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Rheumatology Flashcards

1
Q

approach to joint: single joint

A

septic

crystals

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2
Q

approach to joint: multiple joints

A 
osteoarthritis
lupus
rheumatoid 
scleroderm
myositis
seronegatives
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3
Q

approach to joint pain: chronic

A

osteoarthritis, lupus, rheumatoid, scleroderma, myositis, seronegatives

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4
Q

approach to joint pain: acute

A

septic, trauma, crystal, reactive

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5
Q

approach to joint pain: isolated

A

septic, crystal

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6
Q

approach to joint pain: systemic manifestations

A

seronegative (IBD)
lupus (face, CNS, renal, heart, lung)
rheumatoid (nodules, serositis)
reactive (oral + genital ulcer)

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7
Q

approach to joint pain: degenerative

A

osteoarthritis

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8
Q

approach to joint pain: inflammatory

A

everything else

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9
Q

normal joint serology

A

clear
<2% wbcs
<25% polys
no gram/cx/dx

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10
Q

non-inflammatory joint serology

A 
clear
<2% wbcs
<25% polys
no gram/cx
dz osteoarthritis
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11
Q

inflammatory joint serology

A 
yellow, white
>2, <50 wbcs
>/= 50% polys
no gram/cx
dz everything but OA/infection
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12
Q

sepsis joint serology

A 
opaque
>50 wbcs
>/= 75% polys
\+ gram/cx
dz infection
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13
Q

antinuclear antibodies

A

sensitive lupus

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14
Q

anti-histone antibodies

A

specific drug-induced lupus

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15
Q

anti-ds-DNA antibodies

A

specific lupus + renal involvement

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16
Q

anti-smooth muscle antibodies

A

autoimmune hepatitis

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17
Q

anti-mitochondrial antibodies

A

primary biliary cirrhosis

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18
Q

anti-centromere antibodies

A

scleroderma (CREST)

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19
Q

anti-Ro+La antibodies

A

sjogren’s

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20
Q

anti-CCP antibodies

A

rheumatoid arthritis

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21
Q

anti-RF antibodies

A

rheumatoid arthritis

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22
Q

anti-Jo antibodies

A

polymyositis

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23
Q

anti-topoisomerase antibodies

A

systemic scleroderma

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24
Q

lupus path

A

autoimmune, complex formation

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25
Q

lupus pt

A

women > men

blacks > whites

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26
Q

lupus pt

A 
MD SOAP BRAIN
Malar rash
Discoid rash
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood
Renal failure
ANA
Immunologic
Neurology
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27
Q

lupus dx

A

1st: ANA
then: ds-DNA
- anti-smith
- anti-histone (drug induced)
lupus nephritis
- U/A -> bx kidney
flare
- complement levels decrease in flare
- complement levels increase in infection

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28
Q

lupus tx

A 
reduce flares: hydroxychloroquine
control symptoms: NSAIDs
flare: prednisone
severe: mycophenolate mofetil
nephritis: IV cyclophosphamide
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29
Q

drug-induced lupus path

A

drugs
procainamide
α-methyldopa
hydralazine

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30
Q

drug-induced lupus pt

A

NO visceral involvement

skin and joints only

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31
Q

drug-induced lupus dx

A

anti-histone

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32
Q

drug-induced lupus tx

A

remove drug

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33
Q

antiphospholipid antibody (APLA) syndrome path

A

lupus “anticoagulant” (in the lab) actually causes coagulation (in the body)
anti-cardiolipin antibodies

