UWorld 1 Flashcards
Fibromyalgia presentation
Most commonly in young to middle aged women with widespread pain, fatigue, and cognitive/mood disturbances.
Patients tend to have normal physical exam except for point tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in chest, and greater trochanter.
No specific lab findings. Diagnosed with widespread pain index and symptom severity scale rather than trigger points.
Fibromyalgia tx
Initial FM treatment should emphasize patient education, regular aerobic exercise, and good sleep hygiene.
Patients who do not respond to conservative measures may require meds. TCAs (amitriptyline) are 1st line. SNRIs (duloxetine, milnacipran) and pregabalin are alternate therapies that may be useful in patients not responding to TCAs.
Patients with persistent symptoms may need combo drug therapy, referral for supervised rehab, pain management or CBT.
Fibromyalgia dx
Widespread Pain Index (WPI). Score is 0-19. 1 for each spot.
1) Neck
2) Jaw (L and R)
3) Shoulder (L and R)
4) Upper arm (L and R)
5) Lower arm (L and R)
6) Chest
7) Abdomen
8) Upper back
9) Lower back
10) Hip (L and R)
11) Upper leg (L and R)
12) Lower leg (L and R)
Symptom Severity Scale (SSS). Score is 0-12.
1) Fatigue (0-3)
2) Waking unrefreshed (0-3)
3) Cognitive symptoms (0-3)
4) Somatice symptoms (0-3)
To dx FM you need:
1) WPI of at least 7 and SSS of at least 5. OR WPI of 3-6 and SSS of at least 9.
2) Symptoms present at similar level for 3 months
3) No disorder that would otherwise explain the pain
Manifestations of SLE
Clinical symptoms
1) Constitutional - fever, fatigue, and weight loss
2) Symmetric, migratory arthritis
3) Skin - butterfly rash and photosensitivity. painless oral ulcers.
4) Serositis - pleurisy, pericarditis, peritonitis
5) Thromboembolic events (due to vasculitis and antiphospholipid syndrome)
6) Neuro - cognitive dysfunction and seizures
Lab
1) Hemolyitc anemia, thrombocytopenia and leukopenia
2) Hypocomplementemia (C3 and C4)
3) Antibodies - ANA (sensitive). Anti-dsDNA and Anti-SM (specific)
4) Renal involvement - proteinuria and elevated Cr
Describe the typical joint manifestations of SLE
Arthritis and arthralgias affect 95%. They tend to be migratory, symmetric, polyarticular and are accompanied by brief morning stiffness (much shorter in duration than RA).
Knees, carpal joints, joints of fingers are most often affected. Joint pain often exceeds objective findings on exam. XRs usually show no evidence of joint destruction or erosion (unlike other inflammatory arthritides like RA)
Felty Syndrome
Advanced RA (usually longstanding over 10 years) associated with splenomegaly and neutropenia. Marked morning stiffness.
Diagnosis should not be made without neutropenia!
Behcet Disease
Presents with multiple oral and genital ulcers that are recurrent and painful. Uveitis is common.
Parvo infection - joint manifestation
In adults, most parvo infections are ASx or have flu-like symptoms. Minority of patients develop a symmetric, nonerosive arthritis or aplastic anemia.
These symptoms would not last longer than 3-4 weeks.
Disseminated gonococcal infection - describe the usual presentation
Polyarthralgia, skin lesions, and tenosynovitis. Morning stiffness is rare.
Clinical features of vertebral compression fracture
Causes
1) Trauma
2) Osteoporosis, osteomalacia
3) Infection (osteomyelitis)
4) Bone mets
5) Metabolic (hyperparathyroidism)
5) Paget Disease
Clinical pres
1) Chronic/gradual VCF - painless, progressive kyphosis, loss of stature
2) Acute VCF - low back pain and decreased spinal mobility, pain increasing with standing, walking, lying on back; tenderness at affected level. Can usually point to a specific event like lifting (or a bend, or a cough) where it started.
