Hey, I’ve got something really special for you today, so don’t hit that skip ahead button. I know you do it because I do it too. No worries, I understand. But today is a special day and something really fun going on here at Physician Assistant Exam Review, and I don’t want you to miss out. Today we’re going to be on episode 115 covering rheumatologic disorders. It will probably take us two to three shows to get through this topic. And as we do, we will also be finishing musculoskeletal, which is really exciting.

It’s really exciting because I’m also getting closer to putting out Wallace’s Notebook, which is going to be all the notes from the website completely gone through and organized nicely for you into a great book. Actually, it’s really far along. It’s almost complete. I’ve been giving the rough draft version out to the 33 Days students, but it is not ready for prime time yet. As I finish up the work on each section. It will continue and hopefully late 2023, early 2024, that will be ready. Anyway, my name is Brian Wallace.

I’m the founder here at Physician Assistant Exam Review, where we teach PA students how to get as much as possible out of PA school, not just get through it, but get as much out of it as you possibly can and ultimately pass the PANCE and land your dream job. That’s our goal for you. I have done so much to get to this point. You’ve worked so hard. So many things have gone well for you. And I want that to continue as we move forward. And I’ve got something exciting for you today that is going to help you with that.

And that is a giveaway I’m running that is worth over $2,500. There’s actually going to be three prizes, but the grand prize winner is going to get The Final Step complete package, one registration for the 33 Days program, which the person who won it last time was a didactic student who wasn’t sure that she was all that interested in it. And then a few months later, she found herself struggling a little bit and joined the program because she had it available to her and was blown away seeing her scores go up. So that even if you’re early, early on in your studies, something to keep an eye out on. They’re also going to get one year subscription to the Physician Assistant Exam Scholars newsletter. That’s the newsletter that I write every single month with philosophies, methods, techniques for getting as much as you can out of PA school. That’s where I go really deep and dive down into study topics, test taking skills, self-management skills, the things you need to get through school rotations, interviewing, all of these things.

And then of course, you’ll also be getting the dream job package and so much more. There’s also two runner up packages that will include The Final Step and a bunch of other things. So if you want to find out more, which of course you do, you want to head over to physicianassistantexamreview.com/give, G-I-V-E, physicianassistantexamreview.com/give. And that will get you onto the page. We’ll get you all the information where you can see what’s going on and register for this giveaway.

All right, I’ve got one more exciting thing for you before we get started with the priming questions for today. And I’m going to be doing a talk on the interview process. It’s designed for pre-PAs. Katie and Beth over at Pre-PA Clinic are holding a pre-PA conference this weekend and asked me to go in and talk about the interview process. And I didn’t do a lot of work with PAs applying to PA school, but I’ve done a ton of work with people working on getting jobs, talking with surgeons who are hiring PAs, hiring PAs at my facility, going on my own interviews. So I have a lot to say on this topic, and I have a very specific method, a very specific idea of how to go about it. And that philosophy applies whether you are interviewing for a PA program or interviewing for a job or, in fact, going on rotations and meeting your preceptors.

It really is a simple step process to ingratiate yourself and make yourself part of the team, and it works really, really well. So I’m going to be discussing that on Sunday, September 10th. I think it begins at 4.15. But in order to find out about it, you’ve got to sign up for their Facebook group that is involved in the pre-PA clinic. You can do that. I’m just going to make the link really easy for you at physicianassistantexamreview.com/interview. I should make that really easy.

So again, physicianassistantexamreview.com/interview. You and that will get you over to where you can sign up and join us for that discussion. And there’s going to be all kinds of discussions that we can choose if you want to hop in on anything else. If you’re a pre-PA, we definitely have those out there. Or if you’re looking at coming at ideas on paying off loans and all that kind of stuff, you can see what’s in there if you head over to that link.

All right, great. So let’s go ahead and get started with our priming questions for today as we move into rheumatology. This section lended itself very nicely to priming questions. Made it really easy to come up with them, which also means it’s going to make it really easy for your preceptors and faculty to write their own questions on this, right? Or to use questions on this. So, let’s go ahead and get started. Again, I don’t expect you to know these.

