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Awesome Review > Rheum > Flashcards

Rheum Flashcards

1
Q

Pt with morning stiffness and joint pain in multiple joints but excludes the DIP and Rh and Anti CCP are both negative. Dx and Tx

A

RA and treat with MTX

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2
Q

RA patient with oral ulcers on MTX. WTD

A

Give folic acid

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3
Q

RA patient with sudden onset of back of the knee pain. whats the Dx and how to treat

A

Ruptured popliteal cyts

Intra-articular steroids

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4
Q

RA patient who is postop quadriplegic

A

Atlanto-dontoid subluxation C1-C2

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5
Q

Long-standing RA with hoarseness of voice

A

Cricoarytenoid joint involvement

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6
Q

RA patient with long-standing disease including severe joint deformities. w.t.d before going in for elective hip surgery or any surgery under general anesthesia

A

Xray of the neck

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7
Q

RA pt with swelling in the knee. pt has fever

A

Tap the joint

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8
Q

RA pt on hydroxychloroquine. what general maintains needs to be done while on this medication

A

baseline eye exam now and one in 5 years

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9
Q

the leading cause of death in RA

A

Heart disease

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10
Q

Pt who comes to your office after being tapered off steroids from (Giant cell, polymyalgia rheumatica, or SLE) now has B/L symmetric joint pain and early morning stiffness with no DIP involvement. what is going on

A

Pt has RA

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11
Q

RA patient on MTX. what do you need to be following up on

A

CBC, sCr, AST Qq12 weeks

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12
Q

RA patient is maxed out on MTX dose of 25mg/week and still having symptoms. w.t.d next

A

PPD in prep for biologics
give pneumococcal and flu vaccine (if not already done when you start MTX)
don’t give live vaccines to pts with biologic DMARDs
NO DMARDs to patients with active infection

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13
Q

Young pt with pain in the PIP then MCP and then within a few hours the pain leaves his MCP and then PIP.

A

Palindromic Rheumatism. 1/2 of these patients will go on to have full-on RA. Tx them with DMARD

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14
Q

RA pt with necrotic ulceration of tips of fingers and foot drop

A

Rheumatoid Vasculitis

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15
Q

Long-standing RA with splenomegaly and neutropenia. pt could also have a history of recurrent skin and lung infections and skin ulcers. whats going on and how to treat

A

Felty syndrome and treat with DMARD and steroids

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16
Q

last resort for RA who is refractory to treatment for a long period of time

A

surgery on said joint

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17
Q

Young pt with polyarthritis and fever. Was sick weeks ago and is still having recurrent fevers that are occupied by a salmon-colored rash.

ferritin is high 
leukocytosis 
AST/ALT increased 
Rh-negative 
ANA negative
A

Juvenile idiopathic Rh arthritis

aka: Stills disease

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18
Q

What disease is most likely related to RA

A

Periodontal disease

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19
Q

Which viruses are most likely associated with RA

A

EBV, B19, HTLV-1, HHS-6 and HHS-8

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20
Q

How to diagnose Sjogren’s syndrome

A

Schirmer test

Blotting paper test ( test is + if 5mm wetting in tearing of the eyes in 5mins)

SSA and SSB antibodies. do Bx if these are negative

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21
Q

what are seronegative spondyloarthropathies

A

Rh Factor negative and HLA-27 positive
involves the spine
Asymmetric poly/oligoarthritis (< 4 joints)
Dactylitis can be seen

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22
Q

What are the two main types of seronegative spondyloarthropathies

A

Ankylosing Spondylitis and Reactive arthritis

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23
Q

pt with is long-standing Ankylosing Spondylitis now has renal disease. what happened

A

Renal Amyloidosis

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24
Q

Ankylosing Spondylitis pt with low back pain and decrescendo murmur

A

Aortitis involvement

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25
Q

Pt with back pain and stiffness. Painful red eyes. Loss of forwarding spinal mobility. what is dx, and what is the most specific sign

A

Loss of spinal forward mobility. (Bamboo spine)

Ankylosing Spondylitis

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26
Q

what is the best diagnostic test for Ankylosing Spondylitis

A

X-ray sacroiliac joint

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27
Q

What is the x-ray is negative, and you still have a strong suspicion of Ankylosing Spondylitis. w.t.d

