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140 Cards in this Set
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a 26 yo woman presents with:
*chest pain *fever *facial rash (malar) *pain and stiffness of her hands and wrists *fatigue hx of two miscarriages PE: erythematous rash on cheeks U/A shousl 5-10 RBC's what is dx? |
SLE
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what is SLE?
what gender is it more predominant in? |
chronic inflammatory connective tissue disorder of unknown etiology that can involve joints, kidneys, serous surfaces and vessel walls.
occurs predominantly in young women but also in children |
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what lab value will be high in SLE?
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ANA (antinuclear antibody)
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what must be r/o before making dx of SLE?
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Drug induced lupus like rxn
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what are some key differences of drug induced lupus?
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drug induced:
1.equal sexes 2. renal and CNS not usually involved 3. no hypocomplemetntemia or ab to native DNA |
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how does cutaneous lupus differ from systemic?
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cutaneous is exclusive to skin whre as systemic involves organs
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what is often first sx of SLE?
what would make you suspect SLE on a teen girl? |
*polyarthritis
*alopecia |
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what is a classic rash assoc with SLE?
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malar rash
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what is the dx criteria for SLE?
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must have any 4 or more of 11 possible sx
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what are disorders that mimic SLE?
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*RA
*Mixed connective tissue dz *scleroderma *metastatic malignancy *Psychogeni rheumatism *seb dermatitis * |
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what is tx for mild or remittent SLE?
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there is no tx of choice
*Rest, NSAID, ASA for arthralgia *antimalarials(hydroxychloroquine) for skin and joint |
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what is tx of severe SLE
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*Prednisone (40-60 mg)
*immunosuppressnats *ace inhibitors for proteinuria and heart failure |
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what is leading cause of death in SLE patients?
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opportunistic infection
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what is Sjogrens syndrome?
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chronic systemic inflammatory disorder of unknown etiology characterized by DRYNESS of
*mouth *eyes *other mucous membranes |
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what is most common sx of Sjogrens syndrome?
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*dry eyes and mouth
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what is the word for dry mouth?
what is word for dry eyes? |
mouth=xerostomia
eye=keratoconjunctivitis |
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what are dz that can cause Sjogrens as secondary complication?
what is a potential complication to watch for? |
*SLE
*RA *scleroderma watch for lymphoma |
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what are common diagnostic tests?
what is the only specific dx test? |
tests include:
1. schirmers tear test ( 2. autoantibodies testing 3. lower lip minor salivary gland(ONLY SPECIFIC DX) |
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what is a common cause of Sjogrens to think about before SLE, RA etc.
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meds
*antidepressents *antocholinergics *BB's *diuretics *antihistamines |
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what is tx for Sjogrens?
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*artificial tears
*sugarless gum to stim salivation *cholinergics |
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Pearl:
what should you consider before making a dx of sjogrens? |
parotid tumors
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what is scleroderma characterized by?
where is it manifested? |
characterized by diffuse fibrosis, degenerative changes and vascular abnormalities
manifested in: ~skin, articular surfaces and internal organs |
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what is most common initial complaint with sleroderma?
what will over 90% of patients also have? |
first complain is dysphagia
90% will have raynauds |
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what are the general set of sx for systemic sclerosis
(CREST) |
*Calcinosis in subq layer
*Raynauds *Esophageal dysfxn *Sclerodactyly *Telangiectasia on hands, palms and forearms, face and lips |
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what is tx for sx of sclerderma:
*raynauds *GERD *Arthralgias/myalgias *hand deformity |
raynauds=CCB
GERD=H2B Arthralgias/myalgias=NSAID Prednisone=no role Hand rehab=PT |
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why is myositis an inappropriate name for fibromyalgia?
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b/c myositis indicates inflammation and in fibromyalgia inflammation is absent
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what is fibromyalgia?
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*a group of common nonarticular disorders characterized by achy pain, tenderneess and stiffnes of musclees areas of tendon insertins and adjacent soft tissue structures
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what do labs reveal about fibromyalgia?
what are tx's that have a partially response? |
labs are normal
*partially responsive to exercise and TCA |
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what is fibromyalgia NOT treated with?
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NSAIDS, steroids or opiates
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what is given for pain?
what is new FDA approved drug? |
Ultram
new drug = lyrica |
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what is most beneficial tx for fibromyalgia over time?
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regular aerobic exercise 20-30 min 3-4 days /wk w/ regular stretching
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what is an experimental study of tx for fibromyalgia?
