q bank Flashcards
signs of lumbar spinal stenosis
- usually over 60yo
- back pain that radiates to butt and thighs
- may have numbness and parasthesias
- worse during walking and lumbar extension, but flexion alleviates
- pedal pulses are noral, as perfusion not affected
how to diagnose lumbar spinal stenosis
MRI
signs of lumbar disc herniation
- acute onset back pain with or without radiation down one leg
- pts usually recall an inciting event
- as with stenosis, pain may be radiating and be associating with neurologic symptoms
- however, in herniation, lumbar flexion and sitting will make pain worse
signs of fibromyalgia
- young to middle aged women
- widespread pain, fatigue, and cognitive/mood changes
- fairly nl PE except for point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochdonral junction, and greater trochanter
mgmt of fibromyalgia
- exercise
- good sleep hygiene
- medications (eg: duloxetine, TCAs) reserved for pts who fail initial measures
adhesive capsulitis: cause and signs
aka frozen shoulder syndrome
- glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis and contracture of the joint capsule
- can be idiopathic or secondary to uderlying conditions such as rotator cuff tendinopathy (most common), subacromial bursitis, paralytic stroke, DM, or humeral head fracture
- shoulder stiffness out of proportion to pain
- reduction of passive + active ROM
rotator cuff impingement or tendinopathy vs rotator cuff tear
impingement:
- pain with abduction and external rotation
- subacromial tenderness
- nl ROM w/ positive impingement tests (Neer, Hawkins)
tear:
- similar to above, but weakness with external rotation
- age >40
biceps tendinopathy/rupture
- anterior shoulder pain
- pain w/ lifting, carrying, or overhead reaching
- weakness less common
glenohumeral oosteoarthritis
- uncommon and usually caused by trauma
- gradual onset of anterior or deep shoulder pain
- decreased active and passive abduction and external rotation
clinical symptoms of SLE
- constitutional: fever, fatigue and weight loss
- symmetric, migratory arthritis
- skin: butterfly rash and photosensitivity
- serositis: pleurisy, pericarditis and peritonitis
- thromboembolic events (due to vasculitis and antiphospholipid antibodies)
- neurologic: cognitive dysfunction and seizures
SLE labs
- heemolytic anemia, thrombocytopenia, and leukopenia
- hypocomplementemia (C3 and C4)
- anti-ANA (sensitive)
- anti-dsDNA and anti-SM (specific)
- renal involvement: proteinuria and elevated Cr
uses and SE of cyclophosphemide
- immunosuppressant used in SLE, vasculitis and certain cancers
- hemorrhagic cystitis, bladder carcinoma, sterility and myelosuppression
to help avoid SEs: fluids, frequent voiding, and taking MESNA
subacrominal bursitis
- result of repetitive overhead motions
- pain with active ROM of the shoulder
- pain w/ passive internal rotation and forward flexion at the shoulder
cause of isolated high alk phos
- most likely Paget’s disease of bone
Paget’s disease of bone: pathophysiology
- bone lesions are the result of defective osteoid formation at sites of high bone turnover resulting in hypertrophy of bonee
- most commonly affected bones: skull, clavicles, pelvis and lone bones
complications of Paget’s disease
- pathologic fractures
- pain
- osteosarcoma
- neurologic symptoms
signs of ankylosing spondylitis
- men age 20-30, HLA-B27
- progressive back pain and morning stiffness for more than 3 months
- extraarticular signs: anterior uveitis (monocular pain, blurring, and photophobia)
- signs: reduced ROM in lower back and sacroiliac tenderness
to confirm: film w/ sacroilitis
antibodies for rheumatoid arthritis
- Rh factor
- anti-cyclic citrullinated peptide (anti-CCP)
meaning of seronegative spondyloarthropathies
- test negative for Rh and anti-CCP
glutamic acid decarboxylase antibodies
- seen in 70% of type 1 diabetics
synovial fluid in gout
- leukocytosis (50% neutrophils)
- monosodium urate crystals, needle shaped and negatively birefringement under polarizing microscopy (blue)
synovial fluid in pseudogout
(calcium pyrophosphate dihydrate depsition)