Complications
1) Increased risk for future fractures
2) Hyperkyphosis, possibily leading to protuberant adbdomen, early satiety, weight loss, decreased respiratory capacity
Absent ankle reflexes
Don’t need to be clinically signifiant. Patients over 70 often have this.
Spinal epidural abscess triad
Fever, severe localized back pain, and neuro defects (motor weakness, paresthesias, bowel/bladder dysfunction)
Lumbar spinal stenosis
Refers to a narrowing of the intraspinal canal, lateral recess, or neural foramen. Patients develop low back pain with neuro symptoms (sensory loss, weakness in legs) that is worse with spinal extension (walking, standing) but improved with leaning forward or lying down. Back pain persists when standing still.
Usually in patients over 60. Look out for pseudoclaudication. Vascular claudication is exertion-dependent and resolves when standing still.
Lumbosacral strain
Usually seen after a specific event or action. Patients typically have increased pain with movement and decreased pain with rest.
In addition, pain is in paraspinal area without significant tenderness to palpation of the vertebra
Lateral epicondylitis
Tennis elbow. Pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle. From backhand in tennis or screwdriver use. Any activity with repeated forceful wrist extension and supination
Degeneration of extensor carpi radialis brevis tendon near lateral epicondyle.
Radial tunnel syndrome
Signs and symptoms similar to lateral epicondylitis and may occur in conjunction with it. Tenderness tends to overlie the extensor muscle wad
Pain is elicited by flexing the patient’s long finger while they are actively extending fingers and wrists.
Rupture of long head of biceps tendon
Causes pain in upper arm and shoulder and prominent bulge in midportion of upper arm.
Paget Disease of the bone (phases)
1) Osteolytic phase - osteoclast dominant.
2) Mixed phase - osteoclast plus osteoblast. Some new bone formation
3) Osteosclerotic phase - blasts dominant. Weak, thickened woven bone
Paget Disease of the bone overview
Patient with bone pain, HA, unilateral hearing loss and femoral bowing would be a typical presentation.
This is the most common bone disorder after osteoporosis (3% of adults over40). Characterized by focal increase in bone turnover, in which osteoclast dysfunction leads to bone breakdown and a compensatory increase in bone formation.
Pelvis, skull, spine and long bones are most commonly involved. Microscopic findings include increased numbers of abnormal appearing osteoclasts with a disorganized mosaic pattern of lamellar bone
Early stage lesions will have a lot of osteoclast activity, later progressing through a mixed phase, a predominantly osteoblastic phase and finally a residual sclerotic phase
Most patients are ASx and are identified incidentally by XR or elevated alk phos. Symptoms may include skeletal deformities, bone or joint pain, and fractures. Enlarging cranial bones may lead to increased hat size, HA, and hearing loss due to entrapment of CN8 or encroachment on the cochlea. Benign giant cell tumors of bone and osteosarcoma can also be seen
Avascular necrosis causes
1) Steroid use
2) Alcohol abuse
3) SLE
4) Antiphospholipid syndrome
5) Hemoglobinopathies (Sickle Cell)
6) Infections (osteomyelitis, HIV)
7) Renal transplant
8) Decompression sickness
Clinical manifestations, labs and imaging for Avascular necrosis
Clinical
1) Groin pain on weight bearing
2) Pain on hip abduction and internal rotation
3) No erythema, swelling or point tenderness
Labs
1) Normal WBC
2) Normal ESR and CRP
Rads
1) Crescent sign seen in advanced stage
2) MRI is most sensitive modality
Osteonecrosis
Caused by occlusion of end arteries supplying the femoral head, leading to necrosis and collapse of the periarticular bone and cartilage.
Osteonecrosis is common in patients with sickle cell disease due to disruption of microcirculation in the bone by sickling as well as increased intraosseous pressure due to bone marrow hyperplasia.
Femoral head has 2 main sources of blood - ascending arteries and the foveal artery, which lies within the ligamentum teres.
