IM Rheum and MSK

Question 1

The spine usually isn’t involved in RA, with the exception of this one severe complication

Answer 1

• The atlantoaxial joint (between the atlas and axis) has synovial pockets, and as such may be affected in RA
• May subluxate (become misaligned) in RA due to the swelling of the synovium
• This can result in compression of the cervical spinal cord, causing anesthesia, progressive spastic quadriparesis, and sensation abnormalities

Question 2

Adolescent idiopathic scoliosis

Answer 2

Lateral curvature of the spine that often presents in kids age > 10

Spinal X-ray can show Cobb angle (angle of curvature of spine). Cobb angle > 10 degrees is consistent with scoliosis.

Risk factors: Female sex, age >12, skeletal immaturity, severe curvature (Cobb > 25), and most importantly sexual immaturity (bone growth spurt hasn’t hit yet!)

Question 3

Ddx of neck pain

Answer 3

Question 4

Rheumatologic picture with pancytopenias is likely to be. . .

Answer 4

. . . SLE

No other rheum condition causes pancytopenias

Question 5

DMARDs

Answer 5

• Disease-modifying anti-rheumatic drugs
• Actually improve outcomes rather than just providing symptom relief
• Methotrexate is usually first (even in women who are child-bearing age)

Question 6

Secondary causes of pseudogout

Answer 6

• Hyperparathyroidism
• Hypothyroidism
• Hereditary hemochromatosis

Question 7

Patients with SLE on steroids are at high risk for. . .

Answer 7

. . . avascular bone necrosis, especially of the femoral head.

Diagnose w/ MRI.

Question 8

Complex regional pain syndrome

Answer 8

Question 9

Clinical manifestations of amyloidosis

Answer 9

Question 10

The chief complaint of polymyalgia rheumatica is often. . .

Answer 10

. . . joint stiffness, especially in the neck, shoulders, pelvic girdle

It lessens as the day goes on, like most other inflammatory myalgias

Question 11

Disntinguishing fibromyalgia, polymyositis, and polymyalgia rheumatica

Answer 11

Question 12

Treating symptomatic primary Raynaud’s

Answer 12

• Smoking cessation
• Avoid triggers
• Avoid OTC nasal decongestants
• Dihydropyridine CCBs (amlodipine, nifedipine)

Question 13

Wide Ddx for myopathy

Answer 13

Question 14

Behcet’s disease age of onset and asociated features

Answer 14

• Onset most typically age 25-40
• Accompanied by many features similar to those of sarcoidosis:
  
  • Erythema nodosum
  • Anterior uveitis
  • Other skin changes

Question 15

Disease-modifying antirheumatic drugs and adverse effects

Answer 15

Question 16

Scleroderma renal crisis

Answer 16

• Life-threatening complication of scleroderma
• Renal vascular injury due to collagen deposition results in renal ischemia and runaway RAAS activation
  
  • This creates a vicious cycle and precipitates hypertensive emergency
  • Thrombocytopenia and microangiopathic hemoylsis may be seen
• Treatment is ACUTE RAAS inhibition with ACE inhibitors
  
  • This may seem counterintuitive given Cr elevation, the runaway RAAS is part of why the Cr is elevated in these patients, and so it is therapeutic
  • Hemodialysis may be required if there is respiratory impairment or severe hyperkalemia, but AMS is not an indication

Question 17

Calcaneal apophysitis

Answer 17

Most common cause of heel pain in an active young male – simply an overuse injury to the heel growth plate

Question 18

Posterior hip disolcation

Answer 18

• 90% of hip disolcations, often assocaited w/ traumatic injury
• May also be associated with sciatic nerve injury or facture
• Treatment requires reduction within 6 hours of injury
  
  • Closed (non-operative) if there is no fracture
  • Open (operative) if there is

Question 19

Cases where people feel “weak”, but true weakness is not present

Answer 19

• Fatigue
• Pain limiting joint motion
• Cramping
• Fibromyalgia
• Polymyalgia rheumatica (limited by pain and stiffness but have normal strength)

Question 20

Patients with lassitude often complain that they are weak. In comparison, those with true muscle weakness typically complain that they are unable to __

Answer 20

Patients with lassitude often complain that they are weak. In comparison, those with true muscle weakness typically complain that they are unable to perform specific tasks

Question 21

Asymmetric weakness is likely to be due to. . .

