Rheumatology Flashcards
Osteoarthritis
DIP(heberden’s), PIP (bouchard’s)
Rheumatoid arthritis
PIP, MCP
Psoriasis
DIP
Scleroderma
PIP, MCP
Heartburn + dysphasia + thickened skin=
scleroderma
Poor prognositc factors for Rheum Arthritis
Progressive synovitis
Joit space loss/erosiions
Inc Rh factor >1:80
Inc ESR
70yo F early morning stiffness >45min & symmetric small joint pain in 2nd-4th MCP and 2-5th MCP and PIP in L hand - jnt pain in R knee for 6 wks and ESR 48 - swelling of MCP and PIP RH neg wtd?
Start tx
Anti-CCP +
Antlanto odontoid subluxation
compress vertibrobasilar artery-> lightheadedness, sncope
screen for subluxation with lat xray before anesthesia
Compress cord - snsory motor quadriplegia
8mm asyx - surgical correction
Sx any size sx corretion
Pt with rheum arthritis can present with what?
carpel tunnel tarsal tunnel
Extra articular manifestations of RA
spill over of active disease from synovium
Rheumatoid nodules (inc’d RH factor (- in 15%))
Vasculitis/DR4
RF leaves joint thru capillaries-> inflamm, ulcers
Heart
Effusion
Constrictive pericarditis
Myocarditis
Lung
Rheum nodules (Caplan’s syndrome)
Pleural effusion (low glucose, high LDH, exudative)
BO
Interstitial fibrosis
Hypersenitive pneumonitis (methotrexate)
Blood anemia of inflammation
Vasculitis - nexrosis ulceration at tip of fingers
Nerve - Mononeuritis multiplex->foot/hand drop
Skin - rheumatoid nodules (commonest extra artiuular manifestation - RH factor inc’d - AgAb complex depostion)
Renal - usually lsate stage with amyloid nephropathy
Drug induced NSAID, Peniclliamine, nephrotic syndorme
Eye - scleritis - deeper - r/o globe rupture
episleritis - superficial both autoimmune
Fx vs sprain
4 steps without sx
HCV with mixed cryoglobuinemia
vasulitis and LE ulcers
Tx for RA
Mild - NSAIDS+- hydroxychoroquine (need yearly retinal exam)/sulfasalazine(reactive arthritsi)/Minocycle (leading cause drug induced lupus and hepatitis)
Mod to severe - Add methotrexate(25mg/wk, check folate level) +- low dose steroid+- Leflunomide
Severe Add etanercept (check PPD)/infliximab/adalimumab or anakinra (IL inhib)
Abatacept, Rituximab, Tocilizumab
Egg shell Ca+
siliciosis
Salmon pink rash
still’s dz/inc’d ferritin
Schools of fish or boxcar
chance - haemaphilis ducre
Tx: azithro orceftriaxone
Methotrexate contraindicated in?
Pt on bactrim, Hep B/C, Etoh liver dz
Macular degeneration
lose central vision
Reflexes
L5 lesion - no dorsiflex, no evert, no invert
Peroneal lesion - No dorsiflex, no evert, +invert
45yo p/w joint tiffness>1hr in AM, pain in MCP, PIP and pain while climbing stairs x 6wks Rh+, on tylenol no rlief - started on naproxen no relief Rh still high wtd?
Add methotrexate
Fastest acting DMARD (Disease modifying anti rheum drug) is?
Methotrexate
Which drug decreases mortality in RA
Methotrexate
Floppy iris syndrome
d/c tamsulosin before cataract surgery
What is preictor for CVS dz in Rheumatoid arthritis
Inc’d homocysteine levels
Pt with rheumatoid arthritis on NSAIDs with persistent synovitis, methotreaxate was added and pain improved, 3 months later pt p/w fatigue, Hg low, MCV high best tx would be?
folic acid def (from methotrexate use) - tx with folic acid
S/e NSAIDs
nephrotic syndrome, PUD, int nephritis
S/e hydroxychloroquine
Macular damage loss of accommodation
S/E Methotrexate
Heptox, hyper Pneum, athous ulcer
S/E Lefluonmide
Teratogenic
s/e Corticosteroid
Osteoporoiss, HTN, cataract, avasc necrosis
s/e Infliximab
ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+
s/e Etanercept
ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+) ANA, ANti DNA+, flue like sx
s/e Cyclosporin
ATN, renal insuff, hirsuitism, HTN
Catarct sx?
glare outside lights
Pt with Rhuem Arth p/w sudden onsest pain behind knee an calkf - US neg for DVT? wtd?
ruptured baker cyst - intraarticular steroid
Pt with h/o RA for long time udergoes elective surgery with gen anesthesia - post op is quadriplegic - etio?
Atlanto-odontoid subluxatio C1-C2
Pt with long standing Rh wit oarseness of voice for weeks dx?
Crico arytenoid joint involvement
65yo RA >30yr p/w paraesthesia in hands b/l carpel tunnel release little change - also with occ dizzy spells - pas histor total knee arthor with seree joint def - dec powerand hyperactive reflexes - pt going for hip replacemet wtd?
Xray neck r/o sublux
Pt with RA on methotrex x 1 yr p/w pain and swelling knee joing, fever with inc WBC wtd?
tap joint r/o septic arthritis (all before thinking about steroids)
Tap with turbid exudate labs P
start IV abx
Pt with long standign RA on NSAIDs steroids and MTX p/w cough, tx’d with abs - 4 weeks later progressive SOB no fever - b/l crackes, CXR infiltrates - etio?
