Orthopedics/Rheumatology

Question 1

Costochondritis 
Path:
Pt:
Dx:
Tx:

Answer 1

Path: atypical chest wall pain, non-cardiac in origin; maybe related to trauma, rheumatological causes

Pt: Pleuritic chest pain that is reproducible with palpation of chest wall

Dx: R/O life threatening pathology

Tx:
Pain control-> NSAIDs; steroids (recalcitrant cases)
Avoid strenuous activities 
Ice/Heat therapy 
Refer to PT

Question 2

Gout
Path:
Pt:
Dx:
Tx:

Answer 2

Path: Uric acid deposition in soft tissue joints and bone

Pt: Severe joint pain, erythema, swelling, stiffness
Podagra
Tophi deposition-> helix of ear, eyelids, achilles tendon

Dx:
Arthrocentesis-> negative birefringent needle-shaped urate crystals
X-rays: mouse/rat bite, punched-out erosions
Inc. ESR and WBCs
Serum uric acid levels don’t reflect joint involvement

Tx:
Acute: NSAIDs (indomethacin, naprosyn), colchicine, steroids (prednisone)
Ppx: allopurinol, febuxostat, colchicine, probenecid/sulfinpyrazone

Question 3

SLE
Path:
Pt:
Dx:
Tx:

Answer 3

Path:
Chronic systemic, multi-organ autoimmune disorder of connective tissues
Young females, 20-40ys African Americans, hispanic, native Americans
Drug-induced: hydralazine, isoniazid, procainamide, phenytoin, sulfonamides (HIPPS), quinidine -> + Anti-histone antibodies

Pt: Joint pain, fever, malar rash
Discoid lupus: annular, erythematous patches on face and scalp that heals w/ scarring
Systemic: CNS, cardiovascular, glomerulonephriti, retinitis. Oral ulcers, alopecia

Dx:
+ Anti-nuclear antibody/ ANA (>/= 1:80); + RF (Not specific)
Anti double-stranded DNA and Anti-smith ab
100% specific for SLE (not sensitive)
CBC: anemia, leukopenia, lymphopenia, thrombocytopenia

Tx:
Sun protection 
Hydroxychloroquine-> for lesions; long term use: retinal toxicity-> baseline ophthalmologic exam Q6-12m
Arthritis: NSAIDs or Tylenol 
Pulse-dose corticosteroids
Methotrexate, cyclophosphamide

Question 4

Plantar Fasciitis
Path:
Pt:
Tx:

Answer 4

Path: Inflammation of plantar fascia (calcaneus medial tuberosity -> proximal phalanges) 2/2 overuse
Risk factors: Risk: tight achilles tendon, running, obesity, flat feet (pes planus), high arch feet (pes cavus), heel spur

Pt: Heel pain during first few min walking (1st morning step out of bed)
Pain lessens w/ gradually increased activity and worsens toward the end of the day w/ prolonged weight bearing

Tx:
Orthotics- avoid flat shoes/walking barefoot, silicone heel shoe inserts
NSAIDs
PT- stretching exercises for plantar fascia and calf muscles
glucocorticoids and local anesthetic injection
Avoid surgery

Question 5

Osteoarthritis 
Path:
Pt:
Dx:
Tx:

Answer 5

Path: Cartilage covering the surfaces of the ends of bone begins to to break down and wears away -> pain from bony surfaces rubbing on one another

Pt:
Older pt complaining of hip or knee pain

Dx:
X-ray: subchondral sclerosis, joint-space narrowing, subchondral cysts, osteophytes

Tx:
Oral NSAIDs, topical NSAIDs
Topical capsaicin 
duloxetine 
Intra-articular corticosteroid injections 
Tramadol 
exercise, PT, weight loss 
Joint replacement