Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
141 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
Difference of non-inflammatory joint pain and inflammatory joint pain |
The presence of: redness, heat, and/or swelling
Typically with inflammatory joint pain there is MORNING stiffness. Pain associated with direct palpation of the joint line suggests non-inflammatory arthritis or a joint associated pathology (for example, meniscus injury). |
|
|
|
How to examine a knee effusion
|
Compress the suprapatellar bursa space while palpating the knee joint space.
|
|
|
|
Likely cause of joint pain with passive range of motion
|
Passive range of motion is defined as: the joint is rotated but the tendons are not actively engaged.
Joint pain upon passive range of motion suggest arthritic conditions. |
|
|
|
Joint pain with active range of motion causes
|
Active range of motion is defined as: in which the joint is immobilized why the patient tries to move the extremity. This suggests tendon pathology.
|
|
|
|
Describe monoarticular arthritis
|
Monoarticular arthritis refers to involving one joint.
Monoarticular arthritis is classified as acute or chronic. Acute monoarticular arthritis can be noninflammatory: Trumatic, hemarthrosis, internal derangement; Or inflammatory: crystalline or septic. Treatment of acute monoarticular arthritis: - joint ASPIRATION is needed to evaluate for infectious arthritis. Chronic inflammatory forms of monoarticular arthritis should raise concerns for mycobacterial, fungal, or Borrelia infection Chronic noninflammatory monoarticular arthritis is usually caused by osteoarthritis. |
|
|
|
Definition of oligoarthritis
|
Involvement of two or more joints
|
|
|
|
Polyarthritis definition
|
Involvement of more than 4 joints
|
|
|
|
Keratoconjunctivitis sicca
|
Means dry eyes.
It is the most common ocular condition in rheumatoid arthritis. |
|
|
|
Dupuytren contracture
|
It is a painless thickening and contracture of tissue beneath the skin on the palm of the hands and fingers.
Is commonly seen in diabetes. |
|
|
|
What causes ESR to be elevated?
|
Any condition in the body associate it with markedly elevated fibrinogen levels.
However conditions such as pregnancy, diabetes, and end stage kidney disease may produce falsely elevated ESR. |
|
|
|
What is CRP?
|
C-reactive protein is an acute phase reactant; therefore, in contrast to ESR, it is a direct measure of inflammation and responds more quickly to changing disease state.
|
|
|
|
What is complement?
|
Complement is an Intercal part of the immune response; it acts to augment inflammation and damage to invading organisms. Complement production and consumption increased during information; Consequently, most inflammatory states are associated with increased complement levels.
C3 and C4 are the commonly measured complement components. |
|
|
|
What to send a joint aspiration
|
Cell count and differential,
Gram stain and culture, Crystal analysis |
|
|
|
PML's suggestive of septic joint
|
Greater than 50,000.
Less than 2000 are usually associated with non-inflammatory etiologies. |
|
|
|
Instruments used to measure rheumatic disease activity, progression, and overall patient function
|
1. Health assessment questionnaire
2. Disease activity score |
|
|
|
Names of disease-modifying non-biologic anti-rheumatic drugs (DMARDs):
|
These drugs are immunosuppressive agents. Act by altering the underlying disease versus just treating symptoms.
-Methotrexate -Cyclophosphamide -Hydroxychloroquine, -Azathiprine -Sulfasalazine, -Leflunomide, -Cyclosporine Patients taking MTX should not consume alcohol and require regular assessment of liver function. MTX is highly teratogenic and abortifacient; this agent must be discontinued at least three months prior to pregnancy. Patients taking hydroxychloroquine are at risk for retinal toxicity and require baseline and follow up right now examinations. Patients taking leflunomide who plan to become pregnant who develop toxicity must discontinue the agent and undergo an eight day course of cholestyramine elimination therapy. Cyclophosphamide toxicities are common; careful monitoring for infection and bone marrow, liver, and bladder toxicity is mandatory. |
|
|
|
Names of BIOLOGIC disease-modifying antirheumatic drugs (DMARDs):
|
The work by targeting individual molecules such tumor necrosis factor. TNF is normally used by the body to produce inflammation and can cause joint destruction at excessive amounts. Tumor necrosis factor alpha inhibitors:
-Abatacept, -Rituximab, -Tocilizumab, -Ustekinumab, -Belimumab, -Interleukin 1 beta inhibitor Key points about these drugs: -Surveillance for latent TB with PPD or interferon gamma release assay is indicated prior to use of all biological agents. -Combination of immunomodulating biologic agents should be avoided; infection rates are significantly increased and there is minimal, if any, added efficacy. -Tumor necrosis factor alpha inhibitors in combination with MTX provide the most effective means to reduce rheumatoid arthritis symptoms and structural damage. -Tumor necrosis factor alpha inhibitors are effective in suppressing cutaneous and articular disease in psoriatic arthritis and in improving joint symptoms in patients with ankylosing spondylitis. |
|
|
|
Urate lowering medications for gout: |
Allopurinol,
Probenecid, Uricase, Febuxostat (Uloric) Because urate-lowering therapy may increase the risk of gout attacks for 3 to 6 months or longer after initiation, concurrent prophylaxis with an anti-inflammatory agent, most commonly colchicine is required |
|
|
|
Allopurinol side effects and precautions |
Sensitivity to allopurinol includes:
rash, Bone marrow failure, Hepatic failure, Steven Johnson syndrome Recent evidence suggests that this medication is safe in kidney disease it started at low dose and titrated with careful monitoring. |
|
|
|
Description of uloric
|
It is used in the treatment of gout. This agent is not a purine analog therefore appears to be safe in patients with allopurinol sensitivity.
