Musculoskeletal And Connective Tissue

Front 1

Name the epidermis layers (from surface to base).

Back 1

"Calforinians Like Girls in String Bikinis"
- stratum corneum
- stratum lucidum
- stratum granulosum
- stratum spinosum
- stratum basalis

Front 2

What are Zona occuldens? What are their functions?

Back 2

- tight junctions
- composed of claudins and occludins
- prevents diffusion across paracellular space

Front 3

What are zona adherens? What are their functions?

Back 3

- intermediate junctions
- surrounds perimeter just below zona occludens
- cadherins connect to actin (CADherins are Ca-dependent ADhesion molecules)

Front 4

What are macula adherens? what are their functions?
- what disease is caused by autoantibodies against macula adherens?

Back 4

- desmosome
- small, discrete sites of attachment
- cadherins connect to intermediate filaments
- autoantibodies = pemphigus vulgaris

Front 5

What are gap junctions? What are their functions?

Back 5

- allows adjacent cells to communicate for electric and metabolic functions

Front 6

What are integrins? What are their functions?

Back 6

maintain integrity of basement membrane; binds to laminin in BM

Front 7

What are hemidesmosomes? What are their functions?
- what disease is caused by autoantibodies against hemidesomosomes?

Back 7

- connects cells to underlying extracellular matrix
- autoantibodies = bullous pemphigoid

Front 8

What is the "unhappy triad"/knee injury? How does it occur?

Back 8

- common football injury
- force from the lateral side --> damage to the "unhapyp triad"
1. medial collateral ligament (MCL)
2. anterior cruciate ligament (ACL)
3. Lateral meniscus

Front 9

What is the landmark for pudendal nerve block?

Back 9

ischial spine

Front 10

What is the landmark to find the appendix?

Back 10

2/3 of the way from the umblicius to the anterior superior iliac spine (McBurney's point)

Front 11

What are the shoulder muscles that form the rotator cuff? What are their functions?

Back 11

"SItS"
- 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 12

What is the cause of injury, deficits and sign of damage to axillary nerve (C5, C6)?

Back 12

- cause of injury: fractured surgical neck of humerus, dislocation of humeral head
- motor: deltoid- arm abduction at shoulder
- sensory: over deltoid muscle
- sign: flattened deltoid

Front 13

What is the cause of injury, deficits and sign of damage to radial nerve (C5-C8)?

Back 13

- cause: fracture at midshaft of humerus (saturday night palsy)
- motor: "BEST extensors", brachioradialis, extensors of writs and fingers, supinators, tricepts
- sensory: posterior arm and dorsal hand/thumb
- sign: wrist drop

Front 14

What is the cause of injury (proximal lesion), deficits and sign of damage to median nerve (C6, C8, T1)?

Back 14

- cause: fracture of supracondylar humerus
- motor: lateral finger flexion, wrist flexion
- sensory:dorsal and palmar aspects of lateral 3.5 fingers, thenar eminence
- sign: "Ape hand"; thenar atrophy, loss of opposability of thumb

Front 15

What is the cause of injury (distal lesion), deficits and sign of damage to median nerve (C6, C8, T1)?

Back 15

- cause: carpal tunnel sydrome, dislocated lunate
- motor: opposition of thumb
- sensory: dorsal and palmar aspects of lateral 3/5 fingers
- sign: ulnar deviation of wrist upon wrist flexion

Front 16

What is the cause of injury (proximal), deficits and sign of damage to ulnar nerve (C8, T1)?

Back 16

- cause: fracture of medial epicondyle of humerus, "funny bone"
- motor: medial finger flexion, wrist flexion
- sensory: medial 1.5 fingers hypothenar eminence
- sign: radial deviation of wrist upon wrist flexion

Front 17

What is the cause of injury (distal), deficits and sign of damage to ulnar nerve (C8, T1)?

Back 17

- cause: fracture of hook of hamate (falling onto outstretched hand)
- motor: abduction and adduction of fingers (interossi), adduciton of thumb, extension of 4th and 5th fingers (lumbricals)
- sensory: none
- sign: ulnar claw hand (when asked to stragthen fingers - "pope's blessing/hand of benediction)

Front 18

What is the cause of injury, deficits and sign of damage to musculocutaneous nerve (C5-C7)?

