Rheumatology, MSK, Skin Flashcards
What is the typical age presentation for ankylosing spondylitis?
20 - 40 years of age
What are the common clinical presentations of ankylosing spondylitis?
lower back pain, enthesitis, dactylitis, and extraarticular manifestations include restricitive lung disease and uveitis
What is the diagnosis for ankylosing Spondylitis?
MRI for acute presentation and X-ray for late presentation
Schober test less than 5cm is an indication of positive test for ankylosing spondylitis.
What is the treatment for ankylosing spondylitis?
NSAIDs for acute flares and if the treatment is refractory then we consider TNF inhibitors.
A patient with a history of psoriasis presents with joint pain serum studies are drawn what antigens do you expect to find in the blood?
Keep in mind that psoriatic arthritis is a seronegative arthropathy and thus even though HLA-B27 is associated with disease we typically don’t see it in the serum
What is the diagnosis of psoriatic arthritis?
Labs like the ESR and CRP will be elevated and RF and CCP are negative and a history of psoriasis or a family history
What are the joints most associated with psoriatic arthritis?
Knee, Ankle, and DIP
What is a definitive extraarticular manifestation of psoriatic arthritis?
Onycholysis (nail changes)
Is a manifestation of psoriatic arthritis. Called the pencil in cup deformity. Remember that the spondyloarthropathies are inflammatory disorders and therefore have the opportunity to destroy the joints.
What is the treatment for psoriatic arthritis?
First line is to start NSAIDs (diclofenac, ketorolac, aspirin, etc). Second line would be DMARD’s and we usually start with methotrexate or sulfasalazine. If those are not effective treatment then we move to TNF-a inhibitors.
What are the side affects of steroids?
bone fractures, psychosis, hypercalcemia
If you suspect that joint pain occurs do to an inflammatory bowel disorder what are the labs that you can draw?
Fecal Calprotectin and CRP
What is the most common bug to cause reactive arthritis?
Chlamydia, also consider gram negative organisms like salmonella, shigella, Yersinia, campylobacter and C. Diff
How does reactive arthritis usually present?
The patient typically presents with a viral infection 1-4 weeks before arthritic symptoms . Even though the infection is cleared. It’s because of the molecular mimicry that there is a residual reaction. I can’t, see I can’t pee I cant bend my knees.
Keratoderma blennorrhagica
What joints does pseudogout most commonly affect?
Larger joints like the knee
What is the finding on arthrocentesis of the joint in a patient with pseudogout ?
Calcium pyrophosphate crystals with rhomboid shape and positively birefringent
What is a common X-ray finding of pseudogout?
Chondrocalcinosis seen in cartilage and ligaments
What are the X-ray findings in gout?
Well-defined punched-out erosion with a thin rim of calcification.
What is the treatment for pseudogout?
NSAIDs, colchicine, and steroids if either is ineffective or contraindicated
What are the ways in which we end up with high levels of uric acid?
Either we produce to much or we don’t excrete it effectively (kidneys)
What is the presentation of gout/pseudogout?
Patients develop acute onset of joint pain that is severe.
What medications increase the risk of formation of uric acid stones?
Thiazides and loop diuretics, also aspirin
This is showing uric acid crystals
What is tophaceous gout?
This the chronic accumulation of urate crystals in the soft tissue
What is the contraindication to using Probenicid?
Patients with kidney disease
When should we start prophylactic gout attack medication?
2-4 weeks after an acute gout attack
What are the ways in which septic arthritis may be acquired?
Hematogenous, contiguous spread, and direct inoculation.
What is migratory arthritis?
There is inflammation of joints resolution and joint inflammation will start somewhere else.
What are common causes of migratory arthralgias?
SLE, rheumatic fever, lyme disease, DGI, Reactive arthritis
What are the most common risk factors for septic arthritis?
Rheumatoid arthritis and osteoarthritis
What criteria can we use to estimate the likely hood of septic arthritis?
