CSA CSPE Main Points Flashcards
1
Q
AAA:
Age of Risk=
A
Men= 50+, Peak 80-85
Women= 60+, peak 90+
2
Q
AAA:
Most common Symptom=
A
Pain in Back, Flank, Going, Testes
More often on left
Sometime pulsating
3
Q
AAA:
First Clinical Sign=
A
Pulsatile abdominal mass
4
Q
AAA:
Classic Triad of rupture=
A
Hypotension
Back Pain
Pulsatile Mass
5
Q
AAA:
Who should be screened with ultrasound?
A
Men 65 and 70 who have ever smoked.
6
Q
Ancillary study of choice for AAA rupture
A
CT
7
Q
Can you see a AAA on an x ray?
A
Yes, often on a lateral film due to calcification
8
Q
Cut off between dilation and aneurism of AAA=
A
3.8 cm
9
Q
AAA:
Emergent referral=
Urgent Referral (same day)=
Semi urgent (48h)=
Non- Urgent=
A
Emergent referral= >6cm with pulsating pain, nausea, vomitting, rapidly elevating LBP, Hypotension, non-positional pain.
Urgent Referral (same day)= >6cm on x-ray with LBP but no other sx
Semi urgent (48h)= >6cm w/o any sx
Non- Urgent= <6cm with mechanical LBP and no red flads
10
Q
What % of AAA lead to rupture?
A
1/3
11
Q
Risk of death with Untreated AAA
1 year=
2 year=
5 year=
After rupture=
A
1 year= 50%
2 year= 75%
5 year= 90%
After rupture= 75%-90%
12
Q
What are the 3 most common causes of CES?
A
Midline Disc
Spinal Stenosis
Tumor/SOL
(Rare= Trauma, Manipulation, ASA, Pagets, Meningitis)
13
Q
Typical Presentation of CES
A
51% of time only urinary Sx (retention, urgency, or incontinence)
Bladder Sx often develop simultaneously with back or leg pain.
Saddle Anesthesia or sexual dysfunction
14
Q
What is the gold standard test for CES?
A
MRI
15
Q
How do you manage CES
A
Refer to neurologist, same day
Decompression surgery
Manipulation contraindicated
16
Q
What are potential residual complication of CES
A
Weakness
Impotence
Sensory loss
Incontinence
17
Q
What is the prognosis for CES post surgery?
Indicators making full recovery less likely=
A
Deends heavily on the amount of time the patient was symptomatic.
Indicators making full recovery less likely=
- Delayed tx
- Degree of sphincter involvement
- Sensation loss distribution
- Speed of onset
18
Q
Mgmt for Chest pain/MI
A
Reassure the patient
Monitor vitals
Chew 325mg asprin
Ask history questions
Dont apply oxygen unless they are in shock
19
Q
What is the risk with proximal DVTs?
A
50% lead to pulmonary emboli.
95% of pulmonary emboli are from DVTs
30% mortality rate.
20
Q
What veins are usually involved in proximal DVTs?
A
popliteal veins
21
Q
What veins are usually involved in distal DVTs?
A
Tibial veins (much lower risk of embolii)
22
Q
Classic presentation of DVT:
A
Leg is swollen, tender, red, and warm.
23
Q
What are major risks of DVT
A
Active cancer Immobilization >75 Bedridden Major surgery Hx of embolii Genetics Heparin induced thrombocytopenia Clotting disorder CVA->50% DVT
24
Q
Physical signs of DVT:
Palpation=
Observational=
A
Palpation=
- Tenderness/ palpable hard cord
- Erythema/temp change
Observational=
- Pitting edema
- Dilated collateral veins
- Calf Swelling
- Entire leg swollen
25
DDX for DVT
Bakers cyst
Hematoma
Muscle Strain
Acute Cellulitis
26
Ancillary Studies for DVT
Ultrasound (test of choice)
D-Dimer (Sensitive-rule out)
Venography (done after US & DD)
27
MGMT of DVT
Refer out immediately
Anticoagulant therapy for confirmed DVT
Wear elastic compression stockings and stay mobile.
