5. Medicine Flashcards
1
Q
what are reasons/time/examples
for post-op fever?
A
wind (12-24 h)
- Atelectasis (from muscle relaxers)
- Post-op hyperthermia
water (~24 h)
- UTI
walk (~48 h)
- DVT
- PE
wound (~72 h)
- Post-op infection
wonder drug (anytime)
- Drug fever
2
Q
causes of post-op fever: Wind (12-24 hr)
causes / treatment
A
causes:
- Atelectasis (from muscle relaxers)
- Post-op hyperthermia
treatment:
- Encourage incentive spirometer
- Chest x-ray
3
Q
causes of post-op fever: Water
causes / treatment
A
causes:
- UTI
treatments:
- Straight catheter
- Urine analysis (UA) with Gram stain, culture and sensitivity
- Treat with antibiotics if necessary
4
Q
causes of post-op fever: Walk
causes / treatment
A
causes:
- DVT
- PE
treatments:
- Heparin or Lovenox protocol
- Use SCDs, TEDs, or get patient out of bed
- (SCD: sequential compression device;*
- TED stockings: thromboembolism-deterrent)*
5
Q
causes of post-op fever: Wound
causes / treatment
A
causes:
- Post-op infection
treatments:
- X-ray, Gram stain, culture and sensitivity, blood cultures
- Begin antibiotic
6
Q
causes of post-op fever: Wonder drug
causes / treatment
A
causes:
- drug fever
treatments:
- discontinue drug
- give reversal drug if necessary
7
Q
When do fever peaks occur?
A
Between 4-8 pm
8
Q
What part of the brain regulates the body’s temperature?
A
Hypothalamus
9
Q
malignant hyperthermia: definition
A
A side effect of general anesthesia
Sxs include: tachycardia, hypertension, acid-base and electrolyte
abnormalities, muscle rigidity, hyperthermia
10
Q
malignant hyperthermia: treatment
A
- Dantrolene (for muscle relaxation) 2.5mg/kg IV x l,
- then 1 mg/kg IV rapid push q6h until
symptoms subside or until max dose of l0 mg/kg
11
Q
If a risk of malignant hyperthermia is suspected,
what pre-operative test may be performed?
A
Creatine phosphokinase (CPK)
CPK is elevated in 79% of patients with malignant hyperthermia
12
Q
MOA of local anesthetics
A
Block Na+ channels and conduction of action potentials along sensory nerves
13
Q
toxic dose of lidocaine (Xylocaine)
A
- 300 mg plain (4.5 mg/kg)
- 500 mg with epi (7.0 mg/kg)
14
Q
toxic dose of bupivacaine (Marcaine)
A
- 175 mg plain (2.5 mg/kg)
- 225 mg with epi (3.2 mg/kg)
15
Q
How to convert the percentage of solution to mg/mL?
A
Move the decimal point of percentage one place to the right
(e.g. 1% solution has 10 mg/mL)
16
Q
side effects of lidocaine and bupivacaine
associated with systemic exposure
A
-
CNS effects –
- initial excitation (dizziness, blurred vision, tremor, seizures)
- followed by depression (respiratory depression, loss of consciousness)
-
Cardiovascular effects –
- hypotension,
- bradycardia,
- arrhythmias,
- cardiac arrest
17
Q
What can be given to help reverse
local anesthetic-induced cardiovascular collapse?
A
Intravenous fat emulsion (Intralipid)
18
Q
Is there a risk with intra-articular injections of bupivacaine?
A
Yes,
studies have shown chondrocyte death following prolonged exposure to bupivacaine
19
Q
In what age group should bupivicaine be avoided?
A
Children <12 years of age
should avoid bupivicaine
20
Q
How are amides (lidocaine and bupivacaine) metabolized?
A
Liver
21
Q
How are esters (Novocain) metabolized?
A
Plasma pseudocholinesterase
22
Q
What is the only local anesthetic with vasoconstriction?
A
Cocaine
cocaine is the only local anesthetic with vasoconstriction
23
Q
How is cocaine metabolized?
A
Plasma pseudocholinesterase
(just like other esters)
24
Q
Can local anesthetics cross the placental barrier?
A
Yes,
local anesthetics cross the placental membrane
25
What does MAC (as in MAC with local) stand for?
Monitored anesthesia care
26
For anesthesia,
what **_cannot_** be given to a patient with an **eggshell injury**?
propofol (Diprivan)
27
pain management options for patient
with a codeine allergy?
(STUD or STTUUDDD-N)
* S - Stadol
* T - Toradol
* T - Talwin
* U - Ultram
* D - Darvon
* D - Darvocet
* D - Demerol
* N - Nubain
28
**First choice for oral pain management**
for patient with codeine allergy?
Darvocet N-100 one tab PO q4-6h prn pain
29
**First choice for non-narcotic oral pain mgmt**
for patient with codeine allergy?
tramadol (Ultram) 50 mg
one to two tabs PO q4-6h prn pain,
max daily dose of 400 mg per day
30
**First choice for non-narcotic IV pain mgmt**
for patient with codeine allergy?