MTX induced, interstitial fibrosis, bronchioe obliterhaeran
NOT CMV Pneumonitis
Pt with RA on hydroxychlorquin wtd?
baseline retinal exam and yearly
Leading cuase of death in RA
Heart disease
Pt tx’d with steroids for temproatl arteritis or Polymyalgia Rheumatica or SLE - couple month later steroids tapered fo with improvement of sx - pt returns with b/l symm joint pain and early morning stiffness with MCP, PIP no h/a or shoulder pain - exame with +nodule on L olecranon dx?
Rheum arthritis
Pt on MTX for Rheum Arthritis - what do you follow in term so labs
CBC, Cr, AST q2-4 w, x 3 the 8-12 then q12
Pt with Rh Arthritis with minimal response to MTX wtd?
check PPD, if neg start TNF alpha If 5mm - start INH & pyridoxine Pneumococcal and influenza vacc prior to DMART no varicella, no yellow fever, no MMR don't give DMARD with active infxn
35yo p/w recurrent pain starting in PIP then MCP then knee - few hours later joint swelling - pain resoves in few hours in backwards order - dx?
Pallindromic rheumatism - 1/2 will go on to RA
tx: DMARDs
Pt with RA and necrotic ulceration of finger tips and foot drop dx?
Rheumatic Vasculitis - circulating Ag-Ab (RF) complex blocks small arteries
recurrent skin/lung infxn, +skin ulcers dx?
Felty’s syndrome -
Tx
DMARDs, steroids, G-SF-> splenectomy
32yo F polyarthritis and fever, sore throate several weeks ago - salkmon colored rash on trunk - throat ctx neg, ESR elev, ferritin high , WBC high abx no help, Rh neg, ANA neg dx?
Still’s dz
Joint pain, salmon colored rash, high ferritin, high WBC
WHat dz more likely related to RA
Peeriodontal dz
Sjogren’s
RH+, ANA+, RoLa+, elev ESR
inc’d r/o lymphoma/celiac sprue (check TTG), distal RTA I (U pH >5.5) - CaPO4 stones)
Sx - enlarged salivary glands, dry mouth,
Dx: - lip bx minor salivar glands
Schirmer test + if <5mm wetting in tearing of eyes in 5 min (normal 15mm in 5 min)
Tx: Symptomatic - hydration, pilocarpine, steroids
55yo c/o sdry eyes and mouth - drinks lots of water everyday and uses artifical tears - ROS shows chroic arthralgias - takes NSAIDs - parotid gland swelling - dental caries and dry eyes pt may benefit from ?
pilocarpine
Seroneg spondyloarthropathy - Rh neg, HLSA B27+
involves spine, asy poly/oligoarthritis <4 joints affected
Enethesitis (inflamm ligaments, tendons, joint capsule)
Dactylitis - swelling of entire digit
Ankylosing spondylitis
Reactive arthritis - mucosal inflammation of GI or GU tract
Ankylosing spondylitis
starts after resting better with excercise, loss of forward spinal mobility sx sarcoilitis Uveitis: pain photophobia, lacrimation HLA B27 +, apical fibrosis bamboo spine on xray a/w aortits diminished Chest expansion
Pt loves outdoor work with on/off back pain p/w c/o pain and redness of r eye - also loss of forward spine mobility - inejction aroudn corea - fluroescin eye stain eng - what suggests ankylosing sponylitis in pt?
loss of spinal mobility
Dx: xray lumbosacral spine
more sensitive test - MRI sarco iliac joint
Eye manifestation is Uveitis
Pt p/w low back pain - xray with fusion of sarcoiliac joints and anklylosis of spine (bamboo spine - HLA B27+ most likely a/w?
Aortitis Tx for stiffness? Excercise, physical tx Pain - NSAIDs - if 6 weeks no improvment then anti-TNF (fatigue /morning stiffness) Q3 month xray sarcoilliac joints
Best way to maintain ROM with ankylosing spondylitis is?
Excercise
Follow dz activity with ESR
Uveitis in?
Reiter’s syndorme
Behcet’s dz
Ankylyosing spondylitis
Pt h/o anklyosing spondylitis on NSAIDs c/o new onset back pain - early fx wtd?
xray
Pt p/w asymmetric arthritis with pain in R knee, mouth ulcers, non-specific urethritis and conjunctivitis - HLA B27+, non-specific urethritis, conjunctivitis and asymmetric arthritis dx?
Reactive arthritis
Tx: NSAIDS - DMARD in extremem cases
COnjunctiviits, urethritis asym artrhtis (also mouth ulcers, keratoderma blenorrhagica
wtd next? HIV test
34yo Lt ankle arthritsi and left achilles tendon area pain - redness of eye abd pain adn diarrhea - exam with pai at baseof calcenus dx?
Reactive arthritis
Tx - cipro + NSAID
If no more diarrhea just NSAID
Pt wit reactiev arthritis ongoing arthritic pain for maoe than 6 months not releived with NSAIDs or steroids wtd?
sulfasalazine/MTX
How to tx pt with remote h/o urethris and now enthesitis
Tx chlamydia + NSAID
Causes of reactive arthritis
Yersinnia SHigella Salmonella Campylobater Ureaplasma C diff BCG tx
Pt p/w lower back pain and in DIP, HLA B27+, pitting nail changes present
Psoriatic arthritis Tx Mild - NSAIDS, skin/nail change -> MTX No hydroxychloroquine Worse with UVB
Pt of Middle eastern/japanese descent - recurrent painful apthous stomatitis, genital apthous ulcers, joint pain, erythema nodsoum on legs, HLA B5+, uveitis, pathergy (hyperreactive to needle sticks)
Bechet’s dz
a/w aortic aneurysm
erythema nodosum, apthous ulers
Tx: steroids
24yo M c/o multiple oral apthous ulcers/redness of eye x few months tender nodules on shin - CXR prominent pulm artery - aneursym on CT - dx?
