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- Dust mite
- Rheum History and Physical Exam
- Stiffness
- Weakness
- Raynaud’s
- Arthritis Ddx by category
Drug Fever or Drug Rashmaculopapular rash, resolve after removal of agent Timecourse: most occur several days after starting treatment, but can happen weeks after initiation of offending agent Labs: elevated eosinophils, CRP, LFT’s (e.g. one study found increased LFT’s in 20% of cases of maculopapular rash) Note: if you see it on the outside, the same thing can be happening on the inside (such as the liver, etc) Serum Sickness 7-10 days after primary exposure, 2-4 days after secondary exposure Findings: fever, polyarthralgia, urticaria, lymphadenopathy, glomerulonephritis Treatment: removal of agent, antihistamines, NSAIDs Atopy asthma, eczema, and seasonal rhinitis and conjunctivitis allergic rhinitis: varies with season, treated with antihistamines/topical nasal steroids, itchy vasomotor rhinitis: perennial (no seasonal variation), not itchy Food allergies Most common peanuts (soy beans, shellfish, eggs, milk, nuts) / incidence believe about 1 % / breastfeeding may reduce chance of developing in those predisposed / skin testing (radioallergosorbent tests or RAST ) not as good as a simple food diary / reactions usu. in GI and skin but can cause anaphylaxis/respiratory / best treatment is avoidance Dust mitecommon allergen / grow better in warm, humid environment (so humidifier actually makes worse) / can do skin testing for diagnosis of allergy Insect allergies (e.g. hymenoptera) range from local reactions to anaphylaxis / honeybee (Apis family) is not cross-reactive with Vespid family (e.g. wasps, hornets, yellow jackets) / venom immunotherapy is indicated with history and/or positive skin testing Latex allergy ranges from mild to anaphylaxis / can do scratch test Rheumatology
HistoryGeneral: CC/Chronology/demographics/functional impact/FH/ROS PainDistal (RA), proximal (PMR, fibromyalgia) Gentle activity often improves inflammatory but not pain of OA or fibromyalgia Pain worse as day goes on (OA), wakens from sleep (severe OA, cancer)
gel phenomenon (worse on initiation/resumption of activity) SwellingArticular (arthritis), periarticular (tenosynovitis, ganglion cyst), entire limb (lymphedema), other (lipoma, tumor) Dependent worse as day goes on Weaknessmuscle vs. neurological ConstitutionalFever, inflammation (weight loss) vs. chronic pain (weight gain) Sleep Fibromyalgia and inflammatory disease often poor sleepers (may also have sleep apnea, nocturia, narcolepsy) Raynaud’sThree Stages Ischemic pallor - vasospasm (arteries/arterioles) [pic] Cyanosis – dilation / deoxygenated blood pooling Rubor – reactive hyperemia Primary Secondary Collagen vascular disease (SLE, SSc, others) Arterial occlusive disease Pulmonary HTN Neurologic disorders Blood dyscrasias (e.g. Waldenstrom’s) Trauma
Other: thoracic outlet syndrome (decreased blood flow, short rib) Arthritis Ddx by categoryAcute polyarthritis Infectious: bacterial sepsis, Neisseria, HIV, other virus, Lyme, rheumatic fever Non-infectious: sarcoid, many CTD’s, Spondylarthropathies, juvenile chronic arthritis, gout/CPPD, HSP, HOA, sickle cell, leukemia Intermittent Arthritis Mechanical: loose bodies, partial tears, ligament laxities Crystals: gout, pseudogout, hydroxyapatite Infectious: Lyme, whipple’s Other: palindromic RA, episodic RA, intermittent hydrarthrosis, FMF, Sarcoid Chronic Arthritis RA, JRA, other CTD, crystals, spondylarthropathies, HOA, hypothyroid, metabolic/infiltrative bone/joint disease Acute Monoarthritis Note: these can present with only one joint first, of course Trauma, sickle cell, osteonecrosis Crystals, bacteria, spondylarthropathies, RA, palindromic RA, JRA Chronic Monoarthritis Non-inflammatory OA, mechanical, osteonecrosis, neuropathic, reflex sympathetic dystrophy, adjacent bone lesion (tumor/infection) Inflammatory Tb, fungal, lyme, crystals, RA, JRA, spondylarthropathies, hemophilia, synovial neoplasm, pigmented villonodular synovitis Low Back Pain Etiologies: Inflammatory: AS, Reiter’s, Psoriatic, enteropathic (reactive) Infectious: infectious sacroiliitis, osteomyelitis Musculoskeletal: vertebral compression, degenerative facet joint disease, herniated disc, muscular ligamentous injury Neurologic Psychogenic, worker’s comp Visceral/vascular, referred pain Primary or metastatic malignancy Congenital Conditions: musculoskeletal lumbar sprain or strain (70%): acute or chronic / young adults degenerative disk disease (10%) spinal stenosis (3%): pain often bilateral lower legs / usu. > 60 yrs / worse w/ extension, relieved by flexion, worse with walking (uphill) intervertebral (herniated disc) disease (4%): worse with sitting (lying may help) spondylosis: defect in pars interarticularis, either