{"id":1242,"date":"2017-02-16T15:25:44","date_gmt":"2017-02-16T20:25:44","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=1242"},"modified":"2017-02-16T15:25:44","modified_gmt":"2017-02-16T20:25:44","slug":"ep-17-training-exam-review-part-2-3-heent-hematology-immune-system-musculoskeletal-nervous-system","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-17-training-exam-review-part-2-3-heent-hematology-immune-system-musculoskeletal-nervous-system\/","title":{"rendered":"Podcast Ep 17: In-Training Exam Review, Nervous System, &amp; More"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_17_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p>Put your heart, mind, and soul into even your smallest acts. This is the secret of success. &nbsp; <\/p><cite>\u2013Swami Sivananda<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\">Welcome back to Episode 17! This is part 2 of the 3 part ITE rapid review series. In <a href=\"https:\/\/www.roshreview.com\/blog\/ep-16-training-exam-review-part-1-3-abdominal-cardiovascular-cutaneous-endocrine-environmental-emergencies\/\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\">Episode 16<\/a>, we covered abdominal emergencies, cardiovascular emergencies, cutaneous emergencies, endocrine emergencies, and environmental emergencies. Today we jump right in with HEENT emergencies. Let\u2019s get started!<strong>&nbsp;<\/strong><\/h6>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><u>HEENT Emergencies<\/u><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>The <strong>target pH<\/strong> for eye irrigation after a chemical burn is <strong>7.0\u20137.2<\/strong>. <strong>Alkali burns<\/strong> usually cause more damage than acidic burns due to <strong>liquefactive necrosis<\/strong>.<\/li><li><strong>Acute glaucoma<\/strong> classically presents with a red, <strong>painful eye<\/strong>, <strong>blurry vision<\/strong>, and <strong>asymmetric pupils<\/strong>. First line treatment options include <strong>beta-blockers<\/strong>, <strong>carbonic anhydrase inhibitors<\/strong>, <strong>steroids<\/strong>, and <strong>miotics<\/strong>.<\/li><li><strong>Corneal abrasions<\/strong> should be treated with topical antibiotics such as <strong>erythromycin<\/strong> or <strong>ciprofloxacin<\/strong>. <strong>Tetanus<\/strong> vaccination should also be updated if needed.<\/li><li>The three most common bacterial causes of <strong>acute otitis media<\/strong> are <strong><em>Streptococcus<\/em><\/strong>, <strong><em>Haemophilus<\/em><\/strong>, and <strong><em>Moraxella<\/em><\/strong>. However, viral pathogens are far more common. If treating with antibiotics, the first line is typically <strong>amoxicillin<\/strong>.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><u>Hematologic Emergencies<\/u><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Angioedema<\/strong> secondary to <strong>ACE-inhibitor<\/strong> use occurs due to a buildup of <strong>bradykinin<\/strong>.<\/li><li><strong>Hereditary angioedema<\/strong> is caused by a deficiency or dysfunction of <strong>the C1 esterase inhibitor<\/strong>. Episodes are typically <strong>precipitated by stress or trauma<\/strong>. Treatment is with <strong>replacement of C1 esterase inhibitor<\/strong> or with <strong>FFP<\/strong> if the inhibitor is not available.<\/li><li><strong>TTP<\/strong> is treated with <strong>plasmapheresis<\/strong>. If plasmapheresis cannot be performed expediently, <strong>FFP can be used<\/strong> as a temporizing measure.<\/li><li>For any patient on <strong>warfarin<\/strong> with a life-threatening bleed, <strong>FFP<\/strong>, <strong>PCC<\/strong>, <strong>or recombinant factory VIIa<\/strong> should be given. For a patient on<strong> aspirin<\/strong> with a life-threatening bleed, <strong>DDAVP<\/strong> should be given in addition to<strong> platelets<\/strong>.<\/li><li>Predisposing<strong> risk factors for DVT<\/strong> include <strong>malignancy<\/strong>, <strong>immobilization<\/strong>, recent <strong>surgery<\/strong>, <strong>obesity<\/strong>, <strong>smoking<\/strong>, <strong>oral contraceptives<\/strong>, <strong>recreational drugs<\/strong>, and <strong>hypercoagulable states<\/strong>.<\/li><li><strong>Chronic alcohol abuse<\/strong> leads to a <strong>macrocytic anemia<\/strong> and even <strong>pancytopenia<\/strong> due to ethanol\u2019s <strong>suppressive effects on the bone marrow<\/strong>.<\/li><li>Patients on long-standing <strong>isoniazid<\/strong> are at risk for <strong>sideroblastic<\/strong> <strong>anemia<\/strong> due to a <strong>pyridoxine deficiency<\/strong>.<\/li><li><strong>Vitamin B12 deficiency<\/strong> causes a <strong>megaloblastic anemia<\/strong> called <strong>pernicious anemia<\/strong>. It usually occurs secondary to <strong>absorptive problems<\/strong> rather than poor dietary intake.