kRheumatology/Musculoskeletal/Immunology System: Kaplan Companion to First Aid for USMLE Step 2 CK

A001. Chronic inflammatory disease of spine and pelvis; sacroilitis => fusion of affected joints; 20's - 30's; seronegative; HLA-B27; risk factors – male, family History

A002. History - hip and low back pain, worse with inactivity, worse in mornings, better with activity, thru day; PE - hip pain and stiffness; limited chest expansion; loss of lumbar lordosis; positive Schober test - decreased spine flexion; may have anterior uveitis,; 3rd degree heart block; aortic insufficiency => CHF

A003. Dx based on clinical & XR; HLA-B27; ESR - may be elevated; RF & ANA - negative; spine and pelvic XR - "bamboo spine"

A004. NSAIDs; exercise; physical therapy

A005. "Can't see, can't pee, can't climb a tree"; conjunctivitis; uveitis; urethritis; arthritis; may also have - keratoderma blennorrhagicum, circinate balanitis; after infection with – campylobacter, Shigella, salmonella, chlamydia, ureaplasma; seronegative; HLA-B27; young men

A006. Chronic inflammatory arthritis; psoriasis of skin; psoriatic nail lesions; DIP joints; sausage-shaped digits; "mushroom caps"; HLA-B27; seronegative

A007. Chronic autoimmune diseases; peripheral joints - symmetrically inflamed; progressive destruction of articular tissue; erosion of - cartilage, bones, tendons; systemic Sxs; atlanto-axial subluxation; ruptured Baker's cyst; MC females 35-50; HLA-DR4; T cell activation - why HIV improves pre-existing

A008. Insidious onset of morning stiffness > 1 hr; painful, warm swelling of multiple symmetric joints > 6 wks; MC - wrist, MCP, PIP, any joint may be involved; axial rare except upper cervical spine; ulnar deviation; MCP joint hypertrophy, swan-neck, boutonniere; subq, painless Baker's cysts

A009. RF (anti-Fc IgG Ab); ESR; XR; synovial fluid aspiration - slightly turbid, decreased viscosity, WBC 3,000-50,000

A010. NSAIDs; COX-2 inhib; severe – corticosteroids, methotrexate, hydroxychloroquine sulfate, gold, azathioprine; operative may be necessary.

A011. RA; splenomegaly; neutropenia

A012. Nonmigratory, nonsuppurative, mono- and poly-arthropathy; bony destruction; < 16 y/o; lasts > 6 wks; 95% - disease resolves by puberty

A013. 3 patterns; all patterns may have – fever, nodules, erythematous rashes, pericarditis, fatigue; pauciarticular - MC form, < 4 joints, weight-bearing joints; ANA type - MC subtype, asymm involvement of lg. joint, iridocyclitis – insidious, if not treated => blind; RF type - poor prognosis, HLA-B27 - boys also have spondyloarthropathies,; polyarticular - > 5 joints, similar to adult RA, symmetric, may develop iridocyclitis; Still's disease (systemic) - least common, daily high spiking fever, evanescent salmon-colored rash, hepatosplenomegaly, serositis

A014. No diag tests; XR; RF - positive in 15%; ANA - may be positive; RBC decreased; elevated – ESR, WBC, platelets; normal ESR doesn't exclude Dx

A015. NSAIDs; corticosteroids; ROM and strength exercises; methotrexate; monitor iridocyclitis

A016. Progressive systemic sclerosis; multisys disease; thickening of skin from; accumulation of connective tissue; MCC of death - pulmonary; CREST - better prognosis; MC - females 30-50

A017. All have thick skin & Raynaud's; Lung - pulmonary fibrosis => restrictive lung disease and cor pulmonale; GI - esophageal dismotility, achalasia, decreased motility of small intestines, dilation of large intestines, large diverticula; renal - malignant HTN => ARF; CREST - limited form

A018. Calcinosis; Raynaud's; esoph dysmotility; sclerodactyly; telangiectasias

A019. RF; ANA; eosinophilia; anticentromere Ab - CREST; anti-Scl-70 - systemic

A020. Systemic glucocorticoids; penicillamine - skin changes; Ca2+ channel blockers - Raynaud's; ACE inhibitor - renal disease, HTN

A021. Multisys autoimmune; women - especially Black; Ab-mediated cellular attack; deposits of Ag-Ab complexes; lupus-like syndrome - drug-induced lupus, Hydralazine, penicillamine, Procainamide, INH, methyldopa; rash only, anti-histone Ab, resolves when drug discont.

