Rheumatology Flashcards
1
Q
- women greater than 50 yoa
- joint pain
- MORNING stiffness; SYMMETRICAL, multiple joints of hands, LASTS MORE THAN 1 HOUR
- symptomatic episodes last for at least 6 weeks
A
rheumatoid arthritis
2
Q
how is rheumatoid arthritis (RA) defined?
A
4 or more of the following:
- morning stiffness more than 1 hour
- wrist and finger involvement
- swelling of at least 3 joints
- SYMMETRIC involvement
- rheumatoid nodules
- XR showing erosions
- POSITIVE RF, or anti-CCP Ab
- elevated CRP, or ESR
- synovitis
3
Q
cardiac findings in RA
A
- pericarditis
- valvular disease
4
Q
pulmonary findings in RA
A
- pleural effusion with VERY LOW glucose level
- lung nodules
5
Q
hematological findings in RA
A
anemia with NORMAL MCV
6
Q
neurological findings in RA
A
mononeuritis multiplex
7
Q
dermatological findings in RA
A
nodules
8
Q
Felty’s syndrome
A
- RA
- splenomegaly
- neutropenia
9
Q
joint findings in RA
A
- MCP (metacarpophalangeal) swelling and pain
- Boutonniere deformity
- swan neck deformity
- Baker’s cyst
- C1/C2 cervical spine subluxation
10
Q
Boutonniere deformity
A
PIP flexion with DIP hyperextension
11
Q
swan neck deformity
A
PIP extension with DIP flexion
12
Q
Baker’s cyst
A
outpocketing of synovium at back of knee
13
Q
treatment for RA
A
NSAIDs with DMARD
disease-modifying antirheumatic drug
14
Q
which joint is SPARED in RA?
A
sacroiliac joint
15
Q
what should be started to eliminate XR abnormalities in RA?
A
DMARDs
16
Q
BEST INITIAL DMARD to start in RA
A
methotrexate
17
Q
adverse effects of methotrexate
A
- bone marrow suppression
- pneumonitis
- liver disease
18
Q
name the DMARDs
A
- methotrexate
- biological agents (infliximab, adalimumab, etanercept)
- hydroxychloroquine
- sulfasalazine
19
Q
name the alternate DMARDs
A
- rituximab
- anakinra
- tocilizumab
- leflunomide
- abatacept
- gold salts
20
Q
MOA of rituximab
A
anti-CD20 Ab
21
Q
MOA of anakinra
A
IL-1 receptor antagonist
22
Q
MOA of tocilizumab
A
IL-6 receptor antagonist
23
Q
MOA of leflunomide
A
pyrimidine antagonist (similar to methotrexate)
24
Q
MOA of abatacept
A
inhibits T-cell activation
25
MOA of biological agents (infliximab, adalimumab, etanercept)
block TNF-a
26
what could be added if methotrexate alone fails?
biological agents (infliximab, adalimumab, etanercept)
27
patient being treated with hydroxychloroquine, should get?
regular eye exams
28
adverse effect of sulfasalazine
bone marrow suppression
29
adverse effect of gold salts
nephrotic syndrome
30
what is the role of steroids in RA?
