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MSK, Skin, CT Flashcards

1
Q

muscles and innervation important for arm abduction at :

1) 0-15 deg
2) 15-100 deg
3) >90 deg
4) >100 deg

A

1) supraspinatus (n. suprascapular)
2) deltoid (n. axillary)
3) trapezius (n. accessory)
4) serratus anterior (n. long thoracic)

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2
Q

Rotator cuff muscles

A

SItS (innervated C5-C6)

Supraspinatus (suprascapular nerve) –> abduct
Infraspinatus (suprascapular nerve) –> ext rotate
Teres minor (axillary nerve) –> adduct and ext rotate
Subscapularis (upper and lower subscapular nerves) –> int rotate and adducts arm

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3
Q

Most common rotator cuff mm injury

A

supraspinatus

assess with empty can test

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4
Q

Pitching injury

A

Infraspinatus

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5
Q

Repetitive flexion can cause ___ which results in pain at the medial epicondyle

A

Medial epicondylitis

golfers elbow

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6
Q

Repetitive extension can cause _____ which results in pain at the lateral epicondyle

A

Lateral epicondylitis

tennis elbow

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7
Q

This is palpable in the anatomic snuff box and is the most commonly fractured carpal bone

A

Scaphoid

fracture is due to fall on an outstreched hand

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8
Q

complication of proximal scaphoid fractures

A

avascular necrosis and nonunion due to retrograde blood supply

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9
Q

dislocation of _____ can cause acute carpal tunnel syndrome

A

lunate

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10
Q

______ fractures is due to a direct blow with a closed fist

A

Metacarpal neck fracture or boxers fracture

4th and 5th metacarpals most common

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11
Q

Carpal tunnel syndrome is due to entrapment of ____ nerve in the carpal tunnel.

A

median nerve

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12
Q

The carpal tunnel is between _____ and _____

A

transverse carpal ligament/flexor retinaculum

carpal bones

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13
Q

Carpal tunnel syndrome can result in atrophy where?

A

thenar eminence

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14
Q

In carpal tunnel syndrome, _______ is spared because the ______ enters the hand _________to carpal tunnel

A

sensation
palmar cutaneous branch
external

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15
Q

Compression of the ____ nerve is seen in _____ syndrome that is common with cyclists

A

ulnar nerve

Guyon canal syndrome

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16
Q

Incomplete fracture extending partway through the width of bone following bending stress.

A

Greenstick fracture - common pediatric fracture

bone is bent like a green twig

Compression side in tact

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17
Q

Axial force applied to immature bone causes the cortex to buckle on compression side and fractures.

A

Torus (buckle) fracture - common pediatric fracture

Tension side intact

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18
Q

Muscles, function, and innervation of the thenar eminence

A

Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Superficial head (Deep head by ulnar nerve)

Median nerve

fx: oppose, abduct, and flex (OAF)

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19
Q

Muscles, function, and innervation of hypothenar eminence

A

Opponens digiti minimi
Abductor digiti minimi
Flexor digiti minimi brevis

Ulnar nerve

fx: oppose, abduct, and flex (OAF)

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20
Q

Dorsal interossei

A

DAB

Dorsal ABducts

ulnar nerve

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21
Q

Palmar interossei

A

PAD

Palmar ADducts

ulnar nerve

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22
Q

Lumbricals

A

1st and 2nd is median nerve
3rd/4th ulnar nerve

flex at the MCP joint
Extend PIP and DIP

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23
Q

Patient presents with a flattened deltoid, loss of arm abduction at >15 degrees, What nerve is impacted? What are its roots? What is the likely cause of injury? Other signs/symptoms?

A

Axillary nerve, C5-C6

Fractured surgical neck of humerus or anterior dislocation of humerus

Other sx: loss of sensation over deltoid muscle and lateral arms

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24
Q

Patient presents with loss of forearm flexion and supination. Also loss of sensation over lateral forearm. What nerve is impacted? Roots? Mechanism of injury?

A

Musculocutaneous, C5-C7

Upper trunk compression

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25
Q

Patient presents with wrist drop: loss of elbow, wrist, and finger extension. On physical exam you notice a decrease in grip strength and loss of sensation over posterior arm/forearm and dorsal hand. What nerve is impacted? What are its roots? What is the likely mechanism of injury?

