ortho / Rheum Flashcards
a 35-year-old woman who comes to your office with a 1-year history of “aching and hurting all over.” She also complains of a chronic headache, difficulty sleeping, and generalized fatigue. When questioned carefully, she describes “muscle areas tender to touch.” Although the pain is worse in the back, there really is no place free of pain. She also describes headaches, generalized abdomen pains, and some constipation. What is the likely diagnosis
Fibromyalgia
What is fibromyalgia
Widespread muscular pain, fatigue, muscle tenderness, headaches, poor sleep, and memory problems
Who is fibromyalgia most common in
Middle aged women
What are common symptoms of fibromyalgia
diffuse pain that is worse in the morning, extreme fatigue, stiffness, painful, tender joints, and SLEEP DISTURBANCES. Symptoms often worsened with physical and psychological stress
What are treatment options for fibromyalgia
-stress reduction
-sleep/exercise
-duloxetine (Cymbalta) and -milnacipran (Savella), plus the anti-seizure medicine pregabalin (Lyrica)
Common signs of gout
Usually young, >30 yo, asymmetric; great toe; tophi
How do you diagnose gout and what are the findings
Diagnosis is by arthrocentesis –> rod-shaped negatively birefringent.
*Serum uric acid level >8 (supportive NOT diagnostic)
What is the treatment of choice in an acute gout attack
indomethacin
What is the maintenance treatment for gout
allopurinol (colchicine also an option but bad GI side effects)
What are the common symptoms of pseudo gout
usually >60yo; large joints, lower extremity; no tophi
How is pseudo-gout diagnosed and what are the findings
rhomboid-shaped calcium pyrophosphate crystals – positively birefringent from artherocentesis
What is used in the treatment of pseudo-gout
Acute: NSAIDs
Prophylaxis: Colchicine
What is the polyateritis nodosa
is a blood vessel disease characterized by inflammation of small and medium-sized arteries (vasculitis), which can restrict blood flow and damage vital organs and tissues
a 45-year-old male with a past medical history significant for hepatitis B infection presents with a two-week history of severe, unexplained weight loss and malaise. He reports new-onset, lancinating abdominal pain, especially post-meal, and a painful, erythematous rash on his lower extremities. His blood pressure is elevated, and he has mild kidney impairment. On examination, there is tenderness in the epigastric region without rebound or guarding, and palpable purpura is noted on his legs. His labs show elevated erythrocyte sedimentation rate and C-reactive protein, and an angiogram reveals microaneurysms in the renal and mesenteric arteries. He is ANCA-negative and guaiac-positive. A biopsy of the affected skin confirms fibrinoid necrosis consistent with vasculitis. What is the likely diagnosis
Polyarteritis Nodosa
Who is polyarteritis nodosa seen in
Most common in middle-aged men in their 40s-50s
How do you diagnose polyarteritis nodosa
Biopsy of an affected artery (gold standard) demonstrates necrotizing arteritis ⇒ or arteriography showing the typical aneurysms in medium-sized arteries
How do you treat polyarteritis nodosa
steroids (prednisone) +/- cyclophosphamide if refractory
*Plasmapheresis in patients with Hepatitis B virus
a 62-year-old female complaining of headaches, muscle pain, and weakness. She has no history of headaches but has now started experiencing them every morning for the past two weeks. She reports feeling very weak and tired in the mornings and cannot even raise her arms to brush her hair. On examination, she exhibits bilateral shoulder and hip girdle tenderness with reduced range of motion due to pain. She has difficulty rising out of the exam room chair. Laboratory findings show markedly elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. She has a normal creatine kinase (CK) level, and rheumatoid factor is negative. The patient is started on low-dose corticosteroids, resulting in significant improvement in symptoms within 72 hours. What is the likely diagnosis
Polymyalgia rheumatica
What is poly myalgia rheumatica
an idiopathic inflammatory condition AFFECTING THE JOINTS, causing PAINFUL synovitis, bursitis, and tenosynovitis - aching STIFFNESS of PROXIMAL JOINTS (shoulder, hip, neck) in patients > 50 years old
How are PMR and polymyositis different
Polymyositis is muscle weakness
PMR is joint pain and stiffness
