COMPS:GULICK: Medical Screening for Adults Flashcards
(177 cards)
1
Q
System Review: MSK
Fractures
Types
A
GOOD PICTURE!!!!
2
Q
System Review: MSK
Fractures
Ottawa Ankle Rules
A
see pics
3
Q
System Review: MSK
Fx’s
Screening for Knee Fx’s
4 Decision Rules:
ALL GREAT FOR SCREENING!!! (HIGH Sn***)
A
- Pittsburgh Knee Rules*
- Weber & Colleagues Rules
- Ottawa Knee Rules*
- Fagan & Davies Rules
4
Q
System Review: MSK
Fx’s
Pittsburgh Knee Rules
A
-
Criteria:
- Inability to ambulate
- Fall or trauma
- <12 to >50
-
Stats:
- Sn=100%****
- Sp= 79%
5
Q
System Review: MSK
Fx’s
Ottawa Knee Rules
A
-
Criteria:
- >55yo
- Tenderness of Fib head OR patella
- Flexion <90*
- Inability to WB 4 steps
-
Stats:
- Sn=85-100%***
- Sp= 17-49%
6
Q
System Review: MSK
Osteoporosis
New medication→ Evenity
A
“Bone-building” medication
- Approved for high risk, postmeno women who have not responded to other tx’s
- Blocks Sclerostin→ PRO that stops bone from forming
- Monthly inj’s x 1yr
- 2 others “bone forming”→ 1. Tymlos 2. Forteo
7
Q
System Review: MSK
Osteoporosis
Supplementation?
A
Gained momentum in lg trial showing 43% reduction in hip fx’s among elderly women randomly assigned to take Ca++ and Vit. D supps vs placebo***
8
Q
Lots of different opinions on Ca++
A
see pics
9
Q
System Review: MSK
Osteoporosis
Risk Factors:
A
- Family hx→ NOT isolated to this!
- Low Ca++ intake (in another slide)
- Alcohol, tobacco, caffeine abuse
- Below normal bw→ need exercise!
- Chronic med conditions & meds
- Sedentary lifestyle***
- Early menopause*
10
Q
Risk Factors for OP
More on Low Ca++ intake
A
- Child 1-12→ 800mg/day
- Teens 13-18→ 700-1200mg/day
- Adult→ 700-1000/day
- Pregnant→ 1200 mg/day
- Post-menopause→ 1500mg/day***
NOTE POST-menopausal needing much more!!! HIGHER RISK!!
11
Q
System Review: MSK
Osteoporosis
S/S
A
- Severe & localized T-L-spine pain*
- INC pain w/ prolonged posture
- DEC pain in hook-lying
- INC pain w/ Valsalva maneuver
- Loss of ht >1”
- Kyphosis
- Dowager’s hump
12
Q
Greatest prevalence of THIS in Fibromyalgia
100% prevalence
KNOW IT!!!!
DEFINES FIBROMYALGIA****
A
Tender points (11 of 18)
13
Q
Tender points (11 of 18) you think……
A
Fibromyalgia
14
Q
Fibromyalgia Syndrome
Manifestations vs Prevalence (%)
REMEMBER TENDER POINTS IS #1!!!!
A
SEE PICS
15
Q
Fibromyalgia Syndrome (FMS) Tender Points
A
NOTE: Obscure spots
18 present
FMS will have 11/18
16
Q
Fibromyalgia Syndrome
FACTS: a lot talk about Growth Hormone (GH)
A
- Fact→ GH secretion occurs predom. @ night
- Fact→ If GH is DEC→ mm repair @ night is compromised & muscle endurance/pain INC during day
- Fact→ INC somatostatin limits GH release
- Fact→ Exercise inhibits somatostatin** (helps to restore GH release)
See pattern from beg. to end and how it cycles back to exercise!!!!
17
Q
Fibromyalgia Syndrome
Cycle of Meds along w/ Exercise and back to GH release!!!
A
- Evidence suggests antidepressants DEC pain, fatigue, depression, sleep disturbs
- WHEN ACCOMPANIED W/ AEROBIC EXERCISE→
-
Somatostatin release inhibited
- DEC somatostatin==> INC GH
- INC GH==> INC mm repair, DEC pain
-
Somatostatin release inhibited
18
Q
Has a huge role in Fibromyalgia
A
GROWTH HORMONE
EXERCISE!!! (AEROBIC)
19
Q
System Review: Neuromuscular
Statins
How do they work?
A
Dosage important!!!
- PCSK9 inhibitors
- Taken by injection 1-2x/mo
- Shown to reduce “bad” CHO by 50-60%
20
Q
System Review: Neuromusclar
Statins
Adverse Effects of Statins
A
- Loss of mm coordination
- Trouble talking/enunciating words
- Loss of balance
- Loss of fine motor skills (writing diff)
- Trouble swalling
- Constant fatigue
- Jt and mm aches, stiffness
- Vertigo/disorientation
- Blinding HAs
21
Q
Bone stimulation/growth
HOW? important for OP!!!
A
WB
Muscles pulling
22
Q
System Review: Neuromuscular
Statins
Ask them about meds!!!
2 questions:
A
2 Questions:
- Has any drug/dosage changed in last 2-4wks?
