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Internal Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

[MSK]

Chronic noniflammatory arthritis, involving the DIP, CMC1, hip, knee joints

A

Osteoarthritis

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2
Q

Chronic inflammatory polyarthritis, symmetric involvement, including the PIP, MCP, MTP

A

RA

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3
Q

Heberden nodes is also known as ____

A

DIP

B muna bago H

Heberden = HBD

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4
Q

Bouchard nodes is also known as ____

A

PIP

B muna bago H

Heberden = HBD

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5
Q

Joints in the hands affected in OA

A

DIPOA
PIPOA
CMCOA

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6
Q

Joint in the forearm affected by RA

A

Wrist, MCP

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7
Q

Indications for Fluid Aspiration and Analysis

A
  1. Monoarthritis
  2. Trauma with effusion
  3. Monoarthritis in a patient with chronic polyarthritis
  4. Suspicion of joint infection, crystal-induced arthritis, hemarthrosos
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8
Q

[Characteristic of synovial fluid]

>1mL
reduced viscosity
WBC 2000-50,000
Glucose <50mg lower than blood
Translucent
Turbid, yello
A

Inflammatory

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9
Q

[Characteristic of synovial fluid]

>1mL
Low viscosity
WBC >50,000
<50mg/dL lower than blood
opaque, purulent
culture positive
A

septic

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10
Q

[Characteristic of synovial fluid]

>1mL
High viscosity
<2000 WBC
glucose equal to blood,
clear amber
A

non-inflammatory

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11
Q

What is the best initial treatment for osteoarthritis?

A

X-ray

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12
Q

What is the best initial management?

A

Acetaminophen

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13
Q

What is the pathologic sine qua non of the disease?

A

hyaline articular cartilage

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14
Q

spared joints in OA

A

Wrist, Elbow, Ankle

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15
Q

What is the most common cause chronic knee pain in persons >45 years old

A

OA

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16
Q

[Diagnosis]

35/F hand stiffness, symmetric polyarticular arthritis, stiffness worst in the morning, mild swelling and tenderness over the MCP joints of both hands and knees, elevated ESR

A

Dx: RA
Next diagnostic step: RF, anti-CCP
Accurate test: Anti-CCP antibodies
Initial Tx: DMARDS

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17
Q

What is the cause of ulnar deviation in RA?

A

subluxation of the MCP

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18
Q

The inflammation of the ulnar styloid and tenosynovitis of extensor carpi ulnaris leads to ___ in RA

A

subluxation of distal ulna, piano key movement of ulnar styloid

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19
Q

___ syndrome

Ndoular RA
Splenomegaly
Neutropenia

A

Felty’s syndrome

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20
Q

What is the most common pulmonary manifestation of RA?

A

pleuritis

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21
Q

Most common valvular abnormality in RA?

A

mitral regurgitation

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22
Q

[Deformity in RA]

Flexion of the PIP
Hyperextension of DIP

A

Boutonniere deformity

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23
Q

[Deformity in RA]

Hyperextension of PIP
Flexion of DIP

A

Swan neck

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24
Q

[Deformity in RA]

subluxation of first MCP
Hyperextension of the 1st IP

A

Z-line deformity

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25
Q

The most common site of cardiac involvement in RA

A

pericardium

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26
Q

Conditions with positive RF

A
  1. SLE
  2. Sjogren
  3. Subacute bacterial endocarditis
  4. Hep C and C
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27
Q

Most specific serologic marker for RA

A

Anti-CCP

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28
Q

What is the initial radiographic finding in RA?

A

periarticular osteopenia

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29
Q

Drug class that slows the structural progression of RA

A

DMARD

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30
Q

Drug class that is initially given to control RA before DMARD takes full effect

A

glucocorticoids

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31
Q

Drug class given in acute flares of RA

A

glucocorticoids

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32
Q

What is the best initial DMARD of RA?

A

methotrexate

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33
Q

What DMARDs are safe in pregnancy?