A

get sacroiliac MRI

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28
Q

what are the eye manifestations in Ankylosing Spondylitis

A

Uveitis

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29
Q

How to tx the stiffness from Ankylosing Spondylitis

A

Exercises and physical therapy

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30
Q

How to tx the pain from Ankylosing Spondylitis

A

NSAIDs. but after 6 weeks, if there is no improvement, you are going to jump straight to Anti-TNF-alpha

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31
Q

What is a good disease tracking biomarker for Ankylosing Spondylitis

A

ESR

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32
Q

Ankylosing Spondylitis on NSAIDs, comes in with new onset back pain. w.t.d

A

get xray

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33
Q

pt with Conjunctivitis, URETHRITIS, and asymmetric arthritis. whats going on

A

Reiter’s syndrome

Can also have mouth ulcers and Keratoderma blennorrhagicum (skin peeling)

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34
Q

In a patient with Reiter’s syndrome, what test would you order for the workup

A

HIV test

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35
Q

Young pt with GI or GU illness 2 weeks ago, now has pain in a joint. she also has a history of multiple sexual partners

A

Reactive Arthritis. its NOT Gonococcal arthritis bc there isn’t a history of pustules or rashes. Even if the patient was just treated for chlamydia.

Don’t let the question trick you into thinking this is gonococcal. makes sure there is a clear and active gonococcal infection

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36
Q

how to treat Reactive Arthritis

A

NSAIDs

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37
Q

Lower back pain and with DIP involvement and pitting nail changes on PE

A

Psoriatic Arthritis

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38
Q

how to treat Psoriatic Arthritis

A

mild disease —> NSAIDs
Skin and nail involvement—> MTX
disease reactor to the above start TNF inhibitor or IL-17/23 inhibitor

NO Hydroxychloroquine

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39
Q

What makes Psoriatic Arthritis worse

A

Beta-blockers

infection

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40
Q

young pt with oral ulcers, genital ulcers, along with joint pain. pt is refusing needle sticks

P/E shows Uveitis and tender nodules on shins.

A

Behcets Disease

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41
Q

pt was oral ulcers and CxR revealed hilar fullness

A

Behcets disease.
Hilar fullness was from prominent pulmonary arteries, which is found to be an aneurysm on a CT scan.

Not sarcoid

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42
Q

How to treat Behcets

A

Just mucocutaneous disease —> Colchicine

moderate to severe —> steroids —> azathioprine —>TNF inhibitor

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43
Q

pt has oral and scrotal ulcers and is refusing needle sticks

A

Behcets disease

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44
Q

pt has vulvar ulcers and skin nodules on shins and is refusing needle stick

A

Behcets disease

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45
Q

Painful shin nodules and oral ulcers. Aortic aneurysm. painful red eye and joint pain

A

Behcet’s disease

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46
Q

Pt has oral ulcers, a history of urethral discharge in the past, red eye and ankle pain

A

Reiter’s Syndrome

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47
Q

Pt has painful shin nodules and hilar adenopathy

A

Sarcoid

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48
Q

pt returns from the Caribbean, India, or Africa and now has a fever and joint pain. joint pain is in the small joints of the hands, wrist, and ankle.

A

Chikungunya (from mosquito bite)

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49
Q

A young patient with a history of intermittent diarrhea for two weeks now has joint pain and;

  • painless ulcer on the tongue
  • dactylitis or sausage digit or whole digit swelling
  • severe pain on palpation of the Achilles tendon

Diagnosis?
What is most likely going to be positive in this patient?

A

Reactive Arthritis

Stool culture

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50
Q

An older patient with mid-back pain with;

-decreased thoracic lateral flexion

A

Diffuse Idiopathic skeletal hyperostosis (DISH)

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51
Q

What do you see on x-ray for a patient with DISH

A

Flowing ossifications on the anterior longitudinal ligament

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52
Q

what do you see on xray in RA

A

MARGINAL bony erosions and periarticular osteopenia

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53
Q

What do you see on xray in OA

A

Osteophytes and CENTRAL bony erosions.

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54
Q

pt with morning stiffness, joint pain in the hands (PIP and DIP), Rh factor 1:40 and ANA 1:160. Dx?

