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AAPMR BOARD REVIEW > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is RA

A

Systemic autoimmune disorder; multiorgan dz

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2
Q

Etiology of RA

A

Unknown

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3
Q

What class of joints affected

A

Diarthrodial

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4
Q

What part of joint affected

A

Synovial lining

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5
Q

What is pathognomonic for RA.

A

Erosions ; erosive synovitis > articular destruction

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6
Q

Composition of Diarthrodial joints (5)

A
  1. Type 2 hyaline 2. Subchondral bone 3. synovial membrane 4. Synovial fluid 5. Joint capsule
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7
Q

What is most important destructive element in RA?

A

Pannus

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8
Q

Pannus is a membrane of ______ tissue that covers the ______ bone & cartilage at joint margins

A

Granulation; articular

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9
Q

RA Female:male?

A

2:1

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10
Q

RA prevalence: what % of general pop?

A

1%

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11
Q

RA age range? Peak incidence?

A

20-60 . Prevalence rises with age. Peaks 4th- 5th

Decade

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12
Q

Etiology of RA is unknown. Name 3 theories

A

Environmental ie infectious; genetic predisposition; immunogenetic > class II surface antigen-presenting cells

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13
Q

RA diagnosis is made how?

A

Clinically

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14
Q

$How is RA diagnosed clinically? (3)

A
  1. Based on 1988 American Rheumatologic Association paper by Arnett et al ( current guidelines used by American College of Rheumatology (ACR) 2. Must satisfy 4/7 criteria
  2. Criteria 1 through 4 must be present for at least 6 weeks
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15
Q

$ Name ACR Criteria for RA (7)

A

AM Stiffness> Arthritis of 3 or more joints> Arthritis of the hand joints> Arthritis symmetric> rheum nodules > RF + > radio graphic changes

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16
Q

Review ACR details

A

1.Morning stiffness
•in and around hrs
•must last at least 1 hour before max improvement
2. Arthritis of 3 or more joints
•3 or more joint areas simultaneously affected with STS or
Fluid observed by doc
•14 possible joint areas are bilateral PIP, MCP, wrist, elbow, knee , ankle, & MTP’s
3. Arthritis of the hand joints
•At least 1 joint swollen in wrist, MCP, and/or PIP
4. Symmetric arthritis
• simultaneous involvement at the same joint area bilaterally
5. RHEUMATOID NODULES
• subqt nodules over extensor surfaces, bony prominences, juxta-articular regions, observed by a doc
6. Positive serum RF
7. Radio graphic changes
• erosions, bony decalcification, & symmetric joint-space narrowing seen on hand & wrist X-rays

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17
Q

$Compare/ contrast AM Stiffness in RA , OA, AS:

Joints, duration

A

Jts/ duration
MCP , PIP,MTP. > 1-2 hours: RA
DIP, < 30 mins
AS, LS spine , ~ 3 hours

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18
Q

$What’s most common onset of RA? Insidious, acute, intermediate

A

Insidious> 50-70%. Weeks to months. Systemic or articular

Acute >10-20%. Over several days. Less symmetry . Muscle pain

Intermediate> 20-30%. Over days to weeks
Systemic is more evident

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19
Q

What is lab test is definitive for RA?

A

No single test is definitive

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20
Q

name typical lab findings in active dz

A

RF, Elevated acute phase reactants( ESR, CRP),CBC: | platelets! hypo, micro anemia , eosinophilia, synovial fluid , ab to CCP, hypergammaglobulinemia, hypocomplementia

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21
Q

$ synovial fluid in RA: viscosity, WBC, PMN’s, appearance

A

Low, 1-75 K WBC’s/mm3 (> 70% PMN’s), transparent - cloudy

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22
Q

% of patients with RA Who are RF +?

A

85%

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23
Q

Radio graphic findings in RA

A
  • Early Findings (2)
  • Late Findings (3)
  • characteristic findings
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24
Q

Joints commonly involved in RA

A

Hands & wrists
Cervical spine – C1 to C2
Feet & ankles
Hip & knees

25
Q

Describe/ Name UE Joint deformities

A 
BOUTONNIÈRE
SWAN NECK
ULNAR DEVIATION OF FINGERS
TENOSYNOVITIS
CARPAL BONE INSTABILITY 
ULNAR HEAD FLOATING
RESORPTIVE ARTHROPATHY
PSEUDOBENEDICTION SIGN
SHOULDER 
ELBOW
26
Q

Describe cervical spine concerns in RA

A

Atlantiaxial joint subluxation

What’s most common? Ant or post

Ans. anterior

27
Q

$ with cervical flexion, the atlanto-axial space should not increase sig.
Any space larger than _____ is
Considered abnormal

A

2.5-3mm

28
Q

Hip deformities
Occur in what 50% of RA Patients?
What is protrusio acetabuli?

A

50%
Associated with hip arthritis
Inward bulging of acetabulum into pelvic cavity;

29
Q

Extra-articular manifestations of RA

A 
Constitutional
Skin
Vasculitic 
Ocular
Pulmonary 
Cardiac--- see pericarditis card
GI
Renal
Neuro
Hematologic
30
Q

Extra-articular manifestations of RA

Delineate

A

Xxxx

31
Q

Subqt nodules are seen in ? (2)

A

Gout

RA

32
Q

What is Caplan’s Syndrome ? (4)

A

• associated with RA and pneumoconiosis in coal workers
• Granulomatosis response to silica dust
• +RF
Intrapulmonary nodules– histologically similar to Rheumatoid Nodules

33
Q

What are cardiac findings assoc with RA?

