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296 Cards in this Set
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Difference btwn cellulitis and erysipelas?
|
Cellulitis -infection of superficial skin involving dermis and subq fat
Erysipelas- more superficial involving upper dermis and lymphatics pg 1014 |
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Name a few PO meds used to treat MRSA infections (depending on local epidemiology)?
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Clindamycin, Bactrim, and Doxycycline
pg 1015 |
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What is the main cause of cellulitis?
|
Gram Positives (80%)
B-hemolytic strep, Staph aureus pg 1015 |
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Saltwater infection usually arise from which bacteria?
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Vibrio vulnificus
pg 1016 |
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Freshwater infections usually arise from which bacteria?
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Aeromonas
pg 1016 |
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Most of the bacterial organisms are cleared from an infected skin site in how many hours?
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12hrs but a significant inflammatory response has been initiated.
pg 1016 |
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MRSA suspected. How do you treat a mild skin abscess with cellulitis?
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I&D, abx not necessary if cellulitis < 5cm
pg 1016 |
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MRSA suspected. How do you treat a moderate skin abscess, failed on outpt therapy?
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I&D, admission, Clindamycin 600-900mg IV q 8h or Vanco 1g q12h
pg 1016 |
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MRSA suspected. How do you treat a severe skin abscess, pt with significant comorbidities, and hypotension, fevers, and tachycardia?
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I&D, admission, Vanco 1g q 12hr + Zosyn 4.5g q 6h
pg 1016 |
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12yo M c/o fever, chills, malaise x2 days then small red area burning. Rash is distinctly demarcated from surrounding tissue. Local lymphadenopathy. What is it and txmt?
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Erysipelas - elevate area (drains lymphs). PO Abx (PCN or Amoxicillin). Return precautions for rapid progression, bullae, crepitus (nec fas infx)
pg 1017 |
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What is treatment options for cellulitis?
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Cephalexin 500mg po q 6h or Clindamycin 150-450mg po q6
pg 1018 |
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What is a furuncle vs a carbuncle?
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Furuncle is single deep nodule infecting the hair follicle. Carbuncle are multiple furuncles together.
pg 1015 |
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What is txmt for furuncle or carbuncle?
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Require I&D with consideration of culture, packing and +/- abx.
pg 1019-1020 |
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What are the three ways to classify necrotizing soft tissue infections?
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Anatomical (Fournier's gangrene -scrotum), Depth (necro adipositis, fasciitis, or myositis), and Microbial cause (Polymicrob, monomicrob)
pg 1020 |
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What is the most common microbial cause of necrotizing soft tissue infxn?
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Polymicrobial 55-75% of all , Monomicrobial - Group A Strep or Stap A.
pg 1020 |
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Who are the most common pts presenting with CA-MRSA?
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IV drug abusers, athletes, institutionalized pts
pg 1020 |
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How quickly can a rapid necrotizing infxn spread?
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1in /hr. due to thrombosis of a large number of capillary beds
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Why do antibiotics alone not effective treat necrotizing infections?
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Major tissue ischemia occurs and impedes destruction of bacteria and prevents delivery of abx.
pg 1020 |
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What are some classic symptoms of necrotizing soft tissue infections?
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Pain out of proportion to physical exam, cellulitis, edema, crepitus.
pg 1020 |
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What is the txmt of necrotizing infections?
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Early fluid resus, pRBCs (hemolytic anemia), surgical consult (operative exploration and surgical debridement)
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Pt suspected of having necrotizing fasciitis resulting in gangrenous area on foot. Progressive worsening of condition. HR 115, Tmax 103.4, BP 80/40, AMS, WBC 19. 2L NS given without response. IV Abx started. What is the next step?
|
Early Goal Directed therapy next step is since MAP is < 65 [(DBPx2 + SBP)/ 3] you would use vasoconstrictors but try to avoid in necrotizing pts since he already has tissue ischemia. Consider blood products and immediate surg consult.
pg 1021 |
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What is most common cause of folliculitis?
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Stap Aereus
pg 1021 |
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Most common cause of Whirlpool association?
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Pseudomonas
pg 1021 |
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Most common site for folliculitis and furuncles/carbuncles?
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upper chest, back, axilla, buttocks or any hair bearing region (especially repeated shaving)
pg 1021 |
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Who most commonly gets Hidradenitis Suppurative?
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African decent females.
pg 1021 |
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Where are pilonidal abscess located and what is the cause?
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Upper gluteal cleft and is caused by a abnormal sinus tract lined with squamous epithelium and hair. Hair in the tract leads to blockage and a source for bacteria to invade.
pg 1023 |
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What is the txmt for pilonidal cysts?
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ED txmt I&D, packing and surgical referral for reoccurances.
pg 1023 |
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Blockage of these glands usually causes swelling and tenderness in the labia minora.
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Bartholin Glands
pg 1023 |
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What is the txmt of infected Bartholin Gland abscess?
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I&D, packing or Word catheter, and abx coverage for STDs as well (cephalexin + Metro)
pg 1023 |
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What is sporotrichosis and what is the txmt?
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It is a fungal infxn found in agricultural workers, gardeners etc...3 stage dz (fixed cutaneous, local cutaneous, lymphocutaneous). Txmt Itraconazole 100-200mg QD 3-6months)
pg 1024 |
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What % of the world is infected with Herpes Type 1?
|
85%, thought to have acquired in childhood through nonsexual contact
pg 1025 |
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What is the Hallmark of HSV encephalitis?
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acute onset of fever and neurologic symptoms (hemipareis, CN abnormalities, ataxia, focal seizures, AMS)
pg 1025 |
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Who is more likely to be effected by HSV aseptic meningitis and which type of HSV?
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Type II more common in women
pg 1025 |
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Where does HSV type I and II lay dormant?
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HSV Type I - Trigeminal ganglia
HSV Type II - Sacral ganlia pg 1025 |
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What is the test of choice for HSV infection confirmation?
