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MI Differential Diagnosis & Med Screening > GULICK: Medical Screening for Adults > Flashcards

GULICK: Medical Screening for Adults Flashcards

1
Q

System Review: MSK

Fractures

Types

A

GOOD PICTURE!!!!

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2
Q

System Review: MSK

Fractures

Ottawa Ankle Rules

A

see pics

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3
Q

System Review: MSK

Fx’s

Screening for Knee Fx’s

4 Decision Rules:

ALL GREAT FOR SCREENING!!! (HIGH Sn***)

A
  1. Pittsburgh Knee Rules*
  2. Weber & Colleagues Rules
  3. Ottawa Knee Rules*
  4. Fagan & Davies Rules
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4
Q

System Review: MSK

Fx’s

Pittsburgh Knee Rules

A
  • Criteria:
    • Inability to ambulate
    • Fall or trauma
    • <12 to >50
  • Stats:
    • Sn=100%****
    • Sp= 79%
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5
Q

System Review: MSK

Fx’s

Ottawa Knee Rules

A
  • Criteria:
    • >55yo
    • Tenderness of Fib head OR patella
    • Flexion <90*
    • Inability to WB 4 steps
  • Stats:
    • Sn=85-100%***
    • Sp= 17-49%
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6
Q

System Review: MSK

Osteoporosis

New medication→ Evenity

A

“Bone-building” medication

  • Approved for high risk, postmeno women who have not responded to other tx’s
  • Blocks Sclerostin→ PRO that stops bone from forming
  • Monthly inj’s x 1yr
  • 2 others “bone forming”→ 1. Tymlos 2. Forteo
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7
Q

System Review: MSK

Osteoporosis

Supplementation?

A

Gained momentum in lg trial showing 43% reduction in hip fx’s among elderly women randomly assigned to take Ca++ and Vit. D supps vs placebo***

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8
Q

Lots of different opinions on Ca++

A

see pics

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9
Q

System Review: MSK

Osteoporosis

Risk Factors:

A
  • Family hx→ NOT isolated to this!
  • Low Ca++ intake (in another slide)
  • Alcohol, tobacco, caffeine abuse
  • Below normal bw→ need exercise!
  • Chronic med conditions & meds
  • Sedentary lifestyle***
  • Early menopause*
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10
Q

Risk Factors for OP

More on Low Ca++ intake

A
  • Child 1-12→ 800mg/day
  • Teens 13-18→ 700-1200mg/day
  • Adult→ 700-1000/day
  • Pregnant→ 1200 mg/day
  • Post-menopause→ 1500mg/day***

NOTE POST-menopausal needing much more!!! HIGHER RISK!!

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11
Q

System Review: MSK

Osteoporosis

S/S

A
  • Severe & localized T-L-spine pain*
  • INC pain w/ prolonged posture
  • DEC pain in hook-lying
  • INC pain w/ Valsalva maneuver
  • Loss of ht >1”
  • Kyphosis
  • Dowager’s hump
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12
Q

Greatest prevalence of THIS in Fibromyalgia

100% prevalence

KNOW IT!!!!

DEFINES FIBROMYALGIA****

A

Tender points (11 of 18)

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13
Q

Tender points (11 of 18) you think……

A

Fibromyalgia

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14
Q

Fibromyalgia Syndrome

Manifestations vs Prevalence (%)

REMEMBER TENDER POINTS IS #1!!!!

A

SEE PICS

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15
Q

Fibromyalgia Syndrome (FMS) Tender Points

A

NOTE: Obscure spots

18 present

FMS will have 11/18

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16
Q

Fibromyalgia Syndrome

FACTS: a lot talk about Growth Hormone (GH)

A
  • Fact→ GH secretion occurs predom. @ night
  • Fact→ If GH is DEC→ mm repair @ night is compromised & muscle endurance/pain INC during day
  • Fact→ INC somatostatin limits GH release
  • Fact→ Exercise inhibits somatostatin** (helps to restore GH release)

See pattern from beg. to end and how it cycles back to exercise!!!!

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17
Q

Fibromyalgia Syndrome

Cycle of Meds along w/ Exercise and back to GH release!!!

A
  • Evidence suggests antidepressants DEC pain, fatigue, depression, sleep disturbs
  • WHEN ACCOMPANIED W/ AEROBIC EXERCISE→
    • Somatostatin release inhibited
      • DEC somatostatin==> INC GH
      • INC GH==> INC mm repair, DEC pain
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18
Q

Has a huge role in Fibromyalgia

A

GROWTH HORMONE

EXERCISE!!! (AEROBIC)

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19
Q

System Review: Neuromuscular

Statins

How do they work?

A

Dosage important!!!

  • PCSK9 inhibitors
  • Taken by injection 1-2x/mo
  • Shown to reduce “bad” CHO by 50-60%
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20
Q

System Review: Neuromusclar

Statins

Adverse Effects of Statins

A
  • Loss of mm coordination
  • Trouble talking/enunciating words
  • Loss of balance
  • Loss of fine motor skills (writing diff)
  • Trouble swalling
  • Constant fatigue
  • Jt and mm aches, stiffness
  • Vertigo/disorientation
  • Blinding HAs
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21
Q

Bone stimulation/growth

HOW? important for OP!!!

A

WB

Muscles pulling

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22
Q

System Review: Neuromuscular

Statins

Ask them about meds!!!

