Clinical Medicine

Condition / Disease

Otalgia

Cause

Ear pain

Auricular
Hematoma

Shearing of the auricular

tissues with a perichondral
hematoma

Auricular
Abscess

Infection within an
embryonic pit after
a cyst forms

Signs and Symptoms

Neck lymphadenopathy

Head and neck cancer

Very swollen auricle

History of
physical trauma

May also present as a perichondral abscess

Cut on the auricle

It is quite apparent

Foreign Body
in External Ear
Canal

Something in the ear

You will be able to see it

Malignant Otitis
Externa

Infection of the external

ear canal
Infection by
Pseudomonas aeruginosa

Temporal Bone Osteomyelitis

Laboratory
Result

Treatment

Medications

Other

Otologic Source
Otitis externa
Otitis media
Myringitis
Mastoiditis
Ear canal abscess
Herpes zoster
Acute TM perforation
Referred Pain
Musculoskeletal
TMJ dysfunction
neck pain
Trigeminal neuralgia
Pharyngitis
Oral Pain
Dental work
Neoplasm

Auricular
Laceration

Acute Otitis
Externa

Test

Typical symptoms

Pruritis (fungal)

Gray (fungal)

Spores (fungal)

Chronic otorrhea in an
immunocompromised
patient

Can be seen with

uncontrolled DM

Incision and drainage

Bolster both sides with dental rolls

Culture

Temporal
Bone CT
MRI with
Contrast

Incision and drainage

Helps focus
Empirically treat with antibiotics
antibiotic course if
(covers GP organisms)
no improvement
Excision of cyst (surgery)
Debridement
Excise any protruding cartilage which
prevents closure
Approximate wound and use
interrupted sutures
Antibiotic therapy
Attempt removal if it can be done on
the first try
Completely
obstructing EAC
TM perforation
ENT Referral
present
Indications
Touching the TM
Batteries
(do not lavage)
Insect
Kill insect using mineral oil, alcohol, or
lidocaine
Remove with microscopic forceps
using binocular microscopy
May require ENT consult
Bacterial
Remove debris
Place otowick if canal is too narrow
Topical antibiotic drops
Acetic acid
Fungal
Clotrimazole
drops
ENT consult

EMERGENCY
Failure to treat early can lead to
permanent remodeling of the auricle
("cauliflower ear")

EMERGENCY

Avoid oral antibiotics if AOE is

uncomplicated

EMERGENCY

Diagnostic
IV antibiotics

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Tympanic
Membrane
Perforation

Puncture of the
ear drum

Barotrauma

Rapid pressure changes

cause negative pressure in
the middle ear

Acute Otitis
Media
Acute
Mastoiditis

Signs and Symptoms

Usually posterior, ragged, and bloody

Effusion
Ear pain

Middle ear infection

Post-auricular erythema

Bullous
Myringitis

Infection of the tympanic

membrane

Very painful

Bell's Palsy

Facial paralysis thought to be

caused by inflammation of
CN VII

Abrupt onset of upper

and lower facial paresis
or paralysis

Benign Paroxysmal
Positional Vertigo

Displaced otoliths into

the semicircular canals

Better with head still

Sudden
Sensorineural
Hearing Loss

Audiogram

Audiogram

Intermittent

Ear fullness
Otalgia
Edema

CT

Pain when coughing

or sneezing
Mastoid pain
Hyperacusis
Dry eyes
Altered taste
Provoked by supine head
movements to right
or left
(+) Dix-Hallpike

MRI

Fluid behind the

tympanic membrane
Type of hearing loss in
which the root cause lies
in the vestibulocochlear
nerve

Disabling
Opaque TM

Audiogram

Normal TM

Surveillance for 2 - 3 days if symptoms

are not severe
IV antibiotics
Help delinate the
ENT consult
amount of bone
Admission
involvement
Mastoidectomy (sometimes)
Antibiotic (macrolides)
Topical antibiotics
(if vesicles rupture)
Short-term pain management with
opiates
R/O Other serious
pathology

Common Pathogens
S. pneumoniae
H. influenzae
Moraxella catarhalis

Steroids and antiviral medications

Protect the eye

Sodium diet
Diuretics
Anti-vertigo medication
Surgery
Endolymphatic sac decompression
Intratympanic steriod injection
Unilateral (usually)
Gentamycin injection
Labyrinthectomy

Air-fluid line

Steroids

Physical therapy
Pneumatic
Otoscopy

Amber discoloration

Gray color

Rinne
Pneumatic
Otoscopy
Weber

Normal landmarks

Helps determine if
Nasal steroids
any significant
hearing loss
Surveillance
occurred

Vertigo only
Vertigo
SNHL
Lasts 24 - 48 hours
Several weeks of
imbalance

Weber
Bubbles

Other

Epley maneuvers

Tinnitus

Severe vertigo

Medications

Low-frequency
SNHL

Lasts 1 - 8 hours

Acute Labyrinthitis

Treatment
Non-Ototoxic Ear
Floxin
Drops
Ciprodex
Keep ear dry
Recheck hearing in 1 - 2 months
Surgery (for chronic)

Oral antibiotics for 10 - 14 days

Ear fullness

Vestibular Neuronitis

Evaluation

Hearing loss

Tenderness with protrusion of the auricle

Increased endolymphatic
fluid pressure

Vestibular Neuronitis
Infection or inflammation
and Acute
of the inner ear
Labyrinthitis

Otitis Media
with Effusion

Laboratory
Result

Tinnitus
Drainage with relief
Fever

Spread of infeciton to
mastoid air cells

Meniere's
Disease

Ruptured blood vessels

Test

Translucent TM

Rinne

Immobile TM
Lateralizes to
affected ear
BC > AC in
affected ear
Mobile TM
Lateralizes to
good ear
AC > BC in
affected ear

EMERGENCY

ENT referral
High-dose prednisone
Examine internal auditory canals via
MRI

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Nasal Foreign
Body
Acute Bacterial
Rhinosinusitis

Cause

Something shoved up the

nose

Sudden onset of bacterial

infection of the sinuses

Signs and Symptoms

Foul nasal odor
Chronic discharge
Nasal obstruction
Refractory sinusitis
Chronic Foreign Bodies
Pressure ulcers
Infection
Abscess
Persistent Symptoms (> 10 days)
Localized facial pain
Upper tooth pain
Mucopurulent nasal discharge
Severe Symptoms (3 - 4 days)
Mucopurulent discharge
OR localized facial pain

Fever > 102F

Double Sickening (3 - 4 days)

New onset of headache, Follows viral URI which
fever, and nasal
was improving after
discharge
5 - 6 days
Medication

Epistaxis

Nosebleed

Angioedema

Rapid swelling of the

dermis, subcutaneous
tissue, mucosa, and
submucosal tissues

Pharyngitis

Infection of the pharynx

Hypertension

Thrombocytopenia

Leukemia

Clotting disorder

Liver disease

Local Risk Factors

Digital manipulation
Septal deviation
Inflammation
Cold dry air
Foreign body
Nasal steroids
Neoplasm
Marked swelling of the oral soft tissues
Etiologies
Allergic reaction
ACE inhibitor therapy
Idiopathic
Viral Pharyngitis

Hereditary C1 esterase
inhibitor deficiency

< 5 day duration

Sore throat

Nasal congestion

Cough
Fever

Tonsillitis

Infection of tonsils

Possible exudate

Peritonsillar
Abscess

Collection of mucopurulent
material in the
peritonsillar space

"Hot potato" voice

Severe throat pain
Dysphagia
Inability to open jaw
Asymmetric swelling
Copious salivation
Often follows tonsillitis
Nuchal rigidity
Stridor
Sore throat
Drooling
Potential Sequelae
Mediastinal infection
Airway obstruction
Epidural abscess
Necrotizing fasciitis
Sepsis
Erosion into the carotid
Jugular venous
artery
thrombosis

