First Aid - Musculoskeletal And Connective Tissue

Front 1

Epidermis Layers

Back 1

From surface to base:
Stratum Corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basalis

Front 2

How to remember layers of epidermis?

Back 2

"Californians Like Girls in String Bikinis"
Stratum Corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basalis

Front 3

Epidermal Appendages - Sebaceous gland

Back 3

Holocrine secretion of sebum. Associated with hair follicle.

Front 4

What does holocrine secretion mean? Example?

Back 4

Secretions are produced int he cytoplasm and released by rupture of the plasma membrane, which destroys the cell.

Example: Sebaceous glands

Front 5

Epidermal Appendages - Eccrine Gland

Back 5

Secretes sweat. Found throughout the body.

Front 6

Epidermal Appendages - Apocrine Gland

Back 6

Milky vsicid secretions that become odorous due to bacterial action. Found in the axillae, genitalia, and areolae. Do not become functional until puberty.

Front 7

Epithelial cell junctions - Zona Occludens

Back 7

a.k.a. "Tight Junction"
Prevents diffusion across paracellular space; composed of claudens and occludins.

Front 8

Epithelial cell junctions - Zona adherens

Back 8

a.k.a. "Intermediate Junction"
Surrounds perimeter just below zona occludens; cadherens connect to actin (CADherins are Ca2+-dependent ADhesion molecules)

Front 9

Epithelial cell junctions - Macula adherens

Back 9

A.k.a. "Desmosome"
Small, discrete sites of attachment; cadherins connect to intermediate filaments; autoantibodies --> pemphigus vulgaris (anti-desmoglein)

Front 10

Epithelial cell junctions - Gap junction

Back 10

allows adjacent cells to communicate for electrical and metabolic functions

Front 11

Epithelial cell junctions - Integrin

Back 11

Basolaterally placed - maintains integrity of basement membrane; binds to laminin in BM

Front 12

Epithelial cell junctions - Hemidesmosome

Back 12

connects cells to underlying extracellular matrix; autoantibodies --> bullous pemphigoid

Front 13

Unhappy triad/knee injury

Back 13

Common football injury. Force from the lateral side --> damage to the "unhappy triad":
1. Medial collateral ligament (MCL)
2. Anterior cruciate ligament (ACL)
3. Lateral (not medial) meniscus

"Anterior" and "Posterior" in ACL and PCL refer to sites of tibial attachment.
Posterior anterior drawer sign indicates tearing the ACL. Abnormal passive abduction indicates a torn MCL.

Front 14

Clinically important landmarks - Pudendal nerve block

Back 14

Ischial Spine - to relieve pain of delivery

Front 15

Clinically important landmarks - McBurney's point

Back 15

Appendix - 2/3 of the way from the umbilicus to the anterior superior iliac spine

Front 16

Clinically important landmarks - Lumbar puncture

Back 16

spinal column at the level of the iliac crests

Front 17

Rotator cuff muscles

Back 17

Shoulder muscles that form the rotator cuff:
Supraspinatus - abducts arm initially (before deltoid); most common rotator cuff injury
Infraspinatus - laterally rotates arm; pitching injury
Teres minor - adducts and laterally rotates arm
Subscapularis - medially rotates and adducts arm

Front 18

Bones of the hand and wrist

Back 18

Scaphoid, Lunate, Triquetrium, Pisiform, Trapezium, Trapezoid, Capitate, Hamate

"Some Lovers Try Positions That They Can't Handle"

Front 19

Upper limb nerve lesion mechanisms - Upper trunk

Back 19

Lesioned by trauma

Front 20

Upper limb nerve lesion mechanisms - C7 root

Back 20

Compressed by cervical disk lesion

Front 21

Upper limb nerve lesion mechanisms - Axillary nerve

Back 21

Lesioned by fracture of surgical neck; dislocation of the humerus; intramuscular injections

Front 22

Upper limb nerve lesion mechanisms - Radial nerve in spiral groove

Back 22

Lesioned by midshaft fracture of humerus

Front 23

Upper limb nerve lesion mechanisms - Radial nerve in axilla

Back 23

Compressed in axilla by incorrect use of crutch

Front 24

Upper limb nerve lesion mechanisms - Median nerve (proximal lesion)

Back 24

Compressed by supracondylar fracture of humerus; pronator teres syndrome

Front 25

Upper limb nerve lesion mechanisms - Radial nerve (deep branch lesion)

Back 25

Stretched by subluxation of radius - "Nursemaid's elbow"

Front 26

Upper limb nerve lesion mechanisms - Ulnar nerve (proximal lesion)

Back 26

Lesioned by repeat minor trauma; fracture of medial epicondyle of humerus

Front 27

Upper limb nerve lesion mechanisms - Anterior interosseous nerve

Back 27

Compressed in deep forearm

Front 28

Upper limb nerve lesion mechanisms - Median nerve (distal lesion)

Back 28

Compressed in carpal tunnel syndrome and by dislocated lunate

Front 29

Upper limb nerve lesion mechanisms - Recurrent branch of median nerve

Back 29

Lesioned by superficial laceration

Front 30

Upper limb nerve lesion mechanisms - Ulnar nerve (distal lesion)

Back 30

Lesioned by trauma of heel of the hand; fracture of hook of hamate

Front 31

Dermatomes of the upper limb/hand

Back 31

C4 is the lateral trap/shoulder
C5 is lateral arm
C6 is lateral forearm and thumb, index finger
C7 is middle finger
C8 is ring, pinky finger
T1 is medial forearm and medial arm
T2 is distal axilla

Front 32

Dermatomes of the hand

Back 32

Ulnar nerve - palm and dorsum of medial hand, medial 1 1/2 digits
Median nerve - lateral palm, palmar 3 1/2 digits, dorsum of index, middle, and medial half of ring finger
Radial nerve - lateral half of dorsum of hand and dorsum of thumb

Front 33

Innervation of the Hand - nerve routes

Back 33

Median nerve passes under flexor retinaculum after palmar cutaneous branch comes off, then innervates lateral 3.5 digits

Ulnar nerve sends branch to dorsum of hand before traveling into palm of hand to innervate medial 1.5 digits

Front 34

Brachial Plexus lesions - Upper trunk

Back 34

Waiter's tip (Erb's palsy)

Front 35

Brachial plexus lesions - Lower trunk

Back 35

Claw hand (Klumpke's palsy)

Front 36

Brachial plexus lesions - Posterior cord

Back 36

Wrist drop

Front 37

Brachial plexus lesions - Axillary nerve

Back 37

Deltoid paralysis

Front 38

Brachial plexus lesions - Long thoracic nerve

Back 38

Winged scapula

Front 39

Brachial plexus lesions - Radial nerve

Back 39

Saturday night palsy (wrist drop)

Front 40

Brachial plexus lesions - Musculocutaneous nerve

Back 40

Difficulty flexing elbow, variable sensory loss

Front 41

Brachial plexus lesions - Median nerve

Back 41

Decreased thumb function, Pope's blessing

Front 42

Brachial plexus lesions - Ulnar nerve

Back 42

Intrinsic muscles of hand, claw hand

Front 43

How is the brachial plexus protected in a clavicle fracture?

Back 43

Subclavius muscle covers the brachial plexus

Front 44

Upper extremity nerves - Axillary nerve (C5, C6) - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 44

Cause of Injury: Fractured surgical neck of humerus, dislocation of humeral head, intramuscular injections

Motor Deficit: Deltoid - arm abduction at shoulder

Sensory deficit: Over deltoid muscle

Sign: Flattened deltoid

Front 45

Upper extremity nerves - Radial (C5-C8) - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 45

Cause of Injury: Fracture at midshaft of humerus; "Saturday night palsy" (extended compression of axilla by back of chair or crutches)

Motor deficit: "BEST extensors"
Brachioradialis, Extensors of wrist and fingers, Supinators, Triceps

Sensory Deficit: Posterior arm and dorsal hand and dorsal thumb

Sign: Wrist drop

Front 46

Upper extremity nerves - Median (C5-C8, T1), proximal lesion - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 46

Cause of injury: Fracture of Supracondylar Humerus

Motor Deficit: Opposition of thumb

Sensory Deficit: Dorsal and palmar aspects of lateral 3 1/2 fingers, thenar eminence

Sign: "Ape hand"; thenar atrophy, loss of opposability of thumb

Front 47

Upper extremity nerves - Median (C5-C8, T1), distal lesion - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 47

Cause of Injury: Carpal tunnel syndrome; dislocated lunate

Motor Deficit: Lateral finger flexion, wrist flexion

Sensory Deficit: Dorsal and palmar aspects of lateral 3 1/2 fingers (No thenar eminence b/c cutaneous branch leaves before median nerve goes under flexor retinaculum)

Front 48

Upper extremity nerves - Ulnar (C8, T1), proximal lesion - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 48

Cause of Injury: Fracture of medial epicondyle of humerus, "funny bone"

Motor Deficit: Medial finger flexion, wrist flexion

Sensory Deficit: Medial 1 1/2 fingers, hypothenar eminence

Sign: Radial deviation of wrist upon wrist flexion

Front 49

Upper extremity nerves - Ulnar (C8, T1), distal lesion - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 49

Cause of Injury: Fracture of hook of hamate (falling onto outstretched hand)

Motor Deficit: Abduction and adduction of fingers (interossei), adduction of thumb, extension of 4th and 5th fingers (lumbricals)

Sensory Deficit: Medial 1 1/2 fingers, hypothenar eminence

Signs: Ulnar claw hand (when asked to straighten fingers) - "Pope's blessing/hand of benediction"

Front 50

Upper extremity nerves - Musculocutaneous (C5-C7) - Cause of injury? Motor Deficit? Sensory deficit? Sign?

Back 50

Cause of Injury: Upper trunk compression

Motor Deficit: Biceps, brachialis, coracobrachialis, Flexion of arm at elbow

Sensory Deficit: Lateral forearm

Front 51

Erb-Duchenne Palsy - Cause of Injury? Findings?

Back 51

a.k.a. "Waiter's Tip"
Traction or tear of the upper trunk of the brachial plexus (C5 and C6 roots); follows blow to shoulder or trauma during delivery.

