Rheumatology

Question 1

4 steps to rheum dx

Answer 1

1) Distribution
2) Acute/Chronic
3) Systemic Sx
4) Inflammation

Question 2

1) Distribution
Mono
Oligo
Poly
Migratory

Answer 2

MONOarticular
- OA, Gout, Septic Arthritis

OLIGOarticular assymmetric:
- Spodyloarthropathies (HLA-B27) ( Reactive arthritis, ankylosing spondylitis, psoriatic arthritis, enteropathic)

POLYarticular symmetric
- RA, SLE (no joint destruction)
- Viral (Hep. B, EBV, CMV, B19)

MIGRATORY
- RF, Gonoccocal dz, Lyme dz

Question 3

4) SIgns of Inflammatory cause

Answer 3

Morning stiff>1hr
Red, warm, tender
Erythematous joint
Increased ESR and CRP

Question 4

Contraindications to joint tap

Answer 4

Anticoag. / Bleeding disorders
Cellulitis at site

Question 5

WBC ranges
200-2000
5000-75000
>75000

Answer 5

200-2000= OA/ Traumatic arthritis
5000-75000= Inflammatory (RA, gout)
>75000= Septic arthritis (pus, turbid, purulent)

Question 6

Crystals
Gout
Pseudogout

Answer 6

Gout= Needle shape (-) brirefringent
Pseudogout= Rhomboid (+) birefringent

Question 7

+ANA

anti-dsDNA
anti-SM
anti-histone
anti-Ro()
anti-La()
anti-centro
anti-RNP
anti-Topoisomerase ()

Answer 7

anti-dsDNA= SLE(60%), lupus nephritis
anti-SM= SLE (30%)
anti-histone= Drug induced Lupus (Hydralazine, INH, Procainamide, Phenytoin, Penicillamine, Ethosuxamide)
anti-Ro(ssa)= Neonatal Lupus, SJogrens
anti-La(ssb)= Sjogrens
anti-centro= CREST (only these 5 sx)
anti-RNP= Mixed CT dz
anti Topoisomerase (anti-Scl 70)= scleroderma

Question 8

Erosions/ pannus formations on XR of joint

Answer 8

Think RA

Question 9

RA Mgmt

Answer 9

First line: Methotrexate
- If Inflammation present–> Add NSAID+ glucocorticoid (1wk)
MTX Side effects: Hepatotoxic, Lung Fibrosis, Mouth ulcers… If see mouth ulcers check cell lines… if decreased give leucovorin rescue if no response start backup: Hydroxychloroquine (SE: Retinopathy–> Eye exams q6mo)
Others: Sulfasalazine, Leflonamide, TNF-a inhib

Question 10

Baker Cyst

Answer 10

Popliteal
#1 cause= traumatic (ex. gardener, roofer; uses knees alot)

DDX: Ruptured Baker Cyst vs. DVT
Doppler will show no compromise w/ baker cyst

Question 11

SLE sx but (-) ANA

Answer 11

IF ANA (-) the patient does NOT have lupus

Question 12

Marker of Active lupus

Answer 12

Inc. dsDNA

Question 13

DDX for Lupus flare up

Answer 13

Steroid psychosis (if recently on steroid)
CVA/stroke
Infxn/meningitis

Question 14

Mgmt SLE

Answer 14

DoC= Chloroquine and Hydroxychloroquine for ALL

Steroids for major organ involvement and flare ups
Alt. (if cant take steroid):
Azathioprine (inhibit T cell) or
Cyclophosphamide (crosslinks DNA)-Toxic metabolite= Acrolin–> Hemorrhagic Cystitis/Transitional cell Carcinoma… Prevent with Mesna(1st line) or N-acetylcysteine (2nd line)

Question 15

Pregnancy and SLE

Answer 15

Fertility rate= normal
Spont. abortions–> Antiphospholipid Abs–> Hypercoag.
DoC mgmt: LMWH (Enoxaparin)
SCREEN ALL PREGN. WOMEN W/ SLE–> anti-Ro(ssa) to screen for NEONATAL LUPUS–> can get HEART BLOCK @ BIRTH

Question 16

Drug Induced Lupus

Answer 16

Limited form
No major organ involvement
Dx: Rash+anti-histone abs
complement=NRML

Mgmt: D/C offending drug

Question 17

Scleroderma (Systemic Sclerosis)

Answer 17

Thickening of skin (glove like pattern)
Raynaud phenomenon (vasospasms–> tx with DHP-CCB ex. Amlodipine, Nifedipine)

GI:
Esophageal dysmotility; hypomotility SI–> GERD–> PPI

Pulmonary:
Fibrosis, pum. HTN
Renal:
Malignant HTN (ACE-i/ARB; ALD-R (-))

TX: Glucocorticoids

Question 18

CREST

Answer 18

C- Calcinosis (calcium deposit in the skin)
R- Raynauds
E-Esophageal dysfxn
S-Sclerodactyly (Thickening/tightening of skin on fingers/ hands)
T- Telangiectasias (red marks on skin)

Question 19

DDX of BILATERAL Parotid enlargement

Answer 19

Sjogrens–>Dehydration–> Parotid stones
OR
Fingers in mouth (S. aureus infxn)–> Bulemics/ anorexics

Question 20

Sjogrens

Answer 20

CD8 mediated
Dry eyes/mouth
Lymphoprolif. dz –> Malignant Lymphoma
Bilateral Parotid enlargement
Itchy sand under eye feeling
Keratoconjuctivitis sicca–> corneal destruction–> May lead to blindness ( Prevent w/ synthetic tears)

Dx: Schirmer test (<9mm=underpdc tears confirm dry eyes)
ANA+ (nonspecific)–> anti-Ro(ssa)= specific may also be anti-la (ssb)
Salivary gland Bx–> lymphocytic infilt. but not necessary for dx.

