CT Exam I

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CT Exam I
2012-02-16 19:48:10
Clinical Theraputics Exam

Clinical Theraputics Exam I including Ortho, Anemia, Life skills, X-rays
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  1. Felon
  2. Paronychia
  3. 45 y.o. F with wrist pain for several months that is worse at night. She states that it has been progressively getting worse. Has a tingly sensation in her thumb and index finger. Pt denies fever, joint involvement, neck pain, traumatic injury or past injury to the wrist. What is the next step in this pts evaluation?
    A. inspect the hand and wrist
    B. start motor testing of the mucles of hand and wrist
    C. start sensory testing of the hand and wrist
    D. send pt for an x-ray
    A. Inspect the hand and wrist
    (this multiple choice question has been scrambled)
  4. 43 y.o. F presents with a several month history of wrist pain and hand parasthesia of the first 3 digits. On PE you note no swelling or erythema the skin is intact, no atrophy of the greater thenar prominence, no atrophy of the lesser thenar prominence, no neck pain, nails normal, wrist extension/flexion strength is 5/5 bilaterally. the wrist and hand ROM is normal, She has decreased grip strenght 4/5 on the affected hand with the unaffected hand being 5/5. What would be the next PE test to perform?
    A. Finklestein
    B. O.K sign test
    C. Phalen test
    4. X-ray
    C. Phalen test
    (this multiple choice question has been scrambled)
  5. 50 y.o. M presents with several month history of wrist pain and hand parasthesia of the first 2 digits. His PE is unremarkable except for decreased strength 4/5 on the grip strength of the affected hand and a pain with the Phalen test. Pt denies any trauma to the wrist. What is his Dx?
    Carpal Tunnel
  6. How would you treat Carpal Tunnel syndrome initially?
    Wrist splint possible cortisone injections second line or with severe or limiting pain.
  7. "numbness and tingling to the radial 3 digits of the hand and vauge aching of the thenar area"
    Carpal tunnel syndrome
  8. What is the treatment for severe, persistent carpal tunnel that is refractory to conservative therapy?
    • Surgery
    • Transverse carpal fasciotomy
  9. Pt presents with a painful finger.
    PE: volar aspect of the DP of digit 2 is swollen, erythematous, warm to the touch and very painful to palpation. Swelling does not extend past the DIP
  10. What is the Tx for a Felon?
    I and D and warm soaks
  11. T or F you should X-ray a Felon?
    T to make sure there is no extension to the bone
  12. What is DeQuervain's Tenosynovitis?
    Swelling or stenosis of the tendon sheath that surrounds the APL and EPB tendons at the wrist
  13. What is the test for Dequevain's tenosynovitis?
    Finkelstein's test
  14. How do you perform a Finkelstein's test?
    Bend thumb inside of fist and deviate the wrist to the ulnar side
  15. What is the first line treatment for dequevain's tenosynovitis?
    Thumb spica with NSAIDs
  16. Pt has pain and swelling over the radial styloid and says that the pain is worse when he tries to move his thumb or make a fist what is your diagnostic suspicion? what test would you use to confirm?
    Dequevain's Tenosynovitis, Finklesteins
  17. You have a high suspicion that your patient has flexor tenosynovitis but they only have 2 of the 4 signs. What imaging study would you use to confirm your diagnosis?
    Ultrasound to confirm. with 2 or 3 out of 4 signs of kanavel confirm flexor tenosynovitis with a basin of watern and the hand in the water conduct the ultrasound in the basin.
  18. What will happen if you let flexor tenosynovitis go untreated?
    The patient will loose function of the affected area! very important to catch and treat!
  19. What are the 4 signs of kanavel?
    • Finger swelling of the digit
    • finger held in flexion at rest
    • pain with passive extension
    • pain along the flexor tendon
  20. What is the dispostion for a pt with flexor tenosynovitis?
    IV antibiotics are nessisary so the patient needs to be admitted
  21. What is the treatment for flexor tenosynovitis?
    • Treatment with IV abx ampicillin and sulbactam
    • Hand consult immmediatly
    • Admission
  22. When the flexor tendon sheath becomes infected
    Flexor Tenosynovitis
  23. Colles Fracture
    • Dinner fork deformity
    • Colles fracture
  24. A colles fracture is ___ (dorsally or volarly) displaced while a smith's fracture is (dorsally or volarly) displaced.
