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Red Reflex

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82. Corneal abrasion

contact in entropion) Predisposing factors Contact lens wear Corneal dystrophy Epithelial Basement Membrane (EBM) dystrophy, in which epithelium is abnormal and easily traumatised Corneal exposure dry eye lagophthalmos facial palsy Diabetes Neurotrophic keratitis Symptoms Pain ranges from mild foreign body sensation to severe pain; may be disproportionate to objective findings absence of pain should alert to possibility of neurotrophic keratitis Blepharospasm Photophobia Lacrimation Redness History (...) by failure of the normal blink reflex, or when its sensitivity to touch is reduced by damage to its nerves, as in diabetes or following shingles of the eye. Corneal abrasion can be very painful as the cornea is one of the most sensitive areas of the body. The clinician will assess the area involved and prescribe treatment accordingly. The damage to the surface can be seen more easily if fluorescein, an orange dye, is instilled into the eye. Anti-inflammatory or antibiotic eye drops are often recommended

2018 College of Optometrists

83. Entropion

of the tarsal plate Predisposing factors Age-related degenerative changes in the lid Severe cicatrising disease affecting the tarsal conjunctiva Ocular irritation or previous surgery Symptoms Foreign body sensation, irritation Red, watery eye Blurring of vision Signs Corneal and/or conjunctival epithelial disturbance from abrasion by the lashes (wide range of severity) Localised conjunctival hyperaemia Lid laxity (involutional entropion) Conjunctival scarring (cicatricial entropion) Absence of lower lid (...) Possible management by ophthalmologist The choice of surgical procedure depends on the underlying cause(s) Surgical intervention is indicated if any of the following are persistent: ocular irritation recurrent bacterial conjunctivitis reflex tear hypersecretion superficial keratopathy risk of ulceration and microbial keratitis There is evidence that the combination of horizontal and vertical eyelid tightening is an effective treatment for entropion Evidence base *GRADE: Grading of Recommendations

2018 College of Optometrists

84. Endophthalmitis (post-operative) (Exogenous endophthalmitis)

instruments, solutions, drapes, dressings, gloves (in corneal transplants) donor cornea Patient factors: diabetes, immunosuppression, HIV infection Symptoms Acute presentation: visual loss pain redness photophobia Chronic presentation: similar, usually milder, delayed Signs Acute presentation: lid oedema conjunctival chemosis and hyperaemia corneal haze cells and flare in AC; fibrinous exudate and/or hypopyon if severe pupil light reflex may be sluggish or absent IOP can be normal, low or raised vitritis (...) (inflammation of the vitreous) may eliminate red reflex and preclude view of fundus Chronic presentation: similar, usually milder, delayed Differential diagnosis Post-operative inflammation without infection Other causes of acute red eye, for example acute anterior uveitis Vitreous haemorrhage Management by optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere GRADE* Level of evidence and strength of recommendation always relates

2018 College of Optometrists

86. Appropriate Use Criteria: Imaging of the Spine

of compression ? In a patient with mid-back or radicular pain and red flag signs including: ? Reflex abnormality ? Objective muscle weakness ? Objective sensory abnormality in the thoracic dermatome distribution ? Spasticity Note: Imaging in patients with polyneuropathy without additional abnormalities on neurological exam is not indicated 1-4 Non-specific mid-back pain ? In a patient where focused history and physical exam suggest non-specific thoracic pain and/or referred posterior chest pain and all (...) ? Including but not limited to the following: ? Abscess ? Osteomyelitis ? Discitis Mid-back pain with signs of compression ? In a patient with mid-back or radicular pain and red flag signs including: ? Reflex abnormality ? Objective muscle weakness ? Objective sensory abnormality in the thoracic dermatome distribution ? Spasticity Note: Imaging in patients with polyneuropathy without additional abnormalities on neurological exam is not indicated 1-4 Magnetic Resonance Imaging (MRI) Thoracic SpineMRI

