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Project - USMLE Step 3 > Rheumatology > Flashcards

Rheumatology Flashcards

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USMLE® Step 1 flashcards
1
Q
  • women greater than 50 yoa
  • joint pain
  • MORNING stiffness; SYMMETRICAL, multiple joints of hands, LASTS MORE THAN 1 HOUR
  • symptomatic episodes last for at least 6 weeks
A

rheumatoid arthritis

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2
Q

how is rheumatoid arthritis (RA) defined?

A

4 or more of the following:

  1. morning stiffness more than 1 hour
  2. wrist and finger involvement
  3. swelling of at least 3 joints
  4. SYMMETRIC involvement
  5. rheumatoid nodules
  6. XR showing erosions
  7. POSITIVE RF, or anti-CCP Ab
  8. elevated CRP, or ESR
  9. synovitis
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3
Q

cardiac findings in RA

A
  • pericarditis

- valvular disease

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4
Q

pulmonary findings in RA

A
  • pleural effusion with VERY LOW glucose level

- lung nodules

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5
Q

hematological findings in RA

A

anemia with NORMAL MCV

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6
Q

neurological findings in RA

A

mononeuritis multiplex

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7
Q

dermatological findings in RA

A

nodules

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8
Q

Felty’s syndrome

A
  1. RA
  2. splenomegaly
  3. neutropenia
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9
Q

joint findings in RA

A
  • MCP (metacarpophalangeal) swelling and pain
  • Boutonniere deformity
  • swan neck deformity
  • Baker’s cyst
  • C1/C2 cervical spine subluxation
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10
Q

Boutonniere deformity

A

PIP flexion with DIP hyperextension

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11
Q

swan neck deformity

A

PIP extension with DIP flexion

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12
Q

Baker’s cyst

A

outpocketing of synovium at back of knee

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13
Q

treatment for RA

A

NSAIDs with DMARD

disease-modifying antirheumatic drug

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14
Q

which joint is SPARED in RA?

A

sacroiliac joint

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15
Q

what should be started to eliminate XR abnormalities in RA?

A

DMARDs

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16
Q

BEST INITIAL DMARD to start in RA

A

methotrexate

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17
Q

adverse effects of methotrexate

A
  • bone marrow suppression
  • pneumonitis
  • liver disease
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18
Q

name the DMARDs

A
  • methotrexate
  • biological agents (infliximab, adalimumab, etanercept)
  • hydroxychloroquine
  • sulfasalazine
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19
Q

name the alternate DMARDs

A
  • rituximab
  • anakinra
  • tocilizumab
  • leflunomide
  • abatacept
  • gold salts
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20
Q

MOA of rituximab

A

anti-CD20 Ab

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21
Q

MOA of anakinra

A

IL-1 receptor antagonist

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22
Q

MOA of tocilizumab

A

IL-6 receptor antagonist

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23
Q

MOA of leflunomide

A

pyrimidine antagonist (similar to methotrexate)

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24
Q

MOA of abatacept

A

inhibits T-cell activation

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25
Q

MOA of biological agents (infliximab, adalimumab, etanercept)

A

block TNF-a

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26
Q

what could be added if methotrexate alone fails?

A

biological agents (infliximab, adalimumab, etanercept)

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27
Q

patient being treated with hydroxychloroquine, should get?

A

regular eye exams

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28
Q

adverse effect of sulfasalazine

A

bone marrow suppression

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29
Q

adverse effect of gold salts

A

nephrotic syndrome

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30
Q

what is the role of steroids in RA?

