Rheum/Ortho/Derm Flashcards
avascular necrosis
causes - steroids, alcohol, SLE, antiphospholipid syndrome, hemoglobinopathies (sickle cell), infections (osteo, HIV), renal transplant, decompression sickness
px - groin pain on weight bearing (also occurs with rest and at night)
- eventually pain and reduced ROM on hip abduction and internal rotation
XR may be normal (or may see a crescent sign in advanced stage disease)
- MRI is the most sensitive modality - will show boundary between normal and ischemic bone
tx - NSAIDs, reduced weight beraing
SLE
labs - ANA
exacerbation - rash, fever, mucocutaneous ulcers, polyarticular synovitis
gout
gout
- px - … tophi occur in gout only
- acute treatment - indomethacin (NSAID), colchicine, corticosteroids
- ppx for pts with recurrent attacks - allopurinol
pseudogout
- can occur in the setting of surgery or medical illness
- most commonly of the knee but can occur in the ankle and UE joints
- CPPD crystals, chondrocalcinosis on imaging
- tx - intra-articular glucocorticoids, NSAIDs, colchicine
arthritis
septic arthritis - fever, systemic sxs
- nongonoccoal septic arthritis - RFs include underlying joint disease, immune suppression (and intra-articular glucocorticoid injections), IVDA
- tap that joint
- start IV abx (vanc or 3rd gen ceph) and drain joint
- sometimes RA pts will presents without overt signs of infection
- gonococcal septic arthritis - pt will be febrile, primary infection is usually silent
- purulent monoarthritis and/or triad of tenosynovitis, dermaitis, and polyarthralgias
- blood cultures (often neg); synovial fluid analysis; culture/NAAT urethra, cervix, pharynx, rectum
- tx - IV cef; empiric azithro or doxy for concomitant chlamdyia; drain joint
polyarticular arthritis - SLE, RA, parvovirus
- involves synovial immune complex deposition
psoriatic arthritis - occurs in 5-30% of pts who have psoriasis
- DIP involvement, morning stiffness (note DIPs are not involved in RA, classically PCP and PIP)
- will have soft tissue and nail involvement - enthesitis, dactylitis, nail pitting and onycholysis (separation of the nail bed), swelling of hands or feet with pitting edema
- skin lesions
- tx - NSAIDs, methotrexate, anti-TNF agents
reactive arthritis - subacute-chronic
- oligoarthritis (involves knee and SI joints), nongonococcal urethritis, conjunctivitis
- also oral ulcers, enthesitis
- follows acute GI/GU infection
- tx - NSAIDs
back pain
lumbosacral strain is the most common cause - acute onset pain following physical exertion -
local tenderness and contraction of the paraspinal muscles
- tx - NSAIDs and early mobilization (stretching, exercise therapy)
- if pain continues subacutely or chronically - these pts are more likely to have recurrent or persistent pain
compression fracture - local spinal tenderness
AK and MM - chronic back pain
herniated disc/lumbosacral radiculopathy - epidural glucocorticoid injections can be considered 2nd line
When would you image?
red flag features - age >50, hx of cancer, constitutional sxs, nocturnal pain, no response to tx, significant/progressive neuro deficits
xray - osteoporosis/compression fracture, malignancy, AK
MRI - sensory/motor deficits, cauda equina, suspected epidural abscess/infection
radionuclide bone scan or CT - indications for MRI but pt unable to have MRI
carpal tunnel syndrome
risk factors - obesity, pregnancy, DM, hypOthyroid, RA
…severe disease - weakness of thumb motion, atrophy of thenar eminence
dx - clinical, nerve conduction studies (but dont always need these)
tx - wrist splinting, glucocorticoid injection, surgery
- NSAIDs are NOT effective
neuropathic arthropathy (Charcot joint)
diabetes, syphillis, alcoholism
peripheral neuropathy –> decreased propioception –> frequent trauma and joint destruction
sarcoid
young AA px - constitutional sxs
- cough, dyspnea, chest pain
- extrapulm - skin lesions (erthyema nodosum), A/P uveitis, Lofgren syndrome - sometimes erythema nodosum will be the first manifestation
CXR - bilateral hilar adenopathy, pulmonary reticular infiltrates
- concerned about sarcoid - get CXR
lab - hypercalcemia/hypercalciuria - elevated serum ACE level
path - bx will show noncaseating granulomas
Other diseases with erythema nodosum - strep infection, sarcoid, TB, fungal disease, IBD, Behcet disease
- initial work-up for erythema nodosum - CBC, CMP, anti-streptolysin titers, TB test
fibromyalgia
pain, fatigue, and cognitive/mood disturbances
management - pt education, regular aerobic exercise, good sleep hygience
- TCADs are a last resort
- limited evidence for alternative therapies
Takayasu arteritis
RFs - female, asian, age 10-40
sxs - involves branches of the aorta, constitutional, aterio-occlusive sxs in UE
- mononuclear infiltrates and granulomatous inflammation of media
exam - blood pressure discrepancies, pulse deficits, arterial bruits
dx - elevated ESR/CRP, CXR will show aortic dilation and widened mediastinum
- CT/MRI - wall thickening, narrowing of lumen
tx- systemic glucocorticoids
thromboangiitis obliterans (Buerger disease)
men who are heavy smokers - superficial thrombophlebitis and ischemia & gangrene of digits
cryoglobulinemia
type 1 -
