Medicine Flashcards
Mechanism for majority of diabetic foot ulcerations
Repetitive pressure > 10 kg/cm acting on foot during gait
Tests recommended to assess patient with peripheral arterial disease and disease severity?
ABI, toe pressure and TCPO2
What is the most appropriate vascular study for venous insufficiency?
Venous doppler with reflux study and ABI, duplex scan
Medications that can cause myalgia and myotoxicity in severe cases (rhabdomyolysis)?
Statin medications (HMG-CoA reductase inhibitors) Colchicine Erythromycin Alcohol abuse Methamphetamines Cocaine MDMA (Ecstasy)
Medications that can cause QT prolongation?
Macrolides (erythromycin, clarithromycin) Antihistamines (diphenhydramine, loratidine) Zofran Ketoconazole TCAs Type 1C antiarrhythmics (flecainide, encainide) Type 1A antiarrhytmics (quinidine, procainamide, disopyramide) Class III antiarrhythmics (amiodarone) Antipsychotics
Patients presenting with unstable angina relieved by nitro x 3. What would the ECG show? What should be initiated?
- non-ST elevation consistent with acute coronary syndrome 2. Intensive statin therapy (benefit shown within 30 days)
How does stasis dermatitis typically present?
venous malfunction resulting from anatomic abnormalitis (i.e. valvular incompetence). Erythematous plaques with fissuring and yellowish or brown pigmentation superior to medial malleolus. May have weeping or lichenification
What is the mechanism of inverted champagne bottle appearance to legs?
Fat necrosis (aka sclerotic panniculitis or lipodermatosclerosis) resulting in permanent sclerosis.
Dermatologic pathology associated with seronegative spondyloarthropathy?
plaque psoriatic arthritis 1. Affects 1.5-2% of population 2. Inheritable polygenic trait 3. Results in epidermal hyperproliferation 4. caused by activated T cells infiltrate epidermis and induce keratinocyte production 5. Nail involvement is common 6. Psoriatic arthritis can involve peripheral or axial joints
Cause of equinus in polio patients.
muscle imbalance (weak tibialis anterior and toe extensors)
Localized nodular synovitis vs. pigmented villonodular synovitis
LNS: single multi-lobulated mass benign, proliferative synovial joint lesion Rarely recurrent PVNS: Considerable recurrent rate More difficult to excise d/t diffuse involvement
TSH and T4 levels in primary hypothyroidism (most common and due to thyroid disease)
increased TSH in presence of low serum T4
Characteristic of central hypothyroidism
absence of anti-thyroid perodixase antibodies
TSH and T4 levels in euthyroid hypothyroxinemia
Normal serum TSH and low T4 with normal free T4
Central hypothyroidism of secondary or tertiary. Causes? TSH and T4 levels?
Causes: 1. pituitary mass lesion 2. history of surgery or radiation therap 3. infiltrative disorder of pituitary or hypothalamus 4. head trauma with injury of stalk 5. pituitary apoplexy 6. post-partum pituitary necrosis Levels: low to low-normal serum free T4 and low serum TSH
Skin cancer associated with HPV
squamous cell carcinoma of genital or periungual skin surfaces
Creeping substitution
cutting cone of new osteoblasts, followed by osteoblasts will invade graft from host bone
Osteogenesis
synthesis of new bone by cells residing within graft itself or cells of the host
Osteoinduction
substances in graft induce nonosseous tissue to become osteogenic in presence of favorable environments
Osteoconduction
graft providing a lattice or scaffold that allows surviving host tissue to invade and facilitate new bone formation.
