Ortho, Rheumatology, Vasculitis

Question 1

What is the name when pts with osteoarthritis develop nodules at the DIP joints? What is it called at the PIP joints? Test? Rx? (8)

Answer 1

Osteoarthritis. Herbeden and Bouchards. Xray- Osteophytes and dimineralization seen on. Normal Labs different from RA. 1. Weightloss and Exercise. 2. Acetominophen 3. NSAIDS (2nd line drug due to GI Bleed) 4. Colchicine 5. Capsaicin, Hyaluronic acid injections (Glucosaomine and chondroitin sulfate) 7. Intra-articular steroid injections 8. Joint replacement. Opioids for acute exacerbations.

Question 2

Pt develops pain and swelling in the either the Big toe, Ankle, Knee, DIP and PIP joints Dx? Most accurate Test? Rx? Which med is safe on the kidney?

Answer 2

Gout (Caused by under excretion or over production). Xray and uric acid levels are normal. Most accurate test is the Athrocentesis to r/o infection and it shows 2,000-50,000 WBC and NEGATIVELY Birefringent crystals. (Yellow Crystals parallel and Blue Crystals are perpendicular under polarized light.) ACUTE ATTACK TREATMENT: 1. NSAIDs (Firstline) 2. Steroids 3. Colchicine. CHRONIC treatment: Lose weight, No Alcohol and Red meat, Allopurinol and Febuxostat (stop production), Pegloticase (dissolves the uric acid) Probenacid and Sulfinpyrazone (increase exertion.)
Allopurinol (Can still cause allergic interstitial nephritis, TEN/Stevens) is safe with renal injury.

Question 3

Back pain and a hx of cancer. On physical exam there is vertebral tenderness and hyperreflexia. Dx? Best initial Test? Most accurate test? Rx?

Answer 3

Spinal Cord Compression 2/2 metastatic lesion. Best initial test is Xray. Most accurate is MRI (CT scan if there is a contraindication ie pacemaker) 1. Steroids and Chemo and radiation 2. Surgical Decompression.

Question 4

Back pain, fever, high ESR. There is vertebral tenderness and hyperreflexia on physical exam. Dx? Best initial Test? Most accurate? Rx?

Answer 4

Epidural abscess. Remember may not always present with fever and high WBC. Xray First. MRI is Most Accurate. (CT scan, MRI if contraindication to CT.) Steroids to prevent neurological deficits. Empiric treatment with vancomycin and linezolid. if MSSA then oxacillin, naficillin or cefazolin. Surgical drainage if large collections of fluid present.

Question 5

Back pain in a

Answer 5

Ankylosing spondylitis. Aortic Regurgitation and UC. Xray of scroiliac joint (Bamboo Spine). Rx: Keep Acitve, NSAIDs, Steroids.

Question 6

Pt has pain and numbness of the medial calf or foot. There is loss of knee and ankle reflexes and a positive straight leg on physical exam. Dx? Best initial test? Most accurate test? Rx?

Answer 6

Disk Herniation. Xray best initial test. MRI most accurate test. Keep active (Yoga, PT). NSAIDs, Steroids injections, Gabapentin, Surgery.

Question 7

When do you not order imaging for back pain?

Answer 7

Simple back pain with no neurological deficits even when they have positive straight leg raise.

Question 8

Pt presents with pain that is worse going down hill, sitting or standing and gets better with leaning forward. Dx? Best initial/most accurate? Rx?

Answer 8

Lumbar Spinal Stenosis. Best initial and Most accurate is MRI. 1. NSAIDs, Aspirin, Opiates (tramdol), Gabapentin, Weight loss and Physical therapy 2. Steroid injections 3. Surgical correction (spinal fusion.)

Question 9

Pt usually has a hx of Hemachromotosis or Hyperparathyroidism and presents with pain in swelling of the wrist and knee (big joints) Dx? Best initial test? Most accurate test? Rx?

Answer 9

Psudeogout (Calcium Pyrophosphate Deposition Disease) Uric acid levels are normal. Xray shows calcification of the cartilaginous structures of the joint. Most accurate test is Athrocentesis to r/o septic joint and it shows 2,000-50,000 WBC and Positive Birefrigence/Blue crystals that are Parallel and yellow crystals that are Perpendicular under polarized light. Rhomboid Shaped Crystals. 1. NSAIDs is first line. 2. Steroids (Triamcinolone and/or Colchincine.

