Week 4 Flashcards
Which of the following is the most appropriate treatment plan for an open fracture?
- Debridement, fixation
- Irrigation, reduction and casting
- Debridement, reduction and casting
- Irrigation, debridement, fixation
- Irrigation, fixation
Answer: 4. Irrigation, debridement, fixation. All three are important to reduce infection risk, remove necrotic tissue, and allow for proper healing. Casting and reduction are inadequate treatments for open fractures, which require fixation.
Lecture: SM 235a Musculoskeletal Trauma
Learning objective(s): Explain the diagnosis and treatment of open fractures, compartment syndromes, and major joint dislocations. (MKS 1b, 1d, 1e)
A construction worker presents to the ER after a large, heavy crate was dropped on his right leg. He says it is incredibly painful. His calf is swollen. He is unable to move his big toe; however, you are able to flex it and upon doing so the patient screams. If left untreated, which of the following is most likely to happen next?
- Sepsis
- Loss of dorsalis pedis pulse
- Osteomyelitis
- Wet gangrene
- Rupture of the fascia
Answer: 2. Loss of dorsalis pedis pulse. This question is describing compartment syndrome of the leg, after a crush injury. Pain out of proportion to exam is a big clue that the swelling is due to compartment syndrome. Untreated compartment syndrome will cut off the vascular supply through the compartments, ultimately leading to ischemia and nerve damage.
Lecture: SM 235a Musculoskeletal Trauma
Learning objective(s): Explain the diagnosis and treatment of open fractures, compartment syndromes, and major joint dislocations. (MKS 1b, 1d, 1e)
A construction worker presents to the ER after a large, heavy crate was dropped on his right leg. He says it is incredibly painful. His calf is swollen. He is unable to move his big toe; however, you are able to flex it and upon doing so the patient screams. What is the next best step?
- Emergency fasciotomy
- Burr holes
- Aggressive diuresis
- Watchful waiting
- Amputation
Answer: 1. Emergency fasciotomy. This question is describing compartment syndrome of the leg, after a crush injury. Pain out of proportion to exam is a big clue that the swelling is due to compartment syndrome. Compartment syndrome is an emergency and must be treated as such, with a fasciotomy to relieve the pressure prior to sever vascular compromise and nerve death.
Lecture: SM 235a Musculoskeletal Trauma
Learning objective(s): Explain the diagnosis and treatment of open fractures, compartment syndromes, and major joint dislocations. (MKS 1b, 1d, 1e)
In the absence of any red flag signs in the history or physical exam, which of the following best describes the natural history of low back pain?
- Most patients will ultimately require a CT scan to determine etiology
- Most patients will ultimately require an MRI to determine etiology
- 90% of patients improve without an MD interaction
- Once resolved, only a small subset of patients will suffer a relapse.
- A majority of patients will undergo spinal surgery before relief is achieved
Answer: 3. Many patients will resolve without an MD interaction. so, don’t image immediately unless there are red flags. Usually this happens in 6-12 weeks. A key learning point here is that imaging is usually not an early step for many patients with low back pain. In addition, many patients do suffer from relapsing back pain.
Lecture: SM 235a Back Pain
Learning objective(s): Explain the role of history, physical examination and imaging in the evaluation of low back pain (MKS 1b, 1d). Create a general plan of treatment for a patient with low back pain and make some specific recommendations for acute treatment of low back pain. (MKS 3b)
Which of the following is a component of a good initial treatment plan for many patients with low back pain and a no red flags on physical exam?
- Bed rest until it feels better
- Opioids to encourage use and speed recovery
- Physical therapy focusing on increased flexibility of the lower back
- Physical therapy focusing on Increased flexibility of hips and knees
- 30 minutes daily of aerobic exercise.
- Corticosteroid injection
Answer: 4. PT should focus on flexibility of the hips and knees to support the back, rather than flexibility of the spine. Bed rest can make things worse, rather than better. Opioids as a first line therapy for low back pain is an example of opioid overprescribing. Exercise is only effective for low back pain when it is matched to the pain. Corticosteroid injections are a more invasive measure for select patients who have not responded to other therapies
Lecture: SM 235a Back Pain
Learning objective(s): Explain the role of history, physical examination and imaging in the evaluation of low back pain (MKS 1b, 1d). Create a general plan of treatment for a patient with low back pain and make some specific recommendations for acute treatment of low back pain. (MKS 3b)
As a medical student, you are reviewing patients in a pediatric clinic that you will be seeing this day. A cursory scan of the chart reveals that he has macrocephaly and a previous revealed mild ventriculomegaly. His is now 15 and several weeks ago had an x-ray taken in preparation for this clinic visit. What is the most common cause of this disease?
