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MCCQE1 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Red, hot, swollen joint. Next step?

A

arthrocentesis

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2
Q 
Arthrocentesis
Appearance: Serous
WBC: < 200
Polys: < 25%
Gram/Cx: (-)
Crystals: (-)
A

Normal. Consider Osteoarthrosis

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3
Q 
Arthrocentesis
Appearance: Cloudy
WBC: 200-50,000
Polys: > 50%
Gram/Cx: (-)
Crystals: +/-
A

Inflammatory

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4
Q 
Arthrocentesis
Appearance: Pus, opaque, white
WBC: > 50,000
Polys: > 75%
Gram/Cx: (+)
Crystals: (-)
A

Septic arthitis

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5
Q

ANA. Interpretation?

A

Sensitive lupus

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6
Q

Rheumatoid factor. Interpretation?

A

Rheumatoid arthritis

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7
Q

Anti-CCP. Interpretation?

A

Rheumatoid arthritis

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8
Q

ds-RNA. Interpretation?

A

Lupus + renal involvement

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9
Q

Histone. Interpretation?

A

Drug-induced lupus

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10
Q

Centromere antibodies. Interpretation?

A

Scleroderma (CREST)

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11
Q

Topoisomerase. interpretation?

A

Systemic scleroderma

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12
Q

Smooth muscle antibody. Interpretation?

A

Autoimmune hepatitis

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13
Q

Ro+LA. Interpretation?

A

Sjogren’s

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14
Q

Jo. Interpretation?

A

Polymyositis, dermatomyositis

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15
Q

Anti-Mitochondrial antibodies. Interpretation?

A

Primary biliary cirrhosis

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16
Q

Black woman with malar rash, pleuritic chest pain, oral ulcers, pain in hips, elbows, knees, shoulders, and photosensitivity.

Test show anemia, leukopenia and thrombocytopenia.

Dx, next steps and tx?

A

Lupus

Next steps:

  • 1st ANA: Sensitive test, gate test. If negative, it’s likely that it is not an autoimmune disease
  • sd-DNA (nephritis)
  • Anti-smith
  • Urinalysis, proteinuria, renal function
  • ESR, CRP
  • Low C3 and C4

Treatment:

  • Everyone: Hydroxychloroquine
  • 2nd line: methotrexate
  • Symptomatic: NSAIDs
  • Azathioprine: adjunctive
  • Flare: steroids
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17
Q

Patient taking hydralazine with malar rash, pleuritic chest pain, pain in hips, elbows, knees, shoulders, and photosensitivity.

Dx, next steps and tx?

A

Drug-induced lupus

Next step: Anti-histone antibody

Tx: Remove medication

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18
Q

Patient with Dx of lupus who has HTN and proteinuria.. Dx, next steps and tx?

A

Lupus nephritis

Next steps:
ds-DNA antibodies
Biopsy

Dx: IV cyclophosphamide mofetil then transition to oral mycophenolate

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19
Q

Fever, altered mental status, pleuritic chest pain. C3, C4 low. Dx?

A

Lupus flare.

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20
Q

45 y-o woman, morning stiffness of more than 60 mins, joint pain in > 3 small joints (hands, feet) symmetric and spares the distal interphalangeal (DIP).
Anti-CCP positive
Rx-Ray: erosion and periarticular osteopenia

Dx and Tx?

A

Rheumatoid arthritis

Tx:
Ibuprofen/meloxicam + Methotrexate

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21
Q

Anti-CCP vs Rheumatoid factor in rheumatoid arthritis

A

Anti-CCP: more specific–> if positive, it’s RA

Rheumatoid factor: more sensitive–> if negative, it’s NOT RA

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22
Q

Patient with rheumatoid arthritis in treatment with Methotrexate. Patient with positive pregnancy test. Next step?

A

Change Methotrexate for Hydroxychloroquine

23
Q

Examples of disease-modifying antirheumatic drugs (DMARDs) for RA

A
  • Methotrexate: 1st line
  • Leflunomide: 2nd line
  • Hydroxychloroquine: 3rd line or in pregnant patient
  • Sulfasalazine: 4th line
24
Q

Patient with Dx of Rheumatoid arthritis. In treatment with meloxicam, Methotrexate, Hydroxychloroquine, and Sulfasalazine. Patient still symptomatic despite tx.
Dx, next step, tx?

A

Severe rheumatoid arthritis

Next step:
Vaccinate, screen for TB, screen for fungus

Tx:
Start a biologic (TNF-alfa inhibitor) such as infliximab, rituximab, or etanercept.

