Rheum/MSK/Ortho Flashcards
1
Q
- 6 yo girl with diagnosis of JIA and pain in one knee. CRP 58. Sedimentation 25. ANA negative. No uveitis. What is the next step in management
a. NSAIDS
b. Methotrexate
c. Intra-articular corticosteroids
d. Oral steroids
A
NSAIDs
Oligoarthritis
2
Q
- Girl with systemic JIA well-controlled on methotrexate then re-presents with fever, unwell, rash, liver 3 cm below costal margin. What is the most likely diagnosis
a) MAS
b) Sepsis
c) Methotrexate toxicity
d) Autoimmune hepatitis
——————– - Child with systemic JIA. Presents with fever, purpuric rash, hepatosplenomegaly and irritability. What is the MOST likely diagnosis?
a . methotrexate toxicity
b. macrophage activation syndrome
c. sepsis
——————— - 7 year old girl has oligoarticular JIA and has been on methotrexate as maintenance therapy for her disease. She has sudden onset high fever, anemia, thrombocytopenia, and hepatomegaly with elevated liver enzymes. Which of the following is the cause of her current condition?
a) Methotrexate toxicity
b) Macrophage activation
c) syndrome
——————— - Kid with JIA and MAS features, what is it?
a. MAS
b. Sepsis
A
MAS
3
Q
- 6-year-old with clinical and laboratory evidence consistent with systemic JIA develops persistent fever, extensive and fixed rash, thrombocytopenia and hyponatremia. What is most likely to decrease:
a) Triglyceride
b) Fibrinogen
c) LDH
d) Ferritin
A
Fibrinogen
LOW fibrinogen
HIGH ferritin
HIGH TG
4
Q
- You want to start an 11 year old boy with JIA on Infliximab. Which is most important prior to starting this medication?
a) VZV vaccine
b) MMR vaccine
c) Checking for Mycobacterium Tuberculosis
d) ??
A
Checking for mycobacterium tuberculosis
5
Q
- Kid with fevers, salmon rash, HSM (no joint pain).
a) Systemic JIA
b) ALL
A
Systemic JIA
Arthritis Hot - fever daily Rash - evanescent salmon Adenopathy Serositis HSM
Fever and other systemic features may precede arthritis by weeks to months
6
Q
- A 7 year old boy has a history of recurrent fevers, evanescent pink rash, lymphadenopathy, and hepatomegaly. His MSK exam is normal. What’s the diagnosis?
a. Leukemia
b. Scarlet fever
c. Lyme disease
d. Systemic JIA
—————
Evanescent rash, lymphadenopathy, hepatomegaly without joint pain in 6 yo boy. What is your diagnosis?
a. systemic JIA
b. ALL
————— - Child with spiking fevers and evanescent pink rash, lymphadenopathy, hepatomegaly, splenomegaly, and MSK exam normal, for about 3 weeks Diagnosis.
a. Scarlet fever
b. Lyme disease
c. Systemic onset JIA
d. Leukemia
A
Systemic JIA
7
Q
- Child in rhythmic gymnastics. Has back pain that is worse on extension. On exam has exaggerated lumbar lordosis, hamstring tightness. Bone scan is positive. What does she have?
a) Spondylolysis
b) Posterior overuse sydnrome
c) Herniated disc
d) ring apophositis
——————- - 14 year old female gymnasts presents with a 2 months history of lower back pain on extension. She has tight hamstrings, spasm of her paraspinal muscles, normal sensations and motor function. A bone scan lights up her lumbar vertebrae. What is the diagnosis?
A. Spondylosis
B. Posterior Element Overuse syndrome
C. Disk herniation
D. Vertebral body avulsion fracture
——————- - 12y gymnast presents with 2mo of lower back pain. The pain is worse for 2-3 days after practice. Her sleep is ok. She gets spasms in her paraspinal muscles. On exam, she has tight hamstrings, normal sensation and motor function in her legs with normal anal tone and sensation. A bone scan lights up in her lumbar vertebra over the location of her pain. What is the diagnosis?
a. Spondylolysis
b. Posterior element overuse
c. Disk herniation
d. Vertebral body avulsion fracture
——————- - Low back pain in gymnast. A physical examination shows hyperlordosis, paraspinal muscle spasm and hamstring tightness.
