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Shelf/Step 2 > Rheum/Ortho/Derm > Flashcards

Rheum/Ortho/Derm Flashcards

1
Q

avascular necrosis

A

causes - steroids, alcohol, SLE, antiphospholipid syndrome, hemoglobinopathies (sickle cell), infections (osteo, HIV), renal transplant, decompression sickness

px - groin pain on weight bearing (also occurs with rest and at night)

  • eventually pain and reduced ROM on hip abduction and internal rotation

XR may be normal (or may see a crescent sign in advanced stage disease)

  • MRI is the most sensitive modality - will show boundary between normal and ischemic bone

tx - NSAIDs, reduced weight beraing

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2
Q

SLE

A

labs - ANA

exacerbation - rash, fever, mucocutaneous ulcers, polyarticular synovitis

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3
Q

gout

A

gout

  • px - … tophi occur in gout only
  • acute treatment - indomethacin (NSAID), colchicine, corticosteroids
  • ppx for pts with recurrent attacks - allopurinol

pseudogout

  • can occur in the setting of surgery or medical illness
  • most commonly of the knee but can occur in the ankle and UE joints
  • CPPD crystals, chondrocalcinosis on imaging
  • tx - intra-articular glucocorticoids, NSAIDs, colchicine
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4
Q

arthritis

A

septic arthritis - fever, systemic sxs

  • nongonoccoal septic arthritis - RFs include underlying joint disease, immune suppression (and intra-articular glucocorticoid injections), IVDA
  • tap that joint
  • start IV abx (vanc or 3rd gen ceph) and drain joint
  • sometimes RA pts will presents without overt signs of infection
  • gonococcal septic arthritis - pt will be febrile, primary infection is usually silent
  • purulent monoarthritis and/or triad of tenosynovitis, dermaitis, and polyarthralgias
  • blood cultures (often neg); synovial fluid analysis; culture/NAAT urethra, cervix, pharynx, rectum
  • tx - IV cef; empiric azithro or doxy for concomitant chlamdyia; drain joint

polyarticular arthritis - SLE, RA, parvovirus

  • involves synovial immune complex deposition

psoriatic arthritis - occurs in 5-30% of pts who have psoriasis

  • DIP involvement, morning stiffness (note DIPs are not involved in RA, classically PCP and PIP)
  • will have soft tissue and nail involvement - enthesitis, dactylitis, nail pitting and onycholysis (separation of the nail bed), swelling of hands or feet with pitting edema
  • skin lesions
  • tx - NSAIDs, methotrexate, anti-TNF agents

reactive arthritis - subacute-chronic

  • oligoarthritis (involves knee and SI joints), nongonococcal urethritis, conjunctivitis
  • also oral ulcers, enthesitis
  • follows acute GI/GU infection
  • tx - NSAIDs
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5
Q

back pain

A

lumbosacral strain is the most common cause - acute onset pain following physical exertion -

local tenderness and contraction of the paraspinal muscles

  • tx - NSAIDs and early mobilization (stretching, exercise therapy)
  • if pain continues subacutely or chronically - these pts are more likely to have recurrent or persistent pain

compression fracture - local spinal tenderness

AK and MM - chronic back pain

herniated disc/lumbosacral radiculopathy - epidural glucocorticoid injections can be considered 2nd line

When would you image?

red flag features - age >50, hx of cancer, constitutional sxs, nocturnal pain, no response to tx, significant/progressive neuro deficits

xray - osteoporosis/compression fracture, malignancy, AK

MRI - sensory/motor deficits, cauda equina, suspected epidural abscess/infection

radionuclide bone scan or CT - indications for MRI but pt unable to have MRI

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6
Q

carpal tunnel syndrome

A

risk factors - obesity, pregnancy, DM, hypOthyroid, RA

…severe disease - weakness of thumb motion, atrophy of thenar eminence

dx - clinical, nerve conduction studies (but dont always need these)

tx - wrist splinting, glucocorticoid injection, surgery

  • NSAIDs are NOT effective
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7
Q

neuropathic arthropathy (Charcot joint)

