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On our first core episode this season, we are going to get into a high yield review of the topics on the Emergency Medicine EOR blueprint going in descending order of the category percentages included on the exam. Access the full transcript on the website at www.paspacpodcast.com including links to all the sources used or mentioned on the show.
Itinerary
CARDIO -Topics include Chest Pain, Arrythmias, Cardiac Tamponade, Angina, and more.
ORTHO/RHEUM - Topics include Non-traumatic swollen joints, Arthritis differentials, infections, injuries, and more
GI/NUTRITION - GI Bleeding, Acute Abdomen Differentials, Gallbladder Diseases, and more
PULMONARY - Topics include Shortness of Breath, Pneumothorax vs. Tension Pneumothorax, Infections, and more
NEUROLOGY - Headache Differentials, Intracranial Bleeds, Strokes, and more
HEENT - Red Eye Differentials, Otitis Media, and more
MISC - Remainder of lower percentages topics on the EOR including GU, OBGYN, Psych, and Heme
RAPID REVIEW - 23 Mixed EM Questions
INTRO
Hey everyone and welcome to the show. We have a lot to cover here to prep you for your Emergency med module exam or EOR. I’ll be going in the descending order of the topic percentages from the EOR blueprint. Keep in mind, This will be a compilation of high yield, but not all encompassing or we’d be here all day. With that being said, lets get started with some high yield cardio
CARDIO
What are some differentials for chest pain?
Chest Pain Differentials (Regional; Cardiac (angina, pericarditis, arrythmia etc.), Vascular (aortic aneurysm), Pulm. (pneumonia, pleuritis), MSK (costochondritis), GI (esophageal spasms, GERD, esophageal rupture)
What are some test you can do to rule out life threatening chest pain differentials?
#1 = Good H&P – Is it reproducible with palpation? sudden/chronic, worse with exertion or deep breathing, associated with meals? Has this happened before? Do you see a rash (ex. herpes zoster) or associated injury like the seat-belt sign (after car accident)?
EKG – Assess Conduction
Echo – Asses cardiac structure/ valves (access valves with TEE or pericardium with transthoracic, pleural fluid, etc.)
Cardiac Enzymes – Cardiac Injury, trend these overtime
CXR – Cardiopulmonary processes, broken ribs, PTX
If cardiac suspected, you can get additional diagnostics/therapeutics started including Holter monitor (conduction), NST (angina), or sending for coronary cath
If the problem is more difficult to identify, you may choose to get more imaging like a Chest CT or CT-Angiogram
Your job in ER is to stabilize the patient, initiate the work up/ treatment if possible, and get consults if needed.
Lets get into some high yield cardiac case questions
What do you expect to see on an EKG in a patient with abrupt onset of HR > 150 secondary to a re-entrant pathway in the AV Node?
Narrow complex tachycardia with shortened or absent PRI, AKA paroxysmal SVT.
MCC of SVT is AVNRT which is re-entrant pathway in the AV node. It is also to have a reentrant tachycardia originating outside of the AV Node.
What condition puts a patient at increased risk of a re-entrant tachycardia due to accessory pathway?
Wolff Parkinson White, while not an SVT itself, can increase risk of an re-entrant tachycardia via the accessory pathway named “Bundle of Kent”. High yield EKG findings in WPW is a shortened PRI and long QRS showing delta waves.
What treatment should you initiate in an unstable patient with PSVT?
Synchronized Cardioversion at 100 J (unstable gets the cable)
If they were stable, you could attempt vagal maneuver and then give a rapid 6 mg bolus of IV Adenosine and bump to 12 mg if still in SVT. Successful about 85-90% of the time. Definitive treatment is radiofrequency ablation
What is the most commonly treated cardiac arrhythmia?
Atrial Fibrillation
A stem will typically present with a middle aged or older patient that have paroxysmal fluttering in their chest or shortness of breath. You will usually be given an EKG to interpret, showing an irregularly irregular rhythm with an absence of identifiable p waves. If it is over 100 bpm, the diagnosis is Afib with RVR so make sure you can interpret heart rate.
