Rheumatology, Orthopedics and Sports II Flashcards
What is the likely diagnosis in a young female that presents with a triad of polyarthalgias, tenosynovitis, and a vesiculopustular skin rash?
Disseminated gonococcal infection
What is the likely diagnosis in a young female that presents with foot pain? The patient experiences pain and a clicking sensation when the 3rd/4th metatarsal heads are squeezed together.
Morton neuroma
mechanically-induced degenerative neuropathy; treatment is conservative (e.g. metatarsal support, padded shoe inserts)
What is the likely diagnosis in a young female that presents with tenderness to palpation along the 2nd metatarsal bone? The patient is an avid runner and her BMI is 18 kg/m2.
Stress fracture
more common in patients with the “female athlete triad”; manifests as localized pain
What is the likely diagnosis in a young female with months of progressive achy pain in the anterior right knee? The pain is worsened with running and sitting for an extended period.
Patellofemoral pain syndrome
common cause of anterior knee pain in young women; usually due to chronic overuse or malalignment
What is the likely diagnosis in a young patient that presents with sharp, non-radiating pain on the medial side of the tibia just below the knee after falling one week ago? A valgus stress test has no effect on the pain.
Pes anserinus pain syndrome (anserine bursitis)
no pain with valgus stress test indicates no MCL involvement
What is the likely diagnosis in a young patient with inflammatory bowel disease that presents with the leg ulcer below?
Pyoderma gangrenosum
What is the likely diagnosis in a young woman that presents with fever and migratory joint pain? Synovial fluid analysis reveals 65,000 WBC/mm3 with neutrophilic predominance.
Gonococcal septic arthritis
most common cause of septic arthritis in young, sexually active patients
What is the likely diagnosis in a young woman that presents with joint pain/swelling, especially in the wrists and MCP/PIP joints? She also experiences morning stiffness that lasts for more than an hour.
Rheumatoid arthritis
morning stiffness and involvement of the MCP/PIP joints is classic
What is the likely diagnosis in an afebrile patient that presents with acute right ankle pain that becomes “unbearable” over a few hours? He recalls having a similar episode 1 year ago that resolved with over-the-counter medication.
Gout
typically presents with acute monoarticular arthritis that progresses to maximum intensity within 12 - 24 hours; most commonly involves the big toe
What is the likely diagnosis in an asymptomatic elderly male with isolated elevated alkaline phosphatase? Physical exam, including rectal exam, is insignificant.
Paget disease of bone
most common cause of an asymptomatic elevation of alkaline phosphatase in an elderly patient
What is the likely diagnosis in an athlete that felt a “popping sensation” while playing soccer, followed by rapid pain/swelling? Aspiration of the knee yields grossly bloody joint fluid.
ACL injury
a “popping sensation” with rapid-onset pain/swelling and hemarthrosis are characteristic of ACL injuries (versus slowly progressive or absent effusion in meniscal tears)
What is the likely diagnosis in an elderly female that presents with back pain after lifting boxes? The pain is worse with standing, walking, and lying down. There is tenderness to palpation at the fourth lumbar vertebra.
Vertebral compression fracture
What is the likely diagnosis in an elderly male with low-grade fever, arthritis, diarrhea, and generalized lymphadenopathy? Small intestinal biopsy reveals PAS-positive, acid-fast negative macrophages.
Whipple’s disease
other commonly involved organs include the eye, CNS, and heart; macrophages containing Tropheryma whippelii bacteria stain PAS positive
What is the likely diagnosis in an elderly patient that presents with a 6-month history of unilateral knee pain? The pain is worse in the evening and with activity.
Osteoarthritis
major risk factors include obesity, advancing age, diabetes, and prior joint injury
What is the likely diagnosis in an elderly patient that presents with dry eyes and dry mouth? ANA is negative.
Age-related sicca syndrome
due to age-related exocrine gland atrophy; Sjogren syndrome typically presents in middle-aged patients with a positive ANA
What is the likely diagnosis in an elderly patient with right-sided neck pain and sensory deficits over the posterior forearm? Physical exam reveals limited neck rotation and lateral bending.
Cervical spondylosis
limited neck rotation and lateral bending is due to osteoarthritis with secondary muscle spasm; sensory deficit is due to osteophyte-induced radiculopathy
What is the likely diagnosis in an elderly woman with three months of neck, shoulder, and hip pain/stiffness, as well as malaise and weight loss? ESR is elevated and creatine kinase is normal.
