CMS II Neuro Test 1

Cerebral Vascular Disease

1. Clinical assessment of acute stroke

a. ABC

b. IV, O2 & monitor

c. <3hr ischemia stroke thrombolytic therapy

2. National Institute of Health Stroke Scale (NIHSS): used for stroke classification – primary guide for tPA (tissue plasminogen activator) treatment decision

a. Focuses on 6 major areas of the neurological exam:

i. Level of consciousness

ii. Visual function

iii. Motor function

iv. Sensation and neglect

v. Cerebellar function

vi. Language

3. ED Stroke Protocol = head CT without contrast within 25 min: primary goal to distinguish between ischemic & hemorrhagic strokes

4. No BP control during acute stoke unless: SBP > 220 mmHg or DBP > 120 mmHg

a. Lowering systemic BP in pt with acute cerebral infarction is contraindicated because it may produce clinical deterioration

b. Upper limit of 220/110 “accepted” (185/110 with TPA use)

c. Ex: after stroke, pt with BP of 180/107. Vital organs weren’t compromised? Monitor only

5. Transesophageal Echocardiogram (TEE) when strong suspicion of cardio-embolic etiology

6. Stroke in young or unconscious patient mandates further evaluation – urine drug screen immediately upon admission

7. FDA Approved Intravenous tPA(tissue Plasminogen Activator) for thrombolysis within 3 hours of stroke onset

a. Age >18

b. NIHSS >4

c. Dx of ischemic stroke of <3 hrs duration

8. Off Label Intraarterial tPA for thrombolysis within 6 hours of stroke onset

9. TPA contraindications

a. Symptoms minor – NIHSS score <4, OR rapidly improving

b. Uncontrolled BP > 185/110 despite repeated measurements

c. Glucose is < 50 or > 400

d. Abnormal PT/PTT (On anticoagulation therapy with INR>1.7)

e. Platelets less than 100,000

f. Major GI/GU Hemorrhage in last 3 weeks

g. Stroke/head trauma in last 3 months

h. Presents with seizure

i. Noncompressible arterial puncture site in last 7 days

j. Major surgery in the last 14 days

k. Any history of ICH

l. Symptoms suggest SAH

10. SQ heparin prevents DVT & PE – never give heparin bolus

a. SQ Heparin saves lives because it prevents DVT and Pulmonary Embolism

11. Most effective treatment besides heparin? Aspirin

a. If aspirin is given in the first 48 hours after stroke, there is 1 less death per 100 treated patients

12. Aspirin: only effective antiplatelet for early Tx of acute ischemic stroke – give to all pts without contraindications to reduce recurrent stroke risk

13. Most common type of CVD: ischemic

14. Ischemic stroke most common cause: atherosclerosis (15% also assoc with a-fib)

15. Ischemic stroke primary prevention strategies with greatest risk reduction: atrial fibrillation Tx (70% RR) & HTN Tx

a. Treatment of Hypertension: 38% risk reduction (RR): ACE inhibitors

b. Smoking Cessation: 50% RR

c. Hyperlipidemia: 20-30% RR in setting of CAD: Statin drugs

d. Atrial Fibrillation Treatment: 70% RR

i. Most like you’re going to get a stroke but when?

e. Asymptomatic Carotid Stenosis: 50% RR: carotid endarterectomy

16. Secondary ischemic stroke prevention therapy

a. Risk Factor Assessment and Modification

i. HTN, DM, AFib, Tobacco abuse, Cholesterol, birth control pill, Alcohol abuse

b. Antiplatelet Therapy

c. Anticoagulation

d. Carotid Endarterectomy

e. Cerebrovascular Stent Placement and Angioplasty

17. All pts who have sustained a stroke & have no contraindication should receive an antiplatelet agent to reduce the risk for recurrent stroke

18. Cardioembolic stroke pt with contraindication to anticoagulant therapy: give aspirin (antiplatelet)

a. For patients with cardioembolic stroke & contraindications to anticoagulant therapy aspirin 75-325mg/d

19. carotid endarterectomy: indicated for asymptomatic pts with >80% carotid stenosis or >70% with symptoms

20. Outpatient vs inpatient eval of TIA

a. Reasonable to hospitalize patients with TIA if they present within 72 hours of the event and any of the following are present:

i. ABCD2 score > or = 3

ii. ABCD2 score 0-2 but uncertain that diagnostic evaluation can occur within 2 days as outpatient

iii. ABCD2 score 0-2 and evidence of cerebral infarction

21. Transient Ischemic Attack (TIA): brief, transient episode of neurologic dysfunction caused by focal ischemic event that lasts <24 hours without acute infarction (usually < 1 hour)

22. After TIA, early risk of stroke is high – expedite evaluation to identify high risk conditions (ABCD score)

23. TIA diagnosis/management: Brain MRI with DWI and Carotid Duplex

24. TIA recurring with different symptoms: usually emboli of cardiac source

25. TIA recurring with identical features: usually ischemic within cerebral circulation

26. TIA of the ICA may be manifested as ipsilateral transient monocular vision loss (amaurosis fugax)

27. Middle Cerebral artery occlusion: gaze deviation toward infarct side with contralateral hemiparesis, contralateral hemisensory loss, homonymous hemianopia (on side of weakness) – ex: R MCA occlusion = right gaze deviation, left sided weakness

a. Most common type of focal stroke

b. Dominant: global aphasia

c. Nondominant: contralateral neglect

28. Posterior cerebral artery occlusion: Contralateral homonymous hemianopia

29. Vertebral-basilar artery occlusion: arteries cerebellar findings:

a. Ataxia, diplopia, vertigo—NOT aphasia

30. Subarachnoid hemorrhage stroke: most common cause of non-traumatic SAH – ruptured berry aneurysm or arterial venous malformations

31. Intracerebral hemorrhage risk: highest is uncontrolled HTN (also smoking)

a. Presence of cardiac left ventricular hypertrophy and location deep in brain are common hallmarks

32. Treatment for hemorrhagic stroke: ICU admission

33. Management of ^ ICP: mannitol, mechanical ventilation, sedation

34. Rupture cerebral aneurysm: initiate Nimodipine to prevent cerebral vasospasm

35. Aneurysmal SAH high risk populations: Homocysteinuria pts & 1st degree relatives of aneurysm pts

a. Primary Prevention of Aneurysmal SAH

i. Screening of high risk population

1. Homocysteinuria patients

2. First degree relatives of patients with aneurysms

Electrodiagnostic Studies of the Nervous System

1. Absence seizure EEGs – 3/sec generalized distinctive spike and wave pattern

2. Alpha EEG waves (8-12 Hz): most prominent in awake, relaxed state with eyes closed

a. Represent occipital region, and parietal and frontal regions to a lesser extent.

3. Beta EEG waves (5-30 Hz low amplitude waves): active concentration & thinking

a. Associated with active, busy, or anxious thinking and active concentration

b. Represents parietal and frontal regions

4. Theta waves (4-7 Hz):

a. Parietal and temporal regions in children

b. Emotional stress in some adults (disappointment and frustration)

c. Also seen in focal or generalized cerebral dysfunction

5. delta waves (1-3 Hz): significant dysfunction of underlying cortex when present in adults

6. Radiculopathy – damage proximal to dorsal root ganglion (preganglionic) affects motor but not sensory

7. Brachial plexopathy: damage distal to dorsal root ganglion (postganglionic) affects motor & sensory

8. H reflex: evaluates S1 nerve root specifically for sacral radiculopathy

9. F wave: motor axons of most extremity muscles; assess polyneuropathy

a. Not very helpful except in Guillian-Barre where they are often absent or delayed. Measures potentials near the proximal region of the spinal cord.

10. Nerve conduction study contraindication: implanted cardiac defibrillator

a. significant coagulopathy or blood dyscrasis

b. implanted cardiac defibrillator

c. extra care with anticoagulation

11. Electromyography (EMG): assesses muscle fibers, motor units, and motor end plates

12. Demyelinating polyneuropathy: prolonged distal motor/nerve latency, decreased conduction velocity, and normal amplitude

a.

Headaches

1. Most important component of neurologic diagnosis: history

2. Headache symptoms requiring further evaluation & emergent imaging: confusion/AMS, seizure, fever, sudden onset (thunderclap), papilledema, or neuro symptoms

a. ***Confusion, seizure, fever, or focal neurologic symptoms suggest serious cause requiring further evaluation***

3. Emergent imaging:

a. Sudden onset (“thunderclap”) “worst headache of life”

b. Altered mental status/seizure

c. Focal neurologic deficit

d. Papilledema

e. Severe hypertension

4. Non-contrast CT: preferred study for acute head trauma & acute intracranial hemorrhage

5. Contrast CT: space occupying lesions, complications of HIV, subacute subdural hemorrhage

6. CT is generally able to demonstrate any neurosurgical emergency or contraindications to LP

7. Migraine headache w/o aura 5x in last 3 months & no relief with OTC meds: give ergotamine for abortive & consider prophylactic if headaches exceed 2x/month

8. Triptans: contraindicated in uncontrolled hypertension or CAD (ex: Sumatriptan)

a. May result in vasoconstriction of coronary arteries

i. Small but not negligible chance of MI

ii. Risk factors: men >50 y/o, women >60 y/o, cardiac risk factors, uncontrolled hypertension

b. “Triptans,” unless contraindicated, are medications of choice for abortive therapy

9. Cluster headaches: unilateral, non-throbbing, boring, stabbing, burning, steady, located behind eyes with ipsilateral nasal congestion, conjunctival injection, forehead sweating at same time every day

10. Cluster headache Tx: 100% oxygen for 15-20 min, triptans if needed

11. Tension headaches: bilateral band-like pressure tightening similar to vise; can last hours to days; no nausea/vomiting

12. Tension headache Tx: aspirin or NSAIDs – caffeine can enhance & help

13. Best next step in management for an 18 year-old female with bilateral headache for a week?

a. Cerebral CT scan is the next step. Administration of a drug is withheld until a cause in known.

14. Temporal arteritis symptoms: preauricular or scalp tenderness, jaw claudication, visual disturbances, onset > age 50

15. Temporal arteritis test to order: ESR (inflammation) – next mgmt. step for 75 year old female with severe left-sided temporal headache = ESR to show inflammation

a. Treat with corticosteroids

16. Trigeminal neuralgia: recurrent jaw pain on one side; recurrent paroxysms of sharp, searing, burning or stabbing pain. Touch cheek or hold hand near trigger zone during paroxysm to guard region between attacks. Pain often provoked by light touch to facial trigger zone.

a. Sweet criteria:

i. Paroxysmal pain, provoked by light touch to facial trigger zone, confined to trigeminal distribution, unilateral, normal sensory exam

17. Trigeminal neuralgia etiology: vascular compression of 5th cranial nerve root

a. Associated with MS

b. Mean duration of 15 min

18. Pseudotumor cerebri (papilledema in young, obese female) – next step: CT scan to exclude mass

a. 90% of patients are obese, young females

b. Headache is usually pulsatile, daily, and continuous

c. Commonly affects CN 6

d. Associated with excessive ingestion of vitamin A

e. CT or MRI (more sensitive) – exclude mass or other reason

f. MRA/MRV - exclude venous sinus thrombosis

g. Tx: weight loss, Diamox, therapeutic LPs

19. Brain tumor signs: new onset, progressive headaches that are most pronounced in morning

20. Subarachnoid hemorrhage presentation: sudden, worst headache of life (thunderclap), nuchal rigidity, & fever

21. SAH gold standard for diagnosis & treatment planning: cerebral angiogram

22. Epidural hematoma- lenticular: smooth, biconvex; arterial

23. Subdural: irregular; venous

24. MRI with contrast: use for brain abscess, brain/spinal tumors – more sensitive than CT for any lesion except acute blood

25. Do CT or MRI before LP to rule out extreme ICP – else, could cause brain herniation

26. Meningismus: stiffness with flexion (not rotation) indicates meningeal irritation

General

27. Primary neuronal (Gray matter) disorders: present with cognitive disturbances, movement disorders, or seizures – NOT visual disturbances

28. White matter involvement produces predominantly “long tract” disorders of motor, sensory, visual, and cerebellar pathways.

