UWorld 1

Question 1

Fibromyalgia presentation

Answer 1

Most commonly in young to middle aged women with widespread pain, fatigue, and cognitive/mood disturbances.

Patients tend to have normal physical exam except for point tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in chest, and greater trochanter.

No specific lab findings. Diagnosed with widespread pain index and symptom severity scale rather than trigger points.

Question 2

Fibromyalgia tx

Answer 2

Initial FM treatment should emphasize patient education, regular aerobic exercise, and good sleep hygiene.

Patients who do not respond to conservative measures may require meds. TCAs (amitriptyline) are 1st line. SNRIs (duloxetine, milnacipran) and pregabalin are alternate therapies that may be useful in patients not responding to TCAs.

Patients with persistent symptoms may need combo drug therapy, referral for supervised rehab, pain management or CBT.

Question 3

Fibromyalgia dx

Answer 3

Widespread Pain Index (WPI). Score is 0-19. 1 for each spot.

1) Neck
2) Jaw (L and R)
3) Shoulder (L and R)
4) Upper arm (L and R)
5) Lower arm (L and R)
6) Chest
7) Abdomen
8) Upper back
9) Lower back
10) Hip (L and R)
11) Upper leg (L and R)
12) Lower leg (L and R)

Symptom Severity Scale (SSS). Score is 0-12.

1) Fatigue (0-3)
2) Waking unrefreshed (0-3)
3) Cognitive symptoms (0-3)
4) Somatice symptoms (0-3)

To dx FM you need:
1) WPI of at least 7 and SSS of at least 5. OR WPI of 3-6 and SSS of at least 9.

2) Symptoms present at similar level for 3 months
3) No disorder that would otherwise explain the pain

Question 4

Manifestations of SLE

Answer 4

Clinical symptoms

1) Constitutional - fever, fatigue, and weight loss
2) Symmetric, migratory arthritis
3) Skin - butterfly rash and photosensitivity. painless oral ulcers.
4) Serositis - pleurisy, pericarditis, peritonitis
5) Thromboembolic events (due to vasculitis and antiphospholipid syndrome)
6) Neuro - cognitive dysfunction and seizures

Lab

1) Hemolyitc anemia, thrombocytopenia and leukopenia
2) Hypocomplementemia (C3 and C4)
3) Antibodies - ANA (sensitive). Anti-dsDNA and Anti-SM (specific)
4) Renal involvement - proteinuria and elevated Cr

Question 5

Describe the typical joint manifestations of SLE

Answer 5

Arthritis and arthralgias affect 95%. They tend to be migratory, symmetric, polyarticular and are accompanied by brief morning stiffness (much shorter in duration than RA).

Knees, carpal joints, joints of fingers are most often affected. Joint pain often exceeds objective findings on exam. XRs usually show no evidence of joint destruction or erosion (unlike other inflammatory arthritides like RA)

Question 6

Felty Syndrome

Answer 6

Advanced RA (usually longstanding over 10 years) associated with splenomegaly and neutropenia. Marked morning stiffness.

Diagnosis should not be made without neutropenia!

Question 7

Behcet Disease

Answer 7

Presents with multiple oral and genital ulcers that are recurrent and painful. Uveitis is common.

Question 8

Parvo infection - joint manifestation

Answer 8

In adults, most parvo infections are ASx or have flu-like symptoms. Minority of patients develop a symmetric, nonerosive arthritis or aplastic anemia.

These symptoms would not last longer than 3-4 weeks.

Question 9

Disseminated gonococcal infection - describe the usual presentation

Answer 9

Polyarthralgia, skin lesions, and tenosynovitis. Morning stiffness is rare.

Question 10

Clinical features of vertebral compression fracture

Answer 10

Causes

1) Trauma
2) Osteoporosis, osteomalacia
3) Infection (osteomyelitis)
4) Bone mets
5) Metabolic (hyperparathyroidism)
5) Paget Disease

Clinical pres
1) Chronic/gradual VCF - painless, progressive kyphosis, loss of stature

2) Acute VCF - low back pain and decreased spinal mobility, pain increasing with standing, walking, lying on back; tenderness at affected level. Can usually point to a specific event like lifting (or a bend, or a cough) where it started.

