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MCC Part 1 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Define oligoarthralgia

A
  • pain in 1-4 joints
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2
Q

Define polyarthralgia

A
  • pain in >4 joints
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3
Q

What needs to be ruled out in acute monoarthritis?

A
  • septic arthritis -> risk of permanent joint destruction
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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
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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

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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
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7
Q

Causes of increased serum uric acid?

A
  • overproduction: nutritional (meat, seafood, EtOH), heme malignancy
  • under excretion: dehydration, renal failure, diuretics
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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
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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

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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
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11
Q

Dx post streptococcal arthritis (rheumatic fever)

A 
- hx sore throat, fever
"no rheum for SPECCulation"
- subcutaneous nodules
- polyarthritis
- erythema marginatum
- chorea
- carditis
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12
Q

Likely diagnosis?

  • preceding GI/GU infection
  • mostly joints of lower extremity involved
  • enthesitis/ dactylitis common
A

Post-infectious

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13
Q

Sx of crystal arthropathy?

A
  • hx gout
  • renal insufficiency
  • diuretic use
  • HTN
  • obesity
  • high-purine diet
  • heavy EtOH
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14
Q

Likely dx?

  • morning stiffness >30min - 1hr
  • hx joint swelling, erythema, warmth
  • reduced ROM
  • pain at rest, relief with movement
A

Inflammatory arthritis

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15
Q

Likely dx?
- morning stiffness <30min
- sx worse with activity
+/- swelling

A

Noninflammatory arthritis

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16
Q

Triad of reactive arthritis

A

can’t see - conjunctivitis
can’t pee - urethritis
can’t climb a tree - arthritis

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17
Q

Features of RA?

A
  • symmetric joint involvement
  • swan neck deformity
  • Boutonniere deformity
  • ulnar deviation of MCP
  • radial deviation of wrist
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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
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19
Q

What is FABER test?

A 
Flexion
Abduction
External Rotation 
at hip
-> pain in buttock = SI joint inflammation
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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)
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21
Q

What is this pathognomonic for: limitation in chest expansion of 2cm or less when measuring around chest at nipple level?

A

Spondylitis

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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
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23
Q

What is likely dx?

  • osteophytes
  • Bouchard node (PIP)
  • Heberden node (DIP)
A

OA

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24
Q

What is likely dx?

  • pannus (around MCP)
  • ulnar deviation
A

RA

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25
Q

What do you check for with joint aspiration and synovial fluid analysis?

A

4Cs: culture, cell count, crystals, chemistry

crystals doesn’t r/o septic arthritis

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26
Q

Special serologic tests in patient with arthritis? Other workup?

A
  • 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

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27
Q

Synovial fluid dx:

  • clear, yellow
  • high viscosity
  • WBC <2000
  • PMNs <25%
  • normal protein
  • glucose = blood concentration
A

Noninflammatory

  • OA
  • trauma
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28
Q

Synovial fluid dx:

  • clear to opaque
  • low viscosity
  • WBC >2000
  • PMN >50%
  • protein increased
  • glucose decreased
A

Inflammatory

  • RA
  • crystal
  • CTD
  • spondyloarthropathies
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29
Q

Synovial fluid dx:

  • turbid, purulent, serosanginous
  • variable viscosity
  • WBC >50,000
  • PMN >90%
  • culture/gram stain +
  • protein increased
  • glucose sig decreased
A

Infectious

- septic arthritis

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30
Q

Synovial fluid dx:

  • sanguineous
  • variable viscosity
  • variable WBC and PMN
  • increased protein
  • glucose = to blood concentration
A

Hemorrhagic

  • traumatic
  • hemophilia
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31
Q

CI and precautions for NSAIDs

A
  • GI toxicity
  • renal insufficiency
  • advanced hepatic impairment
  • CHF or HTN
  • known hypersensitivity
  • concomitant use of anticoagulants
  • chronic EtOH abuse
  • platelet dysfunction
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32
Q

Lab investigations for RA

A
  • RF

- anti-CCP (more specific)

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33
Q

Lab investigations for SLE

A
  • 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)
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34
Q

Lab investigations for Scleroderma

A
  • anti-Scl-70

- anticentromere (associated with CREST syndrome)

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35
Q

Lab investigations for Sjogren syndrome

A
  • anti-Ro/SSA (associated with cutaneous manifestations of SLE and having a child with neonatal lupus)
  • anti-La/SSB
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36
Q

Lab investigations for inflammatory myopathies (PM/DM)

A
  • anti-Jo-1 (PM)
  • anti-MI-2 (DM)
  • anti-SRP (PM and DM)
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37
Q

What are non specific inflammatory markers?

