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OMS III > IM Rheumatology > Flashcards

IM Rheumatology Flashcards

1
Q

Osteoarthritis

definition

A

also called degenerative joint disease, is a chornic, slowly progressing, erosive joint damage to joint surfaces

ths loss of articular cartialge causes increasing pain with minimal or absent inflammation

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2
Q

Osteoarthritis

etiology

A

incidence is directly proportional to increasing age and trauma to the joint. modest recreational running will not cause it but plaing contact sports with truam does, obestiy increases incidence

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3
Q

what is the most common cause of joint disease

A

osteoarthritis

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4
Q

Osteoarthritis

presentation

A

most common in weight bearing joints (hip, knee, ankle)

hand is affected by not causing disability, dip more common than pip and mcp

crepitation of joints is common

effusion is rare

stiffness is short (usually under 15 minutes)

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5
Q

Osteoarthritis

DIP enlargement

A

heberdennodes

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6
Q

Osteoarthritis

PIP enlargement

A

Bouchard nodes

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7
Q

Osteoarthritis

lab tests

A

all are normal

esr

cbc

ana

rheumatoid factor

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8
Q

Osteoarthritis

most accurate test

A

xray:

joint space narrowing
osteophytes
dens subchondral bone
bone cysts

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9
Q

Osteoarthritis

treatment

A
  1. weight loss and moderate exercise (swimming, yoga and tai chi)
  2. aceatminophen (best initial analgesic)
  3. NSAIDS: use if symptoms are not controlled with acetaminophen, second bc of toxicity (GI bleeding)
  4. capsaicin cream
  5. intraarticular steroids if other medical erharpy does not control pain
  6. hyaluronan injection in joint
  7. joint rpelacement if disease is severe
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10
Q

Osteoarthritis

pathognomonic

A

absence of inflammation, normal lab tests, and short duration of stiffness

these distinguish it from RA

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11
Q

Osteoarthritis

glucosasmine and chondrotin sulfate

A

no more effective than a placebo

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12
Q

Gout

definition/Etiology

A

defect in urate metabolism with 90% of cases in men, there can be an overproduction or underexcretion

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13
Q

Gout

overproduction

A

idiopathic

increased turnover of cells (cancer, hemolysis, psoriasis, chemotherapy)

enzyme deficiency (lesh-nyhan syndrome, glycogen storage disease)

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14
Q

Gout

underexcretion

A

renal insufficiency

ketoacidosis or lactic acidosis

thiazides and aspirin

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15
Q

Gout

Presentation/what is the most likely dx

A

look for a man who devleops sudden, excruciationg pain, redness, and tenderness of the big toe

comes on at night after a beer drinking binge

fever is common and it can be hard to distinguish the intial gouty attack from infection wihtout arthrocenteses

metatarsal phalangeal joint of big toe is most common but can be in ankle feet and knees

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16
Q

Gout

chronic

A

Tophi: tissue depostis of urate crystals with foreing body reaction. nost often tophi occur in cartilage, subcutaneous tissue, bone, and kideny. often take years to develop

uric acid kidney stones in 5-10% of pts

long asymptomatic periods between attacks are common

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17
Q

tophi occur

A

anywhere in the body

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18
Q

Gout

most accurate diagnostic tests

A

aspiration of the joint showing needle-shaped crystals with nefative birefringence on polarized light, white cell in gluid will be between 2000 and 50000 and are predominalty neutrophils

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19
Q

Gout

why aspirate joint

A

bc it is red warm and tender to you have to exclude infection

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20
Q

Gout

other diagnostic tests

A

uric acid levels: elevated at some point in 955 of pts, a single level during acute gout attack is normal in 25%

acute attacks are associated with an elevated ESR and leukocytosis

xrays: normal in early disease erosions of corical bone happen later

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21
Q

Gout treatment for acute attack

A

nsaids are superior to colchicin as the best initial therapy of acute, painful gouty arthritis

corticosteroids by injectino ni a single joint or orally for mulitple joints are extremely effective, use steroids when:
no response to NSAIDS
contraindication to NSAIDS shuch as renal insufficiency

colchicine is used in those who cannot use nsaids or steroids

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22
Q

colchicine ae

A

diarrhea and bone marrow suppression (neutropenia)

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23
Q

Gout

chronic management

(6)

A
  1. diet:
    decrease consumption of alcohol, particularly beer
    lose weight
    decrease high-purine foods such as meat and seafood
  2. stop thiazides, aspirin, and niacin, use losartan first for htn
  3. colchicine is effective at preventing a second attack of gout colchicine is also effective at preventing attacks brought on by sudden gluctiation in uric acid levels due to probenecid or allopurinol
  4. allopurinol decrease production of uric acid. febusostat is sued if allopurinol is contraindicated. febuxostat is a xanthine oxidase inhibitor
  5. pegloticase dissolves uric acid. uric acid metabolism is accelerated by pegloticase
  6. probenecid and sulfinpyrazone increase the excretion of uric acid in the kideny (uricosuic)
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24
Q

Gout

adverse effects of chronic treatment

A

hypesensitivity (rash, hemolysis, allergic interstitial nephritis) occurs with uricosuric agents and allopurinol

colchicine can suppress wbc production

toxic epidermal necrolysis or stevens-johnson syndrome

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25
Q

what to do if a pt has an acute attack and is already taking allopurinol

A

continue allopurinol, but do not start uricosuic agents (or start allopurinol if not already taking it)

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26
Q

what gout drugs are ci in renal injury

A

probenecid, nsaids, and sulfinpyrazone

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27
Q

what gout drug is safe with renal injry

A

allopurinol

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28
Q

best drug for bp in gout

A

losartan it also lowers uric acid

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29
Q

calcium pyrophosphate (Pseudogout)

definition/etiology

A

from calcium contating salts depositingin the articular cartilage

most common risk factors are hemochormatosis and hyperparathyroidism.

also associated with diabetes, hypthyroidism and wilson dz

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30
Q

calcium pyrophosphate (Pseudogout)

presentation

A

large joints like knee and wrist are affected but not first mcp of the foot (unlike gout)

dip and pip are not affected (unlike osteoarthritis)

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31
Q

calcium pyrophosphate (Pseudogout)

other diagnostic tests

A

uric acid levels are normal

xray shows calcification of the carilaginous structures of the joint and DJD

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32
Q

calcium pyrophosphate (Pseudogout)

most accurate test

A

arthrocentesis, which reveals positively birefringent rhomboid shaped crystals. synovial fluid will show an elevated level of white blood cells between 2000 and 50000 (like ra and gout)

