RHEUMATOLOGY TiKi TaKa

. Systemic lupus erythematosus "SLE": . Female 20-30 ys. . Malar "Butter fly" rash. . Arthritis. . Painless oral ulcers. . Renal disease. . +ve Ds DNA. . Newly diagnosed "Lupus Nephritis" ----> RENAL BIOPSY to detect the type of pathology. . Grading from class 1 "Minimal mesangial" up to class 4 "Advanced Sclerosis". . Then the immunosuppressive therapy is given accordingly. . SLE: . Young, African American woman. . Aged 20 - 40 ys. . Fatigue "Anemia". . Painful oral ulcers. . Non deforming arthritis. . Hematologic abnormalities "pancytopenia". . Low grade fever. . Weight loss. . Malar or discoid rash. . Lupus Arthritis as RA involves MCP & PIP BUT "NO DEFORMITIES". . BLUE TOE $YNDROME: . Due to CHOLESTEROL EMBOLISM. . Cardiac catheterization may cause atheroembolism. . BLUE TOES " But intact pulse". . ++ CREATININE. . Abdominal tenderness. . Accompanied e' Livedo reticularis. . REMEMBER ---> LUMBAR SPINAL STENOSIS Dx ----> Spinal MRI. . Ankle brachial index is used to diagnose peripheral artery disease. . ERYTHEMA NODOSUM: . Painful S.C. pre-tibial nodules. . Associated with SARCOIDOSIS. . Ask for a CXR to detect sarcoidosis. . CXR: Bilateral hilar adenopathy. . AFRICAN AMERICAN FEMALE ! . Cough, Arthritis & uveitis. DiseaseBest initial Tx Rheumatoid arthritisMethotrexate OsteoarthritisWeight loss & Acetaminophen Gout acute attackNSAIDs, Indomethacin Gout prevent. of new attackColchicine CPPDNSAIDs Disk herniationNSAIDs Epidural abscessAbs "Vancomycin". Cord compressionSteroids Spinal stenosisWeight loss & Steroid injection FibromyalgiaAmitriptyline Carpal Tunnel. $Wrist splint & NSAIDs PolymyositisHIGH dose steroids Rotator cuff injuryNSAIDs SLEHigh dose steroids Sjogren $Water the mouth & artificial tears Polymyalgia RheumaticaLOW dose steroids Temporal "Giant cell" arteritisHIGH dose steroids Ankylosing SpondylitisNSAIDs Psoriatic arthritisNSAIDs Reactive arthritis "Reiter's $"NSAIDs Septic arthritisCEFTRIAXONE & VANCOMYCIN Gonococcal arthritisCeftriaxone or cefotaxime . D.D. of CALF SWELLINGS: Cellulitis: ... Infection of skin & S.C. tissue. ... Risk factors: Obesity & Tinea pedis ! ... Red, edematous skin that is hot to touch. ... Regional lymphadenopathy. ... Caused by STAPH & STREPT Group A. DVT = Deep Venous Thrombosis: ... Same presentation as cellulitis . ... BUT .. FEVER never exceeds 38.5 c. ... No regional lymphadenopathy. ... Ruptured BAKER's CYST. . OSTEO-ARTHRITIS (OA): . Old age. . Affects hands & weight bearing joints. . Mild morning stiffness < 30 mins (RA > 1 hour). . Pain ++ with exercise & -- by rest. . Bony crepitus, bony enlargement. . Painful & - range of motion. . Synovial fluid analysis: 200-2000 WBCs, . (Normal 0-200 & Inflammatory 2000-50000 & Septic arthritis >50000). . X-ray: -> NARROWED JOINT SPACE. . X-ray: -> OSTEPHYTE FORMATION. . X-ray: -> SUBCHONDRAL CYSTS.. GOUTY ARTHRITIS: . Middle aged male. . Acute joint pain (1st Metatarsophalangeal joint is the most common). . Swelling & -- range of motion. . Low grade fever. . Synovial fluid analysis is critical for diagnosis, . WBCs 2000-50000, . NEEDLE shaped, NEGATIVELY birefringent crystals under polarized light. . NEGATIVE gram stain & culture. . ++ serum Uric acid is neither sensitive nor specific !! . Tx of acute attack --> INDOMETHACIN (Cot'd in