Urgent Care EOR Exam Topic Reading List PDF

Urgent care EOR Exam Topic Reading List Allergic Rhinitis (M/C type overall) IgE mediated mast cell histamine release Nasal symptoms: nasal congestion, Management due to allergens (pollen, dust, mold, sneezing, clear watery rhinorrhea, nasal - Intranasal corticosteroi...

Urgent care EOR Exam Topic Reading List Allergic Rhinitis (M/C type overall) IgE mediated mast cell histamine release Nasal symptoms: nasal congestion, Management due to allergens (pollen, dust, mold, sneezing, clear watery rhinorrhea, nasal - Intranasal corticosteroid (most effective med for dander) itching, cough allergic rhinitis especially w/ nasal polyps) - Seen in atopic pts - Mometasone Viral: Rhinovirus is the M/C cause Physical exam - Fluticasone Vasomotor: nonallergic and noninfectious Allergic: edematous, pale, boggy - Triamcinolone dilation of the blood vessels (temp changes, turbinates, nasal polyps with cobblestone - 2nd gen oral antihistamine strong smells, humidity) mucosa - Loratidine - Allergic shiner: blue/gray under - Cetirizine Samter’s Triad: Asthma, Allergic Rhinitis, eye - Fexofenadine Aspirin and NSAID sensitivity. - Transverse nasal crease: line at - Antihistamine nasal spray the top of the nose due to wiping - Azelastine - Olopatadine - Avoidance of allergen and environmental control Acute Viral Rhinosinusitis (Common Cold) Symptomatic inflammation Manifestation: nasal congestion & obstruction, clear rhinorrhea Management of nasal cavity and hyposmia paranasal sinuses for LESS Supportive tx with analgesics (NSAIDs, than 4 weeks. Viral sx: cough, headache, malaise Acetaminophen), nasal lavage, Eustachian dysfunction: ear pain, fullness or pressure, hearing loss or decongestants and intranasal Majority of allergic tinnitus glucocorticoids rhinosinusitis is VIRAL Acute rhinosinusitis: facial pain, pressure/fullness worse when bending down and leaning forward, HA, malaise, purulent nasal discharge, fever, Sx are self-limited and reside within 7-10 maxillary tooth discomfort days Physical Exam - Erythematous, engorged nasal mucosa without intranasal purulence Acute Bacterial Rhinosinusitis Secondary bacterial infection of Manifestations Management the sinuses with LESS than 4 - Facial pain, pressure or fullness worse with bending down weeks or leaning forward Analgesics, Nasal Lavage, Intranasal - Purulent nasal discharge glucocorticoids Due to impaired sinus drainage: - Nasal congestion or obstruction m/c complication of viral infection. - HA, fever Antibiotics (sx present for MORE than Allergic of nonallergic rhinitis, 10-14 days with worsening) mechanical obstruction, dental Suggestive of bacterial cause - FIRST LINE: Augmentin infections impaired mucociliary - Persistent sx that last MORE than 10 days w/o improvement - Second line: Doxycycline clearance - Biphasic pattern (double worsening) - first line for penicillin allergy M/C bacteria: S.pneumoniae, Physical Exam - Respiratory FQ: Moxi, Levo Haemophilus influenzae and - Sinus tenderness to palpation moraxella catarrhalis (HSM) - Maxillary M/C - Erythema over involved area Diagnosis - Clinical diagnosis, imaging is not needed - If signs of infection beyond paranasal sinuses - CT Scan - Biopsy and aspiration definitive diagnosis usually not needed Chronic Rhinosinusitis Inflammation of the nasal cavity and paranasal Manifestations Management sinuses that last 12 or MORE consecutive WEEKS - Nasal obstruction & congestion Supportive: nasal lavage, intranasal - Facial pain & pressure glucocorticoids and ENT follow up Etiologies - Mucopurulent nasal discharge Bacterial: S.aureus - Decreased olfaction Abx if bacterial with ENT f/u: Augmentin Granulomatosis with polyangiitis: Wegner Diagnosis granulomatosis - Sinus CT Fungal: Aspergillus - Allergy testing  Upper Respiratory Infections Acute Pharyngitis & Tonsillitis Viral respiratory viruses most Manifestations Management common overall cause of - Sore throat worsens w/ swallowing, pain