranial Hemorrhage)

Definition

Presentation:

Loss of consciousness, laceration, bruise on head

N/V, confusion, smell of EtOH

Difficulty ambulating

 

Assessment:

Accerelation-deceleration injury

alcoholism, elderly

CT shows crescent shaped feathered fluid over surface of brain

Mass effect and midline shift

 

Management:
Neurosurgery consult for potential evacuation

Intubate if low Glasgow Coma Scale

Consider admission to neuro critical care

Address underly medical issues

Term

Epidural Hemorrhage

(Intracranial Hemorrhage)

Definition

Presentation:
obvious site of trauma to head, loss of consciousness

Signs of ICP (blown pupil, BP changes)

Focal neuro deficits, hemotympanum, CSF otorrhea and rhinorrhea (Halo sign)

 

Assessment:

Blunt force trauma to temporal or parietal regions (MMA rupture) 

Skull fracture, Lucid interval of 20-30 min

CT shows lens or balloon shaped mass over surface of brain. Mass effect and midline shift.

May see skull fracture

 

Management:

Evacuation of blood by neurosurgery

Early surgery is key to recovery

Burr holes

 

Most fatal ICH due to high pressure arterial bleed and brain herniation

Term
Migraine Headache
Definition

Presentation:
Unilateral, throbbing pain behind an eye

Slow onset +/- aura

N/V, photophobia, phonophobia

No other focal neuro signs

Patient does not want to move

 

Assessment:

Very detailed history!
Have you every had a headache like this before?

Thorough PE, including items to r/o stroke, meningitis, other infection

CT scan, CMP, CBC, coags

Ammonia levels (hepatic encephalopathy)

ESR, CRP (temporal arteritis)

LP if you suspect SAH or meningitis

 

Treatment

Abortive therapies - Triptans

Symptomatic Tx - anti-emetics, IV fluids, steroids, opiates (beware of rebound HA)

Term
Tension Headache
Definition

Presentation:

Bilateral or whole head non-throbbing HA

Slow onset and no assoc N/V, photophobia

No other focal neuro signs

Patient wants to rest

 

Assessment:

Very detailed history!
Have you every had a headache like this before?

Thorough PE, including items to r/o stroke, meningitis, other infection

CT scan, CMP, CBC, coags

Ammonia levels (hepatic encephalopathy)

ESR, CRP (temporal arteritis)

LP if you suspect SAH or meningitis

 

Treatment:

NSAIDs (Toradol) IV or IM

Acetaminophen

Combination products

Identify triggers

Anti-emetics or opiates in severe cases

Term
Cluster Headache
Definition

Presentation:

Quick onset severe pain lasting < 3 hours

Periorbital, temporal, supraorbital pain

Associated lacrimation, rhinorrhea, conjunctival injections, miosis, and ptosis

Patient is restless

 

Assessment:

Very detailed history!
Have you every had a headache like this before?

Thorough PE, including items to r/o stroke, meningitis, other infection

CT scan, CMP, CBC, coags

Ammonia levels (hepatic encephalopathy)

ESR, CRP (temporal arteritis)

LP if you suspect SAH or meningitis

 

Treatment:

High flow O2 - works every time

Abortive therapies - Triptans

Opiates (beware rebound HA)

Term
Central Retinal Artery Occlusion
Definition

Presentation:

Sudden painless monocular vision loss

Pallor of retina

Cherry spot of fovea

Boxcar retinal veins

Generally embolic in origin

 

Evaluation:

Ophthalmoscope exam

 

Treatment:

Immediate sight-saving procedure

Digital massage of globe

Inhalation 95% O2 and 5% CO2 

Hyperventilate into bag

Medications to lower IOP (Timolol)
EKG and immediate referal

Term
Orbital Cellulitis
Definition

Presentation:
Red eye, blurred/double vision, HA, fever, edema

Erythema, increased warmth

Restricted and painful EOMs

 

Evaluation:

EOMs, culture of blood and fluids, CT

 

Treatment:

Oral abx immediately

Refer immediately with IV abx (?)

Term
Acute Angle Closure Glaucoma
Definition

Presentation:

Acute onset severe pain, blurred vision

Decreased visual acuity

Red eye, mydriasis non-reactive to light

Steamy cornea, eye feels firm

Halos around lights

Nausea and abdominal pain
IOP > 50 mmHg

 

Evaluation:

Measure IOP with Tonometer

 

Treatment:

Ophthalmology consult

IV acetazolamide

Laser therapy

Pilocarpine

Laser peripheral iridotomy

Term
Acute Temporal Arteritis
Definition

Presentation:

Systemic vasculitis of medium and large arteries that can lead to bilateral blindness

Focal tenderness, thickening, nodularity, decreased pulsation

 

Evaluation:

ESR > 50

Biopsy specimens

 

Treatment:

Prednisone

Ophthalmology consult

Term
Retinal Detachment
Definition

Presentation:

Floaters/bugs/spots, flashing lights

Decreased visual acuity, visual field defects

Watery vision, veil or curtain

 

Evaluation:

Slit lamp

 

Management:

Limit activity

NPO

Refer and immediate surgery

Term

Viral Conjunctivitis

Usually adenovirus 3

Definition

Presentation:

Hyperemia of conjunctiva

Itching, tearing

May be assoc with pharyngitis, fever, malaise, preauricular lymphadenopathy

Clear discharge

Common in children

 

Treatment:

Cool compress

Antihistamine

+/- abx

Lasts 7-10 days

 

Do not patch

Term

Bacterial Conjunctivitis

Usually Staph, Strep, Haemophilus, Pseudomonas

Moraxella, GC/C

Definition

Presentation:

Hyperemia of conjunctiva

Irritation, Tearing

Purulent discharge

 

Management:

Antibiotic solution

If GC/C (teens and adults) - oral/IM abx

Evacuate if sx persist

 

Do not patch

Very contagious

Term
Keratoconjunctivitis Sicca
Definition

Dry eye in older women, hereditary, systemic disease, hormone replacement, environmental

 

Presentation:

Burning +/- decreased visual acuity

Bilateral and worse later in day

Pain out of proportion to PE

Conjunctival injection

 

Management:

Artificial tears

Lubricating gel

Preservative-free preparations

Term

Chemical Conjunctivits

Definition

Presentation:
Hyperemia of the conjunctiva

Irritation, Tearing

 

Management:

Irrigation with 2 L water

If alkaline, use at least 3 L or 30 min

Abx solution drops

Cool compress

 

Do not patch

Term
Corneal Abrasion
Definition

Presentation:

Intense pain that is improved with topical anesthetic

 

Evaluation:

Fluorescein stain exam

Slit lamp

 

Management:

Remove foreign body

Limit anesthetic use

Topical abx, maybe patch

Do not patch if caused by contact lens

Term
Bacterial Corneal Ulcer
Definition

Presentation:

Hazy cornea, central ulcer, hypopyon

 

Evaluation:

Gram stain discharge

 

Management:

High concentration of topical abx

Levofloxacin, Ofloxacin, Cipro

Term
Herptic Corneal Ulcers
Definition

Presentation:

Red eye, decreased vision, pain, photophobia

Foreign body sensation

 

Evaluation:

Fluorescein stain exam shows small punctate lesions, single vesicle, or branching pattern

 

Management:

Topical antiviral

+/- oral antiviral (no steroids)

Must evacuate

Term
Fungal Corneal Ulcers
Definition

Presentation:

Trauma from plant material 

Abscesses are common

 

Management:

Topical amphotericin

Corneal grafting

Term
Foreign body in eye
Definition

Presentation:
Pain, irritation, tearing, redness

Feeling of foreign body

 

Evaluation:
Upper eyelid eversion

Slit lamp

 

Management:

Irrigation, cool compress

Evacuate if refractory

Term
Traumatic Hyphema
Definition

Presentation:

decreased vision, pain

Layering of blood in dependent areas of anterior chamber

 

Management:

Keep patient upright, avoid activity

Shield eye

If large, refer for immediate tx

Do not give ASA or NSAIDs

Do not patch

Term
Actinic Keratitis
Definition

Presentation:

Bilateral gritty sensation
Photophobia, tearing, extreme conjunctival erythema, edema of lid

 

Evaluation:

Radiation injury due to UV exposure

Fluorescein stain shows "snowstorm"

 

Management:

remove contacts, single dose anesthetic

Abx solution, NSAIDs, cool compress

Wear sunglasses

12 hour patch and re-check

Term
Iritis
Definition

Presentation:
Unilateral deep pain with photophobia

Blurred vision, decreased visual acuity

+/- trauma, perilimbal injection

Miotic and decreased reactivity of pupil

Consenual photophobia

 

Management:

Mydriatic agents

Immediate evaluation

Term
Cholinergic Toxindrome
Definition

Excess parasympathatic stimulation (ACh)

Caused by sarin, organophosphates, TCAs, mushrooms

 

Symptoms: salivation, lacrimation, urination, defecation, diaphoresis, GI upset, emesis, bradycardia, miosis, muscle fasciculations

 

Term
Anticholinergic Toxindrome
Definition

Excess inhibition of parasympathetic sitmulation

Causes: Benadryl

 

Symptoms: can't see, can't spit, can't pee, can't shit

Very dry, red, hot

Term
Sympathomimetic Toxindrome
Definition

Excess sympathetic stimulation

Causes: Albuterol, Amphetamines, Cocaine, Epinephrine

 

Symptoms: mydriasis, diaphoresis, agitation, hypertension, tachycardia

Term
Opiate Toxindrome
Definition

Excess mu receptor stimulation

Causes: opioids

 

Symptoms: miosis, respiratory depression, CNS depression, response to naloxone

Term
Hydrofluoric Acid Poisoning
Definition

Weakly corrosive acid that causes local and systemic absorption of Ca++

 

Causes: used for glass etching, computer chips, air conditioning, rust removers

 

Symptoms: delayed pain at exposure site


Treat: humidified, dermal, SQ, IM, IV Ca++

Term
Carbon Monoxide Poisoning
Definition

Binds competitively to Hgb and inhibits cellular respiration

 

Symptoms: cherry red/pink skin, flu-like illness with no fever

 

Treatment: oxygen

Term
TCAs Poisoning
Definition

Anti-depressant

 

Causes: Nortriptyline, Amitriptyline, Desipramine, Imipramine

 

Symptoms: cardiovascular, neurologic, anticholinergic

 

Term
Ca Channel Blocker Poisoning
Definition

Excess Ca++ channel blockade

 

Symptoms: bradycardia, hypotension, mental status changes

Term
Organophosphates Toxicity and Antidote
Definition

Cholinergic Toxindrome

 

Antidote: Atropine

Term

Nitrates Toxicity and Antidote

 

Definition

Symptoms: blue color to skin, HA, fatigue, SOB

 

Antidote: Methylene blue

Term

Anticholinergic Toxicity and Antidote

 

Definition

Anticholinergic Symptoms

 

Antidote: Physostigmine

Term

Cyanide Toxicity and Antidote

 

Definition

Symptoms: weakness, HA, giddiness, vertigo, confusion, coma

 

Antidote: Cyanide kit, hydroxycobalamine

Term

Alcohol Toxicity and Antidote

 

Definition
Antidote: Fomezipole
Term
Sulfonylureas Toxicity and Antidote
Definition

Symptoms of hypoglycemia

 

Antidote: Octreotide

 

Term

Opiates Toxicity and Antidote

 

Definition

Respiratory depression, Hypotension, Tachycardia, Miosis, Severe drowsiness

 

Antidote: Naloxone

Term

Isoniazid Toxicity and Antidote

 

Definition

Slurred speech, acidosis, hallucination, hyperglycemia, respiratory distress

 

Antidote: Pyridoxine (B6)

Term

Digoxin Toxicity and Antidote

 

Definition

New arrhythmias, changes in color vision, tired, weak, confused, N/V, anorexia

 

Antidote: Digitalis-Fab

Term

Snake Venom (Copperhead, Water Moccasin, Rattlesnake) Toxicity and Antidote

 

Definition
Antidote: Crofab
Term

Tylenol Toxicity and Antidote

 

Definition

N/V, poor appetite, ab pain

 

Antidote: N-acetylcysteine

Term

TCAs/Na Channel Blockage Toxicity and Antidote

 

Definition

Anticholinergic symptoms

CNS effets, cardiac effects

Long QT

 

Antidote: NaHCO3

Term
Poison Treatment:

Activated Charcoal
Definition

Used in favor of Ipecac

Burned wood with divets can absorb drug

Optimum dose: 10:1 or 1 gram/kg

 

Indications: Phenobarbital, Theophylline, Phenytoin, Carbamazepine

 

Contraindications: acid or alkali ingestion, pure petroleum distillates

 

Ineffective for: elemental metals, electrolytes, pesticides, cyanide, alcohols, hydrocarbons

Term

Poison Treatment:

 

Cathartics

Definition

No proven efficacy, but safe, so why not?