A

Radial nerve, C5-T1

Compression of axilla, midshaft fracture of humerus, repetitive pronation/supination of forearm

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26
Q

Patient presents with Loss of wrist flexion, flexion of lateral fingers, thumb opposition, lumbricals of 2nd and 3rd digits. Also loss of sensation over thenar eminence and dorsal and palmar aspect of lateral 3 1/2 fingers with proximal lesion

A

Median nerve, C5-T1

Supracondylar fracture of humerus (proximal lesion)
Carpal tunnel syndrome and wrist laceration (distal lesion)

“ape hand” or “pope’s blessing”

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27
Q

Patient presents with Radial deviation of wrist upon flexion (proximal lesion), loss of wrist flexion, flexion of medial fingers, abduction and adduction of fingers (interossei), actions of medial 2 lumbrical muscles. Loss of sensation over medial 1 1/2 fingers including hypothenar eminence

A

Ulnar nerve, C8-T1

Fracture of medial epicondyle of humerus “funny bone” (proximal lesion)

Fractured hook of hamate (distal lesion) from fall on outstretched hand

“ulnar claw” on digit extension

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28
Q

Erb palsy

A

“waiters tip”
“Erber trunk=upper trunk”

Injury: traction or tear of upper trunk : C5-C6

Cause: trauma in adults. In infants its lateral traction of neck during delivery

Affected mm: deltoid, supraspinatus, infraspinatus, biceps brachii

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29
Q

Klumpke palsy

A

Injury: traction or tear of lower trunk at C8-T1

Cause: infants due to upward force of arm during delviery. Adults is trauma related

Affected mm: intrinsic hand mms –> total hand claw

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30
Q

Thoracic outlet syndrome

A

Injury: compression of lower trunk and subclavian vessels

Cause: cervical rib or pancoast tumor

Affected mm: intrinsic hand mms

See atrophy of intrinsic hand muscles, ischemia pain and edema due to vascular compression

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31
Q

Winged scapula

A

injury: lesion of long thoracic nerve roots C5-C7

Cause: axillary node dissection after mastectomy or stab wounds

affected mm: serratus anterior

Inability to anchor the scapula to the thoracic cage and therefore cannot abduct arm above horizontal position

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32
Q

Claw presentation

A

Most pronounced when it is a distal lesion of median and ulnar nerves. Less pronounce in proximal

Remaining extrinsic flexors of the digits exaggerate the loss of the lumbricals and so the fingers extend at MCP, flex at DIP and PIP joints

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33
Q

Ulnar claw sign

A

lesion at distal ulnar nerve

seen when extending fingers or at rest

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34
Q

Pope’s blessing sign

A

Proximal median nerve

Seen when making a fist

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35
Q

Median claw sign

A

Distal median nerve

Seen when extending fingers/ at rest

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36
Q

Ok gesture sign

A

Proximal ulnar nerve

Seen when making a fist

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37
Q

ACL

A

Lateral femoral condyle to anterior tibia

“LAMP”

Lateral for ACL
Medial for PCL

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38
Q

PCL

A

Medial femoral condyl to posterior tibia

“LAMP”

Lateral for ACL
Medial for PCL

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39
Q

Anterior drawer sign tests the

A

ACL tear

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40
Q

Posterior drawer sign tests the

A

PCL tear

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41
Q

Abnormal passive abduction

A

MCL tear

Abduction/valgus

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42
Q

Abnormal passive adduction

A

LCL tear

Adduction/varus

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43
Q

Mcmurray test

A

Ext rotation for medial meniscal tear

Int rotation for lateral meniscal tear

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44
Q

Trochanteric bursitis

A

inflammation of the gluteal tendon and bursa lateral to the greater trochanter

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45
Q

_____ is a common injury in contact sports due to lateral force applied to a planted leg. Damage involves : ____, ____, ____

A

Unhappy triad

ACL, MCL, and medial meniscus (attached to the MCL)

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46
Q

What menisci injury is more common: lateral or medial

A

lateral

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47
Q

Popliteal fluid collection in gastrocnemius-semimembranosus bursa commonly communicating with synovial space and related to chronic joint disease (i.e. OA)

A

Bakers cyst

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48
Q

Most common ankle sprain overall

A

Anterior TaloFibular Ligament (ATFL)

due to overinversion/supination of foot

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49
Q

Most common high ankle sprain

A

Anterior inferior tibiofibular ligament

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50
Q

Patient presents with burning or tingling pain in surgical incision site radiating to inguinal and supra pubic region

A

iliohypogastric nerve (T12-L1)

due to abdominal injury

sensory branch –> suprapubic region
Motor branch –> transversus abdominis and internal oblique