Foveal artery is open early in life, but may become obliterated in older patients. For this reason, aseptic necrosis of the femoral head is uncommon in children but the risk rises in older patients
Paget Disease - pathogenesis, labs, imaging and treatment
Pathogenesis - osteoclast dysfunction and increased bone turnover
Labs
1) Increased alk phos
2) Increased bone turnover markers (PINP, urine hydroxyproline)
3) Calcium and phosphorous are usually normal
Imaging
1) XR shows osteolytic or mixed lytic/sclerotic lesions
2) Bone scan shows focal increase in uptake
Tx - bisphosphonates
Polymyositis
Clinical presentation
1) Symmetrical proximal muscle weakness - often in lower extremities and slowly progressive (difficulty negotiating stairs or rising from seated position). Proximal arm weakness usually follows (trouble working with the arms overhead). Patients may develop dysphagia due to involvement of striated muscles of upper pharynx.
2) No/mild pain or muscle tenderness
3) Similar to dermatomyositis but without skin findings
Tests
1) Elevated muscle enzymes (CK, aldolase)
2) Autoantibodies (ANA, anti-Jo-1)
3) Bx (most definitive) - endomysial mononuclear infiltrate, patchy necrosis
Associated conditions
1) Interstitial lung disease
2) Myocarditis
3) Malignancy**
Tx
1) Systemic glucocorticoids
2) Glucocorticoid-sparing agents (methotrexate, azathioprine)
Clinical features of systemic sclerosis (scleroderma)
Systemic
1) Fatigue
2) Joint stiffness and pain
Skin
1) Telangiectasia
2) Sclerodactyly
3) Digital ulcers
4) Calcinosis cutis
Vascular - Raynaud
GI
1) Dysphagia, dyspepsia
2) Angiodysplasia of stomach (watermelon stomach) with GI bleeding
3) Malabsorption due to bacterial overgrowth
4) smooth muscle atrophy and fibrosis of lower esophagus - dysphagia, choking, heartburn, and hoarseness. Manometry shows hypomotility and incompetence of LES
Pulm
1) Pulm fibrosis
2) Pulmonary arterial HTN
Renal
1) Scleroderma renal crisis - acute onset oliguric renal failure with malignant HTN, thrombocytopenia, microangiopathic hemolytic anemia
Cardiac - myocarditis, pericarditis, pericardial effusion
Clinical features of RA
Symptoms
1) Insidious onset, multiple joint pain, stiffness and swelling
2) Morning stiffness lasting hours, improves with activity
3) Small joints (PIP, MCP, MTP) commonly involved
4) Monoarthritis (knees, elbows) can also occur later
5) Spares the DIP joint, unlike OA***
Exam - most commonly affects cervical spine joints in axial skeleton (besides the hands)
1) Affected joints are tender to touch, swollen, with limited ROM
2) Tenosynovitis of the palms leads to trigger finger
3) Rheumatoid nodules (esp on elbows)
4) Cervical joint involvement can lead to spine subluxation leading to spinal cord compression
Labs/Imaging
1) Positive anti-CCP antibodies (diagnostic testing)
2) High IgM RF
3) High CRP and ESR correlate with disease activity
4) XR - soft tissue swelling, joint space narrowing and bony erosions
How high is alk phos in Paget?
Often 10 times normal. Alk phos AKA bone isoenzyme
Urine hydroxyproline
Derived almost exclusively from breakdown of collagen. Levels are high in Paget
What lab values are often normal in Paget?
P and Ca (unless there’s concurrent hyperparathyroidism)
Sjogren Syndrome
Autoimmune condition that most commonly affects women in their fifth or sixth decade of life. Clinical findings include keratoconjunctivitis sicca (xerophthalmia, dry eyes) and xerostomia (dry mouth).
Due to the antimicrobial and lubricating properties of normal saliva, patients with Sjogren will have an increased incidence of dental caries and will complain of difficulty swallowing.
