RHEUMATOLOGY, Orthopedics, Dermatology

deep reflexes

"1,2,3,4,5,6,7,8": S1-2: ankle L3-4: knee C5-6: biceps, supinator C7-8: triceps

Irritant Hand Dermatitis

"Housewives Hands " Excessive dryness leading to inflammation Could be from frequent hand washing Tx: based on stage (Acute, Subacute, Chronic) and prevention

Tinea Corporis & Faciae 1A

(classic "ringworm") 1. Fungal infection of the body or face, Trichophyton rubrum most common cause 2. acute sudden Annular lesions with central depression and outer active border (more inflamed n red) . -can acutely present as itchy inflamed red patches 5. Ix skin biopsy, microscopy and skin culture 6. treatment i. Anitifungal Creams for mild to moderate cases (terbinafine 1%, econazole 1%, miconazoleetc.) ii. Oral antifungals for extensive or resistant cases and for facial tinea (griseofulvin, intraconazole, fluconazole, terbinafine) Questions to ask -Diabetic- like glucose -immunosupression ?

Associated Features of Atopic Dermatitis Atopic Pleats

(dennie-morgan infraorbital fold) may be seen in some atopic children, once thought to be a reliable sign of atopy

Pemphigus Erythematosus (senear Usher Syndrome )

+ positive ANA , variant of Pemphigus Foliaceous and thought to be cross over with LUPUS

Shoulder Joints

- AC joint - Glenohumeral joint

Eczema

- An inflammatory eruption of the skin characterized by itching vesicles and scale. Dermatitis and Eczema may be used synonymously . Anti-histamine to treat itching

female pattern hair loss 1B

- Associated with elevated levels of the serum adrenal androgen dehydroepiandrosterone sulfate -occurs in women with adrogenic alopecia - characterised by diffuse thinning of hair on the scalp due to increased hair shedding or a reduction in hair volume -50-100 hairs lost per day -baldness begins with receding frontal hairline that progresses to a bald patch on top of the head Rx minoxidil (0.25 mg daily) and spironolactone (25 mg daily) combination 6 months to see effects

SEBORRHOEIC KERATOSIS

- Benign plaques (3-20mm) - greasy, "stuck on" appearance. -elderly but may begin in 30-40s - particularly in sun exposed areas - not associated with sebum or sebaious glands and not restricted to sebacious areas as in Seb dermatittis Rx reassurance

HIP PAIN: PUBIC RAMI FRACTURE

- DIRECT TRAUma , usually motobikr "open book fracture -heal on their own if minor -cause permenant disability -if extensive unstable , needs surgery Complications - blood loss due to rupture of pelvic blood vessels

Test for Subscapularis

- Internal rotation lag sign (against resistance) - Gerbers lift off test - Belly press sign

What investigations would you carry out is osteomyelitis ? 1 A

- Ix: FBC (WCC) ESR, CRP, Xray, MRI, culture of bone, abcess or both , WBC MRI preferred

Rotator cuff tears Positive test for impingement

- Neer's test - Hawkins sign - Drop arm test -painful arc test

SPINAL INJURY 1A

- Neurogenic shock: hypotension following SCI due to inteuption to sympathetics, loss of muscle tone due to skeletal paralysis Spinal shock: transient loss of all neurologic function below the level of the spinal cord injury, causing flaccid paralysis and areflexia for variable periods whiplash: : traumatic injury to the soft tissue structures in the region of the cervical spine due to hyperflexion, hyperextension, or rotational injury to the neck Rx: ABCDE. immobilisation, foley catheter, temp regulation. motor and sensory assess,ents: pinprick, light touch, proprioception , XRAY< MRI, CT

features of polymyositis 2B

- Proximal muscle weakness - Dysphagia - Dysphonia - Respiratory failure due to respiratory muscle damage - Systemic features - fatigue, malaise, weight loss, fever - Cardiac failure - Sjogren's syndrome

Polymyositis and dermatomyositis Ix 2B

- Raised ESR and CRP - Raised creatine kinase, LDH, adolase, AST and ALT - Positive anti-JO-1 and anti-MI-2 antibodies - Electromyogram - Muscle or skin biopsy

Dislocation and subluxation Treatment

- Reduction and immobilization for 2 to 6 weeks - Exercises to keep normal ROM

Simple laceration 1A

- SUPERFICIAL, REQUIRING ONE LAYER CLOSURE -may just need cleaing ( saline chlorhexadine) -normal dressing

Polymyositis and dermatomyositis rx 2B

- Steroids - Methotrexate - Azathioprine - Cyclophosphamide - Physiotherapy and exercises - SALT for speech and language

Tendinopathy & Bursitis Treatment

- Systemic analgesics, ice or heat applications, or local injection of an anesthetic and a corticosteroid to reduce inflammation - Bursitis: Aspiration to drain excess fluid -Physical therapy

ROTATOR CUFF TEAR Definition Features Investigations

- Tear in tendons of rotator cuff - common in elderly due to degeneration -results in pain and weakness of shoulder, exacerbated by overhead activity --> often misdiagnosed as subacromial impigmenet - difficult abduction - Normal passive movements - Ix: MRI

Types of displacement

- Translation (Shift) - Angulation (Tilt) - Rotation (Twist) - Length (can cause shortening)

Granulomatosis with polyangiitis (Wegener)

- Vasculitis, cANCA -Upper respiratory tract: perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis, bloody discharge -Lower respiratory tract: hemoptysis, cough, dyspnea. -Renal: hematuria, red cell casts. - joints: mild to full blown arthritis - affects eyes too

SYSTEMIC SCLEROSIS/ SCLERODERMA 2B

- a multi-system, autoimmune disease, characterised by functional and structural abnormalities of small blood vessels, fibrosis of skin and internal organs ( fribroblast dysfunction), and production of auto-antibodies. - four times more common in females, 50-60. -anti-centromere antibodies 3 patterns of disease: 1. Limited cutaneous systemic sclerosis : skin, neck, face, hands, CREST 2. Diffuse cutaneous systemic sclerosis : widespread skin dz , early visceral- renal and pulmonary fibrosis 3. Scleroderma: AFFECTS face and distal limbs predominately associated with CREST syndrome: - Calcinosis : deposition of Ca in skin - Raynaud's phenomenon - oEsophageal dysmotility - Sclerodactyly - Telangiectasia: spider veins-> widened venules Ix for scleroderma - antobodies: anti-scl 70, anti-topoisomerase, RNA polymeras --> ANA 70% , RF (30%), anti-centromere -FB C -ESR -CRP - CXR, ECG, PFTs

Developmental Hip Dysplasia 1B paeds

- abnormal development of hip resulting in dysplasia and subluxation/dislocation of hip - most common orthopedic disorder in newborns -due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular roof spectrum of conditions that lead to hip subluxation and dislocation: dislocated femoral head completely out of acetabulum dislocatable head in socket head subluxates out of joint when provoked dysplastic acetabulum, more shallow and more vertical than normal • painless (if painful suspect septic dislocation) tests: Positive Ortolani sign = definitive "clunk" with hip mov't as femoral head reduces into acetabulum, barlow's test, galeazzi sign. Ix: USS, X-ray after 4-6mos Sx = asymmetric skin folds (non-specific), shortened leg, decr ROM, gluteal muscle atrophy affected side

Syringomyelia

- abnormal longitudinal cavities in the spinal cord cause paresthesias and muscle weakness - can cause incontinence - loss of pain and temperature sensation - more notes in neurology

Elbow dislocation

- anterior capsule and collateral ligaments disrupted - due to : elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion - usually the radius and ulna are dislocated together, or the radius head dislocates and the ulna remains ("Monteggia") -80% are posterior/posterolateral, anterior are rare and usually devastating ss: elbow pain, swelling, flexion contracture, +/- ulnar + radial pulses Ix: x-ray assess NVS before resuction: brachial artery, median and ulnar nerves (can become entrapped during manipulation) Rx: reduction under sedation, long-arm splint, operation , RORIF complcations: stiffness (loss of extension), intra-articular loose body, neurovascular injury (ulnar nerve, median nerve, brachial artery), radial head fracture • recurrent instability uncommon

Vitiligo 1B

- autoimmune disease characterised by symmetrical localised loss of skin pigmentation characterized by milk-white patches (leukoderma) -spontaneous remission can occur - due to destruction of melanocytes -can be drug induced -common in india aex: metastatic melanoma, drugs immune checkpoin inhibitors, diabtes, thyroid dz, addisons, SLE, RA, psoriasis, kobner phenomenon ( site of injury ) Rx - Sunblock - Topical steroids - Phototherapy - Tacrolimus

Bullous Pemphigoid 1B

- autoimmune skin condition characterised by erosive sub-epidermal blistering skin from erupted tense bullae -caused by auto-antibodies to BM, IgG and IgEagainst Protein in the dermo-epidermal junction Benign sub epidermal blistering disease -common in >60 - in pemphigoid bullae are usually intact Features: severely Itchy urticarial apules - tense blisters on abdomen, groin, extremities rupture to form crusted erosions . can affcet eyes, scalp and genitals -Lasts months to years w/o tx -oral cavity may be affected Increased Eosinophils in blister Ix: biopsy of intact bullae edge, immunodluorence biopsy C3 and IgG histology and immunofluoresence, biopsy, CXR malignancy sx- can be part of paraneoplastic syndrime -check BP due to steroid use - doxycycline given as anti-inflammatory Tx:ultra otenet steroids clobetasol , Abx, pain relief, PO steroids, antihistamines

Talar Fracture

- axial loading or hyperdorsiflexion MOI- falling from a height and landing on the foot in a crouched position -talor neck most common -requires closed reduction with cast or ORIF -3+ months NWB

Rheumatoid arthritis 1B

- chronic autoimmune inflammatory condition affecting PIPs, MCP jpints and small joints of the hands and feet -RARELY , can affect knees, hips, DIPs - common in older people >50 -Associated with HLADR4 and HLADR1 FEATURES : RHEUMATISM Rheumatoid factor (RF) +ve in 70% HLA-DR1 and DR-4/ haemoptysis ESR + CRP ⬆/Extra-articular features (PULMONARY fibrosis, subcutaneous nodules, serositis) Ulnar deviation of fingers Morning stiffness better with exercise/MCP+PIP joint swelling Ankylosis/Atlanto-axial joint subluxation/ Autoimmune/ANA +ve in 30%/ Anti-CCP T-cells (CD4)/TNF Osteopenia Inflammatory synovial tissue/ Idiopathic/ IL-1 Deformities (swan-neck, boutonniere) Ix X-rays : periarticular erosions RF anti-CCP CXR ESR and CRP Rx MTX sulfalazine rituximab adalimumab Other conditions associated with a positive RF include: Sjogren's syndrome (around 100%) Felty's syndrome (around 100%) infective endocarditis (= 50%) SLE (= 20-30%) systemic sclerosis (= 30%) general population (= 5%) rarely: TB, HBV, EBV, leprosy DAS score - Assesses severity of disease - Assessment of 28 joints for tenderness and swelling - number of swollen joints, number of tender joints, ESR/CRP, patient global assessment of health - 1.2 is an improvement - 5.2 is an indication for biologic therapy

Tuberculosis Arthritis

- chronic, inflammatory, slowly destructive arthritis with few if any systemic signs - only 50% of CXR (+) - synovial bx are diagnostic; joint cultures may or may not be (+) for organism - tx= Rifampin Features: joint pains, night sweats, fever, erythema noodsum

Biceps tendonitis Dx

- clinical - x-ray to r/o other injury

Dog bites 1A

- common in kids <5 - commonly result in crush injuries, but may also cause scratches, deep cuts, puncture wounds, and tearing of the skin and underlying flesh. -amoxicillin/clavulante. common infections: Pasteurella spp. (50%) Staphylococcus aureus (20%) Streptococcus pyogenes Capnocytophaga canimorsus Various anaerobes. rx prophylactic abx : 1. Amoxicillin clavulanate 2. erythromycin, and clindamycin. hospital if fever, swollen lymph nodes, cellulitis

humerus fracture (proximal ) 1B

- common in young -FOOSH from standing features: proximal tenderness, deformity with severe fracture, swelling , painful ROM, bruising, Ix: axillary nerve function, Xrays, CT scan complications : AVN, nerve palsy (45% _ typically axillary nerve), malunion, post-traumatic arthritis

With a fracture there may be the following damages

- damage to muscles - tearing of blood and lymph vessels - damage to periosteum and blood vessels in the cortex and marrow. - damage to nerves

calcific tendonitis / Acute tendinitis 1B

- depositis of calcium in supraspinatus tendon --> sudden onset of sever shoulder pain - Aex unknown -common in women 40-60 - visible on X-ray -Rx: analgesia, steroid injection, needle aspiration, lavage, open drainage

olecranon #

- due to trauma to posterior aspect of elbow or FOOSH -s&s: localised pain, palpable defect +/- loss of active extension due to avulsion of triceps tendon IX: xray -Rx: nondisplace: cast , displaced: ORIF and ROM

genu varum

- femoratibial angular deformity resulting in bow legged. caused by a tight posterior hip capsule - common in toddlers resolves spontaneously by 18mo - if persistent suspect Blount dz or rickets -blount dz is growth disturbance of the medial aspect of the proximal tibial growth plate; genu varum and tibial torsion may occur. Rx: night splint or osteotomy if severe.

Elbow joint

- flexion and extrenion of forearm -pronation and supination

Dislocation and subluxation are associated generally with ______ but also _____ that cause(3)

- fractures --congenital/adquire disorders --- muscle imbalance ---rheumatoid arthritis --other joint instability

Radius and ulnar shaft #

- high energy direct or indirect (MVA, fall from height, sports) trauma - fractures usually accompanied by displacement due to high force - ss: deformity, pain, swelling, loss of function in hand or forearm Ix: Xray, CT Rx: ORIF with plates complications: soft tissue contracture resulting in limited forearm rotation - surgical release of tissue may be warranted

Humeral shaft fracture 1B

- high energy in young, -low eegry : FOOSH, twisting, metastases (elderly) - s/s: pain, swelling, weakness ± shortening, motion/crepitus at fracture site. NErve test: drop twist, sensory mpairement dorsum of hand Ox: Xray complications: radial nerve palsy

Distal Femur Fracture

- high force - three types: extra articular, partial articular, complete articula - ss: extree pain, knee effusion, short, externally rotated , NV deficits Complications f-emoral artery tear - popliteal artery injury • nerve injury • extensive soft tissue injury • angulation deformities

Erythema nodosum is characterized by

- inflammatory skin condition characterised by raised tender subcutaneous bilateral lesions (red bumps) on anterior surfaces of lower legs - common in women 20-30-40s -Aex: URTI, sarcoidosis, TB, pregnancy, COCP, drugs, IBD

Psoriasis, def, features, Aex, types 1A

- inflammatory skin condition characterised by well-demarcated scaly plaques on erythematous bases, silvery scales, prominent skin lines and pruritus - common in females, onset 16-22 and 55-60 -Aex: Isomorphic Koebner's Phenomenon, Lithium, Beta blockers, antimalarials, systemic steroids , infection, smokingm alcohol Histology: Absent granular layer, Polymorphonuclear abscesses, Elongated and clubbed rete ridges, Neutrophil and lymphocyte infiltrate Clinical Types: 1. Psoriasis Vulgaris/chronic plaque psoriasis 2. Gutatte psoriasis 3. Pustular psoriassis of the palms and soles 4.Pustular psoriasis of the digit 5. Generalized pustular psoriasis 6. Erythrodermic Psoriasis 7. Inverse Psoriasis 8. Nail Psoriasis

septic hip/ Arthritis Paeds ( everything) 1A

- intra-articula infection of the hip - usually Group B( s.aureus, salmonella)) strep or Hib, or Neisseria gonorrhoeae in adolescents - surgical emergency -through haematogenous seeding - extension of osteomyletis ss: acute onset of hip pain, fever, rigor, limp, refusal to bear weight , swelling, effusion, tender warm. hip rests in a position of flexion, abduction, and external rotation (FABER) limited ROM Ix: X-ray, USS, MRI, hip aspiration, cultures, LP Rx: ABx, Urgent operation with emperic IV abx,( oxacillin, gentamicin) surgical drainage, splining Complications : destruction of femur head due to chondrolytic effect of pus

Pes Planus (Flatfoot)) 1A

- loss of arch - > help absorb shock -Flat appearance of infants' feet normal and results from thick fat pads in soles of feet -Flat feet in adolescents and adults results from "fallen arches" usually medial parts of longitudinal arches -can be normal development in children byt developed by age 10 -can be caused by obesity in kids -can be due to neurological probs i.e cerebral palsy or polio -can be due to bony abnormalities: tarsal coalition (fusion of tarsal bones), accessory navicular bone (a small bone which sits in the posterior tibial tendon, weakening support to the arch). -ehlers-danlos syndrome, marfans SS: foot pain in heel or arch, ankle swelling, tight heel cords Ix: x-ray, CT, MRI Rx: arch support, orthotics, stretching exercise, rest, NSAIDs, weight loss, surgery

Insect bites and stings

- may present with papular urticaria ( clusters of irritable urticated papules) -may have pale centre, erythematous, urticarial, papular, vesicular, eczematoid or granulomatous. -Bees, wasps, ants: bullae, swelling, erythematous wheal, systemic anaphylaxos inc urticaria, angioedema, bronchospasm and hypotension. Rx: adrenaline .5ml 1:1000, IV antihistamines, oxygen, venom , steroids Malaria (Anopheles mosquitoes) West Nile fever and Dengue fever (Aedes mosquito) Chikungunya fever (Aedes mosquito) Viral encephalitis (Cu lex mosquito) Filariasis (Culex mosquito) Tularemia (deer fly and black fly) Cat-scratch disease (cat fleas) Plague (fleas) Leishmaniasis and bartonellosis (sandflies, fleas and lice) Onchocerciasis (black fly) Trypanosomiasis (kissing bugs, tsetse fly)

PSEUDOGOUT 1B 1-7

- microcrystal synovitis with Calcium pyrophosphate dihydrate deposition in synovium of large joints - >60 -commonly affects: Knees, wrists, shoulders, ankles, elbows,. -associated w/ arthritis - mimics osteoarthritis Features: acute pain, stiffness, warmth and swelling of affected joint bony deformities Ix ▪CRP, ESR, Urate, Ca+ ▪Joint apirate: exclude septic arthritis ▪Arthrocentesis: positively bifringent rhomboid crystals X-ray: cartilage calcification AKA chondrocalcinosis Rx NSAIDS steroids oral or intra articular

Hip disclocation 1B

- more common post THA anterior -blow to knee (anterior) --limb fixed in external toration and abducted position posterior - force to knee with hip flexed --> dashborad in MVA - SHORTENED AND INTERNALLY ROTATED -can cause sciatic nerve injury associated with acetabular # Complications o post-traumatic arthritis due to articular cartilage injury or intra-articular loose body o femoral head injury including osteonecrosis + fracture: 100% if > 12 hours before reduction o sciatic nerve palsy in 25% (10% permanent) o fracture of femoral shaft or neck o knee injury (PCL tear with dashboard injury)

Juvenile RA / juvenile idiopathic RA 2B

- most common arthropathy in children - arthritis before age of 16 in 1 or more joints for at least 6 wks -chracterised by swelling or effusion, increased warmth, and/or painful limited movement with or without tenderness 7 sub-types - Systemic arthritis (fever, salmon pink urticarial rash when warm, oligo & polyarhtritis, - Serositis - pericarditis, pleuritis, peritonitis, silent effusion, myocarditis, cardiomegaly and failure ) - Oligoarthritis ( common in females, silent ant uveitis., asymetrical involvement of knees, elbows, writs, overgrowth) - RF-positive polyarthritis ( chronic, symmetrical, inflammatory, polyarthritis in 5> joints, common in girls, more aggressive than adult RA, early morning stiffness, worse with inactivity. fever hepatosplenomegaly, adenopathy, pericarditis etc..) - RF-negative polyarthritis (30% IJA, fever, rash, symetrical joint involvement, swelling, stiffness, limited mobility, muscle wasting) - Psoriatic arthritis ( after psoriasis, asymetrical arthropathy- knees, ankles and small joints, nail involvement) - Enthesitis-related ( juvenile ankylosing spondylits, inflammatory spinal pain, sacroilic joint pain) - Undifferentiated

Scaphoid Fracture 1A

- most common carpal fracture -common in young men not children -associated with colles' fracture -Fall on outstretched hand -s/s: pain w/ resisted pronation, tenderness in snuffbox, pain with long axis compression into scaphoid -Ix: xray views maybe negative , MRI confirm diagnosis , CT scan -Rx: non-displaced- thumb spica cast 6-20 wks , displaceed ORIF if suspect- immobilize and repeat x-ray in 1 wk or r/o with MRI or bone scan High non-union rate with scaphoid waist and proximal fractures** COmplications: most common: non-union/mal-union (use bone graft from iliac crest or distal radius with fixation to heal) • AVN of the proximal fragment • delayed union (recommend surgical fixation) • scaphoid nonunion advanced collapse (SNAC) - chronic nonunion leading to advanced collapse and arthritis of wrist

Bisphosphonates side effects

- oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate) - osteonecrosis of the jaw - increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate - acute phase response: fever, myalgia and arthralgia may occur following administration - hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant stop bisphosphonates at 5 years if following: patient is < 75-years-old femoral neck T-score of > -2.5 low risk according to FRAX/NOGG

Subacromial Tendonitis and Bursitis

- painful arc -shoulder pain worse on abduction -reduced abduction between 90-120 degrees -due to trauma or chronic impingement

Human bite 1A

- penetration of skin with human teeth - occurs through violence , rough play, daycare, aggressive sexual play/assault, -high rate of infection ss: tender to touch, semi-circular or oval red ptach +/- bruising signs of infection : fever, redness, swelling, tender,, purulent dx complications: infections with Streptococci Staphylococcus aureus Eikenella Fusobacterium Peptostreptococcus Prevotella Porphyromonas spp. Rx -sterilise wound - pressure to stop bleeding - swabs -prophylactic Abx i.e amoxicillin-clavulanate, metronidazole, doxycycline -tetanus IG

Verrucae (plantar wartwart) 1A

- plantar warts caused by HPV 6&11 - common in children and adolescents -can occur on condyloma b. Can be flat topped or filiform (finger projections) c. "seed warts" black thrombosed capillaries within wart b. Usually painful and multiple (mosaic warts) d. Treatment with spontaneous resolution, salicylic acid (duofilm),cryosurgery,electrocautery, cantharidin (blister beetle) e. When involving the nail (periungual) may be very difficult to treat Rx: Treatment more difficult: spontaneous resolution, Retin A,cryosurgery, cantharidin (blister beetle), electrocautery, efudex (5 fluroruracil), mmunotherapy (DNCB, Interferon), bleomycin (chemotherapeutic agent), laser Use Retin A - help exfoliate and stim immune system

Baker's cyst 1-7

- popliteal cyst, a fluid filled sac behind the knee more obvious on standing . not true cyst,they are distension of the gastrocnemius-semimembranosus bursa. - idiopathic or related to osteoarthritis and usually seen in adults ss: tightness at back of knee, persistent aching - ruptured bakers cyst can sometimes present like a DVT, tenderness, swelling, hot Rx: excision

Biceps tendonitis S/S

- presents as anterior shoulder pain - bicipital groove tenderness - pain with resisted supination of forearm

venous ulcers

- proximal to the medial malleolus, irregular shape, shallow, mild to moderate pain, normal pedal pulses, increased edema, normal skin temp, flaky, dry skin, leg elevation lessens pain Ix- ABPI R/O PVD ( normal .8-1.2 Rx compression bandagess

Patella Tendon Rupture

- sudden forceful contraction of quadriceps during an attempt to stop -Extreme pain with an immediate drop in pain Significant swelling Window shade effect Complete loss of knee extension Previous history of chronic tendinitis -audible pop effusion IX: straight leg test cant complete -> fail

Melasma 1B

- symmetrical Brownish pigmentation of the face during pregnancy; also called chloasma and "mask of pregnancy" - can also occur in men 20-40s - common in brown-skinned people -aex: sunexposure , pregnancy, hormone treatment distributions: Centrofacial pattern: forehead, cheeks, nose and upper lips Malar pattern: cheeks and nose Lateral cheek pattern Mandibular pattern: jawline Reddened or inflamed forms of melasma (also called erythrosis pigmentosa faciei) Poikiloderma of Civatte: reddened, photoaging changes seen on the sides of the neck, mostly affecting patients older than 50 years Brachial type of melasma affecting shoulders and upper arms (also called acquired brachial cutaneous dyschromatosis).

