Penn Med Self Study Questions

Arthritis

• Contrast osteoarthritis with rheumatoid arthritis? If both rheumatoid arthritis and osteoarthritis can lead to end-stage destruction of the joint(and both can) why is it important to differentiate between the two?

• Given the typical (degenerative) etiology of osteoarthritis, how then might a 20 year old person have this condition?

• What is the role of body mass vis a vis osteoarthritis? Why might we think that this not be a pure mechanical phenomenon? (hint: Framingham)

• What are the cardinal signs of osteoarthritis of the knee on plain radiographs? How (mechanistically) do they appear?

• Why is osteoarthritis painful?

Osteoporosis and metabolic bone disease

• Describe the process of bone remodeling?

• What are the three tasks of bone? How can problems related to the two non-structural tasks lead to fracture?

• Define and contrast osteoporosis and osteomalacia?

• How is osteoporosis diagnosed, prevented and treated?

• Describe the relationship between menopause and hip fracture risk. Describe the relationship between body mass and hip fracture risk.

• What are the three fractures typically associated with osteoporosis? Which is worst? Why is it so bad?

• Heaney wrote, "Although bone mass is certainly the most extensively studied of the fragility factors, low bone mass is not the whole of the osteoporosis story and may not even be its most important component (despite frequent assertions to the contrary). If one could magically normalize bone mass in everyone, would one eliminate osteoporotic fractures? The best answer that can be given today is ‘no.’ There would be fewer such fractures, but there would still be many, especially hip fractures." (Heaney RP Bone Mass, Bone Loss, and Osteoporosis Prophylaxis. Annals Internal Medicine 15 February 1998 128: 313-314). Explain what Heaney meant. That is, What else besides intrinsic bone problems could cause hip fracture?

• Mr. Smith, a 72 year old with hip pain, had x-rays ordered by his PCP that showed lytic lesions concerning for bone cancer. The radiology report, however, read the films as “Paget’s Disease” to which Mr. Smith exclaimed with delight, “It’s not cancer! That’s great news! What is Pagets disease of the bone? And why might that diagnosis not be "great news"?

Trauma

• Describe the differences between primary and secondary bone healing?

• What are the necessary conditions for appropriate bone healing (leading to minimal functional residuals) and how may physicians optimize the chances for healing?

• Plating a fracture clearly disrupts the soft tissue envelope around a fracture. Why, then, is surgical plating ever used?

• How can a femoral shaft fracture be lethal?

• What is compartment syndrome and how is it prevented, diagnosed, and treated? What are the consequences of not treating a compartment syndrome and over-treating a suspected compartment syndrome?

• Define joint dislocation subluxation and reduction

• Why is a traumatic hip dislocation typically worse than a shoulder dislocation? Contrast the mechanisms which prevent the normal shoulder from dislocating with those of the hip joint, and consider what structures must be damaged when the joint comes out of place.

• What is osteonecrosis? (also known as “avascular necrosis” or “AVN”) How does hip dislocation lead to avascular necrosis? How does avascular necrosis lead to end stage arthritis?

• Besides osteonecrosis, what other mechanisms may enable a dislocation to cause arthritis?

• A patient falls on his outstretched hand and has normal appear xrays but tenderness in the “anatomic snuff box” (between extensor pollicis longus and abductor pollicis longus and extensor pollicis brevis). Why might such a patient be placed in a cast despite the normal x-ray?

Sports Injuries

• What is a stress fracture? How is a stress fracture treated in a normal person? What are the consequences of a stress fracture which is not treated? Why might a young woman with an eating disorder be at particular risk for stress fracture?

• What is the definitional distinction between grade I, II and III sprains? How would these various grades of injury present distinctly on examination?

• What is the function of the Anterior Cruciate Ligament (ACL) in the knee? How is the ACL torn? Along those lines, why might it be the case (as we suspect) that skiingrelated ACL tears occur disproportionately after 2pm? How is an ACL tear detected on exam?

• Why is it that a tear of the ACL typically requires surgical replacement whereas a grade III sprain tear of the medial collateral ligament of the knee can heal with immobilization and rehab?

• What is the function of the meniscus in the knee? What is the consequence of tearing a meniscus? Why are most symptomatic meniscal tears removed and not repaired?

• What is rotator cuff tendinitis? What are the consequences of labeling it (perhaps incorrectly) as an “---itis"? What are the consequences of labeling rotator cuff tendinitis as “impingement syndrome”?

Spine

• Back pain is a common, self-limited condition in many people. Discitis, cancer and cauda equine syndrome are causes of back pain which are not innocent and self-limiting. First, by way of background, define "cauda equina syndrome", discitis and the common cancers are found in the spine. Next, name some questions a physician might ask to help detect the diagnoses?

• A so-called herniated disc may compress a nerve root and cause radicular complaints/findings. What are the classic motor and sensory findings of L4 L5 and S1 compression? Why, given that an MRI can localize the disc herniation, if present, should/must a student know the motor and sensory findings of each nerve root level? Suggest a medical rationale for not obtaining an MRI in a patient with low back pain and no neurological features. Forget about the cost of the MRI itself: why might a physician considering only the best medical interests of his or her patient choose to omit an MRI?

• What is neurogenic claudication (and contrast with vascular claudication)?

• What is idiopathic scoliosis and what is its relationship to back pain?

Carpal Tunnel Syndrome

• Provide a brief description of Carpal Tunnel Syndrome (including complaints, findings and treatment options)

• Cervical radiculopathy is certainly on the differential diagnosis in a patient with suspected Carpal Tunnel Syndrome. Think of some other entries on that list as well. What complaints would make you think that a patient has one of these, and not Carpal Tunnel Syndrome?

• Tinnel’s sign is not a true sign---in what way? Why might that be significant?

Infection

• What is septic arthritis? What are its causes?

• How is septic arthritis diagnosed definitively? What are the temporal limitations regarding our ability to diagnose definitively? How do we get around that?

• How is septic arthritis treated? Why must septic arthritis be treated expeditiously?

• Both gout and septic arthritis can cause acute pain and swelling of a joint. How can they be distinguished?

• What is osteomyelitis? What are its causes? Although bone is part of the vascular system (and therefore fractures can cause hemorrhage and metastatic cells can lodge in the skeleton) why might IV antibiotics have trouble reaching areas of infected bone?

Pediatric Hip conditions

• What is Developmental Dysplasia of the Hip? How is Developmental Dysplasia of the Hip diagnosed in the neonate and why is it critical to detect this, if present, as soon as possible?

• What is a Slipped Capital Femoral Epiphysis?

• What is Perthes Disease?

• Why might Developmental Dysplasia of the Hip, a Slipped Capital Femoral Epiphysis and Perthes Disease cause arthritis of the adult hip? (ie, later in life). Why might successfully treated Developmental Dysplasia of the Hip have the best prognosis whereas untreated Developmental Dysplasia of the Hip might present the biggest treatment (surgical reconstruction) challenges?

Disorders of the foot and ankle

• What is Club foot?

• What is a Charcot joint?

• Why might a 12 year old boy with a swollen ankle and pain on the distal fibula be treated with a cast despite normal xrays?

• Why do 40 year old men rupture their Achilles tendons? What are the biological and mechanical steps leading to tissue failure?

• The phrase "just a sprain" may grossly understate the impairment such an injury imparts. Why might a grade I ankle sprain cause long term impairment such an injury imparts?