- calcium pyrophosphate crystals: smaller, rhomboid-shaped, weakly positively birefringent
common arthritis seen with hypothyroidism
- bilateral carpal tunnel syndrome (compression of the median nerve)
- thought to be due to protein complex deposition within the perineurium and endoneurium of the median nerve
mechanism of kidney damage in SLE
- immune complex mediated, they are deposited in renal glomeruli causing damage through ways such as complement activation (that
s why serum C3 is decreased in SLE kidney disease and post-step glomerulonephritis)
typical cause of ACL injury
- rapid deceleration or direction changes
- pivoting on lower extremity with foot planted
symptoms of ACL injury
- pan: rapid onset, may be severe
- popping sensation at time of injury
- significant swelling (effusion/hemarthrosis)
- joint instability
Pe and dx of ACL injury
PE: anterior laxity of tibia relative to femur (anterior drawer test)
dx: MRI
etiologies of vertebral compression fracture
- trauma
- osteoporosis, osteomalacia
- infection (eg: osteomyelitis)
- bone metastases
- metabolic (eg: hyperparathyroidism)
- paget disease
signs of vertebral compression fracture
chronic:
- painless
- progressive kyphosis
- loss of stature
acute:
- low back pain and decreased spinal mobility
- pain increasing with standing, walking, lying on back
- tenderness at affected level
effect of thiazides on uric acid
- hyperuricemic effect resulting from hypovolemia-associated enhancement of uric acid reabsorption in the proximal tubule
tophi
- in chronic gout, urate crystals may deposit in the soft tissues forming tumors called tophi
cause of Whipple’s disease
- infection w/ gram + bacillus T. whippelii
signs of Whipple’s disease
- chronic malabsoprtive diarrhea (steatorrhea, flatulence, abdominal distention) with protein-losing enteropathy, weight loss
- migratory non-deforming arthritis
- LAD
- low-grade fever
diagnosis of Whipple’s disease
- small intestinal biopsy and PCR showing PAS+ macrophages in the lamina propria containing non-acid fast gram + bacilli
signs of psoriatic arthritis: arthritis
- DIP joints
- asymmetric oligoarthritis
- symmetric polyarthritis, similar to RA
- arthritis mutilans (deforming and destructive arthritis)
- spondylarthritides (sacroilitis and spondylitis)
signs of psoriatic arthritis: soft tissue and nails
- enthesitis (inflammation at tendon insertion site to bone)
- dactylitis (‘sausage digits’) of toe or finger
- nail pitting and oncholysis
- swelling of the hands or feet with pitting edema
signs of psoriatic arthritis: skin
- arthritis preceds skin disease in 15% of patients
- skin lesions are present but no yet diagnosed in 15% of patients
symptoms of rheumatoid arthritis
- insidious onset, multiple joint pain, stiffness and swelling
- morning stiffness lasting hours, improves with activity
- small joints (eg: PIP, MCP, MTP) commonly involved
- monoarthritis (eg: knees, elbows) can also occur later
- spares the DIp joint, unlike osteoarthritis
signs of rheumatoid arthritis
- affected joints are tender to the touch, swollen, with limited range of motion
- tenosynovitis of the palms ‘trigger finger’
- rheumatoid nodules (esp on elbows)
- cervical joint involvement can lead to spine subluxation –> spinal cord compression
labs and imaging for rheumatoid arthritis
- anti-CCP (diagnostic testing)
- high IgM rheumatoid factor
- CRP and ESR correlate with disease activity
- X-Ray: soft-tissue swelling, joint space narrowing and bony erosions
complications of rheumatoid arthritis and mgmt
- osteopenia, osteoporosis, and bone fractures (because of increased levels of proinflammatory cytokines, steroids, and lack of physical activity)
- degree of bone loss generally correlates with disease activity
mgmt: exercise, calcium and vitamin D, minimization of steroids, and consideration of biphosphonates
initial treatment for OA
acetominopehn
hydroxychloroquine: use and SE
- effective for SLE patients with isolated skin and joint involvement
- SE: retinopathy, corneal damage (eye exams required every 6 months)
what diseases are associated with HLA-B27?
