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  • MUSC1_1

    • Lecture Objectives

    • Musculoskeletal System: Dermatology

    • Lecture 1 - Dermatology

    • Anatomy of the Epidermis

    • Stratum corneum

    • Stratum lucidum

    • Stratum granulosum

    • Stratum spinosum

    • Stratum basalis

    • Basement membrane

    • Review of epidermal anatomy

    • Epithelial cell junctions

    • Zona occludens

    • Zona adherens

    • Zona occludens versus zona adherens

    • Macula adherens (desmosome)

    • Macula adherens (desmosome)

    • Gap junctions

    • Basement membrane - 1

    • Basement membrane - 2

    • Hemidesmosome

    • Hemidesmosome – clinical correlate

    • Integrin

  • MUSC1_2

    • Macule versus patch

    • Papule versus plaque

    • Vesicles

    • Bulla

    • Keloid

    • Pustule

    • Hyperkeratosis - Callus

    • Parakeratosis

    • Parakeratosis - Psoriasis

    • Acantholysis

  • MUSC1_3

    • Common diseases of the skin

    • Verrucae

    • Nevus

    • Dysplastic nevus

    • Urticaria

    • Atopic dermatitis

    • Allergic contact dermatitis

    • Psoriasis

    • Psoriasis - histology

    • Psoriasis – clinical manifestations

    • Psoriasis – histology review

    • Psoriasis – other clinical manifestations

    • Psoriasis – characteristic lesion

    • Seborrheic keratosis

    • Albinism - characteristics

    • Albinism - types

    • Vitiligo

    • Melasma

    • Impetigo

    • Cellulitis

    • Necrotizing fasciitis

    • Staph scalded skin syndrome

    • Hairy leukoplakia

    • Pemphigus vulgaris

    • Pemphigus vulgaris - example

    • Pemphigus vulgaris - histology

    • Pemphigus vulgaris – clinically

    • Bullous pemphigoid

    • Bullous pemphigoid characteristics

    • Dermatitis herpetiformis

    • Erythema multiforme

    • Erythema multiforme - clinically

    • Stevens-Johnson syndrome

    • Toxic epidermal necrolysis

    • Lichen planus

    • Actinic keratosis

    • Acanthosis nigricans

    • Erythema nodosum

    • Pityriasis rosea

    • Strawberry hemangioma

    • Cherry hemangioma

  • MUSC1_4

    • Squamous cell carcinoma

    • SSC - histology

    • BCC - characteristics

    • Melanoma

  • MUSC2_1

    • Learning objectives

    • Muscle cell membrane

    • Sarcoplasmic reticulum

    • Muscle cell receptors

    • Sarcomere

    • Muscle cell contraction -1

    • Muscle cell contraction - 2

    • Muscle cell contraction - 3

    • Muscle cell contraction - 4

    • Muscle cell contraction - 5

    • Muscle cell contraction - 6

    • Muscle cell contraction - 7

    • Muscle cell contraction - 8

    • Muscle cell contraction - 9

    • Skeletal Muscle red versus white fibrers

    • Skeletal muscle atrophy - 1

    • Skeletal muscle atrophy - 2

    • Smooth muscle contraction - 1

    • Smooth muscle contraction - 2

    • Smooth muscle contraction - 3

    • Smooth muscle contraction - 4

  • MUSC2_2

    • Thenar eminence

    • Hypothenar eminence

    • Thenar eminence innervation

    • Hypothenar eminence innervatinon

    • Interosseous muscles

    • Interosseous muscles

    • Lumbrical muscles

    • Interosseous muscle innervation

    • Lumbrical muscle innervation

  • MUSC2_3

    • Rotator cuff muscles

    • Deltoid muscle in abduction

    • Infraspinatus muscle

  • MUSC2_4

    • Ligaments - knee

    • Knee – collateral ligaments

    • Lateral collateral ligaments

    • ACL and PCL

    • Anterior cruciate ligament - 1

    • Anterior cruciate ligament - 2

    • Posterior cruciate ligament

    • Four major knee ligaments

    • Knee menisci

    • Knee injuries – unhappy triad

    • ACL injury on physical exam

  • MUSC2_5

    • Repetitive elbow injury

    • Lateral epicondylitis

    • Repetitive elbow injury - 1

    • Repetitive elbow injury - 2

    • Repetitive elbow injury - 3

  • MUSC3_1

    • Lecture Objectives

    • The brachial plexus - 1

    • The brachial plexus - 2

    • The brachial plexus - 3

    • Antebrachial musculocutaneous nerves

    • The brachial plexus review - 1

    • The brachial plexus review - 2

    • Upper trunk injuries

    • Lower trunk injuries – cervical rib

    • Lower trunk injuries – pancoast tumor

  • MUSC3_2

    • Axillary nerve - 1

    • Axillary nerve - 2

    • Radial nerve - 1

    • Radial nerve - 2

    • Median nerve - 1

    • Median nerve - 2

    • Median nerve injury - forearm

    • Carpel tunnel syndrome