Shoulder instability/ dislocation 2B

- there is separation of the humerus from the glenoid of the scapula at the glenohumeral joint - anterior and posterior -95% anterior -anterior : Abducted arm is externally rotated/hyperextended, or blow to posterior shoulder Posterioir : caused by force applied along the axis of the arm, shoulder is adducted. Internally rotated and flexed associated with (1) Hill-Sachs lesion: indentation of humeral head after impaction on glenoid rim; o (2) Bankart lesion: avulsion of capsule when shoulder dislocates occurs in 85% of all anterior dislocations X-ray: light bulb sign, incogruency of humeral head and outline of the glenoid mercedez-benz sign Nerve damage axillary nerve rnay be damaged. therefore check sensation and contraction over lateral deltoid: for musculocutaneous nerve, check sensation of lateral forearm and contraction of biceps

complex lacerations 1B

- think about tendons and underlying anatomy - disinfectant / sterile technique - analgesia +/- anasthesia - lidocaine - prophylactic abx - tetanus IG - suture require more than layered closure and may require reconstructive surgery

Venous leg ulcers 1B

- ulcer is abnormal break in the skin or mucous membrane - venous leg ulcer is ulceration of lower leg from midcalf -due to calf muscle pump dysfunction --> venous insufficiency -RF: prior DVT, cellulitis, varicose veins, immonility, klinefelter syndrome -fatures: shallow ulcer with irregular border, granulating base. swollen lower legs that feel more comfortable when elevated. chronic lymphoedema, thrombosis, blue-red patch prior to ulceration . pain at the end of the day Ix: ABPI, swabs Rx: compression dressing, wet dressing

arterial ulcers 1B

- ulcers of the foot and toes, webbed spaces due to arterial insufficiency , more often atherosclerosis - ulcers result from acute or chronic ischaemia and/or atheroembolisation of fibrin, platelet and cholesterol debris from a distal source into small vessels of the skin. features: nocturnal pain, hairlessness, chronic ischaemia, pale skin, absent pulses, nail dystropy, waslting of calf muscles,, decreased skin temperature, thin and shiny tissue, hair loss, yellow nails. leg elevation increases pain. ix: check pulses, check sensation, ABPI 0.5 and 0.8 abnormal (1 normal) <.5 revascularisation -RF: vasculitis, chilblains, Raynaud's phenomenon, disseminated intravascular coagulation (DIC), cryoglobulinaemia, hyperviscosity syndrom

Ulnar Nerve Entrapment

- ulnar nerve can become trapped in teh cubital tunnel posteromedial to elbow joint -results in numbness and wasting on the ulnar one and 1/2 fingers Secondary to compression of the *ulnar nerve at the wrist* tunnel of guyon between pissiform and hook of hamate -common in cyclists - affects hypothenar and interosseous muscles -can cause clawing of fingers esp in low lesion - movements of bending hand up/down or side to side at the wrist

Rodent bite or rodent urine and saliva

- usually rats - common in children <5 - Infections Streptobacillus moniliformis Spirillum minus Salmonella spp. Rx fever penicillin hospital in fever, swolen nodes etc...

Roseola Infantum (Exanthem Subitum) 1A

- widespread rash accompanied by systemic symptoms inc. fever, malaise and headache -usually viral -ae: vzv, measles, rubella , roseola ( HPV 6B) A. aka: 6th disease, exanthem subitum B. Etiology: Human Herpes virus 6, type A & B C. Clinical findings: 1. Incubation period 12 days 2. Prodrome of high fever (103-106F), otherwise relatively asymptomatic 3. Rash develops after fever breaks D. Treatment: treat fever, as this is common cause of febrile seizures

de Quervain's Tenosynovitis 1B

-: inflammation in 1st extensor compartment (APL and EPB) common cause of radial wrist pain - >F , Age: 30-50 - synovitis of tendon sheath of abductor pollicis longis and extensor pollicis brevis due Overuse to *repetitive gripping* - s/s: painful fusiform/ along radial aspect of wrist swelling aggravated by twisting of wrist , pain on thumb flexion. -tender over radial styloid process, , painful abduction of thumb against resistenace O/E: pain localised to 1st extensor compartment -test: finkelstein test Ix: clinical dx rX: analgesia, steroid injection, splintage, surgical decompression Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

LICHEN PLANUS 1B

-A chronic and recurrent inflammatory dermatosis characterized by flat-topped, violaceous, shiny, pruritic papules, and milky white papules in the mouth. - Lesions can coalesce into plaques Grouped, linear (isomorphic phenomenon), annular, or disseminatedscattered discrete lesions Wrists (flexor), lumbar region, eyelids, shins (thicker, hyperkeratotic lesions), scalp, and glans penis Mucous Membranes 40% to 60% of individuals with LP (more milky white in appearance) --> causes lacy white streaks, plaques and ulceration with PAIN when in the mucosa as opposed to itching 2. The 5 P's of Lichen planus are Pruritic, Planar, Purple, Polyangular, Papules 3. 30 to 60 years, Females > males, 10% family history Etiology: Drugs may induce a lichen planus like eruption (gold, antimalarials, penicillamine) Prognosis: 1. LP usually persists for months, but in some cases, for years Treatment: 1. Topical and intralesional corticosteroids : 2. Oral prednisolone, retinoids (acitretin or etretinate), cyclosporine,PUVA

Erysipelas ( 1B in both matrices) St. Anthony's fire

-Acute cellulitis of the DERMAL CT and LYMPHATICS involvement -Aex: Strep or stap -characterised by Tense, hot, uniformly elevated, shining patch with irregular outline - sharply defined and raised border.. -Prodromal Symptoms: Malaise, chills, fever, +/- anorexia and vomiting. starts off as one spot Tx: -Strep - phenoxymethylpenicillin -Staph - flucloxacillin IV abx if systemic upset

High median nerve/anterior interosseus nerve entrapment `

-Anterior interosseous nerve innervates FPL, FDP to index and middle fingers, and pronator quadratus - has no cutaneous innervation -In isolation, AIN palsy causes paralysis of IPJ flexion of the thumb and DIPJ flexion of the index and middle fingers (positive O-sign)- NOT loss of flexion of the fingers or sensory deficit -Where the nerve lesion is above the take off of the AIN (i.e. In upper arm) a full median nerve palsy is evident. - only FCU and FDP to little and ring finger function -Special test O-Sign - opposition of the tips of the thumb and index finger only with IP and DIPJs straight

Alopecia areata

-Autoimmune hair loss with antibodies against hair follicles -Leads to patches of baldness -Broken exclamation mark hairs are seen at the edges of bald areas -Associated with nail pitting -Totalis - whole head -Universalis - entire body -RX --> topical steroids

renal osteodystrophy

-Bone lesions due to secondary hyperparathyroidism due to chronic renal disease - presents with hypocalcaemia, hyperphosphataemia and elevated PTH -Kidneys is responsible for Vit D metabolism and calcium resorption -kidney also cannot excrete phosphorus so it builds up in the body - renal failure means Ca+ is not resorbed and Vit D is not being synthesised - body tries to get Ca+ through breaking down bone -phops -Vit D helps absorption of Ca= in intestine, retention in kidneys 1. 25-OH Vit D2 converted to 1,25 OH vit d3 by kidneys . 2. renal failure means no VIt D3 --> low Ca+ --> ( osteomalacia as no mineralisation ) 3. in renal failure phospahte not excreted --> posphate binds Ca+ --> reduced serum Ca+ --> no mineralisation --> osteomalacia 4. Low ca+ --> PTH release --> osteclasts breakdown already soft bone for Ca+ ( subperiosteal bone resorption) 5. pseudofractures , microfractures (osteitis fibrosa cystics) Ix: Ca+ , PhO4, Vitamin D, X-ray

Boxer Fracture / Bennett's 1A

-Closed fist injury*, usually by hitting a wall or person, acute angulation of neck of metacarpal of little finger into palm -S/S: swelling, tenderness over 4th/5th metacarpals Dx: X-ray: fracture of neck of metacarpal with volar angulation. Triangular fragment at base o 4-5the metacarpal Always suspect "closed fist syndrome"; punch to teeth= human bite= OR + IV antibiotics Rx: closed reduction, ulnar gutter splint for 2-3 wk if stable,

Palmo-plantar psoriasis

-Confined to the hands and feet -Sterile pustules that fade to leave brown pinpoint lesions -Pain in affected areas -More common in smokers Rx -top steroids - smol -coal tar 20% , 40% added w/ salicylic acid -diathranol -Vit D analogues ( Calcipitiol)

nappy dermatitis 1B

-Due to infrequent changing of nappies -Leads to faecal or urea irritating the skin and predisposing to infection - Ammonia dermatitis - most common, red desquamating rash, spares the skin folds, due to retention of moisture - RX frequent nappy changing, nappy-free periods, drying, emollients (zinc oxide cream) -Candida/thrush - 50% of nappy rash, satellite lesions, flexural sparing? - RX clotrimazole, 1% hydrocortisone cream - if you try to scrape the patch off it bleeds - pathognomonic -Seborrhoeic dermatitis - diffuse, red, shiny rash extending into the skin folds, occipital rash (cradle cap) - RX frequent nappy changing, nappy-free periods, drying, emollients (zinc oxide cream) -Isolated psoriasis-like plaques - rare, hard to treat -Atopic eczema -Granuloma gluteale infantum: red or purple nodules -Impetigo (Staphylococcus aureus and/or Streptococcus pyogenes): irregular blisters and pustules.

Contact Dermatitis 1B

-Inflammation of the skin due to contact with an exogenous chemical Can be allergic or irritant - allergic is type 4 hypersensitivity has sensitisation stage and an elicitation stage Rhus dermatitis (Posion ivy, sumac, oak) reactions to cashew trees, mango trees, Japanese lacquer trees, and ginkgo shoe dermatitis: Mercaptobenzothiazole rubber used in shoes metal dermatitis: nickle, jewellery, gold Clinically- eyrthematous based vesicles in linear fashion, Tx: steroids, topical steroids, antihistamines

Cauda Equina Syndrome 2B

-Injury at the L1 level and below resulting in a LMN lesion -Flaccid paralysis w/no spinal reflex activity o radiculopathy syndrome affecting both legs, perineum and bladder/bowel function i.e urinary incontinence or retention, saddle anasthesia, erectile dysfunction, lax anal sphincter tine o Due to subtotal/total occlusion of the spinal canal - abductor pollicis longus pulls MC shaft proximally and radially causing adduction of thumb treat with percutaneous pinning, thumb spica x 6 wk

Psoriasis Vulgaris, chronic plaque psoriasis

-Involves pink-red scaly, well-demarcated plaques affecting extensor surfaces with silver scale Typical areas of elbows, knees, scalp, nails, usually sparing palms and soles and face. Can be small papules to large plaques, chronic and recurrent course

Pemphigus Vulgaris 1B

-Lethal Autoimmune, intra epidermal Blistering and erosion of skin and mucous membranes -most common inside mouth -common in >50, jewsm indians -Can occur secondary to captopril or penicillamine IgG complement antibodies against the cell attachments (desmosomes) desmoglein 3 --> keratinocytes separate from each other, and are replaced by fluid, the blister Blisters on trunk, abdomen, extremities, Oral erosions , face, scalp Ix: biopsy (separetd keratinocytes), Tx: Steroids, cyclophosphamide , dapsone, azothioprine, IV IG, rituximab

Basal Cell Carcinoma (BCC) 1B

-Low grade malignancy developing from the basal layer of the epidermis , related to sun exposure, locally aggressive but rarely metastasizes telangiectactic papule/ulcer" - shiny pearly dome-shaped nodule with smooth surface blood vessels across surface central depression/ulceration if older tumour Superficial and nodular - RF: common in elderly males, sun damage, fitzpatrick I -Ix: biopsy -rx:excision, cryo, photodynamic therapy, imiquimoid cream, Fluorouracil cream, radiotherapy

androgenic alopecia 1A

-Male pattern baldness - due to androgens and genetic predisposition -Abdominal sensitivity of hair follicles to androgens -Leads to frontal recession and then thinning of the crown -Family history is positive -RX minoxidil

Trigger Finger 1B

-Stenosing tenosynovitis -repeate trauma to palm --> thickening of flexor tendon to fingers --> cant run freely in & out narrow mouth of tunnels --> causes fingers to jam and flex with click and cannot extend until helped - S&S: *painless nodule in flexor tendon* Dx: clinical Tx: - activity mod., splinting, NSAIDs -steroid injection into tendon sheath -surgical release

VASCULITIS: POLYARTERITIS NODOSA 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

-Systemic necrotising vasculitis affecting small and medium sized muscular arteries. - leads to formation of aneurysms >M, >20-40., Renal disease 70% cases. associated with Hep B. Angiography may show saccular or fusiform aneurysms and arterial stenoses - common in middle aged men S&S MAINLY vasculitic oic with no pulmonary involvement Livedo reticularis, ulceration, bullae, vesicles, purpura and skin infarction Fever prolonged myalgia Abdominal pain , weight loss HAematuria Purpura weight loss Proteinuria Parasthesia Pericarditis Purpura Coronary arteritis jaundice testicular pain haematuria and renal failure IX - Raised ESR and CRP - FBC: Thrombocytosis - U&Es: Raised creatinine in renal ischaemia - Raised LFTs - Conventional digital subtraction angiography Rx - Oral corticosteroids - Azathioprine, cyclophosphamide

TRANSIENT SYNOVITIS 1A

-Transient synovitis is a self-limiting inflammatory disorder of the hip that commonly affects young children. -dz in kids 2-12 esp boys -secondary to a viral upper respiratory tract infection. FEATURES: - presnt w/ mild to moderate hip pain and limp., limited movement -Able to weight bear -positive log roll -Rx: NSAIDs complicaion: destruction of femur head

Lipomas 1A

-a benign, slow-growing fatty tumor located between the skin and the subcutaneous layer - more common in women features: smooth, soft eggshaped lump, mobile. rubbery with dough consistency. usually painless until become angiolipoma--> gained BV common in : neck, shoulders, trunk and arms -skin moves over lipoma vs sebacious cyst Ix: skin biopsy exc. liposarcoma ( vrare) >5CM have to do an uss Rx: none, surgical excision, liposuction

needlestick injury

-accidental puncture wound caused by a used hypodermic needle, potentially transmitting an infection. -encourage bleeding and hold under water -wash wound with soap and water dry and cover -report to Occupational health -Ix: bloods for Hep B, C, HIV, CMV, EBV Rx: Abx, vaccinatiopn, PEP HIV, councelling HIV: PEP can be started up to 72 hrs later . antiretrovirals for 4 weeks, then blood test HEP A: Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation HEP B: booster if they respond to vaccine and HBIG HEP C: monthly PCR interferon +/- ribavirin

POLYMYOSITIS (def 2B

-autoimmune inflammatory dz affecting muscle - Common after 20s an din women -- Associated with non-Hodgkin's lymphoma, RA, IBD, breast, lung, ovary and colon cancer - Involves T cell and monocyte infiltration of muscle fibres leading to muscle fibre necrosis, degeneration and eventual phagocytosis - Rarely seen in children 10-14

FIBROMYALGIA 2B

-chronic dz of unknown cause - characterised by widespread pain throughout the body with tender points at specific anatomical sites -lethargy, sleep disturbance, headaches, mental cloudiness, pain/aching muscle stiffness, fatigue , poor sleep & other somatic symptoms - pain in 11/18 points - - more common in women 30-50 years -Ix: clinical dx -Rx: exercise, local heat, stress management, sleep medication amitriptyline, cyclobenzapine, duloxetine

Cat bite 1A

-common in children and female adults , most are provoked - result in scratches or deep puncture wounds. -prophylactically tx with a five day course of amoxicillin/clavulante. Worse than dog bites. Infections Pasteurella multocida (up to 75%). Staphylococcus aureus (20%) Streptococcus pyogenes Various anaerobes. Bartonella henselae,: the causative agent of catscratch disease , can also be transmitted via a bite from an infected cat. rx wounds should be irrigated, debrided, incised and drained as required. cultures prophylactic abx : 1. Amoxicillin clavulanate 2. erythromycin, and clindamycin. hospital if fever, swollen lymph nodes, cellulitis

L5 radiculopathy

-compression of the L5 nerve root commonly due to vertebral disc herniation or spinal formaninal stenosis. Features 1. back pain radiating down the leg with sensory loss over the buttocks, lateral thigh and calf, and dorsal foot. 2. There also may be weakness of foot dorsiflexion, inversion, eversion, and toe extension.

PSORIATIC ARTHROPATHY NOM

-correlates poorly with cutaneous psoriasis and often precedes the development of skin lesions - Around 10-20% percent of patients with skin lesions develop an arthropathy with males and females being equally affected Types: - rheumatoid-like polyarthritis: (30-40%, most common type) - asymmetrical oligoarthritis: typically affects hands and feet (20-30%) - sacroilitis - DIP joint disease (10%) - arthritis mutilans (severe deformity fingers/hand, 'telescoping fingers') X-Ray: pencil-in-cup deformity (due to periarticular erosions and bone resorption) and plantar spur

meniscal cyst

-degenerative cyst common in middle age and elderly -ass/w meniscal tears -evident on knee extension

Venous stasis dermatitis 1B

-dermatitis that results from: venous HTN, edema, chronic inflamm and microangiopathy - Venous incompetence leads to increased hydrostatic pressure with capillary damage and extravasation of fluid - Seen in elderly people with a history of venous disease, thrombosis and varicose surgery -Features: bilat involvment, commonly above medial malleolus. -Itchy red, blistered and crusted plaques; or dry fissured and scaly plaques on one or both lower legs, brown pigmentation due to haemosiderin depositin - no fever or leukocytosis, Rx: - dont stand for long, leg raise , regular walks -compression stockings longterm -Dry up oozing patches with Condy's solution (potassium permanganate) -PO Abx -flucoxacillin for secondary infection --> impetiginisation w. s aureus and cellulitis common - moisturising creams

Patella #

-direct blow to patella , fall MVC indirect trauma by sudden flexion aaonst contracted quads -ss: tenderness, unable to extend knee, cant straight leg , deformity, -/+ effusion

medial ligaments of the ankle tear

-eversion injury -avulses medial or posterior malleolus and strains syndenosis

Genu valgum (knock knees)

-femoratibial angular deformity in which the knees touch but the ankles do not. -normal up to age 9 -can cause OA if not treated , more prone to injuries too aex: normal, Vit D&C deficiency , RA, OA, obesity Ix: X-ray Rx: surgery at age 10

Clavicle fracture 1B

-incidence: proximal (5%), middle (80%), or distal (15%) third of clavicle • common in children (unites rapidly without complications) -due to fall on shoulder or direct trauma -S/S: pain and tenting of skin, arm clasped to stop , movement , pain radiates to nect, tender swollen AC joint , limited ROM -document pulses -Ix: Xray, CT, crossover test complication : Medial 1/3 fracture may have complication of subclavian artery or intrathoracic injury. brachial plexus nerve damage Rx - middle and lateral third fractures- broad arm sling for 2 weeks - medial 3rd: orthopaedics assessment

septic arthritis

-inflammation of the joint caused by infection - common after joint surgery, DM, hip/knee prsthesis, Immudofe. - Aex: S.aureus, esp. MRSA - ss: single swolllen joint with pain on movement, fever rigors, unwillingness to move in kids signs: swollen, warm , tender, effusion Ix: FBC, cultures, synovial fluid examination (culture) , synovial tissue culture, PCR, USS< CT, MRI. Rx: Abx: flucox, meticillin,

ACNE VULGARIS 1A

-inflammation of the pilosebaceous glands, i-nvolves hyperkeratinisation of hair follicle --> creates keratin plug ( microcomedone). -secretion of sebum by adrogenic hormones --> proliferation of P.acnes in sebum rich environment of plugged hair follicle --> inflammation --> papules and pustule - creates open commedines ( blackheads- central dark keratin plug ) or closed commedones ( white heads) - common in puberty esp females Apperance: open or closed comedones, inflammatory papules, pustules, cysts, scarring Rx -Regular washing and acne soaps -Extraction of comedones -Intra-cystic steroid injection, excision and cryotherapy -Local: benzoyl peroxide, topical tretinoin (0.01 to 0.1%), topical clindamycin, topical azelaic acid, isotretinoin and adapalene, or add TOP clindamycin, erythromycin -Systemic - oxytetracycline, lymecycline, doxycycline, erythromycin and trimethoprim - Ovranette in females Retinoids monitor LFTs and lipids tetragenic SE: cracked, dry skin, epistaxis, hair loss, myalgia, mood changes

Osgood-Schlatter disease 1A

-inflammation or irritation of the tibia at its point of attachment with the patellar tendon - self-limiting -common in adolescents during growth spurt 12-15 (8 in girls) -ss: gradual pain and swelling below knee relieved by rest worse on activity Ix Hip examination is important because some childhood hip conditions (eg, slipped capital femoral epiphysis) can refer pain to the knee., X-ray rx: NSAIDS, steroid injection, advice on exercise first , physio,

Folliculitis 1A

-inflammatory hair follicle dz due to bacterial infection. occurs on all hair bearing sites. Features: -erythematous papules or pustules around hair follicles. -pustules and papules can coalesce ino large painful carbuncles and furncles Aex: Most common form Staph folliculitis by S.aureus. soometimes psedomonas -eosinophilic tye in diabetics , HIV and immunocompromised other causes: fungis, VZV, mechanical ( hair pulling back , razors, chronic friction), 3. Path: infection with s.aureus --> infiltration w/ inflammatory cells --> large abcess 4: Ix: Tissue culture for organism, HSV1 &2 and VZV DFAA, skin biopsy 5: antiseptic( triclosan, benzalkonium chloride, chlorhexidine, and bleach bath ), sodium fusidate, flucloxacillin, cefalaxin.

