Aquifer 4 Flashcards
1
Q
In a pap test, the ___ is rotated several times to obtain a sample from the ___. The ___ is inserted into the os and rotated 180 degrees to obtain a sample from the ___.
A
Spatula; ectocervix; cytobrush; endocervix
2
Q
Women older than ___ years who have had adequate screening within the last ___ years may choose to stop cervical cancer screening. What is adequate screening?
A
65; 10; 3 consecutive normal pap tests with cytology alone or 2 normal pap tests if combined with HPV
3
Q
When should an immunization be withheld temporarily?
A
Moderate to severe illness (high fever, otitis, diarrhea, vomiting); do not withhold in patients with recent exposures to infectious diseases or patients who have a mild lilness
4
Q
Average age of reaching menopause? Range?
A
Average - 52; Range - 40-60
5
Q
Hallmark of perimenopause?
A
Menstrual irregularity
6
Q
Most common symptoms of perimenopause/menopause?
A
Hot flashes/vasomotor symptoms
7
Q
Define full weight-bearing?
A
Ability to take 4 steps independently
8
Q
When is hearing a snap or tear diagnostically significant for an acute injury?
A
Acute knee injury (NOT acute ankle injury)
9
Q
Most common mechanism of injury of ankle sprains?
A
Combination of plantar flexion and inversion (lateral sprain)
10
Q
Why are medial ankle sprains less common than lateral ankle sprains?
A
Bony articulation between the medial malleolus and the talus
11
Q
Most frequently damaged ligaments in ankle sprains?
A
Lateral stabilizing ligaments
12
Q
What is the most easily injured ligament in the ankle?
A
Anterior talofibular ligament (posterior is the strongest of the lateral complex and rarely injured in an inversion sprain)
13
Q
What does the anterior drawer test assess?
A
Integrity of the anterior talofibular ligament
14
Q
What does the inversion stress test assess?
A
Integrity of the calcaneofibular ligament
15
Q
What does the cross-leged test assess?
A
High ankle sprains (syndesmotic injury between tibia and fibula)
16
Q
DDx - acute ankle pain following inversion injury
A
Most likely - lateral ankle sprain, peroneal tendon tear, fibular fracture, talar dome fracture, subtalar dislocation
Less likely - medial ankle sprain, syndesmotic sprain, tibial fracture, arthritis
17
Q
Lateral ankle sprain presentation
A
Acute, after trauma, pain, warmth, some swelling, NO deformity
18
Q
What is typically due to an inversion injury and may occur in conjunction with a lateral ankle sprain?
A
Peroneal tendon tear
19
Q
Peroneal tendon tear presentation
A
Persistent pain posterior to the lateral malleolus +/- swelling
20
Q
Fibular fracture presentation
A
Usually due to a fall, athletic injury, or high velocity injury; severe pain, swelling, inability to ambulate, deformity
21
Q
Typical cause of medial ankle injury? Ligament injured?
A
Forced eversion; deltoid ligament
22
Q
Syndesmotic sprain presentation?
A
Pain and disability are often out of proportion to the injury; positive ankle squeeze test
23
Q
Grade I ankle sprain
A
Stretching and/or a small tear of a ligament
Mild tenderness/swelling
Slight to no functional loss
No mechanical instability
No excessive stretching or opening of the joint with stress
24
Q
Grade II ankle sprain
A
Incomplete tear
Tenderness over involved structures, mild to moderate pain, swelling, ecchymosis
Moderate functional impairment;
Mild to moderate instability
Stretching of the joint with stress but with a definite stopping point
25
Grade III ankle sprain
```
Complete tear and loss of integrity of the ligament
Severe swelling (>4cm about the fibula) and ecchymosis
Inability to bear weight, mechanical instability
Significant stretching of the joint with stress without a definite stopping point
```
26
According to the Ottawa Ankle Rules, when are radiographs of the ankle indicated?
Pain in the malleolar zone AND either: bony tenderness along the distal 6cm posterior of the edge of either malleolus OR inability to bear weight 4 steps BOTH immediately after injury and in the ED
27
According to the Ottawa Ankle Rules, when are radiographs of the foot indicated?
