RHEUMATOLOGY TiKi TaKa

-----------------------. Systemic lupus erythematosus "SLE":

-----------------------------------. Female 20-30 ys.
. Malar "Butter fly" rash.
. Arthritis.
. Painless oral ulcers.
. Renal disease.
. +ve Ds DNA.
. Newly diagnosed "Lupus Nephritis" ----> RENAL BIOPSY to detect the type of pa
thology.
. Grading from class 1 "Minimal mesangial" up to class 4 "Advanced Sclerosis".
. Then the immunosuppressive therapy is given accordingly.
. BLUE TOE $YNDROME:
------------------. Due to CHOLESTEROL EMBOLISM.
. Cardiac catheterization may cause atheroembolism.
. BLUE TOES " But intact paulse".
. ++ CREATININE.
. Abdominal tendrness.
. Accompanied e' Livedo reticularis.
. SLE:
----. Young, African American woman.
. Aged 20 - 40 ys.
. Fatigue "Anemia".
. Painful oral ulcers.
. Non deforming arthritis.
. Hematologic abnormalities "pancytopenia".
. Low grade fever.
. Weight loss.
. Malar or discoid rash.
. Lupus Arthritis as RA involves MCP & PIP BUT "NO DEFORMITIES".
. REMEMBER ---> LUMBAR SPINAL STENOSIS Dx ----> Spinal MRI.
----------------------------------------------------------. Ankle brachial index is used to diagnose peripheral artery disease.
. ERYTHEMA NODOSUM:
------------------. Painful S.C. pre-tibial nodules.
. Associated with SARCOIDOSIS.
. Ask for a CXR to detect sarcoidosis.
. CXR: Bilateral hilar adenopathy.
. AFRICAN AMERICAN FEMALE !
. Cough, Arthritis & uveitis.
. Disease --------------------------> Best initial Tx:
-----------------------------------------------------. Rheumatoid arthritis --------------> Methotrxate.
. Osteoarthritis --------------------> Weight loss & Acetaminophen.
. Gout acute attack -----------------> NSAIDs, Indomethacin.
. Gout prevent. of new attack -------> Colchicine.

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CPPD ------------------------------>
Disk herniation ------------------->
Epidural abscess ------------------>
Cord compression ------------------>
Spinal stenosis ------------------->
Fibromyalgia ---------------------->
Carpal Tunnel. $ ------------------>
Polymyositis ---------------------->
Rotator cuff injury --------------->
SLE ------------------------------->
Sjogren $ ------------------------->
Polymyalgia Rheumatica ------------>
Temporal "Giant cell" arteritis --->
Ankylosing Spondylitis ------------>
Psoriatic arthritis --------------->
Reactive arthritis "Reiter's $" --->
Septic arthritis ------------------>
Gonococcal arthritis -------------->

NSAIDs.
NSAIDs.
Abs "Vancomycin".
Steroids.
Weight loss & Steroid injection.
Amitriptyline.
Wrist splint & NSAIDs.
HIGH dose steroids.
NSAIDs.
High dose steroids.
Water the mouth & atrificial tears.
LOW dose steroids.
HIGH dose steroids.
NSAIDs.
NSAIDs.
NSAIDs.
CEFTRIAXONE & VANCOMYCIN.
Ceftriaxone or cefotaxime.

. D.D. of CALF SWELLINGS:

------------------------.. Cellulitis:
-------------... Infection of skin & S.C. tissue.
... Risk factors: Obesity & Tinea pedis !
... Red, edematous skin that is hot to touch.
... Regional lymphadenopathy.
... Caused by STAPH & STREPT Group A.
.. DVT = Deep Venous Thrombosis:
-------------------------------... Same presentation as cellulitis .
... BUT .. FEVER never exceeds 38.5 c.
... No regional lymphadenopathy.
... Ruptured BAKER's CYST.
. OSTEO-ARTHRITIS (OA):
----------------------. Old age.
. Affects hands & weight bearing joints.
. Mild morning stiffness < 30 mins (RA > 1 hour).
. Pain ++ with exercise & -- by rest.
. Bony crepitus, bony enlargement.
. Painful & - range of motion.
. Synovial fluid analysis: 200-2000 WBCs,
. (Normal 0-200 & Inflammatory 2000-50000 & Septic arthritis >50000).
. X-ray: -> NARROWED JOINT SPACE.
. X-ray: -> OSTEPHYTE FORMATION.
. X-ray: -> SUBCHONDRAL CYSTS.
. GOUTY ARTHRITIS:
-----------------. Middle aged male.
. Acute joint pain (1st Metatarsophalangeal joint is the most common).
. Swelling & -- range of motion.
. Low grade fever.
. Synovial fluid analysis is cirtical for diagnosis,
. WBCs 2000-50000,

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NEEDLE shaped, NEGATIVELY bireferingent crystals under polarized light.

