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?