Rheumatology/Orthopedic Buzz Terms

Rheumatology. I'm not sure there is a more gray area of medicine... perhaps that's why I don't like it that much. I remember sitting in rheumatology class listening to cases thinking, "it could be any of the rheum diseases that we've talked about!" They all sound the same and there is no ONE test that gives you the answer. I find it immensely frustrating (perhaps why I ended up in a surgical field), but I tip my hats to the providers that work in it. It is so difficult to pin down a diagnosis and successfully treat a patient with rheum issues... so for me, I stick to the basics.

See below for my knowledge extent on these rheum/orthopedic PANCE/PANRE test-able gems:

Osteoarthritis (OA)
Exercise, PT
If knee joints involves - encourage weight loss indicting
Pool activities
NSAIDS

Rheumatoid arthritis (RA)
Aspirin, other NSAIDS
methotrexate for severe cases
benefits take months to see after therapy initiation

Ankylosing Spondylitis
PT
Indomethacin
Bamboo spine on plain films

SLE
NSAIDs for joint symptoms
Benign cases only need supportive care
Systemic corticosteroids for serious complications
Could be a cause of thrombosis in young women (oral contraceptives can also cause this)

Rickets
Vit D deficiency

Osteomyelitis
Aspirate and culture
Immobilize
Generally start with IV antibiotics then follow with PO antibiotics




Source: Medical boards Step 2 Made Ridiculously Simple - A. Carl, MD, PhD
Photo: wiki.cns.org

ACA Stroke Basics

Anterior Cerebral Artery (ACA) Stroke

The Anatomy

What deficits might you expect to see in a patient?

• contralateral leg weakness (both motor and sensory), frontal lobe behavioral issues, +/- aphasia if prefrontal cortex involved, grasp reflex

Where does the ACA receive its blood supply from?

• Carotid arteries

Source: http://www.neuroanatomy.ca/stroke_model/aca_info.html
Photo sources: http://missinglink.ucsf.edu/lm/ids_104_cns_injury/response%20_to_injury/watershed.htm

Diabetes Insipidus, Part 1

Diabetes Insipidus, Part 1

What is it?

• The inability to conserve H20 and maintain optimum free H20 levels
• Pts urinate large amounts of diluted fluid, regardless of the body's hydration state
• Sx: extreme thirst (can even wake pts up at night and drink up to 20L per day!), dry skin, constipation

Click to enlarge

Upcoming...
Part 2: Diagnosing DI
Part 3: Treatment for Central DI and Nephrogenic DI






Source: 
Makaryus/Mcfarlane. DI: diagnosis and treatement of a complex disease Cleveland Clinic Journal of Medicine Jan 2006 Vol 73:1

Differentiating the Shakes

Essential Tremor v. Parkinson's Disease, Simplified

Of course this topic could be covered in much more depth than shall be covered here... but this is designed to cover the big picture and help you study for the PANCE.

ET
Characteristic: postural and/or intention tremor, meaning when the patient attempts to do something with their arms, the tremor appears or gets worse... these patients have difficulty with eating and drinking. 
Treatment: propranolol and primadone
Other notes: ETOH usually makes tremor BETTER, 50% of pts have a + family hx, tremor can affect voice (remember to ask the pt to say "EEEEEEEEEEE" - you often hear shaking)



PD
Characteristic: resting tremor
Treatment: sinamet, levodopa-carbidopa
Other notes: other PD sx = bradykinesia (slow movements), cog wheeling with passive movements




Source: Hardcore Pathology, by Wahl

Heart Failure

Quick study material on heart failure:

LEFT SIDED

• dyspnea
• wheezing
• orthopnea
• S3/S4 gallop
• puLsus alternans

RIGHT

• peripheral edema
• nocturia
• JVD
• hepato/spleno-megaly

FUNCTIONAL CLASSES (1 = best, 4 = worst)

Pic source: http://www.remodulin.com/patient/diagnosing-pah.aspx
Source: Medical Boards Step 2 - Made Ridiculously Simple (Andreas Carl, MD)

New PA Student Site

Check out the new microsite dedicated to PA Students! I was part of the team that worked hard to put this together and the AAPA was an integral part of giving us the funding to get this up and running. It is a "one stop shop" that was created BY PA students FOR PA students!

