Rheum and Neuro

Question 1

3-step screening tool for inflammatory arthritis (RA)

Answer 1

1. discomfort with squeezing the MCP and MTP joints
2. 3 or more swollen joints
3. More than 1 hour of morning stiffness

Question 2

key labs for RA

Answer 2

RF: may be pos or neg - but positive = more severe dz

Anti-CCP: confirmatory test for RA

Question 3

RA: poor prognostic indicators

Answer 3

• Functional limitations
• RF + or Anti-CCP +
• Erosions on x-rays
• Extra-articular disease: Interstitial lung disease, vasculitis, scleritis, rheumatoid nodules

Question 4

Guidelines for bone densitometry - who should get a DEXA scan

Answer 4

Women > 65 years and men > age 70 - ALL
Younger postmenopausal women and men aged 50-69 years with a risk factor (must document):
• Prior fragility fracture (before age 50)
• Use of a high risk medication
• Family history of osteoporosis
• Rheumatoid arthritis or condition associated with increased bone loss
• Glucocorticoids > 5mg daily for > 3 months
• Current smoker
• Low body weight (<127 lbs)

Question 5

Guidelines for using pharmacotherapy for osteoporosis

Answer 5

Applicable population: postmenopausal women and men age 50+
• Previous hip or vertebral fx
• T-score -2.5 or less at femoral neck, total hip, or spine
• T-score b/t -1.0 and -2.5 at femoral neck, total hip or spine and 10yr FRAX of >3% at hip or >20% for major osteoporosis-related fxs (humerus, forearm, hip, clinical vertebral fx)

Question 6

Central findings - indicates lesion in CNS (brain and spinal cord - upper motor neurons)

Answer 6

Horizontal axis:

• Hyper-reflexia
• Spasticity: velocity-dependent “catch” with rapid passive extension of joint
• Sensory changes: often harder to localize
• Weakness (flexor posturing in UE; extensor posturing in LE)

Vertical Axis:

• if unilateral, think cortex / brainstem
• if bilateral, think subcortical, brainstem, or spinal cord

Question 7

Peripheral Findings

Answer 7

Horizontal axis:

• Hypo-reflexia
• Atrophy/Fasciculation
• Sensory changes: dermatomal, sensory-nerve dist, glove/stocking (polyneuropathy)

Vertical Axis:

• reflexes: biceps: C5/6, triceps: C7/8, patella: L3/4, achilles: S1/2
• dermatomes
• muscle innervation

Question 8

aphasia - definition and likely location pf lesion

Answer 8

language disorder
Brocas: impaired production
Wernickes: impaired comprehension

lesion: left side – frontal and temporal regions

Question 9

agnosia - definition and likely location pf lesion

Answer 9

inability to process sensory information despite adequate sensory input
• Tactile agnosia
• Prosopagnosia (“face blindness”)

lesion: occipital/parietal lobe

Question 10

apraxia - definition and likely location of lesion

Answer 10

disorder of planning motor tasks, perform learned motor tasks

lesion: posterior parietal lobe

Question 11

amnesia - definition and likely location pf lesion

Answer 11

deficit in memory

lesion: medial temporal lobe, hippocampus, dienceohalon

Question 12

Headache - red flag sxs that suggest secondary cause

Answer 12

SSNOOP
Systemic symptoms (fever, weight loss, vomiting, vision loss)

Secondary risk factors (HIV, cancer, immuno-supressive drugs)

Neurologic symptoms (confusion, impaired alertness)

Onset: sudden, abrupt, pain induced by exertion, wakes from sleep, subsides w/ emesis

Older: new onset and progressive (worsening) HA, esp age > 50 (or < 5yr)

Previous HA history or HA progression: pattern change, first HA, or different (change in quality, frequency or severity)

Question 13

Headache - red flag signs that suggest secondary cause

Answer 13

Abnormal neurologic exam: focal signs

Neck stiffness and especially meningismus

Papilledema (inc. ICP)

Temporal artery palpation

AMS

Question 14

common HA triggers (tension and migraine)

Answer 14

Diet / EtOH
Hormones
Sensory stimuli: light/odor
Stress
Change of environment/habit

Question 15

migraine HA treatment

Answer 15

mild: anti-inflammatory
- acetaminophen/aspirin/caffeine (Excedrin Migraine)
- NSAIDs (Ibuprofen/Naproxen)

Failed analgesics: 5-HT recepto agonists (ergotamines and triptans) - no CV dz

Dopamine receptor antagonists

Question 16

migraine HA prophylaxis - indications

Answer 16

• HA > 2 times weekly
• Contraindications or intolerance to abortive meds
• HA that severely limits quality of life despite abortive therapy
• Presence of uncommon migraine conditions: hemiplegic or basilar migraine, or migraine with prolonged aura

Question 17

migraine prophylaxis - medications

Answer 17

beta-blockers (propranolol, timolol)

tricyclics (amitriptyline, nortriptyline)

anti-convulsants (topirimate, valproate, gabapentin)

Question 18

tension HA - treatment

Answer 18

Simple analgesics (acetaminophen, Aspirin, NSAIDs)

Behavioral approaches: relaxation techniques

Question 19

cluster HA - treatment

Answer 19

First line abortive therapy is oxygen (10-12L via nasal cannula for 15 min)

