2018 Rheumatology and Orthopedics 9% Flashcards
Osteoarthritis
DIP(heberden’s), PIP (bouchard’s)
Rheumatoid arthritis
PIP, MCP
boggy sensation
Psoriasis
DIP
Scleroderma
PIP, MCP
tendon friction rub
Heartburn + dysphasia + thickened skin=
scleroderma
Poor prognositc factors for Rheum Arthritis
Progressive synovitis
Joit space loss/erosiions
Inc Rh factor >1:80
Inc ESR
70yo F early morning stiffness >45min & symmetric small joint pain in 2nd-4th MCP and 2-5th MCP and PIP in L hand - jnt pain in R knee for 6 wks and ESR 48 - swelling of MCP and PIP RH neg wtd?
Start tx
Anti-CCP +
Antlanto odontoid subluxation
compress vertibrobasilar artery-> lightheadedness, sncope
screen for subluxation with lat xray before anesthesia
Compress cord -> sensory /motor /quadriplegia
Pts w/ RA can also present w/ carpal tunnel/ tarsal tunnel syndromes
????8mm asyx - surgical correction
Sx any size sx corretion
Pt with rheum arthritis can present with what?
carpel tunnel tarsal tunnel
Extra articular manifestations of RA
—–‘spill over of active disease from synovium’
-Rheumatoid nodules (inc’d RH factor (- in 15%))**
-Vasculitis/DR4 –> poor prognostic factor
(ulcers in fingertips = .vasculitis)
???RF leaves joint thru capillaries-> inflamm, ulcers
- —-Heart
- Effusion
- Constrictive pericarditis - early S3 positive
- Myocarditis
- —Lung
- Rheumatoid nodules (Caplan’s syndrome)
- Pleural effusion (low glucose, high LDH, exudative)
- BO (bronchiolis obliterans)
- Interstitial fibrosis
- Hypersenitive pneumonitis (methotrexate is a cause)
- —Blood anemia of inflammation
- —Vasculitis - necrosis, ulceration at tip of fingers
- —Nerve - Mononeuritis multiplex->foot/hand drop
—-Skin - rheumatoid nodules (most common extra articular manifestation - RH factor inc’d
-----Renal - usually lsate stage with amyloid nephropathy--> diagnose w/ congo red staining and you see apple green Drug induced( NSAID--> minimal change, Peniclliamine -->nephrotic syndrome)
- –Eye - scleritis - deeper - r/o globe rupture
- –episleritis - superficial both autoimmune, UC> Crohn’s
???Fx vs sprain
4 steps without sx
????HCV with mixed cryoglobuinemia
vasulitis and LE ulcers
Tx for RA
Mild to Mod: Methotrexate (decreases mortality) +/- NSAIDS +/- hydroxychoroquine (plaquenil) (make sure you get a baseline eye exam, opt in 5 yrs, then yearly) /sulfasalazine (Azulfidine)
Add methotrexate +/- low dose steroids +/- Leflunomide (Arava) –> use cholestyramine x 11 days to washout metabolites from system
Methotrexate–> 25mg/wk
methotrexate polyglutamate level –> >60
persistent synovitis
Severe - Add etanercept (Enbrel) (can make anti DS DNA +) or Infliximab (Remicade) or Adalimumab (humira) or anakinra (kineret) or Golimumab (Simponi) Certolizumab (Cimzia)
Abatacept (Orencia) Rituximab (Rituxan) (Rituxan–> good for HBV, HCV) Tocilizumab (Actemra) (Actemra –> diverticular ruputre , OCP faiure, HPL)
???Egg shell Ca+
siliciosis
???Salmon pink rash
still’s dz/inc’d ferritin
???Schools of fish or boxcar
chance - haemaphilis ducre
Tx: azithro orceftriaxone
???Methotrexate contraindicated in?
Pt on bactrim, Hep B/C, Etoh liver dz
???Macular degeneration
lose central vision
???Reflexes
L5 lesion - no dorsiflex, no evert, no invert
Peroneal lesion - No dorsiflex, no evert, +invert
???45yo p/w joint tiffness>1hr in AM, pain in MCP, PIP and pain while climbing stairs x 6wks Rh+, on tylenol no rlief - started on naproxen no relief Rh still high wtd?
Add methotrexate
???Fastest acting DMARD (Disease modifying anti rheum drug) is?
Methotrexate
???Which drug decreases mortality in RA
Methotrexate
???Floppy iris syndrome
d/c tamsulosin before cataract surgery
???What is preictor for CVS dz in Rheumatoid arthritis
Inc’d homocysteine levels
???Pt with rheumatoid arthritis on NSAIDs with persistent synovitis, methotreaxate was added and pain improved, 3 months later pt p/w fatigue, Hg low, MCV high best tx would be?
folic acid def (from methotrexate use) - tx with folic acid
S/e NSAIDs
nephrotic syndrome, PUD, int nephritis
S/e hydroxychloroquine
Macular damage loss of accommodation
S/E Methotrexate
Heptoxicity, hypersen, Pneumonitis, apthous ulcer (tx: folinicacid)
S/E Lefluonmide
Teratogenic
use cholestyramine
s/e Corticosteroid
Osteoporoiss (5mg daily 3 months), HTN, cataract, avasc necrosis
s/e Infliximab
ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+
s/e Etanercept
ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+) ANA, ANti DNA+, flue like sx (use HIV HCV HBV so doesn’‘t get worse)
s/e Cyclosporine
ATN, renal insuff, hirsuitism, HTN
dont drink grapefruit juice
???Catarct sx?
glare outside lights
Pt with Rhuem Arth p/w sudden onsest pain behind knee an calf - US neg for DVT?
wtd?
ruptured baker cyst - intra-articular steroid
Pt with h/o RA for long time udergoes elective surgery with gen anesthesia - post op is quadriplegic - etio?
Atlanto-odontoid subluxation C1-C2
Pt with long standing Rh wit hoarseness of voice for weeks dx?
Crico arytenoid joint involvement
65yo RA >30yr p/w paraesthesia in hands b/l carpel tunnel release little change in the paresthesias 3 months later - also with occasional dizzy spells - past history of total knee arthoroplasty and severe joint deformities. -O/E: dec power and hyperactive reflexes - pt going for hip replacemet wtd?
Xray neck r/o sublux
Pt with RA on methotrex x 1 yr p/w pain and swelling knee joint, fever with leukocytosis wtd?
tap joint r/o septic arthritis (all before thinking about steroids)
Tap with turbid exudate labs P
start IV abx
???Pt with long standign RA on NSAIDs steroids and MTX p/w cough, tx’d with abs - 4 weeks later progressive SOB no fever - b/l crackes, CXR infiltrates - etio?
MTX induced, interstitial fibrosis, bronchioe obliterhaeran
NOT CMV Pneumonitis
Pt with RA on hydroxychlorquin wtd?
baseline retinal exam and then in 5 years and then yearly
Leading cuase of death in RA
Heart disease
Pt tx’d with steroids for temproatl arteritis or Polymyalgia Rheumatica or SLE - couple month later steroids tapered off with improvement of sx - pt returns with b/l symm joint pain and early morning stiffness with MCP, PIP no h/a or shoulder pain - exam with + venodule on L olecranon dx?
