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Block 3: MSK > Clin Med MSK - Rheum - Lec 1 > Flashcards

Clin Med MSK - Rheum - Lec 1 Flashcards

1
Q

Osteoporosis RFs

A
  • postmenopausal women
  • Decr in estrogen
  • persons ≥ 65 years old
  • white & Asian people
  • small body frame
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2
Q

What is the 1 year mortality in white women after a hip fracture?

A

40%

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3
Q

Medical conditions that can lead to osteoporosis

A
  • endocrine disorders
  • GI disorders
  • hematologic disorders
  • rheumatologic & autoimmune disorders
  • CNS disorders
  • meds (anticoag, hormonal therapy, glucocorticoids, immunosuppressants, lithium)
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4
Q

Common fractures seen w/ osteoporosis

A
  • femoral neck fractures
  • pathologic fractures of vertebrae
  • lumbar & thoracic vertebral fractures
  • distal radius fractures
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5
Q

What is a fragility fracture?

A

any fall from a standing height or less that results in a fracture

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6
Q

Who is screened for Osteoporosis?

A
  • all women ≥ 65yo & all men ≥ 70yo
  • postmeno women < 65yo
  • perimeno women & men aged 50-69yo w/clinical RFs for fracture
  • any adult w/ fracture after age 50
  • any adult w/ condition (such as RA) or meds (such as glucocorticoids ≥ 3 months) assoc. w/ low bone mass or bone loss
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7
Q

What is the T-score used in osteoporosis?

A

of standard deviations above or below mean for a gender & ethnicity-matched young adult healthy population

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8
Q

Describe the levels of a T-score

A
  • normal (>/= -1)
  • low bone mass (osteopenia) (-1 to -2.5)
  • osteoporosis (≤ -2.5)
  • severe or established osteoporosis (</= -2.5 & >/= 1 fracture)
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9
Q

Osteoporosis Dx - Labs

A
  • Minimal workup: Serum Ca++, 25-hydroxyvitamin D, TSH
  • Additional workup (looking for 2ndary causes)
  • BUN
  • Cr
  • Albumin
  • Serum Ca++
  • Phosphate
  • PTH
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10
Q

Osteoporosis Tx

A
  • proper Ca++ & Vit D intake
  • Exercise
  • stop smoking
  • avoid excess alcohol intake
  • Bisphosphonates (1st line)
  • Other tx: PTH, selective estrogen response modulators, calcitonin
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11
Q

What is FRAX? & what doe it take into account?

A

Fracture Risk Assessment Tool
- predicts 10 year risk of fracture

  • age, weight, height, smoking status, etoh intake, Fx, femoral neck BMD
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12
Q

When do we use FRAX?

A

to determine if a person w/ osteopenia should go on a bisphosphonate

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13
Q

Ankylosing Spondylitis RFs

A
  • Family History
  • Presence of HLA-B27
  • Associated w/ IBD, anterior uveitis, psoriasis
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14
Q

Ankylosing spondylitis back pain criteria

A

back pain lasting > 3 months, in patient aged < 45 years

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15
Q

Characteristics of ankylosing spondylitis pain

A
  • worse upon waking or after rest
  • lasts ≥ 30 minutes
  • assoc. w/ morning stiffness
  • improves w/ activity or exercise, but not w/ rest
  • may occur at night, awaking pt
  • spinal stiffness & loss of mobility
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16
Q

Ankylosing spondylitis stooped posture may include…

A
  • incr flexion deformity of neck
  • incr thoracic kyphosis
  • loss of normal lumbar lordosis
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17
Q

Ankylosing Spondylitis Dx Criteria

A
  • pts w/ >/= 3mo back pain & less than 45yo
    PLUS
  • Sacroiliitis on imaging & >/= 1 SpA feature
    OR
  • HLA-B27 & >/= other SpA features
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18
Q

Ankylosing Spondylitis SpA features

A
  • Crohn’s/colitis
  • HLA-B27
  • Enthesitis (heel)
  • Arthritis
  • Psoriasis
  • Elevated CRP
  • Dactylitis
  • FHx
  • Uveitis
  • Good response to NSAIDs
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19
Q

What can be seen on X-ray in Ankylosing Spondylitis?

