MSK, Skin, CT Flashcards
1
Q
muscles and innervation important for arm abduction at :
1) 0-15 deg
2) 15-100 deg
3) >90 deg
4) >100 deg
A
1) supraspinatus (n. suprascapular)
2) deltoid (n. axillary)
3) trapezius (n. accessory)
4) serratus anterior (n. long thoracic)
2
Q
Rotator cuff muscles
A
SItS (innervated C5-C6)
Supraspinatus (suprascapular nerve) –> abduct
Infraspinatus (suprascapular nerve) –> ext rotate
Teres minor (axillary nerve) –> adduct and ext rotate
Subscapularis (upper and lower subscapular nerves) –> int rotate and adducts arm
3
Q
Most common rotator cuff mm injury
A
supraspinatus
assess with empty can test
4
Q
Pitching injury
A
Infraspinatus
5
Q
Repetitive flexion can cause ___ which results in pain at the medial epicondyle
A
Medial epicondylitis
golfers elbow
6
Q
Repetitive extension can cause _____ which results in pain at the lateral epicondyle
A
Lateral epicondylitis
tennis elbow
7
Q
This is palpable in the anatomic snuff box and is the most commonly fractured carpal bone
A
Scaphoid
fracture is due to fall on an outstreched hand
8
Q
complication of proximal scaphoid fractures
A
avascular necrosis and nonunion due to retrograde blood supply
9
Q
dislocation of _____ can cause acute carpal tunnel syndrome
A
lunate
10
Q
______ fractures is due to a direct blow with a closed fist
A
Metacarpal neck fracture or boxers fracture
4th and 5th metacarpals most common
11
Q
Carpal tunnel syndrome is due to entrapment of ____ nerve in the carpal tunnel.
A
median nerve
12
Q
The carpal tunnel is between _____ and _____
A
transverse carpal ligament/flexor retinaculum
carpal bones
13
Q
Carpal tunnel syndrome can result in atrophy where?
A
thenar eminence
14
Q
In carpal tunnel syndrome, _______ is spared because the ______ enters the hand _________to carpal tunnel
A
sensation
palmar cutaneous branch
external
15
Q
Compression of the ____ nerve is seen in _____ syndrome that is common with cyclists
A
ulnar nerve
Guyon canal syndrome
16
Q
Incomplete fracture extending partway through the width of bone following bending stress.
A
Greenstick fracture - common pediatric fracture
bone is bent like a green twig
Compression side in tact
17
Q
Axial force applied to immature bone causes the cortex to buckle on compression side and fractures.
A
Torus (buckle) fracture - common pediatric fracture
Tension side intact
18
Q
Muscles, function, and innervation of the thenar eminence
A
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Superficial head (Deep head by ulnar nerve)
Median nerve
fx: oppose, abduct, and flex (OAF)
19
Q
Muscles, function, and innervation of hypothenar eminence
A
Opponens digiti minimi
Abductor digiti minimi
Flexor digiti minimi brevis
Ulnar nerve
fx: oppose, abduct, and flex (OAF)
20
Q
Dorsal interossei
A
DAB
Dorsal ABducts
ulnar nerve
21
Q
Palmar interossei
A
PAD
Palmar ADducts
ulnar nerve
22
Q
Lumbricals
A
1st and 2nd is median nerve
3rd/4th ulnar nerve
flex at the MCP joint
Extend PIP and DIP
23
Q
Patient presents with a flattened deltoid, loss of arm abduction at >15 degrees, What nerve is impacted? What are its roots? What is the likely cause of injury? Other signs/symptoms?
A
Axillary nerve, C5-C6
Fractured surgical neck of humerus or anterior dislocation of humerus
Other sx: loss of sensation over deltoid muscle and lateral arms
24
Q
Patient presents with loss of forearm flexion and supination. Also loss of sensation over lateral forearm. What nerve is impacted? Roots? Mechanism of injury?
A
Musculocutaneous, C5-C7
Upper trunk compression
25
Patient presents with wrist drop: loss of elbow, wrist, and finger extension. On physical exam you notice a decrease in grip strength and loss of sensation over posterior arm/forearm and dorsal hand. What nerve is impacted? What are its roots? What is the likely mechanism of injury?
