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    25 views139 pages

    Bootcamp MSK

    Uploaded by

    amjdnuaimy

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 139
    er a has i Pb re ‘Ae6.yearold female presents to te primary care physician for an annual exam, Two months ago, she fel while walking her dog and fractured her right hip. The patient underwent surgical intervention and has been compliant with physical thorapy tha she bogan afew wooks ago. Sho snow using a cane to ambulato. She has no other sgnicant past mecical history and takes no prescrpon or overthe-counter medications, The last me she was ‘en by a primary care physician was three years age. Vita sigs inclu a temperature of 368°C (98.2°F), ood pressure of 118/70 mm, heat rate of 74 beasimin, and respiratory rate of 16 breathsimin, Physical ‘2xam reveals a lrted range of motion from pain in the right hip and high. Dual-eneray xray absorptiomty scan shows a T-score of-25. The patients biood work reveals serum calcu, phosphorus, and parahyrold hormone al witin reference ranges. What Is the most key agnosis of is patent? (O.A. Primary osteoporosis (0 B. Secondary osteoporosis 0 €.Osteomalacia 0 D.Osteopetrosis © € Ostetisdeformans rn Oo rey Pal gepeetoy er a has el ‘Ae6.yearold female presents to te primary care physician for an annual exam, Two months ago, she fel while walking her dog and fractured her right hip. The patient underwent surgical intervention and has been compliant with physical thorapy tha she bogan afew wooks ago. Sho snow using a cane to ambulato. She has no other sgnicant past mecical history and takes no prescrpon or overthe-counter medications, The last me she was ‘en by a primary care physician was three years age. Vita sigs inclu a temperature of 368°C (98.2°F), ood pressure of 118/70 mm, heat rate of 74 beasimin, and respiratory rate of 16 breathsimin, Physical ‘2xam reveals a lrted range of motion from pain in the right hip and high. Dual-eneray xray absorptiomty scan shows a T-score of-25. The patients biood work reveals serum calcu, phosphorus, and parahyrold hormone al witin reference ranges. What Is the most key agnosis of is patent? VY ® A Primary osteoporosis (70%) (0 B. Secondary osteoporosis 1%) 0 ©. Osteomalaia (4%) 0 D.Osteopetosis (5%) (0. Ostetisdeformans (0%) am © ows 1 azo003 Answered Corey ne Spent ta vpeated ee) iret = Peas This elderly patient presenting with a recent hip fracture, 2 T-score of 2.6, and normal ab values, ikely has primary osteoporosis. Osteoporosis isa skeletal condition characterized by decreased bone mass, associated with reduced bone strength and increased risk of fractures. mary osteoporosis cccu's as 2 consequence of aging, and describes the loss af trabecular and cortical bone despite normal bone ‘mineralization (.., normal CaP, PO,*, PTH); whereas secondary osteoporosis usually presents with stbnoxmal serum chemistry resulting rom underlying medical contions or certain medications. Primary osteoporosis most commonly affects postmenopausal females type 1 primary osteoporosis), due to increased bone resoration resulting from decreased estrogen levels and old age. Its usually diagnosed when bone mineral density (BMD) measurement by DEXA scan of the lumbar spine, hip, or femoral neck demonstrates at least 25 standard deviations below the young adult mean (Le, T-score = -2.8), or when a patient suffers a fragility fracture (eg. fll from stancing height, minimal trauma). Primary osteoporosis is managed with ifestye modification and medications. Affected patents are encouraged to incorporate regular weight-bearing exercise and adequate intake of €a* and vitamin into aly routines. Additonal, madications such as bisphosphonates, PTH analogs, selective estrogen receptor ‘modulators (SERMSs), or denosumab may be used to increase bone mass or prevent further loss. {Choice B}: Causes of socondary osteoporosis include certain medications (29, corticosteroids, anticonvulsants, anticoagulants, thyroid replacement therapy), excessive alcohol use, hyperparathyroiism, yer matle mons nasbeoon ees, nd rr, Seen oop reereneaeeesten iret a re = remsorao mY are Is Pees {Choice B}: Causes of socondary osteoporosis include certain medications (e9., corticostorcids, anticonvuleants, anticoagulants, thyroid replacement therapy), excessive alcoho use, hyperparathyroiiem, hyperthyrcaism, multiple myeloma, malabsorption syndromes, and anorexia, Secondary osteoporosis. Presents 3s a decreased BMD with abnormal ab values. This postmenopausal female patient, who has normal lab values, is more kel to have primary osteoporosis [choice ¢}: Osteomaacia isa disease ofthe bone characterized by decreased mineralization of newly formed ‘stood at sitos of bone turnover, resulting n the development of sft bones. tis most commonly caused by \itamin D deficiency. Patiants may present with fractures, but labs will show alow serum Ca** and PO, and a high PTH and skaine phosphatase, {choice Dj: Osteopetosis refers to increased bone mass, in which bone becomes thickened, hard, and dense. Its caused by failure of normal bone resorption due to impaired osteoclast function. Although bones become thicke, they become more prone to fracture due to decreased flesibity. This patient's T-score indicates low bone mineral density. {choice E}: Paget disease of bone (osteitis detormans) is a lcalzed disorder of bone remodeling caused by excessive osteoclastic and osteoblastic activity, resting in poor-quality bone formation, Patients present with normal serum Ca" and PO,” and high akaline phosphstase. Clinical features include hand and skull enlargement, coarse facil features, and hesring loss, Patents ee also at an increased risk of developing osteosarcoma. ee) iret a ee ad 4 re 2 F dee [ais ee eee ee ee cree | EES a as ni Sod i in Sar ass a arg ay esata ate ge gay arrears een 2] | somatsoumcs oP onthe perennial ere nce an ne a 10 ‘enlargement, coarse facial features, and hearing loss. Patients are also at an increased risk of developing yl i) ‘Key Takeaway: : Sees on see ett emma nee ee i fsa eucpeeed a acees oe reer aa ee aa : a ee ee a Seca ceca ieee eae eee ee a 2 ieee 2 er ae ‘Subject: Pathology ° [AS5.yearold male presen othe primary care physician compiehnng of numbness, sharp pain, and tingling In his feet and logs. He has experienced these symptoms forthe past several mons but was unable fo see a physician a¢ he recent lost his job and metical insurance. His past modal history ie significant for ype I iabetes meltus; however, he adits o being noncompliant with his medication regimen. Vial signs inckde a ‘emporatre of 37.1°C (68.8), blood pressure of 127/82 mmHg, heat rate of 75 boatlmin, an respiratory rate ‘0f 16 breaths/min. The physician asks the pation “loosaly dangle his fet trom the procedure chal. She then \dorsiexes te fot wit her hand, palptes the Aciles tendon wih her oter hand, end gent taps the tendon ‘wth a refx hammer. The physician notices an absence of plantar exon. Abnormal funconing of which of the allowing is rosponsibl or tis loss of response? ©-A. Gola tendon organ (0 B. Muscle singles © ©. Pacinian corpuscles OD. Marka discs (0. Meisner’ corpuscles en iret [AS5.yearold male presen othe primary care physician compiehnng of numbness, sharp pain, and tingling In his feet and logs. He has experienced these symptoms forthe past several mons but was unable fo see a physician a¢ he recent lost his job and metical insurance. His past modal history ie significant for ype I iabetes meltus; however, he adits o being noncompliant