Emergency MedicineBoard Review

Tiffany Allen PA-C

Case Study 1

History of Present Illness:

-A 50 y/o male presents

to the ER with chest

pain x 2 days

-Located in the left side of his

chest radiating into left

shoulder

-Constant, sharp, stabbing

-Gradually getting worse

-Severity 8/10

-Nothing really helps to

alleviate the pain, he took a

Nitro at home but it didn’t help

-When I lay down it seems to

get worse

Review of Systems: +Fever (Subjective)+Dry, non-productive cough+ “hurts to breath”

-No diaphoresis -No palpitations

Past Medical History: -DM II -High cholesterol -MI 6 weeks ago with angioplasty, -GERD

Social History: -Smokes ½ PPD x 30 years -Drinks ETOH socially (3 beers/weekend)

Physical Exam

-Vitals: BP: 110/60, HR 100, T 99.9, RR 20, O2 sat 97% RA

-General: A&O x3, moderate distress, holding chest, leaning forward

-EENT: Normal limits

-Neck: supple, no lymphadenopathy, no bruit

-Heart: Friction rub noted at left lower sternal border, muffled with distant heart sounds

-Lungs: Decreased otherwise normal

-Abdomen: soft, non tender, nondistended, + BS x 4 quadrants

-Extremities: Non tender, no pedal edema

Diagnostic Work-up

-CBC, BMP, Cardiac Enzymes

-Sed rate (ESR), C-reactive protein

-Chest x-ray

-EKG

-Later may consider an echocardiogram

EKG

Diagnosis

Pericarditis-Dressler Syndrome (Post MI Pericarditis): thought

to occur from immune system attacking the damaged area.

Pericarditis

-Usually Viral (Coxsackie, Echovirus-Most Common)

-Associated with:

-Cancer

-Autoimmune Disease

-Rheumatic Fever

-TB

-Hypothyroidism

-HIV/AIDS

-COMPLICATIONS: Arrhythmia, Cardiac Tamponade, Constrictive Pericarditis (may lead to heart failure)

Cardiology Highlights

Pericarditis Cardiology Highlights

• Pleuritic chest pain with inspiration and movement, reduced by sitting up and leaning forward. Aggravated by laying down.

•Becks Triad: 1. Distended neck veins 2. Hypotension 3. Muffled heart sounds

•EKG: Marked ST elevations over all precordial leads

-Ibuprofen 600-800 mg TID

-If Tamponade: Pericardiocentesis

-Recovery is 2 weeks- 3 months

-If bacterial (Rare): Antibiotics

Pericarditis Cardiology Highlights

Treatment

Cardiology Highlights EKGs

Cardiology Highlights Myocardial Infarction

EKG

ST elevation > 1 mm limb leads > 2 mm chest leads

Cardiac Enzymes

CK-MB - Rapid fall to baseline

Troponin - More specific for AMI

Cardiology Highlights Myocardial Infarction

I Lateral aVR ------------

V1 Septum V4 Anterior

II Inferior aVL Lateral V2 Septum V5 Lateral

III Inferior aVF Inferior

V3 Anterior V6 Lateral

Inferior: Posterior Descending Artery via RCA (2, 3, AVF)

Lateral: Circumflex (1, AVL, V5, V6)

Anterior: Left Anterior Descending (V1, V2, V3)

Cardiology Highlights Myocardial Infarction

Cardiology Highlights Myocardial Infarction

Cardiology Highlights Myocardial Infarction

Treatment -Oxygen -Aspirin 325mg chewed -Nitroglycerin 0.4mg sublingually q3-5 minutes up to 3 doses. -Hold NTG if

-Hypotension Systolic <90mmHg. -Bradycardia <50 bpm -Recent phosphodiesterase Inhibitor use (Viagra)

-Morphine - if unresponsive to NTG

Early Reperfusion Therapy Goals -Fibrinolytic Therapy – ED door to drug time - 30 mins. -PCI Therapy – ED door to balloon inflation time – 90 mins.

Cardiology Highlights Arrhythmias

Arrhythmia?

Treatment?

Cardiology Highlights Arrhythmias

Arrhythmia?Treatment?