A
  • BRIDGE to DMARD therapy

- to treat acutely ill pt with severe inflammation

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31
Q

name the seronegative spondyloarthropathies (4)

A
  1. ankylosing spondylitis
  2. reactive arthritis
  3. psoriatic arthritis
  4. juvenile rheumatoid arthritis
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32
Q

characteristics of seronegative spondyloarthropathies

A
  • RF NEGATIVE
  • predilection for SPINE
  • sacroiliac joint INVOLVEMENT
  • association with HLA-B27
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33
Q
  • young male, less than 40 yoa
  • back stiffness, worse at NIGHT, relieved by LEANING FORWARD
  • kyphosis = diminished chest expansion
A

ankylosing spondylitis

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34
Q

rare findings in ankylosing spondylitis

A
  • uveitis
  • aortitis
  • restrictive lung disease
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35
Q

best INITIAL test for ankylosing spondylitis

A

CXR

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36
Q

MOST ACCURATE test for ankylosing spondylitis

A

MRI of SI joint

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37
Q

treatment for ankylosing spondylitis

A
  • NSAIDs
  • biological agents (infliximab/adalimumab)
  • sulfasalazine
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38
Q
  • asymmetric arthritis with h/o URETHRITIS, or GI INFECTION
  • fever
  • fatigue
  • weight loss
  • circinate balanitis
  • conjunctivitis
  • keratoderma blenorrhagicum
A

reactive arthritis

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39
Q

diagnostic triad for reactive arthritis

A
  1. knee (joint)
  2. pee (urinary)
  3. see (eye)
  • h/o Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter
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40
Q

treatment for reactive arthritis

A

reactive arthritis

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41
Q
  • h/o psoriasis
  • sacroiliac spine involvement
  • nail pitting
  • DIP involvement
  • dactylitis (“sausage-shaped” digits)
  • enthesis (inflammation of tendon insertion sites)
A

psoriatic arthritis

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42
Q

diagnostic test for psoriatic arthritis

A

NONE

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43
Q

best INITIAL treatment for psoriatic arthritis

A

NSAIDs

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44
Q

treatment for RESISTANT psoriatic arthritis

A

methotrexate

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45
Q

other treatment for psoriatic arthritis

A

infliximab

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46
Q
  • fever
  • salmon-colored rash
  • polyarthritis
  • lymphadenopathy
  • myalgias
  • hepatosplenomegaly
  • elevated transaminases
A

juvenile rheumatoid arthritis (JRA)

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47
Q

diagnostic test for JRA

A

NONE

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48
Q

characteristic diagnostic tests for JRA

A
  • very high ferritin
  • elevated WBCs
  • NEGATIVE RF
  • NEGATIVE ANA
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49
Q

treatment for JRA

A

NSAIDs

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50
Q

treatment for JRA unresponsive to NSAIDs

A

steroids

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51
Q

treatment for JRA with persistent symptoms

A

methotrexate, or anti-TNF medications

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52
Q
  • diarrhea
  • fat malabsorption
  • weight loss
A

whipple disease

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53
Q

MOST COMMON PRESENTING SYMPTOM OF WHIPPLE DISEASE

A

JOINT PAIN

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54
Q

MOST SPECIFIC test for whipple disease

A

bowel biopsy showing PAS positive organisms

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55
Q
  • morning stiffness LESS THAN 30 MINUTES
  • CREPITUS on moving joints
  • DIP joints
A

osteoarthritis (OA)

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56
Q

name of DIP osteophytes in OA

A

Heberden’s nodes

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57
Q

name of PIP osteophytes in OA

A

Bouchard’s nodes

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58
Q

best INITIAL test for OA

A

joint XR

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59
Q

diagnostic tests that should be ordered for OA

A
  • ANA
  • ESR
  • RF
  • anti-CCP Ab
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60
Q

treatment for OA

A

acetaminophen

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61
Q

how many criteria for systemic lupus erythematosus (SLE) are there, and how are needed to confirm the diagnosis?