NEGATIVE gram stain & culture.
++ serum Uric acid is neither sensitive nor specific !!
Tx of acute attack --> INDOMETHACIN (Cot'd in RF or GIT bleeding) & COLCHICIN
TREATMENT ----> NSAIDs, Colchicine & steroids.
PREVENTION ---> Allopurinol & probenicid.

. PSEUDO-GOUT:
-------------. Calcium pyrophosphate dihydrate (CPPD) deposition.
. Acute onset, pinful , monoarthropathy affecting the knee.
. Synovial fluid ---> RHOMBOID shaped with POSITIVE +ve birefringence.
. Ass. with HYPERPARATHYROIDISM:
.. ++ Ca & -- PO4 --> constipation & excess urination.
.. Disease of GROANS (Abd. pain), STONES (urinary) & Psychic MOANS.
. GONOCOCCAL SEPTIC ARTHRITIS:
-----------------------------. YOUNG, SEXUALLY ACTIVE FEMALE.
. Fever > 38.5 c.
. Redness, hotness, swelling, pain, limitation of movement.
. Synovial fluid analysis: ++ WBCs > 50000.
. Asymmetric polyarthritis.
. May be associated with tenosynovitis or rash.
. OSTEO-ARTHRITIS:
-----------------. Narrowed joint space.
. Osteophytes.
. Suchondral sclerosis or cysts.
. Obesity is the most common risk factor.
. Weight loss is the best initial ttt.
. LUMBAR SPINAL STENOSIS:
------------------------. Old pt.
. Combined low back & leg pain.
. Posture dependent --> Flexion of the back causes widening of the spinal canal
,
. while extension causes narrowing of the spinal canal.
. So, the leg pain is exacerbated by extension of the spine (Standing & walking
),
. but improved by flexion (Sitting & lying down).
. Called "Neurological Claudication".
. Differentiated from claudication of peripheral vascular disease by normal pul
ses!
. Normal Ankle / Brachial index.
. Normal neurological examination.
. -ve Straight leg test.
. Dx: MRI.
. Tx: Conservative or Laminectomy.
. TEMPORAL = GIANT CELL ARTERITIS:
---------------------------------. Age > 50 ys.
. New headache.
. Jaw claudication.
. Scalp pain.
. Visual loss.

. ++ ESR.
. Dx: TEMPORAL ARTERY BIOPSY.
. Tx: HIGH dose steroids.
. ANKYLOSING SPONDYLITIS TIPS & TRICKS:
--------------------------------------. Not only in young males, may affect females !
. BILATERAL SACRO-ILIITIS is DIAGNOSTIC.
. Most imp. extra-articular manifestation is ANTERIOT UVEITIS !!
. May be associated with Aortic insuffeciency with AV Block.
. (Not ass. with Aortic Aneurysm xxxxx).
. N.B. Apophyseal joint arthritis = Ankylosing spodylitis:
--------------------------------------------------------. "Sero-negative spondylo-arthropathies".
. HERNIATED DISC:
----------------. Pain worsens with sitting.
. Low bk pain & sciatica.
. +ve stress leg test.
. VERTEBRAL METASTASIS:
----------------------. Low bk pain.
. H/O of malignancy.
. Weight loss.
. CONSTANT DULL PAIN.
. Failure to improve with conservative therapy.
. Osteomyelitis:
--------------. Caused by STAPH. AUREUS.
. Tx-> Ox, Clox, Dicloxacillin.
. ROTATOR CUFF TENDONITIS:
-------------------------. Due to repititive activity above shoulder height e.g. Painter.
. Passive motion of the arm above the head cause pain & guarding confirming imp
ingement.
. Lidocaine injection cause pain relief,
. in contrast to persistence of pain with NO relief in case of ROTATOR CUFF TEA
R,
. Rotator cuff tear is due to fall on out stretched hand.
. CYCLOPHOSPHAMIDE side effect ---> Hemorrhagic cystitis & Bladder carcinoma.
. ROTATOR CUFF TEAR:
-------------------. results from chronic tendonitis & shoulder trauma.
. Shoulder pain & weakness when lifting the arm above the head.
. Lidocaine injection relieves the pain in case of R.C. Tendonitis,
. while it persists in case of R.C. Tear.
. Dx----> MRI Shoulder.
. VIRAL ARTHRITIS:
-----------------. Secondary to PARVO-virus 19 infection.
. Similar presentation as Rheumatic arthritis !
. Arthritis --> PCP & PIP & wrists.