congenital or secondary to stress fracture spondylolisthesis: anterior displacement of upper vertebral body on the lower body (can mimic symptoms of spinal stenosis) / condition results from spondylosis or degenerative disk disease in elderly cauda equina syndrome: difficulty in micturation, loss of anal tone, saddle anesthesia, progressive motor weakness, sensory level facet joint syndrome: back pain referred to buttock, worse with extension, relieved by flexion / gradual, chronic / more in older patients / may have paravertebral muscle spasm at level inflammatory: onset < 40, morning stiffness, peripheral joints, iritis, rash, urethral discharge non-mechanical low back pain (1%) referred or visceral pain (2%) Diagnosis: history and physical usually enough / don’t get XR unless suspecting tumor, infection because 60% of asymptomatic patients will have positive findings on XR (which will be useless information) / MRI reserved for severe cases and/or when considering surgery Straight-leg raising (not very sensitive or specific) Patrick maneuver distinguishes pain from sacral-iliac joint (patient externally rotates hip, flexes knee, crosses knee of other leg like a number four while examiner presses down on flexed knee and opposite pelvis) Duration: acute: < 3 months / early: 3 to 6 months / intermediate: 6 to 24 months / late: > 2 yrs Red flags: young or old presentation, previous CA, steroids, drugs, HIV, constant (non-mechanical), thoracic, wt loss, ESR > 25, vertebral collapse on XR Treatment: most cases of acute low back pain resolve in 1-6 weeks w/ analgesics (NSAIDs, other), bed rest NOT recommended, physical therapy NOT necessary (3-5% remain disabled for > 3 months)
Referred pain facet joints, intervertebral discs Lumbar hip pain localizing to buttock, lateral thigh Cervical axilla, shoulder hips groin, anterior thigh knee
pancreas back liver shoulder renal (stones, etc) flank/groin/testicle uterine lower back PUD/spleen/pneumonia right shoulder throat ear (via recurrent laryngeal nerve)
Uncommon: mumps, coxsackie, echovirus, adenovirus, VZV, HSV, CMV Other causes of arthropathy: Relapsing polychondritis Neuropathic joint disease Hypertrophic osteoarthropathy and clubbing Fibromyalgia Psychogenic rheumatism Reflex sympathetic dystrophy syndrome Costochondritis or Tietze’s syndrome (with swelling) Musculoskeletal disorders associated with hyperlipidemia Arthropathy of acromegaly, hemochromatosis, hemophilia, hemoglobinopathies, Polyarticular Rheum: RA, OA, gout, CPPD, SLE, vasculitis, scleroderma, PM/DM, Still’s, Behçet’s, relapsing polychondritis, sarcoidosis, palindromic rheumatism, FMF, malignancy, hyperlipoproteinemia / seronegative: AS, psoriatic, IBD
hypothyroidism, neuropathic pain, metabolic bone disease, depression, serum sickness Infectious: lyme, endocarditis, viral (see above), gonococcal, Tb, other Post-infectious or reactive: Reiter’s, rheumatic fever, enteric infection HOA and clubbing Primary HOA (pachydermoperiostosis) AD / childhood / remits in 10-20 yrs Secondary HOA Causes: associated with intrathoracic malignancies, suppurative lung disease, congenital heart disease, and more / without clubbing (vascular grafting) bronchogenic CA (usu. non-small cell) RA-like picture (with effusions/arthralgia) can develop even before onset of clubbing Mechanism: megakaryocyte shunting with R to L arteriolar trapping release of PDGF proliferation [doesn’t seem to explain the classic pattern of progressive development of clubbing from feet to hands seen with congenital heart disease] Treatment: after lung tumor resection (or even just radiation of mets) or lung abscess drainage, symptoms and signs of arthropathy often subside rapidly; radiographic changes remit during weeks and months / NSAID’s, ASA, bisphosphonates, even trial of low-dose steroids may relieve bone pain in some pts Diagnosis: clinical? / bone scan will show periosteal deposition [pic], plain films may reveal changes also Periarticular disorders: bursitis, rotator cuff tendonitis and impingement syndrome, calcific tendonitis, bicipital tendonitis and rupture, adhesive capsulitis, lateral epicondylitis (tennis elbow), medial epicondylitis General Points about OA, RA, gout OA affects many vertebrae, RA particularly C1/C2 (because there’s a bursa there) RA causes destruction and osteoporosis; gout causes destruction but not osteoporosis Osteoarthritis (OA) most common joint disease Causes: primary (80% of population > 70 yrs) or secondary 5% (previously damaged joints, weight-bearing joints, endocrinopathy, metabolic disease, neuropathy, avascular necrosis, Paget’s); 34% of patients presenting with acute knee pain Clinical: age > 50 yrs, morning stiffness < 30 mins, crepitus, bony enlargement or tenderness; no inflammation (no heat), slow progression / normally