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Terms in this set (188)

Sprain: The most common acute ankle injury is a lateral ankle inversion
sprain caused by a combination of plantarflexion and inversion. Because of
the bony articulation between the medial malleolus and the talus, medial
ankle sprains are less common than lateral sprains. In medial ankle sprains,
the mechanism of injury is excessive eversion and dorsiflexion. Medial ankle
stability is provided by the strong deltoid ligament, the anterior tibiofibular
ligament, and the bony mortise.
In general, ankle sprains present acutely (after trauma) with pain, warmth,
and swelling. Usually no gross deformity, although if there is a large amount
of swelling, there may appear to be a deformity. Symptoms generally
improve over time. After an ankle sprain, the joint may develop stiffness if
not exercised within the first few days.
1.
Peroneal tendon tear: Usually due to an inversion injury or repetitive
trauma. May occur in conjunction with ankle sprain. Patient may complain of
persistent pain posterior to the lateral malleolus. Swelling may or may not
be present.
2.
Talar dome fracture: May occur in conjunction with an ankle sprain, and
initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis. Overall prognosis
is related to potential for interruption of the blood supply.
Fibular fracture: Usually due to falls, athletic injury, or high velocity
mechanism, such as a motor vehicle accident. Patient may present with
severe pain, swelling, bruising, deformity, and inability to walk.
4.
Tendonitis: Ankle tendonitis is an inflammatory condition, usually involving
the posterior tibialis tendon. Swelling/warmth may be present in the
affected area in addition to stiffness. Tendonitis tends to worsen initially
with aggravating activity only; it may then progress to discomfort at any
time. The pain of tendonitis is chronic, usually worse during the day and
after exercise.
5.
Subtalar injury: Often due to a high-energy injury. A dislocation involves
the talocalcaneal and talonavicular joints. Pain, swelling, and deformity are
present.
Cardiac arrhythmias: Commonly cause palpitations, particularly when the
heartbeat is fast, though most people with arrhythmias do not notice
palpitations. Symptoms, when present, can be palpitations from rapid or
irregular heartbeat, lightheadedness, chest pain, and shortness of breath.
Some arrhythmias, like paroxysmal supraventricular tachycardia, are more
common in young people. Stress can cause arrhythmias due to adrenergic
overdrive.
1.
Anxiety and panic disorder: Commonly cause palpitations and shortness
of breath. May be difficult to distinguish anxiety from hyperthyroidism, as
tachycardia, tremulousness, irritability, weakness, and fatigue are common
to both disorders. In anxiety, however, the peripheral manifestations of
excess thyroid hormones are absent; the skin is usually cold and clammy
rather than warm and moist. In anxious patients, weight loss usually occurs
due to anorexia as opposed to the increased appetite seen in
hyperthyroidism. Furthermore, panic attacks are distinct episodes of fear
and panic triggered by a particular place or event, or for no apparent
reason. A reasonable screening test for panic disorder is to ask, "Have you
experienced brief periods, for seconds or minutes, of an overwhelming panic
or terror that was accompanied by racing heartbeats, shortness of breath,
or dizziness?" Patients often underestimate how much stress they are under
and how much it can affect them. Especially in the setting of high stress,
palpitations are likely to be due to anxiety or panic disorder. In one
prospective study of 190 patients at a university medical center, 31% of
palpitations were due to anxiety or panic disorder.
2.
Anemia: May cause palpitations because of tachycardia from hypovolemia.
The heart responds to low blood volume by speeding up to increase the
exposure of the blood to oxygenation in the lungs. Anemia can cause
dyspnea on exertion because of the lack of oxygen carrying capacity of the
blood. A common source of anemia in menstruating women is heavy
periods. It is unusual in young people to be losing blood from other sites
without obvious trauma. If the anemia is caused by a nutritional deficiency
(iron, vitamin B12 or folate), it may also be associated with weight loss.
3.