Rheum arthritis
Pt on MTX for Rheum Arthritis - what do you follow based on current guidelines
CBC, Cr, AST q12
Pt with Rh Arthritis with minimal response to MTX 25mg/wk wtd?
check PPD –> do first
?????, if neg start TNF alpha???
If 5mm, wtd next? CXR–> Negative
- start INH (x3 months) and rifapentine
give Pneumococcal and influenza vacc prior to biologic DMARDs
no varicella, no yellow fever, no MMR
don’t give DMARD with active infxn (including viral bronchitis)
35yo p/w recurrent pain starting in PIP then MCP then knee - few hours later joint swelling - pain resolves in few hours in backwards order, in between attacks the pt is absolutely fine. - dx?
Pallindromic rheumatism - 1/2 will go on to RA
tx: DMARDs
Pt with RA and necrotic ulceration of finger tips and foot drop dx?
Rheumatic Vasculitis
???- circulating Ag-Ab (RF) complex blocks small arteries
<1% of pts w/ long standing RA present with splenomegaly and leukpenia–>recurrent skin/lung infxn, +skin ulcers dx?
Felty’s syndrome -
Tx
DMARDs, steroids, G-SF-> splenectomy
32yo F polyarthritis and fever. sore throat several weeks ago - salkmon colored/ faint pink rash on trunk and upper extremitiess - throat ctx neg, ESR 110/hr, ferritin 600 , WBC 24000 w/ 85% PMHs. Pt is started on abx no help. AST/ALT increased. Rh neg, ANA neg. Rh factor negative. dx?
Juvenile idiopathic rheumatoid arthritis aka Still’s dz
(opposite of Fetly’s syndrome)
Joint pain, salmon colored rash, high ferritin, high WBC
WHat dz more likely related to RA
Periodontal dz
Sjogren’s
Enlarged salivary glands, dry mouth, dry eyes
RH+, ANA+, Ro , La+, elev ESR
inc’d r/o lymphoma/celiac sprue (check TTG), distal RTA I (U pH >5.5—> increased Caphosphate crystals - CaPO4 stones)
Sx - enlarged salivary glands, dry mouth,
Dx: - lip bx minor salivar glands
Schirmer test (blotting paper) + if <5mm wetting in tearing of eyes in 5 min (normal 15mm in 5 min)
Tx: Symptomatic - hydration, pilocarpine, steroids
???55yo c/o sdry eyes and mouth - drinks lots of water everyday and uses artifical tears - ROS shows chroic arthralgias - takes NSAIDs - parotid gland swelling - dental caries and dry eyes pt may benefit from ?
pilocarpine
Seroneg spondyloarthropathy - Rh neg, HLSA B27+
involves spine, asy poly/oligoarthritis <4 joints affected
Enethesitis (inflamm ligaments, tendons, joint capsule)
Dactylitis - swelling of entire digit
Ankylosing spondylitis
Reactive arthritis - mucosal inflammation of GI or GU tract
Ankylosing spondylitis
starts after resting better with excercise, loss of forward spinal mobility symptomatic sarcoilitis Uveitis: pain photophobia, lacrimation HLA B27 +, apical fibrosis bamboo spine on xray a/w aortits (Do echo) diminished Chest expansion
Pt loves outdoor work with on/off back pain p/w c/o pain and redness of r eye - also loss of forward spine mobility - inejction aroudn corea - fluroescin eye stain is neg - what suggests ankylosing sponylitis in pt?
loss of spinal mobility
Dx: xray lumbosacral spine-specific
more sensitive test - MRI sarcoiliac joint
Eye manifestation is Uveitis
Pt p/w low back pain - xray with fusion of sarcoiliac joints and anklylosis of spine (bamboo spine - HLA B27+ most likely a/w?
Aortitis Tx for stiffness? Excercise, physical tx Pain - NSAIDs - if 6 weeks w/ minimal improvment in paint, fatigue, and morning stiffness--> then anti-TNF (no MTX, no hydroxychloroquine)
-follow up
Q3 month xray including sarcoilliac joints
Best way to maintain ROM with ankylosing spondylitis is?
Excercise
Follow dz activity with ESR
Uveitis in?
Reiter’s syndorme
Behcet’s dz
Ankylyosing spondylitis
Pt h/o anklyosing spondylitis on NSAIDs c/o new onset back pain - early fx wtd?
xray, if negative check MRI
Pt p/w asymmetric arthritis with pain in R knee, mouth ulcers, non-specific urethritis and conjunctivitis - HLA B27+, non-specific urethritis, conjunctivitis and asymmetric arthritis dx?
Reactive arthritis
Tx: NSAIDS - DMARD in extremem cases
COnjunctiviits, urethritis asym artrhtis (also mouth ulcers, keratoderma blenorrhagica
wtd next? HIV test
34yo Lt ankle arthritsi and left achilles tendon area pain - redness of eye abd pain adn diarrhea - exam with pain at baseof calcenus dx?
Reactive arthritis
How to treat the above pt w. diarrhea? - cipro + NSAID
How to treat pt w/ remove hx of diarrhea and now enthesitis?
NSAID
Pt wit reactiev arthritis ongoing arthritic pain for more than 6 months not relieved with NSAIDs or steroids wtd?
sulfasalazine/MTX
How to tx pt with remote h/o urethris and now enthesitis
Tx chlamydia + NSAID
???Causes of reactive arthritis
Yersinnia SHigella Salmonella Campylobater Ureaplasma C diff BCG tx
Pt p/w lower back pain and in DIP, HLA B27+, pitting nail changes present
Psoriatic arthritis Tx Mild - NSAIDS, skin/nail change -> MTX No hydroxychloroquine Worse with UVB (sunlight), BB, infection
Pt of Middle eastern/japanese descent - recurrent painful apthous stomatitis, genital apthous ulcers, joint pain, erythema nodsoum on legs, HLA B5+, uveitis (blurry vision), pathergy + (hyperreactive to needle sticks aka refuses needlesticks)
Bechet’s dz
Tx: mucocutaneous disease: colchicine
Moderate to sever disease: steroids
???a/w aortic aneurysm
erythema nodosum, apthous ulers
Tx: steroids???
24yo M c/o multiple oral apthous ulcers/redness of eye for the past month. tender nodules on shin - CXR prominent pulm artery - aneursym on CT - dx?
Behcet’s dz
Quinolone:
- ->paretheasias
- -> tendon rupture
- -> disection of arteries
???DTR dec with?
WNV
Tick paralysis (absent)
Toluene
spinal abscess
???DTR inc with?
Serotonin
ecstacy
epidural abscess
NORMAL with MG
Oral apthous ulcer, gential ulcer, refuses needle stick?
Behcet’s dz
Paiful shin nodule, genital ulcer refuses needle stick
Behcet’s dz
Painful shin nodule, oral apthou ulcer, aortic anurysm, painful red eye blurry vsiion, occ knee/ankle pain?
Behcet’s dz
Oral apthous ulcer, h/o urtethral discharge in past. red eye, knee/ankle pain
Reactive arthritis (Reiters syndrome)
Pt returns from the caribbean w/ high fever, pain in small joints hand, wrist, ankle with or without maculopapular rash - dx?
Chikungunya virus (break bone fever)
All these cause reactive arthritis with dactylitis
Yersinia Shigella Salmonella Campylobater C diff Ureaplamsa Inflamm bowel dz NOT E.Coli!!