a. Spondylolysis
b. Posterior element overuse
c. Vertebral avulsion fracture
d. Disc herniation
A
Spondylolysis
- stress fracture of pars interarticularis d/t repetitive spinal extension + rotation
- insidious extension*-related back pain
- O/E: hyperlordosis*, paraspinal m spasm + hamstring tightness
- A/P lat Xray: sclerosis of pars interarticularis
Posterior element overuse syndrome
- insidious extension*-related back pain
- focal tenderness of lumbar spine + paraspinal muscles
- IVx normal
Vertebral body apophyseal avulsion fracture
- fractures that posteriorly displace into spinal cord d/t repetitive spinal flexion + extension
- acute onset lumbar flexion* pain. No neuro Sx
Disc herniation
- acute flexion*-related pain
- back muscle spasms, hamstring tightness
Apophysitis
- tenderness along spinous processes to light palpation
- pain with activity or when sitting
8
Q
- Description of a kid with Kawasaki Disease. What is the most common laboratory finding?
a) Neutropenia
b) Hypoalbuminemia
c) High IgA
d) ASOT
- ——————- - 5 year old child with Kawasaki disease. What lab finding would you expect
a. Hypoalbuminemia
b. Thrombocytopenia
c. Low liver enzymes
d. Leukopenia
A
Hypoalbuminemia
Hot: fever >=5d and >=4/5: Conjunctivitis, bilateral, non purulent Rash Edema Adenopathy (>1.5cm) Mucous membranes (dry cracked lips, strawberry tongue)
9
Q
- A kid has had 6 days of fever despite treatment with amoxicillin, with no response. He also has cracked lips, nonpurulent bilateral conjunctivitis, and a polymorphous rash. What would you expect to see on his labs?
a. Neutropenia
b. Hypoalbuminemia
c. Elevated ASOT
d. Elevated EBV titres
———————- - 4 yr old boy with fever of 40 degrees despite amoxcil. Maculopapular rash, bilateral conjunctivitis,dry cracked lips. What is the most likely lab finding?
a. hypoalbuminemia
b. neutropenia
c. EBV monospot +
d. + ASOT
——————-
5 yo with fever 40 degrees x 6days, bilateral conjunctivitis, cervical lymphadenopathy, cracked lips. Has not responded to 3 days of amoxicillin. What finding is most consistent with this diagnosis?
a. Hypoalbuminemia
b. neutropenia
c. positive ASOT
d. positive monospot
—————-
Kid with >=6 day of fever, non purulent conjuctiviits, MP rash. Clinical picture c/w Kawaski’s dx. Most likely lab abnormality?
a. Low albumin
b. Neutropenia
c. Monospot +
d. Positive ASOT
A
Hypoalbuminemia
10
Q
- Young girl with AOM and fever for 9 days, now with conjunctivitis, cracked lips, ect…kawasaki. Which is the most important to test before she leaves?
a) Cardiac ultrasound
A
ECHO
11
Q
- Girl had fever then swollen extremities, cracked lips. Treated with IVIG and ASA then developed anemia and hematuria.
a) Kawasaki IVIG hemolytic reaction
A
IVIG hemolytic reaction
This is why we consider doing CBC, smear, retic, DAT, bili, 5-7d after Tx with IVIG
12
Q
- Boy with lupus. Most likely test consistent with this Dx
a. ANCA+
b. Thrombocytosis
c. HLAB27+
d. positive RPR
A
Positive RPR (false positive)
Immunologic criteria for SLE ANA pos (SP 95-99%, low SN) Anti dsDNA pos (high SP, helps track disease activity) Anti Smith pos (high SP, doesn't track disease activity) Antiphospholipid Ab pos Anticardiolipin pos Lupus anticoagulant pos FALSE POS RPR
Hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
Low C3, C4, CH50
High ESR CRP
13
Q
Which of the following statements regarding the diagnosis of SEL in .a 15yo girl is correct?
