DDX1

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constantine
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DDX1
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2010-06-14 00:45:45
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Final Exam
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  1. What are the descriptions of Cardiac & Non-Cardiac chest pain?
    Cardiac: Diffuse, Substernal, radiate to left arm or jaw, exertion, 10-30 min

    Non Cardiac: Brief-continuos, localized, non-radiating (dermatome), reproducible (neuromuscular), organ referal not reproducible
  2. What are the findings associated with non-cardiac chest pain in relation to the skin?
    -Mondor's syndrome (thrombosis of superficial vein)

    -Herpes Zoster (varicella virus in DRG, dermatome pattern, vesicles)
  3. What are the findings associated with muscular non-cardiac chest pain?
    Strain: contract/stretch, pecs, intercostals, serratus anterior

    Trigger point: reference point of pain for one muscle, pain at end-range stretch
  4. For non cardiac chest pain, what are the ribs findings?
    Fracture: posterolateral most common, compression pain, oblique xray

    Tietze's syndrome: unilateral pain, costochondral junction of upper rib, older females smoke

    Slipped rib or rib subluxation
  5. What is the finding for non-cardiac chest pain that is referred?
    • Thoraci facet
    • C-spine OA
    • Pleural: hx of URI, local unilateral pain, chest film & recumbent for fluid level
    • Esophageal spasm: mimics angina, hot + cold food rxn, responds to nitro (smooth mm. relax)
    • GI
  6. What are some things that can benefit tx of rib fx?
    • Rest & decrease cough, sneezing
    • Stay mobile
    • stretch
    • Slow full breaths to decrease scar tissue form....
  7. What would be a tx for Tietzes syndrome?
    Corticosteroids inject....
  8. What are the findings for stable angina?
    • -Exertion
    • - < 10 min
    • -Rest & nitro good
    • - ST depression on EKG
    • - Negative enzymes
    • - Due to athero
  9. What are findings for Unstable & Prinzmetal angina?
    • -Occurs @ rest
    • - > 10 min
    • - Nitro usually helps
    • - ST depression or elevation
    • - Unstable due to athero
    • - Prinzmetal due to vasospasm
  10. What are some findings and descriptions of manual therapy for Stable Angina?
    • - Randomized prospective study
    • - 275 ptnts referred for coronary angiography were divided into cervicothoracic angina positive or negative
    • - 75% of the CTA positive reported improvements in pain and general health whereas 22%-25 of negative groups reposrted improvement
    • - Pain intensity improved in both groups
    • - SF-36 changes only found in CTA positive group
  11. What are the findings and details associated with Palpitations?
    • - Patients report: heart beats loud, feel heart skip beat, heart racing
    • - Determine frequency
    • -Situational occurance
    • - Use of medications
    • - Whetther tachycardia is abrupt in onset
    • - How often hear a loud heartbeat?
    • - Confirmation= EKG
    • - * Halter monitor--> monitor ptnt over 24 hours
  12. What are findings asssociated with Tachycardia?
    • - Atrial source may respond to a vagal stimulation
    • - Evaluate patient for associated murmurs
    • -Resting and stress ECG
    • - Echocardiogram for suspected MVP
  13. What are the sx/s of difficulty breathing (Dyspnea)?
    • -Difficulty due to pain on full inspiration: direct trauma, muscle strain
    • - More of a sense of tightness or pressure: radiation into arm or jaw, headaches, dizziness, joint pains
    • - with exertion?
    • - POsition related?
  14. What are the respiratory S/Sx ?
    • - Cough common with many resp.
    • - Chronic non-productive cough in 75% of cases:
    • `post nasal drip
    • `chronic bronchitis
    • `hyperactive airway disease
    • ` GI reflux
    • - Sputum = non specific indicator
    • - Wheezes indicate obstruction (narrowed airway)
