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Awesome Review 2021 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Osteoarthritis

A

DIP(heberden’s), PIP (bouchard’s)

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2
Q

Rheumatoid arthritis

A

PIP, MCP

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3
Q

Psoriasis

A

DIP

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4
Q

Scleroderma

A

PIP, MCP

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5
Q

Heartburn + dysphasia + thickened skin=

A

scleroderma

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6
Q

Poor prognositc factors for Rheum Arthritis

A

Progressive synovitis
Joit space loss/erosiions
Inc Rh factor >1:80
Inc ESR

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7
Q

70yo F early morning stiffness >45min & symmetric small joint pain in 2nd-4th MCP and 2-5th MCP and PIP in L hand - jnt pain in R knee for 6 wks and ESR 48 - swelling of MCP and PIP RH neg wtd?

A

Start tx

Anti-CCP +

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8
Q

Antlanto odontoid subluxation

A

compress vertibrobasilar artery-> lightheadedness, sncope
screen for subluxation with lat xray before anesthesia
Compress cord - snsory motor quadriplegia
8mm asyx - surgical correction
Sx any size sx corretion

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9
Q

Pt with rheum arthritis can present with what?

A

carpel tunnel tarsal tunnel

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10
Q

Extra articular manifestations of RA

A

spill over of active disease from synovium
Rheumatoid nodules (inc’d RH factor (- in 15%))
Vasculitis/DR4
RF leaves joint thru capillaries-> inflamm, ulcers
Heart
Effusion
Constrictive pericarditis
Myocarditis
Lung
Rheum nodules (Caplan’s syndrome)
Pleural effusion (low glucose, high LDH, exudative)
BO
Interstitial fibrosis
Hypersenitive pneumonitis (methotrexate)
Blood anemia of inflammation
Vasculitis - nexrosis ulceration at tip of fingers
Nerve - Mononeuritis multiplex->foot/hand drop
Skin - rheumatoid nodules (commonest extra artiuular manifestation - RH factor inc’d - AgAb complex depostion)
Renal - usually lsate stage with amyloid nephropathy
Drug induced NSAID, Peniclliamine, nephrotic syndorme
Eye - scleritis - deeper - r/o globe rupture
episleritis - superficial both autoimmune

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11
Q

Fx vs sprain

A

4 steps without sx

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12
Q

HCV with mixed cryoglobuinemia

A

vasulitis and LE ulcers

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13
Q

Tx for RA

A

Mild - NSAIDS+- hydroxychoroquine (need yearly retinal exam)/sulfasalazine(reactive arthritsi)/Minocycle (leading cause drug induced lupus and hepatitis)

Mod to severe - Add methotrexate(25mg/wk, check folate level) +- low dose steroid+- Leflunomide

Severe Add etanercept (check PPD)/infliximab/adalimumab or anakinra (IL inhib)
Abatacept, Rituximab, Tocilizumab

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14
Q

Egg shell Ca+

A

siliciosis

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15
Q

Salmon pink rash

A

still’s dz/inc’d ferritin

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16
Q

Schools of fish or boxcar

A

chance - haemaphilis ducre

Tx: azithro orceftriaxone

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17
Q

Methotrexate contraindicated in?

A

Pt on bactrim, Hep B/C, Etoh liver dz

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18
Q

Macular degeneration

A

lose central vision

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19
Q

Reflexes

A

L5 lesion - no dorsiflex, no evert, no invert

Peroneal lesion - No dorsiflex, no evert, +invert

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20
Q

45yo p/w joint tiffness>1hr in AM, pain in MCP, PIP and pain while climbing stairs x 6wks Rh+, on tylenol no rlief - started on naproxen no relief Rh still high wtd?

A

Add methotrexate

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21
Q

Fastest acting DMARD (Disease modifying anti rheum drug) is?

A

Methotrexate

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22
Q

Which drug decreases mortality in RA

A

Methotrexate

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23
Q

Floppy iris syndrome

A

d/c tamsulosin before cataract surgery

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24
Q

What is preictor for CVS dz in Rheumatoid arthritis

A

Inc’d homocysteine levels

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25
Q

Pt with rheumatoid arthritis on NSAIDs with persistent synovitis, methotreaxate was added and pain improved, 3 months later pt p/w fatigue, Hg low, MCV high best tx would be?

A

folic acid def (from methotrexate use) - tx with folic acid

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26
Q

S/e NSAIDs

A

nephrotic syndrome, PUD, int nephritis

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27
Q

S/e hydroxychloroquine

A

Macular damage loss of accommodation

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28
Q

S/E Methotrexate

A

Heptox, hyper Pneum, athous ulcer

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29
Q

S/E Lefluonmide

A

Teratogenic

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30
Q

s/e Corticosteroid

A

Osteoporoiss, HTN, cataract, avasc necrosis

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31
Q

s/e Infliximab

A

ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+

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32
Q

s/e Etanercept

A

ractiv TB, demyel dz, fungal infxn, psoriasis, drug induced lupus (anti sm+, anti DS DNA+) ANA, ANti DNA+, flue like sx

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33
Q

s/e Cyclosporin

A

ATN, renal insuff, hirsuitism, HTN

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34
Q

Catarct sx?

A

glare outside lights

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35
Q

Pt with Rhuem Arth p/w sudden onsest pain behind knee an calkf - US neg for DVT? wtd?

A

ruptured baker cyst - intraarticular steroid

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36
Q

Pt with h/o RA for long time udergoes elective surgery with gen anesthesia - post op is quadriplegic - etio?

A

Atlanto-odontoid subluxatio C1-C2

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37
Q

Pt with long standing Rh wit oarseness of voice for weeks dx?

A

Crico arytenoid joint involvement

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38
Q

65yo RA >30yr p/w paraesthesia in hands b/l carpel tunnel release little change - also with occ dizzy spells - pas histor total knee arthor with seree joint def - dec powerand hyperactive reflexes - pt going for hip replacemet wtd?

A

Xray neck r/o sublux

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39
Q

Pt with RA on methotrex x 1 yr p/w pain and swelling knee joing, fever with inc WBC wtd?

