Clinical Flashcards
What is the major complaint by individuals who have arthritis?
joint pain
What is the easiest way to differentiate articular form non-articular joint pain?
passive joint motion preserved in non-articular injury without pain
Who is most at risk of infectious arthritis?
immunocompromised
[also, diabetes, IV drug use]
What joints are usually affected by infectious arthritis?
1) hip
2) knee
3) ankle
4) wrist
What are the components of synovial fluid analysis?
1) cell count
2) gram stain
3) culture
4) crystal identification
Which pathology is typical of crystal formation?
Gout
Which lab tests suggest gout?
1) crystal identification in synovial fluid analysis
2) uric acid level elevated in blood tests
Are heat and swelling more typical of articular or non-articular injuries?
articular; joint effusion
What is the gold standard of diagnosing Rheumatoid arthritis?
greater than 1 hour of morning stiffness in the affected joints
What are the key signs of osteoarthritis?
1) non-inflammatory
2) pain after use
3) improvement after rest
4) no systemic symptoms
What is the most common form of arthritis?
osteoarthritis; “wear and tear arthritis”
What are the risk factors of Rheumatoid arthritis?
1) age
2) obesity
3) manual labor
4) female
5) trauma
What are bouchard nodes?
bony proliferation of proximal IP joints in OA
What are heberden nodes?
bony proliferation at distal IP joints in OA
What are the causes of septic arthritis?
1) trauma
2) hematogenous spread
3) spread of osteomyelitis
The lump or mass scheme offers us which two ways to begin the investigation?
1) Visible or palpable
2) Non-visible, non-palpable (i.e., “occult”)
When you encounter a lump or mass, what is the essential part of the patient’s history?
examine old medical records
What is the most common cause of a Virchow’s node of the neck?
GI cancer breast cancer (women)
What are the types of biopsies?
1) brush (cheek)
2) leather punches (skin)
3) cotton brush (tongue)
What should first be done with malignancies of the head and neck, associated with or without adenopathy (“swollen” lymph nodes), sbefore an incisional or excisional lymph node biopsy?
panendoscopy (Complete physical examination of the head and neck by pharyngoscopy, laryngoscopy, and upper GI endoscopy “EGD”)
What is the purpose of completing a panendoscopy?
Find the primary tumor of a malignancy of the head and neck
What are the major complication of biopsies?
1) bleeding
2) infection
3) hematoma
4) bruising
5) poor cosmosis (scarring)
Are imaging and biopsy necessary for a mass or lump on his arm?
NO
What is the treatment for an elderly man with a mass or lump on his arm
sling, rest, no surgery
What is Prune-Belly Syndrome?
congenital disorder aka “Eagle-Barret Syndrome” which shows a triad of symptoms:
1) Partial or complete lack of abdominal muscles (wrinkled skin, abdominal distention)
2) Undescended testes (males)
3) Urinary tract abnormalities
What is an inguinal hernia & treatment?
Defect in fascia where piece of intestine slips into inguinal region; best diagnosed by physical examination
treatment: Truss/support or surgical repair
What is an Umbilical Hernia & treatment?
looks like an “outie” belly-button from intestines herniating
treatment: mostly surgical, some close by 2 yo
What is an Incisional Hernia & treatment?
Fascial defect or weakness from prior operation causes intestines/colon to herniate
treatment: repair with mesh
What is Diastasis Recti & treatment?
Presents as a “lump” or “bulge” in the midline of the abdomen; asymptomatic, NO fascial defect
treatment: no repair indicated
What is a Lumbar Hernia?
Grynfeltt-Lesshaft Hernia; rare
Grynfeltt-Lesshaft Hernia: superior lumbar triangle
Petit’s Hernia: inferior lumbar triangle
What is a Spigelian Hernia?
special type of ventral hernia (hernia on ventral abdomen); occurs at semi-lunar line and lateral to rectus musculaturea umbilicus level or below
What is treatment of a sarcoma?
wide surgical excision, radiation, and chemotherapy after diagnosis by MUSCLE BIOPSY
What is the treatment of an osteoma?
local excision
What is the treatment of an osteosarcoma?
amputation, radiation, chemotherapy
What is a Rectus Sheath Hematoma & treatment?
