RHEUMATOLOGY: Viralarthritis: Etiology: ParvovirusB19(MCC)AntiB19IgMantibodies HepatitisB Mumps,rubella,HIVandmanyothers S/S: Symmetricpolyarthritisofacuteonsetandshortduration Jointswellingandlowgradefever Resolveswithin2monthsasopposedtochronicdiseaseslikeRAandSLE. Dx: PositiveRFandANAmaybepresent.

Lackofelevatedinflammatorymarkers(asinRA) Ankylosingspondylitis:(Apophysealjointarthritis) S/S: Insidious,unilateralandintermittentbackpainthatmaybecomebilateral Symptomstypicallyworseatnightorinmorningandimprovewithactivity Musclespasmsmightoccur.Backspasmspresentwithsuddenseverebackpainthatresolveswithin secondstominutesandmayrecur. Enthesitis:e.gpainatthepointoftibialtuberosity,Achillestendonpainmaypresentasheelpain etc FusionofthecostovertebraljointschestwallmotionrestrictionRESTRICTEDlungdiseasewithout decareasingDLcoandFRC(FRCisnormalorINCREASEDb/cthechestwallisfixedintoanispiratory position) DifferentiatingbetweenCompressionvertebralfractureandLigamentoussprain: CompressionVertebralfracture:PainisdirectlyOVERthevertebralbody(percussionofthe vertebraelicitsintensepain)

 Ligamentoussprain:PainistypicallyPERISPINAL.MOREpainfulwithmovementandshouldfeel theirbestinthemorning.

Discherniation: Excruciatingbackpainafterliftingaheavyobject Backtendernessd/tparaspinousmusclespasm Radicularpaininthedermatomaldistribution Straightlegraise+ive Complications:caudaequinasyndrome

Caudaequinasyndrome: Saddleanesthesia Lossofanalsphinctertone Bilateralsciatica Atonicbladderoverflowincontinence

Lumbarspinalstenosis: MCC:Vertebraldegenerativediscdiseasepresentinmiddleagedandelderly. Mechanism: Flexionofthespinerelievespainasitwidensthespinalcanal(Walkinguphill,bending,sitting)andvice versa Neurogenicclaudicationpositionallegpain D/D:Peripheralvasculardisease:intermittentclaudicationinwhichperipheralpulsesarenotnormal ,thereisextertionallegpainandabnormalanklebrachialpressureindex. Dx:MRIspine Tx:Conservativeorsurgicallaminectomy. Behcetssyndrome: S/S: Recurrentoralulcersplus2ofthefollowing: Eyelesions(antorpost.Uveitis,retinalvascularization) Skinlesions(eryhtemanodosum,acneiformnodules,papulopustularlesions,+pathergytest(prickwit haneedle,asmallredbumporpustuledevelopssubsequentlyontheplaceofinsertion) Somepts:GI,skeletal,vascularsystems(aorticaneurysm)involved

 Mayhaverecurrentgenitalulcers Progressestodementiaandblindness D/D: Reiterssyndrome,herpessimplex Dx:Clinical Tx:Steroids Lumbago:Generallowerbackpainrelatedtophysicalstrain.Usuallyparavertebralmuscletenderness Sarcoidosis:cough Secondaryamyloidosis: Mech:DepositionofserumamyloidAinvariousorgansinthesettingofchronicinflammation Etiology: Chronicinfections Psoriasis IBD Autoimmunediseases(RA,SLEetc) S/S: Systemicdisease.Kidney(NephroticsyndromeHTN,proteinuria,facialedema)andGI(hepatomegalyis common)affectedmore.Heart(cardiomyopathy),MSkeletal(pseudohypertrophy),Peripheral neuropathy. Membranousnephropathy: Causes: hepB,C,Syphilis,RA,SLE,penicillamineandmalaria. Hypertensivenephrosclerosis:longstandingHTNlowlevelproteinuria. IBDandankylosingspindylititsmaybepresenttogetherb/cbothhaveHLAB27andmayhavePANCA despitetheabsenceofvasculitis. Trochantericbursitis: Frictionsbtwtendonsofgluteusmediusandtensorfascialataoverthegreatertrochanteroffemur.

 Painlocalizedoverlateralhipmayinterferewithsleeppatternsandworsenedonpalpation. RA:S/Cnodulesatthepointsoffrictionsuchasextensorsurfacesoftheforearm. Differentiate:fibromyalgia(painmultipletenderpoints),Myositis(weakness)Chronicfatigue syndrome(fatiguepresentfor6months) Hypothyroidism: Untreateddiseaseresultsin: Generalizedmyxedema,Myxedemacoma,Myxedemapsychosis Gen.Myxedema: Mech:Depositionofacidicmucopolysaccharidesinskin,nerves,heart. Depositioninthemediannerve:carpaltunnelsyndrome Carpeltunnelsyndrome: S/S:Painandparesthesiasinthumbandlateral2fingers Etiology: Hypothyroidism(CTSd/tdepositonofmucinmucopolysacchrides) Acromegaly(CTSd/tsynovialtendonhyperplasia), RA(CTSd/ttenosynovialinflammation), Amyloidosis(CTSd/tamyloiddeposition) Pregnancy(CTSd/taccumulationoffluid)

Thoracicaorticaneurysmmarfan,ehlers,syphilis Oralulcers:SLE,Behcets,CROHNsdisease Ischemicopticneuropathyandaorticaneurysm(followupwithserialchestxrays Temp.Arteritis) EpiscleritisRAandIBD Fibromyalgia: s/s: Pointtenderness(onplapation)in11/18spots GeneralizedM/SpainWORSENSwithexercise easyfatigability,musclestiffness,IBS,depression

Thesearethe18tenderpointsand11/18shouldbetheretoestablishDx. Tx:TCAsamitriptalineandcyclobenzaprinenighttime(Sleepdisturbancestheekhongee) Depression:SSRIs Osteonecrosis/avascularnecrosis/asepticnecrosis/ischemicnecrosis/osteochondritisdessicansof thefemoralhead: Disruptureofbonevasculatureinfarctioninabilityofbonetoremodel Causes: S/S: Anteriorhippainworsenwithactivityrelievedbyrest,progressestoJointinstabilityandpainatrest. Norestrictionofmovement,progressestoLimitationoftherangeofmotion Normalradiographfindingsonlyintheearlystageofdisease. Dx:MRIandScintigraphyConfirmatorytests Hypercalcemia: Constipation Osteoporosis Abd.Pain(groans) Trauma Chronicsteroidtherapy Alcoholism Hemoglobinopathies(antiphospholipidsyndrome)

 Mentalstatuschange(moans) Urinarystones(stones) MonoarthritishyperparathyroidismassociatedwithCPPDdeposition(Gout) Serumsicknesslikereaction:(Viralinfection antibiotics:Serumsickness),Viral infection aspirin:Reyessyndrome) Presentation:youngboywithsorethroattreatedwithpenicillin,comeswitharthralgiascouldnt havebeenrheumaticfeverb/cboywasTREATEDwithpenicillin) S/S: Fever,rash,polyarthralgias,lymphadenopahy,urticariaetc12wksaftercertaindrugs DrugscausingSS: Cefaclor(MCagent) PenicillinsAmoxicillin TMPSMX Epiduralabscess:(Occurininjectiondrugusersasspreadhematogenouslyandinimmunosuppresed) s/s: causesspinalcordcompression. Backpain,fever,chillsandleukocytosis Dx:EmergentMRIspine Bloodculture Tx:Immediatesurgicaldebridement Empiricantibioticsuntilcultureresultscomein Elevatedalkalinephosphate: Hepatobiliarydisorders BoneDiseasescausingincreasedturnover

PagetsDiseaseOsteitisdeformans:(MCCofasymptomaticisolatedincreaseinALPinanelderly) Increasedosteoclasticactivityandcompensatoryosteoblasticactivity. S/S:

 Skeletaldeformities Bone/jointpain fractures NerveentrapmentofCN8hearingloss Increasedhatsized/tenlargedskullbones Dx:Xray(characteristicfindingslikefemoralbowingetc MCocularmanifestationofhistoplasmosis Retinaldamage Metastaticbonepain typicallyconstantandworseatnight,lackofexacerbationbymovement Cervicalspondylosis:(Cervicalvertebralosteoarthritis) Affects10%pplabove50yrs. s/s: Chronicneckpain LimitedneckrotationandlateralbendingOsteoarthritisandsec.musclespasm Sensorydeficitosteophyteinducedradiculopathy(problemattherootofthenerve)

Dx:clinicalandXrayBonyspursandscleroticfacetjoints(Notspecificasmanyoldasymptomaticppl willhavethesecervicalchanges) Bakerscyst: Canoccurinanyformofkneearthritisandcartilagetear Dx:ExaminationandconfirmedbyUSG CanruptureandleadtoacutecalfpainandmimicDVTorthrombophlebitis Canleakintotheinnerleg hematomaovermedialmalleolusknownascrescentsign.

