RheumRheumRheum
Polymyalgia rheumatica is closely associated with this other rheumatologic disease
Giant cell (Temporal) arteritis
Usu women >50, s/s of unilateral headache where you can feel/see pulsing of temporal artery, monocular visual loss, possible jaw claudication
VOCAB: Amaurosis fugax (transient vision loss)
How do we dx and tx?
A 50yoF comes to your office for lower back pain s/p slipping on her stairs 3 days ago. What important system must you specifically ask about in your ROS to support or contradict a dx of cauda equina syndrome?
GU!
Often presents with urinary retention (can also see incontinence later from overflow), saddle anesthesia, and/or decreased rectal tone, loss of DTRs.
Not always from trauma, malignancy, herniated disc (MCC), epidural abscess, hematoma
Confirm with MRI/CT myelogram, will need emergent surgery.
"If you get thrown off your horse from a loose saddle and hurt your back, you will NOT be peeing like a race horse"
State why it is important to treat a trauma pt with tenderness over their anatomical snuffbox even if imaging is normal.
Possibility of a scaphoid fracture (could be an occult fracture), if this injury is untreated it could lead to avascular necrosis.
Usu d/t a FOOSH.
Tx: Thumb spica splint. Where is your scaphoid??
A 13yo male with a weight in the 99th percentile presents for R hip pain x 3 weeks. On exam his hip is externally rotated. He has not been able to walk on it today and is tearful on exam. Name the likeliest finding on xray.
Slipped capital femoral epiphysis
Xray shows "scoop of ice cream slipping of the cone," femoral head/epiphysis is displaced from the femoral neck
Tx: non-weight bearing until surgery. Risk for avascular necrosis of the hip, don't want to miss this dx!
BUZZWORD: Klein's line
DON'T CONFUSE WITH LEGG-CALVE-PERTHES (idiopathic avascular osteonecrosis of femoral head)!
AKA "Legs Can't Perfuse," younger ages (4-8), almost always unilateral, usually self-limiting.
Neer and Hawkins Tests: what are they for and how are they performed?
Rotator cuff impingement
Hawkins Kennedy Test: Stabilize shoulder, flex elbow to 90 degrees, internally rotate shoulder to elicit pain
Neer test: Fully pronate arm and have pt flex while shoulder is held down to prevent shrugging
Describe the possible cause of fibromyalgia. Describe the tx plan.
An idiopathic, chronic condition that causes widespread muscle pain, extreme tenderness, lower pain threshold, "fibro fog," and sleep disturbances. Believed to be d/t a problem with pain signals from nociceptors
Low levels of serotonin (which usu helps inhibit pain signals), high levels of substance P and nerve growth factor. Together = hypersensitivity to pain.
Tx: Low-impact aerobic exercise (swimming, fast walking, biking), relaxation techniques, sleep hygiene. Meds like amitriptyline, SNRIs, anticonvulsants (pregabalin, gabapentin slow nerve impulses & help sleep), can also help.
Which maneuver tends to exacerbate the pain of a herniated disc but does NOT increase the pain of lumbar spinal stenosis?
Valsalva maneuver.
LSS: Narrowing of spinal canal causing impingement of nerve roots. MCC degenerative arthritis or spondylolysis esp if >60. MCC of spinal surgery in this age group.
PE: Back pain, numbness, and paresthesias that radiate to buttocks and thighs bilaterally. Typically no GU concerns. RELIEVED WITH FLEXION (shopping cart sign).
A 24yoM comes in for left shoulder pain after falling while snowboarding. On PE external rotation of the shoulder against resistance causes him to yelp in pain. Which muscle(s) of the rotator cuff have likely been compromised?
Infraspinatus and teres minor
Abduction: Supraspinatus
Internal rotation: Subscapularis
A 14-day-old female is brought to clinic for a wellness appointment. Her parents are nervous as she is their first child. Baby was in a breech presentation, but was delivered vaginally with no complications. Name and describe the two maneuvers you will use to assess her hips.
Developmental dysplasia of the hips
Barlow maneuver: gentle adduction without downward pressure to feel for dislocatability, resulting in a "click", "clunk" or "jerk".
Barlow breaks
Ortolani maneuver: abduction and elevation to feel for reducibility, resulting in a "click", "clunk" or "jerk".
