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Clin Med II - Exam 2 > Paulson - Rheumatology > Flashcards

Paulson - Rheumatology Flashcards

1
Q

what is the mc complaint in gout

A

my big toe hurts

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2
Q

gout has a __ onset

A

rapid

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3
Q

what finding is pathognomonic for gout

A

tophi

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4
Q

what are tophi

A

deposits of urate

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5
Q

what is podagra

A

gout of the foot

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6
Q

gout is usually __

and affects the __ of the great toe

A

monoarticular

MTP

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7
Q

what are the 3 stages of gout

A
  1. acute
  2. intercritical (interval)
  3. chronic articular and tophaceous
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8
Q

what are 6 rf for gout

A
  1. etoh
  2. red meat
  3. seafood
  4. fructose
  5. HCTZ diuretics
  6. obesity
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9
Q

what is the diagnostic value for serum urate in gout

A

>6.8 → not all w. this finding have gout

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10
Q

for the dx of gout, what 2 lab findings must be present

A
  1. serum urate > 6.8
  2. monosodium urate (MSU) must be present for gout to crystallize
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11
Q

what is the soc for gout diagnosis

A

aspirate of synovial fluid

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12
Q

what does synovial fluid aspirate show with gout

A

negatively birefringent, needle like, when viewed w. polarized light microscopy

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13
Q

what is the tx for asymptomatic hyperuricemia

A

lifestyle mods:

wt loss, reduce etoh, diet, enough fluids to urinate at least 2L/day, avoid hyperuricemic meds

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14
Q

should allopurinol be used in for acute gout attacks

A

no! → but keep pt on it if they are already taking

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15
Q

what are 5 meds that you might use for an acute gout attack

A
  1. NSAIDs
  2. indomethacin/naproxen
  3. celecoxib (Celebrex)
  4. colchine
  5. corticosteroids
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16
Q

what is the soc med for an acute gout attack

A

nsaids

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17
Q

what is the realistic/better choice soc for acute gout attacks

A

indomethacin/naproxen

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18
Q

how long should abortive gout meds be given for acute attack

A

1-2 days after sx resolution → typical course is 5-7 days

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19
Q

what are contraindications for celebrex

A

ckd w. CrCl < 60

active ulcer

NSAID allergy

anticoags

CVD

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20
Q

when might you use colchicine for an acute gout attack

A

NSAID intolerance

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21
Q

what are 2 common s.e of colchicine

A

diarrhea

abdominal cramping

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22
Q

what are contraindications for colchicine

A

severe hepatic/renal dz w/ colchicine

mod-strong P-pd and/or CYP3A4 inhibitor

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23
Q

when would corticosteroids be used for gout

A

can’t take NSAIDs or colchicine

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24
Q

what are indications for prophylactic tx in gout

A
  1. presence of tophi
  2. 2 or more gout attacks
  3. renal insufficiency
  4. joint damage on imaging
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25
Q

what are 2 steps in prophylactic tx of gout

A
  1. address preventie issues during intercritical (asymptomatic) period
  2. bring uric acid down slowly
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26
Q

what is the serum urate level goal for prophylactic gout tx

A

< 6

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27
Q

what prophylactic med is used to slowly reduce serum urate

A

cochicine

OR

low dose NSAID

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28
Q

what class of gout meds reduces uric acid production

A

xanthine oxidase inhibitors (XOI)

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29
Q

what is the main XOI

A

allopurinol

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30
Q

how should you administer allopurinol (in terms of titrating)

A

titrate up every 2-5 weeks

give prophylactic colchicine when initiating

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31
Q

what are s.e of allopurinol

A

rash

severe cutaneous/toxic epidermal necrolysis (TEN)

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32
Q

what is an example of a uricosurig med

A

Probenecid

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33
Q

what are uricosurig meds (2)

A

block tubular reabsorption of urate AND increase rate that uric acid is renally secreted