Another common question regarding a patient with Afib is about cardioversion vs. anticoagulation. If a patient has been in afib for 48 hours, do not attempt cardioversion – they HAVE to be put on anticoagulation for about 4 weeks to decrease their risk of stroke as a complication. You could also order a TEE to rule out a clot before cardioversion if you want to treat earlier than waiting for a/c. Clots from Afib are most commonly found in the LAA. Also, want to keep in mind that RATE control is first and RHYTHM control is second.
What common endocrine diagnosis is associated with Afib?
Clinical or subclinical hyperthyroidism should be considered in new onset AFib. Get TSH and free T4 level to evaluate for this.
Hyper = fast, high metabolic aka high HR -> atrial quivering
What screening tool is used to clarify atrial fibrillation stroke risk?
CHA2DS2-VASC Score
What is Holiday Heart?
Afib secondary to alcohol (usually from binging night/weekend before)
Your 32 year old female patient comes into the ER with fever and chest pain that is worse with breathing and improved with sitting up and leaning forward. Auscultation over the LSB reveals a superficial scratchy sound. EKG shows new global ST elevation and PR depression. CXR is normal and labs reveal leukocytosis. She is stable otherwise. Suspecting the most common etiology for her presentation, what do you recommend as treatment?
For nearly all patient’s with acute idiopathic or viral pericarditis, treatment with NSAIDs and colchicine should be initiated. If NSAIDs are not indicated, can use steroids.
Acute pericarditis is the most common disorder involving the pericardium. It is associated with various underlying disorders such as infection or malignancy. In developed countries, most common cause is viral (ex. coxsackie).
Suspect this diagnosis in stems with chest pain relieved by sitting forward and worsened by breathing, pericardial friction rub, global ST changes, +/- pericardial effusion (not required for dx, but common)
Cardiac tamponade rarely occurs in acute idiopathic/viral pericarditis but should be watched out for especially in those with hemodynamic compromise, malignancy, TB, or purulent pericarditis.
If pericardial effusion is present, you may need to drain via. pericardiocentesis. If recurrent, consider pericardial window.
What are the signs and symptoms of a cardiac tamponade?
Acute CT is life threatening and occurs rapidly and patient may have CP, Tachypnea/Dyspnea. Pulse pressure is NARROW (preload is decreased and afterload is increased 2/2 constriction). Pulsus paradoxes (large decrease in SBP on inspiration) because you’re constricting the heart more as your lungs fill.
Echo may show a small effusion due to stiff pericardium. In Chronic pericardial effusions, the body compensates to allow for a large amount of fluid.
Beck’s Triad: JVD, Hypotension, muffled heart sounds
Your 56 year old male patient arrives to the clinic due to new episodes of tightening chest pain when mowing his lawn, which resolve with rest and never exceed 20 minutes. Which treatment should be given as first line to REDUCE anginal episodes and improve exercise tolerance?
Beta-Blockers: in addition of controlling angina, also improve survival in patients with hx of MI and those with systolic heart failure. Cardio-selective BB include atenolol or metoprolol. Consider CCBs or long-acting nitrates in those that cannot tolerate beta-blockers.
BB contraindicated with Prinzmetal angina, so read stem carefully
To further reduce risk of cardiovascular events and disease progression, all patients with chronic coronary syndrome (unless contraindications exist) should be started on ASA, lipid lowering therapy (ex. statins), and potentially ACE/ARBs if comorbidities with HTN, DM, or CKD.
You can Rx short acting nitrates (SL nitro) to treat acute anginal symptoms. But remember, this just treats the pain associated with the vasoconstriction and does not reduce future events, offer overall cardioprotection, nor treat underlying condition.
You can reduce risk of adverse cardiovascular outcomes in those with T2DM by educating on tight glycemic control and prescribing SGLT2-I (ex. empagliflozin) or GLP1 Receptor Agonists (ex. liraglutide)
ORTHO/RHEUM
Name some differentials for a nontraumatic swollen joint?
Arthritis (ex. rheumatoid, osteoarthritis, psoriatic arthritis, reactive arthritis), Septic Arthritis, Bursitis, Gout, pseudo-gout, tenosynovitis, dactylitis (ex. psoriatic arthritis, spondylarthritis, and sarcoidosis), osteomyelitis, Lyme Disease, Gonococcal Arthritis, etc.
