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A Comprehensive Review for the Certification and Recertification Examination for Physician Asistants > EYE/CREW > Flashcards

EYE/CREW Flashcards

1
Q

Otitis externa treatment

A
  • Treatment involves antibiotic otic drops (tobramycin/gentamicin or cipofloxacin +/- dexamethasone) and avoiding further moisture or ear injury
  • In diabetic or immunocompromised patients, malignant otitis externa may develop, which is a necrotizing infection extending to the blood vessels, bone, and cartilage; this requires hospitalization and parenteral antibiotics (ciprofloxacin)
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2
Q

Peripheral causes of vertigo

A

Labyrinthitis, benign paroxysmal positional vertigo, endolymphatic hydrops (Meniere syndrome), vestibular neuritis, and head injury

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3
Q

Central causes of vertigo

A

Brainstem vascular disease, arteriovenous malformations, tumors, multiple sclerosis, and vertebrobasilar migraine

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4
Q

Vertigo treatment

A
  1. Therapy is based on the underlying etiology
  2. Vestibular suppressants (i.e., diazepam, meclizine) may help with acute symptoms
  3. BPPV may respond to physical therapy maneuvers
  4. Some cases may require interventional/surgical therapies
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5
Q

Labyrinthitis treatment

A
  1. Antibiotics are indicated with associated fever or signs of bacterial infection
  2. Vestibular suppressants are helpful during the initial acute symptoms (diazepam or meclizine)
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6
Q

Barotrauma treatment

A
  1. Patient measures, such as swallowing, yawning, and autoinflation (with descent), as well as the use of systemic or topical nasal decongestants (prior to arrival) can be helpful
  2. Persistent symptoms after landing can be treated with decongestants (phenylephrine nasal spray or pseudoephedrine) and repeated autoinflation. With severe pain/hearing loss, myringotomy may be considered
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7
Q

Laryngitits treatment

A
  • Supportive treatment is typically sufficient. Vocal rest and avoidance of singing or shouting is recommended because it can cause vocal cord hemorrhage, polyp, or cyst formation
  • If bacterial, erythromycin, cefuroxime, or amoxicillin-clavulanate can decrease hoarseness/cough
  • Oral or IM corticosteroids may also hasten recovery for performers but requires vocal cord evaluation before starting therapy
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8
Q

Aphthous ulcers (canker sores, ulcerative stomatitis) treatment

A
  1. Treatment is nonspecific, but topical therapies, such as corticosteroids, can provide symptomatic relief
  2. A 1-week oral prednisone taper can also be helpful
  3. Cimetidine can be used as maintenance therapy in recurrent cases
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9
Q

Oral candidiasis treatment

A
  1. Treatment is with antifungals, which are available in several forms (i.e., ketoconazole or fluconazole orally, clotrimazole troches, nystatin liquid rinses)
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10
Q

Epiglottitis (supraglottitis) treatment

A
  1. Treatment involves IV antibiotics (i.e., ceftizoxime or cefuroxime) and IV corticosteroids (i.e., dexamethasone). As the patient improves, antibiotic therapy can be switched to oral forms to complete a 10-day course and steroids can be tapered
  2. If there is dyspnea or such a rapid course that airway compromise is likely to occur before the medication takes effect, intubation is indicated. Even without intubation, patients should be closely monitored (i.e., pulse oximetry, ICU)
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11
Q

Nasal polyps treatment

A
  1. A 3-month course of topical nasal corticosteroid is the initial treatment of choice. This is effective for small polyps and can reduce the need for surgical intervention. Oral steroids (6-day taper) can also help reduce size
  2. Surgical removal may be necessary if therapy is unsuccessful or if polyps are large
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12
Q

Chronic otitis media: Treatment

A
  • Medical treatment includes removal of infected debris, avoidance of water exposure and topical antibiotic drops (cipro or ofloxacin)
  • Definitive treatment typically will include surgery (tympanic membrane repair/reconstruction)
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13
Q

Latent TB infection treatment

A

INH for 9 months or RIF for 4 months or RIF and PZA for 2 months (only if in contact with TB-resistant persons)

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14
Q

Active TB treatment

A

INH/RIF/PZA/EMB for 2 months, followed by 4 months of additional multidrug treatment based on culture and sensitivity results

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15
Q

Isoniazid side effects

A

Hepatitis, peripheral neuropathy; coadminister vitamin B6 (pyridoxine) to reduce the risk

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16
Q

Rifampin side effects

A

Hepatitis, flu syndrome, orange body fluid (e.g., orange urine)

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17
Q

Ethambutol side effects

A

Optic neuritis (red-green vision loss)

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18
Q

Croup Treatment

A
  1. Mild croup does not usually require treatment. Patients should be well hydrated
  2. Corticosteroids, humidified air or oxygen, and nebulized epinephrine may also be recommended
  3. Hospitalization may be required for patients with severe symptoms
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19
Q

NSCLC treatment

A
  1. Surgery remains the treatment of choice
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20
Q

SCLC treatment

A

Combination chemotherapy is the treatment of choice and results in improved median survival, although patients rarely live for more than 5 years after the diagnosis is established

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21
Q

Bronchiectasis treatment

A
  1. A productive cough should be managed with the appropriate antibiotic, bronchodilators, and chest physiotherapy
  2. Antibiotics are prescribed for 10-14 days for acute symptoms; suppressive therapy may be helpful in severe disease or in patients with rapid recurrence. Amoxicillin, amoxicillin-clavulanate, bactrim, or ciprofloxacin are effective choices
  3. Bronchodilators are helpful for maintenance and for treating acute exacerbations
  4. Patients with disabling symptoms or progressive bronchiectasis can be considered for lung transplant; however, surgical interventions have little long-term benefit
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22
Q

COPD management

A
  1. Anticholinergic inhalers (ipratropium or tiotropium) are superior to beta-adrenergic agonists in achieving bronchodilation
  2. Short-acting bronchodilators should be prescribed for acute exacerbations of dyspnea
  3. These patients are at high risk for acute infections; therefore, oral antibiotics frequently are necessary
  4. Supplemental oxygen is the only therapy that may alter the course of COPD in patients with resting hypoxemia
  5. Graded aerobic physical exercise should be encouraged
  6. Steroids are effective but should be used with caution
  7. Patients should receive the pneumococcal vaccine and yearly influenza vaccine
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23
Q

Pleural effusion treatment

A
  1. Unless the cause has been clearly established, the presence of fluid is an indication for thoracocentesis. Removal of fluid via thoracocentesis allows fluid examination, radiographic visualization of the lung parenchyma, and relief of symptoms
  2. Transudate pleural effusions resolve when the underlying causes are treated
  3. Malignant effusions may require drainage and pleurodesis. The most commonly used irritants are doxycycline and and talc
  4. Empyema requires drainage and antibiotic therapy
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24
Q

Pneumothorax treatment

A
  1. Small pneumothoraces resolve spontaneously
  2. For severely symptomatic or large pneumothoraces, chest tube placement is performed
  3. Tension pneumothorax is a medical emergency. If it is suspected, a large-bore needle should be inserted through the chest wall to allow air to move out of the chest. Placement of a chest tube follows the decompression
  4. Patients should be followed with serial CXR every 24 hours until resolved
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25
Q

Pulmonary embolism treatment

A
  1. Anticoagulation therapy is initiated; heparin is the anticoagulant of choice. Low-molecular-weight heparin or warfarin is continued after the acute phase
  2. Duration of therapy depends on the clinical situation. A minimum of 3 months is advised
  3. Vena cava interruption (filter) is helpful in patients at high risk of recurrence who are unable to tolerate anticoagulants
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26
Q

