Rheumatology Flashcards
1
Q
[MSK]
Chronic noniflammatory arthritis, involving the DIP, CMC1, hip, knee joints
A
Osteoarthritis
2
Q
Chronic inflammatory polyarthritis, symmetric involvement, including the PIP, MCP, MTP
A
RA
3
Q
Heberden nodes is also known as ____
A
DIP
B muna bago H
Heberden = HBD
4
Q
Bouchard nodes is also known as ____
A
PIP
B muna bago H
Heberden = HBD
5
Q
Joints in the hands affected in OA
A
DIPOA
PIPOA
CMCOA
6
Q
Joint in the forearm affected by RA
A
Wrist, MCP
7
Q
Indications for Fluid Aspiration and Analysis
A
- Monoarthritis
- Trauma with effusion
- Monoarthritis in a patient with chronic polyarthritis
- Suspicion of joint infection, crystal-induced arthritis, hemarthrosos
8
Q
[Characteristic of synovial fluid]
>1mL reduced viscosity WBC 2000-50,000 Glucose <50mg lower than blood Translucent Turbid, yello
A
Inflammatory
9
Q
[Characteristic of synovial fluid]
>1mL Low viscosity WBC >50,000 <50mg/dL lower than blood opaque, purulent culture positive
A
septic
10
Q
[Characteristic of synovial fluid]
>1mL High viscosity <2000 WBC glucose equal to blood, clear amber
A
non-inflammatory
11
Q
What is the best initial treatment for osteoarthritis?
A
X-ray
12
Q
What is the best initial management?
A
Acetaminophen
13
Q
What is the pathologic sine qua non of the disease?
A
hyaline articular cartilage
14
Q
spared joints in OA
A
Wrist, Elbow, Ankle
15
Q
What is the most common cause chronic knee pain in persons >45 years old
A
OA
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
17
Q
What is the cause of ulnar deviation in RA?
A
subluxation of the MCP
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
19
Q
___ syndrome
Ndoular RA
Splenomegaly
Neutropenia
A
Felty’s syndrome
20
Q
What is the most common pulmonary manifestation of RA?
A
pleuritis
21
Q
Most common valvular abnormality in RA?
A
mitral regurgitation
22
Q
[Deformity in RA]
Flexion of the PIP
Hyperextension of DIP
A
Boutonniere deformity
23
Q
[Deformity in RA]
Hyperextension of PIP
Flexion of DIP
A
Swan neck
24
Q
[Deformity in RA]
subluxation of first MCP
Hyperextension of the 1st IP
A
Z-line deformity
25
The most common site of cardiac involvement in RA
pericardium
26
Conditions with positive RF
1. SLE
2. Sjogren
3. Subacute bacterial endocarditis
4. Hep C and C
27
Most specific serologic marker for RA
Anti-CCP
28
What is the initial radiographic finding in RA?
periarticular osteopenia
29
Drug class that slows the structural progression of RA
DMARD
30
Drug class that is initially given to control RA before DMARD takes full effect
glucocorticoids
31
Drug class given in acute flares of RA
glucocorticoids
32
What is the best initial DMARD of RA?
methotrexate
33
What DMARDs are safe in pregnancy?
1. Hydroxychlorquine
| 2. Sulfasalazine
34
DMARDs that are teratogenic
MTX
35
What is the major concern in using DMARDs
increased risk for infection
36
What is the next best step after Acute Monoarticular arthritis is diagnosed?
Diagnostic arthrocentesis
37
What is the initial therapy for gout?
NSAID
38
[diagnosi]
male, obese, sudden onset knee and big toe pain, presence of inflammation
Gout
39
What is the most common early clinical presentation of gout?
actue arthritis
40
Vitamin that can cause hyperuricemia
Niacin
41
___ negatively birefringent needle shaped crystal
monosodium ureate = gout
42
___ positively birefringent rhomboid-shaped crystal
Calcium pyrophosphate = pseudogout
43
What are the characteristic radiologic features of gout?
Cystic changes with well-defined erosions and overhanging sclerotic margins and soft tissue masses
44
What is the first line treatment during acute gouty attack?
