Pt with morning stiffness and joint pain in multiple joints but excludes the DIP and Rh and Anti CCP are both negative. Dx and Tx
RA and treat with MTX
RA patient with oral ulcers on MTX. WTD
Give folic acid
RA patient with sudden onset of back of the knee pain. whats the Dx and how to treat
Ruptured popliteal cyts
Intra-articular steroids
RA patient who is postop quadriplegic
Atlanto-dontoid subluxation C1-C2
Long-standing RA with hoarseness of voice
Cricoarytenoid joint involvement
RA patient with long-standing disease including severe joint deformities. w.t.d before going in for elective hip surgery or any surgery under general anesthesia
Xray of the neck
RA pt with swelling in the knee. pt has fever
Tap the joint
RA pt on hydroxychloroquine. what general maintains needs to be done while on this medication
baseline eye exam now and one in 5 years
the leading cause of death in RA
Heart disease
Pt who comes to your office after being tapered off steroids from (Giant cell, polymyalgia rheumatica, or SLE) now has B/L symmetric joint pain and early morning stiffness with no DIP involvement. what is going on
Pt has RA
RA patient on MTX. what do you need to be following up on
CBC, sCr, AST Qq12 weeks
RA patient is maxed out on MTX dose of 25mg/week and still having symptoms. w.t.d next
PPD in prep for biologics
give pneumococcal and flu vaccine (if not already done when you start MTX)
don’t give live vaccines to pts with biologic DMARDs
NO DMARDs to patients with active infection
Young pt with pain in the PIP then MCP and then within a few hours the pain leaves his MCP and then PIP.
Palindromic Rheumatism. 1/2 of these patients will go on to have full-on RA. Tx them with DMARD
RA pt with necrotic ulceration of tips of fingers and foot drop
Rheumatoid Vasculitis
Long-standing RA with splenomegaly and neutropenia. pt could also have a history of recurrent skin and lung infections and skin ulcers. whats going on and how to treat
Felty syndrome and treat with DMARD and steroids
last resort for RA who is refractory to treatment for a long period of time
surgery on said joint
Young pt with polyarthritis and fever. Was sick weeks ago and is still having recurrent fevers that are occupied by a salmon-colored rash.
ferritin is high leukocytosis AST/ALT increased Rh-negative ANA negative
Juvenile idiopathic Rh arthritis
aka: Stills disease
What disease is most likely related to RA
Periodontal disease
Which viruses are most likely associated with RA
EBV, B19, HTLV-1, HHS-6 and HHS-8
How to diagnose Sjogren’s syndrome
Schirmer test
Blotting paper test ( test is + if 5mm wetting in tearing of the eyes in 5mins)
SSA and SSB antibodies. do Bx if these are negative
what are seronegative spondyloarthropathies
Rh Factor negative and HLA-27 positive
involves the spine
Asymmetric poly/oligoarthritis (< 4 joints)
Dactylitis can be seen
What are the two main types of seronegative spondyloarthropathies
Ankylosing Spondylitis and Reactive arthritis
pt with is long-standing Ankylosing Spondylitis now has renal disease. what happened
Renal Amyloidosis
Ankylosing Spondylitis pt with low back pain and decrescendo murmur
Aortitis involvement
Pt with back pain and stiffness. Painful red eyes. Loss of forwarding spinal mobility. what is dx, and what is the most specific sign
Loss of spinal forward mobility. (Bamboo spine)
Ankylosing Spondylitis
what is the best diagnostic test for Ankylosing Spondylitis
X-ray sacroiliac joint
What is the x-ray is negative, and you still have a strong suspicion of Ankylosing Spondylitis. w.t.d
get sacroiliac MRI
what are the eye manifestations in Ankylosing Spondylitis
Uveitis
How to tx the stiffness from Ankylosing Spondylitis
Exercises and physical therapy
How to tx the pain from Ankylosing Spondylitis
NSAIDs. but after 6 weeks, if there is no improvement, you are going to jump straight to Anti-TNF-alpha
What is a good disease tracking biomarker for Ankylosing Spondylitis
ESR
Ankylosing Spondylitis on NSAIDs, comes in with new onset back pain. w.t.d
get xray
pt with Conjunctivitis, URETHRITIS, and asymmetric arthritis. whats going on
Reiter’s syndrome
Can also have mouth ulcers and Keratoderma blennorrhagicum (skin peeling)
In a patient with Reiter’s syndrome, what test would you order for the workup
HIV test
Young pt with GI or GU illness 2 weeks ago, now has pain in a joint. she also has a history of multiple sexual partners
Reactive Arthritis. its NOT Gonococcal arthritis bc there isn’t a history of pustules or rashes. Even if the patient was just treated for chlamydia.
