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Clin Med Exam 5 - FINAL
Hematology/Musculoskeletal
194
Medical
Graduate
04/15/2012

Additional Medical Flashcards

 


 

Cards

Term

first line treatment of IDA

 

when should the Hct return to normal

Definition

ferrous sulfate 325 mg TID - on an empty stomach or with acidic juice

 

Hct should return to normal within 2 months - continue treatment 3 - 6 months after Hct has returned to normal

Term
indications for parenteral iron treatment for IDA
Definition

intolerance to oral iron

refactory disease (to the oral Fe)

GI disease or previous surgery

Term
treatment of IDA for a pt with a GI disease/previous surgery, who is intolerant to oral iron, or is refractory to oral treatment
Definition

sodium ferric gluconate (ferrlecit)

 

IV dose 1.5 - 2 

 

given over 4 - 6 hours

Term
diagnostic criteria for anemia of chronic disease
Definition

serum ferritin normal or increased

 

underlying chronic disease

 

(MCV usually normal; Hct mildly or moderately reduced)

Term
treatment of anemia of chronic disease
Definition

none usually needed

 

EPO for renal failure or cancer or IBD (but reserved for pts dependent on transfusions)

Term
treatment of pt with anemia of chronic disease due to renal failure
Definition

EPO

 

typically reserved for renal failure pts dependent on transfusions

Term
treatment of mild thalassemia (alpha thalassemia trait or beta thalassemia minor)
Definition

alpha thalassemia trait = 2 alpha globin genes/chains

beta thalassemia minor = heterozygous

 

 

no treatment necessary

Term
treatment of Hemoglobin H disease
Definition

Hgb H dz = alpha thalassemia with only one alpha globin gene/chain

 

folate supplements

avoid iron supplements and oxidative drugs (sulfonamides)

transfusions may be required in times of stress/infection/exacerbation (similar to beta thalassemia intermedia)

Term
treatment of severe thalassemia
Definition

typically, beta thalassemia major (homozygous)

 

regular transfusion schedule

folate supplements

if hypersplenism -> splenectomy

deferoxamine (chelates iron)

allogeneic bone marrow transplantation

Term
diagnosis of siderblastic anemia made by
Definition

bone marrow biopsy

showing ringed sideroblasts

(and marked eryhtroid hyperplasia)

Term
treatment of siderblastic anemia
Definition

occasionally requires transfusion

 

does NOT respond to EPO therapy

Term
which anemia does NOT respond to erythropoietin therapy
Definition
siderblastic anemia (acquired bone marrow disorder)
Term
diagnostic criteria for Vitamin B12 deficiency
Definition

low serum Vit B12 < 100 ng/L (normal 160 - 200)

 

(PBS -> macro-ovalocytes and hypersegmented neutrophils w/mean lobe count > 4 or 1 six lobed neutrophil)

Term
first line treatment of Vitamin B12 deficiency
Definition
Vitamin B12 - 100 mcg IM QD for 1 week, then once a week for 1 month, then once a month for life
Term
what is a possible alternative treatment for Vitamin B12 deficiency (aka - not the first line treatment)
Definition
oral cobalamin - 100-250 mcg QD indefinitely
Term
in Vit B12 deficiency, the hematologic picture normalizes after treatment in how many months
Definition

after Vit B12, 100 mcg IM for 1 week, then ever week for 1 month, and then every month for life...

 

hematologic picture normalizes in 2 months

Term
diagnostic criteria for folic acid deficiency
Definition

RBC level of folic acid < 150 ng/mL

 

(PBS -> macro-ovalocytes and hypersegmented neutrophils w/mean lobe count > 4 or 1 six lobed neutrophil)

Term

treatment for folic acid deficiency

 

with total correction of hematologic abnormalities within how many months?

Definition

folic acid, 1 mg PO daily

 

total correction of hematologic abnormalities within 2 months

Term
which anemias will have a rise in reticulocytosis in response to treatment
Definition

Vit B12 deficiency

 

folic acid deficiency

Term
diagnostic criteria for hereditary spherocytosis
Definition

reticulocytosis ALWAYS present

 

hyperchromic RBCs

 

increased osmotic fragility

 

(coombs negative (b/c of an intrinsic problem), PBS shows spherocytosis)

Term
treatment of hereditary spherocytosis
Definition

folic acid, 1 mg PO daily

 

splenectomy - eliminates site of hemolysis, but doesn't correct the membrane defect; may not be necessary in very  mild cases discovered late in adult life

Term
treatment for an adult, just diagnosed with a mild case of hereditary spherocytosis
Definition

folic acid, 1 mg PO daily

 

don't necessarily need a splenectomy if the case is mild enough

Term
diagnostic criteria for glucose 6-phosphate dehydrogenase deficiency
Definition

G6PD enzyme assay negative or < 12 IU/g

 