A

tap joint r/o septic arthritis (all before thinking about steroids)

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40
Q

Tap with turbid exudate labs P

A

start IV abx

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41
Q

Pt with long standign RA on NSAIDs steroids and MTX p/w cough, tx’d with abs - 4 weeks later progressive SOB no fever - b/l crackes, CXR infiltrates - etio?

A

MTX induced, interstitial fibrosis, bronchioe obliterhaeran

NOT CMV Pneumonitis

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42
Q

Pt with RA on hydroxychlorquin wtd?

A

baseline retinal exam and yearly

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43
Q

Leading cuase of death in RA

A

Heart disease

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44
Q

Pt tx’d with steroids for temproatl arteritis or Polymyalgia Rheumatica or SLE - couple month later steroids tapered fo with improvement of sx - pt returns with b/l symm joint pain and early morning stiffness with MCP, PIP no h/a or shoulder pain - exame with +nodule on L olecranon dx?

A

Rheum arthritis

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45
Q

Pt on MTX for Rheum Arthritis - what do you follow in term so labs

A

CBC, Cr, AST q2-4 w, x 3 the 8-12 then q12

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46
Q

Pt with Rh Arthritis with minimal response to MTX wtd?

A 
check PPD, if neg start TNF alpha
If 5mm - start INH & pyridoxine
Pneumococcal and influenza vacc prior to DMART
no varicella, no yellow fever, no MMR
don't give DMARD with active infxn
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47
Q

35yo p/w recurrent pain starting in PIP then MCP then knee - few hours later joint swelling - pain resoves in few hours in backwards order - dx?

A

Pallindromic rheumatism - 1/2 will go on to RA

tx: DMARDs

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48
Q

Pt with RA and necrotic ulceration of finger tips and foot drop dx?

A

Rheumatic Vasculitis - circulating Ag-Ab (RF) complex blocks small arteries

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49
Q

recurrent skin/lung infxn, +skin ulcers dx?

A

Felty’s syndrome -
Tx
DMARDs, steroids, G-SF-> splenectomy

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50
Q

32yo F polyarthritis and fever, sore throate several weeks ago - salkmon colored rash on trunk - throat ctx neg, ESR elev, ferritin high , WBC high abx no help, Rh neg, ANA neg dx?

A

Still’s dz

Joint pain, salmon colored rash, high ferritin, high WBC

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51
Q

WHat dz more likely related to RA

A

Peeriodontal dz

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52
Q

Sjogren’s

A

RH+, ANA+, RoLa+, elev ESR
inc’d r/o lymphoma/celiac sprue (check TTG), distal RTA I (U pH >5.5) - CaPO4 stones)
Sx - enlarged salivary glands, dry mouth,
Dx: - lip bx minor salivar glands
Schirmer test + if <5mm wetting in tearing of eyes in 5 min (normal 15mm in 5 min)
Tx: Symptomatic - hydration, pilocarpine, steroids

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53
Q

55yo c/o sdry eyes and mouth - drinks lots of water everyday and uses artifical tears - ROS shows chroic arthralgias - takes NSAIDs - parotid gland swelling - dental caries and dry eyes pt may benefit from ?

A

pilocarpine

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54
Q

Seroneg spondyloarthropathy - Rh neg, HLSA B27+

A

involves spine, asy poly/oligoarthritis <4 joints affected
Enethesitis (inflamm ligaments, tendons, joint capsule)
Dactylitis - swelling of entire digit
Ankylosing spondylitis
Reactive arthritis - mucosal inflammation of GI or GU tract

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55
Q

Ankylosing spondylitis

A 
starts after resting better with excercise, loss of forward spinal mobility
sx sarcoilitis
Uveitis: pain photophobia, lacrimation
HLA B27 +, apical fibrosis
bamboo spine on xray
a/w aortits
diminished Chest expansion
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56
Q

Pt loves outdoor work with on/off back pain p/w c/o pain and redness of r eye - also loss of forward spine mobility - inejction aroudn corea - fluroescin eye stain eng - what suggests ankylosing sponylitis in pt?

A

loss of spinal mobility
Dx: xray lumbosacral spine
more sensitive test - MRI sarco iliac joint
Eye manifestation is Uveitis

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57
Q

Pt p/w low back pain - xray with fusion of sarcoiliac joints and anklylosis of spine (bamboo spine - HLA B27+ most likely a/w?

A 
Aortitis
Tx for stiffness?
Excercise, physical tx
Pain - NSAIDs - if 6 weeks no improvment then anti-TNF (fatigue /morning stiffness)
Q3 month xray sarcoilliac joints
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58
Q

Best way to maintain ROM with ankylosing spondylitis is?

A

Excercise

Follow dz activity with ESR

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59
Q

Uveitis in?

A

Reiter’s syndorme
Behcet’s dz
Ankylyosing spondylitis

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60
Q

Pt h/o anklyosing spondylitis on NSAIDs c/o new onset back pain - early fx wtd?

A

xray

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61
Q

Pt p/w asymmetric arthritis with pain in R knee, mouth ulcers, non-specific urethritis and conjunctivitis - HLA B27+, non-specific urethritis, conjunctivitis and asymmetric arthritis dx?

A

Reactive arthritis
Tx: NSAIDS - DMARD in extremem cases
COnjunctiviits, urethritis asym artrhtis (also mouth ulcers, keratoderma blenorrhagica
wtd next? HIV test

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62
Q

34yo Lt ankle arthritsi and left achilles tendon area pain - redness of eye abd pain adn diarrhea - exam with pai at baseof calcenus dx?

A

Reactive arthritis
Tx - cipro + NSAID
If no more diarrhea just NSAID

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63
Q

Pt wit reactiev arthritis ongoing arthritic pain for maoe than 6 months not releived with NSAIDs or steroids wtd?

