Department of Internal Medicine - Division of Immunology
Educational Goals: Rheumatology
Rotating Residents
and Medical Students
I. Periarticular/Regional/Soft-tissue disorders
- Fibromyalgia
- Know historical features
- chronic, diffuse musculoskeletal pain
- nonrefreshing sleep
- may be associated with other conditions (i.e. RA, etc)
- Know features of musculoskeletal exam
- no synovitis
- normal ROM and strength
- characteristic tender points
- Describe laboratory features
- lab tests are normal
- check TSH; thyroid dysfunction can imitate
- Describe therapeutic options
- Education
- exercise and stretching
- antidepressants to improve quality of sleep
- Low Back Pain
List at least 9 causes and know their distinguishing features
- Inflammatory back disease
- AM stiffness, better with activity
- ABNL SI films
- elevated ESR in young man
- Osseous Malignancy
- Primary
- multiple myeloma
- lymphoma
- Metastatic
- prostate
- breast
- kidney
- thyroid
- ling
- colon
- Mechanical/ Degenerative back (disc) disease
- better with rest, worse with activity
- little AM stiffness
- Visceral
- perforated ulcer
- pancreas
- pyelonephritis
- ovarian dysfunction
- uterine dysfunction
- others
- Abdominal aortic aneurysm
- diminished peripheral pulses
- pulsatile mass in abdomen
- Radiculopathy (disc)
- radicular radiation, focal neuro findings
- worse with valsalva
- cross over pain
- Spinal Stenosis
- "pseudo (neurogenic)claudication"
- better with back flexion
- Spondylolisthesis/Spondylolysis
- young males
- history of trauma
- Vertebral Compression Fracture
- sudden onset of localized pain
- risk factors (age, therapy with steroids, SLE)
- Infection
- TB
- IV drug abusers
- Know the features that suggest urgency in evaluation
- Unrelenting night pain
- Pain at rest
- Progressive symptoms
- Neurologic compromise
- incontinence
- sexual dysfunction
- saddle anesthesia
- known malignancy
- Know features on history and examination (as above)
- Bursitis (know anatomic location, presenting signs and symptoms, and provocative maneuvers)
- Subacromial
- Subdeltoid
- Prepatellar
- Olecranon
- Trochanteric
- Tendinitis/Tenosynovitis (know anatomic location, presenting signs and symptoms and provocative maneuvers)
- Bicipital
- Epicondylitis
- Posterior Tibial Tendinitis
- Rotator Cuff
- DeQuervain's
- Trigger Finger
II. Articular Disorders
- Osteoarthritis
- Primary
- 8 joints/areas typically affected
- DIP
- PIP
- 1st CMC
- Hip
- Knee
- 1st MTP
- cervical spine
- lumbar spine
- Recognize 2 noninflammatory symptoms
- AM stiffness absent or if present, < 30 minutes
- worse with activity, better with rest
- Recognize other historical/clinical findings
- crepitus
- decreased joint motion
- pain
- gelling
- "bony" swelling (Heberden's/Bouchard's nodes)
- warmth and swelling may be present; not typical
- Know 3 x-ray changes typical for osteoarthritis
- nonuniform joint space narrowing
- osteophytes (spurs)
- sclerosis (white areas in subchondral bone)
- Know 6 important treatment options
- analgesics (acetaminophen may be as effective as NSAIDs)
- exercise
- weight loss
- rest
- ambulatory aids
- joint replacement
- Know 2 indications for surgery
- severe pain unresponsive to conservative management
- limitation in function
- Secondary
- Know definition of secondary osteoarthritis
- same clinical features as osteoarthritis
- unexpected joint (i.e. shoulder, wrist)
- usually secondary to an identifiable cause
- Know 3 most common causes
- Hyperparathyroidism
- Hemochromatosis
- Prior trauma or developmental defects
- Erosive osteoarthritis
- Know definition
- osteoarthritis in typical distribution
- has an inflammatory component
- swelling
- redness
- warmth
- pain
- erosions ("gull-wing") can be seen on xray
- Know 2 typical locations
- DIP
- PIP
- Diffuse Idiopathic Skeletal Hyperostosis (DISH)
- Know definition
- bone-forming condition
- ossification occurs at skeletal sites subjected to stress
- has associated stiffness and pain
- Know 3 xray findings:
- flowing osteophytes connecting ³ 4 vertebrae
- normal disc heights
- normal SI joints
- Know most typical location: thoracic spine
- a
- Crystal disorders
- Gout
- List 3 morphologic features for urate crystals
- needle shaped
- strongly birefringent
- negatively birefringent (yellow when aligned parallel to the axis of red compensator on polarizing microscope)
- Name at least 3 drugs used to treat acute gout arthritis
- NSAIDs
- colchicine
- prednisone/ACTH
- NOT ALLOPURINOL OR PROBENECID!
