Rheumatology Part 2 Paulson (Exam 2)

Question 1

You see a patient with a chronic syndrome of generalized MSK pain often accompanied by fatigue, disordered sleep, cognitive problems, and psych problems. What is at the top of your DDx?

Answer 1

Fibromyalgia

Question 2

You see a 40yo female whose chief complaint includes finding things not typically painful to most people, painful to her. You suspect she has allodynia, which is a symptom of what rheumatic disease process?

Answer 2

Fibromyalgia

Question 3

Your 40 year old female patient complains of chronic pain and stiffness involving all 4 quadrants of the body. She describes it as worst around the neck, shoulders, low back, and hips. She also has problems sleeping, feels fatigued often, has HAs, anxiety, dry mouth, bladder symptoms, tinnitus, and TMJ. You suspect she has fibromyalgia. What labs and imaging would you order?

Answer 3

Labs are generally of little benefit to making the diagnosis, but you could order CBC, ESR, CRP, and TSH

Question 4

While examining your 50 year old female patient, who you suspect has fibromyalgia, you apply 4kg/cm2 of pressure to 9 different points on her body. Generally describe the location of these 9 places.

Answer 4

Anterior:
Neck
Second costrochondral junction
2cm distal to the lateral epicondyle of humerus
At the prominence of the greater trochanter of the femur
At the medial fat pad of the knee
Posterior:
Insertion of the sub-occipital muscle
Mid upper trapezius 
Origin of the supraspinatus
Upper outer quadrant of the buttock

Question 5

While inspecting your 30yo female patient, who you suspect has fibromyalgia, she indicates positive pain in 9 of the 18 tender points. Is this enough to diagnose fibromyalgia?

Answer 5

Negative, you need 11/18

Question 6

While palpating the 9 areas of tenderness on a 20 yo female with a history of trauma, who you suspect has fibromyalgia, what control locations that you palpate should not be painful?

Answer 6

Thumb, mid-forearm, forehead

Question 7

When thinking of treatments for your 45yo female patient with fibromyalgia, what meds should you avoid prescribing?

Answer 7

Opioids
Corticosteroids
NSAIDs

Question 8

While coming up with a treatment plan for your 35 yo female patient with fibromyalgia, what 5 classifications of meds would be appropriate to prescribe?

Answer 8

TCA’s (ex: nortriptyline, but not if SI suspected)
Muscle relaxants (ex: cyclobenzaprine, tizanidine)
SNRI’s (ex: duloxetine aka Cymbalta)
SSRI’s (ex: fluoxetine aka Prozac)
Anticonvulsants (ex: pregabalin aka Lyrica, or gabapentin aka Neurontin)

Question 9

Your 48 year old female patient who comes from a low SES, is unemployed, suffers from depression, and has a BMI of 40 complains of pain in all 4 quadrants of her body and is positive for tenderness in 16 of 18 points. She clearly meets the requirements for a dx of fibromyalgia. You prescribe her prozac and refer her to psychiatry for CBT. Despite your best efforts, she has had minimal or no improvement in symptoms despite a variety of treatment modalities. What else can you try?

Answer 9

Referalls to pain management, PT, Rheumatology, massage/acupuncture, however, most patients seem to do well with close PCP follow-up

Question 10

Your white 55yo female comes in with a CC of pain and stiffness of the hips and shoulders. What should be at the top of your DDx?

Answer 10

Polymyalgia Rheumatica PMR

Question 11

Your elderly white female patient with PMR also complains of HAs, jaw claudication, and visual symptoms. What should you be worried about?

Answer 11

Giant Cell Arteritis GCA

Aka Temporal Arteritis

Question 12

Your elderly white female patient with polymyalgia rheumatica is at risk for having Giant Cell Arteritis GCA because of what social history factor?

What comorbidity can actually decrease risk of GCA?

