gen med unit 4

second impact syndrome

more common in high school

can be fatal

8-9 cases/year

lead to at minimum increased length of sx

chronic traumatic encephalopathy (CTE)

- A degenerative brain disease from repetitive brain trauma-hundreds to thousands of impacts

- Causes: Build up of Tau Protein in the brain-likely genetic; Axons (building block of nerves/brain)-breaking from blunt trauma

- younger head trauma start the higher likeyhood

what is the max HR goal for aerobic exc when doing concussion protocol

50-60%

PE of concussion

gait disturbance, vision testing (pupillometry, objective eye tracking, FNIRS), VOMS

protocol for return to learn

- ATC notifies: Physician-office visit in 3-5 days (less then 1 week), School Nurse, School Counselor

- Coordinator (counselor or nurse or athletic department secretary): Emails all teachers notifying of concussion, No Gym, Pass to go to library prn, get out of class early

- Meet with School Counselor to help with specific modifications: Student, Input of parents/others

- ATC/nurse monitors daily symptoms

sinus headache

pain behind browbone and or cheeckbones

cluster headache

pain is in and around one eye

tension heachache

pain is like band squeezing head

migraine

pain, nausea, visual changes typical

when to refer for headaches?

- New or unusual headaches

- Sudden onset of severe headache

- Change in pattern of a headache

- Chronic headache with localized pain

- Headache that interrupts sleep at night or early morning

- Headache that worsens over days

- Headache with severe nausea and vomiting leading to dehydration

- Visual Disturbances

- Numbness, paralysis or weakness on one side of the face or body

- Headache with associated stiff neck or meningeal signs

- System symptoms-fever or weight loss

- Neurologic Symptoms

- Local Extracranial Symptoms

tx of headaches

relieve stressors, massage of neck, hydration/good diet, dark room for migraines and rest, meds

Stroke (CVA - Cerebrovascular Accident)

lack of O2 to brain

Stroke TIA

shorter episode that does not leave permanent damage to the brain, blockage is temporary

RF for stroke

high lipids, smoking, hypertension, diabetes, obesity, fam hx,lack of vitamin d, Head injury can lead to stroke, Drugs like amphetamines, cocaine and ecstasy can lead to stroke

mnemonic for stroke: FAST

Face - smile, facial droops

Arms - can raise both arms overhead

Speech - slurred/strange

Time - 911

Tx of stroke

Tx w/in 45 min, therapy, stop OCP, tx causes

Guillain Barre Syndrome

- Acute, diffuse demyelinating disorder of the spinal roots and peripheral nerves

- Lymphocytes produce antibodies against myelin sheath

- Virus 1-3 weeks before onset of symptoms

- Dx: rapid muscle weakness, loss of deep tendon reflexes bilaterally,paresthesias and numbness, can progress to paralysis-loss of respiratory drive, Bell's Palsy-Facial droop affecting the facial nerve

- Tx: Most need to be hospitalized, 30% need breathing assistance

bell's palsy

- Facial Nerve-CN VII

- Unilateral or Bilateral weakness and facial paralysis

- Rapid onset and most always resolves in weeks to months

- Cause: Herpes Simplex is most common trigger, also HIV, Lyme,Parotid Tumor, Stroke, Trauma, Some VACCINES

- Send for Eye Exam-ocular Herpes can be very BAD!

- Tx: Steroids, Tx Herpes with anti-virals

vertigo

- Sensation of instability, loss of equilibrium or rotation usually caused by disturbance of semi-circular canal-inner ear or vestibular nuclei of brainstem

- BPPV-Benign Paroxysmal Positional Vertigo-spinning associated with nystagmus: Usually with change in position, lasts less than a minute, Usually not with nausea/vomiting

- Treatment is Dix/Hallpike test, Vestibular Therapy

- Other Causes: Meniere's disease, Migraine, Otitis Media with Effusion,Vestibular Neuritis, Tumor, Low blood sugar, Fatigue, Dehydration, Head Trauma

nociceptive pain

tissue injury or damage or potential injury/damage

- Ex. Ankle Sprain, jamming finger in a door,touching a hot plate

nociceptive inflammatory pain

Inflammatory response after the tissue damage

- Ex. OA, post injury inflammation

neuropathic pain

Injury or disease of nerve tissue

- Ex. Shingles, sciatica, radiculopathy,diabetic neuropathy, neurotoxin (stonefish)

nociceptive vs neuropathic

- Nociceptive: usually ach/throbbing and well localized, time limited but can be chronic, generally responds to conventional analgesics