Pulmonary hypertension treatment

A
  1. Treatment of primary pulmonary hypertension may include chronic oral anticoagulants (warfarin), CCBs to lower systemic arterial pressure, and prostacyclin (a potent pulmonary vasodilator). Despite these measures, heart-lung transplantation is usually required.
  2. Treatment of secondary pulmonary HTN consists of treating the underlying disorder in addition to those treatments mentioned earlier.
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27
Q

Pneumoconioses treatment

A
  1. Management is primarily supportive as no effective treatment is available. Supportive therapy includes oxygen, vaccinations (pneumococcal, influenza vaccine) and rehabilitation
  2. Corticosteroids may relieve the chronic alveolitis in silicosis
  3. Smoking cessation is especially important for patients with abestosis, because smoking interferes with short abestos fiber clearance from the lung. Smoking and abestos are synergistically linked to lung cancer, especially mesothelioma
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28
Q

Sarcoidosis treatment

A

Approximately 90% of cases are responsive to corticosteroids and can be controlled with modest maintenance doses

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29
Q

Shock diagnostic studies

A
  1. All patients require a CBC, blood type and cross-match, and coagulation parameters
  2. Electrolytes, glucose, urinalysis, and serum creatinine will aid in determining the type of shock
  3. Pulse oximetry or serial arterial blood gases are needed to monitor oxygenation
  4. ECG and cardiac biomarkers (troponins, BNP, NT-proBNP) may be useful
  5. Lactate levels can assist in identifying shock as well as monitoring treatment
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30
Q

Shock in treatment

A
  1. The first step in treatment is attention to basic life support (airway, breathing, circulation)
  2. Specific treatments depend on the cause of shock
  3. The Trendelenberg or supine position with legs elevated may maximize blood flow to the brain
  4. Oxygen and IV fluids are essential
  5. Urine flow should be monitored via indwelling catheter and sustained at 0.5 mL/kg/hr or more
  6. Continuous cardiac monitoring
  7. Inotropes (i.e., dobutamine, dopamine, epinephrine) to increase CO
  8. Pressors (i.e., dopamine, phenylephrine) improve pressure by increasing vascular tone
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31
Q

Pharmacologic treatment of heart failure

A
  1. ACE-I or ARB
  2. Beta blocker (Metoprolol ER, Carvedilol, Bisoprolol)
  3. Spironolactone-for class 3 and class 4 HF
  4. +/- Lasix (furosemide) for symptom relief
  5. +/- nitrate, digoxin (doesn’t decrease mortality)
  6. CCB, preferably amlodipine, are used only to treat associated angina or HTN
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32
Q

Metabolic syndrome

A

Includes three or more of the following:

  • Abdominal obesity
  • Triglycerides greater than 150 mg/dL
  • HDL less than 40 mg/dL for men and less than 50 mg/dL for women
  • Fasting glucose greater than 110 mg/dL
  • HTN
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33
Q

What are the three common patterns of UA presentation?

A
  1. Angina at rest
  2. New onset of angina symptoms
  3. Increasing pattern of pain in previously stable patients
    - UA is suspected when the pain is less responsive to NTG, lasts longer, and occurs at rest or with less exertion than previous episodes of angina
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34
Q

Reperfusion therapy for STEMI

A
  • ASA and clopidogrel should be given at once
  • Immediate (within 90 minutes) coronary angiography and primary PCI are superior to thrombolysis
  • Thrombolytic therapy (alteplase, reteplase, and tenecteplase) must be given within the first 3 hours
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35
Q

Pericarditis treatment

A
  1. In the presence of hemodynamic compromise, pericardiocentesis is necessary to relieve fluid accumulation. Recurrent effusions may be treated surgically with a pericardial window
  2. Strictly inflammatory conditions may be treated with steroids or NSAIDs
  3. Infectious conditions require antibiotic therapy only if bacterial infection is suspected
  4. Pericardectomy may be performed to relieve constrictive pericarditis
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36
Q

Endocarditis treatment

A
  1. Empiric antibiotic treatment (gentamicin with ceftriaxone or vancomycin)
  2. Antibiotic prophylaxis to prevent endocarditis is recommended before invasive dental work or surgical procedures in patients with prosthetic valves, previous IE, some congenital heart conditions, some acquired valve disorders, hypertrophic cardiomyopathy, and cardiac transplant recipients with valvulopathy. Amoxicillin is the usual DOC
  3. Valve replacement may be needed
  4. Anticoagulants are not beneficial with native valve infection and are controversial in patients with prosthetic valves
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37
Q

Rheumatic heart disease treatment

A
  1. Strict bed rest is essential until the patient is stable
  2. IM penicillin is used for documented streptococcal infection; in patients who are allergic to penicillin, erythromycin is appropriate
  3. Salicylates reduce fever and relieve joint problems; corticosteroids relieve joint symptoms but do not prevent cardiac disease
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38
Q

PAD treatment

A
  1. Aggressive risk factor modification
  2. BB, ACEI, statins, progressive exercise, and supervised exercise programs have been shown to be helpful at reducing symptoms of claudication
  3. Antiplatelet therapy, with ASA and/or clopidogrel, should be used routinely in all patients without a contraindication.
  4. Symptom relief can be achieved with the addition of cilostazol
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39
Q

Superficial thrombophlebitis treatment

A
  1. It is usually treated with bed rest, local heat, elevation of the extremity, and NSAIDs
  2. Antibiotics may be required if evidence of infection exists.
  3. More serious disease may require surgical intervention
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40
Q

DVT treatment

A

Anticoagulation with enoxaparin (LMW heparin) or unfractioned heparin followed by warfarin

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41
Q

Chronic venous insufficiency

A
  1. General therapeutic measures include elevation of the legs, avoidance of extended sitting or standing, and compression hose
  2. Stasis dermatitis should be treated with wet compresses and hydrocortisone cream; chronic dermatitis may require addition of zinc oxide with ichthammol and an antifungal cream
  3. Ulcerations may be treated with wet compresses, compression boots or stockings, and occasionally skin grafting
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42
Q

If iron deficiency and the anemia of chronic inflammation are excluded in microcytic anemia, what test should be done?

A

Hemoglobin electrophoresis with quantification of HgbA2 and F (this will aid in the diagnosis of thalessemia)

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43
Q

Thalessemia treatment

A
  1. Patients with mild disease should not receive iron if ferritin is normal because of the risk of iron overload
  2. Persons with Hgb H disease (persons with one alpha-globin chain) need folic acid supplements and should avoid iron supplements and oxidative drugs
  3. Treatment for beta-thalessemia major consists of transfusions
  4. Allogeneic bone marrow transplantation also is used with increasing success; splenectomy may also be required
  5. Genetic counseling
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44
Q

For patients with beta-thalessemia major, transfusions is usually given. However, an iron load may result in hemisoderosis, heart failure, cirrhosis, and endocrinopathies. What is given to treat or postpone hemisiderosis?

