Orthopedics and Rheumatology Flashcards
12% of Internal Medicine EORE
What is Complex Regional Pain Syndrome
Complex Regional Pain Syndrome
- History of previous extremity injury, fracture, or surgery
- More common in women, mean age of 40yrs
- Pain > 6 months
- Sx and findings: light touch causes extreme pain, allodynia, autonomic changes, alterations in skin appearance, motor symptoms
- Tx options include physical therapy, NSAIDs, amitriptyline, gabapentin, nerve blocks
What other co-morbid conditions are associated with fibromyalgia?
- Rheumatoid arthritis
- Hypothyroidism
- Sleep apnea
Describe the clinical manifestations of fibromyalgia?
Clinical manifestations include
* diffuse pain that is worse in the morning,
* extreme fatigue
* stiffness
* painful and tender joints
* SLEEP DISTURBANCES
Symptoms often worsened with physical and psychological stress
What medication class is typically used to treat fibromyalgia?
Anticonvulsants (pregabalin/gabapentin)
The FDA has approved three drugs to treat fibromyalgia: the antidepressants duloxetine (Cymbalta) and milnacipran (Savella), plus the anti-seizure medicine pregabalin (Lyrica)
A 35-year-old woman with a confirmed diagnosis of fibromyalgia presents to your clinic with worsening symptoms of pain, fatigue, and cognitive difficulties. She reports that her symptoms have not improved with over-the-counter NSAIDs. She also notes feeling more depressed over the last few months.
Which of the following is the most appropriate next step in the management of this patient?
A) Increase NSAID dosage
B) Start a low-dose tricyclic antidepressant
C) Prescribe opioids for pain relief
D) Refer to physical therapy and recommend aerobic exercise
Start a low-dose tricyclic antidepressant
A 42-year-old woman presents with a 2-year history of diffuse musculoskeletal pain, fatigue, and unrefreshing sleep. She has a history of depression but is otherwise healthy. Physical examination reveals tenderness in 14 of the 18 tender points commonly associated with fibromyalgia. Laboratory tests, including a complete blood count, comprehensive metabolic panel, and thyroid function tests, are within normal limits.
Which of the following criteria is used to diagnose fibromyalgia?
A) Tender points
B) Elevated inflammatory markers
C) Muscle biopsy findings
D) Neurological imaging findings
Tender Points
What antinuclear antibody pattern is most commonly associated with Sjögren syndrome?
Speckled
A 25-year-old man presents to the clinic with concerns about pain in both eyes, right knee pain, and burning in his genitalia. He reports he is sexually active and recently was treated with antibiotics for a sexually transmitted infection. On physical exam, you note bilateral conjunctivitis, erythema of the right knee, and tenderness over the joint line of the knee. Genital examination reveals urethral irritation present at the meatus. Vitals are within normal limits. Which allele is implicated in the most likely diagnosis?
A. Human leukocyte antigen B27
B. Human leukocyte antigen B47
C. Human leukocyte antigen DR2
D. Human leukocyte antigen DR3
Human leukocyte antigen B27 (HLA-27)
What is the most commonly affected joint in gout?
The first metatarsophalangeal joint (big toe), also known as podagra
Which type of crystals are found in synovial fluid analysis of a gout patient?
Needle-shaped, negatively birefringent monosodium urate crystals
What lifestyle modification can help reduce gout attacks?
Reducing intake of purine-rich foods (e.g., red meat, seafood) and alcohol
Which medication inhibits xanthine oxidase to reduce uric acid production in gout?
What patient education must be done prior to prescribing?
Allopurinol
It may make gout worse at first. Rash is the m/c side effect.
What type of crystals are associated with pseudogout?
Which joint is most commonly affected by pseudogout?
Rhomboid-shaped, positively birefringent calcium pyrophosphate dihydrate (CPPD) crystals
Knee
Name a common risk factor for developing pseudogout
Advanced age or metabolic disorders like hyperparathyroidism or hypothyroidism
What is the radiographic finding characteristic of pseudogout?
Chondrocalcinosis (cartilage calcification)
What is the initial treatment for an acute pseudogout flare?