A
  1. Hydroxychlorquine

2. Sulfasalazine

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34
Q

DMARDs that are teratogenic

A

MTX

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35
Q

What is the major concern in using DMARDs

A

increased risk for infection

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36
Q

What is the next best step after Acute Monoarticular arthritis is diagnosed?

A

Diagnostic arthrocentesis

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37
Q

What is the initial therapy for gout?

A

NSAID

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38
Q

[diagnosi]

male, obese, sudden onset knee and big toe pain, presence of inflammation

A

Gout

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39
Q

What is the most common early clinical presentation of gout?

A

actue arthritis

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40
Q

Vitamin that can cause hyperuricemia

A

Niacin

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41
Q

___ negatively birefringent needle shaped crystal

A

monosodium ureate = gout

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42
Q

___ positively birefringent rhomboid-shaped crystal

A

Calcium pyrophosphate = pseudogout

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43
Q

What are the characteristic radiologic features of gout?

A

Cystic changes with well-defined erosions and overhanging sclerotic margins and soft tissue masses

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44
Q

What is the first line treatment during acute gouty attack?

A

NSAID

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45
Q

What is the more effective drug for polyarticular gout?

A

glucocorticoids

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46
Q

Colchicine must me temporarily discontinued at the first sign of what?

A

loose stools

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47
Q

When will you initiate hypouricemic drug therapy?

A
  1. After 2 episodes of acute attacs
  2. Serum uric acid >9
  3. Presence of uric acid stone
  4. Tophi or chronic goit
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48
Q

What are the drug of choice for uric acid underexcreter?

A

Probenecid, benzbromarone, sulfinpyrazone

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49
Q

What are the drug of choice for uric acid overproducer?

A

allopurino, febuxostat

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50
Q

What are the most serious side effects of allopurinol?

A 
1. Life-threatening toxic epidermal necrolysis
2 systemic vasculitis
3. bone marrow suppression
4. granulomatous hepatitis
5. renal failure
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51
Q

The hallmark of RA leads to decreased ROM, reduced grip, trigger fingers. What are affected?

A

flexor tendon tenosynovitis

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52
Q

___ syndrome

Keratoconjunctivitis sicca
Xerostomia
RA

A

Sjogren Syndrome

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53
Q

Most common hematologic abnormality in RA?

A

normochromic normocytic anemia

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54
Q

___ syndrome

Neutropenia
splenomegaly
nodular RA

A

Felty’s syndrome

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55
Q

Offers greatest sensitivity for detecting synovitis and joint effusions

A

MRI

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56
Q

Early sign of inflammatory joint disease

A

Bone marrow edema

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57
Q

most commonly affected joint in calcium pyrophosphate deposition disease

A

Knee

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58
Q

How to differentiate psoriatic arthritis from RA?

A

In psoriatic arthritis,

  1. Seronegative
  2. DIP, spine, sacroiliac joints
  3. Distinctive radiographic features
  4. Familial aggregation
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59
Q

Asymmetric sacroilitis is a characteristic finding of

A

Axial psoriatic arthritis

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60
Q

Radiographic features of PsA from RA

A
  1. DIP involvement/penil-in-cup
  2. Marginal erosions
  3. Small joint ankylosis
  4. Osteolysis of phalangeal and metacarpal bone with telescoping of digits
  5. Periostitis and proliferative new bone at sites of enesthesitis
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61
Q

Hallmark features of psoriatic arthritis

A

dactylitis, enthesitis

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62
Q

What is the criteria used to classify PsA?

A

CASPAR Criteria

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63
Q

What are the components of CASPAR criteria

A

Inflammatory articular disease + >= 3 of:

  1. Current psoriasis (2 points), personal history of psoriasis, family hisotry
  2. Nail dystrophy
  3. Negative test result for RF
  4. Current dactylitis/history of dactilitis
  5. Juxtaarticular new bone formation
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64
Q

[Diagnose]

fever, acute right knee and left wrist pain, papules and pustules on extensor surface of forearms. Synovial fluid analysis reveals leukocytes and PMNs but not organisms on gram stain