Toradol 30-60 mg IV
31
Choice narcotic IV pain med?
(for patient with codeine allergy)
* *Demerol**
* Note: many hospitals, including our own, do not use Demerol due to its side effects*
Side effects:
lightheadedness, dizziness, sedation, nausea, vomiting, sweating, constipation, loss of appetite, headache, weakness, dry mouth, itching, urinating less than usual, flushing, drowsiness
32
Name two **non-narcotic** analgesics
**ketoralac** (Toradol),
**tramadol** (Ultram)
33
what schedule is this drug:
## Footnote
**percocet**
**Class II**
high potential for abuse – requires narcotic script
34
what schedule is this drug:
## Footnote
**vicodin**
**Class III**
moderate potential for abuse
35
what schedule is this drug:
## Footnote
**Tylenol #3**
**Class III**
moderate potential for abuse
36
what schedule is this drug:
## Footnote
**Darvocet**
**Class IV**
low potential for abuse
37
**Percocet 5/325**
*(components and schedule)*
oxycodone/acetaminophen (5 mg/325 mg)
1-2 tabs PO q4-6h prn pain
38
**Roxicet**
*(components and schedule)*
oxycodone/acetaminophen (5 mg/325 mg/5 mL)
*\*Essentially a liquid form of Percocet that is good for pediatric patients*
39
What is the difference between
**Percocet** and **Percodan**?
* **Percocet** has 325 mg of **acetaminophen**
* Percod**_an_** has 325 mg of _ASA_
40
**Vicodin 5/500**
*(components and scheduling)*
hydrocodone/acetaminophen (5 mg/500 mg)
1-2 tabs PO q4-6h prn pain
41
**Tylenol #3**
*(components and scheduling)*
codeine/acetaminophen (30 mg/300 mg)
1-2 tabs PO q4-6h
42
**Darvocet-N 100**
*(components and scheduling)*
propoxyphene/acetaminophen (100 mg/650 mg)
1 tab PO q4h prn pain
43
**Ultram**
*(components and scheduling)*
tramadol 50 mg
1-2 tabs PO q4-6h prn pain
44
**Toradol**
*(components and scheduling)*
ketorolac 10 mg
30 mg IV q6h
1 tab PO q4-6h prn pain
## Footnote
*\*An NSAID not to be used more than 5 days due to possible significant side effects*
45
**Darvon**
*(components and scheduling)*
propoxyphene
1 tab PO q4h prn pain
46
**OxyContin**
*(generic name)*
oxycodone extended-release
47
**Morphine sulphate**
*(components and scheduling)*
2-4 mg IV q2-6h prn mod-severe pain
For very painful dressing change or bedside debridement – 2 mg IV x one dose
48
**MS Contin**
*(components and scheduling)*
morphine sulfate extended-release (15-30 mg)
1 tab PO q8-12h prn pain
49
**Dilaudid**
*(generic name, and scheduling)*
hydromorphone
2-8 mg PO q3-4h prn severe pain
1-4 mg IV q4-6h prn severe pain
## Footnote
*\*This drug is very strong*
50
**Demerol**
*(generic name, note)*
meperidine
## Footnote
*\*Our hospitals do not use this due to its side effects*
51
What therapeutic effects are seen with **acetaminophen**
analgesic and anti-pyretic
52
maximum daily dose of **acetaminophen**
4 grams
53
what therapeutic effects are seen with most **NSAIDs?**
* analgesic,
* anti-pyretic,
* anti-inflammatory
54
on which pathway do **NSAIDs** work?
**Cyclooxygenase (COX)**
NSAIDs **_nonselectively_** inhibit both COX-1 and COX-2 pathways
55
most common **side effect** of NSAIDs
**GI disturbance**
*\*(except with COX-2 inhibitors, because COX-1 protects the stomach lining)*
56
only FDA-approved COX-2 inhibitor
celecoxib (Celebrex)
*\*Others were withdrawn due to i**ncreased risk of heart attack and stroke***
57
NSAIDs with ONLY anti-inflammatory effects
* indomethacin
* tolmetin
58
Do NSAIDs decrease joint destruction?
NO, they only decrease inflammation
59
Do NSAIDs affect bone healing?
Yes
NSAIDs and COX-2 inhibitors **may inhibit bone healing** via their anti-inflammatory effects
60
NSAID causing **irreversible** inhibition of platelet aggregation
Aspirin
*\*(Think: AspIR-in is Ir-reversible)*
61
NSAID that does NOT inhibit platelet aggregation
The COX-2 inhibitor, Celebrex
62
**_Only IV_** NSAID
ketorolac (Toradol)
63
Which NSAID is often given:
**during surgery or immediately post-op**
to decrease pain and inflammation?
