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Muscle and Connective Tissue Pain (Fibromyalgia)

• Muscle and connective tissue pain, also known as myalgia and myofascial pain syndrome, is a condition characterized by widespread pain and discomfort in the muscles and soft tissues.
• This condition is frequently associated with psychological conditions such as depression, anxiety, and posttraumatic stress disorder.

Clinical Presentation

• Widespread pain affecting multiple areas of the body.
• Bowel and bladder issues.
• Fatigue.
• Muscle weakness.
• Palpitations.
• Sleep disturbances.

Labs, Studies, and Physical Exam Findings

• Diagnosis of exclusion.
• Key features include:
  • Widespread pain that affects all four quadrants of the body.
  • Identification of trigger points or tender areas in muscles.

Treatment

• Cognitive-behavioral therapy to address the psychological aspects.
• Antidepressant medications to manage associated depression and anxiety.
• Exercise and physical therapy to improve muscle function and reduce pain.

Differential Diagnosis

Chronic Fatigue Syndrome (CFS), Rheumatoid Arthritis (RA)

Gout (Podagra)

• Arthritis characterized by the crystallization of uric acid in the joints.
• Gout tends to occur more frequently in men than in women.
• Podagra when it specifically affects the big toe joint.

Clinical Presentation

• Sudden onset of severe joint symptoms, such as:
  • Acute joint pain.
  • Joint redness and warmth.
  • Swelling of the affected joint.
• Gout classically affects the metatarsal-phalangeal joint of the big toe but can occur in various joints, with the feet, ankles, and knees being commonly affected.

Labs, Studies, and Physical Exam Findings

• A red, hot, and tender joint with limited range of motion.
• Hyperuricemia although some patients may have levels below the diagnostic threshold.
• X-rays: typically negative until advanced stages of joint damage.
• Joint fluid analysis: negatively birefringent crystals.

Treatment

• Dietary modifications, including limiting alcohol, organ meats, and high-purine foods while increasing water intake.
• NSAIDs, with indomethacin being the drug of choice for acute attacks.
• Steroid injections to reduce inflammation.
• Colchicine to decrease inflammation in acute attacks.
• Allopurinol for long-term treatment, as it reduces the production of uric acid.

Differential Diagnosis

Pseudogout, Septic Arthritis, Rheumatoid Arthritis

Calcium Pyrophosphate Deposition Disease (CPPD) or Pseudogout

• Calcium Pyrophosphate Deposition Disease (CPPD) is a joint disorder characterized by the deposition of calcium pyrophosphate crystals into the joint, leading to inflammation and pain.
• CPPD can manifest as either an acute or chronic condition.

Clinical Presentation

• Joint pain, which can range from mild discomfort to severe pain.

Labs, Studies, and Physical Exam Findings

• CPPD most commonly affects large joints, including the knees, wrists, and shoulders.
• X-rays: Fine linear calcifications within the affected joints.
• Examination of joint fluid: calcium pyrophosphate crystals.

Treatment

• NSAIDs to alleviate pain and reduce inflammation.
• Steroid injections into the affected joints for more severe cases.
• Surgical joint replacement in cases of advanced joint damage.

Differential Diagnosis

Gout, Rheumatoid Arthritis (RA)

Juvenile Rheumatoid Arthritis (JRA)

• Juvenile Rheumatoid Arthritis (JRA) is a form of arthritis that primarily affects children and adolescents.
• It exhibits some key subtypes, including systemic JRA, oligoarticular or pauciarticular JRA, and polyarticular JRA.
  • Systemic JRA may include features such as rash, hepatosplenomegaly, and hepatitis. It often presents with systemic symptoms.
  • Oligoarticular or pauciarticular JRA involves fewer than 5 joints, typically larger ones. Eye issues are most common with this subtype.
  • Polyarticular JRA involves more than 5 joints.
• JRA is more prevalent in girls than in boys, with an onset typically before the age of 16.

