Kenny's Boards 2 Reviews

anatomy
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11?
Double
Bipennate
D'S
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↳ Weakest area of the calcaneus. Breaks in

Rowe calc fractures ( temple trauma

manual)
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ortho /biomechanics
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pediatrics
Developmental Landmarks
9 mos: Sits up
12 mos: Stands up
14 mos: Walks
18 mos: Talks
3 years: Propulsive Gait
Splints and Braces
Use b/t 3mos-3years
For Soft Tissue Problems (Fem Rotation)
Not for Boney Problems (Tib Torsion)
Splint 2x as long as casting
Braces w/ rigid bar should have 20 Deg Varus
Bend to prevent STJ or MTJ sublux.
Ganley Splint
Met Adductus
Convex Pes Planovalgus
Langer Brace
Torsional Abnormalities

Standard AFO
NM Disorders that cause equines
CP, Muscular Dystrophy
Wheaton Brace (System)
Met. Adductu
System: Rotational problems
Osteochondrosis
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Freidbergs Dz – 2nd Met head
3rd, 4th, 5th next most common in that order
Females, 10-18yo
Tx: Sx Shoe
Iselins Dz - 5th met base apophysitis
Kohlers Dz – Navicular
Males, 3-6 yo
Self Limiting
Severs Dz – Calcaneal apophysis
Equinus pts, 6-12 yo
Osgood-Schlatter – Tib-Tuberosity
Males, 10-15 yo
Self Limiting
Blounts Dz – Proximal Tib epiphysis
Bowing of Legs
Infantile <6yo: early walking, obesity
Adolescent 8-15yo: trauma/infxn
Legg-Calve-Perthes – Femoral head
Males, 3-12yo
10% B/L, 30% h/o trauma
Most common Osteochondrosis

Congenital Dislocated Hip
Females, Breech
60% Left Side
Assoc. Met Adductus, Cal. Valgus
Dislocates Post-Sup.
Can be caused by carry babies w/ hips
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Extended and adducted
Signs/Symptoms
(+) Trendelenberg
Asymmetric Thigh Folds
Limited Abduction
Waddling Gait
(+) Ortolanis/Barlows Sign
(+) Galezzi Sign: Dislocate side the knee is lower
Tarsal Coalitions
Most common cause of peroneal spasticity
Males>Females
Decrease ROM
Pain relieved by rest
Fusion Types
Syndesmosis: Fibrous
Synchondrosis: Cartilaginous
Synostosis: Osseous
Talocalcaneal Coalition
45% of all Coalitions
Involve the middle facet

12-16 yo
Radiographs
Harris Beath – facets are not parallel
Lateral – halo sign
Treatment – resection, arthrodesis
Cal-Navicular Coalition (CN-bar)
45% of all Coalitions
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Extra-Articular
8-12 yo
Radiographs (MO and Lateral)
AP: Flattening of nav as it approaches cal.
Lat: Reaching of cal.
Treatment – resection, interposition of EDB
Triple if previous surgery as failed
Tal-Nav Colalitions
Most asymptomatic
3-5 years old
Absence of dorsal cyma line
Met-Adductus
Definition – medial deviation of mets at MTJ
Etiology – unknown
Clinical Features
Males=Females
10% assoc. w/ dislocated hip
30% assoc. w/ internal tibial torsion
L > R when unilateral
Windswept deformity

Met adductus on one foot
Calcaneal valgus on other
Simons Angle Positive
Uncompensated = C-shaped foot
(High Arch)
Compensated = Skewfoot
(Flat Foot)
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Classifications
Dynamic: caused by contracture of ABD-H
Lichtblau Test
Heel Stabalized
5th Met head is braced
Medial pressure
Tight abductor w/ bowstring
Flexible: treat w/ straight laced shoe
Rigid: serial casting/surgery
Measuring Met-Adductus Angle
At Birth: 25-30 Degrees
At 1 year: 20 Degrees
At 4 y/o: 15 Degrees
Treatment
Age 0-2 – serial casting/splinting
Ganley Splint/Wheaton Brace
3 points of pressure (casting)
Abduction med 1st met head
Adduction lat. Side of cuboid
Inversion of heel
Age 2-4 – soft tissue procedures

Heyman/Herndon/Strong (HHS)
ST release of dorsal & medial
structures at lis franc jt
Thompson
Resection of abductor hallucis m.
Age 4-6 – nothing
Age 6-8 – osseous procedures
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Berman/Gartland (BG)
Osteotomies 1-5
6mm distal to 1st met growth plate
2nd, 3rd, 4th not fixated
Clubfoot
Definition (*more severe forms)
FF-Adductus
RF-Varus
Ankle Equinus
*TN-subluxation
*Lateral rotation of talus in ankle mortise
Etiology
NM-Disorders (poor prognosis)

Polio, CP, Spina-Bifida, Myelomeningocele
Post-Traumatic (poor prognosis)
SC Trauma, Post-CVA
Intrauterine Position (good prog)
Incidences
Males > Females
Right > Left, when unilateral
Polynesian>Black>White>Asian

Most common congenital foot def.
Radiographs (Signs)
Talus
Reduced size
Tal-Dec Angle: <135 Degrees
Tal-Cal Angle (Kites)
AP: < 15 Degrees
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Lat: < 20 Degrees
Tal-1st Met Angle
AP: > 15 Degrees
Tal-Head : Body Angle
Add: > 80 Degrees
P/F: > 45 Degrees
Calcaneus
Normal Shape
Underdeveloped Sustentaculum Tali
Navicular
Normal Shap
Hypertrophic Tuberosity
Plantar/Med Subluxation
Simons Rule of 15 (AP View)
Kites: < 15 Degrees
Tal-1st Met: > 15 Degrees
Horizontal Breach: post-displacement of fibula
Treatment
Serial Casting–congential clubfoot
In the following order(AVE)
Adduction

Varus
Equinus
Stretching/Manipulation should be done prior (10-15min)
Infants: lone leg cast, knee flexed at 75 Degrees
Change q1-2 weeks
If no signs of improvement at 12 wks, Sx is needed
Complications
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Met Adductus
Heel Varus
Over-correction – pes plano valgus
Rocker bottoms – overcorrection of equines
AVN of Talar head
Dorsal Nav. Subluxation
Surgical – NM disorders
Soft Tissue releases/lengthening (3-12 mos)
Lengthen all tendons except extensors/peroneals
Release all ankle ligaments except ATF
K-wire fixation of TN joint
Osseous Procedures
2-6 yo
Lateral column shortening
Medial column lengthening
>12 yo: Triple Arthodesis
Vertical Talus (rocker bottom)
Clinical Features
Most rigid form of flat foot
Males=Females
Usually B/L

Right > Left
Nav. Dorsally Dislocated
FF is abducted and D/F
Calcaneus is valgus/equines
STJ abnormal
Ant: Missing
Middle: hypoplastic
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Post: malformed
Etiology
NM-disorders (most common)
Inheritance (autosomal dominant)
Radiographs
AP – Kites Angle > 40
Lateral
Negative/low CIA
Talus: hourglass shape, flat surface
Treatment
Conservative Tx
rarely successful
used only as a means to preparation for sx
Surgery
3mos-3y/o: Post. Release, reduction of TN
3-6 y/o: addition of arthroesis
> 6y/o: wait until 10-14 and perform triple
Calcaneal Valgus
Clinical Features
Severe limitation w/ p/f & inv.
Excessive D/F and Eversion

Loose skin folds below lat. Mall.
Females > Males
Abnormal IU position (young mothers)
Radiographs
AP - Kites Angle – increased
- Nav lateral to talus
Lat – p/f talus, d/f calcaneous (unlike VT)
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Treatment
Conservative (Flexible deformities)
Daily stretching (p/f and inv)
Serial casting (3-6mos)
P/F Foot
FF Adducted
RF neutral to Inv.
Post-Casting
Ganley Splints
Surgery
Soft Tissue
Peroneal Lengthening (correct valgus)
TN and CC capsulotomy (correct FF abduction)
Osseus
Evans, STJ arthroersis
Arthrodesis
Flexible Pes Planus
(+) Hubshcer Mvr
(+) Resupination Test
Not Painful
Long. Arch present during WB

Blacks>Whites
Juvenille HAV : Characteristics
HAV < 20y/o
Females
Maternal
Less valgus rotation than adult
Stages
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I – Slight Abduction
Full ROM, can reduce
Irritation of Prominence
II – Moderate Abduction
Full ROM, can reduce
III – Severe Abduction
Full ROM, can’t be Reduced
“Tracking” Deformity
IV – Lack ROM, Pain/Crepitus
Rare
Surgery
< 6 y/o: only in severe cases
6-10 y/o: if adaptic changes on xray
10-15 y/o: ideal period
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Dermatology
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Dermatology Points
Koens Tumors
multi-firm periungual fibromas assoc.w/ tuberous sclerosis
Epidermolysis bullosa simplex –
- spontaneous blisters from minor trauma (heel without scars)
- Defect in keratins 5 and 14 (genetic disorder)
Henoch-Schonlein Purpura (HSP)
Intermittent purpura of the extremities and buttocks usually affecting children
Tuberous Sclerosis
multiple sebaceous adenoma, mental retardation, koens tumors
Hansen’s Dz (leprosy)
Cutaneous numbness, neurotrophic ulcers, erythema nodosum, erythematous
macules, eye brow loss
Scleroderma
firm sclerotic indurated plaques.Lesions are smooth topped with
white center and purple border
Sx boundrys for plantar warts – dense superficial fascia
Onychomycosis
AIDS pts – superficial and proximal
T. rubrum

Juvenile plantar dermatosis –
Caused by hyperhidrosis (excessive drying of feet)
Tx – application of emollients (Vaseline)
Tests
Auspitz Sign: Pinpt bleedin w/ removal of psoriatic lesions
Diascopy: Blanching of lesions
Nikolsky Sign: Epidermal detachment due lack of skin cohesion
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Seen in Bullus Diabeticorum
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infectious diseases
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Antibiotics Side effects

Penicillin’s
SE
Hypersensitivity Rxns
Delayed (IgG) – rash
Immediate (IgE) – anaphylaxis
Thrombocytopenia
Diarrhea (amox)
Cholestatic hepatitis in males >60y/o (amox)
Potassium changes (Ticarcillin)
CI
Methotrexate
Tetracyclines (cancel each other out)
Cephalosporins
SE
Cross Reactivity with PCN 10%
Diarrhea
CI - Probenecid (increase [ ])
Macrolides
SE

Very long ½ life
Hepatotoxicity
Diarrhea (erythro) - increases GI motility
CI
Stomach Acid (deactivates ABX)
Ca-Blockers (torsades de pointes)
Digoxin
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Coumaden (increase bleeding)
Statins
Aminoglycosides
SE
Nephrotoxic – reversible
Ototoxic – irreversible
NM – blockade (due to fast infusion)
CI
Acidic environments (inactivates ABX)
LE infections (poor penetration)
Quinolones
SE
Tendon Rupture
Diarrhea
Torsades de Pointe
Polymorphic Ventricular Tachycardia in pts with long QT interval.
CI Rapid irregular QRS complexes.
Nursing mothers/Children <18 (cartilage damage)
Diabetics (tequin)
Theophylline (increases effect of asthmatic medication)
CI w/ NSAIDS - can cause siezures
Tetracyclines

SE - Photosensitivity
CI
Dairy products, stomach acid, antacids (decrease absorption of ABX)
Nursing mothers/Children < 8 (stains teeth yellow)
Vanco
SE
Nephrotoxic – reversible
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Ototoxic – reversible
Red man syndrome
Zyvoxx
SE - Thrombocytopenia
CI - SSRI’s
Imipenin
SE - Cross reactivity with PCN (50%)
CI - Pt with h/o seizures
Bactrim
SE - Sulfa Allergy
CI
Pts with G6PD deficiency
Pts taking sulfonylureas for DM
Clinda
SE - Pseudomembranous colitis
Metro
SE
Metallic taste in mouth
Disulfiram rxn
Very dark urine
Peripheral neuropathy

CI
Pregnancy
Pts with h/o seizure
Warfarin (increases bleeding)
Cimetidine (decreases ABX)
Rifampin
SE
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Body Fluids turn orange
Resistance develops rapidly if used alone
INH
SE
Vit B6 def (3-D's symptoms)
Diarrhea
Dermatitis
Dementia
Diflucan
CI - pregnancy
Lamisel
SE
Taste disturbances
Green vision
Liver damage
Sporonox
CI -Pts taking Statins
Cimetidine

CI - increases effects of B-Blockers
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Diabetes
Type
IDDM – Polyuria, Polydipsia, Polyphagia (yet rapid weight loss)
NIDDM – Polydipsia, Pruritus, Fatigue (obesity)
Gestational - self-limiting
Secondary Causes
Pancreatic Dz
Hormonal Dz – Cushings, Acromegaly
Drugs – Thiazides, Diuretics, Steroids, Phenytoin
Diagnosis
Fasting Glucose: > 140mg/dl on more than 2 separate occasions
Hb1Ac
> 7% is pathological indicates the mean level of circulating glucose
for previous 2-3months
Every 1% = 30mg/dl of BS
Drugs

Insulin
Rapid - Humalog/Novolog
Onset - 30 min
Pk - 3hrs
Duration - 5hrs
Long Acting - Lantus
Onset - 2-4hrs
Pk - none
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Duration - 24hrs
Oral Meds
Sulfonylureas – Glipizide (glucotrol), Glimeperide, Glyburide, Tolbutamide
Metformin (glucophage)
Troglitazone
Diabetic Complications
Acute Conditions
DKA (seen only in IDDM pts)
Symptoms
Hyperventilation
Tachy/HOTN/Sycope
Altered mental status
Acetone on breath
Labs
pH < 7.2
High K
Low Na
Tx
Insulin (25-50 unit bolus)
Fluids

Bicarb (if pH <7)
Hypoglycemia (<50mg/dl)
Etiology - insulin rxn
Symptoms
Tachycardia (due to excessive Epi secretion)
Tremors/Siezures/Confusion
Syncope/Sweating
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Treatment
Amp D50 IV pus
Accucheck in 20min
Get Pulse Ox, if <97 give 2L
Orange Juice if concious
Somogyi Effect - rebound
hyperglycemia following, hypoglycemia
Lactose Acidosis
SE of Metformin
Tx - bicarb
Chronic Conditions
Neuropathy (polyol pathway)
Pathogenesis of Hyperglycemia
Increase nerve glucose

AKA sorbitol-aldose reductase pathway
Implicated in DM complications. Too much glucose, hero kinase is

Increase polyol pathway saturated. Excess glucose goes to polyol pathway and is reduced to
sorbitol ( via aldose reductase)Aldose Sorbitol
Sorbitoln
Gwcosen
Reductase. Reductase Fructose
Decrease Na-K pump
,
$A
't
NADPH NADP NAD
't
DH
Decrease NCV
Polyneuropathy .
Affects nerve terminal
Stocking/glove sensory loss and proprioception loss
Can later lead to motor loss of intrinsic muscle – cavus foot, hammertoes