on swallowing or talking pharyngitis: Adenovirus, Rhinovirus, - Cervical lymphadenopathy Symptomatic treatment: oral Enterovirus, Epstein-Barr virus - Viral sx: hoarseness, rhinorrhea, coryza, conjunctivitis, diarrhea hydration, warm saline gargles, Physical Exam topical anesthetics, lozenges, Bacterial: Group A Strep - Tonsillar and pharyngeal erythema, edema w/ or w/o exudate NSAIDs (S.pyogenes M/C bacterial cause of - Anterior stomatitis: discrete ulcers or vesicles on the soft pharyngitis) palate and tonsils Diagnosis - Usually clinical - 3 exceptions to do testing: Influenza, Mono, Acute retroviral syndrome (HIV) Laryngitis Acute inflammation of the larynx, self-limited usually lasting Manifestations Management 3-7 days but LESS than 3 weeks HALLMARK: hoarseness (raspy or breathy voice) Supportive care is Aphonia (loss of voice mainstay: vocal rest, Etiologies Viral URI sx: cough, rhinorrhea, sore throat, hydration, airway - Viral respiratory virus: adenovirus, rhinovirus, influenza diarrhea, anterior stomatitis humidification - Bacterial causes: S. pnuemo, H. influ, M.catarrhalis (HSM) and Mycoplasma pneumoniae Diagnosis ENT or GI follow up - Vocal strain: screaming or singing, GERD, polyps, Clinical: erythema and edema of the vocal cords cancer Streptococcal Pharyngitis Group A beta hemolytic strep Physical Examination Management (S. pyogenes) Enlarged tender anterior cervical lymphadenopathy - Analgesics (NSAIDs, Scarlatiniform rash: erythematous finely papular rash which acetaminophen, Aspirin), Highest incidence of characteristically starts in the groin and axilla and then spreads to the Anesthetics (throat spray, rheumatic fever in untreated trunk and extremities followed by desquamation lozenges) children 5-15 years of age - FIRST- LINE abx: penicillin Diagnosis - Penicillin V Manifestation: abrupt onset of Whom NOT to test: children and adolescents clearly presenting with - Penicillin G sore throat and odynophagia viral illness and children LESS than 3 yrs old - Amoxicillin which may be accompanied by - Penicillin allergy fever, chills, HA abd pain, N/V, Whom to test: children GREATER than 3 yr & adolescents with - Cephalosporins poor oral intake & vomiting evidence of acute tonsillopharyngitis OR exposed to someone w/ GAS - Azithromycin - ≥ 3 Centor criteria - Clarithromycin - Fever ≥ 38C - Clindamycin - Absence of cough Complications - Swollen anterior cervical lymph nodes Rheumatic fever (prevent w/ abx) - Tonsillar exudates/swelling Severe pharyngitis (IM dexamethasone) Testing options Rapid antigen detection test (RADT): best initial Nucleic acid amplification test (NAAT): in place of RADT Throat Culture: definitive COVID-19 Most people will experience mild to Symptoms In non-hospitalized pts, dexamethasone, prednisone moderate respiratory illness - M/C: fever or other corticosteroid are NOT indicated - Fatigue, Dry cough, Dyspnea, Sputum Spread through close range contact Pts w/ acute exacerbation of asthma or COPD should via respiratory particles All symptomatic patient should undergo testing receive tx w/ glucocorticoids - NAAT w/ reverse transcriptase polymerase Hospital Admit for.. Transmission after 7-10 days of chain reaction - Severe dyspnea illness is unlikely - Positive nasopharyngeal swab - O2 stat on RA ≤ 90% - AMS Incubation period is 2-14 days Additional testing Treatment in hospital post-exposure - Chest CT - Venous thromboembolism prophylaxis - Inc ferritin and CRP - Nonsevere disease: supportive - Inc LDH - W/ hypoxia not on O2: remdesivir Asymptomatic individuals - On low flow O2: low dose dexa and remdesivir - Post exposure testing done 5-7 days after - Elevated CRP ≥75 mg/L: tocilizumab exposure - Acetaminophen preferred antipyretic Influenza Originates from the orthomyxoviridae Incubation period is 1-4 days Management RNA virus family Systemic symptoms: fever, malaise, headache, Mild disease & healthy chills, myalgias - Supportive management Transmitted through airborne