Misc Pearls

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Misc Pearls

Aspirin allergy: asthma and nasal polyps

5 causes of eosinophilia:

	Parasites
	Asthma/allergies
	Connective tissue disease
	Adrenal insufficiency
	Cancer

Management of non-ulcer dyspepsia

	H2 blockers, PPIs
	Prokinetic agents (metoclopramide)
	Treatment of H. pylori infection
	Endoscopy if > 55 yo, recent onset of symptoms or change in sxs

Extraesophageal manifestations of GERD

Pulmonary

	asthma
	aspiration pneumonia
	interstitial pulmomary fibrosis
	chronic bronchitis
	bronchiectasis
	cystic fibrosis

ENT

	hoarseness
	chronic cough
	throat clearing
	chronic laryngitis
	globus sensation
	vocal cord ulcers
	laryngeal cancer
	halitosis
	otalgia
	chronic sinusitis
	croup
	stridor
	dysphonia
	abnormal taste

Evaluating Dizziness

	Vertigo (rotational sensation)
	Presyncope (impending faint)
	Disequilibrium (loss of balance without head sensation caused by visual impairment, peripheral neuropathy, vestibulopathy, CNS disease, musculoskeletal disease)

Causes of lower extremity edema:

Cardiac

	CHF
	Diastolic dysfunction (hypertrophic cardiomyopathy)
	Aortic stenosis
	Stenosis of the inferior vena cava
	Atrial fibrillation
	Mitral regurgitation

Sleep apnea

Obesity

Pulmonary

Pulm HTN

Medications

	NSAIDs
	Corticosteroids
	Ca++ channel blockers

Venous stasis

Lymphatic obstruction

Nephrotic syndrome

Glomerulonephritis

Cirrhosis

Cellulitis

DVTs

Miscellaneous High Impact Cases

Acute Pulmonary Edema

Presentation

[ Acute SOB

[ Cough with pink frothy sputum

[ Orthopnea, CHF sx

[ Hx of MI, CHF, COPD?

[ Orthopnea? PND?

[ Trauma?

[ VS à Tm? Tachypneic?

[ HEENT: Perioral cyanosis, JVD?

[ CV: Loud S2 (Pulmonic component), S3

[ Pulm: Bilateral rales

[ Ext: Peripheral cyanosis, edema

DDx

[ Pneumonia

[ PE

[ Asthma/COPD

[ ARDS

[ Pleural effusions

[ MI

[ Tamponade

[ Aortic Stenosis

Labs

[ CBC c diff, ABGs, BMP, Coags, Cardiac Enzymes

[ EKG

[ CXR – bilateral fluffy perihilar inflitrates, Kerley Bs, effusions

[ Spiral CT (if suspect PE)

Treatment

[ O2 à Recheck ABGs à if no response may need intubation and PPV

[ Lasix – 40-100 IV bolus

[ Nitro

[ Morphine

[ Sit up in bed

[ ACEi, Dobutamine

Status Asthmaitcus (Asthma)

Presentation

[ Worsening cough, dypnea, chest tightness, wheeze

[ Sitting forward, diaphoretic, dyspneic

[ Prior hosp? Prior intubation? Fulminating attacks? Frequent ED visits?

[ Recent URI?

[ VS: Tachypnea, Tachycardia, Pulsus paradoxus

[ HEENT: Pallor, Diaphoresis

[ CV: Tachy

[ Pulm: Accessory muscle use, wheezes, if silent or no wheeze à bad sign

[ ABD: Paradoxical movement (bad)

DDx

[ Asthma Exacerbation

[ COPD

[ Pneumonia

[ Acute Pulmonary Edema

[ PE

LABS

[ ABGs

[ CBC c diff

[ EKG

[ CXR

[ PFTs/PEFR (before & after nebs)

[ O2

[ Beta 2 nebs

[ IV steroids

[ Ipratropium (if Beta 2s fail)

[ Epinephrine

Pearls

[ Clues to severe attack

[ Pulsus paradoxus > 15 mmHg

[ Tachypnea > 30/min

[ HR > 120 bpm

Acute GI Bleed

Presentation

[ Hx of large hematemesis or hematochezia

[ May be shocky

[ Hematemesis/hematochezia

[ EtOH use?