Don’t let the question trick you into thinking this is gonococcal. makes sure there is a clear and active gonococcal infection
how to treat Reactive Arthritis
NSAIDs
Lower back pain and with DIP involvement and pitting nail changes on PE
Psoriatic Arthritis
how to treat Psoriatic Arthritis
mild disease —> NSAIDs
Skin and nail involvement—> MTX
disease reactor to the above start TNF inhibitor or IL-17/23 inhibitor
NO Hydroxychloroquine
What makes Psoriatic Arthritis worse
Beta-blockers
infection
young pt with oral ulcers, genital ulcers, along with joint pain. pt is refusing needle sticks
P/E shows Uveitis and tender nodules on shins.
Behcets Disease
pt was oral ulcers and CxR revealed hilar fullness
Behcets disease.
Hilar fullness was from prominent pulmonary arteries, which is found to be an aneurysm on a CT scan.
Not sarcoid
How to treat Behcets
Just mucocutaneous disease —> Colchicine
moderate to severe —> steroids —> azathioprine —>TNF inhibitor
pt has oral and scrotal ulcers and is refusing needle sticks
Behcets disease
pt has vulvar ulcers and skin nodules on shins and is refusing needle stick
Behcets disease
Painful shin nodules and oral ulcers. Aortic aneurysm. painful red eye and joint pain
Behcet’s disease
Pt has oral ulcers, a history of urethral discharge in the past, red eye and ankle pain
Reiter’s Syndrome
Pt has painful shin nodules and hilar adenopathy
Sarcoid
pt returns from the Caribbean, India, or Africa and now has a fever and joint pain. joint pain is in the small joints of the hands, wrist, and ankle.
Chikungunya (from mosquito bite)
A young patient with a history of intermittent diarrhea for two weeks now has joint pain and;
- painless ulcer on the tongue
- dactylitis or sausage digit or whole digit swelling
- severe pain on palpation of the Achilles tendon
Diagnosis?
What is most likely going to be positive in this patient?
Reactive Arthritis
Stool culture
An older patient with mid-back pain with;
-decreased thoracic lateral flexion
Diffuse Idiopathic skeletal hyperostosis (DISH)
What do you see on x-ray for a patient with DISH
Flowing ossifications on the anterior longitudinal ligament
what do you see on xray in RA
MARGINAL bony erosions and periarticular osteopenia
What do you see on xray in OA
Osteophytes and CENTRAL bony erosions.
pt with morning stiffness, joint pain in the hands (PIP and DIP), Rh factor 1:40 and ANA 1:160. Dx?
OA NOT RA
how to treat OA
Weight loss, insoles, braces, knee taping, and assistive
topical NSAIDs or oral with PPI
intra-articular steroids
and you can always replace the joint
Osteophytes
OA
Periarticular osteopenia
RA
Joint space deformity
RA and OA
Central bony erosions in PIP and DIP
OA
Marginal bony erosions in MCP and PIP
RA
Subchondral sclerosis
OA
The most important risk factor for OA
Obesity
A sedentary lifestyle is more of a risk factor in osteoporosis
Elderly pt with pain in the thumb while turning keys and opening car door. P/E shows pain in the thumb during flexion and internal rotation. Crepitus positive
OA of the 1st CMC joint
Pt with OA wants to try glucosamine or chondroitin sulfate. w.t.d
studies show no difference btw between those medications and placebo
Pt with along standing history of OA. Takes Tylenol for rt knee pain. Has pain, swelling, and mild crepitus. No fever. No white count. The right thigh looks smaller than the left
Tap the knee
send to physical therapy
Strengthen quadriceps
Older pt with pain in his groin while running. The pain moves anteriorly toward his knee. During the exam, there is pain during internal and external rotation of the hip
OA
Randomized clinical trials have shown benefits of acupuncture in
OA in the hip and knee
An older patient has DEXA. T score at the lumbar spine is -1.0 but at the anterior superior iliac spine is -2.6. why is this
Osteophytes in the lumbar vertebrae
Farmer with URI and RA for 15 years. PIP and MCP joint swelling. He doesn’t complain of pain. Hand strength is normal.