Radial nerve, C5-T1
Compression of axilla, midshaft fracture of humerus, repetitive pronation/supination of forearm
26
Patient presents with Loss of wrist flexion, flexion of lateral fingers, thumb opposition, lumbricals of 2nd and 3rd digits. Also loss of sensation over thenar eminence and dorsal and palmar aspect of lateral 3 1/2 fingers with proximal lesion
Median nerve, C5-T1
Supracondylar fracture of humerus (proximal lesion)
Carpal tunnel syndrome and wrist laceration (distal lesion)
"ape hand" or "pope's blessing"
27
Patient presents with Radial deviation of wrist upon flexion (proximal lesion), loss of wrist flexion, flexion of medial fingers, abduction and adduction of fingers (interossei), actions of medial 2 lumbrical muscles. Loss of sensation over medial 1 1/2 fingers including hypothenar eminence
Ulnar nerve, C8-T1
Fracture of medial epicondyle of humerus "funny bone" (proximal lesion)
Fractured hook of hamate (distal lesion) from fall on outstretched hand
"ulnar claw" on digit extension
28
Erb palsy
"waiters tip"
"Erber trunk=upper trunk"
Injury: traction or tear of upper trunk : C5-C6
Cause: trauma in adults. In infants its lateral traction of neck during delivery
Affected mm: deltoid, supraspinatus, infraspinatus, biceps brachii
29
Klumpke palsy
Injury: traction or tear of lower trunk at C8-T1
Cause: infants due to upward force of arm during delviery. Adults is trauma related
Affected mm: intrinsic hand mms --> total hand claw
30
Thoracic outlet syndrome
Injury: compression of lower trunk and subclavian vessels
Cause: cervical rib or pancoast tumor
Affected mm: intrinsic hand mms
See atrophy of intrinsic hand muscles, ischemia pain and edema due to vascular compression
31
Winged scapula
injury: lesion of long thoracic nerve roots C5-C7
Cause: axillary node dissection after mastectomy or stab wounds
affected mm: serratus anterior
Inability to anchor the scapula to the thoracic cage and therefore cannot abduct arm above horizontal position
32
Claw presentation
Most pronounced when it is a distal lesion of median and ulnar nerves. Less pronounce in proximal
Remaining extrinsic flexors of the digits exaggerate the loss of the lumbricals and so the fingers extend at MCP, flex at DIP and PIP joints
33
Ulnar claw sign
lesion at distal ulnar nerve
seen when extending fingers or at rest
34
Pope's blessing sign
Proximal median nerve
Seen when making a fist
35
Median claw sign
Distal median nerve
Seen when extending fingers/ at rest
36
Ok gesture sign
Proximal ulnar nerve
Seen when making a fist
37
ACL
Lateral femoral condyle to anterior tibia
"LAMP"
Lateral for ACL
Medial for PCL
38
PCL
Medial femoral condyl to posterior tibia
"LAMP"
Lateral for ACL
Medial for PCL
39
Anterior drawer sign tests the
ACL tear
40
Posterior drawer sign tests the
PCL tear
41
Abnormal passive abduction
MCL tear
Abduction/valgus
42
Abnormal passive adduction
LCL tear
Adduction/varus
43
Mcmurray test
Ext rotation for medial meniscal tear
| Int rotation for lateral meniscal tear
44
Trochanteric bursitis
inflammation of the gluteal tendon and bursa lateral to the greater trochanter
45
_____ is a common injury in contact sports due to lateral force applied to a planted leg. Damage involves : ____, ____, ____
Unhappy triad
ACL, MCL, and medial meniscus (attached to the MCL)
46
What menisci injury is more common: lateral or medial
lateral
47
Popliteal fluid collection in gastrocnemius-semimembranosus bursa commonly communicating with synovial space and related to chronic joint disease (i.e. OA)
Bakers cyst
48
Most common ankle sprain overall
Anterior TaloFibular Ligament (ATFL)
due to overinversion/supination of foot
49
Most common high ankle sprain
Anterior inferior tibiofibular ligament
50
