Rhematology Flashcards
Rheumatology
- Fibromyalgia
- Gout/psuedogout
- Juvenile Rheumatic arthritis
- Osteoporosis
- Polyarteritis nodosa
- Polymyalgia rheumatica
- Polymyositis & dermatomyositis
- Reactive arthritis
- Rheumatoid arthritis
- Sjogren Syndrome
- Systemic Sclerosis (scleroderma)
- Systemic Lupus Erythematous (SLE)
Fibromyalgia
(Female with normal labs & shows 3 months of widespread MSK pain —> give TCA medication)
- chronic disorder of widespread Musculoskeletal pain + somatic symptoms ( fatigue, cognitive disturbance, psychiatric symptoms) —> for few months & other identifiable cause
- women 20-55 years
PE:
- 11 OF 18 defined tender points
Diagnosis:
- clinical diagnosis ( normal lab tests)
Treatment:
- conservative ( exercise program with aerobic conditioning )
- TCA (amitriptyline) or duloxetine
Gout
(Monosodium urate crystal deposition)
( sharp needle shape crystal deposit in the joint lead to severe pain, swelling, effusion)
- condition of hyperuricemia & deposition of (monosodium urate crystals) causing attacks of acute inflammatory arthritis.
Risk factors:
1. Male sex (older men)
2. Diet (purine rich food—> seafood, red meat, alcohol)
—> purine break down into uric acid
3. Medication (PLATE)
- pyrazinamide (for TB)
- ethambutol (For TB)
- loop diuretic ( furosemide)
- Thiazide (hydrochlorothiazide)
- aspirin (low dose)
Symptoms:
1. Severe pain, redness, warmth, swelling
2. Monoarthritis (single joint)
3. Lower-extremity involvement ( Podagra = gout of big toe)
Diagnosis:
1. Arthrocentesis ( negatively birefringent needle shaped crystal = monosodium urate crystal, yellow when parallel)
- X-ray shows sclerotic over-hanged edges (erosive appearance + punched out)
Treatment:
1. Acute —>
- NSAIDs, Steroid, colchicine
- Chronic —>
- allopurinol or feburostat
- probenecid
- colchicine
Note:
- Avoid NSAIDs, if Bad kidney, bad heart, bad GI tract ( renal insufficiency, active duodenal or gastric ulcer, Cardiovascular disease)
- avoid steroid, if diabetic, active infection, post-operation (impaired wound healing) —> can be used in CKD
- Colchicine can be used for acute or chronic treatment, can lead to diarrhea
- allopurinol —> (can lead to SJS, < 10% )
- allopurinol & febuxostat —> are xanthine oxidase inhibitors
- probenecid —> promote renal clearance uric acid secretion (make you pee uric acid)
Pseudogout
( calcium pyrophosphate dihydrate crystal deposition disease, mostly knee, positively birefringent, chonedrocalcinosis, Intraarticular GC injection )
- deposition of calcium pyrophosphate dihydrate in the joint & soft tissue
- knee most common joint affected
Diagnosis:
- arthrocentesis ( positively birefringent calcium pyrophosphate crystal, rod/rhomboid shape, blue when parallel)
- x-ray shows chondrocalcinosis (like a white-line in joint space)
Treatment:
- similar to acute gout treatment ( NSAIDs, steroid, colchicine) but emphasis on first line of Intraarticular Glucocorticoid injection ( when less joints are involved, 1-2 joint
Juvenile idiopathic arthritis
( polyarticular subtype = at least 5 or more joints)
(Oliguarticular subtype = less than 5 joints)
- chronic pediatric inflammatory arthritis + onset before 16 years of age + presence of arthritis for at least 6 weeks
- peak incident between age of 1-5 years (< 16 years old)
—> if after is known as adult onset
Symptoms:
1. Fever (Quotidian pattern) ( persistence for 2 weeks, then everyday spike a fever than return to normal)
2. Arthritis ( at least for 6 weeks)
3. Rash ( salmon-colored rash)
4. Uveitis (only seen with oligo/polyarticular subtypes, & ANA )
Treatment:
1. NSAIDS
Osteoporosis
- metabolic bone disease characterized by deterioration of bone tissue leading to low bone mass & increased skeletal fragility
Risk factors:
1. Advanced age
2. Females
3. Glucocorticoid therapy (long term) ( decrease Ca absorption from GI)
4. Cigarette, alcohol
5. Physical inactivity
6. Celiac, Cushing, diabetes
Symptoms:
1. Silent disease ( no obvious symptoms)
2. Vertebral compression fracture (painless) —> assess of loss of height & kyphosis
3. Hip fracture
4. Distal radius fracture
Diagnosis:
1. DEXA scan (evaluation of bone density via T-score)
1. (-2.5 or less) —> osteoporosis
2. (-2.5 to -1) —> osteopenia
- Fragility fracture test —> fracture occurs with minor trauma ( as fall from standing height)
Treatment:
1. Lifestyle + vitamin D/calcium supplement
2. Bisphosphonate (alendronate, risedronate)
—> (ends with -dronate)
Note:
- bisphosphonate inhibits osteoclastic bone resorption
- adverse drug rxn —>
- lead to pill-induced esophagitis (remain upright at least 30 min, take with 6-8 ounces of water)
- Osteonecrosis of the jaw & atypical femur fracture
Polyarthritis nodusa (PAN)
( screw up arteries & blood supply to organ, does not involve lung or ANCA )
- systemic vasculitis characterized by necrotizing inflammatory lesions that primarily affect medium-sides arteries with occasional involvement of small arteries.