What is polymyositis
a chronic, idiopathic inflammatory DISEASE OF THE MUSCLE causing symmetrical, proximal, PAINLESS muscle weakness
How is polymyositis different from dermatomyositis
dermatomyositis, which is characterized by inflammatory and degenerative changes in the skin and muscles
How is polymyositis confirmed
muscle biopsy
What is Reiter’s syndrome
reactive arthritis
a 23-year-old male presents with eye redness, discharge, and painful urination, along with stiffness and pain in his knee and ankle. He reports a recent new sexual partner but denies any history of chronic illnesses. Physical examination reveals conjunctivitis, asymmetric oligoarthritis, and urethral discharge.Laboratory tests reveal elevated inflammatory markers (ESR, CRP) and a negative rheumatoid factor. Urinalysis shows signs of infection, and STI screening returns positive for gonorrhea. The patient is started on appropriate antibiotics for gonorrhea and NSAIDs for joint pain and swelling. What is the likely diagnosis
Reactive arthritis
What is reactive arthritis
Autoimmune response to infection in another part of the body (Chlamydia +/- gonorrhea MC)
What are the main symptoms of reactive arthritis
CONJUNCTIVITIS, UVEITIS, URETHRITIS, and ARTHRITIS (can’t see, can’t pee, can’t climb a tree, cant have sex with me)
how is reactive arthritis diagnosed
history of infection, clinical exam, positive HLA-B27
What is the mainstay treatment for reiters syndrome
NSAIDs + antibiotics for underlying infection
a 36-year-old woman who comes to your office with a 6-month history of malaise, paresthesia in both hands, and vague pain in both hands and wrists. She also has felt extremely fatigued. She tells you that the pains in her joints are much worse in the morning and improve throughout the day. She is also noticing pain and swelling in both knees. There is a sensation of bogginess and slight swelling in both wrists and multiple metacarpophalangeal (MCP) joints. Both knees also feel swollen and boggy. There are no other joint abnormalities, and the rest of the physical examination is normal. What is the likely diagnosis and what else is needed to DX
RA
- Need rheumatoid factor drawn along with anti-CCP
*Anti-CCP is most specific
What is a typical prodrome of RA
fevers, fatigue, weight loss, and anorexia
What are some physical exam findings with RA
Boutonnière deformity
swan neck deformity
rheumatoid nodules
What is the mainstay treatment of RA
DMARDs (methotrexate)
-Hydroxychloroquine may be added if MTX is not sufficient alone
-If a third agent is needed for management (Sulfasalazine) is added
What are potential biologics to help manage RA
Etanercept
infliximab
adulimumab
(All TNF-a inhibitors)
What is Sjogrens syndrome
relatively common chronic, autoimmune, systemic, inflammatory disorder of unknown cause attacking the exocrine glands
DRY AS FUCK
What are characteristic symptoms associated with sjogrens
dryness of the mouth, eyes, and other mucous membranes
What are the diagnostic tests for sjogrens syndrome
Anti-RO / Anti-La
Schirmer Test (<5mm lacrimation in 5 min)
How is sjogren’s treated
Pilocarpine for xerostoma
Cevimeline for muscarinic stimulation
What is the classic presentation of SLE
Triad of joint pain + fever + malar (butterfly rash) - fixed erythematous rash on cheeks and bridge of nose sparing nasolabial folds
What are the diagnostic tests used for SLE
Anti-Smith (most specific)
ANA tests (most sensitive) –> run first
What is the management of SLE
sun protection, hydroxychloroquine (for skin lesions), NSAIDs, or acetaminophen for arthritis
What is Scleroderma
connective tissue disorder causing thickened skin (sclerodactyly), lung, heart, kidney, and GI tract
How will someone with scleroderma appear
Tight, shiny, thickened skin due to fibrous collagen buildup
What is CREST syndrome and what disease is it associated with
Calcinosis cutis, Raynaud’s phenomenon, esophageal motility disorder, sclerodactyly (claw hand), telangiectasia
associated with Scleroderma
What is used for the acute management of SLE
DMARDs and steroids
What laboratory studies are specific to Scleroderma
+) ANTI-CENTROMERE AB: associated with limited crest disease and better prognosis
(+) ANTI-SCL-70 AB: associated with diffuse disease and multiple organ involvement (+) ANA
What is the treatment of choice for Reynauds associated with scleroderma
CCB for vasodilatory effects
