Exam 1 Study Guide PDF

1.​ 2.​ Know the imaging ABCS and what you would look for in each 3.​ a question on ankylosing spondylitis, gout, spondylolisthesis, and rheumatoid arthritis. What are the symptoms/presentation for each 4.​ lifestyle factors for treating gout (such as weight loss, hydration, and...

1.​ 2.​ Know the imaging ABCS and what you would look for in each 3.​ a question on ankylosing spondylitis, gout, spondylolisthesis, and rheumatoid arthritis. What are the symptoms/presentation for each 4.​ lifestyle factors for treating gout (such as weight loss, hydration, and reducing alcohol intake) 5.​ How to differentiate CT vs. Xray image 6.​ A question that asks to identify an ultrasound picture 7.​ What MRI is used for in the case of a post-traumatic knee (ligament or meniscal tears. Soft Tissue damage) 8.​ Side effects of taking bisphosphonates (GERD Therefore put patient in supine position) 9.​ Definitely what are red flags/yellow flags/ and constitutional symptoms 10.​Also DVT Diagnosis. It gives a case scenario and we had to say what their score was ( +3 points very likely) It is not meant to be all inclusive. It is to guide your study. Pathophysiologic responses in increased workloads Pathophysiologic responses to smoking Smoking induces a range of pathophysiologic responses primarily centered around endothelial dysfunction, inflammation, oxidative stress, and platelet activation, leading to the development of atherosclerosis and contributing to cardiovascular diseases, lung damage, and cancer through mechanisms like impaired vascular function, increased blood clotting tendency, and direct cellular damage from toxic chemicals in tobacco smoke. Phases of tissue healing and major components of each phase Types/causes of cell/tissue injury and which ones are reversible vs irreversible 1.​ Ischemia a.​ Blood flow is insufficient or absent (hypoxia or anoxia) 2.​ Infection a.​ Bacterial Infection i.​ Inflammatory response leads to cell injury/death b.​ Viral infection i.​ Direct cytopathic effect (RNA) ii.​ Indirect Cytopathic effect (DNA) 3.​ Immune reactions a.​ Hypersensitivities or autoimmune disorders 4.​ Chemical factors a.​ Carbon monoxide, ammonia, heavy metals, alkylating agents in pharmaceutical drugs, and free radicals 5.​ Physical/Mechanical factors a.​ Physical: mechanical factors of injury like physical or blunt trauma, temperature (hypo/hyperthermia) radiation, and electricity b.​ Mechanical (subset of physical): include tissue tolerance, age, utilization, load factors such as compression, friction, torsion, or shear forces based on property of tissue, and the magnitude: high load or repeated bouts of moderate load. 6.​ Nutritional factors a.​ Vitamin B12 deficiency - neuropathy b.​ Calcium deficiency - decreased bone quality c.​ Protein malnutrition - edema, weight loss, diminished functional capacity 7.​ Psychological factors  a.​ Fear, tension, anxiety, depression, isolation 8.​ Aging a.​ Progressive decline in homeostasis balance which leads to pathology 9.​ Irreversible cell injury a.​ Cell death b.​ Necrosis (coagulation, liquefactive, gaseous, fatty, fibrinoid) i.​ the end point of a pathological process c.​ Apoptosis i.​ Programmed cell death Types of bone, tendinous, & ligamentous injuries and their associated phases of healing ​ Tendons Intrinsic healing -​ Via vascular internal vascular response resulting in fibroblast proliferation from intrinsic blood supply. -​ What is fibroblast proliferation? Fibroblast are a type of cell found in connective tissue, proliferation is a rapid increase, these cells rapidly increase for tissue repair. Tendons Extrinsic healing -​ Via-vascular-inflammatory-cellular response from adjacent tissue cells. ​ Degree of healing: All depends on injury severity, the need for surgical repair or not, amount