Clinical medicine textbook, Summaries of Clinical Medicine

Download Clinical medicine textbook and more Summaries Clinical Medicine in PDF only on Docsity! P. Kumar, M. L. Clark, Clinical medicine MSK REVIEW STUDY GUIDE MANEUVERS Be familiar with all the maneuvers (especially if highlighted for specific conditions) & know their association and which conditions are using it to be diagnosed Overview CONDITION RTC Tendonitis (Impingement Syndrome) POSITIVE TESTS +Neer, +Hawkins RTC Tear +Neer, +Hawkins +drop arm sign, +empty can test Bicipital tendinitis +infraspinatus strength test, +forearm supination test Acromioclavicular arthritis +crossover test Crossover test: Adduct the arm across the chest (pain = POSITIVE, low specificity) Anterior dislocation of humerus +Apprehension test Apprehension test: abduction and external rotation causes instability Carpal tunnel syndrome +Tinel, +Phalen De Ǫuervain’s Tenosynovitis +Finkelstein Partial MCL tear +Abduction (Valgus stress test) Partial LCL tear +Adduction (Varus stress test) Meniscus tears +Medial or lateral McMurray test ACL tear +Lachman test, +Anterior drawer sign PCL tear +posterior drawer sign Finkelstein’s test: pt grasps thumb against palm & performs ulnar deviation of the wrist (POSITIVE = pain) POSITIVE = DE ǪUERVAIN Medial or lateral McMurray Test (internally rotate the foot and push on medial side to apply varus stress; POSITIVE = sudden pain) POSITIVE = MENISCAL TEARS Lachman Test placing the knee in 30 degrees of flexion; stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand, thereby attempting to produce anterior translation of the tibia. Increased forward translation of tibia is POSITIVE sign and indicates ACL tear or laxity Anterior Drawer Sign performed with the patient lying supine and the knee flexed at 90 degrees. The proximal tibia is gripped with both hands and pulled anteriorly, checking for anterior translation. The test is positive if there is anterior translation. Comparing the degree of translation to the uninjured knee is helpful POSITIVE = ACL TEAR THINK ANTERIOR = ACL Posterior drawer sign (considered most accurate maneuver for detecting PCL injury; w/ pt supine have hip of affected leg flexed to 45o, the knee to 90o and foot in neutral position. Wrap both hands around pt’s proximal tibia w/ thumbs placed in region of tibial tuberosity. Apply posterior force to proximal tibia. Increased posterior tibial displacement compared w/ uninvolved lower extremity = partial/complete tear of PCL) POSITIVE = PCL TEAR THINK POSTERIOR = PCL FRACTURES In general, for fracture reading. If open fractures with neurovascular involvement & major hemorrhage or a wrist drop d/t injury of radial nerve. If those things are present → REFER THAT PATIENT. EMERGENT EVALUATION ● Depending on level of displacement and angulation of some fractures, tx will vary ○ ORIF needs ortho f/u ○ No need to know the angles of displacement Urgent consultation (within 30-60 min): open fracture or neurovascular injury, REFER IMMEDIATELY!!! GET ON IT - According to fracture reading → fractures requiring acute action/consultation: - Major trauma, open fractures that could lead to significant hemorrhage (MC life-threatening condition associated with fractures) - Also predisposed to venous thrombosis and pulmonary embolism Ortho referral within few days of injury: all d/t high rate of complications, but you can delay it if there’s no open fracture or neurovascular injury Indications for consult & referral to ortho ○ Understand when they need to be referred though Adhesive capsulitis Diabetes & thyroid disorder SHOULDERS ● Subacromial impingement syndrome & rotator cuff tears are very similar in presentation but one can precede the other and opposite ○ Impingement can lead to a cuff tear; treat this! Eventually irritation of tendon will lead to the cuff tear. Or a partial tear can lead to impingement ○ Supraspinatus tendon MC affected for both of these ○ Weakness will be associated with a couple of conditions: significant in partial tear/complete tear of tendon or a neurological compromise ○ Specific test: Neer’s & Hawkin’s ← both are nonspecific tests because they’re found in BOTH conditions. But the drop arm test (positive for full weakness tear & partial tear) can be used to differentiate between those two conditions, since it’s only found in RTC