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Emergency Medicine Pearls Steven M. Hochman, MD FACEP Dept of Emergency Medicine St. Joseph’s Regional Med Center October 28, 2009.

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Presentation on theme: "Emergency Medicine Pearls Steven M. Hochman, MD FACEP Dept of Emergency Medicine St. Joseph’s Regional Med Center October 28, 2009."— Presentation transcript:

1 Emergency Medicine Pearls Steven M. Hochman, MD FACEP Dept of Emergency Medicine St. Joseph’s Regional Med Center October 28, 2009

2 Disclaimer Any similarity between the information in this lecture and any material published by the American Board of Osteopathic Emergency Medicine is entirely coincidental Any similarity between the information in this lecture and any material published by the American Board of Osteopathic Emergency Medicine is entirely coincidental Emergency medicine is in the public domain, and the dissemination of accurate, relevant and up-to-date information about the evaluation and care of emergency patients is in the best interests of the medical community as well as the general public Emergency medicine is in the public domain, and the dissemination of accurate, relevant and up-to-date information about the evaluation and care of emergency patients is in the best interests of the medical community as well as the general public

3 Part I Mnemonic Mania

4 Altered Mental Status DDx Alcohol, other drugsA Alcohol, other drugsA Endo/exocrine, electrolytesE Endo/exocrine, electrolytesE Insulin (DM)I Insulin (DM)I Oxygen (low), opiatesO Oxygen (low), opiatesO UremiaU UremiaU Trauma, temperatureT Trauma, temperatureT InfectionI InfectionI PsychiatricP PsychiatricP Space occupying lesions, stroke, shockS Space occupying lesions, stroke, shockS

5 Substances Removed by HD IsopropanolI IsopropanolI SalicylatesS SalicylatesS TheophyllineT TheophyllineT UremiaU UremiaU MethanolM MethanolM BarbsB BarbsB LithiumL LithiumL Ethylene glycol, ethanolE Ethylene glycol, ethanolE

6 Cholinergic Toxidrome (Muscarinic) DiarrheaD DiarrheaD UrinationU UrinationU MiosisM MiosisM BronchorrheaB BronchorrheaB BradycardiaB BradycardiaB EmesisE EmesisE LacrimationL LacrimationL SalivationS SalivationS

7 +AG Metabolic Acidosis CO, CyanideC CO, CyanideC AKAA AKAA TolueneT TolueneT MethanolM MethanolM UremiaU UremiaU DKAD DKAD Paraldehyde, PhenphorminP Paraldehyde, PhenphorminP INH, IronI INH, IronI Lactic AcidosisL Lactic AcidosisL Ethylene glycolE Ethylene glycolE SalicylatesS SalicylatesS

8 (-)AG Metabolic Acidosis HyperalimentationH HyperalimentationH Acetazolamide, AmphoteracinA Acetazolamide, AmphoteracinA RTAR RTAR DiarrheaD DiarrheaD Ureteral diversionsU Ureteral diversionsU Pancreatic fistulasP Pancreatic fistulasP Saline resuscitationS Saline resuscitationS

9 Elevated Osmolar Gap MethanolM MethanolM Ethanol, Ethylene GlycolE Ethanol, Ethylene GlycolE Diuretics (glyc, mann, sorb)D Diuretics (glyc, mann, sorb)D IsopropanolI IsopropanolI

10 Toxic Alcohols etc. +AG+OG+Ketones Ethanol-+- Eth Glycol ++- Isopropyl-++ Methanol+++- ASA+ - (slight) +

11 Serum Osmolarity S osm = 2 Na + BUN/2.8 + Gluc/18 + Ethanol/4.6 S osm = 2 Na + BUN/2.8 + Gluc/18 + Ethanol/4.6 Nl = 285 meq/L Nl = 285 meq/L

12 Toxics Induced Seizures (OTIS CAMPBELL) Oral hypoglycemics, organophosphates, opiates Oral hypoglycemics, organophosphates, opiates Theophylline, TCA’s Theophylline, TCA’s INH, insulin INH, insulin Salicylates, sympathomimetics Salicylates, sympathomimetics Camphor, CO, cocaine, cyanide Camphor, CO, cocaine, cyanide Amphetamines, anticholinergics, antihistamines Amphetamines, anticholinergics, antihistamines

13 Toxics Induced Seizures (OTIS CAMPBELL) Methylxanthines, mushrooms (gyromitra) Methylxanthines, mushrooms (gyromitra) PCP, paraldehyde, plants (jimson, belladonna alkaloids, water hemlock) PCP, paraldehyde, plants (jimson, belladonna alkaloids, water hemlock) B Blockers (propranolol), benzo/barb withdrawal B Blockers (propranolol), benzo/barb withdrawal Ethanol withdrawal Ethanol withdrawal Li, Lidocaine Li, Lidocaine Lead, Lindane, LSD Lead, Lindane, LSD

14 Abdominal Flat Plate (CHIPES) Chloral HydrateC Chloral HydrateC Heavy Metals (Fe, Pb)H Heavy Metals (Fe, Pb)H IodineI IodineI Phenothiazines, Packets (cocaineP heroine) Phenothiazines, Packets (cocaineP heroine) Enteric-coated productsE Enteric-coated productsE SolventsS SolventsS

15 Substances Not Bound to AC CausticsC CausticsC LithiumL LithiumL IronI IronI Methanol, MetalsM Methanol, MetalsM Ethylene glycol, other alcoholsE Ethylene glycol, other alcoholsE

16 Multiple Dose AC TCA’sT TCA’sT TheophyllineT TheophyllineT BarbiTuraTesT BarbiTuraTesT TegretolT TegretolT PhenyToinT PhenyToinT DigiTalisT DigiTalisT ASA?? ASA??