of mobilization or immobilization after injury. ​ Three stages of tendon healing: -​ Acute: Hemostasis, inflammatory phase -​ Subacute: Repair and healing -​ Chronic: maturation and remodeling ​ Tendon healing is detrimental when? -​ The tendon is unloaded completely by temporary paralysis, or when it is overloaded by active mobility or exercise. Tendon healing by cast Immobilization -​ Beneficial for tendon to bone healing -​ Determintial for flexor tendon healing ​ Tendon healing by passive motion -​ Beneficial for flexor tendon healing -​ Determintial for tendon to bone healing What does a tendon need for recovery ? -​ Controlled stress to develop tensile strength of the tendon. ​ A tendon can heal without surgery, usually incomplete injuries. A suture repair can help minimize scar formation by closing the gap between tendon ends. The strength of tendon repairs -​ Weakest at 7-10 days -​ Regaining strength at 21-28 days -​ Near full strength at 6 months. Ligamentous 3 conditions are needed for ligaments to heal or remodel 1.​ Torn ligament Ends must be in contact with each other 2.​ Progressive controlled stress must be applied to the healing tissues to orient scar tissue formation 3.​ Ligament must be protected against excessive forces during remodeling Not all ligaments heal at the same rate or to the same degree -​ Intra Articular ligaments DO NOT heal spontaneously. -​ Extra Articular ligaments heal in this order: -​ Inflammatory phase (inflammation and Hemostasis -​ Repair (fibroplasia and cell proliferation) -​ Remodeling (maturation) ​ What are intra articular ligaments ? Ligaments that stabilize joints and are within the joint capsule, ex : ACL, PCL, ​ Extra articular ligaments ? Outside the joint capsule, ex: MCL, LCL Hallmark signs of OA vs RA on radiograph. Also know risk factors, management and presentation of these conditions. Osteoarthritis (OA) Hallmark Signs 1.​ Joint Space Narrowing (asymmetrical, typically affecting weight-bearing surfaces) 2.​ Osteophytes (bone spurs) 3.​ Subchondral Sclerosis (increased bone density beneath cartilage) 4.​ Subchondral Cysts 5.​ Malalignment & Joint Deformity (late-stage) Rheumatoid Arthritis (RA) Hallmark Signs 1.​ Symmetrical Joint Space Narrowing 2.​ Periarticular Osteopenia (loss of bone density) 3.​ Erosions (especially at the margins of joints, “bare area”) 4.​ Soft Tissue Swelling 5.​ Joint Subluxation & Deformities Risk Factors Osteoarthritis (OA) ​ Age (strongest predictor, usually >50 years) ​ Obesity (especially for knee OA) ​ Joint Trauma (post-traumatic OA) ​ Repetitive Stress (occupational, sports-related) ​ Genetics ​ Female Sex (higher risk for knee/hand OA) Rheumatoid Arthritis (RA) ​ Genetic Predisposition ​ Female Sex (3:1 ratio)  ​ Smoking (strongest modifiable risk factor) ​ Infections (potential triggers) ​ Hormonal Factors (protective effects of pregnancy, worsens postpartum) Presentation ​ Morning Stiffness (1 Hour (improves with movement) ​ Worse with Rest, Better with Use ​ Symmetrical Polyarthritis ​ Commonly Affected Joints: ○​ MCP & PIP (not DIP) ○​ Wrist ○​ Elbow ○​ Shoulder ○​ Knee & Ankle ○​ Cervical Spine (C1-C2 instability, no lumbar involvement) ​ Systemic Symptoms: Fatigue, weight loss, fever ​ Extra-Articular Involvement: Rheumatoid nodules, interstitial lung disease, vasculitis, pericarditis Management Osteoarthritis Non-Pharmacologic: ​ Weight Loss (most effective) ​ Physical Therapy & Exercise (low-impact activities) ​ Surgery Pharmacologic: ​ Acetaminophen (first-line for mild-moderate OA) ​ NSAIDs (effective pain control in moderate to severe OA) ​ DMOADs (Slows or reverse OA Pathology) (viscosupplementation [hyaluronic sulfate] or glucosamine and confronting sulfate Rheumatoid Arthritis (RA) Non-Pharmacologic: ​ Physical Therapy & Occupational Therapy ​ Smoking