Medical Stuff Flashcards
What causes Mono? Who does it effect?
Epstein-Barr Virus. 90-95% of people have immunity by adulthood, effects adolescents and early adults. Usually is clinically silent in childhood. Usually most common between 15-24, and is almost negligible by 35.
Mono Symptoms and Incubations Period? Popular differential?
Has 30-50 day incubation period. Symptoms usually consist of pharyngitis, fever, and lymphadenopathy. 1/3 of cases have posterior palatine petechiae. Differential of streptococcus pharyngitis, mono has fatigue as well.
Spleen and Mono?
Enlarges beyond the margins of the rib cage due to lymphocytic infiltration. Minor injury can cause it to rupture.
How long does mono last?
Acute phase can last 1-3 weeks and recovery phase can take up to 2-3 months.
Return to play with mono?
- Must be asymptomatic to start any activity
- Resolution of laboratory abnormalities (WBC counts, liver function tests) don’t play a role in return to play decisions
- Should rest for 10-14 days and then resume light activity if asymptomatic
- Increase activity at 21 days but no contact and no increase in intra-abdominal pressure
- Unrestricted activity after 28 days if no splenomegaly
If splenomegaly at 14 days then continue light activity until 28 days. If spleen not decreasing in size then they can still return to full play but talk with them about risks. In unlikely scenario the spleen is still increasing then get further testing.
When is spleen most vulnerable during mono?
Most spleen injuries occur within 21 days but are exceedingly rare after 28 days.
Difference in color for arterial vs venous bleeding?
AA = bright
VV = dark red
What is the initial step with any bleeding (after universal precautions)?
Hemostasis
What types of dressings can be used for arterial wounds for hemostasis?
Any, even non-sterile, if sterile are not available due to the emergent nature of this situation.
Steps for managing arterial bleeding?
- Apply direct pressure
- Immediately place tourniquet
- Cover with dressings (sterile if possible) and wrap/bandage/pack
- Tourniquet shouldn’t be removed
- Get to ER
Steps for controlling venous bleeding?
- Apply pressure
- Elevate limb above heart
- Can consider use of pressure points
How to handle lacerations?
- Control the bleeding
- Pay attention to disposition of athlete
- When bleeding is under control evaluate if need to be referred:
Referral:
1. If wound gaps open or can’t approximate/stick edges together
Ways to close wound?
- Steristrips
- Dermabond (helps seal wound). The wound must be cleansed and applied to dry skin that has achieved hemostasis.
How to deal with capillary bleeding?
- Washed with soap/water
- Irrigated under pressure to remove foreign particles.
- Apply pressure with dressings
- After hemostasis achieved, cover with topical antibiotic.
Healthy wound healing environment? Dressings for types of wounds?
- Want moist healing environment for abrasions (when they dry out will scab and can get reinsured)
- Use transparent Semi-Permeable dressings for abbrasions or shallow wounds that aren’t draining (keeps moisture in and allows moisture/oxygen exchange but bacteria out). Semi-permeable film used for deeper wounds that are draining and allow exchange of moisture/gas but keep moist environment
- Hydrocolloid can be used for shallow or moderately deep wound with low/moderate exudate. They keep wound moist and absorb excess moisture. Shouldn’t be used for infected (will trap bacteria) and heavy exudate wounds
How does exercise help with DM treatment?
Improves glucose metabolism and insulin sensitivity.
Type 1 vs Type 2 DM
Type 1: Autoimmune disorder that destroys insulin-producing cells in pancreas (rely on insulin). Usually thin individuals.
Type 2: Usually overweight adults. This is insulin resistance. May require oral medications and in later stages, insulin injections
Athletes more at risk for HTN?
- Blacks
- Elderly
- Obese
- DM
- Renal disease
- H/O HTN in family
- w/c athletes
Classification of BP
Normal = <120 and < 80
Elevated = 120-129 and < 80
HTN Stage 1 = 130-139 or 80-89
HTN Stage 2 = 140+ or 90+
HTN Crisis (Consult MD Immediately) = >180 and/or >120
Usually 200 and 110 are contraindications to exercise.