inflammatory bowel disease (esp UC)
ankylosing spondylitis
- both are therefore associated with the other
- both associated with pANCA as well
signs of systemic sclerosis
- scleroderma (dermal sclerosis with obliteration of skin appendages–hair follicles and sweat glands, and flexion contractures
- raynaud’s
- calcinosis cutis
- hypertension (kidney involvement)
- pulmonary arterial hypertension –> R heart failure
- esophageal and gastric dysmotility –> GERD
antibodies in systemic sclerosis
- anti-ANA
- anti-topoisomerase I
antibodies in primary biliary cirrhosis
- antimitochondrial antibodies
antibodies present in granulomatosis with polyangiitis (wegener’s)
- ANCA
antibodies in autoimmune hepatitis
- anti-smooth muscle
what diseases can have a positive Rh factor
- RA
- SLE
- Sjogren syndrome
- dermatomyositis
- HCV
signs of polymyositis
- progressive proximal weakness of the lower extremities (difficulty with stairs or rising from a seated position)
- then, proximal arm weakness (difficulty combing hair, working with hands overhead)
- may also have dysphagia due to involvement of striated muscles of upper pharynx
- weakness»_space; pain, tenderness
how to diagnose polymyositis
- muscle biopsy: mononuclear infiltrate surrounding necrotic and regenerating muscle fibers
criteria to diagnose OA
- age >50
- crepitus
- bony enlargement
- bony tenderness
- lack of warmth / morning stiffness
- if more than 3 criteria, specificity for OA is 69%
etiology of lateral epicondylitis
aka tennis elbow
- repeated forceful wrist extension and supination (backhand in tennis, use of a screwdriver)
signs of lateral epicondylitis
- pain with supination or extension of the wrist
- point tenderness just distal to the lateral epicndyle
diagnosis of Behcet’s
- recurrent oral ulcers, plus 2 of the following:
1. recurrent genital ulcers
2. eye lesions (anterior uveitis, posterior uveitis)
3. retinal vascularization
4. skin lesions (erythema nodosu, acneiform ndules, and papulopustular lesions)
5. positive pathergy test
most common cause of acute back pain (and signs)
- lumbosacral strain
- acute onset of back pain after physical exertion
- absence of radiation
- presence of paraveterbral tenderness
- negative straight leg raising test
- normal neuro exam
types of disease modifying antirheumatic drugs
- methotrexate
- leflunomide
- hydroxychloroquine
- sulfasalazine
- TNF inhibitors
types of TNF inhibitors
- adalimumab
- certolizumad
- etanercept
- golimumab
- infliximab
methotrexate: mechanism and side effects
- purine antimetabolite
- GI symptoms, oral ulcers or stomatitis, rash, alopecia, hepatotoxicity, pulmonary toxicity, and bone marrow suppression
- folic acid supplementation reduces SE without loss of efficacy
lefflunomide: mechanism and side effects
- pyrimidine synthesis inhibitor
- hepatotoxicity, cytopenias
hydroxychloroquine: mechanism and side effects
- TNF and IL-1 suppressor
- retinopathy
sulfasalazine: mechanism and side effects
- TNF and IL-1 suppressor
- hepatoptoxicity, stomatitis, hemolytic anemia
side effects of TNF inhibitors
- infection
- demyelination
- congestive heart failure
- malignancy
symptoms of polymyalgia rheumatica
age >50
- bilateral pain and morning stiffness > 1 moonth
- involvement of 2: neck or torso, shoulders or proximal arms, proximal thigh or hip, constitutional (fever, malaise, weight loss)
polymyalgia rheumatica: PE and labs
PE: decreased active ROM in shoulders, neck, hips
labs: ESR >40, sometimes >100, elevated CRP, normocytic anemia possible, around 20% can have nl studies
treatment for polymyalgia rheumatica
- low dose glucocorticosteroids
what disease is associated with polymyalgia rheumatica?
giant cell arteritis
synovial fluid in OA
- less than 2000 WBCml
- no organisms
- no crystals
X ray findings in OA
- joint space narrowing
- osteophytes
- subchondral sclerosis/cysts
when to start RA patients on DMARDs
- ASAP as joint damage begins early in its course
- NSAIDs or glucocorticoids should be used for initial temporary symptomatic relief while awaiting response to DMARD therapy
next steps if RA patient is not responsive to methotrexate
one option:
- step up therapy: add biologic agent (aka: TNF inhibitor)
second:
- parallel therapy: add another nonbiologic (sulfasalazine, hydroxychloroquine)
lumbar stenosis pathophysiology
- degenerative condition where the spinal canal is narrowed, causing compression of one or more of the spinal roots
- often results from:
1. enlarging osteophytes at the facet joints
2. hypertrophy of the ligamentum flavum
what is enthesitis?