<\/li><li><strong>Giant Cell Arteritis<\/strong> commonly presents with<strong> unilateral temporal headache<\/strong>,<strong> jaw claudication<\/strong>, <strong>tender temporal artery<\/strong>, and even<strong> sudden painless monocular vision loss<\/strong>. The ESR is usually between 50-100. 50% of patients with giant cell arteritis also have <strong>polymyalgia rheumatica<\/strong>.<\/li><li><strong>Giant cell arteritis<\/strong> should be treated with immediate <strong>steroids<\/strong>, long before biopsy confirms the diagnosis.<\/li><li>In <strong>giant cell arteritis<\/strong>, aortic involvement can lead to<strong> valvular disease and dissection<\/strong>.<\/li><li>Both <strong>hemophilia A and B<\/strong> <strong>are x-linked recessive diseases<\/strong>. <strong>Hemophilia A<\/strong> is caused by decreased synthesis of <strong>factor VIII<\/strong>. <strong>Hemophilia B<\/strong> or <strong>Christmas disease<\/strong> is caused by decreased synthesis of <strong>factor IX<\/strong>. Treatment is with specific <strong>factor replacement<\/strong> or if unavailable, with cryoprecipitate.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><u>Immune System Emergencies<\/u><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>For a new mother with <strong>mastitis<\/strong>, she should be advised to <strong>continue nursing<\/strong> from the affected breast. <strong>Dicloxacillin<\/strong> is the antibiotic of choice.<\/li><li>Prophylaxis for <strong><em>Neisseria meningitidis<\/em><\/strong> should be offered to high-risk contacts, which includes <strong>household members<\/strong>, <strong>school contacts<\/strong> in the prior 7 days, and those with <strong>direct exposure to patients<\/strong>. The preferred antibiotic regimen for prophylaxis is two days of <strong>rifampin<\/strong>. <strong>Ceftriaxone<\/strong> and <strong>ciprofloxacin<\/strong> can also be used but they are slightly less effective.<\/li><li><strong>Fight bites<\/strong> are at risk for contamination with <strong><em>Eikenella<\/em><\/strong>. <strong>Amoxicillin-clavulanate<\/strong> is the oral antibiotic of choice. If an IV antibiotic is required, <strong>ampicillin-sulbactam<\/strong>, <strong>cefoxitin<\/strong>, or <strong>piperacillin-tazobactam<\/strong> can be used.<\/li><li><strong><em>Streptococcus pneumoniae<\/em><\/strong> is classically associated with<strong> rusty colored sputum<\/strong>, whereas <strong><em>Klebsiella pneumoniae<\/em><\/strong> is associated with<strong> currant jelly sputum<\/strong>. In <strong>alcoholics<\/strong>, <strong><em>Streptococcus pneumoniae<\/em> is the most common<\/strong> bacterial cause of pneumonia, however the incidence of <strong><em>Klebsiella pneumoniae<\/em><\/strong> is <strong>higher<\/strong> in this population due to their <strong>increased risk of aspiration<\/strong>.<\/li><li>There are three common <strong>painless penile lesions<\/strong>. They are caused by <strong><em>Chlamydia<\/em><\/strong>, <strong><em>Klebsiella<\/em><\/strong>, and <strong><em>Treponema pallidum<\/em><\/strong>. <strong><em>Chlamydia<\/em><\/strong> causes <strong>LGV<\/strong>, which presents as a <strong>shallow ulcer<\/strong>. <strong><em>Klebsiella<\/em><\/strong> causes <strong>granuloma inguinale<\/strong>, which presents as a <strong>beefy red ulcer <\/strong>and a <strong>painless papule<\/strong>. <strong><em>Treponema pallidum<\/em><\/strong> causes <strong>syphilis<\/strong>, which presents as a painless <strong>chancre<\/strong>.<\/li><li><strong><em>H. ducreyi<\/em><\/strong> causes <strong>chancroid<\/strong>, which typically presents with <strong>multiple painful papules that ulcerate<\/strong>. <strong>HSV<\/strong> causes genital Herpes that tends to present as <strong>tender, shallow penile lesions<\/strong>.<\/li><li><strong>Balanitis<\/strong> is typically caused by a <strong>candidal infection<\/strong>. The treatment is with topical <strong>clotrimazole.<\/strong><\/li><li>In the <strong>modified Centor score<\/strong>, give one point for <strong>tonsillar exudates<\/strong>, one point for <strong>tender anterior cervical adenopathy<\/strong>, one point for <strong>fever by history<\/strong>, one point for the <strong>absence of a cough<\/strong>, and one point for <strong>age less than 15<\/strong>. For an <strong>age over 45<\/strong>, you <strong>subtract one point<\/strong>. For a score of <strong>0 or 1<\/strong> points, <strong>treat supportively<\/strong>; for a score <strong>of 2 or 3 points<\/strong>, <strong>test and treat<\/strong> only if positive; and, lastly, for a score <strong>o<\/strong>f <strong>4 or 5 points<\/strong>, <strong>treat<\/strong> <strong>empirically<\/strong>. The mainstay of treatment is <strong>amoxicillin<\/strong>.