Musculoskeletal, skin, connective tissue Flashcards
what structure is at risk in a fracture of the surgical neck of the humerus? what is the physical manifestation?
Axillary nerve - weakness in the ability to abduct the arm at the shoulder, sensory loss in the lateral upper arm and shoulder
-the lateral border of the quadrangular space is the surgical neck of the humerus
What is the most likely cause of joint pain in:
- Pt > 50 years old
- idiopathic
- rhomboid crystals
- weakly positive birefringent under polar light
Calcium pyrophosphate deposition disease
“pseudogout”
What is the Dx:
Pt has Hx of joint pain in her fingers, wrists, and knees
pain does not improve throughout the day
Serology is positive for Anti-cyclic citrullinated peptide antibodies
Rheumatoid arthritis
What is the HLA type a/w Rheumatoid arthritis?
HLA-DR4
Loss of what cellular structure promotes metastasis and increase chances of gastric adenocarcinoma and infiltrating lobular carcinoma of the breast?
CDH1 - E-cadherin (Adherens junction)
Melanomas originate from which embryologic derivative?
Melanocytes come from neural crest cells
Muscle Weakness
Atrophy
Myotonia
Facial Muscle Atrophy
Identify disease, and mechanism involved?
Myotonic dystrophy - DNA trinucleotide repeate (CTG)
-autosomal dominant, shows anticipation
-instability during maternal meiosis
What the exit points from the skull for the branches of the trigeminal nerve?
- Ophthalmic
- Maxillary
- Mandibular
- Superior Orbital Fissure
- Foramen Rotundum
- Foramen Ovale
What is the treatment of choice for acute Gouty arthritis?
NSAIDs - Indomethacin
What dz and type of collagen is defective in:
bruising, translucency and laxity of skin, hypermobile joints
Ehlers-Danlos - defective Type V collagen
In the Patellar reflex, what is the afferent and efferent Nerves?
Femoral, Femoral
Where does Thoracic Outlet syndrome usually occur?
compression of lower trunk of brachial plexus = extremity numbness, tingling, weakness
Scalene Triangle
- -compression between ANTERIOR and MIDDLE scalene muscles
- -positive Adson test
A Mechanic who uses his screw driver alot presents with progressive hand weakness.
sensation is preserved in upper limb, weakness with extension of fingers and thumb
Tricep reflex is 2+
Where was the affected nerve most likely injured?
Radial nerve (continues to become the posterior interosseous nerve) is probably impinged in the supinator canal
What structure is affect in medial epicondylitis? (golfer’s elbow)
Flexor carpi radialis
pronator teres overuse
During surgery to remove a thyroid lobe a nerve is injured when ligating an artery entering the superior pole of the thyroid lobe
What nerve and muscle function was injured?
Superior thyroid artery runs with:
External branch of superior laryngeal nerve
–Cricothyroid M is the only muscle innervated by this nerve: low hoarse voice with limited range of pitch
How does adrenergic innervation affect pancreatic insulin release?
alpha-2: inhibit insulin release
beta-2: promotes insulin release
54 year old male pt has a neck lump that appears to be a “cold” thyroid nodule
FNA: spindled shape cells in a amorphous background
Calcitonin levels are elevated
Identify dz and gene involved?
Medullary Thyroid Cancers = parafollicular calcitonin-secreting C-cells
Germline mutations of RET proto-oncogene are present in 95% of patients with familial medullary thyroid cancer
What is the class and mechanism of action of ezetimibe?
cholesterol-lowering agent
decreases intestinal absorption of cholesterol - inhibits Niemann-Pick C1-like 1 (NPC1L1) transporter protein
51 year old women has a nodule in left lobe of thyroid
TSH is normal
US: hypoechoic with increased central blood flow
FNA: clusters of overlapping cells with large nuclei containing sparse, finely dispersed chromatin
Numerous intranuclear inclusion bodies and grooves are also seen
what is the dx?
Papillary Carcinoma
large overlapping nuclei, finely dispersed chromatin = Orphan Annie eye
intranuclear inclusion and grooves = Psammoma bodies
PT presents with Xanthelasmas
father died of MI
Biopsy of lesion = lipid-laden macrophages
Immunoblot analysis = lack of ApoE3, ApoE4 in his circulating lipoproteins
what is most likely impaired in patient? what is dz?
Chylomicron remnant uptake by liver
—Familial dysbetalipoproteinemia (type III)
Which two metabolic disease show a cherry red spot in the macula
with hypotonia and neurologic degeneration? How do you tell the two apart?
