Module 1 Flashcards
Osteoarthritis (OA), also known as
degenerative joint disease (DJD) or “wear and tear” arthritis, is the most common articular disease in adults older than age 45. It is the most widespread form of arthritis and is a significant cause of functional impairment, chronic pain, and disability in the older population.
OA risk factors
In addition to age, risk factors include genetics, female sex, joint injury, past trauma, advancing age, obesity, and mechanical stress
Principal sites for OA are
the distal interphalangeal (DIP) joints, the proximal interphalangeal (PIP) joints, and the carpometacarpal (CMC) joint of the thumb in the hand; the first metatarsophalangeal or great toe joint; and the hips, knees, and cervical and lumbar spine.
OA symptoms
Osteoarthritis affects the distal interphalangeal joints (Heberden’s nodes) and PIP joints (Bouchard’s nodes) and presents with swelling, stiffness, pain, and deformity.
RA symptoms
usually presents as bilateral pain, swelling, and stiffness of the metacarpophalangeal and PIP joints with characteristic deformities and spares the DIP joints. Generally, other systemic complaints will occur, and joints other than just those in the hand will be affected as well
OA subjective presentation
slowly developing, localized gradual pain in affected joints
early morning stiffness which subsides after 30 mins “gel phenemenon”
OA objective presentation
minimal or no swelling of affected joints
tenderness on direct palpation
reduced passive/active ROM
crepitus
often asymmetrical
OA DI
Primarily clinical dx
Can use plain XR to r/o other condition- may reveal bony cysts, sclerosis, asymmetrical joint space narrowing
OA tx focus
Control pain
Manage symptoms
Maximize functional independence/mobility
minimize disability
core tx for all OA pts
land based exercise
strength training
weight management
water based exercise
self management
education
non pharm OA tx
Education
weight loss
physical therapy, OT
heat, ice, US
accupuncture, supplements
OA hand pharm tx
*Topical capsaicin
*Topical NSAIDs
*Oral NSAIDs
*Tramadol
knee OA pharm tx
*Acetaminophen
*Oral NSAIDs
*Topical NSAIDs
*Tramadol
*Intra-articular corticosteroid injections
hip OA pharm tx
*Obesity management (moderate evidence)
*Nonnarcotic management (strong evidence): oral NSAIDs improve short-term pain function
*Physical therapy (strong evidence)
*Intra-articular corticosteroid injections (strong evidence)
*Mental health disorder (moderate evidence): management of depression, anxiety, and psychosis impact pain relief, function, and ADL
tramadol contra
etoh, hypnotics, other narcotics, SSRI
steroid injection OA
knee, hip if under fluro
lidocaine typically mixed with steroid
rest joint x1 day, limit activity for 2-3 days
no more than 3-4/yr
can accelerate joint deterioration, increase risk of avascular necrosis
OA most affective sx intervention
total joint replacement
Osteoporosis is a
generalized skeletal disorder characterized by normal bone mineralization but low bone mass (bone mineral density [BMD]) and disruption of the bony architecture, both of which result in an increased risk of fractures
osteoporosis clinical manifestations
vertebral, hip fractures
osteomalacia
, which denotes a decrease in actual bone mineralization
of women older than 50 in USA who will experience hip, spine, wrist fracture
4 in 10
Women have a two to four times greater lifetime risk of sustaining an osteoporotic fracture than men do because
of the loss of BMD following the cessation of ovarian estrogen production at menopause
most rapid bone loss women age
decade after menopause
risk for repeat fracture if already had one
5x
dietary risk factor for osteoporosis
lack of adequate calcium intake throughout life
osteoporosis risk factor
female
smoking
low calcium intake
sedentary lifestyle
long term steroid use
testosterone deficiency
only “early” symptom of osteoporosis
gradual development of upper/mid thoracic back pain associated with activity or long periods of standing/sitting
vertebral compression fracture presentation
sudden, severe onset of pain, point tenderness, “dowagers hump”
osteoporosis risk assessment tools
SCORE, FRAX
osteoporosis screening
DEXA- utilize Z scores and T scores
BAP (bone alkaline phosphatase) most commonly available serum indicator of osteoblastic activity
Medicare-approved indications for BMD testing include
(1) estrogen-deficient women at risk for osteoporosis, (2) patients with vertebral abnormalities, (3) patients receiving or needing to be on long-term glucocorticoids, (4) patients with primary parathyroidism, and (5) patients being monitored for response or efficacy of an approved osteoporosis drug therapy.
