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304 Cards in this Set
- Front
- Back
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what is the difference between disease and illness?
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illness is how the patient interprets the disease, what the disease is doing to the patient, how the patient's life is being changed
disease - actual pathology |
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What is the Technocratic model of medicine?
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mind and body separation
bode as a machine patient as an object focus on curing the disease not healing the sick standardization of the care authority inherent with the provider, not with the patient death as defeat |
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How did Hippocrates change medicine's approach?
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before hippocrates medicine had been a matter for philosophical speculation and magico-religious belief
he redefined the role of medicine as a branch of knowledge that calls for "skill, craft, and observation" -objectivity observation data rejection of the spoken word |
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What is the mechanical model of medicine?
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life can be explained on a mechanical basis, body and mind are separate: body is a broken machine that can be fixed
body - science mind- church |
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What is modernism belief?
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a trend of thought that affirms the power of human beings to creat, improve, and reshape their environment, with the aid of scientific knowledge, technology or practical experimentation
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What does linear thinking mean? and what are the limitation of linear thinking?
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everything is explainable, follows a certain line in thought,
illness threatens sense of indestructibility and omnipotence, we have no way to really measure the effects of illness, |
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What is the butterfly effect or chaotic theory? and who thought of it?
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small variations of the initial condition of a dynamical system may roduce large variations in the long term behavior of the system- Professor Edward Lorenz, MIT
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What are the signs of allergic conjunctivitis?
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allergic shinner, "racoon eye"
little horizontal lines called deni lines tearing red eye |
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What are signs of allergic rhinitis?
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nasal polyposis - gray glistening gelatinous nodes
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What are atopic diseases mediated by?
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IgE
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What is Type I atopic disease?
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Gel and Coombs immediate hypersensitivity
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What is the diagnosis for Allergic Rhinitis?
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presence of one or more of the following nasal symptoms:
sneezing rhinorrhea (anterior or posterior) nasal congestion nasal itching |
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What % of the population is affected by allergic rhinitis?
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10-30% of adults and 40% of children
-beginning early childhood, improves, and then recurs in 30's to 40's |
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What are examples of seasonal allergic rhinitis?
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trees, grass, weed pollens
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what are examples of perennial allergic rhinitis?
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dust mites, cockroaches, animal proteins, and fungi
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What are the two big seasonal allergens in the southeast?
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trees in the beginning of the year and grasses in the summer months
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What are the two big seasonal allergens in the west?
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grasses and weeds in the north and south west all through the summer
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What is the theory of why developed countries are more prone to allergies?
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in developed countries we are less likely to be exposed to bacteria and invasive pathogens, so our body instead of making lots of Th1 cells --> infectious plasma cells that produce IgG, IgM, and IgA, we have a lot of Th2 cells --> allergic plasma cells that produce IgE
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What are the key cytokines used by Th1 and Th2 ?
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Th1: IFN-gamma, TGF-b, NO
Th2: IL-4, IL-5, IL-9 |
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What is the pathophysiology of allergic rhinitis?
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sensitization: allergen specific IgE production on exposure
early phase reaction: mast cells and basophils release histamine, tryptase, heparin, leukotrienes, and cytokines late-phase reaciton: eosinophils and Th2 lymphocytes release additional inflammatory mediators --> chronic allergic reactions |
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How do you ID the allergen? What are the 4 main categories?
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history
home and work environment 4 major allergen categories: pollen insects (house dust mites and cockroaches) animal allergens molds |
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What is the treatment for allergic rhinitis?
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allergic ID and avoidance
pharmacologic therapy immunotherapy |
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What are the potential avoidance measures used to prevent allergic rhinitis for pollen allergy?
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pollen allergy:
close car windows, stay indoors air conditioner showering at bedtime saline nasal spray |
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What are the pharmacologic options for allergic rhinitis?
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-intranasal steroids (INGC's) most effective
-oral antihistamines topical nasal antihistamine mast cell stabilizers leukotriene modifiers Ipratropium (dries out the nose) |
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When should a primary care physician refer a patient to an allergist/immunologist?
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children with moderate to sever AR
failure of pharmacologic therapy and severe AR coexisting asthma or nasal polyposis complications of AR (Recurrent otitis media, recurrent sinusitis) medication side effects patients wanting immunotherapy avoid systemic glucocorticoids identify allergic triggers |
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What are the contraindications of allergy injection immunotherapy?
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can cause anaphylactic reaction
severe asthma unstable cardiovascular disease significant doses of beta blockers non-compliance pregnancy-do not initiate therapy or escalate dose during pregnancy |
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Non-allergic rhinitis triggers are:
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temperature
car and diesel exhaust perfume cleaning agents incense newsprint hairspray alcohol eating spicy foods |
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What is allergic asthma characterized by?
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symptoms of cough, wheezing, dyspnea, and chest tightness that occur in paroxysms and are usually associated with specific triggering events
airways narrowing that is partially or completely reversible increased airways responsiveness to a variety of stimuli |
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What are non allergic asthma causes?
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infectious
hyperactive airway disease occupational |
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What disease testify to the statement:
"all that wheezes is not asthma"? |
chronic obstructive pulmonary disease:
chronic bronchitis - blue bloater - in which the airways are always congested, poor transfer of oxygen emphysema - "pink puffer" decreased lung tissues, leads to all blood that passes through lungs get oxygenated, but just decreased amount of blood passing through lungs --> decreased oxygen delivery can also have a mixture of these disease |
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What are the potential causes of the increased prevalence of asthma in the past 25 years?
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improved hygeine and less exposure to infectious pathogens-conversion from Th1 to Th2 response
increased indoor air pollution increased incidence of early onset respiratory viral infections congenitally small lungs due to maternal cigarette smoking increased awareness by patients and physcicians |
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What is the economic and social toll of asthma?
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2/3 of children with this disease suffer noticeable disability
ten million school days missed major cause of parental work absenteesim $1.6 billion/year spent to care for children with asthma |
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What is the pathology of asthma?
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thickening of BM with type IV collagen depositions
loss of ciliated cells with partial regeneration by goblet and squamous cells mucosal edema hypertrophy and hyperplasia of myocytes luminal plugging with inflammatory cells, cloughed epithelial cells, tenacious mucus, and plasma proteins submucosal inflammatory cells and CT |
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What are Charcot-Leyden crystals?
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caused by the late phase response involving eosinophilic remnats - crystals
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What are Cuschmann's spirals?
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airway lumen casts of exudate, mucus
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What are creola bodies?
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clumps of sloughed epithelial cells
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What do we use to test reversible airflow obstruction?
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pre and post FEV1 tests, that measure the difference between with and without a bronchodilator
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What do reversible airflow obstructive patients usually carry with them?