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33
Q

you cannot confirm cppd wo

A

aspiration of the joint

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34
Q

DJD

Characteristic hx

physical findings

synovial fluid analysis

A

older, slow, worse with use

DIP, PIP, kip and knees

<200 wbcs, osteophytes and joint space narrowing

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35
Q

Gout

Characteristic hx

physical findings

synovial fluid analysis

A

men, acute binge drinking

1st big toe

2000-50000 wbcs, negative birefringent needles

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36
Q

CPPD

Characteristic hx

physical findings

synovial fluid analysis

A

hemochromatosis and hyperparathyroidism

wrists and knees

2000-5000 WBCs, positively birefringent rhomboids

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37
Q

RA

Characteristic hx

physical findings

synovial fluid analysis

A

yoing, femal, morning stiffness better with use

multiople joints of hands and feet

anti-cyclic citrulinated peptide (anti-CCP) in blood 10000-20000 WBC or gluid

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38
Q

Septic arthritis

Characteristic hx

physical findings

synovial fluid analysis

A

high fever, very acute

single hot joint

> 50000 neutrophils, culture of fluid

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39
Q

CPPD

best initial therapy

A

NSAIDS

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40
Q

CPPD

if refractive to nsaids

A

intraticular steroids like triamcinolone

colchicine helps prevent subsequent attacks as prophylaxis between attacks

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41
Q

Low Back Pain

Etiology

A

low back pain is so common over a lifetime (80% of population) that the most important issue is to identify those few pts that have seirous pathollogy that will require readiologic testing and possible surgical tretmeent

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42
Q

DJD above age 50

A

nearly all people of this age have ti and so it is not significant

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43
Q

Low Back Pain

What is the most likely diagnosis overview

A

if all of the disease described in the following are excluded, the pt has simple low back pain from lumbosacral strain or it is idiopathic

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44
Q

lumbosacral strain

A

no imaging and no treatment beyond nsaids

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45
Q

Low back pain

what is the most likely dx

compression of the spinal cord

A

malignancy or infection compressing the spinal cord is a neurlogical emergency that needs urgent identification and treatment. look for a hx of cancer with the sudden onset of focal neurological deficits such as a sensory level

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46
Q

compression at 4th thoracic vertebrae

A

result in a loss of sensation below the nipples

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47
Q

compression at the 10th thoracic vertebrae

A

results in sensory loss below the umbilius

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48
Q

point tnederness at the spine with percussion of vertebrae suggest

A

cord compression

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49
Q

reflexes with cord compression

A

hyperreflexia below the level of compression

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50
Q

epidural abscess

A

staph aureus

presents like cord compression from cancer

high fever and elevated ESR

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51
Q

epidural abscess treatment

methicillin-resistant staph aureus

A

vanco

linezolid

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52
Q

epidural abscess treatment

acute neurologic defects

A

system glucocorticoids

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53
Q

epidural abscess treatment

methicillin sensitive sataph aureus

A

oxacillin

nafcillin

cefazolin

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54
Q

disk herniation (sciatica)

A

herniations at L4/5 and L5/S1 leel account for 95% of all herniations

the straght leg raise test is pain going into the buttock and belowthe know whne the lef is raised above 60 degrees

although only 50% with a postivie SLR have a henriated disk a negative test excludes slr herniation with 95% sensitivity

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55
Q

disk herniation (sciatica)

imaging

A

image to rule out cord compression, epidural abscess, ankylosing sponylitis, and cauda equina syndrome

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56
Q

disk herniation (sciatica)

beest initial test

A

plain x ray (for copmression, infection, and fx)

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57
Q

disk herniation (sciatica)

most accurate test

A

mri, use ct if mri ci,

must use intrathecal contrast in ct (myelogram)

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58
Q

l4 compression

A

lose dorsiflection of foot

lose knee jerk

lose inner calf sensation

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59
Q

l5 compression

A

lose dorsiflexion of toe

lose inner forefoot sensation

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60
Q

s1 compression

A

lose eversion of foot

lose ankle jerk

lose outerfoot sensation

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61
Q

do what before imaging cord compression

A

give glucocorticoids

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62
Q

Cord Compression

What is the most likely dx -

physical findings -

A

What is the most likely dx - hx of cancer

physical findings - vertebral tenderness, sensory level, hyperreflexia

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63
Q

Epidural abscess

What is the most likely dx -

physical findings -

A

What is the most likely dx - fever, high esr

physical findings - vertebral tenderness, sensory level, hyperreflexia

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64
Q

Cauda Equina

What is the most likely dx -

physical findings -

A

What is the most likely dx - bowel and bladder incontinene, ed

physical findings - bilateral leg weakness, saddle area anesthesia

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65
Q

Ankylosing spondylitis

What is the most likely dx -

physical findings -

A

What is the most likely dx - under age 40, pains worsens with rest and improves with activity

physical findings - decreases chest mobility

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66
Q

Disk herniation

What is the most likely dx -

physical findings -

A

What is the most likely dx - pain.numbness of medial calf or foot

physical findings - loss of knee and ankle reflexes, positive slr

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67
Q

cord Compression treatment

A

systemic glucocorticoids, chemo for lymphoma, radiation for many solid tumors, surgicl decompressio if steroids and radiation are not effetive

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68
Q

epidural abscess treatment

A

steroids are used to control acute neurological deficits. use anti staph abs like vanco or linezolid until sensitivity is known. switch to beta lactams (oxacillin, nafcillin or cefazolin). add gentamicin for synergy if staph. can drain surgically if large

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69
Q

think of epidural abscess like endocarditis

A

use vanco at initial empiric therapy

swithc to ocaccilin if sensitive

drain if large enough to produce neuro deficits or it doesnt respond to abs

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70
Q

cauda equina syndrome treatment

A

surgical decompression

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71
Q

disk herniation treatment

A

nsaids with continuation of ordinary activity (conservative)

yoga is just as effective as a more regimented or supposedly specific fomral back exercise program

steroid injetion into epidural space achieves rapid and dramatic benefit who do not get better with

surgery only if focal or progresses

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72
Q

most common wrong answer for sciatica

A

bed rest

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73
Q

sciatica most commonly tested point

A

dont do imaging if focal deficit, give steroids

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74
Q

Lumbar Stenosis

definition/etiology

A

narrowing of the spinal canal leading to pressure on the cord is idiopathicpain occurs when the back is in etension nd the cord presses backwards agasinst the ligamentum flavum

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75
Q

exertion with leaning back leads to worse pain bc of pressure on the cord

A

Lumbar Stenosis

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76
Q

Lumbar Stenosis

presentation/what is the most likely dx

A

over age 60 with back pain while walking, radiating into the buttocks and thigns b/l

pain is worse when walking downhill and better when sitting, but the pedal pulses and ankle/brachial index are normal

unsteady gait and leg weakness when walking occur

some ahve diminished le reflexes

decreased pain with activity where pt leans forward (cycling)

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77
Q

Lumbar Stenosis can simulate

A

peripheral arterial disease but the vascular studies are normal

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78
Q

Lumbar Stenosis

diagnostic test

A

mri is the only test

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79
Q

Lumbar Stenosis

treatment

A

weight loss and pain meds (NSAIDS opiates and aspriin) are first

steroid injections into the lumbar epidural space improve 25-50% of cases

physical therapy and exercise like bicycling or swimming help and can put off surgery

surgical correction to dilate the spinal canal is needed in 75% of pts

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80
Q

Fibromyalgia

What is the most likely diagnosis

A

young woman with chronic muscululoskeleteal pain and tenderness with trigger points of focal tnederness at the trapezius. medial fat pad of the knewss and lateral epicondyle. pain occurs at many sites (neck, shoulders, back and hips)

