MS Flashcards

Question

Juvenile Idiopathic Arthritis H and P: Psoriatic Arthritis ?

Answer 1

Psoriatic rash or family hx of psoriasis Arthritis, sacroiliitis, sausage digits ( swollen or puffy), nail pitting (yellow on nails like psoriasis) Anterior uveitis Variable prognosis Remissions and exacerbations

Answer 2

Inflammation at the site of attachment of tendon/ligament to bone INFLAMMATION AT THE SITE NOT AT THE BONE Pain even without true arthritis Mainly lower extremities Mainly boys 8-12 yo +/- associated with IBD BLOOD diarrhea

Answer 3

(+6 weeks) inflammation of the synoviall lining - decrease ROM, swelling, joint is stiff

Answer 4

No specific diagnostic tests CBC Rheumatoid factor ACCP antibody ESR– normal or elevated CRP– normal or elevated ANA– increased often for oligoarticular Higher likelihood of uveitis Radiographs Bone scan

Answer 5

``` Procainamide Hydralazine Isoniazid Methyldopa Quinidine Chlorpromazine ```

Answer 6

Often relapsing and remitting pattern Fatigue, fever Malar rash - no scaring Discoid rash - tends to scar - usually in circles Photosensitivity Arthralgias Oral ulcers (painless) Lymphadenopathy Renal symptoms polyuria, nocturia, foamy urine

Answer 7

CBC Anemia Leukopenia Thrombocytopenia BUN– may be elevated Creatinine– may be elevated these two only if renal involvement Urinalysis– possible casts, proteinuria ESR– elevated usually ANA– positive 99%, nonspecific Serum complement ( C3 or C4)– low, can monitor for progression Antibodies to Smith antigen– elevated, can monitor for progression Anti-double-stranded DNA– elevated, can monitor for progression Antihistone antibodies– positive in drug-induced lupus

Answer 8

Patient Education Exercise Sun protection Pharmacology NSAIDs - for joint pain often used for musculoskeletal complaints Antimalarials ( hydroxychloroquine or quinacrine) may be used for musculoskeletal complaints and cutaneous manifestations Corticosteroids (as needed for flares) Topical or intralesional preparations are often used for cutaneous manifestations Low- or high- dose oral corticosteroids are used for disease flares and tapered as symptoms resolve. Methotrexate used at low doses for arthritis, rashes, serositis, and constitutional symptoms.

Answer 9

Skin Swelling and tightness in the fingers (sclerodactyly) and hands. May spread to trunk and the face Raynaud phenomenon vasospasm of the digital arteries seen in more than 75% of patients Musculoskeletal pain GERD Limited scleroderma (CREST syndrome) “Skin Score” Rate thickness of skin 0-3 17 locations Helps to monitor progression High degree of subjectivity

Answer 10

ANA– 90% of patients with diffuse type, but nonspecific Anticentromere antibody—positive with CREST (limited type) Anti-SCL-70– may be positive with diffuse disease Indicates poor prognosis

Answer 11

No cure If reflux PPI If renal disease ACEI If Raynaud Calcium channel blockers If pulmonary hypertension Immunosuppressants Early and aggressive tx needed

Answer 12

Peripheral circulation Obliterative vasculopathy Lungs Fibrosis, Pulm HTN GI Constip, GERD, “food stuck” Renal Less often, use ACEIs Cardiac Ischemia, fibrosis MSK Mild to erosive arthritis, joint contractures Sicca Complex Dry eyes and mouth

Answer 13

Sicca features Dry mouth (xerostomia) food can stick to the mucosa tooth decay cause no saline oral infections Dry eyes (xerophthalmia or keratoconjunctivitis sicca) more potential for infection itchy griddy eyes Parotid glands may be enlarged

Answer 14

``` Initial RF ANA anti- Ro antibodies anti- La antibodies ``` More diagnostic Schirmer test - evaluates tear secretions by the lacrimal glands filter paper placed in the lower eyelid for 5 minutes Less than 5 mm wetting is positive for decreased secretions Biopsy of the lower lip mucosa RF positive in 40 -50% - half the time ANA positive in 80% - a lot of the time anti- Ro antibodies positive in 60% anti- La antibodies positive in 40%

Answer 15

Patient Education Management is mainly symptomatic, with the goal of keeping mucosal surfaces moist This can be achieved by using artificial tears and saliva, increased oral fluid intake, and ocular and vaginal lubricants Pharmacology - Pilocarpine may increase saliva flow - Cyclosporine drops may improve ocular symptoms

