Clinical Flashcards
What are the diagnosis criteria of RA?
- Inflammatory arthritis: 3 or more joints, usually symmetrical small joints
- Positive RF and/or anti-CCP?
- Elevated CRP and/or ESR?
- Exclude diseases with similar features
- Duration of symptoms > 6 weeks
What are the non-pharmacological treatment for RA?
- Patient education
- Psychosocial interventions
- Rest, exercise, and physical and occupational therapy
- Nutritional and dietary counseling
- Interventions to reduce risks of cardiovascular disease, including smoking cessation and lipid control
- Screening for and treatment of osteoporosis
- Immunizations to decrease risk of infectious complications of immunosuppressive therapies
Pharmalogical treatment of RA?
- NSAIDs, Corticosteroids
- DMARDs (Disease Modifying Anti-Rheumatic Drugs)
- Methotrexate
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine
- Biologic agents
What are the factors that contribute to RA?
Genetic/biologic
- T cells
- B cells
- Rheumatoid factor (antibody)
- Anti-CCP (Cyclic Citrullinated Peptide) or ACPA (Anti Citrullinated Protein Antibody)
- HLA-DRB1 alleles
- Immune complexes
- Synovial fibroblasts
Environmental
- Smoking
- Periodontal disease
Osteoarthritis affects most commonly which joint?
Distal inter-phalangeal joints (DIP)
RA commonly affects which joint?
Proximal inter-phalangeal joint (PIP) and metacarpo-phalangeal joint (MCP)
Which muscle flexes MCP joint while extends PIP and DIP joints?
Lumbricals
Claw hand is a sign of what?
Lumbricals muscle are paralyzed because of brachial plexus injury or compression of ulnar and/or median nerve
What are the borders of the anatomical “snuff box”?
- Extensor pollicis longus
- Extensor pollicis brevis
- Abductor pollicis longus
Which important structures pass into the anatominal “snuff box”?
The radial artery and the radial nerve
What muscles are involved in the Golfer elbow injury?
Muscles that origine from the medial epicondyle:
- Pronator teres
- Flexor carpi radialis
- Palmaris longus
- Flexor carpi ulnaris
What muscles are involved in the Tennis elbow injury?
Muscles that originate from the Lateral epicondyle:
- Extensor carpi ulnaris
- Extensor digiti minimi
- Extensor digitorum
- Extensor carpi radialis
- Supinator
What carpal bone is most likely to fracture if you fall on your wrist like that?
Scaphoid
Which ligament is most likely to be injured if you pull your child like that?
The annular ligament
What are the indication for a surgery for swimming shoulder?
- Swimmers not responding to rehabilitation with anatomic abnormalities may need imaging and surgery
- Swimmers with associated glenoid labral tears need arthroscopic labral repair
* ***NOT IMPINGEMENT****
A Bony Bankart lesion indicates what?
Anterior glenoid rim fracture
A Hill-Sachs lesion indicates what?
HH Impression fracture (postero-superiorlaterally)
A Bankart lesion represents what?
Anterior tear
Reverse Bankart lesion indicates what?
Posterior tear
Reverse Bony Bankart indicates what?
Posterior glenoid rim fracture
Reverse Hill-Sachs lesion indicates what?
HH impression fracture antero-medially
What are the indications of surgery in a First Acute Anterior Shoulder Dislocation?
- Young athlete
- Associated injury (ex. RC tear)
- Irreducible dislocation
- Failed trial of rehabilitation
- Inability to tolerate shoulder restrictions
- Inability to perform sport-specific drills without instability
Someone come in with that knee and tells you they work a lot on their knees (ex. cleaning the floor).
What is your diagnosis?
Pre-patellar Bursitis
What important veins can be used for heart grafts and can cause varicose?
Small Saphenous Vein
What type of JIA?
- Early Childhood (Peak: 1 – 2 yo)
- Female prevalence
- Knee prevalence
Oligo JIA
What type of JIA?
- Throughout Childhood (Peak: 1 – 3 yo)
- Female prevalence
- Can be RF - or RF +
Poly JIA
What type of JIA?