28
Natural supplements for dyslipidemia:
Garlic
| Red yeast rice
29
Emergent Referral for Neuromusculoskeletal presentations
Cauda Equina Syndrome
- rapid onset of sx
Dislocation
- Open dislocation
- Knee Dislocation
- Vascular, or neuro signs
Fracture
- Compound/open
- Unstable
Head Trauma
- Progressive or neuro sx
Paralysis
- Acute
Septic Arthritis or Osteomyelitis
Stroke
TIA
Vertigo
30
Emergent Referral: Visceral Presentation
AAA
Acute Severe Abdominal Pain
Arrythmias or Altered Pulses
Diabetic Crises
Dehydration
Detached Retina
Ectopic Pregnancy
Meningitis
Myocardial Infraction
Poisoning or drug overdose
Pregnancy with danger signs
Respiratory Distress, Acute
Septicemia
Strangulation Hernia
Unstable Angina
31
Urgernt Referral Neuromusculoskeletal presentations
AC joint dislocaton
Compartment Syndome
Cauda Equina Syndrome of recent onset
Dislocation, closed unreduced
Fracture
Hemarthrosis
Infection
Suspected bacterial pneumonia
Subdural hematoma
Slipped capital femoral epiphysis
Thoracic outlet syndrome with evidence of vascular compromise
32
Urgent referral for Visceral presentation
AAA with back pain but no other Sx
Arrhythmias or altered pulse
Bladder infection
Cellulitis, Lymphagitis
DVT
Esophageal tear, post traumatic
Fever (>104, infant >100, infant over 2 months with >104)
Renal infection
33
What are two possible consequences of VBD?
1) Wallenberg Syndrome
| 2) Locked in Syndrome
34
What is Wallenberg Syndrome?
Posterior inferior cerebellar artery occlusion that results in vertigo, diplopia, and/or dysarthria
35
What is Locked in Syndrome
More serious than Wellenbergs, leaves the patient conscious but paralyzed.
Result of VBD
36
Signs/Sx of Vertebrobasilar Dissection
Episode of neurologic dysfunction with sudden onset lasting no more than 24 hours including 2 of:
- Numbness, weakness or paralysis of face arm or leg.
- Blurred or decreased vision or loss of vision in one or both eyes
- Difficulty speaking or understanding speech
- Decline in consciousness or mental function
- Severe headache or neck stiffness
- Loss of balance or coordination
37
5Ds and 3 Ns of neurologic dysfunction
```
Dizziness
Drop attacks
Dysarthria
Dysphagia
Diplopia
Ataxia of gait
Nausea
Nystagmus
Numbness on one side
```
38
`Tx for VBD
Call 911
| Med: Anticoagulant or antiplatelet agents
39
Presentation of HLD with Sciatica
3+ OR 2+ with imagery
Dermatomal Paresthesia
Dominating leg pain (worse than back)
+ SLR or other nerve tension tests
Neurologic deficits (20% have none)
40
Lumbar Discogenic Clues
Decreased sagittal Tx/Lx ROM
Mannequin sign
P centralization with repetitive end range loading
+ Valsalva
Sitting poorly tolerated
DeJerines Triad
Flexion load sensitivity
41
If neurological signs migrate in the lower extremities, what may this be a sign of?
Uncontained or sequestered herniation
42
When to order MRI or CT with a herniated disc
Signs of CES
Progressive muscle weakness
Herniated disc in doubt
Profound muscle weakness at first
Presurgical assessment
43
HTN Classification
Normal=
Pre-Hypertension=
HTN 1=
HTN 2=
Normal= <120/<80
Pre-Hypertension= 120-139/80-89
HTN 1= 140-159/90-99
HTN 2=160+/100+
44
How do you make the Dx or HTN?
4 measurments on 2 subsequent visits withing 1 month?
45
When do you refer out immediately with HTN?
>180/>110
46
Best non pharmacologic Tx for HTN
Lose weight (5-20 points every 10% loss)
DASH diet (4-14 points)
CoQ10 (11 points)
47
MGMT of HTN
```
Weight loss
Reduce sodium
Stop smoking
Smaller meals
Exercise
Decrease alcohol
Limit sugar and caffeine
DASH diet
```
Supplements:
- CoQ10
- Fish oil
- Magnesium
- Potassium
- Calcium
- Garlic Powder
48
Is lumbar functional instability the same thing as Lumbar Hypermobility or Radiographic Instability?