29. Rapid onset, occurring within seconds or minutes, usually indicates a vascular event, a seizure, or migraine

30. A stuttering onset where symptoms appear, stabilize, and then progress over hours or days also suggests cerebrovascular disease; an additional history of transient remission or regression indicates that the process is more likely due to ischemia rather than hemorrhage

31. A gradual evolution of symptoms over hours or days suggests a toxic, metabolic, infectious, or inflammatory process

32. Relapsing and remitting symptoms involving different levels of the nervous system suggest MS or other inflammatory processes

33. Slowly progressive symptoms without remissions are characteristic of neurodegenerative disorders, chronic infections, gradual intoxications, and neoplasm.

34. CT: best emergent test for head/spine trauma, neuro, acute stroke

a. Good in emergency situations

b. Better for bone, fresh bleeding

c. Method of choice to evaluate head or spine trauma

d. Contrast CT:

i. Brain tumors or infection

35. Brain MRI: especially good for soft tissue

a. Herniated disc

b. With contrast: best way to look at brain or spine tumors or infections

36. Most important job of PCP for pt with new neurologic complaint: assess urgency of specialist referral

37. When would you NOT do neuroangiography? Abscess

a. Neuroangiography: Used to determine whether blood vessels have narrowing, atherosclerotic plaques, ulcerations, abnormal connections to other vessels, aneurysms, or clots

i. Most often- carotid artery

CMS II Neuro 2

Epilepsies and Convulsive Disorders1. Condition with recurrent seizures with no single identifiable etiology- epilepsy

a. Seizure: clinical manifestation of abnormal, excessive, hypersynchronous discharges from an aggregate of CNS neurons

i. Classification based on clinical features and EEG findingsb. Lennox Gastaut syndrome: occurs in children ages 1-8 and is defined by the following

triad: (1) multiple seizure types, (2) EEG showing slow (<3 Hz) spike-and-wave discharges and a variety of other abnormalities, and (3) impaired cognitive function in most, but not all cases - variety of causes - most have poor prognosis because of underlying CNS disease -poorly controlled

2. Which of the following is a type of partial seizure- mesial temporal lobe epilepsya. Common syndrome associated with complex-partial seizuresb. MRI- hippocampal sclerosis c. Refractory to medical anticonvulsant therapyd. Responds well to surgical treatment

3. Seizures associated with metabolic derangements? Tonic-clonica. Metabolic derangements of any type are a systemic condition thus it will affect the brain

globally.b. Partial (focal): discrete areas of cortex

i. Typically associated with structural lesions ii. Simple: consciousness persevered; without alteration in consciousness

1. Jacksonian March: Seizure activity in focal area then spreads to adjacent areas

2. Todd paralysis: localized paresis of involved area after seizure 3. Epilepsial partialis continua: seizure lasts hours to days 4.

iii. Complex: consciousness impaired; more complex symptoms

1. Unable to respond to commands2. Impaired recollection or awareness of ictal phase 3. Stereotypic aura (simple-partial)4. Ictal phase: onset of amnestic phase

a. Sudden behavioral arrest or motionless stareb. Automatisms

i. Involuntary automatic behaviorsc. Lip-smacking, chewing, “picking”, pacing

5.iv. Partial seizures with secondary generalization (tonic-clonic)

1. Frequently follow simple-partial2. Difficult to distinguish from generalized tonic-clonic seizure 3. Differentiation essential due to substantial differences in evaluation and

treatment c. Generalized seizures: diffuse regions simultaneously

i. Bilaterally symmetricii. Cellular, biochemical, or structural abnormalitiesiii. Absenceiv. Tonic-clonic

1.

v. Tonicvi. Atonic: sudden loss of postural muscle tone; head dropvii. Myoclonic: sudden brief muscle contraction

4. How to differentiate between complex and simple partial seizures- impaired consciousness5. In what type of seizures is automatisms seen in? complex partial seizures- focal seizures6. A young boy that goes into “spells” of spacing out with eyelid fluttering for a couple of seconds,

describes which type of seizure? Absence seizuresa. Absence seizures: sudden brief lapses of consciousness without loss of postural control b. Last only secondsc. No postictal confusion d. Usually accompanied by subtle bilateral motor signs

i. Rapid eyelid blinkingii. Chewing movementsiii. Small-amplitude clonic hand movements

e. EEG:i. Generalized, symmetric, 3 Hz spike-wave discharge – begins and ends suddenly ii. More complexes than clinically evidentiii. Can provoked/trigger by hyperventilation

7. A boy that is 9 month year old boy with a seizures and fever, what do you do next? Antipyreticsa. Criteria:

i. Age 3 months - 5 years ii. Fever > 38o C (102o F)iii. No prior non-febrile seizure

b. Must rule out meningitis (esp <2yo)i. LP

8. What answer is correct about pregnancy and epilepsy? Monotherapy should be used if possible, with the lowest effective dose

a. All antiepileptic drugs carry teratogenic risks b. Risk of fetal malformation is increased twofold to threefoldc. Adequate folate should be ensured d. Monotherapy should be used if possible, with the lowest effective dosee. Breast feeding

i. Do not discourageii. Reconsider if effects on infant

9. First seizures with an unremarkable physical exam. What is an appropriate exam to do? EEG to differentiate what type of seizures

10.Discontinuing AEDsa. Seizure free for 2 years implies overall >60% chance of successful withdrawalb. Favorable factors

i. Control achieved easily on one drug at low doseii. No previous unsuccessful attempts at withdrawaliii. Normal neurologic status and EEGiv. Primarily generalized seizures onlyv. “Benign” syndrome

Cerbrovascular Infections11.Where does bacterial meningitis affect? Acute purulent infection within Subarachnoid space

a. Most cases hemtogenous origin b. A medical emergency requiring immediate Dx and rapid Tx with antibioticsc. If suspected: do not delay Tx while awaiting results of labsd. Bacterial meningitis is a reportable disease that needs to be reported to local health

authoritiese. Neurologist if persistent neurologic sequelae develop after bacterial meningitisf. Infectious disease consultant if pt has recurrent bacterial meningitis

12.Clinical presentation of HA, fever, meningismus (nuchal rigidity, photophobia and HA)? Bacterial meningitis

a. Altered MS (75%)b. (+) kernig’s and Brudzinski’s c. Rash- meningococcemia d. Raised ICP

i. Signs of ↑ ICP include: decrease LOC, papilledema, dilated poorly reactive pupils, CN VI palsy, decerebrate posturing, Cushing reflex (bradycardia, hypertension + irregular respirations)

13.LP CSF result for bacterial meningitis?a. Inc neutrophils, dec glucose, inc proteinb. Opening pressure (OP) - incc. ↑ WBC - neutrophils d. ↑ Proteine. ↓ glucose –bacteria feeds on glucosef. Gram stain + culture

i. Culture: positive in 65% to 90% of cases14.Patient with meningitis manifestation without papilledema or contraindications, what is the next

step? LPa. Obtain CT/MRI before LP if:

i. Papilledema, dilated or poorly reactive pupils, focal neurologic deficit, Hx of head trauma, profoundly depressed mental status, recent onset seizure, decerebrate or decorticated posture, or severe coagulopathy, or thrombocytopenia

15.LP CSF result for viral meningitis?a. Inc lymphocytes, normal glucose, inc proteinb. Viral meningitis: Inflammatory process involving meninges, usually accompanied by

mononuclear pleocytosis, without evidence of pyogenic bacterial infection on Gram stain or culture

c. Causes: viral, atypical and nonpyogenic bacterial and fungal meningitis, chemically induced meningitis, drug-induced meningitis, neoplastic meningitis

i. 66% are enterovirusesd. Rash- may mimic meningococcemia with meningitis e. Diagnostics: PCR of CSF

i. Recent development of reverse-transcription PCR for enteroviruses can reduce detection time to as little as 5 hours. Sensitivity in CSF is 85-100% with specificity of 90-100%

f. Treatment for viral meningitisi. Symptomatic w/o hospitalization ii. Unless in deficient humoral immunity, neonates, possibility of bacterial meningitis -

hospitalize16.Clinical presentation of HA, fever, and focal neuro deficit- brain abscess

a. Focal, suppurative process in parenchyma b. Predisposing conditions:

i. Paranasal sinusitis, otitis media, dental infections c. The abscess has a focal infected core: central portion contains neutrophils and pusd. The peripheral portion of the abscess: made up of inflammatory granulation tissuee. Treatment

i. Requires urgent intervention1. Surgery2. Antibiotics3. Glucocorticoids controversial 4. Used w/ increased ICP → + hyperventilation, elevate HOB, mannitol5. Should only be used for short periods6. + prophylactic anticonvulsants

17.Procedure of choice for brain abscess- MRI with gadoliniuma. CT+ contrast when MRI is contraindicatedb. LP: contraindicated

18.Rabies symptoms and likely exposure through caving, what is the treatment? rabies immune globulin and vaccine

a. Synonyms: hydrophobia – cardinal manifestation of the diseaseb. Pain or anesthesia at exposure site (first complaint)c. Difficulty swallowingd. Acute Neurologic Period

i. Extreme hyperactivityii. Bizarre behavior alternating with periods of relative calmiii. Hallucinationsiv. Disorientationv. Seizuresvi. Paralysis: (20%) pts present with ascending symmetric paralysis, easily confused

with GBS; however, rabies progresses to coma and deathvii. Fear, pain, and spasm of the pharynx and larynx caused by drinking viii. Coma, death

e. Causes in US are associated withi. Bats (number one)ii. Raccoonsiii. Foxes iv. Skunksv. Imported cases are usually associated with dogs

f. In domestic animals, incubation period is 3-12 wks but can range from days to months, rarely > 6 mo

g. DDxi. Delirium tremens ii. Tetanus iii. Hysteria iv. Psychiatric disorders v. Other viral encephalitis vi. Guillain-Barré syndrome vii. Poliomyelitis

h. Diagnostici. RT-PCR polymerase chain reaction: Viral Isolation: saliva, CSF, or tissueii. Brain biopsy

1. Analyzed by RT-PCR or direct florescent antibody2. Histological characteristic eosinophic inclusions (Negri bodies) in infected

neurons

3.i. Treatment

i. Non pharmacologic therapyii. Isolation of the patient to prevent transmission to othersiii. Universal precautionsiv. Supportive therapyv. Notify local health departmentvi. Active and passive immunization is most effective when used within 72 hr of

exposure1. Passive: one dose of rabies immune globulin (RIG) infiltrated in and around

the wound (not be administered to previously vaccinated persons)2. Active: 4 doses of vaccine over a 14d period (days 0, 3, 7, 14), or, 2 doses

over 3d period for pts previously vaccinatedj. Prognosis

i. Poorer prognosis: bites to face/neck, extremes of ageii. Better prognosis: thorough cleaning of the wound & post-exposure prophylaxis

19.What antiviral treatment would you use for a patient with viral encephalitis (HSV) and empiric? Acyclovir

a. Close monitoring, support vital functions (ICU care)

Other stuff in yellow highlights that wasn’t on the test20. Meningitis: inflammation of membranes (arachnoid, the pia mater and the intervening CSF) of

spinal cord and brain a. Diagnosis for bacterial meningitis: Electrophoresis, agglutination, CRP, PCR

