1. Rheumatology Board Review Presentation - 2
Vikas Majithia, MD, MPH. 
Professor of Medicine,
Chief and Fellowship Program Director, Rheumatology.

2. Game-Plan Stimulate your mind and think with me Highlight the topics
Go over “educational objectives”
These are potential questions/test pertinent areas
Participate
If you want write, Use the handout from today otherwise just listen

4. Dermatomyositis-Polymyositis
Classification Criteria
Five criteria for DM and PM were proposed in 1975
Symmetric proximal muscle weakness
Elevated plasma muscle enzymes
Myopathic changes on electromyography
Characteristic muscle biopsy abnormalities and the absence of histopathologic signs of other myopathies
Typical rash of dermatomyositis

5. Dermatomyositis-Polymyositis
Other clinical features
1. fever and weight loss,
2. A nonerosive inflammatory polyarthritis,
3. Raynaud's phenomenon
4. Cardiopulmonary abnormalities also may occur.
5. Congestive heart failure due to myocarditis
6. Interstitial lung disease
MYOSITIS SPECIFIC ANTIBODIES:
Anti T Rna Synthetases : Anti Jo-1: associated with ILD
Anti Mi-2 (Dm)
Anti Pm-SCL
Anti SRP: associated with cardiac disease

6. Heliotrope Rash

7. Gottron’s sign/papules
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9. DIFFERENCES BETWEEN DM AND PM
Clinically, DM is associated with certain skin manifestations.
Ocular muscles are more frequently involved in DM.
DM Has a higher incidence of malignancy, although various cancers (GI, Lung, Ovary) can be associated with both DM and PM.
Pathogenetically, DM is associated with immune complex deposition in the vessels, whereas PM appears to reflect direct T cell-mediated muscle injury.

10. TREATMENT Corticosteroids 1 mg/kg are medications of choice
IV pulse steroids may be needed
Usually needed for a long duration: months to years.
Immunosuppressive therapies:
Azathioprine (Imuran)
Methotrexate
Combination of MTX and imuran
IV cyclophosphamide
IVIG
Biologics- TNF blockers, Rituximab

12. Inflammatory Myopathy
Questions asked
Patient scenario: middle aged or elderly female. Male age above 50.
Patient presents with weakness, hand and eyelid rash. Work-up should include? Likely diagnosis?
Same patient is at risk for what? What tests to do? Additional tests in female patient?
Patient with myositis presents with cough, SOB. What test? Antibody? Diagnosis?
Patient with myositis responded to steroids and MTX now weak again, CPK is 650. Diagnosis? Management?
65 year-old-male comes with weakness, CPK 600, abnormal EMG. Treated with prednisone, MTX for 5-6 months but no response. Diagnosis? Appropriate test? Treatment?
Myositis patient with left hip pain and abnormal exam. What test? Likely diagnosis?

13. Monoarthritis Monoarthralgia Exclude Periarticular Disease
Tendonitis, Bursitis, Bone lesion, Myofascial Pain, Sprain/Overuse, soft tissue infection, peri-articular GC infection
Monarticular Arthritis/ Arthalgia
Always consider Aspiration of joint for diagnosis
Cell count, Crystals, Gram stain, Culture
Crystalline disease
Gout/pseudo gout
True inflammatory changes in joint with urate or CPPD crystals on synovial fluid examination; cell count of ,000;
Cystic erosions (gout) or chondorcalcinosis (pseudgout) on X-ray
Osteoarthritis/trauma
Absence of inflammatory changes and <30 minutes AM stiffness with the presence of pain, crepitus, mild swelling, osteophytes; X-ray changes of joint narrowing, osteophytes formation, sclerosis;
Joint fluid aspirate either bloody or cell count<2000;
If diabetic, consider neuropathic joint
Seronegative spondyloarthropathy
Inflammatory changes of joint (particularly knee or ankle);
Synovial fluid cell count of ,000; involvement of eyes (conjunctivitis or uveitis) or back/sacroiliac joints with prolonged (>1 hour AM stiffness)
Early onset inflammatory arthritis
RA or SLE
Inflammatory joint changes with other etiologies excluded; with prolonged (>1 hour AM stiffness); with positive RF or ANA
Infection
Gonococcus
Staphylococcus
Streptococcus
Diagnostic features: True joint Inflammation with pain, swelling, erythema, Leukocytosis and fever, Synovial fluid cell count >50,000,
Positive gram stain and culture