Cardiology Highlights Arrhythmias

Arrhythmia?

Cardiology Highlights Murmurs

Innocent Murmurs: -Still’s murmur: Most common innocent murmur. Systolic murmur at left lower sternal boarder. Grade 1 or 2. -Venous Hum: Most common continuous innocent murmur.

Systolic hum over mid-infraclavicular areas R>L. Grade 1-3. -Pulmonary Systolic Murmur: Soft, blowing systolic murmur at left upper sternal boarder. Grade 1-3.

Systolic Murmurs: -Aortic Stenosis: Aortic area radiating to neck. “Ejection Click”. -Pulmonary Stenosis: Pulmonic area radiating to left shoulder. -Mitral Regurgitation: Mitral area radiating to left axilla. -Tricuspid Regurgitation: Tricuspid area radiating to right of sternum. -VSD: Holosystolic left sternal boarder. Harsh high pitched.

Diastolic Murmurs: Always pathological -Mitral Stenosis: Mitral area with no radiation. “Opening Snap” -Aortic Regurgitation: Aortic area radiating down sternal boarder.

Case Study 2

History of Present Illness:

- A 3 year-old presents to the ED in acute respiratory distress.

- The parents relay a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing.

Review of Systems: +Fever +Decreased appetite +Congestion

-N/V/D

Past Medical/Surgical History: -Asthma

Social History: -Father smokes in the house

Medication: -Daily vitamin

Case Study 2

Diagnosis and Imaging:PE:

listening for stridor/coughprolonged inspiration or expiration, wheezing, and decreased breath sounds.

Chest xray (maybe)Neck xray (maybe)

Pulmonology Highlights Croup (laryngotracheitis) & Epiglottitis

CroupSymptoms: -"barking" cough, stridor, and hoarseness -Prodromal mild cold/flu symptoms

Organism: Parainfluenza virus (75%)

Imagining: “Steeple Sign” (Subglottic Tracheal Narrowing)

Treatment:-Supportive-Cool or moist air -Steamy bathroom

-Steroids / Nebulized racemic epinephrine

-Intubation

Epiglottitis Symptoms: -Dysphagia (" hot potato" voice) -Drooling -Stridor -Dyspnea -Erect or tripod position

Organism: H. influenzae type B

Imagining: “Thumb Sign” -Lateral c-spine - No tongue blade or direct laryngoscopy

Treatment:-Ceftriaxone (Rocephin)-Antipyretics (eg motrin)-Intubation as needed

Case Study 3

History of Present Illness:

-A 22 y/o white college female presents to the ER complaining of right lower quadrant abdominal pain for 2 days.

-Sudden onset of constant stabbing pain without radiation.

-Severity 8/10

-Nothing seems to alleviate or aggravate the pain

Review of Systems: +Nausea +Vaginal bleeding “I have had vaginal bleeding for the past 24 hours. It began as just spotting, but is slowly increasing.”

Past Medical/Surgical History: -LMP 7 weeks ago (typically q 28 days) -Asthma

Social History: -Currently sexual active and does not use protection. -Smokes ½ PPD x 5 years -Drinks ETOH socially (3 beers/weekend)

Medication: -None

Case Study 3

Physical Exam

Temp, 98.8, BP 108/72, HR 89, RR 20

General: A & O x 3, Moderate distress, walking slumped over holding abdomen

EENT: normal limits

Neck: supple, no lymphadenopathy

Heart: RRR, no murmurs/rubs/gallops

Lungs: CTA

Abdomen: soft, moderate tenderness over right lower abdomen. No masses palpated

Pelvic: External exam normal, bright red blood noted on speculum exam, bimanual exam reveals palpable hard mass on right side.