Behcet’s dz
DTR dec with?
WNV
Tick paralysis (absent)
Toluene
spinal abscess
DTR inc with?
Serotonin
ecstacy
epidural abscess
NORMAL with MG
Oral apthous ulcer, gential ulcer, refuses needle stick?
Behcet’s dz
Paiful shin nodule, genital ulcer refuses needle stick
Behcet’s dz
Painful shin nodule, oral apthou ulcer, aortic anurysm, painful red eye blurry vsiion, occ knee/ankle pain?
Behcet’s dz
Oral apthoug ulcer, h/o urtetrald/c in past red eye, knee/ankle pain
Reachtive artrhtiis (Reiters)
Pt returns form Inia, thailand or africa high fever, pain in small joints hand, wrist ankle with or without maculopapular rash - dx?
Chikungunya virus
All these cause reactive arthrisi with dactylitis
Yersinia Shigella Salmonella Campylobater C diff Ureaplamsa Inflamm bowel dz NOT E.Coli!!
25yo p/w pain/swelling of right knee, diarrhea intermittently fo rweek, swelling of entire 2nd toe (sausage digit and sever pin on palpation of achilles tendon - painless ulcer on tongue - dx?
Reactive arthritis
what is +?
Stool ctx
70yo DM male p/w pain in mid back area - early morning stifness of spine, exam with dec’d thoracic lateral flexion - xray spine with flowing sosification o anterior longitudinal lgaments dx?
DISH (Diffuse idiopathic skeletal hyperostosis)
Tx: physical therapy, NSAIDs
Osteoarthritis
Older age
H/o trauma
Obesity, repetive use
2/2 DM, hyperparathyryodi - chondrocalcinosis
Labs - low Rh factor s
Tx: lose wieght, tylenol up to q6hr, NSAIDs, celecoxib with PPI, intrasticular steroids, hyaluronic acid - replace joint
Osteophyte formation -
osteoarthritis
Periarticular osteopenia
RA
Joint space deformity
OA/RA
Marginal bony erosioin in PIP, MCP
RA
Central bony erosion PIP, DIP
OA
Subchonral sclerosis
OA
Pt wit severe OA pain not relieved with tylenol h/o UGIB wtd?
low dose NSAIDs
Pt with fatigue an Hg 9, MCV 75 - pt taking NSAIDs for OA occult + wtd?
D/C NSAID start tylenol
Most important risk factor for OA
Obesity
Elderly pt with pain in thumb while turnign key opening car doors - pain at thumb on fexio and int rotation - crepitus + dx?
Osteoartritsi of 1st CMP joint
Pt with OA - wnat to try glucosamine or chondroitin sulfate wtd?
tell no different than placebo
Pt with longtanding h/o steoartrits takes tylenol for pain - plays tennis occasionally - mild crpitus and swelling of R knee - no fever WBC 8000 - wtd?
Tap knee, +steroids and then Phys tx
Pt with osteoarthris of R knee crpitus with pain acan’t take NSAIDs with inc Cr - steroid /hyaluronan inj with incomplete response
Exam with 10deg valgus def loss of cartilage on lat knee - (points outward)
Medial wedge insole
Exam 10 deg varus deformity with medial knee cartilage loss - wtd? (points inward)
medial unloading brace/lateral wedge insole.
Randomized clinical trial shown benefit of acupuncture in?
OA knee/hip
Topical capsaicin benefit of OA in?
hand
Pt is brick layer p/w painand swellign of PIP and DIP - xray loss of caritlalge and narrowing of joitn space and CENTRAL erosion dx?
erosive OA (PIP/DIP)
Laboro or farmer p/w URI - RA for >15 yrs - swollen PIP/MCP boggy felling does not c/o pain, strength normal - erosion PIP and MCP - dx?
RA (arhritis robustus)
Presentation of pain in OA hip in?
groin
R groin with RA and osteophytids on xray? dx?
secondary OA
R groin pain with RA, xray neg - MRI double line sign T2?
Avascular necrosis
R groin pain in middle aged pateint xray mild osteopenia - MRI T1 diffuse dec’d enhancemnt femoral head, T2 diffuse increase enhancement fem head?
Transient osteoporisis
Pain over anterior aspect of hip or groin - r/o hip joint problem like?
Avascular necrosis
Pain over latral asp of hip can’t sit in car or sleep on that side
direct pain - trochanteric bursitis
tx: inject local steroids
40yr old b/l groin pain L>R worse with activity and internal rotation
Acetabular impingement
Pt with SLE on steroids >2yr pain in hip , walks withi limop - dx test?
MRI r/o avascular necrosis
45yo c/o pain in right buttock shoots down back of thigh for past 3 days - tendernesss over R sciatic notch when pressure applied by thumb and pain on abduction while lying down - dx?