osteoporosis management goals
prevent fractures
stabilize/improve bone mass
maximize physical functioning
relieve symptoms
osteoporosis lifestyle management
smoking cessation
moderation of etoh
weight bearing exercise
adequate calcium, vitamin D
eliminate fall hazards in home
calcium, vitamin D intake daily for osteoporosis
calcium 1200mg daily– however best source is from dietary sources
800 iu vitamin d
type of calcium suggested for osteoporosis
calcium carbonate less expensive, more easily absorbed with meals
first line pharm tx osteoporosis
bisphosphonates
bisphosphonate limitations
pharm therapy for 5 years with no bone density monitoring
bisphosphonate side effects
irritate upper GI mucosa
must be taken whole in the morning with glass of water before other food/drink, remain upright x30 minutes
repeat BMD testing for tx response every
2 years
obesity associated comorbidities
ted public health problems. It is associated with multiple comorbidities, including an increased risk of cancer, cardiovascular disease, disability, diabetes mellitus, gallbladder disease, high blood pressure, osteoarthritis, sleep apnea, and cerebrovascular accident (stroke).
two types of obesity
central (apple shaped)
lower body (pear shaped)
Patients with central obesity have excessive body fat in the abdomen and flank areas and are at a greater risk for
type 2 diabetes mellitus, coronary artery disease (CAD), stroke, and early death,
% of adults overweight or obese
70.2%
overweight BMI
25-29.9
obesity class 1 bmi
30-34.9
obesity class 2 bmi
35-39.9
obesity class 3 bmi
> 40
extragenetic causes of obesity
cultural/environmental factors
suboptimal nutrition/physical inactivity
disrupted sleep cycle
med side effect
stress
neuro dysfunction
viral infection
gut microbiome alterations
cancer risk increase obesity males
colon, rectal, prostate
cancer risk increase obesity females
uterine, gallbladder, biliary tract, breast, ovarian
most common genetic syndromes with obesity
Prader-Willi syndrome
Bardet-Biedel syndrome
obesity subjective symptoms
fatigue, decreased energy, weakness, joint pain, SOB, daytime sleepiness, depression
bmi not accurate in
muscular individuals
methods to measure for central obesity
waist circumference measurment
calculate waist-hip ratio
obesity labs
TSH, glucose, Hga1c, FLP, liver function, alk phos, bili, vitamin D, CBC
Metabolic syndrome is a constellation of risk factors including
hypertension, hyperlipidemia, insulin resistance, and overweight/obesity that significantly increases an individual’s risk of cardiovascular disease and diabetes mellitus
tx obesity
combo of diet, exercise, behavioral intervention
weight loss goal obesity
10% decrease in weight over 6 months
weight loss calorie deficit
500-750 calorie/day deficit
obesity pharm management
orlistat
lorcaserin
phentermine
contrave
saxenda
obesity surgery
BMI over 40 or BMI over 35 with comorbid conditions
must fail conventional weight loss therapies
most common obesity surgery
roux-en Y gastric bypass
gout
metabolic disease produces inflammatory arthritis
risk factor gout
male
use of diuretics
hyperuricemia definition
uric acid above 7 in men
6 in women
Most individuals (90%) with gout have
inappropriate underexcretion of uric acid.