A022. DOPAMINE RASH; Discoid rash; Oral ulcers; Photosensitivity; Arthritis; Malar rash; Immunologic criteria; Neuro Sxs - lupus cerebritis, seizures; Elevated ESR; Renal disease; ANA positive; Serositis; Hematologic abnormalities; Sxs exacerbated - sun exposure, pregnancy

A023. Anemia; leukopenia; TCP; ANA; anti-dsDNA; anti-Sm Ab; active attacks - decreased C3 and C4; antihistone Ab - drug-induced; anti-Ro (SSA) - neonatal lupus, neonatal congenital heart block if pregnant, screen; antiphospholipid Ab – hypercoagulability, thromboembolic disease, recurrent spontan abortions, stillbirths; Tx - LMWH

A024. Arthritis - NSAIDs; major organ involvement - steroids; flare-ups - steroids; antimalarials - rash; nephritis – cytotoxics, cyclophosphamide, azathioprine

A025. Infections; progressive impairment of – brain, heart, lungs, kidney; increased risk - spontaneous abortion (antiphospholipid Ab); neonates - increased risk of congenital complete heart block (anti-Ro/SSA)

A026. Giant cell arteritis; women 2x's > men; > 50 y/o; subacute granulomatous inflamm; large vessels – aorta, external carotid - especially temporal, vertebral a; blindness - occlusion of central retinal; polymyalgia rheumatica - 50%

A027. Headache; temporal tenderness; scalp pain; jaw claudication; fever; monocular blindness - transient or permanent; weight loss; malaise; myalgia; arthralgia

A028. ESR; ophthalmologic evaluation; Biopsy - temporal artery

A029. If suspect TA - start steroids before Biopsy; hi-dose prednisone - 1-2 mos. before taper; monitor eye exams

A030. Immune-mediated vasculitis; IgA immune complexes; small arteries - GI tract; skin; joints; kidney; 2-11 y/o; degree of renal involvement; det. prognosis

A031. Palpable purpura - buttocks and legs; asymmetric, migratory; periarticular swelling; abdominal pain; preceding URI

A032. Usually self-limited; Tx supportive; steroids - Sxs

A033. GI bleeding; intussusception; glomerulonephritis

A034. Elderly females; close association with; temporal arteritis

A035. Pain and stiffness – shoulder, pelvic girdle; especially severe in morning or after inactivity; minimal joint swelling; fever, malaise, weight loss; hard to - get out of chair, lift arms above head; muscles not weak; pain limits muscle effort

A036. Clinical; anemia; ESR high

A037. Low-dose prednisone

A038. Inflammatory muscle diseases; progressive muscle weakness; polymyositis; dermatomyositis; inclusion body myositis

A039. Difficulty with proximal muscles - lifting objects, combing hair, getting up from chair; difficulty with distal later - writing; dermatomyositis - heliotrope rash, Grottron's papules

A040. Most sensitive test - CK - elevated; aldolase - elevated; anti-jo-1 autoAb; EMG; muscle Biopsy - confirms

A041. Steroids - polymyositis; dermatomyositis; inclusion body myositis - resistant to immunosuppressives

A042. Connective tissue d/o; myalgia; weakness; fatigue; no inflammation; associated with – depression, anxiety, IBS; MC women > 50

A043. Pain when palpate at least 11 of 18 tender points; palpate "trigger point"=> pain, body aches; fatigue; sleep disorders

A044. Dx of exclusion; myofascial pain syndrome - < 11 tender points or nonfibromyalgia-associated tender points

A045. Stretching; heat application; hydrotherapy; transcutan electrical; nerve stimulation; patient education; stress reduction; low-dose antidepressants

A046. Chronic autoimmune disease; lymphocytes infiltrate exocrine glands; can become progressive => systemic => lymphoproliferative (malignant lymphome)

A047. Xerostomia; dry eyes; keratoconjunctivitis sicca; "sandy feeling under eyes"; dental caries; parotid enlargement

A048. Schirmer's test - decreased tear production; rose bengal stain - corneal ulcers; anti-Ro (SSA) & anti-La (SSB); Biopsy - lymphocytes infiltrate salivary gland

A049. None; symptomatic Tx - artificial tears

A050. Procainamide; Hydralazine; Isoniazid; Chlorpromazine; Methyldopa; Quinidine

A051. Fever, anorexia, malaise, weight loss; Butterfly rash; Nail fold infarcts; Splinter hemorrhages; Raynaud's Phenomenon

A052. Requires 4 of 11 criteria:; Malar rash; Discoid rash; Photosensitivity; Oral ulcers; Arthritis; Serositis; Renal disorder; Seizures, psychosis; Hematologic; Immunologic; Positive ANA

A053. Refer to rheumatologist; NSAIDS; Antimalarial drugs; Steroids; Immunosuppressive drugs; Anticoagulation

A054. Recurrent venous or arterial occlusions; Recurrent fetal loss; Thrombocytopenia; Antiphospholipid antibodies; No other features of SLE