- BRIDGE to DMARD therapy
| - to treat acutely ill pt with severe inflammation
31
name the seronegative spondyloarthropathies (4)
1. ankylosing spondylitis
2. reactive arthritis
3. psoriatic arthritis
4. juvenile rheumatoid arthritis
32
characteristics of seronegative spondyloarthropathies
- RF NEGATIVE
- predilection for SPINE
- sacroiliac joint INVOLVEMENT
- association with HLA-B27
33
- young male, less than 40 yoa
- back stiffness, worse at NIGHT, relieved by LEANING FORWARD
- kyphosis = diminished chest expansion
ankylosing spondylitis
34
rare findings in ankylosing spondylitis
- uveitis
- aortitis
- restrictive lung disease
35
best INITIAL test for ankylosing spondylitis
CXR
36
MOST ACCURATE test for ankylosing spondylitis
MRI of SI joint
37
treatment for ankylosing spondylitis
- NSAIDs
- biological agents (infliximab/adalimumab)
- sulfasalazine
38
- asymmetric arthritis with h/o URETHRITIS, or GI INFECTION
- fever
- fatigue
- weight loss
- circinate balanitis
- conjunctivitis
- keratoderma blenorrhagicum
reactive arthritis
39
diagnostic triad for reactive arthritis
1. knee (joint)
2. pee (urinary)
3. see (eye)
- h/o Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter
40
treatment for reactive arthritis
reactive arthritis
41
- h/o psoriasis
- sacroiliac spine involvement
- nail pitting
- DIP involvement
- dactylitis ("sausage-shaped" digits)
- enthesis (inflammation of tendon insertion sites)
psoriatic arthritis
42
diagnostic test for psoriatic arthritis
NONE
43
best INITIAL treatment for psoriatic arthritis
NSAIDs
44
treatment for RESISTANT psoriatic arthritis
methotrexate
45
other treatment for psoriatic arthritis
infliximab
46
- fever
- salmon-colored rash
- polyarthritis
- lymphadenopathy
- myalgias
- hepatosplenomegaly
- elevated transaminases
juvenile rheumatoid arthritis (JRA)
47
diagnostic test for JRA
NONE
48
characteristic diagnostic tests for JRA
- very high ferritin
- elevated WBCs
- NEGATIVE RF
- NEGATIVE ANA
49
treatment for JRA
NSAIDs
50
treatment for JRA unresponsive to NSAIDs
steroids
51
treatment for JRA with persistent symptoms
methotrexate, or anti-TNF medications
52
- diarrhea
- fat malabsorption
- weight loss
whipple disease
53
MOST COMMON PRESENTING SYMPTOM OF WHIPPLE DISEASE
JOINT PAIN
54
MOST SPECIFIC test for whipple disease
bowel biopsy showing PAS positive organisms
55
- morning stiffness LESS THAN 30 MINUTES
- CREPITUS on moving joints
- DIP joints
osteoarthritis (OA)
56
name of DIP osteophytes in OA
Heberden's nodes
57
name of PIP osteophytes in OA
Bouchard's nodes
58
best INITIAL test for OA
joint XR
59
diagnostic tests that should be ordered for OA
- ANA
- ESR
- RF
- anti-CCP Ab
60
treatment for OA
acetaminophen
61
how many criteria for systemic lupus erythematosus (SLE) are there, and how are needed to confirm the diagnosis?
- 11
| - 4 NEEDED TO CONFIRM DIAGNOSIS
62
diagnostic criteria for SLE
1. malar rash
2. discoid rash
3. photosensitivity rash
4. oral ulcers
5. arthritis
6. serositis
7. kidney d/o
8. neurological d/o (seizures/psychosis)
9. blood d/o (anemia/leukopenia/lymphopenia/thrombocytopenia)
10. anti-DNA, anti-Smith, or anti-phospholipid Abs
11. ANA
63
best INITIAL test for SLE
ANA
64
MOST SPECIFIC test for SLE
anti-dsDNA Ab, or anti-Smith Ab
65
what is the best to follow the severity of a lupus flare-up?
complement levels (drop), and anti-dsDNA Ab (rise)
66
the presence of anti-Ro, or anti-SSA Abs is a risk for development of?