Piriformis syndrome
Tx: NSAIDs
18 t help - walks with limp
check xray
peri-acetabular osteotomy->arthropalsty
Pt with pain on groin - xray with osteophytes - analgeisa and cane - directions for cane?
use cane on OPPOSITE side of affected joint
Elderly pt with longstanding RA on MTX, hydroxychlroquine, NSAID with groin pain - xray NO joint space and severly impaired mobilization dx?
secondary OA
Tx: replace joint
Gout
Uric acid
Peduogout
Ca Pyrophosphate
Gout&pseduogout preciptiants
Asymmm inflamm arthritis Trauma post surgery 3 days post op major medial illness (MI, CVA, PE) fasting etoh abuse high fructose drinks a/w HTN, DM HCTZ
Do you tx pt with asymptomatic hyperuricemia
NO - only with sx
Is uric acid elev during attack of gout?
No - usually falls during gout attack
Do you need to have hyperuricemia to dx gout?
No - uric acid decreased or normal during gout attack
Pt with great toe swelling first tiem - neg biref crystals on tap
tx?
Colchicine
Pt with contraidication to cochicine 2/2 diarrhea
NSAIDs
Pt with gout, contraindication to NSAID or colchicine with renal inuff, CHF, PUD wtd?
steroids
Pt with only 1 or 2 joint gout?
intraarticular steroids
Polyarticular joint involvement gout
systemic steroids
Pt gouty attach resoved with steroids - wtd after -
start allopurinol (Xanitithine oxidase inhib - dec production) (Probenicid - inc uric acid excretion)
Pt with tophaceous gout never had gouty attack wtd?
colchicine + allopurinol
Pt with h/o gouty attack in past on coclchicine and allopurinol p/w acute gouty attack wtd?
continue allopinol, start NSAID
If recurrent attacks despite ppx
assess adherence to allopurinol
Pt with HTN takes ACEi c/o generalied rash - fever, necrolytic rash wbc 15, eos 10%, BUN cr 40/3.2, AST/ALT inc’d - due to?
allopurinol
allopurinol also inc’d level of azathrioprine
Pt h/o gout p/w swelling knee - tap with neg birefringent crystals WBC 40K, started on NSAIDs taking allpurinol - 1 wk later reaccumulation fluid still pain - tap again with neg birefringent crystals WBC 46K - fluid yellow and turbid - wtd?
Septic arthritis - IV abx
Pt with HTN on HCTZ uric acid elevation - asx
c/w HCTZ
Pt with HTN on HCTZ with uric acid elevation and gouty attack
d/c HCTZ
Elderly pt F on HCTZ p/w pain on PIP/DIP with nodules and swelling distal to nodules
gouty arthritis - monosodium urate deposits
Pseudogout (Calcium Pyrophosphate dihydrate disease)
Causes HyperPTH hemochromatosis HyperCa Hypothyroid Hypophosphatemia Wilson's dz
CPPD can presents as
Pseduo RA
Pseduo Gout
Pseduo OA
Dx knee most commonly affected
Xray - chondrocalcinosis (Ca+ of ligament)
Joint fluid - rhomboid crystal - weakly + birefringence
Tx smiliary to gout - colcihicine/NSAID
55yo p/w pain in knees and wrist fatgue, dec’d libido, swelling wrists/knees - Ca of mensci/traigular ligament - AST/ALT elevated - FBS 150
Pseduogout 2/2 hemochormatosis wtd next?
Serum transferrin saturation and iron level
Pt with artritsi xray with multiple area of joint calcification and fatuge, FBS 158 dx?
Chondorcalcinosis due to pseudogout CPPD - test to do?
TIBC (trasf sat/ferritin
A pt with yperPTH undergoes parathhyroiectomy, post surgery acute onset pain, swelling righ tknee =- reveals?
55K wbc, postive birifrignence (weak)
Post surgery 3 days later wrist, MCP, PIP, DIP, knee pain - knee joint swollen, urica acid inc’d what to expect?
Calcium pyrophosphate crystals
Joint fluid interpreation
inflammatory - WBC 2-75K, PMN>50%, gluc >25
Septic WBC>50K, PMN>75%, gluc <25 (bacterial)
Pt c/o pain on abduction of shoulder - mianly anterior tenderness ovre biciptial groove
Bicipital tendinopathy
Tx - NSAIDS->PT -> steroids close to tendon in bicipital groove
Pt c/o pain in shoulder - started tennis after long time - pain in shoulder while trying to comb hair, lifting dress or lifting weight over head - pain in lat shoulder while laying down at night, painful abduction beyond 40 deg and int rotation
Rotator cuff tendinopathy
75yo M fall from height with streched hand - c/o sohoulder pain - cant shrug shoulder, can’t abduct arm, an’t keep arm up after passive lift (drop arm test +) xray reveals no fx - after xray?
Rotator cuff tear
Pt c/o pain in shoudler - inced on abduction, extremes ofmovement, painless - pain more on active than passive - swings arm back and forth wihtout pain
dx subacromial bursitis
Pt with pain and griding or popping sensation in anterior shoulder while reachig to put seat belt on - pain on abduction beyond 120 deg
acromiolavicular joint arthritis
66yo F gradual onset progress R shoulder pain x 1 yr difficulty combing hairand wahsing fae while showering - minor MVA couple yrs ago - diff abducting and ext rotation of R shoulder with creptius and tenderness over joint - xray narrowing of glenohumeral joint space
Gelnohumeral OA
Tx: NSAIDs, strestching excercises - persistent sx - intraarticular steroids - no response- surgery
72yo F R shoudler pain x 1 year with gradual onset sx with movement of shoulder at night - difficulting abducting shoudler
Xray with Ca of ligaments and some effusion on rap with RBC/WBC 2K, ALIZARIN RED stain basic Clcium phosphate crystals occiasion HYDROXAPATITE crystals
Milwaukee shoulder (apatite crystals, ALIZarin red stain) Tx: NSAID, repeat arthrocentesis -> persisent symptoms - intraarticular steroids -> still sx - arthoplasty
60yo F with cast for arm injury - post removal with stiffness - inability to move shoulder - loss o f both active an passive ROM - tenderness pin around shoulder - xray looks normal - inecting steroid into hsoulder with resistance dx?