A

sulfasalazine/MTX

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64
Q

How to tx pt with remote h/o urethris and now enthesitis

A

Tx chlamydia + NSAID

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65
Q

Causes of reactive arthritis

A 
Yersinnia
SHigella
Salmonella
Campylobater
Ureaplasma
C diff
BCG tx
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66
Q

Pt p/w lower back pain and in DIP, HLA B27+, pitting nail changes present

A 
Psoriatic arthritis
Tx
Mild - NSAIDS, skin/nail change -> MTX
No hydroxychloroquine
Worse with UVB
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67
Q

Pt of Middle eastern/japanese descent - recurrent painful apthous stomatitis, genital apthous ulcers, joint pain, erythema nodsoum on legs, HLA B5+, uveitis, pathergy (hyperreactive to needle sticks)

A

Bechet’s dz
a/w aortic aneurysm
erythema nodosum, apthous ulers
Tx: steroids

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68
Q

24yo M c/o multiple oral apthous ulcers/redness of eye x few months tender nodules on shin - CXR prominent pulm artery - aneursym on CT - dx?

A

Behcet’s dz

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69
Q

DTR dec with?

A

WNV
Tick paralysis (absent)
Toluene
spinal abscess

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70
Q

DTR inc with?

A

Serotonin
ecstacy
epidural abscess
NORMAL with MG

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71
Q

Oral apthous ulcer, gential ulcer, refuses needle stick?

A

Behcet’s dz

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72
Q

Paiful shin nodule, genital ulcer refuses needle stick

A

Behcet’s dz

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73
Q

Painful shin nodule, oral apthou ulcer, aortic anurysm, painful red eye blurry vsiion, occ knee/ankle pain?

A

Behcet’s dz

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74
Q

Oral apthoug ulcer, h/o urtetrald/c in past red eye, knee/ankle pain

A

Reachtive artrhtiis (Reiters)

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75
Q

Pt returns form Inia, thailand or africa high fever, pain in small joints hand, wrist ankle with or without maculopapular rash - dx?

A

Chikungunya virus

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76
Q

All these cause reactive arthrisi with dactylitis

A 
Yersinia
Shigella
Salmonella
Campylobater
C diff
Ureaplamsa
Inflamm bowel dz
NOT E.Coli!!
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77
Q

25yo p/w pain/swelling of right knee, diarrhea intermittently fo rweek, swelling of entire 2nd toe (sausage digit and sever pin on palpation of achilles tendon - painless ulcer on tongue - dx?

A

Reactive arthritis
what is +?
Stool ctx

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78
Q

70yo DM male p/w pain in mid back area - early morning stifness of spine, exam with dec’d thoracic lateral flexion - xray spine with flowing sosification o anterior longitudinal lgaments dx?

A

DISH (Diffuse idiopathic skeletal hyperostosis)

Tx: physical therapy, NSAIDs

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79
Q

Osteoarthritis

A

Older age
H/o trauma
Obesity, repetive use
2/2 DM, hyperparathyryodi - chondrocalcinosis
Labs - low Rh factor s
Tx: lose wieght, tylenol up to q6hr, NSAIDs, celecoxib with PPI, intrasticular steroids, hyaluronic acid - replace joint

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80
Q

Osteophyte formation -

A

osteoarthritis

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81
Q

Periarticular osteopenia

A

RA

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82
Q

Joint space deformity

A

OA/RA

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83
Q

Marginal bony erosioin in PIP, MCP

A

RA

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84
Q

Central bony erosion PIP, DIP

A

OA

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85
Q

Subchonral sclerosis

A

OA

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86
Q

Pt wit severe OA pain not relieved with tylenol h/o UGIB wtd?

A

low dose NSAIDs

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87
Q

Pt with fatigue an Hg 9, MCV 75 - pt taking NSAIDs for OA occult + wtd?

A

D/C NSAID start tylenol

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88
Q

Most important risk factor for OA

A

Obesity

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89
Q

Elderly pt with pain in thumb while turnign key opening car doors - pain at thumb on fexio and int rotation - crepitus + dx?

A

Osteoartritsi of 1st CMP joint

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90
Q

Pt with OA - wnat to try glucosamine or chondroitin sulfate wtd?

A

tell no different than placebo

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91
Q

Pt with longtanding h/o steoartrits takes tylenol for pain - plays tennis occasionally - mild crpitus and swelling of R knee - no fever WBC 8000 - wtd?

A

Tap knee, +steroids and then Phys tx

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92
Q

Pt with osteoarthris of R knee crpitus with pain acan’t take NSAIDs with inc Cr - steroid /hyaluronan inj with incomplete response

A

Exam with 10deg valgus def loss of cartilage on lat knee - (points outward)
Medial wedge insole
Exam 10 deg varus deformity with medial knee cartilage loss - wtd? (points inward)
medial unloading brace/lateral wedge insole.

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93
Q

Randomized clinical trial shown benefit of acupuncture in?

A

OA knee/hip

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94
Q

Topical capsaicin benefit of OA in?

A

hand

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95
Q

Pt is brick layer p/w painand swellign of PIP and DIP - xray loss of caritlalge and narrowing of joitn space and CENTRAL erosion dx?

A

erosive OA (PIP/DIP)

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96
Q

Laboro or farmer p/w URI - RA for >15 yrs - swollen PIP/MCP boggy felling does not c/o pain, strength normal - erosion PIP and MCP - dx?

A

RA (arhritis robustus)

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97
Q

Presentation of pain in OA hip in?

A

groin

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98
Q

R groin with RA and osteophytids on xray? dx?

A

secondary OA

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99
Q

R groin pain with RA, xray neg - MRI double line sign T2?

A

Avascular necrosis

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100
Q

R groin pain in middle aged pateint xray mild osteopenia - MRI T1 diffuse dec’d enhancemnt femoral head, T2 diffuse increase enhancement fem head?

A

Transient osteoporisis

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101
Q

Pain over anterior aspect of hip or groin - r/o hip joint problem like?

A

Avascular necrosis

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102
Q

Pain over latral asp of hip can’t sit in car or sleep on that side

A

direct pain - trochanteric bursitis

tx: inject local steroids

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103
Q

40yr old b/l groin pain L>R worse with activity and internal rotation

A

Acetabular impingement

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104
Q

Pt with SLE on steroids >2yr pain in hip , walks withi limop - dx test?

A

MRI r/o avascular necrosis

105
Q

45yo c/o pain in right buttock shoots down back of thigh for past 3 days - tendernesss over R sciatic notch when pressure applied by thumb and pain on abduction while lying down - dx?