    • Ulnar nerve

    • Sensory innervation of the arm - 1

    • Sensory innervation of the arm - 2

    • Sensory innervation of the arm - 3

    • Sensory innervation of the hand

  • MUSC3_3

    • Axillary nerve injury - 1

    • Axillary nerve injury - 2

    • Radial nerve injury - 1

    • Radial nerve injury - 2

    • Median nerve injury -1

    • Median nerve injury - 2

    • Ape hand injury

    • Median nerve injury - 3

    • Median nerve injury - 4

    • Median nerve injury – 5

    • Ulnar nerve injury - 1

    • Ulnar nerve injury - 2

    • Ulnar nerve injury - 3

    • Ulnar nerve injury - 4

    • Ulnar nerve injury - 5

    • Ulnar nerve injury - 6

    • Musculocutaneous nerve injury - 1

    • Musculocutaneous nerve injury - 2

    • Musculocutaneous nerve injury - 3

    • Brachial Plexus Injury

    • Thoracic outlet syndrome

    • Klumpke’s palsy - 2

    • Klumpke’s palsy - 3

    • Klumpke’s palsy - 4

    • Lumbrical Muscles

    • Ulnar claw

    • Median claw injury

    • Ape hand injury

    • Klumpke’s total claw

    • Long thoracic nerve injury - 1

    • Long thoracic nerve injury - 2

  • MUSC3_4

    • Lumbosacral plexus

    • Superior gluteal nerve injury

    • Inferior gluteal nerve injury - 1

    • Inferior gluteal nerve injury - 2

    • Lower extremity sensory dermatomes

    • Ankle anatomy - 1

    • Ankle anatomy - 2

    • Ankle anatomy - 3

    • Ankle injury- 1

    • Ankle injury- 2

    • Ankle injury- 3

    • Ankle injury- 4

    • Ankle injury - 5

  • MUSC4_1

    • Lecture Objectives

    • Histology and bone formation

    • Woven bone

    • Lamellar bone

    • The haversian canal

    • Canaliculi

    • Bone histology review

    • Spongy versus compact bone

    • Bone characteristics

    • Spongy bone locations

    • Endochondral ossification

    • Membranous ossification

    • Source of osteoblasts

  • MUSC4_2

    • Disorders of bones

    • Achondroplasia

    • Achondroplasia - epidemiology

    • Osteoporosis

    • Type 1 osteoporosis

    • Type 1 osteoporosis etiology

    • Type 2 osteoporosis

    • Osteoporosis – clinical manifestation

    • Osteoporosis management – 1

    • Osteoporosis management – 2

    • Osteoporosis management – 3

    • Osteoporosis management – 4

    • Osteoporosis – bisphosphonates - 1

    • Osteoporosis – bisphosphonates - 2

    • Osteoporosis – bisphosphonates - 3

    • Osteopetrosis

    • Osteopetrosis – x-ray

    • Osteopetrosis – symptoms

    • Osteomalacia versus osteoporosis

    • Osteomalacia - histology

    • Osteomalacia – etiology and treatment

    • Osteomalacia – exam signs

    • Paget’s disease

    • Paget’s disease - etiology

    • Paget’s disease - labs

    • Paget’s disease stages

    • Polyostotic fibrous dysplasia

    • Bone disorders review

    • Osteoporosis and osteopetrosis

    • Osteomalacia and osteoporosis

    • Osteitis fibrosa cystica

    • Paget’s disease of bone

  • MUSC4_3

    • Primary bone tumors

    • Osteoma

    • Osteoid osteoma

    • Osteoblastoma

    • Giant cell tumor

    • Giant cell tumor - histology

    • Osteochondroma

    • Enchondroma

    • Malignant bone tumors

    • Osteosarcoma

    • Ewing’s sarcoma

    • Chondrosarcoma

    • Primary bone tumors

  • MUSC5_1

    • Learning Objectives

    • Osteoarthritis - characteristics

    • Osteoarthritis – exam findings

  • MUSC5_2

    • Rheumatoid arthritis

    • Rheumatoid arthritis - 1

    • Rheumatoid arthritis - 2

    • Rheumatoid arthritis - 3

    • Rheumatoid arthritis - 4

    • Rheumatoid arthritis - 5

    • Rheumatoid arthritis - 6

  • MUSC5_3

    • Gout - characteristics

    • Gout - histology

    • Gout - etiology

    • Gout – treatment

    • Pseudogout

  • MUSC5_4

    • Infectious arthritis

    • Chronic infectious arthritis

  • MUSC5_5

    • Seronegative spondyloarthropathies

    • Psoriatic arthritis

    • Ankylosing spondylitis – 1

    • Ankylosing spondylitis – 2

    • Reactive arthritis

    • Reactive arthritis – reiters syndrome

    • Reactive arthritis – review

  • MUSC5_6

    • Arthritis treatments: eicosanoids

    • Eicosanoids

    • Eicosanoids: cox 1

    • Ecosanoids: review

    • Eicosanoids: prostacyclin

    • Ecosanoids: cox enzyme review

    • Ecosanoids: Leukotrienes

    • Arachidonic Acid Pathway: Pharmacology

    • Zileuton

    • Leukotriene blockers

    • Non-steroidal anti-inflammatory drugs

