Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (102 page)

Primary dyslipidemias

• Familial hypercholesterolemia (FH, 1:500): defective LDL receptor; ↑↑ chol, nl TG; ↑ CAD

• Familial defective apoB100 (FDB, 1:1000): similar to FH

• Familial combined hyperlipidemia (FCH, 1:200): polygenic; ↑ chol, ↑ TG, ↓ HDL; ↑ CAD

• Familial dysbetalipoproteinemia (FDBL, 1:10,000): apoE ε2/ε2 + DM, obesity, renal disease, etc.;↑ chol and TG; tuberoeruptive and palmar striated xanthomas; ↑ CAD

• Familial hypertriglyceridemia (FHTG, 1:500): ↑ TG, ± ↑ chol, ↓ HDL, pancreatitis
Physical exam findings

• Tendon xanthomas: seen on Achilles, elbows and hands; imply LDL >300 mg/dL

• Eruptive xanthomas: pimple-like lesions on extensor surfaces; imply TG >1000 mg/dL

• Xanthelasma: yellowish streaks on eyelids seen in various dyslipidemias • Corneal arcus: common in older adults, imply hyperlipidemia in young Pts
Treatment

• Every 1 mmol (39 mg/dL) ↓ LDL → 22% ↓ major vascular events (CV death, MI, stroke, revasc) in individuals w/ & w/o CAD (
Lancet
2010;376:1670); in healthy individuals w/ LDL <130 mg/dL & hs-CRP >2, rosuvastatin → 47% ↓ CVD/MI/stroke (
NEJM
2008;359:2195) • Fewer clinical data, but TG <400 and HDL >40 are additional reasonable targets

ARTHRITIS—OVERVIEW

Approach to patient with joint pain

•
Articular
vs.
periarticular
(bursitis, tendinitis) pain: typically active ROM more painful in periarticular process than passive ROM

•
Inflammatory
vs.
noninflammatory
pain: features of inflammatory pain include swelling, warmth or redness in specific joint, persistence over days to weeks, prolonged morning stiffness (>30 min), improvement of pain/stiffness w/ motion/exercise • Physical exam (see table): localize complaint and identify objective signs of inflammation • The physical exam is only 50–70% sensitive for detecting inflammatory arthritis

^a
May initially present as arthralgia w/o signs of overt arthritis.
^b
Range of motion (ROM) of joint or joint associated with bursa or tendon.

Approach to arthritis

Figure 8-1 Approach to arthritis

Radiologic features

•
OA
plain films:
osteophyes
, asym joint space narrowing (JSN), subchondral sclerosis/cysts MRI may show early disease not seen on plain films; U/S
MRI for structural damage •
RA
plain films: early=periarticular
osteopenia
; late=
erosions
, symmetric JSN MRI & U/S able to detect early and subclinical disease; MRI
U/S for erosions •
Gout
plain films: early=nonspec swelling; late=
tophus
, joint erosions w/ overhanging edges U/S > MRI for detection of microtophi (double contour sign); MRI
U/S for erosions •
Spondyloarthritis
(sacroiliac joint)
plain films: pseudo-widening of joint space (early), sclerosis, erosions,
ankylosis
MRI most sensitive for early Δ in SIJ; U/S
MRI for early detection of peripheral enthesitis