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
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
3
Q
what is the most common cause of joint disease
A
osteoarthritis
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)
5
Q
Osteoarthritis
DIP enlargement
A
heberdennodes
6
Q
Osteoarthritis
PIP enlargement
A
Bouchard nodes
7
Q
Osteoarthritis
lab tests
A
all are normal
esr
cbc
ana
rheumatoid factor
8
Q
Osteoarthritis
most accurate test
A
xray:
joint space narrowing
osteophytes
dens subchondral bone
bone cysts
9
Q
Osteoarthritis
treatment
A
- weight loss and moderate exercise (swimming, yoga and tai chi)
- aceatminophen (best initial analgesic)
- NSAIDS: use if symptoms are not controlled with acetaminophen, second bc of toxicity (GI bleeding)
- capsaicin cream
- intraarticular steroids if other medical erharpy does not control pain
- hyaluronan injection in joint
- joint rpelacement if disease is severe
10
Q
Osteoarthritis
pathognomonic
A
absence of inflammation, normal lab tests, and short duration of stiffness
these distinguish it from RA
11
Q
Osteoarthritis
glucosasmine and chondrotin sulfate
A
no more effective than a placebo
12
Q
Gout
definition/Etiology
A
defect in urate metabolism with 90% of cases in men, there can be an overproduction or underexcretion
13
Q
Gout
overproduction
A
idiopathic
increased turnover of cells (cancer, hemolysis, psoriasis, chemotherapy)
enzyme deficiency (lesh-nyhan syndrome, glycogen storage disease)
14
Q
Gout
underexcretion
A
renal insufficiency
ketoacidosis or lactic acidosis
thiazides and aspirin
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
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
17
Q
tophi occur
A
anywhere in the body
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
19
Q
Gout
why aspirate joint
A
bc it is red warm and tender to you have to exclude infection
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
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
22
Q
colchicine ae
A
diarrhea and bone marrow suppression (neutropenia)
23
Q
Gout
chronic management
(6)
A
- diet:
decrease consumption of alcohol, particularly beer
lose weight
decrease high-purine foods such as meat and seafood - stop thiazides, aspirin, and niacin, use losartan first for htn
- 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
- allopurinol decrease production of uric acid. febusostat is sued if allopurinol is contraindicated. febuxostat is a xanthine oxidase inhibitor
- pegloticase dissolves uric acid. uric acid metabolism is accelerated by pegloticase
- probenecid and sulfinpyrazone increase the excretion of uric acid in the kideny (uricosuic)
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
25
what to do if a pt has an acute attack and is already taking allopurinol
continue allopurinol, but do not start uricosuic agents (or start allopurinol if not already taking it)
26
what gout drugs are ci in renal injury
probenecid, nsaids, and sulfinpyrazone
27
what gout drug is safe with renal injry
allopurinol
28
best drug for bp in gout
losartan it also lowers uric acid
29
calcium pyrophosphate (Pseudogout)
definition/etiology
from calcium contating salts depositingin the articular cartilage
most common risk factors are hemochormatosis and hyperparathyroidism.
also associated with diabetes, hypthyroidism and wilson dz
30
calcium pyrophosphate (Pseudogout)
presentation
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)
31
calcium pyrophosphate (Pseudogout)
other diagnostic tests
uric acid levels are normal
xray shows calcification of the carilaginous structures of the joint and DJD
32
calcium pyrophosphate (Pseudogout)
most accurate test
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)
33
you cannot confirm cppd wo
aspiration of the joint
34
DJD
Characteristic hx
physical findings
synovial fluid analysis
older, slow, worse with use
DIP, PIP, kip and knees
<200 wbcs, osteophytes and joint space narrowing
35
Gout
Characteristic hx
physical findings
synovial fluid analysis
men, acute binge drinking
1st big toe
2000-50000 wbcs, negative birefringent needles
36
CPPD
Characteristic hx
physical findings
synovial fluid analysis
hemochromatosis and hyperparathyroidism
wrists and knees
2000-5000 WBCs, positively birefringent rhomboids
37
RA
Characteristic hx
physical findings
synovial fluid analysis
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
38
Septic arthritis
Characteristic hx
physical findings
synovial fluid analysis
high fever, very acute
single hot joint
>50000 neutrophils, culture of fluid
39
CPPD
best initial therapy
NSAIDS
40
CPPD
if refractive to nsaids