Retropharyngeal /
Parapharyngeal
Abscess

Abscess near pharynx

Test

Laboratory
Result

Treatment

Medications

Augmentin
5 - 7 days adult
First Line
10 - 14 days
children
Dose
Augmentin
Doxycycline
Second Line
Levofloxacin
Moxifloxacin
Clindamycin / 3rd
gen. cephalo.
Manual compression
Afrin
Stop anticoagulants
Silver nitrate cautery
Daily antibiotic ointment with saline
spray
Nasal packing (if unable to stop
bleeding)
If Nasal Packing
Arterial ligation
Fails
Embolization

Other

Etiologies
S. pneumo
H. flu
M. catarhalis
S. aureus

EMERGENCY
Kiesselbach's Plexus
Anterior nosebleed
Woodruff's Plexus
Posterior nosebleed

EMERGENCY

Benadryl
Steroids
Epinephrine (if airway compromise is
imminent or rapidly progressing
symptoms)
Symptomatic treatment
Penicillin
Amoxicillin
Strep Pharyngitis
Augmentin
EES
Quinolones
Antibiotic therapy if symptoms persist
or compromising airway
Amoxicillin
EES
Antibiotics
Quinolones
Bactrim
Incision and drainage

EMERGENCY

Antibiotic therapy
EMERGENCY
Airway management
Incision and drainage
Antibiotic therapy

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Ludwig's Angina

Croup

Cause

Abscess of spaces under

the tongue

Signs and Symptoms

Laboratory
Result

Submandibular swelling

Medications

Other
EMERGENCY

Surgical drainage
IV antibiotics
Glucocorticoids

Acute laryngotracheitis

Stridor

Seal-like cough
Nebulized epinephrine

Lateral Neck
X-Ray

Infection of the epiglottis

Occur most often in

children

Can lead to rapid and unpredictable

airway obstruction
Etiologies
H. influenzae type B
Staph. species
Strep. species
EMERGENCY

ENT consult

Drooling
"Thumb sign"

Dysphagia

Airway Foreign
Body

Treatment
Airway management

Trismus

Epiglottitis

Test

Avoid touching the epiglottis

IV antibiotics

Coughing

Wheezing

Stridor

Pneumonia

Breath sounds

Broncheictasis

Rigid bronchscopy
Tracheostomy
(if airway compromised)

EMERGENCY

Dental Fracture
Tooth Luxation /
Avulsion

Broke a tooth

Tooth joint becomes

separated

Mandible
Fracture

Broken jaw

Nasal Fracture

Broken nose

LeFort Facial
Fracture
Temporal Bone
Fracture

Very unstable fracture

resulting in disassociation of
skull

Tenants of Prehospital
Trauma Care

What should be done on the

way to the hospital

Criteria for
Activating the
Trauma Team

What kind of trauma

warrants trauma team
involvement

Skull base fracture

Quite obvious

Sealing (within 24 hours)

Repositioned
manually
Splinted in place
Reposition
Lateral Luxation Likely to have an
alveolar fracture
Mandibulomaxillary fixation
Closed reduction with MMR
(non-displaced fractures)
ORIF with MMF
(displaced fractures)
Soft diet for 6 weeks

EMERGENCY

Extrusive Luxation

Commonly result from

trauma to the mouth

Common in small
children

Pain

Mandible ecchymosis

Step off deformity

Malocculsion

Trismus

Intra-oral lacerations

Numbness of chin
History of blunt force trauma
Look for
Epistaxis
Septal deviation
Septal hematoma

EMERGENCY
Splinting
Secure airway

History of high energy force trauma to skull

EMERGENCY

Control bleeding
ORIF

Hearing loss

Facial paralysis

CSF leak

Vertigo

TM perforation
Nystagmus
Prevention of additional injury
Rapid transport
Advance notification to trauma facility
Field interventions
Falls > 15 feet
High speed MVA
in height
Ejection from vechile
Pediestrian vs. vechile
Fatality in same vechile
> 20 mph
Last words that the patient tells friends is
"watch this"

NonContrasted
CT

EMERGENCY
Diagnostic

ENT consult

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Priorities in
Trauma
Management

Cause

What is most important

during a trauma case

Getting the first look at

the trauma patient

Primary
Survery

"ABCDE"

Secondary
Survey

Undertaken when the

patient's ABCs are stable

Signs and Symptoms

Test

Laboratory
Result

Assess and manage the airway and ventiliation

ETI
simultaneously
Control external hemorrhage with manual
CXR
pressure, obtain vascular access, and begin volume
resuscitation with cystalloids blood
Identify source of hemorrhage
Thoracostomy
Conduct thorough exam with frequent
reassessments of the ABCs
X-Ray
Always protect the C-spine
Airway
Assess the airway
Suction (if available)
Intubation
Rapid airway /
nasopharyngeal airway
Chin lift / jaw thrust

Treatment

Medications

Assess airway

Once C-spine is
stable

Breathing
Closure of open
Decompression and
chest injury
drainage of tension
pneumothorax /
Artificial ventilation
hemothorax
Give oxygen
Circulation
Stop external
Establish 2 large-bore
hemorrhage
IV lines
Administer crystaloid fluid
Disability
Assess awakeness and vocal response to pain
Awake (A)
Verbal response (V)
Glasgow Coma Scale
Painful response (P)
Unresponsive (U)
Exposure
Undress patient
Look for injury
In-line immobilization
(if neck or spinal injury suspected)
Head Examination
C-Spine
Standard
Scalp and ocular
External ear and
CXR
emergent films
abnormalities
tympanic membrane
Pelvis
Pain control
Periorbital soft tissue injuries
Focused
Cardiac
Neck Examination
Abdominal
RUQ
Sonography in
LUQ
Penetrating wounds
Subcutaneous
Trauma
Suprapubic
Tracheal deviation
emphysema
Neck vein appearance
Does not visualize
Neurological Examination
hollow viscus,
Brain function
Spinal cord motor
CT
duodenum,
assessment using the
activity
diaphragm, or Assess tetanus status
Glasgow Coma scale
Sensation and reflex
omentum well
Chest Examination
Breath sounds and
Clavicles and all ribs
CBC
heart tones
ECG monitoring
Abdominal Examination
Potassium
Surgical exploration
NG tube insertion
Creatinine
(penetrating wound)
(blunt trauma)
Type and
Standard
Screen
trauma labs
Rectal examination
Insert urinary catheter
Antibiotic therapy (open fractures)
Pelvis and Limbs
Urine Toxicity
Ethyl Alcohol
Fractures
Peripheral pulses
Cuts, bruises, and other minor injuries

Other
Ongoing blood loss causing
hypotension can usually be found in
the chest, abdomen, or
retroperitoneum

If there is blood at the urethral

meatus, a foley catheter should not
be placed.