A

OA NOT RA

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55
Q

how to treat OA

A

Weight loss, insoles, braces, knee taping, and assistive

topical NSAIDs or oral with PPI
intra-articular steroids
and you can always replace the joint

56
Q

Osteophytes

A

OA

57
Q

Periarticular osteopenia

A

RA

58
Q

Joint space deformity

A

RA and OA

59
Q

Central bony erosions in PIP and DIP

A

OA

60
Q

Marginal bony erosions in MCP and PIP

A

RA

61
Q

Subchondral sclerosis

A

OA

62
Q

The most important risk factor for OA

A

Obesity

A sedentary lifestyle is more of a risk factor in osteoporosis

63
Q

Elderly pt with pain in the thumb while turning keys and opening car door. P/E shows pain in the thumb during flexion and internal rotation. Crepitus positive

A

OA of the 1st CMC joint

64
Q

Pt with OA wants to try glucosamine or chondroitin sulfate. w.t.d

A

studies show no difference btw between those medications and placebo

65
Q

Pt with along standing history of OA. Takes Tylenol for rt knee pain. Has pain, swelling, and mild crepitus. No fever. No white count. The right thigh looks smaller than the left

A

Tap the knee
send to physical therapy
Strengthen quadriceps

66
Q

Older pt with pain in his groin while running. The pain moves anteriorly toward his knee. During the exam, there is pain during internal and external rotation of the hip

A

OA

67
Q

Randomized clinical trials have shown benefits of acupuncture in

A

OA in the hip and knee

68
Q

An older patient has DEXA. T score at the lumbar spine is -1.0 but at the anterior superior iliac spine is -2.6. why is this

A

Osteophytes in the lumbar vertebrae

69
Q

Farmer with URI and RA for 15 years. PIP and MCP joint swelling. He doesn’t complain of pain. Hand strength is normal.

Xray shows bony erosions in the PIP and MCP but no DIP

A

RA NOT OA

70
Q

most likely area of pain with OA in the hip

A

Groin area

71
Q

Right groin pain with a Hx of RA and osteophytes on x-ray. dx

A

OA

72
Q

Right groin pain with RA. X-ray negative, but MRI shows double line sign on T2

A

avascular necrosis

73
Q

Pain over the lateral aspect of hip +/- going lateral thigh or buttock. pain getting out of the car and can sleep on that side

A

Greater trochanteric pain syndrome

74
Q

how to treat Greater trochanteric pain syndrome

A

Inject local steroids

75
Q

pt less than 40 yr of age with b/l groin pain, more on left and worse with internal rotation.

A

Acetabular impingement

76
Q

What is the overall message to patients with a cane?

A

When walking on flat ground, use the cane on the opposite side of the injured leg.

When walking UP steps, use good leg followed by bad leg with a cane

When Walking Down steps, use the bad leg first, followed by the good leg and cane

“up to heaven and down to hell”

77
Q

Gout. crystals and Xray

A

Monosodium urate and bony tophus with erosions

78
Q

Pseudogout. crystals and Xray

A

Ca pyrophosphate dihydrate crystals and chondrocalcinosis on xay

79
Q

Do we treat asymptomatic hyperuricemia

A

No

80
Q

Can uric acid levels be normal during an attack of gout

A

yes

81
Q

Middle age pt MAN with sudden onset of toe pain that woke him up this morning. Has had episodes in the past resolved themselves after a few days. Urate acid levels are normal. the patient refuses tap. dx? and the next step

A

Gout and start Colchicine

82
Q

Tx with a pt having Gout attack and has DM

A

NSAIDs

83
Q

Tx with a pt having Gout attack and has CKD

A

Steroids

84
Q

Tx with a pt having Gout attack and has CKD, CAD, and CABG 2 days ago

A

intra articular steroids

85
Q

Recurrent gout tx

A

Systemic steroids and colchicine

OR

NSAIDs and colchicine

NO NSAIDs with steroids

86
Q

Treating a patient for their 2nd gout attack

A

Colchicine and allopurinol.

You can keep allopurinol on if has already been started before the attack.

