Download NR511-Final Exam Study Guide latest update and more Exams Nursing in PDF only on Docsity! NR511 Final Exam Study Guide See Midterm and Week 1 Study Guide for content covering weeks 1, 2 & 3 Common Infections 1. Impetigo Impetigo is a superficial bacterial infection of the skin. It is classified into primary impetigo when there is a direct bacterial invasion of previously normal skin or secondary impetigo when the infection arises at sites of minor skin trauma. The occurrence of secondary impetigo is referred to as impetiginization. Impetigo is most frequently observed in children ages 2–5 years of age, although older children of any age and adults may also be affected. The infection usually occurs in warm, humid conditions and is easily spread among individuals in close contact. Risk factors include poverty, crowding, poor hygiene, and underlying scabies. Impetigo is primarily caused by S. aureus. Group A Streptococcus (GAS) causes a minority of cases, either alone or in combination with S. aureus. Occasionally, MRSA is detected in some cases of impetigo. Variants of impetigo include nonbullous impetigo, bullous impetigo, and ecthyma. • Nonbullous impetigo—most common form of impetigo and begins as papules that progress to vesicles surrounded by erythema. Within a week, the papules eventually become pustules that enlarge, break down, and form thick, adherent crusts with a characteristic golden appearance. Lesions usually involve the face and extremities. Regional lymphadenitis may occur, although systemic symptoms are usually absent. • Bullous impetigo—Bullous impetigo is seen primarily in young children in which the vesicles enlarge to form flaccid bullae with clear yellow fluid, which later becomes darker and ruptures, leaving a thin brown crust. The trunk is more frequently affected. Bullous impetigo in an adult with appropriate demographic risk factors should prompt an investigation for previously undiagnosed human immunodeficiency virus (HIV) infection. • Ecthyma—This form of impetigo, caused by group A, beta-hemolytic Streptococcus (Streptococcus pyogenes), consists of an ulcerative form in which the lesions extend through the epidermis and deep into the dermis. Ecthyma resembles "punched-out" ulcers covered with yellow crust surrounded by raised violaceous margins. Risk factors for community-associated methicillin-resistant S. aureus (CA-MRSA) include the following. • Antibiotic use secondary to antibiotic selective pressure. Use of cephalosporins and fluoroquinolones strongly correlates with the risk for MRSA colonization and infection. • HIV infection • Hemodialysis • Long-term care facilities Patients with drainable abscess should undergo incision and drainage. For patients undergoing incision and drainage of a skin abscess, some experts suggest antibiotic treatment under some conditions. • Single abscess ≥2 cm • Multiple lesions • Extensive surrounding cellulitis • Associated immunosuppression or other comorbidities • Systemic signs of toxicity (fever >100.5° F/38° C) • Presence of an indwelling medical device (such as prosthetic joint, vascular graft, or pacemaker) • High risk for transmission of aureus to others (such as in athletes or military personnel) Quiz: Ian, age 62, presents with a wide, diffuse area of erythematous skin on his left lower leg that is warm and tender to palpation. There is some edema involved. You suspect: a. Necrotizing fasciitis. c. Cellulitis. b. Kaposi's sarcoma. d. A diabetic ulcer. 4. Erysipelas Cellulitis and erysipelas are two of the most common skin and soft tissue infections. Erysipelas involves the upper dermis, and there is clear demarcation between involved and uninvolved tissue. An older name for erysipelas is “St. Anthony’s fire.” Despite the superficial nature of this infection, erysipelas should not be taken lightly, because it can be fatal if it is not treated promptly (especially in the very young and the elderly). Erysipelas is sometimes seen after an episode of strep throat. The most common sites of involvement are the face (especially the cheeks) and the lower legs. Erysipelas occurs in young children and older adults. Erysipelas results almost always results from a group A strep infection. erysipelas is non-purulent. Patients with erysipelas tend to have acute onset of symptoms with systemic manifestations including fever and chills Classic descriptions of erysipelas note "butterfly" involvement of the face. Involvement of the ear (Milian's ear sign) is a distinguishing feature for erysipelas, since this region does not contain deeper dermis tissue. Quiz: Which of the following types of cellulitis is a streptococcal infection of the superficial layers of the skin which does not involve the subcutaneous layers? a. Necrotizing fasciitis c. Erysipelas b. Periorbital cellulitis d. "Flesh-eating" cellulitis 5. Necrotizing fasciitis Considered as a severe case of cellulitis must refer to ER, can be a differential diagnosis of cellulitis Defined as deep infection that results in progressive destruction of the muscle fascia. The affected area may be erythematous, swollen, warm, and exquisitely tender. Pain out of proportion to exam findings may be observed. The hallmark of this infection is its rapid progression and the severity of the symptoms. The progress of the infection is measured in terms of hours instead of days, and the border can be seen to literally spread in just a few hours. This infection is caused by “flesh-eating bacteria,” and loss of life or limb is a potential complication. Quiz: Mark has necrotizing fasciitis of his left lower extremity. Pressure on the skin reveals crepitus due to gas production by which anaerobic bacteria? a. Staphylococcal aureus c. S. pyrogenes b. Clostridium perfringens d. Streptococcus 6. Mammalian bites Soft tissue trauma caused by animal and human bites have serious clinical implications because of the potential for complications. Bite wounds should be irrigated copiously with sterile saline, and grossly visible debris should be removed. Prophylactic antibiotics are administered to patients who present for evaluation of a bite wound who do not yet have signs or symptoms of infection in the following circumstances. • Deep puncture wounds (especially due to cat bites) • Wounds requiring surgical repair • Moderate to severe wounds with associated crush injury • Wounds in areas of underlying venous and/or lymphatic compromise • Wounds on the hand(s) or in close proximity to a bone or joint • Wounds on the face or in the genital area • Wounds in immunocompromised hosts Amoxicillin/clavulanate 875 mg/125 mg twice daily is the agent of choice. Alternative antibiotics include one of the following agents with activity against Pasteurella. • Doxycycline 100 mg twice daily • Bactrim DS twice daily • Penicillin VK 500 mg four times daily • Ciprofloxacin 500 mg twice daily Plus one of the following agents with anaerobic activity. • Metronidazole 500 mg three times daily • Clindamycin 450 mg three times daily First-generation cephalosporins and macrolides should be avoided. The duration of prophylactic oral antibiotics is 3–5 days, with close follow-up. Tetanus toxoid should be given to those who have completed a primary immunization series but who received the most recent booster 5 or more years ago. Patients with mild infection can be treated initially with the same prophylactic antibiotics for 5 to 14 days of therapy. Infection with Pasteurella multocida characteristically develops rapidly following cat or dog bites with erythema, swelling, and intense pain evident as early as 12 to 24 hours after the bite Wound cultures of uninfected bite wounds are not useful. Wound cultures are not indicated in clinically uninfected bite wounds as results do not correlate with likelihood of infection or the pathogen that is present in patients with subsequent infection. If a bite wound appears to be infected The laboratory requisition should note that an animal or human bite wound is the culture source because Eikenella corrodens and Pasteurella multocida are fastidious organisms. I. Identify the likely pathogen associated with cats bites, human bites and dog bites. 1. Human Bites a. Pathogens i. Staph aureus ii. Strep b. Agent of choice: Amoxicillin/clavulanate 875/125 2xday 2. Cat & Dog Bites a. Pathogens i. Pasturella multocida & capnocytophaga canimorsis b. Alternative ATB w/ activity against Pasturella i. Doxycycline 100mg 2xday ii. Bactrim DS 2xday iii. PCN VK 500mg 4xday iv. Ciprofloxacin 500mg 2xday 1. PLUS a. Metronidazole 500mg 3xday b. Clindamycin 450mg 3xday Urology 1. Hematuria - Hematuria is defined as blood in the urine and can be visible (gross) or occult (microscopic) - the ingestion of beets can color the urine red to pink, and medications such as rifampin and phenazopyridine (Pyridium) can give urine a reddish-orange color. The presence of porphyrins, hemoglobin, or myoglobin can color the urine reddish-brown. Pus in the urine is indicative of bacterial infection, such as cystitis, urethritis, or prostatitis. - Menstrual history is always important in a female patient, as well as history of recent strenuous exercise, streptococcal infection (especially poststreptococcal - Type of upper urinary infection: renal pelvis, tubules, or interstitial tissue; may be unilateral or bilateral. Risk factors: -female sex - indwelling catheter - Sexual intercourse - DM -urinary tract obstruction - VUR - Common pathogens: E coli, proteus, and Enterobacter (common in bowel flora) - Acute pyelonephritis usually unilaterally - S/S: - WBC in urine -WBC cast - leukocytosis (inc WBC in blood) - fever - N/V, chills - flank pain at cosovertebral angle Dx: urinalysis: positive for bacteria, proteinuria, leukocyte esterase, urinary nitrites, hematuria, pyuria, and specifically white blood cell (WBC) casts (reflecting the passage of neutrophils through the renal tubules) Urine Cx: demonstrates greater than 100,000 cfu/mL, allowing for identification of the causative organism. -Tx: abx and hydration First-line therapy ciprofloxacin (Cipro) 500 mg two times daily for 7 days, or levofloxacin (Levaquin) 750 mg daily for 5 days. In second-line therapy, trimethoprim-sulfamethoxazole (TMP-SMX) (Bactrim DS, Septra DS) taken orally for 14 days may be as effective as amoxicillin-clavulanate for 14 days in young women with their first pyelonephritis and without anatomical abnormalities. However, given the prevalence of sulfonamide and ampicillin resistance among common uropathogens, TMP-SMX and amoxicillin are likely to be ineffective in cases of recurrent or moderate to severe pyelonephritis (except in cases of Enterococcus infection, which calls for the addition of amoxicillin [Amoxil] 500 mg PO three times daily). Nitrofurantoin should be avoided because it does not achieve adequate tissue levels. Other effective choices are third generation cephalosporins (e.g., cefixime, cefpodoxime, ceftriaxone), aminoglycosides (e.g., gentamicin, tobramycin), or aztreonam, with fluoroquinolones reserved for antibiotic-resistant organisms, hence the critical need for early urine culture to guide pharmacotherapy. 