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121. Guidelines on the management of abnormal liver blood tests

to secondary care (red box). For the remainder, a clinical history alongside evaluation of the pattern of liver blood test derangement will determine choice of pathway and is shown in the grey boxes. A grey box indicates all the tests that should be requested at that stage rather than a hierarchy within it. The presence of metabolic syndrome criteria should be sought to support a diagnosis of NAFLD. For children, the text should be consulted for modification of recommendation. Areas of diagnostic (...) persists even if both values are within the normal refer- ence interval. 39 While it is hard to justify the routine analysis of both AST and ALT together on every liver blood test request, a strategy not supported by the data from the BALLETS study, subsequent testing of AST (or ALT depending which one is undertaken first) to calculate the AST:ALT ratio is clearly desirable. From a patient and cost perspective this is likely to be more cost-effective if performed by ‘reflex’ on the same sera following

2017 British Society of Gastroenterology

122. CRACKCast E120 – Dermatologic presentations

or Stevens-Johnson syndrome. Plasmapheresis is considered in consultation with a specialist. [15] List 6 broad categorical causes of urticaria This is a review from Episode 119! Urticaria appears as papules or wheals that consist of central swelling with surrounding reflex erythema, and it is associated with itching or a burning type sensation → lasting less than 24 hours. This can occur in isolation (mast cell degranulation) or due to systemic disease (histamine, bradykinin, etc). Drug induced (often (...) Should be isolated at home fever and a skin eruption. Well children 6 months to 3 years old. May occur post febrile seizure The rash typically appears with defervescence. The lesions are discrete pink or rose-colored macules or maculopapules 2 or 3 mm in diameter that blanch on pressure and rarely coalesce fever in 10% to 15% of patients, and a characteristic rash. Arthral- gia and arthritis occur commonly in adults but rarely in children. The rash is intensely red on the face and gives a “slapped

2017 CandiEM

123. CrackCAST E129 – Bacteria

Examination – The spatula test involves touching of the oropharynx with a tongue blade. With a negative test result, the patient gags and expels the tongue blade. With a positive test result, the patient has reflex masseter muscle spasm and bites the spatula. This test is 94% sensitive and 100% specific for tetanus. Management Aggressive supportive care Control muscle spasms Avoid unnecessary stimulation / loud noises = these can trigger severe spasms Treat spasms with benzodiazepines Diazepam – widely (...) , patients have decreased muscle tone and depressed deep tendon reflexes. Cranial nerve involvement causes alterations in facial expression, ptosis, and extraocular palsies. Respiratory failure occurs in 50% of patients. Fever is absent unless secondary infection is present. Hallmark signs: gastrointestinal, autonomic, and cranial nerve dysfunction. Bilateral cranial nerve involvement and the progression of neurologic findings should increase clinical suspicion. The diagnosis is confirmed by detection

2017 CandiEM

125. CRACKCast E125 – Electrolyte Disorders

? Box 117.1: “SPARK+” Spurious elevation Acidosis Renal failure (Including nsaids, ACE/ARB) Kell (Cell) death Drugs Spurious elevation: Hemolysis due to drawing or storing of the laboratory sample or post–blood sampling leak from markedly elevated white blood cells, red blood cells, or platelets Renal failure: Acute or chronic Acidosis: Diabetic ketoacidosis (DKA), Addison’s disease, adrenal insufficiency, type 4 renal tubular acidosis Cell death: Rhabdomyolysis, tumor lysis syndrome, massive (...) , parental Impaired elimination—hypomotility: Bowel obstruction, chronic constipation Impaired elimination—medications: Anticholinergics, narcotics, lithium therapy Miscellaneous: Hypothyroidism, tumor lysis syndrome, adrenal insufficiency, milk-alkali syndrome [17]List five clinical manifestations of hypermagnesemia. Table 117.5: Clinical Effects of Hypermagnesemia EFFECT LEVEL (mg/dL) Decreased deep tendon reflexes 4 to 5 Hypotension 5 to 7 Respiratory insufficiency 10 Heart block 10 to 15 Cardiac