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34
Q

anti-cardiolipin antibodies

A

antiphospholipid antibody (APLA) syndrome

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35
Q

antiphospholipid antibody (APLA) syndrome pt

A

arterial AND venous clots
lupus
false + RPR … negative FTA-abs

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36
Q

antiphospholipid antibody (APLA) syndrome dx

A

increase PTT, normal INR
mixing study fails to correct
Russell Viper Venom tests

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37
Q

antiphospholipid antibody (APLA) syndrome tx

A

warfarin + aspirin

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38
Q

rheumatoid arthritis path

A

autoimmune disease
women > men
age > 40
panes formation -> joint destruction

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39
Q

RA pt

A 
Nobody Should Have Rheumatoid Symptoms 3 times (x)
N: nodules
S: symmetric
H: hands
R: RF or CCP
S: stiffness
3: 3 or more joints, spares DIP
X: xray shows erosions
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40
Q

RA dx

A

1st RF or CCP

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41
Q

RF tx

A 
DMARDs (everyone and early)
biologics (severe)
...
NSAIDs (sxs)
steroids (flare)

DMARD = methotrexate
NSAID = ibuprofen/meloxicam
biologics = etanercept, infliximab
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42
Q

RF f/u

A

screen for TB and fungus before biologics
spine involvement = C1 and C2
bilateral carpal tunnel syndrome could be early RA
Felty syndrome = RA + neutropenia + splenomegaly

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43
Q

Giant cell Arteritis path

A

multinucleated giant cells in large vessels like the temporal artery

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44
Q

GCA pt

A

age > 50
unitemporal head pain
tender jaw claudication
vision loss

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45
Q

GCA dx

A

biopsy (skip, treat first)

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46
Q

GCA tx

A

give steroids before biopsy

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47
Q

GCA f/u

A

elevated ESR, CRP, low-grade possible findings

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48
Q

polymyalgia rheumatica path

A

similar pathology to GCA, large-vessel vasculitis

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49
Q

polymyalgia rheumatic pt

A

symmetric pain and stiffness of neck, shoulder, and hip girdle
proximal muscle weakness but normal CK (idiopathic inflam myop)

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50
Q

polymyalgia rheumatica dx

A

clinical (normal CK, high ESR)

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51
Q

polymyalgia rheumatica tx

A

steroids

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52
Q

polymyalgia rheumatica f/u

A

angiogram rules out other diseases

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53
Q

takayasu arteritis path

A

giant-cell arteritis of the aorta, subclavian, or axillary arteries

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54
Q

takayasu arteritis pt

A

asymmetric pulselessness, discordant BPs left to right arm
pulseless disease
< 40

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55
Q

takayasu arteritis dx

A

angiogram (CT, MRI, direct)

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56
Q

takayasu arteritis tx

A

high-dose prednisone

57
Q

polyarteritis nodosa path

A

medium-vessel vasculitis

HepB-related, maybe

58
Q

polyarteritis nodosa pt

A

infarction of multiple organs without common vascular distribution
purpura, mesenteric ischemia, non-glomerulonephritis, renal failure

59
Q

polyarteritis nodosa dx

A

angiogram = micro aneurysms and stenosis

60
Q

polyarteritis nodosa tx

A

high-dose steroids and cyclophosphamide

61
Q

Kawasaki disease path

A

medium-vessel vasculitis

62
Q

kawasaki pt

A

asian child, strawberry tongue, truncal rash, palmar erythema, desquamation

63
Q

kawasaki dx

64
Q

kawasaki tx

A

IVIG and ASA

65
Q

cryoglobulinemia path

A

HepC, cryoglobulins

small vessel, complex deposition

66
Q

cryglobulinemia pt

A

palpable purpura, decreased complement, elevated RF

67
Q

cryoglobulinemia dx

68
Q

cryoglobulinemia tx

A

steroids, plasmapheresis

69
Q

IgA vasculitis path

A

small vessel, IgA deposition

Henoch-Schonlein Purpura

70
Q

IgA vasculitis pt

A

palpable purpura, abdominal pain, abdominal bleeding

71
Q

IgA vasculitis dx

A

biopsy = leukocytoclastic vasculitis with immune complexes

72
Q

IgA vasculitis tx

73
Q

ganulomatosis with polyangiitis path

A

c-ANCA positive, small vessel

necrotizing vascuitis

74
Q

ganulomatosis with polyangiitis pt

A

hematuria, hemoptysis, sinuses

75
Q

ganulomatosis with polyangiitis dx

76
Q

ganulomatosis with polyangiitis tx

A

steroids and cyclophosphamide

77
Q

ganulomatosis with polyangiitis f/u

A

‘eosinophilic’ if p-ANCA, asthma, allergies, and similar presentation
polyangiitis if p-ANCA and no granulomas with similar presentation

