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107 Cards in this Set
- Front
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54 yo m w/ pain on movement of R shoulder. Is a contractor who has been working more lately. When asked to localize pain, pt points to ant./medial aspect.
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1) What is this? 2) How would you treat?
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37 yo m baker presents w/ pain at L lateral elbow, worse w/ tapping on epicondyle. Has been rolling dough for past week. On exam, you notice slight warmth and mild swelling.
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1) What is this? 2) What movement causes this? 3) What do you make sure to include in the DDx? 4) What causes this pain?
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52 yo f painter presents w/ pain and inflammation on R knee. Works in kneeling position. States knee is tender and she is unable to kneel. Swelling since yesterday.
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1) What is this? 2) What tests would you do for dx? 3) Tx?
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55 yo m, w/ type 1 DM, presents w/ painful L shoulder and inability to move it x1 month. States tenderness is diffuse. MRI shows contracted articular capsule.
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1) What is this? 2) What is happening to the joint? 3) What are the risk factors for this?
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66 yo f presents w/ systemic amyloidosis.
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1) Is this common 2) What are the 3 types? 3) How would you test for it? 4) What does primary and secondary mean? 5) What are the sxs like?
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1) What is sarcoidosis? 2) What populations are more likely to get it? 3) What ages? 4) What is the pathogenesis?
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1) Multisystem granulomatous disorder where there's an accumulation of immune cells and caseating granuloma formation--genetic background w/ environmental trigger 2) African Americans and women 3) 20-40 yo 4) Accumulation of T cells and mononuclear phagocytes (lung, skin, eye mostly) w/ noncaseating epithelioid granulomas and derangement of nml tissue (TH1 cell process)
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23 yo f, African American, presents w/ SOB, cough, and hemoptysis x 1 week. Has lymphadenopathy on CXR bilat. Also w/ cutaneous lesions x 3 days and generalized weakness.
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1) What is this? 2) How do you treat? 3) What's the prognosis?
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56 yo m w/ abrupt onset consitutional sxs, malaise, soreness in morning, and weakness. Has had pain in shoulder girdle for 2 weeks.
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1) What is this? 2) What has a 50% comorbidity? 3) What causes this? 4) How do you dx? 5) What's the prognosis?
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54 yo f, unemployed, presents w/ 4 months diffuse pain. Localizes tenderness at every tender point. Sensory and neuro nml. States is unable to sleep and c/o malaise. Denies trauma.
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1) What does this look like? 2) What are the diagnostic requirements? 3) What population is more likely to get this? 4) How to you treat?
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51 yo m presents c/o cold fingers and toes x6 mos. States fingers have been swollen and joints stiff. Also c/o dysphagia recently along w/ some mild GERD.
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1) What do you think? 2) Is this autoimmune? 3) What population most at risk? 4) What are you most worried about w/ this? 5) How do you test?
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39 yo f presents w/ tender, erythematous nodules on extensor surfaces of LEs x 3 days. Pt has been on Bactrim for skin infection for 14 days.
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1) What do you think? 2) What is this the most common form of? 3) What make up the skin lesions histologically? 4) How do you dx? 5) What is this condition often associated with?
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27 yo f presents w/ butterfly rash on face, fever, and generalized pain x 1 week. Also w/ photophobia.
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1) What do you think? 2) Populations at risk? 3) Autoimmune? 4) What organs are affected? 5) What kind of testing would you do? 6) What tx?
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58 yo m, who takes steroids for severe asthma and allergies, presents w/ ongoing dull, achy hips. Sxs have worsened for some months. Occasionally has pain in groin as well.
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1) What do you think? 2) What is this? 3) What are common causes? 4) What can this progress into? 5) How do you treat?
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22 yo m, professional wrestler, buff as hell, presents w/ searing pain over L tibial tuberosity. On exam, swelling and prominence noted.
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1) What do you think? 2) What is the pathology? 2) Males affected more? 3) How do you dx? 4) What do you tell your pt to do?
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54 yo m, lobsterman, presents after 3 months of R knee pain. States the pain is vague, constant, and sometimes the knee catches and locks in place. He has to force it to unlock w/ his hands, which is extremely painful.
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1) What do you think? 2) What aspect of knee is most commonly affected by this? 3) How do you dx? 4) How would you treat?
