WEBVTT

1
00:00:01.320 --> 00:00:04.639
All right, so fifty high old
MSK questions bunch of demonics in there to

2
00:00:04.639 --> 00:00:07.040
help you remember the stuff that you
need to know for your exam. Thank

3
00:00:07.080 --> 00:00:10.080
you as always for the support the
really nice comments. I truly do appreciate

4
00:00:10.119 --> 00:00:11.880
it. If you want to check
out the YouTube channel if you want some

5
00:00:11.960 --> 00:00:14.679
visuals to go along with the audio, let's cram the pants on YouTube.

6
00:00:14.720 --> 00:00:17.199
All right, let's go ahead and
get started. Question one, forty two

7
00:00:17.280 --> 00:00:20.800
year old female presents to the office
today complaining of a burning pain in the

8
00:00:20.800 --> 00:00:24.239
ball of her foot radiating to the
third and fourth toe. She states the

9
00:00:24.239 --> 00:00:27.760
burning sensation is worse after a long
day of standing on her feet, especially

10
00:00:27.800 --> 00:00:32.399
when she wears high heels. Physical
examination reveals tenderness in the plantar aspect of

11
00:00:32.439 --> 00:00:36.960
the distal foot over the third intermeda
tarsal space. What is the most likely

12
00:00:37.000 --> 00:00:41.399
diagnosis in this patient? So that
is going to be a morton neuroma,

13
00:00:41.600 --> 00:00:45.840
So mort neuroma, which is a
compressive neuropathy. When it comes to morton

14
00:00:45.840 --> 00:00:48.719
neuroma, there's three things that you
need to know for the exam that will

15
00:00:48.759 --> 00:00:52.159
be in the vignette. It will
be a woman. They will likely describe

16
00:00:52.159 --> 00:00:56.240
a tight fitting shoe, often high
heels, as overpronation of the foot can

17
00:00:56.280 --> 00:01:00.799
cause this condition and the paristhesias,
the numbness burning is set that these patients

18
00:01:00.840 --> 00:01:04.000
feel is going to be most common
in the third intermetatarsal space. The way

19
00:01:04.000 --> 00:01:07.280
that I used to remember these three
key things for the vignette is by focusing

20
00:01:07.319 --> 00:01:11.719
on the M in more neuroma.
If you turn an M on its side,

21
00:01:11.760 --> 00:01:15.599
it's a three that helps remember the
third intermetatarsal space is the most common

22
00:01:15.599 --> 00:01:18.400
area to be affected. If you
turn the M upside down, it's a

23
00:01:18.560 --> 00:01:23.079
W that helps you remember women are
approximately five times more likely than males to

24
00:01:23.120 --> 00:01:26.959
develop more neuroma. And then the
M it also looks like the spike of

25
00:01:26.959 --> 00:01:30.040
two heels. Las it does to
me and that helps me remember this is

26
00:01:30.040 --> 00:01:33.519
often caused from tight fitting shoes or
high heels from the overpronation of the foot.

27
00:01:33.719 --> 00:01:37.480
So remember from more neuroma third intermetatarsal
space way more common in women.

28
00:01:37.560 --> 00:01:40.760
And then the M tight fitting shoes
like high heels looks like the spike of

29
00:01:40.840 --> 00:01:44.000
high heels, all right. Question
two. A sixty three year old female

30
00:01:44.000 --> 00:01:48.040
presents the office to review the results
of her bone density test. She has

31
00:01:48.040 --> 00:01:52.000
a history of vertebral fractures, and
her recent bone density test reveals a T

32
00:01:52.200 --> 00:01:56.400
score of negative two point eight.
The treating physician decides to start the patient

33
00:01:56.439 --> 00:02:00.560
on reloxifen. The what is likely
positive in this page as pathematical history that

34
00:02:00.599 --> 00:02:07.200
would influence the decision to start her
on reloxofen rather than alternative osteoporosis agents.

35
00:02:07.640 --> 00:02:10.840
So that is going to be breast
cancer. So reloxofin orloxophene is a selective

36
00:02:10.960 --> 00:02:15.280
estrogen receptor modulator, and while it
does not work as well as bisphosphonates,

37
00:02:15.360 --> 00:02:19.599
the unique thing about this drug is
that, in addition to treating osteoporosis,

38
00:02:19.800 --> 00:02:23.919
it also reduces the risk of breast
cancer, so it's usually reserved for osteoporosis

39
00:02:23.919 --> 00:02:28.120
patients when there's also a need for
breast cancer prophylaxis. It's really the only

40
00:02:28.120 --> 00:02:30.400
thing you need to know for this
med So how can you remember that,

41
00:02:30.759 --> 00:02:34.479
Well, there's a much more commonly
used med for breast cancer prophylaxis slash treatment

42
00:02:34.639 --> 00:02:38.639
they probably have heard of in the
same class, and that's tamoxifen, tomoxifen

43
00:02:38.719 --> 00:02:42.680
orloxofin, so it sounds very similar. So remember reloxofin is in the same

44
00:02:42.680 --> 00:02:46.520
class as tamoxifen, and in addition
to training osteoporosis, it can also be

45
00:02:46.599 --> 00:02:50.919
used for breast cancer prophylaxis. Question
three. Forty two year old female presents

46
00:02:50.919 --> 00:02:54.039
to the office complaining of heartburn,
small white lumps on her fingers as well

47
00:02:54.080 --> 00:02:58.479
as a tight feeling in her hands
that makes it difficult to make a fist.

48
00:02:58.759 --> 00:03:02.560
On physical exam, clangiectasias on the
palms and face. Labs are positive

49
00:03:02.599 --> 00:03:08.159
for both anti nuclear antibodies as well
as anti centromere antibodies. What diagnosis should

50
00:03:08.199 --> 00:03:13.919
be suspected in this patient? So
that is going to be limited systemic sclerosis

51
00:03:13.919 --> 00:03:17.479
aka Crest syndrome. So this patient
has a very classic presentation and has a

52
00:03:17.560 --> 00:03:23.479
number of the manifestations of crests syndrome. Remember CREST stands for calcinosis, cutis

53
00:03:23.759 --> 00:03:29.159
ray nood phenomenon, soft geodysmotility,
sclerodactylly, and talangiectasia. So we see

54
00:03:29.159 --> 00:03:32.400
the calcinosis cutas those are those small
calcium deposits in her hands. She has

55
00:03:32.439 --> 00:03:37.919
heartburn, which is from the esophageal
dysmotility disorder. Clangiectasias as well as the

56
00:03:37.960 --> 00:03:42.439
tightening of the skin of the hands
which can progress to sclerodactyly where we have

57
00:03:42.479 --> 00:03:46.439
this claw like appearance of the hands. So this is classic limited systemic sclerosis

58
00:03:46.479 --> 00:03:50.960
aka Crest syndrome, which we know
will generally have a positive ANA and most

59
00:03:51.039 --> 00:03:55.680
importantly a positive anti centromere antibody test
which I used to remember as anti crestomere

60
00:03:55.879 --> 00:04:00.520
instead to help me remember this antibody
is positive in Cress syndrome. So if

61
00:04:00.520 --> 00:04:04.319
you see a positive anti centromere instead
think of anti crustomere and think of crest

62
00:04:04.479 --> 00:04:10.639
syndrome which is associated with limited systemic
sclerosis. Question four. A sixty three

63
00:04:10.719 --> 00:04:14.719
year old female presents to her physician's
office complaining of pain and stiffness in her

64
00:04:14.719 --> 00:04:16.959
shoulders, hip, and neck.
She states the symptoms are very severe in

65
00:04:16.959 --> 00:04:20.600
the morning, sometimes limiting her activity, and as the day goes on there

66
00:04:20.639 --> 00:04:27.279
is moderate improvement. Physical exam reveals
normal muscle strength and slightly reduce range of

67
00:04:27.319 --> 00:04:32.800
motion. Labs reveal elevated erythrocyte sedimentation
rate and C reactive protein cierum rheumatoid factor

68
00:04:32.839 --> 00:04:38.480
as well as creating kindase are normal, the patient is diagnosed with polymylogio romatica

69
00:04:38.519 --> 00:04:43.360
and started on cortico steroids. Clinical
assessment for the presence of what other associated

70
00:04:43.360 --> 00:04:46.759
condition should also be considered in this
patient. So that is going to be

71
00:04:46.879 --> 00:04:53.079
giant cell arduritis. So remember giant
cell arditis is associated with polymyogi romatica.

72
00:04:53.199 --> 00:04:56.600
You have to know that anywhere from
five to thirty percent of patients with PMR

73
00:04:56.800 --> 00:05:00.360
will have giant cell ardoritis. This
always shows up on exam quest and you

74
00:05:00.399 --> 00:05:02.560
don't want to miss this diagnosis in
real life because it can lead to blindness

75
00:05:02.560 --> 00:05:05.000
if it's not treated. So if
you make the diagnosis of PMR and a

76
00:05:05.040 --> 00:05:10.279
patient, make sure you're asking the
patient about headaches, jaw claudication, transi

77
00:05:10.279 --> 00:05:12.759
A vision laws to make sure they
don't need a work up for giant cell

78
00:05:13.319 --> 00:05:15.680
So the way that I used to
remember that Paul E. Myalger romatica is

79
00:05:15.680 --> 00:05:20.160
associated with giant cell arturitis is by
instead of remembering it as Paul E myalgio

80
00:05:20.279 --> 00:05:25.920
romatica, instead remember it as Paul
B. Myalgia romatica Paul B as in

81
00:05:25.959 --> 00:05:29.160
Paul Bunny and the Giant from those
kids books. And then you'll always remember

82
00:05:29.199 --> 00:05:32.240
this is associated with giant cell arderitis. Question five, What is the most

83
00:05:32.240 --> 00:05:38.319
common type of osteoporotic fracture? So
that is going to be vertebral fractures.

84
00:05:38.319 --> 00:05:42.759
So vertebral fractures are the most common
type of osteoporotic fracture. These types of

85
00:05:42.759 --> 00:05:46.639
fractures can sometimes be a symptomatics or
remember to assess for loss of height or

86
00:05:46.759 --> 00:05:50.439
kyphosis, as these are sometimes the
only indicator of a vertebral compression fracture in

87
00:05:50.519 --> 00:05:56.439
an osteoporotic patient. Question six.
Sixty two year old Mail presents the emergency

88
00:05:56.519 --> 00:06:00.079
department after being involved in a motor
vehicle accident, is complaining of severe pain

89
00:06:00.160 --> 00:06:02.800
in his right hip. On physical
exam, you know what. The right

90
00:06:02.879 --> 00:06:09.360
leg is internally rotated and adducted.
X ray reveal a dislocation of the right

91
00:06:09.439 --> 00:06:13.480
hip. What type of dislocation did
this patient likely suffer? Remember, his

92
00:06:13.560 --> 00:06:17.000
leg is internally rotated and adducted,
so that is going to be a posterior

93
00:06:17.079 --> 00:06:23.839
hip dislocation. So why a posterior
hip dislocation? First? Posterior Hip dislocations

94
00:06:23.879 --> 00:06:27.879
are the most common type of hip
dislocation, counting for almost ninety percent of

95
00:06:27.920 --> 00:06:30.519
all types of hip dislocations. And
then the second reason why this is likely

96
00:06:30.560 --> 00:06:35.279
a posterior dislocation is because on physical
exam, the patient's leg is internally rotated

97
00:06:35.319 --> 00:06:42.920
and adducted, which is the classic
presentation for posterior dislocations where anterior are classically

98
00:06:43.040 --> 00:06:47.480
externally rotated and abducted. Question seven. Forty six year old Mail presents to

99
00:06:47.519 --> 00:06:51.839
the office complaining of severe lower back
pain radiating into both legs, as well

100
00:06:51.879 --> 00:06:57.040
as numbness in his inner thighs and
buttocks that started after moving some furniture.

101
00:06:57.279 --> 00:07:01.160
He also reports difficulty with urination.
Physical exam reveals lower extremity, weakness,

102
00:07:01.160 --> 00:07:05.680
saddle parastesia, and loss of rectal
tone. What is the diagnostic test of

103
00:07:05.800 --> 00:07:10.720
choice for the likely diagnosis in this
patient? So that is going to be

104
00:07:10.759 --> 00:07:14.959
an MRI. So this patient very
likely has called a quina syndrome. They

105
00:07:15.000 --> 00:07:19.120
have the classic clinical manifestations lower back
pain radiating to the legs, saddle parastesia,

106
00:07:19.240 --> 00:07:24.040
urinary in continence, loss of rectal
tone. All of these areas are

107
00:07:24.040 --> 00:07:29.360
affected because cata quina syndrome is severe
compression of multiple lumbo sacral nerve roots that

108
00:07:29.399 --> 00:07:32.399
innervate these regions. So when cataquina
syndrome is suspected, you're going to order

109
00:07:32.399 --> 00:07:35.240
an MRI. Generally, this is
with contrast, and this is going to

110
00:07:35.240 --> 00:07:40.079
be your diagnostic test of choice.
Really in any situation where there's suspicion for

111
00:07:40.120 --> 00:07:43.120
a localized process within the spinal cord, and RI is going to be your

112
00:07:43.160 --> 00:07:47.920
test of choice. All right.
Question eight. Anterior dislocation aka forward slippage

113
00:07:48.240 --> 00:07:54.439
of one vertebral body with respect to
the one beneath it is known as so

114
00:07:54.480 --> 00:07:59.079
that is going to be spondulolis thesis. So forward slipping of a vertebral body

115
00:07:59.480 --> 00:08:03.199
relative to an adjacent inferior vertebral body. That's sponded Lo list thesis. Thirty

116
00:08:03.199 --> 00:08:07.240
to fifty percent of the time.
This is a consequent of spondalo lisis.