Can use Sorbitol, Mg citrate, Mg sulfate

 

Contraindications: bowel obstruction, active diarrhea, pt < 1 yo

 

Only give with first dose of charcoal

Term
Orogastric Lavage
Definition

Facilitates charcoal administration

Most effective within 2 hours post ingestion

Protect airways with cuffed ETT

Place tube orally

 

Contraindications: alkali ingestion, bleeding diathesis, use in acid ingestion is controversial

Term

Poison Treatment:

 

Whole Bowel Irrigation

Definition

Large volume of isotonic polyethylene glycol (PEG)

Administer po or NG tube to empty bowel

 

Indications: iron, lithium, drug packets, sustained-release products

 

Contraindications: gastrointestinal pathology, bowel obstruction

Term

Poison Treatment:

 

Enhanced Elimination

Definition

Urinary alkalinization to increased excretion of acidic drugs

 

Add bicarb 

 

Used for increased excretion of salicylates, phenobarbital, chlorpropamide, herbicides

Term

Poison Treatment:

 

Hemodialysis

Definition
Used for salicyltes, lithium, methanol, and ethylene glycol
Term
Liver Function Tests
Definition

Tests: ALT/AST, Alk Phos, GGT, Albumin, PT, Bilirubin

 

Why:

Test for bilirubin level (bilirubin)

 

Test for synthetic function of liver (albumin, PT)

If PT corrects with Vit K, it indicates Vit K deficiency

 

Hepatocyte damage (ALT/AST)

ALT more specific than AST

EtOH hepatitis AST > ALT

Viral hepatitis ALT > AST

 

Obstruction (Alk Phos, GGT)

 

 

Term
Amylase and Lipase
Definition

Pancreatic enzymes

Tests for pancreatic function

Indicates pancreatitis

Term
Serum Electrolytes
Definition

Na, K, Ca, Mg

Glucose

 

Hyponatremia: determine serum osm

Hypernatremia: determine volume status

 

Hypokalemia: inadequate intake, GI, renal losses

Hyperkalemia: inadequate excretion due to to renal failure or K sparing diuretics

Term
Mild to Moderate CHF
Definition

Presentation: 

Dyspnea, fatigue, fluid retenion

Nocturia, orthopnea, non-productive cough, 

wheeze, moderate edema, anorexia

Weight loss, supine chest pain, dizziness

fainting, palpitations, tachycardia, rales

S3/S4, cool skin, hepatojugular reflux, JVD

 

Diagnosis:

CBC, BMP, LFT, cardiac enzymes, BNP

CXR shows Kerly B lines, upper zone redistribution, cardiomegaly, effusions, Bat wing infiltrates

EKG, Echo, Coronary angiogram with angina

 

Management:

First line therapy - ACE/ARB, B blocker, diuretic

Control risk factors and lifestyle

Treat etiologic cause and aggravating factors

Cardiac synchronization, implantable defib

 

Reduce Preload - diuretics, ACE, nitro

Reduce afterload - hydralazine, morphine, nitrates, CCBs, B blockers

Inotropic agents - digitalis, dopamine, dobutamine, BNP

Term
Severe CHF
Definition

Presentation:

Distressed and obtunded

Confusion, cyanosis, pink sputum

Pulsus alterans, hypotension

narrow pulse pressure, gallop

ascites, Cheyne-Stokes respiration

 

Diagnosis:

CBC, BMP, LFT, cardiac enzymes, BNP

CXR shows Kerly B lines, upper zone redistribution, cardiomegaly, effusions, Bat wing infiltrates

EKG, Echo, Coronary angiogram with angina

 

Management:

First line therapy - ACE/ARB, B blocker, diuretic

Control risk factors and lifestyle

Treat etiologic cause and aggravating factors

Cardiac synchronization, implantable defib

 

Reduce Preload - diuretics, ACE, nitro

Reduce afterload - hydralazine, morphine, nitrates, CCBs, B blockers

Inotropic agents - digitalis, dopamine, dobutamine, BNP

Term
Mild to Moderate HTN
Definition

Presentation:

Mostly asymptomatic, unless secondary cause is present

 

Diagnosis:

BP measurements, thorough PE

Urinalysis, CBC, glucose, K, Ca, Cr, estimated GFR, fasting lipid, TSH

EKG, Echo

 

Management:

Goals < 140/90 (lower for DM, renal disease)

Lifestyle modification

Stage 1: thiazides, unless high risk condition indicates otherwise

Stage 2: 2 drug combo including thiazide

Term
Severe HTN
Definition

Presentation:
asymptomatic unless end organ damage

Headache, polyuria, dyspnea

impotence, claudication, angina

 

Diagnosis:

BP measurements, thorough PE

Urinalysis, CBC, glucose, K, Ca, Cr, estimated GFR, fasting lipid, TSH

EKG, Echo

 

Management:

Goals < 140/90 (lower for DM, renal disease)

Lifestyle modification

Stage 1: thiazides, unless high risk condition indicates otherwise

Stage 2: 2 drug combo including thiazide

Term
Hypertensive Emergency
Definition

Presentation:
Defined as > 180-220 SBP with severe symptoms and acute/rapidly evolving end-organ damage

Ability of brain, heart, and kidneys to regulated BP becomes impaired

 

End organ damage: blurred vision, papilledema, hemorrhages, venous tapering, exudates, chest pain, palpitations, dyspnea, displaced PMI, S3/S4, JVD, HA, stroke sx, HTN encephalopathy, renal artery bruits, oliguria, N/V

 

Diagnosis: BMP - look for elevated BUN/Cr

UA for protein

CXR for cardiomegaly, pulm edema

EKG: LVH, T wave inversion, AMI

Head CT: small vessel ischemic changes, hemorrhages

Chest CT: aortic dissection

 

Management:

Guided by end organ damage

Admit to ICU, arterial line for BP monitor

 

Acute MI/Ischemia: Labetelol + nitro

Acute LVF/Pulm Edema: Nitro + ACEI

Acute Renal insufficiency: Fenoldapam to increase renal perfusion

ICH: Esmolol, Labetalol 

SAH: Nimodipine

Aortic Dissection: Labetalol + nitro

Stroke: Labetalol or Nicardipine

Term
Nephrolithiasis/Ureterolithiasis
Definition

Presentation:

Stone in kidney or ureter

Extreme flank pain, very restless

Fever + elevated WBC + elevated CR = hydronephrosis

 

Evaluation:
CBC shows slightly elevated WBC
UA shows hematuria in most

BUN/Cr for kidney function

Helical CT, renal sonogram for hydronephrosis

 

Management:

Most can go home

Admit those with one kidney, uncontrolled pain, vomiting, fever, obstruction, infection, bilateral stones

Percocet, Flomax to relax ureter, strainer

Term
Thiazides for HTN
Definition

Reduce CHD mortality and good for isolated systolic HTN, reverses LVH

 

Do not use with NSAIDs

Can increase glucose, cholesterol, TG

Can increase Ca and uric acid

Term
Beta-Blockers for HTN
Definition

Good for HTN with previous MI or current CAD, migraines, angina, tremor, AFib

 

Can alter lipids, insulin resistance, and cause bronchospasm

 

Not first line monotherapy unless special indication

Term
ACE/ARB for HTN
Definition

Good for systolic CHF, post-MI, DM, stroke, and reversal of LVH

 

No adverse lipid effects, but cannot use in pregnancy or bilateral renal artery stenosis

Term
Ca Channel Blockers for HTN
Definition

Good for angina, systolic HTN, LVH, Raynauds and African Americans

 

Use with caution in CHF

Term
Alpha 1 Blockers for HTN
Definition

Good for lipids and insulin sensitivity, BPH, and LVH

 

Remember first dose effect (syncope)

Do not use as monotherapy

Term
Alpha 2 Agonist (Clonidine) for HTN
Definition
Useful for resistant to therapy, rebound HTN
Term
Methyldopa, Hydralazine for HTN
Definition
Used for pregnant HTN, resistant to therapy
Term
Minoxidil for HTN
Definition
Good with Beta blockers and diuretics
Term
Hydralazine + Nitrates for HTN
Definition
Good for African Americans, unable to tolerate ACE/ARB
Term
Pyelonephritis
Definition

Presentation:

Lower UTI has progressed to upper UTI

More likely to have fever, rigor, chills

Malaise, N/V, flank pain

 

Diagnosis:

UA shows hematuria, pyruia, CBC, BMP, UA, UC

Can do CT with IV contrast 

 

Management:

Fluids, pain control, nausea control

Abx: Rocephin, Fluroquinolone, Unasyn

 

Rule of 2's: 2 L IV fluids, 2g Rocephin, 2 Vicodin, 2 glasses of water, 2 weeks tx

Term
Hematuria
Definition

Presentation:

> 3-5 RBCs per HPF - the concern is about obstruction

 

Causes:

UTI - pyuria, dysuria

Kidney stones - flank pain

Recent vigorous exercise

Painless < 40 - GU infection, nephrolithiasis, trauma, exercise

Painless > 40 - cancer, prostate, renal disease, non-urinary source

Painful - nephrolithiasis, renal vein thrombosis, renal artery occlusion, renal CA, UTI, prostatitis

Rhabdomyolysis if blood with RBC in urine

 

Diagnosis: UA cultures and sensitivities

CBC, CMP, PT/PTT/INR

CT +/- contrast

 

Management:
Tx what you find

Reassure and followup

Term
Testicular Torsion
Definition

Presentation:
True surgical emergency!

6 hours until testicular necrosis

Inadequate fixation of testis to tunica vaginalis

 

Diagnosis:

Sonogram shows no flow

UA, Pre-op labs

 

Management:

Pain control

Manual detorsion (opening a book)

Therapeutic cooling

Term
Priapism
Definition

Presentation:

Abnormal persistent erection of corpora cavernosa > 4 hours - involuntary and unrelated to sexual stimulation

Disturbance of detumescence mechanisms

Can be ischemic (bad) or non-ischemic

 

Diagnosis:

Hx and cavernosal blood gas will show acidosis, low O2, and high CO2

 

Management:

Ice bag to perineum, penis

Terbutamine po 

Pain control

Aspirate with 18ga needle 

Massage, repeat

Surgery

Term
Phimosis
Definition

Inability to retract the distal prepuce over the glans penis that is congenital or acquired

 

Management:

Rarely an emergency, refer

Term
Paraphimosis
Definition

Inability to put back the foreskin because it has become a constricting ring that impairs blood and lymphatic drainage

Leads to ischemia, gangrene, autoamputation

 

Management:

Ice water soaks, compressive elastic dressings

Penile lidocaine block, wrap in topical lidocaine

18ga needle puncture, manual retraction

Dorsal slit, glans penis aspiration

Term
Epididymitis
Definition

Presentation:

Infection of coiled tubular structure posterior to testis

Positive Phren's Sign

Congestion, edema, abscess, necrosis

Urinary sx, urethral discharge, N/V, abdominal pain, flank pain, fever

 

Diagnosis:

UA, DNA probe, CBC, CMP

Sonogram shows increased flow

 

Management:
Tx suspected pathogens

Young: Rocephin, Doxy 10-14 days

Older: Ofloxacin, Levofloxacin

Pain medications

Term
Hydrocele
Definition

Presentation:

Collection of serous fluid from defect or irritation of the tunica vaginalis

 

Diagnosis: 

Transillumintion is not reliable

Doppler sonogram

 

Management:

Urology consultation

Term
Varicocele
Definition

Presentation:

Enlarged twisted vein in scrotum

 

Diagnosis:

Bag of worms

 

Management:
Surgery

Term
BPH
Definition

Prescription:

Walnut sized gland becomes enlarged and may obstruct flow of urine

Urinary frequency, urgency, hesitancy, straining, incomplete emptying, decreasing force, dribbling, retention

 

Diagnosis:

UA culture and screens

DRE, Foley Cath/Coude Cath

 

Management:

Treat if UTI is present

Leg Bag

Urology followup 

Term
Differentiating Scrotal Pain
Definition

Testicular Torsion:

Hx - post vigorous activity, sex

Sx - tender, swollen 

Sudden onset with diffuse pain

Negative cremasteric reflex

Negative Phren's sign

Bell clapper deformity

 

Appendiceal Torsion:

Subacute onset

Leading cause of scrotal pain in childhood

Positive cremasteric reflex

Blue Dot Sign

 

Epididymitis:

Sx - congestion, edema, abscess, necrosis, N/V, ab pain, fever

Subacute onset 

Positive cremasteric reflex

Positive Phren's sign

Term
DKA
Definition

Presentation:

Polyuria, polydipsia, polyphagia, weight loss

Kussmaul breathing, fruity breath odor, dehydration, blurred vision, N/V, ab pain

Altered mental status, hyperglycemia, metabolic acidosis - mostly Type 1 diabetics

 

Etiologies: 

Absolute or relative insulin deficiency, stress hormones, infection

 

Evaluation: 

CBC shows leukocytosis

BMP shows metabolic acidosis and inc BUN/Cr

possible hyperkalemia with pseudohyponatremia

UA shows ketonuria, glucosuria

VBGs show low pH and low bicarb

Other tests to find cause

 

Management:

Goals - intravascular volume expansion, correction of fluids, electrolytes, and acid-base

IV fluids and add KCl one urine output confirmed

Insulin bolus IV (10 units)

Insulin drip IV (0.1 U/kg/hr)

Add HCO3- if pH < 6.9

Give glucose with insulin to maintain blood glucose at 150-300

Term

Hyperglycemia

Hyperosmolar

Non-Ketotic Syndrome

(HHNS)

Definition

Presentation:

Fatigue, weakness, anorexia, cough, abdominal pain, elderly, altered mental statust, dyspnea, CVA, MI, pancreatitis, seizures, sever hyperglycemia

Hyperosmolarity, No ketonemia

Type 2 diabetics

 

Etiologies: 

Impaired access to water

 

Evaluation:

CBC, CMP, UA, Lactate, CXR, Mg, P

Glucose > 600 

Plasma osm > 315

VBG pH > 7.3

Negative to mild ketones

Other tests to find cause

 

Management:

Goals - intravascular volume expansion, correction of fluids, electrolytes, and acid-base

IV fluids and add KCl one urine output confirmed

Insulin bolus IV (10 units)

Insulin drip IV (0.1 U/kg/hr)

Add HCO3- if pH < 6.9

Give glucose with insulin to maintain blood glucose at 150-300

Term
Hyperglycemia
Definition

Presentation:
Polydipsia, polyuria, polyphagia

Weakness, fatigue, HA, blurred vision

Dehydration, lightheadedness, dizziness

Signs of infection are common

 

Etiologies:

known or undiagnosed DM

Complication of untreated DM

Insulin resistance

HTN, PCOS, gestational DM

 

Evaluation:

Random glucose > 200

Fasting glucose > 126

May have sx of DKA or HHNS

Search for underlying cause with necessary labs

 

Management:

admit is you supsect Type 1 diabetes

 

No tx necessary - Mild hyperglycemia with no signs of decompensation

If glucose > 300 - 1 L NS over 1 hr with 

IV insulin 0.1 - 0.5 U/kg

Follow up

 

 

Term
Thyroid Storm
Definition

Presentation:
Extreme presentation of thyrotoxicosis - fatal if untreated!

Fever, tachycardia, AFib, tremor, weight loss

Heat intolerance, diaphoresis, proximal weakness

Palpitations, N/V, diarrhea, altered mental status, menstrual irregularities, Hx of thyroid manipulation, changes in medications, physiologic stressors

 

Etiologies:
Post-operative, radioactive iodine therapy, pregnancy, acute iodine load, uncontrolled DM, trauma, acute infection, drug rxn, MI, CVA

 

Evaluation:
CBC, CMP, UA, bHCG, EKG, BNP, cardiac enzymes

Lactate, cortisol, CXR, Head CT, LP

TSH and Free T4 - not affected during acute phase of thyroid storm, will reflect chronic state

Normal TSH can exclude hyperthyroidism 

 

Management:
Propanolol or Dexamethasone - block peripheral effects of T4/T3

PTU or MMI - stop production of T4

K iodide, Lugol, Lithium - inhibit hormone release

Term
Myxedema Coma
Definition

Presentation:

Severe life-threatening manifestations of hypothyroidism

Altered mental status, bradycardia, hypothermia

Hypoventilation, periorbital edema, hyporeflexia, hypoglycemia, hyponatremia, non-pitting puff appearance of skin and soft tissues

 

Etiologies: 

Hypothyroidism, medication changes, physiologic or psychologic stressors - infection, cold, trauma, major life changes

 

Evaluation:
CBC, CMP, UA, ABG, EKG, cortisol, CXR, TSH, Free T4

 

Management:
Ventilatory support

Thyroid replacement - Levothyroxine

Glucocorticoid

Reverse hypothermia, hypoglycemia, hyponatremia

Term
Addison Crisis/Adrenal Crisis
Definition

Presentation:
Inability of adrenal gland to respond to stress by increasing cortisol production

Hypotension is primary symptom

N/V, diarrhea, flank pain, ab pain

Weakness, fatigue, fever, altered mental status, dizziness

 

Etiologies:
abrupt cessation of steroids, severe trauma, burn, sepsis, surgery, hypoglycemia, MI

Anticoagulant use, pregnancy, AIDS, TB

Anesthesia

 

Evaluation:
Corticotropin Stimulation Test - 

Measure plasma cortisol

Inject Cosyntropin IV/IM

Draw serum cortisol at 30 and 60 min

Normal response is double basal serum cortisol

 

Management:

Goals - high dose replacement of circulating glucocorticoids

Repletion of Na and H2O

Hydrocortisone, Dexamethasone

IV fluids - D5NS or NS

Consider pressors (NE, Dopamine)

Term
Catecholamine Crisis (Pheo)
Definition

Presentation:

Intermittent episodes of HA, palpitations, flushing

Diaphoresis, Hypertension

N/V, ab pain, sense of impending doom

Later findings:
Aortic dissection, encephalopathy, cariomyopathy, pulmonary edema, anion gap metabolic acidosis

 

Etiologies: 

Pheo (intermittent)

MAOI crisis

Cocaine intoxication/sympathomimetics

 

Evaluation:

24 hour urine collection for metanephrins

CT, MRI, isotope scan for tumor

 

Management:

Replace volume deficits, correct electrolytes

Phentolamine (alpha blocker)

Nitroprusside or Fenoldopam

Ca channnel blockers

Beta blocker - Esmolol

Benzos to stunt sympathetic response 

 

Do not Beta block until you Alpha block

Term
Type 1 Diabetes
Definition

Presentation:
usually younger individual, thin, sudden onset

Precipitated by illness, stress

Polys, weight loss, blurred vision, dehydration

 

Diagnosis Criteria (need one):

1. Symptoms of DM + random glc > 199

2. Fasting glc > 125

3. 2 h OGTT > 199

4. Hgb A1c > 6.5

 

Impaired fasting glucose > 140

 

Management:

Target levels - 

Avg fasting and pre-prandial: 70 - 120

Avg 2 hr post-prandial: < 140-160

Should test 3+ times daily

Insulin therapy

Term
Type 2 Diabetes
Definition

Presentation:

usually older age, obese, gradual onset

symptomatic hyperglycemia, recurrent infections

 

Diagnosis Criteria (need one):
1. Symptoms of diabetes + random glc > 199

2. Fasting glucose > 125

3. 2 hr OGTT > 199

4. Hgb A1c > 6.5

 

Management:
Target levels -

Avg fasting, pre-prandial: 70 - 120

Avg 2 hr post-prandial: < 140 - 160

First line therapy: Metformin + lifestyle

Later add Sulfonylurea or basal insulin

Less common therapies: pioglotazone, GLP-1 agonist

Term
Types of Insulin and Onset of Action
Definition

Human Insulin:

regular - 30-60 min

NPH - basal insulin - 2-4 hours

 

Insulin Analogues:

Aspart (Novolog) - 15 min

Glulisine (Apidra) - 15 min

Lispro (Humalog) - 15 min

Glargine (Lantus) - 3-4 hours

 

Premixed Insulins:

Human 70/30, 50/50

Humalog 75/25

Novolog 70/30

(mixed basal/bolus 2x per day, higher risk for hypoglycemia)

Term

Initiating Insulin Therapy

 

and 

 

Adjusting Insulin Therapy

Definition

Begin with bedtime intermediate acting NPH


OR

 

Begin with bedtime/morning long-acting (Lantis)

Long acting is easier to initiate


Check fasting glucose and titrate insulin:

Increase 2-4 Units every 3 days until fasting glucose is at goal

If hypoglycemia occurs, or fasting glucose < 70, reduce bedtime glucose

 

After 2-3 months, check HgbA1c

If < 7% - continue regimen and re-check in 3 mo

If > 7%....intensify insulin:

 

Intensifying Insulin
If fasting glucose is in target range, but HgbA1c is too high, check glucose before lunch, dinner, and bedtime and add a second injection

 

Prelunch glc out of range: add rapid acting insulin at breakfast

Predinner glc out of range: add NPH at breakfast OR rapid acting insulin at lunch

Prebed glc out of range: add rapid acting insulin at dinner

 

Adjust 2 Units every 3 days until glc is in range

 

Do this until glc range and HgbA1c is in range after 3 months

Term
Impingement Syndrome
Definition

Presentation:

Subacromial bursitis + rotator cuff tendonitis + bicipital tendonitis

Inflammation of bursa, rotator cuff tendons, and long head of biceps

Asynchronous shoulder motion

 

Diagnosis:

Impingement signs - 

Neer Impingement sign

Hawkin's Test

 

Bicipital Signs - 

Speed's Test

Yergason's Test

 

Glenohumeral Instability - 

Apprehension sign

 

Treatment:
decrease inflammation with NSAIDs

Restore ROM with PT

Subacrominal injections prn

Surgical decompression, stabilization

Term
Rotator Cuff Tears
Definition

Presentation:

decreased ROM, pain

point tenderness over greater tuberosity

 

Diagnosis:

Impingement signs

full passive ROM but limited active ROM

Positive drop arm test

External rotation weakness is most sensitive sign

X-ray can r/o occult fracture

 

Treatment:

Tx like impingement initially

If function is impaired, do MRI

If tear is confirmed, do surgery

 

Term
Glenohumeral Dislocations
Definition

Presentation:

Mostly anterior dislocations

Posterior dislocations are common in seizures, alcoholics, and electrocution

Pt holds arm in adduction, elbow flexed

Pain with  minor movements

Palpable glenoid fossa

 

Diagnosis:
complete neurovascular exam

document radial and brachial pulses

Should Series X-ray

 

Treatment:

Sedation and reduction

Post-reduction X-rays

Sling and swath

Length of immobilization varies with age

Term
AC Separation
Definition

Presentation:

Direct blow to lateral shoulder

Tender or deformed AC joit

Swelling, tenderness, crepitus

Can be confused with clavicle injury

 

Diagnosis and Treatment:

Prominent distal clavicle and depression of shoulder

Classified according to degree of ligamentous inury

I: strain of AC ligaments, normal X-ray

Ice and sling for comfort

ROM as tolerated, resume activities when ROM is established for 2 weeks

 

II: rupture of AC ligaments, clavicle sublux

Ice, sling for 2 weeks, pendulum exercises, heavy lifting, sports at 6 weeks

 

III: complete rupture of AC and CC ligaments, complete dislocation of clavicle

Similar tx to Type II, anatomic reductino is not always necessary

PT to restore strength and ROM

 

Term
Biceps Tendon Rupture
Definition

Presentation:
proximal or distal rupture - bulging appearance

Due to forceful flexion of arm, older athletes

Ecchymoses depends on location

Predictive of rotator cuff tear

 

Diagnosis: clinical

 

Treatment:

Proximal - surgery if < 40 yo

Distal - surgery for most to preserve supination

Term
Lateral Epicondylitis (Tennis Elbow)
Definition

Presentation:
tendonosis from repetitive pronation/supination 

Pain over lateral epicondyle and into extensor mass

Numbness or tingling - entrapment of sensory branch of radial nerve

 

