rheum III and IV Flashcards

(94 cards)

1
Q

gout

A
  • deposition of uric acid crystals in joints, tissues, fluids
  • hyperuricemia does NOT equal gout
  • common with other comorbidities
  • extremely painful
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2
Q

tophi

A
  • uric acid crystals in tissue
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3
Q

what is the cause of 90% of gout cases?

A
  • under excretion

- mostly associated with renal disorders

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4
Q

over production of uric acid is mainly associated with what?

A
  • excessive dietary purines like red meat, organ meat, shellfish
  • beer
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5
Q

risk factors for gout

A
  • male
  • advanced age
  • AA or pacific islander
  • alcohol and high purine intake
  • obesity, HTN, hyperlipidemia, diabetes
  • diuretics (HCTZ)
  • lead exposure
  • women after menopause
  • genetics
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6
Q

clinical presentation of gout

A
  • podagra
  • very tender
  • acute onset
  • redness
  • 50% first attack in MTP of great toe
  • predilection for feet, ankles, toes
  • renal sx- uric acid stones and gouty nephropathy
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7
Q

PE findings with acute gout

A
  • usually monoarticular and TTP

- skin is warm, tense, red

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8
Q

PE findings with chronic gout

A
  • tophi deposition
  • CT destruction and gross deformities
  • infection
  • drainage
  • bone destruction and erosion -> functional loss
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9
Q

differential dx for gout

A
  • cellulitis
  • bug bite
  • septic joint
  • RA
  • pseudogout
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10
Q

diagnosis of gout

A
  • arthrocentesis shows intracellular UA crystals*
  • negative birefringence under microscopy*
  • check gram stain
  • elevated UA > 6.8 (not diagnostic)
  • get 24 hour urine
  • xrays
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11
Q

xray findings in gout

A
  • early on only soft tissue swelling

- late shows bony erosions with sclerotic margins, calcification

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12
Q

acute gout treatment

A
  • diet modifications
  • NSAIDs first line (indomethacin) within 24 hrs
  • 2nd line- colchicine
  • 3rd line- steroids
  • antihyperuricemic tx for prevention and reversal of consequences
  • treat comorbidities
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13
Q

chronic gout treatment

A
  • lower urate level to < 5
  • 2-4 weeks after acute attack f/u and check urate levels
  • allopurinol first line
  • probenecid is first line if allopurinol is c/i
  • colchicine for flares
  • NSAIDs
  • cherries decrease gout risk
  • combo drugs if levels not achieved
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14
Q

indications for chronic gout treatment

A
  • multiple attacks
  • tophaceous deposits
  • gout with renal insufficiency
  • nephrolithiasis even after tx
  • uric acid levels of 6.5 +
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15
Q

pseudogout

A
  • chondrocalcinosis
  • Ca pyrophosphate dihydrate (CPPD) deposition
  • mainly affects knees
  • can be asymptomatic or mimic other diseases
  • often occurs following anesthesia/ surgery
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16
Q

risk factors for pseduogout

A
  • hypercalcemia

- metabolic conditions

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17
Q

clinical presentation of pseudogout

A
  • may be asymptomatic
  • monoarticular
  • often in knee
  • can affect wrists, MCP, hips, shoulders, elbows, ankles
  • red, warm, tender, swollen
  • valgus deformity
  • often resolves on its own
  • fever possible
  • ligamentum flavum in spine involved
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18
Q

diagnosis of pseudogout

A
  • CPPD deposition in kidneys and joints
  • CPPD stone
  • positive birefringence rhomboid crystals*
  • elevated ESR and CRP
  • chondrocalcinosis on xrays**
  • test for serum Ca, P, Mg, Alk phos, TSH
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19
Q

differential dx of pseudogout

A
  • gout
  • septic arthritis
  • RA if polyarticular
  • primary or post-traumatic OA
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20
Q

acute treatment of pseudogout

A
  • NSAIDs
  • colchicine short term
  • steroids short term
  • drain fluid
  • rest/ice
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21
Q

chronic treatment of pseudogout

A
  • > 3 attacks per year
  • 1st line- colchicine
  • 2nd line- NSAIDs
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22
Q