Back 18

- cause: upper trunk compression
- motor: biceps, brachialis, coracobrachialis, flexion of arm at elbow
- sensory: lateral forearm
- sign: none

Front 19

Describe an Erb-Duchenne palsy (Waiter's tip)

Back 19

- 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 20

Describe Klumpke's palsy

Back 20

- 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

Front 21

What are the features of thoracic outlet syndrome?

Back 21

1. atrophy of the thenar and hypothenar eminences
2. atrophy of the interosseous muscles
3. sensory deficits ont he medial side of the forearm and hand
4. disappearance of the radial pulse upon moving the head toward the ipsilateral side

Front 22

what is the function of the lumbricals?

Back 22

flex the MCP joints and extend both the HIP and PIP joints

Front 23

Describe an ulnar claw.

Back 23

distal ulnar nerve lesion --> loss of medial lumbircal 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 clawes

Front 24

Describe a median claw.

Back 24

- 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 25

Describe an "Ape hand"

Back 25

- proximal median nerve lesion --> loss of opponens pollicis muscle function --> unopposable thumb (inability to abduct thumb)

Front 26

Describe Klumpke's total claw

Back 26

- 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 27

What is the cause of a winged scapula and lymphedema?

Back 27

- damage to long thoracic nerve (C5-C7)
- which supplies the serratus anterior - connects scapula to thoracic cage
- used for abduction above horizontal position
- can be injured in masectomy

Front 28

What are the muscles that make up the thenar muscles? innervation?

Back 28

- opponens pollicis, abductor pollicis brevis, flexor pollicis brevis
- median nerve

Front 29

What are the muscles that make up the hypothenar muscles? innervation?

Back 29

- opponens digiti minimi, abductor digiti minimi, flexor digit minimi
- ulnar nerve

Front 30

What is the funtion of the dorsal interosseous muscles? palmar interosseous muslces?

Back 30

- dorsal = ABduct (DAB)
- palmar = ADduct (PAD)

Front 31

What are the consequences of repetitive elbow trauma?

Back 31

- degenerative injury due to repeated use; leads to tiny tears in tendons and muscles
- may be inflammtory (i.e. lateral epicondylitis (tennis elbow), medial epicondylitis (golf elbow)

Front 32

What is the cause of injury, motor and sensory deficit to the obturator nerve (L2-L4)?

Back 32

- cause: anterior hip dislocation
- motor: thigh adduction
- sensory: medial thigh

Front 33

What is the cause of injury, motor and sensory deficit to the femoral nerve (L2-L4)?

Back 33

- cause: pelvic fracture
- motor: thigh flexion and leg extension
- sensory: anterior thigh and medial elg

Front 34

What is the cause of injury, motor and sensory deficit to the common peroneal (L4-S2)?

Back 34

- cause: trauma to lateral aspect of leg or fibula neck fractuer
- motor: foot eversion and dorsiflexion; toe extension; foot drop, foot slap, steppage gait
- sensory: anterolateral leg and dorsal aspect of foot

Front 35

What is the cause of injury, motor and sensory deficit to the tibial nerve (L4-S2)?

Back 35

- cause: knee trauma
- motor: foot inversion and plantarflexion; toe flexion
- sensory: sole of foot

Front 36

What is the cause of injury, motor and sensory deficit to the superior gluteal (L4-S1)?

Back 36

- cause: posterior hip dislocation or polio
- motor: thigh abduction (positive Trendelenburg sign - hi drops when standing on opposite foot)
- sensory: none

Front 37

What is the cause of injury, motor and sensory deficit to the inferior gluteal nerve (L5-S2)?

Back 37

- cause: posterior hip disloation
- motor: can't jump, climb stairs or rise from seated position; can't push inferiorly (downward)

Front 38

If you injure the peroneal nerve, what will happen?

Back 38

- PED = peroneal everts and dorsiflexes
- if injured, foot dropPED

Front 39

if you injure the tibial nerve, what will happen?

Back 39

- TIP = tibial inverts and plantarflexes
- if injured, can't stand on TIPtoes

Front 40

Which nerve splites into the common peroneal and tibila nerve? Where does this occur

Back 40

- sciatic nerve
- posterior thigh

Front 41

Describe the process of muscle contraction.