No
Functional instability is a loss of the spines ability to prevent unwanted movement or buking due to the spinal stabilization system that consists of mechanoreceptors located around the joint that provide proprioceptive feedback.
49
What are the 4 factors that predict better outcomes with stabilization exercises.
<40
Abberent lumbar movement
SLR >91
+ prone instability test
50
Clues from history for spinal instability
Immediate pain when sitting
Temporary response to manipulation
Decreased response to manipulation over time
Episodic in nature
Reports of catching, locking, giving way.
51
Clues from Physical Exam for Spinal Instability
Altered quality of movement
- Aberant motion (minors sign, catch, reversed lumbosacral rhythm)
- Painful arc
Specific segmental findings
- Positive prone instability test
- Decreased resistance with prone joint play
- Increased motion with motion palpation
Evidence of poor motor control
- Segmental abnormal movements
- Painful arc abolished with abdominal bracing
- Poor motion control during hip extension
- Poor motor control during single leg stand.
52
What are the imaging guidelines for the low back? (When do you not need to order imaging)
Imaging is most appropriate when the results may affect the tx plan.
Imaging is NOT indicated in first six weeks of low back pain if the following criteria is met.
- No neurological signs
- Patient 18-15 years old
- No signs of malignancy
- No hx of trauma
- No constitutional sx (weight loss, fever, malaise, diaphoresis, ect)
53
What is the classic presentation of Central Lumbar Canal Stenosis?
Older patient with a wide based gait. No pain while sitting, thigh pain within 30 seconds of sustained extensions.
54
What are common contributors to CLSS?
Facet Enlargement
Disc Bulge
Ligamentum Flavum enlargment
55
Absolute Clinical Lumbar Spinal stenosis=
Absolute<10mm
Relative=<12mm
CT or MRI
56
What is the pattern of Neurogenic Claudication
Usually seen in central canal stenosis
Paresthsia in dermatomal pattern
Pt sx worse when walking (heaviness, weakness, fatigue)
Leg sx relieved by flexion and worse by repetative extension.
May have neurological deficits.
57
How do you tell the difference between Lateral Recess Stenosis and Spinal Canal Stenosis?
Lateral is more likely to be dermatomal patterns of radiculopathy.
Spinal Canal is more likely to be non dermatomal and can effect both legs.
58
Best clue to rule OUT CLSS from Hx:
Best Clue to rule IN CLSS from Px:
Best Clue to rule OUT CLSS from Px:
Best clue to rule OUT CLSS from Hx: Absence of neurogenic claudication
Best Clue to rule IN CLSS from Px: Wide based gait, abnormal Rombers
Best Clue to rule OUT CLSS from Px: Forward flexion exacerbates leg pain.
59
DDX for CLSS
Peripheral Artery Disease
Herniated Lumbar disc
60
What is the typical presentation of a patient presenting with cervical radiculopathy.
Unilateral Neck and arm pain
Fingertip paresthesia
Sometime neurological deficits
61
General Presentation of cervical myelopathy
Classic= Numb.clumsiness of hands, spastic gait, stiff neck.
```
Spastic gait
Clumsy hands
Atrophy/sensory impairment
Sphincter issues
Motor/reflex changes
Arm (uni/bi) sx's
```
62
Clues from Hx for cervical radiculopathy
Shooting/Lancing pain in dermatome
Arm pain often exceeds neck pain
Aggrivated by minor movements (coughing/sneezing)
Acute NR pain may be unrelenting
Radiates into extremity in narrow specific band.
63
Clues from Px for Cervical radiculopathy
Stiff neck (away from side of involvment)
Torticollis
Bakody's sign
Palm to chest
Reduced active rotation towards side of involvement
+Orthos=
- Compression
- Distraction
- Valsalva
- Shoulder abduction
- Brachial compression
- ULTT
64
When to order radiographs for radiculopathy
High impact injuries (MVA)
Head or neck trauma due to fall
>50
Multiple injury areas
Cx inuries in people under the influence
Pts with special risks (downs, marfans, fused vertebrae)
Significant spasm d/t trauma
Sharp intolerable pain
Significant neck flexor weakness after an injury.
