Module 16: Alterations of the musculoskeletal system

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Module 16: Alterations of the musculoskeletal system Chapters 36 and 37

Inflammation of a tendon where it attaches to the bone at its origin is called:

epicondylitis

A partial tear of a ligament is called a:

second-degree strain

The displacement of two bones in which the articular surfaces partially lose contact with each other is called:

subluxation

Patients with osteoporosis are at risk for which of the following problems?

Pathologic bone fractures

Which disorder presents with significant bone demineralization from a vitamin D deficiency and usually results in skeletal pain?

Osteomalacia

In osteomyelitis, the area of necrotic bone at the site of the infection is called the

sequestrum.

The pathophysiology of osteomalacia involves:

abnormal calcium crystallization.

The cause of most cases of endogenous osteomyelitis is (are):

blood-borne bacteria.

The chief pathologic feature of degenerative joint disease is:

degeneration of articular cartilage.

Risk factors for osteoarthritis include all of the following:

older age, obesity, orthopedic injury

Synovial joint problems in rheumatoid arthritis are due to which of the following pathologies?

Articular cartilage is lost through enzymatic breakdown.

In addition to joint pain, rheumatoid arthritis often manifests with which of the following systemic symptoms?

Fever, Malaise, Lymphadenopathy

Ankylosing spondylitis results in:

vertebral joint fusion

The final stage of gout, characterized by crystalline deposits in cartilage, synovial membranes, and soft tissue, is called:

tophaceous gout.

Episodes of gout are often triggered by all of the following factors:

alcohol, drugs, trauma

A characteristic feature of fibromyalgia is:

trigger point pain

Pain in fibromyalgia is attributed to:

decrease in pain tolerance

Severe muscle trauma from crush injuries can result in which of the following complications?

Rhabdomyolysis

Myoglobinuria (rhabdomyolysis) can result in failure of which of the following organs?

kidneys

Phase 1 of the bone remodeling cycle involves:

bone cell activation

A bone breaks in a place where there was pre-existing disease. What type of fracture is being described?

pathological

All of the following events occur following a bone fracture:

development of a blood clot beneath the periosteum.
leukocyte infiltration into bone tissue.
blood vessel growth at the fracture site.

A torus fracture occurs when:

the cortex of the bone buckles.

A fracture in which the bone breaks into two or more fragments is termed a

comminuted fracture.

Complications that can occur as a fractured bone heals include all of the following:

malunion.
nonunion.
delayed union

Which of the following structures prevents reflux of stomach contents into the esophagus?

Lower esophageal sphincter

Saliva contains all of the following:

water.
IgA.
amylase.

The chief cells of the gastric glands secrete:

pepsinogen

Mucus production in the stomach is blocked by medications that block the release of:

prostaglandins.

Pepsin is necessary for the digestion of which of the following nutrients:

proteins

The following structures are part of the small intestine:

Ileum
Duodenum
Jejunum

The majority of the small intestine receives splanchnic blood flow from which artery?

Superior mesenteric

Which sphincter controls the release of pancreatic enzymes and bile into the duodenum?

Oddi

Parasympathetic stimulation of the digestive system results in:

increased gastric and pancreatic secretions

The cells of the liver lobules that synthesize and release bile are called:

hepatocytes

Bilirubin in bile comes from:

phagocytosis of aged red blood cells.

Functions of the liver include all of the following:

storage of vitamins.
synthesis of plasma proteins.
metabolic detoxification

Common causes of constipation include all of the following except:

inadequate fluid intake.
a low-fiber diet.
medications

Which of the following types of diarrhea can be caused by an inability to digest lactose in dairy products?

Osmotic

The presence of digested dark blood in the stool is called:

melena

The following conditions can cause dysphagia:

Hiatal hernia
Achalasia
Gastroesophageal reflux

Reflux esophagitis is defined as:

an inflammatory response to gastroesophageal reflux.

Common manifestations of gastroesophageal reflux disease (GERD) include:

heartburn, dysphagia, and pain within one hour of eating.

Complications associated with gastroesophageal reflux disease (GERD) include which of the following?

