Summer Flashcards
Describe the posterior element radiation patterns.
What examination method can be used to load the lower lumbar facet joints?
Lumbar extension and rotation.
What is the best approach for SI joint assessment?
Palpation for tenderness.
Manipulation for pain (Flexoin, ABduction, External Rotation)
Compression of the illiac crest with patient on their side
What is the frequency of hyperlordotic or sponlylolysis pain in adolescents?
46%
What is the relationship between sensitivity and specificity of straight leg raise vs contralateral SLR for lumbar disk herniation?
SLR = sensitivity 92%
Contralateral SLR = Specificity 90%
What is the natural hx of LUMBAR SPINAL STENOSIS managed non-operatively?
15-45% improve
15-30% worsen
50-70% remain symptomatically stable
How can the anterior femoral acetabular articulation be palpated?
Palpation of the femoral triangle.
What does FABER test indicate?
Groin pain = intra-articular disorder or illiopsoas involvement
SI Joint pain = SI joint pathology
Posterior hip pain = posterior hip impingement
What does log roll test for hip pain indicate?
Groin pain = intra-articular disorder
Posterior pain (with internal rotation) = posterior mulscle involvement (piriformis)
How is FADIR test done and what does it indicate?
Flexion, adduction and internal rotation.
It is the most sensitive test for femoral impingement.
How is Thomas test done and what does it indicate?
Good leg held up.
Effected leg allowed to drop below the level of the table.
Extend the effected leg PRN to exacerbate the symptoms
Anterior or groin pain = anterior labral pathology or acute hip flexor pathology
What tests can be done to evaluate the piriformis?
Freiberg sign = Buttock pain with passive IR with hip extended (stretches the piriformis) manual muscle testing via resisted external rotation of the leg
Pace sign = Buttock pain with resisted hip abduction while hip is in flexed position
What percentage of body weight loss will help with knee and hip pain?
Knee = 10%
Hip = 5-10%
Cochrane
What percentage of patients with gout will have tendon involvement?
65%
What is the most common site of tendon involvement with gout?
Achilles (52% of patients)
What medications can cause an elevated risk of gout?
HCTZ
Lasix
ASA (low dose only / high dose is uricosuric)
What comorbidities are associated with gout?
Metabolic syndrome (obesity, hyperlipidemia, DM2)
HTN
CVD (VTE, MI, CVA, PAD, CHF)
Chronic kidney disease
What foods increase risk of gout?
Beef, pork, lamb (RR 1.41)
Seafood (RR 1..51)
High fructose corn syrup (female / 1 per day = RR 1.74 or 74% increase)
High fructose corn syrup (female / 2 per day = RR 2.39 or 139% increase)
How does EtOH impact risk of gout?
15 to 30 grams/day (1-2 drinks) RR 1.5
30 to 50 grams/day (2-3 drinks) RR 2.0
> 50 grams/day (>3 drinks) RR 2.5
Beer is the worst offender,
When should cholchicine be used in acute gout?
When there is a contraindication to steroids or NSAIDS.
Efficacy is equivalent.
What is the best prophylaxis for gout?
Cholchicine
6 months after uric acid target achieve AND tophi
3 months after uric acid target achieved with NO tophi
What gout patients need uric acid lowering agents?
Tophus or tophi
> 2 attacks per year
CKD stage 2 or worse
Gout with urolithiasis
Uric acid overproduction and urinary excretion (>1g/day)
What is the target uric acid level in gout treatment?
Below 357mmol/l
Can lithium increase calcium?
Yes
What is the relationship between PTH and calcium?
In primary hyperparathyroidism, PTH is elevated as is calcium.
In tertiary hyperparathyroidism, calcium is normal and PTH remains high. The parathyroids have been turned on and are not autoregulated anymore.
In malignancy, the calcium is elevated and the PTH level is normal. I.E. To workup hypercalcemia, repeat
What levels of calcium need immediate treatment?
- 49 mmol/l if no symptoms
- 99 with symptoms
How much sodium is in a litre of normal saline ?
154 mEq/l
What is severe hyponatremia?
Below 120 mmol/l
What are the two key ways to classify hyponatremia?
Dilutional
Depletional
How are the additional tests in hyponatremia evaluated?
Urine Na+ < 20 mEq suggests kidneys try to hold onto Na+
Urine > 30 mEq suggests kidneys are not avidly holding onto sodium kidney disease
Serum osmolality Helps guide intravascular volume assessment : Dilute vs depleted
How fast can sodium be corrected?
less than or equal to 10mmol/l/24 hours
What are the most dangerous impact of correcting sodium too rapidly?
Pontine mylenolysis (osmotic demylination syndrome)
What constitutes fluid restriction in mild hyponatremia?
1-1.5 litres per day
What are the common causes of hypernatremia?
M edications/meals
O smotic diuretics
D iabetes insipidus
E xcessive H2O loss
L ow H2O intake
How is hypokalemia classified?
Mild: 3.0 – 3.5
Moderate: 2.5 – 3.0
Severe: < 2.5
What are the clinical manifestations of hypokalemia?
Fatigue
Cramps
Constipation
Weakness / Paralysis
Paresthesias
Arrhythmias
What are the EKG abnormalities in hypokalemia?
Flattened T waves
ST depressions
Prominent U waves
How much potassium is there in a banana?
1 meq/inch
What are the EKG abnormalities with hyperkalemia?
Peaked T waves
ST depression
1 st degree AVB/Loss of P wave
QRS widening
What are the “4 C’s” of addiction?
Craving
Compulsion
Control loss
use despite Consequences
What are the key features of opioid dependence?
Tolerance
Withdrawal symptoms.
What are the two combination tablet forms containing buprenorphine plus naloxone available in the 4:1 ratio formulations?
– 2 mg buprenorphine + 0.5 mg naloxone
– 8 mg buprenorphine + 2 mg naloxone
What is the sublingual availability of buprenorphine?
30-55%
What is the mean half-life of buprenorphine?
37 hours
What are the pharmacokinetics of naloxone?
– Has a distribution half-life of 4 minutes
– Has an onset of action within 2 minutes
– Is metabolized by the liver mainly by glucuronic conjugation and excreted in the urine
– Has an elimination half-life of 1.3 hours
What are the pharmacokinetic properties of suboxone?
Onset 30 to 60 minutes
Peak action within 1 to 4 hours
The maximum plasma concentration of buprenorphine following sublingual administration is variable, ranging from 40 minutes to 3.5 hours
The elimination half-life ranges from 24 to 36 hours after sublingual administration
Describe the dose-dependent duration of action for suboxone
Low doses of 4 – 8 mg: 4 – 12 hours
Moderate doses of 8 – 12 mg: ~24 hours
Higher doses of >12 mg: 2-3 days
What is a sports hernia?
Strain or tear of any soft tissue (muscle, tendon, ligament) in the lower abdomen or groin area (AKA athletic pubalgi)