What is the best way to work up a nontraumatic swollen joint, especially if red/angry?
H&P – has this happened before? Does the patient have any associated tophi? Did they recently ingest a lot of high purine foods like seafood/beer? Is the patient at risk for stress fractures?
Arthrocentesis and subsequent synovial fluid analysis. Should also order gram stain & culture. If suspecting gout flare, use polarizing light microscopy to differentiate between gout and pseudo gout
Are WBCS extremely high indicating septic arthritis or is the patient febrile?
Does light microscopy reveal negatively birefringent needle-shaped crystals, indicating gout?
Or does it show positively birefringent rhomboid crystals, indicated pseudogout aka acute calcium pyrophosphate crystal arthritis.
Let’s do a couple case examples
Your 22 year old patient presents to the ER with and painful and swollen right knee. He denies any history of trauma or notable past medical history aside from recent dysuria and red eyes, which he attributed to allergies. There does not seem to be any overlying erythema. His social history is notable for multiple sexual partners. What do you suspect is the causative etiology to this patient’s presentation?
Chlamydia Trachomatis
This patient has reactive arthritis (can’t pee, can’t see, can’t climb a tree). In a stem wanting you to think reactive arthritis secondary to chlamydia, they usually give you a patient under 35 with risky sexual behavior and associate symptoms of urethritis and conjunctivitis. You can confirm with first-catch urine sample or vaginal swab and testing for chlamydia with nucleic acid amplification techniques
Stems discussing recent diarrhea symptoms in the presence of a reactive arthritis presentation should make you think campylobacter, Shigella, salmonella, or yersinia
Consider testing for HLA-B27 in patients with reactive arthritis and low back pain or bamboo spine seen on lumbar x-ray to consider underlying etiology of spondylarthritis, such as ankylosing spondylitis (AS).
Your patient arrives to the ER with an extremely painful and swollen left swollen digit. Physical exam reveals tenderness along the course of the flexor sheath with increased pain along the tendon on passive extension, fusiform enlargement is noted and the patient is keeping her finger in a semi-flexed position at rest. Given suspected diagnosis at this time, what should you initiate as empiric treatment?
This patient has infectious flexor tenosynovitis as indicated by the Kanavel Signs (tenderness of flexor sheath, fusiform enlargement, finger semi-flexed at rest, pain along tendon with PASSIVE extension) Vancomycin and 3rd-Gen Cephalosporin (ex. Ceftriaxone) IV after getting cultures – ensure the patient does not have “fight bite” or empiric treatment would change to ensure coverage of oral flora with an agent like Ampicillin-Sulbactam, Pip-Tazo, or A 3rd gen ceph + metronidazole or clindamycin to cover for anaerobes.
If antibiotics do not improve the presentation within a few days, surgical intervention is warranted, with wither tendon sheath irrigation & drainage +/- debridement or, if a more progressed stage of infection, surgical debridement of tendon sheaths and surrounding necrosis.
After a FOOSH injury, an x-ray reveals ventral displacement and angulation of the distal radial fragment. What is the type of fracture described?
Smith Fracture
VENTRAL/PALMAR displacement of the distal radial fragment is a smith fracture whereas dorsal angulation is considered a Colles Fracture (more common than smith)
Overall, radial fractures are the most common fracture of the upper extremity with FOOSH being the most common mechanism of injury
Smith Fractures are considered unstable and require referral to an orthopedic surgeon
What is the splinting technique of choice for a patient with a stable Colles fracture (dorsal angulation)
Closed reduction and immobilize with sugar tong splint
What if there the patient had a FOOSH injury with a NORMAL wrist x-ray but physical exam is notable for snuff box tenderness ?
Suspect scaphoid fracture and splint with thumb spica splint
Anatomical snuff box is located proximal of the thumb, best observed with gently bringing patient’s wrist into ulnar deviation with slight volar flexion
Blood supply can be easily compromised in a scaphoid fracture leading to avascular necrosis
Initial treatment of suspected/confirmed scaphoid fx includes thumb spica splint and NSAIDs/ICE for pain. Displaced fx should be referred for surgery.
