1.      Whiplash treatments*

1. Short period of Rest, soft protective collar holding neck in slight flexion, activity encouraged asap
2. analgesics to relieve acute pain, NSAIDs soon after injury esp with preexisting degenerative dz. 
3. Cold initially, avoid heat early on (may ↑ inflamm), but is helpful later
4. when acute pain begins to subside: isometric and gentle ROM exercises, gradually d/c collar, PT if symptoms persist after 4-6 wks
5. surgery is rarely indicated and often unsuccessful

1b. Algorithm for whiplash (cervical strain)*

(fig 3-19 pg 40)

1. Neuro exam; AP & lateral Xrays →
2. If nerual deficit or abnormal film (rare) → Brace, & immediate referral for further imaging

   If normal neruo exam and X ray → soft collar 1-2 wks,        ice (30 min every hr) for 24-48 hr, analgesics, rest,            NSAIDs 2 wks → (if not better) DC collar, add PT for          2-4 wk, change NSAID, exercise → (if not better) refer

2.      Common locations of skin cancers*

Basal cells are cells that line the deepest layer of the epidermis

• SCC: cells that compose most of the epidermis. 
• Typically in sun exposed (face, ears, scalp, neck, upper trunk, lower legs) areas of fair skinned individuals. 

3.      Description of basal cell cancers*

[image]

Description of BSC: Waxy or "Pearly" papule w/telangiactatic vessels easily visibleerythematous patch>6 mm or non-healing ulcer (various duration) In sun exposed areas (face, ears, scalp, neck, upper trunk, lower legs) & they tend to bleed. 

• Nodular (most common variety): Waxy papules w/central depression, pearly appearance, erosion or ulceration & bleeding w/rolled (raised) border 
• pigmented: stippled pigmented nodules 
• back/chest: reddish, somewhat shiny, scaly & patchy. 

4a.      S/S of herpes simplex 1*

[image]

Herpes Simplex 1 S/S

• Burning, stinging

• Neuralgia before or w/attacks

• Lesions: small grouped vesicles on:border of lips,penile shaft, labia, Perianal skin, buttocks                                                                                                             • Might have some regional lymphadenopathy

• Lesions Crust & heal in 1 wk

• Recurrent small fluid filled vesicles on erythematous base

• In orolabial & genital areas

4b.      S/S of herpes zoster*

[image]

  S/S of herpes zoster:

• Unilateral Lesions: grouped, tense, deep-seated vesicles distributed unilaterally along a dermatome – usu on face or trunk 

• pain preceeds eruption by 48hrs or more & ↑ in intenstiy after the lesions have gone (Eruption lasts 2-3 wks)

• Regional lymphadenopathy  

• direct fluorescent antibody positive

4c.      S/S of scabies*

[image]

s/s scabies:

• Itching can be severe

• Generalized excoriations w/small pruritic vesicles, pustules & runs or burrows

• Usually in web spaces, on heels of palms, wrists, elbows & around axillae 

• Red papules or nodules on scrotum , penile glans & shaft                                      • Usu spares head & neck

• mites, ova & dots of feces on microscopy

• Burrow: short irregular mark: 2-3 mm long - the Width of a hair

4d.      S/S of tinea corporis*

[image]

S/S of tinea corporis:

• Ring shaped erythematous lesion w/scaly border & central clearing on exposed skin surfaces (face and arms) or trunk.

• Sometimes w/hyperpigmentation

• Itching (maybe)

• KOH prep of scrapings (spaghetti and meatballs)

• Confirm by culture prn

4e.       S/S of impetigo*

[image]

S/S of impetigo:Macules, vesicles, bullae, pustules & honey-colored - once removed leave denuded red areas. Face usu involved. Labs: gram stain & culture confirm dx.

• Ecthyma is a deeper form d/t staph or strep w/ulceraticons, scarring usu on extremtities

Prevention: sunscreens; prophylactic po acyclovir 200mg, valacyclovir 500mg bid (Valtrex) or Famciclovir, 250mg bid - 24hrs prior to surgeries/light exposure          Daily prevention: acyclovir, 400 mg bid (for 5-7 years) - reduces outbreaks by 85% - 50% ↓ risk of transmission.                                                                                  Outbreak txt: Acyclovir (200mg X5d or 800mg tid), Valcyclovir(1000mg bid), Famciclovir (250mg tid)for 7-10d. Recurrent herpes usu mild: don’t need txt - add potent topical steroid(tid) to ↓ pain, size, duration of outbreak.  IN immuno pts only gential dx & severe orolabial lesions are treated. 

• Acyclovir (800mg/5d), famciclovir(500mg tid), Valacyclovir(1g tid):7d 
• Initial severe pain:nerve blocks 
• Prednisone: 60 mg/d:↓acute pain:tapering 3wk course (non-immuno pts only)   
• Local txt: calamine lotion
• postherpetic neuralgia:prevent w/early,aggressive anti-virals. Lesions:capsaicin ointment 0.025-0.075% or Lidoderm topical patches     
• Chronic neuralgia: regional blocks; Amitriptyline 25-75mg qhs; Gabapentin up to 3600mg (start 300tid) adjunct pain relief prevention: vaccine(pts>60) NOTE: Immuno pts should continue antiviral txt until lesions crust(up to 2wks)-IV antivirals if dx progresses

• Kill the scabies mites

• Control dermatitis (can last for mths after mites gone)

• Bedding/clothing cleaned or closed up in plastic bags for 14d

• If there is 2° pyoderma: systemic antibiotics

• All people in family must be treated

• Permethrin 5% cream: very effective & safe (1 app. 8-12hrs) repeated 1 wk 

• Txt pregnant women only if they definitely have scabies

• Pts will continue to itch for a few wks post txt use triamcinolone 0.1% cream to resolves the dermatitis

read pg 138 for immunopts txt

Responds to most antifungals.                                                                          OTC Topicals: Miconazole 2%, Clotrimazole 1%, Betenafine or terbinafine (for 1-2 wks past clearing) Systemics: Griseofulvin (ultramicrosize) (250-500mg bid 4-6 wks) or Itraconazole (200mg qd X1 wk)

• Soaks/scrubbing – unroof lakes of pus under thick crusts

• Bacitracin, mupirocin, retapamuin (topical) for sm. areas

• Usu PO antibiotics: cephlexin (250mg QID) or doxycycline (100mg BID)

• Txt for CA-MRSA if it is cause of impetigo

• Bleach (baths for family members) & to clean house reduces the spread

• Do not share towels

6a.      Etiology & pathophys of herpes simplex virus*

Patho: Infection occurs following exposure of abraded skin/mucosal surfaces. The virus travels to the sensory ganglion, where it replicates & establishes latency. Recurrence occurs when the virus subsequently migrates along the peripheral nerve, replicates & produces a local lesion. Lifelong latency & periodic recurrences are hallmarks of herpes simplex virus infection. These reactivations can follow exposure to UV light, stress, orofacial surgery, fever, hormonal changes, immunosuppression & infection. 

Etiology: >85% & 25% of adults have serologic evidence of HSV-1 & hsv-2 infection respectively. Nowadays, 40% of new genital herpes due to HSV-1

7a.      S/S of basal cell carcinoma*

Waxy or "pearly" papule w/telangiactatic vessels easily visible. Erythematous patch > 6 mm or non healing ulcer (of various duration) In sun exposed areas (face, ears, scalp, neck, upper trunk, lower legs) & they tend to bleed.

• Nodular (most common variety): waxy papules w/central depression, pearly appearance, erosion or ulceration & bleeding w/rolled (raised) border 
• pigmented:stippled pigmented nodules
• back/chest:reddish, somewhat shiny, scaly & patchy. 

The pearly appearance is the most diagnostic feature. one should stretch, squeeze & palpate affected skin to estimate size & depth of tumor. Oblique illumination highlights surface changes (i.e. rolled border)

7b.      S/S of squamous cell carcinoma*

[image]

S/S of SCC: It may originate from actinic keratosis: small, red, conical, hard nodules that occasional ulcerate.

Sign: Nonhealing ulcer or warty nodule. 

P/E: Careful examination of lymph nodes & Palpation of the lips is essential to detect hard or indurated areas that represent early squamous cell carcinoma.

7c.      S/S of actinic keratosis*

[image]

      S/S of actinic keratosis: small, red, conical, hard nodules that occasional ulcerate

7d.      S/S of melanoma*

[image]

 S/S of melanoma: Superficial spreading melanoma: 2/3 of all melanomas arising on intermittently sun-exposed skin: 

-flat or raised (any pigmented lesion that has just changed appearance is suspect

-may have multiple colors (red, white, black, blue) & irregular borders in which pigment appears to be leaking into the normal surrounding skin

-"ABCDE" mnemonic -"asymmetry, border irregularity, color variegation, diameter(>6mm), evolution (most important historical reason for close eval & refferal)". 

-Bleeding & ulceration are ominous signs.

8.      Risk factors for skin cancer*

fair skin, h/o sunburns, excessive sun exposure, sunny or high-altitude climates, moles, precancerous skin lesions, familial or personal h/o skin cancer
weakened immune system, exposure to certain substances (arsenic), increasing age

9.      Comorbidities for seborrheic dermatitis*

[image]

Comorbidities for seborrheic dermatitis:

Psoriasis is #1 but also commonly found in pts w/parkinson's, HIV or those who are acutely ill. 

11a.      Uses for the following meds: Retin*

refractory & severe cystic acne (isotretinoin)
acne related folliculitis
acne rosacea
freckles, lentigens
psoriasis (tazarotene gel)
discoid lupus (recurrence common)
cutaneous t cell lymphoma (used w/puva for progressing dx)
lichen planus (oral & cutaneous)
poor skin tecture
prep for procedures (laser txt & facial surgeries)

11b.      Uses for the following meds: Benzoyl peroxide*

11c.      Uses for the following meds: mycostatin (aka nystatin)* 

11d.      Uses for the following meds: atarax (aka Hydroxyzine)*

1. systemic txt for cold acute or chronic urticaria 
2. itching caused by various allergic conditions
3. tension & anxiety
4. inducing sedation prior to or after anesthesia.

an H1 blocker

12.      Treatment for shingles*

• Acyclovir (800mg/5d), famciclovir(500mg tid), Valacyclovir(1g tid): 7d
• Initial severe pain: nerve blocks
• Prednisone:60 mg/d: ↓acute pain:tapering 3 wk course 
• local txt: calamine lotion  
• postherpetic neuralgia: Prevent w/early, aggressive anti-virals;
• Lesions: capsaicin ointment 0.025-0.075% or Lidoderm topical patches
• Chronic neuralgia: regional block; Amitriptyline 25-75mg qhs; Gabapentin up to 3600mg (start 300 tid); adjunct pain relief prevention:vaccine (pts>60) 

13.      Conditions that favor external genital warts*

[image]

    Conditions that favor external genital warts: 

D/to HPV infection that is secondary to syphillis or AIDS 

14.      Treatment of bleeding skin lesions*

Typically bleeding skin lesions represent melanoma, basal cell carcinoma or scc. A biopsy should be done immediately to confirm dx. Txt for each are as follows:

Melanoma: Excision:“when in doubt, cut it out” → Send to histology if (+) check the margins → re-excise; leave clear margins:1-3 cm → Sentinel lymph node biopsy: for staging (lesions > 1 mm thick) → Refer to skin cancer center

BSC: Surgical excision to stop proliferation. Curettage usu w/ electrodesiccation: ↓usefulness in high-risk areas (i.e. head & neck) w/granulation leading to atrophic, white scars. Mohs surgery:best long-term cure rates (98-99%) Local therapy w/chemo & immune-modulating agents as last resort. Aggressive therapy is needed for variants: micronodular, infiltrating, or morpheaform BCC.