A
  • 11

- 4 NEEDED TO CONFIRM DIAGNOSIS

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62
Q

diagnostic criteria for SLE

A
  1. malar rash
  2. discoid rash
  3. photosensitivity rash
  4. oral ulcers
  5. arthritis
  6. serositis
  7. kidney d/o
  8. neurological d/o (seizures/psychosis)
  9. blood d/o (anemia/leukopenia/lymphopenia/thrombocytopenia)
  10. anti-DNA, anti-Smith, or anti-phospholipid Abs
  11. ANA
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63
Q

best INITIAL test for SLE

A

ANA

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64
Q

MOST SPECIFIC test for SLE

A

anti-dsDNA Ab, or anti-Smith Ab

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65
Q

what is the best to follow the severity of a lupus flare-up?

A

complement levels (drop), and anti-dsDNA Ab (rise)

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66
Q

the presence of anti-Ro, or anti-SSA Abs is a risk for development of?

A

heart block

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67
Q

joint XR finding in SLE

A

normal

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68
Q

type of anemia in SLE

A

ACD is more common than hemolysis

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69
Q

only test MORE specific for lupus than anti-dsDNA Ab

A

anti-Smith Ab

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70
Q

other findings in SLE NOT part of diagnostic criteria

A
  • fatigue
  • hair loss
  • antiphospholipid syndrome
  • elevated sedimentation rate
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71
Q

treatment for ACUTE FLARE in SLE

A

steroids

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72
Q

treatment for joint pain in SLE

A

NSAIDs

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73
Q

treatment for rash and joint pain NOT responding to NSAIDs

A

hydroxychloroquinolone

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74
Q

treatment for SEVERE DISEASE UPON CESSATION OF STEROIDS for SLE

A
  • belimumab
  • azathioprine
  • cyclophosphamide
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75
Q

MOA of belimumab

A

inhibits B cells

76
Q

treatment for nephritis in SLE

A
  • steroids and mycophenolate, OR

- steroids and cyclophosphamide

77
Q

MOA of mycophenolate

A

inhibits B- and T-lymphocyte proliferation

78
Q

MOA of cyclophosphamide

A

alkylates and crosslinks DNA

79
Q

MCC’s of drug-induced lupus

A
  • hydralazine
  • procainamide
  • isoniazid
80
Q

drug-induced lupus ALWAYS has

A
  • anti-HISTONE Ab

- POSITIVE ANA

81
Q

drug-induced lupus NEVER has

A

renal, or CNS involvement

82
Q

complement level, and anti-dsDNA Ab are what in drug-induced lupus?

A

NORMAL

83
Q
  • women (9:1 female predominance)
  • dry eyes
  • dry mouth
  • “sand under eyelids”
  • loss of taste and smell
  • loss of teeth at an early age
A

Sjogren’s syndrome

84
Q

MOST ACCURATE test for Sjogren’s syndrome

A

lip biopsy

85
Q

other diagnostic test for Sjogren’s syndrome

A

Schirmer test (paper held to eye to test lacrimation)

86
Q

serologic testing for Sjogren’s syndrome

A
  • ANA (95% +)
  • RF (70% +)
  • anti-Ro/SSA Ab (50-65% +, but specific)
  • anti-La/SSB Ab (30-65% +, but specific)
87
Q

treatment for Sjogren’s syndrome

A
  • pilocarpine
  • cevimeline

(keep eyes and mouth moist)

88
Q

MOA of pilocarpine, and cevimeline

A

increase acetylcholine

cevimeline is specific to salivary glands

89
Q
  • woman with tight, fibrous thickening of skin
  • tight, immobile fingers (sclerodactyly)
  • Raynaud’s phenomenon
  • digital ulceration
  • joint pain (mild and symmetrical)
A

scleroderma (systemic sclerosis)

90
Q

lung involvement in scleroderma

A

fibrosis and pulmonary hypertension

leading cause of death

91
Q

GI involvement in scleroderma

A
  • esophageal dysmotility

- PBC (primary biliary cholangitis in 15% of patients)

