We're here to provide you short & sweet PANCE review to help you PASS your exam. Today we'll be covering symptoms, diagnosis, and management of inflammatory bowel disease, appendicitis, diverticular disease, IBS, and more. For a complete copy of the show notes including today's take away points, please visit https://pastudysesh.blubrry.net/bowelpart2

We're here to provide you short & sweet PANCE review to help you PASS your exam. Today we'll be covering symptoms, diagnosis, and management of bowel obstruction, intussusception, colon cancer, and Hirschsprung Disease. For a complete copy of the show notes including today's take away points, please visit https://pastudysesh.blubrry.net/bowelobstruction

We're here to provide you short & sweet PANCE review to help you PASS your exam. Today we'll be covering symptoms, diagnosis, and management PUD, gastritis, gastric neoplasms, and pyloric stenosis. For a complete copy of the show notes including today's take away points, please visit https://pastudysesh.blubrry.net/stomach

As always, we're here to provide you with the key blueprint information to help you PASS your PANCE. For full show notes, including my mnemonics and Take Away Points, please visit: https://pastudysesh.blubrry.net/esophagus

So you're procrastinating studying for the PANCE by scrolling through your Facebook Feed and there it is, another "Happy to announce that I'll be working for ______ as a PA!" post. As graduation inches closer, it seems to be all there is. You want to be happy for your classmates, but what you're really thinking is: why can't I find a job?. I want to share with you my experiencing in finding my first job after graduation and assure you that you are not alone in this feeling and that everything will be ok.

https://pastudysesh.blubrry.net/?p=185&preview=true

As always, we're here to provide you with the key blueprint information to help you PASS your PANCE. For full show notes, including my mnemonics and Take Away Points, please visit: https://pastudysesh.blubrry.net/carditis

Disclaimer: new guidelines as of late 2017
Unlikely to be reflected on PANCE yet.
New BP Guidelines:
Elevated: 120-129/< 80
Stage 1: 130-139/80-89
Stage 2: 140+/90+
Hypertensive crisis: 180+/120+ with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
Medication for Stage 1 only if high ASCVD risk (same calculator used in prescribing statins)
 
Now Back to the PANCE:
Hypertension

*  Definition

* Prehypertension 120-139/80-89
* Stage 1 140-159/90-99
* Stage 2 160+/100+
* Urgency 180+/120+ & NO end organ damage
* Emergency 180+/120+ & end organ damage (HERB)
* ON 2 DIFFERENT READINGS


* Symptoms

* Primary Hypertension is typically asymptomatic
* Hypertensive emergency

* Encephalopathy
* Intracranial hemorrhage
* Nephropathy
* Unstable angina/MI
* Papilledema=malignant hypertension




* Treatment (non-urgent/emergent)

* Lifestyle Modifications 1stALWAYS (Including those with Pre-HTN)

* DASH Diet
* Lower Sodium
* Exercise
* Healthy weight
* Smoking Cessation


* Medication Therapy

* Begin at 140/90 (this is also BP goal)

* Unless

* Over age 60
* Normal Kidneys
* No Diabetes
* Then 150/90




* Which med?

* 4 Main Classes to Choose From

* ACE Inhibitor

* Angiotensin converting Enzyme
* -“pril”
* Side Effects:

* Cough
* Hyperkalemia
* Angioedema


* Contraindications:

* Renal artery stenosis
* Pregnancy




* ARB

* Angiotensin II Receptor Blocker
* -“sartan”
* Side Effects:

* Hyperkalemia
* Angioedema


* Contraindications:

* Renal Artery Stenosis
* Pregnancy




* Calcium Channel Blocker

* -“dipine”

* More effective as vasodilators than verapamil and diltiazem


* Side Effects:

* Cardiac depression

* Still have some cardiac effects






* Thiazide Diuretic (HCTZ)

* Side Effects:

* Hypokalemia
* Gout
* Dyslipidemia


* Contraindication:

* Sulfa Allergy




* How to choose?

* If they have CKD or DM

* ACE/ARB (Renal Protective)


* African American

* TZD or CCB


* None of the above?

* Then just pick one!


* You can max out the dose before adding a 2ndor add a 2ndif goal isn’t met, doesn’t matter
* NEVER MIX AN ACE AND AN ARB

* Both inhibit the RAAS

* Renin angiotensin aldosterone system


* So at most, they’ll be on ACT


* Other possible additions

* Beta blockers “olols”

* fib
* Post MI
* Stable Angina
* Heart failure


* Alpha blockers “zosin”

* Pts with BPH


* Pregnant? Use Methyldopa




* Resistant to medication? Consider secondary hypertension

* Renal artery stenosis
* Coarctation of the Aorta (think Peds)
* Sleep Apnea
* Pheochromocytoma
* Primary Hyperaldosteronism
* Thyroid disease


* Treatment

* Urgency

* Decrease by 25% over 24-48 hours

* Rest in a quiet room

This episode is less about boards, more about being thorough and thinking about how to process an EKG systemically in order to not miss something. For boards, it’s ok to jump to what is glaring at you. No questions or take away points associated with this podcast.
As promised, here is my EKG Cheatsheet!
Evidence of a pacemaker?

