_content rheumatology核心内容风湿病学课件

Core ContentCore Content RheumatologyRheumatology Lauren CooperLauren Cooper 1/26/051/26/05 “Id bet my next paycheck that “Id bet my next paycheck that this is some rheumatologic this is some rheumatologic funniness.”funniness.” Lauren Cooper Lauren Cooper 1/26/051/26/05 ChaptersChapters n n 1. Neck pain1. Neck pain n n 2. Thoracic and lumbar pain syndromes2. Thoracic and lumbar pain syndromes n n 3. Shoulder pain3. Shoulder pain n n 4. Emergencies in systemic rheumatic diseases4. Emergencies in systemic rheumatic diseases n n 5. Hand infections5. Hand infections n n 6. Acute disorders of the joints and bursae6. Acute disorders of the joints and bursae n n 7. Soft tissue problems of the foot7. Soft tissue problems of the foot A pain in the neckA pain in the neck Anatomic considerationsAnatomic considerations n n cervical disks less likely than lumbar disks cervical disks less likely than lumbar disks to prolapseto prolapse n n more mobilemore mobile n n less axial loadless axial load n n nucleus pulposus is more anterior and nucleus pulposus is more anterior and reinforced posteriorly along entire width by reinforced posteriorly along entire width by posterior longitudinal ligamentposterior longitudinal ligament Anatomic considerationsAnatomic considerations n n eight paired cervical rootseight paired cervical roots n n exit intervertebral foramina between superior exit intervertebral foramina between superior and inferior pediclesand inferior pedicles n n unlike other vertebrae, in many cases the unlike other vertebrae, in many cases the ventral and dorsal roots are separate at the ventral and dorsal roots are separate at the neural foraminaneural foramina n n therefore, osteophytes or herniated disks may therefore, osteophytes or herniated disks may cause isolated motor or sensory complaintscause isolated motor or sensory complaints DermatomesDermatomes Disk spaceDisk spacePainPainSensorySensoryMotorMotorReflexReflex C1-C2C1-C2Neck, scalpNeck, scalpScalpScalp C4-C5C4-C5Neck, shoulder, Neck, shoulder, upper armupper arm Shoulder, Shoulder, thumbthumb Deltoid, bicepsDeltoid, bicepsBicepsBiceps C5-C6C5-C6Neck, shoulder, Neck, shoulder, scapula, scapula, forearm, thumbforearm, thumb Thumb and 2Thumb and 2nd nd finger, lateral finger, lateral forearmforearm Deltoid, biceps, Deltoid, biceps, pronator, wrist pronator, wrist ext.ext. Biceps and Biceps and brachioradialisbrachioradialis C6-C7C6-C7Neck, posterior Neck, posterior arm, chest, arm, chest, middle fingermiddle finger Middle finger, Middle finger, forearmforearm Triceps, Triceps, pronator terespronator teres tricepstriceps C7-C8C7-C8Neck, posterior Neck, posterior arm, medial arm, medial hand, 4hand, 4th th is neurogenic claudication; therefore, may be indistinguishable from therefore, may be indistinguishable from vascular insufficiency without CT/MRIvascular insufficiency without CT/MRI SacroiliitisSacroiliitis n n pain may be referred to inguinal region, pain may be referred to inguinal region, anterolateral or posterior thigh, or lower anterolateral or posterior thigh, or lower abdomenabdomen n n usually worse at night, with prolonged usually worse at night, with prolonged sitting or standingsitting or standing n n weakness/stiffness in the a.m.weakness/stiffness in the a.m. n n may be associated with new-onset may be associated with new-onset rheumatoid spondylitisrheumatoid spondylitis RadiculopathyRadiculopathy 95% of disk herniations occur at L4-L5 or L5-S195% of disk herniations occur at L4-L5 or L5-S1 L5 compromiseL5 compromiseS1 compromiseS1 compromise Anterior tibial pain, like “shin Anterior tibial pain, like “shin splints”splints” Calf pain, like thrombophlebitisCalf pain, like thrombophlebitis Parasthesia of great toeParasthesia of great toeParasthesia of little toeParasthesia of little toe Reproduced by palpation of Reproduced by palpation of peroneal nerve at fibular headperoneal nerve at fibular head Reproduced by palpation of tibial Reproduced