COMLEX Flashcards
tetralogy of fallot example (ToF)
presentation: cyanotic episodes (tet spells) or symptoms of HF (failure to thrive)
diagnosis: “boot-shaped heart” on CXR
Patient Self-Determination Act
- Inform pt of their right to be involved in medical decisions
- inform pts of their right to create and execute an advance directive
- Ask pts whether they have an advance directive
- Document the pts advance directives in their medical records
Viscerosomatics for thyroid
T1-4; these are also reflective of heart, upper esophagus, upper lung and head and neck pathologies
SSRIs
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Citalopram
Escitalopram
multiple sclerosis
relapsing and remitting course of signs/symptoms including sensory disturbances in limbs/face, unilateral vision loss, acute motor weakness, diplopia and monocular visual loss w blurring; classic diagnostic feature is MRI w presence of *periventricular plaques (Dawson fingers)
Medicare and medicaid
MOAi contraindications
monoamine oxidase inhibitor (MOAi) such as phenelzine irreversibly blocks monoamines (serotonin, NE and dopamine) from degradation; when interacts w tyramine (contains high levels of wine and cheese) increased the end-organ damage (papilledema)
Wine and cheese MUST be avoided w this medication
Schistosomiasis
Schistosoma hematobium lives in freshwater snails; ppl become infected mostly by swimming in lakes in developing nations; eosinophilia, hematuria, and lower abdominal pain (bladder); Praziquantel is the drug of choice, affects the permeability of the membrane
ACL tear
anterior cruciate ligament (ACL) commonly occurs in athletes who sustain twisting to hyper-extension of the knee; hear a “pop”; originates at the *posterior aspect of the lateral femoral condyle and inserts at the anterior-medial aspect of the tibial plateau
pancreatic cancer
presents w epigastric pain radiating to the back, left supraclavicular lymphadenopathy and weight loss; both carcinoembryonic antigen (CEA) and CA19-9 antigens are most likely elevated; a CT scan will show a pancreatic mass
Viscerosomatics of diverticulitis
T12-L2
dependent personality disorder tx
1st line tx is psychotherapy; medications may be added for pts w severe dysregulation
Onchocerciasis
infections caused by Onchocerca volvulus; a parasite transmitted by the black fly which is found in African, Yemen and parts of South America; presents a pruritus, skin atrophy and subcutaneous nodules as well as eye pain, inflammation and progressive vision loss (river blindness); tx of choice is ivermectin an anti-parasitic agent that induces neuromuscular paralysis in the parasite by inhibiting GABA receptors
plan-do-study-act (PDSA) cycle
a quality improvement model used concurrently to analyze the success or failure of interventions
root-cause analysis
when a medical error occurs, the 1st step in this investigation is to interview all the people involved in the error
primary biliary cholangitis (PBC)
PBC is an autoimmune disorder characterized by T-cell mediated destruction of small interlobular bile ducts which leads to cholestasis and eventually hepatic cirrhosis and liver failure; anti-mitochondrial antibodies are elevated (serologic hallmark); also associated w CREST syndrome
Autoimmune diseases affecting the liver
Phase 1 clinical trial
examine dosing and safety in a small group of healthy subjects
PPV
PPV depends on the prevalence of the disease within the population; a pt w a (+) screening test is more likely to actually have the disease if the pt belongs to a population w a high disease prevalence
exhalation rib dysfunction
named for where it likes to go: exhalation rib dysfunction of ribs 3-5 on the R; BITE = tx the top rib by asking the pt to isometrically contract his pectoralis minor muscle during inhalation
DiGeorge syndrome
abnormal 3rd and 4th pharyngeal pouch development plays a key role in DiGeorge syndrome
papillary thyroid carcinoma
most common thyroid malignancy which typically presents as a thyroid nodule, microscopic evaluation will show hollow, large nuclei w a clear center known as “ground-glass” nuclei as well as psammoma bodies (laminar, calcific, rounded, basophilic lesions)
piriformis syndrome tenderpoint
located at the midpoint between the inferior lateral angle (ILA) of the sacrum and the greater trochanter
phase 3 clinical trial
used to determine a drug’s non inferiority, equivalence, or superiority to the existing standard-of-care treatment
neonatal hypoglycemia
occurs as a result of persistent fetal hyperinsulinemia
LSD ingestion
hallucinogen that results in the alteration of sensory perception, mood, and thought patterns; pts will experience heightened perception of sensation, a distorted sense of time, euphoria and *synesthesia - blending of the senses (hearing colors or seeing sound); receptor affected (5-HT2A)
Viscerosomatics of the pancreas
T6-10; commonly found in diabetic pts
Niemann-Pick disease type A
“No Man Picks his nose w his Sphingers” (sphingomyelinase); deficiency of acid sphingomyelinase
Niemann-Pick vs Tay-Sachs
chylothorax
milky fluid withdrawn during a thoracentesis is indicative for chylothorax or the presence of increased triglycerides within the pleural space; caused by leakage of lymphatic fluid from the thoracic duct; most commonly due to lymphoma or trauma caused by thoracic surgery
schizotypal personality disorder tx
1st line tx is psychotherapy; this can improve trust, interpersonal functioning and adherence to tx
primary disease prevention
includes measures that reduce disease incidence; vaccinations, wearing sunscreen and using condoms
corneal reflex
Quadriceps (Q) angle
increased Q angle - genu valgum
decreased Q angle - genu varum
Nephrolithiasis
calcium oxalate stones are the most common composition of kidney stones caused by hypercalcemia such as hyperparathyroidism or increased oxalate excretion; appear envelope-shaped as shown in the image
