Buzz words and core concepts for review Pulmonary 5 gm deoxygenated Hgb to have central cyanosis – you cannot be both anemic and cyanotic; you can look fine with cyanosis if you are polycythemic carbon monoxide – co-oximetry, pulse ox normal bronchiolitis – RSV bad bronchiolitis – preemies, congenital lung/heart disease ribavarin – RSV with congenital heart/lung defects bad asthma – ER visit 1 mo, more than 2 inhalers, 1 ICU/intubation, 2 hospitalization in 12 mo, 3 ER visits in 12 mo Aa gradient (quick): 140-PCO2 –PO2 NL max Aa gradient – (10+age)/10 asthma deaths – inspissated secretions – mucus plugs RSI in asthma - ketamine intubated asthma – think barotraumas if worse; permissive hypercapnia nasal polyps, RAD, NSAID’s combo (also atopic dermatitis) methemoglobin – co-oximetry; sats are low but look fine - dapsone, pyridium, well water, nitrites/nitrates/ peds with GI ARDS – aka NCPE – NL PCWP (<18), PO2<60 mmHg with FiO2>50%, bilateral alveolar infiltrates, normal heart size ARDS TV 6 cc/kg (NL 10 cc/kg) PNA
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Web viewThink HNP. Urinary retention most sensitive finding > 90% sensitivity . Conus medullaris – same symptoms, but ... Drain and insert Word catheter x weeks.
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Buzz words and core concepts for review
Pulmonary5 gm deoxygenated Hgb to have central cyanosis – you cannot be both anemic and cyanotic; you can look fine with cyanosis if you are polycythemic
TOF: Cyanosis not relieved by oxygen, “tet spells”, blood flowing from R to L, squatting increases PVR and increases lung blood flow, boot shaped heart
Other cyanosis: tricuspid atresia, truncus arteriosus, transposition, TAPVR
Cystic fibrosis: most common genetic disorder in whites
Sickle cell: most common genetic disorder in blacks
HSP: rash(purpura), abd pain, arthritis. Intussusception, renal involvement (hematuria)
HUS (think TTP in peds): micronagiopathic hemolytic anemia, uremia, thrombocytopenia, neuro stuff, GI stuff. E. coli assoc. No abx.
Meningitis<2 months: think Listeria (ampicillin) 2 months: usual stuff – Strep, Neisseria, H flu steroids – H flu
Most common cause of pedi hip pain – toxic synovitis
SCFE- rapid growth ages, boys, overweight, often bilateral. Referred knee pain. Slipped snowcone
Maintenance (per 24 hrs):100cc/kg x first 10 kg50 cc/kg for second 10 kg20 cc/kg thereafter
PALS pearls2J/kg defib0.5Jkg for sync CVETT size (uncuffed): (age/4)+4, subtract 0.5 – 1 for cuffed Uncuffed tube until age 8Asystole most common arrest rhythm; brady 2ndNo cric until age 10Bolus 20 cc/kgEpi 0.01 mg/kgAtropine 0.02 mg/kg (min 0.1mg)
ENTAir conduction>bone conductionPinna hematomas: cauliflower ear if not treated
Otitis media – 1/3 viral; strep pneumo, H flu, M. catarrhalisBullous Myringitis – used to be Mycoplasma, now S. pneumoSerous OM – sterile, decreased hearing (affects learning and speech)Cholesteatoma – squamous epithelium mass
Central vertigo Peripheral vertigoOnset Slower onset Rapid onsetNystagmus Horiz/vertical nystagmus
Not fatigableTorsional or horizontal nystagmusFatigable with fixation
Symptoms Not that severe Severe
No N/V/diaphoresis Worse with movementN/V, diaphoresis
Deficits Other CN deficitsNo hearing loss
No other CN deficitsHearing loss
BPPV – most common cause of peripheral vertigo, otoliths, Dix-Hallpike, worse with head movement
Vestibular neuronitis: nystagmus, sudden onset, no hearing loss (different from labyrinthitis)
Labyrinthitis – infection, decreased hearing, and tinnitus
Meniere’s – vertigo, tinnitus and decreased hearing, can last week to years
SinusitisComplications of sinusitis – orbital cellulitis, brain abscess/meningitis, cavernous sinus thrombosis, skul osteoPott’s puffy tumor – skull osteoSame bugs as OM – Strep pneumo, H flu, M. catarrhalis
Cold calorics “COWS” – cold opposite, warm same (for the nystagmus part, which is a cortical function). The tonic deviation is cold same, hot opposite, which is a brainstem function.