Xray shows bony erosions in the PIP and MCP but no DIP
RA NOT OA
most likely area of pain with OA in the hip
Groin area
Right groin pain with a Hx of RA and osteophytes on x-ray. dx
OA
Right groin pain with RA. X-ray negative, but MRI shows double line sign on T2
avascular necrosis
Pain over the lateral aspect of hip +/- going lateral thigh or buttock. pain getting out of the car and can sleep on that side
Greater trochanteric pain syndrome
how to treat Greater trochanteric pain syndrome
Inject local steroids
pt less than 40 yr of age with b/l groin pain, more on left and worse with internal rotation.
Acetabular impingement
What is the overall message to patients with a cane?
When walking on flat ground, use the cane on the opposite side of the injured leg.
When walking UP steps, use good leg followed by bad leg with a cane
When Walking Down steps, use the bad leg first, followed by the good leg and cane
“up to heaven and down to hell”
Gout. crystals and Xray
Monosodium urate and bony tophus with erosions
Pseudogout. crystals and Xray
Ca pyrophosphate dihydrate crystals and chondrocalcinosis on xay
Do we treat asymptomatic hyperuricemia
No
Can uric acid levels be normal during an attack of gout
yes
Middle age pt MAN with sudden onset of toe pain that woke him up this morning. Has had episodes in the past resolved themselves after a few days. Urate acid levels are normal. the patient refuses tap. dx? and the next step
Gout and start Colchicine
Tx with a pt having Gout attack and has DM
NSAIDs
Tx with a pt having Gout attack and has CKD
Steroids
Tx with a pt having Gout attack and has CKD, CAD, and CABG 2 days ago
intra articular steroids
Recurrent gout tx
Systemic steroids and colchicine
OR
NSAIDs and colchicine
NO NSAIDs with steroids
Treating a patient for their 2nd gout attack
Colchicine and allopurinol.
You can keep allopurinol on if has already been started before the attack.
Pt with a history of gout on allopurinol. Come in with an acute gout flare. w.t.d
Start colchicine and KEEP ON the allopurinol
pt with gout attack on allopurinol 300mg daily and colchicine comes back with recurrent attacks. uric levels are 7. w.t.d
increase dose to 800mg QD
if still elevated 3 weeks after —> address adherence to allopurinol
Pt with hx of HTn on ACE. Presents with rash, fever, and necrolytic kind of rash.
white count is elevated with 10% eos and increased LFTs
what’s the cause
Allopurinol
What medication can allopurinol increase
Azathioprine
pt with hc of gout presents with swelling in the knee. you tap the knee and it shows negatively birefringent crystals and WBC of 40k.
a week later you tap it again and nothing has changed and the patient still has pain. w.t.d
Start IV ABx
pt with HTn on chlorthalidone with uric acid levels is high. w.t.d
cont chlorthalidone bc this is asymptomatic hyperuricemia, and we don’t treat that
pt with HTn on chlorthalidone or Lasix with uric acid levels is high. and the patient is having a gouty attack w.t.d
stop Lasix or chlorthalidone and switch to losartan
Elderly pt on chlorthalidone/HCTZ presents with pain in the PIP and DIP with nodules and swelling distal to the nodule. what is this
Gouty arthritis.
these patients will have monosodium urate crystals
what other disease or associated with pseudo gout
Hyperparathyroidism and Hemochromatosis
what joints are commonly affected in pseudo gout
wrist, knee, shoulder
what does the X-ray show in pseudo gout
Chondrocalcinosis
what does the joint fluid show in pseudo gout
Rhomboid crystals with weakly positive birefringence
how to treat pseudo gout
same as gout but colchicine is less responsive
pt with intermittent arthralgias involving the wrist, hands, and shoulder. x-ray shows multiple areas of calcification in multiple joints. pt also is very fatigued. what is the Dx and what test would you get next
Chondrocalcinosis due to calcium pyrophosphate dihydrate deposition
you would want to get a transferrin saturation and TIBC to evaluate patient for hemochromatosis
Pt with hyperparathyroidism undergoes parathyroidectomy.
Five days later pt develops acute onset of pain, swelling, and warmth in the right knee. Serum uric acid level is 7. Tap in done.
what would the tap reveal and how would you treat it
Calcium pyrophosphate dihydrate crystals
NSAIDs
How to treat carpal tunnel
don’t use steroids
Neutral splint at night —> no response or thenar atrophy—>Nerve conduction study—-> surgical release
pt with median nerve involvement, you will most likely see
inability to oppose the little finger with the thumb
Middle age pt with b/l numbness in thumbs and index finger after holding anything for a few minutes. Low heart rate in the 50s. Complaining of fatigue.
