ACR Flashcards
Legionnaire’s Disease
Can cause pneumonia via Legionnaire Pneumophila commonly transmitted via poorly maintained air conditioning
non-specific flu-like symptoms: fever, muscle aches and headache followed by chest pain and dyspnoea
S1 Heart sound
systole: mitral and tricuspid
S2 heart sound
diastole: pulmonary and aortic
systolic murmurs
aortic stenosis, pulmonary stenosis, mitral regurgitation and tricuspid regurgitation, mitral valve prolapse
diastolic murmurs
aortic regurgitation, pulmonary regurgitation, mitral stenosis and tricuspid stenosis
aortic area
right upper sternal border, 2nd intercostal space
pulmonary area
left upper sternal border, 2nd intercostal space
tricuspid area
4th intercostal space left of the sternum
mitral area
midclavicular line, in the 5th/4th intercostal area, also known as apex
aortic stenosis
S1 sound is heard as mitral valve and an ejection click is heard shortly after (opening of stenotic aortic valve) closes ejection click (loud) and then starts again low and increase as heart contracts (more turbulent flow) and as it relaxes the murmur is reduced (lower turbulent flow) this is known as
crescendo-decrescendo murmur
Heard loudly at the aortic area, the murmur can radiate to the carotids of the neck
pulmonary stenosis
basically the same as aortic stenosis (systolic ejection murmur) but then is heard best in pulmonary area and does not radiate to the neck (carotids)
Mitral regurgitation
Pan-systolic murmur (lasts throughout the whole systole)
Mitral valve does not close properly, and as the aortic valve is closed the pressure build up in LV causes blood to fall back into LA
Mitral regurgitation
Pan-systolic murmur (lasts throughout the whole systole)
Mitral valve does not close properly, and as the aortic valve is closed the pressure build up in LV causes blood to fall back into LA
Even if the aortic valve does open and blood leaves through the aorta (meanwhile the pressure in LV is still building up because in chronic mitral regurgitation the LA dilates (lowering LA pressure even further and accepting more blood in the LA) hence same intensity of murmur heart throughout S1 until S2
This murmur can radiate to the left axilla
androcur (cyproterone acetate)
steroidal antiandrogens used to block effect of testosterone and is used to treat advanced prostate cancer
DAME
causes for falls
Drugs
Ageing problems (eyes, balance, senescent gait disorder etc)
Medical diseases (anaemia, CV, endocrine, neuro problems)
Extrinsic factors
Decubiti
pressure ulcer
NPO
nil per os (nothing by mouth (NBM)), prevention of aspiration pneumonia in those undergoing general anaesthesia, weak swallowing musculature, GIT infection or acute pancreatitis
Dementia with lewy bodies
ANS affected and
Bulbar palsy
CN 9-12 lesion due to LMN lesion in medulla oblongata or lesions of lower cranial nerves outside the brainstem
dysphagia, difficulty in chewing, choking on liquids, dysphonia, dysarthria
Signs:
nasal speech lacking in modulation and difficulty with all consonants
tongue is atrophic and shows fasciculations.
dribbling of saliva.
weakness of the soft palate, examined by asking the patient to say aah.
