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40 Flashcards

1
Q

Infant HIV testing

A

HIV DNA PCR at 48hrs, 4-6wk, 3 mo

HIV Ab at 12-18 mo

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2
Q

new HIV labs

A

CBC, LFT, BUN/creat, urinalysis, hepatitis serologies, blood glucose, lipids, genotypic resistance, STIs, opportunistics (toxo, CMV, PPD)

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3
Q

Preventive Txt PCP in HIV

A

CD4 <200 DS Bactrim daily

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4
Q

Preventive Txt Toxoplasmosis in HIV

A

CD4 <100+toxo Ab DS Bactrim daily

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5
Q

Preventive Txt MAC in HIV

A

CD4<50 Azithro or clarithro weekly

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6
Q

Routine Vaccines in HIV

A

pneumovax if CD>200, HAV, HBV, flu

screen for HBV, HCV

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7
Q

HIV Treatment based on CD4 count in adult

A 
Treat CD4500
(WHO defer until <350)
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8
Q

HIV Meds

A

entry inh (fusion inh, CCR5 blockers), NRTIs, NNRTIs, integrase inh, protease inh

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9
Q

HIV med drug interaction

A

inhaled steroids, statins, methadone, OCPs, rifampin, erectile dysfunction, st johns wort, PPIs, coumadin

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10
Q

Protease Inh drug interactions

A

HIGH RISK/CI - simvastatin, lovastatin
mod risk - fibrate+statin, atorvastatin
low risk - fibrates, pravastatin, fluvastatin, rosuvastatin, fish oil, niacin

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11
Q

HBV, HCV, HIV avg transmission rates

A

HBV 30% > HCV 3% gt HIV 0.3%

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12
Q

Occupational exposure risks

A

IM injury 16% > advanced AIDS source pt 6% > visible blood on device/needle enter blood vessel 5% >AZT PEP 0.2%

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13
Q

Post-exposure prophylaxis - occupational and non occ

A

3 drug therapy, 28 days, immediate start to meds important

reduces risk 81%

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14
Q

Post-exposure F/U testings

A

Initial - CBC, creat, LFT, HIV Ab, HCV Ab, HBsAg/Ab
2 weeks - CBC, creat, LFTs
6 weeks - HIV ab, HCV ab, RPR
3 mo+6mo - HIV ab, HCV ab (stop at 3 mo if using p24 ab test)

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15
Q

Pre-exposure prophylaxis

A

Truvada daily

risk reduction 44%, up to 90%

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16
Q

Pre-exposure prophylaxis pre-initiation testing

A

Test for HIV ab, CrCl>60
screen and vaccinate HBV
screen and treat STDs

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17
Q

Pre-exposure prophylaxis F/U

A

F/u - q3mo - HIV ab, STD sx eval, counsel
q6 mo - STD test even is asymp
BUN/creat 3 mo post start then annually

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18
Q

HIV incubation period

A

2-4 weeks

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19
Q

Acute retroviral syndrome timing

A

2-4 weeks post exposure, lasts 3-14 days

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20
Q

Acute retroviral syndrome Sx

A

fever, rash, swollen lymph - high viremia

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21
Q

HIV tests

A

*Elisa - negative until >3-4wk post infection
P24 - 3 weeks
HIV RNA - +10-15 days post infection

  • use unless suspect acute retroviral syndrome
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22
Q

HIV Clinical Latency Sx, tests, duration

A

HIV ab response - cell mediated then humoral
Symptoms - none
Tests - Elisa+ HIV RNA+
Duration - variable

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23
Q

Viral set point HIV

A

predictor of dx - set 3-6 mo post infection

high set point - high rate of transmission

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24
Q

Symptomatic phase - CD4 related dx’s

A

Progression to AIDS
CD4<500 - bacterial pneumo, TB, minor skin infections more common
CD4 200-500 - opportunistic infections - herpes zoster, TB, candidiasis, PCP, toxo, CMV, kaposi, HSV

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25
Q

HIV Screening Guidelines

A

All persons 15-65 - once
High risk pts - annually
Pregnant women - once, again in 3rd tri if high risk area

written consent not required

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26
Q

TB presentations - types

A

pulmonary, pleural, pericardial, GI, lymphnode, GU, skeletal (gibbus malformation, Potts dx)

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27
Q

TB symptoms

A

Chronic cough >2-3 weeks, night sweats, loss of appetite, weight loss/consumption, fatigue

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28
Q

TB exam findings

A

nonpainful cervical LAN

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29
Q

TB testing

A

PPD, CXR, interferon gama release assay IGRAs, sputum AFB smear and culture, fluid exam in localized dx, tissue pathology, ab and antigen detection assays

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30
Q

TB testing shortcomings

A

CXR negative in 50% children w/ active TB
sputum smear 50% reliable, only possible children>10
PPD - limited sensitivity in HIV/TB coinfected

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31
Q

TB First Line Treatments

A

2 months - rifampin, isoniazid, pyrazinamide, ethambutol

continuation phase - 4 months rif, INH

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32
Q

TB Second Line Treatments

A

12-18 month therapy
ethionamide, cycloserine, para-aminosalacylic acid, quinolones
Injectables: streptomycin, capreomycin, kanamycin, amikacin

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33
Q

MDR-TB

A

resistant to INH and rifampin

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34
Q

XDR-TB

A

resistant to INH, rifampin, AND fluoroquinolone AND one of the injectables (capreomycin, kanamycin, amikacin)

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35
Q

MDR-TB Treatment Options

A

Minimum of 4 drugs, 1 year treatment
quinolones - moxiflox, levoflox, gatiflox)
aminoglycosides- streptomycin, capreomycin, kanamycin)
other - pyrazinamide/PZA, cycloserine, ethionamide, PAS

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36
Q

Risks of HIV/TB coinfection

A

Increased progression latent to active TB
more rapid HIV dx progression
higher TB relapse rates
higher rates MDR and XDR-TB

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37
Q

Benefit of HIV/TB cotreatment

A

reduced TB deaths, HIV pts less likely to get TB, lower mortality

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38
Q

Risks of HIV/TB cotreatment

A

Interactions between drugs alter levels –> can lower PI and NNRTI and cause drug failure
Combined SE intolerable
Many many daily doses

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39
Q

HIV/TB cotreatment recommendations

A

Adults/pedi - start TB txt first, start ART asap w/i 8 weeks as tolerated, irrespective of CD4 count
Adult - use EFV as preferred NNRTI

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40
Q

TB Preventions

A

Age treat
Txt latent TB
BCG vaccination
isolation, treatment, contact tracing

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41
Q

LTBI

A

No S+S, can’t spread
Positive - TST, IGRA
Negative - CXR, respiratory smear and culture
Txt to prevent conversion to active TB - INH

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42
Q

Active TB

A

S+S - fever, cough, chest pain, weight loss, night sweats, hemoptysis, fatigue, decreased appetite
Positive - TST, IGRA, CXR (may be normal in adv immunosuppression), respiratory smear and culture (may be - in pulmonary dx)
Txt NEEDED

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43
Q

TB Screening Guidelines

A

Risk - sx TB, healthcare field, spend time around infectious, travel to TB endemic area, poorly functioning immune system

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44
Q

Tuberculin skin test readings

A

> 5mm - HIV or HIV unknown + IVDU, close contact active TB, fibrotic CXR lesions, on steroids, transplant pt
10mm - IVDU and HIV-, high prevalence country, medically underserved, long term care facility
5mm - no increased risk

20% w/ active TB and 80% with active TB and HIV test negative

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45
Q

Latent TB treatments

A

INH daily/BIW for 9 mo
Rif 4 mo
Rif/PZA 2 mo - ONLY IF HIV+

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46
Q

LTBI w/ Drug resistant TB exposure treatments

A

INH resistant exposure - rif 4 mo or rif/PZA 2 mo

MDR exposure - EMB+PZA or quinolone+PZA

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47
Q

LTBI treatment - Pregnant

A

INH for 9 mo - can delay txt

NO DELAY IF HIV+ OR NEWLY EXPOSED

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48
Q

Immune Reconstitution Inflammatory Syndrome IRIS

A

clinical deterioration after starting combo ART
immune system starts working and causes inflammation against infection
weeks - 6 mo after ART initiation (mean 21d)
ARV continued until TB meningitis
Prednisone 2-4mg/kg/day

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49
Q

Migraines criteria

A

2 or more: 4-72hrs, unilateral, pulsating, mod to severe, aggravate by activity
1 or more: N, V, photophobia, phonophobia
w/ or w/o aura
Dx - 5 or more HAs that meet criteria