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a peak flow meter that will drop to 375 or 350 if they are starting to get a cold
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How do we test airway hyperresponsiveness?
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methacholine, cold air, or histamine challenge, in which we will induce a response and if below the normal level of response activation, then the person is hyperresponsive
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What are the 4 classifications of allergic asthma?
and what are the treatments for each class? |
mild, intermittent asthma - SABA PRN
mild, persistent asthma - SABA + inhaled corticosteroids moderate persistent asthma - ICS and LABA severe persistent asthma - ICS + LABA + oral corticosteroids |
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What can childhood asthma be caused from?
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bronchiolitis - common in infancy-caused by respiratory syncytial virus
genetic predisposition smoking habits of the family --> bronchial reactivity of the child emotional influences and stress |
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What is the cause of eczema in infants compared to older children?
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infants - food allergy
older children - inhalant allergy |
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What is the pathology of eczema?
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over activity of Th2 helper cells, IgE in skin may cause type of autoimmune reaction and can be a secondary infeciton of skin (staph aureus)
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What are the physical findings of atopic dermatitis?
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erythema, tiny blisters, and fine scale --> crusting
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What is the normal physical finding of atopic dermaticis (eczema) in an infant?
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erythematous, edematous swelling on face, trunk, or extremities with pruritis
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what should you avoid in treating atopid dermatitis on the face?
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avoid using topical corticosterioids --> subcutaneous fat depletion and will thin the skin, showing the blood vessels, hydrocortizone is the only possibility and in limited use
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What are some typical food allergies that lead to eczema?
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milk protein
eggs grains fish tomatoes carrots apples nuts citrus fruits |
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What is a diet to prevent child from getting atopic dermatitis?
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breast milk
soy, rice, or carob based milk at 6 months add fruit and vegetables at 12 months add grains and meat no fish or eggs before 18 months |
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What is the "cave man diet" and why is it good?
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avoid preservaties, avoid dyes, antioxicants and taste enhancers (monosodium glutamate)
but eat fresh meats, vegetables, and fruit |
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What are the primary preventative measures of latex allergy?
what are the secondary preventative measures of latex allergy? |
lower immunogenic latex milk
washing of raw latex to removes protein avoidance of contact between natural rubber gloves and damaged skin hand washing and disinfection to avoid accumulative toxic dermatitis secondary: unpowered latex gloves latex free gloves avoidance of fig tree-ficus bejamina avoid avocado, kiwi, walnuts, bananas |
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What does primary prevention of treament of allergic diseases mean?
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occupational exposure
private life : avoid house plants, less dyes and tatse enhancers, food additives medications, pets, incense, fragrances |
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What are the secondary prevention means for treatment of allergic diseases?
house dust mite allergy: pollen allergy: |
house dust mite allergy: reduce humidity; avoid drapes, carpet, and uphostered furniture; pillow and mattress covers
pollen allergy: eliminate pollen-laden clothing, wash hair at night, nasal irrigation with saline, shut windows during day |
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What are the tertiary preventions for treatments of allergic diseases?
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avoidance
medications immunotherapy |
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How do immunotherapys work for tertiary treatment of allergic diseases?
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intent is to selectively influence T and B cells responsible for the immune response to a single antigen, conversion of Th2 response to Th1 response, preventive vaccines work on naive T and B cells, but a well established immune response is considerably more difficult to influence
overall we want to silence the disease inducing T cells |
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What does immunotherapy work best for in treatment?
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bee and wasp venoms an dpollen and house dust mites
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What are the physical findings of Anaphylaxis?
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acute onset,
hives, pruritis or flushing swollen lips, tongue, uvula dyspnea, wheeze-bronchospasm, stridor, hypoxia nausea, vomiting, diarrhea, and crampy abdominal pain hypotension, syncope, incontinent |
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What is the breakdown of where most of the signs and symptoms of anaphylaxis is in 4 particular places? (% based)
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cutaneous - 90%
respiratory - 70% GI - 40% cardiovascular - 35% |
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What are two laboratory test you can do to check for Anaphylaxis and what results indicate anaphylaxis?
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Plasma histamine:
- peak in 10-15 mins and normal in 1 hour Serum or plasma total trytase: -within 2 hours of onset may be normal in food related anaphylaxis normal level does not rule out anaphylaxis |
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What is the initial treatment 7 steps of anaphylaxis?
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1. ABC : airways, breathing, and cardiovascular
2. remove antigen 3. HELP 4. IM injection of epinephrine (0.3-0.5 in adults, 0.01ml/kg in childreN) 5 supine position 6. oxygen 7 volume resuscitation |
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What are 6 phamacologic treatments for anaphylaxis?
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epinephrine
glucagon antihistamines - diphenhydramine bronchodilators glucocorticoids - methylprednisone vasopressors |
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What is epinephrine used to treat anaphylaxis?
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alpha-1 agonist receptor effects --> increased vasoconstriction and peripheral vascular resistance decreased mucosal edema
beta-1 adrenergic agonist effects --> increased ionotropic and chronotropic effect beta-2 adrenergic agonists effect --> increased bronchodilation and decreased release of inflammation from mast cells and basophils |
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What patients should you be careful when using epinephrine?
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-cardiovascular disease
-pt's receiving MAO's or tricyclic antidepressants -patient's revieving stimulate medication -pt's ahaving had recent intracranial surgery, known aortic aneurysm, uncontrolled hyperthyroidism or hypertension |
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What is the Pathogenesis of Osteoarthritis?
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1. normal cartilage subject to abnormal loads, work-related repetitive activities, trauma leading to direct cartilage damage or increased load of obesity
2.abnormal tissues subject to normal loads: subchondral bone - osteropetrosis, cartilage ochronosis or hemochromatosis, or collagen fibrils - familial OA |
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What is the actual pathology basis for Osteroarthritis? what intrinsically is occurring?
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not caused by wear and tear but is an active process --> both formation and removal of cartilage matrix are increased but the reparative effort is ultimately inadequate --> progressive cartilage degradation by metalloproteinases and collagenase
articular cartilage thins and softens (joint-space narrowing on x-ray), leading to fissuring and cracking of cartilage, inadequate repair |
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What happens due to thinning and softening of the articular cartilage?
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underlying bone is exposed, allowing synovial fluid to be forced by the pressure of weight into the bone--> cysts or geodes on x-ray
remodeling and hypertrophy of subchondral bone --> subchondral sclerosis and osterophyte (spur) formation |
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What do OA patients present with? and how does OA affect their life? movements?