RF or GIT bleeding) & COLCHICINE. . TREATMENT ----> NSAIDs, Colchicine & steroids. . PREVENTION ---> Allopurinol & probenecid. . PSEUDO-GOUT: . Calcium pyrophosphate dihydrate (CPPD) deposition. . Acute onset, painful , monoarthropathy affecting the knee. . Synovial fluid ---> RHOMBOID shaped with POSITIVE +ve birefringence. . Ass. with HYPERPARATHYROIDISM: .. ++ Ca & -- PO4 --> constipation & excess urination. .. Disease of GROANS (Abd. pain), STONES (urinary) & Psychic MOANS. . GONOCOCCAL SEPTIC ARTHRITIS: . YOUNG, SEXUALLY ACTIVE FEMALE. . Fever > 38.5 c. . Redness, hotness, swelling, pain, limitation of movement. . Synovial fluid analysis: ++ WBCs > 50000. . Asymmetric polyarthritis. . May be associated with tenosynovitis or rash. . OSTEO-ARTHRITIS: . Narrowed joint space. . Osteophytes. . Subchondral sclerosis or cysts. . Obesity is the most common risk factor. . Weight loss is the best initial ttt. . TEMPORAL = GIANT CELL ARTERITIS: . Age > 50 ys. . New headache. . Jaw claudication. . Scalp pain. . Visual loss. . ++ ESR. . Dx: TEMPORAL ARTERY BIOPSY. . Tx: HIGH dose steroids. . LUMBAR SPINAL STENOSIS: . Old pt. . Combined low back & leg pain. . Posture dependent --> Flexion of the back causes widening of the spinal canal, . while extension causes narrowing of the spinal canal. . So, the leg pain is exacerbated by extension of the spine (Standing & walking), . but improved by flexion (Sitting & lying down). . Called "Neurological Claudication". . Differentiated from claudication of peripheral vascular disease by normal pulses! . Normal Ankle / Brachial index. . Normal neurological examination. . -ve Straight leg test. . Dx: MRI. . Tx: Conservative or Laminectomy. . ANKYLOSING SPONDYLITIS TIPS & TRICKS: . Not only in young males, may affect females ! . BILATERAL SACRO-ILIITIS is DIAGNOSTIC. . Most imp. extra-articular manifestation is ANTERIOT UVEITIS !! . May be associated with Aortic insufficiency with AV Block. . (Not ass. with Aortic Aneurysm xxxxx). . N.B. Apophyseal joint arthritis = Ankylosing spodylitis: "Sero-negative spondylo-arthropathies". . HERNIATED DISC: . Pain worsens with sitting. . Low bk pain & sciatica. . +ve stress leg test.

. VERTEBRAL METASTASIS: . Low back pain. . H/O of malignancy. . Weight loss. . CONSTANT DULL PAIN. . Failure to improve with conservative therapy. . Osteomyelitis: . Caused by STAPH. AUREUS. . Tx-> Ox, Clox, Dicloxacillin. . ROTATOR CUFF TENDONITIS: . Due to repetitive activity above shoulder height e.g. Painter. . Passive motion of the arm above the head cause pain & guarding confirming impingement. . Lidocaine injection cause pain relief, . in contrast to persistence of pain with NO relief in case of ROTATOR CUFF TEAR, . Rotator cuff tear is due to fall on out stretched hand. . CYCLOPHOSPHAMIDE side effect ---> Hemorrhagic cystitis & Bladder carcinoma. . ROTATOR CUFF TEAR: . results from chronic tendonitis & shoulder trauma. . Shoulder pain & weakness when lifting the arm above the head. . Lidocaine injection relieves the pain in case of R.C. Tendonitis, . while it persists in case of R.C. Tear. . Dx----> MRI Shoulder. . VIRAL ARTHRITIS: . Secondary to PARVO-virus 19 infection. . Similar presentation as Rheumatic arthritis ! . Arthritis --> PCP & PIP & wrists. . Resolves within just 2 months !! . H/O of frequent