Patient presents with burning or tingling pain in surgical incision site radiating to inguinal and supra pubic region
iliohypogastric nerve (T12-L1)
due to abdominal injury
sensory branch --> suprapubic region
Motor branch --> transversus abdominis and internal oblique
51
Patient has decreased anterior thicg sensation beneath inguinal ligament and an absent cremasteric reflex
Genitofemoral nerve (L1-L2)
Due to laparoscopic surgery
Sensory branch - scrotum/labia major, medial thich
Motor branch - cremaster
52
Patient has decreased thich sensation (anterior and lateral)
Lateral femoral cutaneous (L2-L3)
Due to tight clothing, obesity, pregnancy, pelvic procedures
Sensory branch only
53
Patient has decreased thigh sensation (medial) and adduction
Obturator (L2-L4)
due to pelvic surgery
Sensory-medial thigh
Motor-obturator externus, adductor longus, adductor brevis, gracilis, pextineus, adductor magnus
54
Patient has decreased thigh flexion and leg extension
Femoral (L2-L4)
Due to pelvic fracture
Sensory-anterior thigh, medial leg
Motor-quadriceps, iliacus, pectineus, sartorius
55
This nerve splits into the common peroneal and tibial nerves
Sciatic (L4-S3)
Due to herniated disc or posterior hip dislocation
Motor-semitendinosus, semimembranosus, biceps femoris, adductor magnus
56
Patient is experiencing foot drop symptoms and has loss of sensation on dorsum of foot. The patients foot is inverted and plantarflexed at rest, loss of eversion and dorsiflexion resulting in a steppage gait
Common peroneal (L4-S2)
Superifical peroneal : Sensory for dorsum of foot. Motor- peroneus longus and brevis
Deep peroneal nerve: Sensory in websapce between hallux and 2nd digit. Motor is tibialis anterior
Due to trauma or compression of lateral aspect of leg, fibular neck fracture
57
Patient presents with the inability to curl toes and loss of sensation on sole. Patient is unable to stand on tiptoes.
Tibial (L4-S3)
Due to knee trauma, bakers cyst (proximal lesion), tarsal tunnel syndrome (distal lesion)
Sensory- sole of foot
Motor- biceps femoris (long head),triceps surae, plantaris popliteus, flexor mm of foot.
58
The patient has the trendelenburg sign/gait
Superior gluteal (L4-S1)
Due to iatrogenic injury during intramuscular injection to superomedial gluteal region
Lesion is contralateral to the side of the hip that drops, ipsilateral to extremity on which the patient stands
Motor-gluteus medius, gluteus minimus, tensor fascia latae
59
Trendelenburg sign/gait
pelvis tilts because weight bearing leg cannot maintain alignment of pelvis through hip abduction
60
How can you prevent a superior gluteal injury when giving intramuscular injection to superiomedial gluteal region. What nerve is affected? what sign will you see if injured?
prevent by choosing the superolateral quadrant, preferably anterolateral region
Trendelenburg sign/gait
61
Patient has difficulty climbing stairs, rising from seated position. Also there is loss of hip extension
Inferior gluteal (L5-S2)
Due to posterior hip dislocation
Motor-gluteus maximus
62
Patient has decreased sensation in perineum and genital area. Also suffers from fecal and urinary incontinence.
Pudendal (S2-S4)
Due to stretch injury during childbirth
Sensory- perineum
Motor-External urethral and anal sphincters
63
What nerve can be blocked with local anesthetic during childbirth using ischial spine as a landmark for injection
Pudendal (S2-S4)
64
Abductors of hip?
Gluteus medius and minimus
65
Adductors of hip?
Adductor magnus
Adductor longus
Adductor brevis
66
Extensors of hip?
Gluteus maximus
Semitendinosus
Semimembranosus
67
Flexors of hip?
```
Iliopsoas
Rectus femoris
Tensor fascia lata
Pectineus
Sartorius
```
68
Internal rotation of hip?
Gluteus medius
Gluteus minimus
Tensor fascia latae
69
External rotation of hip?
