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Internal Med EOR > Ortho/rheum 1 > Flashcards

Ortho/rheum 1 Flashcards

1
Q

sx fibromyalgia

A

chronic widespread multisite ask pain, extreme fatigue, stiffness

non restful sleep and cognitive disturbances (fibro fog)

may have numbness

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2
Q

dx fibromyalgia

A

clinical. associated w normal labs. sleep studies show now REM cycle.

Tenderness in at least 11 out of 18 trigger points + chronic pain > 3 months

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3
Q

medical tx for fibromyalgia

A

low dose TCA (amitriptyline)
SNRI (duloxetine, milnacipran)
Cyclobenzaprine
Pregabalin

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4
Q

what other diseases is fibromyalgia associated with

A

hypothyroidism
RA
sleep apnea

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5
Q

widespread pain index and symptom severity scale to dx fibromyalgia

A

Widespread pain index (WPI) > 7 and symptom severity (SS) scale > 5 or WPI 3 to 6 and SS scale > 9

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6
Q

what is Polymyalgia rheumatica

A

idiopathic inflammation of the joints, bursae, and tenders (shoulder and hip girdle)

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7
Q

what disease is Polymyalgia Rheumatica closely associated w

A

giant cell arteritis

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8
Q

sx polymyalgia rheumatica

A

pain and stiffness in the proximal joints and muscles – shoulder and hip girdles, neck, lower back

worse w inactivity and after immobilization –> nocturnal pain and morning predominance w morning stiffness > 45 min

absence of cranial manifestations (distinguishes PMR from GCA)

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9
Q

PE for Polymyalgia rheumatica

A

decreased active and passive ROM
absence of cranial sx
Normal muscle strength

swelling, erythema, warmth usually absent

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10
Q

dx polymyalgia rheumatica

A

ESR is markedly elevated, usually > 50, temporal arteritis is confirmed by biopsy

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11
Q

tx polymyalgia rheumatica

A

Patients respond quickly to low dose corticosteroid therapy, which may be required for up to 2 years and slowly tapered

Methotrexate can also be used

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12
Q

what is gout

A

uric acid (monosodium rate crystal) deposition in the soft tissues, joints, bones

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13
Q

MC etiology of gout

A

under excretion of renal uric acid - MC
uric acid overproduction

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14
Q

triggers for gout

A

purine-rich foods (alcohol, liver, seafood, yeasts)

meds:
thiazide and loops
ACEI/ARBS
Pyrazinamide
Ethambutol
Aspirin

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15
Q

PE gout

A

severe joint pain
erythema
warmth
swelling
exquisite tenderness
limited ROM

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16
Q

dx gout

A

arthocentesis - test of choice; negatively birefringent, needle shaped crystals

radiographs - mouse or rat bite lesions (punched out erosions with sclerotic and overhanging margins)

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17
Q

acute tx gout

A

NSAIDs - initial tx of choice
oral glucocorticoids - refractory to NSAIDs
colchicine - if unable to use NSAIDs or corticosteroids

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18
Q

lifestyle changes for gout

A

decrease alcohol consumption
weight loss
decrease high purine diet

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19
Q

chronic medical tx gout

A

allopurinol (first line) and febuxostat are xanthine oxidase inhibitors (decrease uric acid production)

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20
Q

what is pseudogout

A

calcium pyrophosphate dihydrate deposition in the joints and soft tissue leading to inflammation and bone restruction

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21
Q

risks for pseudogout

A

hemochromatosis
hyperparathyroidism
hypomagnesemia

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22
Q

sx pseudogout

A

asx - majority
sudden severe joint pain, erythema, wearthm, swelling, and tenderness w limited ROM - indistinguishable from gout

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23
Q

dx pseudogout

A

arthrocentsis - test of choice; positively birefringent, rhomboid-shaped calcium pyrophosphate crystals and increased WBC (primarily neutrophils)

radiographs - linear calcification of the cartilage (chonedrocalcinosis)