117
00:08:07.560 --> 00:08:11.399
Anyways, how do you remember spondal
lolist thesis is forward slippage of a vertebral

118
00:08:11.439 --> 00:08:13.319
body. Well, I have this
little trick that worked for me. Maybe

119
00:08:13.319 --> 00:08:16.079
it'll work for you, maybe not. But when I saw spond lo list

120
00:08:16.160 --> 00:08:20.319
thesis at the end of the word, it has list thesis in it,

121
00:08:20.360 --> 00:08:24.079
like list your thesis statement. So
when I see sponded lost thesis, I

122
00:08:24.120 --> 00:08:26.480
think of the sentence, list your
thesis statement on the slip of paper and

123
00:08:26.560 --> 00:08:30.360
pass it forward, like you're in
class and your teacher asks you to pass

124
00:08:30.399 --> 00:08:33.440
the your thesis statement forward. So
when you see spondal lost thesis right away,

125
00:08:33.440 --> 00:08:37.039
think list thesis and then what are
you going to do with your thesis.

126
00:08:37.039 --> 00:08:39.519
You're gonna list it on a slip
of paper and pass it forward.

127
00:08:39.799 --> 00:08:43.840
And that slip of paper being passed
forward helps you remember the vertebral body slips

128
00:08:43.919 --> 00:08:48.320
forward and spond A low list thesis
a little weird, but it definitely worked

129
00:08:48.360 --> 00:08:52.200
for me. Question nine. Thirty
two year old female presents to the office

130
00:08:52.240 --> 00:08:56.039
complaining of fatigue, weakness, fever, and a rash for the past two

131
00:08:56.080 --> 00:08:58.240
months. On physical exam, you
note are a thema over the cheeks and

132
00:08:58.360 --> 00:09:03.879
nose bearing the nasalabial folds. You
suspect lupus and order and anti nuclear antibody

133
00:09:05.120 --> 00:09:09.480
which comes back positive. Which additional
lab test listed below would be most appropriate

134
00:09:09.519 --> 00:09:16.480
to order next to assist in making
the diagnosis answer A anticentromere antibody answer B

135
00:09:16.759 --> 00:09:26.480
ant tissue transglutaminase antibody C anti smith
antibody, D anti cyclic sutrilinated peptide antibody

136
00:09:26.559 --> 00:09:31.879
again, A anticentromere b ant tissue
transglutaminase C anti Smith, d anti cyclic

137
00:09:31.960 --> 00:09:37.559
cutrilinated peptide. So the answer is
going to be C anti Smith antibody,

138
00:09:37.720 --> 00:09:39.960
all right, So let's talk about
why it's not the other ones. First,

139
00:09:39.080 --> 00:09:43.840
A anti centrimere anibodies. As we
discuss before, this is most commonly

140
00:09:43.919 --> 00:09:48.480
used in the diagnosis of limitous systemic
sclerosis subtype aka Crests syndrome. B anti

141
00:09:48.519 --> 00:09:52.840
tissue transglutaminase body that's used for the
diagnosis of celiac disease. And finally,

142
00:09:52.879 --> 00:09:58.960
anti cyclic cutrilinated peptide anibody or anti
CCP. It's most commonly used for diagnosis

143
00:09:58.960 --> 00:10:01.480
of rheumatoid us right, And while
it can be elevated and lupus, it

144
00:10:01.600 --> 00:10:05.720
is in no way the best lab
tests listed here. The best lab to

145
00:10:05.799 --> 00:10:09.879
order out of these four is by
far the anti Smith antibodies. Anti Smith

146
00:10:09.879 --> 00:10:13.600
antibodies as well as anti double stranded
DNA are the most specific lab tests you

147
00:10:13.600 --> 00:10:16.679
can use for lupus, so those
are really the two that you need to

148
00:10:16.720 --> 00:10:20.519
know for lupus. I used to
remember the word lupus sounds like Lou,

149
00:10:20.679 --> 00:10:24.159
like the name Lou, and piss
like taking a piss, So Lou piss

150
00:10:24.399 --> 00:10:28.720
and I used to remember a guy
named Lou taking a piss on his Smith

151
00:10:28.759 --> 00:10:31.320
and Wesson double barrel shotgun. Anytime
I saw the word lupas just created this

152
00:10:31.519 --> 00:10:35.159
very weird visual of Lou taking a
piss on a Smith and Wesson double barrel

153
00:10:35.159 --> 00:10:39.600
shotgun. You won't forget it.
It's such a weird visual. So Smith

154
00:10:39.639 --> 00:10:43.720
and Wesson helped me remember the anti
smith antibodies, and double barrel shotgun helped

155
00:10:43.799 --> 00:10:48.600
me remember the anti double stranded DNA
antibodies. So remember when you see lupas.

156
00:10:48.639 --> 00:10:50.879
I want you to think of Lou
taking a piss on his Smith and

157
00:10:50.879 --> 00:10:54.279
Wesson double barrel shotgun. Create that
visual in your head and you'll remember the

158
00:10:54.320 --> 00:10:56.840
two main specific labs you need to
know for lupas, anti smith and anti

159
00:10:56.879 --> 00:11:01.679
double stranded DNA. Question T.
A three year old boy presents at the

160
00:11:01.679 --> 00:11:07.279
office company by his mother with with
reports of acute right elbow pain and limited

161
00:11:07.360 --> 00:11:11.000
use of the right upper extremity.
The mother states this all started after she

162
00:11:11.080 --> 00:11:13.559
witnessed his older brother swinging the boy
by his arms as they were playing.

163
00:11:13.799 --> 00:11:18.279
The mother denies any other witness trauma
to the elbow, and physical exam,

164
00:11:18.360 --> 00:11:22.960
no focal bony tenderness, bruising,
deformity, or swelling is found. Radiographs

165
00:11:22.960 --> 00:11:26.840
are negative for fracture. What is
the most likely diagnosis in this patient,

166
00:11:26.039 --> 00:11:31.679
So that is going to be a
radial head sub luxation aka a nurse made

167
00:11:31.720 --> 00:11:33.720
elbow. So this one's pretty straightforward. We have a young child under five,

168
00:11:33.879 --> 00:11:37.679
It's typically the age you'll be looking
for with some sort of pulling injury

169
00:11:37.679 --> 00:11:41.519
to the elbow. When this happens
in young children, the annular ligament is

170
00:11:41.519 --> 00:11:45.799
not thick or strong enough to resist
the traction, and a portion of the

171
00:11:45.840 --> 00:11:50.480
annular ligament slips over the head of
the radius and slides into the radio humeral

172
00:11:50.559 --> 00:11:52.679
joint and it gets stuck there until
it's reduced. You always want to make

173
00:11:52.720 --> 00:11:56.200
sure you do a really good physical
exam in these children and make sure there

174
00:11:56.279 --> 00:12:00.320
is no signs of fracture. They
shouldn't have any focal bony tenderness, rusing

175
00:12:00.320 --> 00:12:03.840
deformity. And while the vignette I
added in a negative X ray finding just

176
00:12:03.879 --> 00:12:05.639
to help solidify the answer in real
life. If everything is normal, on

177
00:12:05.639 --> 00:12:11.240
the physical exam and they fit the
classic picture for radiohead subluxation. X rays

178
00:12:11.240 --> 00:12:15.480
are generally not indicated. Question eleven, a fifty one year old female presents

179
00:12:15.480 --> 00:12:18.840
at the office today complaining of muscle
weakness. She describes difficulty combing her hair

180
00:12:18.960 --> 00:12:22.559
and rising from a chair. And
physical exam you note a rash around the

181
00:12:22.600 --> 00:12:28.440
eyes, violacious papules over the dorsal
aspect of both hands, as well as

182
00:12:28.440 --> 00:12:31.879
erathema across the shoulders, upper back, and upper chest. Labs are drawn

183
00:12:31.919 --> 00:12:39.120
which reveal an elevated creating kindness level
as well as positive antime to antibodies.

184
00:12:39.559 --> 00:12:43.399
What treatment should be initiated in this
patient for the suspected diagnosis that is going

185
00:12:43.440 --> 00:12:48.440
to be glucocorticoids. So this patient
has drmato myocytis, She has the gotron

186
00:12:48.480 --> 00:12:52.879
papules, heliotrope, brash, decreased
muscle strength, the Shaw sign plus elevated

187
00:12:52.919 --> 00:12:58.039
CK in antime to antibodies. That's
about as clear cut as you can get,

188
00:12:58.559 --> 00:13:01.039
and then we know for drmato myosis. Glucocorda choids are the cornerstone of

189
00:13:01.080 --> 00:13:05.159
your initial therapy. This is usually
pret in his own at a dose of

190
00:13:05.240 --> 00:13:09.799
one milligram per kilogram per day.
Now Dermato myycitius has a few very high

191
00:13:09.879 --> 00:13:11.440
yield findings in the way that I
used to remember all the high old stuff

192
00:13:11.440 --> 00:13:16.840
foror dermato myocytis was. Instead of
remembering dermato myocytis, I used to remember

193
00:13:16.440 --> 00:13:20.279
it as permato myocytis. So all
you do is replaced the D with a

194
00:13:20.360 --> 00:13:24.840
P, and now you have perm
prm permato myocytis. So why PERM,

195
00:13:24.960 --> 00:13:28.639
Because whenever you think of this disease, we need to think of a lady

196
00:13:28.679 --> 00:13:31.000
getting a PERM. She's sitting in
the chair, her hair is in the

197
00:13:31.039 --> 00:13:35.120
perm helmet thing, and she's getting
the work. She's getting her nails done,

198
00:13:35.159 --> 00:13:37.600
her eyebrows wax, and she's got
the cape or shawl over her shoulders

199
00:13:37.600 --> 00:13:41.240
as you're normally wearing a salon or
a barbershop. She's just relaxing and having

200
00:13:41.399 --> 00:13:46.000
some me time, me time spelled
within m I. It's very hard visual,

201
00:13:46.120 --> 00:13:48.960
so check out the YouTube channel if
you need one. It's hard visual

202
00:13:50.039 --> 00:13:52.759
to create just by kind of saying
it out loud, but that's a visually

203
00:13:52.759 --> 00:13:54.240
you need to create. Lady in
a chair getting her hair permed, getting

204
00:13:54.240 --> 00:13:58.320
her nails done, eyebrows wax with
the cape or shawl thing that you were

205
00:13:58.360 --> 00:14:01.399
in the salon having some meat time. Now, how does that remember?

206
00:14:01.919 --> 00:14:03.080
How does that help you remember what
you need to know. Well, she's

207
00:14:03.080 --> 00:14:07.759
getting her eyebrows wax, and that
helps remember the heliotrope rash that's common around

208
00:14:07.799 --> 00:14:11.440
the eyes, upper eyelids especially.
She's getting her fingernails done. That helps

209
00:14:11.519 --> 00:14:13.480
remember the gotron papules that are the
most common on the top of the fingers.

210
00:14:13.720 --> 00:14:16.679
And she's wearing the cape or shawl, which helps you remember the shaw

211
00:14:16.799 --> 00:14:22.320
sign or photo distributed poikilo derma,
which is most common in the upper back,

212
00:14:22.519 --> 00:14:24.840
neck and upper chest, exactly where
the cape is distributed when you wear

213
00:14:24.879 --> 00:14:28.759
it anytime you get your hair done. And then remember she's having some me

214
00:14:28.960 --> 00:14:31.120
time, me time spelled am I. That helps you remember the anti me

215
00:14:31.240 --> 00:14:35.879
too antibodies which are highly specific for
dermato myocytis. So remember changed the D

216
00:14:37.039 --> 00:14:39.759
to a P and you have permato
myocytis. Lady getting a perm having some

217
00:14:39.879 --> 00:14:43.879
metime, eyebrows wax, getting her
nails done, and wearing a cape.

218
00:14:43.279 --> 00:14:48.879
Question twelve fifty two year old mail
presents in the emergency department complaining of severe

219
00:14:48.960 --> 00:14:52.320
pain in his first metatar sophalangeal joint. He denied trauma to the area and

220
00:14:52.440 --> 00:14:58.279
states it started suddenly. Arthurs sentisis
is performed, which displays negatively by her

221
00:14:58.320 --> 00:15:03.039
farringent needle shaped crystals. Patient has
a history of hypertension, type two diabetes,

222
00:15:03.279 --> 00:15:09.159
hyperlipidemia, and current medications include hydrochlorothiside, metformin, glyposide, and resuvastatin,

223
00:15:09.519 --> 00:15:13.840
which medication that the patient is currently
taking is the most likely culprit leading

224
00:15:13.879 --> 00:15:18.240
to its current clinical manifestations. Again, those meds or hydrochlorothiside, metformin,

225
00:15:18.320 --> 00:15:22.879
glyposide and rsuvastatin. The med is
going to be hydrochloro thyside, all right,

226
00:15:22.919 --> 00:15:24.240
So this is about as clear cut
a case of gout as you can

227
00:15:24.320 --> 00:15:28.080
get severe pain. First tone,
negatively biofur engine needle shaped crystals on arthur

228
00:15:28.159 --> 00:15:33.200
sentesis. So I have to remembers
which meds can cause gaut flares and in

229
00:15:33.279 --> 00:15:39.440
this case is hydrochlorothyside. Remember thyside
Diuretics like hydrochlor thizide increase urate reabsorption at

230
00:15:39.440 --> 00:15:43.440
the proxymorhinal tubule, which can elevate
uric acid levels and precipitate Gaut flares.

231
00:15:43.759 --> 00:15:48.519
So one of the many meds that
can cause gautflares. So, how do

232
00:15:48.559 --> 00:15:50.200
you remember the main meds that can
cause gaut So? I used to remember

233
00:15:50.360 --> 00:15:54.039
if you put too much seafood on
your plate, you'll get gaut. Plate

234
00:15:54.159 --> 00:16:00.320
stands for purizenamide, loop diuretics,
aspirin, thisides like hydrochlor thizide, and

235
00:16:00.399 --> 00:16:07.399
then fambutal. So again plate plat
pierzenamide, loop diuretics, aspirin, thiasides,

236
00:16:07.639 --> 00:16:11.600
Fambutall that helps you remember the main
meds that you need to know that

237
00:16:11.679 --> 00:16:15.559
can lead to Gaut flares. Question
thirteen. Seventy two year old female presents

238
00:16:15.600 --> 00:16:19.799
at the office today for routine checkup. Path medical history includes hypertension, hyperlipidemium.