ABG
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Motor Vechile
Accident Injuries

Common injuries seen in

motor vechile accident

Rapid Vertical
Deceleration

Falling

Penetrating
Wounds

Getting a bullet or
getting stabbed

Tension
Penumothorax

Air trapping in the pleural

space between the lung and
chest wall

Hemothorax
Flail Chest

Blood collect in the

pleural space
Unstable segment of the chest
wall that moves separately from
remainder of thoracic cage

Open
Pneumothorax

Sucking chest wound

Pericardial
Tamponade

Pericardium fills with blood

due to penetrating or blunt
injury to the chest

Pericardiocentesis
Supine Hypotensive
Syndrome

Hypovolemia
in Children

Signs and Symptoms

Test

Laboratory
Result

Absent breath sounds

Air hunger

Distended neck veins

Tracheal shift

Common after
penetrating and blunt
chest trauma

Absent / diminished
breath sounds

Dull percussion

Hemodynamic instability

2 fractures
on 2 ribs

Paradoxical movement
of chest segment

Tube thoracostomy

Signs and symptoms of

hypovolemia in children

EMERGENCY
Source of Bleeding
Lung - intercostal arteries
Chest wall - intercostal arteries
Heart - aorta
Great vessels - aorta
EMERGENCY

Large caliber tube thoracostomy

Distended jugular
veins
Hypotension
Quiet heart
Puncture the skin 1 - 2 cm inferior to
xiphoid process
45 / 45 / 45 degree angle
Advance needle to tip of left scapula
Withdraw on needle during advance
of needle

Other

EMERGENCY

Needle decompression

Early intubation
(if respiratory distress)
Avoid overaggressive fluid
resuscitation

Avoid complete dressing because it

will create a tension pneumothorax

3-Sided occlusive dressing

Chest tube placement remote to site
of wound

Impaired oxygenation and ventilation

Enlarged uterus (after 20 weeks) with

fetus and amniotic fluid compresses
inferior vena cava

Medications

Severe Fall
> 3x height of individual

Large defect of the chest wall

Removal of pericardial
fluid

Treatment

Larynx and tracheal

Soft tissue neck injuries
injuries
Fractured sternum
Myocardial contusion
Pericardial tamponade
Pneumothorax
Hemothorax
Flail chest
Intrabdominal injuries
Factors
Body part that
Distance of the fall
impacts first
Type of landing surface
Stab Wound Factors
Location penetrated
Blade length
Angle of penetration
Location
Gunshot Factors
Type of weapon
Caliber or size of bullet
Bullet deformity
Distance from which the
Tumble and yaw
weapon was fired
of bullet

Rapid evacuation of pericardial space

Beck's Triad

Pericardiocentesis
Open thoracotomy
Complications
Aspiration of ventricular blood
Laceration of cardiac tissue / vessel
Cardiac arrhythmia
Pneumothorax
Puncture of esophagus / peritoneum

Ultrasound
Best to guide
needle
EKG Lead V
Keep in left lateral decubitus position

Venous return

Cardiac output

Tachycardia

AMS

Respiratory compromise
Delayed capllary refill

Absence of peripheral
pulses

Resuscitation of mother
Fetal monitoring

Address skin pallor and hypothermia

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Shock
Hypovolemic
Shock
Hemorrhagic
Shock

Cause

Syndrome of impaired
tissue oxygenation and
perfusion

Shock caused by a
decreased blood volume

Signs and Symptoms

Response
Transient response
No response
Non-Responders / Ongoing Bleeding
External
Chest
Abdomen
Retroperitoneum
Pelvis / long bone fractures
Recent MI

Cardiogenic
Shock

Arrhythmia

Cardiac output
Ventricular filling
pressures
Afterload
Pulmonary edema
Distended jugular veins
S3 gallop

Distributive
Shock

Septic Shock

Cardiac
Compressive
Shock

Loss of peripheral
vascular tone

Shock caused by a severe

infection
and/or sepsis

Obstruction of blood flow

caused by impaired cardiac
filling and excessive afterload

Septic

Adrenal crisis

Neurogenic

Anaphylactic

Hyperdynamic
(High Output
Inflammatory Shock)

Treatment

Low Output
Inflammatory Shock

Combination of sepsis
and hypovolemia

Pericardial Tamponade

Pulsus paradoxus

Tension pneumothorax

Diaphragmatic rupture

Pulmonary embolism

Other

CXR
Evaluation
Pelvis X-Ray
Improve myocardial function
Correct arrhythmias
Cautious fluid administration
Transaortic ballon pump
Extracorporeal membrane
oxygenation
Surgery
Dopamine
NorEpi
Vasoactive Agents
Epi
Vasopressin
Dobutamine

Vasodilitation

Cardiac output

Medications

Airway, ventilation, and breathing

IV
Fluids
Warmed
crystalloid
Blood products
Correct coagulopathy
Treat source of volume loss

Excessive diuresis

Crystalloid

Inadequate circulation of
blood due to primary
failure of the ventricles of
the heart to function
effectively

Laboratory
Result

Subtle clinical findings

Compensated
Mild confusion
Tachycardia
AMS
Uncompensated
Profound hypotension
Oliguria / anuria
Trauma
Hemorrhagic
GI bleed
Nonhemorrhagic
Severe inflammation /
Burns
infection
Vomiting / GI issues
Inadequate oral intake

Major cause of trauma

mortality

Test

Low Output

High Output

Etiologies
Arrhythmias
Valvular / septal defects
Ischemia
Myocarditis
Cardiomyopathy
Systemic / pulmonary hypertension

IV fluids
Antibiotics
Correct GI leaks
Debridement
Drainage of
abscess
Cautious
vasocontriction
Control underlying
cause
IV fluids

IV fluid
Correct the mechanical problem
High-pressure ventilation

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Distributive
Shock

Loss of vascular tone

Warm extremities

Diastolic pressure

Blood pooling in extremities

Pulse pressure

Bradycardia

Neurogenic
Shock

Distributive type of shock attributed

to the disruption of the autonomic
pathways within the spinal cord

Stages of
Shock

Blood
Components of
Transfusion

Decreased cardiac function

How to classify different

levels of shock

What can be transfused

Transfusion
Reaction
Anaphylaxis

Laboratory
Result

Treatment

Medications

Other

Fever
Loss of sympathetic
Loss of vascular tone
innervation
Blood pooling in
Decreased cardiac
extremities
function
Stage 1
Compensated by
15% blood loss
contriction of vascular
BP maintained
bed
Normal respiratory rate
Pallor
Normal mental state
Normal capillary refill
Normal urine output
Stage 2
Cardiac output not
15 - 30% blood loss
maintained
Tachycardia
Respiratory rate
BP maintained
Diastolic pressure
Narrow pulse pressure
Sweating
Mildly anxious / restless
Delayed capillary refill 20 - 30 mL urine / hour
Stage 3
30 - 40% blood loss
Systolic BP < 100 mm Hg
Tachycardia > 120 bpm
Tachypnea > 30 bpm
AMS
Sweating
Pallor
Delayed capillary refill
20 mL urine / hour
Stage 4
> 40% blood loss
Tachycardia > 140 bpm
Weak pulse
Pronounced tachypnea
Systolic BP < 70 mm Hg
LOC
Lethagy
Coma
Moribund
Absent capillary refill
Negligible urine output
PRBCs
Platelets
Plasma products
Fresh frozen plasma
Granulocytes
Factor VIII
Fibrogen
Cryoprecipitate
von Willebrand factor
Factor XIII
Anxiety
Chest back pain
Dyspnea
Fever / chills
Flushing
Clammy skin
Tachycardia
BP
Nausea
Angioedema

Severe immediate
hypersensitivity reaction

Test

History of
Exposure to possible
allergen
Sting or bite

New drug
New food

Rapid, progressing, multi-system illness

IV fluids
Vasoconstrictors
CBC with
Platelets
BMP
PT / INR /
aPTT

Control airway

U/A
Supplemental oxygen / ventilation

ABG
Lactic Acid

IV access
Fibrinogen
Evaluation
Cultures
Pregnancy
Test
CXR
Pelvic X-Ray

Circulatory
Support

Fluid replacement
Vasopressors

Monitor hemodynamic and

physiologic values

CT
FAST Exam

Early surgical consultation / transfer

EKG
Blood Replacement Priorities
Cross-match PRBCs
Fresh frozen plasma
Platelets
Start with 2 units PRBCs
Frequent assessment
Thromboelastography

Control airway
Supplemental oxygen
Limit further exposure
Epinephrine IM
Antihistamines
Albuterol (bronchospasm)
Supportive care
(nonallergic angioedema)

Differential Diagnosis
Myocardial ischemia
Gastroenteritis
Astham
Carcinoid
Epiglottitis
Hereditary angioedema
Vasovagal reaction
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