Ilipsoas
Gluteus maximus
Piriformis
Obturator
70
Iliotibial band syndrome
In runners - pain secondary to friction of IT band against lateral femoral epicondyle
71
Medial tibial stress syndrome
Shin splints in runners and military recruits
Bone resorption that outpaces bone formation in tibial cortex
72
Limb compartment syndrome
Caused by significant long bone fractures, reperfusion injury, animal venoms,
Motor deficits are late sign of irreversible muscle and nerve damage
73
Plantar fasciitis
inflammation of plantar aponeurosis
heel pain worse with first steps int he morning or after period of inactivity
tenderness
74
De Quervain tenosynovitis
Noninflammatory thickening of abductor pollicis longus and extensor pollicis brevis tendons
pain or tenderness at radial styloid
75
Ganglion cyst
Fluid filled swelling overlying joint or tendon sheath
most commonly at dorsal side of wrist
Arises from herniation of dense connective tissue
76
Developmental dysplasia of the hip
Abnormal acetabulum development in newborns
Hip instability/dislocation
Ortolani and barlow maneuvers and confirmed via ultrasound
77
Legg-Calve-Perthes disease
Idiopathic avascular necrosis of femoral head
insidious onset of hip pain that may cause child to limp
78
Slipped capital femoral epiphysis
Obese ~12 yo child with hip/knee pain and latered gait
Increased axial force on femoral head which causes epiphysis to displace relative to femoral neck
79
Osgood-Schlatter disease (traction apophysitis)
Progressive anterior knee pain. Overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center of proximal tibial tubercle
Adolescents after growth spurt
Common in running and jumping athletes
80
Radial head subluxation (nursemaid's elbow)
Common elbow injury in children <5 yo
Due to sudden pull on the arm that causes immature annular ligament slips over head of radius
injured arm held in flexed and pronated position
81
If a disc herniates at L3/L4 then what spinal level is actually impacted. Which way does it herniate and why
L4
Posterolaterally because thin posterior longitudinal ligament and thicker anterior longitudinal ligament along the midline of the vertebral bodies
82
Lumbosacral rediculopathy : L3-L4
weakness of knee extension
decreased patellar reflex
83
Lumbosacral rediculopathy : L4-L5
weakness of dorsiflexion
difficult in heel walking
84
Lumbosacral rediculopathy : L5-S1
Weakness in plantar flexion
Difficulty in toe walking
decreases achilles reflex
85
Motorneuron action potential depend on what neurotransmitter
ACh release
86
Membrane depolarization induces conformation changes in the voltage sensitive _______ and its mechanicall coupled ________. This results in ____ release from the ________ into the cytoplasm
dihydropyridine receptor (DHPR)
ryanodine receptor
sarcoplasmic reticulum
87
_______ is blocking myosin binding sites on the actin filament. Released _____ binds ______ shifting _______ to expose the myosin binding sites
Tropomyosin
Calcium
Troponin C (TnC)
tropomyosin
88
Myosin head is strongly bound to actin forming a ______
crossbridge
89
______ is released, inititating the power stroke
Pi
90
During the powerstroke, muscle shortening includes shortening of what segments
H and I between Z lines
"ZHIZ"
91
What muscle band always remains the same length
A band
A=always
92
What causes the detachment of the myosin head from the actin filament?
ATP
93
What causes the high energy position (cocked) of the myosin head
Hydrolysis of ATP into ADP and Pi causes myosin to return to high energy state
94
Type______muscles increase in proportion after endurance training. they are ______ twitch muscles and have ____ fibers.
Type I
slow twitch muscle
red fibers - increased mitochondria and myoglobin concentration (increases oxidative phosphoyrlation) allow for sustained contractions
95
Type ______ muscles increase in proportion after weight/resistance training/sprinting. They are _____ twitch muscles and have _____ fibers
Type II
fast twitch muscle
White fibers- low mitochondria and myoglobin concentrations (increase anaerobic glycolysis).