17 Whole Bowel Irrigation (PEG, 2L/hr, effluent clear) Fe, heavy metals Fe, heavy metals Lithium Lithium Sustained release, enteric-coated Sustained release, enteric-coated Body packers/stuffers Body packers/stuffers Foreign bodies (batteries) Foreign bodies (batteries)

18 Sick of this yet??

19 More Toxicology

20 Carbon Monoxide Poisoning Fires, propane, home heating (kerosine), engine exhaust (rare) Fires, propane, home heating (kerosine), engine exhaust (rare) Extremes of age, pregnancy (FETUS), CAD/pulmonary disease Extremes of age, pregnancy (FETUS), CAD/pulmonary disease CNS and CV systems most affected CNS and CV systems most affected COHb level—Nl 1-2%, smokers 5-10% COHb level—Nl 1-2%, smokers 5-10% Levels correspond poorly to Sx Levels correspond poorly to Sx

21 CO Treatment Elimination Elimination Room air 21%2-7 hrs (mean 4 hrs) Room air 21%2-7 hrs (mean 4 hrs) 100% 1 Atm90 min 100% 1 Atm90 min 100% 3 Atm23 min 100% 3 Atm23 min HBO—indications HBO—indications End organ damage—LOC, coma, Sz, persistent Sx End organ damage—LOC, coma, Sz, persistent Sx CoHb >25% or >15% in pregnancy CoHb >25% or >15% in pregnancy Abnl neuro exam, dysrhythmia, poor SaO2 Abnl neuro exam, dysrhythmia, poor SaO2

22 Gastric Lavage Ingestions potentially fatal or worsoning vital signs or MS Ingestions potentially fatal or worsoning vital signs or MS TCA’s, CCB’s, Li TCA’s, CCB’s, Li Preferably within 1 hour Preferably within 1 hour Protect airway, L lateral decub position Protect airway, L lateral decub position Adults 36-40 French, Peds 22-24+ French Adults 36-40 French, Peds 22-24+ French

23 Gastric Lavage Contraindications Contraindications Caustic ingestions Caustic ingestions Large FB’s, sharp objects Large FB’s, sharp objects Inability to protect airway Inability to protect airway Drug not accessible in stomach Drug not accessible in stomach Complications Complications Aspiration Aspiration Perforation Perforation Tension PTX, empyema Tension PTX, empyema Impaired oxygenation/ventilation Impaired oxygenation/ventilation

24 Acetaminophen Overdose Rule of 140’s Rule of 140’s

25 Acetaminophen Overdose Rule of 140 Rule of 140 Toxic dose 140 mg/kg Toxic dose 140 mg/kg 70 kg = 9.8 gms = 20 ES Tylenol 70 kg = 9.8 gms = 20 ES Tylenol

26 Acetaminophen Overdose Rule of 140 Rule of 140 Toxic level 140 mcg/ml (really 150) at 4 hours Toxic level 140 mcg/ml (really 150) at 4 hours Rumack-Matthew nomogram, single ingestion at known time Rumack-Matthew nomogram, single ingestion at known time

27 Acetaminophen Overdose Rule of 140 Rule of 140 Initial dose NAC 140 mg/kg po Initial dose NAC 140 mg/kg po Then 70 mg/kg q 4hrs X 17 doses Then 70 mg/kg q 4hrs X 17 doses Off label: 100 mg IV X3 doses over 20 hrs Off label: 100 mg IV X3 doses over 20 hrs

28 Acetaminophen Overdose Rule of 140 Rule of 140 Alternative: Acetadote 150 mg/kg IV over 1 hour Alternative: Acetadote 150 mg/kg IV over 1 hour 2 more doses over next 20 hrs 2 more doses over next 20 hrs

29 Acetaminophen Overdose APAP, ASA level on all suicide attempt pts APAP, ASA level on all suicide attempt pts 1/500 +tox level APAP without h/o APAP ingestion 1/500 +tox level APAP without h/o APAP ingestion Give AC to all; NAC if indicated (within 8hrs) Give AC to all; NAC if indicated (within 8hrs) Potential toxic ingestion Potential toxic ingestion Late presentation, ongoing toxicity Late presentation, ongoing toxicity Chronic overdose, ongoing toxicity Chronic overdose, ongoing toxicity Gastric lavage – only for coingestants Gastric lavage – only for coingestants

30 Acetaminophen Overdose If potential toxicity If potential toxicity LFT’s (AST, INR, Biliruben) LFT’s (AST, INR, Biliruben) Electrolytes, renal function studies Electrolytes, renal function studies New IV formulation: Acetadote New IV formulation: Acetadote 21 hr protocol 21 hr protocol Can use oral form IV ($18 vs. $416) – no good data Can use oral form IV ($18 vs. $416) – no good data