intraticular steroids like triamcinolone
colchicine helps prevent subsequent attacks as prophylaxis between attacks
41
Low Back Pain
Etiology
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
42
DJD above age 50
nearly all people of this age have ti and so it is not significant
43
Low Back Pain
What is the most likely diagnosis overview
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
44
lumbosacral strain
no imaging and no treatment beyond nsaids
45
Low back pain
what is the most likely dx
compression of the spinal cord
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
46
compression at 4th thoracic vertebrae
result in a loss of sensation below the nipples
47
compression at the 10th thoracic vertebrae
results in sensory loss below the umbilius
48
point tnederness at the spine with percussion of vertebrae suggest
cord compression
49
reflexes with cord compression
hyperreflexia below the level of compression
50
epidural abscess
staph aureus
presents like cord compression from cancer
high fever and elevated ESR
51
epidural abscess treatment
methicillin-resistant staph aureus
vanco
linezolid
52
epidural abscess treatment
acute neurologic defects
system glucocorticoids
53
epidural abscess treatment
methicillin sensitive sataph aureus
oxacillin
nafcillin
cefazolin
54
disk herniation (sciatica)
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
55
disk herniation (sciatica)
imaging
image to rule out cord compression, epidural abscess, ankylosing sponylitis, and cauda equina syndrome
56
disk herniation (sciatica)
beest initial test
plain x ray (for copmression, infection, and fx)
57
disk herniation (sciatica)
most accurate test
mri, use ct if mri ci,
must use intrathecal contrast in ct (myelogram)
58
l4 compression
lose dorsiflection of foot
lose knee jerk
lose inner calf sensation
59
l5 compression
lose dorsiflexion of toe
lose inner forefoot sensation
60
s1 compression
lose eversion of foot
lose ankle jerk
lose outerfoot sensation
61
do what before imaging cord compression
give glucocorticoids
62
Cord Compression
What is the most likely dx -
physical findings -
What is the most likely dx - hx of cancer
physical findings - vertebral tenderness, sensory level, hyperreflexia
63
Epidural abscess
What is the most likely dx -
physical findings -
What is the most likely dx - fever, high esr
physical findings - vertebral tenderness, sensory level, hyperreflexia
64
Cauda Equina
What is the most likely dx -
physical findings -
What is the most likely dx - bowel and bladder incontinene, ed
physical findings - bilateral leg weakness, saddle area anesthesia
65
Ankylosing spondylitis
What is the most likely dx -
physical findings -
What is the most likely dx - under age 40, pains worsens with rest and improves with activity
physical findings - decreases chest mobility
66
Disk herniation
What is the most likely dx -
physical findings -
What is the most likely dx - pain.numbness of medial calf or foot
physical findings - loss of knee and ankle reflexes, positive slr
67
cord Compression treatment
systemic glucocorticoids, chemo for lymphoma, radiation for many solid tumors, surgicl decompressio if steroids and radiation are not effetive
68
epidural abscess treatment
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
69
think of epidural abscess like endocarditis
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
70
cauda equina syndrome treatment
surgical decompression
71
disk herniation treatment
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
72
most common wrong answer for sciatica
bed rest
73
sciatica most commonly tested point
dont do imaging if focal deficit, give steroids
74
Lumbar Stenosis
definition/etiology
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
75
exertion with leaning back leads to worse pain bc of pressure on the cord
Lumbar Stenosis
76
Lumbar Stenosis
presentation/what is the most likely dx
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)
77
Lumbar Stenosis can simulate
peripheral arterial disease but the vascular studies are normal
78
Lumbar Stenosis
diagnostic test
mri is the only test
79
Lumbar Stenosis
treatment
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
80
Fibromyalgia
What is the most likely diagnosis
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)
81
cause of Fibromyalgia
unkown
82
Fibromyalgia
pain is associated with
stiffness, numbness, and fatigue
83
Fibromyalgia
diagnostic tests
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
84
Fibromyalgia
best initial therapy
amitriptyline
85
Fibromyalgia
ther treatments
milnacipran an pregabalin
can inect anesthetic into tirgger points
86
milnaciparn