A

Piriformis syndrome

Tx: NSAIDs

106
Q

18 t help - walks with limp

A

check xray

peri-acetabular osteotomy->arthropalsty

107
Q

Pt with pain on groin - xray with osteophytes - analgeisa and cane - directions for cane?

A

use cane on OPPOSITE side of affected joint

108
Q

Elderly pt with longstanding RA on MTX, hydroxychlroquine, NSAID with groin pain - xray NO joint space and severly impaired mobilization dx?

A

secondary OA

Tx: replace joint

109
Q

Gout

A

Uric acid

110
Q

Peduogout

A

Ca Pyrophosphate

111
Q

Gout&pseduogout preciptiants

A 
Asymmm inflamm arthritis
Trauma
post surgery 3 days post op
major medial illness (MI, CVA, PE)
fasting
etoh abuse
high fructose drinks
a/w HTN, DM HCTZ
112
Q

Do you tx pt with asymptomatic hyperuricemia

A

NO - only with sx

113
Q

Is uric acid elev during attack of gout?

A

No - usually falls during gout attack

114
Q

Do you need to have hyperuricemia to dx gout?

A

No - uric acid decreased or normal during gout attack

115
Q

Pt with great toe swelling first tiem - neg biref crystals on tap

A

tx?

Colchicine

116
Q

Pt with contraidication to cochicine 2/2 diarrhea

A

NSAIDs

117
Q

Pt with gout, contraindication to NSAID or colchicine with renal inuff, CHF, PUD wtd?

A

steroids

118
Q

Pt with only 1 or 2 joint gout?

A

intraarticular steroids

119
Q

Polyarticular joint involvement gout

A

systemic steroids

120
Q

Pt gouty attach resoved with steroids - wtd after -

A 
start allopurinol (Xanitithine oxidase inhib - dec production)
(Probenicid - inc uric acid excretion)
121
Q

Pt with tophaceous gout never had gouty attack wtd?

A

colchicine + allopurinol

122
Q

Pt with h/o gouty attack in past on coclchicine and allopurinol p/w acute gouty attack wtd?

A

continue allopinol, start NSAID

123
Q

If recurrent attacks despite ppx

A

assess adherence to allopurinol

124
Q

Pt with HTN takes ACEi c/o generalied rash - fever, necrolytic rash wbc 15, eos 10%, BUN cr 40/3.2, AST/ALT inc’d - due to?

A

allopurinol

allopurinol also inc’d level of azathrioprine

125
Q

Pt h/o gout p/w swelling knee - tap with neg birefringent crystals WBC 40K, started on NSAIDs taking allpurinol - 1 wk later reaccumulation fluid still pain - tap again with neg birefringent crystals WBC 46K - fluid yellow and turbid - wtd?

A

Septic arthritis - IV abx

126
Q

Pt with HTN on HCTZ uric acid elevation - asx

A

c/w HCTZ

127
Q

Pt with HTN on HCTZ with uric acid elevation and gouty attack

A

d/c HCTZ

128
Q

Elderly pt F on HCTZ p/w pain on PIP/DIP with nodules and swelling distal to nodules

A

gouty arthritis - monosodium urate deposits

129
Q

Pseudogout (Calcium Pyrophosphate dihydrate disease)

A 
Causes
HyperPTH
hemochromatosis
HyperCa
Hypothyroid
Hypophosphatemia
Wilson's dz
130
Q

CPPD can presents as

A

Pseduo RA
Pseduo Gout
Pseduo OA
Dx knee most commonly affected
Xray - chondrocalcinosis (Ca+ of ligament)
Joint fluid - rhomboid crystal - weakly + birefringence
Tx smiliary to gout - colcihicine/NSAID

131
Q

55yo p/w pain in knees and wrist fatgue, dec’d libido, swelling wrists/knees - Ca of mensci/traigular ligament - AST/ALT elevated - FBS 150

A

Pseduogout 2/2 hemochormatosis wtd next?

Serum transferrin saturation and iron level

132
Q

Pt with artritsi xray with multiple area of joint calcification and fatuge, FBS 158 dx?

A

Chondorcalcinosis due to pseudogout CPPD - test to do?

TIBC (trasf sat/ferritin

133
Q

A pt with yperPTH undergoes parathhyroiectomy, post surgery acute onset pain, swelling righ tknee =- reveals?

A

55K wbc, postive birifrignence (weak)

134
Q

Post surgery 3 days later wrist, MCP, PIP, DIP, knee pain - knee joint swollen, urica acid inc’d what to expect?

A

Calcium pyrophosphate crystals

135
Q

Joint fluid interpreation

A

inflammatory - WBC 2-75K, PMN>50%, gluc >25

Septic WBC>50K, PMN>75%, gluc <25 (bacterial)

136
Q

Pt c/o pain on abduction of shoulder - mianly anterior tenderness ovre biciptial groove

A

Bicipital tendinopathy

Tx - NSAIDS->PT -> steroids close to tendon in bicipital groove

137
Q

Pt c/o pain in shoulder - started tennis after long time - pain in shoulder while trying to comb hair, lifting dress or lifting weight over head - pain in lat shoulder while laying down at night, painful abduction beyond 40 deg and int rotation

A

Rotator cuff tendinopathy

138
Q

75yo M fall from height with streched hand - c/o sohoulder pain - cant shrug shoulder, can’t abduct arm, an’t keep arm up after passive lift (drop arm test +) xray reveals no fx - after xray?