contact with children e.g. day care workers. . so the diff. bet viral & RA are: . . ACUTE ONSET. . . Lack of inflammatory markers "Anti-CCP & RF". . . Resolution within 2 months ! N.B. . SE of HYDROXYCHLOROQUINE ---> RETINOPATHY. . SE of CYCLOPHOSPHAMIDE ---> BLADDER CARCINOMA. . SARCOIDOSIS: . AFRICAN AMERICAN FEMALE. . Lung involvement --> Cough & dyspnea. . Erythema nodosum. . Anterior uveitis. . Acute polyarthritis. . Parahilar adenopathy. . ++ ACE enzymes (Give ACE Is)! . Biopsy: Non caseating granuloma. . Tx: SYSTEMIC GLUCOCORTICOIDs. . CARPAL TUNNEL $YNDROME: . Compression of the median nerve within the carpal tunnel in the wrist. . Pain & paresthesia in the median nerve distribution. . Worse with wrist flexion (+ve PHALEN test). . May be due to HYPOTHYROIDISM (Fatigue, constipation, menorrhagia & dry skin). . PATHO: Deposition of MUCOPOLYSACCHARIDE PROTEIN complexes (MATRIX SUBSTANCE). . HYPOTHYROIDISM ---> BILATERAL CT$. . FIBRO-MYALGIA: . WOMEN 20-50 ys with Point tenderness in at least 11 - 18 points !! . H/O of generalized musculoskeletal pain not related to another illness. . Disturbed sleep, easy fatigability. . Normal lab values. . Tx: TCAs e.g AMITRIPTYLINE. . DERMATOMYOSITIS: . Proximal extensor ms inflammatory myopathy. . Violaceous poikiloderma. . Periorbital edema with rash "Heliotrope sign". . Rash on chest & lateral neck "Shawl sign". . Rash on the knuckles, elbows & knees "Gottron's sign". . Lichenoid papules "Gottron's papules". . Anti-Mi-2 Abs. . Ass. with internal malignancies "Most common is OVARIAN CANCER" ! . POLYMYOSITIS: . Slowly progressive proximal muscle weakness of the lower limbs. . Difficulty with stair climbing. . Difficulty with rising from a seat. . Muscle tenderness. . Best diagnostic test ---> MUSCLE BIOPSY. . Metastatic disease of the vertebrae: . H/O of Lung cancer (Non-small cell lung carcinoma). . Most common causing cancers: Lung, breast, prostate & thyroid. . CONSTANT pain, worse at night. . LUMBAR STRAIN: . Follow twisting of the bk while lifting heavy objects. . ++ by activity & -- by rest. . No point tenderness. . SPINAL STENOSIS: . Low bk pain at lumbar spine, . ++ With activity. . DISK HERNIATION: . LBP radiating down the buttock, . +ve straight leg raise test. . ANSERINE BURSITIS: . Anserine bursa is located antero-medially over the tibial plateau, . just below the joint line of the knee. . Inflammation may be due to overuse or trauma. . LOCALIZED pain over the ANTEROMEDIAL tibia. . Valgus stress test -->-ve. "Ruling out Medial collateral ligament injury". . NORMAL X-ray. . Tx: Cortico-steroids injection into the bursa.

. Pre-patellar bursitis: . Pain & swelling directly over the patella. DiseaseSpecific Antibodies Rheumatoid Arthritis "RA"Anti-Cyclic Citrulinated Peptide "CCP". Systemic Lupus Erythematosus "SLE"Anti-Double Stranded DNA "DS DNA" SclerodermaAnti-topoisomerase "Scl 70". CREST $Anti-centromere Sjogren $SS-A "Ro" & SS-B "La" Wegener's granulomatosisAnti-neutrophil cytoplasmic Antibody"C-ANCA" Chrug-StraussAnti-myeloperoxidase antibody"P-ANCA" . WHIPPLE's disease: . H/O of malabsorption diarrhea (Steatorrhea, flatulence, abd. distension). . Weight loss. . Migratory arthritis. . caused by Tropheryma Whippelii. . Dx: Small intestinal biopsy ---> PAS +ve macrophages in the lamina propria.

