Clinical medicine textbook, Summaries of Clinical Medicine

Download Clinical medicine textbook and more Summaries Clinical Medicine in PDF only on Docsity! P. Kumar, M. L. Clark, Clinical medicine Shoulder Disorders ● Subacromial Impingement + Rotator Cuff Tears ○ Impingement specific complication is rotator cuff tear which is why you want to tx ○ What muscle/tendon is the MC in both? → supraspinatus ○ Weakness associated with → significant tear/complete tear of a tendon or a neuro compromise ○ Rotator cuff → ongoing pain + older patients + overhead tear + chronic ○ Neers and Hawkins → impingement and rotator cuff ○ Drop Arm Test → Rotator Cuff Tears to indicate partial and/or full tear Subacromial Impingement Rotator Cuff Tears ● MC supraspinatus ○ Bursa inflammation as well ● Impingement if not tx can lead to further complication like Rotator Cuff Tear ● Overuse disorder – think of someone who is constantly having to raise their arm (overhead movement) ● Nocturnal Pain ● Positive NEER + Hawkins Test ● NO WEAKNESS ● Tx: Activity modification, NSAIDs, Physical Therapy ● SITS ○ Supraspinatus (MC) ○ Infraspinatus ○ Teres Minor ○ Subscapularis ● Rotator Cuff Tear can lead to Subacromial Impingement ● Mainly Elderly – because of muscle that is degenerating ● CHRONIC ● Overuse disorder – overhead movement ● Nocturnal Pain ● WEAKNESS w/ resistance for FULL tear ● Positive NEER + Hawkins Test ● Drop Arm Test will help us differentiate from Impingement ● Impingement Lesions/Tears ○ Make sure you are familiar with the difference between three different tears and the MOI 1. SLAP (Superior Labrum from Anterior to Posterior) a. Biceps Tendon Detachment (bc this is where the tendon attaches) b. Think more overuse of the biceps or overuse 2. Bankart Lesion a. This is an anterior inferior labral lesion/tear b. Associated with trauma + anterior shoulder dislocation c. MOI: Usually more traumatic stuff What nerve can be damaged in a humerus shaft fracture? Axillary nerve Radial nerve Median nerve Ulnar nerve Clin Med Quiz Question ● Adhesive Capsulitis ○ What is the other for adhesive capsulitis ■ Frozen shoulder ○ Comorbidities ■ Diabetes and Thyroid disorder ○ MC gender ■ MC women>men ○ MOI: ■ Trauma after chest/breast surgery ■ Prolonged immobilization → can cause adhesion ■ Endocrine disorders ○ Phases ■ Phase I: Inflammatory → Painful ■ Phase II: Freezing + stiffness ■ Phase III: Thawing + patient starts to regain ROM in approx. one year ● Clavicular fractures ○ Middle vs medial ■ Medial is closer to the sternum ■ Middle is middle ■ Middle is MC and the weakest portion of the bone ○ MOI: Trauma/Childbirth (breech) ○ Tx: depending on the level of displacement or any other neurovascular compromise within the area, will they be splinted or need surgical tx ■ Nonoperative: non-displaced, no neurovascular compromise → Sling Which of the following would you expect to find in a patient that fell on an outstretched hand and complains of elbow pain? (pertains to anterior and posterior fat pad assoc. w/ occult fracture) Tenderness of the lateral epicondyle Lightbulb sign Sail sign Tenderness and swelling of the olecranon process Clin Med Quiz Question ■ Operative: open fracture, neurovascular compromise, hemodynamic instability, respiratory compromise → surgery ■ MC ppl will end up being splinted + will have deformities of the clavicle after it healed ○ Complications: Neuro damage → subclavian artery, brachial plexus ● Scapular Winging (not mentioned in review but its on quiz) ○ Medial winging: Long thoracic nerve damage ○ Lateral winging: spinal accessory nerve damage Disorders of the Upper Extremities ● Fat Pads know what they are associated with ○ Overall they are associated with ELBOW fractures ○ Posterior fat pad → Problematic ○ Anterior fat pad → “A - okay” unless it is LARGE ○ Point tenderness helps locate area for imaging ○ It can be called a sail sign! ○ On the vignette look for a pt who has a FOOSH accident, that is unable to have have full extension of elbow ● Elbow fractures are a concern for neurovascular involvement