6. Urethritis - Infections of the lower urinary tract can occur in the urethra, bladder, and prostate. Infection of the urethra (urethritis) and infection of the urinary bladder (cystitis) usually occur together. - Common causes: E. coli, chlamydia or gonorrhea, trichomonas, HSV - Pus in the urine is indicative of bacterial infection, such as cystitis, urethritis, or prostatitis. - Suprapubic tenderness is indicative of a bladder etiology, whereas urethral discharge indicates a urethritis. - Acute cystitis and urethritis produce gross hematuria and are more common in women. - Hematuria is also often present in lower and upper UTI, but not in vaginitis or urethritis. - Urethritis in men is rare; if left untreated or treated inadequately, it can lead to complications such as urethral strictures, periurethral abscess, urethral diverticuli, and fissures. - Vaginal discharge in women and urethral discharge in men may suggest sexually transmitted diseases (STDs). Purulent urethral discharge (Neisseria gonorrhoeae) or whitish-mucoid discharge (Chlamydia trachomatis) should be treated aggressively with the appropriate antibiotic therapy. Cystitis Frequency, urgency, may have gross hematuria Recent sexual intercourse, risk factors present (see Table 2) 15 to 20% have suprapubic tenderness; no costovertebral angle tenderness Usually positive for pyuria and sometimes also positive for bacteriuria and nitrite Subclinical pyelonephritis Frequency, urgency, may have gross hematuria Risk factors present (see Table 5) May have suprapubic tenderness; no costovertebral angle tenderness Usually positive for pyuria and sometimes also positive for bacteriuria and nitrite; positive renal cortical scintigraphy, urine culture usually > 105colony- forming units per mL of urine Acute pyelonephritis Nausea, emesis, fever, sepsis, back/flank pain May have had concurrent or preceding cystitis symptoms (see Table 5) Costovertebral angle tenderness, deep right or left upper quadrant tenderness Pyuria usually present with casts of white blood cells; obtain urine culture and sensitivity Interstitial cystitis Frequency, urgency, gross hematuria (20%) Often middle- aged; longstanding symptoms with negative cultures No costovertebral angle tenderness; may have suprapubic tenderness Urinalysis negative for white blood cells or bacteria; positive for glomerulations on cystoscopy Vaginitis External irritation, vaginal discharge or pruritus, dyspareunia; no hematuria Premenstrual exaggeration of symptoms; sexual activity or recent antibiotic exposure or post- menopausal and not Vaginal discharge, inflamed vaginal mucosa (absent in bacterial vaginosis), inflamed cervix (Trichomonas), vaginal atrophy (postmenopausal) Positive potassium hydroxide or vaginal saline preparation; elevated pH (bacterial vaginosis or Trichomonas) receiving estrogen replacement therapy Genital herpes Dysuria, fever, headache, myalgias, neck pain, vulvar pain, photophobia Sexually active; may have vaginal discharge Grouped vesicles usually on cervix or pubic area, but may be vaginal; tender inguinal adenopathy Viral culture optional Urethritis Usually asymptomatic; if symptoms develop, they are usually delayed (>1 week) History of unprotected sexual exposure No suprapubic pain unless associated with pelvic inflammatory disease; rarely, visible urethral discharge Urethral swab positive for white blood cells; obtain Gram stain to detect intracellular gram-negative diplococci and DNA probe for Chlamydia and gonorrhea 7. Renal calculi - Forms when solid in urine precipitate and is crystalized, due to dehydration or increased in solutes - Calcium oxalate and calcium phosphate stones account for 65% to 85% of all cases of renal calculi. Most common causes: 1. Calcium oxalate (forms in acidic urine) black to dark brown stone, radiopaque on X- ray (white spot)*Most common in men - Risk factors hyperoxaluria: - genetic defect: increase in oxalate excretion - defect in liver metabolism - diet heavy on oxalate rich foods: rhubarb, spinach, chocolate, nuts and beer 2. Calcium phosphate (forms in alkaline urine) dirty white stone, also seen as radiopaque on X-ray) Risk factors hypercalcemia Risk factors hypercalciuria Increased absorption in GI tract impaired renal tubular reabsorption Hormonal causes like primary hyperparathyroidism Low calcium diet: increased oxaluria due to less oxalate bound to calcium in GI tract - vasectomy - hypertension - Lasix 3. Uric acid stones (red-brown radiolucent on X-ray; transparent to X-ray) In the ER, manual reduction of the testis is usually performed and if not successful will be followed by surgical exploration and may require removal of a nonviable testis. Viability of the testicle is directly related to the duration of torsion, so again, time is of the essence. If torsion occurred more than 6 hours prior, the likelihood of viability falls to 10–15%. Beyond 24 hours, the viability rate falls below 10%. There is also a reduced rate of sperm production in patients who have had torsion, whereby reproduction may be affected. 2. Benign Prostatic Hyperplasia The prostate gland, is a walnut size gland positioned at the base of the bladder and in front of the rectum that begins to enlarge as a man ages. It surrounds the urethra and as the prostate gets larger, it can squeeze or partly cause obstruction. BPH is the common name for nodular hyperplasia and is one of the most common conditions affecting men >40yrs old. As many as 50% of men experience symptoms of enlarged prostate by age 60 and 90% of men will report symptoms by age 85 The causes of BPH are not fully understood. Aging is a risk factor and genetic predisposition may play a role. Androgens are thought to play a key role. There has been no concrete evidence that diet, environment, or sexual practices increase the risk for developing BPH. Obesity though does increase the risk of development. Symptoms of BPH usually involve a combination of obstructive and irritative voiding complaints. BPH is not life-threatening but it is life altering. It is important to note that symptoms are not specific to BPH (since many conditions result in an overlap of symptoms) so a complete work-up needs to be completed. Obstructive symptoms include decreased stream hesitancy postvoid dribbling sensation of incomplete bladder emptying overflow incontinence inability to voluntarily stop the urine stream urinary retention straining Irritative symptoms include nocturia urinary frequency urinary urgency dysuria urge incontinence DRE is done to determine the size of the prostate gland. The prostate in BPH is usually smooth and enlarged. If the prostate is nodular or unusually firm, cancer should be suspected. Also, the size of the prostate does not correlate with the severity of symptoms. Quiz: During a digital rectal exam (DRE) on a 75-year-old man, the clinician suspects the patient has prostate cancer. What physical finding should make the clinician suspicious? An enlarged rubbery gland The DDx for BPH is extensive but the diagnoses can be categorized into 1 of the 3 following types: bladder outlet obstruction (cancer, stricture, bladder neck contracture), nonobstructive etiologies (neurogenic bladder, DM, Parkinson’s, Medications) irritative symptoms (neoplasm, bladder cancer, prostatitis, uti) Diagnostic testing urinalysis and urine C&S is done to exclude infection and hematuria PSA is done to assess for prostate cancer urine cytology is done to exclude bladder cancer the AUA no longer recommends a serum creatinine on the initial evaluation should be done on subsequent visits or if obstructive uropathy is present. Keep in mind that there may be an elevation in the PSA in BPH just as it occurs in cancer so the PSA is NOT diagnostic of either. More advanced diagnostics include, should be done by an urologist: urodynamic studies to identify difficulties in emptying the bladder post-void residual urine test (PVR) cystoscopy A patient with mild to moderate symptoms and minimal PVR may only require monitoring as long as more serious conditions have been ruled out. Avoidance of caffeine and alcohol, both known to be bladder irritants, should be recommended. Once prostatic cancer has been ruled out, medications may be tried to treat BPH symptoms. This approach is typically taken when there is not a strong indication for surgical resection or if the patient is not a good surgical candidate. Medications Medication therapy typically includes Alpha 1A Blockers (relaxes the smooth muscle around the bladder neck) and 5-alpha-reductase inhibitors (block the conversion of testosterone to DHT) Alpha 1A Blockers Common A1A medications prescribed include: Tamsulosin (Flomax) 0.4mg-0.8mg QD Doxazosin (Cardura) 4-8mg QD Silodosin (Rapaflo) 4-8mg QD 5-alpha-reductase inhibitors that are commonly prescribed are: Finasteride (Proscar) 5mg QD alone or in combination with Doxazosin Dutasteride (Avodart) 0.5mg QD * Erectile dysfunction should be assessed on patient taking finasteride. Surgery may be indicated when there is urinary retention or when other symptoms are unmanageable in which case a transurethral resection of the prostate (TURP) is performed. 