Goljan Muscles/Skin
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| Monosodium urate crystals (MSU) | yellow when parallel to slow ray of compensator
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| Calcium pyrophosphate crystals (pseudogout) | blue when parallel to slow ray of compensator
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| Osteoarthritis | degeneration articular cartilage; subchondral cysts; eburnation; osteophytes at margins
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| Joints | weight bearing (femoral head); DIP joint (Heberden’s nodes), PIP joints (Bouchard nodes)
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| Neuropathic joint | 2° to neurologic disease; DM, syringomyelia, tabes dorsalis
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| Rheumatoid arthritis (RA) | female dominant; HLA Dr4
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| RF | IgM antibody against Fc portion IgG; causes inflammation of synovial tissue
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| Pannus | inflamed hyperplastic synovial tissue destroys articular cartilage; joint fusion
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| Joints | MCP and PIP joints
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| S/S | morning stiffness; ulnar deviation of hands; carpal tunnel (entrapped median nerve)
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| Rx | methotrexate often used as initial therapy, aspirin
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| Sjogren’s syndrome | destruction lacrimal and minor salivary glands; RA; anti-SS-Ro/SS-La (SSa and SSb)
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| S/S | dry eyes and dry mouth
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| Caplan syndrome | pneumoconiosis + rheumatoid nodules in lungs
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| Felty’s syndrome | RA + splenomegaly with hypersplenism
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| Gouty arthritis | underexcretion uric acid; big toe first affected; tophus in soft tissue sign chronic gout
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| Gout associations | alcohol, Pb poisoning
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| Tophus | MSU crystals produce foreign body giant cell reaction next to joint
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| Uricosuric agents | probenecid and sulfinpyrazone
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| Allopurinol | ↓ synthesis uric acid; xanthine oxidase inhibitor
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| Pseudogout | involves knee; linear calcification in articular cartilage
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| Ankylosing spondylitis | HLA-B27 seronegative (RF negative) spondyloarthropathy; male dominant
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| S/S | sacroiliitis; bamboo spine causing kyphosis; aortitis; uveitis
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| Associations | C. trachomatis MC, psoriasis, ulcerative colitis, Shigella, Campylobacter, Yersinia
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| Reiter’s syndrome | HLA-B27; Chlamydia urethritis; arthritis; conjunctivitis; Achilles tendon periostitis
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| Osteomyelitis children | hematogenous spread of Staphylococcus aureus to metaphysis
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| Osteomyelitis in HbSS | Salmonella paratyphi
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| Pseudomonas aeruginosa osteomyelitis | puncture of foot when wearing rubber foot wear
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| Tuberculous osteomyelitis | usually involves vertebra (Pott’s disease)
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| Disseminated gonococcemia | female dominant; C6-C9 deficiency
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| Disseminated gonococcemia | septic arthritis (knee); tendinitis/synovitis and skin pustules in feet/wrists
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| Lyme disease | bite Ixodes tick; Borrelia burgdorjeri; reservoirs white footed mouse, white tailed deer
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| Early S/S | erythematous concentric rash (erythema chronicum migrans), Rx doxycycline
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| Late S/S | arthritis, Bell’s palsy (often bilateral), myocarditis, Rx doxycycline
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| Babesiosis | carried by Ixodes tick; Babesia are intraerythrocytic parasites; hemolytic anemia
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| Cat bite | potential for Pasteurella multocida septic arthritis
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| Osgood Schlatter’s | inflammation proximal tibial apophysis at patellar tendon insertion; knobby knee
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| Osteogenesis imperfecta | AD; ↓ synthesis type I collagen; pathologic fractures; blue sclera
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| Blue sclera | reflection choroidal veins
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| Achondroplasia | AD; impaired enchondral calcification and premature closure of epiphyses
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| S/S | normal head/vertebral column, short extremities
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| Osteopetrosis | AD/AR; osteoclast defect; too much bone; pathologic fractures
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| Osteoporosis | ↓ bone mass and density; pathologic fractures
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| Postmenopausal osteoporosis | estrogen deficiency - ↑ osteoclastic activity, ↓ osteoblastic activity
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| S/S | vertebral compression fractures, Colles fracture
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| Colles fracture | fractured distal radius with dinner fork appearance
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| Prevention | estrogen (under investigation), calcium, vitamin D, stress exercises (walking, weight lifting)
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| Aseptic necrosis femoral head | femoral head fracture, corticosteroids, sickle cell disease; MRI best test
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| Scaphoid bone fracture | aseptic necrosis in wrist bone
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| Volkmann’s ischemic contracture | fracture of distal radius; damage to brachial artery and median nerve
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| Legg-Perthe’s disease | aseptic necrosis of ossification center (femoral head) in children
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| Paget’s disease | elderly males; lytic/blastic bone lesions produce thick, weak bone
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| S/S | pathologic fractures; ↑ serum AP; ↑ risk for osteogenic sarcoma
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| Osteoid osteoma | radiolucent lesion in cortex proximal femur; nocturnal pain relieved by aspirin
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| Osteogenic sarcoma | adolescent male; RB suppressor gene association; distal femur; ↑ AP
