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TiKi TaKa CK RHEUMATOLOGY
TiKi TaKa CK RHEUMATOLOGY
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. SLE:
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. Young, African American woman.
. Aged 20 - 40 ys.
. Fatigue "Anemia".
. Painful oral ulcers.
. Non deforming arthritis.
. Hematologic abnormalities "pancytopenia".
. Low grade fever.
. Weight loss.
. Malar or discoid rash.
. Lupus Arthritis as RA involves MCP & PIP BUT "NO DEFORMITIES".
. ERYTHEMA NODOSUM:
-------------------
. Painful S.C. pre-tibial nodules.
. Associated with SARCOIDOSIS.
. Ask for a CXR to detect sarcoidosis.
. CXR: Bilateral hilar adenopathy.
. AFRICAN AMERICAN FEMALE !
. Cough, Arthritis & uveitis.
.. Cellulitis:
--------------
... Infection of skin & S.C. tissue.
... Risk factors: Obesity & Tinea pedis !
... Red, edematous skin that is hot to touch.
... Regional lymphadenopathy.
... Caused by STAPH & STREPT Group A.
. OSTEO-ARTHRITIS (OA):
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. Old age.
. Affects hands & weight bearing joints.
. Mild morning stiffness < 30 mins (RA > 1 hour).
. Pain ++ with exercise & -- by rest.
. Bony crepitus, bony enlargement.
. Painful & - range of motion.
. Synovial fluid analysis: 200-2000 WBCs,
. (Normal 0-200 & Inflammatory 2000-50000 & Septic arthritis >50000).
. X-ray: -> NARROWED JOINT SPACE.
. X-ray: -> OSTEPHYTE FORMATION.
. X-ray: -> SUBCHONDRAL CYSTS.
. GOUTY ARTHRITIS:
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. Middle aged male.
. Acute joint pain (1st Metatarsophalangeal joint is the most common).
. Swelling & -- range of motion.
. Low grade fever.
. Synovial fluid analysis is cirtical for diagnosis,
. WBCs 2000-50000,
. NEEDLE shaped, NEGATIVELY bireferingent crystals under polarized light.
. NEGATIVE gram stain & culture.
. ++ serum Uric acid is neither sensitive nor specific !!
. Tx of acute attack --> INDOMETHACIN (Cot'd in RF or GIT bleeding) & COLCHICINE.
. TREATMENT ----> NSAIDs, Colchicine & steroids.
. PREVENTION ---> Allopurinol & probenicid.
. PSEUDO-GOUT:
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. Calcium pyrophosphate dihydrate (CPPD) deposition.
. Acute onset, pinful , monoarthropathy affecting the knee.
. Synovial fluid ---> RHOMBOID shaped with POSITIVE +ve birefringence.
. Ass. with HYPERPARATHYROIDISM:
.. ++ Ca & -- PO4 --> constipation & excess urination.
.. Disease of GROANS (Abd. pain), STONES (urinary) & Psychic MOANS.
. OSTEO-ARTHRITIS:
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. Narrowed joint space.
. Osteophytes.
. Suchondral sclerosis or cysts.
. Obesity is the most common risk factor.
. Weight loss is the best initial ttt.
. HERNIATED DISC:
-----------------
. Pain worsens with sitting.
. Low bk pain & sciatica.
. +ve stress leg test.
. VERTEBRAL METASTASIS:
-----------------------
. Low bk pain.
. H/O of malignancy.
. Weight loss.
. CONSTANT DULL PAIN.
. Failure to improve with conservative therapy.
. Osteomyelitis:
---------------
. Caused by STAPH. AUREUS.
. Tx-> Ox, Clox, Dicloxacillin.
. VIRAL ARTHRITIS:
------------------
. Secondary to PARVO-virus 19 infection.
. Similar presentation as Rheumatic arthritis !
. Arthritis --> PCP & PIP & wrists.
. Resolves within just 2 months !!
. H/O of frequent contact with children e.g. day care workers.
. SARCOIDOSIS:
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. AFRICAN AMERICAN FEMALE.
. Lung involvement --> Cough & dyspnea.
. Erythema nodosum.
. Anterior uveitis.
. Acute polyarthritis.
. Parahilar adenopathy.
. ++ ACE enzymes (Give ACE Is)!
. Biopsy: Non caseating granuloma.
. Tx: SYSTEMIC GLUCOCORTICOIDs.
