Musculoskeletal

Question 1

Elbow Flexion

Answer 1

C5, C6

Question 2

Elbow Flexion

Answer 2

C5, C6

Question 3

Elbow Extension

Answer 3

C6,C7,C8 (Same as grip)

Question 4

Grip

Answer 4

C6, C7, C8 (Same as elbow extension)

Question 5

Finger Abduction

Answer 5

C8, T1, Ulnar nerve

Question 6

Opposition of the thumb

Answer 6

C8, T1, Median nerve

Question 7

Hip Flexion and adduction

Answer 7

L2, L3, L4

Question 8

Hip abduction

Answer 8

L4, L5, S1

Question 9

Hip Extension

Answer 9

S1

Question 10

Knee Extension

Answer 10

L2, L3, L4

Question 11

Knee Flexion

Answer 11

L4, L5, S1, S2

Question 12

Dorsiflexion

Answer 12

L4, L5

Question 13

Plantar Flexion

Answer 13

S1

Question 14

What is the Glascow Coma scale?

Answer 14

Defines neurological impairment
Eyes open- 1-4
Best Verbal Response: 1-5
Best Motor Response: 1-6
8 or less is severe will require automatic intubation and controlled ventilation for ICP and airway control.

Question 15

Plantar Flexion

Answer 15

S1

Question 16

What are the MAOI’s to know?

Answer 16

Iproniazid, phenelzine, isocarboxazid, moclobemide, befloxatone, brofaromine, selegiline (for Parkinson’s)

Question 17

What are some drugs that people with NMD are on?

Answer 17

Steroids, MAOIs, Methotrexate, Pergolide for PD

Question 18

What are some drugs that people with NMD are on?

Answer 18

Steroids, MAOIs, Methotrexate, Pergolide for PD, Anticholinergics, Levodopa, Pain meds: Opiods, ASA, NSAIDS, Anticonvulsants, cholinesterase inhibitors (MG),
Guillane Barre: vasoactives, pressors or BBs

Question 19

What are some drugs that people with Lupus might be on?

Answer 19

Ibuprofen, Indomethacin, ASA, CO2 inhibitors, DVT prevention, Steroids

Question 20

What are some drugs people with RA could be on?

Answer 20

Methotrexate!!!! ASA, NSAIDS, immunosuppresives, steroids

Question 21

What are some drugs people with myasthenia gravis could be on?

Answer 21

Cholinesterase inhibitors, steroids, immunosuppresives

Question 22

What are some drugs people with Parkinsons disease might be on?

Answer 22

Levadopa, MAOIs, anticholinergics, history of Pergolide?

Question 23

What are some concerns for the patient with MS?

Answer 23

● Demyelinating disease of the brain & spinal cord
● These patients are generally on immunosuppressive medications
○ Any recent history of illness or infection?
○ Take extra care with infection prevention
○ Which medications are they taking & how often?
○ Steroids in the past year????
● Remission & exacerbation intervals
● Severity & nature of symptoms
○ Respiratory status
○ Previous triggers or exposure
○ Paralysis (assess for motor strength)
○ Sensory disturbances (assess along dermatomes)
○ Autonomic disturbances (resting heart rate, orthostatic hypotension)
○ Visual impairment (cranial nerve check)
○ Seizures (medications)
○ Emotional Disturbances
● Counsel patient regarding ↑ relapse incidence with surgery

Question 24

What are some concerns for patient with Guillan Barre?

Answer 24

● Document the severity & current state of symptoms
○ Facial paralysis: bulbar involvement (what other concerns might you have here????)
■ Problems at this level could involve brainstem issue
● I.e. HR, VS
○ Difficulty swallowing: pharyngeal muscle weakness
○ Impaired ventilation: current ventilatory support required (vent settings)
○ ↓ deep tendon reflexes: lower motor nerves
○ Extremity paresthesias
○ Pain: headache, backache, muscle tenderness + note medications helpful for controlling pain
recipitating factors
○ Onset of symptoms
○ Disease progression (worsening, stable, improving)
Document time course
**ANS dysfunction!

Question 25

Concerns for patient with Parkinson?

Answer 25

● Progression destruction of dopermagenic neurons in the basal ganglia ● Age of diagnosis, recent exacerbations & hospitalizations ● Current & past symptoms (ex. oculogyric crisis, when? How long did it last? What helped?) ○ ANS symptoms (orthostatic BPs) ○ History of Pergolide therapy? ■ Withdrawn d/t causing valve dysfunction ○ Temperature regulation issues? ○ Pulmonary status optimized? ■ Dysphagia &/or dyspnea On Levodopa? Note nature ROM of extremities

Question 26

What are concerns with patient with acute spinal cord injury?