A

sacroiliitis & bamboo spine

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20
Q

Ankylosing Spondylitis Tx

A
  • Non-pharmaco Tx: exercise & PT
  • Pharmaco Tx: NSAIDs, TNF inhibitors, Interleukin 17 inhibitors
  • Spinal surg, hip arthroplasty in severe cases
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21
Q

Fibromyalgia RFs

A
  • 1st degree relative w/ fibromyalgia
  • female
  • infx (for Lyme dz,hep C)
  • stress (ACEs, illness, trauma, psychosocial)
  • physical trauma or injury
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22
Q

Associated condition with Fibromyalgia

A
  • women: dysmenorrhea, interstitial cystitis, endometriosis
  • Chronic fatigue syndrome, IBS, chronic HA
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23
Q

When should you expect fibromyalgia in a patient?

A

patients who present w/ multifocal pain that don’t have damage or inflammation in affected

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24
Q

Fibromyalgia Labs

A
  • CBC
  • ESR
  • CRP
  • Creatine kinase
  • Metabolic panel
  • Thyroid function testing
  • Anti-nuclear Ab
  • RF
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25
Q

Fibromyalgia Tx

A
  • Goal is to incr quality of life
  • Pharmacologic therapies
  • Cognitive behavioral therapy (1)
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26
Q

What can be done to increase quality of life in fibromyalgia patients?

A
  • Exercise
  • Eat healthy
  • Good sleep habits
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27
Q

Which classes of drugs & examples can be used to treat fibromyalgia?

A
  • Muscle relaxants (Cyclobenzaprine)
  • Antidepressants (Amitriptyline, Duloxetine, Milnacipran)
  • Anticonvulsants (Pregabalin)
  • Analgesic (Tramadol)
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28
Q

Describe Budapest Criteria used for complex regional pain syndrome

A
  • continuing pain that is disproportionate to any inciting event
  • > /= 1 sign in >/= of the categories
  • > /= 1 symp in >/= of the symp list below & >/= 1 sign in >/= 2 signs list below
  • No other Dx can better explain S/S
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29
Q

Complex Regional Pain Syndrome Tx

A
  • PT/OT
  • Meds: gabapentin, corticosteroids, ketamine
  • Cognitive behavioral therapy
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30
Q

Gout dietary factors

A
  • red meat
  • seafood
  • alcohol, especially beer
  • sugar-sweetened beverages (fructose rapidly incr serum urate level)
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31
Q

Uric acids is byproduct of…

A

the breakdown of DNA/RNA

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32
Q

What conditions will cause underexcretion of uric acid?

A
  • Renal impairment
  • HTN
  • Diuretics
  • Ethanol
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33
Q

What conditions will cause overproduction of uric acid?

A
  • Genetic disorders
  • Excessive purine intake
  • Sickle cell anemia
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34
Q

Gout Dx

A
  • GS - monosodium urate crystals insynovial fluid analysis
    –> Negatively birefringent needle shaped crystals
  • If it is not possible to get synovial fluid, an incr serum uric acid is a good clue (over 6)
  • X-ray: may have ”mouse bite”/punched out erosions
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35
Q

Describe synovial fluid analysis results for gout
Gross appearance:
Volume:
Viscosity:
WBC:
Polymorphonuclear cells:
Crystal analysis:
Glucose []:

A

Gross appearance: Opaque
Volume: 5 - 50
Viscosity: Low
WBC: 500 - 75,000
Polymorphonuclear cells: >50
Crystal analysis: (-) birefringent
Glucose []: serum glucose

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36
Q

Gout Immediate Tx

A
  • Prednisone (1st line)
  • NSAID (indomethacin) (2nd line)
  • Pain meds
  • Colchicine (4th line)
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37
Q

Gout Prevention Tx

A
  • Allopurinol
  • Probenecid
  • Colchicine
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38
Q

Pseudogout can affect what joints?

