High Yield 6 Flashcards
What is a pulmonary contusion?
Syndrome following blunt chest trauma of CP + resp difficulty w/ confirmation on imaging
Sx of pulmonary contusion
Usually within hours of injury, peak at 72hrs, resolves within 1 wk
SOB, CP, hemoptysis
Physical for pulmonary contusion
Serial vitals
Palpable + pleuritic CP
Auscultation usually normal (consider hemothorax if lung sounds abnormal)
Inspect naso-oro-pharynx for bleeding
Clear C spine
Abdo exam
CXR findings for pulmonary contusion
peripheral infiltrate in area of trauma when significant contusion occurs:
Generally seen within 6 hr but may take up to 48 hr for radiographic changes
The infiltrate may not correlate to lobular architecture.
DDx for pulmonary contusion
Pulmonary emboli
Traumatic pneumothorax or hemothorax
Diaphragmatic, splenic, or hepatic injury
Pulmonary laceration or hematoma
Spontaneous pneumothorax
Rib fracture or contusion
Naso-oropharyngeal trauma
Management of pulmonary contusion
ABCs
C spine
Transport if SOB
O2
Condition self resolves, rest from strenuous exercise
RTP: 1-2 wks if no SOB or hemptysis
Complications of pulmonary contusion
Posttraumatic empyema
ARDS
Pneumonia
Prevention of pulmonary contusion
Protective equipment + padding
Seat restraints in motor sports
RF for pulmonary contusion
Collision/contact sports
Sports with high speeds or where the athlete is airborne:
Cycling, equestrian, winter sports, auto and motorcycle racing, extreme sports, and so forth
Sx of splenic trauma
LUQ pain, left shoulder pain
Physical for splenic trauma
vitals, postural vitals
Auscultate + palpate abdo
Cullen sign - discoloration of periumbilical area (sign of intra-abdominal bleeding)
Turner sign - discoloration of flank (sign of intra-abdominal bleeding)
Spleen exam:
Place the patient in the right lateral decubitus position, permitting gravity to anteriorly displace the spleen.
Ensure that the patient’s hips and knees are flexed to relax the abdominal muscles.
Proceed with gentle palpation during deep inspiration.
Palpation of the spleen over 2 cm below the left costal margin is an abnormal finding in adults.
Ix for splenic trauma
CBC, lytes, type + crossmatch, serial Hb
Thoracic + pelvic XR
CT abdo pelvis if stable
If unstable, FAST
DDx for splenic trauma
Rib fracture
Diaphragmatic injury
Thoracic aorta rupture
Peritonitis due to liver injury or ruptured hollow viscus
Rectus sheath hematoma
Spontaneous splenic rupture secondary to splenomegaly associated with infectious mononucleosis
Splenomegaly with rupture secondary to:
Congestion: liver disease
Infiltration: amyloidosis; hematologic malignancies such as leukemia, lymphoma, myeloproliferative disorder
Inflammation: acute or chronic such as HIV, tuberculosis, parasitic diseases
Extramedullary hematopoiesis
Management inc RTP of splenic trauma
Conservative (monitoring) vs surgical
If splenectomy, imms administered 2 wks post op
Consider abx prophylaxis
RTP - 8-10 wks
Complications of splenic trauma
Delayed rupture
Splenic pseudocyst
Overwhelming postsplenectomy infection
MOI + sx of renal trauma
MOI
Usually direct impact to abdo or flank, blow to back, fall from height or rapid deceleration
Hx - Gross hematuria
Physical for renal trauma
Vitals
Abdo exam
Ix for renal trauma
CBC, Cr, eGFR
UA
CT abdo pelvis
DDx for hematuria
Glomerular disease (post infectious, SLE, vasculitis, HUS, TTP, Alport’s syndrome, meds)
Hydronephrosis
Polycystic kidney disease
Trauma
Urethral stricture
Urogenital stones
Urogenital neoplasms
Hematologic disorders (e.g., sickle cell disease or trait, Renal artery thrombus, coagulopathies)
Connective tissue disease, inflammation
Infection (UTI, pyelonephritis)
Pregnancy
BPH
NSAIDS/Ibuprofen especially with dehydration
Pseudohematuria due to drugs (Levodopa, Nitrofurantoin, Rifampin, Septra), vegetable dyes, beets, berries
Management of renal trauma
Conservative - monitoring, bed rest til hematuria resolves
Surgery if hemodynamically unstable
Complications of renal trauma
The leading complication is extravasation of urine and infection of this urinoma
Early (acute, <1 mo):
worsening flank pain, uncontrolled bleeding, abdominal distention
Late:
Page kidney phenomenon/arterial hypertension (up to 40% of cases): extrinsic compression of renal parenchyma leading to intrarenal ischemia and activation of the renin-angiotensin system
Hypertension and renal impairment develop and can occur in native kidneys and renal allografts.
Hydronephrosis, stones, chronic pyelonephritis
Causes of hematuria in sport
Exercise induced hematuria
Trauma
Hypoxic damage to nephron
Hx + sx for hematuria
EIH is most pronounced on first void
Relation of hematuria to stream (beginning, throughout, at end)
Flank trauma or pain, frequency, urgency, nocturia, dysuria
Prior stones, UTI, vaginal or penile discharge, sexual activity, relation to menstruation
Recent sore throat
Fever, rashes, wt loss
Physical for hematuria
Usually normal exam for EIH
Vitals
Abdo + flank exam
Genitourinary exam
Management of hematuria associated w/ exertion + RTP
Step 1: If pt <40 y/o, observe + repeat UA in 48hrs
If normal, no further ix warranted
If hematuria persists, move to step 2
Step 2: urine culture, Cr, eGFR, PT, PTT, CK
If normal, move to step 3
Step 3: cystoscopy
If normal, proceed to step 4
Step 4: US or CT KUB
If normal, consider renal arteriogram or renal biopsy
RTP 48hrs if hematuria has resolved
Risk factors for malignancy/urologic cancer in hematuria
age >40 years, tobacco use, analgesic abuse, pelvic irradiation, occupational exposure to dyes or rubber compounds, constitutional symptoms (weight loss, fatigue, anorexia)
What is exercise induced proteinuria?
Transient increase in urine protein, resolves over 24-48hrs
D/t increased glomerular permeability
What are the 3 categories of proteinuria?