  15. What are the Obstructive respiratory disorders?
    • - Exhalation most effected
    • - Obstruction due to mucus or bronchial constriction
    • - Decrease in FEV1
    • - Increased residual volume
    • - Wheezes and rhonci
    • - Asthma, chronic bronchitis, emphysema, and bronchiectasis
  16. What are the restrictive respiratory disorders?
    • - Effects all aspects or respiration
    • - Sources are pulmonary & extra including: neuromuscular, skeletal deformity, pleural
    • - Rales are more prevalent
  17. What are the Blue Bloater clinical appearance of COPD?
    • - Centrilobular
    • - Blockage of distal bronchioles
    • - Decreased CNS sensitivity to CO2= cyanosis
    • - Not in apparent distress
    • - Chronic cough--> smoker
  18. What are the pink puffer clinical appearance of COPD?
    • - Panacinar
    • - Destrution of distal alveoli
    • - 25% of body energy to breath
    • - Thin, frail; flushed
    • - Breaths through pursed lips
    • -Barrel-chest appearance
  19. What are the findings of extrinsic asthma?
    • - Onset childhood
    • - family hx of allergy
    • - Testing: spirometry, allergy
    • - Monitor with peak flow meter
    • - Distinguish from hyperactive airway
  20. What are the findings of intrinsic asthma?
    • - Usually adult > 40
    • - Prolonged URI, smoking, toxins
    • -No allergy relation
  21. What things favor Th1 helper cell responses which is non-inflammatory?
    • - Younger siblings
    • - exposed to daycare
    • - exposed to animals first 6 months
    • - Exposed to TB, measles, hep A
    • - Exposed to rural area
  22. What things favor the inflammatory Th2 helper cel response?
    • - Urban area
    • - Antibiotic use
    • - Western lifestyle with diet
    • - Dust mites + cockroaches
  23. What are some acute phase asthma meds?
    • - Epinephrine
    • - Beta agonists (valine)
    • - Methyl-Xanthines (theophyline)
  24. What are some prophylactic asthma meds?
    • - Cromolyn sodium (intal)
    • - Leukotrine receptor antagonist (zafirlukast)
    • - Beta 2 agonists (salmeterol)
    • - Oral and aerosol corticosteroids
  25. What are the guidelines for exercise Induced Bronchospasm?
    • - Warm up 45-60 min before event
    • - Exercise in warm humid air
    • - Avoid intense workout make short
    • - Sports of short burst activity
    • - Breath through nose
    • - Control breathing
  26. Describe the aspects of heart burn...
    • - Due to irritation of esophagus
    • - lower esophageal sphincter incompetence or loss of tone
    • -Foods decrease tone: fatty, coffee, chocolate
    • - Drugsthat are sympathomimetic
    • - Hiatal hernia 2ndary cause
  27. What are the associated findings with abdominal pain?
    • - Organ pain centrally
    • - Parietal peritoneum or capsule of organ irritated= pain localized
    • - Pain radiates from back of groin= renal/ureter problem
    • - Gynecologic causes=menstrual cycle
    • - Sudden pain= blockage of non intestinal lumen, rupture of organ, major vascular problem
  28. What part invovled in lower right quadrant of acute abdominal pain?
    • - Appendicitis
    • - Pelvic inflammtory disease
    • - Ectopic pregnancy
    • -Renal referral
  29. Whats invovlved in right upper quadrant of acute abdominal pain?
    • - Chilelithiasis
    • - Hepatitis
    • - Fitz-hugh-Curtis
    • -Appendicitis
  30. WHat are findings of Appendicitis?
    • - Begins as central pain over 6-12 hours
    • - Localizes due to peritoneal irritation
    • - nausea/vomiting/WBC increase
    • - Rebound tenderness or Rovsings
    • - US disgnostic
    • -TX: laproscopic removal
  31. What are the important Hx findings and exam most specific for Appendicitis?
    - Hx: RLQ pain with anorexia with pain before vomitting

    -Exam: psoas sign
  32. What are the most highest occurring sensitivity & specificity clinical findings for appendicitis?
    Sensitivity: Rovsing's / anorexia/ pain prior to vomitting/ fever