tears. ○ Rotator cuff is more of an CHRONIC presentation – ongoing, older patient, microtears ○ Any of these conditions can happen to athletes (but an acute problem needs a forceful MOI) SHOULDER IMPINGEMENT ROTATOR CUFF TEARS ● Supraspinatus tendon MC affected ● Can cause rotator cuff tear ● More of an INFLAMMATION, no actual tears ● Cause: repetitive overhead activities MC cause overuse injury ● Presentation: pain with overhead motion & difficult with internal rotation (putting on jacket, bra), nocturnal pain, sense of instability, think of hand dominance/occupation/hobbies ● PE: normal, tenderness over area underneath acromion & AC joint, positive Neer test, positive Hawkin test ● Xrays: 4 views to r/o arthritis, inferior spur, other stuff → AP scapula, Y view, axillary lateral, AP acromioclavicular view ● Tx: activity modification (avoid repetitive overhead motion), PT, NSAIDs/ice ● Supraspinatus tendon MC affected ● Can cause shoulder impingement ● TEARS of one of the shoulder muscles ● Presentation: weakness or pain with overhead movement, difficulty lifting arm, nocturnal pain. Similar findings to impingement syndrome but more pronounced ● PE: weakness if COMPLETE tear, positive Neer, Positive Hawkin, positive drop arm test ● Initial imaging: xray ● Definitive dx: MRI ● Tx: if partial thickness → conservative (PT). If full thickness → SURGERY ● Labral tears: 2 videos on that – be familiar with the different 3 tears and what’s the associated MOI ○ Superior vs Bankart vs Hill Sachs. Know where lesion is specifically SLAP - (superior labrum from anterior to posterior) BANKART HILL SACHS repetitive overhead movements e.g. carpenters, electricians, mechanical wheelchair users ● Sx: radiating pain from anterior shoulder down anterior arm; no distortions of any sort ● Tx: conservative ● More common in males ● Sx: characteristic bulge “Popeye sign”, also “pop” in the arm ● Tx: surgery ● AC separation ○ On PE: it looks like the clavicle is sticking out of your shoulder & actual shoulder looks like it’s dropped ○ 3 different types of grades in terms of classification, 6 total subtypes based on treatment. Why do we care? → because treatment varies ○ Grade 1: may likely not be as obvious so how can we suspect someone has AC separation? What other features we look for: MOI is direct blow to the shoulder. Normal x-ray may be present because it might be a microtear because there’s not a complete tear with distortion in grade 1. ○ Tx for Grade 1 & 2: conservative like ICE, NSAIDs AC SEPARATION ● Acute injury from direct blow to the shoulder (fell directly on ABducted shoulder) ● Grades (3 based on degree of displacement) for classification Normal Grade I: Nondisplaced Grade II: Partially dislocated Grade III: Completely dislocated Stretching or partial tearing of the acromioclavicular joint Complete tear of acromioclavicular joint ligament + there could be some tear/stretching of the coracoclavicular ligament Complete separation of all three ligaments. Complete displacement of the clavicle ● PE: collar bone appears to be “sticking up” shoulder deformity. Also pain, swelling, acute injury → ● Tx: depending on the 6 subtypes Type I & Type II Type III Type IV-VI NSAIDs, rest, ice (+/- sling) Controversial Surgical intervention (increasing displacement) conservative vs surgical treatment ● Shoulder dislocation ○ MC shoulder dislocation is anterior ○ Posterior dislocation sign is Lightbulb sign ○ If someone dislocates their shoulder earlier in life, they’re more likely to have it happen again ○ Make sure to put the shoulder back in place with an acute reduction. Get x-ray to r/o fracture. Additionally, you have to check for PULSES, SENSATION, STRENGTH for neurovascular status. Check it before and after! ANTERIOR shoulder dislocation MC POSTERIOR shoulder dislocation ● MOI: traumatic abduction & external rotation (like from a fall or forceful throwing motion) ● Dx: Y-view x-ray is the best way to see the humeral head displaced inferiorly & medially ● Neuro status MUST BE ASSESSED before & after shoulder reduction ● Be careful – axillary nerve injury is a complication, complete distal neurovascular exam ● Associated with Bankart lesion and humeral avulsion ● Tx: acute reduction & immobilization ● MOI: high energy trauma, electric shock, epileptic seizures ● Sx: arms appear internally rotated and pt unable