Acute Fractures Management- ABC care (Airway, breathing, circulation),musculoskeletal seco, Exams of Nursing

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Acute Fractures Management- ABC care (Airway, breathing, circulation), musculoskeletal second survey

• fluid resuscitation
• early reduction of fracture
• cover open wounds
• surgical irrigation and debridement for open fracture
• Ab's: Cefazolin for gram pos. Clindamycin for tetani infection
• pain: opioids
• tetanus shot of unknown
• calcium upon discharge for osteoporosis
• cement injection in bone with vertebroplasty answers Acute liver failure: findings, management Weakness, fatigue weightless, n/v, Abd pain Change in bowel pattern
• Check BMP, ABG, lactate, toxicology screen, acetaminophen screen, Hep panel, PT/ INR
• Treat specific etiology: charcoal for acetaminophen and N-acetylcysteine) Supportive for Hep A and E Antiviral for Hep B Test for Wilson
• ICU management: watch for cerebral edema, hyperventilate if present, mannitol. CT head for encephalopathy answers Acute pancreatitis findings/ diagnostics- Epigastric Abd pain, abrupt, worse with walking or supine, better with knee to chest, leaning forward
• N/V
• hypoactive bowel sounds
• tachycardia, hypotension
• jaundice
• ascites
• Elevated lipase and amylase
• elevated urine amylase
• elevated trypsin levels
• leukocytosis
• Bili elevated
• Hypocalcemia if severe disease
• Low albumin
• or abdomen: ileus, pancreatic calcifications, gallstones
• CT abdomen preferred over US, and MRI over CT answers Acute pancreatitis management- IV hydration - Fluid therapy to prevent hypovolemia and shock: LR or NS with 20 K at 75- 100 ml/hr.

• May need plasma, RBC, albumin
• Pain control - Morphine, Fentanyl
• AB's, not prophylactically, only when septic or biliary stones.
• NPO, then supplements, small frequent meals
• NG for ileus or vomiting
• replace electrolytes
• enteral feeding answers acute pancreatitis: what and etiology inflammation of pancreas Alcoholism Gallstones Smoking Traumatic or hereditary Infectious (CMV) Meds: Sulfa drugs, thiazide diuretics, Lasix, Corticosteroids, Depakote, Opioids answers Advanced HIV infection: definition, symptoms, prognosisCD4 below 50 Wasting, fevers, fatigue Poor answers AIDS, definition and diagnosis acquired immune deficiency syndrome CD4 low, below 500 and infection with opportunistic organism Or: CD4 below 200 answers Alcoholic liver disease: etiology, findings, management Most common cause of cirrhosis Women twice as sensitive to alcohol toxicity then men Binge drinking High mortality rate Diagnosis on report of alcohol intake, evidence of liver disease, lab abnormalities AST and ALT often high than 2 Score for mortality: Madres' score
• Abstinence
• MDF score greater than 32: prednisone for 4 wks.
• May require liver transplant answers ANA. Tests in rheumatic disease: what, normal level, abnormal with. Antinuclear antibody (ANA). Normal: Titer 1.

Positive with: Sjogren's (SS), SLE (lupus), answers Antiretroviral therapy (ART)- Combination therapy, 3 or more from different drug classes

• Follow up with HIV viral load determination at 4 - 6 wks. after initiation and then every 3 - 6 mo.
• Adherence is vital
• always assess drug- drug interactions/ medication reconciliation
• May make changes when CD4 exceeds evidence level
• check GFR/ create/ BUN monthly for elderly on Tenofovir
• If deteriorating on ART (decline in CD4) then perform drug resistance testing and revision of ART answers Appendicitis findings and diagnostics Abd pain: periumbilical first, then right lower quadrant pain (McBurney's point) Roving’s sign: pain role when touched all Psoas sign: pain with extension of right hip Obturator sign: pain with internal rotation right hip Anorexia n/v constipation low grade fever motionless, right thigh up guarding role Moderate leukocytosis UA: elevated spec gravity, hematuria, pyuria, albuminuria Ultra sound: very sensitive CT to detect: perforation, peri appendiceal abscess answers Appendicitis Treatment Mainstay treatment: surgery IV fluids/ correct electrolytes AB: Cefoxitin 1 - 2 gr Tx for gangrenous/ perforated appendicitis:
• mild/ moderate severity: one AB or Cefazolin/ Ceftriaxone/ Cipro/ Levaquin with Flagyl
• high risk/ severity (immunocompromised, old): Meropenem, Zosyn or Cefepime/ Cipro/ Levaquin with Flagyl. Narrow AB once culture results available Pain Tx: Deluded Morphine answers Appendicitis: what and etiology Acute inflammation of the appendix.