Adhesive capsulitis
Tx: early mobilization
Lying on side pain
Shoulder - rotator cuff tendinopathy
Left precordial - costochondritis
Lateral hip pain - trochanteric bursitis
Student wit pain and swellign elbow near exams or (carpet layer, roofer, et) Can pronate/supinate arm but can’t flex dx?
Olecranon bursitis
etio truama, gout, sepsis
Tx NSAIDs lcoal steroids
Pt with pain/swelling elbows with warmth and tnderness - ROM painess tap with 9000 WBC (<20K)
Dx septic olecranon bursitis
Tx Aspiration, drainage, IV abx NSAIDs
If recurrent - excise bursa
Pt with pain in lateral elbow anterior to lateral epicondyle - pain on ext of fingers and supination of forearm - while in airport lfted suitcase and pain returned dx?
lateral epicodylitis - pain in extension
due to liftign heavy obsjects
Extensor carpi radialis
Reduce recurrence - six weeks phsical therapy with eccentric excercise (opposite direction)
Carpel Tunnel Syndrome
Wk in abductor pollicuis brevis Phalen's Sign (forced flexion wrist) +, Tinel's sign (tinel=tap) Tx: Neutral splint at night IF no response or thenar atrophy Nerve conduction study -> Sx release
Cause of carpel tunnel
RA DM Preg Menopause Myxedema Amyloidosis Acromegaly
Presentation of median nerve issue
unable to oppose little finger with thumb
55yo F numbness both thumbs and index fingers upon holding anything for few min, HR 52, fatigue next test?
TSH
Preg woman with c/o pain and paresthesia both hands and thumb andindex finger esp at night wtd?
Neutral splinting of wrists
45yo RA b/l tingling sensation in both hands worse at night with thenal muscle wasting wtd?
nerve conduction studies
Pt fails neurtral splinting and has thenar atrophy?
Sx release
Numbness fingers, thumb index.iddle with early mornign stiffness>1hr diff opeing bottle
RA
Long distance cyclist p/w tingling numbness in littlea nd 4th finger and ulnar asp of palm - abduction decreased
Ulnar entrapment at wrist, ulnar groove in elbow
Pt in MVA p/w inability to open/exten finger du to pain dx?
Super condylar fx - disrupting brachial blood flow
Pt p/w pain on radial (lateral) asp wrist esp when lfiting children - young man who plays vidoe games - tenderness over radial sytloid process - resisted abduction pain and with ext of thumb - making fist with fully flexed thumb and ulnar dev with pain (Finklestein’s test)
Dequervan’s tenosynovitis
tx: rest tendon (no grip.rasp), splinting - local steroids
If severe surgery
Pt p/w wrist drop, dec’d sensation in radial and dorsal aspect of hand - dx?
Compression of radial nerve at Spiral groove in middle of arm - saturday night palsy
Pt p/w finger stuck in flexion at PIP - straightened with effort of other hand - tenderness at base of finger dx?
Digital tenosynovitis - Trigger finger
tx: steroids or surgery if not working
Pt wit hstiffness ulnar aspect of hand - unable to extend 3rd & 4th fingers - thickening and contraction of palmar facia - DM and etoh liver dz
Duprytrne contracture
Tx: 1st collagenase injections
2nd surgery
Pt fell on outstriched hand - tenderness over anatomic snuff box - xray neg fo rfx wtd?
thumb spica splint (scaphoid fx)
bone scan/MRI
DM pt with inability to completely extend fingers - hand bring hands together with tips of fingers and wrists of both hands but can’t bring MCPs together - no erythema or swelling
DM choropathy due to collagen depostion
Meralgia Paresthetica
DM with burning sensation or numbness in anterior and lateral thigh
Pain worsens with abduction of thigh and with excercise - palpation of RLQ in inguinal region elecits pain
Etio - compression of cutaneous femoral nerve
Tx: wt loss, anticonvulsant, local steroids
Pt c/o hip pain - xray fx of ramus of pubis tx?
early ambulation/PT
Pt p/w pain in patellar region - no skin bkdn - erythema and tenderness over patellar region
pre-patellar bursitis housemaid knee
Tx NSAIDs/local steroids
DM pt with pelvic girdle and thigh pain - no burnign sensation - exam wit hatrophy and wk of thigh muslces dx?
Diabetic amyotrophy
tx: better glucose control
Elderly pt with pain on knee, medial aspect 5cm below joint line - worse with climbing stairs - xray no calc mild osteoarritisc changes
Pes Anserine bursitis (pain with climbing stairs, local pain and swelling)
Tx: local steroids, rest, NSAIDs
Pt c/o pain on side of knee when JOGGING or CYCLING - radiates UP toward thigh - tenderness in lateral knee whiel abducting or ext hip - snap on felxion - int rotation no pain - dx Iliotibial band syndrome tx?
COrrect trining errors, proper foot wear, streching hip abductors
28yo long distance runner c/o pain in knee - pain described as burning sensation on inner and outer asp of patella, also behind patella worse with phyical activity - knee stiffness after sitting for long time (movie goer sign)
Dx: Patellar femoral syndrome
(patellar compression check)
Tx: decreas running/quadricpet strenghening , analgesic
NO SURGERY REQUIRED!