Diagnosis:

Point tenderness over lateral epicondyle

Pain worsened with forced wrist and finger extension

Some X-rays will show spur off lateral epicondyle

 

Treatment:
activity modification, ice massage

Counter force brace

PT for stretching and strength

Term
Elbow dislocations
Definition

Presentation:

2nd most common dislocated joint

Radius and ulnar are displaced together

Pt holds elbow at 45 degree flexion

Visible olecranon deformity

 

Diagnosis:

Assess neurovascular status 

X-rays

 

Treatment:

Reduce asap if NV compromise is present

Reassess for NV injury and then splint and sling

Term

Nursemaid's Elbow

(Radial Head Subluxation)

Definition

Presentation:
25% of elbow injuries in children

Longitudinal traction on arm while elbow is extended and pronated

No deformity visible but tenderness is present over radial head

Children refuse to use arm

 

Diagnosis:

Clinical, X-rays

 

Treatment:

Reduce by stabilizing elbow and applying gentle pressure on radial head, supinating forearm and flexing elbow until click or snap is heard

 

Term

Trigger Finger

(Flexor Tenosynovitis)

Definition

Presentation:
Thickening of flexor tendon that catches as it passes through A1 pulley

Inflammation of flexor tendon sheath

Common in diabetics

 

Diagnosis:

Trigger at PIP

Tenderness over volar MCP

Palpable nodule, PIP is rarely locked

X-rays are negative

 

Treatment:

Cortisone injections into sheath may give transient improvement

Surgical release to divide A1 pulley

Term
Extensor Tendon Laceration
Definition

Presentation:
dorsal finger and hand wound

90% lacerated tendon can retain function

Diminished strength and pain against resistance 

 

Diagnosis:

Provide resistance against extension

 

Treatment:

< 50% tear requires protective splint

Irrigation, inspection, debridement in ER

Tendon suture repair by hand surgeon

Term

Mallet Finger

(Swan Neck Deformity)

Definition

Presentation:

Laceration or avulsion of extensor tendon at insertion of dorsum distal phalanx

Distal finger is forcibly flexed

Pain with resistance

 

Diagnosis: X-ray may be normal

 

Treatment:

Stack splint with DIP in full extension (closed)

Surgery for open 

Term
Boutonniere Deformity
Definition

Presentation:

hyper-extended PIP joint as a result of laceration or blunt trauma to dorsum

Painful swollen PIP

 

Diagnosis: X-rays normal unless dislocation is present

 

Treatment:

4 weeks of PIP splint (closed)

Surgery (open)

Term
Phalangeal Dislocations
Definition

Presentation:

PIP is most common (dorsal dislocation caused by hyperextension and axial compression)

MCP - due to hyperextension

DIP dislocation is rare - axial force to distal phalanx

 

Diagnosis: gross deformity

 

Treatment:

Digital nerve block for PIP and DIP

Ulnar, median, or radial nerve block for MCP

Reduce with splint

PIP volar entrapments are not reducible

Post-reduction X-ray

Term

Gamekeeper's Thumb

(Skier's Thumb)

Definition

Presentation:

Tear of UCL of MCP joint as a result of adbuction force to thumb's MCP 

Pain, swelling, ecchymoses over MCP

Pain is worse on ulnar side

 

Diagnosis:
Assess degree of instability

Stress joint in full extension and 30 deg of flexion

X-rays: stressful views may be helpful

Stener's Lesion: displaced avulsion fracture

 

Treatment:
1% lidocaine block for comfort during stress

Thumb Spica cast

Surgery for avulsion

Term
Fingertip Injuries and Amputations
Definition

Presetation:
Zone 1 - distal amputation

pad loss of < 1 cm, heal by secondary intention


Zone 2 - involve nail bed, partial bone disruption

Zone 3 - extreme nail involvement

Zone 4 - amputation at level of distal phalanx near DIP

Zones 2-4 require hand surgeon

 

 

Term
Knee Dislocation
Definition

Presentation:

Tibiofemoral joint dislocation is an emergency

Seen in high energy trauma or falls

Tenderness, joint effusion, visual deformity

 

Diagnosis:

Careful neurovascular status exam

X-ray confirms diagnosis

Arteriography helps ID arterial injuries

Serial ABI can exclude arterial injury

 

Treatment:

Emergent redution by in-line longitudinal traction

Neurovascular monitoring

Term
ACL Tear
Definition

Presentation:

Deceleration, rotational force, hyperextension, valgus force, effusion, ROM

 

Diagnosis:

Aspirate joint

Re-examine in 7 days if too painful

Anterior Drawer Test, Lachman Test

Pivot Shift

X-rays are typically normal

Segon's sign: postero-lateral corner avulsion

 

Treatment:

Depends on age and level of activity

Rehab, bracing, reconstruction

 

Term
Knee Collateral Ligament Sprains
Definition

Presentation:

MCL > LCL, graded according to severity

Direct force to medial/lateral knee

Leg wrenched into varus/valgus force

Pain over ligament, swelling, ecchymoses

 

Diagnosis:

I: tenderness, no laxity

II: opening of joint, firm endpoint

III: opening of joint w/o endpoint

Assess degree of laxity (if laxity in full extension, ACL is torn)

 

Treatment:

RICE, knee immobilizer, weight bearing as tolerated

I: immediate ROM and strengthening

II, III: immobilizer for 3 weeks, ROM when comfortable, PT at 3 weeks

Return to activity in 6 weeks

Term
Meniscal Tears
Definition

Presentation:

Acute tears due to twisting injury

Chronic tears are degenerative in nature

Pain, locking, catching, giving way, +/- swelling

 

Diagnosis:

+/- effusion, ROM, r/o ligament injury

Meniscal signs: Steinman's sign, Apley's Sign

McMurray Test

 

Presentation:

RICE, activity as tolerated if full ROM

Consider athroscopy if sx > 6 wks

Locked knee: ice and elevated, ROM

Term

Patellar Tendonitis

(Jumper's Knee)

Definition

Presentation:
Tendonosis at insertion into inferior pole of patella

Pain worse with resisted knee extension

 

Diagnosis: X-ray shows spur off inferior pole

 

Treatment:

Activity modification, PT for hamstring and quad stretches

Surgery 

NO CORTISONE!

Term
Compartment Syndrome
Definition

Presentation:

Due to fractures, crush injuries, and burns

Results in ischemia to muscle and nerves

Pain out of proportion to injury

Pain with passive ROM of muscles

Paresthesia, pulselessness

 

Diagnosis:

Must have high index of suspicion

Absolute compartment  pressure > 30

 

Treatment:

Early treatment is key

Adequate surgical decompression of compartment

Term
Ankle Sprain
Definition

Presentation:

Inversion and eversion injuries

ATFL and deltoid ligament tears

 

Diagnosis:
Assess foot and ankle

Jones Fracture: 5th MT

Palpate medial and lateral ankle

Maissoneuve fx: tear of deltoid, tear of IO membrane, and fx of fibula

 

Treatment:

RICE, posterior spint, modified WB for comfort

SLC with WBAT, aircast 

Formal PT for recurrent sprains

Term
Ankle Dislocation
Definition

Presentation:

displacement of talus and foot from tibia - open or closed

Gross deformity of ankle joint

 

Diagnosis:

Assess neurovascular status

X-rays not necessary

 

Treatment:

Reduce and reasses NV

Splint ankle, obtain radiographs and orthopedic consultation

Term
Achilles Tendon Rupture
Definition

Presentation:

Swelling, ecchymoses

Palpable defect, unable to PF ankle/foot

 

Diagnosis:

+/- Thompson-Dougherty Test

X-rays show occasional bony spur

 

Treatment:
Cast immobilization for 6 wks

Surgical repair

Term
Plantar Fasciitis
Definition

Presentation:
Inflammation at insertion into calcaneus

Pain in plantar heel worse in am

Recent weight gain, lack of exercise

 

Diagnosis: 

Pain over plantar-medial calcaneous

Exacerbated with dorsiflexion of great tose

Gastroc tightness

X-rays may show spur off anterior calcaneous

 

Treatment:

NSAIDs, heel cups, shoes with good arch support

Calf stretches, surgical release

Term
Gout/Pseudogout
Definition

Presentation:
Acute monoarthritis, usually in 1st MTP

Overnight, intense pain on awakening

Difficulty walking, inflammed skin

Hx of EtOH, high uric acid meal

 

Diagnosis:

Elevated serum uric acid 

Elevated WBC and ESR

Arthrocentesis

 

Treatment:

Short course NSAIDs (indomethacin)

Colchicine, steroids

Probenecid, Allopurinol for chronic attacks

Term
Fibromyalgia
Definition

Presentation:

Chronic aching pain, stiffness

Prominent around neck, shoulder, low back, hips

Fatigue, sleep disorders, numbness

Chronic HA, IBS are also common

 

Diagnosis: exclusion

Trigger points produce pain by palpation (Trapezius, medial fat pad of knee, and lateral epicondyle)

 

Treatment:

Amitriptyline, Fluoxetine, Chloropromazine

Gabapentin

Exercise

Term
Rhabdomyolisis
Definition

Presentation:

Myalgia, muscle weakness, dark urine

Tenderness, decreased strength, swelling

Bruising, soft extremities, depressed reflex

Normal sensory examination

 

Diagnosis:

Red-tinged urine, turns dark brown, myoglobinuria on dipstick, elevated CK

 

Treatment:

Hydration to ensure high urine volume

NS at 1.5 L/h

Maintain urine at 300 ml/h

Mannitol or NaHCO3- to alkalinize urine

Term
Septic Arthritis
Definition

Presentation:
Fever, painful joint, effusions, erythema

Limited ROM, will appear ill

 

Diagnosis:

Arthrocentesis, cultures 

Synovial lactic acid can exclude dx

Blood cultures - r/o GC

 

Treatment: 

Aspirate

High dose IV abx empiric, then focus with cultures

Term
Osteomyelitis
Definition

Presentation:

Pain, fever, swelling, focal tenderness

 

Diagnosis:

High ESR, X-rays show soft tissue swelling and lytic lesions (late finding)

MRI, bone scan, culture, histology

 

Treatment:

Systemic abx and surgery to drain abscess or debridement

Uncomplicated, child: cover Staph

Term
Back Pain
Definition

Presentation:

Muscle strain is most common cause

May present with pain, paresthesia

 

Diagnosis:

PE shows ROM, areas of tenderness, neuro exam

Radicular signs: indicates nerve root entrapment

Contralateral straight leg raise

 

Treatment:

Activity modification
NSAIDs

PT if the sx persist

Term
Define closed fracture
Definition
broken bone that does not penetrate through the skin
Term
Define open fracture
Definition

fracture associated with overlying soft tissue injury, creating a communication between the fracture site and external surface of the body

 

Includes bone poking through skin or puncture wound that extends on surface of a broken bone

Complication: osteomyelitis

Term
Define articular fracture
Definition
Fracture involving the joint surface of a bone
Term
Define Non-displaced fracture
Definition
Fracture in which the bone cracks with the broken pieces still in alignment
Term
Define Displaced fracture
Definition

fracture in which fragments are offset from one another

(no longer aligned)

Term
Define angulated fracture
Definition

the angles of the respective bone fragments, expressed in terms of direction and amount

 

Direction: 

Varus - apex away from midline

Valgus - apex toward midline

Recurvatum - apex posterior

Procurvatum - apex anterior

 

Amount: amount of unbending, expressed in degrees, that would be required to make the fragments parallel

Term
Define avulsed fracture
Definition
an injury to bone in a place where the ligament or tendon attaches, resulting in the ligament or tendon pulling off a fragment of bone
Term
Define Greenstick Fracture
Definition

Frank disruption of cortex on side of the bone, but no discernable cleavage plane on the opposite side

 

Fractures are angulated, but not displaced because the bones are not actually separated

 

Reduce and cast, 7-10 followup

Term
Growth Plate Fracture
Definition

Salter Harris Fracture

 

 

Term
Sprain
Definition

Presentation:

Injuries to ligaments and may be associated with fx

Grade 1: swelling, ecchymoses

Grade 2: + laxity

Grade 3: + completely unstable joint

 

Diagnosis and Treatment: 

Grade 1: incomplete tear

immobilization, conservative care

 

Grade 2: significant incomplete tear

immobilization, ortho followup

 

