Adult exam 3 study guide Hi class, 💡 Note that exam 3 (Adult Health I) will cover from week 8 to week 11 materials (Neurological, Musculoskeletal, Acute Pain Management in Primary Care, Endocrine disorders), kindly check relevant pages in your textbooks. Also, review the supplemental materials located in this week's content on BB. Updated below on 4/6/2022. Kindly reveiw these topics. ✳️Exam 3 will open on the Wednesday at midnight through Saturday at midnight on week 13. (💡Tip) Student will have 2 attempts for the exam 3, just take the exam when it opens, and study more, and take it again before it closes. Please finish up the exam before the Saturday at midnight on week 13, do not start your exam at the last minute, the exam will be closed on Saturday at midnight. 📕 Week/Module 8 common Acute Neurological Disorders (Chap 13) ● Headaches ○ Migraine Without aura/With aura, ■ Characteristics (1)Most patients have a family history of HA, rarely starts after 50 years of age (2) Migraine without aura happens at least 5 headaches meeting the following criteria: lasts 4 ot 72 hr, at least 2 of the following: unilateral, pulsating, moderate to severe intensity, worsened by routine physical activity (3) at least one of the following during headache: nausea, vomiting, photophobia, phonophobia (4) H&P and neurologic examinations do not suggest underlying organic disease ■ Migrane with aura (1) attacks include transient reversible symptoms (aura) that graually develop over5 to 20min and lasts , 60min (1a) visual flickering lights, spots,lines, loss of vision (1b) sensory: pins and needles, numbness (1c) Speech disturbance (1d) brain stem: diplopia, vertigo, tinnitus (2) has features of migraine without aura, ans HA develops during or within 60 min of aura ○ Tension headache ■ a) Bilateral, nonthrobbing, dull, “tight band” around head (there is often tenderness of muscles in head, neck, or shoulders) b) Mild-to-moderate intensity (not disabling) and can last 30 min to 7 days c) Often related to stress or mental tension; not aggravated by physical exertion d) There are no associated auras, N/V, photophobia, or phonophobia ■ Treatment: a) Naproxen 500 mg, IBU 200 to 400 mg, or ASA 650 to 1000 mg (NSAIDs are less likely to cause medication overuse H/A than other analgesics) b) OTC pain reliever with or without caffeine c) Combinations with opioids or butalbital are not recommended unless the other options are ineffective or contraindicated; do not prescribe >18 tablets a month d) For prevention, consider amitriptyline 10 mg hs and increase the dose by 10 to 12.5 mg q2–3wk as tolerated, until H/A improves or dose reaches 125 mg nightly e) Lifestyle changes may help: regulation of sleep, exercise, and meals (e.g., decrease red meat, sugar, and chocolate); stress reduction, biofeedback, stretching exercises ○ Cluster headache ■ a) More common in men than women, usually after 30 yr of age, intermittent episodes of attacks with periods of remission lasting ≥12 mo b) Occurs up to 8 times qd; often cyclical, occurring at the same time of day; lasts 10 min to 3 hr; the episodes can last for 2 mo or longer c) Pain is exquisitely severe, nonthrobbing, and unilateral in the head and face with pain in, around, or behind eye d) May worsen when lying still and is associated with pacing, rocking, and agitation e) Triggers: ETOH, tobacco, histamines, vasodilators, and seasonal allergies 2. Associated symptoms: only during attacks and are ipsilateral to pain a) Lacrimation, ptosis, and conjunctival injection b) Nasal congestion and rhinorrhea c) Facial flushes, sweating ■ Treatment: a) CT/MRI with initial attack (see Table 4.2); no labs are helpful b) Abortive i) O2 at ≥12 L/min using nonrebreathing mask, with the patient sitting upright; use for 15 min, even if the pain subsides before then. Do not use if patient has severe COPD. ii) Sumatriptan 6 mg IM or 20 mg intranasal (intranasal form is administered contralateral to the side of the H/A); more than 2 doses per day may be needed until the preventative medication has taken effect c) Preventative: start ASAP at onset of a cluster episode and taper medication after expected duration of episode passes i) Verapamil 240 mg qd, increasing daily dose by 80 mg q10–14d, often up to 480 mg or more (regular release form given