These are to get your brain moving, to get your brain thinking. These are a warm up, just like I’m finding out at one of my 45 years old, when I go for my runs, I can’t just get up and run anymore. That’s not the way it works. I need to take a few minutes to get warmed up to get the joints and the muscles functioning. And that’s all about the synovial fluid. It’s all about the blood supply shifting to the muscles away from the digestive organs and all that stuff. And the same thing is going to go for your brain as you’re studying, as you’re thinking, right?

You need to get it warmed up. You don’t have to, I guess, but it works better if you warm it up, just like a muscle. So that’s what our priming questions are for and they’re to get you involved in our, like we always talk about, active studying. So you’re not going to know the answers to these off the top of your head. I’d be shocked if you knew them all. I’d be really impressed unless you’re specifically studying this topic. But I want you to work.

I want you to think. I want you to try or else it’s a waste of your time and you might as well just hit that skip ahead button here. The goal is to try and then to keep an eye out for these things as we go through the notes for today. What is the characteristic rash of polyarteritis nodosa called? What is the characteristic rash of polyarteritis nodosa called? Which type of juvenile rheumatoid arthritis involves systemic symptoms such as rash, hepatosplenomegaly, and hepatitis? What is the diagnostic feature that distinguishes gout from other arthritic conditions when examining joint fluid?

What do you find in the joint fluid of gout that separates it? What is the drug of choice for an acute gout attack? What is the drug of choice for an acute gout attack? What is the primary treatment for polymyositis? What is the primary treatment for polymyositis? In polymyalgia rheumatica, where is muscle pain most commonly experienced? In polymyalgia rheumatica, where is muscle pain most commonly experienced?

Which condition or disease is often associated with polymyalgia rheumatica? Which condition or disease is most commonly associated with polymyalgia rheumatica?

All right. We begin with fibromyalgia or muscle and connective tissue pain. This is a condition characterized by widespread pain and discomfort in the muscles and soft tissue. This condition is frequently associated with psychological conditions such as depression, anxiety, and post-traumatic stress disorder. For a clinical presentation, patients typically come in with widespread pain affecting multiple areas of the body. They may have bowel or bladder issues, fatigue, muscle weakness, palpitations, and certainly sleep disturbances. Lab studies and physical exam findings.

This is often a diagnosis of exclusion, ruling out other potential causes. But two key features are widespread pain that affects all four quadrants of the body and the identification of trigger points or tender areas in the muscles. Treatment here is going to be cognitive behavioral therapy to address the psychological aspects of this disease. Maybe antidepressants and exercise and physical therapy. I want to talk a little bit today and start including differential diagnoses into our notes. I really haven’t done that in the past, but I think it’s really important as I talk about how these are going to show up on your test. They’re going to show up in answer choices one against another.

So you’re going to have to pick out things from essentially a differential diagnosis, from a set of things that are going to be similar but wrong. So our differential diagnosis is exactly what’s going to come up in your tests for your answer choices. So in this case, for fibromyalgia, your differential diagnosis is going to include something like chronic fatigue syndrome or rheumatoid arthritis. I’m not going to go through and differentiate them here because it’s just going to take too much time. I may do that in the future, but for right now, I’m just going to present them to you, but point out to you that that’s something you need to be taking some time and working on. Next is going to be gout or podagra, which we’ll talk about in a second. Gout is a type of arthritis characterized by the crystallization of uric acid in the joints.

So it’s uric acid crystallization in the joints. Gout tends to occur more frequently in men than women. And although it most commonly occurs in the big toe, that would be called podagra, it can also occur in the ankle, the knee, or really any joint. Clinical presentation here is a sudden onset of severe pain in the joint. Have you ever seen anyone with this? It is markedly noticeable. They are dying.

They can’t even put a blanket over their foot. I’ve usually seen it. My father-in-law had a bad case of it in his big toe, has had it a few times, and literally can’t put a blanket over that foot because it hurts so much. So it’s acute joint pain, joint tenderness, redness, and warmth, swelling of the affected area. And again, it’s often that metatarsophalangeal joint of the great toe, but it can be in the feet, the ankles, the knees, all over the place, but most commonly it is in that toe. So if you see someone coming in complaining of ridiculous pain in the big toe, definitely be suspecting gout. Lab studies and physical exam findings.

Just like we said for presentation, red, hot, tender joint with limited range of motion.