w.t.d
order TSH
A pregnant woman complains of pain and numbness in both hands in the thumb and index finger. w.t.d
Neutral splinting of the wrist
Long-standing RA with b/l tingling sensation in both hands. Thenar muscle wasting. next diagnostic step
Nerve conduction study
How would you treat a patient with a tingling sensation in the index finger and thumb with the dropping of objects. ENG study shows median neuropathy with axonal loss
Surgical release
Numbness of thumb, index finger, and middle finger. Early morning stiffness for an hour. difficulty opening bottles
RA
Pt presents with pain in the radial aspect of the wrist, especially when she lifts her children. Or a young man who plays video games. Point tenderness over the radial styloid process. Pain on resisted abduction and extension of the thumb. making a fist with a fully flexed thumb and ulnar deviation is painful
De Quervain’s Tenosynovitis
How to treat De Quervain’s Tenosynovitis
rest tendon —-> splinting —>local steroids—> if disability is severe—> steroids
Pt presents with a wrist drop. decreased sensation on the radial and dorsal aspect of his hand
Compression of the radial nerve at the spiral groove in the middle of the arm
AKA: Saturday night palsy
Pt complaints of pain in the shoulder increased on abduction, and extremes of movement are painless. Pain more on active abduction rather than passive. Swing arms back and forth without pain
Subacromial bursitis
How to treat Subacromial bursitis
Steroids into the bursa
Pt. with episodic swelling of ears. Exam shows a cartilaginous portion of ear swelling. How to est Dx, and what is the Dx. also, how do you treat
Bx of cartilage
Relapsing polychondritis
Immunosuppression
Vasculitis with low complement
Goodpasture's Leukocytoclastic angiitis Cryoglobulinemia SBE SLE RA
Vasculitis with normal complement
Polyarteritis nodosa MPA Eosinophilic granulomatosis with polyangiitis Giant Cell Takayasu arteritis Aortitis
Pt with suspected Giant cell. w.t.d next
ESR
This is positive in 85-95% of patient
pt with suspected giant cell and has elevated ESR. w.t.d
High dose steroids
Pt with suspected Giant cell with ESR of 85 and temporal bx is negative. what the diagnosis and what to do next
giant cell
start steroids and bx the contralateral temporal artery
How to dx Takayasu arteritis disease
Aortography and look for stenosis
how to tx Takayasu arteritis disease
steroids and calcium channel blockers
What is ankylosing spondylitis associated with
Aortitis and Uveitis
Aortitis can be associated with
Ankylosing spondylitis
Uveitis
Syphilis
50 yo man presents to the ER with complaints of abdominal pain which worsens with eating, mainly in the periumbilical area. It gets better when the stomach is empty. The pain has worsened over the past several weeks. He complains of joint pain in his hands and feet. Ulcers on the lower extremities.
BS+. purpuric rash on the lower extremities.
ESR 100
CXR is clean
What is the best test to determine a diagnosis?
Abdominal Angiogram
how to treat PA
Steroids and cyclophosphamide
35 yo with abdominal pain and labs reveal renal insufficiency and HBsAg. Whats the Dx
PAN
A 24 yo woman of Italian/Jewish/Arab descent with recurrent abdominal pain every two months lasting 1-2 days. Pt had an appendectomy in childhood for abdominal pain. She gets high fevers during the attacks of periumbilical pain that spreads all over the abdomen. Swollen knee. Her power in normal and has no ulcers. Abdominal imaging is normal. Father had a similar episode as a child.
Whats the dx, how to treat and what are the complications
Familial Mediterranean fever
Colchicine
AA amyloidosis with CKD
Cause of amyloidosis
FMF RA TB MM AS
how to diagnose Amyloid
First, get abdominal fat pad bx
If negative, then biopsy affected organ
bx will show fibrils of apple green birefringence on congo red staining
Thick-walled cavitary lung lesions
GPA
Histo
Blasto
Thin-walled cavitary lung lesions
Nocardia
Cocci
MAC
How to treat severe GPA
Steroids + cyclophosphamide or rituximab
If GPA is suspected and ANCA is negative. w.t.d
Renal biopsy
Young to middle age pt with a history of asthma. She presents with shortness of breath, wheezing, and complains of weakness in her left foot. SHe uses SABA, ICU and is being weaned off steroids. Exam reveals rales at the right upper lobe.
decreased power in the left foot with hypoactive reflexes
CBC show EOS
CxR shows right upper lobe density
whats the Dx
Eosinophilic granulomatosis with polyangiitis
pt with arthralgias and malar rash. You suspect lupus w.t.d
ANA THEN ds-DNA
What is the most specific test for SLE
Anti-smith
OR
anti-dsDNA