Check it out. Write a blog entry for the site. Submit a new scholarship that you found that is relevant. The continued success of the site is dependent on YOU the PA student to help keep it alive with content!

See the About Us section to know where to send your content!

www.PAStudentEssentials.com

Mnemonic Site

Board Mnemonics Site. Some are super helpful. Some are ridiculous. Enter at your own risk.

Mnemonic: is any learning technique that aids information retention. Mnemonics aim to translate information into a form that the human brain can retain better and even the process of applying this conversion might already aid the transfer of information to long-term memory.




Source: http://en.wikipedia.org/wiki/Mnemonic

Hypoparathyroidism, The Signs

Hypoparathyroidism. It is on the NCCPA's list of diagnoses on the PANCE exam. Two signs associated with hypoparathyroidism are Chvostek's and Trousseau's Signs. Chvostek's sign is a twitching of facial muscles in response to tapping over the area of the facial nerve. The Trousseau's sign is hand/finger spasm that results from ischemia, which can be induced by pressure applied to the upper arm from an inflated BP cuff.

As I was looking through this week's NEJM email I came across and article with videos of each of these signs. Watch it! Once you see it, you won't forget it. I would also read the case, it is very short. That plus visualizing the "signs" will help it stick.

NEJM Video

Photo source: http://www.medicinenet.com/hypoparathyroidism/page2.htm
Source: http://www.nejm.org/doi/full/10.1056/NEJMicm1110569?query=TOC

PANCE REVIEW: Train Your Brain

Here are some more Word-Associations for your PANCE studies... I'll add any tricks that I have found or come up with to remember them. Remember, these are meant as a study tool. Read the entire question and use your clinical know-how to determine your final answer. These are in no particular order:

Retinal Artery Occlusion = cherry red spots [When I think artery, I think RED]
Retinal Vein Occlusion = blood and thunder

Hordeloum = Hurt (painful)
Chalazion = painless

Viral conjunctivitis = preauricular lymphadenopathy + bilateral + watery discharge
Bacterial conjunctivitis = purulent discharge

Macular degeneration = drusen deposits/central vision loss

Rinne/Weber - Conduction/Sensorineural 

Epiglottis = thumb print sign/tripod/drooling

Oral white patches
Candidiasis = uncomfortable/Can be scraped off
Leukoplakia = painless/cannot be scraped off (Left on)

HypOparathyroidism = + Chvostek's sign/Trousseau's sign [due to low Ca+]
Hyperparathyroidism = "bones, stones, abdominal groans, psychiatric moans, and fatigue overtones"

Essential tremor = can temporarily gets better with ETOH

Eczema = flexor surfaces
Psoriasis = extensor surfaces

Actinic Keratosis = sun exposure/pre-cancerous!

Seborrheic Keratosis = greasy/ "stuck on"

PANCE REVIEW: Pesky Vertigo

I can never keep these straight. Every practice exam I'm cursing myself when I get these wrong - so I finally decided to make a chart and learn them.

A couple tips to narrow it down:

*Those with the red circle are SUDDEN onset
*Those with blue circle involve hearing loss - so if it is sudden with hearing loss... you're down to Meniere's!

Source: AAPA and PAEA book

PANCE: Buzz Words

When studying for the PANCE it is difficult to "know it all" - sometimes you need some helpful hints to jog your memory or lead you in the direction of a likely answer....  The following list contains some word association stuff that may help for which organisms in pneumonia are most common in particular populations. Word association is no substitute for knowing and understanding the clinical scenario, but it may help you narrow down the options.