Answer 12

Smoking increases risk

Diabetes decreases risk

Question 13

Your elderly white female with polymyalgia rheumatica and giant cell arteritis has her blood drawn. What polymorphism of alleles could be detected?

Answer 13

HLA-DR alleles

Question 14

Your elderly white female patient with PMR and GCA has painful shoulders and hips. What 2 kinds of cells would you find in her joints causing inflammation?

Answer 14

Lymphocytes and monocytes

Question 15

Your elderly, Scandinavian, female patient has the classic symptoms seen with giant cell arteritis: headache, jaw claudication (high assoc. w/ GCA), and amaurosis fugax (temp vision loss). She looks “ill overall.” You see pallor and edema of the optic disc with scattered cotton-wool patches and small hemorrhages on fundoscopic exam. What is the pathophysiology behind GCA, and what vessels does it commonly effect?

Answer 15

Pathophys: infiltration of inflammatory cells into vessels causing vasculitis

most common sites: thoracic aorta, large cervical arteries (neck), and branches of the external carotid arteries (such as the temporal branch)

Question 16

Your 60yo Northern European female patient complains of shoulder and hip pain and stiffness in the morning and also after an activity. Her pain worsens with movement. She has an impaired range of motion. What is at the top of your ddx?

Answer 16

Polymyalgia rheumatica

Question 17

What labs would you expect to be elevated with PMR and GCA? What is usually normal?

Answer 17

elevated: ESR (<20 is normal, >100 is bad)and CRP

Normal: WBC

Question 18

Your 57yo white female patient with suspected polymyalgia rheumatica PRM and giant cell arteritis GCA needs a diagnosis. How do you diagnose each?

Answer 18

PMR: clinical

GCA: temporal artery biopsy is gold standard

Question 19

Your elderly white female patient who you suspect has polymyalgia rheumatica needs some drugs. You, being the awesome drug dealer you are, decide to give her muscle relaxers and opiods. Just kidding. What is the appropriate tx for PMR vs GCA? Hint: same drug, different doses

Answer 19

Polymyalgia rheumatica isn’t life threatening, so give low dose prednisone 15mgPO QD (normal starting dose is 10-20mg. If no improvement after 7 days, titrate up to 30mg)

Giant cell arteritis can cause vision loss. Begin high dose steroids/prednisone 40-60mg PO daily. Once controlled (usually 2-4 weeks) start tapering by 10% every 1-2wks (will need to be on prednisone for months). Flares are common. Increase prednisone during flare by 10mg.

Question 20

Does polymyalgia rheumatica cause chronic damage to shoulders and knees?

Answer 20

No, many pts have a self-limiting course. Most morbidity is related to long-term steroid use

Question 21

What life-threatening associations come along with giant cell arteritis?

Answer 21

MI, CVA, permanent blindness, and PVD

Question 22

Your 30 yo asian female patient presents to the clinic complaining of claudication, cool extremities, arthralgia, skin lesions, dyspnea, and angina pectoris. She tells you that about a year ago she was trouble with constitutional symptoms of fever, fatigue, weight loss, and headache and chronic pain, but she hasn’t sought medical help until now. You do a workup and discover she has an elevated ESR/CRP, mild anemia, and low albumin. What is at the top of your ddx?

Answer 22

Takayasu arteritis (TA)

Question 23

Your young asian female patient with Takayasu Arteritis (TA) is worried about her health. What do you tell her about the arteries that are most affected by this diesease?

Answer 23

Chronic vasculitis mostly affecting the aorta and main branches: brachiocephalic, left common carotid, left subclavian

Question 24

You complete a PE for your young female asian patient with Takayasu Arteritis TA. What are some things that stand out to you?

Answer 24

BP differential (usually at least 10mmHg)
Diminished, asymmetrical arterial pulses in arms, legs
Bruits

Question 25

You’re a baller primary care PA and decide to order imaging for your young female asian patient with Takayasu Arteritis. What do you see?