25yo p/w pain/swelling of right knee, diarrhea intermittently for week, swelling of entire 2nd toe (sausage digit) and severe pain on palpation of achilles tendon - painless ulcer on tongue - dx?
Reactive arthritis
what is likely +?
Stool culture
70yo DM male p/w pain in mid back area - early morning stifness of spine, exam with dec’d thoracic lateral flexion - xray spine with flowing ossification of anterior longitudinal ligaments dx?
DISH (Diffuse idiopathic skeletal hyperostosis)
???Tx: physical therapy, NSAIDs???
Osteoarthritis
- Joint pain: 1st CMC, knees, PIP, DIP , Hip (groin pain), Cervical and lumbar spine
- osteophytes, central erosions in DIPs on xray
- if no osteophytes, then: morning stiffness, crepitus on movment of joint, join fluid <2,000 WBC’s, labs: low titer Rh factor <1:40 and ANA <1:160 may be positive. type 1 error
joint deformities:
PIP–> Bouchard’s nodes
DIP–> heberden’s nodes
tx: lose weight! –> orthoses: insoles, braces, knee taping, assistive devices
- -> topical agents (knee and hand)
- -> NSAIDs / Non acetylated salicylates –> Celecoxib w/ PPI–> intra articular steroids
- -> replace joint.
?????Older age
H/o trauma
Obesity, repetive use
2/2 DM, hyperparathyryodi - chondrocalcinosis
Labs - low Rh factor s
Tx: lose wieght, tylenol up to q6hr, NSAIDs, celecoxib with PPI, intrasticular steroids, hyaluronic acid - replace joint?????
Osteophyte formation -
osteoarthritis
Periarticular osteopenia
RA
Joint space deformity
OA and RA
Marginal bony erosioin in PIP + MCP
RA
Central bony erosion in PIP + DIP
OA
Subchondral sclerosis
OA
Pt wit severe OA pain not relieved with tylenol h/o UGIB wtd?
tramadol or oral long acting morphine
causes serotoin syndrome, seizures hypoglycemia.
Pt with fatigue and Hg 9, MCV 75 - pt taking NSAIDs for OA of knee, stool occult blood + .
-wtd?
D/C oral NSAIDs start topical NSAIDs
Most important risk factor for OA
Obesity
Elderly pt with pain in thumb while turning keys and opening car doors - pain at thumb on flexion and internal rotation - crepitus + dx?
Osteoartritsi of 1st CMP joint
Pt with OA - wants to try glucosamine or chondroitin sulfate wtd?
no difference from placebo
Pt with longstanding h/o OA takes tylenol for pain - plays tennis occasionally - mild crpitus and swelling of R knee - no fever WBC 8000. R thigh smaller than left- wtd?
Tap the knee +steroids and send patient for Physical tx to strengthen quadriceps
Pt with osteoarthris of R knee crepitus with pain. Topical capsaicin no help. Can’t take NSAIDs due to increased creatinine - steroids and hyaluronan injections with incomplete response
1) Exam with 10deg valgus def loss of cartilage on lat knee - (points outward). What is a good mechanical measure to reduce pain?
2Exam 10 deg varus deformity with medial knee cartilage loss - wtd? (points inward)
1) Medial wedge insole
2) medial unloading brace
??/lateral wedge insole.??
Randomized clinical trial shown benefit of acupuncture in?
OA knee + hip
Topical capsaicin benefit of OA in?
hand and knee
Pt is brick layer p/w painand swellign of PIP and DIP - xray loss of caritlalge and narrowing of joitn space and CENTRAL erosion . dx?
erosive OA (PIP/DIP)
Laborer or farmer p/w URI - RA for >15 yrs - swollen PIP+MCP w boggy felling. does not c/o pain, strength hand is normal -xray shows erosion PIP and MCP - dx?
RA (arhritis robustus)
Presentation of pain in OA hip in?
groin
R groin with RA and osteophytes on xray? dx?
secondary OA
R groin pain with RA, xray neg - MRI double line sign T2?
Avascular necrosis
???? R groin pain in middle aged pateint xray mild osteopenia - MRI T1 diffuse dec’d enhancemnt femoral head, T2 diffuse increase enhancement fem head?
Transient osteoporisis
????Pain over anterior aspect of hip or groin - r/o hip joint problem like?
Avascular necrosis
Pain over latral asp of hip can’t sit in car or sleep on that side
direct pain - trochanteric bursitis
tx: inject local steroids
40yr old b/l groin pain, L>R, worse with activity and internal rotation
Acetabular impingement
Pt with SLE on steroids >2yr pain in hip , walks with limp - dx test?
MRI
??r/o avascular necrosis??
45yo c/o pain in right buttock shoots down back of thigh for past 3 days - tendernesss over R sciatic notch when pressure applied by thumb and pain on abduction while lying down - dx?
Piriformis syndrome
Tx: PT, NSAIDs, yoga pigeon stretch
18 y/o (<20) man presents w/ pain both hips since childhood which has now beocme severed. NSAIds do not help anymore. Walks with limp (–> hip dysplasia). Next step?
xray
tx: weight loss–>periacetabular osteotomy–> arthropalsty
Pt with pain on groin - xray with osteophytes - you prescribe analgeisa and cane - what are your directions for cane?
use cane on OPPOSITE side of affected joint
???? Elderly pt with longstanding RA on MTX, hydroxychlroquine, NSAID with groin pain - xray NO joint space and severly impaired mobilization dx?
secondary OA
Tx: replace joint
Gout
monosodium urate–> bony tophus- erosion
it is an asymmetric inflammatory arthritis (D/C THIS ON PG 60)
pg 60
pseudogout
Ca Pyrophosphate dihydrate–> chondrocalcinosis
it is an asymmetric inflammatory arthritis
pg 60
???? Gout&pseduogout preciptiants
Asymmm inflamm arthritis Trauma post surgery 3 days post op major medial illness (MI, CVA, PE) fasting etoh abuse high fructose drinks a/w HTN, DM HCTZ
Do you tx pt with asymptomatic hyperuricemia
NO - only with sx
Is uric acid elevated during attack of gout?
No - usually falls during gout attack
Do you need to have hyperuricemia to dx gout?
No - uric acid levels may fall to normal range during gout attack
Pt with great toe swelling first time, with CHF, PUD, or on anticoag. - neg birefringent crystals on tap. next step in managmeent
tx?
Colchicine (0.6mg Q8hr= 1.8mg/ day)
(indomethacin–> give 1st if none of those comorbidities)
Pt with contraidication to cochicine 2/2 diarrhea. wtd?
NSAIDs
Pt with gout, contraindication to NSAID or colchicine with renal insuff, liver failure, heart failure, PUD wtd?
steroids
Pt with only 1 or 2 joints involvement. wtd?
intraarticular steroids
pt had Polyarticular joint involvement gout. wtd?
systemic steroids + colchicine OR NSAID + colchicine–> steroid + NSAID
Pt gouty attack resolved. What do you prescribe at the time of discharge to begin 2 weeks later?
Allopurinol
???start allopurinol (Xanitithine oxidase inhib - dec production)
(Probenicid - inc uric acid excretion)???