    Specificity: Psoas sign/ fever/ rebound tenderness
  33. What are the ccauses of pelvic inflammatory disease, s/sx, dx, and tx??
    • - Due to Chlamydia or ghonorrhea
    • - S/SX: fever, chills, lower unilateral ab pain, ab pain worse at end/ after period
    • - Exam: sensitive
    • -DX: culdocentesis
    • - TX: antibiotics w. complication of Fitz-Hugh-Curtis disease
  34. What are general findings and associations with ectopic pregnancy?
    - 1% all pregnancies--> 99% in fallopian tube

    • - Signs of early pregnancy; breast tender, morning nausea
    • - Missed period w. spotting
    • - Pelvic exam 1st--> pregnancy test--> diagnostic US
  35. What are the findings and associations with kidney/ureteral stones?
    • - More common in males, humid climate, summer
    • - Dehydration
    • -Severe pain w. nausea + vomitting
    • -US best
    • -TX: stones to pass if small enough, use lithotripsy, surgery
  36. What are the steps to having a stone formation?
    • 1. supersaturaiton
    • 2. Nidus
    • 3. crystal growth & aggregation
    • 4. stone size increase
  37. What is a good diet form to preventing kidney stones?
    • - normal calcim
    • -decreased animal protein
    • - decreased salt intake
    • - normal calcium
  38. What are the findings with Cholelithiasis and Tx & Dx?
    - common in women, diabetics, Native Americans, oral contraceptive

    • - Cholesterol stones most common
    • - Bilirubin stones--> hemolytic anemias
    • - Severe pain, nausea, vomiting, refferal inferior border of scapula
    • - Dx: US
    • -Tx: laproscopic removal, lithotripsy, dissolving stone chemically
  39. What were findings for acute cholecystitis?
    • - US
    • - Specificity-->Murphy's sign w. lab of fever w. leukocytosis
    • - ALT, AST, alkaline phosphatase, & bilirubin not sensitive or specific
    • - Dx: US--> specificty 80% & sensitivity 88%
  40. What are the associated findings and information about Hepatitis?
    • - Viral infection, meds, alcohol
    • - A, B, C types
    • - MIld symptoms with A--> resolve w. jaundice
    • - A--> contaminated food, water
    • -B & C---> blood, saliva, vaginal fluid, contaminated needles, sex
    • - Testing time sensitive
  41. What are the causes and further findings of Epigastric pain?
    Causes: reflux esophagitis, peptic ulcer, pancreatitis

    • - Pain is recurrent, on empty stomach, relief from antacid
    • - pain on full stomach--> worse with recumbency= reflux
    • - Severe pain radiate to back-->hx: alcohol= pancreatitis
    • Tx: antacids + H2 antagonists
  42. Discuss the association of chronic recurrent abdominal pain....
    • - Differentiate--> location, diarrhea, constipation, change in menstrual cycle
    • - Low ab pain w. bouts of diarrhea--> irritable bowel syndrome (IBS)
    • - Diarrhea primary--> IBS
    • - Menstrual cycle association--> sharp pain--> endometriosis + other pelvic pathology
  43. What are findings of IBS?
    • - Constipatin & diarrhea
    • - Decrease in peristaltic activity (contraction of smooth muscle)
    • - Stress + food triggers
    • - Stool w. mucus
    • - Tx: no medical--> herbs + diet
  44. What are the findings of Inflammatory Bowel Disease (IBD)?
    • - Crohns + Ulcerative colitis
    • - HLA B-27 w. some peripheral joint pain
    • - Crohns= transmural involvement of small intestine, skip lesions
    • - UC= superficial w. heavy bout diarrhea
  45. What are the findings w. Dysmenorrhea?
    • - Primary & secondary
    • - Primary: baseline, normal discomfort w. period
    • - Secondary: abnormal structure, sharp increase of pain
    • - MC--> endometriosis
    • -DX: US, MRI, surgical
  46. What are the findings of Diverticulitis?
    • - Herniation of mucosa/submucosa into colonic muscle wall
    • - Primarily--> Western society, 1/3 over 60, lack fiber
    • - Low abdominal pain, low grade fever, bloody stool, leukocytosis
    • - Hospitalization for acute cases
  47. What are the two major mechanisms of Diarrhea?
    Osmotic: non-digested material like lactose, sorbital, manitol, magnesium antacids

