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71 Cards in this Set
- Front
- Back
Morning stiffness duration |
<15 min --> degenerative (eg osteoarthritis) inflammatory conditions improve with usage so stiffness goes away during the day |
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SLE presentation |
look for joint pain and rash malar rash photosensitivity rash discoid rash |
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Inflammatory conditions that cause low back pain |
1) ankylosing spondylitis 2) psoriatic arthritis 3) reactive arthritis 4) IBD |
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Rheumatoid arthritis physical exam findings |
symmetric joint pain with distal interphalangeal joints unaffected rheumatoid nodules --> nodules on extensor surface that are non-tender and rubbery |
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Criteria for RA |
number of joints affected --> with 10 joints & 1 being a small joint, u get dx elevated ESR duration of Sxs >6 weeks |
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Cytokines involved in RA |
TNF-a --> causes malaise, fatigue, and weight loss & leads to excessive bone erosions & cartilage damage IL-1 --> local swelling & erythema IL-6 --> up-regulates hepcidin that leads to iron sequestration and anemia of chronic dz |
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Tx of RA |
start with NSAID or corticosteroid PLUS methotrexate methotrexate takes ~6 months to start showing an effect with MTX --> follow CBC & LFTs, if AST/ALT starts increasing, d/c immediately MTX may cause flare-ups in process |
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Chronic RA joint deformity |
ulnar deviation of digits radial deviation of wrists |
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RA risk factors |
HLA-DR1, DR4, DR14 MHC I --> HLA-A, B, C MHC II --> HLA-D (subtypes are P, Q, R) smoking is strongly assoc with RA environmental and hormonal factors |
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Rheumatoid factor vs anti-cyclic citrullinated peptide |
anti-cyclic citrullinated peptide is more specific than RF neither are necessary nor sufficient |
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Felty syndrome |
RA splenomegaly granulocytopenia |
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Caplan syndrome |
RA restrictive lung dz bc of lung nodules |
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TNF-a inhibitors |
etanercept infliximab adalimumab golimumab certolizumab use in combination with MTX if MTX doesnt work have to get PPD prior to starting on TNF-a inhibitors |
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TNF-a inhibitor failure |
if TNF-a inhibitors dont work then with MTX, try: abatacept --> assoc with lymphoma, lung ca, & COPD exacerbation OR rituximab |
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Acute joint pain ddx |
1) gout --> uric acid crystals 2) pseudogout --> calcium pyrophosphate crystals 3) septic arthritis 4) trauma |
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Joint aspiration WBC count |
<5000 --> non-inflammatory 5000-50,000 --> inflammatory >50000 --> septic |
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XRay finding in pseudogout |
chondrocalcinosis |
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Septic or gonococcal arthritis |
assoc with fever & leukocytosis gonococcal --> migratory polyarthritis Staph is most common cause of septic arthritis |
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Tx of gout |
Acute tx: NSAIDs (eg indomethacin) or colchicine until pain is no longer present if above doesnt work, can try glucocorticoids orally or intra-articular injection Long-term tx: allopurinol (first line) or febuxostat do not start allopurinol in acute setting bc it can make it worse but if already taking, then no need to d/c |
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Precipitating factors for gout |
excessive etoh ingestion trauma, surgery infection steroid w/d medications (eg hydrochlorothiazide, furosemide, pyrazinamide, ethambutol) serious medical illness |
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Gout microscopy findings |
needle shaped negative birefringent crystals under polarized light microscopy |
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Goal of chronic tx of gout |
decrease uric acid level to <6mg/dL usually life long tx start urate-lowering therapy AFTER acute phase allopurinol is first line probenecid is for those who have high serum uric acid with low urine uric acid --> but contraindicated in pts with renal insufficiency and nephrolithiasis |
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Gout with renal insufficiency |
should not get NSAID or colchicine tx with corticosteroids |
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Best screening test for SLE |
ANA (<3% of SLE are negative) if positive: anti-dsDNA (very specific for SLE) --> may indicate renal involvement anti-Smith (very specific for SLE) Anti-Ro/SSA and anti-La/SSB --> assoc with neonatal lupus (heart block) complement levels are decreased |
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Tx of SLE |
start on prednisone
other immunosuppressants: azathioprine mycophenolate mofetil MTX cyclophosphamide --> only for lupus nephritis bc of severe toxicity for rash --> hydroxychloroquine (but can cause retinitis so need to follow with optho) |
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Clinical criteria for SLE |
need 4 of 11: 1) malar rash 2) discoid rash 3) photosensitivity 4) oral ulcers 5) arthritis 6) serositis 7) renal involvement 8) neuro d/o 9) hematologic d/o 10) serology 11) positive ANA |