- this is timeline for adverse effects***
23
Q
System Review: Neuromuscular
Statins
Conclusions:
A
- Accumulating evidence suggests statins may have a role in colorectal cx prevention & treatment
- LOW dose*
24
Q
When you see “Butterfly Rash” think……
A
Systemic Lupus Erythematosus
25
System Review: **Neuromuscular**
## Footnote
**Systemic Lupus Erythematosus**
* Unexplained fever, swollen glands, **constitutional sx's, athralgia (symmetrical\*),** swollen joints
* **Skin rash→ “Butterfly” pattern (cheeks)\*\*\***
* Chest pain upon deep breath, extreme fatigue, photosensitive, unusual hair loss
* **Pale/purple fingers/toes from cold/stress→ Raynaud's**
* **CNS probs→** SZ, HA, periph. neuropathy, CVA, OBS
* Mouth, nose, vaginal ulcers
* Sx's get worse during menstruation\*\*\*
26
Guillain-Barre' Syndrome is a _____ problem
Demyelination
27
Guillain-Barres' Syndrome
## Footnote
**See chart but KNOW THESE MAIN ONES!!!**
* **Risk Factors**
* Possibly **autoimmune**
* Assoc. w/ **immunizations**
* Freq preceded by **mild resp. or intest. infx**
* Progresses over hrs to days
* Min. mm atrophy
* **Symmetrical paralysis\***
* **Begins in LEs\*\*\* Ascends BILATERALLY\***
* Weakness, Ataxia, B/L parasthesia→ progressing to **paralysis**
28
Gullian Barre Syndrome
## Footnote
**MORE**
**KNOW _BOLD_\*\*\***
* **\*\*Weakness→** Symmetrical **LE\>UE\>resp.**
* Parasthesia starts in **toes** & **progresses _proximally_**
* Pain=\> LB & Buttocks
* CN's effected
* Asymmetrical face weakness, dysphagia, dysarthrias
* **Unstable vital signs (not as common)**
* **DEC reflexes + hypOtonia**
* Fever, nausea, fatigue
* **Cannot go up stairs\*\*\***
29
Myasthenia Gravis think……
**Grave MSK weakness\*\*\*\***
30
Myasthenia Gravis
“Grave MM weakness”
* **Chronic, AI disorder**
* Caused by **defect** in the transmission of **nerve impulses** @ the **N-M junction**
* Antibodies block, alter, or even destroy receptors
31
Myasthenia Gravis
MOST COMMON S/S THINK….
**Diplopia & Ptosis (droopy eyelid)**
32
Droopy eyelid (Ptosis) one….
Myasthenia Gravis
33
Myasthenia Gravis
## Footnote
**s/s:**
* **MOST COMMON→ Diplopia & Ptosis**
* Prox mm weakness, prob controlling eye mvmt & facial expressions, diff swallow/chew, dysarthria/dysphagia, change in voice quality, NO **sensory or DTR changes**
34
Multiple Sclerosis (MS)
## Footnote
**Genetic factors + Triggers**
* **Genetic Factors:** can run in family
* 30% risk for identical twin
* 5% risk for 1st deg. relative
* .1% for no one in family w/ MS
* **Triggers\***
* Epstein-Barr Virus (EBV)
* **Low lvl Vit. D**
* **Geographic Loc.\*\*\***
35
System Review: **Neuromuscular**
## Footnote
**MS**
**1st Attack\***
* **Transverse Myelitis→** DEC strength & sensation
* **Optic neuritis→**
* **1st demyelinating event in 20% pts**
* DEC vision & pain w/ eye mvmts
* **B/L→** children
* **U/L→** adults
36
This is a **prodromal sign** that is present in **MS**
**BEFORE** **Dx is made\*\*\*\*\***
Lhermitte's sign
37
MS
## Footnote
**Other s/s**
* Intermitt. U/L vis. impair, Blurring, Diplopia, Parasthesias, Ataxia\*, Vertigo, **Fatigue**\*\*\*\* (MS fatigue), Extremity weakness, B&B changes
* Reports sensation of **compression** around limb, **HyERreflexia**, **+Babinski**, Dysmetria, **Lhermitte's sign, sensitive to temp change\***, LBP 2\* trunk hypOtonia
38
Lhermitte's Sign → MS
Sp= 97%
This is a good ________ test
DIAGNOSTIC
39
**Lhermitte's Sign**
**MS**
Sn=3% **Sp=97%**
* **Seated, flex head forward=\> electric shock**
* **53% report (+) sign that started in 1st 3mos of dis.**
40
Brudzinski Sign
Tests for \_\_\_\_\_\_\_
**Neural Tension**
**MS in adults**
**Bacterial Meningitis in children**
41
Anacardic Acid
Chem. cmpd found in shell of **cashew nut→** Helps promote repair of **myelin**
42
Amyotrophic Lateral Sclerosis (ALS)
## Footnote
**AKA**
Lou Gehrig's Disease
43
System Review: **Neuromuscular**
## Footnote
**ALS**
Attacks neurons of **brain and SC**
## Footnote
**20%→ genetic defect**
44
New ALS Research
**Now possible to definitively distinguish blood samples of ALS pts from healthy controls**
**see pics**
45
System Review: **Neuromuscular**
## Footnote
**ALS**
**New research shows a _buildup_ of this PRO…… near N-M junctions translates neural signals into motor activity→ causes motor neurons to _degenerate and die_ by _inhibiting mitochondrial production_**
TDP-43
46
System Review: **Neuromuscular**
## Footnote
**ALS**
**S/S**
* MM weakness: hands, arms, legs
* **Progressive weakness** of mms of **speech, swallowing, eventually breathing**
