Joint and muscle probs

Question 1

Parvo B19 in adults

Answer 1

Instead of slapped check, just has nonspecific rash

And polyarticular, symmetric arthritis in peripheral joints

Question 2

Caribbean/West African mosquito
Always severe polyarthralgias
Low WBC and PLT

Answer 2

Chikungunya fever

Question 3

Red/purple papules on dorsum of fingers (or upper eyelids)
Symmetrical, proximal muscle weakness
Polyarthritis, interstitial lung disease, Raynauds, esophageal dysmotility

Answer 3

=Gottron papules (=Heliotrope eruption)

Dermatomyositis (paraneoplastic
Inflammatory myopathy with immune-mediated muscle injury)

Question 4

Knee injury: popping sounds, followed by acute pain

Answer 4

Meniscal tear

Question 5

Patient stands on 1 leg with knee flexed 20 degrees, patients then rotates on flexed knee
-> pain, clicking or catching

Answer 5

Meniscal tear (Thessaly test)

Question 6

Passive knee flexion and extension while holding knee in internal or external rotation
-> pain, clicking or catching

Answer 6

Meniscal tear (McMurray test)

Question 7

Pain at anterior medial knee

No effusion or knee locking

Answer 7

Anserine bursitis (pes anserinus syndrome)
From chronic overuse injury

Question 8

Pain at outside of knee

No effusion or locking

Answer 8

Iliotibial band syndrome (chronic overuse injury)

Question 9

Treatment of stress fractures

Answer 9

Rest and analgesics

If fifth metatarsal -> increased risk for nonunion -> more aggressive tx

Question 10

Acute mono articular arthritis that progress to max intensity within 12-24hr

Answer 10

Gout

Triggered by alcohol, surgery/trauma, dehydration, meds (diuretics)

Question 11

Delayed fontanel closure
Ping-pong ball skull, Enlarged skull, enlarged costochondral joints
Genu varum

Answer 11

=Craniotabes, frontal bossing, rachitic rosary

Rickets!

Question 12

Bone or joint pain, fractures

Increase in hat size, headaches, or hearing loss

Answer 12

Paget disease of bone
(Osteoclasts dysfunction -> increased bone turnover -> enlarging cranial bones -> entrapment of CN 8 or encroachment on cochlea)

Question 13

Back pain that gets worse with rest, better with activity

Answer 13

Inflammatory (spondyloarthropathy)
eg ankylosing spondylitis, psoriatic arthritis, reactive arthritis, arthritis associated with IBD

Inflammation is at ligamentous insertions (enthesitis)

Question 14

Back pain worse at night, not relieved with rest

Answer 14

Cancer

Question 15

Back pain relieved by leaning forward (“shopping cart sign”)

Answer 15

Spinal stenosis
(pseudoclaudication- leg pain from nerves)

Question 16

Back pain -> radiation below the knee, positive straight leg test, neuro deficits

Answer 16

Radiculopathy (eg herniated disk)

Question 17

Back pain -> normal neuro exam, paraspinal tenderness

Answer 17

Mechanical (muscle strain, disc degeneration)

Question 18

Tx for rheumatoid arthritis

Answer 18

Start with methotrexate

If persistent sx for >6mo
Add step-up therapy (eg TNF inhibitor like infliximab or etanercept)
or parallel therapy (sulfasalazine, hydroxychloroquine)

NSAIDs are adjunctive tx but don’t affect progression

Question 19

Recurrently high fevers
arthritis/arthralgias
salmon-colored macular/maculopapular rash

Answer 19

Adult Still disease

Question 20

Lupus markers

Answer 20

ANA- sensitive, nonspecific
first test to get!

anti-dsDNA - more specific, can confirm dx

Question 21

anti-scl70 (anti-topoisomerase)

Answer 21

systemic sclerosis (scleroderma)

Question 22

cyclic citrullinated peptide antibodies (anti-CCP)

Answer 22

RA

Question 23

Joints involved in RA

Answer 23

Spares DIP
Most commonly cervical spine
Worse in morning

Question 24

Rapid onset of pain and swelling
Popping sensation
Hemarthrosis

Answer 24

ACL injury
(Note that MCL injury usually doesn’t cause hemarthrosis)

Question 25

Lupus, esp on steroids Decreased ROM in joint, pain No erythema or swelling

Answer 25

Avascular necrosis | Get MRI!!