- a condition in which inflammation and pain occur at the site of tendon and ligament attachment to bone
- common finding in anklyosing spondylitis
- typical sites of enthesitis include heels, tibial tuberosities, and iliac crests
cause of gout
overproduction or underexcretion of uric acid (byproduct of DNA)
podagra
- acute, monoarticular arthritis affecting the first metatarsophalangeal joint (most common presentation of gout attack)
definitive diagnosis of gout
- joint aspiration: needle-shaped, negatively birefringent urate crystals and a WBC count of 2,000-5,000
drugs for prevention of gout
allopurinol and probenecid
drugs for acute gout attack
colchicine, NSAIDs, and steroids
clinical features of dermatomyositis
- muscle weakness (proximal, symmetric)
- skin findings (Goltron’s papules, heliotrope rash)
- interstitial lung disease
- dysphagia
- myocarditis
diagnosis of dermatomyositis
- increased CPK, aldolase, LDH
- anti-RNP, anti-Jo1, anti-Mi2
- when unsure: EMG, biopsy (skin/muscle)
mgmt of dermatomyositis
- high dose glucocorticoids + glucocorticoid sparing agent
- screening for malignancy
what is associated with dermatomyositis?
- internal malignancy (over 15%)
- most common: ovarian, lung, pancreatic, stomach, or colorectal cancers, or non-Hodgkin lymphoma
primary vs secondary Raynaud’s phenomenon
primary: no underlying cause
secondary: connective tissue diseases, occlusive vascular conditions, sympathomimetic drugs, vibrating tools, hyperviscosity syndromes, nicotine
treatment of raynoud’s
- calcium channel blockers (eg: nifedpine, amlodipine)
how to diagnose anklyosing sponylitis
plain Xray with fused sacoiliac joints and/or bamboo spine
anserine bursitis
- localized pain over the anteromedial part of the tibial plateau just below the joint line of the knee
- pain is worse at night as pressure from knees while lying on side
- valgus stress test neg ruling out damage to MCL
- X-ray normal
signs of disesminated gonococcal infection
- polyarthralgias
- tenosynovitis
- vesiculopustular skin lesions
what is pseudoclaudication? what causes it?
- posture-dependent pain, such as with lumbar spinal stenosis
- lumbar extension worsens pain (eg: walking downhill), lumbar flexion relieves pain (eg: walking while bent forward)
- lower-extremity numbness and tingling, weakness
- low back pain
(whereas vascular claudication is exertionally dependent)
CREST syndrome
- limited form of systemic sclerosis C = calcinosis (nodules on UE, can drain chalky material) R = raynaud's E = esophageal dysmotility S = sclerodactyly T = telangeictasias
synovial fluid:
- 0-200 WBC
- 200-2,000
- 2,000-5,000
- > 50,000
- normal
- OA
- inflammatory condition
- septic
most readily modifiable RF for OA
- obesity, weight loss decreases joint pain, increases function, and slows progression of disease
pathophysiology of secondary amyloidosis
- complication of a chronic inflammatory condition (eg: chronic infections, inflammatory bowel disease, rhematoid arthritis) resulting in extracellular tissue deposition of fibrils into tissues and organs
signs of secondary amyloidosis
- asymptomatic proteinuria or nephrotic syndrome
- cardiomyopathy with heart failure
- hepatomegaly
- mixed sensory and motor peripheral neuropathy and/or autonomic neuropathy
- visible organ enlargement (eg: macroglossia)
- bleeding diathesis
- waxy thickening, easy bruising of skin
diagnosis and treatment of secondary amyloidosis
- abdominal fat pad aspiration biopsy
- tx underlying condition, colchicine for prevention and tx
neuropathic claudication
- used to describe lumbar stenosis
- exacerbation of leg symptoms while waalking (position and remain while standing still)
signs of sarcoidosis
- systemic illness, most often found incidentally on cxr
- lungs (cough, dyspnea, bilateral hilar adenopathy and reticular opacities)
- fever, weight loss
- skin (erythema nodosum)
- eyes (anterior uveitis)
- joints (arthritis)
cause of avascular necrosis of the femoral head
- compromised blood supply
- chronic corticosteroid therapy, alcoholism, hemoglobinopathies
signs of avascular necrosis of femoral head
progressive hip pain without restriction of motion range and normal radiograph on early stages
RF for septic arthritis
- abnormal joint: OA, RA, prosthetic joint, gout
- age >80
- diabetes
- IV drug abuse, alcoholism
- intra-articular glucocorticoid injections
signs of septic arthritis
- acute monoarthritis: hot, swollen, decreased ROM
- fever
- elevated ESR, CRP
diagnosis of septic arthritis
- blood cultures
- synovial fluid analysis: leukocytosis (>50,000) gram stain, culture
initial treatment of septic arthritis
gram + cocci: vancomycin
gram - rod: third generation cephalosporin
negative microscopy: vanco (+3rd gen cephalosporin if immunocompromised)
