MSK Flashcards
Risk factors for carpal tunnel syndrome
pregnancy RA DM Acromegaly hypothyroidism obesity overuse
age 30-55
more common in females
Carpal tunnel syndrome H and P
H and P hand numbness and tingling wrist pain that radiates up the arm dropped objects decreased hand strength decreased palmar 2-point discrimination
thenal muscle atrophy
Tinel sign Phalen sign (hold for about a minute)
EMG and nerve- conduction studies for definitive diagnosis
Carpal tunnel syndrome treatment
wrist spiints activity modification NSAIDs steroid injections surgical release of transverse carpal ligament
Shoulder dislocation
anterior is most common
humeral head comes forward and tears the anterior labrum of the shoulder
Treatment for anterior shoulder dislocation
pain control, then closed reduction, then immobilize with a sling and have the patient follow up with an orthopedic surgeon
Pain control: lidocaine, narcotics, conscious sedation
Bankart lesion
anterior labrum is torn 2/2 anterior dislocation
90% of anterior dislocations
Repair may prevent future dislocation
Posterior hip dislocation
posteriorly directed force on internally rotated, flexed, adducted hip
Treatment: closed reduction bracing abduction pillow confirm normal alignment with xray, without chips of bone in the socket
nerve damage implicated in claw hand
ulnar nerve
ape hand
median nerve
wrist drop
radial nerve
scapular winging
Long thoracic nerve
unable to wipe bottom
thoracodorsal nerve
loss of forearm pronation
median nerve
cannot abduct or adduct fingers
ulnar nerve
loss of shoulder abduction
axillary nerve
weak external rotation of arm
suprascapular nerve, axillary nerve
loss of elbow flexion and forearm supination
musculocutaneous nerve
loss of wrist extension
radial nerve
trouble initiating shoulder abduction
suprascapular nerve
unable to abduct arm beyond 10 degrees
axillary nerve
unable to raise arm above horizontal
long thoracic nerve
spinal accessory nerve
fracture of humoral shaft puts what nerve at risk?
radial nerve
fracture of surgical neck of humerus puts what nerve at risk?
axillary nerve
supracondylar fracture puts what nerve at risk?
median nerve
medial epicondyle fracture puts what nerve at risk?
ulnar nerve
anterior shoulder dislocation puts what nerve at risk?
axillary nerve
Colles fracture
distal radius +/- distal ulna
associated with osteoporosis
Treatment: long cast to immobilize the wrist and elbow (immobilize the joint above and below the fracture)
Smith fracture
fracture of distal radius with anterior displacement
MOI: fall and land on flexed wrist
less common than Colles
Scaphoid fracture
fall on radially deviated outstretched hand
tenderness in snuffbox indicates scaphoid fracture until proven otherwise
Treatment: immobilization of wrist with spica cast
poor union rate even when treated correctly, with risk of avascular necrosis
Boxer’s fracture
MOI: punching a wall
force transferred to 5th metacarpal
Treat:
closed reduction
surgical pinning
open wounds from teeth require surgical exploration to rule out tendon involvement
Copious irrigation
Monteggia fracture
dislocation of radial head and ulnar diaphyseal fracture
defense injuries
falls on outstretched hand with forearm in excessive pronation
Treatment: surgery
Nightstick injury
isolated ulnar shaft fracture
Treatment:
does not require surgery
Galeazzi fracture (DRUJ)
distal radial ulnar joint dislocation and radial diaphyseal fracture
Treatment: this will require surgery
Hip fracture
intratrochanteric
subtrochanteric
increased risk for avascular necrosis with femoral neck fractures
H and P:
injured leg is shortened and externally rotated
Femur fractures
Caused by severe trauma
Treatment: surgery
Increased risk for fat embolizatin
- hypoxemia
- petechiae
serial H/H
compartment syndrome exams
secondary survey as indicated by MOI
XRay, CT, spinal immobilization
Tibial fracture
increased risk for compartment syndrome
Ankle fracture
if unstable, then requires operative stabilization
Pelvic fracture
high risk of major blood loss
decreased pelvic volume