in 3 divided doses qd and sustained release given in 2 divided doses); benefit of medication usually seen within 2 to 3 wk (may use prednisone during the first 2 wk to help) ii) Prednisone 60 to 100 mg qd for 5 to 14 days; taper by decreasing the dose 10 mg qd d) There is no evidence of benefit with botulinum injections or hyperbaric O2 ○ Red flags on exam including new-onset above 35 yr and above, neck stiffness, neuro deficits, papilledema (ED TRANSFER) ■ Not-to-be-missed A. First or new-type or worst-ever H/A (possible intracranial bleeding, CNS infection); immediate transfer to the ED B. New H/A in patient >50 yr of age (possible temporal arteritis, tumor, or intracranial bleed) C. Worsening or change in pattern compared with usual H/A (possible mass or subdural hematoma) D. Signs/symptoms of systemic illness (e.g., fever, vomiting, nuchal rigidity [possible CNS infection]); immediate transfer to the ED E. H/A with exertion (e.g., cough, sneeze, intercourse [possible increased intracranial pressure]) F. Focal neurologic signs (possible CVA, intracranial aneurysm, mass) G. Patient taking anticoagulants (possible intracranial bleeding) H. H/A in children 1. Listen for bruits over the carotid arteries; if asymmetric or continuous, immediate transfer to the ED 2. If the child has a stiff neck with a severe H/A, immediate transfer to the ED (possible subarachnoid hemorrhage or meningitis) ○ Always check BP, pulse, palpate head/neck/shoulders/spine, bruits of arteriovenous malformation(AVM) ● Vertigo (symptoms, etiology, treatment, most cases need referral) ● ● ● ● ○ • Referral • Emergent transfer to ED • New-onset vertigo accompanied by neurological signs/symptoms (e.g., diplopia or dysconjugate gaze, limb numbness or weakness, slurred speech) or acute vertigo with new hearing loss • Symptoms suggestive of aortic aneurysm/dissection or MI (see Table 8.4) • Syncope with unstable VS • Neurologist • CNS signs and symptoms Neuropathy (common features, most common risk factors are diabetes, alcohol abuse) Parkinson’s Disease (resting tremor, presentation/treatment) ○ Resting tremor: typically most noticeable when the involved extremities are at rest and is relieved or absent during activity ○ 1. Most commonly seen with Parkinson disease but can occur with other neurologic diseases 2. May be asymmetric, involving the extremities but not usually the head/neck (although it can affect the tongue, lips, and chin) 3. Typical movement: alternating forearm pronation and supination or “pill rolling” B. Treatment: stop or reduce any drugs that might exacerbate parkinsonism C. Referral: to a neurologist if Parkinson disease is suspected Multiple sclerosis (presentation) ○ Signs and symptoms 1. Sensory symptoms present in most patients some time during the disease: numbness, tingling, “pins and needles,” tightness, coldness, or sensation of swelling of limbs or trunk; may have intense itching (especially unilaterally in cervical dermatomes) 2. Pain is common: trigeminal neuralgia, dysesthesia (unpleasant sensation when touched) 3. Fatigue unrelated to the amount of activity performed; may be improved by rest 4. Coordination: vertigo, gait imbalance; may have intention tremor in limbs and head 5. Bowel and bladder dysfunction B. Treatment: referral to a neurologist; may comanage care Dementia ○ cognitive decline/deficits, how to diagnosis, cognitive testing like MMSE, Physical Exam, Differential Dx, ○ diagnostic studies, assessments, safety assessments/education 📕 Week/Module 9 Common Acute Musculoskeletal Disorders (Chap 14) ● The most Common Orthopedic conditions are.. ○ Osteo Arthritis[OA](features, treatment-pharmacologic/non-pharmacologic) ○ Rheumatoid Arthritis[RA](autoimmune dz, get a good history) ○ Compare RA vs OA. RA - A. Description: symmetric, inflammatory polyarthritis of unknown etiology; it affects at least three joints, including small joints of hands and feet; does not affect DIP joints or thoracic/lumbar spine B. Signs and symptoms 1. Joint stiffness on rising, lasting >1 hr; often improves with activity 2. Affected joints are red, swollen, and warm 3. Ulnar drift or deformities of fingers (swan neck, boutonniere) often present 4. Malaise and/or fatigue often present 5. May have extra-articular manifestations but not early in the