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Boards 2 > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What is the classic ECG findings of pericarditis

A

Diffuse ST elevations

PR depression

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2
Q

Systemic Lupus Erythematous

Definition

Pt

Diagnosis

A
  • Chronic inflammatory autoimmune disease affecting multiple organs
  • Pt
    • African American women 15-45, 40-60.
    • 4 min required
      • malar rash
      • discoid rash
      • photosensitive
      • painless oral ulces
      • arthritis of 2+ joints
      • pericarditis, pleuritis
      • renal disorder
      • neurological disorder
      • Hematologic disorder
      • (+) ANA
      • anti-dsDNA, anti-smith, antiphospholipid
  • Dx
    • (+) ANA.
    • Low C3, C4
    • Anti-histone Ab which are associated with drug induced lupus
      • Sulfonamides, Hydralazine, Isoniazid, Procainamide, Phenytoin
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3
Q

Systemic Lupus Erythematosus

Tx

Complication

A
  • Tx
    • avoid sun exposure
    • Rx: hydroxychloroquine, NSAID, glucocorticoids.
  • Complications
    • Hypercoagulability
    • Immunocompromised
    • Cardiovascular disease
    • Renal failure.
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4
Q

Anti-histone Ab

A

Associated with Drug-induced lupus

SHIPP.

  • Sulfonamides
  • Hydralazine
  • Isoniazid
  • Phenytoin
  • Procainamide
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5
Q

Polymyalgia rheumatica(PMR)

Risk factor

Pt

A
  • Risk factor
    • assoc w/ Giant Cell Arteritis
  • Pt
    • Joint pain and stiffness in shoulder, neck, hips
    • NO MUSCLE WEAKNESS.

**Compare to polymyositis/dermatomyositis which does have muscle weakness**

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6
Q

Polymyalgia rheumatica (PMR)

Dx

Tx

A
  • Dx
    • High ESR, High CRP
    • Anemia
    • MRI = synovial inflammation
  • Tx
    • low-dose corticosteroids x 2-4wk, and taper over 1-2years.
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7
Q

Polymyositis/Dermatomyositis

Pt

Dx

A
  1. Pt
    1. Progressive symmetric muscle weakness of proximal muscles.
    2. Minimal soreness.
  2. Dx
    1. Elevated CK, ALT, AST, Aldolase
    2. (+)ANA
    3. (+) Anti-Jo-1
    4. EMG shows muscle pathology.
    5. Muscle Bx = fiber degeneration

**Dermatomyositis also contains = malar rash, heliotrope rash on eyelids, Gottron’s papules on knuckles, mechanic hands, erythematous rash on anterior chest or over shoulders.

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8
Q

Polymyositis/Dermatomyositis

Tx

Complication

A
  1. Tx
    1. High dose steroids 4-6wk
    2. Methotrexate or Azathioprine can help accentuate steroid effect.
  2. Complications
    1. increased risk of Malignancy
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9
Q

Fibromyalgia

Define

Pt

A
  1. Define
    1. Increased sensitivity to pain without specific anatomic/pathologic cause
  2. Risk FActors
    1. Female 20-30.
    2. associated w/ RA, SLE, depression, IBS
  3. Pt
    1. Diffuse muscle and joint pain; no swelling/inflammation
    2. Multiple tender trigger points.
    3. severe fatigue
    4. Depression
    5. Cognitive disturbance
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10
Q

Fibromyalgia

Dx

Tx

A
  1. Dx
    1. no findings
  2. Tx
    1. Non-pharmacological
      1. reassurance that it is benign Dz
      2. walking/stretching
      3. appropriate sleep
      4. psychiatric disorders addressed.
    2. Pharm
      1. NSAID
      2. pregabalin
      3. SNRIS
      4. sleep aids (trazodone)
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11
Q

Diffuse cutaneous systemic sclerosis

A
  • Widespread sclerosis of skin and visceral organ.
  • Rapid progression, with early involvement of organs
  • Skin
    • shiny, tight, and leads to finger contractions and ulcerations.
  • (+) anti-DNA topoisomerase 1 antibodies / anti-scl-70.
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12
Q

Limited cutaneous systemic sclerosis

A

CREST

  • Calcinosis cutis: calcification of deep layer of skin.
  • Raynauds phenomenon: cyanotic vasoconstriction in fingers
  • Esophageal Dysmotility: sclerosis of LES -> reflux and dysphagia.
  • Sclerodactyly: fibrosis of skin on fingers
  • Telangiectasias: lips, hands, face.
  • (+) anti-centromere Ab.
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13
Q