Back 41

1. AP depolarization opens voltage-gated Ca2+ channels, inducing nt 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 teh voltage-sensitive dihydropyridine receptor, coupled to the ryanodine receptor on the SR, induces a conformational change causing calcium release from SR (calcium-induced calcium release)
5. released calcium binds to troponin C, causing a conformational change that moves tropomyosin out of the myosin-binding groove on actin filaments
6. Myosin releases bound ADP and is displaced on the 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, HIZ shrinkage*

Front 42

Describe the characteristics of type 1 muscle fibers.

Back 42

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

*think "one slow red ox"*

Front 43

Describe the characteristics of type 2 muscle fibers.

Back 43

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

Front 44

Describe the process of endochondral ossification.

Back 44

- 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

-

Front 45

Describe the process of membranous ossification.

Back 45

- flat bone growth (skull, facial bones, and axial skeleton)
- woven bone formed directly without cartilage
- later remodeled to lamellar bone

Front 46

What is the source for osteoblasts?

Back 46

mesenchymal stem cells in periosteum

Front 47

Describe achondroplasia.

Back 47

- failure of longitudinal bone growth (endochondrial 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 48

What is osteoporosis? What are possible consequences?

Back 48

- reduction of primarily trabecular (spongy) bone mass despite normal bone mineralization and lab values
- consequences: vertebral crush factures (acute back pain, loss of height, kyphosis)

Front 49

Describe Type I osteoporosis and its consequences.

Back 49

- postemenopausal
- increased bone resorption due to decreased estrogen levels
- consequences: femoral neck fracture, distal radius (Colles') fracture

Front 50

Describe Type II osteoporosis and its consequences.

Back 50

- senile osteoporosis
- affects men and women >70 years of age
- 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 51

Describe marble bone disease.

Back 51

- 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
- decreased marrow space leads to anemia, thrombocytopenia, infection
- increased extramedullary hematopoiesis
- genetic deficiency of carbonic anhydrase II
- X-rays show "Erlenmeyer flask" bones that flare out
- can result in cranial nerve impingement and palsies due to narrowed foramina

Front 52

Describe osteomalacia/rickets.

Back 52

- defective mineralization/calcification of osteoid --> soft bones
- vitamin D defeiciency in adults --> decrease calcium levels --> increase secretion of PTH, decrease in serum phosphate
- reversible when vitamin D is replaced
- vitamin D deficiency in childhood causes rickets

Front 53

What is Paget's disease (osteitis deformans)?

Back 53

- abnormal bone architecture caused by increase in both osteoblastic and osteoclastic activity
- possibly viral in origin (paramyxovirus)
- serum calcium, phosphorus, and PTH levels are norml
- increase ALP
- mosaic bone pattern; long bone chalk-stick fractures
- increase blood flow from increase arteriovenous shunts may cause high output heart failure
- can lead to osteogenic sarcoma
- hat size can be increased
- hearing loss is common due to auditory foramen narrowing

Front 54

What is polyostotic fibrous dysplasia?

Back 54

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

Front 55

List the types of benign primary bone tumors.

Back 55

1. osteoma
2. osteoid osteoma
3. osteoblastoma
4. Giant cell tumor (osteoclastoma)
5. osteochondroma (exostosis)
6. enchondroma

Front 56

Describe osteoma.

Back 56

- asociated with Garnder's syndrome (FAP)
- new piece of bone grows on another piece of bone, often in the skull.

Front 57

Describe osteoid osteoma.

Back 57

- interlacing trabeculae of woven bone surrounded by osteoblasts
- <2 cm and found in proximal tibia and femur
- most common in men <25 years of age

Front 58

Describe osteoblastoma.

Back 58

- same morphologically as osteoid osteoma, but larger and found in vertebral column
-->interlacing trabeculae of woven bone surrounded by osteoblasts

Front 59

Describe giant cell tumor (osteoclastoma).

Back 59

- occurs most commonly at epiphyseal end of long bones
- peak incidence 20-40 years of age
- locally aggressive benign tumor often around the distal femur, proximal tibial region (knee)
- characteristic "double bubble" or "soap bubble" appearance on x-ray
- spindle-shaped cells with multinucleated giant cells

Front 60

What is osteochondroma (exotosis)?