pain worse with weigh-bearing, motion, but can progress to point where causes pain at rest, at night ACR: osteophytes on XR + at least one of above signs is 90% sensitive, specific for OA Findings: Affected Joints: DIP > PIP > CMC, knee, hip, feet Spared Joints: hands (except DIP/PIP/CMC), wrist, elbow, shoulder, spine Heberden’s nodes (DIP) and Bouchard’s (PIP) seen more in post-menopausal women with genetic predisposition [pic] / only wrist joint involved is 1st CMC [pic] Knees: medial >> lateral involvement / may develop popliteal cysts Radiographic (weight-bearing): osteophytes (77% sensitivity/83% specificity), subchondral sclerosis, subchondral cysts, joint space narrowing (erosions), malalignment, may see soft-tissue swelling Spondylosis is the formation of osteophytes in response to degenerative disc disease / thick and often project laterally (unlike in AS) / spinal stenosis can also occur from hypertrophy of posterior facet joints, spondylolisthesis, synovial cysts, Paget’s disease, epidural lipomatosis, and congenitally small spinal canal Schmorl’s nodes (invasion of disc into vertebral body) are common (often associated with Scheuermann’s disease, osteopenia and degenerative disc disease) / bony margin may be visible on roentgenogram Forestier’s disease (diffuse hyperostosis) can occur (usu. elderly) and may form “flowing ossification” (usu. on right side, thoracic vertebrae, but also can occur on ligamentous, tendinous attachments anywhere) Labs: ESR < 40, RF < 1:40, non-inflammatory synovial fluid (< 2000/mm3) Treatment: NSAIDs (some say glucosamine works in patients who cannot tolerate NSAIDs), when it’s bad enough, only treatment is joint replacement (knee/hip) (~95% 10 yr success rate) / chondroitin sulfate under investigation / multiple, short periods of rest throughout day better than one large period of rest / intraarticular steroids occasionally helpful (esp. in joint “lock up”) Nodal OA DIP/PIP / runs in families Rheumatoid Arthritis females 4:1 / any age / mildly shortened life span Findings: swollen, painful, warm joints (PIP, MCP, not DIP), ulnar deviation of MCP [pic], radial deviation of wrists, swan-neck fingers [pic], Boutonnière or button-hole deformities [pic][pic] Joints: inflamed synovium (pannus) / penetrates to cause erosions, subchondral cysts / fibrin aggregates in joint space (rice bodies) / synovium eventually bridges and ossifies opposing surfaces Skin: 25% have rheumatoid nodules (firm, oval, non-tender, fibrinoid necrosis, inflammation) Vasculitis: rheumatoid vasculitis, ulcers, gangrene, splinter hemorrhages, raynaud’s Neuro peripheral neuropathy (10%; ½ are slowly progressive, distal symmetrical sensory or sensory-motor polyneuropathy) mononeuritis multiplex entrapment neuropathy carpal tunnel Renal: early (drug-induced nephropathies), late (amyloid-like renal disease) Lungs (almost always RF positive): [NEJM] pleuritis/pleurisy, effusion pulmonary nodules (CT will show them if CXR doesn’t) ILD alveolar hemorrhage Heart: pericarditis > myocarditis, valves / conduction abnormalities Eyes: (1st dry eyes or keratoconjunctivitis sicca (Sjögren’s), 2nd episcleritis – may be severe, perforate) Heme: anemia of chronic disease Diagnosis: r/o TB (also has RF) Criteria: 4 of 7 required morning stiffness > 1 hr swelling of 3 or more joints swelling of hand joints (PIP, MCP, wrist) symmetrical swelling rheumatoid nodules positive RF erosions of hand joints (X-ray) Labs: 80% have RF (IgM to Fc of IgG), ANA / HLA DR4, HLA DR1 anti-CCP (worse prognosis; ⅓ with negative RF will have positive anti-citric citrullinated peptide) Radiography: early X-ray changes in feet (MTPs, very specific for RA), ulnar styloid changes (late becomes piano key sign), C1-2 subluxation (can be very serious and damage spinal cord, but if seen incidentally on lateral flexion c-spine at < 5 mm, can observe) Course: usually insidious course / DMARD-remission achievable (15%) (anti-CCP Ab’s increase chances of DMARD-free remission) Treatment: aggressive therapy is the rule / immunosuppressive drugs from day one / frequent re-evaluation and willingness to change therapies based on effectiveness (is a trend that has been advancing more and more) / DAS28 scores (sometimes used), TJC (total joint count), ESR (may vary with effective treatment) Steroids MTX TNF-a inhibitors (some believe in switching from one anti-TNF to another may work in treatment failure; or possibly adding newer agents such as the new Ab’s like rituximab, etc.) Others: Immuran Old school: gold, penicillamine New school (example of regimens): initial tapered high-dose prednisone + MTX and sulfasalazine or infliximab + MTX Prognosis: more nodules, DR4, anti-CCP, more systemic Sx, are worse indicators Download 3.95 Mb. 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