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Pod Med I > 9) Metabolic Diseases > Flashcards

9) Metabolic Diseases Flashcards

1
Q

Essential elements of communication in medical encounters: the Kalamazoo Consensus statement

A

(1) Build the doctor-patient relationship
(2) Open the discussion
(3) Gather information
(4) Understand the patient’s perspective
(5) Share information
(6) Reach agreement on problems and plans
(7) Provide closure

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2
Q

Metabolic diseases

A
  • Fibromyalgia
  • Paget’s disease
  • Osteoporosis
  • Osteomalacia and Rickets
  • Hyperparathyroidism and renal osteodystrophy
  • Acromegaly
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3
Q

Fibromyalgia high-yield facts

A
  • Etiology unknown
  • Fatigue likely from sleep disturbance
  • 90% female, 20 to 60 years
  • Diagnosis with clinical examination
  • Currently no specific diagnostic laboratory test or biomarker available for diagnosis
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4
Q

Fibromyalgia treatment

A
  • Patient education
  • Antidepressants
  • Sleep modification
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5
Q

Fibromyalgia host factors

A
  • Female predominance 9:1
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6
Q

Fibromyalgia disease process

A
  • Poorly understood

- Not inflammatory in nature

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7
Q

Fibromyalgia symptoms

A
  • Widespread pain above and below the waist on both sides of the body
  • Associated with stiffness, fatigue, and sleep disturbance
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8
Q

Fibromyalgia physical exam

A
  • Presence of 11 or more of 18 tender point sites
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9
Q

Fibromyalgia associated features

A
  • Irritable bowel syndrome
  • Tension headaches
  • Paresthesias
  • Sensation of swollen hands
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10
Q

Fibromyalgia laboratory tests

A
  • Normal erythrocyte sedimentation rate (ESR)
  • Complete blood count (CBC)
  • Chemistries
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11
Q

Fibromyalgia tender point sites (bilateral)

A
  • Occiput (suboccipital muscle insertion)
  • Low cervical (anterior intertransverse spaces C5-7)
  • Trapezius (midpoint of upper border)
  • Supraspinatus (midpoint of upper border)
  • Second rib (2nd costochondral jxn, just lateral to jxns on upper surfaces)
  • Lateral epicondyle (2cm distal to epicondyles)
  • Gluteal (upper outer quadrants in anterior fold os muscle)
  • Greater trochanter (posterior to trochanteric prominence)
  • Knee (medial fat pas proximal to joint line)
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12
Q

Digital palpation for tender points in fibromyalgia should be performed with an approximate force of

A
  • Four kilograms

- Patient must state palpation was painful to a tender point to be considered “positive”

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13
Q

Management of fibromyalgia

A
  • Patient education
  • Psychosocial support
  • ID and minimize stress factors
  • Moderate exercise (avoid overexertion)
  • Relaxation techniques to avoid muscle tension
  • Avoid long-term analgesics
  • Enhance restorative sleep (low-dose antidepressants)
  • Increase general fitness and health
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14
Q

Examples of antidepressants that cant be used in fibromyalgia management

A
  • Tricyclics (such as Amitriptyline)

- Pregabalin (Lyrica)

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15
Q

Sleep management in rheumatic disease

A
  • Sleep hygiene
  • Behavior therapy
  • Pharmacotherapy
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16
Q

Paget’s Disease high-yield facts

A
  • Etiology unknown
  • 15-30% have family history of the disease
  • Prevalence is high in the United States, Australia, and New Zealand, but the disease is rare in Asia
  • Occurs in 1-3% of patients over the age of 45
  • Abnormal bone resorption and new bone formation (pain and fractures; misshapen bones)
  • Have elevated alkaline phosphatase blood levels
  • Most patients require no treatment; clinical therapeutics depends on symptomotology
  • Typically localized (effects one or a few bones) versus osteoporosis which is usually generalized
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17
Q

Treatment for Paget’s Disease

A
  • No cure
  • Symptoms are treated with bisphosphonates (i.e. Fosamax)
    and calcitonin
    (a hormone that lowers calcium and phosphate concentrations in plasma and inhibits bone resorption)
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18
Q

Tumor-like conditions of bone

A
  • Paget’s disease – a lytic lesion of bone; a condition probably of viral origin
  • The pseudocyst is accentuated by the increased density of the trabeculae
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19
Q