Effects of hexacarbon abuse
Hexacarbons are present in solvents (exposure is occupational) Exposure results in giant axonal swellings and distal slowing of conduction velocity resembling symptoms of Guillain-Bare Syndrome
Describe the mechanism of GBS
Myelin destruction in areas of nerve trunks with intense inflammation GBS leads to ascending paralysis (demyelinating polyradiculopathy)
Etiologies of Charcot neuropathy
Risk factors: DM, alcoholism, spinal cord injury C: myelomeningocele, spina bifida, CMT, MS, CP, syringomyelia, congenital insensitivity M: DM, alcoholic neuropathy, uremia, pernicious anemia I: tabes dorsalis, polio, leprosy, TB N: tumors in brain, spinal cord, peripheral nerve T: trauma to brain, spinal cord, peripheral nerve D: indomethacin, intra-articular corticosteroids, phenylbutazone
Frostbite degrees
1st: pale skin initially, then erythematoous and edematous (no blister or vesicle formation) 2nd: superficial dermis, blisters and eschars 3rd: subcutaneous layer and chronic edema 4th: full thickness, tissue gangrene. skin may slough and epithelialize with recovery, in many situtations gangrene should be left to demarcate and patient may require amputation
How does hyperglycemia contribute to diabetic foot infections?
Hyperglycemia impairs neutrophil function and reduces blood flow.
Joints affected in rheumatoid arthritis
MTPJs, hips, knees, sacroiliac, glenohumeral, C1-C2 spinal articulation
What may be required in the management of acute inflammatory neuropathies?
Urgent and aggressive IV immunoglobulin or plasmapheresis Mechanical ventilation should be considered for patients with FVC ,30% baseline of FVC <20mL/kg or max inspiratory pressure <30cm of water
Direct Coomb’s test for reactions
-direct antiglobulin test normal positive in ABO-related acute transfusion reactions (results of C3d complement deposition on circulating red blood cells and anti-A, anti-B or anti-A,B antibodies of recipient) -Coombs test would be negative in febrile non-hemolytic reaction (RBCs in sediment with clear urine supernatant in centrifugation tube)
Acute hemolytic reaction
occurs within minutes of transfusion with incompatible ABO blood group Urine turns red and centrifuged urine will distinguish hemoglobinuria from hematuria (hemoglobinuria urine remains red after centrifugation)
Hemoglobinuria vs. hematuria
Hematuria: urine and RBCs from lower urinary tract (RBCs settle in bottom of tube and supernatant urine will be clear yellow) Hemoglobinuria: deposits of hemoglobin monomers and dimers filtered by kidney from plasma
How much volume reductions with lymphatic reconstructive microsurgical procedures?
42-59% volume reductions
Clark levels of invasion
Melanoma invasion: 1: epidermis only (best prognosis) 2: dermis and papillary dermis 3: entire papillary dermis 4: reticular dermis 5: all layers of skin and into fat (worst prognosis)
Lymphatic flow
superficial to deep by muscular contraction reflux (deep to superficial) prevented by passive closure of one-way valves
Clinical Etiology Anatomy Pathophysiology (CEAP) classification
Lower extremity chronic venous disease C0 to C6 based on appearance Signs include: telangieectasias, varicose veins, edema, pigmentation or eczema, lipodermatosclerosis, ulceration Etiologies: congenital, primary or secondary Anatomy: superficial v deep
Pathognomonic sign for rheumatoid arthrtisis
multiple metatarsalgia, prominent and hypertrophic metatarsal heads, limited ankle ROM and synovitis Deformities: clawtoes and digital deformities, equinus Later stage: arch collapse with midfoot and rearfoot collapse
Juvenile rheumatoid arthritis treatment protocol
5 different treatment groups: 1. hx of arthritis in <4 joints 2. >5 joints 3. Active sacroiliac arthritis 4. systemic arthritis without active arthritis 5. systemic arthritis w/ active arthritis start therapy with NSAIDs or anakinra
What is helpful in supporting diagnosis of HCV arthritis?
