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Clinical Medicine I > Rheum > Flashcards

Rheum Flashcards

1
Q

What does RA cause?

A

A deterioration of joints from inflammation

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2
Q

What are key initiators of RA pathogenesis?

A

T lymphocytes

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3
Q

What is the shared epitope among patients with RA?

A

HLA-DRB

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4
Q

What are the clinical manifestations of RA?

A

Synovitis
Rheumatoid Nodules
Joints and specific organs are affected
Cardiac complications

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5
Q

What area of the body is never involved in RA?

A

Lower back

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6
Q

Is RA mono or poly -articular?

A

Polyarticular

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7
Q

What is not involved in RA?

A

trauma to the joints

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8
Q

Are joints symmetrically or asymmetrical affected in RA?

A

Symmetrically however, it may start as asymettrical

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9
Q

What are rheumatoid nodules?

A

SQ nodules that are present on pressure points

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10
Q

What joints are effected in RA?

A 
Cervical Spine
Shoulders 
Elbow
Hand and Wrist
Hip
Knee
Foot and Ankle
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11
Q

What organs are effected by RA?

A 
Lungs --> excess fibrous CT
Eye
Skin
Heart --> pericardial effusion
Nervous System 
Blood --> hypochromatic-microcytic anemia
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12
Q

What are some cardiac complications of RA?

A 
MI
Disambiguation
Stroke
Atherosclerosis
Pericarditis
Endocarditis
Left Ventricualr Heart Failure 
Vasculitis
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13
Q

What is the screening test for RA?

A

ANA positive

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14
Q

What is RF negative RA called?

A

Seronegative

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15
Q

Which RA autoantibody is more diagnostic of RA?

A

Anti-CCP

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16
Q

What is Domain 1 of RA diagnostic criteria?

A

Joint Involvement

Max of 5 points

1 md. - lg. joint --> 0 
2-10 md. to lg --> 1
1-3 small --> 2
4-10 small --> 3
> 10 small --> 5
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17
Q

What is domain 2 of RA diagnostic criteria?

A

Serology

Max of 3 points

Neg. Rh and Anti-CCP –> 0
One positive at low titer, < 3X normal –> 2
One positive at high titer, > 3X normal –> 3

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18
Q

What is domain 3 of RA diagnostic criteria?

A

Duration of synovitis

Max 1 point

< 6 weeks –> 0
> 6 weeks –> 1

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19
Q

What is domain 4 of RA diagnostic criteria?

A

Acute phase reactants

Max 1 point

Neg. CRP or ESR –> 0
Abnormal CRP or ESR –> 1

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20
Q

What is the diagnostic Criteria for RA?

A

patient must get 6 points in order to definitvely diagnosis RA

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21
Q

What is Felty Syndrome?

A

Triad of:

RA
Neutropenia
Splenomegaly

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22
Q

What is Polymyalgia Rheumatica?

A

Pain in proximal muscles

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23
Q

What are the clinical presentations of Polymylagia Rheumatica?

A

General aches and pains and stiffness
“trouble getting dressed”
Pain greater in the morning
Strength is intact but it will exacerbate pain

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24
Q

What is the best test for diagnosing Polymyalgia Rheumatica?

A

ESR

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25
Q

What is the treatment for Polymylagia Rhematica?

A

Oral Prednisone in high doses

Temporal artery biopsy

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26
Q

What causes Reactive Arthritis?

A

Occurs post infection with Chlamydia, Campylobacter, Salmonella, Shigella, and Yesinia

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27
Q

What is the classic Triad of Reactive Arthritis?

A

Noninfectious Urethritis
Arthritis
Conjunctivitis

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28
Q

How do you treat Reactive Arthritis?

A

Treat symptoms and the underlying infection:
Antibiotics
NSAIDs
Corticosteroids
DMARDs –> only if NSAIDs and corticosteroids are ineffective; methotrexate or SULFASALAZINE (for GI)

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29
Q

What is anterior Uveitis?

A 
Red Eye
Pain worsens when reading
Progressive and occurs over a few hours
Blurred vision
Photophobia
Excess tear production
Abnormally shaped pupils
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30
Q

What are the clinical manifestations of Juvenile Idiopathic Arthritis?