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Ribose
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what is Reiters syndrome?
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*ARTHRITIS after GU infection or Gastroenteritis assoc w/ URETHRITIs, cervicitis, CONJUNCTIVITIS and mucocutaneous lesions
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what is the sx triad of reiters?
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Can't see, can't pee, can't climb a tree
*Conjunctivitis *Urethritis *Arthritis |
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what is impt to r/o before dx Reiters?
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disseminated gonococcal infection with a rapid PCR test
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what is tx for reiters?
uveitis assoc w/ reiters chlamydia assoc w/ reiters? |
drug of choice is INDOCIN 50mg po tid prn pain
uveitis=steroid eye drops chlamydia=doxycycline |
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what is the key manifestation of idiopathic inflammatory myopathies?
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muscle weakness
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what muscles get weak first in poly/dermatomyositis?
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bilateral proximal weakness usually in legs first
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what are pathognomonic skin signs?
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Gottrons papules=lichnoid papules inolving hand joints
Gotton's sign=scaly erythema over knuckles elbows and knees heliotrope rash |
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what is the key dx test?
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biospy (but CK and EMG can also help)
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what risk is increased in adult dermatomyositis?
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malignancy
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what is the pathognomonic cutaneous eruption in dermatomyositis?
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the peroribtal edema with heliotrope hue that looks like a sunburn or purplish appearance on eyelid
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what are other Dermatomyositis clinical findings besides the heliotrope rash?
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*shawl sign
*Gottron's sign (periungual erythema, nailbed capillary dilation and scaly patches over dorsal PIP and MP joints |
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what is tx for polymyositis and dermatomyositis
what is first line tx doesn't work? |
prednisone 40-60 mg po then taperd
if steroids don't work us methotrexate or IV immune globuline |
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how do you tx mixed connective tissue dz?
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similar to SLE w/ corticosteroids if mod or severe
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what is mechanics hand?
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fissured scalyhyperkaeratotic and hyperpigmented hands suggestie of manual labor seen in dermatomyositis
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what is the most common arthropod transmitted dz in US/
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lyme dz
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how long must tick be attached to transmit spirochete?
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at leat 24 hours but transmittion more at 35-48 hrs
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what is key finding in first stage of lyme dz?
what percent of patients with lyme dz have this hallmark sign? |
the erythema migrans target lesion
80% *best indicator of lyme dz |
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what are the three stages of lyme dz infection?
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1=early localized infection(erythema migrans and flue like syndrome)
2=early disseminated infection(neurologic and cardiac dysfxn( 3= late persistent(tertiary neuroborreliosis and chronic arthritis) |
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what is dx test for lyme dz?
what is tx? |
test=IgG ab to b. burgdorferi after first few weeks
tx with doxycycline, amoxicillin or rocephin if no response in 2 mo then D/C abx and give NSAIDS or Synovectomy |
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what is low back pain due to most of the time?
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musculoskeletal problem
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what commonly causes referred back pain?
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renal problems
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what is the association b/w herniation and LBP?
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weak, many have asymtpomatic herniation
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what percent of LBP resolves on it's own regardless of tx?
how long does it take to resolve? |
80-90% resolve w/i 4 weeks
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what is acute low back pain defined?
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activity intolerance due to lower back or back related leg sx of less than 3 months
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what are 3 categories of back pain?
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1. serious
~tumor, infection, neuro comprosmise (ex. cauda equina syndrome) 2. sciatica ~lower limb sx suggsting lumbosacral nerve root compromise 3. nonspecific ~neither nerve root compromise or serous underlying condition |
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what is a way to be aware of exaggerated pain responses?
what are other non physical causes of LBP |
test pain by straight leg raise (sitting and supine)
~look up degree that is pos for pain *identify psychological or SES pressures |
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what do the following waddels signs of nonorganicity indicate:
~Superficial tenderness? ~Nonanatomic tenderness ~axial loading ~pain on simulated rotation? |
superficial tenderness=skin discomfort on light palpation
*nonanatomic tenderness=tenderness crossing mulitple anatomic boundaries *axial loading=eliciting pain when pressing down on top of patients head *pain on rotation=rotating the shoulders and pelvis together should not be painful as it does not stretch the structures of the back |
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what are the following waddel's signs of nonorganicity:
*distracted SLR? *regional sensory change? *regional weakness? *overreaction? |
Distracted striaghte leg raise=pt complains of pain on straigh leg raise but not if the examiner extends the knee w/ pt seated 9ex check babinski's)
regional sensory change=stocking sensory loss or sensory loss in an entire extremity or side of body regional weakness=weakness that isjerky w/ intermittent resistance. Organic weakness should be overpowered smoothly Overreaction=exaggerated painful response to a stimulus that is not reproduced when the same stimulus given later |
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what does having 4 or more of 8 waddel signs indicate?
