40 Flashcards
(463 cards)
1
Q
Infant HIV testing
A
HIV DNA PCR at 48hrs, 4-6wk, 3 mo
HIV Ab at 12-18 mo
2
Q
new HIV labs
A
CBC, LFT, BUN/creat, urinalysis, hepatitis serologies, blood glucose, lipids, genotypic resistance, STIs, opportunistics (toxo, CMV, PPD)
3
Q
Preventive Txt PCP in HIV
A
CD4 <200 DS Bactrim daily
4
Q
Preventive Txt Toxoplasmosis in HIV
A
CD4 <100+toxo Ab DS Bactrim daily
5
Q
Preventive Txt MAC in HIV
A
CD4<50 Azithro or clarithro weekly
6
Q
Routine Vaccines in HIV
A
pneumovax if CD>200, HAV, HBV, flu
screen for HBV, HCV
7
Q
HIV Treatment based on CD4 count in adult
A
Treat CD4500 (WHO defer until <350)
8
Q
HIV Meds
A
entry inh (fusion inh, CCR5 blockers), NRTIs, NNRTIs, integrase inh, protease inh
9
Q
HIV med drug interaction
A
inhaled steroids, statins, methadone, OCPs, rifampin, erectile dysfunction, st johns wort, PPIs, coumadin
10
Q
Protease Inh drug interactions
A
HIGH RISK/CI - simvastatin, lovastatin
mod risk - fibrate+statin, atorvastatin
low risk - fibrates, pravastatin, fluvastatin, rosuvastatin, fish oil, niacin
11
Q
HBV, HCV, HIV avg transmission rates
A
HBV 30% > HCV 3% gt HIV 0.3%
12
Q
Occupational exposure risks
A
IM injury 16% > advanced AIDS source pt 6% > visible blood on device/needle enter blood vessel 5% >AZT PEP 0.2%
13
Q
Post-exposure prophylaxis - occupational and non occ
A
3 drug therapy, 28 days, immediate start to meds important
reduces risk 81%
14
Q
Post-exposure F/U testings
A
Initial - CBC, creat, LFT, HIV Ab, HCV Ab, HBsAg/Ab
2 weeks - CBC, creat, LFTs
6 weeks - HIV ab, HCV ab, RPR
3 mo+6mo - HIV ab, HCV ab (stop at 3 mo if using p24 ab test)
15
Q
Pre-exposure prophylaxis
A
Truvada daily
risk reduction 44%, up to 90%
16
Q
Pre-exposure prophylaxis pre-initiation testing
A
Test for HIV ab, CrCl>60
screen and vaccinate HBV
screen and treat STDs
17
Q
Pre-exposure prophylaxis F/U
A
F/u - q3mo - HIV ab, STD sx eval, counsel
q6 mo - STD test even is asymp
BUN/creat 3 mo post start then annually
18
Q
HIV incubation period
A
2-4 weeks
19
Q
Acute retroviral syndrome timing
A
2-4 weeks post exposure, lasts 3-14 days
20
Q
Acute retroviral syndrome Sx
A
fever, rash, swollen lymph - high viremia
21
Q
HIV tests
A
*Elisa - negative until >3-4wk post infection
P24 - 3 weeks
HIV RNA - +10-15 days post infection
- use unless suspect acute retroviral syndrome
22
Q
HIV Clinical Latency Sx, tests, duration
A
HIV ab response - cell mediated then humoral
Symptoms - none
Tests - Elisa+ HIV RNA+
Duration - variable
23
Q
Viral set point HIV
A
predictor of dx - set 3-6 mo post infection
high set point - high rate of transmission
24
Q
Symptomatic phase - CD4 related dx’s
A
Progression to AIDS
CD4<500 - bacterial pneumo, TB, minor skin infections more common
CD4 200-500 - opportunistic infections - herpes zoster, TB, candidiasis, PCP, toxo, CMV, kaposi, HSV
25
HIV Screening Guidelines
All persons 15-65 - once
High risk pts - annually
Pregnant women - once, again in 3rd tri if high risk area
written consent not required
26
TB presentations - types
pulmonary, pleural, pericardial, GI, lymphnode, GU, skeletal (gibbus malformation, Potts dx)
27
TB symptoms
Chronic cough >2-3 weeks, night sweats, loss of appetite, weight loss/consumption, fatigue
28
TB exam findings
nonpainful cervical LAN
29
TB testing
PPD, CXR, interferon gama release assay IGRAs, sputum AFB smear and culture, fluid exam in localized dx, tissue pathology, ab and antigen detection assays
30
TB testing shortcomings
CXR negative in 50% children w/ active TB
sputum smear 50% reliable, only possible children>10
PPD - limited sensitivity in HIV/TB coinfected
31
TB First Line Treatments
2 months - rifampin, isoniazid, pyrazinamide, ethambutol
| continuation phase - 4 months rif, INH
32
TB Second Line Treatments
12-18 month therapy
ethionamide, cycloserine, para-aminosalacylic acid, quinolones
Injectables: streptomycin, capreomycin, kanamycin, amikacin
33
MDR-TB
resistant to INH and rifampin
34
XDR-TB
resistant to INH, rifampin, AND fluoroquinolone AND one of the injectables (capreomycin, kanamycin, amikacin)
35
MDR-TB Treatment Options
Minimum of 4 drugs, 1 year treatment
quinolones - moxiflox, levoflox, gatiflox)
aminoglycosides- streptomycin, capreomycin, kanamycin)
other - pyrazinamide/PZA, cycloserine, ethionamide, PAS
36
Risks of HIV/TB coinfection
Increased progression latent to active TB
more rapid HIV dx progression
higher TB relapse rates
higher rates MDR and XDR-TB
37
Benefit of HIV/TB cotreatment
reduced TB deaths, HIV pts less likely to get TB, lower mortality
38
Risks of HIV/TB cotreatment
Interactions between drugs alter levels --> can lower PI and NNRTI and cause drug failure
Combined SE intolerable
Many many daily doses
39
HIV/TB cotreatment recommendations
Adults/pedi - start TB txt first, start ART asap w/i 8 weeks as tolerated, irrespective of CD4 count
Adult - use EFV as preferred NNRTI
40
TB Preventions
Age treat
Txt latent TB
BCG vaccination
isolation, treatment, contact tracing
41
LTBI
No S+S, can't spread
Positive - TST, IGRA
Negative - CXR, respiratory smear and culture
Txt to prevent conversion to active TB - INH
42
Active TB
S+S - fever, cough, chest pain, weight loss, night sweats, hemoptysis, fatigue, decreased appetite
Positive - TST, IGRA, CXR (may be normal in adv immunosuppression), respiratory smear and culture (may be - in pulmonary dx)
Txt NEEDED
43
TB Screening Guidelines
Risk - sx TB, healthcare field, spend time around infectious, travel to TB endemic area, poorly functioning immune system
44
Tuberculin skin test readings
>5mm - HIV or HIV unknown + IVDU, close contact active TB, fibrotic CXR lesions, on steroids, transplant pt
>10mm - IVDU and HIV-, high prevalence country, medically underserved, long term care facility
>5mm - no increased risk
20% w/ active TB and 80% with active TB and HIV test negative
45
Latent TB treatments
INH daily/BIW for 9 mo
Rif 4 mo
Rif/PZA 2 mo - ONLY IF HIV+
46
LTBI w/ Drug resistant TB exposure treatments
INH resistant exposure - rif 4 mo or rif/PZA 2 mo
| MDR exposure - EMB+PZA or quinolone+PZA
47
LTBI treatment - Pregnant
INH for 9 mo - can delay txt
| NO DELAY IF HIV+ OR NEWLY EXPOSED
48
Immune Reconstitution Inflammatory Syndrome IRIS
clinical deterioration after starting combo ART
immune system starts working and causes inflammation against infection
weeks - 6 mo after ART initiation (mean 21d)
ARV continued until TB meningitis
Prednisone 2-4mg/kg/day
49
Migraines criteria
2 or more: 4-72hrs, unilateral, pulsating, mod to severe, aggravate by activity
1 or more: N, V, photophobia, phonophobia
w/ or w/o aura
Dx - 5 or more HAs that meet criteria
50
Chronic Migraine
Migraine for >=15 days/mo for >3mo
51
Tension type
Bilateral, pressing, tightening, mild to mod, NOT aggravated by activity, no N/V, either phono or photophobia