Cessation Pharmacologic: ​ DMARDs (Disease-Modifying Anti-Rheumatic Drugs) (start ASAP) ○​ Methotrexate (First-line) ○​ Leflunomide, Hydroxychloroquine, Sulfasalazine (alternative DMARDs) ​ Biologic DMARDs (TNF inhibitors: Etanercept, Infliximab, Adalimumab) ​ NSAIDs & Glucocorticoids (for symptomatic relief but not disease-modifying) ABC’S of radiographical assessment Alignment General issues - supernumerary bones, deformed Bones; Paget’s disease Contour of bone - shape and cortical outline (fractures…) Bones relative to other bones - subluxation, Dislocation Bone Density General bone density - osteoporosis? Contrast in density Cortical v. Cancellous bone Bone v. Soft Tissue Abnormal texture - change in trabecular Structure? Local changes i. Bone density - osteoblastic or osteolytic activity Cartilage Joint space width - indicates the thickness of intervening cartilage Epiphyseal plates. - are They bounded. Y smooth margin with zn adjacent sclerotic band? Soft Tissue Muscles/ soft Tissue outlines - gross wasting? Hematoma Fat pads/lines - displaced indicates swelling Periosteal reactions T2 vs T1 MRI vs CT vs Ultrasound vs Conventional Radiograph: pros/cons and be able to differentiate which one is which if shown MRI CT MRI compared to CT Ultrasound Radiograph Radio-dense/radiopaque substances -​ Cancellous bone → cortical bone → heavy metal -​ Increased molecular weight increases radiodensity. Increased radiodensity = increase radiopaque -​ Radiodense: high-density structures appear bright -​ Radiolucency: low density structures appear dark -​ * stuctures that are not dense appear bright if they are thick enough or superimposed on other structures  -​ Fracture healing and stages -​ 3 phases that overlap somewhat: 1.​ inflammation (10% total healing time) 2.​ Reparative (40% of healing time) 3.​ Remodeling (70% of healing time) Strain vs sprain 1.​ Strain: stretching or tearing of the musculotendinous unit 2.​ Sprain: Injury of the ligamentous structure around a joint a.​ Classifications: i.​ First degree - minor tearing, no loss of integrity ii.​ Second Degree - Partial tearing, clear loss of function iii.​ Third degree - severe tear, complete loss of integrity iv.​ Rupture - most vulnerable with tension (complete tear) Signs/symptoms of emotional overlay -​ anxiety -​ depression -​ panic disorder -​ symptoms are out of proportion to the injury -​ symptoms persist beyond the expected time for physiologic healing -​ no position is comfortable  -​ the patient may or may not be aware that they are in fact exaggerating pain responses, catastrophizing the pain experience, or otherwise experiencing pain associated with emotional or psychological overlay. General signs of pain -​ Individuals may demonstrate any number of specific behaviors when experiencing pain -​ Guarding – abnormally stiff or rigid movement when changing positions -​ Bracing – maintaining a fully extended limb for weight bearing/acceptance -​ Rubbing – any contact between hand and injured area -​ Grimacing – obvious facial expressions including narrowed eyes, brow furrow, tightened lips, grimacing -​ Sighing – obvious exaggerated exhalation of air, exemplified by shoulders rising and falling, may see cheeks puff Patient interviewing key points to remember Constitutional signs and symptoms -​ fever -​ diaphoresis (unexplained perspiration) -​ sweats (can occur anytime night or day) -​ nausea -​ vomiting -​ diarrhea -​ pallor -​ dizziness / syncope (fainting) -​ fatigue / weakness -​ unintentional weight loss Common sites for referred visceral pain (unit 1 medical screening overview) ​ Kehr's Sign: most often it is pain felt in the l SHoulder when you palpate the upper L quadrant (usually due to splenic Rupture) because supraclavicular nerves have the same cervical origin as C3, C4, and Phrenic nerve. Presenting symptoms of stroke, osteomyelitis, TB, staphylococcus, and pancreatitis; and complications associated with these conditions Stroke: presenting symptoms 1.