A055. diffuse fibrosis of the skin and internal organs

A056. Limited - CREST; Diffuse - Renal failure, intersitial lung disease, cardiac disease

A057. Calcinosis; Raynaud's syndrome; Esophageal dysmotility; Sclerodactyly; Telangiectasia

A058. Polyarthralgia, Raynaud's phenomenon; Thickened skin, with loss of normal folds; telangiectasia, pigmentation, depigmentation; Dysphagia; Restrictive lung disease; Pericarditis, heart block; Renal disease

A059. mild anemia; normal ESR; positive ANA; SCL-70; Anticentromere antibody (50% w/ CREST)

A060. Severe Raynaud's phenomenon - nifedipine, losartan; Esophageal reflux - H2 blockers, PPI, antacids; Bacterial overgrowth and pseudoobstruction - octreotide; Malabsorption d/t bacterial overgrowth - tetracycline

A061. False

A062. chronic dysfuction of exocrine glands

A063. keratoconjunctivitis; burning, itching, FB sensation in eye; Dry mouth; Loss of taste and smell; Parotid enlargement; Desiccation of nose, throat, larynx, vagina, skin; Dysphagia; Pancreatitis

A064. Mild anemia; Leukopenia; Eosinophilia; Polyclonal hypergammaglobulinemia; Positive RF; ANA; Anti-SS-a and Anti-SS-b; Thyroid-associated autoimmunity; Schirmer test; Lip biopsy; Parotid gland biopsy

A065. quantity of tears secreted

A066. Supportive and symptomatic

A067. Pilocarpine

A068. lymphoma

A069. pain and stiffness in neck, shoulder, and pelvic girdle

A070. pain and stiffness in neck, shoulder, and pelvic girdle; symmetrical symptoms; more prolonged in the morning; low-grade fever, fatigue, weight loss

A071. No

A072. ESR and CRP elevated; Anemia and mild thrombocytosis

A073. Prednisone 10-20 mg/day for 6 months-2 years

A074. Symptoms; Treatment

A075. medium-sized necrotizing arteritis

A076. Idiopathic; Hep B or C; Drugs

A077. PTU; Hydralazine; Allopurinol; Penicillamine; Sulfasalazine

A078. fever, malaise, weight loss; pain in extremities; Foot drop; livedo reticularis; HTN

A079. anemia; elevated ESR; Leukocytosis; Hep B or C

A080. tissue biopsy

A081. corticosteroids (up to 60mg/day); immunosuppressive agents (cyclophosphamide); refer to rheumatologist

A082. mesenteric vasculitis

A083. Reactive arthritis

A084. dysentery - Shigella, Salmonella, Yersinia, Campylobacter; STD - Chlamydia

A085. Urethritis; Conjunctivitis; Mucocutaneous lesions; Aseptic arthritis; Fever, weight loss; Aortic regurgitation

A086. permanent or progressive joint disease (sacroiliac or peripheral joints)

A087. NSAIDS; antibiotics at time of infection; tetracycline; sulfasalazine; methotrexate; anti-TNF agents

A088. False

A089. triad - keratoconjuctivitis sicca, xerostomia, arthritis; also, pancreatitis, fibrinous pericarditis

A090. + ANA, antiRo/antiLa abs, 70% RF +; a/w HLA-DR3

A091. 20 yo; oral/genital ulcers; uveitis, arthritis, other derm disease

A092. young kids, old peeps; symmetric weakness of proximal muscles (can see dysphonia/dysphagia) look for trouble getting out of chair. skin involvement = heliotrope rash around eyes + periorbital edema

A093. high ESR, high CPK, abnormal EMG, muscle biopsy --> inflammation + ANA

A094. <5 yo; truncal rash, fever >104x(>5d), conjunctival injection, cervical LAD, strawberry tongue, skin desquamation. -> coronary vessel vasculitis, aneurysms, MI

A095. NOT STEROIDS; aspirin + IVIG

A096. Associated with hepatitis B + cryoglobulinemia; fever, abdominal pain, weight loss, renal disorder, peripheral neuropathies.

A097. high ESR, leukocytosis, anemia, hematuria/proteinuria. Biopsy of medium-sized vessels --> vasculitis

A098. C - calcinosis; R - raynaud's; E - esophageal dysmotility; S - sclerodactyly; T- telangectasia; heartburn, mask-like leathery facies.