Now, they may have hyperuricemia, but a lot of patients who have gout will not have that. But it will be kind of diagnostic if you come across it. You’re likely going to get an x-ray because they’re complaining of joint pain, but you’re not going to see very much on the x-ray unless there’s some serious damage that’s been going on a very long time. You’re going to get joint fluid analysis, so you’re going to stick a needle in there and suction out the fluid and send it off. And what you’re looking for are negatively birefringent crystals, right? That’s our key term for gout, negatively birefringent crystals. Treatment.

This is one of our priming questions. How do we treat gout? Well, first of all, before we get into the acute setting, dietary modifications are going to help a lot. So include limiting alcohol. That’s a big one. Organ meats and high purine foods and increasing water intake. The water intake is huge.

Something I’m constantly pushing with everyone because all of us don’t drink enough water. It is a tremendous benefit here. So dietary modifications include limiting alcohol, limiting organ meats, limiting foods that are high in purines, and then increasing water intake. NSAIDs are going to be used for acute onset pain relief and to bring that inflammation down. Indomethacin is the one that seems to come up the most here. You can do a steroid injection to reduce inflammation, although that sounds extremely painful. Colchicine is used to decrease inflammation in acute attack as well.

And then allopurinol is for long-term treatment, and it reduces the production of uric acid. Our differential diagnosis here, so the things you should be able to tell it apart from, things like pseudogout, septic arthritis, and rheumatoid arthritis.

Next, we have pseudogout. So you’ll be able to pay attention as we go through this. This is also known as calcium phosphate deposition disease, CPPD. Calcium phosphate deposition disease, pseudogout. This is a joint disorder characterized by the deposition of calcium phosphate crystals into the joint, leading to inflammation and pain. So again, this can be chronic or acute, just like regular gout. Clinical presentation, joint pain, which can range from mild discomfort to very severe.

Labs and studies, physical exam findings. Most commonly, this affects the large joints, including the knees, wrists, and shoulders. So right there, we have a differentiator, right? It is in a different location, generally speaking, than gout. X-rays may reveal fine linear calcifications within the affected joints. I would know that. And then examination of the joint fluid may show calcium phosphate crystals.

Treatment here is going to be NSAIDs to alleviate the pain and reduce the inflammation. Again, we can do a steroid injection. Not going to do that if it’s multiple joints, but if it’s one joint. And then here we can ultimately, if the joint is damaged enough, we can do surgical replacement of that joint. So, what do you suspect our differential diagnosis is here? What do you think? Well, it’s gout and rheumatoid arthritis.

Things that affect maybe one joint or two joints. Things that affect joints. How can you differentiate these from other joint diseases? Our next one is juvenile rheumatoid arthritis. This is an arthritis that primarily affects children and adolescents. There are three key subtypes. Systemic.

Oligoarticular or pauciarticular, I think is how you pronounce that. And then polyarticular. So systemic may include a rash, hepatosplenomy, hepatosplenomegaly, and hepatitis. Usually these patients have systemic symptoms. Oligoarticular involves fewer than five joints, and it’s typically in the larger joints. You can also have eye issues. If you’re going to get a question about juvenile rheumatoid arthritis or eye issues, this is going to be your answer.

And then polyarticular juvenile rheumatoid arthritis involves more than five joints. So pretty straightforward. You either have systemic, fewer than five joints, greater than five 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 in a kid, right? I should raise some alarm bells.

And systemic JRA is characterized by a distinctive rash and recurrent fever. We’ll get to that in just one second. Lab studies and physical exam findings. So, for physical exam, for systemic JRA, they can have this non-pruritic rash described as a salmon pink color. So, not red, more of a pink, and evanescent, meaning it comes and goes, and often that comes and goes with a fever. So, important to note that those kind of go together. Patients may also present with a fever.

X-rays will typically show no significant abnormalities. And there’s no good diagnostic lab work. So you’re going to get a SED rate. And if that’s elevated, that’s obviously going to show some inflammation. And you’re going to look for a rheumatoid factor, which may also be positive, but again, not diagnostic. Treatment management is going to be multidisciplinary. So NSAIDs for pain, physical therapy, to improve joint function and mobility, then occupational therapy to assist with daily activities.

