Rheumatology, Orthopedics and Sports I Flashcards
Adverse hematologic effects associated with methotrexate use include […] and pancytopenia.
Adverse hematologic effects associated with methotrexate use include macrocytic anemia and pancytopenia.
macrocytic anemia likely secondary to folate depletion
All patients with polymyositis/dermatomyositis should be screened for […].
All patients with polymyositis/dermatomyositis should be screened for occult malignancy.
most commonly ovarian, lung, pancreatic, stomach, or colorectal cancers, or non-Hodgkin lymphoma
Common causes of lumbar stenosis include vertebral […], degenerative disk disease, and thickening of the ligamentum flavum.
Common causes of lumbar stenosis include vertebral osteoarthritis, degenerative disk disease, and thickening of the ligamentum flavum.
How do the following laboratory values change in patients with osteoporosis?
Serum calcium: […]
Serum phosphorus: […]
Alkaline phosphatase: […]
Urine hydroxyproline: […]
How do the following laboratory values change in patients with osteoporosis?
Serum calcium: No change
Serum phosphorus: No change
Alkaline phosphatase: No change
Urine hydroxyproline: No change
How do the following laboratory values change in patients with Paget disease of bone?
Serum calcium: […]
Serum phosphorus: […]
Alkaline phosphatase: […]
Urine hydroxyproline: […]
How do the following laboratory values change in patients with Paget disease of bone?
Serum calcium: No change
Serum phosphorus: No change
Alkaline phosphatase: Increase
Urine hydroxyproline: Increase
most common cause of asymptomatic alkaline phosphatase elevation in older patients
Hydroxyproline is a major component of the protein collagen, comprising roughly 13.5% of mammalian collagen. Hydroxyproline and proline play key roles for collagen stability. They permit the sharp twisting of the collagen helix.
Osteoporosis is defined with a DEXA scan T-score […].
Osteoporosis is defined with a DEXA scan T-score -2.5.
i.e. > 2.5 standard deviations below the mean for a young adult at peak bone density
Routine monitoring of which organ is necessary for patient’s being treated with long-term hydroxychloroquine?
Eyes
patient’s should have a baseline ophthalmologic evaluation with annual reassessment after 5 years of treatment
Sclerosis of what organ is the most common cause of death in scleroderma?
Lungs
causes interstitial fibrosis and pulmonary hypertension; second most common cause is kidney involvement (sclerodermal renal crisis)
Spondyloarthropathies associated with HLA-B27 may be remembered with mnemonic “PAIR”:
P: […]
A: […]
I: […]
R: […]
Spondyloarthropathies associated with HLA-B27 may be remembered with mnemonic “PAIR”:
P: Psoriasis
A: Ankylosing spondylitis
I: Inflammatory bowel disease
R: Reactive arthritis
Spondyloarthropathies often result in inflammation at sites of […], leading to gradual onset of low back pain and progressive stiffness.
Spondyloarthropathies often result in inflammation at sites of tendon/ligament insertion (enthesitis), leading to gradual onset of low back pain and progressive stiffness.
pain classically improves with activity or exercise
Synovial fluid analysis in patients with gout is characterized by […]-shaped crystals made of monosodium urate, that are […]-birefringent.
Synovial fluid analysis in patients with gout is characterized by needle-shaped crystals made of monosodium urate, that are negatively-birefringent.
i.e. yellow when lying parallel to polarized light
Synovial fluid analysis in patients with gout is characterized by needle-shaped crystals made of […], that are negatively-birefringent.
Synovial fluid analysis in patients with gout is characterized by needle-shaped crystals made of monosodium urate, that are negatively-birefringent.
i.e. yellow when lying parallel to polarized light
Synovial fluid analysis in patients with pseudogout is characterized by […]-shaped crystals made of calcium pyrophosphate dihydrate, that are […]-birefringent.
Synovial fluid analysis in patients with pseudogout is characterized by rhomboid-shaped crystals made of calcium pyrophosphate dihydrate, that are weakly positively-birefringent
i.e. blue when lying parallel to polarized light.