heart block
67
joint XR finding in SLE
normal
68
type of anemia in SLE
ACD is more common than hemolysis
69
only test MORE specific for lupus than anti-dsDNA Ab
anti-Smith Ab
70
other findings in SLE NOT part of diagnostic criteria
- fatigue
- hair loss
- antiphospholipid syndrome
- elevated sedimentation rate
71
treatment for ACUTE FLARE in SLE
steroids
72
treatment for joint pain in SLE
NSAIDs
73
treatment for rash and joint pain NOT responding to NSAIDs
hydroxychloroquinolone
74
treatment for SEVERE DISEASE UPON CESSATION OF STEROIDS for SLE
- belimumab
- azathioprine
- cyclophosphamide
75
MOA of belimumab
inhibits B cells
76
treatment for nephritis in SLE
- steroids and mycophenolate, OR
| - steroids and cyclophosphamide
77
MOA of mycophenolate
inhibits B- and T-lymphocyte proliferation
78
MOA of cyclophosphamide
alkylates and crosslinks DNA
79
MCC's of drug-induced lupus
- hydralazine
- procainamide
- isoniazid
80
drug-induced lupus ALWAYS has
- anti-HISTONE Ab
| - POSITIVE ANA
81
drug-induced lupus NEVER has
renal, or CNS involvement
82
complement level, and anti-dsDNA Ab are what in drug-induced lupus?
NORMAL
83
- women (9:1 female predominance)
- dry eyes
- dry mouth
- "sand under eyelids"
- loss of taste and smell
- loss of teeth at an early age
Sjogren's syndrome
84
MOST ACCURATE test for Sjogren's syndrome
lip biopsy
85
other diagnostic test for Sjogren's syndrome
Schirmer test (paper held to eye to test lacrimation)
86
serologic testing for Sjogren's syndrome
- ANA (95% +)
- RF (70% +)
- anti-Ro/SSA Ab (50-65% +, but specific)
- anti-La/SSB Ab (30-65% +, but specific)
87
treatment for Sjogren's syndrome
- pilocarpine
- cevimeline
(keep eyes and mouth moist)
88
MOA of pilocarpine, and cevimeline
increase acetylcholine
| cevimeline is specific to salivary glands
89
- woman with tight, fibrous thickening of skin
- tight, immobile fingers (sclerodactyly)
- Raynaud's phenomenon
- digital ulceration
- joint pain (mild and symmetrical)
scleroderma (systemic sclerosis)
90
lung involvement in scleroderma
fibrosis and pulmonary hypertension
| leading cause of death
91
GI involvement in scleroderma
- esophageal dysmotility
| - PBC (primary biliary cholangitis in 15% of patients)
92
heart involvement in scleroderma
restrictive cardiomyopathy
93
renal involvement in scleroderma
may lead to malignant hypertension
94
diagnostic test for scleroderma (systemic sclerosis)
- NO single diagnostic test
- ANA
- anti-topoisomerase Ab (anti-Scl 70)
95
treatment for scleroderma
NO treatment (no treatment is effective in stopping it)
96
treatment for renal involvement and HTN in scleroderma
ACEI
97
treatment for pulmonary HTN in scleroderma
- bosentan (endothelin antagonist)
- prostacyclin analogs
- sildenafil
98
treatment for Raynaud's phenomenon in scleroderma
CCB
99
treatment for GERD in scleroderma
PPI
100
treatment for lung fibrosis
cyclophosphamide
101
CREST syndrome (limited scleroderma)
- Calcinosis of fingers
- Raynaud's
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
102
diagnostic testing for CREST syndrome
anti-centromere Ab
103
thickened skin that looks like scleroderma, WITHOUT:
- hand involvement
- Raynaud's
- heart, lung, or kidney involvement
- MARKED EOSINOPHILIA
- "orange peel" (peau d'orange)
- symptoms are worse with exercise
eosinophilic fasciitis
104
treatment for eosinophilic fasciitis
steroids
105
- cannot get up from seated position
- muscle pain and tenderness
- PROXIMAL muscle weakness
- signs of muscle inflammation
polymyositis
106
- muscle pain and tenderness
- PROXIMAL muscle weakness
PLUS
- Gottron's papules (metacarpophalangeal joint surfaces)
- heliotrope rash (periorbital purplish rash)
- Shawl sign (shoulder/neck erythema)
dermatomyositis
107
tests for polymyositis and dermatomyositis
CPK and aldolase
108
MOST ACCURATE test for polymyositis and dermatomyositis
muscle biopsy
109
the presence of anti-Jo 1 Abs is a risk for development of?
interstitial lung disease
110
MC serious complication of PM/DM
malignancy
111
treatment for PM/DM
steroids
112
- women, with muscle aches and stiffness with TRIGGER POINTS on palpation and nonrefreshing sleep
- depression, and anxiety
fibromyalgia
113
blood tests for fibromyalgia
ALL NORMAL
114
what objective evidence is there for fibromyalgia?