21.Encephalitis: inflammation of white and gray mattera. Almost always associated with inflammation of meninges (meningoencephalitis) b. May involve spinal cord (encephalomyelitis)c. Viral encephalitis

i. Rash: enterovirus infectionii. Most common type: enteroviruses, transmitted by fecal-hand-oral route iii. CSF nucleic acid amplification - PCR

1. Procedure of choice for CMV, EBV, VZV, & enteroviruses22.Myelitis: inflammation of spinal cord

a. Patients often exhibit flaccid limb paralysis, incontinence, weakness or numbness of the limbs, and other symptoms

23. Reye’s syndrome a. Non-icteric hepatic encephalopathyb. Acute brain swelling with fatty infiltration of the viscera – liver

c. Associated with recent viral illness & exposure to salicylatesd. Clinical presentation

i. Protracted vomiting, deliriumii. Progress to coma within 2 daysiii. Seizuresiv. Decerebrate posturingv. Hepatomegalyvi. Signs of sympathetic overactivity (tachycardia, tachypnea, mydriasis)

e. Diagnosticsi. CMP: Blood glucose decreasedii. EEG: delta activity (normally assoc. with deep sleep)

Other Neurologic Disease part 11. Tics: Brief, repeated, stereotyped muscle contractions that are often suppressible. Can be simple

and involve a single muscle group or complex and affect a range of motor activities.a. Simple: movement only affecting individual muscle group (blinking, twitching of nose,

jerking of neck)b. Complex: coordinated involvement of multiple muscle groups (jumping, sniffing, head

banging, and echopraxia - mimicking movements)c. Tend to present between ages 2–15 years (mean 7 years) and often lessen or even

disappear in adulthood d. May present in adulthood and/or in association with other disorders, including PD, HD,

trauma, dystonia, drugs (i.e., levodopa, neuroleptics), and toxinse. Risks of side effects, such as extrapyramidal symptoms and tardive dyskinesia (so

consider the side effects)2. Essential tremors that occurs during voluntary movement- Kinetic

a. Postural: occurs with voluntary maintenance of position against gravityb. Resolves during sleepc. Some voluntary control/suppression- temporaryd. Treatment

i. Primidone (Mysoline) - anticonvulsant3. Type of cerebral ataxia that is non-progressive? congenital

a. Classificationi. Non-progressive (congenital)

1. Manifest either at birth or early life2. Cerebellar hypoplasia3. Clinical presentation

a. Hypotonia and developmental delaysb. Ataxia recognized when unsuccessful at independent walking

ii. Intermittent or episodic1. External stimuli often trigger symptoms or episodes

iii. Chronic or progressive1. identifiable biochemical defects

4. Advances stage of Huntington’s disease - emergence of dystonia a. Advancing disease → reduction in chorea and emergence of dystonia, rigidity,

bradykinesia, myoclonus, and spasticityb. Majority of patients develop dementia

5. Huntington’s disease is fatal – includes descriptionsa. Characterized by rapid, non-patterned, semi-purposeful, involuntary choreiform

movements6. Neurobehavioral disorder that is characterized by multiple motor tics and vocalizations.-

Tourette’s 7. For a patient with disabling tourette’s syndrome- Alpha 2 agonist

a. You can also use atypical neuroleptics, classical neuroleptics

8. Risk factors for Bell’s palsy- diabetesa. Pregnancyb. Travel to area endemic for Lyme disease

9. Most etiology of bell’s palsy- idiopathica. Often viral (herpes simplex)b. May also be manifestation of Lyme disease c. Clinical diagnosis confirmed by focused history and neurologic examinationd. Reassurance

i. Prognosis usually good ii. Virus attacking nerve, not stroke

e. Prevent corneal dryingi. Patch eyeii. Lacri-Lube ophthalmic ointment at nightiii. Artificial tears during day

10.Treatment for bell’s palsy- combination of prednisone and acyclovira. Neurology - diagnosis unclear or clinical course atypical

Other stuff that’s highlighted11. Cerebellar Atrophy

a. Sustained or repetitive involuntary muscle contractionsb. Predominantly a childhood-onset form of dystoniac. Autosomal dominant d. Primarily affects Ashkenazi Jews e. Focal dystonias

i. Most common from ii. 30-50 yoiii. Cause unknown

f. Secondary dystoniai. Consequence of drugs or other neurologic problems

Other Neurologic Disease II1. What is the main etiology affecting gullain-barre syndrome? Campylobacter jejuni

a. Most common cause of acute flaccid paralysis in the U.Sb. Military personnel at ^ riskc. Post-infectious d. Cytomegalovirus (CMV)- most common viral e. Symmetric weakness

f.2. What diagnostic testing is useful for diagnosing gullain-barre syndrome? LP for CSF studies

(Albuminocytologic dissociation)a. Elevation in CSF protein (>0.55 g/L) without an elevation in WBCs

3. Treatment for Guillain-Barre syndrome- high dose IV immunoglobulinsa. Initiate treatment ASAPb. High dose IV immunoglobulins OR plasmaphoresis separately are valid. The IV

immunoglobulins are preferred as the first choice of treatment because of its ease of administration. There is no increased benefit when using both at the same time.

4. Most common type of MS- Relapsing-remittinga. Epstein Barr virus b. Disease lower in equatorial regions c. An inflammatory disease causing multifocal areas of demyelination and scarring in brain

and spinal cord (plaques)d. Optic neuritis: common first demyelinating event e. Most commonly presents in young, healthy adultsf. Hyper-reflexia, (+) Babinskig. Clinical course

i. Progressive-relapsing MS: progressive course with superimposed relapsesii. Secondary progressive MS: worsening disability due to accumulating axonal loss

and new inflammation. This is the long-term outcome of the majority of RRMSiii. Primary progressive MS: gradual insidious worsening from onset without

relapsesiv. Relapsing-remitting MS: most common type. Full recovery of attacks may

occur early on, but with subsequent attacks, recovery is incompleteh. “separated in time and space”i. McDonalds Criteria (on MRI)

i. At least two attacks in timeii. At least two locations in CNSiii. No other explanation

5. A patient with a history of MS is experiencing visual disturbance when taking a hot shower, what symptom does this characterized? Uhthoff’s symptom

6. Most sensitive imaging test for MS? MRI

a.b. CSF: oligoclonal IgG bands

7. What NT is affected in Parkinson disease? Dopamine8. Patient with Parkinson disease (bradykinesia, cogwheel rigidity, resting tremor, and

micrographia), what should you prescribed to them? Levodopa/carbadopa a. Dopamine agonist drugs: first choice medication for most young patients

9. Patient with diplopia and other s/sx of MG what test can confirm this disease? Edrophonium Tensilon Test

a. Thymus involvement 75%b. Painless muscle weakness that increases with muscle use and improves after

restc. Bulbar (chewing and swallowing muscles) and facial muscles (second most

common)d. Myasthenic crisis

i. Inability to swallow, clear secretions, or breathe without artificial assistance10.Patient complaining of weakness in arms and legs. No bowel and bladder problems. The patient

was hyper-reflex and had a positive Babinski sign? ALSa. Involves both UMN’s of corticospinal tract and LMN’sb. Keep in mind, even in the late stages of the illness, sensory, bowel and bladder, and

cognitive functions are preservedc. Ocular motility is spared until the very late stages of the illness

Neuropathies 11.Motor negative phenomena: weakness, atrophy, hypotonia, fatigability, clumsiness

a.12.Intermittent, shooting pain in the face- trigeminal neuralgia

a. most common cause (80 to 90%) is an enlarged looping artery or vein pressing on CN V at the base of the brain

b. Tx:i. carbamazepine (Tegretol®)ii. gabapentin (Neurontin®)iii. start at a low dose and gradually increased with the ideal dosage being that which

controls the pain but does not cause side effects. 13.When to not use lidocaine skin patches for postherpetic neuralgia- on the face

a. Complication of HHV-3 (VZV) infection 14.Characterized by pain, weakness, numbness in the hand and wrist radiating up the arm and

positive phalen test- carpal tunnel syndrome a. DM or other metabolic disorders are at a higher risk

15.Office assistant frequently performing word processing tasks presents with right hand carpal tunnel like symptoms. What is the confirmation test for carpal tunnel? NCS or EMG

16.What disease is associated with deficiency of thiamine- alcoholic polyneuropathya. Wernicke-Korsakoff syndrome

i. CNS injury related to thiamine deficiency17.Chronic alcoholic are at risk for? Peripheral neuropathy

a. Peripheral polyneuropathy is the earliest symptom of chronic alcoholism b. Seizures are common

18.Patient with distal paresthesia and an increase BUN and creatinine ;and have EEG changes- uremic neuropathy

a. Distal paresthesia is the most common and usually the earliest symptomb. Most patients with BUN>60 have EEG changesc. Presents with paresthesia and altered mental statusd. Often occurs postdialysis/postdiuresis

19.DM is the leading cause of peripheral neuropathy.a. Monofilament testb. Foot ulceration and amputation are the most common consequencesc. Vascular and neurological complications are the most common causes of morbidity &

mortalityd. Improved metabolic control is the main goal of treatmente. Daily foot exam by patient is essential!

20.What of the following medication should be avoided for a patient with diabetic neuropathy? Alpha blockers

a. Avoid medications that can cause syncope:i. alpha-blockers, anti-HTN, antidepressants

21.Diabetic neuropathy autonomic symptoms? Impotence (sexual dysfunction)a. Diabetes mellitus autonomic neuropathy produces dysfunction in bowel and bladder

function as well as sexual dysfunction.22.Diabetic retinopathy is the most common cause of adult blindness in the United States23.Charcot-Marie-Tooth disease

a. Peroneal muscular atrophy b. Most common inherited disorder affecting motor and sensory neurons c. In an attempt to re-myelinate, the axons are surrounded by Schwann cells

hypertrophied “onion bulb”

CMS II Ortho 1

Shoulder Disorders1. Extrinsic cause of shoulder pain – C5-C6 radiculopathy (neural impingement)2. Calcific tendonitis x-ray identification- Calcific tendinitis is more common in DM

patients.

3. Clavicle Fx x-ray misaligned bones shown without tenting or other symptoms. Treatment? Sling, figure eight brace

4. AC separation – both ligaments torn with 100% raised Type I Sprain, AC Ligament intact Type II AC Ligament Tear and CC Ligament sprain Type III AC Ligament Tear and CC Ligament tear with AC Joint Dislocated Type IV III with Clavicle Posterior into/thru Trapezius Muscle Type V III with Clavicle elevated > 100% Superiorly Type VI III with Clavicle Inferior

5. Adhesive capsulitis – risks increased for diabetics & thyroid problems6. What lab test should you order in a patient with suspecting adhesive capsulitis in healthy

person – check blood Glucose7. Shoulder impingement caused by overhead overuse8. Shoulder dislocation requires? pre & post reduction xrays9. Anterior shoulder dislocation - what nerve most at risk for secondary injury? axillary

nerve10. X-ray pic of shoulder osteoarthritis- Glenohumeral Joint OA

X- Ray- Loss of Joint Space Osteophytes Flattening of the Bone Subchondral sclerosis Cyst formation

11. 80% of clavicle fracture are in the mid 1/3 of the clavicle12. Rotator cuff tendon tears- Supraspinatus most commonly torn secondary to

Impingement Syndrome, followed by Infraspinatus13.Bicep tendinitis- *Complication: Could turn into Biceps Rupture over time. *

14.

Disorders of the Cervical Spine15. Which of the following is an indication for further evaluation of neck pain?