Complications

1) Increased risk for future fractures
2) Hyperkyphosis, possibily leading to protuberant adbdomen, early satiety, weight loss, decreased respiratory capacity

Question 11

Absent ankle reflexes

Answer 11

Don’t need to be clinically signifiant. Patients over 70 often have this.

Question 12

Spinal epidural abscess triad

Answer 12

Fever, severe localized back pain, and neuro defects (motor weakness, paresthesias, bowel/bladder dysfunction)

Question 13

Lumbar spinal stenosis

Answer 13

Refers to a narrowing of the intraspinal canal, lateral recess, or neural foramen. Patients develop low back pain with neuro symptoms (sensory loss, weakness in legs) that is worse with spinal extension (walking, standing) but improved with leaning forward or lying down. Back pain persists when standing still.

Usually in patients over 60. Look out for pseudoclaudication. Vascular claudication is exertion-dependent and resolves when standing still.

Question 14

Lumbosacral strain

Answer 14

Usually seen after a specific event or action. Patients typically have increased pain with movement and decreased pain with rest.

In addition, pain is in paraspinal area without significant tenderness to palpation of the vertebra

Question 15

Lateral epicondylitis

Answer 15

Tennis elbow. Pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle. From backhand in tennis or screwdriver use. Any activity with repeated forceful wrist extension and supination

Degeneration of extensor carpi radialis brevis tendon near lateral epicondyle.

Question 16

Radial tunnel syndrome

Answer 16

Signs and symptoms similar to lateral epicondylitis and may occur in conjunction with it. Tenderness tends to overlie the extensor muscle wad

Pain is elicited by flexing the patient’s long finger while they are actively extending fingers and wrists.

Question 17

Rupture of long head of biceps tendon

Answer 17

Causes pain in upper arm and shoulder and prominent bulge in midportion of upper arm.

Question 18

Paget Disease of the bone (phases)

Answer 18

1) Osteolytic phase - osteoclast dominant.
2) Mixed phase - osteoclast plus osteoblast. Some new bone formation
3) Osteosclerotic phase - blasts dominant. Weak, thickened woven bone

Question 19

Paget Disease of the bone overview

Answer 19

Patient with bone pain, HA, unilateral hearing loss and femoral bowing would be a typical presentation.

This is the most common bone disorder after osteoporosis (3% of adults over40). Characterized by focal increase in bone turnover, in which osteoclast dysfunction leads to bone breakdown and a compensatory increase in bone formation.

Pelvis, skull, spine and long bones are most commonly involved. Microscopic findings include increased numbers of abnormal appearing osteoclasts with a disorganized mosaic pattern of lamellar bone

Early stage lesions will have a lot of osteoclast activity, later progressing through a mixed phase, a predominantly osteoblastic phase and finally a residual sclerotic phase

Most patients are ASx and are identified incidentally by XR or elevated alk phos. Symptoms may include skeletal deformities, bone or joint pain, and fractures. Enlarging cranial bones may lead to increased hat size, HA, and hearing loss due to entrapment of CN8 or encroachment on the cochlea. Benign giant cell tumors of bone and osteosarcoma can also be seen

Question 20

Avascular necrosis causes

Answer 20

1) Steroid use
2) Alcohol abuse
3) SLE
4) Antiphospholipid syndrome
5) Hemoglobinopathies (Sickle Cell)
6) Infections (osteomyelitis, HIV)
7) Renal transplant
8) Decompression sickness

Question 21

Clinical manifestations, labs and imaging for Avascular necrosis

Answer 21

Clinical

1) Groin pain on weight bearing
2) Pain on hip abduction and internal rotation
3) No erythema, swelling or point tenderness

Labs

1) Normal WBC
2) Normal ESR and CRP

Rads

1) Crescent sign seen in advanced stage
2) MRI is most sensitive modality

Question 22

Osteonecrosis

Answer 22

Caused by occlusion of end arteries supplying the femoral head, leading to necrosis and collapse of the periarticular bone and cartilage.

