Rheumatology Flashcards
tx for Lower back pain from lubosacral strain
NSAIDs
when do you do a MRI for back pain?
Positive SLR + low back pain + sensory deficits *no sensory deficits = no MRI
back pain + super high ESR + fever + point tenderness dx?
Spinal cord abscess (often s.aureus)
back pain, bowel/bladder dysfunction, bilateral leg weakness and saddle anesthesia. dx? tx?
cauda equina sy. tx: steroids + surgical decompresssion
tx of Sciatica?
NSAIDs > stretches > steroids
Felty Syndrome
RA + Splenomegaly + neutropenia
Caplan Syndrome
RA + Pneumoconiosis + lung nodules
MCC of death in ppl with RA?
CAD
if your gonna operate on someone with RA what must you do first? why?
cervical XR looking for C1/C2 subluxation
Rheumatoid Arthritis(RA) dx criteria
4+ of the following: 1. morning stiffness lasting >1hr 2. wrist and finger involvement(MCP, PIP) 3. swelling of at least 3 joints 4. symmetric involvement 5. rheumatoid nodules 6. XR abnormalities showing erosions/joint space narrowing/periarticular osteoporosis w/erosions 7. +RF (70% specific) or + anti-CCP(>80% sen. 95% specific) 8. CRP or ESR elevation
anemia in RA? why?
anemia of chronic dz, normal MCV
tx of RA
NSAIDs + DMARD(methotrexate > infliximab > hydroxychloroquine(check eyes often))
Seronegative Spondyloarthropathies what are they? why they called that?
PAIR = Psoriatic Arthritis, Ankylosing Spondyylitis, Idiopathic Juvenile RA, Reactive Arthritis *called that bc negative Rheumatoid factor
what are all the Seronegative Spondyloarthropathies assocaited wiht…
negative RF, usually involve the spine, sacroiliac joint involvement, HLA B27, Uveitis
Ankylosing Spondylitis sx? dx? tx?
SX: young male <40, spin or back stiffness worse 1st thing in the AM - improves wth movement, relieved by leaning forward +/- arthritis, bamboo spine, uveitis(30%), restrictive lung dz(2-15% due to spinal shit)
DX: XR showing fusion of sacroiliac joints, squaring of the lumbar vertebrae, “bamboo spine”
TX: w/NSAIDs + exercise as well with TNF inhibitors
Reactive Arthritis sx?tx?
cant see cant pee cant climb a tree! * urethrits, GI infection, fever, weight loss, fatigue, arthritis, conjunctivitis, tx: NSAIDs
Psoriatic Arthritis sx? tx?
nail pitting, DIP involvment = pencil in cup, sausage-shaped digits, enthesis(inflammation @ tendon insertion sites) tx: NSAIDs > methotrexate
Idiopathic Juvenile Rheumatoid Arthritis(JRA) sx? tx?
>6wks joint pain, fever(>104), salmon-colored rash, polyarthritis, lymphadenopathy, myalgias, splenmegaly, pericardial effusions, high ferritin, anemia of chronic dz, elevated WBC, negative RF & ANA tx: NSAIDs > steroids
kid with JRA what must you do for him?
EYE EXAM EVERY YEAR TO LOOK FOR UVEITIS
whipple dz sx? tx?
whipple dz Dude with joint pains, diarrhea, fat malabsorption, weight loss, bowel bx shows PAS + shit. tx: TMP/SMX
Osteoarthritis(OA) sx?
morning stiffness <30 min, crepitus, DIPS involved, Heberdens nodes(DIPS), Bouchards(PIPs)
OA dx?
Xray joint + low leukocytes <2k
tx of OA
acetaminophen
Rotator cuff tear/tendonitis/frozen sx
tear = weakness tendonitis = pain on abduction and external rotation + pt tenderness frozen = ^ + decreased ROM
patellofemoral Syndrome sx? tx?
imbalance of quads strength or menisal tear. due to trauma = pain in front of knee behind patell when walking up or down stairs, crepitis, joint locking, worse after moveing from sitting for awhile tx: PT
Systemic Lupus Erythematousus(SLE) dx criteria?