* **EMG→** fibrillations and **fasciculations\***
* Denervation atrophy, elevated mm enzymes, painful UE cramps
* NO change in vision, hearing, taste, B&B
47
Neuromuscular Recap
## Footnote
**GBS, Lupus, Myasthenia Gravis, MS, ALS**
see chart
48
Neuromuscular Recap from chart
## Footnote
**GBS:**
**Joints, DTRs/Tone, Other**
* **Joints→** LE\>UE weakness
* **DTRs/Tone→** DEC
* **Other→** UNSTABLE vitals
49
Neuromuscular Recap from chart
## Footnote
**Lupus**
**Joints, DTRs/Tone, Other**
* **Joints→** Jt **pain&weakness**
* **DTRs/Tone→** NO CHANGE
* **Other→** Butterfly rash\*
50
Neuromuscular recap from chart
## Footnote
**Myasthenia Gravis (droopy eyelid one)**
**Jts, DTRs/Tone, Other**
* **Jts→** _Proximal_ weakness
* **DTRs/Tone→** NO CHANGE
* **Other→ Eye** & **Swallowing probs**
51
Neuromuscular Recap from chart
## Footnote
**MS**
**Jts, DTRs/Tone, Other**
* **Jts→** _Extremity_ weakness
* **DTRs/Tone→** INCd
* **Other→ Lhermitte's sign & Visual changes**
52
Neuromuscular Recap from chart
## Footnote
**ALS**
**Jts, DTRs/Tone, Other**
* **Jts→** Weakness **hands-UE-LE**
* **DTRs/Tone→** INCd w/ **cramping**
* **Other→ EMG _fasciculations_\***
53
System Review: **CV & Pulmonary**
## Footnote
**HTN**
* Spontaneous **epistaxis (nosebleed)**
* **Occipital HA**
* Dizzy, visual changes,
* **Nocturnal urinary freq.**
* Flushed face
54
System Review: **CV & Pulmonary**
## Footnote
**Abdominal Aortic Aneurysm**
**Case Report→ JOSPT 2008**
**Notice the S/S and WHY it would make you think AAA**
* 38yo male w/ hx of NON-mech. LBP
* **Insidious onset→ constant**, deep, boring, **night pain**
* NO lumbar, pelvic, hip impairments\*
* **Strong non-tender palpable pulse\***
55
Risk Factors for **Abdominal Aortic Aneurysm**
## Footnote
**Note the \*'d**
* \***Male sex**
* **\*Older age**
* **\*Tobacco use**
56
Abdominal Aortic Aneurysm
## Footnote
**Palpation effectiveness**
* Sn=68% Sp=75%
* **Sn DECs if abdominal girth is \>100cm (39.4in) → Overweight person\*\*\*\***
* Bc harder to palpate!!!
57
Abdominal Aortic Aneurysm
## Footnote
**Palpation effectiveness**
**Sn DECs if abdominal girth is ___________, bc harder to palpate**
\>100cm (39.4in)
58
Aneurysm Diameter
## Footnote
**Surveillance (how often checked) vs Lifetime risk of rupture**
* **NOTE:**
* **\>5.4cm =** Surgical consult
* **7cm=** 50% lifetime risk of rupture
59
Ritter's Rules
## Footnote
**Are for what?**
**Thoracic Aortic Dissection \*\*\*\***
60
**Ritter's Rules**
**Summarized (most important points)**
* **Urgency→** Thoracic aortic dissection= **MEDICAL EMERGENCY\***
* **Pain→** SEVERE pain= #1 symptom
* **MisDx→** Aortic Dissection can mimic **heart attack**
* **Imaging→** Get the right scan to R/O aortic dissection (CT, MRI, transesophageal EKG
* **Risk Factors:**
* Aortic dissections are often preceded by **aortic aneurysm**
* Personal or family hx of **thoracic dis.**
* Certain genetic syndromes
* Marfan, Loeys-Dietz, Turner, vascular Ehlers-Danlos
* Bicuspid aortic valve disease
* **Triggers→** Lifestyle & trauma can trigger aortic dissection
* **Prevention→** Med. mgmt is _essential_
* BP control, aortic imaging\*
61
Gender Diffs in **MI Sx's**
## Footnote
**Prodromal vs Acute Signs**
Will **differ bw Males & Females!!!!**
* **Prodromal→** S/S leading up to Dx, Days/weeks before
* **Acute S/S→** IN the moment\*
62
S/S OF MI
## Footnote
**Framingham Study= ALL MEN\***
* Substernal pressure, tightness, squeezing
* Pain **unrelieved** by pos. or **nitroglycerin**
* Dyspnea, nausea, vom, dizzy
* Palpitations, diaphoresis (sweating)
63
S/S of MI in **FEMALES**
## Footnote
**TOP Prodromal vs TOP Acute**
**KNOW THIS!!!**
* **Prodromal:**
* Unusual fatigue→ 71%
* Sleep disturbs→ 48%
* **SOB→** 42%
* **Acute:**
* **SOB→** 58%
* Weakness→ 55%
* Unusual fatigue→ 43%
NOTE that **dizzy, cold sweat, nausea (all acute) are sx's similar to men, BUT only 36-39% in Females!!!**
64
Scientific Reports
## Footnote
**MI and Cardiac Probs and Cortisol lvls and Hair**
* Lvls of cortisol diff in people who **had MI vs did not**
* Hormones and chems quickly dissipate from bloodstream BUT **remain in hair for mos.**
* Hair grows few cm/mo
* **Cortisol lvls from in 1-3cm of people who _had MI_ (depicted in hair)**
* **Moral of the story→** Cortisol may be indication of **cardiac probs**
65
All of these may cause **NON-Cardiac chest pain**
Indigestion\*, esophagitis, ulcers, cholecystitis, bronchitis, mm strain, costochondritis, rib fx, Herpes Zoster\*
66
System Review: **Integumentary**
## Footnote
**Herpes Zoster aka**
* Shingles!!!