to externally rotate ● Dx: LIGHTBULB SIGN on AP x-ray ● Tx: acute reduction & immobilization UPPER EXTREMITY ● First half of lecture talked a lot about description of fractures – won’t be shown a ton of x-rays and asked to describe fractures ● One image on clin med portion of the exam but we don’t have to worry about it ● Elbow bone fractures: ○ Significance of anterior and posterior fat pad: ■ if posterior fat pad present there is effusion from hemarthrosis or fluid collecting ■ Anterior fat pads can be normal when visible on x-ray but do a double take! ■ If there is point tenderness whether on ulnar/radial side or over olecranon or epicondyle, suspect a clinical fracture & immobilize the patient until they get to ortho or we can get additional imaging ● Middle of the clavicle is MC for fractures b/c this is where the bone is the weakest & thinnest. Also not close to a joint. As for medial fractures, they’re not as commonly fractures as the middle of the clavicle ● Tx depends ○ NON-OPERATIVE: if non-displaced & NO neurovascular compromise → sling and immobilization x 6 months to let clavicle fuse back together ○ OPERATIVE: open fractures (neuro status has to be established before and after), neurovascular compromise, hemodynamic instability, respiratory compromise If fracture is occult & can’t be seen on x-ray, one way to confirm is to look at these fat pads. On a normal elbow there’s two fat pad. Anterior fat pad is slightly visible but posterior fat pad is never visible on xray. If it is, there’s hemarthrosis which means blood collection w/in joint as a result of a fracture. Hemarthrosis pushes fat pads outward and shadow of it will be seen on x-ray. - Most abnormal fat pads: intraarticular fracture with blood in joint - Small anterior fat pad: can be normal - Larger anterior fat pad: abnormal - Posterior fat pad: virtually always abnormal If fat pad visible on pt w/ acute elbow injury + normal xray then call it an occult fracture – stabilize pt with a splint and send them to orthopedics for CT/MRI. FAT PADS ■ Watch x-ray video ELBOW FRACTURES ǪUICK DESCRIPTION Supracondylar fractures - MC pediatric elbow fracture - MOI: fall on hyperextended elbow - Lateral condyle fracture MC - If single column fracture → tx is urgent referral if open fracture or neurovascular injury - Two column factures → more serious, risk of avascular necrosis with H pattern ○ Be familiar with anatomic locations of nerves ■ Ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and olecranon process ■ Radial nerve is adjacent to the lateral epicondyle (important to note position of radial nerve in relation to the humerus) ● Injury to midshaft humerus → radial nerve involvement ■ Median nerve transverses the antecubital fossa just medial to the brachial artery ○ Ulnar nerve palpation: paresthesia or discomfort (if any neuropathy, numbness/tingling will be on half of the ring finger and pinky) ● Olecranon Bursitis: ○ Bursitis in fracture: limited ROM & inability to lock elbow into extension. On x-ray it will tell you if there’s fracture of olecranon. ○ How to tell if someone has infectious olecranon bursitis vs inflammatory? → FEVER for infectious. Inflammatory has no fever. With infectious, aspiration will help but there may be fever & cellulitic area over elbow as well. ○ Septic bursitis: tx is I&D and IV antibiotics. Suspected if fluctuance over elbow area. BUUUUUT there may also be an inflamed bursa with a superficial infection though, you might not wanna jab them immediately, slow down y’all } OLECRANON BURSITIS ● Carpal tunnel syndrome: ○ Tinel sign and Phalen sign TINEL SIGN PHALEN SIGN ● Presents around bony prominence ● Causes: trauma, infection, arthritis, gout, RA, OA ● Note: differentiate trauma vs septic causes! ○ Septic/infectious will be tender, red, swollen, warm & systemic sx like fever. ○ With trauma, there’s no redness & warmth. ● Sx: focal tenderness & swelling ● Dx: aspiration (or bursal fluid) to r/o infection ○ If >1000 WBC → inflammation ○ If 50,000 WBC → infection (Staph aureus) ● Tx: based on whether inflammatory or infectious ○ If inflammation: rest + elbow pad, NSAIDs, local corticosteroid injection, drainage (runs risk of introducing infection, creating chronic drainage site) ○ If infectious/septic: I&D with IV antibiotics (be careful! You can introduce infection, admit to hospital