* Failure to capture

* Heart doesn’t “capture” signal

* Pacemaker spike, but no P wave




* Failure to Pace/Oversensing

* Pacemaker is over sensing electrical activity

* HR is slow, pacemaker isn’t initiating beats




* Failure to sense

* Pacemaker ISN’T sensing natural heart activity

* sends unnecessary spikes





EKG Interpretation
1 box=0.04s wide x 1mm high

* Rate=how fast

* 6 second strip*10

* can be used for regular or irregular rhythms


* May also use 300-150-100-75-60-50 method

* Refers to # of large boxes in between R waves

* 1 large box=300bpm, 2 large boxes=150bpm


* Rhythm MUST be regular


* Tachycardia is ALWAYS tachycardia (>100bpm)

* regardless of sinus, junctional, or ventricular tachycardia

* Sinus

* Bradycardia >60
* Normal 60-100bpm


* Junctional

* Escape 40-60bpm
* Accelerated Junctional 60-100bpm


* Ventricular

* Idioventricular 20-40bpm
* Accelerated Ventricular 40-100bpm








* Rhythm=pattern

* normal=atria, junction, ventricals
* 1. Should be able to march caliper along R-R intervals without adjustments

* If no, we already know the rhythm is irregular


* 2.  Do we have distinct P waves?

* No?

* Junctional rhythm?

* inverted or absent p waves
* normal QRS complex
* non-compensatory pause


* Ventricular rhythm?

* absent p waves
* wide-bizarre complex
* pre-mature ventricular contraction with compensatory pause


* A fib?


* Yes? Does each P have a QRS?

* No?

* A flutter
* 2nd/3rd degree heart blocks






* 3. Determine if regularly irregular or irregularly irregular.


* P wave

* Normal=2.5×2.5 boxes
* Represents atrial depolarization
* Too wide? (3 boxes)

* Left atrial enlargement
* May also be M shaped
* Left is LONG


* Too tall? (3 boxes)

* Right atrial enlargement




* PR Interval

* Normal= 0.12-0.2s (3-5 boxes)
* Too long?

* Consistent=1st degree heart block
* Inconsistent= 2nd degree heart block (Type 1 or 2)


* Too short? = Pre-Excitation Disorder

* Wolf-Parkinson-White

* Also has delta wave


* Lown-Ganong-Levine




* QRS Complex

* Normal = less than 0.12s (3 boxes)
* Too wide?

* Bundle branch block

* Left

* Deep S in V1 (carrot)
* Broad R in v6


* Right

* RsR’ in v1 (rabbit ears)
* Wide S in v6




* Ventricular rhythm

* Wide, bizarre complex with no p wave




* Height?

* Right ventricular hypertrophy

On this week’s episode, we will be attacking heart failure and finishing off cardiomyopathies. Check out the congenital heart disease episode for information regarding hypertrophic cardiomyopathy here.
Heart Failure

* Systolic vs diastolic

* Systolic #1

* Heart isn’t strong enough to pump blood
* Decreased ejection fraction (aka HFrEF)
* Thin ventricular walls
* Dilated ventricles
* + S3 (passive ventricular filling)
* Etiologies

* s/p MI
* dilated cardiomyopathy
* valvular disorders




* Diastolic

* Heart can’t relax enough to allow chambers to fill
* Normal or increased ejection fraction (HFpEF)
* Thick ventricular walls
* Small VL chamber (small volume)
* + S4 (forced atrial contraction into stiff ventricle)
* Etio:

* HTN
* LVH




* Left vs Right

* Left

* #1 causes are CAD & HTN
* Symptoms

* Remember that left side of the heart takes blood from the lungs and pumps it to the body.

* Slow down that pump=fluid backs into the lungs


* Dyspnea
* Increased pulmonary venous pressure
* Pulmonary congestion

* Rales
* Rhonchi
* Orthopnea (how many pillows??)
* Paroxysmal nocturnal dyspnea (wake up gasping for air)
* Chronic, non-productive cough

* PINK, FROTHY SPUTUM


* CHF=#1 cause of transudative pleural effusions


* HTN
* Cheyne-Stokes breathing

* Deep/fast breathing with periods of apnea


* S3/S4 depending on systolic or diastolic
* Picmonic




* Right

* #1 cause =left

* Right side is the “gentler” side of the heart
* Right side of the heart can’t work against the increased pressure created in the lungs


* Right side takes blood from body to lungs

* Slow it down=fluid backs into body
* Peripheral edema

* Pitting edema
* JVD
* GI/hepatic congestion

* Hepatosplenomegaly
* Many other GI symptoms

* Imagine you’re full.






* Picmonic






* Diagnosis



* Echocardiogram #1

* Measures ventricular function & EF

* Normal EF =55-60%
* <35% need for defibrillator placement




* CXR

* Pleural Effusions (#1 cause of transudative effusion)
* Kerley B lines
* Butterfly pattern infiltrates


* B-type natriuretic peptide or brain natriuretic peptide (BNP)

* Released by ventricles during volume overload

* >100=CHF likely








* Management

* Acute (aka decompensated or congestive)

* LMNOP
* Lasix (loop diuretic)
* Morphine
* Nitrates
* Oxygen
* Position (upright decreases venous return)
* Maybe digoxin


* Chronic Systolic

* SWABD
* Sodium <2g/d
* Water <2L
* ACE/ARB 1stLine!

On this week’s episode, we’ll be discussing vascular disorders. Please note that we’ll be discussing arteriovenous malformations in the neurology chapter.
Peripheral artery disease
PAD Picmonic Here!