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24
Q

tx pseudogout

A

corticosteroids - intraarticular if 1 or 2 joints

NSAIDs first line if > 2 joints

can also use colchicine if 3 or more attacks annually

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25
Q

joints affected in gout vs pseudogout

A

gout - metatarsophalangeal
pseudogout - knee and wrist

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26
Q

what uric acid level helps to confirm dx of gout

A

> 6.8

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27
Q

reactive arthritis used to be known as

A

reiter syndrome

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28
Q

MC cause of reactive arthritis

A

chlamydia trachoma’s

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29
Q

what gene is associated w increased incidence of reactive arthritis

A

HLA-B27

30
Q

sx reactive arthritis

A

triad - arthritis + ocular (conjunctivitis, uveitis) + genital (urethritis, cervicitis, balanitis)

arthritis - asymmetric minor or oligoarthritis commonly involving LE (esp knees)

keratoderma blennorrhagicum - hyperkeratotic lesions on palms and soles

circinate balanitis - painless erythematous lesions w small, shallow ulcers on the glans penis and urethral meatus

31
Q

dx reactive arthritis

A

arthrocentesis - to rule out septic arthritis

increased ESR and IgG, normochromic anemia

Positive HLA-B27

32
Q

tx reactive arthritis

A

NSAIDs (first line)
intraairticular injections
DMARD (sulfasalazine or methotrexate)
can use abx if active infection - but not usually indicated

33
Q

common GI infections that can cause reactive arthritis

A

salmonella, shigella, campylobacter, and yersinia

34
Q

what is rheumatoid arthritis characterized by

A

systemic polyarthritis
bone erosion, cartilage destruction
joint structure loss

35
Q

pathophysiology of rheumatoid arthritis

A

hyperplastic synovial tissue (pannus) leads to T cell mediated joint destruction

36
Q

symptoms rheumatoid arthritis

A

systemic sx - fatigue, fever, weight loss, anorexia
joint pain, stiffness, swelling - insidious onset, worse in the AM, with morning stiffness > 1 hour after initiating movement, improves later in the day

37
Q

what joints are MC affected in RA

A

small joint - wrist, MCP, PIP, MTP, ankle

spares the DIP

38
Q

PE for RA

A

symmetric inflamed joints - warm, erythematous, soft “boggy”

ulnar deviation

rheumatoid nodules over bony prominences

swan neck deformity - flexion at DIP with joint hyperextension at PIP
boutonniere deformities -flexion at PIP, hyperextension of DIP

39
Q

dx RA

A

rheumatoid factor - best initial
anti-cyclic citrullinated peptide antibodies (anti-CCP) most specific

radiographs - symmetric joint narrowing, osteopenia, bone and joint erosions. cervical spine may be involved – C1-C2 subluxation

40
Q

tx RA

A

DMARDs - methotrexate (initial), leflunomide, hydroxychloroquine, sulfasalazine, TNF inhibitors (etanercept, infliximab, adalimumab), anakinra, ritxumab, abatacept

for symptoms - NSAIDs (first line), corticosteroids

41
Q

what is polyarteritis nodosa

A

systemic vasculitis primarily of medium-sized arteries and muscular arterioles (necrotizing)

42
Q

what type of hypersensitivity rxn is polyarteritis nodosa

A

type 3
associated with chronic hep B

43
Q

sx polyarteritis nodosa

A

constitutional sx - fever, arthralgia, arthritis, myalgias
derm - Lower extremity nodules, papules, and ulcers, lived reticular, purpura, raynaud phenomenon
renal - renin-mediated HTN; no RBC casts
GI - postprandial abdominal pain
Neurologic - mononeuritis multiplex. multiple peripheral neuropathies - foot drop MC

44
Q

dx polyarteritis nodosa

A

labs - increased ESR, proteinuria. autoantibodies negative
ANCA negative
Renal or mesenteric angiography - micro aneurysms with abrupt cut-ff of small arteries
bx - definitive; necrotizing medium-vessel vasculitis and no granulomas

45
Q

tx polyarteritis nodosa

A

glucocorticoids
ACE/ARBs for HTN

46
Q

what is polymyositis

A

idiopathic autoimmune disorder leading to muscle inflammation, primarily involving the proximal limbs, neck, and pharynx.

