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2 risk factors for CPPD?



In OA, names of enlarged DIP & PIP?

Heberden = DIP
Bouchard = PIP


What lab tests are abnormal in OA?



Is OA worse or better with movement?

Better - stiffness lasts only SHORT duration


What 3 characteristics distinguish OA from RA?

1) NO inflammation in OA
2) NORMAL lab tests in OA
3) SHORT duration of stiffness in OA


Treatment course for OA?

First = wt loss & moderate exercise

*Second = Acetaminophen (best initial analgesic)

Then = NSAIDs (if Acetaminophen not helping - watch for GI bleeding or renal insufficiency)

Then = Capsaicin cream

Then = Intraarticular steroids


2 etiologies of gout attacks (mechanisms of hyperuricemia) and causes of each?

Overproduction of uric acid
*Increased cell turnover (cancer, hemolysis, psoriasis, chemotherapy)
*Enzyme deficiency (Lesch-Nyhan synd; glycogen storage disease)

Under excretion of uric acid
*Thiazides & aspirin
- Renal insufficiency
- Ketoacidosis/lactic acidosis


Likely presentation of acute gout attack?

Man w/ sudden, excruciating pain, redness, tenderness in big toe after a night of heavy drinking.

Fever is common


What is a tophi?

Tissue deposit of urate crystals within foreign body reaction (take years to develop)


Chronic effect of hyperuricemia?

Kidney stones


Most accurate test for gout? What do you see?


*Negatively birefringent, needle-shaped crystals


Mgmt of ACUTE gouty attack?

*NSAIDs 1st!
Corticosteroid injection if no response to NSAIDs/contraindication to steroids (renal insufficiency)
3rd = colchicine


What are 2 side effects of colchicine?

Neutropenia (bone marrow suppression)


Chronic mgmt of gout?

Diet modification - avoid EtOH, high purine foods (meat/seafood)

*Stop thiazides, aspirin, niacin

Colchicine to prevent 2nd attack

Allopurinol, Febuxostat, Probenecid, Sulfinpyrazone


What treatments of gout are C/I in renal insufficiency?

NSAIDs, probenecid, sulfinpyrazone

Allopurinol OK w/ renal injury


Side effect of allopurinol?

Increased toxicity of some chemotherapy agents
Hypersensitivity (rash, hemolysis, allergic interstitial nephritis)
*Steven-Johnson syndrome & Toxic Epidermal Necrolysis


Best drug to use for lowering BP during gout attack?

Losartan (ARB) --> lowers uric acid


How do diagnostic tests differ b/w CPPD & gout?

Xray --> CPPD shows calcifications in joint spaces; normal in gout

CPPD --> positively birefringent, rhomboid shaped crystals


Best initial therapy for CPPD?

Intra-articular steroids
Colchicine (prevents recurrence)


What is a common eye finding in patients with autoimmune disease (not uveitis)? What are the common findings on physical exam? What is best treatment?

Keratoconjunctivits sicca --> inflammation of cornea & conjunctiva due to DRYNESS

S/S: dry eyes, foreign-body sensation in the eye, photophobia, conjunctival irritation

Tx: artificial tears


Anti-topoisomerase I antibody?

Systemic sclerosis (scleroderma)


What is first-line therapy in management of HTN in patients w/ scleroderma?

ACEi --> shown to delay progression of kidney fibrosis by systemic scleroderma


Initial DOC for OA?

Mild-moderate --> acetaminophen

NSAIDs second line due to GI and renal s/e


What can be followed in SLE during acute exacerbations?

Complement (C3, C4) --> decreased during flares


Most common area for ulnar nerve impingement?

Ulnar groove in medial epicondyle of elbow


Describe the 3 classification of Le Fort fractures?

Le Fort I: involves ONLY maxilla
Le Fort II: involves maxilla, nasal bones, and medial aspect of orbits
Le Fort III: horizontal fracture passing through nasofrontal suture, maxilla-frontal suture, orbital wall and zygomatic arch


13 yo boy presents with tender soft-tissue mass in his proximal humerus. Xray shows findings on metaphysis of humerus. What is most common cause?

What 2 findings on Xray are present?