Back 60

- most common benign bone tumor
- mature bone with cartilaginous cap
- usually in men <25 years of age
- commonly originates from metaphysis
- malignant transformation to chondrosarcoma is rare

Front 61

What is enchondroma?

Back 61

- benign cartilaginous neoplasm found in intramedullary bone
- usually distal extremities (vs. chondrosarcoma)

Front 62

What are some malignant tumors?

Back 62

1. osteosarcoma (osteogenic sarcoma)
2. Ewing's sarcoma
3. Chondrosarcoma

Front 63

What is osteosarcoma (osteogenic sarcoma)?

Back 63

- 2nd most common primary malignant tumor of bone (after multiple myeloma)
- peak incidence in men 10-20 years of age
- commonly found in the metaphysis of long bones, often around distal femur, proximal tibial region (knee)
- predisposing factors include Paget's disease of bone, bone infarcts, radiation, and familial retinoblastoma
- Codman's triangle or sunburst pattern (from elevation of periosteum) on x-ray
- poor prognosis

Front 64

What is Ewing's sarcoma?

Back 64

- anaplastic small blue cell malignant tumor
- most common in boys <15
- extremely aggressive with early mets, but responsive to chemotherapy
- characteristic "oninon-skin" appearance in bone ("going out for Ewings and onion rings")
- commonly appears in diaphysis of long bones, pelvis, scapula and ribs
- 11;22 translocation

Front 65

Describe chondrosarcoma

Back 65

- malignant cartilaginous tumor
- most common in men aged 30-60
- usually located in pelvis, spine, scapula, humerus, tibia, or femur
- may be of primary origin or from osteochondroma
- expansile glistening mass with the medullary cavity

Front 66

What are the characteristics, predisposing factors and classic presentation of osteoarthritis?

Back 66

- mechanical- wear and tear of joints leads to destruction of articular cartilage, subcondral 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 presentation: pain in weight-bearing joints after use (i.e. at end of day), improving with rest. In knees, cartilage loss begins on medial aspect ("bowlegged"). Noninflammatory. no systemic symptoms

Front 67

Describe the characteristics of rheumatoid arthritis.

Back 67

- autoimmune- inflammatory disorder affecting synovial joints, with pannus formation in joints (MCP, PIP), subcutaneous rheumatoid nodules (fibrinoid necrosis surrounded by palisading histocytes), ulnar deviation, subluxation, Baker's cyst (behind the knee),
- No DIP involvement
- females >males; type III hypersensitivity
- 80% of RA pateitns have positive rheumatoid factor (anti-IgG Ab); anti-CCP Ab is less sensitive but more specific
- strong association with HLA-DR4
- classic presentaiton: morning stiffness lasting >30 minutes and improving with use, symmetric joint involvement, systemic symptoms (fever, fatigue, pleuritis, pericarditis)

Front 68

Describe the characteristics of Sjogren's syndrome.

Back 68

- classic triad: 1. Xerophthalmia (dry eys, conjunctivitis, "sand in my eyes"), 2. Xerostomia (dry mouth, dysphagia), 3. Arthritis
- parotid enlargement, increase risk of B-cell lymphoma, dental caries
- autoantibodies to ribonuceloprotein antigens, SS-A (Ro), SS-B (La)
- Predominantly affects females between 40-60 years of age
- associated with rheumatoid arthritis

Front 69

What are the characteristics of Sicca syndrome?

Back 69

- dry eyes, dry mouth, nasal and vaginal dryness, chronic bronchitis, reflux esophagitis
- no arthritis

Front 70

What are the findings of gout?

Back 70

- precipitation of monosodium urate crystasl into joints due to hyperuricemia, which can be caused by Lesch-Nyhan syndrom, PRPP excess, decrease excretion of uric acid (i.e. 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
- most common in men
- 10

Front 71

What are the symptoms of gout?

Back 71

- asymmetric joint distribution
- join is swollen, red and painful
- classic manifestation is painful MTP joint of the big toe (podagra)
- 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 72

What is the treatment for gout?

Back 72

- acute: NSAIDs (i.e. indomethacin), colchicine
- chronic: allopurinol, uricosurics (i.e. probenecid)

Front 73

What are the characteristics of pseudogout?

Back 73

- caused by deposition of calcium pyrophosphate crystals within the joint space
- forms basophillic, rhomboid crystals that are weakly positively birefringent
- usually affects large joints (classically the knee)
- >50 years old, both sexes affected equally
- no treatment

Front 74

What is the difference in findings between gout and pseudogout?