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5 yo m presents w/ mom w/ hip pain. Pt has antalgic gait and decreased ROM. On AP and Lauenstein film, Gage's sign is evident.
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1) What is this? 2) Why does it occur? 3) Describe the grades 4) What is Gage's sign? 5) How do you treat?
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3 yo f presents w/ mother w/ broken femur. You notice on exam that her sclera appear bluish. She is also delayed in her speech and apprehension and you suspect bilat deafness.
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1) What do you think? 2) What is defective in this? 3) How many types are there? Are they common? 4) How would you dx?
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42 yo m presents w/ chronic HAs and myalgias. On exam you notice his face has significant deformity, which he states has been getting worse.
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1) What is this? 2) What's the mechanism? 3) Is this common? 4) How do you dx?
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7 yo f presents w/ parents. Both appear disheveled and pt looks malnourished. Mother is concerned b/c child has been walking strangely. On exam, pt has genu varus. Also noted to have nodules along ribs and an outwardly projecting sternum.
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1) What is this? 2) What's the mechanism? 3) What populations are more likely to get this? 4) How can you dx? 5) How can you treat? 6) How is osteomalacia different? 7) What are the names of the nodules? 8) What's the name for protruding sternum?
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1 yo f w/ hx of fxs, anemia, hydrocephalus, and found to have thick, dense bones on imaging.
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1) What is this? 2) What causes this? 3) Is it rare?
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65 yo f, o/w healthy, presents after falling and experiencing two fxs of her femur. After her bone densitometry, it was noted she has a T-score < 2.5.
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1) What is this? 2) What are the risk factors? 3) What types are there? 4) What is the heralding sign? 5) How can you dx? 6) How can you treat?
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16 yo f presents w/ anterior knee pain bilat. Has been progressing for months. On exam, her knees appear to hit each other as she walks.
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1) What is this? 2) What are some causes?
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6 yo f presents w/ nml gait after seeing you two years ago w/ bowlegged stance and gait. This is what you'd hoped would happen.
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1) What is this? 2) Is it common 3) What uncommon type is progressive and does not correct?
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18 yo m presents w/ problem walking. States he continually walks on the outside of his feet. On exam, he walks w/ plantar flexion and adduction of the heel, the dorsolateral aspect of the foot bearing most of the weight. He also appears to have moderate calf atrophy w/ hypoplasia of tibia/fibula.
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1) What is this? 2) Is it common? 3) What are the 3 types? 4) How do you dx?
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4 yo f presents w/ mother w/ R lower leg inwardly rotated. Mother states pt has not learned to walk properly due to defect. On exam, pt's leg has an 80 degree inward rotation from hip in prone position. Also ligamentous laxity about the femur.
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1) What is this? 2) Males or females more affected? 3) What causes this? 4) How do you dx?
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5 yo f presents w/ mother w/ increased limping and toe-walking, per mother. On exam, pt has lumbar lordosis and R leg appears 15 cm longer than L leg.
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1) What do you think? 2) Why does this occur? 3) Does this occur more in females? 4) What are risk factors? 5) What tests can you do to confirm dx?
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63 yo m presents w/ unrelenting pain, fever, generalized arthralgias and myalgias, and pain in lumbar spine. Has diabetes but states he has been o/w healthy. Did step on a nail outside a couple weeks ago and failed to get a tetanus shot.
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1) What do you think? 2) What is your first move? Second? 3) What is the chief culprit of this (other two?)? 4) Describe Sequestrum, Involucrum, and Brodie abscesses 5) How do you dx? 6) How do you treat?
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If previous pt had Pott's Dz, what would the dx be?
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TB Osteomyelitis
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How would you describe Diffuse Idiopathic Skeletal Hyperotosis (DISH)?
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Degenerative process w/ subsequent ossification of anterior longitudinal ligament, spanning 3 or more segments and adjacent intervertebral discs. Typically in lumbar/thoracic area. Increased incidence in men > 80 yo.
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2 month old f presents w/ mother w/ worsening lack of movement UEs > LEs. On exam, pt is noted to have clubfeet bilat w/ LE contractures, internal rotation of shoulders, flexed elbows, wrists, and fingers. Decreased muscle noted globally.
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1) What is this? 2) What is the most common type called? 3) What possibly causes this?
