Quiz week 3: Back Pain from a Minor Fall

Head and neck anatomy

100

Name the 5 layers of the scalp.

S – skin
C – connective tissue
A – aponeurosis (galea aponeurotica)
L – loose connective tissue
P – periosteum

200

Name the suture that separates the parietal and occipital bones.

lambdoidal suture.

300

What forms Waldeyer’s ring?

Pharyngeal tonsil
Palatine tonsil (2)
Tubal tonsils (2)
Lingual tonsil

400

Which nerve supplies taste and sensation to the posterior 1/3rd of the tongue?

Glossopharyngeal (IX)

500

What is the action of the temporalis muscle?

Maintains the position of the mandible (postural).
Mainly a mandibular elevator but it’s posterior fibres produce retrusion and the anterior/middle fibres cause protrusion.
Lateral deviation of the mandible is produced by simultaneous activation of the ipsilateral posterior fibres and the contralateral anterior/middle fibres.

Myeloma

100

Name 5 clinical features of multiple myeloma.

Bone pain
Pathologic fractures
SC compression
Hypercalcaemia
Infection
Hyperviscosity
Neurologic symptoms
Anaemia

200

What investigations are required for a diagnosis of myeloma?

1. Bone marrow aspirate – plasmacytosis
2. Serum and urine protein electrophoresis – monoclonal band.
3. Skeletal survey – lytic lesions

300

Name 3 causes of renal failure in multiple myeloma.

Hypercalcaemia (most common)
Dehydration
Tubular damage by myeloma light chains (Bence Jones proteins)
Hyperuricaemia
Amyloidosis
Recurrent infections
Occasional infiltration by myeloma cells

400

What is the mechanism of action of Bortezomib (Velcade)?

Proteasome inhibitor.

500

How do you differentiate between MGUS (monoclonal gammopathy of undetermined significance) and asymptomatic myeloma?

In MGUS serum M protein <30g/L and BM shows <10% clonal plasma cells whereas in asymptomatic myeloma serum M protein >30g/L and BM shows >10% clonal plasma cells. In both conditions there is no evidence of organ or tissue impairment (including bone lesions).

Back pain

100

What is a red flag? Name 4 red flags.

Thoracic pain
Fever and unexplained weight loss
Bladder or bowel dysfunction
History of malignancy
Ill health or presence of other medical illness
Progressive neurological deficit
Disturbed gait
saddle anaesthesia
Age of onset <20 years or >55 years

200

What is a yellow flag? Name 4 yellow flags.

Yellow flags are psychosocial factors shown to be indicative of long-term chronicity and disability:
A negative attitude that back pain is harmful or potentially severely disabling
Fear avoidance behaviour and reduced activity levels
An expectation that passive, rather than active treatment will be beneficial
A tendency to depression, low morale, and social withdrawal
Social or financial problems.

300

What is cauda equina syndrome? How does it present?

A group of symptoms caused by compression of the cauda equina. The aetiology is usually a large central herniated disc or a pathological or traumatic fracture.
Bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe compression of the cauda equina.
Cauda equina syndrome is a surgical emergency.

400

Name the components of a physical examination for a patient presenting with back pain.

Inspection of back and posture
Range of motion
Palpation of the spine
Straight leg raising (for patients with leg symptoms)
Neurologic assessment of L5 and S1 roots (for patients with leg symptoms)
Evaluation for malignancy (breast, prostate, lymph node exam) when persistent pain or history strongly suggests systemic disease.

500

Name 4 common differential diagnoses for back pain.

1. Lumbar muscular strain/pain
2. Herniated nucleus pulposus
3. Spinal stenosis
4. Compression fracture
Uncommon: Spondylolysis and/or spondylolisthesis, Vertebral discitis/osteomyelitis, Malignancy, Inflammatory spondyloarthropathy, Connective tissue disease, Aortic abdominal aneurysm, Pancreatitis, Pyelonephritis, Renal colic, Peptic ulcer disease.

Calcium homeostasis and disorders

100

What percentage of total calcium in the serum is represented by ionised calcium?

50%. It is the only biologically active fraction.

200

Name the 3 controls of calcium.

1. Parathyroid hormone.
2. Calcitonin - but no clinical significance in calcium homeostasis.
3. Magnesium - severe hypomagnesaemia "paralyses" calcium homeostasis.

300

Name the 3 mechanisms by which PTH regulates calcium.

1. Increasing absorption from the gut (via vitamin D).
2. Mobilising calcium (and phosphate) from bone.
3. Increasing renal tubular resorption of calcium (along with promoting “dumping” of phosphate).

400

Name 4 possible causes of hypercalcaemia.

Primary hyperparathyroidism (sporadic or genetically determined)
Malignancy (including multiple myeloma)
Drug therapy including lithium, thiazides
Tourniquet artefact
Sarcoidosis
Rare: Familial hypocalcuric hypercalcaemia, tertiary hyperparathyroidism, Vitamin D or A excess, Immobilisation, hyperthyroidism, Williams syndrome, Milk-alkali syndrome.

500

What is trousseau’s sign? How is it elicited?

Medical sign observed in hypocalcaemia.
To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.
The sign is also known as main d'accoucheur (French for "hand of the obstetrician") because it supposedly resembles the position of an obstetrician's hand in delivering a baby.

Pathology

100

What are the characteristic features of multiple myeloma on microscopic examination of bone marrow?

Increased number of plasma cells – usually constitute more than 30% of the marrow cellularity.
Neoplastic plasma cells usually have a perinuclear clearing (due to a prominent Golgi apparatus) and an eccentrically placed nucleus.

200

What are smudge cells and what condition are they associated with?

Smudge cells are remnants of cells that lack any identifiable cytoplasmic membrane or nuclear structure.
They are most often associated with abnormally fragile lymphocytes in disorders such as chronic lymphocytic leukemia (CLL) (However, they can also be seen in degenerating samples; in which case, their origin may not be lymphocytic)

300

Name 3 causes of aplastic anaemia.

Idiopathic (50-70%) – primary stem cell defect or immune mediated
Chemical agents – dose related or idiosyncratic
Physical agents (e.g. whole body irradiation)
Viral Infections (e.g. CMV, EBV)
Inherited – Fanconi anaemia (rare autosomal recessive disorder)

400

What is the characteristic cytogenetic abnormality associated with chronic myelogenous leukaemia (CML)?

Philadelphia chromosome –The result of a reciprocal translocation between chromosome 9 and 22, and is specifically designated t(9;22).
A fusion gene is created by juxtapositioning the Abl1 gene on chromosome 9 to a part of the BCR ("breakpoint cluster region") gene on chromosome 22 → BCR-Abl fusion protein (tyrosine kinase activity).
The presence of this translocation is a highly sensitive test for CML, since 95% of people with CML have this abnormality

500

What is osteitis fibrosa cystica (also known as Von Recklinghausen’s disease of the bone)?

Skeletal disorder caused by a surplus of PTH (seen in primary hyperparathyroidism).
Excess PTH stimulates osteoclasts → osteoclastic bone resorption.
Characterized clinically by bone pain and radiographically by subperiosteal bone resorption on the radial aspect of the middle phalanges, tapering of the distal clavicles, a "salt and pepper" appearance of the skull, bone cysts, and brown tumours of the long bones.
Brown tumour of the hands: