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Heberden's nodes affect what joints in what disease?
DIPs in OA
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Bouchard's nodes affect what joint in what disease?
PIP, OA
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What is found on OA xrays?
Asymmetric narrowing, subchondral sclerosis, cysts, and marginal osteophytes
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Pathophysiology of RA
Hyperplastic synovial tissue may erode cartilage, subchondral bone, articular capsule, tendons, and ligaments
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Dx criteria for RA
- Morning stiffness > 1 hour
- Radiologic changes suggestive of jt erosion or bony decalcification
- Symmetric arthritis, present for at least 6 weeks
- Hand arthritis
- Arthritis in > 3 joints
- RF > 95%
- Nodules on bony prominences, extensor surfaces, or juxta-articular regions
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Extra-articular manifestations of RA
Kidneys, blood, eyes, liver, lungs
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RA lab findings
- elevated RF and anti-CCP in 70-80% of pts (but levels low in early disease)
- Elevated ESR and CRP
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RA radiography findings
soft-tissue swelling and juxta-articular demineralization
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RA initial tx
NSAIDs + DMARD (methotrexate) initially
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Other DMARDS than methotrexate
corticosteroids, sulfasalazine, antimalarials, leflunomide
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New biologic tx for RA
etanercept, abatacept, rituximab, infliximab, and adalimumab
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Still's Disease presentation
Spiking fevers, myalgias, polyarthralgias, and salmon-pink maculopapular rash appearing in the evening with fever
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Koebner's phenomenon
A process in Still's disease where the rash can be elicited by scratching skin in susceptible areas
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Extra-articular manifestations of Still's disease
HSM, lymphadenopathy, leukocytosis, pericarditis, or myocarditis
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WBC count in septic arthritis
>50k
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PMN % in septic arthritis
75%
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When are Still's disease pts at risk for uveitis?
When they have a postive ANA
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lab findings in Stills
- 10-15% have positive RF
- ESR and CRP increased or nl
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Treatment of JRA
- First line: NSAIDS, PT/OT
- Second line: methotrexate or leflunomide
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Prognosis of JRA
- 75-80% remit without serious disability
- Pts who are RF positive are at a greater risk of progressing to disabling arthritis as adults
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m/c pathogen in septic arthitis
staph
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Diff b/w osteomyelitis and septic arthritis
osteomyelitis has systemic sx
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What % of septic arthritis pts have pos blood culture?
40%
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distribution of psoriatic arthritis
few joints, may involve hands and feet
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sausage finger appearance
psoriatic arthritis
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Lab findings in psoriatic arthritis
- Elevated ESR
- normochromic, normocytic anemia
- RF is nl
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Psoriatic arthritis tx
- NSAIDs for mild cases
- Methotrexate for skin inflammation and arthritis
- Avoid corticosteroids and antimalarials
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What is the tetrad of Reiter's
urethritis, conjunctivitis, oligoarthritis, and mucosal ulcers
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Reiter's is a common sequalae to what conditions?
STDs and gasteroenteritis
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Clinical features of Reiter's arthritis
asymmetric arthritis that involves large joints below the waist; mucocutaneous lesions, urethritis, and conjunctivitis
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Leading cause of nontraumatic monoarthritis
Reiter's
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Lab findings in Reiter's
- Positive HLA-B27 in 50-80% of pts
- Negative synovial fluid
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Treatment of Reiter's
- PT and NSAIDs are the mainstay
- ABX given at tiem of infection will reduce the chance of developing the disorder, but do not alleviate the sx of the reactive arthritis
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Podagra
initial gout attack of the great toe
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Joint fluid analysis in gout
rod-shaped, negatively birefringent urate crystals
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Uric acid level in gout
>7.5 (CMDT)
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Gout tx
- Indomethacin 25-50mg TID until sx resolve
- Corticosteroid injections for accessible jts, PO prednisone if other medicines are not tolerated and septic arthritis has been ruled out
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Management of gout between attacks
allopurinol, colchicine, probenacid, sulfapyrazone, or febuxostat
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Pseudogout m/c joints
knee, wrist, and elbow
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Joint aspiration results in CPPD
positively birefringent rhomboid shaped crystals
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SLE epidemiology
women of child-bearing age; AA>C
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Dx criteria for SLE
- MS. PARANOID
- Malar rash
- Serositis
- Photosensitivity
- ANA
- Renal dz (proteinuria, cellular casts)
- Arthritis
- Neurologic disorders (seizures or psychosis in absence of any other cause)
- Oral ulcers
- Immunologic disorders (LE cell, anti-DNA, anti-Sm, false-positive RPR)
- Discoid rash
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What labs should be ordered in SLE?