because nevers run both posterior & anteriorly so know what nerves are of concern given specific elbow fractures Fracture Nerve Involvement Other Supracondylar Humerus Fracture Ulnar Nerve Damage MC pediatric elbow patient Brachial Artery Involvement FOOSH Always check neurovascular before & after tx Single Column Condyle Fracture Ulnar nerve Injury Brachial artery & radial injury Adult Fracture 2 types (1 is more stable) Lateral condyle fx MC Complications → DJD, deformity Two Column Distal Humerus Ulnar nerve injury YOU MUST REFER TO ORTHOPEDICS WITH THIS bc of vascular necrosis AVASCULAR NECROSIS…WITH H PATTERN (FREE FRAGMENT) Uses a Jupiter Classification System Olecranon Ulnar nerve Run the risk for injury of the Anterior interosseous nerve ● Know the difference between Olecranon Fractures vs Olecranon Bursitis. Know how to tx septic bursitis ○ X-RAY WILL TELL THEM APART! Olecranon Fracture Olecranon Bursitis Etiology: ● Trauma Sx: ● Limited ROM, will be more “pointy” than Olecranon ● Loss of EXTENSOR mechanism Etiology: - Trauma - INFECTION - Arthritic Sx: ● Similar to Fracture Which of the following conditions would most likely be diagnosed in a 45-year-old male, complaining of elbow pain, who recently resumed playing golf after a 3 month hiatus? Medial epicondylitis Dupuytren’s contracture Boutonniere deformity Lateral epicondylitis Clin Med Quiz Question ● Lateral Epicondylitis vs Medial Epicondylitis Lateral Epicondylitis Medial Epicondylitis AKA Tennis Elbow Tendon rupture at the lateral side, caused by overuse of EXTENSOR tendon ● Repeated pronation & supination EXTENSION tenderness Tx → Conservative, Cortico injects, surgical AKA Golfers Elbow Tendon rupture at the medial side overuse of the FLEXOR tendon Wrist FLEXION makes it worse Tx → Conservative, Cortico injects, surgical ● Presentations of Radial Neuropathy vs Ulnar Neuropathy Radial Neuropathy Ulnar Neuropathy Causes: ● Crutches, during deep sleep/intoxication, anything that affects the radial nerve that runs from the axial to the wrist Sx: ● WRIST DROP (radial nerve palsy) ● Weakness, tingling ● +/- ability to bend wrist Tx: ● Conservative (PT, wrist splinting, etc) ● EMG if extensive Claw-like appearance & some sensory issues ● If your ulnar nerve is damaged, the muscles it controls don't get some or all of the electrical signals that tell them to straighten leading to a claw-like appearance ● Paresthesias Associated with Cubital Tunnel Syndrome ● That’s right – because in cubital tunnel you are compressing the Ulnar Nerve (5th finger and ½ of the 4th aka your pinky and ½ of your ring finger) ● Know dermatomes & their association with the spine & know what nerves will present with dorsiflex, plantar flex, etc. ● Dupuytren’s Contractures – know the comorbidities associated with it & the patho Dupuytren’s Contractures Patho: ● Benign proliferative disorder characterized by decreased hand function caused by hand contractures & painful fascial nodules. Eventually will have CORD like presentation that will cause contracture of the fingers Associated with… ● Tobacco use ● Alcohol use ● Diabetes ● Epilepsy ● Chronic pulmonary disease ● Tuberculosis ● HIV/AIDS No associated occupational risk Sx: ● MC 4th and 5th digit on the palmar side ● Limits ROM ● CORDLIKE thickening ● Decreased extension of fingers → eventually permanent flexion of the affected finger ● Colles Fracture vs Smith Fracture ○ Both are distal wrist (radial) fractures Colles Fracture Smith Fracture DORSALLY displaced extra articular fracture ● It is above the joint ● Distal radius fracture is going up, dorsally dislocated (dorsal means back of hand + moving up) Volar angulation of fracture ● displacement of the distal radius fragment (opposite of colles) ○ Going down MOI: FOOSH MOI: Fall onto a Flexed Wrist (NOT FOOSH) Also called Fork Fracture Tx: ● ORIF Tx: ● Splint & ORIF, Surgery ● Know general splinting. In class she gave the example of boxer fracture Fracture Splinting Other Hamate Fracture ulnar gutter for 6 weeks Golfers & baseball batters Metacarpal Fractures AKA Boxer’s