. Celiac disease = Celiac sprue = GLUTEN SENSITIVE ENTEROPATHY: . Malabsorptive diarrhea. . Anti-endomysial & Anti-transglutaminase Antibodies. . Biopsy --> Effacement of SI villi. . ANKYLOSING SPONDYLITIS & IBD are associated ! . Both are associated with HLA B27. . Both are associated with P-ANCA. . IBD (UC): Bloody diarrhea, anemia & -ve stool culture, erythema nodosum. . AS: SACROILIITIS. . REACTIVE ARTHRITIS = 3 Can't ( see, pee, climb a tree): . Following infectious diarrhea, . Caused by shigella, salmonella, Yersinia, Campylobacter or C.dificile. . Conjunctivitis "Can't see". . Urethritis "Can't Pee". . Arthritis "Can't climb a tree" . POLY-MYALGIA RHEUMATICA (PMR): . Age > 50 ys. . Aching pain in neck, shoulders & pelvic girdle lasting at least 1 month. . Morning stiffness > 1 hour ! . ESR < 40 mm/hr. . No pain with active or passive range of movement. . Tx: LOW DOSE PREDNISONE. . When do u give HIGH dose prednisone? . -> If associated with GIANT CELL TEMPORAL ARTERITIS to prevent visual loss. . It is diagnosed by temporal artery biopsy. . RHEUMATOID ARTHRITIS MANAGEMENT: . All pts should be started on DMARDs ASAP as joint damage begins early ! . METHOTREXATE is the best initial therapy. . NSAIDs are adjunctive therapy for symptomatic relief, . NSAIDs don't -- disease progression. . Glucocorticoids may reveal symptoms temporarily but they don't prevent future worsening. . Pts sh'd be tested for HEPATITIS B & C & T.B. bef. starting MTx (not used in pregnants)! . Disseminated Gonococcemia: . Migratory polyarthritis. . Skin lesions (Pustules) on the extremities. . Tenosynovitis. . High fever & chills. . Blood & pustule culture --> NEGATIVE (Need specific growth requirements). . SJOGREN $YNDROME: . Women 50 - 60 ys. . Kerato-conjunctivitis sicca (Xerophthalmia & dry eyes). . XEROSTOMIA (dry mouth). . Lack of normal amount of saliva -> Dental carries & dysphagia. . Enlargement & firmness of the salivary glands. . Histology -> Lymphocytic infiltration of the salivary glands. . +ve Anti-SSA(Ro) & or Anti-SSB(La). . SYSTEMIC SCLEROSIS: . AFRICAN AMERICAN FEMALE. . Widespread organ involvement. . Esophagus -->GERD. . Heart ------> Rt Heart failure. . Kidney -----> hypertension. . Most common cause of death is PULMONARY ARTERIAL HYPERTENSION. . +ve Anti-topo-isomerase-I Abs = +ve Anti-Scl70.

. CREST $ = LIMITED scleroderma: . Calcinosis cutis. . Raynaud's phenomenon. . Esophageal dysmotility. . Sclerodactyly. . Telangiectasia. . +ve Anti-Centromere Abs. . PAGET DISEASE OF BONE = OSTEITIS DEFORMANS: . ++ Osteoclastic activity ---> Bone RESORPTION. . Distorted bone formation. . Common sites: Femur & skull & vertebra. . Hypertrophy of the skull -----> Vestibulocochlear nerve compression, . 8th cranial n. compression ---> Deafness "Sensorineural hearing loss". . NORMAL CALCIUM & PHOSPHATE LEVELS. . HIGH ALKALINE PHOSPHATASE LEVEL. . HIGH HYDROXYPROLINE LEVEL "Bone marker". . SUB-ACROMIAL BURSITIS: . Subacromial bursa lies between the acromion & the tendon of the supraspinatous ms. . caused by chronic micro trauma to the supraspinatus tendon. . e.g. overhead work or tennis playing. . Tenderness hen the arm is internally rotated & forward flexed at the shoulder. . No signs of deltoid atrophy. . LATERAL EPICONDYLITIS = TENNIS ELBOW: . Due to repeated forceful wrist extension & supination. . ex: Backhand in tennis or use of a screw driver. . Point tenderness near the lateral epicondyle. . Due to degeneration of extensor carpi radialis brevis.

