Family medicine rotation Flashcards
(184 cards)
1
Q
Gouty arthritis vs pseudogout?
A
Gouty arthritis: MSU crystals in joints due to excess uric acid esp in great toe
Pseudogout: Calcium pyrophosphate dehydrate crystals in joints (dx by rod-shaped, rhomboid, WEAKLY birefringence by crystal analysis)
2
Q
Factors that can induce hyperuricemia/to take into consideration when considering gout attacks?
A
Men 30-50yo
Women 50-70yo
- Recent increase in alcohol consumption
- Large meal (esp if red meat, liver or seafood since they are high in purines)
- Trauma, surgery
- Recent h/o thiazide diuretic use
3
Q
Compare calcium pyrophosphate dehydrate vs calcium hydroxyapatite vs calcium oxalate crystals
A
calcium pyrophosphate dehydrate:
- Rod shaped
- Rhomboid
- Weakly positive birefringence
Calcium oxalate:
- Bipyramidal
- Mostly seen in ESRD pts
- Strongly positive birefringence
Calcium hydroxyapatite:
- Seen by electron microscopy
- Cytoplasmic includions that are NON-birefringent
4
Q
Gross appearance of joint aspirate is essential/non-essential for diagnosis of septic arthritis. T/F?
A
FALSE
- Both septic aspirate and a heavily condensed crystal-induced arthritis may have a thick, yellowish/chalky appearance
- *Thus gross appearance of fluid is NOT very specific
- **To dx crystal-induced arthritis you need polarizing microscopy to reveal MSU crystals
5
Q
How do labs help you distinguish crystal induced arthritis from septic joint?
A
Crystal induced joint aspirate will have avg 2,000-60,000/uL WBCs with 90% PMNs
6
Q
DDx for nontraumatic swollen joint?
A
Gout (or any crystal induced arthritis)
Infectious arthritis
OA
RA
7
Q
Likely bacteria responsible for joint infections in HIV+ patients? IVDU?
A
HIV+
- Pneumococcal, salmonella, H. influenzae
IVDU
- Streptococcal, staphylococcal, gram negative, or Pseudomonas
8
Q
Septic joint will have a very limited ROM. T/F?
A
True; limited ROM due to pain
*Maintain ROM in cellulitis, bursitis, or osteomyelitis
9
Q
OA is most commonly seen in people older than ____ years and is associated with ___
A
>65yo Associated with: - Trauma - Obesity (esp for knee OA) - H/o of repetitive joint use
10
Q
When is an ultrasound indicated in pregnancy?
A
Uncertain gestational age Size/date discrepancies Vaginal bleeding Multiple gestations Other high-risk situations
11
Q
How much radiation is too much for a pregnant woman? Are MRIs safe?
A
> 5 rad; associated with fetal harm
(e.g. dental x ray is .00017 rad)
Fetus particularly sensitive to radiation during 2-15 weeks after conception
*MRIs are NOT shown to be harmful but not recommended
12
Q
How much folic acid should women take if they are thinking of getting pregnant?
A
Should start folic acid supplement at least 1 month prior to attempting to conceive
- Low risk women: 400-800ug daily
- Women who has had child with NT defect: 4mg daily
13
Q
How do you determine the estimated delivery date? When should you obtain this?
A
Obtain at initial prenatal visit
- Get history; get first day of last menstrual period (LMP)
- Use Naegele’s rule: from first day of LMP subtract 3 months and add 7 days
- Make sure LMP is reliable:
- Date is certain
- LMP was normal
- No contraceptive use in the past 1 year
- Pt has had no bleeding since LMP
- Regular menses
- **Not reliable LMP? Get ultrasound!
14
Q
When should you be able to hear heart tones in a fetus?
A
10 week gestation using handheld doppler fetoscope
15
Q
Initial lab screen for pregnant women should include which tests?
A
CBC Blood type Rh status Rubella HIV Hep B surface antigen Rapid plasma reagin UA Urine culture Pap smear Cervical swab for gonorrhea and chlamydia
16
Q
How often should prenatal visits happen?