3 or more? |
4 or more indicate a psychogenic component such as depresssion or anxiety
3 or more indicated likely poor surgical outcome *pt report of pain is not reliable guide |
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what does saddle anesthesia, recent onset of bladder dysfxn and severe or progressive neurologic deficit in lower extremity indicate?
*unexpected laxity of anal sphincter *perianal/perineal sensory loss *major motor weakness |
possible cauda equina syndrome
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what is tx for acute LBP?
are opiods more effective? are muscle relaxants usually needed? |
nonrx NSAIDS (motrin or naprosyn) or acetaminophen
*opiods are NOT more effective *muscle relaxant are NOT needed |
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how long should bed rest be rx'd if necessary?
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2 days (more effective than 7)
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what is the definition of chronic back pain?
what is this often attributed to? |
def=pain unchanged despite tx for 4 weeks; pain that persists more than 12 wks; pain unrelieved by rest or any postural modification
~often attributed to degenrative or traumatic conditions of the spine *HUGE IMPACT ON SOCIETY |
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what some hx indications of chronic low back pain?
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hx of trauma, cancer, fracture, metabolic bone dz, infection, inflammatory arthropathy
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what are red flags of chronic low back pain?
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*asso malaise, fatigue or wt loss
*severe morning stiffness as primary complaint *progressiveneurologic impairment *bowel or bladder dysfxn |
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what are diagnostic tests for chronic low back pain?
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1. XRAYS FIRST
2. CT when bone pathology is suspected 3. MRI when underlying neoplastic or infectious cause suspected |
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what are the three phases of Chronic LBP tx?
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1. non operative
~passive medical and PT during acute soft tissue healing 2. spinal care education and active exercise programs 3. interdisciplinary care to address LBP and disability and physical and psychological deconditioning for chronic dysfxn |
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what are meds used to tx LBP?
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1. triyclic antidepressants
~help increase pain threshold to reduce need for analgesic ~antitryptiline, nortrityline, imipramine, desipramine, doxepin 2. anticonvulsants(stay away from benzodiazepines) ~gabapentin 3. narcotics (not usually helpful) |
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what are other tx's for chronic LBP?
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1. injections of steroid or anesthetics
2. corsets or braces 3. PT 4. Traction 5. Spinal manip 6. exercise 7. surgery if neurocompressed |
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what is a sprain?
what is a strain? |
sparin=trauma to a JOINT that causes pain and disability depending on degree of injury to ligaments
strain=trauma to the muscle or musculotendinous unit from violent contraction or excessive forcible stress |
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are there typically neuro signs in strain patients?
does the x-ray show anything? |
no
not reall |
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when are xrays indicated in strains?
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if pain is severe
*if mech of injry is significant (fallt ?6ft) *age <5 or >55 *if showing neuro signs and sx (b/c shouldn't be) |
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what i s tx for back strain?
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*rest
*NSAID *limited activity for 2 days *can take up to 6WEEKS toheal *recommend ROM activities then back strengthening exercises |
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what is a back contusion a result of?
what are they characterized by? how do you tx? |
result of direct trauma
*characterized by erythema and edema *palpable tenderness *tx with Rest, ice, compression, NSAIDS |
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what is scoliossis??
what gender is it more common in? |
abnormal lateral curvature of the spine due to congenital bone dysplaia or metabolic or parlytic conditions
more often in females |
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what is structural scoliosis?
what is fxnal? |
structural=abnormal in spine itself
fnxal=abnormal when stand and better when bend over |
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is scoliosis painful?
are there neurologic sx? are leg lengths the same? |
*generally painless
*no neurological sx *leg lentgths the same |
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what will exam reveal to confirm scoliosis?
what diagnostic tests should be given? |
H&P shows asymmetry in waist crease and at level of shoulders. Post rib hump on bending
Dx tests include: ~xrays essestnital ~measure Cobb angle |
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when is a brace for scoliosis needed?
when do you not need to refer? |
brace if > or equal to 25 degrees
*no need to refer if radilogically <10 degrees and NOT progressive |
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what are the rods that can be put in to straighten the back?
how long are the rods in? |
harrington rods
*left in for years |
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what is kyphosis?
is neurologic exam normal? what are risk factors for adolescent kyphosis? |
an increase in normal curvature of T spine
neurologic exam is normal *affected kids are taller and heavier (F=M) |
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what diagnostic test must be ordered to dx kyphosis?
