Exam 2 Musculoskeletal/nerves Spring 2024 Flashcards

Question

What is Rheumatoid Arthritis? which joints affected? IG present in how many pts

Answer 1

An autoimmune-mediated, systemic inflammatory disease that usually affects the proximal interphalangeal and metacarpophalangeal joints (2nd & 3rd knuckle). 2-3x higher in woman than men Rheumatoid nodules at pressure points (elbows) Rheumatoid factor (IG antibody present in 90% of patients with RA)

Answer 2

Single or multiple joints Painful synovial inflammation, swelling, and increased fluid **Morning stiffness like OA, but remains stiff throughout the entire day.** Symmetrical distribution of several joints. **Fusiform swelling - Joints become enlarged and the fingers crooked** (*pictured*) Synovitis of the temporomandibular joint (decrease mouth opening) Affects nearly all joints (except the t-spine and lumbosacral spine)

Answer 3

Atlantoaxial subluxation instability (C1 and C2) (>3 mm separation): Odontoid process (dens) protrudes into the foramen magnum. The instability can place pressure on the transverse ligament and spinal cord. Instability can also impair vertebral artery blood flow. Cricoarytenoid arthritis : Acute – hoarseness, dyspnea, and **stridor w/ tenderness over the larynx; swelling and redness of arytenoids** Chronic – asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction Osteoporosis: More common in women than men NM: Weakened skeletal muscles (peripheral neuropathies)

Answer 4

CV: Pericarditis, accelerated coronary atherosclerosis Pulmonary: **Restrictive lung changes**, decrease Vt Hematology: anemia, neutropenia, elevated platelets Dryness: **Keratoconjunctivitis sicca (dry eyes) and xerostomia (dry mouth)**

Answer 5

NSAIDS - Decrease joint swelling, relieve stiffness, provide analgesia - COX-1 inhibitors, COX-2 inhibitors Corticosteroids - Decrease joint swelling, pain, and morning stiffness DMARDs (Disease-modifying antirheumatic drugs) - Halt or slow disease progression (might take 2-6 months to work) Ex: Methotrexate (anti-inflammatory) Tumor necrosis factor (TNF-alpha) inhibitors & interleukin (IL-1) inhibitors - TNF-alpha inhibitors have faster onset than DMARDs - IL-1 inhibitors: slower onset than TNF and less effective Surgery Intractable pain, impairment of joint function, joint stabilization Total replacement

Answer 6

Airway- Atlantoaxial subluxation: minimize movement of head and neck during DL; evaluate vertebral artery interference - TMJ limitation : fiberoptic or video laryngoscopy - Cricoarytenoid joints: hoarseness or stridor; or observation of erythema or edema of the vocal cords during DL Severe rheumatoid lung disease-PFTs, ABGs, post-op vent may be needed Protect eyes - **Keratoconjunctivitis sicca (dry eyes)** Stress dose of corticosteriod

Answer 7

Multisystem chronic inflammation characterized by antinuclear antibody production. - Common in young women & African Americans; ages 15 to 40 Typical manifestations (Usually will have 3 out 5 of the following): 1. **Antinuclear antibodies** 2. **Malar rash (*butterfly rash*)** 3. Thrombocytopenia 3. Serositis- inflammation of a serous membrane around the organ 5. Nephritis

Answer 8

Joint/Spine: **Polyarthritis and dermatitis, symmetrical arthritis (most common sx)**, no spinal involvement, avascular necrosis of the femoral head or condyle CNS: Cognitive dysfunction, psychological changes CV: **Pericarditis**, coronary atherosclerosis, Raynaud’s Pulmonary: Lupus pneumonia, **restrictive lung disease**, vanishing lung syndrome Renal: Glomerulonephritis, decreased GFR, risk of renal failure

Answer 9

GI/Liver: ABD pain, pancreatitis, elevated liver enzymes NM: Skeletal muscle weakness Hematology: Thromboembolism, thrombocytopenia, hemolytic anemia, Skin: **Butterfly-shaped malar rash**, **Discoid lupus lesions, which are thick and disk-shaped. **

Answer 10

NSAIDs or ASA - will treat arthritis and serositis Anti-malarial (*Hydroxychloroquine and quinacrine*) - will treat arthritis and dermatological manifestations Corticosteroids- The development and progression of coronary atherosclerosis is accelerated by treatment with corticosteroids. Immunosuppressants **better alternative than high-dose steroid(*Methotrexate, azathioprine*)

