..............................................................

:




: : :
:
k2 revision

peripheral joints axial joint extra
articular manifestations
Peripheral joints rheumatoid
axial joint ankylosing
spondylitis
extra articular sites & SLE
vasculitis
peripheral joints
Peripheral jonits
swelling pain limitation of movement
axial joints wt about cervical and lumbar movement
limitation pain
extra articular sites cardiology
chest pain Pericarditis dyspnea
heart involved
chest dyspnea lung
branch interstitial lung disease dyspnea
1


..............................................................
wheezy chest vasculitits chronic
cough Interstitial lung disease
lymph node swelling skin rash eye
Kidney hyper tension nephrotic

gait inspection
deformity , swelling , overlying skin
Movement palpation
movement crepitus axial joints
Other systems heart murmur
pericardial rub Lung Intersitial lung disease
crepition

3 gait
comment inspection back
scilosis deformitiy
curvature of the verteberal column
Lumbar movement
joints tempro mandibular joint
examination
Metacarpal and meta tarsal squeeze
Internal rotation hip joint
ballon sign thigh squeeze
thigh effusion in knee joint
patella patella
patella

knee
swelling redness
limitation crepitation
very common Knee effusion
2


..............................................................
ballon sign thigh
patella

lab
rheumatoid factor rheumatoid factor Ig M
Ig G
rheumatoid disease
IgM Ig G
IgM Ig G
complement immune complex synovial
consumption
membrane
complement synovial fluid plasma

complement
low complement in serum systemic lupus with
activity vasculitis glomerulonephritis
membrano proliferative glomerulonephritits
serum

Low complement

rheumatoid Low complement in serum

Low complement in synovial fluid

to detect rheumatoid latex rose

waaler test latex sensitive rose waaler
specific

positive rheumatoid factor

3


..............................................................
rheumatoid
rheumatoid disease rheumatoid factor negative
lupus
poly myositis

infection endocarditis
hepatitis C virus C
rheumatoid factor positive rheumatoid
disease
rheumatoid factor rheumatoid disease
criteria
) ( positive rheumatoid
factor rheumatoid disease
criteria ESR C-reactive protein
Morning stiffness
rheumatoid

rheumatoid disease
rheumatoid factor positive
rheumatoid factor written
& short account on ESR C- Reactive protein
rheumatoid factor ,serum uric acid
written

( ANA (antinuclear antibody self antigen

antibody nuclear protein
nuclear protein


..............................................................
ANA positive specific criteria
Lupus ANA Positive
manifestations
ANA positive lupus
causes ANA
causes ANA pattern
speckled slides

ANA positive

Causes of ANA positive

lupus scleroderma poly myositis
rheumatoid ANA lupoid
hepatitis auto immune hepatitis
titre ANA
normal titre positive
significant ANA positive
low titre

specific antibody ANA ANA anti

body nuclear protein certain
protein nucleus

Anti double strand ANA positive lupus

vasculitis
vasculitis rheumatoid factor negative ANA
negative
vasculitis


..............................................................
vasculitis ANA positive
vasculitis lupus vasculitis
vasculitis Primary vasculitis
Poly arteritis nedosa ANCA
ANA rheumatoid factor Positive

Anti double strand DNA positive lupus

Anti DNA positive activity
Lupus ANA positive Anti DNA
negative activity

anti histone antibody Positive drug

induced lupus anti hypertensive
cardiology lupus
drug induced lupus

Anti smith anti body Lupus

Anti SCL 70 anti body

scleroderma

Ro La lupus Ro La
Anti Ro and La particles
lupus positive ANA
Anti DNA positive confirm
Lupus ANA negative
Lupus lupus %5
Anti Ro and anti La
6


..............................................................

CREST syndrome Antibody to centromere

anti mitochondrial other antibody

primary biliary cirrhosis antibody

auto immune Antismooth muscle Antibodies

primary biliary cirrhosis hepatitis

anti parietal cells anti thyroid antibody

anti Glomerulo islet cells antibody antibody
anti anti adrenal anti body basement membrane
platelet antibody

( ANCA (anti neutrophil cytoplasmic antibodies

positive C-ANCA ANCA
P-ANCA wegener's granulomatosis
Churg- ANCA C & P ANCA
strsuss disease

C-Reactive CRP hematology

CRP protein
almost positive Inflammatory
CRP
infection lupus CRP lupus
negative positive CRP

CRP
7


..............................................................
cardiology positive C-Reactive protein risk factor
coronary heart disease

CRP very high
very high
infection, chronic inflammatory process
atherosclerosis atherosclerosis
inflammatory condition associated CRP
CRP positive associated
coronary heart disease atherosclerosis

examples lupus
systemic lupus written
lupus long case

lupus, rheumatoid and gout

lupus

female 9:1

etiology defect in lymphocyte

T-lymphocyte B- lymphocyte
T-helper T-suppressor
T-suppressor T-helper
triggering B-lymphocyte
antibodies
antibodies self antigens


..............................................................


programmed cell death
GIT apoptosis
apoptosis accelerate apoptosis

triggering
apoptosis skin process of
apoptosis
Intracellular content antigens
intra cellular sequestered
deep layers apoptosis
antigens circulate cells cell
surface immune system trigger
against cells antigens
apoptosis , , lupus

triggering of the immune system

400

Some contributing factors

drug induced lupus MCQ
Lupus phenytoin
drug induced lupus Lupus
brain kidney
lupus kidney
Involved
Lupus kidney Normal
Lupus


..............................................................
ANA positive Anti DNA never
positive Anti histone anti body positive

clinical picture rheumatology

clinical picture investigation

lupus rheumatoid
full dose gradual with
drawl Low dose maintenance
chemotherapy
clinical pictures
Male female
Fever of un known origin fever of unknown
etiology collagen disease rheumatology
Musculoskeletal arthralgia
arthritis MCQ lupus arthritis
arthralgia
lupus arthropathy deformity erosive
arthropathy
tendons Ligaments

deformity
articular cartilage )Jaccoud's
(arthropathy rheumatic
fever 15 term post chronic rheumatic
arthritis rheumatic fever
lupus lupus carditis arthritis fever

chronic rheumatic arthritis rheumatic fever
Lupus 15
10


..............................................................