A

any joint but most commonly the knee

other joints: wrist, hand, pelvis, hip

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39
Q

Is pseudogout monoarthritis or polyarthritis?

A

monoarthritis (89%) > polyarthritis (11%)

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40
Q

Pseudogout Dx

A
  • definitive dx ID Ca++ pyrophosphate dihydrate crystals insynovial fluid or biopsied tissue - (+) birefringence
  • detection of chondrocalcinosis onx-ray
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41
Q

Describe synovial fluid analysis results for pseudogout
Gross appearance:
Volume:
Viscosity:
WBC:
Polymorphonuclear cells:
Crystal analysis:
Glucose []:

A

Gross appearance: Opaque
Volume: 5 - 50
Viscosity: Low
WBC: 500 - 75,000
Polymorphonuclear cells: >50
Crystal analysis: (+) birefringent
Glucose []: serum glucose

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42
Q

Pseudogout Acute Tx

A
  • Steroids (1st line)
  • NSAIDS (2nd line)
  • Colchicine -can be used for prevention as well- (3rd line)
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43
Q

What role do proinflammatory chemicals play in RA?

A

cause development of proteases which break down the cartilage and cause arthritis

44
Q

In RA, proinflammatory chemicals move through the blood to what other organs causing…?

A
  • Vasculitis
  • Lung fibrosis
  • Liver disease
  • Splenomegaly
45
Q

RA genetic RFs

A
  • HLA-DRB1 gene
  • Epigenetic modifications
46
Q

RA non-genetic RFs

A
  • smoking
  • microbiota
  • female
  • western diet
  • ethnic factors
47
Q

RA Dx - Labs

A
  • RF (sensitive but not specific)
  • Anti-Citrullinated Peptide Antibodies (very specific)
  • ESR/CRP high (not specific)
  • Arthritis > 3 joints, morning stiffness, disease duration > 6 wks
48
Q

RA Dx - Imaging

A
  • X-rays: narrowed joint space w/ osteopenia & erosions, deformities
49
Q

How does the Criteria from American College of Rheumatology work?

A

6 points needed for Dx
- the more small joint involvement the more points you get

50
Q

RA Tx

A
  • Target outcome is remission through use of dz-modifying agents (DMARDS)–> methotrexate
  • NSAIDS or steroids for acute flares
51
Q

What is one of the most common chronic dz in children

A

Juvenile Idiopathic Arthritis (JIA)

52
Q

Juvenile Idiopathic Arthritis Dx - Labs

A
  • No specific test - Dx of exclusion
  • elevated ESR, CRP
  • RF (+) in about 15%
53
Q

Juvenile Idiopathic Arthritis Dx - Imaging

A

X-ray may show soft tissue swelling, usually no joint damage early in dz

54
Q

Juvenile Idiopathic Arthritis Tx

A
  • DMARDS - methotrexate - 1st line
  • NSAIDS
  • Steroid joint injections
55
Q

Psoriatic Arthritis Dx

A
  • clinical dx in pts w/ joint inflammation, absence of RF, & typical psoriatic skin & nail lesions
56
Q

Psoriatic Arthritis X-ray findings

A

“pencil in cup” deformity

57
Q

CASPAR criteria: joint inflammation + >/= 3 of the following

A
  • current psoriasis, personal Hx of psoriasis, or family Hx of psoriasis
  • typical psoriatic nail dystrophy, including onycholysis, pitting & hyperkeratosis
  • RF (-)
  • current or Hx of dactylitis (sausage fingers)
  • radiologic evidence
58
Q

Psoriatic Arthritis Tx

A
  • Manage skin dz
  • NSAIDS, corticosteroids, DMARDS
59
Q

How long do arthritic symptoms typically last in reactive arthritis?

A

3 - 5 months

60
Q

What is keratoderma blenorrhagica?