NSAID
45
What is the more effective drug for polyarticular gout?
glucocorticoids
46
Colchicine must me temporarily discontinued at the first sign of what?
loose stools
47
When will you initiate hypouricemic drug therapy?
1. After 2 episodes of acute attacs
2. Serum uric acid >9
3. Presence of uric acid stone
4. Tophi or chronic goit
48
What are the drug of choice for uric acid underexcreter?
Probenecid, benzbromarone, sulfinpyrazone
49
What are the drug of choice for uric acid overproducer?
allopurino, febuxostat
50
What are the most serious side effects of allopurinol?
```
1. Life-threatening toxic epidermal necrolysis
2 systemic vasculitis
3. bone marrow suppression
4. granulomatous hepatitis
5. renal failure
```
51
The hallmark of RA leads to decreased ROM, reduced grip, trigger fingers. What are affected?
flexor tendon tenosynovitis
52
___ syndrome
Keratoconjunctivitis sicca
Xerostomia
RA
Sjogren Syndrome
53
Most common hematologic abnormality in RA?
normochromic normocytic anemia
54
___ syndrome
Neutropenia
splenomegaly
nodular RA
Felty's syndrome
55
Offers greatest sensitivity for detecting synovitis and joint effusions
MRI
56
Early sign of inflammatory joint disease
Bone marrow edema
57
most commonly affected joint in calcium pyrophosphate deposition disease
Knee
58
How to differentiate psoriatic arthritis from RA?
In psoriatic arthritis,
1. Seronegative
2. DIP, spine, sacroiliac joints
3. Distinctive radiographic features
3. Familial aggregation
59
Asymmetric sacroilitis is a characteristic finding of
Axial psoriatic arthritis
60
Radiographic features of PsA from RA
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
61
Hallmark features of psoriatic arthritis
dactylitis, enthesitis
62
What is the criteria used to classify PsA?
CASPAR Criteria
63
What are the components of CASPAR criteria
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
64
[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
Dx: Septic arthritis
Etiology: N. gonorrhea
Next step: antibiotic therapy
Important to evaluateL aspiration fo synovial fluid
65
Commonly involved joints among IV drug user with non-gonoccocal arthritis
Sternoclavicular joints
Spine
sacroiliac joints
66
[diagnose]
fever, chills, rash/papules, migratory arthritis, tenosynovitis
Disseminated gonococcal arthritis
67
[Septic arthritis synovial fluid analysis]
leukocytes 10,000 - 20,000
Negative culture
gonococcal arthritis
68
[diagnosis]
soft tissue swelling, joint space widening, displacement of tissue planes by the distended capsule
septic arthritis
69
What is the empiric DOC for patients with non-gonococcal arthritis?
Cefotaxime or ceftriaxone
70
What is the empiric DOC for patients with gonococcal arthritis?
Ceftiraxone
71
[diagnosis]
young adult, fever, chills,rash, articular symptoms
disseminated gonococcal arthritis
72
[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
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
73
[Classification of LN]
LM: normal
IF: mesangial immune deposits
Class I: minimal messangial
74
[Classification of LN]
LM: purely messangial hypercellularity or mesangial matrix expansion
IF: subendothelial deposits
Class II: mesangial proliferative
Tx: High dose steroids
75
[Classification of LN]
GN < 50%
Class III: Focal
Tx: cyclophosphamide
76
[Classification of LN]
GN > 50%
Class IV: Diffuse
Tx: cyclophosphamide
77
[Classification of LN]
Global or segmental subepithelial immune deposits
Class V: Membranous
Tx: cyclophosphamide
78
[Classification of LN]
>90% without residual activity
Class VI: Advanced sclerotic
Tx: cyclophosphamide
79
Signs and symptoms of SLE
BOSS BRAS
Brain - psychosis
Oral ulvers
Skin - butterfly rash, discoid rash
Synovitis
Blood - hemolytic anemia
Renal - hematuria, proteinuria, RBC cast,
Alopecia
Serology
80
What are the serologic picture of lupus flare?