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81
Q

cause of Fibromyalgia

A

unkown

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82
Q

Fibromyalgia

pain is associated with

A

stiffness, numbness, and fatigue

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83
Q

Fibromyalgia

diagnostic tests

A

no test to confirm

based on a complex of symptoms with trigger points at predictable ponits

all lab tests are normal such as esr crp rf and cpk

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84
Q

Fibromyalgia

best initial therapy

A

amitriptyline

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85
Q

Fibromyalgia

ther treatments

A

milnacipran an pregabalin

can inect anesthetic into tirgger points

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86
Q

milnaciparn

A

inhibits the reuptakes of serotonin and ne

fibromyalgia

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87
Q

steroids are the wrong answer for

A

fibromyalgia

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88
Q

Carpal Tunnel Syndrome

definition

A

a peripheral neuropathy fromt eh copmression the median nerve as it passes under the flexor retinaculum

pressure on the nerve intereres with both sensory and motor function of the nerve

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89
Q

Carpal Tunnel Syndrome

etiology

A

overuse of hand and wrist

pregnancy

diabetes

ra

acromegaly

amyloidosis

hypothyroidism

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90
Q

Carpal Tunnel Syndrome

what is the most likely dx

A

pain in the hand affecting the palm, thumb, index finger, and the radial half of the ring finger.

muscle atrophy of the thenar eminence

pain is worse at night

worse in people who use hands like typing

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91
Q

wrist mri is wrong for

A

MRI

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92
Q

Carpal Tunnel Syndrome

signs

A

tinel sign: reproduction of the pain and tingling iwth tapping or percussion of the median nerve

phalen sign: reproduction of sx with flexion of the wrists to 90 degrees

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93
Q

Carpal Tunnel Syndrome

diagnostic tests

A

usually obvious from the sx

tinel and phalen signs

sqeeuze the nerve to confirm

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94
Q

Carpal Tunnel Syndrome

most accurate tests

A

electromyography and nerve conduction study

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95
Q

Carpal Tunnel Syndrome

best initial therapy

A

wrist splints to immoblilise the hand to relieve pressure

avoid manual activity

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96
Q

Carpal Tunnel Syndrome

treatment

A

steroid injections if splint and ndsaids dont work

surgery is curative by decompressing the tunnel by cutting open the retinaculum

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97
Q

callagenase injection helps

A

early dupuytrn contracture

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98
Q

what happens first in Carpal Tunnel Syndrome

A

sensory then motor sx

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99
Q

Dupuytrn Contracture

definition

A

this is hyperplasia of the palmar fascia leading to nodule formation and contraction of the fourth and fifth fingers

pts cannot extend fingers which is usually more cosmetic than functional

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100
Q

Carpal Tunnel Syndrome

etiology

A

genetic predisposition and an association with alcoholism and cirrhosis

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101
Q

Carpal Tunnel Syndrome

treatment

A

triamcinolone

lidocaine

collagenase injection

surgical realease when function is impaired

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102
Q

rotator cuff injury

overview

A

damage to rotator cuff muscles tendons and the bursae aroundthe shoulder leads to the inability to flex or abduct the shoulder

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103
Q

rotator cuff injury

presents with

A

pain int eh shoulder that is worse at night when lying on the affected hsoulder

severe tenderness at the insertion of the supraspinatus

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104
Q

rotator cuff injury

most accurate test

A

MRI

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105
Q

rotator cuff injury

treatmente

A

nsaids rest and physical therapy

if ineefective steroid injection relieves pain

suregery is used for complete tears and refractory

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106
Q

Patellofemoral syndrome

overvies

A

cause of anterior knee pain secondary to trauma, imbalance of quadriceps strength or meniscal tear

pain is in front of the knee or underneath the patella

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107
Q

Patellofemoral syndrome

presentation

A

pain is particularly bad when walking up or down stairs

sx are worse just after starign to walk after having been seatd for a prolonged perioe

improves after walking

crepitus joint locking and instability

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108
Q

Patellofemoral syndrome

xrays

A

normal

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109
Q

Patellofemoral syndrome

treatment

A

physical ehtrapy and strength training with cycling

knee braces dont help

nothing to fix surgically

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110
Q

Plantar fasciitis

presentation

A

very sever pain in the bottom of the foot near the calcaneus where hte fascia inserts

worst in the morning and improves with wlaking a few steps

point tenderness at bottom of foot wher ethe fascia inserts at the calcaneus

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111
Q

Plantar fasciitis vs tarsal tunnels syndrome

A

tts gets worse with walking

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112
Q

Plantar fasciitis

treatment

A

stretching

arch supports

nsaids

steroid injection for refractory cases

sugical release is rarely needed

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113
Q

Plantar fasciitis

xray

A

not useful

ther is no correlation iwth presence of heel spurs

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114
Q

Rheumatoid Arhtritis

Definition

A

autoimmune diorder predominantly of the joints but with many systemic manifestations of chronic inflammation

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115
Q

Rheumatoid Arhtritis

etiology

A

unknown, there is an association wth specific hla types

more common in women

chornic synovitis leads to overgrowth or pannus formation which damags all structures surrounding the joint (bone ligaments tendons and cartilage)

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116
Q

Rheumatoid Arhtritis

key to dx

A

multiple small inflamed joints is the key to the dx

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117
Q

Rheumatoid Arhtritis presentation

bilateral symmetrical joint involvement:

A

pip joints of the fingers, mcp joints of thehands, and involvement of the wrists, knees, and ankles

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118
Q

Rheumatoid Arhtritis presentation

morning stiffness

A

lasts at least 30 minutes but generally longer

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119
Q

Rheumatoid Arhtritis presentation

rheumatoid nodules

A

(20%) most often over bony prominences

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120
Q

Rheumatoid Arhtritis presentation

ocular sx

A

episcleritis

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121
Q

Rheumatoid Arhtritis presentation

lung involvement

A

pleural effusion and nodules of lung parenchyma

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122
Q

Rheumatoid Arhtritis presentation

vasculitis

A

skin bowel and peripheral nerves

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123
Q

Rheumatoid Arhtritis presentation

cervical joint involvement

A

particularly at C1 and C2 which can lead to lubluxation

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124
Q

what is spared in RA

A

DIP, they are not spared in DJD

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125
Q

Rheumatoid Arhtritis presentation

others

A

baker cyst may rupture and mimic a dvt

pericarditis and pleural disease

carpal tunnel syndrome

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126
Q

Rheumatoid Arhtritis Dx Tests

RF

A

in 70-80%

nospecific and can be associated with other autoimmune dusease and chronic infectious diseases