A
Typical protocol:
- Every 4 weeks until 28 weeks gestation
- Every 2 weeks from 28-36 weeks
- Every 1 week from 36 weeks-delivery
17
Q
Approximate sensitivity and specificity of triple screen? When is it done and what does it screen for? Most common cause of false-positive serum screen?
A
Triple Screen
- Sensitivity: 65-69%
- Specificity: 93%
Between 15-20 weeks, preferably 16-18 weeks
Screens for:
- Trisomy 18
- Trisomy 21
- Neural tube defects
*Most common cause of false-positive is INCORRECT GESTATIONAL AGE
18
Q
Risk factors for increased risk of aneuploidy?
A
- Women older than 35 at delivery if singleton pregnancy (32 if twins)
- Women carrying fetus with major structural anomaly identified by US
- Women with US markers of aneuploidy including increased nuchal thickness
- Women with previously affected pregnancy
- Couples with a known translocation, chromosome inversion, or aneuploidy
- Women with positive maternal serum screen
***Offer prenatal dx by amniocentesis or chorionic villus sampling
19
Q
Most trisomy 21 fetuses are born to mothers older than 35 at time of delivery. T/F?
A
FALSE
Trisomy 21 increases with maternal age but 75% of affected fetuses are born to mothers YOUNGER than 35 at time of delivery
20
Q
When should women be screened for group B strep?
A
ALL women should be offered GBS screening by vaginorectal culture at 35-37 gestation (swab lower vagina, perineal area, and rectum)
If colonized, treat with IV antibiotics at time of labor or rupture of membranes in order to reduce risk of neonatal GBS infection
21
Q
At what week gestation should you consider induction of labor to reduce risk of neonatal mortality and morbidity?
A
42 weeks (twice weekly testing for fetal wellbeing in prolonged pregnancy recommended at 42 week gestation)
22
Q
Influenza vaccine is safe in any stage of pregnancy. T/F?
A
True
provided they have no allergy to its components
23
Q
When do you give RhoGAM to a pregnant woman?
A
Women who are Rh negative and if antibody screen or indirect Coombs test is negative –> then give RhoGAM at 28 weeks gestation and again at delivery if the baby is confirmed as Rh positive
*RhoGAM is given to prevent isoimmunization
24
Q
How is failure to thrive defined?
A
Weight below third or fifth percentile for age
or
Decelerations of growth that have crossed two major growth percentiles in a short period of time
25
You should take blood pressures of children older than age 3. T/F?
True
| If less than three, measure and plot head circumference to monitor growth
26
States vary in terms of which congenital diseaes to screen for but all states require testing for ______
PKU and congenital hypothyroidism
| *since early treatment can prevent development of profound mental retardation
27
Most common cause of anemia in children?
Iron deficiency
28
Risk factors for iron deficiency anemia in children?
Drinking more than 24oz of cows milk
Iron-restricted diets
Low birth weight or preterm
Mother who was iron deficient
29
Leading cause of death in children older than 1 year?
Accidents and injuries
30
Until when should a child sit in a rear facing car seat?
Until they are both 1 year old AND weighs at least 20 bs
Older than 1 and between 20-40lbs should be in forward-facing car seat
>40lbs, child can use booster type seat + lap and shoulder seat belt
*NO CHILD IN THE FRONT SEAT UNTIL 13yo OR OLDER
31
Leading cause of death in infants younger than 1 year?
Sudden infant death syndrome
* Advise parents to place infant on back on firm mattress with nothing else in crib
* *Heavy coverings and soft mattresses are associated with increased risk of SIDS
32
Leading cause of blindness worldwide?
Cataract disease
33
Leading cause of severe vision loss in elderly?
AMD
34
Leading cause of blindness in working-age adults in US?
Diabetic retinopathy
35
What is otosclerosis? What age group do you see this in?
Autosomal dominant disorder of bones in the inner ear --> progressive conductive hearing loss
Onset in late 20's to early 40's
36
Pt has central auditory processing disorder. Would you expect them to be able to understand what you say?
No, they have difficulty understanding spoken language BUT may be able to hear sounds well
37
____% of non institutionalized elderly fall each year.
30%
38
Pt older than 80 yo has a ___% annual risk of falls
50%
39
How does dementia prevalence change as you age?