Mobitz type I AV block
Wenckebach; a type of second-degree AV block that is characterized by a PR interval that becomes longer before every QRS until a beat is dropped”
“longer, longer, longer, drop; that’s the case w Wenckebach”
usually asymptomatic and no tx is needed
chronic lymphocytic leukemia (CLL)
most common type of leukemia in adults (>60) in the Western world; pts presents w typical “B” symptoms (weight loss, fatigue, fevers and drenching night sweats);
acute lymphocytic leukemia (ALL)
most commonly in children and can arise from either B- or T-cel lineages, but B is most common
chronic myelogenous leukemia (CML)
proliferation of myeloid cells; associated w Philadelphia chromosome t9;22 a fusion chromosome that occurs from reciprocal translocation between BCR and ABL genes
hairy cell leukemia (HCL)
uncommon; presents in adult males w splenomegaly and cytopenias; B-cells have characteristic hair-like cytoplasmic projections and stain (+) for tartrate-resistant acid phosphatase
Hodgkin lymphoma
“Reed-Sternberg cells” would be seen in the involved tissue
PTHrP
caused by squamous cell lung carcinoma
viscerosomatics in acute hepatitis
warm and boggy paraspinal tissues of T5-9 (upper GI)
methamphetamine intoxication
a stimulant that can lead to disphoresis, HTN, tachycardia, severe agitation and psychosis pts may abruptly develop severe agitation and use extreme violence; maladaptive behavior, weight loss, perspiration, labile blood pressure and pupillary dilation can also occur
conditional probability
“if.. then what” problem; calculate the fraction of pts who survived the end of the first year (240) and then the end of the second year (180)
180/240=0.75 (75%)
Courvoisier sign
Alport syndrome
genetic disorder with renal, auditory and ocular manifestations; aka hereditary nephritis; X-linked inheritance defect in type IV collagen, mostly the alpha 3,4,5 subunits
noncompetitive, irreversible antagonist
decreases the maximum reaction velocity (Vmax)
McArdle disease
deficiency of muscle phosphorylase which is an enzyme responsible for the release of glucose from glycogen stores in muscles; management is oral ingestion of simply carbs, such as sucrose, before exercise
Boarderline personality disorder
part of the Cluster B personality disorder; pt is deploying splitting, which is an immature defense mechanism (seeing “all good” or “all bad”) as exemplified by “love of my life” to “worst person ever”
near miss
an event that could have had an adverse pt consequence but did not
Chvostek sign
facial muscle contractions when tapping the skin overlying the facial nerve; specific for hypocalcemia
trichomonas vaginalis
motile protozoan
cross-sectional study
battery
intentional and unauthorized (without consent) contact
cranial rhythmic impulse (CRI)
normal at 10-14 cycles per minute
somatic symptom disorder
anxiety about health w significant somatic symptoms without evidence of deception
differential diagnosis of multiple somatic complaints
anterior L1 tenderpoint
located medial to the anterior superior iliac spine (ASIS)
anterior L2 tenderpoint
located medial to anterior inferior iliac spine (AIIS)
anterior L3 tenderpoint
located lateral to anterior inferior iliac spine (AIIS)
anterior L4 tenderpoint
located inferior to anterior inferior iliac spine (AIIS)
anterior chapman point for the prostate
posterior margin of the iliotibial band
Whipple disease
diarrhea, steatorrhea and joint pain caused by Tropheryma whippelii; diagnosed by PAS (+) macrophages within the digestive tract; commonly found in sewage
exhalation somatic dysfunctions of ribs 6-10 on the R with MET
encouraging inhalation at rib 6 using the serratus anterior
prospective cohort study
ask whether a given risk factor will increase the likelihood of the disease
Edwards syndrome (trisomy 18)
VSD is the most common cardiac anomaly
secondary syphillis
a rash involving almost always the palms and soles
Thompson test
muscles of the posterior leg include the gastrocnemius, soleus, and plantaris are all innervated by the tibial nerve (plantar flexion); distally their tendons form the achilles tendon which can be evaluated for injury by performing the Thomspon test (squeezing the calf of the suspected leg while pt lies prone)
Group B Strep (GBS)
Streptococcus agalactiae is a gram (+) cocci that grows in chains; catalase (-), beta-hemolytic and bacitracin resistant
subarachnoid hemorrhage (SAH)
often presents as acute onset of “worst HA of my life”; non-traumatic SAH is commonly due to a ruptured aneurysm; brain CT shows hyper density (white area) in the suprasellar cistern
sacral tenderpoints
posterior S5 tenderpoint
medial and superior to the inferior lateral angle on each side
Zidovudine
a competitive nucleoside reverse transcriptase inhibitor (NRTI) uses in HIV-1 and HIV-2; Zidovudine can cause bone marrow suppression, therefore leading to neutropenia and/or anemia
sacral tenderpoints
Zidovudine
a competitive nucleoside reverse transcriptase inhibitor (NRTI) uses in HIV-1 and HIV-2; Zidovudine can cause bone marrow suppression, therefore leading to neutropenia and/or anemia
primary biliary cholangitis (PBC) associated with CREST syndrome
Zidovudine
a competitive nucleoside reverse transcriptase inhibitor (NRTI) uses in HIV-1 and HIV-2; Zidovudine can cause bone marrow suppression, therefore leading to neutropenia and/or anemia
primary biliary cholangitis (PBC) associated with CREST syndrome
PBC is an autoimmune disorder characterized by T-cell mediated destruction of small interlobular bile ducts which leads to cholestasis and eventually hepatic cirrhosis and liver failure; anti-mitochondrial antibodies are elevated (serologic hallmark)
primary biliary cholangitis (PBC) associated with CREST syndrome
PBC is an autoimmune disorder characterized by T-cell mediated destruction of small interlobular bile ducts which leads to cholestasis and eventually hepatic cirrhosis and liver failure; anti-mitochondrial antibodies are elevated (serologic hallmark)
