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health assessment and primary care > thyroid, musculoskeletal, derm, psych > Flashcards

thyroid, musculoskeletal, derm, psych Flashcards

1
Q

hyperthyroidism
-etiology
-sx

A
  1. Grave’s disease: autoimmune condition; excess thyroid hormone caused by antibodies that stimulate TSH receptors
  2. Thyroiditis: group of inflammatory diseases (usually self limited)

SX:
-increased appetite, weight loss
-irritability, nervousness, sleep disturbances
-heat intolerance exertional SOB
-palpitations
-eye irritation, vision changes
-diarrhea
-amenorrhea, infertility

PHYSICAL:
-enlarged thyroid gland
-hyperfelxia
-tachycardia

Grave’s: exopthalamos/proptosis and pretibial myxedema (non pitting thickening of skin)

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2
Q

best test for diagnosing hyperthyroidism?

lab resuls?

A

TSH!! best initial test for dgx

-Free T4 is usually elevated, serum t3 elevated (most useful when T4 is normal, TSH is low and patient is symptomatic)
-TSH is low
-antithyroid peroxidase (anti-TPO): may be detected in Grave’s disease
-radioactive iodine (RAI) scan with uptake if clinical presentation is not diagnostic of Grave’s disease (uptake increased in Graves, but decreased in thyroiditis)

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3
Q

antithyroid drugs/treatment for hyperthyroidism
1. thionamides (PTU)

  1. RAI therapy
A
  1. PTU: permanent remission in half of patients in 15-20 years
    -clinically euthyroid in 4-8 weeks

*monitor CBC, LFTs, should be treated in pregnancy, PTU first trimester and Methimazole in second

  1. RAI therapy: damages functioning thyroid tissue, reduces symptoms in 6-12 weeks; SE: hypothyroidism in 70% of patients; NOT ok in pregnancy- avoid pregnancy 6-12 months after RAI
  2. beta blockers
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4
Q

management of thyroiditis- often no treatment required but may need…

A

NSAIDs for pain/inflammation

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5
Q

s/sx of thyroid storm
-educate patients on this!

A

exacerbations of hyperthyroidism; acute, life threatening

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6
Q

hypothyroidism
-TSH
-Free t4
-antithyroid peroxidase)

A

-deficient level of thyroid hormone

  1. primary thyroid failure: Hashimoto’s (autoimmune), previous RAI treatment, surgery
    -TSH will be high, Free t4 will be low, + antithyroid peroxidase in Hashimoto’s
  2. secondary: pituitary or hypothalamic disease
    -TSH will be low or normal, free T4 will be low
  3. transient

subclinical hypothyroidism: TSH is high, Free T4 is normals

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7
Q

symptoms of hypothyroidism (think: low and slow)

A

-lethargic, weak
-dry skin, pallor
-slow speech, forgetfulness
-constipation
-amenorrhea, infertility
-weight gain

PHYSICAL: thyroid gland may be normal, diminished reflexes, skin cool, bradycardia, diminished bowel sounds,

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8
Q

T/F women with + TPO antibodies (even when euthyroid) have increased risk for recurrent miscarriage with or without infertility

A

true

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9
Q

management
-primary hypothyroidism

A

NEED LIFELONG TREATMENT
-Levothyroxine: synthetic T4
-dose adjusted every 6 weeks
-safe in pregnancy: measure TSH every 4-6 weeks in pregnancy and adjust dose as needed on trimester-specific TSH levels

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10
Q

treatment of subclinical hypothyroidism
-treat if TSH greater than…

A

TSH > 10–> tx
TSH 5-10 with elevated anti-TPO: also tx

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11
Q

T/F untreated hypothyroidism is asx with LBW, PTD, pp hemorrhage

A

true

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12
Q

low back pain
-acute vs chronic
-lumbosacral vs herniated intervertebral disc
-sxs