- lymphoproliferative or hematologic (MM)
- asx, hyperviscosity (blurry vision), thromobosis (Raynauds), livedo reticularis, purpura
- normal complement
mixed types 2 and 3 - immune complex deposition in vessels –> endothelial injury –> end-organ damage
- chronic HCV/HBV, HIV, SLE
- sxs - fatigue, arthralgias, renal disease (and HTN), pulm (dyspnea, pleurisy), palpable purpura, leukoclastic vasculitis, elevated transaminases
- low C4
tx - address underlying disease, plasmapheresis, immunosuppression (glucocorticoids, rituximab),
antiphospholipid syndrome
antibodies - anticardiolipid antibodies
px - recurrent arterial or venous thrombosis
Whipple disease
multisystem disease
- chronic malabsorptive diarrhea, protein-losing enteropathy, weight loss, migratory non-deforming arthritis, LAD, and low-grade fever
- dx - SI bx will show PAS-pos macrophages (in LP, contain non-acid-fast gram-pos bacilli)
anklyosis spondylitis
inflammatory back pain
- other findings include - arthritis (sacroilitis), reduced chest expansion and spinal mobility, enthesitis, dacytlitis, uveitis
- complications - osteoporosis/fractures, aortic regurg, cauda equina
lab - elevated ESR and CRP, HLA-B27 association
imaging - XR of SI joint (may be negative in early cases –> get MRI)
amyloidosis
Secondary - secondary to chronic inflammatory conditions
- inflammatory arthritis, chronic infections (bronchiectasis, TB, osteomyelitis), IB, malignancy, vasculitis
- pathophys - extracellular deposits
- px - nephrotic syndrome, cardiomyopathy + HF, hepatomegaly, neuropathy, organ enlargment, bleeding diathesis, waxy thickening and easy bruisability of skin
- dx - abdominal fat pad aspiration bx
- tx - tx of underlying condition, colchicine for ppx and tx
polyarteritis nodosa
systemic sxs, livedo reticularis, purpura, kidney disease, abdominal pain, muscle aches/weakness
elevated CRP
Raynauds
Raynauds - cold, emotional stress
secondary Raynauds - due to CT disease, occlusive vascular conidtions, sympathomimetic durgs, vibrating tools, hyperviscosity syndromes, nicotine
- usu M
- tissue injury or digital uclers, abnormal nail fold capillary examination
- management - evaluated and treat underlying disorder, CCB and ASA (for pts at risk for digital ulceration)
systemic sclerosis
progressive tissue fibrosis and vascular dysfunction
- two types - limited cutaneous (prominent vascular manifestations), diffuse cutaneous (prominent internal organ involvement)
- systemic, skin, extremities, GI (decreased esophageal motility), and vascular manifestations
- ANA, anti-topoisomerase (anti-Scl-70), anti-centromere
- complications - lung (ILD, pulm HTN), kidney, heart (myocardial fibrosis, pericarditis, pericardial effusion)
- renal crisis - marked HTN, AKI
- involves coagulation cascade activation - peripheral smear will show microangiopathic hemolytic anemia or DIC with fragmented blood cells
tennis elbow
pain with resisted wrist extension or passive wrist flexion
acne
tx - avoidance of sun exposure
ankle sprain
px - can have ecchymosis around malleolus
tx - use soft protective brace and early ROM exercises
rheumatoid and osteoarthritis
osteoarthritis
- RFs - age, obesity, DM, prior joint injury
- px - Heberden’s nodules (DIP), creptius
- hip osteoarthritis - groin pain
- XR - narrowed joint space, osteophytes, subchondral sclerosis
- tx
- exercise and weight loss
- NSAIDs = diclofenac (note acetaminophen and opioids are less effective)
- topical agents, intra-articular glucocorticoids, intra-articular hyaluronic acid
- surgery, chronic pain management
RA - RF and anti-CCP
- morning stiffness, tenosynovitis of palms (trigger finger), rheumatoid nodules (esp on elbows)
- cervical joint involvement can lead to spine subluxation –> spinal cord compression (neck pain, stiffness, radiculopathy, UMN signs)
- reduced grip strength occasionally occurs - sensitive sign of early disease
- xray
- flares involve multiple joints
Felty syndrome features
- RA - severe erosive joint disease, rheumatoid nodules, vasculitis (necrotizing skin lesions), neutropenia (ANC < 1500), splenomegaly
- dx - anti-CCP and RF are pos in >90% of pts
- get peripheral smear and bone marrow bx to rule out other causes of neutropenia
- improves with tx of underlying RA (with methotrexate)
pyoderma gangrenosum
starts as papule, nodule, vesicle –> expanding ulcer
- 30% of cases are triggered by local trauma
- more than 50% of pts have an underlying systemic disorder - IB, RA, heme conditions
- dx - skin bx
- tx - corticosteroids
peripheral smear findings
Burr cells - spiculated RBCs, seen in liver disease and ESRD
Howell-Jolly bodies - nucleus remant, in pts with no spleen
spur cells - RBCs with irregularly sized and spaced projections, seen in liver disease
reagin-mediated
means IgE mediated
connective tissue disorders
skin rash, joint pains
anabolic steroid/testosterone use
testosterone - ….decreased testicular size and sperm count, hepatic dysfunction, erythrocytosis (secondary to androgen stimulation), decreased HDL levels
- high doses can cause cardiac dysfunction
- tamoxifen - anti-estrogen, can be used to treat gynecomastia
v. s. GH use - hyperglycemia, Na retention, swollen hands, joint and muscle pain
