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Flashcards in Musculoskeletal Deck (102):
1

What is the anterior drawer sign? What does it mean? What is posterior drawer sign? What does is it mean? What is abnormal passive abduction? What does it mean? What is abnormal passive adduction ?What does it mean? What is the mcmurray test? What are some signs and what do they mean?

Pt supine, knee at 90 degree, incr. anterior gliding of tibia
ACL injury

Pt suping, knee at 90 degr., incr. posterior gliding of tibia
PCL inj

Pt. supine and knee either extended or at 30 degr. angle, lateral (valgus) fore leads to medial space widening of tibia.
MCL injury

Same as above, medial (varus) force leads to lateral space widening of tibia
LCL injury

With pt. supine, knee internally and extenally rotated during range of motion:
Pain, popping on external rotation=Medial meniscal tear
Pain, popping on internal rotation=lateral " "

2

What is the unhappy triad? What causes it? Presentation?
What is prepatellar bursitis? Cause? What is a baker cyst? Association?

Contact sports; lasteral force applied to planted leg.

Classically, damage to ACL, MCL, and medial lemniscus (thought its usually the lateral one)

Acute knee pain and signs of joint injury/instability


Housemaids knee. Inflammation/liquid above patella.
Repeated trauma or pressure from extensive kneeling


Popliteal fluid collection
Chronic joint disease

3

What are the muscles that form the rotator cuff? Where are they located in relation to each other? What is the innervation of each? What is the function of each? What spinal levels primarily innervate them? Which is most commonly injured? Which is injured in pitching?

SItS

Supraspinatus
superior to humerus
suprascapular nerve
Most common
Abducts arm initially (before action of deltoid)

Infraspinatus
Posterior superior to humerus
Suprascapular
Laterally rotates arm
Pitching injury

Teres Minor
Posterioinferior to humerus
Axillary
Laterally rotates arm and adducts arm

Subscapularis
Anterior to humerus
Upper and lower subscap nerve
Adducts and medially rotates arm

C5-C6

4

What is medial epicondylitis? Another name? Cause? Presentation? Same Qs for lateral epicondylitis?

Golfers elbow
Repetitive flexion (forehand shots) or idiopathic
pain near medial epicondyle

Tennis elbow
Repetitive extension (backhand shots) or idiopathic
Pain near lateral epicondyle

5

What are the wrist carpal bones? Which is palpated in the anatomical snuff box? Which is most commonly fracture? Complications of fracture/mechanism? What can cause carpal tunnel syndrome? What can cause ulnar nerve injury?

So long to pinky, here comes the thumb

Scaphoid, lunate, triquetrium, pisiform, hamate, capitulum, trapezoid, trapezium (trapezithumb)

Scaphoid in snuff box
Scaphoid most common fracture=avascular necrosis due to retrograde blood supply

Dislocation of lunate-->carpal tunnel

FOOSH--->hook of hamate damage leading to ulnar nerve injury.

6

What is carpal tunnel syndrome? Causes/associations? Symptoms? Pathophys?

Entrapment of median nerve in carpal tunnel leading to nerve compression

paresthesia, pain, and numbness in distribution of median nerve

Pregnancy, RA, Hypothyroidism, repetitive use

7

What is guyon canal syndrome? Usually cause?

Compression of ulnar nerve at wrist or hand

Cyclists due to pressure from handlebars

8

Describe the anatomy of the brachial plexus including which nerves originate from where.

Randy Travis Drinks Cold Beer

Roots, trunks, divisions, cords, branches

Roots of C5, C6, and C7 give off long thoracic
C5 root gives off dorsal scap nerve


C5 and C6 roots make up the upper trunk
C7=middle trunk
C8/T1=lower trunk
Upper trunk gives off suprascapular nerve

All trunks give off anterior and posterior divisions

Anterior divisions of upper and middle trunk make up the lateral cord
All 3 posterior divisions make up posterior cord
Anterior division of Lower trunk make medial cord
Posterior cord gives off upper and lower subscapular nerves and thoracodorsal nerve
Lateral and medial cords give off lateral and medial pectoral nerves
Posterior cord gives off axillary nerve then becomes the radial nerve
Lateral cord and medial cord make up median nerve
Medial cord continues as ulnar nerve
Lateral cord continues as musculocutaneous nerve

9

What levels make up the axillary nerve? What will cause injury? What is the presentation?

C5-C6

Fractured surgical neck of humerus
Anterior dislocation of humerus

Flattened Deltoid
Loss of arm abduction at shoulder
Loss of sensation over deltoid muscle and lateral arm

10

What levels make up the musculocutaneous nerve? What will cause injury? Presentation?

C5-C7

Upper trunk compression

Loss of forearm flexion and supination
Loss of sensation over lateral forearm

11

What levels make up radial nerve? What will cause injury? Presentation?