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50
Q

Chronic Migraine

A

Migraine for >=15 days/mo for >3mo

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51
Q

Tension type

A

Bilateral, pressing, tightening, mild to mod, NOT aggravated by activity, no N/V, either phono or photophobia

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52
Q

Chronic Tension type HAs

A

TTH for >=15 days/mo for >3mo

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53
Q

Cluster HA

A

severe unilateral orbital/supraorbital/temporal pain lasting 15m-3h
1 or more: ipsilateral conjuntival injection or lacrimation, ipsilateral nasal congestion/rhinorrhea, ipsilaterl eyelid edema, ipsilateral miosis/ptosis, restlessness/agitation/pacing
Often at night, wake up from sleep, tend to cluster

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54
Q

Cluster HA risk factors

A

Male, middle aged, assoc w/ ETOH, smoking

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55
Q

Cluster HA Imaging

A

CT if first one since symptoms so severe

If hx cluster, only treat

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56
Q

Primary stabbing HA

A

ice pick HA, <1sec, quick and repetitive, cluster, almost never serious, reassurance best
prophylactic ibuprofen if needed

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57
Q

Hypnic HA

A

wake ppl up from sleep, >50yrs

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58
Q

Daily persistent HA

A

HA for >3mo, daily/unremitting from onset, definite start date
Sx - bilateral, pressing/tightening, mild to mod, not aggravated by activity
Only 1 of following: photo, phonophob, N
No severe N/V
Imaging: usually
Txt: chronic pain management

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59
Q

Migraine location, characteristics, pt appearance, duration, assoc sx

A
  • unilateral, bifrontal, global 30%
  • gradual onset, crescend, pulsating, mod-sev, worse w/ activity
  • rest, dark, quiet room
  • 4-72 hr
  • N/V/photo/phonophob/aura
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60
Q

TTH location, characteristics, pt appearance, duration, assoc sx

A
  • Bilateral
  • pressure, tightness, waxes and wanes
  • Active or resting
  • variable duration
  • no assoc sx
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61
Q

Cluster HA location, characteristics, pt appearance, duration, assoc sx

A
  • unilateral, around eye/temple
  • rapid onset, crescendo w/i minutes, deep, continuous, excruciating pain
  • active pt
  • 30m-3h
  • Sx - ipsilateral lacrimation/redness, stuff nose, rhinorrhea, pallow, sweating, Horner’s syndrome, focal neuro sx rare, sensitivity to ETOH
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62
Q

HA redflags

A

fever, stiff neck, sudden severe HA (onset and terrible w/i 1 sec), worst HA of life, new onset HA >50y, abnormal neuro, hx head trauma w/i 1 wk, HIV+ or risk, Hx cancer, increasing severity or changed character

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63
Q

IHS secondary headache classifications

A

head/neck trauma, cranial vascular d/o, non-vascular intracranial d/o, substance or withdrawal, infection, homeostasis disruption, cranium, neck, eyes, ears, nose, sinus, teeth, mouth, facial d/o, psych d/o

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64
Q

Temporal arteritis/giant cell arteritis Sx

A

Person > 50 w/ piercing, throbbing, localized HA
scalp tenderness, +/- temporal tenderness, low grade fever, anorexia, weight loss, malaise, jaw claudication, +/- PMR sx, visual sx (ask abt PMR sx - often assoc)

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65
Q

Temporal Arteritis Tests

A

ESR >50 (or CRP) - can have near normal ESR, still tret

Temporal artery biopsy - gold standard

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66
Q

Temporal Arteritis Treatment

A

60 mg prednisone daily - start ASAP and stop if biopsy -

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67
Q

Headache relevant PMH

A

HTN, HIV, thyroid, ca, depression, head trauma, dental work, recent medical procedures

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68
Q

Diagnostics needed: >50 new onset HA

A

ESR, CT

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69
Q

Diagnostics needed: young women, migraine criteria, normal neuro

A

no imaging
check TSH
if triptan helps –> basically diagnostic

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70
Q

Diagnostics needed: young heroin addict, new onset

A

CT + LP - brain abscess risk

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71
Q

Diagnostics needed: hx cancer

A

CT - mets

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72
Q

Diagnostics needed: HA, fever, rash

A

LP - meningitis, lymes

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73
Q

Diagnostics needed: elderly, fell

A

CT w/ neck - subdural, fx

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74
Q

Diagnostics needed: aspirin, coumadin

A

CT - brain bleed

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75
Q

Diagnostics needed: new HA, papilledema

A

CT

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76
Q

Diagnostics needed: kids, concerning HA

A

MRI instead b/c radiation concern

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77
Q

Tension type HA treatment

A

acetaminophen, NSAIDS, fioricent (habit forming, rebound HAs, dizzy, sedation), muscle relaxants (soma, skelaxin, flexeril)
prophylactic if freq occurrence

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78
Q

Cluster HA treatment

A 
avoid triggers - etoh, tobacco
O2 - NRB 12L
high dose NSAIDS 1000mg-1200mg motrin
ergotamines, triptans
prophylactic if freq occurrence
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79
Q

Migraine HA treatment - nonpharm

A

HA diary, regulr sleep, exercise, eating patterns, avoid triggers, stress management, massage, DC offending agents (OCP, CCB)

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80
Q

Migraine HA treatment - pharm

A

excedrin migrain - asa, acetaminophen, caffeine

ergotamines, triptans, narcotics (avoid), glucocorticoids (can break bad HA cycle), antiemetics, metoclopromide

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81
Q

Migraine Prophylactic treatment

A

> 2HA/wk, interfere w/ life, abortive txt issues
BB - 20mg inderal BID, up to 40mg
CCB - 20mg verapamil qHS
TCA - 25 mg amitriptyline qHS
Antiseizure - valproate, topiramate - neurologist

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82
Q

Common HA triggers

A

food, hormonal, sensory, stress, environment changes, schedule changes

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83
Q

Ergotamine - cafergot, migranal

A

Oral, sublingual, infectable, nasal spray
MOA - vasoconstriction
CI - pregnancy, heart dx, PVD, can cause vasospasm: raynauds, periph vasc ischemia
NOT w/ ketoconazole, macrolides - periph ischemia
24 hours APART FROM TRIPTANS

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84
Q

Triptans - 5HT serotonin receptor agonist
zomig, maxalt - short T 1/2
amerge, frova - long T 1/2
imitrex, relpax, axert – diff meds work well for diff ppl

A

SC, nasal, tabs
MOA - intracranial vasoconstriction, reduce edema, decrease inflammatory peptide influx, block trigeminal complex pain transmission
CI - pregnancy, CAD, angina
SE - facial flushing, tingling of skin, tightness around chest/neck
serotonin syndrome - decreased dose if w SSRI - confusion, sweating, diarrhea, tremor, high BP
24 hours APART FROM ERGOTAMINES

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85
Q

Focal/partial seizure

A

Starting in one hemisphere

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86
Q

simple seizure

A

consciousness maintained

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87
Q

Generalized seizure

A

starts in both hemipheres, LOC, no aura, +/-convulsions

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88
Q

Types of generalized seizures

A 
absence - LOC, starring spells
atypical absence - LOC, change of tonie, automatisms
myoclonic - jerking, flexing/unflexing
tonic - stiffening/extended
atonic - drop attacks
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89
Q

Idiopathic epilepsy

A

underlying genetic cause, start in infant/early childhood

normal development, normal neuro exam, no neuro d/o

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90
Q

Idiopathic epilepsy types

A

chronic absence - 5-10yrs, outgrows
benign rolandic - 5-15yrs, nocturnal sx
benign occipital - confused w/ migraines, EEG finding
juvenile myoclonic - starts at puberty

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91
Q

Paroxysmal seizure - test to run

A

labs - glucose, Mg, Ca, CBC, urine tox
EEG
LP - not necessary w/ 1st nonfebrile, only if concern
MRI - structural abnormalities, tumors, vascular abn

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92
Q

Epilepsy Dx in Child

A

> =2 unprovoked seizures or 1 unprovoked w abn EEG

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93
Q

Epilepsy Treatment Protocol

A

goal: monotherapy

Before starting: CBC, platelets, LFTs, amylase/lipase - monitor blood work q 3mo

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94
Q

Epilepsy Narrow Spectrum Meds

A

dilantin, phenobarb, tegretol, trileptal, gabapentin, vimpat, sabril
cover partial, focal, absence, myoclonic seizures