- Neuropathic: pain often described as tingling, shock-like, burning, most always chronic, responds poorly to conventional analgesics

factros that increase risk of chronic pain

Increasing Age, Family Hx, Race-AA and Hisp., Obesity, Previous Injury, Depression, Anxiety, other mood disorders, prior trauma/abuse/neglect, Jobs with heavy lifting, smoking, stress

Complex regional pain syndrome

overactivity of the Sympathetic Nervous System-excess and prolonged pain and inflammation following an injury to an arm or leg.

- Acute-less than 6 months

- Chronic-6 months or more

- Sx: pain beyond proportion than normal like with some thing as mild as light touch + changes in skin color, temperature and/or swelling below the site of injury

- Tx: elevate is limb is swollen, Exercise Daily, Compression stockings/sleeves, Rehab-ROM, etc., Psychotherapy, Graded motor imagery, Medications (avoid narcotics if possible)

what causes pain in obesity

- Proinflammatory State- increase inflammatory markers

- Mechanical Stress-musculoskeletal joint pains-loading of the hip, back,knees-mechanoreceptors on chondrocytes

- Metabolic Syndrome-increase insulin-leading to increased sympathetics-raised catecholamines and cortisol levels

- Depression

- Genetics

- secondary: lifestyle, eating analgesia

BMI

18.5-25 normal

>25 overwt

>30 obese (class 1: 30-35; class 2: 35-40; class 3: 40+)

health consequences of obesity

- Increase all-cause mortality

- HTN, High Cholesterol, Type 2 DM, CAD/Stroke

- Gallbladder Disease

- Osteoarthritis

- Sleep Apnea/Breathing Issues

- Cancers-Colon, Endometrial, Esophageal, Stomach, Liver, Kidney, Pancreatic,Multiple Myeloma, Meningioma, Breast, Ovarian, Thyroid (chronic inflammation)

Beighton Score for Hypermobility

- Passive dorsiflexion of each fifth finger greater than 90°

- Passive apposition of each thumb to the flexor surface of the forearm

- Hyperextension of each elbow greater than 10°

- Hyperextension of each knee greater than 10°

- Ability to place the palms on the floor with the knees fully extended

Hypermobility spectrum DO (HSD): generalized

Beighton Score, MSK involvement, (very close to hEDS)

Hypermobility spectrum DO (HSD): peripheral

Usually Neg Beighton Score, Limited to Hands and Feet +one or more secondary manifestation

Hypermobility spectrum DO (HSD): localized

Neg Beighton Score-Single joint or group of joints +one or more musculoskeletal manifestations regional to the joint

Hypermobility spectrum DO (HSD): historical

self reported generalized joint hypermobility with negative Beighton Score +one or more secondary manifestations

sx w HSD

MSK:

- Trauma-dislocations, subluxations, ligament/tendon injury,muscular injury

- Chronic Pain-as a result of trauma or repeated triggering of pain receptors

- Disturbed Proprioception

- Other MSK traits: usually with Generalized HSD flexible flat feet, misaligned bones in the elbow and big toes,scoliosis, kyphosis, mildly reduced bone mass

NonMSK:

anxiety, POTS, functional GO DO, pelvic and bladder dysfunction

ehler danlos

- Inherited-Autosomal Recessive or Autosomal Dominant

- Cause-Defect in Synthesis of Collagen

- Type III - HYPERMOBILITY-most common-no distinctive genetic marker-ie it is a clinical dx-Collagen type IV

- Type IV - Vascular type-MOST SERIOUS-skin thinning, large eyes, thing nose, lobeless ears, short stature,hypermobile joints (fingers only)-arterial rupture,uterine rupture (abnorm type 3 collagen)

Ehler danlos sx

- Hypermobile Skin without fragility (would point to other types)

- Positive Fam Hx

- Recurrent Dislocations/Subluxations

- Chronic Joint Pain• Easy Bruising

- Functional Bowel Disorders

- Postural Hypotension or Orthostatic Tachycardia

- High-narrow palate

- Dental Crowding

pain w ehler danlos

- Chronic pain, distinct from that associated with acute dislocations, is a serious complication of the condition and can be both physically and psychosocially disabling

- It is variable in age of onset (as early as adolescence or as late as the fifth or sixth decade)

- Severity is typically greater than expected based on physical and radiologic examinations.

