Category: NBME Shelf Review

NBME Shelf Review (Part 11) – OBGYN

Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age!
  • It changes the differential diagnosis
  • It changes the medications you can give
  • It changes the tests you can order
Vaginal Bleeding Pearls
  • Non-pregnant vaginal bleeding
    • Order a pelvic ultrasound (for structural causes)
    • Order a CBC and coagulation panel (for anemia and coagulopathy)
  • Pregnant vaginal bleeding
    • If sick…
      • Think ectopic pregnancy (early pregnancy)
      • Think uterine rupture (late established pregnancy)
      • Think placental abruption (recent trauma or cocaine)
    • Don’t forget to order a type and screen
      • Rh- mothers will need RhoGam
    • If patient is unstable and you can’t wait for blood type…
      • Transfuse type O negative blood
  • Postpartum vaginal bleeding
    • Most common cause is retained products of conception
      • Order an ultrasound
    • Consider endometritis if patient also has fever
      • Treat with clindamycin and gentamycin
Vaginal Discharge Pearls
  • Cervical motion tenderness?
    • Pelvic Inflammatory Disease (PID)
  • Thin, grey, and smells like fish?
    • Bacterial vaginosis (BV)
      • Treat with metronidazole
      • Warn patient not to mix metronidazole with alcohol
  • Thick like cottage cheese?
    • Vulvovaginal candidiasis
      • Diagnosis with KOH prep
        • Look for yeast and pseudohyphae
      • Treat with fluconazole
  • Thin Yellow/Green and “frothy”?
    • Trichomoniasis
      • Diagnose with wet prep
      • Look for mobile organisms
      • Treat with metronidazole
      • Partners should be checked and treated too
Ovarian Torsion

Severe and sudden pain

  • Can be intermittent
  • Diagnose with Pelvic ultrasound with Doppler
  • PITFALL: Frequently has normal arterial flow (dual blood supply to ovary)
Additional Reading

NBME Shelf Review (Part 10) – Miscellaneous

Stroke
  • Most appropriate initial tests
    • Blood Glucose
      • Hypoglycemia is a common stroke mimic
    • CT Head without contrast
      • Rules out HEMORRHAGIC strokes
Subarachnoid Hemorrhage
  • Classic description
    • “Worst headache of life”
    • “Sudden and maximal in onset”
    • “Thunderclap”
  • Testing
    • CT Head without contrast
    • (If negative CT) Lumbar puncture
      • Xanthochromia (yellowish fluid)
  • Treatment
    • Nimodipine (Given orally)
      • Prevents vasospasm
Causes of Stroke in Young People
  • Cervical artery dissection
  • Vasospasm
  • Vasculitis
  • Sickle Cell Disease
Meningitis
  • Treatment
    • Vancomycin, Ceftriaxone
    • Add ampicillin (covers listeria) in very young/old
    • Rifampin prophylaxis for close contacts (if patient has petechial rash)
      • Neisseria Meningitidis
HSV Encephalitis
  • Classic symptoms
    • Fevers
    • Headache
    • Altered Mental Status
    • Seizures
  • Treat with acyclovir
Altered Mental Status
  • The two most common causes on your test
    • Hypoglycemia
    • Infections (Especially in elderly)
      • Aka Delirium
Fat embolism
  • Trauma PLUS petechial rash
  • Common with long bone fracture
Schaphoid Fracture
  • Exam shows tenderness over anatomic “snuffbox”
  • Notorious for being missed on X-ray
    • High risk of osteonecrosis
  • If suspicious, place patient in thumb spica splint regardless of X-ray findings
    • Outpatient followup 1-2 weeks for repeat xray
Pericarditis
  • Patient complains of chest pain that is…
    • Sharp
    • Positional
    • Worse when laying flat
  • Friction rub on exam
  • EKG Findings
    • Diffuse ST segment elevation
    • Diffuse PR depression
  • Treat with NSAIDS
Kawasaki’s Disease
  • Mnemonic: CRASH and Burn
    • Conjunctivitis
    • Rash
    • Adenopathy
    • Strawberry Tongue
    • Hands/Feet Swelling
    • Burn = Fever for 5 days
  • Treat with aspirin