Fibromyalgia

A
  • chronic pain disorder wit widespread pain and allodynia
  • central sensitization
  • usually women 20-50
  • increased incidence of depression, anxiety, HA, IBS, chronic fatigue syndrome, SLE, RA
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23
Q

allodynia

A
  • pain d/t stimulus that does not normally provoke pain
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24
Q

clinical manifestations of fibromyalgia

A
  • widespread pain
  • abnormal tenderness, fatigue, sleep disturbances, autonomic disturbances
  • GI or GU sx
  • chronic HA, poor concentration, memory disorder
  • stiffness
  • sensation of swelling without evidence of swelling**
  • widespread multiple tender points**
  • paresthesias
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25
when are fibromyalgia sx worse
- in AM - before bed - cold - stress - new exercise
26
diagnosis of fibromyalgia
- dx of exclusion** - generalized body pain for at least 3 mo - at least 11 of 18 specific tender points - check CBC, vit D, TSH - sleep study - imaging- brain MRI - xray to r/o OA or DJD
27
treatment for fibromyalgia
- CBT - exercise - weight reduction and nutrition counseling - acupuncture, massage, chiro - 1st line- tylenol or tramadol ; tylenol/tramadol (ultracet) - 2nd line- TCAs - 3rd line- SSRI, milnacipram, pregabalin, gabapentin
28
Raynaud's phenomenon
- abrupt onset of well demarcated pallor of digits -> cyanosis with pain and numbness -> reactive hyperemia - vasospastic phenomenon - precipitated by cold or stress - associated with CREST syndrome
29
CREST syndrome
- calcinosis - Raynaud's - esophageal dysmotility - sclerodactyly - telangiectasia
30
clinical manifestations
- vasospastic attack usually only in fingers - vasospasm can occur in toes, nose, ears, lips - PE is normal between attacks in primary cause - in secondary cause pits or ulcerations on finger tips may be present
31
diagnosis of raynaud's
- history - primary- attacks precipitated by cold and bilat without gangrene - for secondary need to r/o other systemic illnesses
32
treatment of raynaud's
- best pharm tx= Ca channel blockers** (amlodipine and nifedipine) - mittens for cold - avoid nicotine d/t potent vasoconstriction - beta blockers may exaggerate sx
33
SLE
- chronic autoimmune inflammatory disease - can attack any body sys at any time - relapse and remitting - severity of disease varies - cause unknown
34
epidemiology of SLE
- majority are women of child bearing age - AA, latinos, and asian women at higher risk - familial occurence - when men affected they have a higher 1 year mortality rate
35
triad of SLE
- fever - arthralgia/ arthritis - butterfly rash
36
common symptom clusters of SLE
- cutaneous, articular and renal sx | - CNS, thrombotic, and muscular sx
37
acute cutaneous lupus erythematosus
- photosensitive rash- malar rash, maculopapular rash on dorsum of hands, or bullous - non-scarring alopecia that correlates with disease activity
38
subactue cutaneous lupus erythematosus
- papulosquamous or annular scaly rash (psoriaform) - most photosensitive - torso and limb, spares face - have anti-SSA and anti-SSB ab - often induced by HCTZ or terbinafine - half of these pts dev SLE
39
chronic cutaneous lupus erythematosis
- discoid lupus - lupus panniculitis - chilblain lupus
40
discoid lupus
- coin shaped - raised erythematous plaque with scale - face, scalp, ears, neck - can scar and lead to skin atrophy - mainly disease of skin and often doesn't go on to SLE
41
lupus panniculitis
- deep nodules | - scalp, face, arms, buttocks, thighs
42
chilblain lupus
- resembles frost bite
43
nonspecific skin lesions associated with lupus
- vasculitis, purpura, livedo reticularis - raynaud's - non-scarring alopecia - nail fold telangiectasias - bullous lesions
44
diagnostic criteria for SLE
- need four of "SOAP BRAIN MD" to dx, can occur at different times - serositis - oral ulcers - arthritis, nonerosive - photosensitivity - blood/heme disorders - renal disorders - ANA - immunologic disorders - neurologic disorders - malar - discoid