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51
Q

Patient has decreased anterior thicg sensation beneath inguinal ligament and an absent cremasteric reflex

A

Genitofemoral nerve (L1-L2)

Due to laparoscopic surgery

Sensory branch - scrotum/labia major, medial thich
Motor branch - cremaster

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52
Q

Patient has decreased thich sensation (anterior and lateral)

A

Lateral femoral cutaneous (L2-L3)

Due to tight clothing, obesity, pregnancy, pelvic procedures

Sensory branch only

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53
Q

Patient has decreased thigh sensation (medial) and adduction

A

Obturator (L2-L4)

due to pelvic surgery

Sensory-medial thigh
Motor-obturator externus, adductor longus, adductor brevis, gracilis, pextineus, adductor magnus

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54
Q

Patient has decreased thigh flexion and leg extension

A

Femoral (L2-L4)

Due to pelvic fracture

Sensory-anterior thigh, medial leg
Motor-quadriceps, iliacus, pectineus, sartorius

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55
Q

This nerve splits into the common peroneal and tibial nerves

A

Sciatic (L4-S3)

Due to herniated disc or posterior hip dislocation

Motor-semitendinosus, semimembranosus, biceps femoris, adductor magnus

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56
Q

Patient is experiencing foot drop symptoms and has loss of sensation on dorsum of foot. The patients foot is inverted and plantarflexed at rest, loss of eversion and dorsiflexion resulting in a steppage gait

A

Common peroneal (L4-S2)

Superifical peroneal : Sensory for dorsum of foot. Motor- peroneus longus and brevis

Deep peroneal nerve: Sensory in websapce between hallux and 2nd digit. Motor is tibialis anterior

Due to trauma or compression of lateral aspect of leg, fibular neck fracture

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57
Q

Patient presents with the inability to curl toes and loss of sensation on sole. Patient is unable to stand on tiptoes.

A

Tibial (L4-S3)

Due to knee trauma, bakers cyst (proximal lesion), tarsal tunnel syndrome (distal lesion)

Sensory- sole of foot
Motor- biceps femoris (long head),triceps surae, plantaris popliteus, flexor mm of foot.

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58
Q

The patient has the trendelenburg sign/gait

A

Superior gluteal (L4-S1)

Due to iatrogenic injury during intramuscular injection to superomedial gluteal region

Lesion is contralateral to the side of the hip that drops, ipsilateral to extremity on which the patient stands

Motor-gluteus medius, gluteus minimus, tensor fascia latae

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59
Q

Trendelenburg sign/gait

A

pelvis tilts because weight bearing leg cannot maintain alignment of pelvis through hip abduction

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60
Q

How can you prevent a superior gluteal injury when giving intramuscular injection to superiomedial gluteal region. What nerve is affected? what sign will you see if injured?

A

prevent by choosing the superolateral quadrant, preferably anterolateral region

Trendelenburg sign/gait

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61
Q

Patient has difficulty climbing stairs, rising from seated position. Also there is loss of hip extension

A

Inferior gluteal (L5-S2)

Due to posterior hip dislocation

Motor-gluteus maximus

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62
Q

Patient has decreased sensation in perineum and genital area. Also suffers from fecal and urinary incontinence.

A

Pudendal (S2-S4)

Due to stretch injury during childbirth

Sensory- perineum
Motor-External urethral and anal sphincters

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63
Q

What nerve can be blocked with local anesthetic during childbirth using ischial spine as a landmark for injection

A

Pudendal (S2-S4)

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64
Q

Abductors of hip?

A

Gluteus medius and minimus

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65
Q

Adductors of hip?

A

Adductor magnus
Adductor longus
Adductor brevis

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66
Q

Extensors of hip?

A

Gluteus maximus
Semitendinosus
Semimembranosus

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67
Q

Flexors of hip?

A 
Iliopsoas
Rectus femoris
Tensor fascia lata
Pectineus
Sartorius
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68
Q

Internal rotation of hip?

A

Gluteus medius
Gluteus minimus
Tensor fascia latae

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69
Q

External rotation of hip?