2017 CandiEM

126. CRACKCast E099 – Urological Disorders

Schistosomiasis Urinary symptoms, with sudden obstruction of the bladder outlet Usually need surgical removal after U/S or CT dx Acute Scrotal Pain – Rosens in Perspective Know your anatomy Know that the left testi normally sits lower than the right They normally sit in the vertical axis “The epididymis is located posterolateral to the testis and is normally nontender and soft. The cremasteric reflex is elicited by stroking or pinching the inner aspect of the thigh; more than 0.5 cm of elevation (...) of the ipsilateral testicle is considered evidence of a normal reflex. This reflex normally is absent in 50% of male infants younger than 30 months.” [1] List causes of acute scrotal swelling by age groups (infant, child, adolescent, adult) Infant Child Adolescent Adult Hernia Hydrocele Hernia Torsion Epididymitis Epididymitis Torsion Trauma Epididymitis Hernia Trauma Tumor Torsion Fournier’s gangrene [2] Describe the physiology, diagnosis and management of testicular torsion Bimodal onset: <1 yr and at puberty

2017 CandiEM

127. Tiny Tip: Back Pain Differential Mnemonic

(if needed). Be sure to keep in mind the red flags for back pain that include: history of IV drug use, history of cancer, night time symptoms, fever, saddle anesthesia, bowel or bladder incontinence, or neurologic symptoms such as weakness or asymmetric reflexes. Certain red flags (saddle anesthesia, bowel/bladder incontinence, neurologic symptoms) can indicate . This syndrome is not specifically listed here, as it has many causes listed below: Tumour, trauma, spinal stenosis, etc. 1,2 As back pain (...) to also consider the likelihood of each presentation and, unless conducting an exercise in coming up with all potential differentials, prioritize them based on it and the potential danger to the patient. For example, in a young and otherwise healthy patient with no red flag symptoms mechanical back pain should come up much earlier in the differential than the causes listed under referred pain. Advanced learners should be able to come up with these categorical clusters without a mnemonic

2017 CandiEM

128. CRACKCast E071 – Ophthalmology Part B

management Scleral globe rupture Occurs in setting of blunt or penetrating trauma May be obvious (contents oozing) or subtle Symptoms: VA / pain Signs: Bloody chemosis / severe subconjunctival hemorrhage / Tear drop pupil RAPD / poor VA / no red light reflex Do NOT do tonometry CT: Only 75% sens. Treatment: Eye shield Head of bed > 45 degrees NPO Antiemetics Analgesics Antitussives Broad spectrum abx: Ceftriaxone & gentamicin & vancomycin 7) List 5 indications for ophtho consultation for eyelid

2017 CandiEM

129. CRACKCast E035 – Back Pain

CRACKCast E035 – Back Pain CRACKCast E035 - Back Pain - CanadiEM CRACKCast E035 – Back Pain In , by Adam Thomas April 13, 2017 This episode of CRACKCast covers Rosen’s Chapter 35, Back Pain. This chapter covers a diagnostic approach to a common ED complaint, with emphasis on the red flags you cannot miss, as well as an approach to treatment. Shownotes – 1) List 10 historical red flags for back pain Red flags on History and Physical Exam History Fracture risks: Trauma history Prolonged steroid (...) . Protrusion — extrusion — sequestration 95% of herniation occur at L4-S1 spaces – with associated radicular symptoms L5: decreased sensation to first webspace in foot Weak extension of the great toe and NORMAL reflexes S1 Decreased sensation to lateral foot and small toe Weak plantar flexion and +/- ankle jerk reflex loss Disk extrusion – is usually symptomatic, the others usually are NOT ⅔ resolve in 6 months on MRI 75% of people’s symptoms improve in 6 weeks If spinal stenosis, it worsens over time

2017 CandiEM

130. CRACKCast E071 – Ophthalmology Part A

SYSTEMIC extension of the infections require IV abx 4) Describe typical features of conjunctivitis and management options Conjunctivitis #1 cause of a red eye Symptoms: Redness, FB sensation, lid swelling, eye crusting, drainage NO photophobia, NO visual loss Caseus: Viral, bacterial, mechanical, allergic, toxic Called KERATOconjunctivitis when the cornea is involved as well Most commonly viral Bacterial causes: Pneumoniae, H. influenzae, Staph, Moraxella, Neisseria gonorrhoeae, Klebsiella, Pseudomonas (...) cause of conjunctivitis (Adenovirus, and others) Symptoms: MORE redness and itching and eye irritation Watery –> purulent d/c Pre-auricular lymphadenopathy Concurrent viral illness Very contagious up to 12 days post onset Treatment: Artificial tears Cool compresses Handwashing Use ABX if NO improvement of symptoms after 72 hrs Allergic conjunctivitis IgE mediated To any allergen (chemical, cosmetics, environmental) Symptoms: Bilateral eye itching Glassy chemosis Watery discharge Treatment