Doll’s eyes – eyes should stay ML when moving head L and R. brainstem reflex
Clusters – minutes, in groups, ocular findings, males. Rx 100% oxygenTension HA – tight
Toxic metabolic – fever, hypoxia, ethanol, COPost-concussive – follows trauma, more in pedsPost-LP HA – 2-3 days after LP, worse when sitting up. Correlates: size of needle, number of attempts. Tx: caffeine, hydration, analgesia, blood patch (definitive, diagnostic and therapeutic)SAH – sentinel HA, “worst HA of life”, sudden onset (thunderclap), LP with xanthochromia. LP better early, LP better later, CT > 90% sensitive if within 12 hours
Pseudotumor cerebri – young females, overweight. Papilledema. Slit-like ventricles. High OPHydrocephalus ex vacuo – from cerebral atrophyNPH – triad of ataxia, incontinence, dementia
SDH – more common than EDH, bridging veins. Assoc with brain parenchymal injury (worse outcome), crescent shaped. Does not cross ML.EDH – lucid interval, arterial bleed (middle meningeal artery), lens shaped. Does not cross suture linesMass – HA worse in am or valsalvaToxo – most common brain infection in AIDS
West Nile virus – birds. Can give pure motor problems.
Seizures:Todd’s paralysis: focal weakness after szGeneralized – T/C or absence. Both hemispheresPartial: simple (preserved mentation) or complex (affects mentation or behavior)Seizure tx: BDZ, phenytoin, phenobarb sequence for most
Status – more than 2 sz without return to normal in betweenStatus: think INH (use B6 – pyridoxine 5 gm or gm/gm ingested)
UMN: spasticity, NL muscle mass, increased DTR’sLMN: atrophy, fasciculations, no DTR’sALS (Lou Gehrig’s) – both UMN and LMN signs, sensation intact
Cauda equina: LMN. Weakness, incontinence, saddle anesthesia. Think HNP. Urinary retention most sensitive finding > 90% sensitivity Conus medullaris – same symptoms, but no recovery
Epidural abscess: back pain, +/- fever, weakness/paralysis. anything that causes bacteremia. Get MRI. Neurosurgical emergency.
Syringomyelia – collection of fluid in center of cord. IO weakness, decreased pain/temp to fingers. Position vibration (post horns are normal)
StrokeIschemic most commonCortex – contralateral weakness to face and body
ACA – more leg than arm weaknessMCA: more arm than leg, Broca’s aphasia with dominant hemisphere, homonymous hemianopsia, hemineglect with non-dominantPCA – homonymous hemianopsia, cortical blindness when bilateral
Brainstem – ipsilateral face and contralateral body
Pons – coma and pinpoint pupils but NL respirationCerebellar – balance, N/V, nystagmus. Can herniated quick.Vertebrobasilar – coma, “locked in” (can blink and vertical gaze)Lacunes – small vessels. Small defects.
Wallenberg syndrome – decreased P/T one side, ipsilateral horner, ipsilateral face and contralateral body
TPA: ischemic, measurable neuro deficit, not rapidly improving, time from onset 3 hrs, no contraindications
Suicide – recently widowed men at greatest risk. Men succeed more; females attempt more
Tarasoff – duty to protect potential victims supersedes confidentiality duty.