2018 AIM Specialty Health

87. Standards and guidelines for clinical genetics laboratories - cytogenetics

for potential mosaicism. If XX and XY cells are observed: Analyze 15 male colonies if available. If a mixture of XX and XY cells is present, it may be helpful to consult with the referring physician about evidence of a twin pregnancy. Laboratories should have a protocol stating when to reflex to additional studies, such as increased counts, 7 and/or FISH, and/or a recommendation for high-resolution ultrasound, uniparental disomy, microarray, and study of a second tissue. While CVS may appear as colonies (...) ) or amniocentesis. In general, diagnostic testing should be appropriate for the suspected anomaly (i.e., chromosomal microarray (CMA) for smaller copy-number changes). Some laboratories may opt to perform fluorescence in situ hybridization (FISH) for the aneuploidy or copy-number change in question and then reflex to either chromosome analysis or CMA, dependent on the FISH results. While FISH is possible for either type of copy-numberchange,itmaynotbeasaccurate,dependingon the exact size of the anomaly

2018 American College of Medical Genetics and Genomics

88. Exam Series: Guide to the Back Exam

roots exit above the corresponding vertebrae, while thoracic and lumbar nerve roots exit below the corresponding vertebrae. Approach to the History The history and physical examination are essential in the evaluation of back pain. Most investigations are only indicated once there is a suspicion of a back pain emergency, therefore a thorough clinical evaluation is needed to identify patients at risk. In particular, “red flags” on history can point to an emergent pathology. History of Presenting (...) as hematogenous spread of bacteria is the most common source. Immunosuppression also increases the risk of spinal infection. Medications : Anticoagulants increase the risk of an epidural hematoma. Prolonged glucocorticoid increase the risk of fragility fractures. In summary, red flags for neurologically significant back pain include bladder and bowel dysfunction, saddle anesthesia, neurologic deficits (esp. if bilateral), constitutional symptoms, and infectious symptoms. Patient characteristics including age

2018 CandiEM

89. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology

the preferred or indicated approach for use or application. Future modifications of the document are to be expected, as diagnostic microbiology is a dynamic and rapidly changing discipline. Pediatric parameters have been updated in concordance with Pediatric Clinical Practice Guidelines and Policies , 16th ed., and The Red Book (2015), both published by the American Academy of Pediatrics. Comments and recommendations have been integrated into the appropriate sections. I. BLOODSTREAM INFECTIONS

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2018 Infectious Diseases Society of America

90. Low Back Pain, Adult Acute and Subacute

Incapacitating pain and/or advancing neurologic symptoms or other underlying pathology Consider re- evaluation, imaging or referral to specialist no Routine imaging is not recommended See Treatment Algorithm Acute 50) and failure to improve after one month had high false-positive rates. The authors concluded that red flags may be useful when combined or with a history of cancer, but by themselves will result in overtesting (Henschke, 2013). Fracture Single red flags that increase the likelihood of spinal (...) fracture in a patient with low back pain include older age, prolonged corticosteroid use, severe trauma and the presence of contusion or abrasion. These red flags increased the probability of fracture to between 10% and 33% (Downie, 2013). In addition, probability of fracture was higher (increased to between 42% and 90%) with the coexistence of multiple red flags, specifically: (Downie, 2013) • The combination of any four of leg or buttock pain, female, older age, BMI 70, severe trauma, prolonged use

2018 Institute for Clinical Systems Improvement

92. Evaluation and Management of Right-Sided Heart Failure

shape change with RV dilation caused by chronic volume or pressure overload ( B ). The red mesh surface is the left ventricle (LV), and the solid blue surface is the RV. P indicates pulmonary valve; and T, tricuspid valve. Reprinted from Sheehan and Redington with permission from BMJ Publishing Group, Ltd. Copyright © 2008, BMJ Publishing Group, Ltd. Physiology of the RV Normal RV function is governed by systemic venous return, PA load (RV afterload), pericardial compliance, and native contractility

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2018 International Society for Heart and Lung Transplantation

93. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

: 1) an exploration of the affect of sociodemographic variables such as age, gender, and ethnicity that may affect pain and response to pharmacologic intervention; 2) identification of pharmacokinetic, pharmacogenomic, and gender-associated factors that influence analgesic responses; 3) a determination of what pain -related behaviors predict self-reported pain ; 4) the development and study of objective measures (e.g., pupillary reflex dilatation response) to determine pain before and during (...) Nociception Index) (76, 77) or incorporating simultaneously different physiologic parameters (e.g., Nociception Level Index) ( ) may be relevant. Pupillary reflex dilation using video pupillometry has shown promising results in pain assessment of critically ill adults ( ), but future research is necessary to investigate the benefits, harms, and feasibility of implementation in the ICU. | Pharmacologic Adjuvants to Opioid Therapy Opioids remain a mainstay for pain management in most ICU settings. However

2018 Society of Critical Care Medicine

94. CRACKCast E177 – Acute Complications of Pregnancy

of symptoms does not correlate well with the risk of miscarriage, although cramping and passage of clots are thought more likely to occur as the miscarriage becomes inevitable. What are 3 treatment options? (assuming pt is stable) Examination & blood sampling (consider Hgb) and Rh status, followed by Ultrasound and expectant management Good return instructions re: ectopic pregnancy risk and red flags Patient education and support Normal moderate daily activities Avoid tampons, intercourse Cramping from (...) have a demonstrated risk of 4% or higher of one of the pregnancies being ectopic. 6) On US, list 3 diagnostic criteria for IUP, 5 findings suggestive of ectopic, and 4 indeterminate findings. Table 178.3 IUP Abnormal/ indeterminate* Ectopic Red = diagnostic Yellow = suggestive Quant HCG Usually > 1000-2000 mIU/mL Usually < 1500 mIU/mL Any value; < 1000 mIU/mL increases the risk of ectopic pregnancy four fold Location Intrauterine fetal pole Empty uterus Non-specific fluid collections Echogenic

2018 CandiEM

95. CRACKCast E176 – Pediatric Musculoskeletal Disorders

in injury to the brachial plexus. Middle third fractures have been associated with neurovascular bundle injuries, pulmonary injury, and pneumothorax. Reasons to call ortho: (red = obvious; black – you may have to know) Open fracture Skin tenting Neurovascular injury Brachial plexus, artery Suspicion for a posterior clavicle displacement injury Fractures with > 100% displacement of the fracture fragment Pathologic fractures Displaced medial third and lateral third fractures Distal clavicular fractures (...) fracture? See the orthobullets notes here – [29] List seven red flags for pediatric back pain. You need to think broadly From Uptodate: MSK Nonspecific – idiopathic low back pain spondylolysis and spondylolisthesis; scoliosis; Scheuermann’s (juvenile) kyphosis; and intervertebral disc degeneration, herniation, or calcification Infectious discitis, vertebral osteomyelitis (including tuberculous), epidural abscess, and bacterial infection of the sacroiliac joint. Non Spinal infections that can present

2018 CandiEM

96. CRACKCast E175 – Neurologic Disorders

(max 1 g) PR: Diazepam Dose: 5 mg/kg Lorazepam Dose: 1 mg/kg Buccal: Midazolam Dose: 5 mg/kg Lorazepam Dose: 1 mg/kg Pro tip: just memorize lorazepam 0.1 mg/kg for any route except IM or IN; in which case its 0.2 mg/kg for midazolam Note: “ During the administration of medications, pulse rate, respiratory rate, BP, cardiac monitoring and oxygen saturation via pulse oximeter should be followed on a regular basis. Anticonvulsant medications may cause loss of airway reflexes, respiratory depression (...) cortical neuronal depression is accompanied by vascular changes. Derangement of the trigeminovascular reflex results in alterations of regional blood flow, and this neurovascular interaction is thought to contribute to neurogenic inflammation and the development of migraine headaches. The primary goal of the ED evaluation is to differentiate life-threatening causes of headaches from primary headaches, such as migraine or tension headaches. A few different terms are used to characterize headaches: acute