SCC: Excision - Mohs surgery (esp. w/↑-risk lesions/recurrent tumors). All txts must be followed up frequently starting at 3mnths 

15a.      S/S of pityriasis rosea*

[image]

S/S of pityriasis rosea: Oval, fawn colored scaly plaque eruptions (<2 cm along body folds) w/crinkled “cigarette paper” scale attached at periphery & free at center. Follow cleavage lines on trunk (“Christmas tree” distribution). Often proximal parts of extremities. NOTE: Initial lesion is a Herald patch. Its larger than later lesions & occurs before the general eruption by 1-2 wks, lasts 6-8 wks & heals fine

15b.      S/S of tinea versicolor*

[image]

S/S of tinea versicolor: Velvety tan, pink or white macules that do not tan resulting in hypopigmentation. Fine scales only seen by scraping & viewing under microscope

On trunk, upper arms, neck & groin. KOH yeilds lrg, blunt hyphae & thick-walled budding spores ("sketti & meatballs").

15c.      S/S of congenital syphilis*

• Syphilis in pregnancy
  • can lead to spontaneous abortion, stillbirth, premature delivery, or perinatal death. It can also cause significant morbidity during infancy, childhood & adolescence. A very strict follow-up of pregnant women before delivery & an active approach to identify & txt exposed neonates born to infected mothers is recommended.
• Early onset congenital syphilis
  • Early manifestations vary & involve multiple organ systems. The most striking lesions affect the mucocutaneous tissues & bones. Mucous patches, rhinitis & condylomatous lesions are highly characteristic features of mucous membrane involvement in congenital syphilis.
  • Nasal fluid is highly infectious. Snuffles are followed quickly by a diffuse maculopapular desquamative rash that involves extensive sloughing of the epithelium, particularly on the palms & soles & around the mouth & anus. In contrast to acquired syphilis, a vesicular rash & bullae may develop. These lesions are highly infectious.
  • Hepatomegaly is reported in almost 100% of cases & biochemical evidence of liver dysfxn is usu observed.
• Late-onset congenital syphilis
  • Scarring from the early systemic dx causes late manifestations of congenital syphilis.
  • Manifestations include neurosyphilis & involvement of the teeth, bones, eyes, and the eighth cranial nerve.

15d.      S/S of psoriasis*

[image]

S/S of psoriasis: there are often no sxs but itching may occur & be severe.

• If lesions appear they are red, sharply demarcated plaques covered w/silvery scales. 
• Nail findings: pitting & onycholysis (separation of nail plate from bed).  Pitting in nails is highly assoc.w/psoriasis. 
• Assoc. arthritis most common is distal & oligoarticular. Rarely, rheumatoid type (-rhem. Factor)
• The combo of red plaques w/silvery scales on elbows & knees (extensor surfaces) w/scaliness in the scalp or nail findings is diagnostic. 
• Do a thorough joint exam!

15e.      S/S of varicella *

P/E:  Rash (characteristic rash appears in crops - each lesion starts as a red macule & passes through stages of papule, vesicle, pustule, & crust. The vesicle on a lesion's erythematous base leads to its description as a pearl or dewdrop on a rose petal). The hallmark is the simultaneous presence of different stages of the rash. Some lesions may appear in the oropharynx. Lesions usu crust by 6 d, & heal by 16 d. 

16.      Treatment for cystic acne*

[image]

Txt for cystic acne : Isotretinoin (aka Accutane) is a vit A analogue used to txt refractory severe, cystic acne - requires informed consent) should be offered before pt has significant scarring. Do 2 serum pregnancy tests BEFORE starting drug & qmth after that. Dosage: 0.5-1 mg/kg/d for 20 wks. S/e: dry lips, nosebleeds, dry eyes, Depression, ↑tg (25% of pts), Hypercholesterolemia (15%), ↓ LDL (5%) LFTs, Serum glucose may be ↑, Myalgias & if headache: check for pseudotumor cerebri. Absolutely contraindicated during pregnancy, therefore 2 forms of bc must be used during txt. labs: Before txt & 4 wks post therapy initiation: Cholesterol, Tg, LFTs

17.      Cancers caused by sun exposure*

18.      Management and diagnosis of head lice (pediculosis capitis)*                

Diagnosis

• All types are itchy

• Head & body lice look similar: 3-4 mm long

• Found on scalp (may look like small pussywillow buds on hair close to neck)

• h/o sharing hats or combs; epidemic among kids of all socioeconomic classes in elementary school

TXT: 

• Head lice: Permethrin 1% rinse(Nix)-OTC Txt of choice: Apply to scalp & hair (on 8 hrs) NOTE: high resistance

• Can use Ovide, very effective but flammable: apply outside

• Eyelashes: apply thick layer of petrolatum bid X 8d; pluck off remaining nits

19a.      S/S of stasis dermatitis*

[image]

Current's (referred to as ulceration): Ultimately ulcers are formed via this mechanism: chronic edema is followed by dermatitis, which is often pruritic then hyperpigmetation, skin breakdown & sclerosis of skin of the lower leg. Ulcer base may be clean but it often has a yellow fibrin eschar.

Skinsight.com: Stasis dermatitis is skin irritation & breakdown d/t fluid accumulation under the skin from dx (venous insufficiency, heart failure, etc.)

• Itching & red, dry areas are usu the 1st sxs 
• The inside ankle area is often 1st affected, gradually involving the lower leg up to the knee. The skin may appear shiny or have reddish-brown patches.
• Swelling (edema) is usu present, but in chronic cases of stasis dermatitis, there is gradual tightening & scarring of the skin leading to hard & sometimes tender areas.
• In severe cases of stasis dermatitis, the skin breaks down w/oozing, crusted areas & ulceration. White, shiny scars are often left after healing.
• In long-standing cases, there may be significant thickening & darkening of the skin from rubbing.

19d.      S/S of dermatophyte infection (i.e. tinea infections)*

Fungal infections overview: Dx is based on location, characteristics of lesions & lab work (results from a scaping in 10% KOH prep)

• tinea versicolor: oval, fawn shaped lesions causing hypopigmentation (not tanning)
• tinea cruris (jock itch): itching (serious) in intertriginous (skin fold) areas; red lesions w/Sharply demarcated. Check feet for infection that moved up leg.
• tinea corporis (ringworm d/t Trichophyton rubrum):ring shaped erythematous lesion w/scaly border & central clearing on exposed skin surfaces (face and arms) or trunk.Itching (maybe).
• tinea pedis (athlete's foot): itching, burning, stinging or scaling on palms or soles.  Nails may be discolored or thickened w/crumbling of the nail plate. The sole/heel: may have grouped vesicles (bacterial infection) or may appear as Asymptomatic scaling Progressing to fissures extending over feet in a "moccasin" distribution. toe webs: scaling & fissuring w/sodden maceration. Fungus can be seen in skin scrapings under microscope. 

19e.    S/S of seborrheic keratosis*

[image]  

 S/S of seborrheic keratosis:

• benign beige-brown or black, 3-20mm, w/warty appearance
• p/e - appear to be "stuck on" to the skin
• common in elderly

20.      Treatment of poison ivy*

[image]

Txt of poison ivy: 

Prevention: Remove allergens by immed. washing w/water & dial soap (w/in 30min) & Avoid exposure by use of clothes, gloves or barrier creams (Stokogard, Ivy Shield, hydropel) Acute weeping dermatitis: cool compresses, Calamine lotion btwn wet dressings (30-60 mins - several/d) - good for extremity lesions Potent topical steroids (gel/cream) w/taper to suppress dermatitis & relieve itching Subacute: topical mid (triamcinolone 0.1%) - high(Fluocinonide 0.05%) steroid bid-tid w/compresses

CHRONIC: High-highest potency steroids (ointment - not on face/skin folds)

Systemic txt: Acute severe: prednisone po (12-21d) Give 78 5mg tabs: 12 1st d, 11 2nd d, etc.) Don’t use prepackaged Medrol Dose pak: not enough dose or time. Takes 2-3 wks to fully heal.

22.      Treatment of scabies patients*

• Kill the scabies mites

• Control dermatitis (can last for mths after mites gone)

• Bedding/clothing cleaned or closed up in plastic bags for 14d

• If there is 2° pyoderma: systemic antibiotics

• All people in family must be treated

• Permethrin 5% cream: very effective & safe (1 app. 8-12hrs) repeated 1 wk 

• Txt pregnant women only if they definitely have scabies

• Pts will continue to itch for a few wks post txt use triamcinolone 0.1% cream to resolves the dermatitis

23.      Define comminuted fracture*

24a.      S/S of rheumatoid arthritis*

Joints: normally gradual symmetrical polyarthritis. (Small joints of hands, feet, wrists, ankles usually affected; others commonly involved: cervical spine, shoulders, elbows, hips, knees). Typically presents as morning stiffness that improves with activity. Progression to some level of destruction in bone, cartilage or tendon sheaths, which can lead to deformity and significant loss of fxn. Synovial cysts (bakers) may occur. 

Tendons: tenosynovitis: inflammation of tendon sheaths causing tendon malalignment, stretching, shortening or rupture, carpal tunnel syndrome

Rheumatoid nodules:(20% of cases) most common on over bony prominences (elbow and shaft of the ulna), but also occur in bursae, tendon sheaths, lungs, sclera

Ocular: dryness of mucous membranes (eyes, mouth, etc) in advanced dz. scleral nodules can cause episcleritis, scleritis, and scleromalacia

Cervical spine: if involved can cause C1-C2 subluxation and spinal cord compression (emergency)

Other: palmar erythema is common. Vasculitis of small vessels can cause tiny hemorrhagic infarcts in nail folds or finger pulps, as well as clots, ulcers, skin necrosis, mononeuritis multiplex or intestinal infarction. Necrotizing arteritis (rare). Pericarditis, pleural dz, pulmonary fibrosis, mononuclear cell infiltration of skeletal muscle and perineurium, hyperplasia of lymph nodes, Felty syndrome or aortitis (late and rare)

Systemic: morning stiffness, fatigue, low grade fever, myalgia, wt loss, anemia

Xray: erosive lesions of bone and cartilage at margins (the site of synovial attachment)

aka Still's Dz, there are 3 types

1. Systemic (20%): acute febrile, characterized by extra-articular sxs. 

- high spiking fevers and rash are most common

- Rash usually appears in evening and may be elicited by gently scratching the skin in susceptible areas (Koebner's)

- Splenomegaly, generalized lymphadenopathy, pericarditis, and myocarditis also occur

- minimal articular findings, but morbidity is usually from chronic arthritis

2. Pauciarticular (30%): girls 4:1

- usually involves large joints, only 1-3 joints involved

- systemic features often minimal

- joint dz rarely causes impairment

- iridocyclitis develops in 30%, with ↑ risk of permanent vision loss

- accelerated growth of affected limb, eventually equalized if inflammation is controlled 

3. Polyarticular (50%): resembles adult RA

- symmetric involvement of small joints of hands and feet (knees and wrists may also be involved)

- Cervical spin commonly involved: causes marked ↓ ROM

- markedly receding chin: from early closure of ossification centers in the mandible

Labs for all: similar to adult RA, except WBC may be very high, and RF is rarely + in children

25.      Pathophys of rheumatoid arthritis*

- inflammatory process occurs in the synovial space and joint fluid due to PMN chemotaxis and activation. Release of prostaglandins and leukotrienes. Generates reactive oxygen types, including free radicles. Enzymes produced by PMNs promote superficial cartilage erosions. 