Etiology:
1. Hepatitis B & C
Symptoms:
1. renal disease ( HTN)
2. Dermatology ( purpura, livedo reticularis/ blue-purple discoloration of skin/due to vessel ischemia, ulcers, pigmentation)
3. Neurologic (mononeuropathy multiplex )
4. Tendency to spare the lungs (opposite to granulomatosis with polyangitis —> ANCA positive)
Diagnosis:
- ANCA negative
- CT angiography —> see a lot of aneurysm due to fibrotic changes (weaken vessels)
Treatment:
- glucocorticoid
Polymyalgia Rheumatica (PMR)
( normal muscle strength, involve joint, bursa, tendon)
- chronic inflammatory condition of unknown etiology leading to pain & stiffness in the neck, shoulder, hip
- > 50 years old women (70-80 years)
- associated with Giant Cell Arteritis & aortic aneurysm
—> headache, jaw claudication, transient vision loss
—> lead to blindness if not treated
Symptoms:
1. Aching & stiffness involving the neck, bilateral shoulder, hip, torso —> worse in the morning, or any period of inactivity
Diagnosis:
1. Increase ESR & CPR
Treatment:
1. Low-dose Glucocorticoid ( response well to treatment !!!!)
Laboratory findings
- Rheumatoid factor & anti- CCP —> Rheumatoid arthritis
- Creatinine Kinase (muscle enzyme) —> polymyositis
- ESR & CRP (increase) —> polymyalgia rheumatica
- Anti-Cardiolipin antibody—> in anti-phospholipid syndrome ( arterial/venous thromboembolism + miscarriage )
- Anti-mitochondrial antibody —> primary biliary cholangitis (PBC) ( fatigue + pruritus + RUQ pain + high ALP)
- Anti-neutrophil cytoplasmic antibody (ANCA)—> granulomatosis with polyangiitis
- Anti-smooth muscle antibody —> autoimmune hepatitis ( asymptomatic elevation of aminotransferase to hepatosplenomegaly +cirrhosis + liver failure)
Polymyositis & dermatomyositis
(Idiopathic inflammatory myopathy)
(dermatomyositis is polymyositis with rash)
- common in female
Symptoms:
1. Muscle weakness (proximal, progressive, symmetric)
—> difficulty climbing stairs, raising arms above head..