inhibits the reuptakes of serotonin and ne
fibromyalgia
87
steroids are the wrong answer for
fibromyalgia
88
Carpal Tunnel Syndrome
definition
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
89
Carpal Tunnel Syndrome
etiology
overuse of hand and wrist
pregnancy
diabetes
ra
acromegaly
amyloidosis
hypothyroidism
90
Carpal Tunnel Syndrome
what is the most likely dx
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
91
wrist mri is wrong for
MRI
92
Carpal Tunnel Syndrome
signs
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
93
Carpal Tunnel Syndrome
diagnostic tests
usually obvious from the sx
tinel and phalen signs
sqeeuze the nerve to confirm
94
Carpal Tunnel Syndrome
most accurate tests
electromyography and nerve conduction study
95
Carpal Tunnel Syndrome
best initial therapy
wrist splints to immoblilise the hand to relieve pressure
avoid manual activity
96
Carpal Tunnel Syndrome
treatment
steroid injections if splint and ndsaids dont work
surgery is curative by decompressing the tunnel by cutting open the retinaculum
97
callagenase injection helps
early dupuytrn contracture
98
what happens first in Carpal Tunnel Syndrome
sensory then motor sx
99
Dupuytrn Contracture
definition
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
100
Carpal Tunnel Syndrome
etiology
genetic predisposition and an association with alcoholism and cirrhosis
101
Carpal Tunnel Syndrome
treatment
triamcinolone
lidocaine
collagenase injection
surgical realease when function is impaired
102
rotator cuff injury
overview
damage to rotator cuff muscles tendons and the bursae aroundthe shoulder leads to the inability to flex or abduct the shoulder
103
rotator cuff injury
presents with
pain int eh shoulder that is worse at night when lying on the affected hsoulder
severe tenderness at the insertion of the supraspinatus
104
rotator cuff injury
most accurate test
MRI
105
rotator cuff injury
treatmente
nsaids rest and physical therapy
if ineefective steroid injection relieves pain
suregery is used for complete tears and refractory
106
Patellofemoral syndrome
overvies
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
107
Patellofemoral syndrome
presentation
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
108
Patellofemoral syndrome
xrays
normal
109
Patellofemoral syndrome
treatment
physical ehtrapy and strength training with cycling
knee braces dont help
nothing to fix surgically
110
Plantar fasciitis
presentation
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
111
Plantar fasciitis vs tarsal tunnels syndrome
tts gets worse with walking
112
Plantar fasciitis
treatment
stretching
arch supports
nsaids
steroid injection for refractory cases
sugical release is rarely needed
113
Plantar fasciitis
xray
not useful
ther is no correlation iwth presence of heel spurs
114
Rheumatoid Arhtritis
Definition
autoimmune diorder predominantly of the joints but with many systemic manifestations of chronic inflammation
115
Rheumatoid Arhtritis
etiology
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)
116
Rheumatoid Arhtritis
key to dx
multiple small inflamed joints is the key to the dx
117
Rheumatoid Arhtritis presentation
bilateral symmetrical joint involvement:
pip joints of the fingers, mcp joints of thehands, and involvement of the wrists, knees, and ankles
118
Rheumatoid Arhtritis presentation
morning stiffness
lasts at least 30 minutes but generally longer
119
Rheumatoid Arhtritis presentation
rheumatoid nodules
(20%) most often over bony prominences
120
Rheumatoid Arhtritis presentation
ocular sx
episcleritis
121
Rheumatoid Arhtritis presentation
lung involvement
pleural effusion and nodules of lung parenchyma
122
Rheumatoid Arhtritis presentation
vasculitis
skin bowel and peripheral nerves
123
Rheumatoid Arhtritis presentation
cervical joint involvement
particularly at C1 and C2 which can lead to lubluxation
124
what is spared in RA
DIP, they are not spared in DJD
125
Rheumatoid Arhtritis presentation
others
baker cyst may rupture and mimic a dvt
pericarditis and pleural disease
carpal tunnel syndrome
126
Rheumatoid Arhtritis Dx Tests
RF
in 70-80%
nospecific and can be associated with other autoimmune dusease and chronic infectious diseases
127
Rheumatoid Arhtritis Dx Tests
anti cyclic citrulinated peptide
anticcp is more than 80% sensitive and more than 95% specific
128
Rheumatoid Arhtritis Dx Tests
radiographs
erosion of joints
osteopenia
129
Rheumatoid Arhtritis Dx Tests
anemia
normocytic
130
Rheumatoid Arhtritis Dx Tests
arthrocentesis
is useful on initial presenation to exclude cyrstal disease and infection if the dx is not clear