Decreased grip strength Radiculopathy- pain, numbness, tingling High-impact trauma New or progressive neurologic deficit Neurologic deficit inconsistent with radiographic findings Suspected spinal tumor Suspected spinal infection Acute myelopathy (hyper-reflexia, gait disturbance, clonus, numbness or paresthesia in

legs) – (+) babinski Acute urinary retention or stool incontinence Neurogenic claudication- causing painful gait

16. Swimmer’s view – visualizes cervicothoracic junction Oblique views: Helpful to see interforamen , pedicle fractures

17. Whiplash symptom identification & treatment – early ROM & PT & hard collar Mechanical pain with aching paracervical pain stiffness (can be significant) beginning after

injury. May also experience HA, malaise, and fatigue. In 20%- 40% of patient’s pain may

persist up to 6mo (Chronic Whiplash Syndrome). Musculoligamentous strain from forced hyperextension and hyperflexion. Rear-end

collisions18. Identify c-spine radiculopathy level by symptoms – parasthesias in index, middle, &

ring fingers with triceps weakness: C6-C7 disk herniation (C7 nerve root)

C7 nerve root C6-7 disc herniation, spondylosis, osteophytes affects C7 nerve root

i. Paresthesias in index, middle or ring fingersii. Weakness in triceps, pronators, wrist flexors, and extensor

C6 nerve root C5-6 disc herniation, spondylosis, osteophytes affects C6 nerve root

i. Paresthesias in the thumb or lateral distal forearmii. Weakness in biceps, brachioradialis, and wrist extensorsiii. Diminish biceps and brachioradialis reflexes

C5 nerve root C4-5 disk herniation, spondylosis, osteophytes affects C5 nerve root

i. Pain, paresthesias, loss of sensation over shoulderii. Weakness of deltoid, biceps, and brachioradialis musclesiii. Diminished biceps reflexes

19. Cervical myelopathy: presents with leg spasticity & gait changes with clumsiness & + Babinski

Babinski sign (Extensor plantar reflexes) Leg spasticity Gait changes Upper extremity weakness, or clumsiness Sensory changes in arms, legs, or trunk (Palmar paresthesias) Sphincter dysfunction Neck pain is not often a prominent symptom Lhermitte’s sign: neck flexion causes electrical shock pain radiating down spine

20. Cervical Degenerative disk disease – most common location: C4-C7 C4-C7 vertebras (C5, C6 and C7 roots): most commonly involved in degenerative

Dz of cervical spine21. C-spine degenerative disk disease definition – cervical disk space narrowing,

vertebral end plate sclerosis & osteophyte development22. Fibromyalgia symptom deep sleep disturbance

Individuals diagnosed with fibromyalgia are very anxious just from the nature of the condition. Sleep is disturbed from this, and these patients lack REM sleep. Tender points are no localized but are generalized.

Clinical diagnosis Chronic pain of at least 6 months duration 90% of patients women

i. Prevalence increases with age23. Fibromyalgia symptoms – recognize Dx

Pain in atleast 11/18 paired tender points24. Jefferson Fx description – anterior & posterior Fx of C1

Bilateral fractures of both anterior and posterior arches of C1 (burst fracture of the

ring of C1) Approx. 1/3 of Jefferson fractures are associated with C2 fracture Mechanism: Axial-loading force on the occiput of the head:

25. Hangman’s Fx xray pic (C2 axis)- Bilateral fractures of the pedicles or pars interarticulars of the axis

Results from a severe extension injury Major complaints: upper posterior cervical pain, occipital neuralgia

26. Odontoid fracture: fractures of the dens Mechanism: high velocity injury Forced hyperflexion mainly or hyperextension in some

i. Hyperflexion injuries cause the dens to be displaced anteriorly, forward subluxation of C1 on C2

ii. Hyperextension injuries cause the dens to be displaced posteriorly, with posterior subluxation of C1 on C2

3 typesi. Type I: Apical (tip) fracture: stableii. Type II: body fracture, passes above a horizontal line drawn through the

upper border of the superior articular facets of the axis. High incidence of nonunion and frequently requires surgical fusion: unstable.

iii. Type III: Basilar fracture: with a fracture line passing into the body of the axis: unstable

27. Flexion compression fracture Wedge fracture

i. Flexion Teardrop Fracture:*

i. Most dangerous and unstable of all cervical spine injuriesii. Fracture through the inferior and anterior corner of the body with

communication through the body. iii. Posterior fragment displace backwards into the spinal cordiv. Acute and serious neurologic defectsv. Posterior neural arch may be fractured as well.

vi.28. Pt with neck pain & positive Spurling’s test – cervical disk herniation

Spurling’s test- Ask patient to rotate and extend the neck to one side. Apply gentle axial load, pain (cervical radiculopathy) on ipsilateral side is a positive test for nerve root compression

29. Spasmodic torticollis- PIC- is a twisted neck which the head is tipped to one side while the chin is turned into the other

30. Thoracic outlet syndrome

“Cervical rib syndrome”i. Hereditary elongation of C7 transverse processesii. Fibrous bands off accessory ribsiii. Bony fusion of variant ribs

Neurogenic (90%) Postural decompensation

i. Forward head, drooped shoulder, collapsed chest31. Extra information:

Clay shovelers (fracture of spinous process C6-T1) i. Mechanism: Hyperflexion with paraspinous contraction on spinous process,

Heavy lifting (shoveling)

ii. Bilateral facet joint dislocation

i. Mechanism: Extreme flexion of head and neck without axial compressionii. Complete anterior dislocation of vertebral body

iii.

Low back pain32. Cauda equine definition

Sever LBP with bilateral sciatica with saddle anesthesia (numbness, urinary retention and bowl dysfunction)

True surgical emergency Emergent MRI is the study of choice Surgical decompression is the only effective treatment

33. Spondylolisthesis – most common location (L4-L5 or L5-S1)34. Spondylolisthesis – forward slip of one vertebrae in relation to another

Most common cause of back pain in adolescents Symptoms often begin with the growth spurt Hamstring tightness is a common finding Patient may exhibit a type of waddling gait Types

i. Isthmic: commonly caused by fatigue or stress fracture of the pars interarticularis

ii. Congenital: commonly seen in women; no defect in the pars interarticularis

iii. Degenerative: common in women >40yo; Usually a result of long-standing instability, most commonly at the junction of the fourth and fifth lumbar vertebrae

iv. Pathologic: less common 35. Spondylolisthesis – shows as what on oblique x-ray? Fx

neck of scotty dog On Posterior Oblique views, there is an image that looks like a "Scotty Dog". In

cases of spondylolysis, there will seem to be a fracture across the neck of the Scotty dog.

36. Meyerding’s classification I-V for

spondylolisthesis Measures the percentage of vertebral slip forward

over the body beneath. Grade 1: 25% Grade 2: 25% to 49% Grade 3: 50% to 74% Grade 4: 75% to 99% Grade 5: 100%* Complete vertebral slippage: spondyloptosis

37. Lower back pain worse when sitting? herniated disk

Pain radiating to the buttocks, legs & feet Pain made worse with coughing, straining or laughing In the lumbar area, >80% of disk ruptures affect L5 or S1 nerve roots Tx- mainstay of treatment for herniated disks is an initial period of rest with pain

and anti-inflammatory medications, followed by physical therapy38. Acute low pain following heavy lifting (sand bags) – lumbar strain: recognize Dx &

Tx The condition is characterized by localized discomfort in the low back area with

onset after an event that mechanically stressed the lumbar tissues. Lumbar strain is one of the most common causes of low back pain. The injury can

occur because of overuse, improper use, or trauma. Position of comfort will tend to be the fetal position

REST39. Ankylosing spondylitis – definition

Is a form of chronic inflammation of the spine and the sacroiliac joints. Common genetic marker: HLA-B27

i. Occurs after exposure to bowel or urinary tract infections Dramatic loss of flexibility in the lumbar spine is an early sign of AS Usually <35 yo Positive response to NSAIDs (indomethacin)

40. Ankylosing spondylitis – the hallmark is involvement of the sacroiliac (SI) joint 41. Multiple myeloma – primary tumor of spine

Night & rest pain are the hallmarks of neoplastic or infectious disorders Will have BONE pain Patients who have been involved in the agricultural, chemical, or radiology

industries are at higher risk of developing the disease MRI most sensitive study

42. Lower back pain affecting big toe extensor & dorsiflexion of feet? L5-S143. Brown-Sequard’s syndrome: loss of sensation & motor function (paralysis &

ataxia) caused by lateral hemisection (cutting) of spinal cord an incomplete spinal cord lesion characterized by a clinical picture reflecting

hemisection of the spinal cord44. Pancreatitis – 25% have radiating back pain

Pain is worst with supine position45. Nephrolithiasis – colicky, nauseous costovertebral pain often referred to lower

abdomen & groin with positive occult blood46. Acute bacterial prostatitis: chills, fever, pain in the lower back and genital area,

body aches, burning or painful urination, and the frequent and urgent need to urinate, often at night.

47. Classification of fractures Compression fracture: While the front (anterior) of the vertebra breaks and

loses height, the back (posterior) part of it does not. This type of fracture is usually stable and rarely associated with neurologic problems. (Osteoporosis)

i. in females, the leading risk factor increasing the likelihood of osteoporosis is menopause, or estrogen deficiency

ii. Additional risk factors that may worsen the severity of osteoporosis include cigarette smoking, physical inactivity, use of prednisone and other medications, and poor nutrition.

iii. In males, all of the above risk factors apply; however, low testosterone levels also may be associated with compression fractures.

Axial burst fracture: You lose height on both the front and back of the vertebra in this type of fracture, often caused by a fall from height in which you land on your feet. (Work/Sports)

Flexion/distraction (chance) fracture: The vertebra is literally pulled apart (distraction), such as in a head-on car crash in which the upper body is thrown forward while the pelvis is stabilized by a lap seat belt. (MVA)

Transverse process fracture: This type of fracture results from rotation or extreme sideways (lateral) bending and usually does not affect stability. (Severe Impact)

Fracture-dislocation: This is an unstable injury involving bone and/or soft tissue in which one vertebra may move off the adjacent one (displaced).

48. Extreme low pain elicited with superficial palpation is often observed in patients with spinal Infections .

49. Spinal stenosis Back pain that is worse when standing up straight Pain in the buttocks, thighs, or calves on walking, running, or climbing stairs. Walking up hills is less painful than walking down Pain is relieved by flexing the back or by sitting

50. Waddell’s sign : used to detect “malingering” patients with back pain Superficial tenderness – skin discomfort on light palpation. Non-anatomic tenderness – tenderness crossing multiple anatomic boundaries. Axial loading – eliciting back pain when pressing down on the top of the patient’s head. Pain on simulated rotation - rotating the shoulders and pelvis together (along with feet)

should not be painful as it does not stretch the structures of the back. Distracted straight leg raise - if a patient complains of pain on straight leg raise, but if

the examiner extends the knee with the patient seated (e.g. when checking the Babinski reflex).

Regional sensory change - Stocking sensory loss, or sensory loss in an entire extremity or side of the body.

i. Nerve distribute in multiple location, it should not just be localized in a stocking pattern

Regional weakness - Weakness that can be overpowered smoothly. Organic weakness will be jerky, with intermittent resistance.

Overreaction - Exaggerated painful response to a stimulus that is not reproduced when the same stimulus is given later.