Hyperthyroidism: Palpitations caused by tachycardia. The increase in
thyroid hormone increases the metabolism, including heart rate. In
hyperthyroidism, weight loss occurs despite increased appetite. Other
effects of hyperthyroidism are loose stools, hyperdefecation, light periods,
and sleep disturbance.
4.
Drug/caffeine abuse: Most patients tell the truth about caffeine use,
though it is important to consider sources other than coffee and tea, such as many sodas. Street drugs, such as cocaine and even alcohol, can also cause
tachycardia. Caffeine and other drugs that cause palpitations (e.g.,
amphetamines, dextroamphetamines) can also cause weight loss. A high
index of suspicion should be maintained if someone has no other obvious
cause of palpitations and has other signs such as dilated pupils, increased
energy, increased blood pressure, and unusual behavior. Most people who
use cocaine would be unlikely to present to a physician office in this
manner.
Propranolol, a beta-blocker, can be used for symptomatic relief of adrenergic
symptoms (tachycardia, tremor, heat intolerance).
Patients diagnosed with Graves' disease should be referred to an
ophthalmologist.
Medications: methimazole and propylthiouracil
Block thyroid gland from making more thyroid hormone
Side effects: Minimal, but low white blood cell count in < 1% of patients
Clinical improvement usually seen after one month, but three months before
thyroid level decreases
Treatment duration: Several years (> 50% of patients become hyperthyroid
when they cease medications)
Requires regular blood monitoring to keep dose optimal. Symptoms and
dose may fluctuate
May try this option initially and switch to radioactive iodine later.
Oral radioactive iodine (single dose):
Side effects: Transient (a few days) soreness of the neck or brief worsening
of symptoms. People with ophthalmopathy may experience worsening of
symptoms.
Over a few months the radioactive iodine destroys many of the overactive
thyroid cells, so that the level of thyroid hormone in the blood decreases.
Occasionally a second dose may be needed.
Eventually many patients become hypothyroid and need to take small doses
of replacement thyroid hormone.
Fewer European patients choose radioactive iodine compared to the U.S.,
where > 70% of patients choose this treatment.
Obtain pregnancy test prior to initiating radioactive iodine treatment. Also,
patient should not be near pregnant women or young children for several
days. Exposure of fetus or young child to radioactive iodine could result in
deleterious effect on their thyroid.
May be able to discontinue propranolol in a few months.
Check TSH every two to three months until it has stabilized and every six or
so months thereafter.
Expect patient to become hypothyroid at some point. Alert them to
symptoms of hypothyroidism in advance, so they can be tested earlier if
need be.
Surgery:
Not usually recommended as first-line therapy
1. Cardiovascular disease (i.e., coronary heart disease and stroke):
Leading cause of death in diabetes patients.
Diabetics 2-4 times more likely to have heart disease or stroke.
Patients with diabetes who have a myocardial infarction (MI) have worse
outcomes.
Diagnosis of diabetes is considered equivalent in risk to having had a
previous MI.
Management of other cardiovascular risk factors is essential in preventing
morbidity and mortality in diabetes patients.
2. Retinopathy and blindness
Diabetes is the most common cause of new cases of blindness among adults
of working age.
Type 2 diabetes patients taking insulin have a 40% prevalence of
retinopathy at five years, while those on oral hypoglycemic agents have a
24% prevalence.
After 15 years of diabetes, almost all patients with type 1 diabetes and two
thirds of patients with type 2 diabetes have background retinopathy.
Proliferative retinopathy is prevalent in 25% of the diabetes population with
≥ 25 years of diabetes.
3. Glaucoma
40% more likely in people with diabetes
Risk increases with duration of diabetes and age.
4. Neuropathy
Heterogeneous condition associated with nerve pathology.
Condition is classified according to the nerves affected: focal, diffuse,
sensory, motor and autonomic neuropathy.
Prevalence of neuropathy (defined by loss of ankle jerk reflexes) is 7% at
one year, increasing to 50% at 25 years for both type 1 and type 2
diabetes.