If hypotensive and can’t find blood in pelvis, consider retroperitoneal hemorrhage
(angiogram to diagnose, then embolize if you find retroperitoneal)
Sprain
injury to ligaments and soft tissues surrounding a joint
Partial or complete tear at the ligament- bone interface
Grade 1: overstretching of muscles with microscopic tears
Grade 2:incomplete tear
Grade 3: complete tear
pain with weightbearing and movement
ankle and knee are most common
Rest
Ice
Compression
Elevation
Ligament tear
ACL, PCL
Anterior drawer
Lachman
MRI for soft tissue
CT for bone
Unhappy triad
medially- directed blow to lateral side of knee
Structures injured:
ACL tear
MCL tear
Lateral meniscus tear
Meniscus tears
H and P:
vague pain inside knee
clicking or locking
joint line pain near knee
Radiology:
MRI
Treatment:
NSAIDS
PT
Arthroscopic repair for debridement
Complications:
Debridement puts the patient at risk for osteoarthritis
most commonly injured knee ligament
MCL
positive Lachman test
ACL
Positive McMurray test aids in diagnosis
Meniscus tear
common dashboard injury in an MVA
PCL
Compartment syndrome
Late manifestations: Pain Pallor Poikilothermia Pulselessness Paralysis Paresthesias
Sensitive screening test:
Compartment pain with passive stretching, pain in excess of what is expected
Diagnosis:
Manometry needle placed into the muscle, greater than 30mmHg makes the diagnosis
also treat if within 20mmHg of diastolic BP
Most common compartments involved: volar compartment of forearm, anterior compartment of leg
Most commonly due to fractures (supracondylar humerus, both- bones of forearm, proximal tibia)
Treatment: emergency fasciotomy of ALL the compartments involved and not just the one compartment
exertional compartment syndrome can happen in young athletes, and resolves with rest, minimal risk of ischemia
Back pain radiating to epigastrium while eating
PUD, GERD, gastritis
Back pain radiating to epigastrium with elevated amylase/lipase
pancreatitis
Back pain radiating to epigastrium with pulsatile mass
triple A
Back pain radiating to pelvis and hematuria
renal stones
Back pain radiating to pelvis and CVA tenderness
pyelonephritis
Back pain only along spine along paraspinals
muscle strain (don’t want patient to be completely inactive)
Back pain only along spine with osteoporosis
compression fracture
Back pain only along spine with back asymmetry
scoliosis
Back pain only along spine with abnormal gait (knees/hips flexed)
anterior slip of disk (spondylolisthesis)
Back pain only along spine along with systemic signs of infection
meningitis
discitis
osteomyelitis
Back pain (radiating) or new neuro symptoms worse with exertion
disc herniation
Back pain (radiating) or new neuro symptoms and pain with walking or standing
spinal stenosis
Back pain (radiating) or new neuro symptoms worse with rest, better with activity
ankylosing spondylitis
young male, 20’s, 30’s
Back pain (radiating) or new neuro symptoms all day
cancer
Back pain (radiating) or new neuro symptoms with bowel/bladder dysfunction, saddle area anesthesia
cauda equina syndrome
degenerative disc disease
radiculopathy
H and P:
- pain extends along path of compressed nerve
- sensory and motor deficits
- pain worsens with straight leg raises or Valsalva
MRI will allow you to diagnose
Treatment: NSAIDs Activity modification epidural steroid injection surgical decompression
Neuropathic pain:
Gabapentin
Pregabalin
Depression + neuropathic pain
Duloxetine
Spinal stenosis
generalized narrowing of the bony spaces in the spine 2.2 arthritic changes
older adults
H and P:
radiating pain
worse with walking/standing
Radiology: CT, Xray, MRI to rule out herniation and look for nerves
Treatment: Analgesics physical therapy epidural injections surgical decompression
Cauda equina syndrome
trauma to the nerves running in the dural sac
H and P: urinary retention change in bowel habits saddle anesthesia due to impairment of the pudendal nerve decreased rectal tone bulbocavernosus reflex impairment
Treatment: surgical decompression, and IV steroids to reduce risk of permanent injury
Radiation in cases of neoplasm
Erb-Duchenne palsy: Waiter’s tip
Superior trunk
