114: OA, Infections and Tumors & How to Know When You’re Done Studying

Hello and welcome to episode 114 of the Physician Assistant Exam Review Podcast. My name is Brian Wallace. We’re going to be, oh my gosh, how many times can I screw this up? I’ve been doing this for so many years and still can’t quite get it right. We’re working through musculoskeletal today, continuing with osteoarthritis, infections, tumors, and then I’ve got some good stuff for you at the end about how to know when you are done studying. It’s a question I get a lot. So without further ado, let’s go ahead and jump right in.

My name is Brian Wallace. I’m the founder and creator here at Physician Assistant Exam Review, where we teach PA students how to dominate PA school and ultimately pass the PANCE and land their dream job. That’s really our goal, right? Is to get you through school, continue to learn, get as much as you possibly can from school, and then put you in a position to get the job that you’ve been dying to get and looking forward to get for so many years. That’s the goal here. That’s what we do. I’ve recently been having, as you know, some fantastic success with the 33 Days program.

The August cohort is on, what’s today, Thursday, the 24th is on day 24 today, and they are just absolutely crushing it. The next cohort will be in November. And one of the things people have and asking me is, you know, that’s all well and good. And I’m so happy those students are doing so well, but is there anything for me in my didactic or my clinical year? Is there anything that I could be using? I’m not sure I want to commit to the 33 Days program because it isn’t, it’s an intensive, you know, I lack for a better term, but it’s like a bootcamp for people who want to learn to be better, students and better test takers. But it’s, it’s, it’s, you know, it’s a little intense.

It’s a month of everything jammed in. And some of the things don’t obviously apply as you’re getting into your PANCE. So what I did this week was start to put together what I’m calling the PASS Academy. And inside of there are going to be a lot of the same lessons, a lot of the same ideas, but more of a way that you can go through them on your own. And you can look more into, so that’s be better for somebody in their didactic year, in the beginning of their clinical year, that sort of thing. So if you want to look into that, that’ll be available this week. I’m not sure exactly going forward, but anyway, you can go take a look at that at physicianassistantexamreview.com/PASS101.

P-A-S-S-1-0-1. All right.

So let’s jump in to talk a little bit about musculoskeletal. This week, we’re going to be moving through some ideas on sort of a mishmash of things before we get into rheumatoid arthritis, rheumatologic issues, and that will wrap us up for musculoskeletal. So, let’s do our priming questions. In what age group is osteosarcoma most commonly found? What’s the most common organism involved in osteomyelitis? What’s the most common malignant cancer of the bone? A sunburst appearance on an x-ray of the knee should make you think of what diagnosis?

A sunburst appearance on an x-ray of the knee should make you think of what diagnosis?

All right, so we’re going to get started with osteoarthritis today. This should be one you should be able to paint a pretty good picture for yourself. Most people have seen or experienced somebody with this. This is the elderly person who has a knee replacement, has a hip replacement, has trouble walking. So this is a degenerative joint disease characterized by a loss of cartilage, bony reformation, and a narrowing of the joint spaces. Again, you’ve absolutely seen people with this disease without question, whether it’s in their hands, like I said, or their shoulders. I do a lot of shoulder replacements at work.

I do a lot of knee replacements at work. We do a lot of hip replacements. I used to work in foot and ankle, so we would do, well, we’ll get to that in just a minute. So these may occur in any joint, including the knees, hips, ankles, hands, spine, and shoulder, and so on. Obviously, it presents a little bit different if it’s a osteoarthritis of the spine than it does of the knee, right? Obviously, but it’s the same degenerative process. This most commonly occurs in patients over 40 and increases incidence with age until…

they say by about 80, almost everybody has some form or another of this. Things that can make or accelerate this process in younger people would be trauma to the joints. So things like one is just trauma like you would think of it. So like a broken bone, a smashed joint in some way or another. If you, one of the issues in orthopedics is always getting the joint line back together. So people would come in with a broken ankle, for example. And if the if the fracture went through the joint line, that was much more dangerous to their for their long-term outcome, right?

Much more likely to lead to arthritis down the road than a fracture away from the joint line. And you always want to make sure there’s not a step off or anything in the joint line. As you fix it, you want to make sure everything is put back out as anatomically as possible. I guess you always want to do that, but more even more so if it’s into the joint. So, trauma like you would think of would certainly lead to osteoarthritis. But there’s also other traumas to joints that don’t just pop into your head when I say trauma. So, things like gout causes trauma to the joint, right?