31 TCA Overdose -yline and -amine (nortriptyline,imipramine) -yline and -amine (nortriptyline,imipramine) Amitriptyline (Elavil) Amitriptyline (Elavil) Block reuptake of NE, DA, Seratonin at central synapses Block reuptake of NE, DA, Seratonin at central synapses ↑Catecholamines – initial HTN ↑Catecholamines – initial HTN Anticholinergic – hot, dry, agitated Anticholinergic – hot, dry, agitated Na Channel blockade – negative inotropy Na Channel blockade – negative inotropy Alpha blockade -- hypotension Alpha blockade -- hypotension Antihistamine effects – sedation Antihistamine effects – sedation GABA antagonism -- seizures GABA antagonism -- seizures

32 TCA Overdose Na channel blockade - Type 1A antiarrhythmic (quinidine-like) effects Na channel blockade - Type 1A antiarrhythmic (quinidine-like) effects Prolonged Phase 0 depolarization  QRS widening Prolonged Phase 0 depolarization  QRS widening EKG: Wide complex dysrhythmias EKG: Wide complex dysrhythmias Sinus tachycardia Sinus tachycardia Terminal 40 ms R axis deviation (Big R in aVR and Big S in aVL) Terminal 40 ms R axis deviation (Big R in aVR and Big S in aVL)

33 TCA Overdose EKG as screening tool EKG as screening tool QRS <100 ms – no significant toxicity QRS <100 ms – no significant toxicity QRS >100 ms – 1/3 had seizures QRS >100 ms – 1/3 had seizures QRS >160 ms – ½ had ventricular dysrhythmias QRS >160 ms – ½ had ventricular dysrhythmias

34 TCA Overdose Treatment Treatment Orogastric lavage if timely Orogastric lavage if timely AC 1 gm/kg AC 1 gm/kg MDAC ½ dose q2 hrs X1-2 MDAC ½ dose q2 hrs X1-2 Ativan, Valium for seizures Ativan, Valium for seizures NaHCO3 for dysrhythmias – 1-2 amps (Peds: 1-2 mEq/kg), repeat EKG NaHCO3 for dysrhythmias – 1-2 amps (Peds: 1-2 mEq/kg), repeat EKG Hyperventilation (serum pH goal 7.45-7.55) Hyperventilation (serum pH goal 7.45-7.55) IVF, pressors for hypotension IVF, pressors for hypotension

35 TCA Overdose Disposition Disposition 6 hour observation – no anticholinergic signs or seizures, nl MS and EKG, no Tx other than AC  DISCHARGE 6 hour observation – no anticholinergic signs or seizures, nl MS and EKG, no Tx other than AC  DISCHARGE Admit for Admit for QRS ≥ 100 ms QRS ≥ 100 ms Seizure, dysrhythmia, MS changes Seizure, dysrhythmia, MS changes ECG abnormalities  MICU, bicarb tx X 12-24 hrs ECG abnormalities  MICU, bicarb tx X 12-24 hrs

36 Zebras & Other Minutiae

37 What’s the Diagnosis? 28 yo male, painful joints, discharge from eyes, burning on urination 28 yo male, painful joints, discharge from eyes, burning on urination

38 Reiter’s Syndrome Triad: Arthritis, Urethritis, Conjunctivitis Triad: Arthritis, Urethritis, Conjunctivitis Spondyloarthropathy, reactive arthritis Spondyloarthropathy, reactive arthritis Mechanism unclear – post infect, AI? Mechanism unclear – post infect, AI? Leading cause inflam arthritis, young men Leading cause inflam arthritis, young men Dx: cervical/urethr swab (**Chlamydia), arthrocentesis, CBC/D, ESR Dx: cervical/urethr swab (**Chlamydia), arthrocentesis, CBC/D, ESR Tx: NSAIDs, sulfasalazine, Tx cervicitis/urethritis; f/u Rheumatology Tx: NSAIDs, sulfasalazine, Tx cervicitis/urethritis; f/u Rheumatology

39 What’s the Diagnosis? 45 yo white female 45 yo white female Recurrent episodes of Recurrent episodes of Eye pain, visual blurriness Eye pain, visual blurriness RLE weakness RLE weakness UE paresthesias UE paresthesias Episodes last up to several hours, with incomplete resolution Episodes last up to several hours, with incomplete resolution Symptoms progressively worse over months Symptoms progressively worse over months

40 Multiple Sclerosis Myelin sheath destruction, ?cause Myelin sheath destruction, ?cause Most commonly periventricular white matter Most commonly periventricular white matter Clinical Dx: 2+ episodes of neurological deficiency Clinical Dx: 2+ episodes of neurological deficiency Objective clinical signs >1 CNS lesion Objective clinical signs >1 CNS lesion Management: Refer to Neuro Management: Refer to Neuro MRI – periventricular plaques MRI – periventricular plaques

