El repaso gigantesco

Chronic autoimmune connective tissue disorder that usually presents with regional arthralgia/arthritis, joint swelling, fever, weight loss, possible neuro sx., and a butterfly rash

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9:1 female to male - childbearing

\**large assoc. to raynaud’s phenomenon*/anti-coagulability\*

Systemic Lupus Erythematosus

What is the typical arthritis presentation associated with SLE?

Jaccoud’s athropathy (non-erosive misalignment of the joints - ulnar deviation of digits 2-5)

Presentation:

Chronic widespread muscular pain syndrome - four quadrant pain above and below the waist for at least three months with pain felt in 11/18 common tender spots. Pain often affects sleep and is exacerbated even with mild activity.

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Associated with AM stiffness >30 min, fatigue, vision changes, paresthesias possible

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\**more common in females of childbearing age/insidious onset but progresses*\*

Fibromyalgia

What are the two pain categories associated with FMS?

hyperalgesia and allodynia, “migraine of the muscles”

Etiology of FMS?

Thought to be hyper activity of our sympathetic nervous system which results in higher muscle activity

PT intervention for FMS? Avoid ____

LOW intensity/LOW impact aerobics/conditioning

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Avoid eccentrics

Unexplained fatigue (mental or physical) for greater than or equal to six months. Must show 1/3: autonomic, neuroendocrine, or immune manifestations. \**not a single disease, cause is still unknown**

Chronic fatigue syndrome

Progressive destruction of CD4 (lymphocyte) and T-cell mediated immunity that is only transmitted via contaminated blood, intercourse, or maternal to child

Acquired Immune Deficiency Syndrome (HIV)

Aerobic exercise (60-80 HRmax) is safe in what CD4 range?

100-1000

What is the main metabolic clinical manifestation associated with HIV/AIDs pharmacy?

Lipodystrophy (abnormal distribution of adipose tissue)

Our body’s toxic/extreme response to an infection that is a life threatening emergency. Caused by untreated infections that enter our bloodstream. \*Can also present in the joint\*

Sepsis

Septic shock is associated with _____

extremely low BP

Bacterial infection that causes severe diarrhea and colitis - \**contact precautions, soap/water only*\*

C diff

Bacterial infection that is typically spread via skin to skin contact or from surfaces. MRSA is a type

Staphylococcal (staph) infection

Most common bacterial pathogen of any age that is associated with a sore/red throat, fever, chills, and enlarged lymph nodes

Group A strep

What are the two life threatening emergencies associated with group A strep?

Streptococcal cellulitis and streptococcal necrotizing fasciitis

Bacterial infection that is the leading cause of neonatal pneumonia, meningitis, and sepsis following a vaginal birth

Group B strep

Bacterial infection that invades an incisional site following surgery/trauma that has no blood supply. Presents as dark necrotic tissue with a foul odor/audible crepitus - \**life threatening emergency*\*

gas gangrene

Viral infection that is sexually transmitted primarily in oral mucocutaneous (1) and genital areas (2).

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Dysphagia, fever, vomiting, anterior chest pain, mouth sores/blisters are common.

Herpes simplex (HSV 1 =oral, HSV = genital)

Presentation:

* Latent virus that causes chicken pox (normally kids) and shingles (painful rash/blisters along the face - ***V1*** or torso - **T3-L3** dermatome).
* Pain is often unilateral with shooting pain/paresthesias followed by a rash that lasts up to **14 days.**
* Pain is often accompanied by flu-like symptoms.
* \**Immunocompromised/previous varicella exposure= risk factors*\*

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What is persistent pain/hypersensitivity known as once the rash disappears (can last months)?

Herpes III (varicella zoster), post-herpetic neuralgia

Viral disease caused by the epstein-barr virus that causes lymphoid proliferation in the blood, lymph nodes, and spleen. Extreme fatigue, fever, and sore throat are all common sx.

Herpes 4 aka infectious MONOnucleosis

DNA herpesvirus that is the most severe for the immunocompromised and unborn babies. S/s - anterior chest pain, painful swallowing, hematemesis, nausea/vomiting

Herpes 5 aka cytomegalovirus

Infectious multisystemic bacterial infection caused by a tick-born spirochete (vector transmission).