- Know the natural history of untreated gout
- asymptomatic hyperuricemia
- acute gout with intercritical periods
- chronic tophaceous gout
- Know 4 commonly involved joints in acute gout
- 1st MTP (presenting joint in 50%)
- ankle
- mid-foot
- knee
- Describe the opposing effects of low-dose versus high-dose salicylates on uric acid excretion
- low: inhibit excretion (urate retaining)
- high: promote excretion (uricosuric)
- List 3 characteristics of cyclosporine-induced gout
- rapidly progressive
- polyarticular
- tophaceous
- CPPD
- List 3 most common sites of acute pseudogout
- knee
- wrist
- shoulder
- List 3 most common sites of chondrocalcinosis
- wrists
- knee
- pubic symphysis
- List 2 most common metabolic etiologies of CPPD
- hyperparathyroidism
- hemochromatosis
- Basic Calcium Phosphate Disease
- List 3 clinical presentations
- calcific periarthritis (rotator cuff)
- acute pseudopodagra (young woman with swellling 1st MTP)
- Milwaukee shoulder (elderly woman with destructive shoulder arthropathy
- Rheumatoid arthritis
- List 4 inflammatory features of RA
- joint swelling, redness and warmth
- AM stiffness greater than 30 minutes
- weight loss
- fatigue
- List 4 articular features of RA
- polyarticular
- symmetric
- chronic
- inflammatory
- List at least 8 typical joints/groups of joints involved in RA
- PIPs (hands and feet)
- MCPs
- MTPs
- wrists
- ankles
- shoulders
- hips
- knees
- List at least 10 extra-articular features
- Skin (3)
- periungual infarcts
- ulcerative vasculitis
- nodules
- Ocular (2)
- episcleritis
- erosive scleritis
- Cardiopulmonary (4)
- pericarditis/effusion
- interstitial pneumonitis
- pulmonary nodules
- pleural effusions
- Neurologic (2)
- Mononeuritis multiplex
- Cervical myelopathy (C1-C2 subluxation)
- Know 3 clinical and 5 serologic features of vasculitis in RA
- periungual infarcts
- skin ulcerations
- mononeuritis multiplex
- RF
- ESR
- low complements
- cryoglobulins
- List 5 factors that correlate with poor prognosis in RA
- rheumatoid factor
- HLA-DR4
- female sex
- erosive disease
- lower level of formal education
- List 3 medications used for treatment of early RA
- NSAIDS
- Hydroxychloroquine
- Sulfasalazine
- Describe 2 indications for addition of "second line" meds
- development of erosions
- progressive/persistent synovitis
- Know what percentage of RA patients are seropositive
- 80%
- Felty's syndrome
- Know diagnostic triad
- Leukopenia
- Splenomegaly
- RA
- Know 3 clinical features of patients with Felty's
- seropositive (usually high titer), nodular
- erosive RA (may be quiet at time of presentation)
- usually have extra-articular features
- Know major complication
- recurrent infections
- Know 4 therapies
- gold
- MTX
- splenectomy
- Lithium
- Adult-Onset Still's Disease
- Know 4 clinical features
- fever (quotidian)
- "salmon-colored" rash that occurs with fever
- polyarticular arthritis
- lymphadenopathy/hepatosplenomegaly
- Know 4 laboratory features
- leukocytosis
- elevated ESR
- seronegative
- elevated ferritin level
- Spondyloarthropathies
- Common features of spondyloarthropathies
- Know 4 characteristics of inflammatory back pain
- insidious onset
- pain greater than 3 months duration
- morning stiffness > 30 minutes
- symptoms better with exercise, worsened with rest
- Know 2 common pathologic features(different than RA)
- enthesitis
- abnormal bone production
- Know 2 extraspinal, musculoskeletal features
- oligoarticular, asymmetric, arthritis of lower extrem
- dactylitis (sausage digits)
- Know 5 extra-articular features
- Uveitis (Iritis)
- Cardiac
- Aortic insufficiency
- Conduction abnormalities
- Pulmonary fibrosis
- Peripheral neuropathy
- Oral ulcers
- Know therapy of inflammatory back pain
- No medications alter underlying process
- NSAIDs may improve symptoms
- Posture and flexibility exercises very important
- HLA-B27
- Know when obtaining HLA-B27 can be useful:
- patient whose pre-test probability of spondyloarthropathy is moderate (approx 50%)
- Know the prevalence of HLA-B27 in AS, Reiter's, Psoriasis and in the general population
- Ankylosing Spondylitis
White males: 90%
Black males: 45%
- Reiter's
- Psoriasis
with sacroiliitis: 50%
without sacroiliitis: 20%