96
Type of ossification seen in axial skeleton, appendicular skeleton, and base of skull
Endochondral ossification
Osteoclasts and osteoblasts later replace with woven bone and then remodeled to lamellar bone
97
Type of ossification seen in calvarium, facial bones, and clavicle
Membranous ossification
woven bone formed directly without cartilage
remodeled into lamellar bone
98
_____ type of bone occurs after fractures and in paget disease
woven
99
Pathway for smooth mm relaxation
Ca release inside the endothelial cells positively stimulate NO synthase
L-arginine ---> Nitric oxide
NO diffuses into smooth muscle cell and causes conversion of GTP into cGMP
cGMP positively stimulated myosin light chain phosphatase MLCP which dephosphorylates myosin
100
The precursor of nitric oxide and the enzyme
L-arginine
NO snythase
101
Pathway for smooth mm contraction
calcium influx due to depolarization
Ca into the smooth muscle cell via the L type voltage gated Ca channel
Increase in the calcium-calmodulin complex
Positvely stimulates the myosin-light chain kinase (MLCK) which phosphorylates myosin
102
Osteoblast function
Builds bone by secreting collagen and catalyzing mineralization in alkaline environment via ALP
activity measured by bone ALP, osteocalcin, propeptides of type I procollagen
103
Osteoclast
dissolves ("crushes") bone by secreting H+ and collagenases
104
Osteoblasts are from _______ cells in the periosteum
mesenchymal stem cells
105
Osteoclasts differentiate from fusion of _____ lineage precursors
monocyte/macrophage
106
Receptor of osteoclast and ligands of osteoblast
Receptor is the RANK
| Ligand is RANKL from osteoblasts
107
Give ____ to decrease osteoclast activity
OPG or osteoprotegerin, a RANKL decoy receptor
108
Effects of low intermittent levels of PTH? Chronic high levels?
Low --> anabolic (build bone)
| High --> catabolic ( osteitis fibrosa cystica)
109
Deficiency in estrogen puts you at risk for _____
osteoarthritis
estrogen inhibits apoptosis in osteoblasts and induces apoptosis in osteoclasts
110
____ causes closure of the epiphyseal plates during puberty
estrogen
111
What is the most common cause of dwarfism?
Achondroplasia - the failure of longitudinal bone growth (Endochondral ossification) which results in short limbs
embranous ossification is affected resulting in alrge head relative to limbs
Aut. Dominant with full penetrance (homozygosity is lethal).
>85% of mutation are sporadic
112
What is activated in achondroplasia
Fibroblast growth factor receptor (FGFR3) which inhibits chondrocyte proliferation
113
Osteoporosis
is mostly due to increased bone resorption related to decreased estrogen levels and old age. Can be secondary to drugs
Trabecular (spongy) and cortical bone loss mass but normal bone mineralization and lab values
DEXA scan <= -2.5
treatment is bisphosphonates, teriparatide, SERMs, denosumab (monoclonal antibody against RANKL)
114
What is a common fracture seen in osteoperosis patients?
Vertebral compression fractures - acute back pain, loss of height, kyphosis
115
Osteopetrosis
Failure of normal bone reposrtion due to defective osteoclasts that results in thickened dense bones that are prone to fracture
osteoclasts lack the acidic environment needed to cause bone resorption
116
Osteopetrosis complication with bone marrow
Overgrowth of cortical bone fills marrow space causing pancytopenia and extramedullary hematopoiesis
can get cranial nerve impingement and palsies due to narrowed foramina
117
Osteomalacia
Defective mineralization of osteoid (osteomalacia)
pseudo fractures and osteopenia
118
Rickets
Defective mineralization of cartilaginous growth plates (rickets)
Rickets shows epiphyseal widening and metaphyseal cupping/fraying, bead like costochondral junctions (rachitic rosary) and craniotabes (soft skull)
119
Physiological mechanism behind rickets/osteomalacia
Vitamin D deficiency --> drop in serum Ca --> increase PTH secretion --> drop in PO4
hyperactivity of osteoblasts --> increase in ALP
120
Pagets disease of bone (osteitis deformans)
Abnormal "mosaic" bone architecture
Localized disorder of bone remodeling caused by increased osteoclastic activity followed by increased osteoblastic activity that forms poor quality bone
Pt commonly complains of an increased hat size and hearing loss due to auditory foramen narrowing