52
Chronic Tension type HAs
TTH for >=15 days/mo for >3mo
53
Cluster HA
severe unilateral orbital/supraorbital/temporal pain lasting 15m-3h
1 or more: ipsilateral conjuntival injection or lacrimation, ipsilateral nasal congestion/rhinorrhea, ipsilaterl eyelid edema, ipsilateral miosis/ptosis, restlessness/agitation/pacing
Often at night, wake up from sleep, tend to cluster
54
Cluster HA risk factors
Male, middle aged, assoc w/ ETOH, smoking
55
Cluster HA Imaging
CT if first one since symptoms so severe
| If hx cluster, only treat
56
Primary stabbing HA
ice pick HA, <1sec, quick and repetitive, cluster, almost never serious, reassurance best
prophylactic ibuprofen if needed
57
Hypnic HA
wake ppl up from sleep, >50yrs
58
Daily persistent HA
HA for >3mo, daily/unremitting from onset, definite start date
Sx - bilateral, pressing/tightening, mild to mod, not aggravated by activity
Only 1 of following: photo, phonophob, N
No severe N/V
Imaging: usually
Txt: chronic pain management
59
Migraine location, characteristics, pt appearance, duration, assoc sx
- unilateral, bifrontal, global 30%
- gradual onset, crescend, pulsating, mod-sev, worse w/ activity
- rest, dark, quiet room
- 4-72 hr
- N/V/photo/phonophob/aura
60
TTH location, characteristics, pt appearance, duration, assoc sx
- Bilateral
- pressure, tightness, waxes and wanes
- Active or resting
- variable duration
- no assoc sx
61
Cluster HA location, characteristics, pt appearance, duration, assoc sx
- unilateral, around eye/temple
- rapid onset, crescendo w/i minutes, deep, continuous, excruciating pain
- active pt
- 30m-3h
- Sx - ipsilateral lacrimation/redness, stuff nose, rhinorrhea, pallow, sweating, Horner's syndrome, focal neuro sx rare, sensitivity to ETOH
62
HA redflags
fever, stiff neck, sudden severe HA (onset and terrible w/i 1 sec), worst HA of life, new onset HA >50y, abnormal neuro, hx head trauma w/i 1 wk, HIV+ or risk, Hx cancer, increasing severity or changed character
63
IHS secondary headache classifications
head/neck trauma, cranial vascular d/o, non-vascular intracranial d/o, substance or withdrawal, infection, homeostasis disruption, cranium, neck, eyes, ears, nose, sinus, teeth, mouth, facial d/o, psych d/o
64
Temporal arteritis/giant cell arteritis Sx
Person > 50 w/ piercing, throbbing, localized HA
scalp tenderness, +/- temporal tenderness, low grade fever, anorexia, weight loss, malaise, jaw claudication, +/- PMR sx, visual sx (ask abt PMR sx - often assoc)
65
Temporal Arteritis Tests
ESR >50 (or CRP) - can have near normal ESR, still tret
| Temporal artery biopsy - gold standard
66
Temporal Arteritis Treatment
60 mg prednisone daily - start ASAP and stop if biopsy -
67
Headache relevant PMH
HTN, HIV, thyroid, ca, depression, head trauma, dental work, recent medical procedures
68
Diagnostics needed: >50 new onset HA
ESR, CT
69
Diagnostics needed: young women, migraine criteria, normal neuro
no imaging
check TSH
if triptan helps --> basically diagnostic
70
Diagnostics needed: young heroin addict, new onset
CT + LP - brain abscess risk
71
Diagnostics needed: hx cancer
CT - mets
72
Diagnostics needed: HA, fever, rash
LP - meningitis, lymes
73
Diagnostics needed: elderly, fell
CT w/ neck - subdural, fx
74
Diagnostics needed: aspirin, coumadin
CT - brain bleed
75
Diagnostics needed: new HA, papilledema
CT
76
Diagnostics needed: kids, concerning HA
MRI instead b/c radiation concern
77
Tension type HA treatment
acetaminophen, NSAIDS, fioricent (habit forming, rebound HAs, dizzy, sedation), muscle relaxants (soma, skelaxin, flexeril)
prophylactic if freq occurrence
78
Cluster HA treatment
```
avoid triggers - etoh, tobacco
O2 - NRB 12L
high dose NSAIDS 1000mg-1200mg motrin
ergotamines, triptans
prophylactic if freq occurrence
```
79
Migraine HA treatment - nonpharm
HA diary, regulr sleep, exercise, eating patterns, avoid triggers, stress management, massage, DC offending agents (OCP, CCB)
80
Migraine HA treatment - pharm
excedrin migrain - asa, acetaminophen, caffeine
| ergotamines, triptans, narcotics (avoid), glucocorticoids (can break bad HA cycle), antiemetics, metoclopromide
81
Migraine Prophylactic treatment
>2HA/wk, interfere w/ life, abortive txt issues
BB - 20mg inderal BID, up to 40mg
CCB - 20mg verapamil qHS
TCA - 25 mg amitriptyline qHS
Antiseizure - valproate, topiramate - neurologist
82
Common HA triggers
food, hormonal, sensory, stress, environment changes, schedule changes
83
Ergotamine - cafergot, migranal
Oral, sublingual, infectable, nasal spray
MOA - vasoconstriction
CI - pregnancy, heart dx, PVD, can cause vasospasm: raynauds, periph vasc ischemia
NOT w/ ketoconazole, macrolides - periph ischemia
24 hours APART FROM TRIPTANS
84
Triptans - 5HT serotonin receptor agonist
zomig, maxalt - short T 1/2
amerge, frova - long T 1/2
imitrex, relpax, axert -- diff meds work well for diff ppl
SC, nasal, tabs
MOA - intracranial vasoconstriction, reduce edema, decrease inflammatory peptide influx, block trigeminal complex pain transmission
CI - pregnancy, CAD, angina
SE - facial flushing, tingling of skin, tightness around chest/neck
serotonin syndrome - decreased dose if w SSRI - confusion, sweating, diarrhea, tremor, high BP
24 hours APART FROM ERGOTAMINES
85
Focal/partial seizure
Starting in one hemisphere
86
simple seizure
consciousness maintained
87
Generalized seizure
starts in both hemipheres, LOC, no aura, +/-convulsions
88
Types of generalized seizures
```
absence - LOC, starring spells
atypical absence - LOC, change of tonie, automatisms
myoclonic - jerking, flexing/unflexing
tonic - stiffening/extended
atonic - drop attacks
```
89
Idiopathic epilepsy
underlying genetic cause, start in infant/early childhood
| normal development, normal neuro exam, no neuro d/o
90
Idiopathic epilepsy types
chronic absence - 5-10yrs, outgrows
benign rolandic - 5-15yrs, nocturnal sx
benign occipital - confused w/ migraines, EEG finding
juvenile myoclonic - starts at puberty
91
Paroxysmal seizure - test to run
labs - glucose, Mg, Ca, CBC, urine tox
EEG
LP - not necessary w/ 1st nonfebrile, only if concern
MRI - structural abnormalities, tumors, vascular abn
92
Epilepsy Dx in Child
>=2 unprovoked seizures or 1 unprovoked w abn EEG
93
Epilepsy Treatment Protocol
goal: monotherapy
| Before starting: CBC, platelets, LFTs, amylase/lipase - monitor blood work q 3mo
94
Epilepsy Narrow Spectrum Meds
dilantin, phenobarb, tegretol, trileptal, gabapentin, vimpat, sabril
cover partial, focal, absence, myoclonic seizures
95
Epilepsy Broad Spectrum Meds
depakote, lamictal, topamax, zonegran, keppra, klonopin, banzel
covers wide variety of seizures - plus absence/myoclonic
96
Meds for localized and complex partial seizures
Tegretol, depakote, topamax, dilantin, lamictil, tripleptil, keppra
97