CMS II – Ortho 2 Study

Disorders of the Upper Extremity 1. Radial head fracture picture – x-ray of elbow

a. Radial head fractures is most common type of elbow fracture in adults.

b.2. Nursemaid’s elbow (radial head subluxation) Dx from scenario & symptoms – mom pulled

daughter’s arma. Common in children 2-4 yob. Arm held pronated and flexed c. Radial head tenderness and pain with supination

3. Radial head subluxation Tx: reduce with gentle, full supination & flexion (listen for a pop)4. Anterior shoulder dislocation – risk of axillary nerve injury

a. Majority of dislocationsb. TUBS (Traumatic, Unilateral, Bankart lesion, Surgery)c. AMBRI (A traumatic, Multidirectional, Bilateral, Rehab, Inferior capsular repair)

5. Scapular Fx – severe mechanism or injury, usually causes additional internal injurya. Aggressively search for associated injuries, found in 85%

6. Radial nerve injury is most commonly associated with humoral shaft fracture.

a. Holstein-Lewis fracture, distal 1/3 fracture of the humerus involving the radial nerve

7. Median nerve injury associated with what Fx: supracondylar a. Neurovascular exam: median/ulnar nerves, brachial arteryb. Common in children. Referral early!c. Fat pad sign/ Sail sign: occult fracture bleeding into the joint

8. Anterior displacement in a humeral fracture anatomically closest to the median nerve9. Sail sign around radius shows on lateral x-ray

a.10. Monteggia Fx: Proximal Ulna Fracture, Shortening forces result in a Radial Head

dislocationa. Fracture of proximal ulna often characterized by anterior angulation of ulna and

anterior dislocation of radial head.

b.11. Galeazzi Fx: Distal radial shaft fracture with disruption of the distal radioulnar joint

(DRUJ) and dislocation of the distal ulna

a.12. Fingers associated with Dupuytren’s contracture – Ring finger most commonly involved,

then little finger, middle finger, thumb, and index finger *a. Nodular thickening and contraction of the palmar fascia causing flexion of the MP

and sometimes PIP joint.13. Ganglion cyst: most common soft tissue tumor of hand

a. Usually dorsal carpal ganglion and located over the scapholunate ligament (can be volar)

b.14. Trigger finger – A1 pulley flexor tendon entrapment

a. The A1 Pulley thickens and narrows from chronic inflammation and entraps the flexor tendon.

b. Catching or triggering of the finger with locking in flexion c. Ring and middle fingers most commonly affected d. Commonly occur with DeQuervain’s disease and CTS

15. Golfer’s elbow (medial epicondyle)a. Often associated with ulnar neuritis b. Resisted wrist flexion and/or forearm pronation elicits pain

16. Tennis elbow (lateral epicondyle )a. Overuse syndrome or tendinosis involving the lateral humeral epicondyleb. Painful resisted extension of the wrist or middle finger

17. De Quervain’s disease symptom exacerbation – thumb extension & aBductiona. A stenosing tenosynovitis of the 1st dorsal compartment at the wrist*

i. APL, EPBb. Finkelstein test indicative of de Quervain’s disease

18. Fx associated with non-union due to lack of blood flow – scaphoida. Scaphoid is most common carpal bone to fracture

b.c. Limited blood supply: blood supply at the distal aspect of the bone d. High rate of nonunion with proximal pole

19. Snuffbox tenderness suggests scaphoid Fx even if none shows on x-raysa. Do not delay treatment!

i. Displaced Fx: Long arm thumb spica cast ii. Nondisplaced: Short arm thumb spica cast iii. Refer to Orthopedic Surgeon

b. Distal pole: 6-8 wks to healc. Middle third: 8-12 weeks to heald. Proximal pole: 12-24 weeks

20. Metacarpal fracture- Boxer’s

a. Metacarpal neck-dorsal angulation of the distal 5th metacarpal with anterior displacement

21. Picture of boxer’s Fx – identify as angulated Fx

a. 22. Mallet finger: Flexion deformity of the DIP joint due to loss of continuity of the extensor

tendon with the distal phalanxa. Avulsion fx “Boney Mallets” – distal phalanx finger fracture at site where extensor

tendon should connect.

i.b. Tx: continuous splinting of the DIP in extension c. Complication: swan neck

23. Boutonniere’s deformity definition – flexion of PIP, hyperextension of DIP & MPa. Frequently in RA patients

24. Most common hand infection – Felon: staph aureusa. Abscess of the fingertip pulpb. Commonly in thumb or index finger

25. Posterior dislocation often missed. Get axillary x-ray.26. Elbow dislocation: posterior lateral dislocation most common (<90%)27. Distal radius fracture

a. One of the most common fractures in adultsi. Colles most common

b. **Colles: dorsal displacement of fracture fragmentc. Smith: volar (anterior) displacement of the fracture fragment

28. Essex Lopresti fracture: Radial Head Fracture, disruption of the interosseous membrane, and dislocation of the distal radioulnar joint (DRUJ)

a. Distal radio-ulnar joint tenderness is most sensitive test to diagnose injuryb. May develop severe wrist pain from radial migration

29. Infection of the hand- Flexor tendon sheatha. Sheath surround flexor tendons (palm of hand to DIP) infection*b. Kanaval signs:

i. Fusiform swelling of the involved fingerii. Tenderness along the course of the flexor tendoniii. Significant increased pain with passive extension

iv. Flexed position of the finger at rest30. Paronychia: Superficial infection of the epidermis surrounding the border of the nail*

a. Staph aureus most common 31. Bite wounds:

a. Human bite wounds: Staph aureus b. Animal: pasteurella multocida

Pelvis, hip, and lower extremity disorders32. Trochanteric bursitis Dx from signs & symptoms

a. The bursa most subject to pain and irritationb. TTP over the trochanter that frequently radiates over the lateral aspect of thigh to

kneec. Hip motion, especially internal rotation and adduction, may be painful

33. Tx for displaced femoral head Fx due to avascular necrosis: complete hip replacementa. After collapse has occurred, hip arthroplasty is the ONLY managementb. Avascular necrosis

i. Often seen in association with gouty arthritis, chronic alcoholism, chronic renal disease, divers and workers who use compressed air, long-term steroid therapy*

ii. Characterized by the development of an area of bone necrosis in the anterosuperior weight-bearing portion of the femoral head*

iii. X-rays reveals an increase in the density of the superior portion of the femur*iv. Steroid can cause osteoporosis leading to AVN of the hip due to femoral head

compression*v. MRI most sensitive test for avascular necrosis and in detection of stress fracture

34. Posterior hip dislocation signs – internal rotation, flexion, shorteninga. In posterior dislocations, the hip is characteristically held in flexion, adduction, and

internal rotation*b. Usually the result of severe trauma and usually in the posterior direction*c. Frequently associated with fractures of posterior acetabular wall*

35. Hip Fx characterized by external rotation & shorteninga. Characterized by shortening and external rotation of the affected leg with pain in the

region of the hip joint *36. Ligamentum teres – disruption causes lack of blood flow to femoral head37. Sciatica Dx from signs & symptoms – leg pain which began after long car trip

a. Sx: Pain originating in the low back that radiates to the posterior or lateral leg, sharp, burning pain

b. Lumbar disc herniation (most common)38. Pelvis Fx – look for other ring injuries

a. Almost never a single isolated fracture- “ring analogy”39. Hip osteoarthritis identification by signs & symptoms

a. Degenerative arthritisi. Common in middle or later years of lifeii. Pain after activity and stiffness at rest are

characteristiciii. X-rays

1. Sclerosis2. Joint space narrowing3. Osteophyte formation4. Bone cysts

40.41. Main blood supply to the femoral head comes from the intertrochanteric region

proximally42. Transient synovitis

a. Toxic synovitisb. Occurs in children (3-8yo)c. May follow a traumatic event or recent URI

Disorders of the Knee43. Tx for Osgood Schlater’s syndrome in young boy (not named – symptoms described) –

RICE, NSAIDS, avoid aggravating activity for 2 monthsa. Localized pain/swelling at tibial tuberosityb. AVOID steroids!!!

44. Gymnast without trauma, 3rd occurrence, hesitant to bend, swollen - patellar subluxationa. Atraumaticb. Knee flexion causes lateral displacementc. Caused by shallow femoral groove or ligamentous injury

45. Recognize ACL tear from symptoms & scenario – pt jumped down from truck, felt popa. MRI – diagnostic test

46. PCL tear results in positive posterior drawer test and sag sign 47. Test for lateral collateral ligament tear: varus stress test

a. MCL: Valgus stress test48. Bucket meniscus tear 3 months post injury – conservative Tx failed, what next? surgery49. Apley’s test (meniscal tears): Prone, flex knee, axially load with int/ext rotation50. McMurray’s test (meniscal tears): Supine, flex knee, int/ext rotate knee51. Plica band: Medial knee pain the most commonly develops in younger patients that

run, row, do squats, ride a bikea. Can become inflamed, snap over the medial condyle, mimic meniscal tear symptoms.

52. Pes anserene bursitis Dx from signs & symptoms – knee hurt on active ROM not passive

a. Frequently in middle aged, overweight women b. Clinical manifestations: Inferomedial knee pain, worse with ROM/ambulation, TTP

over PA bursa 2-3 inches distal to knee medial side 53. Iliotibial Band Syndrome (ITB)

a. Clinical manifestations: Diffuse lateral knee/thigh pain that progresses to sharp lateral knee pain with knee flexion, TTP at lateral femoral condyle

b. Ober’s test 54. Gout

a. Caused by under-excretion or over-production of uric acid. b. Joint aspiration is gold standard for Dx

55. Pseudogout (CPPD)a. Inflammatory arthritis of the knee caused by deposits of calcium pyrophosphate

crystals in the joint.*

b. Aspiration will reveal crystals that are positively birefringent with microscopic evaluation using polarized light.

c. X-ray will reveal chondrocalcinosis

Common Ankle & Foot Disorders56. Achilles tendon rupture – signs & symptoms given (bball player with deformity & no

plantar flexion ability)a. Sudden pain in the heel after attempting a pushing-off movementb. Accompanied by an audible popc. Immediate weakness in affected legd. Ankle plantar flexion is weake. Thompson’s test is dx

57. Lisfranc Fx – test to eval for soft tissue: CTa. The basy architecture of this joint, specifically the ‘keystone’ wedging of the second

metatarsal of the cuneiform forms the focal point that supports the entire tarsometatarsal articulation.

b. Obtain a CT to define soft tissue damage

c.58. Pes Planus picture identification

a.59. plantar fasciitis Dx from description of symptoms

a. First few steps of the day and end of day are absolutely awful with pain – feels like stepping on glass.

b. Over pronation 60. Nail through shoe into foot in pt with current tetanus vaccine – risk of pseudomonas

osteomyelitis a. Pseudomonas organisms – 90% of osteomyelitis – especially if went through a rubber

soled shoei. If tennis shoe or cloth lined shoes treat empirically for Pseudomonas

b. S. Aureus is most common pathogen61. Tx of soft tissue injury to back of leg 6” above calcaneus without deformity or functional

deficit – splint & ortho referral for follow up in 72 hoursa. Stable ankle sprain Tx – air stirrup ankle brace

62. Anterior talofibular- most at risk for inversion (lateral collateral ligaments)63. Deltoid ligaments: provide support and prevent eversion

a. anterior tibiotalar, tibiocalcaneal, posterior tibiotalar, tibionavicular64. Radiographic studies: AP view is taken while talar tilt test is being performed and a

lateral view is taken while the anterior drawer is performed65. Morton’s Neuroma

a. Severe burning pain located in region of 3rd web space b. MRI imaging study of choice

Musculoskeletal Injuries66. Grade 3 ligament tear = complete

a. Classificationsi. Grade 1 – minimal tearing and hemorrhageii. Grade 2 – partial tearing with hemorrhage and inflammationiii. Grade 3 – complete rupture with hemorrhage and inflammationiv. Avulsion from origin or insertion

