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Red Flags of MSK Pain (4)
- 1. Fever, acute joint pain, swelling (infection)
- 2. Pseudoparalysis in single limb (infection)
- 3. Bone pain, esp at night (malignancy)
- 4. Stiffness after immobility (athropathy)
What is the hallmark of inflammatory pain?
Stiffness after immobilization
Discuss the projection of autoimmune disorders.
- Dynamic, symptoms emerge over time
- Diagnosis can take months to years
What is the non-specific term describing painful disorder affecting the loco-motor system including joints, muscles, connective tissue?
- (Rheumatic fever--> affecting heart valves)
Define STEP WaR for MSK.
- S: Swelling--> effusion, soft tissue induration
- T: Tenderness- focal bony, allodynia
- E: Erythema
- P: Pain in motion- try to recreate symptoms
- Wa: Warmth
- R: Range of motion- passive vs active
What are 3 key findings of rheumatic issue?
- 1. Limb-length inequality (accelerated on side of inflammation)
- 2. Muscle atropy adjacent of affected joints
- 3. Bone overgrowth (2nd to hyperemia)
Differenciating Causes of Limb Pain.
-Arthritis of rheumatic fever
- Orthopedic- associated w/ ⇑ activity
- Reactive arthritis - preceded by virus
- Monoarticular- hip or LE
- Bacterial- acute, monoarticular, fever, leukocytosis,⇑ ESR
- Arthritis of rheumatic fever- migratory, transient
Differenciate orthopedic cause of limb pain.
Associated with increased activity, not major trauma
Differenciate reactive arthritides cause of limb pain.
Preceded by viral infection, strep, purpuric rash
Differenciate Monoarticular arthritis cause of pain.
Pain in the hip or lower extremity (consider labs, xray, LDH, bone marrow aspiration)
Differnciate bacterial arthritis cause of limb pain.
Acute Monoarticular (x H flu & gonorrhea( fever, leukocytosis, increased ESR, joint aspiration
Differenciate Arthritis of rheumatic fever causing limb pain.
migratory, transient, more painful than JRA, rare < 5yo, look for rheumatic carditis, evidence of recent strep
Differenciate Lyme arthritis cause of limb pain.
resembles pauciarticular JRA, consider Ab to Borrelia Burgdorferi
What does a positive ANA mean?
Non-specific for auto-antibody
Which is a more normal titer?
1:80 or 1: 1280
1: 1280 because it means its still positive even when more diluted
What are 3 major patterns of presentation of JRA (Juvenile Rheumatoid Arthritis)?
- 1. Acute febrile form
- 2. Polyarticular pattern
- 3. Pauciarticular disease
Describe the Acute febrile form of JRA.
-Fever, evanescent (comes/goes) salmon-pink macular rash, arthritis, hepatospenomegaly, leukocytosis, polyserositis
Symptoms of Polyarticular pattern of JRA.
- -Resembles adult dx, chronic pain/swelling of small or large joings
- -Fever systemic features (iritis possible!)
- -+RF in older children, usually - in younger
Symptoms of Pauciarticular disease of JRA.
- -Chronic arthritis of a FEW joints (often wt bearing)
- -Systemic symp uncommon
- -Extra-articular involvement
- -Inflammation of eye! (30% have insidious, aysmptomatic iritis)
If a patient with pauciarticular dx of JRA, when should ophthalmologic exams performed for + ANA versus - ANA
- + ANA--> q 3mo
- - ANA --> q 6mo
T or F. There is a single diagnostic test for RA.
False (+RF only in 15%)
T or F. ANA is + most of the time in pauciarticular with iridocyclitis
When should you consider joint aspiration?
Red, hot, swollen joint
What are some non-drug txts for JRA?
- -vision services
- -Dental care
- -Emotional support
What is the primary txt for JRA?
NSAIDS & Aspirin
What are secondary txts for JRA?
T or F. In articular forms, 85% diminish gradually and stop by puberty.
True (but can have residual symps/joint damage)
What population is spondyloarthropathy often seen?
Boys > 10yo
Spondyloarthropy is associated with what extremity, give examples.
- -Associated w/ tendonitis of tibial tubercle and heel (helps differ from JRA)
- -Low back pain/sacroilitis--> specific for this arthritis
Spondyloarthropathy is 80% positive for:
T or F. Autoantibodies often seen with spondyloarthropathy.
False: but ESR/CRP may be elevated
What is txt for spondyloarthropathy (tendinitis)?
Enteropathic arthritis includes what 4 diseases?
- 1. Reiter syndrome
- 2. Reactive arthritis
- 3. Arthritis of inflammatory bowel disease
- 4. Celiac disease
What symptoms may distinguish Enteropathic arthritis?
-LE arthritis w/ preceding/concurrent GI symp
(With enteropathic arthritis) IBD associated manifestations include: (4)
iritis, stomatitis, hepatitis, & erythema nodosum
KNOW: erythema nodosum is associated with:
- - They are big raised, red nodules on leg
What is the basic patho of SLE?
-Deposition of immune complexes in the tissue
How does tissue damage occur with SLE?
- 1. Tissue specific antibodies
- 2. Lymphocytes, neutrophils, and complement "attacks"--> evoked by deposition of antigen-antibody complexes deposited on tissue
What 3 things are need for SLE to occur?
- 1. "stupid" t-cells (can't differenciate self)
- 2. Genes more susceptible to "stupid" T-cells
- 3. Inflammation from infection or trauma
What is the normal age onset for SLE in girls?
T or F. A negative ANA rules out SLE.
What are txt for SLE?
- 1. Tailore to individual organ system
- 2. prednisone, plaquenil (know G6PD), NSAIDS, etc
What organ involvement infers a worse diagnosis of SLE?
What is dermatomyositis?
- -Rare inflammatory disease of muscle and skin
- -Responsive to corticosteroids
- -lasts 1-3 years
What are some symptoms of dermatomyositis?
- -Children can have vascular changes (thrombus)
- -Muscle weakness in pelvis, shoulder
- -Late onset neuro involvement
What is the txt for Dermatomyositis?
TXT: prednisone, MTX, IG, cyclosporine
What is polyarteritis nodosa?
- -Inflammation/vasculitis of med-sized arteries causing decreased BF
- -Varied symps: unexplained fever, conjunctivitis, CNS, cardiac symp
- -Dx: bx
- -Txt: prednisone, immunosuppressants, IVIG
What is scleroderma? (Dx, Txt)
- Normal tissue replaced by scar tissue
- Dx: bx
- Txt: PT, MTX, Vit D
What is the triphasic presentation of Raynaud's phenomenon?
- 1. Cold induced pallor
- 2. Cyanosis
- 3. Hyperemia
What are some txt for Raynauds?
-Hand warming, stress management, Ca channel blockers in winter
What is Henoch-Schonlein-Purpura (HSP)? (3 parts)
- -Vasculitis caused by blood vessel inflammation
- -Affects skin/kidneys
- -Purpura--> nonblanching on buttocks/LE
When is HSP usually seen in the clinic?
Spring time following acute pharyngitis or URI--> triggers immune system
KNOW: What is the txt for HSP?
-Supportive, NSAIDs, steroids, immunosuppression (consult w/ peds/nephro)
What are 3 types of Non-rheumatic pain?
- 1. Reflex Sympathetic Dystrophy (complex regional pain--> often after fracture
- 2. Fibromyalgia--> rare in children, diffuse pain w/out associated swelling, classic trigger points
- 3. Chronic Fatigue Syndrome- fatigue w/ specific onset, low grade fever, lymph nodes, neuropsych (dx of exclusion)