will find modest elevation in lymphocytes
131
Rheumatoid Arhtritis Dx Tests
other
elevated esr or crp
132
6 or more points = RA
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)
133
is xray needed to confirm ra
no
134
sicca syndrome
dry eyes mouth and othe mucous membranes
135
Felty syndrome
RA
splenomegaly
neutropenia
136
Caplan Syndrome
RA
pneumoconiosis
lung nodules
137
most common cause of death in ra is
coronary artery disease
138
most important issue in ra is
stopping the progression of the disease
139
any pt with ra and erosive disese on xray needs
at least methotrexate to slow the disease
140
erosive disease means in ra
joint space narrowing
physical deformity of joints
xray abnormalities
141
Disease modigying antirhuematic drugs
if nsaids and steroids arent working
methotrexate
tnf inhibitors (infliximab, adalimumab, etanercept)
rituximab
hydroxychloroquine
sulfsalazine leflunomide abatacept and anakinra
142
RA c spine
can get c1/c2 subluxation so do imaging before procedures
143
best initial dmard
methotrexate
144
methotrexate
ae
liver toxicity
bone marow suppression
pulmonary toxicity
145
tnf inhibitors (infliximab, adalimumab, etanercept
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
tnf inhibitors (infliximab, adalimumab, etanercept
ae
reactivation of tb: screen with a ppd prior to their use
infection
147
Rituximab
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
Hydroxychlorloquine
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
sulfsalazine leflunomide abatacept and anakinra
alternative to add to methotrexated if antitn do no contorl disease
150
sulfsalazine ae
bone marrow toxicity
hemolysis with g6pd defciciency
rash
151
symptomatic control of RA
best inital thearpy
nsaids are the best for the pain of ra, they work immediately to improve inlammation but do nothing to prevent the progression
152
symptomatic control of RA
steroids
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
do steroids prevent the progression of ra
no
154
hydroxychloroquine leads to
retinal toxicity, do a dilated eye exam
155
Adverse effects of antitnf
reactivation of tuberculosis
156
Adverse effects of hydroxychloroquine
ocular
157
Adverse effects of sulfsalazine
rash and hemolysis
158
Adverse effects of rituximab
infection
159
Adverse effects of gold salts
nephrotic syndrome
160
Adverse effects of methrotrexate
liver, lung and marrow
161
Juvenile rheumatoid arthritis or adult still disease
definition and etiology
very difficult to define and there is no known etiology
it will still appera on every usmle exam though
162
Juvenile theumatoid arthritis or adult still disease
presentation/what is the most likely dx (know this)
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
Features of jra rash
often only with fever spikes
salmon colored
on chest and abdomen
164
other features of jra
splenomegaly
pericardial effusion
mild joint symptoms
165
Juvenile arthritis or adult still disease
lab abnormalities
no clear diagnostic test
howdver, anemia, hypalbuminemia, and leukocytosis are often present
ana is normal
ferritin level is markedly elevated
166
ferritin
acute phase reactant, rises with inflammation
167
Juvenile arthritis or adult still disease
treatment
halve of cases improve iwth apsirin or nsaids
if no response then use steroids
if still resistant use tnf drugs
168
Systemic Lupus Erythematosus
definition
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
Systemic Lupus Erythematosus
etiology
dont know
170
Systemic Lupus Erythematosus presentation
must have 4 of the 11 known manifestations of the disease
171
Systemic Lupus Erythematosus presentation
skin
malar rash
discoid rash
photosensitivity
oral ulcer
172
Systemic Lupus Erythematosus presentation
joint
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
Systemic Lupus Erythematosus presentation
serositis
inflammation of the pleura and pericardium gives chest pain potentially with both pericardial and pleural effusion
174
Systemic Lupus Erythematosus presentation
renal
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
Systemic Lupus Erythematosus presentation
neurologic
symptoms include psychosis, siezures, or stroke from vasculitis
176
alopecia
common in sle but not part of the 11 criteria
177
pneumonia alveolar hemorrhage and restrictive lung disease happen in sle
but are not part of the 11 criteria
178
sle ocular findings
not part of the 11 criteria
photophobia
renial lesions (cotton wool spots)
blindness
179
Systemic Lupus Erythematosus presentation
hematologic
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
Systemic Lupus Erythematosus presentation
immunologic (lab) abnormalities