disease (e.g., pleural effusion, HF, A-fib, anemia, vasculitis, neuropathy) C. Diagnostic tests 1. Lab: RA factor (high sensitivity), ESR or CRP, ANA, CBC, CMP, UA; consider anti-CCP (high specificity), serum uric acid, UA 2. Consider x-rays of painful joints (e.g., hands) D. Treatment 1. Referral: to a rheumatologist 2. Monitor patients taking immunosuppressive agents for signs of HF and skin cancers 3. No live vaccines (e.g., for shingles) if taking biologic DMARD agents (e.g., Enbrel, Humira) 4. Consider O.T. referral for splinting and help with ADLs 5. Paraffin baths can help with hand and foot pain OA - A. Description: degenerative changes in joints related to past trauma, aging, and/or obesity 1. Common in weight-bearing joints (e.g., hip, knee, spine) and DIP/PIP joints and base of the thumb 2. Joints usually spared: wrist, elbow, ankle (unless previous fracture) B. Signs and symptoms 1. Joint stiffness on rising, lasting <30 min; occurs more by the end of the day. The joint damage may not correlate with the severity of joint pain and disability. 2. Affected joints are irregularly shaped but not red or warm; pain is dull, achy, worse with activity, and improves or relieved with rest 3. May have nontender Heberden (DIP) and Bouchard (PIP) nodes 4. There are no extra-articular manifestations but consider sleep and mood disturbances because of the pain and change(s) in ability to do desired activities C. Diagnostic tests: consider especially with knee or hip pain or symmetric pain in hands 1. Lab: ESR, RA factor 2. X-ray of the affected joint(s) D. Treatment 1. The goals of treatment are to minimize pain, optimize function, and modify joint damage. 2. Patient education is essential to get the best results a) Discuss the cause(s) of the arthritis and the expected prognosis b) Help patient to set realistic goals and positively reinforce achievements (e.g., start with walking 10 min 3 times a wk with eventual goal to be 30 min 3 times a wk by 3 mo) 3. Nonpharmacologic (tried first or in conjunction with medication) a) Weight loss of at least 10%, if indicated b) Rest joint 12 to 24 hr with acute pain, then resume ROM and exercise (especially aquatic exercise) c) Consider P.T. for suggestion of specific aerobic and strengthening exercises and O.T. for help with ADLs d) Use of items such as cane, knee brace, thumb splint 4. Pharmacologic (use only when symptomatic; none are disease-modifying) a) With hand and/or knee OA: topical NSAIDs (e.g., diclofenac gel bid-qid over affect joints) have similar efficacy to oral NSAIDs and have less GI and renal effects b) With pain in multiple joints and/or hip OA: oral NSAIDs at the lowest dose needed to control the pain, used on a prn basis c) With OA in multiple joints and contraindications to oral NSAIDs: duloxetine 30 mg qd for a wk, may increase to 60 mg qd d) Acetaminophen is no longer recommended as first-line treatment due to safety concerns and negligible effects on pain e) Consider opioids only for short-term use with severe symptoms unresponsive to other treatments f) Glucosamine sulfate 1500 mg qd (shellfish allergy is not a problem with this) g) Intra-articular steroid injection or Hyalgan injections are controversial and may be ineffective; an exception is Zilretta injection (triamcinolone acetonide extended release suspension) for OA knee pain5. Alternative treatments that may be effective for pain relief and decrease inflammation a) Turmeric ½ tsp or curcumin 500 mg bid b) Penetrex cream (OTC) 1 to 2 times qd c) Blue Emu cream at least bid prn d) Arnica gel 2 to 3 times qd prn 6. Referral to an orthopedic surgeon with no response to therapy or functional limitations and pain at rest or at night. ● Most Common Orthopedic Injuries: ○ Ankle/Foot: Ankle sprain (pain grades depend on sprain severity, management-RICE methods, early mobility with splints/braces, analgesics), plantar fasciitis(heel pain) ○ Knee: ACL, meniscal injuries (acute knee pain from meniscal tear and torn ligaments), (How to approach to pt with acute knee pain - Anterior/Posterior[A/P] Stability evaluated with anterior drawer test, posterior drawer test, Lachman test. Meniscus evaluated with McMurray/s test) ○ Shoulder: Rotator cuff Tendinopathy(Impingement syndrome)- Positive painful art test, Rotator cuff tear ○ Wrist: scaphoid fracture(very common injury, if snuffbox tenderness, consider scaphoid fracture) ○ Hip (Depends on pain location) ○ Elbow: Tennis elbow(=Lateral Epicondylitis, tests, management-Rest!! but keep joint moving) ○ Low back pain (2nd most common cause for office visits in the US, get a good history, physical exam, Sciatica, Straight Leg Raise test to confirm acute Radiculopathy) 📕 Week/Module 10 Acute Pain Management in Primary Care (Chap 15) ● Check the supplemental materials located in week 10's content. 