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2018 ABIM Awesome Review > 2018 Rheumatology and Orthopedics 9% > Flashcards

2018 Rheumatology and Orthopedics 9% Flashcards

1
Q

Osteoarthritis

A

DIP(heberden’s), PIP (bouchard’s)

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2
Q

Rheumatoid arthritis

A

PIP, MCP

boggy sensation

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3
Q

Psoriasis

A

DIP

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4
Q

Scleroderma

A

PIP, MCP

tendon friction rub

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5
Q

Heartburn + dysphasia + thickened skin=

A

scleroderma

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6
Q

Poor prognositc factors for Rheum Arthritis

A

Progressive synovitis
Joit space loss/erosiions
Inc Rh factor >1:80
Inc ESR

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7
Q

70yo F early morning stiffness >45min & symmetric small joint pain in 2nd-4th MCP and 2-5th MCP and PIP in L hand - jnt pain in R knee for 6 wks and ESR 48 - swelling of MCP and PIP RH neg wtd?

A

Start tx

Anti-CCP +

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8
Q

Antlanto odontoid subluxation

A

compress vertibrobasilar artery-> lightheadedness, sncope
screen for subluxation with lat xray before anesthesia

Compress cord -> sensory /motor /quadriplegia
Pts w/ RA can also present w/ carpal tunnel/ tarsal tunnel syndromes

????8mm asyx - surgical correction
Sx any size sx corretion

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9
Q

Pt with rheum arthritis can present with what?

A

carpel tunnel tarsal tunnel

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10
Q

Extra articular manifestations of RA

A

—–‘spill over of active disease from synovium’
-Rheumatoid nodules (inc’d RH factor (- in 15%))**
-Vasculitis/DR4 –> poor prognostic factor
(ulcers in fingertips = .vasculitis)
???RF leaves joint thru capillaries-> inflamm, ulcers

  • —-Heart
  • Effusion
  • Constrictive pericarditis - early S3 positive
  • Myocarditis
  • —Lung
  • Rheumatoid nodules (Caplan’s syndrome)
  • Pleural effusion (low glucose, high LDH, exudative)
  • BO (bronchiolis obliterans)
  • Interstitial fibrosis
  • Hypersenitive pneumonitis (methotrexate is a cause)
  • —Blood anemia of inflammation
  • —Vasculitis - necrosis, ulceration at tip of fingers
  • —Nerve - Mononeuritis multiplex->foot/hand drop

—-Skin - rheumatoid nodules (most common extra articular manifestation - RH factor inc’d

-----Renal - usually lsate stage with amyloid nephropathy--> diagnose w/ congo red staining and you see apple green 
Drug induced( NSAID--> minimal change, Peniclliamine -->nephrotic syndrome)
  • –Eye - scleritis - deeper - r/o globe rupture
  • –episleritis - superficial both autoimmune, UC> Crohn’s
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11
Q

???Fx vs sprain

A

4 steps without sx

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12
Q

????HCV with mixed cryoglobuinemia

A

vasulitis and LE ulcers

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13
Q

Tx for RA

A

Mild to Mod: Methotrexate (decreases mortality) +/- NSAIDS +/- hydroxychoroquine (plaquenil) (make sure you get a baseline eye exam, opt in 5 yrs, then yearly) /sulfasalazine (Azulfidine)

Add methotrexate +/- low dose steroids +/- Leflunomide (Arava) –> use cholestyramine x 11 days to washout metabolites from system

Methotrexate–> 25mg/wk
methotrexate polyglutamate level –> >60

persistent synovitis

Severe - Add etanercept (Enbrel) (can make anti DS DNA +) or Infliximab (Remicade) or Adalimumab (humira) or anakinra (kineret) or Golimumab (Simponi) Certolizumab (Cimzia)

Abatacept (Orencia) Rituximab (Rituxan) (Rituxan–> good for HBV, HCV) Tocilizumab (Actemra) (Actemra –> diverticular ruputre , OCP faiure, HPL)

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14
Q

???Egg shell Ca+

A

siliciosis

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15
Q

???Salmon pink rash

A

still’s dz/inc’d ferritin

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16
Q

???Schools of fish or boxcar

A

chance - haemaphilis ducre

Tx: azithro orceftriaxone

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17
Q

???Methotrexate contraindicated in?

A

Pt on bactrim, Hep B/C, Etoh liver dz

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18
Q

???Macular degeneration

A

lose central vision

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19
Q

???Reflexes

A

L5 lesion - no dorsiflex, no evert, no invert

Peroneal lesion - No dorsiflex, no evert, +invert

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20
Q

???45yo p/w joint tiffness>1hr in AM, pain in MCP, PIP and pain while climbing stairs x 6wks Rh+, on tylenol no rlief - started on naproxen no relief Rh still high wtd?

A

Add methotrexate

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21
Q

???Fastest acting DMARD (Disease modifying anti rheum drug) is?

A

Methotrexate

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22
Q

???Which drug decreases mortality in RA

A

Methotrexate

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23
Q

???Floppy iris syndrome

A

d/c tamsulosin before cataract surgery

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24
Q

???What is preictor for CVS dz in Rheumatoid arthritis

A

Inc’d homocysteine levels

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25
Q

???Pt with rheumatoid arthritis on NSAIDs with persistent synovitis, methotreaxate was added and pain improved, 3 months later pt p/w fatigue, Hg low, MCV high best tx would be?

A

folic acid def (from methotrexate use) - tx with folic acid

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26
Q

S/e NSAIDs

A

nephrotic syndrome, PUD, int nephritis

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27
Q

S/e hydroxychloroquine

A

Macular damage loss of accommodation

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28
Q

S/E Methotrexate

A

Heptoxicity, hypersen, Pneumonitis, apthous ulcer (tx: folinicacid)

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29
Q

S/E Lefluonmide

A

Teratogenic

use cholestyramine

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30
Q

s/e Corticosteroid

A

Osteoporoiss (5mg daily 3 months), HTN, cataract, avasc necrosis

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31
Q

s/e Infliximab

A

ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+

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32
Q

s/e Etanercept

A

ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+) ANA, ANti DNA+, flue like sx (use HIV HCV HBV so doesn’‘t get worse)

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33
Q

s/e Cyclosporine

A

ATN, renal insuff, hirsuitism, HTN

dont drink grapefruit juice

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34
Q

???Catarct sx?

A

glare outside lights

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35
Q

Pt with Rhuem Arth p/w sudden onsest pain behind knee an calf - US neg for DVT?
wtd?

A

ruptured baker cyst - intra-articular steroid

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36
Q

Pt with h/o RA for long time udergoes elective surgery with gen anesthesia - post op is quadriplegic - etio?

A

Atlanto-odontoid subluxation C1-C2

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37
Q

Pt with long standing Rh wit hoarseness of voice for weeks dx?

A

Crico arytenoid joint involvement

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38
Q

65yo RA >30yr p/w paraesthesia in hands b/l carpel tunnel release little change in the paresthesias 3 months later - also with occasional dizzy spells - past history of total knee arthoroplasty and severe joint deformities. -O/E: dec power and hyperactive reflexes - pt going for hip replacemet wtd?

A

Xray neck r/o sublux

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39
Q

Pt with RA on methotrex x 1 yr p/w pain and swelling knee joint, fever with leukocytosis wtd?

A

tap joint r/o septic arthritis (all before thinking about steroids)

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40
Q

Tap with turbid exudate labs P

A

start IV abx

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41
Q

???Pt with long standign RA on NSAIDs steroids and MTX p/w cough, tx’d with abs - 4 weeks later progressive SOB no fever - b/l crackes, CXR infiltrates - etio?

A

MTX induced, interstitial fibrosis, bronchioe obliterhaeran

NOT CMV Pneumonitis

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42
Q

Pt with RA on hydroxychlorquin wtd?