A

Dx: Septic arthritis
Etiology: N. gonorrhea
Next step: antibiotic therapy

Important to evaluateL aspiration fo synovial fluid

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65
Q

Commonly involved joints among IV drug user with non-gonoccocal arthritis

A

Sternoclavicular joints
Spine
sacroiliac joints

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66
Q

[diagnose]

fever, chills, rash/papules, migratory arthritis, tenosynovitis

A

Disseminated gonococcal arthritis

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67
Q

[Septic arthritis synovial fluid analysis]

leukocytes 10,000 - 20,000
Negative culture

A

gonococcal arthritis

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68
Q

[diagnosis]

soft tissue swelling, joint space widening, displacement of tissue planes by the distended capsule

A

septic arthritis

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69
Q

What is the empiric DOC for patients with non-gonococcal arthritis?

A

Cefotaxime or ceftriaxone

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70
Q

What is the empiric DOC for patients with gonococcal arthritis?

A

Ceftiraxone

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71
Q

[diagnosis]

young adult, fever, chills,rash, articular symptoms

A

disseminated gonococcal arthritis

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72
Q

[diagnose]

22F fatigue, malaise, fever 10 days, swelling hands and ankles, chest pain on deep inspiration

PE: raised erythema on the skin, hand, and ankle joints swelling

A

Dx: SLE
Initial diagnostic test: ANA
Most specific test: anti dsDNA or Anti-Sm
Correlates disease activity: anti-dsDNA

Maintstay tx for life-threatening SLE: systemic glucocorticoids

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73
Q

[Classification of LN]

LM: normal
IF: mesangial immune deposits

A

Class I: minimal messangial

74
Q

[Classification of LN]

LM: purely messangial hypercellularity or mesangial matrix expansion
IF: subendothelial deposits

A

Class II: mesangial proliferative

Tx: High dose steroids

75
Q

[Classification of LN]

GN < 50%

A

Class III: Focal

Tx: cyclophosphamide

76
Q

[Classification of LN]

GN > 50%

A

Class IV: Diffuse

Tx: cyclophosphamide

77
Q

[Classification of LN]

Global or segmental subepithelial immune deposits

A

Class V: Membranous

Tx: cyclophosphamide

78
Q

[Classification of LN]

> 90% without residual activity

A

Class VI: Advanced sclerotic

Tx: cyclophosphamide

79
Q

Signs and symptoms of SLE

A

BOSS BRAS

Brain - psychosis
Oral ulvers
Skin - butterfly rash, discoid rash
Synovitis

Blood - hemolytic anemia
Renal - hematuria, proteinuria, RBC cast,
Alopecia
Serology

80
Q

What are the serologic picture of lupus flare?

A

Increase anti-dsDNA

Low complement levels

81
Q

[treatment of SLE]

non-life threatening SLE, QOL no acceptable

A

conservative management + low dose glucocorticoids

consider: belimumab

82
Q

[treatment of SLE]

life threatening SLE, unresponsive to high dose glucocorticoids and mycophenolate mofetil

A

Give: belimumab, rituximab, calcineurin inhibitors

83
Q

[treatment of SLE]

life threatening SLE, unresponsive to high dose glucocorticoids and cyclophosphamide

A

Give: belimumab, rituximab, calcineurin inhibitors

84
Q

[treatment of SLE]

how long will you give cyclophosphamide?

A

not more than 6 months

85
Q

[name the serologic marker of SLE]

best for screening mtest

A

ANA

86
Q

[name the serologic marker of SLE]

best for disease activity

A

anti-dsDNA

87
Q

[name the serologic marker of SLE]

Specific for SLE

A

Anti-Sm

88
Q

[name the serologic marker of SLE]

associated with Sicca Syndrome

A

Anti-RO (SS-A)

89
Q

[name the serologic marker of SLE]

drug-induced lupus

A

antihistone

90
Q

[name the serologic marker of SLE]

clotting, fetal loss, thrombocytopenia

A

antiphospholipid

91
Q

[name the serologic marker of SLE]

useful in distinguishing lupus cerebritis and steroid-induced psychosis

A

antiribosomal P

92
Q

[Treatment of SLE]

Drugs for SLE relapse?