Sjögren syndrome

Define

Pt

Dx

Tx

A
  1. Inflammatory autoimmune disorder of exocrine glands.
  2. Pt
    1. Xerophthalmia: dry eyes, conjunctivitis.
    2. Xerostomia: dry mouth, large parotid, dental caries.
    3. arthritis
    4. nasal dryness
    5. vaginal dryness
  3. Dx
    1. (+) Anti-SSA/SSB or Anti-Ro/La
  4. Tx
    1. Eyes: artificial tears, cyclosporine drops, eye patch
    2. Mouth: muscarinic agonist
    3. Arthritis: hydroxychloroquine, methotrexate.
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14
Q

Mixed Connective Tissue Disease

A
  • Features of: SLE, polymyositis, systemic sclerosis
  • Pt
    • raynaud’s, swollen fingers, arthritis, inflammatory myopathy, pleuritis, pulmonary fibrosis.
  • Dx
    • Anti-U1-RNP- antibodies.
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15
Q

65year old Africa American is evaluated for weakness. She was previously active but now has weakness in lower extremities. On exam both legs are equally weak. She has rash on chest. What labs would establish diagnosis?

A

Dermatomyositis

  • aldolase, CK, AST, ALT, LDH.
  • ANA
  • Anti-Jo-1-antibodies.
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16
Q

Proximal muscle weakness w/ facial rash

A

Dermatomyositis

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17
Q

Pain and stiffness in hips and shoulders

A

Polymyalgia rheumatica

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18
Q

Muscle pain and tenderness in multiple distince locations

A

Fibromyalgia

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19
Q

4 skin findings included as diagnostic criteria for SLE

A
  1. Malar rash
  2. Discoid rash
  3. Photosensitivity
  4. Painless oral ulcers.
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20
Q

Most sensitive and specific lab test for Dx of Chronic pancreatitis?

A

LOW fecal elastase

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21
Q

Osteoarthritis

Risk Factors

Pt

A
  • Risk factor
    • aging and obesity
  • Pt
    • noninflammatory arthritis of the hips, kness, ankles, hands/fingers.
    • Pain is worse w/ use and relieved with rest.
    • Asymmetrical arthritis w/ bony enlargement of DIP (herbeden’s) and the PIP (Bouchard’s)
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22
Q

Osteoarthritis

Dx

Tx

A
  • Dx
    • Xray = osteophytes and narrowed joint space.
    • ESR normal
  • Tx
    • Provide adequate joint rest.
    • Wt loss
    • NSAID, Acetominophen(4g/day max). Celecoxib.
    • Glucocorticoid joint injection
    • Hyaluronic acid joint injection
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23
Q

Rheumatoid Arthritis

  • Risk factors*
  • Pt*
A
  • Type III Hypersensitivity reaction. Immune complexes deposit in tissue causing inflammation.
  • Risk
    • female w/ HLA-DR4
  • Pt
    • Chronic inflammatory arthritis of hands, wrists, large joints.
    • Morning stiffness, which improves with motion and worse with rest.
    • Swelling of MCP and PIP.
    • Ulnar deviation of fingers.
    • Swan-neck and boutonniere deformities.
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24
Q

Rheumatoid Arthritis

Dx

Tx

A
  1. Dx
    1. High ESR/CRP
    2. (+) Anti IgG rheumatoid factors antibodise.
    3. (+) anti-citrullinated protein antibodies.
  2. Tx
    1. DMARDS
      1. Hydroxychloroquine, Sulfasalazine, Methotrexate, Leflunomide, Anakinra.
    2. TNF-a inhibitors
      1. etancercept
      2. adalimumab
      3. golimumab
      4. certolizumab
      5. infliximab
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25
Q

Psoriatic Arthritis

Pt

Dx

Tx

A
  • Pt
    • Asymmetrical arthritis of DIP joints or symmetric
    • Severe mutilating arthritis
    • Spondyloarthritis of the spine
    • Dactylitis: inflammation and swelling of finger
    • Anterior uveitis: inflammation of the iris and ciliary bodies.
  • Dx
    • HLA-B27 (+)
    • Negative RF, ANA
    • Xray = “pencil-in-cup deformities”
  • Tx
    1. NSAIDs, Celecoxib
    2. Methotrexate, leflunomide, TNF-a inhibitors.
26
Q