Osteosarcoma --> large, tender mass

"Sunburst" periosteal reaction
Codman triangle --> periosteal elevation


70 yo male with neck, shoulder, and hip pain and stiffness for past 3 months. Has morning stiffness lasting 1-2 hours. Has elevated ESR. What is it? Tx?

Polymylagia Rheumatica
*Morning STIFFNESS lasting > 1-2hrs
*Elevated ESR

Tx: Glucocorticoids


What are common lab findings in Paget disease?

Imaging findings?


High ALP
Normal Ca & Phos
PSA normal

Mixed lytic & osteoblastic lesions --> head often implicated

Tx: Bisphosphonates (block bone turnover)


23 yo male has progressive lower back pain for several months. Morning stiffness lasts around 1 hour. 2 years ago he had an episode of pain, blurring, and photophobia in the R eye. He has tenderness in both SI joints and reduced range of motion in lower back.
What it is?
What is the common complication?
What is commonly found in these patients?

Ankylosing spondylitis

*Anterior uveitis



24 yo female with 3 month hx of progressively worsening anterior knee pain that is worse when she climbs or descends stairs. What do you suspect? What test will confirm? Tx?

Patellofemoral (PF) syndrome

*PF compression test --> pain elicited w/ extending the knee while compressing the patella
*Pain reproduced when squatting, climbing stairs

Strengthen thigh muscles w/ stretching


65 yo man with recent b/l hearing loss presents with acute diverticulitis. His labs show elevated ALP but normal GGT. His Ca, Phos are normal. What bone disorder must you suspect?

Paget's disease

*Hearing loss (b/l) should be suspicious*


What is the pathophys behind ankylosing spondylitis?

What is classic presentation?

What are other classic associations?

Lung findings?

Apophyseal (facet) joint arthritis

20-30 age male with gradual onset lower back pain that is WORSE in the morning but improves with activity throughout the day

**Enthesitis (tendon insertion site inflammation)

*Restrictive lung pattern --> from diminished chest wall and spinal mobility
Reduced VC, TLC
Normal FEV1/FVC


71 yo male presents with back pain that started 3 mo ago and is non-responsive to Tylenol. He is on HCTZ for HTN and recent hearing loss for which he needed a hearing aid. Arterolateral legs have femoral bowing. What is it? What blood level will be high?

*Paget disease of the bone (hyper functioning osteoclasts followed by osteoblasts activity)

**look for enlarging hat size or recent hearing loss

**High ALP


Development of clubbing with sudden-onset joint pain in a chronic smoker raises concern for what?

Best next step?

Hypertrophic osteoarthropathy

*assn with lung cancer



Woman develops rash and swelling over her eyes. She also has difficult arising from seated position and climbing stairs.
What is it?
What antibodies are specific for it?
What is important complication?

Dermatomyositis --> proximal muscle weakness + rash
- Heliotrope sign: periorbital edema and rash over eyes
- Gottron's papules: bright red, scaly papules over joints (hands)


*Look for internal malignancies


Woman develops proximal muscle weakness with elevated ESR and CPK. What is the best tx?

High-dose steroids

Polymyositis or Dermatomyositis --> inflammatory myopathies


What 3 conditions lead to higher incidence of Baker cysts?

Cartilage tears


What actually helps slow the progression of OA?

Weight loss


Most important finding in person suspected of having vertebral osteomyelitis?

What about labs?

Tenderness to gentle percussion over SP of vertebrae

*Look for hx of IV drug use

*Platelets will be high (marker of inflammation/stress)


27 yo school teacher developed bilateral MCP, PIP, wrist, knee and ankle joint pains around 10 days ago. She also had few episodes of loose BM's with mild skin itching and patchy redness. What is most likely diagnosis? What blood test would be elevated? What about if pregnant?

Parvovirus B19
**Contact with children!! (school teachers, daycare)

anti-B19 IgM (+)

**AVOID suspected contacts if women is pregnant --> can get aplastic anemia in baby!!


What is a defining feature of osteoid osteoma?

*Pain RELIEVED with NSAIDs (aspirin, ibuprofen)

Pain is also worse at night with NO relation to activity


Shoulder stiffness with decreased active and passive range of motion - what do you suspect?