. Resolves within just 2 months !!

. H/O of frequent contact with children e.g. day care workers.
. so the diff. bet viral & RA are:
---------------------------------. . ACUTE ONSET.
. . Lack of inflammatory markers "Anti-CCP & RF".
. . Resolution within 2 months !
. SE of HYDROXYCHLOROQUINE ---> RETINOPATHY.
. SE of CYCLOPHOSPHAMIDE ---> BLADDER CARCINOMA.
. SARCOIDOSIS:
-------------. AFRICAN AMERICAN FEMALE.
. Lung involvement --> Cough & dyspnea.
. Erythema nodosum.
. Anterior uveitis.
. Acute polyarthritis.
. Parahilar adenopathy.
. ++ ACE enzymes (Give ACE Is)!
. Biopsy: Non caseating granuloma.
. Tx: SYSTEMIC GLUCOCORTICOIDs.
. CARPAL TUNNEL $YNDROME:
------------------------. Compression of the median nerve within the carpal tunnel in the wrist.
. Pain & paresthesia in the median nerve distribution.
. Worse with wrist flexion (+ve PHALEN test).
. May be due to HYPOTHYROIDISM (Fatigue, constipation, menorrhagia & dry skin).
. PATHOLOGY ----> Deposition of MUCOPOLYSACCHARIDE PROTEIN COMPLEXES (MATRIX SU
BSTANCE).
. HYPOTHYROIDISM ---> BILATERAL CT$.
. FIBRO-MYALGIA:
---------------. WOMEN 20-50 ys.
. Point tenderness in at least 11 - 18 points !!
. H/O of generalized musculoskeletal pain not related to another illness.
. Disturbed sleep, easy fatiguability.
. Normal lab values.
. Tx: TCAs e.g AMITRIPTYLINE.
. DERMATOMYOSITIS:
-----------------. Proximal extensor ms inflammatory myopathy.
. Violaceous poikiloderma.
. Periorbital edema with rash "Heliotrope sign".
. Rash on chest & lateral neck "Shawl sign".
. Rash on the knuckles, elbows & knees "Gottron's sign".
. Lichenoid papules "Gottron's papules".
. Anti-Mi-2 Abs.
. Ass. with internal malignancies "Most common is OVARIAN CANCER" !
. POLYMYOSITIS:
--------------. Slowly progressive proximal muscle weakness of the lower limbs.
. Difficulty with stair climbing.
. Difficulty with rising from a seat.
. Muscle tendrness.

. Best diagnostic test ---> MUSCLE BIOPSY.

. Metastatic disease of the vertebrae:
-------------------------------------. H/O of Lung cancer (Non small cell lung carcinoma).
. Most common causing cancers: Lung, breast, prostate & thyroid.
. CONSTANT pain, worse at night.
. LUMBAR STRAIN:
--------------. Follow twisting of the bk while lifting heavy objects.
. ++ by activity & -- by rest.
. No point tendrness.
. SPINAL STENOSIS:
----------------. Low bk pain at lumbar spine,
. ++ with activity.
. DISK HERNIATION:
----------------. LBP radiating down the buttock,
. +ve straight leg raise test.
. ANSERINE BURSITIS:
-------------------. Anserine bursa is located antero-medially over the tibial plateau,
. just below the joint line of the knee.
. Inflammation may be due to overuse or trauma.
. LOCALIZED pain over the ANTEROMEDIAL tibia.
. Valgus stress test -->-ve. "Ruling out Medial collateral ligament injury".
. NORMAL X-ray.
. Tx: Cortico-steroids injection into the bursa.
. Pre-patellar bursitis:
-----------------------. Pain & swelling directly over the patella.
. Disease ---> Specific Antibodies:
----------------------------------. Rhematoid Arthritis "RA" ------------>
.
. Systemic Lupus Erythematosus "SLE" -->
. Scleroderma ------------------------->
. CREST $ ----------------------------->
. Sjogren $ --------------------------->
. Wegener's granulomatosis ------------>
C-ANCA".
. Chrug-Strauss ----------------------->
.

