Orthopedics/Rheumatology Flashcards
1
Q
reactive arthritis
A
- reiter syndrome: most patients dont have classic findings, so term reactive arthritis is used
- classic triad: arthritis, urethritis, ocular inflamm (conjunctivitis or anterior uveitis) - cant see, cant pee, cant climb a tree
- pt can develop reactive arthritis after nongonococcal urethritis or after enterif infxn with SECSY bugs
- HLA-B27 + pts, asymmetric inflamm oligoarth of the lower extremitis preceded by infxous process remote from the site, sterile inflamm process
- sxs: mucocutaneous lesions, constitutional sxs
- dx: synovial fluid analysis
- tx: NSAIDs (first line), if no response sulfasalazine or azathioprine
2
Q
onset, commonl locations, presence of inflamm, radiographic changes, lab findings, and other features of osteoarthritis vs rheumatoid arthritis vs gouty arthritis
A
- Onset:
- O: insidious
- R: insidious
- G: sudden
- locations:
- O: wt bearing jnts (knees, hips, lum/cerv spine)
- R: hands (PIP, MCP), wrists, ankles, knees
- G: great toe, ankles, knees, elbows
- inflamm?:
- O: no
- R: yes
- G: yes
- radio changes:
- O: narrowed jnt space, osteophytes, subchond sclerosis and cysts
- R: narrowed jnt space, bony erosion
- G: punched-out erosions w/ overhanging rim of cortical bone
- lab findings:
- O: none
- R: high ESR, RF, anemia
- G: crystals
- other features:
- O: no systemic sxs, bouchard nodes, Heberden nodes
- R: systemic = extra articular manifestations, ulnar deviation, swan neck and boutonniere
- G: tophi, nephrolithiasis
3
Q
gout etiology and dx
A
- inflamm monoarticular arthritis caused by crystalization of monosodium urate in jnts
- precipitants: cold, dehydration, stress, excessive ETOH, starvation
- 90% are men >30yo
- dx: joint aspiration and synovial fluid analysis (needle shaped and neg birefringent urate crystals), gram stain and cx, serum uric acid is NOT helpful, XR (punched out erosions
4
Q
Four stages of gout
A
- asx hyperuricemia
- acute gouty attacks (peak onset 40-60yo) - initial attack = one jnt of lower extremity, sudden onset exquisite pain, most often first MT joint, pain and redness, swelling, warmth, +/- fever
- intercritical gout - sxatic period after initial attack, attacks become polyarticular and increase in severity
- chronic tophaceous gout (ppl with poorly controlled gout for >10-30ys), tophi (urate crystals surrounded by giant cells in inflammatory rxn, cause deformity and destruction of hard and soft tissue, common locations = extensor surfaces of forearms, elbows, knees, achilles tendon, pinna of external ear
5
Q
tx of gout
A
- do not tx asx hyperuricemia
- avoid secondary causes of hyperuricemia (meds that increase uric acid, obesity, ETOH, dietary purines
- acute gout: bed rest, NSAIDs (indomethacin), colchicine, steroids if not responding or intolerant to NSAID/colchicine
- prophylaxis: must have 2-3 attacks before initiating prophylactic tx → NSAIDs x 3-6mos, uricosuric drugs (probenecid, sulfinpyrazone), allopurinol (not for acute exacerbations, watch for SJS)
6
Q
rheumatoid arthritis sxs
A
- F>M 3:1, etiology uncertain (maybe viral, genetic)
- inflammatory polyarthritis (PIP, MCP), and wrists, knees, ankles, elbows, hips
- ulnar deviation of MCP jnts, boutionniere, swan neck
- morning stiffness with improvement later in the day, low grade fever, wt loss, fatigue
- cervical spine involvement at C1-C2
- Skin: thing, bruises easy, subcut rheum nodules
- Lungs: pleural effusions - fluid has low glucose and complement, pulm fibrosis, rheum nodules in lungs
- Heart: rheum nodules, pericarditis, pericard effus.
