RHEUMATOLOGY
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ANKYLOSING SPONDYLITIS
Starts after rest, gets better with exercise. Loss of forward flexion of spine
Anterior uveitis: Pain, photophobia, lacrimation
HLA B27 (+), Apical fibrosis
xray: bamboo spine
MRI sacroiliac with gadolinium (early changes of inflammation)
Associated aortitis
Treatment: stiffness : exercise and PT/ Pain: NSAIDS, Anti TNF Alpha
Starts after rest, gets better with exercise. Loss of forward flexion of spine
Anterior uveitis: Pain, photophobia, lacrimation
HLA B27 (+), Apical fibrosis
xray: bamboo spine
MRI sacroiliac with gadolinium (early changes of inflammation)
Associated aortitis
Treatment: stiffness : exercise and PT/ Pain: NSAIDS, Anti TNF Alpha
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ADULT STILL DISEASE
Arthritis
Sore throat
Rash salmon-colored
High fever that spikes once or twice a day.
YAMAGUSHI CRITERIA
The major criteria
- fever that spikes once or twice daily, lasting at least 1 week
- polyarthritis lasting at least 2 weeks
- A salmon-colored nonpruritic macular or maculopapular rash usually found over the trunk or
extremities during febrile episodes
- leukocytosis (leukocyte count ≥10,000/µL [10 × 109/L]) with at least 80% granulocytes )
The minor criteria
- Sore throat
- lymphadenopathy,
- hepatomegaly or splenomegaly, and
- abnormal liver chemistry studies
- Negative results on rheumatoid factor and antinuclear antibody assays
Treatment: NSAIDS, Steroids, Methotrexate, biological response modifiers
Arthritis
Sore throat
Rash salmon-colored
High fever that spikes once or twice a day.
YAMAGUSHI CRITERIA
The major criteria
- fever that spikes once or twice daily, lasting at least 1 week
- polyarthritis lasting at least 2 weeks
- A salmon-colored nonpruritic macular or maculopapular rash usually found over the trunk or
extremities during febrile episodes
- leukocytosis (leukocyte count ≥10,000/µL [10 × 109/L]) with at least 80% granulocytes )
The minor criteria
- Sore throat
- lymphadenopathy,
- hepatomegaly or splenomegaly, and
- abnormal liver chemistry studies
- Negative results on rheumatoid factor and antinuclear antibody assays
Treatment: NSAIDS, Steroids, Methotrexate, biological response modifiers
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Relapsing Polychondritis
Image from American College of Rheumatology
Image from American College of Rheumatology
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SJOGREN
Tendency to develop Lymphoma. Excisional biopsy LN if lymphadenopathy
Tendency to develop Lymphoma. Excisional biopsy LN if lymphadenopathy
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SCLERODERMA
* Pulmonary: Associated with Pulmonary Artery Hypertension (loud P2, fixed split S2, isolated low DLCO)
* GI:
- Related to bacterial overgrowth.
- The presence of fatigue and anemia should make you suspect of Gastric antral vascular ectasia (GVE), also known as watermelon stomach.
- Chronic intestinal pseudo-obstruction (CIPO), chronic or recurrent episodes of abdominal pain, distention, nausea, vomiting, and obstipation; abdominal imaging showing distended loops of small bowel
* Skin: cutaneous telangiectasias as well as mucosal telangiectasias
* Kidney: Scleroderma Renal Crises, give ACEi (also on pregnancy)
* Pulmonary: Associated with Pulmonary Artery Hypertension (loud P2, fixed split S2, isolated low DLCO)
* GI:
- Related to bacterial overgrowth.
- The presence of fatigue and anemia should make you suspect of Gastric antral vascular ectasia (GVE), also known as watermelon stomach.
- Chronic intestinal pseudo-obstruction (CIPO), chronic or recurrent episodes of abdominal pain, distention, nausea, vomiting, and obstipation; abdominal imaging showing distended loops of small bowel
* Skin: cutaneous telangiectasias as well as mucosal telangiectasias
* Kidney: Scleroderma Renal Crises, give ACEi (also on pregnancy)
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GOUT AND PSEUDOGOUT: The 2 most common crystal-induced arthropathies
Gout is caused by monosodium urate monohydrate crystals.
Pseudogout is caused by calcium pyrophosphate crystals.
Gout is caused by monosodium urate monohydrate crystals.
Pseudogout is caused by calcium pyrophosphate crystals.
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SHOULDER PAIN
Biccipital tendinitis: overuse injury. Anterior shoulder pain with forearm supination or elbow flexion.