Grade 3: complete disruption

orthopedic followup for surgical repair

Term
Strain
Definition

Presentation:
injury to muscle-musculotendonous unit

 

Diagnosis:
Also graded according to severity

 

Management:

immobilization, conservative mgmt

Ortho referal and surgical repair maybe

Term
Dislocation (general)
Definition

Presentation:
complete disruptions in normal relationship or articular surfaces of bones making up the joint

 

Diagnosis:

Must assess NV status

 

Management:

reduce

The longer the joint is displaced, the more difficult it is to reduce

Term
Tendon Rupture (general)
Definition

Presentation:

break of a tendon 

Can be caused by steroid injections, gout, RA, and hyperparathyroidism

Signs and sx dependent on location

Often hear pop, snap, sharp pain

Swelling, ecchymoses, palpable defect

 

Diagnosis:

Drop Arm test for biceps

Thompson test for achilles

X-rays may show bony avulsion

 

Management:

often controversial

cast immobilization 

surgical repair

Term
Salter Harris Fracture Class I
Definition

Fracture through the growth plate

 

The epiphysis is separated from the metaphysis without radiographic evidence of metaphyseal or epiphyseal fracture

[image]

 

Term
Salter Harris Fracture Class II
Definition

Fracture through the metaphysis and growth plate (Most common type)

 

Fracture line travels through the physis and is associated with the oblique fracture of metaphysis on the opposite side from the applied force

(Thurston-Holland sign: metaphyseal fragment)

Term
Salter Harris Fracture Class III
Definition

Fracture through the growth plate and epiphysis into the joint

 

Vertical fracture of epiphysis perpendicular to physis, extending into the growth plate

Uncommon, occurs mostly in distal tibia

Term
Salter Harris Fracture Class IV
Definition

Fracture through the metaphysis, growth plate, and epiphysis into joint

 

Result of compressive (rather than rotational or shearing forces) - requires surgical repair

 

 

Term
Salter Harris Fracture Class V
Definition

Crush of growth plate, may not be seen on X-ray

 

Rare, and results from severe crushing force applied to epiphysis in area of physis

Most often distal tibia and knee

Often missed on radiograph and diagnosed during followup visits after shortening deformities

Non-traumatic causes are osteomyelitis and epiphyseal aseptic necrosis

Term
Penicillins V, G coverage
Definition

Gram + 

Anaerobes

Term

Methcillin, Oxacillin, Nafcillin coverage

 

Definition

Gram + 

Staph/MSSA

Gram - Anaerobes

Term

Augmentin, Unasyn (IV) coverage

 

Definition

Gram + 

Staph/MSSA

Gram - 

Anaerobes

Term
Pipercillin, Zosyn, Timentin
Definition

Gram +

Staph/MSSA 

Gram - 

Pseudomonas

Anaerobes

Term

Meropenem, Imipenem (IV only) coverage

 

Definition

Gram + 

Staph/MSSA

Gram - 

Pseudomonas

Anaerobes

 

Generally used only as last resort for in-pt

Term

Cefazolin, Keflex (1st gen) coverage

 

Definition

Gram + 

Staph/MSSA

 

Term

Cefuroxime, Cefoxitin (2nd gen) coverage

 

Definition

Gram + (some)

Staph/MSSA

Mostly Gram - 

Term

Rocephin (3rd gen) coverage

 

Definition

Gram + 

Staph/MSSA

Gram - 

Term

Ceftazidime (3rd gen + pseudo) coverage

 

Definition

Gram +

Staph/MSSA

Gram - 
Pseudomonas

Term

Erythromycin, Azithromycin, Clarithromycin 

(Macrolides) coverage

 

Definition

Gram + 

Staph/MSSA

Gram - 

Atypicals

Term

Ciprofloxacin (Quinolone) coverage

 

Definition

Gram + 

Staph/MSSA

Gram - 

Very good at Pseudomonas

Atypicals

Term

Levofloxacin (Quinolone) coverage

 

 

Definition

Very good at Gram +

Very good at Staph/MSSA

Gram -

Pseudomonas

Atypicals

Term

Gentamicin, Tobramycin, Amikacin (Aminoglycosides) coverage

 

Definition

Gram - 

Pseudomonas

Term
Clindamycin
Definition
Anaerobes
Term
Metronidazole (Flagil)
Definition
Anaerobes in gut (C. diff)
Term
Vancomycin, Linezolid
Definition
MRSA
Term
Bactrim
Definition

Gram - 

Atypicals - PCP

Term
Nitrofurantoin
Definition

Gram + 

Staph/MSSA

Gram - 

 

Best for UTI

Term
Antibiotics that cover Gram +
Definition

Penicillin G, V

Methcillin, Oxacillin, Nafcillin

Augmentin, Unasyn (IV)

Pipercillin, Zosyn, Timentin

Meropenem, Imipenem

Cefazolin, Keflex

Cefuroxime, Cefoxitin

Rocephin

Ceftazidime

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Nitrofurantoin for UTI

Term
Antibiotics that cover Staph/MSSA
Definition
All the same that cover Gram + except Penicillin G and V
Term
Antibiotics that cover Gram - 
Definition

Augmentin, Unasyn (IV)

Pipercillin, Zosyn, Timentin

Cefuroxime, Cefoxitin

Rocephin

Ceftazidime

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Gentamicin, Tobramycin, Amikacin

Bactrim

Nitrofurantoin for UTI

Term
Antibiotics that cover MRSA
Definition

Vancomycin

Linezolid

Term
Antibiotics that cover Pseudomonas
Definition

Pipercillin, Zosyn, Timentin

Meropenem, Imipenem

Ceftazidime

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Gentamicin, Tobramycin, Amikacin

Term
Antibiotics that cover Anaerobes
Definition

Penicillin V, G

Methicillin, Oxacillin, Nafcillin

Augmentin, Unasyn (IV)

Pipercillin, Zosyn, Timentim

Gentamicin, Tobramycin, Amikacin

Metronidazole in gut (C. diff)

Term
Antibiotics that cover Atypicals
Definition

Erythromycin, Azithromycin, Clarithromycin

Ciprofloxacin, Levofloxacin

Bactrim for PCP

Term
Examples of Gram + bugs
Definition

Staph, Strep, Enterococcus

Listeria, Clostridium

Term
Examples of Gram - bugs
Definition

Gonorrhea, Moraxella

Haemophilus

E. coli, Pseudomonas, Klebsiella

Term
Examples of atypical bugs
Definition
Chlamydia, Legionella, Mycoplasma
Term
Antibiotics coverage for Hospital Acquired Pneumonia
Definition

Pseudomonas!!!!!!

Imipenem/Meropenem

Zosyn + Aminoglycoside

Zosyn + Quinolone

Term

General approach to trauma patient

Primary Survey

Definition

Primary Survey:

A - airway 

Intubate if GCS < 8

Continually reassess need for surgical airway

Check placement of ET tube with portable CXR

 

B - breathing

Ventilate with 100% O2

Contralateral tracheal deviation = tension pneumo

Palpate for subcutaneous emphysema

Flail segment = 2 or more ribs broken in 3 or more places (paradoxical respiration)

 

C - circulation

apply pressure to sites of bleeding

Establish 2 large bore IVs

Place central line if peripheral not accessible

Assess pulses and capillary refill

Pulses present at 

a) carotid --> SBP = 60

b) femoral --> SBP = 70

c) radial --> SBP = 80

Beck's Triad for cardiac tamponade: 

JVD, hypotension, muffled heart sounds

 

D - disability

Brief neuro exam 

Pupil size and reactivity, motor assessment, and sensation

Glasgow coma scale: eyes, verbal response, and motor (max of 16 points)

 

E - expose

Completely disrobe pt and log-roll for back injuries

Term

General Approach to Trauma Patient

Secondary Survey

Definition

Trauma Series X-ray includes:
lateral C-spine, chest, AP pelvis

 

Head to Toe exam:

TMs, facial stability, teeth, jaw, neck ROM

Ab exam for distension, tenderness, stable pelvis

Blood at urethral meatus = pelvic fracture, bladder rupture

Rectal tone and blood guiac test 

deformities and open fractures

 

Miscellaneous

Consult with surgery or transfer

FAST U/S exam for ab/chest trauma

Enhanced CT for chest or ab with IV contrast

IV Mannitol for neurological decompensation

IV steroids for spinal cord injury

IV abx for ruptured ab viscus

Term
Define shock
Definition

State of severe systemic reduction in tissue perfusion characterized by decreased cellular oxygen delivery and utilization as well as decreased removal or waste byproducts of metabolism

 

Generally final preterminal event in many diseases

Term
Pathophysiology of Shock
Definition

Determinants of BP are

systemic vascular resistance, HR, preload, and contractiltiy

 

Initial derangements and compensations include 

a) vasodilation causing decrease systemic resistance from sepsis, anaphylaxis, drugs, or cervical cord lesion

The body compensates with tachycardia, thirst

The skin remains perfused and warm

 

b) extremes of HR

 

c) loss of preload volume  causes decreased EDV from blood or volume loss

The body compensates with an increase in systemic resistance, an increase in DBP, narrowed pulse pressures, cholinergic sweating, pale, cool, thirsty, hypotension, tachycardia

 

d) loss of contractility causes an increased ESV from heart failure

The body compensates with an increase in systemic resistance

Term
Hypovolemic Shock
Definition

Primary derangement in EDV caused by blood or volume loss (see initial derangement c)

 

Presentation:
Pale, cool, moist skin, narrowed pulse pressure

Anxiety, tachycardia, dec urine volume

 

Treatment:
stop bleeding or fluid loss and replace it

20 ml/kg crystalloid NS or LR

replace blood (type and cross)

May require surgery

Term
Cardiogenic Shock
Definition

Primary derangement in ESV caused by arrhythmias, MI, cardiomyopathies, or mechanical anomalies (see initial derangement d)

 

Presentation:

pale, cool, moist skin, narrowed pulse pressure

anxiety, tachycardia, dec urine output 

same as hypovolemic shock

Right sided heart failure --> pulm edema

Left sided heart failure --> peripheral edema + JVD

 

Treatment:

Cardioversion is tachyarrhythmia

Transcutanfous pacing if bradyarrhythmia

Atropine for sinus brady, Wenkebach

Supportive O2, ASA, Heparin, fluids

Pressors

Term
Distributive Shock
Definition

Primary derangement in SVR (relaxed tubes)

Subtypes: anaphylactic, septic, neurogenic, drug induced (beta blockers, Ca channel blockers), endocrine (adrenal insufficiency)

 

Presentation:

Loss of vascular tone presents with erythematous warm skin, depsite hypotension

Tachycardia, hyperdynamic heart

 

Treatment:

Anaphylactic: epinephrine, Beta agonist, H1/H2 antagonist, steroids

Septic: targeted abx, pressors

Neurogenic (disruption of sympathetic chain): fluids, vasopressors

Drug induced: IV glucagon, Ca gluconate, general decontamination

Term
Obstructive Shock
Definition

Problem with SV due to mechanical obstruction to preload - causes are often classified as hypovolemic or cardiogenic

Causes: tension pneumo, pericardial disease, massive PE

 

Presentation:

pale, cool, moist skin, narrowed pulse pressure

Anxiety, tachycardia, decrease urine output

same as hypovolemic

 

Treatment:
Tension Pneumo: decompression and chest tube thoracostomy

Pericardial tamponade: U/S guided pericardiocentesis

PE: NE, surgical embolectomy

Term
Flail Chest
Definition

Presentation:

Paradoxical chest wall motion 

inward movement with inspiration

outward movement with expiration

Respiratory distress + signs of hypoxia

 

Diagnosis:

careful inspection and palpation that reveals paradoxical motion of flail segment


Treatment:

intubation!

maintain ventilation and fluids

supplemental oxygen

Term
Tension Pneumothorax
Definition

Presentation:

pneumothorax that interferes with venous return to heart

Respiratory distress, distended neck veins, and unilateral diminished breath sounds

Contralateral tracheal deviation

Percussion typmany

+/- external signs of trauma

 

Diagnosis:

Clinical diagnosis confirmed by CXR

 

Treatment:

emergency thoracostomy 

insert large bore (14ga) needle into 2nd ICS, MCL

Definitive tx is tube thoracostomy in 5th ICS MAL

Term
Cardiac Tamponade
Definition

Presentation:
penetrating or blunt injuries can interfere with intra-pericardial pressure and interrupts diastolic filling, leading to inadequate CO and end organ perfusion