2 questions:

A

2 Questions:

  1. Has any drug/dosage changed in last 2-4wks?
    1. this is timeline for adverse effects***
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23
Q

System Review: Neuromuscular

Statins

Conclusions:

A
  • Accumulating evidence suggests statins may have a role in colorectal cx prevention & treatment
    • LOW dose*
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24
Q

When you see “Butterfly Rash” think……

A

Systemic Lupus Erythematosus

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25
Q

System Review: Neuromuscular

Systemic Lupus Erythematosus

A
  • Unexplained fever, swollen glands, constitutional sx’s, athralgia (symmetrical*), swollen joints
  • Skin rash→ “Butterfly” pattern (cheeks)***
  • Chest pain upon deep breath, extreme fatigue, photosensitive, unusual hair loss
  • Pale/purple fingers/toes from cold/stress→ Raynaud’s
  • CNS probs→ SZ, HA, periph. neuropathy, CVA, OBS
  • Mouth, nose, vaginal ulcers
  • Sx’s get worse during menstruation***
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26
Q

Guillain-Barre’ Syndrome is a _____ problem

A

Demyelination

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27
Q

Guillain-Barres’ Syndrome

See chart but KNOW THESE MAIN ONES!!!

A
  • Risk Factors
    • Possibly autoimmune
    • Assoc. w/ immunizations
    • Freq preceded by mild resp. or intest. infx
  • Progresses over hrs to days
  • Min. mm atrophy
  • Symmetrical paralysis*
  • Begins in LEs*** Ascends BILATERALLY*
    • Weakness, Ataxia, B/L parasthesia→ progressing to paralysis
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28
Q

Gullian Barre Syndrome

MORE

KNOW BOLD***

A
  • **Weakness→ Symmetrical LE>UE>resp.
  • Parasthesia starts in toes & progresses proximally
  • Pain=> LB & Buttocks
  • CN’s effected
  • Asymmetrical face weakness, dysphagia, dysarthrias
  • Unstable vital signs (not as common)
  • DEC reflexes + hypOtonia
  • Fever, nausea, fatigue
  • Cannot go up stairs***
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29
Q

Myasthenia Gravis think……

A

Grave MSK weakness****

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30
Q

Myasthenia Gravis

“Grave MM weakness”

A
  • Chronic, AI disorder
  • Caused by defect in the transmission of nerve impulses @ the N-M junction
  • Antibodies block, alter, or even destroy receptors
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31
Q

Myasthenia Gravis

MOST COMMON S/S THINK….

A

Diplopia & Ptosis (droopy eyelid)

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32
Q

Droopy eyelid (Ptosis) one….

A

Myasthenia Gravis

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33
Q

Myasthenia Gravis

s/s:

A
  • MOST COMMON→ Diplopia & Ptosis
  • Prox mm weakness, prob controlling eye mvmt & facial expressions, diff swallow/chew, dysarthria/dysphagia, change in voice quality, NO sensory or DTR changes
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34
Q

Multiple Sclerosis (MS)

Genetic factors + Triggers

A
  • Genetic Factors: can run in family
    • 30% risk for identical twin
    • 5% risk for 1st deg. relative
    • .1% for no one in family w/ MS
  • Triggers*
    • Epstein-Barr Virus (EBV)
    • Low lvl Vit. D
    • Geographic Loc.***
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35
Q

System Review: Neuromuscular

MS

1st Attack*

A
  • Transverse Myelitis→ DEC strength & sensation
  • Optic neuritis→
    • 1st demyelinating event in 20% pts
      • DEC vision & pain w/ eye mvmts
        • B/L→ children
        • U/L→ adults
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36
Q

This is a prodromal sign that is present in MS

BEFORE Dx is made*****

A

Lhermitte’s sign

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37
Q

MS

Other s/s

A
  • Intermitt. U/L vis. impair, Blurring, Diplopia, Parasthesias, Ataxia*, Vertigo, Fatigue**** (MS fatigue), Extremity weakness, B&B changes
  • Reports sensation of compression around limb, HyERreflexia, +Babinski, Dysmetria, Lhermitte’s sign, sensitive to temp change*, LBP 2* trunk hypOtonia
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38
Q

Lhermitte’s Sign → MS

Sp= 97%

This is a good ________ test

A

DIAGNOSTIC

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39
Q

Lhermitte’s Sign

MS

A

Sn=3% Sp=97%

  • Seated, flex head forward=> electric shock
  • 53% report (+) sign that started in 1st 3mos of dis.
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40
Q

Brudzinski Sign

Tests for _______

A

Neural Tension

MS in adults

Bacterial Meningitis in children

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41
Q

Anacardic Acid

A

Chem. cmpd found in shell of cashew nut→ Helps promote repair of myelin

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42
Q

Amyotrophic Lateral Sclerosis (ALS)

AKA

A

Lou Gehrig’s Disease

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43
Q

System Review: Neuromuscular

ALS

A

Attacks neurons of brain and SC

20%→ genetic defect

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44
Q

New ALS Research

A

Now possible to definitively distinguish blood samples of ALS pts from healthy controls

see pics

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45
Q

System Review: Neuromuscular

ALS

New research shows a buildup of this PRO…… near N-M junctions translates neural signals into motor activity→ causes motor neurons to degenerate and die by inhibiting mitochondrial production

A

TDP-43

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46
Q

System Review: Neuromuscular

ALS

S/S

A
  • MM weakness: hands, arms, legs
  • Progressive weakness of mms of speech, swallowing, eventually breathing
  • EMG→ fibrillations and fasciculations*
  • Denervation atrophy, elevated mm enzymes, painful UE cramps
  • NO change in vision, hearing, taste, B&B
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47
Q