A

< 16
Arthritis in one or more joints
Duration of disease > 6 weeks
Joint inflammation, contractures, and joint damage
Periods of no symptoms and then quick onset of symptoms

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31
Q

What is Systemic Onset JIA?

A

Repeated fevers of 103 with fluctuating slamon collor rash
Inflammation of the intenral organs and joints
Anemia
Leukocytosis

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32
Q

What is polyarticular JIA?

A

Arthritits in 5 or more joints with major symptoms of pain in the knees, ankles, wrists, and fingers
Constant pain

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33
Q

What is Oligoarticular JIA?

A

Arthritis in 4 or fewer joints withint the first 6 months of onset
50% of kids
F>M
Those diagnosed before age 7 have the best change of disease subsiding
High risk of uveitis
Large joints are effected

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34
Q

What is enthesis related JIA?

A

Involves ligaments as well as the spine

Aka Spondyloarthritis

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35
Q

What are the diagnostic tests for JIA?

A

Positive ANA
Synovial fluid Class II inflammatory
X-rays show soft tissue swelling, periarticular osteoporosis, growth disturbances, and loss of joint space

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36
Q

What are the three Inflammatory Myopathies?

A

Polymyositis
Dermatomyositis
Inclusion Body Myositis

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37
Q

What are the clinical manifestations of Polymyositis?

A

Proximal muscle weakness and upper and lower limbs bilaterally
Difficulty raising arms, lifting objects, or combing hair
Trouble climbing stairs and getting up from sitting

Systemic Symptoms:
GI –> dysphagia, bloating, and constipation
Cardiac –> arrhythmias and condition defects
Pulmonary –> Aspiration pneumonia, INterstitial lung disease, and bronchiolitis
Renal –> ATN

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38
Q

What diagnostics are abnormal in Polymyositis?

A

Leukocytosis
Elevated CK and LDH
ANA and myositis antibodies

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39
Q

What is the treatment for Polymyositis and Dermatomyositis?

A

There is no cure!

Corticosteroids for inflammation –> Prednisolone 1mg/kg/day for 4-8 weeks
Monitor CK levels and muscle strenght

Immunosuppresive agents --> Only give these if there is no repsone to steroid within 4 weeks of treatment or if there are extra-skeletal manifestations
Azathioprine
Cyclophosphamide
Chlorabucil
Cyclosporine
IVIG
INflixumab
Rituximab
Diet
Consults
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40
Q

What are the clinical manifestations of Dermatomyositis?

A

Heliotrope Rash –> purple discoloration on upper eyelids, flat red rash on cheeks and upper trunk

Grotton’s papules –> raised violaceous scaly rash on knuckles

Dilated capillary loops at the base of the fingernails

irrgular cuticles

“dirty” horizontal lines that resemble mechanics hands after a day of work

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41
Q

What does a muscle biopsy reveal in patients with Dermatomyositis?

A

Perivascular and perimysial inflammation

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42
Q

What are the clinical manifestations of Inclusion Body Myositis?

A

Asymmetrical weakness
Falling is common due to quadriceps weakness and artophy
Facial muscle weakness but not ocular
Weakness and atrophy of distal muscles, especially the foot extensors and deep finger flexors
Cannot tie a knot or hold a gold club
Dysphagia and choking
Progresses slowly over the years

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43
Q

What is the treatment for Inclusion Body Myositis?

A

Resistant to Immunotherapy so give –>

Azathioprine + Prednisolone for a few months

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44
Q

What are tophi?

A

Deposits of uric acid crystals into tissues

45
Q

What are the risk factors for Gout?

A 
Men
Women after menopause
People with kidney disease
Obesity
HTN
Hyperlipidemia
Diabetes
Family History
46
Q

What is primary Gout?

A

inherited

47
Q

What is secondary gout?

A

acquired

48
Q

What does underexcretion cause in gout and what is it caused by?

A

increased uric acid levels in the blood

Causes by clinical renal disorders like renal insufficiency or a decreased GFR

49
Q

What is overproduction in gout caused by?