78
Q

scleroderma path

A

collagen deposition disease replaces smooth muscle and skin

79
Q

scleroderma pt

A

diffuse cutaneous systemic sclerosis: face, hands, feet - above elbow and knee
visceral inolvement - kidney and interstitial lung disease

80
Q

scleroderma dx

A

anti-topoisomerase = anti-Scl-70

81
Q

scleroderma tx

A

no tx available

NO steroids = harmful!

82
Q

scleroderma f/u

A

renal crisis = ACE-I
reflux = PPIs
Raynaud’s = CCB
ILD = cyclophosphamide

83
Q

CREST path

A

same as scleroderma

84
Q

CREST pt

A 
limited cutaneous systemic sclerosis
C: calcinosis
R: Raynaud's
E: Esophagus
S: Sclerodactyly
T: Telangiectasia
85
Q

CREST dx

A

anti-centromere antibodies

86
Q

CREST tx

A

no treatment available

87
Q

CREST f/u

A

pulmonary HTN without parenchymal disease

88
Q

Sjogren’s path

A

lymphocytic infiltrates of exocrine glands

89
Q

Sjogren’s pt

A

dry eyes
dry mouth
parotid swelling, dental caries

90
Q

Sjogren’s dx

A

anti-Ro, anti-La

Schirmer test

91
Q

Sjogren’s tx

A

artificial tears

artificial saliva

92
Q

idiopathic inflammatory myopathy path

A

dermatomyositis = inflammation epimysium, skin findings
polymyositis = inflammation perimysium, central necrosis
inclusion body myositis = vacuoles

93
Q

idiopathic inflammatory myopathy pt

A

skin findings = Gottron’s papule, heliotrope rash, shawl sign
proximal muscle weakness (myo-pathy)
AND
painful tender muscles (myo-sitis)

94
Q

idiopathic inflammatory myopathy dx

A

1st: elevated serum CK, adolase
then: EMG
best: biopsy of muscle

95
Q

idiopathic inflammatory myopathy f/u

A

anti-Mi, anti-Jo, associated antibodies

96
Q

monoarticular arhtropathies

A 
gout
gonorrhea septic joint
pseudogout
tumor lysis syndrome
staph septic joint
97
Q

gout path

A

monosodium urate crystales
increased production -> allopurinol
decreased elimination -> probenecid

98
Q

gout pt

A

podagra

single hot swollen painful joint

99
Q

gout dx

A

arthrocentesis
negatively birefringent
needle-shaped crystal

100
Q

gout tx: acute

A 
flare
mild = < 4 joints, digits only
- NSAIDs (if not bleeding, CKD)
- colchicine (not if chronic ppx)
- steroids (last choice of three)
mod = >/= 4 joints, or any non-digit joint
- dual therapy:
-- NSAIDs + colchicine (preferred)
-- steroids + colchicine (ok)
severe = same as moderate
101
Q

gout tx: chronic induction

A

xanthine-oxidase inhibitor if:
- > 2 attacks/yr, goal uric acid < 6
colchicine-px until urate < 6 (NSAIDs ok)

102
Q

gout tx: chronic stable

A

d/c colchicine ppx after urate < 6

do not stop allopurinol in flare

103
Q

gout f/u

A

diet: decrease fructose, EtOH, red meat/seafood (purines)
xanthine-oxidase inhibitors: febuxostate = allopurinol but $$$
urate lowering agents: probenecid (rarely useful)
intra-articular glucocorticoids when in acute flare but unsafe for all else