Adhesive capsulitis


Lab values in osteitis deforming (Paget disease of bone)?

Elevated ALP & urinary markers of bone degradation (hydroxyproline)

NORMAL calcium, phosphate


What is classic triad in reactive arthritis?

What other findings should raise suspicion for reactive arthritis?

1) Urethritis
2) Asymmetric oligoarthritis
3) Conjunctivitis

"Can't see, can't pee, can't climb a tree"

**Mucocutaneous lesions (oral ulcers)
**Achilles tendon pain (enthesitis)


Person has asymmetric oligoarthritis with mouth ulcers. He was treated for urethral discharge 2 weeks ago. What is it?

Reactive arthritis


What type of bone cancer is characterized by X-ray findings of lytic lesions, onion skinning, and a moth-eaten appearance with some extension into the soft tissue?

Ewing sarcoma


How do you differentiate b/w polymyalgia rheumatica and glucocorticoid-induced myopathy?

PR: NORMAL muscle strength, muscle stiffness & aching, elevated ESR, CK normal

GIM: PAINLESS proximal muscle weakness; normal CK and ESR


Tx for radial head subluxation?

Apply pressure to radial head and hyperpronate the forearm


Treatments for Raynauds?

Avoiding cold temps and emotional stress
No smoking

**CCB (nifedipine, amlodipine)


S/S of avascular necrosis of femoral head?

Common causes?

Gradual hip pain, but NON-painful to palpation
Restriction in hip abduction and internal rotation

**Chronic steroid use
**Sickle cell disease


What is the earliest manifestation of vaso-occlusive crises in sickle cell disease?

Age of onset?

What is pathophysiology?

Hand-foot syndrome (dactylitis)
*Symmetric swelling in hands and feet with acute pain onset

6mo - 2yo

Vascular necrosis of metacarpals and metatarsals


Purulent arthritis in a sexually active person is what until proven otherwise?

Gonococcal arthritis

*The skin rash and tenosynovitis do NOT have to be present


What other MSK finding is common in RA?


*From corticosteroid therapy, lack of physical activity, increased pro-inflam cytokines


Best treatment of choice for RA to prevent joint destruction and symptoms control?

Methotrexate (DMARD)


52 yo woman has gradual-onset weakness in her leg muscles especially when climbing stairs and rising from a chair. She has no joint or muscle pain and DTRs and sensory exam are normal. What is it? What test is likely to lead to diagnosis?


Muscle biopsy

*Progressive, painless, proximal muscle weakness


"Popping" sensation in the knee followed by immediate swelling of blood in the joint and feeling unstable when wt bearing on the affected side?

ACL tear


If person has Raynaud syndrome, what blood marker can be elevated?

Antinuclear antibody (ANA) -->

*Raynaud often associated with SLE


What common MSK finding is seen with ankylosing spondylitis?

Enthesitis --> inflammation/pain at sites where tendons and ligaments attach to bone
Heel = Achilles tendon
Tibial tuberosity = patellar ligament


How does systemic sclerosis affect the esophagus resulting in dysmotility?

Causes smooth muscle atrophy and fibrosis in lower esophagus


Most common cause of asymptomatic isolated elevation of ALP in elderly patient?

Paget's disease


29 yo with worsening pain in R knee. Xray shows lytic area in epiphysis of distal femur. What is most likely cause?

Giant cell tumor

*Soap-bubble appearance OR expansile/eccentric lytic area


Most important factor for morbidity in SLE?

Best step in assessing this?

Renal disease

Renal biopsy --> different forms of nephritis have different treatments


What are common side effects of methotrexate?

What needs to be given with it?

*Hepatotoxicity (elevated LFTs)
*Oral ulcers (stomatitis)
Cytopenia (neutropenia)

*Give Folic acid --> MTX is a folate antimetabolite


What is pathophys behind pseudo gout?

Acute arthritis from release of calcium pyrophosphate dehydrate (CPPD) crystals from sites of chondrocalcinosis (calcification of articular cartilage) into the joint space.

*Often occurs AFTER recent surgery or medical illness


Mechanism behind pancytopenia in SLE?

Peripheral immune-mediated destruction of all 3 cells lines