rheum!

Question 1

50 year old woman w/ lethargy and fatigue for a year w/ symmetric swelling and tender MCP joints and wrists bilaterally >6 weeks. also has morning stiffness and subq nodules on forearms…dx….

Answer 1

RHEUMATOID ARTHRITIS!!!

-bilateral MCP and wrist involvement very common! esp w/ preceding lethargy and fatigue!!!

Question 2

feltys syndrome?

Answer 2

triad of RA, splenomegaly and leukopenia (dec PMN)

Question 3

RA testing…

Answer 3

pos RF in 2/3 and anti-ccp

Question 4

RA tx…

Answer 4

• *use nsaids and steroids for immediate relief while DMARDs starting to work!
  1. NSAIDS
  2. low dose prednisone 5-10 (dont go over 10 long-term)
  3. DMARD!!
  
  • methotrexta, sulfasalazine, leflunamide, hydroxychloroquine
    
    4. TNF inhib
    5. azathioprine, cyclophosphamide

Question 5

what do you give w/ methotrexate??

Answer 5

FOLIC ACID!!

-watch for hepatotox - can give as long as LFT not >180!

Question 6

contraindication w/ TNFinhib?

Answer 6

CHF!!!

Question 7

dry mouth and dry gritty eyes….

Answer 7

sjrogrens! destruction of lacrimal and salivary glands!

-do schirmer test and look for anti-ro antibodies!!

Question 8

acute onset painful, red, tender joint w/o hx of trauma….

Answer 8

GOUT!!!

*watch for in patients w/ diuretics!!!

Question 9

gout workup

Answer 9

ALWAYS GET ARTHROCENTESIS!!! LOOKING FOR NEGATIVELY BIREFRINGENT YELLOW NEEDLE-SHAPED CRYSTALS!!!

Question 10

gout tx

Answer 10

nsaids, colchicine, allopurinol, d/c diuretics

Question 11

pseudogout…

Answer 11

• a/w hemochromotosis

- BLUE RHOMBOID POSITIVELY BIREFRINGENT CRYSTALS !!!

Question 12

man skinned his knee..now red swollen, warm w/ 200,000 WBC and gluc 20…

Answer 12

ACUTE SEPTIC JOINT!!!

• watch for in patients w/ underlying joint dz i.e. RA w/ acute flare!!!
• WBC typically >50,000 (while gout is 2-50000)

Question 13

most common bug w/ septic arthritis?

Answer 13

always get gram stain and culture! #1 is s. aureus!! (rarely see s. pneumo or ecoli - beta hemolytic strep #2)

Question 14

fibromyalgia pres….

Answer 14

• widespread m/s pain w/o evidence of joint / muscle abnl on exam w/ sig fatigue / lethargy and sleep problems
• patients complain of dropping things and subjective weakness, BUT NO OBJECTIVE WEAKNESS FOUND ON EXAM (oppositive of poly and dermatomyositis which have prox weakness and less pain!!!)
• tender points on xam!

Question 15

fibromyalgia dx…

Answer 15

11/18 tender points w/ nl ESR and CRP (PMR has increased ESR), normal muscle enzymes (increased w/ poly and dermatomyositis)

Question 16

fibromyalgia tx….

Answer 16

• TCA at bedtime, aerobic therapy

* NSAIDS, ASA, colchicine DO NOT HELP!!!!

Question 17

polyarteritis nedosa…pres..

Answer 17

-hits small and medium vessels
NO LUNG INVOLVEMENT!!!
-HTN + rashes / lesions + neuropathy + abnl urinary sediment + abdominal pain + constitutional sx

Question 18

w/ multisystem dz w/ recurrent genital and oral ulcers and DVT…..disease?

Answer 18

Behcets!!

Question 19

-gradual onset bilateral knee pain, relieved w/ rest, with crepitation, mildly warm w/ small effusions and bony enlargement of knees and DIP……

Answer 19

OSTEOARTHRITIS!!!!

Question 20

OA tx…

Answer 20

1. NSAIDS - naproxen w/ cv rf!
2. tylenol - use w/ GI risks
3. capsaicin
4. methylsalicylate - topical nsaid
5. diclofenac (prescription)
6. joint injections 2-3 x year
7. joint replacement

Question 21

seronegative spondyloarthropathies….

Answer 21

• ANA and RF negative, HLA B27 positive!
  1. ankylosing spondylitis - fast response to nsaids
  2. psoriatic arthritis
  3. reactive arthritis (response to GI / GU infection)and reiters
  4. enteropathic / IBD

Question 22

young male w/ insidious back pain that is improved w/ exercise and worse at rest, limited lumbar flexion / extension w/ ant uveitis. sacroilitis on exam and sclerosis on lumbar xray…..dz?

Answer 22

ANKYLOSING SPONDYLITIS!!

• back pain better w/ exercise in young male
• ant uveitis = #1 extra articular sx!
• bamboo spine (sclerosis) on xray!
  tx: NSAIDS 1st line!
  - add TNF inhib w/ refractory / progressive

Question 23

pencil-in-cup hand deformity characteristic of…?

Answer 23

PSORIATIC ARTHRITIS!!

-tx: NSAID, prednisone, DMARD, TNF-inhib

Question 24

reiter syndrome….

Answer 24

young male w/ urethritis, uveitis, oligoarthritis

-more severe type of reactive arthritis – develops weeks after GI / GU infection

Question 25

young female w/ low grade fever, malar rash and migratory arthritis…..dz/

Answer 25

SLE!!!!

• can also see discoid rash, oral ulcers, raynaud, photosensitive, renal dz, seizures, thrombocytopenia and leukopenia
• if controlled and on <10 mg prednisone prego is safe

Question 26

most specific test for sle???

Answer 26

anti-dsdna!

Question 27

raynauds + arthritis + gerd and dysphagia….dz?

Answer 27

SCLERODERMA!!!

• excess collagen in small and medium vessels!
• pos ANA very specific!!

Question 28

temporal arteritis pres…

Answer 28

-headache and jaw claudication in elderly w/ increasing fatige, arthritis / PMR, transient vision loss

Question 29

temporal arteritis dx…

Answer 29

• high ESR

- temporal artery biopsy!

Question 30

temporal arteritis tx…

Answer 30

40-60 mg prednisone x 1 mo, then taper + ASA!

opposite of PMR which responds to low-dose 10-20 mg prednisone!