- General population
Black males: 3-5%a
- Ankylosing Spondylitis
- Know
- back involvement predominates
- 25% may get peripheral arthritis
- Know 5 common radiologic findings
- symmetric sacroiliitis
- vertebral squaring
- "shiny" or "ivory" corners on vertebrae
- syndesmophytes
- joint ankylosis :("bamboo" spine in some)
- Reiter's Syndrome/Reactive Arthritis
- Know classic triad (usually not seen)
- arthritis
- conjunctivitis
- urethritis, cervicitis
- Know 2 initiating events
- dysentery
- sexually transmitted diseases
- Know 2 cutaneous manifestations
- keratodermia blenorrhagicum
- psoriasis-like skin lesions
- seen on palms, soles
- balanitis
- Psoriatic Arthritis
- Know that 5% of patients with psoriasis have arthritis
- Know 5 patterns of arthritis
- Oligoarticular, asymmetric involvement: > 50%
- Symmetric Polyarthritis (like RA): 25%
- Predominant DIP involvement: 5-10%
- Exclusive back involvement: 5%
- Arthritis Mutilans: 5%
- Know that nail changes are associated with arthritis
- 80% with arthritis have nail changes
- Know one characteristic radiologic finding
- "pencil-in-cup" erosions
- Enteropathic arthritis (Crohn's or Ulcerative Colitis)
- Know peripheral arthritis correlates with the activity of the bowel disease; the back disease does not
- Know 2 cutaneous manifestations
- pyoderma gangrenosum
- erythema nodosum
- Infectious Arthritis
- Gonococcal
- Know what demographic features suggest GC
- young, sexually active person
- women especially:
- during pregnancy
- just after menses
- Know 4 articular features
- migratory polyarthralgias in most
- monoarticular arthritis in 40%
- polyarthritis in up to 50%
- tenosynovitis in 67%
- Describe the associated rash
- small papules
- few in number
- frequently missed
- Know the yield of cultures from synovial, urethra/cervix and blood cultures for offending organism; know the yield of gram stain of synovial fluid
- synovial cultures Å in 50%
- blood cultures Å in 20%
- Urethral cultures Å (men) in 60%
- Cervical cultures Å (women) in 85%
- gram stain Å in 25%
- Know a basic treatment regimen
- IV ceftriaxone until significant clinical improvement than switch to oral antibiotics
- Non-gonococcal (adult)
- Know 3 common clinical features
- pain, swelling and severely affected ROM in joint
- usually monoarticular involvement
- fever in most
- Know the 2 joints most commonly affected
- knee (55%)
- hip (11%)
- Know the 2 most common organisms cultured
- Staph aureus (60%)
- Strep (group A) (16%)
- Know 3 unusual organisms and associated conditions
- Pseudomonas - IV drug abusers
- Staph epi - prosthetic joint infections
- Salmonella - patients with sickle cell
- Know at least 3 joints that can be infected in drug abusers that are not typically infected in other patients
- sternoclavicular
- sacroiliac
- pubic symphysis
- Know 3 qualities of joint fluid from an infected joint
- low viscosity
- opaque or purulent
- high WBC (usually > 50,000)
- Know the yield of synovial and blood cultures for offending organism; know the yield of gram stain of synovial fluid
- synovial cultures - nearly 100%
- blood cultures - 50%
- synovial fluid (centrifuged) gram stain
- 75% in staph
- 50% in gram negatives
- Know that serial closed-needle drainage of infected joint fluid is an accepted part of therapy in easily aspirated joints
- Know indications for arthrotomy (or arthroscopic drainage) of septic joint
- hip involved
- long duration (> 3 days since onset)
- prosthetic joint involvement
- difficult to access joint
- loculated fluid
- synovial WBC/volume don't Ø with repeat arthrocentesis
- Have a strategy in mind for empiric antibiotic therapy
- IV nafcillin for suspected community-acquired gram positive infection
- IV vancomycin for suspected MRSA infection
- IV 1st or 3rd generation cephalosporin + nafcillin or vancomycin for suspected gram negative infection
- Viral
- Know 5 viral infections that can present with a symmetric, polyarticular inflammatory arthritis
- Parvovirus B12
- Hepatitis B
- Rubella
- Mumps
- Enteroviruses: Coxsackie and Echoviruses
- Lyme
- Know the etiologic agent and vector of Lyme disease
- agent: Borrelia burgdorferi
- vector: ixodid ticks
- Know the 3 endemic areas in the U.S.
