Ortho/Rheum

Question 1

A patient is complaining of widespread muscular pain, fatigue, muscle tenderness, headaches, poor sleep and poor memory problems. The patient states she has felt like this for 6 months. Muscle biopsy reveals “moth-eaten” appearance of the type I muscle fibers. What else is needed for the diagnosis of fibromyalgia?

Answer 1

Diffuse pain in 11 out of 18 trigger points > 3 months + widespread pain

Question 2

A patient is complaining of widespread muscular pain, fatigue, muscle tenderness, headaches, poor sleep and poor memory problems. The patient states she has felt like this for 6 months. Muscle biopsy reveals “moth-eaten” appearance of the type I muscle fibers. What is the management of this patient?

Answer 2

Exercise (swimming preferred; has a relaxing effect of water on the muscles)

Medical:
TCAs**
Pregabalin FDA approved** 
Duloxetine (SNRI) 
SSRIs

Question 3

What is thought to be the etiology of Fibromyalgia?

Answer 3

May be an increase in pain perception

Increased Substance P*

Question 4

How do you diagnose Sjogren’s syndrome?

Answer 4

ANA especially AntiSS-A (Ro) & AntiSS-B (La)

+ RF
+Schirmer Test (decreased tear production)

Question 5

What is Sjogren’s syndrome?

Answer 5

An autoimmune disorder that attacks EXOcrine glands*:

Salivary glands –> xerostomia (dry mouth)
Lacrimal glands –> keratoconjunctivitis sicca)
Parotid enlargement*

Question 6

What is the management of Sjogren’s syndrome?

Answer 6

Artificial tears and Pilocarpine for xerostomia

Question 7

What is the MOA of Pilocarpine?

Answer 7

Cholinergic drug that increases lacrimation & salivation

Question 8

What are the side effects of Pilocarpine?

Answer 8

SLUDD-C

Salivation
Lacrimation
Urination
Defecation
Digestion
Constriction

Question 9

What is the MOA of Cevimeline?

Answer 9

Stimulates muscarinic cholinergic receptors

Question 10

Sjogren’s syndrome patients have an increase incidence of what condition?

Answer 10

Increase incidence of non-Hodgkin lymphoma*, interstitial nephritis, and pneumonitis

Question 11

What type of Sjogren’s syndrome is associated with other autoimmune disorders such as: SLE, RA…etc.?

Answer 11

Secondary Sjogren’s syndrome

Question 12

What type of Sjogren’s syndrome occurs alone?

Answer 12

Primary Sjogren’s syndrome

Question 13

What is the management for Polymyalgia rheumatica?

Answer 13

Low dose corticosteroids (10-20 mg/day)

NSAIDS
Methotrexate

Question 14

A patient is having bilateral proximal joint aching and stiffness, particularly in the morning. The patient says the stiffness lasts greater than 30 min. She states that her pelvic, neck and shoulder girdle. The patient says she does not notice any muscle weakness. How is this condition diagnosed?

Answer 14

Clinical dx

Increased ESR
Anemia (normochromic, normocytic)

Question 15

What condition is Polymyalgia rheumatica related to?

Answer 15

Giant Cell Arteritis

Question 16

What is Polymyalgia rheumatica?

Answer 16

Idiopathic inflammatory condition causing synovitis, bursitis, and tenosynovitis leading to pain/stiffness of the PROXIMAL joints (shoulder, hip, neck) in patients >50*

Question 17

What age group does Polymyalgia rheumatica affect?

Answer 17

> 50 years

Question 18

What is Scleroderma (Systemic sclerosis)?

Answer 18

A systemic connective tissue disorder: thickened skin (sclerodactyly) of the lung, heart, kidney, & GI tract

Question 19

A patient is seen with tight, shiny, thickened skin of the trunk and proximal extremities. Based on this, what is the most likely diagnosis?

Answer 19

DIFFUSE cutaneous systemic sclerosis

Question 20

A 17-year-old patient is seen with tricolor changes of his fingers, toes, ears, nose, and tongue that he states worsens with cold weather or when he is stressed or smoking. During PE you notice his face, neck, distal elbows and knees are also affected. Based on this, what is the most likely diagnosis?

Answer 20

Raynaud’s phenomenon

Question 21

A 17-year-old patient is seen with tricolor changes of his fingers, toes, ears, nose, and tongue that he states worsens with cold weather or when he is stressed or smoking. During PE you notice his face, neck, distal elbows and knees are also affected. What is the best treatment for this patient?