Osteonecrosis is common in patients with sickle cell disease due to disruption of microcirculation in the bone by sickling as well as increased intraosseous pressure due to bone marrow hyperplasia.

Femoral head has 2 main sources of blood - ascending arteries and the foveal artery, which lies within the ligamentum teres.

Foveal artery is open early in life, but may become obliterated in older patients. For this reason, aseptic necrosis of the femoral head is uncommon in children but the risk rises in older patients

Question 23

Paget Disease - pathogenesis, labs, imaging and treatment

Answer 23

Pathogenesis - osteoclast dysfunction and increased bone turnover

Labs

1) Increased alk phos
2) Increased bone turnover markers (PINP, urine hydroxyproline)
3) Calcium and phosphorous are usually normal

Imaging

1) XR shows osteolytic or mixed lytic/sclerotic lesions
2) Bone scan shows focal increase in uptake

Tx - bisphosphonates

Question 24

Polymyositis

Answer 24

Clinical presentation

1) Symmetrical proximal muscle weakness - often in lower extremities and slowly progressive (difficulty negotiating stairs or rising from seated position). Proximal arm weakness usually follows (trouble working with the arms overhead). Patients may develop dysphagia due to involvement of striated muscles of upper pharynx.
2) No/mild pain or muscle tenderness
3) Similar to dermatomyositis but without skin findings

Tests

1) Elevated muscle enzymes (CK, aldolase)
2) Autoantibodies (ANA, anti-Jo-1)
3) Bx (most definitive) - endomysial mononuclear infiltrate, patchy necrosis

Associated conditions

1) Interstitial lung disease
2) Myocarditis
3) Malignancy**

Tx

1) Systemic glucocorticoids
2) Glucocorticoid-sparing agents (methotrexate, azathioprine)

Question 25

Clinical features of systemic sclerosis (scleroderma)

Answer 25

Systemic 1) Fatigue 2) Joint stiffness and pain Skin 1) Telangiectasia 2) Sclerodactyly 3) Digital ulcers 4) Calcinosis cutis Vascular - Raynaud GI 1) Dysphagia, dyspepsia 2) Angiodysplasia of stomach (watermelon stomach) with GI bleeding 3) Malabsorption due to bacterial overgrowth 4) smooth muscle atrophy and fibrosis of lower esophagus - dysphagia, choking, heartburn, and hoarseness. Manometry shows hypomotility and incompetence of LES Pulm 1) Pulm fibrosis 2) Pulmonary arterial HTN Renal 1) Scleroderma renal crisis - acute onset oliguric renal failure with malignant HTN, thrombocytopenia, microangiopathic hemolytic anemia Cardiac - myocarditis, pericarditis, pericardial effusion

Question 26

Clinical features of RA

Answer 26

Symptoms 1) Insidious onset, multiple joint pain, stiffness and swelling 2) Morning stiffness lasting hours, improves with activity 3) Small joints (PIP, MCP, MTP) commonly involved 4) Monoarthritis (knees, elbows) can also occur later 5) Spares the DIP joint, unlike OA*** Exam - most commonly affects cervical spine joints in axial skeleton (besides the hands) 1) Affected joints are tender to touch, swollen, with limited ROM 2) Tenosynovitis of the palms leads to trigger finger 3) Rheumatoid nodules (esp on elbows) 4) Cervical joint involvement can lead to spine subluxation leading to spinal cord compression Labs/Imaging 1) Positive anti-CCP antibodies (diagnostic testing) 2) High IgM RF 3) High CRP and ESR correlate with disease activity 4) XR - soft tissue swelling, joint space narrowing and bony erosions

Question 27

How high is alk phos in Paget?

Answer 27

Often 10 times normal. Alk phos AKA bone isoenzyme

Question 28

Urine hydroxyproline

Answer 28

Derived almost exclusively from breakdown of collagen. Levels are high in Paget

Question 29

What lab values are often normal in Paget?

