Rheumatoid Arthritis

Diagnostic Criteria for Rheumatoid Arthritis




Morning Stifness: morning stifness lasting at least 1h since the start of the stifness till the complete remision.

Arthritis in three or more joints: Arthritis in three or more joints regions of the fourteen following: metacarpophalageal, proximal interphalageal, wrists, eldbow, knees, anckles and metatarsophalangeal.

Arthritis in the hand: arthritis in the wrist, metacarpophalangeal and proximal interpahlangeal joints.

Symetric Arthritis: The arthritis is symetric and do not affect the lumbar region except the cervical region.

To this part of the list the symptoms has long at least six months.

Rheumatoid Nodules: Subcutaneous nodules in the joints or over bony prominences.

Rheumatic Factor: Rheumatic factor positive and Anti-CCP

Radiographs: Imaging tests indicating rheumatoid arthritis.

If > or = 4 there is Rheumatoid Arthritis diagnose and if the result is 2 the physician cannotexclude the diagnose.

Clinical aspects

There is historical description for rheumatoid arthritis and several presentation forms.

Z deformity: deviation at the wrist with ulnar deviation of the digits, often with palmar subluxation of the proximal phalanges.



Swan-Neck deformity: Flexion of distal interphalangeal joints and extension of metacarpophalangeal joints.

Boutoniere deformity: Extension of the distal interphalangeal joint and flexion of the proximal metacarpophalangeal joint.

Mallet finger: is a swan-neck deformity of the finger with loss of movility and pinch.



Hallux Valgus: is a foot deformity in which the toe has a lateral deviation.




Baker cyst: Is due to accumulation of sinovial fluid of the knee joint in the popliteal region.

SLE - Systemic Lupus Erythematosous

Diagnostic Criteria SLE

Malar Rash: Is a fixed erythema, flat or raised, over the nose, cheeks or forehead.



Discoid rash: Are an erythematous central patches normally raised with keratotic and scaly rims, atrophy scarring may occur.

Renal disorder: Proteinuria > 0.5 g/d, >3+ or cells casts.

Arthralgia: Joint pain in two or more peripheral joints, with tenderness, swelling or effusion.

Photophobia: Rash due UV rays.

Oral ulcers: Oral ulcers usually in the nasopharigeal region or in the oral mucose. Apthous like lessions.

Neurologic Disorder: Seizures or psychosis. Mood change.

Serositis: Pericarditis or pleuritis with effusion.

Cytopenias: Anemia, leukopenia, lymphopenia or thrombocytopenia.

ANA's: Antinuclear antibodies in serum tests or in immunofluorescence test.

Antibodies: Anti-dsDNA, Anti-SM and/or Anti-phospholipids.

If > or = 4 there is high probability to be a SLE patient with 95% sensibility and 75% specifity.

Note: the signs and symptoms could appear at any time of a well documented patient's history.

References

Harrison - Internal Medicine 17º Edition

STREPTOCOCCUS PNEUMONIE

STREPTOCOCCUS PNEUMONIE

Morphology

Is gram + coccus, facultative anaerobic, encapsulated, catalase -, alpha hemoliticus, has no movility, is no spore former, grows in chocolate agar and has 90 serotypes.

Colonies

This bacteria formes a mucose colonia, umbilicated ( with a central depretion) and do viridans hemolysis.

Virulence Factors

Adherence: the adherence to epitellium is mediated by surface proteins.
Capsule: Allow him to elude the immune response. is the most important virulence factor.
Peptidoglicane: Lipoteicoic and teicoic acid allows to ellicit immune response and make bigger inflamation due TLR5.
Coline Phosphate: links to PAF-R and allows the cell enter into the epitellium and elude opsonization and phagocitosis.
Pneumolisine: Is a citotoxic toxine, links to cholesterol and formes pores in the membrane of PMN, monocytes and lymphocites.
Autolisine: Is a protein that clives the peptidoglicane and bring outside the Hypometylated-DNA to performe a immune response due TLR9.

Clinical Manifestations

Neumonie: It's the princiapl manifestation in children and less prevalent in adults. The symptoms include fevere, dispnea, pleuritic pain, chills, night sweat, mucopurulent spute.

Another manifestations: Meningitis, Middle otitis, osteomielitis, sinusitis.

Dx

The diagnostic is performed with clinical manifestations, X-ray and laboratory tests.

Laboratory Tests

Gram Dyeing: With the well taken sputum of the patient, the sample is carried to the laboratory, and the best sample will be the one with: many bacterias, few epitellium and very immune complexes. The culture is only performed in the gram dyeing with mored than 25 bacterias and less than 10 epitellium cells.

Culture: Is performed in chocolate, blood and Mckonkey agar; in sterile recipient.

Antibiograme: Is very useful because of penicilline resistance. Also is very useful to confirme the bacteria with the optoquidine test.

Treatment: 3d generation Cephalosporine (e.g. Ceftriaxone). In resistent infections is useful a macrolide (e.g. Azytromicine) or a quinolone (e.g. levofloxacine)

ABDOMINAL INSPECTION

ABDOMINAL INSPECTION

The following images are an exposition part that i'd do.

When the doctor is doing the abdominal inspection, there are certain cases in which is possible speculate the diagnosis.

Courvoisier-Terrier Sign

If a patient had a visible and palpable gallblader and jaundice, the physician can think in pancreas head carcinoma with a 95% specifity. This is due to biliary duct obstruction by a mass.


Cullen Sign

If a patient has a periumbilical ecchymosis, got Cullen sign due to retroperitoneal bleeding that goes thorugh the falciform ligament, and pass till subcutaneus tissue due to conective tissue of the redondus ligament. This is unusual but indicate an acute pancreatitis.

Turner Sign

If a patient has a flank ecchymosis got the turner sign (also called Grey-turner). This happens due to para-renal space bleeding that goes with the quadratus lumborum muscle and pass through the flank muscle fascia, probably for a defect of the fascia. Lastly, the blood pass through the subcutaneous tissue. This is also unusual and indicate acute pancreatitis.


Erythema Ab igne

If a patient has a brown livedo reticularis-like pigmentation, the doctor could think in two possible options: a physical damage of the skin (e.g. heat exposure) and a chronic pancreatitis.




Sister Mary Joseph's Nodule

Metastasic cancer of the umbilillicus associated with gastrointestinal and ovarian tumors. This condition was named for Sister Mary Joseph (1856–1939), a surgical assistant for Dr. William
Mayo, who noted the association between paraumbilical nodules observed during skin
preparation for surgery and metastatic intraabdominal cancer confirmed at surgery.



References

- Sopeña Bernardo et all; Visible gallbladder. Medical images; 2007

- Mok Daniel H M et all; Erythema Ab igne in chronic pancreatitis: a diagnostic sign; Journal of royal society of medicine; 1984

- Mookadam Farouk et all; Cullen’s and turner’s signs; NEJM; 2005

- Kanter, Judith et all. Sister Mary Joseph's Nodule - NEJM