Anti-Cyclic Citrulinated Peptide "CCP"

Anti-Double Stranded DNA "DS DNA".
Anti-topoisomerase "Scl 70".
Anti-centromere.
SS-A "Ro" & SS-B "La".
Anti-neutrophil cytoplasmic Antibody "
Anti-myeloperoxidase antibody "P-ANCA"

. WHIPPLE's disease:
-------------------. H/O of malabsortion diarrhea (Steatorrhea, flatulence, abd. distension).
. Weight loss.
. Migratory arthritis.
. caused by Tropheryma Whippelii.
. Dx: Small intestinal biopsy ---> PAS +ve macrophages in the lamina propria.
. Celiac disease = Celiac sprue = GLUTEN SENSITIVE ENTEROPATHY :

--------------------------------------------------------------. Malabsorptive diarrhea.

. Anti-endomysial & Anti-transglutaminase Antibodies.
. Biopsy --> Effacement of SI villi.
. ANKYLOSING SPONDYLITIS & IBD are associated !
---------------------------------------------. Both are associated with HLA B27.
. Both are associated with P-ANCA.
. IBD (UC): Bloody diarrhea, anemia & -ve stool culture, erythema nodosum.
. AS: SACROILIITIS.
. REACTIVE ARTHRITIS = 3 Can't ( see, pee, climb a tree):
-------------------------------------------------------. Following infectious diarrhea,
. caused by shigella, salmonella, Yersinia, Campylobacter or C.dificile.
. Conjunctivitis "Can't see".
. Urethritis "Can't Pee".
. Arthritis "Can't climb a tree"
. POLY-MYALGIA RHEUMATICA (PMR):
-------------------------------. Age > 50 ys.
. Aching pain in neck, shoulders & pelvic girdle lasting at least 1 month.
. Morning stiffness > 1 hour !
. ESR < 40 mm/hr.
. No pain with active or passive range of movement.
. Tx: LOW DOSE PREDNISONE.
. When do u give HIGH dose prednisone ?
. -> If associated with GIANT CELL TEMPORAL ARTERITISto prevent visual loss.
. It is diagnosed by Temporal artery biopsy.
. RHEUMATOID ARTHRITIS MANAGEMENT:
---------------------------------. All pts should be started on DMARDs ASAP as joint damge begins early !
. METHOTREXATE is the best initial therapy.
. NSAIDs are adjunctive therapy for symptomatic relief,
. NSAIDs don't -- disease progression.
. Gucocorticoids may reveal symptoms temporarily but they don't prevent future
worsening.
. Pts sh'd be tested for HEPATITIS B & C & T.B. bef. starting MTx.
. MTx sh'dn't be used in pregnants !
. Disseminated Gonococcemia:
---------------------------. Migratory polyarthritis.
. Skin lesions (Pustules) on the extremeties.
. Tenosynovitis.
. High fever & chills.
. Blood & pustule culture --> NEGATIVE (Need specific growth requirements).
. SJOGREN $YNDROME:
------------------. Women 50 - 60 ys.
. Kerato-conjunctivitis sicca (Xerophthalmia & dry eyes).
. XEROSTOMIA (dry mouth).
. Lack of normal amount of saliva -> Dental carries & dysphagia.
. Enlargement & firmness of the salivary glands.
. Histology -> Lymphocytic infiltration of the salivary glands.
. +ve Anti-SSA(Ro) & or Anti-SSB(La).