Esophageal ulcerations
Esophageal cancer
Esophageal strictures

A hiatal hernia is a protrusion of the _____ through the ______.

stomach; diaphragm

Paralytic ileus often occurs after:

abdominal surgery

Intestinal obstruction can lead to all of the following complications

dehydration.
peritonitis.
perforation

The classic symptoms of a small bowel obstruction are:

vomiting, severe abdominal pain, and abdominal distension

The most common cause of chronic gastritis is:

bacterial infection

Individuals with chronic gastritis are at risk for developing which of the following problems?

Gastric cancer
Achlorhydria
Gastrointestinal bleeding

How does a chronic infection with Helicobacter pylori (H. pylori) lead to duodenal ulcers?

H. pylori produces substances that are toxic to the duodenal mucosa.

Which type of ulcer is a stress ulcer that is associated with burn injuries?

Curling

Severe trauma can result in stress ulcers that often first manifest with:

severe bleeding.

Gastrectomy surgery commonly leads to a vitamin B12 deficiency anemia because:

decreased intrinsic factor production results in decreased vitamin B12 absorption in the ileum

Which disorder is characterized by night blindness, osteopathy, and clotting disorders?

Bile salt deficiency

Which disorder is characterized by the inability to digest all nutrients?

Pancreatic insufficiency

Which of the following factors are known causes of ulcerative colitis?

Genetic predisposition
Autoimmune injury
Inflammation

Common characteristics of Chron disease include which of the following?

Vitamin B12 deficiency

Diverticula are:

outpouchings of the colon's mucosa.

Diverticulosis can be related to which of the following dietary problems?

Diet high in refined foods

What is the most common cause of acute mesenteric (vascular) insufficiency?

emboli

Which of the following types of hepatitis is acquired from ingesting contaminated food and manifests acutely with fever, abdominal pain, and jaundice, but does not usually result in fulminant liver failure?

Hep A

Cholelithiasis is:

the accumulation of gallstones in the gallbladder.

The most common cause of portal hypertension is:

liver cirrhosis.

Which of the following statements explains why portal hypertension leads to ascites?

Back-up of blood in the intra-abdominal veins occurs

Cheyne-Stokes resirations are characterized by:

Rapid respirations alternating with periods of apnea
Apneic spells alternating with hyperventilation are called Cheyne-Stokes respirations and often occur with neurologic injury or profound metabolic alterations.

Hypertrophy of the nail beds due to chronic hypoxemia is called:

Clubbing
Clubbing is manifested by enlargements at the base of the fingernails.

Hypoventilation results in:

Hypercapnia
Hypoventilation results in increased PaCO2, a condition called hypercapnia.

Respiratory acidosis can result from:

Reduced tidal volumes
Low tidal volumes (hypoventilation) result in C02 retention and respiratory acidosis.

Which of the following conditions causes a decreased drive to breathe that results in hypoxemia and hypercapnia?

Cental nervous system disorders
Central nervous system disorders result in a decreased drive to breathe due to damage to the respiratory centers.

A decrease in tidal volume results in a decrease in:

Minute ventilation
Tidal volume, or the volume of air inspired, is directly related to ventilation. A decrease in tidal volume results in a direct decrease in minute volume and minute ventilation.

Which of the following alterations in serum lab values would indicate that a patient is hyperventilating?

High pH
Rapid ventilation increases CO2 removal from the blood and results in a low PaCO2 and elevated pH (respiratory alkalosis).

Which of the following diseases will result in a ventilation/perfusion (V/Q) mismatch?

Asthma, pulmonary edema and emphysema
All three pulmonary diseases result in V/Q mismatches due to decreased ventilation and/or impaired diffusion of gases at the alveolar/capillary membrane.

The collapse of a previously inflated area of lung tissue is called:

Atelectasis
The collapse of a previously inflated area of lung tissue is called atelectasis.

Coal miners or individuals exposed to asbestos often develop a chronic respiratory condition called:

Pneumoconiosis
Severe inflammation and scarring in the pulmonary tissue due to prolonged exposure to coal dust, asbestos, and other inhaled toxins is called pneumoconiosis.

In acute respiratory distress syndrome (ARDS), alveolar damage and impaired surfactant secretion lead to each of the following problems except:

Air trapping
Alveolar damage and altered surfactant production have no direct effect on the bronchi and therefore cannot cause air trapping.

Why does airway obstruction in chronic lung disease cause hypercapnia?