C5-T1

Midshaft fracture of humerus
Compession of axilla due to crutches or arm over chair

Wrist drop: loss of elbow, wrist, and finger extension
Decr. grip strength (wrist extension necessary for max action of flexors)
Loss of sensation over post arm/forearm and dorsal hand

12

What levels make up median nerve? What will cause injury? Presentation?

C5-T1

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

DISTAL
Ape Hand and Popes Blessing
Loss of wrist flexion, flexion of lateral fingers, thumb opposition, lumbricals of 2nd/3rd digits

PROXIMAL
Loss of sensation over thenar eminence and dorsal and palmar aspects of lateral 3 1/2 fingers
Tinel sign (tingling on percussion) in carpal tunnel syndrome

13

What levels make up ulnar nerve? What will cause injury? Presentation?

C8-T1

Fracutre of medial epicondyle of humerus (funny bone) (proximal lesion)
Fracture hook of hamate (distal)

"Ulnar claw" on digit extension
Radial deviation of wrist upon flexion (proximal lesion)
Loss of wrist flexion, flexion of medial fingers, abductin and adduction of fingers (interossei), actions of medial 2 lumbrical muscles
Loss of sensation over medial 1 1/2 fingers including hypothenar eminence

14

What levels make up recurrent branch of median nerve? What will cause injury? Presentation?

C5-T1

Superficial laceration of palm

"Ape hand"
Loss of thenar muscle group: opposition, abduction, and flexion of thumb
No loss of sensation

15

Damage to these structures causes what?

Upper trunk:
Lower trunk:
Posterior Cord:
Long thoracic nerve:
Axillary nerve:
Radial nerve:
Musculocutaneous nerve:
Median nerve:
Ulnar Nerve:

Upper trunk: Erb Palsy (waiter's tip)
Lower trunk: Claw hand (klumpke palsy)
Posterior Cord: Wrist drop
Long thoracic Nerve: Winged scapula
Axillary nerve: Deltoid paralysis
Radial nerve: Wrist drop
Musculocutaneous nerve: Difficulty flexing elbow, sensory loss
Median nerve: Decrease thumb function, Pope's blessing
Ulnar Nerve: Intrinsic muscles of hand, claw hand

16

What is the injury in Erbs palsy? Causes? Muscle deficit? Functional deficit?

Tractin or tear of upper trunk
C5-C6

Infants-lateral traction on neck during delivery
Adults-trauma (head forcefully away from shoulder)

Deltoid, supraspinatus (abduction-arm at side)
Infraspinatus (lateral rotation-arm medially rotated)
Biceps (flexion, supination-arm extended and pronated)

17

What is the injury in Klumpke palsy? Causes? Muscle deficit? Functional deficit?

Traction of tear of lower trunk
C8-T1

Infants: upward force on arm during delivery
Adults: Trauma-forceful pulling up on arm

Intrinsic hand muscles: lumbrical, interossei, thenar, hypothenar

Total claw hand: Lumbrical normaly flex MCP joints and extend DIP and PIP joints

18

What is the injury in thoracic outlet syndrome? Causes? Muscle deficit? Functional deficit?

Compression of lower trunk and subclavian vessels

Cervical rib
pancoast tumor

Same as klumpke palsy

Atrophy of intrinsic hand msucles: ischemia, pain, and edema due to vascular compression

19

What is the injury in winged scapula? Causes? Muscle deficit? Functional deficit?

Long thoracic nerve

Axillary node dissectin after mastectomy
Stab wounds

Serratus anterior

Inability to anchor scapula to thoracic cage
Cannot abduct arm above horizontal position.

20

What is the function of the lumbricals? What is the deficit like in proximal lesions? In distal lesions? Why?

Flex at MCP, extend at DIP and PIP joints

Distal: clawing, loss of lumbrical leads to extend MCP, flex IPs

Proximal: deficits less pronounced; seen during voluntary flexion of digits

21

What muscles are i the thenar eminence? Innervation? Hypothenar eminence? Innervation? function of dorsal interossei? Palmar?

Thenar: median nerve=opponens pollicis, abductor pollicis brevis, flexor pollicis brevis

Hypothenar (ulnar): opponens digiti minimi, abductor digiti minimi, flexor digiti minimi

DAB (dorsals abduct)
PAD (palmar adduct)

22

What spinal levels make up the obturator nerve? Cause of injury? Presentation?

L2-L4

Pelvic surgery

Decr. thigh sensation (medial)
Decr. adduction

23

What spinal levels make up the femoral nerve? Cause of injury? Presentation?

L2-L4

Pelvic fracture

Decr. thigh flexion and leg extension

24

What spinal levels make up the common peroneal nerve? Cause of injury? Presentation?

L4-S2

Trauma or compression of lateral aspect of leg
fibular neck fracture

Foot drop-inverted and plantarflexed at rest
Loss of eversion and dorsiflexion
steppage gait
Loss of sensation on dorsum of foot

Foot dropPED=Peroneal everts and dorsiflexes

25

What spinal levels make up the tibial nerve? Cause of injury? Presentation?