. FIBRO-MYALGIA:
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. WOMEN 20-50 ys.
. Point tenderness in at least 11 - 18 points !!
. H/O of generalized musculoskeletal pain not related to another illness.
. Disturbed sleep, easy fatiguability.
. Normal lab values.
. Tx: TCAs e.g AMITRIPTYLINE.
. DERMATOMYOSITIS:
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. Proximal extensor ms inflammatory myopathy.
. Violaceous poikiloderma.
. Periorbital edema with rash "Heliotrope sign".
. Rash on chest & lateral neck "Shawl sign".
. Rash on the knuckles, elbows & knees "Gottron's sign".
. Lichenoid papules "Gottron's papules".
. Anti-Mi-2 Abs.
. Ass. with internal malignancies "Most common is OVARIAN CANCER" !
. POLYMYOSITIS:
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. Slowly progressive proximal muscle weakness of the lower limbs.
. Difficulty with stair climbing.
. Difficulty with rising from a seat.
. Muscle tendrness.
. Best diagnostic test ---> MUSCLE BIOPSY.
. LUMBAR STRAIN:
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. Follow twisting of the bk while lifting heavy objects.
. ++ by activity & -- by rest.
. No point tendrness.
. SPINAL STENOSIS:
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. Low bk pain at lumbar spine,
. ++ with activity.
. DISK HERNIATION:
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. LBP radiating down the buttock,
. +ve straight leg raise test.
. ANSERINE BURSITIS:
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. Anserine bursa is located antero-medially over the tibial plateau,
. just below the joint line of the knee.
. Inflammation may be due to overuse or trauma.
. LOCALIZED pain over the ANTEROMEDIAL tibia.
. Valgus stress test -->-ve. "Ruling out Medial collateral ligament injury".
. NORMAL X-ray.
. Tx: Cortico-steroids injection into the bursa.
. Pre-patellar bursitis:
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. Pain & swelling directly over the patella.
. WHIPPLE's disease:
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. H/O of malabsortion diarrhea (Steatorrhea, flatulence, abd. distension).
. Weight loss.
. Migratory arthritis.
. caused by Tropheryma Whippelii.
. Dx: Small intestinal biopsy ---> PAS +ve macrophages in the lamina propria.
. Disseminated Gonococcemia:
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. Migratory polyarthritis.
. Skin lesions (Pustules) on the extremeties.
. Tenosynovitis.
. High fever & chills.
. Blood & pustule culture --> NEGATIVE (Need specific growth requirements).
. SJOGREN $YNDROME:
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. Women 50 - 60 ys.
. Kerato-conjunctivitis sicca (Xerophthalmia & dry eyes).
. XEROSTOMIA (dry mouth).
. Lack of normal amount of saliva -> Dental carries & dysphagia.
. Enlargement & firmness of the salivary glands.
. Histology -> Lymphocytic infiltration of the salivary glands.
. +ve Anti-SSA(Ro) & or Anti-SSB(La).
. SYSTEMIC SCLEROSIS:
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. AFRICAN AMERICAN FEMALE.
. Widespread organ involvement.
. Esophagus -->GERD.
. Heart ------> Rt Heart failure.
. Kidney -----> hypertension.
. Most common cause of death is PULMONARY ARTERIAL HYPERTENSION.
. +ve Anti-topo-isomerase-I Abs = +ve Anti-Scl70.
. SUB-ACROMIAL BURSITIS:
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. Subacromial bursa lies between the acromion & the tendon of the supraspinatous
ms.
. caused by chronic microtrauma to the supraspinatous tendon.
. e.g. overhead work or tennis playing.
. Tendrness hen the arm is internally rotated & forward flexed at the shoulder.
. No signs of deltoid atrophy.
. De QUERVAIN TENO-SYNOVITIS:
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. NEW MOTHERS who hold their babies with out-stretched thumb (ABDUCTED &
EXTENDED).
. Affects tendons of abductor pollicis longus & extensor pollicis brevis.
. Passive stretch of these tendons elicits pain.
. Chronic Tophaceous Gout:
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. Metatarsophalangeal joint is the most affected.
. Severe swelling & pain in the big toe.
. Due to deposition of the monosodium urate crystals "PODAGRA".
. U.A. crystals ---> Nephrolithiasis.
. Urate crystals may deposit in the soft tissues forming tumors "TOPHI".