Doubles every 5 years after 60yo
| By 85yo, 30-50% of people have some degree of impairment
40
What are some rapid and fairly reliable office based screenings for dementia?
Clock draw and three-item recall
| *fail? further test with MMSE
41
Incontinence affects more men than women. T/F?
False
Men 11%-34%
Women 17-55%
42
Depressive symptoms are more common in elderly vs younger populations. T/F?
True
Depressive symptoms = MORE prevalent vs younger populations
MDD = LESS prevalent vs younger populations
43
What is the HHIE-S?
Hearing Handicap Inventory for the Elderly
| - An initial office screening for general hearing loss with reliability
44
A whispered voice test has low sensitivity when evaluating for hearing loss. T/F?
False;
| Sensitivities and specificities range from 70-100%!
45
What is the next step if an elderly patient gives you a positive response to "Have you felt down/depressed/hopeless in the last 2 weeks? Have you felt little interest or pleasure in doing things?"
Follow up with a Geriatric Depression Scale
| 30 question instrument that is sensitive, specific, reliable for dx of depression
46
___% of hospitalized elderly are malnourished.
50%
| vs 15% of older outpatients
47
How do you assess nutritional status in elderly?
MOST USEFUL METHODS:
Serial weight measurements in the office
Inquiry about appetite
48
Protein undernutrition is commonly seen in the ____ setting. Protein undernutrition is associated with an increased risk of:
Nursing home elderly have a 17-56% prevalence of protein undernutrition.
```
Associated with:
Infections
Anemia
Orthostasis
Decubitus ulcers
```
49
_____ are the drug of choice in treating hypertension.
Thiazides (unless a comorbid condition makes another choice preferable)
50
_____ and ____ are the leading causes of death in the elderly.
Heart disease
| Cerebrovascular disease
51
How does stroke incidence in older adults change with age?
Roughly doubles every 10 years
52
What are the 2 greatest risk factors for stroke?
```
#1 Hypertension
#2 Atrial fibrillation (warfarin reduces risk of stroke in those with afib)
```
53
Screening elderly men for prostate cancer is routinely recommended. T/F? Why or why not?
False
Not definitely shown to prolong life
Risk of incontinence or erectile dysfunction caused by treatments
54
How often should an older woman get a mammography?
Every year until life expectancy falls below 5-10 years
55
How often should colon cancer screening happen?
Colonoscopy every 10 years OR
Annual fecal occult testing + flexible sigmoidoscopy every 5 years
Can be stopped when life expectancy is less than 5-10 years
56
When can you stop screening for cervical cancer?
Women older than 65-70 who have had 3 NORMAL PAPS over the preceding 10 years
57
Osteoporosis risk factors?
```
Older age
Female
White or Asian
Low calcium intake
Smoking
Excessive alcohol use
Chronic glucocorticoid use
```
58
How to reduce risk of osteoporotic fractures in both men and women?
```
Calcium carbonate (500mg TID)
Vit D (400-800 IU/day)
```
59
What is DEXA and when would it be used?
Dual-energy x-ray absorptiometry
| - Tests for bone mineral density; may uncover asymptomatic osteoporosis in patients with multiple risk factors
60
Who should get flu vaccines?
Everyone over 6mos, annually
61
One dose of herpes zoster vaccine is recommended at age ____
60 or older
62
Persons older than age 65 should receive at least ______ (immunizations)
One pneumococcal immunization
| Single booster of tetanus and diphtheria
63
Oral advanced directives are legally binding. T/F?
Oral statements are ethically binding but NOT legally binding in all states
*Written AD's are essential so as to give effect to the patient's wishes in these matters
64
How effective is CPR?
Only ~15% of all patients who undergo CPR in the hospital survive to hospital discharge
65
CPR may result in fractured ribs, _____ and _____
Lacerated internal organs
| Neurologic disability
66
Presentation of presbycusis?
Symmetrical high-frequency hearing loss
Loss of speech discrimination
Difficulty understanding rapid speech, foreign accents, conversation in noisy areas
*Sensorineural mechanism, rather than conductive
67
Hallmark physical exam finding in hypertrophic cardiomyopathy?