A

scaly rash typically on palms, soles, trunk, scalp, and/or scrotum

61
Q

Reactive Arthritis Dx - Labs

A
  • No universally accepted criteria for dx
  • HLA-B27 positive (80%)
  • Look for underlying infx (don’t miss gonorrhea/chlamydia)
  • ESR/CRP likely elevated
62
Q

Reactive Arthritis Dx - imaging

A

X-rays will be normal for 1st several months of dz, then show ill defined erosions

63
Q

Reactive Arthritis Tx

A
  • Antimicrobial therapy if needed
  • NSAIDS
    –> If NSAIDS not helping –> methotrexate–> steroids–> Anti TNF
  • Steroid joint injections can provide pain relief
64
Q

How long do arthritic symptoms typically last in reactive arthritis?

A

3 - 5 months

65
Q

How long will it take for pts to have complete remission in reactive arthritis?

A

6 - 12 months

66
Q

SLE Dx

A
  • have 2 or more systems involved
  • look at sticky notes on notes
67
Q

SLE Tx

A
  • minimizing organ damage, reduce flares & optimize quality of life
  • Hydroxychloroquine
  • NSAIDS
  • Steroids
  • Methotrexate
68
Q

Systemic Sclerosis (Scleroderma) Dx

A
  • (+) ANA (non specific)
  • (+) anti centromere Ab (more specific to CREST syndrome)
  • (+) scleroderma Ab (SCL-70)
69
Q

Systemic Sclerosis (Scleroderma) Tx

A
  • DMARDS (methotrexate)
  • Steroids
  • CCB for Raynaud’s
70
Q

What are the 2 types of scleroderma?

A
  • Limited Cutaneous Systemic Sclerosis (CREST syndrome)
  • Diffuse Cutaneous Systemic Sclerosis
71
Q

What does CREST syndrome stand for

A
  • Calcinosis: calcific nodules in skin
  • Raynaud’s phenomenon
  • Esophageal dysmotility
  • Sclerodactyly
  • Telangiectasia
72
Q

What is the most common type of Scleroderma?

A

CREST syndrome

73
Q

CREST syndrome commonly affects…

A
  • face
  • neck
  • distal elbows & knees
74
Q

Diffuse Cutaneous Systemic Sclerosis affects…

A

trunk & proximal extremities

75
Q

What organs & systems may be involved in SLE?

A
  • kidneys
  • skin
  • Msk system
  • CV system
  • CNS & PNS
  • blood
76
Q

Polyarteritis Nodosa Dx

A
  • no lab tests or specific markers specific
  • serology for hep B&C virus, parvovirus B19, or other chronic viral infx
  • antistreptolysin O titers
  • CBC, kidney & liver function
  • incr ESR/CRP
  • Angiogram will most likely show abnormalities
  • BIOPSY at symptomatic site (preferably skin or muscle) to CONFIRM
77
Q

Polyarteritis Nodosa Tx

A
  • High dose Corticosteroids
  • Pulse methylprednisolone for critically ill pts
78
Q

Polymyalgia Rheumatica Dx

A
  • No specific labs, but will use labs to rule out other dz
  • Imaging not routinely needed
79
Q

Polymyalgia Rheumatica Tx

A
  • Prednisone, 10–20 mg/day PO; if no dramatic improvement w/n 72 hrs, the dx should be revisited
  • Weekly methotrexate may incr successful prednisone taper
80
Q

Polymyalgia Rheumatica Prognosis?

A

1–2 months
can have flares as prednisone is tapered

81
Q

Giant Cell Arteritis/Temporal Arteritis Dx

A
  • ESR very elevated

Giant Cell Arteritis
- MRI or CT angiography establishes the dx by demonstrating long stretches of narrowing of the subclavian & axillary arteries

Temporal Arteritis
- May see changes w/ US
- Temporal Artery Biopsy for definitive dx

82
Q

Giant Cell Arteritis Tx

A
  • Prednisone
  • Low-dose aspirin–> reduce stroke & vision loss
  • tx last 6mo to >2yrs
83
Q

Polymyositis Dx

A

elevated CK, muscle biopsy definitive

84
Q

Polymyositis Tx

A

Steroids, methotrexate

85
Q

Sjogren’s Syndrome Dx

A
  • Rheumatoid factor (+)
  • Anti-ro & Anti-la antibodies
  • The Schirmer test measures the quantity of tears secreted
  • Salivary gland biopsy if other diagnostics unclear
86
Q