A

Parenteral deferoxamine or oral deferasirox

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45
Q

Diagnostic studies in iron deficiency anemia

A
  • Plasma ferritin level (will be decreased)
  • Serum iron (decreased) and TIBC (increased)
  • Transferrin saturation (decreased)
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46
Q

Iron deficiency anemia treatment

A
  1. Ferrous sulfate, 325mg TID. Best absorbed on an empty stomach. Vitamin C may enhance absorption
  2. Therapy should be continued for 6 months or longer
  3. Iron supplementation during pregnancy and lactation is essential
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47
Q

Sideroblastic anemia: Lead toxicity treatment

A
  1. Chelation therapy is needed for symptomatic lead toxicity

2. Transfusion may also be required if the patient is symptomatic

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48
Q

Sickle cell anemia treatment

A
  1. Symptomatic treatment of pain episodes includes administration of analgesics, hypotonic fluids, and rest
  2. Stroke, sequestration, acute chest syndrome, and multiorgan failure may require transfusion or exchange transfusion
  3. Patients should receive low-dose daily penicillin from birth until age 6 years, pneumococcal vaccine (booster vaccine every 10 years), transcranial doppler (TCD) screening for stroke prevention, pulmonary function testing (PFT) for restrictive disease screening, and chronic folate supplementation
  4. Daily lifelong oral hydroxyurea therapy should be considered for all SS and S beta 0 thalessemia patients as young as 1 year old to increase Hgb F production, prevent complications, and increase lifespan
  5. Genetic counseling
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49
Q

G6PD deficiency treatment

A
  1. In most cases, hemolytic episodes are self-limited as red cells are replaced as soon as the offending agent is stopped
  2. Oxidative drugs and fava beans should be avoided
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50
Q

Polycythemia vera treatment

A

1 Phlebotomy is the treatment of choice

  1. Myelosuppressive therapy with hydroxyurea may be indicated
  2. Low-dose ASA reduces the risk of thrombosis
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51
Q

Diagnostic studies for acute leukemias (ALL and AML)

A
  1. CBC reveals panocytopenia with circulating blasts
  2. Bone marrow biopsy
  3. Hyperuricemia may be present
    4 Auer rods can be seen in AML
  4. Terminal deoxynucleotidyl transferase is diagnostic for ALL
  5. Cytogenic studies are the most powerful prognostic factors
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52
Q

Acute leukemias treatment

A
  1. Induction (remission-inducing) chemotherapy
  2. Consolidation therapy
  3. Allopurinol and diuretics to help prevent uric acid stones
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53
Q

CML treatment

A
  1. Imatinib mesylate (Gleevec) is standard therapy. It is very effective during the chronic phase
  2. Allogeneic bone marrow transplantation may be the initial treatment and is the only therapy proven to be curative. This is reserved for patients with severe disease, which progresses after the initial treatment
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54
Q

CLL treatment

A

Treatment of CLL usually is palliative once the disease is advanced

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55
Q

Hodgkin disease is related to what virus and what cells confirm the diagnosis?

A

Epstein-barr virus; Reed-Sternberg cells

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56
Q

Hypercoagulation panel consists of what?

A

Protein S, protein C, antithrombin III assay, factor V Leiden assay, fasting homocysteine level, anticardiolipin antibodies, prothrombin 20210 mutation test, fibrinogen level and HIT assay

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57
Q

Infectious esophagitis diagnostic studies

A
  1. Endoscopy in patients with CMV or HIV reveals large, deep ulcers. Infection with HSV is characterized by multiple shallow ulcers. Candidal infection shows white plaques
  2. Cytology or culture from endoscopic brushings is needed for definitive diagnosis
  3. Evaluate for underlying immunodeficiency
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58
Q

Infectious esophagitis treatment

A
  1. Treatment is specific to the type of infection
  2. Fluconazole or ketoconazole for Candida sp.
  3. Acyclovir for HSV
  4. IV ganciclovir for CMV; foscarnet is indicated in cases of poor tolerability or poor response
  5. Treatment of the underlying immunodeficiency, where possible, will aid in both resolution and prevention of esophageal infection. Consider HIV testing
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59
Q

Esophageal neoplasms diagnostic studies

A
  1. Biphasic barium esophagram is the best initial test to visualize the lesion
  2. Endoscopy with brushings is used for diagnosis
  3. Endoscopic sonography and CT may be used for staging
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60
Q

Esophageal neoplasms treatment

A
  1. Treatment of esophageal cancer is generally surgical. Radiotherapy and adjunctive chemotherapy have been used in various combinations with or without surgery
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61
Q

Which type of ulcer improves with food?

A

Duodenal ulcer; with a gastric ulcer, the pain typically worsens, which leads to anorexia and associated weight loss.

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62
Q

H. pylori treatment

A
  1. Combination therapy for H. pylori regimen should be taken for 2-4 weeks. Options include the following:
    a. PPI with clarithromycin and amoxicillin or clarithromycin and addition of metronidazole
    b. Bismuth subsalicylate plus tetracycline, metronidazole, and PPI
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63
Q

ZES diagnostic studies

A
  1. A fasting gastrin level greater than 150 pg/mL indicates hypergasrinemia
  2. A secretin test is needed to confirm the presence of ZES (it will show levels greater than 200 pg/mL)
  3. Endoscopy,CT, or MRI may help to localize the tumor
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64
Q

ZES treatment

A
  1. Use of PPIs controls gastrin secretion

2. Surgical resection of the gastrinoma should be attempted when possible

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65
Q

Bowel obstruction treatment

A
  1. Treatment include NPO, nasogastric suctioning, IV fluids, and monitoring
  2. Partial obstruction in a hemodynamically stable patient may be managed with IV hydration and nasogastric decompression
  3. Urgent surgical consultation is necessary when mechanical obstruction is suspected, especially of the large bowel
  4. Pain management is necessary for patients with bowel obstruction
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66
Q

Volvulus treatment

A
  1. Endoscopic decompression is possible in many cases

2. Surgical evaluation and treatment is required urgently if volvulus fails to quickly resolve by nonsurgical means

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67
Q

Celiac disease diagnostic

A
  1. IgA antiendomysial (EMA) and antitissue transglutaminase (anti-tTG) antibodies are the serologic screening tests
  2. Small bowel biopsy is needed to confirm the diagnosis
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68
Q

Crohn disease treatment

A
  1. For acute attacks, oral corticosteroids (prednisone) are used with or without aminosalicylates (sulfasalazine). Metronidazole or cipro is added in perianal disease, fissures, or fistulae. Infliximab may be used in refractory cases
  2. Elemental diet is nearly as effective as corticosteroids, but relapse is more likely
  3. Mesalamine is generally the best option for maintenance therapy
  4. Smoking cessation, supplements
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69
Q

Ulcerative colitis treatment

A
  1. Topical or oral aminosalicylates (mesalamine) and corticosteroids are the mainstays of medical treatment. Immunomodulators are indicated for refractory disease
  2. Surgery can be curative in UC.
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70
Q

Diverticulitis diagnostic studies

A
  1. Occult blood in the stool and mild to moderate leukocytosis may occur with diverticulitis
  2. Plain-film radiography should be done to r/o free air
  3. CT is warranted if patients do not respond to therapy
  4. Barium enema should be avoided during an acute episode
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71
Q

Diverticulitis treatment

A
  1. Low-residue diet and broad-spectrum antibiotics (Cipro + Flagyl) are appropriate for patients with mild diverticulitis
  2. Hospitalization for IV administration of antibiotics, bowel rest, and analgesics often is required. A nasogastric tube is inserted if ileus develops
  3. Surgical management may be necessary in severe cases, including peritonitis, large abscesses, fistulae, or obstruction
  4. Patients with diverticulosis should maintain a high-fiber diet to prevent diverticulitis. Evidence has negated the need to recommend avoidance of nuts, seeds, and popcorn
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72
Q

Ischemic bowel disease (acute or chronic mesenteric ischemia) diagnostic studies

A
  1. Plain-film radiography and CT are performed to rule out other causes of abdominal pain or to show areas of dilation or edema
  2. All patients should have duplex ultrasound of the mesenteric arteries, which may be confirmed by angiography
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73
Q

Ischemic bowel disease (acute or chronic mesenteric ischemia) treatment

A

Surgical revascularization. Hydration is also a critical factor

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74
Q

Toxic megacolon treatment

A
  1. Decompression of the colon is required. In some cases, colostomy or even complete colonic resection may be required
  2. Careful attention must be paid to fluid and electrolyte balance
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75
Q

Acute cholangitis diagnostic studies

A
  1. RUQ U/S will generally show biliary dilation or stones and is a good initial test
  2. Leukocytosis with left shift along with increased bilirubin and mildly increased transaminase levels support the diagnosis
  3. ERCP is the optimal procedure for both diagnosis and treatment but, unless urgent decompression is necessary, should not be done until the patient is stable
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76
Q

