Rheumatology Flashcards
Most imp findings in x-ray of pt with OA?
narrow joint space, osteophytes
Most common risk factor?
obesity
Most imp step in life style?
lose weight
Sequence of ttt in osteoarthritis:
First line? 2nd 3rd and 4th
paracetamol
NSAIDs
opioid
intraarticular steroid
Marked impairment of daily activities due to OA, what to do?
replace the joint
Where to hold the stick when i leg is affected?
the opposite side with the diseased leg on the ground
What to see in All labs of OA?
Normal
Old pt with chronic neck pain, sensory deficit:
cervical spondylosis
X-ray findings of OA
bony spurs and sclerotic facet joint
first line TTT of OA ?
paracetamol 1st
Pt with acutal pain, swelling, redness at 1st MTP joint… Dx:
acute gouty arthritis (podagra)
Most imp test for acute gout?
Synovial fluid analysis = arthrocentesis = aspiration of joint fluid
Findings in arthrocentesis:
WBCs 2000-50000,
NEEDLE shaped,
NEGATIVELY bireferingent crystals
NEGATIVE gram stain & culture
GOUT X-ray —>
PUNCHED OUT EROSIONS
++serum Uric acid is neither sensitive nor specific
Management:
Most imp in life style prevention of gout?
Stop Alcohol
OTHERS:
LOW PURINE DIET AND LOSE WEIGHT.
1st line TTT of acute attack?
NSAID
INDOMETHACIN (NOT in RF or GIT bleeding)
PT WITH GOUT , can not use NSAID or STEROIDS?
COLCHICINE
Acute attack in pt with renal failure:
steroid……..vvvvvvvv imp ( colchicine may e used with half dose )
PREVENTION of gout—>
Allopurinol and probenicid
TTT of tophacous gout?
allopurinol (NOT surgery)
Tophacous gout no responding to TTT next step?
increase the dose
Main side effect of colchicine?
diarrhea
Main side effect of allopurinol?
rash
If acute attack occurred while the pt is on allopurinol:
indomethacin and continue the allopurinol .vvvvvvvvv imp
Most common drug causing attack of gout?
Thiazide.VVVVVVV IMP
Main indication for long term use of medications in gout?
renal failure
Starting dose of allopurinol?
50-100 mg
SIDE EFFECTS OF THIAZIDE?
VVVVVVVVVVVVVVVVVVV IMP:
Hyponatremia
Hypokalemia
Hyperglycemia?
induce DM ……………………..vvvvvvvv imp
Hyperurecemia?
contra-indicated in gout……vvvvvvv imp
Hypercalcemia?
hypocalcuria….vvvvvvv imp (prophylaxis against renal stones)
Old Pt with hyper-calcemia develops acute knee joint pain… Dx:
pseudo-gout
Arthrocentesis in pseudo-gout?
rhomboid- shaped crystals, +ve berferingent
TTT of psudogout?
1st line: NSAIDs. If no response: intra-articular steroid
Low Back Pain (LBP)
Pt with LBP not radiating to LL, exam shows para-vertebral ms spasm………. Dx:
lumbo- sacral sprain (lumbago).
TTT of lumbo sacral sprain?
Analgesic and continue activity BUT no bed rest
Pt with LBP radiating to LL, exam shows +ve straight leg test…Dx:
herniated disc
Tx of Herniated disc?
1st line: analgesic and continue movement. If no improvement: surgery
Pt with LBP with severe radicular LL pain, LMNL and urine and stool incontinence… Dx:
Cauda Equina syndrome
Pt with LBP with severe radicular LL pain, UMNL and urine and stool incontinence… Dx:
Conus meddularis syndrome
Inv of choice of both CES and CMS
MRI
TTT of choice of both CES and CMS
surgery
Post- menopausal pt with severe LBP, exam shows localized pain and tenderness to one vertebra… Dx:
vertebral fracture (osteoprotic fracture)
Inv of choice osteoporotic fracture?
X- RAY
If no fracture appears?
DEXA scan
LBP ++ with leaning forward and walking up hill & – with standing up… Dx:
spinal stenosis
Inv of choice and tx choice of spinal stenosis?
MRI.
Tx of choice: surgery
Pt with H/O with back pain:
metastases until proven otherwise
1st step in management in pt with H/O back pain?
Investigation of choice?
long term tx?