45
oral ulcers of SLE
- painless - can occur anywhere in mouth - ulcerations, erythema or petechiae - can also appear in nose, usually nasal septum
46
arthritis of SLE
- symmetrical - non-erosive - pain, swelling, joint effusion - deformities secondary to loosening of ligaments- Jaccoud's arthritis - also causes myalgia, myositis, tenosynovitis, tendonitis, AVN
47
pleuritis and SLE
- tissue around lungs becomes inflamed - painful breathing and chest pain - pleural effusion and interstitial lung disease also possible
48
heart involvement and SLE
- often pericarditis - increased risk MI and arrhythmias - myocarditis - endocarditis- libman sack - accelerated atherosclerosis
49
renal disorder of SLE dx
- best= biopsy - persistent proteinuria > 0.5 g/day or 3+ on dipstick - cellular casts in urine
50
renal disorder and SLE
- most frequent cause of disease related death - worse prognosis if SCr > 2.4 mg/dL - usually asymptomatic - gross hematuria, glomerulonephritis, nephrotic syndrome, acute or end stage RF, HTN
51
most common neurologic disorders associated with SLE
- seizures - psychosis - must rule out other offending agents first
52
hematologic disorders of SLE
- hemolytic anemia with reticulocytosis - leukopenia on 2+ occasions - lymphopenia on 2+ occasions - thrombocytopenia - 50% of pts will have leukopenia that correlates with disease activity
53
ANA testing in SLE
- 98% have positive ANA - ANA does NOT equal SLE - if positive get titer, pattern, and extractable nuclear antigens (ENA)
54
ANA titer
- estimate of how many ANA present - high titer= more severe disease - lowest dilutent is 1:40 - highest dilutent is 1:2560, very severe disease
55
ANA pattern
- suggests presence of SLE subtypes
56
diffuse/ homogenous ANA pattern
- associated with drug induced lupus
57
rim/peripheral ANA pattern
- most specific for SLE
58
speckled ANA pattern
- assoc with SLE and other diseases | - not specific to SLE
59
nuclear/ centromere ANA pattern
- associated with scleroderma
60
ENA's associated with SLE
- anti-dsDNA (correlates to disease activity) | - anti-SM- specific to SLE but not sensitive
61
antiphospholipid antibodies (APLs) in SLE
- associated with high risk blood clot and miscarriages - abnormal IgG or IgM - pos test for lupus anticoagulent if pt has had miscarriage or prolonged PTT - often have false pos for syphilis
62
complement proteins in SLE
- usually low during disease activity
63
treatment for SLE
- refer to rheum*** - NSAIDs for joint pain, pleuritis but avoid sulfa based - steroids for flares - hydroxychloroquine for joint pain, fatigue, derm but risk of retinopathy - VFT every year - immunosuppressants (non-biologics first then biologics) - topical steroids for skin - anticoags for pts with antiphospholipid syndrome
64
lupus and pregnancy
- 20X higher rate miscarriage - considered high risk pregnancies - disease flares in 3rd trimester or post-natal pd - antiphospholipid syndrome -> early pregnancy loss - all pregnant women screened for anti-SSA and anti-SSB because can cause neonatal lupus (complete heart block)
65
drug induced lupus
- fever, arthralgia, myalgia, pleuritis, pericarditis, neurologic sx, and other features of SLE - no renal involvement - pos ANA but no SLE Ab - anti-histone Ab - treat by d/c offending drug, give NSAIDs and steroids
66
drugs that commonly cause drug induced lupus
- methyldopa - procainamide - hydralazine - isoniazid - chlorpromazine - TNF blockers - quinidine - carbamazepine - minocycline - phenytoin
67
localized scleroderma types
- morphea | - linear
68
morphea scleroderma
- common in kids - single or multiple patches of hard skin on trunk - often spontaneously disappears
69
linear scleroderma
- linear bands of hard skin across face, arms, legs - may involve muscle or bone - en coup de sabre- linear patch on scalp/ face
70
systemic sclerosis
- aka scleroderma - multisystem autoimmune disease - diffuse fibrosis of skin and internal organs - overproduction of collagen - classified as either diffuse or limited cutaneous scleroderma
71
what is CREST syndrome
