Exam 5 Flashcards
Most common pathogen to cause septic bursitis
Staph aureus (90%)
Describe the three types of post concussion disorder
- Physiologic: feel good at rest, headache with exertion
- Vestibulo-ocular: dizziness, vertigo, nausea, gait issues, blurred or double vision
- Cervicogenic: neck symptoms predominate, headaches exacerbated by neck movement and not exercise
Describe hemicord (Brown-Sequard) syndrome
- Results from penetrating injury
- Ipsilateral weakness and loss of proprioception and contralateral pain and temperature loss
- Bladder spared
Describe the three genetic risk factors for Alzheimer’s disease
Down syndrome:
- Additional gene dose of APP
- Symptoms at age 10-20
Rare autosomal dominant form:
- Mutations in genes that alter beta-amyloid protein
- Symptoms in 40s
Late onset Alzheimer’s disease (LOAD)
- Most common
- Associated with APOE gene
How can a diagnosis of fibromyalgia be confirmed?
Studies using objective measures of brain activation showing difference in pain threshold compared to normal
What is the joint pattern of involvement in reactive arthritis?
- Asymmetric
- Oligoarticular
- Knees, ankles, or feet
Treatment for gout attacks
- NSAIDs
- Colchicine
- Steroids
- Do not start allopurinol during an attack!
Best imaging tool for Alzheimer’s
MRI
Describe the difference between a radiculopathy and a neuropathy
- Radiculopathy: nerve pinched or damaged at root where it comes off spine
- Neuropathy: pinch or damage in a peripheral area
When would it be best to go straight to MRI (skip x-ray) for a patient with lumbar radiculopathy symptoms?
- Signs of cauda equina syndrome
(neurologic deficits, urinary retention, saddle anesthesia)
Symptoms of trigeminal neuralgia
- Brief paroxysms of severe, unilateral “electric” pain
- Sensation and strength unaffected
Treatment for osteomyelitis
- Surgical debridement optimal
- Vancomycin for staphylococcal infections
- Ciprofloxacin for gram-negative
Symptoms of Bell’s palsy
- Unilateral facial weakness
- not painful
- Appears quickly, then progressively worsens, peak at 3 weeks
The enthesitis in reactive arthritis causes these joint symptoms
- Heel pain
- Metatarsalgia
- Sausage digits
What is the most common type of inflammatory arthritis affecting young adult males?
Reactive arthritis
Describe the differences between cortical and subcortical dementias
Cortical:
- Affects personality
- Amnestic and learning problems
- Alzheimer’s, Picks, frontal lobe degeneration
Subcortical:
- Affects motor
- Dysarthric speech
- Tremors, rigidity, bradykinesia, shuffling
- Parkinson’s, Huntington’s
Define obesity and sarcopenic obesity
- Obesity: an excess or abnormal amount of adipose tissue accumulation for body size
- Sarcopenic obesity: excess adiposity with low muscle mass
How is dementia different from delirium
Delirium is episodic, reversible, and can be drug/illness induced
Side effects of phentermine
- Increased blood pressure
- Tachycardia/palpitations
- Anxiety/agitation
Two of these core features must be present for the diagnosis of dementia with Lewy bodies
- Recurrent visual hallucinations
- Cognitive decline with fluctuations in alertness (good and bad days)
- Parkinsonism (bradykinesia, rigidity, gait issues)
- REM sleep disorder
Name as many medications that cause weight gain as you can
- Psychiatric: paroxetine, citalopram, venlafaxine, mirtazapine, trazodone, amitriptyline, antipsychotics
- Anti-seizure and pain: gabapentin and pregabalin
- Hormone: glucocorticoids, implantable and injectable progestins
- Diabetes: insulin, sulfonylureas, thiazolidinediones
- Heart: beta-blockers, calcium-channel blockers
- Chemo: tamoxifen
- Transplant medications
Risk factors for septic arthritis
- Age >80
- Diabetes
- RA
- Recent joint surgery
- Joint prosthesis, previously damaged joints
- Skin infection
- Young adults with high risk sexual behavior (gonorrhea)
- Immunosuppression
Treatment for diabetic polyneuropathy
- SNRIs, TCAs, gabapentin
- Good glucose control
In a severe head injury you see signs of brain herniation, what are some steps you can take to manage this?
- Sedation
- Hyperventilation
- Mannitol (hypertonic saline)
- Elevate head of bed 30 deg
- Decompressive craniotomy
Symptoms of diabetic polyneuropathy
- Distal, symmetrical polyneuropathy most common
- Progressive loss of distal sensation, followed by motor weakness
- “Stocking-glove” pattern
Can also affect autonomics
- Postural hypotension, gastroparesis, enteropathy with constipation/diarrhea
- And this makes other diseases present differently!