Generalized seizures meds - absence
ethosuximide, valproic acid
98
Generalized seizures meds - primary generalized tonic clonic
topamax, trileptal
99
Febrile seizures in children
Seizure w/ febrile illness, >1 mo, <6yrs
| No CNS infector or e- imbalances. No previous afebrile sz
100
Complex febrile seizure
>10-15min, focal, multiple with same illness
101
Simple febrile seizure
<10min, non-focal
102
Febrile sx risk factors
family hx febrile sz 1st and 2nd relative, developmental delay, neonatal nursery stay >30 days, daycare attendance
Risk NOT related to temp #
103
Simple Febrile Sz LP decision
YES LP if 5
| NO LP - >18mo w/ hx and PE not suspicious
104
Complex Febrile Sx LP decision
YES LP - prolonged duration, focal
| MAYBE LP - multiple seizures in same illness
105
Risk for meningitis w/ febrile sz
focal or prolonged sz, abnormal findings on neuro or PE, seizure later in illness
106
AAP Guidelines Febrile Seizure Diagnostics
LP - strongly recommended w/ meningeal signs (not if fever source known)
EEG - not routine if neuro healthy
E-, Ca, phos, mg, glucose, cbc - not routine
neuroimaging - not recommended for routine eval simple febrile
107
Febrile Status Epilepticus
febrile seizure >30 min
108
Febrile Sz Prevention
NONE recommended
Diazepam/diastat rectally at start of seizure
Diazepam/diastat PO or rectally w/ febrile illness, SE higher than benefit
antipyretic ineffective
109
Concussion S+S
confusion, amnesia, HA, V, dizziness, (LOC uncommon)
| post: cognitively slow, emotionally irritable, drowsy
110
Best predictor of protracted recovery
Dizziness post concussion
111
Treatment
cognitive and physical rest - neuropsych testing
112
Pedi Headaches Presentation
irritable, N, V, lack of appetite, fatigue
113
Pedi Headache management
HA diary (diet and social), tylenol, ibuprofen, Mg vitamin
114
Age of closure of epiphyseal growth plate, hormone responsible
20yrs, estrogen/testosterone
115
Limp from Infection
acute, localized, severe (no weight bearing), fever, high WBC, ESR, CRP
116
Limp from Inflammation
chronic, insidious onset, rash, involve other joints, usually weight bearing (except transient synovitis)
117
Limp for Orthopedic Problem
localized pain to hip, can be referred to thigh/knee, acute or insidious onset, pain increase with activity, decreased with rest, systemic sx absent, ESR/CRP normal
118
Limp for Neoplasm
worse at night, unrelated to activity, may have systemic sx, labs abnormal (anemia, leukopenia, thrombocytopenia)
119
anterior knee pain, increased gradually, pain worse w direct trauma, squatting, climbing stairs, uphill, relieved by rest
Osgood Schlatter
120
Osgood Schlatter risks
age 9-14, rapid growth spurt, active in sports, boys
121
Osgood Schlatter treatment
Pain control, reduce swelling - ice, NSAIDs for 3-4d, protective pad over tubercle
Don't need to avoid sport, no f/u needed
Resolve when plate ossifies, 18-20y
122
Displacement of capital femoral epiphysis from femoral neck through epiphyseal plate
Slipped capital femoral epiphysis
123
```
hip pain, nonradiating, dull aching in hip, groin, thigh, knee, no hx trauma, pain may increase w activity or may be acute, chronic, intermittent
antalgic gait (limp, fixed knee, walk on side of foot)
```
Slipped capital femoral epiphysis
124
Slipped capital femoral epiphysis risks
teens and preteens, obese
125
Slipped capital femoral epiphysis Exam finding
decreased IR, abd, flexion
126
Slipped capital femoral epiphysis Tests
MRI (Xray preferred initial diagnostic) --> ortho
127
Most common nontraumatic hip pain in children
transient synovitis
128
pain and LROM, antalgic gait, hip in abduction, external rotation, no precipitant and resolves gradually, no fever, nontoxic appearing, WBC<2, unilateral or bilateral joint effusion
transient synovitis
129
hip pain, fever
think septic arthritis
130
transient synovitis treatment
NSAIDS and return to full activity as tolerated
| Full recovery 1-4wks
131
Can have prior symptoms of V, D, cold/runny nose, URI, pharyngitis, bronchitis, AOM in 1/2 of case
transient synovitis
132
transient synovitis risks
age 3-8, M>F, fall/winter season, afebrile, well appearing
133
Scoliosis criteria
>10 degree curvature laterally
134
Types of scoliosis
- -neuromuscular - 2nd to MS problem - CP, neurofibromatosis, marfans
- -congenital - 2nd to congenital abn - hemivertebra - manifests BEFORE adolescence
- -idiopathic -most common, no known etiology
135
Scoliosis tests
Adams forward bend test, scoliometer/inclinometer
136
Scoliosis management
10-20d --> exercises to improve posture/muscle/strength
20-40d --> bracing, boston brace, 23 hr/day
40-50d --> spinal fusion surgery
137
Overuse syndrome
microtrauma of tissue
138
Febrile infant 100.4
septic work up to r/o serious bacterial infection --> ER
139
bacteremia S+S
irritability, poor feeding, change in sleep pattern, often no localized sx
140
Toxic appearing infant Sx
irritabile, inconsolable, poor perfusion, poor tone, lethargy
141
Septic workup, <3mo
Blood culture, CBC w diff, U/A + culture
CSF - count and diff, culture, gram stain, glucose, protein
CXR if respiratory sx
Stool culture if D
142
Febrile infant <3mo, w/ negative septic work up Txt
IM ceftriaxone, f/u for 2nd dose, await culture
143
Child 3-36 mo, likely pathogen
S pneumo, S aureus, N menigitidis, H influenza
144
Work up - febrile infant, 12mo-36mo, non toxic appearing
No septic work up required
145
work up - child w fever as presenting sx
CBC w diff, U/A, throat culture, blood culture (maybe CXR, LP)
146
work up - child w fever, abd pain, n/v
CBC w diff, U/A + culture, abd CT scan
147
Bacterial infection lab changes
increase neutrophils and bands -- left shift
148
WBC in allergies, asthma
basophils (histamine release)
eosinophils (parasites/drug sensitivity)
No response to bacterial/viral infection
149
WBC that increases during recovery from illness
monocytes - increase in pneumonia, mono, varicella
150
Viral infection lab changes
increase in lymphocytes and monocytes -- right shift
| also seen in tissue breakdown, burns, allergies, lymphocytic leukemia
151
Reasons high milk consumption can lead to anemia
cow protein causes microscopic blood loss in stool, full on milk and not eating enough iron, bioavailable iron in milk is low
152
Normal WBC
5000-10000
153
Normal RBC
4.5-5.5
154
Normal neutrophils
54-62%
155
Normal bands
3-5%
156
Normal HGB
11.5-15.5
157
Normal HCT
35-45%
158
Normal platelets
150-400K
159
Normal MCV
80-100 (77-95)
160
Normal MCHC
31-37%
161
Normal Retic count
0.5-1.5
162
Normal RDW
11.5-14.5
163
Normal Eosinophils
1-3%
164
Normal Basophils
0-0.75%
165
Normal lymphocytes
25-33%
166
Normal monocytes
3-7%
167
Test to Dx UTI
C+S - >100 in clean catch, >50 in cath
168
Most specific U/A result for UTI
nitrites
169
diet high in citrus fruits/veggies make urine..