67
Systems Review: **Integumentary**
## Footnote
**Herpes Zoster (Shingles)**
* ⅔ pts \>50yo
* Pain, tender, parasthesia **in the dermatome** 3-5d BEFORE **vesicules**
* Prodromal pain may mimic cardiac pain\*\*
* Erythema & vesicles follow a **dermatome\***
* Pustular vesicles last 2-3wks
* **Thoracic & Opthalmic** division of **trigeminal nerve→ MOST COMMON**
* **Contagious→ via resp. droplets or Direct Contact w/ blisters**
68
Shingles Rash
## Footnote
**Think _dermatomal pattern_**
**Contagious→**
* Can spread when rash in **blister-phase**
* NOT infectious BEFORE blisters
* Once rash **crusts→** NO longer infectious
* Shingles LESS CONTAGIOUS vs chickenpox
69
Chickenpox vs. Shingles
* Had Chickenpox→ may dev. shingles
* NEVER had chickenpox→ wont get shingles, can get chickenpox
* Vaccinated for chickenpox→ protected from shingles\*
70
Skin Cancers
## Footnote
**Remember the “Early Warning Signs of Cx”**
**CAUTION**
* **C:** Change in B&B
* **A:** A sore that fails to heal 6wks
* **U:** Unusual bleeding or discharge
* **T:** Thickening/lump (breast or elsewhere)
* **I:** Indigestion or diff swalling
* **_O_: Obvious change in wart, mole, freckle**
* **ABCDE (you'll get into this)**
* **N:** Nagging cough, hoarseness, rust colored sputum
71
Skin Cancers
## Footnote
**Remember the “Early Warning Signs of Cx”**
**CAUTI**_O_**N**
**The _O_ pertains to Skin Cx's!!!**
**O:** Obvious change in wart, mole, or freckle
* **ABCDE**
* **A: A**symmetrical shape
* **B: B**order irregularities
* **C: C**olor→ pigmentation NOT uniform
* **D: D**iameter \>6mm (pencil eraser)
* **E: E**volution (change in status)
72
More Skin Cx ex's
see pics
## Footnote
**Notice “streaking” in nails\***
73
Systems Review: **Integumentary**
**Skin Cx**
**Role of PT**
* Guide to PT Practice:
* **Screen skin exposed during PT sessions**
* **Educate pt**
* **Refer as needed**
74
Systems Review: **Integumentary**
## Footnote
**Lyme Disease**
**What bacteria ?**
B. Burgdorferi
75
Systems Review: **Integumentary**
## Footnote
**Lyme Disease**
* 36-48hrs after attach. of **B. Burgdorferi** to migrate from midgut of tick to salivary glands
* **Removal of tick w/in 24hrs can _usually_ _prevent_ acquisition of Lyme Disease\*\*\*\***
* Sx's early Lyme→ 1-2wks AFTER tick bite
76
**Systems Review: Integumentary**
**Lyme Disease**
**_Early Localized Stage:_**
* Rash w/ erythema→ w/in 7-14d (range 3-30)- BullsEye
* can be solid or BullsEye
* Avg diameter→ 5-6"
* may/may not be warm, usually not itchy/painful
* Fever, malaise, HA, mm ache, jt pain\*\*\*
77
Conditions that **mimic Lyme Rash**
## Footnote
**FYI but may be helpful**
see pics
78
Lyme Tx
Antibx's for \_\_\_\_\_\_\_\_
14-28d
79
Lyme Dis. Tx
* Doxycycline
* Amoxicillin
* Cefuroxime (Ceftin)
* Azithromycin (Zithromax)→ **Z-pack**
80
Systems Review: **GI**
## Footnote
**GI Trauma**
* Needs to be considered w/ **MVA & Athletics**
* **Solid Organs:** Spleen\>Liver\>Kidney
* **Hollow Organs:** Intestine, Bladder
* Look for→ **pain/tender, vomiting**
**“Seat-Belt Sign”**
81
GI Cx's
## Footnote
**WORST→ incidence AND mortality**
Colorectum
82
GI Cx's
## Footnote
**Relating to Pathogenesis of _Obesity_**
**3 Big factors w/ this:**
1. Inflammation
2. Insulin Resistance
3. Hormonal Adaptation
\***Nutrition, weight, body comp== HIGHLY correlated w/ INCd risk of Cx recurrence**
**\*High _salt diet_ inc's risk of GI cx via _direct mucosal damage_ & synergistically w/ _H Pylori_**
**_\*_Colorectal risk inc's w/ diets high in _red meat, processed meats, saturated fats_ due to _dysbiosis, inflammation, cell damage_**
83
GI Patho and **Curcumin (Turmeric)- for GI Dysf**
500-2000 mg/d
1tsp=150mg; **best w/ black pepper & fats**
84
Systems Review: **GI**
## Footnote
**Celiac Iceberg**
**Latent (normal mucosa)→ Silent (manifest mucosal lesion)→ Symptomatic (manifest mucosal lesion)**
* **Onset:**
* 6-24mos AFTER gluten introduced to diet
* **Sx's:**
* diarrhea, abdom distention
* Impaired growth, mm wasting
* Decd appetite, wt loss
* Lethargy, irritability
85
Systems Review: **GI**
## Footnote
**Peptic Ulcer**
**2 types:**
Gastric & Duodenal
\***Break in protective _mucosal lining_**
86
Systems Review: **GI**
## Footnote
**Peptic Ulcer**
**Etiology?**
MULTIfactorial!