- limited cutaneous scleroderma - calcinosis - Raynaud's - esophageal dysmotility - sclerodactyly - telangiectasias - 80% of pts with scleroderma have CREST
72
cause of scleroderma
- unknown - likely genetic and environmental factors - coal miners and stone masons at higher risk d/t silica dust
73
pathogenesis of scleroderma
- vascular fibroproliferative changes in arteries and arterioles - excessive and progressive collagen deposition in skin and internal organs - immunologic changes
74
clinical manifestations of CREST
- restricted and slow progression of skin and distal extremities - chronic raynaud's - nailfold dilated capillaries - late incidence of pulmonary HTN - good prognosis
75
clinical manifestations of diffuse cutaneous scleroderma
- widespread and rapidly progressive skin thickening of trunk, distal and prox extremities - Raynaud's after one year of skin changes - hypo/ hyperpigmentation - nailfold dilated capillaries - early involvement of lungs, heart, GIT, kidneys - muscle and tendon inflammation -> tendon friction rub - poor prognosis
76
antibodies associated with CREST
- anti-centromere Ab
77
antibodies associated with diffuse cutaneous scleroderma
- anti-SCL- 70 (anti-topoisomerase I)- indicates poor prognosis and assoc with lung disease - anti-RNA I/ III polymerase Ab- associated with rapidly progressive diffuse skin, renal, and cardiac disease, poor prognosis
78
stages of sclerodactyly
- 1. edematous stage- "puffiness", shiney without folds - 2. inflammatory- thickening destroys normal oil and sweat glands -> dry skin with intense itching - 3. atrophic stage- skin is tight and waxy, dev joint contractures
79
diagnosis of scleroderma
- requires one major or 2+ minor sx - other sx help support dx - often have pos ANA with nucleolar pattern - anti-SCL-70, anti-centromere, or anti-RNA polymerase may be seen
80
major sx of scleroderma
- proximal scleroderma
81
minor sx of scleroderma
- sclerodactyly - digital ischemia with pitting scars or atrophy of finger pads - bibasilar pulmonary fibrosis
82
treatment for scleroderma
- no disease modifying meds - refer to rheum** - prob will require other specialists - treat symptomatically
83
prognosis of scleroderma
- worse in diffuse - worse in blacks, males, older pts - risk of lung and esophageal cancers
84
what is the most common cause of death in scleroderma
- lung disease (ILD or pulm HTN) | - cardiac and kidney disease death also common
85
Sjogren's syndrome
- chronic systemic autoimmune disease - destroys exocrine glands - dry mouth and eyes - majority of pts are women in 50s - increased risk of non-hodgkins lymphoma**
86
basic pathogenesis of sjogren's
- unknown trigger -> vascular endothelial cells in exocrine glands (in genetically predisposed pts) - lymphocytes activated - cytokines released - gland inflammation and destruction -> sicca sx and parotid swelling
87
primary Sjogren's
- dry eye and mouth
88
secondary Sjogren's
- complication of another autoimmune disease
89
sx of Sjogren's
- dry eye* - dry mouth* - difficulty chewing/ swallowing - increased cavities - bilat parotitis - dry skin, nose, vagina - muscle/ joint pain and weakness - will likely have another autoimmune disease
90
diagnostic criteria for Sjogren's
- need at least 2 of the following: - ocular staining score of at least 3 or more - biopsy of salivary glands shows lymphocytic sialadenitis - pos anti-SSA or anti-SSB - pos RF and ANA
91
schrimers test
- test for Sjogren's - measures tear production - pos if < 5 mm of wetting after 5 min
92
rose bengal staining
- test for Sjogren's - put solution in eye - slit lamp shows flecks of red over lower portion of cornea and conjunctiva
93
labs for Sjogren's
- ANA - Anti SSA and SSB - complement levels- low in severe - cyroglobulins in severe - CBC with diff - thyroid Ab often present - ESR elevated out of proportion to CRP
94
treatment of Sjogren's
- symptomatic - artificial tears - biotene products - fluid intake, gum - avoid anithistamines and anticholinergics - dentist, fluoride - muscarinics like cevimeline or pilocarpine