MSK-Derm Clinical Medicine Flashcards
What is considered “abnormal” in the animal naming test?
Test for dementia. Name as many animals as possible in 1 minute.
<12 animals or repeated animals in 1 minute
What is the Varus Stress Test used for?
Describe the test
Test for LCL tear
- Patient supine, knee flexed 30 degrees. Place one hand on medial knee, pull laterally, while pushing medially at the ankle with the other
- Attempt to push into a varus position
- Positive test
- Pain along the lateral knee or laxity compared to the other side
What percentage of community dwelling older adults will fall every year?
33%
List some of the screening tools for dementia
- MOCA - Montreal Cognitive Assessment
- Mini-Cog
- Three item recall at one minute + clock completion
- Animal naming
- MMSE - Folstein Mini-Mental State Examination (no longer used)
A CRP >____ is considered representative of inflammation
C-Reactive Protein
A CRP >10 is considered representative of inflammation
What are the modifiable risk factors for falls?
How can they be mitigated?
- Orthostasis
- Increase hydration, decrease meds
- Gait and balance disorder
- PT, tai chi
- Vision impairment
- Opthalmology referral
- Polypharmacy
- Review and reduce meds
- Environmental hazards
- Home safety assessment; get rid of throw rugs, instal grab bars
What are the principles of universal design?
- Equitable use
- Flexible use
- Simple, intuitive use
- Perceptible information
- Tolerance for error
- Low physical effor
- Size and space approach and use
Something designed for people with disabilities will be accessible to everyone
The Achilles reflex corresponds to which nerves?
S1
What questions should you ask a patient to screen for incontinence?
- Have you had any problems with bladder or urine control?
- Do you ever lead urine when you lift something, cough, or sneeze?
- Do you have a sudden urge to urinate and then leak before you can reach the bathroom?
Don’t ask about “accidents”
In which blood compartment will you find acute phase proteins?
Plasma
Which of the following is NOT a cardinal sign of inflammation?
A. Warmth
B. Stiffness
C. Loss of function
D. Redness
E. Pain
B. Stiffness
In medicine, when would we want to calculate an incremental cost-benefit ratio?
Any time a new treatment becomes available, and we want to decide if we should use it
Describe the CRP test
- Direct or indirect?
- What does it measure?
- How?
- Direct
- C-reactive protein
- Sensitive, automated test
What aspects of social history are important specifically for geriatric patients?
- Children/grandchildren?
- Who do you live with currently?
- Help at home?
- Hours/days per week?
- How is this paid for?
- Don’t forget social history!
- Sex, drugs, alcohol
How do we normalize all costs to present day value when we are doing an incremental cost-effectiveness analysis?
Discounting
The standard is to use a discount rate of 3%
This is not the sames inflation - it includes inflation as well as opportunity cost
Describe the international classification of functioning, disability, and health
This classification puts the notions of health and disability in a new perspective. Every human can experience a decrement in health and therefore some form of disability at some point in their life. Disability is part of the universal human experience
What is the pretest probability of osteomyelitis in a patient with diabetes?
15%
What does patellar ballotement test for?
Describe the test
Determine if a patient has a knee effusion
- With knee extended, push the patella sharply against the femur
- Positive test:
- Fisible and palpable fluid returning to the suprapatellar pouch
What weight in an older adult may be indicative of malnutrition?
Weight <100 lbs or BMI <20
What are the normal ranges for ESR?
Male: Age/2
Female: (Age + 10)/2
Femal sex tends to elevate ESR, independently of acute phase reactants
What are the advantages of CRP over ESR?
- CRP is more sensitive than ESR
- ESR can be affected by factors independent of acute phase protein levels
- ESR must be run within 2 hours of collection, while CRP is stable for 11 days at room temperature, and 2 months in the fridge
Note: one advantage of ESR is that it’s cheaper
What test assesses a patient’s fall risk?
Describe the test. What do the results mean?
