Rheumatology: - Syrian - Notes - CK - 2 - Step - Usmle - Pieces/8806 - Bits - CK - 2 - Step - Student - HTML

http://www.usmle-forums.
com/usmle-step-2-ck-bits-pieces/8806-usmle-step-2-ck-notes-syrian-
student.html
Rheumatology
OSTEOARTHRITIS
Cervical spondylosis ( cervical OA): history of chronic neck pain ,Limited neck
rotation , lateral bending ( due to osteoarthritis and secondary muscle spasm )
,Sensory deficit ( due to osteophyte induced radiculopathy) ,people older than 50
years of age, and the Typical radiographic findings include bony spurs and sclerotic
facet joints
Obesity is a major risk factor for osteoarthritis .Hence weight loss is the most
Best effective measure in osteoarthritis management
SYNDROMS
Radial tunnel syn: pain in the muscles around the radial head+exam:extend the
finger while the middle finger is flexedcause paindifferentiate it from lateral
epicondylitis .
Diagnosis of Mixed Connective Tissue Disease (MCTD) is made when serology

shows positive anti-RNP antibodies and clinical features of SLE, polymyositis and
systemic sclerosis are present simultaneously
Always consider thyroid abnormalities and fibromyalgia in a patient with diffuse

muscle aches and excessive fatigue with non-restorative sleep,so you have to check
for thyroid function test and CK enzyme after making the diagnosis of fibromyalgia
cauda equina syndrome occurs as a result of compression of lumbosacral nerve

roots by infection or tumor. Usual presentation is with urinary retention or overflow
incontinence Important physical findings include saddle anesthesia around the anus
or perineum and decreased tone of anal sphincter
Leriche syndrome occurs as a result of atherosclerotic vascular disease and is

characterized by impotence and intermittent(vascular) claudication, Physical
findings of patient with intermittent claudication may show absent or diminished
pulses below the level of stenosis. low temperature of the involved extremity, bruit,
impaired wound healing, increased venous filling time, shiny skin, hair loss, and
atrophy of skin
Anserine bursitis having pain over the medial tibial plateau just below the joint line
+history of trauma+ On examination, there is a well-defined area of tendemess over
the medial tibial plateau just below the joint line Valgus stress test does not
aggravate the pain (positive in the collateral ligament trauma) X-ray of the tibia is
normal
Subacromial bursitis is characterized by shoulder pain, which is absent at rest but

present on overhead activity Range of active shoulder movements are limited by
pain Neer's impingement sign (pain on passive internal rotation and forward flexion
at shoulder) is present. No atrophy of shoulder muscle is present .Ultrasonogram or
MRI qeneralty confirms the diagnosis Treatment is conservative with NSAIDs
Reflex sympathetic dystrophy is a syndrome of pain and swelling associated with
vasomotor instability Any extremity may be involved but is more common in the hand
Usually there is associated movement restriction in the shoulder. Direct injury, neck
and shoulder injuries, or myocardial infarction can cause this condition .Examination
reveals a discolored limb with atrophic changes X-ray reveals osteopenia. bone
scan shows increased uptake Physicaltherapy is done to restore function
Prednisone is indicated in resistant cases. Stellate ganglion block is also very
effective
Fibrornyalgia is a chronic widespread pain disorder associated with fatigue, poor

sleep, and depression Patients have multiple trigger points of tendemess
Amitriptyline and cyclobenzaprine have been shown to be effective in the
treatment of fibromyalgia
Chronic fatigue syndrome although resembles Fibrornyalgia, patients
mostly complain of extreme fatigue and not body aches No trigger points can be
demonstrated; symptoms should be present for at least 6 months to make the
diagnosis of chronic fatigue syndrome
Lofgren's syndrome is an acute form of sarcoidosis and consists of triad of bilateral

ankle arthritis (some times knees, wrists or elbows), erythema nodosum and bilateral
hilar adenopatlry(+RF,+ANA)
Systemic steroids are the drugs of choice in sarcoidosis Know the indications
for their use in this disease
Nerve conduction studies are very useful in diagnosing the carpal tunnel
syndrome
Erythema nodosum (EN) is characterized by pink to reddish painful, subcutaneous,

nodules that usually develop in a pretibial location on the anterior surfaces of both
legs in women ages 15-40 years. Erythema nodosum is seen in many diseases:
1) Sarcoidosis often presents with EN as an initial symptom Chest x-ray in these
patients may typically reveal bilateral hilar lymphoadenopathy
2) TB so do PPD in the high risk group
3) IBD so order GI follow -through
De quervemns disease is characterized by tendoni tis of abductor pollicis longus

and extensor pollicis brevis as they pass beneath the retinacular pulley It occurs in
Washerwomen in whom these tendons were chronically irritated by wringing the
clothes and post parturn females due to repetitive lifting of the infant
Leg Pain:
Baker cyst rupture: painful calf in RA joint..