by palpation of tibial nerve in tarsal tunnelnerve in tarsal tunnel Red flagsRed flags FractureFractureTumorTumorCauda Cauda equinaequina Spinal Spinal infectioninfection Major traumaMajor traumaAge 50 or 50 or 3)Polyarthritis (3) n n RARA n n SLESLE n n chronic OAchronic OA n n viral viral Synovial fluid examSynovial fluid exam NormalNormalNoninflamNoninflam matorymatory Inflam-Inflam- matorymatory SepticSeptic WBC/uLWBC/uL 50,00050,000 %PMNs%PMNs 50505050 CultureCulture negativenegativenegativenegativenegativenegative50% 50% positive; 25-positive; 25- 50 in 50 in gonococcalgonococcal CrystalsCrystals nonenonenonenoneMultiple or Multiple or nonenone nonenone Organisms in septic arthritisOrganisms in septic arthritis PatientPatientOrganismOrganism Neonates and infantsNeonates and infantsStaph, Gram neg, GBS, CandidaStaph, Gram neg, GBS, Candida Children 5 yearsChildren 5 yearsStaph,Staph, H. flu H. flu Older children and healthy adultsOlder children and healthy adultsStaph, Strep, GonococcusStaph, Strep, Gonococcus footfootStaph, PseudomonasStaph, Pseudomonas IVDAIVDAStaph, Gram negStaph, Gram neg Sickle-cellSickle-cellSalmonellaSalmonella Other causes of painOther causes of pain n n goutgout n n pseudogoutpseudogout n n Lyme diseaseLyme disease n n rheumatoid arthritisrheumatoid arthritis n n osteoarthritisosteoarthritis n n Reiters syndrome- reactive arthritis preceeded by Reiters syndrome- reactive arthritis preceeded by urethritis or infectious diarrheaurethritis or infectious diarrhea n n ankylosing spondylitis- spine (bamboo spine) and ankylosing spondylitis- spine (bamboo spine) and sacroiliitissacroiliitis n n olecranon and prepatellar bursitis- aspirate, as they may olecranon and prepatellar bursitis- aspirate, as they may be septicbe septic Last chapter: soft tissue problems Last chapter: soft tissue problems of the footof the foot n n calluses become cornscalluses become corns n n plantar warts are plantar warts are caused by HPVcaused by HPV Tinea pedisTinea pedis n n Trichophyton rubrum, Micosporum, Trichophyton rubrum, Micosporum, CandidaCandida, and saprophytic fungi responsible, and saprophytic fungi responsible n n Wash your feet.Wash your feet. n n Dry your feet.Dry your feet. n n Change your socks.Change your socks. n n Use topical (2-3 weeks) or oral (1 week) Use topical (2-3 weeks) or oral (1 week) antifungals.antifungals. More foot problemsMore foot problems n n plantar fasciitis- plantar fasciitis- inflammation of inflammation of plantar aponeurosis. plantar aponeurosis. Rest, ice, NSAIDs, Rest, ice, NSAIDs, heel and arch heel and arch supports.supports. n n tarsal tunnel tarsal tunnel syndrome- posterior syndrome- posterior tibial nerve inferior to tibial nerve inferior to the medial malleolusthe medial malleolus n n 72 year-old woman with a history of polymyalgia 72 year-old woman with a history of polymyalgia rheumatica (PMR) complains of persistant low grade rheumatica (PMR) complains of persistant low grade fever, poor appetite, weight loss and a piercing fever, poor appetite, weight loss and a piercing headache at night. A head CT and spinal tap are normal. headache at night. A head CT and spinal tap are normal. Which of the following procedures would most likely Which of the following procedures would most likely reveal this patients diagnosis?reveal this patients diagnosis? n n A. A dialated fundoscopic examinationA. A dialated fundoscopic examination n n B. CT scan of her head with intravenous contrastB. CT scan of her head with intravenous contrast n n C. MRI of her headC. MRI of her head n n D. Temporal artery biopsyD. Temporal artery biopsy n n E. Muscle biopsyE. Muscle biopsy n n A 19-year old presents to the ED with a chief complaint of pain in A 19-year old presents to the ED with a chief complaint of pain in his knees and a rash. His vital signs are: BP, 120/70; P, 96; T, 38.4 his knees and a rash. His vital signs are: BP, 120/70; P, 96; T, 38.4 C (101.2F). Physical exam reveals diffuse lymphadenopathy and