ITE Pearls

  1. Overall most common cause of septic arthritis is S Aureus. In sexually active young person think of N gonorrhea.  In sickle cell patients consider Salmonella.

  2. Volvulus

    • Older person with volvulus —> sigmoid volvulus

    • Young person with volvulus —> cecal volvulus (think marathon runner)

  3. Most common cause of seizure in new born = hyponatremia

  4. Hypsarrhythmia on EEG —> infantile spasms which are sudden muscle contractions that occur in infants

  5. Tracheitis vs epiglottitis

    • Tracheitis – a prodromal viral illness over a few days then acutely sick appearing

    • Epiglottitis – acutely sick appearing kid with no prodromal infection/thumbprint sign on lateral x ray

    • Keep these kids calm, avoid heroic interventions, and admit to OR for airway

  6. Mushroom toxicity

    • Early GI symptoms (within hours) after mushroom exposure has good prognosis

    • Delayed GI symptoms (6-20 hours) after mushroom exposure has poor prognosis

    • Amatoxin, mushroom toxin that can cause liver toxicity

  7. Epidural head bleed: temporal bone injury, lucid interval, middle meningeal artery, lens shape on CT

  8. Distinguish serotonin syndrome from malignant hyperthermia by presence of clonus

  9. Anterior sternoclavicular dislocations are more common. Posterior dislocations are more dangerous (vascular structures compromised). CT scan is most accurate for diagnosis.

  10. Complications of MI

    • >24hrs —> thromboembolism, myocardial or valve rupture (new murmur post MI), CHF, pericarditis

    • 4wks later —> Dressler’s syndrome: autoimmune pericarditis

  11. Dyspnea is the most common present symptom in patients with PE

  12. Rubella (German measles) hallmark is generalized lymphadenopathy with 3-day rash

  13. Pediatric shock:

    • warm shock high CO and low SVR à norepinephrine

    • cold shock low CO and high SVR à epinephrine

  14. Bupropion lowers the seizure threshold

  15. TB treatment side effects

    • Rifampin: orange body fluids, hepatitis, low platelets.

    • Isoniazid: neuritis (B6 deficiency), hepatitis, seizure in OD (give B6).

    • Pyrazinamide: hepatitis, high uric acid > gout.

    • Ethambutol: optic neuritis.

  16. Earliest sign of ACS on ECG is: hyperacute T waves

  17. Prinzmetal’s angina = pain at night, ecg with stemi, resolve with nitro

    • Treat with CCB

  18. ASA and defibrillation have shown to have mortality benefit in patients with acute MI

  19. Child with pancreatitis à suspect cystic fibrosis

  20. Scorpion stings cause severe local pain reaction. <10% of scorpions have toxic venom. Toxins affect Na channels. Can cause cardiac, neuronal, or cholinergic side effects. Some scorpion venoms are associated with pancreatitis.

  21. Anticholinergic toxidrome can be distinguished from a sympathomimetic one by the absence of diaphoresis

  22. Lateral neck x rays should be obtained with neck extension during full inspiration for best visualization of retropharyngeal abscesses

  23. Cranial nerve III palsy (eye is down and out)

    • with sparing of pupil (spares the parasympathetic fibers running superficially on CN III)

      • in diabetics due to microvascular occlusions

      • in non-diabetics consider ocular myasthenia

    • with dilated pupil posterior communicating artery aneurysm (compresses on parasympathetic fibers)

  24. ASC class of hemorrhagic shock

    • I (0-15%, <750cc): normal vitals

    • II (15-30%, <1500cc): tachycardia

    • III (30-40%, <2000cc): hypotension

    • IV (>40%, >2000cc): AMS/lethargic

  25. Small bowel obstruction most commons causes: adhesions > neoplasms > hernia

  26. Wrist fractures

    • Colle’s fracture: distal radial fx with posterior dislocation at wrist

      • Can cause median nerve injury

    • Smith fracture: distal radial fx with anterior dislocation at wrist (reverse Colle’s fx)