Tay-Sachs:
B-hexosaminidase A deficiency, GM2 build up
Niemann-Pick:
Ashkenazi jews
Sphingomyelinase deficiency (sphingomyelin buildup)
HEPATOSPLENOMEGALY
What Cobb angle measurement:
- is considered moderate (treat with orthotics, phys therapy, OMT)
- respiratory compromise
- cardiovascular compromise
- 20-45 degrees
- > 50
- > 75
Identify the type of hernia:
42 year old male presents with bulge in upper thigh next to his groin. Asymptomatic, has occasional abdominal pain, nausea, vomiting
Femoral Hernia
-located inferior to inguinal ligament, protrude through femoral ring
What layer is a Craniopharyngioma derived from?
Rathke pouch - Surface Ectoderm
mass in lateral neck, anterior to sternocleidomastoid muscle. Immobile during swallowing
Branchial cleft cyst (persistent cervical sinus)
What is lymphatic drainage of the body of the uterus/cervix/superior bladder?
external iliac nodes
What is the lymphatic drainage of the prostate/cervix/corpus cavernosum/proximal vagina?
internal iliac nodes
What is the lymphatic drainage of the distal vagina/vulva/scrotum/distal anus
superficial inguinal nodes
What is the lymphatic drainage of the glans penis?
deep inguinal nodes
pt is stabbed just medial to superior angle of the scapula.
Which muscle is damaged?
which artery (divides around this muscle) is damaged?
Which Nerve is damaged that innervates this muscle??
Levator Scapular M.
- Dorsal scapular artery
- Dorsal scapular N (C3,C4,C5)
Pt presents with numbness and tingling of right hand. Electromyography reveals nerve entrapment at Guyon’s canal. What is entrapped and what other symptom should be observed
Ulnar N. enters Guyon’s canal
-weakness adducting digits
Which intrinsic hand muscles abduct the fingers? adducts?
abduct - Dorsal interossei
adduct - Palmar interossei
(DAB, PAD) - Dorsal ABducts, Palmar ADducts
What is the function of lumbricals
flex the MCP
extend DIP, PIP
What does an
1.increased
2.decreased
Q angle of the knee mean?
- genu valgus
2. genu varus
What Nerve is damaged in:
- Incorrect use of crutches
- Supracondylar fracture of distal humerus
- Midshaft fracture of humerus
- Radial N
- Median N.
- Radial N.
Pitcher presents with shoulder pain after pitching. Difficulty internally rotating shoulder, pain with passive external rotation. Which muscle was damaged?
Subscapularis
70 yr old patient presents with necrosis and gangrene of the right hand. Pt is one day post surgery. He underwent general anesthesia with peripheral IV access at right upper extremity. Where was the IV most likely inadvertently placed?
Ulnar A.
–vasoconstricting meds caused constriction of terminal branch of the ulnar artery = superficial palmar arch
Pt always needs to drink water, has trouble swallowing dry foods, keratoconjunctivitis. palpable enlargement of the bilateral parotid glands
identify dz and expected lab findings
Sjogrens
Positive antinuclear antibody (ANA)
Positive anti-RO antibodies
A pt presents Xray of lumbar spine: fusion of the lumbar vertebrae, fused sacroiliac joints
what dz and what is pt at highest risk for if not treated?
Ankylosing spondylitis (chronic inflammatory disorder that causes fusion of vertebral bodies and SI joints)
–Fracture of the axial spine
12 year old boy has acute swelling, pain in right thigh. Pain is worse at night and accompanied by low-grade fevers. 3 cm palpable round mass in inner thigh. Radiograp shows spiculated periosteal reaction. 11:22 chromosomal translocation
what is dx? What is the gross appearance? What is biopsy appearance?
Ewing’s sarcoma
- localized pain, low grade fevers
- prevalent in long bones
- “ONION SKIN” appearance
- 11:22 translocation
Biopsy: small, round, blue cells, hyperchromatic nuclei and scant cytoplasm
What is the adult structure of the
- Anterior fontanella
- Posterior fontanelle
- Bregma
2. Lambda
Which wrist bones can cause:
- acute carpal tunnel syndrome
- ulnar N. injury?
- Dislocation of the lunate
2. damage the hook of the hamate
How is Becker’s muscular dystrophy different from Duchenne’s muscular dystrophy?
Becker’s - later age of onset, typically after age of 10. milder clinical course - pts usually can abulate into adult life. retardation not as common
—mutation = DYSFUNCTIONAL dystrophin
Duchenne = ABSENCE of dystrophin
- -2-3 yrs old w proximal muscle weakness
- -waddling, toe walking gait, positive Gower’s sign (child uses hands to get up from seated position)
Pt present with joint pains primarily in hands and is worse in the morning. Ulnar deviation of wrists bilaterally and swan neck deformity of the digits. what is most likely diagnosis and where should aggressive OMM therapy be avoided?
RA
-aggressive OMM should be avoided in upper cervical spine
Damage to the ulnar nerve would cause what muscle defects in the hand?