Back 74

- gout: crystals are yellow when parallel and blue when perpendicular to the light
- pseudogout: crystals are yellow when perpendicular and blue when parallel to the light

Front 75

What are the types of infectious arthritis which are septic?

Back 75

- S. aureus, Streptococcus, and Neisseria gonorrhoease 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 (i.e. knee), Tenosynovitis (i.e hand), Dermatitis (i.e. pustules)*

Front 76

What are the types of infectious arthritis which are chronic?

Back 76

- TB (from mycobacterial dissemination)
- Lyme disease

Front 77

What are the characterisitcs of seronegative spondyloarthropathies? What are the types?

Back 77

- arthritis without rheumatoid factor (no anti-IgG antibody)
- strong association with HLA-B27
- occurs more often in males
- types: "PAIR"
--> Psoriatic arthitis
--> Ankylosing spondylitis
--> Inflammatory bowel disease
--> Reactive arthritis (Reiter's syndrome)

Front 78

What are the characteristics of Psoriatic arthritis?

Back 78

- joint pain and stiffness associated with psoriasis
- assymetric and patchy involvement
- dactylitis ("sausage fingers"), "pencil-in-cup" deformity on X-ray
- seen in fewer than 1/3 patients with psoriasis

Front 79

What are the characteristics of ankylosing spondylitis?

Back 79

- chronic inflammatory disease of spine and sacroiliac joints --> ankylosis (stiff spine due to fusion of joints), uveitis, and aortic regurgitation

Front 80

What are the characteristics of inflammatory bowel disease?

Back 80

- crohn's disease, ulcerative colitis

Front 81

What are the characterisitcs of Reactive arthritis (Reiter's syndrome)?

Back 81

- classic triad:
1. conjunctivitis and anterior uveitis
2. urethritis
3. arthritis
- post GI or chlamydia infections
* can't see, can't pee, can't climb a tree*

Front 82

Describe the charactersitics of Systemic lupus erythematosus.

Back 82

- 90% of female and between ages 14-45
- most common and severel in black females
- symptoms: fever, fatigue, weight loss, nonbacterial verrucous endocarditis, hilar adenopathy, and Raynaud's phenomenon
- wire-loop lesions in kidney with immune complex deposition (usually nephritic syndrome)
- death from renal failure and infections
- false positives on syphilis tests (RPR/VDRL) due to antiphospholipid Abs, which cross-react with cardiolipin used in tests

Front 83

Lab tests used to test for systemic lupus erythematosus, will detect presence of which antibodies?

Back 83

1. antinuclear antibodies (ANA) - sensitive (primary screening) but not specific for SLE
2. Antibodies to db-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 84

What does "I'M DAMN SHARP" stand for in relation to SLE?

Back 84

- Immunoglobulins (anti-dsDNA, anti-Sm, antiphospholipid)
- Malar rash
- Discoid rash
- Antinuclear antibody
- Mucositis (oropharyngeal ulcers)
- Neurologic disorders
- Serositis (pleuritis, pericarditis)
- Hematologic disorders
- Arthritis
- Renal disorders
- Photosensitivity

Front 85

What are the characteristics of sarcoidosis?

Back 85

- characterized by immune-mediated, widespread noncaseating granulomas and elevated serum ACE levels
- common in black females
- associated with restrictive lung disease, bilateral hilar lymphadenopathy, erythema nodosum, Bell's palsy, epithelial granulmoas contaiing micrscopic Schaumann and asteroid bodies, uveoparotitis, and hypercalcemia (due to elevated 1alpha-hydroxylase-mediated vitamin D activation in epithelioid macrophages)

Front 86

What is the treatment for sarcoidosis?

Back 86

steroids

Front 87

What does "GRAIN" stand for in relation to sarcoidosis?

Back 87

- Gammaglobulinemia
- Rheumatoid arthritis
- ACE increase
- Interstitial fibrosis
- Noncaseating granulomas

Front 88

What are the symptoms, findings, and treatment for polymyalgia rheumatica?

Back 88

- symptoms: pain and stiffness in shoulders, 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: increase ESR, normal CK
- treatment: prednisone

Front 89

What are the symptoms of polymyositis?