. Tophi may ulcerate & drain a chalky material.
. H/O of water-pills intake for hypertension "THIAZIDEs".
. Hydrochlorothiazide ---> Hypovolemia ---> ++ U.acid reabsorption.
. BEHCET's $YNDROME:
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. Recurrent oral ulcers.
. Recurrent genital ulcers.
. Eye lesions: Anterior uveitis.
. Skin lesions: Erythema nodosum.
. Tx: Corticosteroids.
. More common in TURKISH, ASIAN & MIDDLE EASTERN population.
. Best initial ttt in cases of DISK HERNIATION is NSAIDs & EARLY MOBILIZATION.
. SLE ARTHRITIS:
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. Cortico-steroid induced "AVASCULAR NECROSIS" of the femoral head.
. Progressive hip or groin pain.
. without restriction of motion range.
. Normal radiograph on early stages.
. Dx: MRI is the gold standard.
. LUMBOSACRAL STRAIN:
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. Most common cause of pain.
. Pain starts acutely after physical exertion.
. Pain concentrated in the lumbar area.
. No radiation to thighs.
. Paraspinal tendrness.
. Normal neurological exam.
. -ve straight leg raising test.
. Tx: NSAIDs & early mobilization.
. HERNIATED DISK:
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. Pain radiation to thighs.
. +ve straight leg raising test.
. CERVICAL SPONDYLOSIS:
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. Due to BONY SPUR.
. Age > 50ys.
. H/O of CHRONIC NECK PAIN is TYPICAL.
. Limited neck rotation & Lateral bending.
. Sensory deficits due to osteophyte induced radiculopathy.
. X-ray --> ** BONY SPURS & sclerotic facet joints.
. X-ray --> ** Narrowing of disk spaces.
. X-ray --> ** Hypertrophic vertebral bodies.
. LUMBAR STRAIN:
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. Related to lifting a heavy object.
. No radicular signs.
. Good response to conservative therapy.
. Pt education -----> KEEP THE BACK STRAIGHT WHILE LIFTING AN OBJECT !
.METHOTREXATE:
--------------
. inhibits dihydrofolate reductase.
. SE: Macrocytic anemia (MCV > 100 & -- Hb).
. Other SEs: Nausea, stomatitis, rash, hepatotoxicity, Alopecia.
. HYDROXYCHLOROQUINE:
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. GI distress.
. Visual disturbances.
. Hemolysis in G6PD defeciency.
. CYCLOPHOSPHAMIDE:
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. Nephrotoxicity & Bladder carcinoma.
. SPINAL STENOSIS:
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. Bk pain radiating to the buttocks & thighs.
. Numbness & paresthesia may occur.
. Symptoms r worse during walking & lumbar extension,
. while lumbar flexion alleviates the pain.
. Dx: MRI.
. ANKYLOSING SPONDYLITIS:
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. Young men < 40 ys.
. Low bk pain & stiffness.
. Worse in the morning & improves as the day progress.
. Ass. e' anterior Uveitis (Monocular pain,blurring,photophobia).
. X-ray pelvis --> SACRO-ILIITIS.
. -ve RF & +ve ESR.
. +ve HLA B 27.
. Tx: Pain relief & TNF Alpha antagonists.
. VERTEBRAL OSTEOMYELITIS:
-------------------------
. Injection drug user.
. Pts with sickle cell disease.
. immunocompromized pts.
. STAPHYLOCOCCUS AUREUS.
. TENDERNESS to GENTLE PERCUSSION.
. Pain not relieved by rest.
. Fever & ++WBCs --> UN-RELIABLE !
. ++ Platelet count.
. ++ ESR > 100 mm/hr.
. Dx: MRI.
. Tx: Long term IV Antibiotics.
. EPIDURAL ABSCESS:
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. Enclosed infection in the epidural space.
. Bk pain, fever, chills & leukocytosis.
. More common in injection drug users.
. It may cause SPINAL CORD COMPRESSION.
. LL weakness & Urinary incontinence.
. Acute epidural abscess requires immediate surgical debridement.
. COMPRESSION #:
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. due to VERTEBRAL BODY DEMYELINIZATION.
. Intense focal pain.
. Without neurological symptoms.
. Occur in cases of osteomalacia or osteoporosis.
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. Disruption of bone vasculature.
. Corticosteroid related osteonecrosis of the right femoral head.
