Flashcards in Rheumatology Deck (128):
A woman > 50 y/o presents with at least 6 weeks of symmetrical joint pain and morning stiffness involving multiple joints of the hands and lasting for more than 1 hour in the morning most likely suffers from ..
What are 8 possible criteria for diagnosing rheumatoid arthritis? (of which you only need 4)
1. morning stiffness lasting more than 1 hour
2. wrist and finger involvment (PIP, MCP)
3. swelling of at least 3 joints (except sacroilliac)
5. presence of rheumatoid nodule
6. X-ray abnormalities showing erosions
7. positive rheumatoid factor (RF) or anti-CCP
8. elevated C-reaction protein (CRP) or ESR
What is the single most accurate test for rheumatoid arthritis?
Anti- cyclic citrulinated peptide (anti-CCP)
A pt presenting with rheumatoid arthritis, splenomegaly and neutropenia most likely suffers from ...
What is the most important step in management prior to intubating a pt with rheumatoid arthritis?
check for C1/C2 cervical spine subluxation
.... is flexion of the proximal interphalangeal (PIP) joint with hyperextension of the distal interphalangeal (DIP) joint
(associated with rheumatoid arthritis)
... is extension of the proximal interphalageal (PIP) joint with flexion of the distal interphalageal (DIP) joint
Swan neck deformity
(associated with rheumatoid arthritis)
What are the 4 criteria involved in the new alternate diagnostic criteria for rheumatoid arthritis?
1. synovitis (can be single joint)
2. positive rheumatoid factor (RF) or anti-CCP
3. elevated ESR or CRP (C-reactive protein)
4. prolonged duration (>6 weeks)
What is the characterisitic hematologic finding in rheumatoid arthritis?
normocytic, normochromic anemia
What are the initial steps in management of a suspected rheumatoid arthritis pt? (7)
1. X-rays (erosions)
2. Rheumatoid factor
4. CBC (anemia)
6. CRP (C-reactive protein)
7. aspiration of joint (if effusion present)
What is the best initial therapy for rheumatoid arthritis?
NSAIDs with methotrexate (a disease modifying anti-rheumatic drug- DMARD)
What are the adverse side effects of methotrexate?
1. bone marrow suppression
3. liver disease
What is the next best step in management of a pt with rheumatoid arthritis in which NSAIDs and methotrexate have not been successful?
add biologic agents (infliximab, adalimumab, etanercept block TNF)
What is an adverse side effect of using hydroxycholorquine (type of DMARD)?
retinopathy (pt will require regular eye exams)
What is an adverse side effect of using sulfasalazine (type of DMARD)?
bone marrow suppresion
What is the mechanism of action of rituximab (alternate DMARD)?
What is the mechanism of action of anakinra (alternate DMARD)?
IL-1 receptor antagonist
What is the mechanism of action of tocilizumab (alternate DMARD)?
IL-6 receptor antagonist (added to methotrexate if needed)
What is the mechanism of action of leflunomide (alternate DMARD)?
pyrimidine antagonist (less toxic than methotrexate)
What is the mechanism of action of abatacept (alternate DMARD)?
inhibits T-cell activation
What is the major side effect of gold salts (used as alternate DMARD)?
An acutely ill rheumatoid arthritis pt with severe inflammation should receive what other medication other than NSAIDs and a DMARD as initial therapy?
steroids such as prednisone (bridge to DMARD therapy; allow time for DMARD to take effect)
A young male pt (
(also associated with uveitis, aortitis, restrictive lung disease)
What is the most accurate diagnostic test for ankylosing spondylitis?
MRI of sacroilliac joint
What diagnostic tests should be performed when a pt presents with suspected ankylosing spondylitis?
1. X-ray (followed by MRI)
2. HLA-B27 (positive)
3. ESR (elevated)
4. rheumatoid factor (negative)
What is the best treatment for ankylosing spondylitis? (3)
2. biological agents (infliximab, adalimumab)
A pt with the history of GU/GI infection presents with asymmetric arthritis (especially involving the knee), conjunctivitis, urethritis/ cervicitis/ circinate balantis (lesion around penis head) and keratoderma blenorrhagicum most likely suffers from ...
Reactive arthritis/ Reiter's syndrome
(triad of knee (joint), pee (urinary), see (eye))
What is the treatment for reactive arthritis/ reiter's syndrome?