Toradol 30 mg IV
64
NSAIDs with the **least** nephrotoxicity
* Celebrex,
* Relafen,
* Lodine
65
effect of NSAIDs on asthma
NSAIDs can **_increase/exacerbate_** symptoms of asthma
66
safest NSAIDs for a patient with asthma
* Diclofenac
* ketoprofen
67
NSAIDs that treat **collagen vascular disease**
"SIT"
* sulindac
* Ibuprofen
* tolmetin
68
NSAIDs that are NOT renally cleared
**Indomethacin and Sulindac**
excreted in urine, less effect on renal function
* **Indomethacin**
* ~60% of an oral dose is excreted in the **urine** *(predominantly in glucuronidated form)*
* ~40% is excreted in the faeces after biliary secretion *(a large amount of the dose undergoes biliary recycling)*
* **Sulindac**
* ~50% of dose is excreted in the **urine** *(predominantly the conjugated sulfone metabolite)*
* \<1% of dose appears in the urine as the sulfide metabolite.
* ~25% is found in the feces, primarily as the sulfone and sulfide metabolites.
69
NSAIDs:
## Footnote
**cardiovascular effects**
Can cause **vasoconstriction** and **increase blood pressure**
70
NSAIDs with LEAST cardiovascular effects
Diclofenac & Ketoprofen
*\*(these are also the same 2 drugs that are safest for asthmatic patients)*
71
NSAIDs:
most hepatotoxic
"DIN"
**d**iclofenac, **I**buprofen, **n**aproxen
72
Tx for Indomethacin overdose
**Benadryl**
Benadryl decreases serotonin and histamine release
73
**Arthrotec**
*(components and use)*
**diclofenac/misoprostol** –
use: an NSAID with **protection for the stomach**
74
anti-inflammatory dose of ibuprofen
1200-3200 mg/day in divided doses
75
which NSAIDS work on both the
lipooxygenase and cyclooxygenase pathways
Diclofenac and Ketoprofen
76
difference between Cataflam and Voltaren
* **Cataflam** is diclofenac **potassium** and has an **immediate**-release
* Voltaren is diclofenac sodium and has a delayed-release
77
**Pro-drugs** for NSAIDs
**nabumetone** and **sulindac**
*Recall: a **_pro-drug_** is a medication or compound that, after administration, is **metabolized into a pharmacologically active drug**. Instead of administering a drug directly, a corresponding prodrug can be used to improve how the drug is absorbed, distributed, metabolized, and excreted*
78
**Non-acidic** NSAID
nabumetone
79
NSAIDs with fewer pulmonary problems
Diclofenac and Ketoprofen
*(fewer pulmonary, cardiovascular, and issues with asthma)*
80
Once-a-day NSAIDs
*Think: "One Pill Cada Noche"*
* **o**xaprozin (Daypro)
* **p**iroxicam (Feldene)
* **c**elecoxib (Celebrex)
* **n**abumetone (Relafen)
* others
81
drugs that interact with NSAIDs
* Anti-epileptics
* Anti-hypertensives
* Corticosteroids
* Coumadin
* Digoxin
* Lithium
* Methotrexate
* Probenecid
* Sulfonylureas
82
Effect of NSAIDs with:
## Footnote
**Coumadin**
increases action of Coumadin
## Footnote
*(aka Warfarin - blood thinner)*
83
Effect of NSAIDs with:
## Footnote
**Sulfonylureas**
increases action of sulfonylureas
84
Effect of NSAIDs with:
## Footnote
**Corticosteroids**
increases GI risk
85
Effect of NSAIDs with:
## Footnote
**Anti-epileptics**
increases anti-epileptic toxicity
86
Effect of NSAIDs with:
## Footnote
**Antihypertensives**
**antagonizes** antihypertensive meds
*(recall: NSAIDs induce an increase in blood pressure (BP) and may potentially reduce the efficacy of several antihypertensive drugs)*
87
Effect of NSAIDs with:
## Footnote
**Digoxin**
increases digoxin’s effect
*(NSAIDs can increase Digoxin levels in the body, causing nausea, loss of appetite, visual changes, slow pulse, or irregular heartbeats)*
88
Effect of NSAIDs with:
## Footnote
**Methotrexate**
decreases methotrexate’s clearance
* (by decreasing clearance, increases bioavailability, increasing effects of methotrexate;*
* serious adverse events include **liver toxicity**, **acute renal failure**, and **cytopenia**)*
DOI: 10.1002/pds.4555
Svanström (2018)
89
Effect of NSAIDs with:
## Footnote
**Lithium**
NSAIDs decrease lithium’s clearance
* (by decreasing clearance, increases lithium bioavailability, increased effects;*
* resulting in an increased risk for serious adverse effects like **confusion, tremor, slurred speech,** and **vomiting**)*
* Source: nami.org*
90
Effect of NSAIDs with:
## Footnote
**Probenecid**
increases concentration of NSAIDs;
**enhanced anti-inflammatory** effect can be expected when these 2 drugs are combined
*(MOA: ibuprofen oral will increase the level or effect of probenecid oral by acidic (anionic) drug competition for renal tubular clearance)*
91
causes of **acute arterial occlusion**
* **Embolism** – detached thrombus, air, fat, or tumor
* **Thrombus** – occlusion of vessel by plaque or thickened wall
* **Extrinsic occlusion** – traumatic, blunt, penetrating
92
triad of pulmonary embolism
## Footnote
*(definition)*
* **Dyspnea**
* **Chest pain**
* **Hemoptysis** *(although tachycardia is more common)*
93
Diagnostic tests:
## Footnote
**Pulmonary Embolism**
* Chest X-ray
* Ventilation perfusion scan
* Pulmonary angiography
94
Virchows triad
* **Venous stasis** – tourniquet, immobilization
* **Endothelial wall damage/abnormality** – surgical manipulation, trauma, smoking
* **Hypercoagulability** – birth control, coagulopathy, history of DVT
95
what does Virchow triad predict?