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15 yo m presents w/ R knee pain x 4 days. Has no other presenting sxs. On AP/lateral xray, you note that the femoral neck appears to be anteriorly rotated while the femoral head remains in the acetabulum.
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1) What is this? 2) What causes this? 3) Can this occur bilat? 4) What are the risks? 5) Can a pt present w/ other complaints? 6) How would you treat?
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During a school screening, a 7 yo m was found to have asymmetry of posterior chest wall on forward bending. Also w/ different shoulder, waist, and hip heights.
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1) What would you call this? 2) What is necessary for dx? 3) What is the forward bending test called? 4) What are the 3 forms? 5) How would you treat?
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3 yo f presents w/ L scapula raised abnormally high. Has no spinal abnormalities, but appears to have webbing of skin btn neck and scapula.
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1) What is this? 2) Is it common? 3) What can it be accompanied w/?
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What is the most common congenital limb deficiency?
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fibular hemimelia
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What causes limb deficiencies?
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retarded growth plate leading to shortened limbs (dwarfisms)
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What is the most common dwarfism?
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Achondroplasia, resulting from an autosomal dominant mutation in FGF receptor 3 gene
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You have a skeletal deficiency wherein you have extremely imperfect ossification of your midlines bones, esp. those w/ membrane involved (i.e. clavicle, cranium, pelvis). What's wrong w/ you?
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Cleidocranial Dysostosis -- autosomal dominant mutation in transcription factor Runx2, controlling osteoblast differentiation
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You are getting a foot massage when your masseuse tells you you have really messed up feet. Says he can make your feet flat if he wants, as if there's no arch. You tell him to go to hell and leave. What's wrong w/ you?
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Hypermobile Pes Planus -- common in neonates; caused by laxity of ligaments in medial longitudinal arch; always bilat; generally asymptomatic; make sure to distinguish this from rigid flat feet, which has a more serious pathology
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2 yo presents w/ in-toeing and nml hip alignment.
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1) What is this? 2) What is it likely due to given her age? 3) If she were 6 mos. old, what would likely be the cause? 4) If she were 5, what would likely be the cause?
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3 to f presents w/ adduction of bilat forefoot. Hindfoot appears valgus.
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1) What is this? 2) What are the risks for this? 3) How do you dx? 4) How common?
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47 yo m presents w/ constitutional sxs, weakness and pain in UE/LE/neck, dysphagia and dysphonia x 3 weeks. Has developed joint pain recently. Tests reveal elevated serum CK, lactic dehydrogenase, AAT, and Aldolase.
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1) What is this? 2) Is it autoimmune? 3) How else can it present?
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47 yo f presents w/ periorbital edema and rash at upper eyelids, back, and neck x 2 weeks. Also w/ lesions over knuckles and muscle weakness bilat. Tests reveal increased levels of serum CK.
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1) What is this? 2) What are the names of the lesions on the knuckles? 3) What organs can possibly be affected?
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33 yo f w/ "bumps on hand." On exam, pt w/ 2 3 cm soft tissue masses on the flexor surface of the 2nd and 3rd digit proximal phalanges.
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1) What is this? 2) What's the problem? 3) What ages does this usually occur in? 4) Describe the 2 types
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What is a Baker's Cyst an example of?
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Synovial cyst : synovium that herniates through joint capsule
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29 yo m w/ 7 cm mass on dorsum of hand at base of 1st metacarpal. Painless. Soft.
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1) What is this? 2) What causes it? 3) What can you do?
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On imaging of 66 yo f w/ painful knee joints, you see bone fragments and cartilage debris in joints w/ signs of chronic synovitis. What is this pathognomonic of?
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Neuropathic joints
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What are neuropathic joints?
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severely degenerated joints secondary to loss of innervation, resulting in loss of proprioception and nociception and making it vulnerable. Entire joint can be lost.
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What are the risk factors for neuropathic joints?
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DM, syphilis, leprosy, syringomyelia, congenital indifference to pain
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39 yo m w/ paraspinal pain L2-L4. Qualifies pain as deep and achy. Worse on extension. Sensory and motor nml.
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1) What is it? 2) Describe this. 3) How do you dx? 4) Tx?
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What is degenerative disc dz?
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Changes in intervertebral discs that are ubiquitous w/ age; common cause of low back/neck pain; often occur w/ osteophytes anteriorly/posteriorly; results in loss of height; can lead to degenerative spondylolisthesis; get MRI*; treat w/ sx for disc reduction
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What is spinal stenosis?