Osteoporosis

A
  • Decreased bone mass (brittle bone)
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20
Q

Osteomalacia

A
  • Decreased bone mineralization (soft bone)
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21
Q

Osteopetrosis

A
  • Hard bone
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22
Q

Osteopenia

A
  • Radiographic term that describes decreased bone density
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23
Q

Causes of generalized osteoporosis

A
  • Aging (accelerated in women because decreased estrogen production following menopause)
  • Steroids
  • Heparin (i.e. osteonecrosis)
  • Malnutrition
  • Hyperparathyroidism and other endocrine abnormalities
  • Osteogenesis imperfecta (congenital; “brittle bone disease”; Blue sclerae)
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24
Q

Causes of focal osteoporosis

A
  • Disuse (e.g. after trauma or due to paralysis)
  • Osteomyelitis
  • RSD
  • Tumor
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25
Q

Management of osteoporosis (physical therapy)

A
  • Brace for acute pain management
  • Elevate gait and balance, provide assistive devices if necessary
  • Weight-bearing exercise, fall techniques
  • Back protection, lifting restrictions
  • Improve balance, muscle strength, and tone
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26
Q

Muscles to focus on strengthening in osteoporosis

A
  • Paraspinal muscle stretching and strengthening

- Pelvic girdle and abdominal muscle strengthening

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27
Q

Current treatments for osteoporosis

A

Bisphosphonates

  • Alendronate (Fosamax), a weekly pill
  • Risedronate (Actonel), a weekly or monthly pill
  • Ibandronate (Boniva), a monthly pill or quarterly intravenous (IV) infusion
  • Zoledronic acid (Reclast), an annualIVinfusion
  • Denosumab (Prolia, Xgeva): Shallow injection q 6 month
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28
Q

Causes of secondary osteoporosis

A
  • Endocrine disorders
  • Malabsorption, malnutrition
  • Hepatic or renal dysfunction
  • Genetic disorders
  • Systemic inflammatory diseases
  • Psychiatric disorders
  • Malignancies
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29
Q

Endocrine disorders that may cause secondary osteoporosis

A
  • Cushing’s Disease
  • Hyperparathyroidism
  • Diabetes mellitus
  • Prolactinoma
  • Hypogonadism
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30
Q

Genetic disorders that may cause secondary osteoporosis

A
  • Osteogenesis imperfecta
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31
Q

Systemic inflammatory diseases that may cause secondary osteoporosis

A
  • Rheumatoid arthritis
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32
Q

Psychiatric disorders that may cause secondary osteoporosis

A
  • Anorexia

- Depression

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33
Q

Malignancies that may cause secondary osteoporosis

A
  • Multiple myeloma
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34
Q

Drugs that may cause secondary osteoporosis

A
  • Glucocorticoids
  • Excess thyroid replacement
  • Heparin
  • Methotrexate?
  • Cyclosporin A?
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35
Q

Potential utility of bone density measurement

A
  • Assess future fracture risk
  • Confirm diagnosis of osteoporosis
  • Monitor effects of treatment
  • Assess rate of bone loss
  • Enhance patient acceptance of and compliance with treatment
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36
Q

Peak bone mineral density (BMD) is usually achieved by

A
  • The middle of the third decade of life
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37
Q

Bone mineral density z-score represents

A
  • # SD above/below the mean compared with age/sex-matched population
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38
Q

Bone mineral density t-score represents

A
  • # SD above or below the mean BMD in sex matched normal population
  • Better predictor of fracture risk than the z-score
39
Q

The criteria for osteoporosis established by the World Health Organization in 1993

A
  • Developed as operational definitions to distinguish between normal and abnormal bone mineral density
  • Useful in identifying patients with low bone mass and osteoporosis
  • NOT intended to be used as criteria for pharmacologic intervention
40
Q

Normal BMD t-score

A
  • Greater than/equal to -1.0 SD
41
Q

Osteopenia BMD t-score

A
  • (-)1 to (-)2.5 SD
42
Q

Osteoporosis BMD t-score

A
  • Less than/equal to (-)2.5 SD
43
Q

Severe osteoporosis BMD t-score

A
  • Less than/equal to (-)2.5 with fragility fractures
44
Q

Calcium supplements/requirements

A
  • Supplements should be taken with meals since gastric acid enhances absorption
  • Requirements are lower for women receiving estrogen replacement therapy (due to enhanced absorption of calcium
45
Q