. ROTATOR CUFF INJURY: . Shoulder pain, weakness & -- range of motion. . Due to impingement of the supraspinatus tendon. . De QUERVAIN TENO-SYNOVITIS: . NEW MOTHERS who hold their babies with out-stretched thumb (ABDUCTED & EXTENDED). . Affects tendons of abductor pollicis longus & extensor pollicis brevis. . Passive stretch of these tendons elicits pain. . Chronic Tophaceous Gout: . Metatarsophalangeal joint is the most affected. . Severe swelling & pain in the big toe. . Due to deposition of the monosodium urate crystals "PODAGRA". . U.A. crystals ---> Nephrolithiasis. . Urate crystals may deposit in the soft tissues forming tumors "TOPHI". . Tophi may ulcerate & drain a chalky material. . H/O of water-pills intake for hypertension "THIAZIDEs". . Hydrochlorothiazide ---> Hypovolemia ---> ++ Uric acid reabsorption. . BEHCET's $YNDROME: . Recurrent oral ulcers. . Recurrent genital ulcers. . Eye lesions: Anterior uveitis. . Skin lesions: Erythema nodosum. . Tx: Corticosteroids. . More common in TURKISH, ASIAN & MIDDLE EASTERN population. . SLE ARTHRITIS: . Cortico-steroid induced "AVASCULAR NECROSIS" of the femoral head. . Progressive hip or groin pain. . without restriction of motion range. . Normal radiograph on early stages. . Dx: MRI is the gold standard. . LUMBOSACRAL STRAIN: . Most common cause of pain. . Pain starts acutely after physical exertion. . Pain concentrated in the lumbar area. . No radiation to thighs. . Para-spinal tenderness. . Normal neurological exam. . -ve straight leg raising test. . Tx: NSAIDs & early mobilization. . Main mechanism of kidney damage in SLE is IMMUNE COMPLEX MEDIATED. . Best initial ttt in cases of DISK HERNIATION is NSAIDs & EARLY MOBILIZATION. . HERNIATED DISK: . Pain radiation to thighs. . +ve straight leg raising test. . COMPRESSION # of the VERTEBRA: . OLD age. . Acute onset of pain without an obvious trauma. . H/O of osteoporosis. . H/O of steroids intake. . Normal neurological exam (Absent Babinski reflex is considered NORMAL in elderly). . -ve Straight leg raise test (+ve with DISK HERNIATION). . VERTEBRAL OSTEOMYELITIS: . Lumbar spine. . Back pain. . Low grade fever. . ++ ESR. . Local tendrness on percussion. . Paravertebral muscular spasm. . Dx: MRI. . CERVICAL SPONDYLOSIS: . Due to BONY SPUR. . Age > 50ys. . H/O of CHRONIC NECK PAIN is TYPICAL. . Limited neck rotation & lateral bending. . Sensory deficits due to osteophyte induced radiculopathy. . X-ray --> ** BONY SPURS & sclerotic facet joints. . X-ray --> ** Narrowing of disk spaces. . X-ray --> ** Hypertrophic vertebral bodies. . ACUTE GOUTY ATTACK: . Tx: NSAIDs "INDOMETHACIN" ,COLCHICINE or steroids. . ALCOHOL CESSATION & LOW PURINE DIET are imp. to prevent future attacks. . LUMBAR STRAIN: . Related to lifting a heavy object. . No radicular signs. . Good response to conservative therapy. . Pt education -----> KEEP THE BACK STRAIGHT WHILE LIFTING AN OBJECT! . DMARDs Disease Modifying Anti-Rheumatic Drugs: .METHOTREXATE: . Inhibits dihydrofolate reductase. . SE: Macrocytic anemia (MCV > 100 & -- Hb). . Other SEs: Nausea, stomatitis, rash, hepatotoxicity, Alopecia. . HYDROXYCHLOROQUINE: . GI distress. . Visual disturbances. . Hemolysis in G6PD deficiency. . CYCLOPHOSPHAMIDE: . Nephrotoxicity & Bladder carcinoma. . RED FLAGS of LOW BACK PAIN: . = SYSTEMIC DISORDER or HERNIATED DISC, . or BONY ABNORMALITIES such as LYTIC LESIONS or Compression #s. . Age > 50ys. . H/O of previous cancer. . Unexplained weight loss. . Pain > 1 month duration. . Nighttime pain causing difficulty with sleep. . No response to previous therapy. . Neurological symptoms. . Pain to palpation of the vertebra = spinal infection or lytic lesions in the spine. . 