Beruflich Dokumente
Kultur Dokumente
Viral hepatitis
18. What are the 5 major types of viral hepatitis?
19. What are the clinical features and clinical course of hepatitis A?
20. How is hepatitis A transmitted?
21. How is hepatitis A managed?
22. Who should receive the hepatitis A vaccine?
23. How is hepatitis B transmitted?
24. What are clinical features of hepatitis B?
25. How is hepatitis B infection diagnosed? What is the relevance of tests for hepatitis B e antigen and antibody?
26. What are the serologic patterns of infection with hepatitis B that recovers, and that stays chronic?
27. Who should receive hepatitis B vaccine?
28. What are sequelae of chronic viral hepatitis?
29. What are the available treatments for chronic hepatitis B?
30. Who should receive treatment for chronic hepatitis B?
31. How is hepatitis C transmitted?
32. What is natural history of hepatitis C infection?
33. What is treatment of chronic hepatitis C?
34. What is hepatitis D?
35. What is hepatitis E?
36. What is hepatitis G?
Esophageal disorders
37. What is dysphagia?
38. What are the major causes of dysphagia?
39. What is a reasonable algorithm for the diagnosis of dysphagia?
40. What is odynophagia?
41. List three treatments for achalasia.
42. What is the mechanism of GE reflux in most cases?
43. How can the diagnosis of reflux be confirmed?
44. What are the major complications of GE reflux?
45. What is esophagitis?
46. What is Barrett’s esophagus?
47. What is the key element of treatment of GE reflux?
48. What is the mechanism of parietal cell acid secretion?
49. List 5 proton pump inhibitors.
Gastrointestinal bleeding
64. What are the major causes of upper GI bleeding?
65. What are three high risk unusual causes of upper GI bleeding?
66. What do the following terms mean?
a. Hematemesis
b. Melena
c. Hematochezia
67. What is the natural history of bleeding due to peptic ulcer disease?
68. What are the prognostic factors related to overall outcome in patients with upper GI bleeding?
69. What is the general mortality rate in patients with upper GI bleeding due to peptic ulcer?
70. What are endoscopic findings that predict an adverse outcome in patients with upper GI bleeding due to peptic ulcer?
71. What are general supportive measures related to management of patients with upper GI bleeding?
72. What are specific therapeutic measures for patients with upper GI bleed due to peptic ulcer?
73. What are indications for surgery in patients with upper GI bleeding?
74. What leads to esophageal varices?
75. What are risk factors for bleeding among patients with esophageal varices?
76. What are adverse prognostic factors for bleeding esophageal varices?
77. What specific therapeutic modalities are available for bleeding varices?
78. What is octreotide?
79. What is TIPS?
80. What are major causes of lower GI bleeding?
81. What are the major investigative modalities available for lower GI bleeding?
82. What is a Meckel’s diverticulum?
Acute pancreatitis
83. What are the two major causes of acute pancreatitis?
84. What are the additional important causes of acute pancreatitis?
85. What do patients with acute pancreatitis complain of?
86. What are the major physical findings in a patient with pancreatitis?
87. What laboratory tests are most helpful in the diagnosis of acute pancreatitis?
88. What are other causes of hyperamylasemia?
89. What imaging tests are helpful in diagnosis of acute pancreatitis and its complications?
90. What are the local complications of acute pancreatitis?
91. What are the major elements of treatment?
92. What is the role of endoscopy in the therapy of acute pancreatitis?
Diarrhea
93. What causes acute diarrhea?
94. What causes chronic diarrhea?
95. What are major causes of bloody diarrhea?
96. What tests are appropriate in a patient with chronic diarrhea?
GI cancer screening
133. What is appropriate screening for:
a. Colon cancer
b. Esophageal cancer
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01 ALBERT 2008 Intro to Rheumatology
Friday, February 22, 2008
5:24 PM
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Give an example of a
non-inflammatory,
non-immune
rheumatoid disorder?
Give an example of an
inflammatory, non-
immune rheumatoid
disorder?
Give 3 examples of
inflammatory,
autoimmune
rheumatoid
disorders?(4)
Fibromyalgia and
osteoarthritis are both
categorized as: 1.
Inflammatory, Non-immune;
2. Inflammatory, Non-
immune; or 3. Inflammatory,
Immune?
Some "non-articular"
disorders and crystal arthritis
(such as gout and CPPD) are
(inflammatory or non-
inflammatory) and (immune
or non-immune)?
Give 4 examples of non-
inflammatory, non-immune
diseases?
Give 4 examples of
inflammatory, immune
diseases?
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Which of the
following is an acute
disease and which is
a chronic disease?
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The unifying
characteristic for most
of the rheumatic
diseases is ___?
T/F: The inflammation
in all rheumatic
diseases represents an
abnormal activation of
the ADAPTIVE immune
system?
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Autoimmunity is
usually benign
because of ___
mechanisms?
With respect to
the development
of autoimmunity,
Pro-T cells in the
thymus may be
categoriezed into
which 3 groups?
If self-reactive clones
of pro-T cells escape
the thymus because
self-antigen is NOT
expressed, then what
are the 3 mechanisms
in the periphery that
may lead to
peripheral tolerance?
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List the 3 main
categories of
autoimmune
reactions?
Autoimmune
diseases may be
either ___ or ___?
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Give examples of
autoimmune disease
that are organ specific?
Give examples of
autoimmune diseases
that are non-organ
specific?
What does "epitope
spreading" refer to?
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T/F: there are
extra-articular
features in RA?
List 4 serological
indicators that
may be positive in
Reumatoid
Arthritis?(5)
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In RA, there is edema of the
___ membrane with redundant
folds and villi?
In RA there is a (HYPO or
HYPER) plastic synovial lining
layer?
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Is a hyperplastic
synovial membrane
present in early or
established RA?
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List 3
inflammatory
mediators
involved in RA?
The strongest
evidence for a
genetic link in RA
comes from
evidence that the
___ genes are
associated with RA?
List 3 environmental
and/or lifestyle
factors that have
been implicated in
the development of
RA?
What do DMARDS
stand for?
T/F: Flares and
remissions DO NOT
occur in RA since it
is a chronic,
progressive disease?
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List 2 Anti-TNF
antibodies that are used
in Arthritis
management?
Etanercept is a solube
___ used in Arthritis
management?
Anakinra is a popular
___ used in the
management of
Arthritis?
In the management of
Arthritis, drugs such as
methotrexate and
lefluonmide
counteract the actions
of which cell in the
pathogenetic
progression of Arthritis?
In the management of
Arthritis, cytokine
neturalization drugs
counteract the actions
of which cytokines in the
pathogenetic
progression of Arthritis?
In the management of
Arthritis, Rutizimab
counteracts the actions
of which cells in the
pathogenetic
progression of Arthritis?
While both Etanercept
and Infliximab are both
exert their effect
through cytokine
neutralization, one is a
soluble TNF receptor
while the other one is an
Anti-TNF alpha
antibody; which is
which?
Is Adulimumab a soluble
TNF receptor or an anti-
TNF antibody?
Apart from using a
soluble TNF receptor or
an anti-TNF antibody,
which other drug
mechanism is used for
cytokine neutralization
in the treatment of RA?
IL-1 receptor
blocker
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and Infliximab are both
exert their effect
through cytokine
neutralization, one is a
soluble TNF receptor
while the other one is an
Anti-TNF alpha
antibody; which is
which?
Is Adulimumab a soluble
TNF receptor or an anti-
TNF antibody?
Apart from using a
soluble TNF receptor or
an anti-TNF antibody,
which other drug
mechanism is used for
cytokine neutralization
in the treatment of RA?
IL-1 receptor
blocker
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02 BOOKMAN 2008 Clinical Evaluation of Arthritis
Friday, February 22, 2008
5:24 PM
What is
seropositivity?
Into which
categories may
inflammatory
Arthritis be classified
into?
Into which
categories may
degenerative
Arthritis be classified
into?
Into which
categories may non-
articular Arthritis be
classified into?
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be infectious, associated with the pathogens that cause Lyme
disease, toxoplasmosis, and others.
Polymyositis, like dermatomyositis, strikes females with greater
frequency than males. The skin involvement of dermatomyositis is
absent in polymyositis.
Pasted from <http://en.wikipedia.org/wiki/Polymyositis>
List 4 different
classifications for
seropositive
Arthritis?
List 3
characteristics of
seropositive
arthritis?
How is
seronegative
Arthritis
classified?
What is podagra?
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Infectious
arthritis may be
classified into
which two types?
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For the clinical
evaluation of
arthritis, draw a
tree showing the
classifications in
the approach to
making a
diagnosis?
Is the duration of
AM stifness less
or more in a
patient with
inflammatory vs.
degenerative
arthritis?