67. Extrinsic factor contributing to Fx risk: mechanism of injury – external force applieda. Extrinsic factors

i. Rate mechanical load appliedii. Duration, direction, and magnitude/extent of applied force

b. Intrinsic factorsi. Energy-absorbing capacityii. Modulus of elasticityiii. Fatigueiv. Strengthv. Density

68. When there’s a question of intra-articular Fx – do CT to checka. CT

i. Intra-articular (Within the cavity of a joint) or complex fracturesii. Pre-operative planning

69. Comminuted fx picture – x-ray of humoral Fx

a.70. Salter Fx picture - identify Type II from xray

a.b. Salter- Harris

i. Type 1: fracture extends through epiphyseal plate (may appear as widening of growth plate); NO growth disturbance

ii. Type 2: with fracture of triangular segment of metaphysis; NO growth disturbance iii. Type 3: through epiphyseal plate and epiphysis; growth disturbanceiv. Type 4: through adjacent metaphysis; growth disturbancev. Type 5: crush injury of epiphysis; RARE; growth arrest (shortening or angulation)

71. Incomplete Fx definition – cortex buckles or cracks but bone continuity remains intacta. Incomplete: cortex buckles/cracks, bone continuity intact (greenstick, buckle)b. Complete: continuity disrupted through full thickness of bone c. Closed (simple): fracture fragments contained within intact skin or membraned. Open (compound): external wound connects with fracture site

i. Anytime skin rupture, even if you don’t see any bonee. Non-displaced: fragments in anatomic position and alignmentf. Displaced: fragments separatedg. Depressed: fragment below level of adjacent bone (skull)h. Comminuted: multiple fragments or fracture lines

72. Compartment syndrome – recognize from symptomsa. Most common- anterior compartment of legb. Tissue pressure > intravascular (perfusion) pressurec. 5 P’s: Pain out of proportion to injury, Pallor, Paralysis, Paresthesias, Pulselessness

73. Compartment syndrome risk from crush injuriesa. High risk

i. Long bone fractureii. High-energy traumaiii. Penetrating injury (arterial injury)iv. Venous injury (may have palpable pulses)v. Crush injuryvi. Anticoagulantsvii. Envenomationviii. Burn

74. Compartment syndrome Tx – emergent surgical decompression/consult75. Cryotherapy benefits – limits bleeding, swelling, pain & reduces metabolic requirements

a. Cryotherapy: limits edemab. Heat: Increases blood flow, inflammatory response, and edema

76. If fracture is suggested clinically but films appear negative, treat as if a fracture is present.

77. Check and record neurovascular integrity before and after all reductions and after immobilization.

78. Radiographs Rule of 2’s a. 2 views – AP and lateral (minimum)b. 2 joints – joint above and below injuryc. 2 limbs – comparison views (esp. children)d. 2 x-rays – pre- and post-reduction or immobilization

79. Radionucleotide bone scan: seldom used- replaced by CT and MRI80. MRI : Reserved for instances when diagnosis in doubt and specific findings would

alter treatment81. Casting: Mandatory recheck 24 hours after application82. Surgery indications: Displaced intra-articular fractures (>2 mm)

CMS II Ortho 3

Autoimmune diseases1. Drug-induced lupus: hydralazine

a. Drug-Induced Lupus:i. Nephritis and CNS symptoms are usually not present

ii. Drugs: chlorpromazine, hydralazine, isoniazidb. SLE: may involve any organ system

i. Malar (butterfly) rashii. Discoid rash iii. Alopecia/ nail fold infarcts/ splinter hemorrhages/ raynaudsiv. Triad:

1. Fever, joint pain, rash v. ANA is the best screening test for SLEvi. Anti- Sm (most specific for SLE)vii. A person is classified as having SLE if:

1. There is the presence of biopsy-proven lupus nephritis with positive ANA or anti-dsDNA antibodies.

viii. OR1. Four of the diagnostic criteria that includes at least one clinical and

one immunologic criterion

2.ix. Treatment

1. Protection from sun exposure2. Influenza vaccine 3. NSAIDs, antimalarials (hydroxychloroquine)

2. Anticoagulation is warranted due to risk of thrombosis antiphosopholipid syndromea. Positive test for lupus anticoagulant and anticardiolipin- Risk factor for

thrombosis & miscarriage3. CREST syndrome is limited systemic scleroderma (80%)

a. Calcinosisb. Raynaud Phenomenon- initial sx CCBc. Esophageal dymotilityd. Sclerodactylye. Telangiectasia

4. Scleroderma: characterized by skin thickening, telangiectasia, etc - CREST5. Scleroderma- ACE inhibitors for renal crisis/hypertension

a. Due to initial proliferation of smooth muscle cells in vessels which results in vascular wall thickening and eventual lumen obliteration (especially small arteries, arterioles and capillaries)

i. Results in decreased renal perfusionii. Abrupt hypertension

b. Labsi. Anti-SCL-70 antibody- DSSii. Anticentromere antibody- LSS (CREST)

c. FYIi. GI bacterial overgrowthoctreotide

6. Diagnosis for sjogren syndrome: staining the eye’s surface, schirmer testa. “sicca syndrome”b. Dry eyes, mouth, and other mucous membranes c. Secondary association with RAd. Diagnosis

i. *Two of the three tests must be positive for a person to be diagnosed with Sjögren’s syndrome

1. Anti- SS-A/B serology 2. Labial salivary gland biopsy 3. Staining the eye’s surface with a specialized dye (rose Bengal staining)

e. Medication that can cause “sicca symptoms”i. Antidepressants, anticholinergics, antihis, BB, diuretics

7. Lyme dz: stage 1: early, localized infection rash and flu-like symptoms are most common

a. Stage II: early disseminated infection: secondary skin lesions, CNS, and cardiac symptoms

b. Stage III: late, persistent infection: months to years after exposure- musculoskeletal, neurologic, and skin manifestation

8. Diagnosis of early Lyme disease is clinicaldoxycyclinea. Greatest risk for disease transmission is when a tick remains attached for longer

than 72 hoursb. Diagnosis of Lyme disease requires the detection of antibodies to

B.burgdorferi (ELISA and confirmed by Western Blot)c. Diagnosis of early Lyme disease is clinical: Exposure in endemic area with

documented erythema migrans does not require lab confirmation.

Inflammatory myopathies9. Gottron’s sign and papulesdermatomyositis (inflammatory myopathies)

a. Progressive and symmetric muscle weaknessb. Patients report increased difficulty with everyday tasks that require the use of

proximal muscles.c. Facial and ocular muscles are rarely involvedd. Inflammatory myopathies: diagnosis

i. Proximal muscle weaknessii. Characteristic rashiii. Elevated serum muscle enzymesiv. Characteristic electromyographic (EMG)or MRI muscle abnormalitiesv. ***Muscle biopsy change (the definitive test)

e. Dermatomyositis: i. Complement-mediated vasculopathyii. Heliotophic rash or Gottron’s papules even without

myositisiii. Symptoms of polymyositis with any skin findings

compatible with dermatomyositis.f. PM and IBM:

i. Mediated by CD8+ T lymphocytes g. Cancer screening (CEA)

i. ≥ 40 years old and have dermatomyositisii. ≥ 60 years old and have polymyositis

h. Treatment of DM & PM: PO Prednisone is initial Tx of choice10. Muscle biopsy is recommended before treating polymyositis

a. Inflammation is the histological hallmark but each type has additional characteristics:

b. Polymyositis- scattered inflammatory foci with lymphocytes invading or surrounding muscle fibers.

c. Dermatomyositis- atrophy of fibers at periphery of fascicle (perifascicular atrophy)

d. IBM: vacuoles with lymphatic infiltrates surrounding nonvaculoated or necrotic fibers.

11. IBM: vacuoles with lymphatic infiltrates surrounding nonvaculoated or necrotic fibers.

12. Mechanic’s hands: People with dermatomyositis or polymyositis may develop “mechanic's hands,” a roughening and cracking of the skin of the tips and sides of the fingers, resulting in irregular, dirty-appearing lines that resemble those of a manual labor.

a.13. IBM: Early involvement of quadriceps and distal muscles.

a. Develops at older age (60yo)b. Involves asymmetrical muscle pattern c. IBM is generally resistant to therapy so the goal of therapy is to prevent

further deterioration in muscle strength.d. By 15 years, most require assistance with their ADLs

14. Disease defined with pain syndrome, fatigue, stiffness, parestheis, and insomnia fibromyalgia

a. Pain all over b. All 4 extremitiesc. Pain worse with exertiond. Dx of exclusion

15. Hallmark symptom of fibromyalgia: fatigue16. Reiter’s syndrome (reactive arthritis): Urethritis, cervicitis or dysentery

a. After GI or GU infection b. Linked to HLA-B27c. Triad

i. Conjunctivitis (noninfectous) or uveitis (20% of cases)ii. Urethritis or cervicitisiii. Arthritis

Arthritides 17. Osteoarthritis: Joint enlargement

a. Leading cause of disability in the elderly b. Inflammation is usually minimalc. Sx

i. Joint stiff in the AM (<30min)ii. Crepitusiii. Joint enlargement (heberden nodes (distal) and bouchard nodes (proximal)iv. Asymmetrical v. lack of bone erosionsvi. loss of cartilage vii. sclerosis of subchondral bone

viii. bone proliferation (osteophytes or bone spurs)18. Osteoarthritis: genu varus Due to loss of cartilage in the medial compartment

of the knee.a. Genu valgus: due to loss of cartilage in the lateral compartment of the knee

19. Osteoarthritis nonpharmacological tx: Weight Controla. Other nonpharmacological tx:

i. Exercise- aerobic and/or resistance trainingii. PTiii. Assistive devices iv. Orthopedic surgery

20. Rheumatoid arthritis articular manifestations: Swan neck deformitya. Polyarticular symmetric arthritis of the peripheral jointsb. HLA-DR4c. Sx

i. Begins with systemic as well as joint sx (symmetrical)ii. DIP joints usually spared early iii. Ulnar deviation iv. Swan neck deformity: hyperextension of PIP with flexion of the DIP due to

contractures of muscles and tendonsv. Boutonniere deformity: flexion of the PIP joints and hyperextension of the DIP

joints due to rupture or excess laxity of extensor tendons over the fingers

vi. Commonly involved: wrist and the 2nd and 3rd MCP joints21. Rheumatoid arthritis: Marginal erosions

a. Lack of bone formation b. Synovial cyst formation c. subluxation

22. Methotrexate is DMARD of choice for the treatment of RA23. Rheumatoid arthritis treatment: glucocorticosteroids long term side effects include

osteoporosis, DM, cataracts. 24. Hematogenous osteomyelitis: >50% cases from Staph. Aureus25. Contiguous focus of infection osteomyelitis (80%)- most common in adults

a. Polymicrobial 26. Test of choice for vertebral osteomyelitis because of its high sensitivity

for epidural abscess.a. MRI

27. Gonococcal arthritis: Ceftriaxone is the initial treatment of choicea. Does not usually damage joints permanently

28. Nongonoccocal bacteria arthritis (staph)- can permanently damage joints

29. Infectious arthritis: Arthrocentesis and synovial fluid analysis should be done before starting antibiotics.

30. Gout: compensator reveals monosodium urate crystals (needle-shaped, strongly negative birefringent crystals)

a. Often in the great toe-podagrab. Formation of tophic. Treatment of choice: NSAIDs

31. Allopurinol is contraindication for acute gout. a. Urate-lowering medications should not be stopped (or started) in the setting of an

acute flare up.b. Precipitation of acute attacks

32. Pseudogout: chondrocalcinosisa. Knees are the most common source of pain

Osteoporosis33. World Health Organization (WHO)

a. Severe or established osteoporosis: i. T-score of ≤ -2.5 with one or more fractures

b. Osteoporosis:i. T-score of ≤ -2.5

c. Osteopenia /low bone mass:i. T-score -1 to -2.5

d. Normal: i. T-score -1 and above

34. Osteoporosis: Uncontrolled Risk Factorsa. Over age 50b. Femalec. Menopausal d. FHxe. Low body weight/ being small and thin f. Prior fractures or height loss

35. Excessive bone loss can be due to:a. Increase in osteoclast activityb. Decrease in osteoblast activity

36. Cigarette smokers on average reach menopause 1-2 years earlier than the general population (osteoporosis)

a. Due to its toxic effects on osteoblasts.b. Indirectly modifies estrogen metabolism- decreases estrogen

37. Osteoporosis has no clinical manifestations until there is a fracture 38. A recent fracture at any major skeletal site in an adult aged 50 years or older is

considered a significant event for a diagnosis of osteoporosis.a. Vertebrae, proximal femur/hip, distal forearm (wrist)b. Vertebral fracture are the major predictors of future fracture risk.