A

Ilipsoas
Gluteus maximus
Piriformis
Obturator

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70
Q

Iliotibial band syndrome

A

In runners - pain secondary to friction of IT band against lateral femoral epicondyle

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71
Q

Medial tibial stress syndrome

A

Shin splints in runners and military recruits

Bone resorption that outpaces bone formation in tibial cortex

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72
Q

Limb compartment syndrome

A

Caused by significant long bone fractures, reperfusion injury, animal venoms,

Motor deficits are late sign of irreversible muscle and nerve damage

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73
Q

Plantar fasciitis

A

inflammation of plantar aponeurosis

heel pain worse with first steps int he morning or after period of inactivity

tenderness

74
Q

De Quervain tenosynovitis

A

Noninflammatory thickening of abductor pollicis longus and extensor pollicis brevis tendons

pain or tenderness at radial styloid

75
Q

Ganglion cyst

A

Fluid filled swelling overlying joint or tendon sheath

most commonly at dorsal side of wrist

Arises from herniation of dense connective tissue

76
Q

Developmental dysplasia of the hip

A

Abnormal acetabulum development in newborns

Hip instability/dislocation

Ortolani and barlow maneuvers and confirmed via ultrasound

77
Q

Legg-Calve-Perthes disease

A

Idiopathic avascular necrosis of femoral head

insidious onset of hip pain that may cause child to limp

78
Q

Slipped capital femoral epiphysis

A

Obese ~12 yo child with hip/knee pain and latered gait

Increased axial force on femoral head which causes epiphysis to displace relative to femoral neck

79
Q

Osgood-Schlatter disease (traction apophysitis)

A

Progressive anterior knee pain. Overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center of proximal tibial tubercle

Adolescents after growth spurt

Common in running and jumping athletes

80
Q

Radial head subluxation (nursemaid’s elbow)

A

Common elbow injury in children <5 yo

Due to sudden pull on the arm that causes immature annular ligament slips over head of radius

injured arm held in flexed and pronated position

81
Q

If a disc herniates at L3/L4 then what spinal level is actually impacted. Which way does it herniate and why

A

L4

Posterolaterally because thin posterior longitudinal ligament and thicker anterior longitudinal ligament along the midline of the vertebral bodies

82
Q

Lumbosacral rediculopathy : L3-L4

A

weakness of knee extension

decreased patellar reflex

83
Q

Lumbosacral rediculopathy : L4-L5

A

weakness of dorsiflexion

difficult in heel walking

84
Q

Lumbosacral rediculopathy : L5-S1

A

Weakness in plantar flexion

Difficulty in toe walking

decreases achilles reflex

85
Q

Motorneuron action potential depend on what neurotransmitter

A

ACh release

86
Q

Membrane depolarization induces conformation changes in the voltage sensitive _______ and its mechanicall coupled ________. This results in ____ release from the ________ into the cytoplasm

A

dihydropyridine receptor (DHPR)

ryanodine receptor

sarcoplasmic reticulum

87
Q

_______ is blocking myosin binding sites on the actin filament. Released _____ binds ______ shifting _______ to expose the myosin binding sites

A

Tropomyosin

Calcium

Troponin C (TnC)

tropomyosin

88
Q

Myosin head is strongly bound to actin forming a ______

A

crossbridge

89
Q

______ is released, inititating the power stroke

A

Pi

90
Q

During the powerstroke, muscle shortening includes shortening of what segments

A

H and I between Z lines

“ZHIZ”

91
Q

What muscle band always remains the same length

A

A band

A=always

92
Q

What causes the detachment of the myosin head from the actin filament?

A

ATP

93
Q

What causes the high energy position (cocked) of the myosin head

A

Hydrolysis of ATP into ADP and Pi causes myosin to return to high energy state

94
Q

Type______muscles increase in proportion after endurance training. they are ______ twitch muscles and have ____ fibers.

A

Type I

slow twitch muscle

red fibers - increased mitochondria and myoglobin concentration (increases oxidative phosphoyrlation) allow for sustained contractions

95
Q

Type ______ muscles increase in proportion after weight/resistance training/sprinting. They are _____ twitch muscles and have _____ fibers

A

Type II

fast twitch muscle

White fibers- low mitochondria and myoglobin concentrations (increase anaerobic glycolysis).