A

Excessive dietary purine intake from red meat, organ meat, or shellfish

Alcoholic beverages especially beer

50
Q

How do we diagnose Gout?

A

Arthrocentesis –> will show intracellular uric acid crystals with negative birefrinence under polarized light microscopy
Elevated serum uric acid levels > 6.8 –> not if only finding though
24 hour urine –> underexcretors with have normal levels and overproducers will have elevated levels

51
Q

What are common trigger point areas of Fibromyalgia?

A 
Occiput
Low cervical
Trapezius
Supraspinatus
2nd rib
Lateral epicondyle
Medial fat pad of the knee
Greater trochanter
Upper glute
52
Q

What diseases are large vessel vasculitis?

A 
Giant Cell (temporal) arteritis
Takayasu Arteritis
53
Q

What are the effects of large vessel vasculitis?

A 
Limb claudication
Assymetric blood pressures
Absence of pulses
Bruits
Aortic dilation
54
Q

What diseases are medium vessel vasculitis?

A 
Polyarteritis Nodosa (PAN)
Kawasaki
55
Q

What are the effects of medium vessel vasculitis?

A 
Cutaneous nodules
Palpable purpura
Livedo reticularis 
Digital gangrene
Mononeuritis multiplex
Acute foot/wrist drop 
Microaneurysms
Abdominal pain
Decreased appetitie
56
Q

What disease are small vessel vasculitis?

A 
Microscopic Polyangitis (MPA)
Granulomatosis with Polyangitits (Wegener's)
IgA Vasculitis (henoch-schonlein)
57
Q

What are the effects of small vessel Vasculitis?

A 
Palpable purpura
Vesiculobullous lesions
Urticaria
Glomerulonephritis 
Alveolar hemorrhage
Splinter hemoorhahes
Uveitis
Episcleritis
Scleritis 
Cutaneous extravascular necrotizing granulomas
58
Q

What is the diagnostic criteria for Temporal Arteritits?

A

presence of 3/5 of the following:

> 50 at onset
New onset localizaed headache
Tenderness or decreased pulse of temporal artery
ESR > 50
Biopsy revelas necrotizing arteritis with predominance of mononuclear cells or a granulomatosus process with multinucleated giant cells

59
Q

What is the diagnostic criteria for Polyarteritis Nodosa (PAN)?

A

3 of the following:

Otherwise unexplained wt. loss greater than 4 k
LIvedo reticularis
Testicular pain or tenderness
Myalgias (excluding hip or shoulder)
Weakness of leg muscles
Tendnerss of leg muscles
New onset diastolic BP > 90
Elevated levels of BUN
Biopsy of small or medium sized arteries contains polymorphonuclear cells
Mononeuropathy or polyneuropathy
60
Q

What is the diagnostic criteria for Kawasaki’s?

A

Presence of fever > 5 days wihtout any other explaination with at least 4/5 of the following:

Bilaterally bulbar conjunctival injection
Oral mucous changes, including injected pharynx or fissured lips, or strawberry tongue
Peripheral extremity changes including erythema of palms/soles, edema of hands and feet, and periungal desquamation
Polymorphous rash
Cervical LAD

61
Q

What is the diagnostic criteria for IgA Vasculitis?

A

MANDATORY TO HAVE PURPURA WHICH IS PALPABLE AND IN CLUSTERS

Must have one or more of the following:
Abdominal pain that is usually diffuse with acute onset
Arthritis or arthralgia that is acute onset
Renal involvment of proteinuria or hematuria
Leukocystoclastic vasculitis or proliferative glomerulonephritis with predominant immunoglobulin A deposition

62
Q

What are the constitutional symptoms of SLE?

A

FATIGUE
fever
LAD
UNintentional wt. loss or gain

63
Q

What are the skin/Rash symptoms of SLE?

A 
Malar rash 
Discoid rash
Bullous lesions
patchy or diffuse alopecia
Photosensitivity
Panniculitis
Palpable purpura
Raynaud's
Livedo reticularis
Childbain lupus
64
Q

What are the ocular symptoms of SLE?

