Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 116 where we will be finishing up rheumatologic disorders and finishing up musculoskeletal in general. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review where we teach PA students how to dominate and get as much as possible out of PA school, ultimately pass the PANCE and land their dream jobs. That’s the goal, right? Speaking of dream jobs right up here at the front, I just did a talk for Beth and Katie over at Pre-PA Clinic. They put on a great weekend workshop this past weekend, and I spoke about job interviews.

And actually for the people here, it was for pre-PA. So I spoke about interviewing for PA school, but essentially the ideas are very, very similar in how you would interview for PA school, the preparation, what goes into it, as well as how you would interview for a job you’re really excited about getting. And I had a ton of fun. We had a bunch of pre-PAs on the call. It was really a lot of fun with great questions, great insight. I had an absolute blast. And I thought, geez, I haven’t really talked about this stuff a lot lately.

And it was a lot of fun for me. So what I’m going to do is later on this month in a couple of days, probably I’m going to go ahead and put the dream job package that I have and run a promotion on that. Probably that will be starting Thursday of this week, maybe Friday of this week. So this is September 12th of 2023, if you’re listening in the future. And what I’ll do is I’m going to include a live discussion where we’ll get on and we’ll answer your questions. And I’ll go through some of the information with you. Like I said, I just had a ton of fun doing this.

So we’re going to add that in as part of something you can’t normally get with the Dream Job Package. I can’t do it for everyone when it just sells normally. But if I do it during this promotion period, then we’ll add in a live coaching call where we can get your questions answered and go over some things in more detail. So if you’re on the email list over at physicianassistantexamreview.com, you’ll see all the information about that come out. Also, before we jump into today’s topic and finish up musculoskeletal, just a reminder that the November cohort for the 33 Days to Pass the PANCE program is open for registration. It is starting to slowly fill in now. It’s September, so it’s a little early, but it’s definitely starting to fill in.

And you can find out more information about that at physicianassistantexamreview.com/33. So what we do there is we help turn good students into amazing students, people who have struggled with the PANCE. Absolutely, this is designed for you people with the PANCE coming up. I definitely have people taking the PANRE involved in this almost in every single cohort. Students as early as didactic year who will find themselves behind and struggling in school, looking for new ways to improve their grades. It’s designed for people getting ready for the PANCE, but really, again, it’s all transferable. It’s better ways to study, better ways to take tests, better ways for self-management, for testing anxiety and those sorts of things.

And we do something that no one else does in that program. And I’m really, really proud of the results we’ve been getting. So anyway, all right, let’s go ahead and move on to covering our, let’s get started with our priming questions. There’s a few extra priming questions today. I had a little more fun than usual with this. So bear with me here. What is the primary trigger for reactive arthritis?

What is the primary trigger for reactive arthritis? How soon does it usually occur after that trigger? How soon does reactive arthritis occur after the trigger? What are the common symptoms of reactive arthritis? How do you distinguish clinically rheumatoid arthritis from other types of arthritis? What diagnostic test measures tear production and assesses the severity of dry eyes? Besides dryness, give another clinical finding associated with Sjogren’s syndrome.

Hopefully if you didn’t get those yet, this one should be a little easier. What is the classic clinical finding for scleroderma? What’s the classic clinical finding for scleroderma? Which gender is more frequently affected by scleroderma?

Perfect. All right.

Let’s go ahead and get started with reactive arthritis. Reactive arthritis is an autoimmune response triggered by a prior infection. And this is important here because it’s what you’re going to be looking for in the question stem, right? Or in the clinic. This is where the immune system continues to attack the body after the infection has been cleared. So a lot of these, right, the rheumatological issues are your immune system going haywire. A lot of problems that diseases cause are not necessarily caused by the disease, but they’re caused by your immune system, right?

So it’s something to really understand and get your brain around. This typically affects people ages 20 to 40 years old, and it affects males more frequently than females. Here’s your key line for reactive arthritis. It’s the I can’t see, I can’t pee, and I can’t climb a tree, which reflects the conjunctivitis, the urethritis, and the joint inflammation. It’s an asymmetric joint pain, typically involving larger joints. And then also you get lesions on the hands and feet. Outside of that, you know, the little saying, patients can get enthesitis, which is inflammation at sites where tendons or ligaments attach to the bone.