    • Secretory: bacteria
    • enteroinvasive--> salmonella, shigella, campylobacter
    • enterotoxic--> staph, e.coli, clostridium
  48. What are findings with Diarrhea?
    • - Fecal leukocytes= enteroinvasive
    • - Viral: adenovirus, rotavirus
    • - Dysentry & Giardia
    • - Chronic diarrhea= lab for blood, cysts
    • - IBS
    • - Non-bloody--> antobiotics, drugs, malabsorption, endocrine, IBS
  49. What are the two mechanisms that are invovled with constipation, discuss both?
    - Ineffective filling--> diabetes, drugs, GI disease

    - Ineffective emptying--> from learning habit, local pathology w. painful defecation

    - Common--> low back ptnt
  50. Discuss dysfunctional voiding...
    - Bladder body contracts w. parasympathetic activity--> beta-adrenergic stimulation causes detrusor relaxation & alpha-adrenergic stimulation--> baldder neck tightening

    • - Voiding in senior--> bladder capacity, elasticity, loss cortical inhibition
    • - Young--> void fluid before 9pm
    • -Old--> void after 9pm
  51. What are the findings associated with irratative bladder dysfunctional voiding?
    -Infection/ neurologic: dysuria, nocturia, urgency
  52. What are the associated findings of obstructive bladder in dysfunctional voiding?
    • - Prostate
    • - Congenital --> children
    • - Drugs
    • - Signs: dribbling, minor stream, hesitancy
  53. What are the four relations of urinary incontinence & discuss each..?
    Stress incontinence--> pelvic floor laxity--> hormone change, drugs, obesity, coughing

    Urgency incontinence--> infection, inflammation, neurologic cause

    Overflow incontinence--> obstruction

    Total Incontinence--> neurologic pathology (cauda equina)
  54. What is detrusor instability?
    -Unstable bladder
  55. What are the 3 types of Vaginal discharges?
    - Gardnerella

    - Trichamonis

    - Candida
  56. Discuss the 3 types of Vaginal discharges...
    Gardnerella- 50-60% watery, gray, foul smelling, tx: flagyl

    Trichamonis: high vaginal pH, fould smelling, pelvic exam--> strawberry cervix, Tx: flagyl

    Candida: diabetes, antibiotics, corticosteroids, extreme pruritis w. scant discharge & curd like, TX; OTC (chlortrimazole)
  57. What are the five stages of Vaginal bleeding?
    • 1. pre-menarchial
    • 2. Menarche
    • 3. Reproductive years
    • 4. Peri-menopausal
    • 5. Menopause
  58. Discuss the stages of Vaginal bleeding and their significance
    - 1 & 5: abnormal; 1--> abuse & 2--> cancer

    - 2 & 4: normal--> fluctuating hormonal levels

    • - 3: abnormal--> more than 20 days (polymenorrhea)
    • --> Less 42 days (Oligomenorrhea)
    • --> longer than 8 days (menorrhagia)
    • --> between periods bleeding (metrorrhagia)
  59. What are the findings w. ovulatory vaginal bleeding?
    • -regular
    • - crampy
    • - premenstrual s/sx
    • -pelvic pathology
  60. What are the Anovulatory findings w. vaginal bleeding?
    • - Irregular
    • -No prodrome
    • - Painless
    • - Endocrine in nature
  61. What are the different visual dysfunctions and their causes?
    - Loss of central vision--> cataract, retinal detach

    - Loss of peripheral--> glaucooma, retinis pigmentosa

    - Flashes of light--> migraine, vitreoretinal traction

    - Halos--> glaucoma, corneal disease

    - Transient loss vision--> amaurosis fugx, multiple sclerosis, papiledema

    - Diplopia (monocular)--> cataract, refractive error

    -Diplopia (binocular)--> vascular, tumor, myesthenia gravis, multiple sclerosis

    - Distorted vision--> migraine, macular degeneration
  62. What type of test is used to test a persons central visual field?
    - Amsler's grid
  63. WHat are the areas of facial pain?
    • - Neuralgias: trigeminal, glossopharangeal, sphenopalatine ganglion
    • -Sinusitis
    • -Eye
    • -TMJ
    • -Oral cavity
    • -Headache
  64. What are some of the history clues of facial pain?
    • - Neuralgias: Short, sharp, recurrent pains
    • - Sinus pain: deep, dull, change in atmospheric pressure and bend forward
    • -TMJ: Front of ear, open mouth
    • - Dental: chewing, hot/cold, sweet foods
  65. What are the forms of ear complaints?
    - Pain: internal + external

