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Clin Med III > MSK Exam #2 > Flashcards

MSK Exam #2 Flashcards

1
Q

Osteoporosis

A

Low bone mass
OR
Low bone strength

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2
Q

Osteoblasts and Osteoclasts

A

Osteoblasts build
Osteoclasts break down

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3
Q

Calcitonin activity

A

Stores calcium into the bones

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4
Q

Parathyroid hormone activity

A

Break down bone to get celcium into the blood stream

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5
Q

Estrogen and bones

A

Estrogen inhibits osteoclast activity

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6
Q

Where is trabeculae found

A

Ends of long bones and vertebrae are the ones we care about (are others)

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7
Q

Peak age for bone mass

A

In the 30s

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8
Q

Primary osteoporosis

A

Due to age without underlying disease process

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9
Q

Risk factors for primary osteoporosis

A

Caucasian and Asian
Smoking
Malnutrition
Decreased physical activity

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10
Q

Medications causing osteoporosis

A

Long term steroids
Valproic acid
Heparin
Aromatase inhibitors
Cyclosporine

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11
Q

Steroid dose that causes osteoporosis

A

Over mg Prednisone or equivalent for over 3 months

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12
Q

Presentation of osteoporosis

A

Vague s/s
Pathologic fractures
Shortening
Back pain without trauma

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13
Q

3 places for osteoporotic fractures

A

Vertebrae
Hip
Distal radius

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14
Q

Dx for osteoporosis

A

Via screening or fracture

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15
Q

Screening recommendation for osteoporosis

A

Grade B in women over 65 and postmenopausal women under 65 with risk factors
Grade I in men

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16
Q

Potential screening age for osteoporosis in men

A

70 years and above

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17
Q

DEXA T score interpretation

A

Under -2.5 - Osteoporosis
-2.4 to -1.0 -Osteopenia
Over -1.0 - Normal

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18
Q

Places we check in a DEXA scan

A

Lumbar spine and hips

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19
Q

Z scores for osteoporosis

A

Compare to people the same age - determine primary vs. secondary

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20
Q

Fragility fracture

A

Equivalent to a T score finding - break without trauma -wrist, hip, spine, etc.

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21
Q

Tx for Hip fx

A

Surgery
Only 2/3 return home after
Very dangerous

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22
Q

Other imaging and studies for osteoporosis

A

Plain films show demineralization
Calcium, phosphate, vitamin D

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23
Q

Hyperparathyroidism presentation

A

High calcium - stone, moans, groans, bones

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24
Q

Vitamin D deficiency presentation

A

Fatigue
Bone pain
Muscle weakness
No sun exposure

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25
Q

Diabetes presentation

A

Increased thirst and urination
Blurred vision
Numbness

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26
Q

Hyperthyroidism presentation

A

Tachycardia
Diarrhea
Weight loss
Elevated temp

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27
Q

6 diseases to consider in osteoporosis presentation

A

Hyperparathyroidism
Vitamin D deficiency
Diabetes
Hyperthyroidism
Celiac disease
Alcoholism

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28
Q

Pathway of osteoporosis workup

A

DEXA or fragility fx
Labs to r/o secondary cause
Treat osteoporosis an secondary cause if present

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29
Q

Frax score

A

Gives 10 year risk of osteoporotic hip fracture

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30
Q

Concerning Frax score

A

> 25% of major osteoporotic fx in next 10 years OR >3% of hip fx next ten years

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31
Q

Lifestyle modifications for osteoporosis and clinical pearl

A

Everybody gets!
Exercise and weight loss
Walking 1 hour per week = 20% reduction in hip fracture
Smoking cessation
ETOH moderation
Fall prevention

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32
Q

Minderal replacement for osteoporosis

A

For everyone!
Ideal Vitamin D - 800 IU daily - treat if under 20 with 50,000 weekly

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33
Q

Conditions for which insurance will pay for osteoporosis related vitamin D level - 4

A

DEXA scan under -2.5
Frax >3% for hip >20% for any fx
Frax>3% with T score<1.5
Initiating bisphosphonate therapy

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34
Q

Calcium replacement

A

Calcium citrate can be with or w/o food and may be with PPI
Calcium carbonate obstructed by PPI and must be with food
1200mg total per day is the goal

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35
Q

Who get pharm for osteoporosis

A

Osteoporosis or Osteopenia with +FRAX

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36
Q

Bisphosphonates for osteoporosis

A

End in -dronate
Alen - Weekly
Rise - Monthly
Iban - Q3 months
Zole - Yearly

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37
Q

Holidays for bisphosphonates

A

Need a drug holiday of 1+ year with repeat scores - higher risk means longer time before holiday

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38
Q

Pt Ed for bisphosphonates

A

Take with 8oz of water and NO food
No reclining for 30 minutes - heartburn
Osteonecrosis of the jaw related to dental procedures - SE

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39
Q

Pts who cannot have bisphosphonates

A

eGFR under 30-35
Significant GI disorders - be cautious

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40
Q

Denosumab

A

Becoming first line
Q6 months
Good for CKD patients for osteoporosis
$$$ if not covered
No drug holiday

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41
Q

Estrogen/Progesterone for osteoporosis

A

Last resort

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42
Q

SERM for osteoporosis

A

Inhibits bone resorption and reduces fx risk
Also causes clots and hot flashes
Needed for

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43
Q

Romosozumab

A

PTH Protein analog
Must correct calcium and vitamin D first
Wanes after 12 months
Good for bisphosphonate holiday

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44
Q

Monitoring for osteoporosis

A

New DEXA every 2 years - consider changing therapy if not inmproving
Double therapy not recommended

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45
Q

Indications for endo referral in osteoporosis

A

Osteoporosis before menopause under 50
Failed tx or continual fx

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46
Q

Osteogenesis imperfecta

A

Brittle bone disease, presents with
Blue sclera
Hearing loss
Weak joints and easy fractures

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47
Q

Types of osteogenesis imperfecta

A

I - Mild; Accelerated osteoporosis
II - Lethal - non compatible with life
III - Severe, short stature, etc.
IV- Moderate, skoliosis, etc.

