SG2 Flashcards
Abdominal aorta normal diameter
less than 2cm
Signs of Cushing’s syndrome that are not as obvious
Easy bruising, muscle weakness
Calculating basal metabolic rate
body weight in pounds times 10. multiply by 1.3 if sedentary, 1.7 heavy activity, 1.9 intense activity
Calculating LDL
LDL= total cholesterol- HDL- triglycerides/5
USPSTF lipid screening guidelines
All men over age 35, all women over age 45 and younger adults (20-35) with other CHD risk factors
Management of LDL dyslipidemia- what kind of diet is recommended?
saturated fat less than 7% of calories; less than 200 mg of cholesterol per day; increased soluble fiber (10-25 g/day) and plant sterols to enhance LDL lowering
Side effects of statins
Hepatic dysfunction. So check LFTs before initiating after 12 weeks of therapy, periodically, and with any dose adjustment. Another SE is myopathy
Other meds that treat LDL dyslipidemia besides statins
Bile acid sequestrants, nicotinic acid (niacin), fibric acid derivatives, ezetimibe
Bile acid sequestrants- what are the benefits and side effects
More modest effect on LDL and HDL; can cause increase in triglycerides, may cauase severe GI distress and constipation
Nicotinic acid (niacin)- how does it work to lower LDL and what are the side effects?
more modest effect on LDL; this is the most effective agent for HDL increasing; this can decrease triglycerides; the side effects include body flushing (which can be reduced by taking ASA before the niacin dose)
Fibric acid derivatives- what are they good for?
These are the first line agents for reducing triglcerides; they canse a modes effect on decreasing LDL; these can raise the HDL as well as a benefit
Ezetimibe- how does it work?
Inhibits the absorption of cholesterol at the intestinal brush border; it increases cholesterol clearance; however, it is unclear whether it decreases atherosclerosis or CHD
Monitoring lipids
Check lipids every 6 weeks after starting therapy and every 6-12 mos when patients is on a stable dose
When is medication for weight loss indicated?
When BMI is over 30 or over 27 with risk factors
What are some meds for weightloss?
Orlistat and prentermine
How does Orlistat work?
GI lipase inhibitor that decreases fat absorption. This is the only medication currently FDA approved for weight loss
How does prentermine work?
First of all, you should know it is indicated only for short term use. Next, the side effects are those of other stimulants, tachy, hypertension, tremor, insomnia
When is bariatric surgery indicated?
BMI over 40 or over 35 with comorbidities
How many migraine episodes are needed for diagnosis?
5 episodes are needed for migraine diagnosis
What is the character of a migraine headache?
unilateral pulsating
How long do migraines typically last?
4 to 72 hours
Are migraines aggravated by physical activity?
Yes. However, tension and cluster are not
How many episodes of a tension headache are required for diagnosis?
10 episodes are required for diagnosis
How do you describe the pain of a tension headache?
bilateral or occipital, with a pressing quality
Are tension headaches associated with phono and photophobia like migraines?
Yes, they are associated with photo and phonophobia like migraines
How long do tension headaches last?
30 mins to 7 days
Are tension headaches aggravated by physical activity?
No, only migraines are aggravated by physical activity
How many episodes of cluster headaches are requires to make the diagnosis?
5 episodes of cluster headaches are required to make the diagnosis
How long do cluster headaches last?
15 mins to 180 mins
Criteria for diagnosis of medication overuse headache
Over 15 headaches per month; regular overuse of an analgesic for over 3 mos; development or worsening of headache during medication overuse
Narcotic dependence
Causing clinically significant impairment manifested by at least three of the following: tolerance, withdrawal, increased doses, desire or inability to cut down, significant amount of time spent in search of the drug, interference with activities, continued use despite physical or pscyh problems due to the drug
What is addiction?