any of the following are positive
ana
ant ds dna
antsm
ffalse positive test for syphilis
positive le cell preparation
181
Systemic Lupus Erythematosus presentation
additional findings
mesenteric vasculitis
raynaud phenomenon
antiphospholipid syndromes
182
do not treat an asymptomatic
ana
183
Systemic Lupus Erythematosus diagnostic tests
ANA
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
Systemic Lupus Erythematosus diagnostic tests
Anti-double-stranded DNA (60%) and anti-sm (30%)
these are found only in sle thery are extremely specific for SLE
185
Systemic Lupus Erythematosus diagnostic tests
decreased complement levels
they can correlate with diease activity, they can drop further with acute disease exacerbations
186
Systemic Lupus Erythematosus diagnostic tests
anti ssa and anti ssb
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
in an acute lupus flare
complement levels drop and antids dna levels rise
188
first new lupus drug in 50 years
belimumab
189
Systemic Lupus Erythematosus treatment
acute flares
high dose bolusus of steroids, hydroxychloroquine can conrol mildly chornic disease limited to skin and joint manifestions belimubmat controls progression of the disease
190
Systemic Lupus Erythematosus diagnostic tests
lupus nephritis
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
Systemic Lupus Erythematosus
most common cause of death
young pts - infection
older pts - acceleartaed atherosclerosis make mi most common
192
Antiphospholipid syndrome
definition
idiopathic disorder with igg or igm antibodies made against negatively charded phospholipids. 2 main types are
lupus anticoagulatn
anticardiolipin antibodies
193
Antiphospholipid syndrome
Presentation
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
apl=
clotting+elevated aptt and normal pt
195
Antiphospholipid syndrome
best initial test
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
Antiphospholipid syndrome
most specific test for the lupus anticoagulant
russell viper venom test (RVT). RVVT is prolonged with apl antibodies and does not correct on mixing with normal plasma
197
Antiphospholipid syndrome treatment
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
Antiphospholipid syndrome
what should be investigated for anticardiolipin antibody as a cause of spontaneous abortion
two or more first-trimester events or a single second trimester event
199
Antiphospholipid syndrome
what is the treatement to prevent a recurren spontaneous abortion
heparin and apsirin
200
warfarin is ci in
pregnancy due to secondary teratogenicity
201
Scleroderma/CREST
overview
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
Scleroderma/CREST
what is the most likely diagnosis
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
Scleroderma/CREST presentation
raynauds
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
Scleroderma/CREST presentation
skin manifestations
fibrosis of the hands, face, neck, and extremeties; telangiectasia and abnormalitites of pigmentation occur
205
Scleroderma/CREST presentation
GI
esophageal dysmotility with GERD, large-mouthed diverticuli of small and large bowel
206
Scleroderma/CREST presentation
renal
sudden hypetensive crisis
207
Scleroderma/CREST presentation
Lung
fibrosis leadint to restrictive lung disease and pulmonary htn
208
Scleroderma/CREST presentation
cardiac
myocardial fibrosis, pericarditis, and heart block; lung disease gives right ventricular hypertrophy
209
Scleroderma/CREST Diagnostic tests
ana
positive in 85 to 90% but not specific
210
Scleroderma/CREST Diagnostic tests
esr
usually normal
211
Scleroderma/CREST Diagnostic tests
scle 70
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
Scleroderma/CREST Diagnostic tests
anticentromere
present in half of those with CREST sydrome
213
anticentromee antibodies are extremely specific for
crest syndrome
214
Scleroderma/CREST Treatment
methotrexate slows theundelrying diease process of lmited scleroderma
penicillamine is not effective
215
Scleroderma/CREST Diagnostic tests
renal crisis
ace inhibitores (use even if the creatinine is elevated)
216
Scleroderma/CREST Diagnostic tests
esophageal dysmotility
ppi's for GERD
217
Scleroderma/CREST Diagnostic tests
raynaud
ccb
218
Scleroderma/CREST Diagnostic tests
pulmonary fibrosis
cyclophosphamide improves dyspnea and pfts
219
Scleroderma/CREST Diagnostic tests
pulmonayr htn
bosentan ambrisentan (endothelin antagonist)
sildenafil
prostacyclin analogs: iloprost, treprostinil, epoprostenol
220
Crest Vs Scleroderma
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
Polymyositis and Dermatomyositis
presentation
