rotator cuff Injury is a common cause of shoulder pain and disability in athletes. Prolonged, repetitive overhead activity as in tennis, swimming, pitching or golf can compromise the space between the humeral head and coracoacromial arch leading to impingement syndrome. Subacromial bursitis results from impingement syndrome. It refers to inflammation of the subacromial bursa. Rotator cuff tendon tear and supraspinatus tendonitis can also occur as a part of impeachment syndrome. 1- Subacromial bursitis is characterized by shoulder pain, which is absent at rest but present on overhead activity. Range of active shoulder movements are limited by pain. Neer’s impingement sign (pain on passive internal rotation and forward flexion at shoulder) is present. No atrophy of shoulder muscle is present. Ultrasonogram or MRI generally confirms the diagnosis. Treatment is conservative with NSAIDs, physical therapy and activity modification 2- rotator cuff tear presents with: 1- shoulder pain aggravated by movements like pushing, pulling and positioning the arm above the shoulder (may also complains of night pain when he lies over the affected shoulder), as well as 2- weakness of shoulder resulting in functional impairment. 3- limitation of mid arc abduction or external rotation or both which does not reverse with lidocaine injection thus differentiating the rotator cuff tear from rotator cuff tendinitis. Definitive diagnosis of rotator cuff tear requires MRI or arthrography. MRI should be performed when rotator cuff tear is suspected on clinical grounds and patient has no other serious medical problem that will make the corrective surgery difficult. The above patient does not have any serious medical problem and his symptoms are incapacitating and he is very likely to be benefited from surgery. Cyclophosphamide adverse effects: alopecia, (sterility, amenorrhea), GI (nausea, vomiting diarrhea, mucositis, stomatitis), acute hemorrhagic cystitis, bladder carcinoma, and blood dyscrasias. The proposed mechanism for acute hemorrhagic cystitis and bladder cancer is irritation by acrolein that is a metabolite of cyclophosphamide. Taking plenty of fluids, voiding frequently and avoiding the drug at night can prevent this side effect. Use of mesna is sometimes indicated for this purpose. Sarcoidosis is basically two types: Acute and chronic. 1- Lofgren‟s syndrome (EN+Hilar+arthritis-ankle swelling) & Heerfordt-Waldenstrom syndrome r acute. 2- Chronic sarcoidosis has an insidious onset that develops over months. It mainly presents with respiratory complaints without constitutional symptoms. Very few patients have organs other than lung involved. It leads to permanent lung damage. CREST syndrome (80%)is a form of scleroderma that is localized. In this form hardening of the skin is limited to the face and hands whereas in the diffuse form it extends to involve the trunk and proximal extremities (+ no calcinosis) 20%. Eosinophilic fasciitis also presents with diffuse skin changes similar to systemic sclerosis. The inflammation is limited to the fascia and does not involve the epidermis or the dermis. These patients do not have Raynaud‟ s phenomena. Buerger’s Disease (thromboangiitis obliterans): pale and cold discomfort in his right calf during walk, pain in his feet at rest especially during the night + migratory superficial thrombophlebitis + Raynaud‟s phenomenon. The single most common cause of asymptomatic isolated elevation of alkaline phosphatase in an elderly patient is Paget’s disease. Paget‟s disease should be a strong consideration in a patient who has elevated serum alkaline phosphatase, normal serum calcium and serum phosphates and normal serum aminotransferases. Paget’s disease of the bone is characterized by excessive bone destruction and repair. It generally is asymptomatic and may be suspected by findings of elevated levels of alkaline phosphatase. The serum calcium, serum phosphates, and serum aminotransferases r usually normal. Over a period of time 1-3% of individuals will develop osteosarcoma or sarcomatous changes. This will manifest itself as marked bone pain, new lytic changes and a sudden increase in alkaline phosphatase. Lyme arthritis occurs as a result of untreated Lyme infection(3rd stage) The first episode occurs within six months of having erythema migrans. Joint involvement in Parvovirus infection is