Results from trauma to anterior abdomen and bleeding into rectus muscle (imaging to rule out intra-abdominal injuries with trauma etiology)
treatment: abdominal binder and bed-rest
What can happen with patients on blood thinners in regards to Rectus Sheath Hematomas?
bleed spontaneous into rectus sheath or retro-peritoneum (retro-peritoneal hematoma)
What is a Gastrointestinal Stromal Tumor (GIST) & treatment?
A tumor of the GI tract derived from mesenchymal tissue surrounding the organs (stomach, intestine, etc.); genetic: c-kit pathway gene
treatment: treat symptoms
What is an Endometriosis of Rectus Muscle & treatment?
Pain and Lump in a scar; Mass within an abdominal muscle; Derived from endometrium of uterus [gets worse during menstruation and subdues]
treatment: Hormonal manipulation or surgical excision
What is a Leiomyoma & treatment?
fibroid tumor; muscular wall of uterus
treatment:
1) Ablation
2) Hysterectomy
3) Embolization
4) Myomectomy
5) Hormonal control
What is the treatment for psoas muscle abcess?
percutaneous drainage and antibiotics
aspiration will reveal puss
What are infectious red flags of acute cervical neck pain?
1) fever and chills
2) nights sweats
3) recent bacterial infection
4) unremitting pain despite rest and analgesics
5) night pain
6) IV drug use, immunocompromised
possible infection
Why might a person with an infection causing acute neck pain not cause a fever?
immunocompromised
What are acute neurologic red flags of cervical neck pain?
1) bowel or bladder incontinence
2) saddle anasthesia
etc.
**nerve damage
What are pathologies which can cause an acute neurologic cervical neck pain?
Occipital-Atlantal Dislocation (OAD)
-paresis and apnea of CN VI, X, XII
Herniated Cervical Disc (not very common; usually trauma)
Cervical Radiculopathy and Stenosis
-osteophytes (bone spurs)
What are pathologies which can cause an acute musculoskeletal cervical neck pain?
somatic dysfunction
- computer use
- rigorous workout
- sleep funny
cervical fracture (trauma)
What are pathologies which can cause an acute vascular cervical neck pain?
vertebral artery insufficiency
- check cranial nerve palsies
- bruit on PE (plaque buildup in vessels)
Whiplash
-ligament destruction
What are pathologies which can cause an chronic musculoskeletalcervical neck pain?
Cervical spondylosis (aka "lipping") Myelopathy
Red Flags:
tenderness and restricted ROM
What if thoracic pain doesn’t go away after the fever, chills, night sweats and rest?
chronic infectious
bacterial tonsillitis
cervical discitis
How can abdominal disease cause thoracic pain?
neurologic; organs innervated by nerves
If you see these symptoms, what is the likely cause and what should you do? acute thoracic pain and low blood pressure
thoracic aortic aneurism rupture; perform bedside echocardiogram
What is the most common type of dysfunction which causes back pain?
musculoskeletal dysfunction
What are the two types of thoracic fractures and how are they diagnosed?
compression
burst
pain with motion
When a patient is experiencing pain in both the thoracic vertebrae and the ribs, which should be treated first?
thoracic vertebrae; ribs are secondary (structurally) to the vertebrae
What are red flags of lumbar pain?
hx of cancer
nights sweats, fever
weight loss
aka cancer risk factors
also, corticosteroid use
What is commonly confused as groin pain?
Abdominal Aortic Aneurysm
What is Spondylolisthesis?
chronic lower back pain; vertebrae is slipping forward due to fracture of spondylolysis between spines of connecting vertebrase
What does anisotropic mean?
material which has mechanical properties different in different directions; 3 types: rolling, spinning, gliding
What is the relationship between glide and roll in joint movement?
glide direction is opposite of the roll
What is Reiter Syndrome?
reactive arthritis
What is the classic triad of symptoms of reactive arthritis?
arthritis
conjunctivitis
urethritis
What is the genetic predisposition for Reither syndrome ankylosing spondylitis, and psoriasis?