Ankylosing Spondylitis

Risk factors

Pt

Dx

Tx

A
  • Risk
    • Males 20-30’s/
  • Pt
    • Low back pain worse w/ inactivity and improves w/ exercise
    • Limited spinal mobility.
    • +/- hip + shoulder pain
    • Anterior uveitis.
  • Dx
    • HLA-B27 (+).
    • Xray = SI joint fusion and bamboo spine
  • Tx
    1. Physical therapy and exercise
    2. NSAIDS, celecoxib (scheduled)
    3. TNF-A inhibitors
27
Q

Pencil-in-cup deformities of DIP joint

A

Psoriatic arthritis

28
Q

Bamboo spine on xray

A

Ankylosing spondylitis

29
Q

Noninflammatory arthritis of the DIP and PIP

A

Osteoarthritis

30
Q

HLA-B27 seronegative spondyloarthropathies

A

PAIR

Psoriatic arthritis

Ankylosing spondylitis

IBD arthritis

Reactive arthritis

31
Q

Gout

Risk Factors

Pt

A
  • Risk Factors
    • Hyperuricemia: overproduction or underexcretion (loop diuretics)
    • Obesity and Male w/ diet of meat, seafood, and alcohol
  • Pt
    • monoarticular joint (MTP)
    • red, warm, swollen and painful.
  • Chronic gout can lead to painless, nodules (tophi)
32
Q

Gout

Dx

Tx

A
  • Dx
    • measure serum uric acid levels
    • Synovial aspiration shows Negatively birefringent crystals which are Monosodium urate.
  • Tx
    • Acute
      1. NSAIDS (indomethacin, naproxen)
      2. Glucocorticoids
      3. Colchicine
    • Chronic
      1. Diet changes
      2. Probenecid
      3. Allopurinol (do not start during acute flare.
      4. colchicine- has large ADR of diarrhea.
33
Q

Pseudogout

Pt

Dx

Tx

A

Calcium pyrophosphate dihydrate

  • Pt
    • acute joint inflammation at the knee.
  • Dx
    • synovial fluid = Positivitelybirefringent, Rhomboid shaped crystals.
    • Xray = chondocalcinosis of the affected joint.
  • Tx
    • Intra-articular steroid injection if limited to 1 or 2 joints
    • NSAID +/- colchicine if multiple joints involved.
34
Q

Clinical features and Treatment for Septic arthritis.

A
  • Pt
    • Monoarticular arthritis, pain, tenderness, restricted ROM.
    • >50% in the knee, asymmetric.
  • Tx
    • Surgical drainage and joint irrigation
    • Empiric Abx therapy
      • G(+): vancomycin
      • G(-): ceftriaxone
      • Gran stain is (-): vancomycin
35
Q

Classic presentation of Lyme Disease

A
  1. Early localized disease.
    1. Erythema migrans - target rash w/ central clearing.
    2. HA, fatigue, myalgia, arthralgia
  2. Early Disseminated Diseae
    1. meningitis
    2. Bell’s palsy
    3. radiculopathy, neuropathy
    4. AV heart block
    5. conjunctivitis
  3. Late Lyme Disease
    1. Knee arthritis
    2. Mild encephalopathy
36
Q

What is the Tx for each of the (3) stages of Lyme Disease?

A
  1. Early dz
    1. doxycycline 100mg BID x 14d
    2. amoxicillin
    3. cefuroxime
  2. Early disseminated
    1. bell’s palsy: doxy, amoxicillin, cefuroxime
    2. meningitis: IV ceftriaxone, cefotaxime, penicillin G
  3. Late
    1. doxycycline/amoxicillin x 4wk.
37
Q

Paget disease of Bone

A

Focal areas of excessive bone remodeling (osteoclast progress to osteoblast activity)

  • Pt
    • bone pain, bone deformity, Hearing loss.
  • Dx
    • elevated Alk Phos
    • Xray = osteolytic bone lesions or hyperdense sclerotic lesion
  • Tx
    • Bisphosphonates or calcitonin injection if symptomatic.
  • Complications
    • HIgh risk of osteosarcoma.
38
Q

What primary cancers metastasize to bone?