* Pain in lower extremities increased with exercise, relieved with rest

* Called claudication
* Imagine angina for the legs


* Most commonly in the calf
* Physical exam

* Decreased pulses
* Decreased cap refill
* Atrophic skin changes

* Thin/shiny skin
* Hair loss
* Cool limbs


* Pale on elevation, dusky red with dependency (dependent rubor)
* Lateral malleolar ulcers with well-defined borders

* No artery on the lateral side




* Diagnosis

* Ankle-Brachial Index

* Ratio of BP at ankle compared to arm
* Lower BP in ankle=less blood flow=lower index
* Screening tool
* + if ABI <0.9


* Arteriography

* Gold Standard (because it SHOWS us occlusion)

* Usually only done in practice if revascularization planned






* Management

* Platelet inhibitors

* Cilostazol

* Useful for intermittent claudication


* ASA
* Clodpidogrel


* Exercise!
* Revascularization

* Angioplasty
* Fem-pop bypass





Acute Arterial Embolism

* Can be a complication of PAD
* Thrombus=originates at that spot embolus=originates elsewhere, then lodges
* 6Ps

* Paresthesias
* Pain
* Pallor
* Pulselessness
* Paralysis
* Poikilothermia


* Same as the 6Ps of compartment syndrome!

* Except these patients complain of paresthesias first (and different risk factors)
* “Cut off your circulation”=numb and tingly

* Compartment syndrome=squeeze tightly (like with a cast)=painful


* Tx: Heparin, Thrombolytics if thrombus, embolectomy if needed.



AAA

* >3.0cm
* Most often occurs infrarenally
* Risk Factors:

* Atherosclerosis #1
* Age >60
* Smoking!
* Male
* Connective tissue disorders


* Laplace’s law: larger aneurysms expand more quickly
* Symptoms:

* Often none
* Tender, pulsatile abdominal mass
* Rupture: severe back/abdominal pain, syncope, hypotension


* Diagnosis:

* Abdominal ultrasound

* Initial study of choice
* Used for monitoring (discussing in a minute)


* CT:

* thoracic aneurysms
* pre-surgical planning


* Angiography

* Gold standard (again, shows us a picture)




* Management:

* Beta blockers to decrease rupture risk
* 3-4cm: ultrasound Q1year
* 4-4.5cm: u/s Q6months
* >4.5cm: referral to vascular surgeon
* >5.5 cm or >0.5cm growth in 6 months: immediate surgical repair



Aortic Dissection

* Tear in the intima layer of the aorta

* Creates a false lumen


* Most often ascending (aortic highsections)

* Most fatal


* Risk Factors

* Hypertension
* Age 50-60
* Connective tissue disorders may present younger


* Symptoms:

Coronary Artery Disease

* Atherosclerosis #1 cause

* Fatty streak formation: lipid deposition in white blood cells=1ststep
* Risk Factors:

* Diabetes
* Smoking
* Hyperlipidemia
* HTN
* Male
* Age (>45 men >55 women)
* Family Hx





Stable Angina
Check out the Stable Angina Picmonic!

* Chest pain

* Substernal
* Poorly localized
* Exertional
* Radiation to arm, teeth, lower jaw
* Typically 1-5 minutes, but less than 30 by definition
* Relieved with rest or nitroglycerin


* Levine’s sign

* Clenched fist over chest


* Dx:

* EKG: ST depression, but normal in 50%
* Stress Testing:

* EKG

* + ST depressions


* Echo

* Used in pts with baseline EKG abnormalities

* Helps localize ischemia


* Pharmacologic therapy used with exercise contraindicated
* Pharmacologic=dobutamine

* Increase force of heart contractions
* Increases O2 demand






* Myocardial Perfusion Imaging

* Localizes Ischemia
* Pharmacologic=adenosine or dipyridamole

* Vasodilate normal arteries
* CI: asthmatics




* Coronary Angiogram

* GOLD STANDARD

* Gold standards are usually the test that gives us a definitive picture.


* Defines anatomy=definitive diagnosis




* Tx:

* Statin Therapy

* Helps stabilize lipid plaques
* MI is typically caused from plaque rupture vs occlusion


* Nitrates

* Venodilator (increases supply)
* Caution with use of PDE-5 inhibitors (sildenafil)
* Used for acute pain
* Advised to go to ER if used 3 doses (Q 5min)


* B blockers

* Used for daily, chronic management

* Reduces demand (negative chronotrope/inotrope)




* CCB

* Non-dihydropyridines (verapamil/diltiazem)
* Decrease vasospasm (increase supply)
* Decreases heart rate & contractility (decreases demand)
* For those who B blockers are contraindicated


* ASA

* Doesn’t address supply/demand

* Helps with platelet aggregation to prevent ACS







Unstable Angina

* Chest pain>30 minutes
* Negative cardiac enzymes

NSTEMI

* Chest pain >30 minutes
* Positive cardiac enzymes

* 3 sets Q8hours
* Creatinine Kinase (muscle breakdown marker)
* Troponin (most sensitive & specific)


* Negative

* Unstable Angina


* Treatment for Unstable Angina & NSTEMI is the same

* MONA
* Bblockers
* Heparin



STEMI

* ST elevations greater than 1 mm

* 2 contiguous leads
* May have reciprocal changes in opposite leads
* New LBB is STEMI equivalent (Carrot in V1)


* Anterior=V1-V4

* Left Anterior Descending


* Lateral= I, aVL, V5,V6

* Circumflex


* Anterolateral=I, aVL, V4-V6
* Inferior= II, III, aVF

* Right coronary artery


* Posterior Wall=V1-V2

* ST DEPRESSIONS

Heart murmurs continue with congenital heart diseases.
A Picmonic is available for EVERY topic in today’s episode. Start by checking out our first topic here.
Ventricular Septal Defect

* #1 type of congenital heart disease
* Loud, high-pitched harsh, holosystolic murmur at LLSB
* Typically a left to right shunt (restrictive)

* May switch to right to left 2/2 pulmonary HTN (non-restrictive)

* “Eisenmenger’s syndrome”


* Dx: echocardiogram
* Tx:

* Observe if small

* Most close by age 10


* Surgery

* Symptomatic
* CHF
* Growth Delay
* Large VSDs repaired by age 2







Atrial Septal Defect

* Ostium secundum fails to close
* Often asymptomatic until >30y.o.
* Systolic ejection crescendo-decrescendo flow murmur @ pulmonic area (Left sternal border)

* Mimics pulmonic stenosis


* Widely split, fixed s2

* Does not vary with inspiration

* It’s not on either side of the heart


* Surgery if symptomatic



Coarctation of the aorta

* Narrowing of descending thoracic aorta
* Males>females
* 70% also have bicuspid aortic valve
* Symptoms

* Systolic murmur that radiates to the back/scapula/chest
* HTN (secondary)
* BP upper>lower extremities
* Delayed/weak femoral pulses


* Diagnosis

* Angiogram=gold standard
* CXR:

* Rib notching

* Increased flow in intercostal aa.