for IV antibiotics) ● Most common overuse injury of elbow ● Tennis players from overuse of forearm extensor muscles or hitting ball in racquet ● Follows repetitive wrist flexion ● Golf swing, throwing a baseball; overuse of forearm flexor muscles sports ● MOI: repetitive pronation & supination of forearm (backhand) ● Follows repetitive wrist extension or pronation-supination ● Pain lifting objects, opening doors, starting car ● PE: tenderness over lateral epicondyle, pain reproduced by resisted wrist/finger extension ● Tx: activity modification, PT, NSAIDs ○ If severe, call surgery ● May have paresthesia in ulnar nerve distribution ● MOI: overuse syndrome of flexor/pronator mass at medial epicondyle ● PE: tenderness over medial epicondyle, pain reproduced by resisted pronation or flexion of wrist ● Less common and harder to treat ● Tx: rest first line initial tx 6-12 wks, ice, activity mod, PT ○ If severe, shockwave therapy, corticosteroid injections, surgery Past quiz question presentation: Which of the following conditions would most likely be diagnosed in a 45-year-old male, complaining of elbow pain, who recently resumed playing golf after a 3 month hiatus? → medial epicondylitis ● Radial & ulnar neuropathy: ○ Understand presenting sx ○ Radial - wrist drop ○ Ulnar - pinky and 4th finger paresthesia & claw appearance, sensory deficit in that distribution ● Dupuytren’s contracture ○ Know the comorbidities & pathophysiology & what it presents like ○ Comorbidites: tobacco use, alcohol use, diabetes, epilepsy, chronic pulmonary disease, tuberculosis, HIV/AIDs Dupuytren’s Contractures Description Dupuytren’s disease is a benign proliferative disorder characterized by decreased hand function caused by hand contractures and painful fascial nodules ➔ Predominantly white males of Northen European descent ➔ Genetic link; but sporadic cases MC seen Risks Tobacco use , alcohol use , diabetes, epilepsy, chronic pulmonary disease , tuberculosis, HIV/AIDS Sx Initially: Nodular or cordlike thickening of hand tendons fascia Progresses to: permanent flexion & inability to extend the fingers. Will significantly limit ROM & have negative effects on grasping ability. No associated occupational risk Recurrence is possible Radial gutter - Good for hairline fractures with distal radius fractures Volar splint - Minor distal radius fractures ● Won’t be tested on animal/human bites SPINE ● Know dermatomes for spine and be able to tell you what spinal level presents with (dorsiflexion, plantarflexion) ○ Dorsiflexion: L4/L5 ○ Plantarflexion: S1 ● Understand dermatomal distribution and strength testing on it ● Cauda Equina Syndrome: ○ Know symptoms, presentation CAUDA EǪUINA SYNDROME Vignette: months old newborn, this is a congenital condition Newborns/infants: may have no sx, but have legs of unequal length, asymmetric skin folds around groin Older kids: painless limping & waddling gait If untreated, may result in osteoarthritis in adulthood Dx: Barlow and Ortolani maneuver Vignette: teenagers d/t growth plate Mild: intermittent groin pain (can feel like it’s coming from the thigh or knee), pain worsens with activities, can cause limp Severe: unable to walk, leg appears shorter & externally rotate, difficult to do internal rotation & abduction Vignette: age group 4-10 y/o Childhood hip disorder that occurs when the blood supply to the head of the femur gets disrupted (for unknown reasons) leading to death or necrosis of the tissue (avascular necrosis) Children have: limp & hip pain (sometimes referred to knee), pain gets worse with activity (especially abduction and internal rotation of leg), muscles may atrophy (leg looks smaller than normal one) ● Hip Fractures: ○ Understand location of fractures intracapsular or extracapsular for long term complications ○ X-ray would be the way to differentiate Intracapsular Fractures Extracapsular fractures ● Location: region of femoral head & neck within joints capsule of the hip ● ⬆ Risk of avascular necrosis & displacement of femoral head – the retinacular arteries from the medial circumflex femoral artery are disrupted → no adequate supply ● Imaging findings: loss of Shenton’s line (line drawn from the inferior border of the superior pubic rami along the inferomedial border of the neck of the femur), prominent lesser trochanter d/t external rotation of the femur compared