    • Barton fracture: intra articular distal radial fx with displaced carpal bones

  27. Diarrhea + seizure -> Shigella

  28. Biphasic T wave in V2/3 or deep inverted T —> Wellen’s —> high grade LAD lesion

  29. Malingering have a secondary gain vs. Munchausen the secondary gain is medical attention (i.e. will undergo procedures)

  30. Trauma in pregnancy >24weeks —> 4 hour cardiotocography to look for placenta abruption

  31. High output heart failure: Thyrotoxicosis, chronic anemia, large AVMs, Paget’s disease of bone

  32. Unstable C spine fractures Jefferson Bit Off A Hangman's Toe

    • Jefferson fx (C1 burst fracture, due to axial load)

    • Bilateral facet joint dislocation (due to hyperflexion)

    • Odontoid fx (Type II neck/III body)

    • Altantoaxial dislocation (C1/C2 dislocation)

    • Hangman's fx (bilateral C2 pedicle fracture 2/2 hyperextension)

    • Teardrop fx (anterior and inferior vertebral body fx with interspinous ligament rupture, due to flexion > extension)

  33. Pingecula does not invade cornea as opposed to a pterygeum

  34. Herpangina - Coxackie virus – hand foot and mouth disease

  35. Ehrlichiosis is spotless RMSF. It is a tick borne illness similar to RMSF (rocky mountain spotted fever) in terms of treatment and complications except it is spotless and lives in WBC causing leukopenia.

  36. Typhoid fever: salmonella typhii, food/water borne

    • 1-2wk incubation then fatigue, fever, HA, abd pain and then

    • rose spot rash, anemia, elevated LFT’s, relative bradycardia

    • leukopenia in kids, leukocytosis in adults

    • Tx with FQ or 3rd gen Cephalosporin

  37. Babesiosis: tick borne protozoa, lives in RBC causing hemolytic anemia, tx with atrovaquone

  38. Prostaglandin E: keEps ductus arteriosus open - major complication of prostaglandin E: hypotension and apnea

  39. Huffing glue - hydrocarbon overdose - causes pulmonary toxicity or arrhythmia - tx supportive

  40. Jelly fish sting tx with vinegar which inactivates the toxin

  41. Blast injury types

    • Type I Blast Wave Pressure (hollow viscous injury)

    • Type II Debris from blast/Shrapnel

    • Type III Trauma from pt thrown/hit objects

    • Type IV everything else (burns, smoke, radiation, etc.)

  42. Methanol - vision changes vs. Ethylene glycol - kidney stones

  43. Isopropyl alcohol - coma and ketosis not acidosis

  44. West nile virus - flu like illness in 20%, 1% develop encephalitis, flaccid paralysis anterior horn cells, tx supportive

  45. Stroke patterns

    • same side face and body - cerebral

    • different side face and body - brainstem

    • coma and small pupils - pons

    • ataxia and dizziness - cerebellar

  46. Lead (Pb) toxicity, lead lines on x rays, toxicity can lead to brain edema - tx dimercaprol, EDTA

  47. MUDPILES for anion gap metabolic acidosis - Test yourself and check answer here

  48. Brown recluse spider - local necrotic lesions vs. black widow spider - severe spasms and vomiting

  49. Cahrcot's triad RUQ pain, fever, jaundice - add AMS and hypotension for Reynol'ds pentad

  50. Most common cause of inherited coagulopathy causing PE = factor V Leiden

  51. Corynebacterium diphtheria - in unvaccinated child, diphtheria toxin makes pseudomembranous layer in oropharynx obstructing airway

  52. Methanol converts to formic acid affecting vision and brain - tx ethanol, folate, bicarbonate, dialysis

  53. Poison Hemlock plant - immediate GI symptoms followed by autonomic instability then respiratory failure and convulsions

  54. Ciguatera toxin - most common fish poison in USA

    • Fish: groupers, red snappers, barracuda

    • Symptoms

      • GI distress

      • Neuro: muscle weakness and paresthesia (reverse temperature sensation, teeth fall out)