A 
Conjunctivitis
Sicca symptoms
Photophobia
Blindness
Retinal Vasculitis
Optic Neuritis
65
Q

What are the MSK symptoms of SLE?

A 
Symmetrical arthritis
Polyarthritis
Nonerosive arthritis
Jaccoud's arthropathy
Myalgia
AVN
66
Q

What are the heart symptoms of SLE?

A 
Pericarditis
Myocarditis
Premature atherosclerosis
Conduction system abnormalities
Libman-Sacks endocarditis
67
Q

What are the lung symptoms of SLE?

A

Dyspnea or pleuritic CP suggestive of pleuritis
Pneumonitis
Pulmonary HTN
Diffuse alveolar hemorrhage

68
Q

What are the GI symptoms of SLE?

A 
Peritonitis
Hepatitis
Pancreatitis
Mesenteric vasculitis
Intestinal pseudo-obstruciton
69
Q

What are the GYN symptoms of SLE?

A

history of miscarriages

70
Q

What are the kidney symptoms of SLE?

A 
Proteinuria
LE edema
HTN
Glomerulonephritis
ARF
Interstitial nephritis
Antiphospholipid nephropathy
71
Q

What are the blood symptoms of SLE?

A

Anemia of chronic disease
Leukopenia
Thrombocytopenia
Arterial/venous thrombosis

72
Q

What are the neuropsych symptoms of SLE?

A 
Seizures
Headaches
Psychosis
Cognitive dysfunction
Peripheral Neuropathy
Myelopathy
73
Q

What are the four types of mucocutaneous lupus lesion patterns?

A

Acute cutaneous lupu Erytehmatous (ACLE)
Subacute cutaneous lupu Erythematosus (SCLE)
Chronic Lupus Erythematosus (CCLE)
Nonspecific

74
Q

What rashes are included in ACLE?

A

MALAR RASH = butterfly rash
maculopapular rash = areas that are photosensitive
Non-scarring alopecia

75
Q

What rashes are included in SCLE?

A

papulosquamous or annular
Scaly
Psoriaform
Most photosensitive
Occurs on torso and limbs and spares face
Anti-Ro and Anti-La positive
Induced by medications like HCTZ or terbinafine

76
Q

What rashes are included in CCLE?

A

Discoid lupus = raised, erythematou placques with adherent scale
Lupus panniculitis = deep, firm nodules with predilection for scalp, face, arms, buttocks, and thigh
Childbain lupus that resembles frostbite

77
Q

What are the nonspecific rashes that occur in SLE?

A 
Vasculitis
Purpura
Livedo Reticularis
Raynaud's
Alopecia
Urticaria
Nail-fold periungal capillaries
Bullous lesion
78
Q

What is the diagnostic criteria for SLE?

A

SOAP BRAIN MD

Must have presence of 4 of these criteria

79
Q

What is included in Serositis?

A

Pleuritis
Pericarditis

patients are 40X higher risk of MI and accelerated atherosclerosis

80
Q

What is Jaccoud’s arthroplasty?

A

patients with long standing SLE and they have joint deformities like Boutonniere’s or Swan neck but on x=ray there are no bony erosions

It is due to ligament laxity

81
Q

What blood disorders are common with SLE?

A

Hemolytic anemia with reticulocytosis

Leukopenia < 4000 on > 2 occasions

Lymphopenia < 1500 on > 2 occasions

Thrombocytopenia < 100,000 on > 2 occasions in the absence of offending drugs

Get COOMBS workup

82
Q

What renal disorders are common with SLE?

A

Persistent proteinuria > 0.5 grams/day or > 3+ on dipstick

Urine exam will show cellular casts that are either RBC, HgB, Granular, tibular, or mixed

83
Q

What is the optic diagnostic tool for lupus nephritis?

A

Renal biopsy

84
Q

What is the most frequent cause of death of patients with SLE?

A

Nephritis

Serum Creatinine > 2.4

85
Q

Which immunologic tests are best to diagnose SLE?