-2nd more important process: inflammation in the SYNOVIAL TISSUE causes more destruction of cartilage and bone.

-Proliferative synovial cells are activated by lymphocytes and monocytes, which infiltrate the synovium. This has 3 effects: 1. a matrix of proteins is created that directly degrade cartilage an bone; 2. release of proinflammatory prostanoids (prostaglandins & leukotrienes); 3. monocytes produce IL-1 and TNF-a, which are central to the destruction process (osteoclast activating factors)

-the proliferating synovial membrane invades cartilage/bone and acts like an invasive tumor

-TNF-a and IL-1 induce other cytokines that cause systemic symptoms of the dz 

-B cells and plasma cells in the synovium make RF, which causes more inflammatory immune cascades to occur

26.      Steps in initial fracture care*

If pt has a major long-bone fx, splint them before transported out.

- correct sig rotational or angular misalignment 1st with gentle traction in long axis of bone

- never do this if fracture is open

If dx made by Xray and sending pt to ortho for tmt, treat with a "robert jones" dressing                                         

1. elevate extremity above the heart

2. control swelling with ice

3. check and document neuro and vascular status of entire extremity distal to injury:

Neuro: UE: radial, median, ulnar nerves are all functioning if pt can extend thumb, flex and spread fingers LE: posterior tibialis and peroneal nerves are functioning if pt can flex and extend toes       

*If neuro or vascular problems found, they often disappear after fx or dislocation is reduced

*if neuro problems hang around after reduced, complete recovery is often achieved after exercise tmt

Vascular: if problems remain after reduction, call for STAT vascular consult

27.      Define Tietze’s syndrome*

(from medicinenet.com)

syndrome is an inflammation of the costochondral cartilages of the upper front of the chest. as opposed to chostochondritis in which there is no swelling, localized swelling  at the junction of the ribs and breastbone is characteristic of Tietze. 

Patients with Tietze syndrome develop tenderness and swelling over the ribs and cartilage near the sternum. Redness, tenderness, and heat can also be present, but a localized swelling is the distinguishing finding. The pain is variable, often sharp, can be confused with heart pain, and can last from hours to weeks. It can cause difficulty with sleeping and even rolling over in bed is sometimes painful.

28a.      Post cast care*

1. after cast is on, elevate extremity above horizontal             level of heart
2. apply ice for 48-72 hrs
3. observe for circulatory obstruction or acute compartment    syndrome (excessive pain is probably only symptom)
- any circulatory problems, split and spread cast
- Plaster split on one side; fiberglass on both sides 

- r/o nerve palsy (peripheral nerve testing) and   arterial injury (peripheral pulses)
4. pt should move all joints that are not immobilized asap   5. if cast feels too tight or pressure sores develop,                cut window to evaluate or split for relief

6. relieve itching with ice, antihistamines, blow dryer

7. cover with stockinette if snagging clothes

8. shower: cover with plastic bag and hang outside stream

9. Ecchymosis: normal to see a few days after distal or proximal to fx site 

28b. Cast care follow up*

• Repeat Xrays every 3 weeks to check position of fx
• Healing time varies d/t many variables (quicker in kids and near ends of long bones)
• Xray findings often lag behind true healing by several wks
• give cast enough time for bone to heal, then remove
• Leave cast off if: fx has no motion, not tender to palpation, pressure or stress
• If not sure: use protective splint for 2-3 more wks
• Reapply cast if: motion, tenderness or swelling, for 3 more wks

29a.      S/S of systemic lupus erythematosus*

- Systemic: fever, anorexia, malaise, wt loss

- Skin Lesions: malar (butterfly) rash (<50%); Discoid lupus (more common), Fingertip lesions, Periungual erythema (around nail bed), Nail fold infarcts splinter hemorrhages

- Alopecia

- Mucous membrane lesions occur during exacerbations

- Rayauds phenomenon before any other sxs

- >90% of pts: joint sxs (arthritis)

- ocular manifestations: conjunctivitis, photophobia, monocular blindness (usually transient), blurred vision

- Pleurisy, pleural effusion, bronchopneumonia, pneumonitis (frequent and Restrictive lung dz can result)

- Cardiac: cardiac failure from myocarditis and HTN, Cardiac arrhythmias, mitral regurg with emboli in some, most have pericardial involvement

- Mesenteric vasculitis occasionally (infarct)

- Neuro: psychosis, cognitive impairment, seizures, peripheral and cranial neuropathies, transverse myelitis and strokes

-  Kidney dz (glomerulonephritis): often fatal

30a.      S/S systemic sclerosis (scleroderma)*

Initial: Raynauds phenomenon

Early features of diffuse scleroderma: polyarthralgia, wt loss and malaise.

sub q edema often 1st skin symptom, often itchy

Then skin thickens, with pigmentation and depigmentation as fibrosis occurs

fingertip ulceration

sub q calcification

GERD from hypomotility

small and large bowel hypomotility (in both forms): constipation then diarrhea, malabsorption, obstruction, severe bowel distention then rupture

Pulmonary fiborsis

Cardiac abnormalities: pericarditis, heart block, myocardial fibrosis, RHF (pulm. HTN)

Renal crisis (↑ BUN, Creatinine) 

Labs: mild anemia (hemolytic), renal involvement (proteinuria), +ANA in high titers (higher than SLE), Scleroderma Ab (anti-SCL-70) + in 30% of pts (very high specificity)

31a.      Patho of cervical sprain*

usually a result of a hyperextension force. Virtually synonymous with the term "whiplash", which develops in rear-end auto collisions. Osseous damage is rare; most of force absorbed by ligaments, muscles, and discs. Stretching of muscles, ligaments, esophagus, trachea and sympathetic nerve chains can occur. 

31b. S/S of Cervical sprain*

• few symptoms usually seen immediately after injury.
• Few hrs later: stiffness in neck, followed by pain and inability to move neck normally. Pain is generalized to neck and may radiate to occiput. Discomfort may be noted in the shoulder, interscapular and anterior chest wall. (radicular pain is rare). Nausea, tinnitus, blurred vision, and occipital HA also occur. 
• Clinical findings: mainly subjective, possible findings: generalized tenderness in ant. and post. neck, limited ROM, pain on extension of spine, Mild torticollis, 

32a.      Lab analysis important in rheumatoid*

• Synovial fluid: most helpful (see ? 35d)
• RF  and Anti-CCP (citrulline Ab): 80% of established RA pts are +, but in early dz there is only a 50% sensitivity of both.  Anti-CCP is more specific (95% of those who test + have RA), where many other dz can cause +RF
• ANA: common in RA (30-60% have ↑ titers) but not helpful in dx
• ESR: faster during flares, slower during remission, measures inflamm. not specific to RA
• CRP: measures inflammation, not specific to RA
• RBCs: hypochromic normocytic anemia is common

32b.      Lab analysis important in streptococcal arthritis*

Streptococcus pyogenes causes Rheumatic Fever & according to Current's pg. 731 that is a Group II (Inflammatory) dx (some septic arthritis can present w/group II if it is of low virulence). But usu streptococcal species present as a purulent/septic joint:  Volume: >3.5, Clarity: Opaque, Color: ylw - grn, WBC:>100K, PMNs: 75% or more & Culture: usu (+).  Labs for Nongonococcal Acute Bacterial (Septic) Arthritis: Synovial fluid (+) 75-90%, bld cultures (+) 50%. Xrays: joint effusion only.

32c.      Lab analysis important in gonococcal arthritis*

Peripheral blood leukocyte count: avg. 10K cells/mcL 

Synovial fluid WBC: 30K-60K w/(+) gm stain in 25%, and + cultures in <50%

Bld cultures are (+) in 40% in pts w/tenosynovitis.

XRAY: usu NL or show only soft-tissue swelling.

Urethral, throat and rectal cultures should be done in all pts

32d.      Lab analysis important in sporotrichosis*

Chronic fungal infections caused by Sporothrix schenckii. Most pts have contact w/soil, moss or decaying wood. Cultures are needed to establish dx. Antibody test may be useful. In species other than cats, Sporothrix organisms are often sparse in exudate and infected tissue so that diagnosis usu requires culturing the organism. In cultures, a true mycelium is produced, with fine, branching, septate hyphae bearing pear-shaped conidia on slender conidiophores.

32e.      Lab analysis important in osteoarthritis*

Xrays more important than labs: characterized by degeneration of cartilage & hypertrophy of bone at articular margins. 

• Inflammation minimal (no ↑esr)

• Xray: narrowing of joint space,  osteophyte formation, sharpened "lipping" of marginal bone & thick, dense subchondral bone.  Bone cysts are possible.

•Synovial fluid: straw/yellow colored w/high viscosity. WBC <5K, PMN<25%, evidence of cartilage debris

33a.      S/S of gouty arthritis*

• Initial attack: SUDDEN ONSET

• Single joint of lower extremity

• classic 1st site: MP joint big toe (podagra)

• also: extensor synovium on dorsum of midfoot 

• Pain/inflammation severe

• Pain ppt by exercise, dietary causes, physical/emotional stress,                              • common after illness/surgery

• Typically begin at NIGHT

 P/E: swelling, Heat, Redness, tender to touch, fever, tachycardia; 1st episode: may be followed w/polyarticular involvement; Eventually urate crystal deposits(tophi) form in subq tissue; Xray: Nl in early dx, puched-out in late dx; LABS: Mild leukocytosis, ↑esr, Hyperuricemia (>5 mg/dL) Synovial aspirate: cloudy, mildly inflamm. Nature w/ Urate crystals 

33b.      S/S of osteo*

• Insidious onset

• Articular stiffness (<15mins) initially then pain on motion

• Pain made worse by activity or weight bearing; relieved by rest

• Heberden nodes (dtp), bouchard nodes (pip), flexion contracture, varus deformity of knee 

• Limitation of motion, crepitus,of the affected joint 

• No systemic manifestations

• mild joint effusion possible

33d.      S/S of osteomyelitis*

Acute pyogenic (currents): fever/chills assoc. w/pain & tenderness of involved bone. ESR is extremely high. (practical ortho): preceded by sxs of sytemic dx & general sepsis (anorexia, nausea, malaise, irritability & fever) Eventual chills, diaphoresis, pain, bone tenderness, heat & swelling of soft tissue. Lower extremity is most common (mild limp). types of acute:          

-Hematogenous: sudden onset of sxs. IV drugs users spine is #1 site of dx. (s.aureus #1, p aeruginosa & serratia too). Rapid progression to epidural abscess (fever,pain) & sensory motor loss. Elderly: T & L verterbrae most common sites w/more low-grade fever & gradual bone pain. 