They can get low back pain and sacroiliitis. Lab studies and physical exam findings. You’re going to get a culture of the urethra or the cervix to identify and see what might be causing this, right? If they’re having arthritis symptoms, issues when they urinate, then that’s what you’re going to go for, right? So typically here, it’s going to be chlamydia. Now then, you may not find it, right? Because it’s going to, it could, you get reactive arthritis several weeks after the initial infection, right?

Right after that trigger. So you may not be able to culture for chlamydia, but you’re going to go ahead and do it anyway. You’re going to get something in this case, again, with the varied complaints the patient’s having, you may order a rheumatoid factor, right? Because we’re going to try to rule out rheumatoid arthritis. That’s going to be a common theme throughout all of these, right? So your rheumatoid factor is going to be negative, but you’re still going to be ordering it in these cases. Because again, picture how the patient’s going to walk in to your office, walk in and give you their symptoms.

Well, RA is going to be in your differential for almost all of these things we’ve been talking about, right? So you’re probably going to get a rheumatoid factor. An elevated C-reactive protein is going to show you some inflammation. Again, not really specific, but generally helpful. And then an HLA-B27. So it’s something like 75% of patients with reactive arthritis will have this positive, will have this finding, but obviously it’s not diagnostic for reactive arthritis.

All right, so what’s treatment like? We’ll think about this for a minute. How are we going to treat a reactive arthritis? We have an immune system basically overreacting to an infection. So what are we going to do to treat this? How would you handle this situation? Again, don’t memorize this list.

Think for a minute. What’s the first step in the management of reactive arthritis? Is? Well, step number one is going to be to clear the underlying infection, right? So if we find chlamydia, we’re going to treat that with something like azithromycin. After that, how do we sort of tamp down the immune system? Well, NSAIDs is a good place to start, right?

And then steroids, if we continue to have a problem. And again, I know that these can be difficult to discern between and to separate out that differential diagnosis, which we’ll get to in just a second. But a lot of the times the treatment is going to be very similar, right? The treatment is going to be steroids, get that inflammation under control. So our differential diagnosis here might be something like psoriatic arthritis or reactive arthritis triggered by something else or rheumatoid arthritis. Speaking of rheumatoid arthritis, let’s move on to rheumatoid arthritis. This is a chronic autoimmune disease characterized by inflammation of the synovium, leading to joint damage and pain.

Women are affected more frequently than men. An RA is a systemic condition which can affect any organ or tissue. Clinical presentation. Typically, this affects the small joints of the hands and feet. They’ll present with the classic hand findings, which we’ll get to in a second. They can get stiffness, most prominently in the morning, joint pain, and deformities in the hands and feet, like we said. So the joints will be swollen and stiff.

Usually there’s multiple small joints involved, most commonly the hands, feet, and cervical spine, although it can affect, like we said, any tissues really. Ulnar deviation in the wrists, which is a displacement of the fingers medially. That’s a very telltale sign for rheumatoid arthritis, right? It’s something that you should be able to picture in your mind. If you can’t, certainly pull up an image of it, and you should be something you should be able to hold on to. The same thing with a swan neck deformity or a boutonniere deformity. I’m going to describe them here briefly, but really you’re going to have to go and look at an image.

We’ll make it stick in your head a whole lot better. So a swan neck deformity is a PIP hyperextension with a DIP flexion, which just listening to that isn’t really helpful. Right? And the same with a boutonniere deformity, which is a PIP flexion with DIP hyperextension. You have to take a minute and think that through, right? You can’t just hear me say it. It’s never going to stick.

It has no value, right? I talk about data points in space not being easy to remember. Well, that description fits that perfectly here. You’re never going to hold on to that. You’re never going to remember it unless you sit down, look at an image, maybe draw it out once or twice, draw out the joints that are affected. Really, really simple, a little stick figure with a circle for the joints and get it to stick in your brain. Hammer toes are also very common.

When I used to work in foot and ankle orthopedics, we would see a good amount of of rheumatoid arthritis patients, a lot less than historically because the drugs have become so helpful with these people. But we did a lot of work with hammer toes with surprisingly bad foot deformities in these patients.

