Su 12 Ambulatory Medicine 2-4

Front 1

275. From where do External Haemorrhoids arise?

Back 1

a. Dilated veins from inferior hemorrhoidal plexus distal to dentate line (sensate line).

Front 2

276. From where do Internal Haemorrhoids arise?

Back 2

a. Dilated submucosal veins of superior rectal plexus.
b. Above dentate line (insensate area).

Front 3

277. Risk factors for Haemorrhoids?

Back 3

a. Constipation/straining
b. Pregnancy
c. Portal HTN
d. Obesity
e. Prolonged sitting (especially truck drivers and pilots) or prolonged standing.
f. Anal intercourse

Front 4

278. Clinical features of Haemorrhoids?

Back 4

a. Bleeding and rectal prolapse (main symptoms)
i. Bright red blood per rectum

Front 5

279. Bright red blood per rectum w/haemorrhoids?

Back 5

a. Usually harmless, but look for iron deficiency anaemia (rare).
b. Occult rectal bleeding should prompt an investigation until other conditions are ruled out.
c. Bleeding is usually painless.

Front 6

280. Presentation of External Haemorrhoids?

Back 6

a. Usually asymptomatic unless thrombosed, in which case they present as sudden painful swelling (may ulcerate, bleed).
b. Pain lasts for several days, and then gradually subsides.
c. The response to surgery is rapid.

Front 7

281. Presentation of Internal haemorrhoids?

Back 7

281. Presentation of Internal haemorrhoids?

Front 8

282. General measures to ease Haemorroids?

Back 8

a. Sitz bath
b. Application of ice packs to anal area and bed rest.
c. Stool softeners to reduce strain
d. High-fibre, high-fluid diet
e. Topical steroids.

Front 9

283. More permanent treatment methods for Haemorrhoids?

Back 9

a. Rubber band ligation for internal haemorrhoids- rubber bands applied to haemorroidal bundle leads to necrosis and sloughing of lesion.
b. Surgical (Haemorrhoidectomy)- Perform surg is the condition does not respond to conservative methods, or if severe prolapse, strangulation, very large anal tags, or fissure is present.
c. Surgery can be performed in an ambulatory setting.

Front 10

284. 3 Most common causes of low back pain?

Back 10

a. Musculoligamentous strain
b. Degenerative disc disease
c. Facet arthritis

Front 11

285. 11 causes of low back pain?

Back 11

1. Musculoligamentous strain
2. Lumbar disc herniation
3. Degenerative disc disease (Osteoarthritis)
4. Lumbar spinal stenosis (narrowing of spinal canal).
5. Vertebral compression fracture
6. Neoplasms
7. Infection
8. Ankylosing spondylitis and other spondyloarhtropathies
9. Cauda equine syndrome
10. Spinal deformity (kyphosis, scoliosis)
11. Sponylolisthesis

Front 12

286. Pathophys of back pain due to Musculoligamentous strain?

Back 12

a. This is a tear/strain of muscle fibres/ligaments in the paraspinal muscles around the iliac crest/lower lumbar regions.
b. The resultant bleeding and spasm can cause tenderness in the region

Front 13

287. Hx with back pain due to Musculoligamentous strain?

Back 13

a. The pt usually recalls an episode of bending/twisting or of the back “giving way” when lifting a heavy object, with immediate onset of pain.

Front 14

288. Presentation of back pain due to Musculoligamentous strain?

Back 14

a. Radiation of pain occurs across the low back (often to ass/upper thigh to knee level posteriorly).
b. Pain typically does not radiate distal to the knee because no nerve root injury has occurred.

Front 15

289. Pathophys of lumbar disc herniation?

Back 15

a. Nucleus pulposus (inner portion) extrudes through the annulus fibrosis (outer portion) and impinges on nerve roots, causing lower extremity radiculopathy.

Front 16

290. At what 2 levels do 95% of lumber disc herniations occur?

Back 16

a. L5-S1 and L4-L5.

Front 17

291. Main clinical findings w/lumbar disc herniation?

Back 17

a. Low back pain/stiffness and radiculopathy are main clinical findings.
b. Radiculopathy is due to compression of nerve root by extruded disc.

Front 18

292. Sciatica?

Back 18

a. Term used to refer to pain along the course of the sciatic nerve.
b. Neurologic deficits may be present, depending on the extent/duration of nerve root compression.

Front 19

293. Degenerative disc disease (osteoarthritis)?

Back 19

a. Common cause of chronic low back pain.
b. In addition to low back pain, disc space narrowing and osteophytes can cause compression of nerve roots, causing lower extremity radiculopathy as well.

Front 20

294. Lumbar spinal stenosis (narrowing of spinal canal)?

Back 20

a. May be acquired due to degenerative changes, iatrogenic causes, posttraumatic,) or congenital (achondroplasia or idiopathic).
b. Most cases are acquired and due to advanced degenerative changes that narrow the canal.

Front 21

295. What is pain w/lumbar spinal stenosis due to?

Back 21

a. Activity and relieved by rest or spinal flexion (neurogenic claudication)
b. Spine flexion causes increase size of spinal canal.

Front 22

296. Symptoms of Spinal Stenosis?

Back 22

a. Low back pain
b. Sciatica (involving one or both legs)
c. Decreased ambulatory capacity!!!!

Front 23

297. What is a vertebral compression fracture?

Back 23

a. Acute back pain caused by a minor stress in elderly pts.
b. Pain is at the level of fracture w/local radiation across the back and around the trunk (rarely into legs).
c. In normal bone, this fracture requires severe flexion, compression trauma. In elderly pts w/no osteoporosis, compression fractures can occur w/minimal or o trauma.

Front 24

298. Risk of multiple compression fractures?

Back 24

a. Can lead to severe kyphosis.

Front 25

299. Kyphoplasty?

Back 25

a. Injection of cement into vertebral body.
b. Is effective for pain relief and prevention of deformity.

Front 26

300. In what 3 types of pts is spontaneous vertebral body collapse or pathologic fracture most commonly seen?

Back 26

a. Elderly pts w/severe osteoporosis
b. Pts on long-term steroid therapy
c. Cancer pts w/lytic bony mets or multiple myeloma.