Tourette’s – vocal/motor tics
Night terror – 15 mins, “awake”, incoherent, amnesia
Environmental
Drowning – suffocation from immersionNear drowning – recoverSecondary drowning – dies of complications laterImmersion syndrome – immediate death from coldDry (85%) vs wet drowning
Shock and drowning – think trauma (spinal cord)
Drowning survival: duration of immersion (#1), age, water temp, water contamination, bystander CPR, assoc trauma, assoc dysbarism
DivingBoyle’s law – the volume of the gas is inversely proportional to the pressure applied to it. Squeeze syndromesHenry’s law – the partial pressure of a gas in a liquid is proportional to the partial pressure of that gas in contact with the surface of the liquid. Decompression sickness. Champagne bottle example.Dalton’s law – total pressure of a mixture of gases is equal to the sum of the partial pressure of each gas in the mixture. Nitrogen narcosis.
high altitudehypoxemia leading to vasodilatation and vascular leakagefactors_ rate of ascent, ultimate altitude, duration at altitude (esp sleeping at altitude)Even 1K descent is useful
LungHAPE – 2nd day. Leading cause of high altitude deaths. Steroids, HBO, nifedipine, descent.
HypothermiaRadiation – most of heat loss (head)Conduction – increased 30-50x when wetEvaporation – important in hot environmentsConvection – windchill
Hunter’s response – Cold-induced vasodilatationCold diuresisParadoxical core afterdrop – when rewarming, periphery vasodilates, cold lactate rich blood returns to core, both central pH and temp drop.
Frostbite is irreversible, frostnip is reversibleFrostbite – refreezing is very bad. Leave blisters intact. Conservative surgical managementECG in hypothermia – slow afib and Osborn J waves. Myocardial irritability
HF acid burns – throbbing pain out of proportion. Rx calcium
RadiationIonizing radiationAlpha – least penetrationBeta – 8mm burnsGamma – deep penetration
2Gy – probable survivalmedial lethal dose 4.5Gy8Gy – no survivalEarlier/more severe symptoms – worse outcome
ALC at 48 hrs most important>1200 – good<300 lethal
Biological weaponsDoxy covers all organisms hereAnthrax – black eschar, mediastinitis. Rx cipro or doxyPlague – pneumonic and bubonic, sepsisCholera – rice water stoolsSmallpox – all lesions in same phase
snakesseasnakes – neurotoxiccoral – neurotoxic, red on yellowcrotalidae – hemotoxic>>neurotoxic
Wyeth – 5-10 vials, anaphylaxis, serum sicknessCroFAB 4-6 vials, may need repeat doses
SpidersBlack widow – red hourglass, mimics acute abdomen. Analgesia, BDZ. Has antivenomBrown recluse – dark violin top, necrotic lesion (delayed). Dapsone, HBO, surgery
ScorpionsCenturoides- fasciculation, salivation, delirium. Have antivenom
Hymenoptera (bees, ants, wasps, hornets)Anaphylaxis>10 stings can have toxic systemic reaction (DIC, renal failure)
Tickborne diseases: hyponatremia, fever, tick bite. Hand and feet solesTick paralysis – camperTularemia – rabbitsDengue – breakbone fever, retroorbital painLyme disease – Bell’s palsy, target lesionsVibrio vulnificus – seawater, 3rd gen ceph + doxyVibrio cholera – rice water stool
Marine envenomationsMost are heat labile – immerse in hot water, vinegarBox jellyfish – most deadly. Has antivenomNematocysts – will deploy and make things worseFish: zebra, lion, scorpion, stone (admit this, has antivenom)Cone snail – paralysisPufferfish (fugu)- paralysis
Endocrine
Epinephrine and glucagon are counter-regulatory hormones
C peptide differentiates too much endogenous vs exogenous insulin
GlucoseD50W adultsD25W kidsD10W neonates
Octreotide – antidote for sulfonylurea. Blocks insulin release from pancreas