Synovial fluid analysis in patients with pseudogout is characterized by rhomboid-shaped crystals made of […], that are weakly positively-birefringent.
Synovial fluid analysis in patients with pseudogout is characterized by rhomboid-shaped crystals made of calcium pyrophosphate dihydrate, that are weakly positively-birefringent.
i.e. blue when lying parallel to polarized light
Systemic sclerosis is often characterized by […] peristalsis and […] tone in the lower esophageal sphincter on manometry.
Systemic sclerosis is often characterized by decreased peristalsis and decreased tone in the lower esophageal sphincter on manometry.
due to atrophy/fibrosis of smooth muscle in the lower esophagus; decreased sphincter tone helps differentiate achalasia from SSc
Takayasu arteritis is associated with a […] pulse in the upper extremity.
Takayasu arteritis is associated with a weak or absent pulse in the upper extremity.
may be more pronounced in one extremity, resulting in pulse and/or blood pressure discrepancies
Takayasu arteritis may present with pain in the upper extremities that is […] with activity.
Takayasu arteritis may present with pain in the upper extremities that is worse with activity.
e.g. claudication; may be worse in one extremity than the other
Takayasu arteritis may present with pain in the […] extremities that is worse with activity.
Takayasu arteritis may present with pain in the upper extremities that is worse with activity.
e.g. claudication; may be worse in one extremity than the other
The initial management for patients with fibromyalgia includes a […], patient education, and good sleep hygeine.
The initial management for patients with fibromyalgia includes a regular exercise program, patient education, and good sleep hygeine.
medications (e.g. duloxetine, TCAs) are reserved for patients who fail initial measures
What antibodies are useful for confirming the diagnosis of Sjogren syndrome?
anti-SSA (Ro) or anti-SSB (La) antibodies
diagnosis requires evidence of dry mouth/eyes and evidence of the aforementioned antibodies or histologic evidence of lymphocytic sialoadenitis
What aortic complication is associated with giant cell (temporal) arteritis?
Aortic aneurysm
patients should be followed with serial chest X-rays
What arthritic disorder is associated with hematologic malignancies (e.g. polycythemia vera)?
Gout
due to increased cell turnover
What bladder complications are associated with long-term use of cyclophosphamide?
acute hemorrhagic cystitis and bladder carcinoma
increased fluid intake and MESNA are helpful in preventing complications
What demographic is classically affected by Takayasu arteritis?
young Asian females (< 40)
What imaging modality is initially used to diagnose ankylosing spondylitis?
X-ray (of sacroiliac joints)
classically shows narrowing of the sacroiliac joint space; another classic finding is fusion of vertebral bodies with ossification of intervertebral discs (bamboo spine)
What imaging modality is used to confirm the diagnosis of rotator cuff tear?
MRI
What initial imaging study is recommended for patients with erythema nodosum?
Chest X-ray
useful to evaluate for sarcoidosis and tuberculosis, which are both associated with EN; sarcoidosis patients may have no other symptoms
What is the first-line pharmacologic therapy for patients with fibromyalgia that do not respond to conservative management?
Tricyclic antidepressants (e.g. amitriptyline)
alternatives include SNRIs (e.g. duloxetine, milnacipran) and pregabalin for those not responding to TCAs
What is the first-line treatment for reactive arthritis?
NSAIDs
What is the initial DMARD of choice in patients with moderate-severe rheumatoid arthritis?
Methotrexate
What is the initial pharmacologic therapy for treatment of patellofemoral pain syndrome?
NSAIDs
additional management includes activity modification and strengthening exercises
What is the initial test that should be ordered in a patient with suspected SLE?
Antinuclear antibody (ANA)
very sensitive and cost-effective; more specific test (e.g. anti-dsDNA) can be ordered if ANA titers are elevated
What is the likely diagnosis in a construction worker that complains of his “hard hat being tighter”? CT head reveals thickened skull cortices with mixed lytic and osteoblastic lesions.