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95
Q

Epilepsy Broad Spectrum Meds

A

depakote, lamictal, topamax, zonegran, keppra, klonopin, banzel
covers wide variety of seizures - plus absence/myoclonic

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96
Q

Meds for localized and complex partial seizures

A

Tegretol, depakote, topamax, dilantin, lamictil, tripleptil, keppra

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97
Q

Generalized seizures meds - absence

A

ethosuximide, valproic acid

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98
Q

Generalized seizures meds - primary generalized tonic clonic

A

topamax, trileptal

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99
Q

Febrile seizures in children

A

Seizure w/ febrile illness, >1 mo, <6yrs

No CNS infector or e- imbalances. No previous afebrile sz

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100
Q

Complex febrile seizure

A

> 10-15min, focal, multiple with same illness

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101
Q

Simple febrile seizure

A

<10min, non-focal

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102
Q

Febrile sx risk factors

A

family hx febrile sz 1st and 2nd relative, developmental delay, neonatal nursery stay >30 days, daycare attendance
Risk NOT related to temp #

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103
Q

Simple Febrile Sz LP decision

A

YES LP if 5

NO LP - >18mo w/ hx and PE not suspicious

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104
Q

Complex Febrile Sx LP decision

A

YES LP - prolonged duration, focal

MAYBE LP - multiple seizures in same illness

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105
Q

Risk for meningitis w/ febrile sz

A

focal or prolonged sz, abnormal findings on neuro or PE, seizure later in illness

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106
Q

AAP Guidelines Febrile Seizure Diagnostics

A

LP - strongly recommended w/ meningeal signs (not if fever source known)
EEG - not routine if neuro healthy
E-, Ca, phos, mg, glucose, cbc - not routine
neuroimaging - not recommended for routine eval simple febrile

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107
Q

Febrile Status Epilepticus

A

febrile seizure >30 min

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108
Q

Febrile Sz Prevention

A

NONE recommended
Diazepam/diastat rectally at start of seizure
Diazepam/diastat PO or rectally w/ febrile illness, SE higher than benefit
antipyretic ineffective

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109
Q

Concussion S+S

A

confusion, amnesia, HA, V, dizziness, (LOC uncommon)

post: cognitively slow, emotionally irritable, drowsy

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110
Q

Best predictor of protracted recovery

A

Dizziness post concussion

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111
Q

Treatment

A

cognitive and physical rest - neuropsych testing

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112
Q

Pedi Headaches Presentation

A

irritable, N, V, lack of appetite, fatigue

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113
Q

Pedi Headache management

A

HA diary (diet and social), tylenol, ibuprofen, Mg vitamin

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114
Q

Age of closure of epiphyseal growth plate, hormone responsible

A

20yrs, estrogen/testosterone

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115
Q

Limp from Infection

A

acute, localized, severe (no weight bearing), fever, high WBC, ESR, CRP

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116
Q

Limp from Inflammation

A

chronic, insidious onset, rash, involve other joints, usually weight bearing (except transient synovitis)

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117
Q

Limp for Orthopedic Problem

A

localized pain to hip, can be referred to thigh/knee, acute or insidious onset, pain increase with activity, decreased with rest, systemic sx absent, ESR/CRP normal

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118
Q

Limp for Neoplasm

A

worse at night, unrelated to activity, may have systemic sx, labs abnormal (anemia, leukopenia, thrombocytopenia)

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119
Q

anterior knee pain, increased gradually, pain worse w direct trauma, squatting, climbing stairs, uphill, relieved by rest

A

Osgood Schlatter

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120
Q

Osgood Schlatter risks

A

age 9-14, rapid growth spurt, active in sports, boys

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121
Q

Osgood Schlatter treatment

A

Pain control, reduce swelling - ice, NSAIDs for 3-4d, protective pad over tubercle
Don’t need to avoid sport, no f/u needed
Resolve when plate ossifies, 18-20y

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122
Q

Displacement of capital femoral epiphysis from femoral neck through epiphyseal plate

A

Slipped capital femoral epiphysis

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123
Q 
hip pain, nonradiating, dull aching in hip, groin, thigh, knee, no hx trauma, pain may increase w activity or may be acute, chronic, intermittent
antalgic gait (limp, fixed knee, walk on side of foot)
A

Slipped capital femoral epiphysis

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124
Q

Slipped capital femoral epiphysis risks

A

teens and preteens, obese

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125
Q

Slipped capital femoral epiphysis Exam finding

A

decreased IR, abd, flexion

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126
Q

Slipped capital femoral epiphysis Tests

A

MRI (Xray preferred initial diagnostic) –> ortho

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127
Q

Most common nontraumatic hip pain in children

A

transient synovitis

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128
Q

pain and LROM, antalgic gait, hip in abduction, external rotation, no precipitant and resolves gradually, no fever, nontoxic appearing, WBC<2, unilateral or bilateral joint effusion

A

transient synovitis

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129
Q

hip pain, fever

A

think septic arthritis

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130
Q

transient synovitis treatment

A

NSAIDS and return to full activity as tolerated

Full recovery 1-4wks

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131
Q

Can have prior symptoms of V, D, cold/runny nose, URI, pharyngitis, bronchitis, AOM in 1/2 of case

A

transient synovitis

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132
Q

transient synovitis risks

A

age 3-8, M>F, fall/winter season, afebrile, well appearing

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133
Q

Scoliosis criteria

A

> 10 degree curvature laterally

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134
Q

Types of scoliosis

A
  • -neuromuscular - 2nd to MS problem - CP, neurofibromatosis, marfans
  • -congenital - 2nd to congenital abn - hemivertebra - manifests BEFORE adolescence
  • -idiopathic -most common, no known etiology
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135
Q

Scoliosis tests

A

Adams forward bend test, scoliometer/inclinometer

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136
Q

Scoliosis management

A

10-20d –> exercises to improve posture/muscle/strength
20-40d –> bracing, boston brace, 23 hr/day
40-50d –> spinal fusion surgery

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137
Q

Overuse syndrome

A

microtrauma of tissue

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138
Q

Febrile infant 100.4

A

septic work up to r/o serious bacterial infection –> ER

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139
Q

bacteremia S+S

A

irritability, poor feeding, change in sleep pattern, often no localized sx

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140
Q

Toxic appearing infant Sx

A

irritabile, inconsolable, poor perfusion, poor tone, lethargy

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141
Q

Septic workup, <3mo

A

Blood culture, CBC w diff, U/A + culture
CSF - count and diff, culture, gram stain, glucose, protein
CXR if respiratory sx
Stool culture if D

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142
Q

Febrile infant <3mo, w/ negative septic work up Txt

A

IM ceftriaxone, f/u for 2nd dose, await culture

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143
Q

Child 3-36 mo, likely pathogen

A

S pneumo, S aureus, N menigitidis, H influenza

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144
Q

Work up - febrile infant, 12mo-36mo, non toxic appearing

A

No septic work up required

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145
Q

work up - child w fever as presenting sx

A

CBC w diff, U/A, throat culture, blood culture (maybe CXR, LP)

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146
Q

work up - child w fever, abd pain, n/v

A

CBC w diff, U/A + culture, abd CT scan

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147
Q

Bacterial infection lab changes

A

increase neutrophils and bands – left shift

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148
Q

WBC in allergies, asthma

A

basophils (histamine release)
eosinophils (parasites/drug sensitivity)
No response to bacterial/viral infection

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149
Q

WBC that increases during recovery from illness

A

monocytes - increase in pneumonia, mono, varicella

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150
Q

Viral infection lab changes

A

increase in lymphocytes and monocytes – right shift

also seen in tissue breakdown, burns, allergies, lymphocytic leukemia

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151
Q

Reasons high milk consumption can lead to anemia

A

cow protein causes microscopic blood loss in stool, full on milk and not eating enough iron, bioavailable iron in milk is low

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152
Q

Normal WBC

A

5000-10000

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153
Q

Normal RBC

A

4.5-5.5

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154
Q

Normal neutrophils

A

54-62%

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155
Q

Normal bands

A

3-5%

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156
Q

Normal HGB

A

11.5-15.5

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157
Q

Normal HCT

A

35-45%

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158
Q

Normal platelets

A

150-400K

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159
Q

Normal MCV

A

80-100 (77-95)

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160
Q

Normal MCHC

A

31-37%

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161
Q

Normal Retic count

A

0.5-1.5

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162
Q

Normal RDW

A

11.5-14.5

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163
Q

Normal Eosinophils

A

1-3%

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164
Q

Normal Basophils

A

0-0.75%

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165
Q

Normal lymphocytes

A

25-33%

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166
Q

Normal monocytes

A

3-7%

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167
Q

Test to Dx UTI

A

C+S - >100 in clean catch, >50 in cath

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168
Q

Most specific U/A result for UTI

A

nitrites

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169
Q

diet high in citrus fruits/veggies make urine..

