Midterm CIS Content Flashcards
1
Q
An endometrioma AKA chocolate cyst rupture is often secondary to __________
A
Endometriosis
2
Q
What is the severity of endometriosis dependent on?
A
Hormones
**Sx will progressively worsen without tx & endometriosis is assoc with a higher incidence of multiple allergic sensitivities
3
Q
What is the major risk factor for severe rather than mild or moderate endometriosis?
A
Women that have a sister or mother with endometriosis
4
Q
What type of OMM dysfunction should prompt the search for visceral disease and dysfunction and why?
A
Extended lumbar type II dysfunctions are frequently the product of segmental muscle contraction that results from a viscerosomatic reflex and should prompt the search for visceral disease and dysfunction
5
Q
What does the abrupt increase in severity and radiation of endometriosis indicate the possibility of?
A
Rupture
6
Q
Why should you get a CA 125 level in a pt with a suspected ruptured ovarian endometriotic cyst?
A
ruptured ovarian endometriotic cysts can sometimes mimic ovarian malignancy because of the extremely elevated serum CA 125 concentration
7
Q
What imaging modality is best for detecting hemoperitoneum active bleeding?
A
CT by the active arterial extravasation of IV contrast with a measured attenuation value higher than that of free or clotted blood -> need for prompt surgical intervention
8
Q
What are the signs and sx of endometriosis?
A
- dysmenorrhea
- pelvic pain due to intrapelvic bleeding and periuterine adhesions
- menorrhagia
- hormone dependent
- dyspareunia
- lumbago
- rectal pain
- dyschezia
- infertility
- increased allergic reactions
- positive family history
**may be asymptomatic
9
Q
What are the PE findings assoc with endometriosis?
A
- best performed during early menses
- pelvic tenderness
- nodules found on bimanual exam on uterosacral ligament or in post cut-de-sac
- dec uterine mobility/retroversion
- tender/fixed nodular adnexal masses
- SD of lumbar spine or chapmans points
10
Q
How do you make a diagnosis of endometriosis?
A
- CA-125 may be elevated
- get HCG to r/o pregnancy
- UA to r/o UTI
- CBC, CMP, STI’s
- consider MRI/CT for advanced/severe cases
**Often very difficult to dx endometriosis w/o surgical confirmation
11
Q
_________ (imaging modality) is frequently performed as the first imaging modality for the evaluation of abdominal and pelvic pain of unknown etiology
A
CT
12
Q
What can endometriomas look like on transvaginal US?
A
homogenous cysts
13
Q
What are the visual lesions assoc with endometriosis that are seen on laparoscopy?
A
- classic finding = black powder burns
- non classic finding = red/white lesions
14
Q
What are the potential complications of endometriosis?
A
progressive worsening course -> implants spread to pelvis, GI tract, urinary tract, iliopsoas muscles and lumbar spine
15
Q
What are the etiologies of endometriosis?
A
- retrograde menstruation
- coelomic metaplasia of multipotential cells in peritoneal cavity
- extrauterine stem/progenitor cell
- metastases to bone, lung & brain via vascular/lymphatic dissemination
- presence of abnormal factors like pro inflammatory factors, inc estrogen production by stroll cells, assoc between endometriosis and cancer or shared gene mutations
16
Q
What does the mesonephros give rise to in males?
A
epididymis and ductus deferens
17
Q
What do the mullein ducts (paramesonephric ducts) give rise to in males vs females?
A
- males = vagina masculina, appendix testis
- females = upper parts form uterine tubes & lower parts form uterus and upper vagina
18
Q
What 2 types of cancer is endometriosis assoc with?
A
Endometrioid cancer
clear cell ovarian cancer
19
Q
What is the coelom and what is it derived from?
A
- cavity between splenic and somatic mesoderm in the embryo that forms the lining of the general body cavity in the adult
- derived from mesoderm
20
Q
What do the mullerian ducts and endometrium originate from?