Radiculopathy
Affects nerve root
Causes pain, and dermatome sensory loss
Autonomic Neuropathy
Affects sympathetic ganglion
Causes anhydrosis, bounding pulses, hyperemic foot
Systemic Manifestations
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CV - increase HR, HOTN
GU - inadequate bladder emptying UTI
GI - increase motility, secretions GERD
Treatment for Neuropathy
Amitriptyline
Neurotin
Lyrica
Topical capsacian
Radiograph features
Demineralization
Osteolysis
Vascular Dz
Atherosclerosis – plaques in the arteries
Macroangiopathy - effects popliteal, tibial arteries
Microangiopathy - usually precedes macroangiopathy
Nephropathy
Diffuse – Glomerular-BM widening
Nodular – High PAS (+) at glomerular tufts
Immunopathy – defective PMN function
Retinopathy
Diabetic Charcot

Symptoms
Vasc – bounding pulses, erythema, swelling, warmth
Neuro – decreased
Ortho – rocker bottom deformity, creptitus, MT-subluxation
Dermatology
Collagen inelasticity
(-) Keratinocytes production
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Diabetic Foot Ulcers/Infection

Wagner’s Classification
Stage 0 – pre/post ulcerative lesion (intact skin)
Stage 1 – ulcer down to sub-Q
Stage 2 – ulcer extending to tendon, capsule, bone
Stage 3 – ulcer associated w/ abscess, OM, joint sepsis
Stage 4 – forefoot gangrene
Stage 5 – gangrene of entire foot
Texas Wound Classification
Grade
Grade 0 – pre/post ulcer lesion
Grade 1 – ulcer down to sub Q
Grade 2 – ulcer extending to deep fascia
Grade 3 – ulcer down to bone
Stage
Stage A – clean
Stage B – infected
Stage C – ischemic
Stage D – ischemic & infected
Nat. Pressure Ulcer Classes

Stage 1- Non-blanchable erythema of intact skin (seen over bony prominences)
Stage 2 – ulcer down to dermis
Stage 3 – down to Sub-Q
Stage 4 – down to tendon, bone
Complications
Chronic wounds
Squamos Cell Carcinoma
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Marelins Carcinoma
Necrotic Leg Wound
Calci-flaxis - seen in Renal pts
Work-up
Physical Exam
Systemic Signs – r/o sepsis
F/C/NS?
Lethargic?
Vitals? Tachy, Hypo-TN
Vasc – Pulses, Doppler, CFT
Neuro - protective threshold?
Ortho – assess bony prominences
Dermatological
Ulcer (D-DMB-DOC)
Depth: probe to bone?
Diameter
Margins: undermining? hyperkeratotic? necrotic?
Base: granular? fibrotic? necrotic?
Drainage: serosangous? purulent?
Oder: fecal? (anaerobes) fruity? (pseudomonas)
Crepitus - r/o gas gangrene

Surrounding Skin
Calor? - temp
Dolar? - painful
Rubor? - reddness, erythema
Tumor? - swollen, edematous
Labs
Stat Glucose - hyperglycemia despite normal dose of insulin indicated infection
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C & S (anaerobic/aerobic)
Usually polymicrobial (6)
Staph
Strep
E.coli
Enterococcis
Proteus
Pseudomonas
Bacteriodes
Blood culture to r/o sepsis
UA - r/o Urosepsis
CBC w/ Diff: Left shift (bands)=acute infxn
CMP/BMP
ESR and CRP – to follow progression & regression
HbA1c – to determine longvterm control of DM
Studies
EKG - pre-op for Sx
X-rays
Takes 2 wks for OM to show
Not sensitive, very specific
Get CXR to r/o pneumonia

Bone Scans
Takes 48-72 hrs for OM
Sensitive but not specific
3 Phase Bone Scan (Tc-99)
1st phase - blood flow
Dx - Cellulitis
2nd phase – blood pooling
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Dx - Cellulitis
3rd phase - osteoblast activity
Dx - OM
Indium/WBC Scan (67hr 1/2 life)
Tags WBC’s
2x more specific for acute OM than Tc-99
Gallium
Tags WBCs and plasma proteins
Not dependent on blood flow
More sensitive for chronic OM, and tumors
Ceretec Scan
More specific for chronic OM
Better for whole body scan
MRI
Very specific for OM
T1 - decrease intensity
T2 - increase intensity
Good for abcesses
Osteomyelitis
Classification (Mader)
Medullary - infants/children

Superficial - neuropathic ulcers
Localized - sequestra
Diffuse - invovles entire bone
Definitive Dx requires bone biopsy
80% of bone exposed to air is infxn
ABX rarely effective, Sx needed
Excise necrotic bone
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Get proximal margins
Gentamicin/Vanco beads can be used
6 wk ABX needed afterwards
Etiology (Stept/Staph)
Hematogenous –enters via blood, mostly seen in Pedal Pts
Contiguous – spreads from adjacent tissue
Direct Inoculation – trauma/Sx
Acute Osteomyelitis
Osteolysis
Cortical erosions
Periosteal elevation/reaction
Chronic Osteomyelitis (necrotic)
Sequestrum - Highly opaque bone separated from normal bone
Involucrum - Layer of living bone that formed around necrotic bone
Cloaca - Opening in theinvolucrum
Brodies Abscess: abscess surrounded by sclerotic bone (metaphysis)
Chronic OM can lead to epidermoid carcinoma
Phases of Wound Healing

Inflammatory Phase: 1st week
Neutrophils - day 1

Macrophages - day 2
T-cells - day 5
Chronic wounds in this stage
Proliferative Phase: 2nd, 3rd week
Remodeling Phase: >1 month
Treatment of Wounds (5 D's)
Decompression: I&D, Removal of Sutures
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Drainage - copious lavage
Debridement - of infxn tissue
Dressings - pack open
Drugs - Abx for 6 wks
Treatment Goals
33% decrease in wound size after 4 weeks
Complete closure in 3 mos
Wound Dressings
Regranex
Growth factors
Use for DM ulcers
Panafil
Promotes tissue growth
Debriding agent
Use for DM/Venous ulcers
Don't mix with Silvadene
Accuzyme
Same as Panafil without GF
Silvadene
Antimicrobial
Use on Venous wounds/Burns

CI - Sulfa ALL
Xenoderm
Promotes capillary action
Use for superficial wounds
Dakin's solution
Dilluted Bleach
Toxic to granulation tissue
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Silvasorb
3 day release of Silver
Aquacel
Prevents maceration
Has low levels of Silver
H2O2
Only effective if effervises

Eﬀervesces- gives oﬀ bubbles
Topical ABX
Bacitracin
SoA: G-, G+ (even Erythasma)
SE - fungal super-infxn
Mupirocin (Bactroban) Topical TID 2% cream/ointment.
SoA: G+ , MRSA, Imetigo
Wound Irrigation
50cc Syringe w/ 18 Gauge Needle
60cc per 1cm in size of wound
Minimum of 200cc
Mix w/ Betadine or H2O2
Skin + Soft Tissue Infections

Cellulitis

Strept – streaking
Staph – well demarcated
H.influenza (in children)
Erysipelas (Lymphangitis) Acute superficial cellulitis involving dermal lymphatics
Strept A
Post-Op
Staph
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Necrotizing Fasciitis
Strept A
Strept B (in DM)
Gas Gangrene
C.Perfinges
Farm injuries
Clostridium Species Treat with aminoglycosides
Salt Water injuries
Vibrio species
Mycobacterium Avium
Fresh Water
Pseudomonas
Aeromonas
Puncture Wounds
Pseudomonas (through Sneaker)
High Pressure H20
Acinebactor
Lacerations
25% become infections
Burns
Staph

Enterococcus
Gram (-)
E.coli
Kleb
Pseudomonas
Enterobacter
DM-Wounds
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Staph/Strept
Enterococuss
Gram (-)
E.coli
Pseudomonas
Proteus
Bacteriodes
Impetigo - Staph
Folliculitis
Staph
Pseudo – pools w/ no chlorination
Erythrasma - Corneybacterium
Furuncle/Carbuncles - Staph
Abscesses
Staph
Bacteriodes
Scarlet Fever (strawberry tongue)
Strept A
Bone + Joint Infections
Osteomyelitis
Staph

Pseudomonas (drug addicts)
Salmonella (sickle cell)
OM secondary to DM-foot infxn
Staph/Strept
Pseudomonas
Prosethtic Joints - Staph Epi
Septic Joints - Staph A
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Bites
Tick Bites
Borrelia (lyme dz)
Rickettsia (rocky mtn)
Animal Bite
Pasteurella (cat bite)
Leprosy (armidillo) Word?!
Human Bite - Eikenella
ENT
Otitis/Sinusitis
Moraxella
H.Influenze
Pharyngitis - Stept
Community Acquired Pneumonia
Staph/Strept
H.infleunza
Legionella
Actinomyces/Norcardia
Nosocomial Acquired Pneumonia
Staph
Gram (-)

Kleb
E.coli
Pseudomonas
Immuno-compromised Pneumonia
Myco-Avium/TB
Pneumocystis Carnii
GI
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Diarrhea
Gram (-)
Salmonella/Shigella
Camplyobacter
E.coli
Pseudomembranous Colitis - C. diff
Peptic Ulcer - H.pylori
Urogenitial
STD
Chlamydia
N.Gonnorhea
Treponema (Syphilis)
UTI
Gram (-)
E.coli
Kleb
Pseudomonas – nosicomial
CNS/CV
Endocarditis
Staph/Strept
Enteroccus

Rheumatic fever
Strept
Meningitis
Strept
Listeria
N.meningitis
Sepsis
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Staph/Strept
Tuberculosis
Findings
F/C/NS
Weight loss
Cough - yellow-green sputum
TB Arthritis (50% CXR +)
Tetanus
Spores appear "drumstick" like
Findings
Trismus (lockjaw)
Muscle Spasm
Irritability
Dysphagia
50% mortality
DDx
Strychnine poisoning
Phenothiazines
Treatment
Toxiod (for immunizatio)
DTP

Given to children
2, 4, 6, 15, 48 mos.
Td (25% less toxiod)
Used in peds/adults >7yrs
Used as booster every 10 yrs
.
DT
Used in peds <7yrs
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Tetanus-Ig (post-exposure)
Given to patients w/ unknown history or <3 doses of toxiod
Mycology
Superficial Mycosis
Onychomycosis: Sup White – T. Menta
Sub-Q Mycosis
Sporotrichosis
Lesions along lymphatics
Arthritis
Etiology - rose bush thorns
Chromomycosis
Warty, Tumor-like lesions
Mostly in tropics
Etiology - Cladosporium
Mycetoma (Madura Foot)
Swollen, draining lesions w/ "grains" of colonies
Weeping granulomas
Etiology - Pet. Boydii
Systemic Mycosis
Coccidioidomycosis

San Joaquin Valley Fever
Common in dark skin people
Histoplasmosis (cave fever)
Seen East of Mississippi
Found in bird/bat manure
Blastomycosis
Single bud off mother-cell microscopically
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Paracoccidiodomycosis
Seen in Brazil
"Steering wheel" appearance micrscopically
Cryptococcosis
Found in pigeon droppings
Predilection for brain/meninges
Opportunistic Fungi
Aspergillosis
Fungus ball in lung
Pnuemonia like symptoms
Pneumocystic carinii
Most common opportunitic infxn in AIDS patients
Parasitic Infections
Cutanea Larva migrans
Transmitted via bare feet on cat or dog feces
Tx – topical thiabendazole
Rocky Mountain Spotted Fever
Erythematous macules on ankles and wrists
Viral Diseases

DNA Virus
Adenovirus
Inhabits tonsils (70%)
High incidence in military
Vaccination available
Hepatitis B
STD
Vaccination (HBsAg) available
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(+) HBsAb = immunity
(+) HBsAg = infxn

"
"
Herpes Virus (Tznack smear) herpes Stark
Type 1
Oral sores
Trigeminal Latency
Type 2
STD - genital lesions
Lumbar/Sacral Latency
Intranuclear inclusion bodies
Varicella/Zoster
Chickpox/Shingles
Dorsal Root Latency
Multinucleated giant cells
Epstein-Barr
Mono
Burkitts Lymphoma (in AA)
CMV
Birth Defects
HIV pts
Papillomavirus (warts)

Parvo
Sickle cell --> aplastic anemia
Pox Virus
Largest virus
Molluscum Contagiosum
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RNA Virus
Influenza
A - multilple host's
B - human host only
C - no epidemics, human only
Paramyxoviruses
Mumps
Parotid glands
Vaccine available (live)
Measles (Rubella)
Encephalitis
Vaccine (live)
RSV
Resp infxn in peds <1yrs
Enteroviruses
Polio
CNS, Faccid paralysis
Ant. horn cells
Vaccine (salk inactive)
Coxackie

Hand/foot/mouth Dz
Mild Dz
Hepatitis A
No chronic state
Low fatality
Rhinovirus - common cold

Norwalk virus - winter vomit virus
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Retroviruses (HIV)
Skin Lesions
Kaposi’s Sarcoma
Eosinophilic Folliculitis
Molluscum contagiosum
Thrush
Skin Lesions more severe in HIV
Psoraisis
Alopecia
Onychomycosis
Genital Candial infection
Norwegian Scabies
Infection Complications
Meningitis – Cryptococcus
Brain Abscess – Toxoplasma
CMV retinitis
PCP – Bactrim Px
Cryptococcus, Coccidiodes, Histoplasma pneumonia
Flucanazole Px
M. Avium – Macrolide Px
Tuberculosis - Isoniazid Px
Rabies
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Animal bites
CNS/encephalitis
Negri Bodies in cytoplasm
Vaccine (inactive)
Hepatitis
A - above
B - above
C - IV drug users
D - requires Hep B to work
E - fecal oral route
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Anethesia
Patient Classification
Class 1 – normal healthy
Class 2 - mild systemic dz (HTN, controlled DM)
Class 3 – severe systemic dz (IDDM, vascular compromise)
Class 4 – incapacitating systemic dz (cardiac, renal, pulmonary insuffiency)
Class 5 – moribund patient (not expected to live w/o surgery)
Stages of Anesthesia
Stage 1
A – analgesia
B – partial analgesia and amnesia
C – total analgesia and amnesia
Stage 2 – Delirium, Loss of consciousness
Stage 3 – Surgical anesthesia
A – sleep
B – sensory loss
C – muscle tone loss
D – intercostals paralysis
Stage 4 – Medullary paralysis

A – reversible resp. failure
B – irreversible CV collapse
General Anesthesia Meds

Induction
Halothane
Pro – rapid smooth induction, pleasant smell
Con – mal.hyperthermia, liver damage, CI w/ Epi
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Iso,Sevo,Devoflurane
Pro – rapid induction, non-flammable, compatable w/ Epi
Con – shivering post-op, decrease BP
Nirtous Oxide
Pro – least potent, little effect on HR, rapid induction
Con – no muscular relaxation
Diprivan (Propofol)
Has replaced Na-pentathol
CI in pts w/ Egg Allergy
Sedatives
Diazepam (Valium)
Satisfactory sedative and amnesia effect
Also acts as a muscle relaxor
Can be used to control convulsions
Midazolam (Versed)
Shortest acting IV BDZ
Amnesia Agents
Ketamine
Pt becomes mentally dissociated from environment
SE – hallucinations
Used with BDZ due to SE’s