MOI: hyperadduction of the arm causing widening of the humoral- glenoid gap
Claw hand
Ulnar nerve injury
Injury to medial epicondyle of the humerus
weak finger adduction
poor 4th and 5th finger flexion (extended at MCP, flexed at interphalangeal finger joints)
wrist drop
Site of injury:
radial nerve
inability to extend upper fingers
Deltoid paralysis
axillary nerve injury
associated with anterior shoulder dislocation
Klumke palsy
inferior trunk (C8 and T1) claw hand and dropped wrist
Risk factors for osteoporosis
low dietary calcium smoking alcohol sedentary lifestyle post- menopause decreased testosterone steroids (>3 months, add ppx bisphosphonates)
hyperparathyroidism
hyperthyroidism
Classic presentation:
thin, white or Asian, post-menopausal woman
Less likely to occur in obese people who bear more weight
Complications:
vertebral fracture
colles fracture
Diagnosis:
DEXA scan of hip and lumbar spine
Dual Energy x-ray Absorptiometry
labs normal
Treatment:
weight-bearing exercise
calcium
vitamin D
bisphosphonates (alendronate, etidronate, pamidronate)
Raloxifene (SERM)
Teriparatide (pulsatile PTH analog) daily injection for 2 years that stimulates osteoblasts to lay down new bone
denosumab (RANK-L inhibitor that inhibits osteoclast activity)
Osteopetrosis
rock-like bone impaired osteoclastic activity increased risk of fractures boney compression of nerves (hearing loss, vision loss) thickening of bones in skull and spine
Labs:
anemia
increased acid phosphatase
increased creatine kinase
normal calcium
normal phosphate
normal alk phos
Pagent disease of bone
overactive osteoclasts and osteoblasts
new bone is disorganized
focal discrete lesions
axial spine and long bones of legs are affected
usually asymptomatic
May have symptoms: bone pain increased fractures bowing of tibia kyphosis narrowing of auditory foramen increased cranial diameter overgrowth of bone in skull
Labs:
increased Alk Phos
normal calcium and phosphate
Treatment:
bisphosphonates
calcitonin- injectable SQ
most cases do not require treatment
Osteogenesis imperfecta
pediatric disease type I collagen disorder brittle bones frequent fractures from minimal trauma (may resemble child abuse) blue sclerae pliable skin joint hypermobility teeth deformities deafness or hearing loss
Tx:bisphosphonates
restrict activity
surgical correction of bony misalignment
Gout
arthritis: sodium urate crystals that precipitate out of blood and get deposited in the joints
usually, the small peripheral joints, like first MTP joint
inflammatory response to these crystals causes arthritis and pain
Risk factors: renal disease (hyperuricemia) male sex obesity purine-rich foods- organ meat, seafood, alcohol urate underexcretion diuretics cyclosporine cancer
red hot painful joint, without systemic symptoms
serum uric acid either normal or increased
joint aspiration will show needle-shaped negatively birefringent crystals, yellow when parallel to light, an inflammatory cells
blue needles perpendicular to polarized light
Acute Treatment: NSAIDs -indomethacin -ketorolac -ibuprofen -naproxen -celecoxib Steroids (prednisone) work safer and faster
Colchicine inhibits microtubules, 3rd line, use 2 low doses)
SE- GI upset
Longterm management: decrease alcohol use decrease diuretic use avoid purine-rich foods Probenecid, inhibits uric acid resorption in the kidney
Allopurinol, inhibits xanthine oxidase
Complications:
chronic tophaceous gout
Pseudogout
CPPD
calcium pyrophosphate dihydrate deposited in the joints
affects different joints
knee or wrist MC
postively birefringent rhomboid crystals
yellow when perpendicular
chondrocalcinosis on xray
especially visible in the menisci
treatment: NSAIDs, colchicine to address inflammation
Acute gout treatment
NSAIDs
steroids
colchicine
NOT probenecid or steroids
Pseudogout treatment
NSAIDs
Colchicine
narrowing of the marrow cavity results in low H and H
osteopetrosis
55yo female who trips and sustains distal radius fracture
Colles, osteoporosis
How do we treat osteogenesis imperfecta in children
bisphosphonates
What test do we use to test for Paget disease?