    -Hearing loss

    -Tinnitus
  66. What are the causes of ear pain?
    - Infection: external + internal

    -TMJ

    -Teeth

    -C-spine

    -BAd-fitting glasses
  67. Name the types of questions you would ask for ear pain....
    • - Trauma? (direct or cervical)
    • - S/SX of upper resp. infection?
    • - Dizziness?
    • -Chewing? (dental, tmj)
    • -Neck movement?
    • -Air travel or swimming?
    • - Skin lesions?
  68. What are some associations of hearing loss?
    • - Sudden, gradual, recurrent
    • -Unilateral or bilateral
    • -Dizziness
    • -Hx of meds
    • -Hx of systemic disease
    • -Hx of occupational or enviromental noise
  69. What are some Ototoxic drugs resulting in bilateral hearing loss?
    • - Aminoglycosides
    • - hi-dose erythromycin
    • -NSAIDS
    • -Furosamide (lasix)
    • -Vancomycin
  70. What are some patient Hx clues for hearing problems?
    • - Difficulty with:
    • -->listening on telephone
    • -->following conversation incrowds
    • -->accents or women's voice
    • -->very load seeming sounds unilaterally
  71. What are some tests for hearing loss?
    • - * Whisper test
    • - Audioscope in office to measure loss
    • - Tests to differentiate conductive vs. neural--> Rhine + Weber
    • - Audiologic test
    • -Brainstem evoke resposne
    • - Special imaging
  72. What are some hearing loss disorders?
    • - Presbycusis
    • -Otosclerosis
    • -Congenital
    • -Meniers
    • -Labyrinthitis
    • -Otitis media
    • -Cholesteotoma
    • -Cerumen impact
  73. What are some S/sx to look for in determining Tinnitus?
    • - Localized to an ear or ears &/or it is central
    • -Complain has:
    • --> ringing
    • -->rushing or pulsating
    • -->fluttering (tensor tympany)
    • -->clicking or popping (tmj)
    • * 1/3 of the time can't figure out why
  74. What other tests and checks can you perform to determine Tinnitus?
    - If coomplaint is other than ringing--> determine if objective

    -Use stethoscope--> listen for bruits & murmurs

    -Use two connected stethoscopes--> is it audible to urself?
  75. What are some common causes of Epistaxis?
    • - mild trauma
    • -dry environment
    • -nose picking
    • -constant nose blowing
  76. What are some significant causes of difficulty to control Epistaxis?
    • - hypertension
    • -major trauma
    • -anticoagulant meds
  77. What can you consider if a patient has persistent, recurrent and undiagnosed epistaxis?
    • - Blood dyscrasia
    • - Leukemia
  78. What is difference between anterior bleeding and posterior bleeding of the nose?
    Anterior: most common mild bleeding

    Posterior: profuse and dificult to control
  79. What is some common knowledge of sore throat?
    • - Third most common presenting complaint of primary care
    • -3-4% of all visits
  80. What are some positive findings for strep throat?
    • - Tonsilar exudates
    • -pharyngeal exudates
    • -exposure to strep throat infection in past 2 weeks
  81. What are some negative findings for strep Throat?
    • - Absence of tender cervical lymph nodes
    • -no tonsilar enlargement
    • -no exudate
  82. What is a found conclusion of strep throat?
    - No single element of history or physical exam can sufficiently diagnose or exclude strep throat.
  83. What is known for high risk strep throat patients?
    - Tx: antibiotics
  84. What should be done for patients with moderate risk of strep?
    - recent cough and oral temp. >101= further diagnostic testing--> rapid antigen test or throat culture
  85. What should be recommended for low risk strep patients?
    • - managed symptomatically
    • -likely not to have strep

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