Parietal pain:

Give 5 causes

Decribe pain

What dermatomes are included?

What are 3 signs of parietal pain?

Give two examples of parietal pain.

Five causes: direct irrtation of somatically innervated parietal peritoneum by pus, bile, urine, sucus-entericus, feces

Describe pain acute, sharper, better localized

Corresponds to T6-L1 levels

Examples: herpes zoster, periotnitis

Define referred pain.

Give 5 examples.

Sensations perceived at a site distant from that of a strong primary stimulus

Examples" AAA to lower back, gallbladder to shoulder, ureter to groin, pancreatitis to back, perforated ulcer to RLQ

pain orgininating from abdomen when the actual primary source is from womewhere other than the abdomen

Cardiac to epigastrum

Glaucooma to periumbilical

Appendicitis Epidemiology:

What % of the population will get it ?

What are common age groups?

What are four causes? Which is most common?

10% of population

10-30 years of age

Four Causes:

Obstruction of lymphoid hyperplasia (MOST COMMON)

Fecalith (10%)

Tumor (carcinoid- most common tumor)

Infection (parasitic)

Pt presents with visceral periumbilical pain, nausea, vomiting, anorexia

low grade temp.

obstipation

What's on your ifferential diagnosis?

Mcburney's point tenderness

Rovsig's signs (RLQ tenderness with LLQ palpation)

Psoas sign: pain with RLE active hip extension

Obturator sign: pain with RLE passive hip felxion and internal rotation

 made by clinical diagnosis

CT scan is more accurate, but US can be done too and its' cheaper, faster, and portable

preop hydration with IVF, NPO, and ABX (gram pos, gram neg and anaerobes)

Definitive tx: appendectomy (laparoscopic or open technique)

There are multiple acceptable approaches to antimicrobial therapy as long as the regimen covers anaerobic flora, enterococci, and gram-negative intestinal flora.²⁸ One such sample regimen is monotherapy with either tazobactam-piperacillin 3.375 g IV or ampicillin-sulbactam 3.00 g IV.

short-acting parenteral narcotic such as fentanyladministered IV is a good choice for pain management

cholelithiasis- gallbladder stones

biliary colic

choledocholithiasis (common bile duct stone)

cholecystitis (gallbladder inflammation)

cholangitis (biliary tract infection)

Patient presents with RUQ pain that may refer to the R scapula or epigastrum. Pt presents with nausea, vomiting, fever.

Patient has dark urine, light stools.

What do you think it could be?

Charcot's triad (fever/chills, RUQ pain, jaundice)

Reynold's pentad (Charcot's triad, altered mental status, shock)

Pt presents with sublingual and conjunctival jaundice.

RUQ tenderness

Positive Murphy's sign (and what is this exactly)?

Biliary disease

Pos murphy's sign: sudden cessation of inspiration with R subcostal palpation

for biliary disease:

elevated bilirubin level, AST & ALT suggests:

for biliary disease:

elevated Alk Phos is only associated with...

What is a diagnostic and therapeutic test for common duct stones?

what test is only diagnostic?

ERCP: endoscopic retrograde cholangiopancreatography

MCRP only diagnostic

avoid morphine bc may cause constrictino f sphincter of Oddi.

NPO, IVF, ABX, cholectectomy (laparoscopic or pen)

intraoperative cholangiogram vs ERCP if suspected common duct stones

Diverticular Disease:

__% of people > ___ years of age

majority of people have what type of cases?

what are diverticula?

50%, 80 y/o

uncomplicated

diverticula are "false" mucosal/submuscosal outpouchings through inherent muscular weak spots in the presence of increased pressure

What is diverticulosis?

What is diverticulitis?

Diverticulosis: multiple diverticula

Diverticulitis: infected outpouchings

micro-macroperforation leading to abscess, peritonitis, sepsis

**commonly complicated by fistula

NPO, IVF, ABX for first episode

Colonscopy to R/o neoplasma after episode subsides

possible CT drainage of abscess

Surgical resection in one or two stage procedure depending on if patient is able to undergo bowel prep.

Pt has diverticular disease, what would you expect to see on the following studies:

plain films

CT

**not to self- what?

plain films: free air under diaphragm or locally (micro perforation, signs of ileus, partial colonic obstruction or LLQ mass

CT with PO/IV contrast shows diverticula, wall thickening, pericolic fat infiltration, abscess, extraluminal air

**barium will cause peritonitis if spillage, us water soluble contrast (gastrographin)

simple obstruction: blockage of intestinal lumen only, usually one point of blockage

strangulated: blockage of lumena nd blood supply, usually two points of blockage (closed loop)

Small bowel: Adhesions

Large bowel: neoplasm

Abdominal wall and internal: hernia

intussusception, volvulus, foreign bodies, gallsone ileus, IBD, stricture, cystic fibrosis, hematoma

For small/large intestinal obstruction:

pt reports frequent vomiting, abdominal discomfort, no distension

For small/large intestinal obstruction:

pt presents with colicky abdominal pain, moderate bilious vomiting, distension, constipation-obstipation, pain free intervals

For small/large intestinal obstruction,

pt presents complainign of feculent vomiting, severe distension, and colicky pain...

NPO, IVF, NGT, avoid narcotics

ex. like blowing a balloon- take pressure off intestine so it can recover

Most AAA are _______.

____% are found _____

Affects more _____

Normal infrarenal aorta diameter is ___

aymptomatic

90% are found below renal arteries

affects more males 4:1

Normal diameter is 2 cm. >3 cm is aneurysmal

What labs would you run on pt with AAA?

