Paulson - Rheumatology Flashcards
(193 cards)
1
Q
what is the mc complaint in gout
A
my big toe hurts
2
Q
gout has a __ onset
A
rapid
3
Q
what finding is pathognomonic for gout
A
tophi
4
Q
what are tophi
A
deposits of urate
5
Q
what is podagra
A
gout of the foot
6
Q
gout is usually __
and affects the __ of the great toe
A
monoarticular
MTP
7
Q
what are the 3 stages of gout
A
- acute
- intercritical (interval)
- chronic articular and tophaceous
8
Q
what are 6 rf for gout
A
- etoh
- red meat
- seafood
- fructose
- HCTZ diuretics
- obesity
9
Q
what is the diagnostic value for serum urate in gout
A
>6.8 → not all w. this finding have gout
10
Q
for the dx of gout, what 2 lab findings must be present
A
- serum urate > 6.8
- monosodium urate (MSU) must be present for gout to crystallize
11
Q
what is the soc for gout diagnosis
A
aspirate of synovial fluid
12
Q
what does synovial fluid aspirate show with gout
A
negatively birefringent, needle like, when viewed w. polarized light microscopy
13
Q
what is the tx for asymptomatic hyperuricemia
A
lifestyle mods:
wt loss, reduce etoh, diet, enough fluids to urinate at least 2L/day, avoid hyperuricemic meds
14
Q
should allopurinol be used in for acute gout attacks
A
no! → but keep pt on it if they are already taking
15
Q
what are 5 meds that you might use for an acute gout attack
A
- NSAIDs
- indomethacin/naproxen
- celecoxib (Celebrex)
- colchine
- corticosteroids
16
Q
what is the soc med for an acute gout attack
A
nsaids
17
Q
what is the realistic/better choice soc for acute gout attacks
A
indomethacin/naproxen
18
Q
how long should abortive gout meds be given for acute attack
A
1-2 days after sx resolution → typical course is 5-7 days
19
Q
what are contraindications for celebrex
A
ckd w. CrCl < 60
active ulcer
NSAID allergy
anticoags
CVD
20
Q
when might you use colchicine for an acute gout attack
A
NSAID intolerance
21
Q
what are 2 common s.e of colchicine
A
diarrhea
abdominal cramping
22
Q
what are contraindications for colchicine
A
severe hepatic/renal dz w/ colchicine
mod-strong P-pd and/or CYP3A4 inhibitor
23
Q
when would corticosteroids be used for gout
A
can’t take NSAIDs or colchicine
24
Q
what are indications for prophylactic tx in gout
A
- presence of tophi
- 2 or more gout attacks
- renal insufficiency
- joint damage on imaging
25
what are 2 steps in prophylactic tx of gout
1. address preventie issues during intercritical (asymptomatic) period
2. bring uric acid down slowly
26
what is the serum urate level goal for prophylactic gout tx
\< 6
27
what prophylactic med is used to slowly reduce serum urate
cochicine
OR
low dose NSAID
28
what class of gout meds reduces uric acid production
xanthine oxidase inhibitors (XOI)
29
what is the main XOI
allopurinol
30
how should you administer allopurinol (in terms of titrating)
titrate up every 2-5 weeks
give prophylactic colchicine when initiating
31
what are s.e of allopurinol
rash
severe cutaneous/toxic epidermal necrolysis (TEN)
32
what is an example of a uricosurig med
Probenecid
33
what are uricosurig meds (2)
block tubular reabsorption of urate AND increase rate that uric acid is renally secreted
34
what are two inclusion criteria for uricosurig meds
1. normal renal fxn → CrCl \>60
2. urinate at least 2 L/day
35
what is a contraindication for probenecid
G6PD
36
what do uricase meds do
enzyme from other animals → break down uric acid
37
what is an example of a uricase med
pegloticase
38
when is pegloticase used
last line med for pt who has been refractory to all other therapies
39
what is a contraindication for pegliocase
G6PD
40
most ppl with gout are \_\_excreters of uric acid
under
41
what are rf for uric acid underexcretion
1. renal insufficiency
2. meds: low dose asa, thiazides, loop diuretics
3. aidosis (DKA)
4. volume depletion
5. lead exposure
6. **etoh!!**
42
overproduction of gout is usually __ or
\_\_
inherited
2/2 to dz process
43
what is a rf for both underexcretion and overproduction of uric acid
etoh!