Dupuytren contracture/disiease 1B

-inherited progressive dz that results in contracture of the palmar fascia of the hand or foot. commonly bilateral . -Contracture causes flexion of the MPJ and PIPJ. -Begins as a pit or nodule in palm, spreads distally into the fingers -commonly affects little finger -common in european men >40 that drink alcohol - Trauma might trigger the predisposed individual - Prevalence higher in diabetics and epileptics o Little and ring fingers most severely involved. -positive hueston table-top test -Feet - plantar fascia nodule Peyronies' disease - penis If in younger age group Both hands involved Ix: clinial/ USS Rx -Treatment: surgical referral if hand cannot be flat on the surface Complications: o Recurrence o Extension to other parts of hand o Maceration if left untreated o If neurovascular bundle damaged surgically - numbness or cold intolerance

OSTEOMALACIA/ RICKETS 1B (NONM)

-lack of bone mineralisation due to vitamin D deficiency resulting in deformed, fragile, pliable bones which fracture easily . -Can lead to *secondary hyperparathyroidism* -Rickets is a disorder of the growing skeleton due to inadequate mineralisation of bone as it is laid down at epiphyseal growth plates - it leads to widening at the ends of the long bones which can lead to bowing AEx; : CDP - Exclusive breastfeeding for 12 months - Calcium deficiency - Vitamin D deficiency - dietary, sunlight, malabsorption, genet i- Phosphate deficiency - renal tubular loss of phosphate, Fanconi syndrome, renal tubular acidosis, nephrotoxic drugs 3/4. S&S - Bone pain and aching - Weakness ( muscle ?) & Fractures - Waddling gait - Bowed legs (varus deformity) -knock knee - Growth delay - Swollen wrists 5. Ix Bloods: - Phosphate, calcium, Vit D low -PTH raised secondary hyperparathyroidism - Raised bone-specific ALP - Biopsy may show demineralised bone - X-ray and wrist X-ray - generalised osteopenia, cupping and fraying at metaphyses (in rickets), bowing Rx calcium and vitamin D

Scoliosis 1B

-lateral curvature of spine with vertebral rotation -common in 10-16 -more frequent and severe in women -can co-occur with kyphosis aex: idiopathic, congenital, UMN or LMN lesion, myopathy ss: back pain, curve where spine is affected, asymmetrical shoulder height -adams test : rib hump when bending over prominent scapulae, creased flank, asymmetric pelvi associated pes cavus or leg atrophy# Ix: spine xray Rx: bracing, surgery - spinal fusion

ANTERIOR CRUCIATE LlGAMENT TEAR

-most common tear - Ligament tear is a sprain - indirect varus blow to knee - hyperextension of the knee + tilt mal rotation - audible pop, knee instability, "giving way" - immediate swelling - inability to continue activity Physical o posterolateral joint line tenderness o positive Lachman, anterior drawer o effusion. +/- haemarthrosis o +/- associated medial meniscus tear, MCL injury (O'Donahue's Unhappy Triad) o Special tests Anterior drawer sign Positive Lachman's test - more sensitive and specific Diagnosis: o X-ray - may be associated with avulsion fracture of anterior tibial tubercle o Clinical diagnosis best confirmed with MRI Treatment: o based on activity and functional impairment o stable with minimal functional impairment early mobilization physio and quadriceps strengthening o instability with functional impairment / high demand Iifestyle ACL reconstruction

WHAT IS ERYTHEMA AB IGNE

-mottled (splotchy) skin in area that is habitually exposed to heat (IR) radiation -classified as a 2nd degree burn -WILL show up where pt have been using hot water bottles or exposing skin to heat ( sitting next to open fire) - can cause SCC

Slipped Capital Femoral Epiphysis 1B

-occurs when the head of the femur becomes displaced due to a separation at the growth plate -• type I Salter-Harris epiphyseal injury at proximal hip -most common adolescent hip disorder, peak incidence at pubertal growth spurt - risk factors: male, obese (#1 factor), hypothyroid (risk of bilateral involvement) -Aex: genetic, sex hormone secretion that stabilised physis not releases, overweight, trauma SS: severe acute hip pain with limp, chronic: geoin pain and ant. thigh pain -positive trendelenberg sign - resttricted d internal rotation, abduction, flexion - Whitman's sign: obligatory external rotation during passive flexion of hip Ix: x-ray : posterior and medial slip of epiphysis, disruption kleins line Rx: ORIF if severe, stabilisation Complications • AVN (roughly half of unstable hips), chondrolysis (loss of articular cartilage, resulting in narrowing of joint space), pin penetration, premature OA, loss of ROM

Dyshidrotic Eczema 2B

-relapsing remitting vesicular eruption of palsm and soles, very pruritic - exacerbated by frequent hand washing, hyperhidrosis (excessive sweating), and stress

Biceps tendonitis Tx

-rest, ice, sling, NSAIDs, steroid injection-not into tendon sheath

cuff arthropathy

-result of chronic rotator cuff tear - rotator cuff supports head --> failure ---> drift of ulnar superiorly -synovial fluid can also escape the capsule resulting in destruction of joint surfaces progressing to arthritis - features: pain and weakness of rotator cuff

Osteoarthritis and RA in shoulder joint

-results in pain and ROM i.e cant undo bra, wipe bottoms,

Charcot arthropathy

-syndrome in patients who have neuropathy or loss of sensation. It includes fractures and dislocations of bones and joints that occur with minimal or no known trauma - common in poorly controlled diabetes - bone remodelling seen on xray swelling, redness and increased warmth of the foot and ankle

Non-accidental trauma/ child abuse

-the wide-ranging effects of maltreatment on the child's ongoing physical and emotional development - common in under 5 YOs -risk factors: unplanned preg, step kids, disabilities, first born, premature, single parent, uneployed, drug abuse, abuse as a child. signs: injury incosistent with injury, delay in seeking care, long bone structure in nonmobile child. - coexisting injuries -rib fractres, scapula fractures, bucket handle fractures , shearing strain, Abuse head trauma: subdural haemorrhage in <1, head injury no explanation of trauma, bruising of head, neck, retinal haemorrhage bits: >3cm more likely to be from an adult, bites on breast and neck in kids burns: scalds usually on lower extremeties, buttock or perineum Ix: forensic dental exam for bites, swabs, FBC, fundoscopy, photo of injuries, CT brain, LFTs, amylase

Colles Fracture 1A

-• extra-articular transverse distal radius fracture (~2 cm proximal to the radiocarpal joint) with dorsal displacement ± ulnar styloid fracture -FOOSH -common in >40 esp women w/ osteoporosis -obesity -compaction -dinner fork deformity Elderly person, fall on an outstretched hand** S/S: -swelling, tenderness and contusion over distal radius/ulna - appearance often called a "silverfork" deformity* Dx: -x-ray, distal radius fracture with dorsal angulation* Tx: -closed reduction and full cast + immmobilisation 6-8 wks -cast extends from below the elbow to the metacarpal heads - if intra-articular or comminuted fx = requires surgery complications: median nerve at risk of compression

Necrotising fasciitis

-• rapidly spreading, very painful infection of the fascia with necrosis of surrounding tissues -• infection spreads rapidly along deep fascial plane and is limb and life threatening - well at first then becomes very sick/toxic -b-hemolytic Streptococcus -usually lower leg -within 24hrs of minor injury -pathogens- mixed features -pain out of proportion w/ clinical finding -oedema, tenderness, blistering, ecchymoses, -flu-like illness later: fever, malaise, nausea -late findings : blue black skin, formation of bullae, gangrene - some gases show on x-ray produced by bacteria Investigation - surgical exploration and tissue biopsy -presense of fascial necrosis and mynecrosis, loss of ofascial integrity -finger sweep test -raised CRP -USS - Treatment Rx: ABC,urgent surgical debridement, IV abx Empirically: surgically debride THEN IV meropenem + clindamycin + vancomycin If swabbed and strep --> Benpen + clindamycin IV If swabbed and clostridium perfrigens --> IV Benpen

capal tunnerl pic

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ulnar nerve anatomy

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1. Tinea pedis (athletes foot) 1A

. 1. A ringworm fungus of the foot (athlete's foot) Occurs in the toe clefts due to dermatophyte fungus : Trichophyton (T.) rubrum, T. interdigitale. Rubrum most comon b. Patterns of T. pedis i. Mocassin tinea pedis - involves whole foot ii. Interdigital tinea pedis - toe web spaces iii. Bullous tinea pedis - painful blisters 2. common in males, adolescents 3. Aex: occluive footwear, excessive sweating, DM, HIV 4. features: itchy scaly erosions between the toes Fungal nail infection may also occur 5.Rx 1. topical antifungals : azoles, allylamines, butenafine, ciclopirox, and tolnaftate 2. PO antifungals if no response to topicals : Terbinafine Itraconazole Fluconazole Griseofulvin

Scarlet Fever nom

. aka: scarlatina- NOTIFIABLE B. Etiology: pyrogenic exotoxin of Streptococcus pyogenes C. Clinical findings: 1. Incubation period 2-4 days 2. Prodrome of pharyngitis, fever, nausea, emesis, headache and abdominal pain 1-2 days *BEFORE* to rash- sandpaper like, neck and trunk 3. Sand paper-like maculopapular rash starting on the neck and spreads to the trunk. Linear petichiae (pastia's lines)occur on antecubtal fossae. Strawberry tongue (white tongue with enlarged and red papillae). Rash is followed by heavy desquamation 4-8 weeks later. Ix -throat swab D. Treatment: Penicillin, erythromycin

C8 Radiculopathy presentation

.-Weak flexion of fingers - paresthesia of ulnar border of wrist and forearm

causes of meningitis in neonates

0 - 3 months Group B Streptococcus (most common cause in neonates) E. coli Listeria monocytogenes

General Rules for Steriod use

1) Do not use class I or II on face or intertriginous areas (axilla, groin, inframammary) 2) Do not use class I II or III on children, especially age 2 or younger 3) Apply BID in all cases no benefit to more frequent applications 4) Give a 2 week trail and re-evaluate (if clear do not stop wean to lower strength or q a day application for an additional week) If not improved check compliance and increase strength 5) Do not use steroid/anti-fungal combinations 6) Do not use ultrapotent steroid longer than 2 weeks (ultravate, Temovate) 7) Never give refills of mid or high potency steroids

drugs associated with psoriasis

1) Lithium 2) Beta Blockers 3) Antimalarials - Plaquenil 4) Systemic Steroids

What are thecommon infective agents in osteomyelitis 1A

1) S. aureus - most common 2) N. gonorrhoeae - sexually active young adults 3) Salmonella - sickle cell disease 4) Pseudomonas - diabetics or IV drug abuse 5) Pasteurella - dog or cat bite/scratch 6) TB - Pott disease of the vertebra

PSORIASIS Rx as per NICE

1. 1st line Topical steroids mild (Hydrocortisone) or moderate (Betnovate-RD/Eumovate) 2. Offer second- or third-line treatment options (phototherapy or systemic therapy) at the same time in extensive disease >10% affected and nail disease 3. r/v in 4 weeks after nre treatment, 2 weeks in kids 4. Trunk and limbs: potent steroid (betamethasone dip-, fluticasone, ) + Vitamin D ( OD if no better than BD) r or a coal tar preparation applied once or twice daily 5. very potent steroid Face and flexure, geitals - short term mild or mderate potency steroid OD or BD - areas rticularly vulnerable to steroid atrophy and that corticosteroids should only be used for short-term treatment of psoriasis (1-2 weeks per month). UVB for guttate or plaque psoriasis

Acne Keloidalis

1. A chronic scarring folliculitis of the posterior scalp, commonly seen in African-American males 2. Starts as a folliculitis and then developed indurated papules that become keloids. This can progress to very large keloids in predisposed individuals 3. Treatment is with antibiotics, intralesional steroids, and surgical excision People prone to thickened collagen

Varicella Chicken Pox 1A

1. A highly contagious viral desease, caused by varicella-zoster virus 2. Usually in children prior to puberty; more serious in adults 3. March, April, May most common 4. Contagious 2 days prior to rash and until the last lesion is crusted 5. Vaccine now available 6. Incubation period 14 days, prodrome of fever, malaise, headache 1. Lesions begin on the trunk and scalp and spread to the extremities (centrifugal spread) and are a thin walled vesicle with an erythematous base "dew drop on a rose petal" 2. Lesions begin to crust by day 4, but is common to see new and crusted lesions together 3. Fever can be as high as 105 C 4. Oral and mucosal lesions are common 5. Lesions can be very pruritic, but heal without scarring Rx 1. Antipruritic lotions (Sarna, menthol), antihistamines, antibiotics (for secondary infection) 2. Acyclovir will decrease time of disease by 1 day and cut down the number of lesions by 30%. Persons to be treated are adults and immunocompromised 3. Varicella Zoster immune globulin (VZIG) for acutely ill immunocompromised, newborns, premature infants, pregnant women 4. Varicella immunization - most pediatricians recommend, still some controversy

Leukocytoclastic vasculitis

1. A hypersensitivity reaction with the development of small purpuric papules (palpable purpura) in crops that last for 1-4 weeks 2. Etiology: Drugs, infection, connective tissue disease 3. Internal involvement: Kidneys (hematuria), nervous system (peripheral neuropathy), GI (abdominal pain), Lung, joints (pain), heart (arrhythmias)

Meningococcal septicemia

1. A potentially fatal (6-10%) infection with Neisseria meningitidis 2. Systemic invasion form nasopharynx leads to bacteremia with subsequent CNS invasion 3/4: presents with purpuric rash 3. Rx IM benzylpenicillin immediately hospital

Herpes Zoster (shingles) 1A

1. A reactivation of varicella-zoster virus (chicken pox), occurring in 10-20% of the population 2. Lesions are erythematous based, tender vesicles that involve a whole nerve dermatome 3. Reactivation of the varicella-zoster virus may be due to age, emotional stress, immunosuppressive drugs, CA, illness, and radiation therapy 4. A patient with an active outbreak of herpes zoster could cause a close contact to develop chicken pox, if not previously immune 5. Ix clinical 6. Rx -aciclovir 800mg 5x daily - treat ASAP to prevent herpetic neuralgia

patterns of Lichen Planus

1. Actinic - sun-exposed areas 2. Annular - trunk, external genitalia 3. Atrophic - any area 4. Erosioulcerative - soles of feet, mouth 5. Follicular (lichen plano pilaris) - scalp 6. Guttate (numerous small papules) - trunk 7. Hypertrophic - lower limbs (especially ankles) 8. Linear - zosteriform (leg), scratched area 9. Nail disease - fingernails 10. Papular (localized) - flexor surface (wrists and forearms) 11. Vesiculobuilous - lower limbs, mouth

Acute Uritcaria 1B

1. Acute Urticaria - intense pruritic transient wheals due to acute dermal oedema or angio-oedema -A type 1 hypersensitivity reaction with cross-linkage of IgE on the mast cell membrane leading to leaky capillaries and oedema Aetx - Stinging nettles - Infection - Drug reactions - Food allergy - Physical stimuli - Latex - Autoimmune disease Physical urticaria - Cold - Pressure - Cholinergic (stress or heat) - Solar - Aquagenic - Contact Rx b. A detailed history is usually helpful, labs not necessary -Treat with antihistamines -avoid causes

Erysipeloid

1. Acute skin infection with Erysipelothrix rhusiopathiae (sporulating gram positive rod) 2. Etiology - organism comes from contaminated animals or animal products (fisherman, butchers, farmers, veterinarians) Tx:1. Penicillins, cephalosporins, erythromycin, and clindamycin 2. Can be a self limited course and can have recurrence up to 6 months later due to L. form conversion of the bacteria (loses cell wall)

Lichen Striatus

1. An uncommon, unilateral and linear eruption of erythematous, flat topped and scaly papules that may extend the length of a limb 2. Age of onset 3-14 years, Females > males Etiology: unknown Tx: 1. Spontaneous involution occurs by 9 months duration 2. Topical and intralesional steroids

Treatment of Urticaria

1. Antihistamines: block histamine receptor sites on the cell surface therefore preventing vasodilation, pruritus b. Side effects: Anticholinergic (dry mouth, blurred vision, constipation), CNS sedation in adults, stimulation in children (sedation effect becomes suppressed with long term use) c. H1 antihistamines are used primarily for skin, whereas H2 blockers are more for gastric acid hypersecretion First Generation: Chlorpheniaramine maleate (Chlor-trimeton) Hydroxyzine Hydrochloride (Atarax) Diphenhydramine hydropchloride (Benadyrl)

Steven Johnson Syndrome: def 1B

1. Bullous disease of the skin and mucosa occurring in children & young adults - Mortality is up to 10% 2. 3. Clinically: URI type prodromal symptoms, followed by *flat purpuric tender macules that become bullae.* start on trunk then on face and limbs. lesions can be targetoid, or blisters flaccid ( not tense) -characterised by erythroderma loss >90% skin other: crusted lips, painful mouth ulcers, diarrhoea, URTI AEx Drugs- 3Ps 2s ▪Penicillin , phenobarbital, phenytoin ▪sulfasalazine Ix5.. -skin biopsy, exclude SSS histopathology: keratinocyte necrosis bloods: anaemia, leucopaenia, eosinophilia, proteinuria (mild) Rx 1 . intesive care, topical steroids, antihistamins, withdraw all drugs, Abx, Iv Ig ciclosporin 2. analgesia

RADIAL NERVE

1. C5-8 2. extension of wrist and fingers 3. Humeral midshaft fracture 4. Palsy results in wrist drop

MEDIAN NERVE

1. C6,8, T1 2. LOAF muscles LOAF muscles Lateral two lumbricals Opponens pollis Abductor pollis brevis Flexor pollis brevis 3. Injury/compression: carpal tunne

Treatment of Chancroid

1. Ceftriaxone 2. Azithromycin 3. Erythromycin 4. Augmentin 5. Cipro

Sycosis Barbae

1. Deep bacterial (and occasionally fugal) folliculitis in male beards 2. Treatment with oral antibiotics, after bacterial and fungal culture done

Treatment of Lyphgranuloma Venerum

1. Doxycycline 2. Erythromycin 3. Sulfisoxazole

Treatment of Granuloma Inguinale (donovanosis )

1. Doxycycline 2. Erythromycin 3. Tetracycline 4. Bactrim

Furuncles / Carbuncles

1. Furuncle - a walled off, painful, firm, fluctuent collection of puswith single opening 2. Carbuncle - an aggregate of furuncles, multiple openings 3. Etiology - Staph aureus, most common cause Clinically 1. Occurs in areas prone to friction (buttocks, groin, axillae) 2. Chronic furunculosis is a chronic and recurrent disease in which patients continue to form multiple furuncles due to nasal carriage of Staph aureus 3. Immune defects may predispose some patients Treatment: 1. Warm compresses 2. Incision and drainage / intralesional steroids 3. Oral antibiotics (anti Staph aureus - pcn, cephalosporins) after appropriate culture 4. Topcal bactroban (mupirocin) is applied to the anterior nares BIDfor 5-7 days to try to decrease carriage rate

Angioedema

1. General Info a. Subcutaneous, painful nonpruritic, hive-like swelling usually involving the head and neck, palms, soles, trunk, and genitalia b. Gastrointestinal and respiratory involvement leads to dysphagia and dyspnea

Erythema Multiforme 1B

1. General: a. An acute inflammatory disease characterized by targetoid "iris" erythematous papules, plaques and bullae with central clearing - The lesions are first seen on the backs of hands and/or tops of feet, and then spread along the limbs towards the trunk. -hypersensitivity rxn triggered by infection usually HSV 2. Etiology: Viral Infections (herpes simplex usually ) - mycoplasma pneumoniae - connective tissue disease, pregnancy, malignancy, - Mycoplasma pneumonia, herpes simplex, penicillin, sulphonamides, phenytoin, carbamazepine 3. Clinically: Lesions are itchy, burning, painful and heal in 4 weeks cann affect mouth, anus, genitals, GI tract Ix -CXR, biopsy 4. Treatment: - If mild, no treatment. (self-limiting ) -> does not progress -Prednisone, acyclovir (herpes associated EM), dapsone, azathioprine -antiseptic mouthwash , anasthetics - opthlamology if eye involvement

Toxic Epidermal Necrolysis (Lyell's syndrome) thought to be same as SJS 1B

1. General: Mucocutaneous drug reaction pattern with skin and mucosal tenderness, erythema, followed by extensive cutaneous and mucosal exfoliation <10% more likely to be SJS but TEN if >10% -SCORTEN scoring system 2. Etiology: 80% medication; chemicals, Mycoplasma pneumonia, viral infections, immunization (Sulfa drugs allopurinol, hydantoins, carbamazepine, phenylbutazone piroxicam, chlormezanone, amithiozone, aminopenicillins) -common drugs: penicillins, allopurinol, phenytoin, NSAIDs, carbamazepine, sulphonamides , cephalosporins, tetracyclines. 3. Sings/symptoms - Flu-like ssymptoms -fever - painful skin- burning sensation - erythema progressing to widespread subepidermal blistering which rupture easily -mucosal involvement ( 4. Mortality is 35-40%, sepsis as usual cause of death Ix: skin biopsy, excluse SSS histopathology: keratinocyte necrosis bloods: anaemia, leucopaenia, eosinophilia, proteinuria (mild) 5. Treatment: - refer to Burn unit/ICU to be managed like a burn, -stop drug -plasmaphoresis -fluid and electrolyte management. -Steroids controversial -stop offending drugs regulate temperature -pain management

Erythema Nodusum

1. General: an acute inflammatory/immunologic reaction of the subcutaneous fat characterized by painful, tender red nodules on the legs 2. Epidemiology: Ages 15 to 30 years; females > males 3. Etiology: a. Infections - Streptococci, Upper respiratory infection, Tuberculosis, Psittacosis, Yersiniosis, Lymphogranuloma venereum, Cat-scratch disease, Coccidioidomycosis b. Drugs - Oral contraceptives, Sulfonamides, Bromides c. Systemic illnesses - Sarcoidosis, Inflammatory bowel disease, Hodgkin's disease d. Pregnancy 4. Constitutional symptoms: Fever, malaise arthralgia (50%) 5. Labs: Throat culture, ASO titer, CXR 6. Treatment: Self limited, potassium iodide, Salicylates, Prednisone

Herpes Simples HSV-1 HSV2

1. HSV1 (usually oral infections) & HSV2 (usually genital infections) 2. Can commonly be an asymptomatic infection 3. Transmission is by contact or airborne 4. Clinically: 3-7 days after exposure, tenderness, pain, parasthesias develop as prodrome. May be associated with headache, myalgias, fever and lymphadenopathy. Next, grouped vesicles develop on an erythematous base 5. Lesions develop into cloudy pustules and then crust over in 5-10 days. 6. HSV then enters nerve endings and becomes latent within the dorsal root ganglia 7. Recurrences due to trauma, UV light, menses, illness, stress; usually occur 2-3 times per year; if greater than 6 times per year, prophylactic therapy should be undertaken tx: Acyclovir (Zovirax), Valciclovir (Valtrex), Famciclovir (Famvir)

Ramsey Hunt's Syndrome

1. Herpes zoster of the geniculate ganglion 2. Triad of facial nerve paralysis, vesicles in or on the pinna, and deafness

Herpes zoster opthalmicus

1. Herpes zoster of the opthalmic division of the trigeminal nerve 2. Vesicles involving the tip or side of the nose, due to nasociliary nerve branch involvement is known as Hutchinson's sign 3. This is an ocular emergency due to anterior uveitis and should be seen by Opthalmologist

OBTURATOR NERVE

1. L2-L4, HIP ADDUCTION

SUPERIOR GLUTEAL

1. L4-S1, HIP ABDUCTION 2. Positive trendelenberg in injury DAMAGE Misplaced intramuscular injection Hip surgery Pelvic fracture Posterior hip dislocation

Pseudofolliculitis Barbae

1. Mechanical irritation due to foreign body reaction of hairs "ingrowing" after shaving 2. Typically seen in individuals with curly hair who like a close slave 3. Treatment is to dislodge the ingrown hair, antibiotics, and moisturizing shave gels to soften hair prior to shaving, can also use lasors

spinal stenosis 2B

1. Narrowing of spinal canal causing nerve compression. degenerative, manual labour, >40. 2. Degeneratiive, slipped disc , bone dz, tumour Clinical presentation: Lumbar (75%) : back pain aggaravated by standing relieved by sitting , scieatica, numbness, tingling, ache in buttocks/legs , foot drop. incontinence. neurologic cludication Cervical: neck pain, weakness, paralysis Thoracic: rare o Examination often unremarkable with lack of clinical findings o Often hyporeflexia

Chancroid

1. Organism: Gram meg rod, H. ducreyi MALES!! Incubation 3-5 days Presentation: PAINFUL!! - ulcer with painful lymphadenopathy LABS: Show "School of Fish"

Malignant External Otitis

1. Overgrowth of Pseudomomas aeruginosa in chronic external otitis, mainly in diabetics, with extension to the skull base 2. Clinically: painful, swollen ear, worse at night, with a purulent drainage 3. Treatment: Cipro by mouth for 6 weeks - 6 months

Pseudomomas Celulitis

1. Overgrowth of Pseudomomas aeruginosa in compromised areas, i.e. toe webs, groin, foreskin 2. Clinically: painful, dusky red, ulcerated lesions giving a fruity or mousy odor 3. Treatment: Acetic acid soaks, Cipro by mouth

Dermis

1. Papillary Dermis - haphazardly arranged collagen papillary tips contain vascular and nerve supply 2. Reticular Dermis

Complications of Zoster

1. Post herpetic neuralgia (PHN) a. Pain at the site of Herpes zoster eruption that persists months or years after it has healed b. Pain can be sharp and severe in nature c. Older patients more likely to get PHN 2. Disseminated Herpes zoster - occurs in immunocompromised patients and can be fatal 3. Motor paresis can occur, and is usually temporary 4. Encephalitis - is rare, but can occur especially in immuno- compromised patients

Ecthyma Gangrenosum

1. Pseudomomas aeruginosa infection of the skin from a blood-borne, metastatic, or primary lesion 2. Rare disease, but mortality can occur 3. Associated with immunocompromised patients (Cancer, immunosuppressives, malnutrition, diabetes, burn patients) 4. Clinically: hemorrhagic pustules coalescing to gangrenous ulcerations 5. Treatment: Antibiotics after proper cultures; wound care, mortalityrate 15% for bacteremic form

Complications of Chicken Pox

1. Secondary bacterial infection is most common complication, which can lead to scarring 2. Encephalitis, usually complete resolution in children, mortality rate of 35% in adults 3. Reye's syndrome - an acute encephalopathy associated with = hepatitis in which 20% are associated with varicella; Salicylate used during varicella may increase this risk 4. Pneumonia- most common serious complication in adults, butfatalities are rare

Allergic Phases

1. Senseitization- hapten (lower molecular weight substance) combines with skin proteins and stimulated T cell production over 5-10 days 2. Elicitation- Re-exposure to antigen causes Tcell activation and release of lymphocytes leading to inflammation over 12-48 hours 3. Cross sensitization- a hapten or allergic substance may induce inflammation because the body recognizes it as a previously sensitized molecule, without prior exposure (posion ivy & raw cashews )

ANKYLOSING SPONDYLITIS 1B

1. Seronegative polyarthritis 1b. Fibrosis, ossification then fusion of vertebra. SPine sacroiliac joint first affected 3. HLA-B 27 , YOUNG (20-40) - M> F AEx: genetic S&S ▪nocturnal back pain and stiffness worse in morning improves w/ exercise ▪Chest pain due to enthesis dyspnoea due to reduced chest expansion ▪Kyphosis Other features: (the A's) Apical fibrosis,Amyloidosis Anterior uveitis/iritis Achilles tendonitis Aortic regurgitation, AV node block Others cauda equina syndrome peripheral arthritis (25%, more common if female) Ix CXR Antibodies ESR, CRP x-ray of the sacroiliac joints sacroilitis: - subchondral erosions, sclerosis - squaring of lumbar vertebrae - 'bamboo spine' (late & uncommon) - syndesmophytes: due to ossification of outer -fibers of annulus fibrosus - Squaring of vertebral bodies Examination - reduced lateral flexion - reduced forward flexion - Schober's test - reduced chest expansion Rx -referred to rheumatology exercise: swimming , physio first line: nsaids ( 2 BEFORE TNF) Second line: TNF-alpha blockers (infliximab and etanercept) -steroid injections -bisphosphonates sulfasalazine (DMARD)

