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STEP2 > MSK/Rheum > Flashcards

MSK/Rheum Flashcards

1
Q

Brachial plexus: branches (roots), innervation, deficit

A 
Musculocutaneous (C5-C7)
- should & forearm flexion; supination
- lateral forearm sensation
Axillary (C5-C6)
- deltoid abduction
- shoulder sensation
Radial (C5-T1)
- forearm & finger extension
- posterior arm & posterior 2.5 finger sensation
*wrist drop
Median (C5-T1)
- 1-3 thumb/finger flexion & forearm extension/pronation
- palmar 4.5 finger sensation 
*thumb issues
Ulnar (C7-T1)
- 4-5 finger flexion 
- 4-5 finger sensation (palmar & posterior)
*Claw hand
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2
Q

Anterior shoulder dislocation presentation, nerve risk, dx

A

Most common
Arm in abduction & external rotation

Axillary nerve damage

XR: humeral head anterior & inferior to glenoid

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3
Q

Posterior shoulder dislocation hx/pe*

A

Rare. 2/2 seizure & electrocution

Arm in adduction & internal rotation

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4
Q

Hip dislocation types, etiologies, sequelae, dx

A

Anterior: obturator nerve risk
Posterior: 90%, flexed/adducted hip pushed back, sciatic nerve & avascular necrosis
Dx: XR not sensitive ==> CT if suspicious

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5
Q

Colles’ fracture path, etiology, tx

A

Distal radius fx 2/2 FOOSH

Long-arm cast

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6
Q

Scaphoid fracture etiology, dx, tx, risk

A

FOOSH
Anatomical snuffbox tenderness w/ radial deviation pain

XR may take 2 weeks to become +
Spica thumb cast & repeat XR

AVN

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7
Q

Humerus fracture risk/pe*

A

Radial nerve: wrist drop

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8
Q

Femoral fx risk/hx/pe

A

Fat emboli: fever, MS change, hypoxia, petechiae, low platelet

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9
Q

Tibial fx risk

A

Compartment syndrome

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10
Q

ACL tear pe/dx

A

+anterior drawer & lachman

MRI

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11
Q

MCL tear pe*/dx/tx

A

Medial joint tenderness
+valgus stress test (knee forced into abduction)

MRI to confirm

No surgery

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12
Q

LCL tear pe/tx

A

+varus stress test

No surgery

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13
Q

PCL tear pe

A

+ posterior drawer

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14
Q

Meniscal tear hx, pe, tx*

A

**Clicking/popping during distinctly recalled event!
+McMurray: clicking/popping while medially/laterally rotating tibia while knee in flexion OR flexing/extending while palpating lateral/medial aspects

NSAID/rest ==> MRI if progresses to locking ==> surgery

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15
Q

Knee dislocation nerve, PE

A

Peroneal
Loss of ankle dorsiflexion
Loss of dorsal foot & lateral leg sensation

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16
Q

Compartment syndrome pe, dx, tx

A

Pain (extreme), parasthesias, pallor, poikilothermia…pulselessness & paralysis occur late!

> 30mmHg pressure

Fasciotomy

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17
Q

Volkmann’s ischemic contracture path* / dx

A

Supracondylar fracture @ distal humerus ==> brachial artery tear ==> ischemic injury causes permanent wrist flexion

Radial artery pulse test to ensure no brachial artery entrapment

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18
Q

Carpal tunnel path, presentation, dx, tx*

A

Median nerve entrapment 2/2 MPS matrix deposition*

Parasthesias, pain, atrophy of thenar region and fingers 1-3
Especially at night
Hypothyroidism* (usually more severe & bilateral) & diabetes often
+Phalen’s: full wrist flexion elicits tingling
+Tinnel’s: tapping median nerve elicits tingling

Usually clinical, but EMG can do it ==> MRI if equivocal

Splint ==> NSAIDs (unless pregnant) ==> steroids ==> surgery

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19
Q

Tendinitis pe/dx/tx

A

Pain with resisted strength test / repetition

Clinical diagnosis

Ice/NSAIDs ==> splint

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20
Q

L4 motor, reflex, sensation

A

Ankle dorsiflexion
Patellar
Medial leg, medial big toe

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21
Q

L5 motor, reflex, sensation

A

Great toe extension
None
Lateral leg, dorsal foot

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22
Q

S1 motor, reflex, sensation

A

Plantar flexion & hip extension
Achilles
Plantar foot

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23
Q

Low back pain red flags*

A 
>50
>6 weeks of pain
Cancer hx ==> constant, worse @ night, point tenderness*
Constitutional symptoms
Neurologic deficit
Loss of anal sphincter tone
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24
Q