It is also approved for use in patients with mild to moderate kidney failure. |
|
|
|
How probenecid works
|
It is used in the treatment of gout; particularly in patients who are documented under-excretors of uric acid.
This drug is ineffective in kidney disease. This medication may increase the risk of kidney stones; therefore patients taking it must stay aggressively hydrated. |
|
|
|
Describe rheumatoid arthritis
|
It is a systemic disorder of unknown cause in which chronic inflammation may need to joint destruction and disability. Joint damage occurs rapidly early in the disease course.
Patients with RA have a greater than average prevalence of CAD. Use of MTX and TNF-Alpha inhibitors can reduce the cardiovascular risk that occurs in these patients. Rheumatoid factor and anti-CCP antibodies are neither necessary nor sufficient to cause this disease. RF is absent and 30% of patients with rheumatoid arthritis. Rheumatoid factor is also present in up to 10% of healthy persons. Risk factors for RA: -Smoking, -Asbestos and silica exposure -Lower SES Diagnosis: -May start out as asymmetric oligoarthritis but becomes more symmetrical overtime. Symmetric polyarthritis involving small, medium, and large joints that is associated with prolonged (>60 minutes) morning stiffness. -MCP and PIP joints of the hands, wrists and feet are almost always affected. Treatment: -MTX is the gold standard. Leflunomide (Arava) may also be effective as initial monotherapy in addition to MTX. -Biologic disease-modifying antirheumatic drugs if remission of RA is not achieved and maintained on non-Biologics (DMARDs) |
|
|
|
Felty syndrome
|
It is an extra articular manifestation of rheumatoid arthritis.
Characterized by: Pancytopenia, Splenomegaly, Leg ulcers |
|
|
|
Osteoarthritis
|
Morning stiffness may occur, although it usually last less than 30 minutes.
Symptoms usually worsened with activity. Osteoarthritis of the hand typically leads to bony enlargement of the proximal interphalangeal joints with bone spurs that result in Bouchard and Heberden nodes. Treatment: -Acetaminophen can provide similar relief as NSAIDs, and should be considered first-line agents. -NSAIDs, If Tylenol is ineffective -Steroid injections but no more than 3 per year - Hyaluronic acid injections (only for mild to moderate OA) of the knee. Pain relief can last longer than steroid injections up to six months, and there are no limitations on repeat injections. They are most effective when injected into a dry joint after the effusion is drained. -Surgical joint replacement: The decision to undergo joint replacement surgery is based on the patient's symptoms and quality-of-life, rather then radiographic severity of osteoarthritis. |
|
|
|
Valgus |
Lateral joint-space narrowing (knocked knee)
|
|
|
|
Varus
|
Medial joint-space narrowing (bowlegged)
|
|
|
|
Describe diffuse idiopathic skeletal hyperostosis (DISH)
|
X-rays of DISH and ankylosing spondylitis have similarities; however, ankylosing spondylitis demonstrates vertical bridging syndesmophytes rather than flowing osteophytes that occur in DISH.
|
|
|
|
Eburnation
|
Deformation of joint surface
|
|
|
|
Proper use of a cane
|
1. The cane is placed in the hand contralateral to the symptomatic joint
2. The cane swings forward as the affected limb swings forward. |
|
|
|
Fibromyalgia
|
It is a central pain sensitivity syndrome.
Is characterized by widespread pain and tenderness in which sensory processing systems are altered, producing allodynia and hyperalgesia. Abnormalities in neuropeptide levels and abnormal functional neural imaging studies support the neurobiologic mechanism. It affects 2% of the US population and has female predominance. First-degree relatives of patient with fibromyalgia are more likely to have fibromyalgia, mood disorders, and migraines Symptoms, -Tenderness is generalized, classically more prominent at define tender points -It does not cause any other abnormalities on physical examination, routine laboratory testing or imaging. Treatment: -Nonpharmacological therapy is the cornerstone of treatment. Regular exercise, physical therapy -Lyrica and serotonin-norepinephrine reuptake inhibitor's (SNRIs); Cymbalta in patients with or without depression. -Narcotics should be avoided -NSAIDs usually ineffective unless used with SNRI. |
|
|
|
What is spondyloarthritis
|
This condition was formally known as seronegatives (negative rheumatoid factor) Spondyloarthropathies which include a spectrum of the inflammatory disorders:
-Ankylosing spondylitis, -Psoriatic arthritis, -Inflammatory bowel disease associated arthritis, -Reactive arthritis (formally known as Reiter syndrome) ESR and CRP are typically in the normal range. Testing: -A single anteriorposterior x-ray of the pelvis which provides a view of the sacroiliac joints and the hips. |
|
|
|
Ankylosing spondylitis
|
Approximately 95% of patients with this condition our HLA-B 27 positive.
