Internal Medicine EOR: Orthopedics and Rheumatology (Smarty PANCE)

What is fibromyalgia?

Chronic widespread pain disorder with central pain amplification - diagnosis of exclusion, no inflammation or tissue damage

What are the diagnostic criteria for fibromyalgia?

Widespread pain (≥3 months) in ≥4 of 5 body regions + fatigue, sleep disturbance, cognitive dysfunction (no tender point exam required)

What are the classic symptoms of fibromyalgia? Use mnemonic FIBERS

Fatigue, Insomnia/sleep disturbance, Brain fog (cognitive issues), Extremity pain (widespread), Restless legs, Stiffness

What laboratory findings are seen in fibromyalgia?

Normal labs - normal ESR, CRP, CBC, ANA (helps exclude other conditions)

What is the first-line pharmacologic treatment for fibromyalgia?

Duloxetine (SNRI), pregabalin/gabapentin, or amitriptyline (tricyclic antidepressant)

What non-pharmacologic treatments are effective for fibromyalgia?

Aerobic exercise (most effective), cognitive behavioral therapy, sleep hygiene, stress reduction, patient education

What is reactive arthritis?

Sterile inflammatory arthritis triggered by distant infection (GI or GU) occurring 1-4 weeks after infection

What is the classic triad of reactive arthritis?

Arthritis (asymmetric oligoarthritis), urethritis, conjunctivitis (can't see, can't pee, can't climb a tree)

What organisms commonly trigger reactive arthritis?

GI: Salmonella, Shigella, Campylobacter, Yersinia; GU: Chlamydia trachomatis (most common in US)

What genetic marker is associated with reactive arthritis?

HLA-B27 positive in 60-80% of patients (but not required for diagnosis)

What are the characteristic features of reactive arthritis?

Asymmetric oligoarthritis (lower extremity), enthesitis, dactylitis, keratoderma blennorrhagicum, circinate balanitis

What is the treatment for reactive arthritis?

NSAIDs first-line, intra-articular corticosteroids, antibiotics if active infection, sulfasalazine or methotrexate for chronic cases

What is gout?

Inflammatory arthritis caused by monosodium urate crystal deposition in joints - associated with hyperuricemia

What is the classic presentation of acute gout?

Sudden onset severe monoarthritis (often nocturnal), most commonly in first metatarsophalangeal joint (podagra), with erythema and swelling

What are the definitive diagnostic findings for gout?

Synovial fluid analysis: negatively birefringent needle-shaped crystals on polarized microscopy, WBC >2000

What medications precipitate gout attacks?

Thiazide diuretics, loop diuretics, low-dose aspirin, cyclosporine, niacin

What is the treatment for acute gout?

NSAIDs (indomethacin), colchicine, or corticosteroids - do NOT start urate-lowering therapy during acute attack

What is the first-line urate-lowering therapy for chronic gout?

Allopurinol (xanthine oxidase inhibitor) - target serum uric acid <6 mg/dL

What is pseudogout (CPPD)?

Calcium pyrophosphate deposition disease causing acute inflammatory arthritis - commonly affects knees and wrists

How is pseudogout differentiated from gout?

Synovial fluid: positively birefringent rhomboid-shaped crystals; X-ray: chondrocalcinosis (cartilage calcification)

What is rheumatoid arthritis?

Chronic systemic autoimmune disease causing symmetric inflammatory polyarthritis with progressive joint destruction

What is the classic joint pattern in rheumatoid arthritis?

Symmetric polyarthritis affecting small joints of hands (MCP, PIP) and feet (MTP) - spares DIP joints

What antibodies are associated with rheumatoid arthritis?

Rheumatoid factor (RF) positive in 70-80%, anti-CCP antibodies (more specific, 95% specificity)

What are the classic deformities in rheumatoid arthritis?

Ulnar deviation, swan neck deformity, boutonniere deformity, Z-thumb deformity

What are the extra-articular manifestations of rheumatoid arthritis?

Rheumatoid nodules, interstitial lung disease, pericarditis, scleritis, Felty syndrome (RA + splenomegaly + neutropenia)

What is the first-line DMARD for rheumatoid arthritis?

Methotrexate - start early to prevent joint damage, monitor LFTs and CBC

What are the treatment goals for rheumatoid arthritis?

Remission or low disease activity, prevent joint destruction, improve quality of life - use treat-to-target approach

What is polyarteritis nodosa?

Systemic necrotizing vasculitis of medium-sized arteries causing multi-organ ischemia - spares lungs

What are the classic manifestations of polyarteritis nodosa? Use mnemonic RENAL

Renal involvement (hypertension, renal insufficiency), Eye (retinal vasculitis), Neurologic (mononeuritis multiplex), Abdominal pain/GI bleeding, Livedo reticularis/skin ulcers

What laboratory findings suggest polyarteritis nodosa?

Elevated ESR/CRP, anemia, leukocytosis, p-ANCA negative (helps differentiate from other vasculitides), hepatitis B association

What imaging finding is classic for polyarteritis nodosa?

Angiography showing microaneurysms and beading of medium-sized arteries

What is the definitive diagnosis of polyarteritis nodosa?

Tissue biopsy showing necrotizing vasculitis of medium-sized arteries

What is the treatment for polyarteritis nodosa?

High-dose corticosteroids + cyclophosphamide for severe disease; treat hepatitis B if present

What is Sjögren's syndrome?

Autoimmune exocrinopathy causing dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia)

What are the hallmark symptoms of Sjögren's syndrome?

Dry eyes (sandy/gritty sensation), dry mouth, parotid gland enlargement, dental caries

What antibodies are diagnostic for Sjögren's syndrome?

Anti-SSA/Ro and anti-SSB/La antibodies - positive in 70-90% of primary Sjögren's

What tests confirm Sjögren's syndrome?