Frozen Shoulder or adhesive capsulitis: decreased range of shoulder motion resulting from stiffness
Rotator cuff tendinitis: Pain when reaching overhead or lying on the shoulder. The passive painful-arc maneuver assesses the degree of impingement. . Pain with resisted mid-arc abduction is a specific finding for rotator cuff tendinitis.
Rotator Cuff Tear: arm weakness on abduction and/or external rotation. Inability to smoothly lower the affected arm from full abduction)
Biccipital tendinitis: overuse injury. Anterior shoulder pain with forearm supination or elbow flexion.
Frozen Shoulder or adhesive capsulitis: decreased range of shoulder motion resulting from stiffness
Rotator cuff tendinitis: Pain when reaching overhead or lying on the shoulder. The passive painful-arc maneuver assesses the degree of impingement. . Pain with resisted mid-arc abduction is a specific finding for rotator cuff tendinitis.
Rotator Cuff Tear: arm weakness on abduction and/or external rotation. Inability to smoothly lower the affected arm from full abduction)
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ELBOW PAIN
Olecranon Bursitis
Lateral Epicondylitis or Tennis Elbow
Medial Epicondylitis or Golfer's elbow
Olecranon Bursitis
Lateral Epicondylitis or Tennis Elbow
Medial Epicondylitis or Golfer's elbow
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WRIST and HAND PAIN
Carpal Tunnel Syndrome
Ulnar Nerve Entrapment
Quervain Synovitis: pain on radial aspect of wrist, > when carrying baby. Radialstyloid process tenderness. Tx splint / steroids/ surgery
Digital Sinovitis Stenosans or Trigger Finger: Finger on flexion on PIP. Tx: Surgery
Dupytrens contracture: Stiffness of ulnar aspect of hand. Thickening and contracture of palmar fascia. Unable to extend 3rd and 4th finger.
DM Cheiropathy: Unable to extend completely the fingers. Common on DM. Can't bring MCP of both hands together.
Carpal Tunnel Syndrome
Ulnar Nerve Entrapment
Quervain Synovitis: pain on radial aspect of wrist, > when carrying baby. Radialstyloid process tenderness. Tx splint / steroids/ surgery
Digital Sinovitis Stenosans or Trigger Finger: Finger on flexion on PIP. Tx: Surgery
Dupytrens contracture: Stiffness of ulnar aspect of hand. Thickening and contracture of palmar fascia. Unable to extend 3rd and 4th finger.
DM Cheiropathy: Unable to extend completely the fingers. Common on DM. Can't bring MCP of both hands together.
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FIBROMYALGIA
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KNEE PAIN
Iliotibial Band Syndrome: Pain on lateral aspect of knee, radiates upward toward thigh. Worse on jogging or cycling. Snap on flexion.
Chondromalacia of the patella (patellar-femoral syndrome): Knee stiffness ater sitting long time (Movie goer sign) . Burning on inner and outer aspect of patella and behind. Worse on physical activity. Tx: decrease running, quadriceps strengthening,analgesics.
Osgood Schatter Disease: pain on extending knee, anterior knee pain below knee joint.
ACL tear: popping knee. Drawer and Lachman's sign positive.
Meniscal tear: "knee locks or gives away", popping on external rotation. McMurray's test positive.
Lateral Collateral Ligament Tear: Varus test positive.
Medial Collateral Ligament Tear: Pain medial aspect of knee. Can't pivot or twist. Valgus test positive.
Iliotibial Band Syndrome: Pain on lateral aspect of knee, radiates upward toward thigh. Worse on jogging or cycling. Snap on flexion.
Chondromalacia of the patella (patellar-femoral syndrome): Knee stiffness ater sitting long time (Movie goer sign) . Burning on inner and outer aspect of patella and behind. Worse on physical activity. Tx: decrease running, quadriceps strengthening,analgesics.
Osgood Schatter Disease: pain on extending knee, anterior knee pain below knee joint.
ACL tear: popping knee. Drawer and Lachman's sign positive.
Meniscal tear: "knee locks or gives away", popping on external rotation. McMurray's test positive.
Lateral Collateral Ligament Tear: Varus test positive.
Medial Collateral Ligament Tear: Pain medial aspect of knee. Can't pivot or twist. Valgus test positive.
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AVASCULAR NECROSIS OF THE KNEE OR OSTEONECROSIS
Less common cause of knee pain. The pain is on weight bearing.
A segment of bone in the femur just above the knee loses its blood supply and begins to die.
Etiology: In most cases, the cause is unknown. It is associated with steroid use, obesity, and various diseases.
Xray shows: density changes; subchondral radiolucency; cysts; sclerosis; and, eventually, joint-space narrowing.
Left Image: An x-ray showing avascular necrosis. Reproduced from Johnson TR, Steinbach LS, eds: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 544.
Less common cause of knee pain. The pain is on weight bearing.
A segment of bone in the femur just above the knee loses its blood supply and begins to die.
Etiology: In most cases, the cause is unknown. It is associated with steroid use, obesity, and various diseases.
Xray shows: density changes; subchondral radiolucency; cysts; sclerosis; and, eventually, joint-space narrowing.
Left Image: An x-ray showing avascular necrosis. Reproduced from Johnson TR, Steinbach LS, eds: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 544.
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ANKLE SPRAIN
- Grade I sprains: stretching of a ligament with mild pain and swelling but no joint instability or difficulty ambulating, do not seek medical care.
- Grade II sprains: involve partial tears, moderate pain and some difficulty bearing weight.
- Grade III sprains: complete rupture of ligaments with significant swelling, tenderness, and an inability to bear weight.
Complications of sprains: 15% fractures of the ankle or midfoot;
The Ottawa ankle rules. When to xray? when there is bone tenderness at the posterior edge of either malleolus, pain and bone tenderness in the midfoot, or an inability to bear weight.
- Grade I sprains: stretching of a ligament with mild pain and swelling but no joint instability or difficulty ambulating, do not seek medical care.
- Grade II sprains: involve partial tears, moderate pain and some difficulty bearing weight.
- Grade III sprains: complete rupture of ligaments with significant swelling, tenderness, and an inability to bear weight.
Complications of sprains: 15% fractures of the ankle or midfoot;
The Ottawa ankle rules. When to xray? when there is bone tenderness at the posterior edge of either malleolus, pain and bone tenderness in the midfoot, or an inability to bear weight.
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MERALGIA PARESTHETICA
Patient with DM
Burning sensation and numbness in anterior and lateral thigh
Pain worsens on abduction of thigh and exercise.
Palpation of RLQ in inguinal area triggers the pain
Compression of anterior femoral nerve
Tx: weight loss, local steroids
Patient with DM
Burning sensation and numbness in anterior and lateral thigh
Pain worsens on abduction of thigh and exercise.
Palpation of RLQ in inguinal area triggers the pain
Compression of anterior femoral nerve
Tx: weight loss, local steroids
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ANTISYNTHETASE SYNDROME
Nearly one third of patients with an inflammatory myopathy have the antisynthetase syndrome.
Symptoms: acute / subacute onset of fever; fatigue; Raynaud phenomenon; synovitis; interstitial lung disease; mechanic’s hands.
Diagnosis: antisynthetase antibodies (most common is the anti–Jo-1 antibody) .
Risk for developing interstitial lung disease.
Image: Mechanic Hands
Nearly one third of patients with an inflammatory myopathy have the antisynthetase syndrome.
Symptoms: acute / subacute onset of fever; fatigue; Raynaud phenomenon; synovitis; interstitial lung disease; mechanic’s hands.
Diagnosis: antisynthetase antibodies (most common is the anti–Jo-1 antibody) .
Risk for developing interstitial lung disease.
Image: Mechanic Hands
POLYMYALGIA RHEUMATICA
Hip and shoulder pain.
Management: low-dose prednisone (10 to 20 mg/d); once these symptoms are controlled, the prednisone dosage can then be tapered. If recurs increase prednisone to dose before flair and add methotrexate. Methotrexate in particular has been shown to be an effective steroid-sparing agent in patients with polymyalgia rheumatica.
Hip and shoulder pain.
Management: low-dose prednisone (10 to 20 mg/d); once these symptoms are controlled, the prednisone dosage can then be tapered. If recurs increase prednisone to dose before flair and add methotrexate. Methotrexate in particular has been shown to be an effective steroid-sparing agent in patients with polymyalgia rheumatica.
HENOCH-SCHONLEIN
Henoch-Schönlein purpura self-limited , characterized by purpuric rash, arthralgia, abdominal pain, and renal involvement. Skin biopsy shows leukocytoclastic vasculitis accompanied by perivascular IgA deposition. Management is short-term prednisone.
Henoch-Schönlein purpura self-limited , characterized by purpuric rash, arthralgia, abdominal pain, and renal involvement. Skin biopsy shows leukocytoclastic vasculitis accompanied by perivascular IgA deposition. Management is short-term prednisone.