Back 89

- progressive symmetric proximal muscle weakness caused by CD8+ T cell-induced injury to myofibers
- most often involves shoulders
- muscle biopsy with evidence of perifascicular inflammation is diagnostic

Front 90

What are the symptoms of dermatomyositis?

Back 90

- similiar to polymyositis, but also involves malar rash, (similar to SLE), heliotrope rash "shawl and face" rash, Gottron's papules, "mechanic's hands."
- increasek risk of malignancy

Front 91

What are the findings for polymyositis and dermatomyositis?

Back 91

- increase CK
- increase aldolase and positive ANA, anti-Jo-1

Front 92

What is the treatment for polymyositis and dermatomyositis?

Back 92

steroids

Front 93

Describe the features of myasthenia gravis.

Back 93

- 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

Front 94

Describe the features of Lambert-Eaton syndrome.

Back 94

- autoantibodies to presynaptic calcium channel results in decrease ACh release leading to proximal muscle weakness
- associated with paraneoplastic disease (small cell lung cancer)
- symptoms improve with muscle use
- no reversal of symptoms with AChE inhibitors alone

Front 95

Describe the characteristics of scleroderma (progressive systemic sclerosis - PSS).

Back 95

- 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% females
- two common types

Front 96

What are the two common types of Scleroderma (progressive systemic sclerosis - PSS)? Describe their characteristics.

Back 96

1. Diffuse scleroderma - widespread skin involvement, rapid progression, early visceral involvement
- associated with anti-Scl-70 antibody (anti-DNA topoisomerase I Ab)
2. CREST syndrome - Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia
- limited skin involvement, often confined to fingers and face
- more benign clinical course
- associated with anti-Centromere antibody (C for CREST)

Front 97

What are the features of verrucae?

Back 97

- warts
- soft, tan-colored cauliflower-like lesions
- epidermal hyperplasia, hyperkeratosis, koilocytosis
- verruca vulgaris on hands; condyloma accuminatum on genitals (caused by HPV)

Front 98

What are the features of nevocellular nevus?

Back 98

- common mole
- benign

Front 99

What are the features of urticaria?

Back 99

- hives
-intensely pruritic wheals that form after mast cell degranulation

Front 100

What are the features of ephelis?

Back 100

- freckle
- normal number of melanocytes
- increase melanin pigment

Front 101

What are the features of atopic dermatitis (eczema)?

Back 101

- pruritic eruption, commonly on skin flexures
- often associated with other atopic diseases (asthma, alelrgic rhinitis)

Front 102

What are the features of allergic contact dermatitis?

Back 102

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

Front 103

What are the features of psoriasis?

Back 103

- papules and plaques with silvery scaling, especially on knees and elbows
- acanthosis with parakeratotic scaling (nuclei still in stratum corneum)
- increase stratum spinosum
- decrease stratum grnulosum
- Auspitz sign - bleeding spots when scales are scraped off
- can be associated with nail pitting and psoriatic arthritis

Front 104

What are the features of seborrheic keratosis?

Back 104

- flat, greasy, pigmented squamous epithelial proliferation with keratin-filled cysts (horn cyts)
- 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 (i.e. GI, lymphoid)

Front 105

What are the features of albinism?

Back 105

- normal melanocyte number with decrease melanin production due to decrease activity of tyrosinase
- can also be caused by failure of neural crest cell migration during development

Front 106

What are the features of vitiligo?

Back 106

- irregular ares of complete depigmentation
- caused by a decrease by melanocytes

Front 107

What are the features of melasma (chloasma)?

Back 107

- hyperpigmentation associated with pregnancy ("mask of pregnancy") or OCP use

Front 108

What are the features of impetigo?

Back 108

very superficial skin infection
- usually from S. auerus or S. pyogenes
- highly contagious
- honey-colored crusting

Front 109

What are the features of cellulitis?

Back 109

- acute, painful spreading infection of dermis and subcutaneous tissues
- usually from S. pygoenes or S. aureus

Front 110

What are the features of necrotizing fasciitis?

Back 110

- depper tissue injury, usually from anaerobic bacteria and S. pyogenes
- Results in crepitus from methane and carbon dioxide production
- "flesh-eating bacteria"

Front 111

what are the features of staphylococcal scalded skin syndrome?