CBC, BUN/Cr, UA, ESR, and serum complement (C3 or C4)
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SLE tx
- Regular exercise and sun protection
- NSAIDs for MS complaints
- Anatimalarials for MS and cutaneous manifestations)
- Corticosteroids for skin and disease flares
- Methotrexate (low dose) for arthritis, rashes, serositis, and constitutional sx
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What is polymyositis?
inflammatory dz of striated muscle affecting the proximal limbs, neck, and pharynx
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Other organ involvement in polymyositis
joints, lungs, heart, and GI tract
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disease with a strong association with occult malignancy
polymyositis
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Clinical features of polymyositis
insious, painless, proximal muscle weakness; dysphagia, skin rash (malar or heliotrope), polyarthralgias, and muscle atrophy
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Lab findings in polymyositis
elevated CPK and aldolase
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Polymyositis tx
high dose steroids, methtrexate, or azathioprine until sx resolve
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Pain and stiffness in the neck, shoulder, and pelvic girdles; accompanied by constitutional sx
PMR
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PMR epidemiology
women twice as much as men, usually in pts > 50
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What % of PMR pts develop GCA?
~30%
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clinical features of PMR
- Stiffness, primarily after rest and in the morning
- MS sx are B/L, proximal, and symmetrical
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Lab results in PMR
ESR > 50 mm/hr
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Tx of PMR
low dose cortocosteroids, unless GCA is present, then it's high dose
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What is polyarteritis nodosa?
Small and medium artery inflammation involving the skin, kidney, peripheral nerves, muscle, and gut
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polyarteritis nodosa epidemiology
male > female 3:1, onset between 40-60 yrs, although it can occur in any age group
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Rheum dz with strong association with Hep B
polyarteritis nodosa
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Clinical characteristics of polyarteritis nodosa
fever, anorexia, weightloss, abdominal pain, peripheral neuropathy, arthralgias, arthritsi
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Skin manifestations of polyarteritis nodosa
palpable purpura and livedo reticularis
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Kidney involvement of polyarteritis nodosa
htn, edema, oliguria, uremia
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Lab findings in polyarteritis nodosa
- Dx with vessel bx or angiography
- Elevated ESR and CRP and proteinuria, as well as positive Hep B surface antigen
- presence of ANCA is suggestive but not dx
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Tx of polyarteritis nodosa
- high dose corticosteroids
- cytotoxic drugs and immunotherapy may be used
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scleroderma epidemiology
female > male 4:1; onset b/w 30-50yo
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Difference between body involvement of diffuse and limited scleroderma
- diffuse: skin, heart, lungs, GI tract, and kidneys
- limited: mostly affects the skin of the face, neck, and distal elbows and knees; can cause pulm HTN
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CREST syndrome
calcinosis, raynaud's phenomenon, esophageal dysfunction, sclerodactily, telangiectasias in association with LIMITED scleroderma
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Lab findings in scleroderma
- ANA positive in 90% of pts
- anicentromere Ab in limited scleroderma
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Tx of scleroderma
- no cure
- tx the organ-specific disease processes (PPIs for reflux, ACE-Is for renal dz, avoidance of triggers and tx with CCBs for Raynaud's, immunosuppressive drugs for pulm HTN
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autoimmune disorder that destroys the salivary and lacrimal glands
sjogrens
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What can Sjogren's be a secondary complication to?
RA, SLE, polymyositis, or scleroderma
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Sjogren's epidemiology
most common in middle-aged females
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Enlarged parotid glands
Sjogrens
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Lab findings in Sjogrens
- RF positive in 70%
- ANA positive in 60%
- Anti-Ro Abs in 60%
- Anti-La Abs in 40%
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How can you make the dx?