Glomerular:
Increased filtration of macromolecules across the glomerular capillary wall
Seen with mild-to-moderate exercise
Tubular:
Decreased resorption of filtered proteins
Seen in strenuous exercise in combination with glomerular proteinuria
Overflow:
Increased production of low-molecular-weight proteins (e.g., multiple myeloma)
Unless preexisting condition is present, not seen in exercise-induced proteinuria
Hx qs for exercise induced proteinuria
Exercise type, intensity, duration
Hx of renal dz
Hx of recent illness
Physical for exercise induced proteinuria
Signs of underlying renal dz:
Elevated blood pressure (BP)
Peripheral edema
Flank pain
Abdominal bruits
Ix for exercise induced proteinuria
UA
CBC, Cr, eGFR
If persistent, renal US
DDx of proteinuria
Orthostatic proteinuria (elevated protein when upright)
Fever
Stress
Pregnancy
Szs
Glomerular causes (e.g., minimal change disease, membranous glomerulonephritis)
Tubular causes (e.g., hypertensive nephrosclerosis)
Overflow (e.g., multiple myeloma, hemoglobinuria)
Postrenal causes in patients with inflammation of the urinary tract (e.g., urinary tract infection (UTI), nephrolithiasis, tumors)
Sx + hx qs for anemia
Symptoms: Fatigue, weakness, decrease in performance, light headedness, palpitations, SOB, pica (iron), paresthesias (B12)
Diet (vegetarian, restrictions, gluten free, meat, leafy greens)
Menstrual history in females
Blood in stool, melena, bowel habits, bloating & gas
Hematuria
Family history (Celiac, bleeding disorders)
Physical for anemia
Pallor-check conjunctiva
Flow Murmur
Tachycardia
Abdominal/rectal exam if appropriate
Ix for anemia
Fatigue work-up: CBC, ESR, ferritin, serum iron, TIBC, B12, folate, TSH, peripheral smear (optional: B-HCG, monospot, drug screen, Hep screen)
If suspect GI cause then stool for occult blood, endoscopy/colonoscopy
Celiac screen if GI symptoms or FHx: TTG
Urinalysis, C&S if hematuria
Retic count
Stools for occult blood
DDx of anemia
Microcytic:
Iron deficiency
Thalassemia
ACD
Normocytic
Iron deficiency
ACD
B12 or folate def
Drug induced
Infection
Liver dz or alcohol use
Hemolysis
Hypothyroidism
Macrocytic
B12 or folate def
Drug induced
MDS
Liver dz or alcohol use
Hypothyroidism
High retic count
Management of anemia
Treat cause! (dietician if poor diet, OCP if heavy periods, gluten free diet etc.)
Iron supplementation for iron deficiency anemia
Ferrous fumarate 300 mg OD-BID, ferrous sulphate or gluconate 300mg BID-TID, Hb should increase by 1g/dL per week. If not then check retic count
Continue therapy for at least 3 months then monitor.
IM iron can increase Hb faster but no proof that improves performance.
Hx qs for palpitations/ ?pSVT
Syncope - rest or exertion?
Associated symptoms: chest pain, dyspnea, lightheaded, n/v, diaphoresis, syncope
Symptoms of hyperthyroidism (increased energy, diarrhea, increase appetite, ophthalmopathy)
Caffeine intake
Smoking
Drug and alcohol use inc cocaine
Eating disorder
Stress
Fever
Meds: cold or flu meds inc ephedra
Physical for palpitations/ ?pSVT
Vitals
Listen to heart sounds - dynamic (supine + standing)
Peripheral pulses
Listen to chest
Check thyroid
Ix for palpitations
12 lead ECG + Holter
Echo
Exercise stress test
CBC, lytes, TSH
DDx for palpitations
Anxiety disorder, panic attacks
Angina
Costochondritis
Neurocardiogenic syncope
Heat stroke
Seizure
Thyroid dysfunction
Management of pSVT
Reassure
Avoid caffeine, alcohol, tobacco, stress
Educate re: valsalva, carotid massage
Consider ablation if symptomatic
BB are banned in some competitive sports
If symptoms controlled, no restrictions to sport participation
Sx of angina
Left shoulder pain
Relieved w/ rest
Associated sx: SOB, pre syncope, N/V, palpitations, sweating
Ix for angina
ECG
Stress test
Cholesterol, glucose
RF for angina
Smoking, cholesterol, HTN, fam hx
Management of angina
Rx
GTN
Referrals
Cardiology
FU
Go to ED if sx not resolving
FU w/ GP
BMI for obesity
> 30
Secondary causes of obesity
Hypothyroidism
Hypercortisolism
Hypothalamic dysfunction
Growth hormone deficiency
Prader-Labhart-Willi syndrome
Bardet-Biedl syndrome
Pseudohypoparathyroidism
Polycystic ovary syndrome (PCOS)
Hypogonadism
Insulinoma
Menopause
Primary causes of obesity
Socio economic factors, genetic factors, insulin resistance, poor diet, insufficient activity, insufficient sleep, associated medical illnesses, medications, smoking session, excess alcohol intake
Hx qs for obesity
Wt history
Diet
Eating patterns
Exercise
Mental health
Physical for obesity
BMI
Waist to hip ratio
Thyroid exam
Ix for obesity
CBC, fasting glucose, LFTs, lipids, TSH, T4, morning cortisol, UA, a1c
DEXA body fat composition
Management of obesity
Diet: calorie restricted/low-fat or low carb.
Reduce sugar sweetened drinks, reduce starchy foods, reduced processed grains, reduce foods with hidden sugars.
Behavioural therapy.
Medications: appetite suppressants (phentermine, liraglutide) or orlistat (pancreatic + gastric lipase inhibitor)
Bariatric surgery (gastric banding, gastric bypass, gastrectomy)
Exercise prescription
Moderate intensity 5-6 days per week, 45-60mins
Focus on large muscle group aerobic activities
How to manage obesity in a population (i.e. public health measures)
Inform and educate people, counselling and healthcare, healthy urban design, improving food and drink supply, marketing restrictions, labelling and packaging, incentives for healthy living, school meals
What is included in prescription
Physical activity recommendations - frequency, intensity, time, type
Progression
Exercise is good for mental health
Improving fitness is more important than losing weight
Lifestyle modifications for losing weight
Brisk dog walks
Take stairs
Park far away
Yard work
Cleaning w/ weights
Advice to prevent GI symptoms before exercise.
Train at least three hours after a meal
Limit fat and protein content in the meal before exercise.
Prevent dehydration eat small amounts before and during exercise.
Avoid high fibre foods prior to competition.
If pre-comp anxiety is likely cause, see sports psychologist
Exercise recommendations + considerations in diabetes
Aim to expend at least 1000 calories/ week
Progressive resistance training with lower resistance + intensity, use major muscle groups
Check sugars pre + post exercise and during if prolonged
Reduce insulin that will be acting at time of exercise
Exercise approximately 60 mins after meal
Increase carb intake pre + post exercise
Avoid injecting sites involved in activity
Wear medic alert bracelet
Educate on signs of hypoglycemia
Always have supply of fast acting glucose
Exercise with a buddy
Exercise recommendations + considerations in diabetic peripheral neuropathy, autonomic neuropathy + proliferative retinopathy
Peripheral neuropathy
Avoid trauma to feet, non wt bearing activity preferred
Autonomic neuropathy
Recommend exercise testing to document BP, HR, temp, blood sugar response
Emphasise Borg scale of rating perceived exertion
Proliferative retinopathy
Avoid activity that may increase BP >180 + avoid scuba diving
Exercise recommendations + considerations in HTN
Recommend moderate aerobic activity 2.5 hrs per week
Muscle strengthening >2 days per week once aerobic fitness has improved
Daily flexibility
Start slow, slow cool down, avoid breath holding, avoid head lower than heart exercises
Stop if feeling dizzy, sick, unwell
FU w/ doc if getting CP, palpitations, SOB, blackouts
Exercise recommendations + considerations in arthritis
Focus on functionality exercises
Repeated short bouts of low intensity activity daily
Exercise affected joints with pain free ROM
Avoid overstretching
Avoid vigorous, repetitive exercise on affected joints
Avoid morning exercise in RA
Exercise recommendations + considerations in peripheral vascular dz
Exercise stress test first
Exercise recommendations + considerations in osteoporosis
Moderate impact within limits of pain 4-5/wk
High intensity resistance training 2/wk
Balance training 4/ wk
Avoid deep forward spine flexion.