92
Q

heart involvement in scleroderma

A

restrictive cardiomyopathy

93
Q

renal involvement in scleroderma

A

may lead to malignant hypertension

94
Q

diagnostic test for scleroderma (systemic sclerosis)

A
  • NO single diagnostic test
  • ANA
  • anti-topoisomerase Ab (anti-Scl 70)
95
Q

treatment for scleroderma

A

NO treatment (no treatment is effective in stopping it)

96
Q

treatment for renal involvement and HTN in scleroderma

A

ACEI

97
Q

treatment for pulmonary HTN in scleroderma

A
  • bosentan (endothelin antagonist)
  • prostacyclin analogs
  • sildenafil
98
Q

treatment for Raynaud’s phenomenon in scleroderma

A

CCB

99
Q

treatment for GERD in scleroderma

A

PPI

100
Q

treatment for lung fibrosis

A

cyclophosphamide

101
Q

CREST syndrome (limited scleroderma)

A
  • Calcinosis of fingers
  • Raynaud’s
  • Esophageal dysmotility
  • Sclerodactyly
  • Telangiectasia
102
Q

diagnostic testing for CREST syndrome

A

anti-centromere Ab

103
Q

thickened skin that looks like scleroderma, WITHOUT:

  • hand involvement
  • Raynaud’s
  • heart, lung, or kidney involvement
  • MARKED EOSINOPHILIA
  • “orange peel” (peau d’orange)
  • symptoms are worse with exercise
A

eosinophilic fasciitis

104
Q

treatment for eosinophilic fasciitis

A

steroids

105
Q
  • cannot get up from seated position
  • muscle pain and tenderness
  • PROXIMAL muscle weakness
  • signs of muscle inflammation
A

polymyositis

106
Q
  • muscle pain and tenderness
  • PROXIMAL muscle weakness

PLUS

  • Gottron’s papules (metacarpophalangeal joint surfaces)
  • heliotrope rash (periorbital purplish rash)
  • Shawl sign (shoulder/neck erythema)
A

dermatomyositis

107
Q

tests for polymyositis and dermatomyositis

A

CPK and aldolase

108
Q

MOST ACCURATE test for polymyositis and dermatomyositis

A

muscle biopsy

109
Q

the presence of anti-Jo 1 Abs is a risk for development of?

A

interstitial lung disease

110
Q

MC serious complication of PM/DM

A

malignancy

111
Q

treatment for PM/DM

A

steroids

112
Q
  • women, with muscle aches and stiffness with TRIGGER POINTS on palpation and nonrefreshing sleep
  • depression, and anxiety
A

fibromyalgia

113
Q

blood tests for fibromyalgia

A

ALL NORMAL

114
Q

what objective evidence is there for fibromyalgia?

A

NONE

115
Q

best INITIAL treatment for fibromyalgia

A
  • milnacipran
  • duloxetine
  • pregabalin
116
Q
  • patient 50 years or older
  • profound pain, and stiffness of proximal muscles
  • stiffness worse in morning
  • elevated ESR
A

polymyalgia rheumatica (PMR)

117
Q

on presentation, all forms of vasculitis can have

A
  • fatigue, malaise, weight loss
  • fever
  • skin lesions
  • joint pain
  • neuropathy (mononeuritis multiplex)
118
Q

common laboratory features in all forms of vasculitis

A
  • normocytic anemia
  • elevated ESR
  • thrombocytosis
119
Q

MOST ACCURATE test for all forms of vasculitis

A

biopsy

120
Q

best INITIAL treatment for all forms of vasculitis

A

steroids

121
Q

if steroids are not effective, what alternate treatment and/or additional treatment can used for all forms of vasculitis

A
  • cyclophosphamide
  • azathioprine/6-mercaptopurine
  • methotrexate
122
Q

adverse effect of methotrexate

A

liver, and lung fibrosis

123
Q

PAN features:

A
  • abdominal pain
  • renal involvement
  • testicular involvement
  • pericarditis
  • HTN
124
Q

best INITIAL test for PAN

A

abdominal vessel angiography

125
Q

MOST ACCURATE test for PAN

A

skin, muscle, or sural nerve biopsy

126
Q

treatment for PAN

A

prednisone and cyclophosphamide

127
Q

PAN does NOT affect what?

