Notes on HB Kim Flashcards
CPR norm
Dial 911 then start CPR
Compression30: ventilation2
100 per minute
Anatomical movements
Flex - shorten muscles eg: iliopsoas - hip flexor
Extend - lengthen muscles
Adduct - move toward body
Abduct- move away from body
Most common side effects of Ergotamine in treating migraine
Nausea and cold fingers and toes
Ergotamine works by constricting blood vessels to reduce pain
Side effects of drugs
Myalgia (pain in muscle/s) - Statins, which lower LDL
GI Bleeding - Ibuprofen/aspirin
Tinnitus, Reyes syndrome, asthma, peptic ulcers - Aspirin
Flush - Niacin/Vitamin B3 - lowers LDL and increases HDL
Nausea, cold fingers and toes - Ergotamine - treats migraines
Generic name example
Acetaminophen (generic) - tylenol / panadol
What significantly increases risk of life threatening hypotension with Sildenafil (viagra)
nitroglycerin
Triglyceridee
a type of fat found in blood to make energy. Normal - <150 Borderline high is 150-199 high is 20-499 V high is 500+
Fish oil helps bring down triglyceride levels
Elevation is associated with: Pancreatitis (levels over 1,000), Alcoholism, myocardial infraction, increased fat/sugar
Dermatome for parts of body
A dermatome is an area of skin in which sensory nerves derive from a single spinal nerve root (see the following image).
L5 - top foot st2-s4- perinemum s1 - bottom of foot T4- nopple c6 - thumb t10 - umbilicus
Efectiveness of iron therapy can be monitored by
Hemoglobin and reticulocyte levels (will become RBC)
RBC life span - 120 days
Thrombocyte WBC -
Platelets -5-10 days
Generic name for Aspirin and long term side effects
Salicylate
* can cause tinnitus and GI problems
COX 1 inhibited which protects GI and renal FX, platelets, incraase risk of hemorrhagic stroke and asthma (if you use too much)
If corticoseroids (treats inflammation) are stopped without taper can lead to
Adrenal insufficiency. - Adrenal cortex stops making enough
Adverse effects of corticosteroids:
Osteoporosis, exogenous Cushings, hyperglycemia, increased skin fragility, easy bruising
Sulfonamide is an
Antibiotic
- many people have sulfur allergy: skin rashes
Adverse affects of Pellagra
A disease that occurs when a person does not get enough niacin (b3)
4D Dermititus Diarrhea Dementia Death (untreated)
sympathetic nervous system involved in stimulation of
Bronchodilation
Increased HT rate
vasoconstriction
Parasympathetic - pupil constriction, urination
Point and shoot
Erection - parasympatahetic
Ejaculation: Sympathetic
NSAIDS inhibit formation of
Prostaglandins
HMG CoA reductase - Statin, lower cholesterol
Xanthine oxidase production - allopurinal (chronic gout) (enzyme converts Purines to Uric acid
PDE5 (an enzyme in the walls of blood vessels. It affects blood flow and how cells signal within the body. ) - viagra
Diazepam (valium) and Antihistimine together will cause
Together increase central depressive effect
Valium- central depressive effect
Antihitamine (1st gen - Benadryl) - Drowsiness/sedative effect
median nerve innervates
Palmar aspect - thumb, index, middle and half of 4th/ring
Dorsal Aspect- Distal thumb, distal of index, distal middle, distal and medial of 4th
Normal adult mouth has how many permanent teeth
Permanent: 32
Deciduous teeth: 20
Transient Ischemic Attack (mini-stroke) common SX
- Temp loss of vision (amarosis fugax)
- Difficulty speaking (aphasia)
- Weakness of one side of body (Hemiparesis)
- numbness and tingling (Paresthesia)
Cataracts
Clouded lens (about opacity)
Glaucoma - closed angle - more dangerous/med emergency and open
Retinal disorder- problem with nerve layer in back of eye
Macular degeneration - Disease that destroys sharp and central vision
Smoking tobacco can cause
Lung cancer
Bladder cancer (also, caused by anilon dye, parasite)
Coronary artery disease
spontaneous abortion
screening exam for female over 50
general checkup every year
mammogram every other year
pap smear every 3 years
SX of otitis externa (swimmers ear) inflamaation of outer ear
Ear pain
foul smelling discharge
itching and irritation around ear canal
Structure of inner ear
External ear - ear canal to eardrum
Structure of inner ear
Inner ear - semicircular canals and cochlea - pressbycusis (inner ear problem leading to hearing loss)
External ear - ear canal to eardrum
Middle ear - ear drum to 3 bones marlius, stapes and incas
Thoracic outlet Syndrome Test
Adson’s test - Lose the radial pulse in the arm by rotating head to ipsilateral side with extended neck, followed by deep inspiration.
Apley’s scratch test
Type of ROM test.
Frozen shoulder - problem with external rotation or abduction
Drop arm teset
Tests rotator cuff inury. Supposed to drop arm slowly but will drop fast because of pain.
Speed tests
Biceps tendinitis test.
ptaient supinates aram and tries to push up as physician pushes down
Empty Can Test
Tests for supraspinatous tear (most common in rotator cuff)
90degree shoulder, internal rotation of 30degrees, like your emptying cans. Dr. pushes down as client pushes up. Pain indicates
Supraspinatus
infraspinatus
subscapularis
teres Minor
Lift off test
Tests supraspinatus tear
adduction, internal rotation (broken wing), try to lift hand away from body.
De Quervain Syndrome Test
Blackberry thumb/texting/video games
Test with Finkelstein test. Put thumb inside fist, and physician pushes down
pain over abductor pollicus and extensor pollicus brevis
Lasegue’s Test
Test is used to evaluate sciatic nerve compression
Pain between 30-70 is considered positive
Lift leg straight. Normally a leg can extend to 70-80degrees of hip flexion.
`
Ober Test
Tests tightness of iliotibial band
Lachmens test
ACL test (more specific test) moves forward >6mm
Trendelenburg’s Test
Tests Weak Gluteus medius/mimimus are weak -
hips are uneven if positive
FABERE Test
Leg moved through FABERE motions Tests hip joint and SI joing F- Flexion AB - ABduction ER - External rotation E - Extension
Thomas Test
Problems: tests hip flexor contracture
Contralateral hip flexes
iliopsoas
Hip flexion
flex one hip, other leg will not be bale to stay straight, it will raise up
Posterior Drawer Test
PCL - moves posterior
Hamstring Muscles
Biceps femoris
semitendonisus
semimembranosus
Quadriceps muscles
Vustus medialis, intermeidus, lateralis
Quads lengthen
hamstring contracts
Most common fracture in a child
Greenstick torus or buckle fracture
Their bones are more likely to bend than break. - incomplete fracture (periosteum is stronger and thicker)
Treatment modality for allergic reaction or anaphylaxis
Epinephrine - adrenaline (Epi-pen)
Histamine blockade
Steroid (lowers inflammation)
- With Beta blocker, epi-pen won’t work
Best radiology modality for carotid stenosis and DVT
Duplex ultrasound - how blood moves through veins
*Regular Ultrasound - AAA (Abdominal aortic aneurysm), appendicitis, gallstones, scrotal pathology, pregnancy
Best radiology modality for esophageal obstruction
Barium swallow test- drink liquid barium and take pictures to see if going down properly
upper endoscopy
Radiology modality for head trauma, intracranial bleed, nephrolithiasis
CT without contrast
Ct with contrast (abdominal trauma, diverticulitis)
Weber and Rinne Test for
Hearing loss
differentiate Macule, papule, vesicle, pastule
Macules - flat,
What Reduces LDL and increases HDL
Nicotinic acid (Niacin)
Just Lower LDL - HMG-CoA reductase ihibitors (statis), choloestorol absorption inhibitors (ezetimbe)
Hypothermia is defined as temp of
< 35 deg C (95 deg F)
Risk factors for Gerd - Gastro-esophageal Reflux Disease
Due to LES - lower esophageal sphincter is weakened
- increased pressure - hiatal hernia, Obesity, collagen vascular disease, pregnancy
- Decreased tone - alcohol, caffeine, nicotine, choc, fatty food
HPV for genitala warts
HPV 6 and 11
HPV for Cervical cancer
HPV 16 and 18 ( smoking is a risk factor)
Eeting nonnutritive, non food substances (ice, clay, sand, chalk, soil, paper, metal)
PICA - over a period of >1 month - Cause can be def of vitamins and minerals or parasite, or psychiatric
Dissociative Fugue
Temporary amnesia for ones own identity, typically lasts hours to days + unexpected travel away from home.
Other Dissociative disorders:
Dissociative identity disorder - formerly know as Multiple personality disorder
When using lithium, you must monitor which two organs?
- Renal 2. Thyroid
(narrow therapeutic index) - side effects: Hypothyroidism and nephrotoxicity
Characteristic of barking cough
Croup (Laryngotracheobronchitis) - Wind pipe has swollen tissues and is narrowed (front view) - barking cough
Whooping cough *caused by - pertussis
Epiglottitis - life threatening airway obstruction (side/lateral view) - thumbprint sign - Epiglottis - CN10 (has some taste) Food goes to wind pipe instead of food pipe
Phagocytes for internal parasites
eosinophil (allergic rxn, parasite)
Granular - basophil, neutrophil, eosinophil (allergic rxn, parasite)
Agranular - lymphocyte, moncytes
The most common benign breast disorders
- Fibrocystic changes 30-60% women - mild to moderate pain, +/- lumps - hormonal
The most common tumor in menstruating women <25 yrs
Fibroadenoma - benign tumors - small, firm, unilateral, non-tender mass, freely movable and slow growing.