Answer 25

Arterial luminal narrowing or occlusion with wall thickening

Question 26

You want to order some meds for your young asian female patient with Takayasu Arteritis. What do you choose?

Answer 26

Glucocorticoids
Specifically high dose steroids
Prednisone 45-60mg PO Qam initially
Taper when symptoms controlled/improved
Many need chronic steroids

Question 27

If meds don’t work on your young female asian patient with Takayasu arteritis, how would you intervene surgically?

Answer 27

PTCA (percutaneous transluminal coronary angioplasty)
Bypass grafting
Aortic repair

Question 28

A 30yo male presents to your clinic after suffering from a GI/GU infection with diarrhea or urethritis 1-4 weeks prior. He complains of arthritis in his right knee and left ankle. He also complains of fatigue and weight loss. You notice he has conjunctivitis and anterior uveitis. You examine his penis and note balanitis (inflammation of skin at tip of penis). You look at his lips/mouth and note stomatitis with ulcerations. You look at his feet and note keratoderma blennorrhagicum (resembles psoriasis). What is at the top of your ddx?

Answer 28

Reactive Arthritis (ReA) aka Reiter’s syndrome (Nazi doctor)

Question 29

Your young male patient who just recovered from an STI comes in with asymmetric joint pain in his right knee and left ankle. You suspect Reactive arthritis (ReA) so you order bloodwork. The lab calls you and tells you he has a specific gene correlated with ReA. What is it?

Answer 29

HLA-B27

Question 30

Your young male patient with an HLA-B27 gene and recently recovered from shigella infection presents to the clinic with asymmetric arthritis. What labs might be elevated, and what would you see if you did an aspiration of his knee synovial fluid?

Answer 30

May have elevated CRP/ESR

Synovial fluid has elevated WBC, mostly neutrophils, but won’t have the causative organism

Question 31

You decide to treat your young male patient with an STI for the underlying infection. What else would you prescribe for arthritis treatment?

Answer 31

NSAIDs
If no response, intraarticular glucocorticoids (triamcinolone)
PO glucocorticoids (prednisone)
DMARD (methotrexate or sulfasalazine)

Question 32

What do you tell your young male patient with a previous STI and current asymmetric arthralgia about the prognosis?

Answer 32

Most pts have self-limiting disease that typically lasts 3-5 months

Question 33

Your middle-aged female presents with dry eyes (keratoconjunctivitis sicca) and xerostomia (dry mouth). What should be at the top of your ddx?

Answer 33

Sjogren’s syndrome

Question 34

Your middle aged female patient with dry eyes and mouth presents to your clinic. On PE you note a strawberry tongue, enlarged parotid gland, and decaying teeth. You suspect Sjogren’s syndrome. What 2 HLA genes are associated with Sjogren’s?

Answer 34

HLA-DQ and HLA-DB

Question 35

What is the pathophys of Sjogren’s?

Answer 35

Lymphocytic infiltration into salivary and lacrimal glands

Question 36

What is the name of the test used in Sjogren’s to show decreased tear production?

Answer 36

Schirmer: hold tape measure to eye for 5 minutes

Question 37

What are the names of the two tests for Sjogren’s that shows decreased salivary production?

Answer 37

Saxon test: chew sponge and measure saliva

sialometry: spit into tube and weigh

Question 38

Your middle-aged female patient comes in with dry eyes and mouth. You suspect Sjogren’s. What 4 labswould be positive?

Answer 38

ANA
Anti-Ro
Anti-La
RF

Question 39

What was long considered the gold standard for diagnosis of Sjogren’s?

Answer 39

Salivary gland bx

Question 40

Your middle-aged female patient with suspected Sjogren’s needs treatment. How would you treat her for her oral, and for her ocular issues?

Answer 40

Oral: artificial saliva, drink water, sugar free gum and hard candies, regular dental visits, aggressive mouth care
Cevimeline: saliva production stimulant

Ocular: regular use of artificial tears every 2-4hrs
Ocular cyclosporine (immunosuppressive drug)
Punctal occlusion/plugs

Question 41

You treated your middle aged female patient with suspected Sjogren’s for her dry eyes and mouth, but she has systemic manifestations as well. How would you treat these?