Acute cholangitis treatment

A
  1. Antibiotics (Ceftriaxone + Metronidazole), fluid and electrolyte replacement, and analgesia are the initial treatment
  2. ERCP can be done once the patient is stable. Percutaneous biliary drainage or surgical biliary drainage may be required
  3. Cholecystectomy should be performed after the acute syndrome is resolved
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77
Q

Primary sclerosing cholangitis treatment

A
  1. Localized strictures may be relieved with balloon dilation and stent placement. Long-term stenting increases risk of cholangitis
  2. Liver transplant is the only treatment with a known survival benefit
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78
Q

Hepatitis B surface antigen (HBsAg)

A
  1. First detectable marker
  2. Hallmark of active infection
  3. HBsAg >6 months =chronic infection
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79
Q

Antibody to surface antigen (anti-HBs)

A
  1. Synonymous with HBsAb

2. Signifies recover and immunity (either by past infection or vaccination)

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80
Q

Antibody to hepatitis B core antigen (anti-HBc) IgM and IgG

A
  1. IgM anti-HBc: Indicates acute or recent infection

2. IgG anti-HBc: Indicates prior or resolving infection; persists indefinitely

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81
Q

Hepatitis B e-antigen (HBeAg)

A

Used as an index of infectivity

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82
Q

Antibody to hepatitis B e-antigen (anti-HBe)

A
  1. Indicates lower levels of HBV DNA
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83
Q

Treatment of Hep B when the patient also has HIV

A

Tenofovir with either emtricitabine or lamivudine

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84
Q

Spontaneous bacterial peritonitis treatment

A

Cefotaxime

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85
Q

Glomerulonephritis diagnostic studies

A
  1. Antistreptolysin-O titer is increased and should be considered if there is a possibility of a recent streptococcal infection
  2. UA reveals hematuria, RBC casts, and proteinuria
  3. Serum complement (C3) levels are often decreased
  4. Renal biopsy may be done to determine the exact diagnosis or severity of disease
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86
Q

Glomerulonephritis treatment

A
  1. Steroids and immunosuppressive drugs (cyclophosphamide) may be used to control the inflammatory response, which is responsible for the damage. These are usually not needed in PSGN
  2. Dietary management: Salt and fluid intake should be decreased
  3. Dialysis should be performed if symptomatic azotemia is present
  4. Medical therapy: ACEI in chronic GN
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87
Q

Diabetes insipidus treatment

A
  1. Neurogenic or central DI is best treated with parenteral or intrasnasal desmopressin
  2. Diuretics, chlorpropamide, or carbamazepine can be used in patients with mild disease
  3. Nephrogenic diabetes can be treated with HCTZ or amiloride diuretics or indomethacin. Adequate water intake is essential to prevent dehydration
  4. Dietary measures, such as limiting salt and protein intake, can be helpful in nephrogenic DI
88
Q

Bladder CA diagnostic studies

A
  1. CBC and blood chemistry should be done to evaluate for infection and renal function
  2. Cystoscopy is the definitive diagnostic procedure. Biopsy confirms the pathologic diagnosis
  3. Radiologic procedures include IV urogram, pelvic and abdominal CT, chest radiography, bone scan, and retrograde pyelography for renal pelvic or ureteral tumors and staging
89
Q

Erectile dysfunction diagnostic studies

A
  1. CBC, urinalysis, lipid profile, thyroid function tests, serum testosterone, glucose, and prolactin screening should be done, depending on the suspected cause
  2. Measurement of FSH and LH may be required for patients with abnormalities of testosterone or prolactin
  3. Nocturnal penile tumescence testing
  4. Direct injections of vasoactive substances
90
Q

Amenorrhea diagnostic studies

A
  1. First line test is beta-hCG for pregnancy, TSH, and prolactin
  2. Serum FSH, estrogen, LH, and testosterone levels
  3. Progesterone challenge test
  4. Other tests: thyroid studies, MRI or CT of the hypothalamus and pituitary or pelvis, genetic testing, and pelvic and transvaginal ultrasonography
91
Q

PMS diagnostic studies

A
  1. Tests include daily charting of symptoms, the specific constellation of symptoms is less important than their cyclical pattern of occurrence
  2. Thyroid studies and CBC are used to r/o thyroid disease and anemia
92
Q

PMS drug treatment

A
  1. Pyridoxine (vitamin B6) and evening primrose oil show no benefit but do relieve breast tenderness and depression in some women
  2. +/- OCP
  3. Diuretics (e.g., spironolactone) may be useful for fluid retention symptoms; bromocriptine may help relieve mastalgia
  4. NSAIDs for pain
  5. SSRIs have proven to be beneficial in some patients
93
Q

Menopause diagnostic studies

A

FSH > 30 mIU/mL

94
Q

Dysfunctional uterine bleeding diagnostic studies

A
  1. Urinary beta-hCG levels
  2. CBC, possibly iron studies, PT and PTT, documentation of ovulation, TSH, serum progesterone levels, LFTs, and prolactin and serum FSH levels are needed
95
Q

Uterine fibroids treatment

A
  1. Observation is recommended in most cases of leiomyomata
  2. Symptomatic patients may undergo myomectomy, hysterectomy, or D&C
  3. GnRH agonists (depot leuprolide) and mifepristone may reduce tumor size; in women with small leiomyomata, GnRH agonists may restore fertility. Treatment is limited to 6 months
  4. Use of uterine arterial embolization or endometrial ablation as a treatment for fibroid is increasing for women who have no desire of future fertility
  5. Hysterectomy is the final step
96
Q

Endometrial CA diagnostic studies

A
  1. Women with postmenopausal bleeding should have a Pap smear, endocervical curettage, and endometrial biopsy
  2. Other tests include fractional D&C and transvaginal ultrasonography
97
Q

Endometriosis treatment

A
  1. Total hysterectomy combined with bilateral salpingo-oophorectomy is the basis of treatment and staging
  2. Radiotherapy may be indicated. Chemotherapy is used at advanced stages
  3. Recurrence is treated with high-dose progestins or antiestrogens
98
Q

Endometriosis diagnostic studies

A

Ultrasonography and laparoscopy

99
Q

Endometriosis treatment

A
  1. It is based on the severity of symptoms, location and severity of disease, and desire for childbearing
  2. In women with few symptoms, expectant management may suffice
  3. NSAIDs and prostaglandin synthetase inhibitors may relieve discomfort
  4. Combined OCPs or progestins (SQ DMPA) may relieve symptoms
  5. Surgery may be conservative or definitive; large endometriomas must be resected
  6. Treatment with danazol or GnRH agonist around surgery improves fertility
100
Q

Adenomyosis diagnostic studies

A
  1. Pelvic ultrasonography must detect adenomyosis
  2. Pregnancy should be ruled out
  3. Endometrial biopsy, fractional D&C, or hysteroscopy in a patient with suspected adenomyosis will r/o endometrial cancer
101
Q

Adenomyosis management

A
  1. May be treated with D&C, a GnRH agonist (Leuprorelin), or mifepristone; hysterectomy is the definitive therapy
  2. Hormonal therapy has not been successful
102
Q

Uterine prolapse treatment

A
  1. Nonsurgical approaches include weight reduction, smoking cessation, pelvic muscle exercises, and use of a vaginal pessary
  2. Surgical treatment relieves symptoms, restores normal anatomic relationships and visceral function, and allows coitus
103
Q