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How does the
pattern of
arthritis different
in symmetrical
small joint
polyarthritis vs.
asymmetrical
oligoarthritis?
How is the
pattern of
arthritis in
monoarthritis
different from
that presented in
degenerative
joint disease?
In considering
therapy for the
clnical evaluation
of Arthritis, what
are the 5 factors
that one must
take into
consideration?
List 4 extra-articular
features of arthritis
List 4 Activities of Daily
Living (ADLs) that are
used in the clinical
evaluation of
arthritis?(6)
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A tophus (Latin: "stone", plural tophi) is a deposit of crystallised monosodium urate
in people with longstanding hyperuricemia. At this stage, most have already
developed symptoms of the associated crystal arthopathy known as gout.
Tophi form in the joints, cartilage, bones, and other places throughout the body.
Sometimes, tophi break through the skin and appear as white or yellowish-white,
chalky nodules. Without treatment, tophi may develop on average about ten years
after the onset of the disease, although their first appearance can range from three
to forty-two years. They are more apt to appear early in the course of the disease in
people who are older in age. In the elderly population, women appear to be at
higher risk for tophi than men.
How is class I
functional status
different from class III
functional status in
the clinical evaluation
of Arthritis?
What is the
distinguishing feature
between class I and
class II functional
capacity, as it relates
to the clinical
evaluation of
arthritis?
What is the
distinguishing feature
between class Ii and
class III functional
capacity, as it relates
to the clinical
evaluation of
arthritis?
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List 4 characteristics of
arthritis that are
explored further in
performing a history
and physical?(7)
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03 UROWITZ 2008 Connective Tissue Disorders
Friday, February 22, 2008
5:25 PM
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The pathogenesis
of SLE can be
broadly
categorized into
which 4 main
categories?
List 9 criteria
included in the
1997 Revised
Criteria for the
(mea ning a ra sh with a round or oval shape) Classification of
SLE?(11)
What is serositis?
A RASH POINts MD
Arthritis
Photosensitivity
Oral ulcers
I mmunological disorder (positive LE cell, anti-DNA, anti-Sm, false positive serological test for syphilis)
N eurological disorders (seizures or psychosis, in the absence of other causes)
Malar rash
Discoid rash
Because the malar rash is the most easily recalled finding, this mnemonic uses that word and an
accompanying message that it "points an MD to a possible diagnosis."
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accompanying message that it "points an MD to a possible diagnosis."
Pasted from <http://ard.bmj.com/cgi/content/full/60/6/638a >
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List 3 manifestations
of serositis that may
found in SLE? (hint:
pericarditis, …)
List 3 manifestations
of neurological
disorders that may
found in SLE?(4)
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In SLE, leukocytes,
lymphocytes, and
thrombocytes are
all (reduced OR
increased)?
List 3 manifestations
of hematologic
disorders that may
be found in SLE?(4)
Apart from
patient
education, what
are the 5 other
components in
the approach to
SLE therapy?
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Is it active or
inactive SLE that is
associated with late
deaths in SLE?
Is it inactive or
active nephritis that
is associated with
early deaths in SLE?
Is infection or
atherosclerosis
more commonly
associated with
early deaths from
SLE?
Late deaths from SLE
are associated more
commonly with
(atherosclerosis OR
infection)?
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• What predisposes these people to have subclinical is severity of lupus (as evidenced by increased prevalence of
vasculitis and npl) and also increased risk factors; steroids gives you htn, diabetes, hypercholesterolemia, etc.
• So if there are two things in here, these women are susceptible because they had early lupus and secondly
because they had other risk factors
Dermato/Polymyositis
is a disease in which
inflammation may be
present in which 2
organs?
• Dermato/polymyositis is in mucle only or in skin • Also a red, scaly flaky rash; different from luypus in
only; separate illness that the nasolabial foold is NOT spared
• Usually associated with an underlying illness
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Upper eyelid in patients with dermatox/myox often has a
Nonspecific rash purple discoloration; VERY PATHOGNOMONIC (THESE
HELIOTROPE RASHES) of dermato/polx (dpx)
Purple
discoloration, or
a purple
heliotrope rash,
on the upper
eyelids of
patients is very
pathognomonic
of which disease?
T/F: Patients with
dermato/polymy
ositis have a
typical malar
rash?
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Major issues here:
Scleroderma is
essentially progressive
___?
T/F: In scleroderma
there's a great deal of
skin inflammation?
T/F: Patient with
scleroderma DO NOT
have inflammation but
DO HAVE auto-
antibodies present in
their blood?
Scleroderma = progressive systemic sclerosis
• Malignancies that occur are the common malignancies: man: • Everything we've talked about today is about the tissue getting
lung, pancreas, stomach inflamed; in this condition, there's virtually NO
• Women: ovary, etc. inflmmation; there's progressive sclerosis; tighening,
• This underlying malignancy is more common in men, with thickening, fibrotic reactions in the tissues; these patients do
dermato, and over 50 have autoantibodies but they don't lead to inflammation; they
• So a man, over 50, with dermatocytis, will receive an intensive somehow lead to progressive inflammation through the tissues
workup for an underlying malignancy
The mnemonic
CREST, relating to
the symptoms of
scleroderma,
stands for…?
R = reynaud's phenomenon
• When go in cold, hands turn deep blue and then dead white,
then n rewarming, turn red, this occurs in maybe 10% of the • Sclerodactyly: tightening of tissues
normal popultion; in scleroderma, happens in 95% of people - in the fingers
indicates vascular instability
• Skin tightening can be so drastic that actual • This pic is a picture of the T = telangiectasia: man on his
tissues are choked! Bone is even choked out! lips see these red dots, on his palate, these telangiectasia;
located on mucous membranes and skin; different from
telangiectasia in liver disease; those have red dot and
spider like arms coming out of them; these don't have
spider arms, mjust red dot; these look loike hereditary
teangiectasia; but patients with scelroderma you push on
these telangx and they blanche; here these little blood
vessels are being dilated and open up; so ge the picture
that there's a blood vessel problem in scleroderma
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X-ray of calcinonsis
Weakened Intima
• Here you see the lumen virtualy occluded by heaped up intimal proliferation
• This is a problem of narrowing of blood vessel lumina
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04 ALBERT 2008 Seronegative Spondyloarthropathies
Friday, February 22, 2008
5:25 PM
Psoriatic Arthritis
Ankylosing spondylitis
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• Spondyloarthropathy: disease of the joints of
the spine.
○ seronegative spondyloarthropathies
Where is the
entheses
located?
What is
enthesitis?
spondyloarthropathy
seronegative spondyloarthropathies, a general term comprising a number of
degenerative joint diseases having common clinical, immunologic, pathologic, and
radiographic features, including synovitis of the peripheral joints, enthesopathy, bony
ankylosis of the large peripheral joints, lack of rheumatoid factor, and, in many cases, a
positive status for the human leukocyte antigen HLA-B27. Included in this group are
enteropathic arthritis, psoriatic arthritis, ankylosing spondylitis, and Reiter's syndrome.
Pasted from <http://127.0.0.1:8080/rami?COMMAND=apply Stylesheet(dor @doc.xsl,dor@s/12751920.pub) &sword=12751926>
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Enthesitis is an inflammation of
the entheses, the location
where a bone has an
insertion to a tendon or a
ligament. It is also called
enthesopathy, or any pathologic
condition involving the
entheses. The entheses are any
point of attachment of skeletal
muscles to bone, where
recurring stress or inflammatory
autoimmune disease can cause
inflammation or occasionally
fibrosis and calcification. One of
the primary entheses involved in
inflammatory autoimmune
disease is at the heel. Heel
swelling and inflammation are
therefore used to help diagnose
certain inflammatory
autoimmune diseases, including
ankylosing spondylitis.
Pasted from <http://en.wikipedia.org/wiki/Enthesitis>
Syndesmophyte
a type of bone outgrowth of the spine occurring in various disease, including ankylosing spondylitis,
alkaptonuria and enteropathic arthropathies (Crohns disease, ulcerative colitis, Whipples disease).
In ankylosing spondylitis, ossification of the anulus fibrosus leads to development of a thin vertical outgrowth of bone that
extends across the margin
of the intervertebral disc. Syndesmophytes occur most commonly at the anterior and lateral aspects of thespine, particularly
near the thoracolumbar junction. They can be differentiated from spinal osteophytes by their shape and site of attachment to
the vertebral edges (spinal osteophytes are triangular in shape and arise several mm from the discovertebral junction) and from
the nonmarginal paravertebral ossification of psoriatic arthritis and Reiters syndrome(located at a distance from the vertebral
body and intervertebral disc).
Extensive formation of syndesmophytes is termed syndesmophytosis.