65
Presentation of Complex Regiona Pain Syndrome
5 main types
1) Pain:
- Dominant, severe, burning, regional with palamar or plantar dominance, with hyperalgesia and allodynia.
2) Autonomic Dysfunction:
- Nails thickened, rigid and brittle; darkened rapidly growing hair, temp changes (warm/red/mottled), spasms/ weakness/increased reflexes
3) Edema
4) Movement disorder
5) Dystrophy/atrophy
66
What condition is difficult to tell from facet syndrome?
Disc Derangment
67
Compair and contrast Acute Otitis Media vs Otitis Media with Effusion
AOM
- Pt appears ill
- Ear Pain
- Fever
- Rapid onset
- Previous Upper Resp Tract Infection
- Bulging/Cloudy Tympanic Membrane
OME
- Pt normal to mildly ill
- No pain of ear
- No fever
- Recent AOM
- Slow onset
- Normal or retracted tympanc membrane
Both:
-Conductive Hearing Loss
68
Tx for AOM/OME
Address Sx
Affect Eustachian tube (endonasal)
Instruct patient how to autoinflate
CMT to upper Cx
Refer:
- Infant
- High temp
- Severe ill
- Hearing Loss
- Facial Paralysis
- Failure to improve in 5 days
69
Red flags for serious disease causing LBP
- Sensitive
- Specific
Sensitive
- >50
- No relief with bed rest
Specific
- Previous Hx of cancer
- Unexplained weight loss
- Sx >1 month
- No response to tx >1mo
70
Red Flas from Ancillary Studies with LBP
Elevated ESR/CRP (ESR>50)
Increased Serum Calcium, Protein, or ALP
Anemia
Pathological image
71
Structures that can compression nerves in the thoracic outlet.
Cervical Rib
SOL
Pec Minor
Ant/Middle Scalene
72
What may require urgent referral in TOS? WHo is at risk?
Vascular TOS
Young physically active males
73
What does vascular TOS present like
Cyanosis
No pulsating edema
Distender superficial veins
Fatigue in arm
Overhead TOS will irritate this form the best.
74
What are the 3 products of bone marrow that a CBC measures?
Red Blood Cells
- Number
- Amount of hemoglibin
- Hematocrit
- Indices (MCV, MCH, MCHC)
White Blood Cells
- Neutrophils
- Basophils
- Eosinophils
- Lymphocytes
- Monocytes
Platelets
75
In an Anemic patient, how low does Hgb have to be before the patient might begin having symptoms?
How low does Hgb have to be before you start considering a transfusion?
Sxs= Hgb<10g/dl
Transfusion=Hgb<6.5g/dl
76
What are the RBC indices?
Which one is most important on letting you know which category of anemia?
MCV
MCHC
MCH
MCV tells you which anemia (micro/Macro/normo)
77
What are typical symptoms of anemia?
Fatigue
| Pallor
78
What CBC labs indicate Anemia?
Decreased Hgb, Hct, and/or RBC count.
Hgb most accurate.
79
What are 4 causes for anemia?
1) Iron Deficiency (95%)
2) Thalassemia
3) Chronic Disease
4) Sideroblastic Anemia
80
What do you order to confirm iron deficiency anemia
Iron Panel
81
What is measured in an iron panel and what will they looks like if the patient has iron deficiency anemia?
Si (serum Iron)
TIBC (% iron carrier transferrin that is empty)
%TS (% of transferrin saturate with iron)
Serum Ferritin (storage form of iron)
```
SI V
TIBC ^
%TS V
Serum Ferritin V
- first to go down and last to normalize
```
82
What does RDW measure
If there is a large range in RBC width between cells.
(anisocytosis= cells of varying size)
Can only tell you that all cell are not the same size, but not if they are big or small
83
Results for CBC and Iron panel for Iron Deficiency Anemia
CBC
- RDW ^
- MCV (micro) V
- MCHC V (hypochromic)
- MCH V (hypochromic)
- PBS: Microcytosis, Hypochromia, Anisocytosis
Iron Panel
- SI V
- Serum Ferratin V
- TBCI ^
- %TS V
84
What are the 3 most common causes of iron deficiency anemia?