Hypertension from meds in women? Other meds/drugs in general?
Can occur secondary to the estrogen in oral contraceptives in women. Alcohol, stimulants, tobacco, steroids, NSAID’s, caffeine, diet pills, decongestants.
Exercise Recommendations for High Blood Pressure?
If uncontrolled HTN (>140/90) then limit exercise to low intensity exercise, avoid sports.
If controlled HTN and some end-organ damage limit to the above, same with secondary HTN due to renal origin.
How does insulin decrease plasma glucose? Opposite of this process?
- Decreasing glycogenolysis from liver
- Increasing glucose uptake by muscle and fat
When blood glucose is low, glucagon stimulates liver to generate glucose and insulin is suppressed.
Glucose and hormones during/after exercise?
- Insulin is suppressed to allow for glucose release from liver
- Muscle cells more sensitive to remaining insulin for more efficient glucose uptake
- After exercise insulin levels increase to facilitate storage of excess glucose.
DM1 and DM2 and Exercise Issues?
DM2 don’t generally have hyper/hypoglycemic episodes in exercise. DM1 at high risk for these issues
Symptoms of hypoglycemia?
- Hunger
- Palpitations
- Anxiety
- Lightheadedness
- Fatigue
- Weakness
- Confusion
Exercise advice for diabetics starting exercise program?
High risk patients should start at low intensity/duration and progress. Diabetics with established CAD and no angina should not engage in intense exercise (60-80% max HR). For those with angina, THR should be at least 10 beats below ischemic threshold.
Exercise and PVD?
May need intermittent periods of rest to minimize symptoms. Low intensity exercise below symptomatic level is encouraged.
Exercise problems with autonomic neuropathy and how to deal with this for diabetics?
This can disrupt thermoregulation and are also at increased risk of adverse CV events with exercise. They should go through TM test before starting exercise and you need to watch them in hot or cold environments (proceed with caution). Should probably use RPE instead of heart rate response.
RPE Scale Markers
12-14 = somewhat hard
9 = very light
19 = extremely hard
Peripheral neuropathy: detection and exercise?
Detected with 10-g monofilament test. Significant peripheral neuropathy is reason to limit WB exercise and suggest swimming, cycling, or arm exercises.
Diabetic retinopathy and exercise?
With severe cases of this the athlete should avoid activities that increase intraocular pressure (weight lifting or high-intensity exercise) because of vitreous hemorrhage or retinal detachment.
Relative contraindications to pump use?
Contact, water, and endurance sports. They can be disconnected temporarily for contact or water sports or padded for sports with minimal contact.
Insulin pump and exercise?
It shows no significant difference in hypoglycemic events during or after exercise.
Metformin?
Also called glucophage. It is First line therapy for DM2 and taken with meals. Decreases liver gluconeogensis and increase glucose utilization by peripheral tissues.
Exercise guidelines for athletes with DM1?
- Consume CHO rich meal with low glycemic index 1-3 hours before exercise
- Consider decreasing pre-exercise insulin (decreases risk for hypoglycemia)
- Monitor blood glucose 60 minutes before exercise
What to do with glucose numbers 60 min before exercise?
<70 = postpone exercise, consume carbs and retest in 1 hour
70-99 = consume 15-30 grams carbs prior to exercise
100-199 = optimal but encouraged to consume 15-30 grams prior to exercise
200-249 = Discourage pre-workout snack
250-299 = Check urine ketones
>300 = Don’t exercise and Check urine ketones
With urine ketones if negative you can exercise but don’t take carbs, if positive then postpone exercise and take insulin. If negative, you’ll want to consider postponing competition.
How often to check sugars during competitions for DM? What to do with the numbers?
Every 30-60 minutes
<70 = consider terminating exercise. Take carbs and check every 15-30 minutes and terminate if unable to increase levels.
