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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
joints affected in gout vs pseudogout
gout - metatarsophalangeal pseudogout - knee and wrist
26
what uric acid level helps to confirm dx of gout
> 6.8
27
reactive arthritis used to be known as
reiter syndrome
28
MC cause of reactive arthritis
chlamydia trachoma's
29
what gene is associated w increased incidence of reactive arthritis
HLA-B27
30
sx reactive arthritis
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
dx reactive arthritis
arthrocentesis - to rule out septic arthritis increased ESR and IgG, normochromic anemia Positive HLA-B27
32
tx reactive arthritis
NSAIDs (first line) intraairticular injections DMARD (sulfasalazine or methotrexate) can use abx if active infection - but not usually indicated
33
common GI infections that can cause reactive arthritis
salmonella, shigella, campylobacter, and yersinia
34
what is rheumatoid arthritis characterized by
systemic polyarthritis bone erosion, cartilage destruction joint structure loss
35
pathophysiology of rheumatoid arthritis
hyperplastic synovial tissue (pannus) leads to T cell mediated joint destruction
36
symptoms rheumatoid arthritis
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
what joints are MC affected in RA
small joint - wrist, MCP, PIP, MTP, ankle spares the DIP
38
PE for RA
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
dx RA
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
tx RA
DMARDs - methotrexate (initial), leflunomide, hydroxychloroquine, sulfasalazine, TNF inhibitors (etanercept, infliximab, adalimumab), anakinra, ritxumab, abatacept for symptoms - NSAIDs (first line), corticosteroids
41
what is polyarteritis nodosa
systemic vasculitis primarily of medium-sized arteries and muscular arterioles (necrotizing)
42
what type of hypersensitivity rxn is polyarteritis nodosa
type 3 associated with chronic hep B
43
sx polyarteritis nodosa
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
dx polyarteritis nodosa
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
tx polyarteritis nodosa
glucocorticoids ACE/ARBs for HTN
46
what is polymyositis
idiopathic autoimmune disorder leading to muscle inflammation, primarily involving the proximal limbs, neck, and pharynx. May affect heart, lungs, GI tract
47
inflammatory myopathy in polymyositis is due to
CD8+ lymphocyte infiltration of the endomysium
48
sx polymyositis
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
PE for polymyositis
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
dx polymyositis
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
tx polymyositis
high dose glucocorticoids can add azathioprine or methotrexate
52
what is sjogren syndrome
systemic autoimmune dz primarily affecting the exocrine glands (salivary and lacrimal glands), primarily characterized by dryness of the mouth and eyes
53
inflammatory destruction of the exocrine glands in sjogren syndrome is due to
CD4+ T cells and memory cell infiltration of the exocrine glands
54
sx sjogren syndrome
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
complications of sjogren syndrome
increased risk of non-hodgkin lymphoma, pneumonitis, interstitial nephritis
56
PE for sjogren syndrome
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
dx sjogren syndrome
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
tx sjogren syndrome
artificial tears increase fluid intake vit D supplement - reduces risk of neuropathy and lymphoma cholinergic drugs - pilocarpine or cevimeline ** need to know these
59
what is scleroderma (systemic sclerosis)
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
scleroderma is due to
overproduction of collagen type I and III and matrix proteins
61
what are the 2 main types of scleroderma
limited diffuse
62
what is limited scleroderma
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
what is diffuse scleroderma
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
Dx scleroderma
anti-centromere antibodies - associated w limited scleroderma - specific anti-SCL-70 antibodies (anti-topoisomerase) - associated w diffuse and multiple organ involvement ANA
65
tx scleroderma
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
what is systemic lupus erythematosus (SLE)
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
risk factors for SLE
increased estrogen - women reproductive african americans sunlight exposure
68
sx SLE know the triad and the MC sx
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
antibodies / labs for SLE
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
dx for SLE
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
tx SLE
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

Internal Med EOR (17 decks)

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