Step 3 Master Pile

EF < 35%

lunate

Typically occurs in young adults with trauma that results in loading of a dorsiflexed wrist

• 1 day = chemical conjunctivitis - observe
• 1 week = Chlamydia infxn - oral erythromycin

• CD4 < 200 - TMP/SMX or dapsone for PCP
• CD4 < 100 - TMP/SMX or dapsone for Toxoplasmosis
• CD4 < 50 - azithromycin or clarithromycin for MAC

cycles of apnea followed by hyperapnea causing waxing & waning tidal volume

used to compensate for changing serum partial pressures of O2 & CO2

strongly associated with CHF, also seen in stroke, TBI, brain tumors, CO poisoning

http://www.bing.com/videos/search?q=Cheyne-Stokes+Breathing&FORM=RESTAB#view=detail&mid=54F2DC1CF3D4C35032AA54F2DC1CF3D4C35032AA

• aka, cluster breathing
• groups of quick and shallow inspirations followed by periods of apnea
• very regular and similar-sized respirations

• occur following damage to the medulla oblongata 2/2 strokes or TBI
• very poor prognosis

http://www.bing.com/videos/search?q=Biot's+Respiration+Video&qpvt=Biot%27s+Respiration+Video&FORM=VDRE#view=detail&mid=C25D95617DE4B70A5F95C25D95617DE4B70A5F95

irregular with variable breaths & pauses

PR prolongation >0.2 sec without skipped QRS complexes caused by increased vagal tone

• Pts are usually asymptomatic
• Does not require treatment

a type of stenosing tenosynovitis

Most commonly affects patients >45yo & is more common in diabetics

• Presents with nodule at the MCP joint if index or ring finger
• Patients complain of the finger "catching" & becoming locked in a flexed position

Usually due to A1 pulley 

Treated conservatively with stretching, splinting & ice followed by corticosteroid injections, eventually surgical release of the A1 pulley.

Protamine sulfate.

Protamine is strongly basic and binds with acidic heparin forming a stable complex that neutralizes anticoagulant activity.  May degrade over time requiring re-dosing. 

• Dose
• within 30min: 1-1.5mg per 100USP of heparin (max 50mg)
• Monitor PTT 5-15min after dose then in 2-8 hrs.

Heparin potentiates antithrombin III activity by inactivating factor Xa and inhibiting the conversion of prothrombin to thrombin.

Heparin toxicity measured by PTT

Deformity in the thoracic or thoracolumbar spine in children causing increased kyphosis in the thoracic or thoracolumbar spine with associated backache and localized changes in the vertebral bodies.

Caused by osteochondrosis of the secondary ossification centers of the vertebral bodies.

Presents at age 13-16 years old in children that are taller and have advanced skeletal versus chronologic age.  Some have disproportionate limb lengths.

Deficiency of hepatic uroporphyrinogen decarboxylase (involved in metabolism of heme)

Most commonly occurs in patients with a history of alcoholism, hepatitis C, smoking, or estrogen use.

Present with chronic blistering on sun-exposed areas that fail to heal properly resulting in erosions and skin hyperpigmentation.

• Labs/Exam
• decreased serum uroporphyrinogen decarboxylase
• elevated serum, urine, & fecal porphyrins
• purple urine on Woods lamp exam

• Treatment
• avoid sunlight, alcohol, excess iron
• low dose antimalarials (hydroxychloroquine, chloroquine)

Autoimmune disorder of the skin caused by autoantibodies directed against adhesion molecules (desmoglein 1 & 3) in the epidermis.

• Presents in 60's
• Painful, fragile blisters in the oropharynx, chest, face, or perineal regions.
• + Nikolsky sign (traction on intact skin causes bullae formation)
• Erosions last for weeks before healing with hyper pigmentation of the skin without scarring.

Diagnosis - Anti-epidermal antibodies (IgG & C3) on immunofluorescence

• Treatment
• Oral prednisone +/- azathioprine or cyclophosphamide

Autoimmune disorder of the skin characterized by autoantibodies to the epidermal basement membrane.

• Presents in patients over 60yo
• Triggering factors = captopril, penacillamine
• Widespread tense blistering most prominent over flexor surfaces and perineal region.
• Plaques turn dark red in 1-3 weeks as vesicles and bullae rapidly appear on their surface
• Itching may be moderate to severe
• (-) Nikolsky sign

Diagnosis - Autoantibodies against hemidesmosomal proteins with IgG and C3 at the basement membrane zone on immunofluorescence

• Treatment
• Oral prednisone

aka Hailey-Hailey disease

• Vesicular lesions and crusting erythematous plaques over the genital area, chest, neck , axilla, and in skin folds (most common)
• Also burning, pruritis, and malodorous drainage from secondary bacterial infection (staph & candida)
• Multiple asymptomatic longitudinal white bands on the fingernails.