(PBS -> heinz bodies (oxidized Hgb percipitants) with crystal violet stain; RBC "bite" cells)

Term
treatment of glucose 6-phosphate dehydrogenase deficiency
Definition

typically, no treatment necessary - self limiting; if severe - may require transfusion

 

avoid oxidative triggers

 

few will have chronic hemolytic anemia

Term
treatment of sickle cell trait (Hgb AS)
Definition

no treatment necessary

 

genetic counseling is appropriate

Term
diagnostic criteria for Sickle Cell Anemia (Hgb SS)
Definition

hemoglobin electrophoresis -> homozygous S 95 - 97%

 Hgb F 2 - 5% (the higher the level, the mor benign the course)

NO Hgb A

Term
treatment of Sickle cell disease pt experiencing repeated episodes of acute chest syndrome or w/ >3 pain crises /year requiring hospitalization
Definition
hydroxyurea - increases Hgb F levels
Term
maintenance treatment of Sickle Cell Anemia (Hgb SS) (aka the daily tx, not what tx is used for crises/exacerbations)
Definition
folic acid, 1 mg PO daily
Term
treatment for a pt with Sickle Cell Anemia in a pain crisis
Definition

identify precipitating factors

treat infections if present

aggressive analgesia administration

vigorous hydration

administer O2 only if hypoxic

transfusion for extreme cases (but doesn't shorten the crisis)

Term
treatment for a sickle cell anemia (Hgb SS) pt experiencing acute chest syndrome
Definition

*CP, tachypnea, fever, cough, arterial O2 desat - reflecting insitu sickling w/in lung)*

 

medical emergency - treat in ICU

O2 if sat <90%

Maintain Hct > 30

Term
what is recommended to sickle cell anemia pts that will reduce their incidence of getting infections
Definition
pneumococcal and H. flu vaccines
Term
treatment of sickle cell anemia pt experiencing intractable pain crises, priapism, and stroke
Definition
exchange transfusion
Term
what is the initial treatment for autoimmune hemolytic anemia
Definition
prednisone
Term
what treatment is used when autoimmune hemolytic anemia is refractory to the initial treatment
Definition

splenectomy if prednisone ineffective or recurs

 

rituximab - if refractory to prednisone and splenectomy

 

immunosuppressive agents

 

high dose immune globulin - effective, but short lived

Term
diagnostic criteria for cold agglutinin disease
Definition

Coombs test positive for complement ONLY

 

(positive cold agglutinin test)

Term
treatment of choice for cold agglutinin disease
Definition

rituximab - relapses can  also be re-treated

 

avoid the cold

Term
what forms of treatment are considered ineffective for cold agglutinin disease
Definition
prednisone and splenectomy - because hemolysis takes place in the liver
Term
what are possible lines of treatment for cold agglutinin disease that are alternatives to the treatment of choice
Definition

high dose immune globulin - effective, but short lived

 

immunosuppressive agents - for severe disease

Term
treatment of mild aplastic anemia
Definition

supportive measures only for mild cases

 

antibiotics to treat infections

 

RBC and platelet transfusions as necessary

Term
treatment of choice for young adults and children (< 40 yrs) with aplastic anemia
Definition
allogeneic hematopoietic stem cell transplantation/bone marrow transplant
Term
treatment for older adults (> 40yrs) with aplastic anemia
Definition
immunosuppression (antithymocyte globulin (AGT) and cyclosporine)
Term
what is the initial line of treatment for immune thrombocytopenic purpura (ITP)
Definition
mainstay of initial therapy is short course of corticosteroids w/ or w/o IVIG or anti-D +/- platelets (if bleeding)
Term
when do you typically add platelets to your regimen of initial therapy for a pt with immune thrombocytopenic purpura (ITP)
Definition
if the pt is currently bleeding
Term
treatment of drug induced immune thrombocytopenic purpura (ITP)
Definition
d/c offending agent - resolves in 7 - 10 days
Term
treatment of immune thrombocytopenic purpura (ITP) due to HIV/Hep C
Definition

treatment of infection leads to correction of platelet count in most cases

 

can use IVIG/anti-D, interferon-alpha

 

corticosteroids are NOT recommended for pts with Hep C

Term
what class of drug should be avoided in Hep C pts with immunoe thrombocytopenic purpura
Definition
corticosteroids
Term

treatment for relapsed/persistent ITP

(pt still has platelets < 30,000 or still bleeding)

Definition

corticosteroids

AND

IVIG or anti-D or rituximab

consider splenectomy

Term

treatment for worsening/persistent/refractory ITP

 

(have already tried both first and second line drugs)

Definition

have already tried corticosteroids AND IVIG

 

consider additional agent OR chemo OR laparoscopic splenectomy

Term
what is the definitive treatment of ITP and when is it indicated
Definition

splenectomy is the definitive tx of ITP

 

reserved for severe thrombocytopenia pts who did not respond to initial prednisone or unacceptably high dose is required to maintain adequate platelet count, or pt prefers surgery