Kocher test
In addition to antibiotic therapy what should be the next step in treatment for septic arthritis?
The patient should have joint drained
What is the classic triad for disseminated gonococcal infection?
Polyarthralgia, vesiculopustular rash, tenosynovitis
If you suspect a patient has DGI what test is necessary to confirm Nisseria gonorrhea (hint: the same test is used to diagnose chlamydia)
NAAT
When should we suspect a patient has tuberculosis arthritis?
If they are coming from an endemic area, infection with TB, immunocompromised, malnutrtion or alcholic
What are the diagnostic testing studies that would confirm a patient had TB arthritis?
Tuberculin skin test, IGRA and a synovial biopsy that shows granulomas.
This autoimmune arthritis typically upon waking in the morning takes only a few minutes to resolve?
Osteoarthritis
This autoimune disorder takes several minutes to hours to resolve upon waking in the morning.
Rheumatoid arthritis
_____ and _____ nodes are present in patients with osteoarthritis?
Herbden and Bouchard
What are the X-ray and PE findings of osteoarthritis?
Xray shows joint space narrowing, osteophytes, subchondral calcinosis and even joint effusions. PE shows crepitus
What is the treatment for osteoarthritis?
Acetaminophen is the first line treatment, NSAIDS are the second line, followed by steroids, consider joint replacement if no therapies are helpful.
What are the antibodies for RA?
anti- CCP (citrulinated peptide), Anti- RF which is very non-specific
What are the antibodies for systemic sclerosis that is diffuse
anti- scl-70
What are the antibodies for mixed connective tissue disease
anti-URNP
What are the antibodies for partial systemic sclerosis?
anti-centromere
What are the antibodies for sjorens?
ant- Ro (SSA) and anti-La (SSB)
What are the antibodies in dermatomyositis and polymyositis?
anti- Jo and anti- ANA
What are the antibodies in SLE?
Anti- dsDNA, anti-smith, and ANA
What are the joints affected in rheumatoid arthritis?
metatarsal, wrist, PIP,
What is the treatment for RA?
Methotrexate is the first line, and sulfazalzine and methotrexate would be the second line, TNF inhibtors, surgery is an option for very severe presentations.
What is the diagnostic work up for Sjorens?
Schrimer test and check serology for anti-Ro anti-La (SSA and SSB), and biopsy of the lip if necessary.
What are the criteria that we use in order to diagnose SLE?
What is the treatment for SLE?
hydoxychlorquine, steroids, immunosupressives
What is the complication to the kidney of a patient with SLE?
Nephritic or nephrotic syndrome; this is the most common cause of morbidity and mortality in SLE and thus kidney function studies should always be checked.
What are the antibodies that we can see in phospholipid syndrome?
anti b2, anti-cardiolipin, anti-phospholipid
When should you start a work up for a patient that you may suspect to have anti-phospholipid syndrome?
- multiple incidences of vascular thrombosis, or at least 1 miscarriage after 10 weeks or
What are complication that are we concerned about developing in SLE?
Libmann sac endocarditis (SLE–>LSE), nephrotic syndrome of the kidneys, seizure, sychosis, stroke (TIA), state- hypercoagulable.
What is the criteria to diagnose SLE?
There must be at least 4 of the 11 of SOAP BRAIN MD
What does SOAP BRAIN MD stand for?
Serositis, oral ulcers, Arthritis, Photosensitivity, Blood pathologies Renal anomalies, ANA (+), immunoglobulin (dsDNA and Smith) Malar, Discoid
What is the immunoglobulin for drug induced lupus?
anti-histone
What are the drugs that cause drug induced lupus?
HIPPE (hydralazine, isoniazid, phenytoin, procainamide, entancercept
What are the concerning compliations of RA?
Cervical joint instability, and an increased risk for osteoporosis. Less important, but RA can also be associated with the development of a Baker’s cyst.
What is Felty syndrome?
RA + neutropenia +splenomegaly
What is the clinical presentation of systemic juvenile arthritis?
