Thursday night highlights - high yield Flashcards
1
Q
mechanism of Guillan Barre
A
destroys myelin in patchy manner
2
Q
Most common etiology of a mononeuropathy
A
compression of nerve –> demyelination at the site of compression (think carpal tunnel syndrome)
3
Q
fasciculations are a ___sign (LMN/UMN)
A
LMN
4
Q
which is more common - axonal neuropathies or demyelinating myopathies?
A
axonal, by a long shot.
5
Q
Case: decreased sensation on right thumb, right index finnger, right middle finger, and part of ring finger. Worsened by typing / holding the steering wheel. Normal reflexes. Which nerve?
A
Median nerve - carpal tunnel.
Remember - median is mixed - sensory and motor sx
6
Q
Radial mononeuropathy - symptoms and common cause
A
wrist drop - saturday night palsy (pass out with humerus impacted)
7
Q
Peroneal mononeuropathy - symptoms and common cause
A
foot drop - sitting with legs crossed.
8
Q
3 viruses that cause guillan barre
A
campylobacter, CMV, EBV
9
Q
mechanism of guillan barre -
A
cross reaction of ab’s with gangliosides in myelin/schwann cells.
10
Q
can improved glucose control reverse diabetic neuropathy?
A
nope. but but can prevent progress.
11
Q
What are fasciculations?
A
visible mm twitching
LMN sign
12
Q
cramps - LMN or UMN?
A
LMN
13
Q
Muscle spasticity - UMN or LMN?
A
UMN
14
Q
Atrophied tongue with fasciculations - which disease
A
hallmark of ALS
15
Q
T/F - in diabetic neuropathy myelin is affected. In guillan barre, axons are affected.
A
False. Reverse
16
Q
clinical characteristics of mm disorders
A
diffuse/proximal weakness - usually symmetric!!
normal sensation
normal reflexes (if mm strong enough)
17
Q
characteristics of congenital myopathies - 3
A
inherited
- NON-progressive/slowly progressive
- disorders of the contractile mechanism of skeletal mm
18
Q
What is the example disease for a muscular dystrophy caused by nuclear transcription abnormalities>
A
Fascioscapulohumeral muscular dystrophy (FSHD)
19
Q
What is the example disease for a disorder of mm contraction?
A
Congenital fiber type disproportion.
20
Q
Limb girdle muscle dystrophies are separated into 1s and 2s. Which one is dominant?
A
1 = dominant
2- recessive,
x linked = duchenne becker.
21
Q
what does the dystrophin glycoprotein complex do?
A
It connects the contractile elements of the mm cell to the extracellular matrix
22
Q
when does duchenne MD present?
A
3-5yo. wheelchair by 12
23
Q
duchenne becker MD is x linked _____
A
recessive
24
Q
how do people with duchenne MD typically present?
A
3-5 years old
gross motor delay
trouble walking / running
25
which type of muscle dystrophy can present in adulthood?
becker
26
t/f - 95% of duchenne/becker muscular dystrophy pt's can be diagnosed by genetic testing, without mm biopsy
True
27
calf hypertrophy - which disease?
Duchenne MD
28
Mechanism of Fascioscapulohumeral muscular dystrophy (FSHD)
deletion within a repetitive sequence on chromosome 4 --> DUX4
29
clinical presentaiton of Fascioscapulohumeral muscular dystrophy (FSHD)
```
young - 8 years old
-chicken wings
-trouble lifting things
-sleep w/ whites of eyes showing
-bilateral facial weakness.
"refuses to smile for family photos"
-CK normal
```
30
Which gene mutation is the most common culprit in congenital myopathies like nemaline, etc?
RYR1 (ryanodine receptor).
| plays a role in excitation / contraction coupling
31
categories of congenital myopathies with characteristic path
Core - mitochondria extruded
| nemaline - blue dots in cells
32
Lack of eye mvmts in early child - probably?
congenital myopathy - other diseases rarely affect eyes. - Congenial fiber disproportion!
33
What is a chronic soft tissue injury in youth?
osgood schlatters
34
Presentation of osgood schlatters
10-15 years old.
palpable bump on front of knee.
caused by overuse - jumping too much, kiddo?
35
Mechanism of osgood schlatters
Repeated microfractures on tibia not given a chance to heal. Tears where the patellar tendon meets the bone.
36
What does a stress fracture look like on X ray?
fuzzy stuff around the bone (bone attempting to reheal)
37
Imaging for proximal thigh stress fracture
x ray
| bone scan if x ray negative.
