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Line 80: − + − + − + − + − + − + + + + + + + + + + − =Missed Concepts=+ − *Hemochromatosis diagnosis and association with HCC+ − + − *Complications of untreated scaphoid fracture (e.g. non-union, avascular necrosis) − *Chronic exertional compartment syndrome (worse with exertion) vs. tibial stress fracture (pain with standing) vs. shin splints − − *Myotonic dystrophy is autosomal dominant, caused by CTG repeats with genetic anticipation. Classic form presents in adulthood with muscle weakness and myotonia (impaired muscular relaxation). Infantile presentation includes respiratory failure, hypotonia, inverted V upper lip, cataracts, poor feeding, and clubbed foot. Diagnosis is via genetic testing. −
→Missed Concepts
=Missed Concepts=
*Hemochromatosis diagnosis and association with HCC
*Paget disease diagnosis: bony pain, thickened cortex with sclerotic lesions on xray, elevated ALK, normal Ca.
*Treat Paget disease with alendronate (bisphosphanate) if patient has intolerable pain or involvement of weight-bearing bone.
*Complications of untreated scaphoid fracture (e.g. non-union, avascular necrosis)
*Chronic exertional compartment syndrome (worse with exertion) vs. tibial stress fracture (pain with standing) vs. shin splints
*Septic arthritis of the hip in an infant can lack fever, but presents with pseudo paralysis (due to pain), elevated WBCs, elevated CRP, and effusion. *Legg-Calvé-Perthes disease (idiopathic avascular necrosis of the hip) occurs in children aged 3-8, is insidious in onset, and does not have elevated inflammatory markers.
*Myotonic dystrophy (most common form of '''adult onset muscular dystrophy''') is autosomal dominant, caused by CTG repeats with genetic anticipation. Classic form presents in adulthood with muscle weakness and myotonia (impaired muscular relaxation). Infantile presentation includes respiratory failure, hypotonia, inverted V upper lip, cataracts, poor feeding, and clubbed foot. Diagnosis is via genetic testing.
*FOOSH with "sail sign" (fat pad visible on xray), should be immobilized in a splint.
*Osteoporosis can lead to vertebral compression fractures after minimal trauma in elderly patients, manage with '''Tylenol/NSAIDs and PT.'''
*Indications for bariatric surgery include '''BMI > 40''', BMI > 35 with T2DM/OSA/HTN, BMI > 30 w/ T2DM resistant to treatment or metabolic syndrome.
*Raynaud is treated with '''dhp-CCBs like nifedipine'''.
*'''Lateral''' shoulder pain is the most common symptom in torn rotator cuff.
*Scoliosis that '''causes back pain, is rapidly progressive, or associated with neurological symptoms''' may be pathologic (e.g. spinal tumor). Most cases are idiopathic.
*Fracture of Pars interarticularis causes spondylolisthesis
=Systemic Lupus Erythematosus=
=Systemic Lupus Erythematosus=
Autoimmune inflammatory condition caused by antibody-antigen deposition in various tissues.
Autoimmune inflammatory condition caused by antibody-antigen deposition in various tissues.
*H&P: Young women, blacks, hispanics, asians
*H&P: Young women, blacks, hispanics, asians
*Dx: DOPAMINe RASH 4 of 11 criteria, rule out 2° causes (drug-induced lupus SHIPP: sulfonamides, hydralazine, isoniazid, phenytoin, procainamide). Best screening test is ANA (98% sensitivity), most specific are anti ds-DNA, anti-Sm. Complement C3 and C4 levels can also be low, especially during acute flares.
*Dx: DOPAMINe RASH 4 of 11 criteria, rule out 2° causes (drug-induced lupus SHIPP: sulfonamides, hydralazine, isoniazid, phenytoin, procainamide). Best screening test is ANA (98% sensitivity), '''anti-dsDNA''' is relatively sensitive and specific, and '''anti-Sm''' is the most specific, but not sensitive. Complement C3 and C4 levels can also be low, especially during acute flares.