Airway obstruction causes air trapping
With airway obstruction, air enters the alveoli but has difficulty escaping during exhalation. Air becomes trapped in the alveoli, and expiration must be more forceful and prolonged. When air is trapped, tidal volumes are reduced, causing hypercapnia.

When exposed to inhaled allergens, a child with asthma produces large quantities of:

IgE
During an allergic response (type I hypersensitivity reaction), plasma cells produce large quantities of IgE.

In individuals with asthma, exposure to an allergen leads to which of the following pathophysiological events?

Bronchoconstriction and airway edema
Exposure to an allergen results in mast cell degranulation and release of inflammatory mediators that cause bronchoconstriction and airway edema.

When conducting a physical assessment of an individual during an acute asthma episode, you would expect to observe all of the following except:

Loss of pulsus paradoxus
During an acute asthma episode, pulsus paradoxus increases.

The loss of alpha1-antitrypsin in emphysema results in:

The destruction of alveolar septa and the loss of elastic recoil
The destruction of alveolar septa and the loss of elastic recoil in emphysema lead to the loss of alveolar surface area and the collapse of airways during expiration.

A frequent complication of chronic bronchitis related to the hypersecretion of mucus is:

Recurrent infections
Mucus provides a hospitable enviroment for bacterial colonization.

Pneumonia leads to hypoxemia due to:

The accumulation of exudates and fibrin deposition
The inflammatory response to lung infection results in the accumulation of fibrous exudates, which cause ventilation/perfusion (V/Q) mismatching and impair the diffusion of oxygen at the alveolocapillary membrane.

All of the following physical and laboratory findings are indicative of a bacterial pneumonia except:

a dry cough
A dry cough may occur with viral pneumonia. Bacterial pneumonia usually manifests with a productive cough.

Staff at an inner-city homeless shelter send 46-year-old Henry Ship by ambulance to a local hospital after he begins coughing up blood. On arrival at the emergency room, he is feverish and says that he has felt very fatigued for several weeks. He also reports experiencing night sweats. Mr. Ship's symptoms are most likely caused by:

Tuberculosis
All of Mr. Ship's symptoms are typical of tuberculosis infection (TB). Being homeless and living in a shelter are risk factors for TB since the bacteria are easily transmitted from person to person.

Risk factors for TB include:

Immunosuppression
Immunosuppressed individuals, such as those with HIV, are at high risk for TB, which is easily transmitted by personal contact with infected individuals.

Severe acute respiratory distress syndrome (SARS) is transmitted via which of the following mechanisms?

Droplet inhalation
The particular strain of the coronal virus responsible for SARS is transmitted via inhaled droplets containing the virus or via contact with infected bodily (respiratory) fluids.

What is the World Health Organization's major concern regarding the avian flu, which is caused by the H5N1 virus?

The virus may mutate to a form that can be easily transmitted from person to person.
To date, the H5N1 virus has only been transmitted from birds to humans. If the virus develops an ability to be transmitted among humans, there is a grave fear of a pandemic.

Which of the following patients is at highest risk for developing a pulmonary embolism?

a 67-year-old male hospitalized with a deep vein thrombosis in the femoral vein
The presence of deep vein thrombosis in the lower limb is the most important risk factor for pulmonary embolism. Older age is also risk factor.

Chronic pulmonary hypertension can eventually cause which of the following complications?

Chronic obstructive pulmonary disease
Increased right ventricular afterload from pulmonary hypertension can lead to right ventricular failure. Right ventricular failure due to respiratory disease is also known as "cor pulmonale."

Common sites of metastasis for lung cancer include all of the following except:

The kidneys
Although it may be possible for lung cancerd to metastasize to the kidneys, it is not one of the common sites.

Metaplastic changes to bronchial epithelial tissues are frequently caused by:

Cigarette smoking
Cigarette smoking is the most common stimulus for metaplastic changes in the bronchial epithelium. Although metaplasia is generally reversible, the metaplastic cells can become cancerous if an individual continues to smoke.

Signs and symptoms of dyspnea include:

Feeling short of breath
Dyspnea is the sensation of feeling short of breath.

A high ventilation/perfusion (V/Q) ratio can be caused by:

Obstruction to pulmonary blood flow
Obstruction to pulmonary blood flow results in decreased perfusion and a high V/Q ratio.