44
what are 2 other names for pseudogout
1. calcium pyrophosphate dihydrate deposition dz (CPPD)
2. chondrocalcinosis
3. pyrophosphate arthropathy
45
what is pseudogout
precipitation of calcium pyrophosphate dihydrate crystals (CPP)
46
pseudogout causes
chronic or recurrent arthritis that mimics gout
47
what is the mc location for pseudogout
knee
also shoulders, wrist, elbow
48
pseudogout affects __ joints than gout
larger
49
what is asymptomatic/incidental pseudogout
CPP deposition on radiograph w.o symptoms
50
what is acute arthritis/pseudogout
self-limited, sudden attacks of pain, redness, warmth, disability/swelling
51
acute arthritis/pseudogout can be (in terms of location)
and usually affects __ joints
monoarticular or oligoarticular
larger
52
pseudogout can be triggered by (3)
surgery (esp parathyroidectomy)
trauma
major illness
53
what is chondrocalcinosis
e.o calcification in cartilage
54
what is the dx for pseudogout
synovial joint aspiration
55
what is the positive finding in synovial joint aspiration for pseudogout
weakly positive birefringent rhomboid crystals by polarized light microscopy
56
what is the tx for acute pseudogout
1. aspiration
2. intraarticular glucocorticoid injxn
57
what glucocorticoid is injected for acute pseudogout
triamcinolone
58
what other meds are used for acute pseudogout besides triamcinolone
NSAIDs → indomethacin
naproxen
salicylates
colchicine
systeic corticosteroids
59
what is the prophylactic tx for pseudogout
same as for gout →
consider if 3 or more attacks/year
cochicine
NSAID if colchicine intolerant
60
what is CPP inflammatory arthritis (pseudo RA)
inflammatory arthritis caused by CCP crystals in joint fluid
61
how is CCP/pseudo RA different from RA
asynchronous waxing and waning symptoms
62
what are the mc locations for CCP inflammatory arthritis/pseudo RA
wrists, elbows, glenohumeral joint
63
CCP inflammatory arthritis/pseudo RA usually affects joints in a
symmetric pattern
64
what is prophylactic tx for CCP inflammatory arthritis/pseudo RA
NSAIDs → naproxen, indomethacin
glucocorticoids → if NSAIDs ineffective
65
what is the mc location for OA w. CPPD (pseudo OA)
knees
also wrists, MCPs, hip, shoulders, elbow, spine
66
what are the symptoms for pseudo-OA
same as OA:
tenderness
bony enlargement
crepitus
restricted ROM
67
what is pseudoneuropathic joint dz
severe joint degeneration from CPP crystal deposition
68
what is the differentiating factor between pseudo-neuropathic joint dz and neuropathic arthropathy
no neurologic impairment in pseudo neuropathic arthropathy
69
what are the most common symptoms of fibromyalgia
1. flu like pain in neck and shoulders
2. HA
3. dpn
4. anxiety
70
fibromyalgia can also be associated w
dpn
ibs
cognitive problems
psychiatric symptoms
71
fibromyalgia mc affects
younger women
72
what is allodynia
response to nonpainful stimuli perceived as painful
73
what is hyperalgesia
pain perceived as more intense and lasting longer
74
pain w. fibromyalgia is commonly felt as
chronic pain/stiffness in all 4 quadrants
75
what will pe exam findings be for fibromyalgia
exam normal except for pain at tender points
76
what are tender points in fibromyalgia
soft tissue locations of pain
77
what are control locations in fibromyalgia
locations where there should be no pain
78
for dx of fibromyalgia, how many points must be tender
at least 11
79
labs and imaging for fibromyalgia are generally
unhelpful
+/- CBC, ESR, CRP, TSH
80
what are the first 2 tx steps for fibromyalgia
sleep hygiene
exercise
81
what 4 classes of meds might you consider in fibromyalgia
1. TCAs
2. SNRIs
3. SSRIs
4. anticonvulsants
82
what 2 TCAs might you use in fibromyalgia
1. Amitryptiline (Elavil)
2. Nortriptyline (Pamelor)
83
what med would be helpful for a pt w. fibromyalgia and dpn
SNRI → Cymbalta (Duloxetine)
84
what SSRI might you use for fibromyalgia
Prozac
85
what anticonvulsant might you use for fibromyalgia
Pregabalin (Lyrica)
86
what meds are not helpful for fibromyalgia
opioids
corticosteroids
NSAIDs
87
polymyalgia rheumatica (PMR) and what other dz are very similar
trigeminal neuralgia
88
mc locations for pain/ inflammation in PMR
hips/shoulders
89
what is the “gel phenomenon," and what does it make you think of
stiffness after activity
PMR
90
which is mc, PMR or temporal arteritis
PMR
91
what is the main symptom in giant cell arteritis (GCA)
ha → classically over temple, but can be generalized
92
besides ha, what are 3 other symptoms of GCA
jaw claudication
visual symptoms → bilateral OR unilateral
scalp tenderness
93
almost all pt w. PMR and GCA are \> __ yo
50
94
a major rf assocaited w. GCA is \_\_
a major rf associated w. PMR is \_\_
smoking
DM
95
in PMR pt's will have normal \_\_
but impaired \_\_
normal muscle strength
impaired ROM
96
other than decreased ROM, what is another pe finding associated w. PMR
bursal inflammation in wrists/knees
97
at least \_\_% patients w. GCA also have \_\_
50%
PMR
98
a pe for a pt w. GCA may be totally normal; if not, what are 4 associated findings
ill appearing
thickened/prominent temporal artery
cotton wool patches
99
both PMR and GCA involve polymorphisim of
HLA-DR alleles
100
what 2 labs will be very elevated in PMR and GCA
ESR/CRP
101
PMR is a __ dx
and the gold standard for GCA is \_\_
clinical
temporal artery bx
102
what do you do if the temporal bx for GCA is negative but you have a high suspicion for GCA
bx the other side
103
the tx for both PMR and GCA is \_\_
but for GCA tx is much more \_\_
steroids
emergent
104
should you wait for bx results to start tx for GCA
no!