to contralateral side, shortening/angulation of femoral neck ● Location: outside fibrous joint capsule of the hip (distal femoral neck to the intertrochanteric/ subtrochanteric area) ● Less likely to undergo avascular necrosis b/c the arteries are not disrupted → maintains fxn ● Imaging findings: typically intertrochanteric fractures extending b/w greater & lesser trochanter OR subtrochanteric fractures found distal to the trochanters in the subtrochanteric region Valgus = MCL Varus = LCL ● Avulsion will tear the MCL and involve the medial meniscus. The lateral meniscus makes sense for it to be injured BAKER CYSTS ● Unhappy Triad: Know what that is ○ Commonly tested injury pattern on the knee; multi-structure injury comprising the: ■ ACL ■ MCL ■ Medial meniscus ○ MOI: Lateral blow or valgus force to the knee while foot is fixed on the ground → resulting valgus or rotary force to the knee tears the components of the unhappy triad together ● Patellar Bursitis vs Osgood Sclatter: ○ Briefly review patellar bursitis (it may help with differentials) and its presentations, and Osgood-Schlatter presentation PATELLAR BURSITIS OSGOOD SCHLATTER Acute bursitis: Pain, swelling, redness that is exacerbated by movement - Tends to be seen in children Chronic bursitis: d/t repetitive overuse, microtrauma, rheumatoid arthritis (RA) - Seen in older elderly men Palpable lump below the knee that is painful with physical activities (running, jumping, squatting, going up/down stairs) or when knee gets hit by something - SEEN IN YOUNG ADOLESCENTS/CHILDREN 9-15 y/o ● Baker Cyst: ○ most common cause is meniscus tears. It would allow the fluid to leak in and form the cyst ○ A condition that mimics a ruptured baker’s cyst: DVT because of its posterior location. Typically when the bakers cyst is large enough it could rupture and cause redness, swelling, and warmth to the calf. Very commonly seen clinically so it must be differentiated. History of meniscus tear would be important ■ With this suspicion, the patient would still receive an ultrasound for both ○ For intact Baker’s cyst, there’s no inflammatory response that is seen in a DVT ● Osgood-Schlatter: ○ Remember that it happens in adolescence, and NOT adults because of the formation of tibial tuberosity at that age. In adulthood, it’s already ossified so there’s not much concern. ■ Age of onset: b/w 9-15 y/o – tuberosity hasn’t ossified yet ■ Common in young adolescents who play sports (patellar ligament excessively strains, inflammation of the ligament leading to traction apophysitis) ■ Ossification center can crack; results in callus during healing – resolves itself as ossification continues ● Extrusions of synovial fluid; found in adults & children ● Associated with: trauma, meniscus tears, rheumatoid arthritis, osteoarthritis ● Typically Asx, can present with chronic, painless bulge behind knee ○ But acute sx if cyst ruptures or compresses on nearby structures ○ Ruptured cysts: calf pain, warmth, erythema & swelling that may be confused w/ DVT ■ USE ULTRASOUND to distinguish !! ● Trochanteric bursitis: ○ When small bursa covering greater trochanter gets inflamed ○ Repetitive actions like climbing the stairs ○ Sx: LOWER EXTREMITIES/FOOT ● Lower Extremity Peripheral Nerve Syndromes ○ Fasciotomy (to relieve pressure & reestablish blood flow), can be left open for few days until cause of pressure is tx’d ○ If cause is a bad cast: remove the mf cast → spontaneous recovery ○ In a busy slide from uptodate, it included all the nerve compressions. Know the sites of injury and the area that is typically affected. VERY IMPORTANT ● Achilles tendinitis/tendon rupture ○ Ddx: gastrocnemius strains will present with very similar sx. How to differentiate it? → Thompson test (you squeeze the calf to r/o tendon rupture – foot should plantarflex!) Positive Thompson seen in Achilles tendon rupture. ○ Sx will be very similar. Achilles may be lower pain and gastrocnemius might be higher but Thompson test is helpful for complete tear (maybe not for partial tear). You’d see bruises for complete fractures aka ecchymosis. ● Metatarsalgia and plantar fasciitis: ○ On presentation, how are they different? Both of them can be overused. Plantar fasciitis can have osteophytes first. ○ However, on the PE: plantar fasciitis pts can’t walk when they get up in the morning and metatarsalgia is