Pt with tophaceous gout and chronic kidney disease has never had gouty attack. OR pt. with tophaceous gout and has bony erosions. What is the best management?
colchicine + allopurinol
Pt with h/o gouty attack in past on coclchicine and allopurinol ppx, now presents w/ acute gouty attack wtd?
continue allopinol, start NSAID
Young pt. with gouty attacks on allopurinol and NSAID comes back w/ recurrent attacks wtd?
assess pt adherence to allopurinol
Pt with hx of HTN takes ACEi . Presents w/ c/o generalized rash. Exam reveals fever, necrolytic rash. wbc 15,000 and eos 10%, BUN cr 40/3.2, AST/ALT inc’d. This is most likely due to?
allopurinol
allopurinol also inc’d level of azathrioprine
Pt h/o gout p/w swelling knee - tap with neg birefringent crystals WBC 40K, started on NSAIDs and taking allopurinol - 1 wk later reaccumulation fluid in joint and still pain - tap again shows neg birefringent crystals WBC 46K - fluid yellow and turbid just like during the previous tap - what is the best management?
IV abx
Septic arthritis ???
Pt with HTN on HCTZ uric acid elevation . Asymptomatic. wtd?
c/w HCTZ for asymtomatic hyperuricemia
Pt with HTN on HCTZ with uric acid elevation and has gouty attack. wtd?
d/c HCTZ
Elderly pt’s especiallly women on HCTZ p/w pain in the PIP/DIP with nodules and swelling distal to nodules. This represents?
gouty arthritis . Will have monosodium urate deposits.
[(side note: calcium oxalate crystals–>ESRD, knee swelling (variable bifringence))]
Pseudogout (Calcium Pyrophosphate dihydrate disease) causes:
Causes:
Hyperparathyroidism
hemochromatosis
????(HyperCa
Hypothyroid
Hypophosphatemia
Wilson’s dz??????
CPPD can presents as
[???Pseduo RA
Pseduo Gout
Pseduo OA???}
Dx knee most commonly affected
Xray - chondrocalcinosis (Ca+ of ligament)
Joint fluid - rhomboid crystal - weakly + birefringence
rhomboid shape
Tx smiliary to gout - less responsive to colcihicine
????55yo p/w pain in knees and wrist fatgue, dec’d libido, swelling wrists/knees - Ca of mensci/traigular ligament - AST/ALT elevated - FBS 150
Pseduogout 2/2 hemochormatosis wtd next?
Serum transferrin saturation and iron level
Pt with arthritis, xray with multiple area of joint calcification in multiple joints. Also complains of fatigue, FBS 158 mg/dl dx?
most likely test to do?
Chondorcalcinosis due to calcium pyrophosphate dihydrate deposition
Most likely test to do?
TIBC / Transferrin saturation/ ferritin
A pt with hyperparathyroidism undergoes parathhyroiectomy, post surgery pt develops acute onset pain, swelling right knee. Tap is done. It would reveal?
55K wbc, postive birifrignence
Post surgery 3 days later wrist, MCP, PIP, DIP, knee pains - knee joint swollen, serium uric acid is elevated (can be false +). what to expect in fluid?
Calcium pyrophosphate dihydrate crystals
???Joint fluid interpreation
inflammatory - WBC 2-75K, PMN>50%, gluc >25
Septic WBC>50K, PMN>75%, gluc <25 (bacterial)
Pt c/o pain on abduction of shoulder - mainly anterior tenderness over bicipital groove
Bicipital tendinopathy
Tx - NSAIDS->PT -> steroids close to the tendon in bicipital groove
Pt c/o pain in shoulder - started tennis after long time - new shoulder pain while trying to comb hair or raising pants or lifting weight over head - pain in lat shoulder while laying down especially at night, painful abduction beyond 40 deg and int rotation
Rotator cuff tendinopathy
75yo M fall from a height with outstretched hand - c/o so\houlder pain - cant shrug shoulder, can’t abduct arm, an’t keep arm up after passive intervention to 90 degrees (drop arm test +) xray reveals no fx, only mild narrowing of sub acromial space- next step after after xray?
Rotator cuff tear
Next step after xray–> MRI
Pt c/o pain in shoudler - inced on abduction, extremes ofmovement, painless - pain more on active than passive - swings arm back and forth wihtout pain. dx and treatment?
dx subacromial bursitis
tx–> steroids into bursa
Pt with pain and griding or popping sensation in anterior shoulder while reachig to put seat belt on - pain on abduction beyond 120 deg
acromiolavicular joint arthritis
66yo F gradual onset progress R shoulder pain x 1 yr difficulty combing hairand wahsing face and head while showering - minor MVA couple yrs ago - on exam difficulty abducting and external rotation of R shoulder with creptius and tenderness over joint - xray narrowing of glenohumeral joint space.
dx and treatment?
Gelnohumeral OA
Tx: NSAIDs and stretching excercises –> persistent sx -> intraarticular steroids x 2–> - no response–> surgery
72yo F R shoudler pain x 1 year with gradual onset sx with movement of shoulder at night - difficulting abducting shoudler
Xray shows Ca of ligaments and some effusion which on tap reveals RBC, WBC 2000. ALIZARIN RED stain shows basic Calcium phosphate crystals occasional HYDROXAPATITE crystals
Milwaukee shoulder (apatite crystals, ALIZarin red stain) Tx: NSAID, repeat arthrocentesis -> persisent symptoms --> intraarticular steroids -> degernative changes- >- arthoplasty
60yo F with cast for arm injury - post removal of cast c/o stiffness, inability to move shoulder - exam shows loss o f both active an passive ROM - tenderness and pain around shoulder - xray looks normal - injecting steroid into shoulder with resistance dx? and tx?
Adhesive capsulitis (frozen shoulder) Tx: early mobilization
Lying on side pain
Shoulder - rotator cuff tendinopathy
Left precordial - costochondritis
Lateral hip pain - trochanteric bursitis
Student wit pain and swelling elbow near exams or (a carpet layer, roofer, et) Can pronate/supinate arm but can’t flex dx?
Olecranon bursitis
etiology is trauma, gout, sepsis
Tx NSAIDs, local steroids
Pt with pain/swelling elbows with fever and chill. Exam revelas warmth and tenderness - Range of movements painless. tap with 9000 WBC (could be <20,000). dx and treatment?
Dx septic olecranon bursitis
Tx Aspiration, drainage, IV abx + NSAIDs
If recurrent –> excise bursa
Pt with pain in lateral elbow and anterior to lateral epicondyle - pain on extension of fingers and supination of forearm - while in airport lifted suitcase (or handshake) and pain returned dx?
- lateral epicodylitis aka tennis elbow - pain in extension
- mainly due to lifting heavy objects
- Extensor carpi radialis brevis most commonly affected
-Reduce recurrence in future by - six weeks physical therapy with eccentric exercise
Carpel Tunnel Syndrome
Wk in abductor pollicuis brevis most commonly affected
Phalen’s Sign (forced flexion wrist) can be +, Tinel’s sign (tinel=tap) less sensitive than phalen’s sign.
Tx: Neutral splint at night
IF no response or thenar atrophy–>
Nerve conduction study -> Sx release
?????Cause of carpel tunnel
RA DM Preg Menopause Myxedema Amyloidosis Acromegaly
Presentation of median nerve issue
unable to oppose little finger with thumb
55yo F numbness both thumbs and index fingers upon holding anything for few min, HR 52, fatigue +, next test?