You can also use corticosteroid like prednisone to reduce inflammation and reduce the immune system and disease-modifying anti-rheumatic drugs, DMARDs, methotrexate being the one that I would hold on to. What’s our differential diagnosis here? Maybe things like Lyme disease or lupus. If we’re talking about joint inflammation in a kid, those would be things that you would want to be considering. Polyarteritis nodosa is next. Polyarteritis nodosa is a form of vasculitis characterized by inflammation of the medium and small-sized blood vessels. Men are more prone to getting this and usually occurs between the age of 40 and 60.

Here we have patients come in with fever, weight loss and fatigue, abdominal pain, neuropathy. And then the big one is the skin issues. So it’s called a distinctive mottled purple skin called livedo reticularis. Livedo reticularis. That was definitely one of our priming questions. Lab studies and physical exam findings, skin manifestations, like we just talked about, you can get rashes, ulcers, and livedo reticularis, which is that mottled purple skin. You can get kidney involvement with polyarteritis nodosa.

Remember, we have vasculitis, which is affecting our medium and small-sized vessels, right? So we can get involvement all over the place. But a specific one would be the kidneys, which can give us hypertension, edema, oliguria, and an elevated BUN and creatinine. You can get an elevated white blood cell count. SED rate can be elevated. C-reactive protein might be up. And you’re going to want to get a biopsy showing evidence of vasculitis.

An angiography can also reveal vascular abnormalities. Treatment is going to be aggressive, high-dose steroids to repress this inflammation. So again, high-dose prednisone. So one nice thing in this section is a lot of the treatment choice here is prednisone. Polymyositis is next. Polymyositis is an inflammation of the muscles most frequently affecting the proximal limbs and neck. Women are more commonly affected than men.

They get an insidious onset of proximal muscle weakness with difficulty going upstairs or getting up out of a chair. They can get dysphagia, a distinctive butterfly facial rash. So as we’re going through this, I just rattled off some common symptoms. And you should start to be putting together your differential diagnosis here. A facial rash. Proximal muscle weakness. I can think of two things off the top of my head that would go in a test question up against polymyositis that would make me have to differentiate those in an answer choice.

Lab studies and physical exam findings. There’s nothing really specific here for blood work, but you may find that you have an elevated creatine phosphokinase, an elevated AST, elevated ALT, elevated lactic dehydrogenase, and an elevated myoglobin. Again, not specific, but things you’re going to test for.

Now, the way that you prove this is with a muscle biopsy, right? This is an inflammation of the muscles. So, we’re going to do a muscle biopsy to prove it. Treatment management typically involves high dose steroids to suppress the inflammation. Nice. So, what’s our differential diagnosis? The one that popped into my head immediately was lupus with that butterfly facial rash.

Myasthenia gravis for the proximal muscle weakness. Rheumatoid arthritis, maybe. Fibromyalgia, maybe. And other inflammatory myopathies. A good friend of mine actually has dermatomyositis, which is similar. It affects the muscles and the skin, and he definitely had that distinctive butterfly rash first on his face, which is a unique finding. And he’s been struggling for a long time with this.

He’s on all kinds of medications, including high dose steroids, for probably close to two years now. And you can just see his muscle wasting. He’s having has a ton of trouble moving throughout the day. A lot of issues. It’s not all that different than polymyositis. Really hard to treat, really hard to identify. Anyway, polymyalgia rheumatica, aka PMR.

And if you’re struggling to keep up, this is our last one for today. Polymyalgia rheumatica is pain in multiple muscles, most commonly the neck, shoulders, and hips. Women are affected more often than men and usually in people older than 50. Polymyalgia rheumatica is often associated with temporal arteritis with a significant overlap between the two conditions. Clinical presentation. Muscle pain and stiffness, particularly in the morning. Muscle pain is symmetrical, and the patients will often also have fatigue, fever, and weight loss.

Again, we don’t have good studies here. We don’t have good examinations. We don’t have much to work with. So you might get an elevated sed rate. You’re also probably going to get a C-reactive protein. But again, just not a lot you’re going to find here. Yes, it could be elevated, but not a lot to be diagnostic.