Analgesics
Side Effects
Resp Depression (can develop tolerance)
Constipation (can’t develop tolerance)
Fentanyl – respiratory depression of short duration
Morphine
Reduces GI motility
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Broncho-constricts
Demerol
Can cause seizures or tachy
CI in elderly and pts w/ atrial flutter
Can be used to treat “the shakes” when coming out of Sx
Muscle Relaxors
Succinylcholine
Blocks nicotine receptors
Short duration/non reversible
May cause fasciculations
SE – Hyper-K
Tubocurarine
Blocks nicotinic receptors
Longer duration
Reversible by Neostigmine
Dantrolene – used to treat malignant hyperthermia
Misc
Atropine
Reduces secretions
Reverses effect of parsympathetic nervous system on heart
Bronchodilator

Toradol (Ketorolac)
Only IV NSAID that can be used post-operatively
SE – peptic ulcers (limit 3 days)
Reglan (Metoclopramide) reduces GI motility
D5W – always give to Peds to prevent hypovolemic shock
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Local Anesthetics
MoA
(-) Na-Channels
(-) Depolarization
(-) nerve conduction
1st Pain/Temp
Touch
Motor
(Acidic areas decrease effects)
*mix w/ HCO3 in 1:10 to decrease pain on injection*
Types
Esters
Broken down in plasma by pseudocholinesterases
Higher allergic potential
No “i’” is 1st half of word
Novacaine – most toxic
Amides
Metabolized in Liver
Lidocaine – shortest duration
Marcaine

Longest duration
Most CV toxic
CI in children under 12 due cartilage damage
Epinephrine
Don’t use < 1:200,000 in digits
Toxic Doses
Lidocaine (300mg)
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Lidocaine w/ epi (500mg)
Marcaine (175mg)
Marcaine w/ epi (225mg)
Epidurals and Spinal Anesthesia

Procedure
Local is injected into subarchonoid space (deep to dura)
Indications
Pts not suitable for Muscle relaxants (Myasthenia gravis)
Pts who’s systemic dz prevents general (RA w/ cervical spine, asthma)
Contraindications
Preexisting neurological dz
Extremes in age
Septicemia
Shock
Epidural Advantages (stays w/ pt)
More useful for outpatient Sx
Greater control of anesthesia
No post-op headache
Less HOTN

Good for post-op pain relief
Spinal Advantages
Easier to perform
Less local need
Block occurs faster
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Anesthesia Complications
Malignant Hyperthermia
Hypovolemic Shock
Intubation
Sore throat
Airway obstruction (croup)
Pneumothorax
Tourniquet (200mmHg > stystolic)
Tissue necrosis
Thrombosis
Paralysis
CI – sickle cell, prev. LE bypasses
Supine Position: Ulnar N. compression
Prone Position: Orbital pressure
Peds pts
Hypoglycemia
Hypothermia
NPO
NPO at least 8 hours
DM shouldn’t take oral meds (prevent hypoglycemia)

EKG changes
Low Ca – Wide QRS complex
High K – T-tent
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Arthropathies
Gout
Charcot
Rheumatoid
Juvenile RA
Osteoarthritis
Seronegative Arthropathies
Reiter’s
Psoriatic
Ankylosing spondylitis
Connective tissue Dz
SLE
Scleroderma
Joint Fluid
Non-inflammatory
Transparant, Straw
Viscous
Diagnosis
DJD, OCD

Neuropathic Artropathy
PVNS
SLE/Scleroderma
Inflammatory
Translucent, Yellow
Low viscosity
Crystal (gout)
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>50% PMN
2,000-75,000 WBC
Diagnosis
RA, Gout
Sero-neg's
SLE/Scleroderma
Ulcerative Colitis
Septic Joint
Opaque fluid
Viscosity variable
>75% PMN
>100,000 WBC's
Septic Arthritis
Pathogenesis
Usually Reaches via Blood
Knee most common
Acute Bacterial Arthritis
Medical Ex, requiring Hosp.
Findings

F/C/NS
Red, hot, tender, swollen jt
Good prognosis if Dx <3days
Types
Gonoccal (N.gonorrhea)
1/2 of sex. active adults
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Polyarticular --> Mono
Small rashes/vesicles
Cx all mucous membranes
as bacterial is seldom
found in jt
Non-gonococcal
Seen in pts w/ prev. jt
damage or immuno-
suppressed
Staph (70%) Strept (30%)
Gram (-) w/ IV drug users
H.infuenza in children
Pseudomonas - Ecthyma
gangrenosum
Viral Arthritis
Non-destructive
Poly-articular
Hep B (most common)
Tx - rest and NSAIDs
Lymes Dz
Etiology - Borrelia burgdorferi

Findings
Erythema chronicum migrans
Poly-articular artritis
mostly knee/ankle
Heart arrythmia's
Flu-symptoms
Tx - Doxy is DOC
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Gout
Clinical Signs
Middle age men
Red, hot swollen joint due to build
up or urate cyrstals
Asymmetrical, monoarticular
1st MPJ > Lis Francs > ankle
X-ray Findings
Boney erosion (rat-bite erosions)
Overhanging margins of new bone
(Martels sign)
Joint preserving disease
Types
Overproduction (metabolic gout)
10% of patients
Due to excessive rates of cell/
nucleic acid turnover
Under secretion (renal gout)

90% of patients
Due to renal dysfunction
Psuedogout
Caused by calcium crystals
(rhomboid)
Usually less painful, but
associated with fever
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Seen with Hyper-PTH and
Hypo-Thyroid
Labs
Synovial Fluid – needle like
crystals (send in EtOH)
Uric Acid – increased
ESR – increased
Treatment
Acute Gout
Indomethacin (NSAID)
Colchicine
(-) WBC phagocytizing Urate
Beware of GI toxicity
Dx tool - if pt got better, than
it was gout
Chronic Gout
Allopurinol
For “overproducers”
Inhibits xanthine oxidase
Probenicid
For “undersecretors”

Increase renal excretion
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Charcot
Pathogensis
Etiology
Diabetis
Alcoholism
Tertiary Syphillis/HIV
Vit Def, Heavy Metals
Theories
French (vascular)
Damage to nerves of blood
vessels
Cause hyperemia and active
resorption of bone
German (neuro)
Progressive DJD causes loss of
propioception and protective
sensation
Stages
Fragmentation
Coalescense – absorption of

debris
Remoldling
Clinical Findings
Red, hot, swollen, painful joints
Decrease sensation
Atrophy of Intrinsics
Anhydrosis
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Decrease in DTR’s
Treatment
Fragmentation phase – strict NWB
for 8-12 weeks
Remolding phase – surgery
Rheumatoid Arthritis
Clinical Findings
Middle age females
Synovitis and morning stiffness is
initial symptom
Pain gets better with motion
(worse with rest)
Symmetric joint involvment
Usually involves MTPs and PIPs
RA nodules over pressure points
Bakers Cyst – synovial fluid cyst
located in popliteal
X-ray findings
Even joint space narrowing

Subchondral osteoporsis
Marginal joint erosions
Fibular deviation of toes 2,3,4
Arthritis mutilans
Diffuse osteopenia
Achilles tendon thickening
Lab values
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ESR – increase
RA factor – increase
ANA – positive
Surgery considerations
1 – corticosteroid supplementation
(pre-op)
2 – ASA/NSAID discontinuation,
seven days prior
3 – C-spine X-ray C1,C2
4 – protect skin peri-operative
(very thin)
5 – increase risk of infection
6 – delayed wound healing
7 – TMJ’s (in jaw
8 – DVT prophylaxis
Juvenille RA
Clinical Findings
Self-limiting
Females > males
C2-C4 cervical fusions

Ballooning epiphysis on X-ray
Labs
RA-factor negative
ANA - positive
Osteoarthritis
Clinical Signs
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Asymmetric
Pain worse at end of day
Pain with change in weather
Joint enlargement
Crepitus
X-ray Findings
Subchondral bone cysts
Subchondral sclerosis
Uneven joint space narrowing
Osteophytes
Loose bodies (jt mice)
Lateral Column OA
Seen w/ taral coalitions
Trauma
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Seronegative-Arthropathies
Reiter’s / Reactive Arthritis
Clinical Findings
Triad (can’t see, pee, climb tree)
Urethritis
Conjunctivitis
Arthritis (asymmetric)
Etiology
Chlamydia - Urethritis in males
Camplyobacter
Idiopathic - woman/children
Other Findings
Keratodermas
Digital swelling
Heel Pain (Lover’s heel)
fluffy heel spur
X-ray findings
Joint space narrowing
Osteoporosis
Marginal bone erosion

Bone proliferation
Subluxations
Ankle & calcaneal manifestation
Labs
ESR, CRP – increased
HLA-B27 - positive
Synovial fluid – Reiters cells
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Tx - self limiting
Psoriatic Arthritis
Clinical Findings
Middle age
5% of patients have
papalosquamos psoriasis
Greater % have psoriatic nails
(pitting, beaus lines)
Asymmetric presentation
Digital swelling
X-rays
Joint space widening
Bone proliferation – “paint brush
appearance” of distal
phalanges (ivory phalanx)
Pencil & cup (arthritis mutilans)
Lab values
ESR – increased
HLA-B27 - positive
Ankylosing Spondylitis

Clinical Findings
Young adult males
Effects mostly the sacroiliac jt
Aortic insufficency
X-ray Findings
Multiple ensopathies
Fibular deviation of MPJs
Joint space narrowing
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Labs
ESR - increase
HLA-B27 - positive
Connective Tissue Disease

SLE
Clinical Findings
Young women
Butterfly rash
Photosensitivity
Nephritis
Pericarditis
Arthritis of small joints
Raynauds phenomenon
Lab Tests
ESR – increased
ANA – positive
Anti-dsDNA
RA-Factor
Scleroderma

Clinical Findings
Middle age woman
Thickening and tightening of
skin, beginning in hands/face
CREST
Calcifications in skin
Raynauds
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Esophageal dysfunction
Sclerodactylyl
Telangiectasia
Lab Tests
ANA - positive
RA-Factor
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Hematology
RBC Disoders
Iron Def (most common)
Symptoms
Hypochromia, small RBCs
GI blood loss (in males)
Thalassemias
Etiology - diminished synthesis of globin chain
Symptoms: Hypochromia, small RBC’s
Types: Alpha – seen in asian people high Barts Hb
Beta: Major - Severe (seen in peds), Transfusion dependent
Minor – mild, seen in Mediterranean decent
Macrocytic Anemias
B12 Def. – only anemia w/ neuro
Folic Acid Def – seen in EtOH
Normal Anemias
Aplastic Anemia
BM Dz - pancytopenia

CRF - decreases EPO
Extrinsic Hemolytic Anemia
Auto-Ab
Malaria
Prosthetic valves
DIC
Liver dz
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Intrinsic Hemolytic Anemia
Hereditary Spherocytosis
Small, round, hyperchromic
RBCs, w/ central Pallor
Sickle Cell
High bilirubin, LDH
Gallstone Dz
Sickle cell crises
CVA, Splenic infarction
Salmonella, OM
Normal Microcytic Macrocytic Hypochormic Hyperchromic

Iron Def X X
Thalassemia X X
B12 Def X
Folic Acid Def X
Aplastic (BM Dz) X
Extrinsic X
Sperocytosis (Intrinsic) X X
Sickle Cell (Intrinsic) X
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WBC Disorders
Lympho-Leukemia's
CLL
seen in adults
mature lymphocytes
ALL
seen in children
B cell line = blast forms
Myelogenous Leukemia's
CML
Basophilia, Neutrophilia
Splenomegaly
Philly chromosome
AML
Neutropenia
Splenomegaly
Thrombocytopenia
Blast form cell lines
Lymphomas
Hodgkins (Eosinophilia)

Non-Hodgkins
Disorders of Coags
Platelet Dysfunction
ASA– inhibits TXA
Plavix – inhibits ADP binding
Indomethacin
Von Willebrands - factor 8 def.
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Hereditary Disorders
Hemophilia A
Factor 8 def.
PTT abnormal
Seen only in men
Hemophilia B (X-mas Dz)
Factor 9 def.
Vit K Def
Seen in liver failure
Malabsorption
Prolonged PT
DIC
Activation of intrinsic pathway by endothelial damage secondary to
other diseases
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Cardiology
Heart Sounds
S1 - AV valves closure
S2 - Semi-lunar valves closure
S3 - CHF, Mitral Regurg
S4 - HTN, Aortic Stenosis
CHF
Etiology (of Left, Right side failure)
Systolic Dysfunc. (dec. contract)
MI - causes decreased contract.
Valvular HD - stenosis
HTN
Diastolic dysfunction (dec. relax)
the above or COPD causes pressure/volume overload in the ventricles

Cardiac Hypertrophy
increases stiffness of cardiac muscle
impairs relaxation of ventricle

Clinical Features
Nocturia, Edema, JVD
Tachy, S3 (LSF), S4 heart sound,
Dx – CXR (cardiomegly), EF <55
Treatment
Left Sided Failure
Digoxin – increases contractility via (-) of K-ATPase pump
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ACE (-) – reduces afterload via vasodilation
Diuretics – reduces preload via (-) of tubular abosorption of Na+H20
Right Sided Failure
B-Blocker – only used to prevent cardiac hypertrophy and diastolic failure
Diuretics – for pulmonary edema
CAD
Risk Factors
Age - >50
Gender – males>females
Serum Chol. <200mg/dl
LDL - <130mg/dl
HDL - >40mg/dl
Smoking, HTN, DM
Obesity (20% over normal BW)
Angina (myocardial ischemia)
Stable Angina – gradual pain w/ exertion lasting <15 min
Unstable Angina – pain at rest, or worsening pain
Prinzmetals Angina – pain due to transient coronary spasm
Tx – nitrates, Beta/Ca-blockers

Myocardial Infarct
Clinical Findings
Crushing CP
*if w/ movement, consider musculoskeletal problem Costochondroditis
Radiates to left arm, jaw, neck
S4, atrial gallop
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EKG Diagnosis
Transmural MI
ST elevation (>1mm in 2 leads)
Q-waves
Inverted T-waves
R-waves
Subendocardial Infarction
ST depression
Cardiac Enzymes
CK elevation at 6 hours
CPK-MB (gold standard)
AST – at 12 hours
LDH – at 24 hours
Troponins – min after attack
Order 3 sets Q8
Location of MI
Inf MI – RCAD, AV node block
Ant MI – ADCAD, R or L or complete heart block
Pt's with CAD need to be on....
B-blockers
Statins

Plavix/ASA
Ace (-)
Valvular HD (Mitral mostly)
Systolic Murmer Diastolic Murmer

A. Stenosis X (Harsh)
M. Stenosis Snap X
A. Regurg X
M. Regurg X (Thrill)
T. Regurg X (w/ Inspiration)
Ductus. A X X
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Aortic Stenosis
Etiology – calcification of valves
Dx - harsh systolic ejection murm.
Mitral Stenosis
Etiology – second to rheum. HD
Dx - open snap, diastolic rumble
Aortic Regurg
Etiology – HTN, Marfan
Dx - blowing diastolic murmer
Mitral Regurg
Etiology – MVP, ruptured chordae
Dx – holosystolic murmur w/thrill
Tricuspid Regurg
Etiology – IV drug users, RVF
Dx - holosystolic murmur, increasing with inspiration
Patent Ductus Arteriosus
Etiology - Congenital
Dx- continuous "machine murmer"
Rheumatic HD
Dx - anti-streptolysin O-titers
Endocarditis