70-250 = take 30-100 grams carbs / hour exercise
250-299 = monitor closely and check every 30 minutes
> 300 = consider terminating exercise and check every 15-30 minutes
DM1 and recovery?
Consume 1.2 to 1.5 g of carbs / kg body weight every hour for 4-5 hours (preferably with high GI) and resume insulin with this meal.
When starting exercise for DM what is good recommendation for gauging activity?
Be able to carry on a conversation with a workout partner.
Recommendations for exercise with regards to insulin sensitivity?
Both aerobic and resistance training is better to improve this than either individually.
DM2 and carbs with exercise?
DM2 are not usually hypoglycemic so carb supplementation is usually unnessecary.
Hypoglycemia and DM1?
They can get this after exercise so need to monitor for 24 hours after exercise.
Glucagon
Injection that causes liver to release stored sugar into the blood. Used in cases of severe hypoglycemia in diabetes who have passed out or can’t take anything by mouth.
Does circulating glucose ensure athlete with DM1 uses the sugar?
No. If there is no circulating insulin then glucose is not absorbed by the muscle and it must rely on free fatty acids and keto acids. If the liver continues to make glucose and muscles aren’t taking it in, it could result in severe hyperglycemia.
Insulin adjustments when starting exercise program?
For short acting insulins the pre exercise dose should be decreased by 20-50%. 20-75% for elite athletes or intense exercise.
Recommended insulin adjustments?
Try to reduce short acting insulin 1-3 hours before exercise in a non-exercising area of the body.
Complications associated with NSAID’s?
- GI ulcer
- Bleeding events
- Acute renal failure
Others but not listed
What are risk factors for NSAID-Induced GI Bled?
- Prior peptic ulcer
- Concomitant use of anticoagulants or steroids
- Older age (>60 has 4-5 times greater risk)
NSAID’s and renal disease?
Should be avoided in persons at risk for or with this.
Tylenol vs Ibuprofen/Naproxen for pain relief?
Similarly effective
Selective COX-2 Inhibitors?
Celebrex. They were developed to provide NSAID benefits without affecting GI mucosa, renal tissue, or platelet aggregation. Don’t inhibit beneficial COX-1 prostaglandins. They have higher rate of CV events though.
What are prostaglandins?
Physiologically active lipids made from cell membranes, specifically from 2 enzymes (Cox-1 and Cox-2).
Cox-1 vs Cox-2
Both produce prostaglandin that cause pain, inflammation, fever but Cox-1 prostaglandins help maintain gut integrity and increases platelet aggregation. Prostaglandins produced by Cox-2 are found in high quantities in joints and reduce platelet aggregation. Aspirin blocks COX-1, Celebrex Cox-2, all others block both.
PT’s Role WIth Patients Taking COX-2 inhibitors?
Monitor patients for cardiovascular complications.
NSAID’s and Healing
No alteration in epithelial or tendon healing but modest delay in muscle strain healing during acute phase of healing. There is growing evidence of COX-2 inhibitors significantly (in the purest sense) impairing bone, ligament, and cartilage healing. May contribute to non-union after surgery for bone. Should probably not be used to treat acute joint injuries. This is most significant in the acute phases of healing.
What is the therapeutic dose for ibuprofen?
2400 mg per day. NSAID’s produce greater benefit when taken regularly in a dose schedule that produces near constant levels of the drug. Steady-state is achieved after 4 doses, equal to the drug’s 1/2 life (2 hours for ibuprofen).
Does ibuprofen get rid prostaglandins?
They don’t get rid of existing prostaglandins, only inhibit production so there will still be pain and inflammation from the molecules already there.
What drugs interact with NSAID’s?
- Blood thinners
- Beta blockers (avoid all NSAID’s)
- Steroids
- Diurectics (reduces effect)
How long to take NSAID’s
Generally about 7-10 days.