Bx of lower lip mucosa, to confirm lymphocytic infiltrate and gland fibrosis
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Tx of Sjogrens
- artifical tears and saliva
- increase oral fluid intake
- ocular and vaginal lubricants
- pilocarbine for saliva flow
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What can fibromyalgia be concurrent with?
RA, SLE, and Sjogrens
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Tx of fibromyalgia
- SSRIs, SSNRIS, and TCAs
- Pre-gabalin (Lyrica) only drug that is FDA approved specifically for tx of fibromyaglia
- Aerobic exercise
- pt education, stress reduction, sleep assistance, and tx of psychological problems
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what bones are m/c affected in osteomyelitis?
long bones
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Who is at risk for salmonella osteomyelitis?
SCA
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Use of radiography for dx osteomyelitis
xray evidence lags behind sx by 7-10 days, therefore use ultrasound
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What are sequestra of osteomyelitis?
- dead bone surrounding granulation tissue
- involucrum (periosteal new bone)
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Osteomyelitis tx
- Abx x 3 weeks (1 week IV, 2 weeks PO)
- immobilization and surgical drainage
- surgical tx to remove sequestra, sinus tract, infected bone, and scar tissue
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What Ca mets to the bone?
- BLT with a Kosher Pickle
- Breast, Liver, Thyroid, Kidney, Prostate
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What is the m/c site of bony metastases?
spine``
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M/C primary benign bone neoplasm of the hand
endochondroma
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m/c types of primary sarcomas of the bone
chondrosarcoma, Ewing's sarcoma, and osteosarcoma
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m/c primary malignant bone tumor
multiple myeloma
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Epidemiology of Ewing's Sarcoma
5 and 25 yo
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Where are Ewing's sarcomas found?
diaphyses of long bones, ribs, and flat bones
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Epidemiology of osteosarcomas
10-20 yo
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where are osteosarcomas generally found?
metaphyseal area of long bones
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M/C source of bone lesions in adults > 60 yo
metastatic carcinoma
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soft tissue sarcoma tx
radiation therapy followed by local resection
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When do xrays show decreased bone density?
When 30% of bone loss is present
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Study of choice to dx occult hip fx
MRI
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Open fx tx
- debrided and irrigated within 4-8 hours of injury
- IV abx (1-2G cephs, and aminoglycosides) for 48 hours after the fx and for 48 hours after surgical procedures
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Tx of greenstick fx
If angulation <15%, may long cast; if >15%, refer to ortho
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M/C cause of facial pain
TMJ
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M/C condition affecting cervical spine
spondylosis
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What is spondylosis?
a condition where degenerative changes occur in the disk, m/c C5-C6, with the formation of osteophytes and disk narrowing; later on in the dz, facet joints and the joints of Luschka are affected
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What happens with compression caused by central disk protrusion or osteophytes in spondylosis?
long-tract signs (clonus, Babinskis sign) and gait disturbance
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Hill-sachs lesion
humeral head deformities d/t recurrent dislocations
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Bankart's lesion
tear of glenoid labrum in shoulder dislocation
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Tx of dislocations
- immobilization by sling and swath
- therapy, begin after 1 week if >40 yo; at 3 weeks if < 40 yo
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Features of adhesive capsulitis
pain and restricted glenohumeral movement; arthrography may show decreased volume of the joint capsule
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Tx of adhesive capsulitis
NSAIDs, passive ROM, and occasionally, manipulation under anesthesia
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Tx of clavicle fx
- children: figure of eight slin for 4-6 weeks
- adults: sling for 6 weeks is generally enough to tx the tx
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Neer classification
classification of humeral head fx
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Volkmann's ischemic contractures
caused by injury to brachial artery, possible with supracondylar humerus fx
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Kienbock's disease
osteonecrosis of the lunate
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Dupuytren's Disease affects what parts of the hand?