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PCR (polymerase chain reaction) testing or direct fluorescent antibody test. Tzanck test not useful.
pg 1026 |
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If bacterial meningitis is suspected but LP shows CSF w/ lymphocytic pleocytosis, what must be considered and how would you treat?
|
Viral meningitis (HSV 2,Entroviruses -80%), cover with abx and acyclovir 7-10 days
pg 1026 |
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Varicella vaccine has greatly reduced the occurrence of chickenpox. What percent of adults develop Herpes Zoster?
|
10-20%
pg 1027 |
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7yo with fever, malaise, HA and anorexia x 3 days. Papules, vesicles and crusted lesions on the torso and face. What is the likely cause?
|
Varicella
pg 1027 |
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Herpes Zoster involving more than 3 dermatones is often a clue for______ condition.
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immunodeficient
pg 1028 |
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What is the drug of choice for HSV Zoster infections?
|
Acyclovir.
Famcyclovir and Valacyclovir are not FDA approved for zoster use. pg 1028 |
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CNS involvement or immunodeficient pts require what type of antivirals?
|
IV (acyclovir 10mg/kg IV q 8h)
pg 1029 |
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What time frame should antiviral medication ideally be started for a Varicella infection?
|
w/in 72hrs, consider >72hrs if new vesicles forming or immunocompromised pt.
pg 1029 |
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15yo F c/o fever, swollen glands, and sore throat x 4 days. Tonsils are swollen with white exudate. Palpable spleen. What is dx and txmt?
|
EBV - mononucleosis
tmxt- rest and analgesia avoid contact sports x 4 weeks pg 1030 |
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What is a common rxn when amoxicillin is mistakenly given for a EBV pharyngitis?
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Morbilliform rash
pg 1029 |
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T/F: CMV is a highly contagious dz spread by sexual contact, saliva, breast feeding or organ transplant.
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False: NOT highly contagious
pg 1030 |
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Txmt of HIV or transplant pt with CMV consists of ?
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Ganciclovir IV + immunoglobulin
pg 1030 |
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Abroviral infections are spread by ____ and one of the most common causes of ____ in the world.
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mosquitoes and encephalitis
pg 1030 |
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How do most abroviral present?
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fever, myalgias, arthritis, hemorrhagic rash, and ecephalitis
pg 1031 |
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What antiviral is recommended for the txmt of abroviral infections?
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None. Symptomatic txmt.
pg 1031 |
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What is the mosquito most responsible for transmission of yellow, dengue, and chikuungunya fevers?
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Aedes aegypti
pg 1031 |
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Which type of HIV is most common worldwide?
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HIV type I
HIV type II - restricted to west africa pg 1032 |
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How does HIV affect the immune system?
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HIV selectively attacks host immune cells, primarily CD4+ T cells
pg 1032 |
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How does HIV affect the immune system?
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HIV selectively attacks host immune cells, primarily CD4+ T cells
pg 1032 |
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What are the different avenues HIV can be spread?
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semem, vaginal secretions, blood, breast milk and in utero
pg 1032 |
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What are the different avenues HIV can be spread?
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semem, vaginal secretions, blood, breast milk and in utero
pg 1032 |
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How soon do symptoms develop after exposure to HIV?
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Usually 2-4 weeks
pg 1032 |
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How soon do symptoms develop after exposure to HIV?
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Usually 2-4 weeks
pg 1032 |
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What are the most common early symptoms of HIV?
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fever (90%), fatigue (70-90%), pharyngitis (>70%), rash (40-80%), HA (30-70%) and lymphadenopathy (40-70%)
pg 1032 |
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What are the most common early symptoms of HIV?
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fever (90%), fatigue (70-90%), pharyngitis (>70%), rash (40-80%), HA (30-70%) and lymphadenopathy (40-70%)
pg 1032 |
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AIDS is defined as a CD4+Tcell count of ______.
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<200cells
pg 1032 |
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What are some conditions seen in HIV that are worrisome for AIDS conversion?
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Esophageal Candidiasis, Cryptococcosis, Cryptosporidiosis, CMV retinitis, HSV, Karposi sarcoma, Pneumocystis jiroveci
pg 1032 |
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What is the standard and most common way to diagnosis HIV?
a. detection of viral-specific antigen b. identification of HIV nucleic acid c. isolation of the virus by culture d. detection of antibodies to the virus |
D. Detection of antibodies to the virus
pg 1033 |
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What % of acute HIV infections are not diagnosed early on?
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75%
pg 1033 |
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Which two tests are used to detect and confirm the presences of HIV and what are their sensitivity and specificities?
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ELISA (sens. 98.5% / spec 99%) and Western Blot (sens. 100% / spec. 100%)
pg 1033 |
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CD4+T-cell count of _____ and a viral load of ______ is associated with increased risk of AIDS defining illnesses.
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<200 and >50,000
pg 1033 |
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At what point do you initiate therapy for HIV pts?
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CD4+T-cell count of <200 and viral load of 50,000
pg 1033 |
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If CD4+T-cell count is unknown, what is another way to roughly estimate a CD4+T-cell count?
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Total Lymphocyte count of < 1200 with clinical symptoms translate to CD4+T-cell <200.
pg 1033 |
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What are a couple of physical exam findings that can help with staging of HIV infections?
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Presence of Thrush, evidence of Temporal Wasting, and Dementia.
pg 1033 |
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In addition to normally ordered labs and imaging (RFP, CBC, LFTs, UA, CXR), what additional labs should be drawn on a symptomatic HIV pt?
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Blood cultures, syphilis testing (RPR, VDRL), cryptococcosis, toxoplasmosis, CMV and coccidiomycosis, LP (if fever unknown origin)
pg 1034 |
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What is the source of fever in HIV pts with CD4+ counts >500 without obvious source?
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similar sources as nonimmunocompromised pts
pg 1034 |
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What is the source of fever in HIV pts with CD4+ counts 200-500 without obvious source?
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most likely to have early bacterial respiratory infections
pg 1034 |
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What is the source of fever in HIV pts with CD4+ counts <200 without obvious source?
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PCP (pneumocystis carinii), central line infx, CMV, Tuberculosis, or MAC (mycobacterium aviumintracellare)
pg 1034 |
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This opportunistic infx predominately occurs in pts with CD4+ counts <100 and has persistant F/C/NS, weight loss, diarrhea, anorexia, and malaise. What is it and txmt?
|
Disseminated MAC (mycobacterium aviumintracellare)
Txmt: Clarithromycin 500mg BID +Ethambutol 15mg QD, + Rifabutin 300mg/kg QD pg 1035 |
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What is the most common opportunistic viral infx in HIV pts with most important manifestation being retinitis, and txmt?
|
CMV
Txmt: Foscarnet or Ganciclovir pg 1035 |
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Fever in injection drug users is treated how and what is the major concern? (big picture)
|
Major concern is infective endocarditis
Txmt: blood cultures, broad spec abx, admission for blood culture results and echo. pg 1034 |
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What is the most common noninfectious process causing fever in HIV?
|
Neoplasm and HAART therapy (drug) fever.