alkaline
170
diet high in meat, cranberry juice make urine...
acidic
171
Parkinsons risks
men, 55-65
172
Parkinson cardinal features
akinesia, bradykinesia, cogwheel rigidity, unstable posture, resting tremor
173
Typical 1st Sx Parkinsons
resting tremor - pill rolling - usually do well for 10 yrs if major sx
(late sx in parkinsonian like sx but not parkinsons)
174
Other parkinsons Sx
freezing of gait, micrographia, low pitched indistinct speech, decreased blinking, reduced facial expression, seborrhea, depression anxiety, memory loss, impaired judgment, poor planning, sleep issues b/c of bradykinesia, sexual/urinary/bowel dysfunction
175
Parkinsons cause of death
choking, falls, pneumonia
176
Parkinsons cause
neurodegen of dopamine containing neurons in substantia negra
dopamine from basal ganglia controls movement
symptoms when 50-80% loss of dopamine
177
Parkinsons diagnostic tests
None, imaging to r/o other conditions - PET, SPECT, CT
-- imaging if early balance/gait d/o's, not responsive to levodopa, imaging shows structural involvement other than basal ganglia
178
Surgical parkinsons tx
thalatomy, pallidotomy, deep brain stimulation
179
Parkinsons tx pharm
respond well for 3-5 years then end of dose effects, dyskinesthias
help sx, doesn't stop dx progression
180
Dopamine agonist - mirapex, requip
parkinsons - 1st drug prescribed, activates brain dopamine receptors
181
Dopamine precursor, levodopa
parkinsons - 2nd txt - MAINSTAY OF TXT - can lead to drug induced dyskinesias, impaired judgment
182
Parkinsons meds
dopamine agonist, dopamine precursor, decarboxylase inh, catechol methyltransferase inh, copamine releaser, dopamine receptor blocker, type B MAO, anticholinergics
183
decarboxylase inhibitor, carbidopa
parkinsons - given w/ levodopa, prevents metabolism of levodopa - reduces SE of N,V of levodopa
184
catechol-o-methyltransferase inhibitor - entacapone/comtan
parkinsons - other site in pathway, well tolerated, often given w/ sinemet
185
dopamine releaser, amantadine
parkinsons - helps release dopamine more effectively, brief effect
186
dopamine receptor blocker - domperidone
| Type B MAO inh - seligiline, rasagiline
parkinsons - helps dopamine helps dopamine stay active longer
187
anticholinergics in parkinsons
treat tremor, SE memory impairment, blurred vision, urinary difficulty
188
R/O pre dementia dx
B12, TSH, urine, e-, CBC, meds, CXR, substance abuse, depression
189
Dementia risks
age, family hx, head injury, heart dx, hereditary(APOE-e4)
190
Praxis
Ability to do previously learned task
191
Dementia diagnostics
CBC, TSH, anemia, CMP, urine, glucose, RPR/HIV, tox screen, ETOH, drugs, imaging studies (head CT w/o contrast), neuropsych testing
192
DSM Dx Dementia
decline in memory and decline in at least one of the following (decline must be severe enough to interfere with daily life)
- coherent speech, understanding written/spoken word
- recognition/ID objects
- motor activities
- think abstractly, sound judgements, carry out tasks
193
Frontotemporal/Pick's Dementia presentation
behavioral issues, personality changes, language impairment
194
Dementia w/ lewy body presentation
similar to alz - fluctuation presentation, visual hallucinations, muscle rigidity, myoclonic jerks, tremors common
195
Normal pressure hydrocephalus dementia presentation
enlarged ventricles on CT scan - dips, drips, dementia
196
Vascular dementia presentation and risks
abrupt onset, stepwise deterioration, executive dysfunction, gait changes
risks - HTN, smoking, high cholesterol, PVD, CVD, DM
197
Alzheimers pathophys
amyloid plaques and neurofibrillary tangles - brain atrophy nin cerebral cortex
198
Mild Cognitive Impairment Alzheimers - MMSE + Sx
MMSE 26-30 - memory loss, executive dysfunction, no functional impairment
199
Early, Mild Impairment Alzheimers - MMSE + Sx
MMSE 21-25, 1-3 years from onset of dx
Disoriented to date, difficulty w/ naming, figure copying, finances, recent recall, insight, mood change, social withdrawal, irritable
200
Middle, Moderate Impairment Alzheimers - MMSE + Sx
MMSE 11-20, lasts 2-8 years
Disoriented date, place, aphasia, problems w comprehension, calculation, learning, grooming, lost in familiar places, NO cooking/shopping/banking, restless, depressed, delusions, agitated, aggressive
201
Severe Impairment Alzheimers - MMSE + Sx
MMSE 0-10, lasts 6-12 years
Remote memory gone, unintelligible verbal output, unable to copy/write, no grooming/dressing, incontinent, motor/verbal agitation
202
Vascular and mixed dementia txt
stroke prophylaxis
203
Dementia txt guidelines
treat comorbidities, avoid ACH (benzo, oxybut, TCA, clozapine), limit psychotropic PRN use
204
Dementia pharmacologic use
cholinesterase inhibitors - Aricept
NMDA - namenda
treat behaviors - depression, anx, agitation, hallucinations, paranoia
205
Menopause
12 mo w/o menses, 40, estradiol<35
| OR removal of ovaries (menopause w/i 6 wks)
206
Perimenopause Sx
irregular periods/menorrhagia, PMS sx, vaginal dryness, urinary incontinence, mood swings, sexual dysfunction, decreased fertility
207
Perimenopause length
2-5 years, age 5
208
Premature menopause risk
smoking, type 1 DM, increased altitude, undernourished, vegetarian, cancer patient, hysterectomy w preserved ovaries
209
Vaginal dryness txt
replens, KY, lubrin, vit E 100-600mg/day, evening primrose 2-4caps/day
210
Osteoporosis prevention
diet, exercise, ca 1000-1500mg/day, vit d 400-800mg/day
211
Mood irritability assoc w/ perimenopause txt
SSRI (prozac 20mg), effexor
212
hot flashes and night sweats txt
gabapentin
213
Irregular bleeding txt
1. Endometrial biopsy, US if suspect fibroids
| 2. Stabilize hormones - OCP (COC< POP, LNG-IUD, cycling progesterone), cryoablation
214
How to test if someone on OCPs had menopause
Test FSH on day 7 of placebo week - >40 --> menopause
215
benefits of hormonal contraception, cyclic progestin, LNG-IUD, surgery, and lifestyle mods on perimenopause sx
Hormonal contraception - symptom relief, menses control, contraception, uterine ca prev
Cyclic progestin - some uterine ca prevention
LNG-IUD - menses control, contraception, uterine ca prev
Surgery - menses control, contraception, uterine ca prev
Lifestyle mods - symptom relief only
216
How to treat menopause sx post hysterectomy
SSRI
217
Menopause age
age 51
218
premature menopause age
<50
219
early menopause age
<45
220
late menopause age
>55
221
Long term effects of estrogen decline
vaginal dryness and atrophy, forgetfulness, poor concentration, osteoporosis, atherosclerosis, decreased skin turgor, wrinkling, dry mucus membranes, libido loss from decreased testosterone
222
Irregular bleeding diagnostics
Biopsy, CBC, TSH, vaginal US
223
When to check hormone levels
6 mo w/o bleeding, s/p hysterectomy w ovaries intact and getting sx, using OCPs and unsure
FSH OR estradiol at menopause level but the other not --> perimenopause
224
Hormone replacement therapy benefits
decrease vasomotor sx, improve QOL, improve urogenital sx, decrease osteoporosis risk, decrease CV risk, may protect against dementia
225
Hormone replacement therapy indications
uncontrolled vasomotor sx, improve urogenital sx (topical therapy best), prevent osteoporosis, if early menopause, given until age 51
226
Hormone replacement therapy contraindications
undiagnosed vaginal bleeding, known pregnancy, vascular thromboembolic events, active liver dx, breast/reproductive ca
227
Hormone replacement therapy precautions
type 1 DM, active gallbladder dx, >1ppd smoker, obesity, FMH breast ca, fibroid uterus, PVD hx, migraines, elevated trigs
