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Cardiovascular

[ MI & Post Complicatiosn ]

- ACS – STEMI, NSTEMI, UA; 5% have nl EKG, 33% no cp at presentation; radiation to both arms most predictive, diaphoresis, dyspnea ( ASA, Nitro (contraind if take Sildenafil; Rsided/inferior) [vs Prinzemetal Angina-vasospasm; CP at rest; can have STE but neg trop (CCB, nitrates (No BB)]

- UA/NSTEMI – persistent pain ( Cath

- RCA – Inferior/Rside (III>II, commonly 2ndDegT1 block (IVF)/Posterior(Tall Broad Rw=Qw; upright Tw); LAD – Anterior (can have 3rd degree, 2ndDegT2); Circumflex – Lateral

- Wellens – pain earlier but free on arrival; biphasic (A) or deep inverted Tw often anterior ( ASA, Cath

- LBBB (wide R in I, negative QS/rS in V1) Sgarbosa’s –STE concordant; STE discordant >5 (or ratio >0.25); STD discord >1mm V1-2-3 [vs RBBB= Wide S in I, triphasic RSR’ in V1)

- AVB – w/ MI assoc favorable prognosis [vs - LBBB – more likely develop CHF, AV Block, Vfib; -LPHB – large infarct size, incr cardiogenic shock/mortality; - RBBB – in setting anterior MI – risk developing comlete AVB/cardiogenic shock]

- TPA Contraindications for MI: (i.e. TPA IS BAD) Trauma, Pericarditis, Active Internal Bleed, Intracranial pathology, Stroke (Hemorrhage ever or Ischemic 180/110, Allergy, Dissection

- Cardiac Arrest - #1 CPR/AED( therapeutic hypotherm 32 -36°C w/in 6 hrs, ROSC2 pwaves ( O2

- WPW – delta wave, decr PR ( procainamide if stable; DC if unstable

- Cocaine – contraindic BB (unopposed alpha)

- Other – Arryth R Ventric Dysplasia – fibro fatty material replaced by scarring; syncope & sudden cardiac death young; positive deflection end of QRS (epsilon),complete/incomplete RBBB, QRS prolong, prolong Swave, Twi V1-3 ( cardiac MRI

- Brugada – syncop; convex STE prec +Twi (Type 1), saddle(Type 2 +biphasic Tw, 3 +posit Tw)(defib

- Dig – nl/non toxic=downsloping STD, Twi/flat/biphasic, QT shortened; abnl=bidirectional

[ CHF & Structural ]

- CHF – S3 ( Nitrate (decr preload, afterload, dilate co arteries/decrease demand) [Contraindic in Valvular dysfunction along with diuretics, may cause syncope/hypoTN/worse HF], Bipap

- Diastolic – if LV EF nl, from chronic HTN/LVH=impaired filling

- Cardiogenic Shock – especially with EKG changes ( Cath

- RH(V) Failure/Cor Pulmonale – PE, ARDS COPD; JVD/Hepatomeg/Periph Edema; EKG RVH R axis/prom R wave V1 w/ Twi R precord leads/ large S in I-II-III/ large Q

- Pulm HTN – can develop into RVH, R Axis Deviation

- LVAD – check bp by Doppler with manual (not palp pulses) goal MAP 70-90

|Systolic Murmurs |Diastolic Murmurs |

|MR – “blowing holosystolic” radiates |MS – “opening snap”(@apex) |

|to axilla (heard @apex) ( Nitro |AR – wide pulse pressure, Quinke’s sign, soft |

|MVP – mid-systolic click ( BB |decrescendo, high pitch (@L stern border) |

|AS – harsh “crescendo-decrescendo” to |=Austin flint murmur, waterhammer pulse; can |

|the carotids (@R 2nd IC) (restore |be 2/2 bicuspid, rupture |

|preload IVF (caution using lasix/ngt) |chordate/papillary/valve leaflet; can p/w |

| |rapid onset pulm edema ( BB, Surgery |

|Machine-like murmur |Air embolism (Trendelenberg L lateral decubitus) |

- Endocarditis – IVDA (R side tricuspid/pulmonic)(F, resp, cp; pna; less likely systemic septic emboli), prosthetic, rheumatic HD; Staph/strep; murmur 35%; Osler (painful palp), Janeway (non tender macular), Splinter Hemorr (nails), Roth Spots (retinal hemorr) 7( Blood Cx x3; TTE/TEE; IV Abx (Vanc/Gent)

- Dukes: 2Major / 1Major+3minor / 5Minor; Major – 2+blood cultures, echo valves; Minor – predisposing, temp>38, vascular phenomena (janeway, conjunct hemorr, ic hemorr, mycotic aneyrusm, major emboli, septic pulm infarcts), immunoloc (GM nephritis, Osler, Roth, rheumatoid factor), +culture not meeting major criteria

- Prophylaxis – Undergoing Dental or Invasive Resp: prosthetic valve, previous IE, congenital HD, unrepaired cyanotic CHD (shunts, conduits), repaired+prosthetic material, transplants+valvulopathy

- Rheumatic HD – s/p Strep, MS, afib; F, migratory polyarth, carditis, chorea, subcut nodules, rash (erythem marginatum); Jones (recent strep infxn + 2major/1minor or 1major/2minor

- Prosthetic Valve – Leaks (Pulm Edema, Hemoly Anemia, Regurg) =Mechanical (AC) > Biol (No AC)

- Myocarditis – typically viral or postviral (think when peds prolonged viral p/w HF); Trypanosoma (Chagas), Coxsackie; F/tachyc/HF; send trop ( Echo; Dobutamine if HF, AICD

- Dilated CM – Peds#1Idiopathic (vs Duchenne/Becker, Familial); other=ischemic, valv, infectious, toxic, genetic

- Hypertrophic CM – HOCM in peds (deep Qw inferiorlateral, tall Rw V1-V2, large QRS, Twi-Ant), exert syncope; loud S4, harsh cres-decres midsystolic (does not radiate to neck as opposed to AS), accentuated by decrease LV volume=standing/Valsalva/nitrates ( BB, surgical myomectomy if severe

- Myxoma - #1 cardiac neoplasm; can embolize; fever, tachyc, tachyp

- Acute Pericarditis – pleuritic cp, worse supine/improved sitting forward, diffuse STE / PR dep, pericardial effusion ( NSAIDs, Colchicine (decr recurrence); NOT Steroids (higher recurrence);

- Constrictive – resultant inflamm reparative process from injury leading to fibrous thickening of pericardium; clinical CHF/restrictive CM; pericardial knock; severe ( Surg Pericardiectomy

- Pericardial Effusion/Tamponade – low voltage, alternans ( start with IVF; Pericardiocentesis if HD unstable

[ Vascular ]

- Ao Dissection – CXR= Ao enlarge/wide mediastin/Pl effusion(L)/displaced intimal calcify/ deviat trach&mainstem bronchi &esophagus( first BB (Esmolol, Labetolol) goal HR5 increased risk rupture; symptoms can be similar to renal colic, pulsatile mass, Unstable/Rupture ( US; Vol Resus, Surgery

- Ao Enteric Fistula – GI Bleed, can be primary or secondary; 3rd or 4th duodenum

- Arterial Insuff – sources=recent MI, AAA, AoDiss, Afib; CT Angio( Heparin; Limb Paraylsis (Vasc Surgery

- DVT – Phlegm Alba Dolens= white, ileofem with arterial insuffic; Phlegm Cerulem= blue, venous insuffic; Isolated Calf (20-25% extend to proximal within 1week, 10-15% develop to PE) ( repeat US 2-5d; nl ( Hep/LMWH + Warfarin or new AC [Contraindic AC= neurosurg w/in 10 days, active bleed, severe bleeding diathesis, plts 100), Grimace (none, grimace, cough/sneeze), Activity (limp, some, good), Respirations (absent, slow, good cry)

- Newborn – Dry/Stim/Suck/Warm, HR550ms higher risk sudden death, torsades/vfib; - Commotio cordis – trauma sternum

- SVT – abrupt onset, >230, nl or absent P, little variation ( apply ice to face, straw, tongue depressor

[ Respiratory ]

-

- PTA – trismus, unilat sore throat, F, tonsillar assym, uvula deiv

- RPA – often 10mm (recent arrivals 0.5, P:S LDH >0.6, Pl LDH >2/3 nl (>200); isolated think PE, if L sided only also think Ao Diss & Boeerhaves

- Hemoptysis – r/o GI/epistaxis, #1 Bronchitis (cough with blood streaked purulent sputum); massive ( lay on side with good lung up; first CXR, then CT if gross or massive with continued; may clnically d/c as bronchitis if non –smoker / 100, Immob>3days or Surgery Gastric ( antacid, ppi, wt loss, head of bed elevation, avoid acidic and reflux food

- Perf PUD – preceding PUD then acute severe abd pain radiating to back / shoulder ( cxr free air

- *Peds* Pyloric Stenosis – 2-8 weeks; palp olive shape in mid/ruq; assoc hypoK hypoCl metabol alkalosis ( US; IVF, surgery

- Gastric Outlet Obstruction – PUD complication; early satiety, vomiting, wt loss afer every meal

- GIB – predictors of bad outcome: hct1000, pH 250, LDH > 350, glu> 200;

48 hours – Ca< 8, ΔHct> 10%, PaO2 < 60, base deficit > 4, ΔBUN > 5, sequestered fluid > 6L

- Chronic Panc –pain, malabsorption, dm; pseudocysts, pseudoaneurysm, splenic vein thrombosis, pancr ascites; lipase can be nl ( need CT if in question such as if prolonged or increased (typical known history do not need)

- Panc CA – painless jaundice; Troussau’s Syndrome (hypercoag, migratory thrombophlebitis) ( CT, CA 19-9; Whipples

[ Bowel/LGIB ]

|Brick-red bleeding |Meckel’s diverticulum |

|Cobblestoning |Ulcerative Colitis |

|Currant jelly stool, palpable sausage-like mass|Intussuception |

|Skip lesions |Crohn’s, temporal arteritis|

• Crohn’s disease – noncaseating granulomas, uncommon extraGI manifestations

• Ulcerative colitis – common extraintestingal manifestations (anklyosing spondylitis, vasculitis, pyodermagangrenosum, oral apthous ulcers)

• Malignancy is the most common cause of Large Bowel (haustra, doesn’t cross lumen) obstruction in adults; SBO - Adhesions #1 (#2 Tumor, hernias) dilation >3cm (valvular conniventes/plicae circulares [crosses entire bowel] )

- Sigmoid Volvulus – risk fact bedridden, elderly, neuro illness, h/o constipation(flexible sigmoidoscopy/detorsion, surgery if fail

- Cecal Volvulus – incomplete embryologic fixaction of cecum, peaks 20s-30s

- {*Peds* / Adult }Intussusception – 80% small bowel; 6mo-3yrs most commonly (causes = lead point at Peyer patches s/p viral, HSP, Meckel, vasculitis, CF, other mechanical); adults at risk = HIV/lymphoma (increased LNs, mechanical obstruction); AMS, abd pain, jelly-stool, sausage mass ( US, Air Enema; Adult=surgery

- Hernia – Reducible vs Incarcerated vs Strangulated (bowel ischemia, overlying skin changes, F, hypotension, peritonitis); Direct = abd wall, Indirect = Internal Inguinal Ring, Femoral (more women), Incisional/Ventral, Umbilical, Obturator, Epigastric