Osler Nodes
Small tender nodules
Located on palms/soles
Janeway Lesions
Flat, blueish/reddish lesions
Located on palms/soles
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Syncope
Types
Vasovagal – cause by stress/pain
Orthostatic HOTN
Prodrome (pre-symptoms) - Tachy
Unconscousness – Brady
Treatment
Lay patient flat
Ammonia smells
Don’t let patient stand up for 30 min afterwards
Anaphylaxis
Pathogenesis
Antigen (PCN most common)
(+) IgE’s on Mast cells & Basophils
Release Histamines, and Leukotrienes
Angioedema (upper resp)
Bronchospasm (lower resp)
Urticaria, pruritus
*must be previously sensitized*

Treatment
Epi - 0.5ml of 1:1000 (0.5mg)
Benadryl – 50mg
If patient is on B-blockers and Epi doesn’t work try N-Epi
Cortical Steroid is last line of defense
Anaphylactoid Rxn
Similar to anaphylaxis
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Direct release of mediators w/o prior exposure
Not immune mediated
HTN
Levels
Mild – DS 90-105
Mod – DS 105-115
Severe – DS >115
Effects - Brain, Heart, Kidneys
HTN-encephalopathy can cause papilledema
Treatment
NA-Nitroprusside for rapid BP control
Labetalol
Shock
Types
Hypovolemic (most common)
Tx w/ Fluids
Anaphylactic
Cardiogenic
Septic – G (-) infxn (endotoxins)

Neurogenic
Stages
1 – Compensated HOTN
2 – Signs of renal, cerebral, myocardial insufficiency
3 – Permanent tissue damage from lack of O2
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History & Physical

CC - 76yo DM male ptc w/foot ulcer
HPI
Where is it located?
How and when did this happen?
Has it been getting worse?
Have you or anyone else been
treating this?
On a scale from 1-10, pain level?
Has it been draining?what color?
Have you had any f/c/ns?
What has your BS been running?
Have a h/o foot infxn?
When was the last time you ate?
When was your last tetanus shot?
PMH
Do u have any medical conditions?
Are your immunization up to date?
PSH

Have u ever had Sx?
Have u ever been in the Hospital?
Meds
What medications are u taking?
ALL
Are you allergic to any meds?
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Ever taken PCN?
Ever eaten shellfish?
Are you allergic to latex?
FH
Anyone have DM, HTN, Stroke?
Parents still living? died? how?
SH
Smoke tobacco? Drink EtOH?
Use recreational drugs?
Who do you live with?
ROS
HEENT
Wear contact/eyeglasses?
Have blurry/double vision?
Ringing in ears/hearing loss?
Any dizzyness?
Have any running/nose bleeds?
Been coughing/sore throat?
Resp

Been coughing up blood?
Any SOB? while sleeping?
CV
Have any CP/Palpatations?
GI
Any N/V/D?
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Been constipated?
Any blood in Stool?
GU
Any blood in urine?
Difficulty urinating?
Skin
Experience any itching/rashes?
Musculosketletal
Have any jt stiffness?
Any muscle weakness?
PE
Vitals - Temp, HR, RR, BP
General - NAD, AAOx3
Head - NCAT
Eyes - PERRLA, EOM intact
ENT - clear, (-) drainage, exudate
Neck
(-) JVD, (-) carotid bruits
NT/NP lymph nodes

Lungs - CTA, (-)WRR
CV- RRR, (-) MGRC, (+) S1,S2
GI - Soft ND,NT (+) BS
Neuro - CN 2-12, DTR intact
LEPE
Vasc
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Pulses, CFT, (+) pedal hair
TG WNL b/l
Neuro
Sensation intact SWMF 5.07
Vibratory intact
Light touch/sharp/dull intact
Derm - "DDMBDOC"
Periwound edema/erythema?
Webspaces?
Toenails?
Ortho
Bony prominences?
MMT 5/5 for p/f, d/f, in/ev
Foot type?
Labs
CBC w/Diff
CMP, BMP
CRP, ESR
HbA1C

UA
Studies
C&S
X-rays
Ultrasound
ABI/PVRs
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Venous Dopplers
A/P
76 y/o DM male w/ sub-met 1 ulcer
- sharp debridement
- wound dressed WTD, DSD
- xrays, Cx pending
- continue IV Abx
- will continue to follow
History & Physical

CC:
HPI: (Age) y/o (Sex) w/ (PMH) p/w (CC). Location, How/When?, Worsening?,
Seeing a Podiatrist? / You Treating This? Pain Level / Type of Pain, Any drainage
noted?, Recent BS?, h/o Foot Infxn? Last Tetanus Shot?, Last Meal?, F/C/NS?
PMH/PSH: SH:
Meds/ALL: FH:

ROS: HEENT: ( )Dizziness, ( )Headaches, ( )Blurry Vision, ( )Runny Nose,
( )Sore throat/Congestion
Resp: ( ) SOB, ( ) Blood in Sputum
CV: ( ) CP, ( ) Palps
GI: ( ) N / V / D, ( ) Constipation, ( ) Blood in Stool
GU: ( ) Dysuria, ( ) Hematuria
Vitals: Temp (max/current), Pulse, Resp, BP
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Labs : CBC, ESR, CRP, BMP, UA, Co-Ags
X-rays: Results/Pending
CXR/EKG: Results/Pending
PE: GEN: NAD, OAAx3
HEENT: NCAT, PERRLA, EOMI, Tympanic Membrane Intact, (-) drainage
Patent nares, Throat clear, (-) adenopathy
Neck: (-) JVD, (-) Carotid Bruits, NP-Lymphnodes
Resp: CTA B/L, (-) W / R / R
CV: RSR, (+) S1, S2, (-) M / R / G
GI: S/NT/ND, (+) BSx4
LEPE: Vasc: PT/DP Pulse (Palpable/Non-Palpable), CFT (Brisk/Sluggish),
(+/-) Pedal Hair, TG WNL
Neuro: Protective Sensation Intact SWMF 5.07. Sharp/Dull Sensation Intact
Ortho: No gross foot deformities. MMT intact.
Derm: Location, Size, Depth (Tracking/Probe to Bone), Base (Granular/
Fibrogranular/Fibrous/Fibronecrotic/Nectrotic), Drainage (Serous/
Serosanguous/Sanguous/Purulent), Wound Edges (Undermine/
Macerated/Necrotic/Healthy), Periwound (Erythema/Edema),
Maloder?, Flucutance?

AP: (CC)
Admit under service of Dr. (DPM)
Bedside Debridement/Wound Cx’s Taken/LWC
X-rays results appreciated
Pt started on IV (ABX)
(CBC / CMP / ESR / Co-Ag’s / UA / Blood Cx) ordered
(X-rays / Bone Scan / MRI / Non-Invasive Vasc Studies) ordered
Dr. (MD) of (Specialty) consulted.
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Podiatry Admitting Note

HPI: (Age) y/o (Sex) w/ (PMH) p/w (CC). Location, How/When?, Worsening?,
Seeing a Podiatrist? / You Treating This? Pain Level / Type of Pain,
Any drainage noted?, Recent BS?, h/o Foot Infxn? Last Tetanus Shot?,
Last Meal?, F/C/NS?
Labs : CBC, ESR, CRP, BMP
X-rays: Results/Pending
LEPE: Vasc: PT/DP Pulse (Palpable/Non-Palpable), CFT (Brisk/Sluggish), (+/-)

Pedal
Hair, TG WNL
Neuro: Protective Sensation Intact SWMF 5.07. Sharp/Dull Sensation Intact
Ortho: No gross foot deformities. MMT intact.
Derm: Location, Size, Depth (Tracking/Probe to Bone), Base (Granular/
Fibrogranular/Fibrous/Fibronecrotic/Nectrotic), Drainage (Serous/
Serosanguous/Sanguous/Purulent), Wound Edges (Undermine/Macerated
/Necrotic/Healthy), Periwound (Erythema/Edema), Maloder?,
Flucutance?
AP: (CC)
Admit under service of Dr. (DPM)
X-rays results appreciated
Pt started on IV (ABX)
(CBC / CMP / ESR / Co-Ag’s / UA / Blood Cx) ordered

(X-rays / Bone Scan / MRI / Non-Invasive Vasc Studies) ordered
Dr. (MD) of (Specialty) consulted.
Admit Orders (ADC VANDILMAX)

Admit to ….
ALL
Dx
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Condition
Vitals per protocal
Activity– WB Status, BRP
Nursing – ICE/Elevation, Accuchecks, Reinforce Bandages, Foley
Diet – Reg, 2000-ADA, 2g NA, 3g K
IVF - heplock
Labs
Meds: RISS – accucheck qac & qhs
150-200 – 2 units
201-250 – 4 units
251-300 – 6 units
301-350 – 8 units
351-400 – 10 units
< 65 or > 400 call MD
Ancillary - PT, noninvasive studies
X-rays
Sx Pre-op Note
HPI: (Age) y/o (Sex) w/ h/o (PMH) p/w (CC). Pt receiving IV (ABX) and LWC in the
form of (……). Due to (worsening/non-healing) condition of (CC), Sx intervention

is needed at this time. A/R/C have been d/w pt. Pt opts for Sx Management as per
Dr. (DPM).
Labs : CBC, BMP, Co-Ags
Wound Cx:
EKG/CXR:
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Dx Studies:
UPT: for Females
PE: Location, Size, Depth (Tracking/Probe to Bone), Base(Granular/Fibrogranular

/Fibrous/Fibronecrotic/Nectrotic), Drainage (Serous/Serosanguous/Sanguous
/Purulent), Wound Edges (Undermine/Macerated Necrotic/Healthy), Periwound
(Erythema/Edema), Maloder?, Flucutance?
AP: (CC)
Pt planned to OR for (Procedure) under (Anesthesia)
Pt to be NPO after (midnight/breakfast), IVF ordered
(Anticoagulants), (Blood Thinners), (Oral Hyperglycemics) Held
Risks, Benefits, Complications reviewed. All ?’s answered
(Medical/Cardiac) clearance as per Dr. (MD)
Consent to be signed in OR Holding
Pre-Op Orders
- Pt to OR on (date) for (Sx type)
- Diet
- NPO for at least 8 hrs
- Accu-chek BS Q4 while NPO
- IVF

- Healthy Pts: NS or LR @100ml/h
- DM Pts (order both)
D5W 1/2 NS @70ml/h, BS<200
1/2 NS @70ml/h, BS>200
- Renal/CHF pts: rate to 30ml/h
- Operative consent to be signed in OR holding or in chart
- Pt may take AM po meds with sips of water
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- Hold ASA, Plavix, Lovenox, Pletal, Heparin, Coumadin, Oral Hypoglycemics
- Contact Dr.....for medicalclearance
- If Hb <10 order Type and Cross
- If Hb <8 transfuse, place PRBC on hold
- Order and pertinent labs/studies
Sx Procedure Note (SAPPPA HEMI CC F)

Surgeon
Assistants
Pre-operative Dx
Post-operative Dx
Procedure
Pathology
Anesthesia
Hemostasis
EBL
Materials
Injectables

Complications
Condition
Findings
“Pt tolerated procedure and anesthesia w/o complications and with vital signs
remaining stable throughout the procedure. Pt transported from OR to RR with
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vascular status intact to (R/L) LE, escorted by member of anesthesia dept and
podiatric sx resident”
Post-Op Orders (Same Day)

Vitals per Protocol
WB status w/ Sx Shoe/Crutches
ICE/Elevation
Resume Reg. Diet
D/C IV when pt tolerates PO
Dispense Sx Shoe/Crutches
X-rays
Discharge Orders (Same Day)

D/C Pt home when stable
Pt to keep dressing C/D/I
WB status
Rx for Pain Meds/ABX w/ patient
Pt to f/u w/ Dr. in 1 week
Pt to call if any problems

In Patient Progress Note
Pt seen at bedside in NAD. Pt denies F / C / NS / NVD / CP / SOB / Calf Tenderness.
Pt (reports/complains of) ________________________.
Labs: CBC, BMP, ESR, CRP
Wound Cx :
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Studies:
PE: Location, Size, Depth (Tracking/Probe to Bone), Base (Granular/Fibrogranular/
Fibrous/Fibronecrotic/Nectrotic), Drainage (Serous/Serosanguous/Sanguous/
Purulent), Wound Edges (Undermine/Macerated/Necrotic/Healthy), Periwound
(Erythema/Edema), Maloder?, Flucutance?
AP: (CC)
Condition (improving/stable/worsening)
Wound Cx/Bone Path/X-rays/Bone Scan/MRI results (Awaiting/Appreciated)
Vascular/Infectious Dz Note/Consult appreciated
Continue IV (ABX) (as per ID)
Will (d/w attending / follow closely / plan for possible OR / plan possible D/C)
Vac Progress Note

Pt seen at bedside in NAD. Pt denies F / C / NS / NVD / CP / SOB / Calf Tenderness.
Pt (reports/complains of) ________________________.
Labs: CBC, BMP, ESR, CRP
Wound Cx :
Studies:
PE: Wound Vac at bedside set to (continous/intermittent) mode @ (125/150)mmHg.
~ (#)cc of (Sangous/Serosangous/Serous/Purulent) drainage in the container
Bandages are C/D/I w/ no ST. (-) Cellulitis above bandages.