Answer 29

P and Ca (unless there's concurrent hyperparathyroidism)

Question 30

Sjogren Syndrome

Answer 30

Autoimmune condition that most commonly affects women in their fifth or sixth decade of life. Clinical findings include keratoconjunctivitis sicca (xerophthalmia, dry eyes) and xerostomia (dry mouth). Due to the antimicrobial and lubricating properties of normal saliva, patients with Sjogren will have an increased incidence of dental caries and will complain of difficulty swallowing. Lymphocytic infiltration of the salivary glands will cause enlargement and firmness to palpation of these glands. Dx is made when there is subjective and objective evidence of dry mouth and eyes in the presence of either histologic evidence of lymphocytic infiltration of salivary glands or serum autoantibodies directed against SSA (Ro) and/or SSB (La)

Question 31

Rotator cuff tendinopathy and tear

Answer 31

Rotator cuff impingement or tendinopathy 1) Pain with abduction, external rotation 2) Subacrominal tenderness 3) Normal ROM with positive impingement tests (Neer, Hawkins) Rotator cuff tear 1) Similar to tendinopathy 2) Weakness with abduction and external rotation 3) Usually age over 40 after fall on outstretched arm 4) MRI confirms 5) surgery within 6w of injury is best

Question 32

Erythema Nodosum and its workup

Answer 32

It is painful, subQ nodules more common on anterior lower legs. Arthralgias and malaise can develop alongside these nodules. EN is thought to represent a delayed hypersensitivity reaction to antigens associated with various conditions and is often relatively benign with self-resolution in several weeks. EN can be an early sign of more serious disease though, and ID-ing the cause is important. Can be strep, sarcoid, TB, coccidiomycosis, IBD (Crohn's more than UC), Behcet. Initial workup includes basic lab tests (CBC, LFTs, renalfunction), antistreptolysin-O antibodies, and TB skin testing. CXR should be obtained to assess for sarcoid (bilateral hilar LAD, reticular opacities) or with TB. Prevalence of sarcoid in patients with EN is like 28% in some populations. Absence of pulm symptoms does NOT rule out sarcoid. Still get the CXR (half of sarcoid diagnoses are diagnosed incidentally before symptoms)

Question 33

Osteomyelitis

Answer 33

IV drug users, those with sickle cell and immunosuppressed peeps are at highest risk of osteomyelitis. Also look out for recent distant site infection (UTI) Spine is a common site in IV drug users. In this group, staph aureus is most common pathogen, but infections with gram neg's also occur. Tenderness to gentle percussion over the spinous process of involved vertebra is most important clue. Pain is often not relieved by rest and fever is an inconsistent finding. WBC may be normal or high. Platelets are often high as a marker of inflammation/stress. ESR is often very high (over 100). MRI is most sensitive study. Tx is long term IV ABx with or without surgery

Question 34

Methotrexate mech and adverse effects

Answer 34

Mechanism - Purine antimetabolite Adverse effects 1) Hepatotoxicity 2) Stomatitis (mouth stuff) 3) Cytopenias (bone marrow suppression) 4) oral ulcers 5) Alopecia 6) Pulmonary toxicity Taking folic acid seems to reduce adverse effects Preferred initial DMARD in patients with moderate to severe RA due to established efficacy and safety for long term use.

Question 35

Leflunomide mech and adverse effects

Answer 35

Mechanism - Pyrimidine synthesis inhibitor Adverse effects 1) Hepatotoxicity 2) Cytopenias

Question 36

Hydroxychloroquine mech and adverse effects

Answer 36

Mechanism - TNF and IL1 suppressor Adverse effects 1) Retinopathy

Question 37

Sulfasalazine mech and adverse effects

Answer 37

Mechanism - TNF and IL1 suppressor Adverse effects 1) Hepatotoxicity 2) Stomatitis 3) Hemolytic anemia

Question 38

TNF inhibitors mech and adverse effects

Answer 38

Adalimumab, Certolizumab, Etanercept, Golimumab, Infliximab Adverse effects 1) Infection 2) Demyelination 3) CHF 4) Malignancy usually reserved for patients resistant to initial DMARDs

Question 39

RA treatment

Answer 39

Goal is to induce and maintain early remission and prevent long term joint damage. All patients should be started on disease-modifying antirheumatic drugs (DMARDs) as early as possible. These include nonbiologics (small molecules made by conventional chemical synth to target inflammatory paths) and biologics (large molecules made by recomibinant DNA technqies to target cytokines and cell surface proteins)