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Discoid lupus rash |
circular rash with raised rim over scalp and face disfiguring bc of central atrophy and scarring only 5% of pts with discoid rash will develop SLE |
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Drug-induced lupus |
procainamide hydralazine isoniazid methyldopa p/w ONLY rash and anti-histone antibodies DOES NOT AFFECT CNS OR KIDNEYS |
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Raynaud's Phenomenon |
primary or idiopathic: usually woman 20-40 otherwise normal secondary: nearly all pts with scleroderma collagen vascular dz (eg SLE, polymyositis, RA, Sjogren's) arterial occulsive dz (eg atherosclerosis) drugs (b-blocker, ergot derivatives) if pt p/w Raynaud's phenomenon --> check for ARF, arthritis, anemia, fever |
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Limited scleroderma (CREST) |
CREST syndrome --> calcinosis, raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia affects face & skin distal to elbows & knees high risk of developing pulm HTN less risk of progressing to interstitial lung dz anti-centromere Abs |
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Diffuse scleroderma |
progressive form that affects skin proximal to elbows and knees diffuse organ involvement affecting lungs (interstitial lung dz) & kidneys diffuse pulm fibrosis, cardiac involvement, renal dz common anti-topoisomerase I (Scl-70) |
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Tx of scleroderma |
MTX raynaud's --> CCB (eg nifedipine) renal involvement & HTN --> ACEI (if pt enters renal crisis with scleroderma, increase ACEI) esophageal dysmotility can lead to reflux -> Barrett's -> adenocarcinoma so tx with PPI pulm alveolitis leading to interstitial lung dz --> cyclophosphamide pulm HTN --> phosphodiesterase-5 inhibitors (eg sildenafil), prostacyclin analogs (eg siloprost, epoprostenol, or treprostinil) |
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Osteoarthritis characteristics |
chronic asymmetric arthritis oligoarticular arthritis or monoarticular morning stiffness is <30 mins no constitutional sxs |
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Tx of osteoarthritis |
pt education for joint protection and assistive device (eg cane or walker) diet for weight loss if above not adequate --> trial of acetaminophen on PRN basis if still not adequate --> trial of NSAIDs on PRN basis |
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Osteoarthritis pathology |
target tissue is articular cartilage failure of cartilage secondary remodeling and hypertrophy of the bone NOT an inflammatory dz severity of radiographs NOT related to severity of Sxs |
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Osteoarthritis risk factors |
age female genetics major joint trauma repetitive stress obesity |
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Osteoarthritis XRay |
osteophytes (spurs) --> Bouchard's nodes (prox interphalangeal joint) or Heberden's nodes (distal phalangeal joint) eburnation loss of joint space |
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T score vs Z score on DEXA scan |
T score: compares bone density to young population abnormal if < -2.5 STD below mean (sig risk for osteoporotic fracture) Z score: compares bone density to age-matched population helpful when considering secondary osteoporosis (eg steroids, warfarin) |
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Osteoporosis w/u |
x-ray is first test DEXA scan (gold standard) --> T score < -2.5 means osteoporosis T score < -1.1 means osteopenia |
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Tx of osteoporosis |
oral Ca 1.5 g/day Vit D supplementation alendronate (bisphosphonate) --> can cause esophagitis |
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Type I osteoporosis |
disproportionate loss of trabecular bone assoc with fractures of vertebrae and distal forearms occurs in middle-aged and postmenopausal women |
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Type II osteoporosis |
occurs equally in men and woman age >75 assoc with fractures of femoral neck, prox humerus, prox tibia, & pelvis |
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Proximal muscle weakness Ddx |
1) polymyositis 2) dermatomyositis (can have ocular manifestations) 3) inclusion body myositis (affects both prox & distal muscles) 4) steroid induced myositis 5) fibromyalgia |
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Proximal muscle weakness |
difficulty combing hair standing up climbing stairs lifting objects |
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Distal muscle weakness |
buttoning shirt difficulty writing standing on tip toes |
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Presentation of different myopathies |
dermatomyositis --> typical heliotrope rash (patchy purple/reddish rash) polymyositis --> isolated muscle weakness and no evidence of dermatologic manifestations inclusion body myositis --> affects both prox and distal muscles & typically affects older men |
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Inflammatory infiltrate in myopathies |
dermatomyositis --> perimysial inflammatory infiltrate polymyositis --> endomysial inflammatory infiltrate inclusion body myositis --> inclusions of amyloid in muscle fibers and diffuse inflammatory infiltrate in muscle cells |
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anti-Jo1 Abs |
found in dermatomyositis and polymyositis very specific but not very sensitive so negative test does not r/o dz ANA, however, are positive in 80% of cases |
