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62 Cards in this Set

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What muscles comprise the rotator cuff and what is the function of each?
SITS
Supraspinatus: Shoulder abduction

Infraspinatus: Shoulder external rotation

Teres Minor: External rotation of shoulder

Subscapularis: Internal rotation of shoulder
What are non-musculoskeletal causes of referred shoulder pain?
MI
Lung Cancer
Cholecystitis
Ruptured Ectopic pregnancy
Which musculoskeletal causes of shoulder pain require urgent management?

Why?
Septic glenohumeral arthritis or septic subacromial bursitis

Delay in treatment may lead to tissue destruction, loss of function; extension of infection may lead to osteomyelitis, bacteremia, sepsis
What are red flags for septic arthritis?
Causative organisms?
Red flags: Local redness, swelling; systemic complaints: fever, chills, myalgias

Etiology: primarily staph (including MRSA); lesser extent strep

Predisposing facors: DM, EtOH, immunocompromised

Requires urgent evaluation with u/s or MRI, consult with ortho
Loss of active AND passive ROM is more likely due to ______.
Joint disease
Loss of only active ROM is more likely due to ________.
Muscle tissue pathology
Tine pedia:
Definitive test
Treatment
Scrape sample and expose to KOH

Tx: Tolnaftate (tinactin) bid
Poor posture or rounded shoulder may indicate ________.
Impingement syndrome
Boney deformity in the area of the clavicle or acromioclavicular joint may indicate ________.
Fractured clavicle or sprain of the AC joint
Fullness of the anterior shoulder with a large dimple in posterior shoulder may indicate ________.
Anterior dislocation
Atrophy of large shoulder muscles like deltoid or pactoralis major may indicate _________.
Immobilization or lack of use of joint
Atrophy of smaller shoulder muscles like supraspinatous or infraspinatous may indicate ________.
Torn rotator cuff or nerve impingement
Which muscle is being tested:
Externally rotate with elbows at side
Infraspinatous
Teres minor
Which muscle is being tested:
Internally rotate with elbows at side
Subscapularis
Which muscle is being tested:
Empty can test
Supraspinatous
Where is the damage:
Unilateral scapular winging
Long Thoracic Nerve
Where is the damage:
Bilateral scapular winging
Weakness in scapular stabilizers
What is the Apley scratch test? What does it assess?
Place hand over shoulder behind back and reach for opposite shoulder blade

If pain/decreased ROM-->rotator cuff tendonitis

If unable to raise arm above head: rotator cuff tear
If significant pain/decreased ROM-->impingement/bursitis
What is a sulcus sigan and what does it indicate?
With pt seated, apply downward traction on arm as it hangs by side; look for indentation to appear just below acromion process.

If present, there's inferior glenohumeral instability.
A positive Apley's scratch test indicates _______.
Rotator cuff tendonitis--possible to have preserved ROM and minimal pain with this diagnosis
How does a rotator cuff tear differ from tendonitis in presentation?
Partial/limited rotator cuff tear: Limited ROM with significant pain

Complete tear: Unable to raise arm above head; after a few weeks will result in muscle atrophy
What tests rule out subacromial impingement or bursitis?
Neer, Hawkins-Kennedy
What tests/findings indicate shoulder instability?
Positive sulcus sign
Positive anterior/posterior translation tests
When is an x-ray indicated in rotator cuff injury?
In acute setting, when fracture and/or dislocation are suspected

In chronic setting, when there's red glag for infection/tumor.
What imaging modality is most commonly used for assessment of rotator cuff injury?
MRI--note no imaging studies recommended in initial evaluation of rotator cuff pathology
When is CT scan indicated in assessment of rotator cuff injury?
In setting of complicated fracture, suspected tumor, or in situations where MRI is contraindicated
Management of rotator cuff tendonitis and instability.
Relative rest to limit further damage

Physical Therapy to improve ROM, increase muscle strength of shoulder stabilizers

Topical NSAIDs

Subacromial joint injection after trying above treatments first (usually involves mixture of local anesthetic and corticosteroid)
How does fatigue differ from sleepiness?
Fatigue: feeling of exhaustion or tiredness that is pervasive, NOT relieved by rest, and often worsened by exertion

Sleepiness: Feeling of tiredness that gives a pt tendency to fall asleep, often relieved by either rest or exertion
What are causes of primary fatigue?
Chronic fatigue syndrome
Fibromyalgia
Secondary vs Physiologic causes of fatigue.
Secondary: side f/x of meds, DM, hypo/hyperthy, anemia, acute infection, CV disease, malignancy, chronic conditions such as RA, malignancy, pregnancy, electrolyte imbalances

Physiologic causes:
Acute decrease in sleep
Alternating shift work
Inadequate or poor quality of sleep due to primary sleep disorder (restless leg syndrome, sleep apnea), lifestyle issues (inc'd physical exertion), medical causes (sleep interrupted by nocturia/pain)
What are the USPSTF A, B, C, D, I recommendations?
A: Preventive intervention strongly recommended
B: Recommended
C: Balance of benefits and harms too close to make recommendation
D: Recommends against use of intervention
I: Evidence insufficient for recommending for or against intervention
What are the USPSTF recommendations for breast cancer screening?
Mammogram with or without clinical breast exam every 2 years for women 50+ (Grade B recommendation)

Refer women with strong family history for BRCA genetic counseling
What are the USPSTF recommendation for cervical cancer screening?
Screen women who have been sexually active and have a cervix (Grade A)
What are the USPSTF recommendations for colorectal cancer screening?
Fecal occult testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 and continuing until age 75 (Grade A)

If life expectancy under 10 years, unlikely benefit to screening
What are the USPSTF recommendations for PSA screening? Category?
PSA testing NOT recommended for prostate cancer. PSA screening has minimal or no survival advantage.