4 of: 1. Skin: malar rash, photosensitivity, Oral ulcers, discoid rash 2.Arthralgias 3. blood: leukopenia, thrombocytopenia, hemolysis 4. Renal: benign proteinuria to ESRD(membranous GN) 5. cerebral: behavior change, stroke, seizure, meningitis 6. Serositis: pericarditis, pleuritc chest pain, pulmonary HTN, Pneumonia, myocarditis 7. Serology: ANA(95% sen), DS-DNA(60% sen but more specific 70%)
How can you differentiate a SLE flare vs another illness like pneumonia?
complement levels drop(C3) and Anti-ds DNA rises in flares
Antiphospholipid syndrome PTT & PT
elevated PTT, normal PT and normal INR
antiphospholipid syndrome mixing studies
*mixing with APL = no change in PTT; if due to factor deficiency it would return to normal. *Russel Vipor Venom Test(RVVT) - prolonged and doesnt correct with mixing
tx of antiphosphoplipid syndrome?
heparin then warfarin
Sjogren’s Syndrome sx?
ab to lacrimal glands and salivary glands +/- vasculitis, lung dz, pancreatitis, RTA, dysparenia(pain w/intercourse) *dry eyes, drye mouth, sand under eyes and dental carries
Sjogren Syndrome dx?
- Schirmer test = paper to eye to show decreased wetting 2. lip bx 3. ANA +, RF +
tx of Sjogren syndrome?
moisturizers, Pilocarpine for eyes & Cevimeline = increases the rate of saliva production
ab positive with systemic scleroderma?
anti-topoisomerase = Scl-70
ab positive in CREST scleroderma?
anti-centromere ab
CREST Scleroderma
Calcinosis of fingers, Raynauds, Esophageal Dysmotitlity, Sclerodactyly, Telangiectasia
Eosinophilic Fasciitis sx? tx?
inflammation of the fasia under the skin = thick skin taht can look like scleroderma + “orange peel” appearance. will see EOSINOPHILIA(not seen in scleroderm) *worse with excise tx: steroids
whats the same between polymyositis and dermatomyositis?
both: proximal M weakness(difficulty rising from chair) & muslce inflmmation(pain + tenderness) dermato: DERM SHIT! = Gottrons papules(scales over fingers), Heliotrope rash, Shawl Sign(shoulder and neck erythema)
dx & Tx of poly/dermatomyositis?
elevated CPK, elevated aldolase, abnormal electromyogram(EMG) tx: steroids
anti Jo-1 is associated with…
poly/dermatomyositis + increased risk of intersitial lung dz with both these
what will labs look like in fibro?
all normal!
sx of fibromyalgia?
muscle aches and stiffness with trigger points/point tenderness on palpation and nonrefreshing sleep *depression and anxiety are common
tx of fibro
exercise > SSRI, TCA(amitriptyline)
Polymyalgia Rheumatic(PMR)
sx? ESR? Tx?
SX: >50 yoa profound pain and stiffness on the proximal muscles such as shoulders and pelvic girdle. worse in the morning and is localized to the muscles rather than to the joints + associated with GCTA. Often have difficult time getting out of chair or raising arms over head.
ESR > 100
TX: low dose steroids w/long taper, typically improves by day 2-4 w/steroids.
Common lab finding with all vasculitisissss
normocytic anemai = chronic dz, elevated ESR, thrombocytosis
Polyarteritis Nodosa(PAN) sx? tx?
fatigue, malaise, weight loss, feer, skin lesions = purpura rash, joint pain, neuropathy(mononeuritis multiplex) + abdomainl pain(worse with eatting), renal involvement, testicular involvment, pericarditis, HTN, lower extremeity ulcers tx: prednisone + cyclophosphamide
common findings with all vasculitis list some commonvasculitis
fatigue, malaise, weight loss, feer, skin lesions = purpura rash, joint pain, neuropathy(mononeuritis multiplex) -PAN, Wegners, Churg-Strauss, GCTA, Takayasu, Henoch-Sclone purpura, Cryogloulinemia, Behcet dz,
Wegener’s granulomatosis sx? tx?