Rheumatoid arthritis, infections in the joint, which we’ll get to in a little bit, chronic steroid use, things like sickle cell that change the blood flow, right? All those things can cause trauma to a joint space and lead to osteoarthritis. Clinical presentation, pretty straightforward here. Joint pain and stiffness, often worse in the morning or after not using the joint for some time. So when they talk about, one of the ways students try to remember this is it’s patients who complain about joint pain in the morning and feel better after about 30 minutes of moving around. So once they get the synovial fluid going and they sort of get up and moving, they do feel a little bit better. So it’s that morning stiffness is the kind of the thing you can hold on to for your test questions.

But really, it’s going to come down to the physical exam and the x-ray in the office more than that story about morning pain. These patients may also have swelling in the joints. You might be able to tell that with a joint effusion on physical exam.

Now, again, I’ve been doing this a little bit more lately, but what do you think you would find rather than me just telling you, what do you think you would find on physical exam?

Let’s say you’re looking at, let’s make this more specific to make it easier.

Let’s say you’re talking about someone who has, osteoarthritis of the knee and they come into your office. Now picture this person for me for just a minute. So this is a, you know, 65 year old, slightly overweight female comes into the office limping a little bit and she’s got some complaining of knee pain and you go to do a physical exam, what are you expecting to find on that physical exam? Well, picture her knee in your head. What’s your exam look like? So you’re going to look for range of motion, right? Which may be decreased.

We just mentioned a joint effusion. As you’re working on range of motion, you may also find crepitus, which is that light crunchiness of the bone on bone. And then you may also see an obvious deformity like significant varus or valgus. This is a little bit more subtle in a knee maybe for most people, but one place I think of this a lot because we used to fix them all the time would be a hallux valgus, would be a bunion, right? And you would see the joint in a completely different angle than what it’s supposed to be. And it’s a very obvious deformity. So on these patients, you’re going to be getting x-rays and on those x-rays, you’re going to see a narrowing of the joint space and then pot, which normally there’s a nice, especially in a knee, right?

Knees are kind of a little bit easier to perceive. So I put a, I’m going to put a picture up on the website of a bunch of different, of a knee that looks like it’s supposed to on an x-ray and then a knees that are absolutely trashed with osteoarthritis. You can get a little bit better idea of what this looks like. But normally there’s a nice clean joint space. And the other thing that a lot of people don’t notice right away is bones are relatively smooth into the joint, right? There aren’t any sharp edges. There aren’t any, let’s just say things there that don’t look like they should be there.

Once you get into an arthritis situation and the patient has fairly progressed, there’s a narrowing of that joint space so that space in between the joints goes away until the femur and the tibia are actually touching each other. Which is an extremely painful, extremely progressed disease. But it doesn’t have to be that bad for them to have pain. It just is a narrowing of that joint space. And then you also have these bony overgrowths called osteophytes. You’ll see them maybe off the head of the tibia, where rather than being smooth, there are some jagged edges. And you can see that a lot of times very clearly on x-ray.

And it becomes much more apparent once you open up the knee and look inside for, you know, right in front of you. But even on an x-ray, you can a lot of times see those osteophytes, those bony overgrowths. The treatment, you’re going to start with weight reduction, right? So if this is a hip pain or a knee pain, weight reduction isn’t going to help with arthritis of the shoulder or the hand, but it can certainly help with arthritis of the knee. You can definitely get some relief there and stop the progression of the disease. Physical therapy is a good place to start because you want to maintain flexibility and strength around the joint for sure. Another big one is for patients to continue to move.

This isn’t as easy as it sounds because obviously people who have pain don’t want to use that joint because it hurts. But if you don’t use it, it will lock up, right? So we need to make sure the patients continue to move. Pain medications are going to be on the list. So acetaminophen, tramadol, NSAIDs for sure. So ibuprofen, naproxen, or a COX-2 inhibitor like Celebrex. Intraarticular steroid injections.

So you can inject a steroid directly into the joint. This will calm down the inflammation and give the patient temporary relief. Some patients get a lot of relief from this. Some patients don’t get much relief. It sort of depends, but it’s a nice kind of straightforward, easy procedure that certainly tends to help more people. You can do hyaluronic acid injections. So this is a viscosupplementation.