105
what is the initial starting dose of prednisone for GCA (you need to know this)
AND for PMR
GCA: 40-60 mg po daily x several months
PMR: 15 mg po qd
106
what is a major rf if you delay tx for GCA
blindness
107
flares are common in GCA, how should you treat these
increase dose of steroids by 10 mg
108
what meds should be administered with steroids for GCA
vitamin C
osteoporosis meds
109
takayasu arteritis is similar to \_\_
and \_\_
GCA
PMR
110
takayaus arteritis involves chronic vasculitis that mc affects the
aorta and its main branches
111
name 5 symptoms associated w. takayasu arteritis
**skin lesions**
claudication
syncope
arthralgias
GI issues
112
pe for takayasu arteritis may include (3)
bp differential
diminished pulses
anemia of chronic dz
113
in takayasu arteritis, labs will show elevated (2)
CRP
ESR
114
dx for takayasu can involve __ and/or
\_\_
clinical features
imaging
115
what might you see on imaging for takayasu arteritis (2)
arterial luminal narrowing
occlusion w. wall thickening
116
what is tx for takayasu arteritis (2)
prednisone to taper
+/- surgery → PCT, bypass, grafting, aortic repair
117
reactive arthritis mc affects
weight bearing joints of lower extremities
118
what might a pt have 1-4 weeks prior to reactive arthritis
diarrhea (GI infxn) or urethritis
119
what are skin findings might you see on a pt w. reactive arthritis
rash on palms / toes
120
what are 3 rf for reactive arthritis
young adult
HLA-B27 gene
STDs
121
what bacteria are commonly associated w. reactive arthritis
shigella
e. coli
c. diff
campylobacter
salmonella
yersinia
→ from previous GI infxn
122
dx for reactive arthritis might involve (4)
but there is no single dx test
elevated CRP/ESR
stool culture
urethral swab
synovial fluid analysis
123
what is mainstay tx for reactive arthritis
NSAIDs → naproxen, indamethacin
*steroids/DMARDs if no response*
124
what rheumatologic condition does this make you think of
reactive arthritis
125
sjiorgen syndrome mc manifests in (2)
lacrimal/salivary glands
eyes
126
what are the 2 main symptoms of sjorgen syndrome
xerostomia
severely dry eyes
127
name 5 symptoms of keratoconjunctivitis sicca
diminished tears
dry eyes
AM crust
gritty/sandy feeling
bacterial infxns
128
name 2 complications of sjorgen's syndrome related to xerostomia
dental caries
salivary gland enlargement
129
besides mouth and glands, what 5 other systems can be affected by sjorgen's
GI
**renal**
urogenital
neuro → neuropathy
130
name 5 constitutional symptoms of sjorgen's syndrome
fatigue
low grade fever
purpura
Raynaud's
symmetric arthralgia
131
what do schirmer test and saxon test make you think of
sjorgen syndrome
132
what is a (+) schirmer test
\< 5 mm tears produced in 5 min
133
saxon test measures
saliva production
134
causes of sjorgen syndrome can be \_\_
or \_\_
primary
secondary
135
what 2 labs are often positive in reactive arthritis
ANA
RF
136
what is gold standard dx for sjorgen's syndrome
salivary gland bx
137
what is real life dx for sjorgen's syndrome (2)
1. Schirmer OR Saxon OR imaging showing glandular abnormalities
2. (+) anti-Ro/SSSA and/or La/SSB abs, (+) lip bx OR **established rheumatoid dz**
138
tx for sjorgen's syndrome involves good oral hygiene; what drugs may also help
pilocarpine
cevimeline
139
how do you tx eye symptoms for sjorgen's
ocular cyclosporine + artificial tears
+/- topical steroid per ortho
+/- punctal occlusion/plugs
140
what class of drugs may prescribed for systemic management of sjorgen's
immunosuppressive therapy per rheumo →
hydrochloroquine
methotrexate
141
name 3 cardinal signs of RA
slow, insidious onset
morning stiffness \> 30 min
symmetric swelling of many joints
142
joints mc associated w. RA (5)
PIPs
MCPs
wrists
ankles
knees
143
if you see this joint on a rheumatoid condition, you should not be considering RA
