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Flashcards in 8 Rheum Deck (31):
1

Arthrocentesis for joint pain:
what are 4 possibilities?
appearance, WBC, polys

1. Normal: clear, WBC <2, Polys <25%
2. non inflamm: clear, <2, >25%
3. inflamm: yellow/white, 2-50, >50%
4. septic: cloudy, >50, >75%.

normal
OA
everything else (look for crystals)
septic joint

2

Antibodies to memorize

ANA
Anti-histone
Anti dsDNA
Anti Smooth muscle
Mitochondrial Ab
anti-centromere
topoisomerase
Anti Ro+La
Anti CCP
Anti RF
Anti Jo

ANA--Lupus, sensitive
Anti-histone--drug induced lupus
Anti dsDNA--lupus, specific+renal involvement
Anti Smooth muscle--Autoimmune hepatitis
Mitochondrial Ab--PBC
anti-centromere--CREST/Scleroderma (C for CREST and Centromere)
topoisomerase Ab (aka Anti Scl-70)--Scleroderma, systemic
Anti Ro+La--Sjogrens
Anti CCP--RA
Anti RF--RA
Anti Jo--Polymyositis

3

What ab?

Lupus, sensitive
drug induced lupus
lupus, specific+renal involvement
Autoimmune hepatitis
PBC
CREST/Scleroderma
Scleroderma, systemic
Sjogrens
RA
RA
Polymyositis

ANA--Lupus, sensitive
Anti-histone--drug induced lupus
Anti dsDNA--lupus, specific+renal involvement
Anti Smooth muscle--Autoimmune hepatitis
Mitochondrial Ab--PBC
anti-centromere--CREST/Scleroderma (C for Centromere and CREST)
topoisomerase Ab (aka Anti Scl-70)--Scleroderma, systemic
Anti Ro+La--Sjogrens
Anti CCP--RA
Anti RF--RA
Anti Jo--Polymyositis

4

Lupus criteria

what other 2 things not on criteria to remember:

4 of 11: SOAP BRAIN MD

Serositis
Oral ulcers
Arthritis
Photosensitivity

Blood--hemolytic anemia, antiphospholipid, etc
Renal
ANA+
Immune labs (anti histone, anti dsDNA)
Neuro

Malar Rash
Discoid Rash


-libman-sacks endocarditis
-alopecia

5

Lupus miscarriages: what trimester?

2nd trimester losses

6

Diagnostic tests of SLE:

-screen, confirm, track
-renal involvement screen, confirm
-flare

1st: ANA to screen
confirm: Anti-dsDNA (most spec), anti-Smith, anti-histone (drug)

Track: ESR, CRP

Renal involvement:
Screen: UA
confirm: Kidney bx

Flare: complement levels (low C3, C4)

7

SLE, drug induced
-which drugs
-how present differently than regular SLE

SHIPP

sulfa
hydralazine
INH
procainamide
phenytoin

-spares CNS and Renal sxs. (reminds of FAT RN) Usu skin and joint presentation

8

SLE treatment approach, what to know

Know 3 tx in SLE:

1. arthalgias, serositis: NSAIDs, then Hydroxychloroquine, MTX 2nd line.

2. Flares: Steroids

3. Nephritis, cerebritis, severe flare: Cyclophosphamide, MMF 2nd line

9

RA + splenomegaly, think what

think neutropenia. This is Felty's syndrome
RA, Splenomegaly, Neutropenia

10

Pt going for surgery. Pt has RA, think what and why

Get cervical film. Spine involvement C1,C2.

11

Morning stiffness + spine, think what

C1,C2 then RA
lower back, then Ank Spond.