So you can almost think of this like you’re putting oil into the… It’s not, but just because we’re learning and trying to make things easy. It’s almost like putting oil into the knee and helping that synovial fluid to work a little bit better in a lot of patients. This is a, what is this, every other week for three to five weeks. You do these injections and patients do get some relief out of this. And then finally, at end-stage arthritis, you’re going to do surgery. You’re going to, usually there are two options here.

One is to just, or actually three options. One is you can just go in and remove osteophytes, which is pretty rare. We don’t usually do that. There’s a couple instances where we do, but there’s no point in me talking about those here. You can do a joint replacement, which is something that most people are aware of. So like I said, I work in the operating room and we do a lot of, I think I have one coming up this week or next week, doing shoulder replacements, right? Doing knee replacements, doing total hip replacements, where we go in and actually put a new joint in and the patients get a lot of relief from that.

The other option is when when there are different joints that cannot be replaced. So, for example, the metatarsal phalangeal joint, there is not a good replacement for it. The ankle, there’s not a good replacement for it. They make them, but they have got something like, last I checked, they had like a 30% failure rate. And a 30% failure rate in an ankle is a disaster because you have to take a lot of bone out to put the replacement in. So then when you have to take it back out. It doesn’t go real well.

So the numbers don’t work out right for some of these replacements. But you have a patient come in who has terrible ankle pain because of their arthritis and they can barely walk because their arthritis is so bad. And you take an x-ray of the joint and it’s absolutely collapsed. There’s no space there. So the answer is a fusion. You actually scrape out what cartilage is left and you put screws across the joint and the bone grows together and you fuse that joint. And that sounds kind of terrible to a lot of people, except when you consider that these people already have a fused joint, they already can’t move, it is so frozen that they can’t move the joint, but they have pain.

So, what you’re doing when you fuse the joint is you go in and you put it in a position that is usually advantageous to them because you put it in a better position for walking.

Let’s say if it’s the ankle or the toe, you put in a better position for walking if it’s the great toe. And you fuse it into a position that’s a little bit more functional than where it’s been automatically fused before. So those are a couple surgical options.

All right, let’s talk about osteomyelitis. You can have acute or chronic osteomyelitis. An osteomyelitis is a bone infection, right? So I try to make this stuff so you can picture it in your head and make it a little bit easier. So we say words like osteomyelitis, that may help you. It may not. But it’s just an infection of the bone.

You can have basically two ways of getting a bone infection. One is hematogenous, one is exogenous, so you can spread through the blood. These are most commonly in pediatric cases and usually affecting the long bones. Exogenous infections are typically from an open wound or from surgery. So somebody gets in a car crash and they have an exposed femur, they could get infected, right? Or if we, in the OR, open them up and go to do, let’s say, a joint replacement and we expose them to a bacteria, they can get a bone infection. Staph aureus is the most common pathogen.

That’s probably important to know. I also have here salmonella is the most common cause of osteomyelitis in a patient with sickle cell. And then something that took me a long time to understand, and I certainly didn’t PA school, but not until a few years into practice when I saw this for myself, is the idea of chronic osteomyelitis. So chronic osteomyelitis is a bone infection that may be subclinical for long periods of time. And you treat it with antibiotics, and then it kind of goes down and goes away and sort of goes into hiding, but may be reactivated almost like a herpes, right? It works very similarly to that. And we actually had a patient years and years ago who came in with an absolutely destroyed foot.

And the story she told was that she was on a train during World War II that got bombed. And we took an x-ray of her foot and was absolutely filled with shrapnel. I mean, it was a mess. Just these flakes of metal everywhere. And I can’t remember what the actual procedure we did on her. I think it might have been, it was something medial, but I can’t remember what, but it was on the medial side of her foot. So anyway, we make an incision and we fix that part of her foot.

And what happened was, I think it was about three weeks later, she had had some incisions on the lateral side of her foot from that incident. And those incisions pussed out, the lateral ones, nowhere near where we were. And the only conclusion we could come to was that she had this chronic osteomyelitis that this further insult we had committed gave just enough room for that to reactivate. So it’s a pretty interesting case but just something that I want you to understand that you can get this acute osteomyelitis is something that we’re all familiar with. Not at all but it makes sense, right? It’s right in front of us. It’s that chronic one that’s a little bit different and you don’t see very often but it does exist.