particles - Antiviral (oseltamivir) can be considered for and droplet nuclei Respiratory symptoms: rhinorrhea, congestion, healthy if initiated w/i 48 hours of illness onset discharge High risk Influenza A is worse than B GI symptoms: vomiting and diarrhea - Antivirals (oseltamivir) for hospitalized pts, high risk complication or greater 65 yrs Higher risk of complication in: adults ≥65 Pneumonia is the m/c complication of influenza Oseltamivir: the drug of choice for patients any age, yr, immunocompromised and pregnancy, pregnant, hospitalized or complicated infection. MUST residents of nursing homes & those with Routine influenza testing is not necessary initiate WITHIN 48 hours underlying medical conditions unless the patient is ill enough to admit Annual vaccine is recommended for all persons ABOVE NAAT is preferred over rapid influenza tests 6 months of age (including pregnancy) w/ no contraindications Acute Cystitis Ascending infection of the lower urinary Risk factors: women, pregnancy, infants, Uncomplicated UTI Tx tract from the urethra underlying condition - 1st line: Nitrofurantoin or Trim-sula or fosfomycin E.coli is the m/c pathogen. Second m/c is Irritative symptoms: burning, frequency, urgency, - 2nd line: FQ (Cipro, Levo) or Cephalosporins staph saprophyticus hematuria, suprapubic tenderness (Cephlexin, Cefpodoxime)  Diagnosis Adjunctive tx Urinalysis and dipstick (≥10 WBCs/hpf): pos - Phenazopyridine: bladder analgesic leukocyte esterase, pos nitrates, cloudy urine Complicated UTI - FQ, AMG Urine culture on clean-catch: definitive dx UTI during pregnancy - Amoxicillin, augmentin, cephalexin, cefpodoxime, nitrofurantoin, fosfomycin Acute Pyelonephritis Infection of the upper GU tract (kidney Symptoms: fever, chills, back or flank pain, N/V not common but Management parenchyma & renal pelvis) suggestive of pyelo, dysuria, urgency & frequency - POS CVA tenderness Outpatient M/C etiology E.coli Diagnosis - 1st line: FQ (Cipro, Levo) INpatient UA: ≥10 WBCs/hpf, pos leukocyte esterase, pos nitrates, hematuria, - 3rd or 4th gen Cephalosporins: cloudy urine Ceftriaxone, Pip-Tazo, - WBC casts HALLMARK of pyelo Ampicillin, FQ or AMG - Increased pH with proteus Pregnancy Urine culture is definitive diagnosis - IV Ceftriaxone Urethritis Inflammation of the urethra a common Manifestations Treatment manifestation of STI among males - Typically asx Nongonoccocal: Chlamydia - Dysuria - Doxycycline (100mg twice daily for 7 Nongonococcal: Chlamydia trachomatis - Urethral discharge days) - Mycoplasma genitalium - Penile or vaginal pururitis - Azithromycin Gonococcal Gonococcal: Neisseria gonorrhoeae Diagnosis - Ceftriaxone (single IM dose) - Presumptive therapy for chlamydia UA/dipstick: pos leukocyte esterase M. genitalium First void NAAT is the most sensitive and specific - Moxifloxacin - High dose azithromycin  Follow up - Refrain from sexual activity for 7 days after starting treatment - Repeat NAAT 3 months after tx d/t to high reinfection Syphilis- caused by Treponema pallidum spirochetes Primary syphilis Secondary syphilis Tertiary syphilis Appears in 2-10 weeks Appears 1-3 months after primary Neurosyphilis- neuro probs coordination, memory Painless genital ulceration (chancre) loss, paralysis, gradual blindness or dementia Maculopapular rash on palm and soles, Dx: initial screening nontreponemal test- RPR. fever, HA & general lymphadenopathy Aortic aneurysm and aortic regurg Confirmed with a treponemal test such as Fluorescent treponemal antibody absorption Condylomata lata- moist lesions on the genitals Granulomatous gummas of the CNS, heart and (FTA-ABS) which are highly infectious great vessels Tx: Penicillin Tx: Penicillin Tx: Penicillin Gonorrhea Caused by Neisseriae gonorrhoeae Sx: dysuria, frequency and purulent Ceftriaxone 500 mg IM single dose for pts weighing 300 lbs Chlamydia Caused by chlamydia trachomatis Often asx but may cause dysuria, thin/white mucous Doxycycline BID daily for 7 days