Pasted from <http://www.medcyclopaedia.com/library/topics/volume_iii_1/s/syndesmophyte.aspx>
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What is a
syndesmophyte?
Schober's Test
1. Indication: Evaluation of Lumbar Spine Range of Motion
1. Ankylosing Spondylitis
2. Technique
1. Patient stands erect with normal posture
2. Identify level of posterosuperior iliac spine
1. Mark midline at 5 cm below iliac spine
2. Mark midline at 10 cm above iliac spine
3. Patient bends at waist to full forward flexion
4. Measure distance between 2 lines (started 15 cm apart)
3. Interpretation
1. Normal: distance between 2 lines increases to >20 cm
2. Abnormal: distance does not increase to >20 cm
1. Suggests decreased Lumbar spine range of motion
2. May suggest Ankylosing Spondylitis
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Pasted from <http://www.fpnotebook.com/Rheum/Exam/SchbrsTst.htm>
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opposite anterior
superior iliac crest. Gaenslen's test is performed with the patient supine (on the back). The hip
5. Pain in the sacroiliac joint is maximally flexed on one side and the opposite hip joint is
area indicates a extended. This maneuver stresses both sacroiliac joints simultaneously.
problem with the
sacroiliac joints. Pasted from <http://www.hughston.com/hha/a_15_1_1a.htm>
Pasted from
<http://medinfo.ufl.edu/year1/bcs
/slides/extrem/slide21.html>
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(7)
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The 2 most common
extra-articular
manifestations of AS
are ___?
RARE extra-articular
manifestations of AS
include …(list 3)?(5)
Approximately
what percentage
of patients who
have ankylosing
spondylitis are
positive for HLA-
B27?
The association
between HLA-
B27 and ___ is
one of the
strongest
immunogenetic
associations
observed with
any human
disease?
What is the risk
of ankylosing
spondylitis in
patients who are
positive for HLA-
B27?
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The KEY clinical
symptom of
ankylosing
spondylitis is
___?
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A 35 year old
patient comes to
your office with
a six month
history of back
pain that
improves with
exercise and is
associated with
morning
stiffness. What is
the MOST LIKELY
diagnosis?
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What are the
newly proposed
criteria for
inflammatory
back pain in
young to patients
< 50 years old
with chronic back
pain (list the 4
criteria)?
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Asymmetric
transient
polyarthritis is a
pattern common
to which type of
arthritis?
How do
sacrolitis/spondyl
itis vs. peripheral
arthritis differ in
their course in
relation to the
course of IBD?
Is it
sacrolitis/spondyl
itis OR peripheral
arthritis that is
associated with
HLA B-27?
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Another name for
reactive arthritis is
___ syndrome?
How is reactive
arthritis diagnosed
(list the 3 criteria, ie.
"Following a GI or GU
infection the onset of
…(3))?
List 2 organisms
implicated in the
gastrointestinal
etiology of reactive
arthritis?(4)
List 3 extra-articular
manifestations of
reactive arthritis?(5)
Campylobacter and
Yersinia are both
possible (GI or GU)
causes of reactive
arthritis?
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With respect to
therapy for ankylosing
spondylitis, is
sulfasalazine helpful
for peripheral disease?
With respect to
therapy for ankylosing
spondylitis, is
sulfasalazine helpful
for axial disease?
List 2 drugs that can be
used for anti-TNF
therapy in treating
ankylosing spondylitis?
Indomethacin and
Naproxen are both ___
that can be used in the
treatment of
ankylosing spondylitis?
Indomethacin and
Naproxen are both
NSAIDs that can be
used in the treatment
of ___?
What should you avoid
in using corticosteroids
to treat ankylosing
spondylitis?
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List 3 possible
treatments for
Psoriatic
arthritis?(5)
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05 KEYSTONE 2008 Therapeutics in Rheumatic Diseases
Friday, February 22, 2008
5:26 PM
The incidence of
RA increases in
persons between
the ages of ___
and ___ years
old?
RA affects 3x as
many (women or
men)?
List 3 pharmacologic
interventions for RA?
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List the 5 levels of
treatment in the
traditional
"Pyramid"
approach to
therapy, as
indicated for the
treatment of RA?
Methotrexate is
the GOLD
STANDARD for
the treatment of
moderate/severe
___?
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What is the GOLD
STANDARD for the
treatment of
moderate/severe RA?
When should you
initiate DMARDs
following the initial
diagnosis of RA?
Compared to
methotrexate,
leflunomide has a
more direct effect
on ___ cells?
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___ is a pivotal
cytokine in RA?
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List 3 potential
safety issues with
the use of TNF
antagonists in
the treatment of
RA?(6)
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06 CARETTE 2008 Vasculitis
Friday, February 22, 2008
5:26 PM
1. Skin
2. Joints/muscles
3. Kidneys
4. Nervous system
5. Heart/Lungs
6. Gastro-Intestinal
7. ENT/EYES
8. Other
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List 2 medium
artery
vasculitis's?
List 2 small artery
vasculitis's?(3)
List 2 large artery
vasculitis's?
List 2
arteriole/capillar
y venule related
vasculitis's?
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Giant cell arteritis
is more common
in females or
males?
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07 HAWKER 2008 Osteoarthritis and Low Back Pain
Friday, February 22, 2008
5:27 PM
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• NOT just a cartilage problem!
T/F: Osteoarthritis is
a natural
consequence of aging
that occurs
secondary to
superficial fissuring,
erosions and loss of
cartilage?
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Each risk factor exlpored in slides below
• OA challenges very different from RA
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• It's clearly been shown that people with knee OA had it
BEFORE they started to develop knee OA
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T/F: Exercise is an
economic and effective
though underprescribed
therapy in osteoarthritis?
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08 MCDONALD-BLUMER 2008 Osteoporosis
Friday, February 22, 2008
5:28 PM
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Fra cture of the
di s tal ra dius bone
List 4 common
locations for
fragility fractures?
• At highest risk of
getting in trouble
• Has hepatotoxicity
○ But only becomes toxic when becomes
converted to NAPQI; usually gets
metabolized to glutathione or sulphate
○ NAPQI binds to the first thing it sees
3 potential
treatments for the
treatment of acute
gout are …?(4)
Generally speaking,
the two drugs that
are used to treat
acute gout are ___
and ___?
List 3 cautions for
colchicine
prescription?
Does allopurinol
stimulate or block
xanthine oxidase?
T/F: Allopurinol
hypersensitivity is a
common, mild reaction
to allopurinol that is
mainly manifested as
diffuse petichiae over
the abdomen and chest
areas?
List 2 features of
allopurinol
hypersensitivity?
T/F: Corticosteroids
suppress inflammatory
responses regardless of
their etiology?
T/F: In using
corticosteroids, pain,
erythema, warmth, and
swelling often DO NOT
occur?
What effect do
corticosteroids have on
scar formation and wound
healing?
What effect do
corticosteroids have on
the synthesis of
prostaglandins and
leukotrienes?
What effect do
corticosteroids have on
WBC migration and
function?
Corticosteroids impair (list
2)?(3)
A very serious
ACUTE adverse
effect of
corticosteroids is
___?
List 3 chronic
adverse effects of
corticosteroids?(9)
In avascular necrosis,
there is death of ___
and progressive ___?
(ni trogen narcosis) Avascular necrosis is far
more common in
(men/women)?
Most patients with
avascular necrosis have
___ pain; a minority
have ___ pain?
Risk factors for
avascular necrosis
include (name 3)?(7)
Lots of sclerotic
bone with
radiolucency
Prior to an operation,
a patient with
adrenal insufficiency
should receive (more
or less) steroids?
Does
inflammatory
synovial fluid
have high or low
viscosity?
What is the cut-
off for WBC #'s
for non-
inflammatory
synovial fluid?
What is the
range for
inflammatory vs.
septic synovial
fluid?
Noninflammator
y and normal
synovial fluid is
comprised of
what percentage
of PMNs?
Inflammatory vs.
Septic arthritis is
composed of
what percentage
of PMNs?
Colchicine
Indications
Systemic
Gouty arthritis, chronic (treatment) or Gouty arthritis, acute (prophylaxis and treatment)
Colchicine is indicated to reduce the frequency and severity of acute attacks of gouty arthritis in patients with chronic gout.
Complete remission of such attacks may occur in some patients. Prophylactic administration of colchicine may be especially
important during the first several months of treatment with an antihyperuricemic agent (allopurinol, probenecid, or
sulfinpyrazone) because the frequency of acute attacks may be increased when such therapy is initiated.
Although colchicine is also indicated to relieve the pain and inflammation of acute attacks of gouty arthritis , it has generally
been replaced by less toxic medications for this purpose . Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids
(preferably via intrasynovial injection) are recommended for relief of an acute attack. Therapeutic doses of colchicine should
be reserved for patients in whom these other agents are contraindicated or ineffective .