Term
if pt ops for splenectomy as their form of treatment for ITP, what must the pt receive prior to surgery and how far in advance to the surgery
Definition
pts need pneumovax, HIB, meningococcal vaccines TWO WEEKS BEFORE surgery
Term

what are some laboratory findings relative to thrombotic thrombocytopenic purpura (TTP)

(these aren't necessarily diagnostic, just what was bolded from lecture)

Definition

PBS - showing microangiopathic changes with fragmented RBCs (shistocytes)

 

LDH markedly elevated

 

coag tests = normal

 

Decreased activity of ADAMTS-13 (von willebrand factor cleaving protease)

Term
what is the treatment of choice for thrombotic thrombocytopenic purpura (TTP)
Definition
emergenct large volume plasmapheresis (removing plasma and replacing with FFP) - continue daily until platelet count returns to normal
Term
what is the second line of treatment for thrombotic thrombocytopenic purpura (aka for refractory disease)
Definition

immunosuppression (cyclophosphamide, rituximab)

 

splenectomy for refractory

Term

laboratory findings for hemolytic uremic syndrome (HUS)

 

(just bolded points from lecture, not necessarily diagnositc)

Definition

PMS with significant schistocytes

 

LDH elevated, out of proportion to degree of hemolysis

 

positive stool culture - determines causative agent (typically E. coli)

Term
treatment for hemolytic uremic syndrome (HUS)
Definition
supportive (IV fluids)
Term
lab findings for disseminated intravascular coagulation (DIC)
Definition

serum fibrinogen low

 

thrombocytopenia

 

progressive thrombocytopenia

 

PT and PTT prolonged

 

HELLP findings in pregnancy

Term
what is the first step in the treatment of DIC
Definition
treat the causative agent (using either Abx, chemo, surgery, or delivery)
Term
what is typically transfused as part of the treatment for DIC only if the pt is bleeding or has a high risk of bleeding (aka, the next thing you do after treating the causitive disorder)
Definition

transfuse blood products only if bleeding or high risk of bleeding

 

cryoprecipitate to replete fibrinogen

 

FFP to raise PT/aPTT values

 

PRBC to replete Hgb

 

if persistent bleeding - consider heparin (NO bolus)

Term
if factor VIII is affected in von willebrand's disease, what lab value will you find increased
Definition
when factor VIII is affected, if it possible to have prolonged PTT
Term
what lab values will you find in von willebrand's disease
Definition

low VWF activity level

 

lower factor VIII level

 

total plasma VWF antigen is decreased

 

thrombocytopenia

Term

what is the first line treatment for von willebrand's disease - and what needs to be restricted during treatment

what is the max dosing of this treatment

Definition

DDAVP via IV or by high [  ] nasal spray

 

fluid restriction should be advised for all pts for the 24 hours following each dose

 

more than TWO doses in 48 hours is NOT recommended

Term
what line of treatment is NOT recommended for von willebran's disease
Definition

DDAVP is not effective in VWF-containing factor VIII

 

cryoprecipitate is NOT recommended to treat von willebrand's disease

Term
what line of drugs is added to the normal first line treatment of von willebrand's disease used for mucosal bleeding or for procedures such as dental extractions
Definition
antifibrinolytic agents
Term
what are some lab values consistend with Hemophilia A and B
Definition

isolated reproducibly low factor VIII and factor IX activity level in the absence of other conditions

 

prolonged aPTT - which corrects upon mixing w/normal plasma

 

other coag tests are normal

Term
what are the mainstay of treatment for hemophila A and B
Definition

plasma-derived or recombinant factor concentrates

 

severe pts are typically receiving long term prophylactic infusions of factor by the age of 4

Term
treatment of hemophilia A and B in adults
Definition

generally don't use intense long term prophy

 

factor concentrates as needed for bleeding episodes or prior to high risk activities

Term
what is used adjunctively for hemophilia pts for dental procedures
Definition
antifibrinolytic agents (aminocaproic acid)
Term
treatment of a MILD hemophilia A ADULT pt
Definition
mild hemophila A may respond to PRN IV or IN DDAVP
Term
treatment for activated protein C resistance
Definition