A099. Positive ANA; positive anticentromere Abs = CREST; positive antitopoisomerase = scleroderma

A100. procainamide; hydralazine; dilantin (phenytoin); sulfanomide; INH

A101. Positive antihistone Abs

A102. Positive ANA screen; positive antiSm or anti-ds-DNA

A103. false positive for VDRL or RPR for syphilis; PTT falsely elevated; (SLE actually thrombogenic)

A104. East Asian women 15-30yo; "pulseless" in 1 or both arms. carotid involve --> neuro sign, stroke; CHF

A105. old peep; nose bleeds, nasal perforation, hemoptysis, dyspnea, hematuria, ARF

A106. Weg = old peep, +ANCA; Goodpasture = young peep, positive antiglomerular antibody

A107. Women >50yo; Pectoral and pelvic girdles, neck involvement; a/w temporal arteritis

A108. Really high ESR; normal muscle biopsy/EMG

A109. It is an antibody against the Fc portion of IgG = RF & IgG form immune complexes. which is itself an antibody, IgM or IgA type.

A110. High levels RF: generally > 20 IU/mL; rheumatoid arthritis: present in 80%; Sjögren's syndrome: present in 60%

A111. Chronic hepatitis; Any chronic viral infection; Leukemia; Dermatomyositis; Infectious mononucleosis; Scleroderma; Systemic lupus erythematosus (SLE)

A112. an autoimmune disorder in which immune cells attack and destroy the exocrine glands that produce tears and saliva with Schirmer test(+); A lip biopsy can reveal lymphocytes clustered around salivary gland

A113. Group of related INFLAMMATORY JOINT Ds associated with the MHC class I molecule HLA-B27

A114. Spondylarthropathy & (-)rheumatoid factor (RhF)

A115. Indicator of other rheumatological disease (in particular rheumatoid arthritis)

A116. ankylosing spondylitis Caucasians (AS, 92%),; ankylosing spondylitis African-Americans (AS, 50%),; reactive arthritis (Reiter's syndrome) (RS, 60-80%),; enteropathic arthritis associated with inflammatory bowel disease (IBD, 60%),; Psoriatic arthritis (60%),; isolated acute anterior uveitis (AAU, iritis or iridocyclitis, 50%), and; undifferentiated SpA (USpA, 20-25%).

A117. thromboangiitis obliterans;; idiopathic, segmental, thrombosing vasculitis of intermed/small peripheral arteries and veins; seen in heavy smokers (tx- stop smoking)

A118. intermittent claudication, superficial nodular phlebitis, cold sensitivity, pain

A119. pulseless disease;; granulomatous thickening of aortic arch and/or proximal great vessels;; associated with elevated ESR; primarily affects Asian females < 40 y/o

A120. fever,; arthritis,; night sweats,; myalgia,; skin nodules,; ocular disturbances,; weak pulses in upper extremities

A121. most common vasculitis that affects medium and small arteries, usually branches of carotid; focal, granulomatous; unilateral HA, jaw claudication, impaired vision (occlusion of opthalmic artery- blindness); half of patients have systemic involvement and polymyalgia rheumatica; elevated ESR

A122. steroids

A123. buergers

A124. takayasus

A125. necrotizing immune complex inflammation of medium sized muscular arteries typically involving renal and visceral vessels; sxs: weight loss, malaise, fever, abdominal pain, melena, HA, myalgia, HTN, neuro dysfunction, cutaneous eruptions

A126. hep B;; multiple aneurysms and constrictions on arteriogram; not associated with ANCA (P maybe)

A127. corticosteroids, cyclophosphamide (hemorrhagic cystitis)

A128. traid of focal necrotizing vasculitis,; necrotizing granulomas in the lung and upper airway and necrotizing GN

A129. perforation of nasal septum,; chronic sinusitis,; otitis media,; mastoiditis,; cough,; dyspnea,; hemoptysis,; hematuria; looks like goodpastures but upper respiratory tract is also involved

A130. CANCA,; CXR- may reveal large nodular densities,; hematuria and red cell casts; tx: cyclophosphamide, corticosteroids

A131. granulamatous vasculitis with eosinophilia;; involves lung, heart, skin, kidneys, and nerves; often seen in atopic pts; tx: steroids

A132. acute, self limiting disease of infants and kids;; acute necrotizing vasculitis of small/medium sized vessels; fever, congested conjunctiva, changes in lips/oral mucosa,; LAD, may develop coronary aneurysms,; skin rash,; strawberry tongue; tx: high dose aspirin

A133. most common childhood vasculitis;; skin rash (palpable purpura) below legs,; arthralgia,; intestinal hemorrhage,; abdominal pain,; melena

A134. AV malformation in small vessels;; looks like dilated capillary; hereditary hemorrhagic telangiectasia-AD inheritance; presents with nosebleeds and skin discolorations

A135. Arthrocentesis is a needle aspirate of synovial fluid for microscopic analysis. The cell count is the most accurate way of telling immediately if there is an infection versus inflammation. Counts from 0 to 2,000 are normal; from 2,000 to 20,000 are from inflammatory disorders such as gout. Counts above 50,000 are from infections. Counts between 20,000 and 50,000 are indeterminate.

