Transcript Rheumatology Board Review Presentation

Rheumatology Board
Review Presentation - 2
Vikas Majithia, MD, MPH.
Professor of Medicine,
Chief and Fellowship Program
Director, Rheumatology.
Game-Plan
Stimulate your mind and think with me
Highlight the topics
Go over “educational objectives”
These are potential questions/test
pertinent areas
Participate
If you want write, Use the handout from
today otherwise just listen
SUBJ ECTIVE COMPLAINTS OF WEAKN ESS
Excl ude:
Anemia
Card iopulmonary disease
Chronic infections
Malignancy
Depression
Fibro myalgia
Malingering
Deconditioning
OBJ ECTIVE MUS CLE WEAKNESS
AS YMMETRIC
Regional neuro logical disorders
Cerebrovascular disorders
Spinal cord and spinal root disorders
Demyelinating disease
Co mpression neuropathy
Mononeuropathy/mononeuritis multip lex
Disuse atrophy
Myasthenia gravis
SYMMETRIC
PROXIMAL
Inflammatory myopathy
Metabolic myopathy
Endocrine myopathy
Glucocorticoid myopathy
Mitochondrial myopathy
Drug-induced myopathy
HIV-related myopathy
Duchene’s muscular dystrophy
Myasthenia gravis
SPECIFIC PATTERN
Muscular dystrophy
Hereditary neuropathies
Myasthenia gravis
DISTAL
Peripheral polyneuropathy
Motor neuron disease
Myasthenia gravis
Inflammatory Myopathy:
• Symmetric pro ximal muscle weakness
• Elevated plasma muscle en zy mes
• Myopathic changes on electromyography
• Characteristic muscle biopsy abnormalities and the absence of
histopathologic signs of other myopathies
• Typical rash of dermato myositis
Management includes complete laboratory profile, EM G, Biopsy. Work-up
for underlying malignancy. Start prednisone at .5 mg/kg- 1 mg/kg initially.
Needs appointment in rheumatology in 4-6 weeks or earlier.
Dermatomyositis-Polymyositis
Classification Criteria
Five criteria for DM and PM were proposed in 1975
 Symmetric proximal muscle weakness
 Elevated plasma muscle enzymes
 Myopathic changes on electromyography
 Characteristic muscle biopsy abnormalities and
the absence of histopathologic signs of other
myopathies
 Typical rash of dermatomyositis
Dermatomyositis-Polymyositis
Other clinical features
1. fever and weight loss,
2. A nonerosive inflammatory polyarthritis,
3. Raynaud's phenomenon
4. Cardiopulmonary abnormalities also may occur.
5. Congestive heart failure due to myocarditis
6. Interstitial lung disease
MYOSITIS SPECIFIC ANTIBODIES:
Anti T Rna Synthetases : Anti Jo-1: associated with
ILD
Anti Mi-2 (Dm)
Anti Pm-SCL
Anti SRP: associated with cardiac disease
Heliotrope Rash
Gottron’s sign/papules
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DIFFERENCES BETWEEN DM AND PM
Clinically, DM is associated with certain skin manifestations.
Ocular muscles are more frequently involved in DM.
DM Has a higher incidence of malignancy, although various
cancers (GI, Lung, Ovary) can be associated with both DM
and PM.
Pathogenetically, DM is associated with immune complex
deposition in the vessels, whereas PM appears to reflect
direct T cell-mediated muscle injury.
TREATMENT
Corticosteroids 1 mg/kg are medications of choice
IV pulse steroids may be needed
Usually needed for a long duration: months to years.
Immunosuppressive therapies:
Azathioprine (Imuran)
Methotrexate
Combination of MTX and imuran
IV cyclophosphamide
IVIG
Biologics- TNF blockers, Rituximab
Inflammatory Myopathy
Questions asked
1.
2.
3.
4.
5.
6.
7.
Patient scenario: middle aged or elderly female. Male age
above 50.
Patient presents with weakness, hand and eyelid rash.
Work-up should include? Likely diagnosis?
Same patient is at risk for what? What tests to do?
Additional tests in female patient?
Patient with myositis presents with cough, SOB. What
test? Antibody? Diagnosis?
Patient with myositis responded to steroids and MTX now
weak again, CPK is 650. Diagnosis? Management?
65 year-old-male comes with weakness, CPK 600,
abnormal EMG. Treated with prednisone, MTX for 5-6
months but no response. Diagnosis? Appropriate test?
Treatment?
Myositis patient with left hip pain and abnormal exam.
What test? Likely diagnosis?
Monoarthritis
Monoarthralgia
Exclude Periarticular Disease
Tendonitis, Bursitis, Bone lesion,
Myofascial Pain, Sprain/Overuse, soft
tissue infection, peri-articular GC
infection
Monarticular Arthritis/ Arthalgia
Always consider Aspiration of joint for
diagnosis
Cell count, Crystals, Gram stain, Culture
Infection
Gonococcus
Staphylococcus
Streptococcus
Diagnostic features:
True joint Inflammation
with pain, swelling,
erythema, Leukocytosis
and fever, Synovial fluid
cell count >50,000,
Positive gram stain and
culture
Crystalline disease
Gout/pseudo gout
True inflammatory
changes in joint with
urate or CPPD crystals
on synovial fluid
examination; cell count
of 2000-50,000;
Cystic erosions (gout)
or chondorcalcinosis
(pseudgout) on X-ray
Osteoarthritis/trauma
Absence of inflammatory
changes and <30 minutes
AM stiffness with the
presence of pain, crepitus,
mild swelling, osteophytes;
X-ray changes of joint
narrowing, osteophytes
formation, sclerosis;
Joint fluid aspirate either
bloody or cell count<2000;
If diabetic, consider
neuropathic joint
Seronegative
spondyloarthropathy
Inflammatory changes
of joint (particularly
knee or ankle);
Synovial fluid cell
count of 2000- 50,000;
involvement of eyes
(conjunctivitis or
uveitis) or
back/sacroiliac joints
with prolonged (>1
hour AM stiffness)
Early onset
inflammatory
arthritis
RA or SLE
Inflammatory joint
changes with other
etiologies excluded;
with prolonged (>1
hour AM stiffness);
with positive RF or
ANA
Septic Arthritis
Synovial Fluid Analysis
Normal
Inflammatory
Septic
Hemorrha
gic
Crystal
Induced
Clear/Yellow
Transparent
Yellow/ White
Translucent/
opaque
Yellow/White
Opaque
Red
Opaque
Yellow/
White,
Translucent
/opaque
<2K
2K-50K
>50K
N/a
10K-50K
+/- Gm stain, +/Culture
-ve Gm
stain, Cx.
-ve Gm
stain, Cx.
+ Crystals
-ve Gm stain -ve Gm stain &
& Culture (Cx) Culture
Disseminated GC
Skin pustules in DGC
Infectious arthritis
Questions asked
1. Patient scenario: Male, Acute symptoms
(sub-acute female in DGI)
2. Elderly male presents to the ER with
acute R knee pain/swelling: Next test,
Results abnormal- What to do?
3. 20-40 year old F with migratory arthritis:
Knee-ankle-wrist, Tap shows 15,000
wbc. Has a rash. Diagnosis?
4. Travel to Connecticut, rash, fatigue,
myalgia? History? Diagnosis? Treatment?
5. Same patient (did not get treatment)1
year later has CN palsy/knee arthritis.
What to do?
Polyarthritis/ Polyarthralgia
Determine by History and Physical if inflammatory
(Prolonged AM stiffness, erythema, swelling, warmth, pain)
Evaluation dictated by history and physical may include CBC, urinalysis, liver and kidney function, RF, ANA,
ANCA, ESR, TSH, CPK, HBA1C, CXR and regional/back/SI joint X-rays
Non- Inflammatory
AM stiffness < 1 hour
No joint erythema, swelling and
Normal ESR
Negative RF or ANA
Implies a differential diagnosis of
Myofascial pain
Fibromyalgia
Osteoarthritis
Endocrinopathy
Pain syndrome
Does not clearly fit into either category,
Consider:
Seronegative RA
Seronegative spondyloarthropathy
Inflammatory
AM stiffness > 1 hour
Joint erythema, swelling, or pain
And
Elevated ESR (must exclude other inflammatory
diseases such as infection or cancer)
Or
Positive RF
Positive ANA
Implies a differential diagnosis of:
Rheumatoid arthritis
Connective tissue disease (lupus, PSS, PM/DM,
Sjogren’s)
Viral infection
Seronegative spondyloarthropathy
Sarcoidosis
SPONDYLOARTHROPATHIES
Ankylosing spondylitis
Reactive Arthritis – (Reiter’s)
Arthropathy of inflammatory bowel
disease (Enteropathic Arthritis)
Psoriatic arthritis
Undifferentiated spondyloarthropathies
Juvenile chronic arthritis and juvenileonset ankylosing spondylitis
CLINICAL CHARACTERISTICS OF
SPONDYLOARTHROPATHIES
 Tendency to cause sacroiliitis
 Tendency to cause spondylitis
 Association with enthesopathy (enthesitis)
 Typical pattern of peripheral arthritis: usually lower
limb, asymmetric, tenosynovitis (sausage digits)
 Absence of rheumatoid factor (RF)
 Absence of subcutaneous nodules and other extraarticular features of rheumatoid arthritis (RA)
 Overlapping extra-articular features characteristic of
the group (e.g., anterior uveitis)
 Significant familial aggregation and association with
HLA-B27
Sausage Digits
Management
Physical modalities
NSAIDS - 1st line (Mild cases/stable dzonly Rx)
DMARDs (? Efficacy – SSZ, others)
New treatments- TNF alpha blockers.
Ankylosing Spondylitis
Inflammatory back pain
HLA B-27 associated
Symmetrical Sacroilitis
Spondylitis: erosion, squaring of the
vertebrae
Uveitis; symmetrical
Atypical presentations: female, older age
Occiput to wall test
Schobere’s test
Enthesopathy.
Reactive Arthritis - GU
(Prev Reiter’s Syndrome)
 Inflammatory oligoarticular arthritis in the setting of
previous or intercurrent nongonococcal urethritis
and/or conjunctivitis is characteristic of patients with
Reiter’s syndrome.
 It is important to recognize that the majority of
patients with this disorder present with just one or
two features of the triad.
 Clinical triad of urethritis, conjunctivitis, and
inflammatory arthritis.
 Mucocutaneous manifestations of Reiter’s
syndrome: Circinate Balanitis and keratoderma
 Enthesopathy.
 Remember- Reactive arthritis of GI origin,
Enteropathic arthritis & PsA
Keratoderma
Blenorrhagica
Spondyloarthropathy/Infectious
arthritis
Questions asked
1.
2.
3.
4.
5.
6.
Patient scenario: Male, sub-acute symptoms
Patient with back pain worse in AM and better
with activity. What test? What eye
manifestation (different in RA)? Differentiate
from non-inflammatory back pain?
AS patient come with widened pulse pressure,
heart murmur. What test? Diagnosis?
AS patient comes with weakness in legs, BB
incontinence. Diagnosis? Treatment?
AS patient with pain/numbness affecting all 4
Ext UE>LE? Recently rear-ended? Next test?
Diagnosis?
AS patient with SOB? Diagnosis?
Spondyloarthropathy/Infectious
arthritis
Questions asked
7.
Patient with R knee arthritis, h/o STD.
Diagnosis? Eye manifestation? Associated
Disease?
8. Patient with painful DIP, swollen 2nd toe. Exam
has nail pitting, What else to look for?
Diagnosis?
9. Japanese patient with recurrent oral/genital
ulcers, arthritis. Diagnosis? Treatment?
10. Cruise ship (trip to Mexico etc) had diarrhoea,
Now with 1-2 joint arthritis +/- sausage toe.
Likely diagnosis? Associated organisms?
11. AS patient with back pain not responding to
NSAIDs and SSZ. Treatment?