Question 10

Young woman who presents with PAIN/ TENDERNESS in TRAPEZIUS, fat pad of knee, shoulders, neck back and hips. She also has HA and sleep disorder. Dx? Test? Rx First line? Rx Secondline?

Answer 10

Fibromyalgia. No test all labs are normal. First lines is Patient Education, Aerobic conditioning/Water exercising and GOOD sleep Hygiene. When that fails then AmitryptilinE, Milnilcipran (Savella) or Pregabalin (lyrica)

Question 11

Hyperplasia of the palmar fasica that is associated with alcoholism, cirrhosis and genetics. Dx?Test? Rx?

Answer 11

Duputyren Contracture. Clinical. Steroids, lidocaine, Collagenase injection helps with Duputyren.

Question 12

Pt presents with inability to flex or abduct the shoulder. Pt also complains of pain the shoulder that is worse at night when lying on the affected shoulder. Dx? Most accurate test? Rx?

Answer 12

Rotator cuff injury. MRI. Rest, PT, NSAIDS, Steroids, Surgery

Question 13

Pt presents wit pain below knee. Pain is worse with walking up or down stairs. Symptoms are worse just after starting to walk after being seated for a long time. It improves with walking. Dx? What is present on physical exam Rx?

Answer 13

Patellofemoral Syndrome. On physical exam there is Crepitus And joint locking. When the KNEE IS PUSHED AGAINST AND AND FLEXED. PT and try to strengthen joint. Rest, minimize acitivity, NSAIDS.

Question 14

Pt complains of very severe pain in the bottom of the foot near the calcaneus. The pain is worst in the morning and improves with walking a few steps. Dx? How do you distinguish this from tarsal tunnel syndrome? Rx?

Answer 14

Plantar fasciitis. Tarsal tunnel worsens with use, impingement of the tibial nerve. Exercises, Arch supports, NSAIDs, Steroids, Surgery.

Question 15

Pt presents with bilateral symmetrical joint involvement PIP and MCP joints. DIP joints are sparred. Morning stiffness, nodules, episcleritis, lung involvment and C1 and C2 subluxation. Dx? Test? Rx?

Answer 15

Rheumatoid Arthritis. RF is sensitive but no specific. Anti-Cyclic Citrulniated peptide is more specific. Diagnostic criteria: Join involvement, ESR or CRP, Duration longer than 6 weeks, Positive RF or anti-CCP Rx: Acute: NSAIDs and Steroids (Help pain and inflammation do not prevent disease progression) If presents with erosive DMARD: 1st line: Methotrexate (Macrocytic Anemia, Liver and Lung) and Hydroxychloroquine (Retinal deposits). 2nd line: Rituximab (Block CD 20/infection), Enteracept (infection.)

Question 16

Child presents with high spiking fever (104), salmon Colored Rash on chest and abdomen. Splenomegaly, Pericardial effusion. Dx? Test?

Answer 16

Juvenile Rheumatoid Arthiritis or Adult Still Disease. NO test. Diagnosis of exclusion.

Question 17

Pt presents with raynouds phenonmen, fibrosis of hands, face, neck, lips, extremities, Esophgeal dysmotility, Hypertensive crisis from kidney injury, restrictive lung disease leading to fibrosis and pulmonary HTN, Myocardial fibrosis, pericarditis and heart block. Dx? Test? Rx?

Answer 17

Scleroderma (Systemic Sclerosis) CREST Syndrome (Calcinosis, Raynouds, Esophageal dysmotility, Sclerodactyly, Telangiectasia.) Test: Scl-70 and Anticemtromere/Anti-Topoisomerase are specific. Rx: Renal crisis: ACE-I Esophgeal dysmotility: PPIs for GERD Raynaud: CCBs. Pulmonary fibrosis: Cyclophosphamide Pulmonary HTN: Bosentan, Phosphodiesterase Inhibitor.

Question 18

Pt presents with thromboses of the arteries and veins and recurrent fetal loss. Dx? Best initial test? Most accurate test? Rx?

Answer 18

Antiphospholipid Syndrome (IgG and IgM antibodies to the phospholipids (Lupus Anticoaulant) Mixing study will show elevated aPTT despite in the introduction of clotting factors. Most accurate Russell Viper Venom Test (Venom has activates facto 10, pts still will have prolonged clotting time with the addition of venom.) Falsely positive VDRL. Heparin then warfarin to keep INR 2 -3. Recurrent thrombotic episodes indicated lifelong warfarin.

