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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
Treatment for disk herniation
NSAIDs with continuation of ordinary activity *The most common wrong answer is bed rest*
26
How to differentiate peripheral arterial disease from spinal stenosis
The vascular studies (ABI) are normal for spinal stenosis
27
Diagnostic test for spinal stenosis
The only test is MRI
28
Young woman with chronic MSK pain and tenderness with trigger points
Fibromyalgia Trigger points focal tenderness at the trapezius, medial fat pads of the knee, and lateral epicondyle
29
Treatment for fibromyalgia
The best initial therapy is **amitriptyline** Other treatments are milnacipran (reuptake inhibitor of 5HT and NE) and pregabalin *Steroids are the wrong answer*
30
Peripheral neuropathy from the compression of the median nerve as it passes under the flexor retinaculum
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
31
Diagnostic tests and treatment for Carpal Tunnel
The most accurate diagnostic tests are electromyography and nerve conduction testing (do NOT do wrist MRI) The best initial therapy is with wrist splints
32
Hyperplasia of the palmar fascia leading to nodule formation and contracture of the fourth and fifth fingers
Dupuytren Contracture Genetric predisposition and an *association with alcoholism and cirrhosis*
33
Treatment for Dupuytren contracture
More often a cosmetic embarrassment than a functional impairment **Collagenase injection** helps early contracture **Triamcinolone** or **Lidocaine**
34
Anterior knee pain 2/2 trauma, imbalance of quadriceps strength, or meniscal tear
Patellofemoral Syndrome
35
Treatment for patellofemoral syndrome
PT and strength training with cycling (knee braces don't help) There is nothing to fix surgically
36
Very severe pain in the bottom of the foot near the calcaneus
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
37
Treatment for plantar fasciitis
Stretching, arch support, and NSAIDs Steroid injections if no improvement
38
Morning stiffness (\> 30 minutes) Bilateral, symmetrical, small joint involvement Nodules
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)
39
Diagnostic tests for RA
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
True/False Abnormal x-ray is not necessary to confirm the diagnosis of RA
True
41
RA Splenomegaly Neutropenia
Felty syndrome
42
RA Pneumoconiosis Lung nodules
Caplan syndrome
43
Treatment for RA
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
When are steroids used for RA
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
A patient with long-standing RA is scheduled to have surgery. What is an important study prior to the procedure?
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
What does erosive disease mean
Joint space narrowing Physical deformity of joints X-ray abnormalities
47
Adverse Effects of RA Medications - Anti-TNF - Hydroxychloroquine - Sulfasalazine - Rituximab - Gold salts - Methotrexate
- Anti-TNF: Reactivation of TB - Hydroxychloroquine: Ocular - Sulfasalazine: Rash, hemolysis - Rituximab: Infection - Gold salts: Nephrotic syndrome - Methotrexate: Liver, lung, marrow
48
High, spiking fever (above 104) in a young person that has no clearly identified etiology but is associated with a rash
Juvenile Rheumatoid Arthritis
49
Splenomegaly Pericardial effusion Mild joint symptoms Salmon colored rash on chest and abdomen
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
The most common cause of death in RA
CAD
51
Define SLE
an autoimmune disorder with a number of autoantibodies (ANA, dsDNA) that cause inflammation diffusely throughout the body and the blood
52
Diagnosis of lupus
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
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)?
Acute lupus flare = **decrease in complement** and **rise in anti-dsDNA**
54
Define antiphospholipid syndrome
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
Elevation of aPTT normal PT False positive VDRL/RPR Recurrent spontaneous abortions
Antiphospholipid syndrome Anticardiolipin antibodies more often give spontaneous abortion, and the lupus anticoagulant is more often associated with an elevated aPTT
56
Diagnostic tests for APL syndrome
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
Treatment for APL syndrome
Asymptomatic = no treatment DVT or PE = heparin and warfarin (duration of treatment is unclear)
58
Who should be investigated for anticardiolipin antibody as a cause of spontaneous abortion? If found, what is the treatment to prevent recurrence?
Patients with two or more first-trimester events or a single second-trimester event Heparin and aspirin (warfarin is teratogenic)
59
CREST vs Scleroderma
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
SCL-70
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
Anticentromere
Present in half of those with CREST syndrome
62
Treatment for CREST/Scleroderma
Methotrexate slows the underlying disease process of limited scleroderma Renal crisis = ACEi Esophageal dysmotility = PPIs for GERD Raynaud = CCB Pulmonary fibrosis = Cyclophosphamide
63
Inflammatory myopathies that present with proximal muscle weakness leading to difficulty getting up from a seated position or walking up stairs
Polymyositis and Dermatomyositis *Unlike in myasthenia gravis, they do NOT affect facial or ocular muscles*
64
Malar involvement Shawl sign Heliotrope rash Gottron papules
Dematomyositis
65
Dematomyositis is associated with what 25% of the time?