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Narrowing of vertebral canal
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What is spondylosis deformans?
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Anterior/lateral osteophyte secondary to disc degeneration
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Pt w/ OA has osteophytes in DIP joints and PIP joints. What are they each called? How do you remember that?
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DIP osteophytes: Heberden nodes; PIP osteophytes: Bouchard's nodes; Remember: if you want to hibernate in your den, you have to go to the end of the world
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What's the deal w/ OA?
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It's a failure of all parts of joint, but mostly articular surfaces. Most common joint dz in humans (80-90% >65yo); often in knee, which is the most chronically messed up joint in the developed world
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Describe the phases of OA?
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increased H2O, decreased proteoglycans = weak collagen --> increased cytokines (IL-1 and TNFa) and NO in cartilage --> chondrocyte apoptosis in articular cartilage --> decreased strength --> thinning cartilage and joint space --> underlying bone accepts synovial fluid, creating subchondral cysts --> subchondral sclerosis and osteophytes
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How do you dx OA?
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A: abnml alignment; B: bony subchondral cysts; C: cartilage thin and not calcified; D: Deformities (Heberden and Bouchard); E: No erosion
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2 yo f, who just received her second MMR vaccine, presents w/ mother w/ knee and ankle swelling. States they are painful. Mother reports pt had diffuse rash a few days prior, which cleared.
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1) What do you think? 2) What should you do? 3) Where else can this come from?
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Pt presents w/ OA-like sxs in most joints. C/o morning stiffness and joint swelling. You dx Hemochromatosis after imaging. What is this?
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Disorder of iron metabolism where the Fe accumulates in liver/pancreas. One of most common hereditary dzs in humans*. Mutation in gene HFE on short arm chromosome 6, which regulates Fe absorption in int. epithelium. Fe accumulates at rate 0.5-1.0 gram/hear, thus dz occurs ages 40-60. On imaging, see hook-like osteophytes.
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What is the destructive form of Calcium Apatite Arthritis in elderly?
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Milwaukee shoulder
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How does CAA present?
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Can be asymptomatic, acute, subacute, or chronic; w/ acute synovitis, bursitis, or tendinitis; chronic destructive arthropathy typically in shoulder or knee
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What is gout?
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Complex arthritis that is the endpt of hyperuricemia. Plasma urate = > 7 mg/dL to be hyperuricemic. Characterized by tophi in synovium
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What's a tophus?
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Aggregate of crystalline monosodium urate
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Describe the chronology of gout?
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Uric acid crystals --> distal joints --> chemotactic to leukocytes --> cytokines arrive --> inflammation --> phagocytosis of crystals --> repeated attacks --> gouty arthritis --> TOPHI!!!!!
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What are the risk factors of gout?
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Male @ 18 yo; Women post-menopause; genetic, EtOH, obestiy, drugs, lead
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What is the presentation of gout?
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Acute onset over few hours w/ mod-severe joint pain; attacks often at night at 1st MTP; warm, red, swelling, effusion/cellulitis; Repeated attacks (>10 yrs) lead to tophi and chronic gout
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Pt dx'd w/ Pott's Dz presents w/ insidious, worsening joint pain at R hip. What do you think?
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Tuberculous Arthritis. Chronic, progressive MONOarthritis secondary to mycobacterium infxn; 1-3% ppl w/ TB develop this
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17 yo f, dx'd w/ gonorrhea 6 months ago, presents w/ constitutional sxs and L knee pain w/ decreased ROM. On exam, pt has tenosynovitis in feet, ankles, knees bilat. States had same pain in L hip about a month prior and did not get seen. What is this?
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Gonococcal Arthritis. Seeding of infxn into joint. *Most common septic arthritis in young adults (70% ppl <40yo)*; w/ acute/subacute monoarthritis (most often affecting KNEE), migratory, tenosynovitis LE joints; test by increased SED rate; Treat w/ CEFTRIAXONE
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55 yo m was recently dx'd w/ Calcium Pyrophosphate Dihydrate-induced arthritis. What is this?