What is the screening test of choice?

Routine CBC

T+C 2-4 units**

PT/PTT

Abdominal US

How do you manage AAA?

When is an operation indicated?

IVF, acute resuscitation, T+C, PRBC, platelets, FFP, ABX

Indication for operation: >5 cm, >.5 cm growth in 1 year, acute leak.rupture

Pt presents with abdominal distension and pain. High pitched/tinkling bowel sounds, peristaltic rushes

tympanic to percussion

rectal-fecal impaction, blood

peritoneal signs

Where's a good place to look in H&P for someone you suspect has mesenteric ischemia?

What are you looking for?

Clinical diagnosis

mesenteric angiography and Ct are most useful

Plain film contrast studies may show "thumb printing"

preop hydration (IVF, broad spectrum ABX, monitor and treat shock

DEFINITIVE TX is resection of involved gut and its mesentery

2nd look reoperative to identify if further necrosis

Sometime thrombolytics, vasodilators (papverine is DOC), are used for embolectomy

be wary of reperfusion injury

Pulmonary, kidneys, liver, pancreas

Immune response

Age >55

WBC>16,000

BG>200

LDH>350

AST>250

On physical exam, you find

abdominal pain and distension

ocassional epigastric palpable mass

possible signs of jaundice (why is that?)

Possible signs of shock

Pancreatitis

Jaundice- bc secondary to biliary stone passage

WBC 10-30,000

Increase maylase and lipase X3 normal range

U/A: proteinuria, granular casts, glycosuria

increase BUN/CR due to prerenal state common

hyperglycemia, hypcalcemia, increase T. bili, increase PT/PTT, increase LDH/AST

ABG shows acidosis

most are self-limited, resolve spontaneously

NPO, NGT if vomiting, ileus

IVF hydration especially if prerenal

somatostatin to decrease GI secretions

Tight insulin control

electrolyte replacement

FFP if coagulopathy

Pain control, NO MSO4 if biliary disease bc sphincter of oddi stricture

CT guided drainage

surgical drebridement, marsupialisation

Define referred pain.

Give 5 examples.

Sensations perceived at a site distant from that of a strong primary stimulus

Examples" AAA to lower back, gallbladder to shoulder, ureter to groin, pancreatitis to back, perforated ulcer to RLQ

pain orgininating from abdomen when the actual primary source is from womewhere other than the abdomen

Cardiac to epigastrum

Glaucooma to periumbilical

Appendicitis Epidemiology:

What % of the population will get it ?

What are common age groups?

What are four causes? Which is most common?

10% of population

10-30 years of age

Four Causes:

Obstruction of lymphoid hyperplasia (MOST COMMON)

Fecalith (10%)

Tumor (carcinoid- most common tumor)

Infection (parasitic)

Pt presents with visceral periumbilical pain, nausea, vomiting, anorexia

low grade temp.

obstipation

What's on your ifferential diagnosis?

Mcburney's point tenderness

Rovsig's signs (RLQ tenderness with LLQ palpation)

Psoas sign: pain with RLE active hip extension

Obturator sign: pain with RLE passive hip felxion and internal rotation

 made by clinical diagnosis

CT scan is more accurate, but US can be done too and its' cheaper, faster, and portable

preop hydration with IVF, NPO, and ABX (gram pos, gram neg and anaerobes)

Definitive tx: appendectomy (laparoscopic or open technique)

cholelithiasis- gallbladder stones

biliary colic

choledocholithiasis (common bile duct stone)

cholecystitis (gallbladder inflammation)

cholangitis (biliary tract infection)

Patient presents with RUQ pain that may refer to the R scapula or epigastrum. Pt presents with nausea, vomiting, fever.

Patient has dark urine, light stools.

What do you think it could be?

Charcot's triad (fever/chills, RUQ pain, jaundice)

Reynold's pentad (Charcot's triad, altered mental status, shock)

Pt presents with sublingual and conjunctival jaundice.

RUQ tenderness

Positive Murphy's sign (and what is this exactly)?

Biliary disease

Pos murphy's sign: sudden cessation of inspiration with R subcostal palpation

for biliary disease:

elevated bilirubin level, AST & ALT suggests:

for biliary disease:

elevated Alk Phos is only associated with...

What is a diagnostic and therapeutic test for common duct stones?

what test is only diagnostic?

ERCP: endoscopic retrograde cholangiopancreatography

MCRP only diagnostic

avoid morphine bc may cause constrictino f sphincter of Oddi.

NPO, IVF, ABX, cholectectomy (laparoscopic or pen)

intraoperative cholangiogram vs ERCP if suspected common duct stones

Diverticular Disease:

__% of people > ___ years of age

majority of people have what type of cases?

what are diverticula?

50%, 80 y/o

uncomplicated

diverticula are "false" mucosal/submuscosal outpouchings through inherent muscular weak spots in the presence of increased pressure

What is diverticulosis?

What is diverticulitis?

Diverticulosis: multiple diverticula

Diverticulitis: infected outpouchings

micro-macroperforation leading to abscess, peritonitis, sepsis

**commonly complicated by fistula

NPO, IVF, ABX for first episode

Colonscopy to R/o neoplasma after episode subsides

possible CT drainage of abscess

Surgical resection in one or two stage procedure depending on if patient is able to undergo bowel prep.