Neuromuscular Recap

GBS, Lupus, Myasthenia Gravis, MS, ALS

A

see chart

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48
Q

Neuromuscular Recap from chart

GBS:

Joints, DTRs/Tone, Other

A
  • Joints→ LE>UE weakness
  • DTRs/Tone→ DEC
  • Other→ UNSTABLE vitals
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49
Q

Neuromuscular Recap from chart

Lupus

Joints, DTRs/Tone, Other

A
  • Joints→ Jt pain&weakness
  • DTRs/Tone→ NO CHANGE
  • Other→ Butterfly rash*
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50
Q

Neuromuscular recap from chart

Myasthenia Gravis (droopy eyelid one)

Jts, DTRs/Tone, Other

A
  • Jts→ Proximal weakness
  • DTRs/Tone→ NO CHANGE
  • Other→ Eye & Swallowing probs
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51
Q

Neuromuscular Recap from chart

MS

Jts, DTRs/Tone, Other

A
  • Jts→ Extremity weakness
  • DTRs/Tone→ INCd
  • Other→ Lhermitte’s sign & Visual changes
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52
Q

Neuromuscular Recap from chart

ALS

Jts, DTRs/Tone, Other

A
  • Jts→ Weakness hands-UE-LE
  • DTRs/Tone→ INCd w/ cramping
  • Other→ EMG fasciculations*
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53
Q

System Review: CV & Pulmonary

HTN

A
  • Spontaneous epistaxis (nosebleed)
  • Occipital HA
  • Dizzy, visual changes,
  • Nocturnal urinary freq.
  • Flushed face
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54
Q

System Review: CV & Pulmonary

Abdominal Aortic Aneurysm

Case Report→ JOSPT 2008

Notice the S/S and WHY it would make you think AAA

A
  • 38yo male w/ hx of NON-mech. LBP
  • Insidious onset→ constant, deep, boring, night pain
  • NO lumbar, pelvic, hip impairments*
  • Strong non-tender palpable pulse*
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55
Q

Risk Factors for Abdominal Aortic Aneurysm

Note the *‘d

A
  • *Male sex
  • *Older age
  • *Tobacco use
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56
Q

Abdominal Aortic Aneurysm

Palpation effectiveness

A
  • Sn=68% Sp=75%
  • Sn DECs if abdominal girth is >100cm (39.4in) → Overweight person****
    • Bc harder to palpate!!!
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57
Q

Abdominal Aortic Aneurysm

Palpation effectiveness

Sn DECs if abdominal girth is ___________, bc harder to palpate

A

>100cm (39.4in)

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58
Q

Aneurysm Diameter

Surveillance (how often checked) vs Lifetime risk of rupture

A
  • NOTE:
    • >5.4cm = Surgical consult
    • 7cm= 50% lifetime risk of rupture
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59
Q

Ritter’s Rules

Are for what?

A

Thoracic Aortic Dissection ****

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60
Q

Ritter’s Rules

Summarized (most important points)

A
  • Urgency→ Thoracic aortic dissection= MEDICAL EMERGENCY*
  • Pain→ SEVERE pain= #1 symptom
  • MisDx→ Aortic Dissection can mimic heart attack
  • Imaging→ Get the right scan to R/O aortic dissection (CT, MRI, transesophageal EKG
  • Risk Factors:
    • Aortic dissections are often preceded by aortic aneurysm
    • Personal or family hx of thoracic dis.
    • Certain genetic syndromes
      • Marfan, Loeys-Dietz, Turner, vascular Ehlers-Danlos
    • Bicuspid aortic valve disease
  • Triggers→ Lifestyle & trauma can trigger aortic dissection
  • Prevention→ Med. mgmt is essential
    • BP control, aortic imaging*
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61
Q

Gender Diffs in MI Sx’s

Prodromal vs Acute Signs

A

Will differ bw Males & Females!!!!

  • Prodromal→ S/S leading up to Dx, Days/weeks before
  • Acute S/S→ IN the moment*
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62
Q

S/S OF MI

Framingham Study= ALL MEN*

A
  • Substernal pressure, tightness, squeezing
  • Pain unrelieved by pos. or nitroglycerin
  • Dyspnea, nausea, vom, dizzy
  • Palpitations, diaphoresis (sweating)
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63
Q

S/S of MI in FEMALES

TOP Prodromal vs TOP Acute

KNOW THIS!!!

A
  • Prodromal:
    • Unusual fatigue→ 71%
    • Sleep disturbs→ 48%
    • SOB→ 42%
  • Acute:
    • SOB→ 58%
    • Weakness→ 55%
    • Unusual fatigue→ 43%

NOTE that dizzy, cold sweat, nausea (all acute) are sx’s similar to men, BUT only 36-39% in Females!!!