Answer 41

Immunosuppressive therapy:
Hydroxycholorquine
Methotrexate

Question 42

When do you refer your middle-aged female patient with suspected Sjogren’s to rheumatology?

Answer 42

If she has systemic signs and symptoms

Or if ocular dryness not responding to artificial tears

Question 43

A 59yo female with a 20pack year hx of smoking presents to your clinic with insidious onset of symmetric swelling of many joints that are tender and painful. Specifically, she states her PIP, MCPs, wrists, ankles, knees, and MTPs are affected most. She has morning stiffness for about 45min-60min each morning. You note ulnar deviation of MCP and a swan neck deformity of the DIP and PIP. She also reports fatigue and weight loss. You note subcutaneous nodules in her elbows. What should be at the top of your ddx?

Answer 43

Rheumatoid arthritis

Question 44

A 70yo male with a SHx of 50pack years of smoking presents to your clinic with symmetric joint swelling of the MCP, PIP, and MTPs. You suspect RA. You order labs. What gene is reported by lab?

Answer 44

HLA-MHC

Question 45

Your 80yo male patient with a SHx of smoking presents with all the sxs of RA. You are also worried about Felty syndrome, so you think to yourself, “Santa! I know him!” What symptoms are you worried about with RA Felty syndrome?

Answer 45

Splenomegaly
Anemia
Neutropenia
Thrombocytopenia
Arthritis (Rheumatoid)

Question 46

You ordered labs on your old smoker patient with RA, Harold Felty Rheuman. You see that he is positive for HLA-MHC. What three labs might you expect to be positive?

Answer 46

Anti-CCP antibodies (most specific for RA; assoc w/ aggressive disease)
Rheumatoid Factor (assoc w/ more sever disease)
Elevated ESR/CRP

May see mild anemia, thrombocytosis, mild leukocytosis

Question 47

Harold Felty Rheumatoid first presented to your clinic at age 60 with soft tissue swelling and osteopenia around joints in the wrist and feet. Now, at age 80, what do you expect to see on his radiographs?

Answer 47

Joint space narrowing and erosions

Question 48

MRI’s are more sensitive than radiographs at detecting early RA, but is US?

Answer 48

Yes

Question 49

To make your diagnosis of RA for Harold Felty Rheuman you need inflammatory arthritis in at least how many joints?
And for how long must this disease process be active?

Answer 49

> =3 joints

> =6 weeks

Question 50

You want to treat Harold Felty Rheuman for his RA, so you decide to order some pretreatment screening. You order baseline CBC, Cr, LFTs, ESR, and CRP. What other bloodwork results do you need?

Answer 50

Hep B and C (methotrexate can cause hepatotoxicity)
Latent TB (TNF inhibitor med you prescribe can activate it)

Question 51

Because you really know your shit, you decide to prescribe your RA patient Harold Felty Rheuman some drugs. You prescribe PRN NSAIDs. What two other drugs should you prescribe?

Answer 51

DMARD (anti-rheumatic drug)
Corticosteroid (as a bridge while starting a DMARD then taper off)
-Prednisone 5-20mg/day depending on severity

Question 52

You decide to place Harold F. Rheuman on a DMARD, methotrexate, for his RA. You start him on 10mg of prednisone to bridge treatment. What is your normal starting dose of MTX?

Answer 52

7.5mg PO weekly (max dose 20-25mg/wk)
Usually no improvement within 2-6 weeks
Contraindicated in pregnancy, liver disease, heavy alcohol use, severe renal impairment

Question 53

Once you’ve started Howard F. Rheuman on MTX, what other OTC supplement should you have him take 1mg of PO daily?

