Derm/Rheum/Ortho Flashcards

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1
Q

Non medical complications of acne

A
  1. Scarring 2. Social withdrawal 3. Depression 4. Anxiety 5. Anger 6. Unemployment
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2
Q

SE of isorenitonin

A
  1. Increased ICP 2. HyperTG and mild increased cholesterol 3. Dry nasopharyngeal mucosa 4. Increased S. aureus colonization 5. Abnormal LFTs 6. Arthralgias 7. Abnormal night vision 8. Possible depression (rare)
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3
Q

Top 3 skin diseases of childhood

A
  1. Dermatitis 2. Warts 3. Impetigo
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4
Q

DDx tinea capitus

A
  1. Sebborheic dermatitis 2. Atopic dermatitis 3. Psoriasis 4. Alopecia areata 5. Trichotillomania 6. Allopecia folliculitis
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5
Q

Risk factors for atopic dermatitis

A
  1. FamHx of AD 2. Aeroallergens (pets, mites, pollen) 3. Food allergens (milk, eggs) 4. Severe infantile disease 5. Concurrent asthma & allergic rhinitis
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6
Q

Atopic dermatitis triggers

A
  1. Stress 2. Allergens: food and aeroallergens 3. Infections: SAUR, Malassezia 4. Autoantigens: IgE vs manganese superoxide dismutase (from foreign enzyme)
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7
Q

SLE diagnostic criteria

A

4/11 1. Discoid rash 2. Malar rash 3. Photosensitivity 4. Oral ulcers 5. Non erosive arthritis 6. Renal: nephritis, HTN, nephrotic syn, RF 7. Neuro dz: encephalopathy, szs, psychosis 8. Heme d/o: pancytopenia 9. Pleuritis/pericarditis 10. Immunologic d/o 11. + ANA

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8
Q

6 y female with acne. Prom is coming. History and physical Manage. Medications. Comment on risk of Accutane DDX Most likely diagnosis

A

History - Confidentiality statement - Onset, duration, severity - Associated rashes or location o Nose, chest, back - Complications, ex infection requiring antibiotics - Provocative or palliating factors - Management so far – successful or not? o Make up o OTC and prescription medications o Soap, washing face o Assess compliance and technique. Side effects of medications o Gel, lotion or cream - Menstrual history o Heavy flow, irregular bleeding (PCOS) - Hirsutism - Puberty history - Dietary history - Other skin problems o Eczema or atopy- will affect your management - Other adrenarche o Hirsutism, severe BO - Sports equipment (ex. hockey masks) - Review of systems o Headaches, blurry vision (pseudotumor) o Chest pain, cough o Abdominal pain, cramping o MSK findings o GU findings o Hematologic disorders - PMHx - Birth Hx - Medications o Oral steroids o Dilantin - Allergies - Immunizations - Family history o Family history of acne o CAH, PCOS o Metabolic syndrome, DM2 o Infertility o Sudden death - Social history o Part time jobs (aggravating factors – ex. fast food, mechanics working with oil) - HEADS, impact of illness on patient, self-esteem o Sexual activity o Mood Physical Exam - Vitals - Plot growth (BMI) - General appearance o Signs of Cushingoid, insulin resistance (acanthosis) - Skin- emphasis on acne-prone area o Comedones (open and closed), cystic lesions, nodules, pus o Scarring o Dry skin o Is it really acne: TS, rosacea, etc - Hirsutism - Fundoscopy - Thyroid exam - CVS - Respiratory - Abdominal - Tanner staging (breast + PH) - MSK- joint exams - Affect Manage - Diagnose: acne vulgaris - Reassure, counsel re: timing of improvement o Will take 6-8 weeks! Counsel that may not be better by prom. May get worse before it gets better. o Dispel myths (blackheads are not dirt- frequent soaps are worsening, not related to diet- not caused by chocolate or fast foods) o May need to modify part time job, cosmetic choices o Counsel re: relationship with acne and menses - **Psychosocial impact of illness on youth** o Monitor for depression, suicidality - Patient handouts, diary of symptoms - OCP if PCOS symptoms - Lifestyle changes: wash face with mild soap, avoid cosmetics Medications - Topical retinoids in AM o Low threshold to use - Benzyl peroxide at night o Expect dry skin- use moisturizer - Follow up in 2-3 months for improvement. May increase benzyl peroxide or step up treatment. - Topical or systemic antibiotics (ex. minocycline) - End of line: o Dermatology consult o Accutane o AAP: Systemic retinoids to be used by general pediatricians ONLY if very experienced in messaging these conditions. Can monitor or maybe do shared care if remote practice. Specific Risks of Accutane - Comment on liver disease, teratogenicity, suicidality, severe dry skin and dry MM, photosensitivity o Baseline bloodwork and monitoring - 2 methods of contraception - Screen for depression and suicidality - Screen LFTs - Hyperlipidemia - Pseudotumor cerebri? Worsening of UC? - No vitamin A supplementation while on it - Avoid tetracyclines while on it – will worsen ICP and photosensitivity