AP: (CC)
Continue Vac at current settings, Next Vac change on (Date)
Wound Cx/Bone Path/X-rays/Bone Scan/MRI results (Awaiting/Appreciated)
Vascular/Infectious Dz Note/Consult appreciated
Continue IV (ABX) (as per ID)
Will (d/w attending / follow closely / plan for possible OR / plan possible D/C)
Discharge Summary
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Pt’s name
Medical record #
Physician
Admit date
Discharge date
Date of Sx
Admitting Dx
Discharge Dx
Procedures
History, Physical Exam
Coarse of Tx
Discharge condition
Medications
D/C instructions
Follow-up
Labs
CBC w/diff

WBC (4,000-11,000)
Low - viral infxn, super-infxn
High
Bacterial infxn
Inflammatory dz
Stress
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Lymphocytosis: Viral, CLL, ALL, chronic infx
Lymphopenia: AIDS, hodgkins, acute infxns
Monocytosis: TB, Endocarditis, collagen dz
Neutrophilia
Right Shift (segs 50-65)
Chronic infxn
Liver Dz
Tumor, CML
Left Shift (bands 0-5)
Acute infxn
Neutropenia: Viral infxn, ALL, AML
Basophilia - CML
Eosinophilia: Hodgkins, Addisons, Parasitic infection
Hemoglobin (13-17)
Hematocrit (38-50)
RBC Indices
MCHC
High - Spherocytosis
Low - Fe-def., thalassemia

MCV
Low: Fe-def., thalassemia, Pb-poisoning
High: Folate Def, Vit B12 Def, Liver Dz
Platelets (150,000-450,000)
<25,000 = bleeding
Bleeding Time
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von Willebrand Dz/DIC
ASA/NSAIDs/Plavix
PT/INR (3,7)
Vit K def.
Liver Dz
Coumadin
PTT (8,9,11,12) "Dec, 11th, 1998"
Hemophilia A,B
von Willebrans/DIC
Liver Dz
Heparin
Chem 7
Na (135-150)
High - Cushings, CHF
Low - Addisons
K (3-5)
High - Addisons, ARF, CRF
Low - Diuretics
Cl (95-110)

High - dehydration
Low -ulcerative colitis
HCO3 (20-30)
BUN (10-20)
High - renal dz
Low - liver dz
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Crt (0.5-1.5)
High - renal dz
Glu (60-120)
High - DM, Cushings, Pancreatitis
Low - Liver dz, Addisons
Ca (8.5-10)
High
Hyper-PTH, Hyper-Vit D
Multiple myeloma, Bone tumor
Immobilization
Low
Hypo-PTH, Vit D Def
Renal failure
PO3 (3-4.5)
High - Renal Dz, Hypo-PTH
Low - DM, Hyper-PTH
Alk-Phos (30-85)
High: Liver dz, bone dz, hyper-PTH
Low: Hypo-thyroid, scurvy

Liver/Renal/Heart Labs
Albumin
Low - Liver Dz, Nephrosis
Billirubin
High - Liver dz, hemolytic anemia
Cholesterol
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High - DM, hypo-thyroid
MI Enzyme's
SGOT(AST) - 6-12 hrs
CPK - 12-24 hrs
LDH - 48 hrs
Uric Acid (1.5-7)
Renal dz, Gout, Leukemia, EtOH
Urinalysis
Sepcific Gravity - [ ] of urine
Increased in Diabetes Insipidus
Decreased in DM, Vol. Depletion
Color - Yellow, Clear
Ammonia smell
Sweet - DKA
Putrid - infxn
Maple Syrup
No gluc, ketones, blood, protein, NO3
Blood
RBC (hematuria)

UTI, Endocarditis
Severe HTN/smoking
Free Hb (hemoglobinuria)
Trauma
Glomerulonephritis
Myoglobinuria
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Muscle injury/dystrophies
Electric shock
Protien (albumin)
Nephritis/glomerulonephritis
Nephrosis
Polycystic Kidney
Hyperthyriodism
Bence Jones = multiple myloma
Urubillinogen
Hepatitis
Hemolytic/pernicious anemia
Casts
Hyaline - normal
RBC -glomerulonephritis
WBC – pyelonephritis (infxn of ureters Kidney)
Epithelial - tubular casts
Fatty - any nephritis
pH – 5-7.5
Acidic

High protein Diet
Starvation
DM, COPD
Basic
UTI
(+) Infxn = nitrites & leukocytes
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Kenny’s reviews
Inflammatory Labs
ESR/CRP
CRP is better test as it increases and decreases sooner
ANA/RA-factor positive
SLE/Scleroderma/Sjogrens
RA
Anti-ds DNA – SLE
HLA-B27
Ankylosing spondylitis
Psoriatic arthritis
Reiters syndrome
Infxn Dz Labs
Hb1AC – normal is less than 7
ELISA – HIV test
VDRL/RPR – syphilis
Vanco Peak and Trough
Pk - 20-40 (adjust dose)

Tr - <10 (adjust freq)
Antibiotics
Z-pak (250) 500 QD
Levaquin 500 QD
Cipro 500 BID
Duricef (1st) 500 BID
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Flagyl 500 TID
Aug 500 (875) TID (BID)
Keflex (1st) 500 QID
Clinda 300 TID
Omnicef (3rd) 300 BID
Doxy 100 BID
Bactrim 800/160 BID
Zyvoxx 600 BID
Ancef (1st) 1g Q8
Primaxin 1g Q8
Vanco 1g Q12
Cefepime (4th) 1g Q12
Aztreonam 1g Q12
Invanz 1g Q24
Rocephin (3rd) 1g Q24
Dapto 4mg/kg Q24
Cipro 400 Q12
Clinda 600 Q8
Unasyn (1.5) 3g Q8

Zosyn (2.25)3.375g(4.5) Q8
Antifungals
Sporonox
100mg BID
12 weeks
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CI – Lipid lowering agents
Lamisel
250mg QD
12 weeks
CI – TCA’s, SSRI & Rifampin
Gris-Peg (kills only dermatophytes)
750mg QD
24 weeks
Pain Meds
Demerol (mep) 50 Q4 IM
Dilaudid (hydro) 1mg Q4 IM
Percocet (oxy) 5/325 Q4-6 1-2(T)
Vicoden (hydro) 5/500 Q4-6 1-2(T)
Tyenol 3 (code) 30/300 Q4-6 1-2(T)
Darvocet (pro) 50/325 Q4-6 1-2(T)
Ultram (tram) 50/325 Q6-8
Toradal (nsaid) 30mg Q6 IV x3days
NSAIDS

Naprosyn 500 BID
Lodine XL 500 QD
Relafin 500 QD 2(T)
Daypro 600 QD 2(T)
Voltarin 50 BID
Indocin 50 TID
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Celebrex 200 QD
Anticoagulants
Lovenox (LowMW-Hep)
40mg Daily (Prophylaxis)
1mg/kg (Therapeutic)
Moniter – nothing to monitor
Heparin Prophylaxis
5000u BID SQ
Intrinsic Pathway
Moniter - PTT
Heparin for DVT
10,000u(bolus) IV......then 1000u QH IV
Coumadin (warfarin)
5mg QD PO
Extrinsic Pathway
Moniter PT/INR
Plavix
75mg QD PO
Inhibits platelet aggregation

ASA
81mg QD PO
Inhibits platelet aggregation
Pletal
100 mg BID - vasodilator
Local Anesthetics
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Multiply % by 10 = __ mg/cc
Then multiply # cc’s injected
Ex: 15cc of 1% Lidocaine = 150mg
15cc of 0.5% Marcaine = 75mg
Lidocaine 1%
1cc = 10mg
Max = 300mg, or 30cc
Lidocaine 2%
1cc = 20mg
Marcaine 0.25%
1cc = 2.5mg
Marcaine 0.5%
1cc = 5mg
Sedatives
Xanax 0.5mg PO Short-life
Ativan 1mg PO Med-life

Valium 5mg IV/PO Long-life
Ambien 5mg QHS
DM-Neuropathic Drugs
Neurontin 300 QHS
Lyrica 75 BID
Amitryptiline 10 QHS
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Antiemetics
Zofran 4mg Q6
Tetanus Prophylaxis
Clean Wound:
Unknown Hx or No booster w/in 10 yrs or < 3 doses Tetanus Toxoid
Dirty Wound:
Unknown Hx or < 3 doses Tetanus Toxoid + Ig
No booster w/in 5 years Tetanus Toxoid
Emergency Meds
Nalaxone (1mg Q2 min IM/IV)
Give for narcotic overdoes
Can't give too much
Acetycysteine (70mg/kg Q4 PO)
Give for Tyenol overdose
Atropine (1mg IV)
Give for bradycardia
Ethanol
Give for antifreeze/methanol OD
Protamine Sulfate (1mg IV)

Give for heparin OD
Vit K (10mg PO)
Give for warfarin OD
Physostigmine (1mg IV/IM)
Give for anticholinergic OD
Tricylic Anti-depressants OD
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Flumanzenil (0.2mg Qmin)
Give for Benzodiazepine OD
May induce seizures w/ pts taking TCA's
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Tumors and Cancer

Synovial Chorndomatosis
Metaplasia of synovial tissue --> intra-articular loose bodies
Metastic Lung CA
Tumors below the knees
Periungual Fibromas
Tuberous sclerosis
Basal Cell
“rodent ulcer”
most common cancer in men
Bowens Dz
squamous cell carcinoma in situ
Acral lentiginous Melanoma
seen in blacks
mostly on soles of feet
Nodular Melanoma
Most aggressive
Superficial spreading melanoma

Most common
Classifications for Melanoma
Breslows and Clarks
Fibrosarcoma
more common in LE than UE
Glomus Tumor – “popoff tumor”
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Neurology
Back Pain
Cauda Equina: symptoms include urinary retention
Vertebral Mets: pain worse at night
Anatomy
Brachial Plexus Anatomy
Robert - roots
Taylor - trunks
Drinks - divisions
Cold - chords
Beer - branches
Blocks
Popliteal
7cm proximal to crease
1cm lateral
Saphenous (at knee)

Just distal/ant to med condyle
Neurological Exam
Motor Exam
Grading (0-5)
5 – normal
4 - weakness
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3 – against gravity only
2 - gravity eliminated
1 – slight contractures, no ROM
Nerve Roots
L2,L3 – Adductors and Quads
L4 – TA
L5 – Extensors
S1 – Flexors and Peroneals
S2,S3 – Intrinsics
Spinal Lesions
L5,S1 - mimic shin splints
S1 - can't walk on toes
L5 - can't walk on heels
Sensory Exam
Anterior Tracts – Light touch
Post Columns – Propioception, Vibration
Lateral Tracts – Sharp/Dull
Reflex Exam (grading 0-4)
Patellar – L4

Achilles – S1
Babinski – UMN dysfunction w/ d/f of hallux
UMN vs LMN
UMN
Dysfunctional Dec. Cortical Tracts
Extensors > Flexors
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Hyperreflexia
LMN
Dysfunctional motor unit nerves
Muscle atrophy, hyporeflexia
Neurological Dz’s
Siezures
Generalized (both hemispheres)
CF - sudden loss of consciousness
Grand mal - convulsive
Tx - Phenytoin
Abscence - minor twitching
Tx - Ethosuximide
*Valproic Acid for both types*
Partial (discrete areas of brain)
CF - impaired motor/sensory
Complex-partial
CF - impaired awareness/hallucination
Status Epilepticus
May involve both types

30 min long Generalized-Tonic-Colonic siezure
Tx - Valium
Headaches
Migraines
Etiology
Bright lights
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Foods w/ nitrates
Stress
CMT (Peroneal M. Atrophy)
White Females
Cavus foot type
Steppage/Equinus Gait
PL > TA = p/f medial column
TP > PB > FDL > EDL= clawtoes
Freidrichs Ataxia
Post/Lat Column dysfunction
Late childhood
Nystagmus
Ext/Peroneal muscle weakness
Syringomyelia
Cavitation of SC
LMN, UMN (facial) symptoms
Cerebral Palsey

Spastic, Dyskinetic, Equinus Gait
Muscle contractures
Duchenne’s Muscle Dystrophy

Psuedohypertrophy of calf Fat deposits in muscle
Gower’s Sign – push themselves erect by moving their hands up their thighs.
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Waddling, Equinus Gait
Becker’s – less severe form of Dz
Myasthenia Gravis
Ab's against Ach receptors on muscle
Young women
Thyoma, dysphagia/phalgia
Muscle weakness
Parkinson’s
Rigidity
Fenistrating Gait
Resting tremor
Bradykinesia (slow movements)
"pill rolling"
Multiple Sclerosis
Demyelinating disorder
Middle-age females
LE-spasticity
Ataxic Gait
Optic Neuritis - most common

Charcot triad
Nystagmus
Intention tremor
Scanning speech
Hot weather makes conditions worse
Lhermitte Sign
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Flexion on neck causes pain to radiate down back
Also seen in RA, Ankylosing spondylitis
Guillain-Barre Syndrome
Preceded by infection
CMV, HIV, Hepatitis
C. jejuni, M. pneumoniae
Assoc. w/ SLE, Lymphomas
Steppage Gait
Motor/Sensory weakness distal to proximal, to total paralysis
Dx - elevated CSF protein
No DTRs
ALS
Degeneration of UMN and LMN
Spasticity of muscle groups (begins in hands)
Wasting and weakness
Peripheral Neuropathy
DM/Alcholic/HIV
Hypo-thyroid/B12 Deficiency
Guillian Barre/CMT/Freidrichs

Nerve entrapment
RSD/ CRPS
Clinical Findings
Persistent severe burning pain in all stages
Usually post-traumatic
Middle age Females, psychiatric pts
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Can lead to muscle atrophy & loss of function
Stages
Stage I
Hot, red, swollen limb
Bone scan shows increase uptake in joints
Stage II
Cool, pale limb
X-rays show diffuse osteopenia (5-6 weeks to develop)
Stage III
Pain decreases somewhat
Tightly stretched skin
Treatment
Meds – Steroids, TCA’s
PT – massage, US, ROM, TENS
Nerve blocks
Beir block – local given into veins of tourniquet leg
Vit B12 Def
Demyelination, axonal degenerates
Post, Lat. SC Demyelination

Decrease position/vib. sense
UMN signs
Meningitis
Findings
Brudzinski Sign: Neck flexion = Knee flexion
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Kernigs Sign: Extension of knees w/ passive resistance
N. Meningitis: palpable pupura on lower legs
Nerve Injuries
Seddon Classification
Neuropraxia – bruised nerve
Axonotmesis – bruised axon (Wallerian degeneration)
Neurotmesis – severed nerve (irreversible)
Tarsal Tunnel
Etiology
Pes Planus
Varicosities
STM
Inflammation
Trauma
Laciate Ligment
Medial Planter N
Lateral Planter N

Medial Calcaneal N
Tinel Sign – distal shooting pain
Valleix Sign – prox. shooting pain
Dx
EMG
Assesses electrical signal by muscle fibers
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Movement potentials should be roughly proportional
Denervation results in fasiculations at rest and w/ potentials increasing
in duration and amplitude, but decrease in freq.
NCV
Used to d/t myelin sheath or axonal disorder
Measures Latency of nerve
Normal > 40mq
Common Peroneal N. Palsy
Clinical Findings – Drop Foot
“Saturday Night Palsy”
Compression of Nerve from Bar Stool
Nueroma
Mortons
3rd interspace
Middle age females
Mulders Sign – silent palpable click
Joplins – involves medial plantar digital proper nerve

Controlled Substances
Class 1
Heroin, LSD, Marijuana
No medical use
Class 2
Morphine, Oxycodone, Cociane
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Rx can't be called in (only fax’d)
No-refills
Class 3
Codiene, Hydrocodone
Refills x5 in 6 mos
Class 4
BZDP's, Darvon, Ultram
Rx required
Class 5
Over the counter meds
NSAID's
ASA
DOC - for RA
SE
Prolongs bleeding time
Reyes Syndrome - in peds w/viral infxn
CI
Gout (inhibits uric secreton)
Coumadin

Ibuprofen
2400mg per day max dose
Celebrex
Not CI in pts w/ GI or on anti-coagulant meds
CI - Sulfa ALL
Hematological Agents
Pletal
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Dose - 100mg PO BID
Tx - vasodilates vessels, indicated for claudication
Alteplace (tPA)
Thrombolytic w/ sortest 1/2 life
Activates plasmin
Beware of strokes (bleeding)
Steroids
Topical's
Mild - 2.5% Hydrocortisone
Mod - Cutivate, Kenalog
Potent - Topicort
Super - Ultravate, Temovate
Oral Steriods
Methylprednisone
Medrol Dosepack
Start at 24mg, reduce to
0mg at end of 7 days
Solu-Medrol (IV steriod)
10-100mg
Prednisone - 1mg/kg