L4-S3

Knee trauma
Baker cysts (proximal)
Tarsal tunnel syndrome (distal)

Inability to curl toes and loss of sensation on sole of foot
In proximal lesions, foot everted at rest with loss of inversion and plantar flexion

Can't stand on TIPtoes=Tibial Inverts and Plantar flexes

26

What spinal levels make up the superior gluteal nerve? Cause of injury? Presentation? Muscles

L4-S1=gluteus medius and minimus

Iatrogenic injury during intramuscular injection to upper medial gluteal region

Trendelenburg sign/gait-pelvis tilts b/c weight bearing leg cannot maintain alignment of pelvis through hip abduction. Lesion is CL to side that drops, ipsilateral to extremity on which patients stands.

27

What spinal levels make up the inferior gluteal nerve? Cause of injury? Presentation? Muscles?

L5-S2=gluteus maximus

Posterior hip dislocation

Difficulty climbing stairs, rising from seated position
Loss of hip extension

28

What is the function of the sciatic nerve? Spinal levels?
Function of pudendal nerve? Spinal levels? What is a landmark for local anesthetic during childbirth?

L4-S3-Innervates posterior thigh, splits into common peroneal and tibial nerves

S2-S4-innervates perineum. Ischial spine.

29

What is a lumbosacral radiculopathy? pathophys? Which nerve is affected in the pathophys? Waht are the findings with disc level L3/L4, L4/L5, L5/S1

Paresthesias and weakness in distribution of specific lumbar or sacral spinal nerves

Intervertebral disc herniation
Nerve association with inferior vertebral body is impinged.

L3/L4=weakness of knee extension, decr. patellar reflex
L4/L5=weakness of dorsiflexion, difficulty in heel walking
L5/S1=weakness of plantar flexion, difficulty in toe walking, decr. achilles reflex

30

Describe the steps of muscle conduction and contraction.

AP leads presynaptic voltage gates Ca channels to open, which releases NT

NT binds causing muscle cell depol in the motor end plate

Depol travels along muscle cell and down the T tubule

Depol of voltage sens dihydropyridine receptor couple to ryanodine receptor on sarcoplasmic reticulum induces conformation change, releasing Ca from SR

Ca binds troponin C, which causes tropomyosin to move out of myosin binding groove on actin filaments

Myosin releases bound ADP and PO4 leading to displacement of myosin on the actin filament (power stroke)

Myosin binds new ATP molecule causing detachment of head.

ATP hydrolyzes causing myosin head to cock, ready for next cycle.

31

What are the different lines and bands in skeletal muscle? What happens to them during contraction? What are t tubules? How many T tubules and terminal cisternae in skeletal muscle? Cardiac?

Z line-separates sarcomeres, place to which actin binds (capZ) and myosin (through titin) binds

I band=Just actin filaments (thin filaments), no thick

A band=Myosin filaments, overlapping actin filaments

H band=zone of thick filaments, not superimposed by thin filaments

M line=middle of sarcomere

When they contract, actin moves in towards M line, thus making the H bands and the I bands smaller, as well as the space between the Z lines shorter.
A band stays constant

T-tubules-extensions of plasma membrane juxtaposed with terminal cisternae. They are part of SR

In SM=triad=2 cist. 1 tubule
In CM=dyad=1 cist 1 tub

32

What is type 1 muscle? Speed? Color? Why? Action? type 2?

TYPE 1

Slow twitch
Sustained contraction
Red fibers
Incr mitochondria and myoglobin concentration
Incr. oxidative phoshorylation

TYPE 2

Fast twitch
White fibers resulting from decr. mitochondra and myoglobin conc
Incr. anerobic
Weight training

33

Describe the contraction and relaxation of a smooth muscle cell.

CONTRACTION

Action potential causes depol which activates L type voltage gated Ca channel on plasma membrane

Ca enters cell, binds to calmodulin, which activates MLCK, which phosphorylates myosin, allowing it to bind acting leading to contraction.

RELAXATION

Nitric oxide activates guanylate cyclase which converts GTP into cGMP

cGMP activates myosin light chain phosphatase which dephosphorylates myosin leading to relaxation.

34

Describe endochondral ossification. Which bones? Which cells? When does woven bone occur in adults?

Bones of axial and appendicular skeleton and base of skull

Cartilaginous model of bone is first made by chondrocytes
Osteoclasts and blasts later relplace it with woven bone then remodel it to lamellar bone

Fractures and Pagets

35

Describe membranous ossification? Which bones?

Calvarium and facial

No cartilaginous, straight to woven bone then to lamellar

36

What is the function of osteoblasts? Origination? Osteoclasts? Origination?

blasts=build bone by secreting collagen and catalyzing mineralization.
Mesenchymal stem cells in periosteum

Clasts=multinucleated cells that dissolve bone by secreting acid and collegenases
Monocytes, macrophages

37

What does PTH do to bones at low intermittent levels? At high levels?

Low: anabolic effects on osteoblasts and osteoclasts (indirect)

High: catabolic effects

38

What does estrogen do to bones? Deficiency?