5. Nephropathy
20-40% of people with diabetes develop nephropathy.
Diabetes is the most common cause of end-stage renal disease, resulting in
44% of all newly diagnosed cases in 2005.
Diabetic eye examination: It is important to identify and treat patients early in
the course of disease. Carefully examine patient's eyes and refer her/him to an
ophthalmologist for a fundoscopic exam.
Comprehensive diabetic foot exam: The ADA recommends that all patients
with diabetes receive a comprehensive foot examination at diagnosis and annually
thereafter to identify foot ulceration, the result of impaired sensation (distal
symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and
peripheral vascular disease), both of which are risk factors for foot ulceration and
amputation.
The foot examination should include the following:
Testing for loss of protective sensation: Sensory testing can be
conducted with a 10-gram monofilament plus any one of the following:
Vibration using 128-Hz tuning fork, pinprick sensation, or ankle reflexes.
1.
Assessment of pedal pulses (dorsalis pedis and posterior tibial arteries):
This evaluates for peripheral vascular disease, the strongest risk factor for
delayed ulcer healing and amputation in diabetes patients.
2.
Inspection: At each visit, patient's feet should be inspected for breaks in
the skin, pressure calluses that precede ulceration, existing ulceration and
infection, and bony abnormalities that lead to abnormal pressure
distribution and ulceration. Skin changes such as hair loss and temperature
changes may signal vascular insufficiency. The patient's footwear should
also be inspected for abnormal patterns of wear and appropriate sizing.
Step 1: Diagnosis. If HbA1c > 6.5%: Lifestyle changes plus metformin
Step 2: Assessment. If HbA1c > 8: Continue lifestyle changes and metformin
and add either a sulfonylurea (Glyburide, Glipizide [both second generation] or
Glimepiride [third generation]) or basal insulin (insulin glargine [Lantus], insulin
detemir [Levemir] or intermediate-acting insulin neutral protamine Hagedorn
[NPH]).
Step 3: Reassessment. If HbA1c > 8: Continue lifestyle changes and Metformin
and add basal insulin or (if already added) intensify insulin regimen. Consider
discontinuing sulfonylurea to avoid hypoglycemia.
2nd Tier (fewer well-validated studies support this approach)
Step 4: Explore other treatment options, including:
Adding rapid-acting insulin with meals
Thiazolidinediones: Pioglitazone (Actos) or rosiglitazone (Avandia) may be
useful for those who cannot tolerate the gastrointestinal side effects of
metformin or have hypoglycemia with sulfonylureas. They may also be used Step 1: Diagnosis. If HbA1c > 6.5%: Lifestyle changes plus metformin
Step 2: Assessment. If HbA1c > 8: Continue lifestyle changes and metformin
and add either a sulfonylurea (Glyburide, Glipizide [both second generation] or
Glimepiride [third generation]) or basal insulin (insulin glargine [Lantus], insulin
detemir [Levemir] or intermediate-acting insulin neutral protamine Hagedorn
[NPH]).
Step 3: Reassessment. If HbA1c > 8: Continue lifestyle changes and Metformin
and add basal insulin or (if already added) intensify insulin regimen. Consider
discontinuing sulfonylurea to avoid hypoglycemia.
2nd Tier (fewer well-validated studies support this approach)
Step 4: Explore other treatment options, including:
Adding rapid-acting insulin with meals
Thiazolidinediones: Pioglitazone (Actos) or rosiglitazone (Avandia) may be
useful for those who cannot tolerate the gastrointestinal side effects of
metformin or have hypoglycemia with sulfonylureas. They may also be used
1. Smoking
Single greatest contributor to mortality
During 2000-2004, approximately 443,000 people in the U.S. died
prematurely each year from cigarette smoking or exposure to
secondhand smoke (estimated annual average of 270,000 males and
174,000 females).
Three leading specific causes of smoking-attributable death:
Lung cancer
Ischemic heart disease
Chronic obstructive pulmonary disease (COPD)
An estimated 49,400 lung cancer and heart disease deaths annually
were attributable to exposure to secondhand smoke.