Intravenous administration of colchicine may be considered for treatment of acute attacks of gouty arthritis when oral
administration is ineffective, gastrointestinal side effects limit administration of effective oral doses, or an especially rapid
response is needed . Although the risk of gastrointestinal toxicity is considerably lower with intravenous administration than
with oral administration , the risk of other forms of toxicity is very high , especially in patients with renal and/or hepatic function
impairment ; fatalities have been reported . It is recommended that the medication be administered intravenously with caution,
in low doses, and only to carefully selected patients , if at all .
Pasted from <http://www.pharmgkb.org/do/serve?objId=475&objCls=DrugProperties>
• The sooner you treat the better but don't treat until you have that culture
• Not every joint problem is arthritis;
sometimes may have periarticular
• When thinking
about mono or
polyarthiritis,
always think
about
inflammatory vs.
noninflammatory
• Criitical cell
count: 2000 x
10x6 per liter
Synovial fluid is
an ultrafiltrate of
plasma to which
_____ and other
factors are added
locally by
synoviocytes?
Tendons around
the shoulder
• Even if you forget what a particular tendon's name is , just • Can palpate supraspinatus by moving arm back Rotator cuff pain
rmember you're looking for tenderness along lentght of tendon by • Subscapularis: internal rotation
palpating or put tendon under stretch or stress is referred to the
• Supraspinatus: early part of abduction ___?
• So locla tenderness on plapation, stretch or stress then • Teres minor and infraspinatorus
• If palpate along head of humerus by arm going back then can feel
insertion on humerus; is hard however to stretch the tendons;
most often therefore stress
• Can test impingement at full abduction
• Two other tests:
a. Palm down, hold down scapula and try to
bring rotator cuff tendon forcibly against
acromioclavicular ligament; may produce
pain if jhas impingement
b. Thumb down, internally rotate bent arm
Common extensor tendon: lateral epidcondyle We're going to focus on tennis elbow
No swelling,
• If had olecranon bursistis, see bag of fluid hanging off tip of elbow
• Sometimes
patients with
seronegative
Very common aarthtiritis have
problems with
achilles tendon
• Anteromedial portion of the calcaneus Hip pain means difft things to difft people; if at the side, then from the spine;
• DORSIFLEX TOES CAN STRESS PLANTAR FASCIA TRUE HIP PAIN IS FELT IN THE GROIN REGION!
In the treatment of
acute gout, ___ such
as indomethacin and
___ are the drugs of
first choice?
Colchicine is rarely
used in the treatment
of acute gout because
of its…?
Allopurinol is a ___
inhibitor which
decreases uric acid
synthesis?
Allopurinol is the
preferred ___
lowering drug?
In IgM multiple myeloma get very low ESR; if see sedimentation rate of 0 then think multiple myelome of IgM
multiple myeloma
• So anythign that makes it go faster is a cuase of inflammation
• In polycythenmia vera get clumping of RBCs
○ polycythemia ve1ra, a myeloproliferative disorder of unknown etiology, characterized by abnormal
proliferation of all hematopoietic bone marrow elements and an absolute increase in red cell mass and
total blood volume. The skin of the face is often ruddy and swollen, and ecchymoses are common. Most
patients have splenomegaly, leukocytosis, and thrombocythemia. Hematopoiesis is also reactive in
extramedullary sites (liver and spleen), and in time myelofibrosis occurs. Called also erythremia, p. rubra or
p. rubra vera, myelopathic or splenomegalic p., and Osler's, Osler-Vaquez, Vaquez', or Vaquez-Osler disease.
Cf. secondary p.
Pasted from <http://127.0.0.1:8080/rami?COMMAND=apply Stylesheet(dor @doc.xsl,dor@p/12656167.pub) &sword=12656269>
• Citrulline: alpha-amino
delta-carbamido normal
valeric acid; it is formed
from ornithine and is
itself converted into
arginine in the urea
cycle.
• Citrullinated = arginine
been replaced with
serine
Anti-Jo-1 is specific
for myositis
associated with
_______ and
__________?
Which test
VIRTUALLY RULES
OUT SLE if
negative?
Is a positive ANCA
diagnostic of
vasculitis?
What is the
approximate
sensitivity of HLA-
B27 in patients with
ankylosing
spondylytis?
When is HLA-B27
testing useful?
Case 1
• History
• 32 year old female
• Pain/swelling hands wrists x 6 mo
• Morning stiffness x 2hrs
• Right knee both wrists tender warm swollen, red
• Weaker by mid morning
• Exhausted painful feet by 3:30 pm
• Ibuprofen 8 tablets per day helped
• 5lb weight insomnia down in the ?
Physical
Normal general physical exam
• Tender swollen wrists all mcps pip and right knee
• Small subcutaneous nodule, extensor right ulna
• Weak grip
• Normal back, neck, skin, mucous membranes, neurological
1. Which pattern characteristic this patient's illness in terms of anatomic distribution and historic evolution
a. Acute inflammatory monoarticular arthritis
b. Subacute symmetrical inflammatory oligoarthritis
c. Chronic symmetrical inflammatory
d. ?
e. ?
• Naproxen twice a day wouldn't be sufficient to treat her and cyclophosphamide would be overkill; methotrexate is the gold
standard now for management
• Etanercept use if your more modest treatments failed
• No prednisone because no DMARD added
Case 2
70 Year old female, presents with aching in shoulders, hips upper arms legs , sudden onset after flu, 2-3 hours morning
stiffness, 5 kg weight loss past 2 months, cannot comb hair, reach or use toilet, aunt with rheumatoid
On exam, tender muscles, trapezius delts, extreme pain, strength cannot be assessed due to pain, afebrile
1. What disease?
a. Local non-articular rheumatism
b. Crystal induced arthritis
c. Degeneration
d. General non-articular
e. Seronegative arthritis, B27 positive
Answer: d) blindness
(showed picture of temporal arteritis and pathology, disruption of internal elastic lamina
Case 3
34 man, sever knee pain 24 hours, twisted knee and scraped elbow; pain severe at night; bad with movement, hx of diabetes
juvenile onset 15 year insulin dependent
On exam
Distress, painful immovable knee because of pain, tense warm, has effusion, mild left inguinal lymphadenopathy, and he has
normal general physical exam, and abrasion on left elbow
• Lost dimple in knee medially
Questions:
Yes, monoarthritis
Lab results: Hb good, WBC 20, poly: 70% platelets elevated, Glucose 18, not well controlled, creatinine Somewhat
elevated; no cells, protein, ketones
Answer: d) Arthrocentesis
Results of investigation:
• x-ray of knee : effusion only
• Swabs culture sent
• X-ray of sacroiliac joints normal
• Uric acid elevated
• Arthrocentesis showed 50 cc fluid, yellow and cloudy and culture pending
4. Which of the following lab results NOT expect in the synovial fluid sample?
a. WBC…?
b. WBC…?
Birefringence
A calcite crystal laid upon a paper with some letters showing the double refraction
Birefringence, or double refraction, is the decomposition of a ray of light into two rays (the ordinary ray and the extraordinary ray) when it passes
through certain types of material, such as calcite crystals or boron nitride, depending on the polarization of the light. This effect can occur only if the
structure of the material is anisotropic (directionally dependent).
Applications of birefringence
It is also utilized in medical diagnostics: needle aspiration of fluid from a gouty joint will reveal negatively birefringent urate crystals.
Pasted from <http://en.wikipedia.org/wiki/Birefringence>
Case 4
50 y.o. female painful right knee, worse on golf course, good health, normal general exam; antalgic gait, favoring right, cool
effusion in right knee, stress pain in right knee
Physical: atrophy of right quads; varus alignment soft knees, means bowlegged
QUESTIONS
Gradual accumulations
Answer: B, E (I'm almost positive this is what was written but a little less sure of this)
B would say joint space, loss degree of
E would tell you that there's bland fluid
Case 5
• 56 year old lady abrupt onset thoracolumbar junction back pain
• Bed confined for 3 days
• Muscle spasms on physical
Risedronate is used to prevent and treat osteoporosis (a condition in which the bones become thin and weak and break easily) in women
who have undergone menopause (change of life; end of menstrual periods) and in men and women who are taking glucocorticoids
(corticosteroids; a type of medication that may cause osteoporosis). Risedronate is also used to treat osteoporosis in men. Risedronate is
also used to treat Paget's disease of bone (a condition in which the bones are soft and weak and may be deformed, painful, or easily
broken). Risedronate is in a class of medications called bisphosphonates. It works by preventing bone breakdown and increasing bone
density (thickness).