I will put a list here... quiz yourself (see below for answers):

Which pneumonia organisms would you match with the following patient populations or buzz words?

1. ETOH 
2. COPD
3. Air conditioners/cooling systems
4. Cystic fibrosis
5. Asplenic
6. College
7. Leukemia
8. Kids < 1 yo
9. Kids > 2 yo

 Answers:

1. ETOH = Klebsiella
2. COPD = Haemophilus influenza (H.flu)
3. Air conditioners/cooling systems = Legionella
4. Cystic fibrosis = Pseudomonas
5. Asplenic = encapsulated organisms (strep pneumo/H.flu)
6. College = mycoplasm pneumo or chlamydia pneumo (longer prodrome, sore throat, hoarseness)
7. Leukemia = fungus
8. Kids < 1 yo = RSV
9. Kids > 2 yo = parainfluenza virus

Delirium vs. Dementia

Source: PSYCHIATRY for Medical Students and Residents Nabeel Kouka, MD, DO, MBA (available for free online)

PANCE REVIEW: Jones Criteria

Is it rheumatic fever or not? You need to know the Jones Criteria to make the determination.

Source: AAPA/PAEA Exam Review Book, PANCE review lecture by Janice Herbert-Carter, MD, MGA, FACP

PANCE REVIEW: Dyslipidemia Drugs

PANCE REVIEW: COPD

I made this chart to study for the PANCE. Thought I would share:

 I was asked to add this to this posting. I should add that I am in no way reimbursed to do so. Just seems like a good cause:

Healthline just launched a campaign for called "You Are Not Your COPD" where COPD patients share their story or advice about living with the disease.  http://www.healthline.com/health/copd/inspirational-stories

They have partnered with the COPD Foundation to promote the campaign and have pledged that for every submitted story, Healthline will donate $10 to the COPD Foundation. (added on 4/20/14)

PANCE REVIEW: Get the Most Out of Studying

How do you get the most bang for your buck when studying for the PANCE? Below is a break down of the % of questions for each subject on the PANCE. If you are cramped for time to study - pick the categories with the highest yield. As you can see, CV + GI + Musculoskel + Pulm account for 48% of the questions on the PANCE! If you add Reproductive and EENT to the mix you are up to 65% of your exam.

Organ System             % of Exam Content

*Cardiovascular                      16

Dermatologic                            5

EENT                                        9

Endocrine                                  6

*Gastrointestinal/Nutritional  10

Genitourinary                            6
Hematologic                              3
Infectious Diseases                   3

*Musculoskeletal                     10

Neurologic System                    6
Psychiatry/Behavioral               6

*Pulmonary                              12

Reproductive                             8 

Total: 100%

PANCE REVIEW: Thyroiditis

So today's topic hits close to home because I was diagnosed with Hashimoto's thyroiditis this year after complaining of incredible fatigue. It was getting to the point that I was having difficulty getting through the day past 2p without napping. I was wiped out. So for today's PANCE review we will discuss Hashimoto's specifically - but you should also be familiar with the other forms such as subacute, post-partum, and infectious.

Hashimoto's Thyroiditis, Noteworthy Stuff Only

• Most common form
• Autoimmune or polyglandular syndrome
• More common in women than me
• Familial
• Frequency increases with 1) iodine supp and 2) certain meds
• Diffuse, enlarged, firm nodules (often asymmetric)
• NOT painful*
• Can see depression/chronic fatigue
• Tests: serum antithyroid peroxidase and antithyroid globulin antibodies
• Tx: lifelong thyroid hormone replacement (levothyroxine) for hypothyroidism, watchful waiting if goiter is present

*In contrast to subacute which is PAINFUL!

NOTE: Don't forget - for the PANCE... the single best screening test for thyroid dz is TSH!