Still too FAST, usually presents in patients that are <35 yoA
Still = Still’s disease
Too = 2 weeks of fever spikes
F = Fever
A = arthritis
S = Skin rash (salmon-red/pink colored), Splenomegaly, Serositis
T = Tender lymphadenopathy
Boutnierre is a manifestation of RA
What are common side affects of methotrexate?
Bone marrow suppresion (leucvorin for saving), pulmonary fibrosis, and hepatoxcity.
What are common complications of Sjorens?
Dental caries , dysphagia, and the formation of MALT lymphomas
What are the treatments for Sjoren’s?
Artifical tears, saliva. Cholinergic agents like pilocarpine and cevlimine
What is the workup for SLE?
If patient has any of the features of “SOAP BRAIN MD,” NSIDx is serum ANA (which is the screening test). If ANA is positive, NSIDx is anti-Smith and anti-dsDNA antibodies (these antibodies are specific to SLE, but not sensitive).
____ drugs are absolutely contraindicated in patients that have active SLE?
OCP’s
______ and _____ should be screening in pregnant patient because antibodies can cross the placenta and cause neo-natal lupus and congenital heart block.
SLE (ANA) and Anti-RoLa
Patients with a history of phospholipid syndrome should receive what medications durging pregnancy?
Heparin and low dose Aspirin
What are complication of systemic sclerosis or scleroderma?
CREST: calcinosis, Raynaud/Renal, Esophageal dysmotility, scleordactly, and teleangectasia
Interstitial lung disease which leads to pulmonary HTN (cor pulmonale) this is the most common cause of death in this disease, restrictive cardiomyopathy, and renal crisis.
What is the diagnostic work up for Dermatomyositis?
Creatnine kinase levels, then anti- Jo serology, electromyography, and then muscle biopsy
Myasthenia gravis: ______
Dermatomyositis: _________
Lambert-Eaton:__________
MG: thymoma
Dermato/poly: Malignancy
LAMBE: small cell
Charcot’s foot presents with reduced angle of the arch, osteopenia, osseous fragmentation, new bone formation, and subluxation or dislocation
In Paget’s disease is the osteolytic or osteoblastic phase more predominate?
Osteoclastic
What is pes ansurine bursitis?
This is inflammation of the bursa located antero-medially on the tibial surface. Risks for inflammation are increased with overuse
What are common causes of pseudogout?
hyperparathyroidism, hemochromatosis, hemosiderosis, hypothyroidism and wilsons disease
What are common risk factors for osteoporosis?
age 65>, smoking, first degree relatives with fractures, RA, chronic steroid use, colle’s fracture, and vertebral compression fracture.
What are the risk factors for avascular necrosis?
CHAOS; chronic steroid therapy, HIV, alcoholism, organ transplantation, sickle cell disease and SLE
What is the clinical presentation of Paget’s disease?
Symptomatic presentation is usually due to bony deformities causing nerve impingement (e.g., hearing loss, radiculopathic symptoms), morphological changes (increased hat size) or due to pathological fractures.
What is a life threatening complication of Paget’s disease?
high output cardiac failure due to venous malformation and osteosarcoma
E.G MODE is a pneumonic to help remember where cancers localize in the bone.
Epiphysis; Giant cell, Metaphysis osteosarcoma, and Diaphysis is Ewing
Tenderness in the lateral elbow with Hx of repetitive wrist extension movements?
lateral epicondylitis
Tenderness in medial elbow with history of frequent wrist extension
medial epicondyltits
Duptyrens
Tight waxy skin in the palmar area with nodularities.
Extension of fingers is limited due to subcutaneous fibrosis and contracture of palmar fascia. Fourth and fifth fingers are most commonly involved. Risk factors include HIV,diabetes, and alcoholism
Stenosing flexor tenosynovitis
Hand is routinely in a flexed position which results in difficulty extending.
Tenderness in anatomic snuff box area. Passive flexion of thumb may exacerbate pain
Dequarvein tenosynovitis
Superficial cystic nodules that can be tender. MC location is the extensor surface of wrist and hand joints.