Sjogren’s Syndrome Tx

A
  • symptom relief & prevention of complications
  • Pilocarpine can help reduce symptoms
  • Artificial tears
87
Q

Osteosarcoma Dx

A

Radiographs
- “Codman triangle”
–> New rim of bone forming b/c tumor
- “Sunburst”
–> Inflammation & extra bony growth coming of bone

88
Q

Osteosarcoma Tx

A

Immediate referral - MSK oncologist
- Chemo
- Amputation
- Limb salvaging surg (90%)

89
Q

Ewing’s Sarcoma Dx

A
  • ESR – Elevated
  • Bone marrow aspiration & tumor biopsy

Radiographs
- Large lytic lesion of metaphysis or diaphysis of long bone
- Characteristic “onion skin” appearance

90
Q

Ewing’s Sarcoma Tx

A
  • Refer immediately to a MSK oncologist
  • Chemo & irradiation
  • Possible surgical resection
91
Q

Chondrosarcoma Dx

A

Radiographs
- Intramedullary lesion w/ stippled & ring-like calcification
- Substantial erosion, thickening, & bone destruction
- MRI – more accurate for extent of tumor

92
Q

Chondrosarcoma Tx

A
  • Refer for surgery
  • No chemo usually needed (don’t respond well b/c of slowly differentiating cells)
93
Q

Osteochondroma Dx

A

Radiographs
- Compact, pedunculated protuberance of bone
(big outpouching of bone)

94
Q

Osteochondroma Tx

A
  • May be left untx unless symp
  • Analgesics for minor aches
95
Q

Compartment Syndrome Dx

A
  • Calculate delta pressure
    –> check twice
96
Q

Compartment Syndrome Tx

A

Referral/Consult for immediate fasciotomy

97
Q

Osteomyelitis Dx

A

Radiographs
- Soft tissue swelling
- Osteopenia, bone resorption, new periosteal bone formation

  • MRI – TEST OF CHOICE
98
Q

Osteomyelitis Tx

A
  • ID organism
  • Surg debridement (non-hemato)
  • Abx therapy
  • Consult infx dz & ortho
99
Q

Osteomyelitis: Children Abx Tx

A
  • Children < 3 mos: IV oxacillin + cefoxatime
  • Children > 3 mos: IV oxacillin ± vanc
    –> PNC allergic: vanc alone
100
Q

Osteomyelitis: Adult Abx Tx

A

Vanc + ceftriaxone

101
Q

How long is IV Abx Tx for Osteomyelitis?

A
  • Usually IV Abx - 5-10 days or until C&S is back
  • Continue for 4-6 weeks
102
Q

What is the WBC count for Septic arthritis?

A

> 50,000/mcL

103
Q

Septic Arthritis Dx

A
  • Aspirate affected joint
    –> Cell count w/ diff
    –> Gram stain
    –> Crystal
    –> C&S
  • Blood cultures
  • Radiographs
    –>Help to rule out osteomyelitis
104
Q

Describe what aspirate looks like in septic arthritis.
Gross appearance:
Volume:
Viscosity:
WBC:
Neutrophils:
Gram stain:
Crystals:

A
  • Gross appearance: Yellow/green
    Volume: Cloudy/opaque
    Viscosity: decr viscosity
    WBC: >50,000 WBC count
    Neutrophils: >75%
    Gram stain: (+)
    Crystals: (-)
105
Q

Septic arthritis Abx Tx

A

for 6 ish weeks of Abx (2-4 wks IV then 2-3 weeks PO)

  • Vanc (1 g IV bid, adjusted for age, weight & renal function) + either:
    —> ceftriaxone if concomitant meningitis or endocarditis is suspected)
    —> cefotaxime 1 g IV q 8h
    —> ceftazidime 1 g IV q 8h
106
Q

Septic arthritis Non-Abx Tx

A
  • Frequent aspirations (total WBC count is decr, fluid becoming sterile)
  • NWB
  • Immobilize the joint
  • Consult ortho for surg debridement

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