A
Mesothelium
21
Q
What are the viscerosomatics assoc with endometriosis?
A
- sympathetic = T10-L2
- parasympathetic = S2-4
22
Q
What chapmans points would you expect to find in a pt with endometriosis?
A
- anterior = ascending ramps of the pubis
- posterior = transverse process of L5
23
Q
What are the OMM contraindications assoc with endometriosis?
A
- no absolute contraindications
- relative contraindication is inc pain with treatment -> want to use more indirect tx; don’t usually use HVLA
24
Q
What are the rules of 3s assoc with thoracic spinous process and transverse process?
A
- T1-3 = SP is in same plane as TP
- T4-6 = SP is 1/2 way b/w its own TP and the TP below
- T7-9 = SP is in the plane of the TP one vertebrae below
- T10 = one level below
- T11 = 1/2 way
- T12 = same plane
25
What is the normal ROM for thoracic side bending and rotation?
- sidebending = 40 degrees
| - rotation = 90 degrees
26
At what vertebral level is the most superior portion of the iliac crest?
Spinous process of L4
**All lumbar spinous processes are in the same plane as the transverse processes
27
what nerve roots are responsible for ankle dorsiflexion vs great toe dorsiflexion vs ankle plantar flexion?
- ankle dorsiflexion = L4/L5 nerve root
- great toe dorsiflexion = L5 nerve root
- ankle plantar flexion = S1 nerve root
28
What are the normal ROM's assoc with the lumbar spine?
- flexion = 40-90
- extension = 20-45
- sidebending = 15-30
- rotation = 90
29
Explain the hip drop test
- assess lumbar sidebending
- pt is standing and instructed to bend one knee keeping both feet on the ground; note the amt of lumbar side bending created by the drop in iliac crest height -> normal is 15-30 degrees
- repeat with contralateral side and compare
- if the hip on the unsupported side drops 15 degrees its a normal (negative) test if it doesn't drop 15 then its a positive test on unsupported side
30
What does it mean if the right iliac crest drops 10 degrees during a hip drop test?
Positive R hip drop test -> problems with left sidebending
31
Explain a straight leg raising test (Lasegue test)
- tests for sciatic nerve irritation by stretching the dura
- pt is placed in supine position with knee extended, medially rotate and adduct the pts hip then flex the hip while maintaining knee extension, continue until pt experiences pain in the back of the leg
- sx shouldn't be felt in the lower leg until the leg is raised 30-35 degrees
- if pain is felt at a lesser angle or in opposite leg may indicate a disc protrusion or rupture or radiculopathy
- dura starts stretching at 30degrees, pain above this angle may indicate nerve root irritation, but >70degrees may be related to mechanical low back pain secondary to muscle strain or joint disease
**Check supine and seated for consistency
32
What is the normal ROM for the C-spine?
- rotation = 70-90
- sidebending = 20-45
- f/e = 45-90
33
What are the atypical cervicals?
C0, 1, 7
34
Where do the cervical nerve roots exit in relation to the corresponding vertebral body?
above the numbered vertebra
35
What are the primary motions of the OA joint?
Flexion and extension
36
What does a positive valsalva test of the C-spine indicate?
space occupying lesion in cervical canal
37
What are the boundaries of the thoracic outlet?
1st ribs, 1st thoracic vertebrae, manubrium
38
What are the structures of the thoracic outlet?
Brachial plexus
subclavian v and a
thoracic duct on the L side
39
What is the Roos or EAST test?
- abduct shoulder to 90 and ER w/elbow flexed (football goals); doc instructs pt to open and close fist for up to 3 mins
- positive test = reproduction of sx (pain/paresthesias) -> indicates thoracic outlet syndrome, specifically compression of the subclavian artery
40
What is an adson test?