-infection (prosthesis, decubitus ulcer, neurosurgery & trauma w/s aureus & staph epi most common): localized signs of inflamm but high fever & other toxicity sxs are usu absent. Septic arthritis & cellulitis can also cause this.

-assoc. w/vascular insufficiency: foot & ankle most common sites. Ulcer or other break in skin is usu still present. Bone pain is absent/muted. No fever. Ability to easily advance sterile probe through skin ulcer to bone & ulcer area >2cm are clues to dx.

34a.      S/S of subacute bacterial endocarditis*

-Pts present w/nonspecific flulike illness & symptoms lasting >2 wks: low grade fever, fatigue, chills, sweats, anorexia, malaise, a cough, a headache, myalgia and/or arthralgia, & confusion.  

- Peripheral lesions: petechiae (on the palate, conjunctiva or under finger nails), subungual "splinter" hemorrhages, Osler nodes (painful, violaceous raised lesion on fingers/toes/feet), Janeway lesions (painless erthematous lesions of the palms or soles), Roth spots (exudative lesions in the retina).

-Subacute bacterial endocarditis is more common in pts w/an underlying congenital heart defect.

-Viridian stains of streptococci, enterococci, bacteria, yeasts & fungi tend to cause a more subacute picture.  S.aureus leads to a very septic, ill appearing acute pt.

34b.      S/S of ankylosing spondylitis*

-intermittent bouts of back pain that radiate into butt, is worse in am w/stiffness that lasts hrs but improves w/activity.  

-bilateral sacroiliitis is classic lesion leading to tenderness & limited lumbar motion

-men>women, onset btween 15-30 yo

-Chest expansion is limited (<2.5cm).

-Transient acute arthritis of peripheral joints (50%) w/permanent change (25%) usu in hips, shoulders, knees.

-Enthesopathy (HALLMARK - tenderness at tendon insertion sites): swelling of Achilles, plantar fasciitis (heel pain), "sausage" swelling of finger or toe.

-Anterior uveitis (25%) may be presenting feature.

-Pulm fibrosis of upper lobes leading to bronchiectasis mimicking TB may rarely occur.

-Constitutional sxs are usu absent.

-Severe dx: lumbar curve flattens & thoracic curve exagerates,spine fuses, heart dx (AV conduction defects & aortic insufficiency) 

-Xray: "bamboo spine", and "shiny corner sign"

34e.      S/S of Reiter’s syndrome*

(reactive arthritis)

-pts are young & joint sxs appear w/in 3-4wks of infection (usu GI or GU infections d/t salmonella & chlamydia respectively)

-asymmetric sterile oligoarthritis, usu of lower extremities (knees & ankles)

-low back pain is common

-enthesis & scaroiliitis are common

-synovial fluid is culture (-)

-fever & weight loss at onset

-extra-articular sxs: urethritis, conjunctivitis &mucotaneous lesions: balanitis, stomatitis, keratoderma blennorrhagicum (indistinguishable from pustular psoriasis), pitting & onchylosis (as in PA) are seen.

-HLA-b27 antigen is present as well as elevated ESR

35a.      Synovial fluid results expected in septic arthritis*

• Purulent group III
• volume >3.5 usually
• clarity: opaque
• Color: yellow to green
• WBCs:  >50,000
• PMNs: 75% or more
• viscosity: low
• Chemistry analysis: glucose <40 mg/dl (glucose difference over 50 mg/dL)

35b.      Synovial fluid results expected normal joint*

• Color: clear 
• Clarity: transparent
• high viscosity
• WBCs <200
• PMNs: <25%
• Glucose= serum
• volume <3.5 ml

35c.      Synovial fluid results expected in acute gout*

• Color: yellow, opalescent, white, flaky
• Clarity: cloudy
• WBCs: >10,000
• PMNs: 25-75%
• positive for uric acid (sodium urate) crystals

35d.      Synovial fluid results expected in rheumatoid arthritis*

• Inflammatory fluid (also found with SLE)
• Volume >3.5 usually
• Color: yellow to opalescent
• Clarity: translucent to opaque
• Viscosity: low 
• WBCs: 3,000-50,000
• PMNs: 50-80%
• Rheumatoid factor (an IgM directed against IgG) found in 80-90%
• glucose: > 25 mg/dl lower than serum

35e.      Synovial fluid results expected in osteoarthritis*

• Clarity: clear
• volume >3.5 usually
• color: yellow
• WBCs 200-300
• cartilage debris may be present
• PMNs: <25%
• Glucose = serum

37a.      S/S of bicipital tendonitis*

 commonly assoc. w/anterior pain

-pain in bicipital groove down anterior arm

-tender bicipital groove, pain w/shoulder extension, (+) resistance test

-no sxs below elbow, no pain w/neck motion, no neuro sxs

37b.      S/S of osteochondral fracture*

37c.      S/S of impingement syndrome*

From ClevelandClinic.org: The typical symptoms of shoulder impingement syndrome include: difficulty reaching up behind the back, pain when the arms are extended above the head, & a weakness of shoulder muscles. Can lead to rotator cuff test. 

37d.      S/S of rotator cuff damage*

-pt usu present w/nonspecific pain localized to the shoulder, more noticed at night when lying on affected side (acrominon down to deltoid insertion).

-locking, clicking, grating, cracking sounds & sensations occur w/limited (mild) motion of shoulder, particularly through abduction, external rotation - often in dominant arm shoulder

-sxs are frequently referred down the proximal lateral arm

-tears may result w/inability to abduct or flex 

-maximal tenderness usu noted over the supraspinatous insertion.

-pain w/ROM is most pronounced btwn 60 & 120 degrees of abduction

-partial rotator cuff tendon ruptures present identically to chronic tendinitis & bursitis (mild abduction weakness)

-total ruptures: (+) drop arm test

-Age > 50 suspect tear (partial v. full) w/complaints of (anterior) shoulder pain & night pain until proven otherwise 

-usu from fall 

-no neck or interscapular pain, no tingling, go sxs below elbow

z

37e.      S/S of biceps rupture*

-sudden onset

-sharp snap felt, followed by pain & weakness

-abnormally large mass in the arm is seen "popeye" sign

-some loss of elbow flexion power

39.      Total management of pelvic fractures*

PO: 

-stable (d/t low energy minor falls in kids, elderly & osteoporotic females): txt symptomatically w/1-2d rest followed by ambulation & weight bearing as tolerated.

-unstable (d/t high-energy impact): initial care is directed at stabilization of the pt. Primary treatment of pelvic fracture is for pain with narcotic analgesics. Fracture usu requires prolonged immobilization & occasional surgical repair. 

40a.      Skin manifestations/abnormalities in rheumatoid*

In RA vasculitis is associated with circulating complexes of IgG and Rf, which leads to cutaneous lesions: ulcers and skin necorsis

40b.      Skin manifestations/abnormalities in  Reiter syndrome*

40c.      Skin manifestations/abnormalities in tophaceous gout*

40d.      Skin manifestations/abnormalities in ankylosing spondylitis*

-bilateral sacroiliites is the classic lesion

-enthespoathy (HALLMARK) swelling of achilles tendon at -insertion, plantar fascitis (heel pain) or "sausage" swelling of finer or toe. 

-usu no skin lesions occur but anterior uveitis (25%)

40e.      Skin manifestations/abnormalities in  osteoarthritis*

41a.      S/S of gonococcal arthritis*

1-4d of migratory polyarthralgias involving the wrist, knee, ankle or elbow. Thereafter 2 patterns emerge:

1. Tenosynovitis (wrists, fingers, ankles, toes)

2. purulent monarthritis (knee, ankle, wrist, elbow)

Other Sxs:

-fever <50%

-GU sxs <25%

-characteristic skin lesions (usu 2-10 small necrotic pustules over extremities, palms & soles)

-bld leukocytes avg 10K

-Synovial WBC 30-60K

-urethral, throat & rectal cultures are often + 

41e.      S/S of polymyalgia rheumatica*

- Common disorder of unknown cause affecting older adults (over 50), women 2:1.

- characterized by chronic inflammation that causes stiffness and aching of the shoulder and hip regions

- strong relationship with temporal (giant cell) arthritis

S/S:

- sudden onset of neck, shoulder, low back, hip and thigh pain. B/L shoulder pain most common presenting sx 

- Morning stiffness, lasts 2-3hr (difficult getting out of bed)

- Malaise, depression, wt loss, low grade fever

- Restricted ROM may be present 

- Synovitis may be present in peripheral joints

- Labs: elevated ESR, CRP, and possible anemia

- cranial signs (headache and variable degrees of blindness) if giant cell arteritis also present

42.      Skin involvement associated with joint pain diseases

SLE: malar raxh, discoid lupus, fingertip lesions, periungual erythema, nail fold infarcts, splinter hemorrhages

43a.      S/S of felon*

[image]

An infection of the closed space of the pad of the distal phalanx, 2° to a local puncture wound 

- characterized by rapidly ↑ P and pain

- entire pulp of fingertip is swollen, tense, and reddened 

- swelling does not typically cross the distal flexion creae

- may result in osteomyelitis of the distal phalanx or extension of the infection into the flexor sheath or adj joint

43b.      S/S of dupuytren’s contracture*

[image]

Hyperplasia of palmar fascia & related structures of idiopathic etiology. More common in white men >50 & alcoholics w/chronic systemic disorders (cirrhosis).  

-nodular or cord-like thickening of one or both hands,    w/the 4th 7 5th fingers most commonly affected.

-tightness of involved digits, w/inability to satisfactorily  extend fingers & occasional tenderness

-cosmetic problems are unappealing but condition is well tolerated

43c.      S/S of mallet finger*

[image]

"Baseball finger"

- a common injury with avulsion of the extensor tendon at the base of the distal phalanx (occurs 2° to sudden forceful flexion ie blow to the tip of the extended finger)

S/S:

- Active extension of the distal phalanx is lost

- tenderness and swelling are noted on the dorsum of the DIP joint

- distal phalanx rests in the position of moderate flexion

- long standing cases can develop a mild hyperextension of the PIP leading to a swan neck deformity

- Xray may reveal an avulsion fx of the distal phalanx

43d.      S/S of flexor tendon tear*

[image]

"Jersey finger": tear of the flexor digitorum profundus tendon

- common mech: sudden DIP hyperextension (ex: athlete's finger catching on another players clothing)

- ring finger most commonly involved

S/S: Pain and swelling at the volar aspect of the DIP joint

- finger in extension with hand at rest

- pt unable to flex the distal phalanx

- end of the tendon with its bony fragment may be palpable

- Xray: evident only if the bone is avulsed

43e.      S/S of volkmann’s contracture*

[image]

• The hallmark symptom is pain that does not improve with rest or nonsedating pain medications, and will continue to get worse with time. If the pressure is allowed to persist, there will be decreased sensation, weakness, and paleness of the skin.

three levels of severity:

• Mild -- flexion contracture of two or three fingers only with no or limited loss of sensation
• Moderate -- all fingers are flexed and the thumb is stuck in the palm; the wrist may be stuck in flexion, and there is usually loss of some sensation in the hand
• Severe -- all muscles in the forearm that both flex and extend the wrist and fingers are involved; this is a severely disabling condition

44a.      S/S of osteochondritis dissecans*

- dz of unknown cause in which segment of subchondral bone undergoes avascular necrosis. 