104
Q

gonorrhea septic joint path

A

STD -> hematogenous

intracellular organism

105
Q

gonorrhea septic joint pt

A

STDs, lots of sex, no protection

urethritis, cervicitis

106
Q

gonorrhea septic joint dx

A

arthrocentesis without organisms

NAAT to confirm

107
Q

gonorrhea septic joint tx

A

ceftriaxone AND (azithro or doxy)

108
Q

pseudogout path

A

calcium pyrophosphate

109
Q

pseudo gout pt

A

single swollen joint

110
Q

pseudo gout dx

A

positively birefringent

rhomboid shaped crystals

111
Q

pseudo gout tx

A

NSAIDs (first)
colchicine (better as ppx)
steroids (CKD)

112
Q

tumor lysis syndrome path

A

large tumor burden, cell turnover

blood cancers

113
Q

tumor lysis syndrome pt

A

cancer getting chemo

114
Q

tumor lysis syndrome dx

A

renal failure, lots of stones

115
Q

tumor lysis syndrome tx

A

rasburicase

116
Q

tumor lysis syndrome ppx

A

IVF and allopurinol

117
Q

staph septic joint path

A 
direct inoculation (wound)
hematogenous spread
118
Q

staph septic joint pt

A

penetrating trauma

IVDA, endocarditis

119
Q

staph septic joint dx

A

arthrocentesis with organisms

120
Q

staph septic joint tx

A

nafcillin…vancomycin

121
Q

seronegative arthropathies

A

ankylosing spondylitis
psoriatic arthritis
reactive arthritis (Reiter’s)
IBD-related, enteropathic arthritis

122
Q

ankylosing spondylitis path

A

sacroiliitis

123
Q

ankylosing spondylitis pt

A

low back pain
morning stiffness
better with exercise, worse with rest

124
Q

ankylosing spondylitis dx

A

lumbar lateral xray

‘bamboo spine’

125
Q

ankylosing spondylitis tx

A

NSAIDs (first line)
methotrexate (peripheral skeleton)
intra-articular glucocorticoids (pain)
TNF-α inhibitors (severe or refractory)

126
Q

psoriatic arthritis path

A

autoimmune

127
Q

psoriatic arthritis pt

A

40-50 men
psoriasis + arthritis
‘nail pitting’ ‘sausage digits’
an arthritis question with a picture of a fingernail is psoriatic …. a picture of a deformity is RA

128
Q

psoriatic arthritis dx

129
Q

psoriatic arthritis tx

A

NSAIDs (mild arthritis)
methotrexate (moderate arthritis)
TNF-α inbhibitors (MTX failure)

130
Q

psoriatic arthritis f/u

A

mild: < 4 joints, no erosion
mod: >/= 4 joints, no erosion
sev: any erosion, MTX fails

131
Q

reactive arthritis

A

Reiter’s

132
Q

reactive arthritis path

A

STD, non-gonococcal urethritis

133
Q

reactive arthritis pt

A

cervicitis + arthritis
urethritis + arthritis
urethritis + arthritis + conjunctivitis

134
Q

reactive arthritis dx

A

finding the STD

- swab everywhere semen can go

135
Q

reactive arthritis tx

A 
doxy OR azithro (chlamydia)
IM ceftriaxone (gonorrhea)
136
Q

IBD-related, enteropathic arthritis path

A

inflammatory, idiopathic

137
Q

IBD-related, enteropathic arthritis pt

A

men = women

IBD (Crohn’s or UC) + arthritis

138
Q

IBD-related, enteropathic arthritis dx

139
Q

IBD-related, enteropathic arthritis tx

A 
treat the enteropathy, treat the arthritis 
mild: 5-ASA
mod: azathioprine or 6-MP
severe:
- UC = resection
- Crohn's = anti-TNF

Online Med Ed (18 decks)

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