239
00:16:21.120 --> 00:16:23.480
She says she has concerns about osteoporosis
as her mother was diagnosed with it

240
00:16:23.600 --> 00:16:27.440
in her sixties and wound up with
a hip fracture. A Deexis scan is

241
00:16:27.519 --> 00:16:33.120
ordered, which reveals a T score
of negative two point six. Is decided

242
00:16:33.159 --> 00:16:36.840
that the patient will be started on
the first line medication class for osteoporosis.

243
00:16:37.279 --> 00:16:41.440
What important instructions need to be provided
to the patient about the proper way to

244
00:16:41.519 --> 00:16:45.240
take the medication before she takes her
first dose, so that is going to

245
00:16:45.320 --> 00:16:48.679
be to avoid recumbency for at least
thirty minutes and take with sixty eight ounces

246
00:16:48.720 --> 00:16:52.399
of water. So first you need
to know the first line medication for osteoporosis,

247
00:16:52.639 --> 00:16:56.480
that of course is bisphosphonates, and
one of the most important adverse drug

248
00:16:56.559 --> 00:17:02.039
reactions from bisphosphonates that you have to
know is esophagitis. This can be avoided

249
00:17:02.320 --> 00:17:04.880
by making sure the patient stays upright
for at least thirty minutes after taking the

250
00:17:04.960 --> 00:17:08.640
medication and taking it with at least
sixty eight ounces of water. It's actually

251
00:17:08.680 --> 00:17:14.880
a contraindication listed on all the bisphosphonates
to give these to a patient who cannot

252
00:17:14.960 --> 00:17:18.480
remain upright for at least thirty minutes. It's also important for them to remain

253
00:17:18.599 --> 00:17:22.359
npo thirty minutes after the dose,
so no other food or mead for thirty

254
00:17:22.400 --> 00:17:25.440
minutes. But by far the most
important thing to know that they will test

255
00:17:25.519 --> 00:17:30.160
you on is avoiding recumbreency for at
least thirty minutes. All right, Question

256
00:17:30.279 --> 00:17:33.799
fourteen, Twenty seven year old Mail
presents to the office with pain and swelling

257
00:17:34.119 --> 00:17:38.240
of his left knee he was playing
soccer with friends and as he was running,

258
00:17:38.440 --> 00:17:42.200
he stopped short to change directions and
felt a pop in his left knee,

259
00:17:42.279 --> 00:17:47.599
followed by pain and swelling. A
Lockman test is performed, which demonstrates

260
00:17:47.720 --> 00:17:52.079
increased interior translation of the tibia with
no distinct endpoint. What type of injury

261
00:17:52.160 --> 00:17:56.319
did this patient likely sustain? So
that is going to be an anterior cruciate

262
00:17:56.400 --> 00:18:02.079
ligament injury. So first the history
hop in the knee followed by immediate swelling.

263
00:18:02.480 --> 00:18:07.119
That swelling that hemarthrosis is a very
common presentation for an ACL tear.

264
00:18:07.480 --> 00:18:11.759
Up to seventy seven percent of patients
with acute hemarthrosis after injury of the knee

265
00:18:11.119 --> 00:18:15.640
have an acel tear. And then
you have the positive Lockman test, which

266
00:18:15.680 --> 00:18:18.880
we know is the most sensitive test
for an ACL tear. And you can

267
00:18:18.920 --> 00:18:22.799
remember that the Lockman tests is the
most sensitive test for ACL tears because the

268
00:18:22.920 --> 00:18:26.000
first three letters of Lockman are ACL
rearranged. So in this patient, all

269
00:18:26.079 --> 00:18:30.720
signs point to an ACL tear.
Question fifteen. Fourteen year old boy presents

270
00:18:30.759 --> 00:18:34.640
the office company by his mother complaining
of right knee and thigh pain. He

271
00:18:34.759 --> 00:18:38.359
denies trauma to the area He ascribes
the pain a severe and deep in his

272
00:18:38.519 --> 00:18:41.599
leg, and he often finds the
pain keeps him up at night. Smother

273
00:18:41.680 --> 00:18:45.799
states he has no medical conditions and
is not currently taking any prescription medications,

274
00:18:47.079 --> 00:18:51.079
and denies any other symptoms such as
fever or weight loss. On physical exam,

275
00:18:51.200 --> 00:18:55.960
a tender soft tissue mass is palpated
on the distal femur. X rays

276
00:18:56.079 --> 00:19:00.599
reveal a soft tissue mass in a
radial or sunburst pattern. What is the

277
00:19:00.640 --> 00:19:03.960
most likely diagnosis in this patient?
So that is going to be in osteosarcoma.

278
00:19:04.359 --> 00:19:07.200
So why osteosarcoma? Well, in
real life you're going to need a

279
00:19:07.440 --> 00:19:11.519
biopsy to say for sure, But
for the sake of an exam question,

280
00:19:11.599 --> 00:19:15.079
there's a few key areas that point
to osteosarcoma. First, osteosarcoma is the

281
00:19:15.160 --> 00:19:19.799
most common primary malignancy of bone in
children and young adults, so that alone

282
00:19:19.920 --> 00:19:23.640
is helpful, but not enough of
course. Second clue is the location of

283
00:19:23.720 --> 00:19:26.720
the mass, which is at the
distal femur, and that's the most common

284
00:19:26.799 --> 00:19:32.359
site of osteosarcoma and children thirty two
percent of all patients. And then finally,

285
00:19:32.680 --> 00:19:34.799
the sun burst pattern to the mass. While this can be seen in

286
00:19:34.880 --> 00:19:41.359
other bone malignancies like ewing sarcoma,
it's most common in osteosarcoma. And then

287
00:19:41.400 --> 00:19:47.400
also ewing sarcoma will most often be
described as having an onion skin or mothi

288
00:19:47.480 --> 00:19:51.920
in appearance on X ray, and
then euing sarcoma often will also have systemic

289
00:19:52.000 --> 00:19:56.079
symptoms fever and malaise, etc.
Which is generally absent in osteosarcoma as we

290
00:19:56.119 --> 00:19:59.440
can see in this patient. So
in this case, most likely diagnosis is

291
00:19:59.480 --> 00:20:03.079
going to be an osteosarcoma. Question
sixteen, Which of the following drugs have

292
00:20:03.240 --> 00:20:08.160
been associated with a high risk of
causing drug induced lupus? A procanamide,

293
00:20:08.559 --> 00:20:14.200
B, metformin C, A,
zythromycin, D, gabapentin, E,

294
00:20:14.599 --> 00:20:15.960
L prazen LAMB. So I could
be a second to think about that,

295
00:20:17.200 --> 00:20:19.839
that's going to be a procanamide.
So there's a bunch of drugs that can

296
00:20:19.920 --> 00:20:23.160
cause lupus, close to fifty that
we know of, but the main ones

297
00:20:23.200 --> 00:20:27.920
that you need to know are prokanamide
and hydrolyzine. Those two alone cause around

298
00:20:29.000 --> 00:20:32.119
thirty percent of all of the cases
of drug induced lupus. Then there's a

299
00:20:32.160 --> 00:20:34.200
few other high old ones that often
get tested on that I would remember.

300
00:20:34.720 --> 00:20:41.119
I used to remember thenemonic chips,
c hipps because the letters in drug induced

301
00:20:41.160 --> 00:20:45.119
lupus are d I L as in
dill, and then it makes me think

302
00:20:45.160 --> 00:20:48.680
of those Dill potato chips or Dill
pickle chips. However you want to remember

303
00:20:48.720 --> 00:20:52.759
it. When you see drug induced
lupus d I L dill, think of

304
00:20:52.920 --> 00:20:56.279
Dill chips, chipps, and you'll
know the high old meads that are always

305
00:20:56.359 --> 00:21:02.119
tested on. SO chips stands for
carbon, magic, hydralazine, isoniazid,

306
00:21:02.359 --> 00:21:07.039
prokanamide, penicillamine, and sulfacealazine.
Know those and you'll very likely get the

307
00:21:07.119 --> 00:21:10.039
question right. That's literally all I
remembered for the exam, and I got

308
00:21:10.079 --> 00:21:12.559
both questions right that I was asked
in school. Question seventeen. Thirty two

309
00:21:12.640 --> 00:21:18.200
year old male with a seizure disorder
complains of acute left shoulder pain after sustaining

310
00:21:18.200 --> 00:21:21.799
a seizure earlier this morning. On
a physical exam, the patient holds the

311
00:21:21.920 --> 00:21:26.759
arm in adduction and internal rotation and
is unable to externally rotate the affected arm.

312
00:21:27.400 --> 00:21:32.160
Radiographs are obtained, which reveal a
circular appearance of the humoral head with

313
00:21:32.240 --> 00:21:36.880
a light bulb appearance, what type
of shoulder dislocation did this patient likely sustain?

314
00:21:37.400 --> 00:21:40.720
So that is going to be a
posterior shoulder dislocation. So if the

315
00:21:40.759 --> 00:21:44.279
posterior shoulders dislocation, you're looking for
a few things in the question. One,

316
00:21:44.640 --> 00:21:48.079
the mechanism of injury. Generally,
any kind of trauma or blow to

317
00:21:48.119 --> 00:21:52.839
the anterior portion of the shoulder with
the arm adducted and internally rotated can cause

318
00:21:52.920 --> 00:21:56.240
a posterior dislocation. But what's unique
and very high yield about this kind of

319
00:21:56.319 --> 00:22:02.039
dislocation is that they are common after
a sisure or electrocution due to the violent

320
00:22:02.079 --> 00:22:06.680
muscle contractions that take place during these
type of injuries. So know that seizure,

321
00:22:06.759 --> 00:22:10.200
electric shock super high y'eld for the
exam, and then a physical exam.

322
00:22:10.319 --> 00:22:14.839
The patient with a posterior dislocation will
usually hold the arm in adduction and

323
00:22:15.079 --> 00:22:19.079
internal rotation, generally unable to externally
rotate. And then finally on X ray,

324
00:22:19.200 --> 00:22:22.680
be familiar with the light bulb sign
for posterie dislocations. Because of the

325
00:22:22.720 --> 00:22:27.039
internal rotation of the arm, the
tuberosities no longer project laterally, which result

326
00:22:27.119 --> 00:22:30.599
in a circular appearance of the humoral
head. And supposedly it looks like a

327
00:22:30.680 --> 00:22:36.400
light bulb. So adduction and internal
rotation. Know the mechanism of injury,

328
00:22:36.519 --> 00:22:38.759
shock or seizure, and know the
light bulb sign on X ray, So

329
00:22:38.920 --> 00:22:42.200
remember those high yield things. I
want you to visualize a warning on a

330
00:22:42.319 --> 00:22:45.559
poster board. On the posterboard,
there's a picture of a broken light bulb,

331
00:22:45.599 --> 00:22:48.319
a finger, and a guy being
shocked, and it says if you

332
00:22:48.440 --> 00:22:52.680
add your finger into a broken light
bulb, you'll get shocked. So add

333
00:22:52.920 --> 00:22:57.759
and into helps. Remember adducted in
internal rotation is the common presentation broken light

334
00:22:57.799 --> 00:23:02.680
bulb because remember the light bulb sign
on X ray and shocked because remember the

335
00:23:02.759 --> 00:23:06.240
unique mechanism of injury, electric shock, or seizure. And all this is

336
00:23:06.279 --> 00:23:11.440
on a posterboard because the poster board
helps you remember Posterior dislocation question eighteen sixty

337
00:23:11.480 --> 00:23:17.559
seven year old female presents the office
complaining of persistent hand persistent pain in her

338
00:23:17.599 --> 00:23:21.279
hands and knees for several months.
She describes the pain as being worse in

339
00:23:21.359 --> 00:23:23.920
the evening, with stiffness in the
morning that only lasts for a few minutes.

340
00:23:25.240 --> 00:23:27.359
On physical exam, there is a
bony deformity and enlargement noted on the

341
00:23:27.480 --> 00:23:33.039
distal interflangeal joints. The joints are
hard and enlarged, but not warm to

342
00:23:33.119 --> 00:23:37.160
the touch. Given the patient's likely
diagnosis, what is the name for the

343
00:23:37.319 --> 00:23:41.599
enlargement of the distal interflangel joints seen
in this patient? So that is going

344
00:23:41.680 --> 00:23:45.079
to be Heberden nodes. So this
patient likely has osteo authritis, persistent pain

345
00:23:45.160 --> 00:23:48.200
in the hands and knees, pain
that's worse in the evening, and stiffness

346
00:23:48.240 --> 00:23:52.480
in the morning that only lasts for
a few minutes. Remember, inflammatory authritis,

347
00:23:52.559 --> 00:23:56.640
like rheumatoid arthritis, is morning stiffness
for sustained periods of time, generally

348
00:23:56.720 --> 00:24:02.759
over sixty minutes osteo authors. If
morning stiffness is present, it's usually only

349
00:24:02.839 --> 00:24:06.319
for a few minutes at most.
We also see the joints are hard and

350
00:24:06.519 --> 00:24:10.799
enlarged, unlike rheumatoid authritis, which
usually has warm and boggy joints. So

351
00:24:10.920 --> 00:24:15.119
this is a classic presentation for osteo
authritis and the bony enlargement of the distal

352
00:24:15.200 --> 00:24:18.519
interphalangeal joints we see in this patient
is known as Heberden nodes and these are

353
00:24:18.559 --> 00:24:25.559
considered a clinical marker for generalized osteo
authritis. Question nineteen fifty three year old

354
00:24:25.559 --> 00:24:30.759
woman with the history of diabetes and
hypothyroidism presents the office complaining of shoulder pain

355
00:24:30.039 --> 00:24:33.599
and stiffness over the span of the
past few months. She denies trauma to

356
00:24:33.680 --> 00:24:37.559
the shoulder and states the symptoms have
increased in severity over the past few weeks.