19 in all

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48
Q

Plain films in osteogenesis imperfecta

A

Bowing of bones

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49
Q

Management for osteogenesis imperfecta

A

r/o abuse
Activity restrictions based on severeity
May give bisphosphonate therapy

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50
Q

Osteoarthritis

A

MC joint disease
Mainly d/t aging
May have asymptomatic or incidental findings

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51
Q

Pathogenesis of arthritis

A

Recurrent trauma leading to degeneration of cartilage
Inflammation or loss of estrogen

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52
Q

Osteophyte

A

Bone spur
Trying to strengthen itself d/t trauma

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53
Q

Presentation of osteoarthritis - 6 items

A

Insidious onset
Hx of repeated trauma
Limited ROM
Pain relieved by rest
Knee crepitus
Early AM stiffness - under 10 minutes

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54
Q

Herbeden nodes

A

DIP osteoarthritis nodes

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55
Q

Bouchard nodes

A

PIP nodes - severe osteoarthritis and rheumatoid arthritis

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56
Q

Inlammation of osteoarthritis

A

Non-inflammatory
Yellow, transparent fluid with few WBCs

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57
Q

Dx for osteoarthritis

A

Radigraphic - dx of choice
May see bone cysts, osteophytes, lipping

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58
Q

Management for osteoarthritis

A

PT
Weight loss
Acetominophen is first line 3-4g daily
NSAID - Voltaren/Pennsaid gel or Mobic daily

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59
Q

Intra-articular steroid use

A

Effective for most joints
Minimal systemic effects
Softens up joint space with decreasing efficacy

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60
Q

Hyaluronic acid for joints

A

Helps to lubricate by increasing synovial fluid viscosity
Joint injection

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61
Q

FInal resort for osteoarthritis

A

Surgery

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62
Q

Gouty arthritis

A

Metabolic disease with abnormal amounts of uric acid - monoarticular involvement

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63
Q

MC joint affected by gout

A

Great toe

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64
Q

Tophus

A

Nodular deposit of monosodium urate crystals with an associated foreign body reaction

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65
Q

Podagra

A

Gout of the MTP joint of the great toe

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66
Q

Presentation of gouty arthritis

A

Frequently nocturnal
Sudden onset
Fasting, alcohol, medication changes
Asymmetrical with more than one joint possible
Intense pain with little weight

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67
Q

Presentation of gouty joint

A

Warm, swollen, and tender
Inflammatory!!
r/o infection

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68
Q

Dx for gouty arthritis

A

Uric acid level elevated in 75%
CBC may help
Definitive dx - Negatively birefringent crystals on fluid aspiration

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69
Q

Tx for gouty arthritis

A

Asymptomatic - Cut out purines, alcohol
NSAID for pain - indomethacin/Naproxen
Colchicine

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70
Q

Steroids for gouty arthritis

A

Faster than NSAIDs
Prednisone, Methylprednisilone
Can give directly in joint

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71
Q

Hyperuricemic medications

A

Thiazide and loop diuretics
Niacin

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72
Q

Group III - Foods to avoid with Gout - 5

A

Venison
Nuts
Mussels
Avocado
Sardines

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73
Q

Good foods for Gout (Level I)

A

Cheese
Bread
Vegetables
Butter
Eggs

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74
Q

Urate lowering pharm for gouty arthritis Used between attacks

A

Xanthine oxidase inhibitors
Alopurinol and Uloric

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75
Q

Probenecid

A

Increases uric acid excretion - can be used in gouty arthritis

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76
Q

Chronic trophaceous arthritis

A

Severe gout with large trophi
May need surgery

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77
Q

Pseudogout presentation

A

Positive birefringence
Chondrocalcinosis on XR
Asymmetrical

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78
Q

Tx for psudogout

A

NSAIDs and Steroid injections

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79
Q

Rheumatoid arthritis

A

Chronic systemic inflammatory disease manifesting in synovitis of multiple joints
3x more common in women

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80
Q

Pannus in RA

A

From chronic synovitis,
Overgrowth of the synovium
erodes cartilage, bone, ligaments and tendons

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81
Q

Presentation of RA

A

Symmetrical swelling of multiple joint though may be monarticular first
Over 30 minutes of AM stiffness
Inflammatory
Systemic symptoms

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82
Q

Complications of RA

A

Ulnar deviation of wrist
Boutinierre and Swan neck deformity
Nodules - may be pulmonary

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83
Q

Dx for RA

A

Anti CCP antibodies in 70-8-%
ESR/CRP
Rheumatoid factor only sensitive in 50% of cases

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84
Q

RA anemia

A

Hypochromic, normocytic anemia of chronic disease

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85
Q

Imaging for RA

A

Plain films may not show changes early on
Swelling, demineralization, erosions

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86
Q

Tx for RA

A

Treat both pain and inflammation
Treat early
NSAID or DMARD

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87
Q

Steroids for RA

A

Decrease inflammation and improve pain
Prednisone
Intrarticular triamcinolone
Superior effect for NSAIDs

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88
Q

DMARDs for RA

A

Methotrexate
Pregnancy test needed
GI side effects and pancytopenia - follow labs
No ETOH
Folic acid needed

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89
Q

Hydroxychloroquine for RA

A

DMARD
Cardiomyopathy and QT prolongation are concerns
Risk of retinal toxicity

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90
Q

Sulfasalazine and RA

A

Older drug as well
DMARD
Many side effects

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91
Q

Most recently used drugs for RA - 5

A

TNF inhibitors: Enbrel, Remicade, Humira, Simponi, Cimzia

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92
Q

Acute Bacterial Septic Arthritis

A

Asymmetrical
Typically in weight bearing joints
Prosthetic joints
Staph aureus is MCC

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93
Q

4 subtypes of juvenile idiopathic arthritis

A

Oligoartucular - few joints involved
Polyarticular - many joints involved
Systemiv
Enthesis

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94
Q

Enthesitis

A

Point where tendon/ligament attaches (enthesis) is inflamed

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95
Q

Oligoartucular JIA

A

Four or fewer joints
Assymetrical
Systemic features not common

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96
Q

Polyarticular JIA

A

5+ joints
More symmetrical process
May be rheumatoid factor positive or negative
May have low grade fever

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97
Q

Systemic JIA

A

Multiple joints
High fever
May have an evervescent salmon pink rash

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98
Q

Enthesitis associated JIA

A

MC in males over 10
Lower extremity large joint arhtritis, llow back pain, sacroileitis
Inflammation of tendinous instertions