Findings: limb hangs by side (paralysis of abductors), medially rotated (paralysis of lateral rotators), forearm is pronated (loss of biceps)

Front 52

Klumpke's palsy and thoracic outlet syndrome

Back 52

An embryologic or childbirth defect affecting inferior trunk of brachial plexus (C8, T1); a cervical rib can compress subclavian artery and inferior trunk, resulting in thoracic outlet syndrome:
1. Atrophy of thenar and hypothenar eminences
2. Atrophy of the interosseous muscles
3. Sensory deficits on the medial side of the forearm and hand
4. Disappearance of the radial pulse upon moving the head toward the ipsilateral side
5. Klumpke's total claw hand

You are basically knocking out the median and ulnar nerves.

Front 53

Distortions of the hand - basics

Back 53

Multiple types: ulnar claw, median claw, "ape hand," and Klumpke's total claw (clawing of all digits). To keep things straight, just remember it's all about the lumbriclas, which flex the MCP joints and extend both the DIP and PIP joints.

Front 54

Distortions of the hand - Ulnar claw

Back 54

Distal ulnar nerve lesion --> loss of medial lumbrical function; 4th and 5th digits are clawed ("Pope's blessing"). Cannot extend 4th and 5th digits. When try to open hand, pinky and ring finger stay clawed. Note: Making fist with Proximal median nerve lesion (can't flex lateral fingers) can also look like Pope's blessing

Front 55

Distortions of the hand - Median claw

Back 55

Distal median nerve lesion (after branch containing C5-C7 branches off to feed forearm flexors) --> loss of lateral lumbrical function; 2nd and 3rd digits are clawed. Cannot extend 2nd and 3rd digits.

Front 56

Distortions of the hand - "Ape Hand"

Back 56

Proximal median nerve lesion --> loss of opponens pollicis muscle function --> unopposable thumb (inability to abduct thumb), hence "ape hand"

Front 57

Distortions of the hand - Klumpke's total claw

Back 57

Lesion of lower trunk (C8, T1) of brachial plexus --> loss of function of all lumbricals; forearm finger flexors (fed by part of median nerve with C5-C7) and finger extensors (fed by radial nerve) are unopposed --> clawing of all digits

Front 58

Long thoracic nerve (C5-C7) palsy

Back 58

Serratus anterior - connects scapula to thoracic cage
Used for abduction above horizontal position. Can be injured in mastectomy --> winged scapula and lymphedema.

Front 59

Hand Muscles - details?

Back 59

Thenar (median) -- Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis

Hypothenar (ulnar) - Opponens digiti minimi, Abductor digit minimi, Flexor digiti minimi

Dorsal Interosseous muscles - abduct the fingers

Palmar interosseous muscles - adduct the fingers

Lumbrical muscles - flex at the MCP joint, extend PIP and DIP joints

Front 60

How to keep function of thenar/hypothenar eminence muscles straight?

Back 60

Both groups perform the same 3 functions:
Oppose, Abduct, and Flex

Thenar (median) -- Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis

Hypothenar (ulnar) - Opponens digiti minimi, Abductor digit minimi, Flexor digiti minimi

Front 61

How to remember which interosseus muscles do what?

Back 61

DAB - Dorsals ABduct
PAD - Palmars ADduct

Front 62

Lower extremity nerves - Obturator - What roots? Cause of Injury? Motor Deficit? Sensory Deficit?

Back 62

Roots: L2 - L4
Cause of Injury: Anterior Hip dislocation

Motor Deficit: Thigh adduction

Sensory deficit: Medial thigh

Front 63

Lower extremity nerves - Femoral - What roots? Cause of Injury? Motor Deficit? Sensory Deficit?

Back 63

Roots: L2 - L4
Cause of Injury: Pelvic Fracture

Motor Deficit: thigh flexion and leg extension

Sensory Deficit: Anterior thigh and medial leg

Front 64

Lower extremity nerves - Common peroneal - What roots? Cause of Injury? Motor Deficit? Sensory Deficit?

Back 64

Roots: L4 - S2
Cause of Injury: Trauma to lateral aspect of leg or fibula neck fracture

Motor Deficit: Foot eversion and dorsiflexion; toe extension; foot drop, foot slap, steppage gait

Sensory Deficit: Anterolateral leg and dorsal aspect of foot

Front 65

Lower extremity nerves - Tibial - What roots? Cause of Injury? Motor Deficit? Sensory Deficit?

Back 65

Roots: L4 - S2
Cause of Injury: Knee trauma

Motor Deficit: Foot inversion and plantarflexion; toe flexion

Sensory Deficit: sole of foot

Front 66

Lower extremity nerves - Superior Gluteal - What roots? Cause of Injury? Motor Deficit?

Back 66

Roots: S4-L1

Cause of Injury: Posterior hip dislocation and polio

Motor Deficit: Thigh abduction (positive Trendelenburg sign - contralateral hip drops when standing on leg ipsilateral to site of lesion)

Front 67

Lower extremity nerves - Inferior Gluteal - What roots? Cause of Injury? motor Deficit?

Back 67

Roots: L5-S2

Cause of Injury: Posterior hip dislocation

Motor Deficit: Can't jump, climb stairs, or rise from seated position; can't push inferiorly (downward)

Front 68

How to remember different actions of common peroneal vs. tibial nerves?

Back 68

PED = Peroneal Everts and Dorsiflexes; if injury, foot droPED

TIP = Tibial Inverts and Plantarflexes; if injured, can't stand on TIPtoes

Front 69

Lower Extremity nerves - Sciatic Nerve - What roots? Where does it travel? What does it split into?

Back 69

Roots: L4 - S2
Travels: posterior thigh

Splits into common peroneal and tibial nerve.

Front 70

Muscle Conduction to Contraction - what are the receptors involved? Give the bands/lines of the sarcomere.

Back 70

Ryanodine Receptor on SR, Dihydropyridine receptor on T-tubule membrane

M line - middle of myosin filaments
H band - Only myosin
A band - full length of myosin (does not change)
I band - only actin
Z line - middle of actin filaments

Front 71

Muscle Contraction: describe the steps

Back 71

1. Action potential depolarization opens voltage-gated Ca2+ channels, inducing neurotransmitter release
2. Postsynaptic ligand binding leads to muscle cell depolarization in the motor end plate
3. Depolarization travels along muscle cell and down the T-tubule
4. Depolarization of the voltage-sensitive dihydropyridine receptor, coupled to the ryanodine receptor on the sarcoplasmic reticulum, induces a conformational change causing Ca2+ release from sarcoplasmic reticulum (calcium-induced calcium release)
5. Released Ca2+ binds to troponin C, causing a conformational change that moves tropomyossin out of the myosin-binding groove on actin filaments
6. Myosin released bound ADP and is displaced on actin filament (power stroke). Contraction results in H- and I-band shortening, but the A band remains the same length (A band is Always the same length)

Front 72

Types of Muscle Fibers - Type 1 muscle

Back 72

Slow twitch; red fibers due to increased mitochondria and myoglobin concentration (increased oxidative phosphorylation) --> sustained contraction

Front 73

Types of Muscle Fibers - Type 2 Muscle

Back 73

Fast twitch; white fibers due to decreased mitochondria and myoglobin concentration (increased anaerobic glycolysis); weight training results in hypertrophy of fast-twitch muscle fibers

Front 74

Weight training results in hypertrophy of which muscle fiber type?

Back 74

Type 2 muscle - fast twitch

Front 75

Bone formation - Endochondrial ossification

Back 75

Longitudinal bone growth. Cartilaginous model of bone is first made by chondrocytes. Osteoclasts and osteoblasts later replace with woven bone and remodel to lamellar bone.

Osteoblast source - mesenchymal stem cells in periosteum

Front 76

Bone formation - Membranous ossification

Back 76

Flat bone growth (skull, facial bones, and axial skeleton). Woven bone formed directly without cartilage. Later remodeled to lamellar bone.

Front 77

Smooth muscle contraction - steps

Back 77

Action potential --> smooth muscle membrane depolarization --> Voltage-gated Ca2+ channels open --> increased Ca2+ in cytoplasm --> Ca2+ binds to calmodulin --> Activates myosin light-chain kinase (MLCK) --> myosin is phosphorylated and cross-bridge formation with muscle contraction occurs

Myosin light-chain phosphatase ---> removes phosphate from myosin --> relaxation

Front 78

How does NO induce smooth muscle relaxation?

Back 78

Nitric Oxide --> activates Guanylate cyclase --> cGMP --> inhibition of Myosin Light-chain Kinase (MLCK)

Front 79

Skeletal and Cardiac Muscle Contraction - Power Stroke Cycle

Back 79

Ca2+ binds to troponin C, causing conformational change. This causes tropomyosin to move out of the way to allow actin/myosin cycling. --> Cross-bridged state

Power stroke occurs after ADP detaches from myosin head (still attached to actin)

ADP is released and replaced by ATP which binds to the myosin head and releases the actin filament, allowing cross-bridge cycling and shortening to occur. Lack of ATP causes rigor mortis.

ATP is hydrolyzed and Myosin is put in the "Cocked" state to repeat the cycle

Front 80

Achondroplasia

Back 80

Failure of longitudinal bone growth (endochondral ossification) --> short limbs.

Membranous ossification is not affected --> large head. Constitutive activation of fibroblast growth factor receptor (FGFR3) actually inhibits chondrocyte proliferation. >85% of mutations occur sporadically and are associated with advanced paternal age, but the condition also demonstrates autosomal-dominant inheritance. Common cause of dwarfism. Normal life span and fertility.

Front 81

What signaling molecule is abnormal in achondroplasia (commonly)?

Back 81

Fibroblast growth factor receptor (FGFR3) is constitutively activated which actually INHIBITS chondrocyte proliferation.

Front 82

Osteoporosis - basics? prophylaxis? treatment?

Back 82

Trabecular (spongy) bone loses mass and interconnections despite normal bone mineralization and lab values.

Leads to vertebral crush fractures -- acute back pain, loss of height, kyphosis

Prophylaxis: Exercise and Calcium ingestion before age 30

Treatment: estrogen (SERMs) and/or calcitonin; bisphosphonates or pulsatile PTH for severe cases. Glucocorticoids are contraindicated.