with his medication regimen. Vial signs inckde a ‘emporatre of 37.1°C (68.8), blood pressure of 127/82 mmHg, heat rate of 75 boatlmin, an respiratory rate ‘0f 16 breaths/min. The physician asks the pation “loosaly dangle his fet trom the procedure chal. She then \dorsiexes te fot wit her hand, palptes the Aciles tendon wih her oter hand, end gent taps the tendon ‘wth a refx hammer. The physician notices an absence of plantar exon. Abnormal funconing of which of the allowing is rosponsibl or tis loss of response? ©. Golg tendon organ (29%) LV @ B. Muscle spindles (26%) © ©. Pacinian corpuscles (6%) OD Marka discs) (0. Meissner’ corpuscles (5%) a as @ oor 1 ma0022 newer Conecly Te Spent, test Upestee ery iret “Type labetes mellitus (120M) isthe most common form of clabetes and is characterized asa chronic ‘isorder of elevated bicod gucose levels (hyperglycemia) due toa relative deficiency of insulin and insulin resistance, Uncontrolled T20M can cause numerous manifestation, including nephropathy, cculr disease, and neuropathy, as seen in this patient. ‘The peripheral neuropathy (e.g, 1os5 of vibration sense, proprioception, ight touch) classically has a “stocking-slove” sensory loss patter, asthe distal extremities ae ypicaly the mast signficanty affected. A a he ‘84 year-old male wih a past mescalhiary of essen! mypertenion and hyped presen ote ‘brmary cre physican to reve his recat tasting results. Tho patito presnte wo wooks po. ‘comparing of wexparale weakness in isons, which made feu ohm to ib tas and stare rom 3 ‘seaid poston. A! that ine, asynmetre,etheatous rash was apprecad over his rack, shoulders, and ‘per Boe. Tay. he reports no changes in is symotons Labs are avewed below ANA Poste Antnlot: Poste ‘Aaionacase:Poatve ‘AaiiCCP.Negatve ‘Auth dsDNA: Nogatve ‘ie ational ysl exam ring is most atocaad wih is atts kl dering dagnoss? ©). Nodular ichering over the dorsal DIP ints © B. Noda thickening over the dorsal PP ots © Sealy papuce over ho ovtonsor suse ofthe hands '. PIP Joint hyperextension with DIP join exon DIP jit hyperexinsion wth PIP int exon © Palo ofthe distal gts Finger iting © A Rede tanig rte dol are 2% B.noauaricanng ore coal aes 23) Y © 6. Sey apse over ne ers hand 69 © D.PP jon person tn Pont texan © Pot yer th Pt non 28) © Paro dtl ate 9 © 6 Regering 9 rcoet am eons 2 mnao22 Tis pation has postive autoantbody titers, pointing towards an autoimmune codon, Reina Nis istry, heintalyprosertes ith muscular weakness and rashes. ese frags re most consistent th the ctor ntammstry myoraty, dermatomyositis. Ths charactrzed by symmetric proximal ‘muscle weakness an rashes found in clsscdstibutons. This patent has rashes along the back (shawl ‘sian ane the mock and chest (V san). Dermatomyositis also troquonty associated wth arash onthe pet! ako the face (hllatrape rash) ans the dora hands. Te rash on he dorsum ofthe hands _opeare a volaceous papules on ne metcerpophalngeal nd erpslngeolnt—referred to as Gotten papules, Antinuciear antibodies ae nonspecific or dermatosis. AntiJo-t Antichelease (ant-Mi-2, ne _an-SaP antibodies are spec for dermatomyositis. ealbele esse sisal ee ee ee a hs 5 a He [choices A ano): Heterin nodes re rod torts ofthe clstalntersalangeal ints sean in ‘ostesarit, while thse seen oer the proxnantrpalangeal joints are termed Bouchard nodes, {choice D}: Hyperectension ofthe proximal interphalangeal joint an feson of the itl interphalangeal int Isdesenatve of sean neck deformity, a fading seen in rheumatld ats [choice E: Abnormal extension f the dial itrphalnge cin and xin of he proxi interphalangeal joints i esriptive of Boutonire cory, wbich is associated with haut att [ehoice FI: Decreased blood on othe distal fingers causing paler is indctve of Raynaus's phenomenon. “Tis condion ray