normal or absent jaw jerk
absent gag reflex
Sparing of ocular muscles differentiates it from myasthenia gravis
Cause
Genetic: Kennedy’s disease, acute intermittent porphyria
Vascular causes: medullary infarction
Degenerative diseases: amyotrophic lateral sclerosis, syringobulbia
Inflammatory/infective: Guillain–Barré syndrome, poliomyelitis, Lyme disease
Malignancy: brain-stem glioma, malignant meningitis
Toxic: botulism, venom of bark scorpion (species Centruroides),[2] some neurotoxic snake venoms[3]
Autoimmune: myasthenia gravis
hyperinflated lungs
Indicative of COPD/emphysema, can be also seen in those with asthma, due to blockages in air passages or alveoli that are less elastic and prevents efficient expulsion of air from the lungs
Alzheimer’s Disease
70% with dementia patients, r/f age, 30% > 85 have dementia
- Sporadic AD can affect anyone
- Familial AD, rare genetic defect
- Amyloid plaques outside the brain cells: impair synapses so signals can’t pass between brain cells
- Neurofibrillary tangles: prevent normal transport of food and energy around brain cell
Lead to death of brain cells -> shrinkage -> outer part of brain lost first, hence short-term memory lost first -> long-term memory
AD Diagnosis
○ Clinical diagnosis
§ Detailed medical history, thorough physical and neurological examination, intellectual function, psychiatric assessment, neuropsychological tests, blood and urine tests, lumbar puncture for CSF tests, MRI & PET
○ Allows elimination of DDx nutritional deficiencies/depression
Can only confirm after death via brain tissue (autopsy)
AD symptoms
○ Persistent and frequent memory difficulties, esp recent events
○ Vagueness in everyday conversation
○ Apparent loss of enthusiasm for previously enjoyed activities
○ Routine tasks take longer
○ Forgetting well-known people/places
○ Inability to process questions and instructions
○ Deterioration of social skills
Emotional unpredictability
AD treatment
○ Cholinergic drugs: temporary improvement in cognitive functioning
Community support
Gerstmann syndrome
- Dysgraphia & agraphia
- Dyscalculia & acalculia
- finger agnosia (inability to distinguish fingers on hand)
- left-right disorientation
Mental State Examination
Appearance Behaviour Mood and Affect Speech Cognition Thoughts Perception Insight & Judgment
Number of vertebrae
7 cervical 12 thoracic 5 lumbar 5 sacral 3-5 coccyx -> can be just fused
Size of vertebrae
lower vertebrae larger due to increasing bodyweight however, sacral and coccyx gradually get smaller as the weight is transferred to the pelvic girdle (bony pelvis)
Primary curvature
thoracic and sacral (kyphosis) exist during foetal life
Secondary curvature
Lumbar and cervical (lordosis) develops into adulthood
Degree during movement (flexion) vertebrae movement
Kyphosis (thoracic and sacral) increases whilst lordosis (lumbar) decreases
excessive thoracic kyphosis
the back looks hunched as the thoracic region is accentuated (curved more forward)
- can be due to collapse of anterior aspect of vertebral bodies
excessive lumbar lordosis
excessive bending of the back, pelvis comes out forward
scoliosis
abnormal lateral curvature accompanied by the rotation of the vertebrae
when the individual bends over the ribs protrude out of the side with increased convexity
typical cervical vertebrae (C3-6)
Body: small and triangular in shape, vertebral foramen large, superior surface concave, inferior convex, elevated margin on superior aspect of the body (uncinate process, ‘uncus’)
transverse foramen within transverse process (transmit vertebral artery and vein between C1-6)
transverse process has anterior and posterior tubercles (muscle attachment) between the tubercles is the groove for spinal nerve
anterior tubercles of C6 are called carotid (as common carotid artery can be pressed against it)
articular process: short and set obliquely with nearly horizontal facets (allows various movements within the neck)
spinous process: short, bifid, point posteriorly, horizontally oriented
atypical: C1 vertebra (atlas)
body: two lateral masses, articular surfaces, superior concave (for occipital condyles) and inferior flat and round for C2
anterior arch
posterior arch (with a groove for the vertebral artery & C1 nerve)
transverse processes: project for laterally, transverse foramina
no spinous process
Felty’s syndrome
rare autoimmune disorder characterised by the triad of rheumatoid arthritis, splenomegaly and neutropenia
Vascular dementia
Dementia associted with circulatory problems in the brain
Includes: Multi-infarct and Binswanger’s Disease
Frusemide
Used to reduce oedema or hypertension
Contraindications
- kidney and liver problems, low BP, hepatic coma or precoma, low sodium or potassium, dehydration and jaundice
fourth heart sound
occurs late diastole, just before S1, occurs after atrial contraction and is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle (can be a sign of failing ventricles (esp left), if problem is left more accentuated at cardiac apex, exercise, lying to the left and during expiration.