1st step is X-RAY PLAIN FILM then MRI. . SPINAL STENOSIS: . Bk pain radiating to the buttocks & thighs. . Numbness & paresthesia may occur. . Syms are worse during walking & lumbar extension, while lumbar flexion alleviates the pain. . Dx: MRI. . ILIAC ARTERY ATHEROSCLEROSIS: . Claudication in the buttocks & thighs. . Pain ++ with activity & -- by rest. . Not affected by lumbar flexion or extension. . LUMBAR DISK HERNIATION: . Acute onset back pain. . e' or e' out radiation to one leg. . Pt recalls an incenting event e.g. lifting heavy objects. . +ve straight leg raise test. . ANKYLOSING SPONDYLITIS: . Young men < 40 ys. . Low bk pain & stiffness. . Worse in the morning & improves as the day progress. . Ass. e' anterior Uveitis (Monocular pain, blurring, photophobia). . X-ray pelvis --> SACRO-ILIITIS. . -ve RF & +ve ESR, +ve HLA B 27. . Tx: Pain relief & TNF Alpha antagonists. . VERTEBRAL OSTEOMYELITIS: . Injection drug user. . Pts with sickle cell disease. . immunocompromised pts. . STAPHYLOCOCCUS AUREUS. . TENDERNESS to GENTLE PERCUSSION. . Pain not relieved by rest. . Fever & ++WBCs --> UN-RELIABLE ! . ++ Platelet count. . ++ ESR > 100 mm/hr. . Dx: MRI. . Tx: Long term IV Antibiotics. . EPIDURAL ABSCESS: . Enclosed infection in the epidural space. . Bk pain, fever, chills & leukocytosis. . More common in injection drug users. . It may cause SPINAL CORD COMPRESSION. . LL weakness & Urinary incontinence. . Acute epidural abscess requires immediate surgical debridement. . COMPRESSION #: . due to VERTEBRAL BODY DEMYELINIZATION. . Intense focal pain. . Without neurological symptoms. . Occur in cases of osteomalacia or osteoporosis. . ACUTE GOUTY ATTACK = PODAGRA: . May be due to MYELO-PROLIFERATIVE disorder, . e.g. POLYTHYCEMIA (SPLENOMEGALY & PRURITIS AFTER HOT BATHS). . MPD "polythycemia" -> ++ Catabolism & turnover of proteins -> ++ uric acid production. . GIANT CELL "TEMPORAL" ARTERITIS: . Headache. . Jaw claudication. . Muscle fatigue. . Visual disturbance. . Scalp tenderness. . -- Temporal artery pulse. . ++ ESR > 50 mm/hr. . May involve the branches of the AORTA ----> AORTIC ANEURYSM. . Serial CXRs are imp. to exclude Aortic aneurysm. . REMEMBER AGAIN OA "Matet5ene2sh :) . Degenerative Joint disease. . Wear & Tear Arthritis. . ++ by walking & -- by rest. . Morning stiffness < 30 mins. . limited range of movement. . Tenderness on passive movement. . Due to destruction of the articular cartilage --> Bone on bone friction. . Most common risk factor is OBESITY ! . AVASCULAR NECROSIS = ASEPTIC NECROSIS = ISCHEMIC NECROSIS = OSTEOCHONDRITIS DESSICANS: . Disruption of bone vasculature. . Corticosteroid related osteonecrosis of the right femoral head. . H/O Excessive Alcohol ingestion. . Slowly progressive anterior hip pain with limitation of range of motion. . Dx: MRI. . D.D. of INFLAMMATORY MONOARTHRITIS: (RED HOT SWOLLEN PAINFUL LIMITED MOVEMENT): . Septic arthritis. . Crystal induced arthritis. . Trauma. . Pts with RA are at high risk of developing septic arthritis esp. with STAPH. AUREUS. . RA cause osteopenia & osteoporosis "NOT osteomalacia caused by Ca & Vit. D deficiency". . MTx side effects: . Stomatitis. . Nausea. . Anemia. . Hepatotoxicity. . Tx: Give FOLIC ACID ! . RA: . MORNING STIFFNESS > 1 hour. . Small joints (MCP & PIP). . Spares DIP "Unlike OA". . Tenosynovitis (Trigger finger). . Rheumatoid nodules (Elbow). . Cervical joint involvement ---> Spine subluxation ---> Spinal cord compression. . +ve Anti-CCP Abs. . +ve RF. . ++ CRP & ESR. . X-ray: Soft tissue swelling , joint space narrowing & bone erosions. . Both Obstructive & Restrictive lung disease cause -- in FEV & FEV 1 ! . But .. RESTRICTIVE lung disease cause much more -- in FEV 1 than Obstructive type. . So .. In RESTRICTIVE lung dis. FEV 1 / FEV is > 80 %. . Examples of RESTRICTIVE causes: .. Interstitial lung disease. .. Neuromuscular diseases. .. Chest wall abnormalities. . Ankylosing spondylitis -> costovertebral joint fusion -> chest wall motion restriction. . ENTHESITIS: . Inflammation & pain at ligaments & tendons attached to bone. . Associated with Negative spondylo-arthropathies, . e.g. ANKYLOSING SPONDYLITIS, psoriatic arthritis & reactive arthritis. . Associated with HLA B 27. . Most common sites are shoulder & hip. . REACTIVE ARTHRITIS = Seronegative spondyloarthropathy: . TRIAD of: CAN'T SEE, CAN'T PEE, CAN'T CLIMB A TREE !! . 