- Severity sometimes correlates with degree of joint instability and with sleep impairment

other assoc problems w ehler danlos

Bowel Problems, Aortic Root Dilation, MVP, Premature Rupture of Membranes, Early/Rapid Labor, Depression, Anxiety, Low Self Confidence▫ Poor Balance, Delayed/Resisted onset to anesthesia, Easy Bruising, Etc

Ehler danlos management

- Physical Therapy

- Myofascial release

- Modalities must be tailored to the individual: heat, cold, massage, ultrasound, electrical stimulation, acupuncture, acupressure,biofeedback, and conscious relaxation.

- Low-resistance muscle toning exercise can improve joint stability and reduce future subluxations, dislocations, and pain

- braces, taping

- surgery

marfan's syndrome

- Cause: overproduction of protein—transforming growth factor beta(TGF-β)

- Diagnosis: Clinical, confirmed with genetic test-FBN1 gene

- Symptoms: Visual-dislocated lens, detached retina, glaucoma, cataracts, Abnormally Wide arm span (compared with ht), Long arms, legs and fingers, Tall and thin body type, Curved spine, Chest sinks in or sticks out, Flexible joints, Flat feet, Crowded teeth, Stretch marks on the skin that are not related to weight gain or loss

marfan syndrome thoracic aortic aneurysm

- increase in blood pressure from exercise causes weakening side walls of the aorta thoracic aneurysm

- Athletes cannot exceed 75%maximal effort

- Cause of SCD if exceeds from aorta rupture

- If aorta is replaced, then can do maximal exertion

ortho sequelae for marfan syndrome

- Scoliosis

- Kyphosis

- Back Pain

- Marfan Feet

- Pectus Excavatum

- Hypermobility

juvenile RA (JRA)

- Autoimmune

- Effects 1 or more joints

- Dx: Rf, ESR, ANA, CBC• Xrays, Bone Scans, EKG, etc

- Tx: NSAIDs, Methotrexate (if more severe), Exercise is Good!, Warm up fully, Many kids grow out of it, but some can become permanently disabled, Monitor symptoms-joint pain, redness, swelling

follicular phase hormones

estrogen and LH increase--> endometrium thickens (getting ready for egg implantation)

ovulation phase hormones

spike in LH, decrease estrogen

luteal phase hormones

progesterone increase, estrogen up a little more again

menses hormones

progesterone and estrogen declines

oligomenorrhea vs polymenorrhea

oligomenorrhea: >35 days so less cycles

polymenorrhea: <24 days so more cycles

menorrhagia

excess amnt and or duration

metrorrhagia

irregular interval

menometrorrhagia

irregular interval and amount/duration

tx of dysmenorrhea

NSAIDS, then Oral Contraceptive Pills or IUD, etc

Functional hypothalamic amenorrhea

- Causes/Pathyophysiology: Stress, weight loss, increase in exercise--> decrease GnRH (pulsatility) --> increase CRH --> decrease TSH, decrease T3, decrease FSH/LH and estradiol and increased cortisol (stop ability to ovulate, because you can't maintain/don't have enough extra energy pregnancy)

- Work Up:Serum TSH, Free T4, Prolactin, LH, FSH, Estradiol

- Other Characteristics: BMI <24, low androgens, low LH, normal or low basal insulin levels, decreased endometrial thickness, low bone mineral density

- Treatment: Nutrition counseling, activity modification, avoid oral contraceptives, calcium/vit D if low bone mineral density, consider transdermal estrogen/cyclic progesterone

polycystic ovarian syndrome

frequent or prolonged menstrual periods form imbalance or repro hormones

- increase in androgen hormones and insulin resistance (increase LH)