discharge, cervicitis, PID, infertility - Azithro (preg) - Levo NAAT is gold standard Trichomonas Flagellated protozoan Dx: Wet mount reveals mobile and Treatment pear-shaped protozoa with Metronidazole 2 g PO for preg and nonpreg pts Sx: pruritus, malodorous frothy flagella - Alt. Metronidazole 500 mg PO twice a day for 7 days greenish/gray discharge All partners should be treated Petechiae on the cervix (strawberry cervix) Condylomata acuminata External lesion associated w/ HPV Sx: painless, soft, fleshy, “cauliflower-like lesion” No tx is satisfactory. Relapse is frequent & requires 6,11, endocervical warts caused by - Can be on the vulva, vaginal wall, cervix retreatment HPV 16, 18, 31, 33. and perineum - Podofilox - Cryotherapy Transmitted sexually w/ incubation Dx: biopsy lesion w/ 5% acetic acid to detect - Laser surgery period of 1-6 months - Electrocauterization - Biopsy - Imiquimod Require many applications and frequently fail Herpes Caused by HSV-2. n primary infection pt may Dx: viral culture, PCR, direct fluorescence Topical acyclovir ointment during flareup, oral present w/ fever, malaise and adenopathy antibody and type specific serologic tests acyclovir to decrease rate and severity of recurrence Sx: paresthesias and burning followed by painful Tzank smear for lesions suspicious of HSV vesicles and ulcerations Human Immunodeficiency Virus Asx infection: persistent generalized lymphadenopathy Fourth gen ELISA 2 NRTI + NNRTI, Integrase inhibitor or - detects both IgG, IgM and P24 protease inhibitors Early symptomatic infection: recurrent or persistent antigen oropharyngeal and vulvovaginal candidiasis, seborrheic Post exposure prophylaxis: 2 NRTI + dermatitis and bacterial folliculitis involving S. aureus Western Blot integrase inhibitor - detects both IgG and IgM AIDS: CD4 assess AFTL lig - Talar tilt test-> asses CFL Ankle Fractures Weber Classification- classify ankle fractures on Maisonneuve Fracture Tibial Plafond (pilon) fracture the basis of the lateral malleolus (fibular bone) Spiral fracture of the proximal third of the Fracture of the distal tibia from impact with the Weber A fibula associated with a distal medial mal fx talus high energy rotational or axial load - Below the syndesmosis or rupture of the deep deltoid ligament - Tibiofibular ligament intact Manifestations: severe pain, swelling, deformity - Deltoid ligament intact Proximal films performed in distal fx to rule out - Usually stable proximal fx Management Weber B - Surgical ORIF - Fibular fx at the level of the syndesmosis Weber C - Fibular fx ABOVE mortise - Deltoid ligament damage or medial malleolus fx - Unstable- requires ORIF Knee Sprains Medial and Lateral Collateral Anterior Cruciate Ligament Posterior Cruciate Ligament Ligaments Most common knee ligament injury. D/t noncontact High energy mechanism involve an anterior forced or pivoting injury posteriorly directed force applied to a flexed knee MCL is the most common injury d/t lateral trauma Manifestations: audible “pop”, knee effusion, knee Manifestation: posterior knee pain, anterior bruising - Pain and laxity with valgus stress buckling LCL due to medial trauma Physical exam: posterior drawer test, posterior sag - Pain & laxity with varus stress Physical Exam: lachman (sensitive), pivot shift, anterior drawer Dx: Plain radiographs Management Conservative Management: RICE, NSAID, immobilizer Grade 1 and 2: conservative, pain Diagnosis: MRI is the best to assess control, rehab - POS Segond fx (avulsion of the lateral tibial condyle) pathognomonic for ACL tear Meniscal Injury Grade 3: may require surgery Management Degenerative tear is more common, acute axial loading - Knee immobilizer, crutches, non-weight or rotation when foot is planted. bearing - MEDIAL x3 more common than lateral - Surgical Reconstruction O’Donoghue’s triad: ACL + MCL + medial Manifestations: popping, clicking, catching, locking, meniscus effusion after activities Positive Mcmurry and Positive Thessaly (most sensitive) Dx: MRI most sensitive test Tx: RICE, NSAIDs Knee Fractures Patellar Fracture: direct blow most common Femoral Condyle Fracture Tibial Plateau Fracture (fall on flexed knee) or indirect force applied Mechanism of injury: axial loading (fall Lateral plateau is the most common fracture type through a contracting quad from height, direct blow to the femur) MOI: axial loading, rotation, direct trauma to the knee Manifestations: pain, swelling, deformity of Manifestations: pain, swelling, deformity, the anterior patella, limited knee extension w/ rotation, shortening Manifestations: check for peroneal nerve injury- foot drop pain, inability to extend the leg against gravity of decrease sensation in the posterior first web space Complications: Peroneal nerve injury- Diagnosis: sunrise view on x-ray foot drop or decreased sensation in the Dx: x-ray and CT scan posterior first web space of foot Management: nondisplaced- Management immobilization of knee in extension w/ Popliteal artery injury Conservative: non-weight bearing; short hinge knee brace + knee immobilizer partial weight bearing; ortho follow up Management: immediate ortho consult. Surgical: if displace of severe Displaced: ORIF ORIF Complication: often associated with soft tissue injuries Wrist Fractures Scaphoid Fracture: Most common fx of carpal bone Colles Fracture: Distal radius fracture Smith’s (Reverse Colles’) fracture MOI: FOOSH w/ dorsal angulation. Ulnar styloid Extra-articular distal radius fracture w/ ventral (Chaffer) fx also seen. angulation of the distal fragment Manifestation: pain along the dorsal radial surface with anatomical snuffbox tenderness MOI: FOOSH w/ wrist extension MOI: FOOSH w/ wrist flexion Present with wrist pain w/ passive motion, Presentation: pain worse w/ passive ROM Dx: if snuffbox tenderness then tx as a fx otherwise high swelling, ecchymosis incidence of AVN. Physical Exam: garden spade deformity Physical exam: dinner fork deformity If x-ray negative initially repeat in 7-14 days. MRI or CT (dorsal displacement) Radiographs: lateral view shows ventral/volarly of the wrist. Radionuclide bone scan in 3-5 days displaced or angulated fx of distal radius Radiographs: lateral view- dorsally Management: Nondisplaced- thumb spica splint/cast displace or angulated of the distal radius. Tx: closed reduction & sugar tong splint/cast Lunate Fracture Management: stable- closed reduction with sugar tong splint or cast Most serious carpal fracture since the lunate occupies ⅔ of the radial articular surface Complication: extensor pollicis longus tendon rupture - Radiographs are often negative Complications: AVN of the lunate bone Management: Immobilization with ortho f/u Barton’s Fracture: intra-articular distal radius fracture w/ carpal displacement Lacerations Risks Alternatives Post repair wound care - Infection - Bandages or adhesives for minor lacs, adhesive strips Most wounds should be covered with an - Blood loss cna replace stitches antibiotic ointment and non adhesive dressing - Nerve or tissue damage - Topical skin closure- dermal adhesives for superficial immediately after lac repair - Scarring cuts - Dressing should be left in place for 24 hrs - Impaired functionality - Staples Prophylactic abx decrease the risk of infection in - Glue some animal and human bites, intraoral Benefits Possible complications lacerations, open fractures and wounds that - Optimal healing and - Delayed healing extend into cartilage, joint or tendons recovery - Keloid or hypertrophic scarring - Preservation of function - Chronic pain or sensitivity Allow animal bites especially in non-cosmetic - Minimized risk of infection - Loss of mobility or strength area such as hand and foot to heal by secondary - Cosmetic improvement - Allergic rxn to adhesive, stitches or wound dressing intention Abscess Localized collections of pus resulting from Diagnosis is mainly clinical but U/S or CT Incision and Drainage is the mainstay of bacterial