Source: AAPA, PAEA Exam Review Book
Pic: http://www.nature.com/nm/journal/v10/n9/fig_tab/nm0904-895_F1.html

PANCE REVIEW: Stomach

The PANCE need-to-knows for the stomach are: GERD, gastritis, neoplasms, peptic ulcer dz, pyloric stenosis. That's it for the stomach! Studying seems so much more manageable once you see lists broken down.

I am going to set today's blog up a little differently. I will pose the questions and then you can try to answer them. Scroll down to find the answers.

Gastritis

1. What is gastritis?
2. What causes it?
3. What might you see clinically?
4. What labs/tests might you consider ordering?
5. How do you treat it?

1. inflammation of the stomach
2. imbalance of the "protective" factors in the stomach such as: mucus, bicarb, prostaglandins, mucosal blood flow, etc. - this can be due to autoimmune conditions, H.Pylori, NSAIDs, stress, ETOH
3. dypepsia, abdominal pain, other s/sx that reflect the underlying cause
4. a) endoscope with biopsy b) Urea breath test (looking for H.Pylori) c) condition-specific tests
5. treat the underlying cause + remove caustic factors (ETOH, NSAIDs)




Source: AAPA/PAEA Exam Review book

PANCE REVIEW: Spirochetal infections

Those pesky spirochetal infections:

	LYME	ROCKY MNT SPOTTED FEVER
General	Borrelia burgdorferi, deer tick must feed for 24-36hrs to pass dz, *Most common vector born-dz	Rickettsia rickettsii (wood tick), common in eastern US
Clinical	Stage 1:local infx (7-10d after bite) - erythema migrans "bull's eye", flu-like sx in 50% pts, Stage 2: early dissemination - HA, stiff neck, malaise, fatigue, MS sx, cardiac sx in 20% cases, Stage 3:late persistent infx, MSD, central/perip NS	fever/chills/ N/V, insomnia can develop in 2-14 days, face is flushed and conjunctiva injected, small rash develops on extremities
Lab	antibody detection (immunoflu assay or ELISA), western blot to confirm, Ig M wanes after 6-8 wks, IgG can be indefinite, high likelihood of false+	leukocytosis, thrombocytopenia, hypONa+, proteinuria, hematuria, transient rise in bili, rise in antibody titers in 2nd wk, CSF = pleocytosis, hypocorrhachia
Tx	doxy for erythma migrans or lyme, NSAIDS, prevention	mild, untx cases wane in 2wks, doxy or chloramphenicol hasten recovery, poor outcome for advanced age

PANCE REVIEW: Esophageal Dysmotility

 Esophageal Dysmotility in a nutshell.

6 types that you need to know about:

1- Neurogenic dysphagia

• caused by brain stem injury
• difficulty swallowing BOTH solids and liquids

2- Zenker's Diverticulum

• Regurgitation of undigested solids/liquids several HRS after eating

3-Esophageal Stenosis

• hard to swallow SOLIDS
• slow progress = usually benign (rings)
• fast progress = usually malignant

4- Achalasia

• global motor dysfunc of esophagus
• decrease peristalsis, increase sphincter tone
•  SLOW, PROGRESSIVE dysphagia with episodic regurg and chest pain
• **Parrot-beak** on barium swallow

 5- Esophageal spasms

• intermit chest pain and dysphagia
• may or may not be associated with eating

6- Scleroderma

• often dz progression to esophagus
• decrease in peristalsis, decrease in sphincter tone
• s/sx of reflux

Question: What are the definitions of odynophagia and dysphagia?

Labs:
A. Barium swallow: good for both structural and motility problems
B. Esophagoscopy: must be done to clarify strictures
C. Esophageal manometry: looks at peristalsis

Tx:
Neurogenic? Treat underlying cause.
Stricture? BENIGN = dilation, MALIGNANT = resection



Answer: Odynophagia = painful swallowing, Dysphagia = difficulty swallowing





Pic: http://www.umm.edu/imagepages/19507.htm, http://www.bristolsurgery.com/page.aspx?id=184
Source: AAPA/PAEA Exam Review Book