Male predominance. Peak age onset between 20 and 30. Symptoms: -Progressive inflammatory back pain and stiffness. Initially localized low back, buttocks, and posterior thighs., but with time inflammation and bony changes usually asend the spine, producing a stooped posture with limited mobility of the spine and chest. Diagnosis: -Sacroiliac and hip x-rays may show "bamboo spine". Bringing osteophytes. -MRI if x-rays are negative Treatment: -NSAIDs (high dose) |
|
|
|
Psoriatic arthritis
|
It can affect up to 30% of patients with psoriasis.
Skin cell turnover and psoriasis may also increase the risk of gout. HIV infection is associated with an increase in severity, and should be suspected if severity of this condition increases. Signs: -Dactylitis, -Tenosynovitis, -Arthritis of the distal interphalangeal joints, -Asymmetric Oligoarthritis, -Spondylitis -Onycholysis |
|
|
|
Reactive arthritis
|
It is a POST infectious, aseptic inflammatory, arthritis that occurs in both men and women. Typically manifest within two months of infection.
Detection of pathogen such as chlamydia in patients with arthritis, urethritis and conjunctivitis, supports the diagnosis of reactive arthritis. Gastrointestinal and genitourinal tract infections are implicated in the development of reactive arthritis Classic triad: 1. Arthritis, 2. Ureteritis, 3. Conjunctivitis HIV infection is associated with an increase in severity, and should be suspected if severity of this condition increases. Treatment: -Nonsteroidal's, steroids -Sulfasalazine if above fails Pearls: It is usually self-limited and remits within six months without causing a erosive damage. |
|
|
|
Inflammatory bowel disease associated arthritis
|
It commonly involves the knee.
It usually occurs early in the course of the bowel disease and correlates with bowel inflammation and resolves without specific intervention or destruction to the joints. |
|
|
|
What is spondylarthritis
|
This condition was formally known as seronegatives (negative rheumatoid factor) Spondyloarthropathies which include a spectrum of the inflammatory disorders:
-Ankylosing spondylitis, -Psoriatic arthritis, -Inflammatory bowel disease associated arthritis, -Reactive arthritis (formally known as Reiter syndrome) ESR and CRP are typically in the normal range. Testing: -A single anteriorposterior x-ray of the pelvis which provides a view of the sacroiliac joints and the hips. |
|
|
|
Describe systemic lupus
|
Marked female predominance. Symptoms onset is most common during childbearing years.
2 to 3 times greater in non-white persons. The incidence of SLE has tripled over the last 40 years. Signs: -Mucocutaneous manifestations occur in 90% of patients - photosensitivity 66% -Butterfly rash 30% -MSK symptoms 90% Other organs and diseases affected by lupus: -Lupus nephritis. Should be started on steroids quickly. -Neuropsychiatric systemic lupus erythematosis: Headache, cognitive dysfunction, mononeuropathy, seizure, CVA -Pericarditis -Asymptomatic sterile vegetations (Libman sacks endocarditis) -CAD occurring early -Pleuritis Diagnosis: -Autoantibody tests are important, but do not make the diagnosis in the absence of typical clinical manifestations; -Specific autoantibodies: ANA, anti-double-stranded DNA, Anti-Smith antibodies. Note ANA is not specific to lupus but the other two are. -Decreased complement levels (CH50, C3, or C4) -Other test which should be include anti-Ro/SSA, anti-La/SSB Differential diagnosis: -Parvovirus B19 infection. It can cause joint pain and have transiently positive autoimmune serologies. Treatment: -Joint pain treated it with NSAIDs -Hydroxychloroquine can prevent lupus flares and increased long-term survival. Also permitted during pregnancy. -Cyclophosphamide is generally reserved for lupus nephritis or severe resistant disease but is associated with serious toxicity - Pearls: -Permanent medications during pregnancy: prednisone, hydroxychloroquine, Azathioprine -The risk of preeclampsia is increased in patients with SLE Maternal anti-Ro/SSA and anti-LA/SSB is associated with increased risk of neonatal lupus. |
|
|
|
Antiphospholipid syndrome
|
It can occur as an independent syndrome (primary antiphospholipid syndrome) or secondary to underlying SLE. |
|
|
|
Drug-induced lupus
|
Known drugs to cause this condition are:
-Procainamide, -Hydralazine, -Methyldopa -Minocycline, -Tumor necrosis factor alpha inhibitors Autoantibodies typically include: AMA, anti-single-stranded DNA, and anti-histone antibodies. Anti-double-stranded DNA and anti-Smith antibodies are uncommon and complement levels are typically normal. Pearls: drug-induced lupus caused by tumor necrosis factor may be associated with positive anti-double-stranded DNA antibodies and rare kidney or neurologic involvement. |
|
|
|
Morphea
|
It is a localized form of scleroderma presenting as one or more indurated plaques confined to the torso and proximal extremities.