Signs and symptoms of osteomyelitis
- Midline back or neck pain (adults)
- Fever common
- Pain limiting ROM
- Vertebral tenderness (adults)
Symptoms of CPPD/pseudogout
- Hot, swollen wrist or knee
- Sudden onset, “woke up with it”
What are the point thresholds for mild, moderate, and severe brain injury in the Glasgow Coma Scale?
- Mild 13-15
- Moderate 9-12
- Severe 3-8
Alzheimer’s patients with preserved insight are more likely to be [mood], whereas those with impaired insight are more likely to be [mood]
- Preserved = depressed
- Impaired = agitated or psychotic
For nutrition therapy in obesity it is recommended to reduce carbohydrates to this level
- <130 g/day
OR - <26% of calories
Symptoms of Guillain-Barre syndrome
- Progressive, symmetric weakness
- Starts in the legs and ascends
- Mild paresthesia to complete paralysis and respiratory insufficiency
- Absent/depressed deep tendon reflexes on physical exam
- Many have autonomic dysfunction
Name this injury:
- Avulsion of the spinous process
- Most commonly at C7
- Direct trauma to spinous process or sudden ligamentous pull (MVA, athletes)
- Stable
Spinous process fracture/Clay-shoveler fracture
Name the four seronegative spondyloarthritises
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Inflammatory bowel associated arthritis
What diagnostic criteria is used for fibromyalgia?
- ACR criteria
- Pain must be chronic (>3 months), widespread (bilateral, above and below waist, and axial)
- Need 11 of 18 tender points
Treatment of subdural hematoma
- Urgent surgical hematoma evacuation if signs of elevated ICP or clinical deterioration
- Small hematomas can be managed non-operatively
What is the most common pathogen to cause infections preceding Guillain-Barre syndrome?
Campylobacter jejuni
Which weight loss surgery is best for patients with GERD?
Roux-en-Y gastric bypass
Describe anterior spinal cord syndrome
- Affects anterior 2/3 of spinal cord
- Bilateral weakness and loss of pain and temp
- Proprioception spared
- Caused by disc herniation or spinal cord infarct
Name this injury:
- Abrupt neck extension causes ALL to avulse the antero-inferior corner from the remainder of the vertebral body
- Most commonly at C2
- No loss of vertebral height
- Unstable
Extension teardrop fracture
Treatment for septic arthritis
- Drainage
- Antibiotics
- Early immobilization
Symptoms of Alzheimer’s
- Progressive gradual onset memory impairment
- Most common cognitive deficit = anterograde amnesia (can’t learn new things)
- Anosognosia (loss of self-awareness and insight)
- Word-finding issues
- VIsuo-spatial impairments
- Apathy, depression
- Dyspraxia (loss of daily function)
- Seizures late
What is enthesis?
- Site of insertion of a ligament, tendon, or articular capsule into bone
- Site of initial inflammatory process in ankylosing spondylitis
What is second impact syndrome?
Second head injury while still having symptoms from initial head injury
Risk factors for Alzheimer’s disease
- Age is biggest RF
- Family history, obesity, diabetes, hypertension, hyperlipidemia, sedentary lifestyle
- Genetics
Diagnostic criteria for vascular cognitive impairment
Need both:
1. Cognitive disorder
2. History of stroke or MRI evidence of cerebrovascular disease
Best test to confirm diagnosis
EMG/NCVs
Treatment for Bell’s palsy
- Glucocorticoids within 3 days of onset
- Valacyclovir if severe
What is the most prominent symptom in frontotemporal dementia?
- Language difficulty is biggest
(others: loss of empathy, loss of social control, apathy)
Describe central cord syndrome
- Usually caused by slow growing masses or hyperextension injury
- Upper > lower extremity weakness
- Bladder function lost
Describe the role, origin, and response of leptin in the body
- Anorexigenic (counters ghrelin)
- Secreted by white adipose tissue
- Secreted in response to weight gain (inhibited by weight loss)
Best imaging for osteomyelitis
MRI - how deep in the bone is the infection
Symptoms of peroneal neuropathy
- Acute foot drop
- Sensory loss
- Paresthesia
Side effects of orlistat (Xenical)
- Diarrhea
- Fat soluble vitamin deficiencies
- Cholelithiasis, nephrolithiasis
- Significant drug interactions due to absorption issues
Physical exam tests for ankylosing spondylitis
- Occiput-to-wall test
- Chest expansion
- Schober test
- Pelvic compression
- Gaenslen’s test
- Patrick’s test
Risk factors for obesity
- Ethnicity
- Socioeconomic status
- Genetics
- Body type/fat distribution (apple = abdominal fat)
- Stress
- Sleep quality
Signs and symptoms of septic arthritis
- Intra-articular
- Acute onset of pain, typically in one joint only (most often knee)
- Pain with passive motion in absence of trauma
- Joint pain and swelling
- Red hot circle (round = staph, fingers = strep)
What is the best diagnostic imaging early in the course of septic arthritis?