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
Dermatomyosists may present
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
Dermatomyositis cancer association
25% of cases are associated with cancer
ovary
lung
gi
lymphoma
224
Polymyositis and Dermatomyositis
best initial test
cpk and aldolase
225
Polymyositis and Dermatomyositis
most accurate test
muscle biopsy
226
Polymyositis and Dermatomyositis
other tests
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
Polymyositis and Dermatomyositis
treatment
steroids are usually sufficient
```
can use if steroids dont work:
methotrexate
azathioprine
iv immunoglobulin
mycophenolate
```
hydroxycholoquine helps skin lesions
228
Sjogren Syndrome
definition/etiology
idiopathic autoimmune diosrder secondary to antibodies predominatly against lacrimal and salivary glands, 90% of those affected are women
229
Sjogren Syndrome
associated with
```
RA
SLE
PBC
Polymyositis
hashimoto thyroiditis
```
230
Sjogren Syndrome
presentations
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
Sjogren Syndrome
Less common manifestations
vasculitis
lung disease
pancreatitis
renal tubular acidosis (20%)
232
most dangerous complication of Sjogren Syndrome
lymphoma
233
Sjogren Syndrome
best initial test
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
Sjogren Syndrome
most accurate dx
lip or parotid gland biopsy, reveals lymphoid infiltration in the salivary glands
235
Sjogren Syndrome
best initial blood test
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
Sjogren Syndrome
rose bengal stain
shows abnormal corneal epithelium
237
Sjogren Syndrome
other abnormalities that are present but nonspecifice
ana
rf
anemia
leukopenia
eosinophilia
238
Sjogren Syndrome
best initial treatment
water the mouth
use frequenst sips of water, sugar free gum, and fluoride treatmeants
use aretivical tears to aoid corneal ulcers
239
beware lymphoma in
sjogrens
240
Sjogren Syndrome
other treatment
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
Vasculitis
overview
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
Polyarteritis nodosa
definition
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
Polyarteritis nodosa
pathognomonic feature
there is no pathognomonic feature
244
Polyarteritis nodosa
common features of PAN
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
Polyarteritis nodosa
Mononeuritis multiplex
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
Polyarteritis nodosa
most accurate test
biopsy of a symptomatic site
247
Polyarteritis nodosa
angiography
renal mesenteric or hepatic artery shows abnormal dilation or beading
248
lung is spared in
PAN
249
test all pan pts for
hepatitis B and C
250
Polyarteritis nodosa
other abnormalities
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
Polyarteritis nodosa
treatment
prednisone and cyclophosphamide
treat hepatitis when found
252
Polymyalgia Rhuematica
presentation
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
Polyarteritis nodosa
labs
although there is muscle pain there are no lab findings of muscle destruction
the cpk and aldolase are normal
254
Polyarteritis nodosa
treatment
it has a rapid response to steroids even at low doses
255
Giant cell (temporal) arteritis
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
Giant cell (temporal) arteritis
tests
esr and crp are elevated
most accurate test is abiopsy of the affected artery such as the temporal artery
257
Giant cell (temporal) arteritis
treatment
start with high dose prednisone, quicklu is more improtant than wiating for the biopsy
258
what is not reversible in Giant cell (temporal) arteritis
blindness
259
Wegener Granulomatosis
what is the most likely dx
look for a combo of upper and lwer respiratory tract findings in a ssocaiton with renal insufficinecy
260
Wegener Granulomatosis
upper respiratory tract involvement
sinusitis
otitis media
mastoiditis
oral ang gingival involement
skin joint and eye lesion
261
Wegener Granulomatosis
best initial test
C-ANCA
262
C-anca
anti-proteinase-s antibodies
cytoplasmic antibodies
263
p-anca
anti-myeloperoxidase antibodes
264
what disease for canca
wegener
265
what diseases for panca
chrug strauss
microscopic polyangitis
266
Wegener Granulomatosis
best test
lung biopsy>renal biopsy>sinus biopsy
267
Wegener Granulomatosis
treatment
prednisone and cyclophosphamide
268
unresolving peumonia not better with abs
think wegener
269
Churg-Strauss syndrome
overview
a pulmonary renal syndrome it also has:
asthma and eosinophilia
fever
wieght loss
joint pain
skin findings
270
Churg-Strauss syndrome
what is he most accurate test
biopsy is the most accurate test