GI/NUTRITION
What is the anatomical landmark for generally distinguishing an upper GI bleed from a lower GI Bleed?
Ligament of Treitz
The majority of melena (aka black tarry stools) originates proximal to the ligament of Treitz, while the majority of hematochezia is secondary to origination distal to this. Keep in mind that a brisk upper GIB can result in hematochezia, even though it originates proximal to ligament of Treitz.
What are some ddx for acute upper GIB?
PUD (mcc), esophageal ulcers, esophageal varices, Mallory-Weiss tears, malignancy (ex. gastric ulcers). Differentiate with history in a lot of these stems.
Test of choice for differentiating is endoscopy
What are some ddx for acute lower GIB?
Diverticulosis/ diverticulitis, hemorrhoids, anal fissure, IBD (UC > Crohn’s), angiodysplasia, infectious causes of dysentery
Colonoscopy is the initial exam of choice in acute lower GI bleed, after upper cause is excluded.
EXCEPTION if risk of perforation from colonoscopy (ex. Diverticulitis), then you'd get a CT first
Remember endoscopies/ colonoscopies are diagnostic and therapeutic
Your patient is a 30 year old female who comes into the ER with a chief concern of “vomiting blood”. When you go into assess her, you see a slightly nauseous appearing female with stable vital signs. She says she drank a significant amount last night and has been throwing up all morning when all of a sudden, she saw small streaks of blood in her vomitus. What do you suspect as her diagnosis?
Mallory-Weiss Tear – upper endoscopy can rule out other more nefarious causes of UGIB and rule in MWT by visualization of longitudinal fissures near the esophagogastric junction. You should suspect this diagnosis in a stem of a stable patient with a small UGIB and history of recent vomiting or retching. If no active bleeding is present and the patient is hemodynamically stable without high risk of rebleeding, patient can be discharged after diagnostic endoscopy.
I don’t think I’ve been asked about MWTs more in depth than knowing the history to get the diagnosis and what endoscopy would show.
Suggest being able to differentiate the appearance of EDG findings – ex. esophagitis, Barret’s Esophagus, Mallory Weiss, Esophageal Varices, ulcers, etc.
Your 10 year old patient comes into the ER due to intense abdominal pain, fever, nausea, and vomiting. His parents state this initially occurred around his belly button but has since moved into his right lower quadrant. When palpating his left lower quadrant, he states he has pain in his right lower quadrant. What is the name of this sign and what does it indicate?
Rovsing Sign ; Appendicitis
Appendicitis Is the mc indication for emergent surgery and is mcc by a fecalith.
Appendectomy should be initiated in these patients to prevent rupture. There are many different physical exam test for clinical diagnosis including, rebound tenderness at McBurney point (2/3 between umbilicus to ASIS, ~2 cm from ASIS) , Rovsing sing, Psoas sign, and Obturator Sign.
Of all the physical test names, by far the two highest yield to know are McBurney’s rebound tenderness and Rovsing sign.
What should be suspected in an altered patient with fever, RUQ pain, jaundice, and hypotension?
Cholangitis Suppurativa (aka Cholangitis with hemodynamic compromise)
Reynolds’ pentad = Charcot’s Triad, but with shock (aka HTN and AMS)
Charcot’s triad = fever, RUQ pain, and jaundice = (Cholangitis)
The most common cause of cholangitis is gallstone obstruction leading to ascending infection, most commonly secondary to E. Coli.
The initial test for these patient’s is a bedside RUQ ultrasound or CT if the US is nondiagnostic, however if asked for the gold standard diagnostic test, choose ERCP which is both diagnostic AND therapeutic
Initial tx should include broad spectrum abx like pip-tazo and definitive tx is the ERCP for biliary drainage
Recommend getting really familiar with differentiating all the gallbladder differentials. You can separate them by just a three things:
Quality of pain, presence of jaundice, and temperature
Colicky RUQ pain s/p fatty meals, no jaundice, no fever = Cholelithiasis (GS Dz)
Hx RUQ pain after meals now worse, no jaundice, has fever= Cholecystitis
RUQ/Abdominal pain with jaundice but no fever = choledocholithiasis
Presence of Charcot’s triad = cholangitis and reynalds pentad = cholangitis suppurativa
Don’t forget about gallstone pancreatitis which is due to gallstone blocking ampulla of vater or pancreatic duct leading to acute pancreatitis with an abnormal liver panel
PULMONARY
Name 5 differentials for SOB?