Radionuclide bone scan
What is the imaging of choice for TBIs?
Non-contract CT
Where are the extra-articular manifestations of spondyloarthritis?
- Eye
- GI tract
- Skin
Reactive arthritis is a sterile inflammatory synovitis most commonly following these two types of infection
- Urogenital (GU)
- Enteric (GI)
Treatment for carpal tunnel syndrome
- Physical therapy
- Night splint
- Surgery: carpal tunnel release
What are the gradings of eye opening in the Glasgow Coma Scale?
- Spontaneous
- To speech
- To pain
- No response
What x-ray changes in the spine are seen with ankylosing spondylitis?
- Syndesmophytes (intervertebral bony bridges)
- Bamboo spine
What is the name for acute gouty arthritis of the first metacarpal joint?
Podagra
Which is more predictive of poor outcome after a mild TBI/concussion, initial symptom severity, or initial injury severity?
Initial symptom severity
Best diagnostic test for septic bursitis
Bursa fluid analysis
- Analyze for WBCs, crystals, gram stain, and C&S
Which crystal has the property of negative birefreigence?
Gout crystals
In this spondylarthritis the arthritis is acute in onset, migratory, asymmetric, and pauciarticular (<5 joints), and does not cause x-ray changes
SpA related to bowel disease
Treatment for frontotemporal dementia
- Treat the symptoms (SSRIs, antipsychotics)
- Early education with caregiver
Describe leptin resistance and how it contributes to obesity and other diseases
- In patients with obesity, chronically high levels of leptin lead to desensitization of leptin receptors
- This ultimately leads to decreased/impaired satiety and weight gain despite their excess adiposity
- High levels of leptin increase inflammatory mediators, leading to disease
Which weight loss medication is contraindicated in pregnancy and should have a negative pregnancy test before initiation?
Phentermine AND phentermine + topiramate (Qsymia)
Causes of peroneal neuropathy
- Lying down with pressure on the nerve
- Casts
- Viruses
Which condition is typified by the symptom of acute foot drop?
Peroneal neuropathy
Treatment for frontotemporal dementia
Symptomatic management with SSRIs, behavioral therapy
How to differ Bell’s palsy from stroke based on facial symptoms
- Forehead droop in Bell’s palsy
- Forehead fine in stroke
In gout, the problem is overproduction and under-secretion of [blank]
Uric acid
How does psoriatic arthritis present differently in men and women?
- Men often have DIP only
- Women more symmetric polyarthritis
MRI shows cortical infarcts, subcortical lacunes, and white matter hyper intensities in this type of dementia
Vascular cognitive impairment
Mixed etiology dementia is more common in older adults, but what is the most common combination of dementia types?
Alzheimer’s with vascular cognitive impairment
Cervical radiculopathy is most commonly seen at this spinal level
C5 or C6
Describe the three behaviors measured in the Glasgow Coma Scale and how many points they are worth
- Eye opening (4)
- Verbal response (5)
- Motor response (6)
Treatment for lumbar radiculopathy
PT, steroids, surgery
Describe the pathophysiology of dementia with Lewy bodies
- Alpha-synuclein (Lewy bodies) accumulate in cerebral cortex and brainstem
- Loss of dopaminergic neurons in substantia nigra
- Degeneration of frontal/temporal lobes
- Cholinergic deficit
Best diagnostic test to confirm septic arthritis
Synovial fluid gram stain, culture, or histopathology showing presence of bacteria
Differentiate between acute and chronic osteomyelitis
- Acute: first clinical episode
- Chronic: failed to resolve after one or more treatment attempt
In lumbar radiculopathy that involves L2, L3, L4, where would pain be felt?
Anterior thigh pain
(weakness in hip flexion, knee extension)
Ulnar neuropathy is typically due to compression of the ulnar nerve in this location
At the elbow
Carpal tunnel syndrome is compression of the [nerve]
Median nerve
What is the most common neuropathy in the Western world?
Diabetic polyneuropathy
What are four signs of a basilar skull fracture?