Fracture Hairline → Ulnar gutter splint Look for a pt that says they have punched/hit something/hit a clenched wrist Skier’s OR Gamekeeper’s Thumb Partial tear → Thumb spica Vingette: look for someone who has a reduce ability to pinch/grasp MOI: forceful thumb hyperextension or hyperabducition Boutonneiere Deformity Splint PIP joint in full extension x 6 weeks PIP (proximal phalanges) flexion and DIP (distal) extension Mallet Finger Extension splinting 6-8 weeks x 24 hours (!) Extensor tendon injury Long finger MC MOI: sudden forced flexion of extended fingertip Can’t extend DIP (!) Distal Radius Fractures Sugar-Tong (most secure) Radial gutter (hairline & nondisplaced ) Volar splint (for something minor) ● Treatment for dog bite vs human bites: ○ Note it is the same tx for both Dog Bites Human Bites 1st line ● Augmentin (amoxicillin/clavulanate) 2nd line (if cellulitis) ● ampicillin and sulbactam (IV) Determine if you need rabies vaccination Delayed treatment may require I & D 1st line ● Augmentin (amoxicillin/clavulanate) 2nd line (if cellulitis) ● ampicillin and sulbactam (IV) ● Compartment Syndrome know the causes & what we do for it ● What is it: Increased pressure within a closed space in the body (a compartment) causes decreased blood flow and can result in tissue damage. It usually occurs in the limbs after traumas and fractures, which causes swelling and bleeding within the compartment. ○ Causes: ■ Bleeding inside the compartment ■ Penetrating wounds (IV drug use) ■ Long bone fractures – tibia or forearm ■ Surgical procedures that injure blood vessels ■ Swelling of the tissue after severe burns ■ Reperfusion injury ■ Limb compression ● Crush injury or an inappropriately placed cast ○ Sx: 6 Ps → PAIN (MC), paresthesia, pulselessness, pallor, poikilothermia, paralysis ○ What do we do for it: (IMPORTANT TO TX BC CAN LEAD TO NECROSIS) ■ Surgical ● Fasciotomy: where the fascia is cut open, relieving the pressure and reestablishing blood flow ■ If compartment ● Removal of the cast will result in spontaneous recovery and surgery may not even be needed ● Note: she emphasized on cast* Hip Disorders ● Hip disorders divide them into ages & know what Barlow & Ortolani Maneuver are in relation to Disorder Information Developmental Hip Dysplasia socket or acetabulum – and the femoral head are misaligned, resulting in an unstable hip joint. present at birth In Vignette look for baby that was born in a breech position Dx: ● Barlow Maneuver ● Ortolani Maneuver Tx: ● Pavlik harness Legg-Calve-Perthes Disease For some children, the blood supply to the femoral head becomes interrupted for some reason - and it’s not known why exactly. ● The result is that the tissue begins to die off - a process called avascular necrosis Children 5-8 yrs old MC in males Sx: ● Painless limp Dx: X-ray → Show flatten, misshappen femoral head Tx → can self resolve Slipped Capital Femoral Epiphysis Adolescent growth plate is weak and can slip off Risk factors: OBESITY, hypothyroidism 12 years in girls 13.5 years in boys MC in males Sx: ● Painful limp Dx: ● Pelvic x-ray ○ Taken from frog-leg lateral view Tx → SURGERY is GOLD STANDARD compress the trochanteric bursa against the greater trochanter resulting in inflammation ○ Dx: Based on clinical symptoms such as ■ Chronic pain in the lateral thigh ■ Point tenderness over the greater trochanter ■ Pain can also be elicited by manually resisting abduction of the thigh while the person is lying on the unaffected side ○ Tx: Conservative → lifestyle modification, NSAIDs, glucocorticoid injections Knee Disorders ● Know all tests to determine ○ ACL ■ Lachman Test (!) ● Done by flexing the knee to 30 degrees and stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand, all to produce anterior translation of the tibia ● An intact ACL should limit anterior translation and have a distinctive endpoint ● With ACL injury, there is an increased translation compared with the uninjured knee and a vague endpoint ● LAChman = ALC is in the first letters ■ Anterior Drawer Test ● The individual is supine and the knee