Term
| A 60 yr old presents w/ symmetric pain located in shoulders and hips, morning stiffness, no systemic symptom). Pain without weakness. ESR is 99 and Hgb is low all else is WNL. What other really serious condition should you screen him for? |
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Definition
| GCA is present in 15% of patients with Polymyalgia Rheumatica PMR...PMR is present in 50% of patients w/ GCA |
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Term
| To be sure of your diagnosis of PMR, what should you do? |
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Definition
| Prednisone diagnostic challenge...he'll feel better the next morning and you should put him on low-dose steroids and monitor him for side effects! |
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Term
| In dermatomyositis, an inflammatory myopathy, what clinical signs should you look for? |
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Definition
| Gottron’s sign (red, scaly lesions over extensor surfaces of knuckles or elbows), heliotrope rash around eyes, shawl sign, mechanic’s hands (dry, scaly, cracking hands), periungual erythemia (red base of nails) |
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Term
| An 8 year old black girl presents with significant proximal muscle weakness in both upper and lower extremities, but with no pain. You suspect ________ and look for ___(3)_____ in lab tests. You want to spare the child of the SES of prednisone...So you give her _______? |
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Definition
a) inflammatory myopathy (___myositis)
b) elevated CK, EMG abnormalities and muscle biopsy to see inflammation
c)DMARD |
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Term
| Coincidentally you next see an older patient with similar symptoms and you perform lab tests that also cause you to reach the diagnosis of an inflamm myopathy. What do you suspect this is associated with? |
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Definition
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Term
| Fibromyalgia is a condition involving incorrect processing of pain and sensory information. T/F |
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Definition
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Term
| An Iraq war veteran who had been recently in a combat mission for several months comes to you complaining of excessive sensitivity to loud noises, and various seemingly unrelated pain syndromes including TMJ syndrome, migraines, and ENT problems. You suspect ______, and look for which biomarkers on spinal tap? |
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Definition
Fibromyalgia:
Increased CSF levels of glutamate
Normal/high levels of CSF enkephalins
Decreased CSF levels of biogenic monoamines (products of serotonin, norepinephrine) |
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Term
| For a FM patient, which therapies work best? |
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Definition
| Exercise, CBT for coping strategies, and pharmacotherapy with dual S/NE RIs (Tricyclic antidepressants: amitryptiline, nortriptyline. Cyclobenzaprine, Venlafaxine, duloxetine, milnacipran) |
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Term
| Which therapy does not work well for FM patient: SSRI, S/NE RIs, morphine, tramadol, anticonvulsants. |
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Definition
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Term
| Govind, a 23yo guy wakes up with morning stiffness, and has had nocturnal pain that has kept him up at night for the past 3 months. His ass hurts (and it's not from bhangra practice, which you note actually improves the pain!). You see him walking outside and he's got a hunched back (and it's not him trying to walk with style like he normally does). What radiographic finding are you likely to get when imaging which areas of concern (list 2)? |
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Definition
1) Sacroiliac joint: erosion of joint spaces (starts in synovial portion), eventual fusion (ankylosis) limiting range of motionand
2) Spine: BAMBOO spine involving thoracic and cervical spine |
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Term
| Now that you cleverly picked up on govind's ankylosing spondylitis, name 3 other conditions you are most likely to find in him? |
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Definition
| Anterior uveitis (1/3), inflamm bowel disease, and neurologic symptoms from spinal fracture. |
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Term
| You would probably find a positive HLA B27 test in Govind. True/False |
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Definition
Nope. He ain't white.