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Pain - cardinal feature
pain worse with activity, better with rest, morning stiffness and gel phnemenon <30 mins gait antalgic : characteristic gait resulting from pain on weight-bearing, in which the stance phase of gait is shortened on affected side bony enlargements with little soft tissue swelling pain on passive motion and/or localized tenderness limitation of joint mobility crepitus - creaking, cracking, or grinding noise |
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What are Heberden's nodes? and what arthritis disease are the exclusively found in?
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hard nodules present on the dorsal surface of the DIP joints (distal interphalangeal joints)
exclusively found in OA |
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What are Bouchard's nodes?
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hard nodules present on thedorsal surface of the PIP joints
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What are the x-ray findings for OA and what are the causes of each? 5
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joint space narrowing: cartilage loss,
subchondral sclerosis and osterophytes hypertrophy of subchondral bone, bone cysts: microfractures deformity with subluxation: ligamentous laxity |
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What is a critical thing to remember when taking an X-ray of a patient with potential OA?
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take a weight bearing x-ray when evaluating for joint-space narrowing of lower extremities large joints
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What are 3 risk factors for OA?
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obesity
major joint trauma: cruciate ligament damage and meniscal tears repetitive joint use |
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What are the treatment goals for OA? and what are the current treatments both pharmacologic and non-pharmacologic?
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keep patients active and productive
decreasing pain decreasing inflammation no current disease modifying medications PT and OT and assist devices start with acetaminophen, 2gm/day if unsuccessful move to NSAIDs capsaicin cream - analgesia by inhibiting substance P intra-articular corticosteroids - limited to <5/ year topical NSAIDs - voltaren (diclofenac) gel Viscosupplementation - hyaluronic acid supplementation, synovial fluid, nutriceuticals - glucosamine sulfate and chondroitin sulfate, improvedment of pain as compared with placebo, dietary supplements and therefor not regulated by FDA fish oils: may inhibit COX activity, reduce CV risk, have been known to cause chest pain, diarrhea, aversion to odors and taste and heachache joint replacement : 50% |
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What is the peak incidence of RA?
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perimenopausal/early postermenopausal years
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What is the pathogenesis of RA?
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T lymphoyctes recognize antigens in synovial tissue --> activated T cell, macs, and firboblasts produce pro-inflammatory cytokines --> synovitis and tissue destruction
TNF alpha and IL-1 pro-inflammatory cytokines that enhance synovial proliferation and stimulate secretion of matrix degrading metalloproteinases, and other inflammatory cytokines, PGE2 |
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What do the current treatment strategies focus on in RA?
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TNF alpha and IL-1 inhibitors
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What is found in the infiltrate in RA joints? and what do synovial cells do in response?
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mononuclear cells, CD4 T cells, active macs and plasma cells (RF), synovial cells proliferate and inflamed synovium becomes boggy and edematous and develops villous projections
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What is Pannus and what can it do?
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Pannus is proliferative synovium and is capable of invading bone and cartilage causing joint destruction : resobing cartilage and chewing away of the bone
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What are the RA symptoms?
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AM stiffness in and around joints, 1 hour before maximal improvement
pain primarily of hand joints, wrists, and fee fatigue low grade fever weight loss |
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RA clinical signs:
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1. arthritis of >3 joints
2. arthritis of hand joints: must affect writs, MCP or PIP 3. symmetric arthritis: bilateral involvement of MCP, PIP, or MTP 4. Rheumatoid Nodules, especially extensor surfaces or juxta-articular locations 1-3 must be present for atleast 6 weeks prior to diagnosis |
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If patient present with synovitus at the DIP joints and they have a rash what are they likely to have?
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psoriatic arthritis
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What are the hand deformities involved in RA?
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synovitis
boutonniere deformity swan-neck deformity ulnar deviation of fingers |
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what is boutonniere deformity?
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flexion of PIP and hyperextension of DIP joint (knuckle being pushed thru a buttonhole)
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What is swan-neck deformity?
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contraction of MCP flexors, hyperextension of PIP and flexion of DIP joint
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What is Ulnar deviation of fingres?
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sublaxation of MCP joints
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what are laboratory findings of RA?
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anemia of chronic disease and elevated platelet counts
WBC generally normal ESR and CRP are usually elevated correlating with disease RF positive CCP antibody positive urinalysis, renal and liver function and uric acid are normal |
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Describe RF:
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IgM and IgG that recognize the Fc of a synovial fluid IgG as their antigen,
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What kind of indicator is Rheumatoid Factor?
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not that good, low specificity and low sensitivity, heb b or c will have 75% with positive RF and if you start treatment of RA with methotrexate then can kill patient that already has liver damage
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What kind of indicator is Cyclic Cirullinated peptide?
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good, reduces the false ositive rate and particularly helpful in the hepatits C population, also may be a strong marker for aggressive disease.
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What are the radiographic features of RA?
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early: periarticular osteropenia and soft tissue swelling
later: joint erosions at margins of small joints, more diffuse osteropenia, joint-space narrowing and deformities |
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Where is one of the first places to see erosion in RA?
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ulnar styloid
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What are the extraarticular features of RA?
common uncommon |
common: fatigue, low grade fever, anemia, rheumatoid nodules, keratoconjunctivitis sicca (dry eyes) and carpal tunnel syndrome
uncommon: paricarditis, pulmonary nodules, pleural effusions, scleritis, cervical subluxation, vascultis |
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What are the 7 prognosis factors of RA?
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RF+
CCP_ High ESR Rheumatoid Nodules Female Early erosions Fewer years of formal education |
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Once you know patient has RA how do you treat?
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early aggressive treatment with DMARDs, because 70% RA patients have radiographic damage within 2 years, so one or more DMARDs in addition to symptomatic therapy with pain medication or low dose prednisone
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What DMARDs are used to treat RA?
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methotrexate - gold standard (inhibits IL-1 and leukotriene 4)
Plaquenil (hydroxychloroquine) - inhibits the release of IL-1 by monocytes Sulfasalazine, ARava (leflunomide), Gold, Kineret (anakinra) |
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What are TNF-inhibitors that are used to treat RA?
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enbrel, humira, remicade
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Prognosis for RA:
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shortens survival and produces significant disability,
over 33% of RA patients who were working at disease diagnosis will stop working within 5 years aggressive DMARD therapy can reduce disability by 30% over 10-20 years |
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What are indicators for Psoriatic Arthritis?
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DIP synovitis, nail pits, skin rash
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Patient complains of low back stiffness in am, alleviated by activity,
diagnosis: |
ankylosing spondylitis
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marked knee or ankle swelling, diarrhea, weight loss, diagnosis?
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IBD associated arthritis
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Where is the rash usually located in Psoriasic arthritis?
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extensor surfaces: elbows, knees
behind ears, scalp, LS spine, gluteal cleft, umbilicus |
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What PE painful movements are present in Sacroiliitis?
