UW 1 Flashcards
osteoarthritis - RF
- older than 50
- obesity
- prior joint injury
suspected 2ry Raynaud syndrome - next step
Autoantibodies + infl markers
Raynaud - treatment
1ry –> avoid aggravating factos, CCB if persistent
2ry: evaluate and treat underlying, CCB if persistent, aspirin if risk for ulceration
hemochromatosis - infections?
Listeria, Vibrio vulnificus, yersinia enterocolitica
hemochromatosis - musculosckeletal
arthralgia, arthropathym chondrocalcinosis
pseudogout - treatment
- intra-articular glucocorticoids
- NSAID
- cochicine
pseudogout - diagnosis
- inflammatory effusion; 15-30 wbc
- CPPD crystals (Rhomboid shape, (+) birefringence
- chondrocalcinosis on imaging
attacks of pseudogout often occurs in the setting of
- overuse
- trauma
- surgery
- medical illness
Ankylosing spondilitis - inflammatory back pain (characteristics)
insdious onset atyounger than 40
- symptoms for more than 3 months
- releved with exercise but not rest
- nocturnal pain
Ankylosing spondilitis - complications
- osteoporosis / vert fractures
- cauda equine
- hyperkyphosis
scleroderma - treatment if renal involvement
ACEi
low back pain - physical therapy?
if 6-12 wks pain or longer
low back pain - treatment
acute (less than 6 wks): moderate activity. NSAID or acetaminophen
chronic: consider TCA, duloxetine
Antiphospholipid antibody syndrome - labs
Lupus anticoagulant effect: prolonation of aPTT not reversed on plasma mixing studies
- anticardiolipin antibody
- antibeta2-gp1 antbody
- FP VDRL/PRP
Whipple disease?
infection with gram (+) Trophyrema whippelii)
chronic malabsortive diarrhea, weight loss, migratory, non deforming arthritis, lymphadenopathy ad a low grade fever
PAS (+) Macrophage on small bowel biopsy
smoking - gout
slightly decreases risk
extra symptom of fibromyalgia
muscle tenderness in areas such as the mid trapezius, lateral epincondyle, costochondral junction in the chest etc
a very well known complication of giant cell angitiits
aortic aneurysms –> due to involvement of the branches of the aorta –> serial chest x-rays
cervical spondylolsis
10 % of people older than 50
- history of chronic neck pain
- limited neck rotation lateral bending due to osteoarthritis and 2ry muscle spasm
- sensory deficit due to osteophyte induced radiculopathy
- bony spurs + sclerotic facet joint
Schirmer test
sterile strip of filter paper is placed under lower eyelid –> evidence of dry eyes
2ry amyloidosis (amyloid A) can be 2ry to
- inflammatory arthritis (RA)
- chronic infections
- IBD
- Malignancy
- Vascultisis
2ry amyloidosis - diagnosis
abdominal fat pad aspiration biopsy
2ry amyloidosis - treatment
treat underlying
colchicine for prevention + treatment
gout - xray
punch out erosios with a rim of cortical bone
joint fluid characteristics - normal
clear, less than 200 wbc, less than 25% PMNs
joint fluid characteristics - noninflammatory (eg. Osteoarthtitis)
clear, 200-2000 WBCs, 25% PMNs
joint fluid characteristics - inflammatory (eg. crystals, RA)
translucent or opaque
2000-100.00 WBCs
often more than 50% PMNs
joint fluid characteristics - septic joint
opaque
50000-150000
more than 80% PMNs
Parvovirus B19 infection - signs and symptoms
- most asymptomatic or flulike
- morbiliform rash in adults
- erythema infectiosume: fever, nauseas + slapped cheek rash
- acute symmetric artrhalgias/arthritis: resembles RA)
transient pure red aplasia
(risis if underlying)
parvo B19 - diagnosis
acute: IgM or NAAT for B19
- previous: IgG
- Reactivation: NAAT
possible septic arthrirtis –> … (next step)
obtain synovial fluid
a preexisting factor that increase the risk for 2ry infection of the joint
preexisting joint disorder
septic arthritis vs gout flare (which also can have fever
septic arthritis –> in 3 days
gout –> 12-24 h
lateral epicondylitis - diagnosis
- tederness at epicondyle + proximal extensor muscle
- pain with resisted wrist extension
- pain with passive wrist flexion
rheumatoid nodules
firm, flesh colored and nontender –> typically occur over pressure points (elvbow and extensor surface of the proximal ulna
erythema nodosum in the absence of resp symptoms - next step
chest - x-ray
heel pain - what to think
enthesitis
reactive arthritis - treatment
NSAID
gout - causes
- increased production: 1ry, Myeloproliferative, tumor lysis, HGPT def
- decreaed urate clearance: CKD, thizide/loop diuretics
long term use of cyclophosphamide
hemorrhagic cystitis + Bladder cancer
hydroxychloroquine - SE
optic neuritis
eye examination before initiation
suspicion of SLE - best initial test
ANA (very sensitive: 95-100%)
pyoderma gangrenosum
rapidly progressive and painful ulcer with a purulent base and vilaceous borders
- more than 50% have associated systemic disease (IBD)
- cliically diagnosis after excluding other etioogies (usually with skin biopsY)
- treatment: local or systemic steroids
ecthyma gangrenosum?