38
definition of a sprain
injury to ligament
39
definition of a strain
injury to a tendon (sprain a joint, strain a muscle/tendon)
40
how do you classify sprains?
by ligament laxity.
mild- pain but no laxity
moderate - lax with an end-point (partial tear)
severe= gross laxity (feels like you could dislocate it if you want) = complete tear
41
what is the most common ankle sprain? It is due to which motion?
anterior talofibular ligament.
| due to infersion
42
In an anterior talofibular ligament sprain tenderness will be in which area?
laterally, near the distal fibula and talar neck
43
what test should be done for inversion ankle sprains?
Anterior drawer test. If it is positive talofibular ligament broken
44
If you suspect calcaneofibular ligament injury - what test do you do?
Talar tilt
45
severe inversion ankle sprain - which ligaments affected?
anterior talofibular
| calcaneofibular
46
How many ankle sprains need x rays?
10% if trainer present.
| 15-30% in Emergency room.
47
what are the indications for an x ray of an ankle? (These are the Ottowa rules)- 4
gross swelling
point tender over posterior or distal fibula
-crepitus
-can't bear weight
48
Tib-fib sprain - exam findings
ankle external rotation painful (eversion)
- tender above the ankle on the tibia
- can't walk/push off.
49
most common knee sprain
MCL
50
characteristics of MCL knee sprain
- no joint swelling (MCL is outside the joint)
| - sensitive to valgus force
51
Woman playing soccer. When she planted her foot, she heard a painful pop and then her knee shifted. Likely diagnosis?
ACL. Check for hemarthrosis (knee swelling)
52
A patient has hemarthrosis of the knee.(Swelling) what is the most likely injury? + 2 other less common
70% chance of ACL tear.
Meniscus #2
Articular surface fracture #3
53
Exam test for ACL tear?
Lachman (anterior drawer at 30 degrees bent.
54
What is the key physical exam finding for a meniscus tear? How sensitive / specific?
McMurray's - rotate the leg around, hear a pop. Least sensitive most specific.
55
Which is worse - dislocation or subluxation?
Dislocation.
| Subluxation is pathologic movement of the joint, short of dislocation.
56
Which upper extremity injury is associated with the positive apprehension test?
Shoulder dislocation (glenohumeral separation)
57
lachman's test?
for ACL - similar to anterior drawer
58
Which lower extremity injury associated with apprehension sign?
patellar dislocation
59
In adolescent idiopathis sccoliosis (AIS), which Cobb angles should be treated with braces? What about surgery?
25-40 degrees = brace.
| >50 degrees = surgery
60
lumbar radiculopathy at the L5 level will cause weakness where?
ankle/toe
61
What explains why structure does not equal function in regards to back pain?
Biopsychosocial model
62
Mechanism for Marfan
mutation in fibrillin 1 gene (auto dominant) - cannot form microfibrils - defective elastic fibers lead to more TGF-beta accessible - increased growth!!
63
major cause of death for marfan syndrome
thoracic aneurysm - not abdominal!`
64
other side effects of Marfan
-myopia/glaucoma
-chest wall abnormalities
cutaneous (striae)
-long limbs
65
Mechanism of Ehlers Danlos syndrome
mutation in collagen gene - auto dominant.
66
Clinical presentation of Ehlers Danlos syndrome
- fragile skin - bruising
| - hypermobile/hyperelastic joints
67
When does congenital scoliosis develop?
5-7th week of gestation - in the womb!!
68
Mechanism of congenital scoliosis
defect of formation/ separation of vertebrae
69
What does bracing do for scoliosis?
- prevents progression
- does not improve condiition
- 25-40 degree cobb angle
70
13 yo female - scoliosis with 33 degree cobb angle - what is the treatment?
- Surgery
| - She has a lot of growth left, so it has a high chance of progression.
71
Which area gets fractured in spondylolysis.
Pars interarticularis.
72
What is the likelihood of nerve entrapment in spondylolisthesis?
Low if grade 1. Higher in higher grades (4 is the worst, indicates vertebrae has slipped very far.
73
Most common location for spondylolisthesis.
L5/S1
74
treatment for spondylolisthesis?
Less severe - core strengthening
| More severe = lumbar fixation surgery.
75
Which cancers produce osteoblastic bone tumors?
Breast and prostate
76
Which cancers produce osteolytic bone mets?
kidney / thyroid.
77
Which cancer produces osteolytic and osteoblastic bone mets?
lung
78
Disk Herniation at C6/C7 will produce?
- triceps weakness
| - middle finger sensory loss
79
Disk Herniation at L4/L5 will produce?
- extensor hallucis longus weakness
| - sensory loss in between 2nd and 3rd toe
80
Symptoms of ankylosing spondylitis + mechanism
Low back pain
better with exercise, worse with rest.