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x-ray of lateral spine
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what is the most common etiology of kyphosis?
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a herniated nucleus pulposis at L5-S1
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what type of disk injury is it called when:
annular fibers are intact? when some damage to annular fibers? there is extended bulge and loss of some annular fibers but disc is intact? when nucelus protrudes through anulus? wehn fragment of disc is broken off from nucleus pulposes? |
fibers intact=bulge
some damge=protrusion extended bulge=extrusion nucelues through anulus = herniation fragment of disc broken off=disk sequesration(the worst) |
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what is the best anatomicposition for back pain?
what is the worst? |
best is lying down
sitting is the worst |
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where doe sx of herniation of L5-S1 occur?
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in post thigh and leg
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what is imaging modality of choice in Herniated nucleus propulsus?
when is this recommended? |
MRI if pain is graeter than 6 weeks
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what is tx of HNP?
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NSAids and steroids for 5 days or less (longer and must taper)
also PT |
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what are pitfalls of HNP?
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1. failure to perform complete sensory fxn and motor fxn and reflex exam
2. failure to consider alternative dx for pain(AAA, neurological dz,malignancie, infection) |
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what physical exams must be given when evaluating a HNP patient?
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*Neuro (w/o cranial)
*ABDOMEN *vascular *MS (ROM and SLR) |
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what is the gold standard surgery of HNP?
what does this surgery succeed at? |
open microdisectomy is gold standard but is last resort tx
NOT A CURE *only reduces pain by 93% |
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when is it impt to refer these patients?
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if neurologic deficits
*if severe pain *if fail to improve w/ 6 weeks of tx *if dx not clear |
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what is a subluxation?
what is a dislocation? |
sublux=partial disruption
dislocation=completely moved from normal position |
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what is an open fracture?
how do you tx? |
any open wound overlying a fracture
tx: splinted and immediate to orthopedic |
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what is a closed fracture?
how is it tx? |
closed when overlying skin and soft tissues have NOT been disrupted
may be manipulated for splinting |
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what are vertebral column fx usually caused by?
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severe trauma (fall, MVA)
*flexion, distration and/or rotational forces |
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what is most common location of vertebral frx in C-spine
in lower spine? |
cspine=C5/C6
lower spine is T12/L1 |
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what are two types of vertebral body frx's?
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1. wedge compression
~from flexion forces ~rarely causes injrey to spinal cord or nerve roots 2. burst ~w/ axial compression forces ~contuse or lacerate spinal cord, nerve roots or interfere w/ blood |
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which type of vertebral body fx causes dowagers hum in elderly?
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the wedge compresssion frx
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what are dislocations of vertebral body usually assoc w?
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paraplegia below level of injryu
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what is presume on an unconscious patient until ruled out by xray?
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cpinal column injury
*spine stabilized immediately and any spaces b/w back of neck and board should be filled |
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what must diagnostic test must always be given w/ suspected vertebral body frx?
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CT and X-rays
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what is tx for wedge compresion?
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8supportive and rehab only
*rest until sx allow sitting and standing (IV hydrate and laxatives to prevent paralytic ileus *brace x 3mths *surgey when >20 kyphosis deforimty |
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what is tx for burst frx?
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*ALWAYS UNSTABLE
*emergency referral to orthopedist or neurosurgeon *need surgical repair |
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what is usually cause of spinous process frx?
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a direct blow trauma such as from fighting or sporting evetn
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what is tx for spinous fracture?
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*bracing, analgesics and ortho consult
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what is spondylolisthesis?
what is spondylolysis? what is spondylosis |
spondylolisthesis=the anterior displacement of a vertebral body relative to another
Spondylolysis=fracture in the pars interarticularis(in transverse plane b/w lamina and pedicle) spondylosis=degeneration of two or more vertebrae joints assoc w/ aging and herniation |
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how is spondylolisthesis classified?