Increase anti-dsDNA
| Low complement levels
81
[treatment of SLE]
non-life threatening SLE, QOL no acceptable
conservative management + low dose glucocorticoids
consider: belimumab
82
[treatment of SLE]
life threatening SLE, unresponsive to high dose glucocorticoids and mycophenolate mofetil
Give: belimumab, rituximab, calcineurin inhibitors
83
[treatment of SLE]
life threatening SLE, unresponsive to high dose glucocorticoids and cyclophosphamide
Give: belimumab, rituximab, calcineurin inhibitors
84
[treatment of SLE]
how long will you give cyclophosphamide?
not more than 6 months
85
[name the serologic marker of SLE]
best for screening mtest
ANA
86
[name the serologic marker of SLE]
best for disease activity
anti-dsDNA
87
[name the serologic marker of SLE]
Specific for SLE
Anti-Sm
88
[name the serologic marker of SLE]
associated with Sicca Syndrome
Anti-RO (SS-A)
89
[name the serologic marker of SLE]
drug-induced lupus
antihistone
90
[name the serologic marker of SLE]
clotting, fetal loss, thrombocytopenia
antiphospholipid
91
[name the serologic marker of SLE]
useful in distinguishing lupus cerebritis and steroid-induced psychosis
antiribosomal P
92
[Treatment of SLE]
Drugs for SLE relapse?
1. Cyclophosphamide
2. Azathioprine
3. Mycophenolate mofetil
93
[Treatment of SLE]
Between cyclophosphamide and MMofetil, diarrhea is more common in
Mycophenolate mofetil
94
[Treatment of SLE]
Between cyclophosphamide and MMofetil, nausea is more common in
cyclophosphamide
95
[Treatment of SLE]
DOC for SLE in pregnancy
1. Hydroxychlorquine
| 2. Prednisone or prednisolone
96
Drugs that cause drug-induced lupus
1. Procainamide
2. Hydralazine
3. Propylthiouracil
4. Lithium
5. Phenytoin
6. Isoniazid
7. Nitrofurantoin
8. Sulfasalazine
9. Statine
97
What is the target INR for SLE with APAS
2-2.5
98
What is the target INR for SLE with recurring clots
3-3.5
99
most common acute rash of SLE
butterflu rash
100
leading cause of mortality on the first decade in SLE
nephritis and infection
101
Intermittent polyarthritis in SLE are commonly seen in what areas of the body
Hands
Wrists
Knees
102
most common chronic dermatitis in SLE
discoid rash
103
most common diffuse CNS lupus
cognitive dysfunction
104
most common pulmonary manifestation of SLE
pleuritis
105
most common cardiac manifestation of SLE
pericarditis
106
most serious cardiac manifestion in SLE
1. myocarditis
| 2. Liebman-sacks endocarditis
107
most common endocardial involvement in SLE
1. Mitral valve
| 2. Aortic valve
108
most common hematologic manifestation of SLE
Anemia (normo, normo)
109
most common MSK manifestation of SLE
Arthralgia/myalgia
110
most common cutaneous manifestation
photosensitivity
111
Mainstay treatment for non-life threatening SLE
Analgesics
| Antimalarials
112
Lupus Nephritis with worst prognosis
crescentic lupus nephritis
113
[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
Dx: ARF
Best treatment: aspirin
Secondary prophylaxis: benzathine penicillin G
114
What is the valvular damage that is a hallmark of rheumatic carditis
1. Mitral valve
115
[Jones Criteria]
Initial ARF
2 major OR
| 1 major plus 2 minor
116
[Jones Criteria]
recurrent ARF
2 major OR
1 major plus 2 minor OR
3 minor
117
[Jones Criteria]
Major criteria
```
J - oint polyarthalgia
O - heart, carditis
N - odules
E - erythema marginatum
S - sc nodules
```
118
[Jones Criteria]
Minor criteria, low risk population
Fever > = 38.5
ESR >= 60mm
CRP >= 3mg/dL
Polyarthralgia
119
[Jones Criteria]