Systolic murmur that DECREASES in intensity with the athlete in the supine position (increased ventricular filling, decreased obstruction)
*Functional outflow murmurs increase in intensity upon lying down
68
How would the intensity of an HCM murmur change with the Valsalva maneuver?
Increase!
| Valsalva --> decreased ventricular filling, increased obstruction
69
Most murmurs will decrease in intensity and duration with valsalva. T/F?
True
70
How is the HPV vaccine given? What does it protect against?
3 injections over 6 months
Immunization again 4 strains (6, 11, 16, 18)
- 6, 11 for venereal warts
- 16, 18 for cervical dysplasia/cancer
71
What is GAPS?
Guidelines for Adolescent Preventive Services
- Series of recommendations regarding delivery of health services, promotion of well-being, screening for common conditions, and provision of immunizations for adolescents and young adults between 11-21 years old
72
According to GAPS, all adolescents should be screen for eating disorders, obesity, tobacco/alcohol/drug use, AND hypertension. T/F?
True
| Annual hypertension screening and treat those above 90th percentile for gender and age
73
Routine toxicology and lipid screening is recommended for all adolescents according to GAPS. T/F?
False
- Tox screening not recommended
- Lipid screening recommended for above-avg risk based on PMH of comorbid conditions or Family Hx of HLD, CAD, or other vascular diseases
74
Who should have TB skin testing?
- Lived or living in homeless shelter or area with high prevalence of TB
- Been or being incarcerated
- Exposed to active TB
- Working in health-care setting
75
Pap smears should begin at age 21 OR _____
after the onset of sexual activity in immunocompromised pts
76
Symptomatic and high risk males/females should be screened for _______ via _____
Gonorrhea
Chlamydia
via urine nucleic acid amplification
77
Who can you offer Hep A vaccine to?
- Those living in area with high infection rates
- Travel to high-risk areas
- Chronic liver disease
- IVDU
- MSM
78
Who should get a MMR booster?
If pt did not receive a booster at 4-6 years old
79
Meningococcal vaccine is recommended for:
Routine vaccination at 11-12 years old
Tetravalent polysaccharide-protein conjugate vaccine (MCV4)
If not previously vaccinated, vaccinate BEFORE high school! Also vaccinate:
- College freshmen living in dorms
- Military recruits
- Travelers to endemic areas
- Functionally/anatomically asplenic
80
What are the two HPV vaccines and which has been approved for use in boys?
Gardasil and Cervarix: Both recommended for adolescent girls and young women
Gardasil: Approved for use in adolescent boys
*Both are series of 3 injections over 3 months
81
Who should get HPV vaccine?
- Girls as young as 9 (preferred to provide HPV vaccination PRIOR to onset of sexual activity)
- Routinely recommended at age 11-12
- Females 13-26 who have not completed the vaccine series
- Those who have started sexual activity since it may protect against strains of HPV to which the pt has not been exposed
82
Between Gardasil and Cervarix, why would you use one over another?
Both reduce the incidence of cervical cancer associated with the particular strains of HPV that are included in the vaccine
But Gardasil has also been shown to effectively reduce the incidence of genital warts
83
What physical signs do you look for in Marfans? Why?
```
Arachnodactyly
Arm span greater than height
Pectus excavatum
Tall-thin habitus
High-arched palate
Ocular lens subluxation
```
*Pts with Marfans can have aortic abnormalities that predispose to rupture during sports
84
How would you accentuate or decrease a hypertrophic cardiomyopathy murmur?
Accentuated with decreased preload (e.g. standing, valsalva)
Decreased with increasing preload (e.g. squatting)
85
Adolescent comes in with for a sports preparticipation exam. You think you hear a murmur. When should they be evaluated by a cardiologist prior to clearance for athletic participation?
- Any adolescent with stigmata of Marfan syndrome
- A murmur suggestive of HCM w/ grade 3/6 or louder systolic murmur
- Any diastolic murmur
86
Diagnostic study of choice for HCM?
Echocardiography
87
Complete physical exams are advised every year in early adolescence, midadolescence and late adolescence. T/F?
False;
| ONCE in each of those periods; more often when indicated
88
Why is the medial ankle less likely to be injured vs lateral ankle?