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99
Q

Lab findings for JIA

A

No one test - may see elevated inflammatory markers

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100
Q

Joint fluid analysis indicative of trauma
Cells and Glucose

A

More red cells than white cells with white cells under 2,000
Normal glucose

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101
Q

Joint fluid analysis indicative of reactive arthritis
Cells & Glucose

A

3K-10K WBCs - mononuclear
Normal glucose

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102
Q

Joint fluid analysis indicative of JIA or other inflammatory arthritis

A

5K-69K WBCs - mostly neutrophils
Normal or slightly low glucose

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103
Q

Joint fluid analysis indicative of Septic arthritis

A

Over 60K WBCs, over 90% neutrophils
Low to normal glucose

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104
Q

General trend for joint fluid analysis and inflammation

A

More inflamed/infected leads to lower glucose and higher WBCs
Septic>JIA>Reactive>Trauma

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105
Q

Imaging for JIA

A

May see soft tissue involvement on XR
MRI may be helpful

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106
Q

Tx 1st line and goal for JIA

A

Goal Relieve pain and keepmjoints smooth
NSAIDs first line (naproxen, ibuprofen, meloxicam)

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107
Q

2nd line tx for JIA

A

DMARDs (Methotrexate)\Response in 3-4 weeks

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108
Q

3rd line tx for JIA

A

Insufficiant response to MTX or cannot tolerate
TNF inhibitors (etanercept, infliximab) enbreal and remicade respectively

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109
Q

Seronegative spondyloarthritis

A

Negative for rheumatoid factor but autoimmune - covers a variety of arhtritis
Often affect spine and SI joint

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110
Q

Ankylosing spondylitis

A

Chronic inflammatory disease of the axial skeleton joints (SI joints typically, then spine)
Teens to 20s onset
More common in males

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111
Q

Presentation of ankylosing spondylitis

A

Insidious onset - unilateral to bilateral
AM stiffnes lasting for hours and improving with activity
Lumbar curvature flattens and thoracic curvature exaggerates
SOB from physcal restriction

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112
Q

Five Transient effects of ankylosing spondylitis

A

Anterior Uveitis
Sausage swelling of fingers/toes
Cauda equina
Pulmonary fibrosis
AV conduction issues

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113
Q

Lab results for ankylosing spondylitis

A

Elevated ESR in 85%
Negative RF and anti-CCP
Mild anemia
Positive HLA-B27 (more in white patients)

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114
Q

Marker for ankylosing spondylitis

A

HLA-B27

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115
Q

Imaging for ankylosing spondylitis

A

XR: Changes take time!
Erosion and sclerosis which is bilateral in later stages
Shiny corner sign
Bamboo spine - fusion of facet joints
MRI will show signs sooner

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116
Q

Tx for ankylosing spondylitis

A

NSAID is first line with steroids having low impact on disease (may even decrease bone density)

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117
Q

Biologics for ankylosing spondylitis

A

TNF alpha antagonists - Enbrel, Remicade, Humira

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118
Q

Psoriatic arthritis

A

Psoriasis followed by arthritis in most but not all cases

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119
Q

Presentation of psoriatic arthritis

A

Symmetrical arthritis
DIP joints are MC affected joints
Bright white joint on XR
Nail pitting
Sausage swelling of digits

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120
Q

Arthritis mutilans

A

Severely deforming joint destruction

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121
Q

Labs for psoriatic arthritis

A

Elevated ESR
May have high uric acid levels w/o gout attacks Negative rheumatoid factor

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122
Q

XR findings for psoriatic arthritis

A

Sharpened pencil look on phalanx
Fluffy periosteal new bone

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123
Q

Tx for psoriatic arthritis

A

NSAID - first line
TNF blockers and MTX should also be considered early
Antimalarials may make worse

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124
Q

Reactive arthritis

A

May be precipitated by GI/GU infections
Few joints in low extremities
Extra-articular manifestations are common
HLA-B27 asociated
MC in young men

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125
Q

Presentation of reactive arthritis

A

Triad of: Arthritis, Uveitis/Conjunctivitis, and Urethritis
1-4 weeks after infection
Culture negative synovial fluid
Asymmetric!!
Systemic symptoms - mucocutaneous lesions

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126
Q

Keratoderma blenorrhagicum

A

Skin lesions found on palms and soles associated with reactive arhtritis

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127
Q

Dx testing for reactive arthrtisi

A

Some inflammation indicated by synovial fluid analysis

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128
Q

Tx for reactive arthritis

A

NSAIDs - first line
Sulfasalazine or MTX second line
Anti-TNF for refractory cases

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129
Q

IBF associated arthritis

A

One fifth of people with IBF
More common with crohns

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130
Q

Presentation of IBF associated arthritis

A

Joint disease that paralells IBD
Onset months to years after IBD dx
Can also resent with spondylitis that does not parallell IBD

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131
Q

Tx for IBD assotiated IBD

A

Be careful with NSAIDs - make IBD worse
DMARDs may also be effective
Steroids may be beneficial

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132
Q
A
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133
Q

Presentation of septic arthritis

A

Abrupt onset - urgent ER visit
Chills
Fever
Swelling
May look like gout

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134
Q

Dx for septic arthritis

A

Aspirate fluid
Significant WBC elevation
Gram stain, Crystal ID, Culture

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135
Q

Imaging for septic arthritis

A

Not very useful
May see some swelling

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136
Q

Tx for septic arthritis

A

C&S for joint fluid
Rocephin or Vanc for empiric

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137
Q

Gonococcal arthritis

A

Otherwise healthy individuals
MC in women under 40

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138
Q

Presentation of gonococcal arthritis

A

Migratory polyarthralgias for 1-4 days
Tenosynovitis (more common) or purulent monoarthritis (less common
May have fever, rash, GU symptoms

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139
Q

Dx testing for gonococcal arthritis

A

Inflammatory joint fluid
Looks like gout again!
Pay attention to hx

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140
Q

Tx for gonococcal arthritis

A

Rochephin IV - quicker healing than septic

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141
Q

Rest and inflammatory arthritis

A

Rest makes it WORSE rather than better

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142
Q

Leflunomide (Arava

A

Rheumatoid arthritis drug
Careful in liver disease
CI in pregnancy
Inhibits pyrimidine synthesis