Minor criteria, moderate to high risk population
Fever > = 38
ESR >= 30mm
CRP >= 3mg/dL
Monoarthralgia
120
[Skin lesions]
```
evanescent macular rash
central clearing
serpiginous edge
migrates
non-pruritic
```
Erythema marginatum
121
[Skin lesion]
annular patch
central erythema
bulls eye appearance
expands
erythema migrans
122
[Skin lesions]
erythematous plaque
central vesicle
target or iris
pruritic
erythema multiforme
123
[diagnose]
first degree AV block + evanescent migrating rash
Rheumatic fever
124
[diagnose]
expanding bulls eye rash + complete heart block + tick bite
Lyme disease = Borrelia burgdorferi
125
[diagnose]
multiple target-appearing plaque + drug exposure
erythema multiforme
126
[Secondary prevention of RF]
RF without carditis
5 years after last attack OR until 21 year old
127
[Secondary prevention of RF]
RF with carditis but no residual valvular disease
10 years after last attack OR
| until 21 years old
128
[Secondary prevention of RF]
RF with carditis and persistent residual valvular disease
10 years after last attack OR until 40 years old
129
What is the most accurate test to diagnose Sjogren Syndrome
Labial biopsy
130
Sjogren syndrome is associated with what renal abnormality?
renal tubular acidosis
131
What serologic markers are associated with Sjogren Syndrome
Anti-Ro/SSA
| Anti-La/SSB
132
What drugs are useful to increase tear secretion (for Sjogren Syndrome)
Pilocarpine
| Cevimeline
133
[diagnosis]
woman, thickened skin, tight fingers, reynaud phenomenon or digital pitting scars, arthralgia, interstitial lung disease, acid reflux, dysphagia
Scleroderma/systemic sclerosis
134
Also called limited scleroderma
CREST syndrome
135
What are the components of CREST syndrome
```
Calcinosis cutis
Reynaud's phenomenon
Esophageal dysmotility
Sclerodactyl
Telangiectasia
```
136
[diagnosis]
20F abdominal pain, joint pain, palpable rashes on the buttocks up to the legs
polyarthalgia without frank arthritis
Dx: HSP
Pathophysio: small vessel vasculitis due to immune-complex deposition
Most often seen immune complexes: IgA
137
What is the skin biopsy finding in HSP?
Leukocytoclastic vasculitis with IgA and C3 deposition by IF
138
[Diagnosis]
23F, right arm claudication, malaise, fever, arthralgia, right brachial and radial pulse are absent
Dx: Takayasu arteritis
Pathophysio: Inflammation and stenosis of medium/large sized arteries
139
Most commonly affected artery in Takayasu arteritis?
subclavian
140
Manifestation when common carotid artery is involved in Takayasu Arteritis?
Syncope, TIA, Visual changes, stroke
141
What is the most common pattern of takayasu arteritis in arteriography?
Irregular vessel walls
| stenosis, aneurysm, occlusion
142
[diagnose]
20F dyspnea and rashes 30 mins after IV penicillin.
PE: (+) generalized pruritic urticaria and wheezing on auscultation
Dx: anaphylaxis
| Initial step: administration of epinephrine 0.3-0.5mL 1:1000 SC or IM
143
Which adrenoceptor does epinephrine act to dilate bronchial smooth muscle?
beta 2 adrenoceptor
144
what is the most common presentation of anaphylaxis?
cuaneous
145
Angioedema resulting in death by mechanical obstruction is commonly located in ___
epiglottis and larynx
146
Aside from histamine, this eicosanoid contributes to hypotension in anaphylaxis
PG2
147
[diagnose]
21 M, two day history of well circumscribed wheals with erythematous raised borders and blanched centers after exposure to pollen
Dx: Acute urticaria
148
What is the cut off duration for acute and chronic urticaria?