Anti-HCV, HCV-RNA by PCR, cryoglobulins, Rh factors (54-82%) anti-CCP antibody positivity in less than 7% Clinically: rapid progressive acute arthralgia Similar pattern to RA Bilirubin or transaminase levels may be elevated (ut normal levels do not exclude infection) 20% of pts with HCV have arthralgia
EBS Weber-Cockayne (epidermolysis bullosa simplex)
trauma or friction induced skin blistering autosomal dominant pattern Junctional: skin cleavage within lamina lucida or dermoepidermal junction (autosomal recessive mutation LAMA genes –> preventing assembly and secretion of functional trimeric laminin) Dystrophic: cleavage plane below lamina densa Kindler syndrome: multiple cleavage planes Lethal acantholytic EBS: LOF mutation in DSP and JUP genes
Erythema nodosum
acute nodular eruption on extensor surfaces of legs 2/2 delayed hypersensitivity reaction occurs in sarcoidosis, IBS initial phases: ache, flulike, fever, hard painful leasions 2nd week: fluctuant lesions self-limited NSAIDs provide relief
Period after revascularization to optimize local blood flow?
4-10 days
Onychauxis
thickening of nail plate seen in elderly transverse ridging and lateral deviation
PAD and intermittent claudication
significant sign of atherosclerosis treatment targeted at reduction of symptoms and prevention of disease progression Management: statin therapy (LDL < 100 mg/dL) and antiplatelet therapy w/ aspirin or clopidogrel Smoking cessation associated with increased walking time
Pseudoclaudication
spinal stenosis (low back pain radiating to lower extremities) s/s: numbness, weakness, fatigue
Claudication s/s
cool skin nonpalpable distal pulses nonhealing wounds shiny skin loss of hair abnormal cap refill distal extremity pallor on elevation peripheral neuropathy (stocking glove distribution)
Dexamethasone suppression tests
normal patient: low ACTH at any dose Cushing’s: high dose - low ACTH, low dose - no change ACTH pituitary tumors: high dose - low ACTH, low dose - no change ACTH
Westermark Sign
pulmonary embolism changes on CXR
Stellwag’s sign
thyrotoxicosis Pt unable to blink or infrequently blinks
Quincke’s sign
visible pulsation in capillary bed in ungual region indicates aortic insufficiency associated with aortic regurgitation
Wellens’ Sign
deep inverted T waves (leads V1-V4) associated with severe disease in left anterior descending artery seen ours after NSTEMI
Quincke’s pulses
murmur characteristic of aortic regurgitation associated with wide pulse pressure
Musset’s sign
head bob with each heart beat associated with aortic regurgitation
Mitral valve prolapse
Mid-systolic click increased intensity with Valsalva maneuver associated with: atypical chest pain Palpitations dyspnea hyperventilation dizziness or syncope panic or anxiety disorders numbness or tingling skeletal abnormalities abnormal ECGs
Lichen planus
inflammatory disorder affecting skin, nails, hair, mucous membranes longitudinal ridges and fissures thinning of nail plate erythema of lunula trachonychia (roughness and excessive longitudinal ridging, pitting or thickening of cuticle as a result of defective keratinization of proximal nail matrix) proximal nail fold hyperpigmentation longitudinal melanonychia tx: systemic or intralesional corticosteroids
Trachonychia
Roughness and excessive longitudinal ridging, pitting or thickening of cuticle as a result of defective keratinization of proximal nail matrix
Proper nutrition indicated with:
serum albumin >3.5 gm/dl help collagen synthesis and tensile strength
Risk factors for osteomyelitis
previous history of wound wounds extending to bone or joint recurrent or multiple wounds
When should osteomyelitis be considered?
infected, deep, or large foot ulcer chronic wounds overling bony prominence ulcer depth > 3 mm CRP > 3.2 mg/dL ESR > 60mm/hr
Antibiotic length after radical resection of infected bone
persistent infected or necrotic bone –> four weeks or longer no infected tissue –> 3-5 days
When are occlusive dressings appropriate?
