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Step 3 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What are extra-articular manifestations which may be seen in RA?

A 
Pleural effusion
Normocytic anemia
Pericarditis/valvular disease
Mononeuritis multiplex
Rheumatoid skin nodules
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2
Q

What is the single most accurate test for RA?

A

Anti-CCP

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3
Q

What is Felty’s syndrome?

A

RA
Splenomegaly
Neutropenia

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4
Q

What spinal joint finding may be seen in RA which affects management of the airway?

A

C1-C2 subluxation

Check for before intubating if you can

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5
Q

Baker’s cyst may be assd with what condition?

A

RA

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6
Q

What are adverse effects of MTX?

A

Pneumonitis, Liver toxicity, BM suppression

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7
Q

For what severity level of disease is hydroxychloroquine used in RA? What should patients routinely followup with if on this drug?

A

For mild disease

Eye exams to look for retinopathy

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8
Q

What is Anakinra?

A

IL-1 receptor antagonist

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9
Q

What is Tocilizumab?

A

IL-6 receptor antagonist

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10
Q

What is Leflunomide?

A

Folate antagonist similar to MTX but less toxic

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11
Q

What is Abatacept?

A

Inhibits T-cell activation

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12
Q

When are steroids the answer in RA?

A

For acute disease to control the inflammation and be a bridge to DMARD therapy

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13
Q

Are the seronegative spondyloarthropathies positive for rheumatoid factor?

A

No

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14
Q

When is the pain worse in AS? What relieves it, positionally?

A

Worse at night

Flexion relieves

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15
Q

What are rare associated findings with AS?

A

Aortitis
Uveitis
Restrictive lung disease

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16
Q

What are treatment options for AS?

A

NSAIDs
Biologics
Sulfasalazine

*Steroids are NOT used

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17
Q

How does reactive arthritis present?

Tx?

A 
Monoarticular arthritis
Hx urethritis or GI infection
Fever, fatigue, weight loss
Genital lesions (circante balantis - around head of penis)
Keratoderma blenorrhagicum

Tx: NSAIDs

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18
Q

How does psoriatic arthritis present?

A

Joint pain in setting of psoriasis

Nail pitting
Dacylitis (“sausage fingers”)
Enthesitis: inflammation at tendonal insertion sites
DIP involvement

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19
Q

What is the best initial therapy for psoriatic arthritis?

What other agents are used in resistant cases?

A

NSAIDs

If resistant or need additional control, MTX and/or anti-TNF agents

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20
Q

Why do patients test positive for TB when placed on anti-TNF drugs?

A

TNF helps maintain granulomas which encase TB. Giving anti-TNF drugs allows the granulomas to be “leakier” and cause TB to release

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21
Q

What presents with fever salmon-colored rash, polyarthritis, lymphadenopathy, and myalgias?

A

Juvenille RA (AKA adult-onset Still’s disease)

*May also have hepatosplenomegaly and elevated transaminases

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22
Q

What are essential labs to making the diagnosis of juvenille RA?

A

Very high ferritin
Leukocytosis
Negative ANA and RF are critical to making dx

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23
Q

What is tx of juvenille RA?

A

NSAIDs

If unresponsive can consider giving steroids, if they continue to persist then may give MTX or anti-TNF agents

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24
Q

What is the most common presentation of Whipple’s disease?

A

Joint pain actually

Of course it can present with diarrhea, fat malabsorption, and weight loss

Tx is TMP/SMX

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25
Q

What is the best initial test for OA?

A

X-ray of joint

*Of course order ESR, CBC, ANA, RF, anti-CCP to rule out RA

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26
Q

Is glucoasamine helpful in OA?

A

It is not clearly established so it can’t be recommended. It is basically a placebo

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27
Q

What is the best initial test for SLE?

Most accurate?

A

Initial: ANA
Accurate: Anti-dsDNA; anti-Smith a bit less accurate

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28
Q

What tests would you order if looking for an SLE flair up and what happens to those tests?

A

Anti-dsDNA will increase in flair

Complement levels will decrease in flair

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29
Q

What does the presence of anti-Ro or anti-SSA in pregnant woman put the fetus at risk for?