10 Things to Consider
in a Crashing Patient

Primary Survey in
Musculoskeletal
Trauma

Secondary Survey
in
Musculoskeletal
Trauma

Cause

Signs and Symptoms

Quick things to
remember in a code

Aortic disasters
Acidosis
Bagging / breathing
Baby on board
Compressions
Cooling
Decline
Defibrillation
Effusion
Embolus
Primary Survey
Head tilt
A irway
Jaw thurst
Intubate
Look, listen, feel
B reathing
Ventilate
Perfusion
Control bleeding
C irculation
Type and cross match
IV support
History (AMPLES)
Allergies
Medications
Past history
Last meal
Events of the trauma
LOC
Neurological
Sensation
Cervical spine
Head and Neck
tenderness
Deformity
Thorax and Abdomen
Tenderness
Back / pubic tenderness
Pelvis
Compress iliac crest
Log roll patient
Spine
Palpate entire spine
Control C-Spine
Deformities / crepitus
Extremities
Tenderness
PROM

"AABBCCDDEE"

What is most important

when a musculoskeletal
trauma rolls in

What to examine when

the patient is stable

Test

Laboratory
Result

Treatment

Medications

Other
Aortic Disasters
Thoracic aortic dissection
Abdominal aortic aneurysm

Lateral
C-Spine

Endplate of C7
must be visualized

PA Chest

Pneumothorax
Hemothorax

AP Pelvis

Pelvic fracture
associated with 4
units of blood loss

CT

Frequently
indicated

X-Ray

At least 2
Inner and outer
main ring cortices

High energy pelvis

fracture

Hemodynamically
Unstable Fracture

Associated with organ

and vascular laceration

Pelvic ring fractures

commonly disrupted in
2 places

AP View

Femoral neck fractures

Prone to Avascular
Necrosis
Hip dislocations

Extremity
Arterial Injury

Torn or lacerated artery

that risks loss of limb

Pulsatile hemorrhage

Expanding hematoma

Audible bruit

Pulseless limb

CT

Arteriogram

Inspect 2
small rings
SI joint spaces
should be equal
Symphysis pubis
should align
(< 5 mm joint
space)
Inspect
acetabulum
If fracture
identified or
suspected

Multilevel trauma

Associated Injuries
Knee dislocation
Displaced tibial plateau fracture
"Floating joint"
GSW / knife wounds
Mangled extremity

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Acute
Compartment
Syndrome

Cause

Signs and Symptoms

Increased pressure in
myofascial
compartments of
extremities

Pain out of proportion

Pain with passive stretch
to injury
Paresthesias
Pulselessness (late)
Anterior, lateral,
Volar and dorsal
posterior compartments
compartments of
of lower leg
forearm
Vascular assessment

Mangled
Extremity and
Traumatic
Amputation

Test

Laboratory
Result

Fracture management

Limb salvage

Time From
Amputation to
Replantation

Extremity
"MESS" Score

Severity
Score

Typically underestimated
injury due to a high
pressure paint and
grease gun

Hand
Lacerations

Getting cut on the hand

Threatened Soft
Tissues / Open
Fractures

Pretty obvious

Septic Joint

Infected joint

Enters flexor tendon

sheath and deep spaces
of the hand

6 hours
(warm ischemia)
12 hours
(cold ischemia)
30 hours
(for digits)

Absolute
Indications for
Reimplantation

Thumb

Pediatric
amputations
Immediate incision and drainage of
sheath and deep space
Wound may be left open for serial
debridement

Tissue necrosis
(due to paint)
Fibrosis
(due to grease)

Amputation for severe digit injection

May involve tendons

Check tendon integrity

Close within 8 hours

Between distal palmar

crease and PIP joint
crease

Check tetanus status

"No Man's Land"

Skin closure in ER
(for tendon laceration)
Reduce displaced fractures and
dislocations that are tenting
Open skin to relieve vascular,
neurologic, and skin compromise

Bone fragments coming out of the body

Cover open fractures with saline

moistened dressings and take to OR

Fever

Pain

Joint
Aspiration

Identify organism

Parenteral antibiotics

Bone Biopsy
Incision and drainage

Osteomyelitis

Bone Scan

Infected bone

Luekocytosis

Joint effusion
MRI

Infectious Tenosynovitis

Soft Tissue
Infections

Other

Decompression with fasciotomy

(if > 30 mm Hg)

Mangled

Significant destruction of
soft tissue endangering
limb

Medications

Measure compartment pressures

> 7 needs trauma center

High Pressure
Injection Injury

Treatment

Possible life-threatening
soft tissue emergencies

Septic Bursitis
Necrotizing Fasciitis
Pyomyositis

Bacterial infection of a
tendon and its sheath
Olecranon bursae
Pre-patella bursae
Deep layers of skin and
fasical planes
Pus-filled abscess within
muscle

Localize
osteomyelitis

Hyperbaric oxygen
IV antibiotic therapy
Incision and drainage
(if progressin)

Etiologies
Group A Strep
S. aureus
Common Etiologies
H. influenza
Group A Strep
E. coli
Etiologies
Staph
Strep
MRSA

Fasciotomies
Consider tetanus and rabies
prophylaxis
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Bone
Type

Test

Laboratory
Result

Treatment

Medications

Location
Group
Subgroup
Location

Extremity
Fracture
Classification

1
2
3
4

Other
Other Classification Systems
Denis - spine
Frykman - forearm (radius and ulna)
Gustilo - open fractures
Letournel / Judet - acetabulum
Garden - hip
Neer - humerus
Seinsheimer's - femur

Proximal
Diaphyseal / shaft
Distal
Ankle (Weber)
Type

How to chart fractures

Simple or complex
A
B
C
Transverse
Spiral

Open or closed
Simple
Wedge
Complex (comminuted)
Group
Oblique
Segmental
Subgroup

Degree of angulation,
Indicates amount of
rotation, displacement, instability and prognosis
or shortening
for healing

Common Joint
Dislocations

Most common directions

of joint dislocations

Shoulder
Elbow
Hip
Knee
Ankle

Clavicle
Fracture

Shoulder
Dislocation

Elbow Fracture
Elbow Dislocation

Most common pediatric

fracture

Shoulder is not in the

correct position

Broken elbow

Elbow is out of place

FOOSH

Anterior
Posterior
Posterior
Posterior
Medial
Lateral
Lateral

AP
(Grashey)
Scapular Y

Standard views

Axillary
Non-operative treatment (usually)
Surgical Indications
Comminution + separation
Significant foreshortening
Skin penetration
Nerve injury
Non-union (especially distal )

Direct blow

Anterior ( 95%)
Avulsion of the
Bankart Lesion
antero-inferior
glenoid labrum
Hill-Sachs Lesion

Compression fracture of
posterior humeral head

Posterior
Anterior force
Seizure
Electric shock
Direct blow to
posterior elbow
Indirect avulsion due to
Olecranon
pull of triceps during
FOOSH with elbow
extended
Radial Head

FOOSH causes impaction

Radial head
("nursemaid's elbow")

Usually posterior

Rowe Maneuver

X-Ray

Diagnostic

Stimson
Maneuver

Hippocratic

Anterior Fat
Pad

Touch opposite
ear over head
Prone
Weights off table
Traction / counter
traction

Small is often
present
Pathologic if large

Posterior Fat
Always pathologic
Pad

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Colle's
Smith's

Forearm
Fractures

Common forearm
fractures

Barton's
Galleazzi's
Monteggia
Nightstick
Scaphoid Fracture

Hand Fractures
and Dislocations

Little tid bits of

information about hand
fractures and dislocations

Metacarpal Fracture

PIP and DIP Dislocations

Garden Type I

Femoral Neck
Fracture

Hip Dislocation
Ankle
Fractures and
Dislocations

Fracture of the
femoral neck

Typically posterior (90%)

dislocation of the hip
joint

Most commonly occur in

the distal fibula

Garden Type II
Garden Type III

Any of a bunch of things

that occur after a fracture

Hip flexed

Adducted and
internal rotated

Possible N/V entrapment

Bi- or tri-malleolar

Infection

N/V Injury

Treatment

Medications

Other

Check for tendon injury

Incomplete fracture with
valgus impaction
Complete fracture
without displacement
Complete fracture /
parital displacement
Complete fracture with
total displacement