A

baseline retinal exam and then in 5 years and then yearly

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43
Q

Leading cuase of death in RA

A

Heart disease

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44
Q

Pt tx’d with steroids for temproatl arteritis or Polymyalgia Rheumatica or SLE - couple month later steroids tapered off with improvement of sx - pt returns with b/l symm joint pain and early morning stiffness with MCP, PIP no h/a or shoulder pain - exam with + venodule on L olecranon dx?

A

Rheum arthritis

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45
Q

Pt on MTX for Rheum Arthritis - what do you follow based on current guidelines

A

CBC, Cr, AST q12

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46
Q

Pt with Rh Arthritis with minimal response to MTX 25mg/wk wtd?

A

check PPD –> do first
?????, if neg start TNF alpha???

If 5mm, wtd next? CXR–> Negative
- start INH (x3 months) and rifapentine
give Pneumococcal and influenza vacc prior to biologic DMARDs
no varicella, no yellow fever, no MMR
don’t give DMARD with active infxn (including viral bronchitis)

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47
Q

35yo p/w recurrent pain starting in PIP then MCP then knee - few hours later joint swelling - pain resolves in few hours in backwards order, in between attacks the pt is absolutely fine. - dx?

A

Pallindromic rheumatism - 1/2 will go on to RA

tx: DMARDs

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48
Q

Pt with RA and necrotic ulceration of finger tips and foot drop dx?

A

Rheumatic Vasculitis

???- circulating Ag-Ab (RF) complex blocks small arteries

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49
Q

<1% of pts w/ long standing RA present with splenomegaly and leukpenia–>recurrent skin/lung infxn, +skin ulcers dx?

A

Felty’s syndrome -
Tx
DMARDs, steroids, G-SF-> splenectomy

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50
Q

32yo F polyarthritis and fever. sore throat several weeks ago - salkmon colored/ faint pink rash on trunk and upper extremitiess - throat ctx neg, ESR 110/hr, ferritin 600 , WBC 24000 w/ 85% PMHs. Pt is started on abx no help. AST/ALT increased. Rh neg, ANA neg. Rh factor negative. dx?

A

Juvenile idiopathic rheumatoid arthritis aka Still’s dz

(opposite of Fetly’s syndrome)

Joint pain, salmon colored rash, high ferritin, high WBC

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51
Q

WHat dz more likely related to RA

A

Periodontal dz

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52
Q

Sjogren’s

A

Enlarged salivary glands, dry mouth, dry eyes

RH+, ANA+, Ro , La+, elev ESR
inc’d r/o lymphoma/celiac sprue (check TTG), distal RTA I (U pH >5.5—> increased Caphosphate crystals - CaPO4 stones)
Sx - enlarged salivary glands, dry mouth,
Dx: - lip bx minor salivar glands
Schirmer test (blotting paper) + if <5mm wetting in tearing of eyes in 5 min (normal 15mm in 5 min)
Tx: Symptomatic - hydration, pilocarpine, steroids

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53
Q

???55yo c/o sdry eyes and mouth - drinks lots of water everyday and uses artifical tears - ROS shows chroic arthralgias - takes NSAIDs - parotid gland swelling - dental caries and dry eyes pt may benefit from ?

A

pilocarpine

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54
Q

Seroneg spondyloarthropathy - Rh neg, HLSA B27+

A

involves spine, asy poly/oligoarthritis <4 joints affected
Enethesitis (inflamm ligaments, tendons, joint capsule)
Dactylitis - swelling of entire digit
Ankylosing spondylitis
Reactive arthritis - mucosal inflammation of GI or GU tract

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55
Q

Ankylosing spondylitis

A 
starts after resting better with excercise, loss of forward spinal mobility
symptomatic sarcoilitis
Uveitis: pain photophobia, lacrimation
HLA B27 +, apical fibrosis
bamboo spine on xray
a/w aortits (Do echo)
diminished Chest expansion
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56
Q

Pt loves outdoor work with on/off back pain p/w c/o pain and redness of r eye - also loss of forward spine mobility - inejction aroudn corea - fluroescin eye stain is neg - what suggests ankylosing sponylitis in pt?

A

loss of spinal mobility
Dx: xray lumbosacral spine-specific
more sensitive test - MRI sarcoiliac joint
Eye manifestation is Uveitis

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57
Q

Pt p/w low back pain - xray with fusion of sarcoiliac joints and anklylosis of spine (bamboo spine - HLA B27+ most likely a/w?

A 
Aortitis
Tx for stiffness?
Excercise, physical tx
Pain - NSAIDs
 - if 6 weeks w/ minimal improvment  in paint, fatigue, and morning stiffness--> then anti-TNF
(no MTX, no hydroxychloroquine)

-follow up
Q3 month xray including sarcoilliac joints

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58
Q

Best way to maintain ROM with ankylosing spondylitis is?

A

Excercise

Follow dz activity with ESR

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59
Q

Uveitis in?

A

Reiter’s syndorme
Behcet’s dz
Ankylyosing spondylitis

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60
Q

Pt h/o anklyosing spondylitis on NSAIDs c/o new onset back pain - early fx wtd?

A

xray, if negative check MRI

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61
Q

Pt p/w asymmetric arthritis with pain in R knee, mouth ulcers, non-specific urethritis and conjunctivitis - HLA B27+, non-specific urethritis, conjunctivitis and asymmetric arthritis dx?

A

Reactive arthritis
Tx: NSAIDS - DMARD in extremem cases
COnjunctiviits, urethritis asym artrhtis (also mouth ulcers, keratoderma blenorrhagica
wtd next? HIV test

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62
Q

34yo Lt ankle arthritsi and left achilles tendon area pain - redness of eye abd pain adn diarrhea - exam with pain at baseof calcenus dx?

A

Reactive arthritis
How to treat the above pt w. diarrhea? - cipro + NSAID

How to treat pt w/ remove hx of diarrhea and now enthesitis?
NSAID

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63
Q

Pt wit reactiev arthritis ongoing arthritic pain for more than 6 months not relieved with NSAIDs or steroids wtd?

A

sulfasalazine/MTX

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64
Q

How to tx pt with remote h/o urethris and now enthesitis

A

Tx chlamydia + NSAID

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65
Q

???Causes of reactive arthritis

A 
Yersinnia
SHigella
Salmonella
Campylobater
Ureaplasma
C diff
BCG tx
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66
Q

Pt p/w lower back pain and in DIP, HLA B27+, pitting nail changes present

A 
Psoriatic arthritis
Tx
Mild - NSAIDS, skin/nail change -> MTX
No hydroxychloroquine
Worse with UVB (sunlight), BB, infection
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67
Q

Pt of Middle eastern/japanese descent - recurrent painful apthous stomatitis, genital apthous ulcers, joint pain, erythema nodsoum on legs, HLA B5+, uveitis (blurry vision), pathergy + (hyperreactive to needle sticks aka refuses needlesticks)

A

Bechet’s dz
Tx: mucocutaneous disease: colchicine
Moderate to sever disease: steroids

???a/w aortic aneurysm
erythema nodosum, apthous ulers
Tx: steroids???

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68
Q

24yo M c/o multiple oral apthous ulcers/redness of eye for the past month. tender nodules on shin - CXR prominent pulm artery - aneursym on CT - dx?

A

Behcet’s dz

Quinolone:

  • ->paretheasias
  • -> tendon rupture
  • -> disection of arteries
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69
Q

???DTR dec with?

A

WNV
Tick paralysis (absent)
Toluene
spinal abscess

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70
Q

???DTR inc with?

A

Serotonin
ecstacy
epidural abscess
NORMAL with MG

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71
Q

Oral apthous ulcer, gential ulcer, refuses needle stick?

A

Behcet’s dz

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72
Q

Paiful shin nodule, genital ulcer refuses needle stick

A

Behcet’s dz

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73
Q

Painful shin nodule, oral apthou ulcer, aortic anurysm, painful red eye blurry vsiion, occ knee/ankle pain?

A

Behcet’s dz

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74
Q

Oral apthous ulcer, h/o urtethral discharge in past. red eye, knee/ankle pain

A

Reactive arthritis (Reiters syndrome)

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75
Q

Pt returns from the caribbean w/ high fever, pain in small joints hand, wrist, ankle with or without maculopapular rash - dx?