more due to overuse and stress-related (they have pain at the END of the day) METATARSALGIA PLANTAR FASCIITIS Classification of Arthritis Inflammatory Non-inflammatory I 1 I ( Seropositive } ( Seronegative } ( Infectious: } [ Crystal induced} Rheumatoid arthritis Ankylosing spondylitis) Psonatic Arthritis eae inflammatory Bowel Disease Arthritis  Seropositive +RF, +anti-CCP Seronegative -RF, -anti-CCP Infectious Crystal-induced E Rheumatoid arthritis anti-CCP SPECIFIC for RA Anyklosing spondylitis HLA-B27 strong association Septic arthritis Staph aureus MC WBC > 50,000 Gout (monosodium urate crystals, NEGATIVE BIREFRINGENT) Lupus Anti-Smith + Anti-dsDNA relatively specific for Lupus Psoriatic arthritis Osteomyelitis Staph areus MC Pseudogout (calcium pyrophsophate disposition → CPPD, POSITIVELY BIREFRINGENT) Scleroderma anti-scl 70 antibodies Reactive arthritis (SHY chiCS) include: SHigella, Yersinia, CHlamydia, Campylobacter, Salmonella CAN’T SEE, CAN’T PEE, CAN’T CLIMB A TREE Vasculitis IBD arthritis Crohn’s + ulcerative colitis Sjogren’s Anti-Ro, Anti-La ARTHRITIS (inflammatory) ● Know antibodies and testing to differentiate in this flowchart ○ Seropositive means positive for RF or anti-CCP ○ All of these conditions can test positive for either RF or anti-CCP! Hence why diagnosing rheumatology conditions is difficult. ○ Seronegative is NEGATIVE for either RF or anti-CCP. None! ○ What other marker is positive in these conditions? → HLA-B27 (most of these can be positive for this, but it’s not definitive) and ANA (nonspecific enough that it will likely be positive in inflammatory conditions) ○ There’s one condition of the four with a very strong association HLA-B27: ankylosing spondylitis, young male, stiff back pain is a very classic presentation ○ Recent infection with Shigella or Chlamydia or Salmonella + conjunctivitis or arthritic sx + HLA-B27 = reactive arthritis ● Osteoarthritis: ○ Is non-inflammatory ○ Imaging findings: know what the image of the joint would look like ■ Marginal osteophytes, narrowing of joint space ■ ⬆ density of subchrondral bone ■ Subchondral cysts Diagnostic tests for dry eye: Schirmer test, ocular staining surface, tear breakup time Labs: ⬇ WBC, ⬆ globulins, ⬆ESR, NORMAL or ⬆ CRP, autoantibodies: Anti-Ro, Anti-La - If interstitial nephritis: proteinuria - If glomerulonephritis: hematuria SJOGREN SYNDROME ● Sjogren’s: look for dryness, xerostomia, dry eye ○ Tests: anti-ro, anti-la ● Infectious: ○ Septic arthritis (CANNOT MISS IT, so there will be questions on it). This is an emergency! Don’t be fuckin around Do not send to outpatient. Septic joint = white count > 50,000 on joint aspiration & severe pain with ROM and systemic sx of fever + redness + warmth to the joint. Admit them to the hospital for IV anbx ■ MC bacteria causing septic joint is Staph aureus because it spreads from the skin ○ Osteomyelitis is also considered infectious. Can lead to septic joint OR vice verse with septic arthritis can lead to osteomyelitis SEPTIC ARTHRITIS OSTEOMYELITIS - Gonococcal arthritis in females MC & in sexually active young adults - MC nongonococcal organisms: Staphylococci (Staph aureus) – esp in RA pts Hallmark: acute onset of monoarticular joint pain, erythema, heat, immobility - Other sx: limited ROM, effusion, erythema, increased warmth around joint; febrile pt; MC Staphylococcus aureus MC microorganism that lives on the skin & can invade the skin and spread contiguously to the bone Sx: - Acute: Pain at site of infection, fevers, depending on location → may affect use of bone - Chronic: Prolonged fevers, weight loss → chronic inflammatory state ● Condition characterized by hyperuricemia & deposition of monosodium urate crystals causing attacks of acute inflammatory arthritis ● Risks: males > females ● Causes: ○ Diet → purine rich foods like shellfish, anchovies, red meat, high-fructose corn syrup beverages ○ Meds → Pyrazinamide, Loop diuretics, Aspirin, Thiazides, Ethambutol GOUT affects single joint in nongonococcal MC affected joints: knee & hip for adults (but any joint may be involved), hip for children Labs: joint fluid analysis (synovial fluid leukocyte count elevated >50,000 cells/mm3 + polymorphonuclear cells), blood cultures, culture of possible extra-articular sources of infection - Elevated WBC count - ESR, CRP (elevated) can help monitor tx response - If suspected gonococcus, perform NAAT on synovial fluid Imaging: - radiograph of joint to r/o osteomyelitis, fractures, inflammatory arthritis - MRI: bony erosions with marrow edema suggest acute intraarticular infection - CT scan: early dx of infections of spine, hips, sternoclavicular, sacroiliac joints - Ultrasound: helpful for joint effusions Labs: CBC showing ⬆ WBC, ESR, CRP X-rays: thickening of the cortical bone & periosteum, elevation of the periosteum, loss of normal architecture especially trabecular architecture, osteopenia (loss of bone mass – evidence when half of bone matrix is destroyed) Bone scan or MRI: confirm presence of osteomyelitis & identify an abscess Bone biopsy: may be done to identify the pathogen & confirm the diagnosis ● Gout: Crystal-induced arthritis ○ Classic presentation: things that can cause gout → dietary and meds & on diagnostics: the crystals are different and they’re different in terms of birefringent ○ Typically will not be giving high fever ○ Clinically there won’t be gouty joints, but know it textbook wise in terms of arthrocentesis Description Inflammatory cause of back pain that commonly affects young males - Causes pain in the spine, sacroiliac joints, and entheses S/sx Gradual onset, morning stiffness, improves w/ exercise, DOES NOT improve w/ rest Extra-articular manifestations: uveitis, psoriasis, aortic root dilation → aortic dissection Dx Labs: CBC may show - Microcytic hypochromic anemia - ESR ⬆ - CRP ⬆ - HLA-B27 Imaging: x-ray or MRI showing erosions, sclerosis, narrowing of joint space, characteristic Bamboo spine d/t syndesmophytes (bony growths that often occur in the spine and can cause fusion of the joints) ● SLE: ○ What’s the advice you’d give to patients with Lupus? → don’t go out to the sun. Their photosensitivity can exacerbate their symptoms LUPUS Definition Systemic (any tissue/organ undergoes inflammation), relapsing (periods of illness) & remitting (periods of few or no sx) autoimmune disease. Lupus develops when the immune system recognizes its own nuclear antigens as foreign - Impaired self-tolerance - Antigen-antibody complexes deposit into different organs like kidney, skin, joints, heart Sx + Dx Criteria Classic presentation: female of reproductive age esp of African-American or Hispanic descent Dx: 11 key sx + findings to remember for Lupus (4 groups) THE SKIN: 1. Malar rash “Butterfly rash” after sun exposure 2. Discoid rash – chronic erythematous rash, plaque-like, patchy, scaly 3. Photosensitivity (avoid the sun)!– rashes to exposed areas MEMBRANES: 4. Ulcers in mouth/nose 5. Serositis – pleuritis, peritonitis, pericarditis, myocarditis, Libman-Sacks endocarditis EXTRAGLANDULAR 6. Arthritis (2+ joints) 7. Kidney damage – diffuse proliferative glomerulonephritis 8. Neuropsychiatic conditions: headaches, seizures, psychosis, depression BLOOD 9. Autoantibodies against blood components 10. Antinuclear antibody or ANA (sensitive, NOT specific) 11. Three other autoantibodies: Anti-Smith + Anti-dsDNA relatively specific for Lupus anticardiolipin, lupus anticoagulant, anti-betas glycoprotein Drug-induced Lupus: positive ANA & anti-histone antibodies w/ negative anti-dsDNA antibodies that develops after meds (SHIPP – Sulfonamide, Hydralazine, Isoniazid, Procainamide, Phenytoin) - Characterized by abrupt onset of Lupus sx: fever, arthralgias, pleuritis - Does not affect the oral mucosa, CNS or kidneys X-rays: joint deformities in Lupus usually nonerosive unlike RA ● Unlike ortho and other conditions that are acute, these are more gradual progressions (e.g. ankylosing spondylitis) Their progressions can be in years and not months for the ossification to process. Keep this in mind! ● Rheumatoid arthritis vs osteoarthritis: ○ Know how to differentiate and what specific PE findings they both have (make sure to look over that) RHEUMATOID ARTHRITIS OSTEOARTHRITIS Serum antibodies: - anti-nuclear antibodies (ANA) - myositis-specific antibodies like anti-Jo-1, anti-Mi-2, anti-SRP - ⬆ serum levels of muscle enzymes like aldolase & creatine kinase Serum antibodies: - non-specific autoantibodies like ANA - myopathy-specific antibodies like anti-Mi-2, anti-Jo-1 - ⬆ levels of muscle enzymes POLYMYALGIA RHEUMATICA FIBROMYALGIA AUTOIMMUNE CONDITION: Strong association with Giant Cell arteritis - Affects women > 50 y/o, muscles themselves