Pt has diverticular disease, what would you expect to see on the following studies:

plain films

CT

**not to self- what?

plain films: free air under diaphragm or locally (micro perforation, signs of ileus, partial colonic obstruction or LLQ mass

CT with PO/IV contrast shows diverticula, wall thickening, pericolic fat infiltration, abscess, extraluminal air

**barium will cause peritonitis if spillage, us water soluble contrast (gastrographin)

simple obstruction: blockage of intestinal lumen only, usually one point of blockage

strangulated: blockage of lumena nd blood supply, usually two points of blockage (closed loop)

Small bowel: Adhesions

Large bowel: neoplasm

Abdominal wall and internal: hernia

intussusception, volvulus, foreign bodies, gallsone ileus, IBD, stricture, cystic fibrosis, hematoma

For small/large intestinal obstruction:

pt reports frequent vomiting, abdominal discomfort, no distension

For small/large intestinal obstruction:

pt presents with colicky abdominal pain, moderate bilious vomiting, distension, constipation-obstipation, pain free intervals

For small/large intestinal obstruction,

pt presents complainign of feculent vomiting, severe distension, and colicky pain...

NPO, IVF, NGT, avoid narcotics

ex. like blowing a balloon- take pressure off intestine so it can recover

Most AAA are _______.

____% are found _____

Affects more _____

Normal infrarenal aorta diameter is ___

aymptomatic

90% are found below renal arteries

affects more males 4:1

Normal diameter is 2 cm. >3 cm is aneurysmal

What labs would you run on pt with AAA?

What is the screening test of choice?

Routine CBC

T+C 2-4 units**

PT/PTT

Abdominal US

How do you manage AAA?

When is an operation indicated?

IVF, acute resuscitation, T+C, PRBC, platelets, FFP, ABX

Indication for operation: >5 cm, >.5 cm growth in 1 year, acute leak.rupture

Pt presents with abdominal distension and pain. High pitched/tinkling bowel sounds, peristaltic rushes

tympanic to percussion

rectal-fecal impaction, blood

peritoneal signs

Where's a good place to look in H&P for someone you suspect has mesenteric ischemia?

What are you looking for?

Clinical diagnosis

mesenteric angiography and Ct are most useful

Plain film contrast studies may show "thumb printing"

preop hydration (IVF, broad spectrum ABX, monitor and treat shock

DEFINITIVE TX is resection of involved gut and its mesentery

2nd look reoperative to identify if further necrosis

Sometime thrombolytics, vasodilators (papverine is DOC), are used for embolectomy

be wary of reperfusion injury

Pulmonary, kidneys, liver, pancreas

Immune response

Age >55

WBC>16,000

BG>200

LDH>350

AST>250

On physical exam, you find

abdominal pain and distension

ocassional epigastric palpable mass

possible signs of jaundice (why is that?)

Possible signs of shock

Pancreatitis

Jaundice- bc secondary to biliary stone passage

WBC 10-30,000

Increase maylase and lipase X3 normal range

U/A: proteinuria, granular casts, glycosuria

increase BUN/CR due to prerenal state common

hyperglycemia, hypcalcemia, increase T. bili, increase PT/PTT, increase LDH/AST

ABG shows acidosis

most are self-limited, resolve spontaneously

NPO, NGT if vomiting, ileus

IVF hydration especially if prerenal

somatostatin to decrease GI secretions

Tight insulin control

electrolyte replacement

FFP if coagulopathy

Pain control, NO MSO4 if biliary disease bc sphincter of oddi stricture

CT guided drainage

surgical drebridement, marsupialisation

What color is air on xray?

fat?

water?

metal or bone?

air and fat: black

water: gray

metal or bone: white

**all have the same thing, but different presentations:

Pt presents with mucosal lesion in the oral cavity develops along with cervical adenopathy, edema, and fever

Pt presents with severe abdominal pain and cramping followed by fever and sepsis.

Pt presents with a skin lesion evolving over 2 to 6 days from a papule to a vesicle to a depressed black eschar.

Another pt presents with brief upper respiratory infection followed by hypoxia and dyspnea.

YOu order a chest radiograph and find: mediastinal widening from adenopathy

What could it be? How do you make the laboratory diagnosis (three things)

ANTHRAX

Labs: The laboratory diagnosis is made by (1) isolation of Bacillus anthracis from a clinical specimen, (2) anthrax electrophoretic immunotransblot (EITB) reaction to the protective antigen and/or lethal factor bands in at least one serum specimen obtained after onset of symptoms, or (3) demonstration of B. anthracis through immunofluorescence.

treat: first line is CIPROFLOXACIN or other fluroquinalone

Pt presents saying they had the following:

 Initially fever, severe myalgias, prostration; followed within 2 d by papular rash on the face spreading to extremities (affecting palms and soles) and then to trunk (lesser extent than chickenpox); lesions progress at same rate, becoming vesicular and then pustular with subsequent scab formation.

What is it? How do you treat?

Small pox ( Variola major )

treat: he treatment of choice is 10 to 14 days of either streptomycin or gentamicin

Pt presents with following sxs:

Initially fever, chills, painful swollen lymph node(s); node progresses to bubo (sometimes suppurative)

What could it be?

Pt presents with Fever chills, cough, dyspnea, nausea, vomiting, abdominal pain; clinical condition consistent with gram-negative sepsis.

What could it be?

pneumonic plague

The treatment of choice is 10 to 14 days of either streptomycin or gentamicin

What is the most likely transmission of SEB?