- Ultra-sound can differentiate from cyst
Normal hip flexion using passive ROM
120degrees
Loose connective tissue with elastic and adipose tissue. Lubricate joint cavities.
synovial membrane - join cavities
Serous membrane - closed body cavities (Pericardial, peritoneal, pleural)
mucous membrane - lining to cavities that are open to exterior (digestive)
Cutaneous membrane - covers outside of body (skin)
DEXA,DXA Test evaluates
Bone mineral density, t-score - determines osteoporosis
Low blood chloride levels are due to
severe vomiting and diarrhea (electrolyte disturbance)
Alpha beta blocker used to treat severe hypertension
Trandate (lavetalol)
Others:
Cardizem (Diltiazem)
Vesotec (Enalapril) -pril - ACE inhibitor for high blood pressure
Inderal (propranolol) –olol - just Beta blocker that treats hypertension
Hypertension drugs ACE Beta blocker Calcium Channel Blocker Diuretic
xanthoma
Irregular yellow patch nodule of the skin. Excess triglyceride fatty tissue under the skin.
Ligaments
Connect bone to bone
Tendons
Connect muscle to bone
Fasciae connects
muscle to muscle or muscle to other organs (plantar fasciitis)
Injury of muscle or tendon
Strain
Sprain - Joint out of position, overstretch or rupture of supporting ligament
<p>The most common injured ligament in the foot</p>
<p>Anterior talofibular ligament (around GB40_</p>
<p>Always</p>
<p>Tears</p>
<p>First</p>
<p>Erythropoietin (EPO) is</p>
<p>A hormone secreted by the kidneys that creates the rate of production of red blood cells in response to falling level of oxygen in the tissues (like at high altitude)</p>
<p></p>
<p>Gastrin (in walls of stomach)- stimulates pepsinogen (<span>secreted by the stomach) converts into pepsin, which </span><strong>breaks down proteins in food during digestion</strong><span>.</span></p>
<p>CCK - stimulates emptying of bile <span>Cholecystokinin (in small intestine) stimulates </span><strong>the gallbladder</strong><span> to contract and release stored bile into the intestine. Regulates digestion and appetite</span></p>
<p>hCG - production of embryo following implantation</p>
<p>AKA Human placental lactogen (hPl)</p>
<p>Human chorionic somatotropin (hCS)</p>
<p>hormone produced by placenta that develops during pregnancy to hepl feed the baby.</p>
<p></p>
<p>Treatment for infectious mono</p>
<p>EBV - Epstein Barr Virus</p>
<p>Rest during acute phase so as not to rupture spleen (Avoid heavy lifting and contact sports for 1 month)</p>
<p>sx: swollen lymph, Splenomegaly, fatigue</p>
<p></p>
<p>If you give mono patient penicillin - can get a rash</p>
<p>Menstrual cramps are due to</p>
<p>Prostaglandins</p>
<p>Uterus contracts to help expel lining.P Prostaglandin is involved in pain and inflammation trigger the uterine muscle contractions</p>
<p></p>
<p>Cox-2 inhibitor reduces</p>
<p>Cox 1 - protects</p>
<p>2- inflammation</p>
<p>1- GI</p>
<p>Drugs that are Cox-2 inhibitors: -oxib</p>
<p>Which part of medicare is for hospitalization coverage</p>
<p>Part A</p>
<p>Med insurance - B</p>
<p>Privately purchased supp insurances for additional services - C</p>
<p>Prescription drug - D</p>
<p>Bone, cartilage Blood, adipose tissue</p>
<p>Connective Tissue</p>
<p>Muscle tissues, Cardiac, smooth, skeletal (voluntary, multi-nucleated)</p>
<p>Which drug is associated with miosis (constriction of pupil)</p>
<p>Heroin, oxycodone → opioids (life threatening → respiratory depression)</p>
<p>Amphetamines - (yang) psychomotor agitation, tachycardia, high BP, pupillary dilation</p>
<p>Cocaine - cocaine bug (feel like bugs crawling under skin), chest pain, pupillary dilation, psychomotor agitation, impaired judgement</p>
<p>LSD - pupillary dilation, visual hallucination</p>
<p>PCP - psychosis/violent/impulsive/agitated/ tachycardia,</p>
<p>Scheduled drugs</p>
<p>I. Not accepted for medical use - high potential of abuse - ecstasy, heroine, LSD, PCP</p>
<p>II. Accepted medical use with severe restrictions with high potential of abuse - morphine</p>
<p>III. Accepted medical use with moderate to low potential for abuse - codeine, vicodin</p>
<p>IV. Accepted medical use with potential for abuse but less than schedule III - valium, ambient</p>
<p>V. Accepted medical use with low potential for abuse - Robitusin</p>
<p>Reduced norepinephrine causes</p>
<p>Depression (yin symptom because its reduced- and is a hormone to increase stress response, theres low arisal)</p>
<p>Comes from the adrenal gland</p>
<p></p>
<p>Erythasma</p>
<p>Brown, scaly skin patches</p>
<p>Can happen in diabetic patients</p>
<p>Folate (B9) deficiency and cobalamin (B12) deficiency are associated with</p>
<p>Homocysteine (HCY) (both)</p>
<p>B9 and B12 (hyper-segmented neutrophil)</p>
<p>More B12 - Neurological symptoms</p>
<p>Laparoscopy is used for</p>
<p>Endometriosis (tissue is supposed to be in lining of endometrium) but the tissue is elsewhere, like ovaries, outside uterus (endometrioma/chocolate cyst) , abdomen, fallopian tubes</p>
<p></p>
<p></p>
<p>Most common site of Ectopic pregnancy</p>
<p>Tubular, ampular area</p>
<p>Can do an ultrasound to see</p>
<p>May occur with another health problem, giant cell arthritis (large temporal artery)</p>
<p>Polymyalgia rheumatica (PMR) (<strong>disorder that causes muscle pain and stiffness</strong><span>, especially in the shoulders and hips.)</span></p>
<p>Treatment of BPH (benign prostatic hyperplasia) may be treated by</p>
<p>Tamsulosin (Flomax)*</p>
<p>Proscar (finasteride) *</p>
<p>Dutasteride (avodart)</p>
<p>ICD-10 codes are about</p>
<p>Diagnosis (international classification disease) by WHO</p>
<p>CPT- treatment (current procedural terminology) For US, American Medical Association AMA</p>
<p>CPT insurance code for acupuncture treatment without electro-stimulation</p>
<p>97810 - acu - initial 15 min</p>
<p>97811- acu - each additional 15</p>
<p>97813 -Electro acu initial 15</p>
<p>97814- Electro acu - each additional 15</p>
<p>97140 - myofascial release (Cupping)</p>
<p>Homan's sign</p>
<p>Dorsi flex the foot makes calf muscle pain - positive sign of possible DVT - Deep vein thrombosis -</p>
<p>embolism detaches and is more dangerous</p>
<p>Best diagnostic test and treatment for Bronchiectasis (<strong>long-term condition where the airways of the lungs become widened</strong><span>, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection.)</span></p>
<p>X-Ray and CT of Chest</p>
<p>Treatment - antibiotic, bronchodilators (albuterol), tiotropium, O2 therapy</p>
<p>Tests for Bicipital tendon</p>
<p>Speed test - patient supinates arm while extended to 90 degrees while practitioner pushes down and patient resists - If there is pain→ positive test</p>
<p>Yergasons test - <span>The patient should be seated or standing in the anatomical position, with the humerus in a neutral position and the elbow in 90 degrees of flexion in a pronated position. The patient is asked to externally rotate and supinate their arm against the manual resistance of the therapist produced by wrapping the hand around the distal forearm (just above the wrist joint).</span><a>[2]</a><span> Yergason's Test is considered positive if the pain is reproduced in the bicipital groove and a biceps or a SLAP (</span><strong>tear of tissue that is located on top of the shoulder</strong><span>. SLAP stands for “Superior Labrum Anterior Posterior.) </span><span>lesion is suspected.</span></p>
<p>Which of the following is not a key in identifying Hashimoto Thyroiditis</p>
<ol><li>Anti - thyroid peroxidase antibodies</li><li>TSH</li><li>T4</li></ol>
<p>*T3 is not a crucial to test</p>
<p>Hoshimotos ( teenagers usually had hyperthyroidism as a teenager</p>
<p>Hypo - TSH and T4 is high</p>
<p>Hyper- TSH and T4 is low</p>
<p>What substance Increase the chance of liver toxicity from acetaminophen (Tylenol), or will worsen LV damage that acetaminophen can cause?</p>
<p>Alcohol</p>
<p>Forms of estrogen hormones</p>
<p>E2 - Estra<strong>dio</strong>l (most common type in women in childbearing age) - (Dios willing, I'll get pregnant)</p>
<p>E3- Estriol - (main during pregnancy) - (ol baby is in my belly)</p>
<p>E1 - Estr<strong>one</strong> (only one/estrogen produced after menopause)</p>
<p></p>
<p>Treatment of Gerd consists of lifestyle changes and</p>
<p>Proton Pump Inhibitor - suppress acid production by acid gland</p>
<p>Omeprazole (nexium, prilosec), protonix, prevacid</p>
<p></p>
<p>H2 receptor blockers - can help stop stomach acid - ranitidine (zantac) Famotidine (pepcid), Climetidine (Zantac)</p>
<p>Hematocrit is the proportion of your total blood volume composed of</p>
<p>Red blood cells (RBCs)</p>
<p>Mean corpuscular volume MCV is the avg volume of red cells. Possible MCV for pernicious anemia?</p>
<p><100fl - macrocytic *<strong>causes unusually large red blood cells)</strong></p>
<p><80fl - microcytic - b12 and folate deficiency</p>
<p>Normal - 80-95fl</p>
<p></p>
<p>Best diagnostic test for bronchectaasis</p>
<p>Xray and Ct chest scan</p>
Reflexes for knee
L4 - knee reflex (can also relatae to L2, L3)
s1 - heel reflex/achilles/bottom foot
L5 - dorsum of foot
Digestive enzyme for protein
Pepsin - peptides and aminos
Trypsin- enzyme that aids with digestion of proteins (too much leads to pancreatitis)
Lipase - breaks down fat into fatty acids
Enzymes for carbs is released
in the mouth and Small intestine
Inhibitory neurotransmitter
GABA - inhibitory
Glutamine - Excitatory
Dopamine - both
Diazepam (Valium) and alprazolam (Xanax) are what?