A

diabetes, syphillis, alcoholism

peripheral neuropathy –> decreased propioception –> frequent trauma and joint destruction

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8
Q

sarcoid

A

young AA px - constitutional sxs

  • cough, dyspnea, chest pain
  • extrapulm - skin lesions (erthyema nodosum), A/P uveitis, Lofgren syndrome - sometimes erythema nodosum will be the first manifestation

CXR - bilateral hilar adenopathy, pulmonary reticular infiltrates

  • concerned about sarcoid - get CXR

lab - hypercalcemia/hypercalciuria - elevated serum ACE level

path - bx will show noncaseating granulomas

Other diseases with erythema nodosum - strep infection, sarcoid, TB, fungal disease, IBD, Behcet disease

  • initial work-up for erythema nodosum - CBC, CMP, anti-streptolysin titers, TB test
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9
Q

fibromyalgia

A

pain, fatigue, and cognitive/mood disturbances

management - pt education, regular aerobic exercise, good sleep hygience

  • TCADs are a last resort
  • limited evidence for alternative therapies
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10
Q

Takayasu arteritis

A

RFs - female, asian, age 10-40

sxs - involves branches of the aorta, constitutional, aterio-occlusive sxs in UE

  • mononuclear infiltrates and granulomatous inflammation of media

exam - blood pressure discrepancies, pulse deficits, arterial bruits

dx - elevated ESR/CRP, CXR will show aortic dilation and widened mediastinum

  • CT/MRI - wall thickening, narrowing of lumen

tx- systemic glucocorticoids

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11
Q

thromboangiitis obliterans (Buerger disease)

A

men who are heavy smokers - superficial thrombophlebitis and ischemia & gangrene of digits

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12
Q

cryoglobulinemia

A

type 1 -

  • lymphoproliferative or hematologic (MM)
  • asx, hyperviscosity (blurry vision), thromobosis (Raynauds), livedo reticularis, purpura
  • normal complement

mixed types 2 and 3 - immune complex deposition in vessels –> endothelial injury –> end-organ damage

  • chronic HCV/HBV, HIV, SLE
  • sxs - fatigue, arthralgias, renal disease (and HTN), pulm (dyspnea, pleurisy), palpable purpura, leukoclastic vasculitis, elevated transaminases
  • low C4

tx - address underlying disease, plasmapheresis, immunosuppression (glucocorticoids, rituximab),

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13
Q

antiphospholipid syndrome

A

antibodies - anticardiolipid antibodies

px - recurrent arterial or venous thrombosis

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14
Q

Whipple disease

A

multisystem disease

  • chronic malabsorptive diarrhea, protein-losing enteropathy, weight loss, migratory non-deforming arthritis, LAD, and low-grade fever
  • dx - SI bx will show PAS-pos macrophages (in LP, contain non-acid-fast gram-pos bacilli)
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15
Q

anklyosis spondylitis

A

inflammatory back pain

  • other findings include - arthritis (sacroilitis), reduced chest expansion and spinal mobility, enthesitis, dacytlitis, uveitis
  • complications - osteoporosis/fractures, aortic regurg, cauda equina

lab - elevated ESR and CRP, HLA-B27 association

imaging - XR of SI joint (may be negative in early cases –> get MRI)

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16
Q

amyloidosis

A

Secondary - secondary to chronic inflammatory conditions

  • inflammatory arthritis, chronic infections (bronchiectasis, TB, osteomyelitis), IB, malignancy, vasculitis
  • pathophys - extracellular deposits
  • px - nephrotic syndrome, cardiomyopathy + HF, hepatomegaly, neuropathy, organ enlargment, bleeding diathesis, waxy thickening and easy bruisability of skin
  • dx - abdominal fat pad aspiration bx
  • tx - tx of underlying condition, colchicine for ppx and tx
17
Q

polyarteritis nodosa

A

systemic sxs, livedo reticularis, purpura, kidney disease, abdominal pain, muscle aches/weakness

elevated CRP

18
Q

Raynauds

A

Raynauds - cold, emotional stress

secondary Raynauds - due to CT disease, occlusive vascular conidtions, sympathomimetic durgs, vibrating tools, hyperviscosity syndromes, nicotine