Answer 26

``` ● Spinal Shock ○ Lesion above the heart → no ability to control the heart ● Acute (spinal shock) ○ Fluid & Blood Status ■ CBC, Type & Cross, Chem 7 ○ ECG/Chest X-ray ○ Vasopressor requirement? ○ Ventilatory support (current vent settings)? ■ C3, 4, 5 keep them alive ○ Associated injuries? ```

Question 27

Concerns with chronic spinal cord injury?

Answer 27

○ Risk autonomic dysreflexia, especially with lesion above T10 ○ History of autonomic dysreflexia? What initiated it? ○ Old OR/ICU records helpful → response to vasopressors, tracheal suctioning ○ Ventilatory reserve → level of lesion ○ Assessment of skin integrity ○ Positioning → note normal range of motion

Question 28

Concerns with patient with seizure disorder?

Answer 28

● Type of seizure activity; typical length, frequency, severity, & recovery period ● Precipitating/causative factors (ETOH withdrawal) ● History of status epilepticus (how long did it last, how was it treated, were treatments effective) ● Pharmacologic Therapy: ○ Testing directed based on medications → CBC, platelet, electrolyte panel common ○ Routine levels of anticonvulsants unnecessary in patients with good seizure control ○ Cancel elective surgery until seizure disorder optimized by neurologist

Question 29

SLE: Physical exam?

Answer 29

● Wide systemic autoimmune vasculitis ○ Higher risk with seizures ● Note natural range of motion (arthritis) ● Note neuromuscular strength, cranial & peripheral neuropathies ● Note mentation (CNS involvement) ● Fluid & electrolyte status → chemistry Panel ● Hematologic → CBC, PT/PTT & INR ● Possible chest X-Ray ● Skin: note existing rashes (not to be confused with allergic reactions periop) ● Distal extremities: Raynaud’s common → pulse ox readings difficult (use ear) ● Renal Function: glomerulonephritis, proteinuria, albumin level, chemistry panel ● Cardiac status: Echo, cardiac consult, pericarditis? Conduction abnormalities?, CHF, valvular dysfunction? ● Pulmonary status: pulmonary function tests (restrictive pattern) ● Gastrointestinal: prone to N/V?

Question 30

SLE medications?

Answer 30

``` ● Note dose amount, frequency, timing of last dose, side effects, etc. ● Drugs that affect coagulation status: ○ Ibuprofen ○ Indomethacin ○ ASA ○ Cox-2 Inhibitors ○ DVT preventative therapy → high DVT risk with lupus ● Immunosuppressive therapy ● Steroids ● Optimized by PCP or rheumatologist? ```

Question 31

RA concerns and findings?

Answer 31

● Autoimmune disease that usually affects the joint but can be systemic ● Focus areas: airway, neurological, pulmonary, CV ● Note Natural Range of Motion ○ TMJ: limited mouth opening ○ Atlanto-axial joint: lateral neck radiograph or MRI ■ Can compress this joint & cause paralysis ○ Cricoarytenoid arthritis: hoarseness, pain on swallowing, dyspnea, stridor, laryngeal tenderness ■ Can have narrow airway ○ Individualized airway plan based on findings ● Issues with lungs possible ● Dyspnea is often a sign of cardiac ischemia in this population ○ PFTS & ABG if suspect lung involvement (restrictive pattern) ○ ECHO, ECG (cardiac conduction) especially if cardiac involvement suspected ● Consider effect of medications: ASA, NSAIDS, methotrexate, immunosuppressive drugs & steroids ○ Balance preference to continue meds with anti-coagulation & immunosuppressive characteristics ○ Very dependent on NSAIDs

Question 32

Concerns with Myasthenia Gravis?

Answer 32

● Autoimmune destruction of Ach receptors at the NMJ ● Note degree of skeletal muscle weakness, progression of the disease ● Note medication history ○ Cholinesterase inhibitors ■ I.e. neostigmine ○ Steroids ■ May need supplementation before surgery ○ Immunosuppressive therapy

Question 33

Concerns with Muscular Distrophy?

Answer 33

● Muscle wasting over time ● Note progression of the disease, natural range of motion, muscle strength ● Delayed gastric motility ● Ventilatory status (PFT, cough strength) ● Cardiac: ECG, perhaps ECHO ○ Can have issue on heart as well