* Risk of DVT
* Previous DVT is #1 risk factor for having another DVT
96
**DVT:**
risk factors
(I AM CLOTTED)
* I – immobilization
* A – arrhythmia
* M – MI (past history)
* C – coagulable states
* L – longevity (old age)
* O – obesity
* T – tumor
* T – trauma
* T – tobacco
* E – estrogen
* D – DVT (past history)
97
**DVT**
clinical diagnosis
* **Pain**, heat, swelling, erythema of unilateral limb
* **Positive Pratt** sign – *squeezing of posterior calf causes pain*
* **Positive** Homan sign – *abrupt dorsiflexion of foot causes calf pain*
* **Pulmonary** embolism
98
Diagnostic tests:
**DVT**
* Doppler ultrasound
* Venogram
* D-Dimer
99
drugs for long-term DVT prophylaxis
why?
* **Heparin** – works right away
* **Coumadin** – takes 3-5 days and causes an initial transient hypercoagulable state
100
**DVT** treatments
* Thrombolytic agents
* Heparin
* 5000 Units IV bolus,
* then 1000 Units IV q1h and monitor PTT
101
dosing **Heparin** for perioperative DVT prophylaxis
* 5000 units SC 2h prior to surgery
* 5000 units SC q12h until patient ambulates
102
**Heparin:**
half-life
1.5 hours
103
**Heparin:** MOA
* Intrinsic pathway
* Potentiates antithrombin III 100-fold --\> inhibits the serine protease in the clotting cascade
104
**Heparin**: reversal
Protamine sulfate 1 mg per 100 units of heparin
105
what is **enoxaparin (Lovenox)**?
Low molecular weight heparin (LMWH)
106
dosing **Lovenox** for perioperative DVT prophylaxis
30 mg SC q12h for 7-10 days
(adjust dose to q24h for renal patients)
107
**Lovenox:** half-life
4.5 hours
108
+/- of using Lovenox vs. regular Heparin
* Advantages – Lovenox has longer plasma half-life with significant anticoagulation in trough
* Disadvantages – increased post-op complications when used with spinal/epidural anesthesia
109
How to check **Lovenox?**
\*there is NO TEST for the effects of Lovenox\*
110
Lovenox: reversal
Recombinant Factor VII
111
Coumadin: dosing
5-10 mg PO daily for 3-4 days then adjust for INR
112
Coumadin: half-life
20-60 hours
113
how long before Coumadin is therapeutic?
3-5 days
*before Coumadin becomes therapeutic*
114
Coumadin: MOA
* Extrinsic pathway
* Interferes with clotting factors II, VII, IX, X
115
Coumadin: reversal
* Vitamin K
* Fresh frozen plasma
116
**INR values**:
- normal
- intense anticoagulation
* Normal: 1
* Intense anticoagulation: 2-3
117
levels of **Heparin** and **Coumadin** for
DVT/anticoagulation prophylaxis
* **Heparin** – maintain 2-3 times normal PTT
* **Coumadin** – maintain 2 times normal INR
118
perioperative DVT prophylaxis:
## Footnote
**nonpharmacologic measures**
* **Early ambulation** – most important
* **TEDs** – thromboembolic deterrent stockings
* **SCDs** – sequential compression devices
119
surgical treatment for a patient
with prior DVTs or recurrent PEs
**Greenfield filter**
\*gold standard for inferior vena cava (IVC) filters;