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SI joint palpation
SI joint compression FABERs test: flexion, ABduction, External Rotation of the hip |
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What do you use to diagnose Ankylosing Spondylitis?
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Schober's Test: you mark the patient 5cm above and 5cm below the iliac crest, then bend over and form bottom should be 10-15cm above the bottom line, then you have fused spine,
occiput-to-wall test |
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What are articular structures?
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joint capsule, articular cartilage, the synovium and synovial fluid, intra-articular ligament, and juxta-articular bone.
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What are nonarticular structures?
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periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin
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Describe a synovial joint
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freely moveable, knee and shoulder
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Describe a cartilaginous joints
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slightly movable
-vertebral bodies of the spine |
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Describe fibrous joints
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immovable
-skull sutures |
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What is a spheroidal joint?
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ball and socket
convex surface in concave cavity -shoulder and hip |
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What is a hinge joint?
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flat, planar
-interphalangeal joints of hand and foot, elbow |
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What is a condylar joint?
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convex or concave
-knee; temporo-mandibular joint |
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What are the principle muscles opening the mouth?
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external pterygoids
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What are the muscles that close the mouth?and what are they innervated by?
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masseter
temporalis internal pterygoids all innervated by CN V (trigeminal) |
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What are the three joints that articulate at the shoulder?
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glenohumeral joint
sternoclavicular joint acromioclavicular joint |
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What are the rotator cuff muscles?
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SITS:
supraspinatus infraspinatus teres minor subscapularis |
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What does the axioscapular group do to the shoulder?
and what all belongs in this? |
pulls shoulder backwards
-levator scapulae rhomboids trapezius serratus anterior |
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What does the scapulohumeral group do to the shoulder?
and what muscles are involved? |
rotates shoulder laterally, includes rotator cuff
-supraspinatus, infraspinatus, deltoid teres minor |
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What does the axiohumeral group do to the shoulder?
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rotates shoulder internally
-pectoralis major pectoralis minor latissimus dorsi |
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What does PAD and DAB mean?
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PAD:
palmar - interossei muscles are involved in ADDuction DAB - dorsal interossei are involved in ABduction |
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What is found in the carpral tunneL? and what does it do?
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median nerve, covered by flexor retinaculum,
median nerve provides sensation to the palm and palmar surfaces of most of the thumb, the 2-3 - and 1/2 the 4th, innervates thumb muscles of flexion, abduction, and opposition |
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What part of your back curves concave?
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cervical and lumbar
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what part of your back curves convex?
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thoracic and sacrococcygeal
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Where are the spinous processes usually more prominent?
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C7 - T1
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What 5 landmarks should we be IDing from behind, patients back?
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1. spinous processes (c7-T1 very prominent
2. paravertebral muscles on either side of midline 3. scapulae 4. iliac crests 5. posterior superior iliac spines, usually marked by skin dimples |
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Where would a line drawn above the posterior iliac crest cross the spinal column at?
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spinous process of L4 typically
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What part of the vertebae supports weight bearing?
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vertebral body
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What are the 3 formamen found in the spinal column and what is each do?
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vertebral foramen - encloses the spinal cord
intervertebral foramen - (formed by inferior and superior articulating processes of adjacent vertebrae, creating a channel for the spinal nerve roots transverse formamen (cervical vertebrae) - vertebral artery |
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What makes up an intervertebral discs?
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soft mucoid central core: nucleus pulposus, rimmed by the tough fibrous tissue of the annulus fibrosis
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Where along the spine is there the highest likilihood of disc slipping or subluxation?
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L5 or S1, vertebral colum angles sharply posterior at the lumbosacral junctions and becomes immovable --> very high mechanical stress
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What does trapezius do to neck?
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extension
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What does splenius capitis do to neck?
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extension
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what does sternocleidomastoid do to neck?
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flexion, rotation
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What muscles are involved in cerviacal spine: flexion?
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sternocleidomastoid, scalene, and prevertebral muscles
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What muscles are involved in cervical spine extension?
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splenius, trap, small intrinsic neck muscles
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What muscles are involved in rotation of the neck?
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sternocleidomastoid, small intrinsic
l |
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What muscles are involved in cervical spine lateral bending?
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scalene and small intrinsic neck muscles
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What muscles are involved in flexuion of lumbar spine?
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Psoas major, psoas minor, quadratus lumborum; abdominal muscles such as the internal and external obliques and rectus abdominis, attaching to the anterior vertebrae
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What muscles are involved in extension of the lumbar spine?
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intrinsic muscles of the back, sacrospinalis
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What muscles are involved in the rotation of the lumbar spine?
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abdominal muscles, intrinsic muscles of the back
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What muscles are involved in the lateral bending of the lumbar spine?
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abdominal muscles, intrinsic muscles of the back
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What is the progression of examining the anterior pelvic area?
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-ID the iliac crest - L4
-follow the downward anterior curve and locate the iliac tubercle making the widest point of the crest -then track downward tot he anterior superior iliac spine, place thumbs on as spines and -move your fingers downward from the iliac tubercles to the greater trochanter of the femur -then move your thumbs medially and obliquely to the pubic symphysis, lying on the same level as the greater trochanter |
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What is the process of examining the posterior aspect of the hip?
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locate the posterior superior iliac spines directly underneath the visible dimples just above the buttocks,
-place your left thumb and index finger over the post superior iliac spine, -locate the greater trochanter laterally with your fingers at the level of the gluteal fold and place your thumb medially on the ischial tuberosity -the sacroiliac joint is not palpable, but note the imaginary line between the posterior superior iliac spine would cross at the S2 joint |
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What is the primary flexor muscle for the hip?
|
iliopsoas is the primary
|
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What is the primary extensor muscle for the hip?
|
gluteus maximus
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What are the primary abdutor muscles of the hip?
|
gluteus medius and minimus
|
|
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What are the adductor muscles of the hip?
|
adductor brevis, adductor longus, adductor magnus, pectineus, and gracilis
|
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What are the 3 principle bursa of the hip?
|
anteriorly: iliopectineal (iliopsoas)
lateral/posterior: trochanteric bursa under the ischeal tuberosity: - ischiogluteal bursa (on which a person sites, not always present) |
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What 3 things do we need to note when looking at anterior aspect of the knee?
|
tibial tuberosity
medial condyle lateral condyle |
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What muscles make up the quadriceps femoris?
|
rectus femoris, vastus lateralis, vastus medialis, vastus intermedialis
|
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What muscles make up the hamstrings?
|
gracilis
sartorius semimebranosus semitendinosus |
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How do we feel for the MCL?
|
move your fingers medially and posteriorly along the joint line, then palpate along the ligament from its origin to insertion
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How do we feel for the collateral ligament?
