Rheumatology Flashcards
1
Q
Define oligoarthralgia
A
- pain in 1-4 joints
2
Q
Define polyarthralgia
A
- pain in >4 joints
3
Q
What needs to be ruled out in acute monoarthritis?
A
- septic arthritis -> risk of permanent joint destruction
4
Q
Define septic arthritis. Common organisms?
A
- infection of joint space from hematogenous spread or open injury
organisms: Staphylococcus or Streptococcus - r/o gonoccal arthritis in sexually active adults
5
Q
Classification of autoimmune arthritis?
A
Seropositive arthropathies - RF in blood (e.g. RA, SLE)
- female > male
- symmetrical, multiple joints, MCP/PIPs
- Raynaud phenomenon, sicca, nodules
Seronegative arthropathies - negative RF, associated with predilection for spinal and sacroiliac inflammation (AS, PsA, ReA, EA)
- male > female
- usually asymmetrical, oligoarticular, below waist (except PsA with DIP involvement)
+ enthesitis
- iritis/ uveitis, oral ulcers, cutaneous involvement, GI issues
+ HLA-B27
6
Q
What is gout?
A
- acute inflammatory response to uric acid crystals in the joint accompanied by elevated serum uric acid level and rapid change in uric acid concentration
7
Q
Causes of increased serum uric acid?
A
- overproduction: nutritional (meat, seafood, EtOH), heme malignancy
- under excretion: dehydration, renal failure, diuretics
8
Q
What is CPPD?
A
- pseudogout
- acute inflammatory arthritis due to phagocytosis of IgG-coated calcium pyrophosphate crystals by neutrophils and subsequent release of inflammatory mediators within the joint space
9
Q
What broad category presents with rapidly swelling joint with severe pain and restricted ROM within min-d; pt can often pinpoint exact onset of sx
A
Acute oligoarthritis
- chronic or subacute has more insidious onset lasting wk-mo
10
Q
Risk factors for infectious joint
A
- fever
- sexual history
- sick contact
- IVDU
- DM
- RA
- recent joint surgery
- hip or knee prosthesis
Lyme - region, hx rash (erythema migrant), hx tick bite
11
Q
Dx post streptococcal arthritis (rheumatic fever)
A
- hx sore throat, fever "no rheum for SPECCulation" - subcutaneous nodules - polyarthritis - erythema marginatum - chorea - carditis
12
Q
Likely diagnosis?
- preceding GI/GU infection
- mostly joints of lower extremity involved
- enthesitis/ dactylitis common
A
Post-infectious
13
Q
Sx of crystal arthropathy?
A
- hx gout
- renal insufficiency
- diuretic use
- HTN
- obesity
- high-purine diet
- heavy EtOH
14
Q
Likely dx?
- morning stiffness >30min - 1hr
- hx joint swelling, erythema, warmth
- reduced ROM
- pain at rest, relief with movement
A
Inflammatory arthritis
15
Q
Likely dx?
- morning stiffness <30min
- sx worse with activity
+/- swelling
A
Noninflammatory arthritis
16
Q
Triad of reactive arthritis
A
can’t see - conjunctivitis
can’t pee - urethritis
can’t climb a tree - arthritis
17
Q
Features of RA?
A
- symmetric joint involvement
- swan neck deformity
- Boutonniere deformity
- ulnar deviation of MCP
- radial deviation of wrist
18
Q
What is Gaenslen test?
A
- pt lies near edge of table and hangs one leg over side while flexing other hip and knee against chest
- if increase pain in buttock region of leg hanging = SI joint inflammation/ pathology
19
Q
What is FABER test?
A
Flexion Abduction External Rotation at hip -> pain in buttock = SI joint inflammation
20
Q
What is Modified Schober test?
A
- evaluate degree of movement in lumbar spine with forward flexion
- pt stands upright - mark 10cm above dimples f Venus then ask pt to flex forward and touch toes
- > increase of <4cm between mark and dimples of Venus suggests spine immobility (e.g. AS)
21
Q
What is this pathognomonic for: limitation in chest expansion of 2cm or less when measuring around chest at nipple level?
A
Spondylitis
22
Q
What does occiput to wall distance measure?
A
- pt stands with back to wall and measure distance between occiput and wall -> should be 0
- > monitor kyphotic disease progression
23
Q
What is likely dx?
- osteophytes
- Bouchard node (PIP)
- Heberden node (DIP)
A
OA
24
Q
What is likely dx?
- pannus (around MCP)
- ulnar deviation
A
RA
25
What do you check for with joint aspiration and synovial fluid analysis?