What will you see on labs?

Treatment?

transmission: inhalation

labs: elevation in white cell count with neutrophilic predominance occurs within 24 hours of symptoms

Treatment: supportive

True or false regarding SEB:

Because the illness is not a result of S. aureus, but rather of its exotoxin, no bacteria are likely to be found in routine microscopy, and the toxin itself is too small to be detected with light microscopy

What could this be associated with?

Pt comes in after eating a "hard bean." pt now has the follwoing: delayed gastroenteritis, which may be severe and hemorrhagic, followed by delirium, seizures, coma, and death.

How do you treat?

Ricin

treat: whole bowel irrigation; Patients should be observed for at least 8 to 12 h. Once symptomatic, supportive care involves attention to fluid, glucose, and electrolyte replacement.

Pt presents after doing construction with ceiling tiles. Complains of pain, photophobia, and tearing.

How do you assess pt?

What bug are you worried about?

What's tx?

Assess: fluorescein staining and examination with a cobalt-blue light. The eyelid should be everted and inspected for foreign bodies

Organism: pseudomonas

tx: (Amrit gave cipro)

tintinalli says: Erythryomycin ophthalmic ointment and eye patch

Cycloplegia (cyclopentolate 1%, or homatropine 5%) one drop now and repeat every 6 to 8 h as needed for pain.

Pt was out running in the cold and develops the followng symptoms:

characterized by partial skin freezing, erythema, mild edema, lack of blisters, and occasional skin desquamation several days later. The patient may complain of transient stinging and burning, followed by throbbing.

What is it? WHat degree? How do you treat?

first degree frost bite

excellent prognosis

Pt presents after running in cold with the follwing sxs:

full-thickness skin freezing, formation of substantial edema over 3 to 4 h, erythema, and formation of clear blisters rich in thromboxane and prostaglandins. The blisters form within 6 to 24 h, extend to the end of the digit, and usually desquamate and form black, hard eschars over several days. The patient complains of numbness, followed later by aching and throbbing. 

What degree of frost bite?

second degree frostbite

good prognosis

Pt presents after running in the cold with the follwing sxs: What degree?

characterized by damage that extends into the subdermal plexus. Hemorrhagic blisters form and are associated with skin necrosis and a blue-gray discoloration of the skin. The patient may complain that the involved extremity feels like a "block of wood," followed later by burning, throbbing, and shooting pains. 

Andy ran in the middle of February and experiences the following:

characterized by extension into subcutaneous tissues, muscle, bone, and tendon. There is little edema. The skin is mottled, with nonblanching cyanosis, and eventually forms a deep, dry, black, mummified eschar. Vesicles often present late, if at all, and may be small, bloody blebs that do not extend to the digit tips. The patient may complain of a deep, aching joint pain. 

1) address hypothermia and frostbite

2) Rapid rewarming is the core of frostbite therapy

The injured extremity should be placed in gently circulating water at a temperature of 40° to 42°C (104°–107.6°F) for approximately 10 to 30 min, until the distal extremity is pliable and erythematous.

3) The involved extremities should be elevated and wrapped carefully in dry sterile gauze, with affected fingers and toes separated.

A fracture of the fifth metacarpal neck is often referred to as a _______ fracture. These fractures are usually unstable with volar angulation.

Fractures of the metacarpal neck are usually caused by a direct impaction force.

How do you splint?

boxer's fracture

usually caused by impact of a clenched first with a skull or hard, immovable object (ie. wall or door)

Splint: These fractures should be splinted with the wrist in 20-degree extension and the MP flexed at 90 degrees.

Pt presents after bar fight.

Physical exam reveals: the "knuckle" is flattened and can be palpated on the volar surface.

What type of fracture?

What's management?

Whats treatment?

Boxer's fracture

Management: Xray to determine degree of angulation- agnulation of up to 40 degrees is acceptable in 5th metacarpal. Any more requires reduction

Tx: ice, elevation, and immobilization in a short arm gutter splint in the intrinsic plus position

Pearl: Subtle malrotation can be recognized by looking at the alignment of the nail beds with the digits flexed.

Colles fracture

distal radial metaphysis fracture

distal radial metaphysis fracture that is dorsally angulated and displaced proximally and dorsally

what is it?

pt presents after falling when roller skating.

Pt states they have palmar paresthesias.

What type of fracture is most likely?

Why the parasthesias?

Colles fracture

from tension or pressure on the median nerve.

Rupture of the ulnar collateral ligament occurs when the mechanism causes radial deviation (abduction) of the MP joint.

What type of fracture is described?

Pt has weakness of pincer function and point tenderness at the volar ulnar aspect of the thumb MCP point.

What's next step?

Elderly Susan comes in with PMH of osteoporosis. She fell on an outstretched hand with the elbow extended.

What is most likely fracture?

high: supraspinatus

middle: infraspinatus

lowest: teres minor

radial head subluxation.

also known as..

Who comes in more commonly with nursemaid elbow?

what is the peak incidence of radial head subluxation?

girls are seen more commonly

peak age is 2 to 3 yrs old

what is the usual mechanism of injury for a nursemaid elbow?

3 year old female presents to ED.

clinical examination reveals a toddler who will not move the affected arm, but is otherwise not in any distress. The arm is kept in an adducted, semiflexed, and prone position. On palpation there is no significant point tenderness or swelling. There may be some discomfort on palpation of the radial head on the affected side. Attempts at pronation and supination of the forearm are painful.