Nonunion

Laboratory
Result

Distal radius with dorsal

displacement
Distal radius with volar
displacement
Distal radius intraarticular with possible
carpal disruption
Distal radius with distal
ulna dislocation
Proximal ulna with radial
head dislocation
Mid-shaft ulna
(from direct blow)
Often occult initially
High risk of non-union
Check for rotational and
angular deformity
Boxer's fracture
(5th metacarpal)

Garden Type IV

Delayed Union

Fracture
Complications

Test

X-Ray

Femoral neck
Intertrochanteric
Subtrochanteric
ORIF
Distal femur
(with plate and
screws)
Subtrochanteric
Closed Reduction
Femoral shaft
(with nail)
Allis Maneuver
Anesthesia
Assistant stabilized pelvis with
pressure on iliac spine
Gently flex hip to 90
Apply progressive traction to the
extremity
Apply adduction / internal rotation
Immobilization / splinting
Closed
Hematoma block
Reduction
Check mortise and
Traction
proximal fibula if CRPP (pinning)
"high" ankle sprain
Screws
ORIF
Plates
External fixation

Slow callus formation

No clinical or
radiographic signs of
progression of bony
union
Especially with
open fractures
Always evaluate
circulation and sensation
distal to injury site
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Rhabdomyolysis

Complications of
Musculoskeletal
Trauma

Aftermath of a
musculoskeletal injury

Red Flags for

Child Abuse

Things that automatically

bump child abuse to the
top of the differential
diagnosis

Compartment syndrome
Venous
thromboembolism

Nerve compression
syndromes
Reflex sympathetic
dystrophy
Myositis ossificans

Laboratory
Result

Treatment

Orthopedic
Consult
Indications

Metaphyseal corner
fractures
Vertebral compression
fractures
Epiphyseal separation

Miscellaneous fractures

Other

All fractions but

simple,
non-displaced
Joint dislocations

Type I

Salter-Harris
Fracture
Classification

Respiratory
Distress /
Failure in
Children

Cardiopulmonary
Failure

Growth plate
Growth plate +
metaphysis
Growth plate +
Type III
epiphysis
Epiphysis + growth plate
Type IV
+ metaphysis
Growth plate
Type V
compression / crush
Respiratory Distress
Tachypnea
Respiratory effort
Use of accessory
Nasal flaring
muscles
Retractions
Respiratory Failure
Hypoxemic
Inadequate oxygenation
(PaO2 < 60)
Hypercarbic (PaCO2 > 50)
Respiratory Arrest
Apnea
Absence of breathing
Etiologies of Respiratory Failure
Stidor
Upper Airway
Hoarseness
Obstruction
Distress
Epiglottitis
Wheezing
Lower Airway
Prolonged expiration
Obstruction
Retractions
Asthma
Grunting respiration
Parenchymal Lung
Pulmonary edema
Disease
Pneumonia
Atlectasis
Brain injury
Abnormal Ventilation
OD
Etiologies (4 H's and 4 T's)
Hypoxemia
Hypovolemia
Hypothermia
Hypo / hyperkalemia
Tamponade
Tension pneumothorax
Toxins / poisons /
Thromboemoblism
drugs

Medications

Tendon laceration
or avulsion

Fracture complications
Fractures in various
stages of healing
Long bone fractures in
child < 2 years old
Spinous process
avulsions

Multiple fractures

Test

Type II

Fracture that involves the

epiphyseal plate or
growth plate of a bone

Most common cause of

acute deterioration in
children

Bad situation

Airway patency
Breathing

Rapid
Cardiopulmonary
Assessment (RCA)

Normal Respiratory Rate

Neonatal - 40 - 60 breaths / min
1 Year Old - 24 breaths / min
18 Years Old - 12 breaths / min

Circulation
CNS perfusion

Bag / mask ventilation

Intubation and mechanical ventilation

(if oxygen saturation fails)

IV access

Resuscitation
Fluid Therapy
Maintenance

RCA Needed if
HR

> 200 in infant

> 180 in
1 - 8 year olds
> 160 in
> 8 year olds
< 60 breaths / min

4 C's for Cardiac Deterioration

CNS / cervical spine injury
CV injury
Chest wall disruption
Comorbid injury

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Pediatric Shock

Epiglottis

Croup

Bronchiolitis

Cause

Shock when it occurs in

children

Infection and swelling of

the epiglottis

Subglottic inflammation
due to parainfluenza
virus I, II, or III

Infection of smaller
bronchi and bronchioles
typically by respiratory
syncytial virus (RSV)

Signs and Symptoms

Test

Laboratory
Result

Hypovolemic
Blood volume
Diarrhea
Hemorrhage
Burns
Diabetes
Cardiogenic
Myocardial
CHD
contractility
CHF
Cardiomyopathy
Obstructive
Ventricular outflow
PE
Pneumothorax
Dissociative
Impaired O2 delivery
CO poisoning
Distributive
Sepsis
Impaired peripheral
Drugs
perfusion
Anaphylaxisis
Fever

Abrupt onset

Sore throat

Stridor

Dysphagia

Drooling

1 - 5 day history of
cough and coryza

Followed by 3 - 4 days of
barking cough

Intubation / mechanical ventilation

Aggressive fluid resuscitation

IV antibiotic therapy
CV and respiratory support
Renal protection

X-Ray

Humidified O2 therapy
Nebulized epinephrine
Heliox
Lateral neck in
Intubate
extension during
Blood culture
inspiration

CXR

ELISA RSV
Nasal Wash
WBC

Steeple sign

Humidified O2 therapy
Monitor O2% saturation
Dexamethosone
Nebulized epinephrine
No stridor
3 hours since
last epi
Discharge
Indications
Well-appearing
O2% > 90%
Reliable parents

Hyperinflation
Intersitial
pneumonitis
RUL / RML
infiltrate
Specific and
sensitive
Assessment

Etiologies
RSV
Parainfluenza
Adenovirus
Human metapneumovirus
Mycoplasma

Responsive Infant

5 Back blows
5 Chest thrusts

Responsive Child

Abdominal thrusts
(Heimlich)

Unresponsive
Infant and Child

Look for
foreign body
CPR

Inability to speak
Weak cough

Foreign Body
Aspiration

Stridor

Inhaled a toy, balloon,

hot dog, nut, grape, etc.

Unilateral wheeze
Lower Airway
Obstruction

Cough
Dyspnea

Cefuroxime
Cefotaxime
Ceftriaxone

Antibiotic Therapy

Wheezing
Fever

Other

ABCs

Most common in
6 months - 3 years old

URI symptoms

Medications

Early recognition is essential

X-Ray
Peaks in late fall / early
winter

Treatment

Intubate unstable child

Bronchoscopy
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Retropharyngeal
Abscess

Cause

Infection of S. aureus or
GABS that is most
common in kids
< 5 years old

Signs and Symptoms

Fever
Odynophagia
Stridor
Tender cervical
adenopathy
Sore throat
Dysphagia

Peritonsillar
Abscess

Infection by GABS

Asthma

Chronic inflammatory
disease characterized by
variable and recurring
symptoms, reversible
airflow obstruction, and
bronchospasm

Unilateral tonsillar
enlargement

Cough

High internal
temperature

Expiratory wheezing

Laboratory
Result

SOB

Tachypnea

Diagnostic
Culture

Febrile Seizure

Pediatric
Vomiting

Chest Pain in
Children

Ejection of stomach
contents

Rarely due to cardiac

disease

Genetic predisposition

Simple or complex

May develop epilepsy

(2 - 10%)