* 3 sign

* Narrowed aorta looks like the notch of a 3


* Tx: surgical





Patent Ductus Arteriosus (PDA)

* Connection between descending thoracic aorta & pulmonary artery
* Continuous, machinery murmur loudest @ pulmonic area
* Wide pulse pressure, bounding peripheral pulses
* Dx: echocardiogram
* Tx: indomethacin

* Inhibits prostaglandin production=closes PDA



Hypertrophic Cardiomyopathy

* Subaortic outflow obstruction secondary to hypertrophied septum
* Harsh, systolic, crescendo-decrescendo murmur at LLSB (similar to AS)

* DECREASES with INCREASED venous return

* Squatting, lying supine, etc
* Increased blood pushes septum out of the way


* INCREASES WITH DECREASED VENOUS RETURN

* Valsalva/standing


* Symptoms:

* Dyspnea usually 1st
* Chest pain
* Sudden cardiac death

* Especially during extreme exertion

* Secondary to v fib.


* Dx: echocardiogram
* Management:

* Avoid dehydration & extreme exertion
* B blockers 1st line medical

* Increases diastolic filling time


* Caution with digoxin, nitrates, and diuretics
* Surgical: myomectomy or alcohol septal ablation









Tetralogy of Fallot

* #1 cyanotic congenital heart disease
* Definition

* RV hypertrophy
* Rv outflow obstruction

* Pulmonary artery stenosis


* Overriding aorta
* VSD


* Right to left shunt=cyanotic

* “tet spells”

* Episodes of cyanosis
* Relieved by squatting


* Harsh,

During this week’s episode, we’ll be discussing valvular disorders, in essence, heart murmurs.
There are LOADS of Picmonics available for heart murmurs. A couple of my favorites Mitral Regurgitation and Aortic Stenosis.
Systole=ventricles contracting
Diastole=ventricles relaxing & refilling
S1=beginning of systole. AV valves (mitral & tricuspid) are closing. “lub”
S2=end of systole. Semilunar valves closing (aortic & pulmonic) “dub”
Lub, dub, rest, lub, dub, rest
 
Murmur Accentuation Maneuvers
The following applies to all murmurs except that of hypertrophic cardiomyopathy, in which the opposite is true

* Position:

* Aortic=increased with leaning forward
* Mitral=LLD


* Increased venous return

* Squatting
* Leg raise
* Lying down
* Later click in MVP


* Inspiration

* Right sided murmurs only

* Also due to increased venous return


* Expiration

* Left sided murmurs only

* Also due to increased venous return


* Increased Afterload

* Handgrip
* Increases regurgitation murmurs

* Pushes backward









Aortic Stenosis

* #1 valvular disease
* Etiologies:

* Calcification
* Bicuspid valve (if under 70y.o.)


* Systolic, crescendo-descrescendo ejection murmur

* At right upper sternal border (the location of the aortic valve)
* With radiation to the carotids


* Narrowed pulse pressure
* Pulsus parvus et tardus

* Small, delayed, carotid pulse
* Not specific to aortic stenosis


* Can lead to angina, syncope, LVH, and CHF
* Tx:

* VALVE REPLACEMENT

* Once symptomatic
* Mechanical valves (vs bioprosthetic) require lifelong anticoagulation





Mitral Stenosis

* Etio: rheumatic heart disease
* Early mid-diastolic rumble preceded by an opening snap

* At apex (location of mitral valve)
* Increased in left lateral decubitus position
* Prominent S1 (stenotic mitral valve closes forcefully)


* Symptoms

* Pulmonary symptoms

* Blood backs into lungs
* Pulmonary htn


* Atrial fibrillation

* 2/2 atrial enlargement


* “mitral facies”

* Flushed cheeks with facial pallor


* Treatment:

* Percutaneous balloon valvuloplasty

* Younger patients
* Non-calcified valves


* Valve replacement otherwise





Mitral Regurgitation

* Etio:

* mitral valve prolapse #1
* papillary muscle dysfunction

* ischemia/infarction


* Blowing, holosystolic murmur

* At Apex (location of mitral valve)
* Radiation to axilla
* Blowing=regurg
* Widely split S2

* Aortic valve closes early due to decreased LV ejection time
* Pulmonic valve closes late due to pulmonary htn (increased pressure to overcome)

This week on PA Study Sesh we are starting the cardio chapter and discussing conduction disorders.
Sinus Arrhythmia

* Appears as normal sinus rhythm, but rhythm is irregular
* Normal variant
* INcreases during INspiration

Sinus Bradycardia

* <60BPM
* #1cause=vagal stimulation=increased acetylcholine (increased parasympathetic activity)
* Tx: Atropine (anticholinergic)

Sinus Tachycardia

* >100BPM
* Tx: Vagal maneuvers, adenosine, bblockers, CCB, Digoxin (ABCDs)

Sick-Sinus Syndrome

* Combo of sinus arrest with paroxysms of tachy & brady arrhythmias

* TX: permament pacemaker if symptomatic

* If V-tach=with automatic implanatable cardioverter-defibrillator





Premature Atrial Contraction (PAC)



* Abnormal P wave followed by QRS

* May be unifocal or multifocal


* Non-compensatory pause

* Next normal p wave is not where expected


* Usually benign, though may increase risk of arrhythmias if combined with other heart abnormalities.