Epidermis Layers

1. Stratum Corceum (corneal layer) 2. Stratum Lucidum (lucid layer) thick skin only on the palms and soles 3. Stratum granulosum (granular layer) 4. Stratum Spinosum (spinous layer, prickle cell layer) 5. Straum Basale (Basal Layer) 6. Stratum Germinativum - Stratum spinosum and Stratum Basale

Trigger Factors for Atopic Dermatitis

1. Temperature changes 2. Low humidity 3. Over Washing 4. Irritants 5. Allergens 6. Super infection (staph aureus etc.) 7. Foods ( eggs, peanuts, milk , fish etc.) 8. Stress

Frozen shoulder : DEFINITION 1B

1. Unknown - may be due to a neurovascular reflex 2. Primary Adhesive Capsulitis - Idiopathic - often associated with diabetes mellitus; osteoarthritis 3. Secondary Adhesive Capsulitis - due to .prolonged immobilization ("use it or lose it") - "Shoulder-Hand Syndrome" - hand in cast, (voluntary) immobilized shoulder ' - following Ml, stroke, shoulder trauma -common in women 3 Phases: 1. Increasing shoulder pain with increasing stiffness - aggravated by movement and alleviated with rest. - Sleep interrupted if the patient rolls onto the shoulder. 2. Stiffness with some pain - Marked decrease in all active and passive movements (exclude scapulothoracic movement when testing abduction) - MAINLY EXTERNAL ROTATION 3. Recovery phase - minimal pain with progressive improvement in movement COMMON IN DIABETES

Peri-oral dermatitis

1. a common transient, recurrent or persistent rash characterised by scaly, papular eruption with surrounding erythema around mouth, nose and eyes. may be pruritic 2. causes Topical steroids - especially potent products Inhaled or intranasal topical steroids Moisturisers - especially thick ones Sunscreens and other cosmetics Inadequate face-washing Pregnancy or other hormonal change Rx: -Avoid oil-based facial creams -Cleanse face twice daily with mild soap or non-soap non-cream - Abx : tetracycline 250-500 mg, doxycycline 100mg or minocycline 100mg daily for 4-8 weeks. Use erythromycin in pregnanc - TOPICAL AGENTS NOT EFFECTIVE

herniated nucleus pulposus 1B

1. a rupture of the fibrocartilage intervertebral disk, releasing the nucleus pulposus that cushions the vertebrae above and below--> nerve compression -in the lumbar area, > 80% of disk ruptures affect L5 or S1 nerve roots - in the cervical area, C6 and C7 are most commonly affected. ss: sudden back pain relieved with rest - causes pain, parasthesia and weakness of affected nerve root , muscle spasms -tenderness at spinous process -muscle spasms back dominant pain (central herniation) or leg dominant pain (lateral herniation) Ix: lumbar herniations --> straight-leg raises stretch the lower lumbar roots and exacerbate back or leg pain -Cervical herniation causes pain during neck flexion or tilting. Ix MRI CT Rx analgesia

ANTIPHOSPHOLIPID SYNDROME NOM

1. acquired disorder characterised by predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. ulcers, TIAs, MIs - primary disorder or secondary to other conditions (SLE) - antiphospholipid syndrome causes an paradoxical rise in the APTT (due to ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade) - (paradoxically) prolonged APTT + low platelets - anti-Cardiolipin antibody can assist Associations other than SLE: other autoimmune disorders lymphoproliferative disorders phenothiazines (rare rx aspirin, warfarin

Pseudomomas Folliculitis

1. aka: Hot tub folliculitis 2. Etiology: Pseudomomas aeruginosa from contaminated hot tub 3. Clinically: multiple pruritic papules and pustules, developing in 1-5 days after exposure, worse under bathing suit 4. Treatment: Self limited, can use oral Cipro if not clear by 7-10 days SEEN IN THE BATHING SUIT AREA !!

Eczema Herpeticum

1. aka: Kaposi's varicelliform eruption, Spread of HSV over skin surface in immunocompromised skin (atopic dermatitis) 3. Usually starts as an oral infection, then spreads and is associated with fever and adenopathy can start of as eczema and skin is penetrated 4. Can be fatal if not recognized and treated early Ix: swabs viral and bacteria Rx acyclovir complication: blindness

Prutitic Urticarial Papules and Plaques of Pregnancy (PUPP)

1. aka: Polymorphic eruption of pregnancy 2. Third trimester primigravidas with a sudden onset, of pruritic hives developing within abdominal striae, with spread to proximal body in 2-3 days. 3. Eruption usually clears within one week after delivery 4. Infants are unaffected 5. Treatment: Supportive therapy, steroids if necessary

Schamberg's Disease

1. aka: Progressive, pigmented purpuric dermatosis 2. Petechiae and patches of redish brown "cayenne pepper" like lesions of the legs 3. Etiology: unknown; Males > females; cosmetic problem only- usually older pt. 4. Treatment is difficult, symptomatic itch relieved with topical steroids

Henoch-Schonlein Purpura

1. aka: anaphylactoid purpura/ IgA vasculitis 2. A benign, self limiting hypersensitivity reaction of palpable purpura over legs and buttocks associated with with abdominal pain & GI bleeding (40%), arthralgia (80%), hematuria (20-50%) and URTI 3. More common in spring, preceding URI by history, usually younger patient 4. Diagnosis: Elevated ESR, Decreased complement, IgA deposits in walls of blood vessels via skin biopsy - Urine dipstick: haematuria -hx of joint pains -BP -Swabs 5. Treatment: Treat underlying problem (infection malignancy, food or drug reaction. +/- plasmapheresis, Prednisone

REACTIVE ARTHRITIS/ REITER'S SYNDROME 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. asymmetrical arthritis that develops post infection . symptoms last 4-6 months ( seronegative HLA b-27) . >M, >20-40 - common arthritis in childhood - COMMON POST-INFECTION : - Enteric bacteria - salmonella, shigella, campylobacter, Yersinia - Viral infection - Chlamydia, gonorrhoea - Mycoplasma - Lyme disease 3. s&s (cant see, cant pee, cant climb a tree) FACADE B Fever( low grade) Arthritis, aortitis Conjuctivitis / uveitis Apthous ulcers Dactylitis Enthesis Balanitis- painless vesicles Keratoderma blennorrhagica ( (waxy yellow/brown papules on palms and soles)) Inv - Raised ESR and CRP - X-ray is normal - Culture and gram stain -auto antibodies: ANA, RF -arthrocentesis Management - symptomatic: analgesia, NSAIDS, intra-articular steroids - sulfasalazine and methotrexate are sometimes used for persistent disease -intra-articular steroid injections - symptoms last more than 12 months

TEMPORAL ARTERITIS/ GCA 2A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. autoimmune small and medium vessel vasculitis, affects temporal arteries. 2. > F, > 60, 2. headache, jaw claudication, visual disturbances. aching proximal joints, morning stiffness , fever . associated with PMR rapid onset palpable temporal artery around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness) 2 Ix: ESR (>50), CRP, ANA, RF, UA, urine/blood culture, head CT, biopsy, temporal artery CK and EMG- normal 3 prednisone (40-60mg) , aspirin, omeprozole, calcium, vit D, dexa scan (ready for alendronate) I forget: blood and urine culture, dexa scan and omeprozole (steroid kit) and aspirin GCA and PMR are associated HLA-DR4 like RA other sx stroke claudication in limbs dementia PUO

MARFAN'S SYNDROME NOM

1. autosomal dominant connective tissue disorder - defect in the FBN1 gene on chromosome 15 2. AEx: inherited 3. signs and symptoms MISS TRAPE Mitral valve prolapse (75%), myopia Ingunal hernia Spontaneous pneumothorax Scoliosis/kyphosis Tall Retinal detachment Aortic regurgitation , dissection, aneurysm pectus excavatum/ pes planus/ pneumothorax Eyes: blue sclera

Dermatitis Herpetiformis 1B

1. blistering disease associated . with gluten sensitive Enteropathy, Hypothyroidism, small bowel lymphoma Features: extremely Itchy papules, burning, elbows, knees, butt. NEVER see intact because so itchy IgA against portion of DEJ Ix - anti IgA TTG , endomyseal, -biopsy Tx: Dapsone (1-2mg/kg/day)—itching will subside within 48-72h. - , sulfapyridine, gluten free diet

Rosacea ( D, Aex, Features 1B

1. chronic or episodic skin condition common in middle aged women (30-50) 2. Etiology: unknown; associated with overgrowth of demodex folliculorum (folliclemite), 1. Alcohol 2. Hot beverages 3. Sun exposure 4. Stress 5. Rapid temperature changes 6. Spicy foods Features 1. Erythema, edema, papules, pustules, and telangiectasias (dilated blood vessels) on cheeks, chin and forehead, flusing 2. Deep papules and nodules (granulomatous rosacea), and rhinophyma (nasal hypertrophy) can occur 5. Rosacea occular involvement common, i.e. rosacea blepharitis ( watery eyes Treatment: 1. Oral antibiotics (oxytetracycline, minocycline, doxycycline, and erythromycin) 2. Topcal Metronidizole (metrogel and metocream), cleocin lotion, sulfacetamide / sulfer lotion 3. Accutane for resistant cases 4. Isotrentinoin 5. plastic surgery for rhinophyma

Impetigo 1A

1. common childhood Skin infection with Stretococcus pyogenes or staphylococci (S. aureus most common cause)!!! carhacterised by HONEY COLORED golden CRUST superficial blisters - epidermis superficial -highly infectious -bullous or nonbullous 2. Can lead to glomerulonephritis Bullous Impetigo 1. Staph as a cause, phage Group II 2. Intra epidermal cleavage occurs within the stratum granulosum 3. features - Numerous erythematous based vesicles that become pustular and often rupture revealing a deeply erythematous base 4. Occurs on intact skin Non-Bullous impetigo 1. Strep or staph as cause 2. Occurs on unintact skin, i.e after minor trauma 3. Clinically - erythematous based, honey colored vesicles, face common site Labs: clinical Acute nephritis: 1. Due to infection with the nephritogenic strain 2. Occurs usually age 2-4 years, 2-5% of cases can develop nephritis 3. One-five weeks after onset 4. Symptoms - hematuria, edema, hypertension 5. Most cases heal without sequelae Tx 1. Topical muciprocin or fusidic acid if localised 2 Oral antibiotics *ADULT*: 500mg QDS flucoxacillin *CHILD*: 250 mg QDS flucloxacilllin

OSTEOPOROSIS 1-5 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. condition abnormal BONE REMODELLING --> An imbalance between osteoblastic and osteoclastic activity--> reduced bone mass/density --> and an increased risk of fracture. - Age-related and a post-menopausal condition due to loss of oestrogen's protective effect on bone density (limits amount of RANK on osteoblasts interacts w/ osteoclasts) 2. AEx/RF -old-age, alcohol, lack of weight bearing exercise, smoking , steroid use , low bmi , STEROIDS -endocrine disorders: hyperparathyroidism, hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency,diabetes mellitus multiple myeloma, lymphoma -gastrointestinal disorders: malabsorption ( ibd, coeliac ) - chronic kidney disease osteogenesis imperfecta, homocystinuria Medication causes: SSRIs antiepileptics proton pump inhibitors glitazones long term heparin therapy aromatase inhibitors e.g. anastrozole S&S Height loss Kyphosis Paraspinal pain Restrictive lung disease Protruding abdomen Fractures Ix X-ray wrist, spine, heel, hip : compression fractures, loss of cortical bone, loss of trabeculla bone and cortical thinning - DEXA scan: T score <2.5 and Z score <2 -CT quantitative - sserum Ca+, ALP, albumin, phospahe, Vit D, PTH, -TFT, PTHFs, testoserone, urinary free cortisol Rx - Weight-bearing exercise- stimulates bone remodelling - Smoking and alcohol cessation - Calcium and vitamin D supplementation - Bisphosphonates e.g. aldendronic acid or risodrenatre if not tolerated - Denusomab (monoclonal antibody decoy receptor for RANK-ligand) if cant tolerate bisphosphonates -raloxifene ( Selective oestrogen recept mod) --> osteoclast activity - Calcitonin - inhibits osteoclast function and shrinks them - In steroid users start bisphosphonates T-score less than -1.5 - in women >75 start bisphosphonates dexa not required Alendronate most stomachs hate, So I swap them to risedronate, And if they're still complaing on that, Strontium ranelate comes up to bat.

PAGET'S DISEASE OF THE BONE 1B

1. disease of increased & uncontrolled bone remodelling characterised by excessive osteoclastic resorption followed by increased defective osteoblastic activity to compensate --> disorganised woven thick bones which are weak, painful and bendable Rx bisphosphonates which inhibit osteoclasts. - Paget's disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients Predisposing factors: age, male, FH s&s 1. bone pain , warm and tender to touch 2. deformities -> bowing of tibia , skull enlargement 3. deafness and tinnitus due to bony compression of the vestibulocochlear nerve - chronic facial pain - hydroccephalus 4. only ~5% are symptomatic Ix X-ray: woven bone, lytic lesions - Bloods - hypercalcaemia, raised bone-specific ALP - Bone scintigraphy - multiple hot spots within bony areas of increased turnover - Raised urinary hydroxyproline Rx bisposponates , calcitonin

Myositis 1-5

1. disease of promixam muscle weakness and inflammation in muscle 3/4; S&S - proximal muscle weakness - muscle atrophy -shawl rash -frequent falls/trips - weight loss -fatigue 5. Invx - Jo-1 and Mi-2 antibodis -CK: raised -fever -EMG -ESR -muscle biopsy

COMMON PERONEAL/FIBULAR NERVE

1. divides from sciatic, behind knee, around fibula head, DIVIDES IN 2 BRANCHES 2. foot eversion, dorsiflexion, extensor hallucis 2. damage -> foot drop Tibialis anterior is the muscle that acts to dorsiflex and invert the foot and is innervated by the deep peroneal nerve Tibialis posterior is responsible for the plantar flexion and eversion of the foot

MENISCAL INJURY

1. from twisting 2. locking and giving way 3. popping senstation - cannot extend the leg

POLYMYALGIA RHEUMATICA 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. inflammatory rheumatological illness characterised by rapid onset of aching, morning stiffness in proximal limb muscles (NOT WEAKNESS) esp. neck, shoulder girdle, and/or pelvic girdle ->F, >50 - mean age 70 AEX: PVB19, mycoplasma pneumonia, chlamydia pneumoniae, s&s: usually rapid onset (e.g. < 1 month) also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats Ix ESR > 30 mm/hr CRP⬆ Ultrasound FBC USS Rx 1. Prednisolone 15mg OD then gradually decrease ( rx for 1-2 years maybe longer) 2. MTX +add Calciferol and bisphosphonate ( T-score < -1.5) + folic acid complications 1.GCA

METHOTREXATE

1. inhibits dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines Indications: inflammatory arthritis, especially rheumatoid arthritis psoriasis some chemotherapy acute lymphoblastic leukaemia - methotrexate is a drug with a high potential for patient harm - methotrexate is taken weekly, rather than daily - FBC, U&E and LFTs need to be regularly monitored - folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose CI: avoid prescribing trimethoprim or cotrimoxazole concurrently - increases risk of marrow aplasia

AXILLARY NERVE

1. innervates deltoid and teres minor 2. C5-C6 bracial plexus 3. abduction of arm , internal rotation and flexion 4. damaged in humeral neck fracture/ dislocation 5. Gives rise to upper lateral cutaneous nerve of arm, which innervates the skin over the lower deltoid ('regimental badge area').

FEMORAL NERVE

1. knee extension , thigh flexion 2. damage from hip and pelvic fractures

neck and back pain 1B

1. mechanical or nerve compression (>90%) - degenerative (disc, facet, ligament) - peripheral nerve compression (disc herniation) - spinal stenosis (congenital, osteophyte, central disc) - cauda equina syndrome -sciatica myeloma, discitis : sinister backache 2. others (<10%) - neoplastic (primary, metastatic, multiple myeloma) -infectious (osteomyelitis, TB) , especially in IVDUs -metabolic (osteoporosis) - traumatic fracture (compression, distraction, translation, rotation) - spondyloarthropathies (ankylosing spondylitis) -referred (aorta, renal, ureter, pancreas)

OSTEOARTHRITIS 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. non-inflammatory degeneration of cartilage in synovial joints. results in LOSS - affects articular cartilage and surrouding structures subchondral bone, pericapsular muscles, capsule, and synovium. calcium phosphate crystals associated with degeneration of cartilage -mainly affects hands (DIP), knees, hip and foot , spine (L4-5, L5-S1) . RAARRREEELY ELBOW AEx: age, genetic, obesity, F, trauma 3. S&S pain with movement, better with rest crepitus of passive movements joint line tenderness limited ROM Periarticular muscle atrophy joint locking *HANDS*: bouchards PIP, heberden nodes DIP *HIP*: crepitus, limb shortening, fixed flexion, trendelenburg +Ve 5. Ix CRP ESR RF, ANA synovial fluid X-rays : LOSS loss of joint space osteophytes forming at joint margins subchondral sclerosis subchondral cysts Rx NSAIDs 1st weight loss capsaicin, steroids joint replacement

MCL damage

1. passive abduction of knee 2. damaged from skiing valgus stress

TIBIAL NERVE

1. plantar flexion and inversion 2. posterior knee dislocation causes damage but this is rare , well protected

ACTINIC KERATOSIS ( solar keratosis) 1B

1. precancerous skin lesion of horny tissue formation that results from excessive exposure to sunlight 2. due to DNA damage by short wavelength UVB. 3. features: flat or thickened papule or plaque that is white/yellow, scly, warty or horny. Skin coloured or pigmented. can be tender or asymptomatic 4: Ix: biopsy to exclude SCC 5: Rx: excision, shave curettage, cryo, imiquimoid, 5-fluorouracil

MELANOMA 1B

1. several types: amelanotic melanoma ( appears very quick, very metastatic) , lentigo maligna 3/4. asymmetrical, irregular borders, lack of uniform colour , may bleed, rapidly growing, uneven thickness

SQUAMOUS CELL CARCINOMA

1. skin cancer, rolled raised edges, keratinous 2. excessive sunlight exposure to chemical carcinogens, chronic irritation 3/4: itchy, rolled edges , 5. Ix biopsy

Pityriasis Versicolor ( TInea Veriscolour ) 1A

1. skin yeast infection due to Over growth of Pityrosporum (Malassezia furfur) skin yeast . 1a. common in young adults esp. men affects trunk, scalp and back Highly recurrent in summer common in dry climates Features: ▪hypopigmented erythematous, red-brown scaly macules ▪dark-skinned people have pale/while patches (pityriasis versicolour alba) -may persist for months, until melanocytes are stimulated by sun exposure. -asymptomatic Ix: wood lamp, fungal culture, skin biopsy, microscopy using KOH tx: NICE 1. topical antifungals 1st line: ketoconazole shampoo 2% OD for 5 days 2nd line: selenium sulfide 2.5% shampoo OD for 7 days SMALL AREAS: Imidazole creams: (such as clotrimazole [preferred in pregnancy], econazole, or ketoconazole) can be applied twice a day. 2-3 weeks 2. oral anti-fungals: fluconazole, terbinafine 3. once gone pale skin will remain pale until stimulated by sun

Chrondromalacia Patella ( DNT NEED TO KNOW )

1. softening (degeneration) on articular surface of posterior patella. 2. MOI: direct trauma to the patella, abnormal patella tracking 3. Signs/Symptoms: anterior knee pain while running, pain whilst walking, squatting, going up steps, - swelling around patella, -crepetition when flexing and extending knee (grinding noise) -pain going down stairs

Seborrhoeic Dermatitis 1B

1.General info: Chronic fungal ( malassaezia) skin infection affecting sebaceous, gland-rich regions of the scalp, face, beard, and trunk. *Rash*: papulosquamous scaly patches 2. Aetiology: Parkinsons, HIV patients more susceptible 3: RF: PD, oily skin, immunosupression, tardive dyskinesia, downs, stress 4: features: Ill-defined localised scaly patches or diffuse scale in the scalp, -salmon-pink thin, scaly, and ill-defined plaques in skin folds on both sides of the face, -Petal or ring-shaped flaky patches on hair-line and on anterior chest,Rash in armpits, under the breasts, in the groin folds and genital creases - 3.Clinically: 1. Cradle Cap - baby 2. Tinea Amiantacea - Scalp of children 3. Seborrheic Blepharitis - EYE Lids 4. Classic adult Seborrheic Dermatitis - AIDS pt Rx- NICE - *Scalp and beard*: Ketoconazole 2% shampoo BD for 4 weeks, then once every 1-2 wks for maintenance PLUS steroid if intense itching -*face and body*: Ketoconazole 2% cream or other imidazole cream , shampoo which can be used as body wash PLUS midly potenet steroids to help with inflammation -*severe widespread dz*: consider alternative diagnosis i.e psoarisis. immunocompromised?

GOUT 1A

1.microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium --> attacks of acute inflammatory arthritis, tophi and possible joint destruction -commonly affects 1st metatarsophalangeal joint but can affect any joint AEx -chronic hyperuricaemia (uric acid > 0.45 mmol/l) DARTH D- iuretics: thiazides, loops, salicytes A- lcohol R- enal disease ( urate under-excretion) T- rauma H- HTN and hypothyrpodism S&S: severe painful, warm, red, shiny joint with gouty tophi - Associated with nephritis and nephrolithiasis Ix ESR ⬆ CRP ⬆ Uric acid levels > 7mg M or > 6mg in F Arthrocentesis : negatively birefringent crystals under polarised light X-ray : erosions USS Rx 1. indomethacin / NSAIDs 2. colchicine ( SE diarrhoea) 3. intra-articular steroids 4. Allopurinol prophylaxis >2weeks after attack ( associated with TEN, SJS, DRESS syndrome) 5. lifestyle: ⬇ alcohol, ⬇ weight ⬇ liver, kidneys, seafood, oliy fish

what Frax score warrants dexa scan

10%

Tertiary Syphilis

3 to 60 years Gummas, CNS, Cardiovascular Misdiagnosed as Leprosy

Toxic Shock Syndrome

3. Clinically: a. Temp > 102F b. Diffuse maculopapular eruption that desquamates in 1-2 weeks +/- petechiae c. Mucuous membrane hyperemia, strawberry tongue d. Multi-system involvement: Hypotension, GI upset, elevated creatinine kinase, CNS changes, elevated BUN & creatinine, elevated bilirubin, low platelets, pulmonarysymptoms to include ARDS 4. Treatment: Beta-lactamase resistant antibiotics (oxacillin, nafcillin, cefoxitin, etc.) and supportive therapy

RISK FACTORS FOR PSEUDOGOUT 1B

5 Hs Hypomagnesaemia Hypophosphataemia Hypothyroidism Hyperparathyroidism Haemochromatosis ( wilsons) Acromegraly KIDNEY disease

T scores on DEXA scan

> -1.0 = normal -1.0 to -2.5 = osteopaenia < -2.5 = osteoporosis

Morton's Neuroma 1B 1. Definition 2. RF/ Epidemiology 3. Pathophysiology 4. Symptoms 5. Signs 6. Investigations 7. Treatment

A Morton's neuroma is a fibrous thickening of nerves. located between the third and fourth metatarsal heads where the nerve is the thickest because it receives branches from both the medial and the lateral plantar nerves 2. common in 40-50s, more common in females (4:1) Aex: idiopathic , chronic inflammation 3. Irritation due to compression ss: pain, burning, numbness and tingling between two of the toes of the foot. pain starts in balls of feet Ix: MRI, CT, XRAY Rx: orthotics, pads in shoes, steroid or anasthetic injections, cryotherapy , surgery

Fracture

A break in the continuity of a bone. Occurs when force is applied that exceeds the tensile or compressive strength of the bone

SEBACIOUS CYST

A closed sac found just under the skin containing a cheeselike material formed from skin secretions. Rx -drain : freeze w/ ethyl chloride then drain --> leave open

Ehlers-Danlos syndrome (interest)

A group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls. People who have this syndrome usually have overly flexible joints and stretchy, fragile skin. This can become a problem if you have a wound that requires stitches, because the skin often isn't strong enough to hold them.