14. Septic Arthritis

15. Synovial Fluid Analysis
Normal
Inflammatory
Septic
Hemorrhagic
Crystal Induced
Clear/Yellow
Transparent
Yellow/ White
Translucent/
opaque
Yellow/White
Opaque
Red
Yellow/ White, Translucent/opaque
<2K
2K-50K
>50K
N/a
10K-50K
-ve Gm stain & Culture (Cx)
-ve Gm stain & Culture
+/- Gm stain, +/- Culture
-ve Gm stain, Cx.
+ Crystals

16. Disseminated GC

17. Skin pustules in DGC

18. Infectious arthritis Questions asked
Patient scenario: Male, Acute symptoms (sub-acute female in DGI)
Elderly male presents to the ER with acute R knee pain/swelling: Next test, Results abnormal- What to do?
20-40 year old F with migratory arthritis: Knee-ankle-wrist, Tap shows 15,000 wbc. Has a rash. Diagnosis?
Travel to Connecticut, rash, fatigue, myalgia? History? Diagnosis? Treatment?
Same patient (did not get treatment)1 year later has CN palsy/knee arthritis. What to do?

19. Polyarthritis/ Polyarthralgia
Determine by History and Physical if inflammatory
(Prolonged AM stiffness, erythema, swelling, warmth, pain)
Evaluation dictated by history and physical may include CBC, urinalysis, liver and kidney function, RF, ANA,
ANCA, ESR, TSH, CPK, HBA1C, CXR and regional/back/SI joint X-rays
Non- Inflammatory
AM stiffness < 1 hour
No joint erythema, swelling and
Normal ESR
Negative RF or ANA
Implies a differential diagnosis of
Myofascial pain
Fibromyalgia
Osteoarthritis
Endocrinopathy
Pain syndrome
Inflammatory
AM stiffness > 1 hour
Joint erythema, swelling, or pain
And
Elevated ESR (must exclude other inflammatory diseases such as infection or cancer) Or
Positive RF
Positive ANA
Implies a differential diagnosis of:
Rheumatoid arthritis
Connective tissue disease (lupus, PSS, PM/DM, Sjogren’s)
Viral infection
Seronegative spondyloarthropathy
Sarcoidosis
Does not clearly fit into either category, Consider:
Seronegative RA
Seronegative spondyloarthropathy

20. SPONDYLOARTHROPATHIES
Ankylosing spondylitis
Reactive Arthritis – (Reiter’s)
Arthropathy of inflammatory bowel disease (Enteropathic Arthritis)
Psoriatic arthritis
Undifferentiated spondyloarthropathies
Juvenile chronic arthritis and juvenile-onset ankylosing spondylitis

21. CLINICAL CHARACTERISTICS OF SPONDYLOARTHROPATHIES
Tendency to cause sacroiliitis
Tendency to cause spondylitis
Association with enthesopathy (enthesitis)
Typical pattern of peripheral arthritis: usually lower limb, asymmetric, tenosynovitis (sausage digits)
Absence of rheumatoid factor (RF)
Absence of subcutaneous nodules and other extra-articular features of rheumatoid arthritis (RA)
Overlapping extra-articular features characteristic of the group (e.g., anterior uveitis)
Significant familial aggregation and association with HLA-B27

22. Sausage Digits

23. Management Physical modalities
NSAIDS - 1st line (Mild cases/stable dz-only Rx)
DMARDs (? Efficacy – SSZ, others)
New treatments- TNF alpha blockers.

24. Ankylosing Spondylitis
Inflammatory back pain
HLA B-27 associated
Symmetrical Sacroilitis
Spondylitis: erosion, squaring of the vertebrae
Uveitis; symmetrical
Atypical presentations: female, older age
Occiput to wall test
Schobere’s test
Enthesopathy.

25. Reactive Arthritis - GU (Prev Reiter’s Syndrome)
Inflammatory oligoarticular arthritis in the setting of previous or intercurrent nongonococcal urethritis and/or conjunctivitis is characteristic of patients with Reiter’s syndrome.
It is important to recognize that the majority of patients with this disorder present with just one or two features of the triad.
Clinical triad of urethritis, conjunctivitis, and inflammatory arthritis.
Mucocutaneous manifestations of Reiter’s syndrome: Circinate Balanitis and keratoderma
Enthesopathy.
Remember- Reactive arthritis of GI origin, Enteropathic arthritis & PsA

26. Keratoderma Blenorrhagica

27. Spondyloarthropathy/Infectious arthritis
Questions asked
Patient scenario: Male, sub-acute symptoms
Patient with back pain worse in AM and better with activity. What test? What eye manifestation (different in RA)? Differentiate from non-inflammatory back pain?
AS patient come with widened pulse pressure, heart murmur. What test? Diagnosis?
AS patient comes with weakness in legs, BB incontinence. Diagnosis? Treatment?
AS patient with pain/numbness affecting all 4 Ext UE>LE? Recently rear-ended? Next test? Diagnosis?
AS patient with SOB? Diagnosis?

