fibro, rsd, sys exert intol dis,

Question 1

What are the 7 items included in the standard general anxiety scale?

Answer 1

The general anxiety disorder 7 item scale rates feeling anxious, inabliitly to stop worrying, worrying too much about different things, trouble relaxing, too restless to sit still, afraid something awful might happen, and being easily annoyed or irritable giving 0 to 3 points per item depending on frequency of daily occurrence. A total score >15 Indicates severe anxiety.

Question 2

What are the red flags indicating the need for further evaluation in cases of backache of recent onset?

Answer 2

Red flags indicating possible definite cause for backache include: trauma, unexplained weight loss, age over 50 especially if osteoporotic, unexplained fever, history of urinary tract or other infections, immunosuppression, diabetes mellitus, history of cancer, intravenous drug abuse, long use of corticosteroids, age greater than 70, focal neurologic deficit, progressive or disabling symptoms, associated bowel or bladder dysfunction, duration longer than six weeks, and prior spinal surgery.

Question 3

What commonly causes bilateral knee pain in an adolescent with normal x-rays?

Answer 3

Billateral anterior knee pain is a descriptive diagnosis for a condition formally called chondromalacia patella. The descriptive term is more honest as chondromalacia is difficult to demonstrate as a specific cause of knee pain and is often asymptomatic. Bilateral anterior knee pain seems to occur in late adolescence during vigorous physical activity and then subsides over years. It is not a precursor to osteoarthritis or rheumatoid arthritis. Mechanical irritation in the soft tissues guiding the quadriceps/patellar tendon from overuse and/or poor biomechanical stress tolerance is the probable cause.

Question 4

What are the diagnostic criteria for chronic fatigue syndrome?

Answer 4

Chronic fatigue syndrome criteria include documented fatigue for six months or more, and at least four of the eight following symptoms: post exertion malaise, impaired memory/concentration, unrefreshing sleep, muscle pain, multi-joint pain without redness or swelling, tender cervical or axillary lymph nodes, sore throat, and headache. Fatigue must be severe enough to interfere with work or usual activities.

Question 5

What is the relationship between spinal pain and degenerative disc disease

Answer 5

Spinal pain and degenerative this disease are both very common but not tightly connected given that radiographic disk changes persist and gradually worsen whereas most spinal pain is intermittent. Nevertheless, disc disease probably makes the spine more susceptible to minor trauma/stress which generally is the proximal cause of spinal pain. Radicular pain suggests nerve pressure however discogenic pain can also radiate.

Question 6

What are the diagnostic criteria for fibromyalgia?

Answer 6

The criteria for fibromyalgia include a widespread pain index >7, symptom severity >5. If widespread pain index is only 3 – 6 then symptom severity needs to be >9.Symptoms present >3 months.No other condition is present to explain the pain.Widespread pain index is derived from counting the areas of tenderness including the neck, jaw, shoulder, upper and lower arm, chest, abdomen, upper and lower back, hips, upper or lower legs for a maximum of 19 areas.Symptom severity score is derived from weighting fatigue, waking up refreshed, cognitive symptoms on a 0 – 3 scale. Somatic symptoms are rated from 0 – 3 in terms of their number. The final score is between 0 – 12. Best predictor in normals who develop chronic widespread pain is non restorative sleep.

Question 7

What is the natural course of enthesitis?

Answer 7

Enthesitis refers to the condition where in the site of muscle/tendon and bone attachment becomes painful related to repetitive excessive tension. The term implies inflammation however pathologically there is minimal change so that the precise pain generator is undefined. Probably prostaglandins, cytokines, from either the periosteum or muscle participate in the process. Most instances probably spontaneously resolve however a vicious cycle of damage followed by insufficient healing can lead to persistent pain lasting – maybe priorhs, or years in duration. Enthesitis associated with spondyloarthropathy may require anti-TNF agents to stop the progression.

Question 8

What are the diagnostic criteria for chronic fatigue syndrome?