*Tx: NSAIDs for arthritis and mild serositis; hydroxychloroquine for skin and renal disease; for moderate to severe disease, use corticosteroids or anti B cell biologics; for acute flares, use steroid tapers. Test for anti-SSA in patients thinking about getting pregnant, as this antibody can cross the placenta and cause neonatal lupus and complete heart block. If patient has anti-phospholipid antibody syndrome, they need lifelong warfarin.
*Tx: NSAIDs for arthritis and mild serositis; hydroxychloroquine for skin and renal disease; for moderate to severe disease, use corticosteroids or anti B cell biologics; for acute flares, use steroid tapers. Test for anti-SSA in patients thinking about getting pregnant, as this antibody can cross the placenta and cause neonatal lupus and complete heart block. If patient has anti-phospholipid antibody syndrome, they need lifelong warfarin.
*H&P: middle aged women, HLA-DR4 serotype; morning stiffness that lasts > 30 min and improves with activity; Swan Neck deformity (PIP extension, DIP flexion), Boutonniere deformity (PIP flexion, DIP extension), ulnar deviation of MCP.
*H&P: middle aged women, HLA-DR4 serotype; morning stiffness that lasts > 30 min and improves with activity; Swan Neck deformity (PIP extension, DIP flexion), Boutonniere deformity (PIP flexion, DIP extension), ulnar deviation of MCP.
*Dx: 4 criteria for 6+ weeks. 3 or more joints (PIP, MCP, wrist, elbow, knee, ankle); symmetrical joint synovial hypertrophy with cartilage loss and osteoporosis on xray; elevated CRP, ESR (sensitive, not specific), rheumatoid factor (75% sensitive), or anti-CCP (most specific); inflammatory synovial fluid on joint aspiration; rheumatoid skin nodules (elbow most common).
*Dx: 4 criteria for 6+ weeks. 3 or more joints (PIP, MCP, wrist, elbow, knee, ankle); symmetrical joint synovial hypertrophy with cartilage loss and osteoporosis on xray; elevated CRP, ESR (sensitive, not specific), rheumatoid factor (75% sensitive), or anti-CCP (most specific); inflammatory synovial fluid on joint aspiration; rheumatoid skin nodules (elbow most common).
*Tx: NSAIDs and PT; Sulfasalazine, Hydroxychloroquine, or Glucocorticoids for milds disease; Methotrexate, anti-TNF biologics, or corticosteroids for moderate-severe disease; anti-TNF biologics AND corticosteroids for severe disease. Avoid methotrexate in patients with HIV, liver disease, ILD, renal disease, pregnancy, or bone marrow suppression; avoid anti-TNF in patients with TB.
*Tx: NSAIDs and PT; DMARDS (Sulfasalazine, Hydroxychloroquine, Azathioprine) ± Glucocorticoids for mild disease; Methotrexate (1st line), anti-TNF biologics (2nd line) ± corticosteroids for moderate-severe disease; anti-TNF biologics AND corticosteroids for severe disease. Avoid methotrexate in patients with HIV, liver disease, ILD, renal disease, pregnancy, or bone marrow suppression; avoid anti-TNF in patients with TB. Patients taking methotrexate should also get '''folate supplementation.'''
=Osteoarthritis=
=Osteoarthritis=
==Kawasaki Disease==
==Kawasaki Disease==
*H&P: Medium vessel vasculitis; ≥ 5 days fever with at least 4 of 5 other criteria in a child; often Asian
*H&P: Medium vessel vasculitis; ≥ 5 days fever with at least 4 of 5 other criteria in a child; often Asian
*Dx: CRASH and Burn; differential includes acute rheumatic fever from S. pyogenes (no uveitis); CRP is elevated but not required
*Dx: CRASH and Burn criteria for Kawasaki—'''Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet swelling, AND fever ≥ 5 days'''; differential includes acute rheumatic fever from S. pyogenes (no uveitis); CRP is elevated but not required
*Tx: IVIG; Hold off on live vaccines for 12 months after IVIG therapy; get a TTE to eval for coronary artery aneurysm
*Tx: IVIG; Hold off on live vaccines for 12 months after IVIG therapy; get a TTE to eval for coronary artery aneurysm
=Polymyalgia Rheumatica=
=Polymyalgia Rheumatica=
*H&P: proximal muscle pain without weakness, subjective difficulty getting out a chair
*H&P: Age > 50, F>M. Proximal muscle pain and decreased active ROM but no weakness in neck/hips/shoulders, prolonged morning stiffness, subjective difficulty getting out a chair. Symptoms last at least 2 weeks. Fever, malaise, weight loss. Associated with giant cell arteritis.