- Ogilvie’s – pseudo-obstruction; bed-ridden elderly, malfunction autonomic control, massive dilation without mechanical obstruction ( conservative, rectal tube, NGT, sigmoidoscopy; neostigmine

- Ileus – postop, hypoK common ( IVF, NGT decompress, admit

- *Peds* NEC – premie, within first few weeks; irritability, non bilious emesis, hematemsis, hematochezia, abd distension, rigidity (if perf) ( Abxr pneumotosis coli bowel/biliary or free air or dilated loops; IVF, NGT, BS Abx, Surgery

- *Peds* Malrotation Midgut Volvulus – neonatal/10stools/day then( Abx (Fluoro, bact, Amox, Cephs)

- Shigella – contaminated food, fecal-oral; common kids 1-5yrs; high F, myalgia, headache, diarrhea watery green-yellow, 33% bloody mucoid / dysentery (blood+pus+mucus), seizures in infants, hallucinations ( Abx Ceftraixone qd x5days if immunocomprom, bacteremia (suspected or confirmed), hospitalization, day care, NH

- Campylobacter – contaminated water/food (poultry, eggs), animals, pets; low-grade F, abd pain, V/D

- Vibrio parahaemolyticus – raw seafood; vomiting, cramps, dysentery, explosive diarrhea

- *Peds* HUS – consequence of abx and antimotility for children with hemorrhagic diarrhea; most commonly Shiga-like toxin from E coli 0157:H7; petechial/purp rash, decreased UO, abd pain, bloody diarrhea, rarely CNS (seizures, lethargy); AI/microangio hemolyt anem, thrombocytop, renal fail(Admit

- Dysentery – grossly blood stool + fever; Ecoli, Campylo, Shig, Salm ( Fluoroq x3days

- Legionella – GI + cough

- Cryptosporidium – untreated water, fres-water/lake

[ Ano-Rectal ]

- Proctitis – young adult male anal intercourse, GC/Chlamyd (also herpes); ana pruritis, tenesmus, discharge ( Ceft IM, Doxy PO

- Acute Radiation Proctocolitis – commonly prost CA radiation; abd pain, tenesmus, incontinence, bleeding BRB ( steroid enema, stool softeners, analgesics, sucralfate

- Deep Anorectal Abscess – Ischiorectal / Intersphingertic (causes Fistulas#1) / Supralevator/ Post(Peri)anal ( CT, Surgery c/s

- Pilonidial Abscess – infected hair follicle; often recurs until follicle removal ( I&D, surgery referral

- Fissures – painful rectal bleeding; midline=most is posterior vs anterior, hard stools, lateral = concerning systemic infection (Crohns, HIV, Leukemia, TB, syphilis); #1 anorectal in peds ( WASH (warm water, analgesic agents [nitroglycerin ointment], stool softeners, high fiber diet)

-

- Hemorrhoids – Dentate Line separates Upper/Lower ( WASH, Ellipitlcal Excision if thrombosed

- Rectal Prolapse – cough, valsalva ( granulated sugar

- Pinworms (Enterobius vermicularis) – #1 npruritus ani in peds ( Mebendazole/Albendazole/Pyrantel Pemoate

- Rectal FB ( viscous lidocaine with removal; insert foley distally; some need local (lido epi)/general anesthesia; surgery if suspect perf; DO NOT use enema; can be d/c home if asymptomatic, surgery c/s if post-extraction pain/F/signif bleed

GU/Renal

[ Male GU ]

- Testic Torsion – undesc testis; strenuous exercise; absent cremesteric reflex; tender/swollen, higher than other side; if high suspicion ( Uro c/s then US; can open book

- Epididymitis – Prehn’s sign (relief with elevation), US shows hypervascularity; Cx orchitis and abscess; think GC/Chlamyd if sexually active age35 Ecoli/Klebs/Pseudomonas ( Bactrim or Levo/Cipro;

- Orchitis – fever, scrotal pain, often prepubertal boys; same coverage as epididymitis

- Varicocele – venous varicosity spermatic vein, incomplete drain of pampiniform plexus; most on L side ; bag of worms( do not transilluminate

- Hydrocele – painless fluid collection in tunica vaginalis, most R sided, worse with crying, most resolve by 18mos ( Transillumination; US if >1yr to check tumor or inflamm

- Testic CA – painless scrotal mass

- Prostatitis – F/low back pain/perineal pain/arthralgias; boggy prostate; Younger think GC/Ch ( Ceftriax + Doxy x14d; Older think UTI/Cystitis (Ecoli, Klebs) ( Cipro or Bactrim x4-6wks

- Priapism – Low-Flow = painful (drugs [antipsyc, antidep/ssri, Viagra, cocaine], SCD, leukemia, Peyronie Disease [penile fibromatosis]); High Flow=painless (trauma penile/spinal); >6 hrs ( IV/IM terb, IC Phenyleph, drain 2 and 10 o’clock

- Paraphimosis –cant cover glans ( 1st manual reduction firm pressure 5-10min; then dorsal slit

[vs Phimosis – can’t reveal glans/retract foreskin, only emergency if cannot urinate ( dorsal slit]

- Balanoposthitis – balan=glans, posth=foreskin, can be fungal whitish discharge( Clotrimazole cream; younger w/ bubble baths/soaps ( hydrocortisone cream; bacterial/anaerobic (Top Flagyl

- GC/Chlamyd – (Ceft + Azith or Doxy

- Haemophilus ducreyi – multi painful ulcer, inguin lymphad ( PO Azithro or Cipro, IM Ceftri

- Herpes – multiple painful shallow ulcers over erythem base ( PO Acyclovir

- Syphillis – painless, raised border, red smooth base, punched out ( IM Pen 2.4M U x1 or Doxy

Prim – Chancre; Secondary – Palms/soles 6-12 weeks; Tert – Cardiovasc, CNS (aphasia, dementia, tabes dorsalis)

|Right sided varicocele |IVC thrombosis |

|Prehn’s |Epididymitis (decrease in pain with elevation of the scrotum)|

[ Tract Infxn and Hematuria ]

- UTI – most sensitive = LE, most specif = Nitrates; Uncomplicated ( Bactrim/Macrobid; Comorbid ( same or Fluoroq; Complicated (PO Fluoroq or Bactrim; Pregn (Amox or Bactrim (not 3rd trim) or Macrobid (not 3rd trim) or Keflex

- Pyelo – UTI with F/AMS/Vomiting, may also have back/flank pain; nontoxic(outpt Bactrim or Fluoroq, toxic/preg/uro abnl/ cant PO(inpatient Ceftriaxone or Amp/Gent or Fluoro (not preg)

- Hematuria – microscopic often incidental or stone/glomerulonephritis; gross painless >40yo ( imaging for malignancy; other causes AAA, infxn, bladder cath, urethral meatus irrigation, drug, stone

- Rhabdo – hematuria without RBCs (myoglobinuria); check K / EKG, hyperPhos, hypoCa, hyperUric, hypoAlb; leads to ATN/incr Cr ( CK >5x nl; NS, adjuncts (mannitol, bicarb); goal UOP 3ml/kg/hr

- GM Nephritis –can be Post-Strep; hematuria, proteinuria, RBC casts; also htn, edema, chf ( restrict Na/Water, non-loop diuretic HCTZN, 2nd line ACEI

- GM Nephrosis –proteinuria >3g/24hr, edema, hypoAlb/hyperCholes; peds=50mg/kg/d or UProtein/Cr ration >2.0mg / Alb>Cr, UNa100WBC (>50% Neutrophils)s; if well appearing trial outpt abx (First Gen Ceph or Vanc) into dialysate cover Stap aur/epiderm x10-14d

- Disequilibrium Syndrome – cerebral edema 2/2 quick drop in uremia

- HD – Emergent = Pulm Edema, Uremia w/ sx, HyperK/Acidosis, Toxins

- Tunneled Catheters – leave in while in ED even if infxn, may have balloon inflated, need vascular

- AVF – Bleeding ( Apply pressure (if lose thrill, thrombosis, call vascular)

Obgyn

|Firm, painful lower uterine segment |Abruption – preeclampsia most significant risk factor |

|Fishy odor |Gardnerella, BV |

|Grape-like clusters (gross) |Molar pregnancy |

[ GYN Infections ]

| |Discharge |pH |KOH |Wet Mount |Treatment |

|Candida |“Cottage cheese” |Normal < |Negative |Spores, |Flucon/ topical |

| | |4.5 | |pseudohyphae |clotrimazole |

|Trichomonas |Vag eryth, frothy,malod |High > 5.0|Positive |Mobile |Metronidazole + |

| |green/yellow | | |trichomonads |partners |

|BV (Gardner) |“Fishy smell,” thin |High > 5.0|Positive |Clue cells |Metronidazole (or|

| |gray/white | | | |Clinda) |

|Strawberry cervix |Vaginitis |

|Violin string seen on laparosc |PID |

- PID – GC/Chlamyd; lower abd pain; can have F, discharge, dyspareunia; CMT, adnexal ttp ( IM Ceftriax + PO Doxy x14d; admit if preg; TOA F, vag dc, adnexal mas ( US or CT; IV Abx

- Fitz-Hugh-Curtis – perihepatitis/inflamm capsule, adhesions (violin strings) from abd to liver, from partially treated Chlam; RUQ pain, pleuritic

- Bartholin Abscess- infection gland/cyst, tender fluctuant mass along posterolateral margin of vaginal vestibule (I&D on mucosal surface (if no pus likely failure) + Word (6-8wks); sitz bath

[ GYN Other ]

- Ov Torsion – R>L, childbearing age; r.f=ov mass/ infertility treatments/ preg/ 4-6cm / prev surg; sharp unilateral abd pain/N/V ( US shows enlargement with heterogenous stroma and periph displaced follicles, abnl position of in relation to uterus, late finding decreased flow; may need Laparosc to def r/o

- Vag D/C Non STD – Vag FB (think in peds; malodorous, bloody/dark brown); Contact Vulvovag (irritant; local swelling, itching, burning ( sitz, warm compresses, benadryl; topical steroids if not resolve); Yeast (itching, thick, white adherent to walls d/c, vulvular/vaginal erythema)

- Primary Dysmenorrhea – pain with first few days menses; can be 2/2 Endometrio/PID/IUD, or benign (NSAIDs or APAP

- Fibroids – pain, menorrhagia ( NSAIDs, medroxyprogest rone, GnRH Agonist; surgery (high recurrence), embolize, hysterectomy

- Atrophic Vaginitis – loss of estrogen; vaginal dryness, pruritus, d/c, dysparenuia

[ 1st Trimester Bleed & Changes ]

- Preg Changes – Increase in HR/MAP/ CO, TV/MV, Blood Vol / WBC, Renal Flow/GFR; Decr in FRC, Hct, Serum Cr

- Uterus – 12wks symphysis pubis, 20 wks=umbilicus, 36=xiphoid process

- Bhcg Levels: 4-5 weeks – gest sac – 1000

5 weeks –+ yolk sac – 1000-2000

6 weeks - +pole, cardiac – 10,000-23,000

- Ectopic – r.f.=prior/tubal surgery/PID/tobacco/adv maternal age/IUD/prior ab/prev infertile; Descrim Zone 1500-2000; IUP = Fetal Pole + Yolk Sac; f/u 48hrs

- Ruptured – persistent tachyc despite volume resus ( emergent laparot

- Candidates for Methotrexate – HD stable, no rupture, compliance, sac 20wks, 140/90, proteinuria >300mg/24hr or P/Cr >0.3 or dipstick+1; often pitting edema; (severe 160/110, +/- any = plts 1.1 [or double], elev LFTs 2x-nl, pulm edema, or cerebral visual sx) ( admit, Mg, labetolol, methyldopa(outpt common)