- locate radial pulse on affected arm and abduct, extend and ER shoulder while feeling pulse
- first pts head is extended and rotated toward affected side then its extended and rotated away
- positive test = loss or change in pulse or reproduction of sx (pain/paresthesias) -> indicates thoracic outlet syndrome, specifically compression of the subclavian a between scalene (when looking away) or 1st rib/cervical rib (when looking toward)
41
What is the Wright's hyperabduction test?
- doc locates and monitors radial pulse on affected side then abducts the arm above the head with some extension
- positive test = loss or change in pulse; reproduction of sx (pain/paresthesias) -> indicates thoracic outlet syndrome, specifically neuromuscular entrapment by pec minor
42
What is the costoclavicular test (military/halstead test)?
- doc locates and monitors radial pulse on affected side with elbow extended and supinated, extend the shoulder and apply caudal pressure eon the shoulder
- positive test = loss or change in pulse; reproduction of sx (pain/paresthesia) -> indicates thoracic outlet syndrome, specifically neuromuscular entrapment between 1st rib and clavicle
43
What is a brudzinski sign?
- pt supune and doc flexes neck forward until chin touches chest
- positive test = flexion in both hips and knees -> indicates inflammation in subarachnoid space (ex. meningitis or subarachnoid hemorrhage)
44
What is a kerning sign?
- pt supine and doc flexes hip and leg then extends leg at the knee
- positive test = increased resistance to extension and pain behind the knee, +/- back pain radiating to post thigh -> indicates meningeal/dural irritation
45
What is a jefferson fracture?
Axial compression -> C1 fracture
46
What is a wedge fracture?
Flexion and compression injury
47
What is a dens fracture?
C2 odontoid fracture at junction of process and body. often requires surgery
48
Whats a hangman's fracture?
Hyperextension injury -> C2 b/l arch fracture
49
Whats a clay shovelers fracture?
C6 or C7 fracture
50
Whats a teardrop fracture?
Flexion and compression injury -> anterior-inferior teardrop fragment
51
anterior subluxation is an injury of what motion of the vertebral column?
flexion injury -> facet dislocation without fracture
52
Pt presents with painless cervical LAD that spontaneously comes and goes but doesn't completely disappear. The pt is here for a routine annual exam and feels fine. What is the most common type of leukemia that they could have?
CLL
**5-10% present with classic B sx of lymphoma
53
What are the classic B sx of lymphoma?
- unintentional weight loss >/= 10% of body weight w/in 6mo
- fever >100.5
- drenching night sweats w/out evidence of infection
- extreme fatigue
54
What is the most common abnormal finding on PE of a pt with CLL?
LAD -> most commonly affects the cervical, supraclavicular and axillary regions
55
What are the characteristics of malignant LAD
firm, rounded, discrete, nontender and freely mobile
56
Is there organ enlargement assoc with CLL? if so, what?
yes, splenomegaly which is usually painless and nontender to palpation
**sometimes the liver is enlarged too
57
What is the most commonly involved non-lymphoid organ at the time of CLL dx?
the skin -> these lesions most commonly involve the face and can manifest as macule, papule, nodules, ulcers or blisters
58
What 2 organ locations are uncommon for CLL involvement at the time of dx?
GI mucosa and meninges
59
What is the most noteworthy lab abnormality found in CLL?
Lymphocytosis in the peripheral blood and bone marrow
** Absolute blood lymphocyte threshold for dx of CLL is >5000 but some pts have counts as high as 100,000
60
What is the most common type of anemia seen in CLL pts?
Autoimmune hemolytic anemia -> direct antiglobulin (Coombs) test (DAT) may be positive at some time during the course of the disease
61
When is autoimmune thrombocytopenia suggested in CLL pts?
when a BM biopsy shows adequate numbers of megakaryocytic but the peripheral blood has an abnormally low platelet count.
62
What happens to Ig levels in pts with CLL?
usually all 3 Ig classes are decreased but some pts may only have a decreased in one or 2 classes
**significant hypogammaglobulinemia and neutropenia result in increased vulnerability of CLL pts to major bacterial infections
63
What should be included in a diagnostic workup of CLL?