- Northwest: Northern MD to MA
- MN and WI
- Northern CA and OR
- Know the features of Erythema migrans
- erythematous annular lesion with central clearing
- appears 3-30 days after tick bite
- may see satellite lesions
- Know 4 features of early Lyme disease
- Malaise, fatigue
- Lymphadenopathy
- Polyarthralgias/myalgias
- Fever
- Know 3 manifestations of Lyme neurologic disease
- meningoencephalitis
- cranial neuropathies
- bilateral Bell's palsy
- Know the most common manifestation of Lyme carditis
- AV block
- Know the classic presentation of Lyme arthritis
- Intermittent large joint monoarthritis (typically the knee)
- Can be oligoarticular
- Know the therapy for Lyme disease:
- Early and EM: Tetracyclines > Amoxacillin
- Neuro:
- Isolated Bell's: TCN for > 20 days
- Others: Ceftriaxone or IV PCN
- Cardiac: Ceftriaxone or IV PCN
- Arthritis:
- TCN for > 20 days
- IV Ceftriaxone for failures
- Mycobacterium tuberculosis
- Know 3 most common musculoskeletal locations
- back (Pott's disease) in 50%
- Knee in 15%
- hip in 15%
- Know what % with musculoskeletal TB have evidence of coexistent pulmonary infection
- 10-50%
- Know clinical features
- insidious onset
- monoarticular in 85%
- Know synovial fluid findings
- cloudy
- high WBC (10,000 with PMN predominance)
- low viscosity
- Know yield of synovial fluid smear and culture
- smear Å in 20%
- culture Å in 80%
- Fungal
- Know that fungal arthritis has insidious onset and found frequently in patients with underlying debilitating illnesses
- HIV-associated arthritis
- Know 4 musculoskeletal conditions seen in HIV
- Reiter's syndrome
- Psoriatic arthritis
- Fibromyalgia
- Polyarthralgias
- Know that RA is rarely seen in HIV infection
III. Systemic Diseases
- Systemic Lupus Erythematosus
- Know the following clinical manifestations of SLE
- Mucocutaneous (5)
- malar rash
- subacute cutaneous lupus
- discoid lupus
- oral ulcers
- alopecia
- Lymphoreticular (2)
- lymphadenopathy
- splenomegaly
- Cardiovascular-pulmonary (7)
- Plerisy (+/- effusions)
- Pericarditis (+/- effusions)
- Pneumonitis
- Pulmonary hemorrhage
- Pulmonary hypertension
- Endocarditis (noninfectious)
- Raynaud's
- Gastrointestinal (3)
- Peritonitis (serositis)
- Pancreatitis
- Mesenteric vasculitis
- Genitourinary (1)
Glomerulonephritis
- Mesangial
- Membranous
- Membranoproliferative
- Focal Proliferative
- Diffuse proliferative
- Neurologic (4)
- Organic Brain Syndrome
- Seizures
- Psychosis
- CVA/ focal defects
- Hematologic (4)
- leukopenia
- lymphopenia
- hemolytic anemia
- thrombocytopenia
-
? anemia of chronic disease
Serologic (5)
- ANA (Å in 98%)
- Sm
- DsDNA
- False-positive VDRL
- LE cell
- ? SSA/SSB
? hypocomplementemia
- Know 4 most common causes of drug-induced lupus
- Procainamide
- Isoniazide
- Hydralazine
- a methyl dopa (aldomet)
- Describe the 2 dominant features of drug-induced lupus
- arthritis
- serositis
- Describe 5 clinical and serologic features that distinguish drug-induced lupus from native SLE
- males = females
- no renal or CNS disease
- disease resolves after DC offending medication
- no: DsDNA, low complements, Sm
- Diffuse ANA with histone antibodies only
- Know the ACR criteria for SLE
- List 2 manifestations of active SLE that can be treated with the following doses of prednisone
- low (10-20 mg)
- arthritis
- rash
- moderate (20-40mg)
- serositis
- low-grade hematologic abnormalities
- high (> 40 mg)
- active nephritis
- CNS disease
- vasculitis
- severe hematologic abnormalities
- Sjogren's Syndrome