Paget disease of bone
due to disordered osteoclastic bone resorption
What is the likely diagnosis in a diabetic patient with a severely deformed foot? X-ray shows large osteophytes and several extra-articular bone fragments.
Charcot joint (neurogenic arthropathy)
loss of neurologic input results in trauma to weight-bearing joints, resulting in degenerative joint disease
What is the likely diagnosis in a middle-aged female that presents with dry mouth, oral thrush, dental caries, and dry eyes?
Sjogren syndrome
What is the likely diagnosis in a middle-aged patient with a history of sarcoidosis that presents with progressive hip pain for the past six weeks? The pain is worst with abduction and internal rotation.
Avascular necrosis (osteonecrosis)
secondary to chronic glucocorticoid use; X-ray is often normal (MRI is more sensitive)
What is the likely diagnosis in a middle-aged patient with recently diagnosed diabetes mellitus that presents with pseudogout and hepatomegaly?
Hereditary hemochromatosis
hereditary hemochromatosis is associated with pseudogout and should be suspected in a young patient that also has diabetes and hepatomegaly
What is the likely diagnosis in a middle-aged woman with fatigue and chronic widespread pain with focal areas of tenderness? Serum creatine kinase, ESR, and CRP are within normal limits.
Fibromyalgia
What is the likely diagnosis in a middle-aged woman with symmetrical proximal muscle weakness and mild muscle pain? Serum creatine kinase is elevated.
Polymyositis
significant pain/lack of weakness should prompt consideration of other diagnoses
What is the likely diagnosis in a patient that develops acute posterior calf pain/swelling while walking? Physical examination shows tenderness/induration at the medial head of the gastrocnemius and a crescent-shaped patch of ecchymosis at the medial malleolus.
Ruptured popliteal cyst
may resemble a DVT; before rupture, popliteal cysts present as a painless bulge in the popliteal space
What is the likely diagnosis in a patient that presents with arthralgias, fatigue, and painless, palpable purpura on the bilateral legs? Laboratory examination reveals elevated LFTs, evidence of glomerulonephritis, and low serum C4.
Mixed cryoglobulinemia syndrome
presents with fatigue, palpable purpura, arthralgias, renal disease, positive rheumatoid factor, elevated transaminases, and hypocomplementemia
What is the likely diagnosis in a patient that presents with back pain after carrying heavy packages? Physical exam reveals paravertebral tenderness.
Lumbosacral strain
most common cause of acute back pain
What is the likely diagnosis in a patient that presents with hand swelling/stiffness with skin thickening in the fingers (pictured below)? The patient also experiences Raynaud’s phenomenon.
Systemic sclerosis (Scleroderma)
What is the likely diagnosis in a patient that presents with painful oral ulcers and mildly elevated LFTs? She was recently diagnosed with rheumatoid arthritis and started on medical therapy.
Methotrexate side effect
What is the likely diagnosis in a patient that presents with right shoulder pain and weakness after falling on an outstretched hand? The pain/weakness is worst with abduction and external rotation of the humerus.
Rotator cuff tear
differentiated from rotator cuff tendinopathy by the presence of weakness with abduction/external rotation
What is the likely diagnosis in a patient with a history of lung cancer that presents with one month of low back pain, especially at night? Physical exam reveals local spinal tenderness at L4-L5.
Metastatic bone disease
classically presents with pain that is worst at night
What is the likely diagnosis in a patient with a history of painful arthritis in the fingers and feet that presents to the clinic with the skin findings below?
Tophaceous gout
What is the likely diagnosis in a patient with a history of recurrent pulmonary infections that presents with facial swelling, bilateral lower-extremity edema, hepatomegaly, and palpable kidneys? Urinalysis reveals 4+ proteinuria.
Secondary (AA) amyloidosis
facial swelling, lower extremity edema, and massive proteinuria are consistent with nephrotic syndrome
What is the likely diagnosis in a patient with a one-week history of fatigue and bilateral joint pain/stiffness for 10 - 15 minutes upon awakening? The patient’s ESR is within normal limits. She works at a day care center.