*Benzodiazepines - Facilitates GABA action by increasing the frequency of CL channel opening
Barbituate: Facilitates GABA action by increasing duration of CL channel opening
what is added to ergotamine (used for migraines/cluster headaches) in order to facilitate GI absorption and synergetic effect
Caffeine
Trichomoniasis
STD -
Trichomoniasis - Protozoa, increased yellow-green-frothy discharge, malodorous, PH > 4.5, causes strawberry petechia, Rx: metronidazole - Treat partners
Provides. wealth of helpful info, size and shape of heart (internal chamber size quantification), pumping capacity, and location and extent of tissue damage
*Echocardiogram - Echo
Electroencephalography - EEG - seizure (brain recording)
Electrocardiography ECG - heart rhythm, fainting
Electromyography - EMG - nerve issues/skeletal muscle issues issues (ALS, myasthenia gravis, MS etc.)
Diagnostic test for bells palsy
- Physical exam
- Electromyography
- MRI by using contrast agent for CN VII (some cases)
- swelling -> corticosteroids
Heterophile antibody tests
EBV
for monospot test
Ace inhibitor , drug ends in wht letters
-pril
April
- side effect of ACE inhibitor is cough
- Statin - reduce LDL
Lisinopril inhibits the production of
Angitensin II
-pril is n ACE inhibitor. Angiotensin converting enzyme converts angiotensin I to angiotensin II
Plays. central role of regulation of blood pressure by increasing reabsorption of sodium and water in kidneys
Aldosterone
light colored white or clay colored stool indicates
lack of bile in stool
excess ft in stool - steatorrhea - malabsorption of fat (like celiacs)
Parietal cells of stomach secrete
HCL and intrinsic factor
Gastritis and autoimmune damage parietal cells - can’t produce intrinsic factor, which binds to B12 (in ilium) - can lead to pernicious anemia
Another term for illness
Morbidity
Incidence - newly
prevalence - whole number/snap shot
The potent clot-busting drug needs to be given with how many hours after stroke sx begin?
3 hours
tPA- Clot buster (tPA - toilet paper amazing - for cleaning clots)
2 Kinds of strokes:
1. Ischemic - Thrombosis - tPA clot buster
2 Hemorrhagic stroke
For an ischemic stroke as an immediate treatment given in the emergency rooms to reduce likelihood fo another stroke
Aspirin (prevent clots from forming)
Ischemic stroke: Hemorrhagic stroke (blood vessel ruptures)
80%:20%
CT scan will show if its a hemorrhagic stroke
The first like drug choice for strep throat (streptococcal pharyngitis)
Penicillin
Penicillin given to EBV patient -> rash
Strep- throat is normally grayish
Innervates the dorsal aspect of the index, middle and distal thumb
Radial nerve
medial nerve - palmar side side - full thumb, index, middle, half of 4th
- Distal on dorsal
Which of the following hormones is associated with hypothalamic-pituitary-adrenal axis
Corticotropin releasing hormone (CHR)
Adrenocorticotropic hormone (ACTH)
Cortisol
Negative feedback loop
which types of join are the Shoulder and hip joints?
*ball and socket joints
Can move freely in all directions
Hinged: allow small ROM in Elbow or knee
Pivot: allow a wide ROM, but not as much freedom as ball and socket joints (between atlas and axis)
Gliding - allow sliding motion between two bones (wrist & ankle)
What does FABERE (Patrick’s test) test stand for? What does it test?
Flexion, Abduction, External Rotation, Extension (figure four)
pain in the SI joint is possible - indicates hip or SI joint dysfunction
What tests checks for contraction of iliotibial band (combo of Tensor fascia latae + gluteus maximus)
Ober test.
Abduct the involved leg as far as possible with the knee flexed to 90 degrees and the hip extended to 0. The leg is lowered. If the leg remains abducted = positive -> IT band is tight
Thompson Test
Tests achilles tendon is ruptured
Squeeze calf produces plantar flexion of foot when cord is intact. If foot doesn’t go up, achilles tendon is ruptured
Painful Arc
Tests impingement of supraspinatus muscle
When you make an arc with arm, if there is pain from 60-120 degrees, if it is painful
Yergason’s test
Tests biceps tendinitis
Elbow is flexed to 90degrees with thumbs up
grasp hand (hand shake)
patient supinates against resistances. Pain = positive test.
How do you measure for leg length discrepancy?
ASIS to Medial malleolus
Piriformis syndrome
the Piriformis is one of the causes of sciatica. When its tight, it can pinch sciatic nerve and manifest like sciatica.
Leg will be abducted.
Sometimes pain from sciatica is from back (radiclopathy) - nerve pinched.
FAIR test -
Tests piriformis Flex hip, Adduction Internal Rotation Pain = positive
What is true about hip dislocation
There can be posterior and anterior dislocations
90% of hip dislocations are posterior
Transcervical fracture - neck of bone
Intertrochanteric fracture - doesn’t interrupt blood supply
Subtrochanteric fracture - below inter.
Anterior bursa of the knee
4 anterior knee bursas
- prepattelar - behind
- Suprapatellar -above
- infrapatellar bursa - below - 2 of these: Superficial (subcutaneous), and deep infrapatellar bursa)
- Pes Anserine Bursa- goose foot (medial side) - attachment of sartorius, gracilis, semitendinosus
Housemaid knee is the condition also known as
prepatellar bursitis (down on knees)
Baker’s cyst
A type of fluid collection behind the knee. Too much synovial fluid leads to Bakers cyst.
- Inflammation o knee - arthrits
- A knee injury, like cartiledge tear
What forms the medial malleolus
Distal tibia
Tibia (Tom) - big - leads to medial malleolus
Fibula (friend) - smaller - leads to lateral malleolus
Which ligaments is weakest of ankle ligaments?
Anterior talofibular ligament
Which ligament stabilizes medial ankle
Deltoid ligament
Patellar tendon reflex radiates to
L4 - Patellar tendon L1 - L5 - top of foot S1 - heel, achilles C5- biceps C6- brachoradialis C7- Triceps
How many cervical nerves are there?
8
Even though there are 8 cervical vertabrae
Normal ROM for hip flexion
120 degrees
Standing is neutral
what are the joints of the pelvic girdle
SI joint
Femoroacetabular (hip) joint
Pubic symphasis
(Lumbosacral joint is NOT)
Signs of a positive trendelenburg test?
Test Gluteus medius weakness (on side of buttocks) abducts the hips. If there is weekness, they have difficult abducting.
When you lift L leg, the left hip should be just a little bit higher. When glute medius is weak on the supported side, your unsupported side will drop down.
Standing leg is above the bent leg = positive - weak gluteus medius
Weak on Left - Drop on right
What is the pathology behind avascular necrosis of the femoral head?
Interruption of vascular supply
most common cause steroid or alcohol abuse
women are more likely to suffer from hip fracture.
Most common cause of hip fracture is osteoporosis. Approx. 25% of patients over 50 with hip fractures die within 1 year.
Most common hip fracture - intertrochanteric fracture
DEXA scan is for?
Testing bone density - osteoporosis - Dual energy xray absorptionmetry - minimal xray - measures t-score
What is normal Bone Denisty? For Osteoporosis?
+1- -1
Osteopenia -1 - -2.5
Osteoporosis
which ligament of the spine resists extension?
Anterior longitudinal ligament
Apley’s compression test
tests for meniscus tear
leg at knee, press down and rotate the leg in both directions. If pain, test is positive
Characteristics of plantar fassciitis
- F more than M
- Tenderness over medial foot
- worse pain in morning
- heel spurs may contribute
Most common site for Morton’s neuroma?
between the 3rd and 4th metatarsal bone, the 3rd metatarsal space
Its a nerve tumor that feels like a pebble.
structures that pass through the carpal tunnel into the hand include:
- Five finger flexor tendons
- median nerve
Test for shoulder impingement syndrome include:
Hawkins kennedy sign, Neer Test
Shoulder impingement syndrome, painful arc syndrome, supraspinatus syndrome, swimmer’s shoulder, throwers shoulder
Hawkins-Kennedy Sign
Tests for supraspinatous tear/shoulder impingement. Forward flexes the arm to 90 degrees and then forcibly medially rotates the shoulder. Pain indicates positive test.