amaurosis fugax
acute and painless onset of monocular visual loss due to transient retinal ischemia originating from atherosclerotic carotid artery disease; pts describe “visual loss as a dark curtain that falls down over their eye”
sublimation
a mature defense mechanism in which socially inappropriate desires are replaced by something more acceptable or productive
Hartnup disease
deficiency of tryptophan; precursor to nicotinamide (VitB3) therefore leads to pellagra = 4D’s: dermatitis, diarrhea, dementia and death
automatic implantable cardioverter defibrillator (ACID) placements
purpose of a ACID is to monitor the heart for an arrhythmia and to provide an electrical shock to make the heart beat normally again; ACIDs are life-sustaining therapies, however prior to placement physicians should discuss under what circumstances would the pt like the ACID to be deactivated
Clozapine
agent used to tx schizophrenia; serotonin 2A and dopamine receptor antagonist; adverse effect of agranulocytosis; MONITOR CBC
rubeola (measles)
begins w generalized symptoms (fever, malaise) accompanied by the 3C’s cough, coryza, conjunctivitis; *Koplik spots (small irregular red spots w central gray/white area)
-Subacute sclerosing panencephalitis (SSPE) is a potential delayed complication 7-10 yrs pot infection
-Encephalitis occurs 1-14 days later
-Acute disseminated encephalomyelitis (ADEM) occurs within 2 weeks
Adson test
the pts radial pulse is palpated, the arm is extended at the elbow and the shoulder is extended, externally rotated and abducted; pts then turn their head to the ipsilateral arm; a (+) test occurs when the pulse significantly decreases or disappears; used in pts suspected in suffering from *thoracic outlet syndrome
Nocardia asteroides
a gram (+) weakly acid-fast bacterium found in soil; causes bronchitis, pneumonia, lung abscesses in immunocompromised pts; tx of choice is trimethoprim-sulfamethoxazole
Tay-Sachs disease (tay-saX)
excess storage of the cell membrane glycolipid GM2 ganglioside within cell lysosomes due to a deficiency in B-heXosaminidase A (HeX A)
accountable care organization
an integrated group of multi specialty physicians that care for a defined population, coordinating pt-centered care by focusing on a team approach, using the same electronic health record system and following the same evidence-based guidelines and quality incentives
Swiss cheese model of system failure
describes errors that occur because of both active and latent failure; when process failure or system error (holes in the cheese) in each protective system process (slice of cheese) line up, an adverse effect reaches the pt; the risk is decreased when multiple systems are layered (like slices of cheese) preventing an error from reaching the pt
Anterior thoracic counterstain tenderpoints
T12 anterior tenderpoint
located on the inner ala of the ilium in the midaxillary line b/l
T11 anterior tenderpoint
located halfway between the umbilicus and pubic symphysis
T10 anterior tenderpoint
located 1/4th of the distance from the umbilicus to the pubic symphysis
T9 anterior tenderpoint
located 1/3 of the distance from the tip of the typhoid to the umbilicus
treatment for serotonin syndrome
cyproheptadine which antagonizes serotonin receptors; serotonin syndrome characterized by a triad: cognitive impairment, autonomic instability and somatic effects
Homan test
a (+) Homan sign is present when there is calf pain upon forceful and abrupt dorsiflexion of the foot at the ankle while the knee is extended; used to evaluate the presence of a lower extremity DVT
pyridostigmine
medication of choice for myasthenia gravis; can cause bronchoconstriction and exacerbate asthma and reactive airway disease
cranial vault hold
thumbs: rest above the surface of the cranium
index: greater wings of the sphenoid
middle fingers: pre-auricular
ring fingers: mastoid process
pinky: squamous portion of the occiput
parental refusal of essential treatment for a minor
if parents refuse essential, but not emergent treatment for their child, the physician should pursue a court order to allow for tx of the child against the parents wishes
inhalation anthrax
Anthrax is caused by Bacillus anthracis a gram (+) spore-forming rod; when exposure is suspected, post-exposure prophylaxis (PEP) should be started immediately with a 3-dose series of anthrax vaccine and a 60-day course of ciprofloxacin or doxycycline
COBRA
Consolidated omnibus budget reconciliation act (COBRA); this law helps to prevent people from suddenly losing health coverage when transitioning between jobs or when work hours are cut
GINA
Genetic information nondiscrimination act (GINA) made it unlawful employment practice for an employer to discriminate based on genetic information or to request genetic information
Chagas disease
consists of facial edema and a nodule (chagoma) near the bite coupled w fever, lymphadenopathy and hepatosplenomegaly; drug of choice is *nifurtimox which kills Trypanosome cruzi trypomastigotes in the blood
neostigmine
pt underwent surgery and having symptoms of neuromuscular blockage (unable to lift head) and was given a reversal agent (neostigmine); acts as cholinergic and can cause bradycardia, bradypnea, and bronchoconstriction leading to hypoxia
Vibrio parahaemolyticus
cause of watery diarrhea from eating undercooked seafood, most commonly oysters
fetal circulation
2 umbilical arteries which branch from the internal iliac arteries which carry deoxygenated fetal blood to the placenta; blood leaves the placenta via a single umbilical vein and enters the fetal portal circulation
Haloperidol
a typical antipsychotic commonly used to tx schizophrenia and is notable for side effects of *hyperprolactinemia due to its dopamine-antagonist effects; increased prolactin levels may cause abnormal breast swelling and even lactation
T4 corresponds with the level of the nipple!