Tylenol vs NSAID’s
- Similar pain relief
- NSAID’s have higher risk profile (can exacerbate asthma, have GI/renal side effects, cause hypertension, and other CV diseases)
- Tylenol recommended as first-line for acute and chronic MSK pain
- Tylenol not usually associated with GI irritation
Taking NSAID’s for muscle injury?
Muscle Strain = Usually want to avoid
Muscle Soreness = usually beneficial
Contusion = Very beneficial and can decrease risk of myositis ossificans.
Cox1 inhibition can potentially increase bleeding in acute phase(due to COX-1 helping with platelet aggregation). May want to avoid this or take COX-2 inhibitors during acute phase. If excessive swelling in subacute phase then this is maybe when you want to take them but then in later stages of healing when regeneration is beginning them may impede regeneration. Overall, probably want to avoid NSAID’s with muscle injury.
Rhabdomyolysis
Skeletal muscle injury where muscle cell membrane is injured and releases muscle cell contents into plasma. Can lead to cardiac arrest, compartment syndrome, acute renal failure, or death.
Severe muscle soreness, usually bilateral muscle swelling, and cola-colored urine.
Increased risk when exercising in hot, humid conditions.
When to resume exercise after RHABDOMYOLYSIS?
Once CPK levels normalize (about 1-3 weeks).
Phase 1: Active and passive ROM
Phase 2 (Once full ROM achieved): Low intensity aerobic exercise without pai
Phase 3: Isotonic strengthening for specific muscles
How long does it take broken rib to heal?
4-8 weeks
Types of lung injuries?
- Pneumothorax
- Hemothorax
- Tension Pneumothorax
- Occurs from chest trauma (usually), pulmonary infarction, blood clotting defect.
- Complete collapse of lung. Any condition that causes pneumo can lead to this. Will have more severe symptoms.
In pneumo air can enter and leave the pleural space, with tension pneumo air enters the pleural space with each breath and gets trapped there.
Anemia
Reduction in RBC volume (hematocrit) or hemoglobin concentration. Reduces aerobic capacity and increases fatigue.
Can be seen in endurance athletes and individuals with low body fat percentage.
Management of anemia?
- Eat more iron
- Iron supplementation and vitamin c (enhances absorption)
- Avoid caffeine (it hampers iron absorption)
Sickle Cell Trait
Usually asymptomatic entire life. You only inherit one sickle cell gene. They can participate in athletics. There is risk of sickling with extreme physical activity.
Increased risk factors for problems include fatigue, poor conditioning, altitude changes, heat, and concurrent febrile illness.
Make sure you monitor hydration and be careful during extremely intense workouts and high humidity/heat. Will need to ease into workouts more than others.
May be more likely to get RHABDOMYOLYSIS and splenic infarction (at high altitudes).
Refrain from extreme exercise when recovering from illness.
Sickle Cell Anemia/Disease
Results from abnormalities in Hg structure that produces sickle/crescent shaped RBC that is fragile and unable to transport oxygen.
Contraindication to competitive sports participation.
Exertional Sickling
Clinical presentation is similar to heat-related illness and exertional cardiac illness; although, mentation is typically normal and temperature is normal.
Iron Deficiency
Iron deficiency can occur without anemia (not enough healthy RBC’s to carry oxygen to tissues) and seems to play a role in both subjective and objectives markers relating to athletic performance.
How to deal with decompression sickness?
Prevention:
- Slow ascent with stops
Risks:
- Rapid ascent, dehydration, increased exertion at depth
- Prior decompression illness
Treatment:
- Recompression via hyperbaric oxygen treatment (dissolves gases back into tissues)
- 100% O2 during transport can displace nitrogen from tissues
- Correct hypovolemia with IV fluids
- Aspirin for antiplatelet effects
When to return to diving after decompression sickness?
TYpe 1 (mild): Usually within 2 days but consider 2-4 weeks if symptoms are prolonged
Type 2 (severe): minimum 4 weeks but 3 months with arterial gas embolus.