Asthma, vocal cord dysfunction, pneumothorax, pneumonia, pulmonary embolism, heart failure/pleural effusion or pleuritis, STEMI/ACS, croup/pertussis, retropharyngeal abscess, bacterial tracheitis, foreign body aspiration, lung cancer, tuberculosis, etc.
What would be seen on CXR for a patient with a pneumothorax?
Absence of pulmonary vasculature surrounding collapsed lung with visualized pleural outline
What if it was a tension pneumothorax?
Tracheal and mediastinal deviation TOWARD UNAFFECTED side
Stem in TPTX will also typically say something about hypotension and JVD after trauma and in the setting of absence of breath sounds on affected side or hyperresonance of percussion
Remember your ABCs for nearly all emergencies, however, if patient is in respiratory distress secondary to TPTX, standard is to relieve the PTX before performing endotracheal intubation
In TPTX, first line treatment is needle decompression in the 2ND ICS at midclavicular line with chest tube insertion occurring AFTER needle decompression.
Your 3 year old patient without a history of immunizations arrives to ER due to rapid onset of fever, drooling, and “weird choking sounds”. Physical exam reveals an ill-appearing child sitting in a tripod position with dysphonia and inspiratory stridor. Lateral soft tissue neck XR shows a thumbprint sign. What is the most common cause of suspected diagnosis?
Haemophiles influenza type B (declining in incidence 2/2 HFlu vaccine, with Staph and Strep being seen more often than before)
Avoid doing anything that is going to send the kid into respiratory distress, like using a tongue depressor to try and visualize the epiglottis. Instead, keep patient in position of comfort and consult ENT and Anesthesia for airway management in the OR.
If near-total airway obstruction, controlling airway precedes obtaining diagnosis with bag-valve mask or placement of oral endotracheal tube while awaiting surgical airway.
What is the difference in symptomology of pertussis vs. croup
Pertussis has a characteristic whooping cough usually described with post tussive emesis
Croup presents with a barking or seal-like cough with prolonged inspiratory stridor
NEURO
Name 5 differentials for headaches?
Benign HA or migraines/cluster/tension/ postdural (ex. after LP), head trauma leading to epidural or subdural hematoma or contusion, cerebral aneurysm rupture leading to SAH, infectious causes like meningitis or encephalitis, and HEENT disorders such as sinus infections, orbital cellulitis, glaucoma, etc.
How do you differentiate subdural hematoma from epidural hematoma on a head CT?
Epidural – biconvex or lens shaped (lemon) due to collection of blood limited by the cranial suture lines
Subdural – biconcave or crescent shaped (banana) due to ability to cross suture lines
Your 53 year old patient with history of HTN and Atherosclerosis is brought into the ER by her wife due to sudden onset of paralysis in her right foot and leg with associated sensory loss and lesser, mild weakness affecting ipsilateral arm. Her speech is slowed and soft and gait apraxia is seen when she tries to walk. Where is most likely location of the lesion?
Left Anterior Cerebral Artery
AKA Anterior contra-leg-eral artery
Not to be confused with MCA (affecting face/UE over LE), posterior cerebral arteries (ocular symptoms like homonymous hemianopsia, CN III palsy, etc), or vertebrobasilar (dizziness, vertigo, nausea, vomiting, or bilateral signs)
HEENT
What are you differentials for a painful red eye?
Conjunctivitis, FB or corneal abrasion/ulcer, dry eye syndrome, acute angle closure glaucoma, entropion or blepharitis leading to irritation, allergies (more likely bilateral), uveitis, iritis, scleritis (> episcleritis), endophthalmitis , infectious keratitis
Painless red eye differentials include conditions like subconjunctival hemorrhage and episcleritis or even potentially hypervascularity by pterygium or inflamed pinguecula
Which painful red eye differentials require emergent intervention due to risk of vision loss ?