96
Q

Type of ossification seen in axial skeleton, appendicular skeleton, and base of skull

A

Endochondral ossification

Osteoclasts and osteoblasts later replace with woven bone and then remodeled to lamellar bone

97
Q

Type of ossification seen in calvarium, facial bones, and clavicle

A

Membranous ossification

woven bone formed directly without cartilage

remodeled into lamellar bone

98
Q

_____ type of bone occurs after fractures and in paget disease

A

woven

99
Q

Pathway for smooth mm relaxation

A

Ca release inside the endothelial cells positively stimulate NO synthase

L-arginine —> Nitric oxide

NO diffuses into smooth muscle cell and causes conversion of GTP into cGMP

cGMP positively stimulated myosin light chain phosphatase MLCP which dephosphorylates myosin

100
Q

The precursor of nitric oxide and the enzyme

A

L-arginine

NO snythase

101
Q

Pathway for smooth mm contraction

A

calcium influx due to depolarization

Ca into the smooth muscle cell via the L type voltage gated Ca channel

Increase in the calcium-calmodulin complex

Positvely stimulates the myosin-light chain kinase (MLCK) which phosphorylates myosin

102
Q

Osteoblast function

A

Builds bone by secreting collagen and catalyzing mineralization in alkaline environment via ALP

activity measured by bone ALP, osteocalcin, propeptides of type I procollagen

103
Q

Osteoclast

A

dissolves (“crushes”) bone by secreting H+ and collagenases

104
Q

Osteoblasts are from _______ cells in the periosteum

A

mesenchymal stem cells

105
Q

Osteoclasts differentiate from fusion of _____ lineage precursors

A

monocyte/macrophage

106
Q

Receptor of osteoclast and ligands of osteoblast

A

Receptor is the RANK

Ligand is RANKL from osteoblasts

107
Q

Give ____ to decrease osteoclast activity

A

OPG or osteoprotegerin, a RANKL decoy receptor

108
Q

Effects of low intermittent levels of PTH? Chronic high levels?

A

Low –> anabolic (build bone)

High –> catabolic ( osteitis fibrosa cystica)

109
Q

Deficiency in estrogen puts you at risk for _____

A

osteoarthritis

estrogen inhibits apoptosis in osteoblasts and induces apoptosis in osteoclasts

110
Q

____ causes closure of the epiphyseal plates during puberty

A

estrogen

111
Q

What is the most common cause of dwarfism?

A

Achondroplasia - the failure of longitudinal bone growth (Endochondral ossification) which results in short limbs

embranous ossification is affected resulting in alrge head relative to limbs

Aut. Dominant with full penetrance (homozygosity is lethal).

> 85% of mutation are sporadic

112
Q

What is activated in achondroplasia

A

Fibroblast growth factor receptor (FGFR3) which inhibits chondrocyte proliferation

113
Q

Osteoporosis

A

is mostly due to increased bone resorption related to decreased estrogen levels and old age. Can be secondary to drugs

Trabecular (spongy) and cortical bone loss mass but normal bone mineralization and lab values

DEXA scan <= -2.5

treatment is bisphosphonates, teriparatide, SERMs, denosumab (monoclonal antibody against RANKL)

114
Q

What is a common fracture seen in osteoperosis patients?

A

Vertebral compression fractures - acute back pain, loss of height, kyphosis

115
Q

Osteopetrosis

A

Failure of normal bone reposrtion due to defective osteoclasts that results in thickened dense bones that are prone to fracture

osteoclasts lack the acidic environment needed to cause bone resorption

116
Q

Osteopetrosis complication with bone marrow

A

Overgrowth of cortical bone fills marrow space causing pancytopenia and extramedullary hematopoiesis

can get cranial nerve impingement and palsies due to narrowed foramina

117
Q

Osteomalacia

A

Defective mineralization of osteoid (osteomalacia)

pseudo fractures and osteopenia

118
Q

Rickets

A

Defective mineralization of cartilaginous growth plates (rickets)

Rickets shows epiphyseal widening and metaphyseal cupping/fraying, bead like costochondral junctions (rachitic rosary) and craniotabes (soft skull)

119
Q

Physiological mechanism behind rickets/osteomalacia

A

Vitamin D deficiency –> drop in serum Ca –> increase PTH secretion –> drop in PO4

hyperactivity of osteoblasts –> increase in ALP

120
Q

Pagets disease of bone (osteitis deformans)

A

Abnormal “mosaic” bone architecture

Localized disorder of bone remodeling caused by increased osteoclastic activity followed by increased osteoblastic activity that forms poor quality bone

Pt commonly complains of an increased hat size and hearing loss due to auditory foramen narrowing

121
Q

Labs in pagets disease of bone

A

Serum Ca, phosphorus, and PTH levels are normal. Increase in ALP

122
Q

Stages of paget disease

A

Lytic- osteoclasts
Mixed-osteoclast + osteoblasts
Sclerotic - osteoblasts
Quiescent - minimal osteoclast/osteoblast activity

tx with bisphosphonates

123
Q

Risks and complications in pagets

A
  • long bone chalk stick fractures
  • Increase in blood flow from arteriovenous shunts may cause high output heart failure
  • Increased risk of osteogenic sarcoma
124
Q

