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P-2 Ortho 1 > 4 Neurological And Systemic DO > Flashcards

4 Neurological And Systemic DO Flashcards

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1
Q

What is CRP?

A

Complex regional pain syndrome

Aka reflex sympathetic dystrophy (RSD)

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2
Q

CRP/RSD diagnosis?

A

Clinical diagnosis composed of:

  • pain
  • autonomic dysfunction
  • trophic changes
  • functional impairment

MC associated w upper extremity injury
- 30% have no precipitating injury

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3
Q

Allodynia

A

Pain caused by normal non-painful stimulis

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4
Q

Hyperpathia?

A

Perception of pain that is delayed and extends beyond the normnal nerve distribution

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5
Q

Hyperesthesia

A

Condition that involves an abnormal increase in sensitivity to stimuli

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6
Q

MC precipitating CRPS/RDS injury?

A
  • Distal radius fracture

- Injury to infrapatellar branch of saphenous nerve

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7
Q

Typical CRPS/RSD patient?

A
  • 30-50 yr old
  • Woman
  • Smoker
  • Depressed/anxiety
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8
Q

Symptoms of CRPS?

A

Autonomic nervous system dysfunciton

  • swelling of extremity
  • increased sweating
  • color change from red-> cyanotic
  • temp change
  • increased hair growth
  • excessive nail growth
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9
Q

How long after the distal radius or infrapatellar saphenous nerve injury do pts get symptoms?

A

May not be present for 3-14 days after event

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10
Q

CRPS symptoms, when chronic presentation?

A

The symptoms cycle on and off and may evolve into:

  • loss of skin lines
  • waxy and/or pale
  • joint stiffness/contracture
  • brittle nails
  • muscle spasms/atrophy
  • persistent pain
  • cool extremity
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11
Q

Radiographs of CRPS?

A

Plain films

  • spotty osteopenia
  • demineralization of bones

Three-phase bone scan
- increased uptake in affected limb

Looks cloudy and shitty. Slide 10 if you wanna see

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12
Q

Diagnostic criteria for CRPS?

A

Budapest clinical diagnostic criteria for CRPS

  1. Continuing pain
  2. REPORT - 1 sx in 3/4 categories
    - sensory: hyperesthesia/allodynia
    - vasomotor: temp asymmetry; skin color changes; color asymmetry
    - sudomotor/edema: edema; sweating changes; sweating asymmetry
    - motor/trophic: decreased ROM/motor dysfunction; trophic changes (hair, nails, skin)
  3. ON EXAM 1 sx in 2+ of:
    - sensory: hyperalgesisa (to pinprick) or allodyina (to light or deep touch, joint movement)
    - vasomotor: temp asymmetry, skin color changes
    - sudomotor/edema: edema/sweating changes
    - motor/trophic: decreased ROM or dysfunction (weakness, tremor, dystonia) and trophic changes (hair, nails, skin)
  4. No other diagnosis that can cause this stuff
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13
Q

Budapest clinical diagnostic criteria for CRPS - down and dirty?

A

CRPS diagnostic tool

Must have continuing pain disproportinate to event

Must report 1 symptoms in 3 categories
- sensory
- vasomotor
- sudomotor/edema
- motor/trophic
Must find 1 symptoms in 2 categories
- sensory
- vasomotor
- sudomotor/edema
- motor trophic
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14
Q

CRPS prognosis?

A

Early recognition is key

  • 80% will improve w diagnosis and tx w/in 1yr
  • 50% will have sig disability if untreated over 1 yr

Poorer prognosis if

  • delayed x 6 mo
  • hx of smoking
  • female
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15
Q

Tx for CRPS?

A

Meds

  • Vitamin C
  • Amitryptline
  • Pregabalin
  • Gabapentin

Consults

  • OT/PT
  • Neuro
  • Pain clinic
  • Physical medicine

Expect a long slow recovery and to not make it to 100%

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16
Q

Meds that dont help CRPS?

