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Clinical Med > post midterm 3 rheum > Flashcards

post midterm 3 rheum Flashcards

1
Q

what does the ESR or sed rate measure

A

Distance that RBCs fall in 1 hour – cells aggregate and settle faster when inflammatory proteins are present

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2
Q

what does C reactive protein measure?

A

Acute-phase reactant, secreted by liver in response to inflammatory cytokines
High levels (>10) sensitive but nonspecific for inflammatory states
*Chronic low level elevation (1-10) associated with increased CV risk (high sensitivity or HS-CRP)

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3
Q

what is rheumatoid factor?

A

Antibodies (IgM) against Fc region of human IgG

*but can have false + or -

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4
Q

what does the ANA test measure?

A

Antibodies to nuclear antigens (DNA, RNA, histone and other proteins)

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5
Q

what is lupus anticog?

A

Antibody w/ prothrombotic effects in vivo but prolongs PTT in vitro
Observed in patients with lupus, but can occur in patients w/o lupus

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6
Q

what is the most common joint disease?

A

osteoarthritis

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7
Q

what is osteoarthritis?

what might you see on X ray?

A

*Non-inflammatory joint disease
*assoc w/ advancing age
X-ray findings:
–Loss of cartilage (joint space narrowing)
–Osteophytes (bone spurs)
Some genetics
Trauma / repetitive motion

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8
Q

osteoarthritis affects what aspect of body?

A

Limited to joint involvement:
Distal interphalangeal joints
Proximal interphalangeal joints
1st metacarpophalangeal joint (only)!!

get nodules in fingers
-also affects cervical spine, lumbar spine, hips and knees

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9
Q

primary tx for osteoarthritis?

A

tylenol (since NOT inflammatory!) and maybe physical therapy

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10
Q

what is Carpal Tunnel Syndrome?

what does it affect?

A

Pressure on median nerve in the carpal tunnel

-Digits 1, 2, 3 and ½ of 4th fingers

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11
Q

what can trigger carpal tunnel?

A

Repetitive use
Inflammation (e.g. rheumatoid arthritis)
Trauma

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12
Q

what is rheumatoid arthritis?

A

A systemic autoimmune disease of unknown etiology that includes chronic synovial inflammation, joint destruction, systemic manifestations and ocular inflammation

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13
Q

what kind of pop do you see RA in?

A

Usually presents in young women
Onset may be at any age, but most are 30-40
Some genetic predisposition

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14
Q

what are some clinical features of RA?

A

*Constitutional symptoms
(Fever, weight loss, fatigue)

  • Arthritis: small joints
  • Synovial thickening/pannus
  • -Secondary carpal tunnel syndrome
  • -Articular, periarticular destruction of joint destruction

*Rheumatoid nodules
Extensor surfaces (skin)
Heart, lungs, other organs

*osteoporosis

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15
Q

what are some Ocular Manifestations of Rheumatoid Arthritis?

A

1) Keratoconjunctivitis sicca (associated Sjogren’s syndrome)
2) Episcleritis (mild, transient)
- Pain, no visual impairment
3) Scleritis (edema, pain) – risk for systemic vascular disease*
–Nodular scleritis
–Scleromalacia perforans (choroid pigment visible)
–Brawny scleritis=
inflammation, tenderness or pain of the globe, history of collagen vascular disease
4) Ulcerative keratitis
5) Brown’s syndrome- Tendinitis of superior oblique → diplopia

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16
Q

what is still’s disease?

A

Systemic onset JRA w/
Prominent fever (daily spikes to > 103oF)
Rash, lymphadenopathy, hepatosplenomegaly

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17
Q

In Pauciarticular (or oligoarticular) onset JRA, where Less than 5 joints involved in first 6 months, no systemic features, what kind of ocular features can you see?

A

Chronic bilateral nongranulomatous iridocyclitis is common
–Appears insidiously over months, independent of arthritis, ANA usually (+)

*Significant threat to vision from complications:
posterior synechiae, band keratopathy, cataracts, secondary glaucoma

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18
Q

main tx forms for RA?