Butterfly rash discoid

rash discoid rash scalp
alopecia
photosensitivity Purpuric eruption Purpura
lupus platelets vasculitis
Purpuric eruption raised
egdes vasculitis without raised edges
related to platelets
alopecia Lichen plannus like Like
lichen plannus
Urticaria lupus immune
system
lupus Infection
chemotherapy urticaria
auto immune

red eye conjunctivitis

retinal vasculitis

heart pan carditis

lupus 15 rheumatic fever
pancarditis pericarditis , myocarditis and
endocarditis endocarditis libman
sacks endocarditis
Libman sacks endocarditis
aortic regurge or mitral regurge very mild

pancarditis systemic lupus

11


..............................................................
lupus lupus nephritis
glomerulonephritis lupus itself
.... kidney
.. Proteinuria kidney
Lupus nephritis kidney

GIT mesenteric vasculitis acute

abdomen mesenteric
occlusion emergency serositis
Peritonitis

lung Lung pleurisy

Interstitial lung disease lupus
lupus vascular occlusion
Lupus vascular occlusion
Vasculitis Anti phospho lipid syndrome Anti
phospho lipid syndrome syndrome
vascular occlusion lupus
repeated abortion Lupus
lupus anti phospho lipid
vascular occlusion blood supply placenta
Infarcts placenta intra uterine
fetal death abortion

Lupus 30 history of repeated

abortion anti phospho lipid antibody
blood
shrinking lung syndrome
lung vascular occlusion vascular
occlusion lupus vasculitis anti phospho
12


..............................................................
lipid syndrome Lung infract , infract ,infract
Lung
lung diaphragm
myopathy diaphragm
myopathy in diaphragm bilateral
elevated copula lung
infraction shrinking lung syndrome

Neuro psychiatric vasculitis vascular

occlusion cerebral infraction stroke
female young stroke
Lupus
chorea
pancarditis chorea fever Overlap
rheumatic fever rheumatic
fever recent strepto coccal infection
criteria
criteria rheumatic fever recent
strepto coccal infection category lupus

psychosis lupus




subside
sulpride

13


..............................................................
irritable colon


intestine stress
Motility
anti psychotic
....

Blood
Auto immune thrombocytopenia hemolytic anemia
Auto immune hemolytic anemia
positive comb's test

pregnancy lupus
lupus motile lupus liable to
repeated abortion anti phospho lipid syndrome
renal insufficiency

Lupus Lupus nephritis

aggravating pregnancy

some-times congenital heart disease

criteria Lupus criteria

rheumatic fever
11

lupus

Butterfly rash
Discoid rash
14


..............................................................
Photosensitivity
Oral ulcers Painless
Arthropathy
Serositis
Renal involvement proteinuria
Proteinuria significant
proteinuria
proteinuria significant 500

hematology lympho penia MCQ

lupus lympho penia
hemolysis
immunological
neurological
ANA
Anti DNA, Anti phospholipid antibody

criteria

Proteinuria ANA positive
Proteinuria ANA positive female young
Lupus butterfly

lab anemia of chronic disease
chronic disease chronic infection
chronic inflammatory
15


..............................................................
chronic disease
chronic infection chronic inflammation
interleukin 1 defect bone marrow
chronic disease Normocytic
normochromic anemia
thrombocytopenia ESR disease
activity CRP normal Low

Infection
gamma globulin Non specific
C3&C4 are consumed during disease activity
activity
low C3 & C4 positive Anti DNA
Anti smith Anti Ro , La
Ro , la ANA negative
kidney function


lupus
infection disease activity blood pictures
blood pictures Patient with
lupus Lucocytosis
Luecocytosis
blood pictures neutrophilia
neutrophils lymphocyte esinophils

Infection neutrophilia toxic
granulation toxic granulation
toxic granulation sign neutrophils
16


..............................................................
neutrophils organisms
Organisms neutrophils
cytoplasm neutrophils
toxic granulation
neutrophilia neutrophilia without toxic
granulation neutrophilia
Infection
infection
toxic granulation CBC
infection

CRP

sequences of investigations to diagnose

SLE
ANA Positive confirm Anti DNA
ANA negative lupus %5 ANA
Positive %95 negative Anti Ro , la
subset

)
immune system excited () androgen
immune system ( stabilized
auto immune disorder auto
immune disease malignancy

estrogen
lupus
17


..............................................................
Beta Blocker anti hypertensive

contraindicated
Beta blocker
Beta blocker Beta blocker
vasodilator Ca channel blocker
protein uria
Beta blocker

Beta blocker fatal mistake
Beta blocker contraindicated

Reyenoud
lupus

:

prednisolone
prednisolone
prednisolone
Dexamethasone prednisolone
anti inflammatory steroid side
effects
Dexamethasone myopathy
oestoprosis

hydro cortisone hydro

cortisone
18


..............................................................
applied pharmacology
pharmaco-therpay




Prednisolone 60 12

Prednisolone side effects
osteoprosis myopathy
hydro cortisone


Prednisolone

full dose
full dose 60 60
80
60
... ...