Non-Hodgkins Lymphoma most frequent lesion pg 1034 |
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What is the most common cause of neurological changes in an AIDS pt and what are the changes?
|
AIDS dementia - 30% of pts w/ CD4+ < 100
CNS changes- recent memory loss, cognitive deficits, mental status changes, aphasia, motor abnormalities pg 1035-36 |
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Known AIDS pt presents to ED for HA, fever, confusion, reported seizures, and decreased feeling in right hand. CT head shows multiple subcortical lesions in the basal ganglia. What is the concern for and txmt plan?
|
Toxoplasmosis
Txmt: Admission, pyrimethamine, sulfadiazine, with folinic acid and dexamethasone. pg 1036 |
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What is the leading opportunistic infx causing blindness in AIDS pts and what is the txmt?
|
CMV retinitis
Txmt: Intraocular ganciclovir implants + oral ganciclovir, relapse is frequent pg 1037 |
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What is the most common cause of pneumonia in HIV pts?
|
Streptoccocus pneumoniae
pg 1037 |
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What type of pulmonary infections appear as diffuse interstitial infiltrates?
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PJP (pneumocysitis jiroveci), CMV, Mycobacterium, MAC
pg 1037 |
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What type of pulmonary infxs appear as focal consolidations?
|
Strep pneumo, Mycoplasma,
pg 1037 |
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What type of pulmonary infxs appear as nodular lesions?
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Kaposi sarcoma, Tuberculosis, MAC
pg 1037 |
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This is the most common of all the opportunistic infxs, the leading identifiable cause of death in AIDS, usually presents w/ fever, cough, and SOB. Cause and txmt?
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PJP (pneumocysitis jiroveci)
Txmt: Bactrim PO or IV x 3 weeks +/- steroids pg 1038 |
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What is the rate of TB infxs in HIV pts vs the normal population?
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200-500 times
pg 1038 |
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What CD4+T-cell count range do you typically see TB infx present ?
|
CD4+T-cell 200-500
pg 1038 |
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Why are PPD tests not useful for detecting TB in AIDS pts?
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There is a lack of immune response to the PPD.
pg 1038 |
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What is the diagnostic method of choice for suspected TB in HIV pt?
|
Sputum culture -acid fast stain
pg 1038 |
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What oral lesion is a poor prognostic indicator for HIV pts?
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Oral Thrush
pg 1038 |
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This lesion is a nontender, well circumscribed, raised violaceous lesion that do not blanch. Common sites are on the face, chest, genitals, and oral cavity.
|
Karposi Sarcoma
pg 1039 |
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HIV pt c/o dysphagia or odynophagia is usually indicative of _____.
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Esophagitis
pg 1039 |
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Which people are at highest risk for HIV infections? (2)
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homosexual men and injection drug users
pg 1040 |
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T/F: HIV infx persons should not receive live virus or live bacteria vaccines.
|
True
pg 1040 |
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When is the risk for seroconversion highest in occupational exposure to HIV infected blood?
|
1)deep injury
2)visible blood on injuring device 3)needle placement in a vein or artery of the source pt 4)source pt with late-stage HIV pg 1041 |
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Post HIV exposure prophylaxis should be initiated as quickly as possible, preferably within ___ - ___ hrs.
|
1 -2 hrs
pg 1041 |
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How many of the 4 drug HAART therapy does the CDC recommend for postexposure treatment and for how long?
|
Two drug therapy (azidothymidine and lamivudine) for 4 weeks
pg 1041 |
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What is the cutoff for post HIV exposure prophylaxis in the nonoccupational setting?
|
72hrs
pg 1041 |
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What is the time interval that pts should be tested after a possible exposure to HIV?
|
Baseline, 1 month, 3 months and 6 months.
pg 1041 |
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What is the turnaround time on the four rapid HIV tests?
|
10-20 min
pg 1033 |
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Sudden onset HA, especially during exertion, is an independent predictor of intracranial pathology and up to ___% of these HA are caused by SAH.
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25%
pg 1113 |
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Where is a common location for reported HA associated with SAH?
|
occipitonuchal
pg 1113 |
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Migraine HA characteristics include five things?
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1) pulsatile, 2) duration 4-72hrs, 3) nausea/vomiting, 4) unilateral, and 5) disabling intensity
pg 1113 |
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The history of a HA pt should include non-neurologic causes like: (4)
|
visual changes, eye pain (glaucoma), jaw claudication (temporal arteritis), or congestion/ facial pain (sinusitis).
pg 1113 |
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HA pt should be asked about relatives with hx of SAH, b/c intracranial aneurysms are ___ times higher in first and second degree relatives than the general population.
|
4 times higher
pg 1113 |
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What are some examples of ACEP HA category I?
|
Subarchnoid Hemorrhage, meningitis, brain tumor w/ elevated ICP
pg 1114 |
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What is an example of ACEP HA category II?
|
Brain Tumor w/o raised ICP
pg 1114 |
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What are some examples of ACEP HA category III?
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Sinusitis, HTN, post-LP HA
pg 1114 |
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What are some examples of ACEP HA category IV?
|
Migraine, Tension HA, or Cluster
pg 1114 |
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Primary HAs are the most common diagnosis but at what age should you be more concerned for secondary causes?
|
50yo
pg 1114 |
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What the six major life-threatening causes of HAs?
|
1) SAH, 2) Meningitis, 3) Intraparenchymal Hemorrhage, 4) Subdural Hematoma, 5) Brain Tumor, 6) Cerebral Venous Thrombosis
pg 1115 |
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What is the Gold Standard for the diagnosis of SAH?
|
Xanthochromia on LP
pg 1115 |
|
|
T/F: It is acceptable to start abx on a suspected meningitis pt if the LP must be delayed for some reason.
|
True.
pg 1115 |
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|
Three of the five criteria must be met for the diagnosis of Temporal Arteritis. What are the five?