DisseminatedGonococcalInfection:(Allpts.ShouldundergoHIVscreening) Classicsymptoms: Migratoryasymmetricpolyarthralgias(noswellingandredness)whichmayormaynotprogressto suppurativeinfectiousarthritis(swellingandredness) Tenosynovitispainelicitedalongthetendonsheath PainlesspurpuricorPUSTULARlesionswithahemorrhagiccomponentandoccasionallycentralnecrosis presentonarmsandlegs. Highfeverandchills

CULTURE:Frombloodorskinlesionsmightcomeoutived/tspecificgrowthrequirementsofthe N.gonorrheastrainthatcausesthisdisseminatedformofinfection D/D: Toxicshocksyndrome:hasaDESQUAMATIVErashand3ormoreofthecriteria(InKaplan notes)shouldbetheretolabelitasTSS.Cultureiveascausedbytoxin. AcuteHIVsyndrome:Mononucleosislikereaction(fever,malaise,arthralgias,myalgias, pharyngitis)andarashlikeotherviralexanthemsi.e.MORBILLIFORMmaculesNOTpustules. Gonococcalarthritisalsooccursasaseparateseptic(purulent)arthritisandnotpartofthe dermatitisarthritissyndrome.AffectsonlyONEorafewjoints. SLEArthritis: Migratorypolyarthritiswithpainandnoerosionhencenojointdeformity

PsoriaticArthritis:

Variant:Arthritismutilanspencilincupdeformity

Classicpresentation: DIPjointdeformity Morningstiffness Nailpitting Dactylitis:diffcuselyswollenfingersausagedigitasseeninthepic.

Tx:NSAIDs,AntiTNFagents,MTX. Drugssideeffects: Cyclophosphamide:CYC UsedmostlyinCancers,VasculitisandSLE(forsignificantrenalorCNSdefects) S/E:AcutehemorrhagiccystitisandBladdercancerToxicmetaboliteofCYC.CalledAcrolein Sterilityandmyelosuppression

 Preventingcomplications:Drinkplentyoffluids,frequentvoiding,MESNA. Cisplatinandcarboplatin:Usedintesticular,ovarianandbladdercancer. S/E:Cochleardysfunction EthambutolandHydroxycholoroquine:S/E:Opticneuritis Phenytoin,vincristine,heavymetalsandchronicalcoholism:S/E:Peripheralneuropathy Betablockers:S/E:Raynaudsphenomenon Cyclosporine: Gout Nephrotoxic Predisposestoviralinfectionsandlymphoma

Azathioprine: S/E: Livertoxicity Pancreatitis Dosedependentmarrowsuppression

TypeIDM: Antibodies:70%pts.haveGlutamatedecarboxylaseantibodiesatthetimeofDx. Rotatorcufftendonitis:(Resultsd/trepetitiveactivityaboveshoulder,MCinmiddleagedand elderly)Alsocalled:Impingementsyndrome S/S: Shoulderpainaggravatedbyactivitessuchasreachingorliftingthearmoverthehead. Impingementispresentinallpatients Dx:Neertest:(Passivemotionofarmabovethehead)Painandguardingconfirmsimpingement. lidocaineinjectionimprovesrangeofmotionandpainreliefoccursDifferentiatefromother rotatorcuffpathologies MRIofshoulderfordefiniteDx. Rotatorcufftear:RCT Etiology:

 Trauma(usuallyfallingonoutstretchedhand Chronicimpingement(ragarkhana)andtendonitis

Signsandsymptoms: Sameasrotatorcufftendonitis WeaknessismorecommoninRCT Symptomsdontimprovewiththelidocaineinjection Dx:MRIshoulderisthetestofchoice Frozenshoulder:(Adhesivecapsulitis)Idiopathic S/S: Painandcontracture INABILITYtoraisearmabovehead Lidocaineinjection:stillcantliftarmaboveheadd/tfibrosisoftheshouldercapsule

Subacromialbursitis: Subacromialbursaliesbtwtheacromionandthesupraspinatoustendon. Chronicmicrotraumatothesupraspinatoustendonbygettingcompressedbtwacromionandthe humeralhead,vascularsupplymaybetemporarilycompromisedduringsuchepisodesofcompression. Causes: Repeatedmov.Ofoverheadactivityduringworkorsports.(Tennis,paintingetc) Examination: NeerimpingementsignInternalarmrotationandforwardflexionattheshouldercausespain. Painwithactiverangeofmotionofshoulder. Nosignsofdeltoidatrophy.(Axillarynervepalsy) Lateralepicondylitisandradialtunnelsyndromedifferences: RTS:Painelicitedonflexingtheptslongfingerwhilethept.activelyextendsthefingersandthe wrist

DeQuervainstenosynovitis:(InflammationofthetendonsofAPLandEPBpassingthroughthe fibroussheathattheradialstyloidprocess). Postpartumwomenwhoholdtheirinfantswiththethumboutstretched(abducted/extended)

 Tendernesselicitedwithdirectpalpationoftheradialsideofthewristatthethumbbase. FINKLESTEINTEST:Graspingtheflexedthumbintothepalmwithfingerselicitspain(passive stretchingoftheaffectedtendons)

Triggerthumborfinger: Itisatypeofstenosingtenosynovitisinwhichthesheatharoundatendoninathumborfinger becomesswollen,oranoduleformsonthetendon.(CAUSE:Idiopathic) Affecteddigitsmaybecomepainfultostraightenoncebent,andmaymakeasoftcrackling soundwhenmovedhencetheyareLOCKEDinflexion. Painoverthepalmeraspectofthemetacarpophalangealjoint.