A
  • *primarily just know DMARDs
  • NSAID’s: for symptoms! not strong enough for anti-inflamm
  • -Non-selective (aspirin, ibuprofen, naproxen, etc.)
  • -COX-2-selective (celecoxib)
  • Glucocorticoids
  • Disease Modifying Anti-Rheumatic Drugs (DMARD’s
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19
Q

besides affecting GI tract, NSAIds can also cause what other kinds of problems?

A
  • GI inflammation, erosion, ulceration
  • *Decreased by concomitant use of PPI
  • Renal dysfunction
  • Cardiovascular deterioration (edema, HTN, CHF)
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20
Q

what are the side effects assoc with corticosteroids?

A 
Cushing’s syndrome 
Diabetes
Worsening joint instability
Osteoporosis
Increased cataract risk
*Rarely used alone in modern therapy:
Low dose can be added to DMARD Tx
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21
Q

what are some Disease-Modifying Anti-Rheumatic Drugs: DMARD’s? what are some side effects of each?

A

Methotrexate: can get Hepatotoxicity
Bone marrow suppression

Antimalarials (hydroxychloroquine, chloroquine):
Probably the least toxicity of the DMARD’s
Risk for toxic retinopathy requires monitoring of ocular exam
Asymptomatic initially; early Sx scotomata*
Ocular findings: Irregularity in macular pigmentation* progress to concentric hypopigmentation

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22
Q

describe the course of RA?

A

Course of disease is highly variable:

  • Multiple exacerbations and remissions are common
  • Most show progressive, destructive polyarthritis over years
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23
Q

what is lupus or Systemic Lupus Erythematosis?

A

A systemic autoimmune inflammatory disease of unknown etiology

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24
Q

lupus affects what type of pop? what causes it?

A

women
Onset usually between 15-25 years of age
cause: unknown, genetics does play some role

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25
Q

what kind of clinical symptoms do you see with lupus?

A 
Constitutional symptoms
*Arthritis, arthralgia (92%)
Mucocutaneous lesions
Serositis: affects lungs intest heart
Cardiopulmonary-, nonbacterial endocarditits 
Renal
Neurologic
Hematologic
Ocular
26
Q

what kind of clinical symptoms do you see with lupus?

A 
Constitutional symptoms
*Arthritis, arthralgia (92%)
Mucocutaneous lesions
Serositis: affects lungs intest heart
Cardiopulmonary
Renal
Neurologic
Hematologic
Ocular
27
Q

what is the “malar rash” and what is it assoc with?

A

like a butterfly rash across cheeks, associatied with lupus

28
Q

what kind of arthritis is associated with lupus?

A

Pain, stiffness, swelling of hands, wrists, elbows, knees, ankles
Polyarthritis with benign joint fluid, minimal deformity**

29
Q

what are some possible ocular side effects of lupus?

A

-Conjunctivitis, keratitis, episcleritis, uveitis
-Retinopathy:
CWS, Retinal edema, Superficial hemes, Arteriolar narrowing
-Proptosis
-Keratoconjunctivitis sicca (20%)
-Ischemic optic neuropathy, optic atrophy (rare)
-Neuro-ophthalmologic complications of CNS involvement: cranial nerve palsies (20%) from mononeuritis,

30
Q

what are some possible lab findings for lupus?

A
  • Antinuclear antibodies (ANA) - positive in 90%, but nonspecific
  • Lupus anticoagulant, thrombocytopenia, anemia
  • Biopsy of skin, kidney, etc. revealing Ig/complement immune complex deposition
31
Q

what are some possible tx forms for lupus?

A

1) Anti-inflammatory medications (NSAIDs, aspirin)
2) Glucocorticoids
Useful in treating renal failure, hemolytic anemia, severe psychosis
3) Hydroxychloroquine
4) Immunosuppressive drugs

32
Q

what kind of course does lupus take in progression?

