Internal Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

OA/DJD px

osteoarthritis/degenerative joint disease

A

=loss of articular cartilage

  • absence of inflammation
  • significant pain
  • DIP > PIP & MCP
  • normal labs
  • inc risk with obesity
  • MCC of joint disease
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2
Q

Heberden’s vs Bouchard’s nodes

A

DIP vs PIP enlargement in OA

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3
Q

OA/DJD labs?

A

-normal ESR, ANA, CBC & rheumatoid factor

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4
Q

OA/DJD X-ray shows?

A
  • joint space narrowing
  • dense subchondral bone
  • bone cysts
  • osteophytes
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5
Q

OA/DJD tx

A
  • weight loss
  • acetaminophen = best initial

-NSAIDs

  • capsaicin cream, hyaluronic acid injection, intra-articular steroids
  • NO glucosamine or chondroitin sulfate
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6
Q

gout causes?

A
  • idiopathic overproduction
  • increased cell turnover (cancer, tumor lysis)
  • enzyme deficiency (Lesch-Nyan)
  • renal insufficiency
  • acidosis
  • thiazides (hyperGLUC)
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7
Q

gout px

A
  • men
  • podagra = MTP of great toe
  • tophi = urate crystal deposition (cartilage, bone, kidney)
  • uric acid kidney stones
  • red, warm, tender joint
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8
Q

gout dx

A

-joint aspiration = most accurate
(NEEDLE-shaped crystals with NEGATIVE birefringence on polarized light microscopy)

  • elevated WBC (neutrophils)
  • tap joint to exclude infection
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9
Q

gout acute attacks px

A
  • elevated ESR

- leukocytosis

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10
Q

gout tx

A
  • NSAIDs (acute attack) = best initial

- steroids –when no response or contraindication to NSAIDs (renal insufficiency)

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11
Q

gout chronic management

A
  • diet: dec alcohol, red meat intake
  • stop thiazides
  • colchicine (prevent 2nd attack)
  • probenecid and sulfinpyrazone (inc excretion of uric acid)
  • allopurinol (dec production)
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12
Q

colchicine SE

A

diarrhea

bone marrow suppression (neutropenia)

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13
Q

allopurinol SE

A
  • Stevens-Johnson syndrome
  • hypersensitivity reaction

-safe in renal injury
(as opposed to probenecid, sulfinpyrazone, NSAIDs)

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14
Q

pseudogout

A

= Ca pyrophosphate deposition in articular cartilage

  • risk factors: hemochromatosis, hyperPTH
  • DB, hypothyroid, WIlson’s
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15
Q

pseudogout px

A
  • affects LARGE joints (knee, wrist)

- does not affect DIP or PIP (as in DJD/OA)

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16
Q

pseudogout dx

A

-arthrocentesis = most accurate
(POSITIVELY birefringent RHOMBOID-shaped crystals)

  • elevated WBC
  • normal uric acid
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17
Q

pseudogout tx

A

-NSAIDs = best initial

  • intra-articular steroids (triamcinolone)
  • colchicine prevents 2nd attack
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18
Q

anti-cyclic citrulinated peptide

anti-CCP

A

most specific marker for Rheumatoid arthritis

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19
Q

spinal cord compression px

A
  • point tenderness at spine with percussion of vertebra

- hyperreflexia below level of compression

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20
Q

epidural abscess microbe, px

A
  • staph aureus
  • high fever
  • elevated ESR
  • point tenderness on percussion of vertebra
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21
Q

most common site of disc herniation? dx?

A

-L4/5 & L5/S1

  • dx with straight leg raise (low specificity, high sensitivity)
  • no MRI needed
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22
Q

L4 deficitis

A
  • motor: dorsiflexion of foot
  • reflex: knee jerk
  • sensory: inner calf
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23
Q