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9
Q

6 year old girl referred to you for hair loss. General approach to history and physical

A

History: ChLORIDE FPP Location, patches, % hair loss? Diffuse .vs focal Pattern, Amount, Clumps vs. individual Hair pulling, habit? Hair of different lengths Hair loss in any other areas: eyebrows, axillary Abdo pain, obstruction, Scalp under hair that has been lost PRUITITIS? Travel Sick contacts Triggers: Stress, social, diet, Hair management: Shampoo, conditioner, dying, brushing, hair placed up Infection conditions TIGHT HAIR STYLES NAIL CHANGES OTHER DERM CONDITIONS: Rashes, eczema, pigmentation abN, psoarsis, fungal culture, ROS for Fungal infections: Tinea PSYCH ROS, OCD screening, Anxiety, Depression THYROID ROS Autoimmune conditions:DM, Celiac, Thyroid Pregnancy, crash dieting B Sx: Wt loss, fever, night sweats PMHX: T21 Meds: Chemo, steroid, Allergies FHX: Fungal, alopecia arretia, tinea captis SHx: Affect, embarrassment, school attendance, self esteem Others with hair loss Behavioural issues: trichotillomania, TEASING, BULLY ROS DDX: 1. Alopecia arretia 2. Telogen effugenvem 3. Tineia captis 4. Med SE Physical Exam: Vitals Ht/Wt and Plot DYsmorphisms Nutritional status DERM EXAM Scalp, hair exam Scaling, clean patch of hair loss Pull test Black dot: broken hairs Hair quality Nail changes WHEN WAS THE LAST TIME THE HAIR WAS WASHED H&N Hair in other places Thyroid exam Joints for arthritis Cutis aplasia Common causes: 1. Alopecia arretia 2. Tinea captis 3. Telogen effugen 4. Trauma/Trichotillomania 5. Loose telogen disorder 6. Meds 7. Thyroid 8. Sudden starvation 9. Severe Emotional Stress Healthy with history and physical exam Most likely diagnosis: Telgoen effuigenvum Factors implicated: 1. Stressor 2. Weight loss 3. Diet changes Is an underlying factor always found? No Explanation: How to counsel and management: 1. Explanation: 20-40% to be noticeable. Largely reassured. Do not lose more than 50% of hair, should regrow in 6-12M, benign.If beyond, may need to investigation for systemic disease. May need to refer to derm (outliers). Address underlying etiology. 2. Recommendation: Psychological effects 3. FUin 2-3M 4. Expectation: Counsel things to see sooner 5. Handout/Diary: Handouts from caringforkids handout

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10
Q

5 year old male with limping. Previously healthy. Few days ago: uncomfortable walking, leg hurts.

