Revision as of 06:04, 3 January 2023

Systemic Lupus Erythematosus

Autoimmune inflammatory condition caused by antibody-antigen deposition in various tissues.

H&P: Young women, blacks, hispanics, asians
Dx: DOPAMINe RASH 4 of 11 criteria, rule out 2° causes (drug-induced lupus SHIPP: sulfonamides, hydralazine, isoniazid, phenytoin, procainamide). Best screening test is ANA (98% sensitivity), most specific are anti ds-DNA, anti-Sm. Complement C3 and C4 levels can also be low, especially during acute flares.
Tx: NSAIDs for arthritis and mild serositis; hydroxychloroquine for skin and renal disease; for moderate to severe disease, use corticosteroids or anti B cell biologics; for acute flares, use steroid tapers. Test for anti-SSA in patients thinking about getting pregnant, as this antibody can cross the placenta and cause neonatal lupus and complete heart block. If patient has anti-phospholipid antibody syndrome, they need lifelong warfarin.

H&P: middle aged women, HLA-DR4 serotype; morning stiffness that lasts > 30 min and improves with activity; Swan Neck deformity (PIP extension, DIP flexion), Boutonniere deformity (PIP flexion, DIP extension), ulnar deviation of MCP.
Dx: 4 criteria for 6+ weeks. 3 or more joints (PIP, MCP, wrist, elbow, knee, ankle); symmetrical joint synovial hypertrophy with cartilage loss and osteoporosis on xray; elevated CRP, ESR (sensitive, not specific), rheumatoid factor (75% sensitive), or anti-CCP (most specific); inflammatory synovial fluid on joint aspiration; rheumatoid skin nodules (elbow most common).
Tx: NSAIDs and PT; Sulfasalazine, Hydroxychloroquine, or Glucocorticoids for milds disease; Methotrexate, anti-TNF biologics, or corticosteroids for moderate-severe disease; anti-TNF biologics AND corticosteroids for severe disease. Avoid methotrexate in patients with HIV, liver disease, ILD, renal disease, pregnancy, or bone marrow suppression; avoid anti-TNF in patients with TB.

H&P: Older patients; polyarticular arthritis in the DIP (Heberden), PIP (Bouchard), 1st CMC, elbow, hip, knee, and back; Morning stiffness lasts < 30 min, but pain worsens with activity as the day progresses; can be secondary to trauma or metabolic disease (Wilson or Hemochromatosis)
Dx: Xrays and clinical findings asymmetric joint sclerosis, narrowing, periarticular bone spurs; inflammatory lab markers are normal; joint aspiration has WBCs < 2000
Tx: Exercise, PT, weight loss; NSAIDs, APAP; Glucocorticoid injections; Joint replacement.

H&P: Monoarthritis, swollen, red, very painful joint, most commonly the first carpometatarsal joint; can be associated with tophi if chronic; risk factors include obesity, male, Pacific Islanders, cancer, renal disease, Thiazide diuretic use, and high meat/alcohol consumption.
Dx: Joint aspirate reveals negatively birefringent needle shaped monosodium urate crystals that are yellow with parallel light, with WBCs 3-50k. Differential diagnosis of monoarthritis includes pseudogout (rhomboid shaped, positively birefringent, calcium pyrophosphate crystals), septic arthritis, trauma, reactive arthritis, Hemochromatosis, and Lyme disease.
Tx: First-line is high-dose NSAIDs (e.g. Indomethacin, but avoid in ESRD) or colchicine, second-line is intra-articular corticocorticoids. Give allopurinol once the acute symptoms resolve to prevent recurrences.

H&P: Older women, history of depression or trauma, or IBS; widespread chronic muscle pain in pre-defined areas, insomnia, weakness, fatigue
Dx: WPI 3-6 and SSI > 9, or WPI ≥ 7 and SSI ≥ 5, labs are all negative
Tx: TCAs, SSRIs, Gabapentin, Pregabalin, exercise, PT, hydrotherapy, heat, pain psych

Kawasaki Disease (CRASH and Burn) vs. Acute Rheumatic Fever from S. pyogenes
Hold off on live vaccines for 12 months after IVIG therapy
Hemochromatosis diagnosis and association with HCC
Paget disease diagnosis
Complications of untreated scaphoid fracture
Chronic exertional compartment syndrome vs. tibial stress fracture vs. shin splints
Myotonic dystrophy diagnosis
Diagnosis of Chlamydia

@@ Line 34: / Line 34: @@
 =Polymyalgia Rheumatica=
 =Fibromyalgia=
+*H&P: Older women, history of depression or trauma, or IBS; widespread chronic muscle pain in pre-defined areas, insomnia, weakness, fatigue
+*Dx: WPI 3-6 and SSI > 9, or WPI ≥ 7 and SSI ≥ 5, labs are all negative
+*Tx: TCAs, SSRIs, Gabapentin, Pregabalin, exercise, PT, hydrotherapy, heat, pain psych
 =Polymyositis and Dermatomyositis=
 =Scleroderma=