Rheum 2 Flashcards
Next step in management for a patient with treatment resistant RA on methotrexate?
PPD to screen for TB and start TNF antagonist
Fatigue, Muscle Weakness, Dry Eyes and Dy mouth, Raynaud’s Phenomenon and Hand swelling.
Dx?
What antibodies are associated with this condition?
Mixed Connective Tissue Disease
Anti-U1-RNP (ribonucleoprotein)
Hx of DM and Fatty liver disease. Pt presents with pain in hands, hips, knees, shoulders. Radiographic findings showing chondrocalcinosis and HOOK-LIKE Osteophytes on the Metacarpal Heads. Dx?
Hemochromatosis
Hospitalized patient develops Right Knee Swelling. Synovial fluid shows 20,600 RBCs and 90% neutrophils. R knee Xray shows evidence of chondrocalcinosis with rhomboid shaped Positively Birefringent Crystals. Dx?
Pseudo-gout
(Crystal associated arthritis.)
Aggressive destruction of the glenohumeral joint and rotator cuff causing Large Hemorrhagic Effusion. Dx?
Milwaukee Shoulder
- Medications for Mild RA disease?
- Medications for Moderate and Severe disease/ Erosive RA?
- When is Enteracept used?
- When to give Rituximab?
- Hydroxychloroquine and Sulfasalazine.
- Methotrexate (WBC monitor bone marrow and Cr)
- Given to patients resistant to Methotrexate or in combination with Methotrexate.
- Given to patients with resistance to Methotrexate alone or its given in combination with TNF inhibitor (Entercept)
Young patient presenting with symptoms of Pseudo Gout should be screened for what disease?
Hemochromatosis
After injury patient presents with throbbing pain, parasthesias, things feeling hot then cold as well as local edema. Pt gets immediate relief after never block. Dx?
Complex Regional Pain Syndrome
- Pain and parenthesis in the sole of the foot, distal foot or toes. Nighttime numbness bottom of feet, tingling to palpation behind medial malleus.
- Pain between the 3rd and 4th toes that produces a clicking sensation by squeezing.
- Sharp localized pain over a bony surface
- Tarsal tunnel Syndrome
- Morton Neuroma
- Stress Fracture
Management of men age > 50 and women taking > 7.5 mg/day prednisone?
Start on Bisphosphenate therapy
Recommended to prevent steroid induced osteoporosis.
Pt with hx of parathyroidectomy 1 week ago presents with left knee pain, swelling, effusion, tenderness. Leukocyte count 20,000 with 80% neutrophils. Dx?
Pseudogout caused by calcium pyrophosphate dihydrate crystal arthritis.
Pain and stiffness in both hands, boggy swelling and pitted finger nails. Dx?
Psoriatic Arhtirtis
Xray shows pencil and cup appearance
Best medication for patient with Gout and CKD?
Intra-articular steroids
And oral
Steroids for acute treatment
Low dose allopurinol and febutaxt for prevention
Not
Colchicine and not probenacid
- Lateral Hip pain that radiates into buttock or toward knee with point tenderness of the greater trochanter. Dx?
- Associated with groin pain and limited range of motion? Dx?
- Trochanteric bursitis
- OA of Hip
2. Osteoarthritis of hip
Pt develops neuromyopathy with cytoplasmic vacuolization seen on muscle biopsy in pts with CKD + Gout?
Chronic accumulation of Colchicine
Common complication of Minocycline which is given for Acne?
Drug induced lupus
Isonaizid, Procainamide, Hydralazine
2nd line treatment for osteoporosis?
Teriparatide
Screen for other causes that may cause bone loss (TSH, MM)
Common Clinical Manifestation with Methotrexate?
Name other Side effects?
Stomatitis and Megaloblastic anemia due to depletion of folic acid.
Hepatoxiticty, Nephrotoxicity, Myelosuppression, Pulmonary Damage
Pt presenting with Groin Pain, Limited internal Rotation, Steroid use, and Normal Inflammatory Markers and Vitals.
Dx?
Next step in management ?
Avascular Necrosis
MRI
Seen in patients with Advanced Seropositive RA (Over 10 years). They have Neutropenia, Pleuropericarditis, (Rheumatoid Lung), Skin Ulcers, Splenomegaly.
Felty Syndrome
Seen in patients with CKD who take Colchicine prophylactically.
What is seen on Muscle Biopsy?
Rx?
Colchicine Neuromyopathy
Cytoplasmic Vacuolization
Stop the Colchicine
- Rx for Symptomatic Acute Vertebral Compression Fractures?