Atrial flutter

* “saw tooth” waves
* Tx:

* Stable: vagal maneuvers, b-blockers, ccbs
* Unstable: synchronized cardioversion
* Definitive= ablation



Atrial fibrillation

* #1 chronic arrhythmia
* Irregularly irregular with narrow QRS

* No distinct P waves


* Loads of causes

* Often associated with hyperthyroid
* Also atrial enlargement


* Increased risk of clots (blood isn’t moving properly out of atria)
* Tx:

* Stable: rate control

* B blockers #1: metoprolol
* CCBs: Diltiazem or Verapamil (nondihydropyridines)
* Digoxin if hypotensive or CHF


* Unstable:

* Synchronized cardioversion




* Management:
* Anticoagulation

* Factor Xa inhibitors

* “Xabans”
* Bind to antithrombin III


* Dabigatran

* Direct thrombin inhibitor


* Warfarin

* If other drugs contraindicated







* Dual anti-platelet therapy

* Aspirin + Clopidogrel
* Less effective than anticoagulant monotherapy



Paroxysmal Supraventricular Tachycardia (PSVT)

* 2 types

* AV nodal reentry #1

* 2 paths within AV node (one slow & one fast)


* Av reciprocating

* Accessory pathway outside the av node

* Wolff-Parkinson White
* Lown-Ganong-Levine Syndrome


* Wide or narrow QRS complex

* Depends on which pathway is taken first


* Wolf-Parkinson White

* Accessory pathway=bundle of Kent

* Ventricles are “pre-excited”

* Can develop tachyarrhyhmias


* EKG:

* Delta wave

* Slurred QRS

* Candle


* Wide QRS
* Short PR Interval


* Management:

* Avoid av nodal blockers because current may preferentially travel down accessory pathway








* Lown-Ganong-Levine Syndrome

* Short PR interval with normal QRS


* Bundle of James


* Management (of all PSVT)

* Narrow complex

* Vagal maneuvers

* =increased acetylcholine=decreased heartrate


* Adenosine#1
* B or CCBs


* Wide Complex

* Amiodarone

This week on PA Study Sesh, we’ll learn about Rheumatology.
A note about ANA, RF, ESR, CRP
ANA: Antinuclear antibodies
Shows antibodies against self
Can be positive in healthy people
Also induced by certain drugs & cancers
NONSPECIFIC
CRP: C-reactive protein
Produced in the early stages of inflammatory process.
NONSPECIFIC
ESR: erythrocyte sedimentation rate “sed rate”
Rate at which rbcs settle
NONSPECIFIC
RF: Rheumatoid Factor
Autoantibody to a fragment of IgG
NONSPECIFIC
 
In Summary: These are all NONSPECIFIC and only clue you in to the presence of inflammation and auto-immune disease. They do not help you definitively distinguish one disease from another and therefore (in my opinion) are not worth memorizing their absence/presence in each disease for PANCE/PANRE purposes.
Fibromyagia

* Chronic, widespread muscle pain
* Middle aged women
* Associated fatigue, fibro fog
* Diffuse pain in 11/18 trigger points >3 months
* Clinical diagnosis
* Tx: exercise (swimming), OTC pain medication, TCA

Reactive Arthritis (Reiter Syndrome)

* Autoimmune response to an infection elsewhere
* Young males most common
* Arthritis, conjunctivitis/uveitis, urethritis
* Keratoderma blenorrhagicum (hyperkeratotic lesions on palms/soles)
* s/p chlamydia #1, may also follow gonorrhea or GI infections
* Labs: Often HLA B-27 + (young males like ankylosing spondylitis)
* Can’t pee, can’t see, can’t climb a (bamboo) tree, can’t sleep with me
* Tx: NSAIDS

* Abx if infection not treated



Gout

* Uric acid
* Most patients are under excretors, which explains why associated with food consumption
* Purine-rich foods, TZD, ACE/ARBs, ASA, Pyrazinamide, Ethambutol (TAPE)
* Men most common
* 1st MTP joint = podagra
* Red, swollen, tender joint
* Arthrocentesis=gold standard

* Negatively birefringent, needle shaped urate crystals


* Tophi: colletion of solid uric acid (ears, eyelids, fingers)
* X-ray

* Rate bite erosions (recurrent)


* Tx:

* Acute: NSAIDS (indomethacin), but avoid ASA

* 2nd line= colchicine


* Chronic:

* Colchicine (can be used in both!)
* Probenecid (uricosuric drug)= increase excretion
* Allopurinol (Xanthine Oxidase Inhibitor)- decreases uric acid production, so not used in acute disease.





Pseudogout

* Calcium pyrophosphate
* Large joints. Knee #1
* Red, swollen, tender joint
* Arthrocentesis:

* Postitively birefringent prism shaped (rhomboid)


* Tx: NSAIDS, steroid injection

* Colchicine also used acute & chronic.