Front 83

Osteoporosis - Type I

Back 83

Postemenopausal; increased bone resorption due to decreased estrogen levels

Associated with femoral neck fracture, distal radius (Colles') fractures.

Front 84

What is a Colles' fracture?

Back 84

distal radius fracture, commonly associated with postmenopausal (Type I) osteoporosis

Front 85

Osteoporosis - Type II - Details?

Back 85

Senile osteoporosis - affects men and women > 70 years of age.

Front 86

Osteopetrosis (Marbe Bone disease)

Back 86

Failure of normal bone resorption --> thickened, dense bones that are prone to fracture. Bone defect is due to abnormal function of osteoclasts.

Serum calcium, phosphate, and alkaline phosphatase (ALP) are normal. Primary spongiosa fills medullary cavity, causing decreased marrow space --> anemia, thrombocytopenia, infection; increased extramedullary hematopoiesis.

Genetic deficiency of carbonic anhydrase II. X-ray shows "Erlenmeyer flask" bones that flare out. Can result in cranial nerve impingement and palsies due to narrowed foramina.

Front 87

What genetic abnormality is associated with osteopetrosis?

Back 87

Deficiency of carbonic anhydrase II.

Front 88

What x-ray finding is associated with osteopetrosis?

Back 88

"Erlenmeyer flask" bones

Front 89

Osteomalacia/rickets

Back 89

Defective mineralization/calcification of osteoid --> soft bones. Vitamin D deficiency in adults --> decreased calcium levels -> increased secretion of PTH, decrease in serum phosphate. Reversible when vitamin D is replaced. Vitamin D deficiency in childhood causes rickets.

Front 90

Paget's disease of bone (osteitis deformans)

Back 90

Abnormal bone architecture caused by increase in both osteoblastic and osteoclastic activity. Possibly viral in origin (paramyxovirus is suspected).

Serum calcium, phosphorus, and PTH levels are normal. Alkaline phosphatase is elevated.

Mosaic bone pattern; long bone chalk-stick fractures. Increased blood flow from increased arteriovenous shunts may cause high-output heart failure.

Can --> osteogenic sarcoma.

Hat size can be increased; hearing loss is common due to auditory foramen narrowing.

Front 91

Why is hearing loss common in Paget's disease of bone?

Back 91

Auditory foramen narrowing

Front 92

What virus is suspected to be related to the development of Paget's disease of bone?

Back 92

Paramyxovirus

Front 93

Lab values in bone disorders (Ca2+, Phosphate, ALP, PTH) - Osteoporosis

Back 93

All are normal. Decreased bone mass.

Front 94

Lab values in bone disorders (Ca2+, Phosphate, ALP, PTH) - Osteopetrosis

Back 94

All are normal. Thickened, dense bones.

Front 95

Lab values in bone disorders (Ca2+, Phosphate, ALP, PTH) - Osteomalacia/rickets

Back 95

Decreased calcium, decreased phosphate.
Normal alk phos.
Increased PTH.

Soft bones.

Front 96

Lab values in bone disorders (Ca2+, Phosphate, ALP, PTH) - Osteitis fibrosa cystica

Back 96

Increased serum Ca2+. Decreased phosphate.
Increased alk phos. Increased PTH.

"Brown tumors"

Front 97

Lab values in bone disorders (Ca2+, Phosphate, ALP, PTH) - Paget's disease

Back 97

Normal Ca2+, normal phosphate.
Increased alk phos. Normal PTH.

Abnormal bone architecture.

Front 98

What common lab measurement differentiates osteopetrosis from Paget's disease of bone?

Back 98

Alkaline phosphatase is elevated in Paget's, normal in osteopetrosis.

Front 99

Polyostotic fibrous dysplasia - details?

Back 99

Bone is replaced by fibroblasts, collagen, and irregular bony trabeculae. McCune-Albright syndrome is a form of polyostotic fibrous dysplasia characterized by multiple unilateral bone lesions associated with endocrine abnormalities (precocious puberty) and cafe-au-lait spots.

Front 100

Benign primary bone tumors - 2 types

Back 100

Giant Cell Tumor (osteoclastoma), Osteochondroma (exostosis)

Front 101

Primary Bone Tumors - Giant cell tumor (osteoclastoma)

Back 101

20-40 years of age. Epiphyseal end of long bones.

Locally aggressive benign tumor often around the distal femur, proximal tibial region (knee).
"Double bubble" or "soap bubble" appearance on x-ray.
Spindle-shaped cells with multinucleated giant cells.

Front 102

Primary Bone Tumors - Osteochondroma (exostosis)

Back 102

Most common benign tumor. Men < 25 years of age.

Mature bone with cartilaginous cap. Commonly originates from long metaphysis. Malignant transformation to chondrosarcoma is rare.

Front 103

Malignant Primary Bone Tumors - 3 types

Back 103

Osteosarcoma (osteogenic sarcoma), Ewing's sarcoma, Chondrosarcoma

Front 104

Primary Bone Tumors - Osteosarcoma (osteogenic sarcoma)

Back 104

2nd most common primary malignant bone tumor (after malignant myeloma). Men 10-20 years of age.
Predisposing factors: Paget's disease of bone, bone infarcts, radiation, familial retinoblastoma.
Metaphysis of long bones, often around distal femur, proximal tibial region (knee)

Codman's triangle or sunburst pattern (from elevation of periosteum) on x-ray. Poor prognosis.

Front 105

Primary Bone Tumors - Ewing's Sarcoma

Back 105

Boys < 15 years of age. Commonly appears in diaphysis of long bones, pelvis, scapula, and ribs.

Anaplastic small blue cell malignant tumor. Extremely aggressive with early metastases, but responsive to chemotherapy.
"Onion skin" apperaance in bone ("going out for Ewings and onion rings")
11;22 translocation (11 + 22 = 33, Patrick Ewing's jersey number)

Front 106

Primary Bone Tumors - Chondrosarcoma

Back 106

Men 30-60 years of age. Usually located in pelvis, spine, scapula, humerus, tibia, or femur.

Malignant cartilaginous tumor. May be of primary origin or from osteochondroma. Expansile glistening mass within the medullary cavity.

Front 107

Osteoarthritis - details?

Back 107

Mechanical - wear and tear of joints leads to destruction of articular cartilage, subchondral cysts, sclerosis, osteophytes (bone spurs), eburnation (polished, ivory-like appearance of bone), Heberden's nodes (DIP), and Bouchard's nodes (PIP).

Predisposing factors: age, obesity, joint deformity

Classic Presenation: pain in weight-bearing joints after use (e.g., at the end of the day), improving with rest. In knees, cartilage loss begins on medial aspect ("bowlegged"). Noninflammatory. No systemic symptoms.

Front 108

3 common findings on X-ray in osteoarthritis?

Back 108

Osteophytes (bone spurs), joint space narrowing, and sclerosis

Front 109

Common anatomical changes in Osteoarthritis?

Back 109

Thickened capsule, slight synovial hypertrophy, osteophyte, ulcerated cartilage, sclerotic bone, joint space narrowing, subchondral bone cysts

Front 110

Sjogren's syndrome - details? findings?

Back 110

Classic triad:
1. xerophthalmia (dry eyes, conjunctivitis, "sand in my eyes")
2. xerostomia (dry mouth, dysphagia)
3. Arthritis
Parotid enlargement, increased risk of B-cell lymphoma, dental caries.
Autoantibodies to ribonucleoprotein antigens, SS-A (Ro), SS-B (LA)

Predominantly affects women between 40 and 60 years of age. Associated with rheumatoid arthritis.

Front 111

What is Sicca Syndrome?

Back 111

Dry eyes, dry mouth, nasal and vaginal dryness, chronic bronchitis, reflux esophagitis. No arthritis.

Form of Sjogren's syndrome without arthritis.

Front 112

Rheumatoid Arthritis - Details? Classic presentation? Treatment?

Back 112

Autoimmune - inflammatory disorder affecting synovial joints, with pannus formation in joints (MCP, PIP), subcutaneous rheumatoid nodules (fibrinoid necrosis surrounded by palisading histiocytes), ulnar deviation, subluxation, Baker's cyst (behind the knee).
No DIP involvement.

Females > males. Type III hypersensitivity. 80% of RA patients have positive rheumatoid factor (anti-IgG antibody); anti-CCP antibody is less sensitive and more specific. Strong association with HLA-DR4.

Classic presentation: morning stiffness lasting > 30 minutes and improvement with use, symmetric joint involvement, systemic symptoms (fever, fatigue, pleuritis, pericarditis).

Treatment: NSAIDs, COX-2 inhibitors, glucocorticoids, disease-modifying drugs (methotrexate, sulfasalazine, hydroxychloroquine)

Front 113

3 finger deformities associated with Rheumatoid Arthritis?

Back 113

Boutonniere deformity (PIP), Swan-neck deformity, Z-thumb deformity

Front 114

Gout - Findings?

Back 114

Precipitation of monosodium crystals into joints due to hyperuricemia, which can be caused by Lesch-Nyhan syndrome, PRPP excess, decreased excretion of uric acid (e.g., thiazide diuretics), increased cell turnover, or von Gierke's disease. 90% due to underexcretion; 10% due to overproduction.

Crystals are needle shaped and negatively birefringent = yellow crystals under parallel light. More common in men.

Front 115

Gout - Symptoms

Back 115

Asymmetric joint distribution. Joint is swollen, red, and painful. Classic manifestation is painful MTP joint of the big toe (podragra).

Tophus formation (often on external ear, olecranon bursa, or Achilles tendon). Acute attack tends to occur after a large meal or alcohol consumption (alcohol metabolites compete for same excretion sites in kidney as uric acid, causing decreased uric acid secretion and subsequent buildup in blood).

Front 116

What is podagra?

Back 116

Painful MTP joint of the big toe, seen in Gout.

Front 117

Gout - Treatment - Acute? Chronic?

Back 117

Acute: NSAIDs (e.g., indomethacin), colchicine.

Chronic: Allopurinol, febuxostat, uricosurics (e.g., probenecid)

Front 118

3 common locations of Tophi formation in gout patients?

Back 118

External ear, olecranona bursa, Achilles tendon

Front 119

Pseudogout

Back 119

Caused by deposition of calcium pyrophosphate crystals within the joint space. Forms basophilic, rhomboid crystals that are weakly positively birefringent. Usually affects large joints (classically the knee). > 50 years old; both sexes affected equally.