Burns

  • Parkland formula
    • Weight (kg) x BSA (%) x 4 = Volume of fluid needed in first 24 hours
    • Give half over first 8 hours
  • Rule of 9s
    • Estimates % Body surface area burned

Vascular Injury

  • Hard Signs
    • If present patient needs OR
    • Mnemonic: ABCDE
      • Active pulsatile hemorrhage
      • Bruit
      • Cerebral ischemia
      • Diminished Distal pulses
      • Expanding Hematoma
Infectious Disease Pearls
  • Gram positive cocci in CLUSTERS
    • Staphylococcus Aureus
  • Gram positive cocci in CHAINS
    • Streptococcus Pneumoniae
Additional Reading

NBME Shelf Review (Part 9) – Cardiopulmonary

Pulmonary Embolism
  • Three types of pulmonary embolism
    • “Massive”
      • Hypotension or severe bradycardia
        • Treat with tPA or thrombectomy
    • “Submassive”
      • Normotensive but with Right Heart Strain
      • S1Q3T3 on EKG
      • Elevated BNP
      • Elevated troponin
      • Dilation of RV on ultrasound
        • Treat with heparin/lovenox and admit
    • “Low Risk”
      • Treat with anticoagulation
      • Outpatient vs inpatient treatment
  • Testing
    • CTA of the Chest
      • If severe contrast allergy or other contraindication
        • Ventilation/Perfusion (V/Q) Scan
Inferior STEMI
  • EKG shows ST elevation in 2, 3, aVF
  • Can involve AV node (bradycardia)
    • Avoid beta blockers
    • Treat with atropine
  • Can involve RV (preload dependent)
    • Avoid nitroglycerine
    • Treat with fluids
Common to Nitroglycerine
  • Hypotension
  • Current sildenafil usage
Aortic Dissection
  • Type A (ascending) Dissection
    • Surgical emergency
  • Type B (descending) Dissection
    • Medical management
  • Testing
    • CTA of the chest
    • Chest X-Ray SOMETIMES shows a widened mediastinum
  • Treatment
    • Esmolol (decrease heart rate)
    • Labetelol (decrease blood pressure)
  • PEARL: Aortic dissection can cause STEMI
Heart Failure
  • Treatment
    • Diuresis
    • Nitroglycerin
    • BiPAP
  • If patient needs fluids
    • Decrease size of fluid bolus
COPD
  • Treatments
    • Albuterol/Ipratropium
    • Antibiotics
    • Steroids
    • BiPAP
Pneumonia
  • If alcoholic/homeless/dementia/parkinson’s
    • Treat for aspiration (anaerobes)
  • If recent hospitalization/ventilator
    • Treat for pseudomonas and MRSA
  • If pneumonia PLUS atypical symptoms
    • Treat for legionella
  • If recent influenza
    • Treat for MRSA
Additional Reading

NBME Shelf Review (Part 8) – Abdominal Pain

Acute Mesenteric Ischemia
  • History of atrial fibrillation
  • “Pain out of proportion to exam”
Bowel Obstruction
  • History
    • Abdominal pain
    • Bloating/Distention
    • Vomiting
    • Decrease stool/flatus
  • Exam
    • Abdominal tenderness and distention
    • If guarding/rigidity/rebound tenderness (aka peritonitis)
      • Consider perforated bowel
  • Testing
    • Obtain CT abdomen with IV contrast
  • Treatment
    • Fluids
    • NPO
    • NG Tube
Acute Diverticulitis
  • NOTE: DiverticulOSIS is what causes GI bleeding
  • History/Exam
    • Fever
    • Left lower quadrant pain/tenderness
  • Testing/Treatment
    • CT abdomen with IV contrast
    • Liquid diet
    • Antibiotics
  • Complications
    • Abscess
    • Stricture
    • Fistula
    • Perforation
    • Obstructions

Abdominal Aortic Aneurysm

  • If suspected, perform bedside ultrasound of the abdomen
    • Aortic diameter >3 cm
Spontaneous Bacterial Peritonitis
  • Diagnose by performing a paracentesis
    • Look for >250 white blood cells
  • Treat with ceftriaxone