Cancer Common sites are: ovary, lung, GI, and lymphoma
66
Diagnostic tests for poly/dermatomyositis
Best initial test = CPK and aldolase Most accurate = muscle biopsy
67
Anti-Jo antibodies
Associated with lung fibrosis seen in poly/dermatomyositis
68
Treatment for poly/dermatomyositis
Steroids *Hydroyxchloroquine helps the skin lesions*
69
Define Sjogren Syndrome
An idiopathic autoimmune disorder 2/2 antibodies predominantly against lacrimal and salivary glands Associated with: RA, SLE, PBC, Polymyositis, and Hashimoto
70
Polydipsia Keratoconjunctivitis sicca Rampant dental caries Dyspareunia
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
What is the most dangerous complication of Sjogren
Lymphoma
72
Diagnostic Test for Sjogren
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
Treatment for Sjogren
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
Fever Malaise/fatigue Weight loss Arthralgia/myalgia
General symptoms of all vasculitides
75
Define Polyarteritis Nodosa
PAN is a disease of small and medium-sized arteries that inexplicably spares the lungs
76
What disease is associated with PAN
Chronic hep B and C
77
Tests for PAN
Most accurate = biopsy of a symptomatic site
78
Treatment for PAN
Prednisone and cyclophosphamide Treat hepatitis when found
79
Pain and stiffness in shoulder and pelvic girdle muscles Difficulty combing hair and rising from a chair Elevated ESR Normochromic, normocytic anemia
Polymyalgia Rheumatica CPK and aldolase are normal Excellent response to steroids
80
Upper/lower respiratory tract findings in association with renal insufficiency
Wegener Granulomatosis The clue to answering the "most likely diagnosis" question is unresolving pneumonia not better with antibiotics
81
Test for Wegener Granulomatosis
Best initial = antineutrophil cytoplasmic antibody (ANCA) Most accurate = biopsy Lung biopsy \> Renal biopsy \> Sinus biopsy
82
C-ANCA vs P-ANCA
C-ANCA = anti-proteinase-3 antibodies P-ANCA = anti-myeloperoxidase antibodies C-ANCA = Wegener P-ANCA = Churg-Strauss and microscopic polyangiitis
83
Pulmonary-renal syndrome Asthma Eosinophilia
Churg-Strauss Syndrome Biopsy is the most accurate test Treat with prednisone and cyclophosphamide
84
Vignette describes leukocytoclastic vasculitis on biopsy
Henoch-Schonlein Purpura *Steroids are the answer for severe abd pain or progressive renal insufficiency, but most cases resolve spontaneously*
85
Associated with Hep C Joint pain, purpuric skin lesions, neuropathy, glomerulonephritis
Cryoglobulinemia Positive RF; steroids not effective Treat with interferon, ribavirin, and telaprevir/boceprevir
86
Asian or Middle Eastern person with painful oral and genital ulcers in association with erythema nodosum-like lesions of the skin
Behcet Syndrome Pathergy = sterile skin pustules from minor trauma like a needle stick
87
3 types of seronegative spondyloarthropathies
Ankylosing spondylitis Psoriatic arthritis Reactive arthritis (Reiter syndrome)
88
True/False Corticosteroids are a good treatment for seronegative spondyloarthropathy
False
89
Why is HLA B27 not a confirmatory test for seronegative spondyloarthropathies
8% of the general population is positive
90
Treatment for anklosing spondylitis
Exercise program and NSAIDs Second line = anti-TNF drugs
91
Joint pain Ocular findings (uveitis, conjunctivitis) Genital abnormalities (urethritis, balanitis)
Reactive Arthritis (Reiter syndrome) 2/2 IBD, STIs, and GI infections Treat with NSAIDs (second line = sulfasalazine) and correct underlying cause
92
True/False All blood tests are normal in osteoporosis
True
93
Best empiric therapy for Septic Arthritis
Ceftriaxone and Vancomycin Adjust antibiotics according to culture results
94
If recurrent gonorrhea infection is described, test for...
terminal complement deficiency
95
Children get osteomyelitis from... Adults get it from...
children = hematogenous spread adult = contiguous infection
96
Tests for osteomyelitis
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

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