hemorhagic pustules with surrounding erythema that evolve into necrotic ulcers
- often due to Pseudomonas and occur MC in neutrpenia and Pseudomonas bacteremia
causes of chronic low back pain
- mechanical
- radiculopathy
- spinal stenosis
- inflammatory
- metastatic
- infectious
back pain and suspicion of cancer or infection - management
x-ray and ESR –> if abnormal MRI
- if not able to do MRI –> radionuclide bone
amount of WBC in synovial fluid in septic arthritis
more than 50.000
meniscal vs ACL injury regarding effusion
ACL: immediate, large, and bloody
Meniscal: later, mild, nonbloody
carpal tunnel - RF
- obesity
- Pregnancy
- DM
- Hypothyroidism
- RA
Carpal tunnel syndrome - clinical presentation
pain + paresthesia in median nerve distrubution
- (+) Phalen + Tinel tests
- severe disease: weakness of thumb abduction + opposition, atrophy of thenar eminenece
Carpal tunnel syndrome - confirmatory test
nerve conduction studies
carpal tunnel syndrome - treatment
- wrist splinting (1st choice)
- glucocorticoid injection (significant weakness or refractory to first choice
- surgery for severe refracory symptoms
NSAID are note effective
carpal tunnel syndrome - sensation in proximal palm?
intact because palmar branch does not pass through the canal
gout - RF
- medications
- surgery, trauma, recent hospitalization
- volume depletion
- diet: high protein, high fat, fructose or sweetened beverages
- heavy alcohol consumption
- underlying medical conditions (HTN, Obesity, CKD, organ transplantation)
factors that decrease risk for gout
- dairy product intake
- Vitamin C
- Coffee
Prevention of future gout attacks
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causes of lumbar spinal stenosis
- degenerative arthritis (spondylosis)
- degenerative disk disease
- thickening of the ligamentum flavum
osteoarthritis - joint involvement
- knees
- hips
- DIP
- 1st carpometacarpal joint
osteoarthitis - examination findings
- hard body enlargement of joints
- reduced range or motion
- CREPITUS
hip osteoarthritis - pain exacerbated by
internal rotation
deep pain
meralgia paresthitica
caused by compression of the lateral femoral cutaneous nerve at the waist –> burning pain and paresthesias at the lateral thight –> unaffectd by motion
impingement of the lumbar nerve roots - hip mobility?