Radionuclide bone scan to look for metabolic hot spots
Physcial exam- sIgns of radial nerve damage
wrist drop
lost thumb abduction
Causes of septic joint
MCC: staph a
Sexually active? also consider n. gonorrhea
DM, cancer, other underlying illess: gram- negative rods
Presentation of septic joint
sudden onset joint pain
pain with any motion
children: vague signs of pain, refusal to walk
Labs: increased WBC count, increased ESR, increased CRP
Joint aspiration shows numerous WBCs with >50,000/mm^3 high % PMN decreased glucose positive cultures
Treatment:
surgical irrigation
drainage
Vancomycin if staph aureus (assume MRSA with any staph infection)
Ceftriaxone if n. gonorrhoeae
Aminoglycosides if gram- negative bacteria
Joint aspirate leukocytes in
OA vs. inflammatory arthropathy vs septic joint
OA 50,000/mm^3
Osteomyelitis
MCC staph aureua
Coagulase- negative staph
Pseudomonas
Salmonella MCC in SCD
H and P: Bone pain tenderness fever chills possible skin involvement with a draining sinus
Labs:
increased WBC, ESR, CRP, culture, biopsy
Radiology:
Xrays not helpful until >10 days
bone edema on MRI
on bone scan, increased uptake after 72 hours
tagged WBC scan
Treatment:
IV abx for 4-6 weeks (vancomycin assumin MRSA then alter according to culture results)
I and D for abscess inside bone or surrounding tissue
Complications:
chronic osteomyelitis
amputation
Lyme disease- classic presentation and clinical course
Early localized disease
Early disseminated disease
Early localized disease (80% of patients, usually within 1 month
-erythema chronicum migrans- bull’s eye rash with central clearing that expands over days to weeks
+/- constitutional symptoms (fatigue, HA, myalgias, arthralgias)
Early disseminated disease- weeks to months after the tick bite, may include the following:
- Meningitis (lymphocytic)
- Unilateral or bilateral cranial nerve palsies (esp facial nerve with b/l Bell’s palsy)
- Radiculopathy
- Peripheral neuropathy
- Carditis (AV heart block, myopericarditis)
Late Lyme disease- months to years after infection onset
- arthritis (esp knee)
- subacute encephalitis
Labs: ELISA and Western
Joint aspiration if NOT helpful
What is the treatment for Lyme disease?