Teenager with anterior knee pain below knee joint exam poitn tenderness below knee joint esp on ext knee against resistantce
Dx Osgood Schaltter dz - irritation of patellar ligament, young ppl during growth spurts
20yo to ER with acute pain in kneee with swelling - palyed football 1 hr ago and heard popping sound then pain/sweeting - anterior drawer sign/lachman sign +
ACL tear (forward knee laxity both in anterior drawer sign and lachman test)
Pt presents hours after injury with swelling to knww - locks and gives way, popping sound during injury - palpation of medial joint line with pain, clicking soudn on felxio of nee - McMurray test +
Meniscal tear (flex hip, and knee, valgus pressure then extend knee - if pop/pain then +)
75yo F assisted living with pain on medial aspectof knee fo rseveral months, click on palpation wtd?
PT
Pt p/w pain in knee on medial aspecto finjury sever hours ago - no popping sound can ambulate but no pivor/twist - Drawer neg, lachman neg, varus neg, valgus + with pain on mediail joint
MCL tear (hit from lateral side)
Pt p/w pain and swelling posterior leg - >24hr ago after tennis (out of practice - swelling and tenderness in mid calf area - no h/o RA wt?
US,
Dx: gastocnemium tear
Tx: Rest NSAID crepe bandage
Pt with pain in ankle on ambulation - twisted anglkle on uneven surface - can walk 4 steps without support - compression of posterior malleoli (medial and lateral) no pain -
Ankle sprain - talofibular ligament strain - no need for xray
Tx: NSAID, splint
Long distance runner pain in lower medial aspect of leg - worsened when jogging, xray neg for fx
Dx: Shin aplints - overuse syndrome
Tx: rest, ice packs
Pt p/w pain/burning sensation between 3rd and 4th toes worse while walking with high heels - pain while walking on hard surface - pain radiates in fron tof toes along with parathesias on plantar aspect - better when shoes removed - dx?
Morton’s neruoma - interdigital plantar neuroma
Pt with pain in heel, stiffness during early morning stride - get better with day going on…dx?
Plantar fasciitis
Tx: Ice pack after activity, arch support nSAID
correct raining error, steroid injetion, surgery
streching exc with dorsiflexion of foot
Pt with plantar fasciitis, xray with heel spur - cause of pain likely…
plantar fasciitis
Foot pain, more in morning, difficulty with dorsiflexion - tenderness at base of calcaneous, with inc’d tenderness squeezing heel dx?
Plantar faciitis
Pt with numbness and burning sensation in toes - worse on walking and end of day - sx worse at night - radiates to front of toes, better with shoes off - percussion posterior and inf to medial malleous produces pain
Tarsal Tunnel syndorme
Tx: arch support shoe modification
Local steroids
Sx decompression
Pt p./w painful feet, ankle and knees after prolongued standing fo rfew years - normal feet on exam - but on standing arches of feel colapse and valgus of heel - dx?
Flat feet Pes Planus tx?
-better shoes - podiatrist for orothotic shoe fitting
45yo F with extreme fatigue doesn’t want to get out of bed, also with diffuse muscle ache in most muscle group on exam - no fever, no swelling , ANA 1:64, ESR 30, CPK 98 wtd?
Dx: fibromyalgia
Tx: amitripyline or excercise
elderly woman with generalized body ache adn fatigue started couple dyas ago with pain in upper arms and neck a/w morning stiffness, no focal euro def, minimal OA chagnes on xray, ESR 52, alk phos elev, no changes with NSAID - local steroid to shoulder temp relief dx?
Polymyalgia rheumatica
Pain in neck/shoulder/hip (morning pain)
can be a/w temporal arteritis
TX: low dose prendisone
85yo F recurrent pain in neck ESR 40, low grade temp - restriction of neck movement from pain - Xray Ca of ligaments in neck - Ca noted on other joints as well
Crowded dens syndrome
Relapsing polychondritis
swellilng of ears, hoarseness, aortic regurg
Pt with hoarness, episodic swllign of nears history of intubation 2/2 subglottic stensois
Larygoscopy edema/inflammation
Dx: Bx of cartiliage
Tx; steroids then immunosuppressive agents.
Large Vascululitis
Complement normal
Temporal arteritis
Takayasu’s arteritis
Aortitis
Medium Vasculitis
Complement normal
Polyarteritis Nodosa (PAN)
Granulmatosis with polyangiitis (wegeners)
Chugg strauss
Small vasculitis
Henloch schonlein - abd pain/nodulies Microscopic polyartitis angiits (MPA) - cousin of PAN - MPO Churg Strauss Good pastures Cryoglobulinemia - dec C4>decC4
65yo F c/o frontal h/a moderately sever adn throbbing - scalp urst when combs hair, hurst while chewing - episode of blurry vision - exam no focal deficit wtd?
Check ESR
Steroids
Temporal artiteritis - even if bx neg (can be skip lesions)
65yo M h/a ESR 85 steroids started and temp bx neg - BP both extrem neg - wtd next
US bx contralateral temporal artery
Pt p/w pain/wk left arm after excercise - recent dizziniess/visual distrubance and TIA - BP R 140/80, Lt 155/95
Pt age 25 with h/o maliase and fever - Takayasu’s
Pt elderly with normla ESR - > atherosclerosis - subclavian steel
Pt elderly with high ESR - Temperoal arteritis
WT? steroids, temp artery bx, MRA chest
Dx of Takayasu dz?