-inflammation--> narrowing of disc space --> fusion of spine
81
___ % of low back pain is non-specific
85
82
what are the 2 competing goals common in doing surgery on bone?
local control vs. functional outcomes - ie making sure you have teaken it all out but preserving function as much as possible.
83
6 hallmarks of Cancer pneumonic - SARCOMA
```
S- Self-sufficiency of growth signals
A- Apoptosis/immune evasion
R- Resistance to anti-growth factors
CO - COntinuous replication
M - metastasis
A - angiogenesis
```
84
__% percent of cancer is caused by random mutations
66%
85
Which is standard of care - multi agent chemotherapy or monotherapy for bone cancer?
multiagent - to overcome resistance to one med.
86
sarcoma usually spreads via
blood
87
definition of sarcoma
cancer of mesenchymal origin
- connective tissue(bone, cartilage, muscle, fat)
- nerve sheath
- blood vessels
88
Common sarcomas in young
Ewing/Osteosarcoma
89
Common sarcoma in old ppl
Chondrosarcoma
90
Why are sarcomas rare, even though they make up a large portion of mass of the human body?
Their stem cells don't divide often.
91
T/F sarcoma of bone is often painless
True
92
"Red flags" for malignant tumor in soft tissue
- pain
- growing
- deep
- >5cm dia
93
initial imaging for all bone tumors
x ray
94
T/F - Bone tumors rarely require bone imaging or MRI
True! They are highly misused. Usually you can diagnose the stage via x ray
95
Every time you diagnose an osteosaarcoma, where else should you look for cancer?
Chest CT!! (Commonly metastasizes to lungs).
| Should also get a bone scan, commonly mets to other bones.
96
Chemo for osteosarcoma
Adriamycin-based - only approved agent!
| Used pre-and post-surgery
97
kid has osteosarcoma, gets pre-surgery chemo, then surgery. They look at the bone. What % of necrosis is "good response"?
>90
98
In what circumstances should radiation be used to extend suurgical margins?
if the tumor is close to bone, vessels, or nerves.
99
What is an allograft?
Bone from a cadaver.
100
Describe the RANK pathway and the "vicious cycle" of bone erosion.
tumors produce PTH-like protein -->
PTHrP binds to osteoblasts, makes them upregulate RANKL---->
More RANKL binds to Monocyte precursors of osteoclasts--- >
osteoclasts eat up bone , releasing growth factors--->
growth factors feed tumor.
101
Describe the basic work-up of patients with destructive bone lesion. Goals of management?
labs, CT chest/abdomen/pelvis
```
Surgery Goals (if metastatic) = prevent fracture, restore function, alleviate pain (not cure)
Radiation goals == pain relief
Chemo goals = pain relief / palliative
```
102
If you see a bone tumor, what is the likelihood it is a primary bone tumor?
less than 1/100. almost always metastasis!
103
Pneumonic for all the types of cancer that metastasize to bone
=BLT with Pickles and Ketchup
| Breast, Lung, thyroid, prostate, kidney
104
carcinoma usually spreads via
lymph
105
What is a really important finding for bone weakness/cancer?
if pain increases with weight bearing.
106
What are important labs to take in bone tumors
- CBC
- Serum Ca levels.
- SPEP / UPEP for myeloma
107
MOST important study to do with bone tumor
CT of chest/abdomen/pelvis
| -covers many organs with met to bone - breast, lung, kidneys, colon, prostate.
108
bone-specific agents to reduce "vicious cycle" and inhibit osteoclasts
- bisphosphonates (Zoledronic acid)
- > induce osteoclast apoptosis
-Denosumab- binds to RANKL, blocking osteoclast maturation
109
__% of primary care visits are related to Osteoarthritis
30
110
most common Physical exam for hip osteoarthritis
limited internal rotation with 90deg. flexion (sitting on exam table)
also, tredelenberg gait and thomas test (contracture)
111
physical exam for knee osteoarthritis
antalgic gait.
limited flexion/contraction
quad atrophy
112
T/F - labs are commonly used in the diagnosis of osteoarthritis
False. Not commonly used.
113
indications for surgery for osteoarthritis
severe pain/disability
- advanced bone-on-bone x ray changes
- failure of non-operative treatment
114
What is the most effective non-operative treatment for osteoarthritis?
Weight loss = most effective
115
most common surgery for osteoarthritis
total joint replacement.
116
3 things necessary to make an informed choice about surgery
- alternatives
- benefits
- risks
117
You are counseling a patient with severe osteoarthritis. What are the chances I will be normal after the surgery, doc?