If patient has convincing inflammatory-type back pain, absence of HLA-B27 helpful to rule out AS…IF patient is a Caucasian male |
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Term
| Which therapy is the best for Govind? NSAIDs, glucocorticoids, anti-TNF, hip replacement, breathing exercises |
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Definition
| anti-TNF agents most beneficial |
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Term
| A patient has done some research online and comes to you thinking he has has Gout...Lo and behold it's Dr. Shlafer. But you note that he has DIP, PIP, MCP of a single finger all involved. What early sign could have told you that he would develop a condition that's associated with the HLAB27 and is a seronegative sondyloarthropathy that does also assymetrically involve the SI joint, but is NOT ankylosing spondylitis. |
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Definition
| Nail pitting is often a first sign in psoriatic arthritis |
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Term
| Mr. Hefeweisen was a former Nazi and now gets around in the nursing home. He got chlamydia and now is having difficulty peeing, seeing, and bending his knee...What does he have? |
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Definition
| Reactive arthritis, o Sterile arthritis developing after a non-articular infection, o Other organisms: Salmonella, Shigella, Yersinia, Campylobacter |
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Term
| Patient presents with a history of inflammatory bowel disease and now is complaining peripheral LE limited movement at the joints. Which treatment is best for him? Inflimab, etanercept, Ibuprofen, colectomy for his Crohn's |
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Definition
| Inflimab...B/c Etanercept: doesn’t work for bowel disease. Colectomy only works for ulcerative colitis => arthritis remission. |
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Term
| Name 2 extraarticular manifestations of Reactive arthritis? |
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Definition
Keratoderma blenorrhagicum
Circinate balanitis
Urethritis
Oral ulcers
Acute anterior uveitis |
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Term
| An IVDU but HIV negative lady comes in with a fever, limited flexion/extension at the right knee. What finding upon joint aspiration will you rely on to tell you it's septic arthritis? + blood cultures, + gram stain, high WBCs, gout crystals. |
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Definition
| Assume SA until proven otherwise. High WBC (>50,000), high PMNs, Gram Stain + in 60-80%, Blood cultures + in 50%. can have coexistent crystalline arthritis, so DO NOT rule out septic arthritis and assume it is gout if crystals are found until cultures come back negative. |
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Term
| A school teacher comes in saying standing and walking or lying supine causes a vague/diffuse pain in buttock and thigh (less in the lower back) which gets better upon sitting. What do you think she has? Central canal stenosis, radiculopathy, Sacroiliac involvement, psychogenic condition, or a Pars interarticularis stress fracture? |
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Definition
| CCS: o Flexing the spine makes the spinal canal slightly wider => less ischemia and pain to the nerve roots |
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Term
| A college student comes in and you find she has nerve root tension signs with dermatomal distribution. On PE you find her ability to walk on her heels is impaired and patellar reflex slightly affected. What's her deal? L3, L4, L5, S1 or S2-S4 radiculopathy? |
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Definition
| only L4 can cause both of these |
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Term
| QUIZ: Patient has key findings of Saddle numbness, tremendous back pain, Achilles reflex affected, incontinence and pooping issues. What treatment should be done right away? |
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Definition
| Surgery: Amount of time between onset of symptoms and surgery is key to re-establishing continence. Disc has to herniate straight back to cause this – not as common as other radics |
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Term
| In India, Govind would see these little scrawny guys trying to do heavy squats. One of these dinky gujus stopped doing them and began doing lunges instead...and could only do them bending his back to avoid pain. What's his Dx? and How can you figure it out? |
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Definition
Pars interarticularis stress fracture, o “Scotty dog with collar” = spondylolysis… can progress to “Scotty dog decapitated” = spondylolisthesis
Bone scan, reproduce pain standing on one foot |
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Term
| QUIZ: A construction worker comes in complaining that he can't sit without pain...His occupation alerts you to the diagnosis of _______? And what is this due to? |
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Definition
| Discogenic pain. o Often misdiagnosed/missed. Probably a tear in the posterior annulus fibrosis |
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Term
| Which physical exam test is best for Sacroiliac pain? |
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Definition
faber's at the ipsilateral hip...
or
Resisted hip abduction
Passive reverse straight leg raising (pt supine, knee at 90) |
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