A

Rotator cuff tear

139
Q

Pt c/o pain in shoudler - inced on abduction, extremes ofmovement, painless - pain more on active than passive - swings arm back and forth wihtout pain

A

dx subacromial bursitis

140
Q

Pt with pain and griding or popping sensation in anterior shoulder while reachig to put seat belt on - pain on abduction beyond 120 deg

A

acromiolavicular joint arthritis

141
Q

66yo F gradual onset progress R shoulder pain x 1 yr difficulty combing hairand wahsing fae while showering - minor MVA couple yrs ago - diff abducting and ext rotation of R shoulder with creptius and tenderness over joint - xray narrowing of glenohumeral joint space

A

Gelnohumeral OA

Tx: NSAIDs, strestching excercises - persistent sx - intraarticular steroids - no response- surgery

142
Q

72yo F R shoudler pain x 1 year with gradual onset sx with movement of shoulder at night - difficulting abducting shoudler
Xray with Ca of ligaments and some effusion on rap with RBC/WBC 2K, ALIZARIN RED stain basic Clcium phosphate crystals occiasion HYDROXAPATITE crystals

A 
Milwaukee shoulder (apatite crystals, ALIZarin red stain)
Tx: NSAID, repeat arthrocentesis -> persisent symptoms - intraarticular steroids -> still sx - arthoplasty
143
Q

60yo F with cast for arm injury - post removal with stiffness - inability to move shoulder - loss o f both active an passive ROM - tenderness pin around shoulder - xray looks normal - inecting steroid into hsoulder with resistance dx?

A

Adhesive capsulitis

Tx: early mobilization

144
Q

Lying on side pain

A

Shoulder - rotator cuff tendinopathy
Left precordial - costochondritis
Lateral hip pain - trochanteric bursitis

145
Q

Student wit pain and swellign elbow near exams or (carpet layer, roofer, et) Can pronate/supinate arm but can’t flex dx?

A

Olecranon bursitis
etio truama, gout, sepsis
Tx NSAIDs lcoal steroids

146
Q

Pt with pain/swelling elbows with warmth and tnderness - ROM painess tap with 9000 WBC (<20K)

A

Dx septic olecranon bursitis
Tx Aspiration, drainage, IV abx NSAIDs
If recurrent - excise bursa

147
Q

Pt with pain in lateral elbow anterior to lateral epicondyle - pain on ext of fingers and supination of forearm - while in airport lfted suitcase and pain returned dx?

A

lateral epicodylitis - pain in extension
due to liftign heavy obsjects
Extensor carpi radialis
Reduce recurrence - six weeks phsical therapy with eccentric excercise (opposite direction)

148
Q

Carpel Tunnel Syndrome

A 
Wk in abductor pollicuis brevis
Phalen's Sign (forced flexion wrist) +, Tinel's sign (tinel=tap)
Tx: Neutral splint at night
IF no response or thenar atrophy
Nerve conduction study -> Sx release
149
Q

Cause of carpel tunnel

A 
RA
DM
Preg
Menopause
Myxedema
Amyloidosis
Acromegaly
150
Q

Presentation of median nerve issue

A

unable to oppose little finger with thumb

151
Q

55yo F numbness both thumbs and index fingers upon holding anything for few min, HR 52, fatigue next test?

A

TSH

152
Q

Preg woman with c/o pain and paresthesia both hands and thumb andindex finger esp at night wtd?

A

Neutral splinting of wrists

153
Q

45yo RA b/l tingling sensation in both hands worse at night with thenal muscle wasting wtd?

A

nerve conduction studies

154
Q

Pt fails neurtral splinting and has thenar atrophy?

A

Sx release

155
Q

Numbness fingers, thumb index.iddle with early mornign stiffness>1hr diff opeing bottle

A

RA

156
Q

Long distance cyclist p/w tingling numbness in littlea nd 4th finger and ulnar asp of palm - abduction decreased

A

Ulnar entrapment at wrist, ulnar groove in elbow

157
Q

Pt in MVA p/w inability to open/exten finger du to pain dx?

A

Super condylar fx - disrupting brachial blood flow

158
Q

Pt p/w pain on radial (lateral) asp wrist esp when lfiting children - young man who plays vidoe games - tenderness over radial sytloid process - resisted abduction pain and with ext of thumb - making fist with fully flexed thumb and ulnar dev with pain (Finklestein’s test)

A

Dequervan’s tenosynovitis
tx: rest tendon (no grip.rasp), splinting - local steroids
If severe surgery

159
Q

Pt p/w wrist drop, dec’d sensation in radial and dorsal aspect of hand - dx?

A

Compression of radial nerve at Spiral groove in middle of arm - saturday night palsy

160
Q

Pt p/w finger stuck in flexion at PIP - straightened with effort of other hand - tenderness at base of finger dx?

A

Digital tenosynovitis - Trigger finger

tx: steroids or surgery if not working

161
Q

Pt wit hstiffness ulnar aspect of hand - unable to extend 3rd & 4th fingers - thickening and contraction of palmar facia - DM and etoh liver dz

A

Duprytrne contracture
Tx: 1st collagenase injections
2nd surgery

162
Q

Pt fell on outstriched hand - tenderness over anatomic snuff box - xray neg fo rfx wtd?

A

thumb spica splint (scaphoid fx)

bone scan/MRI

163
Q

DM pt with inability to completely extend fingers - hand bring hands together with tips of fingers and wrists of both hands but can’t bring MCPs together - no erythema or swelling

A

DM choropathy due to collagen depostion

164
Q

Meralgia Paresthetica

A

DM with burning sensation or numbness in anterior and lateral thigh
Pain worsens with abduction of thigh and with excercise - palpation of RLQ in inguinal region elecits pain
Etio - compression of cutaneous femoral nerve
Tx: wt loss, anticonvulsant, local steroids

165
Q

Pt c/o hip pain - xray fx of ramus of pubis tx?

A

early ambulation/PT

166
Q

Pt p/w pain in patellar region - no skin bkdn - erythema and tenderness over patellar region

A

pre-patellar bursitis housemaid knee

Tx NSAIDs/local steroids

167
Q

DM pt with pelvic girdle and thigh pain - no burnign sensation - exam wit hatrophy and wk of thigh muslces dx?

A

Diabetic amyotrophy

tx: better glucose control

168
Q

Elderly pt with pain on knee, medial aspect 5cm below joint line - worse with climbing stairs - xray no calc mild osteoarritisc changes

A

Pes Anserine bursitis (pain with climbing stairs, local pain and swelling)
Tx: local steroids, rest, NSAIDs

169
Q

Pt c/o pain on side of knee when JOGGING or CYCLING - radiates UP toward thigh - tenderness in lateral knee whiel abducting or ext hip - snap on felxion - int rotation no pain - dx Iliotibial band syndrome tx?