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127
Q

Rheumatoid Arhtritis Dx Tests

anti cyclic citrulinated peptide

A

anticcp is more than 80% sensitive and more than 95% specific

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128
Q

Rheumatoid Arhtritis Dx Tests

radiographs

A

erosion of joints

osteopenia

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129
Q

Rheumatoid Arhtritis Dx Tests

anemia

A

normocytic

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130
Q

Rheumatoid Arhtritis Dx Tests

arthrocentesis

A

is useful on initial presenation to exclude cyrstal disease and infection if the dx is not clear

will find modest elevation in lymphocytes

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131
Q

Rheumatoid Arhtritis Dx Tests

other

A

elevated esr or crp

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132
Q

6 or more points = RA

A

joint involvement (up to 5 points)

esr or crp (1 point)

duration for longer than 6 weeks (1 point)

RF or anti-ccp (1 point)

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133
Q

is xray needed to confirm ra

A

no

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134
Q

sicca syndrome

A

dry eyes mouth and othe mucous membranes

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135
Q

Felty syndrome

A

RA

splenomegaly

neutropenia

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136
Q

Caplan Syndrome

A

RA

pneumoconiosis

lung nodules

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137
Q

most common cause of death in ra is

A

coronary artery disease

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138
Q

most important issue in ra is

A

stopping the progression of the disease

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139
Q

any pt with ra and erosive disese on xray needs

A

at least methotrexate to slow the disease

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140
Q

erosive disease means in ra

A

joint space narrowing

physical deformity of joints

xray abnormalities

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141
Q

Disease modigying antirhuematic drugs

A

if nsaids and steroids arent working

methotrexate

tnf inhibitors (infliximab, adalimumab, etanercept)

rituximab

hydroxychloroquine

sulfsalazine leflunomide abatacept and anakinra

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142
Q

RA c spine

A

can get c1/c2 subluxation so do imaging before procedures

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143
Q

best initial dmard

A

methotrexate

144
Q

methotrexate

ae

A

liver toxicity

bone marow suppression

pulmonary toxicity

145
Q

tnf inhibitors (infliximab, adalimumab, etanercept

A

the first line dmards for those not responding to methotrexate or intolerant of methotrexate. thye are often used intial with methotrexate to prevent disease progression

146
Q

tnf inhibitors (infliximab, adalimumab, etanercept

ae

A

reactivation of tb: screen with a ppd prior to their use

infection

147
Q

Rituximab

A

originally develope dfo rnon-hodgkin lymphoma is effective in ra as a dmard by removing cd20 positive lymphocytes from circulation. this leads to exellent long term control of ra

used in combo with methotrexate in those not responding to antitnf

148
Q

Hydroxychlorloquine

A

can ce used as monotherapy as a dmard in cases of mild disease in which we wish to avoid the toxicity of mthetorexate.

more often used in combo with methotrexate as admard

tix to the retina

safe in pregnancy

149
Q

sulfsalazine leflunomide abatacept and anakinra

A

alternative to add to methotrexated if antitn do no contorl disease

150
Q

sulfsalazine ae

A

bone marrow toxicity

hemolysis with g6pd defciciency

rash

151
Q

symptomatic control of RA

best inital thearpy

A

nsaids are the best for the pain of ra, they work immediately to improve inlammation but do nothing to prevent the progression

152
Q

symptomatic control of RA

steroids

A

work in a matter of hours to control pain of ra secondary to inflammation

used hwen nsaids do not control symptoms immediately

used as a bridge when waiting for dnards to take effect

153
Q

do steroids prevent the progression of ra

A

no

154
Q

hydroxychloroquine leads to

A

retinal toxicity, do a dilated eye exam

155
Q

Adverse effects of antitnf

A

reactivation of tuberculosis

156
Q

Adverse effects of hydroxychloroquine

A

ocular

157
Q

Adverse effects of sulfsalazine

A

rash and hemolysis

158
Q

Adverse effects of rituximab

A

infection

159
Q

Adverse effects of gold salts

A

nephrotic syndrome

160
Q

Adverse effects of methrotrexate

A

liver, lung and marrow

161
Q

Juvenile rheumatoid arthritis or adult still disease

definition and etiology

A

very difficult to define and there is no known etiology

it will still appera on every usmle exam though

162
Q

Juvenile theumatoid arthritis or adult still disease

presentation/what is the most likely dx (know this)

A

most improtant feature is the presence of high, spiking fever (above 104) in a young person that has no clearly identified etiology but is associated with a rash

163
Q

Features of jra rash

A

often only with fever spikes

salmon colored

on chest and abdomen

164
Q

other features of jra

A

splenomegaly

pericardial effusion

mild joint symptoms

165
Q

Juvenile arthritis or adult still disease

lab abnormalities

A

no clear diagnostic test

howdver, anemia, hypalbuminemia, and leukocytosis are often present

ana is normal

ferritin level is markedly elevated

166
Q

ferritin

A

acute phase reactant, rises with inflammation

167
Q

Juvenile arthritis or adult still disease

treatment

A

halve of cases improve iwth apsirin or nsaids

if no response then use steroids

if still resistant use tnf drugs

168
Q

Systemic Lupus Erythematosus

definition

A

autoimmune disorder with anumber of autoantibodies (ANA, ds DNA). it causes inflammation diffusely throught he body (skin, brain, kidneys, joints) and the blood. sle has numerous abnomral blood tests assocaited with it (anemia, antism, antiphospholipid antibodies)

169
Q

Systemic Lupus Erythematosus

etiology

A

dont know

170
Q

Systemic Lupus Erythematosus presentation

A

must have 4 of the 11 known manifestations of the disease

171
Q

Systemic Lupus Erythematosus presentation

skin

A

malar rash

discoid rash

photosensitivity

oral ulcer

172
Q

Systemic Lupus Erythematosus presentation

joint

A

arthritis is present in 90% of cases and is often the first symptom that brings pts to seek medical attention, pain w/o deformation, xray is normal

173
Q

Systemic Lupus Erythematosus presentation

serositis

A

inflammation of the pleura and pericardium gives chest pain potentially with both pericardial and pleural effusion

174
Q

Systemic Lupus Erythematosus presentation

renal

A

any degree of abnormality can occur from mild proteinuria to end stage renal disease requiring dialyss.

mist common glomerulonephritis is emmbranous

red cell cast and hematuria occur

175
Q

Systemic Lupus Erythematosus presentation

neurologic

A

symptoms include psychosis, siezures, or stroke from vasculitis

176
Q

alopecia

A

common in sle but not part of the 11 criteria

177
Q

pneumonia alveolar hemorrhage and restrictive lung disease happen in sle

A

but are not part of the 11 criteria

178
Q

sle ocular findings

A

not part of the 11 criteria

photophobia

renial lesions (cotton wool spots)

blindness

179
Q

Systemic Lupus Erythematosus presentation

hematologic

A

hemolytic anemia is part of the diagnostic criterai but the anemia of chornic disease is more commonly found

lymphopenia leukopenia and thrombocytopenia are also seen

180
Q

Systemic Lupus Erythematosus presentation

immunologic (lab) abnormalities

A

any of the following are positive

ana

ant ds dna

antsm

ffalse positive test for syphilis

positive le cell preparation

181
Q

Systemic Lupus Erythematosus presentation

additional findings

A

mesenteric vasculitis

raynaud phenomenon

antiphospholipid syndromes

182
Q

do not treat an asymptomatic

A

ana

183
Q

Systemic Lupus Erythematosus diagnostic tests

ANA

A

found in 95 to 99% of case. a negative ana is extremely sensitive for lupus, but a positive ana has little specificity.