1. **Genetic**
1. Familial tendencies
2. Type O blood
2. **Environmental**
1. Smoking, ETOH
2. NSAIDs\*\*\*
87
Systems Review: **GI**
## Footnote
**Peptic Ulcer**
**PT Implications**
* 50% PT pts taking **NSAIDs have _gastritis_**
* 15% long-term NSAID develop **peptic ulcer**
* Many pts w/ ulcer no sx's and unaware they have ulcers
* @ Risk for serious ulcer comps→ bleeding, perforation of stomach
* encourage to take meds w/ FOOD
* refer to PCP prn
88
Systems Review: **GI**
## Footnote
**Stress Ulcers**
2\* from psychological or physio. stress
**Gastric mucosal changes occur w/in 72hrs in 80% pts w/ burns over 35% of body\***
89
Systems Review: **GI**
## Footnote
**Ulcers**
**WHAT should you ABSOLUTELY REMEMBER about the development of ulcers???? Hx of ________ or presence of _________ \*\*\*\*\*\*\*\***
Hx of **NSAID** OR presence of **H. Pylori infx**
90
Ulcers
* **Hx of NSAID or presence of H. Pylori\*\*\*\*\*\***
* Dull gnawing/burning into midline T6-12 & radiating suprascapula
* Relief→ antacids
* Nausea, coffe-grounds vomit
* **Bloody or black-tarry stools (melenia)**
* **Wks of remission\***
91
Why are NSAIDS problem?
* **Education:**
* Options
* How to take NSAIDs
* **Dx:**
* Is it an “-itis”?
92
Ulcers
## Footnote
**Gastric vs Duodenal**
**What do they both have IN COMMON????**
CRAMPING, TENDERNESS
93
Ulcers
## Footnote
**Gastric vs Duodenal**
IN COMMON→ cramp, tender
* **Gastric**
* 30-60min post
* ****_L_**UQ**
* **Duodenal**
* 2-3hrs post
* ****_R_**UQ**
94
Ulcer Dx
## Footnote
**Test for _________ can ID those _likely to benefit_ from _antimicrobial tx_**
H. Pylori
* **Other:**
* Decd **hematocrit & HgB**
* Blood→ feces/urine
95
GI Bleeding→ **Tests for H. Pylori**
## Footnote
**Just the _Types_**
* **Breath Test→ IDs 99% people w/ H. Pylori**
* **Blood Tests→** enzyme-linked immunosorbent assay (ELISA) measures antibodies to H. Pylori
* **Stool Test→** detects genetic fingerprints of H. Pylori in feces
* **Tissue Biopsy of lining of stomach→ MOST ACCURATE\*;** Endoscopy (invasive)
96
Ulcer Tx
* Remove irritant, meds to restore **mucosa**
* **H. Pylori→ Anti-microbial**
* Avoid coffee
* NO known dietary changes found to reduce **gastric acid secretion→ AVOID** problematic foods\*
97
Systems Review: **GI**
## Footnote
**Gall Bladder Patho think…..**
8 F's\*\*\*\*
98
Systems Review: **GI**
## Footnote
**Gall Bladder Patho**
**Risk Factors→ 8 F's**
1. **F**emale
2. **F**air
3. **F**latulent
4. **F**orty
5. **F**at
6. **F**ertile
7. **F**atty Foods
8. **F**amily Hx
99
Gall Bladder S/S:
## Footnote
**(+) THIS sign……**
(+) **Murphy's sign \*\*\*\***
100
Gall Bladder S/S:
* **RUQ, Scap pain**
* Sx's INC after **fatty meal**
* Pain no resp to analgesics
* Abdom bloating/belching
* **Clay-colored stools\***
* Vom, nausea
* Jaundice (small %)
* **(+) Murphy's Sign \*\*\*\***
101
Gall Bladder Patho **Dx:**
* US, MRI
* **Cholescintigraphy (HIDA scan)=\> Nuclear medicine (HIGH radiation)**
* **Oral cholecystogram (OCG)**
102
Oral Dissolution Therapy is for \_\_\_\_\_\_\_\_
## Footnote
**aka Ursodiol**
Gall Bladder Patho
103
Oral Dissolution Therapy (Ursodiol) → **Gall Bladder Patho**
## Footnote
**Limitations to the use of _Ursodiol_**
* only effective for cholesterol NOT pigment gallstones
* only **small gallstones, \<1-1.5cm**
* takes 1-2yrs for gallstones to dissolve, many reform
* **Ursodiol gen only used by people who are @ high risk for Sx \*\*\*\***
104
Extracorpeal Shock-Wave Lithotripsy aka
**BLASTING gallstones!!!!!!**
105
Gallstones Tx:
**Extracorporeal Shock-Wave Lithotripsy**
“Blasting the gallstones/Shatter”
* Treating gallstones
* **Shock waves _shatter_ gallstone→**
106
Appendicitis
S/S in order of **SIG. Likelihood Ratios\*\*\***
1. **RLQ pain, (+) McBurney's Point=\> R. thigh/testicle\***
2. Nausea, vom, night sweats\*
3. Guarding rectus abdom\*
4. (+) Psoas sign
5. (+) Obturator sign
6. LOW-grade fever
7. (+) Rebound tenderness (Blumberg)
107
Systems Review: **Endocrine**
## Footnote
**Thyroid Palpation**
See pics (YOU KNOW THIS!!!)
## Footnote
**\*Observe for _mvmt_ of any _masses_ w/ _swallowing_**
108
Accuracy of **Physical Exam** in Dx of **HypOthyroidism**
## Footnote
**“Clinical features manifest so slowly that clinicians may fail to notice them”**
**Genetic Link?**
* Family member who had:
* **Hypo/HypERthyroidism**
* **Hair turned gray in 20s**
* **Immune prob, juvenile DM**
109
HypOthyroidism vs. HypERthryroidism think…..