1. Acute < 6 weeks
| 2. Chronic > 6 weeks
149
[Difference of urticaria and angioedema]
superfical dermis involvement, well-circumscribed wheals, blanched centers, <24 hours, pruritic, frequentl migrates, no bruising or scarring
urticaria
150
[Difference of urticaria and angioedema]
deeper dermis and subcutaneous, dramatic swelling, painful than pruritus
angioedema
151
Cite examples of sedating H1 antihistamines
1. Chlorpheniramine
| 2. Diphenhydramine
152
Cite examples of non-sedating H2 antagonist
1. Loratidine
2. Desloratidine
3. Fexofenadine
153
most common sites of urticaria
extremities and face
154
most common site of angioededma
periorbital and lips
155
[diagnosis]
22M, on and off sneezing, runny nose and nasal congestion in the morning, history of atopic dermatitis and food allergy
Dx: allergic rhinitis
| Next step: identify offending allergen by confirming with skin test or serum assay
156
What is the most potent drug for the treatment of rhinitis?
intranasal corticosteroids (high dose)
157
What are the hallmarks of allergic rhinitis?
1. Sneezing
2. Rhinorhea
3. Obstruction of nasal passages
4. Pharyngeal itching
5. Lacrimation
158
What is the skin biopsy finding in HSP?
Leukocytoclastic vasculitis with IgA and C3 deposition by IF
159
[Diagnosis]
23F, right arm claudication, malaise, fever, arthralgia, right brachial and radial pulse are absent
Dx: Takayasu arteritis
Pathophysio: Inflammation and stenosis of medium/large sized arteries
160
Most commonly affected artery in Takayasu arteritis?
subclavian
161
Manifestation when common carotid artery is involved in Takayasu Arteritis?
Syncope, TIA, Visual changes, stroke
162
What is the most common pattern of takayasu arteritis in arteriography?
Irregular vessel walls
| stenosis, aneurysm, occlusion
163
[diagnose]
20F dyspnea and rashes 30 mins after IV penicillin.
PE: (+) generalized pruritic urticaria and wheezing on auscultation
Dx: anaphylaxis
| Initial step: administration of epinephrine 0.3-0.5mL 1:1000 SC or IM
164
Which adrenoceptor does epinephrine act to dilate bronchial smooth muscle?
beta 2 adrenoceptor
165
what is the most common presentation of anaphylaxis?
cuaneous
166
Angioedema resulting in death by mechanical obstruction is commonly located in ___
epiglottis and larynx
167
Aside from histamine, this eicosanoid contributes to hypotension in anaphylaxis
PG2
168
[diagnose]
21 M, two day history of well circumscribed wheals with erythematous raised borders and blanched centers after exposure to pollen
Dx: Acute urticaria
169
What is the cut off duration for acute and chronic urticaria?
1. Acute < 6 weeks
| 2. Chronic > 6 weeks
170
[Difference of urticaria and angioedema]
superfical dermis involvement, well-circumscribed wheals, blanched centers, <24 hours, pruritic, frequentl migrates, no bruising or scarring
urticaria
171
[Difference of urticaria and angioedema]
deeper dermis and subcutaneous, dramatic swelling, painful than pruritus
angioedema
172
Cite examples of sedating H1 antihistamines
1. Chlorpheniramine
| 2. Diphenhydramine
173
Cite examples of non-sedating H2 antagonist
1. Loratidine
2. Desloratidine
3. Fexofenadine
174
most common sites of urticaria
extremities and face
175
most common site of angioededma
periorbital and lips
176
[diagnosis]
22M, on and off sneezing, runny nose and nasal congestion in the morning, history of atopic dermatitis and food allergy
Dx: allergic rhinitis
| Next step: identify offending allergen by confirming with skin test or serum assay
177
What is the most potent drug for the treatment of rhinitis?
intranasal corticosteroids (high dose)
178
What are the hallmarks of allergic rhinitis?
1. Sneezing
2. Rhinorhea
3. Obstruction of nasal passages
4. Pharyngeal itching
5. Lacrimation
179
Most cases of chronic urticaria are
idiopathic
180
What are the components of sclerodermal renal crisis in patients with systemic sclerosis?
1. BOV
2. Severe headache
4. Chest pain
181
Histocompatibility complex associated with ankylosing spondylitis
HLA-B27