Diabetes agentsSulfonylureas - end in “ide”. Long half lives.RepiglanideMetformin – no hypoglycemia. Metabolic acidosisAlpha glucosidase inhibitors – block hydrolysis of carbohydrates
Thiazolidenediones – “glitazones”; no hypoglycemia
Glucagon will not help in those with low glycogen stores (kids, alcoholics, malnourished, etc
DKA – dehydration, free ketoacids, glycosuria, total body K deficitTX: fluids, insulin, treat precipitant, KBicarb may increase risk of cerebral edema in peds. Also hypokalemia, hypernatremia, paradoxical spinal acidosis, decreased O2 offload to tissues
Na correction – decreased 1.6 for each 100 of glucose >100
Alcoholic ketoacidosisToo little insulin and too many counter-regulatory hormonesTx: D5W saline
Non-ketotic Hyperosmolar state (HONK)Glucose very high, profound dehydration, AMS, scant/no ketones, slow onsetTx – fluids (slow), tx precipitant, +/- insulin
ThyroidThyroid problems are generally primary
HyperthyroidismGrave’s disease #1 – antibodies to thyroid glandThyroid storm – neurologic dysfunctionRX – supportive (ASA displaces thyroid hormone from thyroglobulin), steroids (decreased conversions T4 to T3); peripheral blockade (beta blockers); blockade of hormone synthesis (PTU, methimazole); blockade of thyroid hormone release (Iodine after PTU or methimazole); tx precipitating events
HypothyroidismPost-Grave’s #1 and Hashimoto’s #2Symptoms – myxedema, slowed DTR’s, “myxedema madness”Myxedema coma – most severe form
Rx - supportive, steroids, IV T4 (thyroxine).
AdrenalsMost problems are from the pituitary (secondary) and hypothalamus (tertiary – from exogenous steroids)
Glucocorticoids (cortisol) and mineralocorticoids (aldosterone – retain Na and pee K)Waterhouse Friderichsen syndrome – B adrenal hemorrhage post meningococcemia or traumaAddison – primary adrenal insuficiency (hyperpigmentation from too much ACTH). Cosyntropin stimulation abnormal
Hallmark – low Na (most common) and high K. Also fever and hypotension
Tx: fluids, hydrocortisone
Cushing’s syndrome – from too much steroid, pituitary adenomaTruncal obesity (moon facies, buffalo hump, purple striae), HTN,
hirsutism, glycosuria
SIADHADH = vasopressin – posterior pituitaryToo much ADH when I don’t need it – dilution of serum and concentrated urineTo solve problem – brain, lung, drugs (chlorpropamide, etc)
Diabetes insipidus (the opposite of ADH)Pee too much, dilute urine too much and serum too concentratedCentral (CNS not making ADH), nephrogenic (kidney not responsive to ADH, lithium)
Pheochromocytoma – too much epi release from adrenal medulla. P’s – pressure, pain, perspiration, palpitations, pallor, paroxysmsDX ; 24 hr urine for VMA
SodiumHyponatremia: Symptoms depend on level and how fast it got there
Hypovolemic_ V/D, diuretics (lost both Na and water). Rx salineEuvolemic – SIADH, psychogenic polydypsia. Rx water restrictionHypervolemic - IV volume is low so more ADH (CHF, cirrhosis, nephritic). Na and water restriction, +/- diuretics
Pseudohyponatremia – glucose, lipids, proteins
Central pontine myelinolysis – confusion, locked in. Restrict correction to 0.5-1mEq/hrHypernatremia
Most commonly from free water loss (GI, renal, skin) or decreased intake (CVA, kids, elderly)Tx – restore IV volume;Correct slow (0.5mEq/hr) to prevent cerebral edemaTotal water deficit: TBW (70% weight) – 1(desired Na/actual Na)
PotassiumMajor intracellular cationHypokalemia = weakness. ECG U waves
Oral replacement best; 10MEq/hr when using IVNeed normal magnesium to replace
Hyperkalemia = arrhythmias, weaknessRemember – kidney failure, digoxin toxicity, hemolysis, succ, acidosisECG progression– peaked Ts, decreased PR, flat Ps, wide QRS, sine waveRx – calcium gluconate (fast but short lived), albuterol, insulin/glucose, bicarb, kayexalate, HD