Persistent craving, loss of control over drug use, compulsive use, and a strong tendency to relapse after withdrawal
Guideline for imaging for headache
If patient has migraine with atypical headache patterns or focal neuro signs, patient is high risk for a significant abnormality; study results would alter management
Medications that might trigger headaches
progesterone (birth control or hormone replacement); tobacco; caffeine; alcohol; aspartame and phenylalanine (in diet colas)
Migraine-specific abortive meds
tryptans, ergot alkaloids
Contraindications to use of tryptans for migraine abortion
Use of ergotamine, use of MAOI, history of hemiplegia or basilar migraines, pregnancy, CVD or uncontrolled hypertenson, in combination with SSRIs may cause serotonin syndrome
Contraindications to the use of ergot amines for migraine abortive
Use with tryptans; heart disease or angina, hypertension, or peripheral artery disease, pregnancy, renal insuff, breast feeding
Non-specific headache abortants
Aspirin/butalbatal/caffeine; Acetominophn/butalbatal/caffeine; Acetominopne/dchloralpheanzol
What are some prophylactic headache meds?
Beta blockers (propranolol, timolol), Neurostabilizers (depakote, topiramate), TCAs (amitryptiline), CCBs (verapamil); others (magnesium, vit B2)
Pretibial myxedema
AKA Graves Dermopathy; waxy discolored induration of the skin; caused by deposition of hyaluronic acid in the dermis and subcutis
How does excessive iodine cause hyperthyroidism?
Causes thyoriditis
Causes of goiter (can be seen in hyper, hypo, and euthyroid)
Lack of iodine is most common cause of goiter worldwide; Hashimotos disease; Graves disease; Nodules; Thyroid cancer; pregnancy; thyroiditis
HCG secreting tumor can cause hyperthyrodisim with high radioactive iodine uptake test- how?
HCG looks like TSH (or TRH?) in one of its subunits I think
Struma ovarii
AKA goiter of the ovary; contains thyorid tissue; cause of hyperthyroidism
What kind of antibodies do you see in Graves disease?
Thyroid peroxidase antibodies
Management of hyperthyroidism
Propranolol for symptomatic relief; PTU and methimazole; oral radioactive iodine; surgery
Side effects of PTU and methimazole
Low white blood cell count in less than 1% of patients. For this reason, it requires regular blood monitoring
How long does it take for PTU and methimazole to work?
Clinical improvement is seen after 1 month but it is 3 months before thyroid level decreases
What are some side effects of radioactive iodine?
Soreness of neck or brief worsening of symptoms. Patients with opthalmopathy may experience worsening of their symptoms. Eventually, many patients become hypothyorid and need to take thyroid replacement
How do you monitor a patient after she is given radioactive iodine?
Check TSH every 2-3 months until it has stabilized and every 6 mos or so after that
Treatment of hypothyroidism
Levothyroxine. Check TSH one month after starting. In primary hypothyoridism, check annually. In secondary hypothyroidism, must monitor more closely
Most common mechanism of injury of ankle sprain
plantarflexion and inversion (“down and in”)
History of snap or tear
Diagnostically significant in a knee injury but not an ankle injury
The lateral stabilizing ligaments of the ankle
Are the most commonly injured in plantar flex and inversion injuries; These include the anterior talofib, posterior talofib, and the calcaneofibular ligament
Tests to assess the stability of the lateral stabilizing ligaments of the ankle
Anterior drawer test for anterior talofibular ligament; Inversion test for calcaneofibular ligament; Posterior talofibular ligament is rarely injured so there’s no test for it
How do we assess for ankle sprain secondary to eversion and rotation (much less common MOI)
Cross-legged test detects high ankle tibiofibular syndesmotic sprain
Grading ankle sprains I, II, III
I is stretching or small tear (no bruising, no loss of stability); II is incomplete tear (brusing common, moderate functional impairment); III is complete tear and loss of integrity of the ligament (mechanical instability)
Peroneal tendon tear is usually secondary to what kind of injury? How does the pain present?