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CPPD is characterized by calcium salt deposited in articular cartilage and released as crystal into joint; can have rapid onset of typical arthritic sxs--typically bilat; 3 types: idiopathic, hereditary, secondary; hereditary form involved w/ mutation in ANKH gene; To dx, you aspirate and culture/arthrocentesis
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This arthritis is most common in young kids and elderly
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Bacterial arthritis
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Describe bacterial arthritis
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Seeding into joint is typically monoarticular; URGENT to prevent permanent damage; Suppurative; presents w/ acute pain/swelling/fever (40-90%)/rigor (20-60%); Aspirate and culture, ESR, CRP, Synovial biopsy; most common bugs: S. Aureus (60%) Strep, Gram =, S. PNA; Can be contiguous from osteomyelitis; give ABx, drain
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Describe the late stages of untx'd Lyme Dz
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CNS involvement, confusion, loss of joint fxn, swelling, skin changes, loss of higher mental fxn, myocarditis, pericarditis, endocarditis
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How do you dx and treat Lyme Dz?
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Western blot, Ab testing, ECG if indicated, LP if indicated; 1st choice: Doxy > 8 yo, Amox <8 yo; 2nd choice: Cefuroxime PO
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44 yo f presents w/ dry mouth, red eyes, blurred vision, and facial swelling x 2 months. On exam, you note swelling of lacrimal and parotid glands.
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1) What is this? 2) Who does it affect? 3) What is the primary form? 4) What is the secondary form? 5) Is it common?
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How do you test for Sjogren's Syndrome?
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Serum Ab assay, Salivary gland biopsy, Schirmer's test
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What are the late stages of Sjogren's Syndrome like?
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Gland atrophy, hyalinization, and fibrosis
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What is Schirmer's Test?
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Tests for tear production in eyes. A negative (>10 mm of moisture on paper in 5 minutes) test = nml
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This is a complication of long-standing RA and pt presents w/ the triad: RA, splenomegaly, and granulocytopenia
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Felty's Syndrome -- <1% of RA pts
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47 yo m, HIV +, presents w/ worsening joint pain. C/o "fat fingers" that are warm and w/ decreased ROM. On exam, pt w/ psoriatic lesions on scalp, umbilicus, and arms along w/ nail pitting on hands bilat.
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1) What is this? 2) How would you dx?
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How does Ankylosing Spondylitis present?
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Stiff axial spine >1 hr, bilat SI tenderness, decreased chest expansion and lumbar flexibility, back pain, SOB, CP, wt loss, fatigue, fxs
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Describe Ankylosing Spondylitis
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Chronic, progressive AI inflammatory dz preceded by chronic synovitis; axial joints affected, esp. SI; 90% pts are HLA-B27 +; if pt is B27 =, has increased risk of IBD; Dx by film spine/pelvis, AP/lateral, ESR, CRP, Schober's Test
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24 yo f w/ Crohn's Dz presents w/ joint pain in LEs bilat. Stiff in lower back. What is this?
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Arthritis of Irritable Bowel Dz
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How does IBD manifest w/ arthritis?
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"Direct trafficking of lymphocytes from gut wall to synovium of joints" -- 10-20% pts w/ IBD (including Crohn's and ulcerative colitis) have associated arthritis; typically in LEs*
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How do you dx IBD arthritis?
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By exclusion: RF =, films =, non-specific joint inflammation
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How do you treat IBD arthritis?
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Treat bowel dz; NSAIDs can exacerbate sxs
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29 yo m, who had a GI bug one month ago, presents w/ L ankle joint stiffness that has come and gone for several days. States has had similar pain in L knee prior. Also w/ dysuria and frequency as well as conjunctivitis. What is this?
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Reactive Arthritis
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How does Reactive Arthritis present?
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Triad: asymmetric arthritis (often knee or ankle), urethritis or cervicitis, conjunctivitis
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Who gets reactive arthritis?
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Men!!! 20-30 yo
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What is Reactive arthritis?
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asymmetrical sterile arthritis that occurs after infection (one month) elsewhere in body--likely autoimmue; original infection typically of mucosa of GU and GI: chlamydia, shigella, salmonella, yersinia, campy; 80% w/ HLA-B27; Test by: A: ankylosis, B: Bone reactivity, C: cartilage loss, D: Distribution (LE), E: erosion, Soft tissue swelling; Treat w/ bed rest, hot/cold/NSAIDs/glucocorticoids
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6 yo f w/ mother w/ swollen, painful R knee x 2 months. Has taken NSAIDs w/ some relief. Tests reveal leukocytosis and increased ANA Ab.
