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NMSP Exam II > RA, Arthopathies & Gout (Johnston) > Flashcards

RA, Arthopathies & Gout (Johnston) Flashcards

1
Q

RA typically involves which joints?

A

diarthrodial joints (small)

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2
Q

What are the typical systemic features involved with RA?

A

fatigue, fever, anemia, elevated acute phase reactants

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3
Q

Which cells produce rheumatoid factor (RF)?

A

RA synovium (B cells)

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4
Q

Which genetic factor is associated with a high risk of RA?

A

HLA-DRB4

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5
Q

Increased inflammation and synovial fluid leads to what complication of RA?

A

“pannus” that invades cartilage and bone

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6
Q

What imaging should you order if you suspect a patient with RA?

A

plain films X-rays of hands and feet- detect symmetrical involvement of MCP/MTP joints; looking for erosions

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7
Q

Treatment for a patient with RA?

A

being with NSAIDs for pain control and then start DMARDs; can also start low dose steroids

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8
Q

What are the 4 criteria for RA classification?

A
  1. at least one joint with definite clinical synovitis with smaller joint involvement being more significant
  2. serology of at least one positive finding
  3. acute phase reactants of at least one positive finding
  4. duration of symptoms of greater than 6 weeks

Score greater than 6 is definite RA

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9
Q

RA typically spares which joint in the hands?

A

the DIP joint; if affected think OA

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10
Q

RA typically involves what part of the spine?

A

C1-C2; not the rest of the axial spine; if cervical and lumbar spine is involved think OA

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11
Q

A 27-year-old male presents to your office with a history of pain in both feet (indicating the toes) and swelling of both hands (left worse than right). Symptoms present for past two (2) months. PE L hand is swollen, warm and tender over PIP and MCP joints. Toes are sore upon planter flexion.

What is your diagnosis/differential dx? What laboratory tests would you order? What imaging would you order?

A

RA; anti-CCP and RF; X-rays of hands and feet – detect symmetrical involvement of MCP/MTP joints; erosions

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12
Q
A

always RF+ (100% of patients); confirmatory test

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13
Q

Which position would you not want to force the cervical spine in a patient you suspect RA of C1 and C2?

A

do not force into flexion; may cause subluxation

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14
Q

Pyoderma Gangrenosum

A

an extra-articular manifestation of RA; tender reddish purple papule; leads to necrotic non-healing ulcer

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15
Q

What do you see?

A

Pyoderma Gangrenosum; an extra-articular manifestation of RA; tender reddish purple papule; leads to necrotic non-healing ulcer

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16
Q

Rheumatoid vasculitis

A

an extra-articular manifestation of RA; purport, petechial, splinter hemorrhages, digital infarct

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17
Q
A

Rheumatoid vasculitis; an extra-articular manifestation of RA; purport, petechial, splinter hemorrhages, digital infarct

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18
Q

A 58-year-old male presents with a cough and dyspnea on exertion (climbing 1 flight of stairs and while working in the coal mine). Medical history is positive for RA for ten (10) years and smoking (1-2 ppd x 30 years). Chest x-ray reveals a nodular opacity in both lungs and diffuse hyper-lucency of the lungs.

What is your diagnosis? What tests would you order?

A

Coal miners pneumoconiosis with nodular opacities; probably rheumatoid nodule (Caplan Syndrome), RO bronchogenic CA; CT of chest, Bronchoscopy with cytology and biopsy

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19
Q

A 36-year-old female presents to your office with a history of dry mouth, decreased tearing and a sandy- gritty feeling under her eye lids. Recently she complains of “bright light” sensitivity. You have been treating her RA for give (5) years with NSAIDs and methotrexate.

What is your diagnosis? What tests would you order?

A

Extra-articular manifestation of RA due to a secondary Sjogrens Syndrome; Ro/SS-a, La/SS-B and a Schirmers test

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20
Q

Feltys Syndrome

A

a rare, potentially serious disorder that is defined by the presence of three conditions: rheumatoid arthritis (RA), an enlarged spleen (splenomegaly) and a decreased white blood cell count (neutropenia), which causes repeated infections; RF and anti-CCP positive

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21
Q

a rare, potentially serious disorder that is defined by the presence of three conditions: rheumatoid arthritis (RA), an enlarged spleen (splenomegaly) and a decreased white blood cell count (neutropenia), which causes repeated infections?

A

Feltys Syndrome

22
Q

Spondyloarthropathies (SpA)

A

are seronegative arthropathies; anti-CCP and RF negative; some are B27 positive
most common:
Ankylosing Spondylitis (AS)
Reactive arthritis (ReA)
Psoriatic arthritis (PA)

23
Q

Dactylitis definition

A

swelling of a finger or toe (sausage digit); seen in reactive arthritis (ReA) and psoriatic arthritis (PA)

24
Q

Spondylitis definition

A

inflammation of the vertebre

25
Q

Spondylolisthesis definition

A

anterior displacement of a vertebral body relative to the adjacent vertebral body below

26
Q

Some clinical features of spondyloarthropathies

A

affect the axial spine; peripheral joints, periarticular structures, are associated with allele B27 and can have extra-articular manifestations

27
Q

What test/imaging do you want to order for a patient you suspect has a spondyloarthropathy?