Inhibits apoptosis in bone forming osteoblasts and induces apoptosis in bone resorbing osteoclasts

Excess cycles of remodeling and bone resorption leading to osteoporosis.

39

What is the pathophys of achondroplasia? Mutation/genetics? Symtpoms? Epid?

Failure of longitudinal bone growth (endochondral ossification--->short limbs

Membranous ossification is not affected---large head relative to limbs

Activation of FGFR3 inhibits chondrocyte proliferation
85% is sporadic
homozygous is lethal

Most common cause of dwarfism

40

What is primary osteoporosis? Lab values? Diagnosis? Causes? Presentations? What is type I? pathophys? type II? Epid? How can you prevent it? Treat it?

Trabecular (spongy) bone loses masa nd interconnections despite normal bone mineralization and lab values (serum Ca and PO4).

Diagnosed by bone mineral density test (DEXA) with a t score of 70 y.o.

Prevent: regular weight bearing exercise and adequate Ca and vitamin D intake throughout adulthood

Treatment: Bisphosphonates, PTH analogs, SERMs, rarely calcitonin; denosumab (RANKL antibody---against it)

41

What is osteopetrosis? Another name? Pathophys? Symptoms? Mutation? X ray? Complications? Treatment? Prognosis?

Marble Bone Disease

Carbonic anhydrase II mutation leads osteoclasts to have an inability to resorb bone (can't produce acid). Because of this, bone builds up.

Thickened dense bones, prone to fracture
Bone fills marrow space=pancytopenia and extramedullary hematopoesis

Xray-bone in bone appearance

CN impingment and palsies (narrowed foramina)

Bone marrow transplant (new osteoclasts).

42

What is the pathophys of osteomalacia and rickets? Symptoms? Lab findings?

Vit. D defic leads to osteomalacia in adults and rickets in children

Defective mineralization/calcification of osteoid

soft bones that bow out

Decr. Vit D leads to decr. serum calcium leads to incr. PTH secretion leads to decr. PO4

Hyperactivity of osteoblasts leads to incr. ALP (they require alkaline environment.

43

What is the pathophys of paget disease of bone? Histo? Another name? What are the stages? Symptoms? Complications? What does it incr. risk of? Lab values?

Osteitis Deformans

Common, localized disorder of bone remodeling caused by incr. in both osteoblastic and osteoclastic activity

Lytic:osteoclasts
Mixed: clasts and blasts
Sclerotic: blasts
Quiescent: minimal of both

ALP incr.

Serum Ca, PO4, and PTH levels normal

Mosaic pattern of woven and lamellar bone

Long bone chalk stick fractures
Hat size increased
Hearing loss common (auditory foramen narrow)

Incr bloow flow from incr. AV shunts may cause high output heart failure

Incr. risk of osteogenic sarcoma

44

What is the pathophys of osteonecrosis? Another name? Most common site? pathophys there? Causes?

Avascular necrosis

Infarction of bone and marrow

Femoral head: medial circumflex femoral artery

Alcoholism
Sickle Cell Disease
Storage
Exogenous/Endogenous corticosteroids
pancreatitis
Trauma
Idiopathic
Caisson (the bends)

45

What is a giant cell tumor like? Cellularity? Location? Epid? X ray? Histo?

Locally aggressive benign tumor

Often around knee

Osteoclastoma

Epiphyseal end of long bone

X-ray=soap bubble appearance

Multinucleated giant cells

46

What is an osteochondroma like? Epid? Possible risk?

Most common benign tumor (exostosis of the bone)

Mature bone with cartilaginous cap

Male < 25

Rarely transforms to chondrosarcoma

47

What is the epid of osteosarcoma? Ages? Predisposing factors? Location? x ray? Treatment?

2nd most common primary malignant bone tumor (behind multiple myeloma)

10-20 years old and >65

paget disease, bone infarcts, radiation, familial retinoblastoma, Li Fraumeni (p53 mutation)

Metaphysis of bone, near knee

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

Aggressive. Surgical en bloc resection (with limb salvage) and chemo

48

What is the epid of ewing sarcoma? Location? Histo/grade? Treatment/prognosis? Mutation/result?

boys < 15 yo

Diaphysis of long bones, pelvis, scapula, ribs

Anaplastic small blue cell malignant tumor
onion skin periosteal reaction in bone

t(11;22) translocation causing fusion protein EWS-FLI 1

11 + 22=33 (patrick ewings number)

49

Compare and contrast osteoarthritis and rheumatoid arthritis concerning Etiology, joint findings, predisposing factors, classic presentation, and treatment.

ETIOLOGY

OSTEO: mechanical, joint wear and tear destroys articular cartilage

RA: Autoimmune-inflamm destruction of synovial joints. Cytokines and Type III/IV HSR

JOINT FINDINGS

OSTEO: subchondral cysts, sclerosis, osteophytes (bone spurs), eburnation (polished, ivory like appearance), synovitis, Heberden nodes (DIP), Bouchard nodes (PIP). No MCP involvement.