calculate rate on ECG
normal: 300/number of large squares
fast: 1500/number of small squares
calculate rate on ECG
normal: 300/number of large squares (0.2sec)
fast: 1500/number of small squares (0.04sec)
atrial fibrillation
irregularly irregular heart rate
Assessing ABG
Assess the patient Assess the oxygenation Assess the pH Assess the respiratory component of the pH Assess the metabolic component of the pH
Assessing ABG
Assess the patient
Assess the oxygenation
- PaO2 should be 10-14kPa (< 10 = hypoxaemia)
- If patient is on supplemental oxygen PaO2 should be 10kPa lower than inspired oxygen concentration (e.g. 30% oxygen = PaO2 20kPa),
Assess the pH
- normal 7.35 - 7.45
- If the problem is chronic then compensation may have occurred
Assess the respiratory component of the pH
- PaCO2: > 6.0kPa (respiratory acidosis), < 4.5 kPa (respiratory alkalosis)
Assess the metabolic component of the pH
- HCO3- and the BE (base excess)
reduced HCO3- (<22mmol/L or BE < -2mmol/L) = metabolic acidosis
increased HCO3 - (> 26 mmol/L or BE > + 2mmol/L) = metabolic alkalosis
Respiratory Acidosis
COPD and asthma
Respiratory depression (e.g. opiates)
neuromuscular disease (E.g. Guillain-Barre syndrome, muscular dystrophy)
Incorrect ventilator settings (hypoventilation)
Respiratory alkalosis
anxiety, pain, fever pneumothorax pulmonary embolism salicylate poisoning (early) high altitude incorrect ventilator settings (hyperventilation)
Metabolic acidosis
Diabetic ketoacidosis lactic acidosis salicylate poisoning (late) drug overdose (methanol, ethanol, ethanol glycol) chronic renal failure Rhabdomylosis
Metabolic alkalosis
Vomiting
Cardiac Arrest
Multi-organ failure
Cystic fibrosis
Blood transfusion reactions
- Febrile transfusion reactions
- Acute haemolytic transfusion reactions
- Delayed haemolytic transfusion reactions
- Allergic reactions
- Transfusion-related lung injury (TRALI)
- Transfusion-associated circulatory overload (TACO)
- Transfusion associated graft-vs-host disease (TA-GVHD)
Fall Risk Assessment TOOL (FRAT)
- Recent falls
- Medications
- Psychological
Spine Examination
Look - Front: Move: Cervical - Flexion: ROM 0-80 - Extension: ROM 0-50 - Lateral flexion: ROM 0-45 - Rotation: ROM 0-80
Thoracic hard to assess
Lumbar - Flexion: touch your toes - Extension: ROM 10-20 Lateral flexion Lateral rotation
Spinal curvatures
Cervical & Lumbar = Lordosis
Thoracic & Sacrum = Kyphosis
anterior wedging of the vertebra
anterior wedging of the thoracic spine (elderly, kyphosis, probs associated with osteoporosis) they need to hyperextend the cervical vertebrae to compensate for it
Spine Examination
Look
- scoliosis, lordosis, kyphosis
Feel
- palpate spinal processes and sacroiliac joints
- palpate paraspinal muscles (erector spinae muscle)
- feel for tenderness, and other ligaments
- facets joint testing -> 1cm lateral to spinous processes
- Front:
Move:
Cervical
- Flexion: ROM 0-80
- Extension: ROM 0-50
- Lateral flexion: ROM 0-45
- Rotation: ROM 0-80
Thoracic hard to assess
Lumbar - Flexion: touch your toes - Extension: ROM 10-20 Lateral flexion Lateral rotation
Schober’s test
Sciatic stretch test
Femoral nerve stretch test
MSK Exams
Knee exam
- look: scars, wasting, deformity
- Front: quads wasting, deformity, swelling, valgus/varus, trunk - shoulder, ASIS, patella should be level
- Side: genu recurvatum, Baker’s cyst
- Back: hamstric, gastroc muscle
- Gait: squat,
- Feel: feel behind joint
- Move
- Special tests: Effusion - patella tap, swipe test, anterior draw, posterior draw, Lachmann’s test (flex knee to 30deg), LCL instabiity, MCL instability, McMurray’s test
Hip exam
Trendelenburg test: put both hands on the ASIS and ask them to lift up one of their legs
Feel:
- bony points: pubis, pubic symphysis, inguinal ligament, ASIS, greater trochanter
- muscles, quads, adductors
Move
- Flexion, IR and ER
- Adduction
- Abduction
Special tests:
- leg length measurement (true and apparent)
true: ASIS to medial malleolus
apparent: umbiicus to medial malleolus
or just ask x-ray
- straight leg raise: pain between 30-70 degrees.