Neer Sign
Tests for supraspinatous tear/shoulder impingement. Stabilize the patients scapula with one hand, while passively flexing the arm while it is internally rotated. Pain indicates positive test.
Shoulder impingement may result from: (reduced sub-acromial space)
- Extrinsic compression (bone spurring or tendon edema)
- loss of competency of rotator cuff (normally suprspinatus)
- loss of competency of scapula stabilizing muscles
O’Brien’s tests evaluates
Labral abnormalities or SLAP tear - (Superior Labral Tear from Anterior to Posterior)
Shoulder is flexed to 90deg. with the elbow fully extended. The arm is then adducted 15deg and the shouolder is internally rotated with patients thumb pointing down. Downward force is applied to the arm against resistance –> The shoulder is then externally rotated with the palm facing up and the examiner applies downward force on the patients arm, which the patient is instructed to resist.
A positive test = pain during part when thumb points down. lessened when palm faces up.
Labral (keeps the ball of joint in place)
Adhesive Capsulitis or frozen shoulder
- Scar tissue builds up in the capsule around glomulerous joint
- Actively and passive ROM decrease
- occurs more in women
- rx factor - diabetes
What are articulations of the elbow joint?
Ulnahumeral joint radiocapitellar joint Distal radioulnar joint Elbow flexion - 140 is normal (same as knee joint) Forearm pronation - 70-90 Forearm supination 80-90
Tennis elbow typically
From tennis backstroke
Lateral epicondylitis
-pain with resistance to wrist and third digit extension
Golfers elbow is normally medial epicondylitis
- flexor muscles are involved.
Cozen’s Test
Patient extends their wrist while the practitioner pushes down against that force. If patient feels pain in lateral epicondylitis, that’s Cozen’s test positive.
Golfers elbow testing, the concept is the same but patient flexes elbow and practitioner pushes against it.
Most common shoulder dislocation?
“ “ hip ?
- Anterior (95%)
- Posterior (posterior)
Complications of shoulder dislocation
Bankarts lesion - injure lower, anterior labrum
Hill sachs lesion - when the humeral head of the shoulder is fractured
Scapula winging is caused by an injury to which one of the following nerves?
Serrates anterior muscles weakened as is the long thoracic nerve which innervates it (supposed to pull scapular anteriorly) The trapezius pulls the scapula medially .
If the trapezius is damaged, then it will cause lateral winging
Mallet finger is
(Basketball finger)
A rupture of the terminal extensor tendon of the distal phalanx (interphalengeal joint)
Treat with splint
Boxers fracture involves a fracture of which metacarpal bone?
The fifth metacarpal (pinky)
De Quervain’s is a tendosynovitis diagnosed with what test?
Finkelstein’s test is used to diagnose
Normal WBC levels
5,000-10,000
Initial test for bone infection and inflammation (increased ESR and bone sensitivity) - osteomyelitis
X-Ray (initial step)
MRI is the most sensitive for osteomyelitis
Bone biopsy and culture is the most specific
Lekopenia
Low leukocyte counts (below 4,000 per cubic mm)
Leukocytosis - too many wbc (above 4k)
butterfly rash that spares naso-labial fold often indicates lupus and the most sensitive screening test for this condition is:
Antinuclear antibody tests (ANA) test is most sensitive test for - sensitive but not specific- if negative, you can rule out SLE with 95%
- Anti-ds (dog shit) DNA and anti-sm (anti-smith) Ab is the most specific test.
- autoimmune - sx affect joints, skin, KD, blood cells, HT, LU
- Most common and sever is systemic lupus erythematosus (SLE)
- Dermatomyositis does not spare nasolabial fold (inovles)
Neer’s test, tests what?
How is it done?
provocative test is useful in detecting rotator cuff impingement?
Stabilizes that scapula while passively elevating the shoulder, in effect, jamming the humeral head into the acromion. Pain confirms test
Hawkin’s Kennedy Test
Pain with maneuver suggests subacromial impingment or rotator cuff tendonitis.
Performed by elevating the patients arm forward to 90 degrees while forcibly internally rotating the shoulder.
OBrien’s Test
Can be used to detect SLAP tear - the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum.
Patient extends arm, with elbow extended and adducts 10degrees, and internally rotates. Practitioner adds downward pressure and client resists. Does the same while externally rotated. If pain is there with internal rotation but not external, test is positive.
Speed Test
Examiner places patients arm in shoulder flexion, external rotation, full elbow extension, and the forearm is suppinated. Manual resistance is applied by examiner in a downward direction.
Test considered positive if pain is in the biceps tendon or bicipital groove
Which part of deltoid is responsible for arm abduction?
Medial deltoid
supraspinatus initiates shoulder abduction - 0-15 degrees - true abductor
Deltoid - up to 90 degrees - true abductor
90-180 - traps (CN11) and serratus (nerve longus)
Dermatome and Myotome define
Dermatome - area of skin innervated by sensory axons within each segmental nerve (root)
Myotome - collections of muscle fibers innervated by motor axons within each segmental nerve root
T4 - 4th ICS, nipple line
T10 - umbilical line
T12 - inginal ligament /groin
S4/5 (perenium) - some sensation (voluntary movement) - incomplete, no sensation - complete
what portion of clavicle is most commonly fractured?
Middle -80%
Lateral - 15%
Medial/proximal - 5%
Nondisplaced - figure 8 splint
Displaced - Surgery neededd
Most common site for humeral fractures
surgical neck (neck is skinnier than the head) Right below greater tuberocity
Mechanism proposed for SLAP lesions - superior labrum anterior to posterior lesion include:
Test of choice?
- Falling on outstretched hand (FOOSH)
- Overhead throwing motion
Bankart (anterior inferior labrum)
MR Arthogram - test of choice
Nursemaid Elbow, head sublixation, pulled elbow
Radial head dislocation, Most common in kids under 6yrs. Results when kids arms pulled,
Dupuytren’s contracture
one ore more fingers bent in a flexed position. Most commonly in ring finger. 4th-6th decade of life. (30-60yrs)
RXL Usually male, northern European
- at first, its just nodules, but then contracts.
PFPS- Patellofemoral pain syndrom
AKA runners knee - mild to severe discomfort - anterior pain
- Most common cause of knee pain
- Climbing stairs aggravates
Arthrocentesis
Remove synovial fluid from the joint
Gout, arthritis, hemarthrosis
Arthroscopy
Directly visualize the joint
Bone Scan
nuclear scanning test, - cancers/metastesis
X ray
visualize the dense objects like bone
osteoarthritis, bony fracture
MRI
Soft tissue injury, meniscus, ACL etc
“unhappy triad” Includes what 3 structures?
Medial meniscus
Medial collateral ligament
ACL
How do you distinguish specific diagnosis with Acute mono-arthritis
Perform synovial fluid analysis to distinguish different case
(Infection, crystal induced arthritis (gout) , reactive arthritis, trauma, malignancy, systemic disease)
Peripheral artery disease vs Spinal stenosis symptoms
Peripheral artery disease PAD - claudication (vascular), pedal pulse absent, shopping cart sign negative, walking uphill increases metabolic demand and pain.
Spinal stenosis - pseudoclaudication (neurogenic), pedal pulse present, shopping cart sign present, walking downhill - increase lordosis and pain
Organism identified as cause of Lyme Disease
Borrelia Burgdorferi
- Erythema Migrans - bullseye rash- Up to mo
- Chronic can spread to heart, brain, joints - months-yrs
Schober test
Physical exam that measures the ability to flex your lower back.
Modified Sbhober test is used to diagnose Ankylosing spondylitis. From L5, marks 10cm above and 5cm below. If when folding forward, points seperate <5cm, clinical sign of AS
Trigeminal Neuralgia causes and symptoms
CN5 - sensation of jaw. Causes neuropathic pain.
More common - females and MS
Sharp electrical, usually unilateral pain
facial Pain triggered by every day activity: eating, shaving, talking, light breeze.
Branches of Facial Nerve VII
Temporal branches zygomatic branches buccal branches marginal mandibular branch cervical branch
CN 5 - - 3 branches - trigeminal neuralgia
CN7 - 5 branches - Bells Palsy
Gold standard for evaluating rotator cuff
MRI (all soft tissue injury)
Little League Elbow
- Common overuse injury associated with overhand throwing.
- 9-12 yrs typically
- medial elbow pain
- irritation and inflammation of the growth plate (epiphyseal plate) on medial epicondyle
Idiopathic osteoarthritis OA of the knee
wear and tear arthritis
>50yrs
- Bony tenderness
-stiffness (RA, stiffness is more important)
-Cartilage degeneration
Primarily affects interphalangeal DIP joints and PIP
ESR is not relevant b/c its not about inflammation
- joint at base of thumb also is impacted by wear and tear
-Morning stiffness < 30 mins
Rheumatoid Arthritis
Younger smaller joints autoimmune More common in Females 3:1 MCP deviation toward ulnar side synovial inflammation (connective tissue that lines the inner surface of the capsule of synovial joints and tendon sheaths (due to autoimmune) - also affects PIP
RA
Peak onset in the 4th and 5th decade for women and 6th-8th for men
- 40% of RA patients are registered as disabled within 3 years of onset. 80% by 20 years.