271
Churg-Strauss syndrome
treat with
prednisone and cyclophosphamide
272
Henoch-Schonlein Purpura
overview
a vasculitis more frequently seen in children, characterized by:
gi involvement
purpura
arthralgia
hematuria
273
Henoch-Schonlein Purpura
diagnsosi
most often a clinical dx but biopsy is hte most accurate test
274
when the case describes leukocytoclastic vasculitis on biopsy the answer is
henoch-schonlein purpura
painless and palpable purpura in the legs and buttocks
275
Henoch-Schonlein Purpura
treatment
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
serum iga levels in hsp
not reliable
277
Cryoglobulinemia
overview
is most commonly associated with chronic hepatitis Cinfection
it is also found with endocarditis and other connective tissue diseases like sjogren
278
dont confuse cryoglobulinemia with
cold agglutinis both are IgM antibodies
279
Cryoglobulins
Associated with -
manifestations -
treatment -
Associated with - hepatitis C
manifestations - joint pain, glomerulonephritis, purpuric skin lesions, neuropathy
treatment - interferon, ribavirin, and either teaprevir, or boceprevir
280
cold aglutinin
Associated with -
manifestations -
treatment -
Associated with - ebv, mycoplasma, lymphoma
manifestations - hemolysis
treatment - stay warm, rituximab, cyclophosphamide, cyclosporine
281
cryoglobulinemia induced lesions
will not blanch when pressed. blood vessels are damaged and inflamed
282
cryoglobulinemia
tests
positive rf and cold precipitable immune complexes
283
cryoglobulinemia
treatment
steroids have not been shown to be effective for cryoglobulinemia assocaited with hepatitis
treat underlying cause (ifhep c use interferon and ribavirin)
284
usmle loves
cryoglobulinemia questions
285
sle>decreased
c3 or 3 letters (SLE) = c3 hep c>decreased c4 or 4 letters (hep c)=c4
286
Behcet syndrome
most likely diagnosis
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
cryoglobulinemia
diagnostic tests
no characteristic lab abnormality
288
cryoglobulinemia
treatment
Steroids first then to wean them off steroids use:
azathioprine
cyclophosphamide
colchicine
thalidomide
289
Seronegative Spondyloarthropathies
types
ankylosing spondylitis
psoriatic arthritis
reactive arthritis (reiter syndrome)
290
Seronegative Spondyloarthropathies
present with
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
Seronegative Spondyloarthropathies
treatment
corticosteroids are not a good treatment for Seronegative Spondyloarthropathies
292
hla b27 with Seronegative Spondyloarthropathies
neve rthe best initial or most accurate test
293
ankylosing spondylitis
what is the most likely diagnosis
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
Other findings of ankylosing spondylitis
transient peripheral arhtritis of knees, hips, and shoulders (50%)
cardiac: atrioventricular block in 3-5%, aortic insufficiency
uveitis
295
ankylosing spondylitis
best initial test
xray of the sacroiliac joint
296
ankylosing spondylitis
most accurate test
mri
detects abnormalities years before the xray becomes abrnormal
297
ankylosing spondylitis
esr
elevated in 85%
298
Bamboo spine
late finding in ankylosing spondylitis with fusion of vertebral joints
299
ankylosing spondylitis
xray finding
narrowing of sacroiliac joint
300
hla b27 test in ankylosing spondylitis
not a good test bc 8% of the gneral population is positive
301
ankylosing spondylitis
treatment
an exercise program and nsaids are the best initial treatment
if nsaids are insufficient use antitnf agents (etanercept, adalimumab, infliximab)
302
Psoriatic Arthritis
presentation
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
Psoriatic Arthritis
best initial test
xray of the joint showing a pencil in a cup deformity, there will also be bony erosions and irregular bone destruction
304
Psoriatic Arthritis
other tests
elevated esr but it is nonspecific
uric acid level is elevated from increased skin turnover
305
Psoriatic Arthritis
treatment
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
Reactive Arthritis (reiter syndrome)
occurs secondary to
inflammatory bowel disease (equal sex incidence)
sexually transmitted infection (far greater in men)
gi infection (yersinia, salmonella, campylobacter)
307
Reactive Arthritis (reiter syndrome)
what is the most likely dx
triad of:
```
joint pain
Ocular findings (uveitis, conjunctivitis,)
genital abnormalities (urethritis, balanitis)
```
308
Reactive Arthritis (reiter syndrome)
diagnostic test
no specific test for reactive arthritis
hot swollen joints should be tapped to rule out septic joint
look for triad
309
Reactive Arthritis (reiter syndrome)
treatment
