Rheum Flashcards
MCC of joint degeneration
Osteoarthritis (DJD)
Where is DJD syptomatic
Weight bearing joints
What joints of the hand are most affected by OA
DIP
What are DIP enlargements in OA called
Heberden nodules
What are PIP enlargements in OA called
Bouchard nodules
Are there lab abnormalities in DJD
No
Most accurate test for DJD
Radiography of affected joint
XR findings in OA
Joint space narrowing
Osteophytes
Dense subchondral bone
Bone cysts
Most important rx in OA
Weight loss
Exercise
Best initial analgesic in OA
Acetaminophen
Other rx in OA
NSAIDS Capsaicin Intraarticular steroids Hyaluronan injection Joint replacement
Who gets gout
M>F
What causes overproduction of uric acid
Idiopathic
Increased cell turnover - cancer, hemolysis, psoriasis, chemo
Enzyme deficiency- lesch-nyan, GSDs
What causes underexcretion of uric acid
Renal insufficiency
Ketoacidosis, lactic acidosis
Thiazides and aspirin
Presentation of gout
Man, sudden excrutiating pain, redness, tenderness of big toe at night after binge drinking beer
Most frequently affected site in gout
MTP of great toe
Where do tophi most often occur (can occur anywhere)
Cartilage
SubQ tissue
Bone
Kidney
Most accurate test for gout
Aspiration of joint
Shows negatively birefringent needle shaped crystals under polarized light
WBC count in gout
2000-50000
Why tap the joint in gout
Exclude infection
What labs are gouty attacks associated with
Elevated, uric adic, ESR, leukocytosis
Best initial therapy of acute gouty attack
NSAIDs
When to give steroids in acute gout
No response to NSAIDs
Contraindication to NSAIDs
When to give Colchicine in acute gout
Can’t use NSAIDS or steroids
Colchicine AE
Diarrhea and BM suppression
Diet management of chronic gout
No EtOH
Lose weight
Less meat, seafood
What to use for HTN management in chronic gout
Lorsartan
Why give colchicine in chronic gout
Prevent subsequent attacks
Action of allopurinol
Decrease production of uric acid
Action of pegloticase
Dissolves uric acid
Gout drugs contraindicated in renal insufficiency
Probenecid
NSAIDs
Sulfinpyrazone
Action of probenecid and Sulfinpyrazone
Increase excretion of uric acid
Allopurinol AE
Toxic epidermal necrolysis
Stevens-Johnson
Hypersensitivity
Common risk factors for CPPD
Hemochromatosis
Hyperparathyroidism
Other associations w/ CPPD
DM
Hypothyroidism
Wilson
What does CPPD affect
Large joints
WBC count in DJD
200
Best initial therapy for CPPD
NSAIDs
What diseases to exclude in lower back pain
Spinal cord compression
Disk herniation
Features of spinal cord compression
Hx CA
Sudden onset focal neuro deficit
Point tenderness on spine w/ percussion
MCC epidural abscess
Staph aureus
Location for disk herniations
L4/5, L5/S1
Best initial test for disk herniation
Straight leg raise (very specific)
Effects of L4 loss
Motor - Dorsiflexion of foot
Reflex - Knee jerk
Sensory - Inner calf
Effects of L5 loss
Motor - Dorsiflexion of toe
Sensory - Inner forefoot
Effects of S1 loss
Motor - Eversion of foot
Reflex - Ankle jerk
Sensory - Outer foot
Best initial test for cancer w/ compression, infection, fractures
Plain XR
Most accurate test for cancer w/ compression, infection, fractures
MRI
MRI for lower back pain w/ SLR +
No
Back pain w/ Hx CA
Cord compression
Back pain w/ fever, high ESR
Epidural abscess
Back pain w/ bowel/bladder incontinence, ED
Cauda equina syndrome
Back pain under 40 worse at rest, improves w/ exercise
Ankylosing spondylitis
Back pain w/ pain/numbness of medial calf or foot
Disk herniation
Rx cord compression
Glucocorticoids (don’t wait for test results)
Rx cauda equina
Surgical decompression
Rx disk herniation