A
  1. Cyclophosphamide
  2. Azathioprine
  3. Mycophenolate mofetil
93
Q

[Treatment of SLE]

Between cyclophosphamide and MMofetil, diarrhea is more common in

A

Mycophenolate mofetil

94
Q

[Treatment of SLE]

Between cyclophosphamide and MMofetil, nausea is more common in

A

cyclophosphamide

95
Q

[Treatment of SLE]

DOC for SLE in pregnancy

A
  1. Hydroxychlorquine

2. Prednisone or prednisolone

96
Q

Drugs that cause drug-induced lupus

A
  1. Procainamide
  2. Hydralazine
  3. Propylthiouracil
  4. Lithium
  5. Phenytoin
  6. Isoniazid
  7. Nitrofurantoin
  8. Sulfasalazine
  9. Statine
97
Q

What is the target INR for SLE with APAS

A

2-2.5

98
Q

What is the target INR for SLE with recurring clots

A

3-3.5

99
Q

most common acute rash of SLE

A

butterflu rash

100
Q

leading cause of mortality on the first decade in SLE

A

nephritis and infection

101
Q

Intermittent polyarthritis in SLE are commonly seen in what areas of the body

A

Hands
Wrists
Knees

102
Q

most common chronic dermatitis in SLE

A

discoid rash

103
Q

most common diffuse CNS lupus

A

cognitive dysfunction

104
Q

most common pulmonary manifestation of SLE

A

pleuritis

105
Q

most common cardiac manifestation of SLE

A

pericarditis

106
Q

most serious cardiac manifestion in SLE

A
  1. myocarditis

2. Liebman-sacks endocarditis

107
Q

most common endocardial involvement in SLE

A
  1. Mitral valve

2. Aortic valve

108
Q

most common hematologic manifestation of SLE

A

Anemia (normo, normo)

109
Q

most common MSK manifestation of SLE

A

Arthralgia/myalgia

110
Q

most common cutaneous manifestation

A

photosensitivity

111
Q

Mainstay treatment for non-life threatening SLE

A

Analgesics

Antimalarials

112
Q

Lupus Nephritis with worst prognosis

A

crescentic lupus nephritis

113
Q

[diagnosis]

fever, disabling joing pain, previous history of sore throat, small painless lumps on his elbows and pink macules with clear center on his chest

A

Dx: ARF
Best treatment: aspirin
Secondary prophylaxis: benzathine penicillin G

114
Q

What is the valvular damage that is a hallmark of rheumatic carditis

A
  1. Mitral valve
115
Q

[Jones Criteria]

Initial ARF

A

2 major OR

1 major plus 2 minor

116
Q

[Jones Criteria]

recurrent ARF

A

2 major OR
1 major plus 2 minor OR
3 minor

117
Q

[Jones Criteria]

Major criteria

A 
J - oint polyarthalgia
O - heart, carditis
N - odules
E - erythema marginatum
S - sc nodules
118
Q

[Jones Criteria]

Minor criteria, low risk population

A

Fever > = 38.5
ESR >= 60mm
CRP >= 3mg/dL
Polyarthralgia

119
Q

[Jones Criteria]

Minor criteria, moderate to high risk population

A

Fever > = 38
ESR >= 30mm
CRP >= 3mg/dL
Monoarthralgia

120
Q

[Skin lesions]

evanescent macular rash
central clearing
serpiginous edge
migrates
non-pruritic
A

Erythema marginatum

121
Q

[Skin lesion]

annular patch
central erythema
bulls eye appearance
expands

A

erythema migrans

122
Q

[Skin lesions]

erythematous plaque
central vesicle
target or iris
pruritic

A

erythema multiforme

123
Q

[diagnose]

first degree AV block + evanescent migrating rash

A

Rheumatic fever

124
Q

[diagnose]

expanding bulls eye rash + complete heart block + tick bite

A

Lyme disease = Borrelia burgdorferi

125
Q

[diagnose]

multiple target-appearing plaque + drug exposure

A

erythema multiforme

126
Q

[Secondary prevention of RF]

RF without carditis

A

5 years after last attack OR until 21 year old

127
Q

[Secondary prevention of RF]

RF with carditis but no residual valvular disease

A

10 years after last attack OR

until 21 years old

128
Q

[Secondary prevention of RF]

RF with carditis and persistent residual valvular disease

A

10 years after last attack OR until 40 years old

129
Q

What is the most accurate test to diagnose Sjogren Syndrome

A

Labial biopsy

130
Q

Sjogren syndrome is associated with what renal abnormality?