Calcium
PTH – increases Ca and lowers Phosphorus via kidneysVitD – kidney plus sunlight. Increases intestinal absorption of calcium
Hypercalcemia (PAM P SCHMIDT)– hyperpara, MM, Paget’s, Cancer, milk alkali, excess vitamin D, thiazides.Stones, bones, moans, and psychic undertonesECG – short QTcTx: volume and then diuretics
Hypocalcemia Causes – post – parathyroidectomy, kidney failure, pancreatitisChvostek and TrousseauECG – long QTcTx – calcium
MagnesiumHypermagnesemia – rare. Renal failure, iatrogenic. Tx with calcium. HyporrelexiaHypomagnesemia – think in malnourished
PhosphateHigh phosphate – low PTH, renal failure. Rx phosphate binding gel or HD
Low phosphate – weakness. Rx with oral vs IV phosphate
Anion gapHAG – MUDPILES. Na- (Cl + Bicarb)Low anion gap – decreased unmeasured anions (proteins) or increased unmeasured cations (lithium, high calcium, high magnesium). Bromide is measured as chlorideNormal anion gap – HARDUP. Think renal (RTA) or GIMetabolic alkalosis – GI loss of acid or to much base intake
OsmolarityNormal: 285-295, NL gap up to 10 (Na) + glucose /18 + BUN/2.8 + ethanol /4.6
Dermatology and ID
Eczema (atopic dermatitis) – related to hay fever or asthma. AC/pop fossa; infants in face. Rx steroidsContact dermatitis – immediate or delayed (allergic)Exfoliative dermatitis (erythroderma)– red skin all over. Drugs or malignancyPsoriasis – thick white/silver scales. Nail pitting. Arthritis assoc.Seborrheic dermatitis – yellow waxy scales. Scalp and face. Seborrhea shampooPityriasis rosea – herald patch. Christmas tree distribution. SupportivePetechia (<3mm) and purpura (>3mm): nonpalpable (superficial – low platelets), palpable (deep, vasculitis)
Erysipelas – cellulitis from Group B strep. Shiny red. Well demarcated borderErythema nodosum – vasculitis of fat. Painful red/viotel nodules. Pretibial region classicDrug eruptions – think in all acute symmetric rashes
Erythema multiforme/Stevens Johnson (<10%)/TEN(>30%) – target lesions, Nikolsky, mucosal involvement. Rx like burnsSSSS – Nikolsky positive, assoc with Staph. Exotoxin. Young kidsPemphigus vulgaris – flaccid bullae. Autoimmune. Worst oneBullous pemphigoid – tense/thick bullae. Autoimmune. Better of two
Basal cell – most common cell malignancy. Pearly rolled borders. Slow growing
Malignant melanoma – worst one. #1 skin cancer cell. Sun exposed areas. Irregular (shape, color)Squamous – 2nd most common skin malignancy. Indurated raised borders, central ulcer. Face/ear/tongue/hands
Dermatophytes (tineas)Capitis, barbae, pedis, crurisHair loss in areas with hairKerion – inflammatory reaction Topical antifungals – may need oral in hair or nailsVersicolor – malassezia furfur, like seborrhea. Shampoo
Gonococcemia – fever and arthritis (large joints), tenosynovitis. Aspiration often negative, but blood cultures positive
SpirochetesAll Doxy susceptibleLeptospirosis – Weil’s disease (worst: fever, DIC, hepatitis, nephritis)Lyme’s – Ioxdes tick, erythema chronicum migrans (stage 1), Bell’s or myo/pericarditis/heart block or meningitis (stage 2), arthritis (stage 3)Syphilis – painless chancre (1st stage), rash palms and soles, condyloma lata (2nd stage), neuro and CV (third stage).
Jarisch Herxheimer rxn – due to abx treatment
TORCHS infections – cause congenital transmissionToxo, rubella, CMV, herpes, syphilis
Meningococcemia – fever, HA, rashPurpura fulminans – bad outcomeWaterhouse Friderichsen syndrome - adrenal hemorrhages
from this
Necrotizing soft tissue infectionsNec fasc – pain out of proportion. Fournier’s gangrene – scrotum or vulva.