C3& C4 ANA
ESR ...
gradual withdrawal gradual withdrawal
titration

19


..............................................................
60 12
psychotic 12

20
titration

low dose maintenance maintenance 10

maintenance

immune suppressive





.... .... steroid sparing
Azathioprine
30 prednisolone
azathioprine Prednisolone
cushoniod

20


..............................................................
cyclophosphamide azathioprine
cyclophosphamide azathioprine steroid
sparing potentiate Endoxan
cyclophosphamide respond
azathioprine
cyclophosphamide
alopecia Infertility
two patient
Lupus vasculitis
lupus vasculitis
cyclophosphamide
cyclophosphamide toxicity

cyclosporine


pulse steroid therapy
lupus optic neuritis
multiple sclerosis vasculitis
nephrology glomerulonephritis cresentic
glomerulonephritis rapidly progressive
glomerulonephritis pulse steroid therapy

Pulse steroid methyl prednisolone

prednisolone methyl prednisolone
methyl prednisolone 500

pulse 1000


21


..............................................................

pulse steroid therapy

blood sugar
pulse steroid therapy
socially protected
pulse steroid therapy immune

Polymyositis
inflammatory myopathy

weakness bilateral symmetrical proximal
distal myopathy neuro
dystrophy
dystrophy
acquired inflammatory myopathy
poly myositis dermato myositis

primary idiopathic poly myositis
Primary idiopathic dermato myositis
malignancy malignancy

poly myositis
Myopathy myopathy
para malignant

22


..............................................................
bronchogenic carcinoma old
male bronchogenic carcinoma
weakness bilateral symmetrical para
malignant poly myositis
clinical pictures
proximal distal

proximal weak distal weak
muscular dystrophy neuro

reflexes hypo tonia , hypo reflexia
reflexes Preserved hypo reflexia

Heliotope rash

Heliotope rash
joint
heart myopathy myocarditis

skeletal striated upper third of the
esophagus striated muscle fibers upper third
esophagus lower two thirds
dysphagia dysphagia
dysphagia dysphagia

upper dysphagia lower dysphagia
round
dysphagia dysphagia
lesion
poly myositis
23


..............................................................
cancer
esophagus alchalsia

dysphagia
esophagus

investigations
(Electromyography (EMG
Muscle biopsy

biopsy normal
biopsy biopsy guided MRI
MRI biopsy
EMG
ESR ESR
normal
(creatine kinase (CK
CK
poly myositis Myocardial infraction
rhabdomyolsis CK Creatine
kinase myocardial infraction
)(MB fraction
rhabdomyolsis poly myositis NN
fraction skeletal muscle

24


..............................................................
skeletal crush syndrome

full dose gradual withdrawal Low
maintenance
azathioprine steroid sparing
potentiate steroid

Vasculitides
vasculitis written
medium sized vasculitis Medium sized
vasculitis small vessl vasculitis

vasculitis
pathology vasculitis antigen
anti body immune complex Immune
complex Immune mediated inflammation
immune complex wall blood vessels
wall of blood vessels lumen narrowing
vasculitis vascular occlusion

fragility of blood vessels

vasculitis ....
vascular occlusion
vasculitis poly arteritis nodosa

25


..............................................................
vasculitis
circulating immune complex CIC CIC
Immune complex disease
vasculitis Lupus CIC
CIC antigen and anti body
CIC
complement consumed
antigen Hepatitis B antigen

related to poly arteritis nodosa

clinical pictures
rheumatology
vascular occlusion blood vessel
blood vessel Medium sized
arcute kidney renal ischemia hyper tension

lung vasculitis lung infiltrate
interstitial Lung pleurisy
skin lesions palpable purpura purpuric
eruption with raised edges
livedo reticularis

vasculitis MCQ
vasculitis coronary myocardial infraction

vasculitis brain stroke

stroke young person
26


..............................................................
mesenteric occlusion
heart kidney , lung brain
poly arteritis nodosa
poly arteritis nodosa
vascultitis medium sized blood vessel
brain , heart ,kidney
ESR
vasculitits ESR complement
surface antigen liver % 30

vasculitis vasculitis
cortisone cyclophosphamide
sever cases of lupus sever
cases of vasculitis cyclophosphamide
pulse steroid therapy + pulse Endoxan
cyclophosphamide
pulse steroid therapy as before followed by
oral pulse full dose
gradual withdrawal low dose maintenance
Endoxan pulse )
( Intravenous

cyclophosphamide


pulse steroid Pulse Endoxan
Endoxan pulse less side effects
Enoxan oral day
endoxan oral
27


..............................................................
pulse

esinophilia poly arteritis

nodosa
poly arteritis nodosa Churg strauss
vasculitis poly arteritis nodosa
broncho spasm , eosinophilia,
glomerulonephritis ANCA Positive
good response

Giant cells arteritis

giant cells arteritis


temporal artery tender
carotid system ) (
.......... branches external
carotid Internal carotid
temporal tenderness

vasculitis high ESR ESR
steroid responding
clinical pictures unilateral temporal
visual disturbances blindness
jaw claudication claudication jaw

Jaw fatigue
spasm ischemia claudication Lower limb

28


..............................................................
claudication arm
claudication
ESR temporal artery biopsy

Wegner's granuloma
Wegner's granuloma
epistaxis rhinitis , sinusitis
cough , hemoptysis
key hemoptysis renal impairment

good pasture syndrome
frank hemoptysis
hemoptysis hematemesis ESR
renal impairment good pasture
syndrome Wegener's granuloma pulse
steroid therapy renal biopsy
pulse steroid


pulse steroid therapy 72

creatine normal chest
alveolar hemorrhage alveoli )
(
ANCA positive

Wegener's granuloma
glomerulonephritis
29


..............................................................
glomerulonephritis
nephrotic
overloaded Oliguria
hypertensive

pulmonary edema


ESR ANCA positive Pulse steroid
therapy Endoxan
Wegener's granuloma granuloma Lung

granuloma Lung .T.B
sarcodiosis Wegener's granuloma

Takayasu's disease
pulseless disease arch of aorta
branches arch sub clavian artery

claudication
claudication
claudication
lower limb Low
cardiac output
atherosclerosis

lower limb

30


..............................................................
upper limb arm claudication
vascultits Takayasu's disease
jaw claudication Giant cell arteritis
claudication
pseudo claudication lower limb
) ( non ischemic lumbar canal
stenosis lumbar segment
canal spinal cord lumbar canal
spinal cord Lumbar
canal stenosis
claudication
ischemic manifestation