A

Chikungunya virus (break bone fever)

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76
Q

All these cause reactive arthritis with dactylitis

A 
Yersinia
Shigella
Salmonella
Campylobater
C diff
Ureaplamsa
Inflamm bowel dz
NOT E.Coli!!
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77
Q

25yo p/w pain/swelling of right knee, diarrhea intermittently for week, swelling of entire 2nd toe (sausage digit) and severe pain on palpation of achilles tendon - painless ulcer on tongue - dx?

A

Reactive arthritis
what is likely +?
Stool culture

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78
Q

70yo DM male p/w pain in mid back area - early morning stifness of spine, exam with dec’d thoracic lateral flexion - xray spine with flowing ossification of anterior longitudinal ligaments dx?

A

DISH (Diffuse idiopathic skeletal hyperostosis)

???Tx: physical therapy, NSAIDs???

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79
Q

Osteoarthritis

A
  • Joint pain: 1st CMC, knees, PIP, DIP , Hip (groin pain), Cervical and lumbar spine
  • osteophytes, central erosions in DIPs on xray
  • if no osteophytes, then: morning stiffness, crepitus on movment of joint, join fluid <2,000 WBC’s, labs: low titer Rh factor <1:40 and ANA <1:160 may be positive. type 1 error

joint deformities:
PIP–> Bouchard’s nodes
DIP–> heberden’s nodes

tx: lose weight! –> orthoses: insoles, braces, knee taping, assistive devices
- -> topical agents (knee and hand)
- -> NSAIDs / Non acetylated salicylates –> Celecoxib w/ PPI–> intra articular steroids
- -> replace joint.

?????Older age
H/o trauma
Obesity, repetive use
2/2 DM, hyperparathyryodi - chondrocalcinosis
Labs - low Rh factor s
Tx: lose wieght, tylenol up to q6hr, NSAIDs, celecoxib with PPI, intrasticular steroids, hyaluronic acid - replace joint?????

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80
Q

Osteophyte formation -

A

osteoarthritis

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81
Q

Periarticular osteopenia

A

RA

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82
Q

Joint space deformity

A

OA and RA

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83
Q

Marginal bony erosioin in PIP + MCP

A

RA

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84
Q

Central bony erosion in PIP + DIP

A

OA

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85
Q

Subchondral sclerosis

A

OA

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86
Q

Pt wit severe OA pain not relieved with tylenol h/o UGIB wtd?

A

tramadol or oral long acting morphine

causes serotoin syndrome, seizures hypoglycemia.

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87
Q

Pt with fatigue and Hg 9, MCV 75 - pt taking NSAIDs for OA of knee, stool occult blood + .
-wtd?

A

D/C oral NSAIDs start topical NSAIDs

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88
Q

Most important risk factor for OA

A

Obesity

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89
Q

Elderly pt with pain in thumb while turning keys and opening car doors - pain at thumb on flexion and internal rotation - crepitus + dx?

A

Osteoartritsi of 1st CMP joint

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90
Q

Pt with OA - wants to try glucosamine or chondroitin sulfate wtd?

A

no difference from placebo

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91
Q

Pt with longstanding h/o OA takes tylenol for pain - plays tennis occasionally - mild crpitus and swelling of R knee - no fever WBC 8000. R thigh smaller than left- wtd?

A

Tap the knee +steroids and send patient for Physical tx to strengthen quadriceps

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92
Q

Pt with osteoarthris of R knee crepitus with pain. Topical capsaicin no help. Can’t take NSAIDs due to increased creatinine - steroids and hyaluronan injections with incomplete response

1) Exam with 10deg valgus def loss of cartilage on lat knee - (points outward). What is a good mechanical measure to reduce pain?

2Exam 10 deg varus deformity with medial knee cartilage loss - wtd? (points inward)

A

1) Medial wedge insole
2) medial unloading brace

??/lateral wedge insole.??

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93
Q

Randomized clinical trial shown benefit of acupuncture in?

A

OA knee + hip

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94
Q

Topical capsaicin benefit of OA in?

A

hand and knee

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95
Q

Pt is brick layer p/w painand swellign of PIP and DIP - xray loss of caritlalge and narrowing of joitn space and CENTRAL erosion . dx?

A

erosive OA (PIP/DIP)

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96
Q

Laborer or farmer p/w URI - RA for >15 yrs - swollen PIP+MCP w boggy felling. does not c/o pain, strength hand is normal -xray shows erosion PIP and MCP - dx?

A

RA (arhritis robustus)

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97
Q

Presentation of pain in OA hip in?

A

groin

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98
Q

R groin with RA and osteophytes on xray? dx?

A

secondary OA

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99
Q

R groin pain with RA, xray neg - MRI double line sign T2?

A

Avascular necrosis

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100
Q

???? R groin pain in middle aged pateint xray mild osteopenia - MRI T1 diffuse dec’d enhancemnt femoral head, T2 diffuse increase enhancement fem head?

A

Transient osteoporisis

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101
Q

????Pain over anterior aspect of hip or groin - r/o hip joint problem like?

A

Avascular necrosis

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102
Q

Pain over latral asp of hip can’t sit in car or sleep on that side

A

direct pain - trochanteric bursitis

tx: inject local steroids

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103
Q

40yr old b/l groin pain, L>R, worse with activity and internal rotation

A

Acetabular impingement

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104
Q

Pt with SLE on steroids >2yr pain in hip , walks with limp - dx test?

A

MRI

??r/o avascular necrosis??

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105
Q

45yo c/o pain in right buttock shoots down back of thigh for past 3 days - tendernesss over R sciatic notch when pressure applied by thumb and pain on abduction while lying down - dx?

A

Piriformis syndrome

Tx: PT, NSAIDs, yoga pigeon stretch

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106
Q

18 y/o (<20) man presents w/ pain both hips since childhood which has now beocme severed. NSAIds do not help anymore. Walks with limp (–> hip dysplasia). Next step?

A

xray

tx: weight loss–>periacetabular osteotomy–> arthropalsty

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107
Q

Pt with pain on groin - xray with osteophytes - you prescribe analgeisa and cane - what are your directions for cane?

A

use cane on OPPOSITE side of affected joint

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108
Q

???? Elderly pt with longstanding RA on MTX, hydroxychlroquine, NSAID with groin pain - xray NO joint space and severly impaired mobilization dx?

A

secondary OA

Tx: replace joint

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109
Q

Gout

A

monosodium urate–> bony tophus- erosion

it is an asymmetric inflammatory arthritis (D/C THIS ON PG 60)

pg 60

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110
Q

pseudogout

A

Ca Pyrophosphate dihydrate–> chondrocalcinosis

it is an asymmetric inflammatory arthritis

pg 60

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111
Q

???? Gout&pseduogout preciptiants

A 
Asymmm inflamm arthritis
Trauma
post surgery 3 days post op
major medial illness (MI, CVA, PE)
fasting
etoh abuse
high fructose drinks
a/w HTN, DM HCTZ
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112
Q

Do you tx pt with asymptomatic hyperuricemia

A

NO - only with sx

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113
Q

Is uric acid elevated during attack of gout?

A

No - usually falls during gout attack

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114
Q

Do you need to have hyperuricemia to dx gout?

A

No - uric acid levels may fall to normal range during gout attack

115
Q

Pt with great toe swelling first time, with CHF, PUD, or on anticoag. - neg birefringent crystals on tap. next step in managmeent

A

tx?
Colchicine (0.6mg Q8hr= 1.8mg/ day)

(indomethacin–> give 1st if none of those comorbidities)

116
Q

Pt with contraidication to cochicine 2/2 diarrhea. wtd?

A

NSAIDs

117
Q

Pt with gout, contraindication to NSAID or colchicine with renal insuff, liver failure, heart failure, PUD wtd?

A

steroids

118
Q

Pt with only 1 or 2 joints involvement. wtd?