mechanisms that trigger acute attack of gout
trauma
surgery
gout stages
asymptomatic
acute phase
intercritical
chronic tophaceous
acute phase
inflammatory phase
extremely painful joints, red/swollen
elevated wbc, temp, serum uric acid
intercritical phase
interval b/tw phases
asymptomatic
chronic tophaceous
results from recurrent attacks
restrict movement of affected joints
gout subjective
pain tenderness erythema swelling of affected joints
mono articular, joint most frequently affected first joint of big toe
excruciating pain that awakens pt at night
not relieved with rest
gout objective
affected area warm or hot to touch
pain on palpation
limited rom
podagra most affecte
gout testing
serum uric acid
definitive test= microscopic observation of urate crystals in aspirated joint fluid
gout tx initial
NSAIDs- indomethacin or naproxen, steroids, rest,
colchicine
effective to terminate acute attack of gout if given within 36 hours of onset of symptoms
1-1.2mg given at first sign of attack, followed by 0.5-0.6 every 1 until pain relieved
meds to lower uric acid levels
probenecid
allopurinol
febuxostat
not to be started during or within 1 month of acute attack
dietary modifications gout
avoid purine rich foods (meats, seafood, yeast, beer, beans)
adequate fluid intake
moderate etoh
physical activity during acute gout attack
restricted, bedrest x24 hours
linea nigra
, a brownish black pigmented vertical stripe along the midline skin,
The uterus increases in weight from approximately
70 g at conception to almost 1,100 g at delivery, when it accommodates from 5 to 20 L of fluid
anteverted
(forward-leaning)
retroverted
backward leaning
retroflexed
backward bent
chadwick sign
vagina and cervix blue color
leukorrhea of pregnancy
normal vaginal secretions become thick, white and more profuse
hegar sign
palpable softening of cervical isthmus
breast changes during pregnancy
moderately enlarged
more nodular
nipples larger, more erectile
darker areola, more pronounced montgomery glands
EDD
add 7 days to LMP, then add 9 months
Gravidity refers to
the number of times that a woman has been pregnant,
parity is the
number of times that she has given birth to a fetus to a viable age (≥24 gestational weeks), regardless of whether the child was born alive or was stillborn.
prenatal visits
initial visit
q 4 weeks until 28 weeks
q2 weeks until 36 weeks
q1 week until delivery
weight loss due to nausea/vomiting that exceeds
5% is considered excessive, aka hyperemesis gravidarum
Gestational hypertension
is systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg first documented after 20 weeks, without proteinuria or other evidence of preeclampsia, that resolves by 12 weeks postpartum.
mammary souffle
increased blood flow through breast vasculature cause
strongest in 2nd or 3rd intercostal space
fetal movement
can be felt externally @24 weeks
by patient at 18-24 weeks
if fundal height 4 cm larger than expected consider
multiple gestation
large fetus
extra amniotic fluid
uterine leiomyoma
if fundal height 4 cm smaller than expected consider
low level amniotic fluid
missed abortion
IUGR
fetal anomaly
Adnexal tenderness or masses early in gestation
require ultrasound evaluation to rule out ectopic pregnancy. Acute pelvic inflammatory disease is rare in pregnancy, especially after the first trimester, because the adnexa are sealed by the gravid uterus and mucus plug.
unilateral severe edema with calf tenderness
warrants prompt eval for DVT
Leopold maneuvers
used to determine fetal position in maternal abdomen in 2nd trimester, greatest accuracy after 36 weeks
pregnant pt to avoid these foods
Unpasteurized milk and foods made with unpasteurized milk
Raw and undercooked seafood, eggs, and meat
Refrigerated paté, meat spreads, and smoked salmon
Hot dogs, luncheon meats, and cold cuts unless served steaming hot
weight gain in pregnancy
determined by BMI prior to pregnancy
acog physical activity recommendations
<30 min moderate exercise most days of week unless contraindications
leading cause of preventable mental disability in USA
fetal alcohol syndrome
vaccines safe during pregnancy
pneuococcal
meningococcal
hep B
inactivated flu
vaccines not safe during pregnancy
mmr
live attenuated flu
polio
zoster
varicella
prenatal lab screening
ABO and Rh (D) type
RPR
bacteruria
hep b
HIV
iron deficiency
gestational diabetes screening
diabetes screening test in pregnancy
50g oral glucose tolerance test
glucose checked 1 hour after glucose load, threshold of 130-140. If positive, then must do 100g 3 hour diagnostic OGTT
screen 24-28 weeks
prenatal vitamins
folate, b12
iron