|
1) Age > 50, 2) New-onset localized HA, 3) Temporal artery tenderness, 4) ESR >50, 5) Abnormal biopsy
pg 1115 |
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|
23yo F c/o chronic HAs x 3 months. Pt c/o n/v and visual disturbances w/ HA, She is taking snythroid 50mcg qd and Yaz. Pt is overweight. CT is negative. LP opening pressure is elevated. What is the possible cause?
|
Benign Intracranial Hypertension (Pseudotumor Cerebri); linked to young females on birth control, thyroid issues, tetracyclines
pg 1116 |
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|
Txmt for Trigeminal Neuralgia is?
|
Carbamazepine 100mg PO BID
pg 1118 |
|
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Who do cluster HAs effect, how do they present and how are they treated ?
|
Typically men, eye involvement, rhinorrhea, unilateral. Can not sit still, pacing around. Txmt: Oxygen improves 70%, triptans and NSAIDs can also be effective
pg 1117-18 |
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How are the txmt of Migraines and Tensionn HAs different?
|
They are not. Tension and migraine believed to be spectrum of the same disorder. Txmt: NSAIDs, DHE, triptans, Reglan
Pg 1117 |
|
|
Several antiemetics have been shown to be effective against migraine HAs, what are few?
|
Chlorpromazine (Thorazine), Prochlorperazine (Compazine), and Metoclopramide (Reglan).
Pg 1117 |
|
|
What is the issue if DHE and a 'triptan are given within 24hrs of each other?
|
Both are potent vascocontrictors
pg 1116 |
|
|
What does the ED consensus guidelines suggest as first line for migraine HA?
|
DHE (Dihydroergotamine) 1mg IV over 3 min, pretreat with Reglan or Phenergan
pg 1116-17 |
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A family history of SAH and ___ kidney disease increases the likelihood of SAH.
|
Polycystic Kidney Dz
pg 1118 |
|
|
What description of a HA should raise concern for a SAH?
|
Worst HA of my life or a HA different in intensity or quality
pg 1118 |
|
|
In the absence of blunt trauma, what eye finding is pathognomonic for SAH and found in 11-33% of cases?
|
Retinal Subhyaloid Hemorrhage
pg 1119 |
|
|
What are some risk factors for SAH?
|
smoking, HTN, excessive alcohol consumption, Polycystic Kidney Dz, Fam hx, Coarctation of the aorta, Marfans, Ehlers-Danlos
pg 1118 |
|
|
Why does the sensitivity of CT scan decrease at the 24hr mark for SAH?
|
The brain resorbes the blood.
pg 1119 |
|
|
If the CT head is negative for bleed and LP is performed due to clinical suspicion, what two things are you looking for in the CSF?
|
Xanthochromia (yellow appearance to CSF) or RBCs in tubes 1-4
pg 1119 |
|
|
What does the medical management include for confirmed SAH pts?
|
regular reexminations, MAP <130, normotension (using titratable IV HTN drugs such as Labetaolol)
pg 1120 |
|
|
Vasospasm is a complication of SAH and generally occurs how long after the bleed and is treated how?
|
2 days - 3 weeks
txmt: Nimodipine 60mg PO q 4h pg 1121 |
|
|
What can be used to reverse Warfarin in pts with a intracerbral bleed?
|
Vitamin K (takes hours) and FFP
pg 1122 |
|
|
What are the major arteries supplying the anterior circulation of the brain? (internal carotid system)
|
Opthalmic, Anterior Cerebral, and Middle Cerebral
pg 1124 |
|
|
What are the major posterior arteries supplying the posterior circulation of the brain? (vertebral system)
|
Vertebral, Posteroinferior Cerebellar, Basilar, and Posterior Cerebral
pg 1124 |
|
|
What are some symptoms of a stroke?
|
facial droop, arm drift, abnormal speech, weakness, dizziness, or sensory changes
pg 1122 |
|
|
Broca's, Wernicke's aphasia, and the Auditory cortex are all supplied by which circulation system (ant or post) and which artery?
|
Anterior / Middle Cerebral artery
pg 1124 |
|
|
If a pt has awoken with stroke symptoms, what time should be the time of onset?
|
When the pt was last known at baseline.
pg 1124 |
|
|
What are the components of The Los Angeles Prehospital Stroke Screen?
|
1. Age >45, 2. No hx of seizure, 3. New onset neurologic sxs, 4. Pt ambulatory at baseline, 5. Blood glucose 60-400, Asymmetry in smile, grip, arm strength
pg 1125 |
|
|
What is the definition of TIA?
|
transient episode of neurological dysfxn, caused by focal brain, spinal cord, or retinal ischemia, without acute infarct. Think angina of the brain and CVA as the MI of the brain
pg 1128 |
|
|
How does a MCA stroke present?
|
hemiparesis, facial plegia, and sensory loss contralateral to the affected cortex
pg 1128 |
|
|
How does an Anterior Cerebral stroke present?
|
contralateral sensory and motor symptoms in the lower extremity, mutism
pg 1128 |
|
|
How does a Posterior Cerebral stroke present?
|
HA, visual field defects, loss of ability to read, can't name colors
pg 1128 |
|
|
What is the goal timewise for treatment of stroke pts?
|
60minutes
pg 1129 |
|
|
What is the goal time to have imaging in suspected stroke pts?
|
25minutes
pg 1129 |
|
|
What are the BP parameters for thrombolytic pts and nonthrombolytic stroke pts?
|
Receiving Thrombolytics - SBP <185 and DBP <110
No Thrombolytics- SBP <220 and DBP <120 pg 1130 |
|
|
Name three drugs used to control HTN in stroke pts.
|
Labetalol 10-20mg IV, Nitro paste 1-2inches, or Nicardipine (cardene) 5mg titrated IV
pg 1130 |
|
|
What is the advantage of intra-arterial thrombolysis (IAT) to rtPA?
|
Expanded treatment window to 6hrs
rtPA (3 hrs) pg 1132 |
|
|
How is rtPA given?
|
0.9mg/kg (max 90mg), 10% of dose as bolus with the remaining infused over 60minutes.
pg 1132 |
|
|
How long should antiplatelet and anticoagulation medications be held after rtPA txmt?
|
24hrs
pg 1132 |
|
|
When is ASA recommended to be given after a stroke?
