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RheumatologyMain21-30Q1A30-year-oldfemalecomestoyourofficewithacomplaintofpainoverthelateralsideofherwristforthelastfourdays.Sheistwomonthspostpartumandnotesthatherpainismostseverewhensheliftsherinfantfromacrib.Onexamination,thereistendernessovertheradialsideofwristandfirstdorsalcompartment.Passivestretchingofthethumbtendonsovertheradialstyloidwhilethethumbisheldinflexionaggravatesthepain.Shedeniesanyrecenttraumaoverthetenderarea.Whichofthefollowingisthemostlikelydiagnosisinthispatient?A.OsteoarthritisoffirstmetacarpophalangealjointB.TriggerthumbC.DeQuervaintenosynovitisD.ScaphoidfractureE.FlexorcarpiradiaiistenosynovitisA1Correctanswer:CThepatientdescribedmostlikelyhasDeQuervaintenosynovitis,aconditionthatclassicallyaffectsnewmotherswhoholdtheirinfantswiththethumboutstretched(abducted/extended).Thisconditioniscausedbyinflammationoftheabductorpoliicislongusandextensorpoliicisbrevistendonsastheypassthroughafibroussheathattheradialstyloidprocess.Tendernesscantypicallybeelicitedwithdirectpalpationoftheradialsideofthewristatthebaseofthehand.Additionally,theFinkelsteintest,whichisconductedbypassivelystretchingtheaffectedtendonsbygraspingtheflexedthumbintothepalmwiththefingers,elicitspain.(ChoiceA)Osteoarthritisoffirstmetacarpophalangealjointwouldcausepainwithactivityoverthefirstmetacarpophalangealjoint,notatthecarpometacarpaljoint.(ChoiceB)Triggerthumbresultsinpainoverthepalmaraspectofthefirstmetacarpophalangealjointandlockingofthethumbinflexion.(ChoiceD)Scaphoidfracturestypicallyoccurduringforcefulhyperextensionofthewristasmayoccurinafailonanoutstretchedhand.Paintypicallylocalizestotheanatomicsnuffbox.(ChoiceE)Flexorcarpiradialistenosynovitisresultsinpainwithradialflexionofthewristandpointtendernessoverthetrapezium.Educationalobjective:DeQuervaintenosynovitisisaconditionthatclassicallyaffectsnewmotherswhoholdtheirInfantswiththethumboutstretched(abducted/extended).Theabductorpoliicislongusandextensorpoliicisbrevistendonsareaffected;passivestretchofthesetendonselicitspain.Q2A52~year-oldwomancomestothephysicianwitharashoverherfacethatbeganafewweeksago.Lately,thepatienthasalsobeenhavingdifficultyrisingfromaseatedpositionandclimbingstairs.Onexamination,anerythematousrashontheupperchestandviolaceousperiorbitaledemaarepresent.Hervitalsignsarewithinnormallimits.Examinationshowssymmetricproximalmuscleweaknessinthelegs.Thispatient'sconditionismostoftenassociatedwithwhichofthefollowing?A.AlveolarhemorrhageB.AorticaneurysmsC.CarpaltunnelsyndromeD.GlomerulonephritisE.MalignancyF.SuddenvisuallossA2Correctanswer:EThiswomanwithproximalmuscleweaknessandrashhasfeaturesconsistentwithdermatomyositis.Dermatomyositisisanautoimmuneconditionthatis6timesmorecommoninwomen.Initsmostclassicform,itcausesaproximalextensormuscleinflammatorymyopathyandcharacteristiccutaneousfindings(eg,violaceouspoikilodermaovervariousregionsofthebody).Ontheface,theeruptionismostoftenaccompaniedbyperiorbitaledemaandisknownastheheliotropesign.Onthechestandlateralneckitiscalledtheshawlsign.Ontheknuckles,elbows,andkneesitisreferredtoasGottron'ssign.Violaceous,slightlyscalypapulesoverlyingthejointsareknownasGottron'spapules;thesearepathognomonicfordermatomyositis.Patientshaveanelevatedcreatinephosphokinase(CPK)thatisgenerally10timestheupperlimitofnormal.Theclassicautoantibodiesassociatedwithdermatomyositisareanti-Jo-1(antisynthetaseantibody)andanti-Mi-2(againstheiicase).internalmalignanciesaremorecommonInpatientswithdermatomyositis(15%ofadultpatients)comparedtothegeneralpopulation.Themostcommonmalignanciesareovarian,lung,pancreatic,stomach,orcolorectalcancers,andnon-Hodgkinlymphoma.Regular,age-appropriatecancerscreeningisessentialInthesepatients.(ChoiceA)InflammatorydiseasesassociatedwithalveolarhemorrhageincludeGoodpasturesyndrome,granulomatosiswithpoiyangiitis(formerlyWegener's),microscopicpoiyangiitis,eosinophilicgranulomatosiswithpolyangiitis(formerlyChurg-Strausssyndrome),Behcetsyndrome,systemiclupuserythematosus,andantiphospholipidantibodysyndrome.Dermatomyositiscancausepulmonaryfibrosisinroughly10%ofpatients.(ChoiceB)InflammatorydiseasesassociatedwithaorticaneurysmsIncludeBehcetsyndrome.Takayasuarteritis,giantcellarteritis,ankylosingspondylitis,rheumatoidarthritis,psoriaticarthritis,relapsingpolychondritis,lgG4-relateddisease,andreactivearthritis.(ChoiceC)Inflammatoryordepositionaldiseasesassociatedwithcarpaltunnelsyndromeincluderheumatoidarthritis,sarcoidosis,hypothyroidism,andamyloidosis.(ChoiceD)Autoimmunediseasesassociatedwithglomerulonephritisincludesystemiclupuserythematosus,Goodpasturesyndrome,relapsingpolychondritis,cryoglobulinemia,granulomatosiswithpolyangiitis(formerlyWegener's),andmicroscopicpoiyangiitis,amongothers.ItisnotcommonfortheelevatedCKindermatomyositistocauseamyoglobin-inducedacutekidneyinjury,butwhenitdoesitisduetodirectinjurytothetubularcellsratherthantoglomerulonephritis.(ChoiceF)Autoimmunediseasesassociatedwithsuddenvisuallossincludetemporalarteritis,multiplesclerosis,and,rarely,systemiclupuserythematous.Educationalobjective:Derm