41 Multiple Sclerosis – S&S INO – deficiencies of abduct/adduction INO – deficiencies of abduct/adduction Optic neuritis – pain, visual impairment Optic neuritis – pain, visual impairment Transverse myelitis – spinal cord synd Transverse myelitis – spinal cord synd Diplopia Diplopia Ataxia, intention tremor Ataxia, intention tremor UMN signs – weakness, hyperreflex, Babinski’s signs UMN signs – weakness, hyperreflex, Babinski’s signs

42 Multiple Sclerosis – S&S Post column, spinothalamic involvement Post column, spinothalamic involvement Urinary Sx, constipation, sexual dysfunction Urinary Sx, constipation, sexual dysfunction Lhermitte’s sign – electric shock on flexion of neck Lhermitte’s sign – electric shock on flexion of neck

43 What’s the Diagnosis? 48 yo male, h/o lumbar disc disease 48 yo male, h/o lumbar disc disease Lower back pain, radiating down posterior thighs Lower back pain, radiating down posterior thighs Urinary incontinence Urinary incontinence B/L numbness of feet B/L numbness of feet Progressive difficulty ambulating Progressive difficulty ambulating Sx started 2 hours ago Sx started 2 hours ago

44 Cauda Equina Syndrome Compression of lumbar-sacral nerve roots Compression of lumbar-sacral nerve roots Below conus medularis (L1-L2) Below conus medularis (L1-L2) Disc herniation most common cause Disc herniation most common cause Also: trauma, mass effect from tumor, abscess Also: trauma, mass effect from tumor, abscess

45 Cauda Equina Syndrome Physical Exam Bladder or rectal dysfunction – retention or incontenence Bladder or rectal dysfunction – retention or incontenence LE sensory/motor deficits LE sensory/motor deficits Foot dorsiflexion (L5-S1), quadriceps, DTR’s Foot dorsiflexion (L5-S1), quadriceps, DTR’s Perineal sensation – saddle anesthesia Perineal sensation – saddle anesthesia Reduced rectal tone (S3-4-5) Reduced rectal tone (S3-4-5) Absent anal wink Absent anal wink Straight leg raise – sciatica Straight leg raise – sciatica

46 Cauda Equina Syndrome Management Emergent MRI – Confirm Dx and levels Emergent MRI – Confirm Dx and levels But do not delay treatment But do not delay treatment Immediate Neurosurgery Consult Immediate Neurosurgery Consult Methylprednisolone 30+5.4 for trauma Methylprednisolone 30+5.4 for trauma Emergent decompression – improves outcomes Emergent decompression – improves outcomes 6-24 hours – controversy 6-24 hours – controversy >48 hours, ?still benefit >48 hours, ?still benefit

47 Optho Emergencies I-X

48 Opthalmology I Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn

49 Opthalmology I Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn ORBITAL RUPTURE ORBITAL RUPTURE

50 Opthalmology I Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn ORBITAL RUPTURE ORBITAL RUPTURE +Seidel test, NO TONOMETRY +Seidel test, NO TONOMETRY TX: Eye shield (not patch), keep pt still, ABX TX: Eye shield (not patch), keep pt still, ABX Emergent Optho consult Emergent Optho consult

51 Opthalmology II Sudden painless monocular vision loss Sudden painless monocular vision loss PE: Afferent pupil defect PE: Afferent pupil defect Fundoscopic: pale retina, cherry red spot at fovea Fundoscopic: pale retina, cherry red spot at fovea

52 Opthalmology II Sudden painless monocular vision loss Sudden painless monocular vision loss PE: Afferent pupil defect PE: Afferent pupil defect Fundoscopic: pale retina, cherry red spot at fovea Fundoscopic: pale retina, cherry red spot at fovea CENTRAL RETINAL ARTERY OCCLUSION CENTRAL RETINAL ARTERY OCCLUSION TX: Intermittant digital massage TX: Intermittant digital massage OPTHO CONSULT (paracentesis of anterior chamber) OPTHO CONSULT (paracentesis of anterior chamber)

53 Opthalmology III Sudden painless monocular vision loss Sudden painless monocular vision loss Less severe than last case Less severe than last case Fund: Blood and thunder retina (retinal hemorrhages, tortuous retinal veins) Fund: Blood and thunder retina (retinal hemorrhages, tortuous retinal veins)

54 Opthalmology III Sudden painless monocular vision loss Sudden painless monocular vision loss Less severe than last case Less severe than last case Blood and thunder retina (retinal hemorrhages, tortuous retinal veins) Blood and thunder retina (retinal hemorrhages, tortuous retinal veins) CENTRAL RETINAL VEIN OCCLUSION CENTRAL RETINAL VEIN OCCLUSION RF’s: DM, HTN, hyperviscosity RF’s: DM, HTN, hyperviscosity Refer to Optho – confirm Dx and monitor complications; Tx: most ineffective Refer to Optho – confirm Dx and monitor complications; Tx: most ineffective

55 Opthalmology IV Pt entered movie theater, then c/o eye pain, N/V, blurred vision, “halos” around lights Pt entered movie theater, then c/o eye pain, N/V, blurred vision, “halos” around lights PE: Fixed, mid-dilated NR pupil, scleral injection, hazy cornea PE: Fixed, mid-dilated NR pupil, scleral injection, hazy cornea