The Timed Up & Go (TUG) Test
- Patient is asked to rise from a chair, walk 10 feet, turn around, walk back to the chair, and sit down
- Can use asssistive device if used normally
- Assess for pace, balance, stride length, shuffling, arms swing, proper use of assistive device
If >12s, high risk of falls and 34% chance of losing 1 ADL in the next year
What movement of the hip is being demonstrated here?
A. Internal Rotation
B. External Rotation
A. Internal Rotation
What features of a patient’s social history would increase their risk of osteomyelitis?
IV drug use
Smoking
What aspects of the MSK exam are especially important in older adults?
- Inspect for deformities, swelling, redness
- Palpate for tenderness, crepitus
- ROM (active and passive)
- Muscle strength
- Gait assessment
- TUG test
What pre-analytic factors will increase ESR?
(independent of the presence of acute phase proteins)
- Increased temperature
- Bubbles in the test tube
What are the possible adverse reactions of anticholinergics, especially in older adults?
- Urinary retention
- Constipation
- Confusion
Where does CRP come from in the body?
CRP is synthesized by the liver in response to factors released by macrophages
Does this phrase apply to CRP or ESR?
Affected by many factors that are independent of the acute phase response
ESR
What is an incremental cost-effectiveness ratio (ICER)?
Incremental cost divided by the incremental benefit
Increse in cost ÷ increase in benefit
Which test is most often used to screen for dementia?
Describe the test
MOCA (Montreal Cognitive Assessment)
- One-page, 30-point test
- <26 is abnormal
- More sensitive for people with a higher education level
Which test for acute phase reactants is most sensitive?
CRP
It is a direct, sensitive, automated test that is not as easily affected by outside factors
What is “normal” in a strength test?
What level of strength indicates that a patient is able to resist gravity?
5/5 = normal strength
3/5 = can resist gravity
These are the LR+ and LR- for osteomyelitis based on the following two tests.
Which test is better for ruling out disease?
Probe to bone test
A negative probe to bone test is more likely to rule out osteomyelitis than an ulcer <2 cm
What is the definition of disability for clinical practice?
- Medical
- Umbrella term for impairments, activity limitations or participation restrictions
- Social
- Disability is not just a health problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers
The main concept fo the social model of disability is:
- Disabled persons rely on the health care system for solutions
- Disability is a pathologic condition
- Disability is caused by the relationship between the person and their environment
- Disabled persons cannot have active social lives
C. Disability is caused by the relationship between the person and their environment
What defines polypharmacy?
On >4 medications, including OTC or alternative meds
Most common in geriatric patients; important because it increases risk of adverse effects!
Which reflexes are assessed in a standard MSK physical exam?
- Biceps (C5-6)
- Triceps (C7-8)
- Patellar (L3-4)
- Achilles (S1)
What does the LR+ measure?
Likelihood of a positive test in a patient with disease
÷
Likelihood of a positive test in a patient without disease
Simply: The likelihood that a patient who tests positive has the disease
What are the parameters of a Markov model?
- Series of transitions between health states
- Health state = well-defined stage in the disease
- Each health state is independent of others
-
Utilities
- How much each health state is “worth”
- Use QALEs QALYs
- Definied period of time for the model
- Probabilities for the likelihood of moving between states in the pre-defined time period
Acetaminophen will stop my headache for 3 hours and costs 19₵/dose
Ibuprofen will stop my headache for 5 hours and costs 27₵/dose
What is the incremental cost-effectiveness ratio of ibuprofen?
Acetaminophen is 8₵ more expensive and provides 2 more hours of relief
ICER = 8₵ / 2 hours
= 4 ₵/hour
What other conditions are associated with hearing loss?
Depression, dissatisfaction with life, withdrawal from social activities
Describe the ESR test
- Direct or indirect?
- What does it measure?
- How?
- Indirect
- Measures how quickly RBCs settle
- Measure how far RBCs settle in 1 hour
- RBCs will settle more quickly if there are more acute phase proteins present, because they have positive charges that help aggregate the negatively charged RBCs
Does this phrase apply to CRP or ESR?
Automated
CRP
Describe the medical model of disability
Medical model
- Disability is always negative, intrinsic to the person
- Goal is to cure or normalize the person
- Health care professional is the agent of change
What is “dignity of risk?”