- Autosomal dominant gene resulting in premature epiphyseal closure
- X-linked gene resulting in premature epiphyseal closure
- Autosomal dominant gene resulting in increased bone matrix formation
- X-linked gene resulting in increased bone matrix formation
- Autosomal dominant gene resulting in decreased chondrocyte proliferation
- X-linked gene resulting in decreased chondrocyte proliferation
Answer: 5. Achondroplasia occurs from decreased chondroblast proliferation from constitutive activation of the FGFR gene. These mutations are autosomal dominant in nature and occur sporadically 85% of the time.
Lecture: SM 245a Inherited disorders of connective tissue
Learning objective(s): Describe the clinical features of achondroplasia, and the genetic mechanism that causes the dysplasia. MKS 1a, 1b, 1d/knowledge
An 18 year old patient presents to the ER with sudden, atraumatic unilateral loss of vision. He was birthed by a midwife and has never seen a doctor before today. He is very tall, with long extremities. Ophthalmic exam is shown below. After appropriate treatment, the patient is discharged from the hospital and referred to several services, including cardiology as they are at increased risk for:
- Malignant Hypertension
- Pericardial Fibrosis
- Cystic Hygroma
- Myoxma
- Mitral Stenosis
- Aortic dissection
- Pulmonary Arterial Hypertension
Answer: 6. Aortic dissection. This patient is presenting with previously undiagnosed Marfan’s syndrome. Clues include that he is tall with long extremities. He also has a lens subluxation, which is an atypical injury for an 18 year old male in the absence of trauma.
Lecture: SM 245a Inherited disorders of connective tissue
Learning objective(s): Describe the characteristics of Marfan syndrome, osteogenesis imperfecta and Ehlers-Danlos syndromes. MKS 1d/knowledge. Identify the genes associated with these disorders. MKS 1a, 1b/knowledge. Describe the pathogenesis of these disorders. MKS 1b/knowledge
A genetic disease results in long extremities and hypermobile joints. Patients are at risk for many things, including aortic aneurysms, floppy mitral valves, and subluxation of ocular lenses. The gene responsible for this disease encodes a protein that normally:
- Is a bone matrix precursor
- Retains water in the extracellular matrix
- Is collagen
- Hydroxylates collagen
- Serves as a scaffold for elastin
Answer: 5. The FBN1 gene encodes fibrin, which normally serves as a scaffold for elastin. Mutations in this gene cause Marfan syndrome, which affects the skeleton, heart, and eyes.
Lecture: SM 245a Inherited disorders of connective tissue
Learning objective(s): Describe the characteristics of Marfan syndrome, osteogenesis imperfecta and Ehlers-Danlos syndromes. MKS 1d/knowledge. Identify the genes associated with these disorders. MKS 1a, 1b/knowledge. Describe the pathogenesis of these disorders. MKS 1b/knowledge
A 3 yo child from Osaka, Japan, developed a fever and a rash and swelling of her hands and feet over 2 days. On PE, her temp is 37.8oC. There is a desquamative skin rash, oral erythema, erythema of the palms and soles, edema of the hands and feet, and cervical lymphadenopathy. The child improves after a course of IV Ig therapy. Which of the following is most likely to be a complication of this child’s disease if it is untreated?
- Asthma
- Glomerulonephritis
- Intracranial hemorrhage
- MI
- Pulmonary HTN
Answer 4: MI. This patient has Kawasaki disease, which involves large, medium, and small arteries, especially coronary arteries and cardiovascular complications include thrombosis, ectasia, aneurysm formation of coronary arteries.
What is different from this presentation and juvenile idiopathic arthritis? Kawasaki has oral and palm and sole specific presentations without spiking fever or hepatosplenomegaly. Also the skin rash is typically different (ref next slide)
Lecture: SM233a Pediatric Rheumatology
Learning objective(s): Describe the clinical features of Kawasaki disease (MKS1d). Compare the presentation of Kawasaki disease from systemic onset juvenile idiopathic arthritis (MKS1d)
A 7 yo child has had abdominal pain and dark urine for 10 days. PE shows purpuric skin lesions on the trunk and extremities. Urinalysis shows hematuria and proteinuria. Serologic test results are negative for P-ANCAs and C-ANCAs. A skin biopsy specimen shows necrotizing vasculities of small dermal vessels. A renal biopsy specimen shows immune complex deposition in glomeruli, with some IgA-rich immune complexes. Which of the following is the most likely diagnosis?
- Giant cell arteritis
- Henoch-Schönlein purpura
- Polyarteritis nodosa
- Takayasu arteritis
- Telangiectasias
- Granulomatosis with Polyangiitis
Answer: 2. HSP is the child counterpart to adult IgA nephropathy. In HSP, immune complexes form with IgA producing the vasculities that affects arterioles, capillaries, and venules in skin, GI tract, and kidney.
Lecture: SM233a Pediatric Rheumatology
Learning objective(s): Compare the rashes of Kawasaki disease, systemic onset juvenile idiopathic arthritis, IgA vasculitis and juvenile dermatomyositis (MKS1d). Explain the basic epidemiology and pathogenesis of the above four diseases (MKS1b)