Early Lyme disease treatment options (14-21 days)
- Doxycycline (preferred agent, can be dosed over only 14 days, avoid in pregnancy)
- Amoxicillin
- Cefuroxime
Late Lyme disease (carditis, encephalitis, arthritis), usually ceftriaxone for 14-28 days
Treatment for RMSF
Doxycycline for about 7 days
Chloramphenicol in pregnant patients
Osteoarthritis, aka degenerative joint disease
Chronic non-inflammatory
Affects articular cartilage
-hips, knees, ankles, wrists, shoulders
Can cause spinal stenosis and vertebral bodies
RF: advancing age family history obesity previous joint trauma
H and P:
- joint crepitus
- joint stiffness/pain that worsens with activity and weight-bearing, and is relieved by rest
- no systemic symptoms
- decreased range of motion
- Heberden nodes (distal)
- Bouchard nodes (proximal)
- Typically asymmetric
Labs:
normal ESR
Neoplasms
Bony metastases
BLT with a Kosher Pickle
Breast Lung (lytic, breaks down bone) Thyroid Kidney Prostate (blastic, builds up bone)
H and P:
palpable bony mass
fractures following minor trauma
Labs:
biopsy
-increased alkaline, phosphatase
Radiology:
- xray
- bone scan
- MRI
Treatment:
- chemotherapy
- bisphosphonates can help slow bone loss
- radiation therapy
- prophylactic fixation can be performed for an impending fracture
Osteosarcoma
Distal femur
Proximal tibia
Proximal humerus
Risk factors: Paget disease p53 mutation Familial retinoblastoma Radiation exposure Bone infarcts
History and physical:
deep bone pain
palpable bony mass
Labs increased alkaline phosphatase increased ESR increased LDH biopsy provides definitive diagnosis
Radiology: sunburst pattern Codman triangle (periosteum pushed up by tumor) MRI and PET to determine extent Chest CT for determining metastasis
90% 5yr survival rate for low grade
Ewing sarcoma
highly malignant diaphyseal long bone cancer seen in children
Bone pain tissue swelling fever, fatigue, weightloss fractures with minor trauma palpable mass
Labs: increased WBCs decreased hemoglobin increased ESR biopsy important for making this diagnosis
Xray:
large lesions with significant periosteal reaction (this is onion- skinning)
Codmann triangle
MRI to determine extent of cancer
Treatment:
radiation
adjuvant chemotherapy
radical excision
Complications:
20% 5-year survival rate if metastesized
Osteochondroma
lower femur, upper tibia
H and P:
irritated soft tissue overlying mass
nontender
hard on palpation
Xray: bony spur pointing away from the joint
Surgical excision may be indicated
Complications rare
diseases associated with pANCA
1. Pauci-immune glomerulonephritis 2, Microscopic polyangiitis 3, Eosinophilic granulomatosis with polyangiitis (Churg- Strauss syndrome) 4. Ulcerative colitis 5. Primary sclerosing cholangitis
Rheumatoid arthritis
chronic inflammatory arthritis
with a lot of systemic effects
type 3 hypersensitivity, more common in middle- aged and elderly women
Frequently associated with HLA_DR4
Which joints are involved?
PIPs and MCPs
This is a symmetric polyarthropathy
(DIP involvement is more consistent with OA)
- hypertrophy of the synovium
- granulation tissue on the articular cartilage- pannus formation
- active inflammation; squishy, warm, swollen, boggy, when you push on the cartilage
- ulnar deviation
- hypertrophy at MCPs and PIPs
- sawn neck deformities
- Boutonniere deformities
morning stiffness improves with use (Gel phenomenon), unlike OA which gets worse with use
Also: Rheumatoid nodules Pleuritis Pericarditis Scleritis
Diagnostic criteria for RA
Synovitis in at least 1 joint, not better explained by another disease, plus a total score of >6/10 (Add score of categories A-D below)
A. Joint involvement
swelling in 2-10 large joints= 1 point
1-3 small joints (with or without large joints)= 2 points
4-10 small joints= 3 points
>10 joints (at least 1 small joint)= 5 points
B. Serology RF (an IgG positive in 75% of RA patients) Anti-citrullinated antibody low positive RF or ACPA= 2 points high positive RF or ACPA= 3 points