A

Heart block

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30
Q

Does lupus cause destruction of the synovium when causing joint pain?

A

No

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31
Q

How is an SLE flaire up treated?

A

Prednisone

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32
Q

How is SLE joint pain managed? What if resistant to the aforementioned?

A

NSAIDs

Add hydroxychloroquine if not responding to above

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33
Q

If there is severe disease relapse when steroids stopped in SLE what is appropriate treatment?

A

Belimumab, azathioprine, cyclophosphamide

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34
Q

How is lupus nephritis managed?

A

Steroids and mycophenolate

35
Q

What are the most common causes of drug-induced lupus?

A

Hydralazine
INH
Procainamide

36
Q

What is positive in drug-induced lupus?

A

Anti-histone antibodies

37
Q

What is the most accurate test for Sjogrens Syndrome?

A

Lip biopsy

38
Q

What is Schiermer’s test and what is it used for?

A

Shows reduced lacrimation from eye when a piece of paper is held near the eye

Sjogrens

39
Q

What are specific Abs for Sjogrens?

A

Anti-Ro (SSA)

Anti-La (SSB)

40
Q

What are appropriate treatments for Sjogrens?

A

Keep eyes and mouth moist

Pilocarpine and cevimeline both may increase ACh

41
Q

What are the main symptoms of scleroderma?

A

Skin “tightness”
Raynaud’s
Joint pain
(additional symptoms in CREST)

42
Q

In diffuse scleroderma what is the leading cause of death?

A

Fibrosis and pulmonary HTN

43
Q

What Ab is fairly useful in diagnosing in scleroderma?

A

Anti-Scl70 (topoisomerase)

44
Q

Scleroderma does not have many broadly useful treatments. What are specific treatments used in situations with each of the following symptoms:

Renal involvement/HTN:
Pulm HTN:
Raynaud's:
GERD:
Lung Fibrosis:
A 
Renal involvement/HTN: ACEi
Pulm HTN: Bosentan (endothelin antagonist), prostacyclin analogs (e.g. epoprostenol), sildenafil
Raynaud's: CCB
GERD: PPIs
Lung fibrosis: cyclophosphamide
45
Q

What does CREST stand for?

A 
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasias
46
Q

Differently than scleroderma, CREST has what Ab positive often?

A

Anti-centromere

47
Q

What disease may mimic the skin findings of scleroderma?
What will the skin look like?
What is appropriate tx?

A

Eosinophillic fascitis
p’eau d’orange (thickened and orange); symptoms worse with exercise
Steroids

48
Q

CPK and aldolase are elevated in which autoimmune disease?

A

Polymyositis and dermatomyositis

49
Q

Anti-Jo1 is seen in …..

What may it confer?

A

Polymyositis and dermatomyositis

It’s presence indicates greater risk of interstitial lung disease

50
Q

Tx of PM/DM

A

Glucocorticoids

51
Q

What are appropriate therapies for fibromyalgia?

A

Exercise
Milnacriptan (SNRI), duloextine, or pregabalin (best initial)
TCAs can be used but have more side effects

52
Q

Patient presents with profound pain of proximal muscles in setting of normal CPK, aldolase, EMG, and even muscle biopsy. But ESR is elevated. Dx and tx?

A

Polymyalgia rheumatica

Steroids

53
Q

What is one difference between chronic fatigue syndrome and fibromyalgia?

A

CFS patients have much more fatigue and fail to have trigger points on exam

No real effective treatment

54
Q

What are the best initial therapies for vasculitis?

A

Prednisone and gluococorticoids

55
Q

What is the best initial test for diagnosing polyarteritis nodosa?
What is the most accurate test?

A

Initial: Abdominal angiography
Accurate: biopsy of appropriate tissue (e.g. sural nerve)

56
Q

Tx for PAN

A

Prednisone and cyclophosphamide

57
Q

Vasculitis + eosinophillia + asthma =

A

Churg-Strauss Syndrome

*pANCA positive but don’t rely on this

58
Q

Young asian female comes in with diminished pulses. What is on the top of your differential?