A

renal tubular acidosis

131
Q

What serologic markers are associated with Sjogren Syndrome

A

Anti-Ro/SSA

Anti-La/SSB

132
Q

What drugs are useful to increase tear secretion (for Sjogren Syndrome)

A

Pilocarpine

Cevimeline

133
Q

[diagnosis]

woman, thickened skin, tight fingers, reynaud phenomenon or digital pitting scars, arthralgia, interstitial lung disease, acid reflux, dysphagia

A

Scleroderma/systemic sclerosis

134
Q

Also called limited scleroderma

A

CREST syndrome

135
Q

What are the components of CREST syndrome

A 
Calcinosis cutis
Reynaud's phenomenon
Esophageal dysmotility
Sclerodactyl
Telangiectasia
136
Q

[diagnosis]

20F abdominal pain, joint pain, palpable rashes on the buttocks up to the legs

polyarthalgia without frank arthritis

A

Dx: HSP
Pathophysio: small vessel vasculitis due to immune-complex deposition
Most often seen immune complexes: IgA

137
Q

What is the skin biopsy finding in HSP?

A

Leukocytoclastic vasculitis with IgA and C3 deposition by IF

138
Q

[Diagnosis]

23F, right arm claudication, malaise, fever, arthralgia, right brachial and radial pulse are absent

A

Dx: Takayasu arteritis
Pathophysio: Inflammation and stenosis of medium/large sized arteries

139
Q

Most commonly affected artery in Takayasu arteritis?

A

subclavian

140
Q

Manifestation when common carotid artery is involved in Takayasu Arteritis?

A

Syncope, TIA, Visual changes, stroke

141
Q

What is the most common pattern of takayasu arteritis in arteriography?

A

Irregular vessel walls

stenosis, aneurysm, occlusion

142
Q

[diagnose]

20F dyspnea and rashes 30 mins after IV penicillin.

PE: (+) generalized pruritic urticaria and wheezing on auscultation

A

Dx: anaphylaxis

Initial step: administration of epinephrine 0.3-0.5mL 1:1000 SC or IM

143
Q

Which adrenoceptor does epinephrine act to dilate bronchial smooth muscle?

A

beta 2 adrenoceptor

144
Q

what is the most common presentation of anaphylaxis?

A

cuaneous

145
Q

Angioedema resulting in death by mechanical obstruction is commonly located in ___

A

epiglottis and larynx

146
Q

Aside from histamine, this eicosanoid contributes to hypotension in anaphylaxis

A

PG2

147
Q

[diagnose]

21 M, two day history of well circumscribed wheals with erythematous raised borders and blanched centers after exposure to pollen

A

Dx: Acute urticaria

148
Q

What is the cut off duration for acute and chronic urticaria?

A
  1. Acute < 6 weeks

2. Chronic > 6 weeks

149
Q

[Difference of urticaria and angioedema]

superfical dermis involvement, well-circumscribed wheals, blanched centers, <24 hours, pruritic, frequentl migrates, no bruising or scarring

A

urticaria

150
Q

[Difference of urticaria and angioedema]

deeper dermis and subcutaneous, dramatic swelling, painful than pruritus

A

angioedema

151
Q

Cite examples of sedating H1 antihistamines

A
  1. Chlorpheniramine

2. Diphenhydramine

152
Q

Cite examples of non-sedating H2 antagonist

A
  1. Loratidine
  2. Desloratidine
  3. Fexofenadine
153
Q

most common sites of urticaria

A

extremities and face

154
Q

most common site of angioededma

A

periorbital and lips

155
Q

[diagnosis]

22M, on and off sneezing, runny nose and nasal congestion in the morning, history of atopic dermatitis and food allergy

A

Dx: allergic rhinitis

Next step: identify offending allergen by confirming with skin test or serum assay

156
Q

What is the most potent drug for the treatment of rhinitis?