3. Acute & chronic prostatitis - prostatitis accounts for about 25% of all office visits in men and over 50% of men will experience prostatitis in their lifetime - most common chronic non-bacterial prostatitis (8x mre frequent than bacterial prostatitis), complains and PE similar to those with chronic bacterial prostatitis but urine cx will be negative. - acute bacterial prostatitis has an abrupt onset, and always associated with an UTI most predominant in sexually active men between ages 30-50. - Symptom classification: a. Obstructive: weak stream, incomplete bladder emptying, dribbling b. Irritative: urinary complains (frequency, urgency, nocturia, dysuria), pain and discomfort (LBP, penile scrotal pain, fever, chills malaise or painful ejaculation) - Acute Bacterial and non-bacterial will have same s/s: Fever, chills, malaise LBP Dysuria Arthralgia (joint pain) myalgia (muscle pain) Urgency, frequency nocturia bladder outlet obstruction - Chronic Bacterial s/s:* symptoms often are abscent Perineal pain LBP Dysuria 6. Epididymitis - Epididymitis can affect males of any age and is inflammation of the epididymis at the back of the testicle that stores and carries sperm. - There is a predisposition to epididymitis for patients with a history of unprotected intercourse, a new sexual partner, history of UTI, or urinary discharge. Symptoms can also occur following heavy lifting and or straining, trauma, medical procedures that affect the urinary tract and an uncircumcised penis. - Causes of epididymitis in males younger than 35 years are usually due to STIs such as gonorrhea and chlamydia. Chlamydia is responsible for approximately two thirds of acute cases, followed by Neisseria gonorrhea, and E. coli. - In nonsexually active males and men over the age of 35, causes of epididymitis is most commonly due to E. coli, and sometimes Pseudomonas aeruginosa and Staphylococcus aureus. It is also associated with distal urinary tract obstruction or any cause that can cause bacteria to spread from the infected site to the epididymis (prostatitis, surgical procedures, etc.). - S/S: unilateral scrotal pain that often radiates along the spermatic cord or to the flank.Pain may be experienced in the tip of the penis and typical symptoms of UTI are present (dysuria, cloudy urine, hematuria, etc.). With severe infections, fever and chills occur. - The physical examination should include an abdominal examination to detect a distended bladder and costovertebral angle tenderness, a genital examination, and a digital rectal examination. - Scrotal swelling will be present, and the testis may be indistinguishable from the epididymis. Enlarged lymph nodes in the groin or a lump on the testis may be palpated. Rectal exam will reveal a tender prostate, but the hallmark characteristic is relief of discomfort with elevation of the testis and epididymis. It is important to discern epididymitis from testicular torsion by checking for the Prehn sign during the examination. By elevating the affected hemi-scrotum, the pain of epididymitis will be relieved but would exacerbate the pain of torsion. - The CDC guidelines for the treatment of Epididymitis essentially recommend the same antibiotics that treat for GC & CT. Again, fluoroquinolone antibiotics are no longer recommended for the treatment of gonococcal infections in the US due to high antibiotic resistance rates. Co-treatment of Chlamydia is essential since the 2 often coexist. Treatment includes: single-dose IM Ceftriaxone 250mg PLUS single dose oral Azithromycin 1gm or Doxycycline 100mg BID x 7d If the cause is an STI, the patient’s sexual partner needs to be treated, and the patient should avoid sexual contact until the treatment is finished Supportive treatments include pain medication (NSAIDS are effective in reducing swelling, pain, and fever), rest, scrotal support with an athletic strap, ice packs, and the avoidance of lifting heavy objects are additional treatment options. In severe cases a spermatic block with local anesthetics may be necessary. 7. Varicocele & Hydrocele A varicocele is an abnormal degree of venous dilation in the vasculature above the testes. Varicocele incidence is around 10–20%, and there is no particular age group who are predisposed to it. Varicoceles are caused by weak walls and vascular engorgement in the spermatic cord. You can think of it as varicose veins of the testes. Patients may present with pain or engorgement of the testes, however, it is usually noted as part of a work-up for infertility. The hallmark characteristic of varicocele is the sensation that the testes feel like a “bag of worms.” Varicocele can be bilateral, but if it is unilateral it is almost always on the left side due to the anatomy of the vasculature drainage in the testes. On physical exam with the patient sitting upright, tortuous veins located posterior and above the testes can be seen. Venous engorgement may increase with the Valsalva maneuver. When the patient lies down in the recumbent position, the distension will resolve. Diagnosis of a varicocele is mostly clinical and is again typically found incidentally on a work-up for infertility. Men with varicoceles tend to have low sperm counts, and the motility of their sperm is decreased. Because a urologist or reproduction specialist is usually the one to find a varicocele, testing is not often done in primary care. However, a scrotal ultrasound, venography, or thermography all can confirm the diagnosis. Grade 1 varicocele is one that is palpable only when the patient performs the Valsalva maneuver. Grade 2 varicocele is palpable when the patient is standing. Grade 3 varicocele may be assessed with light palpation and visual inspection The differential or varicocele should include hydrocele; spermatocele; testicular tumor; and epididymal cyst. Most varicoceles are minor, but a referral to a surgeon is indicated. Embolization or ligation of the spermatic vein can be performed. Conservative treatment is the preferred management for older men with only minor pain or for whom fertility is no longer an issue. A hydrocele is a collection of peritoneal fluid within the scrotum between the two-layered sac that holds the testes and spermatic cord. Hydroceles are also uncommon (<1% of adult men), but most occur in males >40 years old. Causes of hydrocele include acute epididymitis; teste trauma; testicular tumors; and sequelae of radiation therapy complications. History findings will complain of swelling in the scrotum or inguinal canal. They are usually painless and are reported as a sense of heaviness in the scrotum. The physical exam should include an examination of the scrotum, testes, abdomen, and groin. Additionally, transillumination of the scrotum should be performed. To do this, in a darkened room, place a penlight up against the scrotum. The trapped fluid from a hydrocele will appear light pink, yellow, or red. The testes themselves do not illuminate, and neither does a hematoma. This is typically considered a diagnostic finding. Diagnosis of a hydrocele is a clinical one. If a hydrocele cannot be confirmed by H&P alone, the patient should have an inguino-scrotal ultrasound performed to rule out inguinal hernia. At this point if diagnosis is still unclear, a referral to a urologist is recommended where additional testing with abdominal X-rays or nuclear scan may be warranted. DDx for hydrocele should include indirect inguinal hernia; orchitis (infection of testes); epididymitis; and - ROM shoulder: o Forward flexion: Normal is to 180 degrees. o Extension: Normal is to 40 degrees. o Abduction: Normal is to 120 degrees with the palm down, 180 degrees with the palm up. o Internal rotation: Ask the patient to rotate his arm across his back and walk the fingers as far up the back as possible, recording this by vertebral level. As a guide, the inferior border of the scapula is located at about T7 or 60–90 degrees. o External rotation: Normal is to 90 degrees. - ROM elbow: o The flexion should be between 140–150 degrees. o Extension 0–5 degrees. o Pronation 90 degrees. o Supination 90 degrees 2. M/S examination & diagnostic testing - A useful approach to the initial patient encounter for any musculoskeletal complaint is to determine if the complaint is I. acute or chronic; II. articular or nonarticular; III. inflammatory or noninflammatory; or IV. localized or systemic in distribution Acute Pain o Less than 3 months in duration o Sharp/throbbing/pulsing/electric/paresthesia/burning (peripheral/nociceptive/neurogenic pain systems) in quality o Moderate to severe intensity at first and decreases predictably over time (based on type of tissue injury) o Edema is common and decreases predictably over time o Pain disappears once healing is complete o Mood tends to not change the patient’s complaints o Pain provocation tests produce the patient’s initial complaints o Pain is localized to site of injury or can present in standard referral patterns o Results from something specific, such as an injury or inflammation Chronic pain: o Greater than 3 months in duration o Pain symptoms become more generalized topographically and less localized to the site of injury or initial complaint o Pain referral patterns that shift in location as well as intensity, frequency, and quality o Pain that does not change with movement, rest, or over time o Patients usually report pain as constant or continuous (less like to be intermittent). o Mood or current psychological status