|
24-48hrs has show to reduce recurrent stroke
pg 1133 |
|
|
T/F: Heparin or Lovenox are the anticoags of choice to be started 48hrs after acute stroke.
|
False. Risk of intracranial hemorrhage is too high a risk for the benefits.
pg 1133 |
|
|
What is the most common cause of ischemic stroke in children?
|
Sickle Cell dz
pg 1134 |
|
|
What categories are included in the mini mental status exam?
|
Orientation (date and location), Registration (name three objects to repeat and recall), Attention (counting back from 100 by 7s, or spell WORLD backwards), Recall (three objects), and Language (repeat "no ifs, ands, or buts)
pg 1137 |
|
|
Acute onset of attention deficits and cognitive abnormalities fluctuating in severity throughout the day and worsening at night is diagnostic of what?
|
Delirium
pg 1136 |
|
|
T/F: Delirium is an chronic condition with cognitive changes over months to years and may be caused by drug withdrawal, toxins, CNS dz or intracranial dz.
|
False: delirium occurs over days
pg 1136 |
|
|
What is the difference in time of onset btwn delirium, dementia and psychiatric disorders?
|
Delirium - days
Dementia - insidious Psychiatric disorders - sudden pg 1136 |
|
|
What movement is often seen in delirium but not dementia or psych disorders?
|
asterixis
pg 1136 |
|
|
Impairment of memory, particularly recent memories, with preservation of motor and speech abilities is consistent with _____?
|
Degenerative Dementia
pg 1138 |
|
|
What does normal-pressure hydrocephalus look like on CT?
|
Excessively large ventricles on CT
pg 1139 |
|
|
Pt presents with urinary incontinence and gait disturbance early in the dementia disease process should be worked up for ?
|
Normal-pressure hydrocephalus
pg 1139 |
|
|
At what MAP range does the brain maintain perfusion?
|
roughly btwn 50-100
pg 1140 |
|
|
What are the top three causes for pediatric coma?
|
Toxic ingestion, infections, and child abuse.
pg 1141 |
|
|
Of the coma cocktail which of the medications is the only recommended one for a coma?
|
Naloxone
pg 1141 |
|
|
What are a few ways to decrease ICP?
|
Head of bed >30degress, Mannitol, and brief hyperventilation (increase CO2 30-35), hypertonic saline
pg 1142 |
|
|
If a elderly pt c/o gait disturbance or ataxia, what should be included in the vital signs workup for an easily correctable problem?
|
Orthostatic blood pressures for volume depletion
pg 1143 |
|
|
A neuro exam is not complete until you have assessed the pt's ____.
|
Gait. Observe pt rise, stand, and walk.
pg 1143 |
|
|
What are several exams used to the test the cerebellar fxn?
|
Rapid thigh slapping, finger to nose, heel to shin, Rhomberg (worse with eyes close - posterior column vs ataxia same with eyes open and shut - cerebellar)
pg 1143 |
|
|
Ataxia or gait disorders in a alcoholic should raise the possibility of a ______ problem and can be treated with IV ______.
|
nutritional problem and IV thiamine
pg 1144 |
|
|
Ataxia in a child with cranial nerve and strength abnormalities can be caused by?
|
Posterior fossa mass lesion
pg 1144 |
|
|
Define Vertigo, Syncope, and Disequilibrium.
|
Vertigo -perception of movement where none exists
Syncope - transient LOC w/ recovery Disequilibrium- feeling unsteady, imbalance pg 1144 |
|
|
How does the CNS coordinate balance?
|
Coordinates and integrates sensory input from visual, vestibular, and proprioceptive systems.
pg 1144 |
|
|
Where does sensory input travel along from to the nucleus?
|
Vestibulocholchlear nerve, Eighth cranial nerve
pg 1145 |
|
|
What is the most striking clinical sign of vertigo?
|
Nystagmus
pg 1145 |
|
|
Which type of vertigo is seen with BPPV and which is thought to indicate brainstem abnormalities?
|
Rotational vertical nystagmus with BVVP
Vertical nystagmus w/o rotation is concerning. pg 1145 |
|
|
Which vertigo is more common and less concerning, peripheral or central?
|
Peripheral, though Central vertigo is insidious and less severe.
pg 1145 |
|
|
Insufflation of air by otoscope that precipitates a burst of vertigo w/ nystagmus is diagnostic for?
|
Inner ear fistula
pg 1146 |
|
|
What exam aides the diagnosis of BPPV?
|
Dix-Hallpike maneuver
pg 1146 |
|
|
How do you determine the affected side with the use of the Dix-Hallpike exam?
|
The affected side exhibits nystagmus when the head is turned towards it.
pg 1146 |
|
|
Match temporal patterns:
1. BPPV a. days 2. TIA b. mins 3. Meniere's dz c. secs 4. Viral Labyrinthitis d. hrs |
1. BPPV c. secs
2. TIA b. mins 3. Meniere's dz d. hrs 4. Viral Labyrinthitis a. days pg 1147 |
|
|
Vertigo w/ CNS disturbances briefly or constantly need to r/o what two disorders?
|
TIA - brief
Central vertigo - constant pg 1147 |
|
|
Vertigo occuring with sudden head movements is?
|
BPPV
pg 1147 |
|
|
Vertigo w/ hearing loss and tinnitus, no recent infections?
|
Meniere's Dz
pg 1147 |
|
|
Vertigo w/ hearing loss?
|
Acoustic neuroma
pg 1147 |
|
|
What medicaiton is recommended first line for veritgo?
|
transdermal Scopolamine
pg 1146 |
|
|
What are some second line medications commonly rx for vertigo?
|
antihistamines (benadryl, meclizine), Antiemetics (Reglan, Compezine), Benzo's (Valium), CCBs (Nimodipine)
pg 1148 |
|
|
T/F: Vestibular rehab exercises have proven to be ineffective for the txmt of vertigo.
|
False: safe and effective
pg 1148 |
|
|
Which affected semi-lunar canal will benefit from Dix-Hallpike maneuvers?
|
Anterior and Posterior
pg 1148 |
|
|
What is believed to be the pathogenesis of Meniere's Dz?
|
unknown but suspected to be irregulated endolymph volume, overload
pg 1150 |
|
|
Name some ototoxic drugs commonly used.
|
Aminoglycosides, Erythromcyin, Fluoroquinolones, NSAIDs, Salicylates, Loop diuretics, Antimalarials.
pg 1150 |
|
|
What is Ramsey Hunt syndrome?
|
Herpes zoster oticus. deafness, vertigo, and facial nerve palsy.
pg 1150 |
|
|
Name two types of eighth cranial nerve lesions.
|
Menigiomas, Schwannomas, or Acoustic neuromas
pg 1151 |
|
|
What are some causes of central vertigo?
|
Cerebellar infarct, Vertebral Artery dissection, Multiple Sclerosis, Neoplasms, or migraines.
pg 1151 |
|
|
What are the broad categories of seizures and their subcategories?
|
Generalized Seizures - Tonic-clonic and Absence Seizures
Partial (Focal) Seizures - Simple partial, Complex partial pg 1153 |
|
|
Match seizures.