Pasted from <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a601247.html>
Approach to arthritis
1. What are major categories of rheumatic disease?
2. What are the seropositive diseases?
3. What are the seronegative diseases?
4. What is meant by symmetrical versus asymmetrical?
5. What joints are affected by osteoarthritis?
6. What are non-articular causes of rheumatism?
7. What are features of degenerative versus inflammatory arthritis?
8. What is a useful fourfold classification of functional capacity?
9. What does “avocational activities” mean?
Monoarthritis
10. What are the major causes of mono-arthritis?
11. What tests should joint fluid be sent for in the investigation of a patient with monoarthritis?
12. What tests are available for viscosity?
13. What are the characteristic patterns of findings in the joint fluid for each major category of monoarthritis?
14. What is birefringence?
15. What is chodrocalcinosis?
16. What infectious cause of monoarthritis is most threatening for the joint?
17. What are the features of gonococcal arthritis?
18. What crystals cause arthritis?
19. How is gout treated in the:
a. Acute phase (list four possible treatments)
b. Prevention phase
Spondyloarthropathy
35. What is spondyloarthropathy?
36. What are the major diseases that are spondyloarthropathies?
37. What are typical extra-articular features of spondyloarhropathies?
38. What is HLA-B27?
39. What are clinical findings in a patient with ankylosing spondylitis?
40. What are radiographic findings in a patient with AS?
41. What is amyloidosis?
42. What are the two major categories of causes of chronic low back pain? Which is more common?
43. What are the key features of inflammatory back pain?
44. What are the New York criteria for diagnosis of AS?
45. What are the two major enteropathic arthritidites?
46. What are 5 patterns of psoriatic arthritis?
47. What is reactive arthritis? What is Reiter’s syndrome?
48. What are extra-articular manifestations of reactive arthritis?
49. What are the major elements of therapy of AS?
Rheumatoid arthritis
70. What are pathological features of a rheumatoid arthritic joint?
71. What joints are affected in a patient with rheumatoid arthritis? What joints are seldom affected?
72. What are the criteria used to make a diagnosis of RA?
73. What problems may a patient with RA develop related to the cervical spine?
74. What are typical abnormalities in the blood tests of patients with RA that reflect systemic inflammation?
75. What are the radiographic abnormalities seen in a patient with chronic RA?
76. What is the typical evolution of joint problems in a patient with RA?
Autoimmunity
77. What are three pathways that lead to autoimmune reactions?
78. What is meant by organ-specific autoimmune versus non-organ specific autoimmune diseases, and what are examples
of each?
79. Which organs tend to be affected by non-organ specific autoiimune reactions?
80. What is tolerance?
81. What is a rheumatoid factor?
Vasculitis
82. What is the overall classification of vasculitides?
83. How does vasculitis affect each of the following:
a. Skin (medium versus small vessel)
b. Kidneys
c. Nervous system
d. Heart
e. Lungs
f. ENT
g. Eyes
84. What are the clinical features of giant cell arteritis?
85. What are the two major diagnostic tests for giant cell arteritis?
86. What is the treatment for GCA?
87. What are clinical features of PAN?
88. What underlying viral illness is associated with PAN?
89. What are three types of vasculitis associated with ANCA?
90. What are renal manifestations of ANCA-associated vasculitis?
91. What are the therapeutic strategies used for ANCA-associated vasculitis?
Osteoporosis
119. What is osteoporosis?
120. What determines bone strength?
121. What are the frequency and consequences of hip fracture in women?
122. What about men?
123. What is a fragility fracture? Where do they occur?
124. What are consequences and physical findings of vertebral compression fracture?
125. What are major risk factors for fracture?
126. What are risk factors for low bone mass?
127. What are minor risk factors for osteoporosis?
128. List 4 pharmacological agents useful in the treatment of osteoporosis.
129. With respect to osteoporosis, what is a “T-score” and what level of a T-score is diagnostice of:
a. Osteoporosis
b. Osteopenia
130. What is appropriate intake of calcium at various ages (principles)?
131. What strategies are available in the management of osteoporosis?
132. What are anti-resorptive agents? What is an anabolic agent?
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2_Pre-Op Eval and Prep
Friday, February 29, 2008
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APACHE-acute physiology and chronic health evaluat...[Crit Care Med. 1981] - PubMed Result
http://www.ncbi.nlm.nih.gov/pubmed/7261642
Screen clipping taken: 3/3/2008, 9:42 AM
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Apart from history and
physical, how would you
assess endocrine organ
dysfunction?
Apart from history and
physical, how would you
assess coagulation status?
Apart from history and
physical, how would you
assess renal dysfunction?
Apart from history and
physical, how would you
assess respiratory system
dysfunction?
• Renal: use serum creatinine to tell you Apart from history and
whether or not kidneys working physical, how would you
• Toronto historically lead centre in world assess cardiovascular
for assessment of nutritional readiness of system dysfunction?
patients for surgery Apart from history and
• Endocrine: history: are you a diabetic, do physical, how would you
you take insulin, etc. assess hepatobiliary
dysfunction?
• Amazing how many patients suffer from pulmonary • Patients who are hypo or hyper thyroid react very poorly to
emboli and DVT's after surgery (now that we have CT's general anesthesia and surgery
commonly, see this commonly)
• Most patients in post-op MI simply drop dead
• When patient falls asleep, don't have ANY gag reflex
• Patients may get pneumonia post-operatively
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List 2
cardiovascular
system conditions
and their
associated
treatments that
you can prevent
post-surgical
cardiovascular
complications for?
List 4 preventative
actions that could be
undertaken to prevent
post-operative
• To avoid kidney damage, make sure kidney is well perfused infections?(4)
• To avoid renal damage also avoid nephrotoxins • OR's are cold; even a degree or two of hypothermia will result
• IV contrast for CT is nephrotoxic as is genatmycin Ab in poor outcomes
• Blood is like an immunosuppresant drug; if give blood
transfusion, the infection rate is higher
○ Patient who did NOT get blood transfusion during
surgery is more likely to survivie cancer surgery!
○ Also in renal transplatn operation; patient who has
already had multiple transfusions are less likely to
reject kidney s
So can be used to one's adv., the fact that blood
transfusions cause immunosuppresion
○ Prophylactic antibiotics: endless studies: will decrease
rate of surgical site infection
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List 2 preventative
actions that could be
• Some very influential papers in NEJM from western undertaken to prevent
europe showing in ICU pop. Tight control of blood post-operative
glucose greatly decreased morbitidy and mortality rates endocrine system
• Reasonable blood glucose control therefore improves complications?
outcomes
• Problem with oriignal papers: in reality, too many
episodes of hypoglycemia
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3_Pain Mgm
Friday, February 29, 2008
Pain Assessment:
• VAS - Visual analogue scale (impracticall at bedside)
• VRS - Where is your pain 1/10 (10 worst)
○ Studies correlating VAS and VRS; correlate extremely well
○ Very important to ask for pain with movement! Not just at rest!
• Grimace shown to be very accurate reflection of pain degree
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What is multimodal
analgesia?
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Gabapentin and
Ketamine block the
transmission of pain
along which arm of the
pathway of the pain
pathway?
Celecoxib blocks the
transmission of pain
along which arm of the
pathway of the pain
pathway?
Opioids block the
transmission of pain
along which arm of the
pathway of the pain
pathway?
Acetaminophen blocks
• Pain pathway is complex but even this is an oversimplification of the pathway the transmission of pain
at which site of the pain
pathway?
Which nociceptive
factors does
dexamethasone
prevent the release of?
Which is the primary
nociceptive factor that
is blocked through the
use of celecoxib?
• When we have tissue damage, inflammation occurs; interleukins and cytokines Local anesthetic blocks
released; cyclooxygenase 2 is induced; makes prostaglandin E, which is necessary the transmission of pain
to activate nervous system via lowered threshold of nocicceptors and allows to fire along which arm of the
via stimulation by substances such as bradykinin pathway of the pain
pathway?
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• Dexamthasone: prevents
release of interleukins and
cytokines
• Celecoxib: block
production prost. E
• Can use local anesthetic to
prevent it from travelling
to the spinal cord
• Also can put epidural or
spinal in to prevent further
entry to the spinal cord by
blocking the nerve roots
• Acetaminophen acts on
COX-3; prevents on
• Can use drugs like
gabapentin and Ketamine:
prevents sensitization of
the nervous sytem; thus,
prevents amplification of
the pain signal
• Finally, opioids, prevent
transmission from spinal
cord to the brain
In thinking
conceptually
about the
prevention of
acute pain, which
3 points in the
patin pathway
can be targeted
with drugs? (hint:
Initiation, …)
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T/F: Preventing acute
pain is a minor risk
factor in the prevention
of post-operative
chronic pain?