Clinical Presentation

• Poor appetite.
• Fatigue.
• Lethargy.
• Fever.
• Limping.
• Joint pain.
• Morning stiffness.
• Systemic JRA is characterized by a distinctive rash and recurrent fever.

Labs, Studies, and Physical Exam Findings

• Rash
  • Non-pruritic rash is described salmon-pink and evanescent
• Fever.
• X-rays: typically show no significant abnormalities.
• No specific blood test for diagnosis
  • Elevated erythrocyte sedimentation rate (ESR).
  • Rheumatoid factor.

Treatment

• Management of JRA may involve a multi-disciplinary approach, including:
  • NSAIDs for pain and inflammation.
  • Disease-modifying anti-rheumatic drugs (DMARDs)
    • Methotrexate
  • Corticosteroids
    • Prednisone
  • Physical therapy to maintain joint function and mobility.
  • Occupational therapy to assist with daily activities.

Differential Diagnosis

Lyme disease, Lupus

Polyarteritis Nodosa

• Polyarteritis Nodosa is a form of vasculitis characterized by inflammation of medium and small-sized blood vessels.
• There is a higher incidence in men.
• Most commonly affects people between the ages of 40 and 60.

Clinical Presentation

• Constitutional symptoms such as fever, weight loss, and fatigue.
• Abdominal pain, often due to visceral involvement.
• Neuropathy, which can manifest as numbness or weakness.
• Skin issues, including rashes, ulcers, and a distinctive mottled purple skin discoloration called livedo reticularis.

Labs, Studies, and Physical Exam Findings

• Skin manifestations like rashes, ulcers, and livedo reticularis.
• Kidney involvement, which may lead to hypertension, edema, oliguria, and elevated levels of blood urea nitrogen and creatinine.
• Elevated white blood cell count (WBC).
• Elevated erythrocyte sedimentation rate (ESR).
• Elevated C-reactive protein (CRP).
• A tissue biopsy showing evidence of vasculitis.
• Angiography, which can reveal characteristic vascular abnormalities.

Treatment

• Agressive high-dose steroids to suppress inflammation.

Polymyositis

• Polymyositis is characterized by inflammation of the muscles, most frequently affecting the proximal limbs and neck.
• Women are more commonly affected than men.
• Common clinical features include insidious onset of proximal muscle weakness, such as difficulty going up stairs or getting up from a chair, dysphagia, and a distinctive butterfly facial rash.

Labs, Studies, and Physical Exam Findings

• Enzymes may be elevated, although they are not specific:
  • Creatinine phosphokinase (CPK).
  • Aspartate aminotransferase (AST).
  • Alanine aminotransferase (ALT).
  • Lactate dehydrogenase (LDH).
  • Myoglobin.
• A muscle biopsy is often performed for definitive diagnosis.

Treatment

• Management typically involves high-dose steroids to suppress inflammation.

Differential Diagnosis

Myasthenia Gravis, Rheumatoid Arthritis (RA), Fibromyalgia, Inflammatory Myopathies, Lupus

Polymyalgia Rheumatica (PMR)

• Polymyalgia Rheumatica (PMR) is characterized by pain in multiple muscles, most commonly in the neck, shoulders, and hips.
• Women are more commonly affected, and it typically occurs in people older than 50.
• PMR is associated with temporal arteritis, with a significant overlap between the two conditions.

Clinical Presentation

• Patients with PMR often describe muscle pain and stiffness, particularly in the morning.
• Muscle pain tends to be symmetrical and is accompanied by symptoms like fatigue, fever, and weight loss.

Labs, Studies, and Physical Exam Findings

• Elevated erythrocyte sedimentation rate (ESR) is a common laboratory finding in PMR.

Treatment

• Management usually involves low-dose corticosteroids (10-20 mg of oral prednisone) for several years.

Differential Diagnosis

Giant Cell Arteritis (temporal arteritis), Rheumatoid Arthritis (RA), Fibromyalgia, Inflammatory Myopathies