Kawasaki disease

Kawasaki
Kawasaki
bilateral conjunctival congestion


coronary vasculitis
cervical lymph node enlarged
arthropathy
sequences
presented with fever of unknown etiology

ankle

31


..............................................................
rheumatic fever rheumatic
fever
rheumatoid still's disease

Kawasaki's disease
you will aggravate
the coronary heart disease accelerate the infraction

ECHO ECHO,ECHO
coronary
Kawasaki
coronary
coronary early

coronary heart
disease
Kawasaki's disease

)
(
vasculitis ...... Kawasaki's
disease

(Poly myalgia rheumatica (PMR

32


..............................................................

tender deltoid tender
...... .....
non steroidal response
ESR
....
Giant cell arteritis

written
discuss myopathies myopathies
neurology
poly myalgia rheumatica
Inflammatory myopathy
poly myositis dermato myositis


Myopathies
endocrinal myopathies
drugs myopathies

myopathy ) (

dystrophy neuro

Hyper sensitivity vasculitis

33


..............................................................
Henoch-Schonlein purpura serum sickness

Henoch-Schonlein purpura high level of Ig A
complement normal

treatment of hypersensitivity vasculitis

self limiting steroid

cryoglobulinaemic vasculitis

under graduates cryoglobulinaemic
vasculitis
cryoglobulinaemic assessment serum
cryoglobulin
.......... cryoglobulin
positive
Positive systemic complications
vasculitis glomerulonephritis
vasculitits glomerulonephritis
immune complex disease
creatnine
renal biopsy membrano proliferative
vasculitis
glomerulonephritis therapy
cryoglobulin
antibody invitro
cryo
34


..............................................................
cryoglobulin vasculitis glomerulonephritis

cryoglobulin plasmapharesis

(Scleroderma (systemic sclerosis

clinical case , problem solving
scleroderma pathology
endothelial damage endothelin
vasoconstriction
cytokines Transforming Growth Factors
platelets derived growth factors fibrous
tissue deposits wall blood vessels

blood vessel function vasoconstriction
endothelin antagonist
antihypertensive
Organic scleroderma sclerosis
fibrous tissue collagen derma
systemic sclerosis systemic
derma
fibrous tissue cytokines
fibrous tissue fibrobalst platelets
fibro balst growth factor platelets derived growth
factor fibrous tissue
fibrous tissue wall blood vessels

35


..............................................................
ischemia Organs
vasculitis

Fibrotic features fibro balst collagen

skin Internal organs heart lung GIT

clinical pictures
Skin changes
Initially skin oedematous non pitting
edema inflammatory
skin very tight
Later on skin ulceration calcinosis
calcinosis collagen fibers

chest expansion skin
skin
Raynaud's phenomenon
Raynaud's pallor cyanosis rebound
vasodilation

Raynaud's disease Raynaud's phenomenon

Raynaud's phenomenon
rheumatoid lupus poly myositis
Raynaud's disease Raynaud's disease

GIT dysphagia reflux

36


..............................................................
motility decrease Intestine
motility small intestine
bacterial flora bacterial over growth
bacteria in small intestine colon
enzymes small intestine
mal absorption bile salts digestion
cardiomyopathy heart
interstitial lung disease Lung
narrowing in poly arteritis nodosa kidney
narrowing scleroderma arcute artery
malignant sever ischemia inter lobular artery
hypertension

Investigations
Anti-Scl 70
micro angiopathic haemolytic anemia
blood blood vessels RBCs
blood RBCs collagen vessel wall
wall blood vessels wall vessels
micro angiopathic
RBCs
diseased RBCs hemolytic anemia
term blood vessels
diseased blood mechanical hemolysis of RBCs
vessels

penicilliamine skin soften

Ca channel blockers Raynaud's
37


..............................................................
effective
domperidone dysphagia
symptomatic
essential for hypertension ACE inhibitors

renin renal ischemia hypertension

angiotensin
Endothelin receptor antagonist

CREST syndrome
scleroderma variant CREST syndrome
scleroderma subset
CREST
calcinosis C
E ......Esophageal dysfunction
R .......Raynaud's phenomenon
S......Sclerodactly
T.......Telangectasia
scleroderma CREST
there is minimal visceral involvement
scleroderma more systemic disease scleroderma
.kidney , esophagus , heart , lung .etc
esophagus CREST
minimal visceral Raynaud's
involvement
anti centromere anti body positive
positive Anti Scl 70
38


..............................................................

Mixed connective tissue disease

Scleroderma lupus Myositis mix


features of
Arthritis
Raynaud's phenomenon
Esophageal dys-motility

kidney
collagen diseases
mixed connective tissue renal involvement
diseases

Raynaud's arthropathy
CREST scleroderma dysphagia phenomenon
mixed connective tissue disease

Raynaud's dysphagia
mixed connective tissue scleroderma arthropathy
CREST disease
scleroderma
CREST
good response to mixed connective tissue disease
steroid
39


..............................................................

mixed connective tissue disease

Raynaud's phenomenon arthropathy

lupus

..... involved lupus
kidney normal
scleroderma
...... scleroderma

scleroderma Lupus mixed connective
tissue disease

overlap syndrome
syndrome Overlap

scleroderma auto immune
disease scleroderma lupus
thyroiditis
scleroderma auto immune
manifestations
mixed connective tissue disease
poly myositis scleroderma
lupus

40


..............................................................
frequency organ involvement ANA
positive good response to steroid

Behcet's disease
....

oral ulcers genital ulcers genital
ulcers scrotum

genital ulcers glans
uveitis
neuro Behcet
multiple sclerosis
multiple sclerosis uveitis
genital ulcers , oral ulcers