L5 deficits

A
  • motor: dorsiflexion of toe

- sensory: inner foot

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24
Q

S1 deficits

A
  • motor: eversion of foot
  • reflex: ankle jerk
  • sensory: outer foot
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25
low back pain etiology
- cord compression - epidural abscess - ankylosing spondylitis - cauda equina syndrome
26
low back pain dx
- xray = best initial test - MRI = most accurate -CT -for MRI contraindications; give contrast
27
imaging for disk herniation?
NO -unless there are neurologic deficits
28
cauda equina px
- bowel & bladder incontinence - erectile dysfunction - bilateral leg weakness - "saddle area" anesthesia
29
ankylosing spondylitis px
- <40YO - pain worsens with rest and improves with ACTIVITY - decreased chest mobility
30
cord compression tx
-reduce pressure: - systemic glucocorticoids - radiation of tumors - chemo for lymphoma
31
tx: cauda equina disk herniation (sciatica)
- surgical decompression | - NSAIDs, yoga, steroid injection; NOT bed rest
32
lumbar spinal stenosis px, dx, tx
- pain while walking - radiates to buttocks & thighs bilaterally - dec lower extremity reflexes - pain is less when leaning forward (cycling) - px like peripheral vascular disease, but normal vascular tests - dx: MRI - tx: surgical dilation of spinal canal, weight loss/steroid injections
33
fibromyalgia px
- young woman - chronic MSK pain - trigger points (trapezius, medial fat pad of knee, lateral epicondyle) - headaches - sleep disorders
34
fibromyalgia dx
- no tests (all tests are normal) | - based on hx and trigger points
35
fibromyalgia tx
- amitriptyline (TCA) - milnacipran (SNRI), pregabalin -NEVER steroids (bc not an inflammatory condition)
36
carpal tunnel px
- pain in hand (palm, thumb, index finger, radial half of ring finger, muscle atrophy) - pain worse at night -sensory symptoms occur BEFORE motor symptoms
37
carpal tunnel dx
- Tinel sign (tapping on median nerve) - Phalen sign (wrist flexion) -electromyography & nerve conduction tests = most accurate
38
carpal tunnel tx
- wrist splint = best initial (immobilization) - NSAIDs - steroids - surgery
39
dupuytren contracture
=hyperplasia of palmar fascia --> nodule formation --> contracture of 4th & 5th digits --> unable to extend fingers - associated with alcoholism & cirrhosis - tx: triamcinolone injection (steroid)
40
rotator cuff injury px, dx, tx
- worse at night when laying on shoulder - tenderness at supraspinatus insertion - dx: MRI = most accurate - tx: NSAIDs, rest, PT; steroids, surgery (for complete tears)
41
patellofemoral syndrome px, dx, tx
=anterior knee pain secondary to trauma, imbalance, of quads strength, meniscal tear - improves after walking - worse with stairs - dx: normal xray - tx: physical therapy - no knee brace or surgery
42
plantar fasciitis px, tx
- severe pain near calcaneus - worst in morning; IMPROVES with USE - "tac in the bottom of foot" - point tenderness where fascia inserts into calcaneus - tx: NSAIDs, stretching exercise, steroids - xray not useful
43
osteoporosis px
- older woman - asymptomatic fractures on routine DEXA scan - fractures of weight-bearing bones
44
osteoporosis dx
-DEXA scanning - osteopenia = T-score 1-2.5 SDs below normal - osteoporosis = T-score >2.5 SDs below normal - normal Ca, PTH
45
osteoporosis tx
-vit D & Ca = best initial - bisphosphonates (osteoporosis, not -penia) - estrogens (post-menopausal woman) - raloxifene (postmenopausal women; dec breast cancer risk, dec LDLs) - teriparatide =PTH analog - calcitonin
46
teriparatide SE
osteosarcoma (rats) | hyperCa
47
RA general facts
- women - autoimmune - pannus formation - morning stiffness - multiple small inflamed joints
48
RA px
- bilateral symmetrical bone involvement - PIP & MCP of hands - DIP spared - morning stiffness >30min - rheumatoid nodules - lung nodules, effusions, pericarditis - vasculitis - carpal tunnel syndrome - C1 & C2 subluxation -death in RA often from CAD
49
RA dx
- anti-cyclic citrilunated peptide (anti-CCP) - rheumatoid factor (nonspecific) - elevated ESR, CRP - anemia of chronic disease - lymphocytosis -do arthrocentesis to rule out gout, infection, etc