Dignity of risk = the right to make decisions in your life and therefore, take on the risk that comes with that decision
When can you multiply likelihood ratios together based on test results?
If the tests are “in series,” aka not part of the same pathology
For example:
- You can multiply the LR+ for “diabetes” and “ulcer >2cm” in trying to determine a patients chances of having osteomyelitis
- You cannot multiply the LR+ for “ulcer >2cm” and “positive probe to bone test;” these are both measurements of ulcer size, and therefore part of the same pathology (the ulcer)
What are the possible adverse reactions of sulfonylureas, especially in older adults?
Hypoglycemia
What is usually the first activity of daily living (ADL) to be lost in older adults?
Bathing
In general, what medications should be avoided in older adults?
Sedative-hypnotics
Any of the “antis”
- Narcotics
- Barbituates
- Benzodiazepines
- Antihistamine
- Antihypertensives
- Antiarrhythmics
- Antidepressants
- Antipsychotics
- Genitourinary antispasmodics
Also:
- NSAIDs
- Muscle relaxants
- Hypoglycemic agents
What screening tools can be used to screen for depression?
- PHQ-2
- PHQ-9
An 89 year old woman has an ESR of 41.
Is this normal?
Yes;
(Age + 10)/2 = normal value for a woman
(89 + 10)/2 = 49.5; anything below this is normal
What are the activities of daily living (ADLS)?
In general, things you do when you wake up in the morning
- Transferring
- Toileting
- Bathing
- Dressing
- Grooming
- Eating
Does this phrase apply to CRP or ESR?
Uses a Westergren tube
ESR
What features of a patient’s medical history would increase their risk of osteomyelitis?
- Peripheral vascular disease
- Impaired blood flow
- Diabetes
- Immunosuppresion + vascular disease
- Immunocompromised
- Sickle cell disease
- Impaired blood flow
- Prior injury that impairs blood flow
Does this phrase apply to CRP or ESR?
Must be run within two hours of collection
ESR
What factors contribute to acute urinary incontinence?
DIAPERS
- Delirium
- Infection
- Atrophic vaginitis
- Polypharmacy
- Excess fluid output
- Restricted mobility
- Stool impaction
What is an activity limitation?
Give some examples
An activity limitation is a difficulty encountered by an individual in executing a task or action
Activity limitations usually result from impairments, and may lead to participation restrictions
- After spinal cord injury
- Mobility
- Emptying bowel and bladder
- Sexual dysfunction
- After traumatic brain injury
- Remembering to take medication, pay bills, go to appointments
- Difficulty with time management
- Difficulty negotiating social relationships
What is the McMurray Test used for?
Describe the test
Test for medial and lateral menisci tears
- Examiner cups heel in one hand, other hand with fingers and thumb long medial and lateral joint lines, with the knee flexed past 90 degrees
-
Medial meniscus
- Externally rotate the tibia from the heel, other hand applies valgus stress (push medially) at the knee as the knee is extended
- Positive test = click or pop along the medial joint line
-
Lateral meniscus
- Internally rotate the tibia from the heel, other hand applies varus stress (pull laterally) as the knee is extended
- Positive test = click or pop along the lateral joint line
Which hearing range is usually lost first?
How does this inform your practice?
High frequency range
If your patient has hearing loss, speak lower, slower, and more distinctly (instead of more loudly)
What are the possible adverse reactions of Benzodiazepines, especially in older adults?
- Falls
- Confusion
- Poor balance
Describe the social model of disability
Social model
- Disability may be neutral
- Goal is to change society or the environment, not the person
- Not enough emphasis on the role of the patient
- Many agents of change, inlcuding the health care provider
A patient has a 15% pre-test probability of osteomyelitis due to their history of diabetes.
What are the odds they have osteomyelitis?
17.6%
Odds = probability / (1-probability) = 15/85
What are the possible adverse reactions of doxazosin, especially in older adults?
- Orthostasis
- Dry mouth
- Urinary problems
How would you assess a patinet’s functional status?