28. Spondyloarthropathy/Infectious arthritis
Questions asked
Patient with R knee arthritis, h/o STD. Diagnosis? Eye manifestation? Associated Disease?
Patient with painful DIP, swollen 2nd toe. Exam has nail pitting, What else to look for? Diagnosis?
Japanese patient with recurrent oral/genital ulcers, arthritis. Diagnosis? Treatment?
Cruise ship (trip to Mexico etc) had diarrhoea, Now with 1-2 joint arthritis +/- sausage toe. Likely diagnosis? Associated organisms?
AS patient with back pain not responding to NSAIDs and SSZ. Treatment?

29. THE VASCULITIDES CLASSIFICATION SIZE OF THE VESSELS INVOLVED
ORGAN SYSTEMS INVOLVED

30. CLASSIFICATION
Large vessel: GCA and temporal arteritis, Takayasu’s arteritis, Primary angitis of CNS
Medium size vessels: PAN, Kawasaki disease, Granulomatosis with polyangitis i.e. GPA (Prev Wegener’s granulomatosus) EGPA (Prev Churg strauss syndrome),
Small vessels: GPA (Wegener’s), EGPA (Churg Strauss), Henoch Schonlein Purpura, Microscopic polyangitis (MPA), Mixed cryoglobulinemia, Hypersensitivity vasculitis/leukocytoclastic vasculitis, Vasculitis associated with rheumatic diseases- RA,SLE
Misc. : Behcet’s disease, Relapsing polychondritis, Lymphomatoid granulomatosis

31. CLINICAL MANIFESTATIONS
NON SPECIFIC:
Fatigue and weakness
Fever, skin rash
Arthralgias and/or arthritis
abdominal pain
hypertension
neurological dysfunction/neuritis.
SPECIFIC: PERTAINING TO THE ORANS INVOLVED
Pulmonary nodules
Sinus /nasal inflammation
Gastrointestinal inflammation with its presenting symptoms
Glomerulonephritis/renal insufficiency with an active sediment.

32. Hypersensitivity /leukocytoclastic vasculitis
Age >16
a possible offending agent in temporal relation to the symptoms
Palpable purpura
Maculopapular rash
Biopsy of a skin lesion showing neutrophils around an arteriole or venule
ANY OF THE VASCULITIDES WHICH CAN INVOLVE SMALL VESSELS CAN PRESENT AS PALPABLE PURPURA & HAVE A PATHOLOGY OF LEUKOCYTOCLASTIC VASCULITIS

33. THERAPY Hypersensitivity vasculitis – Systemic vasculitis :
Discontinuing the offending agent may be adequate
NSAIDS,Antihistamines.
Colchicine, dapsone
Corticosteroids as needed
Occasionally cytotoxic agents are required.
Systemic vasculitis :
Corticosteroids are almost always needed.
Cytotoxic agents have to be used in a number of instances.
Rituximab in ANCA associated Vasculitis (AAV)

35. Classification Criteria GPA – Wegner’s Granulomatosis
Nasal or oral inflammation (painful or painless oral ulcers or purulent or bloody nasal discharge)
Abnormal chest radiograph showing nodules, fixed infiltrates, or cavities
Abnormal urinary sediment (microscopic hematuria with or without red cell casts)
Granulomatous inflammation on biopsy of an artery or perivascular area
C-ANCA (anti proteinase-3) is now an important diagnostic test.
Up to 90% sensitive in active systemic disease.
Tissue biopsy can be diagnostic--A nasopharyngeal lesion, Renal biopsy, Lung biopsy

36. Saddle nose

37. Nodules

38. ACR Classification criteria: 3/10 + are 82% sensitive, 84% specific
POLYARTERITIS NODOSA
ACR Classification criteria: 3/10 + are 82% sensitive, 84% specific
Otherwise unexplained weight loss greater than 4 kg
Livedo reticularis
Testicular pain or tenderness
Myalgias (excluding shoulder and hip girdle), weakness of muscles, tenderness of leg muscles
Mononeuropathy (Mononeuritis Multiplex) or polyneuropathy
New onset diastolic blood pressure greater than 90 mmHg
Elevated levels of serum blood urea nitrogen or creatinine
Evidence of hepatitis B virus infection
Characteristic arteriographic abnormalities
A biopsy of small or medium-sized artery containing PMN’s.