*Factor V Leiden*

 

avoid medications that make pt hypercoagulable

consider anticoagulation prior to surgical procedures

Term
treatment for antiphospholipid syndrome
Definition

anticoagulation for emoblic events

 

if no hisotry of embolus - no prophy

Term
treatment for catastrophic antiphospholipid syndrome
Definition
anticoagulation, steroids, plasmapheresis, and/or IVIG
Term
lab finding to diagnoses acute myelogenous leukemia
Definition
auer rods - pathognomonic of AML
Term
treatment of acute myelogenous leukemia
Definition

chemotherapy to induce remission:

anthracycline + cytrarbine

 

postremission therapy:

chemo

autologous transplantation

allogeneic thransplantation

Term
treatment of acute lymphoid leukemia
Definition

to induce remission:

combination chemotherapy

 

to cure:

chemotherapy (but not enough for high risk pts when done alone)

autologous transplantation

allogeneic transplantation

Term
treatment of either AML or ALL with the intent to cure
Definition

chemotherapy

autologous transplantation

allogeneic transplantation

Term
diagnosis of chronic myelogenous leukemia
Definition

philadelphia chromosome, aka bcr/abl genee detected via cytogenic study t(9,22)

 

(WBCs > 100,000, hypercellular bone marrow w/ <5% blasts, mature myeloid cells on PBS)

Term
what lab finding would help support a suspicion of chronic lymphocytic leukemia
Definition

dz is typically a proliferation of mosly B lymphocytes, therefore:

 

monoclonal B-cells.

isolated & persistent lymphocytosis = hallmark; they are typically small & mature

Term
treatment of choice for chronic myelogenous leukemia
Definition

usually not emergent

 

tx of choice: Imatinib mesylate (inhibits tyrosine kinase activity of bcr/abl oncogene)

Term
what treatment is curative for chronic myelogenous leukemia, (but is typically reserved for a pts w/ accelerated phase, dz isn't well controlled, or it progresses after initial control)
Definition

allogeneic stem cell transplant

 

best results if pt < 40 yrs and transplanted w/in 1 year from an HLA-matched sibling

Term
treatment for asymptomatic/early chronic lymphocytic leukemia
Definition
no specific therapy - observation only
Term
tx for symptomatic chronic lymphocytic leukemia
Definition

fludarabine IV dialy for 5 days each month for 4 - 6 months

 

causes immunosuppression

 

best when combined with rituximab

Term
what tx is potentially curative for chronic lymphocytic leukemia (but typically reserved only for pts whose dz cannot be controlled by standard therapies)
Definition
allogeneic transplantation
Term
lab finding for hairy cell leukemia that supports suspicion of diagnosis
Definition
hairy cells with  numerous cytoplasmic projections present in small numbers
Term
treatment of hairy cell leukemia
Definition

cladribine

 

0.14 mg/kg dialy for 7 days

Term
diagnosis of hodgkin's disease
Definition

pathologic diagnosis by lymph node biopsy, seeing

Reed-Sternberg cells

 

(usually arises within a single lymph node area and spreads contiguously)

Term
tx of pt with hodgkin's disease stage IA or IIA
Definition

(A: asymptomatic pt)

 

radiation therapy +/- short course chemotherapy

Term
tx of pt with hodgkin's disease stage IIIB or IV
Definition

(B: + constitutional symptoms of fever, night sweats, weight loss)

 

combination chemotherapy with ABVD or never regimen

adriamycin/doxorubicin

bleomycin

vincristine

decarbazine

Term
diagnosis of non-hodgkin's lymphoma
Definition

tissue biopsy

 

(LDH is a useful prognostic marker, CXR may show mediastinal mass, bone marrow shows paratrabecular lymphoid aggregates)

Term
tx of non-hodgkin's disease that is limited, aka only 1 abnormal lymph node
Definition
localized radiation with a curative intent
Term
tx of non-hodgkin's lymphoma that is indolent and disseminated
Definition

rituximab +/- chemotherapy (CHOP-R)

 

allogeneic transplant

Term
treatment of an intermediate grade non-hodgkin's lymphoma (disease is aggressive, or diffuse large B cell lymphoma)
Definition

chemotherapy with CHOP-R

 

autologous stem cell transplant

Term
tx of burkitt's lymphoma (type of non-hodgkin's lymphoma)
Definition
intensive chemotherapy that is specifically tailored for burkitt's
Term
lab findings of multiple myeloma
Definition

hallmark = paraprotein on serum protein electrophoresis

 

(rouleau formation of RBCs is common on PBS)

Term
tx of minimal multiple myeloma
Definition
observation
Term
tx of symptomatic pt w/ multiple myeloma
Definition

thalidomide + dexamethasone

 

valcade

 

revlimid being investigated

Term
what is lab is required for the diagnosis of osteomyelitis
Definition

bone biopsy culture is required for the diagnosis, unless blood cultures come back positive (ie. don't need bone biopsy, if the osteomyelitis was from a hematogenous spread and the bacteremia gave a positive blood culture)

 

(*cultures from overlying ulcers, wounds, or fistulas are unreliable)