purpose is to trap clinically significant emboli
120
**Greenfield filter** is inserted at what level of the body?
Inferior vena cava **_below_** the renal veins;
## Footnote
*(femoral IVC to prevent DVTs)*
121
**Pletal**
*(generic name, use)*
* Generic: **Cilostazol**
* Use: **vasodilator**
* *used to **reduce the symptoms of intermittent claudication** and can increase your ability to walk further distances*
122
**Trental**
*(generic name, use)*
* Generic: **Pentoxifylline**
* Use: **Anti-inflammatory** and **Vasodilator**
* *can treat poor blood circulation by improving the flow of blood through the vessels*
123
Indications for **Pletal** or **Trental**
Intermittent claudication
124
**CRPS**: define
**Complex regional pain syndrome**
* (previously known as RSD – reflex sympathetic dystrophy)*
* A progressive disease of the autonomic nervous system causing c**onstant, extreme pain** that is _out of proportion_ to the original injury
125
**CRPS:**
types
* CRPS **Type I** (reflex sympathetic dystrophy)
* CRPS **Type II** (causalgia)
126
**CRPS Type I**
*(define, causes)*
**(reflex sympathetic dystrophy)**
* Nerve injury cannot be immediately identified
* Spontaneous pain not limited to single nerve distribution
* Abnormal response in sympathetic nervous system
* Abnormal reflex leading to vasomotor instability and pain
127
**CRPS Type II**
*(define, causes)*
(**causalgia**)
* Distinct, "major" nerve injury has occurred
* o Trauma
* o Peripheral nerve injury
* o Drugs – anti-TB, barbiturates, cyclosporine
* Continued pain not necessarily limited to injured nerve distribution
128
what are the stages of CRPS?
* **Acute** – early (0 to 8-20 weeks)
* **Dystrophic** – mid (2-6 months, possibly up to 1 year)
* **Atrophic** – late (over 6-12 months)
129
**Acute CRPS**
*(timing, characteristics)*
**Acute – early (0 to 8-20 weeks)**
* Constant pain out of proportion (intense burning)
* Possible edema, muscle wasting
* Hyperhidrosis
* Pain increased by light touch, movement, emotion
130
**Dystrophic CRPS**
*(timing, characteristics)*
**Dystrophic – mid (2-6 months, possibly up to 1 year)**
* Increased edema that is indurated (brawny edema)
* Constant pain by any stimulus
* Skin is cool pale and discolored
* X-ray shows diffuse osteoporosis
131
**Atrophic CRPS**
*(timing, characteristics)*
**Atrophic – late (over 6-12 months)**
* Intractable pain spreads proximally to involve entire limb
* Decreased dermal blood flow causing cool, thin shiny skin
* Fat pat atrophy
* Joint stiffen, may proceed to ankylosis
132
**CRPS:**
radiographic findings
On X-ray:
* **Periarticular,**
* **mottled,**
* **irregular bony demineralization (30-60% of cases) and**
* **cortical thinning**
*Per Radiopaedia:*
* *severe patchy osteopenia, particularly in the periarticular region*
* *soft tissue swelling, with eventual soft tissue atrophy*
* *subperiosteal bone resorption*
* *preservation of joint space*
133
CRPS: bone scan
usefulness, sensitivity and specificity
The 3-phase bone scan has **sensitivity of 96%** and **specificity of 98%.**
* A normal scan does not exclude the diagnosis.
* The findings of the bone scan _are based on the phase_.
134
CRPS bone scan findings:
acute, dystrophic, atrophic
1. Acute
* Increased flow and blood pool activity in the affected extremity
* Increased activity particularly in a periarticular distribution on delayed images
2. Dystrophic
* Flow and blood pool abnormalities begin to normalize
* Increased activity on delayed images persists
3. Atrophic
* Flow and blood pool activity can be normal or decreased (in about 1/3 of patients)
* Normal or decreased activity is commonly seen on delayed images, however, persistent increased delayed activity has been reported (up to 40%)
* Decreased flow in advanced stage smay be related to disuse, which is a common feature of post-hemiplegic CRPS
135
CRPS: treatments
* anti-inflammatory drugs
* antidepressant drugs
* local peripheral nerve blocks
* paravertebral sympathetic ganglion blocks
* physical therapy
136
**diabetic ketoacidosis (DKA)**
which DM type?
Type I
| (IDDM)
137
**diabetic coma**
which DM type?
Type II
| (NIDDM)
138
**hypo**glycemia: signs
* nervousness
* tachycardia *(fast HR)*
* diaphoresis *(sweating)*
* nausea
* headache
* confusion
* tremor
* seizures
* coma
139
**hyper**glycemia: signs
* polyuria *(excess urination)*
* polydipsia *(excess thirst)*
* weight loss
140
**biguanide:** function
**anti-hyperglycemic**
| (but NOT hypoclygemic)
141
what is a typical supplemental insulin scale?
142
FDA-approved drugs for
treating **diabetic neuropathy**
* **duloxetine (Cymbalta)**
* **pregabalin (Lyrica)**
143
osteoarthritis (OA):
**clinical** findings
* Pain relieved with rest
* Stiffness aggravated with activity
* Crepitus with motion
* Asymmetric joint swelling
144
osteoarthritis (OA):
**radiographic** findings
* Asymmetric joint space narrowing
* Broadening and flattening of articular surfaces
* Osteophytes at joint margins
* Subchondral sclerosis
145
MC inflammatory arthritis in men over 30?