    • Colles: Dorsal
    • Smith: Palmar (Volar)
  25. What is the cause of a colles fracture?
    FOOSH (fall on outstretched hand)
  26. "dinner fork" deformity
    Colles fracture
  27. Smith Fracture
  28. What is the most common cause of a Smith fracture?
    • Fall on outstretched hand in supination
  29. A 53 y.o. M with CC: Wrist pain. Pt states that he fell on the ice outside his car and fell on the palm of his hand. He has no swelling or deformity he has minimal tenderness and full range of motion. What exam do you want to perform? What fracture are you worried about?
    Palpate the anatomical snuffbox for a scaphoid fracture
  30. Pain in anatomical snuffbox
    Scaphoid fracture
  31. What is the treatment for a scaphoid fracture
    Thumb spica with follow up
  32. What are the 2 things you should always do before and after reduction of a fracture or dislocation???!!
    X-Ray and check neurovascular function
  33. Pt presents to ED after injuring the 4th digit right hand pt reports injuring the finger in a basketball game when a small blonde girl fired a pass at him. On physical examination you note pain, erythema, and inability of the DIP of the 4th digit to extend sensation and skin are both intact. What do you suspect could be a possible cause of the finger pain? What would you order to confirm?
    X ray to confirm Mallet finger with possible avulsion fracture
  34. What don't you let a pt with a mallet finger do?
    bend the finger, NEVER NEVER NEVER bend the finger
  35. What is the treatment for mallet finger?
    splint and refer
  36. What is the typical mechanism of injury for a Mallet finger?
    • sudden force on the tip of the finger causes extension tendon rupture
  37. Mallet finger
  38. Mallet Finger
  39. What ligament is injured in Game keepers thumb?
    Ulnar collateral ligament
  40. How do you treat Gamekeeper's thumb?
    Thumb spica
  41. What is the mechanism of injury for gamekeepers thumb?
    Radial deviation of the thumb to excess or frequent strain radially
  42. What is Jersey Finger?
    • Gina's favorite injury.
    • Injury to the Flexor digitorum profundus and/or flexor digitorum superficiallis tendon. Usually from grabbing.
  43. What is the treatment for Jersey finger?
    Splint and referral
  44. What do you do if a boxer's fracture has an open lac?
    Treat with Augmentin for a human bite/infection. Also check/boost tetanus
  45. What is the treatment for a Boxer's fracture?
    Ulnar Gutter splint
  46. What should you always look for/remove when working with a hand/finger injury?
  47. Boxer's Fracture
  48. Boxer's Fracture
  49. How would you treat a finger dislocation?
    • 1. Visual inspection
    • 2. Neurovascular exam
    • 3. X-Ray
    • 4. Reduction (in the middle of class if necessary)
    • 5. Neurovascular exam
    • 6. X-ray
    • 7. Splint
    • 8. Follow up
  50. Finger dislocation
  51. Car crash pt is fine except for a hip that is flexed internally rotated and adducted
    Posterior dislocation
  52. Car crash pt is fine except for a hip that is minimally flexed, externally rotated and markedly abducted
    Anterior hip dislocation
  53. The majority of hip dislocations are (anterior or posterior)
  54. Where/How do you check sciatic nerve function?
    • Check sensation to the back of the leg and foot
    • Can the patient dorsiflex (peroneal branch) and plantar flex (tibial branch)
