a 77 rold man a of hypertension, copd, 90 r acupuncture a ... · a 77 ryear rold man with a history...

A 77 year old man with a history of hypertension, hypercholesterolemia, COPD, and a 90 pack year smokinghistory presents to your clinic for acupuncture treatment. His temperature is 36.9°C (98.5°F), BP is 82/54 mmHg, pulse is 125/min, and RR is 16/min. A pulsatile abdominal mass is palpable just superior to theumbilicus. There is diffuse abdominal tenderness, although rebound tenderness and guarding are absent. Thereis also slight skin discoloration noted in the left lower back. What is your next course of action?A. Needle PC6 + SP4 combinationB. Needle Four Doors: RN12, ST25, RN6C. Cupping therapy on local regionD. Send the patient to emergency department

Triad for Ruptured AAA

+ +

This patient presents with the classic triad of symptoms for the diagnosis of a ruptured abdominal aorticaneurysm (AAA): abdominal pain, pulsatile abdominal mass, and hypotension.In addition, this patient has several risk factors for an AAA rupture including HTN and COPD.The skin discoloration along the left lower back may be due to a retroperitoneal hematoma that is associatedwith a ruptured AAA.

A patient complains of abdominal pain with a pulsatile abdominal mass is palpable just superior to theumbilicus. What is the diagnosis?A. Thoracic aortic aneurysmsB. Abdominal aneurysmC. PancreatitisD. Bowel obstruction

The USPSTF recommends 1 time screening for abdominal aortic aneurysm (AAA) with ______________ in menaged 65 to 75 years who have ever smoked.Repair is indicated when the aneurysm becomes greater than ______ cm in diameter or grows more than 0.6to 0.8 cm per year. Asymptomatic patients with an AAA should be medically optimized before repair, includinginstitution of beta blockade.Patients with AAA diameters between 5–7 cm have a 5 year risk of rupture of about 33%. A ruptured AAA canbe lethal and demands immediate surgical attention. When ruptured AAA is highly suspected, he patient shouldbe taken immediately to the operating room for surgical repair without further diagnostic tests.

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(c) HB Kim, www.AcupunctureMedia.com

A 62 year old woman presents to the acupuncture clinic complaining of severe abdominal pain for the past12 hours, first beginning as dull pain near the umbilicus but now localized to the right lower quadrant. Sheinitially thought she was suffering from heartburn, but decided to come to the hospital because of theunrelenting pain. On examination the patient appears in distress secondary to pain, tachycardic, slightlyhypotensive, and febrile at 39°C (102°F). She has a diffusely tender abdomen with point tenderness over herright lower quadrant, accompanied by guarding and rebound. Which of the following is the most appropriatemanagement?A. Call 911 for emergent appendectomyB. Needle Lan Wei XueC. Prescribe Da Huang Mu Dan Tang (Rhubarb and Moutan Decoction)D. Needle Lan Wei Xue and prescribe Da Huang Mu Dan Tang (Rhubarb and Moutan Decoction)

APPENDICITIS SIGNS

MCBURNEY POINT TENDERNESS Rebound pain or tenderness at McBurney’s Point (RLQ)

ILIOPSOAS SIGN Extending the RIGHT hip causes pain along posterolateral back and hip

R_______________________ Palpating in the LEFT lower quadrant causes pain in the RIGHT lower quadrant

O_______________________ Passively flex the RIGHT hip and knee and internally rotate the hip causes pain

HAMBURGER SIGN If a patient wants to eat his/her favorite food, rule out appendicitis

Which of the following group of medications helps block excess acid production and provide longest relief?A. H2 blockersB. Proton Pump InhibitorC. OTC AntiacidsD. Beta 2 agonist

Which of the following does NOT belong to Proton Pump Inhibitors?A. Omeprazole (Prilosec)B. Esomeprazole (Nexium)C. Pantoprazole (Protonix)D. Ranitidine (Zantac)

HEARTBURN MEDICATION

ANTIACIDS H2 BLOCKERS PPI (Proton Pump Inhibitors)

Aluminum hydroxide gel (Alternagel, Amphojel)Calcium carbonate (Alka Seltzer, Tums)Magnesium hydroxide (Milk of Magnesia)Gaviscon, Gelusil, Maalox, Mylanta, RolaidsPepto Bismol

Ranitidine (Zantac)Famotidine (Pepcid)Cimetidine (Tagamet)

Omeprazole (Prilosec)Esomeprazole (Nexium)Pantoprazole (Protonix)

Neutralize stomach acid to relieveshort acting heartburn

Reduce stomach acidity to lessenfrequency and severity of heartburn

Hep block excess acid production torelieve severe heartburn pain

Acid control lasts 30 60 minutes Acid control lasts up to 12 hours Acid control lasts up to 3 days

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Which one of the following does NOT belong to H2 blockers?A. Ranitidine (Zantac)B. Famotidine (Pepcid)C. Esomeprazole (Nexium)D. Cimetidine (Tagamet)

Which one of the following belongs to Proton Pump Inhibitors (PPI)?A. FamotidineB. PantoprazoleC. TumsD. Pepto Bismol

Antiacids

Antacids reduce the effects of acid in the stomach.They do this by neutralizing the acid.Antacids can provide fast, short term relief.There are many different brands of antacids.They come in the forms of chewable tablets, dissolving tablets, and liquid.

