RHEUMATOLOGY: Viral arthritis: Etiology: -Parvovirus B19(MCC) Anti-B19 IgM antibodies -Hepatitis B - Mumps, rubella, HIV and many

y others S/S: -Symmetric polyarthritis of acute onset and short duration -Joint swelling and low-grade fever - Resolves within 2 months as opposed to chronic diseases like RA and SLE. Dx: -Positive RF and ANA may be present. -Lack of elevated inflammatory markers ( as in RA) Ankylosing spondylitis: (Apophyseal joint arthritis) S/S: -Insidious, unilateral and intermittent back pain that may become bilateral -Symptoms typically worse at night or in morning and improve with activity -Muscle spasms might occur. Back spasms present with sudden severe back pain that resolves within seconds to minutes and may recur. -Enthesitis: e.g pain at the point of tibial tuberosity, Achilles tendon pain may present as heel pain etc -Fusion of the costovertebral joints chest wall motion restriction RESTRICTED lung disease without decareasing DLco and FRC ( FRC is normal or INCREASED b/c the chest wall is fixed into an ispiratory position) Differentiating between Compression vertebral fracture and Ligamentous sprain: Compression Vertebral fracture: Pain is directly OVER the vertebral body (percussion of the vertebra elicits intense pain)

Ligamentous sprain: Pain is typically PERISPINAL. MORE painful with movement and should feel their best in the morning.

Disc herniation: Excruciating back pain after lifting a heavy object Back tenderness d/t paraspinous muscle spasm Radicular pain in the dermatomal distribution Straight leg raise +ive Complications: cauda equina syndrome

Cauda equina syndrome: Saddle anesthesia Loss of anal sphincter tone Bilateral sciatica Atonic bladder overflow incontinence

Lumbar spinal stenosis: MCC : Vertebral degenerative disc disease present in middle-aged and elderly. Mechanism: Flexion of the spine relieves pain as it widens the spinal canal ( Walking uphill, bending, sitting ) and vice versa Neurogenic claudication- positional leg pain D/D: Peripheral vascular disease: intermittent claudication in which peripheral pulses are not normal ,there is extertional leg pain and abnormal ankle brachial pressure index. Dx: MRI spine Tx: Conservative or surgical laminectomy. Behcets syndrome: S/S: -Recurrent oral ulcers plus 2 of the following: -Eye lesions (ant or post. Uveitis, retinal vascularization) -Skin lesions( eryhtema nodosum, acneiform nodules, papulopustular lesions, +pathergy test(prick wit ha needle, a small red bump or pustule develops subsequently on the place of insertion) -Some pts: GI, skeletal, vascular systems(aortic aneurysm) involved

-May have recurrent genital ulcers -Progresses to dementia and blindness D/D: -Reiters syndrome, herpes simplex Dx: Clinical Tx: Steroids Lumbago: General lower back pain related to physical strain. Usually paravertebral muscle tenderness Sarcoidosis: cough Secondary amyloidosis: Mech: Deposition of serum amyloid A in various organs in the setting of chronic inflammation Etiology: -Chronic infections -Psoriasis -IBD -Autoimmune diseases (RA, SLE etc) S/S: -Systemic disease . Kidney(Nephrotic syndrome- HTN, proteinuria,facial edema) and GI(hepatomegaly is common) affected more. Heart(cardiomyopathy), MSkeletal(pseudohypertrophy), Peripheral neuropathy. Membranous nephropathy: Causes: hep B, C, Syphilis , RA, SLE, penicillamine and malaria. Hypertensive nephrosclerosis: long standing HTN low level proteinuria. IBD and ankylosing spindylitits maybe present together b/c both have HLA B27 and may have P-ANCA despite the absence of vasculitis. Trochanteric bursitis: Frictions btw tendons of gluteus medius and tensor fascia lata over the greater trochanter of femur.

Pain localized over lateral hip may interfere with sleep patterns and worsened on palpation. RA: S/C nodules at the points of friction such as extensor surfaces of the forearm. Differentiate: fibromyalgia (pain-multiple tender points), Myositis(weakness) Chronic fatigue syndrome(fatigue present for 6 months) Hypothyroidism: Untreated disease results in: -Generalized myxedema, Myxedema coma, Myxedema psychosis Gen. Myxedema : Mech: Deposition of acidic mucopolysaccharides in skin, nerves, heart. Deposition in the median nerve: carpal tunnel syndrome Carpel tunnel syndrome: S/S: Pain and paresthesias in thumb and lateral 2 fingers Etiology: Hypothyroidism(CTS d/t depositon of mucin ---mucopolysacchrides) Acromegaly (CTS d/t synovial tendon hyperplasia), RA(CTS d/t tenosynovial inflammation), Amyloidosis(CTS d/t amyloid deposition) Pregnancy(CTS d/t accumulation of fluid)

Thoracic aortic aneurysm-----marfan, ehlers, syphilis Oral ulcers: SLE, Behcets, CROHNs disease Ischemic optic neuropathy and aortic aneurysm(follow up with serial chest x-rays Temp. Arteritis) Episcleritis----RA and IBD Fibromyalgia: s/s: -Point tenderness(on plapation) in 11/18 spots -Generalized M/S pain WORSENS with exercise -easy fatigability, muscle stiffness, IBS, depression

These are the 18 tender points and 11/18 should be there to establish Dx. Tx: TCAsamitriptaline and cyclobenzaprine---night time(Sleep disturbances theek hon gee) Depression: SSRIs Osteonecrosis /avascular necrosis/aseptic necrosis/ischemic necrosis/osteochondritis dessicans of the femoral head: Disrupture of bone vasculature infarction inability of bone to remodel Causes: S/S: - Anterior hip pain worsen with activity relieved by rest ,progresses to Joint instability and pain at rest. -No restriction of movement , progresses toLimitation of the range of motion -Normal radiograph findings only in the early stage of disease. Dx: MRI and Scintigraphy----Confirmatory tests Hypercalcemia: -Constipation -Osteoporosis -Abd. Pain (groans) Trauma Chronic steroid therapy Alcoholism Hemoglobinopathies(antiphospholipid syndrome)

-Mental status change(moans) -Urinary stones(stones) -Monoarthritis-----hyperparathyroidism associated with CPPD deposition (Gout) Serum sickness-like reaction : (Viral infection antibiotics: Serum sickness ),Viral infectionaspirin: Reyes syndrome) Presentation: young boy with sore-throat treated with penicillin, comes with arthralgias---couldnt have been rheumatic fever b/c boy was TREATED with penicillin) S/S: Fever, rash , polyarthralgias, lymphadenopahy, urticaria etc-----1-2wks after certain drugs Drugs causing SS: -Cefaclor(MC agent) -PenicillinsAmoxicillin -TMP-SMX Epidural abscess: (Occur in injection drug users as spread hematogenously and in immunosuppresed) s/s: -causes spinal cord compression. -Back pain, fever, chills and leukocytosis Dx: Emergent MRI spine Blood culture Tx: Immediate surgical debridement Empiric antibiotics until culture results come in Elevated alkaline phosphate: Hepatobiliary disorders Bone Diseases causing increased turn over

Pagets DiseaseOsteitis deformans: (MCC of asymptomatic isolated increase in ALP in an elderly) Increased osteoclastic activity and compensatory osteoblastic activity. S/S:

-Skeletal deformities -Bone/joint pain -fractures -Nerve entrapment of CN 8 hearing loss -Increased hat size d/t enlarged skull bones Dx: X-ray (characteristic findings like femoral bowing etc MC ocular manifestation of histoplasmosis Retinal damage Metastatic bone pain typically constant and worse at night, lack of exacerbation by movement Cervical spondylosis: (Cervical vertebral osteoarthritis) Affects 10% ppl above 50yrs. s/s: Chronic neck pain Limited neck rotation and lateral bending Osteoarthritis and sec. muscle spasm Sensory deficit osteophyte induced radiculopathy (problem at the root of the nerve)

Dx: clinical and X-ray Bony spurs and sclerotic facet joints (Not specific as many old asymptomatic ppl will have these cervical changes) Bakers cyst: Can occur in any form of knee arthritis and cartilage tear Dx: Examination and confirmed by USG Can rupture and lead to acute calf pain and mimic DVT or thrombophlebitis Can leak into the inner leg hematoma over medial malleolus known as crescent sign.

Disseminated Gonococcal Infection: ( All pts. Should undergo HIV screening) Classic symptoms: -Migratory asymmetric polyarthralgias(no swelling and redness)-- which may or may not progress to suppurative infectious arthritis(swelling and redness) -Tenosynovitis pain elicited along the tendon sheath -Painless purpuric or PUSTULAR lesions with a hemorrhagic component and occasionally central necrosis present on arms and legs. -High fever and chills

-CULTURE: From blood or skin lesions might come out ive d/t specific growth requirements of the N.gonorrhea strain that causes this disseminated form of infection D/D: Toxic shock syndrome: has a DESQUAMATIVE rash and 3 or more of the criteria (In Kaplan notes) should be there to label it as TSS. Culture ive as caused by toxin. - Acute HIV syndrome: Mononucleosis-like reaction( fever, malaise, arthralgias, myalgias, pharyngitis) and a rash like other viral exanthems i.e. MORBILLIFORM macules NOT pustules. Gonococcal arthritis also occurs as a separate septic(purulent) arthritis and not part of the dermatitis-arthritis syndrome. Affects only ONE or a few joints. SLE Arthritis: Migratory polyarthritis with pain and no erosion hence no joint deformity

Psoriatic Arthritis:

Variant: Arthritis mutilans pencil-in-cup deformity

Classic presentation: DIP joint deformity Morning stiffness Nail pitting Dactylitis: diffcusely swollen finger sausage digit as seen in the pic.

Tx: NSAIDs, Anti-TNF agents, MTX. Drugs side effects : Cyclophosphamide: CYC Used mostly in Cancers, Vasculitis and SLE (for significant renal or CNS defects) S/E: Acute hemorrhagic cystitis and Bladder cancer Toxic metabolite of CYC. Called Acrolein Sterility and myelosuppression

Preventing complications: Drink plenty of fluids, frequent voiding, MESNA. Cisplatin and carboplatin: Used in testicular, ovarian and bladder cancer. S/E: Cochlear dysfunction Ethambutol and Hydroxycholoroquine: S/E: Optic neuritis Phenytoin , vincristine, heavy metals and chronic alcoholism: S/E: Peripheral neuropathy Beta blockers: S/E: Raynauds phenomenon Cyclosporine: Gout Nephrotoxic Predisposes to viral infections and lymphoma

Azathioprine: S/E: Liver toxicity Pancreatitis Dose-dependent marrow suppression

Type I DM: Antibodies: 70% pts. have Glutamate decarboxylase antibodies at the time of Dx. Rotator cuff tendonitis: (Results d/t repetitive activity above shoulder , MC in middle-aged and elderly) Also called: Impingement syndrome S/S: -Shoulder pain aggravated by activites such as reaching or lifting the arm over the head. -Impingement is present in all patients Dx: Neer test : (Passive motion of arm above the head) Pain and guarding confirms impingement. lidocaine injection improves range of motion and pain relief occursDifferentiate from other rotator cuff pathologies MRI of shoulder for definite Dx. Rotator cuff tear: RCT Etiology:

Trauma(usually falling on outstretched hand Chronic impingement(ragar khana) and tendonitis

Signs and symptoms: - Same as rotator cuff tendonitis -Weakness is more common in RCT -Symptoms dont improve with the lidocaine injection Dx: MRI shoulder is the test of choice Frozen shoulder: (Adhesive capsulitis) Idiopathic S/S: Pain and contracture INABILITY to raise arm above head Lidocaine injection: still cant lift arm above head d/t fibrosis of the shoulder capsule

Subacromial bursitis: -Subacromial bursa lies btw the acromion and the supraspinatous tendon. - Chronic microtrauma to the supraspinatous tendon by getting compressed btw acromion and the humeral head , vascular supply maybe temporarily compromised during such episodes of compression. Causes: -Repeated mov. Of overhead activity during work or sports.(Tennis , painting etc) Examination: Neer impingement signInternal arm rotation and forward flexion at the shoulder causes pain. Pain with active range of motion of shoulder. No signs of deltoid atrophy.( Axillary nerve palsy) Lateral epicondylitis and radial tunnel syndrome differences: RTS: Pain elicited on flexing the pts long finger while the pt. actively extends the fingers and the wrist

De Quervains tenosynovitis: (Inflammation of the tendons of APL and EPB passing through the fibrous sheath at the radial styloid process). Postpartum women who hold their infants with the thumb outstretched(abducted/extended)

Tenderness elicited with direct palpation of the radial side of the wrist at the thumb base. FINKLESTEIN TEST: Grasping the flexed thumb into the palm with fingers elicits pain (passive stretching of the affected tendons)

Trigger thumb or finger: It is a type of stenosing tenosynovitis in which the sheath around a tendon in a thumb or finger becomes swollen, or a nodule forms on the tendon. ( CAUSE: Idiopathic) Affected digits may become painful to straighten once bent, and may make a soft crackling sound when moved hence they are LOCKED in flexion. Pain over the palmer aspect of the metacarpophalangeal joint.