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| Radiograph | “sunburst” appearance, Codman’s triangle
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| Ewing’s sarcoma | primitive neuroectodermal tumor; round cell tumor
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| Radiograph | “onion skinning”
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| Osteochondroma | MC benign bone tumor; exophytic growth off metaphysis of distal femur
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| Chondrosarcoma | MC malignant cartilaginous tumor; pelvic bones, proximal femur
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| Giant cell tumor | epiphysis distal femur/proximal tibia; giant cells + neoplastic mononuclear cells
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| Muscle weakness | primary muscle disease, neurosynapse disease, neurogenic disease
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| Duchenne’s muscular dystrophy | XR; deficiency dystrophin; ↑ serum CK at birth; waddling gait
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| Dystrophin | attaches portions of cell membrane to sarcomere; important in contraction
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| Becker’s dystrophy | XR, defective dystrophin
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| Myotonic dystrophy | AD; trinucleotide repeat disorder; cannot release grip
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| Myasthenia gravis | autoantibody against acetylcholine receptors (type II); thymic hyperplasia B cells
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| S/S | diplopia at end of day first sign; dysphagia solids/liquids upper esophagus; thymoma
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| Dupuytren’s contracture | fibromatosis palmar fascia
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| Lipoma | MC soft tissue tumor
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| Liposarcoma | MC adult sarcoma
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| Embryonal rhabdomyosarcoma | MC childhood sarcoma
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| Autoimmune disease | loss of self-tolerance
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| Serum ANA | greatest sensitivity for detecting SLE
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| SLE | type III reaction; confirm with anti-dsDNA, anti-Sm
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| S/S | malar rash, photophobia, joint pain, fibrinous pericarditis, nephritic GN
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| Drug-induced lupus | procainamide, hydralazine; anti-histone antibodies
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| Antiphospholipid antibodies | lupus anticoagulant, anti-cardiolipin antibodies; vessel thrombosis
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| PSS | excess collagen; anti-topoisomerase antibodies
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| S/S | dysphagia solids/liquids, Raynaud’s, intersitial lung disease, renal failure
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| CREST | centromere antibody/calcinosis; Raynaud; esophageal dysmotility; sclerodactyly; telangiectasia
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| Dermatomyositis/polymyositis | ↑ serum CK; risk of malignancy
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| Mixed connective tissue disease | anti-ribonucleoprotein antibody
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| Antibody against acetylcholine receptor | myasthenia gravis
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| Antibody against basement membrane | Goodpasture’s syndrome
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| Antibody against endomysium and gliadin | celiac disease
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| Antibody against insulin and islet cell | type I diabetes
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| Antibody against intrinsic factor and parietal cell | pernicious anemia
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| Antibody against microsome and thyroglobulin | Hashimoto’s thyroiditis
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| Antibody against mitochondria | primary biliary cirrhosis
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| Antibody against proteinase 3 of neutrophil (cANCA) | Wegener’s granulomatosis
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| Antibody against myeloperoxidase of neutrophil(pANCA) | microscopic polyangiitis
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| Antibody against TSH receptor | Graves disease
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| Ichthyosis vulgaris | ↑ thickness of stratum corneum; absent granular layer
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| Solar lentigo | “liver spot” in elderly; increased melanocytes
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| Senile purpura | trauma to fragile vessels on dorsum of hands; normal finding in elderly
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| Acute eczema | weeping rash with vesicles
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| Chronic eczema | dry, thickened, pruritic skin
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| Atopic dermatitis | dry skin, eczema (type I reaction); children - face, intertriginous areas
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| Allergic contact dermatitis | type IV hypersensitivity; poison ivy, nickel rash
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| Contact photodermatitis | tetracycline; rash in sun exposed areas
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| Superficial dermatophytoses | KOH preparation shows fungi located in stratum corneum
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| Tinea capitis | Trichophyton tonsurans MCC (negative Wood’s lamp)
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| Tinea capitis child with dog | Microsporum canis (positive Wood’s lamp)
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| Tinea versicolor | hypopigmentation; Malassezia furfur; “spaghetti” (hyphae)/”meatball” KOH
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| Seborrheic dermatitis | dandruff; Malassezia furfur
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| Molluscum contagiosum | poxvirus; bowl-shaped with central depression filled with keratin
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| Rubeola | Koplik’s spots; Warthin-Finkeldey giant cells
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| Rubella | teratogenic; rash; postauricular adenopathy; arthritis in adults
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| Parvovirus | “slapped face”; RBC aplasia, aplastic anemia (HbSS), spontaneous abortions, arthritis
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| Roseola | HSV-6; high fever and then rash
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| Toxic shock syndrome | toxin-producing S. aureus; tampon wearing; hypotension, desquamating rash
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| Scarlet fever | group A streptococcus with erythrogenic toxin; strawberry tongue
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| Actinic (solar) keratosis | precursor for squamous cell carcinoma; recur when scrapped off
