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STEP2 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What features are characteristic of osteoarthritis?

A
  • typically presents in an older individual with a history of trauma or obesity
  • will affect the weight bearing joints first but also affects the DIPs more than other hand joints
  • pain worsens throughout the day and with use
  • patients may have crepitus at affected joints
  • DIP enlargement = Heberden nodes, PIP enlargement = Bouchard nodes
  • laboratory testing is normal
  • radiographs show joint space narrowing, osteophytes, and dense subchondral bone
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2
Q

Describe the presentation, diagnosis, and treatment of osteoarthritis.

A
  • presents as pain in weight-bearing and DIP joints, most often in older individuals with history of trauma or obesity
  • patients may complain of crepitus in affected joints, pain that worsens with use, and DIP/PIP enlargement
  • diagnosis is made with radiographs show joint space narrowing, osteophytes, and dense subchondral bone
  • first line treatment is weight loss, moderate exercise, and acetaminophen
  • NSAID and capsaicin cream are second line for pain followed by intra-articular steroids and joint replacement
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3
Q

Describe the etiology, presentation, diagnosis, and treatment of gouty arthritis.

A
  • secondary to urate overproduction (alcohol, cancer, hemolysis, chemotherapy, Lesch-Nyhan syndrome) or under excretion from renal insufficiency
  • presents as sudden, excruciating pain with redness and tenderness, usually of the first MTP, along with fever, tophi, and uric acid stones
  • the most accurate test is joint aspiration showing yellow, needle-shaped crystals with negative birefringence and a predominately neutrophilic infiltrate
  • treat acute attacks with NSAIDs followed by corticosteroids and then colchicine
  • don’t start maintenance therapy during an acute attack
  • after resolution, limit alcohol and meat consumption, stop thiazides and transition to losartan, and add colchicine, allopurinol, febuxostat, pegloticase, probenecid, or sulfinpyrazone
  • colchicine and allopurinol are safe in renal insufficiency
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4
Q

Describe the mechanism of action for the following drugs in the treatment of gout:

  • colchicine
  • allopurinol
  • febuxostat
  • pegloticase
  • probenecid
  • sulfinpyrazone
A
  • colchicine: microtubule inhibitor prevents neutrophil migration
  • allopurinol: xanthine oxidase inhibitor inhibits urate production
  • febuxostat: xanthine oxidase inhibitor inhibits urate production
  • pegloticase: dissolves urate acid and accelerates metabolism
  • probenecid: increases excretion by the kidneys
  • sulfinpyrazone: increases excretion by the kidneys
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5
Q

Describe the etiology, presentation, diagnosis, and treatment of pseudogout.

A
  • calcium pyrophosphate deposition disease most often secondary to hemochromatosis and hyperparathyroidism
  • presents with arthritis of the large joints
  • diagnosis is supported by finding chrondrocalcinosis with radiographs but joint aspiration finding positively birefringent rhomboid crystals is most accurate
  • treat acutely with NSAIDs and intraarticular steroids; use colchicine for maintenance therapy
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6
Q

What is the most likely diagnosis for low back pain? What is first-line management?

A

most cases are lumbosacral strain and first-line treatment is NSAIDs with continued activity as tolerated

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7
Q

What are the indications and imaging modalities used for assessing low back pain?

A
  • get radiographs for those with high cancer risk or suspected compression fracture
  • get MRI for spinal infection, cauda equina, and severe or progressive neurologic deficits
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8
Q

What motor, reflex, and sensory deficit is expected for L4 nerve root impingement?

A
  • weakness with dorsiflexion of the foot
  • diminished patellar reflex
  • anterior thigh and medial calf sensory loss
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9
Q

What motor, reflex, and sensory deficit is expected for L5 nerve root impingement?

A
  • weakness with dorsiflexion of the toe
  • no associated reflex
  • medial foot sensory loss
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10
Q

What motor, reflex, and sensory deficit is expected for S1 nerve root impingement?

A
  • weakness with eversion of the foot
  • diminished achilles reflex
  • lateral foot sensory loss
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11
Q

Vertebral tenderness is suggestive of what etiologies for back pain?

A

vertebral compression fracture, cord compression, and epidural abscess

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12
Q

What is the proper management for suspected epidural abscess?