A

intraarticular steroids

119
Q

pt had Polyarticular joint involvement gout. wtd?

A

systemic steroids + colchicine OR NSAID + colchicine–> steroid + NSAID

120
Q

Pt gouty attack resolved. What do you prescribe at the time of discharge to begin 2 weeks later?

A

Allopurinol

???start allopurinol (Xanitithine oxidase inhib - dec production)
(Probenicid - inc uric acid excretion)???

121
Q

Pt with tophaceous gout and chronic kidney disease has never had gouty attack. OR pt. with tophaceous gout and has bony erosions. What is the best management?

A

colchicine + allopurinol

122
Q

Pt with h/o gouty attack in past on coclchicine and allopurinol ppx, now presents w/ acute gouty attack wtd?

A

continue allopinol, start NSAID

123
Q

Young pt. with gouty attacks on allopurinol and NSAID comes back w/ recurrent attacks wtd?

A

assess pt adherence to allopurinol

124
Q

Pt with hx of HTN takes ACEi . Presents w/ c/o generalized rash. Exam reveals fever, necrolytic rash. wbc 15,000 and eos 10%, BUN cr 40/3.2, AST/ALT inc’d. This is most likely due to?

A

allopurinol

allopurinol also inc’d level of azathrioprine

125
Q

Pt h/o gout p/w swelling knee - tap with neg birefringent crystals WBC 40K, started on NSAIDs and taking allopurinol - 1 wk later reaccumulation fluid in joint and still pain - tap again shows neg birefringent crystals WBC 46K - fluid yellow and turbid just like during the previous tap - what is the best management?

A

IV abx

Septic arthritis ???

126
Q

Pt with HTN on HCTZ uric acid elevation . Asymptomatic. wtd?

A

c/w HCTZ for asymtomatic hyperuricemia

127
Q

Pt with HTN on HCTZ with uric acid elevation and has gouty attack. wtd?

A

d/c HCTZ

128
Q

Elderly pt’s especiallly women on HCTZ p/w pain in the PIP/DIP with nodules and swelling distal to nodules. This represents?

A

gouty arthritis . Will have monosodium urate deposits.

[(side note: calcium oxalate crystals–>ESRD, knee swelling (variable bifringence))]

129
Q

Pseudogout (Calcium Pyrophosphate dihydrate disease) causes:

A

Causes:
Hyperparathyroidism
hemochromatosis

????(HyperCa
Hypothyroid
Hypophosphatemia
Wilson’s dz??????

130
Q

CPPD can presents as

A

[???Pseduo RA
Pseduo Gout
Pseduo OA???}
Dx knee most commonly affected
Xray - chondrocalcinosis (Ca+ of ligament)
Joint fluid - rhomboid crystal - weakly + birefringence
rhomboid shape
Tx smiliary to gout - less responsive to colcihicine

131
Q

????55yo p/w pain in knees and wrist fatgue, dec’d libido, swelling wrists/knees - Ca of mensci/traigular ligament - AST/ALT elevated - FBS 150

A

Pseduogout 2/2 hemochormatosis wtd next?

Serum transferrin saturation and iron level

132
Q

Pt with arthritis, xray with multiple area of joint calcification in multiple joints. Also complains of fatigue, FBS 158 mg/dl dx?

most likely test to do?

A

Chondorcalcinosis due to calcium pyrophosphate dihydrate deposition

Most likely test to do?
TIBC / Transferrin saturation/ ferritin

133
Q

A pt with hyperparathyroidism undergoes parathhyroiectomy, post surgery pt develops acute onset pain, swelling right knee. Tap is done. It would reveal?

A

55K wbc, postive birifrignence

134
Q

Post surgery 3 days later wrist, MCP, PIP, DIP, knee pains - knee joint swollen, serium uric acid is elevated (can be false +). what to expect in fluid?

A

Calcium pyrophosphate dihydrate crystals

135
Q

???Joint fluid interpreation

A

inflammatory - WBC 2-75K, PMN>50%, gluc >25

Septic WBC>50K, PMN>75%, gluc <25 (bacterial)

136
Q

Pt c/o pain on abduction of shoulder - mainly anterior tenderness over bicipital groove

A

Bicipital tendinopathy

Tx - NSAIDS->PT -> steroids close to the tendon in bicipital groove

137
Q

Pt c/o pain in shoulder - started tennis after long time - new shoulder pain while trying to comb hair or raising pants or lifting weight over head - pain in lat shoulder while laying down especially at night, painful abduction beyond 40 deg and int rotation

A

Rotator cuff tendinopathy

138
Q

75yo M fall from a height with outstretched hand - c/o so\houlder pain - cant shrug shoulder, can’t abduct arm, an’t keep arm up after passive intervention to 90 degrees (drop arm test +) xray reveals no fx, only mild narrowing of sub acromial space- next step after after xray?

A

Rotator cuff tear

Next step after xray–> MRI

139
Q

Pt c/o pain in shoudler - inced on abduction, extremes ofmovement, painless - pain more on active than passive - swings arm back and forth wihtout pain. dx and treatment?

A

dx subacromial bursitis

tx–> steroids into bursa

140
Q

Pt with pain and griding or popping sensation in anterior shoulder while reachig to put seat belt on - pain on abduction beyond 120 deg

A

acromiolavicular joint arthritis

141
Q

66yo F gradual onset progress R shoulder pain x 1 yr difficulty combing hairand wahsing face and head while showering - minor MVA couple yrs ago - on exam difficulty abducting and external rotation of R shoulder with creptius and tenderness over joint - xray narrowing of glenohumeral joint space.

dx and treatment?

A

Gelnohumeral OA

Tx: NSAIDs and stretching excercises –> persistent sx -> intraarticular steroids x 2–> - no response–> surgery

142
Q

72yo F R shoudler pain x 1 year with gradual onset sx with movement of shoulder at night - difficulting abducting shoudler
Xray shows Ca of ligaments and some effusion which on tap reveals RBC, WBC 2000. ALIZARIN RED stain shows basic Calcium phosphate crystals occasional HYDROXAPATITE crystals

A 
Milwaukee shoulder (apatite crystals, ALIZarin red stain)
Tx: NSAID, repeat arthrocentesis -> persisent symptoms --> intraarticular steroids -> degernative changes- >- arthoplasty
143
Q

60yo F with cast for arm injury - post removal of cast c/o stiffness, inability to move shoulder - exam shows loss o f both active an passive ROM - tenderness and pain around shoulder - xray looks normal - injecting steroid into shoulder with resistance dx? and tx?

A 
Adhesive capsulitis (frozen shoulder)
Tx: early mobilization
144
Q

Lying on side pain

A

Shoulder - rotator cuff tendinopathy
Left precordial - costochondritis
Lateral hip pain - trochanteric bursitis

145
Q

Student wit pain and swelling elbow near exams or (a carpet layer, roofer, et) Can pronate/supinate arm but can’t flex dx?

A

Olecranon bursitis
etiology is trauma, gout, sepsis
Tx NSAIDs, local steroids

146
Q

Pt with pain/swelling elbows with fever and chill. Exam revelas warmth and tenderness - Range of movements painless. tap with 9000 WBC (could be <20,000). dx and treatment?

A

Dx septic olecranon bursitis
Tx Aspiration, drainage, IV abx + NSAIDs

If recurrent –> excise bursa

147
Q

Pt with pain in lateral elbow and anterior to lateral epicondyle - pain on extension of fingers and supination of forearm - while in airport lifted suitcase (or handshake) and pain returned dx?

A
  • lateral epicodylitis aka tennis elbow - pain in extension
  • mainly due to lifting heavy objects
  • Extensor carpi radialis brevis most commonly affected

-Reduce recurrence in future by - six weeks physical therapy with eccentric exercise

148
Q

Carpel Tunnel Syndrome

A

Wk in abductor pollicuis brevis most commonly affected
Phalen’s Sign (forced flexion wrist) can be +, Tinel’s sign (tinel=tap) less sensitive than phalen’s sign.

