Rheumatology Flashcards
OA/DJD px
osteoarthritis/degenerative joint disease
=loss of articular cartilage
- absence of inflammation
- significant pain
- DIP > PIP & MCP
- normal labs
- inc risk with obesity
- MCC of joint disease
Heberden’s vs Bouchard’s nodes
DIP vs PIP enlargement in OA
OA/DJD labs?
-normal ESR, ANA, CBC & rheumatoid factor
OA/DJD X-ray shows?
- joint space narrowing
- dense subchondral bone
- bone cysts
- osteophytes
OA/DJD tx
- weight loss
- acetaminophen = best initial
-NSAIDs
- capsaicin cream, hyaluronic acid injection, intra-articular steroids
- NO glucosamine or chondroitin sulfate
gout causes?
- idiopathic overproduction
- increased cell turnover (cancer, tumor lysis)
- enzyme deficiency (Lesch-Nyan)
- renal insufficiency
- acidosis
- thiazides (hyperGLUC)
gout px
- men
- podagra = MTP of great toe
- tophi = urate crystal deposition (cartilage, bone, kidney)
- uric acid kidney stones
- red, warm, tender joint
gout dx
-joint aspiration = most accurate
(NEEDLE-shaped crystals with NEGATIVE birefringence on polarized light microscopy)
- elevated WBC (neutrophils)
- tap joint to exclude infection
gout acute attacks px
- elevated ESR
- leukocytosis
gout tx
- NSAIDs (acute attack) = best initial
- steroids –when no response or contraindication to NSAIDs (renal insufficiency)
gout chronic management
- diet: dec alcohol, red meat intake
- stop thiazides
- colchicine (prevent 2nd attack)
- probenecid and sulfinpyrazone (inc excretion of uric acid)
- allopurinol (dec production)
colchicine SE
diarrhea
bone marrow suppression (neutropenia)
allopurinol SE
- Stevens-Johnson syndrome
- hypersensitivity reaction
-safe in renal injury
(as opposed to probenecid, sulfinpyrazone, NSAIDs)
pseudogout
= Ca pyrophosphate deposition in articular cartilage
- risk factors: hemochromatosis, hyperPTH
- DB, hypothyroid, WIlson’s
pseudogout px
- affects LARGE joints (knee, wrist)
- does not affect DIP or PIP (as in DJD/OA)
pseudogout dx
-arthrocentesis = most accurate
(POSITIVELY birefringent RHOMBOID-shaped crystals)
- elevated WBC
- normal uric acid
pseudogout tx
-NSAIDs = best initial
- intra-articular steroids (triamcinolone)
- colchicine prevents 2nd attack
anti-cyclic citrulinated peptide
anti-CCP
most specific marker for Rheumatoid arthritis
spinal cord compression px
- point tenderness at spine with percussion of vertebra
- hyperreflexia below level of compression
epidural abscess microbe, px
- staph aureus
- high fever
- elevated ESR
- point tenderness on percussion of vertebra
most common site of disc herniation? dx?
-L4/5 & L5/S1
- dx with straight leg raise (low specificity, high sensitivity)
- no MRI needed
L4 deficitis
- motor: dorsiflexion of foot
- reflex: knee jerk
- sensory: inner calf
L5 deficits
- motor: dorsiflexion of toe
- sensory: inner foot
S1 deficits
- motor: eversion of foot
- reflex: ankle jerk
- sensory: outer foot
low back pain etiology
- cord compression
- epidural abscess
- ankylosing spondylitis
- cauda equina syndrome
low back pain dx
- xray = best initial test
- MRI = most accurate
-CT -for MRI contraindications; give contrast
imaging for disk herniation?