Medial: Tibiotalar joint and the strong deltoid ligament complex protect the medial ankle
Lateral - in ordered of most commonly injured:
- Anterior talofibular ligament (ATFL)
- Calcaneofibular ligament (CFL)
- Posterior talofibular ligament (PTFL)
89
Describe a grade 1 ankle sprain
Grade 1 sprain:
- Stretching of ATFL, causing pain and swelling
- No mechanical instability and little/no functional loss
- Pt can usually bear weight with, at most, mild pain
90
Describe a grade 2 ankle sprain
Grade 2:
- Partial tear of ATFL
- Stretching of CFL
- More severe pain, swelling, bruising
- Mild/moderate joint instability
- Significant pain with weight bearing
- Loss of ROM
91
Describe a grade 3 ankle sprain
Grade 3:
- Complete tear of ATFL and CFL
- Partial tearing of PTFL
- Significant joint instability
- Loss of function
- Inability to bear weight
92
What are the Ottawa Ankle Rules? How useful are they?
Decision model designed to aid physicians in determining which pts with ankle injuries need x-rays
Sensitivity approaches 100% in ruling out significant malleolar and midfoot fractures
93
When should foot x-rays be done according to the Ottawa Ankle Rules?
- Bony tenderness of posterior edge or tip of distal 6cm of either medial or lateral malleolus
- Pt unable to bear weight immediately or when examinated
- Bony tenderness over navicular bone (medial midfoot)
- Bony tenderness over base of 5th metatarsal (lateral midfoot)
- Pt unable to bear weight
94
How do you manage ankle sprains? Strains?
Initial management of most acute sprains and strains is: PRICE
Protect, rest, ice, compression, elevation
NSAIDs or acetaminophen PRN for pain relief
95
Sprain vs Strain?
Sprain: Stretching or tearing injury of ligament
Strain: Stretching or tearing injury of muscle or tendon
96
What physical exam findings will help you differentiate between a fracture vs a strain?
Fracture: focal area of bony tenderness
Strain: Tender, tight muscle
97
How can you use ROM to differentiate a dislocated joint vs torn tendon?
Dislocated joint or significant joint effusion:
- Limitations in both passive and active ROM
Torn tendon or muscle injury:
- Limited active ROM
- Preserved passive ROM
98
When do you do a knee xray?
Follow Ottawa Knee Rules; any ONE of the following 5 criteria:
- 55yo or older
- Isolated patella tenderness
- Tenderness of head of fibula
- Inability to flex the knee to 90 degrees
- Inability to bear weight for four steps immediately and in the exam room (regardless of limping)
99
Initial imaging study of choice in evaluating an injury that is failing to improve or to acutely rule out a fracture?
X-ray (minimum series of 2 views at 90 degree angles)
If normal x-rays and continued sx or suspected ligament or tendon injuries of shoulder, ankle, knee, hip, use MRI
*MRI is highly sensitive and specific for articular or soft-tissue abnormalities incl ligament, tendon and cartilage tears
100
When should you start ROM exercises after injury in pts with sprains or strains?
48-72 hours
101
Most common cause of persistently stiff, painful, or unstable joints following sprains?
Inadequate rehabilitation
102
Ottawa Ankle Rules apply to ______
Nonpregnant adult patients who have:
- Normal mental status
- No other painful injuries
- Seen within 10 days of injury
*According to rules, xrays of ankle should be performed if there is bony tenderness of the posterior edge or tip of the distal 6cm of either medial or lateral malleolus, or if the pt is unable to bear weight immediately or when examined
103
90% of low back pain patients will recover within 2 weeks of diagnosis. T/F?
True
| Though 85% of pts who present with isolated low back pain will never be given a specific anatomical reason for the pain
104
How to approach/treat low back pain?
Symptomatic therapies for 4-6 weeks without imaging with close f/u in 1 month
(assuming nonremarkable history)
105
Define herniated disc
Rupture of fibrocartilage between the vertebrae leading to leakage of the nucleus pulposus that may impinge on the nerve roots causing pain
106
When would you consider cauda equina syndrome?