many rhuematological disease have a positive ana

184
Q

Systemic Lupus Erythematosus diagnostic tests

Anti-double-stranded DNA (60%) and anti-sm (30%)

A

these are found only in sle thery are extremely specific for SLE

185
Q

Systemic Lupus Erythematosus diagnostic tests

decreased complement levels

A

they can correlate with diease activity, they can drop further with acute disease exacerbations

186
Q

Systemic Lupus Erythematosus diagnostic tests

anti ssa and anti ssb

A

found in 10 to 20 % of cases. they add little to the diagnosi if the DNAis positive thes tests are most often found in sjogren syndrome (65%)

187
Q

in an acute lupus flare

A

complement levels drop and antids dna levels rise

188
Q

first new lupus drug in 50 years

A

belimumab

189
Q

Systemic Lupus Erythematosus treatment

acute flares

A

high dose bolusus of steroids, hydroxychloroquine can conrol mildly chornic disease limited to skin and joint manifestions belimubmat controls progression of the disease

190
Q

Systemic Lupus Erythematosus diagnostic tests

lupus nephritis

A

may need sterods either alon or in com with cyclophosphamide or mycophenolast. they only wat to determine severity of lupus nephritis is with a kidney biopsy. ua is insufficient to tell the severity og lupus nephritis. biopsy can tell if there is glomerullosclerosis or scarring of th kidney, which will not repsond to therapy

191
Q

Systemic Lupus Erythematosus

most common cause of death

A

young pts - infection

older pts - acceleartaed atherosclerosis make mi most common

192
Q

Antiphospholipid syndrome

definition

A

idiopathic disorder with igg or igm antibodies made against negatively charded phospholipids. 2 main types are
lupus anticoagulatn
anticardiolipin antibodies

193
Q

Antiphospholipid syndrome

Presentation

A

thromboses of both arteries and veins

recurrent sponataneous aborstion

elevation of the aptt with normal pt an dnormal inr

false positive vdrl or rpr with a normal fta bc the antibody reacts iwth the reagent in the lab which is cardiolpin

anticardiolipin antibodies more often givespontaneous abortion and lupus anticoa is mor often associate dwith elveated aptt

194
Q

apl=

A

clotting+elevated aptt and normal pt

195
Q

Antiphospholipid syndrome

best initial test

A

the mixing study, in which the pts plasma is mixed with an equal amount of normal plamsa. is the elevation in aptt is from a clotting factor deficiency, the aptt will come down to nromal. if th eapl syndrome antibody is present in plasma, the aptt wil lremain elevated

196
Q

Antiphospholipid syndrome

most specific test for the lupus anticoagulant

A

russell viper venom test (RVT). RVVT is prolonged with apl antibodies and does not correct on mixing with normal plasma

197
Q

Antiphospholipid syndrome treatment

A

thromboeses are treated iwth heparin and warfarin as you would any other from of thrombosis with an inr of 2-3

if single do for 6 months

if recurrent treat for lifetime

198
Q

Antiphospholipid syndrome

what should be investigated for anticardiolipin antibody as a cause of spontaneous abortion

A

two or more first-trimester events or a single second trimester event

199
Q

Antiphospholipid syndrome

what is the treatement to prevent a recurren spontaneous abortion

A

heparin and apsirin

200
Q

warfarin is ci in

A

pregnancy due to secondary teratogenicity

201
Q

Scleroderma/CREST

overview

A

the cuase of slceroderma is unkown, it is diffuse in 20% of cases and limited in 80%. limited slceroderma is also known as CREST sydnrome (calcinosis raynaud esophageal dysmotility, sclerodactyly telangiectasia

202
Q

Scleroderma/CREST

what is the most likely diagnosis

A

look for a young (20s to 40s) woman (3 times more likely than men) with fibrosis of the skin and internal organs such as lung, kidney, and GI tract

203
Q

Scleroderma/CREST presentation

raynauds

A

increased vascular reactivity of the fingers beginning iwth pain and pallor (white) or cyanosis (blue) followed by reactive hyperemia (red). precipitated by cold and emotional stress. can lead to ulcerations and gangrene

204
Q

Scleroderma/CREST presentation

skin manifestations

A

fibrosis of the hands, face, neck, and extremeties; telangiectasia and abnormalitites of pigmentation occur

205
Q

Scleroderma/CREST presentation

GI

A

esophageal dysmotility with GERD, large-mouthed diverticuli of small and large bowel

206
Q

Scleroderma/CREST presentation

renal

A

sudden hypetensive crisis

207
Q

Scleroderma/CREST presentation

Lung

A

fibrosis leadint to restrictive lung disease and pulmonary htn

208
Q

Scleroderma/CREST presentation

cardiac

A

myocardial fibrosis, pericarditis, and heart block; lung disease gives right ventricular hypertrophy

209
Q

Scleroderma/CREST Diagnostic tests

ana

A

positive in 85 to 90% but not specific

210
Q

Scleroderma/CREST Diagnostic tests

esr

A

usually normal

211
Q

Scleroderma/CREST Diagnostic tests

scle 70

A

the most specific test is the scl 70, anti topoisomerase, but present in only 30% of those iwth diffuse disease and 20% of those with limited disease

212
Q

Scleroderma/CREST Diagnostic tests

anticentromere

A

present in half of those with CREST sydrome

213
Q

anticentromee antibodies are extremely specific for

A

crest syndrome

214
Q

Scleroderma/CREST Treatment

A

methotrexate slows theundelrying diease process of lmited scleroderma

penicillamine is not effective

215
Q

Scleroderma/CREST Diagnostic tests

renal crisis

A

ace inhibitores (use even if the creatinine is elevated)

216
Q

Scleroderma/CREST Diagnostic tests

esophageal dysmotility

A

ppi’s for GERD

217
Q

Scleroderma/CREST Diagnostic tests

raynaud

A

ccb

218
Q

Scleroderma/CREST Diagnostic tests

pulmonary fibrosis

A

cyclophosphamide improves dyspnea and pfts

219
Q

Scleroderma/CREST Diagnostic tests

pulmonayr htn

A

bosentan ambrisentan (endothelin antagonist)

sildenafil

prostacyclin analogs: iloprost, treprostinil, epoprostenol

220
Q

Crest Vs Scleroderma

A

when it involves the lungs heart and kidney on top of CREST it is is scleroderma

CREST can cause pulmonary htn although the lungs are normal

221
Q

Polymyositis and Dermatomyositis

presentation

A

proximal muscle weakness leading to difficutly getting up from a seated position or walking up stairs

no facial or ocular muscle involvement like mg

only a quarter have pain and tenderness

dysphagia from involvmeent of the striated muscles of the pharynx

cardiac muscle involvement is rare but xkmb may be elevated

222
Q

Dermatomyosists may present

A

malar involvement

shawl sign: erythemma of face, neck shoulders, upper chest and back

heliotrope rash: edema and purplish discoloration of the eyelids

gottron papules scaly patches ove the bck of the hands particularly the pip can mcp joints