Kidney Stones

  • CT without contrast
  • If the stone is <5mm
    • Treat with analgesics and tamsulosin
  • If the stone is >5mm
    • Consult urology
Common Indications for Emergency Dialysis
  • Mnemonic: AEIOU
    • Acidosis (pH <7.1)
    • Electrolytes (K > 6.5)
    • Intoxication
      • Lithium
      • Ethylene Glycol
      • Methanol
      • Aspirin
    • Overload of volume resistant to diuresis
    • Uremia that is symptomatic
      • Altered mental status
      • Pericarditis
Ectopic Pregnancy
  • Testing
    • BhCG QUANTITATIVE
    • Type and screen for Rh Status
    • Pelvic ultrasound
      • IUP = Gestational sac PLUS a Yolk sac
      • Beware “heterotopic” pregnancy in fertility treatment patients (IVF)
    • Treatment
      • If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG
        • If <1500
          • Consider sending stable patients home and repeat hCG in 48 hours
        • If >1500
          • Ectopic until proven otherwise, consult OBGYN
      • Rh- needs RhoGAM
        • Prevents complications in future pregnancies
Additional Reading

NBME Shelf Review (Part 7) – Abdominal Pain

Hernia
  • 3 classifications for hernia
    • Reducible
      • Able to be reduced (placed back into the abdomen) at bedside
    • Incarcerated
      • Cannot be reduced but not severely tender or erythematous
      • Can occasionally cause bowel obstructions
    • Strangulated
      • Cannot be reduced but LOSING BLOOD SUPPLY
      • Extremely tender and abnormal exam
      • Needs emergent surgical consult
Esophageal Varices
  • Classic presentation
    • Hematemesis/Melena
    • Chronic liver disease (hepatitis, alcoholics)
  • Treatment
    • Fluid bolus if hypotensive
    • Octreotide
    • Ceftriaxone
    • Transfuse blood as needed
      • If hemoglobin <7 transfuse
      • If patient actively bleeding and level <8 transfuse
  • Consult GI for endoscopy
Hepatic Encephalopathy
  • Common findings
    • Altered mental status
    • Asterixis
    • Elevated ammonia level
  • Treat with lactulose or rifamixin
Peptic Ulcer Disease
  • History
    • Hematemesis or Melena
    • Epigastric abdominal pain
    • Chronic NSAIDS or steroids
  • Treatment
    • PPI (such as pantoprazole)
      • Works better than an H2 blocker
Cholecystitis
  • RUQ ultrasound
    • Thickened gallbladder wall
    • Distended gallbladder
    • Pericholecystic fluid
    • Obvious impacted stone
  • HIDA scan
    • Inject radioactive material
    • Absorbed by hepatocytes
    • Secreted into biliary tree into small intestine
      • If gallbladder not visualized
        • Cystic duct obstruction
      • If common bile duct cannot be visualized
        • Choledocolithiasis
Ascending Cholangitis
  • Charcots Triad
    • Fever
    • RUQ Pain
    • Jaundice
  • Patient requires ERCP (gastroenterology consult)
  • Give antibiotics
Acute Pancreatitis
  • Diagnosis
    • Classic description
      • Epigastric pain radiating to back
      • Severe vomiting
    • Lipase
      • >3x upper limit of normal is diagnostic
    • CT scan to look for complications of pancreatitis
Additional Reading

NBME Shelf Review (Part 6) – Common Arrhythmias

“Unstable” Arrhythmias
  • Arrhythmias that cause
    • Hypotension
    • Pulmonary Edema
    • Chest Pain
    • Altered Mental Status
Supraventricular Tachycardia (SVT)
  • Stable
    • Vagal maneuver
    • Adenosine
    • Beta blocker or calcium channel blocker
  • Unstable
    • SYNCHRONIZED cardioversion
Monomorphic Ventricular Tachycardia (VT)
  • Stable
    • Amiodarone
    • Procainamide
    • Lidocaine
  • Unstable
    • SYNCHRONIZED cardioversion
  • Pulseless
    • Defibrillation