- CBC with diff
- examination of peripheral smear
- flow cytometry of peripheral blood for Immunophenotypic analysis of circulating lymphocytes
64
T/F: BM aspirate and biopsy and LN biopsy are not required to dx CLL
True
65
T/F: Chromosomal changes seen in CLL are diagnostic
FALSE -> chromosomal changes are not diagnostic
66
Explain the morphology of a peripheral blood smear of a pt with CLL
- small, mature appearing lymphocytes with a dense nucleus
- these pro lymphocytes usually account for a minority of the overall population of lymphocytes
- smear also often contains smudge cells (AKA basket cells)
67
What is the dx criteria for CLL?
The following 2 must be met
- Absolute B lymphocyte count in peripheral blood >/=5,000 with predominant population of morphologically mature-appearing small lymphocytes
- demonstration of clonality of the circulating B lymphocytes by flow cytometry of the peripheral blood
68
What monoclonal B cell markers should a majority of the B cell population express in CLL?
- extremely low levels of SmIg and either kappa or lambda but not both light chains
- expression of B cell assoc Ags (CD19, 20, 23)
- expression of Cell assoc Ag CD5
69
How do you predict mortality for pts with community acquired pneumonia?
Assign 1 point for each...
- confusion
- BUN >20
- RR > 30
- BP: systolic <90 or diastolic = 60
- Age >/= 65yo
* *0-1 pt = treat as output; 2pt = treat as inpatient; 3 or more = treat in ICU
70
What genetic translocation is assoc with mantle cell leukemia?
t(11;14)
71
What does mantle cell lymphoma strong staidly for?
cyclin D1 and surface membrane Ig
72
What are the cell markers associated with hairy cell leukemia?
```
CD11c
CD103
CD123
cyclin D1
Annexin A1
```
**No CD5 like other B cell leukemias/lymphomas
73
Differentiate between CLL and monoclonal B cell lymphocytosis
identical to CLL but absolute increase in the number of clonal B cells in the peripheral blood does not exceed 5,000
**Pts are also asymptomatic
74
When indicated, how many doses of PCV 13 are recommended for adults?
Only a single dose
**No additional dose is indicated for adults vaccinated with PPSV23 or after 65yo
75
When both PCV13 and PPSV23 are indicated, which should be administered first?
PCV13
**they should not be administered during the same visit
76
What vaccinations are contraindicated in pregnant women?
varicella
zoster
MMR
77
What immunization should be given to every pregnant woman?
Tdap -> given for every pregnancy
78
What are the top 4 organisms that cause community acquired pneumonia in outpatients in decreasing order?
mycoplasma pneumoniae > respiratory viruses > strep pneumoniae > chlamydophila pneumoniae
79
What are the top 4 organisms that cause community acquired pneumonia in inpatients not admitted to the ICU in decreasing order?
Strep pneumoniae > respiratory viruses > mycoplasma pneumoniae > H. influenza
80
What are the top 4 organisms that cause community acquired pneumonia in inpatients admitted to the ICU in decreasing order?
Strep pneumoniae > legionella > gram - bacilli and staph aureus
81
What type of OMT should be done to address biomechanics dysfunctions for the pneumonia pt?
INDIRECT -> esp cervicals, scalenes, pectorals, ribs, thoracics, diaphragm
82
What lymphatic treatments should you do for the pneumonia pt?
- zink patterns and diaphragm release with vacuum
| - tapotement/cupping/slapping to break up consolidation
83
When should chapmans points of a pneumonia pt be addressed?
after addressing all other somatic dysfunctions
84
Where would you expect to find anterior chapman's points in a pneumonia pt?
- 2nd ICS along sternal border = heart, bronchi, esophagus
- 3rd ICS along SB = upper lung
- 4th ICS along SB = lower lung
85
What OMT cranial considerations should be made for a pneumonia pt?