A

HLA B27
X ray of pelvis - attention to SI joint and x-ray of lumbar spine
CT more sensitive for erosions

28
Q

Ankylosing Spondylitis (AS)

A

a type of spondyloarthropathy; associated with HLA B27 (90%) - but this cannot diagnosis, confirm or exclude the diagnosis; most common inflammatory disorder of the axial spine; involves the SI joints; family history (check)

29
Q

What is the most common disorder of the axial spine?

A

Ankylosing Spondylitis (AS)

30
Q

Clinical manifestations of Ankylosing Spondylitis (AS)?

A

low back pain > 3months, morning stiffness; **improved with exercise and worst with rest; there will be symmetrical SI joint pain (sacroilitis) loss of mobility and flexibility; can see tendonitis and planter fasciitis

31
Q

Which spondyloarthropathy improves with exercise and gets better with rest?

A

Ankylosing Spondylitis (AS)

32
Q

What test would you do on PE in a patient who you suspect has an spondyloarthropathy?

A

Schober Test - restricted forward flexion; loss of spine mobility

33
Q

Schober Test

A

a test used to see if there is restricted forward flexion and loss of spine mobility; used in patients suspected of spondyloarthropathies

34
Q

Diffuse idiopathic skeletal hyperosteosis (DISH)

A

calcification along lateral aspect of 4 contiguous vertebrae bodies; **SI joint are not involved (contrast with spondyloarthropathies)

35
Q

Cauda equina syndrome

A

late complication of lumbar stenosis; low back pain

36
Q

Treatment for Ankylosing Spondylitis (AS)?

A

exercise, physical therapy (get them moving around); NSAIDs (pain control); TNF inhibitors and non-biologic DMARDs

37
Q

Reactive Arthritis (ReA)

A

a type of spondyloarthropathy; autoimmune disease; asymmetric mono-arthritis or oligo-arthritis in lower extremities; can see dactylics (sausage toe); may be associated with infection from GI/GU track; associated with HLA B27 (75%) - but this cannot diagnosis, confirm or exclude the diagnosis

38
Q

A 28-year-old male presents with a history of low back pain for the past four (4) months. He denies trauma, heavy lifting or unusual physical activity. He indicates the lower portion of the back over the lumbar – sacral-iliac region, right side worse than left side. He admits to morning stiffness, fatigue and 9lb. weight loss over three (3) months.

What is your diagnosis/differential diagnosis?

A

A spondyloarthropathy:
-ask if physical activity improve the pain, any family history, can bend over (if yes to these will point towards AS)

39
Q

A 26-year-old male presents with pain, swelling and warmth in the right knee. Onset two (2) weeks prior to office visit. Admits to pain in achilles tendon on right side and sore soles of the feet. He does admit to swelling and soreness of the 2nd and 3rd toes on the right foot. He denies eye pain, rash or urethral discharge.

What is your diagnosis/differential diagnosis?

A

A spondyloarthropathy: Reactive arthritis (ReA)

40
Q
A

extra-articular manifestation of Circinate Balanitis in a man with reactive arthritis.

41
Q
A

exra-articular manifestation of Keratodermia blennorrhagica of feet in a patient with reactive arthritis

42
Q

Psoriatic Arthritis (PsA)

A

a type of spondyloarthropathy; young persons disease (30-50 yrs); associated with SI and axial involvement; may be asymmetrical or symmetrical; can see pitting nails, dactylitis and enthesitis; soft tissue swelling, erosions, and destruction of interphalangeal joints; “pencil in cup” appearance; maybe due to a co-infection with HIV

43
Q

Which spondyloarthropathy maybe due to a co-infection with HIV?

A

Psoriatic Arthritis (PsA)

44
Q
A

Pitting of the nail is associated with distal interphalangeal joint arthritis seen in Psoriatic Arthritis (PsA)

45
Q
A

pencil in cup appearance seen in Psoriatic Arthritis (PsA)

46
Q

Gout

A

build up of monosodium urate crystals; usually involves the 1st MTP and presents with podagra; and tophi can be seen

47
Q
A

Tophi - white chalky masses of uric acid; seen in gout

48
Q
A

Podagra - red hot swollen joint seen in gout affecting the 1st MTP joint (most common site)

49
Q
A

NEGATIVE Birefringence, needle-like crystals seen in gout

50
Q

Pseudogout

A

build up of calcium pyrophosphate dehydrate crystals (chondrocalcinosis); involves large joints (knees); can be polyarticular, warm, swollen, erythematous and painful (resembles OA)

51
Q

Calcium Pyrophosphate Dehydrate Deposition (CPPD) crystals

A

seen in pseudogout; they are short blunt rods with a weak POSITIVE birefringence by polarizing microscopy

NMSP Exam II (12 decks)

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