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



* Basic approach to altered mental status (EM Clerkship)* Basic approach to neck trauma (EM Clerkship)