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| Psoriasis | elevated salmon-colored plaques covered by silver-colored scales; nail pitting
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| Pityriasis rosea | herald patch followed by rash in lines of cleavage
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| Varicella | chickenpox; rash at different stages; Reye syndrome association
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| Herpes zoster | vesicular rash following a sensory dermatome
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| HSV and Varicella-zoster virus | remain latent in sensory ganglia
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| Impetigo | group A streptococcus; honey crusted lesions on face
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| Pemphigus vulgaris | autoimmune disease; IgG antibodies against intercellular attachment sites
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| Pemphigus vulgaris | intraepidermal bullae; acantholytic cells; row of tombstones
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| Bullous pemphigoid | autoimmune disease; IgG antibodies against basement membrane
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| Bullous pemphigoid | subepidermal bullae
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| Pemphigus vulgaris/bullous pemphigoid | type II hypersensitivity
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| Dermatitis herpetiformis | autoimmune disease; IgA ICs; subepidermal bullae with neutrophils
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| Dermatitis herpetiformis | association with celiac disease
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| Erythema multiforme | vesicles and bullae; bullseye appearance
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| Risk factors | drugs, M. pneumoniae infection
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| Stevens Johnson syndrome | erythema multiforrne involving mouth
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| Acne vulgaris | androgen dependent (receptor on sebaceous glands)
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| Acne vulgaris | Propionibacterium acnes lipases produce fatty acids causing inflammation
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| Acne rosacea | pustular, erythematous lesion on face resembling malar rash
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| Urticaria | type I and III reactions; type I due to mast cell release of histamine (drugs, fire ant bites)
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| Angioedema | subcutaneous swelling
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| Causes | ACE inhibitor (bradykinin); C1 esterase inhibitor deficiency (C2 and C4 decreased)
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| Sporotrichosis | traumatic implantation of Sporothrix fungus into subcutaneous tissue
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| Causes | rose gardener, lobster fisherman (sphagnum moss)
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| S/S | chain of subcutaneous nodules
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| Tuberculoid leprosy | intact cellular immunity (positive lepromin skin test); granulomas; no organisms
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| S/S | autoamputation of digits; skin depigmentation and anesthesia
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| Lepromatous leprosy | defective cellular immunity (negative lepromin skin test); no granulomas
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| S/S | leonine face, erythema nodosum during treatment
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| Histology | Grenz zone (zone free organisms) foamy macrophages with organisms
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| Rx | dapsone
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| Erythema nodosum | painful nodule on shins; subcutaneous fat inflammation
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| Associations | coccidioidomycosis, TB, leprosy
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| Keratoacanthoma | benign neoplasm; mimics squamous cancer; spontaneously resolves
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| UVB light cancers | basal cell carcinoma, squamous cell carcinoma, malignant melanoma
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| Vitiligo | autoimmune destruction melanocytes producing skin depigmentation
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| Seborrheic keratosis | pigmented, wart-like lesion; “stuck on” appearance
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| Leser-Trelat sign | multiple outcroppings seborrheic keratosis; consider stomach cancer
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| Acanthosis nigricans | verrucoid pigmented lesion usually in axilla; associated with gastric cancer
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| Chloasma | pregnancy mask due to increased melanocytes
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| Nevocellular nevus | benign pigmented tumor modified melanocytes
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| Histology | nevus cells proliferate along basal cell area, dermis, or both
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| Dysplastic nevus | precursor for malignant melanoma
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| Malignant melanoma | malignant tumor of melanocytes; most rapidly increasing cancer worldwide
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| ABCD for melanoma | A, asymmetry; B, irregular border; C, color change; D, increased diameter
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| Risk factors | severe sunburn at early age (MC), dysplastic nevi
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| Radial growth phase | spreads laterally in epidermis/superficial dermis but does not result in metastasis
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| Vertical growth | malignant cells penetrate into dermis; potential for metastasis
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| Lentigo malignant melanoma | face of elderly
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| Superficial spreading melanoma | lower extremities, back
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| Nodular melanoma | aggressive tumor with no radial growth phase
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| Acral lentiginous melanoma | palms, soles, under nails; may occur in blacks
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| Prognosis | depends most on depth of invasion
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| Prevention | sunscreen >15
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| Porphyria cutanea tarda | photosensitive bullous disease; deficiency uroporphyrinogen decarboxylase
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| S/S | hypertrichosis, fragile skin, port wine colored urine (uroporphyrins)
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| Black widow (Latrodectus) envenomation | neurotoxin; abdominal muscle cramps
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| Brown recluse (Loxosceles) envenomation | necrotoxin; skin ulcer
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