56 Opthalmology IV Pt entered movie theater, then c/o eye pain, N/V, blurred vision, “halos” around lights Pt entered movie theater, then c/o eye pain, N/V, blurred vision, “halos” around lights Fixed, mid-dilated NR pupil, scleral injection, hazy cornea Fixed, mid-dilated NR pupil, scleral injection, hazy cornea ACUTE NARROW ANGLE GLAUCOMA ACUTE NARROW ANGLE GLAUCOMA

57 Opthalmology IV ACUTE NARROW ANGLE GLAUCOMA ACUTE NARROW ANGLE GLAUCOMA Shallow ant chamber, iris sits too tightly on lens Shallow ant chamber, iris sits too tightly on lens Resistance of flow of aquaeous humor, elevated IOP (>40) Resistance of flow of aquaeous humor, elevated IOP (>40) Farsighted elderly women Farsighted elderly women

58 Opthalmology IV TREATMENT: TREATMENT: Acetazolamide, Beta blockers (timolol) (decrease production) Acetazolamide, Beta blockers (timolol) (decrease production) Cholinergics (pilocarpine) (increase flow) Cholinergics (pilocarpine) (increase flow) Depress head (separates lens + iris) Depress head (separates lens + iris) E-F-Glycerol, Mannitol (hyperosmotics) E-F-Glycerol, Mannitol (hyperosmotics) Steroids (topical prednisolone) (antiinflamm) Steroids (topical prednisolone) (antiinflamm) EMERGENCY OPTHO CONSULT EMERGENCY OPTHO CONSULT

59 Opthalmology V Painful monocular central vision loss Painful monocular central vision loss Preservation of peripheral vision Preservation of peripheral vision PE: APD, +/- disc swelling PE: APD, +/- disc swelling

60 Opthalmology V Painful monocular central vision loss Painful monocular central vision loss Preservation of peripheral vision Preservation of peripheral vision PE: APD, +/- disc swelling PE: APD, +/- disc swelling OPTIC NEURITIS OPTIC NEURITIS Associated with MS, Lyme, Neurosyphilis, Lupus, Sarcoid, ETOH, toxins Associated with MS, Lyme, Neurosyphilis, Lupus, Sarcoid, ETOH, toxins OPTHO consult, IV steroids (methylprednisolone) OPTHO consult, IV steroids (methylprednisolone)

61 Opthalmology VI Neonate, sticky discharge, conjunctival inflammation Neonate, sticky discharge, conjunctival inflammation 6-8 hrs after birth 6-8 hrs after birth

62 Opthalmology VI Neonate, sticky eye discharge, conjunctival inflammation Neonate, sticky eye discharge, conjunctival inflammation 6-8 hrs after birth 6-8 hrs after birth CHEMICAL CONJUNCTIVITIS CHEMICAL CONJUNCTIVITIS

63 Opthalmology VI Neonate, sticky discharge, conjunctival inflammation Neonate, sticky discharge, conjunctival inflammation 6-8 hrs after birth 6-8 hrs after birth CHEMICAL CONJUNCTIVITIS CHEMICAL CONJUNCTIVITIS TX: AgNO3, resolves 24-48 hrs TX: AgNO3, resolves 24-48 hrs

64 Opthalmology VII Neonate, sticky, purulent discharge, conjunctival inflammation Neonate, sticky, purulent discharge, conjunctival inflammation 2-5 days after birth 2-5 days after birth

65 Opthalmology VII Neonate, sticky purulent discharge, conjunctival inflammation Neonate, sticky purulent discharge, conjunctival inflammation 2-5 days after birth 2-5 days after birth GONONORRHEAL CONJUNCTIVITIS GONONORRHEAL CONJUNCTIVITIS Aggressive, can ulcerate/perforate cornea in hrs/days Aggressive, can ulcerate/perforate cornea in hrs/days

66 Opthalmology VII Neonate, sticky purulent discharge, conjunctival inflammation Neonate, sticky purulent discharge, conjunctival inflammation 2-5 days after birth 2-5 days after birth GONONORRHEAL CONJUNCTIVITIS GONONORRHEAL CONJUNCTIVITIS Aggressive, can ulcerate/perforate cornea in hrs/days Aggressive, can ulcerate/perforate cornea in hrs/days TX: Topical erythro, IV ceftriaxone, irrigation TX: Topical erythro, IV ceftriaxone, irrigation Optho consult Optho consult

67 Opthalmology VIII Neonate, sticky discharge, conjunctival inflammation Neonate, sticky discharge, conjunctival inflammation 5-14 days after birth 5-14 days after birth

68 Opthalmology VIII Neonate, sticky discharge, conjunctival inflammation Neonate, sticky discharge, conjunctival inflammation 5-14 days after birth 5-14 days after birth CHLAMYDIA CONJUNCTIVITIS CHLAMYDIA CONJUNCTIVITIS Leading cause of preventable blindness worldwide Leading cause of preventable blindness worldwide Most common of last three; assoc nasopharyngitis Most common of last three; assoc nasopharyngitis

69 Opthalmology VIII Neonate, sticky discharge, conjunctival inflammation Neonate, sticky discharge, conjunctival inflammation 5-14 days after birth 5-14 days after birth CHLAMYDIA CONJUNCTIVITIS CHLAMYDIA CONJUNCTIVITIS Leading cause of preventable blindness worldwide Leading cause of preventable blindness worldwide Most common; assoc nasopharyngitis Most common; assoc nasopharyngitis TX: Oral and topical erythromycin TX: Oral and topical erythromycin