• Eg. Often before do surgeries, need to make sure pain maangment is intact
• COXIB'S do not affect platelet function
T/F: Coxib's DO NOT
• Eg. Patients come in for knee surgery, but taken off pain relief two weeks before surgery because of effect of affect platelet function?
NSAIDs on platelet function; so patients in pain when come into OR; nervous systems are revved up
• Usually only in hosptial for 5 days and doing great analgesic regiments but then after 5 days go home on Tylenol
3's and that's the weak link; POOR MANAGEMNT AT HOME!
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Name 6 drugs
and/or drug
classes involved in
multimodal
analgesia?
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What effect does NSAID
administration have on
opioid consumption?
What is CELECOXIB?
What effect does
CELECOXIB have on
platelets?
What effect does
CELECOXIB have on
bone fusion?
What effect does
CELECOXIB have on
thrombosis rates?
By approximately how
much do NSAID/COXIBs
improve pain scores?
In addition to
being an
analgesic,
Gabapentin is
also a(n)
_______?
The optimal dose
• Improves movement associated pain of gabapentin is
• If go up to 1200, 1400 mg. then have to consider greater side effects ______mg?
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What effect does
Gabapentin have on
opioid consumption?
What effect does
Gabapentin have on
opioid-related side-
effects?
Gabepentin has
additive effects with
which class of
analgesics?
Is it Dexamethasone,
Gabapentin, or
Ketamine, which has
anxiolytic effects?
T/F: Using
Gabapentin results in
NO increase in
adverse effects?
• No adverse effects
from single dose of
dexamethasone
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Which analgesic
method gives the best
movement associated
pain relief?
Does oxycontin have a
biphasic or monophasic
release?
• The technique that gives best movement associated pain relief
The duration of
• Eg. Continuous femoral nerve blocks also good after knee arthroplasty
oxycontin release is ___
• Goal of nerve blocks: JUST enough nerve blocks to eliminate pain; want to keep sensory and nerve pathways
hours?
• Remember pain carried by C fibers, very small, unmyelinated; bigger ones responsible for motor and sensory
Oxycodone:
Absorption
About 60% to 87% of an
oral dose of oxycodone
reaches the central
compartment in comparison
to a parenteral dose. This
high oral bioavailability is
due to low pre-systemic
and/or first-pass
metabolism. In normal
volunteers, the t½ of
absorption is 0.4 hours for
immediate-release oral
oxycodone. In contrast,
OxyContin Tablets exhibit a
biphasic absorption pattern
with two apparent
absorption half-lives of 0.6
and 6.9 hours, which
describes the initial release
of oxycodone from the tablet
followed by a prolonged
release.
P asted from
<http://w w w .rxlist.com/cgi/generic/
oxy contin_cp-page2.htm>
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Ketamine or Clonidine
consumption will
decrease the
consumption of which
other class of
analgesics?
What is a downside to
the use of ketamines?
List 5 multimodal
analgesics that
have additive
effects?
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What does PCEA
stand for?
List 2 drugs that
reduce PCEA use?
If use
multimodal
analgesia,
can
elminate
opioids
completely!
Why is it
advantageous to
give analgesics
prophylactically
rather than after
surgery has
started?
• Advantage to giving drugs before!! Because if you give after, then cytokines and
interleukins have already been produced! If give these drugs beforehand, then
can prevent the relaese of these substances
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List 5 multimodal
analgesia agents
that improve
outcomes?
• Gabapentin: with ACL
patients had better
knee flexion and less
anxiety: with breast
surgery: lower incidence
chronic pain at 6
months
• Dexamethasone:
laproscopic
cholecystecomies;
better outcomes, better
return to function
• Epidurals: less length
of stay after colon
surgery
• Use of long acting
opioids: less length of
stay after knee surgery
LES = lower extremity
surgery
Week11 Page 22
• HAVE TO CONTINUE MULTIMODAL
ANALGESIA when patient goes home!
Post-operatively, list 5
medications/techniqu
es that you would
consider for post-
operative
analgesia?(7)
Give an example of
• Put spinal in to decrease dosages and medications
sensitization of the CNS for 4 drugs one would use
for preoperative (2hr)
total hip arthroplasty?(5)
Out of the following 4
drugs, which one would
be administered with the
highest dosage pre-
operatively (ie. 1000 mg)
and which one with the
lowest dosage pre-
operatively (ie. 8mg):
celecoxib,
acetaminophen,
gabapentin,
dexamethasone?
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Intra-operatively,
which mediation
would a surgeon
administer via local
infiltration?
Give an example of
dosages and medications
for 3 drugs one would use
for post-operative (2hr)
total hip arthroplasty?(5)
Post-operatively, 1000mg
acetaminophen would be
approximately every ___
hours?
Post-operatively,
100-200mg gabapentin
would be approximately
every ___ hours?
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IL-1
Monday, March 03, 2008
10:44 AM
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Gabapentin
Monday, March 03, 2008
10:43 AM
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Cox-2 Inhibitors
Monday, March 03, 2008
10:45 AM
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Oxycodone / Oxycontin
Monday, March 03, 2008
10:50 AM
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Ketamine
Monday, March 03, 2008
10:56 AM
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PCA
Monday, March 03, 2008
10:58 AM
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5_Gallbladder & Biliary Tree
Friday, February 29, 2008
Week11 Page 56
List 2 populations
in which there is a
clear correlation
between
increased
gallstone risk and
family history?
Why is there an
increased risk of
gallstones in
patients who are
morbidly obese?
List 5 diseases
which are risk
factors for
gallstone
formation?
T/F: Prophylactic
cholecystectomy is
indicated in 1% of
asymptomatic patients
over 20 years?
When is surgery
recommended for
patients suffering from
gallstones?
List 4 symptom
complexes that
patients with gallstones
• US very common now; almost always find commonly present
gallstones; before, tradition was to take with?
gallbladder out but after landmark study,
Acute cholecystitis is
found that you should not take gallbladder
associate with the signs
and symptoms of _____?
The pain from Acute
cholecystitis usually last
more than ___ hours?
Which well known clinical
sign is positive in acute
cholecystitis?
In which percent of
patients suffering from
Acute cholecystitis is
there a palpable mass and
in which percent is
jaundice present?
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Acute cholecystitis is
found that you should not take gallbladder
associate with the signs
and symptoms of _____?
The pain from Acute
cholecystitis usually last
more than ___ hours?
Which well known clinical
sign is positive in acute
cholecystitis?
In which percent of
patients suffering from
Acute cholecystitis is
there a palpable mass and
in which percent is
jaundice present?
http://rezidentiat.3x.ro/eng/litbiliaraeng.files/image002.gif
Screen clipping taken: 3/5/2008, 9:29 AM
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List 2 treatments that are
indicated for biliary colic?
• In biliary colic, the stone obstructs the cystic duct, • Positive murphy's: patient takes in big breath, and
but here, the stone stays stuck (in acute you palpate the right upper quadrant, then as the
cholecystitis), then get secondary infection; MUST patient breathes IN, you may feel the gallbladder
TREAT WITH ANTIBIOTICS coming down
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Treatment of acute
cholecystitis involves the
administration of ___, ___,
and ___?
Approximately which
percentage of patients with
acute cholecystitis improve
without surgery?
When is early laparoscopic
cholecystectomy indicated
for patients with acute
cholecystitis?
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• Gallbladder wall is very thin; 1mm in diameter
Generally speaking,
how do the
complications of
gallstones present (ie.
Complications related
to …, complications
related to …, etc.)?
Are abnormal Liver
Function Tests (LFTs)
pathognomonic of
gallstones?
• Advantage of MRCP is that you avoid ERCP and thereby
avoid ERCP and it gives you the DIAGNOSIS and if has
stones THEN you can do the ERCP
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If in the presence of gallstones,
LFTs are abnormal, then one must
determine whether they are …(3)?
• Gallbladder performation is RARE, except for severe diabetics; 95% • Gallbladder carcinoma: a complication of chronic gallstones; almost never
of time, even with severe cholecystitis, won't have perforation get unless if have stones in gallbladder; stones irritate the gallbladder
• AIR IN THE BILIARY TREE IS NOT NORMAL! Treatment is to take out wall; gallbaldder CA is a terrible disease; 1% of the gallbladders that
stone from gallbladder surgeons send to the pathologist contain gallbladder cancer
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How is alcohol
consumption related to
gallstone formation?
Why should
cholecystectomies be
very carefully considered
AGAINST in patients with
cirrhosis?
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List 3 complications
of CBD stones?
Transient gallstone
blockage of the
Ampulla of Vater
leads to ___?
What is another
name for cholangitis?
What is another
name for biliary
sepsis?
What is the
etiology of
cholangitis?
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List 3 steps in the
management of
cholangitis?