A
  • Typically relapsing/remitting course over years
  • Most do well, with skin/joint disease only
  • Flares often during pregnancy, ↑ risks for miscarriage
  • Can improve after menopause
  • Fulminant downhill course may occur, with death from renal, neurologic, hematologic, infectious complications
  • -Mortality varies but has improved over past decades
33
Q

what is Antiphospholipid Antibody Syndrome?

A

Positive antiphospholipid antibodies PLUS:

  • Arterial and/or venous thrombosis
  • retinal artery occlusion
  • Thrombocytopenia
  • Spontaneous abortions (recurrent)

***can get secondarily w/ lupus

34
Q

what is Sjogren’s?

A

A systemic autoimmune inflammatory disease of unknown cause
–Destruction of exocrine glands -> dry eyes, mouth, etc.
[Frequent association with other autoimmune disorders]

35
Q

what pop do you see Sjogren’s in?

A

women

usually middle aged

36
Q

what are some ocular clinical signs of sjogren’s?

A

Filamentary keratitis
Corneal ulcers
Lacrimal enlargement (unusual)

37
Q

what are some other autoimmune disorders that can give secondary sjogrens?

A 
Rheumatoid arthritis 
S.L.E (Sjogren’s occurs in 30% of patients with R.A. or S.L.E.)
Scleroderma 
Polymyositis
Autoimmune cirrhosis
Hashimoto’s
38
Q

how can you diagnose SJogren’s?

A
  • Clinical features
  • Exocrine gland, lip biopsy diagnostic (lymphocyte infiltration)
  • ANA, rheumatoid factor often positive
39
Q

what is Systemic Sclerosis - Scleroderma?

A

idiopathic autoimmune disorder causing fibrosis of skin, with or without internal organ involvement

-Fibrosis of dermis, with increased collagen deposition

Two clinical subsets of the disease:
Limited cutaneous scleroderma
Diffuse cutaneous scleroderma

-Often family Hx of rheumatologic disease (eg SLE, RA)

40
Q

What is Limited Cutaneous Scleroderma“CREST” Syndrome?

A

Calcium deposits (calcinosis)
Raynaud’s phenomenon
Esophageal dysmotility (dysphagia, reflux - 50%)
Sclerodactyly: dermal scarring, thickening, tightening of skin
Telangiectasias

41
Q

What is Raynaud’s DISEASE?

A

Raynaud’s phenomenon in young women (90%) without associated autoimmune disorder

42
Q

you can see Raynaud’s with what other autoimmune disease?

A

Rheumatoid arthritis (< 5%)
Scleroderma (> 95%)
S.L.E., Sjogren’s syndrome (20-30%)
Polymyositis (25%)

43
Q

what is Diffuse Cutaneous Scleroderma? what do you see clinically?

A

1) Constitutional symptoms and Raynaud’s initially
2) Rapidly progressive skin changes
- Edema and pruritis
- Telangiectasias, calcinosis, dermal fibrosis
- Destruction of skin appendages - sweat, hair, sebaceous
- Hyper-/hypo-pigmentation
3) Arthralgias, tendon involvement, bone destruction
4) Visceral involvement
- Diffuse GI involvement
- Pulmonary fibrosis
- Cardiac fibrosis
- Renal failure and hypertension

44
Q

what are some ocular manifestations of scleroderma?

A 
*Eyelids - lose elasticity
	Retraction
	Exposure keratitis
*Retinopathy (cotton wool spots)
*Keratitis
*Cataracts
*EOM palsy (nerve sheath compression
45
Q

how would you diagnose scleroderma?

A

Characteristic clinical picture, especially skin changes and Raynaud’s

46
Q

what is polymyositis?

A

An inflammatory myopathy causing skeletal muscle weakness

47
Q

what is dermatomyositis?