No visceral manifestations or Raynauds phenomenon |
|
|
|
Describe Sjogren's syndrome
|
It is a slowly progressive auto immune disorder that targets exocrine glands.
It is characterized by: -Dry eyes -Dry mouth -Diverse multisystem manifestations Viral agents, including hepatitis C, may serve as a trigger of clinical disease. It is seen with other autoimmune diseases such as: -Lupus -Rheumatoid arthritis Symptoms: -Dry eyes -Dry mouth -Painless parotid gland enlargement seen in 33% of patients Diagnosis: -Clinical -Anti-Ro/SSA, anti-La/SSB Treatment: -Symptomatic -Immunosuppressive regimens generally do not improve gland function -Steroids and immunosuppressive drugs for severe extraglandular manifestations Pearls: -There is a 44 fold increase risk of lymphoma seen in these patients. Often the lymphoma is B cell or mucosa associated lymphoid tissue (MALT) -Extraglandular involvement occurs in 50% of patients |
|
|
|
Describe mixed connective tissue disease
|
It is characterized by overlapping clinical features of lupus, polymyositis, and systemic sclerosis in the presence of high titers of:
- Anti-U1-ribonucleoprotein antibodies Pearls: -Pulmonary artery hypertension is the main cause of death. |
|
|
|
Describe Gout
|
Uric acid is a breakdown product of purines (adenine or guanine), which are consumed through diet or synthesized do novo.
High purine foods include: -Meats: especially organ meats -Seafood -Beer Additionally increased cell turnover rates can stimulate purine synthesis/breakdown and raise uric acid levels. Such as: leukemia, lymphoma, hemolytic anemia, polycythemia, psoriasis, tumor lysis. Humans and other primates lack uricase, and enzyme that converts uric acid to the more soluble compounds allantoic acid. Much of the bodies uric acid is eliminated via the kidneys. Diets high in fructose also increase serum uric acid, owing to a unique metabolic pathway. Certain drugs may block urate excretion including thiazide and other Loop diuretics. Crystals may form spontaneously at concentrations >6.8 particularly if a rapid increase in serum urate levels. Symptoms: -Mostly at night and first attack usually starts in the first metatarsophalangeal joint of the foot (podagra) -Typically starting out as monoarticular but can involve virtually any joint and maybe polyarticular. Diagnosis: -Aspiration is indicated in most cases. -Positive needle-shaped, NEGATIVELY birefringent urate crystals on the polarize microscopy. -A high blood uric acid level alone cannot determine gout nor a low blood uric acid level can rule out gout. Treatment of acute attack: -NSAIDs (indomethacin is a popular one but all work) -Steroids -Colchicine. 1.2 mg single-dose followed one hour later by 0.6 mg. This medication is most effective at the beginning of an attack. Never start uric acid lowering drugs during the acute phase because lowering your urate levels acutely can precipitate and an attack. Chronic treatment: (two or more attacks in 1 year) Uric acid lowering therapy: -Allopurinol -Uloric -Probenecid (For underexcreters). Note a 24 hour urine uric acid collection is needed to establish that a patient is an underexcretor. General treatment: -Patients should reduce purine and fructose in diet. -Switch out diuretics which may increase blood uric acid levels Pearls: -After initiating uric acid lowering medications, the patient must be covered for six months with an acute treatment of gout such as colchicine |
|
|
|
Describe pseudogout
|
Is a formation and deposition of calcium pyrophosphate crystals leading to inflammation.
These crystals can deposit directly within cartilage (chondrocalcinosis) or may be released into the joint. No gender predilection is recognized. But generally seen in an older population. Symptoms: -Typically a monoarthritis Diagnosis: -POSITIVELY birefringent, rhomboid-shaped crystals Conditions related to pseudogout are: -Hyperparathyroidism -Hypothyroidism -Hemachromatosis -Hypermagnesemia -Hypophosphatasia -Familiar hypocalciuric hypercalcemia Treatment: -NSAIDs -Intra-articular or systemic steroids -Colchicine is effective although less affected then in gout. |
|
|
|
Infectious arthritis
|
Gram-positive organisms are the most common causes of infectious arthritis, with Staphylococcus aureus being the most prevalent.
Most infections with gram-positive organisms are monoarticular and affect large joints, particularly the knee however they can be polyarticular. Gram-negative joint infections with neisseria gonorrhea is most often seen in younger patients. Initiation of antibiotics should be held long enough for cultures to be obtained. Treatment: -Initially IV anabiotics and generally 2 to 4 weeks total antibiotics. -Thorough drainage of infected joints is essential |
|
|
|
The most common joint infection seen in sickle cell
|
Salmonella
|
|
|
|
Organism found an IV drug users in joint infection
|
Pseudomonas
|
|
|
|
Pott disease
|
Mycobacterium TB infection of intervertebral disc, accompanied by destructive osteomyelitis involving the adjacent vertebrae
|
|
|
|
Bacteria which cause joint infection in setting of freshwater or salt water exposure
|
Mycobacterium Marinum
|
|
|
|
Parvovirus B19
|
A children's infection and adults who contract this infection usually have exposure to children.