TSH
Preg woman with c/o pain and paresthesia both hands in the thumb and index finger esp at night wtd?
Neutral splinting of wrists
45yo with longstanding RA b/l tingling sensation in both hands worse at night with thenal muscle wasting. wtd?
nerve conduction studies ***
Pt fails splinting and has thenar atrophy?
Sx release
Numbness of thumb index finger, and middle finger with early morning stiffness of an 1hr. Difficulty opening bottles?
RA
Long distance cyclist p/w tingling numbness in littlea nd 4th finger and ulnar asp of palm - abduction and adduction of interossei decreased
Can’t hold paper between little finger and ring finger. Upon holding paper between thumb and index finger, + flexion and weakness at IP joint of thumb forming a pinch. Severe cases w/ claw hand.
Ulnar nerve entrapment at elbow/ wrist. Occurs at ulnar groove in elbow
?????Pt in MVA p/w inability to open/exten finger du to pain dx?
Super condylar fx - disrupting brachial blood flow
Pt p/w pain on radial (lateral) asp wrist esp when lfiting children OR young man who plays vidoe games . point tenderness over radial sytloid process . pain on resisted abduction and with ext of thumb - making fist with fully flexed thumb and ulnar dev with pain (Finklestein’s test)
Dequervan’s tenosynovitis
tx: rest tendon (no gripping or grasping), splinting -> local steroids
If disability is severe –> surgery
Pt p/w wrist drop, dec’d sensation in radial and dorsal aspect of hand - dx?
Compression of radial nerve at Spiral groove in middle of arm aka saturday night palsy
Pt p/w finger stuck in flexion at PIP - straightened with effort of other hand - tenderness at base of finger dx?
Digital tenosynovitis ( swelling of flexor tendon aka Trigger finger) tx: steroids
Pt with stiffness of ulnar aspect of hand - unable to extend 3rd4th fingers - thickening and contraction of palmar facia - DM and etoh liver dz. Dx and treatment?
Dupuytren’s contracture
Tx: 1st collagenase injections
2nd surgery
Pt fell on outstriched hand - tenderness over anatomic snuff box - xray neg fo rfx wtd?
thumb spica splint (scaphoid fx?? ) and then
bone scan or MRI
DM pt with inability to completely extend fingers - hand bring hands together with tips of fingers and wrists of both hands but can’t bring MCPs together (i.e cant extend fingers) - no erythema or swelling
DM choropathy 2/2 to collagen depostion
Meralgia Paresthetica
DM with burning sensation or numbness in anterior and lateral thigh
Pain worsens with abduction of thigh and with excercise - palpation of RLQ in inguinal region elecits pain in the thigh
Etio - compression of cutaneous femoral nerve
Tx: wt loss/ anticonvulsant/ local steroids
Pt c/o hip pain - xray fx of ramus of pubis tx?
early ambulation and PT
Pt p/w pain in patellar region - no skin breakdown - erythema and tenderness over patellar region. dx and tx?
pre-patellar bursitis (housemaid knee)
Tx NSAIDs/local steroids
DM pt with pelvic girdle and thigh pain - no burnign sensation - exam with atrophy and weakness of thigh muslces dx?
Diabetic amyotrophy
tx: tighter glucose control
Elderly pt with pain on knee, mainly on the medial aspect 5cm below joint line - worse with climbing stairs( semiflexion) - xray: no linear calcification, mild osteoarritisc changes
Pes Anserine bursitis (sartorius bursa)
(???pain with climbing stairs, local pain and swelling???)
Tx: local steroids /rest/ NSAIDs
Pt c/o pain on side of knee when JOGGING or CYCLING - radiates UP toward thigh - focal tenderness in lateral aspect of knee joint just above the midline while abducting or extending hip - snap is heard on flexion - on resisted internal rotation of tibia there is no pain - dx and tx?
Iliotibial band syndrome
tx correct training errors, proper foot wear, stretching hip abductors
28yo long distance runner c/o pain in knee - pain described as burning sensation on inner and outer aspects of patella, also behind patella, exacerbated with physical activity (running, climbing stairs, during squats, ascending/ descending stairs or hills). He also has knee stiffness after sitting for long time (“movie goer” sign). What will help establish diagnosis? Also what is the diagnosis? Tx?
Patellar compression.
Dx: Chondromalacia (Patellar femoral syndrome)
Tx: decrease running/quadriceps strengthening/analgesic
NO SURGERY REQUIRED!
Teenager with anterior knee pain just below knee joint. Exam reveals joint tenderness below the knee joint especially on extending knee against resistance. Most likely diagnosis?
Dx Osgood Schaltter
???dz - irritation of patellar ligament, young ppl during growth spurts???
20yo to ER with acute pain in knee with swelling - played football about 1 hr ago and heard popping sound then pain/sweeting - anterior drawer sign/lachman sign +
ACL tear
???(forward knee laxity both in anterior drawer sign and lachman test)???
Pt presents several hours after injury with swelling. Knee “locks and gives way”. Popping sound during injury- 24 hrs later . w pain and swelling. Palpation of medial joint line with pain, clicking sound on flexion of knee w the ankle in external rotation. McMurray test +. dx?
Meniscal tear
???(flex hip, and knee, valgus pressure then extend knee - if pop/pain then +)???
75yo F assisted living with pain on medial aspect of knee of past several months, click on palpation wtd?
PT
Pt p/w pain in knee on medial aspect after an injury several hours ago - no hx no popping sound. he can ambulate but no pivor/twist - Drawer neg, lachman neg, varus neg, valgus + with pain on medial joint. dx?
Medial collateral ligament injury
???(hit from lateral side)???
Pt p/w pain and swelling posterior leg - > pain began abruptly >24hr ago after tennis for a long time - exam showing ecchymosis, swelling and tenderness in mid calf area - no h/o RA. wt?
US,
Dx: gastocnemium tear
Tx: Rest NSAID crepe bandage
Pt with pain in ankle on ambulation - twisted ankle on uneven surface - can walk 4 steps without support - compression of posterior malleoli (medial and lateral) with NO pain -
what is dx and tx?
Ankle sprain - talofibular ligament strain - no need for xray
Tx: NSAID, splint
Long distance runner c/o pain in lower medial aspect of leg - he has noticed pain over the past 2 days. Pain is worsened when jogging. exam shows diffuse tenderness over medial aspect of his leg. xray neg for fx, dx and tx?
Dx: medial tibial stress syndrome aka Shin splints (??? - overuse syndrome???)
Tx: ice packs, orthotic soles
Pt p/w pain/burning sensation between 3rd and 4th toes worse while walking with high heels - pain while walking on hard surface - pain radiates in fron tof toes along with parathesias on plantar aspect - pain better when shoes removed - dx?
Morton’s neruoma - (interdigital plantar neuroma)
Pt with pain in heel, stiffness during early morning stride - get better with day going on…dx?
Plantar fasciitis
Tx:
-Ice pack after activity, arch support/ NSAIDs
-correct raining errors/steroid injetion/ surgery
-stretching exercise with dorsiflexion of foot
Pt with plantar fasciitis, xray with heel spur - cause of pain likely…
plantar fasciitis
Foot pain, more in morning, difficulty with dorsiflexion - tenderness at base of calcaneous, with inc’d tenderness on squeezing the heel, dx?