NONE
115
best INITIAL treatment for fibromyalgia
- milnacipran
- duloxetine
- pregabalin
116
- patient 50 years or older
- profound pain, and stiffness of proximal muscles
- stiffness worse in morning
- elevated ESR
polymyalgia rheumatica (PMR)
117
on presentation, all forms of vasculitis can have
- fatigue, malaise, weight loss
- fever
- skin lesions
- joint pain
- neuropathy (mononeuritis multiplex)
118
common laboratory features in all forms of vasculitis
- normocytic anemia
- elevated ESR
- thrombocytosis
119
MOST ACCURATE test for all forms of vasculitis
biopsy
120
best INITIAL treatment for all forms of vasculitis
steroids
121
if steroids are not effective, what alternate treatment and/or additional treatment can used for all forms of vasculitis
- cyclophosphamide
- azathioprine/6-mercaptopurine
- methotrexate
122
adverse effect of methotrexate
liver, and lung fibrosis
123
PAN features:
- abdominal pain
- renal involvement
- testicular involvement
- pericarditis
- HTN
124
best INITIAL test for PAN
abdominal vessel angiography
125
MOST ACCURATE test for PAN
skin, muscle, or sural nerve biopsy
126
treatment for PAN
prednisone and cyclophosphamide
127
PAN does NOT affect what?
LUNGS
128
is found in 30% of PAN
hepatitis B
129
name the vasculitides (7)
1. polyarteritis nodosa (PAN)
2. Wegener's granulomatosis (granulomatosis with polyangiitis)
3. Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
4. temporal arteritis (giant cell arteritis)
5. Takayasu's arteritis
6. cryoglobulinemia
7. Behcet disease
130
Wegener's granulomatosis (granulomatosis with polyangiitis)
- UPPER AND LOWER respiratory findings
| - c-ANCA
131
MOST ACCURATE test for Wegener's granulomatosis (granulomatosis with polyangiitis)
biopsy
132
treatment for Wegener's granulomatosis (granulomatosis with polyangiitis)
prednisone and cyclophosphamide
133
Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
- vasculitis
- EOSINOPHILIA
- ASTHMA
134
MOST ACCURATE test for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
biopsy
135
treatment for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
steroids
136
temporal arteritis (giant cell arteritis)
- headache
- jaw claudication
- visual disturbance
- scalp tenderness
- ASSOCIATED WITH POLYMYALGIA RHEUMATICA
137
MOST ACCURATE test for temporal arteritis (giant cell arteritis)
biopsy
138
treatment for temporal arteritis (giant cell arteritis)
steroids
139
- young Asian female
- diminished pulses
- TIA/stroke (from vascular occlusion)
Takayasu's arteritis
140
how is Takayasu's arteritis diagnosed?
aortic arteriography or MRA
141
- ASSOCIATED WITH HEPATITIS C
| - renal involvement
cryoglobulinemia
142
treatment if cryoglobulinemia is d/t hepatitis C
interferon and ribavirin
143
- Middle Eastern, or Asian ancestry
- oral AND GENITAL ulcers
- ocular involvement (uveitis, optic neuritis)
- hyperreactivity to needle sticks
Behcet disease
144
MOST ACCURATE test for inflamed joints
joint aspiration
145
best INITIAL test for septic arthritis
CELL COUNT
| gram stain only positive 50-60%
(can be as few as 20,000, but usually > 50,000-100,000)
146
WBC count in normal joint
less than 2,000
147
WBC count in inflamed joint (gout/pseudogout)
2,000-50,000
148
WBC count in infected joint
more than 50,000
149
- male with sudden onset, severe pain
- toe, or knee (red, swollen, tender)
- at night
gout
150
precipitants of gout attacks
- binge drinking alcohol
- thiazides
- nicotinic acid (niacin)
151
best INITIAL test for gout
arthrocentesis (joint fluid aspiration)
152
MOST ACCURATE test for gout
polarized light exam; shows NEGATIVELY BIREFRINGENT NEEDLES
153
best INITIAL treatment for ACUTE gouty attack
NSAIDs
154
if NSAIDs are insufficient, or CI, what should be used for treatment of ACUTE gouty attack
steroids
155
treatment for ACUTE gouty attack if NSAIDs and steroids cannot be used
colchicine
156
adverse effects of colchicine
- N/V
| - bone marrow suppression
157
what medication should NOT be started during an acute gouty attack?