DIP → almost never affected
144
what RA symptoms is only seen in RF (+) patients
RA nodules
145
mc location for RA nodules
forearms
+/- lungs
146
name 3 systemic manifestations of RA
keratoconjunctivitis sicca
**pulmonary effusions**
pericarditis → from chronic inflammation
147
what are 2 major rf for RA
female
## Footnote
**smoking**
148
what do you think of when you see boggy joints, ulnar deviation of MCP and swan neck, boutinniere, and z deformities
RA
149
what is the most specific lab test for RA
anti-CCP
150
what elevated labs correlate w. dz severity in RA
ESR/CRP
151
what will synovial fluid show with RA
inflammatory effusio
leukocytes 1,500-25,000
152
what is the most specific imaging for RA
x-rays
153
early, initial, and late xray findings w. RA
early: normal
initial: soft tissue swelling/osteopenia
late: joint space narrowing/erosions
154
what is this Xray showing and what condition is it associated w.
joint space narrowing/erosions
RA
155
what is most sensitive imaging for RA
MRI
156
what are 5 dx factors for RA
inflammatory arthritis involving at least 3 joints
positive RF/anti-CCP
elevated ESR/CRP
duration at least 6 weeks
excluded other causes
157
can you dx a seronegative pt w. RA
yes!
158
what are the 3 goals of RA tx
control pain and inflammation
preserve fxn
prevent deformity
159
early initiation of __ in RA is crucial
DMARDs
160
name 3 DMARDs
**methotrexate**
sulfasalazine
leflunomide
161
what drug might you add to DMARDs with RA pt
TNF inhibitor
162
what is mc TNF inhibitor used for RA
Etenercept
163
how should steroids be used in RA tx
as a bridge to start DMARs
164
NSAIDs should never be used as __ in RA
monotherapy
165
what should you do if a RA pt is still in pain after initial therapy w. steroids + DMARDs
increase DMARD
166
how do you tx flares of RA
steroids
167
how do you treat recurrent flairs of RA in medicated pt
increase DMARD
168
name 5 pre-screening tests you should do for RA pt before interventions
hep B and C
baseline CBC, SCr, ESR/CRP
ophthalmic screening
latent TB
baseline radiographs
169
list 4 contraindications for DMARDs
pregnancy
liver dz
etoh
severe renal impairment
170
what are 3 s.e of DMARDs
GI upset
stomatitis
hepatotoxicity
171
1st choice TNF inhibitor for RA
etanercept
172
pro and con of etanercept
well tolerated
expensive, increased risk for infxn
173
you must screen for __ before starting pt on etanercept
latent tb
174
what does SANTA stand for and what is it associated w.
felty syndrome
**S**plenomegaly
**A**nemia
**N**eutropenia
**T**hrombocytopenia
**A**rthritis (rheumatoid)
175
felty syndrome is a rare complication of
ra
176
polyarteritis nodosa (PAN) mc affects
medium to small muscular arteries
177
what systems does PAN mc affect
skin
muscle
peripheral nerves
kidneys
178
\_\_ and
\_\_ are usually not affected by PAN
lungs
veins
179
what organ is mc affected by PAN
kidneys
180
what do you think of when you see
lower extremity ulcerations, HTN, abdominal pain after meals, foot drop, and arthralgias
PAN
181
PAN
182
3 rf for PAN
male
hepB/C
hairy cell leukemia
183
what dz pathology involves necrotizing vasculitis → decreased blood flow → weakened vessels
PAN
184
3 dx factors for PAN
bx of involved organ
angiogram
ACR criteria 3/10
185
bx in PAN will show
necrotizing inflammation of medium sized arteries
186
what will angiogram in PAN show
rosary sign
187
what is this angiogram showing and what condition is it associated w.
rosary sign
PAN
188
if PAN is associated w. viral hepatitis, you should limit \_\_
steroids
189
tx for mild PAN
monotherapy w. corticosteroids
190
how do you tx persistent mild PAN
MTX
191
tx for mod-sev PAN
high dose steroids plus immunosupressant
192
what immunosuppressant drug is used for PAN
cyclophosphamide
193
max length of time pt can take cyclophosphamide
12 mo