Aortography, check for stenosis
Tx: steroids, CCB
Ankylosing spondylitis a/w ?
Aortitis and Uveitis
Aorititis a/w?
Anklyosis sponylitis, Uveitis, syphillis
50yo M pw abd pain worsens while eatin gin periumbilical area - better when somach empty - joint pain in hands and feet 25lb wt loss in 3 months, chronic leg ulcer for years - diff tenderness on palpation of abd - ESR 100, BUN cr elev - best test for dx?
Abd angiogram Polyarteritis Nodosa (spares lungs) a/w Hep B wt loss, Cr elev, elev ESR, pain of abd, ulcers bead sign on aortogram (aneursyms) Tx: prednisone, cyclophosphamide
40yo M c/o wk left hand and abd pain - dec power l hand diffuse abd pain no rebound, high ESR, U/A protein - no obstru on xray dx?
PAN
Tx: steroids + cyclophosphamide
35yo p/w abd pain - labs wit hrenal insuff - Hep B ag + - pt has?
PAN - 30% a/w hep B
24yo F italian/jeiswh/arab descent with recurrent abd pain every 2 months for 1-2 days, appy as child - pain spreads all over abd with fevers - swollen knee, power normal - FATHER WITH SAME SX dx?
Familial mediterrainian fever
Tx: colchicine
complciations - amyloidosis (AA), renal failure
Causes of amyloid
FMF
RA
TB
MM
Amyloidosis
proteinuria +-hematuria with renal failure
Bx congo red stain - fibril of apple green birefringence
abd fat bx if neg then bx affected organ
50yo F pw cough, sob, artritis nasal septum fat - CXR mulptole pulmonary nodules and one cavitary lesion - afb neg, BUN cr elev
BX - vasculitis with necrostizing granulomas c-anca+ ,RH + dx?
Granulomatosis with polyangiitis (Wegeners)
Tx:
Non-sever - steroids + MTX
Severe Steroids + rituximab or cyclophosphamide
In remission - MTX
Relapse - steroids + rituximab
Thin walled cavitary lesion CXR
norcardia
Histoplasmosis
Thick walled cavitary lesion CXR
Wegeners, blastomycosis
24yo M wiht ongoing sinusitis for past couple months a/w cough, tx’d with amox x 7 days tmep 100.5 boggy turbinates with purulent secretions, rhonci on ausculatation CT sinus total oapcification CXR nodular infiltrates - ANA, P and C ANCA+ dx?
Wegeners (lung involvment, no abd invovlement) Granulomatosis with polyangiitis Lung and kidney involvement, nasal d/c Autoimmune attach by ANCA ab (C) Tx: steroids and cyclophosphamide azathroprine MTX, mycophenlate Rituximab (relapse)
40yo F with h/o asthma with several allergies no pets pw SOB wheezing and wk left foot - uses albuterol, amlmetoerol steroids - rales left base, dec power R foot - CBC eos+, RUL density dx?
Churg Strauss
eosinophilic granuloamtosis with polyangiitis
pt w/ h/o reactive airway ie asthma or allergic rhinitis
+eos
IgE NORMAL
+p-ANCA
mononeuropathy/polyneuropathy
pulmonary infiltrate
extravascular eos+
Tx: Prednisone +- azathroprine, cyclophosphamide, MTX (maintenance)
Most specific Ab for SLE
ANti smith/ anti DS DNA
Labs for SLE
inc’d ESR
C3>C4, CH50 dec
anti DSDNA+ (follow dz activity with this)
Tx for SLE
Arthritis - ASA, NSAID->hydroxychloroquine
Photosenstiviyt/rash - avoid sun, use sunscreen-> top steroids - hydroxychlroquin
Throbocytopenia - steroids, IVIG
Hemolytic anemai - steroids
Nephritis - steroids, add cyclophophamide, mycophenalte
in AA/hispanic nephritis - steroids then mycophenolate
Refractive lupus - use Bilimumab
SLE on steroids still with sx
MSK sx - Hydroxychorloquine
Neprhtis/CNS sx/system vasculaitis or alveolar hemorrhage - cyclophosphamide
Serolgically active but clinically quieescent SLE
no tx
Pt on minocycline fo racne or RA >2yr on procainamide >1yr, for arrythmai or infliximab for RA for 6 months, hydralazine CHF for past 2 years or INH for PPD for 8 months p.w malaise, low grade arthralgia of MCP, PIP joints, early morning stiffness, wt loss irreg menses, ESR 65, ANA + 1:320, C2, 4 normal - all favor drug induced lupus …
Normal complement
No pscychosis or sz
U/A no RBC or protein/casts
high ANA
24yo h/o lupus for 4 years foudn to have lupus anticoagulant syndrome and history of spontaneous abortion twice she is on cyclophosphamide and steroids - asks about long term contraception
Progesterone only IU device
Pt on PTU for hyperthyroid pw palpable purpuric lesions on extrem and trunk - P-ANCA+ and ESR high, Heb B neg bx of purpura leukoclastic vasculitis - dx?
PTU induced vasculitis
35yo F dx with SLE and lupus nephritis txd with steroid and IV cyclophoshamide about 2 yrs ago meds were tapered off and was asx and healthy now with low grade fever and arthralzgias what would suggest flare of SLE
Inc’d Anti DSDNA and dec’d complement
Leasding cuase of death in SLE pt is?