- Morning stiffens for over 60 mins
Common sx in idiopathic OA
-Negative rheumatoid factor (or low titer)
Bony enlargements
Bony tenderness
- reduced ROM
- Joint misalignment
-crepitus (grating sound from friction)
- on X-ray, presence of osteophyte- bone spur
- will have clear synovial fluid
- worse with movement
- Frequently involves the spine
- frequently affects carpometacarpal joint (base of thumb)
Physical exam for RA
Joint destruction/erosion
symmetrical joint destruction (systemic autoimmune, inflammatory disorder)
synovial lining - diarthrodial joints
- Erosion on xray
- synovitis noted by ultra or MRI
- In lab, rheumatoid factor positive (non-specific)
- Better with movement
What joint disorder is associated most strongly with obesity in women?
OA of the knee
- First line of treatment: Exercise/PT/weight loss/orthotics/nutraceuticals
- low dose NSAIDS
- Steroids injected to joint
- COX-2s High dose- NSAIDs + gastro protectant
- Surgery
Swan neck deformity
Swan-neck deformity - RA
- DIP Flexion + PIP hyperextension
Boutonniere deformity
- PIP flexion + DIP hyperextension
Deformity = RA
OA Nodes
Herberden’s Node (Herb - a garden picking herb leafs with DIP) - Node on DIP
Bouchard’s Node (When a butcher grabs a knife, its with PIP) PIP node
Master serious complication of OA
Spinal cord compression - Myelopathy
Hoffman’s Sign
When you tap or flick the nail of the middle or ring finger, it produces flexion of the index finger toward the thumb
Indicates spinal cord compression
Rehab for RA
- Resting involved joints
- joint protection instructions
- splinting
- Avoid heavy exercise
Most destructive element of RA
Pannus formation - tissue derived from synovial membrane that causes destruction of cartilage and bone.
- can lead to instability of joint and eventual fibrosis becoming the leading cause of morbidity in patients with RA
Connective tissue fibers
Collagenous fibers - most abundant - vessels, cartilage, gut skin, bone, tendon, ligaments
Elastic fibers - extracellular matrix can stretch up to 1.5x
Reticular Fiber - provide framework and founding LV, marrow and lymph organs.
Osteogenesis Imperfecta
Brittle bone disease, autosomal dominant disorder - gene mutation type 1 collagen
- bone mass is diminished - leads to multiple fractures.
- classically have blue sclera.
- can have bone scoliosis curve
Which vitamin deficiency can cause scurvy?
Vitamin C
def of vitamin C leads to impaired collagen synthesis - resulting in pathological manifestations in tissues and organs containing collagen
Bakers Cyst
can cause acute pain in the back of the knee.
*Gastrocnemius semimebranosus bursa is found between the tendons of the medial head of the gastro and semimebranous muscles
Ganglion cyst
Fluid filled lump associated with a joint tendon or sheath (bible bump)
Lipoma - benign tumor made of fat tissue
Marfans Syndrome
Excess linear growth of long bones, arachnodactyly (spider fingers), and joint lax - tall and slender build with long arms and fingers
- Pectus excavatum - caved in chest (precuts excavatum) or Pectus carinavtum (pigeon chest)
- Dilation of aorta (enlarged) - can be cause of death
ectopic lentil - misplacement of eyes lens
Wrist sign - if they grip their wrist, fingers overlap
Thumb sign, thumb sticks out of hand
Antibodies tested with systemic lupus erythematosus
- Antinuclear antibodies ANA (sensitive)
2 Anti-smith antibodies (specific)
Anthistone antibodies with drug-induced lupus
Characteristics of polymyositis
Proximal muscle weakness (hips affected first, then shoulders), dysphagia, elevated muscle enzymes
Dermatomyositis - Polymyositis + skin signs
dermatological abnormalities in addition to face/eye heliotrope rash (pink/purple color), hand gottrons papule, Neck/shoulder - shawl sign(posterior) and V sign(anterior)
Seronegative arthritis
arthritis in which Rheumatoid factor is negative
HLA- B27 associated with:
Reiters Syndrome (reactive arthritis)
Anyklosing spondylitis
Psoriatic arthritis
Reactive arthritis triad, reiters
Conjunctivitis - can’t see
Urethritis - can’t pee
Arthritis - can’t climb a tree
HLA-b27 positive (seronegative) auto immune
Most common cause of mono arthritis in young adults
Gonococcal arthritis
Rare complication of Gonorrhea
- more common in women
- typically healthy, sexual active adults
- migratory arthritis/skin lesions (wind bi)
can lead to cartilage destruction
- Remove synovial fluid - test
CREST Syndrome
CREST:
calcium deposits in skin
Reynauds phenom
Esophageal dysfunction - acid reflux etc.
Sclerodactyly (thickening and tightening/hardening of skin on fingers and hands)
Telagiectasias - dilation of capillaries causing red marks on surface of skin
Fibromyalgia
Pain in all 4 quadrants
pain in 11-18 tender points - diffuse pain
symptoms for 3+ months
Measures ROMM
Goniometer **
and
Inclinometer
PROM vs AROM vs AAROM
PROM - Passive Range of Motion
AROM - Active Range of Motion
Active Assisted ROM - Active with equipment - like strap
Generally PROM is greater than AROM
Neck ROM
Flexion - 50-70deg
Neck extension - 50-70deg
Lateral - 35-45
Rotation - 70-80
Lumbar
Side bending - 25-35 degrees
extension - 25-35
Flexion - 75-90
Shoulder ROM
Abduction 150-180 adduction: 30-40 Flexion - 150-180 Extension - 50-60 internal rotation -70-90 external rotation - 80-90
HIP
Flexion (Half wind releasing) 100-130 Extension - 15-30 (hot yoga leg lifts) Abduction - 40-50 adduction - 20-30 Internal rotation- 40-45 External rotation - 40-45
Elbow ROM
Flexion - 140-150
Extension - 0
Forearm supination- 80- 90
Forearm pronation -80-90
Knee ROM
Flexion - 130-150
Extension-0
Internal Rotation - 40-50
External Rotation - 30-45
Wrist ROM
Flexion - 70-80
Extension - 60-70
Radial deviation - 20-30
ulnar deviation - 30-50
Ankle ROM
Flexion - 20-30
Extension - 40-50
Supination - 30-40
pronation - 20-30
Cranial nerves definition
Emerge directly from the brain in contrast to spinal nerves which emerge from segments of spinal cord.
CN1
Olfactory (1 nose)
Sensory = smell
12 - last - tongue - motor
CN2
Optic (2 eyes) - vision - sensory
CN3
Oculomotor
3,4,6 - all move the eyeball via extrinsic muscles (Motor)
SO4 - superior oblique - CN4
LR6 - Lateral Rectus - CN6
All the others are CN3
CN4
Trochlear Superior Oblicque (SO4)
CN6
Abducents
LR6 - Lateral Rectus Muscle
CN5
Trigeminal
-sensory and motor
3 branches
V1 - sensory (forehead), V2- sensory (maxilla), V3 - sensory of mandible + motor of mastication
CN7
Facial
Sensory - taste & Motor - facial expressions
- Bells Palsy (motor)
- Taste on anterior 2/3
3 tastests
7 - anterior 2/3 of tongue
9 - posterior 1/3 of tongue
10 - epiglottis
CN8
Vestibulocochlear
Cochlear nerve- hearing (sensory)
Weber and rinne tuning fork test - test hearing
vestibular nerve - balance
CN9
Glossopharyngeal
Posterior 1/3 of tongue
Sensory- taste and Motor - stylopharyngeus Helps widen Larnyx for swallowing and speaking
CN10
Vagus - goes to pharynx and larynx (motor action)
- Motor and Sensory
- Parasympathetic - autonomic ner
- Taste Fibers (sensory)
CN11
Accessory
SCM and Trapezius (parallel)
CN12
Tongue - Motor
Medical Ethics
Risk and Liability for Hospital practice
The Four Fundamental Principles
- Autonomy - Patience right to decide on their treatment
- Beneficence – Do whats best for patient
- Non- maleficence - do no harm
- Justice - equal access to treatment
Vicarious Liability
Respondeat Superior
Refers to being liable for someone else’s actions - employer is responsible for the actions of employees
Types of elder abuse
- Passive neglect - unintentional, overload, lack of info
- Active neglect
- Passive neglect
- physical abuse
- psychological abuse
Children legal rights
In respecting kids autonomy, most ethical to obtain assent even though they don’t have legal consent
Meningitis symptoms
high fever stiff neck severe headache nausea, vomit confusion, sleepiness seizures photophobia
How to avoid breach on contract and tort when closing practice
Send a letter informing patient informing of termination of service with no less than 30 days.
Confidentiality
HIPPA requires patient confidentiality unless there is a waver or clear evidence of imminent danger to another’s health, welfare or safety. You can’t disclose to spouse unless patient agrees.
Emancipation
Free from legal restriction
Minors are 17 or less
- 12+ can consent to treatment for STD, alcohol or drug.
Minor may consent when pregnant, married, victim of sexual assault, armed forces, lives sep from parents/financially self- sufficient
Capacity
Competency
Capacity- determined by physician
Competency - a legal determination
Guillain Barre Syndrome GBS
- Demyelinating neuropathy with autoimmune causation
- Often with prodromal respiratory or gastro infection within 1 mo of onset
- Weakness begins with ascending paralysis (starts lower and moves up)
- facial paralysis
- one of most common causes of respiratory failure
Types of consent
- Implied: provided by behavior of patient
- express: oral or written
- informed: Must give reasonable explanation of proposed procedure so patient can make informed decision
Medical Battery
The tort of intentionally and voluntarily bringing about unconsented harmful or offensive contact
4 elements of medical malpractice
Duty was owed
duty was breached
damage to patient
direct causation
EMTALA
Emergency Medical Treatment and Active Labor Act = requires hospital to provide a medical screening exam to any person who comes to ER, regardless of individuals ability to pay- or transfer to another facility where they can.