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64
Q

Scientific Reports

MI and Cardiac Probs and Cortisol lvls and Hair

A
  • Lvls of cortisol diff in people who had MI vs did not
  • Hormones and chems quickly dissipate from bloodstream BUT remain in hair for mos.
  • Hair grows few cm/mo
  • Cortisol lvls from in 1-3cm of people who had MI (depicted in hair)
  • Moral of the story→ Cortisol may be indication of cardiac probs
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65
Q

All of these may cause NON-Cardiac chest pain

A

Indigestion*, esophagitis, ulcers, cholecystitis, bronchitis, mm strain, costochondritis, rib fx, Herpes Zoster*

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66
Q

System Review: Integumentary

Herpes Zoster aka

A
  • Shingles!!!
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67
Q

Systems Review: Integumentary

Herpes Zoster (Shingles)

A
  • ⅔ pts >50yo
  • Pain, tender, parasthesia in the dermatome 3-5d BEFORE vesicules
  • Prodromal pain may mimic cardiac pain**
  • Erythema & vesicles follow a dermatome*
  • Pustular vesicles last 2-3wks
  • Thoracic & Opthalmic division of trigeminal nerve→ MOST COMMON
  • Contagious→ via resp. droplets or Direct Contact w/ blisters
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68
Q

Shingles Rash

Think dermatomal pattern

Contagious→

A
  • Can spread when rash in blister-phase
  • NOT infectious BEFORE blisters
  • Once rash crusts→ NO longer infectious
  • Shingles LESS CONTAGIOUS vs chickenpox
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69
Q

Chickenpox vs. Shingles

A
  • Had Chickenpox→ may dev. shingles
  • NEVER had chickenpox→ wont get shingles, can get chickenpox
  • Vaccinated for chickenpox→ protected from shingles*
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70
Q

Skin Cancers

Remember the “Early Warning Signs of Cx”

CAUTION

A
  • C: Change in B&B
  • A: A sore that fails to heal 6wks
  • U: Unusual bleeding or discharge
  • T: Thickening/lump (breast or elsewhere)
  • I: Indigestion or diff swalling
  • O: Obvious change in wart, mole, freckle
    • ABCDE (you’ll get into this)
  • N: Nagging cough, hoarseness, rust colored sputum
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71
Q

Skin Cancers

Remember the “Early Warning Signs of Cx”

CAUTION

The O pertains to Skin Cx’s!!!

A

O: Obvious change in wart, mole, or freckle

  • ABCDE
    • A: Asymmetrical shape
    • B: Border irregularities
    • C: Color→ pigmentation NOT uniform
    • D: Diameter >6mm (pencil eraser)
  • E: Evolution (change in status)
72
Q

More Skin Cx ex’s

A

see pics

Notice “streaking” in nails*

73
Q

Systems Review: Integumentary

Skin Cx

Role of PT

A
  • Guide to PT Practice:
    • Screen skin exposed during PT sessions
    • Educate pt
    • Refer as needed
74
Q

Systems Review: Integumentary

Lyme Disease

What bacteria ?

A

B. Burgdorferi

75
Q

Systems Review: Integumentary

Lyme Disease

A
  • 36-48hrs after attach. of B. Burgdorferi to migrate from midgut of tick to salivary glands
  • Removal of tick w/in 24hrs can usually prevent acquisition of Lyme Disease****
  • Sx’s early Lyme→ 1-2wks AFTER tick bite
76
Q

Systems Review: Integumentary

Lyme Disease

Early Localized Stage:

A
  • Rash w/ erythema→ w/in 7-14d (range 3-30)- BullsEye
    • can be solid or BullsEye
  • Avg diameter→ 5-6”
  • may/may not be warm, usually not itchy/painful
  • Fever, malaise, HA, mm ache, jt pain***
77
Q

Conditions that mimic Lyme Rash

FYI but may be helpful

78
Q

Lyme Tx

Antibx’s for ________

79
Q

Lyme Dis. Tx

A
  • Doxycycline
  • Amoxicillin
  • Cefuroxime (Ceftin)
  • Azithromycin (Zithromax)→ Z-pack
80
Q

Systems Review: GI

GI Trauma

A
  • Needs to be considered w/ MVA & Athletics
  • Solid Organs: Spleen>Liver>Kidney
  • Hollow Organs: Intestine, Bladder
  • Look for→ pain/tender, vomiting

“Seat-Belt Sign”

81
Q

GI Cx’s

WORST→ incidence AND mortality

A

Colorectum

82
Q

GI Cx’s

Relating to Pathogenesis of Obesity

3 Big factors w/ this:

A
  1. Inflammation
  2. Insulin Resistance
  3. Hormonal Adaptation

*Nutrition, weight, body comp== HIGHLY correlated w/ INCd risk of Cx recurrence

*High salt diet inc’s risk of GI cx via direct mucosal damage & synergistically w/ H Pylori

_*_Colorectal risk inc’s w/ diets high in red meat, processed meats, saturated fats due to dysbiosis, inflammation, cell damage

83
Q

GI Patho and Curcumin (Turmeric)- for GI Dysf

A

500-2000 mg/d

1tsp=150mg; best w/ black pepper & fats

84
Q

Systems Review: GI

Celiac Iceberg

Latent (normal mucosa)→ Silent (manifest mucosal lesion)→ Symptomatic (manifest mucosal lesion)

A
  • Onset:
    • 6-24mos AFTER gluten introduced to diet
  • Sx’s:
    • diarrhea, abdom distention
    • Impaired growth, mm wasting
    • Decd appetite, wt loss
    • Lethargy, irritability
85
Q

Systems Review: GI

Peptic Ulcer

2 types:

A

Gastric & Duodenal

*Break in protective mucosal lining

86
Q

Systems Review: GI

Peptic Ulcer

Etiology?

A

MULTIfactorial!