flexed at 90 degrees with the foot flat on the bed. With the foot flat and secured to the table, the examiner grasps the leg around the calf with the thumbs placed on the tibial tuberosity and attempts to translate the tibia anteriorly. ● The test is positive if there is laxity or excess anterior translation of the tibia compared to the contralateral side. ○ PCL ■ Posterior Drawer Test (!) There is a “drawer” on the the “dashboard” ● With the foot flat and secured to the table, the examiner grasps the leg around the calf with the thumbs placed on the tibial tuberosity and attempts to translate the tibia posteriorly. The test is positive if there is laxity or excess posterior translation of the tibia compared to the contralateral side. ■ Posterior Sag Sign ● If you place the leg at 90 degrees and look at the knee from a lateral view, it is a positive sag sign when the tibia sags below the level of the uninjured side. ○ MCL ■ Valgus stress test ● The individual will lie on their back with the knee slightly ○ LCL flexed. One hand is positioned on the lateral surface of the knee placing gentle inward pressure, and the other hand placed around the medial ankle applying lateral force in order to crease a valgus stress on the knee, opening up the medial compartment ● If the medial compartment widens and has increased laxity, it is indicative of medial collateral ligament damage as the ligament provides medial knee stability ■ Using varus stress tests ● Having the individual lie on their back with the knee slightly flexed. One hand is position on the medial surface of the knee placing gentle outward pressure, and the other hand placed on the lateral ankle applying medial force in order to create a varus stress on the knee opening up the lateral compartment ● If the lateral compartment widens and has increased laxity, this is indicative of lateral collateral ligament damage as the ligament provides lateral knee stability ○ Medial and Lateral Meniscus Injury ■ Thessaly test ● done with the individual and examiner facing each other, holding hands for support. The individual then stands on the affected leg with the knee flexed to 20 degrees while trying to internally and externally rotate the body. The test is positive if it causes pain or a locking sensation. ■ McMurray test MC ● Involves repeated passive flexion and extension of the knee while simultaneously putting the lower leg and foot into internal or external rotation and pushing upwards on the lower leg to stimulate a loading force. The test is positive if they have palpable locking or clicking, which may be accompanied by pain and crepitus. ○ Will not be given description just the name of the tests UNHappy triad (lateral / medial meniscus) ■ Makes more sense to me lateral Unhappy Triad or Terrible Triad Commonly tested injury pattern on the knee; multistructure injury comprising the: MOI Anterior cruciate ligament (ACL) Medial collateral ligament (MCL) Medial meniscus ● Different types of bursitis ○ May help with differential Types: ● Prepatellar bursitis (housemaids knee) ○ Results from friction between the skin and the patella ○ Presents with pain, erythema, bogginess over the patella ○ Seen in individuals who frequently kneel – gardening or plumbing ● Superficial infrapatellar bursitis ○ Affects the subcutaneous infrapatellar bursa (clergyman’s knee) ○ Results from friction between the skin and patellar ligament ○ Presents with pain and tenderness over the distal patellar ligament ● Deep infrapatellar bursitis ○ Affects the deep infrapatellar bursa and can result from friction between the patellar ligament and the tibial tuberosity ○ Both superficial and deep infrapatellar bursitis can occur when kneeling with a more erect back, such as roofers who don't wear knee pads, or priests praying ● Suprapatellar bursitis ○ Inflammation of the suprapatellar bursa, which extends from deep beneath the quadriceps muscle to beneath the patella ○ Its positioning makes it vulnerable to superficial bacterial infections if there is injury or abrasions to the overlying skin ○ Clinical features include suprapatellar pain and selling, redness, warmth, and a reduced range of motion of the knee ● Pes anserine bursitis ○ The PAB lies just below the medial joint line and reduces friction for the tendons of the sartorius gracilis, and semitendinosus muscles ○ The condition is usually caused by repetitive use, and presents with localized medial knee pain over the pes anserinus ○ MC in those with osteoarthritis or diabetes ● When to x-ray patients ○ Pain persists and can't bear weight ■ X-ray them ○ Tibial Plafond fractures ■ SERIOUS injuries → unstable, non-bearing injuries & NEED surgery. CAN’T MISS THIS BC IT WON’T BE HIDDEN ● inability to bear weight ○ Lateral / medial- can bear weight ○ Point tenderness= x-ray ○ She emphasized to pay attention to the malleolus tenderness (ankle)* ○ NOTE: Anterior talofibular ligament: ATFL (most common) ligament affected Think “always tears first” ● Stress fractures: ○ Clinical Presentation: ■ Insidious onset of pain (pts show up comfortable but they continue to abuse the area that was fractured) ■ Common in athletes & females (hormonal role) → repeated injury ■ Recent change in training ■ Amenorrhea, eating disorders ■ X-ray will show thickening rather than a fracture ■ She mentioned that you can’t identify stress fractures unless you touch the patient – you have to get your hands on them ■ Ex ● Misty Copeland – ballerina that had 6 fractures and continued to perform ■ Example from her: ● People with demanding jobs on their feet ● Look at fractures that are severe ○ Calcaneus, lisfranc, talus ○ May have images Lisfranc Injury Navicular & Cuboid Fractures Calcaneus Fracture Talus Fracture Forced dorsiflexion with high energy Function → Maintains arch of the foot X-ray → widening of the space (!) High energy with compression of medial column Axial load Repetitive use (stress fracture from repetitive use) energy injuries Avulsions Fall from height, MVA (high impact injury) Significant soft tissue injury Deformity → heel shortened, widened, & varus Talus neck fracture is MC location High energy injury, forced dorsiflexion with axial load Fleck sign (cram the pance) X-ray: may be difficult to see and are often missed (initial) CT or MRI better at identifying the fracture Tibial Plafond Fractures SERIOUS injuries → unstable, non-bearing injuries & NEED surgery. CAN’T MISS THIS BC IT WON’T BE HIDDEN Causes: High axial load ((jumping from building straight to feet, MVA) Sx: SEVERE ankle pain, deformity, inability to weightbear. ANKLE MOTION LIMITED/ ABSENT TX → OPERATIVE INTERVENTION Jones Fractures It is a type of Metatarsal fracture of the 5th metatarsal Jones has “5” letters means its the 5th metatarsal ○ Occurs in watershed region of vascular (poor blood supply) ■ Slow healing time & greater risk of nonunion ○ High risk of refracture with non-operative treatment ○ High level of non-union ● Spine Spine Disorders ○ Dermatomal distribution + strength testing ● Cauda Equina ○ What is Cauda Equina? Overview: Gout is a monoarticular inflammatory disease where monosodium urate crystals cause joint damage. Prof B. said its either bc lack of secretion or overproduction of uric acid Risk Factors: excess uric acid, or hyperuricemia, and it can be caused by many things. Obesity and DM male sex Hypertension dyslipidemia alcohol use. Medications→ Hydrochlorothiazide (case patient) Causes: First is underexcretion of uric acid by the kidney, which can be idiopathic Gout - high yield in red applied here, please refer to SG for more:) ● Osteomyelitis = septic joint ○ Pathology and Causes: ● Bacterial infection ○ Stap. aureus MC ○ salmonella (MC in patients with sickle cell disease) ○ Pasteurella Multocida ■ From cat or dog bite ○ M. tuberculosis ■ Bone, bone marrow inflammation Acute Chronic Acute Osteomyelitis Comes to a resolution + the immune system will destroy all bacteria If the lesion is not extensive then osteoblasts + osteoclasts will repair the damage over a period of weeks Sx: pain at the site of the infection, fevers, may affect the use of the bone PPP: acute