- Know 2 demographic features
- 90% patients are women
- usually after age 50
- Know clinical features
- inflammatory autoimmune process of exocrine glands
- dry eyes with Ø tear production and corneal erosions
- dry mouth (increased risk for dental caries)
- parotid swelling
Extra-glandular features
- arthralgias/arthritis in 60%
- Raynaud's phenomenon in 40%
- lymphadenopathy
- purpura
- increased risk for development of lymphomas
- Know laboratory features
- ANA Å in 90%
- RF Å in 60%
- Hypergammaglobulinemia
- SSA/Ro in 90%
- SSB/La in 80%
- Abnormal lip (minor salivary gland) biopsy
- Antiphospholipid Antibody syndrome (APLS)
- List 5 clinical features of APLS
- recurrent fetal loss
- recurrent venous/arterial thrombosis
- livedo reticularis
- thrombocytopenia
- valvular vegetations
- List 3 laboratory features of APLS
- "lupus anticoagulant"
- prolonged APTT (despite mix with normal plasma)
- prolonged Russell Viper Venom Time
- prolonged Kaolin Clotting time
- False positive VDRL/RPR
- Anticardiolipin antibodies (IgG or IgM) in a moderate or high titer
- Inflammatory myositis
- List the diagnostic criteria for inflammatory myositis
- symmetrical, proximal muscle weakness
- elevation of skeletal-muscle enzymes
- CK
- aldolase
- AST
- ALT
- LDH
- EMG evidence of inflammatory myositis
- muscle biopsy evidence of inflammatory myositis
- need 3 of 4 to make diagnosis of polymyositis and typical skin features (plus 3 of 4 criteria) to make diagnosis of dermatomyositis
- Heliotrope: violaceous discoloration/swelling of eyelids
- Gottron's sign: scaly, erythematous dermatitis over dorsal joint surfaces
- Gottron's rash: above rash elsewhere on body
- Shawl rash: erythema/scaling in V of neck
- Mechanic's hands
- Give a differential diagnosis for inflammatory myositis
- thyroid disease
- neuropathy
- inherited myopathy (i.e. muscular dystrophy)
- electrolyte disorders
- metabolic or mitochondrial myopathy
- Parasitic infiltration (trichosomiasis)
- medication side effect
- toxin exposure
- Give features of inflammatory myositis that differentiate it from neuropathy
- proximal weakness
- sparing of sensation and reflexes
- sparing of facial/pharyngeal muscles
- List 3 most common inflammatory myopathies a) Polymyositis b) Dermatomyositis c) Inclusion Body Myositis
- Know that dermatomyositis is associated with malignancies and what needs to be done to evaluate this
- Complete H & P
- CBC, General Screen, UA
- CXR
- Prostate exam in men
- Breast, mammogram, pelvic and PAP in women
- ? Flex sigmoidoscopy
- Know the clinical/ lab features of the anti-synthetase syndrome
- Laboratory features: antibodies directed against amino acid tRNA synthetases (Jo-1 or histidyl tRNA synthetase is most well known
- Clinical features
- Inflammatory myositis
- Interstitial lung disease
- Raynaud's
- Arthritis
- Mechanic's hands
- Describe approach to suspected steroid myopathy
- no specific tests helpful
- CK NL
- muscle biopsy nonspecific
- EMG usually nonspecific
- provocative challenge with higher dose vs. rapid taper
- Scleroderma
- CREST (limited systemic sclerosis)
- Describe the clinical manifestations of CREST
- Calcinosis
- Raynaud's
- Esophageal Dysmotility
- Sclerodactyly
- Telangiectasias
- Know 1 life-threatening (late) complication of CREST
- pulmonary hypertension
- Describe the extent and time course of skin thickening
- usually limited to hands and forearms
- can be seen on face and neck
- progression very slow
- usually seen after years of Raynaud's