Tx: Neutral splint at night
IF no response or thenar atrophy–>
Nerve conduction study -> Sx release

149
Q

?????Cause of carpel tunnel

A 
RA
DM
Preg
Menopause
Myxedema
Amyloidosis
Acromegaly
150
Q

Presentation of median nerve issue

A

unable to oppose little finger with thumb

151
Q

55yo F numbness both thumbs and index fingers upon holding anything for few min, HR 52, fatigue +, next test?

A

TSH

152
Q

Preg woman with c/o pain and paresthesia both hands in the thumb and index finger esp at night wtd?

A

Neutral splinting of wrists

153
Q

45yo with longstanding RA b/l tingling sensation in both hands worse at night with thenal muscle wasting. wtd?

A

nerve conduction studies ***

154
Q

Pt fails splinting and has thenar atrophy?

A

Sx release

155
Q

Numbness of thumb index finger, and middle finger with early morning stiffness of an 1hr. Difficulty opening bottles?

A

RA

156
Q

Long distance cyclist p/w tingling numbness in littlea nd 4th finger and ulnar asp of palm - abduction and adduction of interossei decreased
Can’t hold paper between little finger and ring finger. Upon holding paper between thumb and index finger, + flexion and weakness at IP joint of thumb forming a pinch. Severe cases w/ claw hand.

A

Ulnar nerve entrapment at elbow/ wrist. Occurs at ulnar groove in elbow

157
Q

?????Pt in MVA p/w inability to open/exten finger du to pain dx?

A

Super condylar fx - disrupting brachial blood flow

158
Q

Pt p/w pain on radial (lateral) asp wrist esp when lfiting children OR young man who plays vidoe games . point tenderness over radial sytloid process . pain on resisted abduction and with ext of thumb - making fist with fully flexed thumb and ulnar dev with pain (Finklestein’s test)

A

Dequervan’s tenosynovitis
tx: rest tendon (no gripping or grasping), splinting -> local steroids
If disability is severe –> surgery

159
Q

Pt p/w wrist drop, dec’d sensation in radial and dorsal aspect of hand - dx?

A

Compression of radial nerve at Spiral groove in middle of arm aka saturday night palsy

160
Q

Pt p/w finger stuck in flexion at PIP - straightened with effort of other hand - tenderness at base of finger dx?

A 
Digital tenosynovitis ( swelling of flexor tendon aka Trigger finger)
tx: steroids
161
Q

Pt with stiffness of ulnar aspect of hand - unable to extend 3rd4th fingers - thickening and contraction of palmar facia - DM and etoh liver dz. Dx and treatment?

A

Dupuytren’s contracture
Tx: 1st collagenase injections
2nd surgery

162
Q

Pt fell on outstriched hand - tenderness over anatomic snuff box - xray neg fo rfx wtd?

A

thumb spica splint (scaphoid fx?? ) and then

bone scan or MRI

163
Q

DM pt with inability to completely extend fingers - hand bring hands together with tips of fingers and wrists of both hands but can’t bring MCPs together (i.e cant extend fingers) - no erythema or swelling

A

DM choropathy 2/2 to collagen depostion

164
Q

Meralgia Paresthetica

A

DM with burning sensation or numbness in anterior and lateral thigh
Pain worsens with abduction of thigh and with excercise - palpation of RLQ in inguinal region elecits pain in the thigh

Etio - compression of cutaneous femoral nerve
Tx: wt loss/ anticonvulsant/ local steroids

165
Q

Pt c/o hip pain - xray fx of ramus of pubis tx?

A

early ambulation and PT

166
Q

Pt p/w pain in patellar region - no skin breakdown - erythema and tenderness over patellar region. dx and tx?

A

pre-patellar bursitis (housemaid knee)

Tx NSAIDs/local steroids

167
Q

DM pt with pelvic girdle and thigh pain - no burnign sensation - exam with atrophy and weakness of thigh muslces dx?

A

Diabetic amyotrophy

tx: tighter glucose control

168
Q

Elderly pt with pain on knee, mainly on the medial aspect 5cm below joint line - worse with climbing stairs( semiflexion) - xray: no linear calcification, mild osteoarritisc changes

A

Pes Anserine bursitis (sartorius bursa)
(???pain with climbing stairs, local pain and swelling???)
Tx: local steroids /rest/ NSAIDs

169
Q

Pt c/o pain on side of knee when JOGGING or CYCLING - radiates UP toward thigh - focal tenderness in lateral aspect of knee joint just above the midline while abducting or extending hip - snap is heard on flexion - on resisted internal rotation of tibia there is no pain - dx and tx?

A

Iliotibial band syndrome

tx correct training errors, proper foot wear, stretching hip abductors

170
Q

28yo long distance runner c/o pain in knee - pain described as burning sensation on inner and outer aspects of patella, also behind patella, exacerbated with physical activity (running, climbing stairs, during squats, ascending/ descending stairs or hills). He also has knee stiffness after sitting for long time (“movie goer” sign). What will help establish diagnosis? Also what is the diagnosis? Tx?

A

Patellar compression.
Dx: Chondromalacia (Patellar femoral syndrome)

Tx: decrease running/quadriceps strengthening/analgesic
NO SURGERY REQUIRED!

171
Q

Teenager with anterior knee pain just below knee joint. Exam reveals joint tenderness below the knee joint especially on extending knee against resistance. Most likely diagnosis?

A

Dx Osgood Schaltter

???dz - irritation of patellar ligament, young ppl during growth spurts???

172
Q

20yo to ER with acute pain in knee with swelling - played football about 1 hr ago and heard popping sound then pain/sweeting - anterior drawer sign/lachman sign +

A

ACL tear

???(forward knee laxity both in anterior drawer sign and lachman test)???

173
Q

Pt presents several hours after injury with swelling. Knee “locks and gives way”. Popping sound during injury- 24 hrs later . w pain and swelling. Palpation of medial joint line with pain, clicking sound on flexion of knee w the ankle in external rotation. McMurray test +. dx?

A

Meniscal tear

???(flex hip, and knee, valgus pressure then extend knee - if pop/pain then +)???

174
Q

75yo F assisted living with pain on medial aspect of knee of past several months, click on palpation wtd?

A

PT

175
Q

Pt p/w pain in knee on medial aspect after an injury several hours ago - no hx no popping sound. he can ambulate but no pivor/twist - Drawer neg, lachman neg, varus neg, valgus + with pain on medial joint. dx?

A

Medial collateral ligament injury

???(hit from lateral side)???

176
Q

Pt p/w pain and swelling posterior leg - > pain began abruptly >24hr ago after tennis for a long time - exam showing ecchymosis, swelling and tenderness in mid calf area - no h/o RA. wt?

A

US,
Dx: gastocnemium tear
Tx: Rest NSAID crepe bandage

177
Q

Pt with pain in ankle on ambulation - twisted ankle on uneven surface - can walk 4 steps without support - compression of posterior malleoli (medial and lateral) with NO pain -
what is dx and tx?

A

Ankle sprain - talofibular ligament strain - no need for xray
Tx: NSAID, splint

178
Q

Long distance runner c/o pain in lower medial aspect of leg - he has noticed pain over the past 2 days. Pain is worsened when jogging. exam shows diffuse tenderness over medial aspect of his leg. xray neg for fx, dx and tx?

A

Dx: medial tibial stress syndrome aka Shin splints (??? - overuse syndrome???)

Tx: ice packs, orthotic soles

179
Q

Pt p/w pain/burning sensation between 3rd and 4th toes worse while walking with high heels - pain while walking on hard surface - pain radiates in fron tof toes along with parathesias on plantar aspect - pain better when shoes removed - dx?

A

Morton’s neruoma - (interdigital plantar neuroma)

180
Q

Pt with pain in heel, stiffness during early morning stride - get better with day going on…dx?

A

Plantar fasciitis
Tx:
-Ice pack after activity, arch support/ NSAIDs
-correct raining errors/steroid injetion/ surgery
-stretching exercise with dorsiflexion of foot

181
Q

Pt with plantar fasciitis, xray with heel spur - cause of pain likely…

A

plantar fasciitis

182
Q

Foot pain, more in morning, difficulty with dorsiflexion - tenderness at base of calcaneous, with inc’d tenderness on squeezing the heel, dx?