Again, probably not going to be on your exam But to me, it was a very interesting case and just really changed my view of how the immune system works, how we clear infections, how we’re fighting these things. Sometimes even she was, I think it was 40 years she’d been fighting this thing. Maybe even longer. I can’t do the math on the top of my head, so I’m sorry for those of you who can’t. Clinical presentation for an osteomyelitis. Again, think about what’s the clinical presentation for a bone infection going to be? What is that going to look like when the patient comes through your door?

Well, usually it’ll either be a kid with a hematogenous spread or it’s going to be from after a trauma or after a surgery, right? And generally speaking, it seems to be how the questions would be set up. Clinical presentation, it’s going to be, so it’s going to be what? It’s going to be warm. It’s going to be painful. It’s going to be red. It might be tender, that kind of thing, right?

If it’s open, it might be oozing or foul smelling. And then they may have difficulty using the limb, right? So if it’s something in the tibia, they may have trouble walking, that sort of thing. So this isn’t terribly difficult. These are things you should be able to come up with and think through. Again, I go back to the idea of don’t memorize lists, understand what you’re talking about. Lab studies and physical exam findings.

So again, pretty much like we said, warm, red, tender, you can get some swelling. You’re going to get some x-rays, obviously, but this isn’t going to show much in an osteomyelitis. This is going to show almost nothing, actually, unless it’s very advanced. And pretty late, at which point the x-ray may not be the test you’re shooting for at that point. But an MRI will show this, a bone scan will show it, and then obviously a bone biopsy will get you what the organism is and all that kind of stuff. But you’re going to start with the MRI or the bone scan to prove the presence of an osteomyelitis. Treatment, at least six weeks of antibiotics.

But osteomyelitis is tricky, and that may or may not be enough, depending on what caused it, depending on where we are. Again, you just look think about that person that I talked about with the the chronic osteo, right? She certainly had weeks and weeks of antibiotics, and it didn’t clear the infection. But we start with a minimum of six weeks. Surgical debridement, right? So, you’re going to go in and clear out the the the what you believe to be the infected tissue. This is always one of my…

I don’t know why I think it’s funny, but I do, is when you go into the OR, and you have a a case of something like an osteomyelitis, you go in to debride it, because antibiotics are never going to get in and and clean it out. So you have to go in and actually physically clean it up, but there’s no demarcation, right? There’s no color like in a book that says this is infected tissue. This is non-infected tissue. Yes. The super gross, pus filled tissue is very obvious, but where do you stop is the question, right? Where’s the line?

And you go, do the best you can. You take as much as you think is necessary and you give the patient antibiotics. And a lot of times we now pack the wound with antibiotics and that’s really the method for going after the osteomyelitis as it gets really bad. The other part to that is, you know, the big issue, and you’ll see this when you go into the OR and you do your clinicals with, let’s say, joint replacements. A major issue is you have to remove any hardware that you’ve put in if you wind up with an infection. So I do a lot of work with orthopedics. And let’s say you fix a fracture and an ankle fracture and it comes back as the patient winds up with an infection.

Well, the plate and screws that you fix the ankle fracture with have to come out, right? So then you’re balancing between how long can I leave it in so that the bone heals versus I have to get it out because there are microbes growing on that hardware. And it’s really hard for the antibiotics to work once the, you know, you can think about the organisms kind of hide in that hardware and form sort of a protective fortress there. It’s really hard to clear them if there’s any hardware. So the hardware has got to come out, but it’s a balancing act. And I was talking just a second ago about total joints. Well, again, when you do a total joint, you take a lot of bone, right?

We take a lot of bone out when you do a total joint. So if you go back into a knee, let’s say, and you have to remove the femoral component or the tibial are both, right? You have to put a cement spacer in that’s filled with antibiotics in order to hold that joint open and close the patient up with basically without a joint, right? And this is a bad, bad situation. So when you go into those rooms as a student and you see the surgeons and the assistants and the scrubs all in those spacesuits, and everyone’s kind of watching you super close. This is why. It’s not because they are, you know, they don’t like you.