- HELLP Syndrome – form of severe pre-eclampsia = hemolysis, elev LFT, lower plts

- Eclampsia – with seizures

- Mg OD – diminished DTRs >10, resp depression >13 ( Ca

- Chorioamnionitis - >15 weeks, chorio sac adheres to cervic os=risk infection; normal flora; r.f.=PROM, prolonged rupture, multiple gyn exams; F, ut tender, tachyc, puru dc (IV Abx (Amp+Gent)

[ Delivery and Post-Partum ]

|Kleinhauer-Betke test |Fetal nucleated RBCs in maternal blood |

- PPROM - 4, hypercalcemia( |

| |QT prolongation |

|QTc prolongation |Lithium, hypokalemia |

|GHB |Body builders, rhabdo |

|Characteristic Odor |Intoxicant |

|Garlic |Arsenic – tasteless, odorless, GI effects, wood preservatives |

| |Dimethyl sulfoxide (DMSO) |

| |Organophosphates |

| |Yellow phosphorous |

| |Selenium |

| |Tellurium |

|Bitter almonds |Cyanide |

|Pears |Chloral hydrate |

|Rotten eggs |Disulfram |

| |HS |

| |N-AC |

| |Dimercaptosuccinic |

|Wintergreen |Methyl salicylate |

|Glue |Toluene |

|Carrots |Water hemlock |

|Fruity |Ethanol |

| |Acetone |

| |Isopropyl alcohol |

| |Chlorinated hydrocarbons |

Urine Alk – ASA, Phenobarb, INH; also replace K

HD drugs – ASA, Phenob, Li, Methan/Ethy/Isoprop, Theoph; low molecular weight, small vol distrib, water soluble; (Can’t = CN, TCAs, Fe, Bzd, Phenothiazines, Hallucin)

Uses of whole bowel irrigation – Fe, Li, Ld, drug packers, sustained releases, bezoars

AC – Multidose = SR, Theoph, Phenob, ASA, Carbamazepine; (Can’t = Alcohols, CN, LI, Fe, Ar)

Hypoglycemia Inducing – ASA, APAP, Insulin, Etoh, Oral Hypoglyc, BB

Osm Gap = 2Na + Gluc/18 + BUN/2.8 + Etoh/4.6

Jimson Weed – Anticholingergic Fomepizole (4 Methylpyrazole)

|Drug-antidote pairs |

|Anticholinergic – physostigmine |

|Beta-blocker – glucagon |

|Ethylene glycol – fomepizole |

|Methanol - fomepizole |

|Iron – deferoxamine |

|Organophosphates – atropine |

|Sulfonylurea – octreotide |

Antidotes (More): AntiCholin=Physostig (No for TCA/Heart Block), APAP=NAC, Ar/Ld/Merc = BAL(dimercaprol)/DMS(succimer)/EDTA, ASA/Barb=Alk Diuresis/HD, BB=Glucagon, CCB=Ca/Insulin/Glucagon, Carbamate=Atropine, Cocaine=Bzd/Cool, CO=O2/Hyperbaric, Warfarin=FFP/VitK, CN=Na (Nitrite/Thiosulf) + Hydroxycobalamin, Dig=Digibind, Ethyl/Meth=EtoH/Fomep/HD, HF=Ca/Mg, Iron=Deferox, INH=Pyridoxine B6, Methhgb/Nitrites (levels>25%)=Methy Blue, NMS=Bzd/Dantrolene/Bromocriptine, Opiates/Clonidine=Naloxone, Organophos/Cholinergics=Atropine/2PAM, Oral Hypoglyc=Gluc/Gluca/Octreo, Serotonin=Cool/Cyproheptadine, TCA=Bzd, NaBicarb; Valproic=L-Carnitine

Amatoxin – Delayed/6hrs (not early) GI is more serious, has renal and hepatotoxicity, LFTs can be normal up to 24 hrs after, can cause seizures (pyridoxine-GABA pathway)

APAP – Toxic 140mg/kg or 7.5g, TL 140@4hr; Tx=NAC

Arsenic – vertigo, HA, GI, hemolysis, renal failure, jaundice, sz ( Exchange Transf, UAlk, HD

ASA –TL 100, HypoGlyc, Mixed Acid/Base, (Bicarb/UAlk, HD (Acute >100, Chronic >50, AMS, coma, rising despite alk, renal failure, pulm edema, clinical deterioration)

Brodifacoum (Rodenticide) – Anti-coag, monitor coags for 3-4 days

Carbamazepine – Cerebellar (Dizzy, Ataxia, Nystag), Seizure, Arrythm; (M-AC/Hemoperfus/NaBicarb (QRS)

CO – bilateral basal ganglia hypodensity; L shift on curve (HBO when end organ damage (including MI, dysrythmia), LOC/syncope, coma, sz, confusion, focal neuro, visual sx, COHb>25% (15% preg)

Colchicine – GI, Dehydration, Bone Marrow Suppression (Leukocytosis/Pancytopen), Rhabdo, Renal Fail, sudden cardiac death ( GI Decon, IVF, G-CSF

Dig – N/V, Yellow/Green Halos, PVC#1, bradyc, hypoTN, hyperK; worse if HypoK/Mg/HyperCa; (Digibidn 5-10 vials (if K>5.5, Ventric, Instability), Phenytoin for Ventric Dysryth

Dextromethorphan – NMDA-R antagonist, SSRI; agitation, fatigue, drowsy, slurred speech, visual hallucin, manic, tachyc, nystagmus, mydriasis, hyperthermia, rhabdo ( IVF, Bzd, Cooling, Naloxone

Ethyl Glycol - Glycoaldehyde/Glycolic Acid; CNS, stupor, Renal Failure ( Fomep + B1+B6

Ergotism – miosis, burning sensation in the extremities, CVA, MI, GI sx, seizures; dihydroergotamine for migraines (most common side effect nausea)

GHB – CNS depression, fluctuates, quick return

Hydrogen Peroxide – cerebral gas emboli/stroke ( HBO

Iron – TL 500; I-GI; II-Latent; III-Metabolic Acid/Dehydr/Lactic Acid; IV-Fulm Hepatic Fail; V-SBO

Lead Toxicity – Child: paint chips; Adult: occupational wielding; Acute: N/V/Abd pain/Ataxia/Enceph/Sz; Chronic: HA/Periph Motor Neuropath/Cognit Impair

Li – TL 4 for acute, HypoNa/HypoVol worsen; tremor/N/V/D/Slurred Speech / Seizure / Incr QT / Arryth (Bradycardia, Twi), Decr AG; Acute on Chronic DI/HyperNa; (NS, HD (if >3.5-4 acute, 2.5 chronic, any level with neuro symptoms, can’t fluid hydrate, coma, seizure, unstable)

Methadone – resp depression, sedation, miosis, bradyc, hypoTN; prolong QTc/tdp ( Mg; observe for longer (4-6hrs as opposed to 1-2hrs) due to longer half life

Methanol – Formaldehyde/Formic Acid; GI, CNS, Blindness ( Fomep + Folate

Phenytoin – Cerebellar (nystag, ataxia, vomiting, slurred speech, dystonia, lethargy, coma), Dysrythm/Hypotn, Paradox Seizure; (Lavage, M-AC (Cant HD/Hemoperfus)

Theoph – TL 20

Valproic – hyperammon ; CNS dep, enceph, metab acid, hepato, panc, renal fail, pancyto( L-Carnitine

Intralipids – for local anesthetics, BB, CCB, TCA

|Toxic Alcohol |Example |Mechanism |Symptoms |Labs |Treatment |

|Ethanol | | | |Ethanol level |Supportive |

|Methanol ** |Windshield |Metabolized to a |“Looking through |Serum level; OG +|Fomepizole or |

|lethal in even |wiper fluid, |toxic metabolite |a snowfield;” |AG acidosis |ethanol; folate; |

|small quantities |antifreeze, |by ADH ( |basal ganglia | |urinary |

| |Sterno |formaldehyde, the |injury leading to| |alkalinization; |

| | |by aldehyde |Parkinsonism | |consider HD |

| | |dehydrogenase ( | | | |

| | |formic acid | | | |

|Ethylene Glycol |Antifreeze, |Toxic metabolites |Hypocalcemia, |Serum level; OG +|Fomepizole or |

| |brake fluid, |ADH + ALDH ( |acute renal |AG + ARF; oxalate|ethanol; thiamine|

| |some cleaning |oxalic acid + |failure |crystals in the |and pyridoxine; |

| |products |glycolate | |urine |consider HD |

|Isopropranolol |Rubbing |Toxic metabolite, |Hemorrhagic |Serum level; OG +|Supportive care |

| |alcohol, |ADH ( acetone |gastritis, “twice|acetone level ** | |

| |perfumes, hand| |as drunk for |NO METABOLIC | |

| |sanitizers | |twice as long” |ACIDOSIS | |

• Strychnine – rat poison, opisthotonus, hyperreflexia, clonus (seizure like but awake), trismus within 15-30min, BDZ +/- intubation and paralysis

• ASA toxicity – tinnitus, hearing changes, metabolic acidosis + respiratory alkalosis

• MAO-I (phenelzine - antidepressant)

• NMS – dantrolene, bromocriptine, amantidine

Environmental

|Cherry-red skin, bilateral basal |CO poisoning – RA = 6hr, 100% = 90min, hyperbaric = 30min |

|ganglia hypodensities | |

|Bitter almond smell |Cyanide (amyl nitrite, sodium nitrite—caution methemoglobinemia, |

| |sodium thiosulfate; hydroxocobalamin if also +CO poisoning) |

|Immediate collapse at scene of fire |Cyanide (amyl nitrate) |

|Hot-cold reversal |Ciguatera |

|Rust remover, glass etching |Hydrofluroic acid – topical calcium |

|Basophilic stippling |Lead toxicity, “lead lines,” succimertx (“It succs to eat lead); |

| |acute poisoning (Dimercaprol then EDTA |

|Arsenic |Dimercaprol (BAL) |

|Class A Bioterrorism |Transmission |Symptoms |Treatment |

|Agent | | | |

|B. anthracis (anthrax) |Gram(+) spore-forming |Cutaneous (woolsorter’s |Supportive care, |

| |bacterium; found in |disease): rarely fatal |ciprofloxacin, doxycycline,|

| |grass-eating mammals |GI: ulcers and edema of |or amoxicillin; toxic |

| | |pharynx, abd pain, GIB |patients require triple |

| | |Pulmonary: most deadly, |therapy = cipro/doxy + |

| | |mediastinal widening |rifampin + clinda |

|Yersinia pestis (plague) |Gram(-) bacillus, |Bubonic: bubos, regional |Do not incise bubos |

|– “Black Death” |disease of rodents |painful LAD, 50% to |Multiple antibiotic choice |

| |transmitted by |sepsis if untreated |available |

| |inhalation of flea feces|Pneumonic: inhalational, |Prophylaxis is same as |

| |or flea bite |may be transmitted |treatment |

| | |person-person, f/c, | |

| | |flu-like illness, | |

| | |meningitis, coagulation | |

| | |disturbance ( DIC, | |

| | |sepsis, death | |

|Variola major (smallpox) |US and Russia have |Lesions in the same |Isolation, varicella |

| |repositories |stage, face ( body |immunoglobulin |

|Francisellatularensis |Ticks from lagomorphs or|Localized disease with |NO ISOLATION REQUIRED |

|(tularemia) – “Rabbit |contact/ingestion of |regional LAD, ulcerated |Streptomycin |

|fever” |feces |skin |PPx - doxycycline |

| | |Invasive disease: f/c, GI| |

| | |sx, cough SOB | |

|C. botulinum (botulism) |Gram(+) spore forming | |Supportive care |

| |rod, produces neurotoxin| |Botulinum antitoxin |

| |blocks ACh release ( | |NO ANTIBIOTICS |

| |flaccid paralysis | | |

|Filoviruses, | |Fevers, myalgias, |Supportive care |

|arenaviruses, hantavirus | |petechial hemorrhage, |Antiviral: ribavirin |

|(viral hemorrhagic | |DIC, MSOF, cardiovascular|PPx: ribavirin |

|fevers) | |collapse | |

Mass casualty incident—radiation injury

• Best prognostic indicator lymphocyte count at 48 hours (>1200 good, 2Gy or >200 rads)