Lymphocytic infiltration of the salivary glands will cause enlargement and firmness to palpation of these glands.
Dx is made when there is subjective and objective evidence of dry mouth and eyes in the presence of either histologic evidence of lymphocytic infiltration of salivary glands or serum autoantibodies directed against SSA (Ro) and/or SSB (La)
Rotator cuff tendinopathy and tear
Rotator cuff impingement or tendinopathy
1) Pain with abduction, external rotation
2) Subacrominal tenderness
3) Normal ROM with positive impingement tests (Neer, Hawkins)
Rotator cuff tear
1) Similar to tendinopathy
2) Weakness with abduction and external rotation
3) Usually age over 40 after fall on outstretched arm
4) MRI confirms
5) surgery within 6w of injury is best
Erythema Nodosum and its workup
It is painful, subQ nodules more common on anterior lower legs. Arthralgias and malaise can develop alongside these nodules. EN is thought to represent a delayed hypersensitivity reaction to antigens associated with various conditions and is often relatively benign with self-resolution in several weeks. EN can be an early sign of more serious disease though, and ID-ing the cause is important. Can be strep, sarcoid, TB, coccidiomycosis, IBD (Crohn’s more than UC), Behcet.
Initial workup includes basic lab tests (CBC, LFTs, renalfunction), antistreptolysin-O antibodies, and TB skin testing.
CXR should be obtained to assess for sarcoid (bilateral hilar LAD, reticular opacities) or with TB. Prevalence of sarcoid in patients with EN is like 28% in some populations.
Absence of pulm symptoms does NOT rule out sarcoid. Still get the CXR (half of sarcoid diagnoses are diagnosed incidentally before symptoms)
Osteomyelitis
IV drug users, those with sickle cell and immunosuppressed peeps are at highest risk of osteomyelitis. Also look out for recent distant site infection (UTI)
Spine is a common site in IV drug users. In this group, staph aureus is most common pathogen, but infections with gram neg’s also occur.
Tenderness to gentle percussion over the spinous process of involved vertebra is most important clue. Pain is often not relieved by rest and fever is an inconsistent finding. WBC may be normal or high. Platelets are often high as a marker of inflammation/stress. ESR is often very high (over 100).
MRI is most sensitive study. Tx is long term IV ABx with or without surgery
Methotrexate mech and adverse effects
Mechanism - Purine antimetabolite
Adverse effects
1) Hepatotoxicity
2) Stomatitis (mouth stuff)
3) Cytopenias (bone marrow suppression)
4) oral ulcers
5) Alopecia
6) Pulmonary toxicity
Taking folic acid seems to reduce adverse effects
Preferred initial DMARD in patients with moderate to severe RA due to established efficacy and safety for long term use.
Leflunomide mech and adverse effects
Mechanism - Pyrimidine synthesis inhibitor
Adverse effects
1) Hepatotoxicity
2) Cytopenias
Hydroxychloroquine mech and adverse effects
Mechanism - TNF and IL1 suppressor
Adverse effects
1) Retinopathy
Sulfasalazine mech and adverse effects
Mechanism - TNF and IL1 suppressor
Adverse effects
1) Hepatotoxicity
2) Stomatitis
3) Hemolytic anemia
TNF inhibitors mech and adverse effects
Adalimumab, Certolizumab, Etanercept, Golimumab, Infliximab
Adverse effects
1) Infection
2) Demyelination
3) CHF
4) Malignancy
usually reserved for patients resistant to initial DMARDs
RA treatment
Goal is to induce and maintain early remission and prevent long term joint damage.
All patients should be started on disease-modifying antirheumatic drugs (DMARDs) as early as possible. These include nonbiologics (small molecules made by conventional chemical synth to target inflammatory paths) and biologics (large molecules made by recomibinant DNA technqies to target cytokines and cell surface proteins)
Viral arthritis due to parvo B19
Viral arthritis presents with acute onset of polyarticular and symmetric arthritis that resolves within 2 months. Parvo is amongst the most common causes of viral arthritis and is particularly likely in adults who have frequent contact with kids, such as day care workers.