nsaids and correct the underlying cause
sulfasalazine is used when nsaids do not control it
steroids injections into the joints also help
310
keratoderma blennorhagicum
skin lesion unique to reactive arthritis that looks like pustular psoriasis
311
antibiotics do not reverse arthritis once
joint pain has started
312
Osteoporosis
Presentation
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
Osteoporosis gives spontaneous fx
of wieght bearing bones
314
Osteoporosis
most accurate tests
bone densitometery (DEXA) scanning
the t score compares bone density with the normal density of a young womean
315
osteopenia dexa
bone density (t score) is between 1 and 2.5 standard deviations below normal
316
Osteoporosis dexa
t score more than 2.5 standard deviations velow normal
317
blood tests in Osteoporosis
all are normal
calcium phosphate and parathyroids are all normal
318
bisphosphonates are very rarely associated with
osteonecrosis of the jaw
319
Osteoporosis
treatment (6)
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
Osteoporosis
when multiple options are presented
choose vitamin d, calcium and bisphosphonates
321
ae of bisphosphonates
esophagitis if prolonged contact
322
Teriparatide ae
can cause osteosarcoma in rats
also causes hypercalcemia
323
Septic Arthritis
definition
Septic Arthritis is an infection of any kind finding its way intot he joint space
324
Septic Arthritis
etiology
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
Septic Arthritis
staphylococcus
40%
326
Septic Arthritis
streptococcus
30%
327
Septic Arthritis
gram negative rods
20%
328
Septic Arthritis
presentation
the joint is warm, red, and immobile and often has a palpable effusion. chills and fever happen bc of bacteremia
329
Septic Arthritis
best initial test and most accurate test
aspiration of the joint with aneelde (arthrocentesis)
330
Septic Arthritis
joint fluid shows
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
Septic Arthritis
treatment
ceftriaxone and vancomycin are the best initial therapy
332
options for Septic Arthritis
gram negative bacili
```
quinolones
aztreonam
cefotaxime
piperacillin
aminoglycosides
```
333
other options for Septic Arthritis
gram pos cocci (sensitivt)
oxacillin nafcillin
cefazolin
piperacillin with tazobactam
334
other options for Septic Arthritis
gram pos cocci (resistant)
linezolid
daptomycin
tigecycline
ceftaroline
335
prosthettic joint infection
presentation
warm
red
immobile
tender joint
336
prosthettic joint infection
diagnosis
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
prosthettic joint infection
treatment
remove the joint
treate with abs for 6-8 weeks
then replace the joint
338
most comon organism for prosthettic joint infection
staph epi
339
Gonoccocal arthritis
presentation
hx of stds or a young sexually active person
polyarticular involvement
tenosynovitis
petechial rash
340
Gonoccocal arthritis is more frequent during
menses
341
Gonoccocal arthritis
diagnostic tests
synovial fluid analysis
culture from: pharynx, rectum, urethra, and cevix
342
?what tells you to culture everywhere
Gonoccocal arthritis:
rash
tenosynovitis
polyarticular involvement
343
Septic Arthritis
leukocytosis -
gram stain -
culture -
blood cultutres -
leukocytosis - >50000 - 100000 cells
gram stain - 50-75% sensitivte
culture - 90% sensitive
blood cultutres - 50% wsensitive
344
Gonoccocal arthritis
leukocytosis -
gram stain -
culture -
blood cultutres -
leukocytosis - 30000-50000 cells
gram stain - 25% sensitive
culture - <50% sensitive
blood cultutres - <10% sensitive
345
gonococcal arthritis
treatment
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
recurrent gonorrhea infection
terminal complement dificiency
347
Osteomyelitis
definition. etiology
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
Osteomyelitis
presentation
diabetic pt with an ulcer
redenss warmth and swelling in the area
may be a draining purulent sinus tract
usually afebrile
349
Osteomyelitis
best initial test
xray, i fnormal next step is mri
350
Osteomyelitis
most accurate test
biopsy
351
Osteomyelitis
why do esr
to follow response to therapy
352
Osteomyelitis
culturing the drainage
never
353
Osteomyelitis
bone scan
only when pt has a pacemaker and you would like to do an mri
354
Osteomyelitis
sickle cell disease
think salmonella
355
Osteomyelitis
treatment
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
Osteomyelitis
cipro
only oral therapy used but must only use if gramneg and sensitivity
357
Quinolones toxicity
achilles tendon rupture from interfering with the growth of chondrocytes
ci in pregnancy and children bc the interfere with bone growth