Gout
146
gout:
stages
1. Asymptomatic hyperuricemia
2. Acute gouty arthritis
3. Intercritical gout
4. Chronic tophaceous gout
147
gout:
clinical findings
* Asymmetrical, monoarticular arthritis
* Sudden onset of red, hot, and swollen joint
* Excruciating pain with acute attack
* Tophaceous deposits
* Most commonly affects 1st MPJ
148
gout:
radiographic findings
* Radiographic findings appear late in the disease after multiple attacks
* Bone lysis in acute stages
* Periarticular swelling with preserved joint space
* Tophi at joint margins
* Rat bite – punched-out, periarticular erosions
* Cloud sign – tophaceous material
* Martel sign – periarticular overhanging shelves of bone
149
gout:
laboratory tests
* **Uric acid**:
* males \>7 mg/dL,
* females \>6 mg/dL,
* \*though may be normal during attack
* **Synovial fluid analysis** provides a more accurate diagnosis
150
gout:
what would a **joint aspirate** show?
Needle-shaped monosodium urate crystals that are negatively birefringent (yellow) under polarized light
151
What is CPPD?
Calcium Pyrophosphate Dihydrate Deposition Disease,
aka Pseudogout
152
Pseudogout (CPPD):
what would joint aspirate show?
rhomboid-shaped and positively birefringent (blue)
under polarized light
153
what is a "Martini sign" and what is it associated with?
Histology showing a PMNC engulfing a crystal
(associated with pseudogout)
154
if gout is suspected, what should a specimen be sent in?
* One in formaldehyde (dissolves gouty tophi), AND
* one in alcohol (does NOT dissolve gouty tophi)
155
acute gout: treatment
* Colchicine
* NSAIDS – indomethacin
* Corticosteroids
* ACTH
156
chronic gout: treatment
* Colchicine (prophylactically)
* Allopurinol
* Uricosurics – probenecid, sulfinpyrazone
157
Colchicine: dosage
* 0.6 mg PO q1h until symptoms resolve,
* GI side effects occur, or max dose of 6 mg reached
158
Colchicine: max daily dose
6 mg
159
Can allopurinol, probenecid or sulfinpyrazone
be used for **acute gout**?
No, because they **may cause an initial hyperuremia**
160
how to determine if patient is an
**overproducer** or **underextretor**?
Take a **24 hour uninalysis**
161
which is more common with gout:
**overproducer** or **underexcretor**
\***Underexcretors** make up approx 90%
162
What medication for OVERPRODUCER of gout?
Medication for UNDEREXCRETOR of gout?
("Over-Achieving, Under-Paid")
* Overproducer → Allopurinol
* Underexcretor → Probenecid
163
rheumatoid arthritis (RA):
clinical findings
* Symmetric, progressive, polyarticular, and degenerative inflammatory arthritis
* Pain first thing in morning
* Stiffness after rest and reduced with activity
* Rheumatoid nodules (25%)
* Nail fold infarcts, splinter hemorrhages
* Swan neck deformities – flexed DIPJ and extended PIPJ
* Boutonniere deformities – extended DIPJ and flexed PIPJ
* Other – bullous dermatosis, Raynaud phenomenon, vasculitis
164
rheumatoid arthritis (RA):
epidemiology
* Age of onset between 3-4th decades
* Females \> males
165
rheumatoid arthritis (RA):
laboratory findings
* **Rheumatoid factor** – positive
* **RBC** – slight to moderate anemia
* **WBC** – elevated in acute cases and normal to decreased in chronic
* **ESR & CRP** – moderate to marked elevation
* **Synovial fluid analysis** – elevated WBCs with cloudy fluid
166
rheumatoid arthritis (RA):
radiographic findings
* Clinical symptoms may present several years prior to radiographic findings
* Peri-articular edema
* Periosteal elevation and ossification
* Marginal erosions
* Subluxation and contractures (Swan neck deformities)
* Fibular deviation of digits
* Osteoporosis
* Symmetric joint space narrowing and destruction (late stage finding)
167
what causes fibular deviation of digits
associated with Rheumatoid arthritis?
Erosive changes of medial plantar metatarsal heads compromise the integrity of medial
collateral ligaments leading to lateral deviation of digits
168
**pannus**: define
what disease is it associated with
* Granulation tissue that secretes chondrolytic enzymes which break down articular cartilage
* \*Associated with Rheumatoid arthritis
169
psoriatic arthritis:
clinical findings
* Polyarthritis including DIPJ involvement
* Sausage digits
* Psoriatic skin changes
* Nail lesions
170
psoriatic arthritis (PA):
laboratory findings
* **HLA-27** – positive
* **Rheumatoid factor** – negative
171
psoriatic arthritis:
radiographic findings
* Erosions with bony proliferation
* Symmetric narrowing of joint space
* Increased periosteal activity
* Pencil-in-cup appearance
* Osteopenic changes
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reiter syndrome:
clinical findings
* Polyarticular, asymmetric arthritis of lower extremity (mostly affects small bones of feet, ankle, knee, SI joint)
* Most affects males
* Capsulitis with digital edema
* Bony erosions
* Reiter Syndrome Triad (can't see, can't pee, can't climb a tree)
* Conjunctivitis
* Urethritis
* Arthritis
* Also keratoderma blenorrhagicum
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what is the **Reiter Syndrome Triad?**
(can't see, can't pee, can't climb a tree)
* Conjunctivitis
* Urethritis
* Arthritis
* Also keratoderma blenorrhagicum
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reiter syndrome:
laboratory findings
* **HLA-27** – positive
* **Rheumatoid factor** – negative
* **ESR** – elevated
* **Synovial fluid analysis** – Pekin cells
175
What are Pekin cells?