Respiratory failure is defined by which one of the following laboratory alterations?

High PaCO2
Respiratory failure results in CO2 retention and elevated PaCO2.

Lung injury that results in diffuse pulmonary inflammation and infiltrates and that is followed by development of a hyaline membrane at the alveolocapillary interface is a condition known as:

Acute respiratory distress syndrome (ARDS)
ARDS involves a lung-wide inflammatory response to direct or indirect lung injury and manifests with diffuse pulmonary infiltrates and the development of a hyaline membrane.

Non-cardiogenic pulmonary edema most often is caused by:

Systemic infection (sepsis)
Inflammation present with systemic infections and sepsis is the main cause of non-cardiogenic pulmonary edema (i.e., acute respiratory distress syndrom, or ARDS).

Pulmonary edema is an example of ________ pulmonary disease.

Restrictive
Pulmonary edema restricts alveolar or lung expansion.

Air that enters the pleural space during inspiration and is unable to exit during expiration creates a condition called:

Tension pneumothorax
A tension pneumothorax can collapse the lung because the pressure of the air in the pleural cavity exceeds the atmospheric pressure in the alveoli.

Which of the following characteristics is not typical of asthma?

Asthma causes alveolar collapse
The pathophysiology of asthma does not involve alveolar collapse.

A life-threatening complication of asthma is:

Status asthmaticus
Status asthmaticus is prolonged, severe bronchospasm that can be life-threatening if not reversed.

Airway obstruction in chronic bronchitis is generally the result of:

Thick mucus secretions and smooth muscle hyperplasia
Inspired irritants stimulate inflammation, mucus secretion, and bronchospasm, which can lead to smooth muscle thickening in the airways. All of these factors contribute to airway obstruction in chronic bronchitis.

Individuals who have recently developed chronic bronchitis often present with all of the following except:

a barrel chest
The symptoms that lead individuals with chronic bronchitis to seek medical care include decreased exercise tolerance, wheezing, shortness of breath and chronic productive cough.

The increased anterior-posterior chest diameter associated with obstructive lung disease is caused by:

Increased residual lung volumes
Increased residual lung volumes are a result of air trapping in obstructive lung disease and cause expansion of the chest wall.

Which of the following measures is most effective for preventing pulmonary emboli in patients who are recovering from major surgery?

Ambulate patients frequently to prevent blood clot formation
Venous stagnation, a major risk factor for deep vein thrombosis and pulmonary embolism formation, can be prevented by frequent ambulation after surgery.

Familial pulmonary hypertension usually is caused by:

a genetic mutation
Increased pulmonary vascular resistance from pulmonary emboli causes secondary pulmonary hypertension.

_______ is a term that signifies right-sided heart failure secondary to pulmonary hypertension.

Cor pulmonale
Cor pulmonale is right-sided heart failure secondary to pulmonary hypertension.

Alveolar edema in pneumococcal pneumonia is caused by:

Inflammatory cytokines
The infectious process in pneumococcal pneumonia results in the release of inflammatory mediators that cause alveolar edema.

________ atelectasis is the collapse of lung tissue caused by external pressure exerted by a tumor, fluid, or air.

Compression
Compression atelectasis occurs when a lung tumor, pulmonary edema, pleural effusion, or pneumothorax creates external pressures that collapse alveoli.

Pain on inspiration (pleuritic) is associated with which of the following disorders?

Pleural inflammation
Inflammation of the pleura often manifests with pain on inspiration, fever, and chills.

What is a fracture?

a break in the continuity of a bone
-↑ incidence in males 15-24, greater than 65

classifications:
-complete or incomplete (open or closed)
-comminuted (multiple bone & fragments)
-linear (parallel to long axis of bone)
-oblique
-spiral (wrapping around bone)
-transverse (90 degrees to long axis)

greenstick fracture

a partial fracture of a bone (usually in children)
-fracture of 1 side of cortex & spongy bone splinters

torus fracture

Buckling of the cortex of a long bone from trauma (usually radius or ulna)

bowing fracture

bone in pairs: 1 breaks, other bends

pathologic fracture

fracture caused by diseased or weakened bone

stress (microfracture)