A136. Scleroderma

A137. 1. Hashimoto's; 2. Autoimmune Hepatitis

A138. IDDM; type I diabetes

A139. Myasthenia gravis

A140. Addison's

A141. Goodpasture's

A142. CREST

A143. SLE [specific]

A144. Pemphigus vulgaris

A145. Celiac disease

A146. Drug induced lupus

A147. Rheumatoid arthritis

A148. Pernicious anemia

A149. Primary biliary cirrhosis

A150. Vasculitis

A151. Wegener's granulomatosis

A152. Polyarteritis nodosa

A153. SLE

A154. Hashimoto's

A155. Hashimoto's

A156. Graves' or Hashimoto's

A157. Polymyositis;; dermatomyositis

A158. Pernicious anemia

A159. ITP

A160. SLE

A161. PAIR; Psoriasis,; Ankylosing spondylitis,; Inflammatory bowel diseas,; Reiter's syndrome

A162. Graves Disease, Celiac Sprue

A163. Mulitple sclerosis,; hay fever,; SLE,; Goodpastures

A164. DM Type 1

A165. Rheumatoid Arthritis, DM Type 1

A166. Pernicious anemia = B12 deficiency,; Hashimoto's thyroiditis

A167. Steroid-response nephrotic syndrome

A168. Increased pressure in a confined space; compromises nerve, muscle & soft tissue perfusion; MC - ant. compartment of lower leg & forearm; causes – fractures, crush injuries, burns, ischemic- reperfusion after an injury, casts

A169. The 6 P's:; Paresthesias; Palpation - tense compartment; Pallor; Poikilothermia; Pulselessness; Paralysis; Pain - out of proportion with passive motion of fingers & toes; Volkmann's contracture

A170. Measure compartment pressure - > 30 mmHg not good; delta pressure - diastolic minus compartment; should be > 30 to be OK

A171. Surgical emergency; immediate fasciotomy of all compartments; do in < 6 hrs.

A172. Paraspinous; strains - muscle injury; sprain - ligament injury

A173. If malignancy - pain worse at night; pain not relieved by rest; pain not relieved by changing positions; if point tenderness over vertebral body – osteomyelitis, fracture, malignancy; cauda equina syndrome - bladder or bowel dysfunction, saddle-area anesthesia, impotence, surgical emergency

A174. Motor - foot dorsiflexion, tibialis anterior; reflex - patellar; sensory - medial aspect of leg

A175. Motor - big toe dorsiflexion, extensor hallucis longus; reflex - none; sensory - medial forefoot & lateral aspect of leg

A176. Motor - foot eversion; peroneus longus/brevis; reflex - achilles; sensory - lateral foot

A177. Mainly clinical; XR; MRI; electrodiagnostic studies - nerve conduction velocity test

A178. Sprains & strains - NSAIDs; physical therapy; continue activities as tolerated; rest > 1-3 days unnecessary. 90% recover spontaneously in 6 weeks; surgery - if correctable spinal disease, cauda equina syndrome - surgical emergency: immediate decompression, laminectomy

A179. Nucleus pulposus herniates posteriorly => nerve root or cord compression; neck/back pain; sensory & motor deficits; causes - degenerative changes, trauma, neck/back strain, neck/back sprain; middle-aged & older men after strenuous activity; L4-L5 & L5-S1

A180. Several months of aching pain => sudden onset of severe, electricity-like LBP; pain exacerbated by straining; sciatica: tingling - lower extremities, numbness, muscle weakness, atrophy, contractions, spasms, pain increased by - passive straight leg, crossed straight leg raises, large midline herniations => cauda equina syndrome

A181. MRI

A182. Most cases - bed rest; NSAIDs; physical therapy; localized heat; resolved in 2-3 weeks; if no neuro deficit - bed rest not advised, early mobilization; muscle relaxant, NSAIDs; diskectomy - if persistent or disabling Sxs

A183. Stenosis of cervical or lumbar spinal canal => compression of nerve roots; usually from degenerative joint disease; middle-aged or elderly

A184. Neck pain; back pain - radiates to butt & legs, leg numbness, leg weakness, "spaghetti legs", "walks like a drunken sailor"; leg cramping - at rest, standing, walking; sitting gives relief; leaning forward gives relief (flexing at hips decreased pain)

A185. XR; MRI or CT

A186. Mild to moderate - NSAIDs; abdominal muscle strengthening; advanced - epidural steroid injection; surgical laminectomy - short-term, will recur

A187. Congenital hip dislocation => dislocated femoral heads due to - lax musculature; excessive uterine packing (breech) => poor development of acetabulum, hip; will progress if not corrected; MC - 1st born breech females