121
Labs in pagets disease of bone
Serum Ca, phosphorus, and PTH levels are normal. Increase in ALP
122
Stages of paget disease
Lytic- osteoclasts
Mixed-osteoclast + osteoblasts
Sclerotic - osteoblasts
Quiescent - minimal osteoclast/osteoblast activity
tx with bisphosphonates
123
Risks and complications in pagets
- long bone chalk stick fractures
- Increase in blood flow from arteriovenous shunts may cause high output heart failure
- Increased risk of osteogenic sarcoma
124
Osteonecrosis (avascular necorsis)
Infarction of bone and marrow - very painful
watershed zones: femoral head due to insufficiency of medial circumflex femoral artery
125
Osteoperosis labs
Normal CA, PO4, ALP, PTH
drop in bone mass
126
Osteopetrosis labs
normal or low Ca
dense brittle bones
Ca drops only in severe malignant disease
127
Labs in osteitis fibrosa cystica (primary hyperparathyroidism)
High Serum Ca
Low PO4
High ALP
High PTH
"brown tumors" due to fibrous replacement of bone, subperiosteal thinning
128
Labs in osteitis fibrosa cystica (secondary hyperparathryoidism)
Drop in Ca
Increase in PO4
Increase in ALP
Increase in PTH
Often compensation for CKD where there is a drop in PO4 excretion and production of activated vitamin D
129
Osteomalacia/ rickets labs
Drop in Ca
Drop in PO4
Increase ALP
Increase PTH
130
Hypervitaminosis D labs
High Ca
High PO4
Normal ALP
Drop in PTH
131
Osteochondroma location and characteristic
Most common benign bone tumor in Males < 25 yo
Metaphysis of long bones
Lateral bony projection of growth plate (continuous with marrow space) covered by cartilaginous cap
132
Osteoma location and characteristic
Surface of facial bones
Gardner syndrome
133
Osteoid osteoma location and characteristic
Adults < 25 yo with more M > F
Cortex of long bones
Bone pain that is wrose at night and releived by NSAIDs
bony mass thats < 2 cm with radiolucent osteoid core
134
Osteoblastoma location and characteristic
Vertebrae
similar to osteoid osteoma
>2 cm mass and does not respond to NSAIDs
135
Chondroma location and characteristic
Medulla of small bones of hand and feet
benign tumor of cartilage
136
Giant Cell tumor location and chracteristic
Epiphysis of long bones (knee region)
locally aggressive benign tumor
"soap bubble" appearance on xray
neoplastic mononuclear cells that express RANKL and reactive multinucleated giant (osteoclast like) cells
137
Osteosarcoma (osteogenic sarcoma) location and characteristics
Metaphysis of long bones (often in knee region)
pleomorphic osteoid producing cells (malignant osteoblasts)
Codman triangle (elevation of periosteum) or sunburst pattern on xray
Aggressive. Primary is responsive to treatment but secondary has poor prognosis
138
Chondrosarcoma location and characteristics
Medulla of pelvis and central skeleton
tumor of malignant chondrocytes
139
Ewing sarcoma location and characteristics
Caucasions, boys, <15 yo, aggressive, early metastases, responds to therapy
Diaphysis of long bones especially the femur, pelvic flat bones
t(11;22)
"onion skin" periosteal reaction in bones
Anaplastic small blue cells of neuroectodermal origin
140
Osteoarthritis pathogenesis
Mechanical wear and tear destroys articular cartilage (degenerative joint disorder) which results in inflammation and inadequate repair
Chondrocytes mediate degradation and inadequate repair
treat with acetaminophen, NSAIDs, intraarticular glucocorticoids
141
Patient presents with pain in weight bearing joints after a long day. Her pain improves with rest and is only one of her knees. Her doctors points out that she is starting to lose her knee cartilage medially
Osteoarthritis
142
Joint findings in osteoarthritis
Osteophytes (bone spurs)
Joint space narrowing
Subchondral sclerosis and cysts
Synovial fluid noninflammatory (WBC<2000)
Involves the DIP (heberden nodes) and PIP (Bouchard nodes)
NOT MCP
143
Rheumatoid arthritis pathogenesis
Autoimmune inflammation induces formation of pannus (proliferative granulation tissue) which erodes articular cartilage and bone
HLA-DR4, + Rh factor (IgM antibody that targets IgG Fc region), anticyclic citrullinated peptide antibody
144
Patent presents with pain, swelling, and morning stiffness lasting >1 hour that improves with use. She complains of symmetric pain in both hands and has noticed fever, fatigue, and weight loss.