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143
Q

Etanercept

A

For ankylosing spondylitis, psoriatic arthritis, Rheumatoid arthritis
Risk of anaphylaxis
TNF inhibitor

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144
Q

Bisphosphonates

A

End in ~dronate
Inhibits bone resporption
Take on empty stomach
Osteonecrosis of the jaw
Upright after taking medication

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145
Q

Raloxifene

A

Prevents bone loss
Increased thromboembolism risk

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146
Q

Muscle relaxer use

A

Caution in elderly
Soma can be an addictive substance
Flexeril and Robaxin are common

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147
Q

Presentation of polymyalgia rheumatica

A

Related to temporal arteritis
Pain stiffness in pelvic and shoulder girdle - proximal

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148
Q

3 things that are difficult for pts with polymyalgia rheumatica

A

Troubel combing hair, putting on coat standing

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149
Q

Labs for patients with polymyalgia rheumatica

A

Anemia with elevated ESR/CRP

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150
Q

Management for polymyalgia rheumatica

A

LOW DOSE Prednisone with 2-4 week taper - may take years before you need to taper
MTX for flares

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151
Q

How quickly should a patient on steroids improve from Polymyalgia Rheumatica

A

72 hours

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152
Q

Temporal arteritis

A

MC in women, rare in blacks - often also have polymyalgia rheumatica
Older pts

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153
Q

Marker associated with Temporal arteritis

A

HLA-DR4

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154
Q

Etiology of temporal arteritis

A

Pan-arteritis of medium and large blood vessels - aorta and it branches
Can be an issue for vision

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155
Q

Presentation of temporal arteritis

A

HA
Scalp tenderness
Amaurosis fujax - fleeting blindiness
Jaw claudication
Fever

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156
Q

PE and Dx for temporal arteritis

A

Pulsitile, edematous, tortuous temporal artery
Maybe MRI/CT
Elevated ESR
NO CK elevation!!

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157
Q

Definitive dx for temporal arteritis

A

Biopsy of temporal artery over 3 cm or 1 inch

158
Q

CTA/MRI for temporal arteritis

A

Can help dx systemic involvement

159
Q

Tx for temporal arteritis

A

Begin high dose prednisone 1 month before tapering
Add baby aspirin for stroke prevention

160
Q

Management for vision loss in temporal arteritis

A

1 Gram methylprednisolone may require 2+ years of tx

161
Q

Polyarteritis nodosum

A

Often associated with hepatitis B (10% have it)
Multisystem necrotizing arteritis of small and medium vessels

162
Q

Etiology of polyarteritis nodosa

A

Fibrosis of vessels
Spares the lungs

163
Q

Presentation of Polyarteritis Nodosa

A

Nonspecific - fever, nausea, abd pain, neuropathy, arthralgias
Livedo reticularis
Digital gangrene
Lower extremity ulcerations

164
Q

Dx for polyarthritis nodosa

A

No specific test
ANCA negative
Hep B test
Tissue bx
Angiogram if mesenteric ischemia suspected

165
Q

Acute Management for PAN

A

High dose steroids -methylprednisilone for severe
Cyclophasphamide added - dont use for long

166
Q

Poo prognostic factors for PAN

A

CKD
GI Ischemia
CNS disease
Cardiac involvement

167
Q

Granulomatosis with Polyangiitis (Wegner’s)

A

MC in whites
Can occur at ANY age
Lungs and Kidney destruction

168
Q

Triad of Wegners

A

Upper airway lesions
Lower airway lesions
Renal issues

169
Q

Risk factor of Wegners

A

Chronic nasal staph

170
Q

Presentation of Wegners

A

Severe upper respiratory findings - paranasal pain, drainage, saddle nose deformity
Serous OM
Tracheal stenosis - cough
Skin lesions - purpura

171
Q

Dx for Wegners

A

Tissue biopsy - must have
Elevated ESR
Elevated ANCA

172
Q

Management for Wegners

A

Cyclophosphamide - ANCA does not follow remission
May use with steroids
Rituximab - Maintainance

173
Q

Remission maintainance for Wegners

A

MTX replaces cyclophosphomides
Steroids - continue

174
Q

Abx for infections with Wegners

A

Bactrim for chronic Staph infection

175
Q

Microscopic polyangiitis

A

Necrotizing vascuitis of medium and small arteries and VEINS
Capillaries in lungs and kidneys

176
Q

Presentation of microscopic polyangiitis

A

Purpura
Splinter hemorrhages
Lung fibrosis
Pulm hemorrhage in severe cases

177
Q

Dx for microscopic polyangiitis

A

Elevated ANCA in 75% of cases
Elevated CRP/ESR
RBC casts, Protein on UA

178
Q

Management for microscopic polyangiitis

A

Steroids, Cyclophosphamide to MTX
Immune suppressive tx required for significant involvement

179
Q

Henoch Shonlein Purpura

A

MC vasculitis in children!!
Peak in the spring
MC in males

180
Q

Etiology of HSP

A

IgA deposition -may be allergy mediated
Incited by URI, Drugs, Foods, Insect bites

181
Q

Clinical presentation of HSP

A

Palpable purpura - lower extremities and buttocks
May see intussussception
Arthralgia
May look like abuse

182
Q

Dx for HSP

A

Mild leukocytosis
May see elevated IgA

183
Q

Management of HSP

A

Prednisone in children - may still have proteinuria for 1 year after onset

184
Q

ANCA

A

Anti-neutrophil cytoplasmic antibodies - associated with Wegners and Microscopic polyangiitis