87
Q

Pt with a history of gout on allopurinol. Come in with an acute gout flare. w.t.d

A

Start colchicine and KEEP ON the allopurinol

88
Q

pt with gout attack on allopurinol 300mg daily and colchicine comes back with recurrent attacks. uric levels are 7. w.t.d

A

increase dose to 800mg QD

if still elevated 3 weeks after —> address adherence to allopurinol

89
Q

Pt with hx of HTn on ACE. Presents with rash, fever, and necrolytic kind of rash.

white count is elevated with 10% eos and increased LFTs
what’s the cause

A

Allopurinol

90
Q

What medication can allopurinol increase

A

Azathioprine

91
Q

pt with hc of gout presents with swelling in the knee. you tap the knee and it shows negatively birefringent crystals and WBC of 40k.

a week later you tap it again and nothing has changed and the patient still has pain. w.t.d

A

Start IV ABx

92
Q

pt with HTn on chlorthalidone with uric acid levels is high. w.t.d

A

cont chlorthalidone bc this is asymptomatic hyperuricemia, and we don’t treat that

93
Q

pt with HTn on chlorthalidone or Lasix with uric acid levels is high. and the patient is having a gouty attack w.t.d

A

stop Lasix or chlorthalidone and switch to losartan

94
Q

Elderly pt on chlorthalidone/HCTZ presents with pain in the PIP and DIP with nodules and swelling distal to the nodule. what is this

A

Gouty arthritis.

these patients will have monosodium urate crystals

95
Q

what other disease or associated with pseudo gout

A

Hyperparathyroidism and Hemochromatosis

96
Q

what joints are commonly affected in pseudo gout

A

wrist, knee, shoulder

97
Q

what does the X-ray show in pseudo gout

A

Chondrocalcinosis

98
Q

what does the joint fluid show in pseudo gout

A

Rhomboid crystals with weakly positive birefringence

99
Q

how to treat pseudo gout

A

same as gout but colchicine is less responsive

100
Q

pt with intermittent arthralgias involving the wrist, hands, and shoulder. x-ray shows multiple areas of calcification in multiple joints. pt also is very fatigued. what is the Dx and what test would you get next

A

Chondrocalcinosis due to calcium pyrophosphate dihydrate deposition

you would want to get a transferrin saturation and TIBC to evaluate patient for hemochromatosis

101
Q

Pt with hyperparathyroidism undergoes parathyroidectomy.

Five days later pt develops acute onset of pain, swelling, and warmth in the right knee. Serum uric acid level is 7. Tap in done.

what would the tap reveal and how would you treat it

A

Calcium pyrophosphate dihydrate crystals

NSAIDs

102
Q

How to treat carpal tunnel

A

don’t use steroids

Neutral splint at night —> no response or thenar atrophy—>Nerve conduction study—-> surgical release

103
Q

pt with median nerve involvement, you will most likely see

A

inability to oppose the little finger with the thumb

104
Q

Middle age pt with b/l numbness in thumbs and index finger after holding anything for a few minutes. Low heart rate in the 50s. Complaining of fatigue.

w.t.d

A

order TSH

105
Q

A pregnant woman complains of pain and numbness in both hands in the thumb and index finger. w.t.d

A

Neutral splinting of the wrist

106
Q

Long-standing RA with b/l tingling sensation in both hands. Thenar muscle wasting. next diagnostic step

A

Nerve conduction study

107
Q

How would you treat a patient with a tingling sensation in the index finger and thumb with the dropping of objects. ENG study shows median neuropathy with axonal loss

A

Surgical release

108
Q

Numbness of thumb, index finger, and middle finger. Early morning stiffness for an hour. difficulty opening bottles

A

RA

109
Q

Pt presents with pain in the radial aspect of the wrist, especially when she lifts her children. Or a young man who plays video games. Point tenderness over the radial styloid process. Pain on resisted abduction and extension of the thumb. making a fist with a fully flexed thumb and ulnar deviation is painful

A

De Quervain’s Tenosynovitis

110
Q

How to treat De Quervain’s Tenosynovitis

A

rest tendon —-> splinting —>local steroids—> if disability is severe—> steroids

111
Q

Pt presents with a wrist drop. decreased sensation on the radial and dorsal aspect of his hand