H2 Blockers

H2 blockers reduce the amount of acid the stomach makes.While they don’t relieve symptoms as quick as antacids, they do last longer.H2 blockers usually start to work within an hour.OTC examples are ranitidine (Zantac ) or famotidine (Pepcid ).

Proton PumpInhibitors (PPIs)

PPIs reduce the body’s production of acid.They work well for heartburn that isn’t resolved by antacids or H2 blockers.It may take a little longer for a PPI to help the symptoms, but relief will last longer.Most forms start working in a few days.PPIs are most helpful for people who have chronic heartburn (more than 2 days a week).Omeprazole (Prilosec ) and lansoprazole (Prevacid 24HR ) are examples of OTC PPIs.

H1 receptor H2 receptor

Located in blood vessels and respiratory mucousmembranes

Located in the stomach lining

Binding with histamine causes: blood vessel dilation,narrow airways, increased mucus production andformation of hives on the skin

Binding with histamine causes: increased________________ production

Which group of medicines reduces the amount of acid produced by the cells in the lining of the stomach?A. H1 blockersB. H2 blockersC. H3 blockersD. H4 blockers

Which of the following is a competitive H1 anatagonistand is used for allergic reactions?A. Ranitidine (Zantac)B. Famotidine (Pepcid)C. Cimetidine (Tagamet)D. Loratadine (Claritin)

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Creatine kinase (CK), also known as creatine phosphokinase (CPK), is an enzyme expressed by various tissuesand cell types. Clinically, creatine kinase is assayed in blood tests as a marker of damage of CK rich tissuesuch as in myocardial infarction, rhabdomyolysis, muscular dystrophy, autoimmune myositides, and acutekidney injury. In a case of acute myocardial infarction, __________ levels begin to rise begin to rise 5 to 6hours after the onset of chest pain.A. CK MMB. CK MBC. CK BBD. CK HB

CK =

Three major isoenzyme of CK

CK MM CK MB CK BB

found mostly in the__________ muscles

found mostly in the__________ muscle

found mostly in the__________ tissue

Assessing the active and passive range of motion are an important part of musculoskeletal physical exam.Which range of motion is attained by the examiner without the patient’s assistance?A. Active range of motionB. Assisted Active range of motionC. Passive range of motionD. A and B

Normally, __________ is slightly greater than __________ because joints have a small amount of motion atthe end range that is not under voluntary control.A. AROM, PROMB. PROM, AROM

Assessing and treating loss of knee extension range of motion is an importantcomponent for rehabilitation following any knee surgery. What is the normalrange of motion of knee in full extension?A. 0 degree B. 90 degreeC. 140 degree D. 180 dgree

RANGE OF MOTION (ROM)

Active ROM (AROM) Passive ROM (PROM)

Unassisted voluntary movement of a joint Attained by the examiner without the patient's assistance

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Degenerative joint diseases also known as ______________, this type of arthritis is caused by breakdown andeventual loss of the cartilage of the joints. ______________ is the most common type of arthritis and itusually affects the hands, feet, spine, and large weight bearing joints, such as the hips and knees.A. OsteoarthritisB. Rheumatoid arthritisC. Crystal arthritisD. Ankylosing spondylitis

A 75 year old males complains of right knee pain for the last 3 months. He states that he has trouble goingup stairs due to pain. Physical exam revels decreased range of motion, crepitus, effusion, and tenderness onpalpation at the joint line. There is no sign of redness and the joint is cool to touch. What is the diagnosis?A. Rheumatoid arthritisB. Septic arthritisC. GoutD. Degenerative Joint disease

MORNING STIFFNESS

Arthritis Type Joints involved Morning Stiffness Duration

OA (Osteoarthritis) DIP, knees, hips <

RA (Rheumatoid Arthritis) MCP, PIP, MTP joints >

AS (Ankylosing spondylitis) Lumbosacral spine Approximately 3 hours

DJD =

Cerebrospinal fluid (CSF) is a clear, colorless body fluid found in the brain and spinal cord. There is about125 mL of CSF at any one time, and about 500 mL is generated every day. CSF occupies the______________ and the ventricular system and inside the brain and spinal cord.A. Epidural spaceB. Subdural spaceC. Subarachnoid spaceD. Subpia space

D

A

P

i

Which of the following is caused by bleeding into the area between the arachnoid membrane and the piamater and causes thunderclap headache?A. Epidural hematomaB. Subdural hemorrhageC. Subarachnoid hemorrhageD. Intracerebral hemorrhage

“thunderclap headache” or "worst headache of my life“ or "like being kicked in the head"

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Tardive dyskinesia is a side effect of which of the following medications?A. AntipsychoticsB. Monoamine oxidase inhibitors (MAOIs)C. Tricyclic antidepressants (TCAs)D. Selective serotonin reuptake inhibitors (SSRI)

= Neuroleptics

Antipsychotics, also known as neuroleptics, are a class of medication primarily used to manage psychosis (includingdelusions, hallucinations, paranoia or disordered thought), principally in schizophrenia and bipolar disorder.