All right, what are some other physical exam findings? Rheumatoid nodules. Usually these are painless, firm lumps or masses that can develop under the skin. On an x-ray, well, what are you going to see on x-ray, right? You should be, again, be able to picture this. If we’re talking about some significant arthritis, you’re going to get joint space narrowing, deformities, bone erosion. And then the big one under x-rays, and this is important and something I could definitely see a test question coming up on is the C-spine involvement.

And the reason this is important is because any patient going to the operating room needs to have an x-ray of their cervical spine because you get atlantoaxial subluxation in rheumatoid arthritis patients, which is the first and second cervical vertebrae get instable, which means you can cause a spinal cord compression, especially in the reason you do it before a surgical procedure, is because when you intubate a patient, you’re tilting their head back and you can actually cause that spinal cord compression in an RA patient. So you want to get an X-ray to evaluate the risk of that, right? So very important and easy, easy test question to ask for a surgical question. Again, immunological studies, we’re going to get a rheumatoid factor, anti-nuclear antibodies. Then we’re going to move on to a CBC, a C-reactive protein. There’s also a lab test called an anti-citrullinated protein antibodies or anti-CCP. And a diagnosis is going to require two or more swollen joints, morning stiffness, lasting more than one hour for at least six weeks, rheumatoid factors or autoantibodies against ACPA, which is that anti-citrullinated protein antibody.

But remember, a negative autoantibody result does not exclude a diagnosis of RA. Our treatment here, once again, we’re going to use NSAIDs. You can use something like Celebrex, so a COX-2 inhibitor. And then most commonly is going to be something like methotrexate, which is a disease modifying anti-rheumatic drug. These help to modulate the immune system and keep it basically from overreacting. And methotrexate tends to be the first line, but do be aware it is teratogenic. Differential diagnosis.

So again, what are we separating this from? Basically, with things we’ve been talking about. So psoriatic arthritis, lupus, reactive arthritis, osteoarthritis. You could even from the last one, you can even say gout, right? This may be on your list if you have small joints in the feet that are bothering someone. Maybe if it’s just the one, you’re thinking about gout, but if it’s two, you know, you still have to separate gout from RA.

All right, let’s move on to lupus. Systemic lupus erythematosus, SLE. This is a complex autoimmune disease that can affect multiple organs and systems within the body. So lupus is, again, another autoimmune disease that has a characteristic presentation. SLE impacts females six times as frequently as males. I would definitely have that in my head. It also affects African-Americans more frequently than in Caucasians.

Again, if I’m looking for question stems, I’m going to have that in my picture for SLE, right? It’s probably going to be a African-American female who’s presenting with this. Clinical presentation, joint pain is very common. Hands, wrists, and knees most frequently affected. So what’s the problem there? Well, the problem there is almost everything we’ve talked about so far has joint pain as a symptom, right? So it’s tough to use that to separate these.

They can have general malaise and fatigue. They can get fevers due to the immune responses that they’re having. They can get chest pain due to secondary to pericarditis. The big one that you should hang on to and hope to see on your test, although you may not see it this way, is the butterfly rash across the cheeks and nose, that malar rash, right? They can have mouth sores and photosensitivity. So again, you’re just looking for ways, how do I separate systemic lupus from rheumatoid arthritis? How do I separate it from reactive arthritis?

How do I tell that this patient has lupus? It’s not easy. And I understand that, right? That’s why we’re going through some of these, but it’s not going to be easy in the clinic. It’s not going to be easy in your test. Lab studies and physical exam findings. Yeah, we have that butterfly rash, which you’re hoping is in your test question, but probably won’t be.

You’re going to get a CBC. These patients can have kidney issues, so you’re going to get a BUN creatinine, urinalysis, SED rate, anti-nuclear antibody tests. And this will be 100% of SLE cases will have an ANA, positive ANA, but it’s not specific for lupus. So it’s not diagnostic, but it will help push you in the right direction. Treatments. Well, what are our treatments going to be? NSAIDs for pain relief and inflammation control.

Steroids if we need to, to really tamp down that immune system. And the DMARD of choice for SLE, from what I could find, is hydroxychloroquine. It reduces inflammation and flare-ups for SLE and reduces overall immune system activity or overactivity.