Answer 16

Skin lesions palpable purpura livedo reticularis lacy kinda skin Fever/chills Anorexia Weight loss Abdominal pain- “intestinal angina” Peripheral neuropathy Arthralgias/Arthritis / Myalgias Hypertension, CP, CHF, MI Edema Oliguria distal ishemica that can lead to gangrene **Livedo reticularis is thought to be due to spasms of the blood vessels or an abnormality of the circulation near the skin surface. It makes the skin, usually on the legs, look mottled and purplish, sort of a net-like pattern with distinct borders**

Answer 17

Step 1 ESR– elevated CRP– elevated UA– may have proteinuria, hematuria ( if kidney involvement ) Step 2 ANCA– suggestive, not diagnostic HBsAg– Hepatitis B may be causative Diagnosis Vessel biopsy - might show you necrotizing arteritis Angiography Nerve conduction studies

Answer 18

High doses of corticosteroids Maybe methotrexate or azathioprine Consider - Cytotoxic drugs (cyclophosphamide) Immunotherapy

Answer 19

Delayed growth Pain in the spine, pelvis and legs Muscle weakness

Answer 20

Labs Calcium Phosphorus Alkaline phosphatase - maybe be low cause osteoblast activity Parathyroid hormone - will be high 25-hydroxy vitamin D 1,25-dihydroxyvitamin D very small HL and not accurate level which is why you want to get the 25 one Imaging Skeletal Bowing

Answer 21

Patient Education Ensure adequate supply of Vit-D or appropriate levels of sunshine in children Pharmacology (target vit d levels between 20-40 but depend on geographic location) - 25 hydroxy VD <10 ng/mL [25 nmol/L] - 25 hydroxy VD levels in the range of 10- 30 ng/mL (25 to 50 nmol/L)

Answer 22

Generalized muscular hypotonia (unknown mechanism) Craniotabes (areas of thinning and softening of bones of the skull) ``` Parietal and Frontal Bossing Skeletal bowing (i.e. tibia / fib) ``` Kyphoscoliosis Chest skeletal deformities “Rachitic Rosary” IN THE PIC expansion of the anterior ribs that for irregularities in the costar junctions

Answer 23

History of broken bones Menopause or hypogonadism Diet low in calcium and/or vitamin D Excessive intake of protein, sodium, and caffeine Inactive lifestyle Smoking / Alcohol abuse Certain drugs (e.g., glucocorticoids, anticonvulsants) Certain disease states (e.g., anorexia nervosa, hyperparathyroidism, hyperthyroidism)

Answer 24

Acute pain after a fall or minor trauma Pain is localized to specific, identifiable, vertebral level in the midthoracic to lower thoracic or upper lumbar spine The pain is described variably as sharp, nagging, or dull; movement may exacerbate pain; in some cases, pain radiates to the abdomen Pain is often accompanied by paravertebral muscle spasms exacerbated by activity and decreased by lying supine Patients often remain motionless in bed because of fear of causing an exacerbation of pain Acute pain usually resolves after 4-6 weeks; in the setting of multiple fractures with severe kyphosis, the pain may become chronic

Answer 25

Labs Usually normal in persons with primary osteoporosis CBC LFT TSH 25-Hydroxyvitamin D level: - decreased will be most accurate way to measure VD Serum protein electrophoresis (Multiple myeloma) RULE OUT MM 24 hour urine calcium/creatinine Testosterone ``` Imaging DEXA (Dual-energy x-ray absorptiometry) ```

Answer 26

Patient Education Building bone mass early in life (esp. women) Nutrition Exercise maintaining normal body habitus Pharmacology Bisphosphonates, Calcium Metabolism Modifiers : Alendronate (Fosamax); Ibandronate (Boniva); Zoledronic acid (Reclast) Parathyroid hormone analogues Selective Estrogen Receptor Modulators Monoclonal antibodies Vitamins (Vit D, and Calcium) HRT/Estrogen

Answer 27

Most are asymptomatic Incidental finding of an elevated serum alkaline phosphatase level or characteristic radiographic abnormality may lead to detection of the disease Most common is bone pain If skeletal involvement nonspecific headaches, impaired hearing, and tinnitus commonly result from skull involvement. The patient's hat size may increase as a result of skull enlargement or deformity.

Answer 28

Localized pain and tenderness with manual palpation warmth chalk stick fx.