Caused by: fecalith (fecal stone), inflammation, intestinal worms, strictures, tumors. Gangrene and perforation if not treated within 36hrs. answers Assessment of surgical risk- Unstable cardiac condition (recent MI, active angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD

• patient stable or unstable?
• urgency of the procedure (oncology will be time sensitive)
• risk of procedure
• nutritional status
• immune competence
• determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk) answers Autoimmune hepatitis: what, etiology, findings, management unresolving inflammation of liver with unknown cause More women than men
• Abnormal serum globulins and presence of autoantibodies
• Abnormal serum aminotransferases Prednisone monotherapy, induction and maintenance Prednisone with azathioprine, induction and maintenance May need liver transplant answersC4 Complement. Tests in rheumatic disease: what, normal level, abnormal with. Determines hemolytic activity which speaks to level of inflammatory response Normal: men: 12-72. Women: 13-75 mg/dl Increased with: inflammatory disease Decreased with: RA, lupus, SS answers Calcineurin inhibitors: which, indication, adverse effects Tacrolimus Cyclosporine Prophylaxis of rejection T: tremor, renal dysfunction, hyperglycemia C: tremor, renal dysfunction, hen, hirsutism, gingival hyperplasia Answers Cauda Equina Syndrome Spinal cord compression from metastatic lesion to spine. Causes: gradual to sudden weakness and inability to move/ lift legs, bowel/ bladder incontinence, diminished sensation in legs: saddle. Surgical emergency! answers Cause of fractures Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders

answers Celebrex and Arthritis Analgesic and anti-inflammatory Fewer ulcers than with other NSAIDS Not recommended in renal or liver failure Screen for sulfa allergy May cause cardiovascular thrombotic event May cause GI adverse event answers Cholecystitis: findings/ diagnostics- asymptomatic, developing into bloating/ Abd pain

• biliary colic: intense epigastric pain radiating to shoulder/ back
• N/V
• anorexia
• elevated temp
• pos Murphy's (pain on inspiration with fingers under right rib cage)
• palpable gallbladder
• jaundice
• right upper quadrant pain, fever, leukocytosis, guarding with severe inflammation
• leukocytosis
• elevated bile
• Increased alanine transaminase, aspartate transaminase, lactate dehydrogenase, alkaline phosphatase
• elevated amylase
• egg and or chest to rule out mi or pneumonia
• US: best study for diagnosing gallstones
• ERCP: assess biliary and pancreatic ducts
• Graded by severity: answers Cholecystitis: management IV fluids Pain control (NSAIDS) AB's iv (third gen cephalosporin, Zosyn, mere) Surgery: Cholecystectomy ERCP for stones in bile duct Ursodiol for small stones (smaller than 2cm) answers Cholecystitis: what, etiology Inflammation of gallbladder, acute or chronic. Often with gallstones (cholelithiasis).
• Gallstones: obstruct cystic duct which causes inflammation behind it. From cholesterol.
• Acalculous cholecystitis: rare. With unexplained fever or after multiple trauma and poor oral intake
• bacteria
• cancer

• risk factors: obesity, pregnancy, sedentary lifestyle, low fiber diet, female, older age, high cholesterol mild: no organ dysfunction moderate: leukocytosis, complaints longer than 72 hours, local inflammation Severe: organ dysfunction answers Cholestatic labs- Alkaline phosphatase: increased with cholestasis (flow from liver is blocked)), pregnancy, bone growth/ disease (Paget's)
• GGT: increased with cholestasis but not bone disease, may be elevated with alcohol
• indirect bilirubin: increased with breakdown of blood (DIC), Gilbert's
• direct bilirubin: more than 50% (compared to total) with blocked intrahepatic or extrahepatic duct (bile duct stone, pancreatic tumor)
• bilirubinuria: blocked flow from liver answers Common medical complications in organ transplantation TN Calcium channel blockers often used to treat. Usually, multiple agents necessary. Avoid hypotension in kidney recipient. Posttransplant diabetes mellitus May be related to corticosteroids. Increases risk for graft loss. Tight glycemic control indicated. Renal insufficiency Nephrotoxicity from meds (Calcineurin inhibitors). Treatment: reduce Calcineurin inhibitors dose, limit other nephrotoxic meds Hyperlipidemia From effect of immunosuppressive meds on lipid levels (mostly from sirolimus). Optimize pharm cholesterol management Bone disease Osteoporosis common, related to corticosteroid. Baseline and annual bone scan necessary. Minimize corticosteroid use, give calcium Malignancy Increased incidence of lymphoma, skin ca, Kaposi's sarcoma. Related to Epstein-Barr and high doses of cyclosporine and tacrolimus. Treat: minimize immunosuppression, start radiation. Poor prognosis. answers Common opportunistic organism in AIDS Pneumocystis jives Cryptosporidium Candida albicans answers Compartment syndrome finding and diagnostics pain out of proportion to injury hex of trauma