Osteonecrosis (avascular necorsis)

A

Infarction of bone and marrow - very painful

watershed zones: femoral head due to insufficiency of medial circumflex femoral artery

125
Q

Osteoperosis labs

A

Normal CA, PO4, ALP, PTH

drop in bone mass

126
Q

Osteopetrosis labs

A

normal or low Ca

dense brittle bones

Ca drops only in severe malignant disease

127
Q

Labs in osteitis fibrosa cystica (primary hyperparathyroidism)

A

High Serum Ca
Low PO4
High ALP
High PTH

“brown tumors” due to fibrous replacement of bone, subperiosteal thinning

128
Q

Labs in osteitis fibrosa cystica (secondary hyperparathryoidism)

A

Drop in Ca
Increase in PO4
Increase in ALP
Increase in PTH

Often compensation for CKD where there is a drop in PO4 excretion and production of activated vitamin D

129
Q

Osteomalacia/ rickets labs

A

Drop in Ca
Drop in PO4
Increase ALP
Increase PTH

130
Q

Hypervitaminosis D labs

A

High Ca
High PO4
Normal ALP
Drop in PTH

131
Q

Osteochondroma location and characteristic

A

Most common benign bone tumor in Males < 25 yo

Metaphysis of long bones

Lateral bony projection of growth plate (continuous with marrow space) covered by cartilaginous cap

132
Q

Osteoma location and characteristic

A

Surface of facial bones

Gardner syndrome

133
Q

Osteoid osteoma location and characteristic

A

Adults < 25 yo with more M > F

Cortex of long bones

Bone pain that is wrose at night and releived by NSAIDs

bony mass thats < 2 cm with radiolucent osteoid core

134
Q

Osteoblastoma location and characteristic

A

Vertebrae

similar to osteoid osteoma

> 2 cm mass and does not respond to NSAIDs

135
Q

Chondroma location and characteristic

A

Medulla of small bones of hand and feet

benign tumor of cartilage

136
Q

Giant Cell tumor location and chracteristic

A

Epiphysis of long bones (knee region)

locally aggressive benign tumor

“soap bubble” appearance on xray

neoplastic mononuclear cells that express RANKL and reactive multinucleated giant (osteoclast like) cells

137
Q

Osteosarcoma (osteogenic sarcoma) location and characteristics

A

Metaphysis of long bones (often in knee region)

pleomorphic osteoid producing cells (malignant osteoblasts)

Codman triangle (elevation of periosteum) or sunburst pattern on xray

Aggressive. Primary is responsive to treatment but secondary has poor prognosis

138
Q

Chondrosarcoma location and characteristics

A

Medulla of pelvis and central skeleton

tumor of malignant chondrocytes

139
Q

Ewing sarcoma location and characteristics

A

Caucasions, boys, <15 yo, aggressive, early metastases, responds to therapy

Diaphysis of long bones especially the femur, pelvic flat bones

t(11;22)

“onion skin” periosteal reaction in bones
Anaplastic small blue cells of neuroectodermal origin

140
Q

Osteoarthritis pathogenesis

A

Mechanical wear and tear destroys articular cartilage (degenerative joint disorder) which results in inflammation and inadequate repair

Chondrocytes mediate degradation and inadequate repair

treat with acetaminophen, NSAIDs, intraarticular glucocorticoids

141
Q

Patient presents with pain in weight bearing joints after a long day. Her pain improves with rest and is only one of her knees. Her doctors points out that she is starting to lose her knee cartilage medially

A

Osteoarthritis

142
Q

Joint findings in osteoarthritis

A

Osteophytes (bone spurs)
Joint space narrowing
Subchondral sclerosis and cysts
Synovial fluid noninflammatory (WBC<2000)
Involves the DIP (heberden nodes) and PIP (Bouchard nodes)

NOT MCP

143
Q

Rheumatoid arthritis pathogenesis

A

Autoimmune inflammation induces formation of pannus (proliferative granulation tissue) which erodes articular cartilage and bone

HLA-DR4, + Rh factor (IgM antibody that targets IgG Fc region), anticyclic citrullinated peptide antibody

144
Q

Patent presents with pain, swelling, and morning stiffness lasting >1 hour that improves with use. She complains of symmetric pain in both hands and has noticed fever, fatigue, and weight loss.