NSAIDs
A 52-year-old man presents with sudden onset of excruciating pain in his right big toe. The area is red, swollen, and tender to touch. He admits to consuming excessive beer and red meat over the weekend. Synovial fluid analysis reveals needle-shaped, negatively birefringent crystals. Which of the following is the most appropriate initial treatment?
A) Allopurinol
B) Indomethacin
C) Colchicine
D) Probenecid
Indomethacin
NSAIDs like indomethacin are first-line treatments for acute gout attacks. Allopurinol and probenecid are used for long-term management. Colchicine is an alternative if NSAIDs are contraindicated
A 70-year-old woman complains of acute pain and swelling in her left knee. She has a history of hypothyroidism and hemochromatosis. Joint aspiration shows rhomboid-shaped, positively birefringent crystals. What is the most likely diagnosis?
Pseudogout
The presence of positively birefringent CPPD crystals and chondrocalcinosis on imaging indicates pseudogout, often associated with metabolic disorders like hemochromatosis.
A 65-year-old male with chronic gout is started on allopurinol. Shortly after initiation, he develops a rash and experiences worsening of joint pain. What is the most appropriate next step in management?
A) Increase the dose of allopurinol
B) Switch to febuxostat
C) Discontinue allopurinol
D) Add colchicine to the regimen
Discontinue allopurinol
The development of a rash suggests a hypersensitivity reaction to allopurinol, which can be severe. The medication should be discontinued immediately.
A patient presents with joint pain in the wrists and knees. Imaging reveals chondrocalcinosis. Laboratory tests show normal uric acid levels. Synovial fluid analysis reveals CPPD crystals. Which underlying condition is most commonly associated with this presentation?
A) Hyperparathyroidism
B) Diabetes mellitus
C) Rheumatoid arthritis
D) Systemic lupus erythematosus
Hyperparathyroidism
A 58-year-old woman with a history of chronic kidney disease presents with an acute gout flare. Which medication is contraindicated for her acute management?
A) Prednisone
B) Colchicine
C) Indomethacin
D) Acetaminophen
Indomethacin
NSAIDs like indomethacin are contraindicated in patients with renal impairment. Alternative treatments include low-dose steroids or colchicine.
What is the most commonly affected joint pattern in rheumatoid arthritis?
Symmetrical involvement of small joints (wrist, MCP, PIP, MTP).
Spares the DIP
What is the hallmark laboratory test for diagnosing rheumatoid arthritis?
What imaging finding is characteristic of long standing RA?
Positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies
**Anti-CCP most specific **
Symmetric joint space narrowing and erosions
What is the first-line disease-modifying antirheumatic drug (DMARD) used in the treatment of rheumatoid arthritis?
What is the MOA? And what supplement needs to be initiated with its use?
Methotrexate
Folic antagonist - must initiate supplementation of folic acid
A 42-year-old woman presents with morning stiffness lasting over an hour, pain, and swelling in her hands and wrists. The symptoms have been present for six months, and she reports fatigue and occasional low-grade fevers. Physical exam reveals tenderness and swelling in the metacarpophalangeal joints. Which of the following is the most specific laboratory finding for her suspected diagnosis?
A) Elevated erythrocyte sedimentation rate (ESR)
B) Positive anti-cyclic citrullinated peptide (anti-CCP) antibodies
C) Positive antinuclear antibody (ANA)
D) Elevated C-reactive protein (CRP)
Positive anti-cyclic citrullinated peptide (anti-CCP) antibodies
Anti-CCP antibodies are highly specific for rheumatoid arthritis and are considered more specific than rheumatoid factor (RF) for diagnosing RA.
A 56-year-old male with long-standing rheumatoid arthritis presents for routine follow-up. He reports increasing shortness of breath over the past few months. His medications include methotrexate and prednisone. Pulmonary examination reveals bibasilar crackles. Chest X-ray shows reticular opacities at the lung bases. What is the most likely diagnosis?