a C (101.2F). Physical exam reveals diffuse lymphadenopathy and a maculopapular rash over his trunk. For the past nine days he has maculopapular rash over his trunk. For the past nine days he has been taking penicillin for a streptococcal pharyngitis. He has no risk been taking penicillin for a streptococcal pharyngitis. He has no risk factors for HIV infection, has a single sexual partner and always factors for HIV infection, has a single sexual partner and always uses condoms. Which of the following is his most likely diagnosis?uses condoms. Which of the following is his most likely diagnosis? n n A. Penicillin resistant streptococcal pharyngitisA. Penicillin resistant streptococcal pharyngitis n n B. Serum sicknessB. Serum sickness n n C. Viral syndromeC. Viral syndrome n n D. Rheumatic feverD. Rheumatic fever n n E. GonorrheaE. Gonorrhea n n The diagnosis of acute rheumatic fever can be made on The diagnosis of acute rheumatic fever can be made on finding which of the following set of signs or symptoms:finding which of the following set of signs or symptoms: n n A. Prolonged PR interval, fever and positive throat A. Prolonged PR interval, fever and positive throat culture for group A streptococcusculture for group A streptococcus n n B. Carditis, chorea and feverB. Carditis, chorea and fever n n C. Subcutaneous nodules, fever and positive ASO titerC. Subcutaneous nodules, fever and positive ASO titer n n D. Elevated ESR, fever and positive throat culture for D. Elevated ESR, fever and positive throat culture for group A streptococcusgroup A streptococcus n n E. Prolonged PR interval, fever, elevated ESR and E. Prolonged PR interval, fever, elevated ESR and positive ASO titerpositive ASO titer n n A 10 year-old boy awakes with right knee and A 10 year-old boy awakes with right knee and ankle pain. On examination in the ED he has a ankle pain. On examination in the ED he has a low grade fever and minimally swollen joints. low grade fever and minimally swollen joints. Which of the following test would be of least Which of the following test would be of least importance in diagnosing this patients illness?importance in diagnosing this patients illness? n n A. An echocardiogramA. An echocardiogram n n B. Erythrocyte sedimentation rate (ESR)B. Erythrocyte sedimentation rate (ESR) n n C. Knee x-rayC. Knee x-ray n n D. Anti-strepolysin O (ASO) titerD. Anti-strepolysin O (ASO) titer n n E. Throat cultureE. Throat culture n n An African-American female of child-bearing age An African-American female of child-bearing age presents with fever, joint pain, and a malar rash which is presents with fever, joint pain, and a malar rash which is exacerbated by exposure to light. The patient is noted to exacerbated by exposure to light. The patient is noted to have proteinuria on urine analysis. What potential have proteinuria on urine analysis. What potential complications are associated with this syndrome?complications are associated with this syndrome? n n A. Renal failureA. Renal failure n n B. SeizuresB. Seizures n n C. Hemolytic anemiaC. Hemolytic anemia n n D. ThrombocytpeniaD. Thrombocytpenia n n E. All of the aboveE. All of the above n n Which of the following matches are incorrect?Which of the following matches are incorrect? n n A. DeQuervains Tenosynovitis - Finkelstein testA. DeQuervains Tenosynovitis - Finkelstein test n n B. Calcific tendonitis - flexor carpi ulnaris B. Calcific tendonitis - flexor carpi ulnaris tendontendon n n C. Tenosynovitis of the extensor pollicis longus - C. Tenosynovitis of the extensor pollicis longus - pain over Listers tuberclepain over Listers tubercle n n D. DeQuervains Tenosynovitis - flexor pollicus D. DeQuervains Tenosynovitis - flexor pollicus brevisbrevis n n The presenting symptoms of de Quervains syndrome The presenting symptoms of de Quervains syndrome are:are: n n A. Pain with flexion of the iliotibial bandA. Pain with flexion of the iliotibial band n n B. Pain in the ulnar aspect of the wrist exacerbated wit