IV steroid
MRI
Radiation
Old age male with back pain, anemia and ++ Ca?
Multiple Myeloma (MM)
Young male with chronic LBP:
Ankylosing Spondylitis (AS) until proven otherwise
Inv of choice AS?
X-ray (bamboo spine)
Imp Lab. of AS?
+ve HLA-B27 and -ve RF
Imp. Eye affection in AS?
Anterior uveitis
Imp chest affection in AS?
Chest wall movement restriction
Management:
Non pharmacological of AS?
physiotherapy and hydrotherapy
First line medications AS?
NSAIDs ( naproxen)
Second line tx for AS?
infliximab
Third line for AS?
sulphasalazine
fourth line for AS?
methotrexate
If failed?
infliximab (risk of TB reactivation)
Diseases with pain referred to the back 1-perforated peptic ulcer:
X-ray?
air under diaphragm
TTT of perforated PUD?
…immediate laparotomy
acute pancreatitis initial -Inv?
most specific inv?
amylase and lipase,
CT
TTT of acute Pancreatitis?
NPO, analgesic, IV fluid and PPI
aorta( dissection-ruptured TTT?
Surgery
acute cholecystitis presentation
Female with severe RUQ pain
Inv of cholycystitis
US…….stone at cystic duct and
TTT of cholecystitis?
conservative then scheduled cholecystectomy
Young male cannot see, pee or climb a tree after history of diarrhea:
reiter ( reactive arthritis )
DD of shoulder pain
Pt with shoulder pain, exams show limitation of passive movement BUT no limitation of active movement. After intra-articular lidocaine injection, the pain is markedly relieved…..Dx:
rotator cuff tendonitis
Inv of choice for rotator cuff tendonitis?
MRI
TTT of choice for rotator cuff tendonitis?
NSAIDs
Pt with shoulder pain, exams show limitation of passive movement BUT no limitation of active movement. After intra-articular lidocaine injection, the pain is NOT relieved…..Dx:
rotator cuff tear
Inv of choice rotator cuff tear?
Tx?
MRI
arthroscopic repair
MC injured muscle in shoulder:
supra-spinatus
Pt with chronic shoulder pain, exam shows limitation of both active& passive movement… Dx:
TTT?
adhesive capsulitis…
: physiotherapy
Pt with shoulder pain, exam shows NO limitation of active or passive movement… Dx:
TTT?
subacromial bursitis…
: NSAIDs
DD of muscle pain
Pt with generalized musculo- skeletal pain, disturbed sleep, normal lab……………….Dx:
fibro- myalgia
TTT of choice for fibromyalgia?
Amitryptiline
Pt with pain at shoulder & pelvic girdle and morning stiffness> 1h… Dx:
polymyalgia rheumatic (PMR)
TTT of choice PMR?
low dose steroid.
If PMR associated with giant cell arteritis?
give high dose steroid (risk of blindness)
If u suspect giant cell arteritis…
1st step?
2nd step?
ESR… if increases: Give high dose steroid
confirm diagnosis by temporal a biopsy
Pt with muscle weakness, ++ CK; ++ aldolase… Dx:
polymyositis
Inv of choice for polymyositis?
muscle biopsy
TTT of choice polymyositis?
cortisone
Pt with muscle weakness, ++ CK; ++ aldolase, heliotrope rash and gotron papule… Dx:
dermato- myositis
Pt with kerato-conjunctivitis, difficult swallowing, dyspareunia and enlaged parotid gland… Dx:
Sjogren’s $
Pt with Sjogren $ presented with marked enlarged parotid, what to do?
Biopsy
Most imp inv for sjogrens?
anti-SSA (RO) anti-SSB (LA) antibodies
TTT sjorgrens?
Symptomatic
Young pt with fever, arthritis, abdominal pain, foot drop&; +ve C-ANCA… Dx:
PAN
Inv of choice PAN?
sural nerve biopsy
Imp Inv to be done in pt with PAN:
HBV serology
TTT of choice of PAN?
cortisone, cyclophosphamide
Young female with rash over face and arthralgia:
SLE
Inv of choice for SLE
anti-dsDNA or anti-smith
In SLE Mild joint affection, Tx with?
hydroxycholoroquine…..vvvvvvvvv imp
IN SLE Only skin manifestation, TX with?
hydroxycholoroquine……..vvvvvvv imp
Young female with chronic dry cough and bilateral hilar lymphadenopathy:
next inv,
sarcoidosis……..….
