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Step 2 CK > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Loss of articular cartilage causing pain with minimal or absent inflammation

A

Osteoarthritis (aka degenerative joint disease)

Chronic, slowly progressive, erosive damage to joint surfaces

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2
Q

Pain in weight-bearing joints (knee, hip, ankle)

DIP affected

Crepitations on exam

Stiffness < 15 minutes

A

DJD (aka osteoarthritis)

DIP enlargement = Heberden nodes

PIP = Bouchard

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3
Q

Laboratory tests for DJD

A

All normal (ESR, CBC, ANA, RF)

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4
Q

The most accurate test for DJD

A

X-ray showing:

Joint space narrowing

Osteophytes

Dense subchondral bones

Bone cysts

Absense of inflammation, normal lab tests, and short duration of stiffness distinguishes DJD from RA

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5
Q

Treatment for DJD

A
  1. Wt loss and moderate exercise (swimming and yoga)
  2. Acetaminophen = best initial analgesic
  3. NSAIDs
  4. Capsaicin cream
  5. Intraarticular steroids
  6. Hyaluronan injection
  7. Joint replacement for severe disease
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6
Q

Causes of Gout

A

Overproduction: idiopathic, increased turnover of cells (cancer, hemolysis, psoriasis, chemo), enzyme deficiency (Lesch-Nyhan syndrome, glycogen storage disease)

Underexcretion: renal insufficiency, ketoacidosis or lactic acidosis, thiazides and ASA

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7
Q

Most accurate test for gout

A

Aspiration of the joint showing needle-shaped crystals with negative birefringence on polarized light microscopy

It is essential to tap the joint to exclude infection

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8
Q

Treatment for gout

A

Acute attack =

  1. NSAIDs (superior to colchicine)
  2. Steroids (if no response to NSAIDs or if NSAIDs are contraindicated)
  3. Colchicine

Chronic attack =

  1. Diet
  2. Stop thiazides (use losartan for HTN)
  3. Colchicine
  4. Allopurinol or Febuxostat
  5. Pegloticase
  6. Probenecid and sulfinpyrazone
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9
Q

Best drug for BP management in a patient with gout

A

Losartan (also lowers uric acid)

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10
Q

What drug is safe to use for a patient with renal insufficiency and gout?

A

Acute attack = steroids

Chronic management = Allopurinol (probenecid, NSAIDs, and sulfinpyrazone are contraindicated)

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11
Q

Adverse effects of colchicine

A

Diarrhea

Bone marrow suppression (neutropenia)

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12
Q

Serious adverse effect of Allopurinol

A

TEN or SJS

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13
Q

Most common risk factors for CPPD

A

Hemochromatosis and hyperparathyroidism

Also associated with DM, hypothyroidism, and Wilson disease

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14
Q

Diagnostic test for CPPD

A

X-ray shows calcification of the cartilaginous structures of the joint and DJD

The most accurate test is arthrocentesis: positively birefringent rhomboid-shaped crystals

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15
Q

DJD on x-ray or MRI of the spine in a patient over 50

A

Has no meaning (essentially universal in all patients over 50)

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16
Q

Most likely cause of back pain with:

  1. History of cancer
  2. Fever and high ESR
  3. Bowel and bladder incontinence with ED
  4. Under age 40, pain worsens with rest
  5. Pain/numbness of medial calf or foot
A
  1. Cord compression
  2. Epidural abscess
  3. Cauda equina
  4. Ankylosing spondylitis
  5. Disk herniation
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17
Q

Point tenderness at the spine with percussion of the vertebra is highly suggestive of…

A

cord compression

Hyperreflexia is found below the level of compression

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18
Q

Epidural abscess is most often from…

A

Staph aureus

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19
Q

95% of disc herniations occur at what level?

A

L4/5 and L5/S1

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20
Q

A negative straight leg raise test excludes herniation with what degree of sensitivity?

A

95%

50% of those with a positive SLR actually have a herniated disk; however, answer “NO MRI” for just low back pain with positive SLR

Patient presentations where imaging is essential are: cord compression, epidural abscess, ankylosing spondylitis, and cauda equina

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21
Q

Nerve root innervation for L4-S1

A

L4 = dorsiflexion of foot, knee jerk reflex, and sensory of inner calf

L5 = dorsiflexion of toe, no reflex, and sensory of inner forefoot

S1 = eversion of foot, ankle jerk reflex, and sensory of outer foot

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22
Q

Treatment for cord compression

A

Systemic glucocorticoids (chemo for lymphoma and radiation for solid tumors)

When there is obvious cord compression (h/o cancer, tenderness of the spine, hyperreflexia, and decreased sensation), the most important step is to begin steroids urgently to decrease the pressure on the cord