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Tx of dermatomyositis |
high dose corticosteroids until CPK normalizes then gradually taper in refractory cases, can give MTX or azathioprine hydroxychloroquine is effective for the rash |
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Cancer and dermatomyositis |
perform UA (bladder cancer), CXR, colonoscopy, PSA, Pap smear (cervical cancer), and CA-125 (ovarian cancer) in woman pelvic u/s or CT to exclude ovarian cancer |
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Temporal arteritis with polymyalgia rheumatica |
new onset of headache in a pt >50 scalp tenderness jaw claudication decreased or blurry vision polymyalgia rheumatica: hip & shoulder stiffness prox muscle weakness |
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Temporal arteritis w/u |
ESR (if elevated & you suspect temporal arteritis, treat immediately) temporal artery bx (gold standard) |
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Temporal arteritis pathology |
segmental granulomatous inflammation of the media of lg vessels causing narrowing of the lumen can lead to possible thrombosis of the affected section of the vessel leading to distal ischemia and necrosis |
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Tx of temporal arteritis |
start prednisone (60mg daily) prior to bx results follow ESR and taper steroids once ESR normalizes can develop aortic aneurysm so should be followed |
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Ankylosing spondylitis |
p/w lower back pain X-ray shows bamboo spine and b/l sacroiliitis ESR is elevated 90% are HLA-B27 (on chr 6) seronegative |
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Tx of ankylosing spondylitis |
NSAIDs are main stay tx MTX, sulfasalazine, cyclosporine, azathioprine, retinoic acid derivatives, anti-TNF-a can also be considered |
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Seronegative arthropathies |
1) ankylosing spondylitis 2) reactive/Reiter arthritis 3) psoriatic arthritis 4) IBD assoc arthritis absence ANA and RF involve lower back and sacroiliac joints extra-articular manifestations include aortic valve, lung parenchyma, the eye (uveitis), and skin |
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Reiter's syndrome |
following non-gonococcal urethritis --> conjunctivitis and arthritis can also have mucocutaneous manifestations such as keratoderma blennorrhagica (scraping of palms), circinate balanitis, and oral/genital ulcers pts with HIV can have a particularly aggressive form especially the mucocutaneous parts that resolve with HAART |
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Livedo reticularis |
mottled reticulated vascular pattern lace-like purplish discoloration |
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Polyarteritis nodosa |
assoc with Hep B medium sized vasculitis p/w fever, weight loss, myalgias, arthralgias, cutaneous nodules and livedo reticularis HTN secondary to renal artery involvement Will never get glomerulonephritis or lung involvement bc those are with capillaries dx is suspected with angiography of mesenteric and renal arteries with evidence of aneurysms bx show segmental transmural necrotizing inflammation forming aneurysms with fibrinoid necrosis |
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Hep B titers |
HBsAg --> active infection HBc IgG --> chronic infection HBeAg --> sign of infectivity & assoc with HCC |
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Hep B drugs |
entecavir tenofovir adefovir telbivudine lamivudine |
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Polyarteritis nodosa organ manifestations |
kidney: renovascular HTN GI: abdominal pain and melena skin: cutaneous and livedo reticularis nervous system: peripheral neuropathies (tingling/numbness) & pain in hands, arms, feet, & legs |
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PAN tx |
corticosteroids cyclophosphamide for refractory cases If HbsAg positive --> treat active Hep B |
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Hepatitis vaccination |
all Hep B infected individuals should get Hep A vaccine household contacts should get Hep B vaccine, if they are not immune any chronic liver pt should get both Hep A & Hep B |
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Small vessel vasculitis |
Granulomatosis with polyangiitis (Wegener's) Henoch-Schonlein purpura --> younger pts with abd pain & purpura Churg-Strauss syndrome --> middle aged p/w new onset asthma & eosinophila |
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ANCA |
c-ANCA --> anti-proteinase 3 Abs p-ANCA --> anti-myeloperoxidase |
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p-ANCA / anti-myeloperoxidase positive |
Churg-Strauss syndrome Microscopic polyangiitis |
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Granulomatosis with polyangiitis (Wegener's) |
affects small vessels p/w palpable purpura RBC casts in urine upper respiratory tract complaints destruction of the cartilage of the nose --> saddle nose deformities Sxs similar to chronic sinusitis can also affect eyes --> scleritis, uveitis, & keratitis c-ANCA/anti-proteinase 3 Ab positive p-ANCA/anti-myeloperoxidase negative dx is made via bx tx with high-dose corticosteroids with cyclophosphamide then taper & d/c cyclo & continue tx with MTX or azathioprine for 18 months |
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Methotrexate monitoring |
monthly LFTs and CBC (anemia due to folate def) |
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TMP-SMZ ppx |
any patient on immunosuppression medications should be treated TMP-SMZ for prevention of Pneumocystis jirovecii |