symmetrical. Hands, wrists, knees and feet are the most frequently involved joints. Rash may or may not be present. Patient may have arthralgias or arthritis. Joint involvement most frequently occurs in adult female. Detection of Anti-B19 IgM antibodies is the diagnostic study of choice. Bachet Dz: 1- Recurrent oral ulcers plus 2- two of the following features: recurrent genital ulcers; eye lesions (anterior uveitis and posterior uveitis; retinal vascularization); skin lesions(erythema nodosum, acneiform nodules and papulopustular lesions; and a positive pathergy test). Some patients have involvement of the gastrointestinal, skeletal and vascular systems. Combined environmental and hereditary factors are assumed to play a role in the pathophysiology of this condition. Corticosteroids offer relief from most of the symptoms but do not protect from progression to dementia or blindness. gonococcal arthritis asymmetric migratory polyarthralgia followed (after 1week) by monoarticular purulent arthritis in a sexually active patient with a characteristic skin rash (multiple necrotic pustules over palm and soles). promptly resolve with administration of ceftriaxone These Purulent gonococcal arthritis presents (acutely swollen and painful joint) usually follows (after 1w) disseminated gonococcal infection syndrome (rash+ tenosynovitis + polyarthralgia) may be asymptomatic. Patients of purulent gonococcal arthritis are usually afebrile. E. Coli is a common cause of septic arthritis in intravenous drug abusers, HIV should be considered in patients with Reiter‟s syndrome In patients with frequent attacks of acute gouty arthritis not controlled by colchicine, a 24-hour uric acid levels in urine is determined. This evaluates whether hyperuricemia is due to over production or under secretion of uric acid. A value of less than 800 mg/day suggests under secretion. A value of more than 800 mg/day suggests over production. Hence accordingly a uricosuric agent or a xanthine oxidase inhibitor is added to the patient‟s medication. The goal is to maintain serum uric acid levels to less than 6 mg/dL. anserine bursitis : pain and tenderness in the upper tibia over the medial knee region just medial tibial plateau just below the joint line (No other Abnormalitise- rednee, swelling). history of trauma. Valgus stress test does not aggravate the pain. X-ray of the tibia is normal. . Progressive low back pain not relieved by rest and worse at night suggests vertebral body metastasis. Secondaries to the bone mainly arise from primaries of the prostate, breast, lung, multiple myeloma, and lymphoma. Technetium 99 scinti scanning is the most effective method to assess bone metastasis. In patients with active nephritis, oral contraceptive pills shouldn’t be used as it can aggravate renal disease. Barriers method is used instead. Lumbago (Lumbosacral strain) is usually related to physical strain and has less dramatic onset. Usually paravertebral muscle tenderness rather than spinal tenderness is the feature. Acute onset of pain without an obvious trauma is typical. A compression fracture of the vertebrae is a common complication of advanced osteoporosis. Dupuytren’s contracture occurs in patients over the age of 50, commonly with history of diabetes mellitus, chronic alcoholism, epilepsy, or tuberculosis. It is also associated with Peyronie’s disease(dense fibrous tissue surrounding the corpus cavernosum of the penis cause penile bending and pain on erection), retroperitoneal fibrosis, and Reidel’s thyroiditis. It manifests as nodular thickening of the third and the fourth fingers with inability to extend completely. No functional loss occurs. Steroid injections are helpful in some patients. In others surgical ligation may be used. atheromatous embolism It occurs due to an embolization of atherothrombotic plaques. It is characterized by intact pulses, painful cyanotic toe("blue toe syndrome") along with features of ischemic lesions in distal limbs, such as livedo reticularis. This patient had features of calf discomfort and tenderness, secondary to small vessel problems. The problem can occur spontaneously, as in this patient and may occur secondary to surgical manipulations. Labs are significant for increased ESR, hypocomplementemia (not ordered in this patient) and eosinophilia. Features of renal involvement (high Cr) may occur. Flexor carpi radialis