<\/li><li><strong>Herpes simplex virus<\/strong> is the most common infection associated with <strong>erythema multiforme<\/strong>. <strong>Hepatitis C<\/strong> can also be associated with erythema multiforme, but that usually occurs in the setting of active treatment with<strong> telaprevir<\/strong>. &nbsp;<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><u>Musculoskeletal Emergencies<\/u><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>A <strong>nursemaid\u2019s elbow<\/strong> can be reduced by either <strong>supination<\/strong> followed by <strong>elbow flexion<\/strong> or with <strong>hyperpronation<\/strong>.<\/li><li><strong>NSAIDs<\/strong> are the first-line therapy for <strong>gout<\/strong>. Although there is mixed research on this, classically <strong>allopurinol is contraindicated<\/strong> during an acute presentation for fear of worsening the attack.<\/li><li><strong>Gout<\/strong> is associated with <strong>negatively birefringent crystal <\/strong>on joint aspiration, whereas <strong>pseudogout<\/strong> is associated with <strong>positively birefringent crystals<\/strong>. <strong>Gout<\/strong> typically affects the <strong>first metatarsophalangeal<\/strong> joint, whereas <strong>pseudogout<\/strong> most commonly affects larger joints like the <strong>knees and ankles<\/strong>.<\/li><li>The <strong>Hill-Sachs defect<\/strong> is the<strong> most common complication of anterior shoulder dislocations<\/strong>, occurring in 40% of cases. The Hill-Sachs defect is a<strong> depression fracture of the posterolateral surface of the humeral head<\/strong>. Do not confuse it with a<strong> Bankart lesion,<\/strong> which is a<strong> fracture of the anterior aspect of the inferior glenoid rim<\/strong>.<\/li><li>The <strong>axillary nerve<\/strong> is the most commonly injured nerve in anterior shoulder dislocations. Its function can be tested by<strong> arm abduction and sensation over the deltoid muscle<\/strong>.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><u>Nervous System Emergencies<\/u><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Severe cases of <strong>myasthenia gravis<\/strong> can be treated with <strong>IVIG<\/strong> or <strong>plasma exchange<\/strong>. Although not a cure, <strong>symptoms may also be decreased by cooling<\/strong>. The <strong>edrophonium test <\/strong>can be used to make the <strong>initial diagnosis<\/strong>.<\/li><li><strong>Polycystic kidney disease<\/strong> is associated with an increased incidence of <strong>subarachnoid hemorrhages.<\/strong><\/li><li><strong>Lyme disease<\/strong> is the most common cause of a <strong>bilateral Bell\u2019s palsy<\/strong>.<\/li><li>A <strong>peripheral facial nerve palsy<\/strong> can be distinguished from a central one by <strong>involvement of the forehead<\/strong>.<\/li><li><strong>VP shunt obstruction<\/strong> occurs <strong>proximally more frequently<\/strong> than distally<strong>. <\/strong><strong>Proximal VP shunt obstruction<\/strong> occurs due to <strong>choroid plexus obstruction<\/strong> or <strong>increased protein within the CSF<\/strong>. <strong>Distal VP shunt obstruction<\/strong> occurs due to<strong> abdominal pseudocyst formation<\/strong><strong>,<\/strong> which typically presents with <strong>abdominal pain<\/strong> due to the large size of the cyst.<\/li><li>A <strong>radial nerve palsy<\/strong> is <strong>treated supportively<\/strong> with a <strong>wrist splint<\/strong>.<\/li><li>A <strong>Marcus Gunn pupil<\/strong> is another term for a pupil with an <strong>afferent pupillary defect<\/strong>.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">That is it for part two. We have part three ready for release tomorrow. Let us know what you think about this review by emailing us at <a href=\"mailto:Roshcast@roshreview.com\">Roshcast@roshreview.com<\/a>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Until tomorrow,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Welcome back to Episode 17! This is part 2 of the 3 part ITE rapid review series. In Episode 16, we covered abdominal emergencies, cardiovascular emergencies, cutaneous emergencies, endocrine emergencies, and environmental emergencies. Today we jump right in with HEENT emergencies. Let\u2019s get started! <\/p>\n","protected":false},"author":11,"featured_media":1244,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2762,2766,2859,2866,3076,3111,3465],"coauthors":[],"class_list":["post-1242","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-heent","tag-hematology","tag-immune-system","tag-in-training-exam","tag-musculoskeletal","tag-nervous-system","tag-review"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Podcast Ep 17: In-Training Exam Review, Nervous System &amp; More | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 17), the first question and answer style emergency medicine podcast. 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