22
emotional disturbances
18
quadriplegic aphasia
history

Undergraduates


41


..............................................................
history

aphasic aphasic
history

test the pathergy test test

scratch skin skin

intra dermal saline scratch
papules pustules
pathergy test Pathergy

Investigations Behcet's disease

Behcet inflammatory
inflammatory
ESR CRP positive marker

pathergy test scratch

intradermal saline scratch
saline papules
Test
42


..............................................................

topical steroid oral ulcers

colchicine steroid

osteomalacia
rickets




osteomalacia defect in bone mineralization
qualitative defect quantitative defect
bone quality minerals

pathogenesis rickets Vitamin D

deficiency
D absorption

stimulation para thyroid
secondary hyper para thyroidism para thormone
hormone osteo-clast

Causes of osteomalacia rickets

Vitamin D deficiency
43


..............................................................
vitamin D deficiency
Low phosphorus

D absorption of Ca and phosphorus form

the intestine hypo vitaminosis D Ca low
phosphorus low

Para thormone hormone

phophateuria phosphorus
osteomalacia rickets

clinical pictures
skeletal discomfort muscle pain bone
tenderness

Weakness in muscles

Investigations
Serum Ca low , Ph low
alkaline phosphatase high
para thormone hormone high
bone rarefaction

44


..............................................................

Osteomalacia
looser's zone

Vitamin D , Ca
Alfacalcidol especially in cases of renal failure

wedge
rheumatology
osteomalacia osteoporosis discuss

lupus

osteoporosis
written osteoporosis

quantitative defect bone tissue
pathogenesis
osteoblast and
osteoclast
osteoblast dominant osteoclast
dominance
osteoblast dominant

45


..............................................................
osteoblast
dominant
osteoblast
osteoclast
osteoclast dominant

Risk factor
female

fracture neck femur
DVT Pulmonary embolism

risk factors reduced activity
osteoblast activity

causes types
Type 1 menses


Type 2 senile osteoporosis
secondary osteoporosis
46


..............................................................
cushing's syndrome hyper thyroidism rheumatoid

Clinical pictures
Bony ache fracture fracture
Fracture fracture in neck of femur

fracture neck femur DVT
pulmonary embolism

investigations
lab investigations normal
Ca normal Ph normal para thoromone hormone
normal
osteomalacia
alkaline phosphatase osteomalacia
hypo clacemia para thormone hormone
alkaline phosphatase
X- ray low bone density( rarefaction or osteopenia
(
DEXA scan

DEXA scan results
just osteopenia
good mineralization of bone D
47


..............................................................
DEXA scan 300
DEXA
Osteoporosis definite osteoporosis
D Bisphosphonates
osteoclast inhibitors osteoclast

Prevention
exercise

Osteoporosis

) (

pregnancy lactation
female
.............

fracture neck of femur DVT
pulmonary embolism

family history estrogen

menopause

definite treatment
48


..............................................................
Bisphosphonates )( osteomax or Fosamax

Bisphosphonates
Bisphosphonates




Bisphosphonates

perforation
Acute mediastinitis septicemia

mediastinum heart

reflux

mostly

49


..............................................................
Bisphosphonates calcitonin
osteoclast inhibitor
500 Os-cal
alfacalcidol D
vitamin D analogue chronic renal failure
bon-one

cancer carcinoma Estrogen therapy

estrogen cancer breast uterus
conjugated estrogen progesterone
Incidence of malignancy

Estrogen receptor modulator

estrogen estrogen receptors in breast
estrogen receptors in uterus receptors in bone
estrogen receptors agonist
estrogen receptors
breast breast estrogen receptors
....... cancer

Rheumatoid arthritis
synovial membrane
Inflammation
thick synovial membrane
synovial hypertrophy edematous
articular cartilage membrane
50


..............................................................
villi finger like synovial membrane
Pannus projections
inflamed synovial membrane pannus
articular cartilage hypertrophy
subluxation cartilage erosion
deformity
fibrosed synovial membrane fibrosed
deformity
rheumatoid pathology
articular cartilage synovial membrane
synovial membrane
edematous thick inflamed synovial membrane
finger like projections hypertrophy
erosion cartilages articular cartilages
deformity erosive arthropathy

clinical pictures
male female
acute ploy arthropathy mode of onset
poly arthopathy gradual onset

carpel tunnel syndrome

soft tissue inflammation
rheumatoid

musclo skeletal manifestations

lupus symmetrical Bilateral
51


..............................................................
rheumatoid of both hands
deformity
morning stiffness morning stiffness
....

affecting joints hand deformity hand

ulnar deviation Swan neck deformity
Distal inter-phalangeal joints are flexed
hand rheumatoid meta
carpal inter phalangeal joint proximal
distal
.....
metacarpal squeezing tender
rheumatoid Investigations
Swan neck deformity affection joint
flexors of tendon synovitis
trigger finger
Inflamed tendon
nodules flexion
extension

metatarsal squeezing
rheumatoid

cervical atlanto- axial subluxation

occipital headache occipital

knee

52


..............................................................
tempromandibular
crepitation

Extra articular
lupus
Lupus rheumatoid
fever of unknown etiology
rheumatoid nodule skin
Raynaud's phenomenon
palmar erythema
Lymph node spleen Liver
Felty's syndrome
kerato-conjunctivitis-sicca scleritis eye
myocarditis pericarditis heart
lupus common Endocarditis
Libman sack endocarditis
aortic incompetence Aortic regurge
sero negative arthropathy rheumatoid

Chest
Interstitial lung disease Pleural effusion
rheumatic nodules in lung
crico- cavitation in lung X-ray
hoarseness of aretnoid joint
voice
Caplan's syndrome syndrome