- Describe the natural history of CREST
- NL life-span unless develop pulmonary hypertension
- Centromere antibody predicts good prognosis
- Diffuse Scleroderma
- Describe 6 clinical manifestations
- rapid progression of diffuse skin thickening
- interstitial pulmonary disease
- myocardial fibrosis, pericarditis
- 'scleroderma renal crisis'
- rapid rise in blood pressure
- rapid decline in renal function
- myositis
- arthritis
- Describe the natural history of diffuse scleroderma
- 77% survival at 5 years
- renal, cardiopulmonary disease most common causes of mortality
- SCL-70 (anti-topisomerase) and nucleolar pattern of ANA predict poor prognosis
- Describe the therapeutic goals in 'renal crisis'
- ACE inhibitors dramatically decreased mortality
- rigid control of blood pressure
- Vasculitis
- General
- List 5 common but nonspecific laboratory features:
- ESR/CRP
- Anemia
- Thrombocytosis
- leukocytosis
- Ø albumin
- List 5 causes of pulmonary-renal syndrome
- SLE
- Wegener's Granulomatosis
- Goodpasture's syndrome
- Churg-Strauss
- Microscopic PAN
- Polymyalgia Rheumatica
- List 2 demographic features of PMR
- age > 50 (usually > 60)
- European-American (>95%)
- List 3 clinical or laboratory features
- pain/ache in shoulder/hip girdle
- ESR (usually > 50)
- rapid and dramatic response (within 12-36 hours) to low dose prednisone (10-20mg)
- Giant Cell Arteritis (Temporal Arteritis)
- List 2 demographic features
- age > 50 (usually > 60)
- European-American (> 95%)
- List 6 clinical/laboratory features
- new onset temporal headache
- jaw/tongue claudication
- scalp tenderness
- vision changes (amaurosis fugax or diplopia)
- enlarged, tender temporal artery
- ESR (frequently > 80)
- Describe the diagnostic and therapeutic approach
- ESR, CRP, CBC
- start high-dose corticosteroids (60 mg/day)
- obtain temporal artery biopsy (after starting steroids)
- Polyarteritis Nodosa
- List the following clinical features
- skin (4)
- palpable purpura
- palmar lesions
- livedo reticularis
- digital ischemia
- musculoskeletal (1)
- renal (3)
- glomerulonephritis
- hypertension
- hematuria/proteinuria
- neurologic (2)
- mononeuritis multiplex
- sensorimotor polyneuropathy
- miscellaneous (1)
-
Describe the diagnostic approach
- tissue biopsy showing vasculitis
- vasculitis rarely seen on renal bx
- angiogram showing aneurysms and narrowing
- P-ANCA may be seen in some
- Hepatitis B surface antigen (in ª 15%
- Wegener's Granulomatosis
- List the clinical features
- Upper respiratory tract (4)
- sinusitis
- epistaxis
- serous otitis media
- nasal ulcerations
- Lower respiratory tract (4)
- cough
- hemoptysis
- pulmonary infiltrates
- pulmonary nodules
- Renal (1)
- Musculoskeletal (1)
- Skin (2)
- Systemic (3)
- fever
- malaise
- weight loss
- Describe the diagnosis
- C-ANCA Å in 85-90% with active, systemic disease
- biopsy of tissue showing necrotizing, granulomatous vasculitis
- vasculitis rarely seen on renal biopsy
- Henoch/Schonlein Purpura
- List the classic triad in HSP
- hematuria
- abdominal pain
- palpable purpura (biopsy showing leukocytoclastic vasculitis with IgA deposits)
- Cryoglobulinemia
- Know what cryoglobulins are
- proteins that precipitate at temperatures below body temperature
- associated with a occlusive vasculopathy
- Know the disease most often associated with cryoglobulinemia
- Chronic hepatitis C infection
- Cholesterol Emboli Syndrome
- Know clinical features of cholesterol emboli syndrome
- Purpuric lesions, typically on lower extremities