A

Permanently Relocated Tumors Like Bones

  • Prostate
  • Renal cell carcinoma
  • Testes, thyroid
  • Lung –> lytic lesions
  • Breast
39
Q

Osteosarcoma

A
  • Features
    • Most common malignant primary bone tumor.
    • Teens or >65
    • Rb gene mutation
    • prior chemo/radiation.
    • distal femur, proximal tibia
  • Xray
    • Codman’s triangle
    • Sunburst pattern.
  • Tx
    • Surgery + chemotherapy
40
Q

Ewing’s Sarcoma

A
  • Features
    • M < 15.
    • t(11:22)
    • Grows on the surface of long bones or pelvis
  • Xray
    • Onion skin appearance
  • Tx
    • Chemo + surgery
41
Q

Giant cell tumor

A
  • Features
    • Multinucleated giant cells.
    • M 20-30’s.
    • Distal femur. Benign w/ local destruction
  • Xray
    • soap bubble
  • Tx
    • surgery or radiation
42
Q

Osteochondroma

A
  • Features
    • benign.
    • M < 25.
    • painless bone mass
  • Xray
    • Chunk of bone with cartilaginous cap
  • Tx
    • Surgical excision if symptomatic.
43
Q

Anterior should dislocation

arm position, neuro involved, classic history, PE.

A
  • Position
    • externally rotated and abduction
  • Neuro
    • Axillary artery and axillary nerve injury possible
  • Hx
    • trauma to abducted, externally rotate, extended arm.
  • Physical
    • prominent acromion and loss of shoulder “roundness”
44
Q

Posterior shoulder dislocation

Position, Neuro, scenario, PE

A
  • Position
    • internal rotation w/ adduction
  • Neuro
    • rare
  • Scenario
    • trauma to anterior surface of shoulder.
    • seizure/ electrocution.
  • PE
    • posterior prominence and anterior shuolder is flat.
45
Q

Nerve injured that leads to Scapular winging

A

long thoracic

46
Q

Nerve injured that leads to inability to wipe bottom

A

thoracodorsal

47
Q

Nerve injured that leads to loss of shoulder abduction

A

axillary nn

48
Q

Nerve injured that leads to loss of elbow flexion and forearm supination.

A

musculocutaneous

49
Q

Nerve injured that leads to trouble initiating shoulder abduction

A

suprascapular

50
Q

Nerve injured that leads to inability to abduct arm beyond 10 degrees

A

axillary

51
Q

Nerve injured that leads to unable to raise armabove horizontal.

A

long thoracic + spinal accesssory

52
Q

Colles fracture

A
  • Distal radius +/- distal ulnar Fx
    • radius is dorsal (posterior) dislocated.
  • FOOSH.
  • associated w/ osteoporosis in elderly.
  • Tx
    • long arm cast
    • sugartong splint in ER.
53
Q

Smith Fx

A
  • Distal radial Fx w/ anterior dislocation
  • Fall on flexed wrsit.
  • Casting after reduction
54
Q

Scaphod Fx

A
  • Pain at anatomic snuffbox.
  • Tx
    • immobilize w/ thumb spica
  • Fx can take up to 1-2 week to appear on Xray. Therefore tenderness on anatomic snuffbox = splint and follow up with Xray in one week.

High risk of avascular necrosis.

55
Q

Monteggia Fx

A
  • Dislocation of radial head and proximal 1/3 unlarFx
  • FOOSH w/ pronated forearm.
  • Requires surgery
56
Q

Galeazzi Fx

A
  • Midshaft/distal radial Fx and dislocation of distal ulnar joint.
  • requires surgery
57
Q

Grading of sprains

A
  • Grade I
    • overstretch w/ microtears
  • Grade II
    • Incomplete tear
  • Grade III
    • complete ligamentous tear
58
Q

Unhappy triad of the knee

A

Anterior cruciate ligament

Medial cruciate ligament

Medial meniscus.

More common to se ACL and lateral meniscus tear

59
Q

Meniscus tear

A
  • Pt
    • vague knee pain.
    • Clicking or locking of joint w/ joint line tenderness
  • Dx
    • MRI
  • Tx
    1. NSAIDS
    2. Physical Therapy
    3. Arthroscopic repair; if young, increases risk of early OA onset.
60
Q

Pt complains of back pain that is wose with straight leg raise test or when he Valsalvas

A
  • mostly degenerative disc disease.
    • or disc herniation.
  • Typically consists of nerve impingement that radiates pain down leg.
  • Tx
    • modify activities, NSAID, PT, surgical decompression.
61
Q

Compartment syndrome

A
  • Pt
    • 6 P’s
    • Excessive Pain, pallor, diminished sensation, weakness, paralysis, “wood-like” feeling.
  • Dx
    • clinical presentation
    • Manometry
  • Tx
    1. Fasciotomy when pressure > 30mmHg.

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