Polymyalgia rheumatica
What is the likely diagnosis in an older patient with headache, bone pain, and hearing loss?
Paget disease of bone (osteitis deformans)
bone pain, hearing loss, headaches, and fracture are all consistent with Paget disease of bone
What is the likely diagnosis in an older woman that presents with pain/stiffness in the proximal and distal interphalangeal joints?
Osteoarthritis
the picture demonstrates prominent osteophytes at the DIP joint (Heberden nodes) and PIP joint (Bouchard nodes), which are classic of OA
What is the likely diagnosis in an older woman with pain behind the right heel several days after beginning treatment for a UTI?
Achilles tendinopathy
likely secondary to fluoroquinolone use; risk factors include old age (> 60) and female gender
What is the likely diagnosis in an older woman with unilateral headache, jaw pain, and vision loss? Fundoscopy shows a swollen pale disc with blurred margins. ESR is elevated.
Giant cell (temporal) arteritis
fundoscopy findings are consistent with anterior ischemic optic neuropathy
What is the most common extraskeletal complication of ankylosing spondylitis?
Anterior uveitis
presents with unilateral ocular pain and photophobia
What is the most common finding on cervical radiography in patients with cervical spondylosis?
Osteophytes
low specificity; other findings include disk space narrowing and hypertrophic vertebral bodies
What is the most definitive test for diagnosis of polymyositis?
Muscle biopsy
shows a CD8+ lymphocytic infiltrate in the endomysium (versus CD4+ infiltrate in the perimysium in dermatomyositis)
What is the most sensitive test for the diagnosis of avascular necrosis?
MRI
X-ray may be normal in early stages of disease
What is the next step in management for a patient that presents with suspected lumbosacral radiculopathy (sciatica) after lifting a heavy box? Neurological exam is unremarkable.
Trial of NSAIDs/acetaminophen
most patients will experience spontaneous resolution; indications for MRI include progressive sensory/motor deficits, signs of cauda equina syndrome (e.g. saddle anesthesia), or signs of epidural abscess (e.g. fever, history of IVDA)
What is the next step in management for a patient with a 3-day history of fever and increasing unilateral knee erythema, pain, and swelling?
Synovial fluid analysis
any patient with possible septic arthritis should have urgent synovial fluid analysis; septic arthritis progressively worsens over a few days (versus gout which worsens over 12 - 24 hours)
What is the next step in management for a patient with suspected carpal tunnel syndrome? There is no thenar or hypothenar atrophy on physical exam.
Wrist splinting
glucocorticoids and/or decompression surgery may be considered in patients with significant weakness or refractory symptoms
What is the next step in management for a patient with suspected giant cell arteritis?
High-dose glucocorticoids
treatment should be initiated before confirming the diagnosis (e.g. via temporal artery biopsy)
What is the preferred treatment for symptomatic patients with Paget disease of bone?
Bisphosphonates
bisphosphonates inhibit osteoclasts and suppress bone turnover
What is the recommended imaging modality for a patient with back pain secondary to suspected malignancy (e.g. nocturnal pain, weight loss)?
X-ray
What is the recommended imaging modality for a patient with back pain with neurologic deficits and signs of cauda equina syndrome (e.g. saddle anesthesia)?
MRI
MRI is also useful for patients with suspected epidural abscess (e.g. fever, IVDA)
What is the recommended initial treatment for a patient that presents with their first episode of uncomplicated gout?
NSAIDs (preferred), glucocorticoids, or colchicine
urate-lowering drugs (e.g. allopurinol, febuxostat) are indicated for patients with recurrent attacks or complicated disease (e.g. tophi, uric acid kidney stones)
What is the recommended next step in management for a patient with chronic low back pain despite intermittent use of acetaminophen and NSAIDs?
Exercise therapy
if pain persists after exercise therapy and intermittent acetaminophen/NSAIDs, patients may benefit from TCAs or duloxetine; back braces are not effective for prevention of treatment of lower back pain
What is the recommended screening protocol for osteoporosis?
One-time dual-energy x-ray absorptiometry (DEXA scan) for all women > 65
also recommended for younger women who have an equivalent risk of osteoporotic fracture
What is the recommended treatment for a patient with symptomatic osteoarthritis despite a supervised exercise program and weight loss?
