Rheum Flashcards
1
Q
Pathophys of osteoarthritis?
A
Loss of articular cartilage leading to erosive damage to joint surfaces
2
Q
DIP enlargement in osteoarthritis?
A
Herberden nodes (prominent osteophyte)
3
Q
PIP enlargement in osteoarthritis?
A
Bouchard nodes
4
Q
Most accurate test OA?
A
Radiography
5
Q
Best initial treatment OA
A
Weight loss/moderate exercise AND acetaminophen (best initial analgesic)
6
Q
Causes of Gout?
A
Overproduction (Idiopathic, Increased cell turnover (malignancy, chemo, hemolysis, psoriasis), or enzyme deficiency (Lesch-Nyhan and glycogen storage dz)
7
Q
Most accurate test for gout vs pseudogouth?
A
Arthrocentesis showing needle-shaped crystals with negative birifringence. Pseudogout-rhomboid with positive birifringence
8
Q
Tx. for acute vs chronic gout?
A
Acute-1) NSAIDs 2) Corticosteroids (injection if one and oral if multiple) 3) Colchicine
Chronic-1) Diet, colchicine, allopurinol, febuxostat, probenicid
9
Q
Side effect colchicine?
A
Neutropenia and diarrhea
10
Q
Best BP drug for gout?
A
Losartan. Lowers uric acid
11
Q
Most common risk factors of pseudogout?
A
Hemochromatosis, hyperparathyroidism
12
Q
Best initial/most accurate test hemochromatosis?
A
Best initial: Serum iron, Most accurate: Genetic test (HPE) or biopsy
13
Q
Best initial therapy vs prophylaxis pseudogout?
A
Best initial-NSAIDs, Prophylaxis-colchicine
14
Q
Epidural abscess abx treatment
A
MRSA-Vanco/linezolid
MSSA-Oxacillin, nafcillin, cefazolin
15
Q
Management of neurologic deficits with abscess?
A
IV glucocorticoids; surgical decompression if not effective
16
Q
Most common level of disc herniation and tx.?
A
L5-S1. NSAIDs and CONTINUATION OF ORDINARY ACTIVITIES!!!! (no bed rest!!!))
17
Q
Best initial/most accurate test for compression, infection, herniation, and fractures?
A
Best initial-plain x-ray
Most accurate-MRI
18
Q
L4 herniation deficit, loss of sensation, and reflex affected?
A
Deficit is loss of foot dorsiflexion, loss of sensation inner calf, and knee jerk affected
19
Q
L5 herniation deficit, loss of sensation, and reflex affected?
A
Deficit is loss of toe dorsiflexion, loss of sensation inner foot, and no reflex affected
20
Q
S1 herniation deficit, loss of sensation, and reflex affected?
A
Deficit in loss of foot eversion, loss of sensation outer foot, and ankle jerk reflex affected
21
Q
Bilateral leg weakness, saddle area anesthesia and bowel/bladder incontinence with ED and tx?
A
Cauda equina, surgical decompression
22
Q
Pain that worsens with rest and improves with activity/exercise with decreased chest mobility
A
Ankylosing spondylitis
23
Q
Management of epidural abscess?
A
1) Vancomycin as empiric therapy
2) Switch it oxacillin if sensitive and drain if the infection is large enough to produce deficits or it does not respond to antibiotics alone
* management similar to endocarditis management
24
Q
Best next step with obvious cord compression?
A
BEGIN STEROIDS!!
25
What should you not do in patients without focal neurological abnormalities or with simple lumbosacral strain?
IMAGING STUDIES!
26
Best initial/most accurate spinal stenosis?
MRI
27
Tx. spinal stenosis?
1) Wt. loss and pain meds (NSAIDs, opiates, aspirin)
2) Steroid injections
3) Surgical correction dilate spinal canal (needed in 75% of patients)
28
Tx. fibromyalgia?
TCAs (amitriptyline), pregablin, milnacipran (SNRI). Gradual incremental low impact exercise can help
29
Most accurate test carpal tunnel?