- Raccoon eyes (periorbital ecchymosis)
- Hemotympanum
- Battle’s sign (postauricular ecchymosis)
- Halo sign (CSF otorrhea)
What mechanism of injury is associated with pasteurella multocida septic arthritis?
Bites from dogs and cats
Treatments for Alzheimer’s
- Lifestyle, cognitive therapy
- Cholinesterase inhibitors (donepezil, rivastigmine, galantamine)
- NMDA antagonists (memantine)
- MABs against amyloid beta (lecanemab and donanemab)
- Antidepressants (citalopram, sertraline, paroxetine, mirtazapine)
- Antioxidants (vitamin E)
Symptoms of frontotemporal dementia
Progressive socioemotional behavioral changes, cognitive and linguistic deficits
Name two genetic conditions that can cause obesity
- Prader-Willi syndrome
- Bartlett-Biedel syndrome
What symptoms are associated with reactive arthritis?
- Urethritis
- Conjunctivitis
- Arthritis
- Circinate balanitis
- Keratoderma blennorrhagicum
What is the most common type of weight loss surgery?
Sleeve gastrectomy
Allopurinol dosing for gout should be increased until uric acid levels are [blank]
Less than 6
Treatment for vascular cognitive impairment
- Blood pressure control
- Statins for cholesterol
- Mediterranean diet
(control vascular risk factors)
What are the gradings of motor response in the Glasgow Coma Scale?
- Obeys command
- Moves to localized pain
- Flex to withdraw from pain
- Abnormal flexion
- Abnormal extension
- No response
What is the most common cause of traumatic spinal cord injury
Motor vehicle accidents
What are the alterations in cerebral blood flow seen in the days following a mild TBI/concussion
- 1-3 days = hyper-perfusion
- 4-15 days = hypo-perfusion
Diabetics are particularly prone to getting osteomyelitis in their [blank]
Feet
Which weight loss medication is approved for use in moderate to severe obstructive sleep apnea?
Tirzepatide (Mounjaro, Zepbound) GLP/GIP
Treatments for dementia with Lewy bodies
Non-pharm preferred
(sleep hygiene, melatonin)
Best diagnostic test for peroneal neuropathy
EMG/NCVs
Risk factors for osteomyelitis
- Elderly
- Prior s. aureus infection
- Diabetes
- IV drug sue
- Systemic steroid therapy
- Hemodialysis
- Alcoholism
- Recent spinal injury
How does orlistat (Xenical) help with weight loss?
Prevents absorption of ingested fats
Name three mental status exams that can be used in diagnosis of Alzheimer’s
- MMSE
- MoCA
- CDR
Physical exam signs of carpal tunnel syndrome
- Positive Phalen’s sign/Tinel’s sign/Durkan’s sign
- Diminished sensation in median nerve distribution
- Wasting and weakness of thenar muscles
(enough for clinical diagnosis)
Which weight loss surgery is best for patients with history of nephrolithiasis and higher cardiovascular risk and avoided in patients with significant GERD?
Sleeve gastrectomy
What is the most common cause of facial pain?
Trigeminal neuralgia
Name this injury:
- Vertical compression force through occipital condyles of atlas (C1)
- Fractured anterior and posterior arches of C1
- Highly unstable
C1 burst (Jefferson) fracture
What is the gold standard diagnostic test for osteomyelitis?
Cultures (tissue/bone biopsy)
Most common locations for osteomyelitis
- Adults: Vertebral bodies
- Children (1-15): femur and tibia
Describe the three variants of frontotemporal dementia
- Behavioral: early personality changes, disinhibition, apathy, compulsion (hoarding)
- Non-fluent: progressive aphasia, non-fluent speech, agrammatism
- Semantic: loss of word meaning (anomia)
Which weight loss medication is contraindicated in seizure disorders, anorexia/bulimia, uncontrolled HTN, and chronic opioid use?
Bupropion + naltrexone (Contrave)
What is Milwaukee shoulder?
- Hydroxyapatite crystal deposits
- Huge recurrent bloody effusion in shoulder
- Typically unilateral in context of end-stage OA
In lumbar radiculopathy that involves L5, where would pain be felt?
Back pain that radiates down lateral leg and into foot
(reduced strength in dorsiflexion, toe extension)
(most common of the lumbar radiculopathies)
Treatments for ankylosing spondylitis
- Sulfasalazine and methotrexate for peripheral arthritis
- Anti-TNF therapy very effective
- Exercise (swimming best)
- Avoid large pillows and smoking
Treatment for fibromyalgia
- TCAs
- Cyclobenzaprine
- SSRI
- SNRI (duloxetine and Savella FDA approved)
- Gabapentin/pregabalin
- Exercise
Most common pathogen to cause osteomyelitis
Staph aureus
(GBS and gram negative more common in newborns)
At what age is trigeminal neuralgia most commonly seen?