  1. Genetic
    1. Familial tendencies
    2. Type O blood
  2. Environmental
    1. Smoking, ETOH
    2. NSAIDs***
87
Q

Systems Review: GI

Peptic Ulcer

PT Implications

A
  • 50% PT pts taking NSAIDs have gastritis
    • 15% long-term NSAID develop peptic ulcer
      • Many pts w/ ulcer no sx’s and unaware they have ulcers
  • @ Risk for serious ulcer comps→ bleeding, perforation of stomach
    • encourage to take meds w/ FOOD
    • refer to PCP prn
88
Q

Systems Review: GI

Stress Ulcers

A

2* from psychological or physio. stress

Gastric mucosal changes occur w/in 72hrs in 80% pts w/ burns over 35% of body*

89
Q

Systems Review: GI

Ulcers

WHAT should you ABSOLUTELY REMEMBER about the development of ulcers???? Hx of ________ or presence of _________ ********

A

Hx of NSAID OR presence of H. Pylori infx

90
Q

Ulcers

A
  • Hx of NSAID or presence of H. Pylori******
  • Dull gnawing/burning into midline T6-12 & radiating suprascapula
  • Relief→ antacids
  • Nausea, coffe-grounds vomit
  • Bloody or black-tarry stools (melenia)
  • Wks of remission*
91
Q

Why are NSAIDS problem?

A
  • Education:
    • Options
    • How to take NSAIDs
  • Dx:
    • Is it an “-itis”?
92
Q

Ulcers

Gastric vs Duodenal

What do they both have IN COMMON????

A

CRAMPING, TENDERNESS

93
Q

Ulcers

Gastric vs Duodenal

A

IN COMMON→ cramp, tender

  • Gastric
    • 30-60min post
    • LUQ
  • Duodenal
    • 2-3hrs post
    • RUQ
94
Q

Ulcer Dx

Test for _________ can ID those likely to benefit from antimicrobial tx

A

H. Pylori

  • Other:
    • Decd hematocrit & HgB
    • Blood→ feces/urine
95
Q

GI Bleeding→ Tests for H. Pylori

Just the Types

A
  • Breath Test→ IDs 99% people w/ H. Pylori
  • Blood Tests→ enzyme-linked immunosorbent assay (ELISA) measures antibodies to H. Pylori
  • Stool Test→ detects genetic fingerprints of H. Pylori in feces
  • Tissue Biopsy of lining of stomach→ MOST ACCURATE*; Endoscopy (invasive)
96
Q

Ulcer Tx

A
  • Remove irritant, meds to restore mucosa
  • H. Pylori→ Anti-microbial
  • Avoid coffee
  • NO known dietary changes found to reduce gastric acid secretion→ AVOID problematic foods*
97
Q

Systems Review: GI

Gall Bladder Patho think…..

A

8 F’s****

98
Q

Systems Review: GI

Gall Bladder Patho

Risk Factors→ 8 F’s

A
  1. Female
  2. Fair
  3. Flatulent
  4. Forty
  5. Fat
  6. Fertile
  7. Fatty Foods
  8. Family Hx
99
Q

Gall Bladder S/S:

(+) THIS sign……

A

(+) Murphy’s sign ****

100
Q

Gall Bladder S/S:

A
  • RUQ, Scap pain
  • Sx’s INC after fatty meal
  • Pain no resp to analgesics
  • Abdom bloating/belching
  • Clay-colored stools*
  • Vom, nausea
  • Jaundice (small %)
  • (+) Murphy’s Sign ****
101
Q

Gall Bladder Patho Dx:

A
  • US, MRI
  • Cholescintigraphy (HIDA scan)=> Nuclear medicine (HIGH radiation)
  • Oral cholecystogram (OCG)
102
Q

Oral Dissolution Therapy is for ________

aka Ursodiol

A

Gall Bladder Patho

103
Q

Oral Dissolution Therapy (Ursodiol) → Gall Bladder Patho

Limitations to the use of Ursodiol

A
  • only effective for cholesterol NOT pigment gallstones
  • only small gallstones, <1-1.5cm
  • takes 1-2yrs for gallstones to dissolve, many reform
  • Ursodiol gen only used by people who are @ high risk for Sx ****
104
Q

Extracorpeal Shock-Wave Lithotripsy aka

A

BLASTING gallstones!!!!!!

105
Q

Gallstones Tx:

Extracorporeal Shock-Wave Lithotripsy

“Blasting the gallstones/Shatter”

A
  • Treating gallstones
  • Shock waves shatter gallstone→
106
Q

Appendicitis

S/S in order of SIG. Likelihood Ratios***

A
  1. RLQ pain, (+) McBurney’s Point=> R. thigh/testicle*
  2. Nausea, vom, night sweats*
  3. Guarding rectus abdom*
  4. (+) Psoas sign
  5. (+) Obturator sign
  6. LOW-grade fever
  7. (+) Rebound tenderness (Blumberg)
107
Q

Systems Review: Endocrine

Thyroid Palpation

A

See pics (YOU KNOW THIS!!!)

*Observe for mvmt of any masses w/ swallowing

108
Q

Accuracy of Physical Exam in Dx of HypOthyroidism

“Clinical features manifest so slowly that clinicians may fail to notice them”

Genetic Link?

A
  • Family member who had:
    • Hypo/HypERthyroidism
    • Hair turned gray in 20s
    • Immune prob, juvenile DM
109
Q

HypOthyroidism vs. HypERthryroidism think…..