RA: Pannus (inflammatory granulation tissue) formation in joins (MCP, PIP), subQ rheumatoid nodules (fibrinoid necrosis), ulnar deviation of fingers, subluxation. Rare swan neck and boutonniere deform. Rare DIP involvement

PREDISPOSING

OSTEO: Age, obesity, joint trauma

RA: Females > males. 80% have + RF (anti IgG Ab); anti-cyclic citrullinated peptide antibody is more specific. HLA-DR4

CLASSIC PRESENTATION

OSTEO: Pain in weight bearing joints after use (end of day), improves with rest. Knee cartilage loss begins medially (bowlegged). Non inflammatory. No systemic symptoms

RA: Morning stiffness lasting > 30 min and improving with use, symmetric joint involvement, systemic symptoms (fever, fatigue, weight loss, pleuritis, pericarditis)

TREATMENT

OSTEO: Acetaminophen, NSAIDs, intraarticular steroids

RA: NSAIDS, steroids, disease modifying agents (methotrexate/sulfasalazine), biologics (TNF-alpha inhib)

50

What is pathophys of sjogrens like? Epid? Symptoms? lab findings? Etiology? Complications?

Autoimmune disorder characterized by destruction of exocrine glands (lacrimal and salivary) by lymph infiltrates

Females 40-60

Inflammatory joint pain
xeropthalmia (decr. tear production leading to corneal damage
xerostomia (decr. saliva production)
Bilateral parotid enlargement

antinuclear antibodies SS-A (anti ro) and/or SS-B (anti-la)

51

What are some pathophysiologies of gout? Diagnosis? Symptoms? Precipitating factors? Acute treatment? Chronic? Epid?

Acute inflammatory monoarthritis caused by precipitation of monosodium urate crystals

Hyperuricemia caused by:
Underexcretion of uric acid (90% of pts)-usually idiopathic; can be exacerbated by medications (thiaz)
Overproduction (10%)-lesch nyhan, PRPP excess, incr. cell turnover, von Gierke disease

More common in males

Needle shaped and negative birefringent under polarized light (yellow under parallel light, blue under perpendicular).

Asymmetric joint distribution, usually MTP joint of big toe
Swollen, red, and painful
Tophus formation (external ear, olecranon bursa, or achilles tendon)
Acute attack after large meal or alcohol consumption (vies for secretion spots in kidney with urea)

Acute: NSAIDS, glucocorticoids, colchicine
Chornic: XO inhibitors (allopurinol, feboxostat)

52

What is the pathophys of pseudogout? Presentation? Location? Diagnosis? ASsociated diseases? Acute treatment? Prophylaxis? Epid?

Deposition of calcium pyrophosphate crystals within the joint space (chondrocalcinosis on x ray)

Pain and effusion in a joint, usually large joints (often knee)

Basophilic, rhomboid crystals that are weakly birefringent under polarized light (blue when parallel to light)

hemochromatosis, hyperparathyroidism, osteoarthritis

NSAIDS for sudden severe attacks; glucocorticoids
Colchicine for prophylaxis

Men=women >50

53

What are 3 common causes of infectious arthritis? Symptoms?

S. aureus, streptococcus, and N. gonorrhoeae

Swollen, red, and painful joint

Synovitis, tenosynovitis, and dermatitis

54

What are seronegative spondyloarthropathies? Genetics? Epid? 4 examples?

Arthritis w/o rheumatoid factor (no anti-IgG antibody)

Strong association with HLA-B27

Males

PAIR

Psoriatic arthritis
Ankylosing spondylitis
inflammatory bowel disease
reactive arthritis

55

What is the presentation like in psoriatic arthritis? Prevalence?

Joint pain and stiffness associated with psoriasis
Asymmetric and patchy involvement (only a few fingers)
Dactylitis (sausage fingers)
Pencil in cup deformity on xray

Fewer than 1/3 or psoriasis pts

56

What is the presentation/pathophys like in ankylosing spondylitis? x ray?

Chronic inflamm disease of spine and SI joints leads to ankylosis (stiff spine due to fusion of joints), uveitis, aortic regurgitation

Bamboo spine (vert fusion)

57

What often accompanies Crohns or UC?

Ankylosing spondylitis or peripheral arthritis

58

What is the class triad of reactive arthritis? Cause?

Conjuctivitis with anterior uveitis
Urethritis
Arthritis

Post-Gi (shigella, salmonella, yersinia, campylobacter
chlamydia

59

What is a basic classic presentation in SLE? Epid? What are some symptoms that can occur with SLE? Lab findings (what do they mean?)? What is libman sacks endocarditis? What types of nephritis occur? What are common causes of death in SLE? Treatment?