A) Pneumonia
B) Rheumatoid lung disease
C) Pulmonary embolism
D) Bronchitis
Rheumatoid lung disease
Interstitial lung disease is a known extra-articular manifestation of RA, particularly in patients with long-standing disease or those on methotrexate
A 60-year-old woman with rheumatoid arthritis is started on methotrexate. Which of the following laboratory tests should be monitored regularly during her treatment?
A) Creatinine and BUN
B) Liver function tests
C) Serum potassium
D) Lipid panel
Liver function tests
Methotrexate can cause hepatotoxicity, so liver function tests should be monitored regularly during treatment
A 50-year-old female presents with pain and swelling in her hands and wrists for the past eight months. She reports prolonged morning stiffness that improves with activity. Lab results reveal positive rheumatoid factor and elevated ESR. X-ray of the hands shows joint space narrowing and periarticular erosions. What is the next best step in her management?
A) Start ibuprofen
B) Prescribe low-dose prednisone
C) Initiate methotrexate therapy
D) Recommend physical therapy
Initiate methotrexate therapy
A 38-year-old woman with rheumatoid arthritis presents with increased fatigue and shortness of breath. She is on methotrexate and reports mild joint improvement but has noticed a recent decline in energy and shortness of breath on exertion. Laboratory results show a hemoglobin of 9 g/dL, MCV of 77 fL, and normal ferritin. What is the most likely cause of her anemia?
A) Iron deficiency anemia
B) Anemia of chronic disease
C) Folate deficiency
D) Methotrexate-induced anemia
Anemia of chronic disease
Anemia of chronic disease is common in rheumatoid arthritis patients due to chronic inflammation. Methotrexate can also contribute to anemia, but the normal MCV and ferritin suggest anemia of chronic disease rather than methotrexate-induced anemia or iron deficiency.
A 45-year-old woman presents to her primary care practitioner with painful discoloration of her fingers and nose when cold. She states her fingers become pale when cold and then become red and painful when they begin to warm up. She also reports difficulty swallowing and early satiety. On physical exam, she has tight, shiny skin and multiple telangiectasias. She currently smokes one pack of cigarettes per day and has no significant medical history. Which clinical intervention should be recommended first?
A) Initiating methotrexate
B) Initiating nifedipine
C) Initiating sildenafil
D) Initiating varenicline
What is the diagnosis?
Initiating varenicline
This patient has sceroderma.
Treatment is specific to organ involvement at presentation. Raynaud phenomenon should be treated with smoking cessation (the patient may require assistance with varenicline, nicotine replacement, or bupropion), use of protective clothing to keep the extremities warm, and calcium channel blockers if Raynaud phenomenon is refractory to lifestyle modifications.
What type of blood vessels are primarily affected in polyarteritis nodosa?
Medium-sized arteries
What is a common infectious association with polyarteritis nodosa?
Which organ systems are most commonly involved?
Hepatitis B virus (HBV) infection
The kidney’s, skin, peripheral nerves and GI system
What is the gold standard diagnostic tool for confirming polyarteritis nodosa?
Tissue biopsy or angiography
A 50-year-old man presents with fever, weight loss, muscle pain, and painful nodules on his legs. He also reports recent onset of abdominal pain. Blood work reveals elevated ESR and CRP, and angiography shows microaneurysms in the renal arteries. Hepatitis B serology is positive. What is the most likely diagnosis?
A) Granulomatosis with polyangiitis
B) Polyarteritis nodosa
C) Systemic lupus erythematosus
D) Takayasu arteritis
Polyarteritis nodosa
Polyarteritis nodosa (PAN) is characterized by systemic vasculitis affecting medium-sized arteries. The clinical picture, angiography showing microaneurysms, and association with hepatitis B strongly suggest PAN.
A 55-year-old male with polyarteritis nodosa presents with hypertension, abdominal pain, and hematuria. His renal function is deteriorating. Which of the following is most likely contributing to his symptoms?