A

HypO== SLOW motor

HypER== FAST motor

110
Q

Systems Review: Endocrine

HypOthyroidism

Clinical Questions……. In the past year…

A
  1. Less energetic?
  2. Lack interest in surroundings?
  3. Skin of arms/legs become more dry/rough?
  4. Do you think you’ve put on wt?
  5. Have you or any family mbrs/friends noticed that your voice has become huskier or weaker?
111
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: ALL FIRST

A
  • Course skin
  • Sluggish mvmts
  • PR (HR) <60bpm→ BRADYcardic
  • Pretibial edema
  • Puffiness of face
  • Ankle reflex
112
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: Course Skin

A

hands, forearms, elbows examined to see if rough/thick

113
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: Sluggish mvmts

A

Asked to fold 2m long bed sheet

>1min= sluggish

114
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: HR (pulse rate)

A

<60bpm= BRADYcardic

115
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: Pretibial edema

A

Shin pressed for 30s

(+)= pitting

116
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: Puffiness of face

A

Observe if curve of malar bone was obscure, eyelids boggy

117
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam: Ankle Reflex

A

Contraction/relaxation of calf observed & prolongation of reflex

118
Q

Systems Review: Endocrine

Hypothyroidism

Methods of Physical Exam

Accuracy of Phys Exam findings in Dx of HypOthyroidism

Ones w/ HIGHEST Sp**** (good Diagnostic tests****)

A
  • BRADYcardia (remember SLOW motor)
  • Delayed ankle reflex
  • Course skin, Bradycardia, ankle reflex***
119
Q

HypOthyroidism

Women vs Men?

A

Women > Men ***

120
Q

HypERthyroidism think….

A

FAST motor

121
Q

Systems Review: Endocrine

HypERthyroidism (fast motor)

Possible causes:

A

Autoimmune (environ or stress factors), Nodules on thyroid (goiters), excess thyroid meds (for hypO), excess iodine, thyroiditis

122
Q

OVER-functioning of thyroid i.e. too much thyroid hormone

A

Hyperthyroidism

123
Q

Hyperthyroidism:

Initial Phys Exam:

A
  • Enlarged thyroid
  • TACHYcardia (fast motor)
  • Tremor of DIP
  • Smooth, velvety skin*
  • Inflammation/Bulging of eyes (Females > Males)
124
Q

Hyperthyroidism

Add’l Sx’s

(all make sense bc Fast motor, revved up!!!)

A
  • Fatigue, Sweaty palms, INC appetite/Wt loss, INC sweating (heat intol.), restlessness/insomnia, DEC attn span
125
Q

Hyperthyroidism

Tx

A
  • Anti-thyroid drugs→ PTU & Tapazole
  • Radioactive iodine
    • taken up by thyroid where it destroys thyroid cells to DEC thyroid hormone prod.
  • Sx==> risky
    • remove enough to DEC thyroid hormone
126
Q

Hypo vs Hyper-Thyroidism

127
Q

Symptoms of hyperthyroidism (SWEATING)

A
  • Sweating
  • Weight loss
  • Emotional lability
  • Appetite increased
  • Tremor/ tachycardia
  • Intolerance of heat/ Irregular menstruation/ Irritability
  • Nervousness
  • Goitre and GI problems (diarrhea)
128
Q

Symptoms of hypothyroidism – tends to occur in middle aged women

(MOM’S SO TIRED)

A
  • Memory loss
  • Obesity
  • Malar flush/ Menorrhagia
  • Slowness (mentally and physically)
  • Skin and hair dryness
  • Onset gradual
  • Tiredness
  • Intolerance to cold
  • Raised BP
  • Energy levels fall
  • Depression/ Delayed relaxation of reflexes
129
Q

Parathyroid Gland think…….

A

Controls ALL Ca++ lvls in body*****

130
Q

Parathyroid Gland (think Ca++)

All info

A
  • 4 PTH glands
  • Size/Shape→ grain of rice
  • PURPOSE: Makes “parathyroid hormone”→ controls ALL Ca++ lvls in body***
  • Range→ 8.8-10.2
131
Q

Blood Calcium Lvls in humans

A

see pics but NOTE:

  • 9-10→ actual range of blood Ca++ where 99% humans live and feel GOOD
  • Ca++ lvls in low 10’s often NOT normal and warning sign of HypERparathyroidism
132
Q

PTH INC serum Ca++ via……

A

NEGATIVE FEEDBACK SYSTEM***

  • See pics and understand it is a NEGATIVE Feedback system***
    • DEC Ca++, INC PTH

Decd serum calcium→ PTH→ Incd Ca++ reabsorption (bone and GI)→ Incd serum Ca++

133
Q

Hypo-Parathyroidism

REMEMBER…..

A

VERY RARE

Results from removal of all 4 glands

134
Q

HypOcalcemia Sx’s

RARE!!!!

A
  • Irritable,
  • Cardiac arrhythmia
  • Sk mm cramping
  • tingling fingers
  • dry/scaly skin
  • pigment changes
  • thin hair/brittle nails
  • (+) Chvostek’s Sign
135
Q

HypOparathyroidism

2 tests + Descriptions

A
  • (+) Chvostek’s Sign
    • HypERirritability of facial N. when tapped
  • (+) Trosseau’s Sign
    • Carpal spasm when inflated BP cuff is maintained >SBP for 3 mins.
      • TALKED ABOUT THIS ONE IN CLASS!!!
136
Q

HypERthyroidism peaks when?

