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On Rounds Pearls > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

How can arthritis and tendinitis be distinguished on physical exam?

A

Tendinitis: painful on active movement of joint but not passive manipulation
Arthritis: painful on both active and passive movement

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2
Q

What are Hebergen’s and Bouchard’s nodes?

What disease are they seen in?

A

Nodular, bony swelling of the interphalangeal joints.
Hebergen’s: DIP
Bouchard’s: PIP

Seen in osteoarthritis (although Bouchard’s/PIP nodes may sometimes be seen in RA)

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3
Q

What is a Baker’s cyst?

What can cause this?

A

Benign swelling (pseudocyst) of semimembranosus synovial bursa in the popliteal space behind the knee.

Can be caused by knee arthritis (e.g. OA or RA) or knee injury (e.g. torn meniscus)

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4
Q

What is a complication of a Baker’s cyst and how does this present?

What can it be confused with?

What test is used for diagnosis?

A

Ruptured Baker’s cyst presents with painful inflammation of the calf (swelling, pain, tenderness, problems bearing weight).

Can be confused with thrombophlebitis.

Diagnosis with ultrasound.

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5
Q

What is a Charcot joint?

A

Particularly destructive OA that results from loss of proprioception (leading to unusual stress on joints)

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6
Q

Where do Charcot joints most commonly occur in diabetes?
Syphilis?
Syringomyelia?
Hansen’s disease?

A

Diabetes: Ankle
Syphilis (tabes dorsalis): knee
Syringomyelia: shoulder or elbow (remember capelike distribution)
Hansen’s disease (neuritic form of leprosy): Wrist

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7
Q

How can be olecranon bursitis be distinguished from elbow arthritis on physical exam maneuvers?

A

Both have pain with flexion and extension, but only joint involvement (arthritis) has pain with supination and pronation

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8
Q

What is rheumatoid factor?

What is the sensitivity and specificity of RF for rheumatoid arthritis?

A

IgM autoantibody against the tail (Fc region) of IgG antibodies

Sensitivity: about 70%
Specificity: about 85% (also positive in other CVD and some chronic infections)

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9
Q

In addition to rheumatoid factor, what is another biomarker for RA?

How does its sensitivity and specificity for RA compare to RF?

A

anti-CCP (anti-cyclic citrullinated) antibodies

anti-CCP has similar sensitivity but somewhat greater sensitivity for RA than RF is.

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10
Q

What can lead to positive RF in a patient without RA?

A

Other collagen vascular diseases (e.g. lupus, Sjogren’s syndrome) and some chronic infections (e.g. subacute bacterial endocarditis) can have positive RF

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11
Q

What percent of patients with RA are RF positive at time of presentation?

A

50%

More develop positivity later in course, but 20-25% of RA patients remain seronegative throughout

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12
Q

What is correlated with high RF titers in RA?

A
  1. Long-standing disease
  2. Aggressive joint destruction
  3. Subcutaneous nodules
  4. Vasculitis
  5. Other extra-articular manifestations
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13
Q

What joints are most commonly involved in RA?

A

Small joints of hands, wrists, feet, and ankles (but knees, hips, elbows and spine may also be affected)

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14
Q

What HLA is associated with RA?

Many seronegative spondylarthropathies?

A

RA: HLA-DR4

Seronegative spondylarthropathies: HLA-B27

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15
Q

What is the typical involvement of the ankle joint in RA?

A

Involvement of the subtalar joint (between talus and calcaneus), primairly affecting inversion/eversion rather than flexion/extension

(Flexion/extension are a result of the joints between the talus and the tibia and fibula)

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16
Q

What is the pattern of joint stiffness in RA?

A

Morning stiffness (for at least 1 hour)

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17
Q

In what demographic are extra-articular manifestations of RA more common?

A

Older men

18
Q

Where may rheumatoid nodules occur?

A

Subcutaneous (especially extensor surfaces around hands and elbow)
Visceral (e.g. cardiac, lung)

19
Q

What can result form cardiac rheumatoid nodules?

A

Heart block (if they are positioned to disrupt the conduction system)

20
Q

What are two types of lung involvement in rheumatoid arthritis?

A
  1. Bibasilar pulmonary fibrosis (most common)

2. Rheumatoid pleural effusion

21
Q

Is a rheumatoid pleural effusion an exudate or transudate?

Are glucose, complement, and pH high or low?