Cauda equina syndrome path, presentation, dx, tx*

A

Sacral nerve bundle entrapment @ cord exit

Saddle anesthesia
Bowel/bladder incontinence
Impotence

Glucocorticoids STAT!
Immediate surgery

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25
Q

Low back pain dx/tx

A

MRI: if warning signs or 12+ weeks of pain

NSAIDs
Heat
PT
Regular physical activity…no bed rest

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26
Q

Spinal stenosis hx/tx

A

Neck pain radiating to arms / legs
Improves with hip flexion & forward bending

NSAIDs, PT
Corticosteroid injection
Laminectomy

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27
Q

Osteosarcoma path, presentation, dx*, tx

A

Malignant tumor of bone, often metaphysis distal femur, proximal tibia & proximal humerus ==> metastasizes to lung

Male, 20-30
Night pain, fever, sweat, weight loss
Erythema/enlargement over site

XR: “sunburst” pattern or “Codman’s triangle”
MRI/CT: necessary for staging

Ideally, limb-sparing chemo with pre&post operative chemo

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28
Q

Ewing sarcoma presentation, dx*

A

Child 10-20

XR: onion skinning [bulbous stringy lines] in diaphysis of femur*

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29
Q

Giant cell tumor hx/dx

A

Female 20-40
Knee pain & mass

XR: “soap bubble” appearance of metaphysis/diaphysis

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30
Q

Septic arthritis organisms*, presentation, dx, tx

A

Staph, strep
Prosthetics:
-S. aureus or Pseudomonas if infection occurs 3months post-op

Often prosthetic joints, osteoarthritis, rheumatoid arthritis

Warm, immobile joint
+/- fever, chills
Joint aspiration: +gram stain, >50,000 WBC, culture

Ceftriaxone & vanc
Surgical debridement

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31
Q

Osteoarthritis path, presentation, dx, tx

A

Non-inflammatory 2/2 cartilage deterioration & osteophyte formation in DIP & PIP (farthest and 2nd farthest joints), hips & knees

Old & obese people
*Pain worsens with activity
Morning stiffness  NSAIDs
NSAIDs
Steroid injections
Joint replacement
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32
Q

Rheumatoid arthritis path, presentation, dx, tx

A

Systemic, symmetric autoimmune inflammatory @ MCP (metacarpal phalanges), wrists,

SYMMETRIC, swollen joints, especially wrists, MCP, & PIP (not DIP!!)
Morning stiffness > 1hr ==> improves with use
Constitutional symptoms
Ulnar deviation of MCP
Swan-neck: hyperflexed DIP & hyperextended PIP
Boutonniere: hyperextended DIP & hyperflexed PIP
Pleural effusions
Rheumatoid nodules…soft tissue, cervical spine* (risk of subluxation & intubation difficulty) & heart

> 6 weeks*
Anti-CCP / ACPA [specific]
RF [sensitive]
Synovial aspiration: turbid, leukocytosis, >5000PMN

START with DMARDs**: Methotrexate ==> hydroxycholoroquine, sulfasalazine ==> etanercept, infliximab
**must tests for Hep B&C and TB before starting DMARD
NSAIDs & glucocorticoids

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33
Q

Gout path, presentation, dx, tx

A

Overproduction of uric acid (lesch nyan, hemolysis, malignancy like myeloproliferative*) OR undersecretion (renal disease, NSAIDs) ==> IgG/urate crystals phagocytized by PMN ==> deposition in joints

Excruciating pain, often fat binge-drinkers
Tophi, often first MTP (“podagra”)

Joint aspirate: needle, negatively birefringent; *necessary to rule out septic arthritis
Not helpful: serum uric acid (may be normal)

Attacks: Indomethacin (NSAID) > colchicine (diarrhea) ==> corticosteroids if severe
Chronic: Allopurinol or probenecid

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34
Q

Pseudogout path, hx*/pe, dx

A

Calcium pyrophosphate crystals 2/2 trauma, hyperparathyroidism* or hemochromatosis (2/2 parathyroid Fe?)