185
Q

C and P anca

A

C -Cytoplasmic
P - Pernuclear
Usually test for both

186
Q

Way to remember number of cervical, thoracic and lumbar vertebrae

A

Breakfast - 7
Lunch - 12
Dinner - 5

187
Q

Acute back pain

A

Under 6 weeks

188
Q

Subacute back pain

A

6-12 weeks

189
Q

Chronic back pain

A

Over 12 weeks

190
Q

5 back pain red flags

A

Under 20 or over 50
Nocturnal pain
Fever/Weight loss
Over 1 month
Steroid use

191
Q

Nerve root Innervation for deltoid

A

C5 nerve root

192
Q

Nerve root Innervation for biceps

A

C5 and C6

193
Q

Nerve root Innervation for wrist extensors

A

C6

194
Q

Nerve root Innervation for skin over deltoid

A

C5

195
Q

Nerve root Innervation for thumb, pointer finger and lateral arm

A

C6

196
Q

Nerve root Brachioradialis innervation

A

C6

197
Q

Nerve root innervation of the triceps

A

C7

198
Q

Nerve root innervation of the wrist flexors

A

C7

199
Q

Nerve root innervation of the finger extensors

A

C7

200
Q

Nerve root innervation of middle finger sensation

A

C7

201
Q

Nerve root innervation of the finger abductors and adductors

A

C8

202
Q

Nerve root innervation of the finger flexors

A

C8

203
Q

Nerve root innervation of the pinky and ring finger and medial forearm sensation

A

C8

204
Q

Nerve root innervation for foot dorsiflexion

A

L4

205
Q

Nerve root innervation for patellar tendon reflex

A

L4

206
Q

Nerve root innervation for great tow and medial foot sensation

A

L4

207
Q

Great toe extension (dorsiflexion) nerve root innervation

A

L5

208
Q

Babinski reflex nerve root innervation

A

L5

209
Q

Middle of the foot sensation nerve root innervation

A

L5

210
Q

Innervation of foot eversion

A

S1

211
Q

Innervation of achilles tendon reflex

A

S1

212
Q

Nerve root Innervation of Lateral foot sensation

A

S1

213
Q

Nerve root innervation for anal sphincter

A

S2-4

214
Q

Streight leg raise test

A

Lay down flat with legs extended - worsening radicular pain is positive for disk herniation

215
Q

Sensitivity/Specificity of SLR

A

More sensetive than specific

216
Q

Crossed straight leg raise test

A

Evaluation of the UNAFFECTED leg - lay flat and raise - for radicular pain
More specific

217
Q

Trendelenburg test

A

Weak gluteal muscles on the contralateral side to hip drop

218
Q

Ankle clonus test

A

Perform is achilles tendon reflex is abnormal
Involuntary shaking when forced dorsiflexion of foot

219
Q

Waddel’s test - 4 tests

A

For malingering:
Superficial tenderness out of proportion
Axial loading with pain
No pain when pt distracted
Non anatomic impairment
3/4 is positive

220
Q

Main 3 c spine views

A

AP, Lateral, Odontoid

221
Q

5 C spine views

A

3 views and AP and PA views

222
Q

Scottie dog sign

A

Normal - a fracture through the neck indicates a pars interarticularis fx

223
Q

Common causes of acute low back pain

A

Injury to paravertebral spinal muscles, ligaments, facets, intervertebral disks

224
Q

RF for lower back pain

A

Poor physical fitness
Job dissatisfaction
Smoking
Psychosocial issues

225
Q

Presetation of acute low back pain

A

Hx of repetetive movement/vibration
Transient relief with frequent change in position
Worse with movement
Radiates to buttocks and thighs

226
Q

PE for acute low back pain

A

NO neuro defecits
Difficultly standing straight
Diffuse tenderness in the region - may palpate muscle spasm

227
Q

Workup for acute low back pain

A

XR usually not useful if no trauma - may see aging over 30

228
Q

Management for acute low back pain

A

Education and symptomatic relief
Heat, PT, NSAID or Acetominophen
No bed rest
Caution with muscle relaxers

229
Q

Indications for referral for acute low back pain

A

Neuro symptom
Not improving with conservative therapy - ensure compliance

230
Q

Prognosis for acute low back pain

A

Improvement should be seen after 4-6 weeks

231
Q

4 Risk factors for chronic low back pain

A

Repetetive trauma
Infection
Heredity
Tobacco use

232
Q

Presentation of chronic low back pain

A

Aching +/- radiation
Restricted straight leg raise - limited hip flexion
Improvement lying down
Neuro is NORMAL

233
Q

Workup for chronic low back pain

A

Age related changes on XR
May want to rule out cancer

234
Q

2 age related spine changes

A

Disk space narrowing and Bone spurs

235
Q

Management for chronic back pain - no pharm

A

CBT
Biofeedback/Spinal cord stimulator
Goal oriented activity

236
Q

Cervical strain

A

Whiplash -Hyperextension and Hyperflexion

237
Q

Presentation of cervical strain

A

Diffuse, non-radiating pain from base of skull to
cervicothoracic junction
HA

238
Q

PE for cervical strain

A

Paraspinous Tenderness and limited ROM
NO neuro defecits

239
Q

Workup for cervical strain

A

XR looking at EVERY vertebrae in the spine for hx of trauma or old age

240
Q

Management of cervcal strain

A

Soft cervical collar
Muscle relaxant
NSAID or MILD narcotic
Cervical manipulation CI - may use cervical traction ONLY

241
Q

Prognosis for cervical strain

A

4-6 weeks to resolve, may take up to 12 months

242
Q

3 MOIs for C spine fractures

A

High energy trauma
Extreme ROM injury
Axial compression injury

243
Q

Types of odontoid process fxs

A

1-3 - One is just the tip, 3 is the process and some of the vertebra

244
Q

Presentation of C spine fx

A

Severe neck pain
Focal numbness, global defecits suggest a spinal injury

245
Q

PE for C spine fracture

A

Palpate and inspect for bruising and swelling through the C-collar - look for a step of point indicating slippage of vertebrae

246
Q

Spondylosysis

A

Fracture without slippage

247
Q

Spondylolisthesis

A

Fracture with slippage

248
Q

NEXUS criteria for C spine - 5 criteria

A

IMAGING NOT NEEDED IS ALL FIVE SATISFIED:
1. No posterior midline cervical-spine tenderness
2.No evidence of intoxication
3. Normal level of alertness
4. No local neurologic defecit
5. No painful, distracting injuries

249
Q

Modality of choice for C spine fx

A

CT scan
AP, Lateral and Odontoid
MRI for neuro symptoms

250
Q

Management of c spine injury

A

Immobilize
Steroids controversial
Consult ortho and neurosurgery
Halo vest - Regina George