A pt with a history of silvery scaled patches on their skin presents with nail pitting, arthritis of the sacroiliac spine and distal interphalangeal (DIP) joint, sausaged shaped fingers (dactylitis) and inflammation of tendinous insertion sites (enthesitis), negative for rheumatoid factor but positive for HLA-B27 most likely suffers from ...
(joint involvement with history of psoriasis)
What is the best initial treatment for psoriatic arthritis?
What is the best treatment for resistant psoriatic arthritis?
What is a disease that can possible occur from the use of anti-TNF agents?
reactivation of TB (old TB encased in granuloma held together by TNF)
A pt presenting with fever, myalgias, lymphadenopathy, polyarthritis, salmon-colored rash, hepatosplenomegaly, elevated transaminases, positive for HLA-B27 and negative for rheumatoid factor most likely suffers from...
Juvenile Rheumatoid Arthritis (JRA; adult-onset Still's disease)
What is the treatment for juvenile rheumatoid arthritis?
NSAIDs (use steroids if unresponsive to NSAIDs then use DMARD to get off steroid if needed)
What are the diagnostic findings associated with juvenile rheumatoid arthritis? (3)
1. very high ferritin
2. elevated WBC count
3. negative for rheumatoid factor (RF) and ANA
A pt presents with history of diarrhea, fat malabsorption (steatorrhea, vitamin ADEK deficiency) and weight loss presenting with joint pain most likely suffers from ...
What is the treatment for Whipple Disease?
trimethoprim- sulfamethoxazole (Bactrim)
What is the most accurate diagnostic test for Whipple Disease?
bowel biopsy showing PAS positive organism
An older pt presents with joint pain and morning stiffness that last less than 30 minutes with associated creptius of the joint, affecting the distal interphalangeal (DIP) joint, with the presents of osteophytes on DIP and/ or PIP joint most likely suffers from ...
What are Herberden's nodes?
DIP (distal interphalangeal) joint osteophytes (associated with osteoarthritis)
What are Bouchard's nodes?
PIP (proximal interphalageal) joint osteophytes (associated with osteoarthritis)
What is the best initial test for osteoarthritis?
X-ray of the joint
What is the best initial step in management for a pt presenting with suspected osteoarthritis? (5)
3. Rheumatoid factor
5. aspirate joint fluid (WBC
What is the best treatment for osteoarthritis?
acetominophen (with weight loss and exercise)
What are the 11 criteria used for diagnosing systemic lupus erythematous (SLE)? (4 of which are needed)
1. malar rash (butterfly)
2. photosensitivity rash
3. oral ulcer rash
4. discoid rash
5. arthalgias (joint pain)
6. hematologic abnormality (RBCs, WBCs, platelets)
7. renal abnormality (proteinuria to end stage)
8. neurological abnormality (behavioral, stroke, seizure, meningitis)
9. serositis (pericarditis, pleuritic chest pain, pulmonary HTN, pnemonia, myocarditis)
10. positive ANA
11. positive dsDNA
What is the best initial test for systemic lupus erythematous (SLE)?
What is the most accurate test for systemic lupus erythematous (SLE)? (2)
1. anit- ds DNA
2. anti-Sm (most specific)
What are the best tests to follow the severity of a systemic lupus erythematous flare-up? (2)
1. complement level (decreases in flare)
2. anti-dsDNA (increases in flare)
What is the best initial step in management of a pt with suspected systemic lupus erythematous (SLE)?
1. complement levels
What disease is a baby of a pregnant woman with lupus at risk for if anti-Ro or anti-SSA antibodies are present?
What is the treatment for acute flare-ups of systemic lupus erythematous?
steroids (prednisone); if severe disease relapse after cessation of steroids, use belimumab, azathioprine, cyclophosphamide)
What is the treatment for joint pain of systemic lupus erythematous?
NSAIDs (if joint pain or rash persist use hydroxychloroquine)
What is the treatment for nephritis in systemic lupus erythematous?
steroids and mycophenolate mofetil
what are the three most common causes of drug- induced lupus?
3. isoniazid (INH)
What is the major difference between drug-induced lupus and systemic lupus erythematous? (3)
1. drug induced results in anti-histone antibodies and always has positive ANA
2. no renal/ CNS involvement in drug induced
3. complement level and anti-dsDNA is normal in drug induced
A female pt presents with dry eyes, dry mouth, sensation of sand under they eyelid, loss of taste and smell, presence of anti-Ro/SSA and/ or anti-La/SSB and has history of teeth loss at an early age most likely suffers from ...