Polymorphic Ventricular Tachycardia (aka Torsades de Pointes)

  • Known complication of prolonged QTc
    • Side effect of multiple medications
      • Antipsychotics
      • Methadone
      • Ondansetron
  • Give Magnesium Sulfate
High yield EKG patterns
  • Long QTc
  • Wolf Parkinson White (WPW)
  • Brugada Pattern
Atrial Fibrillation
  • Stable
    • Patient presents immediately after onset (<24-48 hours)
      • Synchronized cardioversion
      • Rhythm control medications
        • Amiodarone
        • Procainamide
        • Flecanide
  • Patient does not present immediately (or unknown onset)
    • Rate control
      • Beta blockers
        • Metoprolol
      • Calcium channel blocker
        • Diltiazem
    • Anticoagulation (heparin)
  • Unstable
    • Synchronized cardioversion
  • Atrial fibrillation with extremely fast rate (200+) is common in WPW
  • Atrial fibrillation with slow rate is common with Digoxin toxicity
Bradycardia
  • AV Blocks
    • 1st Degree
    • 2nd degree (type 1)
    • 2nd degree (type 2)
    • 3rd degree
  • If symptomatic and stable…
    • Atropine
  • If they become unstable…
    • Transcutaneous or transvenous pacing
Additional Reading

NBME Shelf Review (Part 5) – Ophthalmology and Toxicology

Corneal Abrasion
  • Stain the eye with fluorescein and use woods lamp
    • Look for fixed staining (“uptake”) on the cornea
Acute Angle Closure Glaucoma
  • Symptoms
    • Eye Pain
    • Headache
  • Check for intraocular pressure greater than 20
  • Commonly precipitants
    • OTC cough/cold medicine (anticholinergic effect)
    • Dark environment (such as movie theater)
  • Treatment
    • Timolol
    • Pilocarpine
    • Acetazolamide
    • Apraclonidine
Giant Cell Arteritis
  • Common features
    • Severe headache
    • Tenderness of the Temporal Arteries
    • Jaw claudication
    • Elevated ESR (“sed rate”)
  • Treat with steroids
Anterior Uveitis
  • Painful red eye
  • Cell and flair on slit lamp examination
UV Keratitis (“snow blindness”)
  • Common in skiers/snowboarders
  • Diagnose with fluorescein and use woods lamp
    • Punctate lesions on the cornea
Common Poisons/Antidotes
  • Digoxin toxicity
    • Digibind
  • Acetaminophen toxicity
    • N-Acetylcysteine (NAC)
  • Ethylene glycol or methanol toxicity
    • Fomepizole
  • Jimson weed (anticholinergic toxicity)
    • Physostigmine
  • Organophosphate toxicity
    • Atropine
      • Treat until airway secretions have stopped
    • Pralidoxime
  • Opiate toxicity
    • Naloxone
  • Benzodiazepine
    • Flumazenil (falling out of favor)
  • Cocaine toxicity
    • DON’T give beta blockers
      • Unopposed alpha effect
      • Very little data to support this but commonly believed
  • Iron toxicity
    • Deferoxamine
  • Salicylate overdose
    • Sodium bicarbonate
    • Dialysis
  • Tricyclic antidepressent
    • Sodium bicarbonate
  • Beta blocker overdose
    • Glucagon
    • Calcium channel blocker overdose
    • Glucagon
    • IV Calcium
    • High dose euglycemic insulin therapy
  • Sulfonylurea overdose
    • Octreotide
    • Dextrose
  • Heparin reversal
    • Protamine sulfate
  • Cyanide toxicity (common in house fires)
    • Hydroxocobalamin
    • Sodium Nitrite
  • Carbon monoxide toxicity
    • Oxygen oxygen oxygen
    • Hyperbaric oxygen
      • BEWARE: pulse oximetry will be normal
  • Valproic acid toxicity
    • L-carnitine
Additional Reading