1. Tonic-clonic a. No LOC w/ focal deficit 2. Absences b. LOC w/ full body trembling 3. Simple partial c. LOC w/ focal deficit 4. Complex partial d. LOC w/out loss of tone |
1. Tonic-clonic b. LOC w/ full body trembling
2. Absences d. LOC w/out loss of tone 3. Simple partial a. No LOC w/ focal deficit 4. Complex partial c. LOC w/ focal deficit pg 1153 |
|
|
What are some important questions to ask regarding a seizure?
|
Aura? Abrupt or Gradual? Loss of bowel or bladder? Activity was local or general? Duration? Postictal confusion?
pg 1154 |
|
|
What are some common precipitating factors to seizures?
|
Missed dose of meds, recent change in meds, sleep deprivation, alcohol or substance withdrawal, infection, or electrolyte disturb.
pg 1154 |
|
|
What is a transient focal deficit following a simple or complex focal seizure, which usually resolves in 48hrs, called?
|
Todd Paralysis
pg 1154 |
|
|
What labs are required in a known seizure pt?
|
Glucose and anticonvulsant level
pg 1155 |
|
|
What labs are required in a new seizure pt?
|
Serum electrolytes, glucose, BUN, creatinine, mag, calcium, tox labs, and pregnancy test
pg 1155 |
|
|
Treatment of active seizure.
|
Turn the pt to reduce risk of aspiration, clear airway (suction/aduncts)
pg 1155 |
|
|
What is the loading dose of Phenytoin PO and IV?
|
Phenytoin PO - 18mg/kg PO single dose
Phenytoin IV - 10-20mg IVBP pg 1155 |
|
|
What do you do for the seizure pt who reports 2nd seizure in 30 days, anticonvulsant level is within range and reports 1-2 seizures per month?
|
Nothing. This is their normal
pg 1156 |
|
|
What are some effective anticonvulsant drugs commonly used?
|
Carbamazepine (Tegretol), Gabapentin, Lamotrigine (Lamictal), Levetiarcetam (Keppra), Phenytoin (Dilantin)
pg 1156 |
|
|
T/F: Seizures are uncommon in HIV pts, so great care must be taken to work these pt's up.
|
False: Seizures are a common CNS manifestation in HIV
pg 1156 |
|
|
What condition is the second most common cause of secondary seizures in the world?
|
Neurocysticercosis (tapeworm parasite)
pg 1157 |
|
|
T/F: Due to the teratogenic effects of anticonvulsants, seizures during pregnacy are to be monitored.
|
False: despite the teratogenic effects the risks of uncontrolled seizures to mother and fetus warrants use.
pg 1157 |
|
|
26yo F 22weeks pregnant arrives by EMS for HTN and seizures. She is lethargic and confused. UA shows proteinuria. 2+ edema in LE. which medication is more effective Magnesium sulfate 4g IV or Phenytoin 20mg IV?
|
Magnesium >50% reduction in recurrence compared to Phenytoin.
pg 1157 |
|
|
What is the medication of choice for seizures in pts going thru ETOH withdrawal?
|
Benzos (Ativan 2mg)
pg 1157 |
|
|
When should treatment begin in a pt w/ Status Epilepticus?
|
Any seizure activity lasting longer than 5 mins
pg 1158 |
|
|
What medications are recommended as the first line for Status Epilepticus?
|
Lorazepam 2-4mg IV and Phenytoin 20mg/kg IV
pg 1158 |
|
|
What should Phenytoin not be mixed with before giving?
|
Glucose
pg 1159 |
|
|
What medications should be considered if Refractory Status Epilepticus continues despite Phenytoin and Lorazepam?
|
Valproic Acid, Keppra, or Phenobarbital (though may not respond), Propofol, and Versed
pg 1159 |
|
|
Which neuropathy is more likely to be confined to one limb and to present with the involvement of multiple sensory modalities and motor symptoms? (CNS or PNS)
|
Peripheral Nervous System
pg 1159 |
|
|
Which neuropathy is more likely to develop diplopia, dysarthria, and dysphagia?
|
Peripheral and Central alike can affect
pg 1160 |
|
|
Most CNS lesions will result in upper motor neuron signs, like ___, ____, and _____?
|
hyperreflexia, hypertonia, and extensor plantar (Babinski) reflexes
pg 1160 |
|
|
Motor weakness and sensory loss in the ipsilateral upper and lower extermities points to which nervous system involvement?
|
CNS
pg 1160 |
|
|
This neuromuscular junction disorder leads to weakness and respiratory failure. Presents with N/V/D, ab cramps, and blurry vision. Typically associated with improperly stored canned foods.
|
Botulism
pg 1160 |
|
|
Pt with difficulty walking, progressive lower extremity weakness. Pt has not been sick recently but did just get back from a hunting trip.
|
Tick Paralysis - search for and complete removal of the tick
pg 1161 |
|
|
65yo F c/o viral illness two weeks ago, not improving, and bilateral leg weakness slowly ascending.
|
Guillian-Barre Syndrome
pg 1161 |
|
|
What is one of the most important things to manage in Guillian-Barre pts?
|
Respiratory function must be protected.
pg 1161 |
|
|
Numbness and pain on the lateral thigh?
|
Meralgia Paresthetica
pg 1163 |
|
|
What is the most common neuropathy cause in HIV pts?
|
CMV radiculitis (LE involvement and possibly bowel and bladder)
pg 1164 |
|
|
T/F: Lou Gehrig dz (ALS) is a slow progression of muscle atrophy and weakness due to degeneration of both upper and lower motor neurons.