- Thomas test: test rectus femoris muscle which restricts the flattening of the other leg (one leg needs to be pulled
- FABER: femoracetabular impingement, sacroiliac joint dysfunciton
- do a figure 4 shape with the leg
- FADIR:
- Ober test
- McMurray test
Prone
- look
- feel
- bony points: iliac crest, ASIS, PSIS, SIJ, IT
- Move - hip extension
- Special tests: Femoral stretch test (opposite of striaght leg raise)
Extrapyramidal side effects
Resemblance of typical Parkinson’s disease
Hip exam
Trendelenburg test: put both hands on the ASIS and ask them to lift up one of their legs
Feel:
- bony points: pubis, pubic symphysis, inguinal ligament, ASIS, greater trochanter
- muscles, quads, adductors
Move
- Flexion, IR and ER
- Adduction
- Abduction
Special tests:
- leg length measurement (true and apparent)
true: ASIS to medial malleolus
apparent: umbiicus to medial malleolus
or just ask x-ray
- straight leg raise: pain between 30-70 degrees.
- Thomas test: test rectus femoris muscle which restricts the flattening of the other leg (one leg needs to be pulled
- FABER: femoracetabular impingement, sacroiliac joint dysfunciton
- do a figure 4 shape with the leg
- FADIR:
- Ober test
- McMurray test
Prone
- look
- feel
- bony points: iliac crest, ASIS, PSIS, SIJ, IT
- Move - hip extension
- Special tests: Femoral stretch test (opposite of striaght leg raise)
venlafaxine
SNRI
anhedonia
reduced ability to enjoy things once enjoyable
Lacunar infarct: pure motor stroke/hemiparesis
location: posterior limb of internal capsule, corona radiata, basilar part of the pons
It is marked by hemiparesis or hemiplegia that typically affects the face, arm, or leg of the side of the body opposite the location of the infarct. Dysarthria, dysphagia, and transient sensory symptoms may also be present.
lacunar infarct: ataxic hemiparesis
location: posterior limb of the internal capsule, basilar part of pons, and corona radiata, red nucleus, lentiform nucleus, SCA infarcts, ACA infarcts
It displays a combination of cerebellar and motor symptoms, including weakness and clumsiness, on the ipsilateral side of the body. It usually affects the leg more than it does the arm; hence, it is known also as homolateral ataxia and crural paresis. The onset of symptoms is often over hours or days.
lacunar infarct: dysarthria/clumsy hand
basilar part of pons, anterior limb or genu of internal capsule, corona radiata, basal ganglia, thalamus, cerebral peduncle
The main symptoms are dysarthria and clumsiness (i.e., weakness) of the hand, which often are most prominent when the patient is writing.
lacunar infarct: pure sensory stroke
contralateral thalamus (VPL), internal capsule, corona radiata, midbrain Marked by numbness (loss of sensation) on one side of the body; can later develop tingling, pain, burning, or another unpleasant sensation on one side of the body.
lacunar infarct: mixed sensorimotor stroke
thalamus and adjacent posterior internal capsule, lateral pons
This lacunar syndrome involves hemiparesis or hemiplegia (weakness) with sensory impairment on the same side