Answer 11

Based upon manifestations and organ dysfunction **Airway: recurrent laryngeal nerve palsy (common), cricoarytenoid arthritis** **Stress dose of corticosteroids**

Answer 12

A condition where the nerve that controls the muscles of the larynx (voice box) is damaged, which can lead to problems with speaking, breathing, and swallowing. In lupus, the immune system attacks healthy tissues, including the nerves. This can lead to **inflammation of the laryngeal nerve or blood vessels, which can cause them to become compressed or damaged.**

Answer 13

Hypermetabolic syndrome involving a genetic mutation to the **Ryanodine receptor - RYR1 gene or Dihydropyridine receptor** **Caused by exposure to inhaled VA and succinylcholine (*50% mortality, investigate family history*)** Uncontrolled elevation of sarcoplasmic calcium Sustained activation of muscle contraction Rhabdomyolysis

Answer 14

tonsillectomy

Answer 15

**rapidly drives skeletal muscle into a hypermetabolic state that may proceed to severe rhabdomyolysis.**

Answer 16

**The inability of the Ca2+ pumps and transporters to reduce the unbound sarcoplasmic Ca2+ below the contractile threshold (10–6 M)**

Answer 17

Early Sign:Elevated end-tidal CO2 Tachypnea and/or tachycardia Generalized muscle rigidity Mixed metabolic and respiratory acidosis **MASSETER SPASM** – muscle for mastication Masseter spasm if succinylcholine has been used - also caused by etomidate

Answer 18

D/C all triggering gas/drugs Hyperventilate with 100% O2 at 10 L/min Change breathing circuit and soda lime Dantrolene (*Have someone else do this, hard to mix*) 20 mgj vial + 3 G mannitol (*Mix with 60 mL sterile water*) Initial dose 2.5 mg/kg Max upper limit 10 mg/kg Treat arrhythmias ICE, cool them down Monitor urine output

Answer 19

Transfer to ICU 24-48 hours Report to MH registry MH testing for pt and family members: **Muscle biopsy contracture testing **Diagnosis relies on the caffeine–halothane contracture test, measuring contraction forces upon exposure of muscle to caffeine or halothane**

Answer 20

Use TIVA and go slow.

Answer 21

It is located in the posterior triangle of the neck, halfway up the sternocleidomastoid muscle, and within the **prevertebral laye**r of cervical fascia. - The plexus is formed by the anterior rami (divisions) of cervical spinal nerves C1-C4.

Answer 22

- a collection of sympathetic nerves found anterior to the neck of the first rib. Stellate ganglion block indication - refractory angina - scleroderma - it is star-shaped ("stellate" meaning star-shaped) - When blocking the stellate ganglion: we have horner's syndrome - Downside: carotid artery and phrenic nerve are running along the stellate ganglion. So it can be dangerous

Answer 23

- Partial ptosis (drooping or falling of the upper eyelid) - Miosis (constricted pupil) - Facial anhidrosis (absence of sweating) due to a disruption in the sympathetic nerve supply: Anhidrosis, only on the side where it is blocked - Phrenic Nerve Blockade - Horner's syndrome results from paralysis of the ipsilateral sympathetic cervical chain (stellate ganglion) - **caused by blockade of stellate** - **associated with blockade of phrenic, which gives breathing issues**

Answer 24

- The brachial plexus is a network of nerve fibers that supplies the skin and musculature of the upper limb. - It begins in the root of the neck, passes through the axilla, and runs through the entire upper extremity. - The plexus is formed by the anterior rami (divisions) of cervical spinal nerves C5, C6, C7 and C8, & T1.

Answer 25

Spinal roots: C5 and C6. Sensory functions: Gives rise to the upper lateral cutaneous nerve of arm, which innervates the skin over the lower deltoid (‘regimental badge area’). Motor functions: Innervates the teres minor and deltoid muscles.

Answer 26

Nerve roots – C5-C7. Motor functions – muscles in the anterior compartment of the arm (coracobrachialis, biceps brachii and the brachialis). Sensory functions – gives rise to the lateral cutaneous nerve of forearm, which innervates the lateral aspect of the forearm.

Answer 27

Spinal roots: C8-T1. Motor functions: Two muscles of the anterior forearm – flexor carpi ulnaris and medial half of flexor digitorum profundus Intrinsic muscles of the hand (apart from the thenar muscles and two lateral lumbricals) Sensory functions: Medial one and half fingers and the associated palm area.