Anserine Bursitis: Anserine bursa is located anteromedially over the tibial plateau just below the joint line of knee. Causes: Abnormal gait Medial compartment osteoarthritis: Pain on the medial joint line in ppl >40. Xray would show bony spurs and other OA findings. Will result in chronic gait abnormality and cause anserine bursitis. Overuse or trauma

S/S: -

Localized pain over the anteromedial tibia. Pain is often present overnight as pressure from the knees making contact with one another causes pain while the pt. lies on his side

Examination: Tx: -Rest, ice, maneuvers to reduce the pressure over the bursa -corticisteroid injections into the bursa Prepatellar bursitis: Pain and swelling directly over the patella Variable signs of inflammation MCC trauma Well-defined area of tenderness over the medial tibial plateau just below the joint line. Valgus stress test: Does not aggravated the pain ( Ruling out med. Collateral ligament disease)

Patellofemoral syndrome:

Peripatellar pain worsened by activity or prolonged sitting ( d/t sustained flexion)

Septic arthritis: Prosthetic joint increases risk After staph. Strep. is the MC non-gonococcal agent

CREST syndrome: Calcinosis: Localized dystrophic calcification of skin. S/C pink to white nodules on the upper extremity.

. May ulcerate to drain a chalky white material. Telangectasias: Mat-like patches most commonly on face and palm.

Systemic sclerosis: Thickening of skin and edema first in the hands and feetdermal sclerosis flexion contractures> joint pains Systemic HTN give ACE, saves life Pulmonary HTN RHF Antibodies: ANA present in ALL patients, Anti-topoisomerase-1

Chronic tophaceous gout: D/D: Rheumatoid nodules and calcinosis cutis

Chronic tophaceous gout. Tophi can ulcerate and drain a chalky material just like calcinosis cutis.

Rheumatoid nodules commonly form near the extensor surface of the elbow. They can be fixed to the underlying periosteum or can be freely mobile. First line agents for RA MTX, hydroxycholoroquine, TNF (infliximab, etanercept) Consider gout in someone taking a water-pill(hydrochlorthiazide) as it causes hyperuricemia and gout Osteoarthritis: LOOK CLOSELY AT THE X-ray: Subchondral cyst formation at the DIP Heberden and bouchard nodes present. Narrow joint space.

Crepitus with motion of the patella MCC Overuse pain syndrome of the knee

Urinary markers of bone degradation: Hydroxyproline Deocypyridinoline N and C-telopeptide

Hypercalcemia with normal PO4 and ALP Milk alkali syndrome Dermatomyositis: Proximal muscle involvement with cutaneous findings: Poikiloderma over various regions of the body which is extra pigmentation(red-purple) of the skin demonstrating a variety of shades and associated with widened capillaries (telangiectasia) in the affected area. Face: eruption with periorbital edema ( heliotrope sign) Chest and lateral neck: shawl sign

Knuckles, elbows, knees: Lichenoid papules( Gottrons sign)

Gottrons sign

Heliotrope rash. ( can be lighter than this) Classic autoantibody: Anti-Mi-2(against helicase) Associated with internal malignancies: MC- OVARIAN , breast , lung and other female urogenital CA too. Causes PULMONARY fibrosis. Inflammatory diseases ass. With Aortic aneurysm: Behcets Takayasu Temp. arteritis Spondyloarthropathies RA

Vertebral osteomyelitis: Grossly elevated ESR (> 100mm/h) WBC count maybe normal or elevated

Neurogenic arthropathy: ( Charcots joint)

Decreased sensations occurring d/t any of the following and causes a secondary degenerative joint disease as pts unknowingly traumatize their joints: S/S: Mx: Tx underlying disease Provide mechanical devices e.g.special shoes to assist in weight bearing. Mild pain X-ray shows loss of cartilage, osteophytes and loose bodies DM Peripheral nerve damage Syringomyelia SC injury B12 definciency Tabes dorsalis