A

intranasal corticosteroids (high dose)

157
Q

What are the hallmarks of allergic rhinitis?

A
  1. Sneezing
  2. Rhinorhea
  3. Obstruction of nasal passages
  4. Pharyngeal itching
  5. Lacrimation
158
Q

What is the skin biopsy finding in HSP?

A

Leukocytoclastic vasculitis with IgA and C3 deposition by IF

159
Q

[Diagnosis]

23F, right arm claudication, malaise, fever, arthralgia, right brachial and radial pulse are absent

A

Dx: Takayasu arteritis
Pathophysio: Inflammation and stenosis of medium/large sized arteries

160
Q

Most commonly affected artery in Takayasu arteritis?

A

subclavian

161
Q

Manifestation when common carotid artery is involved in Takayasu Arteritis?

A

Syncope, TIA, Visual changes, stroke

162
Q

What is the most common pattern of takayasu arteritis in arteriography?

A

Irregular vessel walls

stenosis, aneurysm, occlusion

163
Q

[diagnose]

20F dyspnea and rashes 30 mins after IV penicillin.

PE: (+) generalized pruritic urticaria and wheezing on auscultation

A

Dx: anaphylaxis

Initial step: administration of epinephrine 0.3-0.5mL 1:1000 SC or IM

164
Q

Which adrenoceptor does epinephrine act to dilate bronchial smooth muscle?

A

beta 2 adrenoceptor

165
Q

what is the most common presentation of anaphylaxis?

A

cuaneous

166
Q

Angioedema resulting in death by mechanical obstruction is commonly located in ___

A

epiglottis and larynx

167
Q

Aside from histamine, this eicosanoid contributes to hypotension in anaphylaxis

A

PG2

168
Q

[diagnose]

21 M, two day history of well circumscribed wheals with erythematous raised borders and blanched centers after exposure to pollen

A

Dx: Acute urticaria

169
Q

What is the cut off duration for acute and chronic urticaria?

A
  1. Acute < 6 weeks

2. Chronic > 6 weeks

170
Q

[Difference of urticaria and angioedema]

superfical dermis involvement, well-circumscribed wheals, blanched centers, <24 hours, pruritic, frequentl migrates, no bruising or scarring

A

urticaria

171
Q

[Difference of urticaria and angioedema]

deeper dermis and subcutaneous, dramatic swelling, painful than pruritus

A

angioedema

172
Q

Cite examples of sedating H1 antihistamines

A
  1. Chlorpheniramine

2. Diphenhydramine

173
Q

Cite examples of non-sedating H2 antagonist

A
  1. Loratidine
  2. Desloratidine
  3. Fexofenadine
174
Q

most common sites of urticaria

A

extremities and face

175
Q

most common site of angioededma

A

periorbital and lips

176
Q

[diagnosis]

22M, on and off sneezing, runny nose and nasal congestion in the morning, history of atopic dermatitis and food allergy

A

Dx: allergic rhinitis

Next step: identify offending allergen by confirming with skin test or serum assay

177
Q

What is the most potent drug for the treatment of rhinitis?

A

intranasal corticosteroids (high dose)

178
Q

What are the hallmarks of allergic rhinitis?

A
  1. Sneezing
  2. Rhinorhea
  3. Obstruction of nasal passages
  4. Pharyngeal itching
  5. Lacrimation
179
Q

Most cases of chronic urticaria are

A

idiopathic

180
Q

What are the components of sclerodermal renal crisis in patients with systemic sclerosis?

A
  1. BOV
  2. Severe headache
  3. Chest pain
181
Q

Histocompatibility complex associated with ankylosing spondylitis

A

HLA-B27

Internal Medicine (10 decks)

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