357
00:24:37.960 --> 00:24:42.759
Physical exam reveals significant limitation in both
active and passive range of motion in

358
00:24:42.920 --> 00:24:48.119
all planes of the affected shoulder.
Rotator cuff strength is normal, and radiographs

359
00:24:48.119 --> 00:24:52.440
of the shoulder display no Apuormladies,
what is the likely diagnosis in this patient?

360
00:24:52.839 --> 00:24:56.160
So that's going to be adhesive capsulitis
aka frozen shoulder. So why is

361
00:24:56.200 --> 00:25:00.880
this adhesive capsulitis and not some sort
of sub a chromeo pathology like rotator cuff

362
00:25:00.920 --> 00:25:06.799
tendinopathy, like impingement syndrome, etc. Well, there's a few reasons.

363
00:25:06.920 --> 00:25:11.559
One, when you have a rotator
cuff tendinopathy and impingement syndrome, usually they're

364
00:25:11.599 --> 00:25:15.559
going to mention the vignette a history
of heavy lifting or repetitive movements related to

365
00:25:15.839 --> 00:25:18.599
occupation or sports, which is not
included in this patient's history. I also

366
00:25:18.680 --> 00:25:22.519
mentioned the vignette the patient has normal
rotator cuff strength, which is another clue

367
00:25:22.599 --> 00:25:26.079
there. And then finally, which
is really important, this patient has weakness

368
00:25:26.359 --> 00:25:32.680
in both active and passive range of
motion. Painful sub chromeial conditions will generally

369
00:25:32.759 --> 00:25:37.839
demonstrate weakness with active range of motion, but will have normal passive range of

370
00:25:37.920 --> 00:25:40.759
motion. And then, of course, this patient fits the classic description,

371
00:25:40.799 --> 00:25:44.599
which is a female in the fifth
or sixth decade of life with a history

372
00:25:44.680 --> 00:25:48.680
of diabetes and or thyroid disorder.
Patient checks all of those boxes and that

373
00:25:48.839 --> 00:25:52.319
is why this is adhesive capsulitis question. Twenty forty nine year old female with

374
00:25:52.400 --> 00:25:56.400
a recent diagnosis of rheumatoid arthritis presents
to the office today. She stays she

375
00:25:56.519 --> 00:26:00.960
was started on the prox in two
months ago after being diagnosed, but the

376
00:26:00.039 --> 00:26:03.839
pain is becoming more severe and the
medication is no longer working as well,

377
00:26:04.480 --> 00:26:08.480
which additional medication will be the best
option to add to a regiment to slow

378
00:26:08.519 --> 00:26:12.160
progression and prevent further erosion of the
joints. So again, remember she was

379
00:26:12.160 --> 00:26:18.680
diagnosed authritis shes given the proxiin.
Symptoms are progressing. What other medications should

380
00:26:18.680 --> 00:26:22.279
you add to this patient's regimen?
A diclofenac, B, prednisone, C,

381
00:26:22.599 --> 00:26:27.480
zolodronic acid, D and fliximab or
E methotrexate. So the answer is

382
00:26:27.519 --> 00:26:32.279
going to be E methotrexate. So
let's talk first why it's not the other

383
00:26:32.359 --> 00:26:34.839
options. First, diclofenac. It's
just another end set like the proxin that

384
00:26:34.880 --> 00:26:38.519
she's already taking, so no value
there. Plus end sets have no impact

385
00:26:38.559 --> 00:26:44.079
on disease progression. Next prednisone.
Prednisone can be used for symptomatic relief,

386
00:26:44.400 --> 00:26:47.519
even has some disease modifying effect,
but it is not the best option on

387
00:26:47.559 --> 00:26:51.160
this list by a long shot.
Next soldronic acid. That's an easy one

388
00:26:51.160 --> 00:26:56.359
because we know this is bisphosphonate not
used for treatment of rheumatoiathritis. Next in

389
00:26:56.400 --> 00:26:59.960
fleiximab. So this is a TNF
inhibitor and it is used in the tree

390
00:27:00.000 --> 00:27:03.440
an of rhumatoidauthritis, but it's not
first line. It's generally used as an

391
00:27:03.480 --> 00:27:07.640
adjunct agent and patients not getting the
therapeuticals with the first line met and that

392
00:27:07.799 --> 00:27:12.200
first line med is methotrex sate.
Methotrex said is a dMar disease modifying anti

393
00:27:12.319 --> 00:27:18.119
raumatic drug, and while there are
other drugs in this class hydroxy chloroquin sulfa

394
00:27:18.160 --> 00:27:22.039
salazine, methotrexate is the most commonly
used d MART and first line for ra

395
00:27:22.519 --> 00:27:25.000
because compared to the other meds,
it has a faster on set of action,

396
00:27:25.160 --> 00:27:29.079
greater efficacy, better long term tolerance. So if there's one drug you

397
00:27:29.160 --> 00:27:33.480
absolutely have to know for rheumatoid athritis, that's definitely going to be methotrexate.

398
00:27:33.880 --> 00:27:38.039
Question twenty one. An injury to
which nerve common and humoral shaft fractures can

399
00:27:38.200 --> 00:27:42.640
lead to weakness and extension of the
wrist i e. Wrist drop and fingers,

400
00:27:44.039 --> 00:27:47.119
that is going to be the radial
nerve. Because the way the radial

401
00:27:47.200 --> 00:27:49.759
nerves wraps around the humorist and travels
down the arm, the radial nerve is

402
00:27:49.799 --> 00:27:55.079
susceptible to injury when a patient suffers
a humoral shaft fracture, and the most

403
00:27:55.200 --> 00:28:00.880
common neurological complication of humoral shaft fractures
is a radial nerve injury. So classically

404
00:28:00.880 --> 00:28:03.599
you'll hear being described as wrist drop, but when this nerve is injured.

405
00:28:03.599 --> 00:28:07.240
The patient can have parastheses of the
dorsal hand or weakness of the wrist and

406
00:28:07.400 --> 00:28:11.920
finger extension, and this injury actual
occurs in around eleven percent of mid shaft

407
00:28:12.000 --> 00:28:15.200
humoral fractures. So when you hear
wrist drop, be thinking of a radial

408
00:28:15.319 --> 00:28:18.759
nerve injury. Question twenty two,
fifty eight year old Mail presents at the

409
00:28:18.839 --> 00:28:22.839
office to seek treatment for his recurrent
episodes of gout. He's not currently taking

410
00:28:22.880 --> 00:28:27.359
any urate lowering medications and he has
treated previous acute attacks with new proxy and

411
00:28:27.400 --> 00:28:32.359
he has at home. Labs are
drawn which reveal an elevation and serum urate

412
00:28:32.440 --> 00:28:37.400
levels in a twenty four hour urinary
uric acid secretion of two hundred and thirty

413
00:28:37.440 --> 00:28:41.119
milligrams. The normal range is two
hundred and fifty to seven hundred and fifty

414
00:28:41.119 --> 00:28:44.519
milligrams per twenty four hours. Remember
his was two hundred and thirty. Which

415
00:28:44.559 --> 00:28:48.599
of the following medications would increase the
excretion of uric acid in the urine for

416
00:28:48.759 --> 00:28:56.920
this patient A indomethicin B, hydroxy
chloroquin C, probenecid D Fubus's stat or

417
00:28:56.039 --> 00:29:00.759
elipurinol. So that is going to
be c robenesid. So there's a lot

418
00:29:00.799 --> 00:29:03.720
of words in this vignette, but
all it's asking you is which one of

419
00:29:03.759 --> 00:29:08.359
these meds make you pee out more
uric acid? And the medication is probenicid.

420
00:29:08.519 --> 00:29:11.519
So that's a uricosuric drug, and
it can be used in patients with

421
00:29:11.720 --> 00:29:15.720
renal under excretion of uric acid,
as we see in this patient. The

422
00:29:15.799 --> 00:29:18.799
other meds starting with endomethicin, which
is just an end said used for a

423
00:29:18.880 --> 00:29:22.799
qute attacks, hydroxychloroquin which is not
used in the treatment of gallons, primarily

424
00:29:22.880 --> 00:29:26.279
used for lupus, and then finally
we have for bucks a statin al pureanol.

425
00:29:26.480 --> 00:29:32.079
Those are both xanthine oxidase inhibitors which
work by decreasing uric acid production.

426
00:29:32.319 --> 00:29:36.759
So the only medication on the list
that increases urinary uric acid secretion is going

427
00:29:36.839 --> 00:29:40.680
to be probenicid. Question twenty three, twenty two year old Mail presents to

428
00:29:40.720 --> 00:29:44.559
the office complaining of chronic right sided
hip and thigh pain for the past six

429
00:29:44.640 --> 00:29:47.799
months. He reports the pain is
worse at night, and he does not

430
00:29:48.000 --> 00:29:51.839
recall any injuries to the leg.
He states that when he takes ibprofen,

431
00:29:52.119 --> 00:29:56.000
the pain is almost completely eliminated for
a short period of time. X rays

432
00:29:56.079 --> 00:30:00.839
reveal a small round lucency with a
sclerotic margin on the proximal femur that is

433
00:30:00.920 --> 00:30:06.119
later diagnosed as an osteoid osteoma.
What is likely being secreted from this benign

434
00:30:06.200 --> 00:30:10.880
tumor that is leading to the pain
the boy is experiencing be a second to

435
00:30:10.960 --> 00:30:15.640
thing about that, So that is
prostaglandins, so osteoid osteoma. There's really

436
00:30:15.680 --> 00:30:18.559
two high old things that you need
to know about this benign bone tumor.

437
00:30:18.759 --> 00:30:22.039
One, this tumor produces high levels
of prostaglandins. And the second thing is

438
00:30:22.119 --> 00:30:26.160
that this type of tumor responds extremely
well to END sets. Within a matter

439
00:30:26.200 --> 00:30:29.960
of minutes, the pain will be
relieved, which will will be mentioned in

440
00:30:30.000 --> 00:30:33.200
the vignette. And this will help
you differentiate from other types of bone tumors

441
00:30:33.480 --> 00:30:37.039
like osteoblastoma, which has minimal pain
relief with ND sets. That's what will

442
00:30:37.079 --> 00:30:41.759
differentiate these two on a vignettes.
So we need to remember that osteoid osteoma

443
00:30:41.880 --> 00:30:45.400
dramatic pain relief with ND sets.
Osteoblastoma minimal pain relief. So why do

444
00:30:45.559 --> 00:30:48.960
ND sets work so dramatically at reducing
the pain. Well, if you remember

445
00:30:49.000 --> 00:30:53.039
back to pharmacology, you remember N
sets block the production of prostaglandins through the

446
00:30:53.119 --> 00:30:59.119
inhibition of cyclooxygenase. So for osteoid
osteoma again, remember two things. One

447
00:30:59.200 --> 00:31:02.640
they crank out a bunch of prostic
landings and two for this reason, the

448
00:31:02.680 --> 00:31:07.359
pain experience responds extremely well to end
SAIDs. And I hate to even mention

449
00:31:07.480 --> 00:31:11.920
this. The way that I used
to remember this osteoid osteoma the letters OOM

450
00:31:11.960 --> 00:31:15.960
whenever i'd see those two o's and
osteoid osteoma. I used to remember that

451
00:31:15.200 --> 00:31:19.039
song that said, oh, oh, it's magic, you know. And

452
00:31:19.079 --> 00:31:23.119
I used to remember, oh,
it's magic, and SAIDs. I hate

453
00:31:23.200 --> 00:31:26.599
that at the fact that I had
to sing there, but to help you

454
00:31:26.680 --> 00:31:30.240
remember that, hopefully you'll remember me
singing it's completely ridiculous, ridiculous, but

455
00:31:30.279 --> 00:31:33.599
it helped. It helped stick for
me. So we see osteoid osteoma,

456
00:31:33.200 --> 00:31:37.799
think ooh it's magic. End sets
because of how well d sets work,

457
00:31:37.880 --> 00:31:41.240
and improving the pain from the increase
in prostic gland is. All right,

458
00:31:41.279 --> 00:31:44.000
now they've heard me sing, Let's
quickly move on to the next question.

459
00:31:44.480 --> 00:31:48.839
Question twenty four. Scoliosis is defined
as an abnormal lateral curvature of the spine

460
00:31:48.880 --> 00:31:53.079
with a cob angle of greater than
blank degrees, So that is going to

461
00:31:53.200 --> 00:31:59.079
be greater than ten degrees. So
cob angle is the most widely used measurement

462
00:31:59.119 --> 00:32:04.279
for quantifying final curvature and scoliosis,
which is calculated using plane radiographs. You

463
00:32:04.319 --> 00:32:07.640
should definitely know that lateral spinal curvature
with a cob angle of over ten degrees

464
00:32:07.680 --> 00:32:10.839
defined scoliosis. And then the only
other number you might want to have in

465
00:32:10.880 --> 00:32:14.880
the back of your head is a
cob angle of anywhere from forty to fifty

466
00:32:14.880 --> 00:32:20.079
degrees or greater as usually where surgical
intervention is indicated. Question twenty five.