223
Q

Dermatomyositis cancer association

A

25% of cases are associated with cancer

ovary

lung

gi

lymphoma

224
Q

Polymyositis and Dermatomyositis

best initial test

A

cpk and aldolase

225
Q

Polymyositis and Dermatomyositis

most accurate test

A

muscle biopsy

226
Q

Polymyositis and Dermatomyositis

other tests

A

ana positive, nonspecific

anitjo antibodies are associated with lung firosis

mri detects patch muscle involvement

electromyography is abnormal

esr crp and rf are abnormal

227
Q

Polymyositis and Dermatomyositis

treatment

A

steroids are usually sufficient

can use if steroids dont work:
methotrexate
azathioprine
iv immunoglobulin
mycophenolate

hydroxycholoquine helps skin lesions

228
Q

Sjogren Syndrome

definition/etiology

A

idiopathic autoimmune diosrder secondary to antibodies predominatly against lacrimal and salivary glands, 90% of those affected are women

229
Q

Sjogren Syndrome

associated with

A 
RA
SLE 
PBC
Polymyositis
hashimoto thyroiditis
230
Q

Sjogren Syndrome

presentations

A

dryness of themouth and eyes, ocular abnormalities gie the feeling of sand in the eyes as well as burning and itching (keratoconjunctiva sicca)

dry mouth makes pt need to constantly drink water and difficulaty swalling. especially dry foods. loss of saliva leads to rampant dental caries and loss of teeth. the main function of salive is to neutralize acid on teeth and physically wash food off teeth

231
Q

Sjogren Syndrome

Less common manifestations

A

vasculitis

lung disease

pancreatitis

renal tubular acidosis (20%)

232
Q

most dangerous complication of Sjogren Syndrome

A

lymphoma

233
Q

Sjogren Syndrome

best initial test

A

Schirmer test - piec of fileter paper is placed aganst the eye andthen observed fo rthe amoutn of tears produced by the amount of weness on the filter paper

234
Q

Sjogren Syndrome

most accurate dx

A

lip or parotid gland biopsy, reveals lymphoid infiltration in the salivary glands

235
Q

Sjogren Syndrome

best initial blood test

A

ssa and ssb these are also called ro and la and are each present in about 65% of pts. sle is associated with ssa and ssb in 10-20% of cases

236
Q

Sjogren Syndrome

rose bengal stain

A

shows abnormal corneal epithelium

237
Q

Sjogren Syndrome

other abnormalities that are present but nonspecifice

A

ana

rf

anemia

leukopenia

eosinophilia

238
Q

Sjogren Syndrome

best initial treatment

A

water the mouth

use frequenst sips of water, sugar free gum, and fluoride treatmeants

use aretivical tears to aoid corneal ulcers

239
Q

beware lymphoma in

A

sjogrens

240
Q

Sjogren Syndrome

other treatment

A

pilocarpine and cevimeline increase ach, the main stimulant to the production of saliva. cevimeline increases rates for saliva production

there is no cure, but lifespan is not shortened. evaluate for lymphom, which occurs in up to 10% of patients

241
Q

Vasculitis

overview

A

cuase is uknown

sx develop over weeks to months

all vasculitides (polyarteritis nodos, wegener granulomatosis, churg strauss) give:
     fever
     malaise/fatigue
     weight loss
     arthralgia/myalgia
242
Q

Polyarteritis nodosa

definition

A

a disease of small and medium sized arteries leading to a diffuse vasculitis that inexplicably spares the lungs. chronic hepatitis b and c are associated with PAN

243
Q

Polyarteritis nodosa

pathognomonic feature

A

there is no pathognomonic feature

244
Q

Polyarteritis nodosa

common features of PAN

A

renal: you cannot distinguish from other forms of glomerulonephritis wihtout a biopsy; UA is not enough to confirm it is PAN

Neurological: any large peripheral nerve can be involved, but peroneal neuropathy leadint to foot drop is the most common neurological abnormality look for a stroke in a young person

GI: abdominal pain is worsened by eatingfrom vasculitis of the mesenteric vessels. bleeding also occurs. nausea and vomiting are common

skin: lower extremity ulcers are most common, livedo reicularis, purpura, nodules, and rarely gangrene also occur

245
Q

Polyarteritis nodosa

Mononeuritis multiplex

A

this is a confusing tem. how can it be mono and multi at the same time?

mononeuritis multiplex is multiple peripheral neuropathies of nerves large neough to have a name. for example, the radial never and the peroneal nerve of the ulnar nerve and the lateral femoral cutaneous nerve

246
Q

Polyarteritis nodosa

most accurate test

A

biopsy of a symptomatic site

247
Q

Polyarteritis nodosa

angiography

A

renal mesenteric or hepatic artery shows abnormal dilation or beading

248
Q

lung is spared in

A

PAN

249
Q

test all pan pts for

A

hepatitis B and C

250
Q

Polyarteritis nodosa

other abnormalities

A

anemia, leukocytosis, est, and crp

panca is present in less than 20%

ua will show protein and red cells but has nothing specific to indicate that it is pan

251
Q

Polyarteritis nodosa

treatment

A

prednisone and cyclophosphamide

treat hepatitis when found

252
Q

Polymyalgia Rhuematica

presentation

A

occurs in those over age 50 with:

pain and stiffness in shoulder an dpelvic girdle muscles

difficulty combing hair and rising from a chair

elevated esr

normochromic normocytic anemia

253
Q

Polyarteritis nodosa

labs

A

although there is muscle pain there are no lab findings of muscle destruction

the cpk and aldolase are normal

254
Q

Polyarteritis nodosa

treatment

A

it has a rapid response to steroids even at low doses

255
Q

Giant cell (temporal) arteritis

A

like pan but also has:

visual sx

jaw claudication

scalp tenderness

ha

sx in other artereis (decreased arm pulse,bruits near the clavicles or aortic regurg)

256
Q

Giant cell (temporal) arteritis

tests

A

esr and crp are elevated

most accurate test is abiopsy of the affected artery such as the temporal artery

257
Q

Giant cell (temporal) arteritis

treatment

A

start with high dose prednisone, quicklu is more improtant than wiating for the biopsy

258
Q

what is not reversible in Giant cell (temporal) arteritis

A

blindness

259
Q

Wegener Granulomatosis

what is the most likely dx

A

look for a combo of upper and lwer respiratory tract findings in a ssocaiton with renal insufficinecy