    • DTR (deep tendon reflex) ankle
  55. The peroneal nerve is responsible for (dorsiflexion or plantar flexion)?
  56. The tibial nerve is responsible for (dorsiflexion or plantarflexion) ?
    plantar flexion
  57. You have an 80 y.o. F who fell what do you have to establish about her fall?
    was it mechanical or syncopal
  58. A hip that presents shortened externally rotated and abducted is most likely...
    Hip fracture
  59. Hip fracture
  60. Mrs. Banderez is an 82 y.o. female with pmhx of htn well controlled who presents to ED with hip pain. Pt stated that she was going to see a movie with her husband (Once Upon a Time in Mexico) when she tripped over him. Pt watched the movie then came to the ED afterwards due to persistent pain and limp. Pt denies head trauma, LOC or neck pain
    PE: no ecchymosis, skin intact no swelling over right hip, tender to palpation over greater trochanter. pain with active and passive movement (ext/flex/int/ext rotation) Pt can ambulate with limp. Pt is NVI
    What test do you do next
  61. 65 y.o. male with worsening right hip pain. Per pt he has had intermittent hip pain for years. It only uesd to hurt when he ran that cleared with rest however progressed until he had pain with only walking and now he has pain at rest. What is your highest clinical suspicion?
  62. Osteoarthritis
  63. What are the 4 classic findings of Osteoarthritis on X-ray?
    • Joint space narrowing
    • Osteophyte formation
    • subchondral cysts (fluid filled sack)
    • subchondral sclerosis (thickening of the bone next to cartilage)
  64. What is the treatment for OA?
    • NSAIDs
    • Activity modification
    • Injections
    • Joint replacement
  65. When testing extension in a knee injury what crucial tendon are you testing?
    patellar tendon
  66. 56 y.o. male falls while ice skating and injures knee. It has minimal swelling and is minimally tender. What is your next step? What "rules" suggest this course of action?
    • X-ray the knee
    • Pittsburg rules
  67. Can a patient sleep with a knee immobilizer on? why?
    • NO
    • sleeping with a knee imobilizer on is a risk for DVT
  68. 43 y.o. F who presents complaining of rt knee pain after running and fell into a hole approx 1 foot deep.
    PE: pt cannot extend lower leg and cannot maintain extension
    What do you suspect is involved in her injury?
    Who should you get involved in her injury?
    • Quad or patellar tendon possibly patella
  69. patellar tendon rupture
    • Patellar fracture
    • immediate ortho consult
  70. What part of your exam would you delay until post X-ray with a patient whom you suspect this?
    Delay movement of the knee ex. ROM until after X-ray to avoid furthur displacement of the fracture
  71. Pittsburg rules are for ____ and Ottowa rules are for ___
    • Knee trauma
    • Ankle injury
  72. Bimalleolar fracture involves the __ and ___ maleolus while a Trimalleolar fracture involves the ___, __ and ___
    • Medial and Lateral
    • Medial Lateral and Posterior
  73. Test that tests function of the achilles
    Thompson Test
  74. Test for dequairvains
  75. Test for carpal tunnel
  76. Why do you X-ray an achiles tendon rupture?
    B/c of risk of avulsion fracture
  77. T or F when you splint an achilles tendon rupture their foot should be at 90degrees
    F. you want them in comfortable plantarflexion
  78. How do you perform a Thompson test?
    have pt lying prone with knee bent and squeeze the belly of the calf to see if there is plantarflexion of the foot
  79. "feels like a baseball bat hit the back of my calf"
    achilles tendon rupture
  80. ___ hours or compartment syndrome can cause irreversible damage
  81. Pt with hx of recent lower leg fracture presents with pain out of proportion to current state of injury.
    Increase in pain with passive stretching
    area is swollen firm and tender
    Compartment syndrome
  82. Pallor, pulselessness, poikilothermia, parasthesias, paralysis, pain SEVERE pain, pain with PROM, swollen tender firm area
    Sx of what?
    Compartment syndrome
  83. an acute swollen hot and tender joint with limited ROM is a __ until proven otherwise
    septic joint
  84. Synovial fluid that has WBC >50,000 with a decreased glucose and increased protein is indicative of
    Septic joint
  85. What is the treatment for a septic joint?
    Vanco + ceftriaxone
  86. Large swollen knee which is nontender not erythematous and not hot with full ROM
  87. When a pt presents with a calcaneal fracture what is the mos common secondary fracture?
    L2 fracture
  88. What other fracture would you be worried about in a pt who presented with this?
    L2 or any lower lumbar fracture
  89. Calcaneal fracture
  90. A proximal 5th metatarsal fracture is also known as a ...
    Jones fracture
  91. Jones fracture
  92. What is a pseudojones fracture?
    an evulsion fracture of the proximal 5th metatarsal
  93. how would you treat a distal phalyngeal fracture of the first digit on the right foot?
    buddy tape!