Pain in the midfoot region AND either: bondy tenderness at the navicular bone or base of the 5th metatarsal OR inability to bear weight 4 steps BOTH immediately after injury and in the ED
28
Management of ankle sprains
RICE: rest for the first 72 hours/stretching after the first few days; ice several times/day for 10 minutes; compression ; elevation
+
Pain control - anti-inflammatory
29
What is the most effective compression for ankle sprains?
Semi-rigid ankle support
30
6 P's of compartment syndrome?
Pain (especially disproportionate, often the earliest sign), Pallor, Pulselessness, Paresthesia (most reliable sign), Perishing cold, Paralysis
31
Treatment of compartment syndrome?
Emergency decompression of muscle compartment via fasciotomy
32
Most low back pain resolves in ___ (time).
2-4 weeks
33
Musculoskeletal causes of back pain
Axial: degenerative disc disease, facet arthritis, sacroiliitis, ankylosing spondylitis, discitis, paraspinal muscular issues, SI dysfunction
Radicular: disc prolapse, spinal stenosis
Trauma: lumbar sprain, compression fracture
34
Non-MSK causes of back pain
Neoplastic: lymphoma/leukemia, mets, multiple myeloma, osteosarcoma
Inflammatory: RA
Visceral: endometriosis, prostatitis, renal lithiasis
Infectious: discitis, zoster, osteomyelitis, pyelonephritis, spinal or epidural abscess
Vascular: aortic aneurysm
Endocrine: hyperparathyroidism, osteomalacia, osteoporosis, paget disease
35
Most likely causes of low back pain?
Lumbar strain, disc herniation, spinal stenosis, degenerative arthritis
36
LBP worse with movement and sitting?
Mechanical cause
37
LBP radiating down the leg, numbness?
Nerve involvement
38
LBP improves when supine?
Spinal stenosis and disc herniation
39
Less likely causes of LBP (DDx)
Spinal fracture, cauda equina syndrome, pyelonephritis, malignancy, anklyosing spondylitis, spondylolisthesis, prostatitis, pancreatitis
40
Three most common categories of back pain?
97% mechanical
2% visceral
1% non-mechanical
41
Three most common causes of back pain?
Lumbar strain/sprain - 70%
Age-related degenerative joint changes in the disks and facets - 10%
Herniated disc - 4%
Less common causes of mechanical back pain - osteoporotic fracture (4%), spinal stenosis (3%)
42
Symptoms of disc herniation (classic + other)
Classic - exacerbation when sitting or bending, relief when lying or standing
Other - increased pain when coughing or sneezing, pain radiating down the leg, paresthesias, muscle weakness such as foot drop
43
LBP with radiation below the knee is more consistent with ___
Sciatica
44
LBP with pain around the buttock is more consistent with ___
Lumbar strain
45
___ can increase pain from a herniated disc
Valsalva
46
Normal ROM - lumbar flexion, lumbar extension, lateral motion
Lumbar flexion - 90 degrees
Lumbar extension - 15 degrees
Lateral motion - 45 degrees
47
Restriction and pain with lumbar flexion indicates?
Herniation, OA, muscle spasm
48
Pain with lumbar extension suggests?
Degenerative disease or spinal stenosis
49
Pain with lateral motion on the same side suggests?
Bone pathology (OA, neural compression)
50
Pain with lateral motion on the opposite side suggests?
Muscle strain
51
Difficulty with heel walk suggests ___ disc herniation; difficulty with toe walk suggests ___ disc herniation.
Heel - L5
| Toe - S1
52
Stoop test (standing to squatting) that reduces pain?
Central spinal stenosis
53
Hyperreflexia indicates?
UMN syndrome (SC compression)
54
Strength testing of hip flexion - nerves tested?
L2, 3, 4
55
Strength testing of hip abduction vs. adduction - nerves tested?
AB - L4, 5, S1
| AD - L2, 3, 4
56
Strength testing of knee extension vs. flexion - nerves tested?
Extension - L2, 3, 4
| Flexion - L5, S1, 2
57
Strength testing of ankle dorsiflexion vs. plantarflexion?
D - L4, 5
| P - S1, 2
58
Decreased strength implies?