What could it be?

There are two maneuvers for reduction, the supination technique, and the hyperpronation technique.

The supination technique (is performed by holding the child's elbow at 90 degrees with one hand, then firmly supinating the wrist, and finally by flexing the elbow so that the wrist is directed to the ipsilateral shoulder.

The hyperpronation technique is reported to be more successful, and it can be used primarily, or as a backup technique when supination fails. The hyperpronation technique is performed by holding the child's elbow at 90 degrees in one hand, then firmly pronating the wrist. Full arm function should return within 30 min, and if it does not, the alternative technique can be applied, or an alternative diagnosis should be considered.

Patients presents after falling on outstretched dorsiflexed hand or by an axial load directed along the thumb's metacarpal

PE: Eliciting pain in this area when the patient resists supination or pronation of the hand, or pain with axial pressure directed along the thumb's metacarpal, is also suggestive of injury.

what's fracture?

What costchondral joints are most affected by costochondritis?

what is the usual age range affected?

third, fourth, and fifth costochondral joints

age range: >40

Pt presents with pain in foot. They state the pain is mainly over bony prominences.

What's diagnostic?

What could it be?

How do you treat?

bursitis

Diagnosis of these lesions is dependent on analysis of bursal fluid, which can be obtained by large-bore needle aspiration. Fluid should be sent for cell count; protein, glucose, and lactate (elevated in septic bursitis) levels; crystal analysis; and Gram stain as well as culture (since initial Gram stains are often negative).

Management: avoid weight bering on afected foot

if septic: PNC resistant ABX

bursitis: more likely to cause focal tenderness and swelling

less likely to affect range of motion of adjacent joint

Pt presetns after sport injury complainign of hearing a "pop" sound and can now not walk on heels or toes.

The Thompson Doherty test was performed (squeezing mid portion of the calf when pt lying in pront position)' normally will plantar flex the foot- this was not the case.

What are you thinking?

How do you manage in the ED?

achilles tendon rupture

splinted in neutral position with a robert jones splint, with prompt referral to ortho

crutches should be given for ambulation

Pt presents with pain along the radial aspect of the wrist that extends into the forearm.

Positive finklestein test.

What could it be?

What is a positive Finkelstein test?

what is it assoc with?

Pt presents with paresthesias that extend into the index and long fingers, the radial aspect of the ring finger, and along the palmar aspect of the thumb. The patient often complains of awakening at night with burning pain and tingling in the hand, or numbness when driving a car or maintaining the wrist in prolonged flexion.

what could it be?

DM

RA

pregnancy

CHF

What's the difference btw tinel sign and phalen sign?

what are they used for?

used for carpal tunnel syndrome

tinel: tap volar aspect of wrist over media nerve

phalen: (more sensitive and specific) flex wrist maxiamlly and hold it in position for at least 1 min.

The presence of median nerve motor deficit requires emergency hand consultation.

Otherwise, initial treatment is a volar splint to maintain the wrist in neutral position, and nonsteroidal anti-inflammatory agents. Surgery may be needed if symptoms do not improve, so referral to a hand surgeon is needed.

Pt presents saying he is an avid golfer and just developed some pain.

Grasping and squeezing, in such tasks as shaking hands or opening jars, are impaired and cause pain.

What's top on your differntial?

Epicondylitis:

if pain is produced by wrist extension than it is _____

if pain is produced by wrist flexion than it is ____

if pain is produced by wrist extension than it is lateral

if pain is produced by wrist flexion than it is medial

NSAIDs and rest are effective in mild cases

Symptoms that persist after 2 weeks of conservative therapy usually respond to infiltration of triamcinolone, 10–20 mg, mixed with 1% lidocaine, 1–2 mL, around the involved epicondyle

You suspect patient has gout so you perform a joint aspiration.

What do you expect crystals to look like under the microscope?

NSAIDs ie. indomethacin; if normal renal function start at 50 mg

alternative therapy: colchicine

core temp high than 40 deg celscius

CNS dysfunction

anhidrosis

Heat stroke initial resucitation:

what tests? what do u give pt?

initiation of high-flow oxygen; use of continuous cardiac monitoring and pulse oximetry; and intravenous access)

An initial infusion of NS or LR solution at a rate of 250 mL/h is recommended for most patients. Glucose level should be promptly assessed with a test strip due to the high incidence of hypoglycemia in exertional heatstroke

Tests:

complete blood cell count, comprehensive metabolic panel, coagulation profile, creatine phosphokinase, myoglobin, urinalysis, toxicology screen, electrocardiogram, and chest radiograph. A lumbar puncture and computed tomography of the head may also be indicated as part of the evaluation of altered mental status.complete blood cell count, comprehensive metabolic panel, coagulation profile, creatine phosphokinase, myoglobin, urinalysis, toxicology screen, electrocardiogram, and chest radiograph. A lumbar puncture and computed tomography of the head may also be indicated as part of the evaluation of altered mental status.

HR

cardiac output

blood pressure

What do you need to be areful of when rewarming a pt with hypothermia.

This is top of mind.

Oxygen and intravenous fluids should be warmed, and patients should have constant monitoring of their core temperature, cardiac rhythm, and oxygen saturation.

most hypothermic pts are thiamine depleted alcoholics so give IV thiamine and glucose

pt presents to ED with the following:

painful, involuntary, spasmodic contractions of skeletal muscles, usually those of the calves, although they may involve the thighs and shoulders.

Pt is sweating profusely.