Follow with same tx as migraine HA

Question 20

medication OD headache - dx and tx

Answer 20

Hx of analgesic use averaging more than 2 - 3 days per wk in association with chronic daily HA supports the diagnosis of MOH

Treatment:

• stop all the overused med
• bridge therapy: long acting NSAID (Naproxen 550 mg BID) or prednisone
• preventative med and revisit triggers (diary)

Question 21

stroke - modifiable risk factors

Answer 21

• HTN (most important risk)
• CV dz - CHF, previous MI, aortic valve disease and atrial fibrillation
• Cigarette smoking
• Carotid Artery Disease: can limit blood flow to the brain, act as a potential source for cerebral emboli
• Diabetes
  Dyslipidemia
  Obesity
  Lack of Exercise
  Use of OCP, Hormone Therapy

Question 22

stroke - non-modifiable risk factors

Answer 22

1. Family History: stroke or CAD
2. Age: risk doubles every 10 yrs after age 55
3. Gender: <55 (men more likely to have stroke); >55 risk same for males and females
4. History of Prior Stroke, TIA or Heart Attack
5. Race: African Americans - higher incidence and risk of death from stroke; Asian Americans – high risk of hemorrhagic stroke

Question 23

symptoms not likely to be a stroke or TIA (non-focal)

Answer 23

Generalized weakness or numbness (bilateral)

Faintness or syncope

Incontinence

Isolated symptoms (occurring alone)

• Vertigo or loss of balance
• Double vision
• Slurred speech or difficulty swallowing

Confusion / reduced LOC
- reduced conscious level is more important predictor of non stroke pathology

Question 24

ABSD2 score

Answer 24

Helps to determine disposition following TIA:

Age [A]: >60 (1 pt)
Blood pressure [B]: >140/90 (1 pt)
Clinical features [C]
 - Unilateral weakness (2 pts)
 - Dysphasia (difficult swallow) w/out weakness (1 pt)
Duration of symptoms [D]
 - >60 min (2 pts)
 - 10-59 min (1 pt)
Diabetes [D]: 1 pt

Question 25

TIA - indications for hospital admit

Answer 25

``` o Crescendo symptoms o Symptom duration > 1 hour o Internal carotid stenosis > 50% o Known Afib or other cardiac source o Known hypercoagulable state o ABCD2 Score >3 ```

Question 26

stroke - imaging

Answer 26

CT (non contrast): fast, available, cheap - R/O hemorrhage - verify cerebrovascular cause to sxs - identify abnormal findings that contradict tPA - goal: door to CT 25 min; 45 min interpretate MRI: higher sensitivity for ischemic stroke (also detects hemorrahage)

Question 27

4 proven interventions for acute ischemic stroke (aka tx for acute ischemic stroke)

Answer 27

SCUs: stroke care units Thrombolysis (tPA): IV alteplase w/ in 3 hrs Aspirin (ASA): 300 mg QD for 14 days (initiate after 24 hrs if using thrombolytics) Decompressive hemicraniectomy - reduces mortality in pts < 55 years with malignant brain swelling after large infarction - make decision w/ neurosurgeon

Question 28

acute tx for hemorrhagic stroke

Answer 28

Management in SCU Regulate BP (not yet found to improve outcome) Control brain edema (not yet found to improve outcome) Neurosurgical consultation: pts at risk for obstructive hydrocephalus

Question 29

acute tx fort TIA

Answer 29

Note: usually not admitted confirm not stroke (imagine - CT/MRI) pt education and good RTC precautions: 10.5 % have stroke w/in 3 mo) Primary prevention measures: - anticoagulants - antiplatelets - carotid endarterectomy

Question 30

thrombolysis alteplase)

Answer 30

can improve recovery following ischemic stroke, but also carries a risk of a brain bleed (so there are several contraindications) - > 3 hrs since stroke onset - bleeding or bleeding risks - meds that cause bleeding / reduced clotting - blood glucose < 50 mg/dl - seizure w/ post-ictal neural impairment

Question 31

Primary Prevention for Stroke or TIA (never had one before)

Answer 31

Anti-coagulation (Warfarin): for patients with atrial fibrillation (CHA2DS2-VASc score) Antihypertensives: for the tx of hypertension Lipid reduction with statins: pts w/ pre-existing ischaemic heart disease Aspirin in women 45 years or older (but not men) Modification of risk factors such as diabetes, moderation of EtOH, reduction in smoking

Question 32

Secondary Prevention for Stroke or TIA (had one before)

Answer 32

Anticoagulants (Warfarin): for pts w/ atrial fibrillation reduces RR of recurrent stroke by about 70% (CHA2DS2-VASc Score) Antiplatelet agents: ASA and extended-release dipyridamole (Persantine) Carotid endarterectomy: pets who have at least 70% stenosis of the symptomatic carotid artery

Question 33

CHA2DS2-VASc Score

Answer 33

used to determine whether to recommend anticoagulants to patients with Atrial Fibrillation - estimate risk of pt having a thromboembolic event if no anti-coagulation medication is used O = low risk: possibly DO NOT use Warfarin / Coumadin 1 or greater = moderate to high risk: recommended to use Warfarin / Coumadin