A

COrrect trining errors, proper foot wear, streching hip abductors

170
Q

28yo long distance runner c/o pain in knee - pain described as burning sensation on inner and outer asp of patella, also behind patella worse with phyical activity - knee stiffness after sitting for long time (movie goer sign)

A

Dx: Patellar femoral syndrome
(patellar compression check)
Tx: decreas running/quadricpet strenghening , analgesic
NO SURGERY REQUIRED!

171
Q

Teenager with anterior knee pain below knee joint exam poitn tenderness below knee joint esp on ext knee against resistantce

A

Dx Osgood Schaltter dz - irritation of patellar ligament, young ppl during growth spurts

172
Q

20yo to ER with acute pain in kneee with swelling - palyed football 1 hr ago and heard popping sound then pain/sweeting - anterior drawer sign/lachman sign +

A

ACL tear (forward knee laxity both in anterior drawer sign and lachman test)

173
Q

Pt presents hours after injury with swelling to knww - locks and gives way, popping sound during injury - palpation of medial joint line with pain, clicking soudn on felxio of nee - McMurray test +

A

Meniscal tear (flex hip, and knee, valgus pressure then extend knee - if pop/pain then +)

174
Q

75yo F assisted living with pain on medial aspectof knee fo rseveral months, click on palpation wtd?

A

PT

175
Q

Pt p/w pain in knee on medial aspecto finjury sever hours ago - no popping sound can ambulate but no pivor/twist - Drawer neg, lachman neg, varus neg, valgus + with pain on mediail joint

A

MCL tear (hit from lateral side)

176
Q

Pt p/w pain and swelling posterior leg - >24hr ago after tennis (out of practice - swelling and tenderness in mid calf area - no h/o RA wt?

A

US,
Dx: gastocnemium tear
Tx: Rest NSAID crepe bandage

177
Q

Pt with pain in ankle on ambulation - twisted anglkle on uneven surface - can walk 4 steps without support - compression of posterior malleoli (medial and lateral) no pain -

A

Ankle sprain - talofibular ligament strain - no need for xray
Tx: NSAID, splint

178
Q

Long distance runner pain in lower medial aspect of leg - worsened when jogging, xray neg for fx

A

Dx: Shin aplints - overuse syndrome
Tx: rest, ice packs

179
Q

Pt p/w pain/burning sensation between 3rd and 4th toes worse while walking with high heels - pain while walking on hard surface - pain radiates in fron tof toes along with parathesias on plantar aspect - better when shoes removed - dx?

A

Morton’s neruoma - interdigital plantar neuroma

180
Q

Pt with pain in heel, stiffness during early morning stride - get better with day going on…dx?

A

Plantar fasciitis
Tx: Ice pack after activity, arch support nSAID
correct raining error, steroid injetion, surgery
streching exc with dorsiflexion of foot

181
Q

Pt with plantar fasciitis, xray with heel spur - cause of pain likely…

A

plantar fasciitis

182
Q

Foot pain, more in morning, difficulty with dorsiflexion - tenderness at base of calcaneous, with inc’d tenderness squeezing heel dx?

A

Plantar faciitis

183
Q

Pt with numbness and burning sensation in toes - worse on walking and end of day - sx worse at night - radiates to front of toes, better with shoes off - percussion posterior and inf to medial malleous produces pain

A

Tarsal Tunnel syndorme
Tx: arch support shoe modification
Local steroids
Sx decompression

184
Q

Pt p./w painful feet, ankle and knees after prolongued standing fo rfew years - normal feet on exam - but on standing arches of feel colapse and valgus of heel - dx?

A

Flat feet Pes Planus tx?

-better shoes - podiatrist for orothotic shoe fitting

185
Q

45yo F with extreme fatigue doesn’t want to get out of bed, also with diffuse muscle ache in most muscle group on exam - no fever, no swelling , ANA 1:64, ESR 30, CPK 98 wtd?

A

Dx: fibromyalgia
Tx: amitripyline or excercise

186
Q

elderly woman with generalized body ache adn fatigue started couple dyas ago with pain in upper arms and neck a/w morning stiffness, no focal euro def, minimal OA chagnes on xray, ESR 52, alk phos elev, no changes with NSAID - local steroid to shoulder temp relief dx?

A

Polymyalgia rheumatica
Pain in neck/shoulder/hip (morning pain)
can be a/w temporal arteritis
TX: low dose prendisone

187
Q

85yo F recurrent pain in neck ESR 40, low grade temp - restriction of neck movement from pain - Xray Ca of ligaments in neck - Ca noted on other joints as well

A

Crowded dens syndrome

188
Q

Relapsing polychondritis

A

swellilng of ears, hoarseness, aortic regurg
Pt with hoarness, episodic swllign of nears history of intubation 2/2 subglottic stensois
Larygoscopy edema/inflammation
Dx: Bx of cartiliage
Tx; steroids then immunosuppressive agents.

189
Q

Large Vascululitis

Complement normal

A

Temporal arteritis
Takayasu’s arteritis
Aortitis

190
Q

Medium Vasculitis

Complement normal

A

Polyarteritis Nodosa (PAN)
Granulmatosis with polyangiitis (wegeners)
Chugg strauss

191
Q

Small vasculitis

A 
Henloch schonlein - abd pain/nodulies
Microscopic polyartitis angiits (MPA) - cousin of PAN - MPO
Churg Strauss
Good pastures
Cryoglobulinemia - dec C4>decC4
192
Q

65yo F c/o frontal h/a moderately sever adn throbbing - scalp urst when combs hair, hurst while chewing - episode of blurry vision - exam no focal deficit wtd?

A

Check ESR
Steroids
Temporal artiteritis - even if bx neg (can be skip lesions)

193
Q

65yo M h/a ESR 85 steroids started and temp bx neg - BP both extrem neg - wtd next

A

US bx contralateral temporal artery

194
Q

Pt p/w pain/wk left arm after excercise - recent dizziniess/visual distrubance and TIA - BP R 140/80, Lt 155/95

A

Pt age 25 with h/o maliase and fever - Takayasu’s
Pt elderly with normla ESR - > atherosclerosis - subclavian steel
Pt elderly with high ESR - Temperoal arteritis
WT? steroids, temp artery bx, MRA chest

195
Q

Dx of Takayasu dz?