Cardiovascular disease
Dec OCP levels
Rifampin
St John’s wart
What causes MAT
COPD
T/F SLE pt inc’d risk of stroke
T
T/F SLE pt with inc’d risk of MI
T
T/F SLE pt inc’d risk of DVT
T
T/F SLE pt inc’d risk of recurrent spontaneous abortions
T
T/F SLE pt in’d riks of avascular necrosis
T
Pt with recently dx SLE p/w complaints of dec urination and wk leg - pain in back , hyperactie reflexese - exam no spinal tenerdness
MRI spine r/o transverse myelitis - dedema of spinal cord c/w inflammation
IV steroids
SLE pt on hydroxychloroquine and Prednisone 20mg/day p/w psychosis - etiology?
steroid induced psychosis if >20mg steroids
SLE if <20mg steroids/day
20yo F delvers baby with CHB - mother with scaly papular rash - ANA neg - woman with what ab?
SSA (anti-RO)
Pt with 1st trim spontaneous abortion for 1st time
No need to check for antiphospholipid
Pt with 3rd trim spontaneous abortion for 1st time
check for antiphospholipid Ab
Pt with recurrent 3rd spont aborition in 1st trimester
check for antiphospholipid Ab
Sclerosis
Generalized - systemic Sclerosis
ANA+
Scl 70_
Anti-topoisomerase+
Limited - Crest - Anticentromere +
Plus muscles - dermatomyositis
Polydermatomyositis
Mi2, AntiJo Anti-PM1
Systemic Sclerosis (Anti-Scl 70+)
Skin - diffuse fibrous thickening, sclerodactylyl, tight face/small mouth, abn nail folds
Joints - symmetric arthritis, MCP
Tendon friction rub - > MTX/NSAID
Raynaud - warm gloves, nifedipine
LUngs - interstitial pneumonitis, interstitial fibrosis - CT scan-> chylophophamid+ steroids
Pulm HTN
Renal - renal crisis (HTN, proteinuria, edema) - ACEi (irrespective of cr) - what precipitates - steroids
GI dysmotility - erythromycin
GERD
Wide mouth diverticula
Bacterial overgrowth syndrome (cipro/flagyl)
Heart - Restrictive pericardial dz
Sclerosis pt can present with?
Intersticial pneumonitis (fiborosign alveolitis)
CREST (anti-centromere+)
C-> Calcinosis cutis (calcif of soft tissue) R -> Raynaud E -> Esopheagela dysmotility S-> Sclerodactyly T->telangiectasias Pulm HTN more common than scleroderma
35yo garderner p/w painful fingers during cold weather, figners white with cold - wears warm glove and doesn’t help - wtd?
nifedipine
How will you recomgnize rhumatic (seond vs primary dz) in pt with raynaud’s
abnormla nail fold capillaries Secondary Age>40, Abn nail folds capillaries Digital ulcerations
45yo played basketball fo r4 hours at family reunion p/w swelling arms/leg sparing hand/feet - exam wit ORANGE PEEL like quality of skin - CBC EOS+
Dx: Eosinophilic Fascitiis
Tx: Self limited-> steroids
Polymyositis (anti Jo+)
Anti Jo+ Inc'd CPK HLA DR3+ Women>Men Prox muslce wk, can't get up from chair or squat can't comb hair, mechanic hangds Abn CPK (10x, inc'd ANA) Biopsy myonecrosis, cellular infiltrates
Polymyositis + skin changes=
Dermatomyositis (Anti- Mi2) Polymyositis sx (weakness) Mechanic hands (dry cracked skin) Heliotropic rash Gottron papules (most specific) screen for ovarian, breast or GI Cancer
Tx: Steroids (no MTX)
66yo F pw complint of diff getting up from chair , diff combing hair exam reveal rash on cheeks forehead eleylids - pt at risk for what?
Malignancy - ovarian breast or GI
What more specific for dermatomyositis
Gottron papules
What predicts poor outcome in dermatomyositis -
dysphagia
West nile virus poor prognositc factor?
inc’d age
RMSF poor prognostic factor
inc’d Cr
55yo F with weakness - phx significant for polymyositis - CPK 950 - started on prednisone 50mg.day - feels better CPK 1990, 3 montsh later CPK level normal bu tnow prox wekaness again dx?
steroid myopathy
Tx: taper steroids
65yo M progressive wk legs, arms, forearms wrists fingers distal>prox, CPK high not responsding to steroids - MTX added, CPK still high - bx wit ENDOMYSIAL inflammation adn bsophilic rimmed vacuoles wtd?
Inclusion body myositis
tx: taper steroids, d/c MTX
Pt with gouty tophus on colchicine and allopurinol - h/o ashtma on inhaled steroids - p/w wk trying to get up from chair, LE prox wk aslo, DTR dec - CPK 850 - bx reveals vaculoles no inflammation dx?
Colchicine induced myopathy
35yo M intubated asthmatic 4 days later on steroids and albuterol - diff extubating - CPK 925 dx?
Critical illness myopathy
Ab for SLE
ds DNA, Smith
Ab for Drug induced SLE
histone
Ab for subacute cutaneous SLE
SSA (Ro)
Ab for Scleroderma
Scl70
Ab for CREST
centromere
Ab for MCTD
RNP
Ab for poly/dermatomyositis
Jo, Mi2
Ab for Sjogren’s syndorme
SSA (ro)/SSB(La)
Ab for Wegener’s
c-ANCA (proteinase 3)
Ab for Microscopic polyarteritis angiitis (cousin of PAN)
P-ANCA (myeloperoxidase)