Age 50+
Describe the pathogenesis of Alzheimer’s disease
- Extracellular neuritic plaques (b-amyloid)
- Intracellular neurofibrillary tangles (tau protiens)
- Progressive neuronal loss and brain atrophy
- Cholinergic deficit
Describe some complications of roux-en-Y gastric bypass surgery that a patient should be counselled on
- Anastomotic ulcers: avoid NSAIDs, nicotine/smoking, alcohol
- Nutritional deficiencies: need bariatric formulation of vitamin supplements lifelong
Symptoms of carpal tunnel syndrome
- Vague aching in palmar hand/forearm
- Numbness and tingling in median nerve distribution
- Night symptoms
- Frequently dropping items
What x-ray findings suggest CPPD/pseudogout?
- Chondrocalcinosis
- Osteoarthritic changes at MCP joints
- Hook osteophytes
Corticotropin-releasing hormone, locus caeruleus-norepinephrine, and the sympathetic nervous system play a major role in this condition
Fibromyalgia
Dementia is an umbrella term for …
- Loss of memory and other thinking abilities severe enough to interfere with daily life
- A group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking, reasoning, and problem-solving
What CSF biomarkers suggest Alzheimer’s?
- Increased total and phosphorylated tau
- Decreased beta-amyloid
How does phentermine help with weight loss?
Sympathomimetic amine (stimulant) that decreases hunger
Risk factors for gout
- Renal insufficiency
- Alcohol
- Cancer/transplant drugs (cyclosporine)
Name one physical exam test for each of the three types of post concussion disorder
- Physiologic: treadmill testing
- Vestibulo-ocular: standardized gait/balance, screen for BPPV (Dix-Hallpike)
- Cervicogenic: Cervical joint position error, check cervical spine alignment and ROM
Name this injury:
- Severe flexion and compression causes one vertebral body to collide with the body below
- Most common in lower cervical spine
- Disrupts the posterior longitudinal ligament
- Associated with anterior spinal cord injury
- Highly unstable
Flexion teardrop fracture
What determines whether a spinal cord injury is complete or incomplete?
Incomplete: some sensation or function in S4/S5 (sacrum spared)
Diagnostic tests for reactive arthritis
- Arthrocentesis excludes septic and crystal arthritis
- ESR, CRP elevated
- Synovial fluid cultures always negative
- Culture body for triggering infection
(HLAB27 is poor screening test, better for prognosis)
How to prevent pulmonary complications in first 3-6 months after a spinal cord injury
- Pulmonary embolism highest risk during acute phase
- Give warfarin or DOAC as prophylaxis
Symptoms of fibromyalgia
- Widespread chronic pain
- Fatigue, unrefreshing sleep
- Cognitive dysfunction
- Depression and anxiety
- Regional musculoskeletal pain
- Visceral pain
Symptoms of vascular cognitive impairment
- Stepwise cognitive decline
- Executive dysfunction > memory impairment
- Hemiparesis (one side weakness), dysarthria, gait issues
- Speech changes
- Depression, apathy, anxiety, psychosis
- Sleep disorders
Symptoms of lumbar radiculopathy
Paresthesia, radiating pain, numbness from inguinal region to feet (depending on nerves)
Name this injury:
- Forceful flexion or extension of head
- Can occur above transverse ligament, base of the dens, or into the body of C2
- One type requires Halo immobilization
Odontoid fracture
What is the most common cause of death in spinal cord injuries?
Respiratory (unable to clear lungs = pneumonia)
Which types of odontoid fracture are unstable and which type requires Halo immobilization?
- Type 1: stable (above transverse ligament)
- Type 2: unstable, requires Halo immobilization, most common (base of the dens)
- Type 3: unstable (extends into body of C2)
What are the most common locations for septic bursitis?
Olecranon and prepatellar bursa
Risk factors for vascular cognitive impairment
- Hypertension
- Diabetes
- Smoking
- Hyperlipidemia
- Strokes (ischemic or hemorrhagic)
Name this injury:
- Pure flexion injury involving the atlas (C1) and axis (C2)
- Unstable
Atlanto-occipital dislocation
Which weight loss surgery goes with each of the following descriptions:
1. Dramatic increase in GLP-1 production and lowers body set point
2. Dramatic reduction in production of ghrelin
- Roux-en-Y gastric bypass
- Sleeve gastrectomy
Signs and symptoms of traumatic brain injuries
- Decreased level of consciousness
- Memory loss before or after injury
- Alteration of mental status
- Neurologic deficits
- Intracranial lesion
Name the four pillars of obesity management
- Physical activity
- Nutrition
- Behavior modification
- Medical interventions
What is the Spurling test used to diagnose?