MRSACA-MRSA: purulent skin and soft tissue infections. Rx doxy, bactrim or clinda; vanco or linezolid for serious
Toxic shock syndrome – tampons. Staph exotoxin
TicksRMSF – SE USA, centripetal rash, palms and soles. Thrombocytopenia and hyponatremia. Tetracycline
Ehrlichiosis – like RMSF with no rash and affects WBC’sBabesiosis – NE USA. like malaria, affects RBC’s. Milder than malaria.
Herpes virusCMV – congenital very bad, also bad in AIDS. Rx gancyclovir or foscarnet. One of TORCHSHerpes 1 – oral; herpes 2 – genital. Grouped vesicles. Rx acyclovir
AIDSPCP is most frequent opportunistic infectionCrypto meningitis – most common CNS fungal infectionToxo – most common cause of encephalitis. Ring enhancing lesionsOral candida – most common GI infectionKaposi’s – purple painless plaques
Molluscum – umbilicated papules
Mononucleosis – EBV. LAD, exudative pharyngitis, atypical lymphocytes. Splenic rupture. Dx with Monospot. NO abx (rash), no sports
OccupationalNeedlesticks:Hep B surface antigen- infectious. Surface antibody – immunized. E antigen – highly infectious. 2% risk infection with surface antigen and 25-30% with E antigenAntibody >10 probably good for life. Can rx with immuneglobulin +/- vaccine.
Hep C – 2% risk for exposures. No tx available
HIV risk from needlestick 0.3%. increased risk – visible blood contamination; deep injury, hollow needle, source with heavy viral load. Rx – start 1-2 hrs; multi-drug regimens (2-3 meds) x4 weeks.
Malaria – most important travel-related illness. Falciparum – most severe disease, lots of resistance. Tx = quinidine + doxy in chloroquine resistant areas (i.e. Africa)Black water fever – severe hemolysisThick and thin smears
Pedi rashes –Erythema infectiosum (5th disease)– Parvo B19, slapped cheeks, lacy rash. Keep away from SCD and pregnant patients (aplastic crisis with parvo, hydrops in pregnancy)
Hand foot mouth – Coxsackie. Painful oral lesions to anterior mouth; fever; gray vesicles to palms and soles. Supportive
Herpangina – oral ulcers on back of OP.
HSP – vasculitis. Abd pain (GIB, intussusception), renal (hematuria), joints, and the vasculitic rash (buttocks and legs)
Kawasaki – MCLNS. Vasculitis. Coronary artery aneurysms. Criteria – 5 days of fever and 4 of these – conjunctivitis, oral changes, extremity changes, rash, adenopathy. Tx ASA, IV IG
Central cyanosis – 5 gm deoxygenated Hgb. Look in tonguemetHgb – 1.5 grams deoxygenated hgb. Fe+3. Local anesthetics, nitrates, aniline
dyes. O2 sat 85% regardless on O2 administration. Rx methylene blue COhgb – “chery red”, but more like don’t turn blueSulfhgb – 0.5 grams for cyanosis. Irreversible.95% oxygen carried in Hgb, not dissolved
cyanosis unresponsive to O2 – abnormal Hgb or R to L shunt
coombs positive – antibodies to RBC’sG6PD – most common enzyme deficiency
PRBC – each until increases Hgb 1 gramsCitrate – chelates Ca – hypocalcemiaHyperK, worse with older bloodInfuse with NSS (LR has calcium)
Blood content – 70 cc/kg or 5L in manMassive transfusion – early transfusion of other products – platelets and FFP
Febrile non-hemolytic – rxn to protein antigens. like the hemolytic one. Labs above are negative.