Claw hand (flexion of PIP, DIP; extension of MCP) when hands is at rest
ulnar N is responsible for abdution and adduction of fingers
also innervates ADDUCTOR pollicis muscle
Where in the spine does Type III Spondylolisthesis occur most often?
Type I? What demographics
Type III - older pts: L4-L5
Type I - younger pts (<15): L5-S1
What is the most likely cause of a LATERALLY winged scapula? what can this impinge on?
Damage to Spinal Accessory N (CNXI)
- -traps cant hold scapula medially
- -can impinge on Triangular Space (Teres Major, Minor, Long head of triceps)
- -Circumflex scapular artery
Which muscle should be treated with Muscle Energy for:
- Rib 1
- Rib 2
- Ribs 3-5
- Ribs 6-8
- Ribs 9-10
- Ribs 11-12
- Anterior Scalene
- Posterior Scalene
- Pectoralis Minor
- Serratus anterior
- Latissimus dorsi
- Quadratus lumborum - treat indirectly
Baby is delivered with skeletal deformities, blue sclera, numberous fractures of the skull, long bones, ribs. Pulmonary hypoplasia
what is the most likely dx?
Osteogenesis imperfecta type 2
- —(type 1 = skeletal deformities uncommon)
- -PULMONARY HYPOPLASIA is associated with type 2
Pt has a posterior hip dislocation - what nerve can be damaged? what Sx?
Inferior gluteal
-difficulty climbing stairs, rising from seat
What is the initial treatment of choice for gonococcal arthritis or DGI?
Ceftriaxone (cephalosporin) given intramuscularly
Which ribs move in:
- pump handle motion
- bucket handle motion
- caliper motion
- 1-5
- 6-10
- 11-12
How is OMM useful for pts with scoliosis?
improves flexibility in pts - decrease severity and help prevent progression
What are the serum electrolyte levels in Pagets dz? (Ca2+, Phosphorus, PTH) what is the etiology
Ca2+, phosphorus, PTH are NORMAL in Pagets, INCREASED ALP
–disorder of bone remodeling from increased osteoclastic activity followed by increase osteoblastic activity that forms poor-quality bone
- -can cause:
- High Output Heart failure
- Increase in skull size (thickening)
- Hearing loss from auditory foramen narrowing
55 year old pt presents with right index finger pain. No hx of trauma. there is a clicking sound when the patient extends and flexes finger. what id dz and what structure is involved?
Stenosing flexor tenosynovitis = “trigger finger”
-Flexor tendon sheath = sheat develops swelling or nodule that prevents it from sliding normally through fibro-osseous tunnels
60 year old African American female presents with progressive bilateral muscle weakness that started 4 weeks ago when she had trouble combing her hair. Today she had a hard time climbing the stairs. Elevated creatine kinase, ESR, AST, ALT. negative rheumatoid factor, positive Antinuclear antibody and anti-jo Ab.
What is most likely dx?
Polymyositis - inflammatory disorder that causes bilateral proximal myopathy
-anti-Jo Ab is SPECIFIC for polymyositis
Dermatomyositis (variant of polymyositis) - presents with variety of skin rashes
Pt follows up after motor vehicle collision. Pt has weakness/deformity of right hand. Right arm is in supinated position. Sensation loss of medial side of forearm and hand. Middle and distal phalanges of the right hand are flexed. What is this called? what cord segments contribute to the damage nerve?
Klumpke’s palsy “claw hand”
- -Injury to C8, T1
- -commonly seen in childbirth when arm is pulled
- -Pancoast Tumor
Which foramen does the middle meningeal artery pass through?
foramen spinosum
What are polarized microscope findings of uremic gout?
Negatively birefringent crystals
A pt with cerebral palsy has rigid muscles and uncontrollable spasms. She has been taking baclofen. what is the mechanism of action for spasm relief?
Binding GABA-B and reducing the release of excitatory neurotransmitters
14 year old male present with 2 month hx of left knee pain. Swelling, tenderness above the knee cap. Radiograph shows destructive expansile lesion of the distal femur with spiculated tumor margins
what is dx? demographic?
Osteosarcoma - metaphysis of long bone in adolescents and young adults
“expansile, obliterative mass within the metaphysis w spiculate periosteal formation circumscribing the tumor” - resembles a “Sunburst”
47 year old male presents with 6 mo hx of right hip pain. Palpable lump within the soft tissues later to the PSIS. Imaging: aggressive appearing soft tissue mass w erosion of the right iliac cortex
what is dx? demographic?