Ovarian cysts diagnostic studies

A

Pelvic ultrasound

104
Q

Ovarian cysts treatment

A
  1. Follow for one or two cycles in premenopausal women with cysts smaller than 8 cm
  2. Large or persistent cysts require laparoscopic evaluation
  3. Cysts in postmenopausal women are presumed to be malignant until proven otherwise
  4. OCPs have not been proven in treating functional cysts
105
Q

PCOS diagnostic studies

A
  1. U/S may demonstrate a characteristic “string of pearls” or “oyster ovaries” appearance within the ovaries
  2. Labs reveal mildly elevated serum androgen levels, increased LH/FSH ratio, lipid abnormalities, and insulin resistance
106
Q

PCOS treatment

A
  1. Weight reduction improves hirsutism, lipid and glucose parameters, and infertility
  2. Hirsutism is treated with androgen-lowering agents, including OCPs
  3. Infertility is usually treated with clomiphene citrate
  4. Lipid abnormalities and insulin resistance should be managed medically. Adding metformin increases ovulation and pregnancy rates
107
Q

Ovarian cancer diagnostic treatments

A
  1. The BRCA1 gene testing; CA-125 may be used to follow treatment, particularly in postmenopausal women
  2. An association exists with mutations in the P53 tumor suppression gene
  3. Transvaginal or abdominal U/S is useful in distinguishing benigns from potentially malignant masses
108
Q

Cervical dysplasia and neoplasia treatment

A
  1. Mild lesions may resolve spontaneously
  2. Preinvasive neoplasia may be treated with electrocautery or cryocautery, laser therapy, conization, large loop excision of transitional zonem or LEEP
  3. Hysterectomy and pelvic lymphadenectomy or radiation therapy is indicated for more severe abnormalities
109
Q

Neoplasm of the vulva and vagina diagnostic studies

A
  1. Application of acetic acid or staining with toluidine blue may help to direct biopsies of suspicious vulvar lesions
  2. Vaginal biopsy for suspected vaginal invasive neoplasm should be directed by colposcopy or Lugol staining
  3. Clear cell adenocarcinoma is diagnosed by careful inspection and palpation of the vagina and cervix
110
Q

Neoplasm of the vulva and vagina management

A
  1. Local excision, topical 5-FU, and laser therapy are used for early vulvar lesions
  2. Surgical excision is required for most vaginal neoplasms; primary vaginal cancer is treated with radiotherapy
  3. For clear cell lesions, radical hysterectomy and vaginectomy or radiation therapy is effective
111
Q

Mastitis treatment

A
  1. Antibiotics (cloxacillin, dicloxacillin, or nafcillin) or a cephalosporin and hot compresses. Breast-feeding may continue because the source is likely to be infant’s oropharynx
  2. Surgical treatment may be required for abscesses or duct ectasia
112
Q

Fibrocystic changes of the breast treatment

A
  1. Many types of fibrocystic breast problems need no treatment other than a supportive bra
  2. Some patients respond to low-salt diet, vitamin E supplementation, or HCTZ premenstrually
113
Q

Pelvic inflammatory disease (PID) diagnostic studies

A
  1. DNA probes for gonorrhea and chlamydia (most common cause of PID) have largely replaced Gram staining and culture of any discharge
  2. Transvaginal ultrasonography is helpful in differentiating acute and chronic inflammation or the presence of adnexal masses
  3. Diagnostic culdocentesis or laparoscopy may be required
114
Q

PID treatment

A
  1. Women with mild disease can be treated as outpatients with antibiotics, analgesics, and bed rest. If present, an IUD should be removed
  2. Women with severe disease should be hospitalized for IV antibiotic therapy and possible surgery
  3. Sex partners should be evaluated and treated
115
Q

Ectopic pregnancy diagnostic studies

A
  1. Serum levels of hCG normally double every 48 hours. If serial increases of hCG are less than expected, ectopic gestation should be suspected until the diagnosis has been definitively excluded
  2. Transvaginal ultrasonography is diagnostic in 90% of cases of ectopic gestation
  3. Women with hCG titer of greater than 1500 mU/mL should show evidence of a developing intrauterine gestation on transvaginal ultrasound. If no such evidence is found, ectopic pregnancy is the clinical diagnosis
116
Q

Ectopic pregnancy treatment

A
  1. Medical treatment with methotrexate can be used to treat up to 80% of ectopic gestations when diagnosed early.
  2. Surgical treatment involves removal of the ectopic gestation most commonly via laparoscopy. Laparotomy usually is reserved for patients with known significant abdominal adhesions or those who are clinically unstable
  3. F/up testing using serum hCG levels or pelvic examination is crucial to exclude any remaining evidence of pregnancy
117
Q

Criteria for methotrexate treatment in ectopic pregnancy

A
  1. Serum hCG titer of less than 5000 mU

2. Ectopic mass

118
Q

Gestational trophoblastic disease (GTD) diagnostic studies

A
  1. With complete molar pregnancy, the hCG level is often greater than 100,000 mU/mL.Persistently elevated levels of hCG may indicate gestational trophoblastic tumor
  2. U/S of a complete hydatidiform mole shows a characteristic “grapelike vesicles” or “snowstorm” appearance consistent with the swelling of the chorionic villi. It may also aid in the diagnosis of a partial mole pregnancy
119
Q

Gestational trophoblastic disease treatment

A
  1. Treatment depends on tumor classification. Benign tumors and low-risk metastatic tumors can be treated with chemotherapy. Metastatic high-risk tumors require a combination of chemotherapy with or without adjuvant radiation and surgery
  2. Surgical treatment includes suction curettage and hysterectomy
  3. After evacuation, patients must be monitored with serial hCG to assure return to baseline and to diagnose and manage sequelae properly. Contraception is recommended for 6-12 months after remission
120
Q

Gestational diabetes diagnostic studies

A
  1. Screening consists of administering a nonfasting 50 g glucose challenge test, followed by a serum glucose test 1 hour later. If the one hour serum glucose value is greater than 130 mg/dL, a 3 hour glucose tolerance test is performed
  2. The 3 hour glucose tolerance test consists of a 100 g glucose load in the morning after an overnight fast . Serum glucose levels are taken at fasting and then at 1, 2, and 3 hours after the glucose load. If two or more of the values are abnormal then the patient is diagnosed with gestational diabetes (see pg. 170 for values)
121
Q

Septic arthritis diagnostic studies

A
  1. Synovial fluid should be collected

2. Radiographs usually only show soft-tissue swelling

122
Q

Septic arthritis treatment

A
  1. Aggressive treatment with IV antibiotics for 2 weeks is required. Ceftriaxone is recommended for empiric treatment
  2. Athrotomy and arthrocentesis often are required
  3. Oral antibiotics should follow the IV antibiotics for up to an additional 4 week
123
Q

Psoriatic arthritis diagnostic studies

A
  1. ESR is elevated; nomocytic nomochromic anemia is seen
  2. Hyperuricemia may occur when skin involvement is severe
  3. RF is normal
  4. “Pencil in cup” deformities of the proximal phalanx are demonstrated on radiography
124
Q

Psoriatic arthritis treatment

A

NSAIDs for mild cases; methotrexate

125
Q

Reactive arthritis diagnostic studies

A
  1. HLA-B27
  2. Synovial fluid is usually culture negative
  3. Evidence of permanent and progressive joint disease may be present on radiography
126
Q

Reactive arthritis treatment

A
  1. Physical therapy and NSAIDs are the mainstay of treatment
  2. Antibiotics given at the time of infection will reduce the chance of developing the disorder but do not alleviate the symptoms of the reactive arthritis
127
Q

SLE diagnostic studies

A
  1. CBC, CMP, urinalysis, ESR, and serum complement (C3 or C4)
  2. Antibodies to smith antigen, double stranded DNA, or depressed levels of serum complement may be used as markers for progression of the disease
  3. ANA is present
128
Q