Pustular psoriassis of the palms and soles

A tender pustular eruption of the palms and soles where pustules come to the surface and desquamate, but do not rupture Higher in SMOKERS!! Very resistant to standard therapy Can have some brown looking spots

Molluscum Contagiosum 1A

A. A common viral infection of the skin with a pox virus - molluscum contagiosum virus (MCV) transfer: skin-skin, shared towel, razors, STD B. Clinically: Multiple, flesh colored papules ( white or pink pearly papules) with central umbilication, commonly seen in children <10 - seen in adults as an STD in groin, abdomen -Consider sexual abuse if seen in genital region on children C. Treatment: spontaneous resolution within 18 months - avoid sharing towels - highly infectious , currettage, cryosurgery, Retin A, salicylic acid (duofilm), cantharidin (blister beetle), bichloracetic and tricholoracetic acid, laser

Blistering Distal Dactylitis

A. Acute skin infection of the volar fat pad of the fingers B. Etiology - Group A beta hemolytic streptococci (most common),or Staph aureus C. Clinically: Vesicles on volar fingertips in children (2-16 years) D. Treatment 1. Incision and drainage 2. Anti strep antibiotics (Penicillins, cephalosporins, erythromycin, and clindamycin) for 10 days

Perianal Cellulitis

A. Bright red erythema, perianal region in children with painful defecation and tenderness B. Treatment with oral antibiotics, penicillin, erythromycin Ages 2-5

Cutaneous Drug Reactions 1A

A. Cutaneous Drug Reactions 1. Rashes are the most common reaction to medications and may occur years after initiating a medication 2. Types a. Immunologic- any of the four types of hypersensitivity b. Non-immunologic- at least 75 % of all drug reactions 3. Maculopapular and urticarial drug eruptions are the most common types A. Cutaneous Drug Reactions (con't) 4. Most frequent medications are anti-microbial and anti- inflammatory meds (see table p 5) 5. Onset is within 4-10 days while on the offending agent, but may been on the medication for years 6. Ampicillin rash is usually maculopapular, not a true allergy, and seen in 50-80% of patients with infectious mononucleosis and on ampicillin A. Cutaneous Drug Reactions (con't) 7. Fixed Drug Eruption: a. Dusky red papules, plaques, or bullae occurring in response to an ingested drug b. Lesions recur in the exact same spot when the drug is re-administered c. Commonly associated meds include Tetracycline & phenolphthalein

Erythema Infectiosum

A. aka: 5th disease, slapped-cheek disease B. Etiology: parvovirus B19 C. Clinical findings: 1. Incubation period 13-18 days 2. Mild prodrome of malaise, mild fever, arthralgias 3. Rash has 3 stages a. Slapped cheek - facial erythema with circumoral sparing is first and fasdes in 4 days b. Nelike rash - fishnetlike rash on trunk 2 days afterthe facial erythema that lasts 6-14 days c. Recurrent phase - rash can come and go for 2-3 weeks D. Arthritis and Pruritus - syndrome seen in adult women exposed toparvovirus B19 E. Treatment: not necessary F. Complications/prognosis: Pregnant women at risk for spontaneous abortion and sickle cell patients are likely to go into aplasticcrisis

Rubella

A. aka: German Measles, 3 day measles B. Etiology: Rubella virus C. Clinical findings: 1. Incubation period 18 days 2. Malaise, mild fever, headache, with neck lymphandenopathy- POSTERIOR OCCIPITAL LYMPHOADENOPATHY 4-7 days prior to rash 3. Maculopapular rash starting on neck for 1 day, spreads to trunk for one day, then disappears by day 3 D. Treatment: not necessary E. COMPLICATIONS: If pregnant woman in first trimester gets rubella, then baby at risk for congenital rubella syndrome (cataracts, deafness, heart defects)

Kawasaki Syndrome

A. aka: mucocutaneous lymph node syndrome B. Etiology: unknown, but thought to be an infectious agent C. Is an acute, multi-system vasculitis that is diagnosed clinically by criteria on next slide D. Treatment: high dose aspirin and gamma globulin E. Prognosis: Cardiac involvement leads to morbidity and mortality

Cellulitis 1A

A. bacterial Skin infection characterized by erythema, oedema and pain, hot . fever may b present. has indistinct borders S/S : Commonly caused by Group A Beta hemolytic Streptococci and Staph aureus (adults) and Haemophilus influenza type B in children or MRSA D.Rx: flucoxacillin for 7 days -clarithromycin if penicillin allergy -mark area to monitor process E. Treatment for children is with second generation cephalosporins (cefuroxime) due to H. influenza as cause

Ecthyma

A. deep ulcerated lesions., oyster shell like cursts common exudative holes B. Associated with poor hygiene! and HIV, drug users C. Caused by Group A Beta hemolytic Streptococci D. Heal with scarring-- involves dermis E. Treat with 10 day course of cloxacillin, dicloxacillin, or cephalosporins, erythromycin Dermis- can see scarring

Subacromial Impingement

AKA - Painful arc Sd - Supraspinatus Sd - Swimmer's shoulder - Thrower's shoulder - as arm is lifted RC pushes humeral head under acromion . -not pushed down properly and thus too close to acromion -irritation and inflammation of rotator cuff tendons (mainly supraspinatus) as they pass through subacromial space - producing a painful arc of movement - pain when attempting to perform overhead activities ( this is when the tendon is pinched causing pain) --> common in plasterers and decorators. -night pain w/ progression eventually cant raise arm -Aex: thickening, inflamation or partial tear in tendon -Ix: hawkins test : arm is held in flexion and then internally rotated.. makes space even smaller--> mimics symptoms -Rx:

full thickness burn: appearance + management 1B

AKA 3rd degree burn ATL protocol -resus with parkland formula - refer to secondary care 3rd degree: Through epidermis and dermis Injury to underlying tissue structures (e.g. muscle, bone) features: insensate, hard leathery escahar that's black, grey/white or cherry in colour. no hairs attached. Management -refer to secondary care - Top Abx to prevent prevent infections most common organisms: S. aureus, P. aeruginosa and C. albicans, - surgical removal of necrotic tissue

Scar

Abnormal Collagen deposition due to injury

Salter- Harris Fracture Classification - II

Above. The fracture lies above the physis, or Away from the joint Most Common

ACNE ROSACEA 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

Acne rosacea 1. chronic skin condition which causes persistent facial flushing/erythema, , telangiectasia, pustules, papules and rhinophyma 2. features - affects nose, cheeks and forehead - sunlight can worsen symptoms It can also affect the eyes causing blepharitis, keratitis, conjunctivitis -rhinophyma - complication of sever rosacea IX : N/A Rx 1. first line- lifestyle, care - mild-moderate: topical metronidazole ( e 0.75% gel) OR azelaic acid ( 15% ) - SEver: oral tetracycline 500mg BD OR - doxy 100mg OD

Pustular psoriasis of the digit

Acrodermatitis continua Clinically: Localized form of psoriasis, found on the finger with tender, eroded and fissured surface Very resistant to standard therapy

Gutatte psoriasis

Acute eruption, with TEAR DROP shaped lesions (pinpoint to 1cm ) occuring 1-2 weeks after upper respiratory infection with strep Obtain throat culture, and anti streptolysin O titers Tx: abx with rapid resolution of lesions

what is Acute osteomyelitis and chronic osteomyelitis 1A

Acute inflammation of the bone and bone marrow which leads to destruction of bone Most commonly the result of a periapical abscess May follow fracture of a bone May result from a bacteremia -can occlude local blood vessels resulting in bone necrosis

ANV of the femoral head 1B

Aetiology o Trauma - subcapital fracture, dislocation of hip o Idiopathic - Perthe's disease (Spontaneous avascular necrosis of the femoral head) o Infection - Tom Smith's arthritis o Caisson's disease - diver's bends -alcohol, steroid and storage dz Clinical presentation -progressive wosening symptoms - pain on movement, weight bearing then ... - sudden onset of severe pain, related to weight-bearing o worse at night o rapid progression (compared to OA) -severe arthritis Diagnosis o x-ray - h/o hip fracture o bone scan - may see a healing fracture o MRI (best) Treatment o early: vascularized fibular graft to preserve femoral head. l o rotation osteotomy in a young patient with moderate disease o late - hip replacement

lower back pain

Aex MECHANICAL: train, Sprain, Annular Tear, Herniated Nucleus Pulposis DEGENERATIVE: Degenerative Disc Disease, Facet Arthropathy, Spinal Stenosis INFLAMMATORY: Rheumatoid Arthritis, Ankylosing Spondylitis INFECTIOUS: Discitis, Osteomyelitis, Epidural Abcess (Pyogenic, Tuberculous, Fungal) TRAUMATIC: Fracture, Subluxation, Dislocation ONCOLOGIC: Benign or Malignant Spine Tumor, Metastatic Spine Tumor CONGENITAL: Scheuermann's Disease, Scoliosis IDIOPATHIC: Unknown PSYCHOGENIC: Psychiatric Disorders with manifestation of back pain ss: back pain, stenosis may present with weakness, numbness in bottom and thighs. sppine infections --> fever chills and weight loss physical: erythema, acchymosis, Ix: x-ray, MRI, CT , CRP, ESR, creatine . calcium, vit D, PTH, ALP ( bone) , RF, anti-CCP Rx: surgery, ice, NSAIDs, massage, accupucnture, orthotics, rest

Dermatosis Papulosa Nigra

African American seborrheic Keratosis MORGAN FREEMAN

Gonorrhea

Age 15-30 Common 1. Male - exudative urethral discharge and dysuria/asymptomatic 2. Female - urethritis, cervicitis, PID, Bartholins gland involvement or asymptomatic 3. Incubation period: 3-5 days Organism: Neisseria Gonorrheae (Gram - Diplo-coc) Some people may have more systemic issues, like arthirits, fever, endocarditis, myocarditis

Generalized pustular psoriasis (medical emergency)

Aka: von Zumbusch Clinically: Rare disease characterized by tiny sterile pustules coalescing into lakes of pus. -Pit is febriles, toxic, and elevated WBCs , Usually hospitalized patient, almost treated like a burn Patient -Renal and liver impairment -usually afetr prescription of oral steroids tx: wet dressings topical steroids, may require oral therapy with etretinate, methotrexate or cyclosporine

sinusitis

An inflammation of the mucous membranes of one or more of the sinuses. -Swelling can obstruct the flow of secretions from the sinuses, which may then become infected. -The disorder often follows rhinitis. Other conditions leading to sinusitis include deviated nasal septum, nasal polyps or tumors, inhaled air pollutants or cocaine, facial trauma, nasal intubation, dental infection, or decreased immune function. symptoms: frontal headache, worse on leaning down , chronic cough possibly post-nasal drip. Rx steroids nasal

HIP PAIN: TRANSIENT IDIOPATHIC OSTEOPOROSIS

An uncommon condition sometimes seen in the third trimester of pregnancy Groin pain associated with a limited range of movement in the hip Patients may be unable to weight bear ESR may be elevated

Cutaneous Manifestations of Diabetes Granuloma Annulare (GA)

Annular flesh colored Asymptomatic papules of hands and feet Tx: Steroids , self limiting

Tendon or ligament injuries Clinical manifestations

Are painful and usually accompanied by soft-tissue swelling and changes in tendon or ligament contour.

Atopic Dermatitis Infantile Childhood Adult

Atopy a term given to patients with a history of hay fever, asthma, dry skin, and eczema - intensely pruritic condition -Associated with atopy and involves a type 1 hypersensitivity reaction -Filaggrin gene mutation leads to a disrupted skin barrier, increased penetration of irritants and antigens -This drives an IgE-mediated hypersensitivity with inflammation due to elevated T lymphocytes activation -Breastfeeding delays onset of eczema -Resolves in 50% by age 12 features: Xerosis, pruiritis , erythema, scaling, vesicles, papules , excoriations , Ichthyosis Vulgaris Most have three or more Major Features (Pruitis , typical morphology - flexural lichenification, facial involvement , Dermatitis, Personal or Family history of Atopy) Thee or more Minor Features - (Icthyosis, Xerosis, keratosis pilaris, palmar hyperlinearity, wool intolerence, IgE elevated, Eczema, food intolerence etc. ) Clinically:"The itch that rashes" Infantile: Starts 3rd month of life Cheeks, trunks, extremeties, spares diaper area Resolves in 50% of infants by 18 months Childhood: Flexural involvement - antecubital fossae, neck, wrists, ankles, popliteal fossae Perspirations of opposing skin surfaces leads to increased pruritus and initiates the itch scratch cycle- leading to linchenificaiton Adult: Flexural involvement, like in childhood phase, hand dermatitis, periocular dermatitis, lichenification of the anogential area. Ix: allergy testing , IgE levels, skin biopsy Rx: 1. emollients 2. steroids: hydrocortisone > triamcinolone/mometasone/betamethasome >clobetasol 3. Oral Abx for s.aureus -Topical tacrolimus (calcineurin inhibitors - reduced IL-2) -Antihistamines -Short courses of steroids for relapses -Wet dressings, baths, emollients, occlusive bandaging - UVA and PUVA - Ciclosporin and azathioprine -coal tar

Systemic Lupus Erythematosus

Autoimmune disease multisystem usually in women Diagnosis: based on having 4 of 11 diagnostic criteria serially or simultaneously: 1. Malar rash 2. Discoid rash 3. Photosensitivity 4. Oral ulcers 5. Arthritis (two or more peripheral joints) 6. Serositis (pleuritis pericarditis, peritonitis) 7. Renal involvement (proteinuria > 500 mg q day; urine casts) 8. Neurological involvement (seizures, psychosis) 9. Hematological involvement (hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia) 10. Positive ANA - antinuclear antibody 11. Immunologic involvement (positive anti-DNA, Sm antibodies, VDRL or LE cell prep

Apocrine gland

Axillae, groin, scalp , forehead, areolae

WHICH MEDICIATION EXACERBATE PSORIASIS

BETA-BLOCKERS

MELANOCYTIC NAEVUS

Benign mole, evenly pigmented. Melano man can but rarely arise EVENLY pigmented

Hangman's fracture

Bilateral fracture of pedicles of C2 due to hyperextension - Unstable

Comminuted

Bone breaks into > 2 fragments

Course complete fracture - Oblique or spiral

Bone tend to shorten and redisplace even if it is splinted

Torus

Buckling of cortex

ULNAR NERVE

C8-T1 innervates first 2 fingers WRIST FLEXION damaged in medial epicondyle fracture --> claw hand Flexor carparis ulnaris supplies all muscles EXCEPT LOAF *LOAF muscles Lateral two lumbricals Opponens pollis Abductor pollis brevis Flexor pollis brevis

Granuloma Inguinale (Donovanosis)

Calymmatobacterium granulomatis INcubation -14- 50 days Painless ulcer BEEFY BASE granulation tissue Bleeds easily No Lymphandenopathy Giemsa Stian- with Donovan Bodies (Bascilli within histiocytes )

Sacral Zoster

Can be associated with autonomic nerve (virus migration) dysfunction causing a neurogenic bladder

Septic bursitis

Caused by a wound infection.

HIP PAIN: MERALGIA PARAESTHETICA

Caused by compression of lateral cutaneous nerve of thigh Typically burning sensation over antero-lateral aspect of thigh

Meralgia paraesthetica

Caused by compression of lateral cutaneous nerve of thigh Typically burning sensation over antero-lateral aspect of thigh. -common in 30-40s, mostly men -Occurs more commonly in those with diabetes than in the general population. - features: Burning, tingling, coldness, or shooting pain in antero-lateral aspect of thigh

Treatment Gonorrhea

Ceftriaxone Cipro Doxycycline or Azithromycin - to treat cocomitant Chlamydia

Lymphgranuloma Venerum

Chlamydia trachomatis Incubation is 5-21 days SMALL PAINLESS Erosions Heals unnoticed Lymphadenopathy , fever, arthritis Groove sign with buboes can be Clinical Diagnosis - Culture of bubo pus on McCoy cells 50% positive

Chronic Urticaria

Chronic Urticaria - hives occurring for 6 weeks or more in duration a. May last for months or years and end spontaneously b. Cause usually not found c. Investigations i. Rule-out physical urticatia ii. Sinus imaging- sinus films found occult infection in 17% of patients with chronic urticaria and when treated with antibiotics, hives improved * Auto immune Thyroid Patients Also see this.. Skin biopsy is appropriate for these patients

Epidermolysis Bullosa Acquisita

Chronic resistant sub epidermal auto-immune mechanicobullous disease IgG and complement 3 against portion of DEJ Blisters hands and feet immunoflourescent studies help diagnose Tx: Prednisone , cyclosporine, Immunoglobins

Vesicle

Circumscribed Collection of clear fluid <1cm

Plaque

Circumscribed change in texture >1cm

Bulla

Circumscribed collection of clear fluid > 1cm

Pustule

Circumscribed collection of cloudy fluid (WBC's) any size

Tumor

Circumscribed deep lesion > 1cm

Nodule

Circumscribed solid deep lesion <1cm

Perioral Dermatitis

Clinically: 1. Erythematous papules with scale occurring in the perioral, perinasal and periocular region, with sparing of the vermillion border Etiology: Topical steroids, moisturizer abuse. Aggravated by drying agents TX:1. Oral tetracycline, Minocycline, erythromycin and Topical antibiotics looks like acne but has scaly - treat like acne

Fracture Classification Complete

Closed/Open Comminuted Linear Oblique Spiral Transverse Impacted Pathologic Avulsion Displaced

Supracondylar Fracture

Common in children*, caused by direct blow or fall on outstretched hand S/S: -Pain and swelling over distal humerus - Evaluate radial/ulnar nerve and arter Dx: -x-ray, look for posterior fat pad sign* - bilateral x-rays helpful in children Tx: - non-displaced- long arm cast - displaced- refer to surgeon complications: bracial artery injury, median/ ulnar nerver injury , compartment syndrome (leads to Volkmann's ischemic contracture), malalignment cubitus varus (distal fragment tilted into varus

HIP PAIN: PUBIC SYMPHYSIS DYSFUNCTION

Common in pregnancy Ligament laxity increases in response to hormonal changes of pregnancy Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

Avulsion

Complete separation of a tendon/ligament from its bony attachments

buckle fracture

Compression injury, the bone buckles rather than breaks

Subluxation

Contact bt two joint surfaces is only partially lost

Pilar Cyst (Wen)

Cysts of hair follicle origin, present on scalp

Wrist sprain

DEF: most common wrist injury. due to injury to ligaments. includes microscopic tears or completely torn ligaments MOI: fall on an outstretched hand, twisting S/S: pain, point tender, swelling, absence of pain over scaphoid bone TX: PRICEMM, taping, x-ray to rule out fracture Rx- can take days if mild, weeks to months if more severe

SULFASALAZINE

DMARD used in rheumatoid arthritis and IBD Cautions: GP6D deficiency allergy to aspirin or sulphonamides (cross-sensitivity)

Scleroderma

Diffuse Scleroderma General: Systemic, autoimmune, multi-system disorder characterized by skin hardening sausaging of fingers and claw deformity of sclerodactly, Raynaud's phenomenon (pallor, cyanosis, hyperermia) GI fibrosis and atrophy of the smooth muscle (dysphagia & esophageal dysfunction) lungs with ↓ vital capacity & dyspnea Anti Scl-70 antibodies Tx: Steroids, Colchicine ,

Smith's fracture

Distal radius fracture with volar angulation (reverse Colles) - fall onto back of hand flexed -Ix: Xray Rx - ORIF -mild angulation- closed reduction and cast sig. angulation- open reduction + internal fixation - poor perative cand --> long arm cast

Delayed Union

Does not occur until approximately 8 to 9 months after a fracture.

Crust

Dried Serum

Drug Induced LE

Drug induced SLE most commonly procainamide (80% of patients on this medicine develop drug induced LE), Diagnosis: clinical findings + positive antihistone antibody titer

Asteatotic Eczema

Dry skin, excessive dryness leading to inflammation History: Previous Eczema underlying atopic state, winter exacerbation Clinically: dryness cracking superficial fissures, lower legs, "Cracked" porcelain" appearance pain rather than itching Tx: Based on stage, topical steroids, cool compress, oral abx, and frequent moisturizing

Greater trochanteric pain syndrome (Trochanteric bursitis)

Due to repeated movement of the fibroelastic iliotibial band Pain and tenderness over the lateral side of thigh Most common in women aged 50-70 years

HIP PAIN: GREATER TROCHANTERIC PAIN SYNDROME (TROCHANTERIC BURSITIS)

Due to repeated movement of the fibroelastic iliotibial band Pain and tenderness over the lateral side of thigh Most common in women aged 50-70 years

Congenital Syphilis

Early congenital- rash snuffles Late- Saddle nose, teeth and eye Hutchinson's Triad ( teeth, 8th nerve palsy, keratitis) Pathognomonic for late congenital syphilis

Syringoma

Eccrine Sweat duct tumors , flesh colored, dome shaped, periocular papules

Test for Supraspinatus

Empty can (Jobe test) Abduction against resistance

Spiral

Encircles bone

Sebaceous Hyperplasia

Enlarged sebaceous glands yellowish umbiliticated papules on face

Epidermal Cyst

Epidermal lined fluid filled cavity Flesh colored, soft/ firm subcutaneous cyst containing yellow keratin typically has central pore opening

Tuberous Sclerosis Complex

Epiloa ( Epilepsy, low intellect, adenoma sebaceum) Ash Leaf , hypo-pigmented macules Adenoma sebaceum - face Shagreen patch - Periungual fibromas

Excoriation

Erosion due to scratching

Hand foot and mouth disease Coxsackie Virus

Etiology: Coxsackie virus B. Clinical findings: 1. Incubation period 4-6 days 2. Prodrome of mild fever, sore throat, malaies, lymphandenopathy 3. Punctate, white oral lesions; hand and foot vesicles last 7-10 days C. Treatment: Supportive

Eccrine Gland

Everywhere except mucocutaneous junctions, earlobes, and nail beds

Sebaceous gland

Except on palms and Soles - Everywhere

Scale

Excess Stratum Corneum

Mastocytosis

Excess numbers of Mast cells 2. Skin and internal disease exist 3. Urticaria Pigmentosa a. Infantile development of red-brown pruritic papules, collections of mast cells b. Uncommonly has internal involvement (bone marrow, GI) c. Itching, flushing, headaches; if internal involvement: bronchospasm, abdominal pain d. Darier's Sign: Wheal and flare reaction elicited when a lesion is scratched e. Exacerbating factors: exercise, stress, hot/cold water, rubbing of lesions, Aspirin, Codeine f. Prognosis: Most resolve by age 2

Test of Infraspinatus

External rotation lag sign (against resistance)

Rheumatoid arthritis complications

Extra-articular: - respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy - ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy - osteoporosis - ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus - increased risk of infections - depression Less common: Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis

INTRACAPSULAR FRACTURE

FEMUR IS BROKEN INSIDE THE JOINT FRACTURES OF FEMORAL . Rx internal fixture w/ cannulated screws in young, hemi arthro if unfit

Calcaneal Fracture

Fall from a height onto heels Osteoporosis Diabetes Loss of foot height Typically require ORIF SPLINT- Post mold OR Vacuum splint, NWB ss: swellingm bruising on heel/sole , varus heel

Genital Herpes Treatment

Famciclovir Valciclovir Acyclovir

Stress Fx Types

Fatigue and insufficiency Transchondral

HIP PAIN: REFERRED LUMBAR SPINE PAIN Cause + Test

Femoral nerve compression may cause referred pain in the hip Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped

Dematofibroma

Firm indurated red borwn or hyperpigmented papule - trauma or insect bite? when squeeze laterally it should damp down

Ulcer

Focal Loss of epidermis and dermis

Erosion

Focal loss of epidermis

Jefferson fracture

Fracture of C1 (atlas) caused by a compressive downward force from the occipital condyles

Clay Shoveler's Fracture

Fracture of C6 or C7 spinous process, relatively innocuous. Stable fx. MOI: Flexion Radiographic findings: Avulsion of posterior aspect of spinous process; frequently an incidental finding

Oblique

Fracture of shaft of the bone is slanted

Bennett's fracture

Fracture of the base of the first metacarpal bone - abductor pollicis longus pulls MC shaft proximally and radially causing adduction of thumb Rx: treat with percutaneous pinning, thumb spica x 6 wk

Odontoid fracture

Fracture of the dens of C2 - Type II and III are unstable and these may present with neurologic impairment

Linear

Fracture runs parallel to the long axis of the bone.

How fractures are displaced

Fractures can be displaced by: - Force of injury - Effects of gravity - Pull of muscles attached to the site

Course complete fracture - Impacted

Fragments jammed tightly together and fracture line is indistinct

Course complete fracture - Transverse

Fragments usually remain in place after reduction

Tinea Capitis 1B

Fungal infection (ringworm) of the hair/scapl, Trichophyton tonsurans most common cause a. Patterns of T. capitis i. Black dot-hair break off at skin level and leave "dots" ii. Inflammatory Kerion - hyper allergic response iii. Seborrheic dermatitis like iv. Pustular type b. Infection is usually endothrix (within the hair shaft) andtherefore will not flouresce with a wood's light c. Clinical pearl: Almost always see lymphadenapathy ofthe neck d. Treatment i. Oral antifungals are necessary to eradicate infection(griseofulvin, intraconazole, fluconazole, terbinafine) ii. Antifungal shampoos for the patient and family members iii. Consider oral steroids for extensive kerion involvement

Dermatophytes

Fungi that cause infection of the hair, skin, and nails. by richophyton, Microsporum, and Epidermophyton genera.