AnserineBursitis: Anserinebursaislocatedanteromediallyoverthetibialplateaujustbelowthejointlineofknee. Causes: AbnormalgaitMedialcompartmentosteoarthritis:Painonthemedialjointlineinppl>40. XraywouldshowbonyspursandotherOAfindings.Willresultinchronicgaitabnormalityand causeanserinebursitis. Overuseortrauma

S/S:

Localizedpainovertheanteromedialtibia. Painisoftenpresentovernightaspressurefromthekneesmakingcontactwithoneanother causespainwhilethept.liesonhisside

Examination: Tx: Rest,ice,maneuverstoreducethepressureoverthebursa corticisteroidinjectionsintothebursa Prepatellarbursitis: Painandswellingdirectlyoverthepatella Variablesignsofinflammation MCCtrauma Welldefinedareaoftendernessoverthemedialtibialplateaujustbelowthejointline. Valgusstresstest:Doesnotaggravatedthepain(Rulingoutmed.Collateralligamentdisease)

Patellofemoralsyndrome:

 Peripatellarpainworsenedbyactivityorprolongedsitting(d/tsustainedflexion)

Septicarthritis: Prostheticjointincreasesrisk Afterstaph.Strep.istheMCnongonococcalagent

CRESTsyndrome: Calcinosis:Localizeddystrophiccalcificationofskin.S/Cpinktowhitenodulesontheupperextremity.

.Mayulceratetodrainachalkywhitematerial. Telangectasias:Matlikepatchesmostcommonlyonfaceandpalm.

Systemicsclerosis: Thickeningofskinandedemafirstinthehandsandfeetdermalsclerosisflexion contractures>jointpains SystemicHTNgiveACE,saveslife PulmonaryHTNRHF Antibodies:ANApresentinALLpatients,Antitopoisomerase1

Chronictophaceousgout:D/D:Rheumatoidnodulesandcalcinosiscutis

Chronictophaceousgout.Tophicanulcerate anddrainachalkymaterialjustlikecalcinosiscutis.

Rheumatoidnodulescommonly formneartheextensorsurfaceoftheelbow.Theycanbefixedtotheunderlyingperiosteumorcanbe freelymobile.FirstlineagentsforRAMTX,hydroxycholoroquine,TNF(infliximab,etanercept) Considergoutinsomeonetakingawaterpill(hydrochlorthiazide)asitcauseshyperuricemiaand gout Osteoarthritis: LOOKCLOSELYATTHEXray: SubchondralcystformationattheDIP Heberdenandbouchardnodespresent. Narrowjointspace.

Crepituswithmotionofthepatella MCCOverusepainsyndromeoftheknee

Urinarymarkersofbonedegradation: Hydroxyproline Deocypyridinoline NandCtelopeptide

HypercalcemiawithnormalPO4andALP Milkalkalisyndrome Dermatomyositis: Proximalmuscleinvolvementwithcutaneousfindings: Poikilodermaovervariousregionsofthebodywhichisextrapigmentation(redpurple)ofthe skindemonstratingavarietyofshadesandassociatedwithwidenedcapillaries(telangiectasia) intheaffectedarea. Face:eruptionwithperiorbitaledema(heliotropesign) Chestandlateralneck:shawlsign

 Knuckles,elbows,knees:Lichenoidpapules(Gottronssign)

Gottronssign

Heliotroperash.(canbelighterthanthis) Classicautoantibody:AntiMi2(againsthelicase) Associatedwithinternalmalignancies:MCOVARIAN,breast,lungandotherfemaleurogenitalCA too. CausesPULMONARYfibrosis. Inflammatorydiseasesass.WithAorticaneurysm: Behcets Takayasu Temp.arteritis Spondyloarthropathies RA

Vertebralosteomyelitis: GrosslyelevatedESR(>100mm/h) WBCcountmaybenormalorelevated

Neurogenicarthropathy:(Charcotsjoint)

 Decreasedsensationsoccurringd/tanyofthefollowingandcausesasecondarydegenerativejoint diseaseasptsunknowinglytraumatizetheirjoints: S/S: Mx: Txunderlyingdisease Providemechanicaldevicese.g.specialshoestoassistinweightbearing. Mildpain Xrayshowslossofcartilage,osteophytesandloosebodies DM Peripheralnervedamage Syringomyelia SCinjury B12definciency Tabesdorsalis