Confirm with ULTRASOUND (why?)
Tx: Pavlik harness
Adams test: what is it for and how is it performed?
Adams forward bend test: most sensitive physical finding for scoliosis
Thoracic or lumbar prominence seen on one side with a forward bend.
Pt stands up straight with their hands at their sides, then they bend forward at a 90 degree angle with their arms hanging down as though trying to touch their toes.
A 55yo female comes in for progressive shoulder and hip pain. She has a hard time getting out of bed in the morning and brushing her hair. How can you determine if the cause is polymyalgia rheumatica or polymyositis?
B/C both cause muscle and joint pain in similar areas, in women, in similar age groups!
A few ways
-Women a little younger (30-50) for polymyositis
MyoSITIS = muscle inflammation/breakdown, so elevated CK and DEC muscle strength
MyALGIA = muscle pain, not necessarily breakdown, normal CK and muscle strength
-Autoantibodies: Anti Jo-1 (myositis-specific antibody often associated with interstitial lung fibrosis and "mechanic hands" - hyperkeratotic palms with a dirty appearance)
- Anti-signal recognition protein (most specific for polymyositis), ANA.
A six-month-old male presents to the pediatrician for a well-child visit. The patient’s mother is concerned about the patient’s vision because he often turns his head to the right. On physical exam, the patient’s head is turned to the right and tilted to the left. He has no ocular abnormalities and is able to focus on his mother from across the room. What is the tx for the likeliest dx?
Torticollis
Treatment: For most, daily stretching and PT. May also need botulinum toxin, diazepam/muscle relaxers, surgery
85-90% of congenital torticollis are resolved with conservative treatment
A patient falls onto their wrist. What information about the position of their wrist during their fall could help you determine if they have a Colles vs Smith fracture? How would the xrays differ?
Colles: Fall on extended wrist, x-ray shows a dorsally displaced/angulated fx of the distal radius, "dinner fork deformity"
Smith's: Fall on flexed wrist, x-ray reveals a volar displacement and angulation of the distal radius "garden spade" deformity
BOTH have pain/swelling over volar aspect of wrist
TX: Closed reduction with sugar tong splint/cast initially, if comminuted or unstable then open reduction & internal fixation
A 15yoM comes in for leg pain during basketball practice. It has been ongoing all season. The pain is below his knees, and he denies any trauma. The patient has tenderness to palpation of his anterior proximal tibias. What is the xray most likely to show, and how will you treat this condition?
Osgood-Schlatter disease, xray typically benign (though possible to see small avulsions).
Tx: RICE, NSAIDS, limit activities, increase quadricep stretching.
Tenderness of tibial tuberosities, usu self-limiting but can take 1-2 years to totally resolve.
Phalen's and Tinel's: what are they for and how are they performed?
Carpal tunnel (can also do Tinel's for cubital tunnel). Which nerves are you testing?
Phalen's: reproduction of symptoms with wrist
hyperflexion for 30-60 seconds
Tinel's: reproduction of symptoms with percussion
over the carpal tunnel
Tx: Volar splint, NSAIDS
An 83-year-old Caucasian women with a BMI of 20 comes to the hospital for back pain. An x-ray reveals a vertebral body compression fracture. She is on a tea-and-toast diet, is a never smoker, and has a history of long-term corticosteroid use. Which test would be definitive for diagnosing this patient? What are her RF?
Osteoporosis: Dual-energy X-ray absorptiometry scan (DEXA scan for bone density). DEXA scan < -2.5 is definitive for osteoporosis. Osteopenia is a DEXA scan between -1 to -2.5.
RF: Age, low BMI, low calcium and Vitamin D, long-term steroid use
A 45yoF presents for sudden onset back pain while killin' it at her CrossFit class yesterday. She says the pain radiates down the back of her right leg all the way to her ankle. The pain is worse when she walks or coughs. Which special test on physical exam would support the likeliest dx?
Positive straight leg test AKA Straight leg raise. Pos if it evokes radiating pain along the sciatic nerve and below the knee (when hip b/w 30-70 degrees flexion). Pain can be anterior/lateral/posterior.
Herniated disc pulposus, usually in the L4-L5 or L5-S1 area.