A

History - Characterize pain o Location o Character o Onset o Time of day (AM stiffness or pain?) o Waking from sleep o Course (worsening/resolving) o Weight bearing o Red or swollen joints - Provocative factors - Palliating factors o Physio? o Medications? - Recent illness o Viral - Constitutional symptoms o Fever o Weight loss o Pallor o Night sweats - Trauma – injuries, abuse - Other injuries - Review of systems o Bleeding o Oral ulcerations o Abdominal pain o Rash - Travel, camping, sick contacts o Tick bites? - PMHx o JIA o SLE or other autoimmune o Chronic disease o Fractures - Pregnancy and delivery history o Late presentation CP? o NICU admission - Medications o Improving? o Meds that may provoke (growth hormone, steroids) - Allergies - Vaccines - Development o Regression - Family history o Oncologic o Consanguinity, ethnicity o Autoimmunity: SLE, IBD, DM1 o Neuromuscular disorders o Hemophilia o Sickle cell - Social history o Child abuse, neglect o Impact on child and family (missed school) Physical Exam - Vitals - Growth + plot - Fever, pallor, lymphadenopathy - MSK: look, feel, move o Compare both sides o Look for arthritis: ROM, effusion, erythema o Look for joint above and below o Skin changes, muscle atrophy o Gait: alignment, circumduction, pelvis swinging § Walk and run o Look at feet (calluses) and shoe soles (uneven wear) - CNS o Strength, sensation o Uveitis o Fundoscopy - CVS - Respiratory o Air entry, WOB, adventitious sounds - Abdominal o HSM - Head and neck: ulceration - Derm: malar rash, erythema nodosum on bony extremities

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11
Q

LImp DDx

A

Differential diagnosis (age dependent): - Septic arthritis - Post-infectious arthritis - Malignancy - Autoimmune: JIA, lupus - Vascular: bony crisis - Trauma - SCFE, AVN - Hemarthrosis - Neuralgia - Developmental Investigations - CBC, ESR, CRP, LFTs, BUN, Cr, lytes, blood culture - Ultrasound - Hip XR - Consider: MRI, joint aspirate, lyme disease, rheum workup, oncologic Discuss management and prognosis - Explain diagnosis o Self-limiting, common o No long term sequelae o Expect resolution in

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12
Q

Identify this rash and provide a DDx

A

Etiology • Infectious Øß-hemolytic Strep ØTB ØSalmonella ØTularemia ØYersinia ØLeprosy ØBartonella ØHSV ØHistioplasmosis ØCoccidiomycosis • Inflammatory Ø UC ØCD ØSarcoidosis ØSpondyloarthropathy Beçets Syndrome • Drugs ØSulfonamides ØPhenytoin ØOCP • Malignancy ØLeukemia ØLymphoma ØCarcinomas Clinical Features • New crops of nodules may develop over weeks, and evolve from erythematous to bluish. • Rash characterized by pretibial or thigh tender erythematous nodules in the deep dermis and subcutaneous tissue. ØIt is thought to be a hypersensitivity reaction. Investigations • Search for underlying disease is always justified. • CXR and CBC are indicated. • Other considerations include throat culture, ASOT, Yersinia titre, TB skin testing, and ESR. Treatment • Treatment is of the underlying etiology. • Supportive treatment includes elevation of the legs, and analgesia. • Medication can be useful in severe cases, choices include NSAIDS, and systemic steroids. ØSteroids should only be used in recalcitrant cases, after an infectious etiology has been ruled out. • The lesions heal without scarring.

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13
Q

A 14 year old girl in your practice presents to your clinic with joint pains and fever for two weeks. She looks well. Her initial work‐up reveals trace blood and protein in her urine. Take history and perform physical exam.

A

History

Symptoms of SLE
o Fatigue, fever, weight loss
o Photosensitivity
o Arthralgias/arthritis
o Raynaud
o Serositis – pleuritis, peritonitis o Nephritis
o Seizures/psychoses
o Alopecia, rashes
o Anemia

Differential
o Broad, based on symptom complex

 Arthritis ‐ infectious, reactive, RA, Rheumatic, sarcoid, FMF, oncologic  Nephritis – IgA nephropathy, PSGN, HSP, MPGN, MCD
 Fevers ‐ infectious

HEADSS Family history, PMH

□ □

Physical exam

□ General: Height, weight, wasting
□ Head/neck: Malar rash, lymphadenopathy, oral ulcers, conjunctival pallor □ Chest: Pericardial rub, pleural rub, murmurs (libman‐sacks)
□ Renal: Fluid overload
□ Abdo: Hepatosplenomegaly, ascites
□ MSK: Arthralgias
□ CNS: cranial neuropathies, cerebritis
□ Skin: Discoid/malar rash, petechiae, bruising

PEP: How would you initially manage this patient?