NSAIDS and continue regular activity
Steroid injection if that doesn’t work
Presentation of lumbar spinal stenosis
Over 60 Back pain on walking radiating to buttocks and thighs Worse when walking downhill Pulses NL Better when leaning forward
Dx test for lumbar stenosis
MRI
Rx lumbar stenosis
Weight loss, NSAIDs
Surgical dilation
Features of fibromyalgia
Young women
Tenderness w/ trigger pts at traps, medial knee, lateral epicondyle
Associations w/ fibromyalgia
Stiffness, numbness, fatigue
HA
Sleep disorder
Best initial therapy for fibromyalgia
Amitryptilyne
Other fibromyalgia treatments
Milnacipran and pregabalin
Causes of carpal tunnel aside from mechanical
Pregnancy DM RA Acromegaly Amyloidosis Hypothyroidism
Features of carpal tunnel
Pain in hand
Atrophy of thenar eminence
Worse at night
PE findings of carpal tunnel
Tinel sign
Phalen sign
Most accurate test for carpal tunnel
Electromyography
Nerve conduction testing
Best initial therapy of carpal tunnel
Wrist splints
Can give NSAIDs
Curative for carpal tunnel
Surgical decomression
What is dupuytren contracture
Hyperplasia of palmar fascia causing contracture of 4th and 5th fingers
Associations of dupuytren contracture
Genetic
Alcoholism and cirrhosis
Rx dupuytren contracture
Triamcinolone, Lidocaine, collagenase
Surgery if functionally impaired
Features of rotator cuff injury
Inability to flex and abduct shoulder
Worse when lying on it
Severe tenderness on insertion point of supraspinatus
Most accurate dx test for rotator cuff injurt
MRI
Rx rotator cuff injury
NSAIDS, rest, PT
Surgery for complete tears
Causes of patellofemoral syndrome
Trauma
Imbalance of quadriceps strength
Meniscal tear
Features of patellofemoral syndrome
Pain in front of knee
Worse when walking up and down stairs
Worse after prolongued sitting
Rx patellofemoral syndrome
PT and strength training
Features of plantar fasciitis
Pain at bottom of foot near calcaneus
Worse in morning, improves with steps
Point tenderness at insertion
Rx plantar fasciitis
Stretching
Arch supports
NSAIDs
Steroids if above fail
Presentation of RA
B/L symmetrical joint involvement Morning stiffness = inflammation Nodules Ocular sx Lung involvement Vasculitis Cervical joint involvement Baker cyst Pericarditis Carpal tunnel
What to screen for in RA before anesthesia/Intubation
Cervical involvement (C1, C2) Can cause para/quadriplegia
What joint is spared in RA
DIP
What are the hand deformities in RA
Boutonniere
Swan neck
What is related to poor prognosis in RA
High RF
More specific than RF in RA
Anti-cyclic citrulinated peptide (Anti-CCP)
What kind of anemia is in RA
Normocytic (can be AOCD)
Why do arthrocentesis in RA
Initially when Dx not clear
Can have 5000-50000 WBCs but no crystals so exclude gout
Dx criteria for RA (6 or more pts = RA)
Joint involvement (up to 5)
ESR/CRP (1)
Longer than 6wks (1)
RF or Anti-CCP (1)
Components of Felty syndrome
RA
Splenomegaly
Neutropenia (prone to G+ infection)
Components of Caplan syndrome
RA
Pneumoconiosis (interstitial lung disease)
Lung nodules
MCC death in RA
CAD
What is the purpose of DMARDs in RA
Stop progression
What is “erosive” RA
Joint space narrowing
Physical deformity
XR abnormalities
Best initial DMARD
MTX
MTX AE
Liver tox
BM suppression
Pulm tox
May cause flare
What to monitor w/ MTX
LFTs and CBC every 2-3 months
First line DMARD if MTX fails
TNF inhibitors
AE TNF inhibitors
Reactivation of TB
Infection
When to use Rituximab
Long term control
Anti-TNF fail
What does Rituximab do
Remove CD20 lymphocytes from circulation
When to use Hydroxychloroquine in RA
Monotherapy in mild disease
Hydroxychloroquine AE
Toxic to retina