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Clinical manifestations include flu like symptoms, neck stiffness, bullseye rash, intermittent/unilateral arthritis (bigger joint(s)- warm/swollen), and PNS/CNS symptoms.

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Sx are worsened with corticosteroid injections

Lyme disease

Most commonly a bacterial infection that affects any part of the urinary system (kidneys, ureters, bladder, or urethra)

UTI

UTI/renal infection refers pain to what location? What might be the first sign in the elderly population? Urine changes?

Unilateral costovertebral, flank, or ipsilateral shoulder

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confusion/memory loss

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dark smelly urine, hematuria, dysuria, nocturia

What are risk factors for UTIs in young women?

Recent sexual intercourse, use of spermacide during sexual intercourse, previous history, DM, inactivity

CAUTION acronym for cancer

C - change in bowl or bladder

A - a sore that won’t heal

U - unusual bleeding or discharge

T - thickening lump

I - indigestion/dysphagia

O - obvious change in a wart or mole

N - nagging cough

Atopic vs contact dermatitis

atopic = eczema (itchy/inflamed skin) that begins in infancy and is associated with high IgE levels/sensitization to food allergens

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contact = skin irritation due to exposure to chemical, mechanical physical, or biological agents

Diffuse autoimmune connective tissue disorder that presents as a thickening of the skin (fibrosis of skin, joints, blood vessels, and sometimes internal organs due to an overproduction of collagen). - Females 25-55, females 4-5x more likely

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S/s: myalgia/athralgia, fatigue, weight loss, hardened skin near hands/knees/elbows, dry mouth/raynauds

Systemic sclerosis aka scleroderma

What are the three stages of scleroderma?

edematous - bilateral/nonpitting

sclerotic - tight/smooth, waxy skin

atrophic - thickening of skin with contractures at PIPs/elbows

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may have dry mouth/eyes (sjorgen’s syndrome)

Diffuse vs limited scleorderma

diffuse reaches organs, limited does not

Chronic, inherited, inflammatory but noninfectious plaques covered with a silvery scale.

Describe the closely related MSC impairment?

psoriasis,

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psoriatic arthritis - bilateral distal distribution (LE common), AM stiffness >30 min, inflammation at tendon insertions/changes in nail beds, pain can come before rash\*\*

Presentation:

* Bacterial infection of the skin and subcutaneous tissue
* Rapid onset of acute edema/erythema/warmth
* NO MOI
* RF = previous history, older adults, malnutrition, DM, steroids, venous insufficiency

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How would you differentiate this from a DVT?

cellulitis, constitutional signs, no vascular/neuro signs

What are the two main fungal infections?

athletes foot and ringworm

Superficial bacterial skin infection that forms small macules/crust near oral regions - common in schools/kids

impetigo

Inflammation of the lymph vessel that can occur from strep/staph infections, local trauma, or wound infection. What is the main clinical manifestation?

lymphangitis - red streaking

Enlargement of a lymph node

lymphadenopathy

Lymphadenopathy due to an infection elsewhere in the body

lymphadenitis

Accumulation of protein rich fluid in the extracellular space due to mechanical insufficiency of the lymphatic system

lymphedema

Lymphedema is often unilateral unless the pt has ____

gynecologic cancer

What are the four stages of lymphedema

Stage 0: No visible edema, may have subjective complaints (latent)

Stage 1: Accumulation of fluid that subsides with limb elevation, pitting but no fibrosis

Stage 2: Pitting + fibrosis

Stage 3: lymphostatic elephantiasis – trophic skin changes (fat deposits, warty overgrowths)

Positive stemmer sign

skin on the dorsum of fingers/toes cannot be lifted

Symmetrical swelling of both legs but does NOT affect the feet. (negative stemmer). Tender upon palpation, no pitting. Elevation, diet changes, nor weight loss decrease the diameter of the legs.

lipedema

Etiology of lipedema

genetic, hyperplasia/hypertrophy of fat cells, women primarily affected

Anterior pituitary disease characterized by an over secretion of ACTH ( ^ cortisol from adrenals) due to a pituitary adenoma

hyperpituitarism - cushing’s disease

Most common paraneoplastic syndrome (altered immune response when cancer is present) that results in only an over-secretion of cortisol

cushing’s syndrome

Identify some s/s of hypercortisolism seen in cushing’s disease/syndrome

* weight gain - android
* moon face
* stretch marks
* easy bruising/poor wound healing
* PROXimal muscle weakness
* increased thoracic kyphosis