251
Q

Thoracolumbar vertebral fx presentation

A

d/t high energy trauma or in osteoporotic / cancerous patients
C collar and backboard
Severe pain - may need narcotic
May have neuro symptoms
Pain on percussion

252
Q

Imaging for thoracolumbar fracture

A

XR - order CT with contrast if abnormal

253
Q

Management for thoracolumbar fracture

A

TLSO (corset) brace 8-12 weeks if compression fx under 20 degrees
Neuro consult
Kyphoplasty for MORE than 20 degrees

254
Q

Torticollis

A

Spasm in one side of the neck causing abnormal rotation
Trapezius or SCM or any other muscle

255
Q

Infection that can cause torticollis

A

Peritonsillar abcess

256
Q

Drugs that can cause torticollis

A

Haldol and Reglan

257
Q

Management of torticollis

A

NSAIDs, Benzos for conservative, Botox for resistant

258
Q

Spinal stenosis presentation

A

Shopping cart sign - need to lean over
Neurogenic claudication - pain with activity but radicular
Improves with flexion

259
Q

PE of spinal stenosis

A

Negative neuro exam
Weakness after
May have + SLR sign
Normal pulses

260
Q

Management for spinal stenosis

A

PT, Water aerobics, NSAIDs for conservative therapy
Reatpeat epidural steroid injections

Surgery if severe

261
Q

Herniated nucleous pulposis presentation

A

Herniated disk - can cause sciatica
Ipsilateral pain
Abrupt severe onset of pain
+ SLR sign

262
Q

Workup for herniated nucleus pulposis

A

XR - not very helpful
MRI is of CHOICE (but insurance may want an XR first)

263
Q

Management for herniated nucleus pulposis

A

NSAIDs, Steroids, Opiates if severe
Rest but not complete rest
Improves over time (up to a month

264
Q

Indications for referral of slipped disc for surgery (1 is emergent)

A

Focal defecit - emergent
Lack of improvement in 3-4 weeks
Recurrent episodes

265
Q

Cauda equina presentation

A

Compression of L2-L4, stenosis, mass on spine, accident
Low back pain and radiculopathy
Saddle anesthesia
Bowel/Bladder incontinence
Foot drop - trip when walking

266
Q

Management of cauda equina

A

Emergent!! - referral to neuro-spine
Surgery

267
Q

Workup for cauda equina

A

Emergent MRI

268
Q

Presentation of sciatica

A

Presentation like a herniated disc but due to some other underlying condition
MRI to workup

269
Q

Kyphosis presentation

A

Hunchback
Dowagers hump - often a cosmetic concern
Poor pulm function
Fall risk

270
Q

Cobb angle

A

Angle of kyphosis - should be 20-40

271
Q

Tx for kyphosis

A

NSAIDs
Muscle relaxants
Back strengthening or bracing
Surgery if elligible

272
Q

Methocarbamol

A

Robaxim
CNS depressant - can knock a patient out
Muscle spasms or tetanus
CI in pregnancy

273
Q

Tizanidine

A

Muscle spasm and/or MSK pain, spastisity
Reduces facilitation of spinal neurons
CI with Cipro, Fluvoxamine, pregnancy
May cause dry mouth

274
Q

Cyclobenzaprine

A

Muscle spasms, TMJ, Fibromyalgia
No use in hyperthyroidism, HF, Arrhythmia, MI
Caution in acute angle closure glaucoma
Pregnancy B

275
Q

Carisoprodol

A

VERY potent
Indicated for acute muscle pain
Causes CNS depression - can reduce seizure threshold
Controlled

276
Q

Metaxalone

A

For acute muscle pain
CI in anemia, hepatic, renal impairment
CNS depressant

277
Q

4 parts of the picture in rheumatology

A

Hx
PE
Imaging
Labs
Constellation of s/s more important than ever

278
Q

Start lab for rhematology workup

A

ANA - Anti-nuclear antibody

279
Q

Rheum - root

A

Joint

280
Q

ANA lab - what does it look for

A

Looks for antibodies that attack cells - ratio of amount of saline that is needed to dilute out all the AB’s - higher is greater likelihood

281
Q

S&S for ANA

A

High sensitivity, Low specificity

282
Q

Threshold for ANA titer

A

1:160 - Get AUTO license at 16

283
Q

ANA with reflex

A

Look for over 40 patterns
Look for what antibodies are for

284
Q

5 SLE antibody titers

A

Anti-dsDNA
Anti-Smith - At least remember this one
Anti-U1-RNP

285
Q

Mneumonic for polymyositis/dermatomyositis ab titers

A

Mia and Joe go married because they liked each other’s skin - Unfortunately Joe wanted to be polyamourous and kept hooking up with some random person who also had nice skin
Anti-Mi - Just Dermatomyositis
Anti-Jo and Anti-SRP - Dermatomyositis and Polymyositis

286
Q

Antibodiy titers for BOTH lupus and sjorgrens

A

Anti-SSA
Anti-SSB

Double S for two S diseases

287
Q

Crest syndrome ab titer

A

Anti-Centromere - With a C!!

288
Q

Drug induced lupus ab titer

A

Have history of taking a drug - Anti-Histone

289
Q

Two Progressive systemic sclerosis ab titers

A

Anti-RNA-polymerase
Anti-Scl-70

290
Q

ENA lab

A

Extractable nuclear antigen - points towards connective tissue disease

291
Q

RF Factor

A

Indicates inflammation - not necessarily rheumatoid arhtritis - not specific/sensitive

292
Q

Most specific lab to rheumatoid arthritis

A

Anti CCP - 90.4% have RA

293
Q

CRP v. ESR

A

CRP is acute
ESR is chronic
Think alphabetical order

294
Q

c-ANCA disease - 2

A

Wegners and Churg-Strauss syndrome

295
Q

Presentation of Lupus

A

Comes and goes in flares in variable periods
Sun, Stress, Infection make it worse
Discoid rash
Photosensitivity
Oral ulcers
Alopecia

296
Q

SLE triad

A

Low grade fever
Joint pain
Butterfly rash

297
Q

Arthritis of SLE

A

Moving arthritis in 2+ joints

298
Q

Lupus nephritis

A

Requires biopsy to dx but guarantees lupus

299
Q

Drug induced lupus

A

Have hx of taking a drug:
Anti histone
Hydralazine, Procainamide
Penicillamine, Quinidine