Answer 21

Vasodilators:
CCB are TOC*
Prostacyclin

Question 22

A 17-year-old patient is seen with tricolor changes of his fingers, toes, ears, nose, and tongue that he states worsens with cold weather or when he is stressed or smoking. During PE you notice his face, neck, distal elbows and knees are also affected. You also notice Cutaneous cutis, telangiectactasia, and sclerodactyly (claw hand). Based on this information, what is the best way to diagnose this patient?

Answer 22

+ Anti-Centromere Ab* = associated with Limited/Crest dz

• More specific
• Better prognosis

Question 23

A patient is seen with tight, shiny, thickened skin of the trunk and proximal extremities. Based on this, what is the best way to diagnose this patient?

Answer 23

+ Anti-Scl-70 Ab = associated with Diffuse & multi-organ involvement

+ ANA (non-specific)

Question 24

How is Scleroderma (Systemic sclerosis) managed?

Answer 24

Acute management: DMARDs or Corticosteroids

Question 25

What is Systemic Lupus Erythematosus?

Answer 25

Chronic systemic, multi-organ autoimmune disorder of connective tissures Type III HSN (hypersensitivity)

Question 26

What populations are at higher risk for developing SLE?

Answer 26

1. Young females 9:1 2. Onset in 20-40s 3. AA 4. Hispanic 5. Native American

Question 27

What environmental factors contribute to a patient developing SLE?

Answer 27

1. Genetic 2. Sun exposure 3. Infections 4. Hormonal (Estrogen)

Question 28

What drugs potentiate SLE?

Answer 28

1. Procainamide 2. Hydralazine 3. INH 4. Quinidine

Question 29

What type of SLE is + for Anti-Histone antibodies?

Answer 29

Drug-induced

Question 30

What is the "triad" of SLE?

Answer 30

1. Joint pain 2. Fever 3. Malar "butterfly" rash (spares the nasolabial fold)

Question 31

What cardiac complications do patients with SLE acquire?

Answer 31

Serositis: pericarditis or pleuritis

Question 32

A patient is seen with annular, erythematous patches on face and scalp that the patient reports heal with scarring. Based on this information, what is the most likely diagnosis?

Answer 32

Discoid lupus

Question 33

What systemic affects does SLE have?

Answer 33

1. CNS 2. Cardiovascular 3. Glomerulonephritis 4. Retinitis 5. Oral ulcers 6. Alopecia*

Question 34

What is the best initial test for SLE?

Answer 34

+ Anti-nuclear Ab: ANA | + RF

Question 35

Which test is 100% specific for SLE?

Answer 35

+ Anti-double-stranded DNA | + Anti-Smith Ab

Question 36

A patient is diagnosed with SLE and Anti-phospholipid Ab syndrome. What are they at higher risk for?

Answer 36

Arterial & venous thrombosis

Question 37

How do you manage a patient with SLE?

Answer 37

Skin: 1. Sun protection 2. Lesions = hydroxychloroquine Arthritis: 1. NSAIDS 2. Acetaminophen +/- Pulse corticosteroids; methotrexate; cyclophosphamide

Question 38

What is Polyarthritis Nodosa (PAN)?

Answer 38

Systemic vasculitis of medium/small arteries that leads to necrotizing inflammatory lesions Type III HSN

Question 39

Which Rheumatologic disorder has an increased association with Hepatitis B?

Answer 39

Polyarteritis Nodosa

Question 40

How do you manage Polyarteritis Nodosa?

Answer 40

Corticosteroids

Question 41

How do you manage refractory Polyarteritis Nodosa?

Answer 41

Corticosteroids | +/- Cyclophosamide

Question 42

How do you manage Polyarteritis Nodosa if the patient is HBV + ?

Answer 42

Corticosteroids | +/- Plasmaphoresis

Question 43

A 45 y/o male patient is complaining of fever, myalgia, arthritis, neuropathy and ulcers. On PE, you notice livedo reticularis. Vital signs reveal HTN. Patient denies any dyspnea or chest pain. Biopsy reveals necrotizing inflammatory lesions, but no granulomas. Based on this, what is the most likely diagnosis?

Answer 43

Polyarteritis Nodosa

Question 44

A 45 y/o male patient is complaining of fever, myalgia, arthritis, neuropathy and ulcers. On PE, you notice livedo reticularis. Vital signs reveal HTN. Patient denies any dyspnea or chest pain. Biopsy reveals necrotizing inflammatory lesions, but no granulomas. Based on this, what is the best way to diagnose this patient?

Answer 44

Tests: 1. Increased ESR 2. Angiography/ Renal/ Mesenteric: micro aneurysms with abrupt cut off of small arteries 3. Classic PAN is ANCA Negative History: 3. Age: 45 4. Gender

Question 45

What is Reactive Arthritis?