Avoid explosive movements and high impact loading + dynamic abdo exercise
Exercise recommendations + considerations in pulmonary dz
Daily exercise
Walking strongly recommended
PRT with emphasis on shoulder girdle and inspiratory and upper extremity muscles is important
Exercise recommendations + considerations in obesity
Focus on daily activity that use large muscle groups and increase total energy expenditure
Equipment modifications
Hyperthermia risk increases, emphasize importance of hydration + proper clothing
Exercise recommendations + considerations in cancer
Slower progression needed.
Maybe immune compromised so should avoid public gyms and swimming pool
Heart rate may be less reliable for monitoring intensity
Patience with lymphoedema should wear compression sleeves during resistance training
Several short of exercise may be better than one single bout
Increased risk of fractures due to bony mats
Patients undergoing radiation should avoid chlorine exposure
Exercise recommendations + considerations in the elderly
Aerobic exercise five days a week, resistance training two days a week, balance three days a week and flexibility twice a week
Exercise recommendations + considerations post MI
Check CI
Stress test + echo
Activity suggestions for rigidity in Parkinson’s
Kayaking, golfing, side bends, bow and arrow, rowing, latissimus pulldown, yoga, chest stretches
Activity suggestions for impaired sensory integration in Parkinson’s
balance on different surfaces, reduce reliance on vision and external cues stability exercises, exercises with eyes closed, exercises with head turns
Activity suggestions for bradykinesia in Parkinson’s
Walking, agility exercises, lunging
Activity suggestions for hypokinesia (small movements, narrow base) in Parkinson.
Boxing, kettlebell swings
Activity suggestions for akinesia (freezing) in Parkinson’s
Obstacle courses, quick tens in corners, lunging, boxing, kettle bell swings.
Activity suggestions for impaired balance.
Stability ball exercises, kettlebell, lunging, tai chi, boxing
What are important considerations for physical activity for people with MS?
Uhthoff’s effect can cause worsening of neurological symptoms if body temperature rises, therefore environment is important, call shower before and after, wearing cooling vest, activities are good
What are important considerations for physical activity for people with epilepsy?
Climbing, flying, hang gliding, shooting, diving, archery, skydiving and motor racing all contraindicated. Skiing, cycling and swimming or contraindicated unless under supervision.
What conditions is exercise contraindicated?
Myocarditis, cardiomyopathy, coronary artery anomalies, vascular Ehlers Danlos
What is PAR-Q?
Questionnaire for ages 15-69 to assess readiness to exercise
Describe the health benefits of regular physical activity?
Reduced risk of premature death, cardiovascular disease, stroke, high blood pressure, high cholesterol, type two diabetes, gestational diabetes, metabolic syndrome, depression and anxiety.
Reduced risk of bladder, breast, colon, endometrial, esophageal, renal and gastric cancer
Prevention of weight gain, decreased pain improved physical function in arthritis, prevention of fools, improve cognitive function, improve to sleep quality, lower risk of hip fracture and lung cancer, increased bone mineral density
What are the risks with physical activity?
MSK injuries including strains, tears, fractures, tended of these, dislocations and bursitis.
Rhabdomyolysis, acute M.I, malignant arrhythmias, sudden cardiac death.
Exercise induced bronchoconstriction.
Heat stroke, dehydration.
What are the five A’s of behaviour change?
Assess, advise, agree, assist, arrange.
Describe resistance exercises by body region.
Chest and shoulders: push-up, bench press, overhead press
Back: pull up or chin up, latissimus pulldown, bent over row
Core: plank, side plank, bicycle crunch
Arms: arm, tricep pull down
Lower body: squats, dead left, seated leg press, side leg raise, car raise
Describe the WHO recommendations for physical activity
150 minutes of moderate intensity aerobic activity through the week.
Aerobic activity should be in about at least 10 minutes.
Muscle strengthening activities involving major muscle groups on two or more days a week.
Adults over 65 with poor mobility should perform activity on three or more days a week to enhance balance and prevent falls
How can intensity be measured?
Rating of perceived exertion (RPE)
Heart rate
Oxygen consumption (VO2 max)
Strategies to minimise sedentary behaviour.
Reduce all forms of screen time.
When using a screen, schedule five minute breaks every 45 minutes to go for a walk during TV ads, perform exercises.
Only watch TV when on a stationary bike or treadmill
Walk to work
Park further away
Take the stairs
Standing desk
What are the barriers to physical activity?
Physical ailments or chronic conditions
Fear of becoming injured.
Lack of time.
Lack of knowledge
Self-consciousness.
Low social economic factors
Lonely safety
Poor weather
Lack of walking and cycling networks
Lack of open public greenspaces
Financial costs
Transport
Lack of availability or access to physical activity programs
Lack of motivation
Low self efficacy
Sx of pneumothorax
SOB
Localised chest pain, worse w/ deep inspiration - may radiate to neck, back, shoulder or abdo
May be asymptomatic
Physical for pneumothorax
Decreased/ absent breath sounds on affected side
Decreased tactile fremitus
Unequal expansion of chest w/ inspiration
Hyperresonance to percussin SC emphysema
Tension pneumothorax: distended neck veins, displacement of cardiac apex beat to non affected side, deviation of trachea to non affected side
RF for pneumothorax
Tall, thin, young, males
Smoking
Substance use (heroin, ecztasy, marijuana, cocaine)
Underlying lung dz (COPD, CF, TB)
Connective tissue disorder (Marfans)
Trauma (commonly first 4 and last 2 rib #, multiple rib #, flail segments, scapular #)
Ix for pneumothorax
CXR - upright PA + lateral chest films
White visceral pleural line seen
Rib XRs
ECG - right axis deviation, decreased QRS amplitude, precordial T wave inversion
DDx for pneumothorax
Lung contusion
Costochondral separation
Muscle strain
#
Management of pneumothorax
Support ABCs
O2
Semi-Fowler position
Needle decompression w/ 18G into 2nd IC space at midclavicular line
If small, no chest tube needed - just monitor for min 6 hrs, FU CXR in 12-48 hrs
If large, pleural aspiration
If this fails, or if pt unstable, insert chest tube (16-22Fr)
Use lidocaine
If hemothorax, insert chest tube
VATS indications:
If pleural aspiration fails
Recurrent primary spontaneous pneumothorax after chest tube insertion
Air travel recommendations in pneumothorax
CI in presence of acute, unresolved pneumothorax
No travel for 2-3 wks after radiographic resolution of pneumothorax
RTP after pneumothorax
3-6 wks
Prevention of recurrent pneumothorax
avoid scuba, contact sports + trauma
What is athletic heart syndrome?