Nerve impingement
59
Loss of sensation in the great toe? Posteriolateral foot?
Great toe - L5
Posteriolateral foot - S1
60
In the passive straight leg raise, what is the normal angle? If less than this, what should be done?
80 degrees
If <80 - either tight hamstring or sciatic nerve problem
Raise the leg to the point of pain, lower slightly, then dorsiflex the foot; if NO pain - tight hamstring
If pain radiating down the posterior/lateral thigh past the knee - positive
61
What does the crossed leg raise test?
Raise the asymptomatic leg; positive if pain in contralateral leg increases - correlates with degree of disc herniation, implies largecentral herniation
62
What does the FABER test look for?
Pathology of the hip joint or sacrum (sacroiliitis)
63
```
Test the L3 nerve root -
Reflex
Pin-Prick Sensation
Motor Exam
Functional Test
```
Reflex - Patellar
Pin-Prick Sensation - lateral thigh and medial femoral condyle
Motor Exam - extend quads
Functional Test - squat down and rise
64
```
Test the L4 nerve root -
Reflex
Pin-Prick Sensation
Motor Exam
Functional Test
```
Reflex - patellar
Pin-Prick Sensation - medial leg and media ankle
Motor Exam - dorsiflex ankle
Functional Test - heel walk
65
Test the L5 nerve root - Reflex
Pin-Prick Sensation
Motor Exam
Functional Test
Reflex - medial hamstring
Pin-Prick Sensation - lateral leg and dorsum of foot
Motor Exam - dorsiflex great toe
Functional Test - heel walk
66
Test the S1 nerve root
Reflex - achilles
Pin-Prick Sensation - posterior calf, sole of foot, lateral ankle
Motor Exam - stand on toes
Functional Test - walk on toes
67
First line treatment for acute LBP
NSAIDs, acetaminophen, muscle relaxants
68
Guidelines to order an x-ray for LBP?
History of trauma, strenuous lifting in patient with osteoporosis, prolonged steroid use, osteoporosis, <20 y/o and >70 y/o, history of cancer, fever/chills/weight loss, pain worse when supine or severe at night, spinal fracture tumor, or infection
69
How is an EMG and nerve conduction studies used in back pain evaluation?
Can confirm the existence of radiculopathy and exclude other peripheral nerve disorders; time sensitive - nerve root abnormalities may not be reliably detectable until 3 weeks after onset of symptoms
70
Joints involved in RA vs. OA
RA - hands and feet
| OA - knees, hip, back
71
Normal ROM of knee flexion and extension?
Flexion - 135
| Extension - 0
72
Lachman's test?
Assesses stability of ACL
73
Anterior and posterior drawer signs?
ACL and PCL, respectively
74
Valgus and varus stress tests?
Valgus - MCL
| Varus - LCL
75
McMurray test?
Medial and lateral menisci; low sensitivity and specificity for tears
76
DDx - knee pain?
Patellofemoral pain syndrome, iliotibial band tendonitis, ACL, MCL, or LCL sprain, meniscal tear, septic arthritis, OA, gout/pseudogout, popliteal cyst
77
Key features of patellofemoral pain syndrome
Dx of exclusion with anterior knee pain; theater sign - pain worsens after prolonged sitting
78
Key features of iliotibial band tendonitis?
Lateral knee pain
| No history of trauma (overuse injury more likely), no effusion
79
Compare features of ACL, MCL, and LCL sprain
ACL - general knee pain; non-contact deceleration forces; moderate to severe joint effusion, swelling with 2 hours of pop
MCL - medial joint line pain; misstep or collision, immediate onset of pain
LCL - lateral joint line pain; varus stress; immediate onset of pain
80
Which is more common - MCL or LCL sprain?
MCL
81
Key features of meniscal tear?
Medial or lateral joint line pain, history of sudden twisting injury
82
Crepitus on exam?
OA
83
Gout vs. pseudogout?
Gout - negatively birefringent rods
Pseudogout - positively birefrigent rhomboids
84
DDx - chronic knee pain?
Knee sprain, OA, RA, gout/pseudogout, psoriatic arthritis
85
Leading cause of disability in the US?
Osteoarthritis
86
What is the Merchant's View and what is it used for?