Chronic Bleeding (MC)
- Menstration
- GI (FIT test or >50 colonoscopy)
Dietary or increased demand (pregnancy)
Malabsorbtion (lack of stomach acids)
85
What is Thalassemia a disease of?
Small red blood cells (MCV)
86
Thalassemia CBC results
MCV= Disproportionately lower than anemia (<70)
RDW= Normal (though small cells)
RBC= ^ V or Normal
PBS= Target Cells
87
If you suspect Thalassemia, what should you do next.
```
Order iron panel to rule out iron deficiency anemia
SI= N/^
TIBC N
%TS= N/^
Serum Ferritin= N/^
```
Hgb Electrophoresis
- reverse HgbA1/A2 ratio (if beta thalassemia)
88
What do CBC and Iron labs look like with chronic disease?
Anemia (Hgb V)
SI V
TIBC= N/V
Serum Ferritin= N/^
Serum Ferritin is biggest indicator.
Other clues=
Elevated WBC
Elevated CRP/ESR
89
What is the indication of a Sideroblastic anemia?
PBS: Sideroblast
Often normocytic
SI: ^
90
Your serum B12 test come back slightly decreased. What are two tests that can be ordered which could help confirm B12 deficiency?
Decreased cobalamin or increased methylmalonic acid.
91
3 Causes of B12 deficiency
Diet
Pernicious Anemia
Malabsorption syndrome
92
What blood test could confirm pernicious anemia
Antiparietal cell antibodies
93
How does reticulocytoses cause macrocytic anemia?
Reticulocytes are immature red cells. Because they are larger than mature RBCs, if they increase in number it increases the average cell size until the MCV registers macrocytosis.
94
What is the cause of Reticulocytosis
Increased bleeding
95
What does BAAAGL stand for and what does that have to do with macrocytic anemia?
BAAAGL stands for bilirubin, alkaline phosphatase, AST, ALT, GGTP, and LDH. Any combination of these may increase signaling liver inflammation. The injured liver can affect size of the RBCs that are made.
96
What is the most common type of macrocytic anemia?
Megaloblastic anemia
97
What are the 5 most common causes of macrocytic anemia?
```
Megaloblastic anemia
Chronic alcoholism
Reticulocytosis
Liver Disease
Hypothyroidism
```
98
What will be the RDW value mostly likely do in a macrocytic anemia? Increase? Decrease? Remain normal?
Increase because some cells will be large, and some will be normal.
99
What condition are hypersegmented PM
Megaloblastic Anemia
100
What are the two most common causes of megaloblastic anemia?
B 12 deficiency and folic acid deficiency.
101
Besides a change in indices, what are the 5 clues from a CBC that would be consistent with a megaloblastic anemia?
Decreased WBCs, decreased platelets, MCV > 110, hypersegmented neutrophils, and macroovalcytes.
102
What are findings on a standard blood chemistry panel that would be consistent with megaloblastic anemia? Explain why they go up?
Increased bilirubin and LDH result from hemolysis due to the fact that the cells are too large and fragile to make their way through the spleen and capillary beds.
103
What 3 values should you look at to determine the category of anemia?
3 Indices
| - MCV, MCHC, MCH
104
How do you treat B12 Deficiency?
Oral B12
Parenteral B12 (in patients with significant neurologic symptoms)
Sublingual B12
Intranasal B12 (Maintenance therapy)
105
How do you tell is macrocytic anemia due to chronic alcoholism?
Increased GGTP
If significant liver cirrhosis blood chem panel will show: (Decreased Protein (albumin), trigs, BUN, and increased NG4 (amonium))
106
What are some causes of reticulocytosis?
Early post bleeding periods
Hemolysis & other conditions
107
What will you see on a CBC and Chem Panel in the case of anemia cause by liver disease?
^ MCV
V Protein, Trigs, BUN
^ NH4 (amonium)
^ BAAAGL ( Bilirubin,
ALT, AST, ALP, GGTP, LDH)
108
How do you rule out Thyroid disease causing anemia?
TSH
109
If you feel snapping or crepitus in the shoulder, what are some areas that this could come from?
Biceps tendon
Labrum
AC