SLE treatment

A
  1. Regular exercise and sun protection are important for all patients
  2. NSAIDs are often used for musculoskeletal complaints
  3. Antimalarials (hydroxychloroquine) may be used for musculoskeletal complaints and cutaneous manifestations
  4. Corticosteroids
  5. Methotrexate is used at low doses
129
Q

Polymyositis diagnostic studies

A
  1. Creatinine phosphokinase (CPK) and aldolase will be elevated
  2. Muscle biopsy should be performed
130
Q

Polymyositis treatment

A
  1. Treated with high dose steroids, methotrexate, or azathioprine until symptoms resolve
131
Q

Polymyalgia rheumatica treatment

A
  1. Patients respond quickly to low-dose corticosteroid therapy, which may be required for up to 2 years and slowly tapered
  2. Higher doses are required if giant cell arteritis is present; treatment should not be delayed while awaiting biopsy
132
Q

Polyarteritis nodosa diagnostic studies

A
  1. The diagnosis is usually established by vessel biopsy or angiography
  2. Elevated ESR and CRP and proteinuria may be present as well as a positive hepatitis B surface antigen (HBsAg)
  3. Presence of ANCA is suggestive but not diagnostic
133
Q

Polyarteritis nodosa treatment

A
  1. Initial treatment is with high doses of corticosteroids
  2. Cytotoxic drugs and immunotherapy (azathioprine or methotrexate) also may be used. Concomitant treatment of hepatitis B may be required.
  3. HTN should be treated if present
134
Q

Scleroderma diagnostic studies

A
  1. ANA is present in 90% of patients with diffuse scleroderma
  2. Anticentromere antibody is associated with CREST syndrome and anti-SCL-70 antibody is associated with diffuse disease
  3. Patients should be monitored for the development of HTN, heralding kidney involvement
135
Q

Scleroderma treatment

A
  1. There is no cure
  2. Treatment is aimed at organ-specific disease processes (i.e., PPIs for reflux disease, ACEI for renal disease, avoidance of triggers and CCBs for Raynaud, and immunosuppressive drugs for pulmonary HTN)
136
Q

Sjogren syndrome diagnostic studies

A
  1. RF, ANA, anti-Ro antibodies, and anti-La antibodies

2. Schirmer test (evaluates tear secretions by the lacrimal glands. Wetting of

137
Q

Sjogren syndrome treatment

A
  1. Mainly symptomatic. This can be achieved by using artificial tears and saliva, increased oral fluid intake, and ocular and vaginal lubricants
  2. Pilocarpine may increase saliva flow
  3. Cyclosporine may improve ocular symptoms
138
Q

Fibromyalgia diagnostic studies

A
  1. It is recognized by the typical pattern of pain and other symptoms as well as by the exclusion of contributory or underlying diseases such as hypothyroidism, hepatitis C, and vitamin D deficiency
  2. There are no routine lab markers; it is often a diagnosis of exclusion
139
Q

Fibromyalgia treatment

A
  1. SSRIs, SNRIs, and TCAs (amitriptyline) are helpful; NSAIDs are not
  2. Pregabalin (Lyrica) is the only drug that is FDA-approved for the treatment of fibromyalgia. Side effects include fatigue, trouble concentrating, sleepiness, and edema
  3. Aerobic exercise improves conditioning and has been shown to improve functioning as long as overtraining is avoided
  4. Patient education, stress reduction, sleep assistance, and treatment of psychological problems may alleviate some of the symptoms
140
Q

Tendinitis and tenosynovitis treatment

A
  1. Ice, rest, stretching may help to alleviate inflammation
  2. NSAIDs may alleviate pain but do not penetrate the tendon circulation adequately. An injection with corticosteroids combined with anesthesia and administered alongside the tendon may be beneficial
141
Q

Bursitis treatment

A

Prevention of precipitating factors, rest, NSAIDs, and steroid injections

142
Q

Osteomyelitis diagnostic studies

A
  1. CBC, CRP, and ESR
  2. Identification of the infectious organism by blood culture or bone biopsy is best
  3. Radiographic evidence of osteomyelitis lags behind symptoms and pathologic changes by 7-10 days. U/S can be useful for early detection of acute osteomyelitis
  4. MRI shows the changes before plain-film radiography or bone scan
143
Q

Osteomyelitis treatment

A
  1. Acute osteomyelitis is treated with a 6- to 8-week course of IV antibiotics (vancomycin + cipro)
  2. Chronic osteomyelitis is treated with a minimum of 4 weeks to 24 months of IV and po antibiotics
  3. Immobilization and surgical drainage may be indicated
  4. Surgical debridement may be required
144
Q

Fractures diagnostic studies

A
  1. AP and lateral films
  2. Radionucleotide bone scanning shows increased uptake at the site of an occult fracture or stress fracture
  3. CT is a better diagnostic method than plain-film radiography or bone scans
  4. MRI is the study of choice to diagnose an occult hip fracture
145
Q

General treatment of fractures

A

Analgesics, immobilization, and emergent referral to an orthopaedist

146
Q

Open fractures treatment

A
  1. Any bleeding fracture should be considered an open fracture until proven otherwise
  2. Ideally, they must be debrided and irrigated within 4-8 hrs of injury
  3. IV antibiotics (gentamicin) should be administered for 48 hours after fracture and for 48 hours after surgical procedures
  4. Immobilization and fixation should be performed to preserve function
147
Q

Intra-articular fractures treatment

A
  1. Open treatment may be indicated to restore and maintain articular congruity
  2. When stable, consider active ROM
148
Q

Femur fractures treatment

A
  1. Treat femoral neck fractures with percutaneous screws or hemiarthroplasty, femoral shift fractures with intramedullary rods or plates, and intertrochanteric fractures with sliding hip screw fixation or a long gamma nail
  2. There is significant potential for hemorrhage with fractures of the femur
149
Q

Tibia and fibula fractures: treatment

A
  1. Fractures of the tibia and fibula are associated with ligamental, meniscal, and vascular injuries
  2. For simple fractures, closed reduction with cast placement is appropriate; for more complicated or unstable fractures, ORIF is required
150
Q

Dislocations and subluxations: Treatment

A
  1. After assessment of the neurovascular status, most dislocations are treated with closed reduction
  2. Dislocations that reduce spontaneously require immobilizations for 2-4 weeks, followed by ROM activity and return to normal activity
  3. If associated fractures or interposed soft tissues are present, the patient needs to undergo ORIF
  4. It is imperative to assess the neurovascular status pre- and postreduction as well as get postreduction radiographs to ensure adequate reduction
151
Q

Strains and sprains treatment

A

Both strains and sprains require supportive therapy: rest, ice, compression, elevation, and support/bracing (RICES)

152
Q

TMJ treatment

A
  1. Suggestion of conservative lifestyle changes and behavior modification can be helpful
153
Q

Neck pain treatment

A
  1. Conservative treatment involves the use of a cervical collar, traction, physical therapy, and analgesics
  2. In advanced disease, cervical fusion or diskectomy may be necessary
154
Q

Rotator cuff syndrome diagnostic studies

A
  1. Radiographs are useful in ruling out calcific tendinitis, glenohumeral or acromioclavicular arthrosis, and bone tumors
  2. Arthrography or MRI can be used to diagnose tears
155
Q

Rotator cuff syndorme treatment

A
  1. Aggravating factors must be avoided
  2. NSAIDs may help to alleviate inflammation and pain
  3. Local steroid injections may be considered
  4. PT may provide relief
156
Q

Shoulder dislocation diagnostic studies

A
  1. AP view of the shoulder as well as a transthoracic “Y” view
  2. Possible MRI
157
Q

Shoulder dislocation treatment

A
  1. Reduction and immobilization
  2. Postreduction films should be obtained and neurovascular status should be assessed
  3. Immobilization by sling and swath (Velpeau sling) is recommended for all
  4. Therapy begins after 3 weeks for those younger than 40 and in one week for those after 40 years of age.
158
Q