A

Takayasu’s arteritis

59
Q

Takayasu’s arteritis has unique vascular complications compared to some of the other vasculitidies. What are they?

Unlike other vasculitidies it is diagnosed differently, how?

A

TIA and stroke

Aortic arteriography or MRA

*Tx is steroids

60
Q

What is treatment of cryoglobulinemia?

A

Interferon and ribavirin

61
Q

What is the classic presentation of Behcet’s disease?

A

Often middle eastern or asian

Oral and genital ulcers
Ocular involvement (e.g. uveitis, optic neuritis)
Skin lesions (hypersensitivity to needle sticks) leading to sterile skin abscesses
62
Q

What is tx for Behcet’s disease?

A

Prednisone

Colchicines (microtubule inhibitors)

63
Q

What is the normal WBC count of synovial fluid?
How many seen in inflammatory conditions?
Infectious conditions?

A

NL: 50000

64
Q

What drugs may precipitate gouty attacks?

A

Thiazides
Nicotinic acid

Also binge drinking and large meat intake

65
Q

What is seen on polarized light exam for gout?

A

Negatively birefringent needles

66
Q

What is seen on polarized light exam of pseudogout?

A

Positively refringent rhomboid-shaped crystals

67
Q

What are vital examinations to conduct on CCS when given a patient case of gout?

A

Joint exam
Joint fluid examination (cell count, culture, protein level)
Serum uric acid (don’t overly rely on)
Xray of toe

68
Q

What is the first medication you should try giving for acute gout?
What is next?
What is another commonly used agent if there are reasons not to use the above?

A

First: NSAIDs
Second: Steroids
If reason not to give the above then give colchicine

69
Q

What is a key medication as part of preventive therapy for gout?

A

Colchicine

70
Q

What are adverse effects of colchicine?

A

Nausea and vomiting

BM suppression

71
Q

What are good meds to use for long-term prevention of chronic gout?

A

Allopurinol
Febuxostat
Uricase (if the above two are not enough)

*Also advise to avoid alcohol and lose weight

72
Q

What are adverse effects of allopurinol?

A

Rash
Allergic interstitial nephritis
Hemolysis

73
Q

At what joints does pseudogout often present?

What is appropriate tx?

A

Usually not the toe. Usually at the knees and wrist

Tx: NSAIDs or steroids. Colchicine is not as effective here

74
Q

What are the most common pathogens causing septic arthrits?

What team should be consulted on CCS for a case of septic arthritis?

A

Commonly S. aureus, Streptococcus, Gram negative bacilli

Consult ortho

75
Q

What is empiric therapy for septic arthrits?

A

IV ceftriaxone and vancomycin

76
Q

Between Paget’s disease and prostate cancer mets which one presents with osteoblastic and which with osteoclastic lesions?

A

Paget’s: osteoclastic

Prostate cancer mets: osteoblastic

77
Q

What is the best initial test for Paget’s disease of bone?

Most accurate?

A

Initial: ALP
Accurate: X-ray

78
Q

What labs should be ordered when evaluating for Paget’s disease of bone?

A

Urinary hydroxyproline
Serum calcium
Serum phosphate
Bone scan

79
Q

How do you want to treat Paget’s disease of bone?

A

Bisphosphonates (inhibits bone resroption) and calcitonin (promotes osteoblastic activity and lowers serum calcium)

80
Q

Patient presents with OA (or RA) and has a swollen calf. What is one thing you suspect?

A

Baker’s cyst (posterior herniation of synovium of knee)

81
Q

What is diagnostic testing used for a Baker’s cyst?

A

Ultrasound of lower leg to r/o DVT

82
Q

How can you distinguish plantar fascitis and tarsal tunnel syndrome?

A

Tarsal tunnel syndrome gets worse with continued activity and may require surgical release (kind of like carpal tunnel syndrome)

83
Q

What is a Morton neuroma?

A

Painful burning sensation in web space between 3rd and 4th toes. May present as a sharp, radiating pain into the toes which improves when shoes are taken off

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