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34
Q

what are two inclusion criteria for uricosurig meds

A
  1. normal renal fxn → CrCl >60
  2. urinate at least 2 L/day
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35
Q

what is a contraindication for probenecid

A

G6PD

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36
Q

what do uricase meds do

A

enzyme from other animals → break down uric acid

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37
Q

what is an example of a uricase med

A

pegloticase

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38
Q

when is pegloticase used

A

last line med for pt who has been refractory to all other therapies

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39
Q

what is a contraindication for pegliocase

A

G6PD

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40
Q

most ppl with gout are __excreters of uric acid

A

under

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41
Q

what are rf for uric acid underexcretion

A
  1. renal insufficiency
  2. meds: low dose asa, thiazides, loop diuretics
  3. aidosis (DKA)
  4. volume depletion
  5. lead exposure
  6. etoh!!
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42
Q

overproduction of gout is usually __ or

__

A

inherited

2/2 to dz process

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43
Q

what is a rf for both underexcretion and overproduction of uric acid

A

etoh!

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44
Q

what are 2 other names for pseudogout

A
  1. calcium pyrophosphate dihydrate deposition dz (CPPD)
  2. chondrocalcinosis
  3. pyrophosphate arthropathy
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45
Q

what is pseudogout

A

precipitation of calcium pyrophosphate dihydrate crystals (CPP)

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46
Q

pseudogout causes

A

chronic or recurrent arthritis that mimics gout

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47
Q

what is the mc location for pseudogout

A

knee

also shoulders, wrist, elbow

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48
Q

pseudogout affects __ joints than gout

A

larger

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49
Q

what is asymptomatic/incidental pseudogout

A

CPP deposition on radiograph w.o symptoms

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50
Q

what is acute arthritis/pseudogout

A

self-limited, sudden attacks of pain, redness, warmth, disability/swelling

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51
Q

acute arthritis/pseudogout can be (in terms of location)

and usually affects __ joints

A

monoarticular or oligoarticular

larger

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52
Q

pseudogout can be triggered by (3)

A

surgery (esp parathyroidectomy)

trauma

major illness

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53
Q

what is chondrocalcinosis

A

e.o calcification in cartilage

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54
Q

what is the dx for pseudogout

A

synovial joint aspiration

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55
Q

what is the positive finding in synovial joint aspiration for pseudogout

A

weakly positive birefringent rhomboid crystals by polarized light microscopy

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56
Q

what is the tx for acute pseudogout

A
  1. aspiration
  2. intraarticular glucocorticoid injxn
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57
Q

what glucocorticoid is injected for acute pseudogout

A

triamcinolone

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58
Q

what other meds are used for acute pseudogout besides triamcinolone

A

NSAIDs → indomethacin

naproxen

salicylates

colchicine

systeic corticosteroids

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59
Q

what is the prophylactic tx for pseudogout

A

same as for gout →

consider if 3 or more attacks/year

cochicine

NSAID if colchicine intolerant

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60
Q

what is CPP inflammatory arthritis (pseudo RA)

A

inflammatory arthritis caused by CCP crystals in joint fluid

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61
Q

how is CCP/pseudo RA different from RA

A

asynchronous waxing and waning symptoms

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62
Q

what are the mc locations for CCP inflammatory arthritis/pseudo RA

A

wrists, elbows, glenohumeral joint

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63
Q

CCP inflammatory arthritis/pseudo RA usually affects joints in a

A

symmetric pattern

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64
Q

what is prophylactic tx for CCP inflammatory arthritis/pseudo RA

A

NSAIDs → naproxen, indomethacin

glucocorticoids → if NSAIDs ineffective

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65
Q

what is the mc location for OA w. CPPD (pseudo OA)

A

knees

also wrists, MCPs, hip, shoulders, elbow, spine

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66
Q

what are the symptoms for pseudo-OA

A

same as OA:

tenderness

bony enlargement

crepitus

restricted ROM

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67
Q

what is pseudoneuropathic joint dz

A

severe joint degeneration from CPP crystal deposition

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68
Q

what is the differentiating factor between pseudo-neuropathic joint dz and neuropathic arthropathy