A

LUNGS

128
Q

is found in 30% of PAN

A

hepatitis B

129
Q

name the vasculitides (7)

A
  1. polyarteritis nodosa (PAN)
  2. Wegener’s granulomatosis (granulomatosis with polyangiitis)
  3. Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
  4. temporal arteritis (giant cell arteritis)
  5. Takayasu’s arteritis
  6. cryoglobulinemia
  7. Behcet disease
130
Q

Wegener’s granulomatosis (granulomatosis with polyangiitis)

A
  • UPPER AND LOWER respiratory findings

- c-ANCA

131
Q

MOST ACCURATE test for Wegener’s granulomatosis (granulomatosis with polyangiitis)

A

biopsy

132
Q

treatment for Wegener’s granulomatosis (granulomatosis with polyangiitis)

A

prednisone and cyclophosphamide

133
Q

Churg-Strauss (eosinophilic granulomatosis with polyangiitis)

A
  • vasculitis
  • EOSINOPHILIA
  • ASTHMA
134
Q

MOST ACCURATE test for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)

A

biopsy

135
Q

treatment for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)

A

steroids

136
Q

temporal arteritis (giant cell arteritis)

A
  • headache
  • jaw claudication
  • visual disturbance
  • scalp tenderness
  • ASSOCIATED WITH POLYMYALGIA RHEUMATICA
137
Q

MOST ACCURATE test for temporal arteritis (giant cell arteritis)

A

biopsy

138
Q

treatment for temporal arteritis (giant cell arteritis)

A

steroids

139
Q
  • young Asian female
  • diminished pulses
  • TIA/stroke (from vascular occlusion)
A

Takayasu’s arteritis

140
Q

how is Takayasu’s arteritis diagnosed?

A

aortic arteriography or MRA

141
Q
  • ASSOCIATED WITH HEPATITIS C

- renal involvement

A

cryoglobulinemia

142
Q

treatment if cryoglobulinemia is d/t hepatitis C

A

interferon and ribavirin

143
Q
  • Middle Eastern, or Asian ancestry
  • oral AND GENITAL ulcers
  • ocular involvement (uveitis, optic neuritis)
  • hyperreactivity to needle sticks
A

Behcet disease

144
Q

MOST ACCURATE test for inflamed joints

A

joint aspiration

145
Q

best INITIAL test for septic arthritis

A

CELL COUNT

gram stain only positive 50-60%
(can be as few as 20,000, but usually > 50,000-100,000)

146
Q

WBC count in normal joint

A

less than 2,000

147
Q

WBC count in inflamed joint (gout/pseudogout)

A

2,000-50,000

148
Q

WBC count in infected joint

A

more than 50,000

149
Q
  • male with sudden onset, severe pain
  • toe, or knee (red, swollen, tender)
  • at night
A

gout

150
Q

precipitants of gout attacks

A
  • binge drinking alcohol
  • thiazides
  • nicotinic acid (niacin)
151
Q

best INITIAL test for gout

A

arthrocentesis (joint fluid aspiration)

152
Q

MOST ACCURATE test for gout

A

polarized light exam; shows NEGATIVELY BIREFRINGENT NEEDLES

153
Q

best INITIAL treatment for ACUTE gouty attack

A

NSAIDs

154
Q

if NSAIDs are insufficient, or CI, what should be used for treatment of ACUTE gouty attack

A

steroids

155
Q

treatment for ACUTE gouty attack if NSAIDs and steroids cannot be used

A

colchicine

156
Q

adverse effects of colchicine

A
  • N/V

- bone marrow suppression

157
Q

what medication should NOT be started during an acute gouty attack?