A188. Barlow's - hip adducted; Ortolani's - thighs abducted; Allis' (Galeazzi's) sign - knees unequal when hip & knees flexed, dislocated side is lower; asymmetrical skin folds; limited abduction of affected hip

A189. Early detection; evaluate clinical; US - if after 10 weeks old; XR - unreliable until 4 mos. old, neonatal femoral head radiolucent

A190. Start Tx early; < 6 mos. - Pavlik harness; 6-15 mos. - spica cast; 15-24 mos. - open reduction; if no Tx started by 24 mos. - significant defect

A191. Complications - joint contractures; AVN of femoral head

A192. 1 of the MC musculoskeletal disorder of kids; MC cause - trauma

A193. May be associated with pain or fever; ask about - history of trauma, recent infections, contact with TB- positive patients; young kids & toddlers - infected joint; adolescent & teens – JRA, slipped capital femoral epiphyses (SCFE), Legg-Calve-Perthes (LCP); disruption in normal gait – Trendelenburg, antalgic gait; infection – erythema, edema, limited ROM; trauma or tumor - point tenderness; always evaluate for – fever, signs of systemic infection, neuro involvement – reflexes, muscle atrophy, changes in sensation, bowel & bladder function

A194. STARTSS HOTT; Septic joint; Tumor; Avascular necrosis (LCP); RA/JRA; TB; Sickle cell disease; SCFE; HSP; Osteomyelitis; Trauma; Toxic synovitis

A195. Thorough H&P; XR; CBC; ESR; CRP; bone scan; nerve conduction studies; joint aspirate & culture - if suspect septic joint

A196. Depends on cause

A197. AVN of femoral head; UNK etiology; boys 4-10; can be bilateral

A198. Usually asymptomatic at first => painless limp or => pain, referred to knee; limited abduction; limited internal rotation; atrophy

A199. Self-limited; observation; if disease extensive or ROM impaired – brace, hip abduction with Petrie cast, osteotomy; prognosis dependent on – age, ROM, extent of involvement, joint stability

A200. Separation of proximal femoral epiphysis through growth plate => fem head displaced; medial & posterior to fem neck; can be bilateral; obese Black 11-13 y/o boys; if < 11 y/o, may be associated with endocrinopathies; may be due to imbalance between GH & sex hormones

A201. Thigh or knee pain; painful limp; acute or insidious; acute - restricted ROM, inability to bear weight. limited internal rotation; limited abduction; hip tenderness; flexion => obligatory external rotation

A202. TSH; XR both hips – AP, frog-leg lat

A203. Start promptly; no weight on limb until; surgical stabilized with screws; acute slip - gentle closed reduction

A204. Chondrolysis; AVN of fem head; premature hip OA => hip arthroplasty

A205. MC - anterior dislocation, axillary artery & nerve, hold arm in external. rotation; posterior dislocations, radial artery, seizures & electrocutions, hold arm in int. rotation

A206. Closed reduction; followed by sling & swath; recurrent - surgery

A207. MC - posterior dislocation, compress sciatic nerve., can cause AVN, posterior directed force on, internal rotated, flexed, adducted hip, "dashboard injury"; anterior dislocation - obturator nerve compromises.

A208. Closed reduction followed by abduction; pillow/bracing; CT after reduction

A209. MC wrist fracture; distal radius; fall onto outstretched hand => dorsally displaced/angle Fracture; common in elderly (osteoporosis), kids

A210. Closed reduction; then long arm cast; intra-articular - open reduction

A211. MC fractured carpal bone; can be 1-2 weeks for XR to show; assume if tenderness in anatomical snuff box; proximal 3rd scaphoid fractures can => AVN

A212. Thumb spica cast; open reduction - displacement; nonunion common

A213. Fracture of 5th metacarpal neck; forward trauma of closed fist

A214. Closed reduction & ulnar gutter splint; excessive angulation - percutan pinning; skin broken - assume infection by human oral pathogens; "fight bite"; surgical irrigation; debridement; IV Antibiotics to cover Eikenella

A215. Direct trauma; radial nerve. wrist drop; loss of thumb abduction

A216. Hanging arm cast or coaptation splint & sling; functional bracing

A217. Ulna shaft fracture; from self-defense - arm against blunt object

A218. ORIF; open reduction & int. fixation

A219. Diaphyseal Fracture; proximal ulnar; subluxation of radial head

A220. ORIF - shaft fracture; closed reduction - radial head

A221. Diaphyseal Fracture; radius; dislocation of distal radioulnar joint; from direct blow to radius

A222. ORIF - radius; cast forearm in supination

A223. MC in osteoporotic women who fall; shortened, ext rotated leg; at risk for DVTs; displaced fem neck fractures - high risk of AVN, fracture nonunion