A

Plantar faciitis

183
Q

Pt with numbness and burning sensation in toes - worse on walking and end of day - sx are aggravated at night time - radiates to front of toes, better with shoes off - on percussion, posterior and inferior to medial malleous produces pain. Dx and tx?

A 
Tarsal Tunnel syndorme
Tx: 
-arch support (shoe modification)
-Local steroids
-Sx decompression
184
Q

Pt p./w painful feet, ankle and knees after prolongued standing, which has happened for the past couple of years - normal feet on exam - but on standing, arches of feel collapse and valgus of heel - dx? tx?

A

(Flat feet) Pes Planus

-orthotic shoes

185
Q

45yo F with extreme fatigue doesn’t want to get out of bed, also with diffuse muscle ache -exam shows tenderness in most muscle group on exam - non restorative sleep, no swelling of joints or erythema. NO FEVER, ANA 1:64, ESR 30, CPK 98 wtd? dx?

A

Dx: fibromyalgia
Tx: amitripyline or excercise

186
Q

elderly woman with generalized body ache and fatigue, it started couple days ago with pain in upper arms and neck, it is a/w morning stiffness. exam shows no focal deficit. xray shows minimal OA changes. ESR 52mm/hr, alk phos elev. dx and tx?

A

Polymyalgia rheumatica
tx: dramatic response to low dose prednisone

(???Pain in neck/shoulder/hip (morning pain)
can be a/w temporal arteritis
TX: low dose prendisone???)

187
Q

85yo F recurrent pain in neck, ESR 40, low grade temp - restriction of neck movement due to pain - Xray shows calcification of ligaments in neck - Calcifications noted on other joints as wel, dx?

A

Crowned dens syndrome

188
Q

????Relapsing polychondritis

A

swellilng of ears, hoarseness, aortic regurg
Pt with hoarness, episodic swllign of nears history of intubation 2/2 subglottic stensois
Larygoscopy edema/inflammation
Dx: Bx of cartiliage
Tx; steroids then immunosuppressive agents.

189
Q

Large Vascululitis

Complement normal

A

Temporal arteritis
Takayasu’s arteritis
Aortitis

190
Q

Medium Vasculitis

Complement normal

A

Polyarteritis Nodosa (PAN)
Granulmatosis with polyangiitis (wegeners)
Chugg strauss

191
Q

Small vasculitis

A
  • Henloch schonlein - (??abd pain/nodulies???)
  • Microscopic polyartitis angiits (MPA) (??? - cousin of PAN - MPO ???)
  • Leukocytoclastic angiitis (hypersensitivity vasculitis), associated w/ –> HCV, –> drug induced: amoxicillin, PCN, augmentin
  • Churg Strauss
  • Good pastures
  • Cryoglobulinemia - dec C4>C3
  • SBE
  • SLE - dec C3> C4
  • Rh Arthritis

pANCA now called myeloperoxidase Ab

192
Q

65yo F c/o frontal h/a moderately sever and throbbing - scalp hurts when combs hair, hurts while chewing - episode of blurry vision - exam no focal deficit- ROS: low grade fevers over the past month. wtd?

A

first :Check ESR
next: Steroids

…ESR is 85 and temporary artery bx is negative. What is the most likely diagnosis?
Temporal artiteritis - even if bx neg (can be skip lesions)

( I learned this during didactics from MKSAP: Temporal artery bx can remain accurate despite treatment for 1-2 wks. don’t delay tx for bx. Suspect when >50 y.o, new HA or diplopia;; + systemic sx): amaurosis fugax, diplopia, jaw claudication, scalp tenderness, PMR)

193
Q

65yo M h/a, ESR 85, steroids started and temp bx neg - BP both extremities normal - wtd next

A

US guided bx of the contralateral temporal artery

194
Q

Pt p/w pain/wk left arm after excercise - recent dizziniess/visual distrubance and TIA - BP R 140/80, Lt 155/95

dx if pt young w/ hx malasie and low grade fevers? dx if pt elderly w/ normal ESR?
if pt is elderly w/ high ESR?

A
  • If Pt age 25 with h/o maliase and fever - Takayasu’s dx: aortography
  • Pt elderly with normal ESR (5-15%) - > Temporal arteritis (d/c this babe, differing answers …pg. 74)

-Pt elderly with high ESR - Temporal arteritis
next? –> steroids–>temp artery bx neg.–> MRA/ CTA chest to r/o aneurysms

195
Q

how to Dx Takayasu dz?

tx?

A

Aortography–>check for stenosis

Tx: steroids, CCB

196
Q

Ankylosing spondylitis a/w ?

A

Aortitis and Uveitis

197
Q

Aorititis a/w?

A

Anklyosis sponylitis, Uveitis, syphillis

198
Q

50yo M pw abd pain worsens while eating in periumbilical area mainly- better when stomach empty - pian has worsened over the past several weeks-joint pain in hands and feet ulcers-BS +. purpuric rash on the lower extremities. ESR 100/hr BUN/ Cr 45/2.0. CXR–> no infliltrates. The best test to determine diagnosis is?

A 
Abd angiogram
Polyarteritis Nodosa (spares lungs)
(???a/w Hep B
wt loss, Cr elev, elev ESR, pain of abd, ulcers
bead sign on aortogram (aneursyms)???)
Tx: steroids, cyclophosphamide
199
Q

40yo M c/o wk left hand and abd pain - on exam: dec power in L hand. ESR 96mm/hr. U/A –> +1 protein, RBCs >50/hpf. KUB and abdominal xray–> no obstruction or perforation. Dx? tx?

A

PAN (polyarteritis nodosa)

Tx: steroids + cyclophosphamide

200
Q

35yo p/w abd pain - labs show renal insuff - Hep B ag + . pt has?

A

PAN - 30% a/w hep B

201
Q

24yo F italian/jewish/arab descent with recurrent abd pain every 2 months lasting for 1-2 days, appendectomy as child - pain periumbilical which spreads all over abd with high fevers - swollen knee, power normal, no ulcers. Abdomen imagin studies normal. - FATHER WITH SAME SX, dx?

A

Familial mediterrainian fever (Serositis and arthritis)
Tx: colchicine for ppx
complications - AA amyloidosis–> renal failure

202
Q

Causes of amyloidosis (chonic inflammation)

A

FMF
RA
TB
MM, K chains > L; low anion gap

203
Q

Amyloidosis

A

(????proteinuria +-hematuria with renal failure???)

Bx –>congo red staining will show fibrils of apple green birefringence. First do an abd fat bx, if neg, then bx affected organ.

204
Q

50yo F pw cough, sob, arthritis. nasal septum flattened- CXR multiple pulmonary nodules and one cavitary lesion (thick walled)- afb smear and c/s neg, BUN cr 40/3.4.
BX -> vasculitis with necrostizing granulomas. U/A –> RBCs >20/hpf, 1+ proein, C-ANCA (proteinase 3) (+), Rh factor (+). Most likely dx?

A

Granulomatosis with polyangiitis (Wegeners)
Tx: Cyclophosphamide + prednisone

…if pt relapses in 2 years? Rituximab

Treatment guidelines: 
-Non-sever -->  steroids + MTX
-Severe --> Steroids + cyclophosphamide
-In remission --> Rituximab
Relapse --> steroids + rituximab

IF cavitary lesion thick, think: histo, blasto, wegener’s
IF cavitary lesion thin, think: nocardia, cocci, MAI

205
Q

Thin walled cavitary lesion CXR

A

norcardia
cocci
MAI

206
Q

Thick walled cavitary lesion CXR

A

Wegeners, blastomycosis, Histo

207
Q

24yo M with ongoing sinusitis for past couple months a/w cough, tx’d with amox x 7 days tmep 100.5 boggy turbinates with purulent secretions, rhonci on ausculatation CT sinus total oapcification CXR nodular infiltrates . ANA +, Proteinase 3 antiboides (c-ANCA) (specific) +, myeloperoxidase anitobodies (p-ANCA) (sensitive)+. dx?