Answer 8

Chronic fatigue syndrome criteria include documented fatigue for six months or more, and at least four of the eight following symptoms: post exertion malaise, impaired memory/concentration, unrefreshing sleep, muscle pain, multi-joint pain without redness or swelling, tender cervical or axillary lymph nodes, sore throat, and headache. Fatigue must be severe enough to interfere with work or activities. Exclusionary medical conditions include COPD, congestive heart failure, cirrhosis, hepatitis B or C, insulin-dependent diabetes, rheumatoid arthritis, specific lupus erythematosus, sickle cell anemia, stroke without full recovery, multiple sclerosis, Parkinson’s disease, dementia, epilepsy, schizophrenia, bipolar disorder, depression with psychotic or melancholic features, anorexia nervosa or bulimia, drug/alcohol/narcotic abuse within two years before fatigue diagnosis, narcolepsy, obstructive sleep apnea, sleep disordered breathing, restless leg syndrome, and periodic limb movement disorder.

Question 9

What are some poor prognostic features in patients complaining of chronic fatigue?

Answer 9

Unexplained persistent or relapsing fatigue that is not the result of ongoing exertion, not alleviated by rest, and results in the reduction of previous levels of occupational, educational, social, and personal activities, may not have a treatable cause.Poor prognostic factors include more than eight unexplained symptoms, lifetime history of a dysthymic disorder, more than 1.5 years of chronic fatigue, less than 16 years of formal education, age exceeding 38 years at presentation, receiving disability or belonging to a self-help group.

Question 10

What is complex regional pain syndrome?

Answer 10

Complex regional pain syndrome (CPRS) usually presents with throbbing, burning, painful paresthesias. Inciting events include soft tissue injury (40%), fractures (25%), myocardial infarction (5 – 20%) cerebrovascular disease 3%, hemiplegia (10 – 20%), following surgery – arthroscopy, shunt placement, or emotional disturbance. No event can be determined in 35%. Three-phase bone scan is helpful initially with plain x-rays being useful in later stages. Response to sympathetic block is usually transient. MRI may show skin thinning and thickening, tissue enhancement with contrast material, and soft tissue edema.

Question 11

How common are physical symptoms in patients with depression who are starting treatment?

Answer 11

In one study of over 500 patients, physical complaints of moderate severity in depressed patients beginning treatment include fatigue in over 60%, sleep problems - 50%, and headaches in - 30%, back pain - 20%, limb pain - 30%. Chest pain occurs - 7%, and G.I. complaints - 20%. Mild complaints are much more frequent, fatigue in over 90%. These complaints vary considerably in their responsiveness treatment, fatigue responds well and pain usually responds poorly.

Question 12

What does the American College of sports medicine recommend in terms of exercise type, duration and intensity?

Answer 12

In order to develop and maintain cardiorespiratory , muscular fitness, and flexibility, scientific evidence suggests the following:
1) Moderate exercise at least 30 minutes per day, at least 5 days per week for total of 2.5 hours per week, or vigorous exercise 20 minutes per day on at least 3 days/week (1 hr). Total energy expenditure should be over 500 – 1000 MET minutes per week. Regular purposeful exercise involving major muscle groups that is continuous and rhythmic in nature is recommended.
On 2 to 3 days per week on also perform resistance exercises for each of the major muscle groups and perform balance, agility, and coordination exercises for a total of one minute per exercise at least two days per week. If previously sedentary, 40 to 50% of maximum force with each repetition, 60 to 70% if fit and over 80% if highly experienced. 10 to 20 repetitions per set, and 2-4 sets per position (2-3 minutes rest between sets) with at least as 48 hours him and between intensely exercising one particular muscle group.

Question 13

How brief can a bout of aerobic exercise be in order to improve endurance?

Answer 13

Short bouts of at least 10 minutes may be repeated as needed to make up these goals.

Question 14

All harmful is prolonged sedentary activity?

Answer 14

There are additional health benefits to reducing total time engaged in sedentary pursuits and by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Pleasant and enjoyable activity and changing varieties help to keep going. Supervision by experienced fitness instructor might help as well.

Question 15

Is there any value to low intensity short duration exercise?

Answer 15

Most sedentary people derive benefit from exercise even at very low intensities and duration.

Question 16

What functional abilities are derived from becoming physically fit?

Answer 16

Physical fitness and the habitual physical activity both contribute to functional independence, and reduced disability, morbidity, and mortality.