4Cs: culture, cell count, crystals, chemistry
crystals doesn't r/o septic arthritis
26
Special serologic tests in patient with arthritis? Other workup?
- RF and anti-CCP if RA suspected
- ANA, anti-dsDNA, C3, C4 if SLE suspected
- ANCA if vasculitis suspected
- HLA-B27 if ankylosing spondylitis suspected
+/- STI investigations
Xray of joint
etc
27
Synovial fluid dx:
- clear, yellow
- high viscosity
- WBC <2000
- PMNs <25%
- normal protein
- glucose = blood concentration
Noninflammatory
- OA
- trauma
28
Synovial fluid dx:
- clear to opaque
- low viscosity
- WBC >2000
- PMN >50%
- protein increased
- glucose decreased
Inflammatory
- RA
- crystal
- CTD
- spondyloarthropathies
29
Synovial fluid dx:
- turbid, purulent, serosanginous
- variable viscosity
- WBC >50,000
- PMN >90%
- culture/gram stain +
- protein increased
- glucose sig decreased
Infectious
| - septic arthritis
30
Synovial fluid dx:
- sanguineous
- variable viscosity
- variable WBC and PMN
- increased protein
- glucose = to blood concentration
Hemorrhagic
- traumatic
- hemophilia
31
CI and precautions for NSAIDs
- GI toxicity
- renal insufficiency
- advanced hepatic impairment
- CHF or HTN
- known hypersensitivity
- concomitant use of anticoagulants
- chronic EtOH abuse
- platelet dysfunction
32
Lab investigations for RA
- RF
| - anti-CCP (more specific)
33
Lab investigations for SLE
- ANA (sensitive, not specific; positive in Sjogrens, inflammatory myopathies and RA too)
- anti-dsDNA (most specific for SLE)
- anti-Sm (associated with lupus nephritis)
- antihistone (associated with drug-induced lupus)
- C3, C4 (decreased in SLE)
34
Lab investigations for Scleroderma
- anti-Scl-70
| - anticentromere (associated with CREST syndrome)
35
Lab investigations for Sjogren syndrome
- anti-Ro/SSA (associated with cutaneous manifestations of SLE and having a child with neonatal lupus)
- anti-La/SSB
36
Lab investigations for inflammatory myopathies (PM/DM)
- anti-Jo-1 (PM)
- anti-MI-2 (DM)
- anti-SRP (PM and DM)
37
What are non specific inflammatory markers?
ESR
| CRP
38
Likely diagnosis?
- malar rash
- discoid rash
- serositis
- oral ulcers
- ANA
- photosensitivity
- blood disorders
- renal involvement
- arthritis
- immunologic phenomena
- neurologic disorder
SLE
| MD SOAP BRAIN = 4+/11 must be present
39
Dx scleroderma
1 major or 2 minor
major: scleroderma proximal to MCPs
minor: scleodactyly, digital pitting scars/loss of substance from finger pad, bibasilar pulmonary fibrosis
40
What diagnosis depends on sicca sx, salivary gland biopsy and autoantibodies (anti-Ro, anti-La, ANA, RF)?
Sjogren syndrome
41
Diagnose:
- symmetric proximal muscle weakness typically involving shoulder and hip girdles
- elevated CK
- EMG changes
- positive muscle biopsy
- typical rash
Inflammatory myopathies
42
Typical rash of DM?
- Grotten papules
- heliotrope rash
- shawl sign
- mechanic's hands
- periungual erythema
43
Dx arthritis with UC or Crohns?
EA
44
Diagnosis:
- dermatologic = psoriasis, nail involvement
- arthritis
- radiologic = syndesmophytes, pencil in cup appearance DIP joints, osteolysis, periostitis
PsA
45
What has negatively birefringent, needle-like crystals on synovial fluid analysis?
Gout
46
Xray:
- top
- soft tissue swelling
- punched-out lesions-erosion with overhanging edge
Gout
47
What has negatively birefringent, rhomboid crystals on synovial fluid analysis; X-ray might show chondocalcinosis (fibrocartilage, articular cartilage, ligaments, joint capsule)
CPPD
48
Treatment of infectious arthritis?
Abx
- IV 3rd gen cephalosporin (Ceftriaxone) + joint drainage (gram -)
- IV vancomycin + joint drainage (gram +)
- Doxycycline (Lyme)
- Pen G (rheumatic fever)
49
Treatment reactive/ post infectious arthritis?