normal
How to confirm diagnosis of ankylosing spondylitis
x-ray of sacroiliax joints (or MRI)
- HLA-B27 is VERY sensitive but not specific (only 5% of HLA-B27 (+) have AS –> not necessary for diagnosis
RA - treatment
all patients should be started on disease modifying antirheumatic agents as soon as possible as joint damage begins early –> NSAID are adjunctive therapies for symptomatic releif but do not reduce disease progression
- Glucocorticid can alo releve symptoms and short term radiographic progression but not preventive eventual joint destruction
- Methotrexate is the best initial choice
RA - do not respond after 6 months
additional DMARD such as TNF as step up
dermatomyositis - management
high dose glucocorticoids PLUS glucocorticoid sparing agent
- screening for malignnacy
shawl sign
dermatomyositis
rash on the chest and lateral neck
MCC of nontraumatic vertebral compression fracture
osteoporosis and osteomalacia
causes of vertebral comprssion fracture
- trauma
- osteoporosis, osteomalacia
- infection
- bone metastasis
- metabolic
- Paget
vertebral compression fracture - clinical presentation
chronic gradual: painless, progressive kyphosis, loss of stature
acute: low back pain + decreased spinal mobility, lying on back, tenderness
avascular necroris - clinical
groin pain on weight bearng
pain on hip abduction + internal rotation- no erythema, swelling or point tenderrnes
avascular necrosis - labs
- no infl markers
- images: crescent sign in advanced stage, MRI is most sensitive
DEXA - when for screening
all women 65 or older and for younger women who have an equivalent risk osteoporotic fracture
DEXA - meaning
dual energy x-ray absorptiometry
lumbar disc herniation - presentation
acute back pain with unilateral radiation down the sciatic nerve to the foot (sciatica) –> usually follows an inciting event and LuMbar flexion makes the pain worse
lumbar stenosis - presentation
back pain in patietns older than 60 –> back pain radiating to the thighs that is worse with lumbar extension and persists while standing still
age related sicca syndrome
exocrine output from lacrimal and salivary glands declines with age, associated with atrophy, fibrosis and ductal dilation of the glunds –> decreased blink rates, oxidative damage, excessive evaporation of teras and use of anticholinergic medication in older individuals can also contribute (think about it if shogren syndrome like but older than 65 and ANA (-))
giant cell arteritis - biopsy vs steroids first
STEROIDS
giant cell arteritis - localized symptoms
- headaches in temporal areas
- jaw claudication (MOST SPECIFIC SYMPTOM)
- polymyalgia rheumatica
- arm claudication: associated bruits in subclavian or axillary areas
- aortic wall thickening or aneurysm
- CNS: TIAs, strokes, vertigo, hearing loss
- visual: amaurosis fugax, anterior ischemic optic neuropathy
most specific symptom of giant cell arteritis
jaw claudication
MC visual manifestation of giant cell arteritis
anterior ischemic optic neuropathy
giant cell arteritis
- polymyalgia only: low dose oral steroids
- giant cell arteritis: intermidiate to high dose oral glucocorticoids
- visual loss: pulse high dose IV glucocorticoid for 3 days follwed by intermediate to high dose oral glucocorticoids
RA - infl markers
increased CRP and ESR during disease activity
IBD arthritis - NSAID
relief arthritis but exacerbate the underlying disease
characteristic of mechanical chronic low back pain
paraspinal tenderness
chronic lower back pain that releif with activity
inflammatory (eg. spondyloarthropathy)
metastatic - characteristic of chronic low back pain
worse at night
extraglandular manifestation of Sjogren syndrome
- Raynaud
- cutaneous vasculitis
- arthralgia/arthritis
- interstitial lung disease
back pain and suspicion of cancer or infection - management
x-ray and ESR –> if abnormal MRI
- if not able to do MRI –> radionuclide bone
paget - labs
- high ALP
- elevated bone turnover markers (urine hydroxyproline)
- normal Ca2+ + P
- x-ray: osteolytic or myxed lytic sclerotic lesions
- bone scan: focal increase in uptake
paget - treatment
biphosphonates
suspicion of hearniated disc or lumbar spondyloysis - best initial step
NSAID (most patients experience spontaneous resolution)
–>MRI if progressive sensory motor deficits, signs of cauda syndrome, concern of abscess
fluoroquinolone mediated tnedinopathy (or rupture)
- most common in Achilles
- within 24 h with a median of 8 days
- stop the drug, avoid exercise, seek medical care
RFs for fluoroquinolone mediated tendinopathy
- older than 60
- female
- normal BMI
- concurrent oral corticosteroid use
- history of organ transplant
