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Flashcards in Rheumatology Deck (113):
1

recurrent inflammatory condition of cartilage of joints, nose, ears, costal cartilage and airways that shows tracheal narrowing on XR - dx? tx?

Dx. relapsing polychondritis
Tx. high dose oral prednisone

2

intensely red, ulcerated and pedunculated mass that formed after minor trauma and bleeds easily - Dx? Tx?

Dx. pyogenic granuloma
Tx. shave and electrodessication OR excision

3

diagnostic criteria for RA (4 out of 8)

1. morning stiffness > 1 hr
2. wrist and finger (MCP, PIP)
3. swelling of at least 3 joints
4. symmetric involvement
5. rheumatoid nodules
6. XR abnormalities
7. elevated CRP or ESP
8. positive RF or anti-CCP

4

single most accurate test for dx. RA

anti-CCP (>95% specificity)

5

Felty's syndrome

RA
splenomegaly
Neutropenia

6

MC involved joint in RA

MCP

7

Tests to order on CCS for RA

XR
RF and anti-CCP level
CBC (normochromic normocytic anemia)
sedimentation rate (high)
if there is an effusion --> joint aspiration

8

what joint in spared in RA

sacroiliac joint

9

standard of care for pts with RA

NSAID + DMARD

10

stepwise management of RA

1. NSAID always - doesnt matter which one
2. add Methotrexate
3. if MTX fails, add anti-TNF (infliximab, etanercept, adalimumab)

11

DMARDs that can be used in RA

MTX
anti-TNF
hydroxychloroquine (only mild disease)
rituximab (anti-CD20)
anakinra (IL1 R antagonist)
Toclizumab (IL6 R antagonist)
Abatacept
Leflunomide (similar in effect to MTX but less toxic)

12

s/e MTX

BM suppression
pneumonitis

13

what needs to be monitored if pt is on hydroxychloroquine

regular eye exam to check for retinopathy

14

role of steroids in managing RA

bridge to DMARD therapy when patient is acutely ill with severe inflammation

15

CF: ankylosing spondylitis

1. young male with back pain/stiffness, >3 mths, better w/ exercise; pain worse at night, relieved by leaning forward
2. limited ROM of lumbar spine; kyphosis
3. diminished chest wall expansion

16

assoc. conditions with ankylosing spondylitis

eye = acute anterior uveitis, cataracts, cystoid macular edema
aortitis; valvular dz - AR, MVP
restrictive lung disease - apical pulmonary fibrosis
varicocele
GI - nonspecific ileal and colonic mucosal ulcerations
IgA nephropathy

17

Tx. ankylosing spondylitis

NSAIDS
Biologic agents -- infliximab, adalimumab
Sulfasalazine

18

triad of knee pain, urinary difficulties dure to genital lesions and conjunctivitis in a patient with history of chlamydia, shigella, salmonella, yersinia or campylobacter infection - dx?

reactive arthritis

19

skin lesion characteristic of reactive arthritis

keratoderma blenorrhagicum

20

which joint is characteristically involved in psoriatic arthritis

DIP

21

Tx. reactive arthritis

NSAIDs
abx for acute infection
DMARDS: sulfasalazine, MTX if sulfa ineffective
progressive exercise

22

Tx. psoriatic arthritis

NSAIDs
if no response to NSAIDS --> start MTX
biologic anti-TNF also effective

23

dx criteria for juvenile RA

fever
salmon-colored rash
polyarthritis
LAD
myalgias
hepatosplenomegaly
elevated transaminases
elevated WBCs, high ferritin level
negative RF and ANA

24

Tx, JRA

NSAIDs
unresponsive cases with steroids

25

Pt presents with diarrhea, fat malabsorption, weight loss and joint pain - Dx? Test? Tx?

Dx. Whipple's disease
Test: biopsy of small bowel (PAS + org)
Tx. ceftriaxone followed by TMP/SMX for a year

26

MC involved joint in osteoarthritis

DIP joints

27

Tx. osteoarthritis

acetaminophen
weight loss, exercise

28

what symptom is present in 95% of SLE patients?

fatigue

29

SLE
- best initial test (1)
- most specific test (2)

1. ANA level
2. anti DS DNA or anti-Sm ab

30

best test to f/u severity of a flare in SLE

complement levels (decrease)
anti-DS DNA (rises)