HLA-B27
Which form of arthritis presents as low back pain in male teens and early 20s?
ankylosing spondylitis
What is psoriasis?
skin grows too fast and forms lesions; t-cell mediated disease
What are the clear signs of psoriasis?
nail discoloration
nail pitting
Which ethnic group does inflammatory bowel disease most commonly effect?
jewish
How is erosive inflammatory osteoarthritis differentiated from rheumatoid arthritis?
EIO:
RA serologic markers (-)
ESR and CRP (normal)
swelling of soft tissue
What are the common causes of neck pain?
postural imbalances
ergonomic factors
What are examples of acute infections of the cervical and thoracic vertebrae and what are red flags?
1) meningitis
2) osteomyelitis
3) discitis
4) epidural abscess
5) fasciitis
**signs of inflammation
What is the main red flag for a deep neck infection?
pain out of proportion to physical findings and “advanced airway signs”
What are examples of acute neurologic of the cervical vertebrae and what are red flags?
occipito-atlanto dislocation
herniated nucleus pulposus
cervical myelopathy
**trauma, bowel/bladder incontinence
What is the main clinical presentation of occipito-atlantal dislocation (OAD)?
cranio-cervical ligamentous instability
What is radiculopathy?
nerve root compression at neck with resultant pain, tingling, and numbness
What are the common causes of radiculopathy?
1) nerural foraminal narowing from cervical arthritis
2) cervical disc lesion
What do strenght, sensory, and reflex testing differentiate between?
radicular pain
peripheral nerve damage
global deficits
How is a neurologic exam typically done for checking nerve deficits?
tapping brachioradialis tendon; hypoactive wrist and hyperactive finger flexion = inverted radial reflex (spinal cord compression)
What are examples of acute musculoskeletal damage of the cervical vertebrae?
whiplash (w/ no neurologic or lab findings)
What is the imaging used to view and diagnose whiplash?
nothing confirms; X-ray done to rule out bony fracture
What are examples of acute vascular damages to the cervical vertebrae?
vertebral artery insufficiency
arterial dissection
When should individuals be examined for chronic neck pain?
1) w/ or w/o hx of remote trauma
2) w/ hx of malignancy
or
3) w/ hx of neck surgery in remote past
What are examples of chronic infections of the cervical vertebrae?
cervical discitis
What are examples of chronic musculoskeletal damages and infections to the cervical vertebrae?
spondylosis
cervical myelopathy
cervical radiculopathy
What is the most common spinal cord disorder?
spondylosis
What is the hallmark symptom of cervical spondylotic myelopathy?
weakness or stiffness in the legs
What does the neurologic exam show for a patient with cervical spondylotic myelopathy?
hyperreflexia
What are examples of chronic vascular damage to cervical vertebrae?
carotidynia
What is carotidynia?
vascular change occurs in coratid artery of neck with hx of migraines
What are examples of acute neurologic of the thoracic vertebrae and what are red flags?
1) stomach or duodenal ulcers
2) pancreatitis
3) angina (cardiac)
4) gastro-esophageal disease (GERD)
5) asthma
6) pneumonia
Which abdominal diseases cause thoracic pain?
1) tumors of stomach or duodenum
2) biliary disease
3) pancreatic disease
4) pyelonephritis
What are examples of acute musculoskeletal damages to the thoracic vertebrae?
fracture
somatic dysfunction
thoracic strain
What is the most relevant finding during the history for a thoracic fracture?
moderate to severe pain related to a traumatic event
How does a patient present with a thoracic aortic aneurysm?
acute pain usually harbinger of rupture
hypotension
**bedside echocardiogram
What is osteomyelitis?
bone infection which can lead to destruction of tissue
What part of a patient’s past medical history suggest that the thoracic spine will be more susceptible to injury?
1) osteoporosis
2) steroid use
What is “stress posture”?
functional thoracic kyphosis