Hip - 95% experience 95% pain relief, 90% return to function
Knee- 85% experience 85% relief, 80% return to activities. high level sports 50/50
118
Most common risk for joint replacement (arthroplasty)
Thromboembolic disease (DVT/PE)
119
How are joints usually fixated
presss-fit with component ingrowth - rough surface, bone grows into it - this done 99% of the time
120
3 major disease mechanisms for osteomyelitis (how you get it)
- contiguous (from cut in skin)
- hematogenous (most common mechanism in kids)
- surgery-
121
3 major disease mechanisms for septic arthritis (how you get it) - Which is most common?
PRIMARILY Hematogenous
- contagious (gonorrhea)
- surgery / trauma
122
Most common microorganism that causes septic arthritis and osteomyelitis
staph aureus
123
What is a sequestrum, and in what disease is it found?
```
devitalized bone (from bone infection acting as a foreign body -
osteomyelitis.
```
124
What is the difference between gonococcal and non-gonococcal septic arthritis?
gonococcal = migratory, polyarthritis
non-gonococcal = monoarthritis, non-migratory
125
guy has dental pain for several years, Exam shows he has caries. X ray shows lytic lesion consistent with osteomyelitis. Mechanism and bugs?
Contiguous.
Polymicrobial, Oral bugs (strep, anaerobes)
126
septic arthritis due to osteomyelitis in the neighboring bone is classified under
contiguous mechanism
127
Gonococcal arthritis mechanism of transmission
hematogenous
128
DDx for a red, hot joint
Crystal disease vs. septic arthritis
129
How to diagnose gonococcal arthritis
Take cultures of urethra/cervix/throat. Joint often is culture negative. Take genital fluid too. Do crystal analysis to rule out crystal joint.
130
treatment for septic arthritis
- joint drainage
- IV antibiotics - 2-4 weeks
- EARLY range of motion exercises, even if painful!! Prevents complications.
131
Definition of hyperuricemia
>7.0 mg/dl
132
podagra =
pain and swelling in the big toe due to gout.
133
How long does it usually take for hyperuricemia to become gout? How about for gout to become chronic/tophaceous gout?
10-20 years of asymptomatic hyperuricemia, usually
Once you have gout, another 10-20 years of intermittent disease, until chronic tophaceous gout.
134
When is it most common for men and women, respectively to start having hyperuricemia?
men- puberty
| women - menopause
135
clinical presentation of acute gout
abrubt onset of acute pain and red hot joint
- no other symptoms
- resolves in one week without treatment.
136
T/.F you can find crystals in an asymptomatic joint in gout sufferes
Yes. 50% chance
137
T/F chronic gout is polyarticular and rate of urate deposition correlates with uric acid level.
tru
138
chronic gout radiology
punched out lesions with radiodense overhanging edges (tophus)
139
T/F gout affects 6% of the general population
False. 3% of the general population
140
Uric acid = the end produce of ___ metabolism
Purine
141
Pathophysiology of gout
hyperuricemia --> trigger(cold, decreased O2 tension) --> crystal deposition --> macrophages try to eat the crystals and are lysed, releasing cytokines.---> inflammatory response occurs
142
gout activates the ___ arm of the immune system.
innate.
143
What are the things that lead to hyperuricema?
Diet (meat)
- alcohol (beer)
- fructose
Underexcretion of uric acid (much more common than overproduction of uric acid)
144
crystal exam of gout
Negatively birefringent
intracellular
parallel yellow
perpendicular to the arrow -->blue
145
Mechanism of colchicine
inhibits assembly of NLRP3 inflammasome, turns off cytokine cascade, decreasing inflammation
146
indications for urate lowering therapy
- 1 gout attack and chronic kidney disease
- presence of tophi
- >2 attacks / year
- history of urolithiasis (kidney stones)
147
what are the zanthine oxidase inhibitors and what are their mechanisms?
Allopurinol and Febuxostat
| They stop purine metabolism, stopping formation of uric acid.
148
2nd line gout treatment
Uricosurics - they increase the renal excretion of uric acid. Used in monotherapy or combination with Xanthine oxidase inhibitors.
149
Difference b/t gout and CPPD
CPPD = big toe involvement uncommon
150
Crystal diagnosis of CPPD
ABC
Aligned Blue Calcium
positively birefringence.
151
dimensional perspective variables in psychiatry
continuous variables
- intelligence
- temperament.
152
key brain area in depression
```
limbic system/ hippocampus
Subgenual cortex (cg25) -this area is overactive in depresesd folks - goal is to inhibit activity in this area.
```
153
glucocorticoid cascade hypothesis
hypothesizes that stress levels/glucocorticoids damage the hippocampus, predisposing to depression - based on work with babboons.
154
neurotrophic model of depression
stress leads to decreased neurotropins--> decreased neuron size in hippocampus.
155
examples of neurotropins
BDNF nd NT3