May affect heart, lungs, GI tract

47
Q

inflammatory myopathy in polymyositis is due to

A

CD8+ lymphocyte infiltration of the endomysium

48
Q

sx polymyositis

A

progressive proximal skeletal muscle weakness (shoulders, hips)

evolves over weeks –> months

systemic sx - dysphagia, polyarthralgia, inflammatory arthritis
constitutional sx - low grade fever, fatigue, weight loss

49
Q

PE for polymyositis

A

decreased muscle strength esp of proximal muscles (proximal arm muscles esp the deltoids and neck flexors, biceps and triceps often involved. hip flexors are MC leg muscles but hamstring and quad weakness is also common)

often symmetrical

may have muscle atrophy

50
Q

dx polymyositis

A

elevated muscle enzymes - creatine kinase, aldolase, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH)

Anti Jo-1
Anti-signal recognition protein
ANA

increased ESR, CRP, RF

abnormal EMG

muscle biopsy - definitive - endomysial inflammation

51
Q

tx polymyositis

A

high dose glucocorticoids

can add azathioprine or methotrexate

52
Q

what is sjogren syndrome

A

systemic autoimmune dz primarily affecting the exocrine glands (salivary and lacrimal glands), primarily characterized by dryness of the mouth and eyes

53
Q

inflammatory destruction of the exocrine glands in sjogren syndrome is due to

A

CD4+ T cells and memory cell infiltration of the exocrine glands

54
Q

sx sjogren syndrome

A

dry mucous membranes - dry mouth (xerostomia), dry eyes (keratoconjunctivitis sicca from decreased tear production), vaginal dryness (may present w dyspareunia)

constitutional - generalized pain, fatigue, fever, weakness, sleep disturbances, anxiety, depression, raynauds

55
Q

complications of sjogren syndrome

A

increased risk of non-hodgkin lymphoma, pneumonitis, interstitial nephritis

56
Q

PE for sjogren syndrome

A

ocular dryness (xerophthalmia), conjunctivitis, corneal ulcers

decreased salivary pool, dry mucous membranes, soreness, ulceration, dental caries, periodontal disease

B/L parotid gland enlargement (may be tender)

57
Q

dx sjogren syndrome

A

screening - ANA, Anti SSA/Ro, Anti SSB/LA

ocular - positive schirmer test - decreased tear production (wetting of < 5 mm of the filter paper placed in the lower eyelid for 5 min). Rose Bengal stain - abnormal corneal epithelium

Minor salivary gland biopsy (lip) or parotid gland bx - standard to confirm - gland fibrosis and lymphocytic infiltration

positive RF, anemia, leukopenia, increased ESR, hypergammaglobulinemia

oral tests - salivary flow rate, sialochemistry, sialography, scintigraphy - none of these are really used

58
Q

tx sjogren syndrome

A

artificial tears
increase fluid intake
vit D supplement - reduces risk of neuropathy and lymphoma

cholinergic drugs - pilocarpine or cevimeline ** need to know these

59
Q

what is scleroderma (systemic sclerosis)

A

systemic autoimmune connective tissue disorder that leads to 1) fibrosis of the skin, muscles, soft tissues, and internal organs (heart, lung, kidney, GI tract) 2) vascular dysfunction (rayndaud phenomenon and pulmonary arterial HTN)

