Rheumatology Flashcards
3 conditions associated w. fibromyalgia
hypothyroidism
RA
sleep apnea
5 sx of fibromyalgia
widespread muscular pain/tenderness
fatigue
HA
poor sleep
memory problems
dx for fibromyalgia
-widespread pain index > 7
-sx severity scale > 5 x 3 mos or more
bx findings of fibromyalgia
moth eaten appearance of type 1 muscle fibers
3 meds approved for fibromyalgia
duloxetine (cymbalta)
milnacipran (savella)
pregabalin (lyrica)
what class of drug is milnacipran
SNRI
pathophys for gout
altered purine metabolism -> sodium urate crystal precipitation into synovial fluid
common presentation for gout
> 30 yo
asymmetric
great toe
tophi
what is podagra
gout attack in MTP of great toe -> mc sx of gout attack
dx for gout
arthrocentesis: rod shaped, negatively birefringent crystals
what level of uric acid is indicative (but not diagnostic) of gout
> 8
XR finding of gout
small, punched out lesions
what 4 foods/drinks are mc associated w. gout attack
meats
beer
seafood
etoh
pharm for gout attack
- indomethacin tid
- steroids (injxn vs oral)
- colchicine
pharm for gout maintenance
allopurinol
colchicine
what 2 meds should be avoided in gout pt’s
thiazide diuretics
ASA
common presentation of pseudogout
> 60 yo
large joints
lower extremity
no tophi
dx for pseudogout
arthrocentesis: rhomboid shaped positively birefringent calcium pyrophosphate crystals
XR findings of pseudogout
fine, linear calcifications in cartilage
crystals associated w. gout vs pseudogout
gout: negatively birefringent, uric acid
pseudogout: positively birefringent, pyrophosphate
pharm for pseudogout: acute vs prophylaxis
acute: NSAIDs
prophylaxis: colchicine
45 yo M w. generalized malaise, fever, sore throat, muscle aches/pains, numbness/tingling, sensory disturbances, and weakness - PE shows tender lumps under the skin of thighs and lower legs - ESR/CRP are elevated
polyarteritis nodosa (PAN)
PAN is a blood vessel dz characterized by inflammation of _ arteries
small/medium (vasculitis)
PAN mc affects what pt pop
middle aged men - 40’s-50’s
what conditions are associated w. PAN
hep B/C
sequela of PAN
-increased microaneurysms w. rupture -> htn, hemorrhage, thrombosis, organ ischemia/infarction
-renal failure
-neuropathy
-amaurosis fugax
4 derm complications of PAN
livedo reticularis
purpura
ulcers
gangrene
what is this showing
tender lumps under the skin -> PAN
dx for PAN
1. gs: bx of affected artery: shows necrotizing arteritis
2. arteriography: shows typical aneurysms in medium sized arteries
3. renal or mesenteric angiography: shows microaneurysms w. abrupt cut-offs of small a
classic lab findings of PAN
elevated ESR/CRP
ANCA negative
+/- p-ANCA positive
tx for PAN
- prednisone
- cyclophosphamide for refractory
- plasmaphoresis if hep B
62 yo F c/o new onset AM HA, muscle pain, weakness, fatigue - can not raise her arm to brush her hair - PE shows normal grip strength, passive ROM limited in all direction, difficulty rising out of chair - ESR elevated
polymyalgia rheumatica (PMR)
pathophys of polymyalgia rheumatica
idiopathic inflammation of joints -> painful synovitis, bursitis, tenosynovitis
PMR mc affects what joints
proximal -> shoulder, hip, neck
PMR is closely associated w. what condition
temporal arteritis
2 ways that PMR is differentiated from polymyositis
PMR: joint pain, stiffness
polymyositis: muscle pain, weakness
hallmark lab finding of PMR
elevated ESR
gs dx for temporal arteritis
temporal a bx
tx for PMR
- low dose steroids (often long term)
- MTX
47 yo F, c/o weakness, fatigue, difficulty raising arms - no f/c, weight changes, or motor deficits - PE shows decreased shoulder strength - labs show elevated creatine phosphokinase, (+) ANCA, (+) anti-JO 1 abs
polymyositis
idiopathic inflammatory dz of the muscle causing symmetrical, proximal, painless muscle weakness
polymyositis
3 hallmark characteristics of polymyositis
symmetrical
proximal
painless muscle weakness
how to differentiate polymyositis from dermatomyositis
dermatomyositis = muscle AND skin changes
no skin changes w. polymyositis
how is polymyositis differentiated from PMR
polymyositis: painless
PMR: painful
gs dx for polymyositis
muscle bx
3 muscle enzyme elevations associated w. PM/DM
aldolase
creatine kinase
ESR
3 labs associated w. PM/DM
anti-JO 1
anti SRP
anti-Mi-2
what antibody is specific to dermatomyositis (DM)
anti-Mi-2
muscle bx finding specific to PM
endomysial involvement
tx for PM/DM
- steroids
- immunosuppresants (MTX/azathioprine)