2018 CandiEM

97. CRACKCast E174 – Genitourinary and Renal Tract Disorders

cephalosporin). urologist should be urgently consulted for a scrotal or testicular abscess. [7] Describe the diagnosis and management of testicular torsion. Key points: Can occur at any age – most commonly 12-18 yrs Time sensitive dx! 10% salvage rate at 24 hrs! Diagnosis: Hx: acute constant scrotal pain, swelling, high riding testicle, with nausea and vomiting. acute scrotal pain and swelling, an elevated testicle and, typically, absence of the cremasteric reflex. This reflex can be demonstrated by lightly (...) stroking the skin of the inner thigh downward from the hip toward the knee. The cremaster muscle on the ipsilateral side rapidly contracts and elevates the testicle.Although absent in the vast majority of cases, the presence of the cremasteric reflex does not preclude testicular torsion. Abnormal (high-riding and transverse) epididymal and testicular position may also be noted , with left-sided torsions slightly more common than right. Pain is typically constant, and the patient may have a history

2018 CandiEM

98. Neonatal stabilisation for retrieval

work of breathing · Respiratory acidosis (e.g. pH less than 7.25 or partial pressure of carbon dioxide (PaCO2) greater than 60 mmHg) · Increasing apnoeic episodes · Increasing bradycardic episodes · Refer to Table 10. Intermittent positive pressure ventilation Care 33 · Observe nares and nasal septum for redness · If CPAP or bubble not being maintained: o Check circuit—set up, patency o Reposition CPAP delivery device o Reposition the baby o Maintain seal o Reassess prong size o Place chin strap (...) securely o Observe cannula site hourly for patency, redness and infiltration · Use UVC o Consider insertion if: § Peripheral IV cannulation is unsuccessful § Baby is critically unwell or LBW o Use double lumen catheter (if available) o Secure with suture and tape o Observe site for redness, leakage and dislodgement o Confirm position on X-ray prior to infusing fluids except when using for emergency resuscitation · Routine umbilical arterial catheter or peripheral arterial line insertion not required

2018 Clinical Practice Guidelines Portal

99. Neonatal jaundice

for nappy · Protect eyes · Continuous observation of baby · Monitor baby’s temperature · Continue normal oral feeds · Assess hydration status · Discontinue depending on baby’s age, TSB and cause of hyperbilirubinaemia Risk factors Maternal · Blood group O · RhD negative · Red call antibodies · Genetic–family history, East Asian, Mediterranean · Diabetes · Previous jaundiced baby required phototherapy Neonatal · Feeding– BF, reduced intake · Haematoma or bruising · Polycythaemia · Haemolysis causing (...) management plan with parents · Provide parents with information brochure · If conjugated bilirubin elevated: o Urgent LFT/BGL/INR o Refer to paediatric surgeon/ gastroenterologist Baby 14 days Baby >24 hours · Check maternal ABO and RhD type and red cell antibody screening · Blood tests: o ABO and RhD type, DAT o Other tests as indicated Yes No · Usually BF related · History and clinical examination · Blood tests: o TSB including conjugated and unconjugated o FBC and reticulocytes o TFT /LFT · Check

2018 Queensland Health

100. Induction of labour

each vaginal and uterine balloon (from green stopcock marked ‘V’ and from red stopcock marked ‘U’) o Reassess and repeat ensuring a minimum of 50 mL of residual volume remains in each balloon o Document the volume removed · Offer analgesia and sedation if woman not in labour and continues to experience moderate to severe discomfort despite balloon deflation · If persistent pain and discomfort following oral analgesia o Review by an obstetrician, or o Transfer to birth suite for further assessment (...) , flushing, electrocardiograph (ECG) changes (including prolonged QT interval), transient hypotension, reflex tachycardia (common with rapid IV injection) 102 Medication safety · The standard oxytocin preparation and administration regimen is recommended for all Queensland facilities as outlined in Section 4.4.1 Oxytocin regimen administration · If required, the same infusion solution can be continued for PPH management and as PPH prophylaxis following CS Before administration · Verify CTG normal

2018 Queensland Health

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