lateral ankle sprain
pt has posterior fibular head causing entrapment of the common perineal (fibular) nerve; lateral ankle sprain, as the lateral malleolus of the fibula is driven anteriorly and the fibular head is driven posteriorly
tricyclic antidepressant (TCA) toxicity
Amitriptyline inhibits the uptake of NE and serotonin at the synapse; in OD pts can convulse and progress to coma; can be thought of the 3 C’s: Cardiotoxicity (wide QRS complexes), anticholinergic and convulsions
disseminated gonococcal infection (DGI)
a STI characterized by a triad: migratory polyarthritis, tenosynovitis and dermatitis; caused by Neisseria gonorrhoeae, a gram (-) diplococci and is the most common cause of septic arthritis in the US; tx is daily IV ceftriaxone for 1 week and doxycycline (tetracycline) - added for common co-infection of clamydia
OMM for costochondritis
when you have linked rib and thoracic SD, it is best to first direct your tx toward the thoracic segment
target muscles for treating exhalation rib SD
stages of sleep
NREM sleep
sleep spindles and K-complexes
uncal herniations
occurs when the medial aspect of the temporal lobe (uncus) herniates across the tentorium cerebelli; initially results in ptosis, mydriasis, lateral strabismus and c/l hemiparesis of the extremities
appropriate technique for sphenobasilar symphysis (SBS) compression
compressed 4th ventricle (CV4) technique, also known as bulb decompression and is an appropriate technique when there is diminished CRI from normal 10-14 cycles
paroxysmal supraventricular tachycardia (PSVT)
ECG findings of a narrow complex tachycardia w P waves buried within or very rarely visible before the QRS complex; *adenosine (Gs) can abort PSVT (bronchoconstriction side effect)
Hunter syndrome
deficiency in *iduronate-2-sulfatase
Apgar Scoring System
a method used to assess the clinical status of a newborn shortly after birth; appearance, pulse, grimace, activity and respiration
brachial plexus posterior cord injury
posterior cord gives rise to axillary and radial nerves; axillary nerve innervates the deltoid muscle (shoulder abduction) and radial nerve control extension at the elbow, wrist and fingers
histocompatibility antigen associated with multiple sclerosis
HLA-DRB1
half life calculation
Gaucher disease
deficiency of lysosomal B-glucocerebrosidase which leads to the accumulation of lipid-laden macrophages (Gaucher cells) in the spleen, liver, bone marrow and other tissues/organs
allodynia
a non-painful stimulus evoking a painful response
hyperalgesia
pain out of proportion to the painful stimulus
hyperpathia
greater stimulus us required to get a neural response, but once evoked, the response goes to maximum intensity
viscero-somatic reflex
visceral pathology causes somatic response ex: MI causing left sided jaw/arm pain (shared T1-4)
viscero-visceral reflex
visceral pathology causes viscera; response; ex: gastric distension causing increased lower intestine motility
somato-visceral reflex
somatic pathology causes visceral response ex:tissue injury in muscular distribution of T1-5 worsening COPD
somato-somatic reflex
somatic pathology causes somatic response ex: torn bicep causes pain in the arm
head and neck viscero-somatic levels
T1-4
heart and lung viscero-somatic levels
T1-4
foregut viscero-somatic levels
T5-9 (stomach, pancreas, liver, gallbladder and spleen)
midgut viscero-somatic levels
T10-11 (distal 1/2 duodenum, small intestine, ascending colon, hepatic flexure and 2/3rds of transverse colon)
hindgut viscero-somatic levels
T12-L2 (distal 1/3rd of transverse colon, splenic flexure, descending colon, sigmoid colon and rectum)
appendix viscero-somatic levels
T12
upper extremity viscero-somatic levels
T2-8
lower extremity viscero-somatic levels
T11-L2
upper ureter and gonads viscero-somatic levels
T10-T11
lower ureter and all else GU viscero-somatic levels
T12-L2
foregut ganglia
T5-9; celiac sympathetic ganglia and vagus parasympathetic ganglia
midgut ganglia
T10-11; superior mesenteric sympathetic ganglia and vagus parasympathetic ganglia
hindgut ganglia
T12-L2; inferior mesenteric sympathetic ganglia and *pelvic splanchnic parasympathetic ganglia
cervical nerve roots
exit ABOVE the corresponding cervical vertebrae; C8 exits BELOW C7 and above T1
“7 UP, 8 down”
referred pain of C3, C4, C5
phrenic nerve refers gallbladder/diaphragm pain to the R shoulder
Scalene muscles and rib attachments
anterior and middle attach to rib 1
posterior scalene attaches to rib 2
Sternocleidomastoid muscle action
sidebending TOWARD and rotation away; pathology = torticollis
cervical vertebrae motions
“the cervical spine is the First Real Segment”
OA = Flexion & extension “type-1-like” opposite
AA = Rotation only
C2-C7 = Sidebending “type-2-like” same
ligaments weak in Down syndrome and Rheumatoid arthritis
alar and transverse ligaments
cervical movement and vertebral artery insufficiency
cautious w cervical *extension due to vertebral artery insufficiency
Whiplash injuries and poor prognosis
loss of cervical spine lordosis or loss of consciousness at the scene of an accident
Orientation of facets
“BUM BUL BM”
cervical = BUM = backwards, upwards, medial
thoracic = BUL = backwards, upwards, lateral
lumbar = BM = backwards, medial
atypical ribs
Ribs w “1” or “2” in their # (ribs 1, 2, 11 and 12)
Rib 1 - only one facet, two grooves for subclavian vessels
Rib 2 - rough area for serratus anterior muscle
Rib 11 - only one facet
Rib 12 - no neck, only one facet
Rib motions
Ribs 1-5 pump handle - AP diameter increases w inhalation
Ribs 5-10 bucket handle - transverse diameter increases w inhalation
Ribs 11-12 caliper motion “down and out” motion w inhalation
treating rib exhalation dysfunctions w muscles
Rib 1 - anterior and middle scalene
Rib 2 - posterior scalene
Ribs 3-5 - Pec minor “pec” w 3 letters
Ribs 6-9 - Serratus anterior (S=six and S=serratus)
Ribs 11-12 - Lats (11 = lowercase L)
thoracic vertebrae and the rule of 3’s
T1-3 = SP/TP in-line
T4-6 = TP 1/2 segment ABOVE SP
T7-9 = TP 1 full segment ABOVE SP
T10 = TP 1 full segment ABOVE SP
T11 = TP 1/2 segment ABOVE SP
T12 = SP/TP in-line
Surgical neck fractures of the humerus
injury of the axillary nerve; flattened deltoid, loss of arm abduction and loss of sensation over deltoid
radial nerve injury
axillary crush (crutches or Saturday night palsy) or a midshaft fracture; wrist drop, decreased grip strength and loss of sensation over posterior arm/dorsal arm
Supracondylar fracture of the humerus
median nerve injury; ape hand and Pope’s Blessing, loss of wrist flexion, thumb opposition, loss of 2nd and 3rd lumbricals, loss of sensation over thenar eminence, dorsal and palmar aspect of lateral 3.5 digits
ulnar nerve injury
Hook of hamate fracture “fall on outstretched hand” or medial epicondyle injury; ulnar claw, radial devaition of wrist during flexion, loss of wrist flexion, AB/ADduction of digits, loss of sensation over medial 1.5 digits and hypothenar eminence
clavicle
the AC and SC joints move in OPPOSITE; if one goes up the other goes down
Carrying angle
where is the ulna moving?