- knee is most affected joint (also seen in talar dome & elbow)

- 1° seen in young adults, children also affected

- may be bilateral

- NO inflammation

Symptoms: pain, stiffness, and swelling that worsen with activity. Painful limp often present, and locking may occur. Exam: Diminished motion and well localized medial joint tenderness.

- Thigh atrophy and abnormal Wilson's sign may be present

Xray often diagnostic

44b.      S/S of chronic medial collateral ligament laxity*

Acute: pain directly over the ligament, Swelling over the torn ligament may appear, and bruising and generalized joint swelling are common 1 to 2 days after the injury.

Chronic: patients often present with episodes of the knee  “giving out” or buckling (pivot shift), especially with activities that require cutting or changing directions.

- synovitis is often present

44c.      S/S of chondromalacia of the patella*

- abnormal softening of the cartilage under the patella

- most common cause of chronic knee pain

- symptoms: Crepitus; generalized pain beneath or near the patella, aggravated by walking up/down stairs, squatting and prolonged sitting ("movie sign"). Giving way or locking may be present, hx of trauma common. 

Stage 1: swelling and softening

Stage 2: softening and fissuring

Stage 3: fragmentation and deformation

- usually bilateral 

- Examination: genearlized tenderness around the patella, direct P against patella is painful, as is contraction of hte quads against patellar P.

- Crepitus may be palpable

- may be signs of malalignment or unstable patella

- commonly exam is completely normal

44d.      S/S of torn medial meniscus*

-usually results in persistent symptoms

44e.      S/S of loose body*

- aka "joint mice": a free floating piece of bone, cartilage or foreign object in a joint

- often found in the knee

Symptoms: swelling and intermittent locking of the joint. often a feeling of weakness and instability. 

Exam: often palpable and freely movable 

Xray: often diagnostic

45.      Description of talipes equinovarus*

[image]

[image]"Club foot"
- A fixed deformity present at birth where the foot is turned inward and downward
- can be uni- or bilateral 
- Consists of 3 major components

(these are fixed and are not passively correctable)
1. equinus of the ankle and forefoot (plantar flexion)

2. varus of the heel (heel turned inward)

3. adduction of the forefoot

46.      Lab and xray findings in osteo*

• characterized by degeneration of cartilage & hypertrophy of bone at articular margins. 

• Inflammation minimal (no ↑esr)

• Xray: narrowing of joint space,  osteophyte formation, sharpened "lipping" of marginal bone & thick, dense subchondral none.  Bone cysts are possible.

47a.      S/S of lumbar strain*

Very common injury causing low back pain. It is either d/t incomplete muscle tear or a ligament sprain. 

-pain & tenderness over injured area

-heals quickly

-usu no radiculopathy

Complicated strain: d/t chronic dx & heals slowly. Risk factors for prolonged healing of complicated strain include obesity, poor muscle tone, smoking, poor work habits, high heel shoes, no daily exercise.

47b.      S/S of osteo of the lumbar spine*

Taken from http://www.spine-health.com/conditions/arthritis/osteoarthritis-symptoms

-stiffness & pain in the lower spine & sacroiliac joint (btwn spine & pelvis)

-pain is typically most pronounced in the am & is decreased during the day 

-“referred pain” to the pelvis, buttocks, or thighs & sometimes to the groin.

-Nerve irritation from a herniated disc or from bone spurs can cause weakness, numbness, tingling and/or pain in the legs that often radiates to one foot.

-Arthritis causing spinal stenosis or narrowing of the spinal canal in the lower back can cause exercise/walking-related symptoms in both legs.

47c.      S/S of herniated disc w/pressure on L5 nerve root*

Pain: lateral, posterolateral aspect of thigh, leg

Sensory change: lateral aspect of leg, dorsum of foot, first web space, great toe & medial forefoot

Motor Weakness: great toe extension, ankled dorsiflexion, heel walking difficult (foot drop may occur)

No reflex associated w/L5

47d.   S/S of herniated disc w/pressure on S1 nerve root*

Pain: Posterolateral aspect of thigh, leg, heel

Sensory change: Posterior aspect of calf, heel, lateral aspect of foot (3 toes)

Motor weakness: calf, plantar-flexion of foot, great toe, toe walking weak

Reflex change: ankle jerk

47e.      S/S of osteo of hip*

Clinical course is gradual & both hips may be affected. 

-pain after activity(subsides after rest)

-stiffness after rest (subsides w/activity)

-pain usu referred to knee joint

-crepitus/grating at hip may develop

-painful limp

-loss of flexion & external rotation at hip

P/E: tenderness over ant/post hip & decreased ROM (esp rotation & abduction); flexion contracture; +Thomas test (pain), difficulty flattening knee down onto exam table. 

48a.      S/S of torn rotator cuff*

Can be an acute or chronic tear. Acute tear occur due to a sudden powerful raising of the arm against resistance or in attempt to cushion a fall (rare). Chronic are usually due to excessive overhead reaching 

Chronic: (no obvious injury), usually >50yo

- Pain, muscle weakness, gratching, grating, cracking sounds, limited ROM

- typically in dominant arm

- Pain usually worse at night and may interfere with sleep

- Gradual weakness and ↓ shoulder ROM develop as pain worsens.

- drop arm test +

- ↓ in ability to abduct or flex arm depending on area torn: supraspinatus most often torn so abduction is more commonly affected. Depressor effect of the rotator cuff is also lost, so sensation of grinding will be ↑

Subscaplularis: forward flexion weakened

infraspinatus: weakness against external rotation

- pain is often referred down deltoid muscle

- defect may be palpable through deltoid muscle with complete rupture

Acute (rare): sudden tearing sensation followed by pain shooting from upper shoulder (front and back) down the arm toward elbow.

Xray: usually negative, but can show calcifications on tuberosity of humerus

U/S: study of choice

- achy anterior shoulder pain that is exacerbated by lifting of elevated pushing or pulling

- pain may be localized in a vertical line along the bicipital groove down the anterior humerus, which worsens with movement or the location of pain may be vague

- symptoms may improve with rest

-usually no acute traumatic injury sustained

Examination:  

- local tenderness usually present over bicipital groove, localized best with arm in 10° of external rotation

- flexion of elbow against resistance aggravates pain

Pertinent negatives: no sxs below elbow, no pain with neck motion, no necrologic sxs

48c.      S/S of fracture of proximal humerus*

more common in older female pts

- severe pain

- severely swollen shoulder

- bruising

- very limited movement of the shoulder

- grinding sensation when shoulder is moved

- possible deformity

48d.      S/S of torn distal biceps tendon*

Sudden, forceful flexion of the elbow against resistance may cause rupture at its insertion into the radius at the elbow. Most commonly occurs in heavy lifting or sports in middle aged men

S/S: 

- painful snap felt at elbow and is followed by swelling, tenderness and sometimes bruising. 

- Flexion of the elbow and supination (palm side up) of the forearm are weakened. (overlying deep fascia of the antecubital fossa may remain intact and prevent a sig loss of flexion)

- on flexion of elbow the belly of the biceps retracts to produce a bulbous swelling in upper arm (also seen with proximal rupture of long head of biceps) 

- MRI to confirm and determine extent of injury

48e.      S/S of shoulder bursitis*

- Causes Impingement syndrome (as does rotator cuff tendonitis)

- often preceded by an injury that sets of the inflammation process

- Common symptoms: 

pain with overhead activities 

pain while sleeping at night

pain over outside of the shoulder/upper arm

- Hawkins and Neer tests often both +

49.     patho of Volkmann’s ischemic contracture*

• occurs when there is a lack of blood flow (ischemia) to the forearm, usually from increased pressure due to swelling (compartment syndrome)
• nerve & muscle perfusion is so minimal that they cannot sustain themselves (muscles shorten and become stiff)
• contracture occurs because stiffened muscle prevent joints from straightening
• In Volkmann's contracture, the muscles of the forearm are severely injured, resulting in contracture deformities of the fingers, hand, and wrist.
• rare complication and most commonly occurs after sever elbow injuries, high tibial fx, and metatarsal fx

50.      Compromised nerve in carpal tunnel syndrome*

• the median nerve 
• it is compressed (entrapped) between the carpal ligament and other structures within the carpal tunnel, due to synovitis of the tendon sheaths or carpal joints, malhealed fx, tumor, congenital abnormalities

51.      Physical findings in L5 radiculopathy*

52.      Diagnosis of Paget’s disease*

Def.: A nonmetabolic idiopathic bone dx characterized by repeated episodes of bone destruction & excessive attempts at repair, which results in weakened bone of increased mass. Unusual <40yo, males:females (2:1).

Sxs: Bone pain is 1st followed w/painful bowing of long bones leading to pathologic fractures. 1/2 pts have hip/pelvic involvement. Inc. bld shunting in extremities may cause limb warmth & heart failure. Characteristic bone hypertrophy leads to skull enlargement & bony overgrowth of the spine causing neuro issues (vision, hearing loss, radicular pain, cord compression.

Labs: Alk phos level is up; inc. urinary excretion of pyridinoline, XRAY show dense expanding bones w/characteristic radiolucency & opacity. 

53.      Muscles in rotator cuff*

1. Teres minor:

O:lateral scapula border I:inferior aspect of the greater tuberosity of the humerus. The teres minor muscle externally rotates the shoulder joint.

2.infraspinatus:

O: below spine of scapula, in the infraspinatus fossa I: posterior aspect of the greater tuberosity of the humerus. It externally rotates the shoulder joint 

3. supraspinatus:

O: above spine of scapula I: greater tuberosity of the humerus. The supraspinatus abducts, or elevates, the shoulder joint. 

4. subscapularis:

O: anterior surface of scapula, sitting directly over ribs I:lesser tuberosity of humerus. The subscapularis muscle depresses the head of the humerus allowing it to move freely in the glenohumeral joint during elevation of the arm.

54a.      Definition of gibbus*

a hump, swelling, or enlargement on a body surface, usually confined to one side

gibbus deformity: a form of structural kyphosis, usually 2° to tb infection of the thoracic vertebral body, in which the vertebral column becomes sharply angulated at the site of lesion

54b.      Definition of kyphosis*

Curvature of the spine with posterior convexity, may be normal or abnormal

- a mild kyphosis is normally present in the thoracic  and sacral spine

54c.      Definition of lordosis*

Curvature of the spine with anterior convexity, may be normal or abnormal

- a mild lordosis is normally present in the cervical and lumbar spine

54d.      Definition of scoliosis*

55.      Complications post total knee arthroplasty*

Asymptomatic deep vein thrombosis has been reported in up to 50-70% of patients who receive total knee arthroplasty. 

Infection is rare following total knee arthroplasty. It occurs in 1-2.5% of cases

Neurovascular complications are rare in total knee arthroplasty. The lateral popliteal nerve may be injured in severe valgus deformity. Tourniquet paralysis may also occur as a rare problem. Major vessel injury may occur in revision procedures or in the rare case in which anatomy is abnormal.

Major long-term problems are late infection (osteomyelitis), wearing of the bearings, loosening and dislocation of the prosthesis. Perioprosthetic fracture and arthrofibrosis are other problems that may occur but are less common.