A

Oral steroids
NSIDS

Do not alter course of disease - not recommended

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17
Q

FMS?

A

Fibromyalgia syndrome
- chronic condition characterized by gen pain, fatigue, tender areas in soft tissues

Women 20-60 yrs

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18
Q

Fibromyalgia does not affect?

A

The joints. Its muscle fibers only

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19
Q

Clinical presentaion of FMS?

A
  • Widespread pain x 3 months
  • axial skeletal pain (neck, anterior chest, thoracic/low back)
  • sleep disturbances
  • muscle stiffness
  • short term memory loss
  • fatigue
  • depression/anxiety
  • somatic complaints (HA, Chest pain, Bursitis/tendonitis, cystitis, IBS, paresthesias in hands/feet)
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20
Q

Definition of widespread pain?

A

All of the following are present:

  • pain in left side of body
  • pain in right side of body
  • pain above waist
  • pain below waist

Should be for 3+ months

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21
Q

PE for fibromyalgia?

A

TTP for 11 of the 18 trigger sites

TTP limited to sfot tissues

  • muscle
  • tendon
  • ligament/bursa

Joint exam is normal

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22
Q

Diagnostic studies for FMS?

A

None

- FMS should be considered in any pt w MSK pain that makes no sense

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23
Q

FMS tx? (Meds)

A

Reassurance

Meds (start low)

FDA approved
- pregabalin (lyrica)
- duloxetine (cymbalta)
- minacipran (savella)
Other
- amitryptline
- cyclobenzaprine
- fluoxetine
- tramadol
- capsasin

Avoid steroids and narcs

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24
Q

FMS tx (non meds)