Wrists & knees affected
Acute pain, swelling, redness
Decreased ROM

Leukocytosis, sometimes
Rhomboid, +birefringence

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35
Q

Ankylosing spondylitis path, presentation, complications, dx, tx

A

HLA-B27 inflammatory condition ==> fusion of hip & spine

Hip/back pain worst in morning& night, worsens with inactivity, improves with exercise

Increased fx risk
Anterior uveitis
Heart block
Restrictive lung disease

Must rule out: 
Reactive arthritis (uveitis, urethritis, arthritis 2/2 infection)
Psoriatic arthritis (sausage digits, often DIP) 
Enteropathic arthritis (IBD-related sacroilitis)

XR: fused sacroiliac joints, bamboo spine, square vertebrae
Rheumatoid factor: negative
ANA: negative

NSAIDs ==> TNF-inhibitors or sulfasalazine

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36
Q

Polymyositis path, hx/pe, association

A

Anti-Jo-1 autoimmune muscle inflammation

SYMMETRIC, PROXIMAL muscle weakness & pain ==> breathing difficulty

Malignancy

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37
Q

Dermatomyositis path, hx/pe, association*

A

Anti-Jo-1 autoimmune muscle & skin inflammation

Heliotrope/butterfly rash: violaceous periorbital rash
Shawl sign: rash in shawl area
V-sign: rash on face, neck, chest
Gottron’s papules: papular, scaly rash on dorsal knuckles

Risk: underlying malignancy (ovarian, breast, lung) ==> needs diagnostic workup

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38
Q

Poly & dermatomyositis dx/tx, ddx*

A 
Two+ = likely myositis: 
Symmetric, proximal weakness
CK: elevated
EMG abnormality
Muscle biopsy: fibrosis
Anti-Jo-1 antibody +
Anti-Mi-2(helicase) ==> dermatomyositis?

Steroids or azathioprine/methotrexate

Hypo/hypothyroid also presents with proximal symmetric weakness

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39
Q

ANA antibody

A

SLE

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40
Q

Anti-CCP antibody

A

RA

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41
Q

Anticentromere antibody

A

CREST syndrome

42
Q

Anti-dsDNA antibody

A

SLE

43
Q

Antihistone antibody

A

Drug-induced SLE

44
Q

Anti-Jo-1 antibody

A

Poly & dermatomyositis

45
Q

Antimitochondrial antibody

A

Primary biliary cirrhosis

46
Q

Antinuclear antibody

A

Scleroderma

47
Q

Anti-scl-70 antibody

A

Scleroderm

48
Q

Anti-Sm

A

SLE

49
Q

Antitopoisomerase 1 antibody*

A

Scleroderma

50
Q

Anti-TSHR antibody

A

Graves’

51
Q

c-ANCA

A

Vasculities, esp. Wegener’s

52
Q

p-ANCA

A

Vasculitis, esp. microscopic polyangiitis

53
Q

Scleroderma path, presentation, dx, tx

A

Inflammation ==> fibrosis with type 1&3 collagen
CREST & diffuse forms

Symmetric thickening of skin

  • CREST: calcinosis, Raynaud’s, Esophageal (&lower GI) dysmotility, sclerodactyly, telangiectasias
  • Diffuse: pulmonary fibrosis* & hypertension, renal failure, GI problems, cardiac problems

CREST: Anticentromere [specific]
Diffuse: *Antitopoisomerase/Anti-Scl-70 [poor prognosis]
+/- RF, ANA, eosinophilia

Corticosteroids
Penacillamine (for skin)
ACE-inhibitors for renal crises

54
Q

SLE path, presentation, dx*, tx

A

Antibody attack & deposition of antibody-antigen complexes*

Malar rash + migratory arthritis + fatigue = most common
Basically anything else can occur too…

Suggestive symptoms ==> ANA: sensitive, not specific
Anti-Sm & Anti-dsDNA: specific, not sensitive
Antihistone: drug-induced SLE

4+criteria:  
Mucucutaneous:  malar/butterfly rash, photosensitivity, oropharyngeal ulcers, discoid rash (red, raised, keratotic)
Arthritis
Pericarditis/pleuritis
Hematologic:  anemia, -cytopenia
*Renal:  proteinuria, casts
CNS: seizures, psycosis
Immunologic:  +RPR (false+syphillis)
\+ANA