NO
-unless there are neurologic deficits
cauda equina px
- bowel & bladder incontinence
- erectile dysfunction
- bilateral leg weakness
- “saddle area” anesthesia
ankylosing spondylitis px
- <40YO
- pain worsens with rest and improves with ACTIVITY
- decreased chest mobility
cord compression tx
-reduce pressure:
- systemic glucocorticoids
- radiation of tumors
- chemo for lymphoma
tx:
cauda equina
disk herniation (sciatica)
- surgical decompression
- NSAIDs, yoga, steroid injection; NOT bed rest
lumbar spinal stenosis px, dx, tx
- pain while walking
- radiates to buttocks & thighs bilaterally
- dec lower extremity reflexes
- pain is less when leaning forward (cycling)
- px like peripheral vascular disease, but normal vascular tests
- dx: MRI
- tx: surgical dilation of spinal canal, weight loss/steroid injections
fibromyalgia px
- young woman
- chronic MSK pain
- trigger points (trapezius, medial fat pad of knee, lateral epicondyle)
- headaches
- sleep disorders
fibromyalgia dx
- no tests (all tests are normal)
- based on hx and trigger points
fibromyalgia tx
- amitriptyline (TCA)
- milnacipran (SNRI), pregabalin
-NEVER steroids (bc not an inflammatory condition)
carpal tunnel px
- pain in hand (palm, thumb, index finger, radial half of ring finger, muscle atrophy)
- pain worse at night
-sensory symptoms occur BEFORE motor symptoms
carpal tunnel dx
- Tinel sign (tapping on median nerve)
- Phalen sign (wrist flexion)
-electromyography & nerve conduction tests = most accurate
carpal tunnel tx
- wrist splint = best initial (immobilization)
- NSAIDs
- steroids
- surgery
dupuytren contracture
=hyperplasia of palmar fascia –> nodule formation –> contracture of 4th & 5th digits –> unable to extend fingers
- associated with alcoholism & cirrhosis
- tx: triamcinolone injection (steroid)
rotator cuff injury px, dx, tx
- worse at night when laying on shoulder
- tenderness at supraspinatus insertion
- dx: MRI = most accurate
- tx: NSAIDs, rest, PT; steroids, surgery (for complete tears)
patellofemoral syndrome px, dx, tx
=anterior knee pain secondary to trauma, imbalance, of quads strength, meniscal tear
- improves after walking
- worse with stairs
- dx: normal xray
- tx: physical therapy
- no knee brace or surgery
plantar fasciitis px, tx
- severe pain near calcaneus
- worst in morning; IMPROVES with USE
- “tac in the bottom of foot”
- point tenderness where fascia inserts into calcaneus
- tx: NSAIDs, stretching exercise, steroids
- xray not useful
osteoporosis px
- older woman
- asymptomatic fractures on routine DEXA scan
- fractures of weight-bearing bones
osteoporosis dx
-DEXA scanning
- osteopenia = T-score 1-2.5 SDs below normal
- osteoporosis = T-score >2.5 SDs below normal
- normal Ca, PTH
osteoporosis tx
-vit D & Ca = best initial
- bisphosphonates (osteoporosis, not -penia)
- estrogens (post-menopausal woman)
- raloxifene (postmenopausal women; dec breast cancer risk, dec LDLs)
- teriparatide =PTH analog
- calcitonin
teriparatide SE
osteosarcoma (rats)
hyperCa
RA general facts
- women
- autoimmune
- pannus formation
- morning stiffness
- multiple small inflamed joints
RA px
- bilateral symmetrical bone involvement
- PIP & MCP of hands
- DIP spared
- morning stiffness >30min
- rheumatoid nodules
- lung nodules, effusions, pericarditis
- vasculitis
- carpal tunnel syndrome
- C1 & C2 subluxation
-death in RA often from CAD
RA dx
- anti-cyclic citrilunated peptide (anti-CCP)
- rheumatoid factor (nonspecific)
- elevated ESR, CRP
- anemia of chronic disease
- lymphocytosis
-do arthrocentesis to rule out gout, infection, etc
Sicca syndrome
=sjogren’s disease
-dry eyes, mouth, mucous membranes
Felty syndrome
RA + splenomegaly + neutropenia
-inc infections
Caplan syndrome
RA + pneumoconiosis + lung nodules
RA tx