A) Renal artery involvement leading to ischemia
B) Glomerulonephritis due to immune complex deposition
C) Autoimmune interstitial nephritis
D) Direct viral invasion of kidney tissue
Renal artery involvement leading to ischemia
In polyarteritis nodosa, renal involvement is common and results from vasculitis of the renal arteries, leading to ischemia and renal dysfunction, not from glomerulonephritis (which is seen in ANCA-associated vasculitis)
A 40-year-old man with polyarteritis nodosa is being treated with high-dose corticosteroids. He is positive for hepatitis B virus (HBV). In addition to corticosteroids, what other treatment should be considered for this patient?
A) Cyclophosphamide
B) Antiviral therapy for HBV
C) Methotrexate
D) Rituximab
Antiviral therapy for HBV
Polyarteritis nodosa associated with hepatitis B infection should be treated with antiviral therapy in addition to immunosuppression (corticosteroids) to control the viral infection and reduce inflammation.
A 55-year-old man with polyarteritis nodosa presents with severe abdominal pain, especially after meals, and gastrointestinal bleeding. Which of the following best explains the pathophysiology behind these symptoms?
A) Ischemia due to vasculitis of the mesenteric arteries
B) Immune complex deposition in the gastrointestinal mucosa
C) Direct viral invasion of the gastrointestinal tract
D) Autoimmune destruction of gastrointestinal smooth muscle
Ischemia due to vasculitis of the mesenteric arteries
Polyarteritis nodosa causes vasculitis of medium-sized arteries, including the mesenteric arteries, leading to ischemia, which results in abdominal pain (often postprandial) and can cause gastrointestinal bleeding.
What are the typical symptoms of polymyalgia rheumatica?
What age group is most commonly affected?
Bilateral pain and stiffness in the shoulders, neck, and hips, especially in the morning.
Adults over 50
Which laboratory marker is typically elevated in polymyalgia rheumatica?
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
What condition is commonly associated with polymyalgia rheumatica and should be monitored for?
Giant cell arteritis (temporal arteritis)
A 70-year-old woman presents with a two-month history of stiffness and aching in her shoulders and hips, particularly in the morning. She denies muscle weakness. Physical examination shows limited range of motion in her shoulders but no muscle tenderness or weakness. Laboratory studies reveal an elevated erythrocyte sedimentation rate (ESR). What is the most likely diagnosis?
A) Polymyalgia rheumatica
B) Rheumatoid arthritis
C) Fibromyalgia
D) Osteoarthritis
Polymyalgia rheumatica
Polymyalgia rheumatica is characterized by bilateral pain and stiffness in the shoulders and hips, particularly in older adults, with elevated ESR and no muscle weakness
A 65-year-old man presents with sudden onset of bilateral shoulder and hip stiffness that is worse in the morning and improves throughout the day. He also reports fatigue and mild weight loss. His ESR is significantly elevated. Which of the following is the most appropriate initial treatment?
A) High-dose prednisone
B) Methotrexate
C) Nonsteroidal anti-inflammatory drugs (NSAIDs)
D) Low-dose prednisone
Low-dose prednisone
A 75-year-old woman with a history of polymyalgia rheumatica presents with new-onset headaches, jaw claudication, and vision changes. She has tenderness over her scalp on the right side. What is the next best step in managing this patient?
A) Immediate high-dose corticosteroids
B) Temporal artery biopsy
C) NSAIDs
D) Referral for rheumatology consult
Immediate high-dose corticosteroids
The patient’s symptoms are suggestive of giant cell arteritis, a condition closely associated with polymyalgia rheumatica. Immediate high-dose corticosteroids should be started to prevent potential vision loss
A 67-year-old man with polymyalgia rheumatica develops new-onset jaw pain and tenderness over his temples. He also reports visual disturbances. What is the pathophysiological mechanism behind the associated condition?
A) Inflammatory vasculitis of the medium and large arteries
B) Degeneration of the small joints
C) Autoimmune attack on muscle fibers
D) Immune complex deposition in renal vessels
Inflammatory vasculitis of the medium and large arteries
Giant cell arteritis, which often accompanies polymyalgia rheumatica, is a vasculitis of medium and large arteries, especially the temporal arteries, leading to jaw claudication, scalp tenderness, and vision changes.
What is the primary clinical feature of polymyositis?
Which laboratory marker is usually elevated in polymyositis?