tends to affect or worsen the pain complaints. Articular structures include the following. o Synovium Synovial fluid o Articular cartridge Intra-articular ligaments o Joint capsule Juxta-articular bone Disorders of these structures are typically characterized by the following. a. Deep or diffuse pain b. Limited AROM and PROM on movement c. Swelling d. Crepitation e. Instability f. Locking g. Deformity Articular disorders are classified based on the number of involved joints. o Monoarticular: One joint o Periarticular: Two to four joints o Polyarticular: Four or more joints Quiz: You have detetected the presence of crepitus on examination of a patient with a musculoskeletal complaint. Additionally, there is limited range of motion (ROM) with both active and passive movement. These findings suggest that the origin of the musculoskeletal complaint is: A)Articular B) Inflammatory C) Nonarticular D)A and B Nonarticular disorders structures include the following. o Ligaments Tendons Bursae o Muscle Fascia Bone o Nerve Overlying skin Disorders of these structures are typically characterized by the following. a. Painful AROM but not PROM b. Demonstrated point or focal tenderness c. Physical findings far from the joint capsule d. Unlikely to see crepitus, instability, or deformity Nonarticular disorders are described as either focal or widespread. Inflammatory disorders can be idiopathic or infectious and usually present with all or some of the four cardinal signs of inflammation. 1. Erythema 3. Warmth 2. Pain 4. Swelling Systemic signs of inflammation may be presents including the following. Fatigue Weight loss Morning stiffness Fever Elevated ESR Elevated C-reactive protein Anemia of chronic disease Hypoalbuminemia Thrombocytosis Noninflammatory disorders tend to be related to o trauma (i.e., meniscus tear); o ineffective repair (OA); o neoplasm; and o pain amplification (i.e., fibromyalgia). There may be pain without swelling or warmth, absence of inflammatory or systemic features, minimal or absent morning stiffness, and normal for age laboratory testing. Quiz: What is the most common cause of generalized musculoskeletal pain in women aged 20 to 55 years? Fibromyalgia syndrome (FMS) Quiz: Which of the following statements is true concerning the musculoskeletal exam? The uninvolved side should be examined initially and compared to the involved side 3. Adhesive capsulitis (frozen shoulder) SLR (straight leg raise test) and sensation should be assessed paying attention to dermatomal patterns as this may indicate nerve root compression (A diagnosis of disk compression is likely if pain radiates from the buttock to below the knee when the angle of the leg is between 30 and 60 degrees) - Differential Diagnosis LBP is a diagnosis of exclusion based on history and compatible physical examination. The differential includes the following. • Fracture of the vertebral body (seen on plain X-rays) • HNP or ruptured disk (unilateral or bilateral radicular pain with leg pain > back pain) • Ankylosing spondylitis • Drug-seeking behavior • Visceral organ disease • Cancer with metastasis to spine or spinal tumor • Spinal infection of epidural space Quiz: Sam is a 25-year-old man who has been diagnosed with low back strain based on his history of localized low back pain and muscle spasm along with a normal neurological examination. As the clinician, you explain to Sam that low back pain is a diagnosis of exclusion. Which of the following symptoms would alert the clinician to the more serious finding of a herniated nucleus pulposus or ruptured disc? Unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain - Treatment Acute low back pain does not warrant radiographic imaging unless there is evidence of neurological dysfunction, significant trauma, osteoporosis, fever >38.5 for >48 hours, suspicion of cancer, or chronic oral steroid use. For chronic low back pain, plan AP and lateral films are appropriate and may show age- related changes such as osteophyte formation and reduced height due to disk degeneration on lateral view. MRI is appropriate after failure of conservative treatment for LBP with radicular symptoms or if neurological deficits such as LE weakness is observed. 5. Radicular pain - pain that radiates down the leg in a dermatomal pattern - Radicular pain may be continuous or intermittent and tends to wax and wane in intensity. There may be associated numbness and tingling in the dermatome of the nerve root affected or decreased muscle strength in the muscles that are innervated by the nerve root being compressed. - For sciatic nerve syndrome: Sciatic nerve syndrome is back pain that radiates into the buttocks and produces tingling in the posterior thigh and posterolateral calf to the lateral malleolus. Often the cause is a herniated disc, spinal stenosis, obturator neuritis, sciatic nerve irritation, direct trauma, or osteoarthritis. The pain may also be secondary to lumbar sacral strain but does not necessarily indicate disc herniation or prolapse. Sciatic nerve compression may result from tumors in the pelvis or from prolonged sitting or lying on the buttocks. The history may reveal twisting, bending, or heavy lifting .The physical exam includes evaluating for point tenderness and ROM in the back. With the patient supine, perform straight-leg raising. A positive finding is radicular pain that occurs below the knee at less than 60 degrees of limb elevation, with pain in the buttock or posterior thigh. Treatment is usually conservative. Any change in bowel or bladder function (cauda equina syndrome) constitutes an emergency and needs immediate intervention. - For cervical radiculopathy: commonly caused by compression of the cervical nerve roots, when the cervical discs place stress on the vertebral bodies. It usually is the result of age-related changes, cervical spondylosis, or a herniated disc. The most commonly involved nerve roots are C6 and C7, which produce paresthesias into the lower lateral arm, thumb, and middle finger. Diagnostic tests include radiological assessment of the cervical spine, and if radicular pain is severe or if there is motor or sensory deficit or hyporeflexia, MRI is indicated. If only radiculopathy is present, a conservative trial of cervical traction as in the use of a soft cervical collar may be warranted. - For lumbar spinal stenosis: Lumbar spinal stenosis is narrowing of one or more levels of the lumbar spinal canal and subsequent compression of the nerve roots. In the order of descending likelihood, L4 to L5, L3 to L4, and L1 to L2 are the levels most commonly involved. Onset of symptoms may follow a lifting incident or minor trauma or may gradually emerge. Often there is pseudoclaudication causing radicular complaints (with or without associated back pain) in the calves, buttocks, and upper thighs of one or both legs. Symptoms progress from a proximal to distal direction. Walking or prolonged standing causes pain and weakness in the legs and buttocks. In cases of vascular claudication, the pain stops when the patient stops walking, but pseudoclaudication does not immediately subside when walking stops. The patient may obtain short-term relief by leaning forward (manifested as “stooping”); when grocery shopping, the patient will be leaning on the cart. Relief after sitting is variable, depending on the degree of neural compression. Patients who sleep on their backs, meaning with the spine extended, might awaken after several hours with back and leg pain. Lumbosacral pain is associated with walking and standing. A vague aching in the legs or leg weakness may also be present. Spondylolisthesis (degenerative or spondylolytic), vascular insufficiency, and osteoarthritis of the hips are often associated with spinal stenosis, as well as obesity. 6. Herniated disc Lumbar Disc Herniation - Herniated nucleus propulsus (HNP) is the medical term for what is commonly known as a herniated or slipped disk. Between each bony vertebra lies a disc that provides cushion, support, and flexibility within the spine. Each disk is named for the vertebrae above and below it, so the disk between the L4 and L5 bones is referred to as the L4–5 disc. The discs are filled with a gelatinous substance that is like a cushiony sac. As part of the normal aging process, the discs degenerate over time and start to become less absorbent. When a small tear occurs in the disc, the inner most portion of that gel-like substance can ooze out of the disc. Typical pain associated with HNP occurs when the contents compress the nerve root on one or both sides. Pain can be mild to debilitating. - History and Physical: The history and physical for suspected HNP is the same as for spinal stenosis. Questions regarding acute injury should be asked as trauma can contribute. Most patients can recall the time when the pain occurred and an inciting event. Some may experience a gradual onset of symptoms. Straight leg test usually reproduces pain on the affected side between the angle of 30 and 60 degrees. With knee extended, raise leg until pain is reproduced, then slowly lower leg until pain is gone. Provider should ensure the foot is dorsiflexed for testing accuracy. The sensitivity is 91%; the specificity is 26%. Quiz: Which of the following statements is true concerning the management of the client with a herniated disc? intolerable pain for more than a 3-month period is an indication for surgical intervention. Gaenslen’s Sign caused by vigorous physical activity or a sudden change in the activity or intensity of an activity. Pain is typically in the anterior aspect of the knee that occurs after periods of strenuous activity but is relieved with rest. - Diagnosis is made by history, and on physical, the pain can be reproduced with the patient asked to squat. X-ray may identify osteochondritis, which has a similar presentation. - Treatment is conservative and includes activity modification, muscle