It’s because they know what the out the bad outcome looks like. Everybody’s had it because there’s it’s a you know it’s going to happen. It’s just a numbers game. If you do enough, someone’s going to get infected. But they do everything they can to keep this to a minimum. That’s That’s what’s going on there. And why everybody, especially in orthopedics or whenever you’re putting in hardware, actually, in any surgery where you’re putting in hardware, not that people aren’t vigilant normally, but you’re extra vigilant at those points because you know what an effect what an infection can lead to.

Next, we have septic arthritis. Septic arthritis, pretty straightforward again here. So osteomyelitis was an infection of the bone. Septic arthritis is an infection of the joint, right? Not complicated. We can picture that in our heads. This is a medical emergency as a joint may be destroyed in a relatively short period of time.

Again, we talked about trauma to the joints can lead to arthritis, right? So we want to do everything we can to prevent that. Again, this can be spread through a hematogenous pathway, or it can be from a trauma, from a physical penetrating trauma into the joint. And again, Staph aureus is our most common cause here. Clinical presentation, pain and swelling in the joint, and a fever is certainly possible. Lab studies and physical exam findings, the joint’s swollen, red, tender, and decreased range of motion, pretty much the same as something like an arthritis, but it would be more prominent depending on how severe the infection is. C-reactive protein and erythrocyte sedimentation rate are elevated.

You’re going to get x-rays and MRI, and then an aspiration. Arthrocentesis is necessary for diagnosis, so a white blood cell count over 50,000, but usually it’s going to be higher than that. Treatment. So IV antibiotics, of course, and then a surgical washout of the affected joint within hours. This is an emergency. It needs to get done. So the joint needs to be washed out.

And it sounds just like it sounds. You literally open up the joint and run fluid through it. And then obviously like we’ve been talking about, you have to remove any hardware if there’s hardware in place. Our last one for today is neoplasms. This is relatively short. I don’t think you’re going to see a lot of this on your exam. Multiple myeloma is the most common primary malignant bone tumor.

Multiple myeloma is the most common primary malignant bone tumor. The most common primary malignancies which metastasize to the bone are prostate, breast, and lung. Bone is the third most common area for metastasis. So, I think that’s important. Those two things, that’s of course, I think that’s important because that’s why I put them there, but multiple myeloma is the most common primary malignant bone tumor. And then the most common primary malignancies which metastasize to the bone are prostate, breast, and lung. Prostate, breast, and lung.

So if you wind up with a bone tumor, you’re going to be looking to the prostate, breast, and lung to see where it came from. Osteosarcomas occur most commonly between the ages of 10 and 20 years old. A sarcoma is cancer cells, which are mesenchymal in origin, including bone, fat, and vascular cancers. Breast, lung, and colon cancers originate from epithelial cells and are usually carcinomas. Just to work on a nomenclature a little bit. Clinical presentation, pain, fatigue, fever, weight loss, pathologic fractures is a good one, right? Keep an eye out for that because that’ll really send you in the right direction.

Lab studies and physical exam findings. So alk phos may be elevated if the bone is remodeling. Excuse me, on x-ray, and this is an important one, right? So a lytic lesions are areas of bone which appear to be eaten away. They may have sharp edges and no clear borders. Lytic lesions are very, very bad. A sunburst lesion on an x-ray equals osteosarcoma or Ewing sarcoma.

That’s definitely one I would know and I would understand what a lytic lesion looks like. You’re going to get a CT or an MRI after the x-ray, of course, bone scan, and then a PET scan to see what’s going on throughout the body. Again, because if we’re looking at a bone cancer, we’re also going to be looking for prostate breast and lung as a primary site. Treatments, chemotherapy and radiation, and then surgical resection of the tumor, often including an amputation, depending on what’s going on. That just needs to be considered.

Alright that one’s kind of ending on a down note, but I guess most of the medicine is on a down note. We’re talking about things that are wrong with people. So, it all sort of heads that way. Obviously bone cancers are horrible horrible things but as far as your test goes those are sort of the things that I would be have an eye out for.

All right let’s pick it up a little with our study tip for today so before we move on to our priming questions our study tip for today is going to be super simple but it’s something that I know I struggle with it’s something that everyone struggles with and it’s the idea of how to know when you’re done? How do you know when you’re finished with something? How do you know when you have completed studying, let’s say for the PANCE, for an end of rotation exam, for a physiology exam? How do you know when to stop? Most people are up all night, which I’m not going to talk about now, but which is a disaster. And they just keep working and working and working. And this is not effective for any number of reasons.