Benign condition of physiologic adaptation d/t increased cardiac workload
Physical exam findings in athletic heart syndrome?
Bradycardia, midsystolic murmurs which resolve w/ valsalva, 3rd + 4th HS
ECG findings in athletic heart syndrome?
Sinus brady
Early repolarization:
J-point elevation, ST elevation, J waves, or terminal QRS slurring in the inferior and/or lateral leads
Normal when present in isolation
Juvenile T wave inversion in leads V1-3
Sinus arrhythmia:
Physiologic heart rate variation associated with respirations (increased with inspiration; decreased with expiration)
Resolves with onset of exercise
Junctional escape rhythm:
QRS rate faster than resting P wave
Regular R-R interval
Sinus rhythm should resume with activity.
1st degree or Mobitz 1 2nd degree AV block present at rest
Increased QRS voltage (LV hypertrophy)
Incomplete RBBB
Echo + CXR findings in athletic heart syndrome?
Echo findings
Biventricular hypertrophy
CXR findings
Cardiomegaly
Globular appearance
Increased pulmonary vascular markings
What are borderline ECG findings?
Left axis deviation
Left atrial enlargement
Right axis deviation
Right atrial enlargement
Complete RBBB
What should you do with borderline ECG findings?
In isolation, no need for further evaluation.
Two or more, further evaluation needed
Possible cardiac causes and evaluation needed for syncope or presyncope during exercise?
Cardiomyopathy, congenital coronary artery anomalies, ion channel disorders (eg Brugada)
ECG, echo, stress test, consider cardiac MRI
Possible cardiac causes and evaluation needed for exertional chest pain?
Coronary artery arthrosclerosis, congenital coronary artery anomalies, cardiomyopathy
ECG, echo, stress test, consider cardiac MRI
Possible cardiac causes and evaluation needed for palpitations?
SVT, ventricular arrhythmias, premature atrial and ventricular contractions, sinus tachycardia, cardiomyopathy, ion channel disorders
ECG, echo, stress test
Possible cardiac causes and evaluation needed for excessive SOBOE?
Cardiomyopathy, myocarditis
ECG, echo, stress test, consider pulmonary function testing
Preferred anti-hypertensive in athletes?
ACE inhibitors
Describe exercise induced laryngeal obstruction + what symptoms pt gets
Abnormal adduction of vocal cords during exercise
Throat tightness, choking, SOB, cough, wheeze, worse during maximal exertion, resolves after five minutes.
Inspiratory stridor
No sx outside of exercise
Evaluation + management of vocal cord dysfunction
Laryngoscopy (direct during exercise)
manage underlying factors (postnasal drip, GERD, laryngeal polyps)
Education
SLP for breathing + postural techniques
RF for septic arthritis
Recent joint injection or surgery
Trauma
RA
OA
Joint replacement
IVDU
Intravascular devices
STI risk
Diabetes, immunocompromised
Young or old
Sx + hx qs for septic arthritis
Rapid onset for arthritis but can be insidious w/ bursitis
Knee > hip > shoulder, ankle, wrist, elbow
Fever/ chills
Recent infection elsewhere (URTI, UTI, strep throat, PNA, STD, diarrhea)
Physical for septic arthritis
Hip held in flexed + externally rotated position
Febrile, tachycardic
Warm, swollen joint
Reduced ROM
Pain
Ix for septic arthritis
Blood culture, CBC, CRP, uric acid, blood glucose
Aspirate for gram stain, culture, leuks, glucose, crystals. PCR if ?lyme dz
DDx for septic arthritis
Cellulitis
Allergic reaction to injection
Reactive synovitis
Gout
Pseudogout
RA
Osteomyelitis
Lyme disease
Management of septic arthritis
Admit
Empiric broad spectrum abx (ceftriaxone if gram negative, vancomycin if gram positive)
4 wks
Assess therapeutic response w/ serial synovial fluid analysis
Complications of septic arthritis
Death
Impaired joint function
Septic necrosis
Ankylosis
Osteomyelitis
How to do subacromial aspiration
Clean skin
Freeze w/ lidocaine (25G needle)
Find the posterior tip of the acromion and insert 18G needle about 1 cm below that landmark
Completely advance the needle in a perpendicular direction under the acromion, aiming in a slightly cephalad direction
Synovial fluid interpretation
Normal
Transparent, clear
WBC <50 / <200
<25% polymorphonuclear leukocytes
Negative culture
Glucose similar to serum
Noninflammatory
Transparent, yellow
WBC 50-1000 / 200-300
<25% polymorphonuclear leukocytes
Negative culture
Glucose similar to serum
Inflammatory
Translucent to opaque
Yellow to opalescent
WBC 1000-75,000 / 300-50,000
>50% polymorphonuclear leukocytes
Negative culture
Lower than serum
Purulent
Opaque
Yellow to green
WBC >75,000 / >50,000
>75% polymorphonuclear leukocytes
Positive culture
Much lower than serum
Hemorrhagic
RF for osteomyelitis
Open or compound fracture
Surgical manipulation (orthopedic, colorectal, genitourinary procedures)
Intravenous (IV) drug abuse
Immunosuppression (AIDS, chronic steroid use)
Peripheral vascular disease/peripheral neuropathy (diabetes mellitus)
Sickle cell disease
Genitourinary or biliary tract infection
Chronic joint disease
Presence of prosthetic orthopedic device
Low socioeconomic status
Infancy
Elderly
Alcoholism
History of tuberculosis (Pott disease)
Sx of osteomyelitis
Fever, chills, fatigue
Restricted ROM, pain, edema
Limp
Ulcers
Physical for osteomyelitis
Fever (temperature >100.4°F) but not always present
Tenderness to palpation, swelling, erythema, warmth over involved area
Fluctuance
Decreased use of extremity, refusal to bear weight
Limited movement of adjacent joint
Ix for osteomyelitis
CBC, CRP, ESR
Blood culture
Bone biopsy - gram stain, culture
XR - osseous changes appear 2 wks after sx onset
MRI if <2 wks sx
DDx for osteomyelitis
Acute leukemia
Acute rheumatic fever
Rheumatoid arthritis (adult or juvenile)
Acute gout, pseudogout
Cellulitis
Malignant bone tumors (Ewing sarcoma, osteosarcoma)
Septic arthritis
Multiple myeloma (elderly)
Sepsis
Deep vein thrombosis, thrombophlebitis
Intervertebral disk disorders
Fracture
Aseptic bone infarction
Neuropathic joint disease (Charcot arthropathy)
Transient synovitis
Management of osteomyelitis
Empiric abx - vancomycin + ciprofloxacin
Duration
Kids - 4 days IV then 4 wks PO
Adults - 6 wks IV - can then do PO for 3-4mo if hardware is infected
Surgery if abx fail or infected surgical hardware
Hyperbaric oxygen may be helpful
Immobilization of affected part
Complications of osteomyelitis
Include bone abscess, bacteremia, fracture, loosening of hardware, overlying cellulitis, and draining soft tissue tracts.