clean wound since dressing provides culture medium for bacterial proliferation occlusive dressing effective in removing eschar, but not justified
Fracture blisters
hemorrhagic blister –> flaccid roof Serous blister –> tense roof fracture blisters lessen the incidence of compartment syndrome
Osborne (J) waves
associated with hypothermia
Lown-Ganong-Levine syndrome
associated with accessory pathway connects the atrium to distal AV node
Wolf-Parkinson-White syndrome
pre-excitation syndrome characterized by congenital atrioventricular bypass tract and tachyarrhythmias ECG: shortened PR interval (<120,s) and initial slurring of QRS complex QRS prolonged (>110ms) and ST and T waves discordant changes
Bundle of Kent
accessory pathway in WPW
Indications for pharmacologic therapy to lower urate in gout patients
Tophus or tophi Clinical or radiographic signs of chronic gouty joitn disease frequent or disabling attacks of acute arthritis gout with CKD stage 2 or greater recurrent uric acid nephrolithiasis urinary uric acid >1100mg/day
Percentage of people with peripheral neuropathy
2.4% of Americans 8% of population seen in family practice clinic
Conn’s syndrome –> Cushing’s syndrome –> Pheochromocytoma –> Addison’s disease –>
- Hyperaldosteronism with adrenal adenomas 2. Excess cortisol 3. Excess catecholamines 4. adrenal insufficiency
Legg-Calve-Perthes disease (LCPD)
avascular necrosis of proximal femoral head
Blount’s disease
osteochondrosis of posteromedial part of tibia
Osgood-Schlatter
apophysitis
Osgood-Schlatter
apophysitis of tibial tuberosity
Preferred method for burn treatment inpatient
open method = topical agent applied directly to wound with no overlying dressings
Myrmecia
warts that grow deep and are usually more painful than common warts occur plantar surface (found on WB surface - heel or met head)
Degeneration pattern of CMT disease
smaller muscle mass equates to earlier degeneration intrinsics are affected first PL and TP maintained for longer –> workhorse tendons contributing to cavovarus deformity Triceps surae largest muscle mass so last to undergo degeneration
Polymyalgia rheumatic
> 50 years pain and morning stiffness in shoulders, hips, neck giant cell (temporal) arteritis Scandinavian people muscle tenderness clinical synovitis or bursitis swelling and pitting edema of hands, wrists, ankles and top of feet
Urate lowering therapy
Allopurinol or febuxostat (XO inhibitor) –> decrease urate production (1st line) (for overproducers) Probenecid or pegloticase (uricosuric) –> increase renal excretion of urate (for under-excretors)
T or F: Hyperglycemia impairs T-cell function
False: Hyperglycemia impairs neutrophil and reduces host defenses
Hypokalemia Periodic Paralysis (HPP)
Most common type of periodic paralysis Causes: fatigue, viral illness, beta agonists, insulin or steroids, excess renal or GI loss of K+ Mechanism: change in Na+ and calcium channels –> low K+ serum K+ low, total body K+ not depleted Muscle dysfunction, not nerve conduction abnormality
Etiology of myopathies based on acuity of symptom onset
- weakness progressing rapidly over hours –> toxic etiology or episodic paralysis 2. weakness over days –> acute dermatomyositis or rhabdomyolysis 3. weakness over weeks –> polymyositis, steroid myopathy or endocrine myopathy
Muscle groups associated with myopathies
Distal muscle weakness: weak grasp, handwriting problems, flapping gait Proximal muscle weakness: difficulty rising, climbing stairs, shaving/combing hair
Symptoms of myopathies
General signs and symptoms: symmetric proximal muscle weakness, malaises and fatigue, dark urine, fever and normal level of consciousness Dermatomyositis: Gottron papules (pink or violacious scaly areas over knuckles, elbows, knees) Absence or sensory complaints or paresthesias DTRs diminished by hypokalemic paralysis
Stemmer sign
inability to pinch dorsal aspect of skin btwn 1st and 2nd toes (not 3rd and 4th) seen in pts w/ lymphedema
False negative gram stains
gram stain sensitivity varies from 29 to 50% negative stain does not rule out early infections or infections by microorganisms such as mycoplasma, mycobacteria, fungi.