Operative incision and drainage

CXR

PEF

Hyperinflation
with flattened
diaphragms

Moderate
(60 - 80%)

IV fluids (if O2% < 94%)

Nebulized albuterol
Nebulizedlevoalbuterol
MDIs
Ipratropium
Steroids
Magnesium sulfate
SQ epinephrine
Admission (if unable to keep O2%
> 93%)
Ampicillin
Infants
Gentamycin
< 3 Months
Ceftriaxone
Cefotaxime
Infants
> 3 Months

LP
MRI

Bilious Vomiting
Sign of intestinal
Duodenal atresia
obstruction
Meconium ileus
Malrotation with
Necrotizing ileus
volvulus
Hirschsprung's
Non-Bilious Vomiting
Pyloric stenosis
Intussusception
TE fistula
Appendicitis
Incarcerated inguinal
Ileus
hernia
Gastroenteritis
Diabetes mellitus
Cardiac Etiologies
Arrhythmias
HCM
Mitral prolapse
Pericarditis
Myocarditis
Musculoskeletal Etiologies
Strains
Trauama
Costochondritis
Resipratory Etiologies
Asthma
Penumonia
Pneumothorax
PE

Unasym

Unasyn 3 g Q6 hours IV

Oral temperature
> 38.5C (am) or
37.8C (pm)
Lethargy
Poor perfusion
Respiratory distress

6 month - 6 years

Other

Clindamycin 600 mg Q8 hours IV

May have unusual fever

Not all fever is infection
patterns

Convulsion associated
with a significant rise in
body temperature

Medications

Operative incision and drainage

Mild (> 80%)

Toxic Infant

Treatment
Clindamycin

Lateral Neck
X-Ray

Severe (< 60%)

Rectal temperature
> 38C

Fever

Sore throat
Dysphagia
Hot potato voice
Pharyngeal erythema
Unilateral pharyngeal
edema
Fever
Drooling
Uvula edema
Contralateral uvula
displacement

Test

Cefotaxime

Evaluate for source of fever

Only if indicated Temperature control

EEG

X-Ray

Ceftriaxone

Common Associated Infections

Pharyngitis / tonsillitis
Cellulitis
Meningitis
Sepsis
UTI
Pneumonia

Rectal diazepam (for prolonged event)

NG tube
Double bubble
sign
IV fluid therapy
(duodenal atresia)
Imaging

Stool Studies

Blood
(necrotizing ileus)

Surgery
Gastrointestinal Etiologies
GE reflux
Foreign body aspiration
Other Etiologies
Sickle cell
Marfan's
Shingles

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Sudden
Cardiac Death

Unexpected death due to

cardiac causes that
occurs in a short time
period

Sudden Infant
Death Syndrome

Sudden death of an infant

< 1 year of age that remains
unexplained after autopsy

Disordered
Control of
Breathing

Signs and Symptoms

Test

Marfan's syndrome (5%)

Other

Congenital coronary
artery abnormal (19%)

Myocarditis (3%)
Non-Cardiac Etiologies
Hyperthermia
Asthma
Anaphylaxis
Trauma
Risk Factors
Prematurity
LBW
Infants of poor mothers
African-American and
who smoke
Native American infants
Sibilings of SIDS infants

Laryngospasm

GER

CNS

50% have identifiable

cause

Depth

Mixing skin with fire

Medications

10 - 25 deaths / year

Classification

Burn

Treatment

HCM (36%)

ALTE Causes

Unusual breathing
patterns

Laboratory
Result

Location

% of BSA loss
Major or minor

1st, 2nd, 3rd,

or 4th degree

Labs
Barium
Swallow
CXR
EEG
EKG
PolySomnography
Home
Monitoring
Coagulation
Studies
Type and
Cross
CBC
BMP
ABG

Prevention
Breast feeding
Avoid exposure to smoke
Evaluation
Avoid soft surfaces
Back to sleep
Parent BLS training
ABCs
Assessment

Fluid resuscitation / maintenance

Surgical management of wounds

Dangerous Rashes
RMSF

Rash

Change of the skin which

affects its color,
appearance, or texture

Paraphimosis

Inability of retracted
foreskin to reduce

ITP
Meningococcemia
Benign Rashes
Measles
Scarlet fever
Viral Exanthems
German measles
Fifth disease
Roseola
Infestations
Dermatitis
Severe pain

Manual reduction
Urinary retention

Necrosis

Emergent circumcision

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Cincinnati Stroke Scale
Right / left facial droop
Facial Droop
No droop
Right / left arm drift

Laboratory
Test
Result
CBC with
Platelets
CMP
Evaluation
PT / PTT
Cardiac
Biomarkers
EKG
Emergent

Treatment

Medications

ABCD's

Do not treat hypertension unless

> 200 / 120
Distinguishes
hemorrhagic from Treat fever
Clear
Non-Contrast ischemic stroke
Speech
Treat cerebral edema
CT
Defines age and
Not clear
anatomic
Prophylatic AED
distribution of
(only if malignant ICP)
Headache
Nausea / vomiting
stroke
CT
rTPA Therapy
Evaluation
Angiography
AMS
DiffusionNo evidence of hemorrhage on CT
Abrupt onset of
perfusion
Hypodensity on CT < hemisphere
hemiparesis
Monocular vision loss
mismatch
Onset of symptoms 3 hours of rTPA
MRI
use
More sensitive
SBP < 185 and DBP < 110
than CT to early
Ataxia
Vertigo
INR < 1.7 and platelets > 100k
ischemic changes
No aspirin or anticoagulation
MR
No trauma or recent surgery
Sudden depressed level
Aphasia
Angiography
of consciousness
Evaluation
Prevent of Future Strokes
Cerebral
Angiography
Anti-platelet therapy
Transient Ischemic Attack
EchoWarfarin
Evaluate heart
Cardiogram
Carotide endarterctomy / stent
placement
Carotid
80% resolve in
Evaluate carotid
PFO closure
Can preceded AIS (30%)
Doppler
60 minutes
stenosis
Ultrasound
Reducing stroke risk factors
Intraventricular Hemorrhage
ABCD's
Headache
Nausea / vomiting
Progressive LOC
ICP
Nuchal rigidity
Fluid and electrolyte management
Intraparenchymal Hemorrhage
Thalamic Hemorrhage
Prevent hyperthermia
Hemisensory loss
Contralateral
Depressed LOC
hemiparesis
Seizure prophylaxis
Parinaud's syndrome
Pontine Hemorrhage
Correct underlying coagulopathy
Horizontal gaze
Abrupt onset of coma
paralysis
Pinpoint pupils
Recombinant factor VII
Autonomic instability
Quadriparesis
Cerebellar Hemorrhage
Hyperventilate
Severe N/V
Avoid mannitol
Sudden onset of
Ataxia
vertigo
Extrenal
AMS
Management of ventricular drain
Lobar Intraparenchymal Hemorrhage
ICP
Usually a clinically
Symptoms depend on
Surgical
silent lesion
site of hemorrhage
evacuation of
Hemiparesis
Aphasia
hematoma
Hemianopsia
Hemisensory loss
Arm Drift

Other

7 D's of Stroke Care

Detection
Dispatch
Delivery
Door
Data
Decision
Drug

No drift

Acute Ischemic
Stroke

Intracranial
Hemorrhage

Sudden loss of blood

circulation to an area of
the brain resulting in
ischemia and
corresponding loss of
neurological function

Hemorrhage inside
the skull

Hypertension is the most common

cause of intraventricular
Parinaud's Syndrome
Paralysis of voluntary upward gaze,
light-near dissociation, convergenceretraction nystagmus, and eyelid
retraction
Etiologies of IP Hemorrhages
Hypertension
Cerebral amyloid angiopathy
Anticoagulation / anti-platelet
medications
Systemic anticoagulated states
Sympathomimetic drugs
Aneurysm, AVM, cavernous angiomas
Brain tumor