. SYSTEMIC SCLEROSIS:
--------------------. AFRICAN AMERICAN FEMALE.
. Widespread organ involvement.
. Esophagus -->GERD.
. Heart ------> Rt Heart failure.
. Kidney -----> hypertension.
. Most common cause of death is PULMONARY ARTERIAL HYPERTENSION.
. +ve Anti-topo-isomerase-I Abs = +ve Anti-Scl70.
. CREST $ = LIMITED scleroderma:
------------------------------. Calcinosis cutis.
. Raynaud's phenomenon.
. Esophageal dysmotility.
. Sclerodactyly.
. Telangiectasia.
. +ve Anti-Centromere Abs.
. PAGET DISEASE OF BONE = OSTEITIS DEFORMANS:
-------------------------------------------. ++ Osteoclastic activity ---> Bone RESORPTION.
. Distorted bone formation.
. Common sites: Femur & skull & vertebra.
. Hypertrophy of the skull -----> Vestibulocochlear nerve compression,
. 8th cranial n. compression ---> Deafness "Sensorineural hearing loss".
. NORMAL CALCIUM & PHOSPHATE LEVELS.
. HIGH ALKALINE PHOSPHATASE LEVEL.
. HIGH HYDROXYPROLINE LEVEL "Bone marker".
. SUB-ACROMIAL BURSITIS:
----------------------. Subacromial bursa lies between the acromion & the tendon of the supraspinatou
s ms.
. caused by chronic microtrauma to the supraspinatous tendon.
. e.g. overhead work or tennis playing.
. Tendrness hen the arm is internally rotated & forward flexed at the shoulder.
. No signs of deltoid atrophy.
. LATERAL EPICONDYLITIS = TENNIS ELBOW:
-------------------------------------. Due to repeated forceful wrist extension & supination.
. ex: Backhand in tennis or use of a screw driver.
. Point tendrness near the lateral epicondyle.
. Due to degeneration of extensor carpi radialis brevis.
. ROTATOR CUFF INJURY:
---------------------. Shoulder pain, weakness & -- range of motion.
. Due to impingement of the supraspinatous tendon.
. De QUERVAIN TENO-SYNOVITIS:
----------------------------. NEW MOTHERS who hold their babies with out-stretched thumb (ABDUCTED & EXTEND
ED).
. Affects tendons of abductor pollicis longus & extensor pollicis brevis.
. Passive stretch of these tendons elicits pain.
. Chronic Tophaceous Gout:

------------------------. Metatarsophalangeal joint is the most affected.

. Severe swelling & pain in the big toe.
. Due to deposition of the monosodium urate crystals "PODAGRA".
. U.A. crystals ---> Nephrolithiasis.
. Urate crystals may deposit in the soft tissues forming tumors "TOPHI".
. Tophi may ulcerate & drain a chalky material.
. H/O of water-pills intake for hypertension "THIAZIDEs".
. Hydrochlorothiazide ---> Hypovolemia ---> ++ U.acid reabsorption.
. BEHCET's $YNDROME:
------------------. Recurrent oral ulcers.
. Recurrent genital ulcers.
. Eye lesions: Anterior uveitis.
. Skin lesions: Erythema nodosum.
. Tx: Corticosteroids.
. More common in TURKISH, ASIAN & MIDDLE EASTERN population.
. Main mechanism of kidney damage in SLE is IMMUNE COMPLEX MEDIATED.
. Best initial ttt in cases of DISK HERNIATION is NSAIDs & EARLY MOBILIZATION.
. SLE ARTHRITIS:
--------------. Cortico-steroid induced "AVASCULAR NECROSIS" of the femoral head.
. Progressive hip or groin pain.
. without restriction of motion range.
. Normal radiograph on early stages.
. Dx: MRI is the gold standard.
. LUMBOSACRAL STRAIN:
-------------------. Most common cause of pain.
. Pain starts acutely after physical exertion.
. Pain concentrated in the lumbar area.
. No radiation to thighs.
. Paraspinal tendrness.
. Normal neurological exam.
. -ve straight leg raising test.
. Tx: NSAIDs & early mobilization.
. HERNIATED DISK:
---------------. Pain radiation to thighs.
. +ve straight leg raising test.
. COMPRESSION # of the VERTEBRA:
------------------------------. OLD age.
. Acute onset of pain without an obvious trauma.
. H/O of osteoporosis.
. H/O of steroids intake.
. Normal neurological exam (Absent Babinski reflex is considered NORMAL in elde
rly).
. -ve Straight leg raise test (+ve with DISK HERNIATION).
. VERTEBRAL OSTEOMYELITIS:
------------------------. Lumbar spine.