Sinus tract formation may be associated with neoplasms, especially with long-standing infection:
Squamous cell carcinoma (Marjolin ulcer) most common tumor associated with chronic osteomyelitis
Recurrence
Cause of mono
Epstein Barr virus
Sx of mono + hx qs to ask
Prodrome of malaise, fatigue
Sore throat, fever, lymphadenopathy
HA
LLQ pain
Infectious contacts
Physical for mono
Fever
HEENT
Exudative pharyngitis
Enlarged cervical, axillary, inguinal lymph nodes
Palatal petechiae
Periorbital edema
Hepatomegaly, percussion tenderness common
Splenomegaly
Ix for mono
Labs - CBC, liver function
>50% lymphocytes
10% atypical lymphocytes
Mono spot - repeat 1 wk later - if negative but strongly suspicious, do IgM ab to EBV
Throat C+S
US abdo for spleen size
DDx for mono
Primarily must be differentiated from nonspecific viral syndromes, lymphoma, leukemia, and Streptococcus pharyngitis.
Concomitant Streptococcus infection is not uncommon.
Many infectious agents may cause mononucleosis-like syndromes: cytomegalovirus, adenovirus, hepatitis A, human herpesvirus 6, HIV, rubella, toxoplasmosis.
Medications causing mononucleosis-like syndromes: phenytoin, sulfa drugs
Management of mono (exc RTP)
Supportive
Prednisone if impending airway obstruction from ++ tonsils, or enlarged spleen, myocarditis or hemolytic anemia
Avoid alcohol
Infectious precautions
Discuss splenic rupture sx
Avoid amox - gives rash
RTP for mono
As soon as asymptomatic for light, non contact sport (usually 3 wks)
1mo for contact unless splenomegaly evident or ongoing sx, consider US at 1mo before RTP
<12cm normal spleen size
Spleen to kidney ratio should be <1.25
Complications of mono
Airway obstruction
PNA
Szs, meningoencephalitis
GBS
Hemolytic anemia, thrombocytopenia
Bacteremia
Hepatitis
Splenic rupture
Ix for traveler’s diarrhea
Stool cultures
Peripheral blood smear
Management of traveler’s diarrhea
If <5% dehydration - give oral rehydration
If >5% dehydration - IV NS
Ciprofloxacin 500mg PO BID x3/7 OR azithromycin 1000mg PO x 1 dose
Imodium (consider for comp)
Pepto bismol
Prevention of traveler’s diarrhea
Pepto bismol 2 tabs at meals + 2 tabs QHS - take while on trip - reduces risk by 65%
SE: darkening of stool + tongue
Don’t take longer than 4 wks
Interferes w/ doxycycline (used as a malaria prophylaxis - stagger meds)
Management of bleeding during play
Leave playing field, only return once given medical clearance (bleeding controlled, lacerations covered)
Uniform should be disinfected or changed if bloody
RTP for hep B
Acute infection (fatigue, fever) - remove from play
Remove from close combat sports until loss of infectivity known (HBV antigen - can last up to 20 wks)
HBAg + - remove athlete indefinitely from contact sport
Recommendations to minimise transmission of blood infections
Hepatitis B vaccine
Clean dressing rooms
Washing soiled clothing, equipment, and services
Avoid sharing towels and drinks
Manage cuts and abrasions
No sharing of razors and toothbrushes
Cover broken skin
Wear disposable gloves when coming in contact with blood
Advice to athletes to reduce infections
Keep stresses to a minimum
Well balanced diet
Avoid over training
Adequate sleep
Avoid rapid wt loss
Keep hands away from eyes + nose
Avoid sick contacts
Moderate training decreases risk but intense training increases risk
What causes herpes gladitorum?
HSV 1 + 2
RF for herpes gladitorum
Abrasions or physical trauma increase the likelihood of acquiring infection.
Physical and mental stressors (i.e., weight loss, sleep deprivation, competition, school responsibilities) may increase likelihood of recurrence.
Close skin contact sports like wrestling
Sx of herpes gladitorum
Prodrome of burning, stinging, itching then clusters of vesicles
Can get fever, lymphadenopathy, malaise, pharyngitis w/ initial episodes
Ix for herpes gladitorum
Viral culture or Tzanck smear
PCR is gold standard
DDx for herpes gladitorum
Impetigo
Herpes zoster
Folliculitis
Allergic or contact dermatitis
Tinea gladiatorum
Cellulitis
Management of acute herpes gladitorum
Acyclovir 200 mg 5 times a day or 400 mg TID for 10 days
Valacyclovir 1 g BID for 10 days
During the ulcer stage, benzoyl peroxide and use of a hair dryer can help dry crusts more rapidly and minimize secondary bacterial infections.
RTP for herpes gladitorum
Scabbed over, no discharge, no evidence of secondary bacterial infection
No new lesions in 48-72hrs
No lymph node swelling in affected area
Primary episode - should be treated for 5-10 days, 14 days if systemic sx present
Recurrent episode - should be treated for 5 days
Prevention of herpes gladitorum
Isolate infected wrestler to prevent skin contact with other wrestlers (control outbreaks among previously infected wrestlers).
Regular wrestling matt cleaning and general hygiene (e.g., avoid sharing towels, soap, razors)
Consider using prophylactic antiviral medications during the season or before competition
Acyclovir 200 mg BID
Valacyclovir 500 mg or 1 g daily
Famciclovir 250 mg BID
Teach skin hygiene (e.g., showering after activity), and protect other skin abrasions from secondary contact.
Educate athletes on how to identify lesions/recurrence, and seek early treatment
Types + differences for impetigo
bullous + non bullous
Bullous
Caused by epidermolytic toxin from S. aureus
Favors intertriginous areas
Is a localized form of scalded skin syndrome
Starts as a vesicular eruption that develops into bullae and then may rupture to form honey crusts
Non bullous
more contagious
Caused by S. aureus and group A β-hemolytic streptococcus (GAS)
Starts as macules or papules and progresses to vesicular eruption, which rupture to form erosions with honey crusts
RF for impetigo
Abrasions or cuts
Sweat or water soaked clothes
Poor hygiene
Prevention of impetigo
Avoid sharing equipment, towels, tape, and ointments.
Avoid dispensing ointments from common containers.
Clean equipment and clothes daily.
Shower immediately after sports activity with antibacterial soap.
Avoid communal hot tubs.
Wear moisture-wicking, synthetic clothing.
Discourage body shaving in contact sports.