- NSAIDs, intra-articular steroids
| - abx if Chlamydia present
50
Treatment seronegative spondyloarthropathies
- NSAIDs (1st line)
| - DMARDs (methotrexate, anti-TNF inhibitors - 2nd line)
51
Treatment polyarticular gout
- acute: NSAIDs, colchicine, systemic or intra-articular glucocorticoids
- urate lowering therapies after acute gout attack (allopurinol, febuxostat, probenecid)
- prevent future attacks: avoid EtOH, red meat, shellfish, foods high in purines
52
Treatment CPPD
- NSAIDs/ colchicine/ systemic or PO glucocorticoids for acute attack
53
Dx:
- medium-vessel vasculitis
- lung involvement
- rapidly progressive glomerulonephritis
Wegners
54
Dx:
- small vessel vasculitis
- palpable purpura
- arthritis
- glomerulonephritis
- abdominal pain
Henoch-Schonlein purpura
55
Mechanism underlying PM/DM?
- muscle inflammation -> damage and weakness
56
Mechanism underlying vasculitis?
- inflammatory destruction of bv; neutrophils invade vessel walls and degranulate, leading to scarring and impediment of blood flow
57
Mechanism underlying scleroderma (systemic sclerosis)
- diffuse associated with malignant HTN vs. limited
| - fibrosis of skin with possible visceral organ involvement
58
Mechanism underlying SLE
- autoantibodies bind to proteins to form immune complexes, which deposit in tissues and trigger inflammatory cascade
59
Mechanism underlying RA
- proliferation of synovial tissue forms a pannus, which invades and destroys cartilage and bone
60
Are mechanical joint pain and degenerative arthritis (OA) the same?
Yes - chronic, noninflammatory arthropathy
61
Pathophys of OA
- deterioration of articular cartilage secondary to local biomechanics factors and release of proteolytic and collagenolytic enzymes
- abnormal local bone metabolism can further damage joints
- > can result in small effusions (synovitis) due to cartilage damage
62
Secondary causes of OA?
- trauma
- inflammation/infection
- skeletal disorders (scoliosis)
- endocrine dz (hyperparathyroidism, hypothyroidism)
- metabolic dz (gout, pseudo gout, hemochromatosis, Wilson dz)
- neuropathic (Charcot joints)
- avascular necrosis
63
Hallmarking findings of OA on X-ray?
- joint space narrowing
- subchondral sclerosis
- subchondral cysts
- osteophytes
64
Where does nonarticular MSK pain originate from?
- soft tissue structures surrounding a joint
| aka soft tissue pain
65
Dx: pain associated with muscle contraction, swelling along tendon sheath, point tenderness along tendon
Tendonitis
66
Dx: inflammation of sac of fluid between tendons, skin, bone; result from trauma or repetitive motion; common in greater trochanteric bursa, knees, heels, elbows, shoulders
Bursitis
67
Dx: medial (golfer's elbow) or lateral (tennis elbow); tendonitis of common wrist flexor (medial) or common wrist extensor (lateral)
Epicondylitis
68
Dx: paresthesia with numbness and tingling more than pain; common sides include ulnar nerve at elbow, median nerve at wrist (carpal tunnel syndrome)
Entrapment syndromes
69
Dx: impingement/ damage to nerve roots; causes include disk herniation, spondylosis, spondylolisthesis, spinal stenosis, spinal neoplasm +/- cards equine
Radiculopathy
70
Dx: damage to peripheral nerves; causes include infection, diabetes, B12 deficiency, neoplasm
Neuropathy
71
Dx: result of infection with herpes zoster; may be debilitating
Postherpatic neuralgia
72
Dx: persistent burning pain following injury accompanied by swelling, damage to skin and soft tissues, muscle wasting, regional osteopenia, sweating; type 1 vs. 2
Complex regional pain syndrome (prev. reflex sympathetic dystrophy)
- type I= peripheral injury
- type II = proximal
73
Dx: increased pressure within one body compartment, with causes insufficient blood supply to surrounding and distal tissues
Compartment syndrome
74
Dx: sign of peripheral arterial disease in which there is insufficient blood supply to muscle during exercise
Intermittent claudication
75
Red flags low back pain
- acute onset localized spine pain
- pain waking pt up at night
- hx cancer
- unexplained weight loss
- immunosuppression (infection risk)
- fever
- trauma
- bladder or bowel incontinence
- urinary retention (overflow incontinence)
- saddle anesthesia
- loss of anal sphincter tone
- motor weakness in lower extremities
- point vertebral tenderness
76
Is pain on forward flexion vs. pain on extension of back likely mechanical or stenosis?
- pain with forward flexion = mechanical cause
| - pain with extension = spinal stenosis
77
What is concerning with patient unable to heal-toe walk?