Answer 53

Folic acid

Question 54

You want to prescribe your RA patient Howard F. Rheuman TNF inhibitors. They are expensive, but he can afford them. He’s been screened for latent TB and was negative. What is the name of the TNF inhibitor med you prescribe?

Answer 54

Etanercept

Question 55

T/F: Pam Beasley and Jim Halpert were the perfect couple?

Answer 55

True

Question 56

Speaking of Pam, PAN, or Polyarteritis nodosa, is a systemic necrotizing vasculitis that usually affects what sized muscular arteries?

Answer 56

Medium or small muscular arteries

Question 57

Polyerteritis nodosa, the systemic necrotizing vasculitis that usually affects medium or small sized muscular arteries, can affect any organ, but what 6 are most commonly affected? What 1 organ system is usually spared in PAN?

Answer 57

SKIN
Muscle
Peripheral nerves
Kidneys
GI tract
Heart

Lungs are spared

Question 58

Your patient, Patrick P. Pandemic, is a male, aged 40-60, with Hep B. He reports fatigue, arthralgias, weight loss, pain in the extremities, lower extremity ulcerations, subcutaneous nodules, and palpable purpura. His bloodwork shows renal insufficiency and he is hypertensive. He holds his belly and says he just ate and has abdominal pain (intestinal angina). You check his EKG and he’s having an MI. You check his LE’s and notice he can’t hold his foot up (foot drop). To say the least, this guy is having a bad day. What is at the top of your DDx?

Answer 58

Polyarteritis nodosa PAN

Question 59

Your polyarteritis nodosa PAN patient, Patrick P. PANdemic wants to know about his disease. What do you explain to him about the pathophys of PAN?

Answer 59

Some cases assoc w/ Hep B/C (secondary PAN)
The inflamed wall of the vessel thickens and lumen narrows, ergo, less blood flow, making a thrombus (blood clot) more likely, as well as ischemia or infarction of tissue. Inflammation of the vessels can also weaken the walls and result in an aneurysm. The veins are not involved

Question 60

Your polyarteritis nodosa patient, Patrick P. PANdemic needs labwork. What do you expect to find?

Answer 60

Elevated CRP/ESR
May have elevated LFT’s (hepatic impairment)
May have elevated Cr (kidney impairment)
Anemia from the narrowed vessels causing hemolytic anemia
CK may be elevated (creatine kinase)

Question 61

You tell your polyarteritis nodosa patient Patrick P. PANdemic that you need to get what test done to have a difinitive diagnosis?

Answer 61

Biopsy of an involved organ
Report will state, and I quote, “Necrotizing inflammation of medium-sized arteries.”
Angiogram will have “rosary sign” due to many small aneurysms

Question 62

To diagnose Patrick P. PANdemic with polyarteritis, you need how many of the following symptoms present?

1. Wt loss > 4kg or 9lbs
2. Mottling of skin aka Livedo reticularis
3. Testicular pain or tenderness
4. Myalgias, weakness, or leg tenderness
5. Mononeuropathy or polyneuropathy
6. Diastolic BP > 90mmHg
7. Elevated BUN >40 or Cr > 1.5
8. Hep B virus
9. Arteriographic abnormality
10. Biopsy of small or medium-sized artery containing PMNs

Answer 62

3/10

Question 63

So, your polyarteritis nodosa (PAN) patient, Patty P. PANdemic, needs some treatment from PA Feelgood. What are you going to prescribe him?

Answer 63

If he has Hep B/C, treat with anti-viral
If it’s mild, corticosteroids alone (high dose steroids: prednisone 1mg/kg daily; taper after 4 weeks if improved)
If resistant to steroids, use MTX, azathioprine
If it’s mod-severe: high dose steroids as above + immunisuppressant (cyclophosphamide)

Question 64

Pat PANdemic wants to know what his prognosis is. What do you tell him, gently?

Answer 64

Poor prognosis with 10% 5 year survival w/o tx, but with tx, like he’s receiving, 80% chance of remission