allopurinol
158
management of prevention of gout attacks
- allopurinol
- weight loss and exercise
- febuxostat (if allopurinol is NOT tolerated)
- rasburicase/pegloticase (if allopurinol/febuxostat are not enough)
159
MOA of allopurinol
inhibits xanthine oxidase, decreasing uric acid production
160
adverse effects of allopurinol
- rash
- allergic interstitial nephritis
- hemolysis
161
MOA of febuxostat
inhibits xanthine oxidase
162
MOA of rasburicase/pegloticase
converts uric acid to allantoin, which can be excreted by the kidneys
163
- knee and wrist involvement
- NO toe involvement
- slow onset
- pt does NOT wake up with severe pain
- may have h/o hemochromatosis, hyperparathyroidism, acromegaly, or hypothyroidism
pseudogout
164
arthrocentesis shows what in Pseudogout?
POSITIVELY birefringent RHOMBOID-shaped crystals
165
best INITIAL treatment for pseudogout
NSAIDs
166
acute management for pseudogout if NSAIDs are ineffective
steroids
167
- swollen, red, immobile, tender joint
| - arthritic and prosthetic joints are at higher risk
septic arthritis
168
risk of septic arthritis based on abnormality
prosthetic joint > RA > OA > normal joint
169
etiology of septic arthritis
- Staphylococcus aureus (40%)
- Streptococcus (30%)
- GNR (20%)
170
in addition to culturing the joint, in disseminated gonorrhea you must also
PANculture all mucosal surfaces ( oropharynx, rectum, urethra, cervix)
171
best INITIAL test for septic arthritis
arthrocentesis: > 50,000 WBCs
172
MOST ACCURATE test for septic arthritis
culture (> 90% sensitive)
173
empiric treatment for septic arthritis
ceftriaxone and vancomycin
174
- asymptomatic
- may have pain, stiffness, aching, fractures
- bowing of tibias
- sarcoma arises in 1% of patients
Paget's disease of bone
175
if osteoLYTIC lesions, think
Paget's, or OP
176
if osteoBLASTIC lesions, think
metastatic prostate cancer
177
best INITIAL test for Paget's disease
AP level (elevated)
178
MOST ACCURATE test for Paget's disease
XR
179
other tests that should be ordered for Paget's disease
- urinary hydroxyproline
- serum Ca++ level (will be normal)
- serum phosphate level (will be normal)
- bone scan
180
treatment for Paget's disease of bone
bisphosphonates and calcitonin
181
what is a Baker's cyst?
posterior herniation of synovium of knee
182
Baker's cysts are seen in which patients?
OA, or RA with a SWOLLEN CALF
183
diagnostic testing for Baker's cyst
US to EXCLUDE DVT
184
treatment for Baker's cyst
- NSAIDs
| - steroid injection if needed
185
- pain on bottom of foot
- very severe in MORNING, better w/ ambulation
- resolves spontaneously over time
plantar fasciitis
186
- pain on bottom of foot
- more painful with use
- may have numbness of sole
- avoid boots/high heels
- may need steroid injection/surgery
tarsal tunnel syndrome
187
- painful burning sensation in INTERDIGITAL WEB SPACE between 3rd and 4th toes
- tenderness
- sharp, intermittent pain radiating toes that improves when shoes are removed
Morton's neuroma