eccur inthe absene of another aseace bts also associated wth condtons suchas Iupus and scleroderma, {choice 6} Piting ofthe tages i associated withthe autoimmune contin scleroderma Koy Takeaway: + Dermatanvosts is an autoimmune inmmatay myopathy ausing symmeti, posal msle ‘weakness ad ashes + Reshes may be astributed over the probit! enon theetope rash, over the dorsum of the hands {Cotton paps, onthe back (shaw sign) a the rack ae chest (Van). + Artincear antibodies are nonspecti for aseas, whe Ant An-heleas ant-M-2), ana ant- RP ativdies are spect or dermatonyosts. ‘A S0- year fomale wha past maszal history oft | dates malts and best presents to th primary ‘are physician wth aque ae sweting inher hands and knees. The pabert seems hapoy when she sieps on ‘me se noting ashe has ot 10 ib 45k) nce Paras Vt vee mone pe han she wakoe uP, she ei exromely sf and has fet waking othe ballroom. She had genetic sting done few years ‘2 and was found to Be HLA-DRA postive. The patent has @ 15 pack yer clgsrate okng Noy but denies ‘Acoto andi rg Us. Val ss are table for a ood pressure of 12904 mmHg hep cte of 72 boatsrin, espatory ao 16 breathemin, and terval of 376°C (8.7°F) On pysical exam, shes wel- _sopenting Cardiac mscuton revel normal Stand 82 bart sounds. Hypresenso fhe posal Interpalengeal ont and exon ce it intephalngea nts ented AGaenlen squeeze ets ‘postive The phys ecermends sarin lrg trm therapy wit ethers. Which ofthe following shoud ‘be usos forte reamont of acute cose asin tis patont? © A. Aatty meaeaton © Prednisone and buprten © C.Hytronsiorogne © D.Etnercnt © E-Alopurne| an ndorettac Pr a has da Pb He od > A. Acty mediation (3) #8. Precnisone an bupoen 82%) © 6 Hysronoroqne (5) © D,Etanerent (58) © Alpine! an indoathacn (6%) Bs 9 ose 5 wrraoze droared Coney Tine Sent Gattpanea “This 59-yearo female presents wth Joint pain, sweling and stitiness, These finding alse eusiion fora agri of cheumatld arthritis RA)an autoimmune cancion tat eral llc the its ait ‘ssoeted wth female sx, smoking, andthe HLA-DRA sectype, The fesuting Inlanmaton resus ‘cassc symptoms, cluding sweling anc pain, A postive Gaenslen squeeze test represented by painon {steal compression ofthe metacarpoptalange ons, is smetines used to support tis agnosis ealbele esse sisal “These patents aso testy have it stress hat mecoues wth use 9, worsen he morrng and beter _at right), Extasrtiodat manifestations ae also common and ince fcings sich a fatigue anc weight loss, Dzease progression fuer recutsn erosive on carage ang subeequet deformity that causes Inereated pain an nail. Th description of his patent's hands i consstnt with a wan neck deformity. ‘Treatment of PA imslvs loa term management with dlcease-mosfyingantreumatic drugs (OMARDs) and 2 "Treatment of RA mses long-term management with dsease-mosyingantheumatic drugs (DMARDs) and =ymptomstic conto tng acute flares. Medietons hat icky reduce ittammation, sich a= prednisone ‘2d Ibuprofen, ae prefered nthe reamant ofthese acute ares. I's important to note hat agents belonging to these cg clases [sttids ana ronsteridalant-ivlanmatory tugs, respectively) ae effective inthe short-term maragerent of RA, but do rot prevent disease progression as DMAROS do {cholee Al: Actvty moeteston s more beneticanpalnts wt deganeatve condtons characterized by mechanical on carnage, sch as osteoarthi. Atvty can lp symptoms and reduce d'sease at and ‘cordovasulr kin those wth RA ute nt racomanded for rst: Ine testmant of acute fares. [choices ¢ and tnereept nd hyronychiorsquine ar agents thst may be used as OMARDS Inthe ‘westmant of RA. DMARDs are used in ang-term anagem. [choice E:Alopurnt and indomethacin ar rugs that my be proscribed in paens with gout Alopuinal = ‘xanthine oxidase inhibitor that usedin watering