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1) What is this? 2) What type is it? 3) If it affected 6 joints, what would it be called? 4) If pt had fever and rash, what would you worry about?
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Describe the mechanism of DESTRUCTION of rheumatoid arthritis.
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Autoimmune rxn associated w/ HLA-DR4/1/14 --> Synovial edema w/ myeloid cells --> projections from synovium --> inflammatory cells (CD4+ and B cells) --> IL-1 and TNFa --> prostaglandins and matrix metalloproteases from synovium --> articular cartilage DESTRUCTION --> increased vascularity --> fibrin --> neutrophils --> osteoclast activity by RANK-L from T cells and fibroblasts --> pannus formation
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45 yo f develops pain in joints of both hands. On exam, has Boutonnierre deformity with ulnar deviation of fingers bilat. Hands erythematous and warm. States has been progressing for years. What is this?
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Rheumatoid Arthritis -- Affects skin, blood vessels, heart, lungs, muscle; progresses to destruction of cartilage and ankylosis of joint; F:M --> 3:1
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How do you dx RA?
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ESR, CRP, RF, films for alignment issues, periarticular osteoporosis, joint space loss, hand deformities, erosion, soft tissue swelling
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21 yo m soccer player presents 3 wks s/p injury wherein he was kicked in the medial posterior thigh w/ a cleat. States area was initially bruised, painful and swollen. Then a painless mass in area, followed by the current hardened mass. Currently tender to palpation. Has continued playing soccer.
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1)What is this 2) Is it common? 3) How does it happen? 4) Who does it happen to?
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41 yo m presents w/ constitutional sxs, hemoptysis, dyspnea, sinusitis, and saddle-nose appearance. On exam, you discover serous OM and possible sinusitis. On CXR, you find PNA w/ bilat cavitating nodules/infiltrates.
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1) What is this? 2) What is the triad of sxs to look for? 3) How do you test?
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32 yo f, Japanese, presents w/ cold hands, visual impairment, and constitutional sxs. On exam, you note retinal hemorrhages, weakened radial pulses bilat, and hypertension of which pt has no hx.
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1) What are you thinking? 2) What is this? 3) How do you dx? 4) What's the pathology?
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What kinds of vessels are affected in Polyarteritis nodosa?
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Necrotizing vasculitis of small-medium vessels
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What organs are affected in Polyarteritis nodosa?
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Renal w/o glomerulonephritis, visceral organs -- NO pulmonary involvement
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What antigen is Polyarteritis nodosa associated with?
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Hep B antigen; test for these
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What vessels are affected in Microscopic polyangitis?
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Necrotizing vasculitis of arterioles, capillaries, and venules w/ involvement of lung and kidney
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What are 2 common systemic manifestations of Microscopic polyangitis?
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*Necrotizing glomerulonephritis and pulmonary capillaritis* (skin, mucus membrane, lungs, brain, heart, and GI can be involved too)
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What Auto-Ab is found in 70% of pts w/ Microscopic polyangitis?
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p-ANCA
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52 yo f presents w/ HA, constitutional sxs, and pain to palpation of Temoral Artery. What do you immediately think?
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Giant Cell Arteritis
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What is Giant Cell Arteritis closely related to?
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Polymyalgia Rheumatica
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Describe Giant Cell Arteritis
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Systemic vasculitis of med-lg. vessels; *Most common systemic vasculitis of adults* F>M; Nordic populations; autoimmune HLA-DR4; Starts w/ immune rxn against vascular wall --> granulomatous inflammation --> fragmentation of internal elastic membrane --> mononuclear infiltrate w/ multinucleated giant cells and Langerhan's cells
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How would you test and treat Giant Cell Arteritis?
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Test: ESR, CBC, LFTs, Alk phos, biopsy of temporal artery; Tx: Glucocorticoids, ASA, Methotrexate
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35 yo f lobsterwoman presents w/ pain and tenderness at radial aspect of L wrist, worse w/ thumb movement. What do you think?
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Tenosynovitis
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What is Tenosynovitis?
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Inflammation of thin inner synovial lining around tendons of abductor policis brevis and extensor policis brevis and they pass through common sheath; COMMON in manual laborers, esp. women; Tx: Rest, NSAIDs, corticosteroid injection, sx
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