Chondrosarcoma - typically affects adults between 40-60
- predilection for flat bones in shoulders/pelvis
- -may also involve the diaphysis of long bones
What is the anatomical insertion site for the supraspinatus muscle?
greater tubercle of the humerus
What is the orientation of the superior facets of the:
- Cervical region
- thoracic region
- Lumbar region
- post, sup, medial
- post, sup, lat
- post, sup, medial
What is the origin and insertion of the Anterior Talofibular Ligament?
Lateral malleolus to neck of talus
A pt with missing taste sensation from the anterior 2/3 of the tongue. What is the most likely cell body affected in this patient?
Geniculate ganglion
–sensory ganglion of the facial nerve
A pt with a hx of rheumatoid arthritis has a new drug added to her regiment. she presents later with tinnitus and blurred vision. Eye exam shows pigmented retinal deposits. what is the new drug?
Hydroxychloroquine - causes retinal deposits
65 year old pt presents with sharp pain in bottom half of right side of her face. very painful to touch - shoots from corner of mouth to jaw. Described as “electric, stabbing”
what is dz and what is pharm treatment?
Trigeminal neuralgia
–Treat with anticonvulsants:
Carbamazepine
Oxcarbazepine
–inhibiting neuronal sodium channels = reducing neuronal excitability.
Pt w
–recurrent rash on hands and face (blistering and scarring) gets worse when exposed to sun or drinking booze.
–Serum/urine analysis reveal elevated uroporphyrin
–face has hair growth and hyperpigmented
Urine is tea colored
- what is most likely dx?
- what is most likely deficient?
- what are 3 exacerbating fx?
Porphyria cutanea tarda
-deficient uroporphyrinogen decarboxylase (UROD) Sx in adults are exacerbated by 1. EXCESS IRON, 2. ALCOHOL, 3. P450 induction,
62 yr old pt presents with urinary incontinence and paresthesias of medial thigh. She is unable to feel toilet paper on her perineum when wiping after urination. Exam shows step-off of the L3 spinous process
what is causing paresthesia? where does spinal cord end?
Cauda equina syndrome
- -cauda to spinal cord termination at L1-L2
- -Sx: bowel/bladder dysfxn. motor sensory impairment, saddle anesthesia
Conus medullaris syndrome would present with additional UPPER MOTOR neuron signs
Which muscle allows you to open your mouth?
Lateral Pterygoid
What is the most likely cause of heart failure in a patient with multiple myeloma?
AL amyloidosis
–overproduction of IgG, Ig and/or lightchains = form insoluble fibrillar deposits that infiltrate the myocardium causing normal sized ventricular cavities to become stiff.
-over time this causes restrictive ventricular filling = biatrial enlargment = acute decompensated HF
Muscle weakness (gradual, difficulty rising from seat/brushing hair), patchy bluish-purple rash on face and eyelids. different rash on nails, knuckles, shoulders. Rash worsens with sun exposure. flat-opped erythematous papules and plaque over the finger joints, elbows, knees, chest, and back.3/5 strength in hip flexion and extension, shoulder strength decreased as well. claims bouts of dysphagia
what is dz? what are serum findings?
Dermatomyositis
- -Shawl sign, heliotrope rash (under eyes = very specific to dermatomyositis), Gottron’s papules, holster sign
- -weakness of proximal muscles
- -proximal esophagus affected more than distal (inflammatory myopathies affect mostly skeletal muscle)
Serum: elevated Creatine Kinase-MM (muscle isoform), Aldolase, AST, ALT, LDH
identify where the disc herniation has occured:
decreased sensation at the left lateral malleolus
L5-S1 disc herniation
S1 compression = decrease in Achilles reflex, sensation over the lat malleolus, toes 4,5, and ankle plantar flexion
What test is used to dx Quervain’s tenosynovitis?
what 2 muscle tendons are involved?
Finkelstein’s
- -abductor pollicis longus
- -extensor pollicis brevis
What neurotransmitter and receptor is responsible for the direct release of sweat from sweat glands?
Acetylcholine; muscarinic receptor
what is the action and innervation of biceps femoris (2 heads)
Knee flexion, hip extension
Common peroneal br
Tibial br of Sciatic N
What is the initial pharm treatment of akylosing spondylitis?
Indomethacin or other NSAIDs
–if no response then: TNF inhibitors (Etanercept) and Sulfasalazine
What is the primary motion of C2-C4?
Rotation
What is the primary motion of C5-C7?
Sidebending
What is the sequence of elbow ossification?
Come Rub My Tree Of Love
```
Shaft first
Capitellum
Radial Head
Medial epicondyle
Trochlea
Olecranon
Lateral epicondyle
~~~
What ligament is injured in ankle eversion injuries?
Tibiocalcaneal ligament (deltoid ligament)
What nerve is damage in a spiral fracture of the distal humeral shaft?
Radial N - traverses through the spiral groove on the posterior side of the humerus