NBME Shelf Review (Part 4) – Environmental

General Bite Wound Management
  • Irrigate thoroughly
  • Update tetanus
  • LOW RISK bites get sutured
    • High risk bites to cosmetic areas (face) get sutured AND antibiotics
    • High risk bites to non-cosmetic areas are left open AND get antibiotics
Rabies
  • Give vaccine if…
    • ANY suspicion for bat bite (bat in room, cave, etc)
    • Bite by wild animal that can’t be monitored
    • Bite by domestic animal that develops symptoms during observation
Black widow spider
  • Painful bite
  • Symptoms
    • Abdominal pain
    • Diaphoresis
    • Myalgias
    • Muscle spasms/cramping
  • Supportive care
Pit Viper Bite
  • Causes Coagulopathy/DIC
  • Swelling around bite site
  • Treat with CroFab antivenin
Brown Recluse Bite
  • Painless bite
  • Ulceration/necrosis around bite site
Altitude Illnesses
  • Acute Mountain Sickness (AMS)
    • Headache
    • Nausea and vomiting
    • Treat with acetazolamide or decent
  • High Altitude Pulmonary Edema (HAPE)
    • Shortness of breath
    • Treat with supplemental oxygen and immediate decent
    • Consider nifedipine or sildefenil
  • High Altitude Cerebral Edema
    • Ataxia
    • Confusion
    • Cushings reflex
      • Bradycardia
      • Hypertension
      • Cheyne-Stokes respirations
    • Treat with supplemental oxygen and immediate decent
    • Consider dexamethasone
Digit Amputation
  • Wrap in saline soaked gauze
  • Put in plastic bag
  • Place on ice
  • Send to surgeon
Tooth avulsion
  • Reimplant tooth in socket
  • Place in glass of milk
Frostbite
  • Remove wet clothing
  • Rewarm at body temperature
Additional Reading

NBME Shelf Review (Part 3) – Pediatrics

Febrile Seizures
  • Simple (All features must be present)
    • Age 6 months – 5 years
    • Febrile
    • Lasts less than 15 minutes
    • Only one seizure in 24 hour period
    • No focal neuro deficits on exam
    • Generalized seizure (must have LOC)
      • Treat with acetaminophen and reassurance
  • Complex
    • Does not meet ALL of the criteria for a simple febrile seizure
      • Consider full workup including lumbar puncture
Pediatric Abdominal Pain
  • Intussusception
    • Classic history
      • Severe emesis
      • INTERMITTENT severe abdominal pain
    • Common causes
      • Meckles diverticulum
      • Henoch-Schonlein purpura
    • Diagnose with abdominal ultrasound
      • Look for target sign
    • Treat with air enema
  • Malrotation with Volvulus
    • Classic symptoms
      • Bilious emesis
      • Projectile
      • CONSTANT severe abdominal pain
      • Peritonitic abdominal exam
    • Common tests (if stable)
      • Upper GI Series
        • Corkscrew sign
        • Coffee-bean sign
  • Necrotizing Enterocolitis
    • Classic symptoms
      • Premature neonate
      • Bloody stool
    • X-Ray shows pneumotosis intestinalis
      • (Air in the bowel wall)
  • Hirschsprungs Disease
    • Delayed passage of meconium
    • Diagnosis
      • Contrast enema (not typically done in ED)
        • Look for distal transition point
      • Rectal suction biopsy (DEFINITELY not done in the ED)
        • Gold standard for diagnosis
Bronchiolitis
  • Commonly caused by RSV
  • Initial fever and URI
    • Progresses to respiratory distress
Croup (laryngotrachealbronchitis)
  • Commonly caused by parainfluenza
  • Initial fever and URI
    • Progresses to stridor
    • Barky cough
  • Neck xray will show “steeple sign” (subglottic narrowing)
  • Treatment
    • Steroids
    • Nebulized epinephrine
Epiglottitis
  • Commonly caused by Haemophilus influenzae¬†
  • Classic symptoms
    • Fever
    • Sore throat
    • Drooling
    • Muffled voice
  • Treatment
    • Keep the child calm
    • Intubation in a controlled environment
    • Antibiotics
Additional Reading