A

alkaline

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170
Q

diet high in meat, cranberry juice make urine…

A

acidic

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171
Q

Parkinsons risks

A

men, 55-65

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172
Q

Parkinson cardinal features

A

akinesia, bradykinesia, cogwheel rigidity, unstable posture, resting tremor

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173
Q

Typical 1st Sx Parkinsons

A

resting tremor - pill rolling - usually do well for 10 yrs if major sx
(late sx in parkinsonian like sx but not parkinsons)

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174
Q

Other parkinsons Sx

A

freezing of gait, micrographia, low pitched indistinct speech, decreased blinking, reduced facial expression, seborrhea, depression anxiety, memory loss, impaired judgment, poor planning, sleep issues b/c of bradykinesia, sexual/urinary/bowel dysfunction

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175
Q

Parkinsons cause of death

A

choking, falls, pneumonia

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176
Q

Parkinsons cause

A

neurodegen of dopamine containing neurons in substantia negra
dopamine from basal ganglia controls movement
symptoms when 50-80% loss of dopamine

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177
Q

Parkinsons diagnostic tests

A

None, imaging to r/o other conditions - PET, SPECT, CT
– imaging if early balance/gait d/o’s, not responsive to levodopa, imaging shows structural involvement other than basal ganglia

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178
Q

Surgical parkinsons tx

A

thalatomy, pallidotomy, deep brain stimulation

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179
Q

Parkinsons tx pharm

A

respond well for 3-5 years then end of dose effects, dyskinesthias
help sx, doesn’t stop dx progression

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180
Q

Dopamine agonist - mirapex, requip

A

parkinsons - 1st drug prescribed, activates brain dopamine receptors

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181
Q

Dopamine precursor, levodopa

A

parkinsons - 2nd txt - MAINSTAY OF TXT - can lead to drug induced dyskinesias, impaired judgment

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182
Q

Parkinsons meds

A

dopamine agonist, dopamine precursor, decarboxylase inh, catechol methyltransferase inh, copamine releaser, dopamine receptor blocker, type B MAO, anticholinergics

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183
Q

decarboxylase inhibitor, carbidopa

A

parkinsons - given w/ levodopa, prevents metabolism of levodopa - reduces SE of N,V of levodopa

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184
Q

catechol-o-methyltransferase inhibitor - entacapone/comtan

A

parkinsons - other site in pathway, well tolerated, often given w/ sinemet

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185
Q

dopamine releaser, amantadine

A

parkinsons - helps release dopamine more effectively, brief effect

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186
Q

dopamine receptor blocker - domperidone

Type B MAO inh - seligiline, rasagiline

A

parkinsons - helps dopamine helps dopamine stay active longer

187
Q

anticholinergics in parkinsons

A

treat tremor, SE memory impairment, blurred vision, urinary difficulty

188
Q

R/O pre dementia dx

A

B12, TSH, urine, e-, CBC, meds, CXR, substance abuse, depression

189
Q

Dementia risks

A

age, family hx, head injury, heart dx, hereditary(APOE-e4)

190
Q

Praxis

A

Ability to do previously learned task

191
Q

Dementia diagnostics

A

CBC, TSH, anemia, CMP, urine, glucose, RPR/HIV, tox screen, ETOH, drugs, imaging studies (head CT w/o contrast), neuropsych testing

192
Q

DSM Dx Dementia

A

decline in memory and decline in at least one of the following (decline must be severe enough to interfere with daily life)

  • coherent speech, understanding written/spoken word
  • recognition/ID objects
  • motor activities
  • think abstractly, sound judgements, carry out tasks
193
Q

Frontotemporal/Pick’s Dementia presentation

A

behavioral issues, personality changes, language impairment

194
Q

Dementia w/ lewy body presentation

A

similar to alz - fluctuation presentation, visual hallucinations, muscle rigidity, myoclonic jerks, tremors common

195
Q

Normal pressure hydrocephalus dementia presentation

A

enlarged ventricles on CT scan - dips, drips, dementia

196
Q

Vascular dementia presentation and risks

A

abrupt onset, stepwise deterioration, executive dysfunction, gait changes
risks - HTN, smoking, high cholesterol, PVD, CVD, DM

197
Q

Alzheimers pathophys

A

amyloid plaques and neurofibrillary tangles - brain atrophy nin cerebral cortex

198
Q

Mild Cognitive Impairment Alzheimers - MMSE + Sx

A

MMSE 26-30 - memory loss, executive dysfunction, no functional impairment

199
Q

Early, Mild Impairment Alzheimers - MMSE + Sx

A

MMSE 21-25, 1-3 years from onset of dx
Disoriented to date, difficulty w/ naming, figure copying, finances, recent recall, insight, mood change, social withdrawal, irritable

200
Q

Middle, Moderate Impairment Alzheimers - MMSE + Sx

A

MMSE 11-20, lasts 2-8 years
Disoriented date, place, aphasia, problems w comprehension, calculation, learning, grooming, lost in familiar places, NO cooking/shopping/banking, restless, depressed, delusions, agitated, aggressive

201
Q

Severe Impairment Alzheimers - MMSE + Sx

A

MMSE 0-10, lasts 6-12 years
Remote memory gone, unintelligible verbal output, unable to copy/write, no grooming/dressing, incontinent, motor/verbal agitation

202
Q

Vascular and mixed dementia txt

A

stroke prophylaxis

203
Q

Dementia txt guidelines

A

treat comorbidities, avoid ACH (benzo, oxybut, TCA, clozapine), limit psychotropic PRN use

204
Q

Dementia pharmacologic use

A

cholinesterase inhibitors - Aricept
NMDA - namenda
treat behaviors - depression, anx, agitation, hallucinations, paranoia

205
Q

Menopause

A

12 mo w/o menses, 40, estradiol<35

OR removal of ovaries (menopause w/i 6 wks)

206
Q

Perimenopause Sx

A

irregular periods/menorrhagia, PMS sx, vaginal dryness, urinary incontinence, mood swings, sexual dysfunction, decreased fertility

207
Q

Perimenopause length

A

2-5 years, age 5

208
Q

Premature menopause risk

A

smoking, type 1 DM, increased altitude, undernourished, vegetarian, cancer patient, hysterectomy w preserved ovaries

209
Q

Vaginal dryness txt

A

replens, KY, lubrin, vit E 100-600mg/day, evening primrose 2-4caps/day

210
Q

Osteoporosis prevention

A

diet, exercise, ca 1000-1500mg/day, vit d 400-800mg/day

211
Q

Mood irritability assoc w/ perimenopause txt

A

SSRI (prozac 20mg), effexor

212
Q

hot flashes and night sweats txt

A

gabapentin

213
Q

Irregular bleeding txt

A
  1. Endometrial biopsy, US if suspect fibroids

2. Stabilize hormones - OCP (COC< POP, LNG-IUD, cycling progesterone), cryoablation

214
Q

How to test if someone on OCPs had menopause

A

Test FSH on day 7 of placebo week - >40 –> menopause

215
Q

benefits of hormonal contraception, cyclic progestin, LNG-IUD, surgery, and lifestyle mods on perimenopause sx

A

Hormonal contraception - symptom relief, menses control, contraception, uterine ca prev
Cyclic progestin - some uterine ca prevention
LNG-IUD - menses control, contraception, uterine ca prev
Surgery - menses control, contraception, uterine ca prev
Lifestyle mods - symptom relief only

216
Q

How to treat menopause sx post hysterectomy

A

SSRI

217
Q

Menopause age

A

age 51

218
Q

premature menopause age

A

<50

219
Q

early menopause age

A

<45

220
Q

late menopause age

A

> 55

221
Q

Long term effects of estrogen decline

A

vaginal dryness and atrophy, forgetfulness, poor concentration, osteoporosis, atherosclerosis, decreased skin turgor, wrinkling, dry mucus membranes, libido loss from decreased testosterone

222
Q

Irregular bleeding diagnostics

A

Biopsy, CBC, TSH, vaginal US

223
Q

When to check hormone levels

A

6 mo w/o bleeding, s/p hysterectomy w ovaries intact and getting sx, using OCPs and unsure
FSH OR estradiol at menopause level but the other not –> perimenopause