A

Diet
Exercise
Support group

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25
Pt’s responses or symptoms that dont fit known patterns of illness or injury?
Non-organic s/s
26
Though not malingering non organic s/s are found?
3-4x more in workers comp and litigation cases
27
Non organic s/s run down?
- Pain travels - Doesn’t fit nerve patterns - Exaggerated response - Pain w/o obvious inj - Muscle testing - lack of sustained effort - Stocking numbness (not DM)
28
How to treat non-organic s/s?
R/o serious d/o Discuss psych/social support to help with things like stress
29
What are seronegative spondyloarthropathies?
Spectrum of multiple syndrome that effect - nervous (eye) - integumentary (skin) - MSK (joints) - GI - heart They are negative for RH and ANA (antinuclear antibodies)
30
Conditions that are seronegative spondyloarthropathies?
Ankylosing spondylitis Psoriatic arthritis Reiter’s syndrome Enthesis (tendon/fascia, joint capsule) They are differentiated from other conditions by surface antigens (HLA-B27)
31
Pt presentation for ankylosing spondylitis?
Men:women 3:1 20-30 y/o Insidious onset of back and hip pain Morning stiffness (30 min to “warm up”) DISH is old people AS is young
32
Common findings or ankylosing spondylitis?
``` Sacroilitis Extra articular infolvment - Uveitis - IBS Bamboo spine Presence of HLA-B27 ```
33
Clinical symptoms for ankylosing spondylitis?
``` Back pain Stiffness (“warm up” in the am) Pain is relieved by leaning forward Enthesis is common (achilles/plantar fascia mc) Asymmetric polyarthritis Fam hx ```
34
Presentation of ankylosing spondylitis in kids?
Asymmetric pauciarticular arthrits (kids 9+) Kids may not have back pain - but they will have limited mobility of spine
35
PE for ankylosing spondylitis?
Modified Schober Test - measure 15cm from posterior iliac spine to upper lumbar region - Have pt flex forward - Points should increase distance by 5-7cm FABER maneuver/patrick’s test - pain Rigid spine (ankylosed) Bilateral sacrioliitis
36
Poor prognostic indicator for ankylosing spondylitis?
Hip involvement at a young age
37
Radiology findings for ankylosing spondylitis?
Obliteration of SI joint - 100% have sacroiliitis Vertical syndesmophytis (vertebrae) Squaring of vertebrae Autofusion of the facet joints -> classic “poker spine” or “bamboo” spine
38
Ankylosing spondylitis treatment?
``` PT NSAIDS TNF-inhibitors (not for AD) hip THA (replacement) Spine-corrective osteomies for flexion deformaties ```
39
What is reactive arthritis?
Arthritis following an infection in a young male - chlamydia - campylobacter - salmonella - shigella
40
Reactive arthritis classic presentation?
Classic triad cant see, cant pee, cant climb a tree - conjunctivitis (or uvitis) - urethritis (sterile pyuria) - enthesis Asymmetrical involvment w enthesis (common in achilles and plantar fascia)
41
Reactive arthritis pts usually also have?
80% are HLA-B27 + | 60% have sacroiliitis
42
Non joint presentation of Reactive arthritis?
Enthesis Dactylitis (sausage digit) - swelling of entire toe or finger
43
Reactive arthrits triad?
GU MSK Extra-articular s/s
44
Asymmetric oligoarthritis?
Reactive arthritis - asymmetric presentation - 2-4 joints in 6 months
45
PE for reactive arthritis?
STI findings Ulcers on palms/soles - keratoderma - blennorrhagicum Plantar heel pain
46
Diagnostic tests for reactive arthritis?
Sterile pyruia - reiter syndrome (chlamydia) Other diagnostic tests - stool culture (salmonella, shigella, campy, yersinia) - NORMAL - acute phase reactants (CRP/ESR) - synovial fluid nonspecific (characteristic of inflammatory arthritis) Radiographs don’t show anythiing
47
Tx for reactive arthritis?
2 fold - relieve symptoms - eradicate infeciton ``` Doxy - chlamydia NSAIDS/tylenol/ASA PT Steroids (site then systemic) DMARDS (refractory to tx) Surgery (arthroplasty) ```
48
If you miss reactive arthritis?
Its ok (for you anyway) 50% resolve in 3-4 months - others last for years
49
5-14% of people with psoriasis develop?
Psoriatic arthritis
50
MC presentation of psoriatic arthritis?
Pt with psoriasis Monoarticular involvment of the KNEE is MCpresentation - then it progresses to other joints in asymmetric fassion
51
Age range for psoriatic arthritis?
Uncommon <15 yrs
52
Upper extremity findings or psoriatic arthritis?
Tenosynovitis of the digitis Nail pitting Pencil in cup deformity
53
Tx for psoriatic arthritis?
Topicals for skin Salicylates, NSAIDS, TYLENOL, ASA, Splinting Oral and intra-articular corticosteroids DMARDS - hydroxychloroquine - methotrexate - Gold PT for ROM/strenth
54
Surg for psoriatic arthritis?
Prevent tendon rupture - Synovectomy or - tenosynovectomy End stage arthritis requires total joint arthroplasty or arthrodesis
55
IBS is associated with?
UC Crohns Pauciarticular arthritis of lower extremity Sentinal symptoms of spondylitis
56
IBS pts with the following need a referral
Kyphosis Pain at rest Painat night (wt bearing joint) Eye involvement (immediate to optho)
57
General approact to the seronegative spondyloarthropathies?
Control inflammation - NSAIDS - Immunomodulators - TNF inhibitors Rehab and activity (symptom improvement) Referrals - rheum - optho - GI - orthopaedic (surgery)
58
Spirochete borrellia burgdorferi?
Deer tick - lyme disease Most prevalent vector-borne illness in US
59
Phases of lyme disease?
1. Early localized - skin lesion (erythema migrans) - viral syndrome 2. Early disseminated 3. Late (months - years) - arthritis and neuro - lyme arthritis (2mc manifestation) - encephalopathy
60
Lyme disease mc involves?
Knee (or large joints)
61
Treatment for lyme?
Catch it early - abx (doxy, amoxicillin) - for 28 days !!! Prevention - remove tick in 24-36 hrs and youre G2G

P-2 Ortho 1 (7 decks)

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