TX: Glucocorticoid
Oral rinse
Synthetic tears

Question 21

Ankylosing Spondylitis
(General)

Answer 21

Usually <40y
Inflammatory disorder
HLA B27 (90%)
y M in 20s w/ chronic low back pain, morning stiffness >1hr gets better w/ exercise
Other DDx in absence of trauma= Metastatic prostate, Multiple myeloma
Tends to be ascending (sacroiliac joints 1st–> cervical last)
Bamboo spine= Syndesmophytes (fusion of vertebrae) mediated by IL17 (increased)

Question 22

Ank. Spond. Extra articular manifestations

Answer 22

Cardiac–> Aortic Insufficiency
Spine–> decreased motility
Eyes–> Ant. uveitis, conjunctivitis
Skin–> Erythema Nodosum (panniculitis) aka inflammation of the fat cells inder the skin

Question 23

Mgmt of Ank. Spond

Answer 23

NSAID
PT
Excercise
IL-17 inhib–>Sekulizumab

Question 24

Prognosis of patient with Ank. Spond

Answer 24

CHEST EXPANSION

Hypoventil–>Atelectasis–> PNA/ RHF (corpulmonale)

PPV (CPAP/BiPAP)…. no response–> Intubate+ MV

Question 25

Reactive arthritis causes and Mgmt

Answer 25

Complication of infxn in body (abs affect joints the infxn is not "in" the joints).... Tap joint--> Inflamm. not infxn Non-Gonococcal urethritis: 1. Chlamydia 2. Urea plasma Infectious Diarrhea: 1. **Campylobacter**= MC cause overall 2. Shigella 3. Salmonella Mgmt: NSAIDs: -Naproxen -Diclofenac -Indomethacin Prompt Abx

Question 26

Psoriatic Arthritis

Answer 26

DIP joint Nail Pitting and destruction (onycholysis) Dactylitis (sausage shaped fingers) +/- psoriasis Enthesitis Ant. Uveitis HLA B27 Dx: Clx TX: Glucocorticoids (prednisone) alt: TNF-a inhib Vit. D Emollients

Question 27

OA- Target? MC Joint affected? 2nd MC? Joint with greatest disability? Secondary causes?

Answer 27

Target- articular cartilage 2/2 Hypertrophy of bone NOT inflammatory dz MC- Knee 2nd- Thumb base Disability- Hip (Diff sitting/ getting up from bed; Diff climbing stairs) Secondary causes: - Gout - DM, Acromegaly - Hemochromatosis - Valgus, Varus

Question 28

Labs w/ OA

Answer 28

CRP and ESR= Nrml (not inflamm.) XR: Osteophytes (spurs/splinters) Unequal joint space Bouchard nodules (PIP) Heberden nodules (DIP)

Question 29

Mgmt OA

Answer 29

#1= weight reduction Correct poor posture PT Drugs 1st- NSAID no response then interarticular steroids Capsaicin (depletes substance P) Duloxetine (SNRI)

Question 30

Medications that predispose to gout:

Answer 30

(2/2 hyperuricemia) EtOH Diuretics: Hydrochlorothiazide, Furosemide Anit-TB: Pyrazinamide, Ethambutol Niacin Chemotherapy (add Allopurinol or Rasburicase)

Question 31

Mgmt Acute gouty arthritis

Answer 31

1st line= NSAID (Indomethacin) 2nd line Colchicine (SE: Watery diarrhea) Steroid (intra-articular/oral)- elderly Both above cleared by kidneys so if renal problems/PUD... alt: Celecoxib OR Glucocorticoid

Question 32

Chronic gout tx

Answer 32

Follow uric acid levels here! U/A<600= under secretors-->Probenacid U/A>700= Overpdc.--> XO(i)... Allopurinol OR Febuxostat

Question 33

Chondrocalcinosis

Answer 33

XR finding- linear radiodense deposits in joint menisci (can see meniscus when normally shouldnt) NOT SPECIFIC: seen in pseudogout, hemophilia, hemochromatosis

Question 34

Septic arthritis causes and mgmt

Answer 34

MCC: Gonorrhea 70% >40yo Elderly/child: S. aureus (pre-existing joint destruction) Non-GC (older) --> IV vanc GC (sexually active)--> IV ceftriaxone (+Doxy/Azithro if chlamydia not r/o) Therapeutic Arthtocentesis for both