  94. Ms. Seamus complains of left foot pain x2 weeks getting progressively worse. she denies any trauma to the foot. pt states pain is worst during her first steps in the morning and as the day goes on the pain gets better pt recently started running what do you DX
    plantar fasciitis
  95. T or F carpal tunnel syndrome is worse at night
  96. Phalen's test tests what ?
    Carpal tunnel syndrome
  97. What is the treatment for a mild case of carpal tunnel with first presentation.
    wrist splint
  98. What is Carpal tunnel?
    Entrapment of the median nerve at the wrist
  99. "numbness and tingling to the radial 3 digits of the hand with vauge aching in the thenar area"
    Carpal tunnel
  100. With any fall/trauma what else are you concerned about besides the primary fracture?
    • Neurovascular integrity
    • Other injuries Head trauma cervical spine trauma etc
  101. If you suspect surgery will be needed it is important to keep the patient ___
  102. With any hand or arm injury where you expect swelling you should remove what?
    Jewelry expecially rings
  103. Pt presents with distal humerus fracture on PE you note decreased 2 point descrimination over the volar aspect of the 5th digit what are you concerned about?
    a. median nerve
    b. ulnar nerve
    c. axillary nerve
    d. radial nerve
    Ulnar nerve
  104. Pt presents with fracture of proximal humerus, you note decreased sensation over the lateral aspect of the upper arm you suspect
    a. axillary nerve injury
    b. long thoracic nerve injury
    c. median nerve injury
    d. radial nerve injury
    Axillary nerve injury
  105. After suffering a mid shaft humeral fracture a pt can not extend his wrist or fingers against resistance what nerve is injured?
    Radial nerve
  106. "wrist drop" is an injury to what nerve
    Radial nerve
  107. Pt presents after falling off his bike with a cc of shoulder pain. Pt is holding the painful arm with his uninjured arm the first intervention you take is to...
    A. assess for other injuries
    B. stat xray
    C. 2 percocet
    D. determine NVI status
    A. assess for other injuries
    (this multiple choice question has been scrambled)
  108. Most common part of the clavical fractured is
    Middle 1/3
  109. Pt who has clavical fracture with no skin tenting who is NVI what is the treatment along with pain meds?
  110. What muscle is responsible for the displacement of the proximal segment of a clavicular fracture superiorly?
  111. "Skin tenting"
    Clavicular fracture
  112. MOI of clavicular fracture is
    falling on or near area/ direct blow to clavical
  113. swelling and tenderness localized to clavicle is supicious for a ___ fracture
  114. You suspect an AC separation. On physical exam you note a step off deformity without prominent distal clavicle what grade of separation do you expect?
    a. Grade I
    b. Grade II
    c. Grade III
  115. What major joint is most commonly dislocated in adults?
  116. If you have a shoulder dislocation do you let it calm a few hours to days or reduce it immediatly?
    Reduce immediatly to avoid prolonged compression of blood supply and nerves
  117. What artery is most likely to be inured with an anterior shoulder dislocation?
    Axillary artery
  118. What nerve is most likely to be injured in an anterior shoulder dislocation?
  119. What is the most common type of shoulder dislocation?
  120. What is the most common artery injured in a humeral fracture?
  121. Pt cannot extend wrist what nerve is injured?
  122. A carpenter presents with localized pain over the lateral aspect of his right elbow. He states that the pain gets worse when he has to manually drive a screw into place. He denies trauma. What manuver will cause him the most pain during physical exam?
    A. pain with resisted wrist extension and radial deviation
    B. pain with resisted pronation
    C. pain with elbow flexion and wrist flexion
    D. pain with resisted wrist flexion and ulnar deviation
    A. pain with resisted wrist extension and radial deviation
    (this multiple choice question has been scrambled)
  123. Impaired sensation over the lateral aspect of the deltoid, lack of contraction of the deltoid. what nerve is injured
  124. This nerve controls sensation to the dorsum of the thumb and index web space and controls extension of the wrist and fingers
  125. This nerve controls ability to abduct the index finger, and sensation to the tip of digit 5
  126. This nerve controls making the O.K. sign with the thumb and forefinger as well as abduction of the thumb and radial side of palm