Plantar faciitis
Pt with numbness and burning sensation in toes - worse on walking and end of day - sx are aggravated at night time - radiates to front of toes, better with shoes off - on percussion, posterior and inferior to medial malleous produces pain. Dx and tx?
Tarsal Tunnel syndorme Tx: -arch support (shoe modification) -Local steroids -Sx decompression
Pt p./w painful feet, ankle and knees after prolongued standing, which has happened for the past couple of years - normal feet on exam - but on standing, arches of feel collapse and valgus of heel - dx? tx?
(Flat feet) Pes Planus
-orthotic shoes
45yo F with extreme fatigue doesn’t want to get out of bed, also with diffuse muscle ache -exam shows tenderness in most muscle group on exam - non restorative sleep, no swelling of joints or erythema. NO FEVER, ANA 1:64, ESR 30, CPK 98 wtd? dx?
Dx: fibromyalgia
Tx: amitripyline or excercise
elderly woman with generalized body ache and fatigue, it started couple days ago with pain in upper arms and neck, it is a/w morning stiffness. exam shows no focal deficit. xray shows minimal OA changes. ESR 52mm/hr, alk phos elev. dx and tx?
Polymyalgia rheumatica
tx: dramatic response to low dose prednisone
(???Pain in neck/shoulder/hip (morning pain)
can be a/w temporal arteritis
TX: low dose prendisone???)
85yo F recurrent pain in neck, ESR 40, low grade temp - restriction of neck movement due to pain - Xray shows calcification of ligaments in neck - Calcifications noted on other joints as wel, dx?
Crowned dens syndrome
????Relapsing polychondritis
swellilng of ears, hoarseness, aortic regurg
Pt with hoarness, episodic swllign of nears history of intubation 2/2 subglottic stensois
Larygoscopy edema/inflammation
Dx: Bx of cartiliage
Tx; steroids then immunosuppressive agents.
Large Vascululitis
Complement normal
Temporal arteritis
Takayasu’s arteritis
Aortitis
Medium Vasculitis
Complement normal
Polyarteritis Nodosa (PAN)
Granulmatosis with polyangiitis (wegeners)
Chugg strauss
Small vasculitis
- Henloch schonlein - (??abd pain/nodulies???)
- Microscopic polyartitis angiits (MPA) (??? - cousin of PAN - MPO ???)
- Leukocytoclastic angiitis (hypersensitivity vasculitis), associated w/ –> HCV, –> drug induced: amoxicillin, PCN, augmentin
- Churg Strauss
- Good pastures
- Cryoglobulinemia - dec C4>C3
- SBE
- SLE - dec C3> C4
- Rh Arthritis
pANCA now called myeloperoxidase Ab
65yo F c/o frontal h/a moderately sever and throbbing - scalp hurts when combs hair, hurts while chewing - episode of blurry vision - exam no focal deficit- ROS: low grade fevers over the past month. wtd?
first :Check ESR
next: Steroids
…ESR is 85 and temporary artery bx is negative. What is the most likely diagnosis?
Temporal artiteritis - even if bx neg (can be skip lesions)
( I learned this during didactics from MKSAP: Temporal artery bx can remain accurate despite treatment for 1-2 wks. don’t delay tx for bx. Suspect when >50 y.o, new HA or diplopia;; + systemic sx): amaurosis fugax, diplopia, jaw claudication, scalp tenderness, PMR)
65yo M h/a, ESR 85, steroids started and temp bx neg - BP both extremities normal - wtd next
US guided bx of the contralateral temporal artery
Pt p/w pain/wk left arm after excercise - recent dizziniess/visual distrubance and TIA - BP R 140/80, Lt 155/95
dx if pt young w/ hx malasie and low grade fevers? dx if pt elderly w/ normal ESR?
if pt is elderly w/ high ESR?
- If Pt age 25 with h/o maliase and fever - Takayasu’s dx: aortography
- Pt elderly with normal ESR (5-15%) - > Temporal arteritis (d/c this babe, differing answers …pg. 74)
-Pt elderly with high ESR - Temporal arteritis
next? –> steroids–>temp artery bx neg.–> MRA/ CTA chest to r/o aneurysms
how to Dx Takayasu dz?
tx?
Aortography–>check for stenosis
Tx: steroids, CCB
Ankylosing spondylitis a/w ?
Aortitis and Uveitis
Aorititis a/w?
Anklyosis sponylitis, Uveitis, syphillis
50yo M pw abd pain worsens while eating in periumbilical area mainly- better when stomach empty - pian has worsened over the past several weeks-joint pain in hands and feet ulcers-BS +. purpuric rash on the lower extremities. ESR 100/hr BUN/ Cr 45/2.0. CXR–> no infliltrates. The best test to determine diagnosis is?
Abd angiogram Polyarteritis Nodosa (spares lungs) (???a/w Hep B wt loss, Cr elev, elev ESR, pain of abd, ulcers bead sign on aortogram (aneursyms)???) Tx: steroids, cyclophosphamide
40yo M c/o wk left hand and abd pain - on exam: dec power in L hand. ESR 96mm/hr. U/A –> +1 protein, RBCs >50/hpf. KUB and abdominal xray–> no obstruction or perforation. Dx? tx?
PAN (polyarteritis nodosa)
Tx: steroids + cyclophosphamide
35yo p/w abd pain - labs show renal insuff - Hep B ag + . pt has?
PAN - 30% a/w hep B
24yo F italian/jewish/arab descent with recurrent abd pain every 2 months lasting for 1-2 days, appendectomy as child - pain periumbilical which spreads all over abd with high fevers - swollen knee, power normal, no ulcers. Abdomen imagin studies normal. - FATHER WITH SAME SX, dx?
Familial mediterrainian fever (Serositis and arthritis)
Tx: colchicine for ppx
complications - AA amyloidosis–> renal failure
Causes of amyloidosis (chonic inflammation)
FMF
RA
TB
MM, K chains > L; low anion gap
Amyloidosis
(????proteinuria +-hematuria with renal failure???)
Bx –>congo red staining will show fibrils of apple green birefringence. First do an abd fat bx, if neg, then bx affected organ.
50yo F pw cough, sob, arthritis. nasal septum flattened- CXR multiple pulmonary nodules and one cavitary lesion (thick walled)- afb smear and c/s neg, BUN cr 40/3.4.
BX -> vasculitis with necrostizing granulomas. U/A –> RBCs >20/hpf, 1+ proein, C-ANCA (proteinase 3) (+), Rh factor (+). Most likely dx?
Granulomatosis with polyangiitis (Wegeners)
Tx: Cyclophosphamide + prednisone
…if pt relapses in 2 years? Rituximab
Treatment guidelines: -Non-sever --> steroids + MTX -Severe --> Steroids + cyclophosphamide -In remission --> Rituximab Relapse --> steroids + rituximab
IF cavitary lesion thick, think: histo, blasto, wegener’s
IF cavitary lesion thin, think: nocardia, cocci, MAI
Thin walled cavitary lesion CXR
norcardia
cocci
MAI
Thick walled cavitary lesion CXR
Wegeners, blastomycosis, Histo
24yo M with ongoing sinusitis for past couple months a/w cough, tx’d with amox x 7 days tmep 100.5 boggy turbinates with purulent secretions, rhonci on ausculatation CT sinus total oapcification CXR nodular infiltrates . ANA +, Proteinase 3 antiboides (c-ANCA) (specific) +, myeloperoxidase anitobodies (p-ANCA) (sensitive)+. dx?