C. Abnormal CRP or ESR= 1 point
D. Duration of symptoms >6 weeks= 1 point
Treatment of RA
Make the diagnosis early
Refer to a rheumatologist
Early use of DMARDs (start using them early)
DMARDs;
Hydroxychloroquine
Sulfasalazine
Methotrexate
TNFalpha inhibitors Etanercept Adalimumab Golimumab Certolizumab Infliximab (check PPD first 2/2 immunosuppression)
Leflunomide (inhibits immune system by inhibiting proliferation of lymphocytes)
Anakinra (IL1 receptor antagonist, which is anti-inflammatory)
Steroids or NSAIDs are used only as adjuncts
SLE
autoimmune, systemic women age 14-45 blacks asians latinas
Anti-histone antibodies
Diagnostic criteria (4/11) Skin disorders -malar rash -discoid rash -photosensitivity -oral ulcers Inflammatory disorders -arthritis -serositis -significantly positive ANA (non-specific), very high Organ system disorders -renal disease -neurologic disorders -hematologic disoders -immunologic disorders
Labs: positive ANA Anti-dsDNA antibodies Anti- smoth abs anti-histone abs False positive RPR and VDRL Antiphospholipid antibodies decreased serum C3 and C4
Treatment: avoid sun NSAIDs hydroxychloroquine steroids anticoagulation
Complications:
Hypercoagulability
increased risk of miscarriage
progressive impairment of lung, heart, brain, kidney function
Infections
Drugs associated with drug- induced lupus
sulfonamides hydralazine INH Procainamide Phenytoin
reversible with drug cessation
look for antihistone antibodies
Lupus immunologic markers
positive ANA
anti-dsDNA abs
anti-Smith abs
false pos RPR
RA immunologic markers
Rheumatoid factor
ANA
HLA-DR4
Anti-citrullinated protein antibody (ACPA)
Polymyositis and dermatomyositis immunologic markers
ANA
Anti-Jo-1 antibodies
ankylosing spondylitis immunologic markers
HLA-B27
Scleroderma immunologic markers
Anti-Scl-70
CREST syndrome immunologic markers
anti-centromere abs
Mixed connective tissue disease immunologic markers
Anti-RNP
Sjogren syndrome immunologic markers
Anti-Ro
Anti-La
Anti-histone antibodies
Drug- induced lupus
HLA-DR4
RA
Anti-Sm antibodies
SLE
Anti-dsDNA antibodies
SLE
Lupus skin findings (n=4)
malar rash
discoid rash
photosensitivity
painless oral ulcers
Anti-Jo-1 antibodies
polymyositis
Anti-topoisomerase antibodies
scleroderma
Polymyositis and dermatomyositis
H and P symmetric, progressive, proximal muscle weakness occurs in legs first myalgias muscle atrophy (later stages)
Rash features:
heliotropic (periorbital) red-purple rash
“shawl sign” rash involving the shoulders, upper chest, back, worsened by UV light exposure
Gottron’s papuls
Erythrodema in the malar region
Mechanic’s hands- roughened, cracking skin on the tips and lateral aspects of the fingers
Polymyositis features:
symmetric proximal muscle weakness
myalgias and muscle tenderness in 25-50% of patients
Labs: elevated CK and LDH elevated ALT and AST ANA is positive in 80% Anti-Jo antibodies elevated serum myoglobin elevated urine myoglobin
DIagnose by muscle biopsy
EMG shows spontaneous fibrillation
Treatment: high- dose corticosteroids methotrexate or azathioprine IVIG interstitial lung disease, increased risk for several malignancies
Polymyalgia rheumatica
multiple sites of muscle pain
associated with temporal arteritis
H and P: temporal arteritis jaw claudication HA blindness or vision problems shoulder and pelvic girdle
PMR:
pain, stiffness, different from myositis b/c it is without weakness
difficulty raising arms and getting out of bed because of pain
malaise
unexplained weight loss
fever
joint swelling
Labs: temporal arteritis
temporal artery biopsy
ESR
Labs: PMR
decreasd HCT
increased ESR
negative rheumatoid factor
Radiology:
- increased signal at tendon sheaths and synovial tissue outside of joints on MRI
- positive emission or PET scans can show increased uptake in large vessels
Treatment:
low-dose corticosteroids, followed by tapered dose or corticosteroids