Used for long term use
Must be weaned off steroids to prevent Addison's
Injectable's
Types
Phophates (short acting)
Celestone-Phos
Dex-Phos
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Acetates (long acting)
Kenalog
Celestone Soluspan
Joint Injections
No more than 15mg
Acetates only used for severe DJD
Diuretics
MoA - Increase NaCl secretion
Tx - CHF, HTN, Edema
Tiazides's (HCTZ)
Hypo-K
Hyper-Uric Acid
Loop Diuretics (Furosemide)
Hypo-K
Hyper-Uric Acid
K-Sparer's (Spironolactone)
Weaker diuretic
Hyper-K, Uric Acid
ACE Inhibitors (prils)
MoA -
(-) Angiotensin formation

Vasodilation & Decrease Aldosterone ....
Increase Na secretion
Decrease BP
Tx - HTN, CHF
Drugs: Enalapril, Monopril, Lisinopril
Ca-Channel Blockers
MoA
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(-) Ca in vascular SM
Coronary A. vasodilation
Tx - Angina, HTN
Drugs
Amiodipine (Norvasc)
Dilitiazem
Nifedipine
Verapamil
Misc
Lactulose
Stool softner
Used to reduce NH4 levels in blood from liver damage
Polyethlene Glycol
Used for bowel cleansing prior to colonoscopy
Colace
Reglan
Metamucil
Milk of Magnesia
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Physical therapy
Heat
Whirlpool
Settings
45 Deg. C. (113 F)
15-30 minutes
Indications
Chronic post-trauma
Nerve Injuries
Stumps
DQ-Ulcers (w/ no bone)
Arthritis
Contrast Baths
Settings
Both hot and cold
Feet are placed alternately every 1 min
Always start cold, end cold

Goal – Hunting effect (reflex hyperemia)
Indications
Stimulating circulation
Muscle fatigue
Edema
RSD
Paraffin Wax
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Settings
Dip foot 6-10x for 5 seconds
Then wrap in plastic/and towel
Let sit for 20-30 minutes
Indications
Sprains/Strains
Arthritis
Ultrasound (Deep Heat)
Settings
Continuous–thermal/mechanical effects
Pulse – mechanical effects only
Goal - Alter cell permeability
Indications
Scar Tissue
Pain
Edema
CI
Areas w/ emboli
Anesthetized skin

Epiphyseal in Peds
Bony prominences
Vascular Dz’s
Acute Infxn
Impants
Malignancies
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Pacemakers
Diathermy
EM radiation to heat tissues
Goal – heating of tissue w/ high water content
Indications
Muscle and Jt problems
E-Stim
TENS
Goal
High TENS - Blocks pain
Low TENS - endorphin release
Indications
Chronic Pain
Muscle Atrophy/Spasms
Edema
CI
Pacemakers
Pregnancy

Ionotophoresis
Goal
Delivering chem’s, non-invasive
Uses direct current
Indications
Topical Anesthetics
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Anti-inflammatory’s
Muscle relaxants
Phophoresis
Goal
Delivering chem’s, non-invasive
Uses Ultrasound
Strengthening Exercises
Isometric Contraction – static
Isotonic Contraction – dynamic
Eccentric – muscle lengthens (resistance)
Concentric – muscle shortens (lifting)
Isokinetic Contraction
Constant velocity (machine)
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Pulmonology
Labs
<60mmhg PaO2 = hypoxemia
<35mmhg PaCO2 = resp alkalosis caused by hyperventilation
>45mmhg PaCO2 = resp acidosis caused by hypoventilation
COPD
Etiology
Tobacco (most common)
Pollution
Antitrypsin def
Chronic Bronchitis
Clinical Findings
Excessive mucus secretion in the bronchial tree
Productive cough for at least 3 mos, in 2 succesive yrs
Blue Bloaters - Cyanosis, edema, weight gain, chronic cough
VQ mismatch
Emphysema
Clinical Findings

Destruction of alveolar walls
Pink Puffers- Exertional dyspnea, weight loss, no cough
No VQ mismatch
Centrilobular Emphysema Assoc. w/chronic bronchitis in smokers
Panlobular Emphysema Assoc. w/ antitrypsin def.
*Pts w/ COPD on high flow O2 can
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suppress hypoxic ventilatory drive
Asthma
Types
Allergic
Type I mediated
Seen in children
Intrinsic
Occurs in adults
No hypersensitivity rxn’s
Symptons
Coughing/SOB
Chest tightness, wheezing
Labs – low PaCO2
Treatment
Pleural Effusion Total protein > 2.9g/dl
Exudate Total LDH > 250mg/dl
Malignancy
Empyema
Infection

PE
Transudate
CHF
Kidney Dz
Dx (thoracentesis)
Exudate
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Quick facts
Infectious Dz
Pen G – for any farm injury
Unasyn < Na than Zosyn/Timetim
Trauma
10 comparment of foot
- Med, Central, Lat x 3 layers
- Calcaneal
Surgery
Peak-a-Boo Sign
- peaking of medial aspect of heel from anterior view
- used to assess cavus deformity
Coleman Block Test - used to differientiate b/t rigid and flexible cavus
Wait at least 6 months before you take any hardware out
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Mnemonics
Codeine ALL – (STUDD)
- Staydal
- Toradal
- UItram
- Demoral
- Darvocet
Pt is having CP give (MONA)
- Morphine
- Oxygen
- Nitro
- ASA
PCN allergy drugs (CLAVE)
- Clinda
- Levaquin
- Aminglycosides
- Vanco
- Erythromycin
Anti-pseudomonal (FAT CIA)

- Fortaz
- Aztreonam
- Ticarcillin/Timentin/Zosyn
- Cipro/Cefepime
- Invanz/Imipenem
- Aminoglycosides
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Tx Hyper-K (C BIG K Drop)
- Calcium gluconate
- Bicarb
- Insulin
- Glucose
- Kaexylate
- Dialysis
OCD of Talus (DIAL a PIMP)
-D/f & Inversion....Ant-Lat lesion
-P/f & Inversion..Med-Post lesion
Signs of Acute Artial Emboli (5 P's)
- Pain
- Pallor
- Parasethesia
- Paralysis
- Pulseless
DVT etiology (I AM CLOTTTED)
- Immobilzation
- A-Fib

- MI (previous)
- Coagability – Factor V Liden
- Longevity – over age of 65
- Obesity
- Trauma
- Tobacco
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- Tumor
- Estrogen (BCP)
- DVT(previous)– most common
Scleroderma clinical signs (CREST)
- Calcifications in skin
- Raynauds
- Esophageal dysfunction
- Sclerodactyly
- Telangiectasia
Reiters Syndrome
- can't see (conjunctivitis)
- can't pee (urethritis)
- can't climb tree (arthritis)
Blood Transfusion Rxn give "BLT"
- Benadryl
- Lasix
- Tyenol
Percutaneous TAL - "LAMP"
- Lateral-

- Anterior Stab incision
- Medial-
- Posterior Stab incision
Layers of the Skin "California Ladies Give Superb, Backrubs"
S. Corneum
S. Lucidum (only palms/soles)
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S. Granulosum
S. Spinosum
S. Basale
Cranial Nerves
1 - Olfactory Oh Some
2 - Optic Oh Say
3 - Occulomotor Oh Marry
4 - Trochlear To Money
5 - Trigeminal Touch But
6 - Abducens And My
7 - Facial Feel Brother
8 - Vestibulo Virgin Says
9 - Glosso-P Girls Big
10 - Vagus Vagina's Boobs
11 - Accessory Ahhh Matter
12 - Hypo-P Hhhh More
Clinic
DDx for 1st MPJ pain

Synovitis, Capsulitis, OM
OA, Gout, RA
HAV, Hallux Limitus/Rigidus
Fx, Bone contusion, Turf toe
Septic Jt, Sesamoiditis/Fx
Wolf's Law
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bone grows in direction of bone growth
Ainhum
idiopathic vessel constriction of 5th toe resulting in amputation
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Vascular
Venous System
DVT
Virchows Triad (Etiology)
Statsis
Blood vessel trauma
Hypercoagulability
Pre-conditions (IAMCLOTTTED)
Immobilzation
A-Fib
MI (previous)
Coagability – Factor V Liden
Longevity – over age of 65
Obesity
Trauma
Tobacco
Tumor

Estrogen (BCP)
DVT (previous)– most important
Clinical Signs
Pain, Heat, Swelling
Homan’s Test – pain on d/f
Pratt’s Sign – (+) Calf PoP
PE – SOB, CP, Hemoptysis
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Diagnosis for DVT
Doppler – modality of choice
Venography – invasive test
DDx
Cellulitis
Compartment Syndrome
Venous Stasis
Diagnosis for PE
Blood Gas
CXR, EKG
V/Q scan
Pul. A-gram (gold standard)
Prophylaxis
Sub-Q Heparin
Pre-op – 5000u 2hrs before Sx
Post-op – 5000u q12
Compression Stockings
Early ambulation
Treatment

IV Heparin
Heme check stools 1st
Get baseline PTT
10,000u bolus
Maintenance 1000u/hr
Moniter PTT Q8 maintain 1.5-2 above control
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Antidote: Protamine Sulfate
SubQ Heparin
DVT Prophylaxis
5000u BID
Coumadin (warfarin)
Peaks 3-5 days after use therefore start 2 days before d/c’ing heparin
Moniter PT/INR maintain 2-2.5x normal
Antidote = Vitamine K, Fresh Frozen Plasma (FFP)
Lovenox (Low MW Heparin)
40mg IM Daily (prophylaxis)
1mg/kg BID (treatment)
No need to moniter PTT
Superficial Thrombophlebitis
Clinical Signs
Palpable Chord
Pain, edema, eyrthema
Tx – heat, elevation, rest, NSAIDS
Venous Insufficiency
Etiology

HTN, CHF, Renal Dz cause....Valve Incomptency (90%)
Post thrombotic (10%) block flow
Cause....
Destruction of Deep valves
Fluid backs up in Superficial veins
Superficial Venous HTN
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Antegrade flow from superficial veins into skin
Causes.....
Edema, Hemosiderin deposits
Causes Dermatitis, Vasculitis
Leads to ulceration, cellulitis
*Dx b/t Deep/Superficial Venous dysfuct. w/ Trendelenburg mvr*
1-Elevate leg
2-Place tourniquet on thigh
3-Have pt stand
4-Deep problem if veins fill
5-if they don't fill, Sup problem
Treatment
Rest, Elevation
Compression Stockings
Diuretics
Varicose Veins
Etiology
Dilated, tortuous superficial veins
Prolonged standing

Heavy lifting
Pregnancy
Clinical Signs
Itching, edema
Pigmentations
Treatment
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Elastic stockings
Sx excision/laser ablation
Lymphadema
Etiology
Obliteration of lymphatic tissue
Excision
Radiation
Infection
Malignant Mets to L.nodes (secondary lymphadema)
Clinical Sings
Non-pitting
Onset is explosive
Treatment - elevation, compression
Arterial System
PVD
Definitions
Arteriosclerosis: Thick, inelastic arteries

Atherosclerosis: Plaque congested arteries
Monkebergs Dz: Calcification of arteries
Risk Factors
DM- PT, Profunda
HTN, Smoking - SFA, Popliteal
Clinical Signs
Symptoms
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Claudication
Pain on ambulation
Relief w/ 3-5min rest
DDx - Lumbar stenosis - requires 20min rest, worst downhill
Tx
Behavior modification - get pts to push through pain so that
muscles use O2 more efficiently
Medications - Pletol
Rest Pain
Pain at night
Relief brought on by putting leg in dependent position
If relief is brought on by walking then it’s a venous
Gangrene
Physical Exam
Derm
Color
Dependent rubor
Elevation pallor
Temp – decreased

Skin – shiny, scaly, atrophic
Nails – thickened, dystrophic
Hair – absent
Vasc
Edema
Pulses diminished/absent
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Cap Fill Time (>3secs)
Elevation pallor
Dependent rubor
Venous Fill Time (>20 secs)
Elevate leg...lower leg....how long for venous arch to fill
Diagnosis
Serial Pressures
>55mmHg needed in foot
>30mmHg needed in toes
ABI (ankle brachial index)
20mmHG, or 0.15 dec. down ipsilateral leg is considered normal
Values
>1.0……… calcified vessels
1.0 – 0.8 … normal
0.8 - 0.5….. claudication
< 0.5……... rest pain/ulcers
PVR (pulse volume recording)
Nomal – bi-triphasic pattern
PVD – monphasic pattern, Toes are always mono-P

Transcutaneous O2 – < 25mmHg indicates PVD
Artergiogram: Used for revasc. assessment or balloon angioplasty/stent
MRA: Consider in pts w/renal failure
Acute Arterial Occlusion
Types
Embolism – h/o MI, Rheumatic Fever
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Thrombus – h/o claudication
Symptoms (Five P's)
Pain
Pallor
Parasethesia
Paralysis
Pulseless
Treatment
Keep extremity in horizontally
Embolism
<6 hrs – embolectomy
>12 hrs–Anticoag./embolectomy
Thrombus – Streptokinase
Raynaud’s Phenomenon
Vasospasm of digits causing local ischemia
Associated w/ SLE, Scleroderma
Females > Males
Buerger’s Dz (Thombolytis Obliterans)
Inflammatory changes to small & medium vessels caused by smoking

Males > females 20-40yrs
Clinical Signs
Gradual onset, distal-->proximal
Very similar to PVD
Arterial ischemic signs
Claudication in arch
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Hyperhydrosis
Raynauds Phenomenon
HLA-B5
Treatement - Daily walking
Leriches Syndrome
Etiology - aortoioliac dz
Findings
Impotence
Buttock, back, calf pain
Livedo Reticularis
Etiology - vasospasm of arterioles
Findings - blue-red discolorations on the legs
Aneurysm's
Def - dilitation of wall of artery
Aorta 80% > Iliac's 20%
Peripheral (2%): Popliteal A. most common
Dx - ultrasound is gold standard
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Venous vs Arterial Ulcers

Arterial Venous
Location Heels, Foot, Toes Medial Ankle, Lower Leg
Pain Severe – relieved by Moderate – relieved by elevation
dependency
Drainage No Yes
Edges Irregular Rounded
Appearance “Punched out” Shallow, irregular
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Arthropathies
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Arthropathies
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Skeletal Dysplasia
Kenny’s reviews
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Osteopenia
Kenny’s reviews
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Nutritional, Metabolic and Endocrine disorders
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Misc. Bone diseases
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Radiology Physics
Basics/Definitions
Filtration
Effects quantity/quality of x-rays
Types
Inherent – Glass
Added – Aluminum (wedged)
X-ray Absorption Factors
Atomic Number
Density
Terms
Compton Effect
Scatter radiation produced by action w/ outer electron shell
Detrimental to image
Causes less exposure to patient
Photelectric Effect
Absorbed radiation produced by action w/ inner electron shell