Case Study 3

Diagnostic Tests:

-CBC -Urine hCG -Serum hCG -Progesterone Level -Pelvic US

OB/GYN Highlights Ectopic Pregnancy

Ectopic Pregnancy

-Fertilized ovum implants anywhere other than endometrium

- Most common area in fallopian tube – distal third

Triad -Amenorrhea -Abdominal pain -Abnormal vaginal bleeding

Risk Factors

-Pelvic inflammatory disease -Previous ectopic pregnancy -Endometriosis -Previous tubal surgery -Previous pelvic surgery -Infertility & infertility treatments -Uterotubal anomalies -History of in utero exposure to diethylstilbestrol -Cigarette smoking

Diagnosis:

-hCG >6500 w/ no gestational sac on US = 86% positive predictive value for ectopic pregnancy

-hCG levels normally double every 1.8 to 3 days for the first 6 to 7weeks

Treatment:

Methotrexate: Causes destruction of rapidly dividing fetal cells. Indications - No evidence of rupture on US

- No fetal cardiac activity - Tubal mass - 3.5 cm in diameter. - Stable with minimal symptoms (compliant)

OB/GYN Highlights Ectopic Pregnancy

OB/GYN Highlights Abortions

Abortion : Termination of pregnancy before fetus capable of extrauterine life <20 weeks

Still birth: > 20 weeks

Inevitable: Cervix dilated with bleeding. No uterine contents passed.

Incomplete: Uterine contents protrude through cervix.

Missed: Fetal death, no expulsion, risk of infection & DIC

Threatened: Cervix closed with uterine bleeding

Complete: Empty uterus by US

OB/GYN Highlights Placenta Abruption Vs. Previa

Placenta Abruption

-Painful vaginal bleeding

-Causes: -Maternal hypertension -Increasing maternal age -Increasing parity -History of smoking -Prior abruption -Cocaine use -Trauma

-Treatment: -Depends on gestational age. Deliver or admit and monitor closely.

Placenta Previa

-Painless vaginal bleeding

-Causes: -Prior C-section -Multiparity

-DO NOT do a pelvic, vaginal, or rectal exam

-Treatment -C-section

Case Study 4

History of Present Illness:

- 38 y/o female was brought to the ER via ambulance.

- Patient was only responsive to painful stimuli.

- EMT stated, “Patient was found unresponsive and vomiting by her daughter. The daughter also found a pill container of morphine on the dresser next to her.”

-In route, EMTs administered 0.4 mg Narcan and started normal saline at 500cc/hr. After narcan was administered patient began to be slightly more alert and vomiting more.

Review of Systems: -Unknown

Past Medical History: -Unknown

Social History: -Unknown

Medication: -Unknown

Physical Exam

-Vitals: BP: 70/43, RR 11, O2 Sat 86% on 2L NC

-General: Responsive only to pain. Cold clammy skin. Shaking.

-Neck: supple, no lymphadenopathy, no bruit

-Heart: RRR / bradycardia

-Lungs: CTA bradypenia

-Abdomen: soft, nondistended, + BS x 4 quadrants

-Extremities: Non tender, no pedal edema. Weak pulses

Case Study 4

Diagnostic Work-up

-Pulse oximetry-Continuous cardiac monitoring-EKG-IV access-Labs -CBC, BMP, ABG-Tox screen -Urine drug screen -Tylenol / Acetominophin -Salicylate -Alcohol Level

Case Study 4

Poisoning Highlights Antidotes

-Opiates: Naloxone (Narcan)

-Iron: Deferoxamine (Desferol)

-Heparin: Protamine sulfate

-Digoxin: Digoxin immune fab (Digibind)

-Cyanide: Amyl nitrate

-Beta blockers: Glucagon, calcium, insulin + dextrose

-Calcium channel blockers: calcium, glucagon, insulin + dextrose

-Carbon monoxide: Oxygen

-Acetaminophen: N-acetylcysteine

-Benzodiazepines: Flumazenil (Romazicon)

-ASA: Sodium bicarbonate

-Warfarin: Vitamin K / FFP

-Methanol: Ethanol

-Extrapyramidal Reaction (Reglan): Benadryl

-Theophylline: Beta Blocker

-Organophosphates (insecticides): Atropine

Orthopedic Highlights Fractures

7 Year old Male

What type of fracture is this?

Orthopedic Highlights Salter-Harris Factures

Salter-Harris Type I: Fx occurs transversely through the physis cartilage. Xray are commonly negative. Growth impairment is rare.

Salter-Harris Type 2: Fx through the physis that exists through the metaphysis. Good prognosis. The most common growth plate injury.