Adhesive capsulitis diagnostic studies

A

Arthrography (may show decreased volume of the joint capsule and capsular contraction)

159
Q

Adhesive capsulitis treatment

A

NSAIDs, passive ROM, and occasionally, manipulation under anesthesia

160
Q

Clavicle fracture diagnostic studies

A

An AP view generally will visualize the fracture

161
Q

Clavicle fracture treatment

A
  1. In children, the figure-of-eight sling is used for 4-6 weeks
  2. In adults, a sling for 6 weeks is generally enough to treat the fracture
162
Q

Acromioclavicular separation imaging studies

A
  1. An AP view of both shoulders usually is necessary
  2. Mild separations may require stress films that are obtained while the patient holds a weighted object to reveal the separation
163
Q

Acromioclavicular separation treatment

A
  1. Conservative management is possible for mild to moderate injuries because they can be managed with a sling and analgesia
  2. More severe injuries usually will require operative repair
164
Q

Humeral head fractures imaging studies

A
  1. AP, lateral, and “Y” views typically are diagnostic
165
Q

Humeral head fracture treatment

A
  1. Closed reduction with the application of a sling and swath (Velpeau sling) can treat most nondisplaced fractures. Early mobilization with pendulum exercises is indicated to prevent frozen shoulder
  2. ORIF is reserved for the management of displaced fractures
166
Q

Humeral shaft imaging studies

A

AP and lateral views that include the elbow and shoulder should be performed.

167
Q

Humeral shaft treatment

A
  1. Initial treatment usually is the application of a coaptation splint
  2. The coaptation splint can be followed by a hanging cast, Sarmiento brace, or operative repair
168
Q

Supracondylar humerus fracture imaging studies

A
  1. AP and lateral views generally are sufficient to make the diagnosis
  2. In children, always obtain comparative views
169
Q

Supracondylar humerus fracture treatment

A
  1. Treatment involves closed reduction in the OR with posterior splint application for displaced fractures in children
  2. Adults should have ORIF
170
Q

Carpal tunnel diagnostic studies

A

Nerve conduction studies and EMG

171
Q

Carpal tunnel treatment

A
  1. Activity modification, volar wrist splint, and NSAIDs (except in pregnancy)
  2. Steroid injections may be used
  3. Surgical interventions may be needed
172
Q

Boxer’s fracture treatment

A

Fractures with 25-30 degrees of angulation should be reduced with the application of an ulnar splint with f/up in 1-2 weeks

173
Q

Colles Fracture treatment

A

Cast immobilization is adequate after reduction in most cases

174
Q

Gamekeeper’s thumb treatment

A

Surgical repair is indicated for a complete rupture, a partial rupture may be treated by immobilization with a thumb spica cast

175
Q

Lateral epicondylitis diagnostic studies

A
  1. AP and lateral views of the elbow may demonstrate osteophytes overlying the lateral epicondyle
  2. MRI is useful in demonstrating tendon disruption
176
Q

Lateral epicondylitis treatment

A

a. Cessation of the provocative activity for at least 6 weeks is probably the most important component in the
treatment.
b. Counterbalance braces (tennis elbow braces) are beneficial.
c. Instruct the patient to pick up objects with the extremity in supination.
d. Physical and occupational therapy
e. Steroid injections may give short-term relief but do not offer long-term treatment.
f. NSAIDs frequently are used
g. Surgery is reserved for those patients who fail at least 6 months of conservative management.

177
Q

Medial epicondylitis imaging studies

A

MRI is typically not indicated but is useful for assessing the ulnar nerve

178
Q

Medial epicondylitis treatment

A

a. Conservative management, including cessation of precipitating activity, NSAIDs, and physical and occupational therapy, most commonly is used.
b. A medial counterforce brace frequently is applied.

179
Q

Olecranon bursitis treatment

A

a. Avoid continued trauma to elbow and use ace wrap for compression. Aspiration of the bursa is not
recommended unless infection is suspected.
b. NSAIDs and warm compresses are used for their analgesic properties.

180
Q

Radial head fracture diagnostic studies

A

AP and lateral films of the elbow usually are sufficient to establish the diagnosis. CT is useful in determining the degree of comminution

181
Q

Scaphoid (navicular) fracture imaging studies

A
  1. AP, lateral, and scaphoid views should be ordered. If negative initially, films may be repeated after 2-3 weeks, at which time the fracture may become apparent
  2. Bone scan or MRI can be used to make the diagnosis at the time of injury
182
Q

Scaphoid (navicular) fracture treatment

A
  1. A delay in diagnosis should be avoided. If it is suspected, it should be treated as a fracture in a long-arm thumb spica cast until bone scan or MRI can be done
  2. There should also be a referral to an orthopaedic surgeon
  3. For displaced: Long arm thumb spica cast. For nondisplaced: referral to an orthopaedic specialist
  4. Displacement of 1 mm or greater requires ORIF
183
Q

de Quervain disease initial treatment

A
  1. Conservative treatment for at least one month using a thumb spica splint, NSAIDs, and physical/occupational therapy is required
184
Q

Red flags that indicate a need for urgent back radiography

A

Fever, weight loss, morning stiffness, history of IV or steroid use, trauma, history of CA, saddle anesthesia, loss of anal sphincter tone, or major motor weakness

185
Q

Low back pain treatment

A
  1. Short-term relative rest (maximum of 2 days) with support under the knees and neck and administration of NSAIDs or analgesics are the first components of treatment
  2. Progressive ambulation to normal activity may follow
  3. A fitness program should be implemented for back rehab
  4. If no improvement occurs after 6 weeks, perform further evaluation with bone scan, MRI, CT, or EMG and a medical workup to rule out spinal tumor or infection
186
Q

Ankylosing spondylitis (AS) diagnostic studies

A
  1. Elevated levels of ESR and CRP are seen. Also HLA-B27 positive
  2. Sacroiliitis is an early radiographic finding. “Bamboo appearance”
  3. Generalized osteopenia of the spine may be seen
187
Q

Ankylosing spondylitis treatment

A
  1. PT with emphasis on posture, extension exercises, and breathing exercises. Swimming is considered the best overall exercise
  2. NSAIDs are the first-line treatment. If there is resistance to NSAIDs, TNF inhibitors have been used with great success
  3. Spine fractures need intervention and stabilization
188
Q

Cauda equina syndrome

A

This is a surgical emergency requiring immediate referral

189
Q

Aseptic necrosis of the hip imaging

A
  1. MRI is the study of choice
  2. Radiography may be normal in the beginning
  3. Bone scans are useful but less sensitive than MRI
190
Q

Aseptic necrosis of the hip treatment

A
  1. Protected weight bearing for early stage disease is considered a temporary treatment. Alendronate has been used to prevent early collapse
  2. Surgical options range from core decompression to total hip replacement
191
Q

Meniscal injury treatment

A
  1. Initial treatment consists of activity modification, NSAIDs, quadriceps strengthening exercises and time
  2. Indications for arthroscopy includes persistent symptoms unresponsive to conservative treatment or irreducible locking
192
Q

Hypoparathyroidism treatment

A
  1. Maintenance therapy includes oral calcium (1-2 g/day) and vitamin D preparations. Calcitrol is also used. Magnesium supplementation may also be required
  2. Phenothiazines and furosemide should be avoided
193
Q

Hyperthyroidism diagnostic studies

A
  1. T3 and free T4 levels (will be elevated)
  2. TSH levels (will be low)
  3. Peroxidase antibodies and thyroglobulin antibodies (+ in Graves disease but not in toxic multinodular goiter)
  4. Radioactive iodine uptake
  5. MRI or CT scan of the orbits is performed for severe or unilateral ocular signs or when causation may be other than Graves
194
Q