Elemental calcium requirement (mg/day)

A
  • F <65 taking estrogen = 1,000
  • F <65 not taking estrogen = 1,500
  • M 25-65 = 1,000
  • F/M >65 = 1,500
46
Q

Osteoporosis imaging

A
  • Plain radiographs not sensitive to detect osteoporosis (since loss of 30-50% of density is needed to be evident)
47
Q

When osteoporosis is radiographically evident

A
  • The differentiation between acute and chronic can be made
48
Q

Acute osteoporosis imaging shows

A
  • Patchy “moth eaten appearance of bone

- Intracortical tunneling

49
Q

Chronic osteoporosis imaging

A
  • Shows thinning of the bony cortex

- Decrease in the trabeculae will give an overall decrease in bone density

50
Q

Osteomalacia resulting from dietary vitamin D deficiency

A
  • Rare in adults
  • Rickets in children
  • Results in severe abnormalities centered around the growth plates
51
Q

Osteomalacia imaging findings

A
  • Blurring of the bone trabeculae

- Loss of distiction between the bony medulla and cortex

52
Q

Rickets

A
  • Weakening and softening of the bone brought on by extreme calcium loss
53
Q

Rickets imaging in children

A
  • Fraying of the metaphysis
  • Cortical margins of the epiphysis are indistinct
  • Characteristic “paint brush” appearance of the metaphyseal region (cupping)
54
Q

Hyperparathyroidism

A
  • Result of increased levels of parathyroid hormone

- Characteristic feature is subperiosteal bone resorption

55
Q

Findings seen in both primary and secondary hyperparathyroidism

A
  • Resorption of subperiosteal cortical bone and subligamentous bone
  • Generalized osteoporosis
  • Soft tissue calcifications can also occur
  • “Calciphylaxis” and secondary hyperparathyroidism
56
Q

Patients with chronic renal failure demonstrate

A
  • Bony abnormalities known as renal osteodystrophy
57
Q

Radiographic features of renal osteodystorphy

A
  • May parallel those seen in hyperparathyroidism, osteoporosis, and osteomalacia (or Rickets if a child)
  • Calcification of vessels and soft tissues is a frequent finding
58
Q

Acromegaly is caused by

A
  • Hypersecretion of growth hormone from the pituitary gland in adult patients
59
Q

Acromegaly results in

A
  • Periosteal and endosteal bone formation
  • Thickening and ossification of cartilage
  • Thickening of soft tissues
  • Organomegaly
60
Q

Radiographic findings of acromegaly hands and feet

A
  • Widened joint spaces
  • Overgrowth of the terminal tufts
  • Enlargement of the sesamoids
  • Soft tissue thickening
61
Q

Types of infectious arthritis

A
  • Septic arthritis
  • Lyme disease
  • Viral arthritis
62
Q

Septic arthritis etiology

A
  • Puncture wound
  • Hematogenous seeding
  • Spread from cellulitis
63
Q

Septic arthritis frequently coexists with

A
  • Psteomyelitis

- Almost always monoarticular

64
Q

Characteristics of septic arthritis in the feet

A
  • 2nd, 3rd, and 4th metatarso-phalangeal joints lie in the middle soft tissue compartment
  • In severe cases, may involve these three met heads as well
65
Q

Septic arthritis on plain film imaging

A
  • Usually the only imaging studies needed
  • Joint effusion may be the earliest sign
  • Followed by joint space narrowing and bony erosions
  • The periarticular bone becomes osteoporotic
66
Q

CT and MRI scans with septic arthritis can be used to determine the extent of any associated

A
  • Osteomyelitis

- Deep soft tissue abscesses

67
Q

Septic arthritis differential diagnosis/treatment

A
  • Charcot joint
  • Noninfectious inflammatory arthritis
  • Antibiotics 2-6 weeks given at two to three times the usual dose
68
Q

Rheumatic fever high-yield facts (1)

A
  • Consequence of pharyngeal infection with group A, ß-hemolytic streptococci
  • Multiple episodes can cause rheumatic heart disease
  • Treat with penicillin, erthromycin
69
Q

Erythema marginatum

A
  • Presence of pink rings on the trunk and inner surfaces of the limbs
  • Come and go for as long as several months
  • Primarily on extensor surfaces
70
Q

Chorea

A
  • “grotesque dance”