31

which abs are a risk factor for developing heart block in baby

anti-RO and anti-SSA ab

32

Tx. acute flare ups of SLE

steroids

33

Tx. rash and joint pain in SLE not responding to NSAIDs

hydroxychloroquine
anti-malarials

34

Tx. severe SLE relapse upon cessation of steroids

bemalimumab
azathioprine
cyclophosphamide

35

Tx. lupus nephritis

steroids + mycophenolate mofetil

36

Dx. criteria Osler-Weber Rendu

1. recurrent epistaxis
2. cutaneous telengiectasias
3. proven visceral AV malformations
4. first degree relative

37

CF in drug-induced lupus

1. presence of anti-histone ab or positive ANA
2. NEVER renal or CNS involvement
3. complement and anti-DS DNA normal

38

drugs that may cause lupus

hydralazine
procainamide
isoniazid
penicillamine
minocycline
diltiazem
methyldopa
chlorpromazine
IFNalpha

39

most accurate test for diagnosing Sjogren's syndrome

lip biopsy or salivary gland biopsy

40

Schirmer test

decreased wetting of paper held to eye

41

pts with sjogrens are at increased risk of what cancer

B cell NHL (polyclonal activation and infiltration of salivary glands)

42

Tx. Sjogrens

keep eyes and mouth moist
Cevimeline --> more specific for oral and ocular secretions (increase Ach which increases secretions)
Pilocarpine

43

ab in Scleroderma

anti-topoisomerase (anti-Scl 70)

44

Tx. scleroderma with renal involvement and HTN

ACEI

45

Tx. scleroderma with pulmonary HTN

bosentan, prostacyclin analogs, sildenafil

46

Tx. scerloderma (Raynauds)

CCBs - nifedipine, amlodipine, diltiazem (not verapamil)

47

Tx. GERD assoc. with scleroderma

PPIs

48

Tx. lung fibrosis secondary to scleroderma

cyclophosphamide

49

dx. testing CREST syndrome

anti-centromere abs

50

Pt presents with thickened skin that has a peau d'orange appearance; On labs, he has marked eosinophillia. Dx? Tx?

Dx. Eosinophilic fascitis
Tx. steroids

51

presence of anti-Jo1 ab in dermatomyositis greatly increases risk for what disaese?

interstitial lung disease

52

what tests should you order for patient with suspected dermatomyositis or polymyositis?

CPK, aldolase
LFTs
ANA
EMG
biopsy - single most accurate

53

Tx, dermatomyositis/polymyositis

steroids

54

Tx. fibromyalgia

1. exercise
2. milnacipran, duloxetine, pregabalin - initial therapy

55

Tx. polymyalgia rheumatica

prednisone 10-20 mg/day (low dose)
if temporal arteritis involved --> 40-60 mg (high dose)

56

features of polyarteritis nodosa

vasculitis with additional findings of abdominal pain, renal involvement, testicular involvement, pericarditis, HTN, HEP B

57

best initial test for PAN

angiography of abdominal vessels

58

most accurate test for any vasculitis

biopsy!

59

Tx. PAN

prednisone
cyclophosphamide

60

lab test in Wegener's granulomatosis

c-ANCA

61

lab findings in Churg Strauss

p-ANCA
anti-myeloperoxidase ab
eosinophillia

62

Tx. Churg Strauss

steroids

63

young asian female + diminished pulses who presents s/p TIA

Takayasu arteritis

64

Dx. Takayasu arteritis

aortic arteriography or MRA

65

Hep C + pt presents with fatigue, malaise, skin lesions, joint pain and renal issues - dx?

cryoglobulinemia

66

Tx. hep C assoc. with cryoglobulinemia

ribavirin and interferon

67

Tx. Behcets dz

prednisone
colchicines

68

things that can exacerbate an acute gouty attack

binge drinking alcohol
thiazides
nicotinic acid
cyclosporin

69

tests to order on CCS for gout

arthrocentesis (best initial)
joint fluid examination: cell count, culture, protein
serum uric acid level
XR
extremity examination for tophi

70

best initial therapy for acute gouty attack

NSAIDs - indomethacin, ibuprofen
- if insufficient response or C/I to NSAIDs (renal failure), use steroids

71

when is colchicine beneficial for gout

1. first 24 hours of attack
2. C/I to NSAIDs, such as renal insufficiency
3. preventive therapy

72

which drugs lower the level of uric acid

allopurinol
probenicid
sulfinpyrazone

73

febuxostat

xanthine oxidase inhibitor
- used in gout if pt is intolerant of allopurinol

74

s/e allopurinol

rash
allergic interstitial nephritis
hemolysis

75

rasburicase/pegloticase

benign drugs that breakdown uric acid
- used if allopurinol or febuxostat is not enough