paresthesia heaviness in affected extremity Six P's: Pain on passive stretch Paresthesia Paralysis of affected limb (late finding) Pulses, bounding first then pulseless later Pallor of affected limb Polar/ poikilothermic (ice cold limb) Elevated WBC Hyperkalemia (tissue necrosis) CPK and LDH elevated Myoglobin in urine Elevated compartment pressure (normal 0-8) Clinical diagnosis, MRI may confirm Acute renal failure (due to myoglobinuria) answers Compartment syndrome management on surgical:

• limb at heart level (do not elevate)
• remove bandages/ immobilizers
• diuretic
• neurovascular checks
• CRRT/ dialysis to treat ARF
• intercompartmental pressure monitoring Surgical:
• fasciotomy, with delayed closure of wounds (negative pressure wound vac)
• skin grafting
• amputation if septic from necrotic tissue Restorative:
• functional splinting
• ROM
• early prosthetic fitting post amputation answers Compartment syndrome: what, who Increased pressure in tissue limits the circulation and function of the contents within that space (compartment: bone, blood vessel, nerves, muscle, soft tissue). Most often in arms and legs (most compartments), also abdomen Men under age 35 stemming from fracture of tibia stemming from splint, cast, scar

increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/ surgery, burn, bite answers Complications from liver disease with treatment- Cardiac: portal HTN, arrythmia's, edema

• Dermatologic: jaundice, pruritis. Cholestyramine or Colestipol for pruritis
• Fluid/ electrolytes: ascites, hypokalemia, hyponatremia, hypernatremia, hypoglycemia. D10 for hypoglycemia. Water restriction for hyponatremia. Replace K. Low sodium diet, fluid restriction, and diuretics, potential paracentesis (give albumin) for ascites. Give Bicarb for severe acidosis.
• GI: GI bleeding, Abd pain, varices, n/v
• Neuro: hepatic encephalopathy. Give lactulose. Limit protein. Rifaximin BID if no lactulose tolerated.
• Resp: Hyperventilation, hypoxemia Mech ventilation possible.
• Renal: RF, oliguria, hyponatremia, hypotension. May need dialysis. answers Complications of PUD- GI bleeding Symptoms: hemateins, melena, coffee ground hemateins, pallor, techy, hypotension, low Hit, BUN up Perform endoscopy Treat: IV fluids, blood transfusion, H2 blockers (Pepcid), no vasopressin or octreotide
• Perforation Symptoms: severe Abd pain, epigastric pain radiating to back, beardlike Abd, absent bowel sounds, knee to chest, fever, leukocytosis, free air on or, barium studies Treat: surgery, watch poor candidates on ab's, iv fluids, and NG.
• Gastric Outlet obstruction Symptoms: early satiety, n/v, epigastric pain unrelieved by food/antacids, succussion splash, NG foul-smelling large amount Perform upper GI endoscopy and saline test at 72hrs (check residual) Treat: Treat hypokalemia, if present because of N/V, Start H2 blocker (Pepcid), surgery

answers Components of informed consent- The nature of the decision/procedure

• Reasonable alternatives to the proposed intervention
• The relevant risks, benefits, and uncertainties related to each alternative
• Assessment of patient understanding
• The acceptance of the intervention by the patient answers Contraindications to receive organs- malignancy
• infection
• smoker, drugs
• noncompliance
• acquired immune deficiency syndrome
• HIV
• morbid obesity answers Corticosteroids and arthritis: what does it do and adverse effects Not for maintenance Use lowest dose Suppresses flares nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections answers Corticosteroids: which, indication, adverse effects Prednisone Solumedrol P: Prophylaxis of rejection S: Induction, treatment and prophylaxis of rejection Fluid retention, hyperglycemia, impaired wound healing, peptic ulcer answers Crohn’s Disease Inflammation and ulceration, structuring, fistula, abscess across entire colon. May cause chronic inflammation, intestinal obstruction, fistula, abscess. At greater risk for developing colon ca, lymphoma, and small bowel adenoma. IBD answers Crohn’s treatment - drugs
• Mesalamine 2.4 - 4.8gr/ day
• Corticosteroids for active disease (prednisone/ methyl prednisone, long course and taper
• Immunomodulating drugs: azathioprine, methotrexate if no response to corticosteroid
• Anti-tumor necrosis factor therapy: infliximab, certolizumab for refractory answers Crohn’s treatment Mild/ moderate: First line: oral mesalamine or Pentise If not responding: Flagyl May give Cipro