    M for Median nerve
  127. What are the 3 types of AC separations?
    • Type I minor sprain to AC ligament x ray is normal
    • Type II disruption of the AC ligament increased space on X-ray
    • Type III complete disruption of the AC and coracoclavicular ligaments
  128. AC joint is usually less than __ mm
  129. CC ligament is usually ___-___ mm
  130. How do you treat AC separation types I and II?
    • conservative treatment
    • sling
    • painmeds
    • PT
  131. How do you treat a type III AC separation?
    Controversial surgery and conservative are both options
  132. How would you treat a AC separations type IV-VI?
  133. What is a Hill Sachs Lesion
    trauma injury associated with compression fracture of the humeral head
  134. Medial epicondylitis is better known as
    "golfers elbow"
  135. Lateral epicondylitis is better known as
    "tennis elbow"
  136. clenched fist with wrist extension and radial deviation is most painful for pts with
    A. Tennis elbow (Lateral epicondylitis)
    B. Carpal Tunnel
    C. Golfer's elbow (Medial epicondylitis)
    A. Tennis elbow (Lateral epicondylitis)
    (this multiple choice question has been scrambled)
  137. clenching the first with the wrist in flexion and ulnar deviation is mos painful for
    A. Tennis elbow
    B. Golfer's elbow
    C. carpal tunnel
    B. golfer's elbow
    (this multiple choice question has been scrambled)
  138. Golfer's elbow is (Medial or lateral) epicondylitis while Tennis elbow is (medial or lateral) epicondylitis.
    • Golfers elbow is medial epicondylitis
    • Tennis elbow is lateral epicondylitis
  139. Medial epicondylitis has the added risk of affecting what nerve?
    Ulnar nerve
  140. Fracture of the radius with dislocation of the distal ulnar-radial joint
    Galeazzi fracture
  141. Fracture of the proximal third of the ulna with a dislocation of the radial head (proximal)
    Monteggia fracture
  142. monteggia fracture dislocation
  143. Galeazzi fracture
  144. Galeazzi fracture
  145. Monteggia Fracture
    • Fat pad sign
    • Epicondylar fracture
  146. 57 y.o. M presents with fatigue x3 mo. You note that he is paler than he has been on previous visits. His labwork shows Hb 11, MCV 74 and low Hct. What is the most likely cause of his anemia? What is your next step?
    Iron deficency anemia due to GI bleed. until proven otherwise, Guiac
  147. A 30 y.o. F pt comes to you with sx consistend with anemia. Her labs are as follows
    Hb: 10.2, MCV 116, MCH 33, RDW nl What type of anemia does she have? (macro or micro or normo)
  148. Name 2 vitamin deficencies that cause macrocytic anemia
    • B12 (cobalamin) deficency
    • folate deficency
  149. What are some causes of Cobalamin deficency?
    • Inadequate dietary intake
    • pernicious anemia
    • gastric bypass
    • PPIs
    • Severe pancreatitis
    • gluten induced enteropathy
  150. Pt presents with fatigue, pallor, anorexia, wt loss, glossitis, angular chelosis, melanin skin hyperpigmentation and peripheral neuropathy...
    B12 deficency
  151. What are some causes for Folate deficency?
    • Dietary
    • Malabsorbtion- tropical sprue and gluten enteropathy
    • excess utilizaiton- pregnancy, hematologic etc
    • inflammatory conditions
    • long term dialysis
  152. What are some things that precipitate sickle cell pain crisis?
    • infection
    • cold
    • dehydration
    • altitude
  153. A pt who you see often for sickle cell anemia checkups presents to you with diffuse muscle pain in their leg and hip you suspect
    Pain crisis
  154. What is the most common cause of acute aplastic anemia in sickle cell?
    parvo virus (virus B19)
  155. How would you manage a sickle cell pt in pain crisis?
    • Fluids and pain control
    • Imaging if pulmonary symptoms or if concered about possible osteomyelitis
    • Labs: cmp, cbc, retic count, type and cross
  156. Sickle cell crisis with pulmonary symptoms and new pulmonary infiltrate
    Acute Chest Syndrome
  157. A pt whom you follow for sickle cell presents with shortness of breath, fever, nonproductive cough, tachypnea and some chest pain 3/10
    What do you suspect they have and how would you manage them?