* Prophylaxis if more than 3 attacks per year





Juvenile RA

* AKA juvenile idiopathic arthritis
* Prior to age 16, typically resolves by puberty
* 3 types

* Oligoarticular (50%)

* Less than 5 joints involved in the first 6 months (typically large joints)
* Swollen, tender, warm, without erythema
* May have concomitant anterior uveitis

* Refer to ophthomology


* + ANA
* Symptomatic treatment (NSAIDS)


* Polyarticular (30%)

* Most similar to adult RA

* If in a teenager, consider early RA presentation


* >5 joints involved during 1st 6 months (usually symmetric)
* Eye involvement less common, but possible
* + ANA +/- RF
* TX: NSAIDS
*


* Systemic (20%) Still’s Disease

* Intermittent,

This week on PA Study Sesh, we will talk disorders of the hip as well as a hodgepodge of other orthopedic topics.

* Pelvic Fx:

* High impact or osteoporotic
* CT scan= gold standard
* Tx: pelvic binder & specialist consult


* Hip Fx:

* Osteoporotic women common
* Externally rotated, Abducted,(first 2 are opposite a dislocation) shortened limb: BREAKS
* Groin pain
* Increased risk of avascular necrosis with femoral neck frature
* Increases risk for DVT/PE


* Hip Dislocation:

* Posteriorly #1
* Adducted, internally rotated, shortened

* HIP is HID
* Exact opposite of shoulder


* Risk to sciatic nerve
* Tx: REDUCE (the answer for all dislocations)


* Legg-Calve Perthes

* Idiopathic avascular osteonecrosis of femoral head & epiphysis in children
* Boys 4-10, often active & thin
* Painless limp, worse at end of day
* Decreased abduction and internal rotation
* X-ray

* Early: increased femoral head density, widening of cartilage space
* Advanced: crescent sign (microfx with collapse)


* Tx:

* Non-weightbearing initially

* Ortho referral


* Resolves spontaneously




* SCFE (slipped capitofemoral syndrome)

* Slipped ice cream off cone
* 7-16 obese, African American male (during growth spurt)
* Hip, KNEE, thigh pain with limp
* Increased external rotation (like a hip fx)
* Tx: non-weight bearing + ORIF


* Developmental Dysplasia of the Hip

* Risk factors

* 1st born (less space in the pelvis)
* Female
* Family hx
* Breech


* Physical exam tests

* Barlow

* Apply posterior pressure (since hips dislocate posteriorly)
* += clunk


* Ortolani

* Abduct & Apply anterior pressure
* + = clunk


* Galeazzi (assess for LLD)

* Flex knees with feet on table, ankles touching buttocks
* Affected hip is shortened




* Clinical diagnosis

* Stress U/S at 3-4 weeks
* Femoral head can’t be seen on x-ray until 3-4 months


* Tx:

* Pavlik Harness
* Avoid swaddling
* Avoid tight fitting clothing
* Monitored with U/S




* FAI (femoral acetabular impingement)

* Pain may be dull or sharp groin pain
* Pincer lesion= acetabulum
* Cam lesion = femoral head
* FADIR= most sensitive, may also have + FABER
* Dx: X-rays, MRI to evaluate soft tissues
* Tx: decrease activity, NSAIDS, PT, Surgical referral


* Labral tear

* Dull or sharp groin pain with possible radiation
* Atrauamatic or insidious onset
* Catching/clicking
* FADIR/FABER +
* Test of choice= MRI Arthrogram
* Conservative vs surgical tx


* Snapping Hip

* Snapping/popping with walking, getting up from a chair, swinging leg
* +/- pain
* Caused from iliopsoas tendon movement
* Increased risk in adolescents, athletes with hyperflexion motion (DANCERS)
* TX: conservative


* Greater Trochanteric Pain Syndrome

* Aka trochanteric bursitis
* #1 cause of lateral hip pain in adults
* Tender to palpation
* Increased with walking, stairs, incline, prolonged standing

* Muscles that insert here are responsible for maintaining upright posture & abduction (the rotator cuff of the hip)


* Pain with resisted abduction
* + Trendelenburg sign

This week on PA Study Sesh, we’ll be covering disorders of the spine and demystifying the dermatomes.

* Cauda Equina

* SURGICAL EMERGENCY
* Symptoms

* Urinary/bowel retention/incontinence
* Saddle anesthesia
* Decreased anal sphincter tone (no anal wink)


* Tx: steroids (decrease inflammation) and emergent surgery


* Spinal stenosis (pseudoclaudication)

* Narrowing of spinal canal
* > 60 y.o. (but can be congenital)
* low back + BIL leg pain

* increased with walking/standing (extension)
* Dcreased with sitting/walking uphill (flexion)


* Diagnose with Xray or MRI
* Tx:

* Injections
* PT
* Sy




* Sprain/Strain

* MOI: lifting/twisting (or whiplash)
* Muscle spasms
* Decreased ROM 2/2 pain
* NORMAL NEURO
* Tx:

* Brief rest (1-2 days)
* Nsaids scheduled
* +/- muscle relaxants
* pt for prolonged pain & to improve mechanics
* majority recover by 4 weeks




* Scoliosis

* Females >10 y.o.
* >10 degrees of lateral curvature
* Typically not painful
* 90% are to the right, left curve requires further evaluation
* Look for shoulder or pelvic obliquity & LLD
* Adams forward flexion exam
* Xrays indiciated if scoliometer >5 degrees

* Evaluate Cobb angle


* Tx:

* Observe if small
* Brace at 20 degrees
* Sy greater than 40 degrees




* Kyphosis

* Increased convex curvature of T spine
* 1/3 also have scoliosis
* brace >60


* Spondylolysis

* Repetitive hyperextension injury (gymnasts, football players)
* Defect of pars interarticularis
* #1 form of back pain in children/adolescents
* Most commonly L5-S1
* X ray:

* Scotty dog sign

* Oblique view x ray
* + dog has a collar


* May progress to spondylolisthesis




* Spondylolisthesis

* Vertebrae slips forward
* Possible step off
* >50% displacement = surgical
* Conservative (same for spondylolysis)

* Symptomatic
* PT
* Bracing


* Happens at C2=hangman’s fx


* Jefferson Fracture

* C1 fx (Atlas)
* Burst fx
* Associated with axial loading (shallow dive or certain MVAs)


* Compression fx

* Fall from a height or non-traumatic
* X-ray: vertebral height narrowing
* Risk factors: chronic steroid use, tobacco use, postmenopausal, osteoporosis, low body weight
* Point tenderness


* Ankylosing Spondylitis (ankly=stiff, spondyl=spine, itis=inflammation)

* White males 15-30
* Axial skeleton & SI joint with increasing stiffness

* Progresses from inferior to superior


* AM stiffness with decreased ROM

* Decreases with activity (most autoimmune arthropathies do)


* Labs

* Increased ESR
* + HLA B-27
* Negative ANA & RF (seronegative)


* X ray:

* Bamboo spine (squaring of vertebral bodies)


* Tx:

* NSAIDS
* PT
* TNF alpha blockers






* Herniated Disc

* Herniation of nucleus pulposus
* Most often posterolateral
* Pain in a dermatomal pattern

* Increases with coughing, sitting


* L5-S1#1
* Physical Exam Tests:

* + SLR
* + Crossover Test

This week on PA Study Sesh we will be discussing disorders of the foot and ankle, bone tumors, and compartment syndrome.

* Ankle Dislocation

* Most commonly posteriorly (calcaneus goes posterior)
* Risk to peroneal n

* Sx: foot drop


* Tx: closed reduction & posterior splint


* Ankle Sprain

* MOI: inversion
* Anterior talofibular ligament (ATFL) #1

* Eversion injury = deltoid ligament


* Test= anterior drawer
* X-ray criteria

* Ankle: TTP along medial or lateral malleolus
* Foot: Midfoot tenderness (navicular) or 5th metatarsal TTP
* Unable to weight bear 4 steps following injury or in office
* Are you concerned about a fx? Get an X-ray. 


* Grading

* 1: stretch
* 2: partial
* 3: complete




* Achilles Tendon Rupture

* Major risk factor: fluoroquinolone (“floxacin”) use, recent increase in activity
* Thompson test: weak/absent plantar flexion when the gastroc is squeezed
* Tx: Progressive equinus splinting vs surgical repair.


* Lateral Ankle/Fibula Fx

* Weber Classification

* A: below ankle
* B: even with syndesmosis
* C: above syndesmosis

* Often with medial malleolar fx and deltoid avulsion
* Unstable
* Spiral=concerning
* Called Maisonneuve fx if proximal fibula

* Recall monteggia fx


* Transverse less concerning as usually direct trauma


* Take away: look for syndesmosis injury




* March fx

* Common military stress fracture
* 3rd metatarsal #1


* Plantar Fasciitis

* First step pain
* Tx: Conservative


* Tarsal Tunnel

* Tibial Nerve
* Medial malleolus, heel, sole numbness


* Bunion (Hallux Valgus)

* Risk factors: poorly fitted shoes #1, flat feet (pes planus)
* 1st metatarsal lateral deviation
* tx: wide toe box


* Hammertoe

* Flexion of PIP, hyperxtension of MTP & DIP
* Typically cause pain due to shoe contact


* Charcot Foot

* Joint damage & destruction 2/2 DM neuropathy
* Microtrauma leads to bone resorption & weakness (autonomic dysfunction)
* Redness decreases with elevation
* Midfoot deformity (foot becomes concave)
* Increased ESR, WBC, CRP
* Tx: NWB!!!! Splint & refer. Ultimately will get total contact cast


* Jones fx

* Transverse fx through diaphysis of 5th metatarsal (distal to 4/5 articulation)
* Risk of avascular necrosis
* Tx: boot/cast vs surgery


* Avulsion fx (pseudojones)

* Below 4/5 articulation


* Lisfranc injury

* Disruption of 2nd metatarsal and medial cuneiform articulation
* MOI: Step off a hole
* Plantar ecchymosis
* Fleck sign: fx at base of 2nd metatarsal= pathognomonic
* WEIGHT BEARING XRAYS
* Tx: NWB!! & boot/cast.

* Surgery if any displacement




* Calcaneus fx

* Fall from a height


* Compartment Syndrome

* Most common after long bone fractures

* Crush injuries
* Tight cast


* Pain out of proportion
* 6 Ps- PAIN, pulselessness, poikilothermia, pallor, paresthesia, paralysis,
* Pain on passive stretching = 1st indicator
* Tx: fasciotomy


* Primary Bone Malignancies

* “have sarcoma” in the name
* Present with bone pain
* Night pain= red flag

This week on PA Study Sesh, we will be covering disorders of the knee and proximal tibia.