Problems with gram stains
clumps of stain or cellular material incorrect blanching of gram stain presence of crystals in synovial fluid
Forms of polio
Bulbar (more severe) Bulbospinal (more severe) Spinal (usually foot and ankle) usually tibialis anterior and quadriceps affected bc of 4th lumbar spinal segment
Parvovirus B19 induced arthritis
Slapped cheek or Fifth disease responsible for 12% of cases of sudden onset polyarticular arthritis in adults exposed to children
Rubella induced arthritis
arthritis appears one week before or after rash symmetric, polyarticular morning stiffness lasting weeks-months
Most common CPs
- Spastic (pyramidal tract lesions) 2. Dyskinetic (extra-pyramidal tract lesions) 3. Mixed (both) 4. Ataxic (rare)
Findings associated with psoriasis
Nail pitting dactylitis splinter hemorrhages enthesopathy onycholysis psoriatic vulgaris psoriatic arthritis (asymmetric polyarthritis)
Histological characteristics of psoriasis
acanthosis (epidermal hyperplasia) parakeratosis dilated blood vessels
Preferred nerves for biopsy
sural or superficial peroneal nerves (with epidermal skin biopsy)
Pneumatic pump is contra-indicated in patients with ____
active infection, CHF, DVT
Syndromes associated with brachymetatarsia
Down, Turner and Larsen
Bone stimulation indicated for:
nonunion, delayed union, bone grafting, infection/osteo, Charcot, AVN, acute fx
Bone stimulation contraindicated in:
malunion, synovial pseudoarthrosis, bony deficit greater than half bone diameter
Candidates for heparin bridging
prior VTE in previosu 3 months and thrombophilia (factor V leiden, protein c or s deficiency, antiphospholipid antibody syndrome)
FEV1/FVC
proportion of vital capacity a person is able to exhale in 1 second normal is 80% obstruction (COPD) –> FEV1 is significantly decreased, so FEV1/FVC ration is decreased Restrictive (emphysema) –> decreased total lung capacity (TLC)
Macrovascular occlusions in diabetics occur in ____
infragenicular or tibial aa
macrovascular occlusions in non diabetics occur in ___
superficial femoral or popliteal aa
Myrmecia
= deep palmoplantar warts plantar (1,2,4) common (2,7) flat cutaneous (3,10)
Natural remedies to be discontinued 1 week prior to surgery
Ginger (increases blood clotting time), ginkgo biloba (bleeding during surgery), ginseng (increase bleeding, lower blood sugar, ), Vitamin E (increases bleeding), garlic (alter coagulation) and fish oil (alter coagulation)
Cellular response to implanted biomaterials
characterized by inflammation, immunologic response , toxicity and carcinogenic evolution
Tissue remodeling
reactive phase of host biologic response to implanted biomaterials characterized by implant encapsulation, bone resorption and sclerosis
Hypersensitivity reactions
Serous v hemorrhagic blisters
Serous filled, tense roof
hemorrhagic filled, flaccid roof (disruption of epidermal-dermal junction)
simple syndactyly v complex syndactyly
simple (failure of soft tissue separation)
complex (failure of bony and soft tissue separation)
Quincke’s sign
visible pulsation in capillary bed of ungual region, may indicate aortic insufficiency
lethal acanthylotic epidermolysis bullosa simplex mutation
loss of function mutations of the DSP and JUP genes
epidermolysis bullosa simplex aka
EBS Weber-Cockayne
trauma or friction induced blistering to palms and soles (localized or dissemated)
most common variety (75-85%)
autosominal dominant
junctional epidermolysis bullosa
skin cleavage at lamina lucida or dermoepidermal junction
autosomal recessive gene mutations at LAMA preventing assembly of trimeric laminin
dystrophic epidermolysis bullosa
cleavage plane below lamina densa
Kindler syndrome
epidermolysis bullosa at multiple planes