are NOT inflamed or weakened unlike other pathologies - Activities associated: hard to get out of bed or up from a chair as well as lifting the arms above shoulder height Labs: - ⬆ inflammatory markers (high ESR, high CRP) - Muscle enzymes remain normal CHRONIC CONDITION - Common women 20-50 y/o - Sx: related to mood, sleep, fatigue: difficulty concentration “fibro fog”, wake up unrefreshed + headache - Decreased levels of serotonin & ⬆ substance P - Dx: clinical Labs: no associated abnormalities ● Polyarteritis nodosa: ○ Be able to answer the framing questions for this condition. Focus on the FǪ ○ Spares the lungs Polyarteritis Nodosa Description A necrotizing arteritis of medium-sized arteries - Organ involvement: involving the skin, peripheral nerves, mesenteric vessels (including renal arteries), heart, and brain but spares the lungs - Associated with hepatitis B viral infection Sx Common sx: fever, abdominal pain, extremity pain, livedo reticularis, mononeuritis multiplex, anemia Dermatologic manifestation: Livedo racemosa, subcutaneous nodules, and skin ulcers reflect involvement of deeper, medium-sized blood vessels Dx Labs: elevated acute phase reactants (ESR or CRP or both) ● 1-2 questions on it BONE TUMORS BENIGN MALIGNANT OSTEOCHRONDROMA - Males <25 y/o - Growth plate tissue and mutations exotosin 1+2. Develops in metaphysis of long bones (distal femur and proximal tibia) - Dx: lateral bony projection from continuous marrow cavity and exotoses with visible cap (hyaline cartilage) on imaging GIANT CELL TUMOR - Common 20-40 y/o - In knee region epiphysis of long bones distal femur and proximal tibia - Dx: multicystic bone lesions that looks like soap bubbles OSTEOBLASTOMA - Common in males - Forms nidus - Dx: large nidus >2 cm - Pain unresponsive to NSAIDs OSTEOID OSTEOMA - Males <25 y/o - Forms nidus - No malignant transformation - Associated with Gardner syndrome - Dx: small nidus <2 cm - Tx: NSAIDs help pain OSTEOSARCOMA - MC primary malignant bone tumor - Males <20 y/o - Dx: sunburst appearance on imaging and Coidman’s triangle EWING’S SARCOMA - Male caucasian teens <15 y/o - Diaphysis of long bones and pelvis flat bones – femur and sacrum - Aggressive with early mets but good prognosis with chemo - Dx: onion skin appearance on imaging CHONDROSARCOMA - Elderly - Dx: patchy lytic lesions “Moth eaten piece of cloth” on imaging IMAGING ● Be familiar with actual anatomy through imaging. If he went over any spine anatomy, be prepared to answer those questions ○ Removing the lamina to operate (pt is on their stomach) ○ If I’m having swelling in the said joint, I’ll have weakness, swelling & instability! ○ Neuroforamen canal is extremely important – there’s nerves there. Every level has a neuroforamen canal and we have spinal nerves that come out of it which correspond to the dermatome ○ What happens when we get compression on nerve? – corresponds to dermatome map, pain, weakness ● Paraspinal muscles are important to determine whether or not we have a stream ● Here we have the spinal nerve roots coming off the spinal cord ● Look at canal and alignment, each vertebrae & disc (in sagittal view) ● The disc has the gelatin-like material that degenerates with age ● Diffusion helps the bones fuse into one large vertebra ● We try to remove the disc herniation (we take out the lamina aka laminectomy to get to there to get to the nerve root) ● We dissect right in the midline where the spinous process and we operate on whichever sides ● It’s important to dissect that bone completely to get to the foramen If we get a tear b/c of injury, the disc has potential to bulge out of their encapsulation. Sometimes it can push into the central canal and you can see the progression here: neuroforamen ● Tx: NSAIDs ● When we look at other different types of plain films, we use them a lot for lumbar spines ● Axial back pain = pain related to spine (central) ● PARS DEFECT OF SPINE = Scottie dog gets a broken neck. Can cause pain and lysis in vertebra https://radiopaedia.org/cases/normal-lumbar-spine-mri?lang=us ● Anterior spine looks good, no herniations ● No signs of inflammation in the bone ● Then look at axial view ● Best imaging to use based on pt sx or injury ● Professor Jahn will not have any imaging questions ● 50 clin med 25 pharm, 15 A&P, 10 imaging – no more than 100 questions The white is CSF