60
Q

scleroderma is due to

A

overproduction of collagen type I and III and matrix proteins

61
Q

what are the 2 main types of scleroderma

A

limited
diffuse

62
Q

what is limited scleroderma

A

80% (MC)
characterized by tight, shiny, thickened skin involving the face, neck, distal to the elbows and knees

spares the trunk

pulmonary HTN in advanced dz

CREST
Calcinosis cutis (calcium deposits in skin and subq tissue)
Raynaud’s phenomenon
Esophageal motility disorder
Sclerodactyly (claw hand)
Telangiectasias

gradual onset

63
Q

what is diffuse scleroderma

A

20%
tight, shiny, thickened skin involving the trunk and proximal extremities

associated w greater internal organ involvement (restrictive lung disease due to pulmonary fibrosis, myocardial fibrosis, renal involvement)

may have some of CREST features

sudden onset

64
Q

Dx scleroderma

A

anti-centromere antibodies - associated w limited scleroderma - specific

anti-SCL-70 antibodies (anti-topoisomerase) - associated w diffuse and multiple organ involvement

ANA

65
Q

tx scleroderma

A

skin - methotrexate or mycophenolate
GERD - PPI
HTN renal dz - ACEI
Raynaud - CCB, prostacyclin (prostaglandin)
Severe - DMARDs - methotrexate or mycophenolate. cyclophosphamide if refractory
Pulmonary fibrosis - cyclophosphamide - use PFTs
Pulmonary HTN - Bosnian, Sildenafil, prostacyclin analogues

66
Q

what is systemic lupus erythematosus (SLE)

A

idiopathic chronic systemic multi-organ autoimmune inflammatory disorder characterized by autoantibodies to nuclear antigens that can affect virtually any organ of the body

type 3 hypersensitivity

67
Q

risk factors for SLE

A

increased estrogen - women reproductive
african americans
sunlight exposure

68
Q

sx SLE

know the triad and the MC sx

A

fatigue MC
triad - joint pain + fever + malar butterfly photosensitivity rash - spares nasolabial folds
may have oral/nasal ulcers
discoid lesions - erythematous raised plaques w keratitis scale and follicular plugging that tend to scar

MSK - joint sx w or without active synovitis

may have heme issues - anemia, thrombocytopenia, leukopenia, etc

serositis - pleuritis with or without pleural effusions, pericarditis with or without pericardial effusion (MC Cardiac manifestation)

neuro - stroke, seizure, HA, psych or behavioral changes

kidney involved - associated w higher morbidity and mortality; hematuria, proteinuria, glomerulonephritis, HTN

Pulmonary - pleuritis, interstitial lung disease, Pulmonary HTN

CV - heat failure, arrhythmias, endocarditis

ocular - keratoconjunctivitis sicca, retinal vasculopathy

raynauds

vasculitis

VTE

69
Q

antibodies / labs for SLE

A

anti-nuclear antibodies (ANA)
anti-smith - most specific
anti-double-stranded DNA - highly specific
antiphospholipid antibodies - increased risk of arterial and venous thrombi

pancytopenia

decreased complement levels (C3, C4, CH50)

increased ESR, CRP

proteinuria or hematuria on UA

70
Q

dx for SLE

A

4 of 11
RASH RAIN
Rash: malar, discoid, oral ulcers, photosensitivity (each count as 1)
Arthritis
Serositis - pericarditis, pleuritis, peritonitis
Hematologic: hemolytic anemia, leukopenia, leukocytosis, thrombocytopenia

Renal disease - glomerulonephritis, proteinuria
ANA
Immunologic disorders - anti-dsDNA, anti-smith, false positive tests for syphilis (RPR, VDRL + negative FTA)
Neurologic - seizures or psychosis in absence of other causes

71
Q

tx SLE

A

Manage with sun protection, hydroxychloroquine (for skin lesions), NSAIDs, or acetaminophen for arthritis

Pulse dose steroids (methylprednisolone); cytotoxic drugs (methotrexate, cyclophosphamide)

Belimumab - unresponsive to other tx

72
Q
A

Internal Med EOR (17 decks)

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