224
Q

Hormone replacement therapy benefits

A

decrease vasomotor sx, improve QOL, improve urogenital sx, decrease osteoporosis risk, decrease CV risk, may protect against dementia

225
Q

Hormone replacement therapy indications

A

uncontrolled vasomotor sx, improve urogenital sx (topical therapy best), prevent osteoporosis, if early menopause, given until age 51

226
Q

Hormone replacement therapy contraindications

A

undiagnosed vaginal bleeding, known pregnancy, vascular thromboembolic events, active liver dx, breast/reproductive ca

227
Q

Hormone replacement therapy precautions

A

type 1 DM, active gallbladder dx, >1ppd smoker, obesity, FMH breast ca, fibroid uterus, PVD hx, migraines, elevated trigs

228
Q

Hormone replacement therapy candidates

A

newly menopausal w/i 5 yr, good health, no risk factors for heart dx or breast ca, non smoker, non obese, normal blood sugar and pressure, mod to severe vasomotor sx –can’t function

229
Q

Hormone replacement therapy risks

A

clots, gall bladder dx, breast ca (10 risk), increased cardiac events in 1st year if prior heart dx

230
Q

ACOG Hormone replacement therapy guidelines

A

short term for vasomotor sx 1-4yr
estrogen alone up to 7 yr
prog/est up to 5 yr

231
Q

Estrogen replacement therapy txt

A

Give 3 mo then re-evaluate
Only if no uterus or builds up uterine lining
premarin, menest, transdermal (avoids liver effects, less effect on trigs/lipids - never near breast tissue), estradiol

232
Q

Combined estrogen/progesterone use

A

Cyclic - take first 10-15 days of month w/ estrogen to bring on menses
Continuous - no menses, may have BTB <6mo
Prempro, premphase, femHRT, activella, ortho-prefest, combipatch, provera/prometrium(not w/ peanuts, prog only)

233
Q

Progesterone SE

A

breast tenderness, irritability, weight gain, fluid retention - usually goes away w/ time

234
Q

HRT SE

A

BTB, withdrawal bleed, increased fibroids, allergic rxn, virilization w testosterone products

235
Q

Menopausal sleep Txt nonpharm

A

sleep hygiene - cool temp, low alcohol and caffeine, dark, quiet, no night exercise, avoid naps, regular sleep/wake cycle

236
Q

Menopausal sleep Txt pharm

A

Melatonin
Gabapentin - 300mg 1-2 hr before bed, up to 600mg
Lunesta - long term use okay - drowsiness, impairment in AM
Ambien - drowsiness, impairment in AM - 5mg, ER ok long term

237
Q

Vasomotor Sx Txt pharm

A

Effexor, clonidine, SSRH low dose

Gabapentin - 600mg qHS or 300 TID depending on timing of sx

238
Q

Vasomotor Sx Txt OTC

A

estroven (soy+cohosh), black cohosh, soy, vitamin E

no evidence - dong quai, acupuncture, yoga, evening primrose, ginseng, kava, red clover, flaxseed

239
Q

Vulvovaginal Sx Txt

A

Vaginal creams - dont need opposing progesterone
premarin - daily for 2 wk then BIW - externally too
estring ring - 90 days
vagifem cap, PO osphena
can still use in breast/GYN ca

240
Q

Osteoporosis risks

A

hx fx, age>50, low E2, Women, caucasian, FMH, weight<20% bone mass in 5-7 yrs post menopause

241
Q

Osteoporosis screening

A

> =65 or >=60 with increased risk

242
Q

Normal Dexa Screen - Tscore, rescreen and txt

A

-1 and higher, retest 10-15yr

Ca, vit D, healthy diet, exercise

243
Q

Osteopenic Dexa Screen - Tscore, rescreen and txt

A

-1.1 to -2.4, retest 2-5 years
Ca, vit D, healthy diet, exercise
Fosamax 35 q week

244
Q

Osteoporosis Dexa Screen - Tscore, rescreen and txt

A

-2.5 and lower, retest 1 yr after txt initiation
Ca, vit D, healthy diet, exercise
Bisphosphonates, serm/raloxifene/evista, estrogen, calcitonin, injectables

245
Q

Alendronate/Fosamax risks

A

spontaneous femur fx - consider 6 mo drug holiday q5y

osteonecrosis of jaw - regular dental, maybe antbx b4

246
Q

Bisphosphonates contraindications

A

hypocalcemia, esophageal dx, inability to follow dosing

247
Q

Alendronate/Fosamax instruction

A

1st thing in AM, empty stomach, upright 30 min post

daily or weekly

248
Q

Ibandronate/Boniva instructions

A

1st thing in AM, empty stomach, upright 60 min post
If miss dose and next dose >7day away, take missed
If miss dose and next dose <7day away, skip missed
daily, monthly, 4x/yr

249
Q

Bisphosphonates

A

fosamax, boniva, actonel, atelvia, reclast (q2yr)

250
Q

SERM/raloxifene/exista action, CI, SE

A

action - decrease bone turnover and bone resorption - increases bone density, acts like estrogen, + effect on cholesterol, no risk breast/uterus
CI - thromboembolic dx (most risky 1st 4 mo and w/ immobilization - D/C before surgery)
SE - leg cramps, hot flashes

251
Q

Calcitonin/fortical/miacalcin - oral/transderm - action, CI, SE

A

prevents further bone loss, suppresses osteoclasts, wont build back
CI - allergy to med or salmon
SE - rhinitis, arthralgias, back pain, HA, epistaxis

252
Q

<6 mo, exhaustion medical txt, care goes where pt is

A

Hospice Care

253
Q

anytime/stage of illness, no time restriction, palliative team setting, may still have aggressive txt

A

Palliative Care

254
Q

Relief of suffering, control of sx, restoration to function capacity

A

Palliative Care

255
Q

Hospice criteria in HF, COPD

A

HF stage 4, COPD Sx at rest

Alz >7 - speech limited to 6 intelligble words, incontinence

256
Q

Key signs of approaching death

A

poor nutrition, weight loss, low albumin <18, decreased mid arm circumference, dysphagia

257
Q

Neer’s sign

A

Impingement syndrome or rotator cuff tear

depress scapula w one hand, elevate arm above head with other

258
Q

Hawkins sign

A

Impingement syndrome or rotator cuff tear

elevate patients shoulder to 90, flex elbow to 90, place forearm in neutral rotation, internally rotate humerus

259
Q

Cross body adduction

A

Arthritis of AC joint

Shoulder at 90 degrees, adducted laterally across body

260
Q

Apprehension sign

A

Anterior instability if apprehension

Arm 90 abducted to side, max external rotation

261
Q

Sulcus sign

A

Inferior shoulder laxity

Arm relaxed at side, pull arm downward

262
Q

Jerk test

A

Posterior instability
Shoulder and elbow 90 degree flexion laterally in front of body, adduct arm across body horizontally while pushing humerus back into joint

263
Q

Loss of active and passive shoulder motion, up to 45 degrees at most

A

frozen shoulder

264
Q

frozen shoulder causes

A

autoimmune dx, injury, immobility, bursitis

265
Q

Shoulder imaging

A

Xray - r/o fx, loose bodies, tumor

MRI - view capsule, r/o rotator cuff tear

266
Q

Frozen shoulder tx

A

NSAIDS, moist heat, injections, PT

surgical - stretch or release contracted joint capsule w/ manipulation/arthroscopy

267
Q

Gradual onset of pain exacerbated by overhead activities, can move arm but pain in last 20-30 d of abduction, downsloped acromium, bursitis, pain w/ reaching up and across

A

Impingement syndrome (mini frozen shoulder)

268
Q

Impingement syndrome PE

A

tenderness, crepitus, pain against resistance, +Neer + Hawkins

269
Q

Impingement syndrome txt

A

NSAIDS, moist heat, injections, PT

surgical - subacromial decompression, anterior acromioplasty

270
Q

Rotator cuff

A

4 muscles and tendons from scapula/thoracic spine to shoulder

271
Q

Cause of rotator cuff tear

A

Overuse, repetitite overhead motion, trauma, chronic impingement syndrome, age related degen

272
Q

Pain, weakness, catching and grating when lifting arm over head

A

rotator cuff tear
partial - can lift arm but weakness
total - cant lift arm, can passively unless from impingement

273
Q

Rotator cuff tear PE

A

sunken shoulder, active ROM limited, shrug, cant hold arm elevated
empty can test - shoulder 90, thumb down, push up against resistance - pain, weakness
+Neer, Hawkins