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Back pain.
Low grade fever.
++ ESR.
Local tendrness on percussion.
Paravertebral muscular spasm.
Dx: MRI.

. CERVICAL SPONDYLOSIS:
---------------------. Due to BONY SPUR.
. Age > 50ys.
. H/O of CHRONIC NECK PAIN is TYPICAL.
. Limited neck rotation & Lateral bending.
. Sensory deficits due to osteophyte induced radiculopathy.
. X-ray --> ** BONY SPURS & sclerotic facet joints.
. X-ray --> ** Narrowing of disk spaces.
. X-ray --> ** Hypertrophic vertebral bodies.
. ACUTE GOUTY ATTACK:
-------------------. Tx: NSAIDs "INDOMETHACIN" ,COLCHICINE or steroids.
. ALCOHOL CESSATION & LOW PURINE DIET are imp. to prevent future attacks.
. LUMBAR STRAIN:
--------------. Related to lifting a heavy object.
. No radicular signs.
. Good response to conservative therapy.
. Pt education -----> KEEP THE BACK STRAIGHT WHILE LIFTING AN OBJECT !
. DMARDs Disease Modyfying Anti-Rheumatic Drugs:
----------------------------------------------.METHOTREXATE:
-------------. inhibits dihydrofolate reductase.
. SE: Macrocytic anemia (MCV > 100 & -- Hb).
. Other SEs: Nausea, stomatitis, rash, hepatotoxicity, Alopecia.
. HYDROXYCHLOROQUINE:
--------------------. GI distress.
. Visual disturbances.
. Hemolysis in G6PD defeciency.
. CYCLOPHOSPHAMIDE:
-----------------. Nephrotoxicity & Bladder carcinoma.
. RED FLAGS of LOW BACK PAIN:
----------------------------. = SYSTEMIC DISORDER or HERNIATED DISC,
. or BONY ABNORMALITIES such as LYTIC LESIONS or Compression #s.
. Age > 50ys.
. H/O of previous cancer.
. Unexplained weight loss.
. Pain > 1 month duration.
. Nighttime pain causing difficulty with sleep.
. No response to previous therapy.
. Neurological symptoms.

. Pain to palpation of the vertebra = spinal infection or lytic lesions in the

spine.
. 1st step is X-RAY PLAIN FILM then MRI.
. SPINAL STENOSIS:
----------------. Bk pain radiating to the buttocks & thighs.
. Numbness & paresthesia may occur.
. Symptoms r worse during walking & lumbar extension,
. while lumbar flexion alleviates the pain.
. Dx: MRI.
. ILIAC ARTERY ATHEROSCLEROSIS:
------------------------------. Claudication in the buttocks & thighs.
. Pain ++ with activity & -- by rest.
. Not affected by lumbar flexion or extension.
. LUMBAR DISK HERNIATION:
------------------------. Acute onset bk pain.
. e' or e' out radiation to one leg.
. Pt recalls an incinting event e.g. lifting heavy objects.
. +ve straight leg raise test.
. ANKYLOSING SPONDYLITIS:
-----------------------. Young men < 40 ys.
. Low bk pain & stiffness.
. Worse in the morning & improves as the day progress.
. Ass. e' anterior Uveitis (Monocular pain,blurring,photophobia).
. X-ray pelvis --> SACRO-ILIITIS.
. -ve RF & +ve ESR.
. +ve HLA B 27.
. Tx: Pain relief & TNF Alpha antagonists.
. VERTEBRAL OSTEOMYELITIS:
------------------------. Injection drug user.
. Pts with sickle cell disease.
. immunocompromized pts.
. STAPHYLOCOCCUS AUREUS.
. TENDERNESS to GENTLE PERCUSSION.
. Pain not relieved by rest.
. Fever & ++WBCs --> UN-RELIABLE !
. ++ Platelet count.
. ++ ESR > 100 mm/hr.
. Dx: MRI.
. Tx: Long term IV Antibiotics.
. EPIDURAL ABSCESS:
-----------------. Enclosed infection in the epidural space.
. Bk pain, fever, chills & leukocytosis.
. More common in injection drug users.
. It may cause SPINAL CORD COMPRESSION.
. LL weakness & Urinary incontinence.
. Acute epidural abscess requires immediate surgical debridement.
. COMPRESSION #:

--------------. due to VERTEBRAL BODY DEMYELINIZATION.