May give oral budesonide as first line Moderate/ severe: Corticosteroid (prednisone 40 - 60mg) until symptoms resolve Anti TNF therapy: infliximab if refractory to corticosteroid Severe/ sudden: Surgery if no response to oral corticosteroid and anti TNF therapy and suspicion for mass, obstruction, abscess. IV corticosteroids IV cyclosporine/ methotrexate (immunomodulator) Maintenance: no corticosteroid Azathioprine (2-3mg/kg/day) or infliximab (immunomodulator and anti TNF monoclinal antibody) Diet: well-balanced, may need supplemental enteral therapy during active disease answers. Tests in rheumatic disease: what, normal level, abnormal with-reactive protein, a non-specific antigen antibody Normal: trace to 6mg/ml Increased with infection and inflammation, RA. Decreased with successful RA treatment answers Diagnose alcoholic liver failure Alcohol use AST higher than ALT Diagnosis of exclusion answers Diagnose alpha1 - antitrypsin deficiency (later in life, while early smoker), asthma Pas + granules in liver alpha1 antitrypsin level pos answers Diagnose autoimmune hepatitis young women ALT higher than AST Will have anti smooth muscle antibody answers Diagnose hemochromatosis Men (women do not store iron because they have periods) ALT and AST equally elevated Ferritin level will be very high Bronze diabetes: pituitary problems, CHF, diabetes (diabetes with a bronze look) answers Diagnose Hep Amoral transmission Increased ALT over AST IgM (IgM anti HAV)

answers Diagnose Hep Intravenous transmission Increased ALT over AST pos for the surface if vaccinated (IgM surface antigen) pos for the core and the surface if infection (Cor IgM antigen and IgM surface antigen) answers Diagnose Hep Intravenous transmission, tattoo's, razors, sex partners Increased ALT over AST Anti HCV Antibody HCV RNA answers Diagnose NASH Obese people! ALT higher than AST Diagnosis of exclusion answers diagnose Wilson’s disease Young, movement disorder and psychiatric disease. Kaiser-Fleisher rings in eyes Increased ALT and AST Low circumplasm (copper sucked up) answers Diagnosing primary biliary cirrhosis Common in middle aged women, causes fatigue and itching. Tired, itching woman Positive anti mitochondrial antibodies (liver biopsy) Lak Phos elevated Portal granulomas (intrahepatic biliary ducts destruction) Increased cholesterol Bilirubin up late in disease answers Diagnosing Primary sclerosing cholangitis Intra end extra hepatic flow is blocked. Associated with ulcerative colitis Fibrosis of biliary duct seen on cholangiography) Lak Phos elevated Total bile elevated answers Dislocation management Early reduction is essential: closed/ manual if no fracture. If fracture then may need surgery. Post reduction immobilization (splint, cast, sling) surgical repair of ligaments PT/ OT NSAIDS Muscle relaxant for muscle spasms

Narcotics for short term use answers Dislocation: what, cause Complete displacement of bone end and position in joint. Common sites: shoulder, elbow (nurse maid), wrist, hip, knee (emergency if loss of integrity of ACL and PCL), ankle/ foot high energy blunt force trauma congenital neuromuscular disorder inflammatory joint disease, RA Loose ligaments younger than 35 often, due to sports Often associated with fracture answers Diverticulitis findings and diagnostics Lower left quadrant pain Fever constipation and diarrhea Abd pain, guarding, spasms, rebound tenderness, n/v hypoactive bowel sounds dysuria/ frequency Leukocytosis elevated procalcitonin CT abdomen (diagnose and rule out fistula) Barium enema may reveal strictures or fistulas Flexible sigmoidoscopy should be avoided in acute phase answers Diverticulitis Treatment Output: oral AB (Cipro or amoxicillin) clear liquids for 2-3 days Input: IV ab (cipro and flaggy) (ceftriaxone and flaggy) (Zosyn) Bowel rest NG for ileus Surgery if failure to response to Tx or free air, abscess, obstruction, peritonitis answers Diverticulitis: what and etiology Perforation of colonic diverticulum (micro or macro with peritonitis) Common in people older than 50yrs (50%) Low fiber diet answers Erythrocyte sedimentation rate (ESR). Tests in rheumatic disease: what, normal level, abnormal with. Rate at which RBC settle out of unclothed blood in 1 hr.