Ulna ABducts (moves away) carrying angle INCREASES
Ulna ADducts (moves towards) carrying angle DECREASES
*wrist and ulna move in OPPOSITES
*VaLgus = Larger angle = increases
*VaRus = Reduced angle = decreases
Radial Head Dysfunction
supination of hand = ANTERIOR radial head (likes to go anterior)
Pronation of hand = POSTERIOR radial head (likes to go posterior)
Thoracic Outlet
1st rib, anterior and middle scalenes, clavicle, pectoralis minor
*pts with a cervical rib (accessory rib)
Rotator cuff muscles
SITS
Supraspinatus = ABduction
Infraspinatus = External rotation
Teres minor = External rotation
Subscapularis = Internal rotation
Winged scapula
protrusion of scapula into abnormal orientation; serratus anterior/long thoracic nerve involvment (C5-7)
Carpal Tunnel Syndrome
entrapment of the median nerve in the Flexor Retinaculum; risk factors = obesity, pregnancy, RA, hypothyroidism and manual labor; diagnosis w Tinel, Prayer, Phalen tests; tx w NSAIDs, splinting, OMT and surgery
Scaphoid Fracture
most common carpal bone fracture “fall on outstretched hand”; proximal scaphoid risk of avascular necrosis (dorsal carpal branch/radial nerve); diagnosis w series of X-rays but if negative and there is high suspicious *get an MRI
Golfer’s elbow
Medial epicondylitis; common insertion point for flexor muscle tendons; “forward throws”
Tennis elbow
Lateral epicondylitis; common insertion point for extensor muscle tendons; “backwards throw”
ACL
ligament that runs from the posteromedial aspect of the lateral femoral condyle to anteromedial aspect of the tibia; stabilizes anterior motion; “popping” sound; diagnose w anterior drawer test and Lachman test (more sensitive)
PCL
ligament that runs from the lateral aspect of medial femoral condyle to fovea centralis; largest intra-articular ligament in the knee; stabilizes posterior motion; diagnose w posterior drawer test
MCL
*most commonly injured knee ligament; ligament that runs from the femoral medial epicondyle to the tibial medial condyle; inferiorly boarded by *Pes Anserinus; injury excessive in valgus stress
Foot/Ankle
ankle sprain - anterior talofibular ligament (ATF) always tear first
type I - ATF injured (1 ligament)
type II - 2 ligaments injured
type III - 3 ligaments injured
Foot/Ankle Pronation
Dorsiflexion, Eversion and ABduction (stable)
Foot/Ankle Supination
Plantarflexion, Inversion and ADduction (unstable = frequent sprains)
Fibular Mechanics and Dysfunction
Spondylosis
refers to degenerative spine usually caused by age-related or use-related “wear and tear”; findings = osteophytes, disc space narrowing, pain w movement; risk factors = obesity and overuse
Spondylolisthesis
refers to anterior slippage of one vertebrae relative to the one beneath it; diagnosed w a *lateral x-ray which shows “step off” point
Spondylolysis
refers to fracture in the pars interarticularis in one of the vertebrae; diagnosed w an *oblique x-ray which shows “scotty dog” sign; pars interarticularis fracture (the neck/collar)
Musculoskeletal Strain
refers to an overuse or traumatic injury causing muscular inflammation; negative straight leg test; tx w NSAIDs/OMT **NO MRI for 4-6 weeks (this is a unnecessary test/pt cost)
Degenerative Joint Disease
osteoarthritis “wear and tear” leading to inflammation; findings = joint space narrowing and osteophytes; tx w NSAIDs/OMT
Lumbar Disc Herniation
intervertebral disc protruding/bulging through the annulus fibrosis; findings = (+) straight leg test; most common @ L5/S1 (S1 nerve root injury); usually posterolateral displacement due to weakness of posterior longitudinal ligament
Lumbar Spinal Stenosis
narrowing of central spinal canal leading to spinal nerve impingement; “shopping cart injury”; pain worse w extension and BETTER w flexion; can also observe a wide gait
Cauda Equina Syndrome vs Conus Medullaris Syndrome
both require emergent surgical consultation
Referred low back pain
Ankylosing Spondylitis
seronegative spondyloarthropathy (all serologies are negative); findings of sacroilitis and Mennell sign; associations of uveitis, enthesitis, restrictive pulmonary disease, IBD; associated w HLA-B27; morning stiffness/pain that improves w motion; tx is *indomethacin
Scoliosis
4 types = idiopathic (most common), neuromuscular, traumatic, and pathologic; most common in females; diagnosis with imaging and measurement of Cobb angle (severity of scoliosis):
Mild = 10-20 degrees = tx w OMT
Moderate = 21-45 degrees = tx w OMT + Bracing (MOBerate)
Severe = 50+ degrees = tx w Surgery
75 degrees or worse = cardiovascular compromise/involvement
Structural vs Functional Scoliosis
Structural Scoliosis - curve does NOT correct w SB
Functional Scoliosis - curve DOES correct w SB
“Functional Fixes”
Functional Short Leg
structurally intact, usually environmental/SD; most commonly due to *hip replacement; lumbar SD = SB away, Rotate towards (SART); anterior innominate rotation
tx w heel lift
Old = 1/16 inch Q2 weeks, Young = 1/8 inch Q2 weeks and the Maximum = 1/2 inch Q2 weeks
Anatomical Short Leg
structurally dysfunctional (congenital); ANY part of the LE can have a defect (femur, tibia, fibula); lumbar SD = SB away, Rotate towards (SART); *posterior innominate rotation