Treatment includes NSAIDs for sudden, severe attacks; steroids; and colchicine.

Front 120

Most common joint affected in pseudogout?

Back 120

Large joints (classically the knee)

Front 121

Difference between crystal characteristics in gout and pseudogout?

Back 121

Gout - crystals are yellow in parallel light and blue in perpendicular light

Pseudogout - crystals are blue in parallel light and yellow in perpendicular light

Front 122

Infectious Arthritis - Septic

Back 122

Septic -
S. aureus, Streptococcus, and Neisseria gonorrhoeae are common. Gonococcal arthritis is an STD that presents as a monoarticular, migratory arthritis with an asymmetrical pattern. Affected joint is swollen, red, and painful.

STD = Synovitis (e.g., knee), Tenosynovitis (e.g., hand), and Dermatitis (e.g., pustules)

Front 123

Infectious Arthritis - Chronic

Back 123

TB (from mycobacterial dissemination), Lyme disease

Front 124

Osteonecrosis (avascular necrosis)

Back 124

Infarction of bone and marrow. Pain associated with activity. Caused by trauma, high-dose corticosteroids, alcoholism, sickle cell.

Front 125

4 causes of avascular necrosis?

Back 125

Trauma, high-dose corticosteroids, alcoholism, sickle cell

Front 126

Seronegative spondyloarthropathies - details? 4 types?

Back 126

Arthritis without rheumatoid factor (no anti-IgG antibody). Strong association with HLA-B27 (gene that codes for HLA MHC I). Occurs more often in males.

1. Psoriatic arthritis
2. Ankylosing Spondylitis
3. Inflammatory Bowel Disease
4. Reactive Arthritis (Reiter's syndrome)

Front 127

Psoriatic Arthritis

Back 127

Joint pain and stiffness associated with psoraisis. Asymmetric and patchy involvement.

Dactylitis ("sausage fingers"), "pencil-in-cup" deformity on x-ray. Seen in fewer than 1/3 of patients with psoriasis.

Front 128

Ankylosing Spondylitis

Back 128

Chronic inflammatory disease of spine and sacroiliac joints --> ankylosing (stiff spine due to fusion of joints), uveitis, and aortic regurgitation.

Bamboo spine.

Front 129

What heart abnormality is associated with Ankylosing Spondylitis?

Back 129

Aortic Regurgitation

Front 130

Inflammatory Bowel Disease - 2 types?

Back 130

Crohn's disease, ulcerative colitis

both are associated with HLA-B27

Front 131

Reactive Arthritis (Reiter's syndrome)

Back 131

Classic triad:
1. Conjunctivitis and anterior uveitis
2. Urethritis
3. Arthritis

"Can't see, can't pee, can't climb a tree."

Post-GI or chlamydia infections.

Front 132

Systemic Lupus Erythematosus - Details? Symptoms? Findings?

Back 132

90% are female and between ages 14 and 45.
Most common and severe in black females.

Symptoms include fever, fatigue, weight loss, Libman-Sacks endocarditis (verrucuous, wart-like, sterile vegetations on both sides of valve), hilar adenopathy, and Raynaud's phenomenon.

Wire-loop lesions in kidney with immune complex deposition (usually nephritis syndrome); death from renal failure and infections. False positive on syphilis test (RPR/VDRL) due to antiphospholipid antibodies, which cross-react with cardiolipin used in tests.

Front 133

Systemic Lupus Erythematosus - Antibody Lab Tests

Back 133

Lab tests detect presence of:
1. Antinuclear Antibody (ANA) - sensitive (primary screening), but not specific to SLE
2. Antibodies to double-stranded DNA (anti-dsDNA) - very specific, poor prognosis
3. Anti-Smith antibodies (anti-Sm) - very specific, but not prognostic
4. Antihistone antibodies - drug-induced lupus

Front 134

Describe Libman-Sacks endocarditis. What disease is it associated with?

Back 134

Verrucous, wart-like, sterile vegetations on both sides of valve

Associated with SLE.

Front 135

How to remember details of SLE?

Back 135

I'M DAMN SHARP:
Immunoglobulins (anti-dsDNA, anti-Sm, antiphospholipid)
Malar rash
Discoid Rash
Antinuclear antibody
Mucositis (oropharyngeal ulcers)
Neurological disorders
Serositis (pleuritis, myocarditis)
Hematologic disorders
Arthritis
Renal disorders
Photosensitivity

Front 136

Sarcoidosis - details?

Back 136

Characterized by immune-mediated, widespread noncaseating granulomas and elevated serum ACE levels. Common in black females.

Associated with restrictive lung disease (interstitial fibrosis), bilateral hilar lymphadenopathy, erythema nodosum, Bell's palsy, epithelial granulomas containing microscopic Schaumann and asteroid bodies, uveitis, parotitis, and hypercalcemia (due to elevated 1alpha-hydroxylase-mediated vitamin D activation in epithelioid macrophages)

Treatment: steroids

Front 137

Why does hypercalcemia develop in Sarcoidosis?

Back 137

elevated 1alpha-hydroxylase-mediated vitamin D activation in epithelioid macrophages

Front 138

Polymyalgia Rheumatica - Symptoms? Findings? Treatment?

Back 138

Symptoms - Pain and stiffness in shoulders and hips, often with fever, malaise, and weight loss. Does not cause muscular weakness. Occurs in patients > 50 years of age; associated with temporal (giant cell) arteritis.

Findings - Elevated ESR, normal CK

Treatment: Prednisone

Front 139

Fibromyalgia

Back 139

Most commonly seen in women 30-50 years of age. Widespread musculoskeletal pain associated with stiffness, paresthesia, poor sleep, and fatigue. Must have >11 of 18 tender points.

Front 140

Polymyositis/dermatomyositis - Symptoms? Findings? Treatment?

Back 140

Symptoms:
Polymyositis - progressive symmetric proximal muscle weakness caused by CD8+ T-cell-induced injury to myofibers. Most often involves shoulders.

Dermatomyositis - Similar to polymyositis, but also involves malar rash (similar to SLE), Gottron's papules, heliotrope rash, "shawl and face" rash, "mechanic's hands." Increased risk of malignancy. Muscle biopsy showing perifascicular atrophy is diagnostic.

Findings: Increased CK, increased aldolase, and positive ANA, anti-Jo-1.

Treatment: Steroids

Front 141

What finding occurs on muscle biopsy in Dermatomyositis?

Back 141

Perifascicular atrophy

Front 142

What are Gottron's papules? What disease are they associated with?

Back 142

Pink patches on the knuckles and other extensor surfaces.

Seen in dermatomyositis.

Front 143

Neuromuscular Junction Diseases - Myasthenia Gravis

Back 143

Most common NMJ disorder. Autoantibodies to postsynaptic AChR cause ptosis, diplopia, and general weakness. Associated with thymoma. Symptoms worsen with muscle use (diagnose with nerve stimulation/compound muscle AP test). Reversal of symptoms occurs with AChE inhibitors (edrophonium test distinguishes under- and overdosing).

Front 144

Neuromuscular Junction Disease - Lambert-Eaton Syndrome

Back 144

Autoantibodies to presynaptic Ca2+ channel results in decreased ACh release leading to proximal muscle weakness. Associated with paraneoplastic diseases (small cell lung cancer). Symptoms improve with muscle use. No reversal of symptoms with AChE inhibitors alone.

Front 145

What is another name for Scleroderma?

Back 145

Progressive Systemic Sclerosis - PSS

Front 146

Scleroderma - details?

Back 146

Excessive fibrosis and collagen deposition throughout the body. Commonly sclerosis of skin, manifesting as puffy and taut skin with absence of wrinkles. Also sclerosis of renal, pulmonary, cardiovascular, and GI systems.
75% female, 2 major types:
1. Diffuse Scleroderma
2. CREST syndrome

Front 147

Scleroderma - Diffuse type

Back 147

Widespread skin involvement, rapid progression, early visceral involvement. Associated with anti-Scl-70 antibody (anti-DNA topoisomerase I antibody)

Front 148

Scleroderma - CREST syndrome

Back 148

Calcinosis
Raynaud's phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia

Limited skin involvement, often confined to fingers and face. More benign clinical course. Associated with antiCentromeric antibody (C for CREST).

Front 149

Drugs that cause drug-induced lupus are metabolized by what mechanism?

Back 149

phase II N-acetylation in the liver

Examples: hydralazine and procainamide

slow acetylators develop lupus more often

Front 150

Bisphosphanates are structural analgoues of what substance?

Back 150

Pyrophosphate, an important component of hydroxyapatite

Front 151

How are bisphosphanates administered? Why?

Back 151

Orally, but only 1% is absorbed. Therefore, these agents are administered in the fasting state with plenty of plain water. Patients also must stay upright for at least 30 minutes to prevent reflux because these agents are caustic to the esophagus.

Front 152

what is the most sensitive modality for diagnosing avascular necrosis?

Back 152

MRI

Front 153

what potential side effect is sometimes seen with Oxygen supplementation in neonatal RDS?

Back 153

Retinopathy of prematurity (a.k.a. retrolental fibroplasia)

Retinal vessel proliferation and possible retinal detachment with blindness

Front 154

In a lung transplant patient, lung biopsy showing areas of total fibrotic obstruction of terminal bronchioles is explained by what?

Back 154

Chronic rejection - Bronchiolitis Obliterans

Front 155

findings of subdural hematoma in combination with bilateral retinal hemorrhages in an infant suggests what syndrome?

Back 155

Shaken Baby Syndrome

Front 156

what substance accumulates in joints in gout?

Back 156

Monosodium urate

Front 157

what crystalloid masses are seen in sputum microscopy from a patient with extrinsic allergic asthma?

Back 157

Charcot-Leyden crystals (contain eosinophil membrane protein)

Front 158

Explain the immune mediators of chronic eosinophilic bronchitis in asthmatics

Back 158

bronchial wall infiltration by numerous activated eosinophils, largely in response to IL-5 released by allergen activated Th2 cells

Front 159

which cytokine induces eosinophil activation in asthmatics?