​ Sudden confusion, trouble speaking, or trouble understanding speech. 2.​ Sudden numbness or weakness, especially on one side of the body. 3.​ Sudden severe headache with no known cause.  4.​ Sudden trouble seeing from one or both eyes. 5.​ Sudden trouble walking, dizziness, or loss of balance or coordination. 6.​ General understanding of how it is we can get referred pain osteomyelitis: presenting symptoms 1.​ Radiculopathy, myelopathy, paralysis 2.​ Radiographs and lab values often negative in early stages. a.​ Adults: back pain or bone pain, low-grade fever b.​ Children: high fever, intense pain, edema, erythema tuberculosis: presenting symptoms 1.​ A cough that lasts three weeks or longer 2.​ Chest pain 3.​ Coughing up blood or phlegm 4.​ Weakness or fatigue 5.​ Weight loss 6.​ Loss of appetite 7.​ Chills 8.​ Fever 9.​ Night sweats Staphylococcus: Presenting symptoms 1.​ Symptoms of a Staphylococcus aureus (staph) infection depend on the part of the body that's infected. 2.​ Symptoms include: a.​ Skin infections: Redness, swelling, pain, warmth, pus, or other drainage at the site of the infection. Infections can appear as pimples or boils, or turn into impetigo or cellulitis. b.​ Bone infections: Pain, swelling, warmth, and redness in the infected area, along with chills and fever. c.​ Pneumonia: High fever, chills, cough, chest pain, and shortness of breath. d.​ Bacteremia (bloodstream infection): Fever, chills, malaise, and difficulty breathing. e.​ Endocarditis: Fever, chills, fatigue, rapid heartbeat, shortness of breath, and fluid buildup in the arms or legs. f.​ Food poisoning: Nausea, vomiting, diarrhea, and fever. g.​ Toxic shock syndrome (TSS): High fever, sudden low blood pressure, vomiting, diarrhea, confusion, and a sunburn-like rash. TSS can lead to organ failure. 3.​ Staph infections can start as small red bumps that quickly turn into painful abscesses. The bacteria can also burrow deep into the body, causing potentially life-threatening infections. Red flags (PMH, risk factors, pain patterns, clinical presentation, etc…the sheet I posted) Routes of administration and general pros/cons about them, including first pass ​ 2 main routes of drug administration 1.​ Enteral (alimentary canal) a.​ Oral ○​ Pros: Convenient, noninvasive, generally cost-effective, self-administration ○​ Cons: Slow onset due to absorption through the GI tract, First-pass metabolism (liver processing reduces drug bioavailability), Affected by food, gastric pH, and enzymes b.​ Sublingual ○​ Pros: Rapid absorption via mucous membranes, Bypasses first-pass metabolism, Useful for emergency medications (e.g., nitroglycerin)  ○​ Cons: Limited to small, lipid-soluble drugs, Can be uncomfortable or dissolve too quickly, Not suitable for sustained drug release c.​ Buccal ○​ Pros: Similar to sublingual (fast absorption, bypasses liver), Can allow for slower, controlled release compared to sublingual ○​ Cons: Drug taste may be unpleasant, Limited drug selection due to solubility requirements, May be difficult for some patients to retain in place d.​ Rectal ○​ Pros: Useful if oral route is not possible (vomiting, unconscious patients), Partial bypass of first-pass metabolism, Suitable for local (e.g., hemorrhoids) and systemic effects ○​ Cons: Variable and sometimes slow absorption, Patient discomfort or reluctance, Irritation of rectal mucosa possible 2.​ Parenteral (non-alimentary Routes) (Drugs administered via injection or external application, bypassing the GI tract) a.