Rheumatoid arthritis
tx with NSAIDS, glucocorticoids, diseas emodifying agents, biologic agents
145
Rheumatoid arthritis joint findings
Erosions, juxta articular osteopenia, soft tissue swelling, subcondral cysts, joint space narrowing
Cervical subluxation, ulnar finger deviation, swan neck, boutonniere
involves the MCP,PIP, and wrist
NOT the DIP or 1st CMC
synovial fluid is inflammatory
146
Acute inflammatory monoarthritis caused by precipitation of monosodium urate crystals in joints. What disease is this? what is a major risk factor?
Gout
Hyperuricemia is a major risk factor
147
Hyperuricemia is a major risk factor for gout. What are some of the causes of hyperuricemia? what do the crystals look like?
Underexcretion of uric acid
Overproduction of uric acid
Needle shaped and (-) birefringent under polarized light (yeLLow under paraLLel light and blue under perpendicular light)
148
Patient presents with asymmetric joint pain at the MTP joint of the big toe (podagra) that is swollen and red. She mentions that her pain is worse after eating foods rich in purines and when she drinks alochol
Gout
Tophus formation is common
alcohol - alcohol metabolites compete for same excretion sites in kidney as uric acid this results in less uric acid secretion and subsequent buildup in blood
149
Calcium pyrophosphate deposition disease
pseudogout if pain and swelling with acute inflammation
pseudo-osteoarthritis if chronic degeneration
Calcium pyrophosphate deposition within the joint spaces, especially the knees
crystals are rhomboid and weakly + birefringent under polarized light (blue when parallel to light)
Can also see chondrocalcinosis (cartilage calcificatio) on xray
150
What drug is used as acute treatment and as prophylaxis for calcium pyrophosphate deposition disease
Colchicine
151
Patient is <12 yo and presents with arthritis in 3 of his joints. His mother also mentions he has daily spiking fevers and a salmon pink macular rash
Systemic juvenile idiopathic arthritis
presents with leukocytosis, thrombocytosis, anemia, increase ESR, Increased CRP
152
Patient presents with bilateral parotid enlargement, inflammatory joint pain, and decreased tear and saliva production
Sjogren syndrome - autoimmune disorder characterized by destruction of exocrine glands (lacrimal and salivary) by lymphocytic infiltrates
- inflammatory joint pain
- keratoconjunctivitis sicca (decreased tear production and subsequent corneal damage)
- Xerostomia (decreased saliva production)
- bilateral parotid enlargement
- Mucosa associated lymphoid tissue (MALT) lymphoma
- Focal lymphocytic sialadenitis on labial salivary gland biopsy can confirm diangosis
153
Sjogren syndrome autoantibodies
```
Anti SSA (anti ro)
Anti SSB (anti la)
```
but can also be seen with SLE
+Anti SSA in pregnant owmen with SLE can increase risk of congential heart block in the newborn
154
Septic arthritis pathogen causes
S aureus
Streptococcus
N gonorrhoeae
Affected joint is swollen, red, and painful
synovial fluid is purulent
155
Gonococcal arthritis
purulent arthritis OR
triad of polyarthralgia, tenosynovitis, dermatitis
156
Seronegative spondyloarthritis
arthritis without Rh factor (no anti IgG antibody)
strong association with HLA-B27 (MHC class I serotype)
157
Psoriatic arthritis
skin psoriasis and nail lesions
dactylitis and pencil in cup deformity of DIP on xray
158
Anklosing spondylitis
Symmetric invovlement of spine and sacroiliac joints --> ankylosis (joint fusion), uveitis, aortic regurg
bamboo spine (vertebral fusion)
can cause restrictive lung disease due to limited chest wall expansion (costovertebral and costosternal ankylosis)
159
Reactive arthritis/ Reiter syndrome
Classic triad: conjunctivitis, urethritis, arthritis
due to shigella, yersinia, chlamydia, campylobacter, salmonella
160
Systemic lupus erythematosus
RASH OR PAIN
```
Rash (malar or discoid)
Arthritis (nonerosive)
Serositis
Hematologic disorder
Oral/nasopharyngeal ulcers
Renal disease
Photosensitivity
Antinuclear antibodies
Immunologic disorder (anti-dsDNA, anti-sm, antiphospholipid)
Neurologic disorders
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161
Systemic lupud erythematosus organ damage is due to