strengthening, and PT. 2. OA of the knee is a progressive disease of the joints that occurs when articular cartilage that covers the ends of bones gradually wear away. Where there once was smooth articular cartilage that made the bones move smoothly, there is now a frayed and rough surface. Joint motion along this exposed surface is painful. OA can affect any joint in the body, and symptoms can range from mild to disabling. OA of the knee is the most common and is characterized by recurrent knee pain that worsens with activity. It may also be associated with crepitus and knee instability. - Imaging: Plain radiography is considered the “gold standard” for morphological assessment of knee OA. - Treatment: Acetaminophen is recommended as first-line therapy. Cortisone injections provide short-term benefits. Hyalurinoc acids may be helpful, but the evidence is conflicting. Indications for total joint replacement include refractory pain (when meds are not helping) and disability and radiographic evidence of knee OA. 3. Ligament sprains and tears of the knee most of these end up being referred to orthopedics for treatment. However, it is important to understand the signs and symptoms of each condition as well as the maneuvers to test them. o Ligament sprain or tears occur after some sort of injury. Symptoms include acute pain, swelling, and possible instability. Physical exam should include the valgus and varus stress tests, which test the MCL and LCL respectively, and are performed at 30 and 0 degrees. The ACL and PCL are tested using the anterior drawer and posterior drawer tests. o Maneuver testing video for valgus and varus test https://www.youtube.com/watch?v=M0KX1rxiyqM Maneuver testing video for posterior and anterior test: anterior or posterior cruciate ligament tear: https://www.youtube.com/watch?v=nFgzUMrb8lo Special Tests: ACL
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In the Tinel test, the provider taps over the median nerve of the affected wrist. The test is positive if tingling occurs in the affected fingers. Phalen’s maneuver, or wrist-flexion test, involves having the patient pressing the backs of their hands and fingers together with their wrists flexed as far as possible, ideally 90 degrees. The test is positive if tingling or numbness occurs in the affected fingers within 2–3 minutes (it may not happen immediately). Confirmatory testing can be done with an EMG or nerve conduction test, which can evaluate the severity of the neuropathy, but it is important to know that symptoms must be present for at least 3 months before an abnormality will be detected on EMG. Treatment starts conservatively with nocturnal wrist splints that extend the wrist upwards, taking pressure off the tunnel. Surgery is reasonable to offer after failure of conservative therapy for 3 months because delayed surgery appears as effective as immediate surgery with 94% versus 92% success rates. It is important to know that NSAIDs, vitamin B6, and diuretics are not effective. 10. Osteoporosis - Osteoporosis is a generalized skeletal disorder characterized by normal bone mineralization (nomal amount of minerals to make bone) but low bone mass (bone mineral density-either makes little bone or or looses too much bone) and disruption of the bony architecture, both of which result in an increased risk of fragility fractures. Its chief clinical manifestations are vertebral and hip fractures, although fractures can occur at any skeletal site. This is contrasted with osteopenia, which is a less severe form of decreased bone mineral density, and osteomalacia, which denotes a decrease in actual bone mineralization. - Women are more likely to have osteoporosis, but men also suffer from this condition. White women are more susceptible than black women; the prevalence of osteoporosis in Hispanic and Asian women is similar to that of white women. - Bone loss after menopause is caused predominantly by estrogen deficiency and is most rapid (up to 7% per year) in the first decade after menopause. Postmenopausal osteoporosis is more prevalent in white and Asian women than in women of other races, with the majority of white women developing osteoporosis by the end of the first postmenopausal decade. By age 65, one-third of women will have had a vertebral fracture, and by the ninth decade of life, one in three will have had a hip fracture. 11. Table 15.8 World Health Organization Diagnostic Criteria for Osteoporosis Diagnosis Diagnostic Findings Normal BMD within 1 SD of young adult reference mean Osteopenia BMD >1 SD below young adult reference mean (21) Osteoporosis BMD >2.5 SD below young adult reference mean (22.5) Osteoporosis(severe) BMD >2.5 SD below young adult reference mean (22.5) andpresence of osteoporotic fractures - Risk factors: Lifestyle Low body weight Cigarette smoking Excessive alcohol intake Low dietary calcium intake Vitamin D deficiency Disease-related risk factors Thyrotoxicosis Hyperparathyroidism Cushing’s disease Hypogonadism Rheumatoid arthritis Inflammatory bowel disease Chronic renal insufficiency Malabsorptive diseases Secondary estrogen deficiency resulting from - There is often an obvious fullness of the anterior capsule on exam and a positive sulcus sign (space under the acromion). In an acute anterior dislocation, pain is severe and ROM is limited. The patient will usually hold the arm slightly abducted and externally rotated. There may be associated neurovascular and/or neurosensory trauma; therefore, the clinician should check the distal pulses and sensation, especially over the deltoid. Posterior dislocations are less common (2%) and less apparent. Deformity is minimal, but any motion of the extremity will cause severe pain. Recurrent dislocations can occur and do not require as severe a force as the initial injury. Reduction is usually the treatment of choice; occasionally, surgery is necessary. Quiz: Jennifer is an 18-year-old girl who comes to the emergency room after a fall during a soccer game. Jennifer explains that she fell on her left side and kept her arm out straight to break her fall. She has been experiencing severe pain and limited range of motion in her left shoulder. The clinician has diagnosed Jennifer with a dislocated shoulder. Which of the following statements are true concerning shoulder dislocation? There is a risk of neurovascular and neurosensory trauma, so the clinician should check for distal pulses. 12. Systemic musculoskeletal symptoms Systemic signs of inflammation may be presents including the following. • Fatigue • Weight loss • Morning stiffness • Fever • Elevated ESR • Elevated C-reactive protein • Anemia of chronic disease • Hypoalbuminemia • Thrombocytosis 13. Other important info not to miss: - maneuver test to confirm a cervical injury is Spurling’s test. I. Explain spinal stenosis Narrowing of the spinal canal w/ compression of nerve roots -Congenital or acquired (age) -Most commonly from enlarging osteophytes at the facet joints, hypertrophy of the ligamentum flavum and protrusion/buldging of the intervertebral discs -May produce symptoms by directly pushing on nerve or interrupting the blood supply to nerve Common source of chronic low back pain, seen most with aging. All older people have some degree of this. A common source of chronic low back pain, seen most with aging, is spinal stenosis. Spinal stenosis is caused by a narrowing of the spinal canal as a result of degeneration of the bony facet joints and the intervertebral disks. Bone spurs or osteophytes may also grow into the spinal canal. Facet joints become enlarged and arthritic making less space for the nerve roots. Spinal canal abnormality occurs in virtually every person as they age because the intervertebral discs become worn, and continued axial loading over the course of a lifetime leads to arthritis in the spine. The severity of symptoms will depend on the size of a person’s spinal canal and the degree of encroachment on the nerves. Symptoms In spinal stenosis, leg pain is commonly greater than back pain and pain is characteristically worse with prolonged standing or walking and improved by rest. In more advanced cases, leg pain with weakness or numbness and tingling can be present. Key questions that can be very revealing in patients with suspected spinal stenosis include the following. o When you go to the grocery store, do you find yourself leaning on the cart to minimize your pain? o If you are standing in the kitchen doing dishes or cooking, do you lean on the counter for support? o If you are walking in the mall, do you find yourself looking for places to sit frequently? - The preferred imaging to determine the degree of spinal canal narrowing and facet arthroplasty resulting in nerve impingement is an MRI II. Discuss common characteristics (subjective and objective findings) of patients with lumbar spinal stenosis Subjective - Radicular complaints in calves, buttocks, upper thighs - Pain w/ walking or prolonged standing o Vascular claudication – pain stops w/ rest o Psuedoclaudication – pain doesn’t stop immediately at rest - Short term relief by leaning forward/stooping - Sometimes relief w/ sitting - Pain in back/leg when sleeping on back at night - Pain w/ walking/standing Objective - Muscle weakness - Impaired proprioception - Diminished reflexes - Sensory changes (numbness/tingling) - Bowel or bladder symptoms o Sphincter tone decreased o Don’t confuse w/ prostate problems in older men III. Identify the red flags associated with back and neck complaints which warrant further investigation “TUNA FISH” T- Trauma F- Fever U- Unexplained weight loss I – IV Drug User N- Neurologic symptoms S – Steroid Use A- Age>50 H – History of cancer (prostate, renal, breast, lung) IV. Differentiate between DeQuervain’s Tenosynovitis and Carpal Tunnel Syndrome Carpal Tunnel Syndrome: - Peripheral nerve compression of the medial nerve - Caused by repetitive flexion