What could it be?

What's the patho?

How do you treat?

heat cramps

patho: pathogenesis of heat cramps is attributed to a relative deficiency of sodium, potassium, and fluid at the cellular level of the muscle.

Treat:

Treatment consists of fluid and salt replacement (PO or IV) and rest in a cool environment. For mild cases, or if an overwhelming number of patients require treatment, a 0.1 to 0.2% saline solution can be given PO. Two 10-grain (650 mg) salt tablets dissolved in a quart of water provide a 0.1% saline solution. Many such electrolyte solution drinks (sports drinks) are commercially available and are much more palatable than 0.1% saline solution. More severe cases of heat cramps will respond to intravenous rehydration with NS. Patients with severe heat cramps may actually have hyponatremia and hypochloremia. Rarely, rhabdomyolysis occurs secondary to diffuse and protracted muscle spasm.

Pt presents with the following sxs on a hot day:

weakness, malaise, lightheadedness, fatigue, dizziness, nausea, vomiting, frontal headache, and myalgias. Clinical manifestations include orthostatic hypotension, sinus tachycardia, tachypnea, diaphoresis, and syncope.

Lab tests show hemoconcentration and hypernatremia.

What is it? How do you treat?

heat exhaustion

tx: Mild cases may be treated with oral electrolyte solutions. Rapid infusion of moderate amounts of intravenous fluids (1 to 2 L of saline solution) may be necessary in some patients who demonstrate significant tissue hypoperfusion. Ideally, the choice of intravenous solutions should be guided by laboratory determinations, but isotonic salt solutions may be used until specific electrolyte abnormalities are identified. In general, these patients do not require hospitalization. Patients with congestive heart failure or severe electrolyte disturbances may require admission, because of the time element needed to correct their fluid and/or electrolyte deficits.

A retired couple just bought a home in Arizona and are visitng during the summer.

They both notice mild swelling of the feet, ankles, and hands that appears within the first few days of exposure to a hot environment.

What is it? How do you treat?

Heat edema

H&P usually allows you to exclude systemic causes. Due to cutaneous vasodilatation and orthostatic pooling of interstitial fluid in gravity-dependent extremities.

Tx: usually goes away in a few days to 6 weeks; no tx necessary

if pt insists on tx: elevate legs, use of support hose

infection of the skin and subcutaneous tissues. it extends below the dermis.

Any region in the body can be involved

s. aureus

h influenzae

s. pyogenes

Pt presents to ED with a PMH of preceding wound.

They complain of erythema, edema, warmth and tenderness to the same site of previous wound.

What tests do you order?

what's tx?

diagnosis made mainly by inspection

tx: dicloxacillin or cephalexin

this is pathognomic for what:

fine erythematous linear or curved lesion with central scale

what is tx?

scabies

tx: permetrhin or lindane

**Lindane: neurotoxic to infants, children and pregnant women

**everyone at high risk of acquiring should be treated even if asymptomatic.

antihistamines (ie. diphenhydramine) can be used for itching

Pt has AOM.

What are two options for meds

Amoxicillin...

if it doesn't go away THEN

augmentin

or cefuroxime axetil

Pt presents with midepigastric or left upper quadrant pain. pt describes as constant, boring pain that radiates to flanks, chest or lower abdomen.

Pain is made worse when supine and relieved when sitting with trunk and knees flexed.

What are you thinking?

PE: reveals low grade fever, tachycardia, epigastric tenderness.

What could it be?

-Most are self limited, resolve spontaneously

-NPO, NGT if vomiting/ileus, TPN for nutrition

                -IVF hydration especially if prerenal

                -Somatostatin to decrease GI secretions

                -Tight insulin control (possible insulin gtt)

                -Electrolyte replacement especially Ca2+

                -FFP if Coagulopathy

                -Pain control, NO MSO4 if biliary disease because sphincter if oddi stricture

                -CT guided drainage of fluid collections

                -Surgical drebridement, marsupialisation

What's the most common cause of LBO?

Name two other big ones.

neoplasms

others:

diverticulitis, sigmoid volvulus

Pt presents with abdominal pain and feculent vomiting.

Xrays show:

Step-ladder pattern of small bowel, apple core lesion large bowel

what are you thinking?

PUD ** most common

gastritis: alcoholics, salicylates, NSAIDS

esophageal varices: : alcoholic liver disease.

mallory weiss tear: due to repeated vomiting

**defined as above ligament of Treitz

Diverticulosis:

is it painFUL or painLESS

neonates, girls, young women and older men

neonates: affects more males

Pt presents with dysuria, frequency, and suprapubic discomfort.

What could it be?

Pt presents with kidney pain, fever, chills, nausea, vomiting, malaise and CVA tenderness, in addition to previous sxs of dysuria, freq and suprapubic discomfort.

What could it be?

Do you know for sure?

acute pyelonephritis

Clinically acute pyelonephritis is indistinguishable from acute cystitis without specialized diagnostic techniques

You suspect pt has UTI infection. What labs are you most interested in?

What does gross blood in urine tell you- where is the infection?

UA looking for nitrite, leukocyte esterase reactions, pyuria, bacteriuria and hematuria

gross urine: prob lower urinary tract

Urine nitrite reaction.

High specificity, but low sensitivity

True or False

True

Positive result suggests the diagnosis, but a neg result does NOT rule it out

pts with chronic indwelling catheters

preg women

children

adult males

E.Coli***

Klebsiella

Proteus

Enterobacter

Pseudomonas

chalymdia

staph saprophyticus

1) 3 day course of fluroquinolone like cipro or levofloxacin

if prego: augmenten or cephalexin

How do you diagnose someone with urinary retention?