Ganglion cyst
Intermittent or persistent neuropathic pain, sweating, and redness of involved extremity. Livedo reticularis (vague purplish net-like rash) can be seen in affected extremities. In chronic cases, X-ray can reveal osteopenia of bones in the involved area.
Complex Regional Pain Syndrome (aka Reflex Sympathetic Dystrophy)
Percussion over the posterior tibial nerve elicits pain, parathesia, foot numbness.
Tarsal tunnel syndrome
Pain that is reproduced with medial-lateral squeezing of the calcaneus
Calcaneal stress fracture
Swelling and tenderness on palpation of 2-6 cm proximal to tendon insertion.
Achilles tendinopathy
A patient presents to your clinic with pain along the bottom of their foot, it is exacerbated when the patient dorsiflexes and flexes the toes. X-ray findings are unremarkable. What’s the diagnosis and what can we r/o based on the history?
Plantar fasciitis, based on the fact that the X-ray is unremarkable we can rule out bone spur, which are typically found in the proximal fascia.
What’s the difference between tendonopathy and calcaneal apophysitis?
Calcaneal apophysitis is usually found in children and adolescents that are active. Although tendonopathy does also occur in active patient usuaully you can illlicit a burn like sensation or pain 2-6 cm from the insertion of the tendon.
What is patellofemoral syndrome
Diagnosis of exclusion, we don’t really know what the etiology is but some risk factors include trauma, muscle imbalance, and mal-alignment. Pt induce pain on a loaded and flexed knee (running, stairs, etc)
When are X-rays indicated in an ankle injury?
What are the risk factors for femoral fractures?
age >65, osteoporosis
How would we treat a femoral neck fracture?
Because the femoral head doesn’t have a very strong vascular supply lack of blood supply can lead to avascular necrosis, maluninion, femoral degeneration. With this being such a delicate fracture open reduction, internal fixation (pins), and hemiarthroplasty (prosthetic hip joint)
What is the pathology behind Pagets’s disease
Osteoclasts are dysfucntional and overstimulated, thus breaking down a lot of bone, there is mild osteoblastic function as well.
What are typical lab values for Paget’s disease?
Elevated ALK phos, PINP, and hydoxyproline. Normal levels of calcium and phosphorous.
What is the treatment for symptomatic Paget’s disease?
Biphosphonate
Positive ANA and positive anti-histone is specific for what disease?
Drug induced lupus
anti-topoisomerase is the same as what antibody?
Scl-70
What are the risk factors for OA (osteoarthritis)
age >40, DM, excessive alcohol intake and joint stress
A patient with chronic cough, use of a proton pump inhibitor for severe GERD, and sensitive to temperature. What is a possible pathology you are considering?
Scleroderma
What is the difference between shin splints (medial tibial stress syndrome) and stress fractures
Usually shin splints are associated with novice athletes and there is diffuse tenderness. The patient who has stress fractures will have point tenderness
A hip dislocation should be reduced in less than ____ hours otherwise we are concerned of osteonecrosis of the femoral head.
6 hrs
What is the next step in management of this patient?
This is osteochondroma they are benign osteophytes that typically grow at the metaphysis. The occur in skeletally immature kids. The osteophytes stop growing when bone growth has haulted. Treatment for this patient would be observation.
Straight leg test, tests for what?
Radicular pain, The pain should be a shooting electrical shock down the leg. If the pain is dull and achy then it’s not a positive sign.
Bone pain that is worse at night, relieved with NSAIDs, and not related to increased activity.
Osteoid osteoma
Bone pain that is worse with activity, is not relieved by NSAIDS, presents in long bone diaphysis in children
Ewing Sarcoma
What’s the age presentation for Ewing sarcoma?
14-15
Bone pain with imaging showing sunburst and codman’s triangle?
Osteosarcoma
What is the acute treatment for gout?
Colchicine