- Ask if they need assistance with ADLs or IADLs
- Ask if ADLs or IADLs are difficult due to health problems
Describe the Mini-cog assessment
- Tell the patient 3 items to remember
- Ask the patient to draw the face of a clock that shows either 2:50 or 11:10. Give them 1 minute to do so
- After the minute is over ask them to recall the 3 items
This test is sensitive and specific even when education is less than high school and primary language is not English
What is the value of the chance node labeled A?
What is the value of the chance node labeled B?
What is the expected value of surgery?
What is the expected value of medical treatment?
A = 7.55
B = 7.78
(need to calculate B in order to calculate A)
What are the cardinal signs of inflammation?
- Warmth
- Redness
- Swelling
- Pain
- Loss of function
When you are conducting a sensitivity analysis, what is analogous to a ROC curve?
Graph of expected value vs. a sensitive variable
Allows you to see the value at which it becomes advantageous to choose one treatment over another
Does this phrase apply to CRP or ESR?
Direct, quantitative measurement
CRP
People with disabilities make up about ___% of the US population
People with disabilities make up about 19% of the US population
What is an impairment?
Give some examples
An impairment is a problem in body function or structure
- Examples after spinal cord injury:
- Weakness of legs
- Neurogenic bowel adn bladder
- Impaired sensation
- Pain
- Examples after traumatic brain injury
- Memory problems
- Difficulty with executive function
- Emotional dysregulation
- Pain
What factors could cause a falsely high CRP?
High bilirubin
Hemolysis
High lipid
What is a participation restriction?
Give some examples
A participation restriction is a problem experienced by an individual in involvement in life situations
- Going back to work after an injury
- Dating
- Living on one’s own
- Impairment w/ executive function
- Acitivity limitation = remembering to pay bills
- Participaton restriction = cannot live on own
What is the best single question to screen for depression?
“Do you ever feel sad or depressed?”
- Sensitivity 85%, specificity 65%
Which test (CRP or ESR) responds most quickly to changes in the level of acute phase reactants?
CRP
Why is the biopsycho-ecological model the best one for understanding disability?
What advantages does it have over the medial or social models?
- Biopsycho-ecological model = most complete; recognizes the roles of the patient, health care professional, and society
- Many goals of care:
- Alter the body, compensate for impairment, and/or alter teh environemnt
- Change social attitudes, public policies
- Patient, healthcare professional, society are all agents of change
- Many goals of care:
- Medical model
- Disability is always negative, intrinsic to the person
- Goal is to cure or normalize the person
- Health care professional is the agent of change
- Social model
- Disability may be neutral
- Goal is to change society or the environment, not the person
- Many agents of change
What is crepitus?
Abnormal popping or crackling sound in a joint
What defines orthostatic blood pressure?
Decrease in SBP by 20 or DBP by 10
(1 minute after standing up from lying down)
What do the ESR and CRP tests measure?
Why is this important?
Acute phase proteins
This helps us measure the acute phase response - a useful marker for inflammation/infection
- CRP is a direct measurement of C-reactive protein
-
ESR is an indirect measurement of acute phase proteins
- It measures teh rate that RBCs settle; they will settle more quickly if there are more acute phase proteins are present
What patient factors will increase ESR?
(independent of the presence of acute phase proteins)
- Anemia
- Hemolysis
- Pregnancy
- Some drugs (steroids and NSAIDs)
- Female sex, older age
What are the possible adverse reactions of NSAIDs, especially in older adults?
- GI bleeding
- AKI
- Hypertension
What is the Valgus Stress Test used for?
Describe the test
Test for MCL tear
- Patient supine, knee flexed 30 degrees. Place one hand on lateral knee, push medially, while pulling laterally wtih the other
- Attempt to push into a valgus position
- Positive test
- Pain along the medial knee or laxity compared to the other side
Given sensitivity and specificity, what is the equation for LR+?
LR+ = sensitivity / (1 - specificity)
What do we do to figure out which data point has the biggest influence on our result?