Corticosteroids
Hydroxychloroquine: skin/joint stuff
Cyclophosphamide: renal stuff

55
Q

Temporal arteritis name, path*, presentation, dx, tx

A

“Giant cell arteritis”

Granulomatous inflammation of aorta*, external carotid (temporal branch) and vertebral arteries ==> central retinal artery occlusion causes blindness

*Polymyalgia rheumatica patients commonly
Bilateral or unilateral headache
Jaw claudication
Temporal tenderness
Monocular vision loss
Myalgia

Temporal artery biopsy: giant cells, lymphocytes; thrombosis; necrosis

High dose prednisone (ONCE SUSPICIOUS; before biopsy)

56
Q

Libmann Sach’s endocarditis path

A

Noninfectious vegetations of mitral valve 2/2 SLE and antiphospholipid antibody syndrome

57
Q

Complex regional pain syndrome presentation, dx, tx

A

Trauma (usually) ==> exquisite pain without clear anatomic correlation ==> loss of function ==> sympathetic dysfunction (skin, hair, soft tissue changes)

Clinical diagnosis

Wide variety of tx…

58
Q

Fibromyalgia presentation, dx, tx

A

Women 30-50 with depression, IBS, sleep disorder etc.
Axial & soft tissue pain WITHOUT joint pain*

ESR: normal
Biopsy: normal
>11 tender ponits in all body quadrants ()

*Exercise, sleep hygiene
Antidepressants, gabapentin etc.
PT

59
Q

Polymyalgia rheumatica presentation, association, dx*, tx

A

Age >50
Pelvic girdle & shoulder pain/weakness causing difficulty rising from chair or raising hands overhead
Constitutional symptoms

Associated with temporal arteritis

Clinical: hip/shoulder pain + ESR*
ESR: elevated
CBC: anemia

Low-dose prednisone

60
Q

Nursemaid’s elbow path/hx/tx*

A

Radial head subluxation 2/2 being pulled

(Child) with non-tender, immobile arm in pronation

Reduction by gentle supination & extension

61
Q

Salter-harris classifications

A 
I:  physis (growth plate) fracture
II:  physis & metaphysis fx
III:  physis & epiphysis fx
IV:  epihysis, physis & metaphysis fx
V:  crush injury of physics
62
Q

Duchenne Muscular Dystrophy path, presentation, dx, tx

A

X-linked recessive causing dystrophin cystoskelton protein ABSENCE

Onset 3-5 years
Often retarded
PROGRESSIVE WEAKNESS: clumsiness, fatigability, difficulty toe walking
Gower’s maneuver: pushing off thighs to stand up
Gastrocnemius pseudohypertrophy
Cardiomyopathy

Western blot: little to no dystrophin
Muscle biopsy: necrotic fibers
GOLD STANDARD*: genetic dystrophin testing

20’s expectancy 2/2 cardiac fibrosis & pulmonary congestion

63
Q

Becker muscular dystrophy path*, presentation, dx, tx

A

X-linked recessive causing dystrophin DYSFUNCTION

Onset 5-15 years
MILDER weakness than Duchenne
Not retarded
Cardiomyopathy

Western blot: dystrophin present but abnormal

Life-expectancy: 40’s 2/2 heart failure

64
Q

Developmental Dysplasia of Hip path, presentation, dx, tx

A

Subluxed or dislocated femoral heads ==> hip degeneration

First born male in breech

Barlow: thighs abducted ==> posterior pressure ==> adduction ==> “clunk”
Ortolani: thighs adducted ==> anterior pressure from greater trochanter ==> abduction ==> “click”
Allis’/Galeazzi’s: knees @ unequal heights when flexed

PE techniques
Ultrasound & XR work after 10 weeks

< 1 year: Harness or cast
> 1 year: surgery

65
Q

Legg-Calve-Perth path, presentation, dx, tx

A

AVN of femoral head

Usually boys 4-10 years old
Limp
Groin or knee pain
Limited abduction & internal rotation

XR: flattened, irregular femoral head

Observation unless ROM decreases ==> surgery

66
Q

Slipped Capital Femoral Epiphysis path, presentation, dx, tx

A

Femoral neck displaces from epiphysis & growth plate, often bilateral

Fat 12 year old kid
Endocrine disorders
KNEE & groin pain
Painful limp
Unstable SCFE:  inability to bear weight
Limited abduction & internal rotation