Normal: men: 0-7mm/hr., women: 0 - 25 mm/hr. Increased with inflammation answers Esophageal varices: Findings/ diagnostics Hematemesis melena Abd pain Hypovolemic shock Gold standard: EGD CBC: hub will then low because volume resuscitation prolonged PT and PTT Hypokalemia Hyponatremia Hyperglycemia Lactic acidosis answers Esophageal varices: management- LR/ NS till blood transfusion

• Blood transfusion
• NPO
• Octreotide, bolus then continuous
• Emergent endoscopy Prevention of re-bleeding:
• Follow up endoscopy (screening endoscopy when cirrhosis)
• TIPS (stent) answers Esophageal varices: what, etiology Submucosal veins that can results in GI bleeding when rupturing. 60% mortality.
• Cirrhosis
• Portal hypertension
• aspirin / NSAID Answers Fealty’s syndrome rheumatoid arthritis, splenomegaly, neutropenia answers Findings and diagnostics dislocation severe pain over affected area hex of mechanism of injury numbness/ tingling distal to injury joint deformity shortened limb contusion/ laceration over affected joint decreased pulses distal to joint decreased rom decreased sensation distally due to nerve damage WBC elevated due to stress

Hgb may be low due to bruising or: dislocation (should get anteroposterior) CT scan for pelvic trauma to rule out hip/ pelvic fracture Order ultrasound for posterior knee dislocation: high incidence of popliteal artery injury answers Findings and diagnostics of fractures Pain History of traumatic event Neuromuscular dystrophy: headache (autonomic dysreflexia) Deformity of limp Diminished/ absent pulses ecchymosis and swelling or, always order anteroposterior and lateral CT scan for pelvic and spinal fractures MRI for suspected spinal cord injury Mortise view (leg inward) for ankle to check talus bone oblique films for humerus, femur, ankle DEXA scan to determine degree of osteoporosis answers Findings and diagnostics soft tissue injury pain swelling feeling of instability of joint Ruptures/ muscle tear: decreased ROM, immediate swelling and hematoma, abnormal contour muscle, instability of joint, pain/ guarding, watch neurovascular integrity Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign) Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding Cartilage: swelling, click during McMurray's test (would indicate meniscus tear), pain/ guarding Bursa: swelling with boggy feeling, erythema over bursa, decreased ROM Skin: abrasion, laceration, puncture answers Findings and diagnostics subluxation Pain over affected area previous subluxation swelling around joints loss of ROM XR, CT, MRI show subluxation Increased WBC (stress response) answers Findings/ diagnostics for duodenal and gastric ulcers Duodenal ulcers:

Epigastric (midline/ right midline) pain 1-3hrs after eating, nocturnal pain. Relieved by food ingestion. Gastric ulcers: Epigastric pain periodic and rhythmic. Not relieved by food. Food may precipitate symptoms. Nausea. Epigastric pain to palpation. Midline or left of midline. Beardlike abdomen and rebound with perforation. Hemateins or melena with bleeding ulcers.

• H. Pylori testing
• CBC: anemia?
• Leukocytosis: perforation or penetration
• elevated amylase: penetration into pancreas
• Upper GI barium studies: after 8-12wks for established ulcer to distinguish benign from malignant
• Endoscopy: Procedure of choice for diagnosis of duodenal and gastric ulcer. Can stop bleeding ulcer, can detect H. Pylori, and inflammatory disorders, and can perform electrocautery answers Fracture Classification - Gustilo- Closed
• Open: Type 1: wound smaller than 1cm Type 2: wound larger than 1cm, moderate contamination Type 3: high degree of contamination, severe fracture instability, soft tissue damage. T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone, T3C: open fracture with arterial injury
• Incomplete or complete
• stress
• traumatic/ pathologic
• displaced/ non-displaced answers Fractures: Reduction- Orthopedic surgeon referral
• buddy-tape toe fracture for immobilization
• radius/ ulna: splint with ace-wrap, unless open
• post reduction or
• check neurovascular function pre and post reduction
• intramedullary rodding for closed femoral and tibial fracture
• external fixation for open fracture answers Fulminant liver failure/ acute liver failure: what, etiology- sudden impairment of liver cell function
• Hep A, B, C, D, E
• CMV, Epstein-Barr
• drug-induced (Tylenol)