A

3rd-4th decade

137
Q

HypER-parathyroidism

A
  • 1 gland “goes bad”→ 91% of time
  • Most often 5th, 6th, 7th decades of life
138
Q

Hyper-Parathyroidism

New Sx technique

A

Radioguided parathyroidectomy

139
Q

Hyper-parathyroidism aka

A

HIGH Ca++ lvls

  • Makes you feel bad
  • Ruins kidneys, liver, arteries
  • Causes strokes & cardiac rhythm probs
  • Kidney stones & OP
  • INCd chance of Cx’s→ breast, kidney, prostate***
140
Q

Hyper-Parathyroidism

A
  • INCd DTRs
  • Fatigue, drowsy
  • PROXIMAL weakness*
  • Arthralgia/myalgia
  • Reflux/peptic ulcer*
  • Kidney stones*
  • INC BP
  • Heart palpitations
  • Pancreatitis, Gout*
  • Thinning hair*
  • Mental slowing or memory probs
  • Emotional irritability
  • HypERcalcemia
  • Diff sleeping
  • HAs
141
Q

EXCESS PTH

A

see chart

  • Brain→ psychosis paranoia
  • Bone→ decalcification; patho. fx.
  • Stomach→ Peptic ulcers and other GI sx’s→ nausea, vom, constipation
  • Blood vessels→ Ca++ deposits in blood vessels== HTN
  • Pancreas→ Pancreatitis
  • Heart→ heart failure assocd w/ vascular damage and kidney patho.
  • Kidneys→ Kidney stones, 2* infx’s, uremia
142
Q

10 Parathyroid Rules of Norman

This one is BOXED AND *‘d !!!!

A

There is only ONE Tx for hypERparathyroidism:

Surgery***

143
Q

10 PTH Rules of Norman

A
  1. NO drugs make Parathyroid disease better
  2. ALL parathyroid pts have sx’s; 95% know it, feel bad
  3. Sx’s DO NOT correlate w/ lvl of Ca++ in blood
    1. many have BAD sx’s and dev. OP
  4. ALL pts w/ parathyroid dis have Ca++ lvls and PTH lvls that fluctuate (Up and Down)→ Typical
  5. All pts w/ HypERparathyroidism dev. OP*
  6. OP drugs have NO place in tx of parathyroid dis.
  7. Parathyroid dis will get worse in ALL pts
  8. There is only ONE tx for hypERparathyroidism: Surgery
  9. Nearly ALL parathyroid pts cured w/ min. operation
  10. Success rate & comp. rate VERY dep. on surgeons experience
144
Q

Parathyroid Sx Outcome:

A
  • OP improves immediately
  • Bone pain→ resolves 6-12hrs
  • Acid reflux→ gone 2-4d
  • HTN→ better in few wks
  • Arrhythmias→ subside w/in 1mo
  • CNS Sx’s→ improve 1-2mos
  • Hair loss→ resolves 3-4mos
145
Q

Breast Cx

Risk Factors:

A

>40yo, Family hx, NONpregnancy, Other cx’s, Fibrocystic dis.

146
Q

Breast Cx S/S

know bolded and *‘d

A
  • Enlarged axillary lymph nodes
  • U/L UE swelling
  • Brachial plexus related dysf.
  • palpable mass, retraction nipple, dimpling of skin over mass, skin red/warm/edematous, firm&painful over mass, fixation of mass to skin or chest wall, discharge nipple, pain w/ mvmt of breast
147
Q

Systems Review: Urogenital

UTI

Risk Factors:

A
  • Immobility/Inactivity→ impaired bladder emptying
  • Catheterization, DM,
  • Obstructions→ renal calculi
148
Q

Systems Review: Urogenital

UTI S/S

A
  • Pain w/ micturition
  • Leukocytes & bacteria in urine→ white casts
  • Cloudy urine
  • Back pain
    • Pain w/ kidney percussion
  • Fever, chills
  • Nasuea
  • Loss of appetite
149
Q

Systems Review: Urogenital

UTI vs Bladder Cx

A
  • Avg time from initial sx claim to bladder Cx Dx was LONGER in women than men
  • Pts presenting w/ hematuria alone, the time to subsequent bladder Cx Dx was similar for women and men
  • Analysis of pts presenting w/ either hematuria OR UTI, time to dx was sig. different
    • “Women had longer interval from UTI to Dx of bladder cx”
150
Q

Systems Review: Urogenital

Endometriosis

S/S

A
  • Recurrent Lumbosacral pain
  • 30-40yo
  • Worse pre- & during menses
  • Pain w/ intercourse
  • Infertility
151
Q

Diff Dx of Endometriosis in a Young Adult Woman w/ NONspecific LBP

A

Mark R. Troyer

FIND IT AND READ IT!!!!!!!!

152
Q

Renal Calculi aka

A

Kidney Stones

153
Q

Kidney Stones aka

A

Renal Calculi

154
Q

Renal Calculi=Kidney Stones

3 sites of obstruction:

A
  1. Ureteropelvic junction
  2. Ureter crosses over Iliac vessels
  3. Ureterovesical junction

Tears ureter → hematuria

155
Q

Renal Calculi

Formation==

A

INCd blood lvl and urinary excretion of principle component

Ca++ oxalate (80-90%), Mg++ ammonium phosphate, Uric acid, Cystine

156
Q

Kidney Stones

Risk Factors

KNOW BOLD

A
  • Family Hx
  • Males 4x > Females from 30-50yo
  • Females > Males in 60-80yo
  • Caucasians > Af Am’s
  • High PRO, low fiber
  • Dehydration
  • Warm climate;
  • Poor mobility
157
Q

Kidney Stones

S/S

What analogy should you remember???????