260
Q

Wegener Granulomatosis

upper respiratory tract involvement

A

sinusitis
otitis media
mastoiditis
oral ang gingival involement

skin joint and eye lesion

261
Q

Wegener Granulomatosis

best initial test

A

C-ANCA

262
Q

C-anca

A

anti-proteinase-s antibodies

cytoplasmic antibodies

263
Q

p-anca

A

anti-myeloperoxidase antibodes

264
Q

what disease for canca

A

wegener

265
Q

what diseases for panca

A

chrug strauss

microscopic polyangitis

266
Q

Wegener Granulomatosis

best test

A

lung biopsy>renal biopsy>sinus biopsy

267
Q

Wegener Granulomatosis

treatment

A

prednisone and cyclophosphamide

268
Q

unresolving peumonia not better with abs

A

think wegener

269
Q

Churg-Strauss syndrome

overview

A

a pulmonary renal syndrome it also has:
asthma and eosinophilia

fever
wieght loss
joint pain
skin findings

270
Q

Churg-Strauss syndrome

what is he most accurate test

A

biopsy is the most accurate test

271
Q

Churg-Strauss syndrome

treat with

A

prednisone and cyclophosphamide

272
Q

Henoch-Schonlein Purpura

overview

A

a vasculitis more frequently seen in children, characterized by:

gi involvement
purpura
arthralgia
hematuria

273
Q

Henoch-Schonlein Purpura

diagnsosi

A

most often a clinical dx but biopsy is hte most accurate test

274
Q

when the case describes leukocytoclastic vasculitis on biopsy the answer is

A

henoch-schonlein purpura

painless and palpable purpura in the legs and buttocks

275
Q

Henoch-Schonlein Purpura

treatment

A

most cases resolve spontaneously

steroids are the answer for severe abdominal pain or pregressive renal insufficiency

streoids do not reverse renal insufficiency but may decrease progression

276
Q

serum iga levels in hsp

A

not reliable

277
Q

Cryoglobulinemia

overview

A

is most commonly associated with chronic hepatitis Cinfection

it is also found with endocarditis and other connective tissue diseases like sjogren

278
Q

dont confuse cryoglobulinemia with

A

cold agglutinis both are IgM antibodies

279
Q

Cryoglobulins

Associated with -

manifestations -

treatment -

A

Associated with - hepatitis C

manifestations - joint pain, glomerulonephritis, purpuric skin lesions, neuropathy

treatment - interferon, ribavirin, and either teaprevir, or boceprevir

280
Q

cold aglutinin

Associated with -

manifestations -

treatment -

A

Associated with - ebv, mycoplasma, lymphoma

manifestations - hemolysis

treatment - stay warm, rituximab, cyclophosphamide, cyclosporine

281
Q

cryoglobulinemia induced lesions

A

will not blanch when pressed. blood vessels are damaged and inflamed

282
Q

cryoglobulinemia

tests

A

positive rf and cold precipitable immune complexes

283
Q

cryoglobulinemia

treatment

A

steroids have not been shown to be effective for cryoglobulinemia assocaited with hepatitis

treat underlying cause (ifhep c use interferon and ribavirin)

284
Q

usmle loves

A

cryoglobulinemia questions

285
Q

sle>decreased

A

c3 or 3 letters (SLE) = c3 hep c>decreased c4 or 4 letters (hep c)=c4

286
Q

Behcet syndrome

most likely diagnosis

A

look for an asian or middle eastern person with painful oral and genital ulcers in assocation with erythema nodosum-like lesions of the skin and:
ocular lesions
arthritis
cns lesions mimicking multiple sclerosis

287
Q

cryoglobulinemia

diagnostic tests

A

no characteristic lab abnormality

288
Q

cryoglobulinemia

treatment

A

Steroids first then to wean them off steroids use:

azathioprine
cyclophosphamide
colchicine
thalidomide

289
Q

Seronegative Spondyloarthropathies

types

A

ankylosing spondylitis
psoriatic arthritis
reactive arthritis (reiter syndrome)

290
Q

Seronegative Spondyloarthropathies

present with

A

joint pain usually in men under the age of 40 w/

involvement of the spine and large joints
negative rf (seronegative)
enthesopathy (inflammation where tendons and ligaments attach to bones)
uveitis
hla-b27

291
Q

Seronegative Spondyloarthropathies

treatment

A

corticosteroids are not a good treatment for Seronegative Spondyloarthropathies

292
Q

hla b27 with Seronegative Spondyloarthropathies

A

neve rthe best initial or most accurate test

293
Q

ankylosing spondylitis

what is the most likely diagnosis

A

young man with low backache and stiffness that radiates to the buttocks with flattening of thenormal lumbar curvature and decreased chest expansion

eventually the spine will not expand in any direction

enthesopathy occurs at the achilles tendon

294
Q

Other findings of ankylosing spondylitis

A

transient peripheral arhtritis of knees, hips, and shoulders (50%)

cardiac: atrioventricular block in 3-5%, aortic insufficiency

uveitis

295
Q

ankylosing spondylitis

best initial test

A

xray of the sacroiliac joint

296
Q

ankylosing spondylitis

most accurate test

A

mri

detects abnormalities years before the xray becomes abrnormal

297
Q

ankylosing spondylitis

esr

A

elevated in 85%

298
Q

Bamboo spine

A

late finding in ankylosing spondylitis with fusion of vertebral joints

299
Q

ankylosing spondylitis

xray finding

A

narrowing of sacroiliac joint

300
Q

hla b27 test in ankylosing spondylitis

A

not a good test bc 8% of the gneral population is positive

301
Q

ankylosing spondylitis

treatment

A

an exercise program and nsaids are the best initial treatment

if nsaids are insufficient use antitnf agents (etanercept, adalimumab, infliximab)

302
Q

Psoriatic Arthritis

presentation

A

80% of people will have preceding psoriasis, it is more common with sevre skin disease

si joint involvement

sausage digits from enthesopathy

nail pitting

303
Q

Psoriatic Arthritis

best initial test

A

xray of the joint showing a pencil in a cup deformity, there will also be bony erosions and irregular bone destruction

304
Q

Psoriatic Arthritis

other tests

A

elevated esr but it is nonspecific

uric acid level is elevated from increased skin turnover

305
Q

Psoriatic Arthritis

treatment

A

nsaids ar the best initial therapy

methotrexate is used when the question describes severe disease or no response to nsaids

ant tng agents are teh answer when methotrexate does not control disease

dont use steroids

306
Q

Reactive Arthritis (reiter syndrome)

occurs secondary to

A

inflammatory bowel disease (equal sex incidence)

sexually transmitted infection (far greater in men)

gi infection (yersinia, salmonella, campylobacter)

307
Q

Reactive Arthritis (reiter syndrome)

what is the most likely dx

A

triad of:

joint pain
Ocular findings (uveitis, conjunctivitis,)
genital abnormalities (urethritis, balanitis)
308
Q

Reactive Arthritis (reiter syndrome)

diagnostic test

A

no specific test for reactive arthritis

hot swollen joints should be tapped to rule out septic joint

look for triad

309
Q

Reactive Arthritis (reiter syndrome)

treatment

A

nsaids and correct the underlying cause

sulfasalazine is used when nsaids do not control it

steroids injections into the joints also help

310
Q

keratoderma blennorhagicum

A

skin lesion unique to reactive arthritis that looks like pustular psoriasis

311
Q

antibiotics do not reverse arthritis once

A

joint pain has started

312
Q

Osteoporosis

Presentation

A

look for an older personmore often a womanwith verteral fx leading to loss of height or wrist fracture

many are asymptomatic and fx are round on routine with bone densitometry which is recommended for all women above age 65