25
Q

Patient with RA who visitis the ER with fever and exacerbated joint pain. Dx and tx?

A

Flare of rheumatoid arthritis

Tx: Short regimen of prednisone (3-5 days)

26
Q

Patient with Rheumatoid arthritis who will go in surgery.

What should be done befeore the surgery?

A

Get an x-ray of the cervical spine. RA can affect cervical spine

27
Q

Felty’s syndrome triad?

A
  • Rheumatoid arthritis
  • Neutropenia
  • splenomegaly
28
Q

Patient with HTN, Reynold’s, severe GERD, no wrinkles, Telangiectasias, GI bleeds, and iron def anemia. Dx, next step and tx?

A

Limited cutaneous systemic sclerosis (CREST)

Next step:
Anti-centromere

Tx:
Penicillamine (for scleroderma), PPI and CCB

29
Q

Patient with HTN, Reynold’s, severe GERD, no wrinkles, Telangiectasias, and Diffuse Pulmonary Lung Disease/constrictive pericarditis/acute kidney injury. Dx, next step and tx?

A

Diffuse cutaneous systemic sclerosis

Next step:
Anti-Scl70 (aka topoisomerase)

Tx:
Penicillamine (for scleroderma), PPI, CCB, ACEI (DON’T give steroids, they might precipitate renal crisis!!!)

30
Q

Patient with history of CKD who develops Sclerodactyly, and loss of wrinkles after receiving gadolinium on a MRI. Dx?

A

Nephrogenic systemic sclerosis

31
Q

Patient with Dry eyes, Dry mouth and Parotid swelling. Dx, next step and tx?

A

Sjogren’s

Next steps:

  • Screening: (+) ANA and RF
  • Confirmatory: Anti Ro and Anti La
  • Schirmer test
  • Screen for lupus and RA

Tx: Artificial tears, artificial saliva

32
Q

Patient with painless subacute difficulty raising from a chair or getting things from overhead or going up and downstairs. On physical exam, purple discoloration around eyes with periorbital edema, scaly lesions that are symmetrical and occur on large joints and photosensitive rash in exposed areas.
Dx, next step and tx?

A

Idiopathic inflammatory myopathy

Next steps:

  • 1st: ↑CK
  • EMG
  • Biopsy of muscle
  • Anti-Mi, anti-Mo

Tx:

  • Steroids
  • F/U: Cancer screening
33
Q

Patient, man, low back pain that gets better with use, morning stiffness in low back.
Lateral lumbar x-ray: Bamboo sign
Dx, tx?

A

Ankylosing Spondylitis

Tx:

  • NSAIDs
  • Local steroids
  • Physical therapy
  • TNF-alfa-inhibitors (Etanercept) if severe disease
34
Q

Patient with ankylosis spondylitis who goes to the ER with back pain. Next step?

A

Do a CT to rule out fracture

35
Q

Patient man, Psoriasis, Arthitis and Nail pitting on physical exam. Dx, next step and tx?

A

Psoriatic Arthritis

Next step: Nothing else needed, dx is clinical

Tx:

  • NSAIDs
  • Local steroids
  • DMARDs (hydroxychloroquine, methotrexate)
  • TNF-alfa-inhibitors (Etanercept) if severe disease
36
Q

Patient, Man, Urethritis, arthritis. Dx, next step and tx?

A

Reactive Arthritis

Next step:

  • Arthrosentesis: inflammatory joint, no evidence of microorganism
  • Swap of mouth, anus, uretra

Tx:

  • Doxycycline, or azithromycin + ceftriaxone
  • NSAIDs
  • Time
37
Q

Microorganism that generally produces Reactive Arthritis?

38
Q

Patient, Man, Urethritis, arthritis, conjunctivitis. Dx?

A

Reiter’s syndrome

39
Q

Patient with history of IBD who now has arthritis. Dx, tx?

A

IBD-related/ Enteropathic Arthritis

Tx: Treating the IBD will improve arthritis

40
Q

Patient at the ER with Red, hot, swollen, tender, loss of function of one joint. Arthrocentesis shows:

  • Appearance: cloudy
  • WBC < 50.000
  • Polys > 50%
  • Gram (-)
  • Crystals: Positively birefringent, rhomboid-shaped crystals

Dx and tx?

A

Flare of Pseudogout

Tx of flare
•	NSAIDs
•	Colchicine (dose-limit by diarrhea)
•	Steroids
***Tx underlying methobolic condition
41
Q

Patient with CKD/EtOH/HCTZ at the ER with Red, hot, swollen, tender, loss of function of one joint. Arthrocentesis shows:

  • Appearance: cloudy
  • WBC < 50.000
  • Polys > 50%
  • Gram (-)
  • Crystals: Negatively birefringent, needle-shaped crystals

Dx and tx?