*Dx:
*Dx: Elevated ESR, normocytic anemia, or normal studies
*Tx:
*Tx: '''Low dose glucocorticoids.''' Follow with a long steroid taper. Symptoms usually resolve rapidly.
=Fibromyalgia=
=Fibromyalgia=
*H&P: Older women, history of depression or trauma, or IBS; widespread chronic muscle pain in pre-defined areas, insomnia, weakness, fatigue
*H&P: Older women, history of depression or trauma, or IBS; widespread chronic muscle pain in pre-defined areas, insomnia, weakness, fatigue
*Dx: WPI 3-6 and SSI > 9, or WPI ≥ 7 and SSI ≥ 5, labs are all negative
*Dx: WPI 3-6 and SSI > 9, or WPI ≥ 7 and SSI ≥ 5, labs are all negative. Order '''CBC, TSH, ESR''' to rule out anemia, hypothyroidism, or inflammatory arthropathy, which can look like fibromyalgia. Ddx includes polymyositis and PMR.
*Tx: TCAs, SSRIs, Gabapentin, Pregabalin, exercise, PT, hydrotherapy, heat, pain psych
*Tx: TCAs, SSRIs, Gabapentin, Pregabalin, exercise, PT, hydrotherapy, heat, pain psych
=Polymyositis and Dermatomyositis=
=Polymyositis=
*H&P: Proximal muscle weakness
*Dx: Elevated CK; Differential includes fibromyalgia and PMR.
*Tx: Can be complicated by '''ILD.'''
=Dermatomyositis=
*H&P: Symmetric proximal muscle weakness. Gottron papules, heliotrope rash
*Dx: Elevated CPK; positive ANA, anti-Jo-1 antibodies
*Tx: High-dose corticosteroids. Screen for malignancy. Screen for ILD with CXR.
=Scleroderma=
=Scleroderma=
*H&P: Women ages 30-65. Skin thickening on the face and extremities.
*Dx: CREST syndrome—Calcinosis, Raynaud's phenomenon, Esophageal dysmotility (GERD), Sclerodactly, and Telangiectasias. It involves the distal extremities and face only, is slowly progressive, has positive anti-centromere antibodies, a fair prognosis, and is associated with pulmonary hypertension. Diffuse scleroderma has generalized skin involvement, is rapidly progressive, has anti Scl-70 (topoisomerase I) antibodies, a poor prognosis, weaker association with calcinosis and telangiectasias, is associated with pulmonary interstitial fibrosis, and is more likely to trigger renal failure. '''Both can cause scleroderma renal crisis, which presents as acute malignant hypertension'''
*Paget disease diagnosis
*Tx: '''ACEI (captopril is preferred) is 1st line for scleroderma renal crisis, even though ACEI are generally avoided in acute renal failure. Also give IV nitroprusside if there is concomitant malignant HTN'''
*Septic arthritis of the hip in an infant can lack fever, but presents with pseudo paralysis (due to pain), elevated WBCs, elevated CRP, and effusion. *Legg-Calvé-Perthes disease (idiopathic avascular necrosis of the hip) occurs in children aged 3-8, is insidious in onset, and does not have elevated inflammatory markers.
*FOOSH with "sail sign" (fat pad visible on xray), should be immobilized in a splint.