infection and inflammation may be required for deeper abscess to treatment confirm location and size - Abx for severe cases: clindamycin, Presents with: pain, redness, swelling, and fluctuance doxycycline, bactrim or vancomycin over the affected area, may also cause fever if severe - Cultures of the purulent material - Percutaneous drainage for deep or systemic should be obtained to guide abscesses therapy - Surgical drainage for ons that don't Common causes: S.aures (MRSA), S. pyogenes - Blood cultures if systemic sx respond to less invasive tx - CBC, ESR, CRP elevated - Tetanus immunization reviewed & updated Risk factors: poor hygiene, trauma, - HIV testing in recurrent or atypical - Complications: spread of infection, sepsis immunosuppression & chronic illness like diabetes cases or chronic sinus formation Common locations include: skin, perianal or liver, brain, lungs Cellulitis Acute spreading infection of the deeper dermis & Clinical manifestation Treatment subq fat. - Localized macular skin erythema Oral abx: cephalexin, cefadroxil, dicloxacillin Bacterial entry occurs after a break in the skin such poorly demarcated, edema, PCN allergy: Trim-sulfa as: underlying skin condition, trauma, surgical wounds warmth and/or tenderness - Clinda IV abx: Cefazolin, Nafcillin, Oxacillin Etiologies: Fever, chills, lymphadenopathy, myalgias Cat,Dog or Human bite: Augmentin - Group A Strep most common - IV: Ampicillin-Sulbactam - S. aureus second most common Clinical diagnosis - Dog or cat bites: pasteurella multocida MRSA: Trim-sulfa + Cephalexin - Clinda or Linezolid IV Vancomycin Acute Abdomen Renal Gallbladder Stomach - CC: colicky right-sided flank pain, - CC: RUQ pain - CC: burning epigastric pain after meals nausea, vomiting, hematuria, CVA - WorkupL RUQUS, CBC, CMP, HIDA scan, - Workup: rectal exam, amylase, lipase, tenderness MRCP/ERCP, amylase, lipase, alk phos, lactate, AST, ALT, bilirubin, Alk phos, - Workup: UA, BUN/Cr, CT Abdomen, bilirubin upper endoscopy, upper GI series Renal US, KUB, blood cultures - Cholecystitis, choledocholthiasis, hepatitis, - Ddx: peptic ulcer disease, perforated - Ddx: nephrolithiasis, renal cell ascending cholangitis, Fitz-Hugh-Curtis peptic ulcer disease, gastritis, GERD, carcinoma, pyelonephritis, Syndrome, acute subhepatic appendicitis cholecystitis, mesenteric ischemia, chronic glomerulonephritis, splenic rupture pancreatitis  Pancreas Liver Spleen - CC: dull epigastric pain that radiate to - CC: RUQ pain, fever, anorexia, nausea, - CC: severe LUQ pain that radiates to left the back vomiting, dark urine, clay stool scapular w/ hx of infectious mono - Workup: CT abdomen, CBc, - Workup: CBC, amylase, lipase, liver - Workup: CBC, CXR, CT/US of the electrolytes, amylase, lipase, AST, enzymes, viral hepatitis serologies, UA, abdomen ALT, bilirubin, Alk phos, U/S abdomen abdomen US, ERCP, MRCP - Ddx: splenic rupture, splenic infarct, - Ddx: pancreatitis, pancreatic cancer, - Ddx: acute hepatitis, acute cholecystitis, kidney stone, rib fracture, pneumonia, peptic ulcer disease, ascending cholangitis, choledocholithiasis. perforated peptic ulcer cholecystitis/choledochlithasis Pancreatitis, primary sclerosing cholangitis, primary biliary cirrhosis, glomerulonephritis Anaphylaxis Signs and Symptoms Treatment - Itchy skin, hives, flushed or pale skin, swelling of lips, Epinephrine 1:1000 0.5-1mL given IM or subQ hands, feet and eyes - Infants weighing 36 week waiting if the pt is stable - Conservative expectant management For pregnancies < 34 weeks with no evidence of blood loss indicated 24-36 weeks if mom & baby stable manage until 37-38 weeks - Scheduled C-section at 36 to 37+6 weeks Previa: painless vaginal bleeding + soft, nontender uterus - Delivery when stable if: L:S ratio > 2:1, > 36 Abruptio: painful vaginal bleeding + abdominal pain + firm weeks, blood loss > 500 mL, persistent tender uterus bleeding, coag defects or persistent labor Previa Painless Abruption Abdominal pain