PUD pain is described as pain ___ meal, ____ with antacids, non-rad epigastric ___ pain, worse during what time of day?
worse preceding meal
relief
burning
night
Gastroenteritis presents with stomach pain + ?
n/v
Patient with bouts of diverticulosis can be managed as outpatient. They have no signs of fever.
.
Acute chole = fever, murphy sign, leukocytosis
normal bili, ast, alt
pancreatitis in US MCC?
gallstone 45%
etoh 35%
Cecal volvulus RF?
Age 25-35
runners
abd surgery
prego
hepatic abscess mgmt?
call surgery to drain (DO NOT IN ER)
triple therapy gent, amox, metro (for gram - coverage)
leukocytosis, transami
hydrothorax w/elevation right hemidia
mgmt of mild diverticulitis?
Admit for IV abs and fluids and bowel rest. no surgery unless complicated (abscess)
Esophageal perf occur in which part esoph?
Esoph perf that's itro occrs hwere?
distal
iatro = eso-gastro jxn or pharyng-eso jxn
NMS?
It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias).
Dantrolene, bromocriptine
Dysotnia
diphenhy, or benztropine
haloperidol SE?
prolong QT
Vertical nystagmus overdose?
PCP
Does first time psych episode need admission?
No
Which is most likely non-organic (psych) cause of agitation? Hx of DM, Etoh, hypothyroid, COPD
hypothy
Complication of being on restraints?
met acidosis
after restraints monitor for rhabdo
Initial Dx test in AMS?
POC glucose
Alcoholics should be given:
Mg empirically bc they usually have it low
thiamine, then glucose
delierium
global inability to relate to environment and process sensory input
Delusions?
Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary
delerioum vs dementia
acute, change in level consciousness,
Cause of nursing home confusion?
hypoNa, hypoK doesn't cause this alone
Signs of organic confusions (vs inorganic)
Abnml vitals, neuro sx's, acute onset
febrile seizure?
tonic clonic, fever, 15 mins or less, 3 mos.-5 years, NO post-octal state
MCC delirium in elderly?
meds, then infxn
AP foreign body trachea or esophagus?
flat = esophagus
side = trachea
Ellis mgmt?
Type 1 enamel
2 = + dentin (yellow), dental consult
3 = + pulp, dental consult
Nasal septal hematoma mgmt?
I&D bc blockage can occur
Trauma to eye and can't look up
inferior orbital wall fx
Best test in trauma to assess neuro?
2-point discrim
ottawa ankle?
ttp lat or med mall, bear weight after or in ed..if any yes then X-ray
suspected ruptured globe
A.ascertainment of intraocular pressure via tonometry (NO!)
B.administration of broad spectrum antibiotic therapy
C.visual acuity assessment
D.ascertainment of tetanus status
E.ophthalmology consultation
blowout fx presents with?
A.diplopia with upward gaze
B.right-sided infraorbital subcutaneous emphysema
C.right-sided epistaxis
D.proptosis (NOT! bc that's retrobulbar hematoma)
E.anesthesia of the right infraorbital region
MCC death 20-40 yo?
trauma
next step is think central cord syndrome?
get mri, not neurosurg consult
dermatome - dorsum foot L5, plantar is S1. Deficiecty in sensation over dorm foot is disk budge with weakness on dorsiflexion?
L4-L5
unstable cervical spine fx's?
"Jefferson bit off hangman thumb"
jeff, bilateral facet, odontiod type 2+3, hangman, and flexion teardrop
Zone 1 neck penetrating trauma mgmt?
Admit w/ angiogram+esophagram. Zone 1 = sternal notch to cricoid
test of choice of solid organ injury?
CT abd
Imaging urlogical injury in flank blunt trauma?
CT ab w/contrast, and transurethral contrast
who gets thoracotomy in ED?
unconscious and pulseless patient with a detectable blood pressure
intubate if GSW in thoracic chest ppx
.
osteoporotic hip fx sx's
hip dislocation
external rotation with abducted
*internal rotation
mgmt of fx with unstable pulse?
conscious sedation and attempt by ER doc to relocate until oath comes (NOT urgent arteriography)
fight bite bug?