- Cervical radiculopathy
- Extend and rotate neck, then push down on head
Name four complications of rapid weight loss (by any method)
- Nephrolithiasis: increased urinary oxalate and decreased citrate
- Gout flares: uric acid released into blood from adipocyte breakdown
- Cholelithiasis: liver releases cholesterol into gallbladder and transient gallbladder contractility decrease
- Hair loss: hair follicles go into resting phase when in “starvation” mode
How to differentiate Lewy body dementia from frontotemporal dementia with symptoms?
No hallucination or fluctuating cognition (good and bad days) in frontotemporal dementia
Is dementia with Lewy bodies typically diagnosed in youth or old age?
Average age of onset mid 70s
What is the most common pathogen to cause septic arthritis?
Staphylococcus
Describe posterior spinal cord syndrome
- Affects dorsal columns
- Gait, ataxia and paresthesia, along with weakness
- Caused by M.S., syphilis, vascular malformations, Friedrich ataxia
What is the most common subtype of psoriatic arthritis?
Asymmetric oligoarticular disease
(DIPs, PIPs, MCPs, MTPs, knees, hips, ankles, dactylitis)
Describe the role, origin, and response of ghrelin in the body
- Orexigenic (only weight promoting hormone)
- Secreted by the gastric fundus and proximal small bowel
- Secreted in response to empty stomach (inhibited when stomach stretched)
In lumbar radiculopathy that involves L1, where would pain be felt?
Inguinal pain
Symptoms of ankylosing spondylitis
- Back pain
- Prolonged morning stiffness, relieved with movement
- Insidious onset
- Decreased spinal mobility
- Reduced chest expansion
- Sacroiliac tenderness
Routine lab testing in every patient with obesity
- CBC (polycythemia, Hgb up)
- CMP (glucose, liver enzymes)
- Fasting lipid panel (LDL and triglycerides up, HDL down)
- HbA1c (prediabetes 5.7, diabetes 6.5)
- TSH (cause and effect)
- Vit D recommended (trapped in fat)
How do GLP-1 agonists (Ozempic, Wegovy) help with weight loss?
- Delays gastric emptying
- Improves insulin sensitivity
- Stimulates beta cell proliferation
Treatment for septic bursitis
- Compression of the bursa with wrap
- Mild: med to cover MRSA
- Mod: aspirate bursa and start oral antibiotic
- Severe: Aspirate bursa, hospitalize, antibiotics, surgical bursectomyW
Describe the eye symptoms associated with ankylosing spondylitis
- Uveitis
- May be the first symptom
- Painful, unilateral, red, very photophobic, no secretions
Where is a first gout attack likely to be?
Around first MTP (podagra)
Symptoms of septic bursitis
- Extra-articular
- Pain and swelling over the bursa develops in hours to days
- Erythema and swelling over the bursa
- Associated cellulitis and regional lymphadenopathy
- No increase in pain with joint movement (differ from septic arthritis)
What are the physical activity guideline recommendations for exercise?
- 150 to 300 minutes of moderate exercise per week
OR - 75 to 150 minutes of vigorous intensity exercise
PLUS - Moderate strength training/resistance two or more days per week
How is the diagnostic criteria for mild neurocognitive disorders different that those for major?
- Only modest cognitive decline and impairment instead of significant
- Cognitive deficits do not interfere with independence and everyday activities
Treatment for reactive arthritis
- Eliminate triggering infection (doxycycline for chlamydia)
- NSAIDs effective for pain
- Intra-articular steroids
- Sulfasalazine
Treatment for cervical radiculopathy
PT
(steroid injections risky, surgery maybe)
What gender and age group is most likely to get carpal tunnel syndrome?
- Women
- Age 45-60
DSM-5 diagnostic criteria for major neurocognitive disorders requires concern of the patient, a knowledgable informant, or the clinician, as well as evidence of significant cognitive decline, that interferes with independence and daily activites, in one or more of these cognitive domains:
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor
- Social cognition
Which, septic arthritis, or septic bursitis, is more likely to have a shorter recovery time?
Septic bursitis as it is extra articular and not affecting meniscus
What types of medications can a patient not take post-bariatric surgery?