Rash, joint pain, and fever
Female of reproductive age
Black

Rash (malar or discoid)
Arthritis
Soft tissue/serositis
hematologic disorders (cytopenias)
Oral/nasopharyngeal ulcers
Renal disease/Reynauds phenomenon
Photosensitivity/Positive VDRL
ANAs
Immunosuppressants (to treat)
Neuro disorders (seizures/psychosis)

RASH OR PAIN

ANA (sens. not specific)
Anti-dsDNA=specific, poor prognosis (renal disease)
Anti-Smith (snRNPs)= specific, not prognostic
Antihistone antibodies=drug induced
Decr. C3/C4/CH50 (immune complex formation)

Non bacterial wart like vegetations on both side of valve

DPGN or membranous glomerulonephritis

CV disease
infections
renal disease

NSAIDS, steroids, immunosuppresants, hydroxychloroquine

60

What is the etiology of antiphospholipid syndrome? How is the diagnosis made (symptoms/lab findings)? Treatment?

Primary or secondary (SLE) autoimmune disorder
hypercoag state

History of thrombosis
Spontaneous abortion

Lupus anticoag (FP VDRL and prolonged PTT)
anticardiolipin (FP VDRL and prolonged PTT)
anti beta 2 GP antibodies

Systemic anticoag

61

What is the pathophys of sarcoidosis? Lab findings? Epid? Presentation? xray? Associations (conditions it can cause)? Treatment?

Immune mediated widespread noncaseating granulomas

Elevated serum ACE levels
Elevated CD4/CD8 ratio

Black females

Often asymptomatic except for enlarged LNs

Bilateral adenopathy and coarse reticular opacities

Interstitial fibrosis, erythema nodosum, lupus pernio, Bell palsy, epithelioid granulomas containing microscopic schaumann and asteroid bodies, uveitis, hypercalcemia

Steroids

62

What are the symptoms of polymyalgia rheumatica? Findings? Epid? Association? Treatment?

Pain and stiffness in shoulders and hips, often with fever, malaise, and weight loss

No muscle weakness

women > 50

Temporal arteritis

Incr. ESR, Incr. CRP, normal CK

Rapid response to low dose corticosteroids

63

What are the symptoms of fibromyalgia? Treatment?

Females 20-50

Chronic widespread MS pain associated with stiffness, paresthesias, poor sleep, fatigue

Regular exercise
Antidepressants
Anticonvulsants

64

What are the lab findings in polymyositis and dermatomyositis? Treatmenet? What ist he presentation and pathophys of polymyositis? What is the pathophys and symptoms of dermatomyositis?

Incr. CK, +ANA, +Anti-Jo-1 AB, Anti SRP, Anti Mi 2 AB

Steroids followed by long term immunosuppressant therapy (methotrexate)

POLY

Progressive symmetric proximal muscle weakness, often in shoulders

Endomysial inflammation with CD8 T cells

DERM

Similar to poly, but with malar rash, gottron papules, heliotrope rash, shawl and face rash, mechanics hands.
Incr. risk of occult malignancy

Perimysial inflammation and atrophy w/ CD4 T cells

65

Compare and contrast myasthenia gravis with lambert eaton myasthenic syndrome concerning prevalence, pathophys, presentation, assocation, and response to AChEIs?

MG

most common NMJ disorder

autoantibodies to postsyn ACh receptor

ptosis, diplopia, weakness
Worsens with muscle use

Thymoma, thymic hyperplasia

Reversal of symptoms


LEMS

uncommon

autoantibodies to presynaptic CA channel leads to decr. ACh release

proximal muscle weakness, autonomic symptoms (dry mouth, impotence)
Improves with muscle use

Small cell lung cancer

Minimal effect

66

What is myositis ossificans? Location? Presentation?

metaplasia of skeletal muscle into bone following muscular trauma

Upper or lower extremity

Suspicious mass at site of known trauma or as incidental finding on radiography

67

What is the triad of scleroderma? Presentation? Describe the two types and associated antibody. Epid? Most common cause of death?

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

Sclerosis of skin (puffy, taut skin without wrinkles), fingertip pitting
Sclerosis of renal, pulmonary, CV, and GI systems

Diffuse: widespread skin involvement, rapid progression, early visceral involvement.
Anti Scl-70 AB=Anti DNA topoisomerase I

Limited: skin involvement confined to fingres and face
CREST:
Calcinosis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
Anti-centromere antibody

68

What are the 3 layers of skin? What are the five layers of the epidermis? What do they contain?

Epidermis, dermis, subQ fat (hypodermis)

Californians like girls in string bikinis

Strateum corneum (keratin)
stratum lucidum
stratum granulosom
stratum spinosum (desmosomes)
stratum basale (stem cell site)

69

What is a tight junction? Another name? Function? What is it made up of? Same questions for adherens junction, desmosome, gap junction, integrins, and hemidesmosome.

Tight: Zonula occludens=prevents paracellular movement of solutes. Claudins and occludins

Adherens Junction: Zonula adherens=below tight junction, forms belt connecting actin cytoskeletons of adjacent cells with CADherins (Ca depend Adhesion proteins).