A

Aortography, check for stenosis

Tx: steroids, CCB

196
Q

Ankylosing spondylitis a/w ?

A

Aortitis and Uveitis

197
Q

Aorititis a/w?

A

Anklyosis sponylitis, Uveitis, syphillis

198
Q

50yo M pw abd pain worsens while eatin gin periumbilical area - better when somach empty - joint pain in hands and feet 25lb wt loss in 3 months, chronic leg ulcer for years - diff tenderness on palpation of abd - ESR 100, BUN cr elev - best test for dx?

A 
Abd angiogram
Polyarteritis Nodosa (spares lungs)
a/w Hep B
wt loss, Cr elev, elev ESR, pain of abd, ulcers
bead sign on aortogram (aneursyms)
Tx: prednisone, cyclophosphamide
199
Q

40yo M c/o wk left hand and abd pain - dec power l hand diffuse abd pain no rebound, high ESR, U/A protein - no obstru on xray dx?

A

PAN

Tx: steroids + cyclophosphamide

200
Q

35yo p/w abd pain - labs wit hrenal insuff - Hep B ag + - pt has?

A

PAN - 30% a/w hep B

201
Q

24yo F italian/jeiswh/arab descent with recurrent abd pain every 2 months for 1-2 days, appy as child - pain spreads all over abd with fevers - swollen knee, power normal - FATHER WITH SAME SX dx?

A

Familial mediterrainian fever
Tx: colchicine
complciations - amyloidosis (AA), renal failure

202
Q

Causes of amyloid

A

FMF
RA
TB
MM

203
Q

Amyloidosis

A

proteinuria +-hematuria with renal failure
Bx congo red stain - fibril of apple green birefringence
abd fat bx if neg then bx affected organ

204
Q

50yo F pw cough, sob, artritis nasal septum fat - CXR mulptole pulmonary nodules and one cavitary lesion - afb neg, BUN cr elev
BX - vasculitis with necrostizing granulomas c-anca+ ,RH + dx?

A

Granulomatosis with polyangiitis (Wegeners)
Tx:
Non-sever - steroids + MTX
Severe Steroids + rituximab or cyclophosphamide
In remission - MTX
Relapse - steroids + rituximab

205
Q

Thin walled cavitary lesion CXR

A

norcardia

Histoplasmosis

206
Q

Thick walled cavitary lesion CXR

A

Wegeners, blastomycosis

207
Q

24yo M wiht ongoing sinusitis for past couple months a/w cough, tx’d with amox x 7 days tmep 100.5 boggy turbinates with purulent secretions, rhonci on ausculatation CT sinus total oapcification CXR nodular infiltrates - ANA, P and C ANCA+ dx?

A 
Wegeners (lung involvment, no abd invovlement)
Granulomatosis with polyangiitis
Lung and kidney involvement, nasal d/c
Autoimmune attach by ANCA ab (C)
Tx: steroids and cyclophosphamide
azathroprine MTX, mycophenlate
Rituximab (relapse)
208
Q

40yo F with h/o asthma with several allergies no pets pw SOB wheezing and wk left foot - uses albuterol, amlmetoerol steroids - rales left base, dec power R foot - CBC eos+, RUL density dx?

A

Churg Strauss
eosinophilic granuloamtosis with polyangiitis
pt w/ h/o reactive airway ie asthma or allergic rhinitis
+eos
IgE NORMAL
+p-ANCA
mononeuropathy/polyneuropathy
pulmonary infiltrate
extravascular eos+
Tx: Prednisone +- azathroprine, cyclophosphamide, MTX (maintenance)

209
Q

Most specific Ab for SLE

A

ANti smith/ anti DS DNA

210
Q

Labs for SLE

A

inc’d ESR
C3>C4, CH50 dec
anti DSDNA+ (follow dz activity with this)

211
Q

Tx for SLE

A

Arthritis - ASA, NSAID->hydroxychloroquine
Photosenstiviyt/rash - avoid sun, use sunscreen-> top steroids - hydroxychlroquin
Throbocytopenia - steroids, IVIG
Hemolytic anemai - steroids
Nephritis - steroids, add cyclophophamide, mycophenalte
in AA/hispanic nephritis - steroids then mycophenolate
Refractive lupus - use Bilimumab

212
Q

SLE on steroids still with sx

A

MSK sx - Hydroxychorloquine

Neprhtis/CNS sx/system vasculaitis or alveolar hemorrhage - cyclophosphamide

213
Q

Serolgically active but clinically quieescent SLE

A

no tx

214
Q

Pt on minocycline fo racne or RA >2yr on procainamide >1yr, for arrythmai or infliximab for RA for 6 months, hydralazine CHF for past 2 years or INH for PPD for 8 months p.w malaise, low grade arthralgia of MCP, PIP joints, early morning stiffness, wt loss irreg menses, ESR 65, ANA + 1:320, C2, 4 normal - all favor drug induced lupus …

A

Normal complement
No pscychosis or sz
U/A no RBC or protein/casts
high ANA

215
Q

24yo h/o lupus for 4 years foudn to have lupus anticoagulant syndrome and history of spontaneous abortion twice she is on cyclophosphamide and steroids - asks about long term contraception

A

Progesterone only IU device

216
Q

Pt on PTU for hyperthyroid pw palpable purpuric lesions on extrem and trunk - P-ANCA+ and ESR high, Heb B neg bx of purpura leukoclastic vasculitis - dx?

A

PTU induced vasculitis

217
Q

35yo F dx with SLE and lupus nephritis txd with steroid and IV cyclophoshamide about 2 yrs ago meds were tapered off and was asx and healthy now with low grade fever and arthralzgias what would suggest flare of SLE

A

Inc’d Anti DSDNA and dec’d complement

218
Q

Leasding cuase of death in SLE pt is?