Electromyography + nerve conduction testing
30
Pathogenesis and tx. of dupuytren contracture?
Pathogenesis-hyperplasia of palmar fascia
| Tx.-Triamcinolone, lidocaine, or collagenase injection may help. Surgical release with impaired function
31
How do you differentiate rotator cuff tendinopathy/impingement vs rotator cuff tear?
Tendinopathy and impingement respond to lidocaine injection and tear does not!
32
Most accurate test rotator cuff injury?
MRI
33
Tx. rotator cuff injury?
1) NSAIDs, rest, physical therapy
2) Steroid injection
3) Surgery (complete tear)
34
Management of patellofemoral syndrome?
Physical therapy and strength training with cycling
35
How to differentiate tarsal tunnel vs. plantar fasciitis?
Tarsal tunnel-pain worsens with use
| Plantar fasciitis-pain better with use
36
Classic hand deformities of RA?
Boutonniere and swan neck
37
What is felty syndrome?
RA, splenomegaly, neutropenia
38
What is caplan syndrome?
RA, pneumoconiosis, lung nodules
39
MCC death in RA?
CAD
40
Diagnostic criteria RA based on point system
Total of 6 or more =RA; Joint involvement (up to 5 points), ESR or CRP (1 point), Duration>6 weeks (1 point), and RF/anti-CCP (1 point)
41
Patient with RA needs surgery. What imaging you need prior to surgery?
Cervical spine x-ray. RA associated with C1/C2 subluxation
42
3 criteria that characterize "erosive" disease in RA?
Joint space narrowing, physical deformity, x-ray abnormality
43
Best initial DMARD for RA and adverse effects?
Methotrexate. Liver toxicity, pulmonary toxicity, bone marrow suppression, macrocytic anemia.
44
1st line for those not responding to methotrexate or intolerant?
TNFalpha inhibitors
45
Used in combination with methotrexate if not responding to anti-TNF medications?
Rituximab
46
DMARD in mild disease if hoping to avoid toxicity of methotrexate and what is this toxicity of this drug?
Hydroxychloroquine, toxic to retina (do dilated eye exam every 6 months)
47
Side effect sulfasalazine?
bone marrow toxicity, G6PD hemolysis, rash
48
Best initial symptomatic control for RA?
NSAIDs/steroids. Do nothing in preventing progression of disease and can help while waiting for DMARD to take effect
49
Adverse effects rituximab?
Infection
50
Adverse effects gold salts?
Nephrotic syndrome
51
Feature of JRA?
Often only with fever spikes (>104), "salmon" colored rash, and on chest and abdomen. Other features include splenomegaly, pericardial effusion, and mild joint symptoms.
52
Tx. of JRA?
1) NSAIDs/aspirin
2) Steroids
3) TNF-alpha drugs
53
6 of 11 needed for SLE diagnosis (list them)?
RASH OR PAIN (Rash (malar or discoid), Arthritis, Soft tissue/serositis, Hematologic (cytopenias), Oral/nasopharyngeal ulcers, Renal disease or raynaud phenomenon, photosensitivity or positive VDRL/RPR, ANA, Immunosuppressants, Neurologic (psychosis, seizure, stroke from vasculitis)
54
What is required for all new onset lupus nephritis?
Renal biopsy b/c treatment differs.
55
Most common glomerulonephritis in SLE?
Membranous
56
Best initial test SLE?
ANA
57
Young patient/old patient MCC death SLE?
Young with infection, old with accelerated atherosclerosis (eg MI)
58
Tx. acute lupus flare vs lupus nephritis
- High-dose bolus of steroids
| - Steroids alone or in combination with cyclophosphamide or mycophenolate
59
Pathophys of antiphospholipid syndrome and presentation
IgG or IgM antibodies made against negatively charged phospholipids. Present with thromboses of both arteries and veins as well as recurrent spontaneous abortions.
60
2 types of antiphospholipid antibody syndrome
Lupus anticoagulant-most often associated with INCREASED PTT, Anticardiolipin antibodies-most often associated with spontaneous abortion
61
Best initial/most accurate APL antibody syndrome?