tenosynovitis is characterized by pain with wrist motion like active wrist flexion or passive wrist dorsiflexion De Quervain’s disease is characterized by tendonitis of abductor pollicis longus and extensor pollicis brevis as they pass beneath the retinacular pulley. It was originally described in washerwomen in whom these tendons were chronically irritated by wringing the clothes. However, in present times it is most commonly seen in post partum females due to repetitive lifting of the infant. Tenderness is noted over the radial side of wrist and first dorsal compartment. Clinical diagnosis can be made by positive Finkelstein maneuver (passive stretching of the thumb tendons over the radial styloid in thumb flexion aggravates pain). Treatment is best with local injection of long-acting steroids. Hydroxychloroquine is the safest drug for systemic lupus erythematosus (SLE). The most common side effects of hydroxychloroquine are allergic skin reactions and nausea but they are not serious ones. macular degeneration; so eye examinations at 6 months to 1 year intervals should be performed in all such patients who are taking this drug. Visual field defects, impaired color vision, bull‟s eye pattern on funds and corneal whirls can all occur with its use. Contraindications to its use include: G6PD deficiency, porphyria cutanea tarda, liver failure and hepatic failure. It is also need to be avoided in pregnancy Thoracic outlet syndrome refers to compression of the neurovascular structures supplying the upper extremity. It may be caused due to compression by scalene muscles, cervical ribs or congenital fibro muscular band. Motor vehicle accidents, playing musical instruments and chronic illnesses are other predisposing factors. Pain usually occurs from the point of compression to the axilla, shoulder, arm, forearm, and hand. Paresthesias are usually aggravated at night. Motor abnormalities include weakness and muscle atrophy. Vascular involvement presents as pallor, pulselessness, and coolness of the affected side; venous obstruction is marked by edema and cyanosis. An elevated arm stress test (EAST) is used for screening purposes. Chest x-ray, MRI, and angiography help in diagnosing the cause of compression. Conduction velocity studies identify the site of compression. Overhead pulley exercises, shoulder bracing and other postural changes help to relieve compression. Hepatitis-C virus infection account for at least 80% of the vasculitis cases associated with mixed cryoglobulinemia. Therefore all such patients should be tested for hepatitis C virus (HCV) infection by serum HCV antibody or HCV RNA. If these tests are negative, cryoprecipitate can be tested for HCV antibody or HCV RNA. (HBV, HIV rarely associated). Photosensitivity (Skin exam reveals round scaly elevated skin lesions with central atrophy on her forearms and chest, and an erythema on her cheekbones). Chronic renal failure is the most common cause of death in systemic lupus erythematosus patients, Acute renal crisis is a complication of systemic sclerosis. Acute renal crisis is characterized by malignant hypertension, which manifest by hypertensive encephalopathy, retinopathy, left ventricular failure, and seizures. cellulitis, which is a diffuse infection of deep layers of skin. Presence of fever, inflammatory signs, no crepitus or bullae and signs of overlying skin necrosis. This patient also had toe web tinea pedis, which is one of the most common portals of entry for the microorganisms, causing cellulitis. Cellulitis of calf is difficult to differentiate from deep venous thrombosis. However presence of high-grade fever, lymphangitis, absence of any risk factor such as orthopedic surgery, or prolonged immobilization make deep venous thrombosis unlikely. Necrotizing fasciitis is a deep-seated cellulitis. It should be suspected in a patient who has evidence of overlying skin necrosis, bullae, with anesthesia due to destruction of nerves, crepitus due to gas producing organism, and fever. Sclerosing panniculitis is acute tender lesion over the medial malleolus. It usually occurs in a patient with venous stasis of lower limb. Erysipelas is a superficial cellulitis. It usually affects cheek. The area involved become erythematous, tender, sharply demarcated and with vesicles or bullae. There is no element of lymphangitis. Fever is usually present. Erysipeloid