Presentation: -Flu like illness: fever, polyarthralgias Diagnosis: -IgM anti-parvovirus antibodies |
|
|
|
What are idiopathic inflammatory myopathies?
|
They are muscle weakness caused by inflammation, although other organ systems may be involved, especially the skin and lungs.
They are associated with autoantibodies. |
|
|
|
What are the different types of idiopathic inflammatory myopathies
|
1. Polymyositis,
2. Dermatomyositis, 3. Inclusion body myositis Symptoms seen in dermatomyositis and polymyositis: -Symmetric proximal muscle weakness with little or no pain -Neck flexor muscles and diaphragm may be involved which can lead to respiratory failure -Gottron papules are pathognomonic for dermatomyositis and heliotrope rash is also seen in this condition. Symptoms in inclusion body myositis: -Insidious and slowly progressive, with weakness in both proximal and distal muscle groups. Diagnosis: -Anti-Jo-1 antibodies -Elevated CK -EMG -Muscle biopsy is gold standard Treatment: -High-dose IV steroids usually continued until creatine kinase levels normalize -Inclusion body myositis is generally resistant to treatment Pearls: -Interstitial lung disease occurs and 65% of patients with polymyositis and dermatomyositis -Malignancy is strongly associated with dermatomyositis and cancer screening must be done. Ovarian cancer is common. |
|
|
|
What is vasculitis
|
Vasculitis is inflammation of blood vessel walls that cause vessel narrowing, occlusion, ANEURISMS, or rupture.
|
|
|
|
Describe Behcet disease
|
Characterized by oral and genital ulcerations, uveitis, vasculitis
Treatment: -Topical steroids -Colchicine -Thalidomide |
|
|
|
Describe relapsing polychondritis
|
It is a rare relapsing-remitting inflammatory disorder characterized by chondritis of the ears, nose, and respiratory track.
Symptoms: -Painful, erythematous swelling of the auricular cartilage occurs in those patients.overtime the inflammation may destroy the cartlidge with loss of structure leading to cauliflower ear. -Inflammation over nasal cartlidge occurs. Treatment: -NSAIDs, steroids, dapsone |
|
|
|
Describe osteogenesis imperfecta
|
This is a disease of collagen.
The disorder manifest as brittle bones, blues sclera,dentinogenesis Imperfecta. |
|
|
|
Described Ehlers-Danlos syndrome
|
Manifest as smooth, velvety, hyperextensibility skin, joint hypermobility, delayed wound healing with atrophic scarring and easy bruisability.
|
|
|
|
Describe Marfan syndrome
|
It is a collagen disorder.
It is associated with overgrowth of long bones as well as ocular and cardiovascular abnormalities. Signs: -Arm span greater than height -Pectus excavatum -Arachnodactyly or long digits Pearl: -Aortic root aneurysm can develop and patients at a young age |
|
|
|
Large vessel vasculitis
|
1. Giant cell arteritis (Temporal arteritis)
2. Polymyalgia rheumatica 3. Takayasu arteritis |
|
|
|
Describe giant cell arteritis or temporal arteritis
|
Symptoms:
-Pain over affected artery Diagnosis: -Elevated CRP and ESR -artery biopsy Treatment: -Prednisones: typically rapid response. Treatment is indicated immediately and patients clinically suspected of having giant cell arteritis and should not await results of temporal artery biopsy. |
|
|
|
Describe polymyalgia rheumatica
|
Characterized by pain and stiffness in the proximal limbs associated with elevated levels of acute phase reactants.
Symptoms: -Pain, stiffness, and limitation in the range of motion of the shoulder and hip girdle muscles. Diagnosis: -Elevated ESR and CRP me Treatment -Primarily prednisone (relatively low dose) -MTX if steroids relatively contraindicated |
|
|
|
Describe Takayasu arteritis
|
It affects the aorta and his major branches as well as the pulmonary arteries.
Symptoms: -Low-grade fever -Fatigue -Malaise -Weight loss -Claudication in the lower extremities Diagnosis: -Very elevated ESR and CRP -Bruits Audible over internal carotid, subclavian, renal, or iliac vessels -Angiography, CT angio or MR angiography demonstrating narrowing of these arteries Treatment during inflammatory phase: -High dose steroids |
|
|
|
Types of medium-size vessel vasculitis
|
1. Polyarthritis Nodosa
2. Kawasaki disease |
|
|
|
Describe polyarthritis nodosa
|
Characterized by inflammation and the curses a medium sized and small muscular artery walls.
Up to 50% of cases occur in the setting of recently acquired hepatitis B infection. Diagnosis: -Demonstration of necrotizing arteritis in biopsies. Biopsies can be taken from skin, muscle, or sural nerve. Treatment: -High-dose steroids Pearls: -The kidney should not be biopsied, because the procedure can result in hemorrhage from renal arteriolar aneurysms |
|
|
|
Describe Kawasaki disease
|
It is a systemic vasculitis involving medium sized to smaller arteries that occurs in children, although there are cases seen in adults with HIV infection.