228
Hormone replacement therapy candidates
newly menopausal w/i 5 yr, good health, no risk factors for heart dx or breast ca, non smoker, non obese, normal blood sugar and pressure, mod to severe vasomotor sx --can't function
229
Hormone replacement therapy risks
clots, gall bladder dx, breast ca (10 risk), increased cardiac events in 1st year if prior heart dx
230
ACOG Hormone replacement therapy guidelines
short term for vasomotor sx 1-4yr
estrogen alone up to 7 yr
prog/est up to 5 yr
231
Estrogen replacement therapy txt
Give 3 mo then re-evaluate
Only if no uterus or builds up uterine lining
premarin, menest, transdermal (avoids liver effects, less effect on trigs/lipids - never near breast tissue), estradiol
232
Combined estrogen/progesterone use
Cyclic - take first 10-15 days of month w/ estrogen to bring on menses
Continuous - no menses, may have BTB <6mo
Prempro, premphase, femHRT, activella, ortho-prefest, combipatch, provera/prometrium(not w/ peanuts, prog only)
233
Progesterone SE
breast tenderness, irritability, weight gain, fluid retention - usually goes away w/ time
234
HRT SE
BTB, withdrawal bleed, increased fibroids, allergic rxn, virilization w testosterone products
235
Menopausal sleep Txt nonpharm
sleep hygiene - cool temp, low alcohol and caffeine, dark, quiet, no night exercise, avoid naps, regular sleep/wake cycle
236
Menopausal sleep Txt pharm
Melatonin
Gabapentin - 300mg 1-2 hr before bed, up to 600mg
Lunesta - long term use okay - drowsiness, impairment in AM
Ambien - drowsiness, impairment in AM - 5mg, ER ok long term
237
Vasomotor Sx Txt pharm
Effexor, clonidine, SSRH low dose
| Gabapentin - 600mg qHS or 300 TID depending on timing of sx
238
Vasomotor Sx Txt OTC
estroven (soy+cohosh), black cohosh, soy, vitamin E
| no evidence - dong quai, acupuncture, yoga, evening primrose, ginseng, kava, red clover, flaxseed
239
Vulvovaginal Sx Txt
Vaginal creams - dont need opposing progesterone
premarin - daily for 2 wk then BIW - externally too
estring ring - 90 days
vagifem cap, PO osphena
can still use in breast/GYN ca
240
Osteoporosis risks
hx fx, age>50, low E2, Women, caucasian, FMH, weight<20% bone mass in 5-7 yrs post menopause
241
Osteoporosis screening
>=65 or >=60 with increased risk
242
Normal Dexa Screen - Tscore, rescreen and txt
-1 and higher, retest 10-15yr
| Ca, vit D, healthy diet, exercise
243
Osteopenic Dexa Screen - Tscore, rescreen and txt
-1.1 to -2.4, retest 2-5 years
Ca, vit D, healthy diet, exercise
Fosamax 35 q week
244
Osteoporosis Dexa Screen - Tscore, rescreen and txt
-2.5 and lower, retest 1 yr after txt initiation
Ca, vit D, healthy diet, exercise
Bisphosphonates, serm/raloxifene/evista, estrogen, calcitonin, injectables
245
Alendronate/Fosamax risks
spontaneous femur fx - consider 6 mo drug holiday q5y
| osteonecrosis of jaw - regular dental, maybe antbx b4
246
Bisphosphonates contraindications
hypocalcemia, esophageal dx, inability to follow dosing
247
Alendronate/Fosamax instruction
1st thing in AM, empty stomach, upright 30 min post
| daily or weekly
248
Ibandronate/Boniva instructions
1st thing in AM, empty stomach, upright 60 min post
If miss dose and next dose >7day away, take missed
If miss dose and next dose <7day away, skip missed
daily, monthly, 4x/yr
249
Bisphosphonates
fosamax, boniva, actonel, atelvia, reclast (q2yr)
250
SERM/raloxifene/exista action, CI, SE
action - decrease bone turnover and bone resorption - increases bone density, acts like estrogen, + effect on cholesterol, no risk breast/uterus
CI - thromboembolic dx (most risky 1st 4 mo and w/ immobilization - D/C before surgery)
SE - leg cramps, hot flashes
251
Calcitonin/fortical/miacalcin - oral/transderm - action, CI, SE
prevents further bone loss, suppresses osteoclasts, wont build back
CI - allergy to med or salmon
SE - rhinitis, arthralgias, back pain, HA, epistaxis
252
<6 mo, exhaustion medical txt, care goes where pt is
Hospice Care
253
anytime/stage of illness, no time restriction, palliative team setting, may still have aggressive txt
Palliative Care
254
Relief of suffering, control of sx, restoration to function capacity
Palliative Care
255
Hospice criteria in HF, COPD
HF stage 4, COPD Sx at rest
| Alz >7 - speech limited to 6 intelligble words, incontinence
256
Key signs of approaching death
poor nutrition, weight loss, low albumin <18, decreased mid arm circumference, dysphagia
257
Neer's sign
Impingement syndrome or rotator cuff tear
| depress scapula w one hand, elevate arm above head with other
258
Hawkins sign
Impingement syndrome or rotator cuff tear
| elevate patients shoulder to 90, flex elbow to 90, place forearm in neutral rotation, internally rotate humerus
259
Cross body adduction
Arthritis of AC joint
| Shoulder at 90 degrees, adducted laterally across body
260
Apprehension sign
Anterior instability if apprehension
| Arm 90 abducted to side, max external rotation
261
Sulcus sign
Inferior shoulder laxity
| Arm relaxed at side, pull arm downward
262
Jerk test
Posterior instability
Shoulder and elbow 90 degree flexion laterally in front of body, adduct arm across body horizontally while pushing humerus back into joint
263
Loss of active and passive shoulder motion, up to 45 degrees at most
frozen shoulder
264
frozen shoulder causes
autoimmune dx, injury, immobility, bursitis
265
Shoulder imaging
Xray - r/o fx, loose bodies, tumor
| MRI - view capsule, r/o rotator cuff tear
266
Frozen shoulder tx
NSAIDS, moist heat, injections, PT
| surgical - stretch or release contracted joint capsule w/ manipulation/arthroscopy
267
Gradual onset of pain exacerbated by overhead activities, can move arm but pain in last 20-30 d of abduction, downsloped acromium, bursitis, pain w/ reaching up and across
Impingement syndrome (mini frozen shoulder)
268
Impingement syndrome PE
tenderness, crepitus, pain against resistance, +Neer + Hawkins
269
Impingement syndrome txt
NSAIDS, moist heat, injections, PT
| surgical - subacromial decompression, anterior acromioplasty
270
Rotator cuff
4 muscles and tendons from scapula/thoracic spine to shoulder
271
Cause of rotator cuff tear
Overuse, repetitite overhead motion, trauma, chronic impingement syndrome, age related degen
272
Pain, weakness, catching and grating when lifting arm over head
rotator cuff tear
partial - can lift arm but weakness
total - cant lift arm, can passively unless from impingement
273
Rotator cuff tear PE
sunken shoulder, active ROM limited, shrug, cant hold arm elevated
empty can test - shoulder 90, thumb down, push up against resistance - pain, weakness
+Neer, Hawkins
274
Rotator cuff tear treatment
non surgical - rest, limit overhead movement, NSAIDS, injections, PT
surgical - debridement/repair
275
Biceps tendonitis
shoulder 90 degrees, thumb up - push up against resistance
276
sudden onset, mimics septic arthritis, no ever, can be coming on for days but pain is acute, crescendos, can't move shoulder b/c of guarding
Calcific bursitis/tendonitis
277
Calcific bursitis/tendonitis txt
cortisone injection
278
Valgus stress test
push on lateral aspect, tests stability of medial ligament
MCL in knee when 25degree flexed, more than MCL if also in straight leg
ulnar collateral in elbow (20degree flexion in test)
279
Varus stress test
push on medial aspect, tests stability of lateral ligament
| LCL in knee when 25 degree flexed, more than LCL if also in straight leg
280
radial head subluxation, pain, avoids usage of elbow, hold arm close to body w forearm and thumb in pronation
Nurse maid elbow
281
Nurse maid elbow txt