tx w heel lift
Old = 1/16 inch Q2 weeks, Young = 1/8 inch Q2 weeks and the Maximum = 1/2 inch Q2 weeks
Short Leg Syndrome treatment
tx w heel lift
Old = 1/16 inch Q2 weeks
Young = 1/8 inch Q2 weeks
Maximum = 1/2 inch Q2 weeks
iliolumbar ligament
stabilizes anterior motion of L5 on the pelvis; FIRST ligament injured in innominate SD
sacrospinous ligament
separates greater and lesser sciatic foramen
piriformis muscle
action: ABducts and externally rotates (open ya legs); innervation of S1-S2; attachment = anterior sacrum and greater trochanter; watch for sciatic nerve injuries
iliopsoas muscle
iliacus + psoas = MAIN HIP FLEXORS; innervation L1-3
sacral motion
Superior sacral axis = craniosacral & respiratory motion
Medial sacral axis = postural motion
Inferior sacral axis = innominate motion
Counterstrain
passive, indirect technique that is meant to resolve the pain of tenderpoints/”gamma gain” (do NOT refer pain); goal is at least 70% reduction in pain
Anterior cervical counterstrain
Cervical SARA: “Flex the Front and Extend the End”
usually the tx involves flexion and SARA; except Maverick TPs (do not resolve when the muscle is shortened): AC1 (RA) “AC1 Rotates Away Son” and AC7 (FSTRA) “Flex STRAw into 7-up”
Anterior cervical counter strain Maverick TPs
do not resolve when the muscle is shortened; resolves when muscle is lengthened
AC1 (RA) “AC1 Rotates Away Son”
AC7 (FSTRA) “Flex STRAw into 7-up”
Posterior cervical counterstrain
Cervical SARA: “Flex the Front and Extend the End”
usually the tx involves extension and SARA (ESARA); except Maverick TPs (do not resolve when the muscle is shortened): PC1 (F) “F PC1” and PC3 (FSARA) “3 isn’t E”
Posterior cervical counterstain Maverick TPs
do not resolve when the muscle is shortened; resolves when muscle is lengthened
PC1 (F) “F PC1”
PC3 (FSARA) “3 isn’t E”
Cervical Sara
“Flex the Front and Extend the End”
Anterior Thoracic Counterstrain
AT1-AT6 all tx w F only
AT7-12 (all the rest) FSTRA
AT7 @ 7th ICS
AT8 @ T12
AT9 @ L2
AT10 @ L4
AT11 @ Sacral Base
AT12 @ iliac crest
Posterior Thoracic Counterstrain
ESARA = Along midline (spinous process)
ESART = Transvere process (lateral)
Anterior Rib Counterstrain
“I’ll STRT w the ribs” all tx w FSTRT
AR1 @ first chondrosternal joint
AR2 @ superior aspect of 2nd rib @ midclavicular line
Anterior rib 1 TP
AR1 @ first chondrosternal joint
“I’ll STRT w the ribs” tx w FSTRT
Anterior rib 2 TP
AR2 @ superior aspect of 2nd rib @ midclavicular line
“I’ll STRT w the ribs” tx w FSTRT
Posterior Rib Counterstrain
PR1 corresponding rib angle tx w ESART
PR2-12 corresponding rib angle tx w SARA (sometimes FSARA)
Anterior Lumbar Counterstrain
“STRA, SART SART SART, SARA” (only 5 to memorize)
AL1 medial to ASIS tx w FSTRA
AL2 medial to AIIS tx w FSART
AL3 lateral to AIIS tx w FSART
AL4 inferior to AIIS tx w FSART
AL5 anterior & superior to pubic ramus tx w FSARA
Anterior Pelvic/Sacral Counterstrain
Posterior Pelvic/Sacral Counterstrain
Physiological Changes in Pregnancy (relaxin and progesterone)
increased relaxin = increase pelvic-sacral laxity, worsen lumbar lordosis and increase hypertonicity in back muscles
increased progesterone = increased venous congestion
Physiological Changes in Pregnancy (hemodynamic changes)
increased CO
increased Na+ and water retention
expanding total blood volume
reduced SVR
decreased lymphatic drainage = worsening thoracic kyphosis, diaphragm and fetal compression of vena cava
OMT in pregnancy
PROMOTE Study = OMT is safe in pregnancy
Diaphragmatic openings
I (IVC) ate (8) ten (10) eggs (esophagus) at (aorta) twelve (12)
T8 - IVC, right phrenic nerve
T10 - Esophagus, vagus nerve
T12 - Aorta, thoracic duct and azygos vein (At 12, its red, white and blue)
breakdown of lactose
galactose and glucose via lactase; deficiency in lactose intolerance
Ketamine
activates opioid receptors within the insular cortex, putamen and thalamus producing analgesia which makes it preferred for painful procedures; also preferred in pts w bronchospasm, asthma or both; adverse effects of hallucinations, nightmares and vivid dreams
Follicular lymphoma
t(14;18) which form a BCL2-IgH fusion gene
Marfan syndrome
AD mut in fibrillin-1 gene
Diabetic nephropathy
albuminuria, hyperfiltration and glomerulosclerosis; findings on biopsy would display *uniform glomerular basement membrane thickening and Kimmelstiel-Wilson nodules
most SPECIFIC diagnostic testing modality for pulmonary embolism (PE)
CT pulmonary angiography; tx is immediate anti-coagulation w heparin
lesions to the posterior limb of the internal capsule
the lenticulostriate arteries that supply the internal capsule are the most common site of spontaneous HTN hemorrhage in pts with longstanding HTN; the posterior limb contains descending corticospinal tract (UMNs) and ascending somatosensory pathways for the body and face; lesions results in c/l hemiparesis and hemianesthesia
abdominal actinomycosis
Actinomycotic abscesses can occur following cholecystectomy complicated by gallstone spillage into the peritoneal cavity; tx is abscess drainage along w intravenous penicillin
Chapman points corresponding to acute appendicitis