• Prodromal ( latent ( manifest illness ( recovery/death

Diving injuries

• Barotrauma – going down or up ( O2, fluids, decongestants, analgesics,

• Nitrogen narcosis (gas toxicity) while at depth, appears intox ( Ascent

• ArterialGasEmbolism (arterial air) coming up; ** immediate, CVA, MI, (decomp chamber

• Decompression Sickness (venous air) ** indolent, joint pains, spinal cord syndrome, ( chamber

• “Cutis marmarta” = skin bends ( answer is detailed neurologic exam

Marine injuries

• Puncture wounds (e.g. urchins) nonscalding hot water (heat labile toxins) (meticulous wound care, XR for retained FB, tetanus, +/- antibiotics (fluroquinolones, doxy ( treat vibrio)

• Stings (e.g. jellyfish, anenomes, coral)- nematocysts, DO NOT PUT FRESH WATER ON, ( use vinegar (5% acetic acid), removal of remainder with tape, +/-anaphylaxis treatment, tetanus, +/- steroids

• Sting Ray ( Hot Water Immersion

• Aeromonas = fresh water

• Vibrio = salt water

o V. vulnificans( ingestion, necfasc, Fournier’s gangrene, in immunocompromised; hemorrhagic bullae, purpurafulminans

o V. parahemolyticus( “oyster shucker’s thumb”

Snakebites

• Crotalids (pit vipers, rattlesnakes): , worse to be bit by a baby because they cannot titrate their venom and release all in one strike; severe local wound symptoms, compartment syndromes, coagulopath, low plts (Anti-Venom; Dry ( Observe 8 hrs;

• Elapadid (coral snake, sea snake): “Red on yellow, kill a fellow. Red on black, venom lack.” Smaller bite, neurotoxin, paralysis, bulbar paralytic syndromes ( Anti-Venom; Immob/Compress Extrem

Scorpion bites( neurotoxic, Centruroidesexilicauda = little yellow bug causes a lot of problems, heightened sensitivity to touch, temperature reversal, antivenin available

DDX for a blackeschar

• Brown recluse spider bite (Loxosceles) – local tissue destruction,dapsone

• Black widow (Latrodectus) – rigid abdomen, neurotoxin, antivenom in severe cases

• Cutaneous anthrax “wool sorters disease”

o Pulmonary anthrax, NOT airborne human-to-human, do not need isolation

o Doxy, cipro

Any case of smallpox is a worldwide emergency, highly contagious via the respiratory route

Buboes – lymphogranulomavenereum (LGV)/Chlamydia 3 wk course of doxy; bubonic vs pneumonic plague contagious once in the lungs #1 state is New Mexico; cat-scratch (Bartonella)

- Altitude – AMS – headache(no further ascent, Acetazolamide (also prophylax); HAPE – DOE (O2, descent/HBO, Nifedipine (also prophylax, as with Dexameth)[Acetazol not helpful]; HACE – (decreased partial pressure leads to) increases in cerebral blood flow leading to edema, ataxia, AMS ( Desc/O2/HBO/Dexameth

- Hypothermia – Profound 9-20, Severe 22-28, Moderate 29-32,Mild 33-35, Coding( Active Rewarm (stop when K>12); Frost Bite ( Wet Rewarm 40-42 (circulating warm water, don’t let refreeze)

- Hyperthermia – Heat Stroke – AMS, sz, coma, multiorgan system failure ( Rapid Cooling

- Burns – Parkland Formula – 4 x kg x %burn; ½ first 8 hrs; Goal UOP 30ml/hr (1-2ml/kg/hr peds)

- Adult – 18=Front/Back/Legx2; 9=Head/Armx2; 1=Palm

- 1st Deg Superficial – Epidermis, sunburn; 2nd Superfic Partial Thickness – Bullous, 2-3weeks heal; 2nd Deep Partial Thickness – Dermis, leathery white, relative painless ( Top Antimicrob Dressing; 3rd Full – Hypodermis (subcut), charred, insensate, eschar

- Drowning – Pneumonitis – mild sx/nl SaO2 and nl CXR( observe x6hrs, no Abx; admit if severe

- Spiders – Brown Recluse – violin; painless bite; then local erythema/edema, hemorr bleb; severe=hemolysis, low plts, renal failure ( supportive (Bzds, Analgesics), (no antivenom, Dapsone controversial); - Black Widow – hourglass; painful; muscle cramps, rapidly spreads, abdomen (acute abdomen), CNS excitation, ( supportive care (Bzd, Analgesics), Antivenom (severe)

- Mammal Bite – Dog to Face/Scalp ( Irrigated, Primary Closure, no routine Abx

- Cat Bites - #1 Pasteurella, deep puncture ( Augmentin

- Human (Fight) Bite – Eikenella corrodens ( leave wounds open, Augmentin

• HS poisoning – rotten egg smell, sewer or manure gas, decoupling of oxidative phosphorylation, rapid coma, shock, lactic acidosis, most will recover spontaneously but can use sodium nitrite (caution methemoglobinemia)

• HF acid – glass-etching, causes hypocalcemia( treat with topical calcium gluconate; can also cause QT prolongation from hypocalcemia; symptoms may be delayed up to 24 hours

• CO poisoning – shifts O2 curve ⎜, normal O2 sat, room air = 4-5h, 100% O2 = 1h, hyperbaric = 30min, bilateral basal ganglia hypodensities

• Amanita phalloides – “death cap” mushroom, amatoxin, delayed GI toxicity, period of false recovery, liver failure, renal failure, DIC

o Psilocybin cubensis – psilocybin toxin, hallucinogenic, tachycardia, mydrasis, seizures

- Phosgene Inhalation – smells like hay, can lead to ARDS ( Admit

- Toulene/Huffers – hydrocarbons, sensitizes myocardium; don’t give catecholamines

ID

|Bronze, violaceous wound |Tetanus or gangrene |

|Cocci in chains |Strep |

|CT with “ring-enhancing” |Toxoplasmosis (pyrimethamine + sulfadiazine) |

|lesion; multiple | |

|subcortical lesions near | |

|the basal ganglia | |

|Currant jelly sputum, |Klebsiella PNA |

|bulging fissure | |

|CXR that looks worse than |Mycoplasma PNA |

|patient | |

|Grape-like clusters |Staph |

|Grey-yellow frothy |Trichomonas |

|discharge | |

|Lancet shaped |Pseudomonas |

|Millet seed appearance |Miliary TB |

|Multinucleated giant cells|Herpes |

|Osler, Janeway, Roth, |Endocarditis |

|splinter hemorrhages | |

|Post-influenza PNA |Staph |

|Pseudomembrane |Diptheria, C.diff |

|Punctured sneaker |Pseudomonas |

|Rash, photo of buccal |Rubeola |

|mucosa | |

|Rust colored sputum |Pseudomonas pneumonia |

|Sandpaper rash, strawberry|Scarlet fever |

|tongue | |

|Slapped cheek appearance |Fifth’s disease |

|Staccato cough |Chlamydia PNA |

|HUS |E. coli OH157 |

|Tongue lesions cannot be |Oral hairy leukoplakia, EBV, HIV |

|scraped off | |

|Aplastic anemia |Acute hepatitis, parvovirus B17, sickle cell, chloramphenicol |

|Cat bite |Pasturella |

|Erysipelas |Distinct borders, “butterfly pattern” over the face, pinna = Millan’s ear |

| |sign ( CTX or Ancef, consider admission |

|Cystercercosis |Taeniasolium |

|Tetanus |Opisthotonus; risussardonicus |

|CF |Pseudomonas COLONIZATION |

|Mumps |Parotidis, orchitis |

|Erysipelas |Lymphatics |

|Empiric Antibiotics for Sepsis |

|CAP |CTX + azithro |

|HCAP |Pip/tazo + vanc + tobramycin |

|UTI |Amp + gent |

|Intra-abdominal |Amp + gent + flagyl |

|Biliary |Pip/tazo |

|Device-related |Vanc + gent |

|Skin/soft tissue |Vanc |

|Disease |Tick Vector |Cause |Clinical |Dx |Tx |

|Babesiosis |Ixodes spp. |Babesia |Spiking fevers |Thick and |Supportive |

| | | |Hemolysis |thin smear; |Deadly in |

| | | |HSM |Maltese |asplenic |

| | | |Dark urine |cross |patients |

| | | |Fatigue | | |

|Colorado Tick |Dermacentorander|Orbivirus |Biphasic fever |Clinical |Supportive |

|Fever |soni (wood tick)| | | | |

|Ehrlichiosis |Ixodes |Rickettsia-like |Abrupt fever |lo WBC |Doxy, |

| | |intracellular |Rash |lo PLT |Rifampin |

| | |coccobacilli |GI sx |hi LFTs | |

|Lyme |Ixodes |Borreliaburgdorferi |E. migrans |Serologic |Doxy, |

| | |(spirochete) |Neurologic, cardiac|testing |Amoxicillin |

| | | |sx | |(pregnant, < |

| | | |Arthritis | |8yo) |

|RMSF |Dermacentorander|Rickettsia rickettsia|Headache |Clinical |Doxy, |

| |soni (wood | |Fever |Serology |Chloremphe |

| |tick); | |Centriped rash | |(pregnant, < |

| |D. variabillis | |Myocard | |8yo) |

| |(dog tick) | |Arhtr/myal | | |

| | | |ARDS | | |

|Tick Paralysis |Dermacentor |Dermacentor |Ascending flaccid |Clinical |Remove tick |

| | |(toxin-mediated) |paralysis | | |

| | | |Loss of DTRs | | |

| | | |Ataxia | | |

|Tularemia |Amblyomma (lone |Francisella |Ulcers |Clinical |Streptomyc |

| |star tick); dog |tularensis |LAD |Serologic | |

| |tick; rabbit; | |Conjunctivitis | | |

| |cat | |Pneumonia | | |

| | | |⎢ Na+ | | |

|Dengue |Aedes mosquito |Dengue virus |F, dramatic bone |Clinical |Supportive |

| |(Caribbean/PR) | |pain |Serologic | |

| | | |Hemorr F; mortality| | |

| | | |50% w/o care | | |

|Trichinosis |Undercooked pork|Trichinella |Multi organ | |Supportive |

| |with roundworm | |Facial edema | | |

[ Other Ticks/Parasites ]

• Babesiosis – protozoan parasite, Ixodes tick, flu-like illness, MAHA, splenomegaly, Maltese cross; mild disease no treatment, severe disease quinine + clinda x 10 days