[ Hx of PUD

[ Abd pain

[ VS: ñ HR, òBP

[ CV: Tachy

[ ABD: Epigastric pain, look for protruberant vessels

[ Ext: Cold & clammy

[ Rectal

DDx

[ Hemorrhagic shock

[ Esophageal varices/perf

[ Gastric ulcer/perf

[ Lower GI Bleed

Labs

[ Type & Cross-Match

[ CBC c diff, BMP, LFTs, Coags, Amylase/Lipase

[ CXR, ABD XR upright and flat plate (free air?)

[ EGD (if upper)

[ If shocky à 2 large bore Ivs à lot ‘o’ fluid til blood arrives

[ O2

[ PRBCs & FFP

[ Esophageal à Minnesota type balloon tamponade

[ If portal HTN à Propranolol, Isordil

[ If gastric ulcer à Omeprazole, NG suction test for heme, Triple therapy

Pearls

[ EGD findings indicative of major bleed à pulsating artery at base; clot at base; active bleed

[ Indications for surgery in bleeding ulcer à =>2 recurrent or intractable ulcers; perf; obstruction; malignancy; exsanguination

Acute Spinal Cord Compression

Presentation

[ Acute onset extremity weakness, loss of bowel/bladder function, paresthesias

[ Trauma?

[ Unilateral vs bilateral? Focal defecits?

[ Bowel/bladder dysfunction?

[ When is worse à AM/PM?

[ NEURO: Absent or òDTRs; Muscle weakness. (May see UMN signs depending on site of lesion)

DDx

[ Spinal Stenosis, Ruptured disc, Tumor, Siactica, Trauma, Psychogenic, Spondylolithesis, Brown-Sequard syndrome, Fracture, Osteomalacia, Paget’s disease, Muscle Strain, OA, DJD, Ank Spond

LAB

[ MRI

[ Spinal XR (if suspect trauma)

[ High dose steroids – dexamethasone 10 mg (PRIOR TO MRI)

[ Immediate Neurosurgery consult

Altered Mental Status

Presentation

[ Confusion, disorientation, coma

DDx

[ Trauma: subdural, epidural, concussion, contusion

[ Metabolic

[ Exogenous: intoxication, withdrawal, carbon monoxide

[ Endogenous: Hypoglycemia, adrenal insufficiency, hypo/hyperthyroidism (esp. in elderly), hyperparathyroidism

[ Fluids/Electrolyte imbalances

[ Hypoxia

[ Thiamine deficiency

[ Organ failure: renal, liver, respiratory

[ Meningitis, encephalopathy

[ Tumors

[ Depression

[ Seizures

[ CVA

[ òCO

[ Alzheimer’s dementia, Normal pressure hydrocephalus

[ Hypo/hyperthermia

[ Meds: (narcotics, illicit drug use, h2 blockers, digitalis, benzos, TCAs, atropine, scopolamine)

[ Trauma?

[ HA, Hemi paresis, Atazia, vomiting?

[ EtOH?

[ DM?

[ Systemic illness? Liver, kidney, etc.

[ Psych hx

[ VS: HoTN, Tachy/Brady?, Fever, Tachypneic

[ HEENT: NCAT? Papilledema, pinpoint pupils, CNs, Tympanic hemorrhage/OM

[ NECK: Nuchal rigidity, bruits, thyroid

[ CV: irregularly irregular pulse (A. Fib), new murmur?

[ ABD: HSM, ascites

[ SKIN: jaundice, angiomas, petechiae

[ NEURO: FND? DTRs

LAB

[ CBC w diff, BMP, LFTSs

[ Dextrose stick

[ ABGs

[ Serum ammonia, TSH, DOA, UA

[ CXR, CT of head

[ LP

EKG