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23
Q

Treatment for epidural abscess

A

Steroids to control acute neurological deficits

Vanc or linezolid for empiric therapy; switch to oxacillin if it is sensitive; drain if the infection is large enough to produce deficits or if there is no response to abx alone

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24
Q

Treatment for cauda equina

A

Surgical decompression

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25
Q

Treatment for disk herniation

A

NSAIDs with continuation of ordinary activity

The most common wrong answer is bed rest

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26
Q

How to differentiate peripheral arterial disease from spinal stenosis

A

The vascular studies (ABI) are normal for spinal stenosis

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27
Q

Diagnostic test for spinal stenosis

A

The only test is MRI

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28
Q

Young woman with chronic MSK pain and tenderness with trigger points

A

Fibromyalgia

Trigger points focal tenderness at the trapezius, medial fat pads of the knee, and lateral epicondyle

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29
Q

Treatment for fibromyalgia

A

The best initial therapy is amitriptyline

Other treatments are milnacipran (reuptake inhibitor of 5HT and NE) and pregabalin

Steroids are the wrong answer

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30
Q

Peripheral neuropathy from the compression of the median nerve as it passes under the flexor retinaculum

A

Carpal Tunnel Syndrome

Look for: pain in the hand that is worse at night, muscle atrophy of the thenar eminence, Tinel (“tap”) and Phalen sign

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31
Q

Diagnostic tests and treatment for Carpal Tunnel

A

The most accurate diagnostic tests are electromyography and nerve conduction testing (do NOT do wrist MRI)

The best initial therapy is with wrist splints

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32
Q

Hyperplasia of the palmar fascia leading to nodule formation and contracture of the fourth and fifth fingers

A

Dupuytren Contracture

Genetric predisposition and an association with alcoholism and cirrhosis

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33
Q

Treatment for Dupuytren contracture

A

More often a cosmetic embarrassment than a functional impairment

Collagenase injection helps early contracture

Triamcinolone or Lidocaine

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34
Q

Anterior knee pain 2/2 trauma, imbalance of quadriceps strength, or meniscal tear

A

Patellofemoral Syndrome

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35
Q

Treatment for patellofemoral syndrome

A

PT and strength training with cycling (knee braces don’t help)

There is nothing to fix surgically

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36
Q

Very severe pain in the bottom of the foot near the calcaneus

A

Plantar fasciitis

The pain is worst in the morning and improves with walking a few steps; X-ray of the foot is not useful because there is no correlation with the presence of heel spurs

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37
Q

Treatment for plantar fasciitis

A

Stretching, arch support, and NSAIDs

Steroid injections if no improvement

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38
Q

Morning stiffness (> 30 minutes)

Bilateral, symmetrical, small joint involvement

Nodules

A

RA

Autoimmune disorder predominantly of the joints but with many systemic manifestations of chronic inflammation (chronic synovitis leads to overgrowth, or pannus formation, which damages all the structures surrounding the joint)

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39
Q

Diagnostic tests for RA

A

RF in 70-80%

anti-CCP (80% sensitive and 95% specific)

Anemia

  • A total of 6 or more points = RA*
  • Joint involvement (up to 5 points)*
  • ESR or CRP (1 point)*
  • Duration for longer than 6 weeks (1 point)*
  • RF or anti-CCP (1 point)*
40
Q

True/False

Abnormal x-ray is not necessary to confirm the diagnosis of RA

A

True

41
Q

RA

Splenomegaly

Neutropenia

A

Felty syndrome

42
Q

RA

Pneumoconiosis

Lung nodules

A

Caplan syndrome

43
Q

Treatment for RA

A

The most important issue is stopping the progression of the disease

  • Methotrexate = best initial DMARD
  • TNF inhibitors (infliximab, adalimumab, etanercept) are best for those not responding
  • Rituximab (removes CD20 positive lymphocytes)
  • Hydroxychloroquine
  • Sulfasalazine, Leflunomide, Abatacept, and Anakinra
44
Q

When are steroids used for RA

A

When NSAIDs do not control pain immediately

As a bridge when waiting for DMARDs to take effect

Steroids DO NOT prevent progression of RA

45
Q

A patient with long-standing RA is scheduled to have surgery. What is an important study prior to the procedure?