300
Q

Monitoring of SLE

A

Every 6 months
Follow with various labs specialties as needed

301
Q

Non-pharm SLE tx

A

Refer appropriately
Psych
SPF over 55
Smoking cessation!!
Immunization, Diet, Exercise

302
Q

Medications to avoid in SLE

A

Bactrim and Minocycline

303
Q

Pharm for mild to moderate lupus

A

Hydroxychloroquine - 1st line for mild
Prednisone for moderate
MTX or azathioprine added

304
Q

Pharm for severe lupus

A

Hydroxychloroquine, High dose IV prednisone
Cyclosporine or monoclonal ab

305
Q

Chloroquin SE

A

Bull’s eye retinopathy

306
Q

Tx for lupus joint symptoms

A

Naproxen - can also try a steroid or muscle relaxer

Use as an add on for flares

307
Q

Presentation of scleroderma - 2 each of Skin, Vascular, and GI

A

Puffiness that does not respond to diuretics
Itching and pigmentation changes
Raynauds
Cutaneous telangiectasias
Constipation
Iron deficiency

308
Q

Scleroderma

A

Things get stiff - in general

309
Q

4 subsets of scleroderma

A

Limited cutaneous - everything is distal
Diffuse cutaneous scleroderma - All over
Systemic sclerosis sine scleroderma
Systemic sclerosis with overlap syndrome

310
Q

CREST syndrome - 5 symptoms

A

MC scleroderma
Calcinosis
Raynauds
Esophageal dysfunction
Sclerodactyly
Telangiectasias

311
Q

Sclerodactyly

A

Thickening and tightening of skin on fingers and hands

312
Q

Labs for scleroderma

A

Anti DNA topoisomerase
Anti-Centromere
Anti RNA polymerase III
Anemia

313
Q

Imaging for scleroderma

A

Get PFT and CT of chest for lung disease screen

314
Q

Treatment for scleroderma

A

nDHP-CCB for raynauds
Stepwise approach to control inflammation - NSAIDs (if kidneys okay), then steroids, the hydroxychloroquine, then MTX, then biologics

315
Q

Indication for immediate MTX use in scleroderma

A

Used in skin sclerosis and diffuse organ involvement

316
Q

Sjorgen’s syndrome

A

Autoimmune dryness due to due to diminished lacrimal and salivary gland function

317
Q

Presentation of Sjorgen syndrome

A

Attack glands - Dry eyes -burning and itching, mouth, Numbness, nerve problems, Vaginal dryness

318
Q

Workup for Sjorgren’s syndrome

A

ANA is often negative
ESR elevated
Anti SSA and SSB antibodies
Schirmers test - for dry eye

319
Q

Schirmer test

A

Paper wick placed in eye - over 10mm soak is a negative test

320
Q

Treatment for sjorgen’s syndrome

A

Eye drops
Skin lotion
Fatty acid dietary increase
Pilocarpine -cholinergic

321
Q

Dermatomyositis and Polymyositis presentation

A

Symmetric progressive, painless proximal weakness
Muscle atrophy
ILD

322
Q

Skin manifestations for dermatomyositis

A

Gottrons papules and Heliotrope eruption on skin
SHAWL SIGN - rash on back of torso

323
Q

Workup for DM/PM

A

Anti-Mi
Anti-Jo
Anti-SRP
(Remember Mia and Joe)
Elevated ESR

324
Q

Treatment for PM/DM

A

Cancer screening every 2 years - age appropriate
Swallow test
Prednison +/- a DMARD (MTX/Sulfasalazine)

325
Q

Presentation of benign tumors

A

Usually don’t cause constitutional symptoms or pathologic fractures/weaken bone

326
Q

Malignant/Aggressive tumor presentation on XR

A

Onion skinning and Moth eaten appearance

327
Q

Eval for bone tumor after XR

A

Get an MRI - to see soft tissue
CT may be better for mets

328
Q

Osteoid osteoma

A

Overgrowth of bone tissue
Males and Long bones most common
Benign

329
Q

Presentation of osteoid osteoma

A

Nidus - secretes prostoglandins causing pain
Deep, severe pain worse at night and with vasodilation
Better with ASA, NSAID

330
Q

Workup for osteoid osteoma

A

XR - Nidus under 1.5cm, calcified looking like a bell - may need serial imaging
CT w/ contrast post XR if any confusion

331
Q

Indication for radionuclear test for OO

A

We cant do a CT - Double density sign

332
Q

Management for OO

A

Serial imaging and OTC therapy for mild presentation
Removal, Surgery, or Crytherapy for severe

333
Q

Osteoblastoma presentation

A

More slow growing than OO
Nidus larger than 2 cm
In patient SPINE! - neuro symptoms
Pain NOT relieved by NSAIDs
Systemic symptoms not common

334
Q

XR findings for osteoblastoma

A

Over 2 cm well circumscribed lesion
Shell of new bone surrounding it
More soft tissue involvement

335
Q

CT for osteoblastoma

A

Always indicated because of spinal involvement

336
Q

Dx for Osteoblastoma

A

Refer to onc for a core needle biopsy

337
Q

Management for osteoblastoma

A

Surgical resection -may need for confirmation
Curettage and grafting or marginal resection with radiation

338
Q

Prognosis for osteoblastoma

A

Recurrence rate of 10-20% (more than OO)

339
Q

Osteochondroma

A

Bony projections with cartilage cap coming off of long bone
MC in tibia, femur, humerus

340
Q

Presentation of osteochondroma

A

Grows as the patient grows
Most asymptomatic
Painless mass
Mechanical symptoms - bursitis, etc.
Can get fractured or interfere with growth plate

341
Q

Imaging for Osteochondroma

A

XR or CT

342
Q

Management for osteochondroma

A

Watch if asymptomatic
Excise if inhibiting function, mechanical issues

343
Q

Prognosis for osteochondroma

A

Recurrence may happen with hereditary osteochondromas

344
Q

Enchondroma

A

Cartilage tume on the insode of the bone - hyaline
From metaphysis into the diaphysis - roughe chondrocytes in the growth plate
Typically 2nd decade of life (think growth spurt time