therapy Indomethacin anonstroé at Inturanatry drug used in acute gout attacks a decrease anmaton Koy Takeaway: + Rheumatol artisan autoimmune tammatory disease that causes in pa, sweting, snes, and detrei + Teatment facie fares of invotvescecressingianmaton wth steroids and nonsteroidal ant- ‘rtmmatory ras. ee ee ee Eee acd da DP He ‘A. year-ld male presnts tothe pray care physician wh his wfe for an annual exam. He wos wormed about her husbras hearng ashe hasbeen tring up the volume on he eles fo a "annoy ud” ‘evo Te pant ptt meal nitr is srfeant or otsrctve sleep sores, for whieh he uses a coninuous postive arma possre device nigh. He has no alge and takes no mcicatons. Rava of sso ‘egatve for ove cits, dyspnea srgna abdominal scomfo.o changes to unaton owen he pint ‘mentors he has had occasional "bone pan is shins.” Vie sins rvea a tempereure of 37 °C (886°) ans ‘lod reser o 12278 mia, Tenderness to dep palpation i ete over hearer surface ofthe rit ia. Lab testing revi caium of 49 mpl, phosphate of 42 mpd, and aru akaine phosphate of 900 UL. What ste most aly agnosis nis pate? © A Osta trae eytea © 8. Metaiateaoease Osta setomane © D.Osteopetonis © E-Osteoesroma ee ee ee Ee as na as x A Ontos tea 128) © B.Meastate donose (58) 0 ©. Osta dtormane (554 © B.cxteoptonts 218) © € cneonarcoma (63) monet a 9 ose 0 woe7a7 ‘Symptons of lower extrerity bone pain end progressive hearing loss inthe presence ofan elevated serum ‘attaline phosphatase, ar consistent with Paget's seas of bone. Pages see of bone ase known 3s ‘osteitis deformane, is 2 foal dsorder of bone metabolism characterized by an acelorated rat of hone ‘remodeling, is caused by a ereae in lcazed eetocae actty foloned by increased steblost, _2ctvy lang toa avrg ol bone with ngived inte, Comenany flected seas clude the sh, ‘spine, peti, and ong bones of he lower extremity. ‘Common mantestaten include bone pain arts, an ong bone chalk-stck fractures. nation involvement the skal may lea deformity, Headache, dziess and hearing loss. Tshearing loss can be mutator neuang + Anois ofthe ossicles (ales, nc, and tapes) leads to conductive hearing ss, + Narowing ofthe tema auatary mest and subsequent compression ofthe vesibulocochiear nerve ‘commen maniestatens include Boe pain, arti, ad ong bone chalkestick fractures. nator, Invlvament of the sl may lead detormiy, Mesdeche, aziness and hearing oss. TNs hearing iss can be mutator nciing + Anglos ofthe ose (males, nes, ad stapes) leads to conductive hearing oss + Narowing ofthe intemal audtary meatus and subsequent compression ofthe vestbulocechear nae ‘ead to snsorneural heseng oss. Ils is camman for patients to complain hat hats no longer fit du to expeason af the evar. Patents wth Paget elsease ar alco tan ncreabed risk of develoning osteosarcoma; haneer, hiss very rae. Laboratory testing typical reves elevaions in serum alatne phosphatase and typ algen tumover makers 9, deotyprcnoine, eloped, C-telopestis,hyroxyproine) with narmalealetum anc ‘Phosphorus levels. On raging tfecad bons pay esto or mizad ectecytic and eeroti sons, ‘wth focal increase in uptake on bone scans. On histlogical exam affected bones dol @mosele patter ‘of woven and lanelar bore with chactically arranged esteoc/es within bone lacunae, Management often Involves teotmen! wth Blaphosphonates [choice A): Ostet ross cysts is a classe skeletal mantsttion of primary hyperparathyroisim ‘carateriescinicaly by bone pain ae radoatephicall by subperiosteal bone eeorpton of te phalonaes, 2 "salt ons pepper appearance of the sul and brown tumors in the long bones. Lab values show an ineea3e ‘ngerum akaine phosphite, elevted calcium eel, and lw phosphiie eels. [ehoice Bl: Bone ite thin most commen organ affects by metastaes, fer the ing ander. Common sald organ cancer