467
00:32:20.440 --> 00:32:23.160
Fifty nine year old female presents at
the office today complaining of right shoulder pain

468
00:32:23.279 --> 00:32:28.440
after a fall from her bike earlier
in the day. Shoulder radiographs are performed

469
00:32:28.480 --> 00:32:32.079
which reveal an anterior dislocation of the
right shoulder. She also complains of numbness

470
00:32:32.160 --> 00:32:37.079
and tingling in the lateral part of
the shoulder. Physical exam reveals deltoid muscle

471
00:32:37.119 --> 00:32:42.160
weakness, which nerve was likely injured
in this patient, so that is going

472
00:32:42.240 --> 00:32:45.240
to be the axillary nerve. So
the axillary nerve is the nerve most often

473
00:32:45.359 --> 00:32:51.960
injured with shoulder dislocations, and approximately
forty two percent patients with anterior shoulder dislocations

474
00:32:52.200 --> 00:32:57.079
will have some degree of axillary nerve
dysfunction. The nerve runs around the surgical

475
00:32:57.200 --> 00:33:00.960
necked of the humorous and this is
important. It innervates the deltoid muscle and

476
00:33:01.160 --> 00:33:06.079
the skin overlying the lateral shoulder,
and that's why this patient is complaining of

477
00:33:06.200 --> 00:33:08.240
numbness and tingling in the lateral part
of the shoulder, also known as the

478
00:33:08.319 --> 00:33:13.880
shoulder badge distribution. And this is
also why she's presenting with deltoid muscle weakness

479
00:33:13.920 --> 00:33:17.680
as the axillary nerve innervates These areas
so very typical presentation for someone who sustained

480
00:33:17.720 --> 00:33:23.799
an anterior shoulder dislocation. So remember, axillary nerve injury is very common in

481
00:33:23.880 --> 00:33:30.359
shoulder dislocations, especially anterior shoulder dislocations. So with anterior shoulder dislocations, there's

482
00:33:30.400 --> 00:33:35.880
a bunch of high old associations,
there's bank art lesions, axillary nerve dysfunction,

483
00:33:36.279 --> 00:33:37.599
So how do you remember all of
them for the exam? So you

484
00:33:37.640 --> 00:33:42.799
remember it all by remembering a guy
named Antonio. And Antonio is this guy

485
00:33:42.880 --> 00:33:45.319
who's holding a picture in one hand
and an axe in the other hand.

486
00:33:45.599 --> 00:33:49.640
The picture that he's holding is of
a bank on top of a hill,

487
00:33:49.960 --> 00:33:52.839
and he's holding both the picture and
the axe up and out by his side,

488
00:33:52.920 --> 00:33:58.160
so his arms are abducted and externally
rotated. So Antonio helps you remember

489
00:33:58.240 --> 00:34:01.000
this is an anterior dislocation. The
picture he's holding with a bank on top

490
00:34:01.039 --> 00:34:06.319
of a hill helps you remember bank
art lesions and hill sack lesions are often

491
00:34:06.440 --> 00:34:09.320
caused by anterior dislocations. And then
the axe he's holding in his other hand

492
00:34:09.519 --> 00:34:15.920
helps you remember axillary nerve actually a
nerve injury is most common in anterior dislocations.

493
00:34:15.159 --> 00:34:19.400
And then finally, the position of
his arms holding these things abducted and

494
00:34:19.480 --> 00:34:22.280
externally rotated, helps you remember both
the way the arm is usually positioned during

495
00:34:22.320 --> 00:34:27.719
physical exam and during the injury too. So remember a guy named Antonio holding

496
00:34:27.719 --> 00:34:30.079
a picture of a bank on top
of a hill in one hand, holding

497
00:34:30.119 --> 00:34:32.599
an axe in the other hand.
Both arms are abducted and externally rotated.

498
00:34:32.719 --> 00:34:37.079
It's all you need to know for
anterior dislocations. Question twenty six, thirty

499
00:34:37.119 --> 00:34:42.360
two year old mother of a six
week old newborn complains of recurrent radial sided

500
00:34:42.679 --> 00:34:45.960
wrist pain that is exacerbated by thumb
and wrist movement. She Denai's trauma to

501
00:34:46.039 --> 00:34:51.559
the area. On physical exam,
tenderness is noted over the radial styloid at

502
00:34:51.599 --> 00:34:55.840
the first dorsal compartment and flection of
the thumb across the palm with ulnar deviation

503
00:34:55.920 --> 00:35:00.039
of the wrist results in pain over
the radial styloid area. What is the

504
00:35:00.119 --> 00:35:04.880
most likely diagnosis in this patient?
So that is going to be decare vein

505
00:35:04.960 --> 00:35:08.559
tendinopathy. So why decoarevein tendinopathy.
First we have a thirty two year old

506
00:35:08.840 --> 00:35:15.000
postpartum female. This fits the most
common demographic perfectly as this is most common

507
00:35:15.039 --> 00:35:19.639
in women thirty to fifty years old, especially four to six weeks after delivery

508
00:35:19.840 --> 00:35:22.119
in the postpartum period. Next,
we have pain in the radial side of

509
00:35:22.159 --> 00:35:27.639
the wrist exascerbated by thumb and wrist
movement. This makes sense as the tendons

510
00:35:27.679 --> 00:35:30.639
evolved in decour vein are the EPB
and APL tendons, which are responsible for

511
00:35:30.760 --> 00:35:36.000
movement of the thumb. And most
importantly, she has a positive Finkel steam

512
00:35:36.039 --> 00:35:38.800
test, which is pain over the
radio styloid with lar deviation of the wrist

513
00:35:39.079 --> 00:35:44.159
with the thumb flexed across the palm. That's classic decore vein tendinopathy. In

514
00:35:44.280 --> 00:35:46.639
case you need a way to remember
the tendons involved in decour veins, because

515
00:35:46.639 --> 00:35:51.599
I did get this on an exam
question. The tendons involved are the abductor

516
00:35:51.679 --> 00:35:57.039
policis longest and the extensor policis brevist
the APL and EPB tendons. Remembering the

517
00:35:57.079 --> 00:36:00.159
abbreviations will be enough to get it
right on a multiple choice question. So

518
00:36:00.239 --> 00:36:06.039
I used to remember apples as an
APL with extra peanut butter as an EPB

519
00:36:06.199 --> 00:36:09.840
tendon are delicious as in decuare vein, So apples with extra peanut butter are

520
00:36:09.920 --> 00:36:15.679
delicious. Apples APL tendon extra peanut
butter, EPB tendant are delicious. Decoare

521
00:36:15.719 --> 00:36:19.800
vein tendant apathy, And that was
enough for me to get the question right.

522
00:36:19.960 --> 00:36:24.719
On an exam question, sixty two
year old mail presents the office complaining

523
00:36:24.760 --> 00:36:29.199
of severe pain. In his first
tone, he denize trauma to the area.

524
00:36:29.480 --> 00:36:34.599
Arthocentesis reveals negatively bier for engine needle
shaped crystals and then the diagnosis of

525
00:36:34.679 --> 00:36:38.599
gout is established. Pasthematical history includes
type two diabetes, osteoarthritis, and end

526
00:36:38.719 --> 00:36:44.360
stage renal disease. Which class of
medication would be most appropriate to treat this

527
00:36:44.519 --> 00:36:47.760
patient's acute gaut flares? To remembery
as a pathematical history type two diabetes,

528
00:36:47.840 --> 00:36:52.840
osteoarthritis, and end stage renal disease. Which class of medication are you going

529
00:36:52.880 --> 00:36:55.800
to treat as acute gautflare with?
So that's going to be glucal cortaquois.

530
00:36:57.000 --> 00:37:00.800
So you have to think about what
are the first line meds to treat acute

531
00:37:00.840 --> 00:37:04.920
gaut flare. So really there's only
three ND sets, steroids and culture scene.

532
00:37:05.039 --> 00:37:07.480
We know ND sets are out of
the question because this patient has end

533
00:37:07.519 --> 00:37:12.000
stage renal disease. Culture scene can
be used in mild kidney disease when GFR

534
00:37:12.119 --> 00:37:15.719
is about thirty, but end stage
renal disease other agents are preferred. So

535
00:37:15.840 --> 00:37:20.119
in this patient, the most appropriate
effective class of medication is your glucal corticoids,

536
00:37:20.320 --> 00:37:23.039
your steroids, as they are safe
and mild all the way to severe

537
00:37:23.119 --> 00:37:28.880
renal disease and extremely effective in treating
acute gaut flares. Question twenty eight.

538
00:37:29.159 --> 00:37:34.199
A distal radius fracture that involves dorsal
displacement of the distal radius fragment is known

539
00:37:34.239 --> 00:37:37.800
as what type of fracture? Again, a distal radius fracture that involves dorsal

540
00:37:37.880 --> 00:37:43.559
displacement of the distal radius fragment is
known as what type of fracture that is

541
00:37:43.599 --> 00:37:46.920
going to be a Collie's fracture.
So there's two different types of distal radius

542
00:37:46.960 --> 00:37:52.519
fractures you should be familiar with.
That's Collies and Smith. Collies involves dorsal

543
00:37:52.639 --> 00:37:58.599
displacement of the distal radius. Smith
involves palmer or volar displacement of the distal

544
00:37:58.719 --> 00:38:02.719
radius. The way that I remember
Collie's associated with dorsal displacement is by remembering

545
00:38:02.800 --> 00:38:06.400
Collie is a breed of dog,
the type of dog that last he was

546
00:38:06.639 --> 00:38:08.800
a Collie dog. So when you
think of Collie's fracture, I want you

547
00:38:08.880 --> 00:38:12.840
to think of a Collie dog.
And the first two letters in dog are

548
00:38:12.880 --> 00:38:15.800
the first two letters in dorsal doo
And this helps you remember Collie fractures are

549
00:38:15.960 --> 00:38:21.639
dorsally angulated radius fractures and by method
of exclusion, Smith is the opposite,

550
00:38:21.679 --> 00:38:24.880
which is a volar angulated distal radius
fracture. So when you see collie fracture,

551
00:38:25.000 --> 00:38:29.599
think of a Collie dog. Question
twenty nine, forty seven year old

552
00:38:29.639 --> 00:38:34.719
mail with history of intravenous drug use
presents the emergency department complaining of progressive lower

553
00:38:34.800 --> 00:38:38.000
back pain and worsening gait and stability
over the last two weeks. On physical

554
00:38:38.039 --> 00:38:43.199
exam, he has point tenderness in
the lumbar region, weakness in bilateral low

555
00:38:43.280 --> 00:38:46.599
extremities, diminished sensation to light touch, and a temperature of one oh three

556
00:38:46.679 --> 00:38:52.760
point to fahrenheit thirty nine point five
degrees celsius. Laboratory studies reveal leucocytosis as

557
00:38:52.840 --> 00:38:58.840
well as in elevation and an orthrocyte
sedimentation rate and see reactive protein radiographs of

558
00:38:58.920 --> 00:39:04.000
the lumbar spine are remarkable. MRI
reveals a ring enhancing lesion at L two

559
00:39:04.079 --> 00:39:08.119
to L four, which bacterial pathogen
would likely be isolated in this patient.

560
00:39:08.360 --> 00:39:12.639
So one's a little bit triggy.
That's going to be staff oreus. So

561
00:39:12.840 --> 00:39:16.559
first, what does this patient likely
have likely has a spinal epidural abscess?

562
00:39:16.679 --> 00:39:20.920
Well, why first do you have
an IVY drug user with a triad of

563
00:39:21.039 --> 00:39:24.079
fever, back pain, and neurologic
deficits. Right away, spinal abcess should

564
00:39:24.079 --> 00:39:28.079
be high on your list of differentials. Next, we have an elevation of

565
00:39:28.119 --> 00:39:31.559
white blood cells as well as elevated
ESR and CRPEP. Around sixty percent of

566
00:39:31.559 --> 00:39:36.880
patients with a spinal abcess will have
lucocytosis. In almost all cases of spinal

567
00:39:36.920 --> 00:39:40.519
epidural abscess will have an elevation of
ESR and CRPEP. Usually, radiographs are

568
00:39:40.559 --> 00:39:45.159
going to be normal and MRI,
which is key, which will reveal an

569
00:39:45.280 --> 00:39:50.960
enhancing epidural mass often described as a
ring enhancing lesion. Definitely know that term,

570
00:39:52.039 --> 00:39:54.000
and that's the confirmation right there,
we have a spinal epidural abscess,

571
00:39:54.280 --> 00:40:00.679
and the leading bacterial pathogen causing a
spinal epidural abcess is staff orea and around

572
00:40:00.760 --> 00:40:05.440
sixty three percent of cases. Question
thirty fifty seven year old Mail reports right

573
00:40:05.519 --> 00:40:08.119
shoulder pain after sustaining a fall at
work two weeks ago. He states he

574
00:40:08.239 --> 00:40:12.800
is unable to lift his arm above
his head without significant pain and finds he

575
00:40:12.880 --> 00:40:15.320
is unable to sleep on the affected
side at night. On physical exam,

576
00:40:15.400 --> 00:40:21.440
with the patient's affected arm completely internally
rotated, thumb pointing down elbow extended at

577
00:40:21.559 --> 00:40:25.440
ninety degrees of an abduction pain and
weakness is experience when the clinician attempts to

578
00:40:25.639 --> 00:40:30.719
adduct the arm while the patient resists. Go to repeat that again. Physical

579
00:40:30.760 --> 00:40:37.639
exam patient's arm affected arm completely internally
rotated thumb pointing down elbow extended ninety degrees

580
00:40:37.679 --> 00:40:42.480
of abduction. Pain and weakness is
experience when the clinician attempts to adduct the

581
00:40:42.679 --> 00:40:46.280
arm while the patient resists. MRI
confirms a full thickness tear of a tendon

582
00:40:46.559 --> 00:40:51.679
in the rotator cuff. Which tendon
of the rotator cuff is likely affected in

583
00:40:51.760 --> 00:40:55.159
this patient, So that is going
to be the superspinades So why well to

584
00:40:55.239 --> 00:41:00.320
start? Majority of rotator cuff lesions
begin as partial tears of the superspin natas

585
00:41:00.320 --> 00:41:02.559
tending, so it's sorry the most
common tended to be affected. So we

586
00:41:02.639 --> 00:41:06.639
have that working for us. But
then the physical exam findings are what's sealed

587
00:41:06.679 --> 00:41:09.440
the deal. We have a patient
performing the empty contest, also known as

588
00:41:09.480 --> 00:41:15.480
the job test. This is generally
considered the gold standard for evaluating superspinatis function

589
00:41:15.800 --> 00:41:20.320
because the position of the arm isolates
the superspinatus, making it the primary muscle

590
00:41:20.360 --> 00:41:23.599
opposing that downward motion of the arm. So the arm completely internally rotated,

591
00:41:23.639 --> 00:41:29.199
thumb pointing down, elbow extended.
Clinician depresses the arm while the patient resists

592
00:41:29.519 --> 00:41:35.039
and pain and weakness is indicative of
a partial or complete superspinadis tend in tears.