    • Acute Chest Syndrome
    • Admit
    • pain control and monitor fluid status
    • broad spectrum abx to cover S. pneumoniae and mycoplasma
    • severe cases may need a transfusion
  158. Tx for priapism
    Hydration, pain control, transfusion and IMMEDIATE urology consult
  159. One of your Sickle cell pts comes in 2wks after a short summer cold with increaseing fatigue and pallor. You note that retuclocyte count is low aprox. 0.2% What do you think they have
    Aplastic Crisis
  160. A 5 y.o. with sickle cell presents to the ED with tachycardia, pallor, hypotension, lethargy and anorexia. What do you suspect and what would you find on PE?
    • splenic sequestration
    • splenomegally
  161. How do you treat splenic sequestration
    fluids possibly a transfusion
  162. A sickle cell pt whom you are treating in the ED for an acute pain crisis suddenly developes a mild fascial droop what do you have to worry about? what do you want to treat with?
    • Stroke, Subarachnoid hemmorhage, isolated function loss
    • treat with emergent transfusion
  163. Asplenic status (mechanical or functional) makes a pt more suseptible to what types of organisms?
    • encapsulated organisms
    • H. Influenza
    • S. pneumonia
  164. Name some conditions that would cause you to admit a sickle cell patient (6)
    • Pt with pulmonary or neurological s/s
    • evidence of bacterial infection
    • pt with splenic sequestration
    • Pt with aplastic crisis
    • pt with intractable pain
    • cannot maintain hydration
  165. Name the 4 microcytic hypochromic anemias
    • Iron deficency anemia
    • Thalassemia
    • Sideroblastic Anemia
    • Chronic disease
  166. What lab value measures the concentration ofthe major carrying pigment of the blood?
    Hemoglobin Hb
  167. What lab value measures the percent of whole blood occupied by intact red blood cells?
    Hematocrit Hct
  168. __ measures the volume of the average circulating red blood cell
    MCV mean corpuscular volume
  169. ___ measures the hemoglobin content of the average RBC
  170. __ measures the variation of RBC volumes
    RDW (RBC distribution width)
  171. What lab value is an indirect measure of transferritin?
    TIBC total iron binding capacity
  172. protein that stores iron in cells
  173. iron transport protein
  174. What lab value measures how well the body is binding and transporting iron?
    Iron saturation
  175. variation in shape of red blood cells on peripheral smear
    poikilocytosis/ anisocytosis
  176. cells with irregularly spaced bulbous projections
  177. Microcytic anemia with low serum ferritin, low serum iron, and high TIBC, normal Transferrin saturation
    Iron deficency anemia
  178. What are some causes of inadequate iron supply?
    • impaired absorbtion
    • diet insufficient
    • Gastric surgery
  179. What are some things that would cause increased iron requirement?
    • Blood loss especially menses and GI bleed
    • Growth
    • Pregnancy and lactation
  180. Should iron supplements be taken with food?
    No! the acidic envrionment of the stomach is nessisary for optimal absorbtion food increases the pH. For this reason antacids also decrease absorbtion. caution the patient against taking these with their iron
  181. What are some SEs of Iron supplements?
    Heartburn, nausea, diarrhea, constipation
  182. 36 y.o. male complaining of jaundice and anemia what labs do you think may be abnormal?
    A. Hb and Cr
    B. Hb and ast
    C. Hb and platelets
    D. Hb and bilirubin
    D. Hb and bilirubin
    (this multiple choice question has been scrambled)
  183. What is the treatment for Beta thalassemia major?
    • Life long blood transfusions
    • monitor pt for overload if overload occurs chelation therapy to prevent cardiomyopathy
    • consider splenectomy
    • Bone marrow transplant is curative
  184. What is the treatment for betha thalassemia intermedia?
    • splenectomy
    • folic acid supplement
    • treat iron over load
    • hydroxyruea
    • treat extramedullary masses
  185. Name a chelation drug
    • derfoxamine
    • deferasirox
    • deferiprone