50
Sicca syndrome
=sjogren's disease | -dry eyes, mouth, mucous membranes
51
Felty syndrome
RA + splenomegaly + neutropenia -inc infections
52
Caplan syndrome
RA + pneumoconiosis + lung nodules
53
RA tx
- NSAIDs = best initial for pain - steroids (pain & bridging to DMARD) - must stop progression of disease.. with a DMARD - methotrexate = best initial DMARD - TNF inhibitors (infliximab, adalimumab, enteracept) - rituximab - hydroxychloroquine
54
erosive RA =
- joint space narrowing - physical deformity of joints - xray abnormality -DMARD = initial therapy (not an NSAID)
55
methotrexate SE
- liver toxicity - bone marrow suppression - pulmonary toxicity
56
TNF-inhibitor SE | infliximab, adalimumab, etanercept
- reactivation of TB | - inc susceptibility to other infections
57
rituximab
- removes CD20 lymphocytes from circulation - good for long-term - screen for HBV (which can be reactivated on this med) - can be combined with methotrexate
58
hydroxychloroquine SE
- toxic to retina | - must do a dilated eye exam
59
juvenile RA px | = Still disease
- high spiking fevers (>104F) + rash - rash: salmon color, chest & abdomen; occurs only with fever spike - splenomegaly, pericardial effusion, mild joint symptoms - no known etiology
60
juvenile RA dx, tx
- no clear dx - anemia, leukocytosis - normal ANA - elevated ferritin -tx: NSAIDs, ASA, steroids
61
SLE
- malar rash, photosensitivity, oral ulcers - arthritis in 90% of pts (normal X-ray) - serositis = inflammation of pleura & pericardium - membranous GN (RBC casts) - seizures, stroke, psychosis - anemia - leukopenia
62
SLE immunology
- ANA (high sensitivity) - anti-dsDNA & anti-Smith (specific) - false positive for syphilis
63
SLE tx
- acute tx: high dose steroids - hydrocychloroquine - GN: cyclophosphamide, myceopholate - bellmumab --> dec symptoms -need kidney biopsy for lupus nephritis
64
cause of death in SLE? young vs old?
young: infection old: MI due to accelerated atherosclerosis
65
antiphospholipid syndrome
IgG or IgM antibodies against negatively charged phospholipids - lupus anticoagulant - anticardiolipin antibodies
66
antiphospholipid syndrome px
- thrombosis of arteries AND veins - -> recurrent spontaneous abortions - elevated PTT - normal PT, INR
67
antiphospholipid syndrome dx
- false positive syphilis test (VDRL, RPR) - anticardiolipin antibodies (abortions) - lupus anticoagulant (elevated PTT) -mixing studies = best initial
68
mixing studies
- patient's plasma is mixed with normal plasma - measure new PT & PTT (should correct, ideally) - will correct with clotting factor deficiency - remains elevated in antiphospholipid syndrome
69
RVVT test = most specific for lupus anticoagulant
- prolonged in presence of antiphospholipid antibodies | - doesn't correct on mixing with normal plasma
70
CREST syndrome
``` calcinosis Raynaud esophageal dysmotility sclerodactyly telangiectasia ``` = limited scleroderma
71
scleroderma px
- young woman - GI dysmotility - fibrosis of skin/lung/myocardium - skin tightening - pulmonary HTN, restrictive lung disease - renal: hypertensive crisis
72
scleroderma dx
- anticentromere Ab = CREST syndrome - SCL-70 (anti-topoisomerase) = most specific - ANA (nonspecific) - ESR normal
73
scleroderma tx
- ACEI for renal crisis - PPIs for GERD/esophageal dysmotility - CCBs for Raynaud - cyclophosphamide for pulmonary fibrosis - bosentan or ambrisentan or sildanefil for pulmonary HTN
74
polymyositis px
- proximal muscle weakness - spares facial and ocular muscles (compared to myasthenia gravis) - dyspagia
75
dermatomyositis px
- malar involvement - heliotrope rash (edema, purplish eyelids) - Gottron papules = scaly patches over back of hands (PIP, MCP) - Shawl sign = erythema of face, neck, shoulders, upper chest, back -associated with cancer in 25% (ovary, lung, GI, lymph)
76
poly and dermatomyositis dx, tx
- CPK and aldolase (leak when muscles break down) - muscle biopsy = most accurate - MRI - electromyography - ANA, ESR, CRP, Rheumatoid factor elevated -tx: steroids; methotrexate, azathioprine, IVIG, mycophenolate, hydroxychloroquine
Internal Medicine
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