| (aka Reiter's cells)
vacuolated macrophages with ingested neutrophils
176
reiter syndrome:
radiographic findings
* Fluffy periosteal reactions
* Large, bilateral heel spur formation
* Inflammation and widening of Achilles tendon insertion
* Deossifications
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ankylosing spondylitis (AS):
clinical findings
* Mostly males affected
* Bilateral sacroiliitis – low back pain and stiffness
* Heel pain
* Peripheral joint pain
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ankylosing spondylitis (AS):
laboratory findings
* **HLA-27** – positive
* **Rheumatoid factor** – negative
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ankylosing spondylitis (AS):
radiographic findings
* Irregular joint widening with erosions
* Reactive sclerosis
* Bony ankylosis
* Sacroiliac joint fusion
* Bamboo spine
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septic arthritis:
clinical findings
* Painful, hot, swollen joint
* Systemic signs of fever, N/V, tachycardia, confusion
181
septic arthritis:
laboratory findings
* **WBC** – elevated with left shift
* **ESR** – elevated
* **CRP** – elevated
* **Blood cultures** – positive
* **Synovial fluid analysis** – elevated WBC with cloudy white or gray color
182
septic arthritis:
radiographic findings
* Normal in early stages
* Joint effusion
* Juxta-articular osteopenia
183
septic arthritis:
etiologies
* Contiguous,
* hematogenous,
* direct implantation,
* surgical contamination
184
septic arthritis:
most common offending organisms
* **All ages** – Staphylococcus aureus
* **Neonates** – Streptococcus and Gram negatives
* **Children** – H. influenza
* **Teenagers** – Neisseria gonorrhea
* **Puncture wounds** – Pseudomonas aeruginosa
* **Adults with sickle-cell** – Salmonella
185
septic arthritis:
treatment
* Needle drainage of joint
* Open arthrotomy if osteomyelitis, joint implant, or chronic infection
* Initial joint immobilization followed by passive ROM
* Appropriate IV antibiotics for 2 weeks followed by 2-4 weeks of oral antibiotics
186
brachymetatarsia:
define
* **Premature closure of epiphyseal plate of metatarsal resulting in a short metatarsal**
* Usually the 4th metatarsal is affected
187
conditions associated with brachymetatarsia
* Downs syndrome
* Turners syndrome
* Cri du chat
* Pseudo- or pseudopseudohypoparathyroidism
* May be idiopathic
188
maximum length that a metatarsal may be acutely lengthened for correction of brachymetatarsia?
**1 cm graft** allows acceptable stretching of neurovascular structures
189
**If more than 1 cm** of lengthening is required, what procedure may be performed?
Callus distraction with Mini-Rail fixation
190
How much lengthening is typically achieved with
**callus distraction**?
**1 mm per day (0.25 mm q6h)**
191
achondroplasia:
define
**Dwarfism** –
all bones short with tibia undergrowth and fibular overgrowth causing genu varum
192
**fibular hemimelia**:
define
Aplasia or hypoplasia of the fibula
193
DISH:
define
**Diffuse Ideopathic Skeletal Hyperostosis (DISH)** –
characterized by multiple ossifications at tendinous
or ligamentous insertions
194
Apert syndrome:
define
multiple bony coalitions
*People with Apert syndrome can have distinctive malformations of the skull, face, hands, and feet. Apert syndrome is characterized by craniosynostosis, a condition in which the fibrous joints (sutures) between bones of the skull close prematurely.*
195
paget disease:
define
**Osteitis deformans –**
* abnormal bony architecture caused by increased osteoblastic and osteoclastic activity.
* More common in elderly
196
**malignant bone degeneration** that may be seen with
## Footnote
**Paget disease**
Osteosarcoma
197
Paget disease:
stages
1. **Destructive** – osteo**lytic**
2. Mixed – osteolytic and osteoblastic
3. **Sclerotic** – osteo**blastic**
198
Charcot:
stages
1. Acute or destructive
2. Coalescence
3. Remodeling
199
conditions with **positive HLA-B27**?
* Ankylosing spondylitis (AS)
* Reiter disease
* psoriatic arthritis (PA)
* reactive arthritis (RA)
* enteropathic arthropathies
200
CREST syndrome:
components
* **C**alcinosis
* **R**aynauds phenomenon
* **E**sophageal dysmotility
* **S**clerodactyly
* **T**elangiectasias
201
CREST syndrome:
what is it?
limited cutaneous form of systemic sclerosis (lcSSc), is a multisystem connective tissue disorder.