1- CONJUNCTIVITIS "CAN'T SEE". . 2- NON GONOCOCCAL URETHRITIS "CAN'T PEE". . 3- ASYMMETRIC OLIGOARTHRITIS "CAN'T CLIMB A TREE". . Mucocutaneous lesions. . Enthesitis "Achilles tendon pain". . STERILE Synovial fluid analysis. . Tx: NSAIDs. . Pts with prolonged H/O of ANKYLOSING SPONDYLITIS: . are at ++ risk of VERTEBRAL #, . Due to -- bone mineral density & may occur with minimal trauma !! . FIBROMYALGIA: . Women 20 - 50 ys. . Generalized musculoskeletal pain in absence of joint swelling or lab abnormalities. . Excessive tenderness on palpation of at least 11 of 18 soft tissue locations. . The sites include the upper quadrants of the buttocks & medial aspect of the knees. . As well as Sternocleidomastoid & Trapezius muscles. . Absent of joint swelling or ms weakness. . PSORIATIC ARTHRITIS: . DIP. . Dactylitis --> SAUSAGE shaped digits = diffusely swollen fingers. . Nail involvement: pitting & oncholysis "separation of nail bed". . Well demarcated red plaques with silvery scaling. . Tx: NSAIDs & MTx. . Steroids are contraindicated.

. N.B. RA ----> MCP & PIP. . N.B. OA ----> DIP. . PSEUDO-GOUT = CHONDRO-CALCINOSIS: . Acute arthritis. . Due to CPPD Calcium pyrophosphate dehydrate crystals deposition. . H/O of recent surgery or medical illness. . Synovial fluid analysis --> RHOMBOID shaped, POSITIVELY birefringent crystals. . GOUT synovial fluid analysis --> NEEDLE shaped, NEGATIVELY birefringent crystals. . BAKER CYST: . Due to excessive fluid production by an inflamed synovium. . Occurs in cases of Rheumatoid Arthritis. . Excess fluid accumulates in the popliteal bursa which expands, . creating a tender mass in the popliteal fossa. . May burst & release their contents into the calf, . resulting in an appearance similar to DVT. . AMYLOIDOSIS: . Ass. with Nephrotic $ (facial swelling, LL edema, massive proteinuria). . Palpable kidneys. . Hepatomegaly. . Cardiomegaly (Audible S4). . H/O of chronic infections e.g. Bronchiectasis & recurrent pulmonary infections. . Tx: COLCHICINE. . OSTEO-ARTHRITIS: . Age > 50 ys. . Morning stiffness < 30 mins. . Bony tenderness. . Bony enlargement. . CREPITUS on active motion. . No warmth i.e. COOL joint ! . SLE Arthritis: . Like RA but --------> NO PERMANENT DEFORMITIES. . SEPTIC ARTHRITIS: . H/O of PROSTHETIC joint. . Red, hot, swollen, painful joint with limited range of motion. . ++ WBCs > 50000. . STAPH. AUREUS is the most common causative organism. . Disseminated Gonococcemia: . H/O of recent unprotected sex with a new partner. . A triad of Polyarthralgia + Tenosyvovitis + Vesiculo-pustular skin lesions. . PAGET's disease of bone: . Age > 40 ys. . ++ bone turn over. . ++ OSTEOCLAST ACTIVITY. . Mosaic pattern of lamellar bone. . Enlarged cranial bone --> ++ hat size. . Entrapment of 8th cranial nerve --> Deafness. . X-ray --> Femoral bowing. . NORMAL CALCIUM & PHOSPHOROUS LEVELS. . ++ ALKALINE PHOSPHATASE LEVEL. . NEUROGENIC ARTHROPATHY = CHARCOT's JOINT: . Due to DIABETIC NEUROPATHY. . H/O of DM is the key word. . -- pain, proprioception & temperature. . caused by D.M., peripheral nerve damage, syringomyelia & B12 deficiency. . X-ray ---> Loss of cartilage, osteophytes formation & loose bodies. . Tx: ttt the cause & special shoes ! . GOUT X-ray ---> PUNCHED OUT EROSIONS + Overhanging rim of cortical bone.

Dr. Wael Tawfic Mohamed