Reduction - pressure at radial head, elbow 90d flexed, grasp wrist and supinate wrist
Ice, NSAIDS, splint/brace
282
dull ache, lose strength in arm, unable to pronate or supinate forearm, unable to lift items or bend elbow, tenderness, bulge, bruise, snap
Biceps tendon rupture
proximal - pain and bruising proximally, difficulty moving shoulder (2 proximal tendons)
distal - pain/bruising in antecubital fossa
283
Biceps tendon rupture PE
complete - muscle bulge w/ flexion resistance, no supination
| partial - no visible defect, pain, weakness w/ flexion/supin
284
Biceps tendon rupture txt
nonsurgical - rest, ice, nsaids, splinting/sling for comfort, PT
surgical - repair, more important if distal since only 1 tendon
285
pain in center of bicep,muscle indented
biceps muscle tear
286
golfers/bowlers elbow
medial epicondyle
287
tennis elbow
lateral epicondyle
288
pain with wrist flexion, tenderness of medial epicondyle, numbness down inner arm
medial epicondylitis - golfers/bowlers
289
pain with wrist extension, tenderness of lateral epicondyle, down arm, across forearm, pain generally distal, not proximal to elbow
lateral epicondylitis - tennis
290
Biceps tendon rupture imaging
xray - r/o avulsion fx
| mri - r/o rotator cuff if proximal, confirm dx
291
Epicondylitis imaging
Xray - r/o arthritis, loose bodies, fx
| MRI - confirm dx
292
Epicondylitis treatment
nonsurgical - modify/eliminate activity, nsaids, ice, injections, brace, PT if no improvement
surgical debride
293
swelling, pain, limited ROM of elbow
Olecranon bursitis
294
Olecranon bursitis cause
trauma, prolonged pressure, RA, infection or gout (fever, red, warm?)
295
Olecranon bursitis imaging
r/o foreign body, bone spur, fx
296
Olecranon bursitis txt
nsaids, elbow pads, activity mod, antbx
aspiration for dx purposes only
surgical - remove bursa
297
finkelsteins test
de Quervain tenosynovitis
| fist w thumb inside, ulnar deviation
298
phalen maneuver
carpal tunnel - median nerve
| wrist 90d with gravity, numbness or tingling w/i 60 seconds
299
froment sign
pt pinches paper with thumb and index which it is being pulled away
300
carpal tunnel causes
repetitive motion, hormonal changes, medical conditions
301
numbness, tingling, pain in hand and or finger, pain in middle of night, common in pregnancy, 1st-3rd finger, sometimes 4th, never 5th
carpal tunnel syndrome
302
carpal tunnel tests
phalen, tinnel
303
carpal tunnel imaging
EMG - evaluate nerve function w muscle contractions
| xray - r/o fx if limited movement
304
carpal tunnel txt
splint/brace (1st only at night), nsaids, injection, changing patterns
surgical - increase tunnel size, 10% recurrence, esp if smoker
305
fall onto outstretched hand, pain, tenderness to thumb side of wrist, swelling to back and side of wrist, unable to grip/move thumb
scaphoid fracture
306
scaphoid fx tests
snuffbox tenderness, decrease motion, decrease grip strength, assess median, ulnar, radial nerve function
307
scaphoid fx imaging
Xray - r/o fx - oblique view, scaphoid series, carpal bone series if still pain 2 weeks later
MRI/CT - r/o fx if not visible on xray
308
scaphoid fx txt
casting/thumb spice, weight bearing protection
| ORIF
309
sudden impact to finger tip, pain, swelling, deformity, limited motion
jammed finger, mallet finger, sprain, strain, dislocation or fx of joint
310
jammed finger tests and imaging
joint stability, froments signs
| xray - r/o fx/dislocation
311
fracture of 5th metacarpal distal metaphysis
| pain, tenderness, deformity, decreased ROM
boxer fracture
312
boxer fx txt
splint in 10-15 degree angulation, protected weight bearing
| ORIF if fingers dont bend down properly - ASAP appt ortho
313
trendelenberg sign
hips stay level when pt standing on one leg
314
FABER test
flexion, abduction, external rotation test - sacroiliac or hip indication
315
Slipped capital femoral head
walk w/ leg externally rotated, decrease abduction, extension, extremity shorter
surgery for percutaneous pinning
316
pain, tenderness over greater trochanter, pain may radiate to knee or ankle but not to foot or butt, worsens with rising from seated position
trochanteric bursitis
317
Trochanteric bursitis causes
Laying on side, old ppl, trauma
318
Trochanteric bursitis PE
point tenderness, pain w/ hip abduction, warmth, pain worse w/ trendelenberg
319
Trochanteric bursitis txt
Nsaids, activity mod, short term assistive device use, injection
surgery - irrigation, debridement, bursa removal
320
Groin pull sx
pain, ecchymosis, swelling, burning, stiffness, weak - tearing of adductor muscle
321
Groin pull tests
inability to adduct, abnormal gait, tenderness
322
Groin pull imaging
MRI to r/o complete tear
323
Groin pull txt
RICE, NSAIDS, protective weight bearing, stretching
| repair if complete tear
324
McMurray Test
medial meniscus - flex knee, externally rotate, extend knee
lateral meniscus - flex knee, internally rotate, extend knee
pain/click - + sign
325
Lachman test
ACL tear
| knee flexed 25deg, pull up on calf, push down on thigh
326
Knee anterior draw test and posterior draw test
anterior - ACL
| posterior - PCL
327
tear from rotational or hyperextension force on knee
| pain, pop, unable to ambulate, swelling
ACL tear
| +lachman + anterior draw
328
tear or sprain from abduction force w/o rotation, assoc w meniscal tear
pain, ABLE to ambulate, swelling, LOCKING
MCL tear
| + valgus stress
329
Knee ligament imaging
Xray- r/o avulsion fx
| MRI - evaluation complete vs partial tear
330
Knee ligament tx
NSAIDS, ice, rest, protective weight bearing, immobilize, PT
| ligament repair
331
tear in fibrocartilaginous pad - twisting injury, degenerative
swelling, stiffness, LOCKING, catching, decrease motion w tightness sensation
+McMurray
332
patella dislocation sx
pain, swelling, deformity, mobility, patella slides laterally
333
Patella dislocation tests/imaging
Apprehension test, tracking assessment
| Xray - r/o fx, MRI - eval soft tissue/ligament/tendons
334
Patella dislocation txt
PT, bracing, change footwear, nsaids
| arthroscopy vs open
335
Ankle anterior drawer test
chronic ankle laxity and severe acute ankle sprains
pull foot anteriorly - not in acute sprain
clunk - ligament ruptured
336
Ankle varus stress
asymmetry or excessive motion - chronic laxity of calcneofibular ligament - not in acute sprain
337
Achilles tendon rupture cause
stop and go sports
338
Achilles tendon rupture sx
sudden, severe calf pain, swelling, difficulty bearing weight, cant plantar flex if total tear, can plantar flex but not w/ weight if partial tear
339
Achilles tendon rupture tests
palpable defect, +Thompson test (prone, foot at rest, squeeze calf, foot should move)
MRI to eval partial or complete
340
Achilles tendon rupture txt
casting, bracing in plantar flexion, protected weight bearing, PT
retracting and repairing tendon - casting 8-12wks
341
stretching of tearing of muscle, sudden stretch on actively contracted muscle
strain
342
strain sx
snap or tearing sensation, pain and swelling maybe only on day of injury, unable to contract muscle
343
stretching or tearing of a ligament, sudden trauma
sprain
344
sprain sx
pop or snap followed by pain, swelling, stiffness, difficulty bearing weight
pain w/ stretch
345
sprain/strain imaging
xray r/o fx, mri r/o complete tear
346
sprain/strain txt
rice, nsaids, immobile, weight bearing protection
| repair of complete tears
347
plantar fasciitis risks
older, overweight
348
heel pain, tenderness, pain intense when rising from resting position, standing, walking
plantar fasciitis
349
Foot imaging?