A

acute (<3 months), chronic, recurrent

etiology:
-lumbosacral strain from stretching, tearing muscles, tendons, ligaments, due to trauma or repetitive mechanical stress; SX: pain located in lower back and butt, sharp, spasms/achey, pain aggravated by standing/flexion, RELIEVED W/ REST
-lumbosacral physical findings: increased pain with back flexion, negative SLR, normal neuro exam

-herniated intervertebral disc causes nerve root compression, resulting in pain below the knee and other neuro signs and symptoms; SX: pain in butt that radiates to lower extremity, sharp, burning shooting, pain increased with bending and maneuvers that increase intra-abdominal pressure like straining for BM, also asx with numbness and tingling
-herniated physical findings: increased pain with back flexion, POSITIVE STRAIGHT LEG RAISE: radicular pain when leg is passively raised

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13
Q

most common disc ruptures involve the L5 or S1 nerve roots
1. L5 root/L4-5 disc
2. S1 rot/L5-S1 disc

A
  1. L5 root/L4-5 disc: pain/numbness lateral calf; weakness of dorsiflexion of great toe; decreased sensation anterior/medial dorsal foot
  2. S1 rot/L5-S1 disc: pain in buttocks, lateral leg, and malleolus, numbness in lateral foot and posterior calf; weakness of plantar flexion/tiptoe walking, diminished achilles reflex
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14
Q

Cauda equina syndrome

A

-characterized by saddle anesthesia, bladder or bowel incontinence, muscle weakness
-immediate referral to neurosurgery

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15
Q

“red flags” with back pain

A

fever, chills, weight loss, recent-onset bladder/bowel dysfunction, lower extremity sensory or neuro deficit

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16
Q

radiograph of lumbosacral spine is only indicated when…

A

-suspicious of fracture
-suspicious of malignancy (pt > 50 years old with persistent bone pain unrelieved by bed rest; hx of malignancy)

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17
Q

MRI or CT is recommended for…

A

suspected disc herniation

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18
Q

nonpharm management and pharm for low back pain

A

NONPHARM: continue daily activities, apply heat/warm baths, physical therapy, low-stress exercises

PHARM
-NSAIDS
-muscle relaxants (Cyclobenzaprin/Flexeril): may cause somnolence, potentiates alcohol and other CNS depressants
-opioids as last resort; no more than 72 hours/3 days

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19
Q

Osteoarthritis
-definition
-SXs
-physical findings

A

noninflammatory joint disease characterized by degeneration of articular cartilage with new bone formation at articular surface

joints commonly involved: distal and proximal interphalangeal joints of hands, hips, knees, and cervical and lumbar spine

can be primary of secondary

SX: gradual onset of joint pain, pain aggravated by join use and subsides with rest, morning stiffness that last less than 30 minutes, ASYMMETRICAL
-bone ends thicken and osteophytes or spurs form

Physical Findings: effusions with minimal warmth/erythema, enlargement of DIP joints (Herberden’s nodes), enlargement of PIP joints (Bouchard’s nodes), CREPITUS with joint movement

20
Q

risk factors for osteoarthritis

A

-increasing age
-female
-obesity
-major joint trauma
-repetitive joint stress

21
Q

diagnostic tests/findings
1. radiography

-4 cardinal radiology features?

A

-radiography will not demonstrate deterioration of cartilage
4 cardinal radiology features:

  1. narrowed joint space
  2. sclerosis of subchondral bone
  3. bony cysts
  4. osteophytes
22
Q

diagnostic joint fluid aspiration
-only if joint effusion

-other labs?