• Rabies – dogs found along US-Mexico border high risk, raccoon with greatest risk overall (38%)

• Chagas – Trypanosomacruzi; reduviid (kissing) bug

• Hantavirus – zoonosis, deer mouse feces; flu-like illness, most deaths from pulmonary edema

• Leptospirosis – contam freshwater (spirochete) conjunc redness w/o exudate; jaundice; ( Doxy

- Lyme – Borelia burgdorferi (spirochete) via tick Ixodes; Early: rash bull’s eye (erythem migrans) (Doxy 100 BID 2-3 weeks [vs Prophylaxis – 200mg x1]; Sec: F, Lymph-aden, b/l Facial, AV Block; Tert: chronic arthritis, myocarditis, subacute enceph, axonal polyneuropathy

- Syphillis – Treponema pallidum (spirochete); Ulcer/Prim/Sec(IM Pen G; Tert(weekly x3wk

Jarisch-Herxheimer ( NSAIDs/APAP

- Malaria – Plasmodium via Anopheles mosquito; Thick and Thin Periph Smear ( Qunidine + Doxy

- West Nile – from Middle East/Africa/Asia; birds and mosquito; F/HA/Fatigue, CNS (mening/enceph/myelitis) ( Supportive

[ Bacterial ]

Indications for endocarditis prophylaxis – manipulation of gingival tissue, periapical region, only

• Prosthetic material used in cardiac valve repair

• Previous IE

• Unrepaired CHD; repaired CHD repaired with prosthetic material 6 months after repair; CHD repaired with prosthetic material with residual defects at the site

• Cardiac transplant + valve regurgitation

• Diphtheria – toxin mediated, multisystem (pharyngitis, paralysis of soft palate, myocarditis, nephritis), diphtheria anti-toxin ( Penicillin/Erythromycin

• Pertussis – risk apnea (Azithromycin

• (Clostrid) Botulism – infant most common form; blocks ACh release; flaccid descending paralysis

• (Clostrid) Tetanus – opisthotonus (rigid spasm of body); risussardonicus; trismus; stimuli may make it worse; ( BDZ+Metronidazole

Update tetanus if high risk wound & >5yrs since last (Tdap once in life 11-64yo; then Td)

Never/underimmunized (Human Tetanus IG+Td

• N. meningitides – macular to purp/petech; prophyl for close contact & mucosal(Rifamp or Cipro

Dissem Gonorrhea – arthritis-dermatitis syndro, papules evolves to tender pustules/vesic (CTX

- SIRS – HR>90, temp >100.4 or 20 or PaCO2 12 or 500- asympt, generalized lymphad

200-500 – Thrush, PNA, Zoster, Hair yLeukoplak, B-Cell Lymph, Hodkins, Kaposi, TB

50yo, localized HA, painful temple palpation, decrease vision, jaw claudication, low grade F, wt loss, valvular involvement (Ao Syndrome/Dissection); ESR >50, abnl biopsy ( High Dose Steroids while await bx

- Kawasaki – see peds; #1 cs of acquired HD in developed countries

[ AI Reaction ]

• HSP – after URI, small vessel vasculitis leads palpable purpura, intussusception, nephrotic syndrome; HSP = skin + joint + GI; low plts/coagulopathy ( supportive; steroids if severe

- Rheumatic Fever – GAS 2-6wks post; 2Maj/1Minor or 1Maj/2Minor ( Pen G; digoxin (if HF)

- Jones – Major: carditis (pericarditis/valv/cardiomeg/murmur), migratory polyarth, Syndenham chorea, erythem margin, non-tender subcut nodules/rash on wrists/elbow/knee; Minor: previous RF, arthralgias, F, elev ESR/CRP, prolong PR, rising Antistrep O-titer

Antipyretics

- Reactive Arthritis – 20-40yr, recent urethritis/dysentery; Chlamyd trach, Salm, Shig, Yersin, Campylobac; asymmetric oligoarth LE joints, lower back pain, conjunct, uveitis, dactylitis, plaque-like rash on palms/soles ( NSAIDS (Indomethacin)

- HIV – Oral Hair Leukplakia – lateral tongue cannot scrap off [vs Thrush – can scrape off]

- Anaphylaxis – type I hypersen (IgE) 2+ systems ( IM epi, benadryl, steroids, pepcid/ranitidine, albuterol, Glucagon (if on BB)

- Cytotoxic – TII (IgG/IgM) – autoimm hemoly anemia, Erythro Fetalis, Goodpasture; requires 2 separate exposures

- Serum Sickness – TIII Hypersens (I-Complex deposits); 1 week after abx (earlier if previous exposure); lupus like; rash, joint pain, F ( supportive, Antihistamine, Acetaminophen

- Cell-Mediated – TIV (T-Cell); contact derm, TB skin, transplant rejection

- Hereditary/Acquired Angioedema – defic of C1 esterase inhib causing increased bradykinin/vasodilation/edema ( FFP with C1 Inhibitor [vs. Drug Induced ACEI/ARB – also incr bradykin but ( supportive ]

- Interstitial Neph – Eiosinophils/uria; most commonly NSAIDs, pen, sulfas, diuretics

- Scombroid – histidine containing fish; erythema, vasodilation (hypoTN, tachy) ( Benadryl

{Transplant}

- Acute Graft Rejection – 1-12weeks after [vs. Hyperacute-minutes/hours; Chronic-progressive/insidious] – decreased UOP, F, pain over site, incr Cr 20% ( High Dose Immunosupp

- Transplant Infection – bacterial early first month; later viral (CMV)

- GVHD – host Ag stimulate transplanted graft containing I-Competent cells but host cannot mount immune response; common leukemia/myeloma patients receiving stem cell transplants; rash, diarrhea, emesis, bleeding, abd pain ( Steroids

• GVHD – nonspecific rash, mucositis, diarrhea; more likely with hematopoetic transplants; 1-12wk after transplant

Endocrine

\

[ DKA/HHS & HypoGlc ]

- DKA – FS>250/bicarb5.5 (hold +supplement if 1 seizure w/o full recovery; >20-30min risk of hypoxia/hypoTN/hypertherm/hypoglyc/metabolic acidosis (FS, Sodium, Upreg; Loraz/Diaz/Midaz; Pheny/Fospheny/VA; Pentobarb/Propofol; [Atypicals – HS, Pyridoxine, Mg]

- Neonatal – subtle; lip smacking, eye deviation, staring, rhythmic blinking, bicycling; Full Sepsis ( Phenobarb, Abx, Acyclovir

- Infant Afebrile 1st Time – emergent neuroimaging if legs, fair prognosis

• Brown-Sequard – hemisection of the cord, ipsilateral loss of motor, proprioception, vibration; contralateral loss of pain and temperature, okay prognosis

- Syringomyelia – cavitary lesion/fluid in spinal cord; HA, neck pain, sensory, CN dysfxn, gait abnl, cape-like distribution loss of pain/temp in UE (preserve light touch/proprioception)

- Cauda Equina- 2/2 herniated disk/trauma/hematoma; back pain, perianal numbness, loss of rectal tone, bowel/bladder (retention post void 100ml), leg weakness, loss of bulbocavernous reflex, loss of DTR

- SC Infections – Epidural Abscess, Osteomyelitis, Myositis – hematog spread#1; DM, IVDU, chronic renal failure, ETOH, immunosupression; #1 Staph aur; back pain+F+neuro ESR, MRI ( Vanc + 3rdCeph; neurosurgery for Decomp Laminectomy 2 limbs (prox lower extrem), variable loss of sensory, lack/loss of DTR, (*rectal tone preserved), SOB (NIF 40 |< 40 |< 40 |

|Protein |> 200 |< 200 |> 200 |> 200 |

- CT Before LP – AMS, immunocompromise, focal neuro, papilledema, CNS lesion, new onset sz, SAH

- Post LP Headache – limit with smaller needle, bevel toward head( APAP, Caffeine, Blood Patch

- Meningitis – HA, F, neck pain, AMS ( Steroids then Abx (Vanc, CTX; add Amp if Listeria) beforeCT

- HSV Encephalitis –10%; F, AMS (behavior, personality), *enceph more than meningitis* Focal Neuro Deficit (seizure, aphasia, motor weakness, hallucinations); elev RBC on CSF; MRI Temporal Lobe

- Neurocysticercosis – Taenia solium, pork; immigrants; seizure; CT/MRI Ring-Enhancing Lesion ( Bzd, Albendazole, Steroids (if edema)

- CNS Lyme – Meningoenceophalitis ( would need Ceftriaxone so need LP for dx]

- Intracranial Abscess – s/p sinusitis; HA, F, focal neuro; hemiparesis, seizure, vomiting, confusion ( CT/MRI Ring Enhancing, IV Abx (Ctx, Flagyl), Neurosurg c/s

- Bell’s – Forehead Involved(Acyclovir, Prednis; Ramsay Hunt – ear pain, facial paralysis, hearing loss

- VP Shunt Infection - #1Staph epid; External vs Internal

- Hypertensive Enceph – AMS, sz ( Nicard, Nitropruss, Lab, NTG } Dec MAP 25% or Dias 110-100

- Central – gradual onset; Vertebrobasilar Insuffic preceding ischemic CVA; difficulty rapidly alternating/finger to nose; vertical nystagmus

- Peripheral – sudden; fatiguable nystagmus; BPPV #1- Dix-Hallpike supports dx ( Epley, Mecliz; Labyrinthitis – preceded by ENT infection + hearing loss ( Steroids, Bzds

• Menierre’s disease – excess of inner ear fluid; triad of vertigo, tinnitus, hearing loss

- Primary Headaches – Migraine w/o Aura #1, recurrent ( Propranolol

- Temporal Arteritis – HA, decr vision, tender temporal artery (see Rheum)

- Cerebral Venous Thrombosis – hypercoag state (preg, ocp, previous DVTs, Factor V Leidein, AntiThomb Defic, Protein S/C Defic, Polycythem Vera); increased ICP; headache, can have sz; papilledema; CT narrow 4th ventric ( MRV

- Cavernous Sinus Thrombosis – recent URI/sinusitis/dental abscess; CN 2/3/4/6 (lateral gaze palsy#1), ptosis/mydriasis (compress CN 3) [vs. Horners – decreased sympathetic; ptosis/miosis/anhydrosis]

-Trigem Neuralgia – 5th CN V2/V3, worse tapping, R>L ( Carbamazepine#1, Gabapent, Phenytoin, VA, Baclofen, Lamotrigine, Levetiracetam; surgery for refractory

- DM Mononeuropathy (3rd CN Palsy) – ; ptosis, “down and out”; can’t adduct, depress, or elevate eye; diplopia; spares pupils (infarct in central oculomotor; peripheral fibers control pupils); unilat>bilat

- Parkinsons – Cause of death #1 Resp Failure, PNA; Levodopa SE: N/V, dysrythmias, psychosis

• Subacute Cerebellar Deg eneration –

• Wernicke’s – vitamin B1 def; opthalmoplegia, ataxia, confusion ( Thiamine, Dextrose (1-2g/kg)

• Korsakoff’s – irreversible memory loss

Psyc

[ Substance Abuse ]

- Abuse – social/medical problems resulting substance use

- Alcohol Witdrawal Syndrom– Tremors, Hallucinations, Sz, DTs; F, tachyc, tachyp, HTN ( Bzd

- Opiod Withdrawal – mydriasis, tachyc, htn( Clonidine

- Cocaine – CP vasospasm can mimic STEMI; ( Bzds

- PCP – Rotary Nystagmus, tachyc, HTN; rhabdo, sz, hypoglyc ( Bzds

[ Mood Disorders ]