- ovaries develop numerous follicles

- Sx: irreg menses, hirsutism, acne, thinning hair, wt gain, darkening of skin, skin tags

- Tx: wt loss, metformin, consider anti-androgen meds, oral contraceptives, other fertility tx

endometriosis

- abnormal growth of tissue inside or around uterus and female repro organs

- cause: hormonal changes from monthly cycle

- Sx: heavy menses and pain, infertility, pain following intercourse or bowel movements, LBP w menstrual cycle

- Tx: pain meds, hormones, surgery to remove cysts, hysterectomy

pelvic inflammatory disease

chronic STI

- Sx: vaginal discharge, pain with intercourse, abnormal vaginal bleeding, lower abdominal tenderness, adnexal tenderness, cervical motion tenderness, fever above 101 (38.3C), elevated CRP/ESR, leukocyte (WBC) in vaginal secretions

- Tx: multiple antibiotic, sometimes surgery if abscess, abstain from sex for several wk/month

- Prevention: condom

- eval for syphilis and HIV

uterine fibroids/tumors

growth on lining of uterus, cause discomfort and abnormal uterine bleeding/painful periods

cervical cancer

screen 21-29 every 3 yrs

30-65 w high risk HPV every 5 yr

- vaginal bleeding, abnorm periods

- slow growing

the longer a contraceptive lasts the _____

more effective

contraception that has estrogen/progesterone

oral contraceptive pill (OCP), ortho evra patch, vaginal ring

contraception that has progestin only

pill, injection, implant, IUD

Oral contraceptive pill

- Most common form of birth control used in US

-Effective 8% failure rate during year typical use

- quick return of fertility

- pituitary gonadotropin secretion is inhibited

- progestin more effective ovulation inhibitor

- progestin also causes cervical mucous thickening, changes to endometrium decreasing sperm transport and embryo implantation

Oral contraceptive pill benefits

-Reducing irregular menses and dysmenorrhea

-Decreased blood loss from menstrual cycle

-Decreased iron deficiency anemia

-Decreased incidence in functional ovarian cysts

-Decreased incidence of ectopic pregnancies

-Decreased incidence of fibroadenomas & fibrocystic breast Dz

-Decreased incidence of endometrial cancer

-Decreased incidence of ovarian cancer

combines contraception risks

- stroke and MI -> >35 and smoke

- cervical neoplasia

- venous thromboembolism (VTE)

VTE w estrogen contraceptives risk

>35 yr

smokes

obesity

<4 wk postpartum

4 wk prior to surgery and 2 wk after surgery

bed rest

personal/family hx of heart attack, stroke, DVT

contraindications for OCP

- Unexplained VTE, pregnancy related VTE, or estrogen related VTE (Unless on anticoagulants)

-Women age 35 and older who smoke tobacco

-Poorly controlled diabetes or diabetes with complications -Vascular, retinopathy, nephropathy

contraceptive patch

- Alternate delivery method for combined hormonal contraception.

-1 patch weekly for 3 weeks then patch free week for cyclic use -can be used in continuous use (no patch free week)

-Similar failure rate to OCPs 8% (backup method first week)

-Transdermal patch produces slight increase in estrogen exposure - Two-fold increase in risk of non-fatal VTE (over OCP)

- Contraindications to the combination OCP also should be considered to apply to the patch and ring

contraceptive ring

-Alternate delivery method for combined hormonal contraception.

-1 ring vaginally every 3 weeks then ring free week

-can be used in continuous use (no ring free week)

-Similar failure rate to OCPs 8% (backup method first week)

progestin pill

- taken continuous w/o break

-Ideal for lactating breastfeeding moms with no reduction in supply.