76

empiric therapy for septic arthritis

IV ceftriaxone and vancomycin

77

MC organisms causing septic arthritis

staph aureus
strep
gram negative bacili

78

best initial test for Paget's disease

serum Ca and ALP level
- elevated ALP, normal Ca

79

most accurate test for Paget's disease

XR
bone scan is more sensitive

80

for CCS, in case of Paget's disease what tests should you order

ALP
XR
urinary hydroxyproline
serum calcium level
serum phosphate level
bone scan

81

Tx. Paget's disease

NSAIDs - pain
bisphosphonates - usual treatment
calcitonin

82

complications of Paget's disease

bone fractures
tumors
high output heart failure
hypercalcemia and nephrolithiasis
compression neuropathy
arthritis of adjacent bone
hearing loss - 37% of pts

83

diagnostic testing for Baker's cyst

none - clinical diagnosis
order an USG to excluse DVT

84

Tx. Baker's cyst

NSAIDs

85

Tx. Mallet finger (extended finger is forcibly flexed)

extensor splinting for 4-5 weeks
tendinous injuries require 6-8 weeks

86

tests to order in pt with suspected fibromyalgia

CBC, ESR, TSH and muscle enzymes (CK)
if all normal, consider psych eval (30% have coexisting depression)

87

pt presenting with proximal muscle weakness and skin lesions - dx? in adults what is this related to often time

Dx. dermatomyositis
usually related to malignancy, esp in presence of RFs

88

CK levels > 10, 000 should make you think of what

rhabdomyolysis

89

CF: rhabdomyolysis

muscle tenderness
increased muscle tone
renal failure
hyperkalemia
hypocalcemia
hyperphosphatemia

90

Tx. rhabdomyolysis

immediate isotonic saline hydration
alkalinization of the urine with bicarb

91

what should you suspect in pt presenting with isolated proximal muscle weakness and what test should you order?

myopathy
order - EMG

92

best initial test in pt with suspected ankylosing spondylitis

plain film XR of sacroiliac joint

93

how do you monitor disease progression in pts with ankylosing spondylitis

AP/lateral XR of lumbar spine
lateral XR of cervical spine
pelvic XR, incl sacroiliac joint and hips
acute phase reactants i.e. ESR

94

next step in management of pt with SLE presenting with kidney involvement

kidney biopsy
- treatment is based on pattern of glomerular involvement

95

Tx. Type I and II lupus nephritis

no therapy required

96

Tx. extensive Type III and all type IV lupus nephritis

IV methylprednisolone

97

Tx. type V lupus nephritis

tx with steroids when proliferative lesions are superimposed

98

when do you use cyclophosphamide for SLE nephritis

if steroids are inadequate or pt has severe disease

99

what can be used to monitor dz activity in SLE

anti-dsDNA and complement levels

100

which ab levels in SLE have been assoc with development of lupus nephritis

anti-dsDNA ab

101

what SLE symptoms is hydroxychloroquine useful for?

arthralgias
serositis
cutaneous symptoms

102

young, female pt presenting with chronic knee pain that is worse with squatting. on exam, she has pain on extension of the knee with anterior patellar compression - dx?

patellofemoral syndrome

103

pain and tenderness at inferior patella; usually in "jumping" sports

patellar tendonitis

104

tx. patellofemoral pain syndrome

exercises to stretch and strengthen the thigh muscles

105

localized pain/tenderness at medial aspect of knee joint distal to the joint line; usually acute in onset

anserine bursitis

106

localized tenderness at tibial tubercle

osgood schlatter

107

anterior knee pain, acute onset, with visible swelling anterior to patella; may be secondarily infected

prepatellar bursitis

108

lateral shoulder or deltoid pain aggravated by reaching or lifting the arms up

rotator cuff tendonitis/tear - weakness + loss of strength
impingement syndrome
frozen shoulder - stiffness + decreased ROM

109

causes of anterior shoulder pain

acromioclavicular or glenohumeral joint OA
biceps tendonitis

110

posterior shoulder pain

usually referred from cervical spine
- nerve impingement 2 to disc herniation
- spinal stenosis

111

tx. of acute gout attack in pt with renal failure

intra-articular corticosteroids

112

which lab finding may be present in pt with inflammatory myositis...

elevated serum ferritin levels (acute phase reactant)

113

tx. inflammatory myositis

high dose steroids --> prednisone, 1mg/kg