- NSAIDs = best initial for pain
- steroids (pain & bridging to DMARD)
- must stop progression of disease.. with a DMARD
- methotrexate = best initial DMARD
- TNF inhibitors (infliximab, adalimumab, enteracept)
- rituximab
- hydroxychloroquine
erosive RA =
- joint space narrowing
- physical deformity of joints
- xray abnormality
-DMARD = initial therapy (not an NSAID)
methotrexate SE
- liver toxicity
- bone marrow suppression
- pulmonary toxicity
TNF-inhibitor SE
infliximab, adalimumab, etanercept
- reactivation of TB
- inc susceptibility to other infections
rituximab
- removes CD20 lymphocytes from circulation
- good for long-term
- screen for HBV (which can be reactivated on this med)
- can be combined with methotrexate
hydroxychloroquine SE
- toxic to retina
- must do a dilated eye exam
juvenile RA px
= Still disease
- high spiking fevers (>104F) + rash
- rash: salmon color, chest & abdomen; occurs only with fever spike
- splenomegaly, pericardial effusion, mild joint symptoms
- no known etiology
juvenile RA dx, tx
- no clear dx
- anemia, leukocytosis
- normal ANA
- elevated ferritin
-tx: NSAIDs, ASA, steroids
SLE
- malar rash, photosensitivity, oral ulcers
- arthritis in 90% of pts (normal X-ray)
- serositis = inflammation of pleura & pericardium
- membranous GN (RBC casts)
- seizures, stroke, psychosis
- anemia
- leukopenia
SLE immunology
- ANA (high sensitivity)
- anti-dsDNA & anti-Smith (specific)
- false positive for syphilis
SLE tx
- acute tx: high dose steroids
- hydrocychloroquine
- GN: cyclophosphamide, myceopholate
- bellmumab –> dec symptoms
-need kidney biopsy for lupus nephritis
cause of death in SLE? young vs old?
young: infection
old: MI due to accelerated atherosclerosis
antiphospholipid syndrome
IgG or IgM antibodies against negatively charged phospholipids
- lupus anticoagulant
- anticardiolipin antibodies
antiphospholipid syndrome px
- thrombosis of arteries AND veins
- -> recurrent spontaneous abortions
- elevated PTT
- normal PT, INR
antiphospholipid syndrome dx
- false positive syphilis test (VDRL, RPR)
- anticardiolipin antibodies (abortions)
- lupus anticoagulant (elevated PTT)
-mixing studies = best initial
mixing studies
- patient’s plasma is mixed with normal plasma
- measure new PT & PTT (should correct, ideally)
- will correct with clotting factor deficiency
- remains elevated in antiphospholipid syndrome
RVVT test = most specific for lupus anticoagulant
- prolonged in presence of antiphospholipid antibodies
- doesn’t correct on mixing with normal plasma
CREST syndrome
calcinosis Raynaud esophageal dysmotility sclerodactyly telangiectasia
= limited scleroderma
scleroderma px
- young woman
- GI dysmotility
- fibrosis of skin/lung/myocardium
- skin tightening
- pulmonary HTN, restrictive lung disease
- renal: hypertensive crisis
scleroderma dx
- anticentromere Ab = CREST syndrome
- SCL-70 (anti-topoisomerase) = most specific
- ANA (nonspecific)
- ESR normal
scleroderma tx
- ACEI for renal crisis
- PPIs for GERD/esophageal dysmotility
- CCBs for Raynaud
- cyclophosphamide for pulmonary fibrosis
- bosentan or ambrisentan or sildanefil for pulmonary HTN
polymyositis px
- proximal muscle weakness
- spares facial and ocular muscles (compared to myasthenia gravis)
- dyspagia
dermatomyositis px
- malar involvement
- heliotrope rash (edema, purplish eyelids)
- Gottron papules = scaly patches over back of hands (PIP, MCP)
- Shawl sign = erythema of face, neck, shoulders, upper chest, back
-associated with cancer in 25% (ovary, lung, GI, lymph)
poly and dermatomyositis dx, tx
- CPK and aldolase (leak when muscles break down)
- muscle biopsy = most accurate
- MRI
- electromyography
- ANA, ESR, CRP, Rheumatoid factor elevated
-tx: steroids; methotrexate, azathioprine, IVIG, mycophenolate, hydroxychloroquine