39. Indications for BMD measurement: Women age 65 and older, regardless of clinical risk factors

a. DXA scan of the lumbar spine and hip is the standard b. T-score: based on a young-adult reference population

i. Postmenopausal women and men age 50 and older c. Z- score: age, sex, and ethnicity-matched reference population

i. Premenopausal women, men <50yo and children

40. Indications for BMD measurement:a. Women >65 yo, regardless of risk factorsb. Men >70, regardless of risk factorsc. Adults who have a fracture after age 50d. Younger postmenopausal women e. Women in menopausal transitionf. Men 50-69g. Low bone mass due to: medical conditions and/or medication

41. Indications for vertebral imaging: Women age 65 -69 if BMD T-score is ≤ -1.5 at the spine, total hip or femoral neck.

a. Vertebral fracture is consistent with a diagnosis of osteoporosis even in the absence of a BMD diagnosis.

b. All women age 70 and older if BMD T-score is ≤ -1.0 at the spine, total hip or femoral neck.

c. All men age 80 and older if BMD T-score is ≤ -1.0 at the spine, total hip or femoral neck.

d. Women age 65 -69 if BMD T-score is ≤ -1.5 at the spine, total hip or femoral neck.e. Men age 70 -79 if BMD T-score is ≤ -1.5 at the spine, total hip or femoral neck.f. Postmenopausal women and men age 50 and older with specific risk factors

42. What factor decreases risk of osteoporosis? High peak bone massa. Vitamins b. Exercise: weight bearing that will ^ compliance

43. Young patient with unremarkable physical exam a month prior was concern that she might have osteoporosis after seeing a commercial on bisphosphonate. What should be done? Advise her to take Ca and vitamin D supplement

44. Pharmacologic therapy: According to the National Osteoporosis Foundation (NOF) postmenopausal women and men > 50 years old with the following should receive pharmacologic therapy:

a. History of hip or vertebral fractureb. Osteoporosis (T-score)

45. A male patient with osteoporosis complains of throat pain that radiates to chest after taking his medication. He takes it at night daily. What is the most likely medication? Bisphosphonates

46. Most common cause of medication-induced osteoporosis (corticosteroid)a. Dose >/ mg daily for at least 3 months

Bone Neoplasms47. Enneking system for staging: used for staging of musculoskeletal sarcomas

based on histological tumor grade, the site (extent) of the tumor, and the presence of regional or distant metastases.

48. Osteoid osteoma: it is dramatically relieved with small doses of aspirin or other prostaglandin inhibitors

a. Focal bone pain at the site of the tumor. b. The pain worsens at night and with increases with activity; c. It is dramatically relieved with small doses of aspirin or other prostaglandin

inhibitors

d.49. Osteoid osteoma is a vascular tumor 50. Osteoid osteoma: characterized by an osteoid-rich nidus 51. Night pain not relieved with rest- exception is osteoid osteoma52. Non-ossifying fibroma (asymptomatic)- femur or tibia; most common bone

tumor in childrena. It is a developmental defect in which areas that normally ossify are filled with

fibrous connective tissue b. Well marginated, radiolucent lesion with a distinct multilocular appearance

c. 53. A little boy brought into the ER after an transverse fracture what is the most likely

etiology of the pathological fracture: osteochondroma a. Peripheral chondroblast grows outward from the metaphysis, acting as an ectopic

growth plate, which ceases growth at skeletal maturation

b.54. Enchondroma: is usually found in the short tubular bones of the hands and feet.

a.

55. Chondrosarcoma: malignant occurring in men between 50-60 yo located in pelvis, proximal femur and shoulder girdle

a. May have hazy or speckled calcifications w/ either a diffuse "salt & pepper" pattern or a more discrete "popcorn" pattern

b. 56. Ewing’s sarcoma: potentially the most lethal of all the bone tumors

a. Common karyotypic translocation between chromosomes 11 and 22b. Affects mostly children c. It is most commonly found femur, tibia and humerus, as well as the pelvisd. May mimic osteomyelitis

e.57. Multiple myeloma: “punched out” lesions diffuse throughout bone

a. Malignant tumor of plasma cellsb. Causes widespread osteolytic bone damagec. Monoclonal immunoglobulin is found on serum electrophoresis. d. Light chain subunits of immunoglobulin are called BenceJones proteins and are

present in urine.

CMS II GI 1

Intro to GI1. abdominal ultrasound: suspected biliary or pancreatic disease

a. first test you order if you suspected colecystitis 2. Common cause of constipation?

a. poor dietary habitsb. overwhelming majority have mild symptoms that after evaluation will reveal that most do not consume enough

fiber (and fluid)3. What diarrhea resolves during fasting?

a. Osmotic diarrhea4. Quantification of fecal fat should be performed- malabsorptive conditions5. Common cause of melena?

a. Slow upper GI bleeding6. Common cause of iron deficiency anemia?

a. Occult GI bleeding

b. Men and postmenopausal women with iron deficiency anemia should be presumed to have occult GI blood loss until proven otherwise

7. What would be elevated in occult GI bleed?a. BUN

8. What is the most common of upper GI bleed?a. PUD

9. True statement regarding upper GI bleed?a. High mortality in those >60 yo

10. A patient just started a new diet and exercise program. He has stopped eating high sugar/carbs and is replacing them with sugar free sorbitol. He drinks water and eat fruits when he is hungry between meals. What is the most likely cause of his diarrhea and flatulence?

a. Sugar free gum (sorbitol)11. A 24 year-old male patient with quadriplegia is at increased risk for which of the following?

a. Constipation due to inactivity 12. Chronic excessive belching is almost always caused by aerophagia (constantly swallowing air), seen in anxious and

institutionalized patient.13. Acute diarrhea and persists for 3 weeks or less it is: infectious, bacterial toxin, or drugs14. Avoid opioid with bloody diarrhea 15. Chronic diarrhea due to secretory conditions

a. ^ intestinal secretion, decreased absorption, and large volume watery diarrhea no change in diarrhea during fasting

16. Acute upper GI bleeding most common presentation:a. Melenab. Hematemesisc. Hematochezia (typ lower but with massive upper GI it can happen)

17. Acute lower GI bleeding: majority from the large colon a. Hematochezia b. Diverticulosis is common cause

Disorders of the Intestines18. Female patient complain of non-bloody diarrhea, fatigue, weight loss and pain in the right lower quadrant. What is the

most likely diagnosis?a. Crohn disease

i. Transmural inflammatory process affect any part of GI tract (80% terminal ileum)ii. Skip lesions and cobblestone

iii. ASCA+19. What disease results in: ulceration, strictures, fistula and abscesses?

a. Crohn disease20. Ulcerative colitis: crypts of Lieberkuhn and pseudopolyps

a. Results in diffuse friability, ulceration, edema, bleeding, fluid and electrolyte loss.b. Has predisposition to nonsmokersc. Bloody diarrhea, abd pain, weight lossd. P-ANCA+e. X-ray: stovepipe appearancef. Sigmoidoscopy to provide diagnosis

21. Presents as alternating constipation and diarrhea accompanied by abdominal cramping.a. Irritable bowel syndrome

i. Diagnosis based on exclusionii. Rome III diagnostic criteria* for Irritable Bowel Syndrome

1. Presence of abdominal pain or discomfort for at least 3 days per month in the last 3 months along with 2 or more of the following:

a. Improvement with defecation.

b. Onset (of each episode of discomfort) associated with a change in frequency of defecation, or

c. Change in consistency of stool.22. Female patient with a history of A.fib with hypotension, abdominal distension with guarding and hypoactive bowel

sounds ischemic bowel/mesenteric diseasea. Tends to occur in older individuals with cardiac or vascular diseaseb. The most significant indicator of survival is the timeliness of diagnosis and treatment.c. **Watershed areas in the colon are more susceptible to ischemic injury than other areas in the colon.

i. Splenic flexure (Griffith’s point)ii. Rectosigmoid junction (Sudeck’s point)

23. Acute abdominal pain with pain out of proportion to physical exama. Ischemia bowel/mesenteric diseaseb. Angiography- gold standard

24. On abdominal x-ray, bowel wall edema or thumb printinga. Ischemic bowel/mesenteric disease

25. What electrolyte is increased in intestinal Ischemia elevated lactate26. What is the initial test for intestinal obstruction?

a. Abdominal x-ray 27. Herniation or saclike projection of the intestinal mucosa through the muscularis propria.

a. Diverticulosisb. Commonly affects the sigmoid colon

28. Colorectal cancer treatment: resection and region lymph node dissectiona. Colonscopy is procedure of choice

29. Screening guidelines for early detection of colorectal cancera. Annual fecal occult blood test and flexible sigmoidoscopy every five years

i. *Combined testing is preferred over either annual FOBT, or FSIG every 5 years alone. 30. Most common symptom for carcinoid syndrome:

a. Flushing occurs typically of the head and neck due to emotional stress, ingestion of food, hot beverages or alcohol.

b. Can also detect 5-hydroxyindoleacetic acid (5-HIAA) in the urinec. Octreotide is the drug of choice for symptoms (flushing and diarrhea)

31. A patient with a first degree relative (37 yo) with colonic polyps, what age should you begin screening?a. 32 yo b. Begin screening 5 years earlier than the age at which polyps were found first-degree relatives

32. What is the preferred test to detect polypys?a. Colonscopy (hemmocult???)b. Sigmoidoscopy: good screening test

i. Only procedure/imaging modality validated to decrease colorectal cancer mortalityc. Capsule endoscopy: Detects polyps in pts who have had an incomplete optical colonoscopy d. Blood DNA: A positive test finding only indicates susceptibility, not the actual presence of a colonic polyp

33. Patient with multiple polyps and positive for APC gene mutation, what should be the next step? Surgical resectiona. Resection: multiple polyps, large, sessile polyps or advanced polyps that recur

34. What is the treatment for nonbleeding angiodysplasias in patients with GI bleeding?a. No treatment: if no symptoms or nonbleeding b. GI angiodysplasias: most common vascular anomalies found in GI

35. Angiodysplasias are most often found in patients >60 years old.36. Toxic megacolon: pts presenting with abdominal distension and acute or chronic diarrhea

a. Characterized by total or segmental non-obstructive colonic dilatation plus systemic toxicityb. Patient appears toxic (altered sensorium, tachycardia, fever, postural hypotension, lower abd distension)

37. Colonic polyps are slow-growing overgrowths of colonic mucosa.a. Rectal bleeding is the most common symptoms.b. PE findings are typically normal.