-Good for patient with DVT/VTE history that want to take a pill

-Short half life and back-up method needed if a pill is missed

Depo-Provera injection (DMPA)

-Depot medroxyprogesterone acetate injection 150 mg

-Given every 3 months IM injection

-3% failure rate typical use, 0.3% failure rate with consistent use

-Ideal for Progestin contraceptive patients

- Longer return of fertility up to 18 months

-Menses may not return for months after discontinuation

-Temporary decrease in bone mineral density with current use -not linked to fractures, Appears to fully recover after discontinuation

Implant

-Etonogestrel 68 mg, 2mm by 4 cm rod

-Subdermal implant for up to 3 years

-Failure rate 0.38%

-Return to fertility is days to weeks

-Ideal for Progestin contraceptive patients

-Does not rely on compliance - but needs to be removed at end of 3 years

IUD

-Highly effective, convenient long duration, reversible

-Rapidly return of fertility

-Early concerns about infection and infertility

- no increased risk- >40% reduction in endometrial cancer risk

-Can be used to prevent endometrial hyperplasia in women treated with estrogen for menopausal symptoms

- Side effects: cramping, amenorrhea, ovarian cyst, device expulsion, irreg bleeding, ectopic pregnancy, pelvic inflammatory diz, perforation of uterine wall, embedment of device in uterine wall

copper IUD

-Highly effective, convenient - good for 10 years

-Can be utilized for emergency contraception

-Copper interferes with sperm movement and egg fertilization -makes the uterus unfavorable for implantation

-Rapidly return of fertility

-Early concerns about infection and infertility- no increased risk

sterilization and vasectomy

- cannot be reversed

- can decrease ovarian cancer

- not change menstruation

- not provide immediate contraception (vasectomy)

male condom

- Reduce the risk of STD transmission

-Inexpensive

-Commonly combined with other BCM options (ie. OCPs and condoms)

-Typical failure rate is 10-15% year of typical use

female condom

-More expensive than male condom

-Acts as a vaginal liner with the end remaining outside to cover the vulva

-Failure rate 21% typical use

-Should not be used together with male condom

diaphragm

-Positioned to completely cover the cervix, fitting behind the pubic bone into posteriorvaginal fornix, can be used with male condom

-Usually used with spermicidal jelly

-Prescription only, fitted by health professional

-Failure rate 16% typical use

-Side effects: UTIs, vaginal irritation, recurrent candida and bacterial infections caused by use

cervical cap

-Similar but smaller than diaphragm

-More difficult to place

-Rx only

-Failure rate 16-32% typical use parous vs nulliparous, respectively

sponge

-Placed high in vagina

-Can be inserted up to 24 hours prior tointercourse and kept in place for up to 6 hours after

-Associated with higher pregnancy rates than diaphragm

spermicide

- Chemical contraceptive barrier - surfactants destroy sperm's cell membrane

-Inserted into the vagina not more than 1 hour prior and left in place for 6-8 hours after

-Failure rates 29% typical use

emergency contraception

- Needs to be with first 72 hours to decrease pregnancy by up to 75%

-Hormonal ECs do not affect an established pregnancy and no harm taken inadvertently during early gestation

- Plan B w/in 72 hr

- Paraguard IUD up to 7 days

obesity and contraception

Obesity can affect the safety and efficacy of various contraceptive methods. However,no contraceptive method is restricted from use in obese women

kidney stones

- salts that form solid crystals

- Most start in the kidney and go distally

- Pain depends on where the stone is lodged-usually in the narrowest area

- Often starts at night or into the morning.

- Classic Sx: unilateral flank pain into the groin

- PE: flank tenderness (Lloyd's), possible testicular pain, costovertebral angle tenderness, may have hypoactive bowel sounds if ileus present

- Once in the bladder is often no longer painful and can pass through urination

- Complications: Infection-Pyelonephritis

- Treatment: Pain management until the stone passes, hydration, strain the urine to catch the stone and send for analysis

- Participation in Sport: ok as long as hydrated and not showing signs of infection

- Causes: Hyperparathyroidism, Intestinal malabsorption, anatomical

sports hematuria

3 of more red blood cells per high-power field associated with physical activity

- Sx: Asymptomatic

- resolve in 72 hr

- Tx: rest 24-72 hr

UTI

- Most common cause of bacterial infection in outpatient clinics

- Complicated-infection in a urinary tract with functional or structural problem: Hx of recurrent UTI, structural issue, catheter, stone, urinary retention, Abscess/Pyelonephritis