Beck's Triad: hypotension, JVD, muffled heart sounds

 

Diagnosis:
EKG shows alternating positive and negative QRS complexes with each beat (pathognomonic)

FAST exam can confirm

Emergency echo TEE

 

Treatment:

Pericardiocentesis

Open thoracotomy

Term
Head Trauma
Definition

Presentation:

Altered MS +/- focal deficits

Cranial lacerations, hematomas

Basilar skull fracture shows hemotympanum, CSF leak, Battle's sign, Raccoon eyes, CN 7 palsy

 

Diagnosis:

Examine head, nose, ears

Rapid neuro exam - GCS, AVPU, pupils, EOMs, posturing, motor function, response to pain, DTR, Babinski

CT without contrast

 

Treatment:

Achieve euvolemia

Maintain PCO2 35 - 40

Hyperventilation indicated if uncal herniation

Mannitol for osmotic diuresis if ICP

Decompressive craniotomy, burr hole if rapid deterioration

Term
Traumatic Injuries to Neck
Definition

Presentation:

Trachea - hoarseness, aphonia, apnea, respiratory distress, stridor, subcutaneous emphysema, bubbling of blood

Esophagus - dysphagia, neck pain

Vascular - Zones 1 - 3

 

Diagnosis:

Examine neck for trauma, hematoma, crepitus, SQ air, external hemorrhage, tracheal deviation, cervical spine tenderness, or deformity

Esophagus - requires CXR and esophagoscopy or barium swallow

Vascular - surgical exploration if in Zone 2, esophagoscopy

Term
Myocardial Contusion
Definition

Presentation:

High velocity blunt trauma to chest (MVA)

that causes hypotension, wall motion abns that lead to a decrease in CO

 

Diagnosis:

EKG shows unexplained sinus tach

EKG may also show other arrhythmias, ST and T wave changes, and heart blocks

Echo, cardiac enzymes

 

Treatment: 

Treat arrthymias

Serial EKGs to assess for changes

Will heal completely

Can d/c if hemodynamically stable, < 55 yo

Term
Pulmonary Contusion
Definition

Presentation:
Trauma to chest causing respiratory distress, hypoxia that worsens over time, and diffuse pulmonary opacities on CXR

One of the most lethal injuries to the chest

 

Diagnosis: 

CXR - beware radiographic findings may be delayed > 24 hours

CT scan can confirm diagnosis before CXR

 

Treatment:

Monitoring and oxygen, ventiltion

Intubation if pulse ox < 90

Term
Aortic Rupture
Definition

Presentation:

requires high index of suspicion based on mechanism of injury

Deceleration, ped struck by vehicle, falls > 30 ft

Pseudocoarctation, diminished femoral pulses

New harsh systolic murmur

50% of pts have no external signs

 

Diagnosis:

CXR may show widened mediastinum > 8 cm 

Tracheal or NG tube deviation to right

Widening of paratracheal stripe > 5 cm

Depression of left main-stem bronchus

Indistinct aortic knob, Left apical capping

Helical CT, TEE

Aortography is gold standard

 

Treatment:

Surgial consult, immediate surgery

BP support with IV fluids, blood

Maintain Hct at 30%, Maintain BP 100-120

Beta blockers, afterload reduction to control HTN

Term
Spinal Trauma
Definition

Presentation:

Logroll pt to examine entire spine

Rectal exa for tone, perineal sensation

+/- neuro deficits early

 

Diagnosis: 

detailed motor and sensory exam to determine all extremities 

Radiography

 

Treatment:

Neuro/ortho consult for deficits/fractures

Term
Abdominal Trauma
Definition

Presentation:
Injuries may be blunt or penetrating, resulting in intra-abdominal bleed

Blunt trauma - spleen

Penetrating trauma - liver, small bowel

 

Diagnosis:

Mechanism of injury, muscle guarding

CBC, electrolytes, lactate, EtOH, drug screen, HCG

Serial FAST exams, CT of ab with IV/oral/rectal contrast

 

Treatment: 
Hemodynamically stable - may be sent to radiology for CT and DPL, FAST

 

Hemodynamically unstable - FAST exam, followed by CT if they become stable

If positive FAST, immediate laparotomy

Term
Genitourinary Trauma
Definition

Presentation:

Pelvic fractures associated with GU injury

Blood in urinary meatus

Scrotal or perineal hematoma

High riding prostate on rectal exam

 

Diagnosis:

retrograde urethrogram prior to Foley insertion

Cystogram

CT scan with IV contrast

 

Treatment:

Treat shock as indicated

Term
Ectopic Pregnancy
Definition

Presentation:
pregnancy outside of uterus

Abdominal pain, vaginal bleeding, Nausea, lightheadedness

 

Diagnosis:

Ultrasound is most sensitive and serum HCG

Will need Rh factor

 

Treatment:

If still intact - manage medically

Ruptured - surgery and stabilization

RhoGAM if indicated

Term
Abnormal Vaginal Bleeding
Definition

Presentation:
Bleeding

 

Diagnosis:
Vitals, compression of uterus, pelvic U/S

 

Treatment:

Treat for trauma

Obtain consult

Term
Placenta Previa
Definition

Presentation:

Placenta attaches to lower part of uterine wall, possibly covering cervix

Presents with bleeding

 

Treatment:

bed rest, transfusions

C-section, possible RhoGAM

Term
Placenta Abruptio
Definition

Presentation:

Separation of placenta from uterine wall prior to delivery

Ab pain, back pain, vaginal bleeding

 

Diagnosis:

U/S and labwork

 

Treatment:

Observation, IV fluids, maybe blood

Routine C-section or emergent delivery

RhoGAM

Term
Uterine Rupture
Definition

Presentation:
Full thickness separation of uterine wall and overlying serosa

Uterine bleeding, fetal distress

Expulsion of fetus, placenta into cavity

Diminished uterine pressure, ab paon

Hemorrhage, shock 

 

Presentation:
Stabilize mother and fetus (C-section)

Mother may need repair or hysterectomy

Obtain Rh factor and treat accordingly

Term
Spontaneous Abortion
Definition

Presentation:

Fetal death < 20 wks gestation

Vaginal bleeding, cramping

 

Diagnosis:
U/S, serial serum HCG

 

Treatment:

Obtain Rh factor and tx accordingly

Misoprostol to help evacute contents

Consider D&C if retained POC persists

Term
Ovarian Torsion
Definition

Presentation:
sudden onset lower abdominal pain

Usually due to mass, tumor > 5 cm

Pregnancy increases risk

 

Treatment:
surgical repair

Term
Ovarian Cyst
Definition

Presentation:

Follicle does not open, creating fluid filled cyst that ruptures and causes mild peritoneal signs

 

Diagnosis:
Pelvic exam and U/S

 

 

Term
PID
Definition

Presentation:

Caused by GC/C

Ab pain, vaginal discharge, vaginal bleeding

Dyspareunia, fever, nausea

Vomiting, signs of peritonitis

PID shuffle

 

Diagnosis:
Clinical, labs

 

Treatment:
Inpt may require IV abx

Outpt: Cefriaxone 250 mg IM one dose + Doxycycline for 14 days

Term
Vaginitis and Vaginal Discharge
Definition

Presentation:
candida, anaerobes, GC

Discharge and pruritis

 

Diagnosis:

Pelvic exam, UA

Wet Prep: bacterial shows clue cells

Wet Prep: candida shows yeast

 

Treatment:

Candida: Diflucan, topical cream

BV: metronidazole

GC: Cefriaxone

Term
Bartholin Abscess
Definition

Presentation:
Infection of Bartholin gland, usually GC

 

Diagnosis:

Physical exam - abscess appears erythematous and tender to palpation in posterior labia major or vestibule

 

Treatment:

Drainage with word cath

Marsupialization

Broad spectrum abx

Term
Acute Gastroenteritis
Definition

Presentation:
N/V, diffuse ab pain, watery diarrhea, low grade fever, HA, myalgias

Pt usually has sick contacts

Usually viral, blood may mean bacterial

 

Diagnosis:
check electrolytes, pregnancy test

 

Treatment:

Rehydration with IV fluids

Correction of any electrolyte abn

Anti-pyretics for fever or body aches

Anti-emetics if pt cant stop vomiting

Low dose immodium will help with viral

Term
Acute Gastritis
Definition

Presentation:
Inflammation of stomach specifically, usually cause by EtOH, NSAIDs

Possible bleeding

Anorexia, Nausea, dyspepsia, pain

Post-prandial emesis

 

Diagnosis: endoscopy

 

Treatment:

Antacids with lidocaine for non-bleeding

Consider PPI or H2 antagonist

Avoid ASA, NSAIDs, caffeine, EtOH

Hospitalize if bleeding

Term
Peptic Ulcer Disease
Definition

Presentation:

H. pyloria, NSAIDs

Gnawing, burning, epigastric pain

Typically 2-4 hours after meals relieved by food

Nocturnal pain, early morning wakening

Symptomatic periods appear in clusters and are followed by sx-free periods

Hematemesis

 

Diagnosis:

H. pylori serum testing

H. pylori breath testing (expensive)

Endoscopy - view mucosa, biopsy ulcerations, sample of stomach for H. pylori and r/o cancer

Confirm there is no GI bleed

 

Treatment:

Stop NSAIDs

Treat H. pylori with PPI

clarithromycin + amoxicillin +/- bismuth

Term
Pancreatitis
Definition

Presentation:
Significant epigastric pain or RUQ pain that radiates through the body to the back

N/V, fever, decreased pain leaning forward, and restlessness

Mild jaundice, tachycardia, guarding

 

Diagnosis:

CBC with differential 
CMP, lipase, amylase (more sensitive), ABG

Must r/o aortic dissection/AAA

CT

 

Treatment:

Aggressive fluid, IV pain control

Abx if pt appear septic

Anti-emetics

NPO, NG tube if vomiting a lot

Treat the precipitant

Term
Diverticulitis
Definition

Presentation:

LLQ pain, fever, malaise, constipation

Bloody stools, sx of peritonitis (rupture)

 

Diagnosis:

CBC shows mild WBC elevation

CT scan with oral and IV contrast

 

Treatment:

High fiber, low fat diet, hydration

NPO

Abx for infection (Cipro, Flagil)

Surgery if abscess

Term
Constipation
Definition

Presentation:
< 3 defecations per week, straining

Incomplete evacuation, no ab pain

Causes: low fiber, medications, DM, dehydration, thyroid disease

 

Diagnosis:

Hx is most important

Unintentional weight loss? melena? BRBPR?