Term
what imaging study is done is osteomyelitis is suspected but site of infection is uncertain
Definition
bone scan is often used when osteomyelitis is suspected but unsure of site
Term
treatment of vertebral osteomyelitis
Definition

antibiotics tailored to C & S - high doses IV for atleast 4 - 6 weeks

 

early surgical debridement and drainage

Term
what lab is required for the diagnosis of acute nongonococcal arthritis
Definition
joint aspiration/synovial fluid analysis is required to establish diagnosis
Term
describe the typical findings in a joint aspiration for acute nongonococcal arthritis
Definition

synovial fluid is turbid, serosanguineous or frankly purulent

leukocyte count in synovial fluid > 50,000 - 100,000 w/> 90% polys

gram stain positive in 75% of staph, and in 50% of G- orgs

positive cultures > 90%

elevated protein

elevated LDH

Term
treatment of acute nongonococcal arthritis when organism has not yet been determined
Definition

prompt IV antibiotic that covers staph, strep, and G-'s:

third generation cephalosporin, ie:

ceftriaxone, cefotaxime, or ceftizoxime

 

immediate ortho consult for timely drainage pf pus and necrotic debris from joint

 

avoid weight bearing until inflamm has subsided

 

early PROM exercises to maintain mobility

Term
treatment of acute nongonococcal arthritis when MRSA is reasonably likely
Definition

prompt IV therapy with vancomycin

 

immediate ortho consult for timely drainage of pus and necrotic debris from joint

 

avoid weight bearing until inflamm has subsided

 

early PROM exercises to maintain mobility

Term
what class of drug should be AVOIDED in the treatment of acute nongonococcal arthritis
Definition
glucocorticoids
Term
what physical findings would be helpful in pointing you toward the diagnosis of gonococcal arthritis
Definition
two to ten small necrotic pustules on the extremities, especially the palms and soles
Term
treatment of gonococcal arthritis
Definition

initial treatment: ceftriaxone (recephin) 1 g IV daily

OR

cefotaxime 1 g IV q 8 hrs

 

after 24 - 48 hours, and pt improvement: switch to an oral 7 - 10 day course of

oral ciprofloxacin, 500 mg BID

OR

oral cefixime, 400 mg BID

 

*REPORT to health department*

Term
what is required to make the diagnosis of viral arthritis
Definition
viral serologies
Term
treatment of viral arthritis
Definition

NSAIDs

 

if pt has Hep C arthritis - symptoms 2ndary to Hep C may respond to interferon-alpha

Term
treatment of arthritis due to lyme disease
Definition

doxycycline

OR

amoxicillin

Term
treatment of arthritis due to syphilis
Definition
PCN
Term
treatment of arthritis due to a fungus
Definition

drainage and lavage of joint

 

IV antifungal agents

 

intra-articular antifungal agents

Term
what is required to make the diagnosis of arthritis due to a fungus
Definition
diagnose with culture and stain of synovial fluid
Term
what is needed to make the diagnosis of mycobacterial arthritis
Definition
diagnose with acid-fast staining of synovial fluid and cultures
Term
treatment of mycobacterial arthritis
Definition
multi-drug therapy for 6 - 9 months
Term
what are the imaging findings that would help steer you toward the diagnosis of mycobacterial arthritis
Definition
radiographs showing peripheral erosions at the points of synovial attachment
Term
what are the radiographic findings of osteoarthritis
Definition

narrowing of the joint space

 

osteophyte formation

 

lipping or marginal bone

 

thickened, dense subchondral bone

 

bone cysts

Term
how to prevent osteoarthritis
Definition

weight reduction - esp reduces risk for knee OA

 

maintain normal Vit D levels - reduces occurence and progression

Term

what is the non-medical treatment for osteoarthritis

(aka - pt has mild to moderate OA of weight bearing joints)

Definition

moderate physcial activity:

therapeutic walking program

hydrotherapy classes

tai chi

weight loss

Term
what is the first line treatment for mild osteoarthritis
Definition

acetaminphen

 

pts should not use NSAIDs unless they aren't responding to acetaminophen - avoid high doses

Term
what
Definition
Term
what line of treatment could be used for an osteoarthritis pt, if you are trying to discontinue their daily oral drug regiment
Definition
traiamcinolone - intra-articular injections normally 4 times a year
Term
what type of surgery is effective for osteoarthritis and which one is not effective
Definition

effective treatment: total hip and knee replacement

 

not effective: arhtroscopic surgery for the knee

Term
what finding is diagnostic for gouty arthritis
Definition

identification of sodium urate crystals in joint fluid or material aspirated from a tophus

 

OR

 

when a "rate bite" (punched out erosion w/overhanging rim or cortical bone) is adjacent to a soft tissue tophus

Term
what is typically seen on polarized light microscopy for gouty arthritis
Definition

urate crystals that are needle-like

and

negatively birefringe

when examined by polarized light microscopy

Term
treatment of asymptomatic hyperuricemia
Definition
do not treat until it progresses to gouty arthritis, renal calculi, or tophi
Term
treatment of choice for acute gouty arthtitis
Definition