• Toxins (mushrooms)
• Vascular (heat stroke)
• other liver disorders answers General rules for surgery: testiness before surgery only if coronary disease, except when low risk surgery Stress test not indicated before surgery Do not do prophylactic coronary revascularization answers GERD (gastroesophageal reflux disease): what, etiology Chronic condition in which gastric contents enter and stay in lower esophagus because of impaired esophageal function. May cause reflux esophagitis.
• Due to hiatal hernia, gastroparesis, gastric outlet obstruction
• diet: caffeine, citrus, spicy, large meals, fatty meals, onions, mint, alcohol, lying down after eating
• anxiety
• pregnancy
• smoking
• meds (aspirin, NSAIDS, CCB, antihistamines) answers GERD findings/ diagnostics Hallmark: heartburn (after eating, supine, bending) Regurgitation Hypersalivation Dysphagia Belching Pneumonia, chest pain, cough, hoarse, sore throat
• Clinical history
• 24 - hr ambulatory PH monitoring (most specific and sensitive): gold standard. Electrode PH probe above LES
• Barium swallow test (as screening tool and rule out inflammation, ulcers, and strictures)
• Endoscopy (for diagnosis and possible biopsy and dilation of stricture)
• Bernstein test (infusion of acid and ns) answers GERD management Phase 1: Elevate head No exercise before bed No large meals before bed Avoid chocolate, fats, alcohol, mint, spicy, citrus, coffee, tomato juice Reduce weight Stop smoking Avoid aggravating meds Use antacids PRN (after meals and bedtime) and over the counter H2 blocker (ranitidine/ famotidine) for 8 - 10 wks.

Phase 2: Continue phase 1. weight loss No supine No eating before bed Phase 3 (start after 2 - 4 wks. of other phases and no improvement): Increase dose of initial drug Start long term daily PPI If worse: add lifestyle changes then add drug If better: remove drug Phase 4: surgery (reflux related palm disease, ulcerative esophagitis, esophageal strictures, hiatal hernia) answers Giant cell arteritis findings- headache

• jaw pain
• visual impairment
• throat pain
• arm claudication
• difficulty talking
• fever
• enlarged and tender temporal artery
• blindness CT: arterial narrowing WBC normal ESR elevated CRP elevated Gold standard: biopsy of affected artery answers Giant Cell arteritis treatment Prednisone, do not wait for biopsy IV for 3 days when vision loss Oral for 6 wks. to 2mo answers Giant cell arteritis, definition and etiology Inflammation of the medium and large arteries, often temporal artery or aorta, represents polymyalgia rheumatica
• adults older than 50
• more women than men
• most will also have polymyalgia rheumatica
• at risk for aortic aneurysm answers Gout findings, diagnostics- acute painful joint, often great toe (warm, swollen)
• pain at night

• flank pain because of renal calculi
• fever
• leukocytosis
• elevated erythrocyte sedimentation rate
• tophi (bump under skin) on ear
• limited joint motion
• elevated serum uric acid (greater than 7mg/dl)
• urate crystals seen with joint aspiration
• or: joint erosion and renal stones answers Gout treatment- NSAIDS: naproxen, indomethacin, sulindac
• Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also, for prophylaxis
• Corticosteroids, if NSAIDS and colchicine not tolerated
• 24hr urine for uric acid
• Allopurinol after flare is over (100mg PO daily)
• Biological modifiers of disease (BMD): Epiglottises. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid answers Gout: what, who Inflammatory disorder in response to high uric acid production/ levels in blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean)
  • impaired renal function which causes excess uric acid
• foods high in purine, such as dairy, red meat, shellfish, beer answers Grading of Ulcerative colitis Mild: normal albumin normal ESR HR less than 90 Hit normal stool #: <4/ day temp: normal weight loss: none Moderate: albumin 3 - 3. ESR 20- 30 HR 90 - 100 Hit 30 - 40 stool #: 4 - 6/ day temp: 99 - 100F weight loss: 1 - 10% Severe:

albumin less than 3 ESR more than 3 HR higher than 100 Hit less than 30 stool #: more than 6/ day temp: above 100F weight loss: greater than 10% answers. Pylori testing Detection of H. Pylori:

• Endoscopic biopsy (gold standard)
• urea breath test (pos is H. Pylori)
• PPI can cause false negative
• serum H. Pylori antibody test (can also mean previous infection)
• fecal antigen H. Pylori (can assess if treatment was successful) answers. pylori treatment (BID) + 2 of the following antibiotics --Clarithromycin --Metronidazole (when allergic to pan) --Amoxicillin Antiulcer treatment for 3- 7 wks.: Duodenal ulcer: Omeprazole - 7 wks. H2 blocker: 6- 8 wks. answers Heart transplantation, incidence and complications cardiomyopathy, cardiac tumor, congenital heart defect, valvular disease Bleeding Rejection Cardiac allograft vasculopathy Leading cause of death. Accelerated form of CAD causing HF, ventricular arrythmia's, death. Denervation altered response to drugs, little response to digoxin and atropine seashell syndrome: what, signs, treatment hemolysis, elevated liver enzymes, low platelets Triad: jaundice, coagulopathy, low platelets Steatosis (fatty liver) Intrahepatic hemorrhage Deliver baby

answers Hepatitis A: what, etiology, findings, management Viral Hepatitis Spread by fecal-oral route. Poor sanitation.