Osteolysis is a major problem with polyethylene and metal wear fragments. 

Patellar component complications: Patella tendon auvulsion

56a.      Etiology of Horner’s syndrome*

Horner syndrome is a rare disorder that occurs when the nerves that travel from your brain to your eyes & face are damaged. It is d/t damage to the sympathetic nerves of your face & eyes, typically affecting only 1 side. Horner syndrome isn't a disease itself. Rather, it's a sign of another medical problem — such as a stroke, tumor or spinal cord injury — that damages the nerves to your face. In some cases, however, no underlying cause can be found. Hallmark findings of Horner syndrome include a drooping eyelid, decreased eye pupil size & decreased sweating on the affected side of your face.

56b.      Etiology of Sjogren’s syndrome*

• Sjogren's can occur in isolation (primary) or in association with another rheumatic dz, most commonly with RA. Can also occur with SLE, 1° biliary cirrhosis, scleroderma, polymyosisis, Hashimoto thyroditis, polyarthritis, and IPF
• The exact etiology of Sjögren syndrome is unknown, but is likely multifactorial. A combination of viral, genetic, neural, and environmental factors is thought to be involved.
  
• markers commonly found are: ANA (95%), RF (75%), Anti-SS-A (65%) and Anti-SS-B (65%)
• Viral: (EBV, HCV, enterovirus, HTLV); Genetic: HLA-DR; Immuno: ↑ levels of TNF-a and IL-6 often 

  found

56c.      Etiology of systemic lupus erythematosus*

•  Although the specific cause of SLE is unknown, multiple factors are associated with the development of the disease, including genetic, racial, hormonal, and environmental factors. Many immune disturbances, both innate and acquired, occur in SLE
• 85% are women
• sex hormones involved (usually occurs after menarche & before menopause) (older pts, gender distribution more equal)
• Race: more often in blacks (1:250) vs whites (1:1000)
• Genetics: runs in families, concordant in 25-70% of identical twins.
• High frequency of +HLA (esp DR2, DRS)
• ANA: aggregates of +ANA seen in asymptomatic family
• members, other rheumatic dz ↑ in close relatives. 

56d.      Etiology of Felty’s syndrome*

• exact cause is unknown
• rare complication of RA
• these pts have high #s of WBCs in the bone marrow despite low numbers in the blood

57.      Differential diagnosis for lupus*

• Rheumatoid Arthritis
• systemic vasculitis
• scleroderma
• inflammatory myopathies
• Hepatitis C
• sarcoidosis
• acute drug reactions
• drug-induced lupus: esp from Hydralazine, Isoniazide, or Procainamide (which is not off the market)

58a.      S/S of plantar fasciitis*

• Definition: inflammation and pain at the proximal plantar fascia. Pain is illicited only when fascia is stretched. 
• 90% have pain in the proximal, medial area of the plantar aponeurosis
• Hx of morning pain with first few steps initially (can progress to constant) and pain after sitting during 1st few steps of ambulation
• NWB relieves pain
• Upon exam, point tenderness noted with firm deep palpation at medial calcaneal tuberosity and proximal medial plantar fascia
• Xray not helpful

58b.      S/S of Achilles tendonitis*

• local tenderness
• pt tender at achilles 2-6cm from insertion 
• Crepitus
• ↓ plantar flexion and strength

Mech: micro tearing in tendon or tendon sheath with repeated trauma leading to chronic inflammation and degeneration

Tmt: I.C.E c, stretching, NSAIDs, Heel lifts b/l, ↓ stress, mileage, avoid hills, PT if not responding

58c.      S/S of olecranon bursitis*

[image]

"students elbow"

classic finding: post. elbow swelling that is clearly demarcated, appears as goose egg over olecranon process

Acute: develops after an acute traumatic injury

- characterized by pain, swelling and inflammation of the olecranon bursa. Elbow motion is usually normal

Chronic: Due to repeated trauma

- formation of thickened rubbery bursa, which is usually not painful. Palpation may reveal multiple, small, hard nodules that feel like loose bodies. 

Infectious: usually staph infection following injury

- area may be warm and red

58d.      S/S of calcaneal apophysitis*

(Sever's dz)

- low-grade inflammatory rxn at the insertion of the Achilles tendon, often b/l

- common in boys 8-14 yo due to irregular ossifiacation and sclerosis of calcaneal apophysis

S/S: local pain, tenderness. and swelling aggravated by activity and passive stretching of the heel

Xray: may reveal sclerosis of of the apophysis, but this can also be seen on normal feet

58e.      S/S of Morton’s neuroma*

- commonly involves the 3rd webspace

- insideous onset

- burning pain in affected toes

worse w/ narrow toe box or elevated heels

pts remove shoes and massage foot to alleviate pain and parastesias

digital numbness seen late in dz

- pain on plantar web space of involved digits

- direct P between metatarsal heads just distal reproduces    pain and parastesias

Compression test  will illicit pain

59.      Autoimmune diseases with eye involvement*

RA: episcleral nodules, keratoconjunctivitis sicca, scleritis, keratitis, ulcerative keratitis, retinal detachments, macular edema

Juvenile RA: Uveitis 
Sjogren's: keratoconjunctivitis sicca. 
SLE: conjunctivitis, photophobia, monocular blindness (often transient), blurred vision, keratoconjunctiitis sicca, uveitis, keratitis, retinal hemorrhages, ischemic optic neruopathy, oculomotor abnormalities, visual hallucinations

Giant Cell Arteritis: amaurosis fugax, diplopia, permanent blindness from anterior ischemic optic neuropathy (often no fundoscopic findings for the 1st 24-48 hrs after onset of blindness.

Alkylosig spondylitis: Uveitis

Psoriatic arthritis: Uveitis, conjunctivitis, keratitis

MS: 

Graves Dz: proptosis, lid lag, keratitis, decreased visual acuity and visual fields, loss of color vision

Myasthenia gravis: diplopia, eyelid ptosis

Sarcoidosis: Uveitis, conjunctival nodules, cranial nerve palsies, enlarged lacrimal glands, optic neruopathy

Wegener's: Proptosis, orbital cellulitis, uveitis, corneal ulcers, optic neruopathy

Bechet's: uveitis, hypopyon

Polyarteritis nodosa: episcleritis, scleritis, optic neruopathy

Dermatomyositis: eyelid/conjunctival edema, retinopathy, uveitis

Takayasu's arteritis: ischemic optic neuropathy, cataracts

60a.      S/S of first degree sprains*

• mild sprain: caused by over-stretching or slight tearing of ligaments with no joint instability
• s/s minimal pain, swelling, and little or no loss of functional ability. Bruising is absent or slight, and pt normally able to put wt on joint

60b.      S/S of second degree sprains*

• moderate sprain: further, but incomplete tearing of the ligament 
• s/s: briusing, moderate pain and swelling. 
• some difficulty putting wt on joint, and some loss of fxn. 
• Xray may be used to r/o fx

60c.      S/S of third degree sprains*

• severe sprain: complete tear or rupture of ligament
• s/s: severe pain, swelling and bruising
• pt unable to put wt on joint
• Xray used to r/o fx

60d.      S/S of subluxations*

incomplete/partial dislocation of a joint

S/S: may include local joint pain, swelling, bruising, difficulty moving the joint crepitus, popping, cracking, feeling that the joint will give out, laxity, pain weakness or numbness 

- in the Back: may cause a pinched nerve with associated pain, numbness, tingling, weakness

61a.      S/S of Behcet’s syndrome*

-common in persons of Asian, Turkish or Middle Eastern descent

-HALLMARK: recurrent, painful apthous ulcers of the mouth & genitals

-erythema nodosum-like lesions, follicular rash, "pathergy" phenomenon (sterile pustule formation at the site of needle stick)

-nonerosice arthritis (66%) affecting knees/ankles

-anterior (photophobia, red eye - can lead to hypopyon)/post uveitis

-neuro lesions that mimic MS: sterile meningitis (headaches), cranial nerve palsies, seizures, encephalitis, mental disturbances, spinal cord lesions.

-hypercoaguable tendencies leading to DVT, PE

-clinical course may be chronic w/remissions & exacerbations

61c.      S/S of psoriatic arthritis*

-30-55 yo 

-peripheral arthritis is very common & is usu symmetric polyarthritis that resemble RA w/fewer small joints (hands, feet)

-oligoarticluar form: may lead to considerable destruction

-DIP joint are primarliy affected (may be monarticlar early in dx w/asymmetric joint involvement & pitting of nails/onycholysis

-severe for (arthritis mutilans) w/marked osteolytis (usu hand)

-spondylitic form: sacroiliitis & spinal involvement (pts usu HLA-B27 +)

-assoc w/skin dx 

-"sausage swelling (enthesopathy) is common clue.

61d.      S/S of HIV associated arthritis*

·      - Reactive arthritis

·      - Psoriatic arthritis

·       - Osteomyelitis

·  ·    -Vasculitis

·         -Infected joints

·       - Fibromyalgia

·       -Ankylosing spondylitis

      -DILS (Diffuse infiltrative lymphocytosis syndrome): HIV+ pts w/low CD4 counts (similar to Sjogren's w/painless parotid* submanidbular swelling & sicca). DILS usu improves w/HAART

·      -Polymyositis & dermatomyositis: polymyositis also possible as part of HAART–assoc. immune reconstitution syndrome

62a.      S/S of fracture*

62b.      S/S of Paget’s disease*

62c.      S/S of strain*

injury to a muscle or tendon

- pain (at rest and when used)

- limited motion

- muscle spasms

- possible muscle weakness

- localized swelling, cramping or inflammation. Bruising also possible

- some loss of muscle fxn

- pain and general weakness upon attempt to move affected muscle

- severe strains that have torn the muscle or tendon are very painful and disabling

62d.      S/S of bone tumor*

Benign bone tumors: symptoms are often related to the location and size of the tumor 

- can range from asymptomatic to painful

- pathologic fractures may develop

Malignant bone tumors: often present with painful swelling, bone pain, as well as other constitutional sys (anorexia, wt loss, etc)

-osteosarcoma often develops in conjunction with Paget's dz 

63.      Mechanism of action of NSAIDs*

• Inhibit prostaglandin synthesis by inhibiting cyclooxygnease (COX)
• aspirin and non-selective NSAIDs (ex: ibuprofen, indomethacin) inhibit both COX1 and COX2 
• selective NSAIDs (ex. Celebrex/celecoxib) preferentially inhibit COX2, although high doses can inhibit both. These have less GI toxicity, but renal toxicity still there
• Cox 1: PGE2 in gastric mucosa and kidney, and thromboxane A2 in platelets
• Cox 2: PGE2 production in synovial cells and by activated leukocytes (goes directly to site of inflammation). Less effect of platelet fxn, so those on COX2 inhibitors don't have the cardio protection that COX1 inhibitors provide (give baby asa to counter this)

64.      Sequelae of dislocated hip*

65a.      S/S of polymyositis*

Systemic disorder of unknown cause 

- affect any age, peak in 5th-6th decade

- women 2:1 and more often blacks

- principle manifestation b/l muscle weakness, most often gradual & progressive, but may begin abruptly

- weakness 1° in proximal muscles of the upper and lower ext. and neck (do not affect face or ocular muscles)

- 25% have pain and tenderness 

- 25% have dysphagia (if striated muscles of upper pharynx affected)

- muscle atrophy and contractures are late complications

- Muscle Bx is only specific dx test

65b.      S/S of  giant cell arteritis*

-aka temporal arteritis (b/c freq involved)

- a systemic panarteritis affecting medium and large vessels, in pts over 50

-  50% also have polymyalgia rheumatica

- Classic symptoms: headache, sclap tenderness, visual symptoms (particularly amaurosis fugax or diplopia), jaw claudication, or throat pain. 