593
00:41:35.159 --> 00:41:37.480
Remember if you see the empty contests
or the job test being performed,

594
00:41:37.760 --> 00:41:43.599
this is to assess the superspinatus question. Thirty one forty one year old female

595
00:41:43.599 --> 00:41:46.840
has symptoms consistent with rheumatoid athritis and
labs are drawn to assist in making the

596
00:41:46.920 --> 00:41:52.079
diagnosis. The decision assistant informs the
patient that a rheumatoid factor as well as

597
00:41:52.119 --> 00:41:59.000
a very specific antibody for rheumatoid arthritis
are both elevated. Which antibiotics, which

598
00:41:59.039 --> 00:42:04.239
antibody specific to rheumatoid arthritis is likely
elevated in this patient. So again,

599
00:42:04.559 --> 00:42:08.280
which antibody specific to rheumatoid athritis is
likely elevated in this patient? So that

600
00:42:08.480 --> 00:42:15.000
is going to be your anti cyclic
cutrilinated peptide aka your anti CCP. So

601
00:42:15.159 --> 00:42:20.519
your anti CCP antibodies are very specific
for rheumatoid arthritis. Usually over ninety percent

602
00:42:20.599 --> 00:42:22.840
specific for the disease, So if
they ask for the most specific test for

603
00:42:23.039 --> 00:42:28.159
RA, generally this will be your
anti CCP. And compared to this rheumatoid

604
00:42:28.199 --> 00:42:32.559
factor, which has a relatively poor
specificity since they're found in healthy individuals and

605
00:42:32.679 --> 00:42:36.599
up to thirty percent of patients with
lupus. So your most specific test again

606
00:42:36.639 --> 00:42:40.360
for rumatoiouthritis is your anti CCP.
And if you can't remember which specific which

607
00:42:40.440 --> 00:42:45.400
is the specific antibody for RA specific
is spelled with two c's, look for

608
00:42:45.440 --> 00:42:47.039
the antibody with two cs in it, and that's going to be your anti

609
00:42:47.119 --> 00:42:52.639
CCP question. Thirty two sixty three
year old Mail presents at the office today

610
00:42:52.679 --> 00:42:57.199
complaining of diarrhea and abdominal cramping for
the past few days. Denies any recent

611
00:42:57.280 --> 00:43:00.199
dietary changes, no recent travel,
and states the only change in his life

612
00:43:00.519 --> 00:43:04.760
was that he was recently diagnosed with
gout and started on a new medication.

613
00:43:05.280 --> 00:43:08.199
Which medication did this patient likely start
on for the treatment of gout? So

614
00:43:08.360 --> 00:43:13.559
that is culture scene. So culture
scene is notorious for causing GI problems,

615
00:43:13.719 --> 00:43:16.719
especially diarrhea, so much so that
on Appocrates it actually says in the comments

616
00:43:16.760 --> 00:43:21.079
diarrhea will likely proceed pain relief,
which I thought. It's very funny,

617
00:43:21.519 --> 00:43:23.400
so definitely know this for adverse drug
reactions. For culture scene, It's an

618
00:43:23.440 --> 00:43:27.840
exam favorite for some reason, and
I definitely remember getting a question about it

619
00:43:27.920 --> 00:43:30.519
in school. Question thirty three.
Fourteen year old boy presents to the office

620
00:43:30.559 --> 00:43:35.639
complaining of anterior knee pain. He
states the pain is most severe when he

621
00:43:35.679 --> 00:43:39.440
plays basketball or squats down. On
exam, you note a pronounced tender tibule

622
00:43:39.519 --> 00:43:44.679
tubercle. What is the mainstay of
treatment for the likely diagnosis in this patient?

623
00:43:45.079 --> 00:43:47.119
So that is going to be conservative, and says I set her up.

624
00:43:47.440 --> 00:43:52.039
So this is osgod Schlauter disease.
We have a fourteen year old boy

625
00:43:52.360 --> 00:43:54.599
fits the demographic already, as osgod
Schlatter is most common in males nine to

626
00:43:54.719 --> 00:43:59.519
fourteen years of age, especially in
those who have undergone a rapid growth spurt.

627
00:44:00.119 --> 00:44:02.519
Pain is usually exacerbated when squatting,
jumping, running, etc. Which

628
00:44:02.559 --> 00:44:06.760
is common during sports like basketball,
as we see in this patient. And

629
00:44:06.840 --> 00:44:10.880
then an exam the pronounced tender tibial
tubercle seals the deal. As we know

630
00:44:12.000 --> 00:44:17.360
this is an injury caused by repetitive
strain and chronic evulsion of the a hypothesis

631
00:44:17.440 --> 00:44:21.320
of the tibial tubercle. A lot
of hard words for me to say right

632
00:44:21.360 --> 00:44:24.360
now. So the mainstafe treatment Frosgat
schlaughter disease is conservative and says etc.

633
00:44:24.920 --> 00:44:30.639
Surgical repair is rare and you can
remember instead of osgod schlaughter disease, remember

634
00:44:30.719 --> 00:44:35.199
Osgod's squatter denase SULPs. Remember it's
exacerbated by activity like squatting, and then

635
00:44:35.320 --> 00:44:37.960
Denise helps you remember this is an
issue with the knees. Question thirty four,

636
00:44:38.079 --> 00:44:42.480
a forty three year old female presents
to the office complaining of numbness and

637
00:44:42.559 --> 00:44:45.880
tingling in her hands, mostly affecting
the thumb, index and middle finger and

638
00:44:46.119 --> 00:44:50.679
part of the ring finger. She
states it is worse at night, sometimes

639
00:44:50.760 --> 00:44:53.559
waking her from sleep. Both a
tunnel and phalin test are positive. On

640
00:44:53.639 --> 00:45:00.320
physical exam, patient is likely experiencing
compression of which nerve, so is the

641
00:45:00.480 --> 00:45:04.480
median nerve sus. Patient is experiencing
carpal tunnel syndrome, which is a compression

642
00:45:04.519 --> 00:45:07.280
of the median nerve. We know
this because we have a patient with parastheses

643
00:45:07.280 --> 00:45:10.760
and the median nerve territory, which
would be the first three fingers and radio

644
00:45:10.840 --> 00:45:14.800
half of the fourth. In addition, she states it's worse at night,

645
00:45:14.840 --> 00:45:17.559
which is very common for carporal tunnel. Finally, have a positive Tannell and

646
00:45:17.639 --> 00:45:22.239
Phalin test which seals the deal.
So we know this is carpal tunnel,

647
00:45:22.719 --> 00:45:27.239
which is median nerve compression. And
just a quick tip the two maneuvers that

648
00:45:27.280 --> 00:45:30.239
were listening to this vignette for carpal
tunnel, the Tannelle tests and Phalin test

649
00:45:30.519 --> 00:45:34.199
they're often tested on, so it's
good to know what they involved. So

650
00:45:34.360 --> 00:45:37.440
the Tannell tests is just percussing or
tapping over the median nerve to see if

651
00:45:37.480 --> 00:45:42.000
pain or parastheses is reproduced in the
median nerve innervated fingers. So you used

652
00:45:42.000 --> 00:45:45.519
to remember the t and Tennelle stood
for tapping. And then the Phalin test

653
00:45:45.599 --> 00:45:49.039
you basically just flop your hands over
and put the dorsal surfaces or the back

654
00:45:49.079 --> 00:45:52.880
of the hands together for a minute. Positive tests pain or parasteses and the

655
00:45:52.920 --> 00:45:57.800
media nerve innervated fingers. And I
used to remember the word phalin sounds like

656
00:45:57.960 --> 00:46:00.159
fallen, so I used to remember
this is the test for your hand have

657
00:46:00.280 --> 00:46:02.079
fallen or flopped over because that's what
it looks like men perform the test.

658
00:46:02.199 --> 00:46:06.079
You can look at a picture of
it and then so you just remember that

659
00:46:06.159 --> 00:46:08.800
the hands have fallen or falin over
because that's how the test is performed.

660
00:46:09.079 --> 00:46:13.719
Question thirty five. A sixty seven
year old Mail presents to the office today

661
00:46:13.719 --> 00:46:16.599
complaining of persistent elbow pain. He
does not recall any trauma to the elbow,

662
00:46:16.639 --> 00:46:20.880
but the pain he is experiencing in
his elbow is affecting his golf game.

663
00:46:20.920 --> 00:46:23.400
As he is an avid golfer.
An exam pain is elicited by performing

664
00:46:23.440 --> 00:46:29.679
wrist flexion against resistance. Tenderness would
likely be felt over which part of the

665
00:46:29.760 --> 00:46:31.760
elbow in this patient. Give you
a second to think about that, So

666
00:46:31.920 --> 00:46:37.760
that is the medial epicondyle. So
we have a classic case of medial epicondolitis

667
00:46:37.039 --> 00:46:42.079
aka golfer's elbow. We have a
sixty seven year old Mail, avid golfer

668
00:46:42.159 --> 00:46:45.400
with elbow pain, no preceding trauma, and the key is that the pain

669
00:46:45.519 --> 00:46:49.239
is reproduced on exam with the risk
being flex against resistance. So in this

670
00:46:49.320 --> 00:46:52.280
case, the patient would likely have
pain in the medial epicondyle. As the

671
00:46:52.360 --> 00:46:57.320
medial epicondol is the bony origin for
the wrist flexors which is affected in this

672
00:46:57.440 --> 00:47:00.840
condition. The way that I remember
the high oldt about medial epicondo lightis aka

673
00:47:01.000 --> 00:47:06.480
golfer's elbow was by remembering the sentence
mini golf is fun. So the M

674
00:47:06.559 --> 00:47:10.840
and mini helps remember this is the
medial epicondol involved in golfer's elbow golf obviously

675
00:47:12.039 --> 00:47:14.800
because this is also known as golfer's
elbow. And then the F and fun

676
00:47:14.920 --> 00:47:19.639
helps you remember this involves flexion.
So whether it's pain with wrist flexion against

677
00:47:19.719 --> 00:47:22.800
resistance on exam, the fact that
it involves the flex or carpi radialis or

678
00:47:22.920 --> 00:47:28.519
that it's caused from repetitive flection.
Mini golf is fund M for medial epicondol

679
00:47:28.760 --> 00:47:32.800
golfer golf, golfer's elbow, and
then F for flection flex or. Question

680
00:47:32.920 --> 00:47:37.119
thirty six, which test is performed
as part of the physical exam in a

681
00:47:37.239 --> 00:47:43.800
suspected Achilles tend in rupture, then
involves squeezing the gas strucnemius muscle and watching

682
00:47:43.880 --> 00:47:46.800
for plant our flection of the foot. So that's the Thompson test. So

683
00:47:46.960 --> 00:47:51.280
Thompson tests nice and simple is squeeze
the calf and look to see if the

684
00:47:51.280 --> 00:47:54.239
foot planter flexes. If not,
this is a positive test indicating a likely

685
00:47:54.280 --> 00:47:59.239
Achilles tend in rupture. Question thirty
seven. Thirty one year old male was

686
00:47:59.280 --> 00:48:02.559
playing football with his friends when one
of his friends landed on the lateral aspect

687
00:48:02.599 --> 00:48:07.320
of his right knee in an attempt
to tackle him. He immediately felt a

688
00:48:07.400 --> 00:48:12.000
tearing cessation, which was followed by
severe pain. A Valgus stress test is

689
00:48:12.039 --> 00:48:16.159
performed, which displays pain and laxity
at approximately thirty degrees of flexion. What

690
00:48:16.440 --> 00:48:21.760
structure of the knee did this patient
likely injure? So that's the medial collateral

691
00:48:21.840 --> 00:48:23.960
ligment. So we have a patient
with lateral trauma to the knee and a

692
00:48:24.079 --> 00:48:29.679
positive Valgus stress test. The MCEL
will be the most common structure to be

693
00:48:29.719 --> 00:48:35.119
injured in this setting. So the
medial collateral ligament injuries have a positive Valgus

694
00:48:35.199 --> 00:48:38.960
stress test. Lateral collateral ligament injuries
have a positive v rust stress test.

695
00:48:39.159 --> 00:48:42.920
It's easy to get those mixed up. So this is how I used to

696
00:48:42.960 --> 00:48:46.320
remember them. So first, how
do you associate MCL injuries with Valgus stress

697
00:48:46.679 --> 00:48:50.800
So Valgus has the word gus in
it. So whenever I see Valgus,

698
00:48:51.159 --> 00:48:54.679
I think of Mucco Gusto, the
m and mucho Gusto helps me remember this

699
00:48:54.960 --> 00:48:59.920
is a test of the MCL ligament. And then VA Russ test for LCO

700
00:49:00.199 --> 00:49:02.360
injuries has the word rusts in it, and that makes me think of rust

701
00:49:02.480 --> 00:49:07.519
as in the sentence leaky pipes rust
and the L and leaky helps you remember

702
00:49:07.519 --> 00:49:12.559
the VA rust stress involves the LCIL. So remember mucho gusto for Valgus test

703
00:49:12.639 --> 00:49:16.360
to help your remembrances soociated with injuries, and then leaky pipes rust for vera

704
00:49:16.440 --> 00:49:22.440
rust test to help your remembrance associated
with LCIL injuries. Question thirty eight fifty

705
00:49:22.519 --> 00:49:25.519
sixty year old female presents to the
office complaining of persistent heal pain that is

706
00:49:25.559 --> 00:49:30.199
worse when first getting out of bed
in the morning. She states, and

707
00:49:30.199 --> 00:49:32.119
improves as the day goes on and
stretching in the morning seems to help.