- cauda equina - secondary to multiple nerve root involvement
78
What is straight leg raise test?
- pain between 30-60 degrees = nerve root irritation
| - pain on crossed straight leg raise = disk herniation
79
Where is radiculopathy if patient has weakness of dorsiflexion at first MTP and ankle?
L4/L5
80
What nerve roots are tested with medial, dorsal and lateral areas of foot?
```
medial = L4
dorsal = L5
lateral = S1
```
81
What is femoral stretch testing?
- pt lies prone and hip is extended and knee flexed
- flex knee and lift thigh off exam table
- pain = lumbar nerve root irritation
82
Treatment neuropathic pain?
- TCA
- SNRI
- anticonvulsant
- long-acting opiate
- topical lidocaine
- capsaicin cream
- intrathecal opioid or clonidine
- botox injection
- nerve block
surgical - dorsal column neurostimulator, DBS (thalamus)
83
Ddx generalized pain disorders
Noninflammatory
- FM
- chronic fatigue syndrome
Systemic inflammatory arthropathies
- PMR
- RA
- SLE
- ankylosing spondylitis
Inflammatory myositis
- PM
- DM
Mental health
- depression
- somatoform disorders
Endocrine
- hypothyroidism
84
```
Dx
- overwhelming fatigue and cognitive dysfunction (fog)
- gradual insidious onset of 'total body pain'
- sleep disturbance
- aggravated by emotional stress
+/- IBS, headaches, Raynaud phenomena
hx trauma, depression, other MSK disease
- women>men (10:1) in 30-50 yrs of age
```
FM
| - dx with pain index and SS score
85
Dx
- acute/subacute onset of pain in neck, shoulders, pelvic girdle
- subjective weakness
- prolonged AM stiffness
- constitutional sx (fever, malaise, anorexia), aches, and pains in neck, shoulders and pelvic girdle
- usually age >50
PMR
- normal muscle strength on MSK exam
- decreased ROM shoulders, neck, hips
- evidence of synovitis and bursitis
check for temporal arteritis
86
Dx
- headache
- scalp pain
- visual changes
- jaw claudication
- PMR often associated
Temporal arteritis (GCA)
- check temporal arteries form tenderness, pulsation, thickening
- check vision and visual fields
87
Dx
- progressive muscle weakness
- difficulties with tasks requiring proximal muscles (getting up from chair, climbing stairs)
- myalgia, polyarthralgias, fatigue
- swallowing difficulties
PM/DM
- findings of symmetric proximal muscle weakness
- muscle atrophy
- skin manifestations with DM - V sign, shawl sign, Holster sign, periungual erythema, Gottron papule, mechanic's hands, heliotrope rash
88
Dx criteria FM?
WPI and SS scale
- WPI = number of painful body regions over 1 week
- SS scale = measure of fatigue, unrefreshing sleep, cognitive and somatic sx
>3mo sx
(no tender point count)
89
PMR diagnostic criteria?
- age >50
- bilateral aching and AM stiffness for at least 1mo (in 2 out of 3 areas: neck/torso, shoulders/proximal arms, hips/ proximal regions of thighs)
- ESR >50
- anti-CCP, RF, ANA usually negative
r/o CT disease, RA, malignancy, infection
90
Treatment/ diagnosis temporal arteritis?
- treat with corticosteroids
- temporal artery biopsy
- > can cause blindness if not tx promptly
91
Diagnostic criteria DM/PM?
- symmetric proximal muscle weakness
- elevated muscle enzymes: CK, aldolase
- myopathic changes on EMG
- muscle biopsy abnormalities
PM = endomysial inflammatory infiltrates, muscle necrosis, atrophy
DM = perifascicular atrophy, perivascular/ perimysial inflammation
DM - cutaneous involvement
additional tests
- autoimmune: anti-Jo-1, anti-MI-2, anti-SRP
- CXR (interstitial lung disease)
- skin biopsy (DM)
92
Medical tx fibro?
- TCAs (amitriptyline)
| - gabapentin/ pregabalin
93
Adverse effects of corticosteroids?
- infection (check TB)
- osteoporosis
- anxiety
- hyperglycaemia (DM)
- hypoadrenalism if withdrawn inappropriately
94
Treatment PMR?
10-15mg/d prednisone until sx resolve then taper
| -> rapid response to steroids
95
Treatment PM/DM
- corticosteroids
- second line = methotrexate, IVIG, azathioprine
- third line: cyclophosphamide, mycophenolate, cyclosporin, tacrolimus
-> follow DM closely because high risk developing malignancy