    • tx supportive

  55. Scombroid toxicity - peppery taste in fish - histamine like toxicity

  56. Mengitis and age diagram

    • < 1month – GBS, E coli, Listeria

      1. Ampicillin and cefotaxime

    • 1mo to 23 mo – GBS, E coli, S pneumo, Hib

      1. vanc and ceftriaxone

    • 2yo to 49 yo – Strep Pneumo, N Mening

      1. vanc and ceftriaxone

    • > 50 year or immune suppressed – strep pneumo, N mening, Listeria

      1. vanc, ceftriaxone, ampicillin

  57. Avoid succinylcholine in patients with hyperK -> crush injury, major burn, stroke, spinal injuries (after 5 days of incident, resolves after 6mo) - musculoskeletal dystrophy MS ALS (do not forget about these muscle disorders)

  58. NMDA OD - hallucinations, interpersonal emotions, hyperthermia, hypoNa, stimulatory symptoms like teeth grinding

  59. garlic smell in OD = arsenicselenium, or organophosphate Vs. almond smell in OD = Cyanide

  60. bidirectional ventricular tachycardia is pathognomonic for digoxin OD

  61. hemorrhagic mediastinitis - think anthrax pneumonia

  62. diarrhea buzz words

    • seizure and fever = shigella

    • pet turtles, amphibians, eggs = salmonella

    • seafood, oysters = vibrio

    • pseudo appendicitis and bloody diarrhea = yersinia

    • backpacker/camper and water = giardia

  63. when to CT scan for kidney injury in trauma - gross hematuria (blood at meatus), hypotension with microscopic hematuria, significant decelerationinjury. 

    • No need to image patients with minor flank pain or isolated microscopic hematuria

  64. legg calve perthes LCP vs slipped slipped capital femoral epiphysis SCFE (both boys> girls)

    • LCP (avascular necrosis)

      • younger than 10 – around 6yo

      • slow course

    • SCFE

      • older than 10 – usually 13yo

      • obese

      • acute

  65. QT prolonged + hearing loss = Jervell lange Nielson disease

  66. trigeminal neuralgia can be tx with carbamazebine. pt should follow up with neurology and obtain brain MRI for risk of MS or brain lesion

  67. NMS vs SS treatment:

    • NMS: dantrolene/bromocriptine and benzo

    • SS: cyproheptadine

  68. central cord injury occurs from hyperEXTension while anterior cord injury occurs from hyperFLEXion

  69. hydrofluoric acid exposure - crosses skin and binds Mag and Ca --> hypo Mag and hypo Ca and delayed hypo K - tx by applying topical mag and Ca

  70. beta block OD tx - 

    • 1st fluids, atropine, glucagon, Calcium, epi/norepi 

    • then 2nd high dose insulin 

    • then 3rd line lipid emulsion

  71. tumor lysis syndrome electrolytes - hyperKhyperPhoshypoCahyperurecemia

  72. submandibular gland is the most common site of sialolithiasis

  73. retropharyngeal abscess on lateral x ray,  numbers to remember

    • >7 or 14cm at C2 or C6 respectively in kids

    • >7 and 21cm in adults

  74. Chalazion is painless vs Stye is painful

  75. Uveitis is a complication in patients with oligoarticular juvenile arthritis --> early ophtho consult

  76. Reactive arthritis or Reiter’sarthritisuveitisurethritis. Follows recent chlamydia infection or dysentery (campylobacter, salmonella, shigella, Yrsenia). Tx: NSAIDS, can add doxy or rifampin

  77. Pediatric handle bar injuries: can have delayed hollow viscus or pancreaticinjuries

  78. Changes in pregnancy

    • Increase tidal volume but same respiratory rate

    • Increase GFR

    • Increase plasma volume, HbWBC counts

  79. Breast milk vs breast feeding jaundice (both unconjugated hyperbili)

    • Breast FEEDing jaundice: 1st week of life, increase FEEDing

    • Breast milk jaundice: after 1st week of life, stop breast milk x2 days then resume

  80. B Pertussis phases

    • Incubation for 8wks then Catarrhal: 1-2 wks of URI sx, highly contagious phase

    • Paroxysmal: 1-6 wks of whooping cough

    • Convalescent: 2-3 wks with increase susceptibility to other infections esp. PNA