hematogenous spread is MC in kids Chronic Osteomyelitis Lasts months-years and bone can become necrotic Sx: Prolonged fevers, weight loss – chronic inflammation PPP: sinus tract drainage (!) Sequestrum (!) (segments of necrotic bone formation that surrounds necrotic bone) Involucrum (new periosteal bone formation that surrounds necrotic bone ● Gout → ○ Classic presentation ○ Know things that can cause it (diet & meds) ○ Diagnostics … what would show up on their joint aspiration Sx: ○ when the cause is not known; due to renal failure ○ or it can be exacerbated by medication, like thiazide diuretics and aspirin. ● Second is overproduction of purines. ○ This can occur with increased consumption of purine-rich foods such as shellfish, anchovies, and red meat. ● Chronic gout can eventually lead to permanent deposits of urate crystals, called tophi, which form along the bones just beneath the skin. She said on a test: Pt could say it is the worst pain of there like so much that the patient won't want a sheet on top of the affected area ● Symptoms of gout are high-yield and frequently tested, and they depend on which joint is affected and if the presentation is acute or chronic. ● usually symmetrical ○ affects the first metatarsal joint of the foot ○ or the base of the big toe ○ but the joints of the ankles, knees, wrists, and elbows can be involved too. ○ When it involves the big toe, this condition is called podagra. ○ Classically, in an acute gout attack, individuals feel sudden pain over the affected joint that’s so severe ■ it even wakes them up from sleep feeling like their big toe is on fire. ○ People describe this pain as the worst they ever had but, fortunately, the pain generally lessens over time. ● it is an inflammatory process, the affected joint is also swollen, warm, and red. ● Occasionally, a gout attack triggers a systemic inflammatory response manifesting with ○ Fever ○ leukocytosis ○ elevated sedimentation rates ○ elevated C-reactive protein, or CRP. Triggers: ● acute attacks tend to occur after a ○ large meal (with foods rich in purines) & alcohol consumption ○ Trauma ○ Surgery ○ Dehydration ○ Diuresis. ● They can also be triggered by alcohol consumption ○ Alcohol metabolites compete for the same excretion sites in the kidney as uric acid, causing decreased uric acid excretion. Dx: ● elevated serum urate levels ● synovial fluid analysis. ○ Synovial fluid analysis is when synovial fluid is extracted with a syringe from the affected joint, and then analyzed on a microscope for increased white blood cell count with a neutrophil dominance, and the presence of monosodium urate crystals. ● A high yield fact is that on a microscope, under polarized light, monosodium urate crystals can be both inside and outside the cells, have a sharp, needle-like form, and are negatively birefringent. ○ Negative birefringence means they are yellow under parallel light, and blue ○ Epidemiology: ● The most common non-gonococcal organisms are Staphylococci (S. Aureus) MC (40%) Streptococci – 2nd MC (28%) gram-negative bacilli (19%) Less common are MC pathogen for septic arthritis under perpendicular light. Tx: Treatment of gout is also high yield. ● First-line treatment in a gout attack is ○ nonsteroidal anti-inflammatory medications, or NSAIDs, ● Second-line medication includes ○ Colchicine. ○ Keep in mind that colchicine is not preferred over NSAIDs due to its side effects, which include nausea, abdominal pain, and diarrhea. ○ It should also be avoided in the elderly or those with renal dysfunction. ● For chronic tx it is Allopurinol (can cause SJS) Prevention: ● he most high yield medications include ○ xanthine oxidase inhibitors like allopurinol and febuxostat, which decrease uric acid production by inhibiting xanthine oxidase. Someone ‘urinates’ (urate involvement) and the pee touches their ‘toe’ (toe involvement) and has to ‘get out’(kinda sounds like gout) of public cuz they are embarrassed Calcium pyrophosphate deposition disease or CPPD (previously known as pseudogout) Dx: ● definitive diagnosis requires synovial