Presenting sx of:
- Increasing neuro deficits
- Leg weakness
- Bowel and urinary incontinence
- Anesthesia, paraesthesia in saddle distribution
- B/l sciatica
Physical:
- Pain elicited by straight leg raise test
- Reduction in anal spinchter tone
- Decreased ankle reflexes
107
What findings do you look for in back pain with possible underlying cancer?
```
History of cancer
Unexplained weight loss
Worsening pain at night
Failure to improve after 1 month of therapy
>50yo
```
--> CBC, ESR, x-rays --> MRI and/or bone scan if needed
108
Sciatica improves with lying down and decreases with Valsalva. T/F?
False
Improves with lying down
Increases with Valsalva, sneezing, or coughing
109
A contralateral leg raise test is more specific for sciatica compared to a straight leg raise. T/F
True
Contralateral leg raise test: 29% sensitive, 88% specific
Straight leg raise: 91% sensitive, 26% specific
110
Vertebral level tested for knee strength/reflex? Great toe and foot dorsiflexion? Plantar flexion and ankle reflexes?
Knee: L4
Great toe/foot dorsiflexion: L5
Ankle reflexes/foot plantarflexion: S1
111
Where do most lumbar disc compressions occur?
90% of lumbar disc compression of nerve roots occurs at L4/L5 and L5/S1
112
You should not MRI sciatica pts. T/F
True
| Not recommended unless sx last for >1mo or if pt is not a candidate for surgery or epidural injection
113
How do you treat sciatica?
Conservative:
- NSAIDs or acetaminophen
- Possibly short-course steroids
- Activity modifications
- Opioids reserved for severe pain and exhausted non-narc options
- PT for persistent mild-moderate sx of 3 weeks or more since majority of pts are likely to experience spontaneous improvement in first 2 weeks
- Surgical if they suffer from disabling radicular pain of 6 weeks or more
114
Common acquired causes of lumbar spinal stenosis?
Degenerative arthritis
| Spondylolisthesis
115
Congenital causes of spinal stenosis?
Dwarfism
Spina bifida
Myelomeningocele
116
How does spinal stenosis present?
Low back and leg pain
Leg weakness
Pseudoclaudication with walking (vascularity of legs intact)
117
Tx of spinal stenosis?
Initially with NSAIDs and analgesics, PT, epidural corticosteroids
118
Spinal stenosis pain is worse with ____ and better with ____
Worse with activity
| Better with bending over, squatting, lying, or sitting
119
Vertebral compression fractures are more common in those with ____
Osteoporosis
| Chronic steroid use
120
How do pts with vertebral compression fractures present?
Acute onset of back pain after certain suddent movements such as lifting, bending, or coughingly
121
Vertebral compression fractures are usual well localized to ______ segment
T12-L2
122
How to evaluate and treat vertebral compression fracture?
X rays of spine
| Treat with pain control, PT, calcitonin and bisphosphonates, treatment of underlying osteoporosis
123
Bed rest for at >2 days is recommended for treating acute mechanical back pain. T/F?
False;
| No significant benefit of best rest >2 days, opioids, or systemic corticosteroids
124
Approach to treating acute low back pain?
```
NSAIDs
Acetaminophen
Muscle relaxants (sedative so use at night)
Heat
Early mobility
```
125
Lumbar support braces prevent back pain. T/F?
False; exercise has been proven to help prevent first episodes of back pain
126
What is microscopic hematuria?
Presence of three or more RBCs per HPF on 2 or more properly collected urinalyses
127
Best next step if patient comes in with asymptomatic microscopic hematuria?
Repeat urinalysis; if it persists, do imaging of upper and lower urinary tract and urine sent to cytology and culture
128
How do you image the upper urinary tract?
Kidneys and ureters are imaged by IV pyelogram or CT scan
129
How do you image the lower urinary tract?
Cystoscopy (endoscopic procedure)
130
Incidence of cancer presenting as asymptomatic microscopic hematuria is LOW/HIGH?
LOW
131
What makes up the ankle?
Distal fibula, distal tibia, talus
132
What tendons stabilize the lateral aspect of the ankle?
Peroneus longus and brevis tendons
133
What is the primary plantar flexor? Primary everters?
Primary plantar flexor: achilles
| Primary everters: Peroneus brevis and longus tendons
134
Common causes of achilles tendinosis?