Best initial: mixing study (APL shows elevated PTT), Most accurate: russell viper venom (prolonged with APL antibodies)
62
Prophylaxis to avoid pregnancy loss?
Low dose aspirin and LMWH
63
Diffuse vs limited (CREST) scleroderma test antibodies?
Diffuse-ANA and anti-scl 70 (anti-DNA topoisomerase I)
| Limited-ANA and anti-centromere Ab
64
Tx. slowing disease process, renal crisis, esophageal dysmotility, raynaud, pulmonary fibrosis?
Slowing disease process (methotrexate), renal crisis (ACEi even with INCREASE creatinine), esophageal dysmotility (PPI), Raynaud (ca2+ blocker), pulmonary fibrosis (cyclophosphamide)
65
Best initial/most accurate dermatomyositis/polymyositis?
Best initial: CPK/aldolase. Most accurate: muscle biopsy
66
What antibodies associated with lung fibrosis in dermatomyositis/polymyositis?
Anti-Jo antibodies.
67
Tx. dermatomyositis/polymyositis?
Steroids usually sufficient. When unresponsive, use methotrexate, azathioprine, IVIG, or mycophenolate, hydroxychloroquine (helps with skin lesions)
68
Most dangerous complication of Sjogren
Lymphoma
69
Best initial/Most accurate Sjogren and what does it show?
Best initial-Schirmer test (looks for amount of tears and wetness of filter paper), Most accurate-lip or parotid gland biopsy (lymphoid infiltration of salivary glands)
70
Best initial therapy Sjogren
Water mouth and use fluoride treatment and artificial tears, pilocarbine and cevimeline increase acetylcholine, main stimulant to production of saliva.
71
What is mononeuritis multiplex?
multiple peripheral neuropathies of nerves large enough to have a name
72
Clinical features/most accurate test of PAN?
-Small/medium vessel vasculitis that inexplicably spares lungs. Most common neurological abnormality is foot drop and look for stroke in young person. Associ with Hep B/C. Biopsy of site is most accurate test
73
Tx. PAN?
Prednisone and cyclophosphamide
74
PMR vs. Polymyositis/Dermatomyositis?
Similar presentation, but CPK and aldolase normal in PMR and markedly elevated ESR>100 in PMR
75
Best initial/most accurate wegener granulomatosis?
Best initial-ANCA (C-anca=anti-proteinase 3 Ab), most accurate-biopsy (specifically lung as most accurate)
76
Tx. wegener?
Prednisone/cyclophosphamide
77
Churg-Strauss presentation?
Pulmonary-renal syndrome with asthma and eosinophilia
78
Biopsy of HSP?
Leukocytoclastic vasculitis
79
If cause of arthritis is in doubt, what do you do?
Obtain radiograph and aspirate fluid
80
Septic arthritis most common organism?
S. aureus except in sexually young adults, most common pathogen is N. gonorrhoeae
81
Most common joint affected in ankylosing spondylitis and triad?
Sacroiliac joints; ankylosis (stiff spine), uveitis, aortic regurg
82
First line tx. psoriatic arthritis
NSAIDs
83
Tx. of hemophilia induced arthritis?
Acetaminophen. Avoid nsaid/aspirin b/c bleeding concern
84
Define charcot joint. Clues to presence?
Most commonly in diabetes but seen in other mononeuropathies. Lack of sensation and overuse/misuse of joints that can become deformed and painful
85
Takayasu arteritis presentation and tx.
Granulomatous narrowing of arotic arch and accessory vessels. Pulseless disease with WEAK upper extremity pulses. If carotid involved, can cuase stroke. Tx. steroid
86
Behcet syndrome presentation and tx.
20s, male, oral and genital ulcers. May have uveitis, arthritis, and other skin lesions (especially erythema nodosum). Tx. Steroid
87
What condition associated with temporal arteritis?
Polymyalgia rheumatica
88
Pediatric patient with uveitis and inflammatory arthritis, but negative RF. What disease?
RA
89
Primary vs. Secondary Raynaud tx.