Symmetrical proximal muscle weakness
Creatine Kinase (CK)
What diagnostic test is definitive for confirming polymyositis?
Which autoantibody is often associated with polymyositis?
Muscle Biopsy
Anti-Jo-1 Antibody
What is the first line treatment for polymyositis?
Corticosteroids (prednisone)
A 48-year-old woman presents with progressive difficulty climbing stairs and lifting objects above her head over the past three months. She denies pain but notes generalized muscle weakness. Physical exam reveals 3/5 strength in the proximal muscles of both upper and lower extremities. Creatine kinase (CK) is elevated. What is the most likely diagnosis?
A) Polymyositis
B) Polymyalgia rheumatica
C) Multiple sclerosis
D) Rheumatoid arthritis
Polymyositis
Polymyositis presents with progressive, symmetrical proximal muscle weakness without significant pain. Elevated CK levels support the diagnosis of an inflammatory myopathy.
A 55-year-old woman with a recent diagnosis of polymyositis presents with new onset shortness of breath. She denies chest pain but has a dry cough. Chest X-ray shows interstitial lung disease. Which of the following antibodies is most likely associated with this complication?
A) Anti-Smith antibody
B) Anti-Ro/SSA antibody
C) Anti-Jo-1 antibody
D) Anti-dsDNA antibody
Anti-Jo-1 Antibody
Anti-Jo-1 antibodies are associated with polymyositis and can indicate an increased risk of interstitial lung disease, a known complication of the disease.
A 47-year-old woman with polymyositis presents with muscle weakness that has worsened over the past few weeks despite treatment with corticosteroids. Muscle biopsy shows increased fibrosis along with ongoing inflammation. What is the most likely explanation for the worsening of her condition?
A) Corticosteroid resistance
B) Fibrosis from chronic inflammation
C) Myasthenia gravis
D) Mitochondrial dysfunction
Fibrosis from chronic inflammation
Chronic inflammation in polymyositis can lead to fibrosis of the muscle tissue, contributing to progressive weakness despite treatment.
What is the classic triad of symptoms in reactive arthritis?
- Arthritis
- Urethritis
- Conjunctivitis
What infections are commonly associated with triggering reactive arthritis?
What genetic marker is often associated with reactive arthritis?
- Gastrointestinal (Shigella, Salmonella, Campylocator)
- Genitourinary (Chlamydia)
HLA-B27
What is the first line treatment for arthritis in reactive arthritis?
NSAIDs
What is the typical joint involvement pattern in reactive arthritis?
Asymmetric involvement of large joints, especially the lower extremities (knee’s, ankles)
A 28-year-old man presents with joint pain, redness, and swelling in his right knee. He also complains of painful urination and eye redness. He had a recent episode of diarrhea two weeks ago. Physical examination reveals conjunctivitis and joint tenderness. Which of the following is the most likely diagnosis?
A) Rheumatoid arthritis
B) Septic arthritis
C) Reactive arthritis
D) Ankylosing spondylitis
Reactive Arthritis
Reactive arthritis is classically associated with a triad of conjunctivitis, urethritis, and asymmetric arthritis, often triggered by a preceding infection (in this case, likely gastrointestinal).
A 32-year-old woman presents with pain and swelling in her left knee and right ankle, as well as eye redness. She was recently treated for a urinary tract infection caused by Chlamydia trachomatis. What is the most appropriate initial treatment for her joint symptoms?
A) Oral prednisone
B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Methotrexate
D) Antibiotics
NSAIDs
NSAIDs are the first-line treatment for managing the joint pain and inflammation in reactive arthritis. Antibiotics are used to treat the underlying infection but do not directly improve the arthritis.
A 27-year-old male presents with pain and swelling in his knees and ankles, as well as inflammation of the Achilles tendon. He reports recent dysuria and eye discomfort. He is found to be HLA-B27 positive. What other musculoskeletal finding is commonly associated with reactive arthritis?