• Treatment
• Topical steroids +/- cyclophosphamide or methotrexate (severe cases)

aka transient acantholytic dermatosis

• Benign, self-limited dermatologic condition that appears suddenly as a itchy papular rash over the chest/trunk, may spread to neck, shoulders, and upper thighs
• 1-3mm keratotic papules that are red to brown 

• Patients are usually men in their 40-50s
• Usually a history of heat exposure such as hot tub use, occurs in summer months.

• Diagnosis
• Skin biopsy - acantholysis (separation of cells in the epidermis) & dyskeratosis (changes in epidermal cells)

• Treatment
• Symptomatic, with topical corticosteroids for pruritis.

Rotation - L5 rotates opposite the sacrum

Sidebending - L5 is always in the same direction as the engaged oblique sacral axis

• F/E/N - Neutral when rotation & sidebending are  opposite
• Neutral mechanics (type1) are associated with forward sacral torsions

• increased gonadotropin, estradiol, FSH, LH
• decreased bone mineral density

A gastrinoma of the duodenum or pancreas which causes recurrent ulcers.

• Diagnosis
• 1st test - fasting serum gastrin level, if elevated, then →
• 2nd test - secretin infusion test
• Imaging: Somatostatin-receptor scintigraphy

associated with MEN1

non-tender, palpable gallbladder

a sign of pancreatic cancer

discoloration of the flank

associated with pancreatitis

periumbilical discoloration

associated with pancreatitis

migratory thrombophlebitis

a palpable nodule that bulges into the umbilicus

• may be a sign of metastases of a pelvic or abdominal cancer
• indicates poor prognosis

(aka Burnett's syndrome)

hypercalcemia caused by repeated ingestion of calcium and absorbable alkali

nausea, vomiting, lethargy, altered mental status, depression, fatigue, acute dysrhythmias (QT shortening & PR prolongation)

Named for convexity.  Prominent hump on the right = dextroscoliosis

Etiology - idiopathic, may be a genetic component

Mild = Cobb angle 5-15, Treat with OMT & Konstancin exercises

• Moderate = Cobb angle 20-45, Treat with spinal orthotic bracing (goal is to prevent further progression of the curve, not correct pre-existing curvature)
• - Boston brace: thoraco-lumbo-sacral-orthotic, used for curves in the lumbar or thoraco-lumbar spine
• - Charleston bending brace: indicated for spinal curves of 20-35 with the apex of the curve below the shoulder blade; bends the patient toward the convexity of their curve overnight
• - Providence brace: used for lower thoracic or thoraco-lumbar curves, worn at night
• - Wilmington brace: used for lumbar or thoraco-lumbar curves, made from light weight plastic and designed as a "body jacket"
• - Milwaukee brace: cervico-thoraco-lumbo-sacral-orthosis, indicated to treat high thoracic curves.

Severe = Cobb angle >50, Treat with surgery (Harrington rod placement, Cotrel-Dubousset system, Texas Scottish Rite Hospital system, Zielke system)

Risk factors for scoliotic curve progression = female gender, primarily thoracic curves, larger initial curve magnitude, skeletal immaturity (Risser sign)

Thickening of the tendons of the extensor pollicis brevis and abductor pollicis longus due to repetitive or acute trauma



Seen in new parents who are lifting children in a repetitive manner.

• Diagnosed with Finkelstein's Test:
• Ask the patient to hold their thumb inside their palm.  The physician then ulnar deviates the hand.  Pain over the extensor pollicis brevis and abductor pollicis longus tendons is a positive test.

• Treatment
• Avoiding exacerbating activities &
• Injection of corticosteroid into the sheath of the first dorsal compartment

• Allen's Test - collateral circulation for a-line.
• Ask the patient to hold a tight fist for 30 seconds.  The physician then applies pressure to both radial and ulnar arteries.  Next the patient is instructed to open their hand.  The physician then releases the ulnar artery.  If the blood flows to the patient's pallored hand in less than 10 seconds, then collateral circulation through the ulnar artery is considered intact.