- Major Depression –

- Bipolar – mania: racing speech/though

- Suicide – predictors: prior history, depressed, substance abuse, loss rational thinking, plan

[ Psychosis/Personality ]

- Schizophrenia – delusions/disorg speech/halluc/negative sx >1month; think organic if rapid, visual hallucinations, fluctuating consciousness

- NMS – rigidity, htn, tachyc, hyperthermia( Bzd, Dantrolene, Bromocriptine, Amantidine

- Antisocial – disregard rights of others

- Anorexia – body image disturbance

[ Anxiety ]

- PTSD – diffic falling/staying asleep, diffic concentr, hypervig, irritable, angry outburst, startle response

- Phobia – unreasonable feer of trigger

[ Other ]

- Somatoform – unintentional symptoms, external incentives (?); wide variety complaints, long medical history

- Malingering – intentional symptoms, external incentives

- Facticious/Munchausen – intentional symptoms, no external incentives; hospital shop, extensive medical record, often well spoken

- Hypochondriasis – fear of disease, symptoms disproportionate, doctor shopping

- Sexual Assault – perform with forensic evidence collection; if unknown status of assailant ( prohylaxis (HBV, HIV, pregnancy, GC/Chlamyd, trich/BV); don’t do routine STD testing

- Elderly Abuse – lack of family support; ulcers, bruises ( Adult protective services

- Grief – Denial, Anger, Bargaining, Depression, Acceptance

Trauma

|Inferior orbital wall |Infraorbital anesthesia, enopthalmos |

|fracture | |

|Bike handle-bar injury |Duodenum or pancreas |

[ General ]

- Hemorr Shock – I-750ml (20; II-750-1500ml (15-30%), HR>100, decr PP, RR20-30; III-1500-2000ml (30-40%), HR>120, SBP 2000ml (>40%), HR >140, SBP40, UOP neglig

[ Head ]

- Cushing’s Reflex – Increased ICP; HTN, Bradyc, Abnl Resp

- Traumatic Brain Injury, Herniation– ( Elevation of Head, Mannitol or HS to reduce ICP (indications: neuro deterioration such as dilated pupil, hemiparesis, LOC), Hyperventilate (only when pending herniation); Avoid HypoTN & Hypoxia (Secure Airway First); Reversal if on AC (FFP, PCC, IV Vit K); consider Sz prophylaxis (Phenytoin/Keppra), PO Nimodipine for spasm

- Epidural Hematoma – Temporal Lobe, Middle Meningieal Artery, crosses midline but not suture line( needs emerg nsgy

- Subdural Hematoma – Bridging Veins

- Basilar Skull Frx – hemotympanum, raccoon eyes, battle sign, CSF leak

- Postconcussive Syndrome – (Concussion – brief LOC, amnesia, no focal neuro, negative CT if indicated); headache, diffic concentrating, irritability ( Outpt W/u

[ Eye & Face ]

{Eye}

- Traumatic Hyphema – blood in anterior chamber;risk of rebleed ( Elevate Head of Bed, Avoid Antiplatelets/AC, Cycloplegics (Avoid in SCA), BB/Manitol/Acetazolamide (if increased IOP), Surgery if Grade 4

- Corneal Abrasion – pain, photophobia, tearing, FB sensation, conjunct infection; Fluorescin Uptake ( Top Abx, Anti-Pseudom for contact wearers, Cyclopleg/Top Steroids if severe pain

- Corneal Ulcer – 2/2 trauma or incomplete closure of eye; assoc with contacts; hypopyon which can cause perforation/endophtalm ( hourly top Abx

- Traumatic Iritis – painful, (consensual) photophobia, decreased visual acuity, floaters,

tearing, cillary flush (perilimbal conjunct injection), sluggish pupil, cells & flare ( Ophtho consult, Steroids, Mydriatics, Cycloplegic (Homatropine, results in non-reactive dilated pupil), Analgeiscs

- Ultraviolet Keratitis – skiers, wielders; burning, tearing photophobia; fluorescin=multiple punctuate corneal lesions ( Top Cycloplegic, Top Abx, PO analgesics, Ophtho 24hrs

- Chemical Burn to Eye – goal ( pH 7.0-7.2 irrigation; can add Top Erythromycin, add Cyclopleigic if Corneal Defect/clouding Anterior Chamber; ophtho f/u

- Globe Rupture – teardrop, massive conjunct hemorr, flat anterior chamber, chemosis, +Seidel on fluoros, can also get CT orbits ( Ophtho for surgery

- Retrobulbar Hematoma – IOP >40, proptosis, decreased vision, APD ( Lateral Canthotomy (Contraind Globe Rupture)

- Retinal Detachment – tear/hole in neuronal retina layer, generally >45yrs, men>women; painless flashes of lights/floaters, curtain-like vision loss; direct fundoscopy ( Bedside US

- Vitreous Hemorr – sudden unilateral signif vision loss; blood fills vitreous humor

- Complex Eyelid Lac – thru orbital septum, tissue loss, lid margins, levator/canthal tendons, canaliculr system (medial lower eyelid)( OMFS/Ophtho for repair

{Facial & ENT}

- Le Fort – I – Roots of Teeth thru Maxilla; II – Nasal Bridge+Maxilla+Lacrimal Bones+Orbital Floor+Rim; III – Thru Orbital Walls and into Zygomatic Arch

- Tripod Frx / Zygomaticomaxillary Complex – Lateral Orbit, Zygoma, Maxilla; face sinks

- Orbital Fracture – thinnest=Inferior/Medial; infraorb anesthesia, subcut emphysema, binocular diplopia on upward gaze (inferior rectus entrapment); 33% assoc ocular injuries (traumatic iritis, retinal detachment) ( CT Orbits

- Blowout Fracture – Inferior Orbital Wall, Maxillary Bone#1; direct blunt; upward gaze diplop, decreased EOMI (entrap inferior rectus), periorb ecchymosis, eyelid edema, subconjunc hemorr

- Open Mandible Frx – pain, malocclus, inability bite down , anesthesia (CT, Abx, Admit

- Avulsed Teeth – do not replace if primary; Storage ( Milk, Saline; Adult 60min (Citric Acid/Fluoride, C/s OMFS

- Dental Frx – I – Enamel(smoothen, dental f/u; II – Dentin(smoothen, apply CaOH or ZnOH + alum foil, dental f/u; III – Pulp (dental c/s for pupotomy

- Nasal Hematoma – risk of deformity if not corrected ( I&D, Pack, Top Abx

- Auric Hematoma – cauliflower ( I&D + Pressure Dressing + Next Day f/u

[ Neck Soft Tissue ]

- Zones – I-Stern to Cricoid; II-Cricoid to Angle of Mandible; III-Mandib to Mastoid Air Cells

- Hard Signs – Airway Obstruc, Cerebral Ischemia, Decr Radial Pulse, Expanding Hematoma, Fluid Non-respons shock, Severe Acute Bleeding, Vascular Bruit/Thrill

- Soft – Dysphagia, Dyspnea, FND, Hematemesis, Mediastinal Emphysema, Non-expand Hematoma, Subcut Emphysema

- #1 Cause of death=exsanguinations; #1 vessel-IJ (#1 arter=carotid)

[ Thoracic ]

- Chest Tube – 4th-5th IC @ Anterior/Mid Axillary Line; Pregnant=2nd IC

- Traumatic Hemothorax – Refractory Shock, >20ml/kg (Adult 1500ml ) initial; >3ml/kg (Adult 200ml/hr) continuous x4 hrs, whited-out even after chest tube ( Ex Thoracotomy

- Open PTX – (Occlusive dressing w/ tape 3 sides

- Flail Chest – contiguous rib fractures in multiple places, paradox movement of chest, underlying pulm contusion; may need ( Mech Vent

- Pulm Contusion – positive pressure, keep euvolemic (fluids can be harmful) ( Good Lung Down if still hypoxic

- Traumatic Ao Disruption – CXR similar to Ao Dissection but also deviation trachea to R, depression of L bronchus, elevation R bronchus, Aopulm window obscured, deviation esophagus to R, widened paraspinal interfaces, L hemothorax, Frx of 1st/2nd/Scapula

- Myocardial Contusion – risk of developing pericardial effusion approx 2 weeks after; suspect with Sternal Fracture; EKG/trop changes, need ( Echo

- Commotio Cordis – assoc Vfib more than others

- Clavicle Frx -#1=Middle Third ( Sling for Comfort, F/u Ortho; Admit if Open; 72hr Fu if displaced>2cm or shortened ( Passive ROM encouraged but not Active ROM x1month

[ Abdominal ]

- FAST Positive + Hypotension ( OR (also Peritonitis, Free Air on CXR)

- Splenic Injuries – most common blunt

- Diaphragm Injury – L(Spleen) > R(Liver) (Laparoscopy most sensitive

- Seatbelt sign –assoc Chance Frx, if US/CT negative should still ( admit (may miss hollow viscous)

- Retroperitoneal Injuries – hematuria, Grey-Turner, Cullen’s, Kehr’s (L shoulder pain 2/2 splenic)

[ Pelvic & GU ]

- Types: Lateral Compression (T-bone/ped struck side), AP (head on), Vertical (fall)

- Open Book - ( External Pelvic Binder over greater trochanters; Ex Fix/Embolize

- Isolated Pubic Rami Fx – nondisplaced(conservative with weight bearing, physical therapy

- Bladder Rupture – Extraperitoneal ( nonsurgical with Foley 1-2 weeks, possible admit; Intraperitoneal ( Surgical Repair (can lead to bacterial peritonitis) after stabilization

- Uretrhal Injury – Blood at Meatus , needs (RUG check for extravasation

- Microscopic Hematuria - >10RBCs HPF w/o gross blood; if >50RBC ( consider imaging (or if hemodynamic instability or gross); if 24weeks ( Continous Cardiotocographic Monitoring

- Escharotomy – full thickness so should be insensate; should be minimal bleeding; perform even if compartment 6mm @C2, >22mm @C6

- Pseudosubluxation- up to 3mm peds C2-C3 & C3-C4

- Neurogenic Shock – HypoTN, Bradyc, Poikliothermia; w/in 30min of injury, at or above T5, lasts up to 6 weeks ( airway, fluids, pressors, atropine [vs Spinal Shock – temporary loss of sensorimotor function below injury; flaccid paraylysis, bowel incont/urinary retention, priapism; lasts hours to days]

{Thoracic & Lumbar}

• Chance fracture – associated with bucket handle tears of the mesentery (may not be seen on CT), seatbelt signs, more common prior to the use of shoulder harnesses

Conus Medullaris = SC syndrome; has UMN defect (hyperreflexia); Cauda Equina = Nerve Root, LMN (hyporeflexia)

[ Upper Extremity ]

{Shoulder & Humerus}

- Anterior Dislocation - **Axillary N injury (sensation over deltoid, distal med/rad/ulnar)

- Hill-Sachs Deformity - #1complication 40% – depression frx of posteriolat hum head (from compression of head by lower glenoid rim); more likely with recurrent

- Bankart – 10-20% frx of anterior aspect of infer glenoid rim Greater Troch – 15%

• Milch – external rotation + abduction

- Inferior Shoulder Dislocation (Luxatio Erecta) – placed upward; **Axillary A and Brachial Plexus,

- AC Dislocation – sports, direct blow; I & II( Sling, ortho f/u couple weeks; III ( exped f/u