NBME Shelf Review (Part 2) – Trauma

Penetrating Abdominal Trauma
  • Anything below the 4th intercostal space (nipple) is potentially an abdominal injury
    • Gunshot wounds to the abdomen
      • Needs immediate exploratory laparotomy
    • Stab wounds to the abdomen
      • Needs immediate exploratory laparotomy IF…
        • Hemodynamically unstable
        • Peritonitis on exam (rebound, rigidity, guarding)
        • Organs hanging out of abdomen
Blunt Abdominal Trauma
  • If the patient is unstable
    • Perform FAST exam
  • If the patient is stable
    • CT scan of the abdomen/pelvis with contrast
Basilar Skull Fracture
  • Bilateral post-auricular ecchymosis (Battle’s Sign)
  • Raccoon eyes
  • Hemotympanum
  • Otorrhea/Rhinorrhea
Tension Pneumothorax
  • Classic findings
    • Hypotension
    • Obstructive shock
    • Absent breath sounds
    • Jugular vein distension (JVD)
  • Treatment
    • Needle decompression
      • 2nd intercostal space
      • Mid-clavicular line
    • Tube thoracostomy
Hemothorax
  • Hypotension
    • Hemorrhagic shock
  • Absent breath sounds
  • NO jugular vein distension
Cardiac Tamponade
  • Beck’s Triad
    • Hypotension
      • Obstructive shock
    • Jugular vein distension
    • Muffled heart sounds
  • Perform bedside ultrasound
    • Diastolic collapse of right ventricle (RV)
  • EKG
    • Electrical alterans
Traumatic Aortic Rupture
  • Rapid deceleration injuries
  • Tears at ligamentum arteriosum
  • Widened mediastinum on chest X-Ray
Pulmonary Contusion
  • Blunt chest trauma
  • Respiratory distress
    • NO paradoxical chest movement with breathing
  • Chest X-Ray
    • Shows non-lobar infiltrates
    • Located near location of injury
Additional Reading

NBME Shelf Review (Part 1) – General Concepts

General Approach to a Test Question
  • Read the last sentence of the question
  • Read the answer choices
  • THEN read the vignette
Common Scenarios with Quick Answers
  • Hypotensive patients
    • Give a fluid bolus
  • Altered mental status
    • Check a blood glucose
  • Hypoglycemia
    • Orange juice if can swallow safely
    • D50 if patient cannot swallow and mildly altered
    • IM glucagon if unresponsive
  • Patient with altered mental status and possible drug overdose
    • Give empiric naloxone
  • Female patients of childbearing age
    • Get a pregnancy test
  • If you need to give contrast for a CT scan (example CTA for pulmonary embolism)
    • Need renal function
Hyperkalemia
  • Common scenarios
    • Crush injury
    • Severe burns
    • End stage renal disease
    • Especially if missed dialysis
    • Leukemia on chemotherapy
  • Remember: Don’t give succinylcholine to a patient with hyperkalemia
  • Common EKG findings on test
    • Hyperacute T waves
    • Sinusoidal waves
  • Treatment
    • Stabilizes cardiac cell membranes
      • Calcium
    • Shifts potassium into the cells
      • Insulin/Glucose
      • Albuterol
      • Sodium Bicarbonate
    • Removes potassium
      • Furosemide
      • Dialysis
      • Kayexalate
Hypokalemia
  • EKG findings
    • Flattened T waves
    • QTC prolongation
    • U waves
  • At risk for ventricular arrhythmias
  • Treatment
    • Oral potassium replacement
    • IV potassium replacement
    • Consider magnesium replacement
Hyponatremia
  • Hypertonic saline IF
    • Comatose
    • Actively seizing
  • Otherwise treat with normal saline
  • Pseuohyponatremia
    • Correct the sodium if patient has severe hyperglycemia
    • Add 1.6 to sodium for every 100 glucose above normal limit
Hypercalcemia
  • Symptoms
    • “Stones, bones, groans, psychiatric overtones”
  • Treatment
    • IV fluids (promotes excretion) FIRST
    • Then calcitonin/bisphosphates
Torsade de Pointes
  • Common in patients with prolonged QTc
    • Hypokalemia
    • Hypocalcemia
  • Treat with magnesium
Additional Reading

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