Rheum Flashcards
Which antibody should be done for lupus first?
The Anti nuclear antibody (ANA) is the most sensitive test for Lupus - it should be done first–>If negative, then it is probably not Lupus
Anti-double-stranded DNA and Anti-Smith antibodies are both specific for Lupus.
Which antibodies should be assessed for Rheumatoid arthritis?
Both the RF and the Anti-cyclic Citrullinated Peptide Antibodies should be assessed. If either is positive, as long as diagnostic criteria for RA is met, the patient has RA.
RF is more sensitive
Anti-CCP more specific
What must you do BEFORE starting a biologic such as infliximab?
Check for TB exposure
Screen for Hepatitis B and Hepatitis C
When is Probenecid used in the treatment of gout?
probenecid is used in under-excreters of uric acid
Urine studies will be shown that reveal low uric acid levels in the setting of repeated gout attacks.
Patient will be described as unable to use Allopurinol
When is Allopurinol used in the treatment of gout?
Allopurinol, a xanthine-oxidase inhibitor, is useful for controlling gout flares long-term
Indicated when there are two or more attacks of gout in a single year.
Goal is to lower uric acid levels to less than 6, which will hopefully reduce the frequency of gouty flares.
Don’t start it during an active flare
When is the treatment for gout flare?
Treatment is preferred in this order but will depend on contraindications:
1) NSAIDs- avoid if high bleeding risk
2) Colchicine- Dose limited diarrhea
3) Prednisone-
How will a pt with RA present?
bilateral, symmetric swelling of fingers that spare the DIPs
Morning stiffness
Hematologic findings (anemia) Bony erosions and periarticular osteopenia on XRays
What is psoriatic arthritis?
patient who have psoriasis and arthritis
Or test may say no rash but give nail pitting and arthritis
Either way:
nail pitting and arthritis = psoriasis;
psoriatic plaque + arthritis = psoriatic arthritis.
Two ways to get there.
tx with methotrexate
What is the management of rheumatoid arthritis?
Methotrexate is the drug of choice for initial therapy of RA, with additional DMARDs or biologics added if the disease progresses.
NSAIDs for symptomatic relief (never as monotherapy in RA)
Steroids for RA flares
Usually DMARD (MTX) & Biologics (rituximab) combo is best
What is the treatment for ankylosing spondylitis?
NSAIDs—meloxicam, naproxen, etc.— are the first step in medication therapy for patients with ankylosing spondylitis, especially when there is only axial involvement
if one NSAID doesn’t work, you should try another NSAID before moving onto the next line of defense: TNF-alpha inhibitors, like etanercept.
Nonbiologic disease-modifying anti-rheumatic drugs, (DMARDs), such as methotrexate, sulfasalazine, and hydroxychloroquine, are more helpful for peripheral disease.
What does arthrocentesis of gout look like?
Negatively birefringent needle-shaped crystals.
What does arthrocentesis of pseudogout look like?
Positively Birefringent Rhomboid-Shaped Crystals are for psueodgout.
What does arthrocentesis of septic arthropathy look like?
Gram positive cocci in clusters (Staph) or Gram Negative Diplococci (gonorrhea) would be a septic arthropathy
white blood cells >50,000 means septic arthritis
Managment of acute gout flare?
NSAIDs AND Colchicine is preferred for gouty flares. NSAIDs are contraindicated in kidney disease and bleeding. Colchicine is not preferred when used in a gout regimen 14 days before the flare, in AKI, or in bone marrow suppression.
If can’t give either then put them on short term prednisone
How is scleroderma renal crisis treated?
All you have to see is renal failure + scleroderma = ACE-inhibitor, such as Lisinopril
Carpal tunnel vs RA?
A seemingly clear case of carpal tunnel syndrome may actually be the initial presentation for rheumatoid arthritis, especially if bilateral.
What antibody will you see in drug induced lupus?
Anti-histone antibody
Think anti-Histone for Hydralazine
What antibody is associated with CREST (limited scleroderma)?
CREST (limited scleroderma) is associated with anti-centromere antibodies.
C- calcinosis R- Raynaud's E- esophageal dysmotility S- sclerodactyly T- telangiectasia.