Allergic transfusion rxns – Not dose related. hives, wheezing, can be anaphylactic. Can continue depending on severity
Infections – HIV 1:2million, Hep C 3:10K
Other – vol overload, hypothermia, hyperK, hypoCa
Type O - universal donor. Rh negative for women of child bearing age.Type AB – universal recipient
Platelets – 5 day storage. Donated by apheresis. 1 unit of platelet raises by 10K (50-60 K if apheresis unit)spont bleeding with platelets <10K; 50K for procedures/traumadysfunctional platelets – ASA (irreversible inhibition), kidney failurelow platelets – ethanol, aplastic marrow, large spleen
ITP – immune rxn to platelets. low platelets. Stop immune system first and then give platelets if bleeding. Tx = steroids splenectomy
HUS – like TTP but kids and more kidney involvement
FFP - what remains after RBC and platelets removed – give 1 per each 5U PRBC’s
Cryo – subproduct of FFP. Pooled (more risk of infection)
Hemostasis testBleeding time now done by platelet function testVon Willebrand factor – released from vessels, tells platelets to aggregate if not in vessel lumen. It also carries factor 8Protime - measures extrinsic system and common pathway (5, 7, 9). WarfarinPTT – measures intrinsic and common. Heparin
DIC – can either cause ischemia (consumption coagulopathy) or bleeding. Low platelets, low fibrinogen, increased FSP, high dimmer, fragmented RBC’s. Prolonged PT!! Rx – give FFP if bleeding, consider heparin if thrombosis
Heparin – does not cross placenta. HIT complication, antidote: protamineLMWH - smaller molecule, no monitoring. Less freq dosing.Warfarin – inhibits 2,7,9,10, C, S (Vit K dependent). Rx with vit K and PCC (FFP if no
PCC)
Contraindications to thrombolysis – BP >185/100, active bleeding or recent <14d bleeding, recent spine or brain surgery (2 weeks), brain tumor or malformations, recent CVA (2-6 mo) or hemorrhagic CVA, bleeding diathesis, on anticoagulants, pregnancy, suspected aortic dissection or pericarditis.
Sickle cell anemia – anemia, high retic count, pain, functional aspleniaPain crisis – from cell sludgingChest syndrome – leading cause of death in sicklers. Pulm infarction. Tx = abx, exchange transfusionSplenic sequestration – kids with shock. 2nd most common cause of deathAplastic crisisCNS crisis – strokesHand foot syndrome – kids with swollen hands and feet.Priapism
Salmonella – it thrives on iron rich tissues
Hemophilia – blood bad to cartilage
A – 85% of cases. factor 8 def. Give DDAVP and then factor 8 concentrate (FFP if not available). Treat before studies.B – factor 9 def
Von Willebrand disease – Most common inherited coagulation disorder. “guides” platelets and carries factor 8. Rx same as hemophilia
HIV related emergenciesLactic acidosis – mitochondrial damage. Medication reactionImmune reconstitution syndrome – when HAART reactivates immune system, exaggerated immune responseKidney stones – indinavir. RadiolucentHypoglycemia – pentamidinemetHgb - dapsoneCMV and varicella – eye complicationsPCP – single cell fungus. CD4<200. Disproportionate dyspnea and hypoxemia. Steroids before abx if hypoxic (PaO2<70 or A-a gradient >35, Bactrim 1st line, atovaquone or pentamidine 2nd lineToxo (ring enhancing lesion) and criptococcus (most common systemic fungus, India ink)– CD4<50. Thrush
muffled heart sounds. ECG – low voltages, electrical alternansSVC syndrome – Lung cancer. egress of blood from head is obstructed. Neck veins,
plethora, face swelling, HAHypercalcemia – PTH hormone-like substance secretion. Also from mets. Lung,
renal, MM, breast. ECG short QTc. Stones, bones, moans, and psychic undertones. Rx fluids and diuretics. Biphosphonates etc later.Calcium x phosphorus product =40
Seronegative spondyloarthropathies (rheumatoid factor negative) – symmetric, sacral involvement of joints and tendon/ligament insertions
Ankylosing spondylitis – bamboo spine, uveitis (most common extra articular finding)Reiter’s – arthritis, urethritis, conjunctivitis. Heel preference (“lover’s heel”)Psoriatic arthritis IBD arthritis – both UC and Crohn’s
Rheumatic fever – Jones criteria (CASES); GABHS infection2 major, or 1 major and 2 minor
OB/Gyn
STD’sUlcerative lesions increase risk for HIVNon-ulcerative lesions have discharge
Chlamydia - #1 STD. related to PID. Can be asymptomatic. Nuclear amplification test. Rx doxyPID – cause of infertility and ectopics. Fever, discharge, CMT, abd pain, and adnexal tenderness – treat empiricallyTOA – Admit.Fitz-Hugh-Curtis – perihepatitis from PID. Admit
LGV – C. trachomatis also. Buboes (groove sign) with no genital lesion. Rx doxy x 3 weeks
Syphilis – painless chancre. Rash, condyloma latum (2ry); CNS – psychosis/neuropathies/tabes dorsalis – no propioception, and heart-aortitis (3ry). Rx PCN LA 2.4 million units
Chancroid – painful ulcer and bubo at same time.Herpes – type 2. Painful vesicles in crops. Recurrent Trichomonas - strawberry cervix. Grey yellow malodorous frothy discharge.