A

Rheumatoid arthritis

tx with NSAIDS, glucocorticoids, diseas emodifying agents, biologic agents

145
Q

Rheumatoid arthritis joint findings

A

Erosions, juxta articular osteopenia, soft tissue swelling, subcondral cysts, joint space narrowing

Cervical subluxation, ulnar finger deviation, swan neck, boutonniere

involves the MCP,PIP, and wrist

NOT the DIP or 1st CMC

synovial fluid is inflammatory

146
Q

Acute inflammatory monoarthritis caused by precipitation of monosodium urate crystals in joints. What disease is this? what is a major risk factor?

A

Gout

Hyperuricemia is a major risk factor

147
Q

Hyperuricemia is a major risk factor for gout. What are some of the causes of hyperuricemia? what do the crystals look like?

A

Underexcretion of uric acid
Overproduction of uric acid
Needle shaped and (-) birefringent under polarized light (yeLLow under paraLLel light and blue under perpendicular light)

148
Q

Patient presents with asymmetric joint pain at the MTP joint of the big toe (podagra) that is swollen and red. She mentions that her pain is worse after eating foods rich in purines and when she drinks alochol

A

Gout

Tophus formation is common

alcohol - alcohol metabolites compete for same excretion sites in kidney as uric acid this results in less uric acid secretion and subsequent buildup in blood

149
Q

Calcium pyrophosphate deposition disease

A

pseudogout if pain and swelling with acute inflammation
pseudo-osteoarthritis if chronic degeneration

Calcium pyrophosphate deposition within the joint spaces, especially the knees

crystals are rhomboid and weakly + birefringent under polarized light (blue when parallel to light)

Can also see chondrocalcinosis (cartilage calcificatio) on xray

150
Q

What drug is used as acute treatment and as prophylaxis for calcium pyrophosphate deposition disease

A

Colchicine

151
Q

Patient is <12 yo and presents with arthritis in 3 of his joints. His mother also mentions he has daily spiking fevers and a salmon pink macular rash

A

Systemic juvenile idiopathic arthritis

presents with leukocytosis, thrombocytosis, anemia, increase ESR, Increased CRP

152
Q

Patient presents with bilateral parotid enlargement, inflammatory joint pain, and decreased tear and saliva production

A

Sjogren syndrome - autoimmune disorder characterized by destruction of exocrine glands (lacrimal and salivary) by lymphocytic infiltrates

  • inflammatory joint pain
  • keratoconjunctivitis sicca (decreased tear production and subsequent corneal damage)
  • Xerostomia (decreased saliva production)
  • bilateral parotid enlargement
  • Mucosa associated lymphoid tissue (MALT) lymphoma
  • Focal lymphocytic sialadenitis on labial salivary gland biopsy can confirm diangosis
153
Q

Sjogren syndrome autoantibodies

A 
Anti SSA (anti ro)
Anti SSB (anti la)

but can also be seen with SLE

+Anti SSA in pregnant owmen with SLE can increase risk of congential heart block in the newborn

154
Q

Septic arthritis pathogen causes

A

S aureus
Streptococcus
N gonorrhoeae

Affected joint is swollen, red, and painful

synovial fluid is purulent

155
Q

Gonococcal arthritis

A

purulent arthritis OR

triad of polyarthralgia, tenosynovitis, dermatitis

156
Q

Seronegative spondyloarthritis

A

arthritis without Rh factor (no anti IgG antibody)

strong association with HLA-B27 (MHC class I serotype)

157
Q

Psoriatic arthritis

A

skin psoriasis and nail lesions

dactylitis and pencil in cup deformity of DIP on xray

158
Q

Anklosing spondylitis

A

Symmetric invovlement of spine and sacroiliac joints –> ankylosis (joint fusion), uveitis, aortic regurg

bamboo spine (vertebral fusion)

can cause restrictive lung disease due to limited chest wall expansion (costovertebral and costosternal ankylosis)

159
Q

Reactive arthritis/ Reiter syndrome

A

Classic triad: conjunctivitis, urethritis, arthritis

due to shigella, yersinia, chlamydia, campylobacter, salmonella

160
Q

Systemic lupus erythematosus

A

RASH OR PAIN

Rash (malar or discoid)
Arthritis (nonerosive)
Serositis
Hematologic disorder
Oral/nasopharyngeal ulcers
Renal disease
Photosensitivity
Antinuclear antibodies
Immunologic disorder (anti-dsDNA, anti-sm, antiphospholipid)
Neurologic disorders
161
Q