Imaging top view of the knee obtained with the knee bent at a 45-degree angle, showing the alignment of the patella in the groove of the femur; evaluates the patellorfemoral joint
87
First line analgesic for short and long-term treatment of mild to moderate knee pain?
Acetaminophen (up to 4g/day divided)
88
Tinel's sign?
Tap over the median nerve at the wrist to reproduce symptoms - 36% sensitive, 75% specific for carpal tunnel
89
Phalen's test?
Flex wrist by having the patient place dorsal surfaces of hands together in front for 30-60 seconds to reproduce symptoms (57% sensitive, 58% specific for carpal tunnel)
90
Three most helpful findings in predicting the electrodiagnosis of carpal tunnel?
Hand symptom diagrams (symptoms in at least 2 of digits 1, 2, and 3, or with palmar symptoms as long as not confined only to the ullnar aspect)
Hypalgesia (decreased pain sensitivity)
Weak thumb abduction strength testing
91
Loss of active and passive ROM of shoulder vs. loss of active ROM only?
Both - joint disease more likely
Active only - muscle tissue issues more likely
92
Origin, Attachment, and Function of Supraspinatous?
Origin - superior and posterior aspect of the scapula
Attachment - greater tuberosity of the humerus
Function - assists with raising of the arm (abduction)
93
Origin, Attachment, and Function of Infraspinatous?
Origin - Lower and posterior aspect of the scapula
Attachment - greater tuberosity
Function - assists with external rotation of the shoulder
94
Origin, Attachment, and Function of Teres minor?
Origin - below infraspinatous
Attachment - greater tuberosity
Function - assists the infraspinatous in external rotation of the shoulder
95
Origin, Attachment, and Function of Subscapularis?
Origin - anterior of the scapula
Attachment - lesser tuberosity of the humerus
Function - assists with internal rotation of the shoulder
96
List the three anatomic stabilizers of the shoulder joint
Labrum (increases the articulating surface area and depth of the glenoid fossa)
Rotator muscle group (essential dynamic stabilizer of shoulder joint)
Glenohumoral or capsular ligaments (support and static stability to the shoulder joint)
97
Between 4-6 years of age, a child needs what booster shots, assuming they received all previous vaccines and are otherwise healthy?
DTaP, IPV, MMR, Varicella
98
Vaccines and doses children should receive through age 6
```
2 HepA
3 HepB
5 DTAP
4 IPV
2 MMR
2 Varicella
3 or 4 Hib
4 PCV13
2 or 3 RotaV
```
99
What are the general adult immunizations?
Tetanus - TDaP should replace a single dose of Td for adults 19-64 who have not previously received Tdap, then Td every 10 years
Pneumococcal - 1 dose if >65 years
Influenza - 1 dose annually
Zoster - 1 dose if >60 years
Shingrix (recombinant zoster) - every adult age 50 (2 doses); adults >60 who received the live vaccine should be re-vaccinated
100
Which children get the flu shot?
All persons 6+ months without contraindications
101
True or false - the prophylactic administration of acetaminophen has been associated with decreased antibody concentrations for some vaccine antigens.
True, although all concentrations remain in the protective range
102
Empiric treatment for uncomplicated UTI?
TMP/SMX
103
Most common bacterial STI in the US?
Chlamydia
104
Presentation of chlamydia and gonorrhea?
Dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, breakthrough bleeding; either may be asymptomatic
105
Dx chlamydia?
NAAT of urine, endocervical sample, or urethral sample
106
Dx gonorrhea?
NAAT of urine, endocervical sample, urethral sample; culture rectal or pharyngeal specimens
107
Dx trichomonas?
Saline wet mount, rapid antigen testing, or culture
108
Presentation trichomonas?
Vaginal discharge with odor or itching; asymptomatic
109
___% of women will have breast cancer before 80 years old.
1/8
110
Non-modifiable risk factors for breast cancer?
Family history of breast cancer in a first degree relative, prolonged exposure to estrogen (menarche before 12, menopause after 45), genetic predisposition (BRCA), advanced age, female sex, increased breast density
111
Other hormonal risk factors for breast cancer?