THE VASCULITIDES
CLASSIFICATION
SIZE OF THE VESSELS INVOLVED
 ORGAN SYSTEMS INVOLVED
CLASSIFICATION
Large vessel: GCA and temporal arteritis,
Takayasu’s arteritis, Primary angitis of CNS
Medium size vessels: PAN, Kawasaki disease,
Granulomatosis with polyangitis i.e. GPA (Prev
Wegener’s granulomatosus) EGPA (Prev Churg
strauss syndrome),
Small vessels: GPA (Wegener’s), EGPA (Churg
Strauss), Henoch Schonlein Purpura,
Microscopic polyangitis (MPA), Mixed
cryoglobulinemia, Hypersensitivity
vasculitis/leukocytoclastic vasculitis, Vasculitis
associated with rheumatic diseases- RA,SLE
Misc. : Behcet’s disease, Relapsing
polychondritis, Lymphomatoid granulomatosis
CLINICAL MANIFESTATIONS
 NON SPECIFIC:
Fatigue and weakness
Fever, skin rash
Arthralgias and/or arthritis
abdominal pain
hypertension
neurological dysfunction/neuritis.
 SPECIFIC: PERTAINING TO THE ORANS INVOLVED
Pulmonary nodules
Sinus /nasal inflammation
Gastrointestinal inflammation with its presenting
symptoms
Glomerulonephritis/renal insufficiency with an active
sediment.
Hypersensitivity /leukocytoclastic
vasculitis
 Age >16
 a possible offending agent in temporal relation to the
symptoms
 Palpable purpura
 Maculopapular rash
 Biopsy of a skin lesion showing neutrophils around an
arteriole or venule
 ANY OF THE VASCULITIDES WHICH CAN INVOLVE
SMALL VESSELS CAN PRESENT AS PALPABLE PURPURA
& HAVE A PATHOLOGY OF LEUKOCYTOCLASTIC
VASCULITIS
THERAPY
Hypersensitivity vasculitis –
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Discontinuing the offending agent may be adequate
NSAIDS,Antihistamines.
Colchicine, dapsone
Corticosteroids as needed
Occasionally cytotoxic agents are required.
Systemic vasculitis :
• Corticosteroids are almost always needed.
• Cytotoxic agents have to be used in a number of
instances.
• Rituximab in ANCA associated Vasculitis (AAV)
Classification Criteria GPA –
Wegner’s Granulomatosis
 Nasal or oral inflammation (painful or painless oral ulcers or
purulent or bloody nasal discharge)
 Abnormal chest radiograph showing nodules, fixed infiltrates, or
cavities
 Abnormal urinary sediment (microscopic hematuria with or without
red cell casts)
 Granulomatous inflammation on biopsy of an artery or perivascular
area
 C-ANCA (anti proteinase-3) is now an important diagnostic test.
 Up to 90% sensitive in active systemic disease.
 Tissue biopsy can be diagnostic--A nasopharyngeal lesion, Renal
biopsy, Lung biopsy
Saddle nose
Nodules
POLYARTERITIS NODOSA
ACR Classification criteria: 3/10 +
are 82% sensitive, 84% specific
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Otherwise unexplained weight loss greater than 4 kg
Livedo reticularis
Testicular pain or tenderness
Myalgias (excluding shoulder and hip girdle), weakness of muscles,
tenderness of leg muscles
Mononeuropathy (Mononeuritis Multiplex) or polyneuropathy
New onset diastolic blood pressure greater than 90 mmHg
Elevated levels of serum blood urea nitrogen or creatinine
Evidence of hepatitis B virus infection
Characteristic arteriographic abnormalities
A biopsy of small or medium-sized artery containing PMN’s.
Renal angiogram
Giant Cell (Temporal) Arteritis
& Polymyalgia Rheumatica
 PMR is classically characterized by aching and
morning stiffness in the shoulder, hip girdles, neck
and torso in patients over the age of 50.
 The symptoms are usually symmetric and associated
with a high ESR, but asymmetric pain and normal
ESR can occur.
 GCA (temporal) arteritis is a chronic vasculitis of
large and medium size vessels which commonly
occurs among individuals over 50 years of age.
 Polymyalgia rheumatica occurs in about 50 percent
of patients with GCA, while approximately 15 percent
of patients with PMR as the primary diagnosis
develop GCA
Symptoms/signs
• NON SPECIFIC:
fatigue, weakness, fever, arthralgias.
• SPECIFIC:
new headache(60-70 %)
jaw claudication (30-40%)
Permanent partial or complete loss of vision in one or
both eyes(15-20%)
arm claudication (10 %)
Tender or thickened temporal arteries.