- Throughout Childhood (No Peak)
- Rash
- Fever daily
- Female = male
Systemic JIA
What type of JIA have ACUTE uveitis?
Enthesitis Related JIA
What are the treatments of JIA?
- Team approach
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Second line agents such as methotrexate for poly and systemic JIA
- Biologics such as anti-TNF for poly and systemic JIA
- Intra-articular corticosteroid injections
- Physiotherapy/Occupational therapy
- Regular eye examinations
How do we diagnose a lower motor neuron (LMN) disease?
- Neurological exam: proximal weakness (neck flexion, limb girdles) and muscle atrophy
- EMG: can be abnormal but findings often subtle…a normal test does not rule out myopathy
- CK (creatinine kinase) level: muscle enzyme released into the blood with muscle damage
- Muscle biopsy
- Genetic testing: expensive and multiple possibilities, but…if strong suspicion, may start with this
Someone present with ocular weakness and you run a test and discover antibodies to the acetylcholine receptors. What’s the diagnosis?
Myasthenia gravis
Name toxic myopathies?
- Medications eg. Statins, steroids
- Thyroid disease
- Botulism: antibodies to proteins involved in vesicle docking so Ach cannot be released
- Anaesthesia: blocks the acetylcholine receptors
Those are signs of what?
- Weakness
- Rash
- Nailfolds abnormal with periungal erythema and visible dilated capillary loops
- Strength 4/5 proximal muscles
- Gottron’s Papules
- Heliotrope Rash: periorbital violaceous erythema
- Shawl Sign and V-sign: macular violaceous erythema in symmetric distribution
- Mechanic Hands: hyperkeratosis, scaling, and horizontal fissuring of the palms and fingers bilaterally
- Erythroderma
- Cutaneous Calcinosis (juvenile++)
- Arthralgias and arthritis
- Subclinical cardiac involvement (CHF, arrhythmia/conduction abnormalities, myocarditis/pericarditis)
- Pulmonary complications: hypoventilation, aspiration pneumonia and interstitial lung disease
- Dysphagia
- Malignancies: lung, ovary, breast, colon and more rarely hematological malignancies
Idiopathic inflammatory myopathies
What are the indications for urate lowering treatment (ULT)?
- Frequent gout attacks 2-3x/year
- Urate overproducers(occurs in 10% of cases)
- Renal stones, urate nephropathy
- Pre-chemotherapy
- Tophi development
- Erosive and destructive arthritis
What is the therapeutic goal for the treatment of recurrent gout?
To maintain sUA at <360 µmol/L
When do we think the problem is in the plexus (ex. brachial or lombo-sacral)?
- Both motor and sensory symptoms (usually)
- Unilateral
- Proximal involvement
- Complexity
- Clinical context (history), especially the mechanism and location of injury
How can a plexus injury occur?
- Childbirth
- Erb-Duchenne* (upper plexus)
- Dejerine-Klumpke* (lower plexus) - Trauma
- Operative
- Inflammatory: Idiopathic brachial neuritis
- Cancer: radiation
- Proximal diabetic neuropathy
What is the most critical diagnosis to consider in the patient with monoarticular arthritis?
SEPTIC ARTHRITIS
How do you investigate monoarthritis?
History
- Patient demographics: younger think infections, older think crystal or arthritis
- Trauma: hemarthrosis (bleeding in joint) or bursitis
- First episode or recurrent
- Articular or non articular
- Timing: gradual or acute
- Which joints are affected
- Travel, risk factors for sexually transmitted diseases, or other infections
- Constitutional symptoms: fever suggests infection
- Other symptoms: uveitis, GI, psoriasis, conjunctivitis, dactylitis, enthesitis
- Other medical conditions: IBD, psoriasis, diabetes, CKD
- Family history
- Medication: gout, immunosuppressive and anticoagulants
Physical exam and labs
- CBC, inflammatory markets and uric acid (comes after attack of gout)
- Aspirate the joint and analyze synovial fluid to firm the diagnosis and guide therapy à GOLD STANDARD FOR MONOARTHRITIS
Arthritis-Dermatitis Syndrome is suggestive of what?