A

ESR

CRP

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38
Q

Likely diagnosis?

  • malar rash
  • discoid rash
  • serositis
  • oral ulcers
  • ANA
  • photosensitivity
  • blood disorders
  • renal involvement
  • arthritis
  • immunologic phenomena
  • neurologic disorder
A

SLE

MD SOAP BRAIN = 4+/11 must be present

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39
Q

Dx scleroderma

A

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
Q

What diagnosis depends on sicca sx, salivary gland biopsy and autoantibodies (anti-Ro, anti-La, ANA, RF)?

A

Sjogren syndrome

41
Q

Diagnose:

  • symmetric proximal muscle weakness typically involving shoulder and hip girdles
  • elevated CK
  • EMG changes
  • positive muscle biopsy
  • typical rash
A

Inflammatory myopathies

42
Q

Typical rash of DM?

A
  • Grotten papules
  • heliotrope rash
  • shawl sign
  • mechanic’s hands
  • periungual erythema
43
Q

Dx arthritis with UC or Crohns?

A

EA

44
Q

Diagnosis:

  • dermatologic = psoriasis, nail involvement
  • arthritis
  • radiologic = syndesmophytes, pencil in cup appearance DIP joints, osteolysis, periostitis
A

PsA

45
Q

What has negatively birefringent, needle-like crystals on synovial fluid analysis?

A

Gout

46
Q

Xray:

  • top
  • soft tissue swelling
  • punched-out lesions-erosion with overhanging edge
A

Gout

47
Q

What has negatively birefringent, rhomboid crystals on synovial fluid analysis; X-ray might show chondocalcinosis (fibrocartilage, articular cartilage, ligaments, joint capsule)

A

CPPD

48
Q

Treatment of infectious arthritis?

A

Abx

  • IV 3rd gen cephalosporin (Ceftriaxone) + joint drainage (gram -)
  • IV vancomycin + joint drainage (gram +)
  • Doxycycline (Lyme)
  • Pen G (rheumatic fever)
49
Q

Treatment reactive/ post infectious arthritis?

A
  • NSAIDs, intra-articular steroids

- abx if Chlamydia present

50
Q

Treatment seronegative spondyloarthropathies

A
  • NSAIDs (1st line)

- DMARDs (methotrexate, anti-TNF inhibitors - 2nd line)

51
Q

Treatment polyarticular gout

A
  • 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
Q

Treatment CPPD

A
  • NSAIDs/ colchicine/ systemic or PO glucocorticoids for acute attack
53
Q

Dx:

  • medium-vessel vasculitis
  • lung involvement
  • rapidly progressive glomerulonephritis
A

Wegners

54
Q

Dx:

  • small vessel vasculitis
  • palpable purpura
  • arthritis
  • glomerulonephritis
  • abdominal pain
A

Henoch-Schonlein purpura

55
Q

Mechanism underlying PM/DM?

A
  • muscle inflammation -> damage and weakness
56
Q

Mechanism underlying vasculitis?

A
  • inflammatory destruction of bv; neutrophils invade vessel walls and degranulate, leading to scarring and impediment of blood flow
57
Q

Mechanism underlying scleroderma (systemic sclerosis)

A
  • diffuse associated with malignant HTN vs. limited

- fibrosis of skin with possible visceral organ involvement

58
Q

Mechanism underlying SLE

A
  • autoantibodies bind to proteins to form immune complexes, which deposit in tissues and trigger inflammatory cascade
59
Q

Mechanism underlying RA

A
  • proliferation of synovial tissue forms a pannus, which invades and destroys cartilage and bone
60
Q

Are mechanical joint pain and degenerative arthritis (OA) the same?

A

Yes - chronic, noninflammatory arthropathy

61
Q

Pathophys of OA

A
  • 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
Q

Secondary causes of OA?

A
  • trauma
  • inflammation/infection
  • skeletal disorders (scoliosis)
  • endocrine dz (hyperparathyroidism, hypothyroidism)
  • metabolic dz (gout, pseudo gout, hemochromatosis, Wilson dz)
  • neuropathic (Charcot joints)
  • avascular necrosis
63
Q

Hallmarking findings of OA on X-ray?

A
  • joint space narrowing
  • subchondral sclerosis
  • subchondral cysts
  • osteophytes
64
Q

Where does nonarticular MSK pain originate from?