Answer 45

Autoimmune response to an infection in another part of the body

Question 46

What population does Reactive Arthritis typically affect?

Answer 46

1. 20-40s | 2. Males

Question 47

What is the most common etiology of Reactive Arthritis?

Answer 47

1-4 weeks post Chlamydia*** Gonorrhea GI infections: Salmonella, Shigella, Campylobacter, Yersinia

Question 48

What is the triad for the Clinical Manifestation of Reactive Arthritis?

Answer 48

1. Arthritis (asymmetric inflammation; esp lower extremities) "sausage toes/fingers" 2. Conjunctivitis 3. Urethritis

Question 49

What is Keratoderma blennorrhagicum?

Answer 49

Associated with Reactive Arthritis = hyperkeratotic lesions on palms/soles

Question 50

A patient with arthritis in his knees and ankles, conjunctivitis and urethritis is suspected of Reactive Arthritis. What is the best way to diagnose this patient?

Answer 50

1. + HLA-B27 2. CBC: WBC 10-20K Increased ESR Normochromic anemia Increased IgG 3. Synovial fluid: WBC 1-8K cells/m3 Fluid is bacterial culture negative = Aseptic

Question 51

A patient with arthritis in his knees and ankles, conjunctivitis and urethritis is suspected of Reactive Arthritis. What is the best way to manage this patient?

Answer 51

NSAIDS are the mainstay of tx

Question 52

A patient with arthritis in his knees and ankles, conjunctivitis and urethritis is suspected of Reactive Arthritis. What is the best way to manage this patient? The patient is having no response to normal NSAID tx?

Answer 52

Methotrexate Sulfasalazine Steroids Anti-TNF agents: Etanercept, Infliximab

Question 53

What is Polymyositis?

Answer 53

Idiopathic inflammatory muscle disease of proximal limbs, neck, pharynx -May affect heart, lungs, and GI

Question 54

How does Clinical Manifestation of Polymyositis?

Answer 54

Progressive symmetrical proximal muscle weakness* Usually painless Dysphagia Skin rash Polyarthritis Muscle atrophy (difficulty rising from chair/climbing stair, combing hair; problems with overhead movements)

Question 55

A patient is complaining of dysphagia, skin rash, polyarthritis, and difficulty rising from chair and climbing stairs and combing his hair. What is the best way to diagnose this patient's condition?

Answer 55

Increase muscle enzymes (increased aldolase*; creatinine kinase) Increased ESR Abnormal EMG +Anti-Jo 1 Ab: myositis specific antibody* + Anti-ARP Ab Muscle biopsy: endomysial involvement

Question 56

A patient is complaining of dysphagia, skin rash, polyarthritis, and difficulty rising from chair and climbing stairs and combing his hair. What is the best way to manage this patient?

Answer 56

1st line: high dose corticosteroids +/- Methotrexate Azathioprine IV immunoglobulin

Question 57

What is the best initial test to help diagnose RA?

Answer 57

+ RF

Question 58

What test is more specific for helping to diagnose RA?

Answer 58

+ Anti-cyclic citrullinated peptide antibodies

Question 59

What is RA?

Answer 59

Chronic inflammatory disease with persistent SYMMETRIC polyarthritis bone erosion cartilage destruction joint structure loss (due to destruction by pannus) **T cell mediated

Question 60

What population is at increased risk for RA?

Answer 60

1. Females | 2. Smokers

Question 61

What is pannus?

Answer 61

granulation tissue that erodes into cartilage and bone

Question 62

How would a patient experiencing the prodrome of RA be feeling?