- Humeral Shaft Fracture – direct blow, falls, MVC; **Radial N injury (wrist drop, can’t extend fingers/thumb/wrist) ( Sugar Tong + Gravity

{Elbow & Forearm}

- Radial Head Frx – I-nondisplaced, II-min displace, III-comminuted, IV-dislocation; most ( conservative/non-op, Splint + early ROM

- Galeazzi – Frx distal Radius, Disloc distal radioulnar; **Anterior Interosseous N of Median N (paralysis of thumb/index to make OK sign) ( ORIF

- Monteggia – Ulnar Frx w/ Prox Radial disloc, **Radial N

- Elbow Dislocation – posterior 90%, Brach Artery, Med N > Ulna N (Anter Disloc&Olecrenon)

{Wrist & Hand & Fingers}

- N Injuries/Deformities >> Ulnar-Claw Radial-Drop Med-Ape

- Lunate Dislocation – FOOSH, spilled tea cup, lunate not connected to radius and volar displaced; risk of **Median N, AVN, compartment syndrome ( Hand surgen for open reduc

- Perilunated Dislocation – hyperextension; lunate connected to radius but capitates dorsally dislocated

- Scapholunate Dislocation – forceful extension; gap between scaphoid and lunate “Terry Thomas” >3mm ( Thumb Spica, hand f/u

- Colle’s – Dorsal angulation

- Smith’s – Volar angulation, **Median N injury ( Reduce, Immob in Long-arm or Sugar-tong, Ortho f/u; unstable or intraartic will need op intervention

- Scaphoid Frx – snuffbox ttp; #1Avasc Necrosis complication (>malunion)

- Boxer’s – Metacarpal neck; Allowable Angulations: Index 10, Middle 15, Ring 20, Pinky 50; No rotational is allowable

- Gamekeepr’s Thumb – Ulnar Collatoral Ligament , cannot pinch ( Thumb Spica [vs. Rolando-commin fracture/dislocation of thumb metacarpal; Bennet – same but noncomminuted] --

- Mallet Finger – DIP in flexion, can develop Swan-neck deformity

- Boutonniere – PIP flexion, DIP hyperextension

- Duputyren’s – thickened palmar fascia, nodules on flexor tendons

- Jersey Finger – avulsion of profundus tendon

• Flexor Tenosynovitis (Knavel’s signs) – (pain with passive flexion ** 1st), tender along the flexor tendon sheath, fusiform digit, held in flexion

- DeQuervains Tenosyn – thumb pain; Finklestein’s sign (held in closed fist, ulnar deviation)

- Herpetic Whitlow – grouped vesicles on erythem base ( Analgesia, clean dressing; NO I&D (PO Acyclovir controversial)

- Subungal Hematoma – blood is liquid for 36 hrs ( trephinate; nail removal if unstable fingertip (broken nail or nail edges disrupted) or signific nail bed injury; ok to trephinate even if fracture; only Abx if open fracture not over nail bed

- Paronychia – I&D, No Abx

- Felon – I&D through all pulp compartments

- Joint Sprains – I-min tear; pain on palpation; II- deep tear; pain with ROM, soft tissue swelling/hemorr; III-complete disruption; joint instability, hemarthroses

[ Lower Extremity ]

- Nerve Deficits: Superior Gluteal=Tendelenburg gait; Inferior Glut=decr hip extension; Obturator=decr thigh sensation/adduction; Femoral=decr thigh flexion/leg extension; Common Peroneal (Fib Frx)= decr foot eversion/dorsiflexion; Tibial= decr foot inversion/plantarflexion

{Hips & Femur}

- Posterior Hip Dislocation (more common)– held in hip flexion, adduction, shortened and internally rotated; **Sciatic N & **Femoral N, **Femoral Artery; risk of AVN of femoral head if >6hrs; if no pulses ( reduction without delay/XR

- Anterior Dislocation (less common) – abducted in flexion and external rotation (down and out)

• Legg-Calve-Perthes – boys > girls, unilateral > bilateral, avascular necrosis of the femoral head

{Knee & Tib/Fib}

- Ottawa Knee –exclusion if Age >55, Isolated TTP Medial Fib Head or Patella, cannot flex >90 deg, cannot ambulate 4 steps

- Knee Dislocation – suspect if unstable ligaments; assess for **Popliteal Artery injury (also pop vein, **Common Peroneal N) esp if posterior dislocation; assess for Hard Signs ( Angio; check neuro before and after reduction

- Patella Dislocation – ( Closed Reduction, XR, Knee Immobilzer, Ortho f/u

- Patella Frx – conservative vs surg; if cannot extend ( surgery

- Patella Tendon Rupture – can’t extend affected knee, high riding patella (Alta) ( Immobilize in Extension, apply Ice/compressive dressing

- Quadricepts Tendon Rupture – low riding patella

- Segond Frx – avulsion frx of Prox Lateral Tibia, assoc with ACL

- Tib Plateau Frx – subtle, assess Anter Tib Artery

- ACL – from decl/hyper-extension or marked internal rotation; hemarthroses; Lachman Test#1 sensitive (increased anterior tibial displacement)

- PCL – posterior drawer

- Medial Meniscus – McMurray Test

{Ankle & Foot}

- Achilles Tendon Rupture – r.f.=fluoroquin use; cant plantar flexion, +Thompson Test ( Posterior Splint 20-30deg flexion (equinas)

- Ottawa Ankle Rules – bony ttp distal 6cm of posterior-lateral malleolus; and medial malleolus; cannot bear weight 4 steps both time of injury and time of eval

- Maisseneuve – extenrnal rotaton mechanism; ankle + prox fib

- Ottawa Foot – bony ttp at navicular bone, base of 5th metatarsal, cannot bear weight 4 steps both time of injury and time of eval

- Calcaneal – Bohlers 30-40 or diastolic – compartment pressure 0.5)-Pustule Papule– Nodule (>0.5 )(solid superfic elev)

Mac(nonpalp) –Patch(barely elev)-Plaque(plateau) Petechiae – Purpura -Ecchymosis

• Erythema nodosum – tender, subcutaneous fat inflammation, No known cause, Drugs (OCPs, sulfa, PCN, vaccines), Other (TB, herpes, EBV, pregnancy), Strep/sarcoidosis, UC, Malignancy (leukemia, lymphoma)

[ Bacterial Infections ]

- Nec Fasc – I-Polymicrob, II-GAS; pain out of proportion, F, edema/erythema, crepitus; gas in soft tissue on XR ( Abx, Surg c/s

- Fourniers Gangrene – Bact fragilis, E coli; perineal, groin discolor, crepitus ( Abx, Surg

- Vibrio vulnificus – ingestion seafood/water; can lead to cellulitis, hemorr bullae, Nec Fasc

- Cellulitis – r/o lymphad; poorly demark borders, Simple(Kef/Amox/Diclox; Pen Allergic(Clinda/Erythro/Azithro; MRSA(Bactrim/Doxy

- Impetigo – Staph>S pyo; honey crust, can cause PSGN ( Top Mupirocin

[ Fungal and Other Infectious ]

- Tinea Versicolor – can have Patch (Selen Sulfide

- T Capitus –can develop kerion; need system AF + Shampoo + Steroids

- T Corporis – central clearing, scale, raised margin

- Infantile Seborr Dermatitis – cradle cap, honeycome disease; 60yo; bullae; Nikolsky neg ( Steroids, Immunosup

- Psoriasis – well-demarc plaques/pauples with silvery white scales on extensor surfaces; Auspitz=bleeding when remove

- Melanoma - #1 Cs skin CA death; good prognosis if caught early

[ Other ]

- Allergic Contact Dermatitis – poison ivy; linear eruption pruric ( System Steroids 2-3wks

- Eryth Multiform – erythem popular, most commonly hands/forearms; target lesions surrounded by pale ring and erythem halo; hypersens to meds (sulfa, pen, barbs, pheny), infxn (herpes, mycoplasma), malignancies, collagen vascular

- SJS – 30%; both +Nikolsky ( IVF, Burn ICU, Infx control

- Eryth Nodosum – delayed hypersen to infx, drug (sulfa, pen, ocp, phenytoin), systemic disease; tender subcut nodules w/ blue hue when resolve; pretibual most common; arthrlagieas seen in 90% ( self limited, NSAIDs for arthrlagias

- Eryth Migrans – from Lyme; most commonly central clearing

- HSP – s/p URI; F, abd pain (r/o Intussus), arthritis, hematuria; palp symmetric rash legs/buttocks (NSAIDs, dapsone, prednisone; most resolve w/in 6-8 weeks

ENT(Non Traumatic)

[ Ears ]

|Malignant Otitis Exeterna |Facial nerve, Pseudomonas, DM |

- OM - #1 organism = Strep pnuemo; #1 complication = perf; if Hemorr Bullous Myritis think Strep or Mycoplasma

- Mastoiditis – Complic of OM; otalgia, F, HA, postauric erythema/ttp ( Abx; ENT c/s if Abx fail

- OE - #1 Pseudomonas; otorrhea, otalgia, pinna ttp ( suction, gentle warm irrigation, Acetic Acid otic washes, Top Abx (Neomycin/Polymyxin/Hydrocortisone) Suspension

- Malignant OE – immunosupp (DM, HIV, elderly); severe pain and pruritus, hyperacusis, foul-smelling otorrhea, HA, auric swelling; complications: CN/Osteo/Mening/Brain Abscess/Sigmoid Sinus Thrombosis ( IV Abx (Fluro- Cipro), Surgic c/s, Debride

- Cholesteatoma – keratinized squamous epithelium in middle ear; conductive hearing impairment

- TM Perf – 2/2 direct trauma, blast, barotraumas ( keep dry, analgesics, ENT f/u

[ Nose ]

- Mucormycosis – black sputum

- Cavernous Sinus Thrombosis - #1 Staph; sinusitis or midface infection; HA, periorbital edema, CN 6#1 (others 2, 3, 4) ( CT, MRI

- Epistaxis – Anterior=Kiesselbachs; Posterior=Sphenopalatine; TSSS with poster packing

- Sinusitis – often viral (analgesics/antipyretics/decongestants; bacterial suggested if not improved after 7 days ( Abx (Amox)

[ Throat ]

- Ludwig’s Angina – cellulitis of submandib/sublingual/submental spaces; trismus, F, dysphonia, odynophagia; posterior displacement of tongue; assoc with laryngospasm ( emergent ENT/OMFS; BS Abx, OR for Airway if severe (or Fiberoptic)

- Quinekes – Uvula swelling, treat like anaphylaxis

- Branchial Cleft Cyst = Lateral Thyroglossal Cyst=Midline

- Peritonsillar Abscess – complic of acute tonsillitis; trismus, drooling, tonsil asymmetry,/exudates, cervic lymphad (needle aspiration/I&D + Abx if cellulitis

- Pharyngitis – most viral, bacterial is GAS ( Dexameth can reduce pain

- RPA– see peds

- Epiglottitis – sore throat, drooling, muffled sounds; XR=thumbpint(Abx, Fiberoptic

[ Mouth ]

- Parotid Stone (Sialolithiasis) – most commonly submandib firm/tender mass changes in size with eating (as opposed to tumor) (most pass on own, aid with sialogogues (sour lourenges)

- Mumps – nonsuppurative parotid swelling

- Parotitis – supparrative: Staph, S pyogenes, Hi (anaerobes) ( Augmentin/Unasyn

• Alveolar osteitis = dry socket; s/p 3-5d ( irrigate, gauze pack, dental paste, +/-Abx

