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Internal Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

OA/DJD px

osteoarthritis/degenerative joint disease

A

=loss of articular cartilage

  • absence of inflammation
  • significant pain
  • DIP > PIP & MCP
  • normal labs
  • inc risk with obesity
  • MCC of joint disease
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2
Q

Heberden’s vs Bouchard’s nodes

A

DIP vs PIP enlargement in OA

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3
Q

OA/DJD labs?

A

-normal ESR, ANA, CBC & rheumatoid factor

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4
Q

OA/DJD X-ray shows?

A
  • joint space narrowing
  • dense subchondral bone
  • bone cysts
  • osteophytes
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5
Q

OA/DJD tx

A
  • weight loss
  • acetaminophen = best initial

-NSAIDs

  • capsaicin cream, hyaluronic acid injection, intra-articular steroids
  • NO glucosamine or chondroitin sulfate
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6
Q

gout causes?

A
  • idiopathic overproduction
  • increased cell turnover (cancer, tumor lysis)
  • enzyme deficiency (Lesch-Nyan)
  • renal insufficiency
  • acidosis
  • thiazides (hyperGLUC)
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7
Q

gout px

A
  • men
  • podagra = MTP of great toe
  • tophi = urate crystal deposition (cartilage, bone, kidney)
  • uric acid kidney stones
  • red, warm, tender joint
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8
Q

gout dx

A

-joint aspiration = most accurate
(NEEDLE-shaped crystals with NEGATIVE birefringence on polarized light microscopy)

  • elevated WBC (neutrophils)
  • tap joint to exclude infection
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9
Q

gout acute attacks px

A
  • elevated ESR

- leukocytosis

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10
Q

gout tx

A
  • NSAIDs (acute attack) = best initial

- steroids –when no response or contraindication to NSAIDs (renal insufficiency)

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11
Q

gout chronic management

A
  • diet: dec alcohol, red meat intake
  • stop thiazides
  • colchicine (prevent 2nd attack)
  • probenecid and sulfinpyrazone (inc excretion of uric acid)
  • allopurinol (dec production)
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12
Q

colchicine SE

A

diarrhea

bone marrow suppression (neutropenia)

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13
Q

allopurinol SE

A
  • Stevens-Johnson syndrome
  • hypersensitivity reaction

-safe in renal injury
(as opposed to probenecid, sulfinpyrazone, NSAIDs)

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14
Q

pseudogout

A

= Ca pyrophosphate deposition in articular cartilage

  • risk factors: hemochromatosis, hyperPTH
  • DB, hypothyroid, WIlson’s
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15
Q

pseudogout px

A
  • affects LARGE joints (knee, wrist)

- does not affect DIP or PIP (as in DJD/OA)

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16
Q

pseudogout dx

A

-arthrocentesis = most accurate
(POSITIVELY birefringent RHOMBOID-shaped crystals)

  • elevated WBC
  • normal uric acid
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17
Q

pseudogout tx

A

-NSAIDs = best initial

  • intra-articular steroids (triamcinolone)
  • colchicine prevents 2nd attack
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18
Q

anti-cyclic citrulinated peptide

anti-CCP

A

most specific marker for Rheumatoid arthritis

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19
Q

spinal cord compression px

A
  • point tenderness at spine with percussion of vertebra

- hyperreflexia below level of compression

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20
Q

epidural abscess microbe, px

A
  • staph aureus
  • high fever
  • elevated ESR
  • point tenderness on percussion of vertebra
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21
Q

most common site of disc herniation? dx?

A

-L4/5 & L5/S1

  • dx with straight leg raise (low specificity, high sensitivity)
  • no MRI needed
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22
Q

L4 deficitis

A
  • motor: dorsiflexion of foot
  • reflex: knee jerk
  • sensory: inner calf
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23
Q

L5 deficits

A
  • motor: dorsiflexion of toe

- sensory: inner foot

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24
Q

S1 deficits

A
  • motor: eversion of foot
  • reflex: ankle jerk
  • sensory: outer foot
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25
Q

low back pain etiology

A
  • cord compression
  • epidural abscess
  • ankylosing spondylitis
  • cauda equina syndrome
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26
Q

low back pain dx

A
  • xray = best initial test
  • MRI = most accurate

-CT -for MRI contraindications; give contrast

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27
Q

imaging for disk herniation?

A

NO

-unless there are neurologic deficits

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28
Q

cauda equina px

A
  • bowel & bladder incontinence
  • erectile dysfunction
  • bilateral leg weakness
  • “saddle area” anesthesia
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29
Q

ankylosing spondylitis px

A
  • <40YO
  • pain worsens with rest and improves with ACTIVITY
  • decreased chest mobility
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30
Q

cord compression tx

A

-reduce pressure:

  • systemic glucocorticoids
  • radiation of tumors
  • chemo for lymphoma
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31
Q

tx:
cauda equina
disk herniation (sciatica)

A
  • surgical decompression

- NSAIDs, yoga, steroid injection; NOT bed rest

32
Q

lumbar spinal stenosis px, dx, tx

A
  • 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
33
Q

fibromyalgia px

A
  • young woman
  • chronic MSK pain
  • trigger points (trapezius, medial fat pad of knee, lateral epicondyle)
  • headaches
  • sleep disorders
34
Q

fibromyalgia dx

A
  • no tests (all tests are normal)

- based on hx and trigger points

35
Q

fibromyalgia tx

A
  • amitriptyline (TCA)
  • milnacipran (SNRI), pregabalin

-NEVER steroids (bc not an inflammatory condition)

36
Q

carpal tunnel px

A
  • pain in hand (palm, thumb, index finger, radial half of ring finger, muscle atrophy)
  • pain worse at night