Sensitivity analysis
- If the outcome changes when when you change a variable, the outcome is sensitive to that variable
- If the outcome does not change when you change a varible, the outcome is robust to that variable
What are the differences in the presentation of osteomyelitis in adults vs. children?
- Adults
- More chronic spread, smoldering infection
- Usually starts as a skin or soft tissue infection and spreads contiguously
- Can get acut osteomyelitis from hematogenous spread, but less likely
- Children
- Usually acute onset - fever, redness, bone pain
- Hematogenous spread - bloodstream infection seeds the bone
What aspects of ROS are especially important to check in geriatric patients?
DDDEEP In
- Dementia
- Depression
- Drugs
- Eyes
- Ears
- Physical performance (Falls)
- Incontinence
- Nutrition
Important to screen for these in geriatric patients
If a patient with a low pre-test probability of osteomyelitis has a low ESR or CRP, what is your next step?
No further assessment needed!
How do you conduct a sensitivity analysis?
(In general, we don’t acutally have to be able to do this)
Change one variable at a time and look at the effect on the outcome
- If the outcome changes when you change a variable, the outcome is sensitive to that variable
- Then, you can determine the value of that variable at which given intervention makes sense
- Ex: At what efficacy is advantgeous to “treat now” vs “wait”?
- If the outcome does not change when you change a variable, the outcome is robust to that variable
Do this for all variables to see which variables affect the outcome
Why is it important to screen for dementia?
- Often underrecognized and underdiagnosed
- Prevalence doubles with every 5-year increase in age
Screening is semi-controversial because it doesn’t fit the “classic” criteria; there isn’t really a treatment that can change the course of disease if implemented early
The patellar reflex corresponds to which nerves?
L3-4
The triceps reflex corresponds to which nerves?
C7-8
What are the possible adverse reactions of tricyclic antidepressants, especially in older adults?
- Orthostasis
- Sedation
What is decision analysis?
An explicit, quantitative, prescriptive approach to decision making under conditions of uncertainty
Use “trade off” analysis to incorporate risks and benefits of any medical decision
When a Markov model is constructed, where do the probabilities and utilities come from?
- Probabilities
- Prognosis or cross-sectional studies
- Utilities
- Usually from survey information
Does this phrase apply to CRP or ESR?
Most sensitive acute phase reactant
CRP
The biceps reflex corresponds to which nerves?
C5-6
What does the LR- measure?
Likelihood of negative test in a patient with disease
÷
Likelihood of a negative test in a patient without disease
Simply: The likelihood that a patient who tests negative does not have the disease
What factors in the plasma will increase ESR?
(independent of the presence of acute phase proteins))
- Increased fibrinogin/globulin
- Hypercholesterolemia
What is the gold standard for diagnosing osteomyelitis?
Bone biopsy -> histology and/or cultures
When would you do the Lachman Test?
Describe the test
Test for ACL tear
- Knee flexed to 15-30 degrees, femur stabilized with one hand. Other hand behind the proximal tibia pulls the tibial anteriorly
- Positive test
- Increased anterior translation of the tibia onto the femur compared to the opposite side => ACL tear
What is the whispered voice test?
How is it performed?
Used to screen for hearing loss if you have a strong suspicion, but the patient denies difficulty hearing
- Stand at arms length behind the patient’s field of vision
- Whisper while gently using the end of your figer to occlude and rub the external auditory canal of the other hear
- Take a full breath, exhale, and then whihsper a set of 3 random numbers and letter
- Ask patient to repeat back
- All correct = normal
- If not, repeat - need 3/6 to pass
- Repeat on the other side
Does this phrase apply to CRP or ESR?
Indirect measurement
ESR
In a Markov model, what kind of parameter is cost?
A utility (like a QALE)
What pre-analytic factors will decrease ESR?
(independent of the presence of acute phase proteins)
- Improper anticoagulant
- Old sample
- Low temperature
What are the instrumental activities of daily living (IADLS)?
The things you needed to do on your own when you went to college
- Transportation
- Shopping
- Cooking
- Laundry
- Household chores
- Finances
- Medications
- Telephone