|
cross one leg so the ankle rests on the opposite knee and find the firm cord that runs from the lateral epicondyle of the femur to the head of the fibula
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How does the ACL cross in the knee? and what does ACL prevent knee from doing?
|
from lateral femoral condyle to the medial tibia, preventing tibia from sliding forward on the femur
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How does PCL cross and what does it prevent the knee from doing?
|
lateral tibia and lateral meniscus to the medial femoral condyle, preventing the tibia from slipping backwards on the femur,
|
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What are the principal joints of the ankle?
|
tibiotalar joints and subtalar (talocalcaneal) joint
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What muscles enables platar flexion?
|
gastrocnemius, posterior tibial muscles, and the toe flexors
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What muscles allow for dorsiflexotion?
|
anterior tibial muslces and toe extensors
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What ligament protects against ankle eversion stress?
|
deltoid ligament:
protects from ankle bows inward |
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What ligament is most at risk of injury from inversion of the ankle? and what two other ligaments can/are also involved?
|
anterior talofibular ligament - most
calcaneofibular ligament posterior talofibular ligament |
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What are 6 common/concerning musculoskeletal symptoms?
|
low back pain
neck pain monoarticular or polyarticular joint pain inflammatory or infectious joint pain joint pain with sytemic feaures such as fever, chills, rash, anorexia, weight loss, weakness joint pain with symptoms from other organ systems |
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What are causes of midline back pain?
|
musculoskeletal strain,
vertebral collapse disc herniation spinal cord metastases |
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WHat are causes of off the midline back pain?
|
sacroliiitis, trochanteric bursitis, sciatica, or arthritis int he hips
|
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What secondary symptoms do you note for when looking at neck pain?
|
alert symptoms:
-weakness loss of sensation loss of bladder or bowel function |
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What do you have to determine about joint pain?
|
localized or widespread
acute or chronic inflammatory or noninflammatory timing, quality, and severity of symptoms |
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What does pain in one joint suggest?
|
trauma, monoarticular arthritis, possible tendinitis, or bursitis
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Patient presents with migratory pattern of spread of joint pain? what's the diagnosis?
|
rheumatic fever or gonococcal arthritis
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Patient present with additive pattern with symmetric involvement of joint pain. Diagnosis/
|
RA
|
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Patient present with severe pain of rapid onset in a swollen joint in the absence of trauma, diagnosis?
|
acute septic arthritis or gout
|
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Child presents with severe pain of rapid onset in a swollen joint int he absence of trauma, diagnosis?
|
osteomyelitis in bone contiguous to a joint
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Patient presents with fever, chills, warmth, redness, diagnosis?
|
septic arthritis, consider gout and possibly rheumatic fever
|
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Patient presents with pain, selling, loss of active and passive motion, "locking" , diagnosis?
|
deformity in articular joint pain
|
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Patient presents with loss of active but not passive motion, tenderness outside the joint, diagnosis?
|
absence of deformity in nonarticular pain
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Patient present with stiffness and limited motion after inactivity, diagnosis?
|
gelling - degenerative joint disease but usually lasts only a few minutes
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Patient presents with stiffness 30+ minutes, diagnosis?
|
RA, fibromyalgia, and polymyalgia rheumatica
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Patient presents with scaly rash and pitted nails as well as joint pain, diagnosis?
|
psoriatic arthritis
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Patient presents with few papules, pustules, or vesicles on reddened bases, located on the distal extremities, and joint pain/swelling, diagnosis?
|
gonococcal arthritis
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patient presents with joint pain and expanding erythematous patch, diagnosis?
|
lyme disease
|
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Patient presents with joint pain/swelling and hives, diagnosis?
|
serum sickness, drug reaction
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Patient presents with erosions or scales on the penis and crusted scaling papules on the soles and palms, and joint pain/swelling, diagnosis?
|
Reiter's syndrome: which also includes arthritis, urethritis, and ureitis
|
|
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Patient presents with maculopapular rash and joint pain/swelling, diagnosis?
|
arthritis of rubella
|
|
|
Patient presents with clubbing of fingernails and joint pain/swelling, diagnosis?
|
hypertrophic osteroarthritis
|
|
|
Patient presents with conjunctivitis and joint pain/swelling, diagnosis?
|
Reiter's syndrome, Behcet's syndrome
|
|
|
Patient presents with previous sore throat and how joint pain/swelling, diagnosis?
|
acute rheumatic fever or gonoccocal arthritis
|
|
|
Patient presents with diarrhea, abdominal pain, cramping, joint pain/swelling, diagnosis?
|
arthritis with ulcerative colitis, regional enteritis, scleroderma
|
|
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Patients presents with Urethritis and join pain/swelling, diagnosis?
|
Reiter's syndrome or possible gonococcal arthritis
|
|
|
Patient presents with joint pain/swelling and has mental status change, facial or other weakness, stiff neck, diagnosis?
|
lyme disease with CNS involvement
|
|
|
What are elderly fall risk factors?
|
unstable gait, imbalanced posture,
reduced strength, cognitive loss as in dementia, deficits in vision and proprioception, and osteoporosis, Poor lighting, stairs, chairs at awkward heights, slippery or irregular surfaces, and ill-fitting shoes are environmental dangers |
|
|
What are medications that affect balance?
|
benzodiazepines, vasodilators, and diuretics
|
|
|
What is the definition of osteoporosis?
|
bone density >2.5 standard deviations below normal bone mass in young women
|
|
|
How does a 10% drop in bone mineral density change the risk of fracture?
|
increases risk of fracture by 20%
|
|
|
Patient presents with fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended, diagnosis?
|
Dupytren's contracture - increase size of palmar fascia
|
|
|
Patient presents with palpable bogginess or doughiness of the synovial membrane, diagnosis?
|
synovitis, can be accompanied by effusion
|
|
|
Patient presents with palpable joint fluid in effusion, tenderness over the tendon sheaths, diagnosis?
|
tendinitis
|
|
|
The joint is swollen and warm, what could it possibly be?
|
arthritis, tendinitis, bursitis, osteomyelitis, infection
|
|
|
What does redness over a tender joint suggest?
|
septic or gouty arthritis or possibly RA
|
|
|
Swelling, tenderness, and decreased range of motion suggest?
|
inflamed joint
|
|
|
How do we check the TMJ joint?
|
palpate ethe joint, place tips of fingers just in front of the tragus of each ear, ask the patient to open mouth, fingertips should drop into the joint
|
|
|
Patient presents with a lateral flattened looking shoulder, diagnosis?
|
anterior dislocation
|
|
|
Patient comes in with the anterior aspect of the shoulder looking flattened, diagnosis?