12

RA: what joints

MCP and PIP.
If DIP, then NOT RA! never affects DIPS

13

RA tests

Rh factor: sens
Anti-CCP: spec

14

RA dx criteria

"Nobody Should Have Rhematoid Symptoms 3X"

Nodes
Symmetric
Hand
RF or CCP
Stiffness, AM
3+ joints, spares DIPs
X-ray findings of erosions

However, IRL can have RA with Rh-, CCP-; or no RA with Rh+ and CCP+

15

RA Treatments, how to approach

4 categories to know:

Start MTX (or other DMARD) even at first presentationt! can slow progression

1. DMARD--everyone gets. MTX, Hydroxy 2nd line
2. Anti-TNF--severe.
3. Steroids--flares
4. NSAIDs--symptomatic

16

RA refractory to MTX and hydroxychloroquine.
What to do next?

Start Anti-TNFs because failure of DMARDs.
Always get TB screen and vaccinate first!

17

CREST vs systemic scleroderma

CREST: Think: SKIN AND GI, SPARES HEART AND KIDNEYS

CREST: Calcinosis, Raynauds, Esophageal dysmotility, Sclerosis, Telangiectasia

Scleroderma, systemic: CREST +
heart (pericarditis, restrictive)
kidneys (renovascular HTN)

18

Myopathy DDx (5)
-sxs differences? Pain vs weakness
-lab results for each?

"SPISH"

1. steroid induced--PAINLESS, prox weakness
2. polymyalgia rh--pain and morning stiffness esp shoulders, NO WEAKNESS
3. inflamm myopathy--pain, prox weakness
4. statin-induced--pain, possible weakness
5. hypothyroid--pain and prox weakness

ESR, CK
1. nl, nl
2.high, nl
3. high, high
4. nl, high
5. nl , high

19

Gonorrhea, disseminated sxs

Triad:
-tenosynovitis--asymmetric, wrists, hands, finges
-arthritis--migratory
-dermatitis--macular; spares face, palms, soles

20

Septic joint tx? non-gonococcal

Test: Naf, wait for cx/sens
IRL: Vanc

21

You suspect septic joint, tap shows nothing on gram stain. Think what?

Gonorrhea is intracellular, may not show on G strain. Still do empiric double coverage (Ceftriaxone and Vanc)

Dx with NAAT. tx while testing

22

Gout from Tumor lysis syndrome. What tx for ppx? If ppx didn't work, use what?

Allopurinol
Rasburicase

23

You dx Septic joint and tx. What else to think about?

Source?
1. direct inoculation--trauma
2. hematogenous (think endocarditis, IVDA, intra-abd abscess)

24

Seronegative arthropathies
-name them

PAIR

Psoriatic arthritis
Ank Spond
IBD
Reiter's reactive arthritis--can't see, pee, climb tree

25

psoriatic arthritis
-which joints
-what to be careful in tx

symmetric DIP, PIP (like OA)

-NO ORAL STEROIDS, topical good

26

Reactive arthritis
-dx--how do you know urethritis and arthritis is not gonococcal septic joint?
-tx

Can't see/pee/climb tree
-symmetric arthritis, as opposed to unilateral in gonorrhea

-Doxy for chlamydia, and NSAIDs

27

Wegener's sxs

"weCeber's triad:"
-nasopharynx
-lungs--hemoptysis
-kidneys--hematuria

28

Vasculitis--list them by categories

large vessel: Temporal arteritis, Takayasu's
med: PAN (Hep B), kawasaki's
small: Wegener's (triad), microscopic polyangiitis (wegener's -nasopharynx), churg-strauss (asthma), HSP

29

Kawasaki's sxs

CRASH and burn

Conjunctivitis
Rash--truncal and hands
Adenopathy
Strawberry tongue
Hands (rash)

Fever 5+days

30

Scleroderma renal crisis/sxs, think what?

Ace-i as treatment, always.

Tx the renovascular HTN

31

Ank Spond.
tx?

NSAIDs first line, esp if only axial involvement

Etanercept if NSAIDs fail. works for axial and peripheral skeleton

Nonbiologic DMARDs (eg MTX, hydroxy) can be used only for peripheral arthropathy. Etanercept always tried first, these can be added on.