C dz! = CANCA, UR+ LR findsing, + kidney + otitis dx = bx tx: steroids + cyclo
Churg-Strauss Syndrome
aka allergic angiitis = PANCA, Vasculitis, Eosinophilia & asthma
Giant Cell Temporal Arteritis
sx? tx?
SX: fever weight loss fatigue, jaw claudication, visual sx, HA, scalp tenderness/pain when brushing hair, decrease pulses in arm, aortic regurge, central retinal artery occlusion(acute loss of vision, curtain over eyes, cherry red spot)
TX: HD steroids 1st & taper over 1-2 months, then bx – this is bc blindless can often be permanent
Takayasu Arteritis
arteritis of the aorta = different pulses n shit
Cryoglobulinemia
vasculitis + fatigue, malaise, skin lesions, joint pain & ASSOCIATED WITH HEPATITIS C = TX HEP C AND WILL GO AWAY
Behcet Disease sx? tx?
oral/genital ulcers, middle eastern ppl/asian, ocular involvment(uveitis, optic neuritis), skin lesions = pathergy = hyperreactivity to mild skin trauma, CNS disease tx: prednisone and colchicine
Gout birefringent?
negative needles
tx of gout
NSAIDS, steroids then colchicine within 1st 24 hrs or as preventative *allopurinol for prevention only do not use as acute tx
Calcium Pyrophosphate (Pseudogout) birefringent? what is this associated with?
positive rhomboid *hyperparathyroidism & hemochromatosis **usually effects big joints
Carpel Tunnel Syndrome nerve? whats the tunnel?
median nerve trapped under felxor retinaculum
Tinel & Phalen sign
tinel = pain when tapping median nerve phalen = pain with wrists at 90 degrees *carpel tunnel syndrome
Dupuytren Contraction
hyperplasia of palmer fascia leading to nodule formation and contraction of 4-5th digits
what is dupuytren contraction associated with?
alcohol, cirrhosis
tx of dupuytren contraction
Triamcinolone > surgery
Plantar Fasciitis vs Tarsal Tunnel Syndrome
PF: tenderness at insertion, sever in morning, imporves with walking, tx NSAIDs will resolve TTS: more painful with use, like carpel tunel of foot, tx avoid high heels, may need steroids, may need surgery
baker’s cysts dx? tx?
posterior herniation of the synovium of the knee, usually seen with RA or OA; dx w/ U/S tx: NSAIDs or steroids
Morton Neuroma sx
painful burning senation in the INTERDIGITAL WEB SPACE BETWEEN THE 3rd and 4th toes, tenderness when pressure is applied, shap intermitten pain radiating nto the toes that feels better with shoes off
Pulmonary complications see with patient with Polymyositis?
patients with polymyositis can also develop a number of pulmonary complications, including interstitial lung disease (ILD), infection (due to immune suppressive therapy), drug-induced pneumonitis (eg, methotrexate pneumonitis), and respiratory muscle weakness. ILD is especially common in patients with a positive anti-Jo-1 antibody, and can be identified on high-resolution CT imaging as ground-glass opacities, reticular changes, honeycombing, or patchy consolidation. Pulmonary function tests (PFTs) should be performed to distinguish ILD from respiratory muscle weakness and will show decreased forced vital capacity, total lung capacity, and diffusing capacity. Initial management of ILD in patients with polymyositis is similar to treatment of the underlying polymyositis with systemic glucocorticoids and corticosteroid-sparing agents, but ILD may progress despite improvement in myopathic features.