XR: posterior & inferior displacement of femoral head
TSH: send if kid is short

Tx: no weight bearing until SURGICAL PINNING

67
Q

Scoliosis dx/tx/sequelae

A

XR

20-50 degrees curvature: brace
50+ degrees: surgery

Restrictive lung disease

68
Q

Juvenile idiopathic arthritis subtypes, presentation, dx, tx

A

Acute febrile/Still’s: high fever, rash

Usually girl 5 joints, symmetric

No diagnostic…only nonspecific elevated rheum labs

NSAIDs ==> steroids

69
Q

Drug-induced lupus hx

A

No renal or CNS involvement

Drugs: hydralizine, procainamide, isoniazid, chlorpromazine, methyldopa

70
Q

Sjogren path / risks, dx

A

Primary: lymphocytic salivary infiltration
Secondary: Above + other rheum conditions

Risk: non-hodgkin’s lymphoma, dental carries*

Sensitive: ANA or RF
*Specific: Ro or La

71
Q

Neonatal SLE presentation

A

Heart block

72
Q

Reactive arthritis path/hx

A

Infection w/ salmonella, shigella, campylobacter, chlamydia, yersinia ==> asymmetric arthritis, uveitis, urethritis (can’t pee/see/climb tree)

73
Q

Takayasu’s arteritis path, presentation, dx, tx

A

Vasculitis of aortic arch and major branches

Younger asian women
Constitutional symptoms
Pain over involved vessels
Absent carotid, radial pulses
Aortic regurgitation
Stroke

Arteriogram

Steroids and/or surgical recantation

74
Q

Churg-strauss path, presentation, dx, tx

A

Vasculitis of multiple organ systems

Constitutional symptoms
Pulmonary: asthma, dyspnea
Skin: nodules, purpura

P-anca
Biopsy necessary

Steroids

75
Q

Wegener’s alt name, path, presentation, dx, tx

A

Granulomatosis with polyangiitis

Necrotizing vasculitis of kidneys & respiratory tract

Middle-aged ppl
Pulmonary: epistaxis, rinorrhea, ulcers, sinusitis, airway, cough/hemoptysis
Renal: hematuria 2/2 glomerulonephritis ==> renal failure
Cutaneous: nodules, purpura, ulcers

CXR: nodules*/cavitations/infiltrates
\+c-ANCA = sensitive & specific!
Light microscope:  CRESCENT formation
Immunoflouresence: segmental necrotizing (Goodpasture's = linear)
Confirmatory:  lung biopsy

cyclophosphamide & steroids ==> most die

76
Q

Polyarteritis nodosa hx/pe/dx

A

Wegener’s without respiratory involvement… p-anca, renal failure etc.

77
Q

Buerger’s / Thromboangiitis Obliterans path/hx/pe

A

Inflammation of small arteries/veins of legs

Young male who smokes ==> claudication, cyanosis of extremities

Smoking cessation

78
Q

L3 motor

A

Knee extension

79
Q

L2 motor

A

Hip flexion

80
Q

Cervical myelopathy path / hx

A

Cervical spinal stenosis

Gait dysfuction, loss of dexterity ==> inability to ambulate & loss of bowel/bladder function

81
Q

Disc herniation usual level, presentation, dx, tx

A

L5-S1 & L4-L5

Radiating pain down posterior/lateral leg
Possible loss of reflexes
Worsened with valsalva
Lying relieves pain
Dorsiflexion & leaning forward exacerbates

MRI

NSAIDS & ice!
Surgery: only if loss of bowel/bladder or terrible pain

82
Q

Bursitis pe*

A

Pain worsens with palpation (not with arthritis)

83
Q

Rotator cuff tendonitis (impingement) vs tear hx/pe/dx

A

Tendonitis:

  • repetitive use
  • pain with passive motion overhead
  • lidocaine injection HELPS

Tear:

  • fall/trauma
  • pain with passive motion overhead
  • drop test: when passively abducted to 90, arm drops when adducting
  • lidocaine injection DOESN’T help
84
Q