Beneficial to image
1 Sv of Radiation = 100 rems
Foot Annual Limit – 50 rems
Body Annual Limit – 5 rems
Lifetime Limit = Age x 1 rem
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Settings
Kvp – quality of x-rays (inversely related to contrast)
Decrease Kvp – reduce scatter rad
Decrease Kvp – increase photo-electric effect
Decrease Kvp – increase contrast
Increase Kvp - decrease contrast
Increase Kvp - increase penetration
Increase Kvp – reduce exposure to pt, but have lower quality of picture
mA – quantity (intensity) of x-rays (directly related to time)
Increase mA – 4 thick body parts
Increase mA – decrease exposure time
Increase mA – brighter xray
SID – source-image distance (directly related to sharpness, inversely related to
mag)
Increase SID – increase sharpness
Increase SID – decrease magnify
OID – object image distance (inversely related to sharpness, directly related to
mag)

Decrease OID- increase sharpness
Decrease OID – decrease magnify
Focal Spot – 1mm (inversely related to sharpness)
Decrease Focal Spot – increase sharpness (detail)
OD – Optical Density (amount of blackness when developed)
Increase in OD = Overexposure
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Decrease in OD = Underexposure
Directly proportional to mA
15% Rule
Increasing Kvp 15% = 2x mA
Want to decrease contrast so…..
You increase Kvp 15%.....
But this will double mA….
Which cause overexposure….
So that means you need to ½ the time of exposure….
Since mA = time
Decreasing Kvp 15% = 1/2 mA
Want to increase contrast so….
You decrease Kvp 15%.....
But this will ½ mA….
Which can cause underexposure
So that means you need to double the time of exposure
Since mA =time

Ideal Viewing Settings
mA- 15
Kvp – 62
Time – 1/3 second
SID – 28 inches
Soft Tissue Viewing
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Increase mA (2x)
Decrease Kvp (15%)
Fiberglass Cast Viewing
Increase Kvp (10)
Increase mA (2x)
ANA – positive
Anti-dsDNA
RA-Factor - positive
Scleroderma
Clinical Findings
Middle age woman
Thickening and tightening of skin, beginning in hands/face
CREST
Calcifications in skin
Raynauds
Esophageal dysfunction
Sclerodactylyl
Telangiectasia
Lab Tests

ANA - positive
RA-Factor - positive
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Pre-op Orders
Stop ASA and smoking 1 week prior
NPO after midnight, or at least 6hrs before Sx
EKG for pts over 40
CXR for pts over 60 (if they smoke then pts over 40)
Pregnancy test – for all women of child bearing age
ABX prophylaxis – give 30 minutes before cuff is inflated
Sx on dirty wounds
Valvular Heart dz, Rhuematic Murmer, Prosthetic valves
Sx longer than 2hrs
Inplants
Pre-existing infection
Blood transfusion
Meds
Ancef
Vanco – if PCN ALL
Amox – prevent bacterial endocarditis
Erythro – if PCN ALL to above
Clinda – if PCN ALL to above
Cancel Elective Sx

Hb < 10
WBC < 2400
Platelets < 100,000
K<3
Glu > 200
BUN > 50
Crt > 3
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Peri-operative
Tourniquet
Inflate 100-120mmHg above systolic pressure
Max Ankle – 250mmHg
Max Thigh – 500mmHg
Pre-op requirements
Anticoags/platelets
7 days prior - stop ASA
3 days prior - stop Coumadin
3 days prior - stop Plavix
1 day prior – stop Lovenox
6 hours prior - stop Heparin
RA pts - Get C-spine X-ray
NPO after midnite, or 8hrs b4 Sx
EKG for pts over 40, or any MI
CXR for pts over 60 (40 if smokes)
Previous MI - wait 6 mos
Pregnancy test – childbearing age

ABX prophylaxis – 30min before cuff
Sx on dirty wounds/infection
Valvular Heart Dz pts
Sx longer than 2hrs
If using hardware/implants
Meds
Ancef (DOC)
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Vanco:
PCN ALL
Implants
Amox: Endocarditis
Erythro: Endocarditis
Clinda: Endocarditis
DM Management
Keep BS b/t 140-240
NIDDM: Hold AM Dose of Oral ABX
IDDM
1/2 dose of Standing Insulin Orders
1/2 D5W/NS @ 70cc/hour
Steriod Patient (>7.5mg QD > 1mos) / (>20mg QD > 1wk)
Minor Sx: Reg. Dose w/ Surgery
Maintenance Dose after Sx
Major Sx: 100mg Pre-Op Q6
Reduce by 50% Daily (starting after Sx) until Maintenance Dose
Cancel Elective Sx
Hb < 10

WBC < 2.5
Platelets < 100
K < 3.0
Glu > 200
BUN > 50
Crt > 3.0
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Peri-Operative Management
Tourniquet (100mmHg > Systolic-P)
Max Ankle – 250mmHg
Max Thigh – 500mmHg
Contraindications
I&D and Amputations
Sickle cell pts
Absolute Indications
Malignant tumors
Complications
Malignant hyperthermia
Susceptibility– EKG abnormality
Etiology – anesthetics/genetic
Symptons
Jaw clenching (1st sign)
Tachy (before temp rise)
Muscle spasm
Rising temp/sweating
Cyanosis at Sx Site

Tx
Dantrolene 1mg/kg IV
IV Iced Saline
Surface cooling
*avoid amides on future Sx's
Local Anesthetic Toxicity
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Etiology - usually Ester's
Findings
CNS symptoms
restlessness, confusion
dizziness, tremors
convulsions
CV symptoms (higher doses)
tachy-->brady, HTN
Treatment
Valium (CNS)
Atropine/Epi (CV)
Post-op Complications
Post-op Fever (100.4)
Wind (0-12) - Atelectasis (90%)
Walk (12-24) - DVT
Water (24-48) - UTI
Wound (48-72) - Infxn
Wonder Drug (>72hrs)

Anytime - catheter/IV ifxn
Treatment
Blood Cx – x2
Tyenol 650mg Q6 prn temp 100.4
Severe Pain
Cast/dressings too tight
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Sutures too tight
Hematoma
Treatment
Extravasation
Pop a stitch or two
Squeeze out blood
Aspiration – large bore needle
Steroid injection
Edema (due to dependent position)
Ischemia
White Toe
Etiology
Macro-emboli
Arterial insufficiency
Overstretching of NV-bundle
Tx
D/C ice and elevation
Place foot in dependent position
Loosen bandage

Twist K-wire
Warm compresses
Local nerve block
Vascular Sx consult
Blue Toe
Etiology
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Arterial insufficiency
Cold
Doesn’t blanch w/ pressure
Venous insufficiency
Warm
Blanch w/ pressure
Tansient vasospasm of vessels
SLE/Scleroderma/Raynauds/RA
Treatment
Arterial Insufficiency: Heat, vasodilators (lidocaine)
Venous Insufficiency: Avoid dependency
Sx Pre-op Note
Subjective
CC
PMH, PSH
Meds, ALL
SH, FH
Objective
Labs – BMP, CBC, Coags, UA

X-rays – foot and chest
EKG
Assesment - Impression
Plan
1 – sx correction of _____
2 – anesthesia to be used
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3 – pt medically cleared for
procedure by Dr. _____
4 – procedure reviewed w/ pt
including risk, benefits and
complications
5 – all questions answered
6 – consent signed
7 – pt to be NPO after midnight
Sx Post-op Note (SAPPPA HEMI CC)

Surgeon
Assistants
Pre-operative Dx
Post-operative Dx
Procedure
Pathology
Anesthesia – the type
Hemostasis –
Pneumatic tourniquest inflated to

250mmHg for 30 minutes
Estimated blood loss (EBL)
Materials – suture, inplants, drains
Injectables
Complications
Condition
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“pt tolerated both procedure and anesthesia w/o apparent complications and with vital signs
remaining stable throughout the procedure. Pt transported from OR to RR with vascular
status intact to (R/L) LE, escorted by member of anesthesia dept and podiatric sx resident”
Admit Orders (ADC VANDILMAX )

Admit to the service of Dr _____
Dx
Condition
Vitals per protocal
Activity– NWB, BR privilages
Nursing – elevate & ice
Diet – normal, 1800 ADA, low Na
IV Fluids
NS @ 85 cc per hour (for dehydrated old people)
Less than 50 cc if patient has CHF
D5W for DM if NPO
D5W/NS @ 120ml/hr
HL (hep lock) IV for healthy individuals
Labs
Meds
RISS – accucheck qac & qhs
150-200 – 2 units

201-250 – 4 units
251-300 – 6 units
301-350 – 8 units
351-400 – 10 units
< 65 or > 400 call MD
ALL
Ancillary - PT, noninvasive studies
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X-rays
In Patient Progress Note

Date/Time
Subjective
Pt seen at bedside in NAD
Pt denies f/c/ns/nvd/SOB/CP
Pt denies calf pain b/l
Objective
VS – Tmax, Tc, HR, RR, BP, O2
Labs - BMP, Coags, CBC, Cx
LE
Wound location, size, depth
Base- granular, fibrotic, necrotic
Wound Margins
Drainage - purulence,serosang.
Periwound erythema/edema
A&P/ 75 yo male submet 1 ulcer
1 – dressing changes performed
2 – continue IV ABX (day 5)

3 – will repeat cultures tomorrow
4 - will continue tommorrow
Discharge Summary
Pt’s name
Medical record #
Physician
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Admit date
Discharge date
Date of Sx
Admitting Dx
Discharge Dx
Procedures
History, Physical Exam
Coarse of Tx
Discharge condition
Medications
D/C instructions
Follow-up
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foot surgery
Types of Wound Healing
Primary Intention: initial closure of incision
Secondary Intention: healing by formation of
granulation tissue
Tertiary Intention: delayed primary closure
Wound Healing Phases
Substrate Phase (1-4 days)
Vasodilation
Hemostasis
Leukocyte response
Macrophages
Proliferative Phase (4-21 days)
Macrophages
Fibroblast lay down collagen
in random pattern

Remodelling Phase (>3weeks)
Collage realigns along long axis
of linear scar
Complications of Wound Healing

Local Factors
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Incisions improperly placed w/ RSTL
Traumatized Tissue
Failure to irrigate
Inadequate hemostasis
Desication of tissue
Prolonged dependency
Local Corticosteriods
Systemic Factors
Uncontrolled DM
Alcoholism
Vit C Def
Steroids
Hb<10
Tarsal Tunnel Syndrome

Anatomy
Post. Tib N. divides into 3 nerves
below the Lacinate Ligament
Medial Plantar N

Lateral Plantar N
Medial Calcaneal N
Penetrates ligament
Etiology
Trauma
Ganglion
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Lipoma/Shwannoma
Pes Planus: Pronation
Exostosis
Venous Complex – usually B/L
Accessory Muscles
Os Trigonum Syndrome
Abductor H. hypertrophy
Myxedema: Synovial thickening
Symptoms
Shooting/Deep Trobbing pain
Worse at Night, prolong WB
Venous tourniquet test - causes symptoms to worsen
Dx
Nerve Condution Study
Dec. Latency/Amp
Dec. NCV
Get B/L Studies
R/O Common peroneal
(+) Tinels Sign – distal shooting

(+) Valleux Sign – proximal shooting
(+) Turks Test
DDx
Plantar Fasciitis
ID Neuroma
Disc Lesion
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Plantar Fibroma/Neurioloma
PVD/Claudication
Neuropathic Pain
Ganglion
Tenosynovitis
Tx
Surgery (External Neurolysis)
Release of laciniate lig.
15% recurrence
don’t reaproximate
NSAIDS/Steriods
Physical Therapy
Orthotics
Surgical Steps
Free up Base of Post-Tib N.
Free up Distal Tip of Tibia
Abductor Canal
Flexor Retinaculum
Neuroma Sx

Histopathology
Sclerosis of epineurium
Thickening of Epi/Peri/Endoneurium
Demylinization of nerve fibers
DDx
Capsulitis/Synovitis
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Ganglion Cyst
Neuritis
RA Nodule
Freiberg Infarction
Bursitis
Met Stress Fx
Pre-Dislocation Syndrome
Characteristics
Females Middle Aged
3rd Interspace most common
2nd Interspace 2nd most common
Sullivans Sign: splay of digits
Mulders Click
Joplans Neuroma
Involves medial plantar digital
Proper nerve
Diagnosis
T1-MRI
US (98% Sensitive)

EMG/NCV – r/o prox. pathology
Conservative
Wide Shoe Box
Cookie Pad
Injection
Surgery
193
Kenny’s reviews
Dorsal Incision
Transects DTML
Avoid WB Scar
Web Space
Difficult Exposure
Avoid WB Scar
Plantar Incision
Excellent Visualization
Preserves DTML
Can transect nerve more prox.
Decreases hematoma formation
WB Scar
Best for “re-do” Neuroma
Neurectomy vs Epineurolysis
Neurectomy
Excision of nerve/branches
80% good results
Epinuerolysis
Freeing of surrounding tissues

Preserves sensation
80% good results
Post-Op
Compression, maybe drain
PWB to heel
Regular shoe gear in 2-3 weeks
194
Kenny’s reviews
Complications
Hematoma
Stump Neuroma (neurectomy)
Recurrence (epineurolysis)
Hallux Varus
Etiology
Staking Met Head
Fib Sesamoid Excision
Overtightening Med. Capsule
Muscular Imbalance
Overcorrection of IM/PASA
Aggressive Splinting
Surgical
1) Soft Tissue Release
2) Medial Capsulotomy
3) Tibial Sesamoidectomy
4) EHL transfer laterally
5) Reverse Osteotomy
6) Arthoplasty/Implant/Fusion
Tendon Transfers

Lose of 1 grade of muscle strength
Must be grade 4 or higher to qualify
Postpone CVA pt’s 6 mos
Post Op
NWB cast 4 weeks
Isometric excercises 3 weeks
195
Kenny’s reviews
Active ROM at 4 weeks
Ankle Fusion
Position of Fusion
Sagittal: 90 Degrees
Frontal: 0-5 Degrees Valgus
Leg: ER 5-10 Degrees
Posterior displacement of talus
Counter acts Achilles
Preserve heel prominence
Bone Healing
Definitions
Osteoblasts: derived from precursors located
In walls of blood vessels
Osteoclasts: multinucleated cutting cones
Osteoid: non-calcified matrix 95% collagen
Mineralization: osteoid deposited w/ Ca-PO3
Occurs 8-10 days after osteoid is formed
Occurs at 1um per day
Stages

Inflammation (1-4 days)
Hematoma around site
Edema acts as splint
Soft Callus (4 days – 4 weeks)
Fibrous and cartilaginous tissue
Hard Callus (4 weeks – 4 mos)
196
Kenny’s reviews
Lamellar bone
Remodeling (4 mos – 2 years)
Resorption of excessive bone
Types of Bone Healing

Primary
Simultaneous formation & remolding of new bone
No callus formation
Requires no motion & good Opposition
Types
Gap Healing: microscopic gaps
Contact Healing: surfaces in direct contact
Secondary
Involves Soft callus/hard callus formation
Occurs when there is motion at Fracture/osteotomy site
Remodels secondary to wolfs law
Normal Healing on Bone Scan
1-4 wks: diffuse uptake at fracture site
4-12 wks: biphasic pattern, uptake localized at fracture ends
(seen in hypertrophic non unions)