Question 40

Viral arthritis due to parvo B19

Answer 40

Viral arthritis presents with acute onset of polyarticular and symmetric arthritis that resolves within 2 months. Parvo is amongst the most common causes of viral arthritis and is particularly likely in adults who have frequent contact with kids, such as day care workers. Parvo infection in adults most often presents with arthritis/arthralgias involving the MCP, PIP and wrist joints. The slapped cheek rash is unusual in adults. Presence of systemic symptoms is variable. Distinguished from RA and other symmetric arthritides by acute onset, lack of elevated inflammatory markers and resolution within 2 months

Question 41

Psoriatic arthritis

Answer 41

Often affects the DIP joints. Dactylitis (sausage fingers), nail findings and psoriasis of skin are characteristic

Question 42

Pain and stiffness of pelvis and shoulders in older patient

Answer 42

Classic for polymyalgia rheumatica but a markedly elevated ESR is critical for diagnosis

Question 43

Patellofemoral pain syndrome

Answer 43

One of the most common causes of knee pain in young athletes and predominantly affects women. It is usually triggered by chronic overuse or malalignment (angular deformities, weakness of hip abductors) but can also be seen acutely following trauma Dx is based on clinical findings with pain localized to anterior knee, usually described as an aching sensation, and worsened with activities such as climbing up or down stairs. Patellofemoral compression test (reproduction of pain when patella is compressed into trochlear groove) is helpful tho no single finding has high sensitivity or specificity Initial management includes reduced intensity of exercise (esp running), activity modification, and NSAIDs. Patients should be counseled on stretching and strengthening exercises with an emphasis on quads, knee extensors and hip abductors Surgery only recommended when patients have failed 6-12months of conservative management

Question 44

Overview of running injuries of foot and ankle (5)

Answer 44

Stress fracture 1) Insidious 2) Focal pain in navicular or metatarsals - sharp, localized pain and tenderness over a bony surface 3) Risk factors - abrupt increase in intensity of training, poor running mechanics, female with eating disorder 4) Female athlete triad is associated with it (oligomenorrhea, decreased caloric intake, osteopenia/osteoporosis) Plantar fasciitis 1) Plantar surface of the heel 2) Worse when initiating running or first steps of the day. Better with activity then worse again at end of day with prolonged weight bearing. Achilles tendinopathy 1) Burning pain or stiffness 2-6cm above posterior calcaneus Morton neuroma 1) Numbness or pain between 3rd and 4th toes 2) Clicking sensation when palpating space between 3rd and 4th toes while squeezing the metatarsal joints Tarsal tunnel syndrome 1) Compression of tibial nerve at ankle 2) Burning, numbness, aching of distal plantar surface of foot/toes 3) Usually caused by a fracture of the bones around the ankle.

Question 45

Morton neuroma

Answer 45

Commonly in runners. Not a true neuroma, but is a mechanically induced neuropathic degeneration of the interdigital nerves that causes numbness, aching, and burning in distal forefoot from metatarsal heads to third and fourth toes. Symptoms worse by walking on hard surfaces and wearing tight or high heeled shoes On exam, squeezing the metatarsal joints will cause pain on plantar surface of foot along with crepitus between third and fourth toes (Mulder sign) Tx - involves metatarsal support with bar or padded shoe inserts to decrease pressure on metatarsal heads. Surgery reserved for patients who fail conservative treatment

Question 46

Features of ACL injury

Answer 46

Mechanism - rapid deceleration or direction changes, pivoting on lower extremity with foot planted Symptoms 1) Pain, rapid onset, may be severe 2) A popping sensation at time of injury 3) Significant swelling (effusion/hemarthrosis) 4) Joint instability Exam 1) Anterior laxity of tibia relative to femur (anterior drawer test, Lachman test) Dx - MRI Tx - RICE (rest, ice, compression, elevation) measures plus/minus surgery

Question 47

What drugs are often linked to achilles tendinopathy?