A224. ORIF; parallel pinning of femoral neck; anticoagulant; > 80 y/o - may need hip hemiarthroplasty

A225. Direct trauma (MVA); fat emboli; fever; scleral & axillary petechiae; confusion; dyspnea; hypoxia

A226. Intramedullary nailing; open fractures - thorough irrigation; debridement

A227. Direct trauma; car bumper & pedestrian injury; compartment syndrome

A228. Casting vs. intramedullary nailing

A229. Orthopedic emergency; must go to OR in < 6 hrs. (risk of infection)

A230. OR emergently to repair; Antibiotics

A231. MC in unfit men in sports; hear sudden "pop"; sounds like rifle shot; limited plantar flexion; pos Thompson test - pressure on gastrocnemius; doesn't => ft plantar flexion

A232. Long-leg cast for 6 wks

A233. From forced hyperflexion; positive anterior drawer sign; Lachman's test; rule out meniscal or MCL injury

A234. Surgery; graft from patellar or hamstring tendons

A235. From forced hyperextension; positive posterior drawer test

A236. Operative PCL repair - for highly competitive athlete

A237. Clicking or locking; joint line tenderness; positive McMurray's test

A238. Conservative; unless associated with Sxs or ligament injuries

A239. MC fractured long bone in kids; birth-related (lg infants); brachial n. palsies; usually middle 3rd of clavicle; proximal end displaced superiorly; from pull of sternocleidomast

A240. Figure-of-8 sling vs. arm sling

A241. Incomplete fracture; cortex of one side of bone

A242. Reduction with casting; order films at 7-10 days

A243. Radial head subluxation; from being pulled or lifted by hand; kid will not bend elbow

A244. Manual reduction - gentle supination of elbow; at 90 degrees of flexion; no immobilization necessary.

A245. Buckling of cortex of long bone; secondary to trauma; usually distal radius or ulna

A246. Cast immobilization; 3-5 wks - dep. on age

A247. 5-8 y/o; proximal to brachial a. risk of Volkmann's contracture

A248. Cast immobilization; closed reduction; percutan pinning - if significant displaced

A249. Overuse apophysitis of tibial tubercle; localized pain; especially with quadriceps Ctx; active young boys

A250. Decreased activity 1-2 yrs; neoprene brace

A251. Fractures of growth plate of kids; classified by fracture location; I - physis; II - metaphysis & physis; III - epiphysis & physis; IV - epi-, meta- & physis; V - crush injury of physis

A252. I & II - nonoperatively; others & unstable fractures-operatively; prevents leg-length inequality

A253. 2nd MC primary malignant; bone tumor; metaphyses - distal femur; proximal tibia; proximal humerus; can metas to lungs; men; 20s-30s; Paget's can precede development of secondary osteosarcoma

A254. Progressive pain => intractable pain; worse at night; constitutional Sxs; at site of tumor - erythema; enlargement

A255. MRI; CT; XR - Codman's triangle, sunburst pattern

A256. Limb-sparing surgical proc; pre- and postop chemo – methotrexate, doxorubicin, cisplatin, ifosfamide; amputation - may be necessary if big

A257. Osteoclasts accelerate bone turnover in local areas => hyper osteoblastic repair => abnorm structure that weakens bone; may be associated with paramyxovirus infection; mainly disease of elderly

A258. Often asymptomatic; if Sx occur, develop insidiously; deep bone pain; bone softening => tibial bowing, kyphosis, freq fractures; increased in cranial diameter - (frontal bossing); deafness - CN8 compressed

A259. Alkaline phosphatase; increased urinary hydroxyproline; serum Ca2+ & phosphate- normal; XR - bony cortex very expanded, jigsaw/mosaic bone pattern, thick trabeculae

A260. NSAIDs; calcitonin; alendronate

A261. Fracture; hi-output cardiac failure; arthritis; deafness; secondary osteosarcoma; vertebral collapse => spinal cord compression

A262. Recurrent attacks - acute monoarticular arthritis; monosodium urate crystals; middle-aged, obese men, Pacific Islanders; hyperuricemia - secondary to uric acid underexcretion; other causes - Lesch-Nyhan, diuretics (furosemide, HCTZ), trauma, surgery, infections, steroid withdrawal, cyclosporine, malignancy, excessive red meat or red wine, hemoglobinopathies

A263. MC - elderly or preexisting joint damage; if < 50 y/o - metabolic abnorm, hyperparathyroidism, hypophosphatasia, hypomagnesemia, hemochromatosis; knee - #1, also ankle, wrist, shoulder; Dx - fluid aspiration, Positive birefringent rhomboid crystals; XR - chondrocalcinosis; Tx - same as gout; low dose of colchicine - prevents recurrence