Bruits in cranial and upper extremity vessels
• Characteristic laboratory abnormality is a high ESR
upto 100mm/h. normal values may occasionally be
seen.
CRITERIA FOR GCA
 Age greater than or equal to 50 years at time of
disease onset
 Localized headache of new onset
 Tenderness or decreased pulse of the temporal artery
 Erythrocyte sedimentation rate greater than 50 mm/h
(Westergren)
 Biopsy which includes an artery, and reveals a
necrotizing arteritis with a predominance of
mononuclear cells or a granulomatous process with
multinucleated giant cells
TREATMENT
Corticosteroids are the mainstay of treatment
Prednisone is started in at 10-20 mg for PMR
and titrated to a response in clinical and
laboratory markers.
For GCA prednisone is started at a higher
dose of 0.5 to 1 mg/kg. IV steroids may be
needed for acute visual changes.
Subsequently Slow taper is recommended.
Usually treatment is continued for 1- 2 years
after remission.
Cytotoxic medications and methotrexate can
be used and may be required both during
acute and chronic phases.
Classification Criteria for
Relapsing Polychondritis
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Recurrent chondritis of both auricles
Nonerosive inflammatory polyarthritis
Chondritis of nasal cartilage
Inflammation of ocular structures, including
conjunctivitis, keratitis, scleritis/episcleritis
and/or uveitis
Chondritis of the respiratory tract involving
laryngeal and/or tracheal cartilages
Cochlear and/or vestibular damage manifest by
neurosensory hearing loss, tinnitus, and/or
vertigo
The Vasculitides
Questions asked
1.
2.
3.
4.
5.
6.
7.
Elderly (>50) patient presents with fever,
stiffness? Next test? Treatment?
Same patient has headache, visual loss. Next test?
Shortcoming of the test? Treatment?
Young Asian/Hispanic patient with pain, weakness
in left arm. Finding on exam? Next test?
Diagnosis?
Male patient with abdominal pain, weight loss,
arthritis, leg ulcers, purpuric rash. Next test?
Diagnosis? Associated findings?
Same patient also has history of IV drug abuse.
underlying disease? What results on ANCA
testing?
Same patient with foot drop. Diagnosis? Next
test?
40-50 year old male patient with abdominal pain,
arthritis, leg ulcers, purpuric rash. Next test?
Diagnosis? Associated findings?
The Vasculitides
Questions asked
8.
9.
10.
11.
12.
13.
14.
15.
16.
Male patient with SOB, cough, weight loss, active
urinary sediment, + p-ANCA. Next test? Diagnosis?
Treatment?
Patient with sinusitis, nasal ulcer. Next test? Diagnosis?
Treatment?
Same patient with hemoptysis, cough, renal
insufficiency? Next test? Diagnosis? Treatment?
Patient with h/o asthma, rhinitis, now has cough,
purpuric rash. chest x-ray: infiltrates. Next test?
Diagnosis? Treatment?
Purpuric rash, URI, hematuria. Diagnosis? Treatment?
Urticarial rash, hematuria- active urinary sediment- Dx &
Tx?
Recreational drug assoc pseudovasculitis- clinically
vasculitis, -ve imaging & bx. Serology- ANCAs may be +.
Culprit drugs? Cutting agents? Tests?
Patient started on HCTZ, now has a rash: palpable
purpura. Diagnosis? Management?
Patient of Mediterranean descent with recurrent
abdominal pain, fever, arthritis. + family history.
Diagnosis? Treatment? Complication?
Osteoporosis: Diagnosis
and Evaluation
 Central DXA
(Dual Energy X-ray
Absorptiometry)
remains the state-ofthe-art diagnostic
standard
 Bone density is the
most important
predictor of
fracture risk
What is a T-score? What is
a Z-score?
The BMD results are expressed as standard
deviations from a comparison to the referent
mean.
A T-SCORE is the number of standard deviations
the bone mineral density measurement is above
or below the YOUNG-NORMAL MEAN bone
mineral density.
A Z-SCORE is the number of standard deviations
the measurement is above or below the AGEMATCHED MEAN bone mineral density.