202
cutaneous larva migrans:
treatment
"Promethia under occlusion";
* Anthelmintics (tiabendazole, albendazole, mebendazole and ivermectin)
* Topical thiabendazole is considered the treatment of choice for early, localised lesions.
* Oral treatment is given when the cutaneous larva migrans is widespread or topical treatment has failed.
* If these are unavailable, physical treatments (liquid nitrogen cryotherapy or carbon dioxide laser) may be used to destroy the larvae.
* Antihistamines and topical corticosteroids may also be used w/ anthelminthics to provide symptomatic relief of itch.
203
Lyme disease:
treatment
Doxycycline 100 mg PO daily, or
Rocephin l g IV daily
204
necrotizing fasciitis:
drug of choice
**Primaxin 250-1000 IV q6-8h**
| (most commonly 500 mg IV q8h)
205
Felty syndrome:
define
* Rheumatoid arthritis,
* splenomegaly,
* leukopenia
206
mycosis fungoides:
define
Cutaneous T-cell lymphoma that can resemble eczematoid or psoriasis
207
erythrasma:
define
Chronic, superficial infection of intertriginous skin caused by **Corynebacterium minutissimum.**
* Interdigital lesions appear as maceration.
208
ecthyma:
define
* Ulcerative pyoderma of the skin
* often caused by **Streptococci**.
* Infection extends into dermis and is characterized by ulcers with overlying crusts.
209
cellulitis:
define
* Acute spreading infection of dermal and subcutaneous tissue
* commonly caused by **group A Strep or Staph aureus**
* Affected area is erythematous, warm, edematous, and tender.
210
erysipelas:
define
* Superficial infection that extends into the lymphatics.
* Lesions are erythematous, indurated with sharply-demarcated margins, and have erythematous, ascending streaks.
211
lymphangitis:
define
Inflammation of the lymphatics as a result of a distal infection
212
psoriasis:
define
* Hereditary disorder with chronic scaling papules and plaques in areas of body related to repeated minor trauma.
213
psoriasis:
symptoms
* Positive Koebner phenomenon and Auspitz sign.
* **Koebner phenomenon:** *formation of skin lesions on parts of the body where a person doesn’t typically experience lesions; "isomorphic response"*
* **Auspitz sign:** *pinpoint bleeding that can occur when the surface of a scaling rash has been removed and capillaries just beneath the skin's surface rupture*
* Other sxs:
* joint pain
* nail changes incl pitting, beau lines, oil spot, subungual hyperkeratosis, and discoloration
214
lichen planus:
define
* Inflammatory dermatosis involving skin or mucous membranes with **pruritic, violaceous papules** clustered into large, flat-topped lesions with distinct borders.
* Lesions possibly covered with **Wickham striae** (white streaks).
* Ridges, onycholysis, subungual hyperkeratosis, and discoloration.
215
**"6 P's"** of lichen planus
* Planar (flat-topped)
* Purple
* Polygonal
* Pruritic
* Papules
* Plaques
216
another name for **menopausal lipoma**
juxtamalleolar lipoma
*semi-fluctuant, irregular lobulated fatty mass anteroinferior to the lateral malleolus, commonly occurring bilaterally*
217
main screening test if suspecting AIDS
ELISA (Enzyme Linked Immunosorbent Assay)
218
What test should be performed to
confirm the diagnosis of AIDS?
Western blot
219
effects of steroids
**Anti-inflammatory**
* Decreases production of prostaglandins, cytokines, and interleukins
* Decreases proliferation and migration of lymphocytes and macrophages
**Metabolic**
* Decreases osteoblast activity
220
difference between **phosphate** and **acetate-based** steroids
Phosphate-based – soluble with shorter half-life
* Minimize inflammatory reaction and edema
Acetate-based – insoluble with longer half-life
* May delay inflammatory process or healing and can mask infection
221
common complication following steroid injection
* Steroid flare – hypersensitivity reaction.
* Apply ice.
222
glucocorticoid metabolism
* Metabolized in the liver
* Secreted in urine
223
diazepam:
use
* Valium, a benzodiazepine
* an anxiolytic/anticonvulsant/muscle relaxant
224
diazepam: how to reverse
* **Flumazenil (Romazicon)** for benzodiazepine reversal
* Dosage
* 0.2 mg IV over 15 seconds, then
* 0.2 mg IV prn over 1 minute
* (up to 1 gram total)
225
insomnia: drugs
(BE HARD)
* B – Benadryl
* E – estazolam
* H – Halcion
* A – Ambien
* R – Restoril
* D – Dalmane
\*Most commonly used are **Benadryl 25 mg PO qhs** or **Ambien 5 mg PO qhs**
226
drugs causing **metallic taste in the mouth**
* Flagyl
* Lamisil
227
treatment for Tylenol overdose
acetylcysteine (Mucomyst)
228
Gray Baby Syndrome:
what causes it
Chloramphenicol
229
what is chloramphenicol?
An antimicrobial