2017 CandiEM

132. CRACKCast E029 – Nausea and Vomiting

) Content of vomit: Bile – means duodenum and stomach are connected (no outlet obstruction) Undigested food – achalasia, esophageal stricture, Zenker’s diverticulum, Feculent material – distal bowel obstruction Associated symptoms and signs: Chronic nausea/vomiting with headaches – CNS pathology Vomiting without nausea – CNS pathology Social/Medical history: ETOH use GI disease / surgeries Medication list Physical exam Red flags: Adult vs. Pediatric exam varies – need to do a full physical exam Bulging (...) reflex Medications: Pharmacologic categories: Histamine antagonists – inhibit vestibular stimulation and vestibular-cerebellar pathways Also have some anticholinergic effects Dimenhydrinate or meclizine – great for motion sickness s/e: drowsiness, blurred vision, dry mouth, hypotension Cetirizine – is less effective as an antiemetic, but is non-sedating Muscarinic antagonists (anticholinergic) Scopolamine (patch) or hyoscine Good for motion sickness only Dopamine antagonists – D2 receptor in the CTZ

2017 CandiEM

133. Final recommendation statement: vision in children ages 6 months to 5 years: screening.

in primary care settings. Visual acuity tests screen for visual deficits associated with amblyopia and refractive error. Ocular alignment tests screen for strabismus. Steroacuity tests assess depth perception. For children younger than 3 years, screening may include the fixation and follow test (for visual acuity), the red reflex test (for media opacity), and the corneal light reflex test (for strabismus). Instrument-based vision screening (i.e., with autorefractors and photoscreeners) may be used (...) in very young children, including infants. Autorefractors are computerized instruments that detect refractive errors; photoscreeners detect amblyopia risk factors (ocular alignment and media opacity) and refractive errors. Vision screening in children older than 3 years may include the red reflex test, the cover-uncover test (for strabismus), the corneal light reflex test, visual acuity tests (e.g., Snellen, Lea Symbols [Lea-Test], and HOTV [Precision Vision] charts), autorefractors and photoscreeners

2017 National Guideline Clearinghouse (partial archive)

134. Clinical Practice Guideline for the Care of Women with Decreased Fetal Movements

Support (SANDS); Red Nose; Women’s Healthcare Australasia; and Still Aware. Suggested citation: Gardener G, Daly L, Bowring V, Burton G, Chadha Y, Ellwood D, Frøen F, Gordon A, Heazell A, McDonald S, Mahomed K, Norman JE, Oats J, Flenady V. Clinical practice guideline for the care of women with decreased fetal movements. Centre of Research Excellence in Stillbirth. Brisbane, Australia, August 2017. Disclaimer: The main objective of this guideline is to provide advice to health care providers (...) the fetus within the amniotic sac. Antenatal The period of the pregnancy before birth Antepartum Before the onset of labour. Apgar score A system to assess the status of the baby after birth. The Apgar score is recorded at 1 minute and 5 minutes after birth and is based on the following five variables: heart rate, respiratory effort, muscle tone, reflex irritability and colour, with a maximum score of 10. Body mass index (BMI) A person's weight in kilograms divided by the square of height in meters

2017 Clinical Practice Guidelines Portal

135. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association

to be the first day of fever) together with at least 4 of the 5 following principal clinical features. In the presence of ≥4 principal clinical features, particularly when redness and swelling of the hands and feet are present, the diagnosis of KD can be made with 4 d of fever, although experienced clinicians who have treated many patients with KD may establish the diagnosis with 3 d of fever in rare cases ( ): 1. Erythema and cracking of lips, strawberry tongue, and/or erythema of oral and pharyngeal mucosa (...) is based on the presence of ≥5 days of fever (first calendar day of fever is illness day 1) and the presence of ≥4 of the 5 principal clinical features ( , ). In the presence of >4 principal clinical criteria, particularly when redness and swelling of the hands and feet are present, the diagnosis may be made with only 4 days of fever. Similarly, experienced clinicians who have treated many KD patients may make the diagnosis in rare instances with only 3 days of fever in the presence of a classic