Back 111

- 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 112

What are the features of hairy leukoplakia?

Back 112

- white, painless plaques on the tongue that cannot be scraped off
- EBV mediates
- occurs in HIV-positive patients

Front 113

What are the features of pemphigus vulgaris?

Back 113

- potentially fatal autoimmune skin disorder with IgG Ab against desmosomes (anti-epithelial cell Ab)
- immunofluorescence reveals Abs around cells of epidermis in a reticular or netlike pattern
- Acantholysis - intrapeidermal bullae involving the skin and oral mucosa
- positive Nikolsky's sign (separation of epidermis upon manual stroking of skin)

Front 114

What are the features of bullous pemphigoid?

Back 114

- autoimmune disorder with IgG Ab against hemidesmosomes (epidermal basement membrane; Abs are "bullow" the epidermis)
- shows linear immunofluorescence
- Eosinophils within blisters
- similar to but less severe than pemphigus vulgaris
- affects skin but spares oral mucosa
- negative Nikolsky's sign

Front 115

What are the features of dermatitis herpetiformis?

Back 115

- pruritic papules and vesicles
- deposits of IgA at the tips of dermal papillae
- associated with celiac disease

Front 116

What are the features of erythema multiforme?

Back 116

- associated with infections (i.e. M. pneumoniae, HSV), drugs (i.e. Sulf drugs, B-lactams, phenytoin), cancers, and autoimmune diseases
- presents with multiple types of lesions (macules, papules, vesicles, and target lesions - red papules with a pale central area)

Front 117

What are the features of Stevens-Johnson Syndrome?

Back 117

- 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 118

What are the features of Lichen planus?

Back 118

- Pruritic, Purple, Polygonal Papules
- sawtooth infiltrate of lymphocytes at dermal-epidermal junction
- associated with hepC

Front 119

What are the features of Actinic keratosis?

Back 119

- premalignant lesions caused by sun exposure
- small, rough, erythematous or brownish papules
- "cutaneous horn"
- risk of carcinoma is proportional to epithelial dysplasia

Front 120

What are the features of acanthosis nigricans?

Back 120

- hyperplasia of stratum spinosum
- associated with hyperinsulinemia (i.e from Cushing's disease, diabetes) and visceral malignancy

Front 121

What are the features of erythema nodosum

Back 121

- inflammatory lesions of subcutaneous fat, usually on anterior shins
- associated with coccidioidymycosis, histoplasmosis, TB, leprosy, streptococcal infections, sarcoidosis

Front 122

What are the features of pityriasis rosea

Back 122

"herald path" followed days later by "Xmas tree" distribution
- multiple papular eruptions; remits spontaenously

Front 123

What are the features of strawberry hemangioma?

Back 123

first few weeks of life (1/200 births)
- grows rapidly and regresses spontaneously at 5-8 years of age

Front 124

What are the features of cherry hemangioma?

Back 124

- appears in 30-40s; does not regress

Front 125

What are the characteristics of squamous cell carcinoma?

Back 125

- 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 126

What are the characteristics of basal cell carcinoma?

Back 126

- most common in sun-exposed areas of body
- locally invasive, but almost never metastasizes
- rolled edges with central ulceration
- gross pathology -> pearly papules, commonly with telangiectasias
*basal cell tumors have "palisading" nuclei*

Front 127

What are the features of melanoma?

Back 127

- common tumor with significant risk with metastasis
- S-100 tumor marker
- Associated with sunlight exposure
- fair-skinned persons are at increased risk
- depth of tumor correlates with risk of metastasis
- dark with irregular borders
*dysplastic neuvs (atypical mole) is a precursor of melanoma*

Front 128

What is the mechanism of aspirin?

Back 128

- irreversibly inhibits cyclooxygenase by covalent binding, which decreases synthesis of both thromboxane and prostaglandin
- a type of NSAID

Front 129

What is the clinical use of aspirin?

Back 129

- low dose (<300 mg/day) ->decreases platelet aggregation
- intermediate dose (300-2400 mg/day) --> antipyretic and analgesic
- high dose (2400-4000 mg/day) -> anti-inflammatory

Front 130

What is the toxicity of aspirin?

Back 130

- gastric upset
- chronic use can lead to acute renal failure, interstitial nephritis and upper GI bleeding
- Reye's syndrome in children with viral infection

Front 131

What are some common NSAIDs?