Again, I’m not going to go down that road right now, but tons of reasons why this is no good. So we have to know when to be done. And how do you do that? Well, one effective way I’ve used over time is to decide ahead of time when I’m going to be done with a clock, with a calendar, right? So depending on what you’re doing, it’s either going to be 11 o’clock tonight, I’m done. Five o’clock this afternoon, I’m done. On August, on September 9th, I’m done studying for my PANCE.

That’s it, I’m done and picking that date and drawing a line in the sand, picking that time and drawing a line in the sand. And the reason that I say it this way is because I can’t remember the name of the principle. There’s a principle out there, Peter. No, I can’t think about that. And it makes total sense is the idea that work grows to fill time, right? So if you’re studying, you could be studying EKGs from now until, you know, 2030, and you still wouldn’t be done. You still wouldn’t know everything.

You still wouldn’t be comfortable treating patients. You still wouldn’t be comfortable taking your tests. It doesn’t matter, right? So at some point you have to draw a line in the sand. And one of the things that drawing that line in the sand does is it forces you to, one, to keep moving and two, to decide what to spend time on and not waste time. Because I find also when you increase time, you increase how much time you’re fiddling on your phone, you increase how much time you’re willing to accept interruptions. If you have a finite time, you can’t accept interruptions.

You have to keep moving and you have to decide what to work on. So one of the most powerful ways to get through your work when you need to is to set a done time, right? Set an end time, set an end date. And that’s very freeing. I know that can be terrifying for some people, because what if I’m not done by then? But you will be if you set that time and you stick to it. So anyway, our study tip for today, set a I’m done date, set an I’m done time, and then stick with it.

That’s the most important part. It’s like Seinfeld’s old joke about reservations, right? There’s a scene where he goes in to rent a car and they don’t have a car there for him. And he’s like, wait, I made a reservation. And she said, I know you made a reservation. He said, I don’t think that you do because I don’t have a car here. And she said, you know, I know that you made the reservation.

And he explained that taking the reservation doesn’t really help. It’s holding the reservation. So same thing here. It’s not setting the I’m done date. It’s sticking to it. It’s creating that line in the sand and actually forcing yourself to run with it.

All right, our priming questions.

Let’s wrap this up for today. In what age group is osteosarcoma most commonly found? In what age group is osteosarcoma most commonly found? We said this, right? 10 to 20-year-olds. What is the most common organism involved in osteomyelitis? Did you catch that one?

What is the most common organism involved in osteomyelitis? Staph aureus. What is the most common malignant cancer of the bone? I said this like three times. What is the most common malignant cancer of the bone? Multiple myeloma. And then a sunburst appearance on X-ray of the knee should make you think of what diagnosis?

Osteosarcoma. One more I should have put in here and I didn’t. What’s the white blood cell count on an infected knee that we’re looking for? Do you remember? It was greater than 50,000, right? Greater than 50,000.

All right. I just want to say thank you so much for being part of the community. Thank you so much for sharing the show with your classmates, with your friends. I really do appreciate all of that. I appreciate you being here. I appreciate you showing up for the show week after week. It makes a huge impact in my life knowing that you’re out there listening and going through this and getting a lot out of it as I get emails from people all the time, letting me know.

And I do appreciate those. Of course, they certainly help my ego. If you’d like to dig a little bit deeper, like I said, this week, I’m opening up the PASS Academy where I’m going to be teaching a lot of skills, techniques, and foundational information for studying. You can find out more at physicianassistantexamreview.com/PASS101. But if you’re coming up on your test and you really wanted on your PANCE rather, or you’re really struggling and you’re looking for a huge impact and like today, in November, I’m to be running the 33 Days program once again. And that is just an absolute high impact bootcamp on how to study, how to take high yield, high risk, high, high risk, high stress, high stakes, high stakes is the word they use high stakes exams. And it’s really been incredibly powerful.

So definitely look into that at physicianassistantexamreview.com/33. But that’s it. Like I said, I just want to say thank you so much for being part of the community. And I look forward to talking to you guys again in the next show. And when we finish up rheumatology, take care.