Hidradenitis Suppurativa 1B

General info: 1. A chronic suppurative and scarring condition of apocrine sweat seen in axillae and groin 2. Etiology: unknown; Apocrine gland occulsion vs. keratinous folllicular plug Clinically: 1. "Double Comedone," papules, pustules, nodules abcesses and scarring 2. Chronic and episodic course, associated with obesity, arthropathy,and follicular occulsion triad (acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp) Tx: Inflammatory conidition... 1. Oral antibiotics (tetrecycline, minocycline, doxycycline, and erythromycin 2. Topcal Retin A 3. Intralesional Steroids 4. Accutane for resistant cases 5. Surgical Excision for very resistant cases

Pityriasis Rosea 1A

General info: - Papulosquamous eruption characterised by Scaly eruption onset 2nd-3rd decade of life (ave. age 23 years),winter and summer outbreaks common. post-viral infection Etiology: Unknown, thought to be viral related, possible "slow virus". possibly HHV6 or 7 Clinically: 1. Starts with a single lesion ("herald patch") usually on the trunk resembling "ringworm," - followed by eruption of oval to round thin, pink papules and plaques with fine scaly margin in christmas tree distribution - rash spares the face, palms, and soles 3. Lesions usually confined to trunk and proximal aspects of the arms and legs. Rarely on face. Tx: 1. Self limiting within 6 weeks 2. steroids, UVB DDX: guttate psoriasis, drug rxn

Psoriatic Arthritis

General info: Rheumatoid factor negative 5% of psoriatic have true psoriatic arthritis , and usually have more extensive cutaneous involvement Tx: with NSAIDS, gold, methotrexate!!

Pityriasis Rubra Pilaris (PRP)

General info: a rare, chronic disease characterized by thickened and yellow palms and soles, erythroderma (red skin all over) Etiology: Uknown Onset in adulthood (most common) or childhood ( typticall more red) Adults will be more yellowish Clinically: Red scaling plaque on face or upper body that enlarges over days to weeks with thickening of the palms and soles SKIP AREAS of redness occur and red follicular papules on elbows and knees, ITCHING IS ABSENT Other features: thickened nails, ectropion Duration of disease- 3 years in 80 % of patients Childhood PRP- red to orange keratotic plaques confined to the elbows and knees with a longer chronic course Tx: Lubricants, Vit D3, retinoids (accutane, etretinate) methotrexate

Polymyositis (PM)

General: An inflammatory, autoimmune muscle disease Muscle disease only = polymyositis dermatomyositis usually more severe case of myositis

Dermatomyositis (DM) 1-7

General: An inflammatory, autoimmune muscle disease affecting skin and muscle Skin and Muscle disease = dermatomyositis Heliotrope rash, gottron's papules, Violaceous Scaling patches, Peri-ungual erythema, telangiectosia, poikiloderma proximal muscle weakness, +/-tenderness difficulty arising from a chair or climbing stairs. difficulty lifting heavy items, brushing hair etc.. interstitial lung disease dysphagia, dysphonia does not affect facial muscles Investigations (anti-synthetase antibodies), including: antibodies against histidine-tRNA ligase (also called Jo-1) antibodies to signal recognition particle (SRP) anti-Mi-2 antibodies ANA (80%) CK CRP ESR Muscle biopsy EMG Tx: Steroids, methotrexate

Nummular Eczema/discoid eczema/dematitis 1B

General: Coin shaped papules and plaques of eczema . Wet or dry - wet/ exudative: can be caused by S.aureus-plaque appears after trauma or infection: thermal burn, scabies, varicose vein surgery, insect bite, impetigo , drug allergy wet can last months, starts acutely Dry discoid eczema: usually due to dry skin - dry sometimes associated w/ elevated skin lesions such as seborrhoeic keratoses and melanocytic naevi (Meyerson's naevus). both - common in females >50 History:, worse in winter, back of hand most common site, extremities clinically: erythematous, annular papules, and plaques, can display vesicles, dryness, and scale, itching is moderate to severe site: common on back of hands but also occurs affect scalp, face, trunk and limbs. Rx: skin swabs, culture , fungal culture to R/O tinea corporis tx: 1. emmolients 2. topical steroids - mild for dry and potent for exudative 3. PO anti-staph Abx: flucoxacillin, dicloxicillin, erythromycin, trime+ sulphamethoxazole 4. wet dressings if severe+ steroids

Nevus subaceous

General: a conglomerate of immature sebaceous and pluripotent cells usually found on scalp Tx: get them removed by plastic surgeon because may turn malignant later in life

CREST SYNDROMe

General: a more benign, chronic variant of systemic sclerosis Clinically: Calcinosis - palmar finger tips, knees, elbows, spine, painful and red Raynaud's Phenomenon - vasospastic disorder of the fingers and toes precipitated by temperature changes Esophageal Dysomotility Sclerodactyly Telangiectasia Labs: Positive Anticentromere antibody

Pyogenic Granuloma

General: proliferative vascular lesion due to trauma Clinically: single, violaceous and eroded exophytic papules occuring in response to trauma; "proud flesh" or granulation tissue

Lichen Sclerosus et Atrophicus NOM

Generally 1. A chronic mucocutaneous disosrder, charactized by white, angular, well defined and indurated papules and plaques 2. Mainly adults, but some children (1-13 years) 3. Female : Male 10 : 1 Etiology: unknown Clinically: 1. Non-genital lesions are usually asymptomatic; genital often asymptomatic, however, vulvar lesions may be painful, (dysuria; dyspareunia) 2. Whitish, sharply demarcated, macules and forming plaques with keratin plugs (dells) 3. Kraurosis vulvae--female anogenital vulvar plaques with a keyhole or hour glass shaped arrangement; lesions may become maceratedand vulva may become atrophic & shrunken. Fusion of labiaminora and majora may occur 4. Balanitis xerotica obliterans - In males, prepuce becomes scerotic and cannot be retracted leading to acquired phimosis 5. Squamous cell carinoma, although very uncommon may develop in genital lesions, predominantly in females. Tx: 1. Waxes and wanes, may undergo spontaneous resolution 2. Patients should be followed every 12 months to moniter for carcinoma development 3. Topical corticosteroids, topical testosterone, antimalarials, circumcision in males

Pityriasis Lichenoides et Varioliformis Acuta (PLEVA)

Generally 1. aka: Mucha-Habermann disease 2. A benign, self limited papulosquamous disease, char by crops off reddish brown papulonecrotic lesions in clusters. Trunk and extremities most common 3. Lesions become necrotic and fade over 2-5 weeks and can beassociated with arthritis; may mimic chicken pox Chronic: 1. Generalized eruption of brownish papules, with adherent scale that may persist for years TX: 1. Erythromycin, tetracyline, dapsone 2. Ultraviolet light A & B 3. Methotrexate, steroids and gold

Fracture Classification Incomplete

Greenstick Torus Bowing Stress Transchondral

Genital Herpes

HSV 1 and HSV2 ( More commonly HSV2 ) Incubation 3-7 days Presentation: Painful with Tender ulceration Lymphadenopathy recurrence likely- first episode is the worst! Tzanck Smear and PCR testing, Giemsa Elevated IgM HSV

Vascular sickle cell

Haemolytic anaemia resuls in reduced levels of NO caused by release of haemoglobin and arginase from lysed red blood cells --> vasoconstriction , prolifera tive vasculopathy, pulmonary hypertension. pulmonary hypertension --> RV failure AVN of hip or shoulder chronic anaemia--> low O2 --> heart pumps faster and harder for more O2 --> cardiomegaly - iron overload --> HF

Malunion

Healing of the bone in a nonanatomic position.

Iliopsoas abscess

Hip flexion ( T12-L5) abcess: Collection of pus in iliopsoas compartment (iliopsoas and iliacus) common in IVDU commonly caused by staph aureus and sttrep S&S: -fever -backpain radiating to groin or just back pain -problem on hip flexion -better on lying back common in IVDU

MCL tear

History o valgus force to knee o +/- "pop" heard o severe pain with partial tears o complete tear may be painless Physical o swelling o tender above and below medial joint line o assess joint space opening with valgus force pain MCL laxity with end point - partial tear absence of end point - complete tear may be associated with ACL and medial meniscus tear Diagnosis: o X-ray - may be associated with an avulsion fracture of medial femoral epicondyle o Clinical diagnosis best confirmed with MRI Treatment o minor immobilize briefly. early ROM and strengthening o moderate hinged ROM brace and protected weight bearing early PT with ROM and strengthening o severe or combined surgical repair of associated injuries surgical repair of isolated MCL tear is rarely indicated

Rotator cuff Tendinitis causes

Holding elbow above waist level Holding upper arm away from the body

Cutaneous Larva Migrans

Hookworm Larve Ancylostoma braziliense; aka creeping eruption Southern US/ Carribean Dogs and Cats are normal host - doesnt get to where it needs to live in a human , migrates through the epidermis then dies 2-8 weeks TX: Thaibendazole topical / oral

FROZEN SHOULDER INVESTIGATIONS 1A

INVESTIGATIONS: Radiology: 1. plain x-rays to exclude significant pathology 2. MRI arthrogram shows reduced joint volume - esp. decreased axillary fold 3. often there are incidental tears of the rotator cuff

SYSTEMIC LUPUS ERYTHEMATOSUS 2B 1-5

IgG mediated autoimmune disease ( HLA B8, DR2, DR3) e characterized by the production of autoantibodies, which deposit within tissues and fix complement leading to systemic inflammation.. > F (9:1), > african, asian, 20-40 can affect any organ including the skin, joints, kidneys and brain AEx autoimmune drug induced : hydralazine, isoniazid, procainamide, phenytoin (HIPP) MD SOAP BRAN -Malar rash - butterfly -Discoid rash - scarring on sun-exposed areas -S erositis - pleurisy, pericarditis, abdominal pain -O ral aphthous ulceration -A rthritis, bone disease and myalgia -P hotosensitivity: avoid going in sun -Blood pathology - anaemia, haemolytic anaemia, leucopenia, thrombocytopenia, antiphospholipid syndrome, lymphopaenia -Renal - nephritis , HTN, proteinuria, nephrotic syndrome and CKD -Autoantibodies - ANA, A dsDNA -Raynaud's syndrome -Neurological pathology - seizures, headache, psychosis, depression and anxiety Ix FBC , U&Es aPTT ESR, CRP - autoantibodies: ANA (99*%), ENA, anti-dsDNA ( highly specific >99%) , anti-smith ( most specific >99%) , anti-histone (80-90%), anti-ro ( cause bradycardia), antiphospholipid, RF, Anti-ro/La CXR ECG Rx - NSAIDs - Hydroxychloroquine- may result in a severe and permanent retinopathy, monitor eye - Steroids - Cyclophosphamide - Rituximab for severe disease Monitoring - ESR , CRP is normal during active disease - Complement C3, C4 low in active dz

Greenstick

Incomplete fx Perforates one cortex and splinters spongy bone

Greenstick Fx

Incomplete fx breaks occurs in one side bc the rest bend. common in children (bones softer & more elastic)

Neonatal Herpes

Infants born to infected mothers Neurologic and respiratory symptoms 50 % mortality Rate Higher incidence in women who acquire primary infection while pregnant

Bursitis

Inflammation of Bursal sacs They are smalls sacs lined with synovial membrane and filled with synovial fluid; bursa are located among the tendons, muscles, and bony prominences.

Tendinitis

Inflammation of a tendon

Epicondylitis/Elbow Sprains and strain 1A

Inflammation of a tendon where it attaches to a bone. -Sprain is a tear or stretch in the ligrament -Tear or stretch in tendon or muscle - due to overuse Tennis elbow: Lateral epicondylitis Golfer's elbow: Medial epicondylitis

Benign Familial Chronic Pemphigus (Hailey-Hailey) disease

Inheritable ! intra epidermal Vesicular Disease Abnormal Keratincoyte adhesion Itchy annular vesicles developing in tertriginois areas back and neck - worse in summer UV exposure and friction tx: Abx, topical steroids, sunscreen

Prophyria Cutanea Tarda

Inheritable - sub epidermal blistering - in patients with liver disease "were wolf disease" Ass. with Hep C deficiency in Uroporphrinogren Decarboxylase Blisters - sun exposure, photosensitivy Urine maybe red brown in color, Pink under woods light Ts: Alcohol use, Phlebotomy, Cholorquine

INTERFERON

Interferons (IFN) are cytokines released by the body in response to viral infections and neoplasia - IFN-alpha and IFN-beta bind to type 1 receptors whilst IFN-gamma binds only to type 2 receptors

Gardner's Syndrome

Intestinal Polyposis Skull osteomas Adenomatous polyposis of colon Epidermal inclusion cysts 100% malignancy - Colectomy

Burrow

Intraepidermal channel due to parasite

Bowenoid Papulosis/ Bowen's disease

Intraepithelial Squamous Cell carcinoma (bowen's disease) Associated with HPV 16 bcc IN SITU Appearance: dark or erythematous warty/scaly plaque which is well defined flat edges TX: Electrosurgery , Laser, incision

Myasis

Invasion of Human skin by Maggots!! Dermatobia hominis - botfly; Cordylobia anthropophaga - tumbu fly Red papule Resembling furuncle , central pore for larvae, pain, exudate Tx: Petroleum, bacon occlusion

Nonunion

Is the failure of the bone ends to grow together. Gap between the broken ends of the bone fills with dense fibrous and fibrocartilaginous tissue. Occasionally, fibrous tissue contains a fluid-filled space that resembles a joint: Referred to as a false joint or a pseudarthrosis.

Seabather's Eurption

Jelly fish larva (Cnidaria) exposure SALT WATER Itchy papules on bathing suit COVERED skin 3-4 days Cool compress, antihistamine, topical steroids

Black Widow Spider Bites

Lactrodectus mactans, shoe-button spider (Eats mate after copulation) Asymptomatic painful bite- 2hrs later abdominal pain rigidity and numbness .. 2-3 days later shock and death Tx: Ice , morphine , Calcium Gluconate, Antivenin

Fissure

Linear Loss of Epidermis and Dermis

Xanthomas

Lipid Deposits in the Skin Periocular, palms, eyelids - Biliary Cirrhosis Tuberous - subQ tissue - hypertriglyceridemia Tendinous- Hypercholesterolemia

Candidiasis / Monoilaisis

Lives on normal flora of the mouth, vagina, gut Over growth can be due to pregnancy, BCP, antibiotics, Diabetes, and moist environments Vulvovaginitis- vaginal infx Oral Candidiasis- mouth infx Candida balinitis - Penis! Candida INtertrigo- In the inguinal crease Candida diaper - babies Angular Chelitis - Angles of the mouth Tx: Topical or oral antifungal agents - that are effective against yeast

Chronic Cutaneous LE (Discoid Lupus)

Localized chronic cutaneous form of lupus, red topped plaques "carpet tack" scale heal with atrophy scarring and alopecia ANA ( usually negative) TX: high potency Steroids

Bowing Fx

Longitudinal force is applied to a bone. Common forearm, fibula

Salter- Harris Fracture Classification - III

Lower. The fracture is below the physis in the epiphysis.

Brown Recluse Spider Bites

Loxoscelidae reclusus, fiddle-back spider Southern half of USA Yellow Tan to brown with dark violin shape on back Bee ting like bite with bulla formation, pain, local necrosis, greyish halo, wound may heal weeks to months Posible DIC and renal failure and death. TX: Ice elevation, Dapsone, Rest Abx for secondary infection

Cervical Fractures

MOI: Axial loading of the cervical vertebra from a force to the top of the head combined with flexion of the neck S/S: point tender; restricted movement; cervical muscle spasm; pain, numbness; weakness; paralysis in limbs or trunk; loss of bladder and/or bowl control Tx: treat for neck injury, refer MD CErvical break of C1-C7 C1-2: may need ventilation, breathing affacted C4- pain in lower neck, trapezius C5- pain in neck shoulder and dorsal forearm C6/7: shoulder pain, radiates to fingers Lumbar ones: pain in thigh, ankle, buttocks - dislocation : injury of ligamanet in the neck and spinal bones become disconnected -Aex: MVAs, falls, violence, sport activities. abrupt imapct or twisting of neck -common in ages 12-25

A Monteggia fracture

MURder M-onteggia U-lnar #, R-adial disloc Proximal ulnar shaft fracture with radial head dislocation

posterior cruciate ligament

Mechanism: hyperextension injuries Tibia lies back on the femur Paradoxical anterior draw test

Rheumatoid arthritis: drug side effects

Methotrexate SE: Myelosuppression Liver cirrhosis Pneumonitis Sulfasalazine SE: Rashes Oligospermia Heinz body anaemia Interstitial lung disease Leflunomide SE: Liver impairment Interstitial lung disease Hypertension Hydroxycholorquine SE: Retinopathy Corneal deposits Prednisolone SE: Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts Gold SE: Proteinuria Penicillamine SE: Proteinuria Exacerbation of myasthenia gravis Etanercept SE: Demyelination Reactivation of tuberculosis Infliximab SE: Reactivation of tuberculosis Adalimumab SE: Reactivation of tuberculosis Rituximab SE: Infusion reactions are common NSAIDs (naproxen, ibuprofen) SE: Bronchospasm in asthmatics Dyspepsia/peptic ulceration

Pemphigus Foliaceous

More superficial - intra epidermal blistering disease IgG and complement 3 against desmosomes in high epidermis Erythema, scaling, crusting, starts on FACE or trunk- resembles CORN FLAKES on skin FOgo selvagem: PF in brazil that is related to black fly bites Tx: Steroids, cyclophosphamide, dapsone, Azothioprine

Cowden's Disease

Multiple Hamartoma Syndrome Skin: Facial, Verrucoid papules on hands, oral mucosal papules BREAST CA ( 25% mastectomy) Thyroid cancer

rotator cuff tear

Muscles surrounding the shoulder joint are involved in rotating the shoulder with upper arm and hand forward and backward, among other movements. The tendons of these muscles also contribute to the structural strength of the shoulder joint. Hard, fast movements, such as in tennis and baseball can tear one of these tendons resulting in pain and decreased mobility of the shoulder. Surgery may be needed to repair a torn tendon.

NOF #

NECK OF FEMUR: -young due to MVC -fall from height. elderly: twisting, fall from standing. - ss: acute hip pain , can't weight bear, short &externall rotatated leg, painful ROM RX- Idynamic hip screw or hemiarthroplasty if unfit. Extracapsular: dynamic hip screw

nodular BCC

NODULAR BCC Most common "telangiectactic papule/ulcer" - shiny pearly dome-shaped nodule with smooth surface blood vessels across surface central depression/ulceration if older tumour

Staphylococcal Scalded Skin Syndrome 1B

NOT ON THE SKIN_ BUT SOMEWHERE ELSE !!! 1. aka: Ritter's disease, SSSS; an epidermolytic toxin syndrome seen in children less than 5 years old 2. Etiology: Staph aureas phage group II (types 55, 71 3A, 3B). Toxin is epidermolytic toxin A or epidermolytic toxin B which cleaves the epidermis beneath the granular layer 1. Begins as a localized infection of the throat, conjuctiva, nares or umbilicus 2. Toxin develops and causes tender erythema with a sandpaper like texture. 3. Fever associated and skin forms fragile blisters and peels off and heals within 7-10 days 4. Can be localized or widespread Diagnosis: 1. Bullous impetigo will usually have positive skin cultures 2. SSSS will have negative skin cultures, because skin lesions are due to the toxin 3. Skin biopsy shows split in the stratum granulosum Treatment: 1. NO Steroids!! 2. Oral antibiotics for localized, IV antibiotics and hospitalization for more extensive cases

causes of meningitis in 3-6 months

Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae

Lichen Simplex Chronicus

Neurodermatitis, chronic itchy spot Excessive rubbing and scratching Previous eczema or itchy skin, subconscious rubbing Clinically: well-circumscribed erythematous, hyperpigmented, patches and plaques of thickened lichenified skin commonly occurring on the neck, ankles, scalp, pubis, vulva, scrotum, and extensor forearms, as a result of chronic rubbing and scratching. Can lead to true neurotic excoriations tx: Topical steroids, antihistamines and frequent moisturizing

Tennis elbow: Lateral epicondylitis Cause S/S Dx Tx

Overuse-repetitive supination and wrist extension* S/S: -point tenderness over lateral epicondyle, pain on resisted wrist extension . pain when gripping, pronating or wrist flexion due to strain on common extensor tendon on lateral epicondyle Dx: -clinical, x-ray to r/o arthritis or loose body Tx: -rest, ice, NSAIDs, counter force strap, steroid injection

Golfer's (pitcher's) elbow: Medial epicondylitis Cause S/S Dx Tx

Overuse-repetitive wrist flexion and pronation* S/S: -point tenderness over medial epicondyle, pain on resisted wrist flexion Dx: -clinical, x-ray to r/o arthritis or loose body Tx: -rest, ice, NSAIDs, steroid injection, stretching exercises

hyperparathyroidism

PT gland --> secretes PTH in response to low Ca+ PTH increases Ca+ absorption from intestine, increases Ca+ re-absorption from kidneys , increases osteoclast activity in bones --> Ca+ increase Vit D: increases Ca+ absorption PTH converts Vit D to active form Primary- tumour --> increased secretion --> increased Ca+ and increased PTH secondary: Low Vit D, or renal failure --> hypocalcaemia --> PTH excrete more PTH to compesate --> overtime increase in PTH glands (hyperplasia) --> secrete more PTH . serum Ca++ is normal but PTH is raised Tertiary PTH--> chronic secondary HPTH --> hyperplasia of prarathyroid gland --> increase in PTH --> high absorption of Ca+ in intestine, kidney

HIP PAIN: INFLAMMATORY ARTHRITIS

Pain in the morning Systemic features Raised inflammatory markers

Dislocation and subluxation Clinical manifestations

Pain, swelling, limitation of motion, joint deformity

Carpal Tunnel Syndrome

Painful Disorder secondary to *Median nerve compression* due *repetitive wrist flexion* -more common in females -aex: tumours, fractures, hypothyroidism, acromegaly, RA, infections. S/S: - Numbness , tingling and night-time pain in thumb, index and middle finger .. fingers feel swollen, - *+/- thenar muscle wasting (late in disease)* -positive *Phalen( prayer sign til parasthesia) & Tinel ( percussion on medan nerve causing parasthesia)* sign Dx: clinical, EMG/NCV if unsure of diagnosis Tx: - night-time splinting, steroid injection, surgical release

Tendinosis

Painful degradation of collagen fibers

Pronator Sd - Definition (nerve & muscle) - Causes

Painful disorder of wrist & hand caused by compression of median nerve by pronator muscle Holding lower arm away from torso of body

Chondrodermatitis Nodularis chronica Helicus

Painful eythematous papule of the pinna in the elderly trauma or sun exposure

Rotator cuff Tendinitis

Painful inflammation of muscle tendons in shoulder region

Primary Syphilis

Painless indurated well demarcated chancre Incubation: 18-21 days up to 3 months Organism present in lesions (T. Pallidum)

Peduculosis (Lice infection)

Pediculus humanus capitis (head), Pediculus humanus corporis (body), & Pthirus pubis (crabs); Insects Children - Girls - rare in African - american kids Humans - live 10 days off hair, can involve eye lashes Transmission is close contact - can have fever associated with it Corporis ( on the body ) - itchy Pediculosis Pubis - Contagious STD, sensation of bugs crawling "Maculae Cerulae- Grey blue patches 1-2cm Rx:malathion, permethrin or ivermectin

Treatment of Syphilis

Penicillin G or Doxycycline Follow up with VDRL in 3,6,12 months

Pigmented Basal cell carcinoma

Pigmented nodule BCC increased melanin production may contain pigmented flecks can simulate melanoma

Comedone

Plugged pilosebaceous unit

Secondary Syphilis

Polymorphic, asymtomatic Great Imitator! 3 weeks to 2 years , beings after the chancre resolves Classic Palms and Soles with flu like symptoms and adenopathy

Anti-Jo-1 diseases

Polymyositis, dermatomyositis muscle weakness

Epidermal Nevus

Proliferation of cells in the epidermis , keratinocyte proliferation, usually verrucoid and linear present at birth or childhood

Galeazzi fracture

RADIAL FRACTURE at wrist with dislocation of DISTAL radioulnar joint GRUsome G-aleazzi R-adius #, U-lnar-radial disloc

Salter- Harris Fracture Classification - V

Rammed (crushed). The physis has been crushed.