Parvovirus B19 infection
may present similar to rheumatoid arthritis in adults, however, it is more transient and there is less joint swelling
What is the likely diagnosis in a patient with back pain radiating to the buttocks and thighs? It is relieved when walking uphill or bicycling.
Spinal stenosis (“neurogenic claudication”)
diagnosis is made by clinical history and findings on MRI (e.g. narrowing of the lumbar canal)
What is the likely diagnosis in a patient with bilateral proximal muscle weakness? Physical exam reveals erythematous papules involving the dorsum of his fingers.
Dermatomyositis
erythematous rash represents Gottron papules; patients may also have a rash around the upper eyelids (heliotrope rash)
What is the likely diagnosis in a patient with difficulty rising from a seated position and climbing stairs? The patient also has a violaceous, periorbital rash.
Dermatomyositis
periorbital rash is referred to as a heliotrope rash
What is the likely diagnosis in a patient with elbow pain that worsens with arm extension and passive flexion of the wrist?
Lateral epicondylitis (“tennis elbow”)
due to non-inflammatory angiofibroblastic tendinosis at the common extensor origin
What is the likely diagnosis in a patient with joint pain/stiffness in the hands, especially in the DIP joints (pictured below)?
Psoriatic arthritis
classically involves the DIP joints and causes dactylitis (“sausage digit”) and nail pitting
What is the likely diagnosis in a patient with one day of unilateral knee pain/swelling? Laboratory examination reveals significant hypercalcemia.
Pseudogout (calcium pyrophosphate dihydrate deposition disease)
likely secondary to hyperparathyroidism; pseudogout is also seen with hypothyroidism and hemochromatosis
What is the likely diagnosis in a patient with two months of progressive left shoulder stiffness? The patient has markedly decreased passive and active abduction, flexion, and rotation of the left shoulder.
Adhesive capsulitis
characterized by stiffness out of proportion to pain and reduction in both active and passive ROM
What is the likely diagnosis in a postpartum patient with lateral wrist pain that is worst with ulnar deviation while grasping the thumb?
De Quervain tenosynovitis
classically affects new mothers who hold their infants with the thumb outstretched; due to inflammation of the abductor pollicis longus and extensor pollicis brevus tendons
What is the likely diagnosis in a young adult female with bilateral joint pain/swelling? Laboratory examination reveals pancytopenia and proteinuria.
Systemic lupus erythematosus (SLE)
joint involvement in SLE tends to be symmetric, migratory, non-erosive, and associated with brief morning stiffness (versus RA)
What is the likely diagnosis in a young adult female with stroke-like symptoms and a positive RPR test despite no clinical evidence of syphilis?
Anti-phospholipid syndrome
characterized by a thrombotic event or pregnancy morbidity in the setting of positive antibodies (e.g. antiphospholipid, anticardiolipin, or beta-2 glycoprotein-1); patients with APS may have a false-positive RPR due to cross-reactivity with anti-cardiolipin antibodies
What is the likely diagnosis in a young adult male that presents with diffuse enthesitis and lower back pain? The lower back pain is improved with activity.
Ankylosing spondylitis
What is the likely diagnosis in a young adult male that presents with knee pain and urethral discharge? The patient also complains of pain over the Achilles tendon and mouth ulcers.
Reactive arthritis
classically presents with a triad of conjunctivitis, urethritis, and arthritis (“can’t see, can’t pee, can’t climb a tree”); other findings include mucocutaneous lesions and enthesitis
What is the likely diagnosis in a young adult male with one month of shortness of breath, nonproductive cough, and fatigue? The patient is hypercalcemic and has bilateral hilar fullness on CXR.
Sarcoidosis
turns out sarcoidosis doesn’t exclusively effect young African American females
L4
- weakness of knee extension
- decreased patellar reflex
L5
- weakness of dorsiflexion
- difficulty heel walking
S1
- weakness on plantar flexion
- difficulty toe walking
- decreased Achilles reflex