World Health Organization Interpretation of Bone
Density
Patient’s T-Score
-0.5 T
Classification
Normal
-1.0 T
-1.5 T
-2.0 T
Osteopenia
-2.5 T
Osteoporosis
Severe Osteoporosis
(with fragility fractures)
National Osteoporosis Foundation
Who should be evaluated for OP.
• Bone density test vs Fracture risk assessment?
• Women:
o Age > 65 without risk factors
o Age > 50 with risk factors1
• Men
o Age > 70
o Earlier – if there are risk factors*- osteoporotic
fracture, hypogonadism, malignancy etc.
1. Risk factors for osteoporotic fracture include: low body weight;
history of fracture; Caucasian; cigarette smoking; estrogen deficiency,
early menopause; low calcium intake; alcoholism; recurrent
falls; and inadequate physical activity.
* Not well-defined
Fracture Risk Assessment Score- FRAX
• FRAX- Tool to assess fracture risk
(Developed by WHO)
• Decision making alogrithm for assessing the risk of fracture in
an individual based on clinical information and using that
to make therapeutic decisions.
• Can add BMD in the calculation
• Gives a 10-year risk
• A 10 year risk of overall fracture > 20% or hip fracture > 3% is
felt to be significant.
National Osteoporosis Foundation
Who should be considered for treatment of
OP.
•
Complicated answer
• Women:
o Age > 40 with low BMD (T-score <-2.5 i.e.
OP) or high FRAX (T-score>1&<2.5 i.e.
osteopenia)
o Age < 40- individualize (risk factors,
fracture, steroid use)
• Men
o low BMD (T-score <-2.5) or high FRAX
o Younger patient, ?Age - individualize (risk
factors, fracture, steroid use)
Traditional Nonpharmacological
Management for Prevention
and Treatment
Calcium (1200 – 1500 mg/day in
divided doses)
Vitamin D 400-800 IU/day*
Weight-bearing exercise
Fall-prevention techniques
*800 IU/day for patients over age 65
Fracture Prevention:
Role of Drug Therapy
 Anti-resorptive therapies:
Hormone replacement therapy (HRT)
Raloxifene
Bisphosphonates (C/I if GFR < 30)
Alendronate
Risedronate
Ibandronate
Pamidronate
Zolendronate
Calcitonin
RANK Ligand inhibitor- Denosumab (Prolia) (OK in
moderate/sever renal disease)
 Bone formative: PTH (Forteo)
Osteoarthritis
 Primarily a disorder of cartilage associated with cartilage
destruction and secondary bone changes
 Most Common rheumatic disorder
 Common cause of joint pain especially in elderly
 Joint Pain: weight bearing joints, worse with activity &
better with rest
 AM stiffness is minimal
 Typically involves DIP and PIP
 Can have secondary synovitis (inflammation)
 Common cause of back pain: remember SPINAL
STENOSIS and its features
 Typically normal lab studies
 X-rays: joint space narrowing and osteophyte formation
Osteoarthritis
Management
•Acetaminophen
•NSAIDs: Any NSAID works fine
•Weight reduction and physical therapy
•Local therapy
•Intra-articular steroids
•Intra-articular viscous supplementation ( Hyalgan, Synvisc etc)
only in knee OA
•Narcotics
Role of joint replacement Surgery:
•Treat patient not radiograph
•Symptoms of Rest pain and night pain are indications for surgery
•Functional impairment is also indication for surgery
•Adequate medical work-up due to risk factors
Back Pain
 Mechanical Back Pain
Minimal AM stiffness
Intermittent
Improved with rest
Decreased ROM in all directions
 Inflammatory Back pain
Prolonged AM stiffness
Persistent
Improved with activity
Decrease in Flexion/extension of spine: Schobere’s test
 Remember symptoms and neurological signs of nerve impingement
syndromes at various levels
 Remember back pain (typically at night time) in elderly could be
sign of malignancy
 Remember back pain in elderly/immunosuppresed could be sign of
chronic infection typically TB
Fibromyalgia
 Clinical Syndrome not a disease
 Typically middle aged white females
 No objective sign of joint inflammation
 Associated with myofascial pain, fatigue, stiffness,
lethargy
 Alterations in normal sleep pattern
 Associated with psychiatric syndromes, IBS, migraine,
premenstrual syndrome
 No diagnostic test: must rule out a serious underlying
disorder
 Tender points on examination ( 11 out of 18)
 Management includes: counseling, improving sleep
hygiene, graded exercise, SSRIs, Muscle relaxants,
Ultram, treatment of psychiatry disorders
Osteoarthritis, OP, Fibromyalgia
and Back pain
Questions asked
1.