A

ANTI-dsDNA
ANTI-SM
COmplement = disease activity they will be low

86
Q

What neurological diseases are associated with SLE?

A

Seizures

Psychosis

87
Q

What drugs cause drug induced lupus?

A 
Hydralazine
Quinidine
Carbamazepine
Isoniazid
Methyldopa
Minocycline
Chlorpromazine
Procainamide
Phenytoin
INfliximab
Etanercept
Adalimumab
Simponi
Cimzia
88
Q

What is en coupe de sabre?

A

linear patch of scleroderma on scalp/face

89
Q

What is localized scleroderma?

A

Morphea - single or multiple patches of hard skin form on the trunk especially in kids and spontaneously disappear

Linear scleroderma - linear bands of hard skin across face, single arm, or leg

90
Q

What is sytemic Scleroderma?

A

Limited Cuteanous =80% of patients; CREST

Diffuse cutaneous = 20%; internal organs

91
Q

What are the phases of Sclerodactyly seen in scleroderma?

A

Edematous stage = shiny and loose skin folds
Inflammatory stage = Thickening continues; destroys normal sweat glands; intense itching
Atrophic Stage = very tight, joint contractures causing hands to come in

92
Q

What are the diagnostic criteria for Scleroderma?

A

Patient must have one major criteria or > 2 minor criteria:

Major –> Proximal scleroderma
Minor –> Sclerodactyly, digital ischemia with digital pitting scars or atrophy of finger pads, or bibasular pulmonary fibrosis

93
Q

What is the number 1 disease to kill patients with scleroderma?

A

lung disease

94
Q

Which type of scleroderma has worst prognosis?

A

Diffuse

95
Q

What is the pathogenesis behind Sjogren’s Syndrome?

A

Unknown trigger leads to vascular endothelial cells in the exocrine glands in genetically predisposed patients

Lymphocytes are attracted into the gland and are activated

Cytokines are released

Gland inflammation and destruction occur causing the sicca symptoms and parotid swelling

96
Q

What is primary Sjogrens?

A

Keratoconjunctivitus sicca and xerostomia

97
Q

What is secondary Sjogren’s?

A

Complication of anotehr systemic autoimmune disease like SLE, RA, or primary biliary cirrhosis

98
Q

What is the diagnostic criteria for Sjogren’s?

A

Ocular staining score of at least > 3

Biopsy of salivary glands showing lymphocytic sialadenitits

Positive Anti-Ro or Anti-La OR positive RF and Positive ANA

Patients must have 2 citeria

99
Q

What is Hypertrophic Arthritits?

A

Characterized by bone formation at the site of involved joint

Contained within the bone = subchondral sclerosis
Protrudes from the parent bone = Osteophytes

100
Q

What is erosive arthrittis?

A

RA

Indicates underlying inflammation

Characterized by tiny, marginal, irregularly shaped lytic lesions in or around the joint surfaces

101
Q

What is infectious arthritis?

A

Characterized by joint swelling, osteopenia, and destruction of long, contiguous segments of the articular cartilage

102
Q

What is primary degenerative arthritis?

A

Occurs on weight bearing joints such as hips, knees, humerus, feet, and hands

103
Q

What is secondary degenerative arthritis?

A

Post-traumatic infection

104
Q

What is erosive degenerative arthritis?

A

Associated with inflammation and synovial proliferation

105
Q

What are modifiable risk factors of osteoarthritis?

A

These cause susceptible joint

Muscle strength of quadriceps femoris
Physical activity/occupation --> constant use
Joint injury --> ACL tear increases risk
Joint alignment
Leg length inequality
106
Q

What is the strongest predictor of knee osteoarthritis progression?

A

Knee mal-alignment

107
Q

What are Modifiable Systemic Risk Factors for OA?

A

Obesity
Diet
Bone Metabolism

108
Q

What are non-modifiable risk factors of OA?

A

Age –> older
Sex –> WOmen
Genetics
Ethnicity

109
Q

What are the risk factors for Infectious Arthritis?

A 
IV drug use
Chronic Steroid use
Joint replacement
Recent joint trauma
Diabetes

Clinical Medicine I (15 decks)

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