Patient comes in with pain with overhead reaching and

+ Hawkins, + Neer. 

What do they have?

A diabetic patient comes into your office and tells you that they can't move their arm as high as they used to.

What do they have?

Adhesive capsulitis

Frozen shoulder

Rotator Cuff Tendinopathy

While rock climbing, the rope breaks and Jill falls to the ground, landing on her shoulder. During her exam you hear a popping noise in the front of her shoulder and a bump on top of her shoulder.

What's your diagnosis?

A patient comes in with pain when reaching overhead. You find out that they have a + yergasons and + speeds (whatever that is).

What's your diagnosis?

A thin shot-putter decides to swim across the English channel. Once she finishes, she realizes her arm feels vaguely loose. Her arm has increased ROM at the shoulder, + apprehension, and a sulcus sign.

What's your diagnosis?

Shoulder instability

Dead arm

Serena Williams walks into your office and tells you that it hurts when she opens the pickle jar and when she dorsiflexes her wrist.

What's her diagnosis?

Lateral elbow

Epicondylitis

Tennis elbow

Tiger woods walks into your office and tells you that he has trouble opening the pickle jar and pain with volar flexion of the wrist.

What's his diagnosis?

Medial elbow

Epicondylitis

Golfer's elbow

Popeye walks into your office and says it hurts when he leans on his elbow. During the PE you notice swelling over his elbow.

What should you check for before diagnosing it?

Crystals and infection

He has posterior elbow = olecranon bursitis

Someone comes in with tingling in fingers 1 - 3.5 and pain that worsens upon flexion. The patient has a + phalen, + tinel, thenar atrophy, and decreased 2 point discrimination.

What do you use to confirm the diagnosis?

What risk factors might this person have?

EMG to confirm

Diabetes, pregnant, obese, hypothyroidism

They have carpal tunnel syndrome

Someone comes in with De Quervains tenosynovitis from repetitive wrist movements. They have pain in the anatomical snuff box.

Which test would you use to confirm this diagnosis?

A patient has ulnar side tenderness after having their wrist hit by a baseball bat.

What's the diagnosis?

TFCC

Triangular Fibrocartilage Complex injury

x-ray since they probably have a distal radial fracture

aka Colle's fracture

While doing an annual check-up on Mr. Smith you notice a bump on the back of his wrist. He says it's been there for months and it doesn't hurt. His fingers and wrist have full range of motion.

What's his diagnosis?

Dorsal ganglion cyst

leave it alone unless they have trouble moving wrist/fingers

When evaluating the spine to determine the cause of back pain, what 6 red flags should you look out for?

What test should you do on someone if they have a red flag or they have an abnormal neuro exam?

1. trauma

2. motor or sensory deficits

3. incontinence

4. fever, chills, weight loss

5. history of cancer

6. IV drug use

Xray

Name the common causes of back pain for the following age groups:

20s

30s

40s

50s

60+

20s- disc injury, spondylolisthesis

30s- disc herniation

40s- disc herniation, spondylolisthesis

50s- disc herniation and degeneration, multiple myeloma, metastatic tumor

60+: metastatic tumor, spinal stenosis (also disc herniation & degeneration)

Entrapment of which nerve roots would cause the following neck and radicular arm pain?

pain to triceps, index, long finger

pain to lateral shoulder

pain to thumb and radial aspect of forearm

C6-7

C4-5

C5-6

People with herniated cervical disks will rest their arms on their head to relieve pain.

People with should pain will rest their arm on their side to relieve pain.

What is the most likely cause of low back pain in a:

25yo

45yo

75yo

25- sprain surrounding soft tissue

45- herniated disk

75- disc degeneration

What does back pain and unilateral leg pain suggest?

What makes the pain worse?

What does back pain and exercise induced bilateral leg pain suggest?

disc herniation from L4-S1 level

sitting

spinal stenosis

A young person comes in with a herniated disc and pain on their radial side of forarm.

What test would help diagnose cervical radiculopathy?

1. Fever, chills, weight loss

2. History of cancer

3. Significant nighttime pain

4. Pain for more than 6-12mo

5. Hx of pathological fractures

6. Deformity

7. Loss of major motor function

8. Bowel or bladder dysfunction

A patient comes into your office with abrupt onset of acute low back pain that travels down the posterior aspect of the leg to foot. The pain is worsened by sitting, coughing, and sneezing.