palmar aponeurosis, ring, little and middle fingers, causing painful nodules, pitting, and contractures
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M/C mononeuropathy
Carpal tunnel
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Organism specific to human mouth
Eikenella corrodens
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silver fork deformity
colles fx (distral radius fx with dorsal angulation)
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m/c injury of wrist
colles' fx
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What is gamekeeper's thumb?
sprain or tear of the UCL of the thumb
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m/c common overuse injury of the elbow
lateral epicondylitis
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What muscle is involved in lateral epicondylitis?
extensor carpi radialis brevis
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m/c organism causing olecranon bursitis
staph aureus
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tx of nursemaid's elbow
holding affected arm just above the wrist and just below the elbow, place thumb of proximal hand over the radial head while fully supinating and felxing the forearm and applying posteriorly directed pressure (screws the radial head back within annular ligament)
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Presentation of nursemaid's elbow
child will present with extremity fully pronated, with slight flexion and held tightly to side
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m/c fx carpal bone
scaphoid
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what supplies blood to scaphoid?
radial artery by way of lateral and distal branches
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What is DeQuervain's Disease?
stenosis tenosynovitis involving the abductor pollicus longus and extensor pollicis brevis
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epidemiology in de quervains
diabetics, females > 30
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sx of de quervains
radiation of pain up in the forearm, pain and tenderness occur at the wrist and base of the humb
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m/c types of scoliosis
right thoracic curves at the T7 or T8 level
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How do you manage scoliosis?
- 10-15 degree curves: 6-12 month f/u with clinical evaluation and possibly xrays
- 15-20 degree surves: serial AP radoigraphs q3-4mo for larger curves and q6-8months for smaller curves
- 20+ degree curves: refer to ortho
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Scheurmann's disease
Juvenile kyphosis
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M/C extrapulmonary location of TB after the LN
TB of the spine (Pott's disease)
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What is spinal stenosis?
nerve compression caused by narrowing of the spinal canal or neural foramina
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what is central stenosis?
compression of the thecal sac
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What is lateral spinal stenosis?
impingement of the nerve root lateral to the thecal sac
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Clinical features of spinal stenosis
neural claudication and exacerbation of pain with walking, pain relieved by leaning forward, variable back and leg pain
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What is ankylosing spondylitis?
a seronegative spondyloarthropathy that progresses to fusion of the vertebrae
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What are sx of ankylosing spondylitis?
- restricted lumbar motion
- limited motion int hes houlders and hips, synovitis of the knees, plantar fascitis, and achilles tendinitis, hip contractures and fixed cervical, thoracic, and lumbar kyphosis
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extra-articular manifestations of ankylosing spondylitis
uveitis, cardiac abnormalities, and interstitial lung dz
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lab findings in ankylosing spondylitis
- elevated ESR and CRP
- HLA-B27 positive in 90% of whites, 50% of blacks
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What is cauda equina syndrome?
rare condition involving a large midline risk herniation that compresses several nerve roots, usually at L4-L5
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what are clinical features of cauda equina syndrome?
- bowel and bladder function is severely impaired
- leg pain, numbness, saddle anesthesia and/or paralysis
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What is aseptic necrosis?
results from loss of blood supply to the trabecular bone which causes a collapse of the femoral head
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What is aseptic necrosis called in children?
Legg Calves Perthes
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When is the peak age for LEgg Calve Perthes
4-8 years old
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Imaging of choice for aseptic necrosis of the hip
MRI
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What is SCFE?
weakening of the epiphyseal plate of the femur, resulting in a displacement of the femoral head
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What ligament is m/c involved in an ankle sprain?
anterior talofibular ligmanet
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What is hallux valgus?
Bunions
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What causes hallux valgus?
lateral deviation of the proximal phalanx
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What is considered abnl with an xray of a bunion?
an angle of greater than 15 degrees
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What is a morton's neuroma?
a results of traction of the interdigital nerve against the transverse metatarsal ligament causing degeneration of the nerve and chronic inflammation
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Where does a morton's neuroma m/c affect?
third web space
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what are sx of morton's neuroma?
pain and localized numbness when walking and standing, which is relieved with rest; pain localized to web space commonly with a palpable mass; squeezing forefoot will often reproduce sx
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