Frequent skin checks by athletic trainers and athletes in contact sports
Frequent handwashing by athletic trainers and affected athletes
Cover any injured skin immediately.
Use topical triple antibiotic for skin wounds
Sx of impetigo (for both types)
Bullous:
Starts with superficial vesicles, which progress to flaccid bullae without surrounding erythema
When the bullae rupture, they ooze and create honey-colored crusts.
Self-limited and may spontaneously resolve in weeks if left untreated
Nonbullous:
Starts as a single macule or papule that develops into a vesicle
Vesicle may rupture and form an erosion, and the contents become honey-colored crusts that are often pruritic.
May spontaneously resolve without scarring if left untreated for weeks
Management of impetigo
Soak affected skin in warm water for 5 to 10 min 3 times daily until cleared.
Gently remove honey-colored crusts to improve antibiotic penetration.
Topical mupirocin BID x5
If widespread, add amox-clav or keflex x7/7
If MRSA, clindamycin x7/7
RTP for wrestling for impetigo
Oral abx x72hrs
No new lesions for 48hrs
No moist or exudative lesions
Complications of impetigo
Poststreptococcal glomerulonephritis up to 3 wk after skin infection:
Occurs in 20% of nonbullous-type impetigo
Risk not decreased with antibiotic treatment
Hyperpigmented area after healed lesions mostly in dark-skinned athletes
Cellulitis
Lymphangitis
Guttate psoriasis
Toxic shock syndrome
Staphylococcal scalded skin syndrome
Sepsis
Osteomyelitis
Pneumonia
RTP + management of carbuncles, abscess, folliculitis etc for wrestling for
RTP: 72 hrs of treatment, 48 hrs of no new lesions
Carbuncle/ abscess - needs I+D
RTP for contact sports + management of molluscum
Watchful waiting - usually resolve within 6-12mo
Can use LN2, curettage, salicylic acid
Wait 24hrs after lesions resolve to compete in contact sports
Rx + RTP for tinea pedis
Rx w/ topical terbinafine 1% BID x1 wk
If severe or extensive, oral terbinafine 250mg daily x2-6 wks
No limits for RTP
Educate re footwear in showers, drying, don’t share towels
Rx + RTP for tinea corporis
Rx w/ topical clotrimazole 1% or terbinafine 1% BID x2-4 wks
oral/topical antifungal tx x 72 hrs on skin
Rx + RTP for tinea capitis
Terbinafine 250mg PO daily x2-4 wks
oral/topical antifungal tx x 14 days on scalp
Rx + RTP for tinea cruris
Jock itch
Rx w/ topical clotrimazole 1% or terbinafine 1% BID x2-4 wks
oral/topical antifungal tx x 72 hrs on skin
If coverable, and under treatment, can participate earlier
RTP for Hiradenitis suppurativa in wrestling
No extensive or purulent draining lesions, covering not permissible
RTP for verruca
If cannot be covered, cannot wrestle
Solitary or scattered lesions can be curetted prior - no seeping
Management of closed blister + open blister
drain fluid w/ needle + syringe, inject space w/ diluted betadine, leave until stinging stops then drain betadine. Create foam donut and place around blister, cover hole in middle w/ 2nd skin, secure dressing w/ tape
Management of open blister
Clean, dry, leave open when not training, offload w/ foam donut when training
What should be included in a pre season medical?
Family history
Screen for RED-S
Screen for CV dz (syncope, palpitations, signs of marfans)
Provide education, counselling, intervention for general wellness and injury prevention
What are training related ECG changes?
Early repolarisation
Incomplete RBBB
Sinus bradycardia
First degree AV block
Voltage criteria for LVH
What are the issues with screening ECGs?
High false positive rate
Lack of qualified interpreters of young athlete ECGs
What to include when making travel plans as a team doc
Athletes + staff
PMH
Injuries
Illnesses
Allergies - epi pen
Med list
Ensure no banned substances
Meds in original bottles
Immunisations
Dental check up
Medic alert bracelets
Passport expiry dates
Visa requirements
Medical insurance
Emergency contacts
Food + water
Avoid uncooked foods, unpeeled veggies, street food, unpasteurised dairy
Bottled water only
Avoid ice cubs
Wash hands w/ alcohol gel
Hygiene + infection control
No fresh water swimming
Walk in shower w/ sandals
Mosquito repellant, long sleeve shirts
No contact w/ animals
General Advice
Sun protection
No tattoos
Safe sex, condoms
Doc + supplies
Malpractice insurance
Contact host medical, embassy, hospitals, physicians
Disaster planning
Transfer of care/ medical records
Forms (Wada list, TUE, rx pad, encounter notes, SCAT6)
Jet lag
Sleep
Nutrition
Acclimatisation
Travel
Hydration
illness prevention
Med bag
Cover letter for medical kit
Prophylaxis meds (malaria, altitude, travels diarrhea, probiotics, STIs)
Be familiar with medical kit
Post trip
Check in re illness
What immunisations are recommended for travel
MMR
TdaP
Varicella
Hep B
Hep A
Meningococcal
HPV
BCG
Cholera
Japanese encephalitis
Rabies
Tick borne encephalitis
Influenza
Post splenectomy - add:
Pneumovax
HiB
What factors should you think about when making travel plans
Location
Urban/ rural, domestic/ international
Proximity to local medical resources
Medical conditions (malaria, zika)
EAP for each venue
Customs/ regulations/ culture
Different anti doping rules
Language
Environment
Climate, altitude
Sport
Athletes, gender, age, support staff
Communication
Between athletes + staff
SIM card/ internet access
What should be included when thinking about event planning?
Who
Athletes
Numbers
Skill level
Ages
Prior information
Crowd
Numbers
Seated or mobile
Medical care
Staff - ratio of staff to participants
Roles
Medical
AT, chiro, PT, RMT, ED doc, sports med doc
Notify ED dept
Credentials
Attire
What
Sport
Type of event
Most common type of injury
Duration of event
Where
Venue
Med room, change rooms
AED location
Meal areas
Fenced or unfenced, access points
Paramedics, access points + exit, aid stations
Medical
Local ED
Environment
Weather - temp, humidity
Altitude, water, terrain
How
Procedures:
Roles
Call, charge, control
Scope of care
When to send for further care
Location of medical staff, aid tents etc
Record keeping
Orientation
Practice scenarios
EAP
Transportation
Weather, appropriate vehicle, monitoring during transport, medical personnel on transport
Equipment + supplies
Communication
radios, phones
Universal signs
Mitigate risks
Ensure adequate access to water for athletes + spectators and communication strategy to stay hydrated
Prevent exposure w/ water sprinklers, shade, advisories to wear a hat, blankets, heated areas
Identify and fence off hazards, guide pedestrian flow to safer areas, adequate lighting, signage, ensure no overload of structures
Worst possible scenario
Disaster planning
What are the universal signs?
Arms crossed over chest - no help needed
1 arm raised straight in air - require extra assistance
2 arms raised + crossed overhead - activate EAP, require EMS
What equipment + supplies are needed for events?