A
  • first step is steroids to limit cord compression
  • should start vancomycin pending cultures and sensitivities
  • get an MRI and surgical consult
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13
Q

What is the best first step in managing low back pain suggestive of cord compression?

A

glucocorticoids with MRI and surgical consult to follow; add vancomycin if suspecting an epidural abscess

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14
Q

Describe the presentation, diagnosis, and treatment of lumbar spinal stenosis.

A
  • presents with back pain that radiates to the buttocks and thighs bilaterally and is worse with back extension; may be accompanied by unsteady gait and leg weakness
  • diagnosis is with MRI
  • treatment begins with weight loss, analgesics, and PT followed by steroid injections and eventually surgery
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15
Q

Describe the presentation and treatment of fibromyalgia.

A
  • presents with widespread pain, fatigue, and sleep disturbance, and cognitive or mood symptoms
  • exam is normal apart except point tenderness over the trapezius, medial fat pad of the knee, and lateral epicondyle
  • treatment involves aerobic exercise, good sleep hygiene, and TCAs
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16
Q

Describe the presentation, diagnosis, and treatment of carpal tunnel syndrome.

A
  • presents with pain in the hand worse at night along the median distribution and atrophy of the thenar eminence
  • most accurate test for diagnosis is EMG/NCS
  • best initial therapy is wrist splints and NSAIDs followed by steroid injections
  • surgery is indicated for refractory disease and muscle wasting
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17
Q

Describe the pathophysiology, associations, and treatment of a Dupuytren contracture.

A
  • associated with alcoholism and cirrhosis
  • due to hyperplasia of the palmar fascia
  • treat with triamcinolone, lidocaine, or collagenase injections followed by surgery if there is functional impairment
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18
Q

What is the most accurate test for rotator cuff injury and how is it treated?

A
  • MRI is the most accurate diagnostic test
  • treat with NSAIDs, rest, and PT; second-line is steroid injection
  • surgery is reserved for complete tears and refractory cases
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19
Q

Describe the presentation and treatment of plantar fasciitis.

A
  • presents with severe pain in the bottom of the foot near the calcaneus which is worst in the morning and first few steps of the day
  • treat with stretching exercises, arch supports, and NSAIDs followed by steroid injections if refractory
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20
Q

What are the signs & symptoms of rheumatoid arthritis.

A
  • symmetric involvement of the joints with sparing of the DIPs
  • cervical joint involvement leading to C1/C2 subluxation
  • morning stiffness that improves with activity
  • fever, malaise, weight loss, and myalgias
  • rheumatoid nodules
  • vasculitis
  • baker cysts
  • pericarditis and pleuritis
  • anemia of chronic disease
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21
Q

Describe the diagnosis of rheumatoid arthritis.

A
  • anti-CCP is far more specific and sensitive than rheumatoid factor
  • patients likely have an elevated ESR and CRP as well as labs consistent with anemia of chronic disease
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22
Q

Describe the treatment of rheumatoid arthritis.

A
  • the best initial therapy is methotrexate
  • every patient needs a DMARD as part of initial therapy: this may include methotrexate, TNFa inhibitors, rituximab, hydroxychloroquine, or sulfasalazine
  • NSAIDs and steroids are used for acute pain management while waiting for DMARDs to take effect and neither prevents disease progression
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23
Q

What is Felty syndrome?

A

combination of RA, splenomegaly, and neutropenia

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24
Q

What is Caplan syndrome?

A

combination of RA, pneumoconiosis, and lung nodules

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25
Q

Name the five TNFa inhibitors as well as their mechanism of actions and indications.

A
  • adalimumab, certolizumab, golimumab, and infliximab are all TNF-a antibodies indicated for RA, ankylosing spondylitis, and IBD
  • etanercept is a TNF-a decoy receptor indicated only for RA and ankylosing spondylitis
26
Q

What is the side effect associated with each of the following immune modulators:

  • TNF-a inhibitors
  • hydroxychloroquine
  • sulfasalazine
  • rituximab
  • gold salts
  • methotrexate
A
  • TNF-a inhibitors: reactivation of TB
  • hydroxychloroquine: retinopathy
  • sulfasalazine: rash and hemolysis
  • rituximab: recurrent infections
  • gold salts: nephrotic syndrome
  • methotrexate: lung, marrow, and liver toxicity
27
Q

Describe the presentation and treatment of juvenile rheumatoid arthritis.