. Intense focal pain.
. Without neurological symptoms.
. Occur in cases of osteomalacia or osteoporosis.
. ACUTE GOUTY ATTACK = PODAGRA:
-----------------------------. May be due to MYELO-PROLIFERATIVE disorder,
. e.g. POLYTHYCEMIA (SPLENOMEGALY & PRURITIS AFTER HOT BATHS).
. MPD "polythycemia" -> ++ Catabolism & turn over of proteins -> ++ uric acid p
roduction.
. GIANT CELL "TEMPORAL" ARTERITIS:
--------------------------------. Headache.
. Jaw claudication.
. Muscle fatigue.
. Visual disturbance.
. Scalp tenderness.
. -- Temporal artery pulse.
. ++ ESR > 50 mm/hr.
. May involve the branches of the AORTA ----> AORTIC ANEURYSM.
. Serial CXRs are imp. to exclude Aortic aneurysm.
. REMEMBER AGAIN OA "Matet5ene2sh :)
----------------------------------. Degenerative Joint disease.
. Wear & Tear Arthritis.
. ++ by walking & -- by rest.
. Morning stiffness < 30 mins.
. limited range of movement.
. Tenderness on passive movement.
. Due to destruction of the articular cartilage --> Bone on bone friction.
. Most common risk factor is OBESITY !
. AVASCULAR NECROSIS = ASEPTIC NECROSIS = ISCHEMIC NECROSIS = OSTEOCHONDRITIS DE
SSICANS:
-------------------------------------------------------------------------------------. Disruption of bone vasculature.
. Corticosteroid related osteonecrosis of the right femoral head.
. H/O Excessive Alcohol ingestion.
. Slowly progressive anterior hip pain with limitation of range of motion.
. Dx: MRI.
. D.D. of INFLAMMATORY MONOARTHRITIS: (RED HOT SWOLLEN PAINFUL LIMITED MOVEMENT)
:
------------------------------------------------------------------------------. Septic arthritis.
. Crystal induced arthritis.
. Trauma.
. Pts with RA are at high risk of developing septic arthritis esp. with STAPH.
AUREUS.
. RA cause osteopenia & osteoporosis "NOT osteomalacia caused by Ca & Vit. D def
eciency".
. MTx side effects:

-----------------. Stomatitis.
. Nausea.
. Anemia.
. Hepatotoxicity.
. Tx: Give FOLIC ACID !
. RA:
---. MORNING STIFFNESS > 1 hour.
. Small joints (MCP & PIP).
. Spares DIP "Unlike OA".
. Tenosynovitis (Trigger finger).
. Rheumatoid nodules (Elbow).
. Cervical joint involvement ---> Spine sublaxation ---> Spinal cord compressio
n.
. +ve Anti-CCP Abs.
. +ve RF.
. ++ CRP & ESR.
. X-ray: Soft tissue swelling , joint sapce narrowing & bone erosions.
. Both Obstructive & Restrictive lung disease cause -- in FEV & FEV 1 !
---------------------------------------------------------------------. But .. RESTRICTIVE lung disease cause much more -- in FEV 1 than Obstructive
type.
. So .. In RESTRICTIVE lung dis. FEV 1 / FEV is > 80 %.
. Examples of RESTRICTIVE causes:
-------------------------------.. Interstitial lung disease.
.. Neuromuscular diseases.
.. Chest wall abnormalities.
. Ankylosing spondylitis -> costovertebral joint fusion -> chest wall motion re
striction.
. ENTHESITIS:
-----------. Inflammation & pain at ligaments & tendons attached to bone.
. Associted with Negative spondylo-arthropathies,
. e.g. ANKYLOSING SPONDYLITIS, psoriatic arthritis & reactive arthritis.
. Associated with HLA B 27.
. Most common sites are shoulder & hip.
. REACTIVE ARTHRITIS = Seronegative spondyloarthropathy:
------------------------------------------------------. TRIAD of: CAN'T SEE, CAN'T PEE, CAN'T CLIMB A TREE !!
. 1- CONJUNCTIVITIS "CAN'T SEE".
. 2- NON GONOCOCCAL URETHRITIS "CAN'T PEE".
. 3- ASYMMETRIC OLIGOARTHRITIS "CAN'T CLIMB A TREE".
. Mucocutaneous lesions.
. Enthesitis "Achilles tendon pain".
. STERILE Synovial fluid analysis.
. Tx: NSAIDs.
. Pts with prolonged H/O of ANKYLOSING SPONDYLITIS:
-------------------------------------------------. are at ++ risk of VERTEBRAL #,
. due to -- bone mineral density & may occur with minimal trauma !!
. FIBROMYALGIA:
--------------