Back 159

IL-5

Front 160

a lung biopsy showing dense fibrosis, fibroblast proliferation and cyst formation, most prominent in the subpleural regions is most consistent with what disease?

Back 160

Pulmonary Interstitial Fibrosis

Front 161

what two cell types contain/secrete elastase in the lungs?

Back 161

Macrophages and Neutrophils (in large, azurophil granules)

Front 162

What enzyme is thought to be the major factor in the development of centriacinar and panacinar emphysema?

Back 162

Elastase

Front 163

"Aggregates of Epithelioid Cells" in a granuloma of sarcoid is referring to what cell type?

Back 163

Activated macrophages

Front 164

Describe the four stages of sarcoidosis

Back 164

Stage I - Bilateral hilar lymphadenopathy on CXR
Stage II - bilateral hilar lymphadenopathy and Pulmonary Infiltrates, commonly in the upper lobes
Stage III - Disappearance of hilar lymphadenopathy, CXR shows lung infiltrates only
Stage IV - lung fibrosis

Front 165

If a father has achondroplasia (regardless of how he got it), what is the chance that his child will have it?

Back 165

It is autosomal dominant, and homozygotes die before or soon after birth. Therefore you can assume that the dad is a heterozygote, and so the chance of inheritance is 50%, regardless of gender.

Front 166

In a clavicle fracture, what muscle causes the medial portion of the clavicle to be displaced upward?

Back 166

sternocleidomastoid

Front 167

Why do sarcoid patients develop hypercalcemia?

Back 167

Extrarenal 1alpha-hydroxylase activation in macrophages is increased due to T-lymphocyte secretion of IFN-gamma. This leads to overproduction of activated Vitamin D.

also occurs in Hodgkin's lymphoma and other granulomatous diseases.

Front 168

What three diseases are still treated with Streptomycin?

Back 168

Tuberculosis, Plague, and Tularemia

Front 169

What drug regimen is used to treat MAC in HIV patients?

Back 169

Clarithromycin or Azithromycin plus Rifabutin and/or Ethambutol

Front 170

What is a serum marker for osteoblast activity?

Back 170

bone-specific alkaline phosphatase (can be differentiated from liver/GI alk phos because it is easily denatured with heat)

Front 171

What is a serum marker for osteoclast activity?

Back 171

Urine Deoxypyridinoline excretion

Front 172

What is the most common focal dystonia?

Back 172

Cervical Dystonia (a.k.a. spasmodic torticollis)

Front 173

What is blepharospasm?

Back 173

involuntary, forcible closure of the eyelids

Front 174

where is the proximal attachment of the PCL?

Back 174

anterior-lateral surface of the medial epicondyle of the femur

Front 175

What are gottron's papules?

Back 175

Seen in dermatomyositis. Red or violaceous flat-topped papules with a light scale that appear over bony prominences. Most common locations are MCP, PIP, and DIP.

Specific to dermatomyositis.

Front 176

what two substances secreted by osteoblasts are important for osteoclast activation?

Back 176

M-CSF and RANK-L

Front 177

Neuromuscular lesions, ragged red skletal muscle fibers and lactic acidosis in multiple family members?

Back 177

Mitochondrial Encephalomyopathy - maternal inheritance pattern

Front 178

Define heteroplasmy

Back 178

Condition of having different organellar genomes (e.g., mutated and wild type) within a single cell. For mitochondrial diseases, patients with more severe disease are those with a higher proportion of defective mitochondrial genomes within their cells.

Many mitochondrial proteins are encoded for in the nuclear genome, but mitochondria also contain their own genomes.

Front 179

what is an ideal agent in treating a patient with hypertension/CHF who is also at risk for osteoporosis?

Back 179

Hydrochlorothiazide - increases renal calcium absorption in the distal convoluted tubule

Front 180

lecithin is also called what substance?

Back 180

phophatidylcholine

Front 181

lecithin is compared to what other substance in order to assess fetal lung maturity?

Back 181

sphingomyelin

Front 182

an inherited abnormality of which cell type is likely responsible for a patient developing Achondroplasia?

Back 182

chondrocytes - mutated fibroblast growth factor receptor 3 (FGFR-3)

Front 183

which beta blockers are non-specific and should not be used in an asthmatic or COPD patient for any reason?

Back 183

Propranolo, Timolol, Nadolol

Front 184

Which beta blockers can be used in asthmatics and COPD patients?

Back 184

Selective Beta1 antagonists - e.g. Metoprolol

Front 185

infant born with flaccid lower extremities and absent ankle reflexes, and x-ray showing poorly developed lumbar spine and sacrum - what disease?

Back 185

Caudal regression syndrome - associated with poorly controlled maternal diabetes, patients are born with agenesis of the sacrum and occasionally lumbar spine and experience resultant flaccid paralysis of the legs, dorsiflexed contractures of the feet, and urinary incontinence

Front 186

Dermatologic macroscopic terms - Macule

Back 186

Flat discoloration < 1 cm (e.g., Tinea versicolor)

Front 187

Dermatologic macroscopic terms - Patch

Back 187

Macule > 1cm

Front 188

Dermatologic macroscopic terms - Papule

Back 188

Elevated skin lesion < 1 cm (e.g., acne vulgaris)

Front 189

Dermatologic macroscopic terms - Plaque

Back 189

Papule > 1 cm (e.g., Psoriasis)

Front 190

Dermatologic macroscopic terms - Vesicle

Back 190

Small fluid-containing blister (e.g., Chickenpox)

Front 191

Dermatologic macroscopic terms - Wheal

Back 191

Transient vesicle (e.g., Hives)

Front 192

Dermatologic macroscopic terms - Bulla

Back 192

Large fluid-containing blister (bullous pemphigoid)

Front 193

Dermatologic macroscopic terms - Keloid

Back 193

Irregular, raised lesion resulting from scar tissue hypertrophy (follows trauma to skin, especially in African-Americans)

(e.g., T. pertenue [yaws])

Front 194

Dermatologic macroscopic terms - Pustule

Back 194

Blister containing pus

Front 195

Dermatologic macroscopic terms - Crust

Back 195

Dried exudates from a vesicle, bulla, or pustule (e.g., Impetigo)

Front 196

Dermatologic microscopic terms - Hyperkeratosis

Back 196

increased thickening of stratum corneum (e.g., psoriasis)

Front 197

Dermatologic microscopic terms - Parakeratosis

Back 197

Hyperkeratosis with retention of nuclei in stratum corneum (e.g., psoriasis)

Front 198

Dermatologic microscopic terms - Acantholysis

Back 198

Separation of epidermal cells (e.g., pemphigus vulgaris)

Front 199

Dermatologic microscopic terms - Acanthosis

Back 199

Epidermal hyperplasia (increased spinosum)

Front 200

Dermatologic microscopic terms - Dermatitis

Back 200

Inflammation of the skin

Front 201

Common skin disorders - Verrucae

Back 201

Warts. Soft, tan-colored, cauliflower-like lesions. Epidermal hyperplasia, hyperkeratosis, koilocytosis. Verruca vulgaris on hands, condyloma acuminatum on genitals (caused by HPV)

Front 202

Common skin disorders - Nevocellular nevus

Back 202

Common mole. Benign.

Front 203

Common skin disorders - Urticaria

Back 203

Hives. Intensely pruritic wheals that form after mast cell degranulation.

Front 204

Common skin disorders - Ephelis

Back 204

Freckle. Normal number of melanocytes, increased melanin pigment.

Front 205

Common skin disorders - Atopic dermatitis (eczema)

Back 205

Pruritic eruption, commonly on skin flexures. Often associated with other atopic diseases (asthma, allergic rhinitis)

Front 206

Common skin disorders - Allergic contact dermatitis

Back 206

Type IV hypersensitivity reaction that follows exposure to allergen. Lesions occur at site of contact (e.g., nickel, poison ivy).

Front 207

Common skin disorders - Psoriasis

Back 207

Papules and plaques with silvery scaling, especially on knees and elbows. Acanthosis with parakeratotic scaling (nuclei still in stratum corneum). Increased stratum spinosum, decreased stratum granulosum. Auspitz sign (bleeding spots when scales are scraped off). Can be associated with nail pitting and psoriatic arthritis.

Front 208

Common skin disorders - Seborrheic keratosis

Back 208

Flat, greasy, pigmented squamous epithelial proliferation with keratin-filled cysts (horn cysts). Looks "pasted on." Lesions occur on head, trunk, and extremities. Common benign neoplasm of older persons.

Sign of Leser-Trelat - sudden appearance of multiple seborrheic keratoses indicating an underlying malignancy (e.g., GI, lymphoid.)

Melanoma is on the differential.

Front 209

Pigmented skin disorders - Albinism

Back 209

Normal melanocyte number with decreased melanin production due to decreased activity of tyrosinase. Can also be caused by failure of neural crest cell migration during development.

Front 210

What is Leser-Trelat?

Back 210

sudden appearance of multiple seborrheic keratoses indicating an underlying malignancy (e.g., GI, lymphoid).

Front 211

Pigmented skin disorders - Vitiligo

Back 211

Irregular areas of complete depigmentation. Caused by a decrease in melanocytes.

Front 212

Pigmented skin disorders - Melasma (chloasma)

Back 212

"Mask of pregnancy" - hyperpigmentation associated with pregnancy or OCP use.

Front 213

Infectious skin disorders - Impetigo

Back 213

Very superficial skin infection. Usually from S. aureus or S. pyogenes. highly contagious. Honey-colored crusting.

Front 214

Infectious skin disorders - Cellulitis

Back 214

Acute, painful spreading infection of dermis and subcutaneous tissues. Usually from S. pyogenes or S. aureus.

Front 215

Infectious skin disorders - Necrotizing fasciitis

Back 215

Deeper tissue injury, usually from anaerobic bacteria and S. pyogenes. Results in crepitus from methane and CO2 production. "Flesh-eating bacteria."

Front 216

Infectious skin disorders - Staphylococcal scalded skin syndrome (SSSS)

Back 216

Exotoxin destroys keratinocyte attachments in the stratum granulosum only. Characterized by fever and generalized erythematous rash with sloughing of the upper layers of the epidermis. Seen in newborns and children.