- Dermatomyositis:
- Gottron papules (psoriasis in dorsum of hand)
- Heliotrope rash (rash on around eyes)
- Photodistributed poikiloderma (shawl sign or V-sign)
(pigmentation in sun exposed area) (upper back/neck/chest) - Can lead to adenocarcinoma (malignancy)
Diagnosis:
1. Elevated muscle enzyme ( Creatine kinase & aldolase)
2. Myositis-specific antibodies ( anti-Jo-1, & anti-Mi 2)
—> anti-Mi-2 is highly specific for dermatomyositis
3. Biopsy to confirm if needed
Treatment:
- glucocorticoid (prednisolone) ( 9-12 months)
- glucocorticoid-sparing agent (methotrexate) to minimize the side effect of glucocorticoid
Reactive arthritis
- starts after infection of GI, or genital urinary
1. GI: salmonella, shigella, Campylobacter, C.diff
2. Genital: chlamydia
Symptoms: (can’t PEE, can’t SEE, can’t CLIMB the tree)
1. Peripheral arthritis (asymmetric, oligarthritis of lower extremities/knee)
2. Ocular symptoms (conjunctivitis, uveitis)
3. Genitourinary symptoms (urethritis)
Diagnosis:
- clinical diagnosis
- arterocentesis to rule out septic arthritis
- HLA-B27
Treatment:
- Treat underlying cause infection
- NSAIDs ( for arthritis)
Rheumatoid arthritis (RA)
(Cytokines allow pannus to grow bigger in the synovial space & break stuff inside joint)
- chronic, systemic, inflammatory, autoimmune disease of unknown etiology that can lead to the destruction & deformity of joint due to erosion of cartilage & bone
- female
Symptoms ( 7 S)
1. Symmetric (joint involvement)
2. Swollen (tender & warm)
3. Soft (boggy joint)
4. Small (joint of hand, feet, wrist)
5. Spares the DIP ( the last knuckle) (osteoarthritis involves DIP)
6. Sixty min of more ( morning stiffness for extended period of time) (osteoarthritis morning stiffness lasts for minutes)
7. Swan neck deformity (DIP flex, PIP hyperextend)
Diagnosis:
1. Positive Rheumatoid factor (not specific)
2. Positive Anti-CCP (specific for RA) (anti-cirullinated peptide)
Treatment:
1. NSAIDs ( treat inflammation & pain)
2. Methotrexate (DMARDS) ( reduce the irreversible joint damage) —>
Note:
1. Rheumatoid factor can also be positive in hepatitis C & SLE
2. Seronegative RA (when anti-CCP & rheumatoid factor are negative) —> FAVORABLE PROGNOSIS
- Methotrexate side effect:
- hepatotoxicity: measure LFT before initiating drug
- oral ulceration:
- macrocytic anemia: due to folate depletion & impaired DNA synthesis - better combine folic acid with methotrexate for better use
Sjogren syndrome
(Anti-Ro & anti-La) ( dry eyes, dry mouth & parotid swelling)
- systemic autoimmune disease characterized by lymphocytes (T/B cells) infiltration of exocrine glands (lacrimal & salivary).
Symptoms:
1. Dry eyes
2. Dry mouth
3. Parotid gland swelling
Diagnosis:
1. Positive ANA
2. Anti-Ro (SSA) & anti- La (SSB)
3. Schirmer test (put paper in eye and see how much it gets wet)
4. Biopsy ( if needed)
Treatment:
1. Muscurinic agonist (pilocarpine, cevimeline)
Avoid use of atropine & atrovin because they cause dryness
Systemic sclerosis (scleroderma)
(Too much collagen leads to fibrosis)
- systemic connective tissue disease, where excessive collagen deposition leads to progressive fibrosis of the skin & internal organs. (Reduce blood flow & result in ischemic damage)
- female
Types:
1. Limited cutaneous systemic sclerosis ( CREST Syndrome)
- distal limbs & spares the trunk
- calcinosis cutis + Raynaud phenomena + esophageal dysmotility + sclerodactyly (claw hand) + telangiectasia
- Diffused cutaneous systemic sclerosis
- proximal limbs, trunk & organ involvement (heart, lung, kidney)
Diagnosis:
1. Anti- Centromere antibody ( associated with limited disease)
2. Anti-topoisomerase 1 (anti-SCL-70) antibody ( associated with diffused disease)
Treatment:
1. Treat symptoms of Crest signs
2. Treat sclerodermal renal crisis ( acute HTN + AKI) with ACE-i (captopril)
3. Treat Raynaud phenomenon with CCB (amlodipine)
Systemic lupus erythematosis (SLE)
( treat with hydroxychloroquine)
- multi-systemic immune-mediated disorder characterized by autoantibodies to Nuclear & Cytoplasmic antigens.