39. Renal angiogram

40. Giant Cell (Temporal) Arteritis & Polymyalgia Rheumatica
PMR is classically characterized by aching and morning stiffness in the shoulder, hip girdles, neck and torso in patients over the age of 50.
The symptoms are usually symmetric and associated with a high ESR, but asymmetric pain and normal ESR can occur.
GCA (temporal) arteritis is a chronic vasculitis of large and medium size vessels which commonly occurs among individuals over 50 years of age.
Polymyalgia rheumatica occurs in about 50 percent of patients with GCA, while approximately 15 percent of patients with PMR as the primary diagnosis develop GCA

41. Symptoms/signs NON SPECIFIC: SPECIFIC:
fatigue, weakness, fever, arthralgias.
SPECIFIC:
new headache(60-70 %)
jaw claudication (30-40%)
Permanent partial or complete loss of vision in one or both eyes(15-20%)
arm claudication (10 %)
Tender or thickened temporal arteries.
Bruits in cranial and upper extremity vessels
Characteristic laboratory abnormality is a high ESR upto 100mm/h. normal values may occasionally be seen.

44. CRITERIA FOR GCA
Age greater than or equal to 50 years at time of disease onset
Localized headache of new onset
Tenderness or decreased pulse of the temporal artery
Erythrocyte sedimentation rate greater than 50 mm/h (Westergren)
Biopsy which includes an artery, and reveals a necrotizing arteritis with a predominance of mononuclear cells or a granulomatous process with multinucleated giant cells

45. TREATMENT Corticosteroids are the mainstay of treatment
Prednisone is started in at mg for PMR and titrated to a response in clinical and laboratory markers.
For GCA prednisone is started at a higher dose of 0.5 to 1 mg/kg. IV steroids may be needed for acute visual changes. Subsequently Slow taper is recommended.
Usually treatment is continued for 1- 2 years after remission.
Cytotoxic medications and methotrexate can be used and may be required both during acute and chronic phases.

46. Classification Criteria for Relapsing Polychondritis
Recurrent chondritis of both auricles
Nonerosive inflammatory polyarthritis
Chondritis of nasal cartilage
Inflammation of ocular structures, including
conjunctivitis, keratitis, scleritis/episcleritis
and/or uveitis
Chondritis of the respiratory tract involving laryngeal and/or tracheal cartilages
Cochlear and/or vestibular damage manifest by neurosensory hearing loss, tinnitus, and/or vertigo

47. The Vasculitides
Questions asked
Elderly (>50) patient presents with fever, stiffness? Next test? Treatment?
Same patient has headache, visual loss. Next test? Shortcoming of the test? Treatment?
Young Asian/Hispanic patient with pain, weakness in left arm. Finding on exam? Next test? Diagnosis?
Male patient with abdominal pain, weight loss, arthritis, leg ulcers, purpuric rash. Next test? Diagnosis? Associated findings?
Same patient also has history of IV drug abuse. underlying disease? What results on ANCA testing?
Same patient with foot drop. Diagnosis? Next test?
40-50 year old male patient with abdominal pain, arthritis, leg ulcers, purpuric rash. Next test? Diagnosis? Associated findings?

48. The Vasculitides Questions asked
Male patient with SOB, cough, weight loss, active urinary sediment, + p-ANCA. Next test? Diagnosis? Treatment?
Patient with sinusitis, nasal ulcer. Next test? Diagnosis? Treatment?
Same patient with hemoptysis, cough, renal insufficiency? Next test? Diagnosis? Treatment?
Patient with h/o asthma, rhinitis, now has cough, purpuric rash. chest x-ray: infiltrates. Next test? Diagnosis? Treatment?
Purpuric rash, URI, hematuria. Diagnosis? Treatment?
Urticarial rash, hematuria- active urinary sediment- Dx & Tx?
Recreational drug assoc pseudovasculitis- clinically vasculitis, -ve imaging & bx. Serology- ANCAs may be +. Culprit drugs? Cutting agents? Tests?
Patient started on HCTZ, now has a rash: palpable purpura. Diagnosis? Management?
Patient of Mediterranean descent with recurrent abdominal pain, fever, arthritis. + family history. Diagnosis? Treatment? Complication?