• Pos Immunoglobulin IgM anti-HAV - first week of disease, disappears after 3 - 6 mo. So pos when infected in last 6mo. Neg: no infect in last 12mo
• ALT AST elevated
• Pos IgG anti-HAV. Means previous exposure and immunity. If neg: no infection.
• Bedrest till jaundice resolves, no lifting
• High caloric diet, small frequent meals. Low protein, no fatty foods, high carb
• no alcohol
• hospital for encephalopathy or coagulopathy
• antiemetics Vaccine: Hep A for children 1 year and people increased risk answers Hepatitis B: what, etiology, findings, management Viral hepatitis Bloodborne, saliva, semen, vaginal secretions, so transmitted through sex, drug use, piercing, tattoo, blood products
• Pos Hep B surface antigen or Hep B core antigen, in acute infection
• Total Hep core antigen can indicate past exposure
• Hep B surface antibody after clearance of Hep B surface antigen or vaccination, which means: recovery, noninfectious, protection from current infection
• pos Hep B e-antigen: acute or chronic infection
• Hep B e-antibody means success from antiviral therapy (e-antigen has become e- antibody)
• Treat if liver-related mortality risk in next 5-10yrs is high and chance of viral suppression high
• Antiviral therapy:
• Peginterferon alpha, weekly/ 48 wks. (many side effects)
• Entecavir, PO daily, renal adjustment
• Tenofovir, PO daily Vaccination: Not live, in 3 doses answers Hepatitis C: what, etiology, findings, management Viral Hepatitis Blood-borne. Small risk for sexual or perinatal transmission. Common, but often asymptomatic. May develop cirrhosis, which can lead to liver transplant.

• Pos Anti HCV antibody. Very sensitive. If neg, then unlikely.
• Pos Recombinant immunoblot assay: gold standard to confirm HCV infection. Detects virus not antibodies.
• Chronic infection: Peginterferon and ribavirin. Give for 48wks. 28 wks. for genotype 2 and 3. Add Boceprevir for genotype 1. Vaccination: no vaccination. Screen one time based on age, born between '45 and '65 answers Hepatitis DRNA virus that can only cause infection with Hep B Prevented with Hep B vaccine answers Hepatitis E: what, etiology, findings, management acute infection, no chronic ingestion from fecal matter, poor sanitation Like HAV Mortality higher in pregnant women No vaccine answers Hepatitis Common in drug users, transmitted percutaneously answers Hepatitis Inflammation of the liver, caused by Hep A, C, D, E as RNA and B as DNA answers Hereditary Hemochromatosis: what, etiology, findings, management Inappropriate absorption of dietary iron, that can lead to cirrhosis, hepatocellular ca, diabetes, heart disease Caucasian/ Northern European/ Celtic Elevated iron ferritin Hemochromatosis gene detection Iron overload? Then phlebotomy with goal of ferritin 50 - 100 No Vit C and iron No dietary restrictions Family screening answers Herniated disk findings and diagnostics- Decreased/ absent reflexes
• Atrophy of muscles
• limp
• possible straight leg raise test/ radiculopathy
• limited rom spine

• or anteroposterior and lateral of spine
• CT with and without dye: detects bony defects
• MRI: detects soft tissue defects
• myelogram
• EMG (tests nerve innervation) answers Herniated disk L4 root finding (disk between L3 and L4)- quadriceps weak, difficulty extending quadriceps (have pt squat and rise)
• pain and numbness radiating into medial malleolus
• diminished/ absent knee jerk answers Herniated disk L5 root finding (disk between L4 and L5)- dorsiflexion of great toe and foot weak (have pt walk on heels of feet)
• pain and numbness into lateral calf and between first toe web space answers Herniated disk management on surgical:
• functional bracing
• rest
• PT for muscle strengthening
• heat/ ice alternate
• weight loss
• transcutaneous electrical nerve stimulator
• NSAIDS
• antispasmodic
• Narcotics for short-term use
• epidural steroid injection Surgical:
• Laparoscopic diskectomy
• hemilaminectomy
• total disk replacement arthroplasty answers Herniated disk S1 root finding (disk between L5 and S1)- weakness of plantar flexion of great toe and foot (have pt walk on toes)
• pain along buttock, lateral leg and lateral aspect of foot and posterior calf
• diminished Achilles calf answers Herniated disk: what, who Bulging or protrusion of nucleus through a defect in the annulus of spine, may cause nerve entrapment
• Trauma
• Obesity/ sedentary lifestyle
• Age 35 - 45
• Often located at L4- L5, L5 - S1 answers High risk surgeries aortic/ cab

transplants spinal reconstruction peripheral vascular surgery answers HIV - acute retroviral syndrome, symptoms fever, chills fatigue diffuse erythematous rash HIV test may be negative, based on how long since infection HIV viral load increased, CD4 within normal range answers HIV - latent phase- asymptomatic