A

Cervical spine x-ray

RA is associated with C1/C2 subluxation; cervical spine imaging to detect possible instability of the vertebra is essential prior to the hyperextension of the neck that typically occurs with endotracheal intubation

46
Q

What does erosive disease mean

A

Joint space narrowing

Physical deformity of joints

X-ray abnormalities

47
Q

Adverse Effects of RA Medications

  • Anti-TNF
  • Hydroxychloroquine
  • Sulfasalazine
  • Rituximab
  • Gold salts
  • Methotrexate
A
  • Anti-TNF: Reactivation of TB
  • Hydroxychloroquine: Ocular
  • Sulfasalazine: Rash, hemolysis
  • Rituximab: Infection
  • Gold salts: Nephrotic syndrome
  • Methotrexate: Liver, lung, marrow
48
Q

High, spiking fever (above 104) in a young person that has no clearly identified etiology but is associated with a rash

A

Juvenile Rheumatoid Arthritis

49
Q

Splenomegaly

Pericardial effusion

Mild joint symptoms

Salmon colored rash on chest and abdomen

A

Juvenile Rheumatoid Arthritis

Half of cases improve with ASA or NSAIDs; if there is no response use steroids; steroid resistant cases are treated with TNF drugs

50
Q

The most common cause of death in RA

A

CAD

51
Q

Define SLE

A

an autoimmune disorder with a number of autoantibodies (ANA, dsDNA) that cause inflammation diffusely throughout the body and the blood

52
Q

Diagnosis of lupus

A

4 of 11 known manifestations

  1. Malar rash
  2. Discoid rash
  3. Photosensitivity
  4. Oral ulcers
  5. Arthritis
  6. Serositis
  7. Renal involvement
  8. Neurologic symptoms
  9. Hemolytic anemia
  10. Anti-dsDNA
  11. Anti-Sm
53
Q

When a patient with SLE presents with signs/symptoms of a severe infection, how do you determine if it is a lupus flare (treat with high-dose steroids) or an infection with sepsis causing confusion (where high-dose steroids would be harmful)?

A

Acute lupus flare = decrease in complement and rise in anti-dsDNA

54
Q

Define antiphospholipid syndrome

A

An idiopathic disorder with IgG or IgM antibodies made against negatively charged phospholipids (the majority of cases are not associated with SLE)

2 main types:

Lupus anticoagulant and Anticardiolipin antibodies

55
Q

Elevation of aPTT

normal PT

False positive VDRL/RPR

Recurrent spontaneous abortions

A

Antiphospholipid syndrome

Anticardiolipin antibodies more often give spontaneous abortion, and the lupus anticoagulant is more often associated with an elevated aPTT

56
Q

Diagnostic tests for APL syndrome

A

The best initial test is the mixing study (aPTT remains elevated)

The most specific test for lupus anticoagulant is the Russell viper venom test (RVVT)

57
Q

Treatment for APL syndrome

A

Asymptomatic = no treatment

DVT or PE = heparin and warfarin (duration of treatment is unclear)

58
Q

Who should be investigated for anticardiolipin antibody as a cause of spontaneous abortion? If found, what is the treatment to prevent recurrence?

A

Patients with two or more first-trimester events or a single second-trimester event

Heparin and aspirin (warfarin is teratogenic)

59
Q

CREST vs Scleroderma

A

CREST = Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, and Telangiectasia

When is also involves the lungs, heart, and kidney = Scleroderma

Scleroderma is diffuse in 20% of cases and limited in 80%

60
Q

SCL-70

A

AKA anti-topoisomerase

The most specific test for Scleroderma, but present in only 30% of those with diffuse disease and 20% of those with limited disease

61
Q

Anticentromere

A

Present in half of those with CREST syndrome

62
Q

Treatment for CREST/Scleroderma

A

Methotrexate slows the underlying disease process of limited scleroderma

Renal crisis = ACEi

Esophageal dysmotility = PPIs for GERD

Raynaud = CCB

Pulmonary fibrosis = Cyclophosphamide

63
Q

Inflammatory myopathies that present with proximal muscle weakness leading to difficulty getting up from a seated position or walking up stairs

A

Polymyositis and Dermatomyositis

Unlike in myasthenia gravis, they do NOT affect facial or ocular muscles

64
Q

Malar involvement

Shawl sign

Heliotrope rash

Gottron papules

A

Dematomyositis

65
Q

Dematomyositis is associated with what 25% of the time?