Schirmer test (<5mm wetting in 5 minutes), ocular staining score, salivary gland biopsy showing lymphocytic infiltration

What extra-glandular manifestations occur in Sjögren's?

Arthralgia/arthritis, interstitial lung disease, peripheral neuropathy, renal tubular acidosis, lymphoma risk (increased 40x)

What is the treatment for Sjögren's syndrome?

Artificial tears/saliva, pilocarpine or cevimeline for secretion stimulation, hydroxychloroquine for systemic symptoms

What is polymyalgia rheumatica?

Inflammatory condition causing bilateral shoulder and hip girdle pain/stiffness in patients >50 years old

What are the classic symptoms of polymyalgia rheumatica?

Bilateral shoulder and hip pain/stiffness, morning stiffness >1 hour, constitutional symptoms (fever, fatigue, weight loss)

What laboratory findings are characteristic of polymyalgia rheumatica?

Markedly elevated ESR (often >50, usually >100), elevated CRP, normal or mild anemia - normal CK (differentiates from myositis)

What is the association between polymyalgia rheumatica and giant cell arteritis?

10-20% of PMR patients develop GCA; 40-60% of GCA patients have PMR - screen for GCA symptoms

What is the treatment for polymyalgia rheumatica?

Prednisone 15-20 mg daily with dramatic response within 24-72 hours (if no response, question diagnosis)

What is the typical duration of treatment for polymyalgia rheumatica?

1-2 years with slow taper - monitor ESR/CRP and symptoms during taper

What is systemic lupus erythematosus?

Multisystem autoimmune disease with antibodies against nuclear antigens causing inflammation in multiple organs

What are the classic mucocutaneous manifestations of SLE?

Malar (butterfly) rash, discoid rash, photosensitivity, oral/nasal ulcers, alopecia

What is the most specific antibody for SLE?

Anti-double stranded DNA (anti-dsDNA) - correlates with disease activity and lupus nephritis

What is the most sensitive antibody for SLE?

Antinuclear antibodies (ANA) - positive in >95% of SLE patients, but not specific

What are the hematologic manifestations of SLE?

Anemia (chronic disease or hemolytic), leukopenia, lymphopenia, thrombocytopenia

What are the renal manifestations of lupus?

Lupus nephritis (most common serious complication) - proteinuria, hematuria, nephritic or nephrotic syndrome

What is the treatment for mild SLE?

NSAIDs, hydroxychloroquine (cornerstone of therapy), topical corticosteroids for skin manifestations

What is the treatment for severe SLE (organ-threatening)?

High-dose corticosteroids + immunosuppression (mycophenolate mofetil or cyclophosphamide for lupus nephritis)

What is antiphospholipid syndrome and its association with SLE?

Autoantibodies (anticardiolipin, anti-β2GP1, lupus anticoagulant) causing thrombosis and pregnancy loss - occurs in 30-40% of SLE patients

What monitoring is essential for SLE patients?

Regular urinalysis, complement levels (C3/C4), anti-dsDNA, CBC, renal function - screen for disease flares

What is polymyositis?

Idiopathic inflammatory myopathy causing symmetric proximal muscle weakness without skin manifestations

What is the classic presentation of polymyositis?

Symmetric proximal muscle weakness (difficulty rising from chair, climbing stairs, lifting arms), muscle pain in 25-50%

What laboratory findings are characteristic of polymyositis?

Markedly elevated creatine kinase (CK), elevated aldolase, myoglobinuria, positive anti-Jo-1 antibodies (in 30%)

What are the EMG findings in polymyositis?

Fibrillations, positive sharp waves, myopathic motor unit potentials (short duration, low amplitude, polyphasic)

What is the gold standard for diagnosing polymyositis?

Muscle biopsy showing endomysial inflammation with CD8+ T-cell infiltration

What is the difference between polymyositis and dermatomyositis?

Dermatomyositis has characteristic skin findings: heliotrope rash, Gottron's papules, shawl sign, V-sign

What malignancies are associated with dermatomyositis?

Ovarian, lung, gastric, colorectal, pancreatic cancers - screen adults with new-onset dermatomyositis

What is the treatment for polymyositis/dermatomyositis?

High-dose corticosteroids (prednisone 1 mg/kg/day) + methotrexate or azathioprine as steroid-sparing agents

What is systemic sclerosis (scleroderma)?

Autoimmune connective tissue disease characterized by fibrosis of skin and internal organs plus vasculopathy

What are the two major subtypes of systemic sclerosis?

Limited cutaneous (lcSSc): skin involvement distal to elbows/knees; Diffuse cutaneous (dcSSc): proximal skin involvement

What is CREST syndrome?

Limited systemic sclerosis variant: Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasias

What antibodies are associated with systemic sclerosis subtypes?

Anti-centromere (limited/CREST), Anti-Scl-70/topoisomerase (diffuse, worse prognosis), Anti-RNA polymerase III (diffuse, renal crisis)

What is Raynaud's phenomenon?

Episodic vasospasm causing color changes (white→blue→red) in fingers/toes triggered by cold or stress - almost universal in scleroderma

What are the major organ complications of systemic sclerosis?

Interstitial lung disease (most common cause of death), pulmonary arterial hypertension, scleroderma renal crisis, GI dysmotility

What is scleroderma renal crisis?

Acute hypertensive emergency with renal failure - treat immediately with ACE inhibitors (captopril)

What is the treatment for systemic sclerosis?

No disease-modifying therapy; organ-specific: calcium channel blockers for Raynaud's, ACE inhibitors for renal crisis, immunosuppression for ILD

What screening is essential in systemic sclerosis patients?

Annual pulmonary function tests with DLCO, echocardiogram for PAH, blood pressure monitoring for renal crisis