Anterior pituitary disorder that causes increased GH/abrupt growth in children

gigantism

Anterior pituitary disorder thats causes increased GH/gradual growth after the epiphysis closes in adults

acromegaly

Caused by removal/destruction of the pituitary and is associated with GH deficiency/hypothyroidism

hypopituitarism

Posterior pituitary disorder that results in a physiological imbalance of water due to an __ deficiency and causes HYPERnatremia

diabetes insipidus, ADH

What are the two biggest clinical manifestations associated with diabetes insipidus

thirsty all the time, polyuria (causes dehydration)

Medical emergency that is characterized by excessive release of ADH causing HYPOnatremia and water intoxication

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Common with over treatment of ___

syndrome of inappropriate ADH secretion

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diabetes insipidus

Decreased TSH from ant pit., increased T3/4 which results in a generalized elevation of the body’s metabolism. Other name for this condition?

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S/s:

* Weight loss
* Fatigue
* Diarrhea
* Feeling warm
* Hair loss
* Light/short periods
* Racing heart
* Bulging eyes

hyperthyroidism/Grave’s disease

Common MSC clinical manifestation of hyperthyroidism? What about hypothyroidism?

hyper = weakness/muscle atrophy due to a negative nitrogen balance

hypo = muscle/joint pain/stiffness in shoulders or hips (proximal jts.)

Increased TSH from ant pit., decreased T3/4 which results in a generalized decrease of the body’s metabolism.

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S/s:

* Weight gain
* Fatigue
* Hair loss
* Heavy irregular periods
* Diarrhea
* Feeling cold

hypothyroidism

Enlargement of the thyroid gland that is seen in both hypo/hyperthyroidism. Normally caused by a lack of ____

goiter, iodine

Autoimmune disorder where lymphocytes cause destruction/inflammation of the thyroid gland. Most common form of hypothyroidism in the US.

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**genetic component**

Hashimoto’s thyroiditis

An increase in PTH that results in impaired calcium, phosphate, and bone metabolism. Normally caused by a benign adenoma and is rare in children.

Hyperparathyroidism

Why does hyperparathyroidism cause brittle bones and lead to osteoporosis?

hypercalcemia in the blood results in less calcium in bones

Reduced PTH causes ___ in the fingertips, mouth, and feet

acute tingling/burning

What are the two signs associated with hypoparathyroidism/hypocalcemia?

Trousseua’s (Wrist/MCP flexion with brachial pressure from BP cuff) and chvostek’s (CN VII irritability)

Primary adrenal insufficiency aka (___) which results in a decreased production of ___

Addison’s disease - decreased cortisol/aldosterone (diminished response to stress/immune response)

Autoimmune destruction of pancreatic beta islet cells that occurs in childhood \**requires lifelong insulin*

Type 1 Diabetes Mellitus

Polyneuropathies, retinopathy, CVD, neuropathic ulcers, loss of protective sensation, glycosuria, and charcot foot are all related to what condition?

Type 1 DM

Most serious complication of type 1 DM?

diabetic ketoacidosis (liver processes fat into ketones when there isn’t adequate insulin for glucose to be transpoted as a form of energy) - medical emergency

Cellular resistance to insulin action and inadequate compensatory insulin response

Type II DM

What is criteria for diagnosis of diabetes in terms of FPG, 2 hour plasma glucose, and HbA1c?

FPG > 126, 2 hour over 200 mg/dL, A1c: over 6.5%

Shallow breathing, decreased reflexes, tachycardia in hyper or hypoglycemia?

hypoglycemia

Deep, rapid breathing, weak pulses, and fruity breath in hyper/hypoglycemia

hyperglycemia

If unsure whether someone is hypo or hyperglycemic, which one should you treat and why?

hypoglycemic (provide juice anyways) - hypo has much worse complications

When should rapid acting insulin be given to a patient before meals? When is exercise appropriate?

10-15 min before meal, exercise = 3 hrs after meals

When should short acting insulin be given to a patient before meals? When is exercise appropriate?