Subacute Dermatitis

Red, scale, fissuring, parched appearance Symptoms: Slight to moderate itch, Pain, Stinging, burning Etiology: Allergy, irritation, atopic dermatitis, fingertip eczema Tx: Topical Steroids, Lubrication, antihistamines, abx

FELTY'S SYNDROME

Rheumatoid arthritis Splenomegaly Neutropenia

WHAT ARE X-RAY FINDINGS IN RA 1B

Rheumatoid presents with 'LESS'- Loss of joint space, Erosions, Soft bones, Soft tissue swelling.

Rock Mountain Spotted Fever

Rickettsia rickettsii South Atlantic States Tick must be attached for 6-10 hours for transmission 3-21 days after bite - fever, Headache, myalgia, emesis Rash: day 4 macular petechial, ankles wrists palms soles, trunk. 15% no rash Systemic - pulm GI CNS issues can die if untreated Tetracycline, Doxycycline Chloramphenicol for pregnant women and children under 8

Cat scratch Disease

Rochalimaea henselae - scratch or cat bite especially young cats - painless blisters - self-limiting weeks to months - sx: lymphoadenopathy, fever, arthralgia, Severe cases: cardiac probs and meningoencephalitis, seizures

Management of osteoporosis

Rx - Weight-bearing exercise- stimulates bone remodelling - Smoking and alcohol cessation - Calcium and vitamin D supplementation - Bisphosphonates e.g. aldendronic acid or risodrenatr if not tolerated - Denusomab (monoclonal antibody decoy receptor for RANK-ligand) if cant tolerate bisphosphonates -raloxifene ( Selective oestrogen recept mod) --> osteoclast activity - Calcitonin - inhibits osteoclast function and shrinks them - In steroid users start bisphosphonates T-score less than -1.5 - in women >75 start bisphosphonates dexa not required Alendronate most stomachs hate, So I swap them to risedronate, And if they're still complaing on that, Strontium ranelate comes up to bat.

Osteomyelitis Rx 1A

Rx: Abx penicillinase-resistant (eg, nafcillin or oxacillin , flucloxacillin or vancomycin 1 g IV q 12 h 1st line flucoxacillin for 6 weeks clindamycin in penicillin allergy

Rx for BCC

Rx: excision, cryo, photodynamic therapy, imiquimoid cream, Fluorouracil cream, radiotherapy

Gamekeeper's Thumb S/S Dx Tx

S/S: -pain with radial stress of thumb* Dx: Radial deviation > than opposite side Tx: - Partial lig. rupture- thumb spica cast - Complete lig. rupture- ORIF

ROTATOR CUFF MUSCLES

SITS: supraspinaus: ABDuction -> most commonly injured infraspinatus: lateral rotation teres minor: ADDuction, external rotation, axillar n. subscapularis: ADDuction and medial rotation

INFERIOR GLUTEAL

SITTING , CLIMBING STAIRS ADDUCTING HIP LATERAL ROTATION AND HIP EXTENSION

What are the signs and symptoms of osteomyelitis ? 1A

SS: acute: weight loss, fatigue, fever, and localized warmth, swelling, erythema, and tenderness. back pain in vertebral osteomyelitis.. advance dz can cause caude equina - chronic: intermittent bone pain and tenderness

OPEN FRACTURE MANAGEMENT

STAND Splint Tetanus prophylaxis Antibiotics IV Neurovascular status (before and after) Take photo Dressings (to cover wound)- erile soaked gauze and impermeable film. Cover wound

superficial BCC

SUPERFICIAL BCC second most common common in younger adults Slowest growing least aggressive Slightly scaly, irregular superficial plaque resembles psoriasis or eczema thin, translucent rolled border stretch skin to make peraly broder obvious Multiple microerosions

Treatment of Zoster

Same Antivirals but triple the dose Cold compress Oral steriods, if a lot of pain

Scabies 1A

Sarcoptes scabiei mite (arachnid family) Incubation 3-5 weeks Lives only 2 days off host in Stratum Corneum ; life cycle 30 days Spread by close personal contact , sexual contact -Severe nocturnal Pruritus, burrows, papules, - affects finger webs, wrists, hands, feet , ass, ankles Usually no neck or face involvement Diagnosis- with glass slide from scraping Rx: 1. creams: Permethrin, Malathion, Ivermectin 2. Benzyl benzoate 3. Treat all contacts and perform contact tracing

Muir Torre Syndrome

Sebaceous gland tumors Keratoacanthomas COlon Cancer!

Erythrodermic Psoriasis

Severe disease usually occuring in previous psoriatic patients where precipitating factors (systemic steroids , stress, illness etc. ) Has lead to worsening state ->90% of skin - can result in hypothermia -also occrus in Tx: cool compresses oatmeal baths, and systemic therapy with etretinate or methotrexate, fluid balance, keep pt warm, emollients, top steroid. treat underlyihg disease

Condyloma Accuminatum/ Viral Warts ( 1A ) GEt notes from obs&gybae

Sexually transmitted lesion due to HPV HP 6& 11 Most common Vrial STD Typical Presentation, intravaginal, intraurethral and, intraoral lesions fleshy papules may bleed or itch Diagnosis - Biopsy Acetic Acid soaks - "Aceto-whitening "

lumbar spinal lesion effect

Should be able to sit Flaccid paralysis in the lower limbs

Atrophy

Skin Depression from thinned epidermis dermis or both

Lichenification

Skin thickening with accentuated skin lines

Salter- Harris Fracture Classification - I

Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)

Fire Ants

Small Aggressive stinging Painful! papule vesicle 10 days Tx: Cool compresses, baking soda, antihistamines , prednisone

Wheal

Specific type of papule or plauque resulting from fluid accumulation in dermis

Lymes Disease

Spirochete, Borrelia burgdorferi White deer ticks ( Ixodes dammini East USA ) I. pacificus (west coast USA), I. ricinus (Europe) and White footed mouse Tick must be attached 24-48 Hours for transmission Erythema Chronicum Migrans (EM) - wheel hive like plaque expands over 2-3 weeks then disappears 60-80% of cases Stages of Disease - 1 (3-32 days) constitutional type symptoms 2- Disseminated infection - AV block, tendonitis, Bell' palsy 3- ACA atrophy , Chronic memory, mood, sleep disturbances. Diagnosis of exclusion Early - Doxycycline , amox, azithro Disseminated: Ceftriaxone Prophylaxis: not necessary for person bit by tick

Tendon or ligament injuries Treatment

Splinting, promotion of early motion, and rehabilitation Suturing: To treat a complete rupture - If suturing is not possible: Tendon or ligament grafting Prolonged rehabilitation exercises

Ligament tear

Sprain

Bee Stings

Stinger imbedded - venom Toxic Rxn- pin prick, wheal , burning, multiple stings could lead to death Allergic rxn- Urticaria, angioedema, anaphylaxis TX: antihistamine SQ Epinephrine , IV fluids, Benedryl

Transverse

Straight across the bone

Tendon tear

Strain

Herpes Gestationis (pemphigoid Gestationis)

Sub - epidermal Blistering disease of Pregnancy IgG against protein in DEJ Edematous itchy papules - blisters on trunk can have recurrence with preg. or menses - maybe premature delivery Tx: Systemic Steroids

Cicartricial Pemphigoid

Sub epidermal Scarring, diseasing disease of oral and ocular mucosa IgG - against protein of DEJ Tx: Topical Steroids, Dapsone, Prednisone, Cyclophosphamide Can lead to blindness

Cyst

Subcutaneous fluid filled cavity

Gram (-) Negative Acne

Sudden onset of perinasal pustules in patients on long term antibiotic Carriage of E.coli, Proteus, Klebsiella, etc. Tx. Ampicillin, trimethoprim/sulfamethoxazole

Muscle Strain

Sudden, forced motion, causing the muscle to become stretched beyond its normal capacity. Causes local muscle damage. Can also involve the tendons. Regardless of the cause of trauma, muscle cells can usually regenerate. May take up to 6 weeks.

Milia

Superficial keratin Cysts

HIP PAIN: AVASCULAR NECROSIS

Symptoms may be of gradual or sudden onset May follow high dose steroid therapy or previous hip fracture of dislocation

Pott's disease

TB of the spine. inetrvertebral joints

LATERAL EPICONDYLITIS 1-7 1A

TENNIS ELBOW 1. typically follows unaccustomed activity such as house painting or playing tennis 2. most common in people aged 45-55 years and typically affects the dominant arm 3. repetitive movements 4/5. Features -pain and tenderness localised to the lateral epicondyle -pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended -episodes typically last between 6 months and 2 years. -Patients tend to have acute pain for 6-12 weeks Ix - clinical Rx advice on avoiding muscle overload simple analgesia steroid injection physiotherapy

Dislocation

Temporary displacement for its normal position in a joint - Simple - Complex (involves fracture)

kyphosis 1B

The thoracic spine is rounded - excessive rounding of the thoracic spine is kyphosis o A curve of more than 45˚ is considered excessive o Thoracic spine curve increases with age. Causes o Postural - poor posture o Idiopathic - Scheuermann's disease o Congenital o Neuromuscular o Post-fracture dislocation o Post-infection e.g. tuberculosis o Metabolic - osteoporosis Clinical presentation o Deformity o Pain o Stiffness o Tenderness o Fatigue Diagnosis o Radiology Treatment o Non-operative - physiotherapy, back strengthening, abdominal core strengthening o Surgery - for severe symptomatic deformity

Chronic Dermatitis

Thickened skin, skin lines and accentuated, excoriations, fissuring Symptoms: Moderate itch, maybe periods of intense itch Etiology: Atopic dermatitis, lichen simplex, chapped fissure feet, fingertip eczema, hyperkeratotic eczema Tx: Topical steroids, intralesional steroids, Antihistamines, Abx

Epidermal cyst:

This cyst can develop into what type of cancer. Discharge of a foul-smelling "cheese-like" material

Salter- Harris Fracture Classification - IV

Through Everything. The fracture is through the metaphysis, physis, and epiphysis

Gamekeeper's Thumb

Thumb forced into radial deviation*, stresses ulnar collateral ligament (ski pole)

Treatment of Psoriasis less than 20% of skin involved

Topical steroids: •Advantages - rapid response, controls inflammation and itching, best for intertriginous areas and face, convenient, not messy •Disadvantages - temporary relief (tolerance occurs), less effective with continued use, atrophy and telangiectsia occur with continued use, brief remissions, very expensive •Comments - best results occur with pulse dosing (e.g., 2 weaks of medication and 1 week of lubrication only); plastic occlusion is very effective Calcipotriol (Dovonex): Vitamin D analog - normalizes keratinization process •Advantages - well tolerated, long remissions possible •Disadvantages - burning, skin irritation, expensive •Comments - best for moderate plaque psoriasis Anthralin: •Advantages - convenient short contact programs, long remissions, effective for scalp •Disadvantages - purple-brown staining, irritating, careful application (only to plaque) required •Comments - used on chronic (not inflamed) plaques; best results occur when used with UVB light Tar: •Advantages - new preparations are pleasant •Disadvantages - only moderately effective in a few patients •Comments - most effective when combined with UVB (Goeckerman regimen) e.) UVB and lubricating agents or tar: •Advantages - insurance may cover part or all of treatment, effective for 70% of patients, no need for topical steroids •Disadvantages - expensive, office-based therapy •Comments - used only on plaque and guttate psoriasis, travel and time required Tape or occlusive dressing: •Advantages - convenient, no mess •Disadvantages - expensive; only for a limited disease •Comments - may be used to occlude topical steroids Intralesional steroids: •Advantages - convenient, rapidly effective, long remissions •Disadvantages - only for limited areas, atrophy and telangiectasia occur at injection site •Comments - ideal for chronic scalp and body plaques when small and few in number Tazorac (tartarozene) topical retinoid/normalizes cell differentiation

Tendinopathy is cause by

Trauma or repetitive stress

FROZEN SHOULDER RX

Treatment: 1. active and passive ROM (physiotherapy) when thawing commences 2. NSAlDs and intra-articular steroid injections (although little proven benefit) 3. MUA (manipulation under anaesthesia) - may cause dislocation, fracture or rotator cuff tear 4. Arthroscopy for debridement decompression (rarely used) - may be best used in phase where movement starts to recover Prognosis: 1. Idiopathic adhesive capsulitis is commonly a self-limiting condition with eventual spontaneous recovery in 9-18 months of a good ROM (usually not a complete ROM) 2. Diabetics usually have a poor outcome

Osteoblastoma 2B

Tumors of the bone arising from osteoblasts common in spine and long bones -grown rapidly -painful rx: excision

p-ANCA

UC, PSC, everyting else

Treatment of Psoriasis with greater than 20% of the body involved

UVB and tar administered in physician's office: •Advantages - more effective than UVB alone •Disadvantages - more expensive and carcinogenic than UVBalone; requires many office visits PUVA: •Advantages - allows patients to be ambulatory; effective •Disadvantages - many treatments needed; many office visitsrequired Methotrexate:*** •Advantages - "gold standard" for efficacy; helps arthritis •Disadvantages - hepatotoxicity; liver biopsy periodically required Etretinate: •Advantages - effective for palmer-planter-pustular, erythrodermic, and pustular types of psoriasis; fast, effective; helps arthritis •Disadvantages - teratogenic; usually ineffective as a single therapy for plaques Newer version of retinoid now available Cyclosporine: •Advantages - fast, effective; helps arthritis •Disadvantages - hepatotoxic; nephrotoxic; •Neoral g.) Hospitalization or office say treatment for tar, anthrain, and combinations of all therapies above: •Advantages - most effective for those who are unresponsive to topical agents or for whom systemic agents are inappropriate •Disadvantages - time-consuming; expensive New Tumor Necrosis Factor inhibitors (TNF inhibitors) FDA approved for RA (Remicade)

Drop arm test

Unable to lower arm further with control Tear rotator cuff (mostly supra) (deltoid function able to lower arm to 90`)

thoracic spinal lesion efect

Upper limbs are spared but there is spastic paralysis of the legs May not be able to sit unaided

Syphilis Labs

VDRL/ RPR - measures IgG and IgM FTA-ABS ( directly detects T. Pallidum antibodies) Dark Field Microscopy - Spirochetes

RAYNAUD'S 1-7

Vasospastic disorder characteristically causing discolouration of fingers and toes (white -> blue -> red). Classic triggers: cold and emotional stress Primary: Raynaud's disease Secondary: Raynaud's phenomenon typically present in young women with symmetrical attacks Features: Factors suggesting underlying connective tissue disease: onset after 40 years unilateral symptoms rashes presence of autoantibodies features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages digital ulcers, calcinosis very rarely: chilblains Secondary causes: connective tissue disorders: scleroderma (most common), rheumatoid arthritis, SLE leukaemia type I cryoglobulinaemia, cold agglutinins use of vibrating tools drugs: oral contraceptive pill, ergot cervical rib First line: calcium channel blockers (nifedipine) Second line: IV prostacyclin infusion: effects may last several weeks/months

Acanthosis Nigricans

Velvety hyperkeratosis of the intertriginous area ( neck, axillae, groin) Skin tags Ass. Diabetes, Obesity, Insulin Resistance , Stomach CA TX: Treat underlying issue

Acute Dermatitis

Vesicles and Blisters intense red Symptoms: intense itch Etiology: Contact allergy (poison ivy) severe irritation Tx: Cold wet compress, oral or IM steroids, topical steroids, Abx, antihistamines

Neurofibromatosis (NF)

Von Recklinghausen Cafe au lait Macules - Crow's Sign , lische nodules (eye hamartomas) Pheochromocytoma, schwannoma, optic glioma, CML

Flea Bites

Wingless insects Carried by cats and dogs Methoprene - prevents flea larvae from maturing BUBONIC PLAGUE

Dislocation and subluxation most common in persons

Younger tha 20y2

osteophytes and pic

a bony outgrowth associated with the degeneration of cartilage at joints. common in OA AS

superficial burn 1A

a burn that involves only the epidermis, the outer layer of the skin. It is characterized by reddening of the skin and perhaps some swelling. An example is a sunburn. Also called a first-degree burn. Erythema involving the epidermis only Usually dry and painful Typical of severe sunburn. Ix: FBC, ABG, biopsy, culture - cleaning, topical creams, keep moist, +/- aloa - NSAIDS, analgesia -prophylactic abx silver sulfadiazine, mafenide topical

Subacute Cutaneous LE (SCLE)

a cross over of cutaneous and systemic lupus Skin findings: erythematous papulosquamous or annular polycyclic pattern on trunk, arms, axillae, but spare the knuckles and below the waist; adherent scale and atrophy are NOT seen; photosensitivity, periungual telangiectasias, vasculitis; Diagnosis: clinical annular lesions + photosensitivity + post Anti Ro/SSA antibody

Radial Head Fracture

a fall on outstretched hand * - common # in young adults S/S: - present splinting in flexion - swelling and diffuse elbow pain over lateral elbow, dec ROM at elbow +/- mechanical block to forearm pronation and supination • pain on pronation/supination Dx: X-ray, look for posterior fat pad sign*(demonstrates blood in joint) Tx: -non-displaced or occult: sling 2-4 wks displaced : ORIF

ganglion cyst

a harmless fluid-filled swelling that occurs most commonly on the outer surface of the wrist arising from a joint or tendon sheath. -tansilluminable -painless o May present because of pressure effects on adjacent structures: Ulnar nerve in tunnel of Guyon. Radial artery on palmar side of the wrist Carpal tunnel syndrome with volar ganglia Diagnosis o Diagnosis is made clinically - reassure - review if not settling

patellofemoral syndrome

a heterogenous group of patellofemoral conditions causing anterior knee pain o commonly seen in young adults, especially females o softening of, fissuring and ulceration of articular cartilage, usually medial aspect of patella Aetiology o overuse - excessive knee strain (athletes) o malalignment and mal-tracking of the patella - subluxation, recurrent dislocation of patella, genu valgum, femoral anteversion, high patella (patella alta), shallow intercondylar groove o quadriceps muscle imbalance o tight iliotibial band and lateral retinaculum History: o deep aching anterior knee pain o exacerbated by prolonged sitting, strenuous athletic activities, stair climbing Clinical presentation: o crepitus in the patellofemoral joint o effusion o tenderness on palpation of underside of medially displaced patella o mal-tracking of the patella in ROM o pain on resisted knee extension localised to the anterior aspect of the knee o Clark's sign - Patient lies supine with knee in extension. Place the web space of the thumb and index finger against the superior pole of the patient's patella and ask the patient to perform an isometric quadriceps contraction. A positive test is indicated by the presence of pain sufficient to prevent the patient from maintaining a quadriceps contraction against resistance. Non-specific for patellafemoral conditions. Diagnosis o X-Rays: AP, lateral, skyline o Best seen on MRI Treatment: o conservative treatment physio (isometric quads strengthening) NSAIDs o surgical treatment with refractory patients arthroscopic debridement, in carefully selected patients with excessive lateral pressure, lateral release may benefit release of lateral retinaculum Realignment of extensor mechanism

Osteosarcoma 2b 1-7

a malignant tumor of bone in which there is a proliferation of osteoblasts. - usually presents in 10-30s, more common in males - hx of pagets -frequently metastasises features: o painfully tender, poorly defined swelling o x-ray shows Codman's Triangle: characteristic periosteal elevation and spicule formation (sunray) representing tumour extension beneath the periosteum with calcification -bony destruction o treatment with complete resection (limb salvage, rarely amputation) adjunctive chemo, radiotherapy

Achilles tendinitis

a painful inflammation of the Achilles tendon caused by excessive stress being placed on that tendon i.e foor fitting footwear -thickened tendon, palpable mass, pain, stiffness, crepitus

Strawberry Hemangiomas

a proliferation of endothelial cells seen in 1-3% of neonates, UNCOMMON bright red papule or nodules, 1/3 present at birth or within the first month of life;

stress fracture

a small crack in the bone that often develops from chronic, excessive impact - Most common in the weight bearing bones - lower extremity commonest site - metatarsals 2 and 3 other common sites - calcaneus, fibula; talus, talus, narvicular (a small bone in the ankle joint); and the navicular (a bone on the top of the midfoot). o may go on to displace if untreated and activity continues o will usually heal in 2 months Diagnosis o often difficult to see on a first x-ray o may not be visible until several weeks later when callus appears o can be detected earlier by CT, MRI and bone scan Treatment o Ceasing activity o Rest o Splintage

Port Wine Stain ( Nevus Flammeus)

a vascular malformation or dilation of vessels (in contrast to proliferation of endothelial cells) that does NOT fade with age

Pitted keratolysis

a. A bacterial infection that may mimic T. pedis b. Punched out lesions sole of foot with sweaty feet c. Micrococcus sedentarius and Dermatophilus congolensis d. Treat with topical erythromycin and drying agents

Acute Anigoedema

a. Acute form: (type I hypersensitivity reaction) due to food, drugs (NSAIDS, ACE inhibitors), insects, pollen, contrast dye

Acne Fulminans

a. Acute onset of cystic acne associated with myalgias, arthralgias, and fever b. Usually adolescent boys c. Associated with wt. Loss, fever, leukocytosis, and elevated ESR d. Treatment with oral antibiotics, accutane, prednisone

Pyoderma Faciale (Rosecea Fulminans)

a. Acute onset of cystic acne confined to the face b. Usually adult women, no prior history of acne c. Usually "flushers and blushers" d. Treatment with oral antibiotics, accutane, prednisone

Acne Conglobata

a. Chronic, inflammatory, cystic acne characterized by the "double comedone", papules, pustules, cysts, abscesses and draining sinustracts b. Associated with the "follicular occlusion triad of acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp c. 85% of patients are African-American d. Arthralgias seen, but no fever or wt. Loss

Hereditary Angioedema

a. Cutaneous swelling, severe upper airway and GI involvement b. 30% mortality rate (resp failure) c. onset late childhood, with swelling developing over 12-18 hours and lasts 2-3 days d. Etiology: Lack of C1 esterase inhibitor e. Treatment: fresh frozen plasma (steroids and antihistamines not helpful)

Pressure Uticaria

a. Deep, pruritic, burning and painful hives occurring 4-6 hours after pressure stimulus b. Age of onset is early 30's, chronic course lasting 1-40 years c. Associated with malaise, fatigue, fever, chills and arthralgia; also with chronic urticaria and angioedema d. Treatment: systemic steroids, antihistamines are of no help

Tinea Barbae

a. Fungal infection of the beard area, usually caused by a zoophilic dermatophyte with inflammatory like reaction b. Treatment requires oral antifungals in order to eradicate infection (griseofulvin, intraconazole, fluconazole, terbinafine)

Tinea Manuum 1B

a. Fungal infection of the hand, Trichophyton rubrum mostcommon cause b. Frequently misdiagnosed as dry skin or eczema c. Two foot one hand syndrome - is tinea pedis and tineamanuum of one hand. Look for foot involvement when hands are involved d. Treatment i. Anitfungal Creams for mild to moderate cases (terbinafine, econazole, etc.) ii. Oral antifungals for extensive or resistant cases (griseofulvin, intraconazole, fluconazole, terbinafine)

Tinea Cruris (jock itch) 1B

a. Fungal infection of the skin of the groin, Trichophyton rubrum most common cause b. Intertrigo is macerated intertriginous zones that can mimictinea cruris c. Erythrasma is a bacterial infection (corynibacterium minutissimun) of moist intertriginous zones that flourescescoral red with a wood's light and is treated with topical erythromycin d. Treatment i. Creams for mild to moderate cases (terbinafineeconazole, etc.) ii. Oral antifungals for extensive or resistant cases (griseofulvin, intraconazole, fluconazole, terbinafine) iii. Decrease moist environment

Pyoderma Gangrenosum

a. General: an ulcerating chronic and recurrent skin disease b. Associations: Ulcerative colitis, Crohn's disease, rheumatoid arthritis, hepatitis, malignancy c. Clinically: tender red papules that progresses to nodules that enlarges and ulcerates, most commonly on lower legs, can be solitary or multiple d. Treatment: Avoid trauma, IL steroids, oral steroids, dapsone

HSV infection of a non mucosal surface

a. Herpetic whitlow - HSV of the finger tip, used to be commonly seen in healthcare workers (contact with oral secretions) b. Buttock and trunk lesions c. Neck lesions

Cold Urticaria

a. Hives and/or angioedema occurring after sudden drop in air temperature or exposure to cold water b. Treatment: Cyproheptadine (periactin), doxepin, avoidance

7. Senile / Solar Comedones (Favre Rachouchot's syndrome)

a. Large open comedones in periocular region b. Due to excessive sunlight and collagen degeneration of the skin

Steroid Acne

a. Monomorphous eruption of papules, sudden onset, after oral steroid therapy (i.e. asthma attack) b. Considered a drug eruption c. Treatment is to stop the steroids, and use benzoyl peroxides They all come out at once, all look the same

Neonatal Acne

a. Papules and pustules may develop in the neonatal period b. Due to maternal hormonal influence on baby's sebaceous glands, which shrink down over 2-4 weeks and do not become active again until puberty