Desmosome: Macula adherens-structural support via keratin interactions

Gap Junction: Channel proteins call connexons permit electrical and chemical communication b/w cells

Hemidesmosome: connects keratin in basal cells to underlying BM

Integrins: membrane proteins that maintain integrity of Basolateral membrane by binding to collagen and laminin in BM.

70

What is a macule? Example? Patch? Papula? plaque? Vesicle? Bulla? Pustule? Wheal? Scale? Crust?

Macule: flat lesion with well circumscribed change in color < 1cm=freckle, labial macule

Patch? macule > 1 cm=large birthmark

Papula? elevated solid skin lesion < 1cm=mole, acne

plaque? papule > 1 cm=psoriasis

Vesicle? Small fluid containing blister < 1 cm=chickenpox

\Bulla? large fluid containing blister > 1cm bullous pemphigoid

Pustule? Vesicle containing pus=pustular psoriasis

Wheal? transient smooth papule or plaque=hives

Scale? flaking off of stratum corneum=eczema, psoriasis, and SCC

Crust? dry exudate=impetigo

71

What is this? Example?

hyperkeratosis:
parakeratosis:
spongiosis:
acantholysis:
acanthosis:

hyperkeratosis: incr. thickness of stratum corneum=psoriasis and calluses

parakeratosis:hyperkeratosis with retention of nuclei in stratum corneum=psoriasis

spongiosis:epidermal accumulation of edematous fluid in intercellular spaces=eczematous derm

acantholysis: separation of epidermal cells=pemphigus vulgaris

acanthosis: epidermal hyperplasia (incr. spinosum)=acanthosis nigricans

72

What is albinism? Pathophys? Other causes? Risks?

Normal melanocyte number with decr. melanin production due to decr. tyrosinase activity or defective tyrosine transport

Failure of neural crest cell migration

Incr. risk of skin cancer

73

What is melasma? Associations? What is vitiligo? Cause?

Hyperpigmentation associated with pregnancy or OCP use

Irregular areas of complete depigmentation caused by autoimmune destruction of melanocytes

74

Waht is acne? Pathophys? epid?

obstructive and inflammatory disease of the pilosebaceous unit predominantly found in the face and trunk

Adolescents most common

75

What is atopic dermatitis? Presentation? Associations?

Eczema=type I

Pruritic eruption, commonly on skin flexures

Asthma, allergic rhinitis

Starts on face in infancy then appears in antecubital fossae

76

What is the pathophys of allergic contact dermatitis? Causes?

Type IV HSR to nickel poison ivy or neomycin

77

What is a melanocytic nevus? risks? Intradermal presentation? Junctional presentation?

Common mole. Benign

Risk of melanoma

Intradermal=papular

Junctional=flat

78

What is the presentation of psoriasis? Histology? What is auspitz sign? ASsociations?

Papules and plaques with silvery scaling (knees and elbows)

Acanthosis with parakeratotic scaling (nuclei still in corneum).
Incr. spinosum, decr. granulosum
Auspitz sign=bleeding when taking off scales (exposure to dermal papillae)

Nail pitting and psoriatic arthritis

79

What is rosacea? Pathophys/presentation? risk?

inflamm facial skin disorder characterized by erythematous papules and pustules but no comedones

Facial flushing to external stimuli

Rhinophyma (deformation of nose)

80

What is the presentation of seborrheic keratosis? Location? Pathophys? What is the leser trelat sign? Cause?

flat, greasy, pigmented squamous epithelial proliferation with keratin filled cysts

Looks stuck on (dark brown stuck on coin)

Head trunk and extremeties

Common benign neoplasm of older persons

Leser trelat=sudden appearance of multiple seborrheic keratoses, indicating underlying malignancy

81

What are verrucae? Cause? Histo?

Warts

HPV

Soft, tan colored cauliflower like papules

epidermal hyperplasia, hyperkeratosis, koilocytosis

Condyloma acuminatum

82

What is urticaria? pathophys? Characterized?

Hives.

Pruritic wheals that form after mast cell degranulationn

Superficial dermal edema and lymph channel dilation

83

What is impetigo like? Depth? Causes? Bullous impetigo?

very superficial

S. aureus or S. pyogenes

Honey colored crusting

Same but with bullae=staph

84

What is cellulitis like? depth? Bug? Cause?

Acute painful spreading infection

Deeper dermis and subQ

S. pyogenes or S. aureus

Break in skin from trauma or other infection

85

What is erysipelas like? Depth? Bug?

Well defined demarcation between infection and normal skin

Upper dermis and superficial lymph

S. pyogenes

86

What is an abscess like? Depth? Cause?

collection of pus from walled off infection

deeper layers of skin

S. aureus (MRSA)

87

What is necrotizing fascitis like? Cause? Depth? Bug?

Bullae and purple color to skin
crepitus from methane and CO2 productionn
Flesh eating bacteria

Deeper tissue

S. pyogenes or anaerobic bacteria

88

What is the pathophys of staphylococcal scalded skin syndrome? Presentation? Epid?