*treat arthritis first, hyperuricemia later*

 

NSAIDs - indomethacin 25 - 50 mg q 8hrs PO, until symptoms have resolved (5 - 10 days)

Term
treatment of acute gouty arthritis when indomethacin is contraindicated
Definition

celecoxib, 200mg BID day1, then 100mg BID until resolution

 

OR

 

corticosteroids - IV or oral, tapered over 7 - 10 days

if monoarthritis, can use intra-articular

Term
what is the management of gouty arthritis BETWEEN attacks for a pt who just experienced their first single episode (and are willing to lose weight and stop drinking)
Definition
if they are willing to lose weight and stop drinking alcohol - they are at low risk for another attack (& therefore don't typically need long term therapy)
Term
what is the management of gouty arthritis between attacks
Definition

colchicine - 0.6 mg QD or BID

 

if uncontrolled by colchicine prophy:

uricosuric drug (probenacid or sulfinpyrazone) or

xanthine oxidase inhibitor (allopurinol or febuxostat)

Term
when managing gouty arthritis between attacks, what is typically added to the administration of a uricosuric drug or allopurinol to suppress a potential attack precipitated by abrupt change in serum uric acid level
Definition
Term
for pts with gouty arthritis, who are under secreters of uric acid, what drug can be added to their care
Definition

uricosuric drug:

probenacid

OR

or sulfinpyrazone

Term
for pts with gouty arthritis, who are over producers of uric acid, what drug can be added to their care
Definition

xanthine oxidase inhibitor:

allopurinol

OR

febuxostat

Term
what test is diagnostic for CPPD/pseudogout
Definition
definited diagnosis requires rhomboid or rod-like crystals in synovial fluid or articular tissue with weak positive birefingence w/polarized light microscopy
Term
treatment of CPPD/pseudogout
Definition

joint aspiration and NSAIDs, or intra-articular steroids

resolution normally < 10 days

Term

treatment of frequent recurrent attacks of CPPD/pseudogout

 

or when it is severe polyarticular attacks

 

(these are two different questions, was lazy and didn't want to make two cards)

Definition

frequenct recurrent: daily prophylactic colchicine

 

severe polyartiuclar: short course glucocorticoids or anakinra (IL-1B antagonist)

Term
what is the treatment of CPPD/pseudogout that has resulted in progressive destructive large joint arthropathy
Definition
joint replacement
Term

what are typical lab/image findings for osteoporosis

 

(not necessarily diagnostic)

Definition

serum Ca, phos, and PTH = NORMAL

 

alk phos = normal to elevated (elevated esp after a fx)

 

Vit D deficiency

Term
WHO T score criteria for determining osteoporosis
Definition

T score > -1 : Normal

 

T score -1.0 - -2.5 : osteopenia (low bone density)

 

T score < -2.5 : osteoporosis

 

T score < -2.5 w/a fx : severe osteoporosis

Term

ways to prevent osteoporosis

 

(this is not all inclusive)

Definition

adequate protein, total calories, Ca and Vit D

 

d/c corticosteroid use if poss

 

if hypercalciuric - take thiazides

 

stair climbing

 

weight bearing exercises

Term
indications for treatment of osteoporosis in women
Definition

all women w/ T score below -2.5 (ie. osteoporosis)

 

all who have had fragility fx's

 

as prophy in advanced osteopenia (T score -2.0 - -2.5)

Term
what are the different lines of treatment for osteoporosis
Definition

Vit D and Ca - give Ca only for pt w/low Ca diet

 

bisphosphonates

 

HRT (women = estrogen; men = testosterone, don't take give if pt has prostate CA)

 

SERMS: teriparatide

 

calcitonin

 

denosumab

Term
what line of treatment is effective in preventing corticoid-induced osteoporosis
Definition
bisphosphonates
Term
what are the directions you need to tell your pt about how they need to take their bisphosphonate pills for the treatment of osteoporosis
Definition
must be taken in the morning with atleast 8 oz of plain water atleast 40 minutes prior to any consumption, and pt must remain upright after taking the pill to reduce the risk of esophagitis
Term
atypical "chalk-like" fractures are possible side effects of what drug used in the treatment of osteoporosis
Definition
bisphosphonates
Term
at what point can you stop bisphosphonate therapy, for the treatment of osteoporosis, because of its extremely long half life
Definition
can consider discontinuing a bisphosphonate after 5 yeras of therapy b/c alendronate has a half life of 10 years in bone
Term
which line of treatment for osteoporosis is typically reserved for pts w/severe osteoporosis who did not tolerate other treatments; and when would you not use this drug
Definition

denosumab

 

it decreases Ca levels, therefore do not use in a pt/HYPOcalcemia

Term
in what instance would you NOT give testosterone as the line of treatment for osteoporosis in a male
Definition
when pt has prostate CA
Term

history of back pain at night that is unrelieved by rest leads you to what diagnosis?