A

Granulomatosis w/ polyangiitis

( ???? Wegeners (lung involvment, no abd invovlement)
Granulomatosis with polyangiitis
Lung and kidney involvement, nasal d/c
Autoimmune attach by ANCA ab (C)
Tx: steroids and cyclophosphamide
azathroprine MTX, mycophenlate
Rituximab (relapse) ???)
208
Q

40yo F with h/o asthma with several allergies no pets pw SOB wheezing and wk left foot - uses albuterol, salmeterol inhaler and is being weaned off of steroids - rales left base, dec power R foot w/ hypoactive reflexes. CBC eos+/ IgE high or normal, CXR: RUL density.
What is dx?

A

Churg Strauss (allergic angiitis)

(???eosinophilic granuloamtosis with polyangiitis
pt w/ h/o reactive airway ie asthma or allergic rhinitis
+eos
IgE NORMAL
+p-ANCA
mononeuropathy/polyneuropathy
pulmonary infiltrate
extravascular eos+
Tx: Prednisone +- azathroprine, cyclophosphamide, MTX (maintenance)???)

209
Q

Most specific Ab for SLE

A

Anti smith antibody or anti DS DNA titer (both are sensitive and specific)

210
Q

other labs Labs for SLE

A

C3 ↓ >, C4, CH50 decreased

Follow disease activity w/ anti dsDNA levels.

211
Q

Tx for SLE

A

Arthritis -> ASA, NSAID->hydroxychloroquine (plaquenil)–> Belimumab

Photosensitivity/rash - avoid sun/ use sunscreen-> steroids -> hydroxychlroquine +/- Quinacrine

thrombocytopenia –> steroids –> IVIG

Hemolytic anemia–> steroids

Nephritis -> steroids->add cyclophophamide-> mycophenalte mofetil ( dont use during pregnancy, use 1st for african americans) –> cyclosporine

In AA and hispanic nephritis -> steroids–> mycophenolate mofetil

(???Refractive lupus - use Bilimumab???)

212
Q

SLE on steroids, still with sx

A

MSK sx - Hydroxychorloquine

Neprhtis/CNS sx/system vasculaitis or alveolar hemorrhage - cyclophosphamide

213
Q

????Serolgically active but clinically quieescent SLE

A

no tx

214
Q

Pt on minocycline for acne OR Rh artheritis for >2yr OR on procainamide >1yr, for an arrythmia OR hydralazine for CHF for 2 yrs

presents w/ malaise, low grade T, arthralgia of MCP, PIP joints, ESR 65, ANA + 1:320, C2, 4 normal - all favor drug induced lupus …

A

Normal complement
No pscychosis or seizures
U/A no RBC or protein/casts
high ANA titer

only exception–> eteanercept –> high anit ds DNA titer

215
Q

24yo h/o lupus for 4 years foudn to have lupus anticoagulant syndrome and history of spontaneous abortion twice she is on cyclophosphamide and steroids - asks about long term contraception

A

Progesterone only IU device

IF has DVT–> copper IUD

216
Q

????Pt on PTU for hyperthyroid pw palpable purpuric lesions on extrem and trunk - P-ANCA+ and ESR high, Heb B neg bx of purpura leukoclastic vasculitis - dx?

A

PTU induced vasculitis

217
Q

35yo F dx with SLE and lupus nephritis txd with steroid and IV cyclophoshamide about 2 yrs ago meds were tapered off and was asx and healthy now with low grade fever and arthralzgias what would suggest flare of SLE

A

Inc’d Anti DSDNA and dec’d complement

218
Q

Leasding cuase of death in SLE pt of 10 yrs is?

A

Cardiovascular disease

219
Q

????Dec OCP levels

A

Rifampin

St John’s wart

220
Q

????What causes MAT

A

COPD

221
Q

T/F SLE pt inc’d risk of stroke

A

T

222
Q

T/F SLE pt with inc’d risk of MI

A

T

223
Q

T/F SLE pt inc’d risk of DVT

A

T

224
Q

T/F SLE pt inc’d risk of recurrent spontaneous abortions

A

T

225
Q

T/F SLE pt in’d riks of avascular necrosis

A

T

226
Q

Pt with recently dx SLE p/w complaints of dec urination and wk legs - pain in back , hyperactive reflexes +, on exam NO spinal tenerdness. wtd?

A

MRI spine r/o transverse myelitis

MRI will show–> edema of spinal cord c/w inflammation…wtd? —> IV steroids

227
Q

SLE pt on hydroxychloroquine and Prednisone 20mg/day p/w psychosis - etiology?

A

steroid induced psychosis if >20mg steroids(auditory hallucinations)

SLE itself if <20mg steroids/day (visual and tactile disturbances)

228
Q

20yo F delvers baby with Complete heart block - mother with scaly papular rash - ANA neg - woman with what ab?

A

SSA (anti-RO)

229
Q

Pt with 1st trim spontaneous abortion for 1st time

A

No need to check for antiphospholipid antibody

230
Q

Pt with 3rd trim spontaneous abortion for 1st time

A

check for antiphospholipid Ab

231
Q

Pt with recurrent 3rd spont aborition in 1st trimester

A

check for antiphospholipid Ab

232
Q

Sclerosis

A 
1) Generalized -->  systemic Sclerosis: 
ANA+
Scl 70 +
Anti-topoisomerase+
antipolymerase III abs --> poor prognostic factor

2) Limited –> Crest:
Anticentromere +

3)Plus muscles –>dermatomyositis
Mi2
AntiJo +
Anti-PM1

233
Q

Systemic Sclerosis (Anti-Scl 70+)

A

-Skin –> diffuse fibrous thickening: sclerodactylyl
tight face/small mouth
abnormal nail fold capillaries
—> PUVA tx

-Joints - symmetric arthritis, MCP
Tendon friction rub +
— > NSAIDs , then add –>MTX

-Raynaud –> dilated nail bed capillaries
(??? warm gloves, nifedipine???)

-LUngs - interstitial pneumonitis, interstitial fibrosis, pulmonary HTN–> high resolution CT scan–> chylophophamid+ steroids

-Renal - renal crisis (HTN, proteinuria, edema):
Tx wtih ACEi, irrespective of cr!! - what precipitates it?–>steroids

GI--> dysmotility -> erythromycin
GERD--> PPI
Wide mouth diverticula
Bacterial overgrowth syndrome-->  cipro+ metronidazole
--> B12 ↓ + folate high

-Heart - Restrictive pericardial dz

234
Q

Sclerosis pt can present with?

A

Intersticial pneumonitis (fiborosign alveolitis)

235
Q

CREST (anti-centromere+)

limited scleroderma

A

C-> Calcinosis cutis (calcif of soft tissue)
R -> Raynaud phenomenon
E -> Esopheagela dysmotility
S-> Sclerodactyly
T->telangiectasias
Pulm HTN more common than scleroderma. Can be present even w/o xray changes

236
Q

35yo garderner p/w painful fingers during cold weather, figners white with cold. next step in management?

A

–> wear warm gloves/ avoid cold

If wears warm glove and doesn’t help - wtd?
Nifedipine

237
Q

How will you recomgnize rheumatological (seconary vs primary) disease in pt with raynaud’s phenomenon?

A

abnormal nail fold capillaries

-Age>40,
-Abn nail folds capillaries
-Digital ulcerations
All of the above suggest secondary reaynauds phenomenon

238
Q

45yo played basketball fo r4 hours at family reunion p/w swelling arms/leg SPARING hand/feet (fingers and toes) - exam wit ORANGE PEEL like quality of skin - CBC EOS+
dx and tx?