Patient with severe, persistent knee/hip pain, night pain.
Treatment?
2. X-Ray findings, Treatment algorithm for OA
3. 70-year-old female with back pain, night time worsening,
point tenderness. Likely Diagnosis?
4. 30-year-old with back pain radiating to leg. No
neurological deficit. Diagnosis? Treatment?
5. 45 year old with left sided back pain, radiation to foot,
can not dorsi-flex big toe. What level is impingement?
What reflex to look for?
6. 35 year old female with fatigue, aching, poor sleep, ANA
1:40. Likely diagnosis? Treatment?
7. 50 year old with history of radius fracture? What to workup for? Test of choice?
8. Male with OP? testing?
9. Secondary causes of OP?
10. Comparative efficacy of various agents, SE and C/I
11. Fracture risk reduction of various agents
Other Board Pertinent Disorders
 Pain, swelling of extremity after trauma. Area cool to
touch, edematous, Hyperalgesia? Diagnosis? Test of
choice?
 Shoulder Injury and now pain in wrists/hands with
above findings. Treatment?
 Lyme disease- Arthritis (2nd stage), associated
fibromyalgia. No ABX treatment of arthritis if treated in
past
 Pain hip: remember back/spine origin, tender outside
(lateral side) of hips-diagnosis?
 Pain knee: Normal exam,, Look for hip abnormality.
 Pain knee: normal exam- ilio-tibial band syndrome.
Medial side of tibia. Diagnosis?
Other Board Pertinent Disorders
Sarcoidosis: EN, Lofgren’s syndrome, others
Obese or diabetic patient with pain/burning pain
ant thigh. Mild Sensory loss. Normal EMG.
Diagnosis?
60 year old, smoker with pain in ankles, hands.
Tender above ankle, clubbing, radiographs
periosteitis. Diagnosis?
Corticosteroid toxicities including associated
myopathy, AVN and osteoporosis
Carpal Tunnel Syndrome & association with
hypothyroidism.
Buerger’s disease/
Thromboangiitis obliterans
Non-atherosclerotic, segmental, inflammatory
disease that most commonly affects the small
and medium sized arteries, veins, and nerves of
the extremities
Normal ESR & CRP
Cellular/Inflammatory thrombus
Normal: auto-antibodies/other serologic tests
Cork screw blood vessels
Stop smoking
Osteomalacia, Vitamin D
deficiency
Usually, the cause of osteomalacia is a
deficiency in vitamin D
There are other causes: Low phosphate
Normal 25-OH vitamin D levels: 30 ng/ml
Replace with 50, 000 units once or twice
a week for 3-6 months
DISH
 Calcification and
ossification
along the
anterolateral
aspect of at
least four
contiguous
vertebral bodies
 Preservation of
intervertebral
disc height
 Lack of findings
of AS
Paget’s Disease (osteitis
deformans)
 Focal skeletal disorder characterized by an accelerated
rate of bone turnover.
CLINICAL MANIFESTATIONS
 Pain
 Skeletal deformities and fractures
 Bone tumors (remember osteosarcoma)
 Neurologic complications (Hearing loss, CN Palsies)
 Cardiac complications: Heart failure, Aortic stenosis,
Conduction abnormalities
 Calcium and phosphate metabolism, Elevated Alkaline
phosphatase.
Treatment:
 Bisphosphonates
Erythema Nodosum
Causes
 Idiopathic
 Sarcoidosis
 IBD
 TB
 Fungal
 URI: Viral/Bacterial
 OCs
 CTD
Treatment
 NSAIDs
 Potassium Iodide
 GCs
 Treat underlying disease
GOOD LUCK
(REMEMBER DINNER AT
CHAR IS GOING TO AWAIT
YOU)