Salter-Harris Type 3: Fx through the physis that exits through the epiphysis. Requires open reduction & internal fixation to preserve the growth plate.

Salter-Harris Type 4: Fx extends upward from the joint line across the epiphyseal plate, passes through the physis & exits at the metaphysis. Requires open reduction & internal fixation to preserve growth plate

Salter-Harris Type 5: Crush injury that obliterates the growth plate & results in growth arrest. Requires open reduction.

Orthopedic Highlights Salter-Harris Factures

Orthopedic Highlights Dislocations / Compartment Syndrome

Shoulder Dislocations: -Anterior dislocation is most common (90%) -After a seizure, think posterior dislocation

Hip Dislocations: -Posterior dislocation is most common (90%) -May result in avascular necrosis

Compartment SyndromePE (5 P’s)

-Pain out of proportion to injury-Paresthesia-Pallor-Paralysis-Pulselessness

Treatment:-Remove offending agent (eg spint, cast)-Fasciotomy effective if performed within hours of onset

Nephrology / Urology Highlights

Nephrolithiasis

Nephrolithiasis -Most common type: Calcium Oxalate

- Less that 5mm patient can pass

-Radiolucent: Uric acid stones -Radiopaque: All the other ones

- Noncontrast helical CT

OB/GYN Highlights Pelvic Inflammatory Disease

PID- Ascending infection from GU to pelvis

Signs / Symptoms: -Lower abdominal tenderness -Bilateral uterine and adnexal tenderness -Cervical motion tenderness -Signs of lower genital tract infection (discharge)

Treatment: -Chlamydia trachomatis:

-Doxycycline 100 mg po BID x 7 days-Azithromycin 1 gm po single dose

-Neisseria Gonorrhea-Rocephin (Ceftriaxone) 250 mg IM single dose-Cipro 500 mg po single dose

Complications: -Ectopic Pregnancy -Infertility -Fitz-Hugh-Curtis Syndrome (bacteria from pelvis spread through abdomen and cause inflammation of tissue surrounding the liver

Nephrology / Urology Highlights

STIs

-Chancroid -PAINFUL -Organism: Haemophilus Ducreyi -Sharply defined irregular borders base is covered with a gray or yellowish-gray material. -Treatment: Azithromycin

-Syphilis -PAINLESS -Organism: Trepenoma Pallidum -Stages -Primary- Ulcer Stage -Secondary-Systemic (Rash on hands and feet, mucocutaneous lessions -Tertiary: Cardiovascular -Gold Standard: Darkfield exam -VDRL / RPR -Treatment: Benzathine penicillin G IM

-Herpes -PAINFUL -Tzanck Prep, Viral Culture, PCR -Treatment: Acyclovir

-Granuloma Inguinale -PAINLESS -Organism: Klebsiella granulomatis -Beefy red “friable” -Donavan Bodies on Biopsy -Treatment: Doxycycline

-Lymphogranuloma Venereum -PAINLESS -Organism:Chlamydia Trachomatis - Buboes -Groove formed by the inguinal (Poupart’s) ligament -Treatment: Doxycycline

Dermatology Highlights Burns

Dermatology Highlights Burns

Solution to Pollution is Dilution

Fluid Resuscitation -Ringers Lactate in adults, D5RL in children -Parkland formula -4ml x weight(kg) x % 2nd/3rd degree burns over 24 hours -50% of required fluids given over the first 8 hours then 25% over next eight and 25% over last eight -Titrate to urine output of 1 ml/kg/hr for over 30kg

Corticospinal – motor, ipsilateral, upper motor neuron

Spinothalamic – sensory, crosses over in cord, deep pain and temperature

Dorsal Column – sensory, ipsilateral, proprioception, vibration, kinesthesia, light touch

Trauma Highlights Spinal Trauma

Spinal Tracts

Complete Cord Lesion - Total loss of motor and sensory function distal to the site of injury.

Anterior Cord Lesion -Paralysis and hypalgesia below level of injury, but with preservation of posterior column functions, position, touch, vibratory sense

Brown-Sequard -Ipsilateral motor paralysis, proprioceptive loss, vibratory loss, in conjunction with contralateral sensory hypesthesia and temperature.

Cord Lesions

Questions?