is an edematous, purplish plaque with central clearing. It is caused by Erysipelothrix insidiosa. It usually occurs on the hands of fishermen and meat handlers. It is not very painful like cellulitis. Fever is not present. CTS: Tinel’s sign is elicited by tapping over the median nerve Phalen’s sign – flexion of both wrists to 90 degrees with the dorsal aspect of hands held in opposition for 60 seconds leads to pain or paresthesia along the median nerve. Carpal compression test is performed by, applying pressure over the carpal tunnel. This reproduces the patient‟s symptoms Square wrist sign - in this the ratio of wrist thickness to wrist width is measured. If the value is more than 0.7 then it is Nerve conduction studies are very useful in diagnosing the carpal tunnel syndrome. Erythema nodosum (EN) is characterized by pink to reddish painful, subcutaneous, nodules that usually develop in a pretibial location (on the anterior surfaces of both legs). They evolve into bruise-like lesions that resolve without scarring over a 2- 6week period. Histologically, this is a panniculitis involving inflammation of septa in the subcutaneous fat tissue. EN is commonly associated with recent streptococcal infections((ASO) titer), sarcoidosis (CXR), TB (PPD) in 3rd world, inflammatory bowel disease. Regular exercise/physiotherapy is the only beneficial treatment that halts the disease progression in ankylosing spondylitis, NSAIDS r added for pain. The treatment of choice for reactive arthritis or Reiter‟s syndrome is with NSAIDs. acute back pain: acute onset of pain(not localized) + positive straight-leg raise test => disk herniation.(( At the same time, no neurologic deficit is present and the perianal area is intact (it is always important to rule out cauda equina syndrome).)) These patients are managed conservatively. Patients should be advised to return to daily activities as soon as possible. Pain and stiffness is better managed with NSAIDs and muscle relaxants If the pain persists after 4-6 weeks of conservative treatment or progressive neurologic deficit evolves, high-resolution diagnostic modalities are usually employed: MRI. Emergency surgical decompressionis indicated in case of significant or rapidly progressive neurologic deficit (foot drop, weakness of the legs). Rheumatoid nodules are present in five to seven percent cases of SLE (acive Dz) In OA: x-ray shows narrow joint space, subchondral bone cysts, with bony spur. positive birefringence, which means these crystals appear blue when parallel, and yellow when perpendicular to the axis of the compensator. Coffin lid shaped crystals represent struvite crystals seen in nephrolithiasis. cervical spondylosis. It is estimated that cervical spondylosis affects 10% of people older than 50 years of age. The history of chronic neck pain is typical. Limited neck rotation and lateral bending is due to osteoarthritis and secondary muscle spasm. Sensory deficit is due to osteophyte-induced radiculopathy and isolated sensory abnormalities are associated with good prognosis. Typical radiographic findings include bony spurs and sclerotic facet joints. Interestingly, such „osteoarthritic‟ changes are common in asymptomatic patients older than 50 years of age; therefore, specificity of these findings are low. Other findings during cervical spondylosis may include narrowing of the disk spaces and hypertrophic vertebral bodies. Her PT is 9 sec (normal value is 8.2-10.3sec) and APTT is 39 sec (normal value is 21- 32sec). Myositis can be a feature present in cases of SLE but it is not included in the diagnostic criteria of SLE The titers of anti-DsDNA correlate well with disease activity of lupus nephritis. Complement deficiency is not the initial event and it results from complement activation by immune complexes(DsDNA) deposited in the glomerulus. Anti phospholipid antibody syndrome is characterized by recurrent arterial or venous thrombosis or recurrent fetal losses in the presence of anti phospholipid antibodies. Anti phospholipid antibodies are of three types. The first is responsible for false-positive syphilis serology. The second is lupus anticoagulant, which falsely elevates APTT. The third is anticardiolipin antibody. Reflex sympathetic dystrophy is a syndrome of pain and swelling associated with vasomotor instability. Any extremity may be involved but is more common in