- Uncomplicated-normal urinary tract

- Sx: painful urination (dysuria), blood in urine or cloudy urine, urinary urgency and frequency, N/V, abd pain-suprapubic, groin, and/or flank pain

- Tx: based on culture results but 7-10 days of antibiotic

Pyelonephritis

- infection in the kidney--very concerning

- May need IV antibiotics

5 Ps of STD

Partners, Practices, Protection from STIs, Past STIs, Pregnancy Intensions

gonorrhea

- yellow vaginal discharge, painful urination, painfulintercourse-but may be ASxatic

- Dx: Urine for Gonorrhea

- Tx: Antibiotics- Azithromycin x 1 dose and Rocephin IM x 1 dose

- Test of cure at 14 days

chlamydia

- yellow vaginal discharge, painful urination, painfulintercourse, but may be Asxatic

- Dx. Urine for Chlamydia

- Tx: Antibiotics- Azithromycin x 1 dose OR doxycycline x 1 week

- Most Common STI in US

- No sex x 7 days, test of cure at 4 weeks if still symptomatic,test of re-infection at 12 weeks

- Consider to Treat partners: Chlamydia-oral doxycycline x 7 days,Gonorrhea-oral cefixine x 1 dose

syphilis

- painful sores at the site and swollen lymph nodes/2nd stage is skin rash on palms and soles

- Dx: RPR blood test

- Tx: Antibiotics-PCN

trichomonas

- greenish yellow, frothy vaginaldischarge, patchy vaginal rash, irritation, painful urination of intercourse, or may be Asxatic

- Often found with Bacterial Vaginosis (which is not an STI)

- Dx: swab and microscopy

- Tx: Antibiotics-Metronidazole 500mg twice daily x 7 days for female, but males can do 1 dose of 2g Metronidazole (don't drink when you take this)

genital herpes

- tingling, itching or burning, small painful blisters, headache, fever, malaise, burning with urination

- Can be recurrent with stress, etc

- Dx: Swab with Culture

- Treatment: no cure but treat with antivirals-acyclovir or valacyclovir

genital warts

- From Human Papilloma Virus-painless, fleshy growths on genitals

- Dx: Physical Exam, consider Biopsy

- Treatment: removal, cautery, chemicals

- Prevent: most with HPV vaccine

Hep B

- jaundice, fatigue, abd pain, N/V, loss ofappetite

- Dx: Blood test-Hepatitis Titers

- Treatment: Anti-virals to keep it from progression but NO CURE,

- Prevent: Vaccine

HIV/AIDs

- short term flu-like symptoms initially/long term weight loss, fatigue, swollen lymph nodes, infections

- Dx: Blood Test/ Treatment: Anti-virals to keep it from progressing but NO CURE

sx, PE, imaging of testicular injury

- Symptoms: Scrotal pain, abdominal discomfort, swelling, bruising, N/V, Prehn Sign-no relief with physical lifting of the testicle, No cremaster reflex-touching the medial thigh causing the testicle to rise

- PE: inspection for laceration, bruise or swelling, palpation

- Imaging: US

levels of pain for testicular injury

- Mild- pain and scrotal swelling are minimal, testes are normal on exam with intact scrotom; Treatment: bed rest, ice packs for about 20 minutes 3-4 times a day, supportive underwear, NSAIDs

- Moderate: Moderate pain and swelling; Treatment: US for imaging, evaluation by surgeon

- Severe: Significant pain, swelling and/or unable to perform exam from pain; Treatment: US by imaging, evaluation by surgeon

testicular torsion

- Rotation of the testicle leading to venous obstruction,then arterial ischemia, then infarction of the testicle

- more common if warmer temps

- Symptoms: severe unilateral scrotal pain, scrotal swelling,abdominal pain, N/V

- Diagnosis: Color doppler US

- Treatment: UROLOGIC EMERGENCY

testicular rupture

- Rip or tear in the outer lining of the testicle leading to extrusion of the testicular contents

- From sports or MVA

- Treatment: surgery with repair-90% successful when txed in 72 hours

testicular degloving

- scrotum is torn away from the testicle

- From large industrial accidents

- Treatment: Surgery