A
  • the most important feature is a high spiking fever in a young person accompanied by a rash and without a clear etiology
  • STILLS: salmon-colored rash, temperature elevation, ill-appearing patient, lymphadenopathy, leukocytosis, and splenomegaly
  • labs demonstrate anemia, hypoalbuminemia, leukocytosis, and elevated ferritin
  • treat with aspirin or NSAIDs then use steroids
28
Q

What are the potential manifestations of SLE?

A 
MD SOAP BRAINS
Malar
Discoid
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood (anemia, thrombocytopenia)
Renal failure
ANA
Immunologic (other antibodies)
Neuro
29
Q

Describe the presentation, diagnosis, and treatment of SLE.

A
  • presesents with skin, joint, pleural, pericardial, renal, neurologic, vascular, and hematologic manifestations
  • young patients die of infection while older die of accelerated atherosclerosis and MI
  • ANA is highly sensitive while anti-dsDNA and anti-Sm antibodies are specific; anti-histone is specific for drug-induced lupus
  • decreased complement and rising anti-dsDNA levels correlate with disease activity
  • ribosomal P suggests cerebral lupus and anti-SSA/SSB increases the risk for neonatal lupus manifesting as heart block
  • everyone should get hydroxychloroquine for maintenance therapy and steroids for flares
  • do a renal biopsy to diagnose nephritis, give IV cyclophosphamide then PO mycophenolate
30
Q

Describe the role each of the following plays in SLE:

  • ANA
  • anti-dsDNA
  • anti-Sm
  • anti-histone
  • anti-SSA/SSB (aka Ro and La)
  • ribosomal P
  • complement levels
A
  • ANA: very sensitive
  • anti-dsDNA: very specific, correlates with disease activity, and predicts lupus nephritis
  • anti-Sm: very specific but doesn’t correlate with disease activity
  • anti-histone: specific for drug-induced lupus
  • anti-SSA/SSB (aka Ro and La): predicts the risk of neonatal SLE but more common in Sjogren’s
  • ribosomal P: higher risk for cerebral lupus
  • complement levels: correlates with disease activity
31
Q

SLE patients with anti-SSA and anti-SSB antibodies have what risk? How is this managed?

A

there is a higher risk of passing on neonatal SLE which manifests as neonatal heart block and should be evaluated for with EKG

32
Q

Describe the pathophysiology, presentation, diagnosis, and treatment of anti-phospholipid syndrome.

A
  • lupus anticoagulant, anticardiolipin antibodies, and beta-2 glycoprotein mediate the disease as they target negatively charged phospholipids
  • presents with venous and arterial thrombosis, elevated PTT, and recurrent spontaneous abortions
  • the best initial test is the mixing study looking for correction of PTT with mixing
  • the most specific test is the Russell viper venom test which is prolonged and does not correct with mixing
  • treat thromboses with anticoagulation and recurrent pregnancy loss with heparin and aspirin
33
Q

When should you consider anti-phospholipid syndrome as the cause of recurrent pregnancy loss? What tests are used for this? How is it treated?

A
  • consider for 2 or more first-trimester events or a single a single second-trimester event
  • best initial test is PTT mixing study and most specific is the Russell viper venom test which doesn’t correct with mixing
  • treat with heparin and aspirin
34
Q

What are the features of CREST syndrome?

A
  • calcinosis
  • raynaud
  • esophageal dysmotility
  • sclerodactyly
  • telangiectasia
35
Q

Describe the presentation, diagnosis, and treatment for scleroderma.

A
  • presents with Raynaud syndrome, skin fibrosis, esophageal dysmotility, sudden hypertensive crisis, restrictive lung disease and pulmonary hypertension, pericarditis, and heart block
  • ANA is highly sensitive but anti-topoisomerase (SCL-70) and anti-centromere are more specific test
  • treat with methotrexate, ACEi for renal crisis, PPIs for GERD, CCBs for Raynauds, and cyclophosphamide for pulmonary fibrosis
36
Q

How are CREST and diffuse scleroderma differentiated?