Avoid extended release formulations due to absorption issues
In sickle cell patients [blank] is the most common cause of osteomyelitis
Salmonella
Treatment for trigeminal neuralgia
- Carbamazepine
- Surgery to cushion nerve if refractory
Reasons to order a CT scan for evaluation of a TBI
- Glasgow coma scale <15
- Depressed skull fracture
- Any sign of basilar skull fracture
- Two or more episodes of vomiting
- New neurologic deficit
- Bleeding diathesis
- Seizure
- Age 60+
- Retrograde amnesia 30+ minutes
- Potentially high impact injury
- Intoxication, headache, or abnormal behavior
Side effects of GLP-1 agonists (Ozempic, Wegovy)
- Nausea #1
- Vomiting
- Diarrhea
- Constipation
- Sarcopenia
In a moderate or severe head injury, the patient should be intubated if the [blank] Score is [blank]
If the Glasgow Coma Score is <8
Other than BMI, what objective measurements can be used to diagnose obesity?
- DXA body fat %: 30+ in men, 35+ in women
- Waist circumference: 40+ in men, 35+ in women
Treatment for psoriatic arthritis
- NSAIDs
- Gold, sulfasalazine, methotrexate, cyclosporine
- Anti-TNF agents
(anti-malarial drugs and steroids worsen/flare)
Symptoms of cervical radiculopathy
- Neck pain that may radiate to arm
- Motor or sensory symptoms
Repeated mild TBI/concussions may result in a “tau-opathy” known as …
Chronic traumatic encephalopathy (CTE)
(aggression, paranoia, impulsivity, depression, anxiety, suicidality)
Most people with spinal cord injuries can be independent if the injury is at [blank] or better
C7 or lower
What is the gold standard diagnostic method for Alzheimer’s disease?
Biopsy (autopsy)
Symptoms of ulnar neuropathy
- Numbness and tingling in 4th and 5th digits
- Elbow pain
- Worse with elbow flexion
- Weakness and wasting in dorsal interosseous/hypothenar region
Describe the Schober test and what it’s used for
- Ankylosing spondylitis
- Patient bends forwards
- Measured points on lower back should increase from 10 cm to at least 15 cm
Describe the difference between primary and secondary injury in a severe TBI
Primary:
- immediate injury (contusion, penetration, vascular injury)
Secondary:
- cascade of events hours to days later (edema, loss of autoregulation, excitatory neurotransmitter release, hypotension and ischemia, increased ICP)
Traumatic spinal cord injuries are more often [complete/incomplete] and [tetraplegic/paraplegic]
More often incomplete and cause tetraplegia
Pyoderma gangrenosum and erythema nodosum are extra-articular manifestations associated with this type of spondylarthritis
SpA related to bowel disease
Treatment for Guillain-Barre syndrome
- Hospitalization (monitor autonomic status)
- IV immunoglobulin plasma exchange
What are the gradings of verbal response in the Glasgow Coma Scale?
- Oriented to time, person, and place
- Confused
- Inappropriate words
- Incomprehensible
- No response
Which weight loss medication is contraindicated in patients with family history of medullary thyroid cancer or personal history of pancreatitis?
GLP-1 agonists
What is the side effect of Krystexxa?
Congestive heart failure exacerbation
Is ankylosing spondylitis more common in men or women?
Men
What is the first imaging method that should be used for osteomyelitis?
X-ray - but it will be normal for the first 2-3 weeks
Best diagnostic test for Guillain-Barre syndrome
- Lumbar puncture
- Shows elevated protein and normal to mildly elevated leukocytes
Treatment for ulnar neuropathy
- Activity modification and night splints to stop flexion if no muscle wasting
- Surgery if severe and symptoms over 6 months
In a moderate or severe head injury what are the goal perfusion and systolic blood pressures, and what agents can be used to achieve them?
- Cerebral perfusion pressure >60 mm Hg
- Systolic blood pressure >90 mm Hg
- Phenylephrine, norepinephrine, dopamine
Treatment for CPPD/pseudogout attacks
- NSAIDs, colchicine, steroids
- Intra-articular steroid injections
Where are the extra-articular manifestations in psoriatic arthritis?
- Nails
- Eyes
- Skin
Describe the grades of concussion
- Grade 1: transient mental changes lasting less than 15 minutes, no loss of consciousness
- Grade 2: loss of consciousness for <15 minutes
- Grade 3: loss of consciousness for >15 minutes
Which lumber radiculopathy can be found with the straight leg raise test?
L5
(maybe L4 too)
Which is likely to be diagnosed earlier in life, dementia with Lewy bodies or frontotemporal dementia?
- Frontotemporal onset usually before age 65
- Dementia with Lewy bodies = mid-70s
How to differentiate Alzheimer’s from frontotemporal dementia with symptoms?