Primary-CCB
| Secondary-CCB and aspirin if risk for digital ulceration
90
Leflunomide MOA and toxicity?
-Pyrimidine synthesis inhibitor, hepatotoxicity, cytopenias
91
TNF alpha inhibitors toxicity?
Infection, demyelination, CHF, malignancy, TB reactivation
92
Main 2 causes avascular necrosis? and pneumonic for all
Steroid/alcohol use. ASEPTIC (Alcohol, Sickle cell, Endogenous steroids, Pancreatitis, Trauma, Idiopathic, Caisson ("the bends")
93
Cryoglobulinemia vs. Cold agglutinin (Associations, manifestations, treatment). Both are IgM antibodies
Cryglobulinemia-assoc with hep c, manifested with joint pain (arthralgias), glomerulonephritis, palpable skin lesions, peripheral neuropathy, tx. inteferon, ribavirin, and either telaprevir or boceprevir
Cold agglutinin-EBV, mycoplasma, lymphoma, manifests as hemolysis, tx. stay warm, rituximab, cyclophosphamide, cyclosporine
94
Diagnosis of cryoglobulinemia?
Decreased C4, Increased RF, Increased AST/ALT, increased cryoglobulins
95
Presentation and diagnosis Behcet
Young turkish, middle eastern, asian with recurrent oral apthous ulcers +2 of following (recurrent genital lesions, eye lesions (leading to uveitis and blindness), anterior/posterior uveitis, retinal vascularization, erythema nodosum, + pathergy, acneiform lesions)
96
Best initial/most accurate ankylosing spondylitis?
Best initial-SI joint x-ray
| Most accurate- MRI
97
Ankylosing spondylitis and IBD may occur in assocation. What lab value are they assoc with?
P-ANCE despite absence of vasculitis
98
Best initial tx ankylosing spondylitis?
NSAID/exercise program. If not sufficient, anti-TNF drug (etanercept, adalimumab, inflixamab)
99
Best initial test psoriatic arthritis?
X-ray involved joint
100
Best initial treatment psoriatic arthritis?
1) NSAIDS, 2) Methotrexate 3) Anti-TNF, NO STEROIDS
101
Best initial treatment reactive arthirits?
1) NSAID 2) Sulfasalazine
102
Best initial therapy osteoporosis
1) Vitamin D/calcium
| 2) Bisphosphonates T score
103
What is teriparatide and side effects?
Parathyroid hormone analogue to stimulate bone matrix formation. Caused osteosarcoma and hypercalcemia
104
Incidence of septic arthritis is worse with what?
Joint damage (Joint replacement>RA>OA) for risk of damage
105
Best initial and most accurate for Septic arthritis test and empiric therapy?
Test-aspiration
| Tx-IV cefriaxone and vancomycin
106
Management of septic prosthetic joint?
Remove, abx 6-8 weeks, replace
107
Difference btwn gonococcal arthritis and septic arthritis? How do you manage cultures?
Gonococcal has polyarticular involvement, tenosynovitis (inflammation of tendon sheaths, making finger movement painful), and petechial rash. Need to have multiple diffuse sites of culture such as pharynx rectum urethra and cervix
108
Best initial tx disseminated gonorrhoeae?
Ceftriaxone, cefotaxime, ceftizoxime
109
What should you test for if gonorrhoea infection described?
Terminal complement deficiency
110
Best initial/most accurate test osteomyelitis?
Best accurate-xray, most accurate biopsy
111
Features of all spondyloarthropaties?
-Age >40, men, involvement of spine and large joints (sacroiliac), negative RF (seronegative), enthesopathy, uveitis, HLA B27, > 3mnoths
112
Triad of disseminated gonococcal infection?
Polyarthralgias, tenosynovitis, and vesiculopustular skin lesions generally without genital signs of venereal disease
113
Side effects cyclophosphamide?
Hemorrhagic cystitis, bladder carcinoma, sterility, and myelosuppression
114
Complication of giant cell arteritis and management?
Aortic aneurysm. Need serial CXR