    • COX 2 inhibitors

    • Aspirin – 1

    • Aspirin – 2

    • Other NSAIDs – 1

    • Other NSAIDs – 2

    • NSAIDs: Selective COX 2 inhibitors

    • NSAIDs: Acetaminophen – 1

    • NSAIDs: Acetaminophen – 2

    • Gout – treatment

    • Gout treatment: probenecid

    • Gout treatment: allopurinol - 1

    • Gout treatment: allopurinol - 2

  • MUSC6_1

    • Musculoskeletal and Connective Tissue

    • Sjögren’s syndrome

    • Sjögren’s syndrome

    • Sicca syndrome

  • MUSC6_2

    • Systemic lupus erythematosus

    • SLE – diagnostic criteria - 1

    • SLE – diagnostic criteria - 2

    • SLE – lupus nephritis

    • SLE – Lab findings

    • SLE – antibody review

  • MUSC6_3

    • Sarcoidosis

    • Sarcoidosis – signs and symptoms

    • Sarcoidosis – labs

    • Sarcoidosis – histology

    • Sarcoidosis – histo and treatment

  • MUSC6_4

    • Polymyalgia rheumatica

    • Myositis disorders

    • Polymyositis

    • Dermatomyositis - 1

    • Dermatomyositis – 2

  • MUSC6_5

    • Neuromuscular junction diseases

    • Myasthenia gravis

    • Lambert-Eaton syndrome - 1

    • Lambert-Eaton syndrome - 2

  • MUSC6_6

    • Scleroderma - 1

    • Scleroderma - 2

  • MUSC6_7

    • TNF alpha inhibitors

    • TNF alpha inhibitors - Etanercept

    • TNF alpha inhibitors - Infliximab

    • TNF alpha inhibitors - Adalimumab

  • MUSC6_8

    • Musculoskeletal summary

Nội dung

Musculoskeletal and Connective Tissue Stephen Bagley, M.D Resident Physician, University of Pennsylvania MUSC1_1MS01- Musculoskeletal System: Dermatology Anatomy, physiology, and disease of: – – – – – Skin Muscles and ligaments Peripheral nerves Bones Connective tissue MUSC1_1MS01- Musculoskeletal and Connective Tissue Lecture - Dermatology MUSC1_1MS01- Skin layers from surface to base Epidermal layers: Basement membrane C – Stratum corneum L – Stratum lucidum G – Stratum granulosum S - Stratum spinosum Stratum basalis B – Stratum basalis Mnemonic: Californians Like Girls in String Bikinis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane C – Stratum corneum • Top layer • Continuously sloughed off Stratum basalis • Composed of keratin filled anucleate cells • Calluses: stratum corneum hypertrophy Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane L – Stratum lucidum • This layer is only found in thick skin (e.g palms and soles) Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane G – Stratum granulosum Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane S - Stratum spinosum Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane B – Stratum basalis • Home to stem cells Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Basement membrane: • Separates the epidermis from the dermis en:wp, commons.wikimedia.org Used with permission FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- 10 Myositis Disorders • Characteristics: • Ongoing inflammation of the muscles • Labs: • ↑ Creatinine kinase levels FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Polymyositis • Characteristics: • Inflammation of multiple muscle groups • Progressive and symmetric • Proximal muscle groups affected the most (e.g hips and shoulders) • Etiology: • • CD8+ T-cell injury to myofibers Histology: • • Endomysial inflammation, within muscle fibers Labs: • ↑ Creatinine kinase levels Muscle biopsy on H&E showing endomysial inflammation Polymyositis HE.jpg, commons.wikimedia.org Used with permission FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Dermatomyositis • Characteristics: • Inflammation of multiple muscle groups • Proximal muscle groups affected the most (e.g hips and shoulders) • Histology: • • Perivascular (perimysial) inflammation, within muscle fibers Labs: • ↑ Creatinine kinase levels • ↑ Aldolase levels Perimysial inflammation Dermatomyositis – high mag.jpg, commons.wikimedia.org Used with permission FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Dermatomyositis: Signs and symptoms Signs/symptoms: • Heliotrope rash (periorbital) • “Shawl and face” rash • Gottron’s papules develop on the dorsal fingers, over joints • “Mechanic’s hands” (i.e callused hands) Other characteristics: • ↑ Risk of malignancy (e.g colon and ovarian cancer) • Antibodies: • ANA (sensitive yet non-specific) • Anti-Jo-1 (very specific) • Copyright Richard Usatine, M.D Used with permission • Copyright Richard Usatine, M.D Used with permission • Treatment: • Steroids to reduce inflammation Heliotrope rash FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Neuromuscular junction diseases Kaplan Pathology 2010 Figure 29.2 Neuromuscular Junction Physiology FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 MUSC6_5- Myasthenia gravis • Etiology: • Antibodies against the post-synaptic acetylcholine receptors of the NMJ Bind to and inactivates the receptor • • Signs/symptoms: • • Muscle weakness that worsens with prolonged use Typically affects the facial muscles • Ptosis • Extraocular muscles • Double vision • • Respiratory muscle involvement Diagnostic tests: • Electromyography: repetitive nerve stimulation testing • • • Progressive decrease in action potential size of affected muscle groups Edrophonium (an achetylcholinesterase inhibitor) improves symptoms Other characteristics: • Associated with thymoma FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 Kaplan Immunology-Microbiology 2010 Figure I-13-5 MUSC6_5- Lambert-Eaton syndrome • Etiology: • Antibodies against the presynaptic calcium channels of the neuromuscular junction Antibody mediated attack • • Decreased acetylcholine release with neuronal transmission Signs/symptoms: • • Proximal muscle weakness that improves with repeated use Other characteristics: • Associated with malignancy, occurring as a paraneoplastic syndrome (e.g small cell lung cancer) FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 Kaplan Pathology 2010 Figure 29.2 MUSC6_5- Lambert-Eaton syndrome • Diagnostic tests: • Electromyography: repetitive nerve stimulation testing • Progressive increase in action potential size of affected muscle groups Antibody mediated attack • Edrophonium does not improve symptoms Kaplan Pathology 2010 Figure 29.2 FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 MUSC6_5- Scleroderma (progressive systemic sclerosis – PSS) • Two types • Diffuse scleroderma • Excessive fibrosis and collagen deposition throughout the body • Rapidly progressive • Sites of involvement: • Skin involvement (thick and leathery) • Visceral organ involvement • Lungs involvement (interstitial lung fibrosis) is usually the cause of death • Etiology: • Anti Scl-70 antibodies against topoisomerase FA 2013: 395.1 • FA 2012: 423.1 • FA 2011: 387.1 ME 3e: 107, 264 • ME 4e: 107, 264 Perioral Scleroderma Involvement Copyright Richard Usatine, M.D Used with permission MUSC6_6- Scleroderma (progressive systemic sclerosis – PSS) • Two types Diffuse scleroderma: CREST syndrome: • Sites of involvement: • • • • • Calcinosis Raynaud’s phenomenon Esophageal dysmotility (associated with GERD) Sclerodactyly Telangiectasia • Limited skin involvement • More benign course • Etiology: • Telangiectasias fingers scleroderma Copyright Richard Usatine, M.D Used with permission Anti centromere antibodies FA 2013: 395.1 • FA 2012: 423.1 • FA 2011: 387.1 ME 3e: 107, 264 • ME 4e: 107, 264 MUSC6_6- Tumor Necrosis Factor Alpha (TNF-α) Inhibitor: • General characteristics: • A class of drugs that inhibit the affects of TNF-α • TNF-α is an important inflammatory mediator FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Etanercept • Mechanism: • Recombinant form of the human TNF receptor that binds TNF • Decreases the net effect of TNF-α • Clinical Use: • Rheumatoid arthritis • Psoriasis • Ankylosing spondylitis FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Infliximab • Mechanism: • Anti-TNF antibody • Decreases the net effect of TNF-α • Clinical use: • Crohn’s disease • Rheumatoid arthritis • Ankylosing spondylitis • Adverse effects: • Predisposition to infections • Particularly latent tuberculosis reactivation • It’s important to assess for signs of TB prior to initiating Infliximab FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Adalimumab • Mechanism: • Anti-TNF antibody • Decreases the net effect of TNF-α • Clinical use: • Rheumatoid arthritis • Psoriasis • Ankylosing spondylitis FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Musculoskeletal and Connective Tissue: Summary • Anatomy, physiology, and disease of: • Skin • Muscles and ligaments • Peripheral nerves • Bones • Connective tissue MUSC6_8- ... patients Copyright Richard Usatine, M.D Used with permission FA 2013: 3 95. 2 • FA 2012: 423.2 • FA 2011: 387.2 ME 3e: 157 • ME 4e: 157 MUSC1_2- Pustule Name Description Pustule Blister containing pus... Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane C – Stratum... Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane L – Stratum

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