- Usually follows instrumentation of large, atherosclerotic vessels (cardiac catheterization is prototype)
- May have associated:
- elevated ESR
- low complement levels
- eosinophilia
IV. Bone Disorders
- Osteoporosis (Know risk factors)
- age
- heredity
- gender (female)
- hormonal (estrogen and testosterone)
- tobacco use
- alcohol use
- low activity levels
- low body weight
- drugs
- steroids
- thyroid (if TSH suppressed)
- heparin
- Diseases
- renal failure
- hepatic failure
- myeloma
- hypercalciuria
- falls risk
- Avascular Necrosis
- know typical locations
- femoral neck
- humeral head
- talus
- scaphoid
- Risk factors
- steroids
- trauma
- SLE
- RA
- hemoglobinopathies
- osteoporosis
- Diagnosis:
- MRI: most sensitive
- Plain films: staging system
- CT
- Bone scan
- Most progress and if symptomatic will require surgery
- Insufficiency Fractures
- know definition:
- fracture
- normal or abnormal loading
- structurally weak bone
- know typical clinical features
- usually in elderly females
- usually unaccompanied by significant trauma
- know typical locations
- femoral neck
- vertebral bodies
- sacrum/pelvis
- ribs
V. Neurovascular Disorders
- Reflex Sympathetic Dystrophy
- Know historical and exam features
- hyperpathia (persistent pain after DC stimuli)
- allodynia (pain from nonpainful stimuli)
- vasomotor instability
- pain
- atrophic skin changes
- Know 3 diagnostic modalities that could confirm suspicions
- osteopenia on plain films
- asymmetric uptake on 3-phase bone scan
- chemical sympathectomy & symptom improvement
- Know 2 therapeutic modalities
- physical therapy
- corticosteroids
- Cervical and Lumbar Radiculopathies
- Know 6 common sensory distributions
- C6
- C7
- C8
- L4
- L5
- S1
- Know distributions of deep tendon reflexes
- biceps C5
- triceps C6
- brachioradialis C7
- patellar L4
- Achilles S1
- Entrapment Neuropathies
- Carpal Tunnel Syndrome
- Know 3 presenting features
- pain, paresthesias in 1st-3rd fingers
- can involve wrist and forearm
- typically nocturnal
- Know 5 exam features
- Ø 2-point discrimination
- Ø pinch strength (late)
- thenar atrophy (late)
- Tinnel's sign - tapping over nerve
- Phalen's sign - pressing flexed wrists together
- Know 3 therapeutic options
- splint
- inject
- operate
- Know indications for referral for surgery
- motor involvement
- intractable pain unresponsive to conservative therapy
- Ulnar Nerve Entrapment
- pain, paresthesias in 4th, 5th fingers
- know locations of entrapment
- elbow (cubital tunnel)
- wrist (Guyon's canal)
- Neuroarthropathies
- know clinical features
chronic, painless (in 50%) with deformity
- know typical disease associations
- diabetes ... foot
- syphilis ... lower extremity
- syringomyelia ... upper extremity
- know typical radiologic presentation
- destruction
- debris
- dislocation
- osteophytes
- Raynaud's
- Know typical symptoms: color changes associated with cold
- Know 2 'types' of Raynaud's
- primary (idiopathic)
- secondary (part of systemic autoimmune disease)
- Know 3 features associated with systemic autoimmune disease
- nailfold capillary abnormalities
- ANAÅ
- older age of onset
- Know 2 conservative therapeutic maneuvers
- avoidance of stimuli (cold, etc)
- vasodilators
- Have at least 7 point differential
- Idiopathic
- SLE
- Systemic Sclerosis
- CREST (limited systemic sclerosis)
- Scleroderma (diffuse systemic sclerosis)
- Sjogren's syndrome
- Vasculitis
- Malignancies
- myeloma
- macroglobulinemia
- Previous cold injury
VI. Medications
- Know
- major indications
- drug interactions