A

-synovial fluid analysis: WBC count < 2000, negative cultures, negative for crystals

rule out RA: with RF/ANA, CBC

23
Q

management of osteoarthritis
-nonpharm
-pharm

A

nonpharm: appliances, exercise, yoga, TENNS

pharm: acetaminophen, Tramadol, NSAIDs, topical analgesic, intra-articular injection (glucocorticoids, hylauraonic acid)

24
Q
A

low bone mass and structural deterioration of bone tissue, leading to increased risk of hip, spine, and wrist fracture

25
Q

osteopororsis risk factors

A

-increasing age
-female
-lifestyle: low calcium intake, alcohol (>3 drinks/day), current cigarette smoking, Vit D deficiency, high salt intake, inadequate physical activity, immobilization, falling, prior hx of osteoporotic fracture, thin, low BMI
-genetic: parental hx of hip fracture
-anorexia nervosa and bulimia
-diabetes mellitus
-meds: glucocorticoids (long term se), aromatase inhibitors

26
Q

loss of height of…

A

> 1.5 cm could indicate osteoporosis
kyphosis “hunchback”

27
Q

Bone mineral density tests
-normal
-osteopenia
-osteoporosis

A

-normal: BMD within 1 SD of a young adult women; T score above -1.0

-osteopenia (low bone mass): BMD between 1 and 2.5 SD of young normal adults’ T score between -1 and -2.5

-osteoporosis: BMD 2.5 SDs or more below that of young normal adults; T score at or below -2.5

28
Q

Vertebral Fracture Assessment (VFA) should be considered in women who are: (3)

A
  1. 70 or older and BMD T score is at or below -1
  2. 65-59 if BMD T score is at or below -1.5
  3. post menopause with low trauma fracture during adulthood, historical height loss of 4 cm or more, prospective height loss of 2 cm or more, recent or ongoing long term glucocorticoid treatment
29
Q

what is the FRAX score used to?

A

calculates 10 year probability of hip fracture and 10 year probability of a major osteoporotic fractures
used to make decisions regarding medications for postmenopausal women with osteopenia

30
Q

mangement/tx
-non pharm: prevention

A

a. adequate intake of calcium and vitamin d: 12000 mg Calcium and 800 IU of vitamin D/day
b. regular weight bearing exercises (thirty minutes three to four times each week)
c. strength training
d. fall prevention strategies

31
Q

pharm interventions should be considered for postmenopausal women presenting with any of the following:
(3)- consider T score, fracture probability

A
  1. hip or vertebral fracture
  2. T score of -2.5 or less at femoral neck or spine
  3. T score between -1.0 and -2.5 at femoral neck or spine and 10 year probability of hip fracture of 3% or greater or a 10 year probability of major osteoporotic-related fracture of 20% or greater based on FRAX
32
Q

PHARM FOR OSTEOPOROSIS
1. estrogen/hormone therapy
2. bisphosphonates
3. estrogen agonist/antagonists (SERMS)

A
  1. estrogen/hormone therapy: short term (<5 years) for prevention if patient needs treatment for VMS or vulvovaginal atrophy; not approved tx for existing osteoporosis
  2. bisphosphonates: Alendronate; indicated for prevention and treatment; inhibits osteoclast activity; PT EDU: must sit upright for 30 minutes after taking it, take on empty stomach (interacts with calcium and antacids)
  3. estrogen agonist/antagonists (SERMS): Raloxifene (Evista); indicated for prevention and treatment; may cause hot flashes and leg cramps
  4. Denosumab (Prolia) tx of postmenopausal women with osteoporosis at high risk for fracture; subq admin every 6 months; ok to use if they are using aromatase inhibitor for breast cancer
  5. calcitonin: indicated for treatment ONLY; increased risk of malignancy **- NOT TO BE USED AS FIRST LINE and must be use LESS THAN 6 months
    -directly inhibits bone resorption of calcium
  6. Parathyroid hormone: PTH approved for tx if patient is at high risk for fracture
  7. Humanized monoclonal antibody (IGG2), Romosozumab (Evenity)
    -12 doses
33
Q

monitoring pharm therapy effectiveness in osteoporosis patient
-BMD
-repeat test every…
-urine/serum biochemical markers