​ Intravenous (IV) ○​ Pros: Immediate drug effect (fastest route), 100% bioavailability (no loss through digestion), Precise dosage control ○​ Cons: Requires sterile technique and skilled administration, Higher risk of infection or complications (e.g., phlebitis), Once administered, difficult to reverse b.​ Intramuscular (IM) ○​ Pros: Faster absorption than oral but slower than IV, Suitable for depot (slow-release) drugs, Bypasses first-pass metabolism ○​ Cons: Painful injection, risk of muscle damage, Limited volume per injection, Variable absorption based on muscle perfusion c.​ Subcutaneous (SubQ) ○​ Pros: Easier and less painful than IM injections, Can allow slow, sustained absorption (e.g., insulin, heparin), Self-administration possible ○​ Cons: Slower absorption than IM or IV, Limited volume (small doses only), May cause local irritation d.​ Topical ○​ Pros: Direct local action with minimal systemic absorption, Easy to apply, Fewer systemic side effects ○​ Cons: Limited to superficial conditions (skin, eyes, etc.), Absorption can be unpredictable, Potential for skin irritation e.​ Transdermal ○​ Pros: Prolonged drug release (steady plasma levels), Bypasses first-pass metabolism, Convenient for chronic conditions (e.g., nicotine, fentanyl patches) ○​ Cons: Slow onset of action, Limited to lipophilic (fat-soluble) drugs, Skin irritation or allergic reactions possible Major aspects of pharmacokinetics (general understanding/definitions) a.​ Pharmacokinetics: The movement of the drug through the body  i.​ Four Processes 1.​ Absorption: transfer of a drug from site of administration to the bloodstream 2.​ Distribution: process whereby drug leaves the bloodstream and enters the tissues 3.​ Metabolism (aka Biotransformation): chemical changes that take place in the drug following administration 4.​ Excretion (aka Elimination): removal of the drug from the body b.​ Bioavailability: Extent to which the drug reaches the systemic circulation i.​ Expressed as a percent of the drug administered that reaches the bloodstream ○​ Example: 100 mg administered, 50 mg in blood = 50% bioavailable b.​ First Pass Effect: the extent of drug metabolism by the liver or gut wall before reaching the systemic circulation i.​ Only orally administered drugs undergo first-pass effect c.​ Drug Elimination Rate: Helps to determine the amount and frequency of its dosage i.​ Two primary measurements of drug elimination: ○​ Clearance: rate at which drug is removed from the body ○​ Half-life (t ½): Amount of time for a drug to decrease concentration in the plasma by 1/2 of its original value Drug safety Therapeutic Index (TI) ​ TI = TD50 / ED50 ​ ​ TD50: median dose of drug when 50% of the population has a toxic effect ED50: median dose of drug when 50% of the population has a beneficial effect. LD50: In animals, the median dose of drug when 50% of the animals die NSAIDS vs Tylenol and risks/benefits of each NSAIDS Risks  -​ Cardiovascular ​ Risk of thrombotic events (myocardial infarction, stroke) ​ Can lead to hypertension ​ Higher cardiovascular risk w/ selective COX-2 inhibitors -​ Gastrointestinal ​ Risk of ulceration, bleeding, and perforation ​ Can be fatal ​ Greater risk w/ advanced age, hx of ulcers, concomitant use of steroids. anticoagulants, and high doses NSAIDS Benefits -​ Treats of mild to moderate pain & inflammation -​ Treats of fever -​ Prevents excessive blood clotting -​ Prevents colorectal cancer Tylenol Benefits -​ Treats fever and noninflammatory conditions associated w/ mild-to-moderate pain Tylenol Risks -​ Can cause fatal hepatic necrosis at high doses in healthy individuals Pharmacological management of MSK infections and adverse side effects of the drugs a.​ Infectious Musculoskeletal Disorders i.