Front 217

Infectious skin disorders - Hairy leukoplakia

Back 217

White, painless plaques on the tongue that cannot be scraped off. EBV mediated. Occurs in HIV-positive patients.

Front 218

Blistering skin disorders - Pemphigus vulgaris

Back 218

Potentially fatal autoimmune skin disorder with IgG antibody against desmosomes (anti-epithelial cell antibody); immunofluorescence reeals antibodies around cells of epidermis in a reticular or netlike pattern.

Acantholysis - intraepidermal bullae causing flaccid blister involving the skin and oral mucosa. Positive Nikolsky's sign (separation of epidermis upon manual stroking of skin).

Front 219

Blistering skin disorders - Bullous pemphigoid

Back 219

Autoimmune disorder with IgG antibody against hemidesmosomes (epidermal basement membrane); shows linear immunofluorescence. Eosinophils within tense blisters. Similar to but less severe than pemphigus vulgaris - affects skin but spares oral mucosa. Negative Nikolsky's sign.

Front 220

Blistering skin disorders - Dermatitis herpetiformis

Back 220

Pruritic papules and vesicles. Deposits of IgA at the tips of dermal papillae. Associated with celiac disease.

Front 221

Blistering skin disorders - Erythema multiforme

Back 221

Associated with infections (e.g., Mycoplasma pneumoniae, HSV), drugs (e.g., sulfa drugs, Beta-lactams, phenytoin), cancers, and autoimmune disease. Presents with multiple types of lesions - macules, papules, vesicles, and target lesions (red papules with a pale central area).

Front 222

Blistering skin disorders - Stevens-Johnson syndrome

Back 222

Characterized by fever, bulla formation and necrosis, sloughing of skin, and a high mortality rate. Usually associated with adverse drug reaction. A more severe form of Stevens-Johnson syndrome is known as toxic epidermal necrolysis.

Front 223

Miscellaneous skin disorders - Lichen planus

Back 223

Pruritic, Purple, Polygonal Papules. Sawtooth infiltrate of lymphocytes at dermal-epidermal junction. Associated with hepatitis C.

Front 224

Miscellaneous skin disorders - Actinic keratosis

Back 224

Premalignant lesions caused by sun exposure. Small, rough, erythematous or brownish papules. "Cutaneous horn." Risk of carcinoma is proportional to epithelial dysplasia.

Front 225

Miscellaneous skin disorders - Acanthosis nigricans

Back 225

Hyperplasia of stratum spinosum. Associated with hyperinsulinemia (e.g., from Cushing's disease, diabetes) and visceral malignancy.

Front 226

Miscellaneous skin disorders - Erythema nodosum

Back 226

Inflammatory lesions of subcutaneous fat, usually on anterior shins. Associated with coccidioidomycosis, histoplasmosis, TB, leprosy, streptococcal infections, sarcoidosis.

Front 227

Miscellaneous skin disorders - Pityriasis rosea

Back 227

"Herald patch" followed days later by "Christmas tree" distribution. Multiple papular eruptions; remits spontaneously.

Front 228

Skin cancer - Squamous cell carcinoma

Back 228

Very common. Associated with excessive exposure to sunlight and arsenic exposure. Commonly appear on hands and face. Locally invasive, but rarely metastasizes. Ulcerative red lesion. Associated with chronic draining sinuses. Histopathology: keratin "pearls"

Actinic keratosis - is a precursor to squamous cell carcinoma

Front 229

Skin cancer - keratoacanthoma

Back 229

A variant of squamous cell carcinoma of the skin that grows rapidly (4-6 weeks) and regresses spontaneously (4-8 weeks)

Front 230

Skin cancer - basal cell carcinoma

Back 230

Most common in sun-exposed areas of body. Locally invasive, but almost never metastasizes. Rolled edges with central ulceration. Pearly papules, commonly with telangiectasias. Basal cell tumors have "palisading" nuclei.

Front 231

Palisading nuclei - what is it? what skin cancer is it associated with?

Back 231

palisading is where the nuclei line up, almost looking like a wall or fence

Basal cell carcinoma

Front 232

Skin cancer - melanoma

Back 232

Common tumor with significant risk of metastasis. S-100 tumor marker. Associated with sunlight exposure; fair-skinned persons are at increased risk. Depth of tumor correlates with risk of metastasis. Dysplastic nevus (atypical mole) is a precursor to melanoma. Look for Asymmetry, Border irregularity, Color variation, Diameter > 6 mm, and history of change.

Front 233

Arachidonic acid products

Back 233

Lipoxygenase pathway yields Leukotrienes.
LTB4 is a neutrophil chemotactic agent.
LTC4, D4, and E4 function in bronchoconstriction, vasoconstriction, contraction of smooth muscle, and increased vascular permeability.

PGI2 inhibits platelet aggregation and promotes vasodilation ("Platelet Gathering Inhibitor")

Front 234

Describe the arachidonic acid pathway and where different drugs inhibit it.

Back 234

Membrane lipid (e.g., phosphatidylinositol) is cleaved by phospholipase A2 (inhibited by corticosteroids) to release Arachidonic acid.

Lipoxygenase cleaves a portion of arachidonic acid (inhibited by Zileuton) to produce hydroperoxides which will then be converted to the various leukotrienes.
LTB4 induces neutrophil chemotaxis. All other leukotrienes (LTC4, LTD4, etc) increase bronchial tone (inhibited by zafirlukast, montelukast).

The other pathway is that AA is cleaved by Cyclooxygenase (COX-1, COX-2) into endoperoxides (PGG2, PGH2). This step is inhibited by NSAIDS, acetaminophen, COX-2 inhibitors.

Prostacyclin (PGI2) is one product of endoperoxide cleavage. PGI2 inhibits platelet aggregation, vascular tone, bronchial tone, and uterine tone.

Prostaglandins (PGE2, PGF2alpha) increase uterine tone, decrease vascular tone, and decrease bronchial tone.

Thromboxane A2 increases platelet aggregation, increases vascular tone, and increases bronchial tone.

Front 235

What are the actions of LTB4?

Back 235

Induces neutrophil chemotaxis

Front 236

What are the actions of LTC4, LTD4?

Back 236

Increase bronchial tone

Front 237

What are the actions of PGI2 (prostacyclin)?

Back 237

Inhibits platelet aggregation, inhibits vascular tone, inhibits bronchial tone, inhibits uterine tone.

Front 238

What are the actions of prostaglandins (PGE2, PGF2alpha)?

Back 238

Increase uterine tone, decrease vascular tone, decrease bronchial tone.

Front 239

What are the actions of thromboxane (TXA2)?

Back 239

Increase platelet aggregation, increase vascular tone, increase bronchial tone.

Front 240

What is the endoperoxide family?

Back 240

PGG2, PGH2 - produced by cyclo-oxygenase activity on arachidonic acid.

These molecules are cleaved into prostacyclin (PGI2), prostaglandins (PGE2, PGF2alpha) and thromboxane (TXA2).

Front 241

What is the hydroperoxide family?

Back 241

Formed by lipoxygenase activity on arachidonic acid.

Cleavage of these molecules leads to production of Leukotrienes (LTB4, LTC4, LTD4).

Front 242

Aspirin - mechanism? Clinical use? Toxicity?

Back 242

Mechanism - irreversibly inhibits cyclooxygenase (both COX-1 and COX-2) by acetylation, which decreases synthesis of both thromboxane A2 (TXA2) and prostaglandins. Increases bleeding time. No effect on PT, aPTT. A type of NSAID.

Clinical use: Low dose (<300mg/day): decreased platelet aggregation; Intermediate dose (300-2400 mg/day): antipyretic and analgesic; High dose (2400-4000mg/day): anti-inflammatory.

Toxicity: Gastric ulceration, hyperventilation, tinnitus (CN VIII). Chronic use can lead to acute renal failure, interstitial nephritis, and upper GI bleeding. Reye's syndrome in children with viral infection.

Front 243

What is aspirin's effect on PT? aPTT?

Back 243

no effect on either

Front 244

NSAIDs - examples? Mechanism? Clinical use? Toxicity?

Back 244

Ibuprofen, naproxen, indomethacin, ketorolac
Mechanism: Reversibly inhibit cyclooxygenase (both COX-1 and COX-2). Block prostaglandin synthesis.

Clinical use: Antipyretic, analgesic, anti-inflammatory. Indomethacin is used to close a PDA.

Toxicity: Renal damage, fluid retention, aplastic anemia, GI distress, ulcers

Front 245

COX-2 inhibitors (celecoxib) - Mechanism? Clinical Use? Toxicity?

Back 245

Mechanism: Reversibly inhibit specifically the cyclooxygenase (COX) isoform 2, which is found in inflammatory cells and vascular endothelium and mediates inflammation and pain; spares COX-1, which helps maintain the gastric mucosa. Thus, should not have the corrosive effects of other NSAIDs on the GI lining.

Clinical Use: Rheumatoid and osteoarthritis; patients with gastritis or ulcers.

Toxicity: increased risk of thrombosis. Sulfa allergy. Less toxicity to GI mucosa (lower incidence of ulcers, bleeding than NSAIDs)

Front 246

Acetaminophen - Mechanism? Clinical Use? Toxicity?

Back 246

Mechanism: Reversibly inhibits cyclooxygenase, mostly in CNS. Inactivated peripherally.

Clinical Use: Antipyretic, analgesic, but lacking anti-inflammatory properties. Used instead of aspirin to prevent Reye's syndrome in children with viral infection.

Toxicity: Overdose produces hepatic necrosis; acetaminophen metabolite depletes glutathione and forms toxic tissue adducts in liver. N-acteylcysteine is antidote - regenerates glutathione.

Front 247

Bisphosphonates - Examples? Mechanism? Clinical use? Toxicity?

Back 247

Etidronate, pamidronate, alendronate, risedronate, zoledronate (IV)
Mechanism: Inhibit osteoclastic activity; reduce both formation and resorption of hydroxyapetite.

Clinical use: Malignancy-associated hypercalcemia, Paget's disease of bone, postmenopausal osteoporosis.

Toxicity: Corrosive esophagitis (except zoledronate), nausea, diarrhea, osteonecrosis of the jaw.