Always xray
350
plantar fasciitis tests
tight achilles, tenderness along fascii, +pain with passive dorsiflexion of toes
xray - r/o bone spur
351
plantar fasciitis txt
rest, ice, nsaids, orthotics, stretching, injections, PT
| surgical - BAD option, removal or heel spur, debridement of fascii
352
swelling, tenderness, ecchymosis of muscle, pain with active and passive stretch
muscle contusion
353
muscle contusion txt
monitor for compartment syndrome
| rice, nsaids, rom, stretching
354
muscle cramps
heat, stretch, hydrate, replenish nutrients
355
assoc w/ prolonged activity, pain in distal 3rd of medial tibia
shin splints
356
shin splints pathophys
inflammation of tibial periosteum 2nd to repetitive muscle contractions, small muscle tears
357
Shin splints tests
tenderness, pain w/ pressing on muscle to side of bone
358
Shin splints txt
r/o stress fx w/ xray
limit activity to soft surfaces, orthotics, decrease activity, NSAIDS, ice, massage, stretch
surgery rare - fasciotomy of tibial periosteum
359
stress fractures sx, tests, imaging
pain, tenderness on bone of shin
Xray, repeat in 3-4 wks
bonescan/mri/ct - confirm dx
360
stress fx txt
rest, activity mod, splint/brace, protective weight bearing, NO NSAIDS (TYLENOL ONLY)
ORIF
361
arthritis sx, tests
pain, swelling, decreased ROM
tenderness, pain, gait abn
xray r/o bone spur/fx, CT confirm dx
362
arthritis txt
nsaids, orthotics, inj, antbx, pt
| joint replacement, debridement, fusion
363
painful joint + fever
ER, when in doubt, blood work, elevated WBC--> ER
364
osteoarthritis signs
heberdens nodes of DIP joint, fusiform swelling of joints
365
RA signs
boutonniere nodes of PIP joint, ulnar deviation of MCP joints, swan neck deformity of fingers
366
Burners/stingers sx
electric schock/lightening bolt down arm into hand, burning, numbness, weakness
367
Burners/stingers tests
xray - r/o fx/sublux
mri - confirm injury, tear
EMG - neuro injury
368
Burners/stingers patho
injury to nerve roots exiting spinal cord, hit in neck, nerves get stretched, stinging down arm
369
Burners/stingers txt
no return to contact sports until resolved, PT
| surgery - repair of torn ligaments, fusion, discectomy
370
Whiplash patho
rapid flexion/ext - ligament and muscle injury
371
whiplash sx
pain from base of skull to cervicothoracic junction, occipital HAs, irritability, fatigue, sleep disturbances, difficulty concentrating, pain worst next day, NO numbness
372
Whiplash tests
tenderness, limited ROM
xray r/o fx/sublux
mri r/o disc herniation
373
whiplash txt
immobilization v mobilization, NSAIDS, ice/heat, massage, PT
| surgery - fusion, discectomy
374
Acute low back pain Sx
r/o fx v muscle v ligament
pain into butt, difficulty standing erect, change position frequently
tenderness, decreased forward flexion
375
Chronic low back pain
>3 mo
pain into butt and thighs, aggravated by activities, relieved by rest
tenderness, exhibit side or forward stance, may have +SLR, nonanatomic localization of sx
376
Back pain imaging
xray - r/o fx or sublux or DDD
MRI r/o infection, disc, ligament, muscle cord injury -- get if increasing sx or pain or numbness running down legs
Labs - r/o infection
377
acute back pain txt
bracing, nsaids (not if fx), ice/heat, injections, activity mod, PT
378
chronic back pain txt
referral to pain management, PT, TENS, counseling, flip table 5-10min daily
379
Avoidant/restrictive food intake d/o Criteria
lack of interest in food, sensory concern or aversion, failure to meet nutritional needs, labs off, not gaining weight
1. sign weight loss
2. significant nutrient deficiency
3. dependence on enteral or supplements
4 marked interference w/ psychosocial functioning - obsessed w/ not wanting to get sick/gag
NOT explained by food shortage, med condition, psych d/o, NO evidence of weight disturbance
380
Anorexia Nervosa
Must be underweight
381
Anorexia types
Restricting - fasting, excessive exercise - no binging in 3 mo
Binge-eating/purging - binging/purging in 3 mo - vomiting, laxatives, diuretics, enemas
382
AN severity levels
Mild BMI>17
Mod BMI 16-16.99
Severe BMI 15-15.99
Extreme BMI <15
383
AN Remission
partial - past dx AN previously met, LBW now not met
| full - past dx AN, no criteria currently met
384
AN health risks
heart failure, kidney failure, low protein stores, digestive problems, e- imbalances
385
Bulimia nervosa criteria
Recurrent episodes of binge eating at least 1x/wk for 3mo
1. eating large amt of food in 2hrs, 3k-5k cal
2. lack of control during eating episode
recurrent compensatory measures - vomiting, laxatives, diuretics, meds, fasting, exercise
386
Bulimia/purging severity levels
Mild 1-3bx/wk
Mod 4-7bx/wk
Severe 8-13bx/wk
Extreme 14+bx/wk
387
Bulimia health risks
e- imbalance, laxative dependence, dental problems, stomach rupture, irregular menses
388
Binge eating d/o criteria
recurrent binge eating w/ 3 + of:
eating more rapidly than normal
eating until over full
eating large amts when not hungry
eating alone bc embarrassment
feeling disgusted w self/depressed/guilty after
must interfere w/ life, NO purging, at least 1x/wk
389
Atypical anorexia
criteria for AN but normal weight
390
bulimia nervosa or binge eating d/o, low freq, limited duration
<3mo
391
Purging d/o
Purging to affect weight, no binging
392
Night eating syndrome
excessive consumption after awakening from sleep, after evening meal, aware and recall eating - causes pt distress, impaired functioning
393
Male eating d/o risks
low weight oriented sports - jockeys, wrestlers, runners, gymnasts
obsessive thoughts - all person thinks abt, can be lifting/protein etc
394
Comorbid eating and psych d/o
social iolation, depression, anxiety, OCD, rigid cognitive styles, lack of interest in sex, OCD, personality d/o, sexual abuse, substance abuse
395
Bulimia sx
chronically inflamed, sore throat, salivary glands in neck and jaw swollen, cheek/face puffy, parotid glands large/tender (can need antbx), tooth enamel off, tooth decay, GERD, intestinal problems, C, D, kidney problems if diuretics, severe dehydration
396
AN sx
no menses, osteopenia, osteoporosis, dry hair/skin/nails, pale, pasty skin, mild anemia, muscle wasting, lethargy, C, drop in BP, slow HR + RR, orthostatic vitals, bradyC if bad, internal body temp fails, always cold, night sweats (metabolism changing), depression, lethargy
397
Family based txt
Maudsley approach - family cooks, pt must eat
398
Labs in eating d/os