to underge bene metstasisincae those hat aise the east ng prostate Shed ee ee ee as 5 a He sold org cancers to undergo bone metastasis nce hose that arc nthe reas, na, prostate ney. though bone pn ia key festzeof bore metstss, the remainder of this pallens histery and Isbortery values dona ale high velo suspicion fr magnanc. However, symptoms such as extrme ‘igus unexplained weightloss andthe occurence ofa pathologie ature woul warrant further Irvesigaon. [choice b}: Onteoparosis refers to created bone mis, n which bone becomes Wickaned hard and ‘dense, 1s eased by fale of ermal bone resorption due to aired esteodas function Although bones become tke, hay become more pana fracture due toa dereac in elt. Osteopeto Is most ‘commonly the resut ol inherited genetic detec, Patents ten present with one pain and fractures ery in We L2beratory testing wil lasicaly show noma zerum esieun phate and ane phorphataee level [choice E: Osteosarcoma isthe most comon primar bone malgnarey. is eused by neoplastic ‘rotation of pleomorphic oteoi-producing el. Osteosarcoma acount fo 20% af rary bone ‘cancers en has bade age dstrbuton, Inedenes e mast cermon in those below the age of 20 and above 165, The major of eaten present wih alecalzed pan, enraing massa the primary tuner ste. Patents ‘may also expeincepathlogc fractures. This patient's presentations more consistent witha dagnasis of Pagers disease, wich incurs slaty incressed riko ostosarcoms. Key Takeaway: + Page's esse of bone i localized disorder of bone remodling tha results inthe formation of errs, poor susity bone + Patients develop elevated allie phosphatase, bone pl, snd symptoms related tothe aftected sions of te eto. Ee as da Pb oe fe Lorain i css sow ral serum clin, phosphate, and kale ptoshuase ier [choice E:Osteosareoms isthe most common pnary bone maligna. Its eaused by neoplastic prolferaton of leanorphieesteal-predusng cells. Osteasrcome sceauns fr 20% of primary Bone ‘cancers ac has bimada ge detibutlon,egence le meet common nthaee below the age of 20 and above 16, The maorty of satin presant wih aJecazed pain, enlaraing mass atthe primary tuner sto. Patants| tay also experiance patholai tactures, Tie atl’ presentations mere consstnt wth a dlagnosis of Paget's ease hichineur a aghtyietessedrak of osteosreoms. Koy Takeaway: + Page's east of ane i lead larder of bone reeling thal results nthe formation of erage, poor-custy bone + Palers dvelopolovatedalaline phosphatase, bone pal, and symptoms lated tothe atectod ‘eaion ofthe skeleton. + nthe sal, common cial etuesineude headache, heed ckcunference enlargement, and hearing oe ‘unetonal unt of mci call anise the famenis wih markar Aandi laments wth marker. She ‘ton ples elcrodes onthe sk of ubject nd apps an electtcal cure o simu maton othe ‘unetina unt nang contacto). tem 012 ‘nich the lowing rion corti ony rather Rand shane ing stiches? Gates oantes = Cmte 2 © D.Aband 2 © Eland a erry ® oe © AZiine YO BLM and m8) X # 6.Mine ar) © D.Aband (5%) 2 © E I band (58) ncoret om oom 9 arom een Peseta Covey Tinea Catpdaed “The sarcomere isthe functional unto 2 muscle cl, Each sarcomere I composed of two main potln ‘arent responsible for misculecontracton, Thick laments are organized bundles of myosin, hie thin ‘aments are made of actin song with two regulatory proteins (waponin an tropomyosin) ach ssrcomere Is vided ino aferentines and zones, or bands, whch en be abserved onan electen mcogreph, 35 shown below The lines dine the boundaries ofthe eercomere and consistently of actin, Te line ‘uns down the contr ofthe sarcorare and consis enily of myosin, cen hn aren) uyoon ree taner a 2 | 128) hens tele paitasg ban coment twat are a © £8) nan ars oma sane haan se ty ar en oreo,

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