|
posterior dislocation
|
|
|
Patient presents with localized tenderness with adduction of shoulder, diagnosis?
|
acromioclavicular joint arthritis or inflammation
|
|
|
Patient experiences pain when physician passively extends the shoulder by lifting the elbow posteriorly, diagnosis?
|
subacromial or subdeltoid bursitis, degernerative changes or calcific deposits in the rotator cuff
|
|
|
patient presents with inability to lift the arm above the shoulder level, diagnosis?
|
rotator cuff injury, most commonly the supraspinatus
|
|
|
Patient in unable to hold the arm fully abducted at the shoulder level, drop arm test, diagnosis?
|
tear in the rotator cuff:
suprspinatus infraspinatus teres minor subscapularis |
|
|
Patient is unable to abduct are against resistance, what muscle is involved?
|
supraspinatus
|
|
|
Patient is unable to rotate forearm medially against resistance, what muscle is invovled?
|
subscapularis
|
|
|
Patient is unable to rotate forearm laterally against resistance, muscle involvement?
|
infraspinatus and teres minor
|
|
|
Patient is unable to adduct forearm against resistance, muscle involvement?
|
thoracohumeral group
|
|
|
Where is the tenderness for tennis elbow?
|
lateral epicondylitis
|
|
|
where is the tenderness for golfer's or pitcher's elbow?
|
medial epicondylitis
|
|
|
Patients hands have poor finger alignment, what does this suggest?
|
flexor tendon damage
|
|
|
DIP joint nodules are -
|
Heberden's nodes
|
|
|
PIP joint nodules are -
|
Bouchard's nodes
|
|
|
RA has what type of nodules?
|
PIP and MCP
|
|
|
Patient presents with thenar atrophy what is the likely cause?
|
median nerve compression from carpal tunnel syndrome
|
|
|
Patient presents with hypothenar atrophy what is the cause?
|
ulnar nerve compression
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|
|
What can cause contractures of the 3-5th fingers?
|
thickening of the palmar fascia, pulls down on flexor tendons
|
|
|
Patient presents with tenderness over the distal radius, diagnosis?
|
colles' fracture
|
|
|
Patient presents with tenderness over the snuff box, diagnosis?
|
scaphoid fracture
|
|
|
Patient experiences pain in the MCP when shaking hands, diagnosis?
|
Synovitis
|
|
|
Patient presents with Herberden's nodes, diagnosis?
|
DIP joints, osteroarthritis
|
|
|
tenderness and swelling over the extensor and abductor tendons of the thumb as they cross the radial styloid, diagnosis?
|
De Quervain's tenosynovitis
|
|
|
Patient comes in with lateral deviation and rotation of the head, diagnosis?
|
torticollis (opposite side SCM muslce contraction)
|
|
|
Patient comes in with unequal shoulder heights, diagnosis?
|
Sprengel's deformity of the scapula, winging of the scapula (loss of innervation to serratus anterior by long thoracic), or in contralateral waekness of trapezius
|
|
|
Unequal heights of the iliac crests or pelvic tilt suggest?
|
scoliosis, or with herniated lumbar disc
|
|
|
Where does arthritis most likely to occur in the vertebral column?
|
C5 and C6
|
|
|
Patient presents with step-offs of the spinal column, diagnosis?
|
spondylolisthesis, forward slippage of one vertebra, may compess the spinal cord
|
|
|
Patient presents with tenderness over the sacroiliac joint, diagnosis?
|
ankylosing spondylitis
|
|
|
Where are the two most common places to have herniated intervertebral discs?
|
L5 and S1 or between L4 and L5
|
|
|
What does persistence of lumbar lordosis suggest?
|
ankylosing spondylitis
|
|
|
What does a wide base gait suggest?
|
cerebellar disease or foot problems
|
|
|
Tenderness and swelling in ischiogluteal bursa suggests?
|
ischiogluteal bursitis - weaver's bottom
|
|
|
what is genu varum?
|
bowlegs
|
|
|
what is genu valgum?
|
knock knees
|
|
|
Inability to extend the knee suggest?
|
partial or complete tear of the patellar tendon
|
|
|
Patient presents having pain with patellar movement during quadriceps contraction, diagnosis?
|
chondromalacia, or degenerative patella
|
|
|
What meniscus is more likely to be torn and tender?
|
medial meniscus is more likely
|
|
|
What is "housemaid's knee"?
|
prepatellar bursitis, from excessive kneeling
|
|
|
Patient presents with anserine bursitis, what could cause this?
|
running, valgus knee deformity, fibromyalgias, osteroarthritis
|
|
|
What is a Baker's cyst?
|
popliteal cyst, from distention of the gastrocnemius semimembranosus bursa
|
|
|
What is the buldge sign?
|
milk fluid downward in knee behind patellar ligament, then apply pressure on the lateral side, while tapping the fluid on the medial side, you should see waves, if knee has minor effusion
|
|
|
What is a positive balloon sign?
|
suprapatellar compression ejects fluid into the spaces adjacent to the patella, a palpable fluid wave signifies a positive balloon sign, for a large effusion
|
|
|
Patient presents with pain or laxity of resistance when putting abduction stress pushing medially from the lateral side of the knee, (valgus stress), what does this indicate?
|
MCL tear or laxity
|
|
|
Patient presents with pain or laxity when performing adduction stress, from the medial side pushing laterally, what does this indicate?
|
lateral collateral ligament tear or laxity
|
|
|
What does the anterior drawer sign test for? and what is a positive anterior drawer sign?
|
ACL tear, forward jerk showing the contours of the upper tibia is a positive anterior drawer sign, suggest tear
|
|
|
Patient comes in with a defect in the gastrocnemius with tenderness and swelling, diagnosis?
|
ruptured achilles tendon
|
|
|
What movements are done at the tibiotalar joint?
|
dorsiflex and plantar flex
|
|
|
What movements are done at the talocalcaneal joint?
|
inversion and eversion
|
|
|
What is the Phalen's Test and what does it indicate?
|
hold the patients writs in acute flexion for 60 seconds, or have them put the wrist together so that backs of hands are both at right angles
test for carpal tunnel syndrome |
|
|
Patient presents with sharp pain radiating from the back down the leg, diagnosis?
|
L5 or S1 distribution suggests tension on or compression of the nerve roots, possible herniated lumbar disc
|
|
|
What does a positive crossed straight leg raising sign suggest?
|
when pain in affected leg occurs when other leg is up and crossed, confirms herniated disc at L5 or S1
|
|
|
What are the 6 patterns of lower back pain?