flagylCandida – white cottage cheese, KOH with hyphae. Rx fluconazole
Bartholin gland abscess – lower aspect of introitus at 5 and 7 o’clock. Drain and insert Word catheter x weeks
Mittleschmerz – ovulation 14 days before menstrual cycle. Pain with ovulationOvarian cyst – usually in luteal phase. Ruptured look like ectopic. Can torse if bigger
(>4 cms) (like torsed testicle, dx with US).Ovarian masses – can also torse, esp dermoids. Ovarian CA – 2nd most common gyn
malignancy. Meig’s syndrome (ascites and pleural effusion)Endometriosis – chocolate cysts. Can be anywhere. Catamenial PTX. Assoc with
infertility.Uterine fibroids – excessive bleedingUterine CA – consider in AUB in perimenopausal women; painless uterine
enlargement.Cervical CA – HPV assoc. is an AIDS defining illness
Ectopic pregnancy – positive preg test, abd pain, bleeding. Discriminatory zone: 2K for transvag and 65K for transabdominalBeware of heterotopic in assisted reproduction patients.
RhoGam: passive immunization to all Rh negative moms. 50 mcg if <12 weeks and 300 mcg after that
Molar pregnancy – very high HCG’s, snowstorm appearance on US; passing “grape like stuff”
Abruptio placentae – risks – cocaine/trauma. Uterine tetany, fetal distress. Painful 3rd trimester with dark blood
Placenta previa – reliably seen in US, bright red painless bleeding. NO pelvic exam!
TraumaMaternal stabilization is 1stDisplace uterus in hypotension third trimesterKB test for fetomaternal hemorrhageAPGAR – appearance, pulse, appearance, grimace, respiration
PROM – ferning test, nitrazine paper – high pH. Sterile exam.
Nephrotic syndrome – protein in urine; hypercoagulable (urinates antithrombin 3), high lipids (lose lipid transporting proteins)
Nephritic syndrome (active sediment – casts, red cells); HTN, volume up
Test taking strategies
Note key word and red flagsEliminate obviously wrong answersOK to guessDo questions!Avoid controversial answers, stay with gold standardPictorial – read the question and try to answer before you see the pictureDon’t get stuck on calculations – waste of time and increases frustrationB most common correct answer; D after that – for numerical questions. Written choices are randomized by first letter of answer, and most verbs start with vowels, which tends to randomize most to ABCStem – question partFoil –wrong answer
4 types of questionsFact questions often have a destabilizer – a rarely know fact. Often not the answer. Can be a “red herring” if in the stem – nothing do to with the case.
2 part question – present a disease and then ask about management or complications. Look at the answers then go back and make the dx
long question with lots of info (camouflage)– look at the answers first and then read the statement again
research questions – similar questions throughout the exam. They are looking at correlation with scores (“test questions”)