Answer 62

``` Systemic sxs: Fever Fatigue Weight loss Anorexia Decreased ROM ```

Question 63

What are Classic RA manifestations?

Answer 63

1. Small joint stiffness: MCP, wrist, PIP, knee, MTP, shoulder, ankle) 2. Worse with rest 3. Morning joint stiffness >60 min after initiating movement, improves later in the day 4. symmetric, swollen, tender "boggy" joint

Question 64

Which of the following are you more likely to see in an RA patient? A. Heberden's node + Bouchard's node B. Swan neck deformity + Boutonniere deformity

Answer 64

B. Swan neck deformity + Boutonniere deformity = RA A. Heberden's node + Bouchard's node = OA

Question 65

Which of the following are you more likely to see in an RA patient? A. Ulnar deviation at MCP joint B. PIP Osteophytes C. Radial deviation at MCP joint D. DIP Osteophytes

Answer 65

A. Ulnar deviation at MCP joint

Question 66

What is a PIP Osteophyte?

Answer 66

Bouchard's node

Question 67

What is the Felty's syndrome and which Rheumatologic condition is t associated with?

Answer 67

Associated with RA -Rare: Triad of: 1. RA 2. Splenomegaly 3. Decreased WBC/repeated infections -

Question 68

What is the Caplan syndrome and which Rheumatologic condition is t associated with?

Answer 68

Pneumoconiosis + RA

Question 69

What X-ray finding is consistent with RA?

Answer 69

1. Narrowed joint space (Osteopenia/erosions) *** 2. Subluxation 3. Deformities 4. Ulnar deviation of the hand

Question 70

What is the management of an RA patient?

Answer 70

PROMPT initiation of DMARDs (Methotrexate) NSAIDs are 1st line for PAIN control Steroids are 2nd line if no relief with NSAIDs

Question 71

What is the benefit of treating an RA patient with DMARDs?

Answer 71

They reduce permanent joint damage

Question 72

If a patient is having arthritis in > or = to 3 joints for more than 6 weeks; and the patient is complaining of morning stiffness, what is the most likely diagnosis?

Answer 72

RA

Question 73

What is OA?

Answer 73

Chronic disease due to articular cartilage damage and degeneration

Question 74

What is significant risk factor for OA?

Answer 74

Obesity

Question 75

Where does OA most affect the body?

Answer 75

Weight bearing joints - hips - knees - cervical/lumbar spine

Question 76

A patient is complaining of evening joint stiffness that gets better with rest. The patient states the pain gets worse throughout the day and with changes in the weather. On PE, you notice hard body joints and no obvious signs of inflammation. X ray findings reveal joint space loss and osteophytes. What is the most likely diagnosis?

Answer 76

OA

Question 77

A patient is complaining of evening joint stiffness that gets better with rest. The patient states the pain gets worse throughout the day and with changes in the weather. On PE, you notice hard body joints and no obvious signs of inflammation. X ray findings reveal joint space loss and osteophytes. What is the best way to manage this patient?

Answer 77

Acetaminophen preferred initial tx* in elderly with bleeding risk & mild-moderate disease NSAIDs are more effective

Question 78

What population is at higher risk for Calcium pyrophosphate dehydrate deposition disease?

Answer 78

1. Elderly >60 | 2. Females

Question 79

What is the acute form of Calcium pyrophosphate dehydrate deposition disease?

Answer 79

Acute = Pseudogout (acute arthritis) red, swollen, tender joint

Question 80

A patient is coming in for an acute flare up of her Calcium pyrophosphate dehydrate deposition disease, what part of the body is most likely affected?

Answer 80

Knee

Question 81

A patient is coming in to follow up on her Chondrocalincosis. What would her X ray likely resemble?

Answer 81

Cartilage calcification* Linear radio densities

Question 82

A patient is coming in for a follow up of her chronic Calcium pyrophosphate dehydrate deposition disease, what other rheumatologic condition does this likely resemble?

Answer 82

RA / inflammatory arthritis

Question 83

What does OA + Calcium pyrophosphate dehydrate deposition disease resemble?

Answer 83

Osteoarthritis

Question 84

A patient is seen with a red, swollen, tender knee. History is indicative of Calcium pyrophosphate dehydrate deposition disease. How would you diagnose this patient?

Answer 84

Arthrocentesis: positively birefringent, rhomboid-shaped CPPD crystals (pseudo gout)

Question 85

A patient is seen with a red, swollen, tender knee. History is indicative of Calcium pyrophosphate dehydrate deposition disease. Arthrocentesis reveals positively birefringent, rhomboid-shaped crystals. How do you manage this patient?

Answer 85

Pseudo gout: Intra-articular corticosteroids 1st line NSAIDs Colchicine (acute or for prophylaxis)

Question 86

A patient is coming in for a follow up of her chronic Calcium pyrophosphate dehydrate deposition disease. Initially, the patient did not have any symptoms, so no treatment was needed. Now, the patient has become symptomatic. PE and Hx are negative for an acute flare up. What do you offer her for her chronic CPPD?

Answer 86

Start off with NSAIDs,Colchicine, and if no response, low dose steroids

Question 87

A patient is coming in for a follow up of her chronic Calcium pyrophosphate dehydrate deposition disease. Initially, the patient has been using NSAIDs and Colchine, but now she states they are not working for her. What do you offer her for her chronic refractory CPPD?

Answer 87

Start off with NSAIDs, Colchicine (as the patient did) and IF NO RESPONSE: low dose steroids

Question 88

A patient has CPPD that is resembling OA. How do you manage this patient?

Answer 88

Pseudo-OA: treat like OA (Acetaminophen is preferred 1st line)