Radiculopathy: disease of nerve root (pinched nerve, tumor). Herniated disc is the MCC of nerve root compression.
To Dx: Need MRI
A 12yoF presents with forearm pain after getting hit by a softball during her first day at the batting cages. On PE the pt has point tenderness on the proximal aspect of the ulna, and she also has wrist drop. Which is the likeliest dx, and why would she have wrist drop?
Monteggia fracture.
Fx of the proximal ulnar shaft WITH radial head dislocation (can cause radial nerve injury), usu caused by a direct blow.
How does this compare to a Galeazzi fx?
-Mid to distal radial shaft fx with ulnar dislocation, usu from FOOSH
Tx for both: Usu open reduction & internal fixation (ORIF), can do temp sugar tong splint (elbow/wrists/forearms)
GRUsome Gun MURder
If a pt presents with knee pain and states they heard/felt a "pop" with the injury, what is towards the top of your differentials?
Often a sign of a meniscus tear or a loose piece of cartilage within the joint, but can also be MCL, ACL.
BUT for your exams, probably ACL.
PCL and LCL uncommon.
Finkelstein's test: what is it for and how is it performed?
De Quervain tenosynovitis, inflammation of extensor pollicis brevis and abductor pollicis longus
First dorsal compartment pain with ulnar deviation of wrist while the thumb is flexed in the palm or pain with thumb extension.
Tx: Thumb spica splint, NSAIDs
A 50yo male comes to clinic for what he is sure is “the flu.” He has a low-grade fever, generalized malaise, and muscle weakness. His only medical hx is of chronic Hepatitis B. His vitals are WNL except for a BP of 143/94. On PE you see a vascular rash on his foot and leg that gives off a starburst-like appearance. Given the likeliest dx, which answer pairs the correct size blood vessels with the system least likely to be affected?
Medium-sized vessels, renal system
Large-sized vessels, GI system
Small-sized vessels, central nervous system
Medium-sized vessels, pulmonary system
#1 - Polyarteritis Nodosa (PAN), Medium vessel vasculitis
MC in males 40-50 that affects medium-sized vessels, usu affecting kidneys (htn from renal artery stenosis), CNS (peroneal nerve aka foot drop), and GI (abdo pain worse with eating) vessels.
Malaise, fever, sore throat, joint and muscle aches and pains
PE will show tender lumps under the skin, especially on the thighs and lower legs. Palpable purpura.
Labs will show ↑ ESR, ANCA negative
Diagnosis is confirmed by biopsy that shows necrotizing arteritis or by arteriography
Treatment is steroids.
BUZZ WORDS: Rosary sign, “starburst” livedo (from livedo reticularis rash)
A Cobb angle greater than ______ is consistent with scoliosis.
10 degrees.
Surgical correction considered if >40 degree Cobb angle. MRI if above this angle, or if pt has an atypical left thoracic curve (how could you tell on PE?).
Scoliosis: lateral curvature ("S" or "C" shaped)
Kyphosis: Thoracic spine curved forward (Hunchback)
Lordosis: Lumbar spine curves forward
A babysitter comes to the ED with a 3yo. She had been swinging her by her wrist when the girl began crying. She refused to move her right arm complaining that it hurt. In the emergency room, the girl is holding her right arm in a flexed, pronated, and adducted position. There is no crepitus, swelling, or point tenderness along the entire right arm or clavicle. What is the next step in management of this patient?
Relocate the radial head for Nursemaid's elbow/radial head subluxation. NO IMAGING REQUIRED FIRST.
How?
Hyperpronation: apply pressure to radial head while hyperpronating
Supination-flexion: supinate and fully flex elbow while applying pressure to radial head and pulling with gentle traction
Name the 6 P's of compartment syndrome. If the delta pressure (diastolic BP - direct pressure/measured compartment pressure) is >30 mm Hg, what is the appropriate tx?
Paresthesias, pallor, pulselessness, poikilothermia,
paralysis, and pain out of proportion to exam.
Tx: Emergent fasciotomy.
McMurray test: what is it for and how is it performed?
Meniscal Tears
Positive McMurray sign: pop, pain, or click/snap/thud when the knee is flexed and then externally rotated and extended with valgus stress applied (you are trying to recreate the twisting MOI).
If you have a positive McMurray's test, which is the best diagnostic imaging?