2 types:
fatigue & insufficiency (new activity vs. fatigue fracture in abnormal bone)

transchondral fracture

fragmentation and separation of a portion of the articular cartilage that covers the end of a bone at a joint

bone fractures

a broken bone can cause damage to the surrounding tissue, the periosteum (which is a vascular membrane covering bones) and the blood vessels in the cortex & marrow

hematoma formation

-1st stage in bone fracture healing
-clot forms at damaged edges of bone

what is the second stage of bone fracture healing?

bone tissue destruction triggers an inflammatory response (fractured ends of bone decalcify)

procallus formation

invasion by osteoblasts, calcium deposition

callus formation

-mineralized new bone built up
-osteoclasts destroy dead bone

remodeling

excess callus resorbed & trabecular bone laid down

Remember:
bone (like liver) will form new bone not scar tissue when healing

what are the steps in callus formation?

A.) hematoma formation
B.) organization of hematoma
C.) invasion of osteoblasts, deposition of calcium
D.) callus formation
E.) remodeling

What are the manifestations of bone fractures?

unnatural alignments, swelling, muscle spasm, tenderness, pain, impaired sensation, & possible muscle spasms

What are the treatments for bone fractures?

-closed manipulation (most), traction (maintain reduction w/ force), open reduction (surgery)
-internal (screws) and external fixation (bars)

What can happen if bone fracture is not treated properly?

improper reduction or lack of immobilization: need to keep bone from moving or nonunion occurs

nonunion

ends of bone does not grow together

delayed union

prolongation of expected healing time for a fracture: 8-9 months

malunion

Occurs when the fracture heals in a position that does not resemble the original anatomical form of the bone and alters the mechanical function of the bone.

dislocation fracture

-temporary displacement of 2 bones
-loss of contact between articular cartilage

sublaxtion fracture

contact between articular surfaces is only partially lost

dislocation & subluxation fractures

are associated with fractures, muscle imbalance (weight lifters), rheumatoid arthritis, or other forms of joint instability
- < 20 years old
-shoulder, elbow, wrist, hip, knee

dislocations of hip

-Anterior (rare): land on feet after falling
-Posterior: auto accident- knee hits dashboard

may disrupt circulation → necrosis of the joint → hip replacement (Bo Jackson)

Rx: reduction

what is a strain?

tear or injury to a tendon
-1st (least severe, 2nd, 3rd degree (most severe)

What is a sprain?

tear or injury to a ligament

What is an avulsion?

complete separation of a tendon or ligament from its bony attachment site

What is the treatment for a support structure injury?

suture together (min 8 weeks healing)

what is tendinitis?

acute inflammation of a tendon due to new activity
-resolves w/ rest, ice, & anti-inflammatories

What is tendinosis?

painful degradation of collagen fibers due to repeated trauma

what is bursitis?

inflammation of a bursa (small sacs filled with synovial fluid located between tendons & muscles)
-skin over bone, skin over muscle, & muscle & tendon over bone
-caused by repeated trauma
-septic bursitis is caused by a wound infection

What is epicondylitis?

inflammation of a tendon where it attaches to a bone in the elbow

tennis elbow

lateral epicondylitis

golfer's elbow

medial epicondylitis

What is a muscle strain?

a sudden, forced motion causing the muscle to become stretched beyond its normal capacity
-local muscle damage
-muscle strains can also involve the tendons
-6 weeks healing time

What is Myositis Ossificans?

-complication of local muscle injury
-inflammation of muscular tissue w/ subsequent CALCIFICATION & ossification of the muscle

-"rider's bone" in equestrians (adductor in thigh)
-"drill bone" in infantry soldiers (pectoral m.)
-thigh muscles in football players

What is Rhabdomyolysis?

is a life-threatening complication of severe muscle trauma w/muscle cell necrosis: myoglobinemia → myoglobinuria → KIDNEY TOXICITY

What are the causes of Rhabdomyolysis?

-crush syndrome (most severe presentation)
-compartment syndromes - local- (caused by limb ischemia, local trauma, excessive muscular activity, or heat stroke):
(Volkmann) ischemia contracture- flexion contracture of fingers/wrist due to ischemia of forearm

What are the treatments for compartment syndrome?

1.) Fasciotomy (of anterior & posterior compartments) to relieve pressure
2.) "flush" kidneys w/ diuretics (build up of myoglobin)

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