313
Q

Osteoporosis gives spontaneous fx

A

of wieght bearing bones

314
Q

Osteoporosis

most accurate tests

A

bone densitometery (DEXA) scanning

the t score compares bone density with the normal density of a young womean

315
Q

osteopenia dexa

A

bone density (t score) is between 1 and 2.5 standard deviations below normal

316
Q

Osteoporosis dexa

A

t score more than 2.5 standard deviations velow normal

317
Q

blood tests in Osteoporosis

A

all are normal

calcium phosphate and parathyroids are all normal

318
Q

bisphosphonates are very rarely associated with

A

osteonecrosis of the jaw

319
Q

Osteoporosis

treatment (6)

A
  1. vitamin d and calcium are the best initial therapy
  2. bisphosphonates are used when the t score is more than 2.5 sd below normal
  3. estrogen replacement is especially useful in postmenopausal women
  4. raloxifene is used as a substitute for estrogen in postmenopausal women, it also reduces the risk of breats cancer and decreases ldl levels
  5. teriparatide is an analgoue of parathyroids hormone that stimulates new bone matrix formation
  6. used as a nasal spray, calcitonin decreases the risk of vertebral fractures
320
Q

Osteoporosis

when multiple options are presented

A

choose vitamin d, calcium and bisphosphonates

321
Q

ae of bisphosphonates

A

esophagitis if prolonged contact

322
Q

Teriparatide ae

A

can cause osteosarcoma in rats

also causes hypercalcemia

323
Q

Septic Arthritis

definition

A

Septic Arthritis is an infection of any kind finding its way intot he joint space

324
Q

Septic Arthritis

etiology

A

bc synovial lining has no basement membrane, it is relatively loose and both bacteria and antibiotics easily find their way across it

relatively rare in an undamaged joint

the risk of infection is directly proportional to the degree of joint damage

osteoarthritis provides a slight risk with ra having a freater risk bc of greater destruction

prosthetic joint has the greatest risk

bacteremia can spread into the joint space which is hwy endocarditis and injection drug use causes septic arthritis

325
Q

Septic Arthritis

staphylococcus

A

40%

326
Q

Septic Arthritis

streptococcus

A

30%

327
Q

Septic Arthritis

gram negative rods

A

20%

328
Q

Septic Arthritis

presentation

A

the joint is warm, red, and immobile and often has a palpable effusion. chills and fever happen bc of bacteremia

329
Q

Septic Arthritis

best initial test and most accurate test

A

aspiration of the joint with aneelde (arthrocentesis)

330
Q

Septic Arthritis

joint fluid shows

A

Leukocytosis: more than 50000-100000 cells predominantly neutrophils

gram stain: positive in 50-70% of patients. sensitivity of the gram stain is greater iwth gram positive cocci and less with gram negative bacillin

synovial fluid culture: 70-90% sensitive

Blood julstures: 50% sensitive

331
Q

Septic Arthritis

treatment

A

ceftriaxone and vancomycin are the best initial therapy

332
Q

options for Septic Arthritis

gram negative bacili

A 
quinolones
aztreonam
cefotaxime
piperacillin
aminoglycosides
333
Q

other options for Septic Arthritis

gram pos cocci (sensitivt)

A

oxacillin nafcillin
cefazolin
piperacillin with tazobactam

334
Q

other options for Septic Arthritis

gram pos cocci (resistant)

A

linezolid
daptomycin
tigecycline
ceftaroline

335
Q

prosthettic joint infection

presentation

A

warm

red

immobile

tender joint

336
Q

prosthettic joint infection

diagnosis

A

xray or ct to see if the infection is limited to the joint space or has spread into the bone around the joint

no mri bc the joint is usually metal

if there is lucency around the implantation of the joint or the joint is loose infection is likely present

337
Q

prosthettic joint infection

treatment

A

remove the joint

treate with abs for 6-8 weeks

then replace the joint

338
Q

most comon organism for prosthettic joint infection

A

staph epi

339
Q

Gonoccocal arthritis

presentation

A

hx of stds or a young sexually active person

polyarticular involvement

tenosynovitis

petechial rash

340
Q

Gonoccocal arthritis is more frequent during

A

menses

341
Q

Gonoccocal arthritis

diagnostic tests

A

synovial fluid analysis

culture from: pharynx, rectum, urethra, and cevix

342
Q

?what tells you to culture everywhere

A

Gonoccocal arthritis:

rash
tenosynovitis
polyarticular involvement

343
Q

Septic Arthritis

leukocytosis -

gram stain -

culture -

blood cultutres -

A

leukocytosis - >50000 - 100000 cells

gram stain - 50-75% sensitivte

culture - 90% sensitive

blood cultutres - 50% wsensitive

344
Q

Gonoccocal arthritis

leukocytosis -

gram stain -

culture -

blood cultutres -

A

leukocytosis - 30000-50000 cells

gram stain - 25% sensitive

culture - <50% sensitive

blood cultutres - <10% sensitive

345
Q

gonococcal arthritis

treatment

A

ceftriaxone, cefotaxime, or ceftizoxime is best empiric treatment

fqa are not the best initial therapy bc more than 5%are resistant (so only use if organism is sensitive

346
Q

recurrent gonorrhea infection

A

terminal complement dificiency

347
Q

Osteomyelitis

definition. etiology

A

infection of the bone

staph areuas is ost common cause any organism can infect bone

children get it through hematogenous spread

adutls get it from contiguous (nearby) infection

348
Q

Osteomyelitis

presentation

A

diabetic pt with an ulcer

redenss warmth and swelling in the area

may be a draining purulent sinus tract

usually afebrile

349
Q

Osteomyelitis

best initial test

A

xray, i fnormal next step is mri

350
Q

Osteomyelitis

most accurate test

A

biopsy

351
Q

Osteomyelitis

why do esr

A

to follow response to therapy

352
Q

Osteomyelitis

culturing the drainage

A

never

353
Q

Osteomyelitis

bone scan

A

only when pt has a pacemaker and you would like to do an mri

354
Q

Osteomyelitis

sickle cell disease

A

think salmonella

355
Q

Osteomyelitis

treatment

A

takes weeks to progress so obtain a biopsy and then treate the organism

sensitive staph use oxacillin, cefazolin, nafcillin, or ceftriaxone

resistant staph use vanco or linezolid

gram negs use cipro (must confirm sensitivity firsst)

356
Q

Osteomyelitis

cipro

A

only oral therapy used but must only use if gramneg and sensitivity

357
Q

Quinolones toxicity

A

achilles tendon rupture from interfering with the growth of chondrocytes

ci in pregnancy and children bc the interfere with bone growth

OMS III (21 decks)

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