Orthopedics/Rheumatology Flashcards
Gout Path: Pt: Dx: Tx:
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
Pseudogout Path: Pt: Dx: Tx:
Path:
Calcium pyrophosphate crystals
Surgical removal of parathyroid gland can cause flares
Pt:
Middle-Aged man
Monoarticular arthritis-> MC knee
Dx:
Synovial fluid: positively birefringent, rhomboid-shaped crystals
X-ray: “white line of chondrocalcinosis”
Tx: NSAIDs Intra-articular steroid injection Colchide Systemic corticosteroids
Gout vs Pseudogout Crystal composition: Crystal shape: Birefringent: MC joint affected: Radiography:
Crystal composition: uric acid/ calcium pyrophosphate
Crystal shape: needle-like/rhomboid
Birefringent: negative/weakly positive
MC joint affected: 1st MTP/knee
Radiography: “rat-bite” erosions/white lines of chondrocalcinosis
Fibromyalgia
Pt:
Dx:
Tx:
Pt:
Women
Widespread musculoskeletal pain for >3m, nonrestrictive sleep and generalized fatigue
Dx:
PE will show tenderness of at least 11 out of 18 anatomic sites (symmetrical trigger points)
Labs will be normal
Tx:
Education, antidepressants, avoid opioids
Aerobic exercise
Polyarteritis Nodosa Path: Pt: Dx: Tx:
Path: Systemic vasculitis of medium and small arteries-> necrotizing inflammatory lesions
High association with Hep B
Pt:
Renal: HTN (inc renin), Renal failure
Constitutional: fever, myalgias, arthritis (Lungs usually spared!)
CNS: Neuropathy, Mononeuritis multiplex, Amaurosis fugaz, peripheral neuropathy
Dermatologic: Livedo reticularis, purpura, ulcers, gangrene, nodules, Raynaud’s phenomenon, Tender lumps under the skin especially on thighs and lower legs
Starburst livedo (pathognomonic)-> Painful violaceous plaques surrounded by livedo reticularis
Dx:
Elevated ESR
Classically ANCA negative (p-ANCA positive in <20% cases)
Bx: necrotizing inflammatory lesions
Renal or mesenteric angiography: microaneurysms w/ abrupt cut off of small arteries
Tx:
Corticosteroids (+/- cyclophosphamide if refractory)
+/- plasmapheresis if HBV +
Polymyalgia rheumatica Path: Pt: Dx: Tx:
Path: Idiopathic inflammatory condition causing synovitis, bursitis and tenosynovitis
Seen in ~50% pts w/ giant cell arteritis
Pt:
>50 yrs old
“curtains coming down” vision loss, Amaurosis fugax: transient loss of vision in one or both eyes; classic finding in giant cell arteritis
Symmetrical aching and stiffness of shoulders, hip girdle, neck, torso, Worse on arising in morning
Dx: Clx
Elevated ESR
Anemia-> normochromic, normocytic
Tx:
Steroids
NSAIDs, Methotrexate
Polymyositis
Pt:
Dx:
Tx:
Pt:
Progressive symmetrical weakness of proximal muscles over a period of months
Dx: Anti-Jo-1 most specific to myositis Anti-SRP ANA, RF Labs: elevated CK, aldolase, AST, ALT EMG: irritable myopathy Muscle bx: perivascular lymphocytic infiltrates Large nuclei, fiber size variation, atrophy and the simultaneous presence of necrotic and normal type I and type II fibers
Tx:
Corticosteroids
Complications:
Interstitial lung disease, non-erosive arthritis, fever, Raynaud’s phenomenon, Gottron papules
Reactive arthritis Path: Pt: Dx: Tx:
Path: Linked to genetic factor HLA-B27
Pt:
Arthritis, urethritis and conjunctivitis
Palms and soles: Brownish-red papules or macules eventually become hyperkeratotic and crusted
Dx: Clx-> presence of: arthritis, urethritis and conjunctivitis in the setting of recent infection
Tx: Supportive, NSAIDs, topical steroids
Rheumatoid arthritis Path: Pt: Dx: Tx:
Path: Autoimmune destruction of synovial joints
Pt: Women>men, Morning stiffness lasting >30mins
Dx: PE: symmetrical soft, red, tender, swelling in joints MCP, PIP Bilateral ulnar deviation at MCP Boutonniere deformity Swan-neck deformity
Labs:
Rheumatoid factor assay: sensitive, not specific
Anti-cyclic citrullinated peptide antibodies: most specific for RA
ESR, CRP, CBC, ANA
Tx:
DMARDs-> reduce joint damage
Methotrexate (1st line)
Steroids and NSAIDs for pain and sx control
Heat and cold compresses, orthotics and splints, therapeutic exercise, occupational therapy
Sjogren syndrome Path: Pt: Dx: Tx: Complications:
Path: Autoimmune disorder attacks exocrine glands
Pt:
Salivary glands-> xerostomia (dry mouth)
Lacrimal glands-> keratoconjunctivitis sicca (dry eyes)
Parotid enlargement
Dx:
+ Schirmer test
Labs: SSA (anti-Ro) or SSB (anti-La)
Tx:
Artificial tears
pilocarpine-> xerostomia
Cholinergic drug that increased lacrimation and salvations
Cevimeline: stimulates muscarinic cholinergic receptors
Complications: Inc incidence of Non-Hodgkin lymphoma
Systemic Lupus Erythematosus Path: Pt: Dx: Tx:
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, myasthenia pyelonephritis, retinitis. Oral ulcers, alopecia
Dx: Anti-nuclear antibody/ ANA; + RF Not specific Anti double-stranded DNA and Anti-smith ab 100% specific for SLE (not sensitive)
Tx: Sun protection Hydroxychloroquine-> for lesions Arthritis: NSAIDs or Tylenol Pulse-dose corticosteroids Methotrexate, cyclophosphamide
Systemic Sclerosis Path: Pt: Dx: Tx:
Path: Thickened skin, lung, heart, kidney and GI tract
Pt:
Tight, shiny, thickened skin (localized or generalized)
CREST syndrome: limited cutaneous systemic sclerosis
Calcinosis cutis
Raynaud’s phenomenon-> Tx: CCB, prostacyclin
Esophageal motility disorder
Sclerodactyly (claw hand)
Telangiectasia
PE: rat bite necrosis-> small painful ulcerations at the fingertips
Dx:
+ANA w/ anti-centromere ab: limited/CREST dz
+anti-scl-70 ab (anti-topoisomerase ab): diffuse dz & multiple organ involvement
Tx:
DMARDs
Corticosteroids