A

Exudate (inflammatory)

Glucose, complement, and pH are low.

22
Q

What is a potential complication of bibasilar pulmonary fibrosis in RA?

A

Pneumonia requiring long treatment (especially if immunosuppressed or there is neutropenia in Felty’s syndrome)

23
Q

What is a possible sign of rheumatoid vasculitis on physical exam?

A

Linear ulcerations around digital arteries of terminal phalanges of the hands

24
Q

What are three important sites of potential involvement of rheumatoid vasculitis?

A
  1. Digital arteries (can lead to linear ulcerations around digital arteries of terminal phalanges of hands on exam and hint at diagnosis).
  2. Coronary arteries
  3. Vasa vasorum (nerve infarcts and mononeuritis multiplex)
25
Q

What can result from rheumatoid vasculitis of the coronary arteries?

A

Myocardial ischemia and infarction

26
Q

What is Felty’s syndrome?

A

Clinical triad of:

  1. Rheumatoid arthritis (long-standing, aggressive, high RF)
  2. Splenomegaly
  3. Neutropenia (and so immune compromise)
27
Q

What is a differential you must consider for an RA flare?

What are signs suggestive of this?

Most common cause?

A

Septic arthritis

May be febrile with an acute joint, especially large joints (hip or knee) in contrast to small joints of RA.

Most common cause: Staph aureus bacteremia

28
Q

What is palindromic rheumatism?

A

Episodic form of inflammatory arthritis with bouts of acute arthritis that resolve without chronic joint damage or deformity.

29
Q

What is the clinical picture of adult Still’s disease?

A
  1. Fever pattern spiking twice daily

2. Intermittent erythematous macolupapular rash on trunk, especially the back in areas exposed to pressure

30
Q

What joints are most commonly affected in psoriatic arthritis?

What are associated findings on exam (other than psoriasis)?

A

Distal phalangeal joints

Associated with nail pitting and onycholysis (separation of nail from bed)

(In rare cases, joint disease can precede skin disease in psoriasis)

31
Q

What triggers reactive arthritis?

A

Bowel or urogenital infections by Chlamydia, Campylobacter, Shigella, Yersinia, or Salmonella

32
Q

What is the pattern of joint involvement in reactive arthritis?

A

Large joints of lower extremities.

Affects one or a few joints and is asymmetric.

33
Q

What is the clinical triad of reactive arthritis?

A
  1. Conjunctivitis (can’t see)
  2. Urethritis (can’t pee)
  3. Arthritis (can’t climb a tree)
34
Q

What skin lesions are associated with reactive arthritis?

A

Keratoderma blenorrhagica

Papulosquamous lesions with serpiginous border classically on palms and soles

35
Q

What is circinate balanitis?

What is it associated with?

A

Shallow erosions of the penis associated with reactive arthritis

36
Q

Gout vs. pseudogout:

  1. Joints most commonly affected?
  2. Substance that precipitates in joint?
  3. Crystal appearance?
A

Gout:

  1. Most commonly metatorsophalangeal joint of big toe
  2. Monosodium urate crystals
  3. Negatively birefringent, needle-shaped crystals

Pseudogout:

  1. Most commonly knee or wrist
  2. Calcium pyrophosphate dihydrate
  3. Positively birefringent, rhomboid crystals
37
Q

What is the relationship between uric acid levels and gout?

A

Hyperuricemia underlies the disease, but may not be present during the attack itself

38
Q

What are three common precipitants of acute gouty attacks?

A
  1. Unrelated hospitalization
  2. Surgery (may wake up with flare)
  3. Alcohol (elevated lactate decreases urate excretion)
39
Q

What is a risk during initiation of antihyperuricemic therapy?

What preventative measure should be taken?

A

Acute fall in sodium urate can precipitate acute gouty arthritis.

Prophylaxis with colchicine (or a non-aspirin NSAID)

40
Q

What are the two major types of medications to lower urate levels in patients with gout in between flares?

What is the classic example of each?

A 
Xanthine oxidase inhibitors (e.g. allopurinol)
Uricosuric drugs (e.g. probenecid)
41
Q

What can result from chronic hyperuricemia (other than acute gouty attacks)?

A

Tophi: precipitation of monosodium urate in soft tissues adjacent to joints and in ear lobe

42
Q

What are three common co-morbidities with gout?

A

Obesity, HTN, DM

On Rounds Pearls (3 decks)

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