A
  • CREST typically involves the extremities distal to the elbows and knees, may cause hypertension, and has a an association with anti-centromere
  • diffuse scleroderma involves the proximal extremities, causes pulmonary fibrosis as well as hypertension, and has an association with anti-topoisomerase (SCL-70) antibodies
37
Q

What are each of the following associated with:

  • ANA
  • Rheumatoid Factor
  • anti-CCP
  • anti-dsDNA
  • anti-Sm
  • anti-SSA/SSB (aka Ro and La)
  • ribosomal P
  • anti-topoisomerase
  • anti-SCL-70
  • anti-centromere
  • anti-Jo
  • anti-U1 RNP
A
  • ANA: nonspecific for several rheumatological diseases
  • Rheumatoid Factor: sensitive but non-specific for RA
  • anti-CCP: highly specific for RA
  • anti-dsDNA: highly specific for SLE and correlates with disease activity
  • anti-Sm: highly specific for SLE
  • anti-SSA/SSB: most associated with Sjogren’s but conveys a risk for neonatal SLE and heart block
  • ribosomal P: associated with cerebral lupus
  • anti-topoisomerase: associated with diffuse scleroderma
  • anti-SCL-70: associated with diffuse scleroderma
  • anti-centromere: associated with CREST
  • anti-Jo: lung fibrosis in those with dermatomyositis
  • anti-U1 RNP: mixed connective tissue disease
38
Q

Describe the presentation and diagnosis of polymyositis and dermatomyositis.

A
  • both present with proximal muscle weakness but dermatomyositis also has dermatologic manifestations: malar and heliotrope rashes as well as Gottron papules
  • the best initial tests are CPK and aldolase, next is EMG, and most accurate is muscle biopsy
  • anti-Jo antibodies are associated with lung fibrosis
  • treat with steroids for muscle weakness and hydroxychloroquine for skin lesions
39
Q

Describe the pathophysiology, presentation, diagnosis, and treatment of Sjogren syndrome.

A
  • due to antibodies against lacrimal and salivary glands
  • presents with dryness of the mouth and eyes including dysphagia, keratoconjuncitivits, and dental carries
  • the most dangerous complication is lymphoma
  • best initial test is the Schirmer test for tears ut most accurate is a lip or parotid gland biopsy
  • anti-SSA/SSB are common
  • treat with artificial tears, pilocarpine, frequent watering of the mouth, and fluoride treatments; evaluate for lymphoma
40
Q

Describe the presentation, diagnosis, and treatment of polyarteritis nodosa.

A
  • many of the symptoms are non-specific, but it notably spares the lungs and is associated with chronic hepatitis
  • may have GI pain worse with eating, lower extremity ulcers, mono neuritis multiplex with foot drop, and stroke
  • the most accurate test is biopsy; angiography shows “beading”
  • treat with prednisone and cyclophosphamide
41
Q

Describe the presentation and treatment of polymyalgia rheumatica.

A
  • presents with pain and stiffness in proximal muscles with an elevated ESR but normal CPK and aldolase
  • treat with steroids and look for temporal artertitis
42
Q

Describe the presentation and treatment of temporal arteritis.

A
  • presents with visual symptoms, jaw claudication, and headache and is associated with polymyalgia rheumatica
  • treat with prednisone before biopsy results are back
43
Q

Describe the presentation, diagnosis, and treatment of granulomatosis with polyangiitis.

A
  • also known as Wegener’s granulomatosis, it involves the oropharynx, lungs, and kidneys
  • typically with sinusitis, otitis, pharyngitis, nasopharyngeal ulcers, hemoptysis, and glomerulonephritis
  • the best initial test is c-ANCA and the most accurate is biopsy
  • treat with prednisone and cyclophosphamide
44
Q

Describe the presentation, diagnosis, and treatment of Churg-Strauss syndrome.

A
  • now called eosinophilic granulomatosis with polyangiitis
  • it is a pulmonary-renal syndrome with asthma and eosinophilia as the hallmark features
  • the most accurate test is biopsy, also may find p-ANCA
  • treat with prednisone and cyclophosphamide
45
Q

Describe the presentation, diagnosis, and treatment of Henoch-Schonlein purpura.

A
  • presents with GI pain, purpura on the lower extremities, arthralgias, and IgA nephropathy; there is also an association with intussusception
  • it is a clinical diagnosis but the most accurate test is biopsy showing leukocytoclastic vasculitis
  • it is self-limited but use steroids for severe disease
46
Q

Describe the pathophysiology, presentation, diagnosis, and treatment of cryoglobulinemia.