CBC, chem panel, Mg, phosphate, vit d, B12, iron, ferritin, folic acid, CPK, hycosamine, EKG (check b4 starting any meds)
399
Tx low WBC and alk phos in severe AN
add zinc 30mg BID after eating or V
400
ED nutritional tx
Weight gain 0.5-1kg inpatient, 0.5 kg outpatient (3500-7000 cal extra/wk)
if losing weight outpatient, go inpatient
401
Refeeding syndrome
metabolic disturbances - insulin, glucose, phosphate --> most common w/i 1st 4 days - hypophosphatemia
402
ED nutritional tx meds
simethicone PRN w/ meals, Gaviscon PRN, digestymes, probiotics for D
403
Vitamins for ED
multivit, calcium, d3, b12, iron, zinc, omega 3 fatty acid
404
SSRI in ED
only if normal weight or increased SI - good w OCD, bulimia (prozac, sertraline)
405
wellbutrin/buproprion black box warning
w/ eating disorders - increased seizure risk
406
drugs that prolong QT- TCA, macrolide, antipsychotics, antihistamines
NOT IN AN -- check EKG before starting always in others
407
Sleep in ED
low dose remeron, vistaril, trazodone
| melatonin (best w/ kids, NOT WITH SSRIs)
408
Med for purging/cutting
naltrexone
409
med for binge eating
topamax, 2nd line naltrexone
410
med for obsessive thoughts
zyprexa (10mg highest in ED), risperdal, seroquel, abilify
411
med for instrusive thoughts/anxiety rt eating
neurontin, vistaril, ativan (short term, 30 min b4 mealtime)
412
Depolarization/repolarization ions
Na+ fast moving, SA, atrial, bundle of HIS, purkinje
Ca++ slower moving AV node
K+ repolarization
413
PR interval length
0.12-0.2
414
QRS complex length
0.06-0.12 (>0.12 BBB)
415
QT interval length
men <.46
416
Rate 300 method
300, 150, 100, 75, 60, 50
300/#boxes between R waves
Count Rs on 6 second strip x10
417
Sinus tachycardia causes + tx
PE, hypoxia, hypovolemia, anemia, fever, pain, anxiety, hyperthyroid
correct underlying cause
418
Inappropriate sinus tachycardia
no apparent heart dx or cause - elevated rest HR or exaggerated exercise response - possibly autonomic or psychosomatic cause
1. refer to cardio 2. treat sx BB daily or when sx
419
Sinus arrhythmias
from SA node, rate variable w respiration, common in young healthy adults
420
wandering atrial pacemaker
irrefular rhythm, at least 3 diff P wave morphologies
421
Afib
no discernible P waves, Arate 350-450, stroke risk, multiple foci
422
Aflutter
saw tooth, Arate 250-350, multiple foci
423
Premature atrial beat PACs
irritable atrial focus, p wave early, often hides T wave or hidden in QRS
424
Supraventricular tachy
catch all
atrial tachy - AV node reentrant tachy - p waves look different
junctional tachy
425
wolff-parkinson white syndrome
Delta waves, gradual upsloping appears as short PR or prolongs QRS - premature depolarization
426
ventricular tachy
>90 bpm from ventricles, broad QRS - briefly stable then CPR/ACLS
427
ventricular fib
no heart pumping - CPR, ACLS, defib
428
1st degree AV block
prolonged PR interval, >0.2
429
2nd degree AV type 1 Wenkeback
PR interval lengthens until QRS drops
430
2nd degree AV type 2 Mobitz
normal, stable P-QRS interval then QRS dropped
431
3rd degree - complete heart block
AV dissociation, no connection between p's and qrs's
432
bundle branch block
QRS>0.12 - delay in polarization between ventricles - conjoined QRS's w/ 2 R waves
433
Depolarization direction
left and down -30 to 90
434
Left axis deviation
towards -60
| LVH, pregnancy, ascites, abd tumor, LBBB, hyperkalemia, inferior wall MI
435
Right axis deviation
towards +120
| RVH, RBBB, lateral wall MI, atrial septal defect
436
LVH cause
HTN, cardiomyopathy, aortic and mitral valve dx
437
Sokolov lyon index
LVH measure - depth of S wave in mm in V1 + height of R wave in V5 >35mm
438
EKG changes w/ ischemia
inverted T wave, reduced blood supply
439
EKG changes w/ injury
ST segment elevation - early,will return to baseline w time
440
EKG changes w/ necrosis
Q waves, first downward stroke in QRS complex
| significant Q wave is 1 square wide OR 1/3 R wave height
441
ST changes in lateral infarct
I + AVL
442
ST changes in anterior infarct
V1-V4
443
ST changes in inferior infarct
II, III, AVF
444
seborrheic derm causes
androgen driven in women, hereditary, worse w age, better w OCP/spirono, worse w HIV/DM, seizure meds
445
seb derm txt
emollients, keto 2% BID, desonide
446
nummular eczema risk
age 15-30, if older and never had b4, unlikely
447
atopic derm txt
emollients, topical steroids, prednisone, cyclosporine, UVB
448
Psoriasis risks
hereditary, autoimmune, onset early adult (not common in kids or older ppl), assoc w other autoimmune d/o, drug induced (BB), alcohol, stress, obesity, inflamm d/o
449
psoriatic arthritis
stiff, sore in morning, subsides w activity, distal fingers, hands, toes
450
psoriasis txt
```
emollients
topical steroids, tar, dovonex
NB UVB - remission possible
systemic - methotrexate, cyclosporine - always w/ arthritis
bio drugs - remicade, enbrel, humira
```
451
tinea corporis, cruris, pedis, capitis
ring worm - body, jock itch, feet, scalp
452
Tinea txt
topical clotrimazole
topical ketoconazole/econazole - broader spectrum
systemic terbinafine
systemic itraconaze - CYP
453
Candida txt
oral - nystatin S+S
perleche nystatin cream on side of mouth
vaginal - metro cream, fluconazole PO
body folds - nystatin cream
prevention - talc/cornstarch/nystatin powder, antibacterial soap
r/o inverse psoriasis if recurrent
454
Candida risk
DM, obesity, nutritional def, immune suppression
455
BCC, young people
internal malignancies, colon ca, renal cell ca, basal cell nevus sx
456
BCC spread
rarely metastatic, can be invasive if immunosuppressed or older
457
BCC txt
biopsy, cryo, efudex, aldara, photodynamic therapy, electrodessication/curettage, simple excision, mohs
458
SCC risk
immunosuppressed pts, renal pts (need annual skin check), light skinned, >50, poor sun habits
UV light, thermal injury, chemical, radiation, HPV, chronic inflamm condition (ulcer)
459
SCC location
skin, mucus membranes (HPV)
460
SCC spread
mets possible, r/t site and immune status of pt
461
Melanoma risk
light skin, UV radiation, blistering burns, indoor tanning 10x risk, more common with atypical nevi, 1st degree family hx, personal hx
poor prognosis in dark skin ppl bc found late
462
Melanoma txt
biopsy w complete excision w wide margins
staging via sentinel lymph node biopsy, labs, CT, PET
chemo/immunotherapy
463
Tinea capitis txt
fungal culture before start therapy
topical ketoconazole shampoo or cream x 2mo
kids - systemic griseofulvin 2-4 mo
adults - systemic terbinafine 2-4 mo