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Subarachnoid
Hemorrhage

Cause

Bleeding into the

subarachnoid space

Signs and Symptoms

Sudden-onset
"thunderclap headache"

"Worst headache of
my life"

CN III palsy

CN VI palsy

Rertinal hemorrhages

AMS

Nuchal rigidity
Risk Factors

Status
Epilepticus

Guillan-Barre
Syndrome

Single seizure or back-toback seizures without

return of consciousness
lasting > 30 minutes
(WHO definition)

Acute polyneuropathy
affecting the peripheral
nervous system

Age
Smoking
Hypertension
Cocaine use
Connective tissue
Heavy alcohol use
disorders
Sickle cell disease
1st degree relatives with aneurysms
Signs of trauma
Nuchal rigidity
End organ injury
Tachycardia
Pupil dilation
Nystagmus
and hippus
Irregular respirations
Etiologies
Idopathic (24%)
Febrile (24%)
Remote symptomatic
Acute symptomatic
(23%)
(23%)
Progressive degenerative (6%)
Acute Symptomatic Etiologies
Stroke
Subarachnoid
Vascular
hemorrhage
Hypoxic ischemic
encephalopathy
Cocaine
Alcohol withdrawl
Toxic
Various medications
AED non-compliance
or withdrawl
Hyper- / hyponatremia
Hypoglycemia
Metabolic
Hypocalcemia
Liver / renal failure
Meningoencephalitis
Infectious
Brain abscess
Trauma
Neoplastic
Progressive ascending
Various cranial
weakness
neuropathies
Areflexia

Minimal sensory deficits

Progression over days to

4 weeks
Bulbar and respiratory
compromise
No sensory level

Preceding infection or
immunization
Diminished / absent
DTRs

Autonomic dysfunction

Laboratory
Result
Will pick up
> 90% SAH
Sensitivity drops
to < 50% after
CT
2 weeks
Carefully evaluate
basilar cisternss
for hemorrhage
If high suspicion
and negative CT
Opening
Lumbar
pressure
Puncture
RBC that does
not clear
Xanthochromia
Digitial
Gold-standard
Subtraction
Angiography

Treatment

Test

Radicular pain /
paresthesias

BMP

Quiet room / sedation

Gastrointestinal

Phenobarbital
Seizure Treatment
Lorazepam
Aneurysm
Treatment

Anticonvulsant
Therapy

Endovascular
coiling
Airway
Breathing
C/V
Dextrose

10% of epilepsy patients will have at

1 episode of SE in their lifetime

Benzodiazepine
Therapy
Long-Acting
Anticonvulsant
Therapy

CT
Refractory Status
If indicated
Albuminocytological
dissociation
Multifocal,
asymmetrical
demyelination
with 2 axonal
degeneration
Slowing of nerve
conduction
velocities

Long-acting AED
(10 - 30 minutes)
Refractory status
(>30 minutes)

Assessment

Ammonia

Nerve
Conduction

Surgery

Benzodiazepine
(10 minutes)

ABG

CSF

H2 blocker
Stool softener
NPO

Nimodipine (vasospasm)

ABCD's

CPK

Lumbar
Puncture

Other
Aneurysmal rupture account for 80%
of cases
Fatality rate is 50% 2 weeks
15% will have > 1 aneurysm
30% survivors require lifelong care

Maintain temperature

AED

LFTs

Medications

ABCD's

Lorazepam
Diazepam
Phenytoin
Phenobarbital
Secure airway
Transfer to ICU
Extra lines for
hypotension
EEG monitoring
Pentobarbital

Airway / breathing serial examinations

Use cautions when treating hypo- or
hypertension
ICU monitoring until patient reaches
Nadir of Weakness
IVIG (5 day infusion)
Plasmapharesis (5 exchanges)
Do not use steroids
Mechanical ventilation (10 - 20%)
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Acute
Myelopathy

Altered Mental
Status

Syncope

Cause

Signs and Symptoms

Sudden disease of the

spinal cord

Acute Flaccid Paralysis

(ipsilateral to side of lesion)
Dropped DTRs below
Anterior horn cell
level
dysfunction at level
Extensor plantar
Superficial reflexes
responses
absent below level
Sensory Level
Contralateral pain /
Ipsilateral vibration /
temperature
joint position
sensory loss
sensory loss
Ptosis
Horner's Sign
Meiosis
Anhydrosis
Sphincter dysynergy
Bladder Dysfunction
Spastic bladder with
incontinence
Constipation /
Bowel Dysfunction
incontinence
Diminished rectal tone

Any measure of arousal

other than normal

Abrupt and transient loss

of consciousness
associated with absence
of postural tone followed
by complete and usually
rapid spontaneous
recovery

Patient not awake, not

alert, or not oriented

Patient not aware of

their environment

Patient not oriented to

person, place, or time

Patient confused

Patient unable to demonstrate an understanding

of what is being said
AEIOU-TIPS
Alcohol
Trauma
Endocine, electrolytes,
Intracranial or infection
encephalopathy
Insulin
Poisoning or psychiatric
Opiates
Uremia
Seizures or syncope
SMASHED
Substrates or sepsis
Hyper- / hypothyroidism,
Meningitis or mental
-thermia, hypotension,
illness
hypoxia, hypercarbia
Alcohol
Electrolyte imbalance or
Seizure or stimulants
encephalopathy
Drugs of any sort
Pain / noxious stimuli
Situational
Carotid sinus
Neurocardiogenic /
hypersensitivity
Vasovagal
Fear
Prolonged standing /
heat exposure
Arrhythmia
Cardiovascular
Valve stenosis
(most dangerous)
HOCM
Orthostatic Hypotension (DAAD)
Drugs
Autonomic insufficiency
Alcohol
Dehydration
Neuro / functional / psychiatric (5%)

Test

Laboratory
Result

Treatment

Medications

MRI

Diagnostic

Emergent neurosurgical consultation

Other
Etiologies
Spontaneous epidural or subdural
hematoma
Metastatic or primary tumors
Ischemia
Hemorrhagic
Transverse myelitis
Vasculitis
Epidural / subdural abscess
Osteomyelitis / discitis

CT
Myelogram

Finger Stick
Blood Sugar
Finger Stick
Hemoglobin

ABC's

ABG
Pulse Ox

Assessment

CMP
CBC
UA
Drug Levels
UDS
Anion Gap
Osmolality
Head CT
Lumbar
Puncture
CXR

Assess for dysrhythmia

As indicated

Echo
Stress Test
Ischemic
Evaluation
Posterior
Circulation
Imaging of
Brain

Head CT

Signs and Symptoms of Opiates

Constricted pupils
Sweating
Nausea / vomiting / diarrhea
Needle marks
Loss of appetite
Slurred speech
Slowed reflexes
Depressed breathing
Depressed pulse rate
Drowsiness
Fatigue
Mood swings
Impaired coordination
Depression
Apathy
Stupor
Eurphoria

High risk

If suscpicion of
neurological
syncope

Admission (high risk)

Holter monitor or event monitor

(if frequent episodes)

High Risk
Evidence of significant heart disease
Arrhythmia signs / symptoms
Comorbidities
Carotid ultrasound has poor utility in
syncope workup

Only if patient has

or experienced
Implantable loop recorder
focal deficits or
(if infrequent episodes)
received head
trauma
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Coma

Catatonia
Tension
Headache

Migraine

Cause

Signs and Symptoms

Unarousable
unresponsiveness in
which the subjects lie
with eyes closed

Clues from History

Associated neurologic
Onset of symptoms
symptoms
Medications
Breathing
Central-reflex
Abnormalities of
hyperpnea
respiration can help
Apneustic
localize but almost
Cluster
always in the context of
Ataxic
other signs
Loss of automatic
breathing
Cranial Nerve Exam