Answer 28

Nerve roots – C5-T1. Sensory – Innervates most of the skin of the posterior forearm, the lateral aspect of the dorsum of the hand, and the dorsal surface of the lateral three and a half digits. Motor – Innervates the triceps brachii and the extensor muscles in the forearm.

Answer 29

The anterior rami of the L1-L4 spinal roots divide into several cords. These cords then combine together to form the six major peripheral nerves of the lumbar plexus. These nerves then descend down the posterior abdominal wall to reach the lower limb, where they innervate their target structures. A useful memory aid for the branches of the lumbar plexus is: I, I Get Leftovers On Fridays. This stands for the Iliohypogastric, Ilioinguinal, Genitofemoral, Lateral cutaneous nerve of the thigh, Obturator and Femoral.

Answer 30

The iliohypogastric nerve is the first major branch of the lumbar plexus. It runs to the iliac crest, across the quadratus lumborum muscle of the posterior abdominal wall. It then perforates the transversus abdominis, and divides into its terminal branches. Roots: L1 (with contributions from T12). Motor Functions: Innervates the internal oblique and transversus abdominis. Sensory Functions: Innervates the posterolateral gluteal skin in the pubic region. (Tip: an easy way to remember that the IlioHypogastric comes before the IlioInguinal is that Hcomes before I in the alphabet!)

Answer 31

The ilioinguinal nerve follows the same anatomical course as the larger iliohypogastric nerve. After innervating the muscles of the anterior abdominal wall, it passes through the superficial inguinal ring to innervate the skin of the genitalia and middle thigh. Roots: L1. Motor Functions: Innervates the internal oblique and transversus abdominis. Sensory Functions: Innervates the skin on the superior antero-medial thigh. In males, it also supplies the skin over the root of the penis and anterior scrotum. In females, it supplies the skin over mons pubis and labia majora.

Answer 32

This nerve has a purely sensory function. It enters the thigh at the lateral aspect of the inguinal ligament, where it provides cutaneous innervation to the skin there. Roots: L2, L3 Motor Functions: None. Sensory Functions: Innervates the anterior and lateral thigh down to the level of the knee.

Answer 33

Roots: L2, L3, L4. Motor Functions: Innervates the muscles of the medial thigh – the obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis. Sensory Functions: Innervates the skin over the medial thigh.

Answer 34

Roots: L2, L3, L4. Motor Functions: Innervates the muscles of the anterior thigh – the illiacus, pectineus, sartorius and quadriceps femoris. Sensory Functions: Innervates the skin on the anterior thigh and the medial leg.

Answer 35

The sacral plexus is a network of nerve fibers that supplies the skin and muscles of the pelvis and lower limb. It is located on the surface of the posterior pelvic wall, anterior to the piriformis muscle. The plexus is formed by the anterior rami (divisions) of the sacral spinal nerves S1, S2, S3 and S4. It also receives contributions from the lumbar spinal nerves L4 and L5.

Answer 36

The sciatic nerve is a major nerve of the lower limb. It is a thick flat band, approximately 2cm wide – the largest nerve in the body. Nerve roots: L4-S3. Motor functions: Innervates the muscles of the posterior thigh (biceps femoris, semimembranosus and semitendinosus) and the hamstring portion of the adductor magnus (remaining portion of which is supplied by the obturator nerve). Indirectly innervates (via its terminal branches) all the muscles of the leg and foot. Sensory functions: No direct sensory functions. Indirectly innervates (via its terminal branches) the skin of the lateral leg, heel, and both the dorsal and plantar surfaces of the foot

Answer 37

Nerve roots: C6 – T1 (also contains fibers from C5 in some individuals). Motor functions: Innervates the flexor and pronator muscles in the anterior compartment of the forearm (except the flexor carpi ulnaris and part of the flexor digitorum profundus, innervated by the ulnar nerve). Also supplies innervation to the thenar muscles and lateral two lumbricals in the hand. Sensory functions: Gives rise to the palmar cutaneous branch, which innervates the lateral aspect of the palm, and the digital cutaneous branch, which innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand.

Answer 38

Part of brachial plexus Covers shoulder On US image on right: shows how close we are to important things Downside: sits around carotid and vertebral artery, stellate ganglion, phrenic nerve When you deposit local anesthetic here... you can block everything else as well