Parvo infection in adults most often presents with arthritis/arthralgias involving the MCP, PIP and wrist joints. The slapped cheek rash is unusual in adults. Presence of systemic symptoms is variable.
Distinguished from RA and other symmetric arthritides by acute onset, lack of elevated inflammatory markers and resolution within 2 months
Psoriatic arthritis
Often affects the DIP joints. Dactylitis (sausage fingers), nail findings and psoriasis of skin are characteristic
Pain and stiffness of pelvis and shoulders in older patient
Classic for polymyalgia rheumatica but a markedly elevated ESR is critical for diagnosis
Patellofemoral pain syndrome
One of the most common causes of knee pain in young athletes and predominantly affects women. It is usually triggered by chronic overuse or malalignment (angular deformities, weakness of hip abductors) but can also be seen acutely following trauma
Dx is based on clinical findings with pain localized to anterior knee, usually described as an aching sensation, and worsened with activities such as climbing up or down stairs.
Patellofemoral compression test (reproduction of pain when patella is compressed into trochlear groove) is helpful tho no single finding has high sensitivity or specificity
Initial management includes reduced intensity of exercise (esp running), activity modification, and NSAIDs. Patients should be counseled on stretching and strengthening exercises with an emphasis on quads, knee extensors and hip abductors
Surgery only recommended when patients have failed 6-12months of conservative management
Overview of running injuries of foot and ankle (5)
Stress fracture
1) Insidious
2) Focal pain in navicular or metatarsals - sharp, localized pain and tenderness over a bony surface
3) Risk factors - abrupt increase in intensity of training, poor running mechanics, female with eating disorder
4) Female athlete triad is associated with it (oligomenorrhea, decreased caloric intake, osteopenia/osteoporosis)
Plantar fasciitis
1) Plantar surface of the heel
2) Worse when initiating running or first steps of the day. Better with activity then worse again at end of day with prolonged weight bearing.
Achilles tendinopathy
1) Burning pain or stiffness 2-6cm above posterior calcaneus
Morton neuroma
1) Numbness or pain between 3rd and 4th toes
2) Clicking sensation when palpating space between 3rd and 4th toes while squeezing the metatarsal joints
Tarsal tunnel syndrome
1) Compression of tibial nerve at ankle
2) Burning, numbness, aching of distal plantar surface of foot/toes
3) Usually caused by a fracture of the bones around the ankle.
Morton neuroma
Commonly in runners. Not a true neuroma, but is a mechanically induced neuropathic degeneration of the interdigital nerves that causes numbness, aching, and burning in distal forefoot from metatarsal heads to third and fourth toes.
Symptoms worse by walking on hard surfaces and wearing tight or high heeled shoes
On exam, squeezing the metatarsal joints will cause pain on plantar surface of foot along with crepitus between third and fourth toes (Mulder sign)
Tx - involves metatarsal support with bar or padded shoe inserts to decrease pressure on metatarsal heads. Surgery reserved for patients who fail conservative treatment
Features of ACL injury
Mechanism - rapid deceleration or direction changes, pivoting on lower extremity with foot planted
Symptoms
1) Pain, rapid onset, may be severe
2) A popping sensation at time of injury
3) Significant swelling (effusion/hemarthrosis)
4) Joint instability
Exam
1) Anterior laxity of tibia relative to femur (anterior drawer test, Lachman test)
Dx - MRI
Tx - RICE (rest, ice, compression, elevation) measures plus/minus surgery
What drugs are often linked to achilles tendinopathy?
Fluroquinolones (look for recent treated UTI). Continued use of the med can lead to rupture of the tendon.
Risk is over 60, female, normal BMI, concurrent oral corticosteroid use, history of organ transplant.