anterior chapman point is tip of the right 12th rib
posterior chapman point is located on the lamina of the transverse process of T11-T12
lacunar infarct
an acute lacunar infarct in the basal ganglia leads to HA, difficulty walking, incoordination in the UE and HTN; most commonly caused by uncontrolled HTN and lack of medical care
Atheroma formation
platelet-derived growth factors are related from activated platelets, macrophages and endothelial cells where they then recruit smooth muscle cells from the arterial wall media and induce their proliferation in the intima; this contributes to plaque growth and stabilization
Sibson fascial release
thoracic inlet release is initiated by contacting Sibson fascia
isotonic contraction
a bicep curl is an example of isotonic contraction; in this type of contraction the muscle tension is constant as the muscle changes length
CXR findings in an obstructive atelectasis
ipsilateral diaphragm elevation and ipsilateral tracheal deviation
amiodarone-induced pulmonary toxicity
amiodarone is a potent anti-arrhythmic drug w multiple potential side effects, including interstitial pneumonitis, pulmonary fibrosis. hypothyroidism or hyperthyroidism, hepatic toxicity, cardiac toxicity, neuropathies and skin reactions
benign paroxysmal positional vertigo (BPPV)
abnormal sensation (vertigo) that is elicited by certain critical provocative positions; underlying pathogenesis is due to *otolith displacement from the utricle of the semicircular canal
acute mesenteric ischemia
causes pain that is “out of proportion” to the physical examination findings; the most common cause is decreased intestinal blood flow (vascular occlusion) from an arterial embolism, typically originating from the heart
Function of ApoE
clearance of lipoproteins and chylomicrons
Dipeptidyl peptidase IV (DPP-IV) inhibitors
sitagliptin, saxagliptin and linagliptin meds used for better glycemic control in DM2; unique and most common adverse effect of *upper respiratory infections and nasopharyngitis
Chronic myelogenous leukemia (CML)
BCR-ABL fusion gene which increases tyrosine kinase activity; leukemia w splenomegaly and a decreased leukocyte alkaline phosphatase activity is a clue for CML
Pompe Disease
lysosomal storage disease due to acid maltase deficiency; infantile form of alpha-1,4-glucosidase deficiency results in myopathy affecting multiple organ systems; key clinical features include severe generalized hypotonia, muscle weakness, respiratory distress, failure to thrive and cardiomegaly early in childhood
Asherman syndrome
the result of removal of the stratum basalts after too forceful or repetitive dilation and curettage procedures, commonly resulting in intrauterine adhesions as an inflammatory response to damages stratum basalis leading to secondary amenorrhea and infertility
Wiskott-Aldrich syndrome (WAS)
X-linked congenital immunodeficiency characterized by recurrent pyogenic infections and eczema due to IgM deficiency and IgA excess
Polycythemia vera
one of the chronic myeloproliferative disorders characterized by a rise in RBC mass accompanied by an increase in WBC and platelet production; pruritus after a warm shower or bath is the most common presenting symptom; characteristic lab findings include a JAK2 mut and low serum EPO levels; tx w phlebotomy and hydroxyurea
absolute contraindications in HVLA
joint instability, severe osteoporosis or spondylosis, metastasis in the area to be treated, severe herniated disc w radiculopathy (not a small one), infection of the tissues being treated, Down syndrome or rheumatic disease affecting the spine
theca lutein cyst
also called lutein cysts, are luteinized follicle cysts within the ovary that form as a result of overstimulation from high levels of hCG or hypersensitivity to hCG; recent pregnancy is a risk factor
viscero-somatic reflexes from dysfunctions of the head and neck
tissue texture changes at T1-T4
most common cause of death in children less than 1 yr old
congenital malformation; best advice for a mother is to evaluate for trisomy and complete nuchal translucency testing
Alkaptonuria
an AR disorder that results from homogentisic oxidase deficiency; results in elevated levels of homogentisic acid which forms a pigment that is deposited in CT and joints throughout the body; presents in the 3rd decade of life w abnormal dark-colored urine when it is left standing
IT Brand Syndrome
the most common cause of knee pain in athletes, especially long-distance runner; IT band arises from the tensor fascia late, gluteus minimus, gluteus medius and gluteus maximus muscles proximally; travels along the lateral side of the thigh and inserts on Gerdy tubercle at the proximal lateral tibia
Ataxia-telangiectasia
AR form of ataxia due to ATM gene mut causing defective DNA repair; pts develop progressive cerebellar ataxia, abnormal eye movements, telangiectasias and immune deficiency resulting in frequent sinopulmonary infections
Pancoast tumor
AKA superior sulcus tumors; diagnostic criteria require the tumor to invade the parietal pleura and cause pain, paresthesias or other neurologic manifestations; when the brachial plexus is involved, the inferior portion is typically affected, thereby producing signs and symptoms in the ulnar distribution