What antibody is associated with Systemic Scleroderma?
Disseminated Systemic Sclerosis includes features of CREST but then goes deeper. It causes interstitial lung disease, renal disease, and will have an anti-topoisomerase antibody (also called Scl70).
Side effects of steroids?
low dose prednisone– osteoporosis
high dose prednisone–>Cushing’s syndrome–> obesity and diabetes
What antibodies is Sjogren’s syndrome associated with?
Sjogren’s syndrome presents with dry eyes (keratoconjunctivitis) and a dry mouth (xerostomia)
Associated with Ro and La antibodies.
Tx with eye drops and saliva replacement
What will the arthrocentesis of osteoarthritis show?
few white blood cells, no crystals, and no organisms.
What is enteropathic arthritis?
arthritis in patients with inflammatory bowel disease—usually UC more than Crohn’s
asymmetric arthritis
seronegative with an elevated ESR
Patients with ankylosing spondylitis and screening?
Patients with ankylosing spondylitis are at higher risk of fractures from even mild trauma. This can be easily and quickly assessed with a plain radiograph.
Septic arthritis due to gonorrhea
Septic arthritis in a patient who endorses unprotected sex is most likely due to Gonorrhea, even if the organism is not seen on initial gram stain and culture (hard to grow)
Perioperative evaluation of patients with RA
RA is systemic seropositive arthropathy that can also target the spine, specifically C1 and C2
So, perioperative evaluation of patients with RA must include an x-ray of the neck.
Golfer’s Elbow
Medial epicondylitis
Pain with resisted wrist flexion
Tender at medial epicondyle
Tennis Elbow
Lateral epicondylitis
Pain with resisted wrist extension and possible supination
Tender at lateral epicondyle
Winged scapula
Damage to the long thoracic nerve can cause serratus anterior dysfunction and a winged scapula
A common mechanism of injury is during mastectomy and axillary lymph node dissection.
Subacute Cutaneous lupus erythematosus and HLA Association
HLA-DR3
HLA-B8
Psoriasis and HLA association
HLA-Cw6
Dermatitis herpetiformis and HLA association
HLA-DQ2
HLA-DQ8
- Ankylosing spondylitis
- Reactive arthritis
- Psoriatic arthritis
- Inflammatory bowel disease-related arthritides
and associated HLA
HLA-B27
Behcet disease and (human leukocyte antigen) HLA association
HLA-B51
Cheyne stokes breathing
cycles of apnea followed by hyperpnea
CHF, brainstem injury, Central sleep apnea
Biot’s breathing
Rapid deep respirations with short pauses
Head injury, Multiple CNS conditions
Kussmaul’s breathing
Deep increased respirations
Metabolic (DKA, Renal failure)
Femoral neck fractures
Commonly occur in elderly patients that fall laterally onto their hip
Patients are usually unable to ambulate and have a shortened and externally rotated lower extremity on the affected side.
Obstructive sleep apnea (OSA) Diagnosis
Patient has an apnea hypopnea index > 5 events per hour on polysomnography plus symptoms of sleep apnea,
or > 15 events per hour independent of symptoms.
Giant cell tumor
Multinucleated giant cells, will show a characteristic “soap bubble” appearance on x-ray.
Osgood-Schlatter disease
Traction injury to the tibial tuberosity where patellar tendon causes an avulsion fracture
Presents during children’s growth spurts and they will complain of knee pain
Osteosarcoma
Limb pain and is characterized by a sunburst pattern on x-ray with periosteal separation.
Ewing’s sarcoma
More common in males
On x-ray it can show the classic “onion-skinning”
Polymyalgia rheumatica
Pain and stiffness of the shoulder and pelvic girdle musculature
Muscle weakness is not present (what makes it different from Polymyositis)
Elevated ESR, anemia
Tx: low dose prednisone
Pes anserine bursitis
Three muscular tendons (gracilis, sartorius, and semitendinosus) insert on anteromedial aspect of the tibia
pain with lateral movements commonly observed in agility sports such as soccer, basketball, and field hockey
Trigger finger (ie, stenosing flexor tenosynovitis)
Painful nodule near the metacarpophalangeal joint and can cause episodes of painless catching or locking of the digits.