Hyperthyroidism treatment

A
  1. Beta blockers (primarily propanolol) for symptoms
  2. PTU (for preggers) or MMI
  3. Ophthalmopathy respond best to IV methylprednisolone but may respond to high dose, tapered prednisone treatment, particularly in nonsmokers
  4. For atrial fibrillation, it is not likely to convert electrically.
    a. Digoxin may be used in large doses and beta blockers with caution (especially in the presence of cardiomyopathy or heart failure)
    b. Anticoagulation with warfarin is recommended
195
Q

Side effects of PTU

A

Arthritis, lupus, aplastic anemia, thrombocytopenia, and hepatic necrosis

196
Q

Side effects of methimazole

A
  1. Less risk of hepatic necrosis

2. Serum sickness, cholestatic jaundice, alopecia, nephrotic syndrome, and hypoglycemia

197
Q

Hypothyroidism treatment

A
  1. Levothyroxine. Remember to adjust dosage after 4-6 weeks

2. Assess patients for adrenal insufficiency and angina prior to initiating treatment

198
Q

Thyroiditis suppurative diagnostic studies

A
  1. Fine-needle aspiration (FNA) with Gram stain and culture is required
199
Q

Thyroiditis suppurative treatment

A

Medications for the underlying cause (i.e., dicloxacillin) and surgical drainage with fluctuation

200
Q

Subacute painful thyroiditis background

A
  1. It is the most common cause of a painful thyroid gland

2. It is believed to be the result of a preceding viral illness

201
Q

Subacute painful thyroiditis labs

A
  1. Thyrotoxicosis initially presents, followed by a period of hypothryoidism with resumption of euthyroid within 12 months
  2. The ESR is markedly elevated and antithyroid antibody titers are low
202
Q

Subacute painful thyroiditis treatment

A
  1. Treatment of choice is ASA
  2. Steroids have proven no additional benefit
  3. Symptoms may be lessened with beta blockers and iodinated contrast products. Antithyroid medication is usually of no benefit.
203
Q

Types of thyroid nodules

A
  1. Follicular adenoma is the most common type
  2. Papillary adenomas are very rare
  3. Hurtle cell has eosinophilic staining and has malignant potential
204
Q

Thyroid nodules work-up

A
  1. If the TSH is low, the patient should be assessed for hyperthyroidism and undergo radionuclide thyroid scan. Cold nodules (no uptake) are hypofunctioning and require surgery. Hot nodules (increased uptake) are functional, and therefore, carry a lower risk of malignancy
  2. High-resolution U/S is the test of choice
  3. Malignancy is suspected in the presence of irregular or indistinct margins, heterogenous echogenicity, intranodular vascular margins, microcalcifications, complex cyst patters, or size greater than 1 cm.
  4. Lesions suspicious for malignancy should undergo U/S guided FNA
205
Q

Cushing syndrome diagnostic studies

A
  1. First, determine cortisol excess using overnight dexamthasone suppression test. Additional testing includes a 24-hour urine collection for free cortisol and creatinine. Late night salivary cortisol assays may also be useful
  2. Plasma or serum ACTH of less than 20 pg/mL suggests an adrenal tumor; higher levels suggest pituitary or ectopic production
  3. MRI is preferred to identify pituitary tumors.
206
Q

Cushing syndrome treatment

A
  1. Transsphenoidal selective resection of the pituitary tumor cures 75-90%
  2. Irradiation for non-resectable tumors
  3. Medical therapy before surgery can inhibit glucorticoid synthesis. Mitotane, metyrapone, or ketoconazole may suppress hypercortisolism. Parenteral octreotide suppresses ACTH in one third of cases
207
Q

Addison disease diagnostic studies

A
  1. CBC, CMP

2. Low (

208
Q

Addison disease treatment

A
  1. Primary disease is treated with a combination of corticosteroids and mineralcorticoids. These include oral hydrocortisone or prednisone and fludrocortisone acetate for its sodium-retaining effect
  2. DHEA may be give
  3. Patients must be fully informed about their condition
209
Q

Signs of anterior circulation stroke

A

Aphasia, apraxia, hemiparesis, hemisensory losses, and/or visual field defects

210
Q

Signs of posterior circulation stroke

A

Coma, drop attacks, vertigo, nausea, vomiting, and/or ataxia

211
Q

Stroke diagnostic studies

A
  1. CBC, ESR, platelet count, PT, PTT, lipid panel, and blood glucose level
  2. Additional tests: VDRL test for syphilis, HIV antibody, Lyme disease antibody, antinuclear antibodies, and antiphospholipid antibodies depending on patient risk factors
  3. Blood cultures should be considered if endocarditis is suspected
  4. Non-contrast CT is recommended during the acute phase
  5. Cardiac monitoring
  6. Lumbar puncture and angiography should be reserved for patients with suspected hemorrhage or vascular malformations
212
Q

Stroke treatment

A
  1. Thrombolytic therapy (recombinant tissue plasminogen factor) is given to reduce the extent of deficit; it is most effective if given within 3 hours of symptoms but can be attempted up to 4.5 hours after the onset of symptoms
  2. Antiplatelet therapy is initiated for ischemic stroke and TIA, whereas anticoagulant therapy is indicated in the setting of cardiac emboli
  3. Endarterectomy may be indicated if greater than 70% stenosis of the common or internal carotid artery is present
  4. Hemorrhagic stroke is treated with conservative and supportive measures, including management of hypertension and antiedema therapy (mannitol and corticosteroids). Endovascular repair and surgical clipping or coil embolization are options available for some patients with specific anatomic foci
  5. Long-term supportive therapy, follow-up physical therapy, and social supports are important
213
Q

If the TIA is related to a disturbance in the carotid circulation, patients may demonstrate what signs and symptoms?

A

Contralateral hand-arm weakness with sensory loss, ipsilateral visual symptoms or aphasia, and/or amaurosis fugax. Carotid bruit may be present, but with a high-grade stenosis, it may be absent

214
Q

If the TIA is related to a disturbance in the vertebrovascular circulation, what are the signs and symptoms?

A

Diplopia, ataxia, vertigo, dysarthria, crania nerve palsies, lower extremity weakness, dimness or blurring of vision, perioral numbness, and/or drop attacks

215
Q

TIA diagnostic studies

A
  1. Noninvasive transcranial Doppler and duplex ultrasound. CT angiography or MRI are other options (minimally invasive) to evaluate the patient; conventional angiography remains the definitive study but is invasive and associated with a small risk of stroke
  2. Head CT or MRI will exclude a possible small cerebral hemorrhage
  3. Cardiac workup should be done to exclude arrhythmia and new murmurs
  4. Hematologic workup (ESR, CBC, lipid panel, PT, PTT, and antiphospholipids)
216
Q

TIA treatment

A
  1. Prophylactic antiplatelet therapy is initiated with the TIA is not cardiogenic. This therapy might include aspirin, clopidogrel, ticlopidine, or ASA/extended-release dipyrimadole
  2. Cardiogenic TIA requires anticoagulation initially with IV heparin for those who are admitted to the hospital and with warfarin for long-term therapy
  3. Carotid endarterectomy may be indicated in patients with anterior circulation TIAs and moderate to high-grade carotid stenosis on the side appropriate to account for the symptoms
  4. Adjunctive therapies include control of BP, cholesterol, glucose, and afib.
217
Q

Cerebral aneurysm/subarachnoid hemorrhage diagnostic studies

A
  1. Noncontrast CT is the initial imaging study for suspected SAH
  2. Lumbar puncture with evaluation of CSF
  3. Cerebral angiography
  4. Electroencephalography

A Comprehensive Review for the Certification and Recertification Examination for Physician Asistants (8 decks)

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