49. Osteoporosis: Diagnosis and Evaluation
Central DXA (Dual Energy X-ray Absorptiometry) remains the state-of-the-art diagnostic standard
Bone density is the most important predictor of fracture risk

51. What is a T-score? What is a Z-score?
The BMD results are expressed as standard deviations from a comparison to the referent mean.
A T-SCORE is the number of standard deviations the bone mineral density measurement is above or below the YOUNG-NORMAL MEAN bone mineral density.
A Z-SCORE is the number of standard deviations the measurement is above or below the AGE-MATCHED MEAN bone mineral density.

52. World Health Organization Interpretation of Bone Density
Patient’s T-Score
Classification
-0.5 T
-1.0 T
-1.5 T
-2.0 T
-2.5 T
Normal
Osteopenia
Osteoporosis
Severe Osteoporosis
(with fragility fractures)

53. National Osteoporosis Foundation
Who should be evaluated for OP.
Bone density test vs Fracture risk assessment?
Women:
Age > 65 without risk factors
Age > 50 with risk factors1
Men
Age > 70
Earlier – if there are risk factors*- osteoporotic fracture, hypogonadism, malignancy etc.
1. Risk factors for osteoporotic fracture include: low body weight;
history of fracture; Caucasian; cigarette smoking; estrogen deficiency, early menopause; low calcium intake; alcoholism; recurrent
falls; and inadequate physical activity.
* Not well-defined

54. Fracture Risk Assessment Score- FRAX
FRAX- Tool to assess fracture risk (Developed by WHO)
Decision making alogrithm for assessing the risk of fracture in an individual based on clinical information and using that
to make therapeutic decisions.
Can add BMD in the calculation
Gives a 10-year risk
A 10 year risk of overall fracture > 20% or hip fracture > 3% is felt to be significant.

55. National Osteoporosis Foundation
Who should be considered for treatment of OP.
Complicated answer
Women:
Age > 40 with low BMD (T-score <-2.5 i.e. OP) or high FRAX (T-score>1&<2.5 i.e. osteopenia)
Age < 40- individualize (risk factors, fracture, steroid use)
Men
low BMD (T-score <-2.5) or high FRAX
Younger patient, ?Age - individualize (risk factors, fracture, steroid use)

56. Traditional Nonpharmacological Management for Prevention and Treatment
Calcium (1200 – 1500 mg/day in divided doses)
Vitamin D IU/day*
Weight-bearing exercise
Fall-prevention techniques
*800 IU/day for patients over age 65

57. Fracture Prevention: Role of Drug Therapy
Anti-resorptive therapies:
Hormone replacement therapy (HRT)
Raloxifene
Bisphosphonates (C/I if GFR < 30)
Alendronate
Risedronate
Ibandronate
Pamidronate
Zolendronate
Calcitonin
RANK Ligand inhibitor- Denosumab (Prolia) (OK in moderate/sever renal disease)
Bone formative: PTH (Forteo)

58. Osteoarthritis
Primarily a disorder of cartilage associated with cartilage destruction and secondary bone changes
Most Common rheumatic disorder
Common cause of joint pain especially in elderly
Joint Pain: weight bearing joints, worse with activity & better with rest
AM stiffness is minimal
Typically involves DIP and PIP
Can have secondary synovitis (inflammation)
Common cause of back pain: remember SPINAL STENOSIS and its features
Typically normal lab studies
X-rays: joint space narrowing and osteophyte formation

61. Osteoarthritis Management Acetaminophen NSAIDs: Any NSAID works fine
Weight reduction and physical therapy
Local therapy
Intra-articular steroids
Intra-articular viscous supplementation ( Hyalgan, Synvisc etc)
only in knee OA
Narcotics
Role of joint replacement Surgery:
Treat patient not radiograph
Symptoms of Rest pain and night pain are indications for surgery
Functional impairment is also indication for surgery
Adequate medical work-up due to risk factors

62. Back Pain Mechanical Back Pain Minimal AM stiffness Intermittent
Improved with rest
Decreased ROM in all directions
Inflammatory Back pain
Prolonged AM stiffness
Persistent
Improved with activity
Decrease in Flexion/extension of spine: Schobere’s test
Remember symptoms and neurological signs of nerve impingement syndromes at various levels
Remember back pain (typically at night time) in elderly could be sign of malignancy
Remember back pain in elderly/immunosuppresed could be sign of chronic infection typically TB