12-2 wks: coalescence, focal uptake at Fx site alone
Complications of Bone Healing
Pseudoarthrosis
End stage of nonunion
Fibrocartilaginous surface develops b/t to bones
Malunion: Fx that heals in wrong position
197
Kenny’s reviews
Delayed Union
Healing that goes into the 4-6 months
Tx – requires strict NWB cast
Non-Union
Established when all reparative processes of healing have stopped
Usually around 8-9 months (medicare considers it at 3mos)
Diagnosis of Nonunion
X-ray – sclerotic borders, osseus void
Tc99 bone scan
Hypertrophic Nonunion
Persistent biphasic uptake pattern at Fx ends
Atrophic Nonunion
Low uptake on all phases
Tx – depends on type
Hypertrophic
Bone stimulator (3-6mos)
ORIF
Atrophic
Bone graft

Corticotomy w/ORIF
Bone Stimulation
Tissue Effects
Increases pH
(-) osteoclasts
promotes bone formation
198
Kenny’s reviews
Decreases pO2
Enhances Ca-Deposition
Desensitize osteoclast to PTH
Indications
Nonunions, Delayed Unions
Congenital pseudoarthrosis
AVN
Contraindications
Uncontrolled motion
Synovial pseudoarthrosis
Fracture gap >1cm or ½ diameter of bone
Pregnancy
Active OM
Tumor
Bone Grafts
Indications
Delayed/Non-Unions
Arthrodesis

Defect Replacement
Stabilization
Types
Autograft – from ones own body
Allograft – dead bone from same species (usually freeze dried)
Xenograft – different species
Synthetic Grafts
199
Kenny’s reviews
Graft Healing
Vascular Ingrowth (1-2 weeks)
Takes a little longer in Allografts
Osteogenesis– forming new bone
Osteoinduction
Presence of bone morpheogenic Protein
Causes differentiation of mesenchymal cells into osteoblasts
Osteoconduction
"Scaffolding effect"
Acts as conduit for migration of cells
Creeping Substitution
Replacement of graft w/ viable bone
Graft Remodeling
Reformation of graft in response to biomechanical forces in accordance to
Wolfs law
Autograft vs Allograft
Autograft
Osteoinductive
Osteoconductive

Faster healing
Use for AVN
Allograft
Osteoconductive
Unlimitied amount
Slower healing
Cortical vs Cancellous
200
Kenny’s reviews
Cortical
Radiolucent when healing
Used to proved stability
Less blood supply
30-40% strength loss 6-8 wks
Takes 6 days to revasc
Cancellous
Radiodense when healing
Used to fill defects
Osteoconductive
Takes hours to revasc
Better for AVN
Allograft Types
Frozen: little reduction in antigenicity
Freeze-Dried: 95% of moisture removed
Reduction in antigenicity
Loss of torsional/bending strength
Decalcified: promotes osteoinduction
Reduction in antigenicity

Incorporates very quickly
DMB is trade name
Site for Autograft
Iliac Crest – corticocancellous graft
Middle 1/3 Fibula – good source of cortical
Misc
201
Kenny’s reviews
Low O2 favors cartilage
>6cm defect require BS transfer
Fixation
AO Goals
Anatomic reduction
Preservation of BS
Stable internal fixation
Early active Mobilization
Principles of Internal Fixation
Inter-Frag Compression
Static
Lag
Eccentric Loading Plate
Ex-Fix
Dynamic
Tension Band
Splintage
Internal

K-wires, Nails, Pins
Cerclage Wire
Neutral plating
External
Ex-Fix
Concepts of Mechanics
202
Kenny’s reviews
Stress: pressure you put on material
Strain: measured deformation that results in a material after a
certain stress has been applied
Yield Pt: the point where the strain on material can’t return to original shape
Stress Shielding: stress absorbed by implanted material instead of the bone,
However can cause disuse and osteopenia
Tension: side opposite of the compression side where plates are placed
(creates neutral axis of bone)
Reasons to Fixate
Intra-articular Fx
Open Fx
Non-reducible Fx
Non-union
Early Mobilization
Pathological Fx (Tumor/Inf)
Multiple Trauma
Screw Anatomy
Shank – unthreaded portion
Run-out- junction b/t shank + threads

Weakest point of screw
Pitch – distance b/t threads
Tip: trochar, round, or fluted (self-tap)
AO Lag Screw Technique (2.7mm)
1 – Drill hole (2mm)
Perpendicular to Fx site for best compression
203
Kenny’s reviews
2 –Overdrill (2.7mm)-near surface
3 – Countersink
4 – Measure
5 – Tap (2.7mm) – far surface
6 – Validate position of screw after insertion
Self-Tapping vs Non-Self Tapping
Self-Tapping Screws
Large pilot hole
Threads don’t penetrate as deep
Better in thin cancellous bone
Non-self-Tapping
Less heat is generated due to decreased resistance
Cortical vs Cancelous Screws
Cortical (DOCMTV)
Smaller pitch
Require bicortical penetrations
Only partially threaded
Cancellous (DCMTV)
Larger pitch

Don’t need overdrill
Screw Set Components
Mini Frag
1.5 Cortical
2.0 Cortical
2.7 Cortical
204
Kenny’s reviews
Small Frag
3.5 Cortical
4.0 Cancellous (Partially/fullythreaded)
Standard Frag
4.5 Cortical
4.5 Malleolar - similar to partially threaded cortical
6.5 Cancellous - Partially/Fully threaded
Cannulated Screws
3.0mm, 4.0mm, 4.5mm sizes
Plates
Plate Sizes
Semi-Tubular: 4.5mm screws
1/3 Tubular: 3.5mm screws
Dynamic Compression Plate
Allows compression across Fx site as screws
Are tightened due to plate screw hole shape
Butrresing Plate: Used to maintain separation to protect bone graft
Neutralization Plate
Protects the lag screw

Can exert compression along long axis
(like a screw that’s perpendicular to cortex)
Limited Contact Dynamic Compression Plate
Minimal disruption of blood supply on the periosteum
Other Fixation Devices

K-Wires ("28", "35", "45", "62")
205
Kenny’s reviews
Cross K-wires need to be crossed proximal to osteotomy site
When used with screw it provides rotational stability
Can cause tracting infections
Acute Angles use Trochar Tips
Absorble K-Wires (orthosorb)
Polydioxanone (PDS)
Degraded by hydrolysis
May cause inflammatory rxn
50% dec. holding power 4-6wks
Steinman Pins
Large K-wires
Cerclage Wire’s
24-30 guage wires
Used w/ small fragments or osteoporitic bones
Best compression of all hardware
Can cause irritation of overlying skin/tendon
Tension-band Wiring
Used in areas where soft tissue pulls on fx site
Staples

Good for bone with high cancellous/cortical ration
Can shatter the cortex, if the staple is to thick
Can cuase distraction of Fx ends
External Fixation
Advantages
Dec. Soft Tissue dissection
Can be used to maintain large defects
206
Kenny’s reviews
Can be used w/ infection
Allows for post-op adjustments
Early ROM and WB
Terms
Dynamyzation: procedure by which
All the wires are loosened and pt allowed to WB,
before ex-fix is removed
Ligamentotaxis – pulling of fx frag’s into alignment
using distraction
Materials
Pins – greater diameter than wires
Divergent>Convergent>Parallel
Wires – stronger than wires
Classification (Pin Fixators)
Simple
Pro: easy, versatile
Con: prior reduction required
Modular
Pro: very versatile

Con: complex
Ring
Pro: can adjust in all planes
Con: bulky
Functions
Lengthen bone (Callus distraction)
207
Kenny’s reviews
Preserve periosteum
1mm/day (0.25 qid)
Compress for 7 days prior to removal
Compression
Neutralization
Indications
Open Fx
Communition
Arthrodesis
Osteotomy Fixation
Soft Tissue Stabilization
Suture
Terms
Elasticity – return to original length
ei. Ethibond
Plasticity – elongation persists
ei. Prolene
Intermediate – possess both

ei. Nylon, Vicyrl
Types
Absorbable
Vicryl - Polyglactin 910
Monocryl – Poliglecaprone 25
PDS – Polydioxanone (monofilament)
208
Kenny’s reviews
Nonabsorbable
Silk – skin, highest tissue reactivity
Nylon – skin, high tensile strength
Prolene – very inert, holds knots better
Ethibond (polyester)
Braided, used for tendons
Staples – least reactive
Point Config
Reverse Cutting: Skin
Conventional Cutting: Skin
Taper Cutting: Tendon
Taper Point: SQ / Fascia
Diameter
Smaller the #, the greater thewidth of suture mateial
Sub-Q - closes w/ 2-0, 3-0
Skin - closes w/ 4-0, 5-0
Techniques
Simple
Mattres - good eversion

Subcuticuler
Retention - amp sites
Running
Tensile Strength (50% loss)
Monocryl – 2 weeks
Vicryl – 3 weeks
209
Kenny’s reviews
PDS – 4 weeks
Misc Sx Tools
Bone Paste
used to prevent bleading of bone
indicated for CN-bar and bunionectomy
Drains
Remove in 24-48hrs
Penrose & TLS (tiny little sucker)
Trephine
Allows for removal of screws by overdrilling
Classification
Autograft: same person
Isograft: same twin
Allograft: same species
Xenograft: different species
Types
Full Thickness

Epidermis/Dermis
Donor Site
Flexor surfaces, especially groin
3:1 length to width for closure
Fascia/SQ must be removed
Pro’s
210
Kenny’s reviews
don’t shrink, or change color

Con’s
“take” is not as good
higher infxn rate
Split Thickness
Epidermis/Some Dermis
Donor Site
Upper thigh, using Dermatome
Pro’s
good “take” cause of revasc.
Con’s
they shrink (50%)
become hyperpigmented
Size
Thin – 0.01 in
Int – 0.015 in
Thick – 0.02 in

Procedure
Meshing
Pro’s – expands tissue area, allows drainage
Con’s – easily torn, not good aesthetic appearance
Recipient Site
Graft can’t be over bone or tendon
211
Kenny’s reviews
Must be free of infxn (<10000)

Debride Granulation tissue
Stages of Healing
Plasmatic (1-2 Days): Formation of Fibrin Layer
Inosculation (>2 days: Revasc. Of graft tissue
Reorganization/re-innervation
Post-Op
Compressive/Absorbant Dressing
Pt to remain NWB
“Pink up” of graft takes 48 hrs
Dressing remains 5-7 days
Failure
Seroma (most comon)
Hematoma
Infection (2nd most common)
Stept A, Pseudomonas
Shearing Forces
Synthetic Grafts

Apligraf
Epidermis (dull)
Dermis (glossy)
Human Fibroblast, in Bovine Collage
Indicated w/ Venous Ulcers
Graft Jacket
212
Kenny’s reviews
Integra Graft
Resting Skin Tension Lines
Regular shaped furrow created upon pinching the skin. Usually perpendicular to muscle
bellies. Placing incisions parallel creates ideal scar
213
Non-Union
Kenny’s reviews
214
Nail Surgery
Kenny’s reviews
215
Skin Flap -Plastic
Kenny’s reviews
216
Bunion Evaluation
Kenny’s reviews
217
Head Bunionectomties
Kenny’s reviews
218
Neck Bunionectomties
Kenny’s reviews
219
Shaft Bunionectomties
Kenny’s reviews
220
Base Bunionectomties
Kenny’s reviews
221
Kenny’s reviews
Hallux Limitus Procedures
222
Lesser Metatarsals Sx
Kenny’s reviews
223
Kenny’s reviews
Hammer Toe Lesser Mets Sx
224
Kenny’s reviews
Tailor’s Bunion Procedures
225
Kenny’s reviews
Pes Planus Transverse Procedures
226
Kenny’s reviews
Pes Planus Sagittal Procedures
227
Kenny’s reviews
Pes Planus Frontal Procedures
228
Kenny’s reviews
Ankle Instability procedures
229
Haglund’s
Kenny’s reviews
230
Equinus
Kenny’s reviews
231
Triple Arthrodesis
Kenny’s reviews
232
Kenny’s reviews
Pes cavus Soft tissue Procedures
233
Kenny’s reviews
Pes cavus osseous Procedures
234
Ankle scope
Kenny’s reviews
235
Amputations
Kenny’s reviews
236
Amputations
Kenny’s reviews
237
trauma
Kenny’s reviews
238
Kenny’s reviews
239
Watson Jones
Kenny’s reviews
240
Stewart
Kenny’s reviews
241
Sneppen
Kenny’s reviews
242
Sanders
Kenny’s reviews
243
Salter-Harris
Kenny’s reviews
244
Rowe’s
Kenny’s reviews
245
Jahss
Kenny’s reviews
246
Lis Franc Injury
Kenny’s reviews
247
Hawkins
Kenny’s reviews
248
Gustillo- Anderson
Kenny’s reviews
249
Essex-Loprosti
Kenny’s reviews
250
Eckert-Davis
Kenny’s reviews
251
Berndt-Hardy
Kenny’s reviews
252
Ankle Sprains
Kenny’s reviews
253
Ankle Fractures
Kenny’s reviews
254

Kenny&#39;s Boards 2 Reviews

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Kenny&#39;s Boards 2 Reviews

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anatomy

↳ Weakest area of the calcaneus. Breaks in

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3 years: Propulsive Gait

Splints and Braces

Use b/t 3mos-3years

For Soft Tissue Problems (Fem Rotation)

Not for Boney Problems (Tib Torsion)

Splint 2x as long as casting

Braces w/ rigid bar should have 20 Deg Varus

Bend to prevent STJ or MTJ sublux.

Convex Pes Planovalgus

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NM Disorders that cause equines

CP, Muscular Dystrophy

Wheaton Brace (System)

System: Rotational problems

3rd, 4th, 5th next most common in that order

Iselins Dz - 5th met base apophysitis

Severs Dz – Calcaneal apophysis

Equinus pts, 6-12 yo

Blounts Dz – Proximal Tib epiphysis

Infantile <6yo: early walking, obesity

Adolescent 8-15yo: trauma/infxn

Legg-Calve-Perthes – Femoral head

10% B/L, 30% h/o trauma

Most common Osteochondrosis

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60% Left Side

Assoc. Met Adductus, Cal. Valgus

Can be caused by carry babies w/ hips

Asymmetric Thigh Folds

(+) Ortolanis/Barlows Sign

(+) Galezzi Sign: Dislocate side the knee is lower

Most common cause of peroneal spasticity

Pain relieved by rest

45% of all Coalitions

Involve the middle facet

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Harris Beath – facets are not parallel

Lateral – halo sign

Treatment – resection, arthrodesis

Cal-Navicular Coalition (CN-bar)

45% of all Coalitions

Radiographs (MO and Lateral)

AP: Flattening of nav as it approaches cal.

Lat: Reaching of cal.

Treatment – resection, interposition of EDB

Triple if previous surgery as failed

3-5 years old

Absence of dorsal cyma line

Definition – medial deviation of mets at MTJ

10% assoc. w/ dislocated hip

30% assoc. w/ internal tibial torsion

Kenny's Boards 2 Reviews

Kenny's Boards 2 Reviews