Training errors
Running in improper shoes
Running on hills
Running on uneven/hard surfaces
135
Common causes of Achilles tendon rupture?
Jumping sports
Complication of steroid injections
Complication of FQ antibiotics
136
What does the talar tilt test test?
Calcaneofibular ligament stability
*Performed by stabilizing the distal lower leg in one hand while grasping each side of the foot at the talus and applying a varus stress
137
What is a positive anterior drawer test of the ankle? What does it test?
3 mm difference between ankles suggests disruption of the anterior talofibular ligament
138
What is a high ankle sprain?
Syndesmosis sprain
| Evaluate via squeeze test that compresses the tibia and fibula together above the midpoint of the calf
139
What is the Thompson test?
Midcal compression test that assesses the Achilles tendon
Pt prone with feet extended over edge, compress gastroc and soleus by squeezing calf and if foot plantar flexes, normal. If foot does not move, test is positive = complete or near complete rupture of the tendon
140
How do you treat grade I sprains?
Symptomatically with RICE
| Does NOT require immobilization, MOVE AROUND
141
How do you treat grade II sprains?
RICE for 48-72 hours + immobilization in a splint for 2-7 days
Crutches if needed
142
Which three ankle/feet fractures should be referred to an orthopedic surgeon?
Jones (base of 5th metatarsal)
Lis Franc (proximal second, third, or fourth metatarsal)
Salter-Harris (growth plate)
143
How do PCL injuries commonly occur?
MVA when flexed knee hits dashboard
144
OA can be managed with twice daily exercise programs and low impact aerobic conditioning. T/F?
True; remember low impact aerobic (most important factor in protecting weight bearing joints is maintaining an appropriate body weight)
Activity that causes pain lasting longer than 2 hours should be avoided
145
Major environmental risk factor for RA?
Smoking
146
OA or RA: Synovium forming a pannus of granulomatous tissue that erods cartilage, ligaments, tendons, and eventually bone.
RA
147
Other than RA, when would see a positive RF?
Bacterial endocarditis
TB
Sarcoidosis
Malignancies
148
How does RF relate to RA?
Up to 40% of RA pts are seronegative early in course when they are often likely to first present.
25% will never have a positive RF so they have "seronegative RA"
149
What are the three management approaches to RA?
Pyramid: for milder RA; NSAIDs for sx, if no improvement in 2-3 weeks, use DMARD (methotrexate or in combo with sulfasalazine or hydroxychloroquine)
Step-down bridge: for very aggressive disease
- High dose oral corticosteroids (60mg prednisone daily) + hydroxychloroquine, sulfasalazine, and methotrexate + folic acid --> then meds withdrawn sequentially and taper corticosteroids
Sawtooth:
- Single or combined DMARDs, usually including TNF receptor blockers
- Local joint flare ups treated with intraarticular injections of corticosteroids
150
Concern with using corticosteroids long term for RA?
Osteoporosis
* Most rapid bone mineral loss occurs in first 6-12 months of therapy
* *Use lowest dose of steroids for shortest period of time, add calcium and vit D
151
What can you treat an RA pt refractory to NSAIDs, DMARDs, and low-dose corticosteroids?
TNF receptor blockers
| e.g. infliximab, etanercept, adalimumab
152
What percentage of joints that will be affected over time in an RA patient will be involved during the first year of the disease?
>90%
153
Poor prognostic factors in RA?
```
Rheumatoid nodules
Extraarticular involvement
Persisting acute phase reactants
>20 joints involved
Psychological helplessness
Significant functional disability within 1 year of onset
```
154
RA commonly goes into remission during ____
Pregnancy
155
Most common inflammatory arthritis in men older than 40?
Gout (more common in men and AA)
156
Contraindicated tx's in acute gout?
Allopurinol
Febuxostat
Low dose aspirin therapy
157
Pts with chronic gout are advised to minimize their intake of beer, liquor, and wine. T/F?
False
| Wine is okay; the former two have purines and block renal excretion of urate
158
Tx for chronic gout in urate overproducers? Underexcretors?
Overproduers: allopurinol, febuxostat
Underexcretors: probenecid
159
How is polymyalgia rheumatica characterized?