FIRST GENERATION SECOND GENERATION

1st gen (low potency) 1st gen (high potency) 2nd genChlorpromazineProchlorperazine (Compro)

FluphenazineHaloperidol (Haldol)

Aripiprazole (Abilify)Clozapine (Clozaril)Olanzapine (Zyprexa)Quetiapine (Seroquel)Risperidone (Risperdal)

A condition affecting the nervous system, often caused by long term use of some psychiatric drugs.Tardive dyskinesia is caused by long term use of neuroleptic drugs, which are used to treat psychiatric conditions.Tardive dyskinesia causes repetitive, involuntary movements, such as grimacing and eye blinking.Stopping or tapering drugs that may be contributing to involuntary repetitive movements can help. In rare cases,botulinum toxin, deep brain stimulation, or medications can help.

Vitamin D is a group of fat soluble secosteroids responsible for increasing intestinal absorption of calcium,magnesium, and phosphate, and multiple other biological effects. What is the side effect of Vitamin D whenit is overdosed?A. considered non toxicB. rough skin, hair lossC. burning flush on face and handsD. nausea, vomiting, loss of appetite, diarrhea, constipation

VITAMINS

WATER SOLUBLE FAT SOLUBLE

BIG DECK OF (“DEKA”) CARDS

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MEGALOBLASTIC ANEMIA is an anemia that results from inhibition of DNA synthesis during red blood cellproduction and is characterized by red blood cells that are larger than normal. It's known that ____________or FOLATE deficiency causes MEGALOBLASTIC ANEMIA.A. Alcohol abuseB. Vitamin B12C. Vitamin CD. Vitamin D

ANEMIA

Microcytic Normocytic Macrocytic

MCV <80 fL MCV 80 100 fL MCV >100 fL

Iron deficiency anemiaSideroblastic anemiaThalassemiaAnemia of chronic disease

Anemia of chronic diseaseParoxysmal nocturnal hemoglobinuriaG6PD deficiencyHereditary spherocytosis

MEGLOBLASTICVitamin B12 / Folate deficiency

NON MEGALOBLASTICAlcohol abuse, Liver disease

Secondary hypertension is a type of hypertension which by definition is caused by an identifiable underlyingprimary cause. Which organ disease is a well known cause of secondary hypertensions?A. Pulmonary diseaseB. Hepatic diseaseC. Renal diseaseD. Gastrointestinal disease

HYPERTENSION

PRIMARY HYPERTENSION (95%) SECONDARY HYPERTENSION (5%)

A.K.A. Essential Hypertension, No established cause of known Secondary to other potentially rectifiable causes

CHAPS

Cushing’s syndromeHyperaldosteronismAortic coarctationPheochromocytomaStenosis of Renal Arteries

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A 63 year old male who was diagnosed with large central disc herniation last year complains of lumbar andbuttock pain, lower limb weakness, and perianal discomfort. Patient also reports bowel retention, urinaryincontinence, and sexual dysfunction. Physical exam reveals saddle anesthesia including the back of the leg,buttocks, and soles of the feet. Which of the following is the most appropriate management?A. Needle UB40, DU3, UB23B. Cupping on the lower back and buttock regionC. Send patient home with Du Huo Ji Sheng Tang (Angelica Pubescens and Sangjisheng Decoction)D. Refer the patient to neuro surgery

Cauda equina syndrome (CES) is a condition that occurs when the bundle of nervesbelow the end of the spinal cord known as the cauda equina is damaged.Signs and symptoms include low back pain, pain that radiates down the leg, numbnessaround the anus, and loss of bowel or bladder control. Onset may be rapid or gradual.The cause is usually a disc herniation in the lower region of the back. Other causesinclude spinal stenosis, cancer, trauma, epidural abscess, and epidural hematoma. Thediagnosis is suspected based on symptoms and confirmed by medical imaging such asMRI or CT scan.The management of true cauda equina syndrome frequently involves ________________.When cauda equina syndrome is caused by a herniated disk early surgical decompressionis recommended.

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a 77 rold man a of hypertension, copd, 90 r acupuncture a ... · a 77 ryear rold man with a history...

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