Question 19

What will show on lab test that a pt is having an actual flare up of SLE?

Answer 19

Decreased complement (C3) due to active inflammation. Give Steroids (Steroid Acne, Bone necrosis)

Question 20

Pt presents with 4/11: Skin: Malar rash, discoid rash, photosensitivity, oral ulcers, arthritis of joints, serosititis, glomerulopnephritis, psychosis, seizures, stroke from vasculitis. Dx? Test? Rx for flare ups? Skin manifestations? What drug actually controls disease progression? Most accurate test and Rx for lupus nephritis?

Answer 20

Systemic Lupus Erythematous. Anti- smith and Anti- dsDNA. ANA sensitive but not specific. Rx: 1. For flare ups need Steroids. 2. Hydroxycholorquine for skin and joint issues. 3. Belimumab Controls disease progression. 4. Prednisone and cyclophosphamide for lupus nephritis (Kidney biopsy most accurate test for this.)

Question 21

Pt presents with dryness of the mouth and eyes. Pt needs to constantly drink water and has many dental caries. Can be associated with RA, SLE, Polymyositis. Dx? Etiology? Best initial test? Most accurate test? Rx? What are pts predisposed to with this disease?

Answer 21

Sjogren Syndrome. (antibodies predominantly against lacrimal and salivary glands. Best initial test: Schirmer test (piece of filter paper is place against eye and then observed for the amount of tears produced by the amount of wetness on the paper.) Check SS-A and SS-B (Rho/La) (but not specific/accurate because these are also present in SLE and Polymyositis.) Most accurate test: is LIP or PAROTID GLAND Biopsy to reveal lymphoid infiltration in the salivary glands) Best initial therapy: Artificial Saliva and Tears. 2. Pilocarpine and Cevimeline increase actylcholine (secretions.) Evaluate for lymphoma.

Question 22

This is a Vasculiits of the Small and Medium sized vessels that SPARES the LUNGS. Dx? What are 2 diseases associated with this? What is this disease known to cause? Best initial test? Most accurate test? What other test can be done? Rx?

Answer 22

Polyarteritis Nodasa. Hep B and C. Mononeurtitis Multiplex. ( multiple peripheral neuropathies of nerves ie peroneal nerve and ulunar nerve - wrist and foot drop) Best initial: Check for P-ANCA. Most accurate: Biopsy of Symptomatic site. Can do angiography of the renal Mesenteric and Hepatic arteries. Prednisone and cyclophosphamide.

Question 23

Pt is an old lady over 50 who presents with pain and STIFNESS of shoulder and pelvic gridle muscles. She has difficulty combing and rising from chair. She has elevated ESR. There is no muscle pain CPK and aldolase are normal. Dx? Rx?

Answer 23

Polymyalgia Rheumatica. Low dose Prednisone as oppose to high dose used in Giant Cell Arterities.

Question 24

Pt is an old lady who presents with HA, loss of vision, jaw claudication upon chewing and scalp tenderness. Dx? Test? Rx? What is important with the management of this disease? What other 2 conditions is this associated with?

Answer 24

Giant Cell (Temporal) Arteritis. ESR, CRP. Biopsy most accurate. Prednisone. Give prednisone before biopsy if you suspect Giant Cell. Associated with aneurysms and Polymyalgia Rheumatica - Rx Prednisone.

Question 25

This vasculitis affects the Upper and Lower Respiratory tract. Pts can also present with Sinusitis and Otitis media. There is Oral and Gingival involvement. Dx? Test? Rx?

Answer 25

Granulomatosis with Polyangitis (Wegners.) Best initial: C-ANCA. Best most accurate test: Lung Biopsy. Prednisone and Cyclophosphamide. (Hemorrhagic Cysitis)

Question 26

This vasculitis presents with asthma and eosinophilia. Dx? test? Rx?

Answer 26

Churg-Strauss Syndrome. P-ANCA. Biopsy most accurate. Prednisone and cyclophosphamide.

Question 27

Child presents with abodominal pain, swollen testes, palpable purpura, athralgia and hematuria. Dx? What childhood GI illness is this associated with? Test? Rx?

Answer 27

Henoch Schonlein Purpura. Intussception. Clinical. Biopsy most accurate. Self limiting.

Question 28

Associated with Hep C. Pt presents with joint pain, glomerulonephritis, palable pura and neuropathy. Dx? Test? Rx?