Which ab is associated with drug induced lupus?
antihistone antibody
Libman-sacks endocarditis what is it?
deposits of immune complexes on edge of valve or valve ring
ALS always spars……1st sx is usually……
ALS preserves ocular motility, sensory, bowel, bladder and cognitive functions preserved even with advanced disease. *early sx are oral dysfunction and asymmetric weakness.
ALS tx
Riluzole - glutamate inhibitor, prolong survival and delays need for a tracheostomy
What labs to monitor disease severity in SLE?
ds DNA & Compliment
26 yo M w/low back pain x8m that has progressivly worsened. Pain is worse in the AM & improves throughout the day. Dad has back problems as well. Limited ROM of lumbosacral spine, reduced chest expansion. testing to dx? monitoring? what should you advise this pt to avoid?
XR sacroiliac joint to look for sacroiliitis = ankylosing spondylitis *can monitoring with repeat XR q3m or acute phase reactants like ESR *AVOID smoking! pt limited chest expansion likely to develop into restrictive lung dz with apical pulmonary fibrosis - smoking will only worsen. Also exercise improves function without worsening disease =) *no change in life expenctancy
Sarcodosis vs Scleroderma sx?
*Sarcoidosis:GRUELING-CC Granulomas, rheumatoid arthritis, uveitis, erythema do some, lymphadenitis, interstitial fibrosis, negative PPD, gamma globe anemia, increase calcium, cardiac problems
*Scleroderma - systemic sclerosis/collagen deposits(anti scl-70(diffuse) & anti-centromere ab(CREST)) = CREST: Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly & Telangiectasias
Sarcodosis vs Scleroderma sx?
*Sarcoidosis:GRUELING-CC Granulomas, rheumatoid arthritis, uveitis, erythema do some, lymphadenitis, interstitial fibrosis, negative PPD, gamma globe anemia, increase calcium, cardiac problems
*Scleroderma - systemic sclerosis/collagen deposits(anti scl-70(diffuse) & anti-centromere ab(CREST)) = CREST: Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly & Telangiectasias
Best HTN medication for scleroderma induced HTN? why?
ACEi = Captopril (fast onset), counters ACE induced vasoconstriction causing Vasodilation efferant > afferent arteriols. can cause transient increase in Cr but long term is beneficial
Polymyositis Sx, age range, labs? Vs hypothyroid myopathy?
polymyositis, including progressive, painless proximal muscle weakness with elevated muscle enzymes (eg, creatine kinase, transaminases) and inflammatory markers (eg, C-reactive protein). Polymyositis is an inflammatory myopathy triggered by unknown, possibly viral, antigens. Peak incidence occurs at age 40-50. Proximal muscle weakness typically manifests as difficulty climbing stairs, getting into or out of a low chair or car, or working with the arms overhead (eg, combing hair). Joint pain (as in this patient) or swelling may be present. Polymyositis can also involve the upper esophageal musculature, leading to dysphagia with regurgitation and aspiration. Dermatomyositis is a similar disorder, but with characteristic skin manifestations. Most patients have detectable autoantibodies (eg, antinuclear antibody, anti-Jo-1). Definitive diagnosis is established on muscle biopsy. Polymyositis and dermatomyositis may occur as paraneoplastic syndromes, so patients should undergo careful examination and age-appropriate screening tests. Hypothyroid myopathy is a common cause of muscle weakness and can be associated with creatine kinase elevation. However, it is typically also associated with myalgias, delayed reflexes, and other symptoms of hypothyroidism. This patient has an elevated TSH consistent with subclinical hypothyroidism, but his thyroxine level is normal.
what would you see on an XR of a hand with gout?
normal in early disease, punched out = rat bite lesions at joints
When should u order an XR of the spine?
when u suspect OM, cancer, fracture or ankylosing spondylitis or those who fail to improve with initial therapy after 2-4 weeks of conservative therapy
Most low back pain will improve within — weeks.
6 weeks