A

no neurologic impairment in pseudo neuropathic arthropathy

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69
Q

what are the most common symptoms of fibromyalgia

A
  1. flu like pain in neck and shoulders
  2. HA
  3. dpn
  4. anxiety
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70
Q

fibromyalgia can also be associated w

A

dpn

ibs

cognitive problems

psychiatric symptoms

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71
Q

fibromyalgia mc affects

A

younger women

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72
Q

what is allodynia

A

response to nonpainful stimuli perceived as painful

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73
Q

what is hyperalgesia

A

pain perceived as more intense and lasting longer

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74
Q

pain w. fibromyalgia is commonly felt as

A

chronic pain/stiffness in all 4 quadrants

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75
Q

what will pe exam findings be for fibromyalgia

A

exam normal except for pain at tender points

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76
Q

what are tender points in fibromyalgia

A

soft tissue locations of pain

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77
Q

what are control locations in fibromyalgia

A

locations where there should be no pain

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78
Q

for dx of fibromyalgia, how many points must be tender

A

at least 11

79
Q

labs and imaging for fibromyalgia are generally

A

unhelpful

+/- CBC, ESR, CRP, TSH

80
Q

what are the first 2 tx steps for fibromyalgia

A

sleep hygiene

exercise

81
Q

what 4 classes of meds might you consider in fibromyalgia

A
  1. TCAs
  2. SNRIs
  3. SSRIs
  4. anticonvulsants
82
Q

what 2 TCAs might you use in fibromyalgia

A
  1. Amitryptiline (Elavil)
  2. Nortriptyline (Pamelor)
83
Q

what med would be helpful for a pt w. fibromyalgia and dpn

A

SNRI → Cymbalta (Duloxetine)

84
Q

what SSRI might you use for fibromyalgia

A

Prozac

85
Q

what anticonvulsant might you use for fibromyalgia

A

Pregabalin (Lyrica)

86
Q

what meds are not helpful for fibromyalgia

A

opioids

corticosteroids

NSAIDs

87
Q

polymyalgia rheumatica (PMR) and what other dz are very similar

A

trigeminal neuralgia

88
Q

mc locations for pain/ inflammation in PMR

A

hips/shoulders

89
Q

what is the “gel phenomenon,” and what does it make you think of

A

stiffness after activity

PMR

90
Q

which is mc, PMR or temporal arteritis

A

PMR

91
Q

what is the main symptom in giant cell arteritis (GCA)

A

ha → classically over temple, but can be generalized

92
Q

besides ha, what are 3 other symptoms of GCA

A

jaw claudication

visual symptoms → bilateral OR unilateral

scalp tenderness

93
Q

almost all pt w. PMR and GCA are > __ yo

A

50

94
Q

a major rf assocaited w. GCA is __

a major rf associated w. PMR is __

A

smoking

DM

95
Q

in PMR pt’s will have normal __

but impaired __

A

normal muscle strength

impaired ROM

96
Q

other than decreased ROM, what is another pe finding associated w. PMR

A

bursal inflammation in wrists/knees

97
Q

at least __% patients w. GCA also have __

A

50%

PMR

98
Q

a pe for a pt w. GCA may be totally normal; if not, what are 4 associated findings

A

ill appearing

thickened/prominent temporal artery

cotton wool patches

99
Q

both PMR and GCA involve polymorphisim of

A

HLA-DR alleles

100
Q

what 2 labs will be very elevated in PMR and GCA

A

ESR/CRP

101
Q

PMR is a __ dx

and the gold standard for GCA is __

A

clinical

temporal artery bx

102
Q

what do you do if the temporal bx for GCA is negative but you have a high suspicion for GCA

A

bx the other side

103
Q

the tx for both PMR and GCA is __

but for GCA tx is much more __

A

steroids

emergent

104
Q

should you wait for bx results to start tx for GCA

A

no!

105
Q

what is the initial starting dose of prednisone for GCA (you need to know this)

AND for PMR

A

GCA: 40-60 mg po daily x several months

PMR: 15 mg po qd

106
Q

what is a major rf if you delay tx for GCA

A

blindness

107
Q

flares are common in GCA, how should you treat these

A

increase dose of steroids by 10 mg

108
Q

what meds should be administered with steroids for GCA

A

vitamin C

osteoporosis meds

109
Q

takayasu arteritis is similar to __

and __

A

GCA

PMR

110
Q

takayaus arteritis involves chronic vasculitis that mc affects the

A

aorta and its main branches

111
Q

name 5 symptoms associated w. takayasu arteritis

A

skin lesions

claudication

syncope

arthralgias

GI issues

112
Q

pe for takayasu arteritis may include (3)

A

bp differential

diminished pulses

anemia of chronic dz

113
Q

in takayasu arteritis, labs will show elevated (2)