NSAIDs/acetaminophen
What is the recommended treatment for patients with symptomatic sarcoidosis?
Glucocorticoids
What is the recommended treatment for polymyalgia rheumatica?
Low-dose glucocorticoids
versus giant cell arteritis, which requires high-dose; if PMR does not improve rapidly with steroids, another diagnosis should be suspected
What musculoskeletal pathology is associated with narrowed joint space, osteophytes, and subchondral sclerosis on radiographs?
Osteoarthritis
What musculoskeletal pathology is significantly more prevalent in patients with rheumatoid arthritis?
osteopenia/osteoporosis
due, in part, to increased levels of proinflammatory cytokines, corticosteroid therapy, and lack of physical activity
What pathology is associated with anti-topoisomerase I antibodies?
Systemic sclerosis (scleroderma)
also known as anti-Scl-70; other associated antibodies include anti-RNA polymerase III and anti-centromere antibodies
What pathology is associated with positive anti-Jo-1 (anti-synthetase) and anti-Mi-2 (anti-helicase) titers?
polymyositis/dermatomyositis
What pharmacologic treatment is recommended for patients with symptomatic primary Raynaud’s phenomenon?
Calcium channel blockers
typically presents in women age < 30 with symptoms of symmetrical episodic attacks
What physical exam test is helpful for diagnosing patellofemoral syndrome?
patellofemoral compression test
i.e. extension of the knee while compressing the patella
What sickle cell disease complication commonly presents with progressive hip pain and reduced range of motion without fever?
Avascular necrosis
What skin rash is commonly found in patients with sarcoidosis?
Erythema nodosum
What study may be used to confirm the diagnosis of carpal tunnel syndrome if the diagnosis is uncertain?
Nerve conduction studies
What symptom classically arises in patients with Paget disease that affects the temporal bone?
Hearing loss
What valvular defect is associated with ankylosing spondylitis?
Aortic regurgitation
What vascular complication is a major cause of morbidity in patients with Behcet syndrome?
Thrombosis
both venous and arterial thrombosis
What viral infections are commonly associated with mixed cryoglobulinemia syndrome?
HCV and HIV
also associated with systemic lupus erythematosus
What X-ray finding is characteristic of pseudogout (calcium pyrophosphate dihydrate crystal deposition disease)?
Chondrocalcinosis
i.e. calcified articular cartilage
Which form of Raynaud’s phenomenon, primary or secondary, is characterized by asymmetric attacks with clinical features of tissue ischemia (e.g. numbness, ulcers)?
Secondary Raynaud’s phenomenon
patients should be tested for autoantibodies (e.g. ANA) and inflammatory markers
Which form of Raynaud’s phenomenon, primary or secondary, is characterized by symmetric attacks without tissue injury (e.g. numbness, ulcers)?
Primary Raynaud’s phenomenon
Which region of the spine is most commonly affected by rheumatoid arthritis?
Cervical spine
may predispose to cervical spine subluxation with spinal cord compression
[…] is approved for both treatment and prevention of secondary (AA) amyloidosis.
Colchicine is approved for both treatment and prevention of secondary (AA) amyloidosis.
Behcet syndrome is characterized by a triad of recurrent […] ulcers, as well as […] ulcers and uveitis.
Behcet syndrome is characterized by a triad of recurrent aphthous ulcers, as well as genital ulcers and uveitis
classically presents in a young adult of Turkish, Middle Eastern, and Asian descent; other manifestations include thrombosis and skin lesions (e.g. erythema nodosum)
[…] syndrome is characterized by a triad of recurrent aphthous ulcers, as well as genital ulcers and uveitis.
Behcet syndrome is characterized by a triad of recurrent aphthous ulcers, as well as genital ulcers and uveitis.
classically presents in a young adult of Turkish, Middle Eastern, and Asian descent; other manifestations include thrombosis and skin lesions (e.g. erythema nodosum)
Felty syndrome classically presents with a triad of rheumatoid arthritis plus […] and […].
Felty syndrome classically presents with a triad of rheumatoid arthritis plus splenomegaly and neutropenia.
[…] classically presents with a triad of rheumatoid arthritis plus splenomegaly and neutropenia.
Felty syndrome classically presents with a triad of rheumatoid arthritis plus splenomegaly and neutropenia.