mostly a type III hypersensiitivity reaction
associated with deficiency of eraly complement proteins which decreases clearance of immune complexes
162
SLE pt are at risk for what kind of endocarditis
Libman sacks endocarditis - nonbacterial verrucous thrombi usually on mitral or aortic valve
163
SLE pts are at risk for what kind of nephritis
Diffuse proliferative is most common and severe
164
SLE pts commonly die from
Renal disease most common
infections
cardiovascular disease
165
Antiphospholipid syndrome
primary or secondary autoimmune disorder most commonly in SLE
thrombosis (arterial and venous) or spontaneous abortion
lab finding: lupus anticoagulant, anticardiolipin, anti beta2 glycoprotein antibodies
note: anti cardiolipin antibodies can cause false positive VDRL/RPR and lupus anticoagulant can cause prolonged PTT that is not corrected by addition of normal platelet free plasma
166
Mixed CT disease is related to what antibodies
anti-U1 RNP antibodies (speckled ANA)
167
Pt presents with pain and stiffness in proximal muscles, fever, malaise, weight loss. She does not complain of muscular weakness and she has a history of giant cell (temporal) arteritis
Polymyalgia rheumatica
high ESR, CRP
normal CK
rapid response to low dose corticosteroids
168
Patient presents with widespread musculoskeletal pain that is associated with tender points, stiffness, paresthesias, poor sleep, fatigue, cognitive disturbances
Fibromyalgia
treatment is regular exercise, antidepressants, neuropathic pain agents
169
Polymyositis/dermatomyositis markers
```
Increase CK
+ ANA (nonspecific)
+ anti-jo-1 / histidyl-tRNA synthetase (specific)
+ anti-SRP (specific)
+ anti-Mi-2 (specific)
```
170
Polymyositis
Progressive symmetric proximal muscle weakness
endomysial inflammation with CD8+
intersitial lung disease
Mostly involves the shoulders
171
Dermatomyositis
```
Similar to polymyositis
malar rash at nasolabial folds
Gottron papules
heliotrope (violaceous periorbital) rash
Shawl and face rash
darkening and thickening of fingertips and sides resulting in irregular dirty appearing marks
increase risk of occult malignancy
perimysial inflammation and atrophy with CD4+ T cells
interstitial lung disease
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172
Pt presents with ptosis, diplopia, weakness, dyspnea. She mentions that it is worse when she uses her muscles. What disease is this? What is its mechanism of action?
Myasthenia gravis
most common NMJ disorder
autoantibodies to postsynaptic ACh receptor "post death you have a grave"
173
Myasthenia gravis is commonly associated with ___?
thymoma
| thymic hyperplasia
174
How do you dx myasthenia gravis? how to you treat?
Diagnose when use edrophonium (tensilon) test and see improvement
treat with pyridostigmine
175
Pt presents with proximal muscle weakness, autonomic symptoms like dry mouth and impotence. Patient explains that her symptoms improve with muscle use
lambert eaton myasthenic syndrome
autoantibodies to presynaptic Ca channel --> decrease ACh release
"PREpare to eat"
176
Lambert eaton myasthenic syndrome is commonly associated with ___?
small cell lung cancer
177
raynaud disease vs raynaud syndrome? how to treat?
disease is primary
syndrome is secondary to another disease. Can see digital ulceration
treat with calcium channel blockers
178
Pt presents with sclerosis of skin, her face is puffy and her skin taut. She has no wrinkles and you notice her fingertips are pitting
Scleroderma (systemic sclerosis)
triad of autoimmunity, noninflammatory vasculopathy, and collagen deposition with fibrosis
can see other systems involved too (GI, renal, pulm, CV)
179
Diffuse scleroderma
widespread skin involvement
Rapid progression
Early visceral involvement
anti-scl-70 antibody (anti-DNA topoisomerase I antibody)
180
Limited scleroderma
limited skin involvement confined to fingers and face
CREST syndrome
```
Calcinosis cutis
Anti-centromere antibody
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
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benign course
181
Children
metaphysis of long bones
hematogenous infection
osteomyelitis most commonly affected the metaphysisi of long bones due to decreased blood flow in these areas