- Movements look purposeful but are actually involuntary

71
Q

Rheumatic fever symptoms

A
  • Polyarthritis
  • Erythema marginatum
  • Carditis
  • Chorea
  • Subcutaneous nodules

note the difference between erythema migrans and erythema marginatum

72
Q

Gonococcal arthritis/synovitis-high-yield facts

A
  • Systemic gonococcal infection
  • Gram negative intracellular and extracellular diplococcus
  • Produces a septic arthritis to hands, wrists, elbows, ankles, and rarely the axial skeleton
73
Q

Gonococcal arthritis/synovitis has the highest incidence in

A
  • Sexually active women between the ages of 16 and 35

- Palmar pustules may be the most important clue

74
Q

Diagnosis and confirmation of gonococcal arthritis/synovitis

A
  • History and physical make the diagnosis

- Confirmed by aspiration and culture of pustule or effused joint

75
Q

Treatment of gonococcal arthritis/synovitis

A
  • Penicillin, Spectinomycin, Ceftriaxone 250 mg IM single dose
  • PLUS Azithromycin 1 g orally in a single dose (CDC 2015 Guidelines)
76
Q

Classic symptom of Lyme Disease

A
  • Erythema chronicum migrans, an expanding “bull’s eye” red rash with central clearing
  • Also affects joints, CNS, and heart

note the difference between erythema migrans and erythema marginatum

77
Q

Lyme disease is caused by

A
  • Borrelia burgdorferi, which is transmitted by a tick
  • Mice are important reservoirs
  • Deer required for tick life cycle
  • Named after Lyme, Connecticut (common in northeastern US)
78
Q

Lyme Disease treatment

A
  • Tetracycline
79
Q

3 stages of Lyme Disease

A
  • Erythema chronicum migrans, flu like symptoms
  • Neurologic and cardiac manifestations
  • Autoimmune migratory polyarthritis
80
Q

Erythema chronicum migrans (also known as erythema migrans)

A
  • Rash often (though not always) seen in the early stage of Lyme disease
  • Can appear anywhere from one day to one month after a tick bite
  • Does not represent an allergic reaction to the bite, but rather an actual skin infection with the Lyme bacteria
  • “Bulls-eye” erythematous rash
81
Q

Normal synovial fluid classification

A
  • Clear, colorless, viscous

- Leukocytes <200 (<25% PMNs)

82
Q

Noninflammatory synovial fluid classification

A
  • Clear, yellow, viscous

- Leukocytes 200-2,000 (<25% PMNs)

83
Q

Inflammatory synovial fluid classification

A
  • Cloudy, yellow, watery
  • Glucose may be low
  • Leukocytes 2,000-100,000 (>50% PMNs)
84
Q

Septic synovial fluid classification

A
  • Purulent
  • glucose very low
  • Leukocytes >80,000 (>75% PMNs)
85
Q

Viral arthritis

A
  • No specific test for any type
  • Diagnosis based on other symptoms
  • Usually blood work and X-rays don’t help
  • In many cases, diagnosis after a search for other causes turns up negative and symptoms or history suggest a virus as the cause
86
Q

In most cases, viral arthritis runs its course fairly quickly, treating with

A
  • OTC meds (acetaminophen, NSAIDs)
  • Hot or cold packs on the inflamed joints
  • Rest
87
Q

Fibromyalgia summary

A
  • Non-inflammatory syndrome characterized by widespread pain
  • 90% female, 20 to 60 years
  • Clinical examination makes the diagnosis (no exclusion lab tests)
88
Q

Paget’s Disease summary

A
  • Unknown etiology
  • Results in abnormal bone resorption and new bone formation
  • Gives bone a “salt and pepper” appearance radiographically
89
Q

Osteoporosis summary

A
  • Decreased bone mass (quantity)

- Defined by the WHO as a T-score of < -2.5 SD when measuring bone mineral density

90
Q

Osteopenia summary

A
  • T-score of -1.0 to -2.5 when measuring bone mineral density
91
Q

Osteomalacia and Rickets summary

A
  • Result from dietary vitamin D deficiency
92
Q

Resorption of subperiosteal cortical bone and subligamentous bone, generalized osteoporosis, and soft tissue calcifications may be seen in

A
  • Hyperparathyroidism

- Renal osteodystrophy

93
Q

Systemic infections may lead to arthritic conditions as seen in

A
  • Septic arthritis
  • Lyme disease
  • Viral arthritis

Pod Med I (3 decks)

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