What does she probably have?

An old person walks into your office with low back pain and leg pain. The pain is worse when standing and better when sitting.

What do they have?

Connect the disease with the symptom:

Disease:

Cauda Equina syndrome

Vertebral osteomyelitis

Thoracolumbar fracture

Degenerative spondylolisthesis

N. cord compression

Symptom:

Overflow incontinence

Complication of cancer

Can't walk

Pain worsened with bending

Tenderness to spinal percussion

Cauda Equina syndrome- Overflow incontinence

Vertebral osteomyelitis- Tenderness to spinal percussion

Thoracolumbar fracture- Can't walk

Degenerative spondylolisthesis- Pain worsened with bending

N. cord compression- Complication of cancer

An 80 yr old patient comes in complaining of shoulder and pelvic pain. They feel tired and have a fever with elevated ESR.

What should you treat them with?

Prednisone- they have a big response to it

They have polymyalgia rheumatica

A 3yr old girl comes into your office with pauci-articular arthritis. Besides her joints, what should be the next organ that you examine?

Do you expect her to have a + or - ANA?

Eye- uveitis is most common in pauci-articular JIA

+ANA

HLA-DR4

she has polyarticular arthritis

big fingers- dactylitis

indentions in their nails- nail pitting

symmetrically swollen peripheral joints >4

Remember- they get rash AFTER the arthritis sets in

Someone comes in with 1 hot, swollen, painful joint and a fever.

What do they have?

What age groups are they in?

Septic arthritis- probably staph

<2 or >80

Need 4 of these to diagnose lupus

RASH ON MAIDS

1. Renal- proteinuria or casts

2. ANA +

3. Serositis

4. Heme abnormal

5. Oral ulcers- painless

6. Neuro- seizures or psychosis

7. Malar rash- spares nasolabial folds

8. Arthritis- non-erosive Jaccoud's, mimics RA

9. Immunologic- anti-DNA OR anti-SM, HLA-DR2, 3

10. Discoid rash

11. Sun sensitivity

What 3 things should you avoid if you have lupus?

What are the 2 most specific tests for lupus?

What is anti-dsDNA associated with?

What is ribosomalP associated with?

sun, sulfa drugs, smoking

anti-DNA, anti-Sm

nephritis

Neuropsychiatric lupus

Phenytoin, procainamide, hydralazine, minocycline

Remember-- these drugs do NOT cause serositis, rash, ulcers, CNS problems, and are not associated with gender or age

Myositis:

Lab signs?

What would the EMG show?

What is the gold standard for diagnosing it?

elevated muscle enzymes- creatine kinase, aldolase, AST, ALT

irritability of myofibrils w/ short duration

biopsy muscle

Poly- endomysial infilatration w/ CD8+ lymphocytes, fatty and fibrous replacement

Dermato- perivascular infiltration w/ CD4+ cells w/ membrane attack complex C5-9, atrophy

Gottron's sign- scaling on the knuckles

Heliotrope rash- purple eyelids

Myositis

Fever

Arthritis

Mechanic's hands

Interstitial lung disease

Primary- in women, starts w/ menarche, affects all fingers, lasts >10 days, worse w/ stress, vasomotor-migraines

no tissue damage, not related to a systemic disease, benign, ANA-, normal ESR

Secondary- M=F, mid 20s, begins w/ 1 finger, <5 days, secondary to scleroderma, ANA+,

worse symptoms:

assoc. w/ vasospasm, digital pitting scars, tissue damage, finger edema, periungal erythema, ulcers

Separate the characteristics between limited and diffuse scleroderma:

later distal skin involvement

start w/ rapid skin proximal skin involvement

assoc. w/ internal organ involvement in 4 yrs incl scleroderma renal crisis (SRC)

can progress to CREST syndrome

can get pulmonary artery hypertension

assoc. w/ antitopoisomerase Abs (anti-Scl 70)

assoc. w/ anticentromere Abs

higher risk of pulmonary fibrosis

worse prognosis

Both start w/ raynaud's

Limited- later distal skin involvement, can progress to CREST syndrome, assoc. w/ anticentromere Abs, can get pulmonary artery hypertension

Diffuse- start w/ rapid skin proximal skin involvement, assoc. w/ internal organ involvement in 4 yrs incl. scleroderma renal crisis (SRC), assoc. w/ antitopoisomerase Abs (anti-Scl 70), higher risk of pulmonary fibrosis, worse prognosis

Just remember:

Swimming instruction is not recommended as the sole means to prevent drowning.