Answer 47

Fluroquinolones (look for recent treated UTI). Continued use of the med can lead to rupture of the tendon. Risk is over 60, female, normal BMI, concurrent oral corticosteroid use, history of organ transplant. Stop drug, avoid exercise and/or use of affected area, and seek medical care for symptom eval and changing to a non-fluoro ABx Can be within 24h of drug but usually 8d after starting the med is when it start.

Question 48

Causes of gout

Answer 48

Increased urate production 1) Primary gout (idiopathic) 2) Myeloproliferative/lymphoproliferative disorders (don't forget PV is a myeloproliferative disorder) 3) tumor lysis syndrome 4) Hypoxanthine guanine phosphoribosyl transferase deficiency (Lesch-Nyhan) Decreased urate clearance 1) CKD 2) Thiazide/loop diuretics

Question 49

Presentation of antiphospholipid syndrome

Answer 49

Presents with a thrombotic event (DVT or arterial thrombus) or pregnancy morbidity (fetal loss, severe preeclampsia, placental insufficiency) plus a positive serology for 1 of 3 antiphospholipid antibodies - anticardiolipin, anti-Beta-2glycoprotein-I, or lupus anticoagulant. Biggest risk factor for APS is SLE. APS occurs in up to 40% of SLE patients. Minority of healthy patients may develop transient antiphospholipid antibodies so all positive serologies for APS should be repeated at 12w to confirm. Patients with APS often require anticoagulation for life (heparin product or warfarin) as the risk of recurrent thrombus is high. For those with concomitant SLE, hydroxychloroquine is also added

Question 50

Polymyalgia rheumatica

Answer 50

Symptoms 1) Age over 50 2) Bilateral pain and morning stiffness for more than 1 month (usually lasts more than an hour) 3) Involvement of 2 of the following - neck/torso, shoulders/proximal arms, proximal thigh/hip, constitutional (fever, malaise, weight loss) PE - decreased active ROM in shoulders, necks and hips. Frequently unremarkable Labs 1) ESR over 40, sometimes over 100 2) High CRP 3) Normocytic anemia possible 4) about 20% can have normal studies Tx - response to glucocorticoids (low dose prednisone - like 10-20 mg per day). Should result in rapid symptom relief. If not, dx may be wrong. Often associated with giant cell arteritis (look for HA, jaw claudication, vision loss, tenderness over temporal artery). If this is expected get expedited temporal artery biopsy and give higher dose prednisone (40-60)

Question 51

Ankylosing spondylitis

Answer 51

Inflammatory back pain 1) Insidious onset at age less than 40 2) Symptoms for more than 3 months 3) Relieved with exercise*** but not rest 4) Nocturnal pain Exam 1) Arthritis (sacroiliitis) 2) Reduced chest expansion and spinal mobility 3) Enthesitis (tenderness at tendon insertion sites) 4) Dactylitis (swelling of fingers and toes) 5) Uveitis Complications 1) Osteoporosis/vertebral fractures 2) Aortic regurgitation 3) Cauda equina Labs 1) Elevated CRP and ESR 2) HLA-B27 association (not specific enough for dx tho and not needed for diagnosis) Imaging 1) XR of sacroiliac joints** (confirms the dx) - demonstrating radiographic changes to axial skeleton IS needed for diagnosis 2) MRI of sacroiliac joints

Question 52

When should you suspect ankylosing spondylitis?

Answer 52

It's more in males, but suspect in ANY young patient with progressive low back pain and stiffness lasting over 3 months

Question 53

Musculoskeletal causes of back pain (4)

Answer 53

1) Mechanical (muscle strain, spasm, degenerative arthritis) - normal neuro exam, negative straight leg raise, possible paraspinal tenderness 2) Herniated nucleus pulposus/disk disease - radiculopathy (usually L4 L5), possible positive straight leg raise, possible neuro deficits* 3) Spinal stenosis - pseudoclaudication, better with spine flexion, worse with extension, Older age*** 4) Compression fracture - older age***, more common in women, trauma/fall (may be minor)***

Question 54

Inflammatory causes of back pain

Answer 54

Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD (PAIR) - better with activity or exercise, no improvement with rest, gradual onset, HLAB27 present***