PEP: How many diagnostic criteria do you need to make a diagnosis of lupus?

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14
Q

12 year old referred to you for scoliosis. CARD: Hx, Px, management.

A

History

HPI

Open‐ended – what brings them in or understanding? OLD SCARS, onset, symptom progression, current state Hx of trauma
Work‐up, treatment

Management at home

Neuromuscular Disorder/myopathy

Gross motor skills
Weakness, hypotonia, hypertonia, toe walking
Hemiplegia
Abnormal gait
Syndromes NF1 – skin changes (coloured spots,freckling, bumps, lumps), development Marfan – body habitus, joint hyperextensibility, chest pain/palpitations/exercise

− intolerance/dyspnea (CVS)

Complications

Back pain (usually painless)

− pulmonale)

Psychosocial

Pubertal History

Changes associated with puberty noticed Hair growth (pubic hair, body hair (+axillary), facial hair Voice change, acne
Breast development

Testicular and Penile changes Menses

Development

Focus on gross motor

Extended family history

Extended screen:
Scoliosis Congenital skeletal deformity Neuromuscular disorder/myopathy Syndromes: NF1, Marfan

Social History

Physical Examination

Usual exam

 MSK:

Adam’s forward bend test, assess from anterior and posterior Asymmetric rib prominence, waist line, or shoulder height suggests scoliosis Leg length discrepancy Joint hyperextensibility, arachnodactyly, pectus, other Marfanoid features

Neuromuscular screen if suggested on hx NEURO exam: 20% associated with intraspinal pathology CARDIAC exam (always if considering Marfan)

SKIN and eye exam (NF1)

Differential Diagnosis

IDIOPATHIC (most)

Others
Congenital (eg. hemivertebrae) 2° to neuromuscular disorder/myopathy (eg UMN: CP, LMN: SMA, myopathy: DMD) Syndromes (NF, Marfan)

Compensatory: leg‐length discrepancy

Investigations

X‐rays
o PA and Lateral STANDING of entire spine o Cobb’s Angle:

1) Determine end vertebrae of the curve (upper and lower limits of the curve)
2) Draw two perpendicular lines to measure angle as shown

Curve > 10° = scoliosis

Indication for MRI
o Left thoracic curves and back pain are associated with ↑ intraspinal pathology (syrinx or tumor)

Management

REFERRAL to Orthopedics (these criteria depending on who you ask!) > 20° in skeletal immature for orthosis Rapidly progressive curvature
Respiratory or Cardiac impairment

Cosmesis
Assist with psychosocial Work‐up for underlying syndrome or neuromuscular disease

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15
Q

A 15 year old boy comes to see you with a history of right knee pain for past 6 months. Take history and then do a focused physical exam.

A

 Ensure confidentiality (thinking ahead to STI questioning)

 Pain history (how long, etc)

 Swelling, warmth, stiffness

 Any other joints affected

 Back pain, buttock pain, jaw pain

 Enthesitis/insertion points

 B symptoms (fever, weight loss, night sweats)

 Bone pain? Location?

 Recurrent fevers

 Pain with activity, night pain, pain that wakes from sleep

 Travel history

 Camping or insect bites

 Treatment (alleviating, exacerbating)

 Trauma

 Sexual activity

 How does this affect you now (functional impairment)

 ROS (think DDx)

o Head and neck (eye pain, redness, uveitis, photophobia) o Oral ulcers
o Headaches
o Skin changes (malar rash, evanescent rash (JIA)

o Abdominal pain, diarrhea, bloody stools

o GU symptoms (dysuria, discharge)

 Past medical history (including previous joint pain, surgeries, etc)

 Meds, Allergies, Immunizations, Herbal

 Family history (arthritis, inflammatory disorders, rheumatologic history, IBD, bone cancers)

 Developmental history

 Social history

Physical

 Growth parameters and vital signs

 Mention joints above and below

 Look

o Observe standing (e.g., leg length discrepancy)
o SEADS – swelling, erythema, atrophy, deformity, symmetry)…including muscle bulk o Remember to inspect when patient lying or supine (not sitting → can distort

appearance)