• Phalen's Test - carpal tunnel syndrome
• Flex the patient's wrist against each other for one minute (reverse prayer sign).  A positive test causes parasthesias in the distribution of the median nerve (thumb, index, middle, 1/2 ring fingers)

• Finkelstein's Test - DeQuervain's Tenosynovitis
• Ask the patient to hold their thumb inside their palm.  The physician then ulnar deviates the hand.  Pain over the extensor pollicis brevis and abductor pollicis longus tendons is a positive test.

• Tinel's Test - carpal tunnel syndrome
• Use a reflex hammer over the carpal tunnel of the wrist.  Paresthesias in the distribution of the median nerve is a positive result. 

• Adson's Test - thoracic outlet syndrome
• Palpate the radial pulse while moving the upper extremity through its range of motion and asking the patient to rotate their head toward the involved side while taking a deep breath and holding it.  An absent or weakened pulse is a positive test.

• Hawkin's test - supraspinatus & infraspinatus impingement in the subacromial joint space
• Patient's arm is passively brought to 90 degrees with the forearm flexed and then internally rotated.  Reproduction of shoulder pain is a positive test.

• Apley's test - glenohumeral joint ROM
• Pt instructed to actively reach behind their lower back then behind their head, ROM from one side is compared to the other

• Drop Arm test - rotator cuff tendon tear
• Pt's shoulder is passively abducted to 90 degrees, the patient is then instructed to slowly lower the arm to their side.  Inability to slowly return the arm to neutral against gravity (arm drops) is a positive test

• Speeds test - proximal bicipital tendonitis
• Pt's arm is extended and forearm is extended & supinated, the patient actively flexes the arm at the shoulder against resistance.  Reproduction of shoulder pain or palpable tendon subluxation from the bicipital groove is a positive test.

• Empty Can test (supraspinatus strength test) - rotator cuff impingement, tear, or tendonitits
• Pt's arm is passively flexed to 90 degrees, slightly abducted and fully internally rotated, then pt is asked to maintain that position against downward resistance.

• FABERE test - sacroiliac joint dysfunction/hip pathology
• Pt is supine, leg is passively flexed, abducted and externally rotated at the hip, then the examiner places a downward force to achieve extension.  Reproduction of groin pain prior to hip extension = primary hip pathology.  Reproduction of posterior hip pain with forced extension = SI dysfunction

• Lachman test - ACL laxity/tear
• Pt lies supine, knee flexed to 30 degrees.  Examiner applies anterior force to the posterior aspect of the patient's leg.  Increased mobility is a positive test.

• Thomas test - hip flexion contracture
• Pt lies supine, one hip is flexed fully to reduce lumbar lordosis while the contralateral hip is extended.  If that hip cannot be fully extended then a hip flexion contracture is present.

• McMurray test - postero-medial meniscus injury
• Pt lies supine, knee is flexed to 90 degrees, one hand along the knee joint line and the other holds the calcaneus.  The leg is then externally rotated while the knee is extended through a full ROM.  Pain or crepitus along the medial joint line is a positive test.  (assess the lateral meniscus by internally rotating while extending; pain or "click" is a positive test)

• O'Brien's test - labral tear
• Pt's arm is passively flexed to 90 degrees, slightly adducted & fully internally rotated.  The pt is then asked to resist a downward force on the arm.  The arm is then fully externally rotated and the pt is asked to resist a downward force on the arm.  Pain with downward force in internal rotation that is relieved in external rotation is a positive test.

• Yergason's test - proximal bicipital tendonitis & bicipital tendon stability within the bicipital groove.
• Pt's forearm is flexed to 90 degrees and fully pronated with shoulder in neutral.  Pt instructed to supinate against resistance.  Reproduction of shoulder pain or palpable tendon subluxation from the bicipital groove is a positive test.

results from micro tears in the extensor muscles, primarily extensor carpi radialis brevis

lateral elbow pain can be reproduced with restricted wrist extension

occurs in association with activities that involve grasping the hand and twisting at the elbow (using a screwdriver or racket sports)

• Treatment
• rest, activity modification, oral NSAID's, or corticosteroid injections
• surgical debridement for refractory cases

Torsion - 1 AP axis (greater wing of sphenoid asymmetry)

Vertical Strain - 2 horizontal axes

Lateral Strain - 2 vertical axes (parallelogram)

Sidebending Rotation - 2 vertical & 1 AP

Pronation - radial head moves posteriorly

Supination - radial head moves anteriorly

• Rib 2 - posterior scalene
• Ribs 3-5 pectoralis minor
• Ribs 6-9 - serratus anterior
• Ribs 10-11 - latissimus dorsi
• Rib 12 - quadratus lumborum