Difficult meningitis scenarios were reviewed. The best resource to read is Harrisons textbook of internal medicine.
Acute meningitis presentations - bacterial, viral and encephalitis vs subacute presentations of bacterial brain abscess Viral meningitis does not cause somnolence / drowsiness Bacterial meningitis progresses to confusion Encephalitis often presents with bizarre behaviour Meningism, kernigs and neck stiffness are late signs and only present in <20% of adults and fewer children. mortality once meningism is present is 20-30% -- so don't use this to rule out meningitis!!! Best resource for difficult types of meningitis eg TB, cryptococcal, syphillis is Nelsons textbook of paediarics or UTD. see tables attached below
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This is a massive topic in the EM syllabus. Detailed discussions were completed on : Stroke syndromes - aca amca pca etc, lateral medullary syndrome - anatomy, ct findings, mri and correlation with clinical features A good resource for this is Harrisons Acute thrombolysis guidelines and current literature =such as acem policy on acute stroke, - detailed knowledge of the stroke protocol is needed - suggested reading includes UpToDate or stroke review articles knowledge of HIHSS scoring and modified ranking evaluation is important Medical management and hypertensive management in stroke situations. A review of the topic of headache was completed in the webinar focussing on:
Classification - Primary (migraine, cluster etc) vs Secondary headache (infection, ich, mass, trauma, etc) Key dangerous causes to exclude eg sah, ich, mass, infection, trauma, face, ear, throat, Giant cell arteritis, teeth, sinus. International headache classification and definitions evidence based pharmacology for migraine management incl details of which drugs in which types of patients - detail from UTD required. This webinar introduced the topic of neurology and started with an exam favourite - seizures. The approach to seizure classification - organic (trauma, infection, metabolic, toxin, ins lesion) vs idiopathic epilepsy (and its types eg generalised, myoclonic etc) and definitions around provoked and unprovoked seizures. A consultant approach to managing: Airway and critical threats diagnosing the cause of the seizure seizure termination done in a seemless and simultaneous fashion. A detailed approach to RSI and ongoing sedation in the SE patient An appreciation of the important pivotal clinical features to look for followed by investigation approach. The topics of first seizure approach vs second seizure is important. A detailed review of status epileptics and drug knowledge is important and should be reviewed in Up To Date. The table in Rosens on special seizure situations eg hyponatraemia / eclampsia and departures from standard therapy. This was a jam-packed session on surgical conditions common to the exam (and the floor!!) We reviewed a good approach to abdominal plain film and CT abdomen referencing Rabi et al and CT radiology teaching atlas. AXR useful for obstruction, perforation, volvulus patterns, toxic megacolon 1.assess general gas pattern - caecum, tvs, descending, air in rectum, small bowel pattern in middle. 2.free air pattern? RUQ air? gas around organs? air on both sides of bowel wall ? ligament teres or falciform lig signs? 3. obstruction patterns- fluid levels, large bowel or small dilated , ileocecal valve competent? cecal or sigmoid volvulus CT / CTA abd wall - free air beneath free fluid liver and liver kidney area (hepatorenal space) spleen and kidney (splenorenal space) gallbladder - thickening cecum - tvs - descending - sigmoid colon - rectum - in axial profile bowel wall thickening - infection, inflammatory, ischemia, cancer, ibs gas in gallbladder gas in portsplenic circ pneumatosis intestinalis (air in bowel wall) sma ischemia on cta bush on trauma cta - bleeding Assessment QuestionUsing the above summary tool for assessment we reviewed films ct and uss on the following topics.
The 'analysis' part of the question was the image analysis and the knowledge component was review of causes, classification, symptoms etc using the guide above we did a rapid 1 min of sections using UpToDate: Sigmoid colitis TVS colitis Diverticulitis risk factors, 5 points on clinical review, severity assessmnt, complications checking for all of these on the scan Gallstones - colic vs acute cholecystitis vs cholangitis Tokyo guidelines 2013 Pancreatitis - focussed on severity scoring for prognosis and disposition - BISAP vs ransons vs CT severity index vs apache vs sirs score BISAP = renal f + SIRS + age + effusion BUN > 25 mg/dL (8.9 mmol/L) Abnormal mental status with a Glasgow coma score < 15 Evidence of SIRS > 60 years old Pleural effusion Bowel wall thickening DD: ischemia infection - clostridium, shigella, campylobacter, e coli (has related toxin producing), yersinia inflammatory - UC / chrohns / vasculitis / sle neoplasm - primary adenocarcinoma / mets / sec to nodes form lymphoma ibs - low on the list Click here Today we covered some key areas in surgery for the acem exam. Mesenteric ischemia The 4 key patterns of presentation include embolic - AF or ventricular aneurysm related - 50% of all MI thrombosis low flow states venous thrombosis each of these have a specific risk factor profile which are distinct recognising aetiology, sensitive or specific findings on clinical assessment, and diagnosis on CTA is important, as well as severity grading or assessment of complications such as infarction and organ failure is key. Management options of laparotomy for bowel resection or embolectomy vs angiography for clot retrieval or local papaverine is considered Pancreatitis
diagnostic criteria - 2 of 3 - lipase Elevation, clinical features, imaging findings classification -oedematous vs necrotic severity assessment - based on organ failure prognostic scores : be ale to compare and contrast - BISAP - renal function, effusion, gcs, sirs, 60 yo ransons, apache, sirs, have some knowledge of imaging of the pancreas Toxic megacolon was covered in detail, reviewing the 2 common presentations from IBD or clostridium difficile. Imaging diagnosis of tvs colon > 6 cm and diagnostic criteria including systemic illness and anaemia, wcc elevation, sirs the treatment options varied with underlying cause associations of metabolic alkalosis, hypokalaemia, dysmotility agents Clostridial infecting and predictors or risk factors for clostridial such as antibiotic use, COPD, hospital admission were discussed in detail. Lastly we covered MCQ golden rules: read the question assess if you have the knowledge in an area, or not your gut feeling is only good if you have reviewed the area concerned always study the topic highlighted in the mcq know why an option is correct and why incorrect good resources for MCQ: de Alwis Emergency medicine mcq Dunn mcq's / Tintinalli mcq's emcee practice |
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