Question 17

How is chronic pain defined by the ACR, the psychiatric community, and the anesthetists?

Answer 17

Chronic widespread pain is defined by the ACR as being present for at least three months, located in the left and right sides of the body, and above and below the waist, and the presence of axial skeletal pain (anterior chest, cervical or thoracic spine, or low back).
The diagnostic and statistical manual of mental disorders defines chronic pain as lasting for six months.
The American Society of anesthesiology defines chronic pain as any pain not directly related to neoplastic involvement extending integration beyond that expected due to tissue injury or normal healing, and adversely affecting the function or well-being of the individual.

Question 18

What is complex regional pain syndrome and what are the usual causes?

Answer 18

Complex regional pain disorder (CRPS) is characterized by pain, limited range of motion, skin changes often with edema and local discoloration that often follows injury with an exaggerated local response often continuing for weeks to months. About 90% have no definite neurological lesion (type I) and type II does have neurological dysfunction. Inciting events include soft tissue injury in 40%, fractures and 25%, myocardial infarction and 12%, CVA in 3% with no obvious cause in up to 35%.

Question 19

What are the mediators of CRPS and what changes occur in the CNS?

Answer 19

The pathophysiology involves excessive sympathetic stimulation with sympathetic nerve dysfunction resulting in inflammation due to neuronal secretion of substance P, neuropeptide Y, and calcitonin gene-related peptide. Allodynia is a common feature. Serum IL-8 and soluble TNF receptor levels are elevated but not CRP, or IL-6 levels. CSF shows elevated IL-1 beta and IL-6 but not TNF alpha. Lowering the core body temperature increases sympathetic tone and the area of allodynia. Reorganization of somatosensory perception is suggested by fMRI which resolves after clinical resolution. Stronger activation of the posterior cingulate cortex occurs during painful stimulation. The patients have increased HLA-A3, B7, and DR2.

Question 20

What clinical changes occur in stages 1, 2, and 3 of CRPS, and what other organ system dysfunction may occur?

Answer 20

In stage I there is usually throbbing diffuse uncomfortable aching, with localized edema which may progress to stage II characterized by increased edema, skin thickening, muscular wasting, and restricted motion. Stage III may develop with contractors, trophic skin changes, ridged nails, and severe bony demineralization.
Complications may include bladder dysfunction with urgency, frequency, incontinence, or urinary retention. Cricopharyngeal spasm, and gastroparesis may also develop.

Question 21

What tests are used to confirm the diagnosis of CRPS?

Answer 21

Bones scintigraphy is more sensitive and specific than plain x-rays in stage I but not stage II. MRI and scintigraphy are specific but usually not very sensitive. Three-phase bone scan shows the best sensitivity with higher negative predictive value that MRI in stage I. MRI may show skin thickening, contrast enhancement, and soft tissue edema.
Doppler studies showing decreased blood flow and quantitative sudomotor axon reflex testing is helpful if medical legal issues require documentation.

Question 22

What other diseases should be considered when diagnosing CRPS?

Answer 22

Differential diagnosis of CPRS includes cranial nerve root compression, Pancoast syndrome, vasculitis, migratory osteolysis, arteriovenous fistula, progressive systemic sclerosis, disuse atrophy, and angioedema. Rheumatoid arthritis, conversion disorder, and Munchausen syndrome may produce similar symptoms.

Question 23

What treatments are known to work in CRPS?

Answer 23

Vitamin C at 200 mg, 500 mg and 1500 mg reduced the relative risk in wrist fracture in older women-RR 0.13, 0.17, and 0.41. Other effective medications include anticonvulsants, biphosphonates, oral glucocorticoids (prednisone 10 mg tid ups to 12w), nasal calcitonin. Consensus experts suggest starting with bicyclic antidepressant, anticonvulsant, NSAID (responce 17% vs steroid 83%), and perhaps opioids. Stellate ganglion block, and perfusion with lidocaine, ketamine, phentolamine may help but is no longer considered essential. Clonidine patches seem to be effective only in the area covered by the patch. Mirror visual feedback therapy shows promise.