and extension of the wrist or direct compression of medial nerve - Pain and/or numbness are usual presenting symptoms Procedure: Percuss the median nerve at the wrist. If the patient complains of tingling in the digits (POSITIVE TINEL SIGN), compression at the site of percussion is likely. VI. Differentiate between lateral and medial epicondylitis Lateral epicondylitis (AKA tennis elbow) is an overuse syndrome or tenosynovitis (inflammation involving synovial sheaths surrounding the tendon and the tendon) – typically from wrist extension and pronation and supination of the forearm. Presents with pain (worse with motion such as gripping) in elbow and forearm. Diagnosis made with PE. Xray can be used to r/o other causes of pain. MRI will show severe tenosynovitis but not necessary. Treated with rest, ice, NSAIDS, PT, and possible corticosteroid injections and splinting. Medial epicondylitis (AKA golfer’s elbow) is less common. Overuse syndrome of wrist flexion. Pain on medial epicondyle worsens with wrist flexion. Treated same as lateral epicondylitis. Imaging: Usually unnecessary, but it may be useful if needed to rule out alternative diagnoses. VII. Identify at least 3 physical exam maneuvers to assess the knee 1. Diagnosing ACL injury: Lachman’s test (https://www.youtube.com/watch?v=gfN-p- xZx24) ; anterior drawer test (https://www.youtube.com/watch?v=nFgzUMrb8lo) 2. Diagnosing meniscal tears: McMurray (https://www.youtube.com/watch?v=fkt1TOn1UfI) and Apley (https://www.youtube.com/watch?v=6Z_9lfX_Pc8) 3. Diagnosing PCL injury: posterior drawer test (https://www.youtube.com/watch? v=nFgzUMrb8lo) and Thumb sign 1. Radioactive iodine (RAI)—This essentially destroys thyroid tissue and creates hypothyroidism in the patient. It is contraindicated in pregnancy, lactation, or in women seeing pregnancy within the next 6 months. 2. Anti-thyroid drugs (ATD)—There are two main drugs used here in the United States; before initiating these medications, it is important to obtain a CBC and LFTs because they can cause rashes, elevated LFTs, agranulocytosis, and hepatotoxicity. 1. Methimazole (MMI): Usually started at 10 mg daily unless FT4 levels are more than twice normal 2. Propylthiouracil (PTU): Starting doses of 50–150 mg TID 3. Beta blockers can be used as an adjunct for patient with symptomatic tachycardia over 90 bpm and/or with CVD. 3. Thyroidectomy—this is a surgical procedure that is a definitive cure and used primarily in individuals who have failed ATDs or are not candidates for ATDs. Recommendations for the type of therapy related to a specific condition can be found in Table 5 of the ATA Guidelines. Most cases of hyperthyroidism will need at least one consultation with an endocrinologist. Hyperthyroidism is a situation where the course of progression is often hyperthyroidism initially and then, as the thyroid “burns out,” it becomes hypothyroid. Pregnant or lactating women or women seeking pregnancy within the next 6 months should be managed by an endocrinologist. 2. Thyroid testing There are differing opinions on whether to screen for thyroid disorders in asymptomatic adults. Recommendations of 6 Organizations Regarding Screening of Asymptomatic Adults for Thyroid Dysfunction Organization Recommendation American Thyroid Association Women and men > 35 years old should be screened every 5 years. American Association of Clinical Endocrinologists Older patients, especially women, should be screened. Academy of American Family Physicians Patients > 60 years old should be screened. American College of Physicians Women > 50 years with an incidental finding suggestive of symptomatic disease should be evaluated. U.S. Preventative Services Task Force There is insufficient evidence for or against screening. Royal College of Physicians of London Screening of the healthy adult population is unjustified. Adapted from the ATA/AACE Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine Practice, 18(6). Although there is no consensus about population screening in healthy individuals, there is evidence to support screening in the following at-risk populations, including those with autoimmune disorders; pernicious anemia; first-degree relative with AI thyroid disease; history of neck radiation; history of prior thyroid surgery or dysfunction; abnormal thyroid examination; and psychiatric disorders. Additional diagnoses that support thyroid screening are listed in Table 9 of the ATA/AACE Clinical Practice Guidelines. National organizations differ in their recommendations for routine screening in asymptomatic patients. In 2004 the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence for or against routine screening for thyroid disease in adults without symptoms, and the USPSTF has not updated this recommendation. If the patient is symptomatic or in a high-risk category, such as having a family history of thyroid disease or previous history of thyroid disease or autoimmune disorders, screening is appropriate. The initial screening tests for suspected hyperthyroidism are measurement of the serum- sensitive TSH assay to detect suppressed levels in the setting of elevated thyroid hormones, T4 and T3. Laboratory protocols that add free thyroxine immunoassay (FT4) and T3 if the TSH is low can avoid additional blood draws and expense. If the protocol is not in place, an FT4 and T3 should be tested next. The sensitive TSH assay has a functional sensitivity of 0.02 mcg/dL or less, although units for this test are typically expressed as mIU/L or mcIU/mL. A 24-hour radioactive iodine uptake (RAIU) test can differentiate Graves’ disease from subacute thyroiditis and toxic nodular goiters, thereby refining treatment recommendations. It identifies areas of increased and decreased thyroid function, often termed hot and cold spots, within the gland. Patients with toxic nodular goiter and Graves’ disease have a high RAIU, whereas in subacute thyroiditis, iodine uptake is low. A thyroid scan is critical to determining functionality of any dominant thyroid nodule in a patient presenting with thyrotoxicosis, because cold nodules are highly suspicious for concomitant malignancy and must be evaluated further. An ultrasound of the thyroid will assist in differentiating a cyst from a nodule A fine-needle biopsy is the preferred initial diagnostic technique for evaluation of thyroid masses, particularly solid masses, to rule out malignancy. Magnetic resonance imaging is the preferred test to assess for ophthalmopathy resulting from Graves’ disease 3. Graves’ disease Graves’ disease is by far the most common cause of spontaneous hyperthyroidism in the United States. An autoimmune disorder characterized by autoreactive, agonistic antibodies to the thyroid-stimulating hormone (TSH) receptor, Graves’ disease accounts for 80% to 90% of hyperthyroid cases, peaking in young adults aged 20 to 40 years. It is also the most common form of hyperthyroidism occurring in pregnancy. A diffusely enlarged goiter involving both thyroid lobes, hyperthyroid ophthalmopathy (periorbital edema, conjunctival edema and injection known as chemosis, proptosis, lid lag, and even diplopia), and excessive uptake of radioactive iodine on diagnostic testing are all common characteristics. Subsequent Testing In Graves’ disease, antithyroglobulin and antimicrosomal antibodies are elevated. A TSH receptor antibody test is usually elevated in Graves’ disease and is part of subsequent testing. The diagnosis of thyrotoxicosis is considered in cases of hyperthyroidism when TSH levels are depressed and measurements of T4 are normal. The three treatment options for Graves’ disease are antithyroid drugs, radioactive iodine, or surgery. None of these treatments alters the underlying autoimmune process of Graves’ disease. The most successful treatment in achieving a permanent euthyroid state is surgery; however, it is rarely the preferred method of treatment unless the thyroid gland is extremely enlarged and is pressing on other structures in the neck. -Graves’ disease—This is an autoimmune disorder characterized by agonist antibodies that cause an overproduction of thyroid hormone. Graves’ disease accounts for 80–90% of hyperthyroid cases. - Thyroperoxidase antibodies (TPO Abs)—Useful in detecting autoimmune thyroiditis (Graves’ or Hashimoto’s) - Thyroglobulin antibodies (TBG Abs)—Useful in confirming or differentiating between autoimmune thyroiditis types (Graves’ or Hashimoto’s) 4. Toxic multinodular goiter - Toxic multinodular goiter—This is a complication of chronic, inactive nodule goiter, typically due to iodine deficiency. A 70-year-old patient presents with a complaint of difficulty swallowing, tachycardia, sweating, and unintentional weight loss. Upon physical exam, the patient is found to have an enlarged thyroid that has an abnormal contour. Without any further testing, what diagnosis would you say is the most likely? Overt hypothyroidism Hashimoto’s thyroiditis A nonradioactive alternative to thyroid radioablation for severe Graves’ disease or subacute thyroiditis involves administering a large quantity of concentrated iodine as a saturated solution of potassium iodide (SSKI, 35–50 mg iodide per drop, 1–2 gtts in water PO 2 times daily; Lugol solution, 8 mg iodide per drop, 3–5 gtts in water PO 3 times daily) or iopanoic acid (Telepaque, 1–3 g PO or 0.5 g PO 2 times daily). These concentrated iodine therapies effectively block the conversion of T4 to T3 and inhibit the release of thyroid hormones. Persons receiving radioactive iodine therapy should avoid contact with infants, children, and pregnant women for 7 days after ingestion. Women who receive this treatment postpartum must not breastfeed for at least 3 to 6 months, because radioactive iodine is excreted in breast milk and can ablate the infant’s thyroid. HYPOTHYROIDISM Common symptoms include hoarseness, deafness, confusion, frank psychosis, dementia, ataxia, depression, constipation, intolerance