Treatment: -High dose salicylates and early IV immunoglobulin -Steroids if not responding to the above |
|
|
|
Types of small vessel vasculitis
|
1. Wegener's granulomatosis
2. Microscopic polyangiitis 3. Churge-strauss syndrome |
|
|
|
Henoch-Sholan Purpura
|
Characterized by purpuric rash, arthritis, abdominal pain, and hematuria.
It may be associated with malignancy and patients over the age of 50. |
|
|
|
Describe sarcoidosis
|
It is a multi system disorder characterized by well formed NONCASEATING granuloma that infiltrate tissues.
Diagnosis: -Patients with acute lower extremity arthritis, erythema nodosum, Lofgren syndrome can be diagnose without biopsy -Tissue biopsy is needed to diagnose sarcoidosis except in cases of classic Lofgren syndrome with symmetric hilar lymphadenopathy. |
|
|
|
Describe giant cell arteritis or temporal arteritis
|
Symptoms:
-Pain over affected artery Diagnosis: -Elevated CRP and ESR -artery biopsy Treatment: -Prednisones: typically rapid response. Treatment is indicated immediately and patients clinically suspected of having giant cell arteritis and should not await results of temporal artery biopsy. |
|
|
|
Signs of meniscal tear:
|
-Clicking or locking of the knees secondary to loose cartilage
-Pain only on walking typically, particularly going up or down stairs |
|
|
|
Went to suspect basic calcium phosphate deposition disease?
|
In older patients, especially women, in the setting of recent trauma. BCP crystals are most commonly associated with highly destructive inflammatory arthritis such as Milwaukee's shoulder. BCP crystals cannot be seen under polarized light but can be visualized as aggregates after alizatin staining of synovial fluid.
|
|
|
|
Which antibody is associated with Wegener Granulomatosis?
|
ANCA
|
|
|
|
Best medication to treat systemic sclerosis related alveolitis?
|
Cyclophosphamide
|
|
|
|
Which mononeuropathy is associated with rheumatoid arthritis?
|
Carpal tunnel. Synovitis of the wrist or subsequent bony changes can compromise the carpal tunnel and cause entrapment of the median nerve.
|
|
|
|
What's the first thing that must be done if proliferative lupus nephritis is suspected in a patient with active lupus?
|
Kidney biopsy. Kidney biopsy well-established class and level of activity and class, which aide in predicting prognosis. Treatment once biopsy is complete will likely be cyclophosphamide.
|
|
|
|
Most common pathogen associated with reactive arthritis?
|
Chlamydia trichomonas which can often be asymptomatic. Urine nucleic acid amplification testing for tric.
|
|
|
|
What is the first line treatment for axial spondylarthritis?
|
-NSAIDs at max dose.
-TNF alpha's are second line |
|
|
|
When to refer patients with osteoarthritis for possible knee replacement?
|
-No response to conservative therapy
-Functional limitations |
|
|
|
Patients who benefit from arthroscopy eval:
|
Only if symptoms of meniscal tear (catching or locking)
|
|
|
|
When to do joint hyaluronate injection?
|
Mild to moderate osteoarthritis, not severe.
|
|
|
|
What disease to think about when observing typical osteoarthritis features, along with chondrocalcinosis, and locations atypical for osteoarthritis?
|
Chronic calcium pyrophosphate arthropathy. Not exactly the same as pseudogout all the same Crystal.
|
|
|
|
The lupus medication Leflunomide's metabolites can be eliminated from circulation by the use of which medication?
|
Cholestyramine
|
|
|
|
Which trimester should nonsteroidals be avoided to prevent premature closure of ductus arteriosus?
|
Third
|
|
|
|
What medication class is avoided and psoriasis and psoriatic arthritis?
|
Oral steroids because they may cause flair of psoriatic skin disease.
|
|
|
|
The type of arthritis seen in hemachromatosis?
|
Osteoarthritis-like in atypical joints such as metacarpophalangeal and wrist joints.
|
|
|
|
Antibody to check if rheumatoid factor is negative and suspected rheumatoid arthritis?
|
Anti-cyclic citrullinated peptide (CCP). Can be seen early in disease and is 95% specific for RA.
|
|
|
|
What is the treatment of choice in patients with polyarteritis nodosa and hepatitis B infection:
|
-Entecavir (antiviral) & Prednisone
|
|
|
|
Best agent to use for osteoarthritis if nonsteroidals contraindicated and Tylenol and effective?
|
Tramadol
|
|
|
|
The most common disease related cause of death in patients with mixed connective tissue disease?
|
Pulmonary arterial hypertension
|
|
|
|
The most common organism in infectious arthritis?
|
Staph aureus
|
|
|
|
What is the first-line medication for rheumatoid arthritis?
|
Methotrexate. Experts recommend patient began disease modifying antirheumatic drugs within 3 months of onset.