Front 248

Chronic gout drugs - Probenecid

Back 248

Inhibits reabsorption of uric acid in proximal convoluted tubule (also inhibits secretion of penicillin)

Front 249

Chronic gout drugs - Allopurinol

Back 249

Inhibits xanthine oxidase, decreases conversion of xanthine to uric acid. Also used in lymphoma and leukemia to prevent tumor-lysis associated urate nephropathy. Increases concentrations of azathioprine and 6-MP (both normally metabolized by xanthine oxidase).

Front 250

What drug, at high doses, has some ability to inhibit reabsorption of uric acid?

Back 250

High-dose salicylates.

It is not recommended to treat chronic gout with salicylates, because all but the highest doses actually depress uric acid clearance. Even the highest doses (5-6 g/day) have only minor uricosuric activity.

Front 251

Chronic gout drugs - Febuxostat

Back 251

Inhibits xanthine oxidase.

Front 252

Acute gout drugs - Colchicine

Back 252

Binds and stabilizes tubulin to inhibit polymerization, impairing leukocyte chemotaxis and degranulation.

GI side effects, especially if given orally (Note: indomethacin is less toxic; also used in acute gout.)

Front 253

Acute gout drugs - NSAIDs

Back 253

Naproxen is used

Front 254

Explain the pathway leading to uric acid production, excretion, etc.

Back 254

Purines from the diet and nucleic acid degradation are converted to hypoxanthine.

Xanthine oxidase converts hypoxanthine to xanthine, as well as converting xanthine to plasma uric acid. This is how urate crystals are deposited in joints leading to gout.

Uric acid is filtered in the glomerulus, and reabsorbed in the PCT (inhibited by probenecid and high-dose salicylates). It is secreted in the PCT in certain conditions, and this is inhibited by diuretics (acetazolamide) and low-dose salicylates.

Front 255

TNF-alpha inhibitors - what side effect is common to the drugs in this class?

Back 255

All TNF-alpha inhibitors predispose to infection including reactivation of latent TB since TNF blockade prevents activation of macrophages and destruction of phagocytosed microbes.

Front 256

TNF-alpha inhibitors - Etanercept - Mechanism? Clinical use?

Back 256

Mechanism: Recombinant form of human TNF receptor that binds TNF.

Clinical uses: Rheumatoid arthritis, psoriasis, ankylosing spondylitis

(NOTE: EtanerCEPT is a TNF decoy reCEPTor.)

Front 257

TNF-alpha inhibitors - Infliximab - Mechanism? Clinical uses?

Back 257

Mechanism: Anti-TNF antibody

Clinical use: Crohn's disease, rheumatoid arthritis, ankylosing spondylitis, Psoriatic arthritis

Front 258

TNF-alpha inhibitors - Adalimumab - Mechanism? Clinical use?

Back 258

Mechanism: Anti-TNF antibody

Clinical use: Rheumatoid arthritis, psoriasis, ankylosing spondylitis, Crohn's disease

Front 259

What skin lesions are associated with Primary Biliary Cirrhosis?

Back 259

Xanthelasma and other forms of xanthoma (tuberous, eruptive, tendinous) - caused by hyperlipidemia from the cholestasis that BPC causes

If you biopsy the lesion it will show numerous lipid-laden macrophages.

Front 260

Mental retardation, eczema, and a mousy, musty body odor are suggestive of what disease?

Back 260

Phenylketonuria (PKU) - autosomal recessive disease caused by mutation of the gene that codes for phenylalanine hydroxylase

Front 261

a patient is on methotrexate, prednisone, indomethacin, and levothyroxine and develops a pathalogic vertebral body fracture, which drug most likely caused it?

Back 261

Prednisone - patients taking as little as 7.5 mg of prednisone daily for > 6 months can develop osteoporotic bone changes, 30-50% of patients on long term prednisone can develop pathologic vertebral body fractures

Front 262

In a humeral shaft fracture and signs of radial nerve lesion (inability to extend the right wrist), what artery is most likely injured?

Back 262

Deep brachial artery (runs with the radial nerve)

Front 263

Anterior dislocation of the humerus most commonly causes what nerve to be damaged?

Back 263

Axillary nerve

Front 264

if a patient has morning stiffness for 15 minutes, should I rule out OA and assume maybe RA?

Back 264

NO - you can have morning stiffness in OA but its short duration (<30 minutes)

Front 265

if a smoker has progressive shortness of breath and CXR shows opacification of the entire right lung with trachial deviation to the right, what does he likely have?

Back 265

The tracheal deviation to the same side as the opacification points towards a right mainstem bronchus lesion (likely cancerous) - preventing ventilation of the right lung and therefore leading to alveolar collapse throughout the right lung.

Front 266

Mediastinal mass biopsy in a 65 yo smoker shows clusters of ovoid cells that are smaller than resting lymphocytes. Immunohistochemical staining is positive for chromogranin. What disease?

Back 266

Small cell carcinoma - on light microscopy it is composed of round or oval cells with scant cytoplasm and large hyperchromatic nuclei

Can display varying degrees of neuroendocrine differentiation. Immunohistochemical stains are frequently positive for neuroendocrine markers, such as neuron specific enolase, chromogranin and synaptophysin.

Front 267

what is a side effect of long-term topical corticosteroids for eczema?

Back 267

Dermal atrophy (corticosteroids decrease the production of ECM and GAGs)

Front 268

Where is the common peroneal nerve particularly susceptible to damage?

Back 268

as it crosses the lateral neck of the fibula - damage typically occurs via compression or leg fracture

Front 269

If a patient is found on autopsy to have a small fibrotic focus in the lower lobe of the right lung and a calcified lymph node int he right lung hilus, what TB situation are we looking at?

Back 269

That is a GHON complex from primary TB.

Front 270

If a patient has Tuberculoid leprosy, what type of WBCs will be seen in the skin lesion on biopsy?

Back 270

dominance of CD4+ Th1 lymphocytes - in contrast to lepromatous leprosy where there is a weak cell-mediated response

Front 271

In a woman with postmenopausal osteoporosis and a vertebral body pathologic fracture, how is serum calcium responding to PTH in that patient?

Back 271

normally - its about bone density and serum calcium and PTH are both in the normal range

Front 272

70yo man has bone pain, elevated alk phos, and histological exam shows haphazardly oriented cement lines, that create a mosaic pattern of lamellar bone - what cell type is most likely involved in the initial lesion of this disease?

Back 272

Paget's disease of bone - starts with marked osteoclastic activation followed by osteoblast activation - OSTEOCLASTS FIRST THOUGH

Front 273

IM injection into the superomedial buttock may cause what functional abnormality?

Back 273

"Gluteus medius gait" - hip dips downward when the ipsilateral foot is lifted off the ground - due to injury of superior gluteal nerve

Front 274

What is spongiosis?

Back 274

In acute eczematous dermatitis there is an epidermal accumulation of edematous fluid int he intercellular spaces - a.k.a. "Spongiosis"

The intercellular bridges become more distinctive in an edematous background and the epidermis is often described as appearing "spongy."

Front 275

What five types of xanthomas exist?

Back 275

Eruptive xanthoma (yellow papules that abruptly appear when plasma triglycerides and lipids increase)

Tuberous and tendinous xanthomas (the latter are often present on Achilles tendons and the extensor tendons of the fingers); plane xanthomas (linear lesions in skin folds that are strongly associated with primary biliary cirrhosis); and xanthelasma (soft eyelid or periorbital plaques with no associated lipid abnormalities in 50% of affected individuals)

Front 276

Histologically, what are xanthomas composed of?

Back 276

benign macrophages packed with finely vacuolated, "foamy" cytoplasm containing high levels of cholesterol, phospholipids, and triglycerides

Front 277

if a patient has lyme disease and doxycycline is unavailable, what else works?

Back 277

Ceftriaxone (penicillin-type antibiotics)

Front 278

What test should be performed before a patient is put on Etanercept?

Back 278

PPD test - TNF-alpha inhibitors can lead to reactivation and dissemination of latent TB

You shouldn't give these drugs to any patient with any infection.

Front 279

patient on HCTZ comes to ER with muscle weakness and cramping - what electrolyte abnormality?

Back 279

Hypokalemia - HCTZ decreases intravascular volume stimulating aldosterone secretion --> potassium secretion

Front 280

Before reaching the wrist, the median nerve courses between what two muscles?

Back 280

Flexor digitorum superficialis and flexor digitorum profundus

Front 281

18 yo girl being treated with nafcillin, what did her disease likely present as?

Back 281

Folliculitis or cellulitis or skin abscess with MSSA

Front 282

cells in Melanoma come from what part of the ectoderm?

Back 282

Neural crest

Front 283

what is the primary impairment in a patient with osteogenesis imperfecta?

Back 283

Bone matrix formation

Front 284

why do patients with osteogenesis imperfecta have blue sclera?

Back 284

Abnormality in connective tissue deposition allows vessels to show through the eye.

Front 285

What is the inheritance pattern of osteogenesis imperfecta?

Back 285

Autosomal Dominant, most commonly

Front 286

Hemolysis in sickle cell anemia leads to what 3 blood test abnormalities?

Back 286

increased indirect bilirubin concentration, increased LDH, decreased haptoglobin

Front 287

What is the most important determinant of peak bone mass?

Back 287

Genetic factors (Not activity or consumption of calcium/vitamin D!!! although they do contribute)

Front 288

Parakeratotic scaling, increased stratum spinosum (acanthosis), decreased stratum granulosum, and intermittent clusters of neutrophils suggest what disease?

Back 288

Psoriasis

Front 289

Para-aminobenzoic acid (PABA)-containing sunscreens protect against which type of UV radiation?

Back 289

UVB only (this is the major source of most of the harmful effects of sunlight, and is the major source of UV radiation burns)

Front 290

UVA light does make contributions to cutaneous photo damage, which sunscreen types cover all types of UV light?

Back 290

Zinc oxide-containing sunscreens protect against UVB, UVAI and UVAII

Front 291

a 26yo semi-pro baseball player has a comedonal and inflammatory nodular eruption on his face, chest, and back - what is most likely occuring?

Back 291

He has nodular and comedonal acne in his twenties, when he should have outgrown it - he is likely taking methyltestosterone (anabolic steroids)

Front 292

What type of bone is most commonly affected in osteoporosis? Why?