Patient should experience significant improvement almost immediately
Any patient diagnosed with PMR should immediately be worked up for temporal arteritis
most commonly seen in elderly women
Fibromyalgia
associated with depression, anxiety, and IBS
non-inflammatory, unknown etiology
possible link to sleep apnea, RA, hypothyroid
women age 20-50
myalgias weakness without inflammation trigger points fatigue depression, sleep disturbances, dizziness, HA, mood disturbances
Treatment:
reassurance that it’s a real illness that is benign, not life- threatening, not deforming
Walking, strength training, stretching daily
relaxation techniques
stress reduction
encourage journaling and emotional writing of past traumatic experiences
Appropriate sleep: address any sleep hygiene issues
Address any other psychiatric disorders: depression, anxiety, PTSD
Pharmacological treatment options:
Amitriptyline or nortriptyline at bedtime- improvement in 25-45% of patients
Acetaminophen + tramadol- 50% pain reduction
Pregabalin
Duloxetine (SNRI)
Fluoxetine (+/- amitriptyline at bedtime)
Milnacipran
Ankylosing spondylitis
RF: 20-40yo, M>F, Caucasians > blacks
H and P:
hip and lower back pain worse in morning and following inactivity
pain improves over course of day
limited ROM of spine
Painful kyphosis relieved by bending forward
+/- anterior uveitis
Labs: Positive HLA-B27 Increased or normal ESR Negative rheumatoid factor Negative ANA
Radiology:
Bamboo spine on xray (encased intervertebral discs)
MRI shows increased signal in the sacroiliac joints
Treatment: physical therapy NSAIDs Sulfasalazine Methotrexate Anti-TNF drugs
Psoriatic arthritis
develops in 10-20% of patients who have psoriasis
DIP joints and spine are more commonly affected
H and P: asymmetric joint pain and stiffness symptoms worse in the morning, improved with activity \+/- anterior uveitis joint line pain pain with stress on joints pitting of nails
Labs:
negative rheumatoid factor
negative ANA
positive HLA-B27
Radiology:
destructive lesions of DIP and PIP on xray
“pencil in cup deformity”
marrow edema on MRI
Treatment: NSAIDs Methotrexate Sulfasalazine Anti-TNF drugs
PEAR Psoriatic arthritis Enteropathic arthritis (IBD) Ankylosing spondylitis Reactive arthritis (Reiter syndrome)
Limited Cutaneous systemic sclerosis: CREST Scleroderma
chronic multisystem sclerosis
H and P: Arthralgias, myalgias, hand swelling Raynaud phenomenon Esophageal dysmotility skin thickening
no wrinkles
intestinal hypomotility
dyspnea
arrythmias or heart failure
Labs:
Positive Anti-SCL-70 ANA
Primarily, CREST is a clinical diagnosis, but lab studies can provide support. CREST=
Calcinosis cutis: subQ calcifications often in the fingers, not always present
Raynaud phenomenon: cyanotic vasoconstriction, especially in the fingers
Esophageal dysmotility: due to lower esophageal sphincter sclerosis leading to reflux, dysphagia
Sclerodactyly: skin fibrosis, especially in the fingers, hands, and face
Telangiectasias: on the lip, hand, or face; not always present
Labs: anti-Scl-70
anti-RNA
anti-U1-RNP
anti-centromere (lab work can support the diagnosis but cannot rule out scleroderma)
Treatment: supportive care ACE inhibitors Dihydropyridine CCBs Avoid caffeine, nicotine, decongestants Methotrexate Corticosteroids
Complications:
Pulmonary fibrosis
Heart failure
Acute renal failure caused by malignant hypertension
Mixed connective tissue disease
A mix of symptoms and feature
can progress
+ anti-ribonucleoprotein (RNP)
Sjogren syndrome
-dry eyes, dry mouth (sicca syndrome)
-enlarged parotid glands
purpura of the legs
-peripheral neuropathy
-possible symmetric arthritis with other autoimmune conditions
Positive anti-Ro antibodies
Positive anti-La antibodies
lymphocytic infiltration of exocrine glands
Treatment:
supportive care
corticosteroids
What labs do you order when you suspect dermatomyositis?
CK aldolase AST, ALT LDH ANA Anti-Jo 1 BMP CBC