the hand. Usually there is associated movement restriction in the shoulder. Direct injury, neck and shoulder injuries, or myocardial infarction can cause this condition. Examination reveals a discolored limb with atrophic changes. X-ray reveals osteopenia, bone scan shows increased uptake. Physical therapy is done to restore function. Prednisone is indicated in resistant cases. Stellate ganglion block is also very effective frozen shoulder in which there is limited range of motion due to stiffness of glenohumeral joint. Chronic pain may be present but the most prominent symptom is joint stiffness. On examination, range of motion is restricted both on active and passive movement in all cardinal movements. This is a result of pericapsulitis. Majority of the cases are idiopathic. Arthroscopy establishes the diagnosis by showing decreased joint space volume, and loss of normal axillary pouch. The treatment involves NSAIDs, corticosteroids injection into the joint space, and physical therapy.. Prophylactic allopurinol is the most effective method to prevent gout in patients at risk for tumor lysis syndrome. lumbar stenosis: “spaghetti legs” or walking “like a drunken sailor” Total knee replacement is indicated in patients with severe restriction of walking and nocturnal and rest pain. Though the rehabilitation after knee replacement takes a long time, there is an excellent functional recovery. Intra-articular sodium hyaluronate injections may help in reducing symptoms to certain degree only. Not indicated in severely afflicted patients. Capsaicin cream is used to reduce pain, in individuals who cannot tolerate NSAIDs. Intra-articular triamcinolone injections are used in patients with osteoarthritis and knee effusion. Also used when NSAIDs are contraindicated. Thoracic aortic aneurysm, that is 16 times more common in patients of giant cell arteritis than the general population, is a serious complication and such patient need to have continuous monitoring. This aneurysm may dissect and prove to be fatal. The possible explanation for the development of aneurysm is disruption of collagen and elastin by chronic aortitis. Lip biopsy is the only specific diagnostic technique in Sjogren‟ s syndrome. It is a simple procedure with minimal risk involved. The diagnosis is confirmed when the biopsy shows lymphoid foci in accessory salivary glands. Parotid gland biopsy is not done as a diagnostic procedure in patients suspected to have Sjogren‟ s syndrome. It is usually reserved for those with atypical presentations. relapsing polychondritis is an idiopathic disorder characterized by recurrent inflammation of cartilaginous structures and other internal organs. Multiple organs may be involved in this disorder but involvement of ear is the most frequent. Other organs involved include eyes, joints, vascular system, skin and nervous system. Unilateral or bilateral inflammation of auricle occurs with sparing of the non-cartilaginous ear lobules and produces marked pain and tenderness. Skin of the auricle becomes violaceous or erythematous. There may be repeated episodes producing deformity of the auricle. Eye involvement is usually in the form of conjunctivitis, episcleritis or scleritis. Punched out erosion with a rim of cortical bone is the characteristic x-ray finding of gouty arthritis. Narrowing of joint space and juxta articular erosions is the characteristic x-ray finding in rheumatoid arthritis (RA). Normal joint space and soft tissue swelling is seen in patients with infectious arthritis such as Gonococcal arthritis. Marginal bony erosions and irregular joint destruction is found in patients with psoriatic arthritis. Narrowing of joint space and osteophyte formation for OA osteoarthritis. - Acetaminophen is the initial therapy to relieve pain in patients of osteoarthritis. -If analgesics, like acetaminophen, fail to control pain NSAIDs, like indomethacin, are indicated. -Cyclooxygenase-2 (COX-2) inhibitors, like celecoxib, are indicated for the treatment of osteoarthritis when patient is at risk for upper GI bleed and has failed to respond to analgesics. Weight reduction and exercise program only complement drug treatment. - Exercise program is meant to improve functional status of the patient. Weight reduction may improve the symptoms of knee osteoarthritis, but this patient is not obese and his symptoms are not too severe.