A
  • soft tissue structures surrounding a joint

aka soft tissue pain

65
Q

Dx: pain associated with muscle contraction, swelling along tendon sheath, point tenderness along tendon

A

Tendonitis

66
Q

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

A

Bursitis

67
Q

Dx: medial (golfer’s elbow) or lateral (tennis elbow); tendonitis of common wrist flexor (medial) or common wrist extensor (lateral)

A

Epicondylitis

68
Q

Dx: paresthesia with numbness and tingling more than pain; common sides include ulnar nerve at elbow, median nerve at wrist (carpal tunnel syndrome)

A

Entrapment syndromes

69
Q

Dx: impingement/ damage to nerve roots; causes include disk herniation, spondylosis, spondylolisthesis, spinal stenosis, spinal neoplasm +/- cards equine

A

Radiculopathy

70
Q

Dx: damage to peripheral nerves; causes include infection, diabetes, B12 deficiency, neoplasm

A

Neuropathy

71
Q

Dx: result of infection with herpes zoster; may be debilitating

A

Postherpatic neuralgia

72
Q

Dx: persistent burning pain following injury accompanied by swelling, damage to skin and soft tissues, muscle wasting, regional osteopenia, sweating; type 1 vs. 2

A

Complex regional pain syndrome (prev. reflex sympathetic dystrophy)

  • type I= peripheral injury
  • type II = proximal
73
Q

Dx: increased pressure within one body compartment, with causes insufficient blood supply to surrounding and distal tissues

A

Compartment syndrome

74
Q

Dx: sign of peripheral arterial disease in which there is insufficient blood supply to muscle during exercise

A

Intermittent claudication

75
Q

Red flags low back pain

A
  • 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
Q

Is pain on forward flexion vs. pain on extension of back likely mechanical or stenosis?

A
  • pain with forward flexion = mechanical cause

- pain with extension = spinal stenosis

77
Q

What is concerning with patient unable to heal-toe walk?

A
  • cauda equina - secondary to multiple nerve root involvement
78
Q

What is straight leg raise test?

A
  • pain between 30-60 degrees = nerve root irritation

- pain on crossed straight leg raise = disk herniation

79
Q

Where is radiculopathy if patient has weakness of dorsiflexion at first MTP and ankle?

A

L4/L5

80
Q

What nerve roots are tested with medial, dorsal and lateral areas of foot?

A 
medial = L4
dorsal = L5
lateral = S1
81
Q

What is femoral stretch testing?

A
  • pt lies prone and hip is extended and knee flexed
  • flex knee and lift thigh off exam table
  • pain = lumbar nerve root irritation
82
Q

Treatment neuropathic pain?

A
  • 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
Q

Ddx generalized pain disorders

A

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
Q 
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
A

FM

- dx with pain index and SS score

85
Q

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
A

PMR

  • normal muscle strength on MSK exam
  • decreased ROM shoulders, neck, hips
  • evidence of synovitis and bursitis

check for temporal arteritis

86
Q

Dx

  • headache
  • scalp pain
  • visual changes
  • jaw claudication
  • PMR often associated
A

Temporal arteritis (GCA)

  • check temporal arteries form tenderness, pulsation, thickening
  • check vision and visual fields
87
Q

Dx

  • progressive muscle weakness
  • difficulties with tasks requiring proximal muscles (getting up from chair, climbing stairs)
  • myalgia, polyarthralgias, fatigue
  • swallowing difficulties
A

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
Q

Dx criteria FM?

A

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
Q

PMR diagnostic criteria?

A
  • 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
Q

Treatment/ diagnosis temporal arteritis?

A
  • treat with corticosteroids
  • temporal artery biopsy
  • > can cause blindness if not tx promptly
91
Q

Diagnostic criteria DM/PM?

A
  • 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
Q

Medical tx fibro?

A
  • TCAs (amitriptyline)

- gabapentin/ pregabalin

93
Q

Adverse effects of corticosteroids?

A
  • infection (check TB)
  • osteoporosis
  • anxiety
  • hyperglycaemia (DM)
  • hypoadrenalism if withdrawn inappropriately
94
Q

Treatment PMR?

A

10-15mg/d prednisone until sx resolve then taper

-> rapid response to steroids

95
Q

Treatment PM/DM

A
  • corticosteroids
  • second line = methotrexate, IVIG, azathioprine
  • third line: cyclophosphamide, mycophenolate, cyclosporin, tacrolimus

-> follow DM closely because high risk developing malignancy

MCC Part 1 (22 decks)

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