Any meds?

diagnosis confirmed by placing a foley catheter

if pt at risk for long period of urinary retention, abx can be given

EPI:

Nephrolithiasis

what population is most at risk?

What age range?

What disease predispose you?

Males

30 to 50's

renal tubular acidosis, hyperparathyroidism, and cystinuria

Kidney stones: patho

what three elements need to be present for stone formation?

75% of renal calculi are composed of ______

What is the most common site of stones?

calcium

common site: ureterovesical junction due to small diameter

other: posterior pelvis in women, where the ureter is crossed anteriorly by the pelvic blood vessels and broad ligament

Pt presents with severe pain while the patient is sedentary or at rest. Ureteral distention and peristalsis cause the acute onset of remarkably severe, episodic visceral pain and little, if any, tenderness on examination. Typically pain originates in either flank, radiates anteroinferiorly around the abdomen, and progresses toward the ipsilateral testicle or labium majorum. The discomfort can be intense and may be associated with nausea, vomiting, or diaphoresis. Patients may be unable to find a comfortable position to relieve their symptoms. Consequently, they may be anxious, pacing, and reluctant to lie still on the examining table.

What could it be?

cardiac, respiratory, musculoskeletal, and dermatologic systems.

Make sure to r/o AAA, PE, pneumonia

How do you diagnose nephrolithiasis?

What is mainstay of tx?

CT is modality of choice

UA: look for hematuria or infection; hematuria supports diagnosis

BUN: Creatinine: if pt has nephrotoxicity and may need contrast...

be careful when diagnosing stone composiiton: The presence of oxalate or urate stones on microscopic urinalysis can be an aid to identifying stone composition

However, because crystals may be seen without renal stones, their presence is not diagnostic and should be interpreted cautiously. An elevated urine pH (>7.6) is associated with infection and may indicate the presence of a urea-splitting organism. 

Tx: pain control; opiate plus an NSAID; if emesis, give anti-emetic

Burns:

What produces more damage? alkaline or acid?

alkaline

At similar volumes and manner of contact, alkalis usually produce far more tissue damage than acids. Acids in general cause coagulation necrosis with protein precipitation, tending to form a tough leathery eschar. The eschar typically limits deeper penetration of the agent. Alkalis produce liquefaction necrosis and saponification of lipids. The result is a poor barrier to chemical penetration and deeper, ongoing burns. 

1. Terminate the burning process: remove garments and copious irrigation of skin

2. ocular: 1-2L normal saline--check visual acuity and pH after ocular irrigation

3. phenol and phenolic compounds should be irrigated immed with water

4. Hydroflouric acid burns require calicum gluconate to bind fluoride and neutralize toxic effects.- can be gel, injection or intraarterial infusion

5. IV fluid resuscitation, analgesia and tetanus immunoprophylaxis

What is this:

classic symptoms are an abrupt onset over several hours of high fever, sore throat, stridor, dysphagia, and drooling. Some cases may develop over 1 to 2 days. Physical examination reveals a toxic-appearing, apprehensive child with an ashen-gray color. The child often sits in a tripod position, or the "sniffing" position, with the neck slightly extended and the chin forward. As opposed to the child with croup, there is no cough. The voice may be muffled, but supraglottic foreign bodies, peritonsillar abscess, and retropharyngeal abscess may present similarly. If inflammatory changes extend beyond the epiglottis to include the vocal cords, voice pitch will be altered as well.

Nebulized racemic epinephrine should be considered to decrease airway edema. The child should be kept seated upright.

The referral center should be alerted as soon as possible, so that decisions concerning intubation or tracheostomy can be made in concert with consultants, and so that support personnel can be mobilized as needed. Patients usually are intubated by the most skilled individual available as soon as the diagnosis is made. Sedation, paralytics, and vagolytics are used as indicated. 

ABX

A second- or third-generation cephalosporin such as cefuroxime, cefotaxime, or ceftriaxone is generally administered to ensure adequate coverage of H. influenzae. With the increasing incidence of S. pneumoniae as a cause for epiglottitis and the marked increase in resistance of this organism to cephalosporins, one may empirically give vancomycin also.

PATHO of asthma

what four mechanism cause problems?

airway hyperresponsive ness causes bronchoconstriction

swelling and edema of the airways

airway remodeling

mucus plug formation

cyclooxygenase products: prostaglandins

also lipoxygenase products: LTC4, D4

wheezing

SB

chest tightness

chest pain

sputum production

cough

CYSTIC FIBROSIS!

*always a board question- get sweat test!

beta agonist

methylxanthines

anticholinergic

What are methylxanthines?

what about its side effects limit its uselfulness?

family of agents including theophylline, caffeine, theobromine

third line treatment

toxic effects:

GI: n/v/d

Cardiac: arrythmias, palpitations

relaxes smooth muscle by blockign cholinergic (bronchoconstricting) tone

more useful in severe acute asthma as add-on therapy

O2 delivered by mask

give nitroglycerin to decrease BP- if sxs dont improve then try nitroprusside

Morphine for venodilation

IV diuretic (Furosemide or bumetanide)

pt come sin with carpopedal spasms (occurs in severe cases), lightheaded and can't catch their breath. They have PMH of anxiety.

What are you thinking?

whats tx?