Hydroxychloroquine as a mono therapy may be effective only in mild cases early in the disease course for patients without poor prognostic features |
|
|
|
What are the antibodies seen in mixed connective tissue disease?
|
Anti-U1-Ribonucleoprotein (RNP)
|
|
|
|
Treatment of lupus
|
Joint pain treated it with NSAIDs
-Hydroxychloroquine can prevent lupus flares and increased long-term survival. Also permitted during pregnancy. -Cyclophosphamide is generally reserved for lupus nephritis or severe resistant disease but is associated with serious toxicity |
|
|
|
When to start chronic treatment for gout?
|
After two or more attacks in 1 year
|
|
|
|
The type of scleroderma characterized by skin thickening involving areas proximal to elbows and/or knees.
|
Diffuse cutaneous systemic sclerosis (dcSSc)
|
|
|
|
Type of scleroderma that does not progress proximal to the elbows and knees?
|
Limited cutaneous systemic sclerosis (lcSSc)
|
|
|
|
What is CREST syndrome
|
A form of scleroderma including:
-calcinosis -Raynaud phenomenon -esophageal dysmotility -Sclerodactyly -Telangiectasia |
|
|
|
Type of scleroderma typically seen in childhood affecting one side of the body?
|
Linear scleroderma
|
|
|
|
What RA drug requires a baseline retinal exam?
|
Hydroxychloroquine. Exams should be done once a year starting at baseline then five years after being in medication.
|
|
|
|
Preop management to be done for RA patient with long history of disease?
|
Cervical spine x-ray with flexion and extension views. To rule out atlantoaxial subluxation or dynamic instability.m
|
|
|
|
Rheum drug that cholesterol level must be followed?
|
Tocilizumab infusion.
|
|
|
|
What RA drug requires a baseline retinal exam?
|
Hydroxychloroquine. Exams should be done once a year starting at baseline then five years after being in medication.
|
|
|
|
Preop management to be done for RA patient with long history of disease?
|
Cervical spine x-ray with flexion and extension views. To rule out atlantoaxial subluxation or dynamic instability.m
|
|
|
|
White blood cell count and Gram stain seen in disseminated gonococcal joint infection?
|
-Leukocyte count typically less than other types of bacterial arthritis
-Gram stain and culture commonly negative |
|
|
|
What are the prodromal findings of disseminated gonorrhea?
|
-Tenosynovitis
-Migratory or additive polyarthritis -Cutaneous lesions that progress to papules or macules to pustules |
|
|
|
Physical findings of dermatomyositis?
|
-Photosensitivity rash
-proximal muscle weakness's -Nailfold capillary abnormalities with cuticle hypertrophy -Renaud phenomena -arthralgia -fatigue -Erythematous, violaceous, clumped papules (Gottron Papules are pathognomonic for this condition)) |
|
|
|
Treatment of dermatomyositis without extra-muscular manifestations?
|
First-line: High-dose steroids
Second line: intravenous immune globulin with high-dose steroids |
|
|
|
The best radiographic test to diagnose ankylosing spondylitis?
|
Sacroiliac MRI with gadolinium.
|
|
|
|
What is treatment of scleroderma renal crisis?
|
ACE I. Remember in lupus proliferative glomerulonephritis A renal biopsy needs to be done quickly and then the patient started on IV cyclophosphamide.
|
|
|
|
Wegener granulomatosis
|
A condition of granulomatosis with polyangiitis. It is a systemic necrotizing vasculitis that predominantly affects the:
- upper and lower respiratory tract and -kidneys |
|
|
|
Which type of cryoglobulinemia vasculitis is associated with active hepatitis C infection?
|
Type II. Type I May occur as a complication of para proteins associated with Sjogren syndrome.
|
|
|
|
What is the leading cause of death in patients with inflammatory myopathys such as polymyositis and dermatomyositis?
|
Interstitial lung disease. High-resolution CT of the chest and pulmonary function test or appropriate in these cases. Additionally anti-Jo-1 antibodies are highly specific for inflammatory myopathies and are associated with increased risk for interstitial a lung disease.
|
|
|
|
Which blood pressure medication increases blood urate levels?
|
Hydrochlorothiazides. They also increase calcium levels in the blood by blocking calcium excretion in the urine.
|
|
|
|
What is the difference in the similarity in the presentation of polymyositis versus dermatomyositis?
|
Polymyositis has proximal muscle and distal muscle weakness WITHOUT rash. CD8 eight T-cells on biopsy.
Dermatomyositis has similar muscle weakness but is characterized by typical RASH (heliotrope rash, photosensitive rashes), and CD4 positive T cells on biopsy, Gottron papules |
Heliotrope rash
|
|
|
Describe muscle biopsy seen in inclusion body myositis:
|
Rimmed vacuoles and reddish inclusions.
|
|
|
|
How does steroids cause osteoporosis?
|
They enhance bone reabsorption and decreased bone formation - directly through their action on osteoblast and osteoclast, and indirectly by inhibiting calcium absorption.