Acute angle closure glaucoma – tx w with pressure lowering agents (topical and systemic) with same-day laser iridotomy
Endophthalmitis – can be evident by hyphemia (blood in a/c) or hypopyon (pus in a/c) and requires emergent ophthalmic evaluation for intraocular aspiration and culture / abx admin
Iritis – should be seen by ophthalmologist within few days to treat, usually with steroids
Infectious keratitis – ex. secondary to contact lens use leading to p. aeruginosa infection or herpes simplex keratitis classically described with branching-opacity seen with fluorescein stain
Scleritis – Refer within a few days and consider systemic disease as underlying etiology
Your 2 year old patient is brought into the ER due to a fever. Her mom says she has been excessively crying and pulling at her left year. Visualization with the otoscope reveals a bulging tympanic membrane and middle ear effusion. Though she appears uncomfortable, she is non-toxic appearing and vital signs are stable. What is the mainstay of treatment for suspected diagnosis?
Pain management with analgesics like PO ibuprofen/Tylenol. If unresponsive to pain management, therapeutic tympanocentesis may be considered.
Antibiotic therapy is also recommended over observation for other patients as well due to quicker symptom resolution, but some families may reasonably choose to observe > treat with abx if they are over 2, unilateral AOM without severe symptoms or otorrhea.
Abx of choice in AOM is HD Amoxicillin or Augmentin
MISC
What should be suspected in a teenager abrupt onset of severe scrotal pain, nausea, and vomiting and how is it diagnosed?
Testicular Torsion PE will likely show edematous and indurated scrotum that does NOT improve with scrotal elevation (for example, like the way it would in epididymitis – called the Prehn sign) and absent cremasteric reflex.
Diagnosis can be made clinically with prompt urologic/surgical consult. If clinical findings are not definitive, use of a color doppler ultrasound revealing decreased perfusion or twisting of spermatic cord warrants emergent surgical consult with detorsion performed within 6 hours.
Manual detorsion can be attempted prior to surgery if emergent OR is not rapidly available.
Definitive tx is surgical detorsion and orchiopexy or orchiectomy if the testicle is nonviable.
Your 27 year old female patient with PMHx recurrent UTIs comes to the ER with fever, chills, and intense flank pain, nausea, and vomiting. Physical exam is positive for ipsilateral costovertebral angle tenderness. What is your top differential?
Acute Pyelonephritis should be your top ddx for a patient with risk factors for ascending infection (ex. recurrent UTIs), fever, and CVAT.
Send urine for urinalysis and culture/susceptibility testing (+ pyuria and bacteriuria)
CT may be warranted, but normal CT does not rule out mild pyelo.
To admit or not admit
Generally, you should admit all toxic appearing (aka septic or critically ill) patients or pregnant patients with pyelonephritis. Also, if PO is compromised due to nausea/vomiting, they’ll need to stay until able to tolerate PO.
Tx is usually with broad spectrums that have good gram negative coverage like ceftriaxone or piptazo
When should you suspect placental abruption over placenta previa?
Painful third trimester bleeding - particularly if history of HTN or recent cocaine use
What are the 3Ds of endometriosis?
Dysmenorrhea, Dyspareunia, and Dyschezia/Diarrhea
Also associated with dysuria, abdominopelvic pain, AUB, and chronic fatigue
Can only be definitively dx by visualizing ectopic endometrium via laparoscopy or histological evaluation of biopsy
What diagnosis should be considered in a patient who reports 7 days of expansive and elevated mood, decreased need for sleep, pressured speech, goal-directed behaviors, decreased inhibitions, with or without features of psychosis?
Bipolar type I – type I is 7 days or mania with presence of psychotic features
Type II is at least 4 days and has predominating MDD with episodes of hypomania
Which hematologic diagnosis can result in pruritus from taking a hot shower?
Polycythemia Vera – symptom is called aquagenic pruritus
PV is chronic myeloproliferative neoplasm 2/2 clonal proliferation of myeloid cells
other key findings are erythromelalgia (burning pain in feet/hands with erythema, pallor, or cyanosis but palpable pulses), transient visual disturbances like amaurosis fugax, and epigastric/GI pain
PE usually notable for palpable spleen
Labs will show increased RBCs/hct/hgb, plt +/- wbcs and peripheral smear usually shows thrombocytosis. Bone marrow aspiration will be hypercellular. HY clonal marker for this dx is JAK2 Mutations.