Cellulitis of calf: diffuse infection of deep layers of skin ,Presence of fever,
inflammatory signs, no crepitus or bullae and signs of overlying skin necrosis
also toe web tinea pedis, which is one of the most common portals of entry for the
microorganisms, causing cellulitis, high-grade fever,Lymphangitis (linear streaks of
erythema along the thigh)
DVT: the same as cellulitis but there are risk factor for that: orthopedic surgery, or
prolonged immobilization.
Necrotizing fasciitis: is a deep-seated cellulitis It should be suspected in a patient
who has evidence of overlying skin necrosis, bullae, with anesthesia due to
destruction of nerves, crepitus due to gas producing organism, and fever
sclerosing panniculitis is acute tender lesion over the medial malleolus It usually
occurs in a patient with venous stasis of lower limb
shoulder pain:
Frozen shoulder should be suspected when an Old patient presents with stiffness
and limited range of both active and passive motion over head and all directions.
Tx: NSAIDs + steroid injection +rehab.
Rotator cuff tear or rotator cuff tendinitis presents with severe pain and weakness
of the shoulder abduction .Movements of shoulder like positioning the arm above the
shoulder aggravate pain .Range of motion is limited only on active movement but is
normal on passive flexion .A positive drop arm sign, with inability to actively maintain
90 degree of passive abduction, may be present in large tears Rotator cuff tendinitis
can be distinguished from rotator cuff tear by injecting
Iidocaine that wiII result in improvement in range of motion in cases of rotator cuff
tendinitis but no effect in range of motion in cases of rotator cuff tears.
RA
Corticosteroid-induced avascular necrosis of the femoral head usually presents as
progressive hip or groin pain without restriction of motion range and normal
radiograph on earty stages MRI is gold standard for the diagnosis of avascular
necrosis of hip
Acute Parvovirus infection :Joint involvement in Parvovirus infection is symmetrical

Hands, wrists, knees and feet are the most frequently involved joints Rash may or
may not be present .Patient may have arthralgias or arthritis Joint involvement
most frequently occurs in adult female. Detection of Anti-B19 IgM antibodies is the
diagnostic study of choice
Ankylosing spondylitis
Regular exercise/physiotherapy is the only beneficial treatment that halts the
progression of the ankylosing spondylitis
Sulfasalazine is effective for symptom control of peripheral join t involvement and no
role in halting the disease progression
Plain X-ray of the Sacroiliac joint is the next best step in a suspected patient of
ankylosing spondylitis and if it is negative or equivocal ,do CT scan,then MRI.
Young patients with high spiking fevers associated with characteristic salmon
colored evanescent rash, arthralgias, and leukocytosis most likety have adult
stills disease
SLE
AntiSm antibodies are high specific for SLE but they are not very sensitive (30-
40%)
Again, though oral contraceptive pills are safe in most patients with SLE, patients
with the increased risk of thrombosis (anti phospholipid and nephrotic syndrome) and
active renal involvement should avoid its use
Eye examinations at 6 months to 1 year intervals should be performed in all patients

who are taking hydroxychloroquine
Diffuse proliferative glomerulonephritis is the severest form of glomerular disease

inpatients of systemic lupus erythematosus (SLE). Hematuria, proteinuria, renal
insufficiency, hypertension, marked hypocomplementemia and marked elevation of
anti-DsDNA are all present
LOPUS NEPHROPATHY
Kidney biopsy is indicated to guide the treatment in all systemic lupus
erythematosus patients with renal involvement. especially in those cases
where renal involvment is less severe with miId proteinuria and hematuria or when
presentation is of nephrotic syndrome with bland urinary sediment. Therapy is then
directed by pattern of glomerular involvement. There are five patterns of renal
involvement and treatment of each type is different. Type I and type II requires no
treatment. Extensive type III, and all type IV require immunosuppression Type V
requires treatment when proliferative lesions are superimposed.
Corticosteroids are the mainstay of treatment; usually IV methylprednisolone is
used Immunosuppressive agents, like cyclophosphamide, may be needed when
response to steroids is inadequate to improve renal disease or the disease is
aggressive .Serial measurement of anti-dsDNA and C3 levels is used to monitor
response to treatment .Anti-DsDNA antibodies are prirnarity involved in the
pathogenesis of lupus nephritis
Chronic renal failure is the most common cause of death in systemic lupus
erythematosus patients.
GOUT
Prophylactic allopurinol is the most effective method to prevent gout in patients at risk
for tumor lysis syndrome,also adequate hydration help.
Cessation of alcohol and staying on a low purine diet are important measures in
the prevention of future attacks in patients with acute gouty arthritis
Hyperparathyroidism ,hemochromatosis, transfusion hemosedrosis,

hypothyroid, hypomagnesimia and hypophosphatemia ( all of them cause
increase Ca) patients are more prone for pseudogout .
In patients with frequent attacks of acute gouty arthritis not controlled by