A

Cardiovascular disease

219
Q

Dec OCP levels

A

Rifampin

St John’s wart

220
Q

What causes MAT

A

COPD

221
Q

T/F SLE pt inc’d risk of stroke

A

T

222
Q

T/F SLE pt with inc’d risk of MI

A

T

223
Q

T/F SLE pt inc’d risk of DVT

A

T

224
Q

T/F SLE pt inc’d risk of recurrent spontaneous abortions

A

T

225
Q

T/F SLE pt in’d riks of avascular necrosis

A

T

226
Q

Pt with recently dx SLE p/w complaints of dec urination and wk leg - pain in back , hyperactie reflexese - exam no spinal tenerdness

A

MRI spine r/o transverse myelitis - dedema of spinal cord c/w inflammation
IV steroids

227
Q

SLE pt on hydroxychloroquine and Prednisone 20mg/day p/w psychosis - etiology?

A

steroid induced psychosis if >20mg steroids

SLE if <20mg steroids/day

228
Q

20yo F delvers baby with CHB - mother with scaly papular rash - ANA neg - woman with what ab?

A

SSA (anti-RO)

229
Q

Pt with 1st trim spontaneous abortion for 1st time

A

No need to check for antiphospholipid

230
Q

Pt with 3rd trim spontaneous abortion for 1st time

A

check for antiphospholipid Ab

231
Q

Pt with recurrent 3rd spont aborition in 1st trimester

A

check for antiphospholipid Ab

232
Q

Sclerosis

A

Generalized - systemic Sclerosis
ANA+
Scl 70_
Anti-topoisomerase+

Limited - Crest - Anticentromere +

Plus muscles - dermatomyositis
Polydermatomyositis
Mi2, AntiJo Anti-PM1

233
Q

Systemic Sclerosis (Anti-Scl 70+)

A

Skin - diffuse fibrous thickening, sclerodactylyl, tight face/small mouth, abn nail folds
Joints - symmetric arthritis, MCP
Tendon friction rub - > MTX/NSAID
Raynaud - warm gloves, nifedipine
LUngs - interstitial pneumonitis, interstitial fibrosis - CT scan-> chylophophamid+ steroids
Pulm HTN
Renal - renal crisis (HTN, proteinuria, edema) - ACEi (irrespective of cr) - what precipitates - steroids
GI dysmotility - erythromycin
GERD
Wide mouth diverticula
Bacterial overgrowth syndrome (cipro/flagyl)
Heart - Restrictive pericardial dz

234
Q

Sclerosis pt can present with?

A

Intersticial pneumonitis (fiborosign alveolitis)

235
Q

CREST (anti-centromere+)

A 
C-> Calcinosis cutis (calcif of soft tissue)
R -> Raynaud
E -> Esopheagela dysmotility
S-> Sclerodactyly
T->telangiectasias
Pulm HTN more common than scleroderma
236
Q

35yo garderner p/w painful fingers during cold weather, figners white with cold - wears warm glove and doesn’t help - wtd?

A

nifedipine

237
Q

How will you recomgnize rhumatic (seond vs primary dz) in pt with raynaud’s

A 
abnormla nail fold capillaries
Secondary
Age>40,
Abn nail folds capillaries
Digital ulcerations
238
Q

45yo played basketball fo r4 hours at family reunion p/w swelling arms/leg sparing hand/feet - exam wit ORANGE PEEL like quality of skin - CBC EOS+

A

Dx: Eosinophilic Fascitiis
Tx: Self limited-> steroids

239
Q

Polymyositis (anti Jo+)

A 
Anti Jo+
Inc'd CPK
HLA DR3+ Women>Men
Prox muslce wk, can't get up from chair or squat
can't comb hair, mechanic hangds
Abn CPK (10x, inc'd ANA)
Biopsy myonecrosis, cellular infiltrates
240
Q

Polymyositis + skin changes=

A 
Dermatomyositis (Anti- Mi2)
Polymyositis sx (weakness)
Mechanic hands (dry cracked skin)
Heliotropic rash
Gottron papules (most specific)
screen for ovarian, breast or GI Cancer

Tx: Steroids (no MTX)

241
Q

66yo F pw complint of diff getting up from chair , diff combing hair exam reveal rash on cheeks forehead eleylids - pt at risk for what?

A

Malignancy - ovarian breast or GI

242
Q

What more specific for dermatomyositis

A

Gottron papules

243
Q

What predicts poor outcome in dermatomyositis -

A

dysphagia

244
Q

West nile virus poor prognositc factor?

A

inc’d age

245
Q

RMSF poor prognostic factor

A

inc’d Cr

246
Q

55yo F with weakness - phx significant for polymyositis - CPK 950 - started on prednisone 50mg.day - feels better CPK 1990, 3 montsh later CPK level normal bu tnow prox wekaness again dx?

A

steroid myopathy

Tx: taper steroids

247
Q

65yo M progressive wk legs, arms, forearms wrists fingers distal>prox, CPK high not responsding to steroids - MTX added, CPK still high - bx wit ENDOMYSIAL inflammation adn bsophilic rimmed vacuoles wtd?

A

Inclusion body myositis

tx: taper steroids, d/c MTX

248
Q

Pt with gouty tophus on colchicine and allopurinol - h/o ashtma on inhaled steroids - p/w wk trying to get up from chair, LE prox wk aslo, DTR dec - CPK 850 - bx reveals vaculoles no inflammation dx?

A

Colchicine induced myopathy

249
Q

35yo M intubated asthmatic 4 days later on steroids and albuterol - diff extubating - CPK 925 dx?

A

Critical illness myopathy

250
Q

Ab for SLE

A

ds DNA, Smith

251
Q

Ab for Drug induced SLE

A

histone

252
Q

Ab for subacute cutaneous SLE

A

SSA (Ro)

253
Q

Ab for Scleroderma

A

Scl70

254
Q

Ab for CREST

A

centromere

255
Q

Ab for MCTD

A

RNP

256
Q

Ab for poly/dermatomyositis

A

Jo, Mi2

257
Q

Ab for Sjogren’s syndorme

A

SSA (ro)/SSB(La)

258
Q

Ab for Wegener’s

A

c-ANCA (proteinase 3)

259
Q

Ab for Microscopic polyarteritis angiitis (cousin of PAN)

A

P-ANCA (myeloperoxidase)

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