Management is a low-dose corticosteroid, 10 to 20 milligrams of prednisone, as opposed to something like 50 for a high dose. And again, this is treated for years. Our differential diagnosis here. So again, giant cell arteritis, which is that temporal arteritis we talked about, it usually goes along with rheumatoid arthritis, fibromyalgia, and other inflammatory myopathies.

All right, fantastic. We made it through the first part of rheumatological diseases. These are tough, right? Because there’s no clear tests for a lot of them. There’s no clear information. So you should really pull out the ones that have clear tests. So if you have a muscle biopsy, right, that’s going to be your definitive diagnosis for what?

A distinct butterfly facial rash. How are you going to tell these apart? That’s what’s really going to be important. And again, that brings us right into our study tip for today, which is going to be the idea of differentiation. When I studied a little while ago, I talked about association. This week, I want to talk about differentiation, which is how first you want to put these diseases together so that you can remember them better. I’m not going to go back into that here.

I dive deep into it in a lot of the different programs I offer in the newsletter and so on. But with differentiation is the idea that you’re trying to look at diseases and tell them apart. So first you’re associating them and now you’re pulling them apart. So they’re associated by being rheumatological diseases, right? They hand you the associations. Now we’re going to pull them apart. So you’re going to study them by looking at each disease and its differential diagnosis and coming up with the one or two things that will have to be in the question or in the patient’s labs or in the patient’s presentation if you’re doing this in the clinic.

Because again, the tests just look a lot like the clinic looks. The one or two things that are going to point you in a direction to a specific diagnosis.

Now, this isn’t always easy. In the clinic, it isn’t, right? For example, how are you going to know polymyalgia rheumatica from polymyositis? It’s going to be hard. No good labs, but we do have the muscle biopsy in polymyositis. We do have that distinctive rash. How am I going to tell that from polyarteritis nodosa?

Well, that’s going to be the livedo reticularis, right? Look for the things that differentiate one disease from the other. And then when you’re studying, focus on that one thing. What is, I hesitate to say pathognomonic because the butterfly rash is not pathognomonic for polymyositis. Like we said, lupus has that too. There are other disease states that also have that. So pathognomonic is a stretch, but it’s a really good thing to hold onto and remember and create an anchor point for you to separate it from any other disease.

So when I study, I am first associating diseases with things I already know, with other diseases that are similar so that I can hook them all together in my mind. But then I’m moving on to what I call differentiation, which is then being able to pull them apart and tell them one from another and really work toward that understanding. And again, that’s the point of me including the differential diagnosis here today. And what I’m going to do moving forward is to give you ideas, not just of what you should be including in your differential, but that differential is what’s going to be our answer choices and how do you separate them? How do you differentiate one answer choice from another?

All right, let’s give you the answer to our priming questions. What is the characteristic rash of polyarteritis nodosa? What’s it called? I just said it not 30 seconds ago. Come on, you got this. Which type of juvenile rheumatoid arthritis involves systemic symptoms such as rash, hepatosplenomegaly, and hepatitis? Systemic juvenile rheumatoid arthritis.

I said that kind of in the question, didn’t I? Oh well. What is a diagnostic feature that distinguishes gout from other arthritic conditions when examining the joint fluid? What’s the joint fluid look like in gout? What’s that key term? Negatively birefringent crystals. What’s the drug of choice for an acute gout attack?

How do we get the pain under control? What’s the first thing we do? NSAIDs, specifically indomethacin. What’s the primary treatment for polymyositis? High-dose steroids. In polymyalgia rheumatica, where is the muscle pain most commonly experienced? Neck, shoulders, and hips.

Which condition is often associated with polymyalgia rheumatica? Giant cell arteritis, which is also known as temporal arteritis, right? So we know those are linked together.

Fantastic. All right, so we just cruised through rheumatology part one. Our next show will be rheumatology part two. We should be able to finish that up and get through all of that will end musculoskeletal, which is super exciting. Thank you for joining me here today. Always happy to have you aboard. And now, before I let you go, don’t forget to head over to physicianassistantexamreview.com/give and get yourself entered into the drawing for that ridiculous grand prize or one of the two runner-up prizes, right?

So definitely go over to physicianassistantexamreview.com/give to go ahead and get that for yourself. Take care, and I look forward to talking to you again next time. So long. Thank you.