Question 26

Fibromyalgia vs. polymyositis vs polymyalgia rheumatica

Answer 26

Fibromyalgia: widespread pain with normal labs Polymyositis: weakness, NO PAIN, elevated CK, anti-Jo. Dermatomyositis is the same but with heliotrope rash, shawl sign, Gottron papules on backs of hands Polymyalgia rheumatica: STIFFNESS and pain. elevated ESR, CRP. associated with temporal arteritis. tx with steroids.

Question 27

Drug for RA causing macrocytic anemia

Answer 27

methotrexate (inhibits DHFR)

Question 28

Headache, jaw claudication, muscle fatigue, visual disturbance, Scalp tenderness, decreased temporal artery pulse. ESR >50 Complication?

Answer 28

Giant cell arteritis Complication: aortic aneurysm. Follow with serial X-rays!

Question 29

``` Recurrent painful oral aphthous ulcers Genital ulcers Uveitis, Skin (erythema nodosum) Pathergy: exaggerated ulcerating skin response after minor injuries thrombosis ```

Answer 29

Behcets Note: oral ulcers in SLE are NOT painful

Question 30

Point tenderness at muscle insertion points and bony prominences tx?

Answer 30

fibromyalgia first line tx: tricyclic (amitriptyline) others: pregabalin, duloxetine, milnacipran)

Question 31

hydroxycloroquine for SLE can cause what

Answer 31

retinopathy

Question 32

Gout vs pseudogout

Answer 32

Gout uric acid crystals are needle-shaped, neg birefringent, and first affect big toe. Middle aged binge-drinking makes. Prevent with allopurinol (decreases production). or probenicid (increases secretion). Treat accutely with NSAIDS or colchicine. Pseudogout CPPD (calcium pyrophosphate dehydrate) crystals are rhomboid shaped, pos birefringenet, and first affect wrists and knees. Assoc with hemochromatosis, hyperPTH

Question 33

Ankylospondylitis

Answer 33

Fused sacroiliac joints. Squaring of lumbar vertebrae. Bamboo spine. +HLA-B27 Elevated ESR, CRP Negative RF, negative ANA. Tx: NSAIDs TNF inhibitors or sulfasalazine for refractory cases.

Question 34

Anti-Jo

Answer 34

polymyositis, dermatomyosis

Question 35

Anti-CCP

Answer 35

RA

Question 36

anti-histone

Answer 36

drug-induced lupus

Question 37

anti-mitochondrial

Answer 37

PBC

Question 38

anti-SCL70

Answer 38

systemic sclerosus (scleroderma, non-CREST)

Question 39

anti-Sm

Answer 39

lupus

Question 40

anti-smooth muscle

Answer 40

autoimmune hepatitis

Question 41

anti-topoisomeriase

Answer 41

systemic sclerosus

Question 42

anti-U1RNP

Answer 42

mixed connective tissue dz

Question 43

SANTA ``` Splenomegaly Arthritis (rheumatoid) Neutropenia Thrombocytopenia Anemia ```

Answer 43

Felty syndrome | RA + pancytopenia + splenomegaly

Question 44

anticentromere

Answer 44

CREST

Question 45

anti-Ro

Answer 45

neonatal SLE

Question 46

Treatment of lupus

Answer 46

Mild joint symptoms: NSAIDs Acute exacerbations: corticosteroids Isolated skin and joint involvement: hydroxychloroquine Severe cases of lupus nephritis: cyclophosphamide

Question 47

What is Libman-sacks endocarditis?

Answer 47

Noninfectious vegetations on mitral valve | Associated with SLe and antiphospholipids

Question 48

Fibromyalgia treatment

Answer 48

Tx SSRIs

Question 49

Predisposition to osteonecrosis of femoral head | And definitive tx?

Answer 49

Steroid use, alcohol, SLE Hip replacement is definitive tx