345
Q

Presentation of enchondroma

A

Asymptomaic - Find an incidental knot
May have pain, fractures, widening of bones
Painless

346
Q

XR and workup for enchondroma

A

Centrally located sclerotic looking lesion
Use CT/MRI to r/o other diseases

347
Q

Management of enchondroma

A

Monitor for small, low-risk lesions
Curettage and bone grafting for more concerning

348
Q

3 Risk factors for a pathologic fracture to consider when managing an enchondroma

A

Weight bearing bone
>25mm in diameter
Involving >50% of the diameter of the cortex

349
Q

Prognosis for enchondroma

A

Usually self limiting - may transform to chondrosarcoma - more likely if they have many

350
Q

Chondroblastoma

A

Tumor in the epiphysis or apophysis of the bone - MC on proximal humerus

351
Q

Presentation of chondroblastoma

A

Chronic pain - not affected by exercise
Localized tenderness
Muscle atrophy and limp may be present

352
Q

Imaging for chondroblastoma

A

Small well defined lesions with sclerotic border
XR usually enough, bipsy to confirm

353
Q

Management, prognosis and complications for chondroblastoma

A

Curettage and bone grafting
Recurrence of 20%
Pulmonary mets possible

354
Q

Fibrous dysplasia

A

Abnormal fibrous tissue and trabecular bone replacing normal bone amrrow
Slow growing
MC in males

355
Q

Presentation of fibrous dysplasia

A

Most asymptomatic
Shepherds crook
Varus defomity or facial assymetry

356
Q

Mccune albright syndrome

A

fibrous dysplasia that is genetic - cafe au lait spots present

357
Q

Imaging for fibrous dysplasia

A

Mass with ground glass opacities
Thinning of cortical bone
May bone scan for multi bone involvement

358
Q

Management for fibrous dysplasia

A

Nothing if asymptomatic
IV bisphosphonates - Fosfamax, curettage not as helpful
Send to endo

359
Q

Prognosis for fibrous dysplasia

A

Recurrence is high
May stabilize with maturity

360
Q

Ossifying fibroma

A

Slow growing bony lesion
Tibia in peds, Jaw in adults
Firm swelling, tibial bowing
Painless

361
Q

Ossifying fibroma imaging

A

XR - Intracortical lesion
Lytic appearing - chunk out of bone

362
Q

Management of ossifying fibroma

A

Monitor if asymptomatic with repeat XR every 6 months
Resection, Curettage, and bone grafting AFTER skeletal maturity for symptomatic

363
Q

Nonossifying fibroma

A

Collection of fibrous tissue - in kids
Usually asymptomatic without bone weakness
Lytic on XR and not centered in bone (eccentric)

364
Q

Tx for nonossifying fibroma

A

None if asymptomatic
Surgery for large lesions and lesions in high stress areas

365
Q

Unicameral bone cyts

A

Fluid filled bone tumor common in kids 5-15
Asymptomatic unless pathologic fx

366
Q

XR presentation of unicameral bone cyst

A

Well defined cystic lesions at the metaphysis or metadiaphysis
Fallen leaf or fallen fragment sign

367
Q

Management for unicameral bone cyst

A

Usually resolve after puberty Aspirate and inject methylprednisolone if concerned for fx (ie. contact sports
Curettage and graft for LARGE cysts

368
Q

Aneuriymal bone cyst

A

Rapidly growing and estructive bengn lesion
Lots of blood supply
MC in females!

369
Q

MC sites for aneurysmal bone cyst

A

Tibia - MC
Femur
Posterior vertebral elements
Pelvis

370
Q

Presentation of aneurysmal bone cyst

A

Pain tenderness and swelling
Edema and pathologic fracture
Neuro if in spine
Stunted growth

371
Q

Imaging for aneurysmal bone cyst

A

Aggressive
Eggshell sclerotic rim
Soap bubble appearance
Lytic metaphyseal lesion

372
Q

Management for aneurysmal bone cyst

A

Excision, curettage, and bone grafting always
May cauterize blood vessels
Recurrence in 10-50% of cases

373
Q

Osteosarcoma

A

MC malignant bone tumor - metaphysis of long bones
Early adolescence, Adults of 50 are twin peaks

374
Q

Presentation of osteosarcoma

A

Pin and swelling without eccymosis or erythema
Worsening pain and limited ROM
No systemic symptoms early on

375
Q

Imaging for osteosarcoma

A

Osteolytic lesions
Moth eaten appearance
Starburst and Codmans triangle

Bone scan for mets

376
Q

Management for osteosarcoma

A

Surgery with pre and post op chemo to try and save as much limb as possible
Radiation usually not effective

377
Q

Chondrosarcoma

A

Many types - Malignant
May be fast or slow growing
Older adults
MC in pelvis or shoulder girdle
May arise from a benign lesion

378
Q

Presentation of chondrosarcoma

A

Deep, dull, progressive, aching pain
Worse at night
Neuro symptoms possible
Limited ROM

379
Q

Classic XR finding for chondrosarcoma

A

Endosteal scalloping on XR

380
Q

Potential area for chondrosarcoma mets

A

Lungs

381
Q

Management for chondrosarcoma

A

Surgical excision is primary tx with amputation rarely needed

382
Q

Ewing sarcoma

A

Rare tumor that can proliferate in bone or soft tissue
11 and 22 chromosome translocation

383
Q

MC areas for ewing sarcoma

A

Pelvis and Femur

384
Q

Presentation of Ewing sarcoma

A

Localized pain and swelling
Constitutional symptoms

385
Q

Dx for Ewing Sarcoma

A

Onion skinning on XR
Poorly marginate lesion - no round mass

386
Q

Management for Ewing Sarcoma

A

Multi-drug chemo, surgery and radiation - hard to control
Better prognosis if young, appendicular skeleton, no mets

387
Q

5 cancer that commonly metastasize to the bone

A

Breast
Lung
Thyroid
Kidney
Prostate

388
Q

Presentation of metastatic disease to the bone

A

Pain,
Pathologic fracture
Anemia

389
Q

Dx for metastatic cancer to the bone

A

PET scan and biopsy of lesions

390
Q

Tx for Metastatic bone disease

A

Radiation and pain medication
Chemo
Bisphosphonates

Clin Med III (4 decks)

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