Tx: Start with Stretching, splinting, and applying ice, followed by corticosteroid injections and, finally, surgery.
Dupuytren contracture
Loss of full extension of the affected finger or fingers at the MCP joint
Painless and nodular lesions are typically seen in the palmar fascia.
Subacromial bursitis
Shoulder pain that is worst when doing overhead activities
1st- Rest and NSAIDs
2nd- subacromial injection of Corticosteroid
3rd- subacromial decompression
Legg-Calve-Perthes disease
Idiopathic avascular necrosis of the proximal femoral epiphysis
Most commonly seen from 4-10 years of age
Lose internal rotation and abduction
IT band dysfunction (IT band tightness = positive Ober test and tenderness around greater trochanter)
Xray of Legg-Calve-Perthes disease
Hip radiograph demonstrates a misshapen, horizontal growth plate and a flattened femoral head.
Bennett fracture
A fracture at the base of the first metacarpal (thumb base) with intra-articular extension into the carpometacarpal joint space
Boxer fracture
Involves the fourth metacarpal bone, fifth metacarpal bone, or both
Closed fist strike against an opponent or a solid flat surface, often a wall
Colles fracture
Fracture of the distal radius with dorsal and radial displacement of the distal fracture fragment
Falling onto an outstretched hand
gamekeeper thumb fracture/ Skier thumb
Avulsion fracture off the base of the proximal phalanx of the thumb with associated injury to the ulnar collateral ligament
Jones fracture
Stress fracture involving the base or proximal third of the fifth metatarsal
Arsenic poisoning
caused by pesticides or contaminated ground water. It presents with severe headaches, abdominal pain, diarrhea, delirium, convulsions and breath that smells like garlic. It can be treated with chelating agents such as succimer or dimercaprol.
Osteoporosis treatment
1st line is Bisphosphonates
However Bisphosphonates should not be used to treat osteoporosis in patients with GFRs below 30–35 mL/min/1.73m2. In these patients, preference should be given to denosumab because it is not cleared by the kidneys.
Guyon canal syndrome
ulnar nerve entrapment at the wrist
Cubital tunnel syndrome
ulnar nerve entrapment at the elbow
Spondylolisthesis
Anterior displacement of one vertebra in relation to the one below it
Start with Xray
Do MRI is symptoms persist
Gold standard for diagnosing carpal tunnel syndrome
Electromyography and nerve conduction studies
Maneuver to test for Thoracic outlet syndrome (TOS)
Adson maneuver is a test utilized in the evaluation of TOS, with a decrease in radial or ulnar pulse with abduction of the upper extremity overhead indicating a positive test.
Test for De Quervain’s Tenosynovitis
Finkelstein’s test- patient is asked to make a fist around their thumb on their affected side. The patient is then asked to ulnarly deviate their wrist while maintaining their fist. Pain elicited over the radial wrist is a positive test.
Best study to verify osseous union.
CT is best to assess scaphoid fracture union prior to return to high-impact activities
Small, round blue cells on bone biopsy
Ewing sarcoma
Langerhans cells, eosinophils, and lymphocytes on bone biopsy
Eosinophilic granuloma/ Langerhans cell histiocytosis
Common to find these lesions in the skull
Common causes of acromioclavicular (AC) joint septic arthritis
AC joint is a common joint affected in intravenous drug abusers. While Staphylococcus aureus is a common cause of AC joint arthritis in intravenous drug abusers, Pseudomonas is also a very common cause.
Normal range of the Q angle is 14º-17º
What is Genu valgum?
Genu valgum is defined as a Q angle greater than 17º. This gives the appearance of being knock-kneed. Can lead to inappropriate patellar tracking–> Patellofemoral pain syndrome
Normal range of the Q angle is 14º-17º
What is genu varum?
An angle less than 14º is called genu varum and gives the appearance of bowleggedness.
Patellofemoral syndrome
Runner’s knee, refers to anterior knee pain that worsens while going up or down stairs, walking hills, or with prolonged sitting with knees flexed (theater sign)
Associated with weakness of the vastus medialis
Look for the J sign (lateral tracking of knee with extension due to stronger vastus lateralis)