All right, so what do you think our differential diagnosis is going to be here, right? So it could be rheumatoid arthritis. It could be systemic sclerosis, which we’re going to get to in a second. It could be dermatomyositis. It could be all kinds of things, right? And that’s what makes these so very difficult.

All right, let’s talk about systemic sclerosis or scleroderma. Sclero means hardening and derma means skin. So scleroderma is actually more descriptive, but because it affects more than just the skin, we need a better term. There are two subtypes for scleroderma. You have limited scleroderma or CREST syndrome and diffuse scleroderma. You should definitely know what the acronym CREST stands for. So calcinosis, which is nodules under the skin.

The R is for Raynaud’s, which hopefully you know is a vascular issue usually found in the hands, where in severe, in any kind of cold, you get vasoconstriction, extreme spasm of the vessels in the hands where the blood flow just drops. So the patient’s fingers will turn blue and then white because they’re literally not getting blood supply. It’s usually triggered by cold. I know a lot of people who have this, who have trouble scrubbing before surgery even, or because we keep the OR so cold, they have trouble with their hands secondary to this. The E is for esophageal problems, so they have difficulty swallowing. S is for sclerodactyly, so the thickening of the skin over the fingers. And T is for telangiectasias, those dilated little blood vessels.

Or you could have diffuse scleroderma, so that was for limited scleroderma, that’s CREST syndrome, or diffuse scleroderma, which affects larger skin areas and one or more organ systems. So again, we can get a more systemic issue there. Clinical presentation. So those CREST symptoms like I talked about, I’m not going to go through each of them again. They can get chest pain or shortness of breath though, because if you have heart or lung involvement and a dry cough, if you have lung involvement, you can get joint pain and decreased range of motion. Again, if we have joint involvement, it’s not the primary symptom here, but it’s certainly on the list. Lab studies and physical exam findings.

There’s a characteristic thickened skin on physical exam, the patient discussing or demonstrating Raynaud’s, and then those telangiectasias if you see those. Again, not a ton to go on there, right? And as far as labs go, again, not incredibly helpful. Your rheumatoid factor is going to be negative. Antinuclear antibody is typically positive, but not diagnostic. C-reactive protein is going to be elevated. Your inflammation markers will be elevated.

And then if they have other symptoms, you can obviously do your urinalysis and BUN, creatinine. All of those will come up and be helpful. But again, none of that is really going to settle you in here. This is a picture you have to be able to have an idea in your head and kind of be looking for it. As far as treatments go, there’s no cure for scleroderma. You’re going to manage the symptoms so like Raynaud’s, you’re going to avoid cold weather. You can use vasodilators for Raynaud’s, which will help, calcium channel blockers.

In all of these things, we can wind up with NSAIDs and steroids to help with pain and inflammation. And something like antacids if they’re having esophageal symptoms. So, you can treat each symptom essentially as we go. And try to keep the patients as comfortable as possible. Our differential diagnosis here would obviously include lupus, rheumatoid arthritis, maybe dermatomyositis, polymyositis, those sorts of things, reactive arthritis. So how do we, again, in a test question, how are you going to write it? How are you going to separate them?

Our last one for the day is Sjogren’s syndrome, which is a little easier for people to get their minds around. It’s a little easier to hold on to the picture of as opposed to the last few we’ve been talking about, which are, again, hard to separate out those pictures. But Sjogren’s is an autoimmune disease characterized by the destruction of the salivary and lacrimal glands. So you get a lot of dryness symptoms, right? So the clinical presentation is dry eyes, xerostomia, which is a dry mouth, cavities is a big one because of that dry mouth, dry skin, and vaginal dryness. Lab studies and physical exam findings. So Schirmer’s test is one I would definitely hold on to here.

It’s a diagnostic test to measure tear production. An anti-nuclear antibody may be positive. You may get elevated rheumatoid factor, but this is not going to be specific enough to be diagnostic. Then there’s something called the Rose Bengal test, which is used to evaluate lacrimal gland function and the extent of the dry eye syndrome. Treatment. So again, there’s no cure for Sjogren’s. We’re just managing symptoms.