Answer 29

Labs Serum alkaline phosphatase (elevated due to osteoclastic activity) Imaging Plain radiographs and bone scan scintigraphy Radiolucencies Radiodensities Overall bone size enlarged Coarse trabecular pattern Advanced “flame shaped” lytic lesions in long bones Supplemental diagnostics BONE SCAN- All patients at the time of diagnosis to define involved bones. Radionuclide bone scan showing the area of increased uptake in the right tibia suggesting active Paget's disease. The whole body scan is useful for picking up other areas of uptake that may be asymptomatic and otherwise un-diagnosed.

Answer 30

Patient Education Importance of proper posture, body mechanics, and avoidance of trauma. Precautions against falling should be reinforced PT good idea to increase muscles in areas of pain to reinforce the bone Pharmacology Bisphosphonates - consider Reclast is treatment of choice and is IV form 5 mg dose so give this until alk phos is normalized by 98% with this therapy, the alk phos will NL within 2 years Vit D and Ca suppléments need to be considered Surgery or procedures Fixative for items such as fractures

Answer 31

Foods that are rich in purines include anchovies, sardines, sweetbreads, kidney, liver, meat extracts. ``` Fructose-rich foods / high-fructose corn syrup cause purines to be released Hypertension Diabetes mellitus Renal insufficiency Hypertriglyceridemia Hypercholesterolemia Obesity Anemia ```

Answer 32

Spontaneous onset of excruciating pain, edema, and inflammation in the metatarsal-phalangeal joint of the great toe (podagra) Affected joints are red, hot, and exquisitely tender Other sites: such as the knee, wrist, elbow, or ankle are possible Podagra is not synonymous with gout, however: it may also be observed in patients with pseudogout, sarcoidosis, gonococcal arthritis, psoriatic arthritis, and reactive arthritis

Answer 33

Erythema over the joint may resemble cellulitis Skin may desquamate as the attack subsides. The joint capsule becomes quickly swollen, resulting in a loss of range of motion of the involved joint May be febrile (during acute attack) Tophi (collections of urate crystals in the soft tissues)- take years to develop after initial attack

Answer 34

Labs Microscopy of joint aspirate Negatively birefringent monosodium urate crystals Measurement of serum uric acid is NOT diagnostic of gout Imaging Plain radiographs may show findings consistent with gout Supplemental diagnostics Arthrocentesis of the affected joint is mandatory for all patients with new-onset acute monoarthritis Very strongly recommended for those with recurrent attacks whose diagnosis has never been proved by microscopic visualization of crystals

Answer 35

High-purine foods should be either avoided or consumed only in moderation. Foods very high in purines include organ meats such as sweetbreads (eg, pancreas and thymus), smelt, sardines, and mussels. Foods moderately high in purines include anchovies, trout, haddock, scallops, mutton, veal, liver, bacon, salmon, kidneys, and turkey However, studies show this has only a slight impact on gout Important Ask pt about a Hx of peptic ulcer disease, renal disease, or other conditions that may complicate the use of the medications used to treat gout i.e. may need to use corticosteroids in place of NSAIDS for renal failure patients.

Answer 36

Acute attack: ``` NSAIDs (most common) Naproxen Indomethacin (Indocin) Corticosteroids Colchicine ``` Long-term (do not give in acute attack): Xanthine oxidase inhibitors (allopurinol) or febuxostat (Uloric) or Uricosuric agent (Colchicine, Probenecid)

Answer 37

Return for a follow-up visit in approximately 1 month to be evaluated for therapy to lower serum uric acid levels If uric acid–lowering therapy is begun, patients should be seen within 2 weeks to ensure that no toxicity has developed Then every 1-2 months while medication dosages are adjusted to achieve the target uric acid level of 5-6 mg/dL

Answer 38

Aka Calcium Pyrophosphate Deposition (CPPD) | formerly called Pseudogout

Answer 39

Many cases are idiopathic, but pseudogout has also been associated with trauma and many different metabolic abnormalities, the most common of which are hyperparathyroidism and hemochromatosis

Answer 40

Same as gout Spontaneous onset of excruciating pain, edema, and inflammation in the joint (mostly knee) Affected joints are red, hot, and exquisitely tender Most common sites: large joints, such as the knee, wrist, elbow, or ankle

Answer 41

Similar to gout Usually involves the knee or the wrist, although almost any joint can be involved, including the first metatarsophalangeal (MTP) joint, as occurs in patients with gout.