Right to refuse treatment
Can’t save life if someone refuses treatment
CBC
BMP
CBC - complete blood count
BMP -
Hemoglobin - less than 7, blood transfusion
If you see indications of child abuse
Must contact Law enforcement or CPS - Child Protective Services
Adult protective Services (APS)
Spouse abuse - not required
Kidney disease
Increase in creatine - problematic sign for Kidneys (small increase over short period can be dehydration)
McBurneys point
Tenderness over RLQ - appendicitis
Rebounding pain - releasing the pressure creates pain - Peritonitis
Rovsings Sign
When you press on the LLQ, creates pain on RLQ - appendicicits
Hambergers Sign
Checks for appendicitis
If people don’t want to eat their favorite food - positive
Cellulitis
Bacterial skin infection
- red, swollen, heat, pain
- (Hong, zhong, re, tong)
Res ipsa loquitur
“The thing speaks for itself” - the occurence of an accident implies negligence
Doctor must inform family about genetically predisposed diseases (if not patient)
Physician has a duty to take reasonable steps to tell family members about genetically transmissible conditions
FAP - start colonoscopy at 10-11, every 2 years
Does patient have right not to know diagnosis?
Patient has right to request not to be told the truth about a diagnosis. The physician should advise the patient to give thought to this decision. Recommend her to stay for further test without telling her she has breast cancer.
Autonomy vs Paternalism
Soft paternalism - agent is incompetent to make decision
Strong paternalism - overriding of competent patients wishes (can be sued for medical battery)
Defnition of Home Hospise care
Be expected to have less than 6 months to live - comfort - narcotics
Causes of Restless leg
Can be an Iron deficiency
Treat with dopamine agonist (praamixpexole, repinirole*, cardidopa, levadopa) and iron replacement
Can be confused with parkinsons (forward posture, rigidity, bent elbow, small writing, shaking not just in legs)
When is screening - for cervical neoplasia started (cervical cancer, HPV)
21 - pap smear
If abnormal - colposcopy is recommended
Colposcopy closely examines what?
The cervix ,vagina or vulva
Larynx and trachea - brochoscopy
Dueudenum - endoscopy
bladder - cystoscopy (for men, you can see enlarged prostate)
Important Genital HPV types
6,11: genital warts - low cancer potential (90% of warts)
16,18: Low and high grade genital lesions, high potential cancer (70% cervical cancer)
NCS
EMG
Nerve conduction Study (NCS) - probe checks nerves
Electromyography (EMG) - check muscles with a thin needle connected with EMG machine and can see muscle twitching
Important Antioxidants
Beta Carotene - carrots (precursor of vitamin A
Lycopine - tomatoes
*Selenium - mushroom, brazil nuts
Vitamin ACE have antioxidant properties
Fat soluble - A D E K
Water Soluble - B C
Hemoglobin A1c (HvA1c)
reflects how well diabetes is controlled befcause it attaches to glucose
<5.6 - normal
6- prediabetic
>6.5 - diabetes
SSRI (selective serotonin re-uptake inhibitor)
Depression Effective - Escitalopram (lexapro) For - Fluoxetin (prozac) Sadness - Sertraline (zoloft) Panic - Paroxetine (Paxil) Compulsions - Citalopram (Celexa)
Neurotransmitter in brain. Blocks seratonin absorption and makes it more available in brian.
Side effects of SSRI
S-S-S
Stomach upset
sexual dysfunction
serotonin syndrome* - caused bb MAOI, SNRI, Triptans, lithium, levodopa
serotonin syndrome symptoms
Delirium, agitation, tachycardia, diaphoresis, diarrhea, seizures, high temp, hyperferflexia, myoclonus (jerky)
Triad of Serotonin syndrome
Mental changes, Autonomic instability BP/HR, neuromuscular abnormality
What foods can cause MAOI Induced Hypertensive Crisis?
A patient with acute hypertension and a history of MAAO use aand consumption of tyrmaine rich foods (cheese, picked foods)
- MAAOIs inhibit breakdown of dietary amines. This raises tyramine, which in turn displaces norepinephrine from storage vesicles, leading to hypertensive crisis.
Diagnosis of Pregnancy
hCG- human chorionic gonadotropin (urine test kit)
- Produced by placenta and beaks by 10 weeks
- Levels double every 48-72 hrs during early pregnancy.
- When abnormal can be ectopic pregnancy
- Can be detected in blood 11 days after conception, in urine 12-14 days
During pregnancy, ultrasounds is used to confirm:
An intrauterine pregnancy (meaning conception is in uterus)
- 5 weeks - visible
B vitamins and impacts of deficiency
B1 - Thiamin - alcoholic B2 - Riboflavin B3 - Niacin - Pellagra - Diarrhea, dermatitis, Dementia) - too much causes flush on face B5- Pantothenic Acid B6- pyridoxine - peripheral neuropathy B7 - biotin b9- Folic acid - spinal cord defects infants B12 - cyanocobalamin - pernicious anemia
mulders sign
Tests Morton’s Naroma
compression of the metatarsal heads produces a palpable click due to displacement of an inter-metatarsal mass
Common cause are narrow shoes- more in Females
Test with ultrasound - confirms dx
DX alcoholism
CAGE C- have you ever felt you should CUT down on drinkning A- Annoyed by criticism for drinking G - Guilt about drinking. E- First thing in morning (Eye opener)
Alcohol withdrawl
Tremor 12-24) , seizure (24hr) , delerium tremens 24-48hr )
Delirium Tremens - hallucinations, seizures, brian damage - Give banana bag - vitamins and minerals to treat withdrawal.
Wernicke-korsakoff
Thiamine (B1) deficiency from alcoholism
Acute phase - delirium, hallucinations symptoms
Which vitamins enhances absorption on non-heme iron?
Vitamin C - by 2-3x
insufficient vit C causes scurvy, anemia, depression, infection, tooth/gum problems, muscle deterioration, fragile bones, poor wound healing
Common tests for looking at internal organs
Cystoscopy - Bladder
Colposcopy - cervix
Lower endoscopy - colonoscopy - intestine
Laryngoscopy - larynx, part of throat
RX factors Bladder cancer
smoking
Analine Dyes
Chemical exposure
Parasite
Erectile Dysfunction
Organic -physical - Gradual, always, constant, (Early morning erection negative) - Diabetes type II, SSRI, Beta Blockers - more common
Phycogenic ED - sudden, situational, intermitten (Early morning and nocturnal erection positive) 10-50%
Drugs absolutely contraindicated when using sildenafill (viagra)
Nitrates - both are vasodilators -> severe hypertension + death
Sildenafil was originally for high BP
Dermatomes
Area of the skin supplied by single dorsal nerve root C6 - thumb T4- Nipple T10 - umbilicus L4 - Knee L5- top of foot S1 - bottom of foot S2 - S4- perineum
Fat soluble Vitamins
Fat Soluble - A, D, E, K - stored in body, slower onset deficiency, excess toxicity is more common
A fat DEK (dick)
Water soluble - B complex, C
Deficiency of vitamin K can cause hemorrhage in newborn infants (especially breast fed) K helps with Clotting
Vit K - mainly Green leafy veggies - Coumadin or Wafrain inhibits synthesis of vitamin K - avoid green leafy veggies (BS)
Warfarin
VS
Heparin
Warfarin - extrinsic pathway - Vitamin K, by moth PO, slow onset, check INR, cant give during pregnancy; crosses placenta
Heparin - intrinsics pathway - Inactivate thrombin, IV (given at hospital), if they are immobile give this, fast onset, doesn’t cross placenta
Mechanism of Action for clotting is different (MOA)
Indications for anti-coagulants like warfarin
Deep vein thrombosis
pulmonary embolism
Atrial fibrillation * (irregular pulse, PQRST of EKG)
Artificial heart valve
International Normalized Ration INR measures
If too low, blood clots won’t be prevents
too hight: increased risk of bleeding
Therapeutic: 2-3
Risk factor of Atrial fibrillation
Congestive heart fail Hypertension 75+ Diabetes Mellitus Prior stroke or TIA (low score - Aspirin, high dose- Warfarin - anti: coagulant class)
Anti-throbotic
Inhibit platelet aggregation
Aspirin, clopidogrel - block formation of clot
Anticoagulant blocks growth of clot
Thrombolytics- tPA/fibrinolytics - 3-4.5hrs - Once clot is already formed, it can dissolve - CT Scan (for stroke- shows if there is bleeding- hemorrhages- 20%) If ischemia, use tPA - clot buster
Menopause
Cessation for min of 12 months.
avg -51 yrs
hot flashes, vaginal atrophy, insomnia, anxiety, irritability, poor concentratioon, mood, loss libido, dyspareunia (pain with sex - dry)
*Diagnosis - Check blood levels **FSH and then LH. Both are elevated during menopause.