Eikenella
leave wound description of GSW entrance, exit to foresincs
ragged edges with ecchymosis is exit wound usually
.
different high-dose electricity from lightening?
deep burns..both cause arrhythmia
rule of 9's
18 for anterior chest
4.5 for anterior arm (9 total arm)
ifn-alpha inc risk of?
suicide
RF for suicide?
Overall, men have higher rates of completed suicide and women have greater numbers of suicide attempts. Suicide risk among men shows a bimodal distribution,15 and 24 and after age 65. Suicide risk among women peaks after age 60. People who suffer from a chronic disease such as AIDS. Underlying psychiatric illness increases a person’s risk of suicide. Major depression, bipolar, borderline personality disorder, schizophrenia, and panic disorder are all associated with increased suicide rates. Presence of breast implants portends a higher risk of suicide.
Greatest risk for complete suicide? panic d/o, depression, ptsd, schizo
panic
On SAD PERSONS depression scale, what only gets 1 point?
divorced or widowed
Silent Suicide vs Occult Suicide vs Chronic Suicidal Behavior vs Mass or Group Suicide vs Parasuicide
- repeatedly because of non-compliance with treatment
-self-destructive acts disguised as accidents and should be suspected in those who have "accidental" self-inflicted gun shot wounds, and in those who "unintentionally" overdose
-consists of recurrent self-destructive acts
suicide
- involving a number of people.
- "Parasuicide" is an attempted suicide, which is seen more as a gesture than a serious act
Suicide risk is increased in this patient population:
B.
Tx of septic joint?
arthro, iv abx, OR
tx bartholin gland cyst?
4 and 8 o'clock
I&D
use Word catheter
what is comic-lehane?
grading scale for visualization of vocal cords during intubation
RSI sedative of choice for reactive airway disease pt?
ketamine, bc bronchodilation
SE of etomidate and propofol?
etom (benefit is cardioprotective) - adrenal suppression
propofol - allergy to egg/soy
Which of the following local anesthetics is characterized by average potency (lipid solubility), low toxicity and rapid onset of action?
A.tetracaine
B.bupivacaine
C.procaine
D.lidocaine
lido, bupi (intermediate onset, last longer), tetra (used topically), pro (least potent)
complication of spinal epidural?
spinal epidural hematoma, presenting with back pain worse with coughing
posterior tibial nerve block vs sural nerve block
medial malleous vs lateral
Which of the following is an absolute contraindication to surgical cricothyrotomy?A.Acute laryngeal disease
B.Bleeding diathesis
C.Age < 5
D.Massive neck edema
all of relative contra, except C (absolute)
eyebrow lac can use dermabond
.
what can help reduce post-stitches infxn?
undermining the subq
earliest sign of lidocaine toxicity?
lightheaded/dizzy
lac on ulnar side of hand nerve block?
ulnar n. block
reversal for fentanyl toxicity/ketamine/bzd?
- naloxone
- none
- flumazenil
high dose fentanyl toxicity?
chest wall rigidity and glottic spasm and low resp rate
post LP headache mgmt?
smaller needle a/w lower incidence of post LP HA
usually b/l and worse upright, better supine
normal ratio of CSF glucose:serum glucose
0.6:1
paronychia mgmt?
if small - simple lifting of nail is good enough
if looks infected and large - digital block, surgerical intervention, and abx
true about charcoal?
need ng tube, within 2 hours
gastric lavage indications?
only for serious meds (TCA's), not NSAID/kerosene/metoprolol
belladona blackberries is ?
anticholinergic - dry, mad, flushed, pupil dilated, dec bowel sound
contra for charcoal?
caustic and metals
Lithium toxicity mgmt?
hemodialysis, no charcoal or lavage
bzd overdose with no breathing mgmt?
intubate before flumazenil
ASA toxicity causes?
met acid with rest alka so normal pH with low bicarb and pCO2
Mgmt tylenol ingestion?