A

Polymyositis with skin manifestations

48
Q

what clinical features do you see with Polymyositis and Dermatomyositis? what is pathognomonic?

A

**Muscle weakness (85%) – proximal
[Difficulty: standing from chair w/o arms, getting out of car, reaching overhead, brushing hair]
**Skin lesions: Gottron’s papules -pathognomonic sign of dermatomyositis

***Association with underlying malignancy often-like cancer

--not as much of a focus--
Arthritis
Raynaud’s phenomenon
Associated autoimmune disorders
S.L.E.			
Scleroderma
Sjogren’s syndrome
49
Q

what kind of ocular side effects do you see with Polymyositis and Dermatomyositis?

A 
Periorbital edema
Heliotropic rash on lids
Retinopathy
Cotton wool spots			
Hemorrhages
EOM involvement (unusual)
Episcleritis (unusual)
50
Q

what kind of ocular side effects do you see with Polymyositis and Dermatomyositis?

A 
Periorbital edema
Heliotropic rash on lids
Retinopathy
Cotton wool spots			
Hemorrhages
EOM involvement (unusual)
Episcleritis (unusual)
51
Q

what pop do you see GCA in?

A

Affects elderly population exclusively:
Peak incidence at 60-75 y.o., all are > 50 y.o.
Women : men = 3 : 1
more caucasians, genetics

52
Q

what pop do you see GCA in?

A

Affects elderly population exclusively:
Peak incidence at 60-75 y.o., all are > 50 y.o.
Women : men = 3 : 1
more caucasians, genetics

53
Q

what will GCA cause in eye?

A

ocular ischemia
Posterior ciliary artery - Ophthalmic artery – Internal carotid

-Anterior ischemic optic neuropathy
-Amaurosis fugax (10-12%) or sudden total blindness
Permanent visual loss in 8-23%
Unilateral visual symptoms in first month, bilateral by second
***Second eye involved 65% of untreated patients (why it’s so imptnt to tx)
(Onset transient or sudden, partial or complete)
**Findings: sludging, disk pallor, papillitis, optic atrophy
-EOM palsies (2-14%):
-Central retinal artery occlusion (unusual)

54
Q

what are some Extraocular Neurologic Complications of Giant Cell Arteritis

A
  • Vertigo, hearing loss
  • Hemianesthesia or paralysis of tongue
  • Facial pain (facial artery)
  • Mononeuritis multiplex
  • Cervical myelopathy (anterior spinal artery)
  • Carotid, vertebrobasilar TIA or stroke
55
Q

T/F: negative temporal artery biopsy excludes GCA

A

FALSE

56
Q

how do you tx GCA?

A

Moderately high doses initially (60-80 mg/d prednisone)
Slow taper (5-10 mg less, q3-4 wks)
Maintenance = 3-5 mg/day, usually x 3-4 years
**also remember Prophylaxis for osteoporosis
with glucocort

57
Q

what is Polymyalgia Rheumatica?

A

DO NOT CONFUSE with polymyositis, there is no muscle inflamm or weakness

  • Bilateral, symmetrical muscle pain, without weakness
  • -Increased with motion
  • -Stiffness most severe after rest
  • -Muscle tenderness typical, arthritis is not
58
Q

what is Polymyalgia Rheumatica?

A

DO NOT CONFUSE with polymyositis, there is no muscle inflamm or weakness

59
Q

what is Behcet’s Syndrome:

what kind of clinical features do you see

A

A rare multisystem inflammatory disorder of unknown cause

  • Recurrent oral and genital ulcers
  • Ocular inflammation
  • Systemic features (don’t worry about what)
60
Q

Describe the ocular inflamm you see with Behcet’s:

A

Ocular inflammation (25 - 75%); recurrent → visual loss (25%)

  • Uveitis (anterior, posterior, or panuveitis)
  • Conjunctivitis, scleritis
  • Retinal vasculitis (arterial/venous occlusion)
  • Optic neuritis

Clinical Med (10 decks)

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