. H/O Excessive Alcohol ingestion.
. Slowly progressive anterior hip pain with limitation of range of motion.
. Dx: MRI.
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. Septic arthritis.
. Crystal induced arthritis.
. Trauma.
. Pts with RA are at high risk of developing septic arthritis esp. with STAPH.
AUREUS.
. RA:
----
. MORNING STIFFNESS > 1 hour.
. Small joints (MCP & PIP).
. Spares DIP "Unlike OA".
. Tenosynovitis (Trigger finger).
. Rheumatoid nodules (Elbow).
. Cervical joint involvement ---> Spine sublaxation ---> Spinal cord compression.
. +ve Anti-CCP Abs.
. +ve RF.
. ++ CRP & ESR.
. X-ray: Soft tissue swelling , joint sapce narrowing & bone erosions.
. Both Obstructive & Restrictive lung disease cause -- in FEV & FEV 1 !
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. But .. RESTRICTIVE lung disease cause much more -- in FEV 1 than Obstructive
type.
. So .. In RESTRICTIVE lung dis. FEV 1 / FEV is > 80 %.
. Examples of RESTRICTIVE causes:
--------------------------------
.. Interstitial lung disease.
.. Neuromuscular diseases.
.. Chest wall abnormalities.
. Ankylosing spondylitis -> costovertebral joint fusion -> chest wall motion
restriction.
. ENTHESITIS:
------------
. Inflammation & pain at ligaments & tendons attached to bone.
. Associted with Negative spondylo-arthropathies,
. e.g. ANKYLOSING SPONDYLITIS, psoriatic arthritis & reactive arthritis.
. Associated with HLA B 27.
. Most common sites are shoulder & hip.
. FIBROMYALGIA:
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. Women 20 - 50 ys.
. Generalized musculoskeletal pain in absence of joint swelling or lab
abnormalities.
. Excessive tendrness on palpation of at least 11 of 18 soft tissue locations.
. The sites include the upper quadrants of the buttocks & medial aspect of the
knees.
. As well as Sternocleidomastoid & Trapezius muscles.
. Absent of joint swelling or ms weakness.
. PSORIATIC ARTHRITIS:
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. DIP.
. Dactylitis --> SAUSAGE shaped digits = diffusely swollen fingers.
. Nail involvement: pitting & oncholysis "separation of nail bed".
. Well demarcated red palques with silvery scaling.
. Tx: NSAIDs & MTx.
. Steroids are contraindicated.
. PSEUDO-GOUT = CHONDRO-CALCINOSIS:
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. Acute arthritis.
. Due to CPPD Calcium pyrophosphate dehydrate crystals deposition.
. H/O of recent surgery or medical illness.
. Synovial fluid analysis --> RHOMBOID shaped, POSITIVELY birefringent crystals.
. GOUT synovial fluid analysis --> NEEDLE shaped, NEGATIVELY birefringent
crystals.
. BAKER CYST:
------------
. Due to excessive fluid production by an inflammed synovium.
. Occurs in cases of Rheumatoid Arthritis.
. Excess fluid accumulates in the popliteal bursa which expands,
. creating a tender mass in the popliteal fossa.
. May burst & release their contents into the calf,
. resulting in an appearance similar to DVT.
. AMYLOIDOSIS:
-------------
. Ass. with Nephrotic $ (facial swelling, LL edema, massive proteinuria).
. Palpable kidneys.
. Hepatomegaly.
. Cardiomegaly (Audible S4).
. H/O of chronic infections e.g. Bronchiectasis & recurrent pulm. infections.
. Tx: COLCHICINE.
. OSTEO-ARTHRITIS:
-----------------
. Age > 50 ys.
. Morning stiffness < 30 mins.
. Bony tendrness.
. Bony enlargement.
. CREPITUS on active motion.
. No warmth i.e. COOL joint !
. SLE Arthritis:
---------------
. Like RA but --------> NO PERMANENT DEFORMITIES.
. SEPTIC ARTHRITIS:
------------------
. H/O of PROSTHETIC joint.
. Red, hot, swollen, painful joint with limited range of motion.
. ++ WBCs > 50000.
. STAPH. AUREUS is the most common causative organism.
. Disseminated Gonococcemia:
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. H/O of recent unprotected sex with a new partener.
. A triad of Polyarthralgia + Tenosyvovitis + Vesiculo-pustular skin lesions.