- temporal artery is usually normal but may be nodular, enlarged, tender or pulseless. 

- blindness can occur (usually permanent) 

- asymmetry of pulses in ams, a murmur of aortic regurg, or bruits heard near clavicle if aorta affected

- aneurysm or stenosis of large arteries

- elevated ESR

- Nonclassic sxs: respiratory tract problems (dry cough), nomoneuritis multiples (painful paralysis of shoulder), fever of unknown origin

66a.      S/S of stenosing tenosynovitis* 

- common condition of unknown origin

- may develop from overuse or direct trauma

resultant inflammation and irritation hinder normal gliding motion of the tendon

- Different syndromes depending on location:

De Quervain's Dz: in the 1st dorsal extensor compartment of the wrist. 

- Pain, tenderness, crepitus with motion of the tendon, which may radiate up the forearm and into the thumb

- active and passive motion of thumb aggravates pain

- inflammation may cause involvement of radial sensory nerve (tingling or numbness over thumb and web space), and can also lead to tendon sheath cyst formation

Trigger finger/thumb: due to swelling of the flexor tendon and sheath at the MCP. 

- snapping or "triggering" of the affected finger at the MCP joint, effect is seen at the DIP joint which can even be locked in flexion or extension

- sxs worse after rest and improve with active use

- the nodular thickening is usually palpable and quite tender

66b.      S/S of polyfibrositis

66c.      S/S of fibromyalgia*

most common rheumatic syndromes (3-10% population).

-chronic aching pain & stiffness involving entire body (esp. neck, shoulders, low back, hips)

-fatigue, sleep disorders, subjective numbness, chronic headaches & IBS sxs 

-minor exertion aggravates pain & increases fatigue

-P/E NL except for "trigger points" of pain (trapezius, medial fat pad of knee, lateral epicondyle of elbow)

67c.      S/S of felty’s syndrome*

Complication of RF + RA: Rare

- Splenomegaly

- Leukopenia

- recurrent pulmonary infections 

- leg ulcers and vasculitis 

- malaise, fatigue, anorexia, wt loss, pale looking skin

- joint swelling, stiffness, pain and deformity

- recurrent infections 

- eye burning or discharge

- characterized by a triad of: RA, Splenomegaly and granulocytopenia

67d.      S/S of raynaud’s phenomenon*

- Paroxysmal b/l symmetric pallor and cyanosis followed by rubor of the skin of the digits. 
- precipitated by cold or emotional stress, relieved by warmth
- 1° affects fingers but can also affect toes, nose and ears
- 1° form benign, 2° form can cause digital ulceration or gangrene
- nail-fold capillary abnormalities is an early clue that a person has 2° rather than 1°. digital pitting,ulceration or other physical findings are other clues

67e.      S/S of Pott’s disease*

Spinal TB (develops years after 1° TB infection, with reactivation of dz that was transmitted through the blood from lungs to spine)

-seen 1° in immigrants from developing countries or immunocompromised pts

- back pain, often for months

- associated radicular pain and lower ext weakness may be present

- constitutional sxs usually absent, <20% have active pulmonary dz

- leads to characteristic gibbus deformity of the spine (due to destruction of the anterior aspect of vertebral bodies)

68a.      Definition of tophi*

68b.      Definition of bouchard’s nodes*

68c.      Definition of heberden’s nodes*

69.      Etiology of osteoporosis*

Osteoporosis is low bone mass, deterioratio of bone tissue, disprution of bone architecture, comprimise of bone strength & increased risk of fracture d/t:

-Hormone deficiency (estrogen & androgen) & excess (Cushing's steroid us, thyrotoxicosis, hyper parathyroid)

-immobilization & microgravity

-smoking, alcoholism

-malignancy (multiple myeloma)

-meds (too much vit D/vit A, SSRIs, heparin, rosiglitasone: men w/DM2)

-dx: RA, DM, anorexia nervosa, celiac, IBD, liver dx 

Risk increases w/age, being female, being thin, h/o personal/1st degree relative fracture <50yo & post-menopausal

70.      Clinical manifestations of rickets*

In kids its called rickets in adults its osteomalacia.) Rickets is an abnormal Ca, P or vit D metabolism.

-softening of skull bones

-enlargement of the ribs & costochondral jxns

-limb deformities & epiphyseal swelling

-shorter stature

-easily fatigued & irritable

- Pigeon breast deformity & indentation of lwr ribcage at insertion of diaphragm (Harrison's grooves)

-diminished pulm ventilation d/t decreased thoracic vol. 

71.      Conservative treatment of tennis elbow*

[image]

• I.C.E
• Stretching
• Strengthening (light weights)
• counter-force brace
• NSAIDs
• local injection with corticosteroid/lidocaine mix often provides permeant or long lasting relief (can be repeated 2-x)
• Referral in 2-4 weeks if unresponsive

72.      Etiology and S/S of sarcoidosis*

-idiopathic dx characterized by granulomatous inflammation of the lungs.

- insidious onset of: malaise, fever, dyspnea

-abnormal chest xrays (bilateral hilar/right paratracheal lymphadenopathy)

-erythema nodosum is common

-hypercalcemia, hypercalciuria

73a.      Fluid analysis findings in gout*

Appearance: Cloudy, white & flaky

Viscosity: Decreased 

Mucin clot: Fair/poor

WBC/%PMN: 10K, 25-75%

Misc: Na+ Urate crystals

73b.      Fluid analysis findings in pseudogout*

Appearance: Cloudy

Viscosity: decreased

Mucin clot: Fair/Poor

WBC/%PMN: 5-15K, 25-75%

Misc: Ca2+ pyrophosphate crystals

74.      Treatment of disc disease in cervical region*

treatment is always conservative unless major neurological deficit is present. Fewer than 5% req surgery, which only helps with radicular arm pain. SEE fig 3-16, pg 38

1. Rest: cornerstone of tmt. Acute dz: permits healing of soft parts. Chronic dz: allows inflammatory rxn to subside. If not possible, soft collars restrict motion and give support
2. PT: moist heat, massage, home cervical traction. usefulness is uncertain
3. NSAIDs: particularly for degenerative disc dz. may not relieve pain when nerve compression is present and Narcotics may be req. Muscle relaxers are only useful as sedatives 
4. Epidural pain blocks: for radicular pain
5. After pain subsides, Isometric exercise and use of a pillow that is 7.5 to 10 cm thick for sleeping

to treat non-traumatic neck pain with or without arm pain: (fig 3-16 pg 38)

1. Major neuro deficit (rare) → immediate referral to ortho or neurosurgeon
2. no/minimal neuro deficit→ rest, heat, NSAID, analgesic (2 wks)→ (if not better) Xray, change NSAID, add collar, PT? (2-4 wks) → (if not better) refer

75.      S/s of tennis elbow (aka lateral epicondylitis)*

-pain at site of tendon insertion

-pain w/grasping, squeezing (shaking hands, opening jars)

-P/E: elicitation of point tenderness over the involved site

-characteristic pain reproduced by clenching the fist & extending the wrist against the pressure of the examiner's palm

76.      Comorbidities in osteoarthritis*

77.      Sequelae after pelvic fracture*

Per emedicine.com & PO: Sequelae d/t unstable fractures: 

-The incidence of deep venous thrombosis is increased.

-Post fractures esp. may produce or injury to pelvic vasculature causing massice retroperitoneal bleeding

-GU problems (bladder, urethral, prostate or vaginal injuries) 

-Sexual dysfunction may develop.

-Infections from disruption of bowel or urinary system may develop

-Chronic pelvic pain or traumatic arthritis

78.      Confirmation of tinea versicolor*

Diagnosed via: fine scales only seen by scraping & viewing under microscope. KOH yeilds lrg, blunt hyphae & thick-walled budding spores ("sketti & meatballs").

P/E: Velvety tan, pink or white macules (4-5mm to lrg confluent areas) that do not tan resulting in hypopigmentationon trunk/back, upper arms, neck & groin. Some itching may be present.on trunk, upper arms, neck & groin.

79b.      S/S of contact dermatitis*

[image]

Contact Dermatitis - Allergic:

• Acute: tiny vesicles & weepy, crusted lesions

• Chronic: scaling, erythema, thickened skin

• severe itching w/erythematous macules, papules & vesicles

• Hot, swollen area w/crusting & oozing: infection

• Poison oak or ivy: linear streaked vesicles on extremities

Irritant: 

red & scaly but not vesicular & not weepy or crusty

79c.      S/S of brown recluse spider bites*

[image]

Brown recluse bite (many of the lesions misdiagnosed are d/t ca-mrsa not brown spiders): causes progressive local necrosis as well as hemolytic reactions (rare).  This venom is a collection of enzymes. One of the specific enzymes, once released into the victim's skin, causes destruction of local cell membranes, which disrupts the integrity of tissues leading to local breakdown of skin, fat, and blood vessels. This process leads to eventual tissue death called necrosis in areas immediately surrounding the bite site.

79d.      S/S of flea bites*

[image]

flea bites sxs: saliva of tick produces rxn of papular urticaria in sensitized pts. Also: hives, itching (can be severe, and may be all over or just where the rash is located) & rash w/small bumps that itch. When pressed the area turns white (blanches to touch)

Note: Symptoms often begin suddenly (within hours)

79e.      S/S of tick bites*[image]

Sxs of tick bites: Generally painless, local redness, itching, burning, occasional muscle weakness/paralysis. The majority of tick bites result in few, if any, immediate symptoms.

80a.      S/S of warts*

Usu no sxs but plantar warts can elicit tenderness w/pressure & anogential can be itchy.  

P/E: Verrucous (cauliflower-like) papules on skin or mucous membranes,< 1 cm w/prolonged incubation period 2-18 mths.                                                              • Flat warts: most evident w/oblique lighting

• Periungual: dry, fissured and hyperkeratotic – resembling hangnails or other non-specific changes

• Plantar: look like corns or calluses

80b.      S/S of dermatofibroma*

[image]

S/S of dermatofibroma: A common idiopathic cutaneous nodule (more in women). It frequently develops on the extremities (mostly the lower legs) & w/usu no sxs but, pruritus & tenderness are seen. The prevalence of the latter makes dermatofibroma the most prevalent of all painful skin tumors. Clinical appearance: solitary, 0.5- to 1-cm nodule (pt can have up to 15) The overlying skin ranges from flesh - gray, yellow, orange, pink, red, purple, blue, brown or black, or a combo. Palpation: hard (feels like frozen pea/small pebble fixed to skin surface) & is freely movable. Tenderness elicited w/manipulation of the lesion. There is characteristic tethering of the overlying epidermis to the underlying lesion w/lateral compression, called the dimple sign. 