Smoking during pregnancy resulted in an estimated 776 infant deaths
annually during 2000-2004.
The average annual smoking-attributable mortality estimates also
include 736 deaths from residential fires caused by smoking.
2. Obesity
Approximately 300,000 deaths annually
Rapidly gaining on smoking as the greatest cause of mortality in our
country
A body mass index (BMI) > 32 kg/m2 has been associated with a
doubled mortality rate among women over a 16-year period.
A BMI of 30-35 reduces life expectancy by two to four years
Severe obesity (BMI > 40) reduces life expectancy by 20 years for
men and 5 years for women.
3.
Diabetes
213,062 deaths annually
Majority of deaths from diabetes result primarily from increase in
cardiovascular disease and chronic renal failure. (The risk of
cardiovascular disease in diabetics is so high that it is assumed that
they have cardiovascular disease if they have diabetes.)
Diabetics have twice the mortality risk of non-diabetics.
4.
Hypertension
19,250 deaths annually
Uncontrolled hypertension decreases life expectancy by 20 years.
Most deaths are due to increased risk for coronary artery disease,
hypertensive cardiomyopathy, cerebrovascular disease, and chronic
renal disease.
1. Electrocardiogram: To assess rate and rhythm issues such as bradycardia,
tachycardia, or an underlying heart block. Beta blockers or calcium channel
blockers may be contraindicated for people with abnormal rates or rhythms. Look
for evidence of ischemic disease, previously undiagnosed myocardial infarctions,
or cardiac hypertrophy. Left ventricular hypertrophy (LVH) is the second best
prognostic factor for death in all people with or without hypertension. LVH is
reversible with proper attention and medical management.
2. Urinalysis: Proteinuria can indicate hypertensive nephropathy (target-organ
damage). Glucosuria may indicate undiagnosed diabetes or poorly controlled
diabetes (a potential co-morbid illness and sign of metabolic syndrome).
3. Blood glucose: An elevated random or fasting blood glucose may be evidence of
undiagnosed diabetes or poorly controlled diabetes (a potential co-morbid illness
and sign of metabolic syndrome). This may affect the choice of the first-line agent
used in managing hypertension.
4. Hematocrit: Low hematocrit may reveal anemic states in hypertensive patients.
Anemia makes the likelihood of a major cardiovascular event (e.g., stroke, heart
attack) more likely. If a hypertensive patient is found to be anemic, the
underlying cause (e.g., colon cancer or uterine fibroids) must be found and
addressed, and the anemia corrected. Anemia may also be the product of
target-organ damage in moderate to severe end-stage renal disease.
5. Serum potassium (K): Several blood pressure medications can cause potassium
derangements (angiotensin converting enzyme [ACE] inhibitors, angiotensin
receptor blockers [ARBs], and potassium- sparing diuretics, all of which may
cause or exacerbate hyperkalemia). A baseline potassium level is necessary for
determining any potential changes from antihypertensive therapy. Furthermore,
potassium disturbances can occur in Cushing's syndrome or primary
hyperaldosteronism.
1. Serum creatinine or the corresponding estimated GFR: An elevated serum
creatinine (or the corresponding low estimated GFR) may indicate end- organ
damage (hypertensive nephropathy) from long-term uncontrolled hypertension.
Some blood pressure medications—such as ACE inhibitors, ARBs, and
diuretics—also elevate creatinine.
2. Fasting serum cholesterol panel (total cholesterol, LDL, HDL,
triglyceride): Obtained after a 9 to 12-hour fast, a lipid profile that includes
measurement of high-density lipoprotein (HDL), low-density lipoprotein (LDL),
and triglycerides is indicated to assess lipid co-morbidities. Hypertensive patients
have periodic fasting lipid panels as surveillance for cholesterol problems, and not as a general screening tool.