- type 3 hypersensitivity reaction
- common in younger female
- African American female
Symptoms: (MD CHART)
1. Systemic symptoms: Fever, fatigue, weight loss
2. Malar rash ( spares nasolabial fold) (butterfly rash)
3. Symptoms occur with Photosensitivity ( after sun exposure)
4. Discoid lesion ( round erythematous patches)
5. Arthritis (similar to RA in erosion, but morning stiffness is 10-15 min —> similar to osteoarthritis in length)
6. Cardiovascular
7. Renal
8. Thromboembolic disease ( with anti-phospholipid )
9. Hematologic abnormality ( anemia, thrombocytopenia, leukopenia)
10. Low- complement protein
Diagnosis:
1. Screen first with ANA (anti-nuclear antibodies)
2. Anti-dsDNA
3. Anti-smith antibody
4. Anti-phospholipid antibody (high risk for arterial/venous thrombosis & miscarriages)
Treatment:
1. Hydroxychloroquine —> perform eye examination periodically (retinal toxicity with prolonged use )
Felty syndrome
- rheumatoid arthritis
- neutropenia ( low wbc) ( risk of increase infection)
- splenomegaly
—> anti-CCP & rherumatoid arthritis are positive
—> increase ESR
Diffuse proliferative glomerulonephritis seen in SLE patient
- treat with:
1. Cyclophosphamide & stop hydroxychloroquine
—> this new regimen increases the risk for developing bladder carcinoma & hemorrhagic cystitis
Drug adverse effect
- Bisphosphonate (-dronate) —> esophagitis
- Hydroxychloroquine —> retinal toxicity
- Cyclophosphamide —> bladder carcinoma & hemorrhagic cystitis
Cryoglobulinemia
(Immunoglobulin that precipitate at < 37 degree)
Mixed cryoglobulinemia syndrome (MCS)
—> Small vessel vasculitis
—> causes:
1. Palpable purpura
2. Glomerulonephritis (hematuria & proteinuria)
3. Arthralgia ( joint pain)
4. Peripheral neuropathy
—> laboratory:
1. Cryoglobulin
2. Rheumatoid factor
3. Low complement protein
4. Positive ANA
—> chronic hepatitis C is the most common cause
—> associated disease: SLE, sjogren
Drug-induced SLE
- associated with: anti-histone
- drugs:
1. Hydralazine ( treat HTN)
2. procainamide (Treat irregular heart rhythm)
3. Isoniazid ( treat TB)
—> lead to new onset of fever, arthralgia, & serositis (inflammation of serous surrounding organ) after initiation of causative medication
Takayasu arteritis
(Large-artery vasculitis)
- Female + asian + age (10-40)
- Symptoms:
- constitutional symptoms ( fatigue, fever, weight loss)
- arterioocclusion (claudication, ulcer) in upper extremity
- arthralgia/myalgia - Signs:
- blood pressure differences (in both arms)
- absent pulses
- arterial bruits
Diagnosis:
- increase ESR & CRP
- x-ray: widen mediastinum
- CT angiography: wall-thickening
Treatment:
1. Glucocorticoid
Psoriatic arthritis
- symptoms:
1. Involves DIP
2. Nail involvement
3. Deformity
4. Dactylitis ( sausage digit )
5. Morning stiffness
6. History of psoriasis - treatment: NSAIDs, methotrexate, & anti-tumor necrosis factor agent
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Vasculitis
- Small vessel: takayasu arteritis
- Small/medium: glumerulosis with polyangiitis
- Medium: polyartheritis nodosum (PAN)
Dry eyes + dry mouth + parotid gland swelling
- In younger people —-> sjogren syndrome (autoimmune destruction of the exocrine gland)
- In older patient —> age-related sicca syndrome ( age-related exocrine gland atrophy)
Sarcoidosis
- treated with glucocorticoid
- hilar LAD + hypercalcemia
- Erythema nodosum on pretibial of leg
- do chest x-ray
African america (associated conditions)
- sarcoidosis
- sickle cell disease
- SLE
Methotrexate
- anti-folate immunosuppressant
- used for RA
Acute mono-arthritis with chonedrocalcinosis ( calcium pyrophosphate dihydrate crystal deposit in joint )
—> associated with pseudogout
—> patient should be assessed for secondary causes:
- Hyperparathyroidism
- Hypothyroidism
- Hemochromatosis ( recent diagnosis of diabetes + hepatomegaly) —> induce- iron deposition & genetic analysis shows HFE mutation
Rheumatoid arthritis can cause exudative pleural effusion & associated with interstitial lung disease
Characterized by:
- low glucose
- high LDH
- low pH
Major complication of systemic sclerosis (sclerodermal)
- pulmonary HTN ( extertional dyspnea + right-sided heart signs)