HypO== **SLOW motor**
HypER== **FAST motor**
110
Systems Review: **Endocrine**
## Footnote
**HypOthyroidism**
**Clinical Questions……. In the past year…**
1. Less energetic?
2. Lack interest in surroundings?
3. Skin of arms/legs become more dry/rough?
4. Do you think you've put on wt?
5. Have you or any family mbrs/friends noticed that your voice has become huskier or weaker?
111
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: ALL FIRST**
* Course skin
* Sluggish mvmts
* PR (HR) \<60bpm→ BRADYcardic
* Pretibial edema
* Puffiness of face
* Ankle reflex
112
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: Course Skin**
hands, forearms, elbows examined to see if rough/thick
113
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: Sluggish mvmts**
Asked to fold 2m long bed sheet
\>1min= sluggish
114
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: HR (pulse rate)**
\<60bpm= BRADYcardic
115
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: Pretibial edema**
Shin pressed for 30s
## Footnote
**(+)= pitting**
116
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: Puffiness of face**
Observe if curve of **malar bone** was obscure, eyelids boggy
117
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam: Ankle Reflex**
Contraction/relaxation of calf observed & prolongation of reflex
118
Systems Review: **Endocrine**
## Footnote
**Hypothyroidism**
**Methods of Physical Exam**
**Accuracy of Phys Exam findings in Dx of HypOthyroidism**
**Ones w/ HIGHEST Sp\*\*\*\* (good Diagnostic tests\*\*\*\*)**
* BRADYcardia (remember SLOW motor)
* Delayed ankle reflex
* Course skin, Bradycardia, ankle reflex\*\*\*
119
HypOthyroidism
Women vs Men?
Women \> Men \*\*\*
120
HypERthyroidism think….
FAST motor
121
Systems Review: **Endocrine**
## Footnote
**HypERthyroidism (fast motor)**
**Possible causes:**
Autoimmune (environ or stress factors), Nodules on thyroid (**goiters),** excess thyroid meds (for hypO), **excess iodine,** thyroiditis
122
OVER-functioning of thyroid i.e. **too much thyroid hormone**
Hyperthyroidism
123
Hyperthyroidism:
## Footnote
**Initial Phys Exam:**
* Enlarged thyroid
* TACHYcardia (fast motor)
* **Tremor of DIP**
* Smooth, velvety skin\*
* Inflammation/**Bulging of eyes** (Females \> Males)
124
Hyperthyroidism
## Footnote
**Add'l Sx's**
**(all make sense bc Fast motor, revved up!!!)**
* Fatigue, Sweaty palms, INC appetite/Wt loss, INC sweating (heat intol.), restlessness/insomnia, DEC attn span
125
Hyperthyroidism
## Footnote
**Tx**
* Anti-thyroid drugs→ PTU & Tapazole
* Radioactive iodine
* taken up by thyroid where it **destroys thyroid cells to DEC thyroid hormone prod.**
* Sx==\> risky
* remove enough to DEC thyroid hormone
126
Hypo vs Hyper-Thyroidism
see pics
127
**Symptoms of hyperthyroidism (SWEATING)**
* **S**weating
* **W**eight loss
* **E**motional lability
* **A**ppetite increased
* **T**remor/ tachycardia
* **I**ntolerance of heat/ Irregular menstruation/ Irritability
* **N**ervousness
* **G**oitre and **G**I problems (diarrhea)
128
**Symptoms of hypothyroidism – tends to occur in middle aged women**
**(MOM’S SO TIRED)**
* **M**emory loss
* **O**besity
* **M**alar flush/ **M**enorrhagia
* **S**lowness (mentally and physically)
* **S**kin and hair dryness
* **O**nset gradual
* **T**iredness
* **I**ntolerance to cold
* **R**aised BP
* **E**nergy levels fall
* **D**epression/ **D**elayed relaxation of reflexes
129
Parathyroid Gland think…….
Controls ALL **Ca++ lvls in body\*\*\*\*\***
130
Parathyroid Gland (think Ca++)
## Footnote
**All info**
* 4 PTH glands
* Size/Shape→ grain of rice
* **PURPOSE:** Makes “parathyroid hormone”→ **controls ALL Ca++ lvls in body\*\*\***
* **Range→ 8.8-10.2**
131
Blood Calcium Lvls in humans
see pics but NOTE:
* 9-10→ actual range of blood Ca++ where 99% humans live and feel GOOD
* Ca++ lvls in **low 10's** often NOT normal and **warning sign** of HypERparathyroidism
132
PTH INC **serum Ca++ via……**
NEGATIVE FEEDBACK SYSTEM\*\*\*
* See pics and **understand it is a NEGATIVE Feedback system\*\*\***
* **DEC Ca++, INC PTH**
Decd serum calcium→ PTH→ Incd Ca++ reabsorption (bone and GI)→ Incd serum Ca++
133
Hypo-Parathyroidism
REMEMBER…..
VERY RARE
Results from _removal_ of **all 4 glands**
134
HypOcalcemia Sx's
RARE!!!!
* Irritable,
* Cardiac arrhythmia
* Sk mm cramping
* tingling fingers
* dry/scaly skin
* pigment changes
* thin hair/brittle nails
* **(+) Chvostek's Sign**
135
HypOparathyroidism
## Footnote
**2 tests + Descriptions**
* (+) Chvostek's Sign
* HypERirritability of **facial N.** when tapped
* **(+) Trosseau's Sign**
* **Carpal spasm when inflated BP cuff is maintained \>SBP for 3 mins.**
* **TALKED ABOUT THIS ONE IN CLASS!!!**
136
HypERthyroidism peaks when?