 

back pain that is worse with rest and improves with activity

 

worse with activity, and improves with rest

 

writhing back pain

Definition

pain at night: malignancy or compression fx

 

worse with rest: inflammatory:ankylosis spondylitis

 

worse with activity: degenerative arthritis or disk disease

 

writhing: kidney or gallstone, rupturing aneurysm

Term
what are some rapidly progressive neurologic symptoms associated with back pain
Definition

bilateral leg weakness (mult lumbar n root compression, epidural abscess)

 

saddle anesthesia, bowel/bladder incontinence, impotence (cauda equina syndrome)

 

pain most prominent w/less prominent numbness (herniated disk involving single root, epidural abscess)

 

 

Term
positive straight leg raise occurs at what angle/degree and indicates what
Definition

positive if radicular pain is reproduced at 60% or less and indicated herniated disk at L4-5 or L5-S1

 

crossed straight leg: raise contralateral leg, if pain is reproduced on affected side = positive and supports above findings

Term
for a pt with acute back pain, when would you consider ordering an MRI
Definition

when you have a high suspicion of:

 

abscess: bilat leg weakness; pain worse than amount numbness; incontinence

osteomyelitis: spinous process tender to palpation

cadua equina syndrome: incontinence, impotence

spinal stenosis

herniated disk: pain is worse than amount of numbness

mets

Term
treatment of acute/subacute back pain
Definition

*< 4 weeks, 4 - 12 weeks*

 

remain active, NO ROLE FOR BED REST

 

avoid heavy lifting (>10 lbs), prolonged sitting, twisting/bending - until symptoms resolve

 

back exercises to minimise recurrent flares

 

NSAIDs 1 -2 weeks, and then PRN

 

muscle relaxants is spasm for first 1 - 2 weeks

Term

for acute/subacute back pain, what would you give/do:

 

for pt with muscle spasms

 

to temporarily improve sciatica

 

for pt with serious symptoms

Definition

spasms: muscle relaxants for first 1 - 2 weeks

 

sciatica: steroid injection

 

serious symptoms: decompressive surgery

Term
procedure of choice for a herniated/ruptured disk
Definition
partial hemilaminectomy w/excision of prolapsed disk +/- fusion of involved lumbar segments (if spondylolisthesis)
Term

treatment of chronic back pain due to degenerative conditions:

 

spinal stenosis

facet joint hypertrophy

Definition

spinal stenosis: NSAIDs, exercise, pain management, surgery is not resolved

 

facet joint: surgical foraminotomy

Term
treatment of tendoitis (regardless of location)
Definition

NSAIDs and rest (rest may include splinting)

 

if refractory: consider PT

Term
treatment of bursitis
Definition

treat  underlying cause (RA, thyroid, Ca deposits, gout DM)

drain bursa - to send off for infection/gout

 

if due to overuse:

inject steroid

NSAIDs (try to avoid opioids)

compressive wrap

Term
numbness and shoulder pain that radiates below the elbow makes you think...
Definition
usually due to cervical spine disease NOT shoulder disease
Term
what findings support your thought of impingement syndrome
Definition

shoulder pain occurs with overhead motion

 

pt lacks full ACTIVE ROM but has full PASSIVE ROM w/pain

 

positive neer's sign

 

positive hawkin's sign

Term
a positive neer's signs supports what diagnosis
Definition

impingement syndrome

 

OR

 

rotator cuff tear

Term
a positive hawkin's signs supports what diagnosis
Definition

impingement syndrome

 

OR

 

rotator cuff tear

Term
what x-ray view is preferred to help in the diagnosis of shoulder disorders (ex - impingment syndrome)
Definition
lateral "Y" scapula view
Term

first line treatment for impingement syndrome of the shoulder

 

what is given for short term relief of impingement syndrome

 

if above two are not effective

Definition

first line:

activity modification (stop what they are doing)

physical therapy

NSAIDs

 

short term relief:

corticosteroid injection

 

above not effective:

arthroscopic acromioplasty

bursectomy (acromioplasty typically done before bursectomy)

debridement/repair of rotator cuff tears

Term
what imaging modality is best for visualizing rotator cuff tears
Definition

MRI

 

(US is good for full tears, but not good at detecting partial rotator cuff tears)

Term
treatment of a partial rotator cuff tear
Definition

PT strengthening

NSAIDs - pain control

if spasm - muscle relaxant

consider orthopedic referall

Term
treatment of a complete rotator cuff tear
Definition

automatic orthopedic referral

usually requires surgery it young and healthy and active

if older - typically aren't good surgical candidates, therefore just limit their acitivty and the ROMs

Term
treatment of adhesive capsulitis
Definition

NSAIDs

 