Systemic lupud erythematosus organ damage is due to

A

mostly a type III hypersensiitivity reaction

associated with deficiency of eraly complement proteins which decreases clearance of immune complexes

162
Q

SLE pt are at risk for what kind of endocarditis

A

Libman sacks endocarditis - nonbacterial verrucous thrombi usually on mitral or aortic valve

163
Q

SLE pts are at risk for what kind of nephritis

A

Diffuse proliferative is most common and severe

164
Q

SLE pts commonly die from

A

Renal disease most common

infections
cardiovascular disease

165
Q

Antiphospholipid syndrome

A

primary or secondary autoimmune disorder most commonly in SLE

thrombosis (arterial and venous) or spontaneous abortion

lab finding: lupus anticoagulant, anticardiolipin, anti beta2 glycoprotein antibodies

note: anti cardiolipin antibodies can cause false positive VDRL/RPR and lupus anticoagulant can cause prolonged PTT that is not corrected by addition of normal platelet free plasma

166
Q

Mixed CT disease is related to what antibodies

A

anti-U1 RNP antibodies (speckled ANA)

167
Q

Pt presents with pain and stiffness in proximal muscles, fever, malaise, weight loss. She does not complain of muscular weakness and she has a history of giant cell (temporal) arteritis

A

Polymyalgia rheumatica

high ESR, CRP
normal CK

rapid response to low dose corticosteroids

168
Q

Patient presents with widespread musculoskeletal pain that is associated with tender points, stiffness, paresthesias, poor sleep, fatigue, cognitive disturbances

A

Fibromyalgia

treatment is regular exercise, antidepressants, neuropathic pain agents

169
Q

Polymyositis/dermatomyositis markers

A 
Increase CK
\+ ANA (nonspecific)
\+ anti-jo-1 / histidyl-tRNA synthetase (specific)
\+ anti-SRP (specific)
\+ anti-Mi-2 (specific)
170
Q

Polymyositis

A

Progressive symmetric proximal muscle weakness
endomysial inflammation with CD8+
intersitial lung disease
Mostly involves the shoulders

171
Q

Dermatomyositis

A 
Similar to polymyositis
malar rash at nasolabial folds
Gottron papules
heliotrope (violaceous periorbital) rash
Shawl and face rash
darkening and thickening of fingertips and sides resulting in irregular dirty appearing marks
increase risk of occult malignancy
perimysial inflammation and atrophy with CD4+ T cells
interstitial lung disease
172
Q

Pt presents with ptosis, diplopia, weakness, dyspnea. She mentions that it is worse when she uses her muscles. What disease is this? What is its mechanism of action?

A

Myasthenia gravis

most common NMJ disorder

autoantibodies to postsynaptic ACh receptor “post death you have a grave”

173
Q

Myasthenia gravis is commonly associated with ___?

A

thymoma

thymic hyperplasia

174
Q

How do you dx myasthenia gravis? how to you treat?

A

Diagnose when use edrophonium (tensilon) test and see improvement

treat with pyridostigmine

175
Q

Pt presents with proximal muscle weakness, autonomic symptoms like dry mouth and impotence. Patient explains that her symptoms improve with muscle use

A

lambert eaton myasthenic syndrome

autoantibodies to presynaptic Ca channel –> decrease ACh release

“PREpare to eat”

176
Q

Lambert eaton myasthenic syndrome is commonly associated with ___?

A

small cell lung cancer

177
Q

raynaud disease vs raynaud syndrome? how to treat?

A

disease is primary
syndrome is secondary to another disease. Can see digital ulceration

treat with calcium channel blockers

178
Q

Pt presents with sclerosis of skin, her face is puffy and her skin taut. She has no wrinkles and you notice her fingertips are pitting

A

Scleroderma (systemic sclerosis)

triad of autoimmunity, noninflammatory vasculopathy, and collagen deposition with fibrosis

can see other systems involved too (GI, renal, pulm, CV)

179
Q

Diffuse scleroderma

A

widespread skin involvement
Rapid progression
Early visceral involvement

anti-scl-70 antibody (anti-DNA topoisomerase I antibody)

180
Q

Limited scleroderma

A

limited skin involvement confined to fingers and face

CREST syndrome

Calcinosis cutis
Anti-centromere antibody
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia

benign course

181
Q

Children
metaphysis of long bones
hematogenous infection

A

osteomyelitis most commonly affected the metaphysisi of long bones due to decreased blood flow in these areas

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