Treatment is hormone replacement treatment
Postmenopausal - DEXA scan for t-score -1 or higher - avg. -2.5 and lower - osteoporosis. Between - osteopenia
Barium Enema is an xray exam that can detect abanormalities in the
Colon
Also called lower GI series - lower GI tract xray radiography
Barium makes GI white so you can see it
Upper GI series
Lower GI Series
Upper GI series- xray for upper GI - esophagus, stomach, duodenum (first part of SI) are made visible by liquid suspension
Lower GI Series -barium enema - - for colon (LI) X-rays are taken with barium sulfate, radioactive contrast agent- helps avoid more invasive colonoscopy
Impetigo
Bacterial infection in epidermis layer
Cellulitis affects epidermis, Dermis and subcutaneous fat & fascia.
Erysipelas - infection of upper dermis
Necrotizing fasciitis - all the way to fasciae
Epidermis, Dermis, Hypodermis, subcutaneous fat layer
Impetigo Sx
well-localized vesicles filled with serous fluid, vesicles rupture leaving yellow, honey colored dried crusts/scabs.
-
Accessory Nerve Test CN11
Shrug shoulder test, resist head against hand
Irritable Bowel syndrome
Dx of exclusion - no diagnosis. Its a functional disorder w/o anatomical problem. Good for acupuncture.
- chronic abdominal pin, discomfort, bloat, diarrhea, constipation, alternates
Normally related to stress/emotional issues - psychiatric
- pain relieved by defections
Reassurance
pharmacological - anti spasmodic
dietary - fiber, psyllium
Ulcerative colitis - bleeding diarrhea
IBS vs IBD
IBD - anatomical problem, inflammatory bowel disease (Crohn’s, ulcerative colitis) - can be life threading, can cause colon cancer, surgery can treat also anti-inflammatory meds
Crohn’s - mouth to anus, discontinuous/irregular, fistula access, 80% in terminal ileum
Ulcerative colitis - Isolated in rectum always involved, continuous - doesn’t go to SI, isolated in colon - bleeding more common
3 parts of SI in order
Duodenum, Jejunum, Ileum
Duodenal ulcer - peptic ulcer - decrease pain with food
Gastric Ulcer - Greater pain with food
Ileum - Pernicious anemia - B12 + Intrinsic factor (combines and absorbed in Ilium) With Crohn’s disease, if there is inflammation in ilium can lead to pernicious anemia
Statins
HMG- CoA reductase inhibitors re a class of lipid lowering meds
HMG CO-A –> Mevalonic acid –> Cholesterol
Statins block the above process
Side effects:
1. Myalgia *muscle pain - severe is rhabdomyalgia - breakdown of damaged skelatol muscle
2. Liver enzyme increase due to damage
Red yeast rice is the natural version (full grain) less side effects. Take LV enzyme test
3. Can also leda to Diabetes (DM)
Grapefruit juice with stains may keep statin or other drug in body increasing rx of LV damage and muscle breakdown. Inhibits cytochromo p450 enzyme (more side effects)
Other drug classes
Warfarin -coumadin- coagulant - a-fib
Levodopa - Parkinsons
Paroxetine - paxil - depression
How to test rhabdomyosis (damage of myocradial nand skelatal muscles)
Creatine Kinase elevated in blood.
CK mb - Increases 12-24 hours, normal in 2-3 days. After 3 days, there shouldn’t be high levels. Would indicate secondary HT attack
Most common cause of CKD, Chronic KD disease?
Diabetes - 44% of all KD failure - #1 cause for KD disease
Hypertension is second lead cause
DM complications Microvascular Veins Eyes - Retinopatahy KD - Nepropathy
Macrovascular
Brain -
Heart
Extremity
Diabetic Nephropathy
Chronic loss of KD fx Chronic Kidney Disease - CKD
Long term - ESR - End stage Renal disease - Dialysis
Will change Metabolic panel (BMP, CMP). Increased BUN creatine, Potassium
GFR - Stages of Chronic KD disease
- Normal >90
- Damage mild - 60-89
- Moderate -mild - 30-59
- severe - 15-29
- End stage renal disease <15
Diabetes main cause of CKD, #2 cause is Hypertension
Diabetic nepropathy - protein in urine
ACE Inhibitor good for DM Nephropatahy
HTN - High blood pressure
CHF - congestive HT failure
CKD - Chronic KD disease - Diabetic nephropathy
Propanol -olol- 1 - Beta blocker HTN CHF Migraine prevention hyperthyroidism severe - thyroid storm
ACE - APRIL - ends in -pril
RAAS (renin-aangiotennsin-aldosterone-system)
Angiotensinogen–> (Renin converts) Angiotensin I –> (ACE Converts)Ang. II –> aldosterone (increases BP)
ACE blocks high BP - lowers BP
ACE side effects - angioedema -
Cough (dry) (common)
Angioneurotic oedema - swelling of face, eyes, lips, throat (uncommon)
Calcitonin VS. PTH (Parathyroid Hormone)
Calcitonin (thyroid): Increases bone calcium content and decreases the blood calcium levels
Stimulates osteoblasts
inhibits osteoclasts
PTH (parathyroid Hormone): Increased PTH causes the bones to release their calcium into blood 3 mechanisms: Decomposition of bone Absorb calcium from food Reabsorb urine from KD
Winged Scapula, which muscle is typically impacated?
- Where the scapula protrudes from a persons back in an abnormal position.
Medial scapular winging
Most common cause is serratus anterior paralysis - because of the long thoracic nerve - (Comes from nerve root C5, 6, 7)
Corticosteroid Actions
- reduce inflammation (asthma, allergic, urticaria)
- suppress immune system (RA, Lupus, Crohn’s, Ulcerative Colitis)
- replace hormones/steroids in body (Addison’s disease- adrenals don’t produce right amount of hormones - adrenal insufficiency - severe fatigue, hypotension, hyperpigmentation)
NSAID- GI b
Side effects of Corticosteroids
Short: increase appetite weight gain fluid retention Insomnia mood change
Long: Osteoporosis* Can lead to high blood sugar - Diabetes vulnerability to infections cataracts and glaucoma
Bisphosphonates - decrease risk of fractures
Myasthenia Gravis
Autoimmune disease - attacks postsynaptic
Acetecholine (ACH) Receptor
*Key Sx: drooping eyelids (ptosis), double vision (diplopia), problems swallowing (dysphasia), trouble walking (worse after use, later in day)
Lambert Eaton Syndrome
Autoimmune Neuromuscular junction disorder
Attacks pre-synaptic calcium channel
Creatine Kinase (CK/CPK)
Exercise -creatine converts to ATP by creatine Kinase - goes both ways
CK-BB - brain
CK-MM.- Skelatol muscle
CK- MB - Cardiac muscle (HT attack)
Troponin is the most important/specific/sensitive test for HT attack (MI - Myocardial Infarction)
Pre-eclampsia VS Eclampsia
Pre-eclampsia
- New hypertension after 20 weeks of pregnancy, proteinuria, edema
Eclampsia- Eclampsia + seizure
Trendelenburgs Gait
Unusual gait found with weak abductor muscle supplied by superior glute.
T Sign: If patient haas weakness of one side of the pelvis, when the patient stands on that side, the pelvis on the contra aside will drop.
Gluteus Muscles
Maximus - biggest, on back of butt - extension
Hip abductor muscles include: Medius, minimus, tensor fascia lata (sl interior to IT)
- move away from midline and rotate in joint
- Hip abductor - stabilize during walking and one leg movement
- glute medius - relates to trendelenburgs gait pattern
Medius and minimus are abductors and innervated by Superior gluteal nerve innervates
Ketosis
Ketosis - normal metabolic process. When body does not have enough glucose for energy - burns stored ft instead and leads to build of of acids called ketones
ketogenic diet (LCHF) low carb high fat
- originally for controlling seizure
- brains main source of food is glucose - less = less activity
- mimics starvation by cutting down on carbs
- Test - diabetic ketoacidosis - acitone smell from mouth - high concentration ketone bodies from breakdown of fatty acids
diabetic ketoacidosis
- acetone smell from mouth - high concentration ketone bodies from breakdown of fatty acids
causes:
Diabetic (majority from Type I) - ttreata with IV fluid- must send to ER
alcoholic
starvation
Diabetic Ketoacidosis DKA
Can be life threatening - send to ER
Sx
Vomit, ab pain, nausea, fruity smelling breath*, kussmaul breathing - deep, gasping breathing (hyperpenia - rapid and deep - remove CO2 from blood)
Dx:
Hyperglycemia - Blood glucose more than 250
7.35-7.45 = normal blood PH - less is acidosis
Treatment: IV fluid
Hyperosmolara Hyperglycemic State (HHS)
Type 2 DM
PH>7.3
High blood sugar in high osmolarity without significant ketoacidosis
Type 2 DM
Signs and Sx
Dehydration, weakness, leg cramps, trouble seeing, altered consciousness
Blood glucose greater than 600 mg/dl and PH above 7.3
Treat with IV fluid too
Type I vs Type II DM
Type I: Due to autoimmune pancreatic beta cell destruction leading to insulin deficiency and abnormal glucose metabolisms - insulin dependent (can’t produce insulin) - Generally before age 40
Type II- can come from lifestyle choices - can’t produce enough insulin - after Age 40 normally. - dysfunction in glucose metabolism due to varying degrees of insulin resistance
Endometriosis
Tissue supposed to be in uterus. Endometrial tissue outside of uterus.