Use of rummack-mathew nomogram tells us what mgmt will be after 4 hours
clonidine toxicity mimics what other drug?
opioids
antidote betablock, CCB, methheme, iron, INH
glucagon, meth blue, deforaximine, pyrodoxine
lead toxicity
C.
chocolate brown colored blood
methhemegb, seen in lidocaine, antidote = meth blue
pulse ox still 100%
During opiate withdrawal which of the following symptoms would you expect to find?A.Pruritis
B.Constipation
C.Urinary retention
D.Tachypnea
d
epidemiology asthma race, gender, genes, prev?
dec in 1990s
male children > female, in adults it's reverse
blacks have higher prev
pulsus parodoxus?
seen in SEVERE asthma, and others
drop >10mmHg when inspire
steroids and asthma
anticholin and asthma
avoid inhaled CST! can use oral or IV
anticholin help too
Which is most beneficial in copd exac? steroids or albuterol
albut
Regarding the pathogens involved in community-acquired pneumonia, which of thefollowing is true?
D.
Which of the following patients is the most likely to develop S. pneumoniae pneumonia?A.65 year old woman with no past medical history
B.59 year old woman who is a cigarette smoker.
C.61 year old man with hypertension
D.64 year old man with type 2 diabetes
d,
Persons at risk for developing S. pneumoniae pneumonia include the elderly (>65), and those with a history of alcoholism, diabetes, cardiovascular disease, splenectomy, sickle cell disease, malignancy, and immunosuppressive disorders. Vaccination is recommended for all people at increased risk.
Cytomegalovirus does not usually cause pneumonia in immunocompetent adults.
Varicella zoster virus (VZV), the etiologic agent of chicken pox, more commonly presents as pneumonia in adults (NOT KIDS), especially smokers or pregnant women.
What's true about TB?
TB causes more deaths worldwide than any other infectious agent.
chief complaint of “shortness of breath” is most likely to have cavitary lesion with air-fluid levels on CXR?
A.32 year old female who is 36 weeks pregnant
B.64 year old female with history of congestive heart failure
C.54 year old male with history of recent myocardial infarction
D.43 year old homeless male with history of alcohol abuse
d, bc anaerobes/staph a/fungus cause it
In the emergency department, regarding the disposition of patients diagnosed with pneumonia:
A.Patients with co-morbidities should be admitted
RF for spontaneous pneumotho
cig smoking
aspiration of food in lung?
On chest X-ray, aspiration is more likely to be detected because of secondary signs, such as hyperinflation or atelectasis of the involved lung
Pulseless electrical activity in Emergency Department cardiac arrest victims is associated with PE in __%
33
Up to two-thirds of patients with PE have no symptoms of DVT. PE is also found in about half of patients who have DVT but who do not have symptoms of PE
Regarding the role of malignancy in the diagnosis of pulmonary embolism (PE):
A.The risk of PE is decreased in patients on chemotherapy
B.25% of PE patients without identifiable risk factors are diagnosed with cancer within 2 years.
C.Autopsy studies indicate that greater than 60% of patients who die of ovarian cancer have PE.
D.Hematologic malignancies such as leukemia and have the highest incidence of venous thromboembolism
b,
a = INC
c = 30%
d = LOWER
Tachycardia is the most common finding of EKG associated with PE
.
PNA + bullous myringitis?
mycoplasma PNA
An 82 year old man presents from the nursing home with fever, cough, nausea, vomiting and diarrhea. His vitals signs are T 102, P 65, BP 100/50, RR 24, and SpO2 92%. The most likely causative organism is:
A.Legionella
B.Mycoplasma
C.H. influenzae
D.Strep. pneumoniae
E.viral
a, bc GI sx's and in ELDERLY!
mgmt v-fib
defib (200J), then epi, then amio/lidocaine
In PEA, what will inc survival chances?
finding etiology
ET tube meds dosing?
2x the IV dose
standard initial ACLS dose of IV epinephrine is:
A.
Treatment asystole?