A264. 1st episode - awakened from sleep; sudden onset of joint pain; podagra; usually 1st MTP joint, knee, ankle, DIP & PIP; joint – erythematous, swollen, tender; as becomes chronic - multiple joints involved; urate crystals deposited in connective tissue (tophi), kidneys

A265. Joint-fluid aspirate - needle-shaped, negative birefringent crystals; yeLLow when paraLLel to condenser; increased WBC; advanced - "rat bite" = punched-out erosions - of long- standing tophus, "overhanging margin"

A266. Acute - decrease inflammation; NSAIDs (indomethacin); IV colchicine or steroids - if elderly maintenance - decrease uric acid level:; probenecid if underexcrete, inhibits reabsorb of uric acid; allopurinol if overproduce or have RF or have kidney stones, can precipitate acute attack

A267. Degen joint disease; deterioration of articular cartilage of moveable, weight- bearing joints; MCC- idiopathic; secondary - any diseases that causes stress or trauma to joint; knee OA - MCC of chronic disability in elderly in West; risk factors – obesity, family History, history of joint trauma; especially intra-articular fractures, repetitive stress

A268. History - joint stiffness - insidious onset; pain - insidious onset; worse by activity & weight-bearing; relieved by rest; crepitus; decreased ROM; PE - weight-bearing joint involved; DIP - heberden nodes; PIP - bouchard nodes; MTP joint of 1st toe; cervical spine

A269. Based on clinical & XR; XR - irregular joint space narrowing, osteophytes, subchondral sclerosis, subchondral bone cysts; ESR normal; synovial fluid aspiration - straw-colored fluid, normal viscosity, WBC < 3000

A270. Weight reduction; physical therapy; NSAIDs; intra-articular corticosteroid injections; elective joint replacement - total hip/knee arthroplasty

A271. XLR; defect of dystrophin - cytoskeletal protein; MC muscular dystrophy; most lethal; ages 2-6; Becker – milder, XLR, abnormal-sized dystrophin

A272. History - axial and proximal before distal muscles; progressive clumsiness; fatigability; hard to stand or walk; hard to walk on toes; waddling gait; Gower's maneuver; PE - pseudohypertrophy of gastrocnemius; possible MR

A273. CK - always high; EMG; muscle Biopsy; DNA; diagnostic - immunostain for dystrophin

A274. No cure; Tx supportive; physical therapy; achilles tendon release; wheelchair by 13 y/o; death in 20s

A275. X-linked recessive defect in a tyrosine kinase gene associated with low levels of all classes of Igs

A276. Brutons agammaglobulinemia (B cells)

A277. DiGeorge syndrome/thymic aplasia (T cells)

A278. DiGeorge syndrome

A279. 22q11 deletion

A280. SCID - B and T cell deficiency

A281. SCID

A282. disseminated mycobacterial infections

A283. hyper-IgM syndrome (decreased activation of B cells)

A284. hyper-IgM syndrome

A285. Wiskott-Aldrich syndrome (decreased activation of B cells)

A286. infections, thrombocytopenic purpura, eczema (WIPE)

A287. Wiskott-Aldrich syndrome

A288. Job's syndrome (decreased activation of macrophages)

A289. JOb's syndrome

A290. defect in LFA-1 adhesion proteins on phagocytes

A291. leukocyte adhesion deficiency syndrome

A292. autosomal recessive

A293. Chediak-Higashi disease

A294. Chediak-Higashi disease

A295. chronic granulomatous disease

A296. negative nitroblue tetrazolium dye reduction test

A297. chronic granulomatous disease

A298. idiopathic dysfunction of T cells specifically against candida albicans

A299. selective IgA deficiency - presents with sinus and lung infections;; milk allergies and diarrhea are common

A300. B cells

A301. ataxia-telangiectasia

A302. C1 esterase inhibitor

A303. C3

A304. C6-C8

A305. decay-accelerating factor

A306. C3 deficiency;; not detected until later in life

A307. IgG-mediated opsonization in the spleen

A308. measles or the live attenuated measles vaccine

A309. HLA-DR4

A310. non-Hodgkin's lymphoma

A311. indirect Coombs test to measure IgG anti-Rh antibody

A312. common variable immunodeficiency

A313. strep pneumo,; H. flu,; Neisseria

A314. integrins - function both in adhesion of leukocytes to other cells and in the phagocytosis of complement-coated material

A315. HLA-DR2 and HLA-DR3

A316. mitral valve disease

A317. scleroderma/systemic fibrosis - likely to develop diffuse systemic fibrosis & death from consequences of systemic disease such as pulmonary fibrosis or malignant hypertension

A318. LFA-1; interacts with ICAM-1

A319. IL-10

A320. C5a and C8

A321. CD19, CD20, CD21

A322. IgA

A323. non-specific inflammation - one of the most commonly measured acute-phase reactants