3rd-4th decade
137
HypER-parathyroidism
* 1 gland “**goes bad”→ 91% of time**
* Most often 5th, 6th, 7th decades of life
138
Hyper-Parathyroidism
## Footnote
**New Sx technique**
Radioguided parathyroidectomy
139
Hyper-parathyroidism aka
HIGH Ca++ lvls
* Makes you feel bad
* Ruins kidneys, liver, arteries
* Causes strokes & cardiac rhythm probs
* Kidney stones & OP
* INCd chance of Cx's→ breast, kidney, prostate\*\*\*
140
Hyper-Parathyroidism
* INCd DTRs
* Fatigue, drowsy
* PROXIMAL weakness\*
* Arthralgia/myalgia
* Reflux/peptic ulcer\*
* Kidney stones\*
* INC BP
* Heart palpitations
* Pancreatitis, Gout\*
* Thinning hair\*
* Mental slowing or memory probs
* Emotional irritability
* HypERcalcemia
* Diff sleeping
* HAs
141
EXCESS PTH
see chart
* **Brain→** psychosis paranoia
* **Bone→** decalcification; patho. fx.
* **Stomach→** Peptic ulcers and other GI sx's→ nausea, vom, constipation
* **Blood vessels→** Ca++ deposits in blood vessels== HTN
* **Pancreas→** Pancreatitis
* **Heart→** heart failure assocd w/ vascular damage and kidney patho.
* **Kidneys→** Kidney stones, 2\* infx's, uremia
142
10 Parathyroid Rules of Norman
## Footnote
**This one is BOXED AND \*'d !!!!**
There is only **ONE Tx for hypERparathyroidism:**
## Footnote
**Surgery\*\*\***
143
10 PTH Rules of Norman
1. NO drugs make Parathyroid disease better
2. ALL parathyroid pts have sx's; 95% know it, feel bad
3. Sx's DO NOT correlate w/ lvl of Ca++ in blood
1. many have BAD sx's and dev. OP
4. ALL pts w/ parathyroid dis have Ca++ lvls and PTH lvls that fluctuate (Up and Down)→ Typical
5. All pts w/ HypERparathyroidism dev. OP\*
6. OP drugs have NO place in tx of parathyroid dis.
7. Parathyroid dis will get worse in ALL pts
8. **There is only ONE tx for hypERparathyroidism: Surgery**
9. Nearly ALL parathyroid pts cured w/ min. operation
10. Success rate & comp. rate VERY dep. on surgeons experience
144
Parathyroid Sx Outcome:
* OP improves _immediately_
* Bone pain→ resolves 6-12hrs
* Acid reflux→ gone 2-4d
* HTN→ better in few wks
* Arrhythmias→ subside w/in 1mo
* CNS Sx's→ improve 1-2mos
* Hair loss→ resolves 3-4mos
145
Breast Cx
## Footnote
**Risk Factors:**
\>40yo, Family hx, NONpregnancy, Other cx's, **Fibrocystic dis.**
146
Breast Cx **S/S**
## Footnote
**know bolded and \*'d**
* **Enlarged _axillary_ lymph nodes**
* **U/L UE swelling**
* **Brachial plexus related dysf.**
* palpable mass, retraction nipple, dimpling of skin over mass, skin red/warm/edematous, firm&painful over mass, fixation of mass to skin or chest wall, discharge nipple, pain w/ mvmt of breast
147
Systems Review: **Urogenital**
## Footnote
**UTI**
**Risk Factors:**
* Immobility/Inactivity→ **impaired bladder emptying**
* Catheterization, DM,
* Obstructions→ **renal calculi**
148
Systems Review: **Urogenital**
## Footnote
**UTI S/S**
* Pain w/ micturition
* Leukocytes & bacteria in urine→ white casts
* Cloudy urine
* Back pain
* Pain w/ kidney percussion
* Fever, chills
* Nasuea
* Loss of appetite
149
Systems Review: **Urogenital**
## Footnote
**UTI vs Bladder Cx**
* Avg time from **initial sx claim** to **bladder Cx Dx** was LONGER in women than men
* Pts presenting w/ **hematuria alone,** the time to subsequent bladder Cx Dx was similar for women and men
* Analysis of pts presenting w/ **either hematuria OR UTI,** time to dx was sig. different
* “Women had longer interval from UTI to Dx of bladder cx”
150
Systems Review: **Urogenital**
## Footnote
**Endometriosis**
**S/S**
* **Recurrent Lumbosacral pain**
* 30-40yo
* **Worse pre- & during menses**
* Pain w/ intercourse
* Infertility
151
Diff Dx of **Endometriosis** in a Young Adult Woman w/ NONspecific LBP
Mark R. Troyer
FIND IT AND READ IT!!!!!!!!
152
Renal Calculi aka
Kidney Stones
153
Kidney Stones aka
Renal Calculi
154
Renal Calculi=Kidney Stones
## Footnote
**3 sites of obstruction:**
1. Ureteropelvic junction
2. Ureter crosses over Iliac vessels
3. Ureterovesical junction
**Tears ureter → hematuria**
155
Renal Calculi
## Footnote
**Formation==**
INCd blood lvl and urinary excretion of principle component
**Ca++ oxalate (80-90%)**, Mg++ ammonium phosphate, Uric acid, Cystine
156
Kidney Stones
## Footnote
**Risk Factors**
**KNOW BOLD**
* **Family Hx**
* **Males 4x \> Females from 30-50yo**
* **Females \> Males in 60-80yo**
* Caucasians \> Af Am's
* High PRO, low fiber
* Dehydration
* Warm climate;
* Poor mobility
157
Kidney Stones
S/S
**What analogy should you remember???????**
Pacing like a tiger!!!!