A

-baseline BMD before onset of therapy

-repeat test every… 2 years

-urine/serum biochemical markers: only as adjunt

34
Q

criteria for fibromyalgia
a. widespread pain index
b. symptoms present for at least…
c. exclusion
d. WPI
3. SS scale score

A

a. widespread pain index: score of 7 or greater and symptom severity (SS) scale score of 5 or greater or WPI of 3-6, SS scale score of 9

b. symptoms present for at least…3 months

c. exclusion of other disorders

d. WPI: number of areas in which patient has had pain over the last week (0-19)

  1. SS scale score: presence and severity of fatigue, waking unrefreshed, cognitive symptoms over past week (0-12)
35
Q

FDA-approved drugs to tx fibromyalgia
a. gamma aminobutyric (GABA) analogue
b. SNRIs

A

a. gamma aminobutyric (GABA) analogue: Pregabalin (Lyrica)

b. SNRIs: Cymbalta

both cause CNS depression

36
Q

strain vs sprain

A

strain- injury to muscle or tendon; temporary weakness, pain with stretching

sprain- stretching or tearing of ligaments; marked swelling and loss of function

RICE: rest, ice, compression, elevation

37
Q

Headaches (primary)
1. migraine headaches

  1. tension headaches
  2. cluster headaches
A
  1. migraine headaches
    a. migraine with aura/classic migraine: aura consist of focal neuro symptoms that may precede or accompany HA (flashing lights, difficulty focusing)
    b. unilateral tendency, lasts 4-72 hours, moderate to severe intensity, throbbing, pounding, N/V, photophobia, phonophobia, fatigue
  2. tension headaches; most common form of headache
    a. gradual onset, bilateral, diffuse, dull, pressure, episodic = less than 15/month, can last hours to days
  3. cluster headaches
    a. abrupt onset, unilateral, retro-orbital, usually 35-40 minutes, asx with facial pain, nasal congestion, occurs in CLUSTERS lasting a few weeks
38
Q

headache phases
1. prodrome
2. aura
3. early and late stages of migraines
4. postdrome

A
  1. prodrome: occurs 24 hours prior to onset of HA: fatigue, euphoria
  2. aura
  3. early and late stages of migraines
  4. postdrome: individual feels “wiped out”, fatigued
39
Q

headache “red flags” suggesting secondary cause

A

-headache beginning after 50
-sudden onset, worse HA ever
-headaches increasing in frequency or severity
-headache initiated by exertion: coughing or straining
-focal neurologic symptoms that do not resolve within 60 minutes of headache onset
-headache subsequent to head trauma
-systemic illness/fever (meningitis)

40
Q

what lab needs to be drawn on all patients with new onset headaches older than 40 years to rule out temporal arteritis?

A

erythrocyte sedimentation rate

41
Q

CT/MRI is only indicated when…

A

there is persistent focal neuro findings or history of trauma

42
Q

migraine abortive therapy
-first line
1. mild to moderate
2. moderate to severe

A
  1. first line:
    a. NSAIDs, acetaminophen
    b. Combination analgesics: acetaminophen 250 mg/aspiring 250 mg/ caffeine 65 mg- one table every 6 hours
  2. first line: moderate to severe
    a. sumatriptan, zolmitriptan: may initially cause tightness of throat/chest, flushing, numbness, tingling; some concerns about use in pregnancy
43
Q

second line migraine abortive therapy

A

ergotamines
-do NOT give with triptan
-CI during pregnancy

44
Q

Migraine headache- prophylactic therapy should be considered in patients who…

A

…who experience more than two severe headaches per month, need acute tx more than two times per week, or are unable to tolerate abortive agents

  1. beta blockers
  2. CCB- Verapamil
  3. Anti-epileptic agents- Valproic acid (Valproate)
45
Q

Tension- episodic vs chronic tx

A

EPISODIC:
-NSAIDs, acetaminophen
-combination caffeine, butabital, acetaminophen

CHRONIC
-TCAs
-SSRIs

health assessment and primary care (5 decks)

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