Stop drug, avoid exercise and/or use of affected area, and seek medical care for symptom eval and changing to a non-fluoro ABx
Can be within 24h of drug but usually 8d after starting the med is when it start.
Causes of gout
Increased urate production
1) Primary gout (idiopathic)
2) Myeloproliferative/lymphoproliferative disorders (don’t forget PV is a myeloproliferative disorder)
3) tumor lysis syndrome
4) Hypoxanthine guanine phosphoribosyl transferase deficiency (Lesch-Nyhan)
Decreased urate clearance
1) CKD
2) Thiazide/loop diuretics
Presentation of antiphospholipid syndrome
Presents with a thrombotic event (DVT or arterial thrombus) or pregnancy morbidity (fetal loss, severe preeclampsia, placental insufficiency) plus a positive serology for 1 of 3 antiphospholipid antibodies - anticardiolipin, anti-Beta-2glycoprotein-I, or lupus anticoagulant.
Biggest risk factor for APS is SLE. APS occurs in up to 40% of SLE patients.
Minority of healthy patients may develop transient antiphospholipid antibodies so all positive serologies for APS should be repeated at 12w to confirm.
Patients with APS often require anticoagulation for life (heparin product or warfarin) as the risk of recurrent thrombus is high.
For those with concomitant SLE, hydroxychloroquine is also added
Polymyalgia rheumatica
Symptoms
1) Age over 50
2) Bilateral pain and morning stiffness for more than 1 month (usually lasts more than an hour)
3) Involvement of 2 of the following - neck/torso, shoulders/proximal arms, proximal thigh/hip, constitutional (fever, malaise, weight loss)
PE - decreased active ROM in shoulders, necks and hips. Frequently unremarkable
Labs
1) ESR over 40, sometimes over 100
2) High CRP
3) Normocytic anemia possible
4) about 20% can have normal studies
Tx - response to glucocorticoids (low dose prednisone - like 10-20 mg per day). Should result in rapid symptom relief. If not, dx may be wrong.
Often associated with giant cell arteritis (look for HA, jaw claudication, vision loss, tenderness over temporal artery). If this is expected get expedited temporal artery biopsy and give higher dose prednisone (40-60)
Ankylosing spondylitis
Inflammatory back pain
1) Insidious onset at age less than 40
2) Symptoms for more than 3 months
3) Relieved with exercise*** but not rest
4) Nocturnal pain
Exam
1) Arthritis (sacroiliitis)
2) Reduced chest expansion and spinal mobility
3) Enthesitis (tenderness at tendon insertion sites)
4) Dactylitis (swelling of fingers and toes)
5) Uveitis
Complications
1) Osteoporosis/vertebral fractures
2) Aortic regurgitation
3) Cauda equina
Labs
1) Elevated CRP and ESR
2) HLA-B27 association (not specific enough for dx tho and not needed for diagnosis)
Imaging
1) XR of sacroiliac joints** (confirms the dx) - demonstrating radiographic changes to axial skeleton IS needed for diagnosis
2) MRI of sacroiliac joints
When should you suspect ankylosing spondylitis?
It’s more in males, but suspect in ANY young patient with progressive low back pain and stiffness lasting over 3 months
Musculoskeletal causes of back pain (4)
1) Mechanical (muscle strain, spasm, degenerative arthritis) - normal neuro exam, negative straight leg raise, possible paraspinal tenderness
2) Herniated nucleus pulposus/disk disease - radiculopathy (usually L4 L5), possible positive straight leg raise, possible neuro deficits*
3) Spinal stenosis - pseudoclaudication, better with spine flexion, worse with extension, Older age*
4) Compression fracture - older age, more common in women, trauma/fall (may be minor)**
Inflammatory causes of back pain
Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD (PAIR) - better with activity or exercise, no improvement with rest, gradual onset, HLAB27 present***
Malignancy as a cause of back pain
Metastatic cancer to the bone
1) History of malignancy
2) Age over 50
3) Worse at night
4) Unintentional weight loss
5) Cauda equina syndrome - weakness, urine retention/incontinence, saddle anesthesia
Infectious causes of back pain
Osteomyelitis, discitis, abscess
1) Recent infection
2) IV drug use*
3) Diabetes
4) Fever, exquisite point tenderness*
5 common causes of shoulder pain
Rotator cuff impingement or tendinopathy
1) Pain with abduction, external rotation
2) Subacromial tenderness
3) Normal ROM with positive impingement tests (Neer, Hawkins)
Rotator cuff tear
1) Similar to tendinopathy
2) Weakness with external rotation
3) Age over 40. Fall on outstretched arm.