Diagnosis with laparoscopy (also for GB surgery)
Chocolate cyst - in ovary
Sx: pelvic pain, dyspareunia, dysmenorrhea
Endometritis
Infection oof uterine linding
usually after C- section
Sx
- foul smelling lochia, tachycardia
Albuterol
Activates beta receptors to relax smooth muscles around lungs - Short acting beta agonist SABA - rapid onset of cation. Works for exercise induced asthma
First line of treatment
Beta 1 - found in Heart
Beta 2 - found in Lung
Some beta blockers are non specific - so you can’t use these for people with history of asthma
Long acting - works more than 12 hrs.
Step 2 -low dose cortico.
3 - medium dose cortico
6- s
Poliomyetis (Polo)
Sx
Asymmetrical muscles weakness that leads to flaccid paralysis - No treatment- prevent with vaccine
Guillan Barre syndrome - Bilateral* lower extremity weakness and goes up
Banana bag
For delirium tremens (alcohol withdrawal)
thiamine*
folic acid
Magnesium
Opiods
Euphoria, apathy, CNS depression (Coma), constipation, pupillary constriction - pin point pupils (miosis), respiratory depression (life threatening)
Hallucinogens/meth - dilate pupils
Cocaine - pupillary dilation (mydriasis), bugs under skin feeling, paranoia, euphoria
AAA Abdominal aortic aneurysm
TRIAD
Ab pain
Pulsatile abdominal mass*
Low BP
Send to ER
Vital signs not stable
BP drops (hypotension)
HT rate increases (tachycardia)
Discoloration in LL back
Pulsatile in Chest - thoracic aneurysm
Pulsatile in head -
Use ultrasound - +5.5 - surgical repair
Appendicitis
Dull pain near umbilicus
localize to RLQ - mcburneys point (palp LLQ and RLQ hurts - Rovsing sign)
Iliopsoas sign - extending hip back causes pain along
Obturator sign: Pain on passive internal rotation of the hip when the right knee is flexed. It is present when the inflamed appendix is in contact with the obturator internus muscle.
Hamburgers sign - if patient wants his favorite food - rule out appendicitis
Tachycardia
hypotensive
guarding and rebound pain - (peritonitis sign - appendix explodes-> bacteria in peritoneal cavity)
Blocks acid production and provides longest relief
Drug root name
Antiacid - doesn’t stop production of stomach acid -neutralize acid- short acting, relieves Sx
H2 blocker stops ST acid. - Histamine 2 blocker - reduces gastric acid Drugs root: -Tadine - lasts up to 12 hrs
PPI - blocks excess acid product. - Lasts up to 3 days Drug root: –Prazole
acid reflux
sx: Heartburn
GERD (chronic acid reflux)
H1 receptor vs H2 receptor
H1 located in blood vessels and respiratory mucous membrane
Binding with histamine causes blood vessel dilation, narrow airways, increase mucus production and formation of hives on skin. To medicate: H1 blocker (more side effects - drowsy)
H2 receptors are located in the stomach lining. Binding with histamine causes increased stomach acid production. To medicate: H2 blocker (less sedating)
Rhabdomyolysis
Severe muscle breakdown - CK rises
Creatine Kinase
CK-MM - Skeletal
CK-MB - cardiac
CK- BB- Brain
Epidural space - epidural hematoma - normally from trauma - *lucid interval
Dura
Subdural space- subdural hematoma - more chronic, gradual increasing headache
Arachnoid
subarachnoid space - Subarachnoid hemorrhage (location of CSF) - thunderclap headache- worst of life
Pia
Brain
Antipsychotics
Neuroleptics - 1st generation - cause neurolepsis -Psychomotor slowing. Emotional quieting. Affective indifference.
side effects - Tardive dyskinesia protrusion and rolling of tongue involuntary movement Chewing motion facial dyskinesia
Serotonin Syndrome
2 SSRI can cause Serotonin syndrome Agitation or restlessness. Confusion. Rapid heart rate and high blood pressure. Dilated pupils. Loss of muscle coordination or twitching muscles. Muscle rigidity. Heavy sweating. Diarrhea.
SSRI - a type of antidepressant drug that inhibits the reabsorption of serotonin by neurons, so increasing the availability of serotonin as a neurotransmitter.
Vitamin D side affects when overdose
Nausea, vomiting, and other GI problems
Others:
Rough skin, hair loss - A side effect
Burning lush on face/hands - B3/Niacin (used for high cholesterol)
Essential/primary hypetension
No established/known cause
Secondary Hypertension
Renal problems can cause
Cauda Equina Syndrome
(Horse Tail syndrome)
Saddle anesthesia - loss of sensation around buttocks, perineum, inner thighs. Bowel, bladder incontinence.
Surgery case. - Refer to neurosurgeon - surgical decompression
Babinski sign
Checks upper motor neuron
UMN sign: increase tone, spastic
Deep tendon reflexes increases
Use babinski sing: positive is dorsi flexion of big toe - pathological in adults (normal for infants up to 12 mos)
lower motor neuron
UMN sign: decreased tone, flaccid
Deep tendon reflexes decrease
upper motor neuron: Brain –> Spinal cord
Lower motor neuron: Spinal cord–> Muscles
ALS - Motor neuron disease - but UMN and LMN
Adrenergic Receptor
Beta Blockers
Located throughout body
Receptors for sympathetic neurotransmitters
Beta I - Heart
Beta 1 receptor increases heart strength of contraction and heart rate (HR)
B1 blocker - metoprolol - lower BP or heart rate for tachycardia (Side effect - bradycardia)
Beta II- Lungs
Increases dilation of bronchial passages
B2 agonist - Albuterol
B1 and B2 blocker (non selective)
Propranolol (migraine prevention) - Don’t give this if someone has asthma
Gamma-glutamyl Transferase (GGT) is an enzyme found in many organs of body, with highest concentrations in what organ?
Liver. Elevated GGT is most widely use marker for alcohol abuse.
Other liver Fx tests include: Alanine Transaminase (ALT) * Alkaline Phosphatase (ALP) Bilirubin* L-Lactate Dehydrogenase (LD) Aspartate transaminase (AST)* Albumin and total protein Prothrombin time (PT)
Key symptoms of MS
Separated in time and space - episodes occur months or years apart and affect different anatomical locations
Most common initial Sx: Paraesthesia and visual disturbance
Then weakness, fatigue, loss of bladder control
Demyelination of white matter in brain and spinal cord -
Most common type: Relapsing and remitting
Dual energy x-ray absorptiometry DEXA
Bone density t-score scan Very little radiation -2.5 osteoporosis -1--2.5: Osteopenia 1 to.- 1 normal
Current cervical cancer screening recommendations
Thiamine (B1) deficiency causes
Beriberi - peripheral neuropathy
Included in banana bag -
Wernicke Korsakoff syndrome (B1 deficiency)
Sx: mental confusion, vision problems, coma, hypothermia, low blood pressure, and lack of muscle coordination (ataxia). Korsakoff syndrome (also called Korsakoff’s amnesic syndrome) is a memory disorder that results from vitamin B1 deficiency and is associated with alcoholism.
Banana bag with thiamine, potassium, magnesium etc
Graves disease
From hyperthyroidism: thyroid storm: Yin deficiency
Main Sx: Exophthalmos (eyes bulging out)
Autoimmune condition Hashimoto’s thyroiditis causes and severe form
Hypothyroidism, Myxedema, yang deficiency
What is the major risk of iregulra irregular ht beat?
A-Fib - can lead to blood clots, stroke, ht failure and other complications.
If not symptoms with A Fib- refer to primary physician - anticoagulants, statins/Coumadin: Which slow down bodies process of making clots by inhibiting vitamin K.
Anti-platelets like aspirin to prevent blood cells from clumping together to form a clot.
If clot already formed to dissolve - Thrombolytics (ischemic type, not hemmorhage)
If symptoms + A Fib - send to ER
Scabies Sx
Linear burrow tracks and intense itching between fingers and genitals
From infection of Mites
Lyme - tick
Malaria- mosquito
Main complaint of people on Statins?
Myopathy - myalgia.
What hormone is measured to confirm menopause?
FSH
When a woman’s FSH blood level is consistency elevated to 30mIU/mL or higher, and she hasn’t had her period for a year - menopause
When a woman has excess hair on body and face
PCOS
Usually related to diabetes and obesity
Side effect of viagra - Slidenafil
Hypotension (can’t take with nitrate drug because same mechanism of action)
Bulimia Nervosa can lead to what electrolyte imbalance
Hypokalemia (low potassium) - muscle weakness, cardiac arrhythmia, death
Bulimia - normal to obese
Anorexia nervosa- very thin body
Meniere’s diseaasae vs Labrinthitis
both hearaing loss, vertigo, nausea
Labrinthitis
Meniere’s disease only - tinnitus *
Presbycusis
Most common type of sensorineural hearing loss caused by natural aging of auditory systems. Occurs gradually and initially affects ability to hear higher pitched sounds.
Antipyretic means
reduces fever- NSAIDs
Trace minerals that are antioxidants
Selenium
Copper
Zinc
ACE - major vitamins that are antioxidants
Dimpling of breast tissue similar to orange peel and red and bruised appearance of breast most likely is
Inflammatory breast cancer
Mammogram frequency
Over 50 - every 2 years (some recommend starting age 40)
If you have family history, start earlier
Cytochrome P450
enzymes is related to drug drug interaction that cause unanticipated adverse rxn or therapeutic failures.
Comes from grapefruit - avoid when on staatin
Herb that blocks impacts of statins
St Johns Wort
When measuring BP, the systolic pressure is defined as
First clear tapping sound - systolic BP
Capitation
A method of insurance reimbursement to physicians based on number of patients seen, rather than services performed