A

Flare of Gout

Tx:
• Flare: NSAIDs, colchicine (dose-limit by diarrhea), steroids
• Prevent future flares with lifestyle modifications (↓EtOH, meat, complex carbs), stop change BP meds

42
Q

Patient more that 2 podragra episodes during the past year. Dx, next step and tx?

A

Gout

Next step: Get uric acid (should be > 6 for dx)

Tx:
• Lifestyle modifications: ↓EtOH, meat, complex carbs
• Allopurinol
• Flare prophylaxis with colchicine, NSAIDs, steroids in lower doses

43
Q

Patient with leukemia/lymphoma on Chemotherapy with renal failure. Dx, next step?

A

Tumor lysis syndrome

Prophylaxis of gout with IVF and allopurinol
If prophylaxis fails: Rasburicase

44
Q

Gout produced by reduced elimination of uric acid. Tx?

A

Probenecid

45
Q

Patient who had a penetrative trauma in a joint which is now red, hot, swollen, and tender.
Arthrocentesis:
- Appearance: Plus, opaque, white
- WBC > 50.000
- Polys > 75%
- Gram (+) for gram positive cocci in clusters
- Crystals: (-)

Dx and tx?

A

Septic joint

Tx:
• Nafcillin for methicillin-susceptible Staphylococcus aureus (MSSA)
• Vancomycin or linezolid for methicillin-resistant Staphylococcus aureus (MRSA)

46
Q

Patient PWID/hemodyalisis/ endocardiatis who has a red, hot, swollen, and tender joint.
Arthrocentesis:
- Appearance: Plus, opaque, white
- WBC > 50.000
- Polys > 75%
- Gram (+) for gram positive cocci in clusters
- Crystals: (-)

Dx and tx?

A

Non-gonococcal (staph) septic joint

Tx:
• Nafcillin for methicillin-susceptible Staphylococcus aureus (MSSA)
• Vancomycin or linezolid for methicillin-resistant Staphylococcus aureus (MRSA)

47
Q

Patient STD, HIV, syphilis, cervicitis, urethritis, sex worker who has a red, hot, swollen, and tender joint.

  • Appearance: Plus, opaque, white
  • WBC > 50.000
  • Polys > 75%
  • Gram (-)
  • Crystals: (-)

Dx, next step and tx?

A

Gonococcal septic joint

Next step: Nucleic acid amplification test

Tx: Ceftriaxone 7-14 days IV + doxycycline/azithromycin

48
Q

Patient > 50, Jaw claudication, Amaurosis fugax, temporal headache, Temporal tenderness oh physical exam. Dx, next step and tx?

A

Giant cell arteritis (Large vessels like External carotid, ophthalmologic, temporal)

Next step: Star steroids, don’t wait for Bx to show granulomas.

49
Q

Patient < 40, Pulselessness on femoral and brachial arteries. Dx, next step and tx?

A

Takayasu (large vessels)

Next step: Angiogram

Tx: Steroids

50
Q

Asian child, who presents to the ER with chest pain, strawberry -like tongue and rash with desquamation in palms and soles. Dx and tx?

A

Kawasaki (medium vessels)

Tx: IV Ig + ASA

51
Q

Patient with history of Hepatitis B with mesenteric ischemia/renal failure, purpura, subcutaneous painful nodules, motor and sensory deficit in a peripheral nerve that comes and goes (mononeuritus multiplex).

Dx, next step, tx?

A

Polyarteritis nodosa (medium vessels)

Next step: Angiogram –> aneurisms of medium vessels

Tx: Steroids + cyclophosphamide

52
Q

Patient with hemoptysis, hematuria, and nasal involvement. Dx, next step, tx?

A

Wegener’s–granulomatosis with polyangiitis (small vessel)

Next step: C-ANCA, Bx of pulmonary tissue

Tx: steroids + cyclophosphamide

53
Q

Patient with history of Hepatitis C who has palpable purpura. Dx, next step, tx?

A

Cryoglobulinemia (small vessel)

Next step:
• ↓complement
• Cryoglobulins

Tx:

  1. Treat Hep C
  2. Steroids
  3. Cyclophosphamide
  4. Severe: plasmapheresis
54
Q

Patient with GI bleed, abdominal pain, and palpable purpura. Dx, next step, tx?

A

Henoch-Schönlein purpura (small vessel)

Next step: Bx of purpura–> Leukocytoclastic vasculitis

Tx: Steroids

MCCQE1 (19 decks)

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