. Women 20 - 50 ys.
. Generalized musculoskeletal pain in absence of joint swelling or lab abnormal
ities.
. Excessive tendrness on palpation of at least 11 of 18 soft tissue locations.
. The sites include the upper quadrants of the buttocks & medial aspect of the
knees.
. As well as Sternocleidomastoid & Trapezius muscles.
. Absent of joint swelling or ms weakness.
. PSORIATIC ARTHRITIS:
--------------------. DIP.
. Dactylitis --> SAUSAGE shaped digits = diffusely swollen fingers.
. Nail involvement: pitting & oncholysis "separation of nail bed".
. Well demarcated red palques with silvery scaling.
. Tx: NSAIDs & MTx.
. Steroids are contraindicated.
. N.B. RA ----> MCP & PIP.
. N.B. OA ----> DIP.
. PSEUDO-GOUT = CHONDRO-CALCINOSIS:
---------------------------------. Acute arthritis.
. Due to CPPD Calcium pyrophosphate dehydrate crystals deposition.
. H/O of recent surgery or medical illness.
. Synovial fluid analysis --> RHOMBOID shaped, POSITIVELY birefringent crystals
.
. GOUT synovial fluid analysis --> NEEDLE shaped, NEGATIVELY birefringent cryst
als.
. BAKER CYST:
-----------. Due to excessive fluid production by an inflammed synovium.
. Occurs in cases of Rheumatoid Arthritis.
. Excess fluid accumulates in the popliteal bursa which expands,
. creating a tender mass in the popliteal fossa.
. May burst & release their contents into the calf,
. resulting in an appearance similar to DVT.
. AMYLOIDOSIS:
------------. Ass. with Nephrotic $ (facial swelling, LL edema, massive proteinuria).
. Palpable kidneys.
. Hepatomegaly.
. Cardiomegaly (Audible S4).
. H/O of chronic infections e.g. Bronchiectasis & recurrent pulm. infections.
. Tx: COLCHICINE.
. OSTEO-ARTHRITIS:
----------------. Age > 50 ys.
. Morning stiffness < 30 mins.
. Bony tendrness.
. Bony enlargement.
. CREPITUS on active motion.
. No warmth i.e. COOL joint !
. SLE Arthritis:
---------------

. Like RA but --------> NO PERMANENT DEFORMITIES.

. SEPTIC ARTHRITIS:
-----------------. H/O of PROSTHETIC joint.
. Red, hot, swollen, painful joint with limited range of motion.
. ++ WBCs > 50000.
. STAPH. AUREUS is the most common causative organism.
. Disseminated Gonococcemia:
--------------------------. H/O of recent unprotected sex with a new partener.
. A triad of Polyarthralgia + Tenosyvovitis + Vesiculo-pustular skin lesions.
. PAGET's disease of bone:
------------------------. Age > 40 ys.
. ++ bone turn over.
. ++ OSTEOCLAST ACTIVITY.
. Mosaic pattern of lamellar bone.
. Enlarged cranial bone --> ++ hat size.
. Entrapment of 8th cranial nerve --> Deafness.
. X-ray --> Femoral bowing.
. NORMAL CALCIUM & PHOSPHOROUS LEVELS.
. ++ ALKALINE PHOSPHATASE LEVEL.
. NEUROGENIC ARTHROPATHY = CHARCOT's JOINT:
-----------------------------------------. Due to DIABETIC NEUROPATHY.
. H/O of DM is the key word.
. -- pain, proprioception & temperature.
. caused by D.M., peripheral nerve damage, syringomyelia & B12 defeciency.
. X-ray ---> Loss of cartilage, osteophytes formation & loose bodies.
. Tx: ttt the cause & special shoes !
. GOUT X-ray ---> PUNCHED OUT EROSIONS + Overhanging rim of cortical bone.
Dr. Wael Tawfic Mohamed
-------------------------