Granulomatosis w/ polyangiitis
( ???? Wegeners (lung involvment, no abd invovlement) Granulomatosis with polyangiitis Lung and kidney involvement, nasal d/c Autoimmune attach by ANCA ab (C) Tx: steroids and cyclophosphamide azathroprine MTX, mycophenlate Rituximab (relapse) ???)
40yo F with h/o asthma with several allergies no pets pw SOB wheezing and wk left foot - uses albuterol, salmeterol inhaler and is being weaned off of steroids - rales left base, dec power R foot w/ hypoactive reflexes. CBC eos+/ IgE high or normal, CXR: RUL density.
What is dx?
Churg Strauss (allergic angiitis)
(???eosinophilic granuloamtosis with polyangiitis
pt w/ h/o reactive airway ie asthma or allergic rhinitis
+eos
IgE NORMAL
+p-ANCA
mononeuropathy/polyneuropathy
pulmonary infiltrate
extravascular eos+
Tx: Prednisone +- azathroprine, cyclophosphamide, MTX (maintenance)???)
Most specific Ab for SLE
Anti smith antibody or anti DS DNA titer (both are sensitive and specific)
other labs Labs for SLE
C3 ↓ >, C4, CH50 decreased
Follow disease activity w/ anti dsDNA levels.
Tx for SLE
Arthritis -> ASA, NSAID->hydroxychloroquine (plaquenil)–> Belimumab
Photosensitivity/rash - avoid sun/ use sunscreen-> steroids -> hydroxychlroquine +/- Quinacrine
thrombocytopenia –> steroids –> IVIG
Hemolytic anemia–> steroids
Nephritis -> steroids->add cyclophophamide-> mycophenalte mofetil ( dont use during pregnancy, use 1st for african americans) –> cyclosporine
In AA and hispanic nephritis -> steroids–> mycophenolate mofetil
(???Refractive lupus - use Bilimumab???)
SLE on steroids, still with sx
MSK sx - Hydroxychorloquine
Neprhtis/CNS sx/system vasculaitis or alveolar hemorrhage - cyclophosphamide
????Serolgically active but clinically quieescent SLE
no tx
Pt on minocycline for acne OR Rh artheritis for >2yr OR on procainamide >1yr, for an arrythmia OR hydralazine for CHF for 2 yrs
presents w/ malaise, low grade T, arthralgia of MCP, PIP joints, ESR 65, ANA + 1:320, C2, 4 normal - all favor drug induced lupus …
Normal complement
No pscychosis or seizures
U/A no RBC or protein/casts
high ANA titer
only exception–> eteanercept –> high anit ds DNA titer
24yo h/o lupus for 4 years foudn to have lupus anticoagulant syndrome and history of spontaneous abortion twice she is on cyclophosphamide and steroids - asks about long term contraception
Progesterone only IU device
IF has DVT–> copper IUD
????Pt on PTU for hyperthyroid pw palpable purpuric lesions on extrem and trunk - P-ANCA+ and ESR high, Heb B neg bx of purpura leukoclastic vasculitis - dx?
PTU induced vasculitis
35yo F dx with SLE and lupus nephritis txd with steroid and IV cyclophoshamide about 2 yrs ago meds were tapered off and was asx and healthy now with low grade fever and arthralzgias what would suggest flare of SLE
Inc’d Anti DSDNA and dec’d complement
Leasding cuase of death in SLE pt of 10 yrs is?
Cardiovascular disease
????Dec OCP levels
Rifampin
St John’s wart
????What causes MAT
COPD
T/F SLE pt inc’d risk of stroke
T
T/F SLE pt with inc’d risk of MI
T
T/F SLE pt inc’d risk of DVT
T
T/F SLE pt inc’d risk of recurrent spontaneous abortions
T
T/F SLE pt in’d riks of avascular necrosis
T
Pt with recently dx SLE p/w complaints of dec urination and wk legs - pain in back , hyperactive reflexes +, on exam NO spinal tenerdness. wtd?
MRI spine r/o transverse myelitis
MRI will show–> edema of spinal cord c/w inflammation…wtd? —> IV steroids
SLE pt on hydroxychloroquine and Prednisone 20mg/day p/w psychosis - etiology?
steroid induced psychosis if >20mg steroids(auditory hallucinations)
SLE itself if <20mg steroids/day (visual and tactile disturbances)
20yo F delvers baby with Complete heart block - mother with scaly papular rash - ANA neg - woman with what ab?
SSA (anti-RO)
Pt with 1st trim spontaneous abortion for 1st time
No need to check for antiphospholipid antibody
Pt with 3rd trim spontaneous abortion for 1st time
check for antiphospholipid Ab
Pt with recurrent 3rd spont aborition in 1st trimester
check for antiphospholipid Ab
Sclerosis
1) Generalized --> systemic Sclerosis: ANA+ Scl 70 + Anti-topoisomerase+ antipolymerase III abs --> poor prognostic factor
2) Limited –> Crest:
Anticentromere +
3)Plus muscles –>dermatomyositis
Mi2
AntiJo +
Anti-PM1
Systemic Sclerosis (Anti-Scl 70+)
-Skin –> diffuse fibrous thickening: sclerodactylyl
tight face/small mouth
abnormal nail fold capillaries
—> PUVA tx
-Joints - symmetric arthritis, MCP
Tendon friction rub +
— > NSAIDs , then add –>MTX
-Raynaud –> dilated nail bed capillaries
(??? warm gloves, nifedipine???)
-LUngs - interstitial pneumonitis, interstitial fibrosis, pulmonary HTN–> high resolution CT scan–> chylophophamid+ steroids
-Renal - renal crisis (HTN, proteinuria, edema):
Tx wtih ACEi, irrespective of cr!! - what precipitates it?–>steroids
GI--> dysmotility -> erythromycin GERD--> PPI Wide mouth diverticula Bacterial overgrowth syndrome--> cipro+ metronidazole --> B12 ↓ + folate high
-Heart - Restrictive pericardial dz
Sclerosis pt can present with?
Intersticial pneumonitis (fiborosign alveolitis)
CREST (anti-centromere+)
limited scleroderma
C-> Calcinosis cutis (calcif of soft tissue)
R -> Raynaud phenomenon
E -> Esopheagela dysmotility
S-> Sclerodactyly
T->telangiectasias
Pulm HTN more common than scleroderma. Can be present even w/o xray changes
35yo garderner p/w painful fingers during cold weather, figners white with cold. next step in management?
–> wear warm gloves/ avoid cold
If wears warm glove and doesn’t help - wtd?
Nifedipine
How will you recomgnize rheumatological (seconary vs primary) disease in pt with raynaud’s phenomenon?
abnormal nail fold capillaries
-Age>40,
-Abn nail folds capillaries
-Digital ulcerations
All of the above suggest secondary reaynauds phenomenon
45yo played basketball fo r4 hours at family reunion p/w swelling arms/leg SPARING hand/feet (fingers and toes) - exam wit ORANGE PEEL like quality of skin - CBC EOS+
dx and tx?