​ Osteomyelitis: Inflammation of bone caused by an infectious organism ○​ Treatment: ​ 0Depends on causative agent; bacteria is most common ​ Systemic and local high-dose antibiotics (treat the acute infection) ​ Extensive courses of antibiotics (treat recurrent / chronic infection) ○​ Common side effects of Antibiotics: ​ Hypersensitivity reactions (skin rashes, itching, and respiratory difficulty) ​ GI problems (nausea, vomiting, diarrhea) ​ Light sensitivity (depending on the antibiotic) ​ Fluoroquinolone Antibiotics increase risk of tendon pain and inflammation (tendinitis) – Severe tendinitis with fluoroquinolones can lead to tendon rupture ii.​ Myositis: Inflammation of the muscles ○​ Treatment: ​ Glucocorticoids ​ Immunosuppressants ​ IV Immunoglobulin ○​ Adverse Side Effects: ​ Glucocorticoids: Hyperglycemia, weight gain, osteoporosis, hypertension, infections, mood changes, GI ulcers, Cushingoid features.  ​ Immunosuppressants: Infections, leukopenia, nephrotoxicity, hepatotoxicity, hypertension, neurotoxicity, GI distress, cancer risk. ​ IV Immunoglobulin (IVIG): Infusion reactions, anaphylaxis, thrombosis, kidney injury, hemolysis, aseptic meningitis. Risk factors, signs/symptoms, and management of osteoporosis, osteomalacia, Paget’s disease, and gout Osteoporosis -​ Signs/Symptoms ​ Low back pain ​ Fractures (often silent) ​ Postural changes (thoracic kyphosis, loss of body height) ​ Primary Osteoporosis (most common form can occur in both genders at all ages but often follows menopause in women and occurs later in life in men) ​ Secondary osteoporosis (caused by medications/conditions) -​ Non-modifiable Risk Factors ​ Age: >50; menopausal (natural or surgically induced) ​ Race: Caucasian/Asian ​ Family history ​ Lactose intolerance ​ Depression ​ Immobilization -​ Modifiable Risk Factors ​ Inactivity or sedentary lifestyle ​ Diet and nutrition ​ Tobacco and alcohol ​ Estrogen deficiency ​ Long-term use of certain medications (such as glucocorticoids or antacids) -​ Management Osteomalacia -​ Signs/Symptoms ​ Diffuse aching and fatigue, bone pain and periarticular tenderness ​ Proximal myopathy, sensory poly-neuropathy, and muscular weakness ​ Postural deformities: T/S kyphosis, heart-shaped pelvis, femur & tibia bowing -​ Risk Factors ​ Older age ​ Residence in cold geographic area ​ Vitamin D deficiency ​ Gastrectomy ​ Intestinal calcium malabsorption ​ Long-term use of medications ​ Increased skin pigmentation -​ Management Paget’s Disease -​ Signs/Symptoms -​ Risk Factors ​ Onset >35 yrs ​ Possible genetic susceptibility -​ Management Gout -​ Signs/Symptoms ​ Erythema ​ Warmth ​ Extreme tenderness ​ Hypersensitivity -​ Risk Factors -​ Management Screening for intermittent claudication, DVT, and arterial disease Intermittent Claudication Key Signs & Symptoms: ​ Pain/cramping in legs during exertion, relieved by rest ​ Weak/absent distal pulses ​ Cool skin, hair loss, pale or bluish skin ​ Prolonged capillary refill (>3 seconds) Screening Tests: ​ Ankle-Brachial Index (ABI): ABI < 0.9 suggests peripheral arterial disease (PAD) ​ Treadmill Test: Pain onset during walking, relief with rest ​ Palpation of Pulses: Diminished or absent dorsalis pedis/posterior tibial pulses Deep Vein Thrombosis (DVT) Key Signs & Symptoms: ​ Unilateral leg swelling, warmth, redness ​ Pain/tenderness, especially in the calf ​ Dilated superficial veins ​ Recent immobilization, surgery, or trauma Screening Tests: ​ Wells’ Criteria for DVT: Score ≥ 2 → high probability, consider imaging ​ Homan’s Sign (not reliable): Pain with passive dorsiflexion ​ D-dimer Test: Elevated levels suggest possible DVT, requires further imaging (e.g., Doppler ultrasound) Arterial Disease (PAD & Acute Arterial Insufficiency) Key Signs & Symptoms: ​ Chronic PAD: Claudication, cold extremities, weak pulses, slow wound healing ​ Acute Arterial Occlusion (Emergency): The 6 P’s → Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (cold skin) Screening Tests: ​ Ankle-Brachial Index (ABI): Normal (1.0–1.3), PAD (