- Eyes: scleritis, scleromalacia, dry eyes and mucous membranes
- Nervous system: mononeuritic multiplex (infarct of nerve trunk), pt cant move arm or leg
- Felty syndrome: RA, neutropenia, splenomeg; happens late in RA dz process
- Blood: anemia of chronic dz (mild, normocytic, normochromic)
- Vasculitis
- Juvenile RA: begins before 18yo, Still dz
7
Q
Rheumatoid arthritis labs
A
- Rheumatoid factor
- anticitrullinated peptide/peptide antibodies (ACPA)
- ESR/CRP elevated
- normolytic normochromic anemia
- XR: loss of juxtaarticular bone mass (periarticular osteoporosis) near fingers, narrowing of jnt space, bony erosions, synovial joint fluid analysis
8
Q
rheumatoid arthritis tx
A
- preventative: exercise, NSAIDs, steroids (low dose)
- primary: DMARDs (initiate early, slow onset 6+ wk)
- first line: methotrexate (best initial DMARD - can cause hepatocellular injury, pulm fibrosis, oral ulcers, bone marrow suppression; monitor LFTs and renal fn, supplement w/ folate)
- alternatives: leflunomide, hydroxychloroquine (requires biannual eye exam), sulfasalazine, anti-TNF inhib agents (etanercept, infliximab)
- severe: surgery (synovectomy decreased jnt pain, swelling; jnt replacement for severe cases)
9
Q
synovial jnt fluid analysis: normal, noninflammatory, inflammatory, and septic arthritis
A
10
Q
Systemic lupus erythematosus presentation and dx
A
- sxs: fatigue, malaise, fever, wt loss, butterfly rash over cheeks and bridge of nose, photosensitivity, discoid lesions, oral and nasopharyngeal ulcers, Raynaud, alopecia
- jnt pain, arthritis (symmetric), peri/endo/myocarditis, hemolytic anemia or reticulocytosis of chronic dz, leukopenia, lymphopenia, thrombocytopenia, proteinuria, azotemia, pyuria, N/V, seizures, psychosis, depression, HA, TIA, CVA, Sjogren syndrome
- dx: +ANA screening, anti-ds DNA (100% specific), anti-Sm Ab, Antiphospholipid ab, anti-ss DNA, antihistone Abs (drug induced lupus), false + w/ syphillis, complement decreased
11
Q
lupus tx
A
- avoid sun, NSAIDs if less severe, local or systemic corticosteroids, systemic steroids for severe manifestations
- Long-term tx: best = antimalarials (hydroxychloroquine) w/ annual eye exam, cytotoxic agents (cyclophosphamide) for active GN
- monitoring: BUN/Cr (renal dz), blood pressure (HTN)
- Prevalence: women of childbearing age (90%), AA
- prognosis: more severe in children, appears in late childhood or adolescence
12
Q
Fibromyalgia
A
- adult women, unkown etiology, somatization not a proven cause
- sxs:stiffness, body aches, fatigue, pain is constant and aching, aggravated b weather, stress, sleep dep, cold temp (worse in morning); better with rest, warmth, mild exercise; sleep disrupted, anxiety and depression = common
- Dx: multiple trigger points (TTP - symmetrical, 18 characteristic locations including occiput, neck shoulder, ribs, elbows, buttocks, knees), widespread pain including axial pain for at least 3 mo, pain in at least 11 of the 18 possible tender pnt sites
- Tx: advise pt to stay active and productive, meds not very effective (SSRI and TCAs, avoid narcotics), CBT, exercise, psychiatric eval
13
Q
Polyarteritis nodosa
A
- associated: hepatitis B, HIV, drug rxns
- sxs: early sxs are constitutional sxs (fever, weakness, wt loss, myalgias, and arthralgias), abd pain (bowel angina), HTN
- signs: mononeuritic multiplex, livedo reticularis
- dx: bx of involved tissue or mesenteric angiography, ESR high, +/- p-ANCA, test for FOBT
- tx: corticosteroids (if severe, add cyclophosphamide)
- prognosis: poor, but improved to limited extent with tx
14
Q
polymyositis sxs
A
- females
- hypothesis: when genetically susceptible individual + environmental trigger
- sxs: symmetrical proximal mm weakness over wks to mos (earliest and most severely affected mm = neck flexors, shoulder girdle, and pelvic girdle), myalgias, dysphagia
- dermatomyositis - heliotrope rash (butterfly), gottron’s papules (papular, red, scaly lesions over knuckles), V-sign (rash on face, neck, and ant chest), shawl sign (rash on shoulders, upper back, elbows, and knees), periungual erythema with telangiectasias, subcutaneous calcifications (children), associated findings (arthralgias, CHF and conduction defects, interstitial lung dz)
- dermatomyositis only - vasculitis of GI tract, kidneys, lungs, eyes (children), increased malignancy risk in adults (lung, breast, ovary, GI tract, myeloproliferative disorders)
15
Q
polymyositis dx and tx
A
- dx criteria: if 2 of first 4 = possible; if 3 of first 4 = probable; if all 4 = definite
- symmetric proximal muscle weakness, elevation in serum creatinine phosphokinase, EMG findings of a myopathy, bx evidence of myositis, characteristic rash
- labs: CK elevated, corresponds to deegree of necrosis/severity, LDH, aldolase, AT/ALT elevated, + ANA in 50%, anti-synthetase abs (anti-Jo-1): abrupt onset fever, Raynaud’s, pulm fibrosis, arthritis - doesnt respond well, anti-signal recognition particle: cardiac manifestations and worst prognosis
- EMG: abnl in 90%
- muscle bx: inflamm and muscle fiber firbosis
- tx: steroids (initial) until sxatic improvement, then taper up to 2y, immunosuppressants: methotrexate, cyclophosphamide, chlorambucil, PT