Name 3 primary predictors of injury prevention counseling in the office setting.

Name 2 secondary predictors.

1. importance of providing counseling

2. Self-efficacy

3. Sense of effectiveness

1. Time constraints

2. Reimbursement for services

The answers are hematogenous seeding, contiguous infection, both:

Which is acute?

Which is subacute or chronic?

Long bones in kids and vertebrae in adults?

Due to diabetes or vascular disease?

Due to endocarditis, UTI, IVDA, TB?

Monomicrobial (Staph aureus only)?

Polymicrobial?

Results in a nidus of bacteria which is protected inside bone.

Results in avascular bone= sequestrum

acute- hematogenous

subacute or chronic- both

long bones & vert.- hematogenous

Due to diabetes or vascular disease?- contiguous

Due to endocarditis, UTI, IVDA, TB?- hematogenous

Monomicrobial (Staph aureus only)? hematogenous
Polymicrobial? contiguous

Results in a nidus of bacteria which is protected inside bone.= contiguous

Results in avascular bone= sequestrum- contiguous

Which is the best test for screening for osteomyelitis?

For diagnosing osteomyelitis?

For making a definitive identification of the pathogen causing osteomyelitis?

xray

MRI

bone biopsy and culture

Acute- antibiotics- IV then oral

Chronic- aggressive surgical debridement to prevent avascular necrosis and sequestrae

+

Antibiotics for a few months

All of these can lead to which disease?

Chondrocalcinosis

DISH- diffuse idiopathic skeletal hyperostosis

Erosive joints in old women

Syphilis

Diabetes

How long does chronic osteomyelitis last?

When someone has chronic osteomyelitis, what can you see on their skin surface?

<4 wks

Sinus tract

What disease is this?

Female in knees and hands

loss of articular cartilage, narrow joint space

thickened subchondral bone

PIP + DIP affected

acromegaly

hemochromatosis

osteonecrosis

Name the disease:

gelling

bony enlargement

crepitus

decreased ROM

non-inflammatory

sclerosis and cyst formation

Name 3 symptoms associated with fibromyalgia besides pain.

Name 4 overlapping regional syndromes associated with fibromyalgia.

fatigue, paresthesia, memory problems

irritable bowel, headaches, TMJ symptoms, chronic pelvic pain

Some comes into your office with 1 painful joint.

Name 4 possible inflammatory causes.

Name 5 non-inflammatory causes.

1. Crystal- gout, pseudogout, hydroxyapatite

2. Infectious- bacterial, gonococcal, fungal

3. Early polyarticular- RA, spondyloarthropathy

4. Juvenile idiopathic arthritis

OA, avascular necrosis, trauma, neuropathic, malignancy

What is the primary defect in acne?

What 3 things cause this defect?

keratin plug in the hari follicle

genes, adrogens stimulating the sebaceous glands, Propionibacterium acnes

IgE

Eosinophils

Th2 cells

skin folds will also have a rash

white scales on the plaques

pinpoint pustulo-vesicular satellite lesions present

b hemolytic strep OR staph aureus

topical mupirocin

What term would you use to describe a severe inflammatory reaction resulting in inflamed, tender, boggy, purulent plaque with multiple draining orifices with crusts and stumps of hair interspersed.

This can cause permanent alopecia due to tinea capitis.

Parvovirus B19

Erythema Infectiosum

HHV6

Roseola infantum, 6th disease

Exanthem subitum

Scarlet fever

Name the UV ray:

100-290 nm

C

Name the UV ray:

290-320

used for vitamin D synthesis

treats psoriasis and vitiligo

Blocked by clear glass

Name the UV ray:

320-340

Name the UV ray:

340-400

What causes eczematous plaques in sun-exposed areas with lichenification and is super puritic?

It happens in old men