|
-mechanical low back pain (tenderness at sight)
-radicular low back pain (nerve) -back and leg pain from lumbar stenosis -chronic persistent low back stiffness (chronis inflammation, arthritis) -Aching nocturnal back pain, unrelieved by rest -Back pain referred from the abdomen or pelvis |
|
|
What should you consider with aching nocturnal back pain?
|
consider metatatic malignancy in the spine, prostate cancer, breast, lung, thyroid, and kidney
|
|
|
Patient comes in with pain in the muscles of the hip girdle and shoulder girdle, symmetrically, diagnosis?
|
polymyalgia rheumatica
|
|
|
What causes frozen shoulder? (adhesive capsulitis)
|
fibrosis of the glenohumeral joint capsule,
|
|
|
What are swan neck deformities?
|
hyperextension of the proximal interphalageal joints with fixed flexion of the distal interphalageal joint
|
|
|
What are boutonniere deformities?
|
persistent flexion of the proximal interphalageal joints with fixed hyperextension of the distal interphalageal joints
|
|
|
What are the 3 possible signs in the hands of chronic RA?
|
ulnar deviation, swan neck deformity, or boutonniere deformity
|
|
|
What is a trigger finger?
|
when there is a nodule in a flexor tendon in the palm, nodule is too big to enter easily into the tendon sheath so when the person extends finger with assistance there is a palpable and audible snap as the nodule pops into the tendon sheath,
|
|
|
What are the coagulation factors that are Vit K dependent?
|
factors: II (thrombin), VII, IX, X
|
|
|
How does heparin and warfarin affect PT and PTT?
|
PTT: affected by both
PT: only affected by Warfarin and insensitive to Heparin |
|
|
What are three important things for evaluating a patient for bleeding risk and specifically what should you be asking about?
|
Personal History, Family Hx, and physical exam really help
Ask about: circumcision, menses, tooth extraction, childbirth, surgery |
|
|
What can physical exam help distinguish between in bleeding risk patient?
|
thrombocytopenic bleeding from coagulopathis
Thrombocytopenia - produce mucous membrane bleeding, ecchymoses, and petechiae coagulopathies - produce soft tissue bleeds, ecchymoses, hematomas and hemarthroses |
|
|
How are Hemophilias A and B inherited, what is the deficiency in each, and what clinically happens in the severe form?
|
both are inherited in sex linked manner (recessive)
Hem A: F VIII Hem B: F IX - Christmas disease severe forms present as recurrent hemarthroses in childhood which leads to chronic arthritis |
|
|
What are the classic findings for Hemophilias A and B?
|
deep muscle or joint bleeding
initial cessation of bleeding from small cuts with re-bleeding hours later long term joint deformities family history is very important but may be negative in 1/3 severe hemophiliacs |
|
|
PT normal
PTT prolonged Platelet count normal bleeding time prolonged -has started mensus three weeks ago and hasn't stopped bleeding, diagnosis? |
bleeding from mucous membranes - platelet (thrombocytopenia),
mother and aunt - autosomal; platelets are normal in number but bleeding time is long - platelet functional problem possible clotting factor problem with an elevated PTT von Willebrand's Disease: |
|
|
Describe VWD:
|
usually milder than hemophilia-no joint bleeds
autosomal dominant inheritance VWF is necessary for platelet adhesion and is the carrier of protein for F VIII So no platelet adhesion make increased bleeding time, and platelet mimicing disorder VWF deficiency will decrease F VIII leading to an increased PTT |
|
|
What are the 4 aquired coagulopathies?
|
1. liver disease
2. Vit K deficiency 3. Disseminated Intravascular Coagulation 4. Rare things |
|
|
55 yo male admited for GI bleeding, drinks 6-pack daily for 20 years, PT elevated, PTT mildly elevated, platelets borderline thrombocytopenia, what during the physical exam should you look for?
|
look in patients eyes: scleral icterus
look for spider angiomata - present on upper back feel the patietns liver - hard edges feel the patients spleen (enlarged) check for fluid wave in the abdomen cancel the expensive factor assay and check liver tests |
|
|
What clotting factors will be affected in liver disease?
|
II, V, VII, IX, X,
fibrinogen is low only in end stage liver disease factor VIII often elevated |
|
|
How can liver cirrhosis affect platelet counts?
|
platelets are low due to pooling in the enlarged spleen, due to portal hypertension caused from liver disease,
|
|
|
Outside of platelets and coagulation factors how does liver cirrhosis additionally affect bleeding?
|
increased secondary fibrinolysis which may aggravate bleeding tendency, low grade DIC is often present
|
|
|
55 yo Female develops complications after gall bladder surgery, placed on NPO and given antibiots, 10 days later she begins to ooze from venepuncture sites and has bruising, PT and PTT prolonged, platelets are normal, diagnosis?
|
Vit K deficiency
|
|
|
What do we get Vit K deficiency from?
|
newborns
bile duct obstruction-can't absorb fat soluble vitamins poor diet and antibiotis ingestion of coumarins |
|
|
74 yo Female, abdominal pain and vomiting, bowel perforation on exploratory surgery, post ob she develops fever, low BP, and began to ooze from venepuncture site, PT and PTT both prolonged, what cold you do to get diagnosis without doing lab test? what would the results indicate?
what is the diagnosis? |
get blood sample and measure retracted blood clot size:
large amounts of shed rbcs in retracted blood clot in patient with hypofibrinogenemia DIC: unregulated coagulation occurs in the circulation which consumes coagulation factors, especially fibrinogen, and platelets patients bleed from factor deficiencies but may also have thromboses |
|
|
What is the hallmark for DIC?
|
low platelets with low fibrinogen levels
|
|
|
What are the causes of DIC?
|
obstetrical accidents, abruptio placenta, eclampsia, retained product of conception
sepsis and hypotension malignancies: promyelocytic leukemia, adenocarcinoma miscellaneous: trauma, burns, snake bites |
|
|
What are 2 acquired coagulation inhibitors?
|
1. lupus anticoagulant - does not cause bleeding, (antiphospholipid antibody)
2 acquired factor VIII antibodies |
|
|
What are 2 acquired factor deficiencies?
|
1. amyloidosis facotr X
2. nephrotic syndrome factor IX |
|
|
25 yo female, with recent onset of bruising, red spots on her legs, Hb 13gm%, wbc is 5,200/mm3 with normal differential, platelets are 7,000/mm3. PT and PTT are normal, (normal PE except for bruises and petechiae), diagnosis?
|
immune thrombocytopenic purpura - autoimmune disorder affecting young women
but must exclude: thrombotic thrombocytopenic purpura |
|
|
What happens in ITP and what can cause it?
|
autoantibodies against platelets are produced which causes their destruction int he spleen, but splenomegaly usually does not occur, can also occur from drug related immune thrombocytopenia
|
|
|
How do we treat ITP?