- major or unique side effects
- NSAIDS
- Inflammatory arthropathies
- antihypertensives, warfarin
- Ulcers/gastritis, renal insufficiency, bleeding, bruising
- aseptic meningitis with propionic acids
- altered CNS with indocin
- nonacetylated salicylates with no PG inhibition and no platelet aggregation
- Corticosteroids
- Many
- -
- Major Side Effects
- osteopenia
- HPA axis suppression
- immune suppression
- hypertension
- petechiae/bruising
- acne
- hirsuitism
- hyperglycemia
- centripetal fat deposition
- hypokalemia
- striae
- glaucoma
- accelerated cataract formation
- accelerated atherosclerosis
- psychosis/mood disorder
- insomnia
- Hydroxychloroquine
- SLE, RA, cutaneous lesions
- -
- Retinal toxicity, GI
- Sulfasalazine
- RA, Spondyloarthropathies
- -
- GI, cytopenias, LFTs, oligospermia, hemolytic anemia in G6PD deficient patients
- Gold
- RA, Psoriasis
- ACE inhibitors (nitritoid reaction)
- proteinuria, stomatitis, nitritoid reaction, rash, cytopenias
- Methotrexate
- RA, Myositis, SLE, Vasculitis, Sarcoidosis
- sulfa medications, probenecid
- cytopenias, cirrhosis/fibrosis, GI, stomatitis, pneumonitis
- List 4 laboratory tests that need to be monitored periodically
- CBC
- AST
- ALT
- Albumin
- List 2 things to caution patients about when using MTX
- avoidance of alcohol
- effective birth control
- Azathioprine
- RA, SLE
- Allopurinol
- cytopenias, hepatitis, aseptic meningitis, risk for lymphomas
- D-Penicillamine
- RA, Systemic sclerosis
- -
- cytopenias, proteinuria, autoimmune diseases, dysgeusia
- Cyclophosphamide
- SLE, Vasculitis
- ? allopurinol ( marrow toxicity)
- cytopenias, bladder inflammation/malignancy, ovarian failure
- Colchicine
- Gout, CPPD
- -
- GI, cytopenias
- Allopurinol
- indications
- > 1100 mg/24hour urine uric acid
- tophi
- renal insufficiency
- renal stones
- anticipated tumor lysis
- serum uric acid > 11.0 mg/dl (controversial)
- azathioprine
- Allopurinol hypersensitivity syndrome: Know the clinical features:
- occurs in 2-3 %
- 30% who get it have fatal reaction
- occurs 2-3 weeks most commonly after starting it
- fever, eosinophilia, rash
- renal insufficiency may predispose
II. Laboratory Tests
- ANA
Patterns
- Know
- specific or not
- antigens that antibodies are directed against
- Speckled (Most common)
- Nonspecific
- antibody directed against extractable nuclear antigens
- Homogeneous
- Nonspecific
- directed against histone
- Centromere
- Specific
- associated with CREST
- Nucleolar
- Somewhat specific
- associated with Scleroderma
- ESR
- Know that ESR is nonspecific marker of inflammation
- Know Age correction
- Men: Age/2
- Women: (Age + 10)/2
- Know differential of ESR >100
- 33% due to infections
- 33% autoimmnune disease
- 25% malignancy
- RF
- Found in 80% RA patients
- Associated with more agressive disease
- Extractable Nuclear Antigens (know disease association)
- Sm- associated with SLE
- RNP - associated with MCTD
- SSA/SSB - associated with:
- Sjogren's syndrome
- SLE
- Neonatal lupus syndrome
- Miscellaneous (Know disease associations)
- DsDNA
- associated with SLE
- ANCA
- cANCA
- associated with Wegener's Granulomatosis
- pANCA
- associated with microscopic PAN, other vasculitides, limited Wegener's, others
- Jo-1 (anti-histidyl tRNA synthetase)
- associated with polymyositis and interstitial lung disease
- Anti histone antibody
- associated with drug-induced lupus
- HLA
- B27-spondyloarthropathies
- DR4-RA
- DR3-SLE,Sjogren's syndrome
- SCL-70 (anti-topoisomerase)
- diffuse scleroder