CT chest
Inv of choice in sarcoidosis ?
biopsy ( lung or skin )
Ca level and ACE in sarcoidosis?
increased
TTT of sarcoidosis ?
oral steroid
Patient with rheumatoid arthritis now swelling at back of knee:
baker cyst …..if rupture……severe pain at calf
Young male with severe selling at knee, with redness and fever:
Next step?
septic arthritis until proved otherwise:
immediate aspiration
Most common organism of septic arthritis?
staph aureus
Old age female with rheumatoid arthritis now severe swelling and pain at knee joint : next step
aspiration to exclude septic arthritis
Female with joint pain and morning stiffness that decreases with activity:
rheumatoid arthritis
Female with treated rheumatoid arthritis now elevated liver enzymes:
methorexate induced hepatitis
For symptomatic control In acute attack of RA?
NSAIDS and splinting
Most imp inv for a RA pt will do operation?
X-RAY CERVICAL vertebrae……exclude C1-C2 vertebrae
Pt with RA died on table while intubation:
C1-C2 fracture
Most common cause of death with RA?
CVS
Best drug for RA?
methotrexate
FELTY’S SYNDROME?
RA + Splenomegaly + neutropenia
. methotrexate shouldn’t be used in pregnant
DO u do surgery to sc nodules?
noooooooo
Drugs that can be used safely in pregnancy:
vvvvvvvvvv imp Prednisone Sulphasalazine Hydroxychloroquine CASH
Drugs that affect male fertility????
vvvvvvvvvvvvvvv imp
Methotrexate
sulphasalazine
MaleS
Test should be done before giving azathioprine:
Thiopurine methyltransferase Genotype
Hydroxychloroquine …safe in pregnancy and doesNOT affect male fertility
Female with basal crepitations over back, colored fingers with some fingers amputated and difficulty in swallowing»>
sclerderma…..anti-scl antibody…..most common cause of death is pulmonary HTN
TTT of renal crisis with scleroderma?
ACEI
CREST $ = LIMITED scleroderma
Ab?
. Calcinosis cutis. . Raynaud's phenomenon. . Esophageal dysmotility. . Sclerodactyly. . Telangiectasia. . +ve Anti-Centromere
Old age male on large dose of cortisone now limping»>
DX of choice?
avascular necrosis ….
MRI
Patient patient with peripheral neuropathy manifestations now marked swelling and redness at mid foot:
charcoat joint ….next step is cast and immobilization
Drug of choice”
Rheumatoid arthritis ————–>
Methotrexate.
. Osteoarthritis ——————–>
Weight loss and ; Acetaminophen.
. Gout acute attack —————–>
NSAIDs (Indomethacin).
. Gout prevent. of new attack ——->
allopurinol.
. CPPD ——————————>
NSAIDs.
. Disk herniation ——————->
paracetamol.
. Epidural abscess ——————>
Abs “Vancomycin”.
. Cord compression ——————>
Steroids.
. Spinal stenosis ——————->
Weight loss & Steroid injection.
. Fibromyalgia ———————->
Amitriptyline.
. Carpal Tunnel. $ ——————>
Wrist splint & NSAIDs.
. Polymyositis ———————->
high dose steroids.
. Rotator cuff injury —————>
NSAIDs.
. SLE ——————————->
High dose steroids.
Tx of Sjogren $ ————————->
Water the mouth & atrificial tears.
Tx of Polymyalgia Rheumatica ————>
LOW dose steroids.
Tx of Temporal “Giant cell” arteritis —>
HIGH dose steroids.
Tx of Ankylosing Spondylitis ————>
NSAIDs.
Tx of Psoriatic arthritis —————>
NSAIDs.
Tx of Reactive arthritis “Reiter’s $” —>
NSAIDs.
Tx of Septic arthritis ——————>
CEFTRIAXONE & VANCOMYCIN.
Tx of Gonococcal arthritis ————–>
Ceftriaxone or cefotaxime
Ab in Rhematoid Arthritis “RA” ————>
Anti-Cyclic Citrulinated Peptide “CCP”.
Ab in Systemic Lupus Erythematosus “SLE” –>
Anti-Double Stranded DNA “DS DNA
Ab in Connective tissue disease?
anti ribonucleo protein
Ab in Scleroderma ————————->
Anti-topoisomerase “Scl 70”.