70 Opthalmology IX Painless vision loss, spider webs across visual field, curtain coming down Painless vision loss, spider webs across visual field, curtain coming down Fund: retinal tears, vitreous hemorrhages Fund: retinal tears, vitreous hemorrhages

71 Opthalmology IX Painless vision loss, spider webs across visual field, curtain coming down Painless vision loss, spider webs across visual field, curtain coming down Fund: retinal tears, vitreous hemorrhages Fund: retinal tears, vitreous hemorrhages RETINAL DETACHMENT RETINAL DETACHMENT

72 Opthalmology IX Painless vision loss, spider webs across visual field, curtain coming down Painless vision loss, spider webs across visual field, curtain coming down Fund: retinal tears, vitreous hemorrhages Fund: retinal tears, vitreous hemorrhages RETINAL DETACHMENT RETINAL DETACHMENT TX: Keep pt still, Optho consult TX: Keep pt still, Optho consult Retinal attachment surgery Retinal attachment surgery

73 Opthalmology X 58 yo female, sudden monocular vision loss, ipselateral headache 58 yo female, sudden monocular vision loss, ipselateral headache PE: AFD; Fund: pale swollen optic disc PE: AFD; Fund: pale swollen optic disc

74 Opthalmology X 58 yo female, sudden monocular vision loss, ipselateral headache 58 yo female, sudden monocular vision loss, ipselateral headache PE: AFD; Fund: pale swollen optic disc PE: AFD; Fund: pale swollen optic disc TEMPORAL ARTERITIS TEMPORAL ARTERITIS Vasculitis med-large arteries, can cause optic nerve infarction Vasculitis med-large arteries, can cause optic nerve infarction F>M, 50+ yo F>M, 50+ yo

75 Opthalmology X TX: IV methylprednisolone, Optho/IM consult TX: IV methylprednisolone, Optho/IM consult DX: Temporal artery biopsy DX: Temporal artery biopsy DO NOT DELAY TX PENDING DEFINITIVE DX DO NOT DELAY TX PENDING DEFINITIVE DX

76 Most Common…

77 Most Common: Metabolic abnormality in newborns: Metabolic abnormality in newborns:

78 Most Common: Metabolic abnormality in newborns: Metabolic abnormality in newborns: Hypoglycemia Hypoglycemia

79 Most Common: Metabolic abnormality in newborns: Metabolic abnormality in newborns: Hypoglycemia Hypoglycemia Rhythm in pediatric cardiac arrest: Rhythm in pediatric cardiac arrest:

80 Most Common: Metabolic abnormality in newborns: Metabolic abnormality in newborns: Hypoglycemia Hypoglycemia Rhythm in pediatric cardiac arrest: Rhythm in pediatric cardiac arrest: Bradycardias Bradycardias

81 Most Common: Metabolic abnormality in newborns: Metabolic abnormality in newborns: Hypoglycemia Hypoglycemia Rhythm in pediatric cardiac arrest: Rhythm in pediatric cardiac arrest: Bradycardias Bradycardias Site in pediatric esophagus where foreign bodies trapped: Site in pediatric esophagus where foreign bodies trapped:

82 Most Common: Metabolic abnormality in newborns: Metabolic abnormality in newborns: Hypoglycemia Hypoglycemia Rhythm in pediatric cardiac arrest: Rhythm in pediatric cardiac arrest: Bradycardias Bradycardias Site in pediatric esophagus where foreign bodies trapped: Site in pediatric esophagus where foreign bodies trapped: Cricopharngeal narrowing (C6) Cricopharngeal narrowing (C6)

83 Most Common: Cause of syncope during normal pregnancy: Cause of syncope during normal pregnancy:

84 Most Common: Cause of syncope during normal pregnancy: Cause of syncope during normal pregnancy: Vasovagal Vasovagal

85 Most Common: Cause of syncope during normal pregnancy: Cause of syncope during normal pregnancy: Vasovagal Vasovagal Cause of maternal death in 1 st trimester: Cause of maternal death in 1 st trimester:

86 Most Common: Cause of syncope during normal pregnancy: Cause of syncope during normal pregnancy: Vasovagal Vasovagal Cause of maternal death in 1 st trimester: Cause of maternal death in 1 st trimester: Ectopic pregnancy (1.5% of all pregnancies) Ectopic pregnancy (1.5% of all pregnancies)

87 Most Common: Cause of syncope during normal pregnancy: Cause of syncope during normal pregnancy: Vasovagal Vasovagal Cause of maternal death in 1 st trimester: Cause of maternal death in 1 st trimester: Ectopic pregnancy (1.5% of all pregnancies) Ectopic pregnancy (1.5% of all pregnancies) Medical cause of death in pregnant women (overall): Medical cause of death in pregnant women (overall):