 Feel
o Warmth, tenderness, joint line pain
o Enthesitis points (2, 6, and 10 o’clock)
o Baker’s cyst (posterior)
o Tibial tuberosity (e.g., Osgood-Schlatter)

 Move (active and passive ROM) → hip and knee!

o Assess for crepitus with passive ROM

o Patellar movement and pain

 Examine (at least mention) joint above and below (and other side)

 Special tests

o ACL, PCL, medial and lateral ligaments o Assess menisci (McMurray test)
o Effusion (ballot, fluid wave)
o Gait

 Consider complete joint exam (e.g., JIA) Differential Diagnosis

 Ligamentous sprain/tear (ACL/PCL, MCL/LCL)

 Patellar pain (patellofemoral syndrome, patellar dislocation/subluxation, patellar tendonitis)

 Osgood-Schlatter, iliotibial band tendonitis (running)

 Osteochondritis dissecans (primary necrosis of bone and underlying cartilage)

 Septic arthritis, osteomyelitis

 Arthritis (e.g., JIA)

 Malignancy (e.g., osteosarcoma, Ewing’s)

 Referred hip pain (SCFE, LCP, stress fracture of femoral neck)

 Spondyloarthropathy

 Connective tissue disease

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16
Q

A 3 year old girl has been referred to you by a family physician with a working diagnosis of JIA, based on a history of 2 months of left knee swelling. History and counsel.

A

Introduction:

 Introduce self

 Elicit chief complaint

 Understanding of situation/information to date

History

 Swelling:

o how long, which joints, # of joints; associated armth, stiffness/decreased

ROM
 Associated pain:

o exacerabating/alleviating, severity, frequency, duration, effect on function o migratory or constant, temporal patterns (worse in AM?)
o pain with activity, night pain, pain that wakes from sleep
o back pain, buttock pain, jaw pain

o enthesitis/insertion points

 B symptoms (fever, weight loss, night sweats)

 Bone pain?

 Recurrent fevers

 Recent viral illness, sore throat

 Travel history

 Camping or insect bites

 Treatment (alleviating, exacerbating)

 Trauma

 Physical activity

 How does this affect you now (functional impairment)

 Investigations/treatment to date

 ROS (think DDx)

o Head and neck (eye pain, redness, uveitis, photophobia, Roth spots)
o Oral ulcers
o Headaches
o Skin changes (malar rash, evanescent rash (JIA), stigmata of RF (Osler nodes,

Janeway lesions)
o Abdominal pain, diarrhea, bloody stools o GU symptoms (dysuria, discharge)

 Past medical history - previous joint pain, surgeries, celiac, chronic cardiac/resp, CF, IBD, psoriasis

 Meds, Allergies, Immunizations, Herbal

 Family history - arthritis, inflammatory disorders, rheumatologic history, IBD, bone cancers

 Developmental history

 Social history

Physical

 Growth parameters and vital signs

 MSK screening: pGALS (Pediatric Gait Arms Legs Spine), bony tenderness, occult #

 Specific joint exam: SEADS, ROM (passive, active), special tests

 HEENT: oral ulcers, pallor, conjunctivitis, uveitis, Roth spots, LAD

 CVS/RESP: murmur, heart sounds, tachypnea/WOB, breath sounds

 ABDO: tenderness, masses, HSM

 CNS: CN deficits, tone, DTRs, power, sensation

 DERM: erythema nodosum, pyoderma gangrenosum, jaundice, salmon-coloured rash,

stigmata of RF, bruising, petechia

o NSAIDs
o Intra-articular steroids
o DMARDs (methotrexate, anti-TNF agents) o Physiotherapy

 Complications:
o Uveitis (risk highest in ANA+ oligoarthritis)  need ophtho screening

Age at onset <6 years, + ANA
Duration of disease ≤ 4 years: eye examination every 3 months Duration of disease > 4 years: eye examination every 6 months Duration of disease > 7 years: eye examination every 12 months

o Joint contracture

o Leg length discrepancy  often Tx with lift, if minor; if significant, may require Sx