A

Compression of the radial nerve at the spiral groove in the middle of the arm

AKA: Saturday night palsy

112
Q

Pt complaints of pain in the shoulder increased on abduction, and extremes of movement are painless. Pain more on active abduction rather than passive. Swing arms back and forth without pain

A

Subacromial bursitis

113
Q

How to treat Subacromial bursitis

A

Steroids into the bursa

114
Q

Pt. with episodic swelling of ears. Exam shows a cartilaginous portion of ear swelling. How to est Dx, and what is the Dx. also, how do you treat

A

Bx of cartilage

Relapsing polychondritis

Immunosuppression

115
Q

Vasculitis with low complement

A 
Goodpasture's 
Leukocytoclastic angiitis 
Cryoglobulinemia 
SBE 
SLE 
RA
116
Q

Vasculitis with normal complement

A 
Polyarteritis nodosa 
MPA 
Eosinophilic granulomatosis with polyangiitis
Giant Cell 
Takayasu arteritis 
Aortitis
117
Q

Pt with suspected Giant cell. w.t.d next

A

ESR

This is positive in 85-95% of patient

118
Q

pt with suspected giant cell and has elevated ESR. w.t.d

A

High dose steroids

119
Q

Pt with suspected Giant cell with ESR of 85 and temporal bx is negative. what the diagnosis and what to do next

A

giant cell

start steroids and bx the contralateral temporal artery

120
Q

How to dx Takayasu arteritis disease

A

Aortography and look for stenosis

121
Q

how to tx Takayasu arteritis disease

A

steroids and calcium channel blockers

122
Q

What is ankylosing spondylitis associated with

A

Aortitis and Uveitis

123
Q

Aortitis can be associated with

A

Ankylosing spondylitis
Uveitis
Syphilis

124
Q

50 yo man presents to the ER with complaints of abdominal pain which worsens with eating, mainly in the periumbilical area. It gets better when the stomach is empty. The pain has worsened over the past several weeks. He complains of joint pain in his hands and feet. Ulcers on the lower extremities.

BS+. purpuric rash on the lower extremities.
ESR 100
CXR is clean

What is the best test to determine a diagnosis?

A

Abdominal Angiogram

125
Q

how to treat PA

A

Steroids and cyclophosphamide

126
Q

35 yo with abdominal pain and labs reveal renal insufficiency and HBsAg. Whats the Dx

A

PAN

127
Q

A 24 yo woman of Italian/Jewish/Arab descent with recurrent abdominal pain every two months lasting 1-2 days. Pt had an appendectomy in childhood for abdominal pain. She gets high fevers during the attacks of periumbilical pain that spreads all over the abdomen. Swollen knee. Her power in normal and has no ulcers. Abdominal imaging is normal. Father had a similar episode as a child.

Whats the dx, how to treat and what are the complications

A

Familial Mediterranean fever

Colchicine

AA amyloidosis with CKD

128
Q

Cause of amyloidosis

A 
FMF 
RA 
TB 
MM
AS
129
Q

how to diagnose Amyloid

A

First, get abdominal fat pad bx

If negative, then biopsy affected organ

bx will show fibrils of apple green birefringence on congo red staining

130
Q

Thick-walled cavitary lung lesions

A

GPA
Histo
Blasto

131
Q

Thin-walled cavitary lung lesions

A

Nocardia
Cocci
MAC

132
Q

How to treat severe GPA

A

Steroids + cyclophosphamide or rituximab

133
Q

If GPA is suspected and ANCA is negative. w.t.d

A

Renal biopsy

134
Q

Young to middle age pt with a history of asthma. She presents with shortness of breath, wheezing, and complains of weakness in her left foot. SHe uses SABA, ICU and is being weaned off steroids. Exam reveals rales at the right upper lobe.

decreased power in the left foot with hypoactive reflexes

CBC show EOS
CxR shows right upper lobe density

whats the Dx

A

Eosinophilic granulomatosis with polyangiitis

135
Q

pt with arthralgias and malar rash. You suspect lupus w.t.d

A

ANA THEN ds-DNA

136
Q

What is the most specific test for SLE

A

Anti-smith

OR

anti-dsDNA

Awesome Review (3 decks)

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