In frontotemporal dementia memory is preserved early on
Which hypertension and cholesterol medications are good and bad for gout?
- Good: Losartan (mild uricosuric) and Fenofibrate (helps UA excretion)
- Bad: HCTZ (decreases excretion)
Describe the differences between an epidural and subdural hematoma
Epidural:
- arterial blood (MMA)
- lentiform/biconvex/lemon shape
- does not cross suture line
Subdural:
- venous blood
- crescent/banana shape
- crosses suture line
Imaging for cervical radiculopathy
- Not really
- MRI if motor deficit/infection/tumor
- EMG/NCVs better if symptoms over 3 weeks
What are the different causes of lumbar radiculopathy in younger (40-50) and older patients?
- Younger: disc herniation
- Older: spondylosis
How should patients starting allopurinol for gout be counselled?
- Warn patient about increased risk of attacks in first 3-6 months
- Prophylaxis against attacks when starting (colchicine, NSAIDs, steroids)
- Never stop and start allopurinol
- Rare hypersensitivity reaction (bright red skin) most common in old women on HCTZ
Name this injury:
- Forced hyperextension of skull, atlas (C1), and axis (C2)
- Bilateral pedicle fractures
- Unstable but often spares spinal cord
C2 hangman’s fracture
Treatment for CPPD/pseudogout chronic inflammatory disease (MCP)
- Plaquenil
- Methotrexate
Treatment for peroneal neuropathy
- Remove pressure on nerve
- AFO (ankle-foot orthosis, cast that keeps foot in dorsiflexion)
- PT
Autonomic dysreflexia is a medical emergency that can happen with spinal cord injuries at level T6 or above. Describe what happens
- Uninhibited sympathetic response to noxious stimuli below level of injury
- Diffuse vasoconstriction and hypertension
- Compensatory vasodilation above injury leads to hypotension
(typical stimuli: bladder distension, UTI, nephrolithiasis, bowel impaction, pressure sore, or occult fracture)
What conditions are associated with the HLAB27 gene?
Spondyloarthritises
BMI ranges for:
- Normal weight
- Pre-obesity/overweight
- Class 1 obesity
- Class 2 obesity
- Class 3 obesity
- Normal weight: 18.5 to 24.9
- Pre-obesity/overweight: 25 to 29.9
- Class 1 obesity: 30 to 34.9
- Class 2 obesity: 35 to 39.9
- Class 3 obesity: 40+
Name this injury:
- Flexion-rotation injury
- Best seen on open-mouth odontoid or CT
- Associated with RA, inflammatory spondyloarthropathies
- Unstable
Atlanto-axial dislocation
Describe the NEXUS criteria
- Used to clear patients with cervical spine injury without needing imaging
- Only for age <65
- Criteria: normal alertness (GCS 15), no intoxication, no focal neurologic deficit, no painful distracting injury, no midline cervical tenderness
In a moderate or severe head injury the goal for CO2 and oxygen tension levels are …
- CO2 40 mm Hg
- O2 tension >60 mm Hg
Describe psoriatic nails
- Soft and boggy
- Hyperkeratotic (thickened)
- Subungual debris
- Onycholysis
- Pitting
- Oil spots
This condition is an immune system attack on myelin that typically follows a recent URI/gastroenteritis infection in the previous four weeks
Guillain-Barre syndrome
Which group of dementia conditions can be caused by Pick bodies?
Frontotemporal dementias
(all Pick diseases are FTD, not all FTD are Pick)
Risk factors for septic bursitis
- Male
- Immune deficiency
- Alcoholism
- Diabetes
- RA
Imaging for lumbar radiculopathy
- X-ray first because more likely degenerative changes
- MRI best
- EMG/NCVs
What is a tophus?
Lumps under the skin formed by deposits of urate crystals
At what ages do gout and CPPD/pseudogout typically show up?
Gout:
- men in 20s
- women only after menopause
CPPD/pseudogout:
- elderly, 70s, oldsters
Vertebral body osteomyelitis can lead to this neurologic complication that is a medical emergency
Cauda equina syndrome
What is the best imaging method that should be used
MRI
Describe the difference between gout and calcium pyrophosphate crystals
Gout crystals:
- needle shaped
- negative birefringence
CPPD:
- rhomboid (stubby)
- weakly birefringent
- harder to find
Does spondylarthritis more commonly begin in youth or old age?
Usually begins in late adolescence/young adulthood
Is a higher or lower level of spinal cord injury worse for the patient?
Higher is worse
Which age group is at particular risk for prolonged symptoms of mild TBI/concussion?
Adolescents (13-17)