|
False: progresses quickly
pg 1166 |
|
|
What are the typical presenting symptoms associated with Amyotrophic Lateral Sclerosis?
|
extremity cramping, fatigue, weakness, and atrophy especially in the upper extremities.
pg 1166 |
|
|
What is the major problem that will cause the worst prognosis for ALS pts?
|
Respiratory Failure 2/2 diaphram and respiratory muscle weakness
pg 1166 |
|
|
Myasthenia Gravis is an autoimmune disorder characterized by muscle weakness and fatigue. What antibodies cause this?
|
Acetylcholine Receptor Antibodies
pg 1166 |
|
|
Which muslces are more likely involved in myasthenia gravis pt's?
|
muscles of repetative use
pg 1167 |
|
|
What is myasthenia gravis typcially misdiagnosed as in the elderly?
|
Ischemic Stroke
pg 1167 |
|
|
How is the dx confirmed in myasthenia gravis pts?
|
administer edrophonium chloride, if muscle weakness is improved then +Myasthenia
pg 1167 |
|
|
What is considered a possible cause of myasthenia gravis, dysfunction gland?
|
The Thymus gland
pg 1167 |
|
|
What are some treatment options for Myasthenia Gravis?
|
Thymectomy,acetylchoinesterase inhibitors, pyridostigmine, or neostigmeine
pg 1167 |
|
|
Respiratory failure is the most significant event in the ED and intubation is often need, what medications do you avoid?
|
Depolarizing and nondepolarizing agents due to increased sensitivity of th cells
pg 1167 |
|
|
Edrophonium is given to a pt suspected of having Myasthenia Gravis and the pt goes in to bradycardia (25bpm) and passes out. What medication can be used to reverse?
|
Atropine 0.5mg
pg 1168 |
|
|
Who does MS usually affect?
|
Young people
pg 1169 |
|
|
Which extremities are typically affected first in MS?
|
Lower extremities (tripping, clumsiness are initial complaints)
pg 1169 |
|
|
Optic neuritis, causes acute or subacute central vision loss, may be the initial sign of MS in __% of pts.
|
30%
pg 1169 |
|
|
What is Uhthoff Syndrome (regarding Multiple Sclerosis)?
|
visual acuity worsens with increased body temperature (fever, exercise, hot bath).
pg 1169 |
|
|
What are the medications used to treat MS?
|
Steroids, interferon Beta, Glatiramer, Natalizumab, or Mitoxantrone
pg 1169 |
|
|
Why is it important to r/o UTI and Pyelonephritis in an acute MS exacerbation?
|
Decreased Autonomic Nervous system leads to urinary retention.
pg 1169 |
|
|
Pt has resting tremor, slow wide gait, and cogwheel rigidity. what is the concern for?
|
Parkinson's Dz
pg 1170 |
|
|
What are the four hallmark neuro signs of Parkinson's?
|
TRAP: resting Tremor, cogwheel Rigidity, Akinesia, impairment in Posture
pg 1170 |
|
|
What lab and imaging is definitive for Parkinson's diagnosis?
|
None.
pg 1170 |
|
|
What are treatment goals of medications given?
|
increase dopamine, increase dopamine receptor agonist
pg 1170 |
|
|
What is the treatment for dopaminergic therapy toxicity causing cardiac dysrhythmias, orthostatic hypotension, dyskinesias and dystonias?
|
Back down on the drug dose or consider drug holiday.
pg 1171 |
|
|
This enterovirus is transmitted via oral to oral or fecal to oral. From the GI system it reproduces and spreads to the large motor nuclei of the spinal cord and brain. It affects neurons causing cycles of muscle denervation and reinnervation. What is the cause?
|
Poliomyelitis
pg 1171 |
|
|
Polio is rare due to vaccines but prevent in India, Afghanistan, and Nigeria. What three neuromuscular findings characterize polio?
|
1) Flaccid weak muscles
2) Absent tendon reflexes 3) Fasciculations pg 1172 |
|
|
What is the most important cause of paralysis on the differential that must be considered and excluded during a workup?
|
Guillen-Barre syndrome
pg 1172 |
|
|
What is the txmt for Polio?
|
symptomatic, analgesia and NSAIDs
pg 1172 |
|
|
Most common causes of baterial meningitis in the US are?
|
Step pneumo (61%), Neisseria meningititidis (16%), Group B Streptococcus (14%) and H. Influenza (7%)
pg 1172 |
|
|
Military barracks and college dorms are typical environments in which clusters of which type of meningitis occur?
|
Neisseria meningitis
pg 1173 |
|
|
What are the classic signs and of baterial meningitis?
|
Fever, neck stiffness, HAs, AMS
pg 1173 |
|
|
T/F: The absence of fever, neck stiffness, and AMS does not exlude meningitis in adults.
|
True
pg 1173 |
|
|
What are the treatment steps for suspected bacterial meningitis?
|
1) IVF
2) Abx therapy ASAP +/- Dexamethasone 10mg 3) Bld cx / LP 4) CT scan (may be before LP if immunocompromised, CNS, >60yo) pg 1174 |
|
|
How long do you have after starting abx before the CSF is sterilized?
|
2hrs
pg 1174 |
|
|
What are the abx of choice for pt's <50yo and >50yo?
|
<50yo - Rocephin 2g IV q 12 and Vanco 1-2g IV q 12
>50yo - Rocephin 2g IV q12, Vanco 1-2g IV q12, + Ampicillin 2g IV q4 pg 1174 |
|
|
What are some ways to treat cerebral edema (clinical evidence or imaging evidence)?
|
Elevate HOB >30, Mannitol, Hyperosmotic IVF
pg 1175 |
|
|
What should be considered in a pt with new psych sx, cognitive deficit, seizures, or movement disorders, +/- fever?
|
Encephalitis
pg 1176 |
|
|
Is imaging required for diagnosis of encephalitis?
|
Yes, not only to exlcude brain abscess, but also sensitive for HSV encephalitis
pg 1176 |
|
|
What is the agent of choice for HSV encephalitis and CMV encephalitis?
|
HSV - acyclovir
CMV - Ganciclovir pg 1176 |
|
|
What are some contraindications to LP?