PT - ROM and stretching

 

steroid injection into subacromial space or glenohumoral joint

 

surgical: manipulation, arthroscopic release

Term
positive maudsley test supports what diagnosis
Definition

lateral epicondylitis

 

(pain on resisted extension of middle finger)

Term

what physical exam finding will support your suspicion of:

 

lateral epicondylitis

 

medial epicondylitis

Definition

lateral:

pain on resisted wrist extension

 

Medial:

pain on resisted forearm pronation

pain on resisted wrist flexion

Term

treatment of epicondylitis

 

what would give short term relieve

 

when would you refer to ortho

Definition

modification of offending activity

 

NSAIDs

 

PT - stretching and strengthening

 

may require surgical release and repair

 

short term relief: steroid injection

 

refer: no improvement after 3 - 6 months, or to give steroid injection

Term
positive phalen's test supports what diagnosis
Definition
carpal tunnel syndrome
Term
positive tinel's sign supports what diagnosis
Definition
carpal tunnel syndrome
Term
positive durkan compression test supports what diagnosis
Definition

carpal tunnel syndrome

 

*highest sensitivity/specificity of all specialty exams for carpal tunnel*

Term
finkelstein's test supports what diagnosis
Definition
de quervain's tenosynovitis
Term
treatment of carpal tunnel syndrome
Definition

avoid repetitive movement of wrist

 

wrist splinting in neutral position up to 3 months

 

NSAIDs and oral steroids

 

injection steroids into carpal tunnel

 

surgical release of carpal tunnel - endoscopic, minimally invasive

Term
treatment of de quervain's tensosynovitis
Definition

*extensor pollicis brevis and abductor pollicis longus*

 

NSAIDs and ice

avoid offedning activities

thumb spical brace to rest EPB and APL tendons

steroid injection if initial therapy fails

Term
treatment of ganglion cyst
Definition

NSAIDs

cyst aspiration and injection of steroid

surgical excision

1/3 resolve spontaneously

Term

intial treatment of trigger finger

 

treatment of refractory trigger finger

Definition

initial:

NSAIDs and buddy tape finger in extension

steroid injection in tendon sheath

 

refractory:

surgical release of tendon sheath

Term
treatment of fibrous dysplasia
Definition

aka: bone cysts, osteofibroma

 

local excision

Term
lab/image findings that support diagnosis of paget's disease of the bone
Definition

serum alk phos is markedly elevated

urinary hydroxyproline elevated in active disease

 

radiographs: advancing flame shaped lytic lesions in long bones, and become subsequently sclerotic, eventually becoming thickened and deformed

Term
treatment of asymptomatic paget's disease of the bone
Definition
surveillance and no treatment unless extensive involvement
Term
treatment of choice for paget's disease of the bone
Definition

bisphosphonates given cyclically, when alk phos normalized give a 3 month break until serum alk phos starts to rise again and then do another cycle

 

correct ant Vit D if present BEFORE prescribing bisphosphonates

Term
the four most common malignant nonhematopoietic bone tumors
Definition

osteosarcoma

 

chondrosarcoma

 

ewig's sarcoma

 

malignant fibrosis histiocytoma

Term
benign tumors that have the potential of becoming chrondrosarcomas (malignant)
Definition

enchondroma

 

osteochondroma

Term
which benign sarcomas have the potential of becoming malignant fibrous histiocytoma or osteosarcoma
Definition

fibrous dysplasia (bone cyst/osteofibroma)

 

bone infarct's

 

paget's disease of the bone

Term
radiographic findings supportive of osteosarcoma
Definition

destructive lesion w/moth eaten appearance, sunburst appearance and a cuff of new bone formation at the margin of the soft tissue mass

*likes metaphyses of long bones*

Term
diagnostic criteria for osteosarcoma
Definition
pathologic diagnosis established w/ core needle biopsy or an open biopsy w/ appropriately placed incision to allow limb sparing later
Term
treatment of osteosarcoma
Definition

preop chemo

followed by limb-sparing surgery

followed by postop chemo

 

*RADIORESISTANT - XRT has NO ROLE in management*

Term
which sarcoma is radioresistant, and therefore XRT has no role in its management
Definition
osteosarcomas
Term
diagnosis of chondrosarcoma is determined how?
Definition

influenced by H&P

new onset of pain, signs of inflammation, progressive increase in size of mass all suggest malignancy 

Term
treatment of chrondrosarcoma
Definition
surgical resection of primary or recurrent tumor including lung mets
Term
which sarcoma is resistant to chemo
Definition
chrondrosarcomas
Term
radiographic findings supportive of ewing's sarcoma
Definition

characteristic "onion peel" periosteal reaction w/generous soft tissue mass

 

mass is better seen with CT or MRI

Term
treatment of ewing's sarcoma
Definition

*very aggressive*

 

systemic chemo, often preop

 

surgical resection usually w/limb sparing or radiation

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