- low DLCO, normal FEV1, normal FVC, normal FEV1/FVC
—-> Lead to lumen narrowing of pulmonary arteries - Interstitial lung disease ( restrictive lung disease) —> common with diffused cutaneous systemic sclerosis
Mixed connective tissue disease ( SLE + polymyositis + scleroderma)
- detected by —> anti-U1 ribonucleoprotein
Symptoms:
1. Arthritis / Hand swelling
2. Raynaud phenomena
3. Myopathy
Heridetary hematochromatosis (HH)
- often resembles osteoarthritis, differ at age of onset (< 40)
Symptoms:
- chondrocalcinosis
- MCP involvement
- iron overload
- diabetes + hepatomegaly ( elevated ALT & AST)
—> Treat with phlebotomy
Rheumatoid arthritis can lead to osteopenia, osteoporosis, bone fracture
- lead to generalized loss of bones
Inflammatory bowel disease (IBD)
(EN, PSC, Arthritis )
Lead to:
1. Erythema nodosum
- Primary sclerosing cholangitis (via UC)
- Inflammatory arthritis (elevated CRP) (involves axial/peripheral joints) —> treatment with NSAIDs exacerbate underlying IBD
Rheumatoid arthritis vs. psoriatic arthritis vs. osteoarthritis
RA:
- small joint
- spare DIP
- PIP, MCP, wrist
- prolonged morning stiffness
Psoriatic arthritis
- larger joint
- involves DIP
- prolonged morning stiffness
- pitting nail
Osteoarthritis
- larger joint
- involve DIP
- transient morning stiffness
Bechet disease
( oral & genital ulcers + skin & eye involvement)
- young adult
- turkish, middle eastern , asian
Symptoms:
1. Recurrent, painful oral ulcer
2. Genital ulcer
3. Eye lesion
4. Skin lesion ( erythema nodosum)
5. Thrombosis ( lead to morbidity(
Evaluation
1. Exaggerated skin ulceration with minor trauma (needle stick)
Chronic taphaceous gout
—> persistent hyperuricemia in gout lead to taphaceous gout ( lead to nodular formation)
- urate crystal deposit in the skin
- result in formation of tumor with chalky white appearance
- seen in the joint of the hand/feet ( TOPHI)
Triggers of gout
- usually a monoarticular arthritis that quickly progress to maximum intensity within 12-24 hours of trigger
Triggers:
1. Alcohol use
2. Surgery/trauma
3. Dehydration
4. Medication (diuretics) (PLATE)
5. Myeloproliferative disorders
Ankylosing spondylitis (AS)
- Chronic inflammatory back pain & stiffness
- Lumbosacral tenderness
- Reduced spinal range of motion
- Use x-ray to show sacroiliitis
- Associated with HLB27
Osteoarthritis
( age > 40 + progressive pain relieved by rest & worst with activity) ( felt at groin, buttock ,lateral hip —> radiate to lower thigh or knee) ( joints are not tender & no systemic symptoms)
- Associated with: obesity, old age, previous joint injury
- Lead to: bony enlargement + tenderness + crepitus with movement + painful & decrease range of motion + chronic joint pain that is worse after activity (at the end of the day)
- X-ray: narrow joint space + osteophytes + subchondral sclerosis/cysts
Septic arthritis
( fever + arthritis/limited range of motion + antibiotics/drainage)
- acute monoarticular arthritis + restricted range of motion + fever + previous joint disease (RA…)
- Perform synovial fluid analysis
- Treatment: antibiotics + drainage
Disseminated gonococcal infection
- purulent monoarthritis (of wrist)
- sexually transmitted infection ( multiple sexual partner)
- detection of Neisseria gonorrhea in urine, cervical or urethral sample
- diagnosis: NAAT
- treat: ceftriaxone (IV)
Adolescent idiopathic scoliosis
(Lateral curvature of the spine)
- Female, < 12 years
- Asymmetric scapula, asymmetric shoulder, thoracic/lumbar prominence on forward bend
- Cobb angle ( degree of curvature) > 10 confirms sclerosis
- Early pubertal status ( premenarchal)
Paget disease of bone
(Take NSAID without relief) ( hat don’t fit anymore) ( thickened bone)
( normal Ca & Po4) ( high ALP & urine hydroxyproline)
- older male + smoker
Symptoms:
1. Headache + hearing loss + vertigo
2. Spinal stenosis + radiculopathy
3. Bowing + fracture + arthritis
4. Giant cell tumor + osteosarcoma
5. Hat does not fit anymore (big head size)
Prognosis:
1. Osteoclast dysfunction
2. Increase bone turnover
Laboratory:
1. Elevated ALP
2. Elevated PINP & urine hydroxyproline ( bone turnover markers)
3. Calcium & phosphorus are normal
Imaging:
1. X-ray: osteolytic or mixed lytic/sclerosis lesion
2.. bone scan: focal increase in radiotracer uptake
Treatment:
1. Bisphosphonate
Seronegative spondyloarthropathies ( ankylosing spondylitis)
- men, age (15 -35 years)
- elevated ESR & CRP
- Back pain worse with rest & better with activity
Lumbosacral strain
- most common cause of acute back pain
- triggered by twisting, lifting, or physical exertion
- pain is localized at the lumbar paraspinal area —> may radiate to buttock, hip, thigh
- normal Straight-leg raising test
- normal neurologic examination
Vertebral compression fracture
- associated with osteoporosis
- caused by minor trauma ( lifting, coughing/sneezing, bending)
- localized midline/spinal tenderness
- normal neurological examination
Lumbar spinal stenosis. ( caused by osteoarthritis of spine)
(Low back & leg pain)
(Vascular claudication —> resolve with standing)
( neurogenic claudication —> persist with standing)
- common cause of back pain in patient > 60
- back pain radiates to the thigh + worse with walking or prolonged standing ( lumbar extension)
- vascular claudication is exertion-dependent & resolves with standing still
- neurogenic claudication is position dependent (exacerbated by lumbar extension) & persist even with standing still
Hammer & claw toe deformities
( reflect imbalance between strength of flexors & extensor muscles of the toe)
- Seen with diabetic peripheral neuropathy
- Hammer toe: DIP dorsal flexion, PIP planter flexion, MTP dorsal flexion
- Claw toe: DIP planter flexion, PIP planter flexion, MTP dorsal flexion
- Others —> callusing (thickening of skin), ulceration, joint subluxation (dislocation) & charcot arthropathy (loss of sensation in foot & ankle)
Avascular necrosis (osteonecrosis)
Symptoms:
1. Groin/thigh/buttock pain on weight bearing & worse with activity
2. Pain on hip abduction & internal rotation
3. No erythema, swelling, or point tenderness
Laboratory:
1. Normal WBC
2. Normal ESR & CRP
Imaging:
1. MRI —> can show crescent sign (advanced stage)
Caused by:
1. SLE
2. Sickle cell disease
3. Steroid use
4. Alcohol use
5. Decompression sickness
6. Anti-phospholipid syndrome
7. Infection ( HIV, osteomyelitis)
8. Renal transplant
Fat embolism syndrome
- Fracture of bone (containing alot of marrow) —> can release fat into venous circulation
- Diagnosis based on clinical signs ( respiratory distress, neurologic dysfunction, petechial rash)
- Management is supportive ( supplemental oxygen)
Injury of the foot & ankle
(Stress fracture, plantar fasciitis, Achilles tendenopathy, morton neuroma, tarsal tunnel syndrome)
- Stress fracture
- insidious onset
- focal pain in navicular or metatarsal
- risk factor: abrupt increase in intensity of training, poor running mechanism, female with eating disorder - Plantar fasciitis
- plantar surface of the heel
- worse when initiating running or first step of the day - Achilles tendinopathy
- burning pain or stiffness 2-6 cm above the posterior calcaneus - Morton Neuroma
- numbness or pain between the 3rd & 4th toes
-clicking sensation when palpating space between the 3rd & 4th toes, while squeezing the metatarsal joint (Mulder sign) - Tarsal tunnel syndrome
- compression of tibial nerve at the ankle
- burning, numbness & aching of the distal plantar surface of the foot/toes
Other causes of osteoporosis ( bone loss)
( malabsorption, hyperthyroidism, hyperparathyroidism, hypercortisolism, Rheumatoid arthritis, hypogonadism, multiple myeloma)
- Malabsorption
- diarrhea + weight loss
- low 25-hydroxyvitamin D, low urine Ca excretion - Hyperthyroidism:
- weight loss + heat intolerance + tremor
- Goiter - Hypercortisolism
- central obesity + cushingoid habitus
- hyperglycemia - Hyperparathyroidism:
- hypercalcemia + hypercalciuria
- kidney stone - Inflammatory disorder ( rheumatoid arthritis)
- joint pain + morning stiffness
- high ESR & CRP - Hypogonadism
- female: amenorrhea + weight loss + anorexia
- male: low libido + erectile dysfunction + loss of body hair - Multiple myeloma
- anemia
- hypercalcemia + high creatinine
Chronic DIC
- Associated with cancer (pancreatic cancer)
1. Signs of venous/arterial thrombosis + mucocutanoues bleeding