A

allopurinol

158
Q

management of prevention of gout attacks

A
  • allopurinol
  • weight loss and exercise
  • febuxostat (if allopurinol is NOT tolerated)
  • rasburicase/pegloticase (if allopurinol/febuxostat are not enough)
159
Q

MOA of allopurinol

A

inhibits xanthine oxidase, decreasing uric acid production

160
Q

adverse effects of allopurinol

A
  • rash
  • allergic interstitial nephritis
  • hemolysis
161
Q

MOA of febuxostat

A

inhibits xanthine oxidase

162
Q

MOA of rasburicase/pegloticase

A

converts uric acid to allantoin, which can be excreted by the kidneys

163
Q
  • knee and wrist involvement
  • NO toe involvement
  • slow onset
  • pt does NOT wake up with severe pain
  • may have h/o hemochromatosis, hyperparathyroidism, acromegaly, or hypothyroidism
A

pseudogout

164
Q

arthrocentesis shows what in Pseudogout?

A

POSITIVELY birefringent RHOMBOID-shaped crystals

165
Q

best INITIAL treatment for pseudogout

A

NSAIDs

166
Q

acute management for pseudogout if NSAIDs are ineffective

A

steroids

167
Q
  • swollen, red, immobile, tender joint

- arthritic and prosthetic joints are at higher risk

A

septic arthritis

168
Q

risk of septic arthritis based on abnormality

A

prosthetic joint > RA > OA > normal joint

169
Q

etiology of septic arthritis

A
  • Staphylococcus aureus (40%)
  • Streptococcus (30%)
  • GNR (20%)
170
Q

in addition to culturing the joint, in disseminated gonorrhea you must also

A

PANculture all mucosal surfaces ( oropharynx, rectum, urethra, cervix)

171
Q

best INITIAL test for septic arthritis

A

arthrocentesis: > 50,000 WBCs

172
Q

MOST ACCURATE test for septic arthritis

A

culture (> 90% sensitive)

173
Q

empiric treatment for septic arthritis

A

ceftriaxone and vancomycin

174
Q
  • asymptomatic
  • may have pain, stiffness, aching, fractures
  • bowing of tibias
  • sarcoma arises in 1% of patients
A

Paget’s disease of bone

175
Q

if osteoLYTIC lesions, think

A

Paget’s, or OP

176
Q

if osteoBLASTIC lesions, think

A

metastatic prostate cancer

177
Q

best INITIAL test for Paget’s disease

A

AP level (elevated)

178
Q

MOST ACCURATE test for Paget’s disease

A

XR

179
Q

other tests that should be ordered for Paget’s disease

A
  • urinary hydroxyproline
  • serum Ca++ level (will be normal)
  • serum phosphate level (will be normal)
  • bone scan
180
Q

treatment for Paget’s disease of bone

A

bisphosphonates and calcitonin

181
Q

what is a Baker’s cyst?

A

posterior herniation of synovium of knee

182
Q

Baker’s cysts are seen in which patients?

A

OA, or RA with a SWOLLEN CALF

183
Q

diagnostic testing for Baker’s cyst

A

US to EXCLUDE DVT

184
Q

treatment for Baker’s cyst

A
  • NSAIDs

- steroid injection if needed

185
Q
  • pain on bottom of foot
  • very severe in MORNING, better w/ ambulation
  • resolves spontaneously over time
A

plantar fasciitis

186
Q
  • pain on bottom of foot
  • more painful with use
  • may have numbness of sole
  • avoid boots/high heels
  • may need steroid injection/surgery
A

tarsal tunnel syndrome

187
Q
  • painful burning sensation in INTERDIGITAL WEB SPACE between 3rd and 4th toes
  • tenderness
  • sharp, intermittent pain radiating toes that improves when shoes are removed
A

Morton’s neuroma

Project - USMLE Step 3 (82 decks)

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