Back 131

ibuprofen, naproxen, indomethacin, ketorolac

Front 132

What is the mechanism of NSAIDs?

Back 132

- reversibly inhibit cyclooxygenase (both COX-1 and COX-2)
- block prostaglandin synthesis

Front 133

What is the clinical use of NSAIDs?

Back 133

antipyretic, analgesic, anti-inflammatoyr
- indomethacin is used to close a PDA

Front 134

What is the toxcity of NSAIDs?

Back 134

- renal damage, fluid retention, aplastic anemia, GI distress, ulcers

Front 135

What is the mechanism of COX-2 inhibitors (Celecoxib)?

Back 135

- reversibly inhibits specifically the cyclooxygenase (COX) isoform 2, which is found in inflammtory cells adn 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

Front 136

What is the clinical use of COX-2 inhibitors (Celecoxib)?

Back 136

- rheumatoid and osteoarthritis
- patients with gastritis or ulcers

Front 137

What is the toxicity of COX-2 inhibitors (Celecoxib)?

Back 137

- increased risk of thrombosis
- sulfa allergy
- less toxicity to GI mucosa (lower incidence of ulcers, bleeding than NSAIDs)

Front 138

What is the mechanism of acetaminophen?

Back 138

- reversibly inhibits cyclooxygenase, mostly in CNS
- inactivated peripherally

Front 139

What is the clinical use of acetaminophen?

Back 139

- antipyretic, analgesic, but lacking anti-inflammatory properties
- used instead of aspirin to prevent Reye's syndrome in children with viral infections

Front 140

What is the toxicity of acetaminophen?

Back 140

- overdose produces hepatic necrosis
- acetaminophen metabolit depletes glutathione and forms toxic tissue adducts in liver
- N-acetylcysteine is antidote --> regenerates glutathione

Front 141

What is the mechanism for bisophosphonates?

Back 141

- inhibit osteoclastic activity
- reduce both formation and resorption of hydroxyapatite

Front 142

What are some common bisophosphonates?

Back 142

- etidronate, pamidronate, alendronate, risedronate, zoledronate (IV)

Front 143

What is the clinical use of bisphosphonates?

Back 143

- malignacy-associated hypercalcemia, Paget's disease of bone, postmenopausal osteoporosis

Front 144

What is the toxicity of bisphosphonates?

Back 144

corrosive esophagitis (except zoledronate), nausea, diarrhea, osteonecrosis of the jaw

Front 145

Describe the characteristics of the gout drug, colchicine.

Back 145

-used for acute gout (w/NSAIDs)
- binds and stabilizes tubulin to inhibit polymerization, impairing leukocyte chemotaxis and degranulation
- GI side effects, especially if given orally

Front 146

Describe the characteristics of the gout drug, probenecid

Back 146

- used for chronic gout
- inhibits reabsorption of uric acid in PCT (also inhibits secretion of penicillin)

Front 147

Describe the characteristics of the gout drug, allopurinol.

Back 147

= used for chronic gout
- inhibits xanthine oxidase, decrease conversion of xanthine to uric acid
- also used in lymphoma and leukemia to prevent tumor lysis-associated urate nephropathy
- increased concentrations of azathioprine and 6-MP (both normally metabolized by xanthine oxidase)

Front 148

What are common TNF-alpha inhibitors?

Back 148

- ethanercept
- infliximab
- adalimumab

Front 149

What is the mechanism of ethanercept?

Back 149

- recombinant form of human TNF receptor that binds TNF

Front 150

What is the clinical use of etanercept?

Back 150

- rheumatoid arthritis
- psoriasis
- ankylosing spondylitis

Front 151

What is the mechanism of infliximab?

Back 151

- anti-TNF Ab

Front 152

What is the clinical use of infliximab?

Back 152

- Crohn's disease
- rheumatoid arthritis
- ankylosing spondylitis

Front 153

What is the toxicity of infliximab?

Back 153

predisposes to infections (reactivation of latent TB)

Front 154

What is the mechanism of adalimumab?

Back 154

anti-TNF Ab

Front 155

What is the clinical use of adalimumab?

Back 155

- rheumatoid arthritis
- psoriasis
- ankylosing spondylitis