Advanced age at first pregnancy, DES exposure, hormone therapy
112
Environmental risk factors for breast cancer?
Therapeutic radiation, obesity, excessive alcohol intake
113
Decreased risk for breast cancer?
Pregnancy at an early age, late menarche, early menopause, high parity, SERMs, NSAIDs, aspirin use
114
Relationship of smoking to breast cancer?
No increase in risk
115
What are characteristics of a lump that increase the likelihood of breast cancer?
Single, hard, immobile lesion of approximately 2cm or larger with irregular borders
116
Diagnostic tests to evaluate a breast lump?
If it feels cystic - aspiration and cytology
Solid - mammogram
Unsure - U/S can distinguish solid from cystic
117
Physiologic causes of nipple discharge?
Pregnancy, excessive breast stimulation
118
Pathologic causes of nipple discharge?
Prolactinoma, breast cancer, hormone imbalance, injury/trauma, breast abscess, medications (antidepressants, antipsychotics, some antihypertensives, opiates)
119
Risk factors for osteoporosis?
Low estrogen states (early menopause, prolonged premenopausal amenorrhea, low weight, BMI), lack of physical activity, inadequate calcium intake, family history of osteoporosis/osteoporotic fracture (especially hip fracture in a first degree relative), personal history of previous fracture as an adult, cigarette smoking, white race, corticosteroid use, heavy alcohol use, low body weight
120
What is the single best predictor of low bone mineral density?
Low body weight (<70 kg)
121
True or false - obesity is associated with a higher estrogen level and can be protective against menopausal symptoms and osteoporosis
True
122
Premenopausal women need ___mg calcium daily; post-menopausal women need ___mg.
1000; 1200
123
Components of fall prevention?
Checking and correcting vision and hearing
Evaluating any neurologic problems
Reviewing prescription meds for side effects affecting balance
Providing a checklist for improving safety at home
124
List the treatment options for osteoporosis and when they are used.
1. Bisphosphanates
2. Parathyroid hormone - approved for those with osteoporosis at high risk for fracture
3. Raloxifene - used if bisphosphonates are not tolerated
4. Calcitonin - less effective
125
MOA - bisphosphanates?
Potent inhibitors of bone resorption; reduce bone turnover, resulting in increased bone mineral density; decrease risk of vertebral and non-vertebral fractures
126
Raloxifene, a SERM, only works to prevent ___ fractures.
Vertebral
127
Common causes of headache (3)
1. Tension
2. Migraine
3. Medication overuse
128
Serious causes of headache (4)
Meningitis, brain tumor, intracranial hemorrhage, TBI (concussion)
129
Compare severity of migraines, tension, and cluster headaches
M - moderate to severe
T - mild to moderate
C - severe
130
Compare associated symptoms of migraines, tension, and cluster headaches
M - N/V, photophobia, hyperacusis; aura
T - photophobia or hyperacusis
C - rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, ptosis
131
Compare quality of pain of migraines, tension, and cluster headaches
M - pulsating; can be unilateral
T - pressing, tightening, bilateral
C - severe, unilateral, orbital, peri/supraorbital temporal
132
Compare aggravating factors of migraines, tension, and cluster headaches
M - physical activity
| T - not worsened by physical activity
133
Compare duration of symptoms of migraines, tension, and cluster headaches
M - 4-72 hours
T - 30 minutes to 7 days
C - 15-180 minutes
134
Compare # of episodes needed for diagnosis of migraines, tension, and cluster headaches
M - 5
T - 10
C - 5
135
Presentation of meningitis?
Headache with fever, mental status change, stiff neck
136
Presentation of intracranial hemorrhage?
Sudden onset headache, severe headache, recent trauma, elevated BP
137
What are the features of medication overuse headache (aka analgesic rebound headache?
Mild to moderate severity, diffuse bilateral headaches that occur almost daily and are often present on first waking; often aggravated by mild physical or mental exertion; can be associated with restlessness, nausea, forgetfulness, and depression; chronic use of any analgesic can cause; may improve slightly with analgesics, but worsen when medication wears off
138
Dx criteria for medication overuse headache
>15 headaches/month
Regular overuse of an analgesic for >3 months
Development or worsening of a headache during medication overuse
Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused med