HY tx to know is Therapeutic phlebotomy and LD ASA
Rapid Review Questions
1. MCC Volvulus - Sigmoid Volvulus (suspect in elderly patients with hx constipation and bent inner tube appearance on KUB, in which loop points toward RUQ)
2. What is the MCC of Acute Coronary Syndrome?- Arthrosclerosis leading to thrombus obstruction of the coronary arteries
3. What is the most definitive treatment for Benign Paroxysmal Positional Vertigo? - Epley maneuver (don’t confuse with the test for dx, which is the Dix-Hallpike test)
4. MCC SBO? – mechanical obstruction from adhesions s/p abdominal surgery
5. What is the MC symptom of PE? Dyspnea
6. What is the MC Sign in PE? Tachypnea
7. What drug is a contraindication for a pt with SL Nitro? - ED Meds, aka. PDE-5 inhibitors like sildenafil or tadalafil.
8. Which diagnosis should be suspected in patient with decreased GFR, proteinuria on UA and positive RBC casts ~3-6 weeks after impetigo infection? - Acute Poststreptococcal Glomerulonephritis – also suspect if 1-2 weeks after pharyngitis
9. What is the most common cause of hematuria? UTI (mcc uti = e.coli which is also mcc prostatitis)
10. What should be suspected in a patient complaining of sudden onset of flashes and floaters in one eye with black curtain appearing to encroach into their visual field? - Retinal detachment (non-painful, not typically red unless a/w trauma)
11. What is the first line treatment for active seizure? - Benzodiazepine (preferably Diazepam or lorazepam) – obviously ensure ABCs first and foremost
12. What is the classic triad of sx seen in intussusception?- Colicky abdominal pain and vomiting, palpable sausage shaped abdominal mass, and currant jelly stools
13. What diagnosis is evident by a lateral soft tissue neck x-ray showing a thumbprint sign? - Acute Epiglottitis
14. Which diagnosis should be considered in a pt with bitemporal hemianopsia?- Pituitary adenoma (presses on the optic chiasm)
15. What is the most common injured vessel in acute subdural hematoma?- Tearing of the bridging veins, located between arachnoid membrane and dura (slower bleed), correlate with symptomology
- MCC Epidural bleed – injury to middle meningeal artery (faster bleed)
16. What is the difference between an incarcerated and strangulated hernia?
- Incarcerated = trapping of hernia contents without ability to reduce
- Strangulation = Occurs when trapped hernia contents have compromised blood flow due to increasing edema which results in ischemia and necrosis
17. What is the sign on PA soft tissue x-ray of the neck indicative of Croup?- Steeple Sign – subglottic narrowing distension of hypopharynx
18. What is the most common cause of an acute upper GI Bleed?- PUD – most commonly caused by infection with H. Pylori
- Duodenal most common and will present with symptoms that are better with food and worse a few hours after eating (“Cram The PANCE “Dude, Give me Food”). Gastric ulcers, which are worse with food and improved by not eating, are more nefarious than duodenal ulcers because of their connection with for gastric cancer.
19. What is the most common complication of a lumbar puncture?- Postdural headache – prevent with higher gauge smaller caliber non-cutting needle (Pencil Point Witacre or Sprotttle). If intractable and debilitating, can perform epidural blood patching. Otherwise, tx with bed rest, hydration, NSAIDs, +/- IV Caffeine.
20. What is the first line treatment for scabies? - Permethrin 5% lotion for pt and close contacts – safe for infants
21. ST elevations in which leads indicate obstruction in the right coronary artery. - Inferior leads – II, III, AVF
22. Entrapment of which extraocular muscle presents with a classic upward gaze deviation from an orbital floor fracture? - Inferior rectus muscle
23. Which mood stabilizer is classically associated with an adverse effect of nephrogenic diabetes insipidus? - Lithium – also causes adverse effect of hypothyroidism
Resources
· Cardio Resources
· Ortho/Rheum Resources
GI/NUTRITIONAL
PULMONARY
NEURO
HEENT
MISC
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