Esophageal disorders38. GERD is the term applied to the symptoms that are due to tissue damage(esophageal mucosa)) that occurs secondary to

reflux of acidic gastric contentsa. Hiatal hernias are commonly associatedb. Heartburn is the most common symptoms

39. Peptic strictures: reduction of heartburn, because stricture acts as a barriera. Occur at junction b. Patient start complaining of dysphagia that progresses

40. In uncomplicated GERD with typical symptoms of heartburn: behavioral modificationa. Concluded that there was only evidence supporting the effectiveness of weight loss and head of bed elevation

41. GERD: barium esophagographya. Barium esophagography: as always, usually the first study obtain with complaint of dysphagia

42. What statement best distinguishes GERD from PUDa. GERD symptoms increase when lying supine

43. What is the treatment for the following image?a. Oral nystatin

b.44. Infectious esophagitis

a. Candida: shows diffuse, linear white to yellow plaques that are adherent to the mucosai. Topical nystatin, fluconazole

b. HSV: reveals multiple, small deep ulcerations of the mucosai. Oral acyclovir

c. CMV: shows several large superficial ulcerations of the mucosai. IV ganciclovir

45. A chronic alcoholism with hematemesis? a. Mallory-weiss syndrome (esophageal mucosal tears)

i. Located at gastroesophageal junction46. What differentiate diverticula with other dysphagia disorder?

a. Halitosisb. Barium esophagography confirms the dx by the appearance of a posteriorly projecting sac that contains the

contrast medium47. What clinical findings would you not see with esophageal varices and chronic cirrhosis?

a. Varices do not cause symptoms such as : dysphagia, dyspepsia or vomiting or retchingb. Bleeding varices is the important and first sign

48. Esophagography shown below in a 65 year-old patient with hepatic cirrhosis and bright red blood vomitingesophageal varices

a.49. Progressive dysphagia and nocturnal regurgitation? Achalasia

a. Idiopathic disorder characterized by loss of peristalsis and impaired relaxation of the LESb. Incidences of squamous cell carcinoma is ^ed 16 fold regardless of therapy c. Major complaint is the gradual onset of dysphagia

d.50. bird’s beak: symmetric tapering of the distal

a. achalasia

b.51. 72 year-old male with 20 year hx of GERD presents with dysphagia and complaint of weight loss. Adenocarcinoma is

common esophageal cancer (vast majority of barrett’s esophagitis) Barium esophagography shows:

a.b. Esophageal cancer

Disorders of the stomach1. 69 year-old male with 48 pack year history of smoking, 9 month history of weight loss, early satiety, N/V. X-ray reveals

mass in the epigastric region and palpable left supraclavicular lymph node. What is the study of choice?a. endoscopy

2. Endoscopya. Used to evaluate difficulty/ painful swallowing, abdominal pain, hematemesis

3. Gastritis: Group of disorders that cause inflammatory changes in the gastric mucosa4. Which statement is true in regard of gastritis and duodenal ulcers?

a. Clinical distinction can usually be made by whether food helps or worsen it5. Diagnostic testing to evaluate hematemesis in a 42 year-old male with 3 yr history of gastritis?

a. Endoscopy/gastroscopy6. Test to identify H.pylori

a. CLO test7. What is the 3 drug regimen to treat H.pylori?

a. PPi, amoxicillin (metronidazole), clarithyromycin 8. Common cause of gastritis?

a. NSAIDs and H.pylori9. NSAID cause gastritis by inhibiting?

a. prostaglandins10. Common nonerosive, nonspecific gastritis

a. H. pylorib. Pernicious anemia gastritis

11. Major complications of PUDa. GI bleeding- extremely commonb. Ulcer perforation

12. Patient with PUD that’s refractory to treatment is most likely? noncompliance13. Patient with c/o diarrhea, weight loss and elevated gastrin

a. Zollinger- Ellison Syndromei. Excess acid production from gastrinomas

ii. Gastrinoma triangle: porta hepatis, neck of pancreas, third portion of the duodenumiii. Sx: very watery loose diarrhea, steatorrhea, wt loss, N/V, and GI bleeding

14. Signet ring carcinoma- adenocarcinoma

a.15. Adenomatous polyps- premalignant16. Neoplasms

a. 4 presentations:i. Polypoid, ulcerations, superficial mass, deep mass

17. Malignant neoplasmsa. Virchow’s node: L supraclavicular nodeb. Sister mary joseph nodule: umbilical nodulec. Blumer’s shelf: rigid/hard rectal shelf

Acute Abd18. Acute abdomen pain: careful history and physical19. Visceral pain: deep, diffuse pain

a. Parietal pain: sharp, better localized20. 18 yo female with acute abdominal pain, what should you first rule out?

a. Pregnancyb. Rule out pregnancy (6-60 yo)

21. Diffuse/severe colicky abdominal pain with vomiting and abdomen distension, tinkling bowel sound: bowel obstructiona. Tinkling: high-pitched, rushes

i. Associated with pain and mechanical bowel obstruction 22. Peritonitis: lie very still with knee flexed

a. ^ pain with stretching of peritoneum23. Patient came in complaining of abd pain for the past 2 hrs/ abd rigidity/ no bowel sounds/ x-ray shows free air under

diaphragm: perforated duodenal ulcers (acute pancreatitis??)24. Diagnostic test of choice initial evaluation of abdominal pain? Acute abdominal series25. Lateral decubitus abdominal xray use to evaluate free air26. Small bowel obstruction

a.27. Peritoneal signs: involuntary guarding, localized tenderness, rebound tenderness28. Pancreatitis pain: radiation of pain from epigastrium straight through to midback29. Splenic pathology, diaphragmatic irritation, or free intraperitoneal fluid: radiation of pain to left shoulder or

independent pain in left shoulder 30. Perforation of gastric or duodenal ulcer, ruptured aortic aneurysm, or ruptured ectopic pregnancy: onset of pain

associated with syncope31. Toxic look: pallor, hypothermia, tachycardia, diaphoresis32. Abd exam not complete without digital rectal exam.33. CT is Imaging modality of choice for abd pain.34. Pain > 6 hours is surgical until proven otherwise

CMS II GI 2

1. What is the screening recommendation for the general population for colorectal cancer?a. 50 years of age

2. What is consider the normal BM with normal consumption of fibers?a. At least 3b. Constipation = fewer than 3 BMs/week in person consuming > 19 g of fiber/day

3. Causes of condyloma acuminatum?a. HPV

4. What is the most common cause of rectal bleeding in infants?a. Anal fissure

5. Where are most anal fissure location?a. Posterior midline 90%

6. First line of treatment for anal fissure?

a. Nitroglycerin, nifedipine and diltiazem (CCB), botox 7. What are the classification for hemorrhoids that bulge with defecation and no prolapse?

a. First degree: bulge with defecation, no prolapseb. Second degree: prolapse reduces spontaneouslyc. Third degree: prolapse reduces with manual reduction d. Fourth degree: permanent prolapse - will not reduce

8. What is a risk factor for hemorrhoids?a. Pregnancy, porta HTN, and constipation

9. Mucosal prolapsea. Complete eversion of anal mucosab. Radial folds on surface of tissuec. Anoderm also everted and visible externallyd. Surgical treatment - excision of redundant mucosa

e.10. A patient complains of pain at the superior aspect of gluteal fold. Pain, swelling, fluctuance, purulent discharge over

sarococcygeal/ intergluteal region.a. Pilonidal disease

11. Direct hernias pass through medial triangle12. Which of the following would you see in an inguinal hernia?

a. bulge13. A patient with a bulge in the left groin after lifting. On examination, the bulge if 8 cm and is unable to reduce. Patient

denies N/V/D. What is the description?a. Incarceration

14. What would be the treatment of the question above?a. Emergent Surgical consult

15. What of the hernia passes beneath inguinal ligament into upper thigh?a. Femoral hernia

16. Upon Valsalva a mass is felt on the side of the finger?a. Direct inguinal hernia

17. A women with 4 children have a bulge in between the xyphoid process and umbilical, what is your next management?a. Reassure her that its benign (diastasis recti)

18. A female with a bulge on the ventral right lateral between the umbilicus and pubis symphisis. What type of hernia is it?a. Spigelian hernia

19. A patient with c/o pain at the trocar incision due to previous laproscopy. On exam, there’s a bulge that have a bowel sound. What is the type of hernia?

a. Richter hernia 20. What is the portal triad?

a. Bile ducts, portal vein, hepatic artery21. In a patient with no history of medical illness, have an increase in AST: ALT (2:1) and increase in GGT. What is the most

like cause of the abdominal pain?a. Alcoholic cirrhosis

22. 23. Which is unlikely to be part of clinical presentation of a 65 year-old Caucasian male with complicated hepatic cirrhosis?

a. Dysphagia 24. What describe SPB?

a. Infection of ascitic fluid without apparent source25. A patient with c/o N/V/cramps. Recently traveled to Haiti and reports eating local food. What is the most of common

etiology?a. Hep A

26. Which of the following does not become chronic hepatitis?a. Hep A

27. Which of the following is a drug-induced hepatitis?a. Isoniazidb. Aspirin, statins, acetaminophen, NSAIDs

28. Which of the following would cause an elevation in alpha fetoprotein?a. Hepatocellular carcinoma

29. What is the main cause of portal hypertension?a. Cirrhosis

30. A patient with a history of alcoholism with no significant medical history. On exam you reveal ascites, hepatomegaly..? what is the most likely cause?

a. Portal hypertension31. What is the technique of choice to supplement transabdominal US? For biliary duct stones

a. MRC32. What benign polyps is precancerous to liver cancer?

a. Adenomas >1cm33. If Bilirubin > 4 mg/dl, suggests choledocolithasis (stones in the biliary duct)34. Most common type of cholelithiasis?

a. Cholesterol 35. What is the initial choice of work up for cholecystitis?

a. US36. If US is unfavorable, what is the next test to rule out cholecystitis?

a. HIDA37. Treatment of choice of cholelithiasis?

a. Cholecystectomy is treatment of choice for virtually all symptomatic gallbladder stones38. Which of the following is not part of the charcot’s triad?

a. Rovsin’s signb. Know the triad

i. Biliary colic ii. Fever

iii. Jaundice

39. What study can be diagnostic and therapeutic when evaluating patient for CBD obstruction?a. ERCP

40. A chronic cholestatic liver disease characterized by fibrosing inflammatory destruction of both the intra- and extrahepatic bile ducts

a. Primary sclerosing cholangitis41. Which of the following laboratory test is elevated in pancreatitis?

a. Serum amylase42. Which CI in treatment of acute pancreatitis?

a. morphine43. Which of the following is not part of the Ranson criteria?

a. Age <30 yob. Know the ranson criteria

44. Which of the following test would suggest cholecystic?a. Murphy’s sign

45. Specific organisms suspected are based on?a. Incubation period and predominant symptoms

46. What type of mechanism involves in nausea, vomiting, with no fever and recover within 24 hours?a. Ingestion of preformed toxin

47. A patient with c/o fever and vomiting who recently eat KFC chicken. What is the most likely description of the diarrhea?a. Watery

48. Which bacteria are found in fried rice?a. Bacillus cereus

49. Diarrheal illness coincedes with or precedes paralysis. What is the most likely cause?a. Clostridium botulinum

50. Which two bacteria cause watery diarrhea that may become bloody?a. EHEC and Shigella

51. 25 patients came into the ER complains of abdominal cramps and watery diarrhea who all recently ate at the same burger joint (beef). What is the most likely cause?

a. EHEC52. Which of the following treatment is similar for all bacteria food poisoning?

a. Rehydration (isolation??)53. Which of the following bacteria would need antibiotic treatments?

a. Travelor’s diarrhea b. No antibiotics for B. cereus, S. aureus, C. perfringens, V. parahaemolyticus, Yersinia, and enterohemorrhagic and

enteroinvasive E. coli54. If suspected botulism, which of the following should you do?

a. Antitoxin should be administered early