Usually inversion injury or repetitive trauma. Persistent pain posterior to the lateral malleolus
Talar dome fracture
Initial xrays may miss. Watch out for avascular necrosis
Tendonitis in the ankle
Usually involves posterior tibialis tendon. Swelling, warmth and stiffness are common
Subtalar injury
Dislocation invoves talocalcaneal and talonavicular joints
Tarsal tunnel syndrome
Entrapment of the tibial nerve. Pain, tingling, and burning sensation along the sole of the foot and/or the inside of the ankle
Syndesmatic injury
Positive ankle squeeze test. Involves interosseous membrane and anterior inferior tibiofibular ligament
Ottawa ankle rules
Sensitivity of 97 to 100%. Xrays of the ankle are needed if: there is pain in the malleolar zone and EITHER bony tenderness along the distal 6 cm of the posterior edge of the malleolus OR inability to bear weight both immediately and in the ED
Ottawa foot rules
Xrays are indicated if there is pain in the midfoot region and EITHER bony tenderness at the navicular base or base of the fifth metatarsal OR inability to bear weight both immediately and in the ED
What is the management of an ankle sprain?
RICE; Rest x 72 hours; Ice several times throughout the day for 10 mins at a time. Compression. Elevation
Most lower back pain resolves in how long?
2-4 weeks
What is the recurrence rate for back pain?
35-75%
Pain on the same side as bending laterally
Suggestive of bony pathology (OA or neural compression)
Pain on the opposite side as bending laterally
Suggestive of muscle strain
Difficulty with heel walk suggests what pathology?
L5 herniation
Difficulty with toe walk suggests what pathology?
S1 herniation
Decreased patellar reflex means nerve impingement where?
L3/L4
Hip flexion is what roots?
L2, L3, L4
Hip abduction and hip adduction are what roots?
Abduction is L4, L5, S1; Adduction is L2, L3, L4
Knee extension and flexion
Knee extension is L2, L3, L4. Knee flex is L5, S1, S2
Ankle dorsiflex and plantar flex
Dorsiflex is L4, L5; plantarflex is S1, S2
What is the “crossed leg raise”?
Asymptomatic leg is raised and the test is pos if pain is increased in the contralateral leg. Much less sensitive but highly specific for herniated disc
What is the FABER test?
Looks for pathology of the hip joint or sacrum. Test is positive if pain at the hip or sacral joint or if the leg cannot lower to the point of being paralelle to the opposite leg. Should be done on all patients suspected ofhaving SI pain
Achilles tendon reflex is which nerve root?
S1
Symptoms of spondylolisthesis
Aching back and posterior thigh pain that increases with activity or bending
When to order studies for lower back pain?
In the absence of red flags, imaging is not indicated until after 4 to 6 weeks of conservative treatment
Red flags for ordering plain films of the back
Age less than 20 or over 70, Hx of trauma, lifting in patient with osteoporosis, hx of cancer, fevers/chills/nightsweats, pain worse when supine or severe at night
No studies support the use of steroids in LBP
But NSAIDs and opioids help
Spinal manipulation is safe treatment for lower back pain and can help in the short term
right
Diagnosis of hypertension
Two measurements at least 5 mins apart, one in each arm, on two separate visits
Studies recommended for a new diagnosis of hypertension
ECG, U/A, Hct, serum K, Cr and GFR, lipid panel, urinary albumin excretion or albumin/cr ratio (optional in HTN but required in those with DM or CKD), serium calcium
Antihypertensive drugs used in the treatment of heart failure patients
Thiazides, ACE/Arbs, aldosterone antag, beta blockers
Antihypertensives for someone needing recurrent stroke prevention
thiazides and ACEis
Lifestyle modifications that will lower BP
Number 1 is weight reduction then DASH diet then sodium restriction then physical activity then moderation of alcohol consumption
Hydrochlorothiazide should be avoided in what patients?
Those with a history of gout
SE of HCTZ
Hyponatremia
Doses of HCTZ above what level do not decrease BP further
Above 25 mg (which is where most adults start. Elderly patients can start lower)
Definition of resistant hypertension
Not able to meet BP goal in patients who are adhering to 3 dose BP regimen, including a diuretic.