Hyperventilation

pt may benefit from Xanax (alprazolam)or Ativan (lorazepam)

What is the most serious cause of anaphylaxis?

What's second most common cause?

epinephrine, intravenous fluids, and oxygen

Epi route shoudl be IM--preferred route 

Adults: .5 ml of 1:1000

Children: .01 ml/kg of 1:1000

&should take effect in 2 min..if not then

epi .1 ml of 1:1000 mixed in 10  ml or NS (1:100,000) admin IV over 10 min

In addition,

give pt Diphenyhydramine

Ranitidine

if bronchospams give albuterol

Salu-medrol (methylpredinsone) for controlling persistent or delayed allergies response

for mild reactions, observe for 3 to 4 hours before discahnge.

Mod to severe sympsoms should be admitted.

Always discharge on an antihistamine and prednisone for 4 days. Counsel about the need to return in the event of late recurence of symptoms.

What is the screening tool of choice to detect rib fractures?

What do you do if you suspect multiple fractures?

xray

if multiple fractures: get CT of abdoemn to r/o intrabdominal bleed from liver or spleen

In regards to D-dimer,

what is the more SENSITIVE test?

ELISA OR the erythrocyte agglutination assay?

heparin plus warfarin

second line: fibrolytics (streptokinase, urokinase and alteplase) 

if is there sustained problems- pt may seek benefit from surgical thrombectomy

1. supplemental O2 to maintain a pulse ox reading >95%

2. IV access should be secured and crystalloid IV fluids given to augment preload and correct hypotension.

3. Anticoagulation with a heparin is standard tx for acute PE. (Dosing of unfractionated heparin should be weight based, with 80 units/kg given as an initial bolus followed by 18 units/kg per hour. Low molecular weight heparin (ie. Enoxaprin) safe and effective for acute PE

Absolute Contraindications: intracranial hemorrhage or active GI hemorrhage

If high pretest probability and no contraindications: start heparin therapy before diagnostic testing

4. Thromboembolytic therapy should be considered for pts who require aggressive tx for PE (ie pts with hemodynamic instability) Ex: Pts with ECG evidence of rt ventricular dysfunction

Three regimens of tx include streptokinase, urokinase, and alteplase (tissue plasminogen activator).

Most common regimen: alteplase 50 to 100 mg infused over 2 to 6 hrs, although itmay be given as a bolus in the case of severe shock.

5. Stable patients can be admitted to telemetry bed. Pts who show signs of circulatory compromise and all pts who receive thrombolytic therapy should be admitted to an ICU.

6. An IVC filter shoud be considered when anticoag fails or is contraindicated.

You shoudl have high suspicion of what if pt comes in with the following:

Pt who has sustained sudden severe deceleration or a high-speed impact from the side.

Pt states they were in a MVA and now they are experiencin retrosternal or interscapular pain.

What is top of mind?

On physical exam for pt who was just in MVA... you note the following: (what could it be?)

1) an acute onset of upper extremity hypertension,

2) difference in pulse amplitude between the upper and lower extremities

 3) the presence of a harsh systolic murmur over the precordium or posterior interscapular area.

1.     Pts should nto be allowed to develop systolic BP >120 mmHg or to perform a valsalva maneuver. Fluid admin should be monitored carefully and admin of sedatives, vasodilators, analgesics and beta blockers may be required to reduce the systolic BP. An NG tube should be placed to avoid gagging or coughing in the patient

Although surgical repair is the accepted standard of care, aggressive medical control of BP with delayed repair and prolonged observation may be alternatives to pts at high risk for surgery. Endovascular stending may provide a less invasive approach to surgical repair.

trauma, dissection, thrombosis, embolism (**most originate from heart)

clotting disorders, atherosclerosis

Oxygen

Cardiac monitoring

Pulse Ox

12 lead EKG

IV access

frequent vitals

Nitroglycerin

Beta blocker and ACEi

IV furosemide or bumetanide

IV cocaine users bc of greater frequency of injections, less chance of sterilization bc cocaine does not need to be heated, and greater likelihood of needle sharing.

AND vasoconstrictive properties of cocaine may cause interstitial or endothelial damage which predisposes to infection

Pt presents with following sxs:

fever, cardiac murmur, cough, pleuritic chest pain, and hemoptysis.

PMH: unremarkable

SH: Smoker and cocaine user

staph aureus

pseudomonas due to using tap or toilet water in preparation of drugs

1. Hypertensive emergency: elevated BP assoc with target organ (CNS, cardiac or renal) dysfunction. Immed recognition and tx required.

2. Hypertensive urgency: elevated BP assoc with risk for imminent target organ dysfunction. Decreased the BP over 24 to 48 hrs and follow up the next day are recommended.

3. Acute hypertensive episode: SBP above 180 mmHg and DBP above 110 mmHg without signs or symptoms. Usually no immed tx is required, but the pt should have follow up the next day.

4. Transient HTN: elevated BO assoc with another condition (ie. anxiety, alcohol withdrawal, or cocaine abuse) Pts usually become normotensive once the precipitating event resolves.

Initial bolus of NS to increase intravascular volume, facilitate right heart filling and increase cardiac output

Pericardiocentesis is initial definitive therapy and for diagnostic evaluation

Sudden onset of chest pain that feels better when leading forward

ST elevation in all 12 leads

rubs noted on heart exam.

May have fever

What could it be?

NSAIDS

look for a cause

follow up with echocardiogram

lab studies

chest xray