- Acute Necrot Ulcerative Gingivitis (Trench Mouth) – poor hygein; anaerobic fusobacterium and spirochetes; painful, edematous, ulcers, pseudomembrane, foul smelling, metallic taste ( warm saline irrigation, Abx (Pen, Clinda, or Flagyl), Hydrog Perox/Chlorhex rinses; Dental f/u

- Periapical Abscess – assoc w/ carries ( Abx (Pen), Dental 48hrs

Optho (Non Traumatic)

|Box-carring of retinal vessels, sudden |CRAO |

|painless loss of vision | |

|Cells and flare |Uveitis |

|Fat through eyelid wound |Ophtho consult |

|Floaters, curtain over vision |Retinal detachment |

|Pseudodendrites, Hutchinson’s sign |Zoster opthalmicus (VZV) |

|Dendrites |Herpes keratitis (HSV) |

|CVST (MRI/MRV) |“Empty delta sign;” CN IV palsy (trochlear) – superior oblique |

| |paralysis, so the eye is stuck looking upwards |

|Walked into dark movie theater |Acute angle closure glaucoma |

[ Decrease Vision ]

• CRAO – “boxcar-ing” of the retinal vessels, “cherry red spot,” pale macula, sudden, painless ( optic massage, Acetazolamide, Timolol, CO2 (paper bag)

• CRVO – “blood and thunder,”sudden, painless, assoc DM/HLD ( urgent ophtho f/u

• Acute angle closure = IOP>20, closure of anter chamber, severe pain, vision loss, HA/N/V; red/firm to touch globe, steamy/hazy cornea, dilated pupil (Reduce IOP: Pilocarpine, Timolol, Predniso, IV Acetazol, Mannitol

- Endophthalmitis – inflamm/infectious vitreous/aqueous humor of globe; often 2/2 surgery or penetrating trauma or hematog spread; eye pain, decreased visual acuity, photophobia, discharge, loss of vision, headache; eyelid edema, sclera injection, chemosis, hypopyon (wbc in anterior chamber) ( Opth c/s, Intravitreal Abx

- Optic Neuritis – painloss of vision from demylin of Optic N; assoc MS; APD

- Amarosis Fugaz – shade coming down

- Sublux/Displaced Lens – monocular diplopia

[ Red Eye ]

- Conjunctivits – FB sensation, drainage, lid swelling, crusting; allergies; Viral (#1Adenovirus) ( Cold Compresses, Artificial Tears; Bacterial(Polytrim

- Subconjunct Hemorr – blood vessels rupture; spontaneous or valsalva or trauma; painless/no visual loss/photophobia; is flat, bright red, doesn’t cross limbus ( Reassure

- Scleritis – painful sclera ( cyclopleg, steroids, oral NSAIDS

- Episcleritis – painless (but if pain treat with steroids) ( Artificial tears, Warm Compresses

[ Other ]

- Ptergium – begning conjunct growth, medial sclera, fb sensation [vs Pinguecula-not cornea]

- Blepharitis=eyelid inflamm;

- Stye/Hord =eyelid margin, oil gland infxn;(WC; Chalazion=middle, cyst (WC, Top Abx

- Dacrocystitis–infx of lacri sac 2/2 obstruc; Staph; swell/red/pain (TopAbx, +PO Unasyn/Augmentin Optho Referral, WarmCompress [vs Dacryoadenitis – superolateral orbital pain/swelling ( Warm Compresses; Abx if infxn]

- Orbital Cellulitis – complic of ethmoid/max sinusitis; F, eyelid swell/pain, restricted eye move, proptosis, decr visual, painful/limited eye move, delayed pupils(CT, Admit, Abx

Misc

35°C/95°F< NORMAL TEMPERATURE (37°C) < 38°C

|Drugs that can be delivered down the ETT |

|Adult |Pediatric |

|Naloxone |Lidocaine |

|Atropine |Atropine |

|Vasopressin |Naloxone |

|Epinephrine |Epinephrine |

|Lidocaine | |

| | |

| | |

Most common calculations

• AG = Na – [Cl+CO2]

• OSM gap (normal 285-295) = [2 x Na] + [BUN/2.8] + [glu/18] + [ETOH/4.6]

• TBW = Wt(kg) x 0.6

• Water deficit = TBW x [1-(desired Na/current Na)] replaced over 48 hours

• Parkland = 4cc x wt(kg) x BSA per day of LR, with ½ the volume given in first 8hr

• MAP = DBP + (SBP-DBP)/3

• Peds ETT size = UNCUFFED age/4 + 4, CUFFED age/4 + 3 or 3.5; depth = 3x tube size [cricoid ring = narrowest area]

• A-a gradient – normal is 5-10

• For every 100mg/dL glucose above 100mg/dL, Na+ ⎢ by 1.6mEq/L

• Factor replacement: Wt (kg) x 0.5 x %Δ factor OR wt (kg) x 50 for 100%

• LP: Allowed 1 WBC per 1,000 RBC in traumatic tap

• FeNa = [(urine Na)x(plasma Cr)]/[(urine Cr)x(plasma Na)]

Criteria

• DPL ( +10mL blood

• < 34 weeks EGA = betamethasone

• SPB = > 250 PMNs

• Ranson’s Criteria – age > 55, WBC > 16, AST > 250, LDH > 350, glu> 200; 48 hours – Ca< 8, ⎢ΔHct> 10%, PaO2 < 60, base deficit > 4, ⎡ΔBUN > 5, sequestered fluid > 6L

• Jones Criteria – rheumatic fever from GAS, dx need +GAS test AND 2 of following: Joints ** (most common), Oh, no—carditis, Nodules, Erythema marginatum, Syndenham’s chorea; tx penicillin, high-dose ASA, steroids for carditis or chorea

• SIRS: HR > 90, T < 36°C (96.8°F) or > 38°C, RR > 20 or PaCO2 < 32, WBC > 12 or < 4 or > 10% bands

• Septic joint (> 50,000WBC

• Septic bursitis ( 10,000 WBC

• Level 5 = HPI 4, ROS 10, PFSHx 2, PE 8

• Level 3 = HPI 1, ROS 2, PFSHx 1, PE 2

• Maximum dose of lidocaine for local anesthesia 3-5 mg/kg

• Light criteria (one or more of the following = exudate): Protein pleura: protein serum> 0.5;

LDH pleura : LDH serum> 0.6; LDH pleura> 200

• Hard signs of vascular injury: expanding hematoma, pulsatile blood loss, palpable thrill, “six Ps”

Classic comparisons

• SSSS vs. TEN – SSSS no mucous membrane involvement, +Nikolsky (superficial layers of epidermis only)

• ITP vs. TTP – ITP PLT < 30 = steroids + IVIG; TTP = fever + MAHA + thrombocytopenia + ARF + AMS

• EM vs. SJ vs. TEN – SJ min epidermal involvement 10% TBSA, TEN 30% TBSA; all may have mucosal involvement

• Heat stroke vs. heat exhaustion vs. heat cramps – stroke = mental status change, ataxia, organ damage; exhaustion = dehydration, n/v, weakness; cramps = cramps

• HAPE vs. HACE vs. HAFE – dexamethasone once severely symptomatic

• Neurogenic shock vs. spinal shock – neurogenic is a type of shock, function of a loss of a sympathetic outflow—thoracolumbar region, must be a higher lesion than the T spine; spinal shock isn’t really shock, but “stun”

• TRALI vs. TACO – TRALI (is like ARDS) associated with hypotension, whereas TACO is associated with a rapid rise in blood pressure, higher association with platelet and plasma transfusions, begin during transfusion or within 6 hours

• SS vs. NMS – MAOI + SSRI = SS, myoclonus, hyperreflexia, Demerol, cyproheptadine to reverse effects; NMS with antipsychotic medications, “lead pipe” rigidity, bradykinesia, bromocriptine to reverse effects

• Physostigmine vs. pyridostigmine – physostigmine controversial for use in anticholinergic toxicity, may cause dysrhythmias and seizures

• HSP vs HUS – HSP has PALPABLE PURPURA, vasculitis; HUS E. coli OH157

• E. multiforme = target lesions, palms/soles (hypersensitivity reaction to meds and some infections)

E. marginatum = rheumatic fever, migratory

E. nodosum = nodules, arthralgias

E. migrans = Lyme disease, expanding red lesions with “central clearing”

• Condylomataacuminata = HPV; condylomatalata = 2°syphilis

• Chalazion= meibomian/Zeis gland, UNDER lid; hordeolum (stye) = eyelash follicle, painful, meimobian gland, OVER lid

• Competency = legal term; capacity = medical term

• Hodgkin’s = localized LAD/neck mass, teenagers, Reed-Sternberg cells; NHL = extranodal involvement, school-aged children, EBV

• Breastfeeding jaundice = < 7d, unconjugated; breast milk jaundice = > 7d, unconjugated

• Jones = midshaft 5th metatarsal fracture( NWB; pseudo-Jones = avulsion fracture 5th metatarsal( WBAT

Classes of evidence

• I: supported by large body of evidence with consistently positive results

• IIa: similar to I but lacking in large randomized controlled trials

• IIb: generally, but not consistently positive results

• III: unacceptable and sometimes with evidence of harm

Malpractice coverage

• Occurrence-based = tail coverage

Four elements of medical malpractice

1. A duty was owed – a legal duty exists whenever a hospital or HCP undertakes care or treatment of a patient

2. A duty was breached – the provider failed to conform to the relevant standards of care ** for a successful malpractice settlement against a physician, plaintiff must prove breach of duty

3. The breach caused injury –the breach of duty was a direct and proximate cause of injury

4. Damage – without damage, there is no basis for a claim, regardless of whether the medical provider was negligent; likewise damage can occur without negligence

Categories of drug safety in pregnancy

A. Adequate and well-controlled studies in humans fail to demonstrate risk

B. Animal studies fail to demonstrate risk

C. Animal studies have not been conducted or indicate fetal risk. Acceptable for use if benefits > risk.

D. Positive evidence of fetal risk in humans. Acceptable if benefits > risk.

X. Risk clearly outweighs benefit

N. FDA has not classified the medicine

Procedures

- Peds Cric – needle for 5days, ?Myasthen Gravis?; lower dose for Eaton-Lamb/Hypothy/Organophos; lasts 3-5min (Roc=20-75)

- PTA – avoid carotid (lies lateral, posterior); aim superfic and medially

- Escharotomy – medial & lateral in extremities

- Venous Cutdown – Greater Saphenous: Anter/Super to Medial Mall

- Thoracentesis – Midscapular line 1-2 spaces below dullness (lowest=8th ICS)

- Pericardiocentesis Complications – Subxiphoid=RA injury; PS=Ptx, Internal Mammary A (1-2cm from sterna)

- Arthrocentesis – Ankle: Medial Mal medial to tibialis anterior tendon direct toward mal

- TV Pacemaker – RIJ, L Subclavian

- Facial Blocks: Supraorbital – forehead; Infraorbital-midface/lower eyelid/cheek/nose/upper lip; Mental-skin of chin/lower lip; Inferior Aveolar-mandible/lower ramus/mandib teeth/floor of mouth/anterior 2/3 tongue

- Amides=2 I’s (Lidocaine); Esters=1 I (Procaine); Benzocaine can cause Methemoglob

- Needlestick – Tenofovir+Emtricitabine+Raltegavir; window w/in 72hrs (but w/in 2 hours most effective); for 4wks

- Nursemaids – Suppinate+Elbow Flexion; or exteme Pronation

- McMurray – for meniscus injuries

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