A 
Pericarditis 
$ classic findings
• chest pain
• pericardial friction rub
• EKG abnormalities ( diffuse ST elevations)
34
Q

Pericarditis assoc with RA may lead
Constrictive pericarditis with ?

May be found in ____ of RA Patients

How often symptomatic?

A

Right-sided heart failure
Half
Rarely

35
Q

In addition to pericarditis, what other cardiac finding is associated with RA ?

A

Valvular heart dz

36
Q

$ What is Feltys syndrome ?

A

Classic triad of:
RA
Splenomegaly
Leukopenia

37
Q 
Feltys syndrome 
Seen in \_\_\_\_\_\_\_RA with \_\_\_\_\_
Occurs in what decade of life?
Duration of RA?
Gender
Assoc with \_\_\_\_\_\_ ulcers
A 
Seropositive; nodules
5th or 7th 
> 10 years 
Women comprise 2/3 cases
Leg
38
Q

Treatment of RA (6)

A 
Education 
Rest
Physical modalities 
Orthotics
Meds
Surgery
39
Q

Poor prognosticators (6):

A 
\+RF
Rheumatoid nodules
X-ray consistent with erosive dz
Persistent synovitis 
Insidious 
Antibodies to CCP ( cyclic citrullinated peptides)
40
Q

Important determinants in classifying arthritis:

A

Inflammatory vs non-inflammatory
Symmetric vs asymmetric

Accompanied by systemic & extra articular manifestations

41
Q

ARTHRITIC DZ

What 3 items will often lead to a specific dx?

A

Good H&P
Appropriate labs
Appropriate X-rays

42
Q

Clinical features that suggest inflammatory dz:

A 
Acute painful onset
Erythema overlying skin of joint
Warmth of joint(s)
Tenderness usually commensurate 
    The degree of inflammation
43
Q

Lab & X-ray findings that suggest

An inflammatory process (4)

A

Increased WBC with left shift
Increased ESR
Group II joint fluid
X-ray : STS, periostitis, bony erosions or uniform cartilage loss

44
Q

Inflammatory Arthritis may fall into 4 different groups. It may be mono or poly articular

Name/Describe

A
  1. Inflammatory CT
  2. Inflammatory Crystal-induced
  3. Inflammatory induced by infectious agents (e.g. Bacterial, viral, spirochete , tuberculosis , fungal
  4. Seronegative spondyloarthropathies
45
Q

Non inflammatory arthritis may be classified as? (2)

A

Degenerative

Metabolic ie lipid storage , hemochromatosis , ochrinosis, etc

46
Q

Many types of arthritis have a specific distribution in terms of ?
Name 4.

Name two other potential influencing factors

A

Age, gender, race , geographic appearance

Genetics and occupation

47
Q

RA & Medications
One of the main goals of pharmacotherapy in RA is to
________ systemic inflammation & consequently _________ joint erosions and deformities

A

Reduce

48
Q

Name the commonly used medications (3) hint: Name the three

Groups and examples

A

Non-DMARDS
NDAIDS
Glucocorticoids

DMARDS – mainstay of RA pharmacotherapy
Biologicals
Non-Biologicals

49
Q

Surgical intervention in RA (5)

A

Surgical fusion of c1-2 for atlantoaxial instability

Synovectomy: most commonly?
Arthroplasty: most common?
Arthrodesis: typically for ?
Tendon repairs: successful?

50
Q 
Synovectomy: most commonly?
Arthroplasty: most common?
Arthrodesis: typically for ? 
Tendon repairs: successful?
(RA)
A

Synovectomy: most commonly with
Extensor tenosynovitis at wrist

Arthroplasty: most commonly of knee and hip; shoulder, MCP infrequent; elbow rare

Arthrodesis: typically for ankle, occ for wrist or thumb

Tendon repairs: generally successful; most hand/wrist tendinopathies require tendon transfer

51
Q

Name non bio DMARDS (8)

Least to very toxic

A 
Sulfasalazine-- safer
MTX --- safer
Cyclosporine 
Gold, IM/oral
Azathioprine
D-penicillamine
Chlorambucil--- very toxic
Cyclophosphamide ---very toxic
52
Q

Name 4 categories of bio DMARDS

A

Anti-tumor necrosis factor (Anti-TNF) agents: reduce levels of TNF-alpha

Co-stimulation Modulators: prevent T-cell activation by interfering with antigen-presenting cell interaction with T cells

Anti-B-cell antibodies
Depletes B-cells

Interleukin Antagonists
Antagonizes IL-1 by binding to interleukin receptors

53
Q

Other drugs for RA
ASA
NSAIDS
Corticosteroids

ASA
NSAIDS
Common side effects(4):

A

GI Ulceration & bleeding
Renal insufficiency
Hepatic inflammation
HTN

54
Q

Corticosteroids

Side effects

A 
Hyperglycemia 
Inhibits immune response
Osteoporosis 
PUDZ
Emotional lability
55
Q

Anti-TNF Alpha Agent examples (3)

A

Etanercept ( Enbrel) = soluble receptor

Infliximab ( Remicade)= chimeric antibody

Adalimumab (Humira)= human monoclonal antibody

56
Q

Co-stimulation Modulators

Give an example

A

Abatacept (Orencia)

57
Q

Anti-B-cell antibodies

Example

A

Rituximab

58
Q

Interleukin Antagonists

Name one

A

Anakinra (Kineret)

59
Q

What is ASA therapeutic level?

Greater than ? Is toxic.

A

15-25 mg/DL ; 30

AAPMR BOARD REVIEW (5 decks)

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