Question 55

Malignancy as a cause of back pain

Answer 55

Metastatic cancer to the bone 1) History of malignancy 2) Age over 50 3) Worse at night 4) Unintentional weight loss 5) Cauda equina syndrome - weakness, urine retention/incontinence, saddle anesthesia

Question 56

Infectious causes of back pain

Answer 56

Osteomyelitis, discitis, abscess 1) Recent infection 2) IV drug use*** 3) Diabetes 4) Fever, exquisite point tenderness***

Question 57

5 common causes of shoulder pain

Answer 57

Rotator cuff impingement or tendinopathy 1) Pain with abduction, external rotation 2) Subacromial tenderness 3) Normal ROM with positive impingement tests (Neer, Hawkins) Rotator cuff tear 1) Similar to tendinopathy 2) Weakness with external rotation 3) Age over 40. Fall on outstretched arm. Adhesive capsulitis (frozen shoulder) - glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis and contracture of the joint capsule. Can be secondary to rotator cuff tendinopathy (most common) or idiopathic. Also secondary to fractures and stuff. 1) Decreased passive AND active ROM*** (more than 50% reduction is needed for dx) 2) More stiffness than pain (stiffness out of proportion to pain) Biceps tendinopathy/rupture 1) Anterior shoulder pain 2) Pain with lifting, carrying, or overhead reaching 3) Weakness less common Glenohumeral osteoarthritis 1) Uncommon and usually caused by trauma 2) Gradual onset of anterior or deep shoulder pain 3) Decreased active and passive abduction and external rotation

Question 58

Baker's cyst

Answer 58

Tender mass located in popliteal fossa. Develops as a result of excessive fluid production by inflamed synovium, as occurs in cases of RA, OA and cartilage tears. As synovial fluid volume expands, excess fluid accumulates in the popliteal bursa. Popliteal bursa bulges beyond its usual size and fills the fossa producing tender synovial fluid-filled mass Baker cysts occasional burst and release their contents into the calf, resulting in an appearance similar to a DVT

Question 59

Risk factors for gout

Answer 59

1) Medications (diuretics, low dose aspirin, allopurinol, cyclosporine) 2) Surg, trauma, recent hospitalization 3) Volume depletion 4) Diet - high protein (meat, seafood), high fat, fructose or sweetened beverages 5) Heavy alcohol consumption 6) Underlying medical conditions (HTN, obesity, CKD, organ transplant) Lower risk 1) Dairy products 2) Vit C (over 1500 per day) 3) Coffee (at least 6 cups per day)

Question 60

What bone disease are RA patients most at risk for?

Answer 60

Osteoporosis. Increased levels of proinflammatory cytokines, corticosteroid therapy, and lack of physical activity may contribute to local (around inflamed joints) or generalized loss of bone mass. There is increased risk of osteopenia, osteoporosis, and bone fractures ESP if other risk factors (low body weight, female, family history of osteoporosis, cigarette smoking, postmenopausal state, excess alcohol use and other comorbidities) are present. Degree of bone loss correlates with disease activity. Strategies to prevent bone loss (good physical activity, optimization of vitamin D and calcium intake, minimization of glucocorticoid dose) should be implemented. Most experts suggest low threshold for starting bisphosponate therapy in RA patients.

Question 61

What is the most common extraarticular manifestation of ankylosing spondylitis?

Answer 61

Anterior uveitis (iritis). It happens in 25-40% of cases. Characterized by inflammation of uveal tract (iris, ciliary body and choroid). Typically presents with intense pain and photophobia in one eye.

Question 62

What disease is episcleritis associated with?

Answer 62

This is inflammation seen at the white of the eye, without involvement of uveal tract. Most seen in RA and IBD. Not seen in AS.

Question 63

Carpal tunnel syndrome

Answer 63

Risk factors 1) Obesity 2) Pregnancy 3) Diabetes 4) Hypothyroidism 5) RA Clinical 1) Pain and paresthesias in median nerve distribution (first 3.5 digits) 2) Positive Phalen and Tinel tests 3) Severe disease - weakness of thumb abduction and opposition, atrophy of thenar eminence Confirmatory test - nerve conduction studies Tx - wrist splinting then glucocorticoid injection then surgery for severe or refractory