  81. food born illness

    • S aureus: ham/eggs/poultry, vomiting toxin, 1-6hr onset, lasts 8 hrs

    • C perfringes: meat/poultry, in vivo toxin, 6-12hr onset, lasts 24h

    • V parahemolyticus: raw fish, direct intestinal invasion and enterotoxin, explosive watery diarrhea and bloody stool

    • B Cereus: 2 types

      • rice, toxin mediated with acute vomiting similar to S Aureus in presentation 

      • in vivo toxin mediated similar to C perfringes

  82. most common PNA in kids

    • 6mo to 5 year: RSV > S Pneumo, tx   amoxicillin

    • 5yr to 15 year: M Pneumo and C tracho, tx erythromycin

  83. cutaneous candidiasis à satellite papules and pustules beyond margins of a macerated weeping patch

  84. Mississippi and Ohio river

    • Histoplasmosis causing pulmonary infection

    • Blastomycosis causing disseminated disease

  85. Legionella: PNA, increase LFTbradycardia, hematuria, hyponatremia, tx macrolide

  86. Concerned about bacterial meningitis? Start antibiotics do not delay because of LP, and add steroids to treatment

  87. CT head before LP if there is suspicion for increase ICP: focal deficits, altered mental state, hx of cancer

  88. Acute chest Diagnosis is sickle cell: Fever, cough, dyspnea and one of

    • Fever

    • increase work of breathing, wheezing, tachypnea, hypoxemia

  89. finkelstein test for deQuervian tenosynovitis, tx NSAIDS and thumb spica

  90. phalen test is more sensitive than tinel test for carpal tunnel

  91. elevated arm stress test  for thoracic outlet syndrome

  92. Lachman test most sensitive for ACL injury

  93. cardiotocography is the best test for placental abruption, ultrasound alone is not very sensitive 

  94. hydatidiform mole

    • complete: 46XX, paternal, haploid, no fetal parts (complete mole)

    • incomplete: 69XXX or XXY, paternal + maternal, + fetal parts

  95. Palm and sole rash differential

    • STI: disseminated gonorrhea, Syphilis

    • Meningococcemia

    • Hx of being outdoors: RMSF

    • Peds: Kawasaki, hand foot mouth disease

    • EM spectrum, SJS, TEN

  96. Chagas disease from parasite T Cruzi can cause cardiomyopathy

  97. Azithromycin covers the following atypical PNA: Legionella, mycoplasma, chlamydia

  98. Epididymitis in <35yo think G and C vs. >35yo non sexually active think E coli

  99. Infective endocarditis

    • Native valve à Strep viridans

    • Prosthetic valve à coagulase negative staph aureus

    • IV drug use à staph aureus and tricuspid valve

  100. Stone heart: giving calcium in setting of digoxin toxicity causes sustained contraction

  101. centripetal rashes progressing from extremities to trunk

    • RMSF

    • Syphilis

    • Dengue

    • Coxackie Virus

    • Kaposi

  102. Pregnant woman with sudden cardiovascular collapse during labor à mitral stenosis

  103. Chest pain + new diastolic murmur + ‘water hammer’ pulse à aortic dissection causing aortic valve insufficiency

  104. Non cardiac causes of syncope: bleeding (ruptured AAA, retroperitoneal bleed, ruptured ectopic), neurologic, medication related, vasovagal

  105. Obtain a pregnancy test for all females with syncope as it can be the only presenting sign ofruptured ectopic

  106. tension pneumothorax: tachycardia/hypotension, JVD, unilateral decrease breath soundstracheal deviation 

    vs.

  107. cardiac tamponade: tachycardia/hypotension, JVD, muffled heart sounds

  108. Simple febrile seizures:

    • 6mo to 5yrs age

    • less than 15 min

    • one in 24hours

    • generalized seizure

  109. strychnine - found in pesticides/plants - sardonic smile, opisthonus muscle spasms

  110. lunate vs perilunate dislocation

    • lunate: lateral view of hand lunate displaced volar

    • perilunate: capitate and MC bones are displaced dorsal

    • Median n. injury is common in either

  111. Toxidrome: patient sleepy but with normal vital signs

    • Sedative hypnotics

    • Benzodiazepine

    • Opiates

    • Alcohol

    • Gabapentin

  112. Decompression illness types

    • Type I: the bends (musculoskeletal pains, skin, and lymphatic involvement)