A

CRP

ESR

114
Q

dx for takayasu can involve __ and/or

__

A

clinical features

imaging

115
Q

what might you see on imaging for takayasu arteritis (2)

A

arterial luminal narrowing

occlusion w. wall thickening

116
Q

what is tx for takayasu arteritis (2)

A

prednisone to taper

+/- surgery → PCT, bypass, grafting, aortic repair

117
Q

reactive arthritis mc affects

A

weight bearing joints of lower extremities

118
Q

what might a pt have 1-4 weeks prior to reactive arthritis

A

diarrhea (GI infxn) or urethritis

119
Q

what are skin findings might you see on a pt w. reactive arthritis

A

rash on palms / toes

120
Q

what are 3 rf for reactive arthritis

A

young adult

HLA-B27 gene

STDs

121
Q

what bacteria are commonly associated w. reactive arthritis

A

shigella

e. coli
c. diff

campylobacter

salmonella

yersinia

→ from previous GI infxn

122
Q

dx for reactive arthritis might involve (4)

but there is no single dx test

A

elevated CRP/ESR

stool culture

urethral swab

synovial fluid analysis

123
Q

what is mainstay tx for reactive arthritis

A

NSAIDs → naproxen, indamethacin

steroids/DMARDs if no response

124
Q

what rheumatologic condition does this make you think of

A

reactive arthritis

125
Q

sjiorgen syndrome mc manifests in (2)

A

lacrimal/salivary glands

eyes

126
Q

what are the 2 main symptoms of sjorgen syndrome

A

xerostomia

severely dry eyes

127
Q

name 5 symptoms of keratoconjunctivitis sicca

A

diminished tears

dry eyes

AM crust

gritty/sandy feeling

bacterial infxns

128
Q

name 2 complications of sjorgen’s syndrome related to xerostomia

A

dental caries

salivary gland enlargement

129
Q

besides mouth and glands, what 5 other systems can be affected by sjorgen’s

A

GI

renal

urogenital

neuro → neuropathy

130
Q

name 5 constitutional symptoms of sjorgen’s syndrome

A

fatigue

low grade fever

purpura

Raynaud’s

symmetric arthralgia

131
Q

what do schirmer test and saxon test make you think of

A

sjorgen syndrome

132
Q

what is a (+) schirmer test

A

< 5 mm tears produced in 5 min

133
Q

saxon test measures

A

saliva production

134
Q

causes of sjorgen syndrome can be __

or __

A

primary

secondary

135
Q

what 2 labs are often positive in reactive arthritis

A

ANA

RF

136
Q

what is gold standard dx for sjorgen’s syndrome

A

salivary gland bx

137
Q

what is real life dx for sjorgen’s syndrome (2)

A
  1. Schirmer OR Saxon OR imaging showing glandular abnormalities
  2. (+) anti-Ro/SSSA and/or La/SSB abs, (+) lip bx OR established rheumatoid dz
138
Q

tx for sjorgen’s syndrome involves good oral hygiene; what drugs may also help

A

pilocarpine

cevimeline

139
Q

how do you tx eye symptoms for sjorgen’s

A

ocular cyclosporine + artificial tears

+/- topical steroid per ortho

+/- punctal occlusion/plugs

140
Q

what class of drugs may prescribed for systemic management of sjorgen’s

A

immunosuppressive therapy per rheumo →

hydrochloroquine

methotrexate

141
Q

name 3 cardinal signs of RA

A

slow, insidious onset

morning stiffness > 30 min

symmetric swelling of many joints

142
Q

joints mc associated w. RA (5)

A

PIPs

MCPs

wrists

ankles

knees

143
Q

if you see this joint on a rheumatoid condition, you should not be considering RA

A

DIP → almost never affected

144
Q

what RA symptoms is only seen in RF (+) patients

A

RA nodules

145
Q

mc location for RA nodules

A

forearms

+/- lungs

146
Q

name 3 systemic manifestations of RA

A

keratoconjunctivitis sicca

pulmonary effusions

pericarditis → from chronic inflammation

147
Q

what are 2 major rf for RA

A

female

smoking

148
Q

what do you think of when you see boggy joints, ulnar deviation of MCP and swan neck, boutinniere, and z deformities

A

RA

149
Q

what is the most specific lab test for RA

A

anti-CCP

150
Q

what elevated labs correlate w. dz severity in RA

A

ESR/CRP

151
Q

what will synovial fluid show with RA

A

inflammatory effusio

leukocytes 1,500-25,000

152
Q

what is the most specific imaging for RA

A

x-rays

153
Q

early, initial, and late xray findings w. RA

A

early: normal
initial: soft tissue swelling/osteopenia
late: joint space narrowing/erosions

154
Q

what is this Xray showing and what condition is it associated w.