Exotoxin destroys keratinocyte attachments in stratum granulosum only.

Fever and generalized erythematous rash with sloughing of the upper layers of the epidermis that heals completely

Newborns, children, adults with renal insufficiency

89

What is the pathophys of pemphigus vulgaris? Presentation? Locations? Diagnosis?

Potentially fatal autoimmunde skin disorder with IgG ab against desmoglein (part of desmosome)

Flaccid intraepidermal bullae caused by acantholysis (no desmosomes to hold stratum spinosum together)

Oral mucosa involvement

IF=Abs around epi cells in a netlike pattern
Nikolsky sign==separation of dermis upon manually stroking of skin

90

What is the pathophys of bullous pemphigoid? Presentation? Locations? Diagnosis?

Less severe than pemphigus vulgaris. IgG Ab against hemidesmosomes (bullow the epi)

Tense blisters containing eosinophils that affect skin but not oral mucosa

IF=Linear pattern at epi/derm junction

Nikolsky sign negative

91

What is the presentationn of dermatitis herpetiformis? Location? Pathophys? ASsociation?

Pruritic papules, vesicles, and bullae (often on elbows)

IgA at tips of dermal papillae

Celiac disease

92

What are some associations with erythema multiforme? Presentation?

Infections (Myco, HSV), drugs (sulfa, beta lactams, phenytoin), cancers, autoimmune

Multiple types of lesions (macules, papules, vesicles, target lesions)

93

What are the symptoms of stevens johnson syndrome? Locations? Presentation? Assocation? What is toxic epidermal necrolysis? What is SJS-TEN? How is TEN different from staph scalded skin syndrome?

Fever,
bullae formation and necrosis
Sloughing of skin
High mortality rate

2 mucous membranes involved
Targetoid lesions mmaybe

Adverse drug reaction

>30% of body surface = TEN ( destroys epi/derm junction, not just the stratum granulosum connections)

10-30%=SJS=TEN

94

What is acanthosis nigricans? Location? Assocations?

Epidermal hyperplasia causing symmetric, hyperpigmented thickening of skin, especially in axilla or on neck.

Hyperinsulinemia (diabetes, obesity, cushing)
Visceral malig (gastric adenoCA)

95

What is actinic keratosis? Presentation? Risks involved?

Premalignant lesions caused by sun exposure.

Small rough erythematous or brownish papules or plaques

Risk of Squam cell CA proportional to degree of dysplasia

96

What is erythema nodosum? Associations?

Painful inflammatory lesions of subQ fat, usually on anterior shins.

Idiopathic

Sarcoid, coccidiomycosis, histoplasmosis, TB, streptococcal infections, leprosy, crohns.

97

Presentation of lichen planus? Mucosal involvement? Histo? Assocation?

6 Ps

Pruritic
Purple
Polygonal, Planar Papules and Plaques

Wickham Striae (retic. white lines)

Sawtooth infiltrate of lymphocytes at dermal epidermal jucnitons

Hep C

98

What is presentation of pityriasis rosea? Prognosis?

Herald Patch followed days later by other scaly erythematous plaques in a christmas tree distribution

Multiple plaques with collarette scale

6-8 weeks self resolve

99

What is a sunburn? Pathophys? What do UVA and UVB lead to? What can it lead to?

acute cutaneous inflammatory reaction due to excessive UV irradiation

DNA mutations, inducing apoptosis of keratinocytes

UVA=tanning and photoaging
UVB=Sunburn

Impetigo, skin cancers

100

Epid of Basal cell CA? Location? Spread? Typical Appearance? Other appearances? Histo?

Most common skin cancer

Sun exposed areas

Locallly invasive, no mets

Pink, pearly nodules, commonly with telangiectasias, rolled borders, central crusting or ulceration

Nonhealing ulcres with infiltrating growht
Scaling plaque

Palisading nuclei

101

Squamous cell CA epid? Assocations? Location? Spread? Appearance? Histo? What is keratocanthoma like?

SEcond most common skin cancer

Excessive exposure to sunlight
Immunosuppression
Chronic draining sinuses
Sometimes arsenic exposure

Locally invasive, maybe to LNs, rare mets

Ulcerative red leasions with frequent scale

Face, lower lip, ears, hands

Keratin pearls

Variant that grows rapidly (4--6 weeks) and may regress spontaneously over months

102

Spread of melanoma? Tumor marker? Assocations? Risk factors? What does depth of tumor indicate? What is the appearance like? What are the 4 different types? Mutation? Treatment? Treatment in metastatic or unresectable with BRAF V600E mutation?

Significant risk of metastasees

S-100

Sunlight exposure
Fair skinned

Depth correlates to risk of mets

ABCDE
Asymmetry
Border irregular
Color variation
Diameter > 6mm
Evoluation over time

Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous

Activation of BRAF kinase

Excision with wide margins

Vemurafenib, a BRAF kinase inhibitor