708
00:49:32.400 --> 00:49:37.599
She denies trauma to the area.
Radiographs are negative and on physical exam point

709
00:49:37.639 --> 00:49:42.320
tenderness is noted over the medial tubercle
of the calcaneus. What is a likely

710
00:49:42.400 --> 00:49:45.159
diagnosis in this patient? So that
is going to be plantar fasciitis. It's

711
00:49:45.159 --> 00:49:49.480
a pretty easy one. Anytime you
have a patient complaining of heal pain that's

712
00:49:49.519 --> 00:49:52.159
worse in the morning when they first
get out of bed, or worse after

713
00:49:52.239 --> 00:49:54.960
periods of inactivity, especially with point
tenderness right at the insertion side of the

714
00:49:55.000 --> 00:49:59.800
plant or fascia, which is the
medial tubercle of the calcaneus. Obviously,

715
00:50:00.000 --> 00:50:02.480
plant or fasciators should be high the
listed differentials. Treatment is generally going to

716
00:50:02.519 --> 00:50:06.400
be conservative for these patients. Rest
and said it's better shoes, etc.

717
00:50:07.199 --> 00:50:10.280
Question thirty nine sixty seven year old
female presents to the office four months after

718
00:50:10.360 --> 00:50:15.159
fracturing her left hand. The hand
was properly splinted at the time of injury

719
00:50:15.639 --> 00:50:20.800
and recent radiographs reveal a well healed
fracture without any indication of malunion. She

720
00:50:20.920 --> 00:50:23.559
presents to the office due to new
symptoms in the left hand. She notes

721
00:50:23.599 --> 00:50:29.000
the hand appears to perspire profusely compared
to the right side, along with noting

722
00:50:29.079 --> 00:50:34.719
severe pain to even the slightest touch. Physical exam demonstrates hyperaesthesia and weakness in

723
00:50:34.800 --> 00:50:37.880
the affected hand. Increased hair growth
and brittle nails are also noted compared to

724
00:50:37.920 --> 00:50:42.639
the unaffected side. What is the
most likely diagnosis in this patient? So

725
00:50:42.679 --> 00:50:45.440
I'm gonna give you a second thing
about that is a little complicated. So

726
00:50:45.639 --> 00:50:50.760
that is complex regional pain syndrome.
Anytime you see a patient that had an

727
00:50:50.840 --> 00:50:52.800
injury in the vignette, they go
out of their way to say it healed

728
00:50:52.880 --> 00:50:55.920
properly, it was treated properly,
etc. And yet the patient is still

729
00:50:57.039 --> 00:51:01.199
in excruciating pain months later. Always
have complex regional pain syndrome at the top

730
00:51:01.320 --> 00:51:06.559
of your list of differentials. So
if complex regional pain syndrome, the treatment

731
00:51:06.599 --> 00:51:09.800
and diagnostic tests are pretty low yield, the highest yield thing to know about

732
00:51:09.800 --> 00:51:15.119
it is its bizarre combination of clinical
manifestations. So the way that I remember

733
00:51:15.159 --> 00:51:19.440
the common clinical manifestations that you will
see in a vignette for complex regional pain

734
00:51:19.519 --> 00:51:24.000
syndrome is by instead of remembering complex
regional pain syndrome, I remembered complex regional

735
00:51:24.440 --> 00:51:30.840
paint syndrome. And what does paint
stand for? So PA I NT so

736
00:51:30.079 --> 00:51:35.400
the P stands for perspiration. This
is due to the autonomic dysfunction. Forty

737
00:51:35.440 --> 00:51:39.639
percent of patients will experience increased sweating
the A and paint stands for after injury

738
00:51:39.920 --> 00:51:44.840
because remember this will most commonly take
place after some sort of bone or soft

739
00:51:44.840 --> 00:51:47.199
tissue injury, so look for some
sort of injury mentioned in the vignette weeks

740
00:51:47.280 --> 00:51:52.280
or months prior. The I stands
for inappropriate pain because it's out of proportion

741
00:51:52.360 --> 00:51:57.639
to the initial injury. Pain is
typically the most prominent in debilitating symptom of

742
00:51:57.760 --> 00:52:01.159
CRPS. So remember I stands or
inappropriate pain. It's not appropriate to have

743
00:52:01.239 --> 00:52:04.840
ten out of ten pain in your
hand from a fracture you had four months

744
00:52:04.880 --> 00:52:08.760
ago that has healed so high for
inappropriate pain. N stands for nail changes.

745
00:52:09.039 --> 00:52:13.880
Remember your trophic changes, so these
patients can have both increased or decreased

746
00:52:13.960 --> 00:52:16.639
nail growth brittle nails. Also look
for changes in hair growth as well.

747
00:52:16.960 --> 00:52:21.679
And then the TEA stands for temperature
changes, so relating back to the autonomic

748
00:52:21.800 --> 00:52:24.800
change these patients can have, and
some patients, you'll notice a difference difference

749
00:52:24.800 --> 00:52:30.239
in skin temperature on the effective versus
the unaffected size of a side of one

750
00:52:30.320 --> 00:52:34.760
or more degree celsius. Question forty. A fourteen year old mail presents to

751
00:52:34.800 --> 00:52:38.000
the office complaining of right thigh pain
and swelling that has persisted for several weeks

752
00:52:38.280 --> 00:52:42.760
after he bumped his leg at school. He also reveals he has had trouble

753
00:52:42.800 --> 00:52:46.119
sleeping at night because he often feels
hot and sweaty. On exam, tenderness

754
00:52:46.159 --> 00:52:51.119
and warmth is felt on the lateral
aspect of his right thigh. Radiographs are

755
00:52:51.239 --> 00:52:55.079
negative for fracture, but reveal a
permeative or moth eaten appearance of the approximal

756
00:52:55.159 --> 00:53:00.159
femur, as well as a periosteal
reaction with layers of reactive bone that resemble

757
00:53:00.280 --> 00:53:05.719
layers of an onion. Skin.
Biopsy is obtained which displays sheets of uniform

758
00:53:06.159 --> 00:53:12.199
small round blue cells, and cytogenetic
testing reveals a chromosomal translocation of eleven and

759
00:53:12.320 --> 00:53:15.599
twenty two. What is the most
likely diagnosis in this patient? So that

760
00:53:15.719 --> 00:53:19.960
is going to be using sarcoma.
So you have a young male, minor

761
00:53:20.000 --> 00:53:22.239
trauma to the leg leading to localized
pain and swelling that is not improving.

762
00:53:22.519 --> 00:53:28.679
He has constitutional symptoms fever and night
sweats, all very typical of ewing sarcoma.

763
00:53:29.000 --> 00:53:31.119
But then we have our keywords or
numbers, moth, onion, blue,

764
00:53:31.320 --> 00:53:36.159
eleven and twenty two. Out of
all the words that vignette, those

765
00:53:36.199 --> 00:53:38.920
are the key to choosing the right
answer. So the X ray findings that

766
00:53:39.079 --> 00:53:43.360
moth eat and appearance and the onion
skin appearance, while they can be seen

767
00:53:43.400 --> 00:53:45.360
in other conditions, for the sake
of a vignette, it will very likely

768
00:53:45.440 --> 00:53:50.039
be Ewing sarcoma as this is a
common finding on X ray. And then

769
00:53:50.079 --> 00:53:53.320
we have the translocation between chromosome eleven
and twenty two and the small round blue

770
00:53:53.320 --> 00:53:58.639
cells on histology. That just solidifies
the diagnosis. And here's how I used

771
00:53:58.639 --> 00:54:01.920
to remember most of the keywords.
So when I would see Euing sarcoma Ewing

772
00:54:02.039 --> 00:54:07.440
sarcoma, I would think of another
famous person with that name, Patrick Ewing.

773
00:54:07.679 --> 00:54:09.800
So Patrick Ewing was a famous basketball
player. He wore the number thirty

774
00:54:09.880 --> 00:54:13.480
three, played for the New York
Knicks. So how does that help.

775
00:54:13.519 --> 00:54:17.039
Well, First, Patrick Ewing's number
was thirty three and eleven plus twenty two

776
00:54:17.519 --> 00:54:22.920
equals thirty three, so that helps
remember the eleven twenty two translocation. Second,

777
00:54:22.039 --> 00:54:25.760
the famous New York Knicks basketball jersey
was almost all blue with a little

778
00:54:25.800 --> 00:54:29.960
touch of orange, and the blue
jersey helped me remember the blue cells on

779
00:54:30.039 --> 00:54:32.360
histology. And then finally, I
just used to remember Patrick Ewing like Steed

780
00:54:32.400 --> 00:54:36.760
onion rings and just visualized him showing
down on some onion rings, which helped

781
00:54:36.800 --> 00:54:39.440
me remember the onion skin appearance on
X ray. So whenever I see Ewing

782
00:54:39.480 --> 00:54:44.760
sarcoma, I visualized Patrick Ewing wearing
his blue jersey with the number thirty three

783
00:54:44.800 --> 00:54:46.480
on it, eating some onion rings, and I remembered all the things that

784
00:54:46.599 --> 00:54:52.760
I needed to know for Ewing sarcoma. Question forty one. Forty six year

785
00:54:52.760 --> 00:54:54.800
old male who suffered a fall from
his roof earlier in the day has just

786
00:54:54.920 --> 00:54:59.800
completed a series of X rays.
The X ray revealed a number of fractures

787
00:54:59.800 --> 00:55:02.920
as as well as a dislocation of
the right tibio for moral joint aka the

788
00:55:04.039 --> 00:55:08.760
knee joint. What is the most
dangerous potential complication that can arise following a

789
00:55:08.880 --> 00:55:13.920
tibio FORMORL dislocation that needs to be
considered in this patient, So that is

790
00:55:13.960 --> 00:55:17.440
going to be a pop lteal artery
injury. This is the most dangerous complication

791
00:55:17.519 --> 00:55:22.639
following a tibio FORMORL dislocation aka a
knee dislocation, and delay in diagnosis or

792
00:55:22.679 --> 00:55:25.760
impair can lead to amputation. So
you need to make sure after you reduce

793
00:55:25.800 --> 00:55:30.280
the dislocation. You assess the distal
and poploteal pulses, measure, ankle brachial

794
00:55:30.320 --> 00:55:35.440
index, et cetera to ensure there's
no signs of vascular compromise. Question forty

795
00:55:35.480 --> 00:55:38.719
two, what is the most common
ligament to injure in an ankle sprain?

796
00:55:39.079 --> 00:55:44.719
So that is going to be the
anterior tilo fibular ligament aka the atf ligament.

797
00:55:45.280 --> 00:55:47.480
I used to remember that by remembering
the letters in atf ligament. Standford

798
00:55:47.519 --> 00:55:52.440
always tears first because this is the
ligament in the ankle most likely to tear

799
00:55:52.519 --> 00:55:55.519
in an ankle sprain. Question forty
three. Seventeen year old Mail presents to

800
00:55:55.599 --> 00:56:00.159
the ear after sustaining an injury to
his right arm. After X rays are

801
00:56:00.199 --> 00:56:06.079
complete, the attending physician informs him
the ray reveal a proximal ulnar fracture accompanied

802
00:56:06.119 --> 00:56:09.800
by a radial head dislocation. I'll
repeat that the X rays reveal a proximal

803
00:56:09.960 --> 00:56:15.280
ulnar fracture accompanied by a radial head
dislocation. This type of injury is also

804
00:56:15.400 --> 00:56:20.880
known as what type of fracture?
So that is a montegia fracture. So

805
00:56:21.000 --> 00:56:24.239
there's two types of fractures. Slash
dislocations you need to know for the forearm.

806
00:56:24.559 --> 00:56:28.280
First one, as we saw in
this vignette, is a Montegia fracture,

807
00:56:28.320 --> 00:56:31.599
which is a proximal ulnar fracture accompanied
by a radial head dislocation. And

808
00:56:31.679 --> 00:56:36.320
then the second type is known as
a Galiazzi fracture, which is a radial

809
00:56:36.400 --> 00:56:40.360
midshaft fracture with dislocation of the distal
radial owner joint. And while it's a

810
00:56:40.480 --> 00:56:45.320
dislocation or instability of the radio owner
joint, it's most common that the ulna

811
00:56:45.760 --> 00:56:50.440
gets dorsally displaced. So how can
you remember which is which? You remember

812
00:56:50.599 --> 00:56:54.880
something known as gruesome murder. Gruesome
murder helps you remember which bone is fractured

813
00:56:55.079 --> 00:57:00.360
and then secondly which is dislocated.
So the first three letters of gruesome gru

814
00:57:00.760 --> 00:57:05.679
The G stands for Galiazzi, the
R stands for radius fracture, and then

815
00:57:05.760 --> 00:57:09.000
the U stands for ulnar dislocation.
And then murder. First three letters are

816
00:57:09.159 --> 00:57:14.039
Mu, R M stands for Montezia, U stands for ulnar fracture, and

817
00:57:14.079 --> 00:57:16.960
then the R stands for radiohead dislocation. So again, remember gruesome murder.