274
Q

Rotator cuff tear treatment

A

non surgical - rest, limit overhead movement, NSAIDS, injections, PT
surgical - debridement/repair

275
Q

Biceps tendonitis

A

shoulder 90 degrees, thumb up - push up against resistance

276
Q

sudden onset, mimics septic arthritis, no ever, can be coming on for days but pain is acute, crescendos, can’t move shoulder b/c of guarding

A

Calcific bursitis/tendonitis

277
Q

Calcific bursitis/tendonitis txt

A

cortisone injection

278
Q

Valgus stress test

A

push on lateral aspect, tests stability of medial ligament
MCL in knee when 25degree flexed, more than MCL if also in straight leg
ulnar collateral in elbow (20degree flexion in test)

279
Q

Varus stress test

A

push on medial aspect, tests stability of lateral ligament

LCL in knee when 25 degree flexed, more than LCL if also in straight leg

280
Q

radial head subluxation, pain, avoids usage of elbow, hold arm close to body w forearm and thumb in pronation

A

Nurse maid elbow

281
Q

Nurse maid elbow txt

A

Reduction - pressure at radial head, elbow 90d flexed, grasp wrist and supinate wrist
Ice, NSAIDS, splint/brace

282
Q

dull ache, lose strength in arm, unable to pronate or supinate forearm, unable to lift items or bend elbow, tenderness, bulge, bruise, snap

A

Biceps tendon rupture
proximal - pain and bruising proximally, difficulty moving shoulder (2 proximal tendons)
distal - pain/bruising in antecubital fossa

283
Q

Biceps tendon rupture PE

A

complete - muscle bulge w/ flexion resistance, no supination

partial - no visible defect, pain, weakness w/ flexion/supin

284
Q

Biceps tendon rupture txt

A

nonsurgical - rest, ice, nsaids, splinting/sling for comfort, PT
surgical - repair, more important if distal since only 1 tendon

285
Q

pain in center of bicep,muscle indented

A

biceps muscle tear

286
Q

golfers/bowlers elbow

A

medial epicondyle

287
Q

tennis elbow

A

lateral epicondyle

288
Q

pain with wrist flexion, tenderness of medial epicondyle, numbness down inner arm

A

medial epicondylitis - golfers/bowlers

289
Q

pain with wrist extension, tenderness of lateral epicondyle, down arm, across forearm, pain generally distal, not proximal to elbow

A

lateral epicondylitis - tennis

290
Q

Biceps tendon rupture imaging

A

xray - r/o avulsion fx

mri - r/o rotator cuff if proximal, confirm dx

291
Q

Epicondylitis imaging

A

Xray - r/o arthritis, loose bodies, fx

MRI - confirm dx

292
Q

Epicondylitis treatment

A

nonsurgical - modify/eliminate activity, nsaids, ice, injections, brace, PT if no improvement
surgical debride

293
Q

swelling, pain, limited ROM of elbow

A

Olecranon bursitis

294
Q

Olecranon bursitis cause

A

trauma, prolonged pressure, RA, infection or gout (fever, red, warm?)

295
Q

Olecranon bursitis imaging

A

r/o foreign body, bone spur, fx

296
Q

Olecranon bursitis txt

A

nsaids, elbow pads, activity mod, antbx
aspiration for dx purposes only
surgical - remove bursa

297
Q

finkelsteins test

A

de Quervain tenosynovitis

fist w thumb inside, ulnar deviation

298
Q

phalen maneuver

A

carpal tunnel - median nerve

wrist 90d with gravity, numbness or tingling w/i 60 seconds

299
Q

froment sign

A

pt pinches paper with thumb and index which it is being pulled away

300
Q

carpal tunnel causes

A

repetitive motion, hormonal changes, medical conditions

301
Q

numbness, tingling, pain in hand and or finger, pain in middle of night, common in pregnancy, 1st-3rd finger, sometimes 4th, never 5th

A

carpal tunnel syndrome

302
Q

carpal tunnel tests

A

phalen, tinnel

303
Q

carpal tunnel imaging

A

EMG - evaluate nerve function w muscle contractions

xray - r/o fx if limited movement

304
Q

carpal tunnel txt

A

splint/brace (1st only at night), nsaids, injection, changing patterns
surgical - increase tunnel size, 10% recurrence, esp if smoker

305
Q

fall onto outstretched hand, pain, tenderness to thumb side of wrist, swelling to back and side of wrist, unable to grip/move thumb

A

scaphoid fracture

306
Q

scaphoid fx tests

A

snuffbox tenderness, decrease motion, decrease grip strength, assess median, ulnar, radial nerve function

307
Q

scaphoid fx imaging

A

Xray - r/o fx - oblique view, scaphoid series, carpal bone series if still pain 2 weeks later
MRI/CT - r/o fx if not visible on xray

308
Q

scaphoid fx txt

A

casting/thumb spice, weight bearing protection

ORIF

309
Q

sudden impact to finger tip, pain, swelling, deformity, limited motion

A

jammed finger, mallet finger, sprain, strain, dislocation or fx of joint

310
Q

jammed finger tests and imaging

A

joint stability, froments signs

xray - r/o fx/dislocation

311
Q

fracture of 5th metacarpal distal metaphysis

pain, tenderness, deformity, decreased ROM

A

boxer fracture

312
Q

boxer fx txt

A

splint in 10-15 degree angulation, protected weight bearing

ORIF if fingers dont bend down properly - ASAP appt ortho

313
Q

trendelenberg sign

A

hips stay level when pt standing on one leg

314
Q

FABER test

A

flexion, abduction, external rotation test - sacroiliac or hip indication

315
Q

Slipped capital femoral head

A

walk w/ leg externally rotated, decrease abduction, extension, extremity shorter
surgery for percutaneous pinning

316
Q

pain, tenderness over greater trochanter, pain may radiate to knee or ankle but not to foot or butt, worsens with rising from seated position

A

trochanteric bursitis

317
Q

Trochanteric bursitis causes

A

Laying on side, old ppl, trauma

318
Q

Trochanteric bursitis PE

A

point tenderness, pain w/ hip abduction, warmth, pain worse w/ trendelenberg

319
Q

Trochanteric bursitis txt

A

Nsaids, activity mod, short term assistive device use, injection
surgery - irrigation, debridement, bursa removal

320
Q

Groin pull sx

A

pain, ecchymosis, swelling, burning, stiffness, weak - tearing of adductor muscle

321
Q

Groin pull tests

A

inability to adduct, abnormal gait, tenderness

322
Q

Groin pull imaging

A

MRI to r/o complete tear

323
Q

Groin pull txt

A

RICE, NSAIDS, protective weight bearing, stretching

repair if complete tear

324
Q

McMurray Test

A

medial meniscus - flex knee, externally rotate, extend knee
lateral meniscus - flex knee, internally rotate, extend knee
pain/click - + sign

325
Q

Lachman test

A

ACL tear

knee flexed 25deg, pull up on calf, push down on thigh

326
Q

Knee anterior draw test and posterior draw test

A

anterior - ACL

posterior - PCL

327
Q

tear from rotational or hyperextension force on knee

pain, pop, unable to ambulate, swelling

A

ACL tear

+lachman + anterior draw

328
Q

tear or sprain from abduction force w/o rotation, assoc w meniscal tear
pain, ABLE to ambulate, swelling, LOCKING

A

MCL tear

+ valgus stress

329
Q

Knee ligament imaging

A

Xray- r/o avulsion fx

MRI - evaluation complete vs partial tear

330
Q

Knee ligament tx

A

NSAIDS, ice, rest, protective weight bearing, immobilize, PT

ligament repair

331
Q

tear in fibrocartilaginous pad - twisting injury, degenerative
swelling, stiffness, LOCKING, catching, decrease motion w tightness sensation

A

+McMurray

332
Q

patella dislocation sx

A

pain, swelling, deformity, mobility, patella slides laterally

333
Q

Patella dislocation tests/imaging

A

Apprehension test, tracking assessment

Xray - r/o fx, MRI - eval soft tissue/ligament/tendons

334
Q

Patella dislocation txt

A

PT, bracing, change footwear, nsaids

arthroscopy vs open

335
Q

Ankle anterior drawer test

A

chronic ankle laxity and severe acute ankle sprains
pull foot anteriorly - not in acute sprain
clunk - ligament ruptured

336
Q

Ankle varus stress

A

asymmetry or excessive motion - chronic laxity of calcneofibular ligament - not in acute sprain