NOT shock! Give epi while doing CPR
contra for chin lift?
C-spine injury
do jaw thrust
With respect to laboratory findings in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNC), all of the following guidelines are generally true EXCEPT:
C.
In a 70kg male DKA patient with serum glucose of 573 mg/dL, all of the following statements with regard to fluid and electrolyte imbalances are true EXCEPT:A.The patient is likely to be total body phosphorus depleted.B.A normal magnesium level is reassuring and obviates the need for magnesium replacement.C.Total body water deficit is approximately 5L.D.Serum sodium of 129 mEq represents dilutional hyponatremia and the corrected value is approximately 137 mEq.E.Despite a serum potassium level of 4.8 mEq, the patient is probably total body potassium depleted.
b
Regarding the treatment of hyperosmolar hypertonic nonketotic coma (HHNC) and its associated symptoms, which of the following is correct: A.Hyperosmolarity should be corrected within the first few hours in the emergency department.B.Since patients are not acidotic, close monitoring of glucose is not necessary.C.In HHNC patients with severe dehydration, bleeding diathesis is a major clinical concern.D.Half of the fluid deficit should be corrected over the first hour and the remainder over the following 8 hours.E.Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC.
Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. Half of the fluid deficit should be replaced over the first 8 hours, and the remainder over the ensuing 24 hours. Glucose must be tightly monitored as fluid resuscitation alone may normalize serum glucose or precipitate hypoglycemia in aggressive fluid resuscitation. Too-rapid correction of hyperosmolarity may result in development of cerebral edema, especially in children. Subcutaneous heparin should be considered in patients with severe dehydration due to increased risk of thrombosis from hypovolemia and hyperviscosity.
Regarding the development of cerebral edema in patients being treated for DKA, all of the following are true EXCEPT:
A.Mortality of patients developing cerebral edema is 90%.
B.Patients with serum glucose below 250 mg/dL still being treated with insulin are most likely to develop clinically evident cerebral edema.
C.Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema.
D.Children have a higher incidence of cerebral edema.
E.Cerebral edema typically occurs six to ten hours following onset of treatment.
c, steroids contra..mannitol okay
true facts about hypoglycemia
- glucagon ineffective
- sx's below 40 mg/dl
- any kind of neurology deficits can happen
hypothermia sx's
Moderate hypothermia is temperatures of 28-32 C. Shivering ceases at about 32 degrees Celsius. Moderate hypothermia is associated with altered mental status, absence of shivering, bradycardia, and bradypnea
With regard to laboratory findings in hypothyroidism, which of the following is false?A.Free thyroxine (T4) is always depressed in hypothyroid states.B.Free T4 and TSH levels are typically low in secondary and tertiary hypothyroidism.C.Serum thyroid-stimulating hormone (TSH) is the most sensitive test to diagnose primary hypothyroidism.D.Total thyroxine levels may be normal due to elevated thyroxine-binding globulin (TBG) levels.E.T3 level may be normal in hypothyroid states.
a
Metabolic abnormalities often seen with hypothyroidism include all of thefollowing EXCEPT:A.hypercholesterolemiaB.respiratory acidosis from hypoventilationC.hyperglycemiaD.hyponatremiaE.anemia
c
tx of suspected but no confirmed adrenal insuff?
CST, bc cosyntropin will affect the future ACTH stim test
Treatment with hyperbaric oxygen (HBO) is associated with contraindications. Which of the following is not a relative or absolute contraindication to HBO?A.pregnancyB.COPD with air trappingC.otitis mediaD.untreated pneumothorax
a
thyroid storm tx?
beta block, prednisone, PTU THEN iodine
avoid amio thyroid storm
bc has iodine component
A 4 year old girl is brought to the ED two hours after being stung by a scorpion while on a camping trip in Arizona. She has periods of agitation and restlessness alternating with calmness. Her vital signs are: blood pressure 106/61, pulse 120, respiratory rate 24, temperature 37.0C, and oxygen saturations of 99% on room air. On physical examination you note drooling, a disconjugate gaze, and occasional jerking movements of the extremities. Which of the following is the most correct regarding the treatment of a scorpion sting in this child?A.Treatment with antivemon is not indicated because these symptoms will be self-limitingB.The patient should be intubated because respiratory failure is expectedC.Analgesics have a minimal role in controlling symptomsD.Complications of treatment with antivenom include delayed serum sickness
d
Sx's and mgmt scoprion sting?