General: chairs, tables, exam beds, stretchers, garbage, toilets, sheets, towels, curtains/dividers, disinfectant, gloves, masks, gowns, computer, paper/pens for documentation
Diagnostics: stethoscope, BP cuff, O2 sat, POC glucose, POC Na, ophthalmoscope, otoscope, rectal thermometer
Emergency: oral airways, resuscitation masks, AED, O2 tank and equipment, spinal board, ice water tub, water, ice, IV equipment, IV fluid (NS, 3-5% hypertonic solution, D50), glucose, electrolyte drinks, drinking cups, urine dipsticks, blankets
Medications: epi 1:1000, dexamethasone, dextrose 50% (D50), cardiac meds (atropine, lidocaine), local anesthetic (xylocaine); salbutamol; ASA, APAP, NSAID, nitroglycerine, loperamide, antihistamine; lubricant for chafing, proparacaine (eye)
Wound care: gauze, bandaids, tensors, tape, slings, disinfectant, splints, suture kits, syringes, needles, scalpel, scissors, eye pads, dental kit
What should be included in an EAP and when to activate it
Transportion from venue to medical facility
Map of facility inc exits + access points, AED location, location of staff
Addresses of facilities nearby
Contact phone numbers, radio channels
Call (calls 911, calls venue organizers, calls ahead to ED, calls athlete emergency contact), charge (enters field of play, in charge of medical care) + control person (controls crow, clears pathway for EMS)
Identify + list emergency equipment + roles
GPS coordinates for helicopter
When to activate EAP?
If athlete not breathing, no pulse, bleeding profusely, impaired consciousness, injured neck, back or head or visible major trauma to limb
How to reduce the risk in open water swimming
Mandate a maximum group size
Regulate the start line/course with
Time the gaps between waves
Consider the number and visibility of boys
Consider straight line distance before requiring swimmers to take a turn, allowing them to spread out
Ask swimmers to select into waves of appropriate ability
Facilitate a climatisation and anxiety reduction, including pre-race immersion
Increase the amount of cover in the first part of the swim
Considerations for organising events in the heat
Adapt schedule (early AM or late PM)
Communicate information to athletes about the weather and how to prepare
Event modification in case of extreme environmental conditions (extra breaks, reduced climbing/ distance)
What is the criteria for a substance to be banned?
2 out of 3:
Potential to enhance performance.
Potential to be detrimental to health
Violate the spirit of sport
What are the criteria for a therapy to be medically justified?
Pt requires it to stay healthy
No reasonable alternatives
Pt will not surpass a normal state of health
What are the types of violations?
Presence of a substance
Use of a substance
Evading or reducing
Whereabouts failures
Tampering
Possession
Trafficking
Administration
Complicity
Prohibited association
What are the sanctions?
Suspension for 2-4 yrs to life
What is on the prohibited list?
Substances and methods prohibited at all times, in and out of competition
Nonapproved substances, anabolic agents, peptide hormones, growth factors, beta 2 agonists, hormone and metabolic modulators, diuretics and masking agents
Prohibited methods (in + out of comp)
Manipulation of blood and blood components, chemical and physical manipulation, gene doping
Prohibited classes of substances (in comp only)
Stimulants, narcotics, cannabinoids, glucocorticosteroids
Substances prohibited in particular sports
beta blockers
Benefits + SE of EPO
Benefits
Increases red blood cell (RBC) count → enhances oxygen delivery → improved endurance
Used medically for anemia (e.g., CKD patients)
Risks & Side Effects
Cardiovascular: Thickened blood (polycythemia) → increased risk of DVT, stroke, MI
Hypertension: Due to increased blood viscosity
Flu-like symptoms: Headaches, fatigue
Risk of undetected doping: Banned in most sports
Benefits + SE of Human growth hormone
possible increased growth, allergic reactions, acromegaly
Benefits + SE of beta 2 agonists
Possible anabolic effects, tachycardia, tremor, palpitations
Benefits + SE of Diuretics
Rapid weight loss, decreases concentration of drugs in urine
Electrolyte imbalance, dehydration, muscle cramps
Benefits + SE of Stimulants
Increased alertness, improved performance
Anxiety, insomnia, hypertension, arrhythmias
Benefits + SE of blood doping
Improved endurance, transfusion reaction, increase blood viscosity
What stimulants are banned?
ADHD meds, ephedrine, epinephrine, cocaine
What qs to ask in a hx when someone is using ergogenic aids or has qs about them
Training - duration, results, goals
Diet - food groups, calories
Meds + supplements
Prior steroid use
Benefit vs adverse effects of steroids
Benefits
Significant increases in muscle mass, strength, and endurance
Faster recovery from training and injuries
Risks & Side Effects
Cardiovascular: Dyslipidemia (↑ LDL, ↓ HDL), increased risk of stroke and heart attack
Endocrine: Hypogonadism, infertility, gynecomastia, virilization in females
Hepatic: Liver toxicity, cholestasis (especially with oral steroids)
Psychiatric: Mood swings, aggression (“roid rage”), dependence
Musculoskeletal: Premature closure of growth plates in adolescents
What steroids are banned + what are the limits to use?
Systemic use prohibited - IM/IV/PO/rectal (rectally inserted hemorrhoid cream or suppository)
Topical use allowed (derm or hemorrhoidal), local intra-articular injection allowed
Inhaled allowed for asthma but daily max limit
Symbicort, advair, combivent, serevent - max 200mcg/ 24hrs
Singulair (montelukast) not prohibited
What are the restrictions on beta agonists + what are the exceptions?
LABA/ SABAs
All are banned at all times
Exceptions for inhaled salbutamol (1600mcg/ 24hr, not to exceed 800mcg/ 12 hrs) - 1 puff inhaler = 100mcg - 1 puff diskus = 200mcg
Formoterol - max 54mcg/ 24hrs
Salmeterol - 200mcg/ 24hrs
What are the IV fluid rules?
IV infusion >50ml in any 6hr period are prohibited unless:
Used legitimately during hospital admission, surgical procedure or approved clinical investigation
Prohibited at all times, in and out of competition
What sports ban beta blockers?
In + out of competition
Archery
Shooting
In competition
Ski jumping, freestyle, snowboard halfpipe + big air
Automobile
Billiards
Darts
Golf
Underwater sports (spearfishing, target shooting)
What is the athlete biological passport?
To monitor selected biological variables over time that indirectly reveal effects of doping
Hematological modules - profile of haem variables for detection of blood doping
Steroidal modules - urinary steroid concentrations over time
What is information vs intelligence?
Information = knowledge in raw form
Intelligence = information plus analysis
What is ADAMS?
Anti doping administration + management systems
Monitor athlete’s whereabouts, biological passport, competition schedules, TUEs, prior tests
When is EtOH prohibited?
In competition for air sports, archery, automobile, powerboating
Epi pen rules in comp
Okay to use in emergency but WADA requires emergency TUE be submitted following treatment
When is a TUE needed + what is the duration it lasts for
Required before using prohibited substance or method
Valid for duration of treatment, max 4 yrs
What is needed in an application for a TUE?