A

Cancer

Common sites are: ovary, lung, GI, and lymphoma

66
Q

Diagnostic tests for poly/dermatomyositis

A

Best initial test = CPK and aldolase

Most accurate = muscle biopsy

67
Q

Anti-Jo antibodies

A

Associated with lung fibrosis seen in poly/dermatomyositis

68
Q

Treatment for poly/dermatomyositis

A

Steroids

Hydroyxchloroquine helps the skin lesions

69
Q

Define Sjogren Syndrome

A

An idiopathic autoimmune disorder 2/2 antibodies predominantly against lacrimal and salivary glands

Associated with: RA, SLE, PBC, Polymyositis, and Hashimoto

70
Q

Polydipsia

Keratoconjunctivitis sicca

Rampant dental caries

Dyspareunia

A

Sjogren Syndrome

Dry mouth results in constantly drinking water; loss of saliva leads to caries and loss of teeth (saliva neutralizes acid on teeth and physically washes food away)

71
Q

What is the most dangerous complication of Sjogren

A

Lymphoma

72
Q

Diagnostic Test for Sjogren

A

Best initial test = Schirmer test (filter paper placed against the eye and observed for tear production)

Most accurate = lip or parotid biopsy

Best initial blood test = SS-A and SS-B (“Ro” and “La”)

73
Q

Treatment for Sjogren

A

Best initial therapy = water the mouth and fluoride treatments; artificial tears to avoid corneal ulcers

Pilocarpine and cevimeline increase ACh (main stimulant in the production of saliva)

There is no cure

74
Q

Fever

Malaise/fatigue

Weight loss

Arthralgia/myalgia

A

General symptoms of all vasculitides

75
Q

Define Polyarteritis Nodosa

A

PAN is a disease of small and medium-sized arteries that inexplicably spares the lungs

76
Q

What disease is associated with PAN

A

Chronic hep B and C

77
Q

Tests for PAN

A

Most accurate = biopsy of a symptomatic site

78
Q

Treatment for PAN

A

Prednisone and cyclophosphamide

Treat hepatitis when found

79
Q

Pain and stiffness in shoulder and pelvic girdle muscles

Difficulty combing hair and rising from a chair

Elevated ESR

Normochromic, normocytic anemia

A

Polymyalgia Rheumatica

CPK and aldolase are normal

Excellent response to steroids

80
Q

Upper/lower respiratory tract findings in association with renal insufficiency

A

Wegener Granulomatosis

The clue to answering the “most likely diagnosis” question is unresolving pneumonia not better with antibiotics

81
Q

Test for Wegener Granulomatosis

A

Best initial = antineutrophil cytoplasmic antibody (ANCA)

Most accurate = biopsy

Lung biopsy > Renal biopsy > Sinus biopsy

82
Q

C-ANCA vs P-ANCA

A

C-ANCA = anti-proteinase-3 antibodies

P-ANCA = anti-myeloperoxidase antibodies

C-ANCA = Wegener

P-ANCA = Churg-Strauss and microscopic polyangiitis

83
Q

Pulmonary-renal syndrome

Asthma

Eosinophilia

A

Churg-Strauss Syndrome

Biopsy is the most accurate test

Treat with prednisone and cyclophosphamide

84
Q

Vignette describes leukocytoclastic vasculitis on biopsy

A

Henoch-Schonlein Purpura

Steroids are the answer for severe abd pain or progressive renal insufficiency, but most cases resolve spontaneously

85
Q

Associated with Hep C

Joint pain, purpuric skin lesions, neuropathy, glomerulonephritis

A

Cryoglobulinemia

Positive RF; steroids not effective

Treat with interferon, ribavirin, and telaprevir/boceprevir

86
Q

Asian or Middle Eastern person with painful oral and genital ulcers in association with erythema nodosum-like lesions of the skin

A

Behcet Syndrome

Pathergy = sterile skin pustules from minor trauma like a needle stick

87
Q

3 types of seronegative spondyloarthropathies

A

Ankylosing spondylitis

Psoriatic arthritis

Reactive arthritis (Reiter syndrome)

88
Q

True/False

Corticosteroids are a good treatment for seronegative spondyloarthropathy

A

False

89
Q

Why is HLA B27 not a confirmatory test for seronegative spondyloarthropathies

A

8% of the general population is positive

90
Q

Treatment for anklosing spondylitis

A

Exercise program and NSAIDs

Second line = anti-TNF drugs

91
Q

Joint pain

Ocular findings (uveitis, conjunctivitis)

Genital abnormalities (urethritis, balanitis)

A

Reactive Arthritis (Reiter syndrome)

2/2 IBD, STIs, and GI infections

Treat with NSAIDs (second line = sulfasalazine) and correct underlying cause

92
Q

True/False

All blood tests are normal in osteoporosis

A

True

93
Q

Best empiric therapy for Septic Arthritis

A

Ceftriaxone and Vancomycin

Adjust antibiotics according to culture results

94
Q

If recurrent gonorrhea infection is described, test for…

A

terminal complement deficiency

95
Q

Children get osteomyelitis from…

Adults get it from…

A

children = hematogenous spread

adult = contiguous infection

96
Q

Tests for osteomyelitis

A

Best initial = x-ray (if normal, the most appropriate next step is an MRI)

Most accurate = biopsy

ESR is the answer when following response to therapy

Step 2 CK (18 decks)

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