818
00:57:17.239 --> 00:57:22.199
First three letters of gruesome help you
remember a Galiazzi fracture. It's a radius

819
00:57:22.239 --> 00:57:25.440
fracture and a ulnar dislocation aka the
radio owner a joint to be specific,

820
00:57:25.639 --> 00:57:30.000
and then the first three letters of
murder mure help you remember Montezia ulnar fracture

821
00:57:30.320 --> 00:57:35.880
and radiohead dislocation. Question forty four. Twenty six year old female presents at

822
00:57:35.880 --> 00:57:38.039
the office complaining of fatigue, joint
pain, and a low grade fever for

823
00:57:38.079 --> 00:57:43.119
the past few weeks. She also
reports that she develops a painful burn after

824
00:57:43.199 --> 00:57:45.239
being in the sun for just a
short period of time. On physical exam,

825
00:57:45.320 --> 00:57:49.880
you note a rash that is distributed
over the cheeks and nose, sparing

826
00:57:49.880 --> 00:57:53.519
the nasal labial folds, as well
as diffuse discoid lesions. What would be

827
00:57:53.599 --> 00:57:58.360
the best initial test to order in
this patient? So that is your anti

828
00:57:58.480 --> 00:58:02.719
nuclear antibody IKA, your ANA test. So in this patient, systemic lupus

829
00:58:02.840 --> 00:58:07.519
erthematosis should be at the top of
your list of differentials. Anytime you have

830
00:58:07.599 --> 00:58:09.880
a young female of childbearing age with
a joint with joint pain, rash,

831
00:58:09.920 --> 00:58:14.960
and fever, always consider lupus.
On exam, she has the classic mail

832
00:58:15.039 --> 00:58:19.320
or butterfly rash that spares the nasal
labial folds as well as the discoid lesions,

833
00:58:19.519 --> 00:58:22.960
and then she describes a photosensitive rash
that burn after a short period of

834
00:58:22.039 --> 00:58:25.079
time in the sun. So the
best initial or screening test and a patient

835
00:58:25.199 --> 00:58:30.159
you suspect may have lupus is your
ANA, your anti nuclear antibodies. It's

836
00:58:30.239 --> 00:58:31.920
not a specific test, but it's
very sensitive, and this is where you'll

837
00:58:31.920 --> 00:58:36.000
always start when screen for lupus,
and then after you proceed to your more

838
00:58:36.039 --> 00:58:40.119
specific antibodies, your anti double stranded
DNA in your anti Smith question forty five,

839
00:58:40.440 --> 00:58:44.400
twenty seven year old Mail presents to
the ear after a bicycle accident he

840
00:58:44.480 --> 00:58:46.599
had earlier on in the day.
He states his bike hit a pothole which

841
00:58:46.599 --> 00:58:51.599
sent him flying off his bike,
landing on his outstretched hands. He is

842
00:58:51.639 --> 00:58:54.039
now complaining of pain along the radial
side of the right wrist and is tender

843
00:58:54.159 --> 00:58:59.119
just proximal to the base of the
thumb at the anatomic snuff box. A

844
00:58:59.239 --> 00:59:02.800
fracture of bone should be suspected in
this patient until proven otherwise. So that's

845
00:59:02.840 --> 00:59:07.599
the scaffoid. This is a very
simple one scaffoid or an avicular fracture.

846
00:59:07.880 --> 00:59:09.480
You have a patient who had to
fall into an outstretched hand, which is

847
00:59:09.559 --> 00:59:14.719
most often the mechanism of injury for
a scafoid fracture. He has pain on

848
00:59:14.760 --> 00:59:17.119
the radial side of the wrist.
Snuffbox tenderness. You're done. This is

849
00:59:17.159 --> 00:59:22.119
a scaffoid fracture until proven Otherwise,
as soon as you hear snuffbox tenderness,

850
00:59:22.320 --> 00:59:25.679
always be thinking of a scaffoid fracture. Question forty six forty seven year old.

851
00:59:27.079 --> 00:59:30.159
Forty seven year old female presents to
the office complaining of dry mouth and

852
00:59:30.280 --> 00:59:32.559
dry eyes for several months. She
has used over the counter eye drops with

853
00:59:32.639 --> 00:59:38.119
minimal improvement. Physical exam reveals dry
mucus membranes and swollen parodied glands. Explain

854
00:59:38.199 --> 00:59:42.280
to the patient who will be performing
a test to assess for tear production.

855
00:59:42.639 --> 00:59:45.880
What is the name of the test
that will be performed. So that is

856
00:59:45.920 --> 00:59:49.679
going to be the Schermer test.
So this patient very likely has Scholgrin syndrome.

857
00:59:49.880 --> 00:59:52.079
Of course we would need to perform
some labs your anti row anti law

858
00:59:52.199 --> 00:59:55.960
ana, but she has all of
the classic clinical manifestations dry eyes, dry

859
00:59:57.039 --> 01:00:00.119
mouth, product gland enlargement. And
then the test we performed to assess for

860
01:00:00.199 --> 01:00:06.159
tear production is called the Schermer test. Now with Shogrin syndrome. In addition

861
01:00:06.199 --> 01:00:08.960
to your Schermer test, there's two
really high y old things that you need

862
01:00:09.000 --> 01:00:13.599
to know, and that's your anti
row and anti law antibodies that are used

863
01:00:13.599 --> 01:00:15.920
in diagnosing this condition. And the
way that I used to remember these three

864
01:00:16.079 --> 01:00:21.719
high old tests is by instead of
remembering Shogrin syndrome, I would remember slow

865
01:00:21.800 --> 01:00:25.880
green syndrome slow green instead of showgreen. And what's slow in green? A

866
01:00:27.000 --> 01:00:31.159
frog? That helps remember a slow
green, slow green frog landed in my

867
01:00:31.280 --> 01:00:35.199
cup of Sherbert. So create that
visual in your head if a cup of

868
01:00:35.239 --> 01:00:38.559
sherbet, that little frozen fruit treat, and then a frog landed right in

869
01:00:38.639 --> 01:00:43.960
it, So showgreen is now slow
green. A slow green frog landed in

870
01:00:44.039 --> 01:00:46.039
your cup of Sherbert. Frog.
The second two letters are our, O

871
01:00:46.400 --> 01:00:51.840
that helps you remember anti row landed. First two letters are LA that helps

872
01:00:51.880 --> 01:00:55.000
you remember anti law and Sherbert helps
you remember Schermer test. So that worked

873
01:00:55.039 --> 01:00:59.639
for me. Just remember slow green
instead of showgreen. Remember that slow green

874
01:00:59.679 --> 01:01:02.880
frog landing in your cup of Sherbert. Question forty seven, twenty seven year

875
01:01:02.880 --> 01:01:07.480
old mail presents to the office with
right knee pain after a sports related injury.

876
01:01:07.519 --> 01:01:09.480
A few days prior, he was
running and felt a sudden pop in

877
01:01:09.559 --> 01:01:13.840
his knee, and the past few
days he has found the knee is often

878
01:01:13.920 --> 01:01:16.760
locking up, making it difficult to
fully extend. And physical exam you note

879
01:01:16.840 --> 01:01:21.760
joint line tenderness in the right knee
as well as a palpable click and pain

880
01:01:22.159 --> 01:01:25.880
when performing the McMurray test. What
type of injury to this patient likely sustain?

881
01:01:27.280 --> 01:01:29.800
So that's going to be a meniscal
tear, all right, So what

882
01:01:29.880 --> 01:01:31.239
are the keys here to tell us
this is a meniscal injury and not some

883
01:01:31.400 --> 01:01:36.199
other type. First the pop and
lock of the knee. It's common for

884
01:01:36.239 --> 01:01:38.880
a patient with a miniscal injury to
complain of a pop, lock and drop,

885
01:01:39.199 --> 01:01:43.639
so the knee popping, locking where
they can't fully extend the knee,

886
01:01:43.679 --> 01:01:46.079
and then sometimes the knee even giving
out where they drop because the knee just

887
01:01:46.199 --> 01:01:51.440
gave way. And then finally the
physical exam findings which are key. First

888
01:01:51.480 --> 01:01:54.480
the joint tenderness, which is a
very sensitive physical exam finding, but it's

889
01:01:54.519 --> 01:01:58.920
non specific. But then we have
our McMurray test, which seals the deal,

890
01:01:59.159 --> 01:02:01.920
which is a pain will pop or
click in the knee with repetitive passive

891
01:02:02.000 --> 01:02:07.079
flection and extension. If you ever
forget that, the McMurray test is associated

892
01:02:07.079 --> 01:02:10.679
with meniscal injuries. So Murray is
obviously a man's name, and meniscal when

893
01:02:10.760 --> 01:02:15.440
broken down, has the words men
is call, So men is call?

894
01:02:15.639 --> 01:02:19.519
Remember men is called? And what
are men called? Murray as in the

895
01:02:19.599 --> 01:02:24.079
McMurray test. So if you see
an exam question or the answers with the

896
01:02:24.159 --> 01:02:28.639
name Murray in it, remember that's
a man's name, and it's what men

897
01:02:28.760 --> 01:02:30.880
are called, as in menace called. And then I'll help you. Remember

898
01:02:31.000 --> 01:02:36.400
the McMurray test is used in miniscal
tears. Question forty eight. Twenty two

899
01:02:36.480 --> 01:02:39.000
year old Mail presents the office today
complaining of swelling in his right upper arm

900
01:02:39.280 --> 01:02:44.360
that has increased in size over the
past year. State's theoria is not painful.

901
01:02:44.800 --> 01:02:49.519
Radiographs are obtained which reveal a large
pedunculated lesion that is pointing away from

902
01:02:49.559 --> 01:02:52.559
the joint space. A biopsy is
obtained in the physician informs the patient that

903
01:02:52.679 --> 01:02:57.599
the swelling they have in their arm
is caused from the most common type of

904
01:02:57.679 --> 01:03:01.079
benign bone tumor. What type of
benign bone tumor? Does this patient likely

905
01:03:01.199 --> 01:03:07.920
have, so that is an osteochondroma. So osteochondromas are the most common benign

906
01:03:07.960 --> 01:03:10.920
bony tumor, counting for thirty percent
of all benign bone tumors. Usually,

907
01:03:10.960 --> 01:03:15.519
these types of tumors are seen in
the second decade of life, more common

908
01:03:15.599 --> 01:03:19.519
in males than females, and often, although not always, the mass will

909
01:03:19.519 --> 01:03:22.360
be described as pain less and then
on radiograph look for them to describe as

910
01:03:22.719 --> 01:03:27.920
the mass as pointing away from the
joint space. And then sometimes the lesion

911
01:03:27.960 --> 01:03:30.320
can be described as being pedunculated,
which we see in this patient, which

912
01:03:30.360 --> 01:03:34.719
just means the cap is larger than
the base. Think of a mushroom,

913
01:03:35.639 --> 01:03:38.599
so narrow stock, big cap be
aware. Also, sometimes the legions can

914
01:03:38.639 --> 01:03:42.719
be described as sessile, which means
the base is larger than the cap,

915
01:03:43.159 --> 01:03:47.159
but often you'll see them being described
as pedunculated. Question. Twenty nine year

916
01:03:47.159 --> 01:03:52.280
old female presents the the office complaining
of anterior knee pain. She denies history

917
01:03:52.440 --> 01:03:54.519
of trauma to the knee. She
is an avid runner and has a marathon

918
01:03:54.599 --> 01:03:58.519
coming up in the next few weeks
and is hoping for some improvement before the

919
01:03:58.599 --> 01:04:03.159
event. And physical exam lateral movement
of the patella results in discomfort and apprehension

920
01:04:03.239 --> 01:04:08.559
from the patient. What common disorder
of the knee is this patient likely suffering

921
01:04:08.639 --> 01:04:12.880
from. So that is patelo femorl
syndrome. So when you get this question

922
01:04:12.960 --> 01:04:15.719
on an exam, it's always going
to look the same. It's going to

923
01:04:15.760 --> 01:04:18.760
be a female runner or cyclist with
knee pain, no trauma. You really

924
01:04:18.840 --> 01:04:23.679
just need to decide on one thing. Is this patelo flemorl syndrome or is

925
01:04:23.760 --> 01:04:28.280
this iliotibial band syndrome? Very simple. If it's anterior knee pain, it's

926
01:04:28.320 --> 01:04:31.920
patelo flemorl syndrome. If it's lateral
pain, it's iliotibial band syndrome. Easiest

927
01:04:31.960 --> 01:04:34.960
way to remember this is just to
think of the anatomy involved. Maybe you

928
01:04:35.039 --> 01:04:39.760
can't remember where your iliotibial band is, but I'm sure all of us know

929
01:04:39.840 --> 01:04:43.199
where our patella is, our kneecap, anterior side of the knee. So

930
01:04:43.199 --> 01:04:45.760
if it's a female runner with anterior
knee pain, it's patelo flemorl syndrome.

931
01:04:46.000 --> 01:04:49.639
As in the case of our patient
in this vignette, she also has a

932
01:04:49.679 --> 01:04:54.360
positive apprehension sign, which is where
you have the patient flex the knee slightly,

933
01:04:54.400 --> 01:04:57.599
apply some lateral pressure to the patella, and if they squirm around or

934
01:04:57.599 --> 01:05:00.679
attempt to straighten the knee, that's
a positive test. If you can't remember

935
01:05:00.760 --> 01:05:04.719
that Patelo fmorl syndrome is the most
is most common among female runners, just

936
01:05:04.840 --> 01:05:09.320
remember it like I did, instead
of remembering Patelo femoral syndrome. Instead of

937
01:05:09.360 --> 01:05:13.559
remember it as Patelo female run syndrome. So instead of Patelo femoral syndrome,

938
01:05:13.760 --> 01:05:16.199
Patelo female run syndrome. As those
are the key things to remember about this

939
01:05:16.320 --> 01:05:23.639
condition. Question fifty blank fractures are
the most common carbal bone fracture. Blank

940
01:05:23.800 --> 01:05:28.280
fractures are the most common carpal bone
fracture. So that's scafoid fractures. So

941
01:05:28.320 --> 01:05:30.119
I figured i'd end this on an
easy one. Scafoid fractures are the most

942
01:05:30.159 --> 01:05:33.719
common carbal bone to fracture. As
we just went over a few minutes ago

943
01:05:33.760 --> 01:05:36.840
in question forty five, make sure
to look out for snuffbox tenderists in these

944
01:05:36.880 --> 01:05:41.480
types of fractures. All right,
those fifty high old MSK questions. Hopefully

945
01:05:41.480 --> 01:05:43.920
that will help you for your exam. Thank you as always for listening to

946
01:05:44.000 --> 01:05:46.360
the podcast. Good Luck on your
exams, good luck in PA school,

947
01:05:46.400 --> 01:05:48.159
your pants, your pantry and your
rs.