* Medial and lateral collateral ligament injuries (MCL & LCL)

* MCL=valgus stress LCL= varus stress
* MCL more common than LCL injury
* Grade I & II (sprain & incomplete tear)= conservative
* Grade III (complete) = surgical


* ACL (anterior cruciate ligament) injury

* #1 knee ligament injury
* MOI: pivoting injury, may also be hyperextension
* Females > Males
* May have associated meniscus injury

* Unhappy (O’Donoghue’s) triad: ACL, MCL, medial meniscus tear


* May also have associated lateral tibial condyle avulsion= Segond fx

* Pathognomonic for ACL tear


* Symptoms: swelling +/- hemarthrosis, “buckling”
* Lachman’s test= most sensitive

* Patient supine
* Knee flexed 20-30 degrees
* Stabilize femur and pull tibia forward
* Lack of firm endpoint is positive
* Compare both sides
* Patient needs to be fully relaxed


* Anterior Drawer

* Hip & knee bent to 90
* Stabilize foot (sit on it)
* Thumbs on joint line & pull forward
* + translates anterior without a firm endpoint


* Diagnosis MRI. May consider Xray
* PT vs Surgery (primarily surgical for younger patients)


* PCL (posterior cruciate ligament)

* Dashboard injury

* Anterior force while knees are flexed


* Typically not seen in athletes
* Posterior Drawer Test
* Posterior Sag Sign

* Elevate leg and will see the leg “sag”


* Tx: surgical


* Meniscal Tears

* Medial 3x>>> lateral (lateral is injured less)

* Less mobile & more stress is able to be applied medially


* Degenerative or traumatic (twisting or hyperflexion)
* Joint line pain
* “locking”, popping, giving way
* Difficulty with stairs (up or down) & squats
* McMurray’s Test

* Lots of ways to describe
* Grab heel with one hand and joint line with another
* Medial= externally rotate heel, flex knee, extend while providing valgus stress
* Lateral= internally rotate heel, flex knee, extend while providing varus stress


* Tx: Conservative vs Surgical


* PFPS (patellofemoral pain syndrome) aka chondromalacia

* #1 knee complaint in primary care
* Injury to patellar cartilage
* Commonly seen in runners
* Pain “under” or “behind” patella
* crepitation
* + Long car ride or theatre sign
* Difficulty with stairs
* Look for malignment and improper patellar tracking

* + patellar glide, patellar grind, patellar apprehension. Used to assess mobility and associated pain with patellar movement


* Tx: conservative, NSAIDS, rest, PT


* Patellar Tendonitis

* “jumpers knee”
* Pain of patellar tendon
* Conservative tx


* IT Band Syndrome

* #1 cause of knee pain in runners
* Lateral knee pain
* + Ober Test
* Conservative tx


* Baker’s Cyst

* Pain & swelling with prolonged standing
* May be asymptomatic
* Tx: NSAIDS, Aspiration/Injection, Compression Brace. Surgery rare


* Patellar Fracture

* MOI: direct blow

* extreme contraction of quads [kiddos (patellar sleeve)]


* X-ray: AP, lateral & Sunrise views
* Tx: immobilized in extension. Refer to ortho for cast vs surgery


* Patellar Dislocation

* MOI: Twisting on a flexed knee

This week on PA Study Sesh, we will be finishing the upper extremity.

* Supracondylar fx

* MOI: FOOSH with hyperextended elbow
* Kids 5-10
* X-Ray:

* Normal: anterior humeral line must intersect capitulum (lateral view)

* May still be in alignment with fx


* Fat Pad sign=refer

* Anterior to humerus = sometimes normal
* Posterior to humerus = always abnormal
* Darkness=blood


* Anterior interosseous nerve @ risk (branch of median n)

* “ok” sign (A-ok)

* if not=immediate surgery


* Brachial artery @ risk

* Can lead to Volkmann Ischemic Contracture

* Contracture of wrist 2/2 ischemia










* Radial Head fx



* #1 elbow fx in adults
* MOI: FOOSH
* Xray:

* Often difficult to see
* + fat pad sign


* Unable to fully extend elbow




* Elbow Dislocation

* Rare
* Posterior most common (olecranon goes backwards)
* Often associated with medial condyle fx
* R/o brachial a, median, ulnar, radial n injury
* Tx: emergent reduction, splint/sling


* Nursemaid’s elbow

* Dislocation of radial head, stretched annular ligament

* Annular= ring shaped, radius=circle


* MOI: sudden pull of a pronated arm

* Grabbing from street
* Playing airplane


* Kids 1-4
* Presentation:

* Arm fully extended or slightly flexed and pronated
* REFUSES to use
* Pain increases with supination. Mild tenderness
* Usually no swelling


* Reduction:

* hyperpronation with pressure over radial head
* supination and flexion with pressure over radial head


* Lollipop test
* Imaging after 2 failed reduction of child continues to refuse to use arm.


* Olecranon fx

* Ulnar n at risk


* Olecranon bursitis

* Repetitive trauma or rhematologic conditions
* “goose egg” swelling
* +/- decreased ROM and tenderness
* Erythema and warmth may suggest infection
* Tx:

* Ice
* NSAIDS
* Avoid pressure
* Pads/sleeves




* Lateral epicondylitis

* “tennis elbow”
* extensor/supination muscle group
* local pain and swelling
* pain with wrist extension against resistance (elbow fully extended)


* Medial epicondylitis

* “golfer’s elbow”
* flexors & pronators (golf & flexor both have f)
* pain with wrist flexion against resistance (elbow fully extended0


* Tx: for epicondylitis (both)

* Acute: sling, wrist brace, Ice, NSAIDS
* Preventative: forearm strap
* Recurrent: steroid injections, surgical debridement




* Nightstick fx:

* Ulnar shaft fx
* Defensive injury
* Tx: Cast or ORIF


* Monteggia fx

* Proximal ulnar shaft with radial head dislocation
* May have radial n injury (wrist drop)


* Galeazzi fx

* mid distal radial shaft f x with dislocation of DRUJ


* both Galeazzi & Monteggia are unstable (any joint dislocation)
* TAKE HOME; evaluate elbow and wrist with forearm injury


* Cubital tunnel

* Ulnar nerve compression
* RF/SM tingling/numbness

* Increases with elbow flexion


* Decreased grip strength
* Tinel’s sign:

* Tap groove between olecranon process and medial epicondyle