Monckeberg arteriosclerosis
uncommon disease process that occurs in older adults; characterized by calcification of the tunica media; often is discovered incidentally on imaging
McCune-Albright syndrome
presents w precocious puberty, cafe-au-lait spots and a history of long bone fractures secondary to fibrous dysplasia; mut in GNAS gene that results in constant G protein activation activation and increased production of pituitary hormones
elevated serum markers in ovarian cancer
CA-125
Giant cell arteritis
an inflammatory arteriopathy affecting the major branches of the aorta; pts often present w HA, scalp tenderness, jaw claudication and insidious onset of constitutional symptoms (fever, fatigue, unintentional weight loss); tx is high-dose glucocorticoids (tx should not be delayed due to the possibility of progression to permanent vision loss)
functional residual capacity
the amount of hair in lungs at the end of normal expiration
muscarinic effects
remember parasympathetics increase bronchoconstriction, increased lacrimation (tearing) and sweating
Heme synthesis
Drug of choices for GU infections
Neisseria gonorrhoeae = Ceftriaxone
Chlamydia = Azithromycin
BV and trichomoniasis = Metronidazole
Syphilis = Penicillin
MCAD deficiency
presents w hypoketotic hypoglycemia and evidence of liver failure; lab results show hypoketotic hypoglycemia (no ketones and low glucose) and dicarboxylic acids on urinalysis; tx involves avoidance of prolonged fasting
Meralgia Paresthetica
pain/paresthesias in the anterolateral thigh; caused by compression od the lateral femoral cutaneous nerves, usually as the nerve travels under the inguinal ligament; frequently in pts who sit for prolonged periods of time, especially those who are obese
CSF in MS pts
oligoclonal bands (immunoglobulins); found in the CSF of most pts multiple sclerosis
photoaging and solar damage
pts w extensive sun exposure history; presents w coarse and fine wrinkles; biopsy shows loss of rete ridges within the dermis and loss of both collagen and elastin w an accumulation of breakdown products (solar elastosis)
lung adenocarcinoma
more commonly occurs in women and is not associated w smoking; presents w dyspnea and cough; CXR peripheral “coin lesion”
metastatic brain cancer as chartcaterized by multiple and b/l lesions at the junction of the gray and white matter; most common sites of metastasis are lung, breast, kidney, and colorectal and melanoma
renal blood flow calculation
RBF = renal plasma flow / (1-hematocrit)
measurements of renal function
Chadwick sign
pt is likely pregnant; the bluish hue of her vaginal is one of the earliest signs of pregnancy; warfarin is contraindicated in pregnancy
slipped capital femoral epiphysis (SCFE)
most commonly occurs in overweight/obese children (10-13 yrs) and is characterized by slippage of the overlying end of the femur (metaphysis) from its anatomical position in the acetabulum; presents w acute onset of groin and hip pain in the absence of trauma
Brucellosis
transmitted through direct contact w infectious animal fluids or the ingestion of unpasteurized milk or cheese; commonly presents w undulating fever, profuse sweating and joint pain
hypothalamic thermoregulatory center
anterior and posterior hypothalamic nuclei
tx of an acute asthma attack
treated w oxygen, short-acting B-agonist and IV steroids; BETA BLOCKERS are CONTRAINDICATED!
paraneoplastic association w small cell carcinoma
Cushing syndrome (ACTH)
Hyponatremia (SIADH)
Lambert-Eaton syndrome (calcium pre-synaptic antibodies)
paraneoplastic association w squamous cell carcinoma
hypercalcemia (PTHrP)
characteristics of lung cancer
menopause
permanent cessation of menses (>12 months) as a result of non pathological age-related decline in the number of ovarian follicles; loss of ovarian function leads to decreased ovarian estrogen production (decreased estrogen) which reduces the negative feedback on the anterior pituitary resulting in increased FSH and LH; significantly elevated FSH is diagnostic of menopause
craniosacral motion
occurs at the superior transverse axis found at S2
Fetal hydantoin syndrome (FHS)
characterized by microcephaly, mid facial underdevelopment (cleft palate), hypoplasia of digits and nails, cardiac defects, intrauterine growth restriction and developmental delay; associated w anti epileptic drug phenytoin during pregnancy
Rett Syndrome
X linked dominant (men die in utero); mut in MECP2 gene; 4 stages:
1st phase: develop normal up to 6 months - loss of verbal, cognitive and physical (regression)
2nd phase: occurs 1-4 yrs - loss of purposeful movement of hands
3rd phase: apraxia (cannot carry out purposeful movements
4th phase: scoliosis and abnormal posturing
Rett Syndrome
X linked dominant (men die in utero); mut in MECP2 gene; 4 stages:
1st phase: develop normal up to 6 months - loss of verbal, cognitive and physical (regression)
2nd phase: occurs 1-4 yrs - loss of purposeful movement of hands
3rd phase: apraxia (cannot carry out purposeful movements
4th phase: scoliosis and abnormal posturing
