Rheumatology Flashcards by Alice Richards

3 conditions associated w. fibromyalgia

hypothyroidism
RA
sleep apnea

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5 sx of fibromyalgia

widespread muscular pain/tenderness
fatigue
HA
poor sleep
memory problems

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dx for fibromyalgia

-widespread pain index > 7
-sx severity scale > 5 x 3 mos or more

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bx findings of fibromyalgia

moth eaten appearance of type 1 muscle fibers

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3 meds approved for fibromyalgia

duloxetine (cymbalta)
milnacipran (savella)
pregabalin (lyrica)

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what class of drug is milnacipran

SNRI

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pathophys for gout

altered purine metabolism -> sodium urate crystal precipitation into synovial fluid

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common presentation for gout

> 30 yo
asymmetric
great toe
tophi

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what is podagra

gout attack in MTP of great toe -> mc sx of gout attack

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dx for gout

arthrocentesis: rod shaped, negatively birefringent crystals

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what level of uric acid is indicative (but not diagnostic) of gout

> 8

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XR finding of gout

small, punched out lesions

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what 4 foods/drinks are mc associated w. gout attack

meats
beer
seafood
etoh

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pharm for gout attack

indomethacin tid
steroids (injxn vs oral)
colchicine

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pharm for gout maintenance

allopurinol
colchicine

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what 2 meds should be avoided in gout pt’s

thiazide diuretics
ASA

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common presentation of pseudogout

> 60 yo
large joints
lower extremity
no tophi

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dx for pseudogout

arthrocentesis: rhomboid shaped positively birefringent calcium pyrophosphate crystals

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XR findings of pseudogout

fine, linear calcifications in cartilage

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crystals associated w. gout vs pseudogout

gout: negatively birefringent, uric acid
pseudogout: positively birefringent, pyrophosphate

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pharm for pseudogout: acute vs prophylaxis

acute: NSAIDs
prophylaxis: colchicine

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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)

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PAN is a blood vessel dz characterized by inflammation of _ arteries

small/medium (vasculitis)

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PAN mc affects what pt pop

middle aged men - 40’s-50’s

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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

1. prednisone 2. cyclophosphamide for refractory 3. 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

1. low dose steroids (often long term) 2. 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

1. steroids 2. 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

1. NSAIDs 2. 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

1. ANA: best initial 2. 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)