• may have persistent lymphadenopathy
• HIV load and CD4 load variable (ultimately HIV load high, CD4 low) answers HIV and age- Can live beyond 50 years, but survival decreases after 45 yrs., unless tested.
• Antiretroviral meds are approved for younger than 50yrs, so older pt's need close monitoring answers HIV etiology Africa/ Asia: heterosexually acquired Western nations: men who have sex with men, iv drug user, congenital spread answers HIV prevention- Condoms
• Male circumcision
• Pre-exposure prophylaxis (Prep), for MSM sexually active men, adult iv drug users, women with HIV pos partner who try to conceive. Give Tenor with Emtricitabine
• Post exposure prophylaxis (PEP), 28 - day course of 3 drugs, emtricitabine, tenofovir, rotogravure answers HIV serologic testing- ELISA: test for antibodies, requires seroconversion (neg to pos) which happens 3wks to 6mo after infection
• Rapid test: fast but not as sensitive as ELISA
• Confirmatory HIV test: Western blot test (HIV antibody test), used after pos with ELISA answers drugs:Aminosalicylates: Sulfasalazine, non sulfa: mesalamine. For induction and maintenance of remission. May cause N/V and folate malabsorption. Give folate! Corticosteroids: Prednisone, Budesonide, Methylprednisone Suppress acute flares, no maintenance May cause N/V, gastritis, adrenal suppression, osteoporosis Immunomodulators:

6 - mercaptopurine, Azathioprine, Methotrexate, Cyclosporine, Tacromilus For maintenance, steroid sparing effect May cause pancreatitis, bone marrow suppression, hepatotoxicity Anti TNF Monoclonal antibodies Infliximab, certolizumab Only for Crohn's. May cause infusion related reactions: fever, pruritis, chest pain, hypotension, htn, infections/ sepsis. Expensive! answersImmune response- from B cells or T cells, that react and form antibodies

• Human leukocyte antigens (HLA) recognize self and non-self. Panel reactive antibody (PRA) measures preformed HLA and indicates a good match when elevated. Crossmatching required before kidney, but post heart, lung, liver, pancreas transplant answersimmunosuppression: what and general considerationsPharmacological manipulation of immune system to prevent/ suppress rejection.
• Started before or after transplant for up to 2 wks to delay first rejection episode
• maintenance for live of graft
• caution with conversion between generic and brand forms of cyclosporine
• Calcineurin inhibitors metabolized via cytochrome P450 enzyme, so may alter other drig concentrations
• avoid grapefruit juice when on calcineurin inhibitors (may cause increase) answersInfections in organ recipients: general thoughts and types- infections are leading cause of death
• Increased risk 6 mo post transplant
• fever and wbc count not as pronounced because of immunosuppressive meds Viral: CMV, cause of morbidity and rejection Requires frequent monitoring Prophylaxis with ganciclovir is recommended Fungal: Candida in post-liver, Aspergillus in post-lung Oral fluconazole for fungal prophylaxis or Trimethroprim-sulfamethoxazole (bactrim) for pneumocystis prophylaxis Bacterial: Most common infections Intra-abd infections for liver, pancreas and intestinal transplant Pneumonia for heart and lung transplants UTI for renal and pancreas transplant

answersInitiation of Antiretroviral therapy (ART)- Start for all asymptomatic HIV infected patients to reduce viral load and risk of disease progression. Also for HIV+ peope to for prevention of transmission.

• Start for every symptomatic patient regardless of CD4count or viral load
• Pt's should understand regimen, risks, benefits and importance of adherence before commencing,
• Should be managed by HIV/ AIDS specialist answersintermediate risk surgeriesHead/ neck surgery thyroidectomy Intraperitoneal Prostate Laminectomy Hip/ knee Hysterectomy cholecystectomy nephrectomy non majot intrathoracic answersIntestinal transplantation, incidence and complicationsNecrotizing enterocolitis, Chrohn's, stenosis of small bowel Surgical: Bleeding Bowel obstruction Ascites Perforation Biliary leaks Hypermotility In early posttransplant phase. Give antidiarrheals and fiber. Rejection Infection answersIschemic liver failureAST and ALT very high (in the 1000) shock state answerskidney transplantation, incidence and complicationsESRD, creat clear less than 15ml/min Surgical: Graft thrombosis, 2-3 days post-op. Thrombosis with loss of urine or hematuria. Diagnosis with renal us. Will cause graft loss.