A

Dx: Eosinophilic Fascitiis
Tx: Self limited-> steroids

239
Q

Polymyositis (anti Jo+)

A

Anti Jo+
HLA DR3+ Women>Men
Prox muslce wk, can’t get up from chair or squat position
can’t comb hair, mechanic’s hands (scaly dry, darkened, cracked horizonatl lines on palmar area, finger pads, and lateral aspect)
Abn CPK >10x normal, inc’d ANA
Biopsy –> myonecrosis w/ cellular infiltrates

240
Q

Polymyositis + skin changes=

A

Dermatomyositis (Anti- Mi2)

(?????
Polymyositis sx (weakness)
Mechanic hands (dry cracked skin)
Heliotropic rash
Gottron papules (most specific)
screen for ovarian, breast or GI Cancer

Tx: Steroids (no MTX)
?????)

241
Q

66yo F pw complint of diff getting up from chair , diff combing hair exam reveal rash on cheeks forehead , upper eleylids - pt at risk for developing which disorder?

A

Malignancy - ovarian breast or GI

1st beast–mammo
2nd GI–colonoscopy
3rd Ovary–TV US

242
Q

What more specific for dermatomyositis

A

Gottron papules

243
Q

What predicts poor outcome in dermatomyositis -

A

dysphagia

244
Q

West nile virus poor prognositc factor?

A

inc’d age

245
Q

RMSF poor prognostic factor?

A

inc’d Cr

246
Q

55yo F with weakness - phx significant for polymyositis - CPK 950 - started on prednisone 50mg.day - feels better CPK decreases to less than 190, 3 months later CPK level normal but now prox wekaness again dx?

A

steroid myopathy

Tx: taper steroids

247
Q

65yo M progressive wk legs, arms, forearms wrists fingers distal>prox, CPK high (<10x normal). Not responsding to steroids - MTX added, CPK still high - bx wit ENDOMYSIAL inflammation and bsophilic rimmed vacuoles wtd?

A

Inclusion body myositis

tx: taper steroids, d/c MTX

248
Q

Pt with gouty tophus on colchicine and allopurinol - h/o ashtma on inhaled steroids - p/w wk trying to get up from chair, LE prox wk aslo, DTR dec - CPK 350 - bx reveals vaculoles no inflammation dx?

A

Colchicine induced myopathy

249
Q

35yo M intubated asthmatic 4 days later on steroids and albuterol - diff extubating - CPK 925 dx?

A

Critical illness myopathy

250
Q

Ab for SLE

A

ds DNA, Smith

251
Q

Ab for Drug induced SLE

A

histone

252
Q

Ab for subacute cutaneous SLE

A

SSA (Ro)

253
Q

Ab for Scleroderma

A

Scl70

254
Q

Ab for CREST

A

centromere

255
Q

Ab for MCTD

A

RNP

256
Q

Ab for poly/dermatomyositis

A

Jo, Mi2

257
Q

Ab for Sjogren’s syndorme

A

SSA (ro)/SSB(La)

258
Q

Ab for Wegener’s

A

c-ANCA (proteinase 3)

259
Q

Ab for Microscopic polyarteritis angiitis (cousin of PAN)

A

P-ANCA (myeloperoxidase)

260
Q

Hemochormatosis

A

MCP

261
Q

Tophi

A

calcium deposit in pulp of finger and b/w DIP and PIP in pt with gout taking HCTZ

262
Q

Dactylitis

A

DIP, PIP, MCP

263
Q

Diagnostic Criteria for RA

A 
-Joint involvement:
2-10 large joints: 1 point
1-3 small joints: 2 points
4-10 small joints: 3 points
>10 joints: 5 points

-Serological abnormality ( Rh factor or Anti-CCP)
low positive: 2 points
high positive: 3 points

  • ESR or CRP elevation: 1 point
  • Duration of symptoms >6 weeks: 1 point

6 POINTS –> RA!!!

X ray changes:
marginal bony erosions
periarticular osteopenia

264
Q

Poor prognostic factors for RA

A

progressive synovitis
joint space loss/ erosions
high Rh factor
high ESR

265
Q

70 y/o F w/ early morning stiffness >45 min and symmetrical small join pain in her 2nd, 3rd, 4th MCP in R hand and 2nd, 3rd, 4th, 5th MCP and PIP in L hand.
R knee joint pain for the past 6 wks. ESR 48. Exam shows swelling MCPs and PIP of both hands. RH factor is neg. wtd? what is most likely to be positive?

A

wtd? —> start treatment

What is most likely to be positive? –> anti citrulline abs
sensitivity only 80%
specificity is 100% (better than RF, RF is 80% sensitive therefore you miss 20%)

266
Q

fastest acting DMARD (disease modifying agents for RA) is?

A

methotrexate (non biologic DMARD)

267
Q

Which of the above drugs decrease mortality in RA?

A

Methotrexate (non biologic DMARD)

268
Q

Sernegative spondyloarthropathies (Rh factor negative, HLA B27+)

A

Involve spine
asymmetric poly/oligoarthritis (<4 joints affected)
Enthesitis (inflammation of ligaments, tendons, joint capsule, etc.)
Dactylitis( swelling of entire digit)

  • ankylosing sponydlitis
  • reactive arthritis (mucosal inflmmation of GI or GU tract)
269
Q

Conjunctivitis, urethritis w/ asymmetric arthritis…dx?

What test would you do next?

A

Reiter’s syndrome

other features:
mouth ulcers
keratoderma blenorrhagica

What test do you do next? HIV test

270
Q

A pt w/ one knee OA walks w/ cane. What directions when ascending and descending stairs?

A

Ascend stair w/ good leg, follow w/ affected leg and cane. Descend stair w/ affected leg first and then follow w/ cane and good leg

“up to heaven and down to hell”

271
Q

What is most commonly affected area for pseudo gout?

A

knee

272
Q

A 35 y/o F preparing for marathon for the past 2 months p/w pain in her leg for the past 4 weeks. It has gradually increased over time. Exam reveals focal tenderness over the tibia. dx ? wtd next? and tx?

A

Stress fracture
next? Xray
if neg? MRI
tx? Rest

273
Q

20 y/o M presents w/ complains of difficulty walking and running and has a hx of falls for the past several months. Exam reveals atrophy of calf muscles b/l and hammer toe w/ a high plantar arch of the foot, Dx ?

A

Charcot marie tooth disease

274
Q

Granulomatosis w/ polyangiitis (Wegener’s disease)

A

kidney + sinusitis + lung nodule/ thick cavitary lesion

275
Q

In a pt w/ arthralgias and malar rash. you

are suspecting lupus. Wtd next?

A

ANA

276
Q

Pt w/ lupus nephritis is started on cyclophoshamide and steroids, a week later sudden onset of headache, confusion, visual disturbanc. BP 160/100. MRI brain shows enhancement in occipital lobes. Dx? Tx?

A

Progressive leukoencephalopathy syndrome

tx: control BP

277
Q

Pt w/ lupus is in remission presents for a follow up in 6 months. she has no symptoms. anti ds DNA titer is elevated. dx? tx?

A

seriologically active clinically quiescent disease

tx: DON;T TREAT

278
Q

T/F anitpolymerase II abs predict increase risk of :

1) diffuse thickening of skin?
2) cancer
3) renal criss

A

all true

279
Q

40 y/o w/ short stature presents w/ back pain. exam reveals blue sclerae and scoliosis. Excessive joint flexibility. dx?

A

osteogenesis imperfecta

280
Q

Pts exam reveals a upper body to lower body ratio is decreased and arm span reater than the height. Thumb sign, wrist sign, pectus carinatum. Some scoliosis and heel valgus

A

Marfan’s syndrome

281
Q

Pt w/ joint laxity and hypermobility, translucent skin, easy bruising, atrophic scars, scolisos and pes planus

A

Ehler danlos

282
Q

Conditions mimicking polymyositis?

A

colchicine polymyositis

inclusion body myositis

283
Q

Dermatomysotis

presents w/? wtd next?

A

heliotrope rash
gottron’s papules
weakenss

wtd next? CPK
if CPK elevate wtd? steroids (NOT MTX)

2018 ABIM Awesome Review (14 decks)

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