23 yo M w. conjunctivitis and discharge, pain w. urination, and knee pain/stiffness - treated for gonorrhea infxn 5 weeks ago
reactive arthritis
pathophys of ractive arthritis
autoimmune response to infxn in another part of the body - think CT/GC
hallmark sx of reactive arthritis
asymmetric inflammatory arthritis
how to remember sx of reactive arthritis
“can’t see, can’t pee, can’t climb a tree:”
conjunctivitis
uveitis
urethritis
arthritis
4 infxns associated w. the development of reactive arthritis
CT/GC
salmonella
shigella
campylobacter
dx for reactive arthritis
hx of infxn
(+) HLA-B27
clinical
tx for reactive arthritis
- NSAIDs
- abx if indicated for underlying infxn
describe pain w. RA
-morning joint stiffness > 30 min that improves throughout the day
-worse w. rest
describe pain w. OA
-pain that worsens throughout the day
-if morning stiffness is presents, < 30 min
-improves w. rest
prodrome associated w. RA
fever
fatigue
wt loss
anorexia
RA mc affects what joints
small:
MCP
PIP
MTP
4 PE findings of RA
boutonniere deformity
swan neck deformity
ulnar deviation at MCP
rheumatoid nodules
what is this showing
flexion at PIP
hyperextension at DIP
boutonniere deformity
what is this showing
flexion at DIP
hyperextension of PIP
swan neck deformity
what is this showing
ulnar deviation at MCP -> RA
what is this showing
rheumatoid nodules
dx for RA
(+) RF
(+) anti ccp abs
elevated ESR/CRP
most specific lab for RA
(+) anti CCP abs
tx for RA
1. MTX
2. hydroxychloroquine (plaquenil)
3. sulfasalazine (SSZ)
4. leflunomide (LEF)
5. azathoprine, gold, cyclosporine
6. biologics: etanercept, -mabs
NSAIDs/steroids for acute
triple therapy for RA
MTX
SSZ
HCQ
55 yo F w. loss of teeth, dry mouth/eyes, and parotid gland enlargement
sjorgens
sjorgen syndrome is a chronic, autoimmune condition that attacks the
exocrine glands
3 glands mc affected in sjorgens
-salivary -> xerostomia
-lacrimal -> keratoconjunctivitis sicca
-parotid
dx for sjorgens
- (+) ANA:
anti-SS-A (RO)
anti-SS-B (La) - (+) RF
- (+) schirmer test
what is a positive schirmer test
<5 mm lacrimation in 5 min
tx for sjorgens
artificial tears
pilocarpine
cevimeline
moa for pilocarpine
cholinergic -> increased lacrimation/salivation
moa for cevimeline
cholinergic agonist (stimulates muscarinic receptors)
44 yo F w. intermittent joint pain in hands, wrists, feet - also c/o worsening fatigue, muscle aches, and dpn - PE shows painless oral ulcers, erythematous maculopapular lesions on face, and bilat wrist edema
SLE
SLE triad
joint pain
fever
malar rash
what is this showing
fixed, erythematous rash on cheeks and bridge of nose -> malar rash -> SLE
the classic malar rash of SLE spares the _
nasolabial folds
abs associated w. SLE
- ANA: best initial
- anti-double stranded DNA
anti smith: most specific
dx or SLE
4 or more of the following:
malar rash
discoid rash
photosensitivity
mucosal involvement
serositis
joint arthritis
renal d.o
neuro d.o
hematologic d.o
(+) ANA
(+) anti smith, anti-dsDNA, anti-phospholipid
management of SLE
sun protection
skin lesios: hydroxychloroquine
NSAIDs vs APAP
steroids
MTX
cyclophosphamide
41 yo F w. cold, blue hands in cold weather, progressive dysphagia to solids, and red skin spots - PE shows thickened hand skin w. calcific nodules, and multiple telangiectases of skin/face
systemic sclerosis (scleroderma)
scleroderma/systemic sclerosis is a systemic connective tissue d.o that affects the (5)
skin (sclerodactylyl)
lungs
heart
kidneys
GIT
what is CREST syndrome
limited cutaneous systemic sclerosis:
calcinosis cutis
raynaud’s
esophageal motility d.o
sclerodactylyl (claw hands)
telangiectasia
what are mechanic’s hands
hyperkeratotic, cracked hands w. a dirty appearance -> PM/DM
CREST affects what parts of the body (4)
face
neck
distal to elbow
knees
diffuse cutaneous systemic sclerosis affects the (2)
trunk
proximal extremities
raynaud’s syndrome is worse w. (3)
smoking
cold
emotional stress
tx for raynaud’s
ccb
2 labs associated w. scleroderma
(+) anti-centromere abs
(+) anti-scl-70 abs
which lab is associated w. CREST and has a better prognosis
(+) anti centromere abs
which lab is associated w. diffuse scleroderma and has a worse prognosis
(+) anti-scl-70 abs
(+) ANA
management of scleroderma
MTX
steroids
rheumatology conditions to know
fibromyalgia
gout/pseudogout
polyarteritis nodosa
polymyalgia rheumatica
polymyositis
reactive arthritis (reiter syndrome)
RA
OA
sjorgen’s
SLE
systemic sclerosis (scleroderma)