Answer 21

. . . a lesion in the central or peripheral nervous systems

Question 22

Features of distal muscle weakness

Answer 22

• decreased grip strength,
• weakness of wrist flexion or extension,
• decreased plantar flexion strength,
• and foot drop

Question 23

Features of proximal muscle weakness

Answer 23

• Difficulty flexing or extending the neck against resistance
• Deltoid muscle strength can be assessed by pressing down on the patient’s fully abducted arms with the elbows flexed
• Sitting up may be difficult or even impossible in patients with more severe proximal muscle weakness (Gower’s sign – patients use hands to “climb” up from seated position, often seen in Duschene’s muscular dystrophy but not specific)
• unable to perform a deep knee bend.

Question 24

MRI in inflammatory myositis

Answer 24

Can be an excellent way to confirm which exact muscle inflammation is present in, and where within that muscle. This is not itself diagnostic, but can identify the exact area that needs to be biopsied for diagnosis.

Question 25

Inclusion body myositis

Answer 25

• Twice as likely in men, usually over age 50
• Slowly progressive weakness of both the proximal and distal muscle groups
• Muscle biopsy shows endomysial inflammation and characteristic intramuscular vacuoles that resemble inclusion bodies of aggregated proteins.

Question 26

Dermatomyositis is often part of a ____

Answer 26

Dermatomyositis is often part of a paraneoplastic syndrome

Caused by autoantibodies against neoplasms, or idiopathic. Often w/ lung, ovarian, GI cancer, or non-Hodgkin’s lymphoma

All patients with dermatomyositis should be tested for underlying malignancy

Question 27

Dermatomyositis and Polymyositis summary image

Answer 27

Question 28

Pattern of aching pain without weakness and multiple points of tenderness over body without signs of inflammation indicates. . .

Answer 28

. . . fibromyalgia

Also often associated with non-restorative sleep, daytime somnolence.

Question 29

Heat-induced weakness is a hallmark for ___

Answer 29

Heat-induced weakness is a hallmark for Multiple Sclerosis

Question 30

Heberden vs Buchard nodes

Answer 30

Question 31

Classic presentation of granulomatosis with polyangitis

Answer 31

Combination of upper and lower respiratory tract involvement (sometimes including ears and nose) with glomerulonephritis

Question 32

Complex levator ani injury

Answer 32

Question 33

Tophi on radiography

Answer 33

• May or may not be radiopaque! Depends how much calcium has been recruited.
• A hard mass that is radiopaque in a location highly assocaited with gout is still highly likely to be a tophus
• Bursitis may present similarly, but will universally be inflammatory and painful, while tophi are nonpainful when they are stable

Question 34

Torus palatinus

Answer 34

• Benign bony growth of the hard pallate
• Often congenital, but may happen later in life
• If it ever becomes symptomatic it can be surgically removed

Question 35

Features of the SLE patient

Answer 35

Question 36

“Neuropathic” claudication

Answer 36

• Another term for lumbar spinal stenosis, the most common cause of which is degenerative joint disease and disc herniation
• Symptoms are exacerbate by walking, paricularly uphill (whereas downhill walking exacerbates compression fractures)
  
  • Standing/walking downhill extends the spine, making symptoms worse
  • Sitting/walking uphill flexes the spine, making symptoms better
• Diagnose w/ MRI

Question 37

Nonbenzodiazepine muscle relaxants

Answer 37

• Second-line for muscle pain after NSAIDs
• Cyclobenzaprine
• Tizanidine
• May cause drowsiness, anti-cholinergic symptoms

Question 38

Diagnosis of osteoarthritis

Answer 38

You don’t need an X-ray unless there is any question.

If you see Heberden’s and Buchard’s nodes with a consistent history, you are good.

Question 39

Morton neuroma

Answer 39

• Mechanically induced neuropathic degeneration of interdigital nerves
• Common in runners
• Numbness between 3rd and 4th toes
• Clicking sensation when squeezed together, accompanied by pain
• Conservative treatment: Padded shoes
  
  • If fails, surgery can fix

Question 40

Suprascapular nerve entrapment

Answer 40

Question 41

Answer 41

Early discoid lupus rash

Question 42

___ provides rapid short-term relief for severe rheumatoid arthritis. ___ is the long-term preventative treatment.

Answer 42

Corticosteroid injection provides rapid short-term relief for severe rheumatoid arthritis. DMARD therapy is the long-term preventative treatment.