|
usually respond to steroids (2-5 days) but often need splenectomy as well
|
|
|
27 yo Female hospitalized because of purpura. Hb 7.2g/dl, corrected reticulocyte count is 8.6. Leukocyte count is 6800/uL, platelets count is 52,000/uL. Peripheral blood smear shows many fragmented erythrocytes, plateles are large, patient develops fever, diplopia, slurred speech within 24 hours. Serum creatitine is 4.1md/dl. PT and PTT and fibrinogen are normal, diagnosis?
|
thrombotic thrombocytopenic purpura
|
|
|
What is the hallmark presentation of TTP?
|
Pentad:
1. low platelets 2. microangiopathic hemolytic anemia 3. renal disease 4. neurologic signs 5. fever |
|
|
57 yo male additted from emergency after alcoholic binge with eccymoses and bleeding. PT and PTT were normal, PE had no signs of cirrhosis or splenomegaly, platelet count was low, diagnosis?
|
alcohol can have a direct affect on platlets and megakaryocytes, leading to gradual decreases over time, regardless of folid acid levels
|
|
|
When evaluating a patient with anemia what clinical question should you ask/ and what should you look for?
|
1. prior h/o anemia?
2. any systemic disease or organ dysfunction? 3. family h/o anemia? 4. symtoms of anemia: fatigue, dyspnea, menstrual dysfunction, constipation, sexual dysfunction? 5. signs of anemia - pallor, koilonychia, glossitis, splenomegaly, jaundice 6. signs of other disease (liver, malignancy, inflammation) |
|
|
When testing for anemia what all should be ordered in the hemogram?
|
CBC: wbc, Hb, Hct, rbc, platelets, differentials, indices: MCV, MCHC, MCH, RDW, and MPV, reticulocyte index
|
|
|
How do you calculate a RI and what does this mean?
|
reticulocyte index
RI = Reticulocyte % x Hct/45 RI = marrow production of rbcs (# times the normal) |
|
|
What is the RI of a patient with Hct of 22% and reticulocytes of 4%?
|
4% x 22/45 = 2
reticulocyte index of 2 times the normal rate of rbcs made in bone marrow |
|
|
What outside of cells do you look for in the blood when evaluating a patient for anemia?
|
1. iron, iron binding capacity and ferritin
2. heptoglobin, bilirubin, LDH 3. Vit B12, folate, homocysteine, and methyl malonic acid levels 4. Hb electrophoresis, Hb A2 levels |
|
|
When evaluating for anemia, after you have done the History taking, and Hemogram, what should you do next?
|
test for specific anemias
|
|
|
In anemia evaluation, what should you do after you test for specific anemias? and where do you go from here?
|
Look for indications for marrow examination for anemia:
1. anemia with other cytopenias 2. unexplained normocytic, nonhemolytic anemia |
|
|
What the categories of anemia clinically?
|
acute, chronic
hereditary, acquired |
|
|
What are the morphological classifications for anemia?
|
macro, micro, normocytic
with/without other cytopenias |
|
|
What are the functional categories for anemia?
|
marrow response adequate or not (RI)
|
|
|
18yo son comes with chronic fatigue, low blood count since childhood, never been transfused, mild jaundice for several years, no family hx, older brother is normal,
labs: Hb=7Gm%, Hct=22%, MCV = 68, MCHC =32, wbc =5,400/,,#; platelets 175,000/mm; reticulocytes = 4% What is the diagnosis? |
1. chronic anemia since childhood,
2. microcytic and no other cytopenias, could be iron deficiency or thalassemia 3. marrow is responding but not adequately-suggests ineffective erythropoiesis, such as seen in thalssemia RI = 2 Beta thalassemia minor |
|
|
35 yo woman, fatigue, pleuritic chest pain, rash for several months, recurrent pains in her hands, wrists, and knees, no Fx, facial rash and some swelling of the PIP joints, palpable spleen tip.
Labs: Hb: 9.9Gm%; Hct: 33%; MCV 101, MCHC 33, wbc = 3200/mm; platelets =35,000; reticulocytes: 6% What do these findings suggest? |
clinically sounds like acquired,
morphologically: macrocytic anemia may reflect the HIGH reticulocytes, B12 or folate deficiency THe other cells are low suggesting a marrow problem or destruction of all cell types Functionally: 6% x 33/45 = RI of 4, an adequate marrow response so the marrow is not the problem must be destructive Autoimmune Hemolytic anemia: suggestive of Lupus Erythematosis: anti-DNA antibodies |
|
|
45 yo woman, gradual onset of fatigue over 6 months, has happened before and when she is given iron she feels better, brother has similar condition, mother used to get "low blood", menses are normal, a child that sometimes needs iron,
Labs: Hb:7.5% Hct: 28%, MCV: 75; wbc: 7,000; platelets: 450,000; reticulocytes 1% What do these findings suggest? |
clinically: inherited
morphologically- microcytic anemia, iron deficiency or thalassemia functionally: marrow definitely not responding adequately more like iron deficiency Hereditary Hemorrhagic Telangiectasia |
|
|
What are blood smear findings of Hereditary Hemorrhagic telangiectasia?
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microcytic cells with elliptocytes
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What skin morphology is seen in HHT?
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telangiectases of the skin and mucous membranes indicate the sites of chronic GI bleeding
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What is the pathology of HHT?
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multiple telangiectases in the bowel result in chronic slow bleeding with resultant iron deficiency anemia,
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How id HHT inherited?
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autosomal dominant fashion
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What is a note about iron deficiency in adult?
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ALWAYS due to bleeding never due to dietary deficiency
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65 yo man became dizzy when standing up suddenly, fell and struck his head, no personal or Fx of anemia,
labs: Hb8%, Hct: 25%, MCV:87, MCHC: 32, wbc: 7500; platelets:250,000 and reticulocytes: 1%. Mild rouleaux on blood smear suggestive of? X-ray of skull shows moth-eaten appearance lytic lesions, diagnosis? |
clinically: qcuired
morphologically: normocytic anemia other cells OK -this should lead us to think of renal insufficiency, anemia of chronic disease, and others runctionally marrow is not responding adequately, multiply myeloma which often presents with a normocytic anemia with other cells being normal diagnosis was suspected from rouleaux formation on the smear and appearance of x-ray, |
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What does the diagnosis of multiple myeloma require?
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bone marrow results
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What is the overall summary of evaluating an adult with anemia?
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1. suspect anemia with any generalized symptom or pallow but neither are necessary findings
2. evaluate the patient with Hx and PE FIRST 3. DO cbc and reticulocyte count and categorize the findings 4. correlate 2 and 3 and do further testing |