|
Skin infx, increased ICP, Platelets <20,000 (>50,000 is safe), INR >1.5, on Heparin/ Lovenox, or trauma
pg 1178 |
|
|
What are some common complications seen in LPs?
|
Post LP HA, transtentorial herniation, or epidural hematoma
pg 1179 |
|
|
CSF shunt malfunctions are most commonly due to what and where?
|
Obstruction (proximal tubing, then distal, then valve chamber)
pg 1181 |
|
|
What are the preferred anti-HTN medications used in DM?
|
ACE-I and ARBs
pg 1429 |
|
|
ACE-I are effective in prevention and slowing the progression of what in diabetic pt's, regardless of their effect on BP?
|
Diabetic nephropathy
pg 1429 |
|
|
What are some typical drugs used to treat diabetic neuropathy?
|
Amitriptyline, Nortriptyline, Gabapentin, Prgabalin.
pg 1429 |
|
|
What is the characteristics of a diabetic foot ulcer that makes it concerning for a life-or-limb threatening infection?
|
>2cm, Deep ulcer, Odor or purulent discharge, fever, sepsis
pg 1430 |
|
|
What should always be considered in the setting of altered mental status?
|
Hypoglycemia
pg 1431 |
|
|
Which class of DMII medications causes the greatest risk for hypoglycemia?
|
Sulfonylureas (Glyburide, Glipizide)
pg 1426 |
|
|
Goal HbA1C is what for DMII pts?
|
<7%
pg 1415 and 1425 |
|
|
Failure to respond to parenteral glucose should prompt consideration for other causes of hypoglycemia such as?
|
Sepsis, toxin, insulinoma, hepatic failure, adrenal insufficiency.
pg 1432 |
|
|
What is the definition of Type 1 Diabetes Mellitus?
|
an absolute insulin deficiency and failure of the Beta-cells in the pancreas.
pg 1415 |
|
|
24yo M DM I pt with arrives by EMS confused, agitated, and slurring his speech. Primary survey is completed. During expose pt is found to have a pager sized device on his belt line with a catheter to his abdomen. What is the cause of his symptoms and what should be done?
|
Pt on Continuous Subcutaneous Insulin Infusion device should be thoroughly inspected for kink, empty reservoir, or priming errors.
pg 1416 |
|
|
How do you diagnose DKA and what is the txmt?
|
Dx: glucose >250, pH < 7.3, urine/serum ketones
Txmt: IVF (5-6L), Insulin drip, and electrolyte replacement (especially K+ up front with drips) pg 1436 |
|
|
At what point do you switch which type of fluid a DKA pt is receiving?
|
When the serum glucose reaches 250 D5% in 0.45 NS should be started.
pg 1435 |
|
|
At what rate should fluid resuscitation take place in a DKA pt?
|
first 2 liters over 2hrs, next 2 liters over 6hrs, next 2 liters over 12hrs
pg 1435 |
|
|
At what K+ level should you replace K+ and what level should you monitor?
|
If the K+ is 3.3 - 5.5 you should start replacing with the IVF and insulin drip.
If >5.5 monitor but be prepared to administer. pg 1435 |
|
|
What is the most life threatening factor in DKA?
|
Hyperkalemia
pg 1435 |
|
|
What is a contraindication to starting insulin therapy in a DKA pt?
|
K+ < 3.3
|
|
|
What is the end goal for treatment of DKA, how do you know when to d/c the insulin drip?
|
Insulin infusion should continue until the Anion gap and ketonemia has normalized.
pg 1437 |
|
|
T/F: Bicarb should be given to DKA pts with pH <7.10.
|
False: Pt's correct acidosis with IVFs and insulin
pg 1437 |
|
|
What can have a wide anion gap, serum ketones, and a normal glucose?
|
Alcoholic Ketoacidosis
pg 1439 |
|
|
What is the txmt for Alcoholic Ketoacidosis?
|
IVFs, glucose and electrolyte repletion
pg 1440 |
|
|
How is Hyperosmolar Hyperglycemic State defined?
|
severe hyperglycemia (>600), elevated serum osmolality >315, without serum Ketones
pg 1441 |
|
|
How do you treat HHS?
|
IVFs (10-12L), Insulin and electrolyte repletion.
pg 1443 |
|
|
Which is cerebral edema more evident in HHS or DKA?
|
DKA
pg 1443 |
|
|
What primary hyperthyroid dz is the most common?
|
Grave's Dz 85%
pg 1447 |
|
|
What cardiac med can induce hyperthyroidism?
|
Amiodarone (contains iodine)
pg 1447 |
|
|
What is the preferred txmt of hypothyroidism?
|
IV T4 >> T3. T4 is more stable and longer lasting. T3 is more rapid but has a highly fluctuating serum levels.
pg 1446 |
|
|
How do you treat hyperthyroidism?
|
Supportive care, PTU, then Iodine, Beta blocker (propanolol) Steroids (dexamethasone), then ablation or surgery
pg 1451 |
|
|
What is the most common iatrogenic cause of acute adrenal crisis?
|
withdrawal of steroids
pg 1453 |
|
|
What is the most common cause of primary adrenal insufficiency (Addison's Dz) world-wide and in the U.S.?
|
Tuberculosis - World
HIV - U.S pg 1453 |
|
|
What is the drug of choice in adrenal crisis or insufficiency?
|
Hydrocortisone 100mg for 3-4weeks, due to it's glucocorticoid and mineralocorticoid effects.
pg 1455 |
|
|
Testing distinction and txmt of Chlamydial infxn?
|
Nucleic Acid Amp Test (NAAT)
Azithromycin 1g PO or Doxycycline 100mg PO QD x 7 days pg 991 |
|
|
Testing distinction and txmt of Gonorrhea?
|
Intracellular diplococci
Ceftriaxone 125mg IM x1 pg 991 |
|
|
Testing distinction and txmtt of Trichomoniasis?
|
Flagellated Protezoan
Metronidazole 2g PO x1 pg 991 |
|
|
Testing distinction and txmt of bacterial vaginosis?
|
Clue cells (Gardnerella)
Metronidazole 500mg PO BID x 7days pg 991 |
|
|
Testing distinction and txmt Syphillis?
|
RPR or VDRL
Pen G 2.4million units IM q week x3 pg 991 |
|
|
Testing distinction and txmt of HSV?
|
PCR
Acyclovir 400mg PO TID x 7 days pg 991 |