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6_Abdominal Infection
Friday, February 29, 2008
Some terminology...
• Inflamatory response not only kills bacteria but inflammation sets off coagulation
fibre and deposition; localization: whwerever there's it is and coagulation, a sticky
goo is deposited; purpose is to prevent spread of micro-organisms
• Absorption: bacteria are absorbed via lymphatics under the diaphragm
• What's connecteed o the bloodstream that sucks out and kills bactera?
Reticuloendothelial system
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• Diverticular disease is a benign condition of the colon;
characterised by outpouchings of colon
• In this case patient has perforation (pinpoint)
• Left alone, this patient dies!
Ileus is a disruption of the normal propulsive gastrointestinal motor activity from non-mechanical mechanisms [1][2].
Motility disorders that result from structural abnormalities are termed mechanical bowel obstruction. Some
mechanical obstructions are misnomers, such as gallstone ileus and meconium ileus , and are not true examples of
ileus by the classic definition [3].
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• Had small bowel lymphoma; got chemo; shrinked tumor so fast that now
hole in part of bowel; feels fine; next day after chemo ends, temp goes • Age is like an immunosuppressant; also don't feel/complain about as much pain
down; on high doses of steroids, immune suppresents; they don't send him • Ischemic gut: common in older people; may thrombose to a vessel supplying
home; on day 5 he gets short of breath; do chest xray and see gross free air; part of the gut
What is a PEG
tube?
• Common enough that in the ICU you'll learn that when patient
• PEG: Percutaneous Endoscopic Gastrostomy
going sour in the icu, abdominal infection is always on the
differential dx
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• Really, these are the diagnostic signs! • Abd operation followed by organ failure, think of leaked anastomosis
• NOT PICKED UP OFTEN ENOUGH!
• DELAY IN DIAGNOSIS AND TREATMENT IS THE PRIMARY REASON FOR
POOR OUTCOME!
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7_Bowel Obstruction
Friday, February 29, 2008
Ogilvie's syndrome,
colonic distention
resembling that caused by
obstruction, but without
evidence of mechanical
obstruction; it is usually
due to a defect in the
sympathetic nerve supply.
Called also false colonic
obstruction.
Give an example of an
intraluminal cause of
large bowel obstruction?
Give 2 examples of
intramural causes of large
bowel obstruction?(3)
Give an example of an
• Intramural causes of small bowel obstruction extraluminal cause of
large bowel obstruction?
• Crohn's disease can go on to cause stricturse Give 2 examples of
○ One common example of an intramural benign inflamatory cause of bowel obstruction intraluminal causes of
○ Another one: radiation stricturs small bowel obstruction?
Thrownthis in because a number of benign inflamatory problems that can cause this; mentioned Give an example of an
intraluminal cause of
ulcers; typically in women who have been treated with a combination of external beam radiation and
stomach and duodenal
internal seed radiation with carcinoma of the cevix; get rctal stricturse because of proxilmity and obstruction?
terminal ileum also sitting behind it so get radiation enteritis Give 3 examples of
So ther are multiple benign lesions that can affect the bowel intramural causes of small
• Extramural causes of small bowel obstruction: dhesions: usually the result of a surey; wheneer operate on the bowel obstruction?
Give 3 examples of
stomach, in the process of healing, patients often left with fibrous bands from one arae of the body to the
extramural causes of
other; this allows a fixed point of the small bowel to kink or herniate small bowel obstruction?
• Basic idea is always the asme: adhesions sually from surgery; maybe also had appendicitis Give an example of an
• Adhesive bowel obstruction therefor quite common in ER extramural cause of
• 2nd to that and worldwide same order of magnitude: incarcerated hernias: can have a femoral aor groin stomach and duodenal
obstruction?
hernias: cough vigorously and the neck of the henia would be pinched by the contours of the hernia: px: painful
groin mass and signs and syplmtomsp of bowel obsturcution
• Incarceration:
• Peirtoneal carcinomatosis: many cancers in the perineal cavity: thesecan grow up and twist off any portion of
bowel
○ Usually metastases: caells on the serosal aspect of the stomach will go off and break off; most common
with overian cancer; usulally very diff. to treat, esp. if tumor dsn' respond to chemox
• Large bowel
○ Intralumnial
Very uncommon; since bowel is so large;
Typically see what appears to be large bowel obstruction due to constipation; usually hard stool in
distal ends of the rctum
○ Intramural
Number of posibilities
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□ Benign
Ibd - particularly crohn's diseaseradiation strictursre (women radiated for carx of the
cervix)
□ MALX:
Most common: ADENOCARCINOMA: commonly prsents with large bowel obstruction
○ Sigmoid volvulus:
List 2 common
signs/symptoms of gastric
outlet obstruction?
List 3 common
• Early satiety: Eat breakfast okay but not much lunch or dinner; signs/symptoms of small
don't get hunger pangs; sometimes may compalin of vomiting bowel obstruction?
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With respect to
laboratory findings,
prolonged gastric
outlet obstruction
leads to ___?
A Spigelian hernia (or lateral ventral hernia) is a hernia through the spigelian fascia, which is the aponeurotic layer
between the rectus abdominis musclemedially, and the semilunar linelaterally. These hernias almost always
develop at or below the linea arcuata, probably because of the lack of posterior rectus sheath. These are generally
interparietal hernias, meaning that they do not lie below the subcutaneous fat but penetrate between the muscles The laboratory finding of
of the abdominal wall; therefore, there is often no notable swelling. hypochloremic,
Most of these hernias are small, and, as such, there is a high risk of strangulation. Most of them develop around hypokalemic metabolic
age 50 (4th-7th decade of life). As an entity, they are rare,[1] when compared other types of hernias. alkalosis is pathognomic of
___?
Pasted from <http://en.wikipedia.org/wiki/Spigelian_hernia> What is the treatment for
a malignant obstruction?
What is an incarcerated
hernia?
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If make a diagnosis of malx obstruction,
then never going to get beter if you just
lleave them alone; typically fixing done
surgically
• Nowadays, particularly, if in rctum, then
can do stent placed in
• Occassionally perioteneal carcinosis due
to carcinoma of the ovry, then can treat
with radiation
○ Not often can do this though
• Radiation enteritis: no
particular treatment for it;
often treat non-operatively
in the hopes that it does get
better on its own; often
does get better
• Incarcerated hernias: in
children works to push on
the hernia; in adults doesn't
work
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Closed loop bowel obstruction
Tuesday, April 01, 2008
8:48 PM
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8a_Abdominal Infections
Friday, February 29, 2008
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• Begin with proximal bowel: stmach, duodenum, and proximal small bowel, number of bacteia tends to be low (10^4 per mL of fluid and most are
aerobic; usually organisms that we swallow; therefore consequeces of peeforation there are far less sever and dramatic than in the distal bowel
• In the small bowel: 10^8; aerobes roughly equal anaeobes but as get to colon, now 10^12 per gram of stool and there the anerboc pop
outnumber the aeobic population 1000:1 or so
• Most of the organisms in the proximal bowle will be aerobic; distal anaerobic
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Approximately how
long before surgery
should prophylactic
antibiotics be
started (pre-
operatively)? Why
may you need a
second dose to be
administered?
Antibiotic prophylaxis
for abdominal surgery
on the surgical sites of
the colon and
appendectomy include
which two antibiotics?
Antibiotic prophylaxis
for abdominal surgery
on the surgical sites of
the biliary tract,
stomach/duodenum,
and small bowel include
which two antibiotics?
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Is abdominal infection
usually the result of
perforation of the GI
tract or does it more
commonly sponatenously
present?
How can the incidence of
surgical site infection
following abdominal
surgery be lowered?
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8b Abdominal Infections Notes
Friday, February 29, 2008
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9_Intro to Anesthesiology
Friday, February 29, 2008
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What are the 5 A's of
anesthesiology?
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• Most common benzo is midazolam: has prominent amnesia • Koran patient diagnosed with pancreatic cancer; tried to kill himself
effects stabbing with kitchen knife
○ Story of the wimpy football player :-) • ANY OPERATION IS CONTROLLED TRAUMA
• Rohipnol: what they call midazolam in the UK; most chemically • Job of anesthesiologist is to keep vital signs stable
resembles midazolam
In the process of
preparing
someone for
surgery and during
the surgery is itself,
• Stres axis is euphamism for sympathetic tone (body's when is
esponse to stress or pain) sympathetic tone
• Opiates, muscle relaxants, propofol, have to give to the highest?
counteract stress rseponse
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• NOT GOOD TO DO ANESTHESIA IN THIS PATIENT BECAUSE WILL VOMIT IN RESPONSE
TO ANESTHESIA ADMINISTRATION • Here do a ring block
• Jaundice: suspicious: perhaps prolems with absorption and elminiation of anesthetics • If on area of the body you can't do a ring
• Chest pain: remember have stress rseponse with surgical sitmulus block, then just put a little lidocaine
• Best therefore get all these issues rsolved before operation or at least bette managed around area of wound
What is the
distinction between a
regional and local
never block?