30-40 min before meals, exercise = 45 min after meals

Can exercise up to ________ mg/dL glucose if no ketones in urine

300

For Type 1 diabetics, what time of day for exercise best serves those who struggle with hypoglycemia versus those who struggle with hyperglycemia?

hypoglycemia: first thing in morning before breakfast

hyperglycemia: afternoon

For type 1 patients, what should we think about with carbohydrates during exercise? What to do if glucose

consume simple carb every 30-60 min during prolonged exercise, if under 100 give simple carb and wait 15 minutes, give carb after exercise to prevent delayed onset hypoglycemia (6-12 hrs after)

Autosomal recessive disorder that is characterized by excessive iron absorption by the small intestine and bronze skin coloration \**hepcidin not present**

hereditary hemochromatosis

Collection of symptoms (spoon shaped nails, organ damage, and SOB) due to an abnormal quality or quantity of red blood cells -

MAJOR CAUSE OF FALLS

anemia

Always a malignant form of cancer that affects white blood cells (B and T cells) in bone marrow

Leukemia

What are the five main clinical manifestations associated with leukemia?

* Anemia
* infection
* bleeding/bruising tendencies
* weight loss
* FEVER

Acute leukemia disorders normally has a more rapid onset with illness, with vague __ pain and __ pain being one of the first symptoms experienced

thoracolumbar

hip

acute myelogenous leukemia = ___

acute lymphoblastic leukemia = ___

adults

children

Lymphoid malignancy that transforms B cells to reed sternberg cells. Most common in adolescents 15-19.

Hodkin’s lymphoma

“B” symptoms associated with Hodkin’s lymphoma

fever, night sweats, weight loss

Lymphoid malignancies that present as solid tumors are often associated with epstein barr/HIV

Non-Hodkin’s lymphoma

Presentation:

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Diffuse anterior neck pain with swelling and tenderness to palpation of the lymph nodes combined with fever, fatigue, weight loss, night sweats, and itching (hod) without evidence of skin lesion

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Most common >50 yo

Lymphoma

Presentation:

* Primary bone cancer characterized by a malignancy of the plasma cells (bone marrow).
* Aching bone pain in vertebrae or ribs may be the first sign of this disease following pathological vertebral fracture and vertebral collapse
* Peripheral neuropathy
* Frequent infections/fever/weight loss common
* Age >60 most common (

multiple myeolma

Low back pain for individuals over 50 years old, worse in supine, occurs at night or awakens pt, band like distribution around body

multiple myeloma

Etiology of multiple myeloma is related to jobs near what?

agriculture, lumber, petroleum, leather

What are the two main inherited clotting disorders? (s/s = excessive bleeding/menstruation, purple spots/bruises, muscular hematoma)

VonWillebrands disease and hemophilia

Hot swollen joint after a traumatic fall with a history of hemophilia might indicate __

hemarthrosis (intraarticular bleeding)

Inflammation and degeneration of a joint affected by recurrent hemarthroses episodes

hemarthropathy

Hereditary blood disorder that results in an abnormally shaped RBC, deoxygenated hemoglobin, and low blood pH

sickle cell disease

ID this complication:

* Pt with a history of sickle cell disease has diffuse pain that spreads to chest/limbs and sometimes back.
* Pain is aggravated movement/deep breathing
* Pain is often precipitated by stress, illness, strenuous PA, or temp. changes
* Episodes last 5-6 days

sickle cell crisis

Any condition that produces degeneration, thickening or hardening of the arterial walls

arteriosclerosis (PAD)

Inner layer of of a blood vessel becomes thickened through the accumulation of lipids, macrophages, or T-lymphocytes (often asymptomatic until an acute cardiac event) \*

atherosclerosis

Two forms of Ischemic heart disease? (aka coronary insufficiency) How do they differ?

coronary artery disease (macro, hearts major vessels only)

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coronary microvascular disease (plaque uniform around the small arteries off coronary artery)

What is the cause of angina? What makes angina unstable and a medical emergency? Where is the pain felt?

cardiac workload exceeds the oxygen supply to the heart

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“gripping/pressure” like chest pain AT REST or angina lasting 20-30 min

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Angina refers to left arm/shoulder, intrascapular region, neck, or jaw

Presentation:

* Angina refers to left arm/shoulder, intrascapular region, neck, or jaw
* Preceding factors=eating, emotion, exercise, cold

angina

Stable angina should last less than __ minutes and subside with __

2-10 minutes, rest