Up to 30% of the bone loss occurs in the first few months of treatment with steroids. |
|
|
|
When to start bisphosphonates if on chronic steroids?
|
If steroid use is expected to continue for at least 3 months of treatment equal to or greater than 7.5 mg/day.
|
|
|
|
True or false, the United States preventative services task force advises against using estrogen or estrogen plus progestin for the prevention of chronic diseases such as osteoporosis after menopause?
|
True, because of a trend toward an increased risk of breast cancer, coronary heart disease, stroke, DVT, and urinary incontinence.
|
|
|
|
What is the difference between lateral epicondylitis and Olecranon bursitis?
|
Lateral epicondylitis or tennis elbow is caused by repetitive movements of the forum which leads to injury and inflammation to the tendon. There is usually no bursa swelling or erythema which is seen in a Olecranon bursitis as shown in the photo above.
|
|
|
|
Digit nail pitting is seen and what rheum condition?
|
-Systemic sclerosis
-Psoriasis and psoriatic arthritis |
|
|
|
Treatment of acute digital ischemia in the setting of systemic sclerosis:
|
Intravenous Epoprostenol which is a prostacyclin analog that causes vasodilation.
Oral Bosentan is effective in preventing recurrent digital ulcers in severe Raynaud's but not for acute ischemia. |
|
|
|
The best lupus medication to use during pregnancy with mild presentation?
|
Hydroxychloroquine. This is in spite of it being category C medication.
|
|
|
|
Which vasculitis is associated with antecedent onset of asthma, allergic rhinitis, or sinusitis?
|
Churg-Strausse syndrome. Presentation usually shows eosinophilia, migratory pulmonary infiltrates, purpuric skin rash, mononeuritis multiplex, fever, Arlthralgias, and myalgia. p-ANCA.
|
|
|
|
Age and sex difference in inclusion body myositis and polymyositis?
|
Inclusion body myositis: patients older than 60, mostly men.
Polymyositis: younger patients, mostly women. |
|
|
|
Characteristics of Statin induced myopathy:
|
-Muscle pain and muscle cramping
-Onset usually within 6 months of starting therapy -Resolves within 2 months of stopping medication -Dose related -Risk is increased in patients with impaired kidney function |
|
|
|
Describe Gottron papules:
|
-Violaceous to pink plaques with scaling overlying the extensor surface of the hand joints, knees, and elbows. Pathonemonic for dermatomyositis.
|
|
|
|
Management of parotic plan swelling in setting of Sjogren's syndrome:
|
Productline biopsy to rule out non-Hodgkin's lymphoma. these patients have a 44 fold increase of lymphoma. parotid gland locations the most common but MALT also seen.
|
|
|
|
What are the tumor necrosis factor inhibitors/biologic agents:
|
1. Adalimumab (Humira)
2. Etanercept (enbrel) 3. infleximab (Remicade) 4. golimumab (simponi) 5. certolizumab (cimzia) |
|
|
|
What is the primary drug classes of treatment for rheumatoid arthritis?
|
-Disease modifier:Methotrexate
-Biologic: Tumor necrosis factor alpha inhibitors |
|
|
|
What is a bursa?
What is bursitis? |
It is a connective tissue sac with a potential space that facilitates smooth movement of one tissue over another.
Bursitis results when a bursa becomes inflamed (usually from trauma or an overuse syndrome) or infected. |
|
|
|
First and second line treatment for fibromyalgia?
|
First line: Lyrica (pre-Gabalin)
Second line: Cymbalta (duloxetine). Cymbalta is a serotonin and norepinephrine reuptake inhibitor. Because fibromyalgia is not an inflammatory condition, nonsteroidals or steroids are usually not effective. |
|
|
|
What conditions are associated with antiphospholipid antibody syndrome?
|
-Thrombocytopenia
-Valvular heart disease -Livedo reticularis -Microangiopathic kidney insufficiency |
|
|
|
A condition seen in young athletes with lateral hip pain radiating down the outside of the leg?
|
Iliotibial band syndrome.
|
|
|
|
Conditions in which the straight leg raise test is positive:
|
Lumbar radiculopathy/sciatica
|
|
|
|
The scleroderma spectrum disorder characterized by Woody induration of the extremities SPARING the hands and face without Raynaud phenomenon?
|
Eosinophilic fasciitis
|
|
|
|
What is the cause of extremity induration (of skin) after MRI with gadolinium?
|
Nephrogenic systemic fibrosis. Often seen as a complication of receiving gadolinium when GFR less than 30.
|
|
|
|
The condition that causes recurrent 12 to 72 hour episodes of fever with serositis (abdomen or pleural), synovitis (typically monoarticular affecting lower extremities), and erysipeoid rash?
|
Familial Mediterranean fever. Best to treat it with Colchicine.
|
|
|
|
Condition that causes purpuric rash of lower extremities, arthritis, abdominal pain, and hematuria?
|
Henoch-Schoenlein Purpura. This condition is associated with the presence of solid tumors or myelodysplastic syndrome. patient should have further cancer work up.
|
|
|
|
Median nerve territory of the hand:
|
Palm surface of the first three fingers and the radial aspect of the fourth.
|
|
|
|
Treatment of carpal tunnel syndrome
|
-Brace at night
-Reduce repetitive actions -Surgical relief in severe cases documented by clinical information or EMG evidence. -Nonsteroidals often use but no clinical evidence that they work. |
|
|
|
Fungus that is associated with plant litter and other organic materials?
|
Sporothix schenckii. Joint infections must be diagnosed with synovial biopsy.
|
|