Dx: Eosinophilic Fascitiis
Tx: Self limited-> steroids
Polymyositis (anti Jo+)
Anti Jo+
HLA DR3+ Women>Men
Prox muslce wk, can’t get up from chair or squat position
can’t comb hair, mechanic’s hands (scaly dry, darkened, cracked horizonatl lines on palmar area, finger pads, and lateral aspect)
Abn CPK >10x normal, inc’d ANA
Biopsy –> myonecrosis w/ cellular infiltrates
Polymyositis + skin changes=
Dermatomyositis (Anti- Mi2)
(????? Polymyositis sx (weakness) Mechanic hands (dry cracked skin) Heliotropic rash Gottron papules (most specific) screen for ovarian, breast or GI Cancer
Tx: Steroids (no MTX)
?????)
66yo F pw complint of diff getting up from chair , diff combing hair exam reveal rash on cheeks forehead , upper eleylids - pt at risk for developing which disorder?
Malignancy - ovarian breast or GI
1st beast–mammo
2nd GI–colonoscopy
3rd Ovary–TV US
What more specific for dermatomyositis
Gottron papules
What predicts poor outcome in dermatomyositis -
dysphagia
West nile virus poor prognositc factor?
inc’d age
RMSF poor prognostic factor?
inc’d Cr
55yo F with weakness - phx significant for polymyositis - CPK 950 - started on prednisone 50mg.day - feels better CPK decreases to less than 190, 3 months later CPK level normal but now prox wekaness again dx?
steroid myopathy
Tx: taper steroids
65yo M progressive wk legs, arms, forearms wrists fingers distal>prox, CPK high (<10x normal). Not responsding to steroids - MTX added, CPK still high - bx wit ENDOMYSIAL inflammation and bsophilic rimmed vacuoles wtd?
Inclusion body myositis
tx: taper steroids, d/c MTX
Pt with gouty tophus on colchicine and allopurinol - h/o ashtma on inhaled steroids - p/w wk trying to get up from chair, LE prox wk aslo, DTR dec - CPK 350 - bx reveals vaculoles no inflammation dx?
Colchicine induced myopathy
35yo M intubated asthmatic 4 days later on steroids and albuterol - diff extubating - CPK 925 dx?
Critical illness myopathy
Ab for SLE
ds DNA, Smith
Ab for Drug induced SLE
histone
Ab for subacute cutaneous SLE
SSA (Ro)
Ab for Scleroderma
Scl70
Ab for CREST
centromere
Ab for MCTD
RNP
Ab for poly/dermatomyositis
Jo, Mi2
Ab for Sjogren’s syndorme
SSA (ro)/SSB(La)
Ab for Wegener’s
c-ANCA (proteinase 3)
Ab for Microscopic polyarteritis angiitis (cousin of PAN)
P-ANCA (myeloperoxidase)
Hemochormatosis
MCP
Tophi
calcium deposit in pulp of finger and b/w DIP and PIP in pt with gout taking HCTZ
Dactylitis
DIP, PIP, MCP
Diagnostic Criteria for RA
-Joint involvement: 2-10 large joints: 1 point 1-3 small joints: 2 points 4-10 small joints: 3 points >10 joints: 5 points
-Serological abnormality ( Rh factor or Anti-CCP)
low positive: 2 points
high positive: 3 points
- ESR or CRP elevation: 1 point
- Duration of symptoms >6 weeks: 1 point
6 POINTS –> RA!!!
X ray changes:
marginal bony erosions
periarticular osteopenia
Poor prognostic factors for RA
progressive synovitis
joint space loss/ erosions
high Rh factor
high ESR
70 y/o F w/ early morning stiffness >45 min and symmetrical small join pain in her 2nd, 3rd, 4th MCP in R hand and 2nd, 3rd, 4th, 5th MCP and PIP in L hand.
R knee joint pain for the past 6 wks. ESR 48. Exam shows swelling MCPs and PIP of both hands. RH factor is neg. wtd? what is most likely to be positive?
wtd? —> start treatment
What is most likely to be positive? –> anti citrulline abs
sensitivity only 80%
specificity is 100% (better than RF, RF is 80% sensitive therefore you miss 20%)
fastest acting DMARD (disease modifying agents for RA) is?
methotrexate (non biologic DMARD)
Which of the above drugs decrease mortality in RA?
Methotrexate (non biologic DMARD)
Sernegative spondyloarthropathies (Rh factor negative, HLA B27+)
Involve spine
asymmetric poly/oligoarthritis (<4 joints affected)
Enthesitis (inflammation of ligaments, tendons, joint capsule, etc.)
Dactylitis( swelling of entire digit)
- ankylosing sponydlitis
- reactive arthritis (mucosal inflmmation of GI or GU tract)
Conjunctivitis, urethritis w/ asymmetric arthritis…dx?
What test would you do next?
Reiter’s syndrome
other features:
mouth ulcers
keratoderma blenorrhagica
What test do you do next? HIV test
A pt w/ one knee OA walks w/ cane. What directions when ascending and descending stairs?
Ascend stair w/ good leg, follow w/ affected leg and cane. Descend stair w/ affected leg first and then follow w/ cane and good leg
“up to heaven and down to hell”
What is most commonly affected area for pseudo gout?
knee
A 35 y/o F preparing for marathon for the past 2 months p/w pain in her leg for the past 4 weeks. It has gradually increased over time. Exam reveals focal tenderness over the tibia. dx ? wtd next? and tx?
Stress fracture
next? Xray
if neg? MRI
tx? Rest
20 y/o M presents w/ complains of difficulty walking and running and has a hx of falls for the past several months. Exam reveals atrophy of calf muscles b/l and hammer toe w/ a high plantar arch of the foot, Dx ?
Charcot marie tooth disease
Granulomatosis w/ polyangiitis (Wegener’s disease)
kidney + sinusitis + lung nodule/ thick cavitary lesion
In a pt w/ arthralgias and malar rash. you
are suspecting lupus. Wtd next?
ANA
Pt w/ lupus nephritis is started on cyclophoshamide and steroids, a week later sudden onset of headache, confusion, visual disturbanc. BP 160/100. MRI brain shows enhancement in occipital lobes. Dx? Tx?
Progressive leukoencephalopathy syndrome
tx: control BP
Pt w/ lupus is in remission presents for a follow up in 6 months. she has no symptoms. anti ds DNA titer is elevated. dx? tx?
seriologically active clinically quiescent disease
tx: DON;T TREAT
T/F anitpolymerase II abs predict increase risk of :
1) diffuse thickening of skin?
2) cancer
3) renal criss
all true
40 y/o w/ short stature presents w/ back pain. exam reveals blue sclerae and scoliosis. Excessive joint flexibility. dx?
osteogenesis imperfecta
Pts exam reveals a upper body to lower body ratio is decreased and arm span reater than the height. Thumb sign, wrist sign, pectus carinatum. Some scoliosis and heel valgus
Marfan’s syndrome
Pt w/ joint laxity and hypermobility, translucent skin, easy bruising, atrophic scars, scolisos and pes planus
Ehler danlos
Conditions mimicking polymyositis?
colchicine polymyositis
inclusion body myositis
Dermatomysotis
presents w/? wtd next?
heliotrope rash
gottron’s papules
weakenss
wtd next? CPK
if CPK elevate wtd? steroids (NOT MTX)