A

joint space narrowing/erosions

RA

155
Q

what is most sensitive imaging for RA

A

MRI

156
Q

what are 5 dx factors for RA

A

inflammatory arthritis involving at least 3 joints

positive RF/anti-CCP

elevated ESR/CRP

duration at least 6 weeks

excluded other causes

157
Q

can you dx a seronegative pt w. RA

A

yes!

158
Q

what are the 3 goals of RA tx

A

control pain and inflammation

preserve fxn

prevent deformity

159
Q

early initiation of __ in RA is crucial

A

DMARDs

160
Q

name 3 DMARDs

A

methotrexate

sulfasalazine

leflunomide

161
Q

what drug might you add to DMARDs with RA pt

A

TNF inhibitor

162
Q

what is mc TNF inhibitor used for RA

A

Etenercept

163
Q

how should steroids be used in RA tx

A

as a bridge to start DMARs

164
Q

NSAIDs should never be used as __ in RA

A

monotherapy

165
Q

what should you do if a RA pt is still in pain after initial therapy w. steroids + DMARDs

A

increase DMARD

166
Q

how do you tx flares of RA

A

steroids

167
Q

how do you treat recurrent flairs of RA in medicated pt

A

increase DMARD

168
Q

name 5 pre-screening tests you should do for RA pt before interventions

A

hep B and C

baseline CBC, SCr, ESR/CRP

ophthalmic screening

latent TB

baseline radiographs

169
Q

list 4 contraindications for DMARDs

A

pregnancy

liver dz

etoh

severe renal impairment

170
Q

what are 3 s.e of DMARDs

A

GI upset

stomatitis

hepatotoxicity

171
Q

1st choice TNF inhibitor for RA

A

etanercept

172
Q

pro and con of etanercept

A

well tolerated

expensive, increased risk for infxn

173
Q

you must screen for __ before starting pt on etanercept

A

latent tb

174
Q

what does SANTA stand for and what is it associated w.

A

felty syndrome

Splenomegaly

Anemia

Neutropenia

Thrombocytopenia

Arthritis (rheumatoid)

175
Q

felty syndrome is a rare complication of

A

ra

176
Q

polyarteritis nodosa (PAN) mc affects

A

medium to small muscular arteries

177
Q

what systems does PAN mc affect

A

skin

muscle

peripheral nerves

kidneys

178
Q

__ and

__ are usually not affected by PAN

A

lungs

veins

179
Q

what organ is mc affected by PAN

A

kidneys

180
Q

what do you think of when you see

lower extremity ulcerations, HTN, abdominal pain after meals, foot drop, and arthralgias

A

PAN

181
Q

PAN

A
182
Q

3 rf for PAN

A

male

hepB/C

hairy cell leukemia

183
Q

what dz pathology involves necrotizing vasculitis → decreased blood flow → weakened vessels

A

PAN

184
Q

3 dx factors for PAN

A

bx of involved organ

angiogram

ACR criteria 3/10

185
Q

bx in PAN will show

A

necrotizing inflammation of medium sized arteries

186
Q

what will angiogram in PAN show

A

rosary sign

187
Q

what is this angiogram showing and what condition is it associated w.

A

rosary sign

PAN

188
Q

if PAN is associated w. viral hepatitis, you should limit __

A

steroids

189
Q

tx for mild PAN

A

monotherapy w. corticosteroids

190
Q

how do you tx persistent mild PAN

A

MTX

191
Q

tx for mod-sev PAN

A

high dose steroids plus immunosupressant

192
Q

what immunosuppressant drug is used for PAN

A

cyclophosphamide

193
Q

max length of time pt can take cyclophosphamide

A

12 mo

Clin Med II - Exam 2 (14 decks)

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