A

Pacing like a tiger!!!!

158
Q

Kidney Stones

S/S

A
  • Stab pain→ costovertebral angle
  • Intermitt, excruciating pain into ipsilateral genitals (comes in waves)
  • Ureter spasms into medial thigh
  • Pain starts when stone moves into narrow ureter=> pressure build up in kidney***
159
Q

Kidney Stones

S/S more

A

Chills/nausea/vom, freq urge to urinate, burns when urinate, blood/cloudy/smelly urine, INCd BP (bc pain)

160
Q

Kidney Stone Dx

A
  • US, CT, MRI
  • Urinalysis
    • hematuria, infx, crystals, pH***
      • formation of various kidney stones strongly influenced by urinary pH

90% calculi are radiopaque

161
Q

Kidney Stone

Tx

A
  • Stones <5-6mm pass spontaneously
  • Pain meds, antibx, Fever==medical emergency for drainage (catheter)
  • Removal:
    • USE→ Ureteroscopic Stone Extraction
    • ESWL→ Extracorporeal Shock Wave Lithotripsy
      • BLASTS THE STONES
162
Q

Kidney Stone Tx

MORE

A
  • Reoccur in 50% w/in 5yrs
  • IF assocd w/ hypERparathyroidism→ ADDRESS!!
  • PT→ NON-mechanical pain
163
Q

RED FLAGS

Adults→ Cx

Lymphoma (Hodgkin’s Disease)

A
  • Rare in children <5
  • More common females 5-10yo
  • Peaks 25-30
  • Males > Females (5:1)
  • Painless swelling of lymph nodes in neck or axilla, fever & night sweats, wt loss***
164
Q

500-700 Lymph Nodes

A
  • Normal size→ 1cm in size; >1cm=abnormal
  • Infx’s, Cx, other cond’s cause them to expand as immune system reacts to problem
165
Q

RED FLAGS

Adults→ Cx

Talk about lymph nodes RED FLAG

A

>1cm→ Tender, firm, rubbery (lasting longer than 4wks*****

166
Q

Adults-Cx

RED FLAGS

A

Pruritus (greater @ night), fever/night sweats, anorexia/anemia/cyanosis, jaundice, edema, non-productive cough/dyspnea, chest pain

167
Q

RED FLAGS

Adults→ Cx

Colon Cx

A
  • Environmental & familial factors
  • Risks:
    • INCing age
    • Polyps
    • Ulcerative colitis, Crohn’s dis.,
    • diet HIGH in animal fat & LOW in fiber
168
Q

RED FLAGS

Adults→ Cx

Colon Cx - REDUCTION of Risks

2 ways:

A
  • ASA (aspirin)→ daily 81mg x 20yrs reduces risk colon cx by 50%
  • Estrogen→ women who take estrogen replacement >1yr LESS likely to die of colon cx; LONGER take estrogen, LOWER risk colon cx
169
Q

RED FLAGS

Adults→ Cx

Ovarian Cx

2 really important things to know:

A
  • 2nd most common female urogen. cx, BUT most lethal
  • Poor outcome is based on diff w/ Dx→ Most have metastatic disease by time of Dx
170
Q

Red Flags

Adults→ Cx

Ovarian Cx

A

2nd most common urogen. cx, but most lethal

  • Risks
    • 40-60, Caucasian & Hawaiin
    • Geo loc. (NW Europe, US, Canada)
    • Nulliparity (hx of infertility*)
    • Fam hx
    • Endometrial or breast cx
171
Q

Ovarian Cx

This is common w/ it….

A

Metastatic Dis.→ unexplained wt loss, weakness, ascites

  • Other s/s
    • vague
    • bloating, freq abdom fullness after eat, w/ nausea & vom, flatulence, abnorm bleeding, gen abdom discomfort
    • 5yr survival only 30%
172
Q

Sx’s of Metastases

ALL FIRST

173
Q

Sx’s of Metatastases

Pulmonary

A

Cough, dyspnea, fecal odor breath, constant pleural pain, onset of wheezing

174
Q

Sx’s of Metastases

CNS

A
  • Confusion, change in memory
  • Depression, irritability, drowsy, blurred vision, HA,
  • Balance probs, weakness
175
Q

Sx’s of Metastases

Skeletal (Vertebrae, Pelvis, Ribs, Femur)

A
  • Significant pain relief w/ ASA (aspirin)*
  • PAIN
    • w/ WB
    • @ night*
  • Prior hx of cx
176
Q

Sx’s of Metastases

Talk about this test:

Percussion w/ Reflex hammer over Bony Areas→ Vert. spines, ribs, scapula, pelvis**

A

PAIN==> Metastatic Dis. to bone via lung, breast, or prostate cx’s

177
Q

Statins & Cx Mortality

Risk cut up to a HALF

A
  • Statins use assocd w/:
    • Women→ 22-55% reduction in various Cx deaths
    • Men→ Looked @ statins together w/ anti-DM meds Metformin
      • 40% reduction in prostate cx mortality
  • Speculated→ statins interfere w/ cell growth & metastasis by blocking cholesterol prod→ affects molecular paths & inflamm response

MI Differential Diagnosis & Med Screening (12 decks)

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