- When the initial treatment fails what to use?
- NSAIDs, Acetaminophen
- Intranasal Calcitonin for 2-4 weeks
Management of OA?
- Exercise, Weight-loss first line
- Oral NSAID (Avoid in CKD, Heart Disease, HTN, > 65, GI) or Topical Diclofenac
- Surgery, Chronic pain management (non Surgical Candidates.
62 yo Man presents with 1 week lower back pain that progressively worsening, worse with movement and present at night.
3 weeks ago he was treated for UTI and had enlarged prostate.
Next step in Management?
MRI Lumbar Spine to check for Vertebral Osteomyelitis. ( Hematogeous spread) - also order blood cultures
Name the 3 Antibodies associated with SS?
- Anti-Topoisomerase (Scl-70)
- Anti-Centromere
- Anti-RNA Polymerase III
- Small effusion, Locking Sensation with Extension, Joint line tenderness. Inability to fully extend. POSITIVE McMurray Test?
- POP sensation with Rapid Onset. Large Effusion. Positive Anterior Drawer & Lachman Test?
- Effusion with instability with lateral movement (Valgus laxity)?
With medial movement (Vargus laxity)?
- Meniscal Tear
- Cruciate Ligaments (ACL/PCL)
- Medial and Collateral ligaments
Which 2 Rheumatolgic Diagnoses are associated with Esophageal Dysmotility?
Systemic Scerlorsis and Dermatomyositis
What should patients be started on when they are starting Steroid medication for >7.5mg per day for at least 3 months?
Bisphosphenate therapy. (Aledronate or Riserdronate)
Associated with foot drop and steppage gait. Occurs after prolong hospitalization, trauma or leg casting. Dx?
Common Peroneal Nerve Injury
Name the cause of the shoulder pain:
- Pain with w/ abduction, External rotation, normal range of motion with positive impingement test (Neer, Hawkins)
- WEAKNESS with Abduction of Arm and external rotation, age > 40
- Decreased passive & active ROM,
Stiffness > Pain - Anterior Shoulder pain, pain with lifting, carrying, over head reaching
- Rotator Cuff Impingement or Tendinopathy
- Rotator Cuff Tear
- Adhesive Capsulitis
- Biceps Tendinopathy/Rupture
What are the WBC ranges:
- Noninflammatory OA
- Inflammatory ( Crystals, RA)
- Septic Joint
- 200-2000
- 2000-100,000
- 50,000-150,000
Common Injuries of the Knee:
- Common in Female Runners, Localized Anterior Knee pain, Pain with Squatting
- Poorly localized Lateral KneePain, Tenderness at Lateral Femoral Epicondyle with flexion and extension
- Highly Localized Medial Knee Pain. Seen in OA and DM.
- Localized Pain in Inferior Patella. Tenderness at the Insertion of the Tendon. Common in jumping Sports
- Anterior Knee bogginess & Tenderness. Propensity to Secondary infection with S. Aureus. Common with people who work on Knees
- Seen in Obese individuals or Wearing Tight fitting clothing. Lateral thigh tingling/numbness.
- Patellofemoral Syndrome
- Iliotibial band Syndrome
- Pes Anserine Bursitis
- Patellar Tendinopathy
- Patellar Bursitis
- Meralgia Paresthetica
Name the foot and ankle diagnosis:
- Insidious Onset, Focal pain in Navicular or Metatarsals. Due to Abrupt increase in intensity of training, Poor running Form, female with Eating Disorder
- Pain at the plantar surface of the heel, Worse with taking the First Few Steps
- Burning pain or Stiffness 2-6cm above the posterior calcaneus
- Numbness OR Pain between the 3rd & 4th toes. Clicking sensation when palpating space between 3rd & 4th toes while squeezing the metatarsal joints
- Compression of the tibial nerve at the Ankle. Burning numbness & aching of the distal plantar surface of the foot/toes
- Stress Fracture
- Plantar Fasciitis
- Achilles Tendinopathy
- Moron Neuroma
- Tarsal Tunnel Syndrome
What is important to check with a patient with Giant Cell Arteritid?
DEXA to screen for Osteoporosis and Xray to screen for Thoracic Aneurysm.
Treatment for Lupus that involves life-threatening organ involvement. (lupus nephritis or lupus pneumonitis (pleuritic CP and infiltrate)
Hydroxychloroquine + mycophenolate or IV cyclophosphamide.
