IM Rheum and MSK Flashcards
The spine usually isn’t involved in RA, with the exception of this one severe complication
- The atlantoaxial joint (between the atlas and axis) has synovial pockets, and as such may be affected in RA
- May subluxate (become misaligned) in RA due to the swelling of the synovium
- This can result in compression of the cervical spinal cord, causing anesthesia, progressive spastic quadriparesis, and sensation abnormalities
Adolescent idiopathic scoliosis
Lateral curvature of the spine that often presents in kids age > 10
Spinal X-ray can show Cobb angle (angle of curvature of spine). Cobb angle > 10 degrees is consistent with scoliosis.
Risk factors: Female sex, age >12, skeletal immaturity, severe curvature (Cobb > 25), and most importantly sexual immaturity (bone growth spurt hasn’t hit yet!)
Ddx of neck pain
Rheumatologic picture with pancytopenias is likely to be. . .
. . . SLE
No other rheum condition causes pancytopenias
DMARDs
- Disease-modifying anti-rheumatic drugs
- Actually improve outcomes rather than just providing symptom relief
- Methotrexate is usually first (even in women who are child-bearing age)
Secondary causes of pseudogout
- Hyperparathyroidism
- Hypothyroidism
- Hereditary hemochromatosis
Patients with SLE on steroids are at high risk for. . .
. . . avascular bone necrosis, especially of the femoral head.
Diagnose w/ MRI.
Complex regional pain syndrome
Clinical manifestations of amyloidosis
The chief complaint of polymyalgia rheumatica is often. . .
. . . joint stiffness, especially in the neck, shoulders, pelvic girdle
It lessens as the day goes on, like most other inflammatory myalgias
Disntinguishing fibromyalgia, polymyositis, and polymyalgia rheumatica
Treating symptomatic primary Raynaud’s
- Smoking cessation
- Avoid triggers
- Avoid OTC nasal decongestants
- Dihydropyridine CCBs (amlodipine, nifedipine)
Wide Ddx for myopathy
Behcet’s disease age of onset and asociated features
- Onset most typically age 25-40
- Accompanied by many features similar to those of sarcoidosis:
- Erythema nodosum
- Anterior uveitis
- Other skin changes
Disease-modifying antirheumatic drugs and adverse effects
Scleroderma renal crisis
- Life-threatening complication of scleroderma
- Renal vascular injury due to collagen deposition results in renal ischemia and runaway RAAS activation
- This creates a vicious cycle and precipitates hypertensive emergency
- Thrombocytopenia and microangiopathic hemoylsis may be seen
- Treatment is ACUTE RAAS inhibition with ACE inhibitors
- This may seem counterintuitive given Cr elevation, the runaway RAAS is part of why the Cr is elevated in these patients, and so it is therapeutic
- Hemodialysis may be required if there is respiratory impairment or severe hyperkalemia, but AMS is not an indication
Calcaneal apophysitis
Most common cause of heel pain in an active young male – simply an overuse injury to the heel growth plate
Posterior hip disolcation
- 90% of hip disolcations, often assocaited w/ traumatic injury
- May also be associated with sciatic nerve injury or facture
- Treatment requires reduction within 6 hours of injury
- Closed (non-operative) if there is no fracture
- Open (operative) if there is
Cases where people feel “weak”, but true weakness is not present
- Fatigue
- Pain limiting joint motion
- Cramping
- Fibromyalgia
- Polymyalgia rheumatica (limited by pain and stiffness but have normal strength)
Patients with lassitude often complain that they are weak. In comparison, those with true muscle weakness typically complain that they are unable to __
Patients with lassitude often complain that they are weak. In comparison, those with true muscle weakness typically complain that they are unable to perform specific tasks
Asymmetric weakness is likely to be due to. . .
. . . a lesion in the central or peripheral nervous systems
Features of distal muscle weakness
- decreased grip strength,
- weakness of wrist flexion or extension,
- decreased plantar flexion strength,
- and foot drop
Features of proximal muscle weakness
- Difficulty flexing or extending the neck against resistance
- Deltoid muscle strength can be assessed by pressing down on the patient’s fully abducted arms with the elbows flexed
- Sitting up may be difficult or even impossible in patients with more severe proximal muscle weakness (Gower’s sign – patients use hands to “climb” up from seated position, often seen in Duschene’s muscular dystrophy but not specific)
- unable to perform a deep knee bend.
MRI in inflammatory myositis
Can be an excellent way to confirm which exact muscle inflammation is present in, and where within that muscle. This is not itself diagnostic, but can identify the exact area that needs to be biopsied for diagnosis.
Inclusion body myositis
- Twice as likely in men, usually over age 50
- Slowly progressive weakness of both the proximal and distal muscle groups
- Muscle biopsy shows endomysial inflammation and characteristic intramuscular vacuoles that resemble inclusion bodies of aggregated proteins.
Dermatomyositis is often part of a ____
Dermatomyositis is often part of a paraneoplastic syndrome
Caused by autoantibodies against neoplasms, or idiopathic. Often w/ lung, ovarian, GI cancer, or non-Hodgkin’s lymphoma
All patients with dermatomyositis should be tested for underlying malignancy
Dermatomyositis and Polymyositis summary image
Pattern of aching pain without weakness and multiple points of tenderness over body without signs of inflammation indicates. . .
. . . fibromyalgia
Also often associated with non-restorative sleep, daytime somnolence.
Heat-induced weakness is a hallmark for ___
Heat-induced weakness is a hallmark for Multiple Sclerosis
Heberden vs Buchard nodes
Classic presentation of granulomatosis with polyangitis
Combination of upper and lower respiratory tract involvement (sometimes including ears and nose) with glomerulonephritis
Complex levator ani injury
Tophi on radiography
- May or may not be radiopaque! Depends how much calcium has been recruited.
- A hard mass that is radiopaque in a location highly assocaited with gout is still highly likely to be a tophus
- Bursitis may present similarly, but will universally be inflammatory and painful, while tophi are nonpainful when they are stable
Torus palatinus
- Benign bony growth of the hard pallate
- Often congenital, but may happen later in life
- If it ever becomes symptomatic it can be surgically removed
Features of the SLE patient
“Neuropathic” claudication
- Another term for lumbar spinal stenosis, the most common cause of which is degenerative joint disease and disc herniation
- Symptoms are exacerbate by walking, paricularly uphill (whereas downhill walking exacerbates compression fractures)
- Standing/walking downhill extends the spine, making symptoms worse
- Sitting/walking uphill flexes the spine, making symptoms better
- Diagnose w/ MRI
Nonbenzodiazepine muscle relaxants
- Second-line for muscle pain after NSAIDs
- Cyclobenzaprine
- Tizanidine
- May cause drowsiness, anti-cholinergic symptoms
Diagnosis of osteoarthritis
You don’t need an X-ray unless there is any question.
If you see Heberden’s and Buchard’s nodes with a consistent history, you are good.
Morton neuroma
- Mechanically induced neuropathic degeneration of interdigital nerves
- Common in runners
- Numbness between 3rd and 4th toes
- Clicking sensation when squeezed together, accompanied by pain
- Conservative treatment: Padded shoes
- If fails, surgery can fix
Suprascapular nerve entrapment
Early discoid lupus rash
___ provides rapid short-term relief for severe rheumatoid arthritis. ___ is the long-term preventative treatment.
Corticosteroid injection provides rapid short-term relief for severe rheumatoid arthritis. DMARD therapy is the long-term preventative treatment.