53


..............................................................
rheumatic nodules associated pneumoconiosis
silicosis asbestosis in lung
rheumatic nodules in rheumatoid disease Lung
caplan's lung

rheumatoid hematology
leucocytosis inflammatory
no toxic granulations neutrophils
evidence of infection
Inflammatory rheumatoid
platelets thrombocytosis platelets
inflammatory
chronic chronic disease rheumatoid
anemia of chronic disease disease
normocytic normochromic anemia

abuser for non steroid rheumatoid

iron gastric erosion anti inflammatory
deficiency anemia
nausea
Pain in GIT bleeding
epigastrium

carpel tunnel syndrome neuro

Kidney lupus kidney

54


..............................................................
glomerulonephritis lupus
glomerulonephritis rheumatoid
commonest cause of renal involvement in rheumatoid is
non steroidal drug induced
minimal lesion glomerulonephritis
interstiatium nephritis
non Gold , penicillamine
steroidal

commonest inflammatory disease rheumatoid

rheumatoid inflammatory

amyloidosis amyloidosis kidney

rheumatology kidney
??? The commonest cause of amyloidosis kidney
Rheumatology

vasculitis

ANCA ANCA vasculitis
ANA rheumatoid factor

ESR diagnosed vasculitis vasculitis
rheumatoid factor positive
presented rheumatoid vasculitis primary
lupus vasculitis
55


..............................................................
vasculitis ANA positive lupus
presented vasculitis

tempromandibular joint syndrome

tempromanidublar joint


tricyclic
rheumatoid

tempromandibular joint

)
(
dislocation

complications of rheumatoid
arthritis complications of lupus

Lupus problem
complications
complication Lupus
clinical pictures complications

lupus coronary vasculitis

clinical pictures complications

56


..............................................................
complications in collagen disease
serious in clinical pictures
glomerulonephritis lupus
epilepsy coronary brain stroke vasculitis
clinical pictures
butterfly rash complications of lupus
discoid rash
clinical pictures complications :
complications ...........

complications of rheumatoid
clinical pictures amyloidosis
stroke coronary cervical
clinical pictures
collagen disease
heart Heart brain kidney complications
stroke brain vasculitis , coronary
failure kidney

rheumatological septic arthritis

emergency
emergency

criteria of rheumatoid arthritis

morning stiffness
three joints arthritis

57


..............................................................
hand
symmetry
rheumatoid nodules clinical
x-ray patient with
arthropathy
investigations



ESR C-Reactive protein rheumatoid factor
ANA uric acid X-ray
CBC


osteoarthritis No lab
abnormalities

investigations
CBC normocytic normochromic anemia
ESR
CRP
marker of disease activity thrombocytosis


serology Anti DNA positive
Anti cyclic citrullinated peptide antibody
((Anti CCP specific rheumatoid factor

58


..............................................................
x-ray radiology
x-ray hand soft tissue shadow
articular cartilage
space space articular cartilage
articular cartilage
narrow joint space
elbow rheumatoid
elbow elbow
osteoporosis juxta-articular osteoporosis

other investigations synovial
biopsy ultasonic CT scan MRI

Established criteria criteria X-ray serology

To monitor disease activity, to monitor disease damage

Rest, splint and physiotherapy

full dose steroid
investigations positive negative gradual
withdrawal low dose
maintenance azathioprine
cyclophosphamide sever lupus
sever vasculitis Endoxan ,steroid pulse
therapy
pulse endoxan pulse steroid

rheumatoid
59


..............................................................
Non steroid anti inflammatory for symptomatic relief
course of the disease Diclofenac
ketoprufen
side effects anti platelets ,nephrotoxicity ,
bronchospasm
dose 7.5

course of the disease

D
Bisphosphonates esophagus
intra articular steroid
precautions
Infection
disease modifying drugs course
disease Anti malarial hydroxychloroquine
MCQ rheumatoid disease
antimalarial hydroxychloroquine follow up
fundus examination
retinopathy

Sulphasalazine anti folate ..... folic acid

antagonist folic acids sulphasalazine
.......... Inflammatory bowel disease
Inflammatory bowel disease
sulphasalazine sero negative

penicillamine
nephrotoxic

60


..............................................................
Gold

Methotrexate
7.5 Oral
injection for how long

methotrexate

azathioprine methotrexate
immune suppressive category chemo
therapy

liver enzymes CBC

leflunomide ) (
methotrexate Avara
side effects

rheumatoid combination steroid +

methotrexate

biological therapy
61


..............................................................
blockade of interleukin-1 and interleukin-6 receptor

(Still's disease(systemic onset arthritis

problem arthropathy
rheumatic fever
splenomegaly
rheumatic fever
still's disease 12 with arthropathy
hepatosplenomegaly
rheumatoid factor negative
negative anti streptolysin O titre manifestations
ESR C-Reactive protein

rheumatic anti streptolysin O titre
negative rheumatoid rheumatoid
factor negative
ESR C-Reactive protein
splenomegaly Still's disease

Kawasaki fever , spleen

rheumatic fever
Still's disease Kawasaki
Kawasaki
) (
Kawasaki coronaries
)
(

62


..............................................................
pauci articular
Juvenile rheumatoid arthritis

uveitis
Kawasaki
juvenile arthropathy spleen Uveitis
uveitis

arthopathy
rheumatic fever juvenile rheumatoid
brucella ....
infection
arthropathy rheumatic
fever !!!!
brucella

Salicylates
methotrexate Methotrexate
.. rheumatoid

Felty's syndrome
Felty's syndrome classic rheumatoid
hypersplenism
63


..............................................................
rheumatoid blood picture
leukocytosis, thrombocytosis
pancytopenia hypersplenism
Felty's syndrome
Felty's syndrome rheumatoid factor positive

Sjogren's syndrome
Sicca syndrome dry eye , dry
mouth Ocular dryness schimer
tear test

investigations sjogren's
( anti salivary duct antibody ( siogren's antibody
salivary gland