of cold temperatures, dry skin, or hair loss. Hashimoto’s thyroiditis, a type of primary hypothyroidism, is the most common form of autoimmune thyroid disease. This type of hypothyroidism occurs at least four times more often in women than in men, with the average age at onset from 30 to 60 years. Thyroid Association recommends measuring thyroid function in all adults starting at age 35 years and then at least every 5 years. The American College of Physicians recommends TSH measurement in women older than 50 with one or more general symptoms that could be caused by thyroid disease. All patients with a prior history of any medically or surgically treated thyroid disease should be screened with a serum TSH measurement yearly. In addition, patients with other autoimmune diseases and those with unexplained depression, diabetes mellitus (DM), cognitive dysfunction, prior external radiation to the head and neck, hypercholesterolemia, or other risk factors should be screened with TSH measurements. Women experiencing unexplained infertility should be screened for thyroid dysfunction, and postpartum women with vague complaints may benefit from screening. Patients with secondary or tertiary (central) hypothyroidism show a low, normal, or mildly elevated TSH level with low FT4 and T3 by radioimmunoassay. The laboratory values for patients with subclinical hypothyroidism show a mildly increased TSH (4.5–10 mIU/L) with a normal FT4 level. The diagnosis of hypothyroidism is made by measuring serum TSH. TSH and FT4 should be used to follow treatment. When autoimmune thyroiditis is the suspected underlying cause, it is helpful to confirm this via antithyroid antibody titers, either antimicrosomal antibody (antithyroid peroxidase [TPO] antibody) or antithyroglobulin antibody. Once a diagnosis of hypothyroidism is confirmed, additional testing may be necessary to determine the effect of the disease on other body systems. Because T3 is nonspecific and not sensitive, it is not routinely used as an initial diagnostic tool. Because anemia is a frequent complication of hypothyroidism, a complete blood count should be done. A complete blood chemistry profile should be done to assess for alterations in electrolytes, blood urea nitrogen, creatinine, serum osmolarity, and glucose, because a decreased glomerular filtration rate (affecting renal function) can occur. A complete urinalysis should also be performed, with specific attention to the presence of protein (indicating possible renal impairment). Changes in the chemistries may be an indication of deteriorating thyroid function leading to myxedema. 7. Subclinical hypothyroid Subclinical hypothyroidism is the presence of normal free thyroxine immunoassay (FT4) with an elevated thyroid-stimulating hormone (TSH). As many as 15% of patients older than age 65 years have these levels, as do many other adults. However, few of these patients report symptoms, or their symptoms are nonspecific The American Thyroid Association and the American Association of Clinical Endocrinologists recommend treating subclinical disease when there is presence of antithyroid antibodies, when evidence of atherosclerotic cardiovascular disease exists, when heart failure exists, or if the patient is symptomatic at this TSH level. Some patients with subclinical hypothyroidism feel better when treated with levothyroxine. Medication therapy has potentially dangerous adverse effects but may improve subtle abnormalities, prevent goiterous growth, and prevent the development of frank hypothyroidism. Therapy is advisable especially if thyroid autoantibodies are positive, because overt hypothyroidism frequently develops. in young patients or patients with goiter, consider initiating levothyroxine therapy. If the decision is made not to treat these patients, they should be evaluated at 6- to 12-month intervals for evidence of more severe clinical and biological loss of thyroid function. A lower dose (0.5–1.0 mcg/kg) could be given in the treatment of subclinical hypothyroidism. 8. Primary hypothyroid More than 95% of patients with hypothyroidism have primary or thyroidal hypothyroidism, involving dysfunction or atrophy of the thyroid gland. When the thyroid dysfunction is caused by failure of the pituitary gland, the hypothalamus, or both, it is known as central hypothyroidism. Interferon-α, thalidomide, and the antiretroviral agent stavudine have also been associated with primary hypothyroidism. Thyroid hormone deficiency beginning in early infancy and childhood is characterized by growth retardation, mental deficiency, and delayed dentition. Adolescents with primary hypothyroidism may manifest an enlarged sella turcica and, rarely, precocious puberty, in addition to growth retardation. Growth retardation is treatable with hormone replacement therapy, but mental retardation persists. The sensitive thyrotropin assay is the most specific test for diagnosing primary hypothyroidism. A rise in the TSH will precede any other abnormality of thyroid function as the first evidence of primary hypothyroidism. Hypothyroidism caused by primary thyroid failure can be confirmed by a concomitant finding of a decrease in serum FT4. Patients in an early stage of hypothyroidism may present with an increase in serum TSH together with a normal or low-normal serum FT4. By radioimmunoassay, primary hypothyroidism is associated with low FT4 with an elevated TSH level. The normal range of TSH is 0.35 to 2.5 mIU/L. There is general agreement that a TSH level above 10 mIU/L should be treated in patients with primary hypothyroidism. Levels of 4.5 to 10 mIU/L have varied recommendations. The goal of thyroid hormone replacement in primary hypothyroidism is to normalize, not suppress, the TSH. Suppressed TSH, particularly in postmenopausal women or individuals with levothyroxine overreplacement, causes decreased bone mineral density after several years, leading to osteoporosis. Quiz: A patient is diagnosed with hypothyroidism. Which of the following electrocardiogram (ECG) changes should the clinician expect as a manifestation of the disease? Sinus bradycardia Quiz: After 6 months of synthroid therapy, the clinician should expect which of the following in the repeat thyroid studies? Normal TSH 9. Secondary hypothyroid More specifically, secondary hypothyroidism refers to the failure of the pituitary gland to secrete adequate amounts of TSH. Referral to an endocrinologist is necessary if the patient has cardiac disease, symptoms of myxedema, or central (secondary or tertiary) hypothyroidism. After starting hormone replacement therapy, if signs or symptoms of myxedema, chest pain, or thyrotoxicosis occur, the endocrinologist should be consulted. Drugs Commonly Prescribed 16.2 Hypothyroidism: Lifelong Pharmaceutical Treatment Drug Indications Adverse Reactions and Prescribing Considerations Synthetic L-thyroxine* T4 (Levothroid, Levoxyl, Synthroid) Patients with increased TSH level, usually three times the upper limit of the assay. Overt hypothyroidism, lifelong pharmaceutical treatment. Goal: To give enough thyroid supplement orally to result in normal free T4 and TSH levels. Monitor antihyperglycemics, oral anticoagulants, and potential sympathomimetics. Wait 4–5 hours after cholestyramine ingestion. Not to be prescribed for obesity. Use with caution in patients with cardiovascular disease, diabetes, o TSH levels are increased, but the FT4 is within range o Some have symptoms, others do not XI. Differentiate between Hashimoto’s thyroiditis and Grave’s disease Both are autoimmune, attacking thyroid cells. Graves – overproduction of thyroid leading to hyperthyroidism - 90% of hyperthyroidism cases Hashimoto’s – underproduction of thyroid leading to hypothyroidism -Identified via TPO and TBG Abs in blood XII. Identify the roles of TSH, FT4, TT3, and TPO Abs in determining thyroid function Thyroid Stimulating Hormone (TSH)—Pituitary “messenger” to thyroid to increase or decrease thyroid hormone production. used to diagnose hypothyroidism. TSH and FT4 should be used to follow treatment. If the TSH is low or insufficiently elevated in the presence of low T4, central hypothyroidism caused by hypothalamic or pituitary disease should be excluded before starting replacement therapy. Free T4 (FT4)—Circulating unbound thyroid hormone produced by the thyroid, replaced by levothyroxine medication, useful for the diagnosis of hypothyroidism both overt and subclinical *Primary or overt hypothyroidism is associated with a low FT4 and elevated TSH *Subclinical hypothyroidism is a mildly increased TSH with a normal FT4 Total T3 (TT3)—Circulating unbound thyroid hormone that has been converted from T4. T3 is not routinely used as a diagnostic tool because it isn’t sensitive or specific to the hypothyroidism. T3 levels may be normal in early disease, and may not fall until late in the disease. Thyroperoxidase antibodies (TPO Abs)—Useful in detecting autoimmune thyroiditis (Graves’ or Hashimoto’s) Diagnostic for Hashimoto’s thyroiditis when found in high titers (1:400). Higher levels TPO = more thyroid destruction = more severe hypothyroidism - No universal screening recommendations for thyroid disease. - ATA recommends screening for o Baseline at 35 o Pregnant women o Women older than 60 o Individuals with autoimmune disease. - Thyroid Stimulating Hormone (TSH)—Pituitary “messenger” to thyroid to increase or decrease thyroid hormone production - Free T4 (FT4)—Circulating unbound thyroid hormone produced by the thyroid, replaced by levothyroxine medication, useful for the diagnosis of hypothyroidism both overt and subclinical - Total T3 (TT3)—Circulating unbound thyroid hormone that has been converted from T4, useful for the diagnosis of hyperthyroidism - Thyroperoxidase antibodies (TPO Abs)—Useful in detecting autoimmune thyroiditis (Graves’ or Hashimoto’s) - Thyroglobulin antibodies (TBG Abs)—Useful in confirming