80c.      S/S of cherry hemangioma*

81a.      S/S of tinea crura*

[image]

Sxs tinea cruis ("jock itch"):

-Itching (serious) in intertriginous (skin fold) areas 

-Red lesions w/sharply demarcated, central clearing & active, spreading scaly peripheries. 

-Lesions are confined to groin & gluteal cleft - spreads peripherally, spares scrotum.   -Scrape & KOH prep it - might have a fungal infection of feet or toenails from where it has spread

81d.      S/S of pityriasis alba*

[image]

Pityriasis alba (PA):common skin disorder in childrens. Characterized by presence of ill-defined, scaly, faintly erythematous patches that subside to leave areas of hypopigmentation. Lesions may progress through 3 clinical stages: Papular (scaling) erythematous,  Papular (scaling) hypochromic, Smooth hypochromic. Lesions subside, leaving areas of hypopigmentation that slowly repigment to normal. The duration of pityriasis alba varies from 1mth - 10 yrs (most cases resolve over several mths to 1yr). Dx is made clinically. It is a nonspecific finding that is commonly assoc. w/atopic dermatitis. 

82.      Treatment of athlete’s feet*

Prevention: hygiene, open toed sandals in community bathing areas & dry btwn toes after showering (hair dryer); change socks often (nonsynthetic), powders w/antifungals (Zeasorb-AF); antifungal creams.

Macerated stage: Aluminum subacetate soak (20min bid) + topical imidazole qd. If that fails: allylamine (terbinafine or butenafine).

Dry & scaly stage: antifungals (Miconazole 2%, Clotrimazole 1%, Betenafine or terbinafine ); on soles add urea 10% lotion. Severe: PO griseofulvin, itraconazole 200mg qd X 2 wks

83.      Treatment of warts*

Prevention: condoms or vaccine (genital warts)

Genital warts: Imiquimod cream (better in women); 20% podophyllin antimitotic soln; 0.5% podofilox soln; 5% 5-fluorouracil cream or snip biopsy

Common warts:                                                                                                  - snip off + trichloroacetic acid 

-Freezing w/Liquid nitrogen

-Burning (electrocautery) 

-Laser therapy                                                                                                    -40% salicylic acid plaster                                                                                    -bleomycin dilute injection                                                                                    -warm h2o soak (10-30mins x6wks)                                                                      -immunotherapy (pg 132)

84.      Scabicides associated with neurotoxicity in infants*

Most of the information I found had to do w/the med lindane causing seizures in kids. Family Practice Notebook.com states:

Effects: Neurotoxicity

1. seizures
2. headache
3. paresthias
4. Incoordination
5. tremor

85.      Treatment for infants with thrush and diaper rash*

Nystatin cream for the butt, 

Nystatin suspension applied w/cotton swab (wiped on cheeks) for thrush.

86a.      Description of malignant melanoma*

Flat, raised or both - any pigmented lesion that has just changed appearance is suspect. May have multiple colors (red, white, black, blue) & irregular borders in which pigment appears to be leaking into the normal surrounding skin. 

87.      First line treatment for acne vulgaris*

Antibiotics: mainstay of tmt for papular inflammatory acne

Accutane (isotretinoin): cystic acne

Comedonal: topical retinoids or antibiotics

88.      Rash description in atopic dermatitis (eczema)*

[image]

Rash description in atopic dermatitis (eczema)

• Rough red patches on neck, face, upper trunk usu w/o thick scale & bends of elbows, wrists & knees 

• Chronic cases: skin dry, leathery, lichenified 

• Black pts w/severe dx: pigment may be lost in these areas                                    • Acute flares may produce widespread redness w/weeping & diffuse or discrete plaques are common.

89.      Description and pathophys of cellulitis*

[image]

Description/patho of cellulitis: 

Definition: Diffuse spreading infection of dermis & subq tissue d/t gram + cocci (esp. Group A β-hemolytic strep & s. aureus) Most common entry point: tinea pedis of toe web w/fissuring in otherwise healty pts. Venous insufficiency can predispose pt to cellulitis.

Sxs: starts as a small patch that is tender w/Swelling, erythema, pain. Lesion expands over hrs (onset to presentation 6-36 hrs). Pt becomes sicker as lesion grows: chills, fever, malaise. 

If pt becomes septicemic: hypotension/shock, edematous, expanding, erythematous warm plaque w/or w/o vesicles, bullae, often in lower leg

90.      Damage via tanning booths*

From http://www.healthcentral.com/skin-care/c/75934/24339/beds-fast-facts:

Skin cancer is certainly associated with sunburn from UVB rays, but scientists at the FDA and other respected institutions now have evidence that even moderate tanning due to UVA rays produces the same long-term skin damage as a sunburn, increasing your risk of skin cancer and premature skin aging, and damaging your immune system. UVA rays penetrate deep into your skin, causing significant destruction and loss of skin elasticity. UVA exposure is associated with an increased risk for squamous cell carcinoma, basal cell carcinoma[10] and melanoma.

91.      Best skin cancer screening test?*

full body derm exam 

according to ACS: every 3 years between 20-40, then yearly

According to AMA: frequency of screening should be determined by physician, those with increased risk should be screening anually

- skin self-examination should be performed monthly

92.      Description and prognosis of cherry hemangiomas*

[image]

  Description and prognosis of cherry hemangiomas                                                    From emedicine.net:

Cherry hemangiomas are the most common cutaneous vascular proliferations. They are often widespread and appear as tiny cherry red papules or macules. These benign lesions are formed by a proliferation of dilated venules.

Prognosis: The appearance of cherry angiomas has essentially no effect on the patient's life span, except in very rare situations in which the angiomas are present as a paraneoplastic sign in association with the development of an internal malignancy

93.      Skin lesions and descriptions associated with HIV infection*

Per Currents pg.1215: 

1. Viral infections: herpes simplex, herpes zoster, molluscum contagiosum caused by pox virus (characteristic umbilicated fleshy papular lesion have a propensity for spreading widely over the patient's face & neck & should be txt w/topical liquid nitrogen).
2. Bacterial: Staph (most common bacterial cause of skin dx) presents as: folliculitis, superficial abscesses (furnucles), bullous impetigo.
3. Fungal: d/t dermatophytes & Candida - common in inguinal region. txt of choice: ketoconazole
4. Non-specific dermatides: bacillary angiomatosis (caused by 2 closely related organisms: Bartonella henselae & Bartonella quintana. Their epi is suggestive of zoonotic transmission from fleas/infected cats. Sxs: raised, reddish, highly vascular skin lesions that can mimic Kaposi sarcoma. Fever is common. Doxy is txt of choice.
5. Misc: Seborrhic dermatitis, Xerosis, Psoriasis
6. Malignancies: Kaposi sarcoma, NHL, primary lymphoma of the brain & invasive cervical.

95.      Patho and treatment of nursemaid’s elbow*[image]

aka pulled elbow

- Mech: subluxation of radial head generally results from a sudden pull on the upper limb such as that exerted by an adult to prevent child from falling or when a child is lifted up by the wrists/hands

- usually 1-3 yo, rare after 4 

- child presents w/ injured elbow protonated, partially flexed and held by side 

- Tmt: obtain Xray, reduction (referral), R.I.C.E, sling for comfort

96.      S/S of L4 nerve root deficit*

Due to herniation/degeneration at L3-L4

- Pain in low back, posterolateral thigh, across patella, anteromedial leg

- Sensory changes seen at anterior knee and anteromedial leg

- Motor weakness/ atophy seen in quadriceps (knee extension)

- Knee jerk reflex change

Etanercept (Enbrel)

Infliximab (Remicade): monoclonal Ab to TNAa, given by periodic IV infusion. Is rapidly and tremendously effective

Adalimumab (Humira): injectable synthetic protein that blocks inflammatory effects of TNFa

• TNF inhibitors: Entanercept, Infliximab, adalimumab
• T cell blockers: Abatacept (Orencia)
• Depletion of B cells: Rituixmab (Rituxan)

• mild anemia (hemolytic),
• renal involvement (proteinuria),
• +ANA in high titers (higher than SLE),
• Scleroderma Ab (anti-SCL-70) + in 30% of pts (very high specificity)
• CREST syndrome: anticentromere antibodies (50%)
• RF (30%)

• CREST syndrome (80% of pts)
• • Calcinosis cutis (calcium deposits in skin)
  • Raynaud's phenomenon
  • Esophageal motility disorder
  • sclerodactylyl (tightening of skin)
  • Telangiectasia (small bld vessels near surface of skin or mucus membranes)
  • Hardening of skin limited to face an hands
  • digital ischemia (causes finger loss)
  • life threatening pulmonary HTN

• skin changes include trunk and proximal extremities
• Tendon friction rubs over forearms and shins only in diffuse dz
• Kidney, interstitial lung dz
• cardiac involvement
• fibrosis throughout most organs

• ANA: (95-100% of pts)
• anti-Native DNA (60%) usually means lupus, rarley RA
• RF: (20%)
• anti-Sm: (10-25%) no other autoimmune dz has this
• depressed serum complement; normal in remission
• up to 20% also have Anti-SS-A or Anti-SS-B
• CBC: may have anemia (hemolytic), leukopenia, lymphopenia, thrombocytopenia

29c. Criteria for SLE*

Need 4 of the 11 for Dx:

1. Malar rash

2. discoid rash

3. photosensitivity (burn immediately, rash worsens)

4. oral ulcers

5. Arthritis

6. Serositis (inflammation of serous linings) 

7. Kidney Dz (preteinuria/casts)

8. Neuro dz

9. Hematologic disorders (anemia, leukopenia, lymphopenia, thrombocytopenia_

10. +ANA

11. Immunologic disorder (+LE cell prep, + anti-native-DNA, +anti-sm, false + syphilis test)

types of acute:          

-Hematogenous: sudden onset of sxs. IV drugs users spine is #1 site of dx. (s.aureus #1, p aeruginosa & serratia too). Rapid progression to epidural abscess (fever,pain) & sensory motor loss. Elderly: T & L verterbrae most common sites w/more low-grade fever & gradual bone pain. 

-infection (prosthesis, decubitus ulcer, neurosurgery & trauma w/s aureus & staph epi most common): localized signs of inflamm but high fever & other toxicity sxs are usu absent. Septic arthritis & cellulitis can also cause this.

-assoc. w/vascular insufficiency: foot & ankle most common sites. Ulcer or other break in skin is usu still present. Bone pain is absent/muted. No fever. Ability to easily advance sterile probe through skin ulcer to bone & ulcer area >2cm are clues to dx.

More common than acute - d/t txt w/antibiotics resulting in a semicontained bone lesion. 

-sxs present >2wks after onset of infection & are less severe that acute (pain present  but systemic issues are not)

-Staph is most common bug

-ESR is elevated 

-often confused w/neoplasm

-Brodie's abscess is a form (small, localized, painful cavity which develops in metaphysis & is surrounded by dense, sclerotic bone.)

Commonly caused by open fracture or wound & rarely surgical procedure. 

-seen in lower extremities of DM pts

-onset of inflamm & cellulitis after open fracture or persistent drainage of acute osetomyelitis.

-fever, pain & mild systemic sxs 

-external physical findings are minimal

-soft tissue inflamm & tenderness 

-may become latent post-txt but can be reactivated years later by minor trauma