Anti Ro , Anti la
Anti Ro , Anti La Positive
lupus ANA negative
lupus Sjogren's

Sjogren's syndrome
dryness in mouth
) (
64


..............................................................


calories
calories

Spondyloarthropathies

)(seronegative arthropathies
rheumatic fever rheumatoid factor
negative osteoarthritis rheumatoid factor negative
seronegative
seronegative
negative rheumatoid factor
criteria
general features
limited
Sacroiliitis spondylitis
lumbar movement .....sacroiliac joint
Uveitis
HLA tissue 27 Enthesitis
inflammation of the enthesis (the site of insertion of
( ligaments or tendons into bone
tendon features

65


..............................................................

familial association

(Ankylosing spondylitis (AS

auto immune
disease
poly arteritis nodosa Ankylosing spondylitis
gout
gout

hyper urecemia uric
acid
bad sign )
(
uric acid very low
) (
pathology vertebral column
vertebral ligaments calcified
vertebrae
Syndesmophytes
intervertebral disk calcifications
Bambo spine

clinical pictures
vertebral column limited lumbar movement
.... spasm
.....
66


..............................................................
Lumbar spine intervertebral disk
prolapse lumbar spondylosis Ankylosing spondylitis
inflammatory
spasm ESR
C-Reactive protein
Ankylosing spondylitis
inflammatory

inflammatory

ESR C-Reactive protein

clinical pictures Enthesopathy

tendo Achilles

peripheral joints asymmetrical

involvement
uveitis
uveitis suspect
systemic ankylosing spondylitis
Aortic regurge
ankylosing chronic inflammatory kidney
amyloidosis

........
spondylosis spasm
Ankylosing ...........
family history
ankylosing
67


..............................................................
circadian
rhythm
non steroidal anti inflammatory
non steroidal anti inflammatory
insomnia

ESR C-Reactive protein

inflammatory inflammatory

mechanical mechanical
spasm disk prolapse
very important

Ankylosing spondylitis Back

ache inflammatory mechanical
mechanical

Schober test

investigations
bamboo spine ESR C-Reactive protein
rheumatoid factor negative HLA B27
HLA B27
HLA B27
68


..............................................................

non steroidal anti inflammatory
early exercise
early

uveitis Local
Tendo Achilles local steroid
tendon

Reiter's syndrome
problem Reiter's syndrome reactive
arthritis
arthritis reactive arthritis
following infection rheumatic fever
reactive arthritis

reactive arthritis post dysentery

genital infection male urethritis ,prostatitis
female cervix
Reiter's syndrome
bacillary dysentery dysentery diarrhea
mucus blood

patient diarrhea dysentery mucous
and blood ....... arthropathy red eye

69


..............................................................
Reiter's syndrome

clinical pictures
onset urethritis , conjunctivitis and arthritis
urethra

planter faciitis sole

sole

tendo Achilles skin

keratoderma circinate balanitis ulcers
glans penis

Reiter's syndrome
genital ulcers red eye
Reiter's syndrome

vasculitis Reiter's
syndrome seronegative
Behcet's uveitis
Reiter's conjunctivitis
Behcet's ulcers scrotum
Reiter's ulcers Glans penis

70


..............................................................
Inflammatory ESR C-Reactive
protein seronegative rheumatoid factor
negative HLAB27 positive in 80%
non steroidal anti inflammatory drugs

tendo Achilles


.....................

psoriatic arthropathy

....................................

% 10
clinical pictures rheumatoid
distal inter phalangeal joint
Distal inter phalangeal
joint
Distal inter
phalangeal joint spared in rheumatoid affected

psoriasis osteoarthritis

71


..............................................................

Crystal induced arthropathy

Gout and Hyperuricemia

Pathway
purines
inosine mono phosphate
hypoxanthine XO xanthine oxidase
hypoxanthine Xanthine XO uric
acid

Xanthine Oxidase
Allopurinol Xanthine Oxidase inhibitor
synthesis of uric acids

hypoxanthine inosine mono phosphate

enzymes hypoxanthine-guanine-
phosphoribosyl-transferase

defect uric acid

uric acid
uric acid
classifications of hyper uricemia
enzymatic defect

72


..............................................................
defect uric
acid congenital hyper uricemia syndrome
Lesh-Nyhan syndrome
Lesh-Nyhan Lesh-Nyhan
mental
retarded self
mutilation

Lesh-Nyhan syndrome

renal idiopathic kidney uric

acid isolated defect
uric acid
secondary causes hemolysis Leukemias
Lymphomas Uric acids
) ( tumor lysis syndrome leukemia
lymphoma underchemotherapy lysis
malignant cells
leukemia Lymphoma acute sever hyper
uricemia uric acid 25
......... acute renal failure
tumor lysis syndrome
Leukemia sore throat
liver, spleen lymph nodes
thrombocytopenic
Uric acid
tumor lysis syndrome
Uric acid

secondary renal renal failure

73


..............................................................
primary renal secondary
renal
primary renal kidney Isolated defect
uric acid normal uria nromal

secondary renal renal failure

uric acid
uric acid GIT urine

causes of hyperuricemia Lesh-Nyhan
hyper uricemia
hypo uricemia Pregnancy
pregnancy glomerular filtration rate
high clearance of uric acid uric
acid

hyper uricemia uric acid

male female

Pathology

uric acid crystal
leucocyte uric acid Inflammatory
mediators mediators articular cartilage
uric acid crystal injurious
.
74


..............................................................
articular cartilage
(neutrophils (WBCs uric acid
............. WBCs
phagocytosis uric acids Inflammatory
mediators acute gout Pharma
mechanism of action of colchicine colchicine
WBCs uric acid crystals
Migration of WBCs WBCs blood
uric acid articular cartilage
colchicine WBCs uric acids
colchicine specific

chronic gout gout

erosive arthropathy kidney tophi

clinical pictures
% male 95 female 5%

uric acid
uric acid
acute gout
gout hyper uricemia
asymptomatic hyperuricemia
uric acid
asymptomatic hyper uricemia
acute gouty arthritis big toe
first metatarso phalangeal joint