- dural tension
- tension around jugular foramen - relieve vagus
**These would be considered SNS treatments
86
What cranial treatment could be used to treat general ANS of a pneumonia pt?
CV4
87
How does an inc parasympathetic tone affect pneumonia sx?
Thickens secretions and causes relative bronchiole constriction
88
What PNS treatments can you do for a pneumonia pt?
- OA, AA, C2
- tenderpoints
- compression of occipitomastoid sutures and occipitoatlantoid joint
89
How does an inc sympathetic tone affect pneumonia sx?
causes bronchiole dilation
90
What SNS treatments can you do for a pneumonia pt?
T1-7 -> direct inhibition, tenderpoints, gentle rib raising
91
What treatments could you do on a pneumonia pt to inc ANS motor
C3-5 (phrenic nerve to the diaphragm; irritation caused by dec excursion and overuse)
**Can also treat tenderpoints
92
How can lymphatic pumps help a pneumonia pt?
has been shown to inc circulating leukocytes reflecting an enhancement of the immune response
93
What behavioral modifications can be made to help treat a pneumonia pt?
- maintain hydration
- nutritious diet
- reassurance -> the ability to give sx relief inc the pt trust in you
94
Where would you expect to find posterior chapman's points in a pneumonia pt?
- lateral to SP of T2 = bronchi, esophagus
- Intertransverse space between T2-3 & intertransverse space between T3-4 = upper lung
- Intertransverse space between T4-5 = lower lung
95
Explain the "VINDICATE" mnemonic for creating a ddx
```
Vascular
Infection/inflammation
Neoplasm
Drugs (toxins)
Idiopathic/iatrogenic
Congenital
Autoimmune/allergic
Trauma
Endocrine/metabolic; Environment/work
```
96
What is Whipple's Triad?
- sx potentially explained by hypoglycemia
- low blood glucose during sx
- relief of sx with administration of glucose of glucagon
97
How is hypoglycemia treated?
- removing offending agent
- fast acting carbs -> glucose tablets, hard candy, fruit juices
- severe cases = D50 or glucagon
- hospitalization: snacks in between meals and at bedtime
- frequent glucose monitoring
98
What is the IV fluid choice for hypoglycemia?
- D5 or 10 - supportive only; until sulfonylurea has normalized -> 24-48hrs
99
when giving NS IV fluids to a DKA pt, what needs to be monitored?
- Na & Cl
- glucose
- anion gap and pH
100
What are the effects of insulin on the muscle vs adipose tissue?
- muscle: inc glut 4 on cell membrane and inc glycolysis
| - adipose: inc glut 4 on cell membrane and inc lipogenisis
101
What effect of insulin helps normalize ketonemia in a DKA pt?
Increased lipogenesis -> inc utilization of ketone bodies for fat generation and dec lipolysis
102
Explain glyburide
- 2nd gen sulfonylurea
- blocks K-ATP channel
- **NOT a euglycemic drug
103
What happens when glyburide and naproxen are given together?
enhanced hypoglycemia -> both drugs are tightly albumin bound so adding naproxen will inc free glyburide in the blood
104
What happens when glyburide and alcohol are given together?
enhanced hypoglycemia -> ethanol enhances glyburide effects and inhibits gluconeogenesis
105
Why is glucagon not a good choice for treating glyburide-induced hypoglycemia?
- very short acting -> T1/2 ~10 min
| - may not be effective in cases of prolonged hypoglycemia when glycogen stores are depleted
106
What is the DOC for glyburide-induced hypoglycemia?
Octreotide -> somatostatin receptor agonist -> suppresses insulin release by beta-cells
107
What is the major treatment for DKA due to an insulin deficit?
hydration!
**can give insulin too
108
What effect does DKA have on K+ levels?
Causes K+ levels to shift from the cells to the serum resulting in pseudohyperkalemia
109
what are Kussmaul respirations?
deep rapid respirations associated with acidosis
110
How is anion gap calculated?