.CREST $ —————————–>
Anti-centromere.
Ab found in Sjogren $ —————————>
SS-A “Ro” & SS-B “La”.
Ab in Wegener’s granulomatosis –>
Anti-neutrophil cytoplasmic Antibody “C-ANCA”.
.Ab in Chrug-Strauss ———————–>
Anti-myeloperoxidase antibody “P-ANCA
Drugs that cause azospermia in males?
sulfasalzine and methotrexate
Peripheral neuropathy due to prednisone
B12 deficiency
MCC of peripheral neuropathy
DM
Take of pancytopenia due to methothrexate
FOLINIC ACID
Middle aged woman with narrowing of joint space and osteopenia….suspect?
RA
Single most accurate test for RA
Anti CCP
Esr and ck raised…think
Polymyositis
ESR raised ….CK NORMAL think?
Polymyalgia rheumatica
ESR and Ck NORMAL…think?
Drug induced myalgia
Pts with sjorgrens should be evaluated for what disease?
Lymphoma
DMARD safe in pregnancy
CASH for DMARD In pregnancy Cyclosporin Azithioprine Sulfasalazine Hydroxychloroquin
Tx for osteopenia
Vit D plus Ca
Tx of pagets dusease
Pamindronate
P for P
Osteoporosis plus PUD TX with
Zolindronate
Highest risk for developing Osteoporosis?
Early menopause
Inv of choice for Herniated disk?
MRI
a‐ stop methotrexate and continue hydroxychloroquine
b‐stop hydroxychloroquine and continue methotrexate
c‐stop both and give leflonomide
d‐stop both and give adalimumab
e‐ stop Mtx and start sulfasalazine
Ans. is A
. Mtx is contraindicated in pregnancy but hydroxychloroquine is relatively safe(source
davidson).
Patient with RA she takes ibuprofen and methotrexate to control her disease, they mention the
time it was years for both of drugs, patient complains of upper abdominal pain, and her labs are given
ALT, AST, GGT, even bilirubin all were high, which of the following cause this condition?
A. Methotrexate induced hepatitis
B. Ibuprofen induced hepatitis
C. Autoimmune hepatitis
D. Viral hepatitis
E. Alcoholic hepatitis
Ans is A .
Drug induced hepatitis AST , ALT and spexy GGT raised .
Ibuprofen is less hepatotoxic than MTX
Which of the following is not considered an extra‐articular manifestation of Rheumatoid Arthritis?
a) Osteoperosis
b) Peripheral neuropathy
c) Cutaneous nodules
d) Pericardial effusions
e) Hepatomegaly
Answer is E.
Splenomegaly + low cell count== felty’ nodule
Lung involved (nodule in lung)== Caplan’s syndrome
A 50 year old man who suffers from rheumatoid arthritis and who has been treated with prednisolone
for 3 years develops peripheral neuropathy of the
lower extremities. This neuropathy is most likely due to?
A. arsenic poisoning
B. thiamine deficiency
C. development of necrotising arteritis
D. ruptured intervertebral disc
E. Vit b12 deficiency
Ans is C
4.50 years female with pain in KNEE... there is swelling of knee joints and hand small joints... she has hx of morning pain reliefs with activity. RIght knee joint has swelling and thick effusion... she is on some medication. Tx Allopurinol B naproxen C paracetamol D cholcicine E steroid
Aready defective joint …. Pseudogout …
B is correct naproxen.
Back pain + red eye, think?
Ankylosis spondylitis with Uveitis
Best diagnostic test for acromegaly
OGTT with serial growth hormones
best initial test for acromegaly
IGF 1
pt presents with acute gout, cant use NSAID or steroids, what to use?
Colchicine
best initial tx for ASpondylitis…
if non responsive
- exercise and NSAID
2. anti-TNF drugs such as etanercept, adalimumab, or infliximab.
best diagnostic test for ASpondylitis
MRI
Long term management of SLE?
immunosuppresives plus antiplatelets
Cryoglobinemia is associated with?
Hep C
Initial investigation for Kawasaki?
Best inv?
ESR
Echo
Initial Tx for Kawasaki?
Best Tx?
Aspirin
IVIG
Initial Tx of adhesive capsulitis?
Physio