158
Kidney Stones
## Footnote
**S/S**
* **Stab pain→ costovertebral angle**
* Intermitt, excruciating pain into **ipsilateral genitals (comes in waves)**
* Ureter spasms into medial thigh
* **Pain starts when stone moves into narrow ureter=\> pressure build up in kidney\*\*\***
159
Kidney Stones
## Footnote
**S/S more**
Chills/nausea/vom, **freq urge to urinate,** burns when urinate, **blood/cloudy/smelly urine,** INCd BP (bc pain)
160
Kidney Stone Dx
* US, CT, MRI
* **Urinalysis**
* hematuria, infx, crystals, pH\*\*\*
* **formation of various kidney stones strongly influenced by urinary pH**
90% calculi are **radiopaque**
161
Kidney Stone
## Footnote
**Tx**
* **Stones \<5-6mm pass _spontaneously_**
* Pain meds, antibx, Fever==medical emergency for drainage (catheter)
* **Removal:**
* **USE→ Ureteroscopic Stone Extraction**
* **ESWL→ Extracorporeal Shock Wave Lithotripsy**
* **BLASTS THE STONES**
162
Kidney Stone Tx
## Footnote
**MORE**
* Reoccur in 50% w/in 5yrs
* **IF assocd w/ hypERparathyroidism→ ADDRESS!!**
* **PT→** NON-mechanical pain
163
RED FLAGS
## Footnote
**Adults→ Cx**
**Lymphoma (Hodgkin's Disease)**
* Rare in children \<5
* More common females 5-10yo
* **Peaks 25-30**
* **Males \> Females (5:1)**
* **Painless swelling of lymph nodes in neck or axilla, fever & night sweats, wt loss\*\*\***
164
500-700 Lymph Nodes
* Normal size→ 1cm in size; **\>1cm=abnormal**
* Infx's, Cx, other cond's cause them to expand **as immune system reacts to problem**
165
RED FLAGS
Adults→ **Cx**
**Talk about lymph nodes RED FLAG**
\>1cm→ Tender, firm, rubbery (**lasting longer than 4wks\*\*\*\*\***
166
Adults-Cx
RED FLAGS
Pruritus (greater @ night), fever/night sweats, anorexia/anemia/cyanosis, jaundice, edema, non-productive cough/dyspnea, chest pain
167
RED FLAGS
Adults→ **Cx**
**Colon Cx**
* Environmental & familial factors
* **Risks:**
* INCing age
* Polyps
* **Ulcerative colitis, Crohn's dis.,**
* **diet HIGH in animal fat & LOW in fiber**
168
RED FLAGS
## Footnote
**Adults→ Cx**
**Colon Cx - REDUCTION of Risks**
**2 ways:**
* **ASA** (**aspirin**)→ daily 81mg x 20yrs reduces risk colon cx by 50%
* **Estrogen→** women who take estrogen replacement \>1yr LESS likely to die of colon cx; LONGER take estrogen, LOWER risk colon cx
169
RED FLAGS
Adults→ **Cx**
**Ovarian Cx**
**2 _really important_ things to know:**
* 2nd most common female urogen. cx, **BUT most _lethal_**
* Poor outcome is based on diff w/ Dx→ **Most have _metastatic disease_ by time of Dx**
170
Red Flags
Adults→ Cx
**Ovarian Cx**
2nd most common urogen. cx, but **most lethal**
* **Risks**
* 40-60, Caucasian & Hawaiin
* Geo loc. (NW Europe, US, Canada)
* **Nulliparity (hx of infertility\*)**
* Fam hx
* Endometrial or breast cx
171
**Ovarian Cx**
**This is _common_ w/ it….**
**Metastatic Dis.→** unexplained wt loss, weakness, ascites
* Other s/s
* vague
* bloating, freq abdom fullness after eat, w/ nausea & vom, flatulence, abnorm bleeding, gen abdom discomfort
* 5yr survival only 30%
172
Sx's of Metastases
ALL FIRST
SEE PICS
173
Sx's of Metatastases
## Footnote
**Pulmonary**
Cough, dyspnea, **fecal odor breath,** constant pleural pain, onset of wheezing
174
Sx's of Metastases
## Footnote
**CNS**
* Confusion, change in memory
* Depression, irritability, drowsy, blurred vision, HA,
* Balance probs, weakness
175
Sx's of Metastases
## Footnote
**Skeletal (Vertebrae, Pelvis, Ribs, Femur)**
* Significant pain **relief** w/ **ASA (aspirin)\***
* **PAIN**
* w/ WB
* @ night\*
* Prior hx of cx
176
Sx's of Metastases
## Footnote
**Talk about this test:**
**Percussion w/ Reflex hammer over Bony Areas→ Vert. spines, ribs, scapula, pelvis\*\***
**PAIN==\>** Metastatic Dis. to **bone** via **lung, breast, or prostate cx's**
177
Statins & Cx Mortality
## Footnote
**Risk cut up to a _HALF_**
* **Statins** use assocd w/:
* **Women→** 22-55% reduction in various Cx deaths
* **Men→** Looked @ statins together w/ anti-DM meds **Metformin**
* 40% reduction in **prostate cx mortality**
* Speculated→ **statins interfere w/ cell growth & metastasis by blocking cholesterol prod→ affects molecular paths & inflamm response**