63. Fibromyalgia Clinical Syndrome not a disease
Typically middle aged white females
No objective sign of joint inflammation
Associated with myofascial pain, fatigue, stiffness, lethargy
Alterations in normal sleep pattern
Associated with psychiatric syndromes, IBS, migraine, premenstrual syndrome
No diagnostic test: must rule out a serious underlying disorder
Tender points on examination ( 11 out of 18)
Management includes: counseling, improving sleep hygiene, graded exercise, SSRIs, Muscle relaxants, Ultram, treatment of psychiatry disorders

64. Osteoarthritis, OP, Fibromyalgia and Back pain
Questions asked
Patient with severe, persistent knee/hip pain, night pain. Treatment?
X-Ray findings, Treatment algorithm for OA
70-year-old female with back pain, night time worsening, point tenderness. Likely Diagnosis?
30-year-old with back pain radiating to leg. No neurological deficit. Diagnosis? Treatment?
45 year old with left sided back pain, radiation to foot, can not dorsi-flex big toe. What level is impingement? What reflex to look for?
35 year old female with fatigue, aching, poor sleep, ANA 1:40. Likely diagnosis? Treatment?
50 year old with history of radius fracture? What to work-up for? Test of choice?
Male with OP? testing?
Secondary causes of OP?
Comparative efficacy of various agents, SE and C/I
Fracture risk reduction of various agents

65. Other Board Pertinent Disorders
Pain, swelling of extremity after trauma. Area cool to touch, edematous, Hyperalgesia? Diagnosis? Test of choice?
Shoulder Injury and now pain in wrists/hands with above findings. Treatment?
Lyme disease- Arthritis (2nd stage), associated fibromyalgia. No ABX treatment of arthritis if treated in past
Pain hip: remember back/spine origin, tender outside (lateral side) of hips-diagnosis?
Pain knee: Normal exam,, Look for hip abnormality.
Pain knee: normal exam- ilio-tibial band syndrome. Medial side of tibia. Diagnosis?

66. Other Board Pertinent Disorders
Sarcoidosis: EN, Lofgren’s syndrome, others
Obese or diabetic patient with pain/burning pain ant thigh. Mild Sensory loss. Normal EMG. Diagnosis?
60 year old, smoker with pain in ankles, hands. Tender above ankle, clubbing, radiographs periosteitis. Diagnosis?
Corticosteroid toxicities including associated myopathy, AVN and osteoporosis
Carpal Tunnel Syndrome & association with hypothyroidism.

67. Buerger’s disease/ Thromboangiitis obliterans
Non-atherosclerotic, segmental, inflammatory disease that most commonly affects the small and medium sized arteries, veins, and nerves of the extremities
Normal ESR & CRP
Cellular/Inflammatory thrombus
Normal: auto-antibodies/other serologic tests
Cork screw blood vessels
Stop smoking

68. Osteomalacia, Vitamin D deficiency
Usually, the cause of osteomalacia is a deficiency in vitamin D
There are other causes: Low phosphate
Normal 25-OH vitamin D levels: 30 ng/ml
Replace with 50, 000 units once or twice a week for 3-6 months

69. DISH
Calcification and ossification along the anterolateral aspect of at least four contiguous vertebral bodies
Preservation of intervertebral disc height
Lack of findings of AS

70. Paget’s Disease (osteitis deformans)
Focal skeletal disorder characterized by an accelerated rate of bone turnover.
CLINICAL MANIFESTATIONS
Pain
Skeletal deformities and fractures
Bone tumors (remember osteosarcoma)
Neurologic complications (Hearing loss, CN Palsies)
Cardiac complications: Heart failure, Aortic stenosis, Conduction abnormalities
Calcium and phosphate metabolism, Elevated Alkaline phosphatase.
Treatment:
Bisphosphonates

71. Erythema Nodosum Causes Idiopathic Sarcoidosis IBD TB Fungal
URI: Viral/Bacterial
OCs
CTD
Treatment
NSAIDs
Potassium Iodide
GCs
Treat underlying disease

72. (REMEMBER DINNER AT CHAR IS GOING TO AWAIT YOU)
GOOD LUCK
(REMEMBER DINNER AT CHAR IS GOING TO AWAIT YOU)