88 Most Common: Cause of syncope during normal pregnancy: Cause of syncope during normal pregnancy: Vasovagal Vasovagal Cause of maternal death in 1 st trimester: Cause of maternal death in 1 st trimester: Ectopic pregnancy (1.5% of all pregnancies) Ectopic pregnancy (1.5% of all pregnancies) Medical cause of death in pregnant women (overall): Medical cause of death in pregnant women (overall): Pulmonary embolism Pulmonary embolism

89 Most Common: Obstructive cardiac lesion in the elderly: Obstructive cardiac lesion in the elderly:

90 Most Common: Obstructive cardiac lesion in the elderly: Obstructive cardiac lesion in the elderly: Aortic stenosis Aortic stenosis

91 Most Common: Obstructive cardiac lesion in the elderly: Obstructive cardiac lesion in the elderly: Aortic stenosis Aortic stenosis Valvular heart disease in industrialized countries: Valvular heart disease in industrialized countries:

92 Most Common: Obstructive cardiac lesion in the elderly: Obstructive cardiac lesion in the elderly: Aortic stenosis Aortic stenosis Valvular heart disease in industrialized countries: Valvular heart disease in industrialized countries: Mitral valve prolapse (3% of population) Mitral valve prolapse (3% of population)

93 Most Common: Obstructive cardiac lesion in the elderly: Obstructive cardiac lesion in the elderly: Aortic stenosis Aortic stenosis Valvular heart disease in industrialized countries: Valvular heart disease in industrialized countries: Mitral valve prolapse (3% of population) Mitral valve prolapse (3% of population) Presenting symptom of L heart failure, MS, AI, all other acute valvular disorders: Presenting symptom of L heart failure, MS, AI, all other acute valvular disorders:

94 Most Common: Obstructive cardiac lesion in the elderly: Obstructive cardiac lesion in the elderly: Aortic stenosis Aortic stenosis Valvular heart disease in industrialized countries: Valvular heart disease in industrialized countries: Mitral valve prolapse (3% of population) Mitral valve prolapse (3% of population) Presenting symptom of L heart failure, MS, AI, all other acute valvular disorders: Presenting symptom of L heart failure, MS, AI, all other acute valvular disorders: Dyspnea, especially on exertion Dyspnea, especially on exertion

95 Most Common: Radiographic finding in aortic dissection: Radiographic finding in aortic dissection:

96 Most Common: Radiographic finding in aortic dissection: Radiographic finding in aortic dissection: Widened mediastinum Widened mediastinum

97 Most Common: Radiographic finding in aortic dissection: Radiographic finding in aortic dissection: Widened mediastinum Widened mediastinum Top three cardiovascular diseases in US, in order: Top three cardiovascular diseases in US, in order:

98 Most Common: Radiographic finding in aortic dissection: Radiographic finding in aortic dissection: Widened mediastinum Widened mediastinum Top three cardiovascular diseases in US, in order: Top three cardiovascular diseases in US, in order: (1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined) (1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined)

99 Most Common: Radiographic finding in aortic dissection: Radiographic finding in aortic dissection: Widened mediastinum Widened mediastinum Top three cardiovascular diseases in US, in order: Top three cardiovascular diseases in US, in order: (1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined) (1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined) Symptom of acute pericarditis: Symptom of acute pericarditis:

100 Most Common: Radiographic finding in aortic dissection: Radiographic finding in aortic dissection: Widened mediastinum Widened mediastinum Top three cardiovascular diseases in US, in order: Top three cardiovascular diseases in US, in order: (1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined) (1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined) Symptom of acute pericarditis: Symptom of acute pericarditis: Precordial or SS CP, described as sharp or stabbing Precordial or SS CP, described as sharp or stabbing

101 Most Common: Physical finding in acute pericarditis: Physical finding in acute pericarditis:

102 Most Common: Physical finding in acute pericarditis: Physical finding in acute pericarditis: Pericardial friction rub (??) Pericardial friction rub (??) Cause of acute arterial occlusion in limb: Cause of acute arterial occlusion in limb:

103 Most Common: Physical finding in acute pericarditis: Physical finding in acute pericarditis: Pericardial friction rub (??) Pericardial friction rub (??) Cause of acute arterial occlusion in limb: Cause of acute arterial occlusion in limb: Embolus (80-90% originate in heart) Embolus (80-90% originate in heart)

104 Most Common: Physical finding in acute pericarditis: Physical finding in acute pericarditis: Pericardial friction rub (??) Pericardial friction rub (??) Cause of acute arterial occlusion in limb: Cause of acute arterial occlusion in limb: Embolus (80-90% originate in heart) Embolus (80-90% originate in heart) Most common infection and 5 th leading COD in elderly: Most common infection and 5 th leading COD in elderly:

105 Most Common: Physical finding in acute pericarditis: Physical finding in acute pericarditis: Pericardial friction rub (??) Pericardial friction rub (??) Cause of acute arterial occlusion in limb: Cause of acute arterial occlusion in limb: Embolus (80-90% originate in heart) Embolus (80-90% originate in heart) Most common infection and 5 th leading COD in elderly: Most common infection and 5 th leading COD in elderly: Pneumonia Pneumonia

106 Most Common: Viral agent implicated in post-transplant pulmonary infection: Viral agent implicated in post-transplant pulmonary infection:

107 Most Common: Viral agent implicated in post-transplant pulmonary infection: Viral agent implicated in post-transplant pulmonary infection: Cytomegalovirus Cytomegalovirus

108 Most Common: Viral agent implicated in post-transplant pulmonary infection: Viral agent implicated in post-transplant pulmonary infection: Cytomegalovirus Cytomegalovirus Cause of abdominal pain in adults presenting to ED: Cause of abdominal pain in adults presenting to ED:

109 Most Common: Viral agent implicated in post-transplant pulmonary infection: Viral agent implicated in post-transplant pulmonary infection: Cytomegalovirus Cytomegalovirus Cause of abdominal pain in adults presenting to ED: Cause of abdominal pain in adults presenting to ED: Nonspecific abdominal pain Nonspecific abdominal pain

110 Most Common: Viral agent implicated in post-transplant pulmonary infection: Viral agent implicated in post-transplant pulmonary infection: Cytomegalovirus Cytomegalovirus Cause of abdominal pain in adults presenting to ED: Cause of abdominal pain in adults presenting to ED: Nonspecific abdominal pain Nonspecific abdominal pain GI diagnosis in ED patients above age 50: GI diagnosis in ED patients above age 50:

111 Most Common: Viral agent implicated in post-transplant pulmonary infection: Viral agent implicated in post-transplant pulmonary infection: Cytomegalovirus Cytomegalovirus Cause of abdominal pain in adults presenting to ED: Cause of abdominal pain in adults presenting to ED: Nonspecific abdominal pain Nonspecific abdominal pain GI diagnosis in ED patients above age 50: GI diagnosis in ED patients above age 50: Biliary tract disease Biliary tract disease

112 Most Common: Surgical emergency in older patients with abdominal pain: Surgical emergency in older patients with abdominal pain:

113 Most Common: Surgical emergency in older patients with abdominal pain: Surgical emergency in older patients with abdominal pain: Acute cholecystitis Acute cholecystitis

114 Most Common: Surgical emergency in older patients with abdominal pain: Surgical emergency in older patients with abdominal pain: Acute cholecystitis Acute cholecystitis Symptom of abdominal aortic aneurism: Symptom of abdominal aortic aneurism:

115 Most Common: Surgical emergency in older patients with abdominal pain: Surgical emergency in older patients with abdominal pain: Acute cholecystitis Acute cholecystitis Symptom of abdominal aortic aneurism: Symptom of abdominal aortic aneurism: Abdominal pain Abdominal pain

116 Most Common: Surgical emergency in older patients with abdominal pain: Surgical emergency in older patients with abdominal pain: Acute cholecystitis Acute cholecystitis Symptom of abdominal aortic aneurism: Symptom of abdominal aortic aneurism: Abdominal pain Abdominal pain Diagnostic mistake in patients with AAA: Diagnostic mistake in patients with AAA:

117 Most Common: Surgical emergency in older patients with abdominal pain: Surgical emergency in older patients with abdominal pain: Acute cholecystitis Acute cholecystitis Symptom of abdominal aortic aneurism: Symptom of abdominal aortic aneurism: Abdominal pain Abdominal pain Diagnostic mistake in patients with AAA: Diagnostic mistake in patients with AAA: Diagnosing renal colic in these pts Diagnosing renal colic in these pts

118 Most Common: Rhythm disturbance in PE: Rhythm disturbance in PE:

119 Most Common: Rhythm disturbance in PE: Rhythm disturbance in PE: Sinus tachycardia (on Boards pts: S1Q3T3) Sinus tachycardia (on Boards pts: S1Q3T3)

120 Most Common: Rhythm disturbance in PE: Rhythm disturbance in PE: Sinus tachycardia (on Boards pts: S1Q3T3) Sinus tachycardia (on Boards pts: S1Q3T3) ECG abnormality in PE: ECG abnormality in PE:

121 Most Common: Rhythm disturbance in PE: Rhythm disturbance in PE: Sinus tachycardia (on Boards pts: S1Q3T3) Sinus tachycardia (on Boards pts: S1Q3T3) ECG abnormality in PE: ECG abnormality in PE: Non-specific ST-T wave changes Non-specific ST-T wave changes

122 Most Common: Rhythm disturbance in PE: Rhythm disturbance in PE: Sinus tachycardia (on Boards pts: S1Q3T3) Sinus tachycardia (on Boards pts: S1Q3T3) ECG abnormality in PE: ECG abnormality in PE: Non-specific ST-T wave changes Non-specific ST-T wave changes CXR abnormality in PE: CXR abnormality in PE:

123 Most Common: Rhythm disturbance in PE: Rhythm disturbance in PE: Sinus tachycardia (on Boards pts: S1Q3T3) Sinus tachycardia (on Boards pts: S1Q3T3) ECG abnormality in PE: ECG abnormality in PE: Non-specific ST-T wave changes Non-specific ST-T wave changes CXR abnormality in PE: CXR abnormality in PE: Infiltrate or atelectasis (50%), Elevated hemidiaphragm +/- pleural effusion (40%), NORMAL (30%) Infiltrate or atelectasis (50%), Elevated hemidiaphragm +/- pleural effusion (40%), NORMAL (30%)

124 Thank you for your Attention Thank you for your Attention


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