Avascular necrosis hx*/pe

A

> 90% = chronic steroid use & alcohol use

Progressive pain with limited range of motion

85
Q

Tennis elbow path, hx/pe

A

Lateral epicondylitis 2/2 repeated wrist extension

Point tenderness @ lateral epicondyle
Pain with wrist extension and supination

86
Q

Vertebral osteomyelitis path, presentation, dx*, tx

A

Staph aureus

Pain worsening with activity
*May or may not have fever, constitutional symptoms
Injection drug users, sickle cell, immunosuppressed
*Exquisite tenderness to palpation

*CBC: may or may not have leukocytosis
ESR: elevated
MRI: most sensitive

IV abx

87
Q

Polyarteritis nodosa presentation

A

Skin
Kidney
Muscle aches/weakness
ESR elevation

88
Q

Patellofemoral syndrome hx/pe, dx*, tx

A

Chronic anterior knee pain
Worse climbing stairs & squatting

Patellofemoral compression test: press patella while extending knee ==> reproduce pain?

Dx: clinical

PT

89
Q

Osgood-Schlatter disease hx/pe*

A

Young active children
Anterior knee pain

Pain to palpation @ tibial tubercle

90
Q

Paget’s disease path, presentation, dx**, tx*

A

Osteoclast hyper function with excessive compensatory osteoblast bone growth ==> enlarged, weak, inferior woven bone replaces in pelvis, skull, spine, long bones

Bone/joint pain
Hearing loss* (2/2 bone enlargement @ auditory meatus)

XR:  thickened cortex, femoral bowing
Alk-P elevation (bone formation marker)
Urinary N-telopeptide elevation (bone resorption marker)
NORMAL Calcium & Phosphorous
Mosaic lamellar bone

No cure
Bisphosphonates help symptomatically

91
Q

Behcet’s syndrome path, dx, tx

A

Autoimmune multisystem vasculitis

Oral ulcers & 2+
Genital ulcers
Eye lesions (uveitis)
Skin lesions

…sometimes skin lesions, CNS, constitutional symptoms

Steroids

92
Q

Psoriatic arthritis hx/pe*

A

*DIP arthritis
Sausages
Red plaques

93
Q

Morton’s neuroma dx*

A

Painful clicking upon palpation to plantar 3rd/4th toe space

94
Q

Stress fx hx, pe, dx*

A

Classically anorexic female athlete

Tenderness to palpation on any bone

95
Q

LE innervation & sensation**

A

Obturator: medial thigh adduction / medial thigh sensation

Femoral: hip flexion & knee extension / anteromedial thigh & anteromedial leg sensation (saphenous)

Sciatic branches:
Tibial: knee flexion & foot-toe flexion / posterior thigh & posterior leg & dorsal foot sensation

Peroneal/fibular nerve: anterolateral leg flexion & sensation

96
Q

Bicep tenon tear pe

A

Popeye’s sign: lump in bicep

Weakness supinating

97
Q

Long thoracic nerve injury pe*

A

Wing scapula 2/2 serratus anterior paralysis

98
Q

Trendelenberg sign pe & path*

A

Contralateral hip drop when standing on one leg

Gluteus weakness 2/2 superior gluteal nerve damage or myopathies

99
Q

Steinert’s disease path, presentation, dx, tx

A

Autosomal dominant trinucleotide problem causing skeletal & smooth muscle dysfunction

Onset 12-30 years old
Weakness 2/2 impaired relaxation
Unable to release grip from handshake
Facial weakness w/ temporal wasting
Dysphagia
Thenar wasting
Testicular atrophy

Death 2/2 respiratory or heart failure

100
Q

Neonatal conjunctivitis path, presentation, dx, tx*

A

2/2 gonorrhea, chlamydia, or chemical

Chemical: 24hrs post-birth 2/2 silver nitrate ==> mild

Gonorrhea: 2-5 days post-birth ==> severe swelling and discharge ==> IM ceftriaxone or cefotaxime

Chlamydia: 5-14 days post-birth ==> milder swelling and discharge, though bloody discharge often ==> oral erythromycin

101
Q

Lupus hypercoagulability path, dx, tx

A

Lupus anticoagulant or antiphospholipid antibody

Miscarriage hx

Prolonged PTT (2/2 Ig against assay chemical...thus artifact)
False + VDRL 
Thrombocytopenia
Non-correcting with mixing study
Normal bleeding time

Prophylactic aspirin & LMWH

STEP2 (16 decks)

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