Symptom complex associated with

severe psychiatric disease or
organic brain disease

Typically occur between

ages 20 - 50

Neurological disorder
characterized by
recurrent moderate to
severe headaches

CN 2 - 3

Pupillary light response

CN 3, 4, 6, and 8

Occulocephalic / calorics

CN 5 and 7
CN 9 and 10

Corneal reflex
Gag reflex

Stupor

Excitement

Mutism

Posturing

Test

Laboratory
Result

Occur 5 - 30 minutes
(20%)
Dysphasia

NSAIDs (1st line)

Tylenol (2nd line)
Exercise
Follow up with PCP or neurology

Nausea / vomiting
Hemiparesis
Ataxia

Toradol 30 mg
Benadryl 25 mg
Reglan
Anxiolytic (if cocktail fails)
5HT1 agonist (sumatriptan)
Oxygen
Ergotamine
Intranasal lignocaine
Verapamil
Prophylactic
Lithium
Treatment
Prednisolone
(with above)
Follow up with PCP or neurology
Migraine Cocktail

Can last 4 - 72 hours

Sharp

Most common in 3rd

decade of life

Stabbing
Up to 8x / day
No preceding aura

Traumatic Head
Injuries

Vertigo

Severe bonk on
the head

False sense of motion

Attacks of short duration

> 3 hours

Headache
Cardiovascular and
neurologic symptoms

Vertical nystagmus
(central lesion)

Horizontal nystagmus
(peripheral lesion)

Rhomberg sign
(peripheral sign)

Positive Dix-Hallpike maneuver

(PPV 83% and NPV 52%)

Rebound headache occurs up to 45%

Darkened quiet room

Excruciating

Cluster
Headache

Other

Reasssurance
Warm packs

Photophobia

Scintillating scotoma

Medications

Coma Mimics
Akinetic mutism
"Locked-in" syndrome
Catatonia
Conversion reactions
"Locked-In" Syndrome
Infarction of basis pontis
EEG shows normal or shows alpha
activity

Episodic
Moderately painful
Associated with a
Self limiting with
stressful event
OTC analgesia
Chronic
Recur daily
Associated with muscles
Bilateral and
of the scalp (possibly)
occipitofrontal
Blurred vision

Treatment

CT

Associated Cranial Parasympathetic

Symptoms
Lacrimation
Rhinorrhoea
Ptosis / miosis
Alcohol and tobacco may precipitate
attack

Helps with
Analgesia
decision making

Audiometric
Testing

If Menier's disease
Medical therapy
suspected
Acute vertigo
Contrast MRI
Sensorineural
hearing loss
BPPV
Vertebrobasilar
MRA
circulation

Epley maneuver
Medical therapy

Meclizine
Dimenhydrinate
Diazepam
Lorazepam
Metoclopramide
Prochlorperazine
Promethazine

Central Etiologies
Cerebellopontine angle tumor
Cerebrovascular disease
Migraine
Multiple sclerosis

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Head Trauma

Cause

Injury to the head

Subarachnoid
Hemorrhage

Collection of blood within

the substance of the
brain

Epidural
Hematoma

Collection of blood in the

epidural space

Subdural
Hematoma

Collection of blood in the

potential space between
the dura and arachnoid

Concussion

Temporary interruption
of neurologic function
after minor head trauma

Post Concussive
Syndrome

Seen in many patients after

mild traumatic brain injury

Signs and Symptoms

Skull compromised and
Open
brain exposed
Closed
Brain not exposed
Scalp Injuries
Contusions
Lacerations
Avulsions
Significant hemorrhage
Scalp Wound
May lead to shock in
Highly vascular
children
Bleeds briskly
Skull Fracture
Liinear nondisplaced
Depressed compound
Large contusion or darkened swelling
Retroauricular
Periorbital ecchymosis
ecchymosis
Battle's sign
Basilar Skull Fracture
Raccoon eyes
Spontaneous or
Sudden onset
traumatic
Diffuse headache

Nausea

Most common in frontal

or temporal lobes
Brief loss of
More common in
consciousness followed
younger patients
Usually present within
"Talk and die"
hours

Test

May acute / subacute /

chronic

Unstable Fracture
CT

Frequently sports
related

Confusion

Amnesia

Direct pressure
Dressings

Always indicated

Avoid direct
pressure

Diagnostic
CT

CT

Surgical management is controversial

Admission

Watch for signs of herniation

Can be missed if
< 6 hours after
Phenytoin (consider)
injury
Prompt diagnosis and therapy
Diagnostic

Immediate neurosurgical referral

Surgical decompression
Hyperdense lesion
that hugs the
covexity of the
Surgical evacuation
brain with a
crescent shape
Extends beyond
the suture lines

Frequently result from a tear in a

menigeal vessel

Caused by a tear in the "bridging

veins" passing between the cerebral
cortex and cerebral sinuses
Always suspect non-accidental
trauma / abuse in infants

Neuro checks Q4 hours at home

Patient education
Discharge to home with responsible
adult

Headache
Insomnia

Irritability

Poor concentration

Headache

Usually resolves within several days few weeks

Dizziness
ABCD's
Neurologic deficits

Spinal Trauma

Other
Glasgow Coma Scale
3 - 8 - severe head injury
9 - 13 - moderate head injury
14 - 15 - mild head injury
Decorticate Extremity Posturing
Arms flexed and legs extended
Decerebrate Extremity Posturing
Arms and legs extended

CT Indications for Mild Head Trauma

Worsening headache
Headache of sudden onset
Persistent emesis
Loss of consciousness
Intoxication with drugs or alcohol
Anterograde amnesia

CT

LOC

Medications

Dressings

Variable symptoms

History of brain atrophy

(elderly and alcoholics)

Treatment
No Stable
Fracture

Photophobia

Sudden acclerationdeceleration
(MVA or fall)

Laboratory
Result

Any injury to the spine

Immobilization
Prevention of
Hypotension

Locations
Cervical (55%)

Thoracic (15%)

Thoracolumbar (15%)

Lumbosacral (15%)

Maintain
Oxygenation

Rigid collar
Spine board
Dopamine
IV fluids
Nasal canula

25% of patients with a spinal injury

will have a head injury

Intubate if needed

Solumedrol ( recovery of function)

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Neurogenic
Shock

Body's response to the

sudden loss of sympathetic
control

Spinal Shock

Occurs immediately after

a spinal cord injury

Temporary suppression of all reflex activity below

the level of injury

Central Cord
Syndrome

Most common of incomplete

spinal cord lesions

History of forced hyperextension injury

(forward fall with facial impact)
Disproportionately greater weakness in the upper
extremities than in the lower extremities

Hypotension

Hemisection of the cord

Anterior Cord
Syndrome

Infarction of the cord in

the region supplied by
the anterior spinal artery

NEXUS
Criteria

Qualities of a stable
C-spine

Indications for Thoracic

or Lumbar Imaging

When to order imaging

Immobilization
Clearance Criteria

Things to think about

Laboratory
Result

Treatment

Medications

Other

Bradycardia
Hypothermia

Penetrating injury

Brown-Sequard
Syndrome

Test

Better prognosis than other

incomplete injuries

Very rare

Ipsilateral motor
Contralateral loss of pain
paralysis and loss of
and temperature
touch / vibration sense
Bony fragment
Disc herniation
protrusion
Cord contusion
Paraplegia with sensory
secondary to cervical
loss of pain and
hyperflexion
temperature
Proprioception, vibration, and pressure sense is
preserved
No posterior midline tenderness
No evidence of alertness
Normal level of alertness
No focal neurological deficits
No painful distractng injury
High-force mechanism
GCS < 15
Pain / tenderness
Local signs of injury
along spine
Neurologic deficit
Previously identified spinal injury
AMS
Intoxication
Neurologic deficits
Midline bony tenderness
Suspected extremity fracture or
distracting injury

Poorest prognosis of the incomplete

injuries

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015