337
Q

Achilles tendon rupture cause

A

stop and go sports

338
Q

Achilles tendon rupture sx

A

sudden, severe calf pain, swelling, difficulty bearing weight, cant plantar flex if total tear, can plantar flex but not w/ weight if partial tear

339
Q

Achilles tendon rupture tests

A

palpable defect, +Thompson test (prone, foot at rest, squeeze calf, foot should move)
MRI to eval partial or complete

340
Q

Achilles tendon rupture txt

A

casting, bracing in plantar flexion, protected weight bearing, PT
retracting and repairing tendon - casting 8-12wks

341
Q

stretching of tearing of muscle, sudden stretch on actively contracted muscle

A

strain

342
Q

strain sx

A

snap or tearing sensation, pain and swelling maybe only on day of injury, unable to contract muscle

343
Q

stretching or tearing of a ligament, sudden trauma

A

sprain

344
Q

sprain sx

A

pop or snap followed by pain, swelling, stiffness, difficulty bearing weight
pain w/ stretch

345
Q

sprain/strain imaging

A

xray r/o fx, mri r/o complete tear

346
Q

sprain/strain txt

A

rice, nsaids, immobile, weight bearing protection

repair of complete tears

347
Q

plantar fasciitis risks

A

older, overweight

348
Q

heel pain, tenderness, pain intense when rising from resting position, standing, walking

A

plantar fasciitis

349
Q

Foot imaging?

A

Always xray

350
Q

plantar fasciitis tests

A

tight achilles, tenderness along fascii, +pain with passive dorsiflexion of toes
xray - r/o bone spur

351
Q

plantar fasciitis txt

A

rest, ice, nsaids, orthotics, stretching, injections, PT

surgical - BAD option, removal or heel spur, debridement of fascii

352
Q

swelling, tenderness, ecchymosis of muscle, pain with active and passive stretch

A

muscle contusion

353
Q

muscle contusion txt

A

monitor for compartment syndrome

rice, nsaids, rom, stretching

354
Q

muscle cramps

A

heat, stretch, hydrate, replenish nutrients

355
Q

assoc w/ prolonged activity, pain in distal 3rd of medial tibia

A

shin splints

356
Q

shin splints pathophys

A

inflammation of tibial periosteum 2nd to repetitive muscle contractions, small muscle tears

357
Q

Shin splints tests

A

tenderness, pain w/ pressing on muscle to side of bone

358
Q

Shin splints txt

A

r/o stress fx w/ xray
limit activity to soft surfaces, orthotics, decrease activity, NSAIDS, ice, massage, stretch
surgery rare - fasciotomy of tibial periosteum

359
Q

stress fractures sx, tests, imaging

A

pain, tenderness on bone of shin
Xray, repeat in 3-4 wks
bonescan/mri/ct - confirm dx

360
Q

stress fx txt

A

rest, activity mod, splint/brace, protective weight bearing, NO NSAIDS (TYLENOL ONLY)
ORIF

361
Q

arthritis sx, tests

A

pain, swelling, decreased ROM
tenderness, pain, gait abn
xray r/o bone spur/fx, CT confirm dx

362
Q

arthritis txt

A

nsaids, orthotics, inj, antbx, pt

joint replacement, debridement, fusion

363
Q

painful joint + fever

A

ER, when in doubt, blood work, elevated WBC–> ER

364
Q

osteoarthritis signs

A

heberdens nodes of DIP joint, fusiform swelling of joints

365
Q

RA signs

A

boutonniere nodes of PIP joint, ulnar deviation of MCP joints, swan neck deformity of fingers

366
Q

Burners/stingers sx

A

electric schock/lightening bolt down arm into hand, burning, numbness, weakness

367
Q

Burners/stingers tests

A

xray - r/o fx/sublux
mri - confirm injury, tear
EMG - neuro injury

368
Q

Burners/stingers patho

A

injury to nerve roots exiting spinal cord, hit in neck, nerves get stretched, stinging down arm

369
Q

Burners/stingers txt

A

no return to contact sports until resolved, PT

surgery - repair of torn ligaments, fusion, discectomy

370
Q

Whiplash patho

A

rapid flexion/ext - ligament and muscle injury

371
Q

whiplash sx

A

pain from base of skull to cervicothoracic junction, occipital HAs, irritability, fatigue, sleep disturbances, difficulty concentrating, pain worst next day, NO numbness

372
Q

Whiplash tests

A

tenderness, limited ROM
xray r/o fx/sublux
mri r/o disc herniation

373
Q

whiplash txt

A

immobilization v mobilization, NSAIDS, ice/heat, massage, PT

surgery - fusion, discectomy

374
Q

Acute low back pain Sx

A

r/o fx v muscle v ligament
pain into butt, difficulty standing erect, change position frequently
tenderness, decreased forward flexion

375
Q

Chronic low back pain

A

> 3 mo
pain into butt and thighs, aggravated by activities, relieved by rest
tenderness, exhibit side or forward stance, may have +SLR, nonanatomic localization of sx

376
Q

Back pain imaging

A

xray - r/o fx or sublux or DDD
MRI r/o infection, disc, ligament, muscle cord injury – get if increasing sx or pain or numbness running down legs
Labs - r/o infection

377
Q

acute back pain txt

A

bracing, nsaids (not if fx), ice/heat, injections, activity mod, PT

378
Q

chronic back pain txt

A

referral to pain management, PT, TENS, counseling, flip table 5-10min daily

379
Q

Avoidant/restrictive food intake d/o Criteria

A

lack of interest in food, sensory concern or aversion, failure to meet nutritional needs, labs off, not gaining weight
1. sign weight loss
2. significant nutrient deficiency
3. dependence on enteral or supplements
4 marked interference w/ psychosocial functioning - obsessed w/ not wanting to get sick/gag
NOT explained by food shortage, med condition, psych d/o, NO evidence of weight disturbance

380
Q

Anorexia Nervosa

A

Must be underweight

381
Q

Anorexia types

A

Restricting - fasting, excessive exercise - no binging in 3 mo
Binge-eating/purging - binging/purging in 3 mo - vomiting, laxatives, diuretics, enemas

382
Q

AN severity levels

A

Mild BMI>17
Mod BMI 16-16.99
Severe BMI 15-15.99
Extreme BMI <15

383
Q

AN Remission

A

partial - past dx AN previously met, LBW now not met

full - past dx AN, no criteria currently met

384
Q

AN health risks

A

heart failure, kidney failure, low protein stores, digestive problems, e- imbalances

385
Q

Bulimia nervosa criteria

A

Recurrent episodes of binge eating at least 1x/wk for 3mo
1. eating large amt of food in 2hrs, 3k-5k cal
2. lack of control during eating episode
recurrent compensatory measures - vomiting, laxatives, diuretics, meds, fasting, exercise

386
Q

Bulimia/purging severity levels

A

Mild 1-3bx/wk
Mod 4-7bx/wk
Severe 8-13bx/wk
Extreme 14+bx/wk

387
Q

Bulimia health risks

A

e- imbalance, laxative dependence, dental problems, stomach rupture, irregular menses

388
Q

Binge eating d/o criteria

A

recurrent binge eating w/ 3 + of:
eating more rapidly than normal
eating until over full
eating large amts when not hungry
eating alone bc embarrassment
feeling disgusted w self/depressed/guilty after
must interfere w/ life, NO purging, at least 1x/wk

389
Q

Atypical anorexia

A

criteria for AN but normal weight

390
Q

bulimia nervosa or binge eating d/o, low freq, limited duration

A

<3mo

391
Q

Purging d/o

A

Purging to affect weight, no binging

392
Q

Night eating syndrome

A

excessive consumption after awakening from sleep, after evening meal, aware and recall eating - causes pt distress, impaired functioning

393
Q

Male eating d/o risks

A

low weight oriented sports - jockeys, wrestlers, runners, gymnasts
obsessive thoughts - all person thinks abt, can be lifting/protein etc

394
Q

Comorbid eating and psych d/o

A

social iolation, depression, anxiety, OCD, rigid cognitive styles, lack of interest in sex, OCD, personality d/o, sexual abuse, substance abuse

395
Q

Bulimia sx

A

chronically inflamed, sore throat, salivary glands in neck and jaw swollen, cheek/face puffy, parotid glands large/tender (can need antbx), tooth enamel off, tooth decay, GERD, intestinal problems, C, D, kidney problems if diuretics, severe dehydration