Gonococcal Arthritis (N. gonorrhea)
Someone has a proximal femur fracute, what should you worry about?
Avascualar necrosis because of damage of medial femoral circumflex artery (motherfucker artery)
When does a callus formation occur after a fracture?
After secondary healing due to relative stability
What are the ABNORMAL signs of limping AKA RED FLAGS?
- Asymmetry
- A limp that doesn’t go away is NEVER NORMAL, NEVER LET A CHILD WHO REFUSES TO BEAR WEIGHT LEAVE THE ER
- Developmental Dysplasia of the Hip (DDH): asymetrical hip folds, positive Galeazzi, Barlow or Trtolani (up to 3 months)
- Continuous pain
- Functional impairment
- Gowers test: sign of proximal weakness (NMD like Duchenne)
What are some normal/physiological deformities in children?
- In-toeing/out-toeing: normal, reassure
- Bow-legs (Genu varum): normal from 0-3 years
- Knock-knees (Genu valgum): normal from 3-7 years
- Flat feet: normal exepct if RIGID
- Toe-walking: normal if between 1-2 years
When should you think about a hip replacement after a hip fracture?
Elderly people (> 80), NOT YOUNG
How can you assess pain in Non-communicative Demented Patients?
Behavioral observation
- Facial expressions
- Verbalizations, vocalizations
- Body movements
- Changes in interpersonal interactions
- Changes in activity patterns and routines
- Cognitive changes
What ligament of the foot is most likely to tear in a INVERSION spained ankle?
Anterior talofibular
What is the terrible triad of the knee
Foot is planted & blow causes knee hyperextension
- ACL tear
- MCL tear
- Medial meniscal tear
Someone hurts his knee and you hear a loud POP, what should you think about?
ACL tear (DUH)
Which test should you do in an ACUTE ACL tear?
Lachman (The knee is flexed at 15 degrees with the patient supine) because better sensitivity in ACUTE settings than the drawer
THIS IS HIGH YIELD
What is the #1 overuse knee injury in children?
Patellofemoral syndrome (PFPS)
What are the causes of Patellofemoral syndrome (PFPS)?
- Abnormal alignment of lower extremity:
- Valgus knee
- Hip internal rotation due to weal hip external rotation muscles
- Patella Alta (superior to normal position) or Baja (inferior)
- Stiffness, tightness of structures around the patella
- Tight hamstring can cause knee flexion
- Weakness of structures around the patella
- Quadriceps Muscle (VMO) Weakness
- Cinema sign
- Anterior knee pain often bilateral (worst with stairs and knee flexion)
- CHRONIC ATRAUMATIC
- Knee “gives away”
What is your diagnosis?
Patellofemoral syndrome (PFPS)
What is the best imaging option for Achilles and Biceps?
MRI best imaging for soft tissue injury (xrays first STILLZ)
Knee injury imaging modalities?
- X-ray (ALWAYS START WITH THAT)
- MRI best imaging for soft tissue injury (would still do xrays first) and for extensor mechanisms
Shoulder injury imaging modalities?
- X-ray
- US for rotator cuff
- MRI for labral tear
Choice of imaging modality for everything on the planet?
X-RAYYYYYY !!!!!!
What questions should you ask > 65 years old patients as a routine part of your exam?
- Have you fallen in the past year?
- Do you feel unsteady when standing or walking?
- Do you worry about falling?
What can you do as a doctor to prevent falls in your elderly patients?
- Assess for fall risk
- Review medications
- Vision checks yearly
- Adopt safe behavior and make home safety interventions
- Exercise regularly ….refer to STAND-UP!
Name 2 leading causes of institutionalisation in elderly people?
- FALLS
- Sarcopenia
What are the 3 aims of the use of theoretical approaches in implementation science?
- Describing and/or guiding the process of translating research into practice
- Understanding and/or explaining what influences implemetation outcomes
- Evaluating implemetation
What are the five 5 categories of theories, models and frameworks of the use of theoretical approaches in implementation science?
- Process models
- Determinant frameworks
- Classic theories
- Implementation theories
- Evaluation frameworks
