Approach to a Patient with Musculoskeletal Pain - Breuer

Question 1

What is the grade from 0-5 of muscle power grading?

Answer 1

0 No visible contraction.
1 Visible or palpable contraction without motion.
2 Motion only with gravity eliminated.
3 Motion against gravity.
4 Motion against gravity and applied load.
5 Normal Power,I.e.against a significant load.

Depending on person, age and normal activity

Question 2

What are the types of acute mono/oligoarthritis?

Chronic?

Answer 2

Acute:
infectious (not common but emergent)
gout
pseudogout
reactive (post-infectious)
psoriatic
rheumatic fever (migratory)
traumatic

Chronic:
Seronegative spondyloarthropathies (SNSA)
-Ankylosing spondylitis
-Psoriatic arthritis
-Reactive arthritis/Reiter’s syndrome
-Inflammatory bowel disease-related
Juvenile chronic arthritis
Osteoarthritis
Gout, pseudogout

Question 3

Which polyarthritis syndromes are symmetric and which are asymmetric?

Answer 3

Symmetric:
rheumatoid arthritis (RA)
lupus (SLE) and other CTDs
polymyalgia rheumatica (PMR)
viral
osteoarthritis

Asymmetric
SNSA
Gout
Rheumatic fever
Behcet’s disease
Viral
osteoarthritis

Question 4

Which diseases are associated with HLA-B27?

Answer 4

Spondyloarthropathies:

• Ankylosing Spondylitis (>90%)
• Reactive Arthritis (80-85%)
• Psoriatic Arthritis (50% with spondylitis and 15% with peripheral arthritis)
• Juvenile Chronic arthritis
• IBD associated arthritis (50%)
• Arthritis associated with Acute Anterior Uveitis
• Undifferentiated SpA

Whipple’s Disease (30%)

Question 5

Which diseases show positive anti-nuclear antibodies?

Answer 5

rheumatologic diseases:
SLE, polymyositis, scleroderma, Sjogren’s dis., vasculitis, RA
liver diseases:
primary billiary cirrhosis, CAH, interstitial lung diseases
neoplastic diseases
drugs:
procainamide, hydralazine, quinidine, anti-epileptics, drug induced lupus, others
other autoimmune diseases:
thyroid diseases, multiple sclerosis, others

Question 6

Which diseases are the following associated with?

1. Anti-dsDNA
2. Anti-SSA (Ro) and antiSSB (La)
3. Anti-Sm
4. Anti-RNP
5. Anti-jo-1/ Anti-tRNA synthetase
6. Anti-histone
7. Anti-centromere (part of ANA)
8. Anti-Scl-70 (topoisomerase)
9. Anti-phospholipid (APLA)
10. Anti-neutrophil cytoplasmic antibodies (c-ANCA, anti-proteinase-3)
11. p-ANCA (myeloperoxidase)
12. Low Complement
13. ASO (Anti-Streptolysin O)
14. Anti-CCP

Answer 6

1. SLE (v. high specificity, esp for renal dz monitoring)
2. Sjogren’s syndrome, SLE (and congenital heart block in pregnancy)
3. SLE (v. specific)
4. SLE, MCTD (specific)
5. polymyositis (high specificity)
6. SLE (50%, Drug induced, 75-90%)
7. CREST (limited cutaneous scleroderma)
8. Diffuse cutaneous scleroderma (systemic sclerosis)
9. Anti-phospholipid syndrome (high correlation with disease)
10. High sensitivity and specificity to Wegener’s granulomatosis
11. Churg-Srauss, microscopic polyangiitis, glomerulonephritis, ulcerative colitis, SLE, RA, SBE
12. Immune-complex vasculitis (SLE, cryoglobulinemia, correlate with disease activity), congenital deficiency
13. Any streptococcal infection including GBS carriers and rheumatic fever
14. RA (predicts aggressiveness, correlates with dz activity)