Answer 42

Labs Positively (but weakly) rhomboid shaped birefringent crystals Imaging Plain xray Supplemental diagnostics Joint aspirate

Answer 43

Patient Education Same as gout Pharmacology Same as gout

Answer 44

Slow, occurring over several years or decades Pain is usually the initial symptom Deep, achy joint pain exacerbated by extensive use. Reduced range of motion and crepitus Stiffness during rest Morning joint stiffness usually lasting for less than 30 minutes

Answer 45

Reduced range of motion Malalignment with a bony enlargement (possible) Most cases of osteoarthritis DO NOT involve erythema or warmth Distal interphalangeal (DIP) joints (but may also involve the proximal interphalangeal (PIP) joints and the joints at the base of the thumb) Heberden nodes, DIP joints, women > men Bouchard nodes- PIP

Answer 46

Labs Not very helpful Imaging Plain xray Supplemental diagnostics Possibly arthrocentesis to r/o out disorders

Answer 47

Patient Education Cardiovascular or resistance exercise Aquatic exercise Weight loss, for overweight patients Pharmacology Topical capsaicin Topical nonsteroidal anti-inflammatory drugs (NSAIDs) Oral NSAIDs (naproxen, ibuprofen, and diclofenac) Oral opioid (Tramadol) Intra-articular corticosteroid injections Nonpharmacologic interventions are cornerstones: Heat and cold Weight loss Exercise Physical therapy Occupational therapy Unloading in certain joints (eg, knee, hip) Arthroscopy Fusion

Answer 48

Degeneration of cartilage and hypertrophy of the bone at the articular margins Heritable metabolic causes (eg, hemochromatosis) Hemoglobinopathies (eg, sickle cell disease ) Underlying morphologic risk factors (eg, congenital hip dislocation and slipped femoral capital epiphysis) Disorders of bone (eg, Paget disease and avascular necrosis) Previous surgical procedures (eg, meniscectomy) ``` Age / Obesity / Trauma Genetics (significant family history) Reduced levels of sex hormones Muscle weakness Repetitive use (ie, jobs requiring heavy labor) Infection Crystal deposition Acromegaly Previous inflammatory arthritis ```

Answer 49

mortality rate depends on organism N gonorrhoeae septic arthritis mortality is low S aureus as high as ~50% mortality S aureus is the most common cause of septic arthritis in all age groups

Answer 50

Triad of: Fever (40-60% of cases) Fever is usually low-grade (< 102°F) Pain (75% of cases) Impaired range of motion - wont be able to move knee at all! but gout they can move it a little bit

Answer 51

The most commonly involved joint in septic arthritis is the knee (50% of cases) Hip (20%) Shoulder (8%) / ankle (7%) / wrists (7%) Erythema, swelling (90% of cases), warmth Usually exhibit an obvious effusion Marked limitation of both active and passive ranges of motion (ROMs)

Answer 52

Labs Joint aspirate of synovial fluid for crystals via polarizing microscopy and for organisms via gram stain Always send the aspirate for culture, regardless of the result of the screening evaluation Imaging Plain imaging is of limited value but may help r/o other pathology xray nay show effusion

Answer 53

Start ABX asap (draw labs first then start ABX) Ceftriaxone (Rocephin) GM Neg rods Drug of choice (DOC) against N gonorrhoeae Vancomycin (Vancocin) Against methicillin-sensitive S aureus (MSSA)

Answer 54

Guttate psoriasis– disseminated lesions developing after streptococcal infection (i.e. strep pharyngitis)

Answer 55

Psoriasis rash usually preceding pink silvery scales leave it alone! dont scratch it or pick at them ``` Symmetric arthritis (involve the hands and feet) hands and feet ``` Sausage-finger appearance (dactylitis) Nails Pitting, “oil spot” Onycholysis - separation