3. Urinary albumin excretion or albumin/creatinine ratio: The JNC 7 considers
the measurement of urinary albumin excretion or albumin/creatinine ratio (ACR)
optional, except for those with diabetes or kidney disease, in whom annual
measurements should be made. This may become a recommended test for all
hypertensive patients in the future JNC 8 report because microalbuminuria does
appear to have prognostic implications.
4.Serum calcium (Ca): JNC 7 also recommends serum calcium (Ca) level.
One-third of patients with hyperparathyroidism and hypertension may have illness
attributable to renal parenchymal damage due to nephrolithiasis. Increased
calcium levels can also have a direct vasoconstrictive effect. It is unclear why the
increased serum calcium level in hyperparathyroidism raises blood pressure, as
epidemiologic studies suggest that a high calcium intake lowers blood pressure. It
is also not clear why calcium channel blockers are effective antihypertensive
agents.
Dysrhythmias: While these frequently cause palpitations, most patients
with dysrhythmias are unlikely to report having palpitations. Physical exam
and electrocardiogram do not rule dysrhythmias in or out. The patient may
have dysrhythmias that were not captured on the electrocardiogram. Loop
monitoring for two weeks would provide a greater chance of capturing the
event.
1.
Valvular heart disease (e.g., aortic insufficiency or stenosis, mitral valve
prolapse, atrial or ventricular septal defects, congenital heart disease,
cardiomyopathy, congestive heart failure, and pericarditis) can cause
palpitations. *Mitral valve prolapse is commonly associated with palpitations
and may be recognized on exam. It is classically a midsystolic click followed
by a crescendo-decrescendo murmur, usually best heard at the apex. It is
enhanced by Valsalva maneuvers and decreased by squatting.*
Coronary heart disease (CHD): An atypical presentation may include
palpitations. History suggesting cardiac etiology: the duration of palpitations
greater than five minutes, a description of an irregular beat (for example,
the patient can tap it out with their fingers), a previous history of heart
disease and male sex were more likely to predict a cardiac etiology. Also, a
history of palpitations affecting sleep or during work would increase the
likelihood that an arrhythmia was the cause of the palpitations.
3.
Anxiety/panic attack: These are a frequent cause of palpitations,
especially in the setting of high stress. In a prospective study of 190
patients at a university medical center, 31% of palpitations were due to
anxiety or panic disorder (43% had palpitations due to cardiac causes, and
6% had palpitations due to prescription or recreational drugs).
4.
Vasomotor symptoms of the climacteric (menopause) are a potential
cause of palpitations in menopausal women and are associated with heat
intolerance and sweating during a hot flash.
1. Electrocardiogram (ECG): Readily available and might show unanticipated
information such as ischemia or some evidence of structural abnormalities.
Unlikely to identify dysrhythmia unless the patient experiences a dysrhythmia at
that precise moment.
electrocardiograph machine that allows readings to
be made over a 24-hour period, while patient is performing the usual activities of
daily living at home or at work. However, patient would have to have daily or
frequent palpitations to have much chance of capturing the dysrhythmia.
2.Loop recorders: A loop recorder can monitor heart activity for weeks to months,
while the device is worn by the patient at home. A permanent record is kept only when the patient activates the recorder during periods when symptoms are felt.
This device increases the diagnostic yield with regard to detecting dysrhythmias in
patients with palpitations.
3. Complete blood count (CBC): To rule out anemia.
4. Thyroid-Stimulating Hormone (TSH): To check for hyperthyroidism.
5. Urine drug screen: May be indicated to evaluate drug abuse. You should have a
low threshold for ordering this test.
6. Echocardiogram (ECG): Can rule out valvular and structural abnormalities.
7.Fasting lipid profile: To be fasting, the patient must have nothing to eat for 9 to
12 hours prior to the test. NCEP ATP III recommends a complete lipoprotein
profile as the preferred initial test rather than screening for total cholesterol and
HDL alone. Goals of therapy for the treatment of hypercholesterolemia are based
on LDL levels. May obtain a direct LDL measurement, which does not require
fasting.