Na-(Cl + HCO3)
111
What are the causes of metabolic acidosis w/an anion gap?
```
MUDPILES:
Methanol
Uremia (renal failure)
DKA
Paraldehyde/propylene glycol
Infection/iron/isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
```
112
Pt presents w/ CC of abdominal pain. He is found to have kussmaul breathing, unintentional wt loss over last 2 months, polyuria, polydipsia, polyphagia, hyperglycemia, positive ketones in urine and blood, low pH with anion gap. What is the dx?
DKA
113
what is the most common cause of hypoglycemia?
medications
**Organ failure and sepsis can also cause; rarely hormonal deficiency or endogenous hyperinsulinism
114
What medications most commonly cause hypoglycemia?
exogenous insulin, sulfonylurea and meglatinides and alcohol
115
Where should you admit a pt with DKA or hypoglycemia?
ICU -> one-on-one nursing, continuous cardiac monitoring, and frequent lab evaluation
116
What is the most important tx for DKA?
DKA requires high volume of Intravenous fluids (fluids/fluids/fluids-dehydrated)
117
what electrolytes typically need replaced and monitored in DKA pts and which are covered in a CMP vs need to be ordered separately?
K, Mg, phosphorous -> only K comes in CMP
118
When blood glucose is high, you should calculate a corrected sodium value. How do you do this?
Na + [(glucose -100) x 0.016]
119
What IV fluid is given initially to DKA pts and when/why is it changed?
Initially normal saline, switch to D51/2 NS when patient on insulin gtt when their glucose gets to 250 to prevent hypoglycemia
120
What is the goal of treatment for DKA?
FIX ACID BASE DISTURBANCE NOT BRING SUGAR TO NORMAL LEVEL
**they can have a “normal” sugar and still have an anion gap acidosis, they will go right back into DKA if you stop too soon.
121
When can you end a DKA protocol?
When gap closed -> Switch to subcutaneous (SQ or SC) insulin, stop gtt 2 hours after administration of SQ long acting (they
will go right back into DKA if you stop too soon.)
122
Pt presents with Weakness or shakiness, sweating (diaphoresis), altered mental status (confusion, slurred speech), seizure. He has a FH of gout and dementia, what is the most likely dx?
hypoglycemia
123
what is the best tx for hypoglycemia when the pt is awake and alert?
fast acting carbohydrates such as oral glucose tablet, hard candy
124
What is the best tx for hypoglycemia when the pt has a decreased level of consciousness or seizure?
intravenous D50, glucacon IM
**Once the acute symptoms are improved, identify the cause of hypoglycemia. Medications are the most cause of hypoglycemia. Patients with DM and episodes of hypoglycemia require a thorough review medication use, diet and exercise habits.
125
Chapman point of Pancreas
R 7th intercostal space tissue texture changes
126
Sympathetics of Pancreas
T5-10 (increased warmth, tension, and moisture)
127
Parasympathetics of Pancreas
OA E RLSR, AA RR
128
What are the sympathetics and parasympathetics to the kidneys?
- Kidneys:T10-L2onR
| - Kidneys: OA, AA
129
Chapman point of kidney
1" superior and 1" lateral to the umbilicus
130
What cranial techniques can be used on the DKA or hypoglycemic pt?
CV4 or condylar decompression can be used to promote lymphatic flow and restore CRI. Could be used for patients with complications of cerebral edema s/p DKA
131
what does the Right Lymphatic Duct drain?
Drains right head and neck, right UE, all lung lobes except upper left
**Thoracic duct drains the rest of the body
132
what is the sequence of lymphatic drainage of the body from the thoracic inlet back to the thoracic inlet?
Thoracic Inlet -> Thoracic Area -> Abdominal Area -> UE or LE depending on which is more dysfunctional -> UE or LE -> Head and Neck -> Thoracic Inlet