colchicine, a24-hour uric acid levels in urine is determined .This evaluates wether
hyperuricemia is due to under secretion of uric acid(<800)(in this case NS id
uricosuric) or over production (>800) in this case the next step is allopurinol
VASCULITIS
The triad of occlusive disease of the arteries (young), migratory superficial

thrombophlebitis(old), and Raynaud's phenomenon in a smoker male is classic of
Buerger's Disease(Berger disease is IgA nephropathy)
HCV infection is associated with 80% cases of mixed essential cryoglobulinemia

vasculitis.
Thoracic aortic aneurysm is a serious complication of giant cell

arteritis(TA,PMR,Takayasseu) which can be fatal so such patient must be monitored
continuously
GERIATRIC RHEUMATOLOGY
Back pain
1) Lumbar spinal stenosis: Pain of neurogenic claudication radiates back to the

buttocks, upper or lower legs; it becomes better with sitting or leaning forward due to
flexion of the lumbar spine or hips and gets worsened by extension of the lumbar
spine . Wide gait ( as drunken sailor) and positive Romberg sign are specific but
not sensitive for lumbar spinal stenosis . Pain of herniated disc syndrome becomes
worsened with sitting and lumbar flexion and therefore is different from pain of spinal
stenosis
MRI is the investigation of choice for suspected lumbar spinal stenosis
2)In patients with (herniated disk) acute mechanical back pain without significant
neurologic deficit,conservative approach is preferred for a period of 4-6 weeks This
includes early mobilization, muscle relaxants, and NSAIDs( Bed rest and
physicaltherapy has not been shown to be helpful) .
If the pain persists after 4-6 weeks of conservative treatment or progressive
neurologic deficit evolves. High-resolution diagnostic modalities are usually
employed MRI and CT with or without contrast
3)Lumbago (Lumbosacral strain) is usually related to physical strain and has less
dramatic onset .Usually paravertebral muscle tendemess rather than spinal
tenderness is the feature
4)A compression fracture of the vertebrae is a common complication of advanced

osteoporosis It usually manifests as acute back pain without an obvious preceding
trauma in a predisposed patient Neurologic examination will be normal
Dupuytren's contracture occurs in patients over the age of 50, commonty with
historyof diabetes mellitus, chronic alcoholism, epilepsy, or tuberculosis It is also
associated with Peyronie's disease, retroperitoneal fibrosis, and Reidel's
thyroiditis. It manifests as contracture of palmer fascia and nodular thickening of the
third and the fourth fingers with inability to extend completely No functional loss
occurs. Steroid injections are helpful in some patients In others surgical ligation may
be used
The most common cause of asymptomatic elevation of alkaline phosphatase and

NL level of calcium and phosphorus in an
elderly patient is Paget's disease.

Rheumatology: - Syrian - Notes - CK - 2 - Step - Usmle - Pieces/8806 - Bits - CK - 2 - Step - Student - HTML

Uploaded by

Copyright:

Available Formats

Rheumatology: - Syrian - Notes - CK - 2 - Step - Usmle - Pieces/8806 - Bits - CK - 2 - Step - Student - HTML

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Rheumatology: - Syrian - Notes - CK - 2 - Step - Usmle - Pieces/8806 - Bits - CK - 2 - Step - Student - HTML

Uploaded by

Copyright:

Available Formats

http://www.usmle-forums.

Diagnosis of Mixed Connective Tissue Disease (MCTD) is made when serology

Always consider thyroid abnormalities and fibromyalgia in a patient with diffuse

cauda equina syndrome occurs as a result of compression of lumbosacral nerve

Leriche syndrome occurs as a result of atherosclerotic vascular disease and is

Subacromial bursitis is characterized by shoulder pain, which is absent at rest but

Fibrornyalgia is a chronic widespread pain disorder associated with fatigue, poor

Lofgren's syndrome is an acute form of sarcoidosis and consists of triad of bilateral

Erythema nodosum (EN) is characterized by pink to reddish painful, subcutaneous,

De quervemns disease is characterized by tendoni tis of abductor pollicis longus

Baker cyst rupture: painful calf in RA joint..

Corticosteroid-induced avascular necrosis of the femoral head usually presents as

Acute Parvovirus infection :Joint involvement in Parvovirus infection is symmetrical

Eye examinations at 6 months to 1 year intervals should be performed in all patients

Diffuse proliferative glomerulonephritis is the severest form of glomerular disease

for tumor lysis syndrome,also adequate hydration help.

Hyperparathyroidism ,hemochromatosis, transfusion hemosedrosis,

In patients with frequent attacks of acute gouty arthritis not controlled by

The triad of occlusive disease of the arteries (young), migratory superficial

HCV infection is associated with 80% cases of mixed essential cryoglobulinemia

Thoracic aortic aneurysm is a serious complication of giant cell

1) Lumbar spinal stenosis: Pain of neurogenic claudication radiates back to the

MRI is the investigation of choice for suspected lumbar spinal stenosis

4)A compression fracture of the vertebrae is a common complication of advanced

The most common cause of asymptomatic elevation of alkaline phosphatase and

You might also like