396
Q

AN sx

A

no menses, osteopenia, osteoporosis, dry hair/skin/nails, pale, pasty skin, mild anemia, muscle wasting, lethargy, C, drop in BP, slow HR + RR, orthostatic vitals, bradyC if bad, internal body temp fails, always cold, night sweats (metabolism changing), depression, lethargy

397
Q

Family based txt

A

Maudsley approach - family cooks, pt must eat

398
Q

Labs in eating d/os

A

CBC, chem panel, Mg, phosphate, vit d, B12, iron, ferritin, folic acid, CPK, hycosamine, EKG (check b4 starting any meds)

399
Q

Tx low WBC and alk phos in severe AN

A

add zinc 30mg BID after eating or V

400
Q

ED nutritional tx

A

Weight gain 0.5-1kg inpatient, 0.5 kg outpatient (3500-7000 cal extra/wk)
if losing weight outpatient, go inpatient

401
Q

Refeeding syndrome

A

metabolic disturbances - insulin, glucose, phosphate –> most common w/i 1st 4 days - hypophosphatemia

402
Q

ED nutritional tx meds

A

simethicone PRN w/ meals, Gaviscon PRN, digestymes, probiotics for D

403
Q

Vitamins for ED

A

multivit, calcium, d3, b12, iron, zinc, omega 3 fatty acid

404
Q

SSRI in ED

A

only if normal weight or increased SI - good w OCD, bulimia (prozac, sertraline)

405
Q

wellbutrin/buproprion black box warning

A

w/ eating disorders - increased seizure risk

406
Q

drugs that prolong QT- TCA, macrolide, antipsychotics, antihistamines

A

NOT IN AN – check EKG before starting always in others

407
Q

Sleep in ED

A

low dose remeron, vistaril, trazodone

melatonin (best w/ kids, NOT WITH SSRIs)

408
Q

Med for purging/cutting

A

naltrexone

409
Q

med for binge eating

A

topamax, 2nd line naltrexone

410
Q

med for obsessive thoughts

A

zyprexa (10mg highest in ED), risperdal, seroquel, abilify

411
Q

med for instrusive thoughts/anxiety rt eating

A

neurontin, vistaril, ativan (short term, 30 min b4 mealtime)

412
Q

Depolarization/repolarization ions

A

Na+ fast moving, SA, atrial, bundle of HIS, purkinje
Ca++ slower moving AV node
K+ repolarization

413
Q

PR interval length

A

0.12-0.2

414
Q

QRS complex length

A

0.06-0.12 (>0.12 BBB)

415
Q

QT interval length

A

men <.46

416
Q

Rate 300 method

A

300, 150, 100, 75, 60, 50
300/#boxes between R waves
Count Rs on 6 second strip x10

417
Q

Sinus tachycardia causes + tx

A

PE, hypoxia, hypovolemia, anemia, fever, pain, anxiety, hyperthyroid
correct underlying cause

418
Q

Inappropriate sinus tachycardia

A

no apparent heart dx or cause - elevated rest HR or exaggerated exercise response - possibly autonomic or psychosomatic cause
1. refer to cardio 2. treat sx BB daily or when sx

419
Q

Sinus arrhythmias

A

from SA node, rate variable w respiration, common in young healthy adults

420
Q

wandering atrial pacemaker

A

irrefular rhythm, at least 3 diff P wave morphologies

421
Q

Afib

A

no discernible P waves, Arate 350-450, stroke risk, multiple foci

422
Q

Aflutter

A

saw tooth, Arate 250-350, multiple foci

423
Q

Premature atrial beat PACs

A

irritable atrial focus, p wave early, often hides T wave or hidden in QRS

424
Q

Supraventricular tachy

A

catch all
atrial tachy - AV node reentrant tachy - p waves look different
junctional tachy

425
Q

wolff-parkinson white syndrome

A

Delta waves, gradual upsloping appears as short PR or prolongs QRS - premature depolarization

426
Q

ventricular tachy

A

> 90 bpm from ventricles, broad QRS - briefly stable then CPR/ACLS

427
Q

ventricular fib

A

no heart pumping - CPR, ACLS, defib

428
Q

1st degree AV block

A

prolonged PR interval, >0.2

429
Q

2nd degree AV type 1 Wenkeback

A

PR interval lengthens until QRS drops

430
Q

2nd degree AV type 2 Mobitz

A

normal, stable P-QRS interval then QRS dropped

431
Q

3rd degree - complete heart block

A

AV dissociation, no connection between p’s and qrs’s

432
Q

bundle branch block

A

QRS>0.12 - delay in polarization between ventricles - conjoined QRS’s w/ 2 R waves

433
Q

Depolarization direction

A

left and down -30 to 90

434
Q

Left axis deviation

A

towards -60

LVH, pregnancy, ascites, abd tumor, LBBB, hyperkalemia, inferior wall MI

435
Q

Right axis deviation

A

towards +120

RVH, RBBB, lateral wall MI, atrial septal defect

436
Q

LVH cause

A

HTN, cardiomyopathy, aortic and mitral valve dx

437
Q

Sokolov lyon index

A

LVH measure - depth of S wave in mm in V1 + height of R wave in V5 >35mm

438
Q

EKG changes w/ ischemia

A

inverted T wave, reduced blood supply

439
Q

EKG changes w/ injury

A

ST segment elevation - early,will return to baseline w time

440
Q

EKG changes w/ necrosis

A

Q waves, first downward stroke in QRS complex

significant Q wave is 1 square wide OR 1/3 R wave height

441
Q

ST changes in lateral infarct

A

I + AVL

442
Q

ST changes in anterior infarct

A

V1-V4

443
Q

ST changes in inferior infarct

A

II, III, AVF

444
Q

seborrheic derm causes

A

androgen driven in women, hereditary, worse w age, better w OCP/spirono, worse w HIV/DM, seizure meds

445
Q

seb derm txt

A

emollients, keto 2% BID, desonide

446
Q

nummular eczema risk

A

age 15-30, if older and never had b4, unlikely

447
Q

atopic derm txt

A

emollients, topical steroids, prednisone, cyclosporine, UVB

448
Q

Psoriasis risks

A

hereditary, autoimmune, onset early adult (not common in kids or older ppl), assoc w other autoimmune d/o, drug induced (BB), alcohol, stress, obesity, inflamm d/o

449
Q

psoriatic arthritis

A

stiff, sore in morning, subsides w activity, distal fingers, hands, toes

450
Q

psoriasis txt

A 
emollients
topical steroids, tar, dovonex
NB UVB - remission possible
systemic - methotrexate, cyclosporine - always w/ arthritis
bio drugs - remicade, enbrel, humira
451
Q

tinea corporis, cruris, pedis, capitis

A

ring worm - body, jock itch, feet, scalp

452
Q

Tinea txt

A

topical clotrimazole
topical ketoconazole/econazole - broader spectrum
systemic terbinafine
systemic itraconaze - CYP

453
Q

Candida txt

A

oral - nystatin S+S
perleche nystatin cream on side of mouth
vaginal - metro cream, fluconazole PO
body folds - nystatin cream
prevention - talc/cornstarch/nystatin powder, antibacterial soap
r/o inverse psoriasis if recurrent

454
Q

Candida risk

A

DM, obesity, nutritional def, immune suppression

455
Q

BCC, young people

A

internal malignancies, colon ca, renal cell ca, basal cell nevus sx

456
Q

BCC spread

A

rarely metastatic, can be invasive if immunosuppressed or older

457
Q

BCC txt

A

biopsy, cryo, efudex, aldara, photodynamic therapy, electrodessication/curettage, simple excision, mohs

458
Q

SCC risk

A

immunosuppressed pts, renal pts (need annual skin check), light skinned, >50, poor sun habits
UV light, thermal injury, chemical, radiation, HPV, chronic inflamm condition (ulcer)

459
Q

SCC location

A

skin, mucus membranes (HPV)

460
Q

SCC spread

A

mets possible, r/t site and immune status of pt

461
Q

Melanoma risk

A

light skin, UV radiation, blistering burns, indoor tanning 10x risk, more common with atypical nevi, 1st degree family hx, personal hx
poor prognosis in dark skin ppl bc found late

462
Q

Melanoma txt

A

biopsy w complete excision w wide margins
staging via sentinel lymph node biopsy, labs, CT, PET
chemo/immunotherapy

463
Q

Tinea capitis txt

A

fungal culture before start therapy
topical ketoconazole shampoo or cream x 2mo
kids - systemic griseofulvin 2-4 mo
adults - systemic terbinafine 2-4 mo

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