Investigations (depend on history):

 CBC, diff, lytes, renal function, LFTs, ESR, CRP, LDH, RF

 urinalysis

 ASOT, throat culture

 blood and urine cultures

 Lyme serology

 immunoglobulins, C3, C4

 auto-antibodies as indicated: ANA, anti-dsDNA, ANCA, anti-RNP, ASCA, etc.

 joint aspiration: cell count, diff, gram stain, culture

 Imaging: Xray involved joint(s), U/S hip if involved, bone scan

Management/Counselling:

 Explain JIA – inflammatory arthritis, unknown cause

 Subtypes of JIA – pauci- vs. polyarticular, systemic; determined by joint involvement in first 6

months

 No cure, but treatable; oligo JIA is often benign and self-resolving

 Tx options:

17
Q

Joint pain ddx

A

 Rheumatologic: JIA, RF, spondyloarthropathies (AS, psoriasis), reactive arthritis, SLE, JDM, serum sickness, HSP, Goodpasture, mixed connective tissue disease, Sjogren’s, sarcoidosis, KD, periodic fever syndromes, fibromyalgia, complex regional pain syndrome

 ID: Lyme, gonococcal arthritis, mononucleosis (EBV), Hep B, malaria; if single joint - septic arthritis, osteomyelitis, CRMO

 GI: IBD, Wilson’s

 Malignancy: leukemia, lymphoma, Ewing’s, osteosarcoma, neuroblastoma

 Endocrine: hypercalcemia

 Psychiatric: somatization, conversion

 Psychosocial: abuse, neglect

 MSK/Ortho: overuse, post-injury; if no swelling and confined to specific joints - LCP, SCFE,

Osgood Schlatter, Scheuermann

18
Q

Joint pain history & physical

A

o Head and neck (eye pain, redness, uveitis, photophobia, Roth spots)
o Oral ulcers
o Headaches
o Skin changes (malar rash, evanescent rash (JIA), stigmata of RF (Osler nodes,

Janeway lesions)
o Abdominal pain, diarrhea, bloody stools o GU symptoms (dysuria, discharge)

History

 Pain history (how long, which joints, # of joints, migratory or constant, exacerabating/alleviating, severity, frequency, duration, temporal patterns)

 Swelling, warmth, stiffness

 Pain with activity, night pain, pain that wakes from sleep

 Back pain, buttock pain, jaw pain

 Enthesitis/insertion points

 B symptoms (fever, weight loss, night sweats)

 Bone pain? Location?

 Recurrent fevers

 Recent viral illness, sore throat

 Travel history

 Camping or insect bites

 Treatment (alleviating, exacerbating)

 Trauma

 Physical activity

 Sexual activity (if older)

 How does this affect you now (functional impairment)

 ROS (think DDx)

 Past medical history - previous joint pain, surgeries, celiac, chronic cardiac/resp, CF, IBD, psoriasis

 Meds, Allergies, Immunizations, Herbal

 Family history - arthritis, inflammatory disorders, rheumatologic history, IBD, bone cancers

 Developmental history

 Social history

Physical

 Growth parameters and vital signs

 MSK screening: pGALS (Pediatric Gait Arms Legs Spine)

 Specific joint exam: SEADS, ROM (passive, active), special tests

 HEENT: oral ulcers, pallor, conjunctivitis, uveitis, Roth spots, LAD

 CVS/RESP: murmur, heart sounds, tachypnea/WOB, breath sounds

 ABDO: tenderness, masses, HSM

 CNS: CN deficits, tone, DTRs, power, sensation

 DERM: erythema nodosum, pyoderma gangrenosum, jaundice, salmon-coloured rash,

stigmata of RF

Investigations:

 CBC, diff, lytes, renal function, LFTs, ESR, CRP, LDH, RF

 urinalysis

 ASOT, throat culture

 blood and urine cultures

 Lyme serology

 immunoglobulins, C3, C4

 auto-antibodies as indicated: ANA, anti-dsDNA, ANCA, anti-RNP, ASCA, etc.

 joint aspiration: cell count, diff, gram stain, culture

 Imaging: Xray involved joint(s), U/S hip if involved, bone scan

19
Q

General approach to rheumatology specific history and investigatinos

A

ROS:

Eyes, fever, urogenital (urine, ulcers), GI, growth, joints, rashes, dysphagia(dermatomyositis), abdo pain, orchitis

Fam Hx: FMF
PX:

□ Joints (swelling, effusion, contractures)
□ Muscles (proximal weakness in dermatomyositis) □ Tendons
□ Skin
□ Nails (psoriatic changes)
□ Fingers (dactylitis)
□ Cardiac, lungs (effusion)

Investigations:

□ r/o malignancy
□ ASOT
□ Borrelia
□ ANA ( to ddx JIA from SLE, also as a risk factor for uveitis if +) □ DsDNA (SLE)

□ Anti Ro/Anti La (SLE) □ HLA B‐27 (ERA)
□ RF
□ Anti CCP

□ Anti phospholipid Ab □ ESR, CRP, ferritin
□ CBC
□ LFT’s

□ CK, LDH, AST (elevated in dermatomyositis) □ Urine dip (HSP)
□ EMG
□ Muscle bx

20
Q

8 yr boy with mild fever, fatigue and mild increased work of breathing for 1 week.

A

History

Sore throat 2 weeks prior.
Very sore Right knee for 3 days then it resolved and now the left hip hurts. Fever to 38.7C, not spiking.
No rashes.
No abnormal movements
No previous episodes
No nodules.
No eye/palm changes
No diarrhea or GI symptoms
Not black/Mediterranean ancestry
No sexual activity or suspected abuse
No other infections

Examination

Vitals - Stable
General state/ ABC’s -
Eye – conjunctivitis, Cu deficiency
Nose – discharge
Pharynx – erythema, exudates, strawberry tongue Neck – lymphadenopathy
Resp – crackles, decreased air entry
CV – complete
Abdomen –
GU – signs of trauma

Neuro – signs of chorea, tics
Skin – erythema marginatum, subcutaneous nodules (extensor surfaces)

Reactive arthritis Kawasaki disease Viral Myocarditis Rheumatoid arthritis Sickle cell

Lyme
Viral pericarditis Gonococcal infection Innocent murmur Malignancy

Plan

If diagnosis uncertain… ESR or CRP
EKG (long PR) Echocardiography Pharygneal culture for strep ASOT

Anti-DNAseB Anti-streptococcal Antibodies Anti-hyaluronidase

Treatment

Penicillin po x 10d (or Erythro)
Benzathine Penicillin IM x1
Antibiotic prophylaxis x5yr or until 21yr of age

Benzathine Pen G 1.2million IU IM q4wk Pen V po bid
Prophylaxis for dental procedures

21
Q

Rheumatology physical exam

A

Communicator:
□ Introduces self to patient
□ Discusses examination to be performed □ Appropriate draping / privacy
□ Gentle examination technique

Medical Expert:
□ States would like Height + Plot □ States would like Weight + Plot □ HR
□ BP
□ Temp
□ RR
□ Rashes:

o Malar
o Discoid
o Gottron’s papules o Heliotropic
o Photodistributive o Psoriasis

§ Examines scalp

§ Examines skin □ Oral ulcers

□ Nail pits
□ Nail fold exam: must use muco jelly
□ Uveitis / Photosensitivity
□ Hepatosplenomegaly
□ Pericarditis: rub, muffled heart sounds, JVP □ Muscle

o Atrophy
o Deltoid
o Hip flexors

§ Timed squats □ Lymph nodes

o Cervical
o Axillary
o Supraclavicular o Inguinal

□ Joint exam: Proper technique o Hands

§ Nodules/calcifications on tendons o Elbows

o TMJ

o C-spine
o Lumbosacral spine
o Modified Schober
o Hips
o SI joints: Palpation and FABER
o Knees
o Ankles and subtalar joints
o MTP and IP joints
o Enthesitis: minimum requirement is plantar fascia and Achilles

□ Gait
□ Trigger Points

Additional Question: Define ‘active’ joint.

Active Joint: Any Swelling / Effusion OR 2 of the following:

  • Heat
  • Limited ROM
  • Tender / Painful ROM
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