Back 292

Trabecular (spongy) bone - although only comprises 15% of total skeleton, has high surface area and is therefore more metabolically active

Front 293

In a 32yo patient with septic arthritis, after a tap is performed, what should be done?

Back 293

Give abx (ceftriaxone) to treat likely causative organisms (most commonly gonococcus in this age group)

Front 294

A deep laceration shows actin-containing fibroblasts and increased MMP activity 3 weeks later, likely due to what complication?

Back 294

Contracture - induced during healing by second intention by activity of myofibroblasts

Front 295

actinic keratosis is most likely to lead to what skin cancer?

Back 295

Squamous cell carcinoma

Front 296

Which single axis movement would lead to shoulder pain in a patient with a calcified supraspinatus muscle?

Back 296

Abduction of the humerus!!!! Just using the muscle!

Front 297

What is pleiotropy?

Back 297

the occurrence of multiple phenotypic manifestations, often in different organ systems, as a result of a single genetic defect

Front 298

BRAF mutation V600E is associated with what cancer type?

Back 298

BRAF is specific to melanocytes and when activated promotes growth, survival and metastasis

Front 299

What is Vemurafenib?

Back 299

A potent inhibitor of mutated BRAF - has anti-tumor effects with improved survival and long-term outcomes in stage 3 and 4, V600E positive melanoma patients

Front 300

How does colchicine work?

Back 300

binds to the protein subunit of microtubules and prevents their aggregation. This in turn disrupts membrane-dependent functions such as chemotaxis and phagocytosis. It also reduces formation of LTB4.

Front 301

What is the inheritence pattern for male-pattern baldness (androgenetic alopecia)?

Back 301

Polygenic, however mutations in the androgen receptor have recently been shown to be critical for developing this disease and they are inherited in an X-linked recessive manner.

Front 302

What are the major side-effects of colchicine?

Back 302

Diarrhea, less commonly nausea and vomiting - gastric mucosal cells are affected by the drug's effects on microtubules.

Front 303

What are the side-effects of succinylcholine use?

Back 303

1. Malignant Hyperthermia (esp. with halothane use, and in genetically predisposed patients)
2.Severe hyperkalemia in patients with burns, crush injuries, myopathies
3. Bradycardia from parasympathetic action or tachycardia from sympathetic ganglionic activity

Front 304

what ligament is injured in radial subluxation (nursemaid's elbow)?

Back 304

annular ligament

Front 305

what color does tetracylcine use in children cause their teeth to become?

Back 305

yellow, gray, or brown

Front 306

What artery is at most risk of damage in a femoral neck fracture?

Back 306

Medial circumflex (which travels posteriorly around the neck)

Front 307

What is the defective mechanism in Xeroderma Pigmentosum?

Back 307

impaired DNA excision repair - damaged DNA nucleotide sequences are usually excised and replaced, and in this disease one of those two steps is impaired

Front 308

Where is the most common site of hemotogenous osteomyelitis in children?

Back 308

Long bone metaphysis because of its rich blood supply

Front 309

What is OPG?

Back 309

Osteoprotegerin - a decoy molecule that binds to RANK-L and prevents the activation of osteoclasts and therefore inhibits bone resorption

Front 310

Name 7 risk factors for osteoporosis.

Back 310

1. smoking
2. menopause
3. corticosteroid therapy
4. Physical inactivity
5. caucasian race (immutable)
6. Low total body weight
7. Alcohol use

Front 311

What is the allergic triad?

Back 311

Asthma, atopic dermatitis (eczema), and allergic rhinitis

Front 312

what molecule allows osteocytes to remain connected to one another once they have been bathed in ECM?

Back 312

gap junctions

Front 313

What bursa is affected by prolonged kneeling?

Back 313

Prepatellar bursa ("Housemaid's knee")

Front 314

How can CREST syndrome lead to right sided heart failure?

Back 314

Thickening of the intima of the pulmonary vasculature --> pulmonary HTN --> cor pulmonale. Look for an accentuated second heart sound over the LUSB.

Front 315

What two antiviral therapies are good for patients with HIV-associated viruses that have absence of viral thymidine kinase?

Back 315

Foscarnet (a viral DNA polymerase inhibitor) and Cidofovir (a cytosine-monophosphate analogue that does not need the phosphate added by viral kinase)

Front 316

Explain the mechanism by which antipsychotics cause extrapyramidal symptoms.

Back 316

They block D2 receptors in the mesolimbic-mesocortical pathway in the brain, but they also block D2 receptors in the nigrostriatal pathway. This leads to unchecked ACh activity which causes extrapyramidal symptoms such as akithisia, tardive dyskinesia, and spasmodic torticollis. First generation blockers (e.g., haloperidol) have a stronger affinity for D2 receptors and so these drugs cause more EPS.

Front 317

What is first line therapy for acute gout?

Back 317

COX inhibitors - DO NOT GIVE xanthine oxidase or uricosurics because they can worsen symptoms of acute gout!

Front 318

What is pilocarpine?

Back 318

Nonselective muscarinic agonist

Front 319

What do you use to treat the side effects of pyridostigmine in myasthenia gravis patients?

Back 319

muscarinic receptor antagonists such as scopolamine

Front 320

Which band in the sarcomere represents only myosin filaments?

Back 320

H band

Front 321

Name the three bones, in order from lateral to medial, that exist in the proximal row of wrist bones.

Back 321

Scaphoid (lateral), Lunate (middle), triquetrum (medial)

Front 322

How many bones are in the proximal row of the wrist bones?

Back 322

only three!!!!!

Front 323

How does congenital hypothyroidism present?

Back 323

neonate is lethargic, feeds poorly, exhibits prolonged jaundice, demonstrates constipation, muscle hypotonia, and a hoarse cry. They have myxedema (edema of subcutaneous fat and skin), macroglossia, and pale, dry, cool extremities. Coarse facial features and umbilical hernia are also common. They are at increased risk for having ASD and VSDs.

T4 is imperative for normal brain development, and if this disease goes undiagnosed, severe, irreversible mental retardation can occur.

Front 324

In vitamin D synthesis, what step occurs in the skin with the aid of sunlight?

Back 324

7-dehydrocholesterol --> cholecalciferol (Vitamin D3)

Light opens up the B ring of the molecule, and then thermal isomerization occurs.

Front 325

How do you help prevent stomatitis (oral ulcers) in patients on methotrexate?

Back 325

Folic acid supplementation

Front 326

How do you test for Trendelenburg sign?

Back 326

Have the patient stand facing away from you, and push up with either heal. A positive sign occurs if the patient's hip tilts to the unaffected side when pushing on the affected side. This is due to superior gluteal nerve deficit.

Front 327

What histological changes can be seen in Ricket's?

Back 327

accumulation of unmineralized osteoid around bony trabeculae, widening between osteoid seams

Front 328

What are major clinical findings in patients with Rickets?

Back 328

Genu varus (weight bearing bones bow laterally), bony prominences at the costochondral junctions (rachitic rosary), indentations in the lower ribs (Harrison's sulci), softening of the skull (craniotabes), hypocalcemia, hypophosphatemia, hypertonia, and growth retardation

Front 329

How does Vitamin C deficiency cause its symptoms?

Back 329

Vitamin C is a reducing agent that is necessary for proline and lysine hydroxylation. Hydroxyproline and hydroxylysine are necessary for cross-linking of collagen molecules. Without vitamin C, connective tissue does not have its appropriate tensile strength leading to easy bruising (damage to capillary walls), gum swelling, loosening of teeth, periodontal infections and poor wound healing.

Front 330

How do topical Vitamin D analogues treat psoriasis?

Back 330

Bind to and activate Vitamin D receptor, a nuclear transcription factor that inhibits keratinocyte proliferation and promotes keratinocyte differentiation.

Front 331

If you see rhomboid crystals in a knee tap...what disease?

Back 331

pseudogout

Front 332

What is malignant acanthosis nigricans?

Back 332

Acanthosis nigricans that develops secondary to a visceral malignancy as opposed to insulin-resistance.

Front 333

What major ways can bullous pemphigoid be distinguished from pemphigus vulgaris, clinically speaking?

Back 333

Nikolsky's sign is positive in pemphigus vulgaris and negative in bullous pemphigoid. This sign is positive when gentle traction of skin produces bullae.

Oral mucosal involvement is only associated with pemphigus vulgaris, NOT bullous pemphigoid.

Front 334

Why can a patient's ability to expand their chest become diminished with ankylosing spondylitis.

Back 334

Enthesopathies of the costovertebral and costosternal junctions can occur. This can cause pain which may prevent maximal chest expansion leading to hypoventilation.

Front 335

With urticaria, what layer of the skin is affected?

Back 335

you see dermal edema, the epidermis is unaffected

Front 336

What structure causes abrupt muscle relaxation when a weight-lifter tries to pick up far too much weight?

Back 336

the Golgi-Tendon Organ - this structure exists at the muscle-tendon interphase, and is in series with the contracting extrafusal fibers and the tendon itself. The structure is sensitive to changes in pressure and through 1b sensory fibers, activates an inhibitory motor interneuron that, when stimulated, leads to rapid inhibition of the alpha-motoneuron in order to prevent damage to the musculoskeletal system

Front 337

How does parvovirus B19 infection present in adults?

Back 337

symmetrical polyarthritis, usually involving the MCPs, wrists, knees, PIPs, and ankle joints

Front 338

What three cytokines are initially released in order to induce inflammation systemically?

Back 338

IL-1, IL-6, TNF-alpha

They are secreted by local neutrophils and macrophages when an injury occurs.

Front 339

What histologic findings occur in VZV reactivation (Shingles)?

Back 339

Multinucleated inclusion-bearing giant cells as well as acantholysis of keratinocytes and intraepidermal vesicles

Front 340

How does PTH stimulate bone resorption?

Back 340

Binds to PTH receptors on osteoblasts, and induces expression of RANK-L and Monocyte Colony-stimulating factor.

Front 341

What is the underlying cause of hypopigmentation in vitiligo?

Back 341

Melanocyte absence in the skin - mechanism unclear but thought to be associated with auto-immune disorders

Front 342

What is the cutoff in diameter between purpurae and ecchymoses? between petechiae and purpurae?

Back 342

1 cm; 5mm