2017 American Heart Association

136. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society

4.2.5. Cardiac Sarcoidosis: Recommendations e36 4.3. Inheritable Arrhythmic Conditions: Recommendations e37 4.3.1. Brugada Syndrome: Recommendations e37 4.3.2. Short-QT Syndrome: Recommendation e37 4.3.3. Long-QT Syndrome: Recommendations e37 4.3.4. Catecholaminergic Polymorphic Ventricular Tachycardia: Recommendations e37 4.3.5. Early Repolarization Pattern: Recommendations e37 5. Reflex Conditions: Recommendations e37 5.1. Vasovagal Syncope: Recommendations e37 5.2. Pacemakers in Vasovagal Syncope (...) : Recommendation e38 5.3. Carotid Sinus Syndrome: Recommendations e38 5.4. Other Reflex Conditions e38 6. Orthostatic Hypotension: Recommendations e38 6.1. Neurogenic Orthostatic Hypotension: Recommendations e38 6.2. Dehydration and Drugs: Recommendations e39 7. Orthostatic Intolerance e39 8. Pseudosyncope: Recommendations e40 9. Uncommon Conditions Associated with Syncope e40 10. Age, Lifestyle, and Special Populations: Recommendations e40 10.1. Pediatric Syncope: Recommendations e40 10.2. Adult Congenital

2017 American Heart Association

137. Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

should be made to improve coronary perfusion pressure and reverse the tachycardia by giving volume if the end-diastolic volume is low, or an inotrope if contractility is low. Because CO = HR × SV, therapies directed to increasing SV will often reflexively reduce HR and improve CO. This will be evident in improvement of the shock index (HR/systolic blood pressure [SBP]) ( ), as well as CO. Children have limited HR reserve compared with adults because they are already starting with high basal HRs

2017 Society of Critical Care Medicine

139. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope

. Inheritable Arrhythmic Conditions: Recommendations e81 4.3.1. Brugada Syndrome: Recommendations e81 4.3.2. Short-QT Syndrome: Recommendation e82 4.3.3. Long-QT Syndrome: Recommendations e82 4.3.4. Catecholaminergic Polymorphic Ventricular Tachycardia: Recommendations e83 4.3.5. Early Repolarization Pattern: Recommendations e84 5. Reflex Conditions: Recommendations e84 5.1. Vasovagal Syncope: Recommendations e84 5.2. Pacemakers in Vasovagal Syncope: Recommendation e85 5.3. Carotid Sinus Syndrome (...) : Recommendations e86 5.4. Other Reflex Conditions e86 6. Orthostatic Hypotension: Recommendations e86 6.1. Neurogenic Orthostatic Hypotension: Recommendations e86 6.2. Dehydration and Drugs: Recommendations e88 7. Orthostatic Intolerance e88 8. Pseudosyncope: Recommendations e88 9. Uncommon Conditions Associated with Syncope e89 10. Age, Lifestyle, and Special Populations: Recommendations e89 10.1. Pediatric Syncope: Recommendations e89 10.2. Adult Congenital Heart Disease: Recommendations e91 10.3. Geriatric

2017 American Heart Association

140. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

undergo significant physiological alterations during pregnancy. The following sections highlight the physiological changes that have particular relevance to the management of gravidas with CHD. Antepartum Blood Volume Maternal blood volume begins to increase with the early hormonal changes of conception. Overall, pregnancy increases maternal blood volume by ≈40% for a singleton and 67% for twins, with peak values at ≈32 weeks of gestation , ( ). Both plasma volume and red cell mass contribute (...) to the hypervolemia, with respective increases of ≈45% to 55% and 20% to 30%. Estrogen has a key role in plasma volume expansion and promotes sodium and water retention by upregulating the production of angiotensinogen, renin, and aldosterone. The disproportionate expansion of plasma volume relative to red cell mass contributes to the physiological anemia of pregnancy, with mean±SD hemoglobin concentrations of 10.9±0.6 and 12.4±1.0 g/dL for the second and third trimesters, respectively. Figure 1. Pregnancy

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2017 American Heart Association

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