Question 24

ros epic

Answer 24

Constitutional:.no weight loss, fever, night sweats, feels well, feels ill, fatigued, generally weak, weight gain, weight loss, loss of appetite, fever, chills, night sweats and see HPI
Ophthalmic: notes- blurry vision, decreased vision, double vision, dry eyes, excessive tearing, eye pain, itchy eyes, loss of vision, photophobia, scotomata, uses contacts and uses glasses.
Denies {ros eyes symptoms:310656:o:”red eye or painful eye”}.
ENT: notes- {rosent symptoms:310658::”no complaints”}.
Denies epistaxis, headaches, hearing change, nasal congestion, nasal discharge, nasal polyps, oral lesions, sinus pain, sneezing, sore throat, tinnitus, vertigo, visual changes, vocal changes or :oral ulcers or sinus pain.
Endocrine:-notes breast changes, galactorrhea, hair pattern changes, hot flashes, malaise/lethargy, mood swings, palpitations, polydipsia/polyuria, skin changes, temperature intolerance and unexpected weight changes.
Denies polydipsia, unexplained weight loss.
Respiratory:notes- cough, hemoptysis, orthopnea, pleuritic pain, shortness of breath, sputum changes, stridor, tachypnea and wheezing.
Denies chest pain with deep breaths, hemoptysis.
Cardiovascular :notes- chest pain, dyspnea on exertion, edema, irregular heartbeat, loss of consciousness, murmur, orthopnea, palpitations, paroxysmal nocturnal dyspnea, rapid heart rate and shortness of breath.
Denies chest pain on exertion, orthopnea.
Gastrointestinal :notes- abdominal pain, appetite loss, blood in stools, change in bowel habits, change in stools, constipation, diarrhea, gas/bloating, heartburn, hematemesis, melena, nausea/vomiting, stool incontinence and swallowing difficulty/pain.
Denies .
Genito-Urinary :notes- change in menstrual cycle, change in urinary stream, dysmenorrhea, dyspareunia, dysuria, erectile dysfunction, genital discharge, genital ulcers, hematuria, incontinence, irregular/heavy menses, nocturia, pelvic pain, scrotal mass/pain, urinary frequency/urgency and vulvar/vaginal symptoms.
Denies kidney stones, bloody urine.
Dermatological : notesacne, dry skin, eczema, hair changes, lumps, mole changes, nail changes, pruritus, rash and skin lesion changes.
Denies rash, ulceration.
Musculoskeletal: AM joint stiffness, joint swelling, joint redness, back pain, gout, fibromyalgia, muscle weakness, muscle pain, nocturnal cramping.
Neurological :notes - behavioral changes, bowel and bladder control changes, confusion, dizziness, gait disturbance, headaches, impaired coordination/balance, memory loss, numbness/tingling, seizures, speech problems, tremors, visual changes and weakness.
Denies {rosneuro symptoms:310664:o:”:seizures, black outs”}.

Question 25

ros fib

Answer 25

fatigue, fevers, oral ulcers, chest pain, palpitations, abdominal pain, bloating, constipation/diarrhea, alopecia, rashes/photosensitive, Raynaud’s, subcutaneous nodules, muscle weakness, gait disturbance, joint pain/swelling lasting longer than a few days, memory loss, headaches, paresthesias, depression, anxiety,.

Question 26

What are the features of SEID systemic exertion intolerance syndrome?

Answer 26

Diagnostic criteria for systemic exertion intolerance disease developed by the Institute of Medicine includes all 3
1. substantial reduction or impairment inability to engage in occupational, educational, social, or personal activities that persists for more than six months accompanied by fatigue which is often profound, new or definite onset (not lifelong) and not the result of ongoing excessive exertion, not substantially alleviated by rest
2. post exertional malaise
3. Unrefreshing sleep
and at least one of the following
1. Cognitive impairment
2. Orthostatic intolerance
frequency and severity of symptoms should be assessed
the diagnosis of systemic exertion intolerance disease (encephalomyelitis/chronic fatigue syndrome) should be questioned if patients do not have the symptoms at least half the time with moderate, substantial, or severe intensity.
Chronic fatigue syndrome criteria also include muscle pain, multi-joint pain without redness or swelling, tender cervical or axillary lymph nodes, sore throat, and headache.