Pain and stiffness in cervical spine and shoulder/hip girdles
Affects older, esp women
160
Muscle relaxants are not effective in treating myofascial trigger points. T/F?
True
161
Most common cause of chronic widespread pain in the US?
Fibromyalgia syndrome
162
How is fibromyalgia syndrome characterized?
More in women
| Widespread musculoskeletal pain (all four quadrants and axial skeleton + 11 of 18 tender points on physical exam)
163
How to diagnose polymyalgia rheumatica?
Based on clinical grounds
Elevated sedimentation rate >60mm/hour
Anemia
Occasionally elevated LFTs (esp ALP)
164
What is reactive arthritis?
Refers to rheumatic presentation that follows after certain infections of GI (Shigella, salmonella, campylobacter) or GU tract (chlamydia trachomatis)
165
In which populations would you look out for reactive arthritis?
Young men
HLA-B27 positive
HIV+
166
Triad of reactive arthritis?
Non-gonococcal urethritis
Conjunctivitis
Arthritis
167
What medical emergency should you be concerned about in patients with polymyalgia rheumatica?
Giant cell arteritis (temporal arteritis)
Dx with biopsy of temporal artery
--> inflammatory swelling of temporal arteries --> headaches, loss of vision, scalp tenderness, jaw claudication, sudden blindness
Tx: immediate high-dose steroids
168
What age range has the highest incidence of herniated discs?
30-55yo
169
Key distinguishing factor between sciatica and non-radicular causes?
If sx radiate past the knee since non-radicular causes of LBP do not radiate below the knee
170
Risk factors for osteoporosis?
```
Female, early menopause
Northern European or Asian
Cigarette smoking
Sedentary lifestyle
Chronic steroid use
```
171
When is low back pain considered chronic?
>3 months
172
Most consistently identified risk factor for low back pain?
History of back pain
```
Others:
heavy lifting
frequent bending, twisting and lifting
Repetive work with exposure to vibration
Psychosocial issues like depression, poor coping strategies, somatization, fear avoidance, etc
```
173
Back belts and lumbar supports are recommended for preventing back pain in workers. T/F
False, strong evidence that it is not effective
174
How many people in the US experience an MI each year?
1.5 million people/year
| 1/3 are fatal but continuous decline in mortality over past 3 decades
175
What are the NYHA classifications of angina?
Class I - Angina with only unusually strenuous activity
Class II - w/ slightly more prolonged or slightly more vigorous activity than usual
Class III - w/ usual daily activity
Class IV - at rest
176
What is unstable angina?
New onset angina, with angina at rest or with minimal exertion OR
Crescendo pattern of angina with episodes of increasing frequency, severity, or duration
177
What is the cause of acute MI 90% of the time?
Atherosclerosis leading to plaque rupture and then cascading to coronary artery thrombosis
178
All patients who rule in for MI should receive ____ and ____ if there are no contraindications
Aspirin
| Antithrombotics (e.g. heparin; reduce the risk of subsequent MI and cardiac death in patients with unstable angina)
179
Physical exam findings of pericarditis?
Sharp pain radiating to trapezius that increases with respiration, decreases with sitting forward
Look for global ST elevation noted on ECG too
180
Physical exam findings of PE? Studies?
Sudden onset of pleuritic pain
Tachycardia
Tachypnea
Hypoxemia
D-dimer, V/Q scan, Chest CT, pulmonary angiogram
181
Physical exam findings of gastroesophageal reflux? Studies?
Burning epigatric/substernal pain, acid taste in mouth
Increased with meals
Decreased with PPIs or antacids
Endoscopy, esophageal pH probe
182
DDX of chest pain - physical exam findings of anxiety?
TIghtness sensation of chest
SOB
Tachycardia
183
Physical exam findings of pneumothorax? Studies?
Unilateral sharp pleuritic pain of sudden onset
CXR findings
Unilateral decreased breath sounds and/or hyperresonance
184
First line drug for new onset angina? What drug is contraindicated?
First line are beta blockers; increase survival
*Nitroglycerin would abate chest pain but NOT shown to impact survival
CCB like nifedipine are contraindicated because they increase mortality in multiple trials
