Day 11 - Ms3

Question 1

Dx criteria for rheumatoid arthritis

Answer 1

4 of 7 criteria: (1) Morning sx (2) Symmetrical polyarthritis (3) MCP/PIP/Wrist involvement (4) More than 3 joints involved (5) Rheumatoid nodules (subcutaneous nodules over bony prominences) (6) Rheumatoid factor (non-specific, also in Sjogren’s, Lupus, healthy elderly), anti-cyclic citrullinated peptide (CCP) (7) Radiographic erosion of cartilage or bony decalcification of hands/wrist/feet

Question 2

Tx RA

Answer 2

NSAIDs at full doses (800 mg of Ibuprofen, 500 mg Naproxen); May also use COX-2 inhibitors, other pain control; Other disease-modifying antirheumatic drugs (DMARDs) - Sulfasalazine, Hydroxychloroquine, Methotrexate, Lefluonomide, Cyclosporine, Anti-TNF agents; Less commonly, Azathioprine, Penicillamine, Gold (old school)

Question 3

Classic dermatomyositis p/w

Answer 3

Rash features heliotrophic red purple rash, shawl sign (shoulders, upper chest and back) sign worsened by uv; Grotton’s papules (papular rash with scales on dorsum of hands & bony prominences, may be mistaken for psoriasis); Erythroderma in malar region, cheeks, forehead; Mechanic’s hands - roughened, crackened skin on tips and lateral aspects of fingers

Question 4

Tx Fibromyalgia

Answer 4

Reassurance (real but not life-threatening); Walking, daily stretching, Relaxation, Sleep (address any sleep hygiene issues), De-stress; Encourage journaling and emotional writing; Address any other psychiatric disorders (depression, anxiety, PTSD); Med tx options - Amitriptyline (Elavil), Pain meds (nothing addictive - Acetaminophen or Tramadol (=Ultram)); 3 FDA approved tx: (1) Pregabalin (Lyrica) (2) Duloxetine (Cymbalta) (3) Milnacipram (SNRI); Can also use SSRIs technically

Question 5

CREST scleroderma dx

Answer 5

Clinical findings: Calcinosis (subcutaneous calcifications, often in fingers), Raynaud phenomenon (especially in fingers), Esophageal dysmotility (lower esophageal slcerosis - dysphagia, GERD), Sclerodactyly (skin fibrosis, especially fingers/hands/face), & Telangiectasias (lips/hands/face); Labs: Scl-70, Anti-RNA, G1RNP, Anticentromere; Classic sx trump labs

Question 6

Screening for developmental dysplasia of the hip

Answer 6

Hip sonogram at 6 wks IF female & breech OR fem w/ FH of CDDH; Sometimes, also if male breech

Question 7

Tx slipped capital femoral epiphysis (SCFE)

Answer 7

Avoid weight bearing with bedrest, crutches, &/or wheelchair until surgically repaired; Prompt surgical pinning of head of femur; If acute & unstable, admit for surgical tx; If chronic & stable, urgent outpt eval; Closed reduction of acute slips prior to surgical pinning is controversial; Ppx pinning of contralateral side in context of hypothyroidism

Question 8

Which infants should receive Vit D supplementation

Answer 8

All children, including breastfed: 400 IU daily, starting first few days of life; in 32 oz formula, 1 qt required to have this amt of Vit D on daily basis (not need to supplement if using this amt of formula); Particulary important recommendation if Sun-light exposure or darker skin

Question 9

Tx Juvenile Idiopathic Arthritis

Answer 9

NSAIDs; If unresponsive to trial of 2 different NSAIDs, then methotrexate or corticosteroids

Question 10

Most common sx of Osgood-Schlatter disease

Answer 10

Anterior knee pain increases over time, worsened by quadricep contraction

Question 11

Signs of Osgood-Schlatter

Answer 11

Tibial tuberosity: soft tissue swelling, palpable bony mass, and/or pain upon quadriceps flexion

Question 12

Tx Osgood-Schlatter

Answer 12

Okay to continue sports, typically resolves within 6-18 mo; Rehab, including stretching of quadriceps & hamstrings, strengthening of quads; Protective pad over tibial tuberosity, Ice to affected area after activity, NSAIDs for pain; Knee immobilizers are contraindicated

Question 13

Tx clavicle fracture in newborn

Answer 13

Occurs .2-3.5% spontaneous delivery; NO intervention needed (no shirt pin needed), Eval for brachial plexus injury - PT if applicable

Question 14

Tx clavicle fracture in older kids

Answer 14

Figure of eight (may be uncomfortable, but leaves elbow and hand free) and or arm sling (outcomes no different); Instruct how to tighten sling, may require assistance; NO ortho consult needed; Fu in 1-2 wks, then every 2-3 wks if asx; Repeat X-ray at 6 wks; ROM exercises important

Question 15

Child presents to ER w/ parents, unable to bend elbow after father jerked him out of street - Dx & Tx

Answer 15

Nursemaid’s elbow; Do NOT need x-ray (if classic H & P); Reduce by gently flexing and supinating arm with one hand while supporting elbow & applying radial head pressure; Popsicle so forced to use arm

Question 16

Tx Legg-Calve-Perthes disease

Answer 16

Non weight bearing on affected side for extended period of time; If limited femoral head involvement & ROM, observation; If extensive, bracing, hip abduction with petrie cast or osteotomy

Question 17

Childhood spondylolithesis p/w

Answer 17

Forward or anterior slip of vertebrae, resulting in palpable step off on PE; Usually L5/S1; Subacute back pain, exacerbated by hyperextension of spine; Hip flex gait in cases where sacrum becomes relatively more vertical & hip extension is impaired; Possible neuro dysfunction, including urinary incontinence but very rare