Grade I recommendation
Which cancer screenings have a Category D recommendation?
Pancreatic cancer screening
Testicular cancer screening
What are the USPSTF recommendations for total body skin exam?
Category I
What are the patient barriers to screening?
Lack of awareness
Denial of vulnerability
Lack of insurance
Not having received a screening recommendation
Fear of pain with a procedure
Fear of finding bad results
What is the second most common cause of cancer-related death in the US?
Colorectal cancer
What diseases increase risk for colorectal cancer?
Personal h/o ovarian, endometrial, breast cancer

Personal h/o long-standing ulcerative colitis or Crohn's colitis

h/o DM
What is the SPIKES strategy for delivering bad news?
Set up interview (private room, sit face to face with patient)
Perception (before you tell, ask what pts knows)
Invitation (ask how pt would like to explain information about diagnosis)
Knowledge (give knowledge and information)
Emotions/Empathy (identify emotion patient is feeling and identify reason for it)
Strategy/Summary: lay out plan for what will happen next
What is chronic fatigue syndrome?
Criteria for diagnosis?
Syndrome that causes disabling levels of fatigue lasting more than 6 months

Fatigue is characterized as being unrelieved by rest and worsened with exertion

6+ months disabling fatigue not explained by any other medical cause

Plus 4 of these: impaired memory/concentration, post-exertional malaise, tender LAD, sore throat, HA, myalgias, arthralgias

Note that this is a diagnosis of exclusion.
What lab tests should be ordered to evaluate fatigue?
CBC
Iron studies if blood loss suspected
ESR fi signs of CT disease or chronic infection
Glucose
TSH


DO NOT ORDER EBV TITER
Medical management of iron deficiency anemia in adult male.
Ferrous sulfate 325 mg TID
Docusate sodium 100 mg bid PRN constipation
Colonoscopy if concerned for GI cause
Who should be screened for rubella susceptibility?
All females of childbearing age
Who should be screened for gonorrhea/chlamydia?
Women under 25 and others at inc'd risk
What are the symptoms and diagnostic tests for chlamydia?
Dysuria
Penile/vaginal discharge
Dyspareunia
Abdominal or testicular pain
Breakthrough bleeding
May be asymptomatic

Dx: Nucleic acid amplification of urine, endocervical sample, or urethral sample

SAME GOES FOR GONORRHEA
What are the symptoms and diagnostic tests for trichomonas?
Vaginal discharge with odor or itching

May be asyx

Dx via saline wet mount, rapid antigen testing, trichomonas culture
What are the three main types of testicular tumors? Which is the most common?
Germ cell tumor (95% of primary testicular tumors; classified as either seminoma, (45%) or nonseminoma (50%))

Non-germ cell (Leydig cell, Sertoli cell tumors)

Extragonadal (lymphoma, leukemia, and melanoma are most common malignancies that mets to testicle)
What are the risk factors for testicular cancer?
KLINEFELTER'S (47XXY) have higher incidence of testicular cancer; as do those with Down syndrome, testic feminization, true hermaphrodites

FMH
Cryptorchidism
Exposure to DES, agent orange, solvents used to clean jets

h/o prior testicular cancer
What interview topics should be addressed in an adolescent interview?
HEEADSS
Home
Education/Employment
Eating
Activities
Drugs
Sexuality
Suicide/Depression
Safety/Violence
What is testicular lie?
What is a normal lie?
Position of testicle within scrotum (high vs low)--left testicle normally sits slightly lower than right
What is the cremasteric reflex?
What is its diagnostic utility?
Light stroking of superior medial thigh results in brisk ipsilateral testicular retraction

Should be attempted after inspection and before palpation

If reflex is present, may r/o torsion (reflex is usually absent with torsion)
What is the blue dot sign?
What is its diagnostic utility?
Small bluish discolorartion visualized through skin of upper pole of testis--pathognomonic for appendiceal torsion
What is Prehn's sign?
What is its diagnostic utility?
Physical lifting of testicles relieves pain of epididymitis but not that caused by testicular torsion?
What are the signs and symptoms of acute epididymitis?
Relatively rare, but can cause serious illness

Severe swelling, exquisite pain in involved side (isolated to edpidymis)
Often accompanied by high fever, rigors, irritative voiding symptoms
What are the signs and symptoms of a hydrocele?
Painless scrotal fluid collection; may complain of slowly growing mass that causes pulling or dragging sensation

Generally asyx unless a/w infection/trauma
What are the signs and symptoms of a varicocele?
Collection of dilated and tortuous veins in plexus surrounding spermatic cord

Most commonly on left side (85-95%)
This hernia develops as a result of persistent process vaginalis.
Indirect hernia
This hernia develops as a result of weakness in the transversalis fascia.
Direct hernia
Color Doppler Ultransonography vs Radionuclide Scintigraphy:
What can these both assess?
Difference?
Color Doppler U/S:
If torsion present, intratestic blood flow is decd or absent
Faster, more readily available

Radionuclide scintigraphy:
If torsion present, dec'd radiotracer in ischemic testis
100% sensitivity, may help prevent unnecessary surgery when color Doppler u/s shows equivocal flow
Medical management of testicular torsion.
Immediate surgery within 6 hours after onset of pain

Delay can lead to loss of testis, which may lead to impaired fertility

Viability of testis is 90% at 6 hours
50% at >12 hours
10% at >24 hours