or differentiating between autoimmune thyroiditis types (Graves’ or Hashimoto’s) XIII. Identify at least one “at-risk” population who should be considered for thyroid screening -Pregnant women -Women older than 60 years -Persons with other autoimmune diseases -Persons with pernicious anemia -Persons with a family history (1st degree relative) of thyroid disease -Persons with a history of prior thyroid surgery or dysfunction or neck radiation -Persons with Abnormal thyroid exam -Persons with psychiatric disorders (Dunphy, p. 847 & 859 and “Thyroid Disorders” Lecture) XIV. Discuss one physical characteristic seen in a hyperthyroid patient -Smooth, velvety skin -Soft, thin hair -Skin with increased pigmentation, spider angiomas, and vitiligo -Onycholysis (splitting and spooning of the nails) -Exophthalmos (buldging eyes) (Dunphy, p. 851 & Hollier, p. 231) Muscle atrophy, tremors, hyperpigmentation, warm flushed moist skin, fine silky hair, thin hair, increased LFT, Exopthalamos, lid lag and edema, corneal ulceration, sinus tach, elevated BP, A.Fib, symptoms of CHF, gynecomastia, osteoporosis, hypercalcemia, potassium wasting 10. Obesity XV. Identify the categories of obesity based on the BMI Overweight BMI is 25-29.9; relative weight is 100%-120% Obesity BMI is 30-40 140%-200% Severe (morbid) obesity BMI is greater than 40 greater than 200% XVI. Identify treatment options for obesity based on BMI and comorbid conditions BMI >25: Diet, exercise and behavior modification BMI >27 with comorbidity or >30 with or without comorbidity: Medication BMI >35 with comorbidity or BMI>40 with or without comorbidity: Surgery Comorbidity is defined as HTN, dyslipidemia, T2DM, OSA Treatment options: lifestyle changes (diet, exercise- 45-60 minutes/day), managing behavior (i.e. H.A.L.T. – hungry, angry, lonely, tired, behavior modification), reduce caloric intake, drugs (i.e. fenfluramine/Fen Phen, dexfenfluramine/Redux, phentermine, diethylopropion, orlistat). Surgical intervention (vertical-banded (mason) gastroplasty and roux-en-Y bypass) for BMI over 40 OR over 35 with comorbities A structured weight loss diet is most effective. Encourage formal programs or weight loss groups (WW, etc.). Diet goals should include a program with 1200–1500 calories per day for women and 1500–1800 calories per day for men; 500–750 calorie deficit per day; low CHO diet, increased fiber, and decreased saturated fats; and less than 800 calories per day in certain circumstances under medical supervision. XVII. Identify at least 3 risks associated with obesity diabetes, CVD, Afib, HTN, NSTEMI, varicosities cancer, skin infections arthritis gallbladder disease, GERD, acute pancreatitis, NAFLD stress incontinence, infertility OSA XVIII. Identify at least 3 causes of obesity Calorie excess—either overeating or high intake of carbohydrates Food insecurity—eating from a fear of potential hunger or past experience with poor availability of food on a regular basis Genetic predisposition with familial history—influences of ghrelin and leptin levels Medication influences—antidepressants, anti-seizure, steroids, insulin, oral contraceptives Psychological factors—self-soothing, large CHO intake = increased serotonin Disease states—hypothyroidism, insulin resistance, PCOS, Cushing’s Quiz: How often should the clinician examine the feet of a person with diabetes? At every visit *safe sex practices - latex condoms *needle exchange programs *universal testing of donated blood products *education to HIV positive women of childbearing age about c-sections, arv drugs for mother and baby *voluntary HIV testing a routine part of medical care *new models for HIV diagnosing outside medical setting *prevent new infection by working with HIV infected and their partners to minimize risk IV. Identify physical exam findings in the patient with HIV. fever, sore throat, myalgia, headaches, cervical lymphadenopathy, night sweats, majority are asymptomatic flu-like sumptoms 6 days to 6 weeks after viral transmission dark purple colored spots (karposi's sarcoma) hairy leukoplakia: condition that is characterised by irregular white patches on the side of the tongue and occasionally elsewhere on the tongue or in the mouth. non-productive cough, SOB, and fever for several weeks pulmonary symptoms: pcp pneumonia, tb, bacterial pneumonia localized candida infections other STD's weight loss anemia, leukopenia, and/or thrombocytopenia Anemia 1. Types of anemia and RBC indices on a CBC Normal values (general) Hgb 13-18 g/dL Hct 37-55 % Reticulocytes 0.4-1.5 % To diagnose anemia first you have to understand causes, can be caused by destruction (bleeding, hemolysis) or decreased production (kidney problem, marrow problem) First look at reticulocytes (normal 0.4-1.5) a. Reticulocyte high-> due to destruction Bleeding Hemolysis: - jaundice, increase bilirubin, bilirubin gallstone - Increased LDH (lactic acid dehydrogenase, normal 100-230) - decreased haptoglobin (normal 30-200) - abnormal RBC morphology b. Reticulocyte low or normal ->due to decreased production, next step look at MCV (normal 78-93) 1) Low MCV (microcytic): think 1st iron deficiency anemia, could also be due to a genetic disorder like Thalassemia, inflammation disorder, sideroblastic anemia, etc. 2) High MCV (macrocytic): classified as megaloblastic->decreased folate, decreased B12 or non-megaloblastic->?marrow a/hypo plasia 3) Normal MCV (normocytic): classified as myelophthisic->marrow invasion, leukemia, granulomas, cancer or most common non-myelophthisic-> renal failure, inflammation, ?marrow a/hypo-plastic https://www.youtube.com/watch?v=ecCEN2iypgI Tremor & Vertigo 1. Parkinson’s Parkinson's disease is a progressive neurologic disorder with four hallmark signs. Resting tremor Cogwheel rigidity Bradykinesia Postural instability Other characteristics include the following. Facial masking Difficulty standing from the chair Tendency to freeze when initiating movement/ambulating Festinating gait: This gait is a quick, short stride with head down and flexed at the waist. It may appear that the patient cannot stop themselves and may fall forward. Reduced arm swing on the affected side Short, shuffling strides that way require multiple steps to turn. The resting tremor associated with PD is often asymmetric involving the upper extremities. It can also involve the lower extremities or the tongue. Keep in mind that there is a group of Parkinsonian syndromes that present similarly: progressive supranuclear palsy, multiple system atrophy, and vascular or ischemic Parkinson’s disease. Resting tremor may also be medication induced. Certain medications can cause extrapyramidal side effects similar to Parkinson's disease. Antipsychotics are the most common offending agent. Metaclopromide (Reglan) and phenothiazines such as Compazine can also cause Parkinsonian features, including a resting tremor. Quiz: Sam, aged 65, is started on L-dopa for his Parkinson's disease (PD). He asks why this is necessary. You tell him: "The primary goal of therapy is to replace depleted stores of dopamine." 2. Intention, Postural & Resting tremors Resting tremor occurs when a body is at complete rest against gravity or sitting still with arms resting in the lap. The most common conditions that are associated with resting tremor are Parkinson's disease and medication tremors. Wilson's disease is another condition that is associated with resting tremor. This is a very rare genetic disorder associated with copper toxicity. Patients who are affected may have extrapyramidal symptoms [similar to Parkinson's] with a slow and progressive course. There may be symptoms of incoordination in the hands, dysarthria, and gait disorder, bradykinesia, rigidity, and ophthalmologic changes. The work up for Wilson’s includes serum ceruloplasmin and copper. Diagnosis is confirmed with liver biopsy, which identifies the copper toxicity. Treatment is aimed at lowering copper levels. Postural tremor can be seen when the patient is asked to extend their arms in front on them. The most common type would be essential tremor. This is the most common form of all movement disorders. This tremor is seen in the hands, and at times the head, and there are cases where the voice may be involved. The tremor is bilateral and generally symmetric. There is often a positive family history of similar tremor and drinking alcohol often reduces it. Postural tremors can also be medication induced. Signs and symptoms of drug-induced tremors depend on the drug used and the patient’s predisposition to its side effects. Medications such as steroids, caffeine, anti-epileptics, antidepressants, and asthma medications may cause a postural tremor. Eliminating the offending agent is often the treatment of choice. Intention or kinetic tremor is characterized by an increase in amplitude when the patient attempts voluntary movement. It can be assessed by having the patient perform the finger-to-nose movement. Intention tremor may be associated with medications, alcohol or drug abuse, multiple sclerosis, stroke, or a mass affecting the cerebellum. Because intention tremor is a symptom of one of these disorders, it cannot be treated, per se. Coping mechanisms such as occupational therapy can be offered. I. Identify at least three laboratory tests to rule out systemic causes of tremor. Electrolyte/ABGs (metabolic imbalances, drugs, caffeine, physiological fatigue) Serum glucose (hypoglycemia) Toxicology screen/drug levels (toxic conditions, antipsychotic drugs, caffeine) To rule out systemic causes of tremor, basic laboratory tests should be ordered. Thyroid function tests should be done to rule out hyperthyroidism as well as CMP to rule out hypoglycemia, electrolyte imbalance, and liver disease. Additional testing may be considered based on the suspected etiology. For example, an MRI would be indicated if patient exhibited cerebellar dysfunction during the examination.