📕 Week/Module 11 Common Acute Endocrine Disorders (Chap 16) ● Diabetes Mellitus ○ Risk factors - A. Consider diagnosis with one or more of the following: 1. Presence of PCOS 2. Weight gain 3. Dyslipidemia 4. Systolic BP elevated after eating 5. Clotting abnormalities 6. Presence of nonalcoholic fatty liver disease (NAFLD) 7. Presence of diastolic dysfunction a) S4 heart sound b) Possible HF c) Echo shows stiff left ventricle (secondary to free fatty acid [FFA] deposits) 8. Gout (increased FFA deposits in kidneys interfere with uric acid excretion) 9. Presence of acanthosis nigricans around the neck or under the arms; it usually improves with treatment ○ ADA diagnostic criteria-T2DM and Pre-DM ○ ○ ○ ○ ○ ● Initial management ADA suggested A1C goals by age for T2DM Recommendations for reducing risks, DM monitoring including history and physical exam, labs ADA first line tx-metformin, other diabetes medications - class, advantages, disadvantages, mechanism of actions Insulin use - types, onset of action, duration, examples) Thyroid disease ○ HYPOTHYROID ■ Hypothyroidism I. Possible causes (in most patients, it is a permanent condition requiring lifelong therapy) A. Autoimmune disease of thyroid B. Post thyroidectomy C. Treatment for hyperthyroidism (including post radiation to neck) D. Medications II. Signs and symptoms A. General 1. Weakness, fatigue, lethargy 2. Cold intolerance 3. Mild weight gain or difficulty losing weight 4. Depression; confusion (in elderly patients, this may be the only sign) B. Integumentary 1. Dry skin and/or hair 2. Hair loss, including loss of the lateral third of eyebrows 3. May have brittle nails C. Cardiac: bradycardia, possible cardiac enlargement D. Genitourinary: amenorrhea, menorrhagia, infertility E. Gastrointestinal: constipation F. Metabolic 1. Complains of feeling cold easily 2. Hypercholesterolemia 3. Elevated CK 4. Hyponatremia 5. Macrocytic anemia G. Neurological: slow DTRs (e.g., patellar and ankle jerk), slow speech III. Diagnostic tests: elevated TSH and low free T4 A. If the patient has signs and symptoms but normal lab results, consider depression B. With elevated TSH but normal free T4, consider subclinical hypothyroidism 1. With TSH ≥10 units/L: treat with levothyroxine to normalize TSH and decrease the risk of progression to overt hypothyroidism 2. With TSH 4.5 to 10 units/L: routine treatment is controversial; consider levothyroxine with symptoms suggesting hypothyroidism IV. ■ Treatment A. Levothyroxine (T4) is the medication of choice; start with 25 to 50 mcg qd and increase by 12.5–50 mcg qd q2mo until TSH normalizes (average maintenance dose in adults is approximately 1.6 mcg/Kg/d). Then recheck lab yearly and prn. B. It is most effective when taken on an empty stomach with no other medications; if unable to take on an empty stomach, be consistent with when it is taken C. Some patients may be taking desiccated thyroid USP (e.g., Armour Thyroid), which is a combination of T4 and T3 hormones 1. Consider using if patient has not felt well on just T4 since thyroidectomy or radioiodine ablative therapy or who has a low or low normal free T3 2. It is not recommended in patients with cardiovascular disease (more prone to arrhythmias), older patients or pregnant women 3. Thyroid USP metabolism may be erratic 4. 60 mg thyroid USP = 100 mcg levothyroxine in potency 5. Adjust doses by 15 mg qd D. Consider brand name Synthroid if unable to correct TSH with generic levothyroxine E. Discourage overreplacement with medication, which can cause subclinical or overt hyperthyroidism ○ T3, T4, TSH background, hypothyroidism ○ How to replace primary hypothyroidism with L-thyroxine(synthetic T4), replacement in middle/older adults- initial dose, increase how often, upper limit dose. Updated on 4/6/22.