Do ab and rectal exam, hemorroids, fissures, prolapse

May need CT, hemoccult, colonoscopy

 

Treatment:
Chronic: fiber supplements bid, stool softeners, increased hydrations, exercise, more fiber

Acute: enemas, Mg citrate po, Miralax, manual disimpaction, hydration

Term
Hemorroids
Definition

Presentation:
weakening of supportive tissues cause hemorrhoids to bleed - BRBPR

Perianal itching, irritation

Mucofecal staining of underwear

Frank prolapse

Hx of constipation or constipating meds

 

Treatment:

High fiber fiet

1% hydrocortisone cream briefly

Careful anal hygeine

Referal to colorectal surgeon for rectal prolapse or chronic anal problems

Term
Pilonidal Cyst
Definition

Presentation:

Superior aspect of intragluteal cleft

Acute or chronic presentation

Due to hairs that puncture the skin

Erythematous, edematous, warm, tender skin superior to gluteal cleft

Low grade fever


Diagnosis:

CBC may show elevated WBC if surrounding cellulitis

 

Treatment:

Incision and drainage with packing

Abx if cellulitis or immunocompromised

Recurrent cyst may need wider incision

Term
Anorectal Abscess/Fistulas
Definition

Presentation:
Collection of pus in anus or rectum

May be due to blocked crypts or infection

Can cause fistula, systemic sepsis

 

Diagnosis:

CBC will show elevated WBC

Do CT if abscess is deep or if you are concerned for fistulae

U/S if abscess is more superficial

 

Treatment:

Incision and drainage by surgeon

Complications can include transection of anal musculature leading to incontinence

IV abx if sepsis or cellulitis

Term
Appendicitis
Definition

Presentation:

Diffuse periumbilical pain that localizes to RLQ

Anorexia is the most sensitive sign

N/V, diarrhea, low grade fever

 

Diagnosis:
Mostly clinical diagnosis

McBurney's point tenderness

Rovsing's sign (deep LLQ palpation)

Psoas sign (hip flexion against resistance)

Obturator sign (internal rotation)

CBC, CMP, wet prep in women, UA, HCG

CT scan with oral, IV contrast

RLQ U/S for pts who can't have CT

 

Treatment:

Surgical removal

IV abx if surgery is delayed or rupture

 

Term
Acute Cholecystitis
Definition

Presentation:

Gallbladder inflammation - usually due to gallstones

5 F's 

RUQ pain, radiation to back or shoulder

Constant and severe, assoc with fever

Worse post-prandial, N/V, anorexia

+ Murphy's sign, pt is very still

 

Diagnosis: 

CBC, CMP, Lipase to r/o pancreatits

U/S most sensitive test - may show gallstones, thickened wall, sonographic Murphy's, pericholecystic fluid

Can do HIDA scan 

 

Treatment:

GI tract rest - NPO

IV pain meds and hydration

Possible surgery

Abx if pt has fever, elevated WBC, or any other reason to suspect actual or threatened ascending infection

Term
Perforated Viscus
Definition

Presentation:

Perforation of any abdominal organ caused by trauma, infection, instrumentation, or obstruction

Abrupt onset pain or relief from pre-existing pain at time of perforation

Fever, hypotension, rigid abdomen

 

Diagnosis:

Plain films (supine, upright)

Possible CT

CBC for WBC

 

Treatment: 

Call surgery now

Supportive care until surgery takes them to OR

Term
Foreign Body Ingestion
Definition

Presentation:
Abrupt onset dysphagia w/ inability to swallow saliva

Neck tenderness, sense of fullness

Attempts to induce vomiting

 

Diagnosis:

Hx of recent ingestion of meat, achalasia, esophageal strictures, previous impactions

Plain films of neck, chest, abdomen may show radiopaque foreign body, signs of esophageal perforation, or nothing

Check for SQ air on X-ray

 

Treatment:
IV Glucagon to relax esophagus

Endoscope can be used to push food down

May need esophageal dilation

Disc batteries must come out

Some things can be allowed to pass

Sharp or long > 5 cm can be removed by GI doc or general surgery

Term
Ruptured AAA
Definition

Presentation:

Aorta 2x width of normal diameter

Abrupt onset ab, chest, or flank pain, hypotension

Pulsatile mass in abdomen

May be unconscious

 

Diagnosis:

Bedside U/S

CBC, PT/PTT/INR, chemistries

More stable pts - CT w/ IV contrast

 

Treatment:

Call vascular surgery!

At least 2 large bore IVs

Type and cross 10 U of blood

Aggressive rehydration IV fluids

O2 via nasal cannula

Serial Hgb/Hct

Patient to OR asap

Term
Mesenteric Ischemia
Definition

Presentation:
Arterial emboli and venous thrombosis causing severe acute or chronic pain presenting in diffuse pattern. May also be sub-acute.

Usually older pts with hx of MI, CHF, PVD, AFib, AAA, dissections, hypercoaguable states, hypercholesterolemia, PVD, pancreatitis, diverticulitis, appendicitis, trauma, DM

 

Diagnosis:
Pain out of proportion to exam

Heme-positive stool

Elevated serum lactate (hypoperfusion)

CT, Angiography is gold standard

 

Treatment:
IV fluids immediately to improve flow 

Immediate surgery consult

IV abx to protect pt in case of perforation

Aggressive pain control

Heparin if known thrombus

Term
Small Bowel Obstruction
Definition

Presentation:

Hx of adhesions (surgery), hernias, tumors, strictures, Crohn's disease

Crampy ab pain, inability to pass flatus or stool

Vomiting, vomiting stool, ab distension

Crampy developing into constant pain may be a sign of strangulation

 

Diagnosis:

Signs of peritonitis, ab distenstion, high pitched bowel sounds, diffuse ab tenderness to light palpation, surgical scar

X-rays - supine and upright shows air/fluid levels or free air under diaphragm

CT if X-ray is non-specific

CBC, coags, chemistries, gastroccult

 

Treatment:

NG tube, NPO

IV hydration

Surgery maybe if no resolution after 12-24 hr

Term
Otitis Media
Definition

Presentation:
Acute, chronic/recurrent, or with effusion

Antecedent to sx of URI - ear pain, hearing loss, tinnitus

Children may have fever, irritability, otorrhea, lethargy, otalgia of sudden onset, poor sleeping, poor feeding

TM mobility is decreased, bulging

No light reflex, redness

 

Diagnosis:
Usually infectious - suppurative or viral

Paraflu, RSV, Flu, Adenovirus, Rhinovirus

Strep pneumo, Hib, Strep pyogenes, S. aureus, Mycoplasma

 

Complications:
Mastoiditis, meningitis, brain abscess, labyrinthitis, facial paralysis

 

Treatment:
Amoxicillin

Augmentin

Ceftin

Erythromycin if allergic to penicillins

Admit if febrile toxic child < 1 yo

Term
Otitis Externa
Definition

Presentation:

Hx of 1-2 days progressive ear pain, hx of water exposure

Itching, purulent discharge, conductive hearing loss

Feeling of pressure, fullness

Caused by trauma, pseudomonas, Staph, Gram -, fungal, yeast

 

Diagnosis:

PE shows pain on traction

Periauricular adenitis

Speculum reveals erythema, edema, accumulation of moist debris in canal

TM may be difficult to visualize, but normal insufflation 

Eczema of pinna may be present

 

Treatment:

Clean debris from canal

Ofloxacin can cure in 5-7 days (drops)

Follow up in 3-5 days

Term
TM Perforation
Definition

Presentation:
Complication of AOM or due to trauma

Middle ear barotrauma from scuba diving

Otorrhea, Weber lateralizes to side of perforation

Traumatic often lacks discharge

 

Treatment:
Will heal spontaneously in 4-6 wks

Keep ear dry and refer to ENT

Drop use + oral abx is controversial

Corticosporin Otic suspension or Cipro drops

Term
Cerumen Impactions
Definition

Presentation:
Can cause pain, pressure, vertigo, hearing loss, blocked TM

 

Diagnosis:

visualize TM, ask about Q-tips

Hx of perforation?

 

Treatment:

Use ear wax softeners (Debrox)

Currette

Irrigate with warm saline + Hydrogen peroxide

Do not irrigate a perforated TM

Term
Peripheral Vertigo
Definition

Presentation:

Dizziness, hearing loss, tinnitus, feeling of fullness

N/V, recent caffeine, nicotine, EtOH, head trauma

 

Causes:

BPV, vestibular neuronitis, suppurative labyrinthitis

Meniere's disease, Acoustic neuroma

 

Diagnosis:

Ear inspection, CNs, cerebellar function

CT/MRI for suspected central cause or elderly pt with equivocal findings

Dix Hallpike maneuver - if it makes sx worse, and you see nystagmus, probably peripheral

 

Treatment:

Dix-Hallpike sometimes helps

IV hydration

Meclizine

Diazepam

Anticholinergics (Diphenhydramine, Dimenhydramine)

Term
Central Vertigo
Definition

Presentation:

Dizziness, hearing loss, tinnitus, feeling of fullness

N/V, recent caffeine, nicotine, EtOH, head trauma

 

Causes:

Cerebrovascular disease

Cerebellar degeneration

Migraine, MS, EtOH intoxication

Tumor of brainstem, cerebellum

Phenytoin toxicity

Aminoglycoside, Quinolones are ototoxic

 

Diagnosis:

Ear inspection, CNs, cerebellar function

CT/MRI for suspected central cause or elderly pt with equivocal findings

Dix Hallpike maneuver - if it makes sx worse, and you see nystagmus, probably peripheral

 

Treatment:

Inpt management

IV hydration

Meclizine

Diazepam

Anticholinergics (Diphenhydramine, Dimenhydramine)

 

Term
Labyrinthitis
Definition

Presentation:
Vertigo, dizziness, hearing loss, N/V, tinnitus

Malaise, nystagmus

 

Diagnosis:

exam shows clear ears, EOM and pupils normal

Dix-Hallpike, CNs, balance, Romberg, Tandem gait, cerebellar function

Must exclude meningitis, mastoiditis, acoustic neuroma, stroke, brain abscess, epidural hematoma

 

Treatment:
Tx underlying cause

Meds for vertigo, antibiotics, antivirals

Lie still with eyes closed in dark room

Visual-vestibular execises

Term
Meniere's Diease
Definition

Presentation:

Increased volume and pressure of endolymph leading to unilateral hearing loss, tinnitus, vertigo with sudden onset and short duration, wooshing noise

Intense, recurrent labyrinth vertigo with N/V, distress, nystagmus during attacks, not in between

 

Diagnosis:
Otoscopy, gross hearing, Rinne/Weber, Formal hearing tests

 

Treatment:
Low salt diet, meds for vertigo

Surgery for severe cases

Term
Mastoiditis
Definition

Presentation:

Otitis externa gone wrong - can lead to osteomyelitis of the skull bone

Fever, chills, pain, swelling

Erythema at mastoid process

 

Diagnosis:

Normal canal and findings of current AOM

 

Treatment:
ENT consult

Admit these pts, IV abx broad spectrum 3rd and 4th gen cephalosporins

Term
Barotrauma
Definition

Presentation:

Abrupt onset pain, feeling of fullness, conductive hearing loss

Dizziness, tinnitus, N/V, vertigo

Transient facial paralysis

TM rupture w/ Valsalva

Crying in children 

 

Treatment:
open eustachian tube - chew gum, Valsalva, yam

 

Meds: 

Antihistamines, decongestants, abx if severe, surgery

Term
Sudden Hearing Loss
Definition

Presentation:

Conductive - obstruction, otosclerosis, cerumen, otitis externa, foreign body, otitis media, TM perforation

 

Sensory - acoustic trauma, acoustic neuroma, presbycusis, Meniere's disease, Hematologic, noise damage, ototoxic meds, infections (mumps, measles, influena, HSV, HZV, mono, syph, meningitis)

 

Diagnosis:
determine if conductive or sensory with finger rubs and tuning fork, formal hearing test

Rinne: if pt can hear tuning fork through air after removing it from bone, then there is no conductive hearing loss

Weber: if pt lateralizes sound to affected ear, there is conductive loss. If pt lateralizes sound to unaffected ear, the loss is sensorineural

 

Treatment:

Tx underlying disorder

Consult

Follow ups

Term
Acute Sinusitis
Definition

Presentation:
Transient inflammation of mucosal linig of paranasal sinuses < 4 wks

Nasal congestion, purulent rhinorrhea, post-nasal drip, NA, facial pain, anosmia, cough, fever

 

Etiologies:
Strep pneumo, H. flu, Moraxella

 

Treatment:
Most clear w/o tx

If bacterial, begins with viral URI and develops into more severe sx 
Give cephalosporins, Amoxicillin, Augmentin

Term
Chronic Sinusitis
Definition

Presentation:

Symptoms lasting more than 12 wks

or > 90 days in children

Chronic low grade sx experience increase in mucous flow, change in viscosity or color, secretion

 

Treatment:
Tx for 12 weeks

Term
Allergic Rhinitis
Definition

Presentation:
Inflammation of nasal passages caused by allergies

Often co-exists with other disorders

Nasal congestion, clear rhinorrhea, runny nose, itching red eyes, nasal salute, allergic shiners

 

Diagnosis:

Seasonal vs. Perennial

Assess symptoms

 

Treatment:
Oral antihistamine

Nasal antihistamine

Nasal steroids

Nasal decongestant

Ipratropium bromide

Nasal cromone

Term
Epistaxis
Definition

Presentation:
Nosebleed - comon in cold weather, elderly, make, HTN, infection, trauma, nose picking, coagulopathy, spontaneous Kiesselbach's bleed, polyps, tumor

 

Diagnosis:

Good medical hx!