Cholinergic Utricaria

a. Small, 2-4 mm papules with erythematous flare occurring usually on the chest and neck after exercise, stress, or overheating b. Onset occurs 2-20 minutes after above with usually mild itching, tingling, burning, warmth, and last only about 30 minutes c. Treatment: limit activity or stress, prophylactic antihistamines

Demographism

a. aka: "skin writing" due to hive production by rubbing the skin b. Most common form of physical urticaria, occurring in 5% of the general population c. Recurrent and chronic coarse with remissions and exacerbations d. Treatment: Antihistamines

Sweets Syndrome

a. aka: Acute Febrile Neutrophilic dermatosis b. Associations: URI, malignancy, inflammatory bowel disease, pregnancy c. Clinically: Sudden onset of fever, arthralgias, tender red plaques and ↑ WBC count. Lesions occur on head, neck, hands, trunk d. Labs: ↑ WBC count, with ↑ neutrophil count, ↑ ESR, and skin biopsy with infiltrate of neutrophils e. Treatment: Steroids

Majocchi's Granuloma 1B

a. tinea corporis involving the hair follicles resulting in pustules and nodules. zoophilic fungus (from animals) that penetrates in and around the hair follicles b. Requires oral antifungals for cure

inverse psoriasis/ flexural

aka: Psoriasis inversus Clinically: Intertriginous psoriasis ( gluteal fold, groin , diaper area) characterized by red, smooth plaques that commonly fissure at the base of the body crease)

Measles 1A

aka: Rubeola, morbilli Etiology: the measles virus, a paramyxovirus C. Clinical findings: 1. Incubation period 10 days 2. Cough, coryza, conjuctivitis and fever 3-4 days prior to rash 3. Maculopapular rash starting behind the ears and spreads to the trunk "morbilliform," followed by light desquamation 4. Koplik's spots - blue-white macules with red halos on the buccal mucosa 1-2 days prior to rash D. Treatment: Supportive, Oral Vitamin A for extensive cases, Immunglobulin E. Complications/prognosis: Encephalitis possible, pneumonia, otitis media, eye involvement, cornea

bedsore/decubitus ulcers 1B

an ulcer, sore, or inflammation of the skin that results from prolonged pressure on the skin generally this occur over the bony parts of the body - common in Px admitted - RF: older people, modbiliy issues , impaired sensation ( diabetes) features: shallow open wound or tissue loss on areas subjected to pressure ( grade 2) can be full thickness ( G 3 and 4) . tenderness and warmth on the area -clinical dx, swabs of wounds

BISPHOSPHONATES

analogues of pyrophosphate, a molecule which decreases demineralisation in bone - inhibit osteoclasts by reducing recruitment and promoting apoptosis Clinical uses: - prevention and treatment of osteoporosis - hypercalcaemia - Paget's disease - pain from bone metatases Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet

Cutaneous Manifestations of Diabetes Necrobiosis Lipoidica ( Diabeticorum) NL

annular eythematous asymptomatic papules with yellow brown center 50 % of people have diabetes lower legs- women Tx: Topical steroids

unhappy triad

anterior cruciate ligament medial collateral ligament meniscus

Diffuse scleroderma ab

anti-Scl-70 antibodies

SJOGREN'S SYNDROME 2B

autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. there is lymphocytic infiltration of exocrine glands - may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders - usually develops around 10 years after the initial onset - much more common in females (from 14:1 to 24:1) - marked increased risk of lymphoid malignancy (40-60 fold) 4/5 Features - Xerophthalmia ( no production of tears) - Xerostomia ( dry mouth) with depapillation - Dysphagia - Dysphasia - Dental cavitation and poor dental hygiene -Dyspareunia due to dry vagina - Fatigue, fever, weight loss and other systemic features -hearing loss -autoimmune thyroiditis arthralgia Raynaud's, myalgia sensory polyneuropathy renal tubular acidosis (usually subclinical) -fatigue, raynauds, pulmonary fibrosis, Parotid or submandibular gland swelling Ix - rheumatoid factor (RF) positive in nearly 100% of patients - ANA positive in 70% & anti-Ro (SSA) antibodies in 70% of patients with PSS - anti-La (SSB) antibodies in 30% of patients with PSS - Schirmer's test: filter paper near conjunctival sac to measure tear formation -salivary gland biopsy salivary flow rate - histology: focal lymphocytic infiltration - also: hypergammaglobulinaemia, low C4 -ESR ⬆, CRP ⬆ -FBC: leukopaenia, thrombocytopaenia Rx artificial saliva and tears pilocarpine may stimulate saliva production

Still's disease features

autoimmune dz characterised by pyrexia, artralgia, salmon pink rah 16-40 elevated serum ferritin rash: salmon-pink, maculopapular and rash lymphadenopathy rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative manage w/ NSAID and steroids , MTX

Chronic Angioedema

b. Chronic form: i. Idiopathic: 40-50 year old women, milder form ii. Acquired C1 inhibitor deficiency: Complement deficiency leads to angioedema and can be associated with malignancy (Lymphoma/Leukemia) or autoimmune disease

Achrochordons / papillomas, skin tags

benign growth of epidermis and dermis and subcutaneous tissue. flesh colored

IX for basal cell carcinoma

biopsy

Azathioprine side effects

bone marrow depression nausea/vomiting pancreatitis

Hydroxychloroquine side effects

bull's eye retinopathy - may result in severe and permanent visual loss - colour retinal photography and spectral domain optical coherence tomography scanning of the macula

Biceps tendonitis Cause

by overuse of the biceps muscles, usually heavy or excessive lifting

Pathologic

caused by diseases that weakens the bones

Rheumatoid arthritis crystals

cholesterol crystals, these are rhombic/brick-shaped with a negative birefringence

Petechiae

circumscribed blood deposit <.5cm

Macule

circumscribed change in color <1cm

Patch

circumscribed change in color > 1cm

Papule

circumscribed change in texture <1cm descriptive modifiers, umbilicated, verrucoid, flat-topped, excoriated, atrophic, follicular etc.

Purpura

circumsribed blood deposit >.5

Tinea incognito

clinically masked dermatophyte infection due to inappropriate therapy with topical steroids

Hip fracture 1B

common fracture in elderly (greater incidence of osteopenia) o female > male o in osteopenic individuals, fracture may precede simple fall (muscle stronger than bone) o in younger individuals, fracture related to high energy injury markedly displaced associated with other injuries S+S: unable to bear weight on affected limb o limb shortened, externally rotated, painful ROM, antalgic gait if patient can weight bear Ix: AP of pelvis and lateral of involved hip o if findings equivocal - MRI, bone scan and tomograms Rx- Intracapsular hip fracture: Undisplaced Fracture: internal fixation, or hemiarthroplasty if unfit. Displaced Fracture: young and fit i.e. <70 years- Reduction and internal fixation (if possible) Extracapsular hip fracture dynamic hip screw if reverse oblique, transverse or subtrochanteric: intramedullary device . older and reduced mobility- Hemiarthroplasty or total hip replacement.

MONGOLIAN SPOT

common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns usually at the butt or sacrum

BEHCET'S SYNDROME

complex multisystem disorder associated with presumed autoimmune mediated inflammation of the arteries and veins. characterised by : Recurrent attacks of oral aphthous ulcers, genital ulcers, uveitis, and skin lesions - more common in the eastern Mediterranean (e.g. Turkey) and Asia - more common in men - tends to affect young adults (20 - 40 years old) - associated with HLA B5 and MICA6 allele - around 30% of patients have a positive family history features classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis thrombophlebitis arthritis neurological involvement (e.g. aseptic meningitis) GI: abdo pain, diarrhoea, colitis erythema nodosum, DVT Ix clinical Rx steroids immunosupressive drugs

dermoid cyst

congenital tumor composed of displaced embryonic tissue (teeth, bone, cartilage, and hair); typically found in an ovary and usually benign can be found on skin as painless, swelling. they are lined by hair and squamous epithelium

epithelial inclusion cyst 2B

cysts are fluid filled or semifluid filled nodules - benign cysts occurring on neck, scalp , trunk -this cyst is a response to an injury. Skin is tucked in to form a sac that is lined by normal epidermal cells that continue to multiply, mature and form keratin. -can turn in to cancer

Risk factors for osteomyelitis

diabetes mellitus sickle cell anaemia intravenous drug user immunosuppression due to either medication or HIV alcohol excess

Telangiectasia

dilated superficial blood vessel

LEFLUNOMIDE

disease modifying anti-rheumatic drug (DMARD) mainly used in the management of rheumatoid arthritis - very long half-life which should be remembered considering it's teratogenic potential CI: pregnancy and pre-existing lung and liver disease Monitoring: FBC/LFT and blood pressure Stopping: leflunomide has a very long wash-out period of up to a year which requires co-administration of cholestyramine

Cutaneous Horn

firm conical projection made of keratin, Resembles animal Horn FACE, ARMS, hand, ears hard as a rock!

LENTIGO MALIGNA

freckle-like proliferation of melanin-producing cells that may develop on sun-exposed skin; may transform later into melanoma perisist in winter can be found in some conditions i.e Carney complex, Peutz-Jeghers syndrome

Tinea unguium (onychomycosis) 1B

fungal infection of the nail due to Dermatophytes such as Trichophyton rubrum (T rubrum), T. interdigitale. The infection is also known as tinea unguium. increases with age features: white yellow opaque streat o n side of nail, end of nail lifts up, thickening of nail plate Rx i. Anitfungal Creams for mild to moderate cases (terbinafine, econazole, etc.) ii. Oral antifungals for extensive or resistant cases (griseofulvin, intraconazole, fluconazole, terbinafine)

Leflunomide side effects

gastrointestinal, especially diarrhoea hypertension weight loss/anorexia peripheral neuropathy myelosuppression pneumonitis

gout sxray

gout1

physis

growth plate

Charcot-Marie-Tooth disease

hereditary condition characterized by progressive degeneration of the muscles of the lower leg, specifically those associated with the fibula wasting

knee disclocation

high energy trauma caused by tears of multiple ligaments -ss: effusion, pian, knee instability, iscahemic limb Specific Complications • high incidence of associated injuries popliteal artery tear peroneal nerve injury capsular tear • chronic: instability, stiffness, post-traumatic arthriti

SUBTROCHANTERIC :

high trauma, osteoporosis ss: ss: acute hip pain , cant weight bear, short &externall rotatated leg, painful RO

Associated Features of Atopic Dermatitis hyperlinearity of palms

i

AZATHIOPRINE

immunosupressant inibits purine synthesis used in autoiimne dz IB, RA, - thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity SE: pancretitis, BM depression Interactions: - Allopurinol (both inhibitors of xanthine oxidase): causes bone marrow suppression

paronychia 1A

inflammation around the nail bed mainly with S.aureus (common) , MRSA, S.pyogenes, peudomonas, HSV 1, candia acute <6 weeks chronic > 6 weeks Aex: nail biting, ingrown toe nails, manicuring, oral retinoids ( causes drying) . EGFRs and BRAF chronic form common is: dairy farmers, fishermenm houewives, cleansers features: pain, redness , swelling. if HSV yellow puss under cuticle, nail bed lifts (onycholysis) if pyogenes : fever lymphangitis, tender lymphoadenopathy Complications: hand cellulitis Ix: culture, swab, gram stain microscopy, Tzanck smear, nail clipping culture for mycology Rx: 1. soak in warm water 2. avoid wet work, waterproof gloves 3. keep fingernails clean 4. emolients 5. topical steroids 6. steroid injections 7. antiseptics or antifungals 8.Oral antifungal agent (itraconazole or fluconazole), if C albicans is confirmed.

DERMATOMYOSITIS

inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions - may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older) - polymyositis is a variant of the disease where skin manifestations are not prominent

compartment syndrome 1B

involves the compression of nerves and blood due increased interstitial pressure in an anatomical "compartment" (forearm, calf) with little room for expansion, resulting in decreased perfusion and potential muscle/nerve necrosis associated with SUPRACONDYLAR ( common in children from FOOSH) AND TIBIAL SHAFT FRACTURES look for "the 6 Ps" - ss: o pain on passive movement (out of proportion to injury) and respond to normal dose of analgesics o pallor o paralysis (inability to move limb) o pulse discrepancies o parasthesia o polar (cold) Ix: compartment pressure monitoring in unresponsive or unreliable patients ( pressure >20mmHg abnormal, 40mmHg diagnostic - CK -myoglobin • requires prompt decompression: remove constrictive casts, dressings; fasciotomy may be needed emergently Rx Fasciectomy

Achilles Tendon Rupture

loading activity stop and go sports secondary to chronic tendonitis, steroid injection usually one to two inches above tendinous insertion on calcaneous, greatest btwn 30-50 yrs of age, typically be unable to stand on their toes and tend to exhibit a positive Thompson test pop, sudden pain, sensation of being kicked in heel , palpable gap weak plantar flexion

saddle anesthesia

loss of sensation restricted to the area of the buttocks and perineum - young men -emergency

Chondrosarcoma

malignant tumor of cartilage >40 YO

HYDROXYCHLOROQUINE

management of rheumatoid arthritis and systemic/discoid lupus erythematosus Monitoring: Ask patient about visual symptoms and monitor visual acuity annually using the standard reading chart

Bunions -Hallux Valgus Deformities 1B

medial displacement of 1st metatasrsal and lateral deviaton of hallux -valgus alignment of 1st metatarsal -associated w/ poor fitting shoes, heridtory, sec to Oa -more common in women -reactive exostosis forms with thickening of the skin creating a bunion -ss: pain and redness, bursitis medial to the joint, and mild synovitis. rx: shoe with a wide toe box, protective pads, and orthotics steroid injection for bursitis or synovitis

Cherry Angioma (Senile Angioma)

most common vascular lesion, EVERYONE WILL ALMOST GET TEHM single or multiple red papules trunk, extremities, genitals, oral mucosa, bleed easily with trauma

PCL tear

much less common than ACL injury History o fall onto flexed knee with plantar flexed foot o hit anterior tibia on dashboard in motor vehicle accident o hyperflexion or hyperextension with anterior tibial force Physical o positive posterior sag sign o false positive anterior drawer o true positive posterior drawer Diagnosis: o X-ray - may be associated with an avulsion fracture of posterior tibial tubercle o Clinical diagnosis best confirmed with MRI Treatment o Vast majority managed non-surgically and do well. Reconstruction only indicated in multiple ligamentous injuries of the knee and those that have instability despite adequate non-surgical management

Methotrexate side effects

mucositis myelosuppression pneumonitis pulmonary fibrosis liver cirrhosis Pregnancy: women should avoid pregnancy for at least 3 months after treatment has stopped men using methotrexate need to use effective contraception for at least 3 months after treatment

Nail psoriasis

nail pitting- most common and well known cause of nail pitting Onycholysis- lifting of the nail, plate off of the nail bed subungal hyperkeratosis- scale under the nail plate nail deformity- if nail matrix is involved

Bursae (bursitis) of the knee 1B

o Prepatellar (nursemaid's knee) - overlying the patella commonest bursa of knee o Infrapatellar - overlying the patellar ligament and tibial tuberosity o Due to chronic kneeling - e.g. carpet layers, wrestlers o Commonly infected o Soft cystic swelling over front of knee o Check for inflammation o Aspiration and culture/sensitivity Treatment o Aspiration and steroid injection - recurrence 20% o Surgery Excision Incision and drainage if infected

femoral diaphysis fracture 1B

o high energy (MVA, fall from height, gunshot wounds) o low energy (spiral fracture in children) o high morbidity/.mortality (haemorrhage, fat embolism, ARDS, MODS) o blood replacement often required o frequently comminuted o associated soft tissue trauma Clinical findings o leg is shortened, externally rotated o unable to weight bear o assess neurovascular status o examine for evidence of an open fracture, with soft tissue compromise o suspect child abuse with spiral femoral shaft fractures in children Treatment o ABC's of trauma are essential o immobilize leg with Thomas Splint o adequate analgesia . o surgical fixation (intramedullary nail) within 24 hours high rate of surgical union after 6 to 12weeks o early mobilization of hip and knee

meniscal tear

o medial meniscus torn 8x more the lateral o ½ are traumatic,1/2 are degenerative o often associated with other ligamentous injuries if traumatic History: o twisting force when the knee is partly or completely flexed e.g., squatting and then rotating rapidly, skiing, football, tennis o acute - immediate pain, difficulty weight bearing.+/-Iocking o chronic - pain, swelling, instability Types of meniscal tears 1. Horizontal 2. Oblique 3. Circumfrencial 4. Transverse 5. Degenerative 6. Bucket-Handle Clinical presentation o Locking, clicking, giving way of knee o effusion o kick of full extension (locking) o pinpoint joint line tenderness o McMurray's or Thessaly test positive Diagnosis and Treatment o MRI for diagnosis only Treatment o conservative (unless locked) ROM and strengthening exercises NSAIDs o failed conservative - persistent pain, locking, giving way arthroscopy (diagnostic and therapeutic) o excise torn section o repair marginal tears

multiple myeloma

o most common primary malignant tumour of bone in adults o anaemia, anorexia, renal failure, nephritis, o weakness, bone pain Diagnosis o osteoporosis, punched out lesions in cancellous bone (esp. skull), compression fracture of spine o ESR elevated o serum / urine protein electrophoresis o bone marrow aspirate`

LCL

o varus force to knee o similar history, physical to MCL o often associated with common peroneal nerve injury o treatment as for MCL

Sulfasalazine side effects

oligospermia Stevens-Johnson syndrome pneumonitis / lung fibrosis myelosuppression, Heinz body anaemia, megaloblastic anaemia may colour tears → stained contact lenses

Associated Features of Atopic Dermatitis Pityriasis alba

patches of hypo pigmentation thought to represent subtle areas of inflammation associated with atopic dermatitis

ankle anaotmy

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osteomyelitis CT

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renal osteodystrophy xray

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Auspitz's Sign

pin point bleeding when scale is removed

Associated Features of Atopic Dermatitis keratosis pilaris

pinpoint hyperkeratotic papules of posterior arms, anterior thighs, buttocks, face

IFN-gamma

produced by T lymphocytes & NK cells weaker antiviral action, more of a role in immunomodulation particularly macrophage activation may be useful in chronic granulomatous disease and osteopetrosis

IFN-beta

produced by fibroblasts antiviral action reduces the frequency of exacerbations in patients with relapsing-remitting MS

IFN-alpha

produced by leucocytes antiviral action useful in hepatitis B & C, Kaposi's sarcoma, metastatic renal cell cancer, hairy cell leukaemia SE: flu-like symptoms and depression

Isomorphic Koebner's Phenomenon

psoriasis developing in the site of skin trauma

Ruptured achilles

results from jumping- sudden pain above heel. impossible to tiptoe

Sjogren syndrome antibodies

rheumatoid factor (RF) positive in nearly 100% of patients ANA positive in 70% anti-Ro (SSA) antibodies in 70% of patients with PSS anti-La (SSB) antibodies in 30% of patients with PSS

Lateral cutaneous nerve of the thigh

sensory only lateral and posterir surfaces of thigh -> tingling and numbness

diaphyseal

shaft of a long bone

Swimmers Itch

shistosome cercarial (flatworm larva) exposure Fresh water great lakes Region Itchy papules and pustules on EXPOSED skin Cool compresses, antihistamines, topical steroids

Anterior cruciate ligament injury

sports Damage may result from twisting injuries Anterior drawer test and Lachman test may be positive if damaged RAPID joint swelling (haemoarthrosis)

what drg can cause depigmentation of the skin

steroids (topical) especially in dark skinned people

spine special tests

straight-leg test Lasegue maneuver: dorsiflexion of foot during straight leg raise makes symptoms worse or, if leg is less elevated, dorsiflexion will bring on symptoms femoral stretch test: with patient prone, flexing the knee of the affected side and passively extending the hip results in radicular symptoms of unilateral pain in anterior thigh

shoulder strain 1B

stretching or tearing of a muscle or tendon in the shoulder. -aex: heavy backback on while shoulder, swimming, tennis

Epiphysis

the end part of a long bone, initially growing separately from the shaft.

metaphyseal

the flared portion of the bone at the ends of the shaft

Psoriatic arthropathy management

treat as rheumatoid arthritis - but better prognosis

ACL injury

twisting positive anterior drawer test

Types of spinal fractures

types: - compression (flexion) : anterior vertebra breaks and loses height, usually stable neurological problems are rare -Axial burst fracture: both front and back of vertebra broken . stable - fracture dislocations: when ligaments or discs connecting vertebrae are stretche or torn results in instability and compression -flexion distraction: hyperflexion and distraction of posterior elements SS: localised neck pain , stiffness. numbness or weakness if compression . difficulty breathing -Rx: stabalisation surrgery or braces Ix: CT, MRI, Xray

Claw hand

ulnar nerve damage c8-t1

rotator cuff muscles (SITS) (shoulder)

upraspinatus (suprascapular nerve), abduction infraspinatus (suprascapular nerve, external rotation ) teres minor (axillary nerve, exterbal rotation ) , subscapularis (subscapular nerve, internal rodation and adduction )

patella dislocation

usually a non-contact twisting injury - lateral displacement of patella after contraction of quadriceps at the start of knee flexion in an almost straight knee joint - direct blow, e.g. knee/helmet to knee collision -young female, obesity , highriding patela ss: knee give way when walking, severe pain , tenderness, weak knee extension, effusion Treatment - Reduce patella - gentle ROM - Strengthen quadriceps - Support during sporting activities

Ankle Fracture

usually involves - ipsilateral ligamentous tears or transverse bony avulsion contralateral shear fractures (oblique or spiral) • classification systems Danis-Weber Lauge-Hansen: based on foot's position and motion relative to leg Type A (infra-syndesmotic): pure inversion injury, avulsion of lateral malleolus below plafond or torn calcaneofibular ligament , ± shear fracture of medial malleolus • Type B (trans-syndesmotic): external rotation and eversion (most common), ± avulsion of medial malleolus or rupture of deltoid ligament, spiral fracture of lateral malleolus starting at plafond • Type C (supra-syndesmotic): pure external rotation avulsion of medial malleolus or torn deltoid ligament, ± posterior malleolus avulsion with posterior tibio-fibular ligament, fibular fracture is above plafond (called Maisonneuve fracture if at proximal fibula) frequently tears syndesmosis

Venous Lake

violet blue papules on oral mucosa or pinna in elderly

osteomyelitis xray

x-ray: become abnormal after 2 to 4 wk, showing periosteal elevation, bone destruction, soft-tissue swelling, and, in the vertebrae, loss of vertebral body height or narrowing of the adjacent infected intervertebral disk space and destruction of the end plates above and below the disk.

INTERTROCHANTERIC FRACTURE:

young due to MVC, fall from height. elderly: twisting, fall from standing. ss: acute hip pain , cant weight bear, short &externall rotatated leg, painful ROM

Pulled elbow (nursemaid's elbow)

• Distal subluxation of radius; Radial head slips out of annular ligament • Forceful pull on hand-pick up heavy object, sudden forceful pulling -common in children up to 7 years, bones and muscles still developing ss: pain., child holds arm still in flexed position Ix: clinical diagnosis • Displacement is reduced (closed) - May be followed by sling with elbow flexed and supinated.

plantar faciitis

• inflammation of plantar aponeurosis at calcaneal origin • common in athletes (especially runners, dancers) • also associated with obesity, DM, seronegative and seropositive arthritis due to : repetitive injury causng microtears and inflammation of plantar fascia • insidious onset of heel pain, pain when getting out of bed and stiffness -intense pain when walking from rest that subsides as patient continues to walk, worse at end of day with prolonged standing -

ANKLE FRACTURE: lateral ligament complex tear Anterior Talofibular, Calcaneofibular, Posterior Talofibular

• inversion injury, >90% of all ankle sprains • ATF most commonly and severely injured if ankle is plantar flexed • swelling and tenderness anterior to lateral malleolus • ++ ecchymoses • positive ankle anterior drawer • may have significant medial talar tilt on inversion stress x-ray

Shoulder sprain 1B

• separation/ subluxation of acromialclavicular ligament/joint - falling onto shoulder/sstretched arm , fracture may be present, contact sports -Trauma from car accident - - grade 1 ( stretch ) grade 2( partial tear , grade 3 (separation, minor cvla displacement, grade 4-6 Both ligaments ruptured, significant displacement of clavicle ) -S/S: pain, swelling, bruising, limited movement , outer end of the clavicle is abnormally prominent and tender, may see lump ( clavicle which has become detached) . pain on adduction or palpaption on AC joint , limited ROM Ix: Xray bilateral AP Rx: sling 1-3 2 wks, analgesia, rehab operatiom grades 4-6 ortho surgeron

distal humeral fracture 1B

• young: high energy trauma (MVC) • elderly: FOOSH S/S: elbow pain and swelling • assess brachial artery Investigations: x-ray: AP and lateral of humerus and elbow , CT scan: helpful when suspect shear fracture of capitulum or trochlea Classification: supracondylar, distal single column, distal bicolumnar and coronal shear fractures