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5 grades with 5 being over 100% slippage and the rest of the categories increasing by quarters
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what type of spondylolisthesis is:
~a dysplastic sacral facet joint allowing forward movement? ~a stress frax of pars interarticularis ~an intersegmented instability produced by facet arthropathy ~is very rare ~bony disorder or iagtrogenic |
dysplastic=type 1 congenital
stress frx=type II isthmic intersegmental instability=type III degenerative rare=type 4 traumatic bony disorder or iatrogenic=type V pathologic |
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what are common vertebra that an isthmic stress fracture occurs in?
degenerative? |
Isthmic:
80% L5-S1 11% L4-L5 degenerative: L4-L5 most common |
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what is a universal finding in PE of isthmic, traumatic and dysplastic spondylolisthesis?
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hamstring tightness
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when does spondylolysis occur in adolescents?
what are common s&s? |
spondylolysis in kids with hyperextension and rotation or repetitive flexion-extionsion (ex. gymnasts, javelin throwers, pole vaulters, weight lifters, judoists)
S&S= *low back pain *paraspinal spasms *inceased pain w/ extenison *tight hamstrings |
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what is the characterisitc spondylolysis finding on the lateral xray?
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SCOTTY DOG
*if the dog has a collar then positive finding |
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what is tx of spondylolysis?
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*bracing isc controversial
*possible corticosteroid injections *analgesics prn -PT |
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what is ankylosing spondylitis?
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a chronic inflammation that affects axial joints
*causes eventual fusion of the spine |
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what are some characteristic os S&S of ankylosing spondylitis?
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*adolescents
*gradual onset with pain worse in am and better during day *pain better w/ activity and worse with rest |
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**** what is the ascending pattermof ankylosing spondylitis?
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Gradual from low back to throacic and cervical
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what are complications assoc with ankylosing spondylitis?
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systemic and n eurological
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what lab value will show up in 90-95% of pts w/ ankylosing spondylitis?
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HLA B27 antigen
*although can dx with xray and don't need labs |
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what is a characteristic xray finding of progressive ankylosing spondylitis?
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bamboo spine from decrease in density of vertebrae and fusion of facet joints
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what is tx of ankylosing spondylitis?
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*exercise
*pain and inflammation control *anti TNF therapy *surgery to stabilize antlantoaxial sublux and correct thoracid kyphosis |
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what is spinal stenosis?
what are causes? |
a reduction in diameter of spinal canal, lateral nerve canals or neural foramina
causes include: -localized degeneration -trauma -congenital defects -malignancy |
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what happens to ligamentum flavum with:
excessive flexion? excessive extension? |
flexion=stretches and thins
extension=thickens and sometimes buckles |
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what is spinal stenosis the most common dx for?
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peopl >65 undergoing spinal surgery
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what are some s&S?
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* pain worse w/ activity
*releived by rest *have "water or dcandle wax drippng down leg feeling |
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what is best diagnostic imaging technique for spinal stenosis?
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CT then xray b/c will show deger of fact joints
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what is nonsurgical tx of spinal stenosis?
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*NSAID
*ice orheat *PT *exercise *wt reduction |
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what is surgical tx of spinal stenosis?
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* laminectomy
*fusion if coexist w/ spondylolisthesis |
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what is cauda equina syndrome?
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nerve root compression at level of spinal cord termination
*can be traumatic or atraumatic |
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if this sign is present when doing PE then this will rule out cauda equina syndromne?
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babinski
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what is the best dx test for cauda equina
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myelogram (xrays helpful to look for other conditions but NOT cauda)
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what is tx?
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*stabilize acute life threateneing conditions
*possible surgical emergency if loss of sphincet or bladder tone *no proven med tx |
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what are medical legal pitfalls?
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failure to conside CES in pt with back pain and bowel/bladder dysfxn
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what is brown sequard syndomre?
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hemiplegia of spinal cord
*ipsilateral upper motor neuron paralysis and loss of proprioception *contralateral loss of pain and temp |
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what are causes of brown dsequard?
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*tumors
*trauma (knife, gunshot) *degenrative herniation or spondylitis *ischemia*Herpes, TB, syph *myelitis, MS *subdural hemorrhage |
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what is best imaging modality to dx?
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MRI to define extent of spinal cord injury.
x-ray r/o bony injury |
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what is tx of brown sequard?
what is the prognosis for this? |
*stabilize spine
*consult neurosurg *high dose steroid early? (failure to administer in timely manner is a pitfall) *PT/OT *surgery prn for spinal stability POOR PROGNOSIS |
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what are pitfalls of brown sequard?
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*failureto realize cord injry may be partial and not complete
*failure to consider other injuries *failure to recognize hypotension may not be neurogenic *failure to administer steroids in a timely manner |