Form completed by athlete + physician
Comprehensive medical hx
Results of exams/ tests/ imaging/ investigations
Independent medical opinion in the case of non-demonstrative condition
Relevant correspondence between physicians regarding dx + rx
What is needed for a TUE for ADHD?
Dx by a specialist in management of ADHD
Must have evidence of standard diagnostic criteria
Evidence of sx onset before 12
Athlete ideally on stable dose of medication
Evidence of other interventions (psych, behaviour management)
Regular review (min annually) by the same specialist physician
What is the rule relating to diuretics + threshold substances?
Any quantity of substance subject to threshold limits (asthma, epherine, pseudoephidrine) in conjunction w/ diuretic (or masking agent) requires a TUE for both diuretic + threshold substance
What is the definition of heat stroke?
> 40 + CNS sx
What conditions are treated with hormone + metabolic modulators?
Breast cancer, diabetes, female infertility, PCOS
How would you know if you need a TUE?
Use global DRO to check meds
Use CCES website medical exemption wizard to find out what organisation to submit application to
How would you apply for a TUE?
Use CCES website medical exemption wizard to find out what organisation to submit application to (eg international federation vs CCES)
Complete form, including physician letter + documentation to support diagnosis
What conditions are treated with anabolic agents?
Male hypogonadism
What conditions are treated with peptide hormones or growth factors?
Anaemia, male hypogonadism, growth hormone deficiency
What conditions are treated with stimulants?
ADHD, cold + flu sx, anaphylaxis
Give examples of anabolic agents
Testosterone
Give examples of peptide hormones + growth factors
EPO, LH, GnRH
Give examples of hormone + metabolic modulators
Letrozole, clomifene, tamoxifen, insulin
Give examples of diuretics + masking agents
Acetazolamide, spironolactone, HCTZ, furosemide, mannitol, desmopressin
Give examples of glucocorticoids + which routes are banned
IM, IV, PO, PR banned but inhaled, topical, intranasal okay
Betamethasone, budesonide, prednisone
What is the definition of hypothermia
<35
What are chilblains?
Mild inflammatory lesions caused by exposure to cold after longterm exposure to non freezing, damp conditions
Itch/ pain/ swelling + blanch able erythematous/ violet discolouration, occurs 12-24hrs after exposure
What is the management of chilblains?
Supportive
Nifedipine can expedite healing + prevent recurrence
What is immersion foot (trench foot)?
Soft tissue injury from prolonged cooling, usually with moisture
Tingling that progresses to numbness
What is the definition of high, very high and extreme altitude?
High = 1500-3500m
Very high = 3500-5500m
Extreme = >5500m
Describe the physiological changes that occur at altitude
Hypoxia causes hyperventilation which leads to respiratory alkalosis
This leads to a compensatory metabolic acidosis
Increased pH induces a leftward shift of Hb dissociation making it easier for Hb to be saturated w/ O2
What are the effects of altitude on performance?
Decreased exercise tolerance
Sleep quality reduced
Appetite suppression
Peripheral vasoconstriction leading to fluid retention
Wt loss
What is snow blindness?
Photokeratitis
High altitude has increased UV rays, worsened by reflection from snow, leading to transient eye injury
Sx: pain, lacrimation, FB sensation, eyelid twitching
How do you diagnose + treatment snow blindness?
Increased uptake of fluorescein
Cover eyes w/ UV protection (goggles), artificial tears, cold compress
Risks, benefits + SE of testosterone use
Benefits
Increased muscle mass and strength
Enhanced recovery from exercise
Improved bone density
Increased red blood cell production
May improve mood and libido
Risks & Side Effects
Cardiovascular: Increased risk of hypertension, thrombosis, myocardial infarction
Endocrine: Suppression of natural testosterone production, leading to testicular atrophy, infertility, and gynecomastia
Psychological: Mood swings, aggression, irritability
Liver: Risk of liver damage, particularly with oral forms
Other: Acne, hair loss, prostate hypertrophy
What are the risks, benefits + SE of creatine?
Benefits
Increased ATP regeneration → improved strength, power, and short-duration performance
Promotes lean muscle mass gain
May aid in post-exercise recovery
Potential neuroprotective effects
Risks & Side Effects
Water retention (can cause weight gain)
GI discomfort (bloating, diarrhea in some individuals)
Kidney concerns in pre-existing renal disease (but safe in healthy individuals)
What are the risks, benefits + SE of casein protein?
Benefits
Slow digestion → provides prolonged amino acid release (ideal for nighttime recovery)
Supports muscle protein synthesis and recovery
High in calcium and bioactive peptides
Risks & Side Effects
Dairy allergy/lactose intolerance → potential GI discomfort
Excess intake may contribute to kidney strain (in those with pre-existing renal disease)
What are the risks, benefits + SE of whey protein?
Benefits:
Rapidly absorbed, high in leucine → excellent for post-exercise recovery
Supports muscle growth and repair
Risks & Side Effects:
Lactose intolerance may cause bloating, gas, diarrhea
Kidney concerns in those with pre-existing renal disease
What are the risks, benefits + SE of essential amino acids?
Benefits:
Stimulates muscle protein synthesis (especially leucine-rich EAAs)
Beneficial for recovery and muscle maintenance
Risks & Side Effects:
No significant risks, but redundant if consuming adequate protein
What are the risks, benefits + SE of caffeine?
Benefits
CNS stimulant → improves alertness, reaction time, endurance, and strength
Enhances fat oxidation during exercise
Reduces perceived exertion
Risks & Side Effects
Insomnia, anxiety, jitteriness
Tachycardia, palpitations, increased BP
GI distress (e.g., acid reflux)
Diuretic effect (mild dehydration in excess)
Withdrawal symptoms (headaches, fatigue)
What are the risks, benefits + SE of nitrates?
Benefits
Enhances nitric oxide (NO) production → vasodilation, improved oxygen delivery
May improve endurance and high-intensity exercise performance
Risks & Side Effects
Hypotension, dizziness (especially in individuals on antihypertensive meds)
GI upset (bloating, nausea)
Methemoglobinemia (rare but possible in very high doses)
What are the risks, benefits + SE of beta alanine?
Benefits
Increases muscle carnosine levels → buffers lactic acid → delays fatigue in high-intensity exercise
Beneficial for activities lasting 1–4 minutes (e.g., sprinting, rowing, wrestling)
Risks & Side Effects
Paresthesia (tingling sensation) → dose-dependent, transient, harmless
No major long-term risks identified
What are the risks, benefits + SE of sodium bicarbonate?
Benefits
Acts as a buffer, reducing muscle acidity and delaying fatigue
Useful for high-intensity sports (e.g., swimming, sprinting, combat sports)
Risks & Side Effects
GI distress (bloating, nausea, diarrhea) → common at high doses
Metabolic alkalosis (with excessive intake)