  • usu M
  • tissue injury or digital uclers, abnormal nail fold capillary examination
  • management - evaluated and treat underlying disorder, CCB and ASA (for pts at risk for digital ulceration)
19
Q

systemic sclerosis

A

progressive tissue fibrosis and vascular dysfunction

  • two types - limited cutaneous (prominent vascular manifestations), diffuse cutaneous (prominent internal organ involvement)
  • systemic, skin, extremities, GI (decreased esophageal motility), and vascular manifestations
  • ANA, anti-topoisomerase (anti-Scl-70), anti-centromere
  • complications - lung (ILD, pulm HTN), kidney, heart (myocardial fibrosis, pericarditis, pericardial effusion)
  • renal crisis - marked HTN, AKI
  • involves coagulation cascade activation - peripheral smear will show microangiopathic hemolytic anemia or DIC with fragmented blood cells
20
Q

tennis elbow

A

pain with resisted wrist extension or passive wrist flexion

21
Q

acne

A

tx - avoidance of sun exposure

22
Q

ankle sprain

A

px - can have ecchymosis around malleolus

tx - use soft protective brace and early ROM exercises

23
Q

rheumatoid and osteoarthritis

A

osteoarthritis

  • RFs - age, obesity, DM, prior joint injury
  • px - Heberden’s nodules (DIP), creptius
  • hip osteoarthritis - groin pain
  • XR - narrowed joint space, osteophytes, subchondral sclerosis
  • tx
  • exercise and weight loss
  • NSAIDs = diclofenac (note acetaminophen and opioids are less effective)
  • topical agents, intra-articular glucocorticoids, intra-articular hyaluronic acid
  • surgery, chronic pain management

RA - RF and anti-CCP

  • morning stiffness, tenosynovitis of palms (trigger finger), rheumatoid nodules (esp on elbows)
  • cervical joint involvement can lead to spine subluxation –> spinal cord compression (neck pain, stiffness, radiculopathy, UMN signs)
  • reduced grip strength occasionally occurs - sensitive sign of early disease
  • xray
  • flares involve multiple joints

Felty syndrome features

  • RA - severe erosive joint disease, rheumatoid nodules, vasculitis (necrotizing skin lesions), neutropenia (ANC < 1500), splenomegaly
  • dx - anti-CCP and RF are pos in >90% of pts
  • get peripheral smear and bone marrow bx to rule out other causes of neutropenia
  • improves with tx of underlying RA (with methotrexate)
24
Q

pyoderma gangrenosum

A

starts as papule, nodule, vesicle –> expanding ulcer

  • 30% of cases are triggered by local trauma
  • more than 50% of pts have an underlying systemic disorder - IB, RA, heme conditions
  • dx - skin bx
  • tx - corticosteroids
25
Q

peripheral smear findings

A

Burr cells - spiculated RBCs, seen in liver disease and ESRD

Howell-Jolly bodies - nucleus remant, in pts with no spleen

spur cells - RBCs with irregularly sized and spaced projections, seen in liver disease

26
Q

reagin-mediated

A

means IgE mediated

27
Q

connective tissue disorders

A

skin rash, joint pains

28
Q

anabolic steroid/testosterone use

A

testosterone - ….decreased testicular size and sperm count, hepatic dysfunction, erythrocytosis (secondary to androgen stimulation), decreased HDL levels

  • high doses can cause cardiac dysfunction
  • tamoxifen - anti-estrogen, can be used to treat gynecomastia
    v. s. GH use - hyperglycemia, Na retention, swollen hands, joint and muscle pain

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