• Distinction between a local and rgional block • Takes five needle punctures around area of the foot
○ If neve has name, then it's regional • All the complications of a general anesthetic can be avoided by doing
○ In this case would do an ankle block spot neve blocks
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Another example of regional anesthetic • In this case, rathe rthan blocking
small neve, block at level of the
spinal chord
• Diff between spinal and epidural:
○ Epidural: insert eedle
patient back, just outside
the dura; princple ther is
that if you inject lidocain,
eg. Passive diffusion into
dura and into csf which
pabthes spinal chord; so if
you block at right level,
won't feel labour pains
○ Classically use it for labour,
but also for circumcision in
• Spinal little bbies or anything in
○ Same procedure, through skin, ligaments, between spines, and then actually the lower body
○ Why not higher? C345
• Local anesthetic options: specific nerve blocks around the cervix through the dura; much smaller needle, then give a much lowr dose, and
one shot (because don't have to worry about diffucison of meds); principle is keeps the diaphragm
• Early in labor most of pain coming from cervical dilation
the sam though, blocking nerve impulses alive..put patient in rsep
• General anesthesia is too much for labor
• Midline solution is the epidural (spinal) What's the highest you can do this at? failure
□ Sinal tap is L1 or L2: where the spinal chord ends ○ Can do an epidural
thorugha big enough
lneedle and can put tubing
into needle, so that can
have contninuous infusion
of anesthetic meds; handy
because duration of nedle
is unknown
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Skipped everything until here (from gen. anesth. Slide)
Malignant hyperthermia
typically occurs in
response to
administration of which
anesthetics?
Is malignant hyperthermia
autosomal dominant or
recessive?
T/F: The penetrance of
KNOW MALIGNANT HYPETHERMIA FOR EXAM! malignant hyperthermia IS
NOT variable?
What is the approximate
incidence of malignant
hyperthermia?
Ventricular fibrillation What is the incidence of
malignant hyperthermia
caused secondary to
nitrous oxide
administration?
• Classic description of MALIGNANT HYPERTHERMIA! • Mechanism of action: due to a mutation in the ryanodine rceptior
which is responsible for calcium uptake in SR in skeletal muscle, so
what winds up appening is that the raynodine rceptor is mutated
and these patients end up having an enormous amount of
intracellular calcium; body is constantly spending ATP to equalize
the intracellular calcium; so atp pumps draining calcium from
intracellular calcium and this is exothermic, so get hypethemia
• Calcium metabolism causes rhabdomyoliysis, ATN, (see below)
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NMS DOES NOT EQUAL MHS (MALIGNANT
HYPERTHERMIA SYNDROME)
What is malignant
hyperthermia?
What is NMS
(neuroleptic malignant
syndrome)?
How are malignant
hyperthermia and
neuroleptic
hyperthermia syndrome
different?
What is the treatment
for malignant
hyperthermia?
Prior to the use of
Dantrolene as a
treatment for malignant
• Dantrolene blocks the ryanodine receptor • Should differentiate this from malignant hyperthermia hyperthermia, what was
the mortality rate from
malignant hyperthermia?
T/F: Malignant
Hyperthermia is the
modern name of
Neuroleptic Malignant
Syndrome?
• Jehova witness Sign consent that Absolutely would not want to be trasnfused with any blood or
blood products
• Get factor VIII concentrate intraoperatively
palliation
Referral, second opinion; tell them that you won't do it but they have the right to choose
another surgeon
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2_Mgm Airway Breathing
Friday, March 14, 2008
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3_Hypotx in Trauma
Friday, March 14, 2008
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4_Thracic and Abd Trauma
Friday, March 14, 2008
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• Can get lots of false positives and negatives
• Injury to
spleen often
accumulates
between
spleen and
kidney
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• Never used to diagnose specific injury; looking for
free fluid (blood)!
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• Ful laparotomy; pack all 4 sponges and take out
one at a time to see if bleeding from any 4
quadrants; can get liver bleeding stopped, etc.
• If you stay there and try to fix all injuries, then patient gets lethal triad, and patients die
• Bleeding from a liver (can't take liver out) the more you touch it, the more it bleeds; for a bleeding spleen the spleen can take it out
• One downside to damage control laparotomy: bowel will be more restrictive; if do all this and close the abdomen, presure will be very
high; if have ongoing oozing, then the pressure goes swso high that you get renal failure and bowel ischemia and more acidosi s; increased
pressure to thoracic cavity and collapse aof lung and get hypoxemic and hypercarbic; all this if you close it up; so instead leave abdomen
open and put special expanisve dressing on it
○ Increased pressure of abdomen following this called abdominal compartemtn syndrome
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5_Cerv Spine and Spinal Cord Trauma
Friday, March 14, 2008
Common reasons
why people miss
c-spine injuries
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• Incidence of patients worsening
neurologically after reaching hospital is 2 to
10%
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If meet all 4 criteria, then can
say have cleared the c-spine
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• Complete: spinal cord function below level of
injury is TOTAL; the impulses from above are NOT
getting past area of injury
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If CVP is higher than CSF pressure then use CVP pressure Intercostals
can helps you
draw air in; if
only have
diaphragm;
under normal
circumstance
may be
adequate but if
have asthma
attack
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6_Neurotrauma - Brain Injuries
Friday, March 14, 2008
• Google brain trauma foundation for great resources related to this lecture
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SUBDURAL HEMATOMA CONTUSION; really hematomas in the brain
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Ie. GCS drops from 12 to 8, then ct head
• By the time see them in the hospital, they've already had their injury
• Maintain CPP (Mean arterial presure - ICP); normal CPP = 90 mmHg; normal ICP about
10mmHg
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If ICP increases, you can herniate
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Veins of skull drain into internal jugular (mainly right)
• If spine not clear and hypotensive patient
• Trandellenburg is head down; reverse trandellenburg is head up
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7_Organ_Tissue Donation
Friday, March 14, 2008
List 3 conditions
associated with
Neurological Death
Donation?(4)
In order for
Neurological Death
to be diagnosed,
which 3 conditions
must absolutely be
met?
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Canadian medical
standard for the
neurological
determination of death
(NDD) require that
which 6 factors be
fulfilled?
If the 6 factors from
the minimum clinical
criteria CANNOT be
fulfilled, then what
types of ancillary tests
can be done?
What 2 types of
cerebral imaging
studies could one do
to investigate
neurological death?
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TGLN = Trillium
Gift of Life
Network
• These patients still have reflexes; can blink back and forth and can answer yes
and no; can be very ethically challenging when have these kinds of situations;
• Next of kin therefore usually decision makers
• What that involves: they decide to withdraw life suppolt; first and foremost
decision has to be firmly made then the decision can be made for donation;
decision made with the attending team!
• If the family do decide to go forward with donation then wait the adequate
amount of time depending on which hospital you were in and it 's very fast
and diff. process from most of regular donors (for those after cardiac death
(maintained right up to withdrawal process)
• Use the person's name in expressing sorrow/regret over their death; avoid medical
jargon; often times patients don't understand; if they did get the message, you can ask
○ "so what is your understanding of what just happened?"
○ "We are very sorry that [John] has died"
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8_Tues Sem
Friday, March 14, 2008
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List 3 muscle groups
that are involved in
the mechanics of
inspiration?
Which muscle
groups are involved
in NORMAL
expiration?
Central chemical
control of breathing is
via pCO2 or PO2?
Peripheral control of
breathing is via PO2 and
H+ or pCO2?
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The horizontal fissure is located on the right or left lung?
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09 FMP 2008 THURS Trauma Radiology Seminar Notes.pdf
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FMP 2008 Trauma Week Q & A - PART 1.pdf
Tuesday, April 01, 2008
10:20 PM
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FMP 2008 Trauma Week Q & A - PART 2.pdf
Tuesday, April 01, 2008
10:20 PM
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FMP 2008 Trauma Week Q & A - PART 3.pdf
Tuesday, April 01, 2008
10:20 PM
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Week 12 Review Questions
Saturday, March 22, 2008
5:30 PM
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00 FMP 2008 Week 13 Intro Pages.pdf
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Pain Week Student Manual 2008
Saturday, March 22, 2008
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T/F: almost all acute and
cancer pain can be
relieved?
T/F: a patient's self-report
of pain should be used
whenever possible?
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T/F: while there many
different types of pain,
such as acute,
recurrent, chronic non-
cancer and cancer
related pains, most
people usually have
more than one type.
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