A
  • it is associated with chronic hepatitis C and results from the precipitation of serum proteins at cold temperatures
  • presents with arthralgia, glomerulonephritis, purpuric and ulcerative skin lesions, and peripheral neuropathies
  • labs demonstrate positive RF and cold-precipitable immune complexes
  • treatment consists of treating the underlying hepatitis
47
Q

Describe the presentation and treatment of Behcet syndrome.

A
  • presents with painful oral and genital ulcers in association with erythema nodosum-like lesions
  • pathergy, sterile skin pustules from minor trauma like a needle stick, is also a hallmark feature
  • treat with corticosteroids
48
Q

What is pathergy?

A

the presence of sterile skin pustules from minor trauma like a needle stick, seen in those with Behcet syndrome

49
Q

What features are common to all seronegative arthropathies?

A
  • tend to present in men under the age of 40 who are of the HLA-B27 genotype
  • presentation involves the spine as well as enthesopathy and uveitis
  • patients are negative for rheumatoid factor
50
Q

Describe the presentation, diagnosis, and treatment of ankylosing spondylitis.

A
  • hallmark is low backache and stiffness worsened by rest and relieved by activity along with flattening of the normal lumbar curvature and decreased chest expansion
  • other symptoms are enthesopathy, uveitis, and cardiac involvement (AV block and aortic insufficiency)
  • the best initial test is SI radiograph but the most accurate is MRI
  • treat with exercise and NSAIDs before moving on to TNFa inhibitors
51
Q

Describe the presentation, diagnosis, and treatment of psoriatic arthritis.

A
  • presents with SI joint pain, sausage digits, and nail pitting
  • the best initial test is a radiograph of the hands showing “pencil in a cup” deformity
  • treat with NSAIDs, methotrexate, or TNFa inhibitors
52
Q

Describe the presentation and treatment of reactive arthritis.

A
  • presents with joint pain, ocular findings, and genital abnromalities; “can’t pee, can’t see, can’t climb a tree)
  • typically in those with IBD or STI
  • treat with NSAIDs, sulfasalazine, and steroids
53
Q

How are osteopenia and osteoporosis diagnosed?

A

the most accurate test is a bone denisometry scan (DEXA) showing a T-score 1-2.5 SD below the mean for osteopenia and more than 2.5 SD below for osteoporosis

54
Q

What is the first line treatment for osteoporosis? What are other options?

A
  • best initial therapy is vitamin D, calcium, and bisphosphonates
  • can use denosumab (RANK-L inhibitor), raloxifene, teriparatide (parathyroid analog), or calcitonin
55
Q

What are the benefits of raloxifene?

A
  • improves bone denisty
  • lowers LDL
  • reduces risk for breast cancer
56
Q

Describe the etiology, presentation, diagnosis, and treatment of septic arthritis.

A
  • most commonly caused by staphylococcus, streptococcus, or gram-negative rods
  • presents with a warm, red, immobile joint with palpable effusion, fever, and chills
  • the best initial and most accurate test is arthrocentesis showing more than 50K WBCs with a neutrophil predominance
  • empiric treatment is with ceftriaxone and vancomycin
57
Q

How does prosthetic joint infection differ from natural joint infection?

A
  • more commonly due to Staph epidermidis infection if the joint was recently placed
  • need to get a CT or radiograph to look for surrounding lucency or physical loosening of the prosthetic which are signs of infection
  • treat with joint removal, antibiotics, and then joint replacement
58
Q

Describe the presentation, diagnosis, and treatment for gonococcal arthritis.

A
  • presents with polyarticular arthritis, tenosynovitis, and a petechial rash
  • diagnosis begins with an arthocentesis, typically with 30-50K WBCs; gram stain isn’t very sensitive so must culture multiple diffuse sites
  • treat with ceftriaxone
59
Q

If a patient presents with recurrent gonorrheal infection, what is the best next step?

A

look for terminal complement deficiency

60
Q

Describe the etiology, presentation, diagnosis, and management of osteomyelitis.

A
  • most commonly caused by S. aureus in the general population and Salmonella in patients with sickle cell
  • children get it through hematogenous spread while adults get it from contiguous spread
  • presents with overlying warmth, redness, and swelling
  • radiograph is the best initial test, MRI is the next step, and culture is the most accurate test
  • use ESR to follow response to treatment

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