A) Erosive changes in the small joints of the hands
B) Dactylitis (sausage digits)
C) Bilateral sacroiliitis
D) Ulnar deviation of the fingers
Dactylitis (sausage digits)
Dactylitis, or “sausage digits,” is a common feature of reactive arthritis, along with asymmetric large joint involvement and enthesitis (inflammation of tendon insertions such as the Achilles tendon).
What is the most common joint pattern affected by rheumatoid arthritis?
Symmetrical involvement of small joints, especially the hands (metacarpophalangeal and proximal interphalangeal joints).
What is the hallmark lab test for diagnosing rheumatoid arthritis?
Positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP)
A 60-year-old woman with rheumatoid arthritis is started on methotrexate. Which of the following laboratory tests should be monitored regularly during her treatment?
A) Creatinine and BUN
B) Liver function tests
C) Serum potassium
D) Lipid panel
Liver function tests
Methotrexate can cause hepatotoxicity, so liver function tests should be monitored regularly during treatment.
What are the two most common clinical symptoms of Sjögren’s syndrome?
- Dry Eyes (xerophthalmia)
- Dry Mouth (xerostomia)
Which autoantibodies are commonly associated with Sjogren’s Syndrome?
Anti-Ro/SSA and Anti-La/SSB antibodies
What test is commonly used to evaluate tear production in suspected Sjogren’s syndrome?
Schirmer’s Test
What is a common extra-glandular manifestation of Sjögren’s syndrome?
- Arthralgias
- Interstitial Lung Disease
- Vasculitis
What is the first-line treatment for dry eyes and dry mouth in Sjogren’s Syndrome?
Artificial Tears and Saliva Substitutes
A 60-year-old woman presents with dry mouth, dry eyes, and swelling of her parotid glands. Laboratory studies reveal positive anti-Ro (SSA) antibodies. Which of the following tests would be most useful in confirming decreased tear production?
A) Slit-lamp examination
B) Schirmer’s test
C) Salivary gland biopsy
D) Rheumatoid factor
Schirmer’s Test
A 57-year-old woman with Sjögren’s syndrome presents with new-onset bilateral parotid gland swelling and night sweats. She reports unintentional weight loss over the past three months. What is the most concerning potential complication in this patient?
A) Lymphoma
B) Oral candidiasis
C) Sialadenitis
D) Interstitial lung disease
Lymphoma
Patients with Sjögren’s syndrome are at an increased risk for developing non-Hodgkin lymphoma, particularly when presenting with new-onset parotid gland swelling, night sweats, and weight loss.
A 60-year-old woman with Sjögren’s syndrome presents with persistent dry eyes and mouth despite using artificial tears and saliva substitutes. Which of the following medications can be added to stimulate saliva production?
A) Pilocarpine
B) Methotrexate
C) Hydroxychloroquine
D) Prednisone
Pilocarpine
Pilocarpine is a cholinergic agonist that stimulates salivary and tear secretion, and it is often used to manage xerostomia in patients with Sjögren’s syndrome.
A 55-year-old woman presents with dry eyes, dry mouth, and joint pain. Laboratory tests reveal positive anti-Ro (SSA) antibodies. Which of the following best describes the pathophysiology of Sjögren’s syndrome?
A) Deposition of immune complexes in the joints
B) Autoimmune destruction of exocrine glands
C) Immune-mediated inflammation of muscle fibers
D) Degeneration of peripheral nerves
Autoimmune destruction of exocrine glands
Sjögren’s syndrome is an autoimmune disorder characterized by lymphocytic infiltration and destruction of exocrine glands, particularly the lacrimal and salivary glands, leading to dry eyes and mouth.
A 58-year-old woman with Sjögren’s syndrome presents with worsening shortness of breath and a dry cough. Chest CT reveals interstitial lung disease. What is the likely pathophysiological mechanism underlying this complication?
A) Immune-mediated inflammation of the alveoli
B) Direct infection of lung tissue
C) Deposition of fibrous tissue in the pleura
D) Infiltration of neutrophils into the bronchi
Immune-mediated inflammation of the alveoli
In Sjögren’s syndrome, interstitial lung disease is caused by immune-mediated inflammation of the alveoli, which can lead to progressive pulmonary fibrosis.