-sensory symptoms occur BEFORE motor symptoms

37
Q

carpal tunnel dx

A
  • Tinel sign (tapping on median nerve)
  • Phalen sign (wrist flexion)

-electromyography & nerve conduction tests = most accurate

38
Q

carpal tunnel tx

A
  • wrist splint = best initial (immobilization)
  • NSAIDs
  • steroids
  • surgery
39
Q

dupuytren contracture

A

=hyperplasia of palmar fascia –> nodule formation –> contracture of 4th & 5th digits –> unable to extend fingers

  • associated with alcoholism & cirrhosis
  • tx: triamcinolone injection (steroid)
40
Q

rotator cuff injury px, dx, tx

A
  • worse at night when laying on shoulder
  • tenderness at supraspinatus insertion
  • dx: MRI = most accurate
  • tx: NSAIDs, rest, PT; steroids, surgery (for complete tears)
41
Q

patellofemoral syndrome px, dx, tx

A

=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
42
Q

plantar fasciitis px, tx

A
  • 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
43
Q

osteoporosis px

A
  • older woman
  • asymptomatic fractures on routine DEXA scan
  • fractures of weight-bearing bones
44
Q

osteoporosis dx

A

-DEXA scanning

  • osteopenia = T-score 1-2.5 SDs below normal
  • osteoporosis = T-score >2.5 SDs below normal
  • normal Ca, PTH
45
Q

osteoporosis tx

A

-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
46
Q

teriparatide SE

A

osteosarcoma (rats)

hyperCa

47
Q

RA general facts

A
  • women
  • autoimmune
  • pannus formation
  • morning stiffness
  • multiple small inflamed joints
48
Q

RA px

A
  • 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

49
Q

RA dx

A
  • 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

50
Q

Sicca syndrome

A

=sjogren’s disease

-dry eyes, mouth, mucous membranes

51
Q

Felty syndrome

A

RA + splenomegaly + neutropenia

-inc infections

52
Q

Caplan syndrome

A

RA + pneumoconiosis + lung nodules

53
Q

RA tx

A
  • 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
54
Q

erosive RA =

A
  • joint space narrowing
  • physical deformity of joints
  • xray abnormality

-DMARD = initial therapy (not an NSAID)

55
Q

methotrexate SE

A
  • liver toxicity
  • bone marrow suppression
  • pulmonary toxicity
56
Q

TNF-inhibitor SE

infliximab, adalimumab, etanercept

A
  • reactivation of TB

- inc susceptibility to other infections

57
Q

rituximab

A
  • removes CD20 lymphocytes from circulation
  • good for long-term
  • screen for HBV (which can be reactivated on this med)
  • can be combined with methotrexate
58
Q

hydroxychloroquine SE

A
  • toxic to retina

- must do a dilated eye exam

59
Q

juvenile RA px

= Still disease

A
  • high spiking fevers (>104F) + rash
  • rash: salmon color, chest & abdomen; occurs only with fever spike
  • splenomegaly, pericardial effusion, mild joint symptoms
  • no known etiology
60
Q

juvenile RA dx, tx

A
  • no clear dx
  • anemia, leukocytosis
  • normal ANA
  • elevated ferritin

-tx: NSAIDs, ASA, steroids

61
Q

SLE

A
  • 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
62
Q

SLE immunology

A
  • ANA (high sensitivity)
  • anti-dsDNA & anti-Smith (specific)
  • false positive for syphilis
63
Q

SLE tx

A
  • acute tx: high dose steroids
  • hydrocychloroquine
  • GN: cyclophosphamide, myceopholate
  • bellmumab –> dec symptoms

-need kidney biopsy for lupus nephritis

64
Q

cause of death in SLE? young vs old?

A

young: infection
old: MI due to accelerated atherosclerosis

65
Q

antiphospholipid syndrome

A

IgG or IgM antibodies against negatively charged phospholipids

  • lupus anticoagulant
  • anticardiolipin antibodies
66
Q

antiphospholipid syndrome px

A
  • thrombosis of arteries AND veins
  • -> recurrent spontaneous abortions
  • elevated PTT
  • normal PT, INR
67
Q

antiphospholipid syndrome dx

A
  • false positive syphilis test (VDRL, RPR)
  • anticardiolipin antibodies (abortions)
  • lupus anticoagulant (elevated PTT)

-mixing studies = best initial

68
Q

mixing studies

A
  • 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
69
Q

RVVT test = most specific for lupus anticoagulant

A
  • prolonged in presence of antiphospholipid antibodies

- doesn’t correct on mixing with normal plasma

70
Q

CREST syndrome

A 
calcinosis
Raynaud
esophageal dysmotility
sclerodactyly
telangiectasia

= limited scleroderma

71
Q

scleroderma px

A
  • young woman
  • GI dysmotility
  • fibrosis of skin/lung/myocardium
  • skin tightening
  • pulmonary HTN, restrictive lung disease
  • renal: hypertensive crisis
72
Q

scleroderma dx

A
  • anticentromere Ab = CREST syndrome
  • SCL-70 (anti-topoisomerase) = most specific
  • ANA (nonspecific)
  • ESR normal
73
Q

scleroderma tx

A
  • ACEI for renal crisis
  • PPIs for GERD/esophageal dysmotility
  • CCBs for Raynaud
  • cyclophosphamide for pulmonary fibrosis
  • bosentan or ambrisentan or sildanefil for pulmonary HTN
74
Q

polymyositis px

A
  • proximal muscle weakness
  • spares facial and ocular muscles (compared to myasthenia gravis)
  • dyspagia
75
Q

dermatomyositis px

A
  • 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)

76
Q

poly and dermatomyositis dx, tx

A
  • 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

Internal Medicine (9 decks)

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