    • type II: other organ system involvement

  113. deWinter ECG is a STEMI equivalent with an upsloping ST depression and tall symmetric T waves in V2-V4 à proximal LAD lesion

  114. Refeeding syndrome leads to heart failure

    • patient with no food à hypophosph, hypoK, hypoMg

    • new food introduced without replenishing electrolytes à can’t make ATP

    • heart failure – first organ to be affected

  115. first sign of HACE is ataxia. Typically follows acute mountain sickness within 12 hours

  116. symptoms of hypoCa  à irritability, paraesthesia, tetany, chovstek (lip twitch), and tourseau (BP cuff causing spasm)

  117. Ellis classification of tooth fractures (enamel, dentin, and pulp)

  118. Normal pressure hydrocephalus symptoms from most common to least: wobblywacky then wet

  119. Swan neck deformity vs. boutonniere (both common in RA)

    • Swan neck: PIP hyperextended, DIP flexed (neck)

    • Boutonniere: PIP flexed, DIP extended

  120. Peds one pill can kill à admit to ICU even if well appearing

    • Glipizide/sulfonylurea

    • Beta block

    • Ca Channel block

    • TCA

    • Methadone/opiates

    • Bupropion

  121. peripheral neuropathy + bowel ischemia à Polyarteritis nodosa

  122. arterial or coronary ischemia + pulseless or claudication + ESR and CRP elevation in Asian decent à Takayasu arteritis

  123. URI symptoms then glomerulonephritis à Wegner (Granulomatosis with polyangiitis)

  124. Asthma for few years then renal involvement à Chrug strauss (Eosinophilic granulomatosis with polyangiitis)

  125. Most common cause of hyperCa à primary hyperparathydoid

  126. Absolute contraindication to tpA in STEMI

    • availability of PCI within 90 min

    • Active bleed

    • CVA (ischemic within 6 months, anytime if hemorrhagic)

    • Intracranial surgery within 2 months

    • Intracranial neoplasm, AVM, aneurysm

    • Aortic dissection

  127. What is the dermatome level for the following (check answer here)

    • Clavicle

    • Nipple

    • Umbilicus

    • Inguinal ligament

    • Thumb and index

  128. posterior fat pad on lateral elbow x ray in

    • a child à supracondylar fracture

    • an adult à radial head fracture

  129. Maisonneuve fracture has all of the following

    • medial malleolar fx

    • spiral fx in upper fibula

    • talofibular syndenosis (ruptured interosseous membrane)

    • torn deltoid ligament

  130. Kanavel signs for flexor tenosynovitis à treat with IV abx and stat surgery consult

    • Tender flexor tendon sheath

    • Symmetric swelling

    • Pain with passive extension

    • Flexed position

  131. Nexus criteria does not include cervical pain: 1 cervical ttp, 2 distracting pain, 3 ams, 4 intoxication, 5 neuro deficits

  132. Wedge vs burst vs chance fractures

    • Wedge: compression of anterior column.

    • Burst: crush with multiple fragments involving anterior and middle columns.

    • Chance: fracture through all columns, associated with lap belt injuries.

  133. What population is highest risk of intimate partner violence? Pregnant women

  134. Abdominal pain and bruising (Grey Turner and Cullen Sign) in hemorrhagic pancreatitis

  135. What are Ranson’s criteria for acute pancreatitis? (answer)

  136. Achalasia = impaired relaxation of LES, bird beak sign

  137. Chest pain after vomiting = boerhaave’s, may have crepitus and Hamman crunch (crunch around heart). CT scan, iv abx, and surgery consult

  138. Foreign body in esophagus narrow areas: cricopharyngeous at C6, aortic arch at T4, GE jxn T11

  139. Most common cause of cirrhosis in USA is ETOH, worldwide is hep C

  140. Caustic ingestions

    • Alkali are worse and cause liquefactive necrosis and deep burns

    • Acid ingestions cause coagulative necrosis and are more superficial

    • GI consult for both +/- gen surg