75


..............................................................
........ trauma
swollen, redness and
hotness podagra
) (

elbow

Dramatic relief colchicine

typical attack attack

the typical attack rapid onset

maximum severity
early morning

attack
Inflammatory
Inflammatory leukocytosis ESR
C-Reactive protein

chronic tophaceous gout (chronic arthropathy ,

( tophi, nephropathy
uric acids arthropathy joint
destruction
tophi uric acid crystals
subcutaneous


skin
gouty tophi
76


..............................................................
skin around joint , ear lobule tendo Achilles
elbow gouty kidney
uric acid tumor lysis
syndrome uric acid 25
tubules acute renal failure

gouty nephropathy Interstitial

nephritis gout uric acid stones

Xanthine Oxidase Allopurinol hypo

uricemic
hypoxanthine Inosine mono
phosphate

hyper uricemia
primary secondary
primary uric
acid over weight
Lesh-Nyhan syndrome
enzymatic defect hyper
uricemia Mental retardation
Primary kidney primary renal no
renal failure isolated defect kidney
uric acid

secondary secondary to another disease

77


..............................................................
another disease leukemia , lymphoma
tumor lysis syndrome
secondary to renal disease renal failure

pathology gouty arthritis

uric acid injurious articular cartilage
articular cartilage WBCs
........... WBCs uric acid crystals
Inflammatory mediators .... colchicine
WBCs articular cartilage

Chronic tophaceous gout tophi

clinical pictures
male female female

clinical presentation
Asymptomatic
acute gouty arthritis podagra
precipitated trauma Precipitated surgery
inflammatory
Uric acid C-Reactive protein
leukocytosis ESR

chronic tophaceous gout erosive arthropathy

78


..............................................................
tophi uric acid crystals
subcutaneous ear lobule
elbow
uric acid Kidney

tumor lysis syndrome actue renal failure
chronic gouty
check up hyper uricemia
gout uric acid
chronic renal failure
process
Proton pump
Investigations creatinine

investigations
uric acid ESR
aspiration of synovial fluid
uric acid crystals
articular cartilage joint
space lost erosive arthropathy

asymptomatic
: family history of renal stones
uric acids 11

acute gouty arthritis

colchicine

79


..............................................................
non steroidal anti inflammatory drugs
Indomethacine colchicine
colchicine FMF
attacks amyloidosis

long acting

Allopurinol NO-
uric Zyloric 100 300
100 renal impairment old age
side effects Liver enzymes
hyper sensitivity Allopurinol
gouty kidney
gout fluids alkaline urine
sodium citrate Allopurinol

Diet gout
) gout ( Zyloric
restrictions

restriction gout

80


..............................................................

Chondrocalcinosis
calcium pyrophosphate deposition on joint
uric acids calcium pyrophosphate

etiology hemochromatosis Wilson's disease
gout crystals gout uric
acid
calcium pyrophosphate
Haemochromatosis arthropathy

calcium pyrophosphate
pseudo gout
gout pseudo gout
gout pseudo gout
pseudo gout calcium pyrophosphate

X-ray
articular cartilage crystal
Calcification
arthropathy ESR C-Reactive protein
non steroidal
pseudo gout non steroidal
common

81


..............................................................
pseudo pseudo gout crystals
hydroxy-appatite crystals
written crystals
induced arthropathy gout pseudo
gout pseudo pseudo gout

Pseudo pseudo pseudo gout !!!!

Osteoarthritis


osteoarthritis osteoarthrosis
degenerative joint disease
degenerative Inflammatory
osteoarthropathy osteoarthritis

Risk factors
Wear and tear
obesity

knee joint articular cartilage articular
cartilage

pathogenesis
82


..............................................................
matrix loss articular cartilage Proteases
collagenase recent
interleukin 1 tumor necrosis factor
articular cartilage

bone irritative osteophyte
narrowing of joint space
bone osteophyte
osteophyte growth factor
irritation
knee hip
knee

classifications
Primary
secondary
common primary
secondary occupational

osteoarthritis

83


..............................................................
secondary metabolic hemochromatosis
viral hepatitis C viral
hepatitis B lupoid
liver

clinical pictures
Pain
Morning stiffness
Gelling phenomenon


Gelling phenomenon
tenderness crepitus
sensation cartilage
deformity
osteoarthritis
osteophyte
Distal inter phalangeal joint

Heberden's nodules swelling in distal inter
phalangeal joint
Bouchard's nodules bony swelling of
proximal inter phalangeal joint
MCQ

84


..............................................................
lab investigations normal
ESR C-Reactive protein normal normal
hip
osteoarthritis
X-ray joint space narrowing osteophytes

Weight reduction

............

.... very high IQ

weight reduction
knee cage





quadriceps muscle
....
obese

pharmacology
non steroidal oral and gel symptomatic
85


..............................................................
oral glucosamine ....
Genophil ...........
articular cartilage

glucosamine plus

vitamin D

Intra articular steroid

) (
::

)( septic arthritis

86


..............................................................
Unhealthy joint +bacteremia
bacteremia
strept staph emergency

clinical pictures

fever , swelling , redness , hotness and
C-Reactive protein ESR leukocytosis
Rest, drainage and antibiotic

69

osteogenesis imperfecta

marfan syndrome
aortic regurge high arched palate Lens dislocation
Mitral valve prolapse

hyper mobility of joints Ehler-Danlos syndrome

classification of joint disease

Non inflammatory
Inflammatory
rheumatology
87


..............................................................

differential diagnosis of back ache

neck pain written

recurrent arthritis
Mono arthritis

rheumatology

**** !!!!!
"..... ,
" *****

88