fluid analysis. ○ CPPD crystals might not be as evident as monosodium urate crystals ■ They are weakly positively birefringent under polarized light, which means they have the opposite pattern seen in gout; they are blue under parallel light and yellow under perpendicular light. ○ They also have a rhomboid or rod-shaped appearance and can be seen either in or outside the cell. ○ In addition, because CPPD disease and gout can coexist, monosodium crystals might be observed as well. ● Polymyositis , Dermat, Fibromyalgia — not on the chart ○ Know which one is related to Giant Cell, jaw pain, vision issues ○ What has heliotrope rash, Gottron’s papules ○ Know which one has Anti-Jo & Anti-Mi Polymyositis Dermatomyositis Fibromyalgia Polymyalgia Rheumatica Inflammation in & around the muscles → attacking occurs repeatedly which can involve different muscle groups progressive and bilateral weakness and muscle wasting Weakness usually develops slowly Neck flexors affected Neck pain and weakness Similar sxs like polymyositis but in this disease can cause derm conditions Heliotrope rash (purple rash on the eyelids), also on the back, shoulder kind of resembling a shawl Malar rash (butterfly shaped rash) under the eyes, onto the nose and cheeks Gottron’s papules (rashes that are raised and scaly on the PIP, MCP, DCP) worsen when exposed to sunlight widespread muscle pain and tenderness in various parts of the body MC in women 20-50 y.o But no actual damage to the muscles or joints CK will NOT be elevated b/c there is not muscle damage affects the JOINTS NOT THE MUSCLES Giant Cell Arteritis - Jaw pain - Vision problems - Headaches Muscles are not inflamed or weakened but there is muscular pain that results from damage to the structures surrounding joints. Referred pain. Paul B carried the big ax around all day so his shoulders hurt, but Paul is a giant so he Dysphagia or difficulty swallowing Diaphragm/intercosta l muscles weakened Difficulty breathing Anti Jo & Anti Mi (photosensitive), pruritus, painful Shawl sign Mechanic hands (skin will have oil like appearance because of the dark appearance) Anti Jo & Anti Mi is STRONG (no muscle weakness) but he is stiff from working out High ESR & CRP – inflammatory markers Muscle enzymes are normal which distinguish it from other disorders (CK normal b/c no muscle damage) Poly Nadosa — know all the framing questions: ○ micro - don't spend time on this but know that it spares the lungs! ● What sized arteries are affected in Polyarteritis nodosa? ○ A necrotizing arteritis of medium-sized vessels ● What organs are typically affected and spared in polyarteritis nodosa? ○ has a predilection for involving the skin, peripheral nerves, mesenteric vessels (including renal arteries), heart, GI tract, and brain but spares the lungs ● Which viral illness can cause polyarteritis nodosa? ○ Approximately 10% of cases are caused by hepatitis B; most cases of hepatitis B–associated disease occur within 6 months of onset of hepatitis B infection ● What is the typical dermatologic manifestation of polyarteritis nodosa? ○ Livedo racemosa (reddish-blue to purple skin), subcutaneous nodules, and skin ulcers reflect involvement of deeper, medium-sized blood vessels ○ Digital gangrene is common ● Name some symptoms of polyarteritis nodosa. ○ Fever, malaise, weight loss, and other symptoms develop over weeks to months ○ Pain in the extremities ○ Vasculitic neuropathy ● What lab values are typically elevated in polyarteritis nodosa? ○ Acute phase reactants (ESR, CRP) are often (but not always) strikingly elevated ○ Patients are ANCA-negative ○ Rheumatoid factor or antinuclear antibodies may be present in low titers ○ Tests for active hepatitis B infection (HBsAg, HBeAg, hepatitis B viral load) should be performed ○ Requires confirmation with either a tissue biopsy or an angiogram Viohypogastrie n. Cluneal nn. Genitofemoral n, ioinguinal n. Posterior femoral ‘cutaneous n, Lateral femoral ‘cutaneous n. Obturator n: ‘Anterior cutaneous ‘branches of femoral n. at Common peroneal (Seatien) Ulnar nerve Radial nerve