 

Treatment:

Anterior packing, balloon, nasal tampon, Rhino Rocket

Posterior packing - these are more emergent

Shot of epinephrine near origin of bleed

Afrin for small bleeds

Term
Tooth Fracture
Definition

Presentation:
tooth fracture, subluxation, avulsion

Post-extraction hemorrhage

 

Diagnosis and Treatment:

Fracture Ellis Class

 

I: enamel alone

no urgent tx needed


II: dentin (see yellow)

at risk for bacterial penetration, irrigate with saline and cover with CaH paste or foil


III: pulp (pink spot, bleeding)

same as II but need dental consultation in 24 hr

Term
Tooth Subluxation or Avulsion
Definition

Subluxation: loose tooth

Avulsion: lost tooth

 

If sub < 2 mm: soft diet, get to dentist

If sub > 2 mm: reset and splint

 

Treatment for Avulsion:

tooth in milk or saliva or Hank' solution

Replant in sock immediately, splint tooth 

5 days prophylactic abx and dental follow up

Term
Post-Extraction Tooth hemorrhage
Definition

Presentation:
dislodegement of clot from base of the socket

May be a sign of underlying coagulopathy

 

Diagnosis:
Coag studies

 

Treatment:

Place rolled gauze in socket and ask pt to bite down for 20 min

Lidocaine-Epi injection into gingiva at bleeding site before placing gauze

dental consult

Term
Acute Tonsilitis or Pharyngitis
Definition

Presentation:
sore throat, pharyngeal edema, exude, odynophagia

Fever, cervical adenopathy, decrease po

Fatigue, petechiae

 

Etiologies:

Viral - cough, rhinorrhea

Strep - scarlet rash, ab pain, no cough, N/V, HA

Mono - hepatosplenomegaly, jaundice, rash

Diphtheria - pharyngeal membrane, myocarditis

GC - sign of abuse, recurrent

 

Diagnosis:

Must r/o epiglottitis, peritonsillar abscess
Throat culture, Rapid strep screen

CBC with diff

Mono spot

 

Treatment of Strep:
Penicillin

Erythromycin

Term
Peritonsillar Abscess
Definition

Presentation:
Common infection of head and neck region bounded by tonsillar pillars, piriform fossa, hard palate

Progressively worsening sore throat, localized to one side

Fever, dysphagia, otalgia, odynophagia

 

Diagnosis:

PE show erythematous swollen tonsil with contralateral ulnar deviation

Trismus, edema, purulent exudate, drooling, muffled voice

cervical lymphadenopathy

Neck CT with IV contrast 

 

Treatment:

aspiration for dx and tx

Incision and drainage + abx (Clindamycin)

Term
Dental Abscess
Definition

Presentation:
toothache, loose tooth, sensitivity to pressure, temperature, or tapping

Bad breath, unpleasant taste, drooling, trouble swallowing

Fever, pain, redn, swelling

 

Diagnosis: painful to percussion

 

Treatment:

Incision and drainage by dentist

Abx, pain meds, soft diet

Term
Sialoadenitis
Definition

Presentation:

infection of major salivary glands by retrograde transmission of bacteria from oral cavity via salivary duct

Enlarged, painful galnd, purulent drainage from duct orifice, red/painful duct, fever

Decreased secretion

 

Treatment:

Heat, cold compress with massage

Aggressive hydration

Lemon drops or citrus drops

Abx: Pen VK, Erythromycin, Augmentin

Pain meds

ENT consult

Term
Sialolithiasis
Definition

Presentation:

Formation of hard deposits in ductal salivary gland

Colicky post-prandial pain and swelling

 

Treatment:
Lemon or citrus drops

Abx coverage of S. aureus

Analgesic NSAIDs

Warm compresses, increased po

Refer to ENT

Term
Contact Dermatitis
Definition

Presentation:

Inflammation that results from direct contact - irritant or allergic

 

Irritant - erythematous vesicles, crusting, scaling, sharp margins, and only confined to site of exposure. Rapid onset (hrs) and may occur in anyone

 

Allergic - same visual presentation, but the initial sharp margins may spread, also assoc with urticaria - more systemic symptoms 

delayed onset - 12-72 hours

 

Treatment:

ID and remove causative agent

Burrows solution (Al acetate) for symptoms

Aveeno oatmeal baths for pruritis

Topical steroids (Triamcinolone, Hydrocortisone)

Antihistamines (Benadryl, Atarax)

Systemic steroids (Prednisone)

Term

Rhus Dermatitis 

(Poison Ivy/Oak/Sumac)

Definition

Presentation:

Erythematous vesicles in linear distribution

Appear 8-48 hours after exposure

Intense pruritis

 

Treatment:
Self limiting for 3 weeks

Oral antihistamine for sx

Topical steroids for sx

Term
Erythema Multiforme
Definition

Presentation:
Self limited and sometimes recurring skin condition assoc with certian infections, meds, other triggers

Sudden onset, progressive

Diffuse symmetrical erythematous macules (target lesions) of many various sizes, perhaps with central clearing (mimicing fungal)

Seen on palms, soles, dorsal, and extensor surfaces - very symmetric

Not scaly or crusty or pruritic

May be burning, viral prodrome

If involves mucous membranes, more serious 

 

Treatment:

Mild - Tylenol, NSAIDs, Burrow solution, Magic Mouthwash, topical steroids, antivirals

Severe - tx like thermal burns

Term
SJS/TEN
Definition

Presentation:

similar to erythema multiforme, but extensive mucous membrane involvement and large % of TBSA with desquamation of skin

Immune-complex mediated hypersensitivity caused by drugs, infections, malignancies

Assoc with secondary infections (UTI, pneum)

Macular --> papular --> large bullae

Rapidly progressive

TEN: tends to be very severe form

 

Treatment:

Admission to burn unit

Manage airway

IV fluids

Electrolytes

Pain control

Tetanus shot

Term
Molluscum Contagiousum
Definition

Presentation:

Grouped centrally umbilicated papules

Caused by poxvirus via skin-skin

Usually asymptomatic +/- itching


Treatment:
Self limiting for 2 months

Cryotherapy, Lasertherapy, Currettage

Aldara

Term
Tinea
Definition

Presentation:

General term used for skin mycoses

Erythematous maculo-papular annular rash with area of central clearing

Can be scaly and sharply marginated

 

Body - corporis

Groin - cruris 

Head - capitus

Fee - pedis

 

Treatment:

Topical azoles bid for 2 wks

Continue tx even after rash disappears

 

Capitus - Griseofulvin for 6-8 wks

Term
Scabies
Definition

Presentation:

infection by sarcopetes scabiei mite

Intense pruritis, burrows located on interdigital webs of hands, wrists, elbows, genitalia, axillae, ankles

Grouped and generally linear pustules with erythematous bases

 

Treatment:
Permetherin cream applied from head to toe, left on for 8 hours

Antihistamines for itch

Term
Pediculosis (Lice)
Definition

Presentation:
Person to person contact as well as fomite spread

Pruritis is common sx with 2ndary bacterial infection due to itching

 

Treatment:

Permetherin shampoo, cream

Do not have to apply head to toe

Term
Lyme Disease
Definition

Presentation:
Characteristic bulls-eye rash (erythema migrans) 2 weeks after exposure from burgdorferi deer tick

Fever, HA, fatigue, myalgia, arthralgias, lymphadenopathy

 

Diagnosis:
extensive hx

can progress to neurological, MSK, cardiac involvement (bells palsy, AV block, aseptic meningitis, arthraglias)

Lyme ELISA, Western Blot

 

Treatment:

If diagnosed, Doxycycline for 3 weeks

Amoxicillin for kids

Cefuroxime also an option

Term
Herpes Zoster
Definition

Presentation:
erythematous rash with assoc vesicles in dermatomal pattern with some confluence

Painful, unilateral, non-infectious

 

Treatment:
Acyclovir, Valcyclovir

Narcotic analgesia

Term
Urticaria
Definition

Presentation:
Maculopapular well-circumscribed erythematous rash with wheals

Very itchy and always blanches

 

Treatment:
H1 and H2 blockers (Benadryl, Atarax, Zantac, Pepcid)

Steroids

Consider epi if airway is compromised

Term
Angioedema
Definition

Presentation:

deep, SQ, submucosal edema due to increased vascular permeability

Can involve any part of body

ACEI can cause with +/- urticaria

 

Treatment:

Tx similar to urticaria/allergic rxn

Severe cases may require airway mgmt

SQ epinephrine

Term
Impetigo
Definition

Presentation:

Superficial infection of S. aureus and S. pyogenes

Honey colored crust and pustules

Bullous - consider MRSA infection

 

Treatment:

Bactroban topical

Keflex for MSSA

Clindamycin for MRSA

Term
Cellulitis
Definition

Presentation:
confluent erythematous macular rash that is hot, painful, swollen

Infection of dermis and SQ tissues

Usually caused by small break in skin

 

Treatment:

Outpt - po Clindamycin, Bactrim, Doxy, Augmentin, Keflex, Tetanus prophylaxis

Follow up

 

Inpt - Clindamycin, Vancomycin

Term
Abscess
Definition

Presentation:
Localized collection of pus (mostly MRSA)

Erythematous swollen indurated infected soft tissue 

may or may not be able to detect pus from outside

 

Treatment:

Incision and drainage 
warm compress

Bactrim, Doxy, Clindamycin

Wound check in 48 hrs

Pt ed

Term
Volar Hand Splint
Definition

Prevents flexion and limits extension of fingers and wrist

 

Used for metacarpal and phalangeal fractures

Extensor/flexor tendon injuries

Complex dislocations

Soft tissue injuries

 

Apply from fingertips to mid-forearm

Wrist 30 flexion

MCP 90

Term
Dorsal Hand Splint
Definition

Prevents extension and limits flexion of fingers and wrist

 

Used for metacarpal, phalangeal fractures

Extensor/flexor tendon injuries

Complex dislocations

Soft tissue injuries

 

Apply from fingertips to mid-forearm

Wrist 30 flexion

MCP 90

Term
Volar Wrist
Definition

Prevents flexion and extension of wrist

 

Used for wrist sprain, tendonitis, carpal tunnel syndrome, non-displaced carpal, distal radius, and ulnar fractures

 

Apply from distal palmar flexor crease to mid-forearm

Wrist 30 extension

MCP from movement

Term
Radial Gutter
Definition

Immobilizes thumb, limits extension and flexion of the wrist

 

Used for thumb fractures and dislocations

1st metcarpal fractures

Tendon injuries

Ulnar collateral ligament injuries

 

Apply from dorsal aspect of distal thumb to mid-forearm

Wrist 30 extension

MCP 90 flexion

Term
Ulnar Gutter
Definition

Prevents flexion and limits extension of ring and small fingers and wrist

 

Used for 4th and 5th metacarpal and phalanx fx

Extensor/flexor tendon injuries

Complex dislocations

Soft tissue injuries

 

Apply from 4th and 5th fingertips to mid-forearm

Wrist 30 extension

MCP 90 flexion

Term
Thumb Spica
Definition

Immobilizes thumb

Limits extension and flexion of wrist

 

Used for thumb fractures and dislocations

1st metacarpal fractures

Extensor tendon injuries, scaphoid fractures

Punture wounds of thenar eminence

Soft tissue injuries to thenar eminence

 

Apply from volar aspect of distal thumb across thenar eminence to mid-forearm

Wrist 30 extension

Thumb in extension and slightly abducted

Term
Posterior Elbow
Definition

Immobilizes wrist and forearm

Prevents supination/pronation

 

Used for radial head and elbow fractures with inability to pronate/supinate 

Soft tissue and joint injuries

 

Apply from MCP ulnar aspect around the elbow and mid-upper forearm

Elbow 90 flexion

MCP free

Term
Sugartong Forearm
Definition

Immobilizes wrist and forearm

Prevents pronations/supination 

 

Used for midshaft radius and ulnar fractures

Distal radius and ulnar fractures with inability to pronate/supinate

Colles/Smith fractures

Radial head fractures

 

Apply from distal palmar flexor crease around the elbow to the dorsal MCP joints

Wrist 30 extension

Elbow 90

MCP free

Term
Posterior Ankle
Definition

Immobilizes ankle

Prevents plantar and dorsi flexion

 

Used for ankle sprains, non-displaced and stable distal tib-fib fx

Achilles injuries

Heel/foot bony and soft tissue injuries

 

Apply from distal plantar foot to posterior calf

Ankle 90

Term
Sugartong Ankle
Definition

Immobilies ankle

Prevents inversion/eversion

 

Used for ankle sprains, non-displaced and stable distal tib-fib fx

 

Apply from mid-medial calf to mid-lateral calf

Ankle 90 

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