Adhesive capsulitis (frozen shoulder) - glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis and contracture of the joint capsule. Can be secondary to rotator cuff tendinopathy (most common) or idiopathic. Also secondary to fractures and stuff.
1) Decreased passive AND active ROM*** (more than 50% reduction is needed for dx)
2) More stiffness than pain (stiffness out of proportion to pain)
Biceps tendinopathy/rupture
1) Anterior shoulder pain
2) Pain with lifting, carrying, or overhead reaching
3) Weakness less common
Glenohumeral osteoarthritis
1) Uncommon and usually caused by trauma
2) Gradual onset of anterior or deep shoulder pain
3) Decreased active and passive abduction and external rotation
Baker’s cyst
Tender mass located in popliteal fossa. Develops as a result of excessive fluid production by inflamed synovium, as occurs in cases of RA, OA and cartilage tears.
As synovial fluid volume expands, excess fluid accumulates in the popliteal bursa. Popliteal bursa bulges beyond its usual size and fills the fossa producing tender synovial fluid-filled mass
Baker cysts occasional burst and release their contents into the calf, resulting in an appearance similar to a DVT
Risk factors for gout
1) Medications (diuretics, low dose aspirin, allopurinol, cyclosporine)
2) Surg, trauma, recent hospitalization
3) Volume depletion
4) Diet - high protein (meat, seafood), high fat, fructose or sweetened beverages
5) Heavy alcohol consumption
6) Underlying medical conditions (HTN, obesity, CKD, organ transplant)
Lower risk
1) Dairy products
2) Vit C (over 1500 per day)
3) Coffee (at least 6 cups per day)
What bone disease are RA patients most at risk for?
Osteoporosis.
Increased levels of proinflammatory cytokines, corticosteroid therapy, and lack of physical activity may contribute to local (around inflamed joints) or generalized loss of bone mass. There is increased risk of osteopenia, osteoporosis, and bone fractures ESP if other risk factors (low body weight, female, family history of osteoporosis, cigarette smoking, postmenopausal state, excess alcohol use and other comorbidities) are present.
Degree of bone loss correlates with disease activity.
Strategies to prevent bone loss (good physical activity, optimization of vitamin D and calcium intake, minimization of glucocorticoid dose) should be implemented. Most experts suggest low threshold for starting bisphosponate therapy in RA patients.
What is the most common extraarticular manifestation of ankylosing spondylitis?
Anterior uveitis (iritis). It happens in 25-40% of cases. Characterized by inflammation of uveal tract (iris, ciliary body and choroid). Typically presents with intense pain and photophobia in one eye.
What disease is episcleritis associated with?
This is inflammation seen at the white of the eye, without involvement of uveal tract.
Most seen in RA and IBD. Not seen in AS.
Carpal tunnel syndrome
Risk factors
1) Obesity
2) Pregnancy
3) Diabetes
4) Hypothyroidism
5) RA
Clinical
1) Pain and paresthesias in median nerve distribution (first 3.5 digits)
2) Positive Phalen and Tinel tests
3) Severe disease - weakness of thumb abduction and opposition, atrophy of thenar eminence
Confirmatory test - nerve conduction studies
Tx - wrist splinting then glucocorticoid injection then surgery for severe or refractory