A. A strongly positive ANA test has a high specificity for the diagnosis of SLE
B. A strongly positive anti-dsDNA antibody test is the most sensitive antibody test for the diagnosis of SLE
C. A strongly positive anti-Sm antibody test is the most sensitive antibody test for the diagnosis of SLE
D. Anti-cardiolipin antibodies have a high specificity for the diagnosis of SLE
E. Both anti-DNA and anti-Sm antibodies are highly specific for the diagnosis of SLE
A
Anti DNA + anti Sm are specific
Positive ANA = sensitive Anti-DNA antibodies* Anti Sm antibodies* *Highly specific for SLE Anti-phospholipid antibodies Anticardiolipin Lupus anticoagulant
Other:
- anti RNP: Raynaud, pulm HTN
- anti Ro (SSA), anti La (SSB): neonatal lupus, may be Sjogren
- antiphospholipid ab (includes anticardiolipin): venous + arterial thrombotic events
- antihistone: drug-induced lupus
14
Q
- Woman with rash, arthritis, nephritis (SLE?). What associated?
a. Pancytopenia
b. ??
A
Pancytopenia
15
Q
- 14 yr old with fevers, polyarthralgia, wt loss. Appears pale. No arthritis on exam. Urine + for protein and blood. Decreased WBC and lymphs. Normal platelets. What is the most likely diagnosis.
a. SLE
b. Systemic JIA
—————-
12 yo girl – fever, malaise, arthralgia for 3 weeks. ESR 50, WBC 3 (leukocytes 10%, neutrophils 90%). Trace proteinuria/hematuria. BUN/Cr normal. What is your diagnosis?
a. lupus
b. systemic JIA
c. PSGN
——————
Child with wt loss anemia, normal plts, low WBC, protein/blood in urine. Dx?
a. SLE
b. RF
c. PSGN
A
SLE
Systemic JIA Fever >=2wks, daily for >=3d Need >=1 of Rash Adenopathy Serositis HSM Not specified
16
Q
- Which ECG change is characteristic of acute rheumatic fever?
a) Peaked T waves
b) Prolonged PR interval
c) Sinus tachycardia
A
Prolonged PR interval
17
Q
- 13 y.o. Girl presents with antalgic gait and pain for 2 weeks. She has difficulty with rotation and adduction of her leg. X-ray was similar to the one below. What is the diagnosis?
a) Septic joint
b) Calve-Perthes
c) SCFE
d) Fracture
e) Post-infectious
A
SCFE - adol, obese. Can weight bear, limp, groin/knee/thigh pain.
Internal rotation, abduction, and flexion Limitation
(FAB IRL)
PIN!
Legg Calve Perthe - 4-8yo. Antalgic limp. Restriction of internal rotation and abduction
18
Q
- If a child has a septic hip, what position do they normally hold their hip in?
a) abducted and internally rotated
b) abducted and externally rotated
c) adducted and internally rotated
d) adducted and externally rotated
- —————————– - What is the position of the septic hip in a patient with septic arthritis?
a. Abducted and internally rotated
b. Abducted and externally rotated
c. Adducted and internally rotated
d. Adducted and externally rotated
A
Held in ABDuction and external rotation (FABER)
Knee usually flexed
Sepsis has an outgoing personality
19
Q
- 3 year old with refusal to walk for 3 days. Temp 38.1C, mildly tachycardic, very irritable when you examine right leg which is held in slight abduction and external rotation. Right hip has decreased ROM and he is in pain when you move his hip. He refuses to walk. Bloodwork shows ESR 48, CRP 20, WBC 14, normal Hgb and platelets. Most likely diagnosis:
a. transient synovitis
b. osteomyelitis
c. septic arthritis
d. Legg-Calve-Perthes disease
————————–
5 year old fever 38.5 degrees, had a recent URTI. Hip was externally rotated and child not weight-bearing. ESR was 40. Diagnosis?
a. transient synovitis
b. JIA
c. septic arthritis
A
Kocher criteria
1) Failure to wt bear
2) FEver > 38.5%
3) WBC > 12
4) ESR >40 or CRP>20
If 4/4: 99.6% chance of septic arthritis
20
Q
- Septic joint next step?
a) Aspirate
b) Urgent consult to Ortho
c) Admit and start IV antibiotics
A
If hip or shoulder, surgical emergency, urgent consult to ortho
If not hip or shoulder, aspirate for definitive diagnosis