Answer 28

Cryoglobulinemia. RF and low C4 (HepC = 4 letters). Steroids are not effective. Rx: Pegylated Interferon, Ribavrin, Teleprovir/Borceprovir

Question 29

Asian and middle eastern presents with Oral and Genital Ulcers associated with Erythema nodosum lesions of the skin and Pathergy. Dx? Rx?

Answer 29

Bechet Syndrome. Pathergy is the sterile skin pustules from needle stick. Prednisone.

Question 30

Pt has a hx of psoriasis and now presents with sausage digits and nail pitting. Dx? Test? Rx?

Answer 30

Psoriatic Arthitis. Most accurate test is Xray to check for pencil cup deformity of the finger. 1. NSAIDs 2. Methotrexate.

Question 31

This can occur after a GI infection, STD or associated with UC or Chrons dz (inflammatory bowel dz.) Arthritis, Uveitis and Urethritis. Dx? Test? Rx?

Answer 31

Reactive Arthritis (Reiters.) No specicific test. Need to rule out joint infection so do Athrocentesis. NSAIDs.

Question 32

Pt presents with Warm, Red, Swollen and Immobile joint (Monoarticular). Dx? Etiology? Organisms? Test? Rx of bugs?

Answer 32

Septic Arthritis. Osteoarthritis, Rheumatoid and prosthetic joint. S. Aureus, Strept, Gram negative rods. Aspiration of joint. (50,000-100,000 WBCs, neurtophils 80%, Gram stain and culture. Empiric treatment with Vancomycin and Ceftrixaone.) Once sensitivities com back: MSSA (Oxacillin, Naficiliin Cefazolin) MRSA (Linezolid, Dapotmycin) Gram negatives (Cipro, Aztreonam)

Question 33

Management of prosthetic joint septic athritis?

Answer 33

Need to remove joint then treat with 6 - 8 weeks of abx.

Question 34

Sexually active male or female presents with POLYarticular arthritis, tenosynovitis and PETECHIAL rash. Dx? Test? What parts of the body should you culture to get the most sensitive results. Rx?

Answer 34

Gnococcal Arthritis. Aspiration ( 30,000 - 50,000 WBCs Gram stain 25% sensitive, Culture

Question 35

Presents in sickle cell pt and diabetics with ulcer. What is the difference in mechanism of disease btw adults and children? Best initial test? Most accurate test? Rx?

Answer 35

Osteomyelitis. (Salmonellla in SS) S. Aureus in everyone else. Children get it from hematogenous spread. Adults get it from contingous spread. Best initial test is Xray. Next step after that is MRI or Bone scan if MRI contraindicated (Pacemaker.) Most accurate test is Biopsy (To identify the organisms). Rx: MSSA: Oxacillin, Naficillin, Cefazolin.

Question 36

Give the diagnosis: 1. Immediate pain with trauma to contralateral aspect of knee. 2. Immediate pain with twisting of knee or direct impact 3. Immediate pain with forced hyperextension of knee. 4. Delayed pain (12-24 hrs) with twisting of knee.

Answer 36

1. MCL/LCL 2. ACL Tear 3. PCL Tear 4. Meniscial Tear. MRI

Question 37

Can occur after trauma, infection or retropharyngeal abscess in children (<12 yrs). Children resists passive flexion of the neck and rotation to the left side. Dx? Test?

Answer 37

Acquired Torticollis. Xray.

Question 38

Child with back pain, urinary incontinence and papable step off felt on back examination. Dx?

Answer 38

Spondelithiasis.

Question 39

Management of clubfoot? (Varus Foot deformity)

Answer 39

Early plaster casting is essential.

Question 40

Eccentric Lytic Area and bone pain and Swelling in a young person. Dx? Test shows what?

Answer 40

Giant Cell bone tumor Soap Bubble appearance on xray.

Question 41

Avuolusion at the site of the tibial turbercle occurs from repetitive use in young children who are undergoing growth spurts. Dx?

Answer 41

Osgood Schlatter Disease

Question 42

Brown tumors of long bones. Dx?

Answer 42

Ostitis firbrosa Cystica 2/2 hyperparathyroidism from parathyroid cancer.

Question 43

Sclerotic, cortical lesion with central nidus of lucency. (Punched out lesion on bone) Pain worse at night. Dx? Rx?

Answer 43

Osteiod Osteoma. Rx with Aspirin.