So if they’re having pain, they can use NSAIDs. Eye drops and artificial tears and lubricants are helpful. So there’s something called a punctal plug, which is a tiny device you insert into the tear duct to slow down the drainage of the tears and keep the eyes moist. Don’t know personally anything about it, but it sounds interesting. You can use vaginal lubricants. And then regular dental care is really important for these patients, because without the salivary glands, they develop a lot of cavities. It’s really important for these patients.

Differential diagnosis, again, is going to be something like rheumatoid arthritis or lupus. And that, my friends, will wrap up not only rheumatological disorders, but also musculoskeletal system, which I know there’s a group of people who love musculoskeletal, and there’s a group of people out there who greatly dislike musculoskeletal and find it very difficult and they struggle with it. This section in particular is hard, right? Reactive arthritis, polymyositis, rheumatoid arthritis, scleroderma, fibromyalgia, juvenile RA. All these things are really tough to separate. And understand it’s the same in the clinic. It’s not easy.

Like I said, I have a very good friend who has dermatomyositis, and it took them months to diagnose them. This is not run-of-the-mill strep throat, right? These are difficult things to separate out and diagnose and then treat appropriately. So if you feel a little lost in these sections, let it, it’s okay. You kind of should, right? Practitioners who do this all the time feel lost in these sections and will miss these diagnoses. Diagnoses, I’m struggling myself.

So just be, give yourself a little bit of grace here. And honestly, that can be our study tip for today is this section’s hard. If you can really grab onto one or two of these, Sjogren’s syndrome, for instance, you should absolutely hang on to Sjogren’s syndrome because that’s easy to pull apart, right? That’s the dryness one. But to separate lupus from scleroderma may be difficult for you. Separating RA from polymyositis may be difficult. I’m sorry, RA may be difficult.

Grab onto one or two of these and learn it really well. So when you get to your test, if it’s that one, you’re going to nail it. Or you can at least remove it from your multiple choice answers and help yourself. Then add in a second one, then add in a third one. Don’t try to learn them all at once. It’s much too hard unless you can learn them to compare them to each other like we’ve talked about. I hope that makes sense and I hope you take that to heart.

That’s really a valuable approach that I just gave you. I know I just sort of glossed over it. But if you can learn one or two of these from the last two sessions and really know them well, and then over time add one or two more, I think you’ll be in really good shape.

All right, let’s answer our priming questions. What is the primary trigger for reactive arthritis? Well, it’s going to be a bacterial infection, usually GU or GI, typically chlamydia. And symptoms typically develop one to four weeks after the trigger. What are the common symptoms of reactive arthritis? Eye pain, joint pain, and genitourinary symptoms, right? Can’t see, can’t pee, can’t climb a tree.

What is the primary feature that distinguishes RA from other types of arthritis? This one is something, again, you should hold on to this. Here you have symmetric joint involvement and systemic features. So RA will have both hands involved, right? Osteoarthritis is going to be one knee hurts. Maybe both knees, right? Could.

But with RA, it’s generally going to be symmetric. What diagnostic test measures tear production and assesses the severity of dry eyes and Sjogren’s syndrome? Do you remember which one that was? That was Schirmer’s test. Besides dryness, give another clinical finding associated with Sjogren’s syndrome. What else do you find in Sjogren’s syndrome besides the dryness? What will often bring patients in?

It’s the cavities, right? Their dentist will send them in. What is the classic clinical finding for scleroderma? That butterfly rash. What laboratory test is present in 100% of scleroderma cases but is not specific to scleroderma? Anti-nuclear antibody. And then lastly, which gender is more frequently affected by SLE?

Which gender is more frequently affected by SLE? Females are six times as likely to get it as males. If you’re looking for more questions like this, you can head over to the website physicianassistantexamreview.com/msk. That will get you 25 more questions just like this on the musculoskeletal system pulled straight from The Final Step. You can find all the notes, as always, over on the website for this section, all the previous sections, if you go to physicianassistantexamreview.com and look for, I think it’s under blueprint in the top menu bar, and you’ll find all that there. Anyway, that’ll wrap us up for musculoskeletal, and I look forward to starting neuro with you next time. Good luck, take care, and I can’t wait to see you again.

Thank you.