usually pain and paresthesia; The mainstay of treatment is analgesia
A 5 year old male is bitten by a snake while playing along a ditch. The child is brought to the ED by his parents with complaint of fang marks to the right index finger. On physical exam, you note absence of swelling to the right hand or fingers. He does appear to have 2 small superficial fang marks, but no bleeding or oozing is present. Vital signs are normal. What is the next most appropriate step in the management of this patient?A.Administer prophylactic antibiotics with gram positive sensitivityB.Administer weight based antivenom in pediatric patientsC.Discharge home in 8 hours if patient’s exam remains unchangedD.Admit for observation of potential compartment syndrome
c; no ex's by 8 hours then unlikely to have envenomation
A 55 year old male, who has been missing for several days in wintertime, is found in a forested area several miles away from his house. He is brought to the ED where he is found to have a core temperature of 27 degrees Celcius. He clearly has diminished mental capacity. His initial ECG demonstrates atrial fibrillation with a ventricular rate of 110. Which of the following is the best treatment option?
A.Start calcium channel blockage
B.Apply a Bair Hugger
C.Administer warm IV fluids
D.Immerse in a warm water bath at 40 Celcius
While answers B through E are all active rewarming techniques (active external – Bair Hugger, AVA rewarming, immersion, active core – peritoneal lavage), the best answer for someone with severe hypothermia with mental status change and cardiac dysrhythmias is probably active core rewarming
false positive and neg of guiaic test?
+ = Red fruits or meats, methylene blue, chlorophyll, iodide, cupric sulfate and bromide preparations
- = bile or ingestion of magnesium-containing antacids or ascorbic acid
thumbprinting on abd xray, bloody diarrhea, abd pain
ischemic colitis
Diverticulosis and angiodysplasia account for 80% of lower GI bleeds
.
In general, however, the mortality of upper gastrointestinal bleeding is higher than lower gastrointestinal bleeding. In adults, the most common cause of upper gastrointestinal bleeding is peptic ulcer disease. In children, it is esophagitis. Unfortunately, it can be difficult to diagnose the source of gastrointestinal bleeding as the bleeding may often stop and start spontaneously or from different sites
.
Use 18 or lower number (bigger diameter needle) in hemodynam unstable pt
.
A 49 year old presents complaining of 1 day of painful bright red blood per rectum. He has painful bowel movements and streaks of blood appear on the toilet paper. He has had hard stools for two weeks after starting opiate pain medication for a broken arm. He has never had these symptoms before. Based on the patient’s history, the physician examining the patient will likely find:A.An anal fissureB.A thrombosed external hemorrhoidC.A nonthrombosed external hemorrhoidD.An internal hemorrhoid
a... thrombosed external hemorrhoid causes painful bleeding on defecation. Usually there is a history of external hemorrhoids and associated itching, swelling, and mucoid drainage
A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent substernal chest pressure. A report from the patient’s primary care physician’s office states that an EKG performed four days ago was completely normal. Repeat EKG in the ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What intervention would be indicated to provide definitive management for the findings seen on EKG in this patient?A.Urgent placement of a cardiac pacemaker
B.Radiofrequency ablation
C.Emergent revascularization with thrombolytics or percutaneous coronary intervention (PCI)
D.Continuous cardiac monitoring for 24-48 hours
not c, but a bc at risk for heart block
TIA are warning what type of stroke is coming? thrombotic or embolic
thrombotic
Which of the following is not a known complication of subarachnoid hemorrhage in the immediate several weeks following the initial bleed?A.hydrocephalusB.cerebral artery vasospasmC.seizureD.hypernatremiaE.rebleeding