Answer 56

``` Rheumatoid factor– negative ESR– elevated CRP– elevated Uric acid– elevated if severe CBC-- normocytic normochromic anemia anti-CCP is negative as well ? ``` XR affected joint (usually hand) “Pencil in cup” deformities middle phalanx withers away while distal stays the same and it can subluxation or dislocatee cause it is loose in there

Answer 57

Pharmacology ``` NSAIDs First line for mild Methotrexate Helps skin inflammation and the arthritis Other DMARDs for severe disease Immunomodulators (Etanercept) TNF inhibitors ``` Surgery or procedures Surgery for end-stage joint destruction joint replacement if recurrent dislocations

Answer 58

Preceding infection (GI, GU) Acute asymmetric arthritis large joints usually below the waist Knee and ankle common , also foot down in feet can cause sausage digits of the toes Mucocutaneous ulcers(balanitis, stomatitis) Urethritis/cervicitis Conjunctivitis Enthesitis

Answer 59

Rheumatoid factor– negative HLA-B27– 30-50% positive Synovial fluid– culture negative but cloudy and increased WBC’s - causing cloudiness XR joint– nonspecific degenerative Culture – dependent on antecedent infection ESR/CRP - elevated

Answer 60

PT NSAIDs Steroids DMARD (sulfasalazine) if refractory to the NSAIDs or steroids If active infection Antibiotics given at the time of infection will reduce the chance of developing reactive arthritis later on do not alleviate the symptoms self limited and spontaneously regress but it can take 5 months can turn into function disability

Answer 61

Pain for at least 3 months Pain on both sides of the body bilateral Pain above and below waist Must involve the axial skeleton

Answer 62

Nonarticular musculoskeletal aches, pains Fatigue Sleep disturbances Multiple tender “ trigger” points enough pressure to blanch finger nail and they will experience spots pain in 11 of the 18 spots then it is dx. ``` Mood changes Cognitive disturbances Anxiety Depression Headaches Irritable bowel syndrome Dysmenorrhea Allodynia in 11 of 18 sites ```

Answer 63

``` Diagnosis of exclusion CBC CMP ESR, CRP Thyroid panel ```

Answer 64

Patient Education (and friends, family, employer) Aerobic exercise– improves functioning Avoid overtraining but keep them moving Sleep education Cognitive behavioral therapy - “ i can make it through the day”

Answer 65

Tramadol Pregabalin ( Lyrica) or gabapentin (Neurontin) FDA- approved Reported reduced pain and improved sleep Side effects– fatigue, trouble concentrating, sleepiness, edema TCA or SSRI– may be used if depression or if additional psychiatric sx been replaced with SSRIs

Answer 66

Arthralgias Fever Erythema marginatum Subcutaneous nodules Chorea

Answer 67

EKG PR interval prolonged CRP or SED rate elevated ASO titer Rising ( ABS increasing) Rapid strep Positive Strep culture Positive Echo - look at the valves

Answer 68

Bed rest until stable Penicillin IM (Erythromycin if PCN allergic) Salicylates - watch for reyes syndrome Optional Corticosteroids

Answer 69

carditis erythema marginatum and subcutaneous nodules chorea polyarthritis

Answer 70

fever polyarthralgias reversible prolongation of the PR interval ↑ ESR or CRP

Answer 71

``` 5-15 year olds History of strep Jones criteria Valve vegetations, mitral most common Penicillin ```

Answer 72

Common cause of mitral stenosis

Answer 73

Multisystem granulomatous disorder Characterized by noncaseating granulomas Common areas affected: Bilateral hilar adenopathy Pulmonary reticular opacities Skin, joint, and/or eye

Answer 74

``` Malaise Fever Anorexia Arthralgias Dyspnea on exertion Cough Chest pain ```

Answer 75

Lung sounds usually normal may have crackles Skin Erythema nodosum Lupus pernio uveitis

Answer 76

Labs ``` ESR/ CRP– elevated serum angiotensin-converting enzyme (ACE) – usually elevated Liver enzymes– elevated if involvement TB test– negative Serum amyloid A (SAA)– negative Urine calcium– may be elevated Serum calcium– may be elevated ``` Imaging CXR CT (chest) Supplemental diagnostics PFT - see how much lung involvement there is Cardiac Workup

Answer 77

Course Supportive Pharmacology Corticosteroids (but may increase relapse rate) Surgery or procedures Lung transplant for end-stage parenchyma involvement

Answer 78

Takayasu arteritis - broken heart syndrome GCA - Behcet disease

Answer 79

Polyarteritis nodosa Buerger disease

Answer 80

Immune-complex mediated Cutaneous leukocytoclastic angiitis (“hypersensitivy vasculitis”) Henoch-Schonlein purpura Granulomatosis with polyangiitis ( formerly Wegener granulomatosis)

Answer 81

Varies – depending on system involved which vessels

Answer 82

palpable purpura

Answer 83

Biopsy Gold standard

Answer 84

Glucocorticoids Cytotoxic agents Cyclophosphamide Methotrexate Immunoglobulins

Answer 85

``` Airway Epinephrine Stop source Corticosteroids IV fluids ``` Consider Antihistamines Albuterol Ipratropium Surgery or procedures Intubation Perform early if indicated Swelling may progress Cricothyroidotomy if necessary

MS Flashcards

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