(can also have ANA and RF present)
What is the most accurate test for Sjogren's syndrome?
What is the schirmer test and what disease is it used for?
decreased wetting of paper held to eyes showing decreased lacrimation; Sjogren's syndrome
What is the treatment for Sjogren's syndrome?
pilocarpine- everywhere and cevimeline- salivary glands (increase ACh to increase oral and ocular secretions)
A pt presents with tight, fibrous thickening of skin, sclerodactyly (immobile fingers), raynaud's phenomenon (painful vascular hyperreactivity turning white-> blue-> red), giant capillaries in nail folds, and mild symmetrical joint pain most likely suffers from ...
Scleroderma (systemic sclerosis)
What other systems besides skin and joints are involved in Scleroderma (systemic sclerosis)?
1. lung (fibrosis, pulmonary HTN)
2. GI (reflux, barrett's esophagus, primary biliary cirrhosis)
3. heart (restrictive cardiomyopathy
4. renal (malignant HTN)
What diagnostic test is specific for scleroderma (systemic sclerosis)?
Antitopoisomerase (anti-Scl 70)
What is the treatments used for the different systems affected in scleroderma (systemic sclerosis)?
1. renal & HTN: ACE inhibitor
2. pulmonary HTN: bosentan, prostacyclin analogs, sildenafil
3. raynaud's: calcium channel blocker
4. GERD: PPI
5. lung fibrosis: cyclophosphamide
A pt presents with calcinosis of the fingers, raynaud's phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia most likely suffers from ...
CREST syndrome (limited scleroderma)
What diagnostic findings is more commonly associated with CREST syndrome (limited scleroderma)?
A pt presents with thickened skin that looks like scleroderma, "orange peel" appearance (peau d' orange), and marked eosinophilia that worsens with exercise most likely suffers from ...
What is the treatment for eosinophilic fasciitis?
A pt presents with inability to stand from seated position without using arms, muscle pain and tenderness, proximal muscle weakenss, elevated CPK and elevated aldolase most likely suffers from ...
A pt presents with rash, inability to stand from seated position without using arms, muscle pain and tenderness, proximal muscle weakenss, elevated CPK and elevated aldolase most likely suffers from ..
What are Gottron's papules and what disease are they associated with?
rash over metocarpophalangeal joint; dermatomyositis
What is a heliotrope rash and what disease is it associated with?
periorbital, purplish lesion around eyes; dermatomyositis
What is the Shawl sign and what disease is it associated with?
erythema of the shoulder and neck; dermatomyositis
What is the most accurate test for polymyositis and dermatomyositis?
What is the initial best step in management for suspected polymyositis and dermatomyositis? (5)
1. liver function test
2. CPK (elevated)
3. aldolase (elevated)
5. electromyogram (abnormal EMG)
What disease is a pt with signs and symptoms of polymyositis/ dermatomyositis with presents of anti-Jo1 antibody at risk for?
interstitial lung disease
What is the most common serious complication of polymyositis/ dermatomyositis?
What is the treatment for polymyositis/ dermatomyositis?
A female pt presents with muscle aches, muscle stiffness and pain that can be triggered by palpation at certain locations on the body, nonrefreshing sleep and may have depression and/or anxiety most likely suffers from ...
What is the best initial treatment for fibromyalgia?
milnaciprin, duloxetine, or pregabalin
(second line is TCAs)
A pt > 50 y/o presents with fatigue/ malaise, profound muscle pain and stiffness of the proximal muscles (shoulders, pelvic girdle) that is worse in morning and has associated elevated ESR and normocytic anemia most likely suffers from ...
What is the treatment for polymyalgia rheumatica?
A pt presenting with fatigue and malaise lasting more than 6 months and history of nonrefreshing sleep without any other abnormalities most likely suffers from ...
Chronic fatigue syndrome
A pt presents with fatigue, malaise, weight loss, fever, abdominal pain, renal involvement, testicular involvement, pericarditis, HTN, Hep B surface antigen, elevated ESR, joint pain and neuropathy most likely suffers from ...
(type of vasculitis)
(tx: prednisone and cyclophosphamide)
What is the best initial test for Polyarteritis Nodosa?
angiography of abdominal vessels
What is the most accurate test for vasculitis?
What is the best initial treatment for vasculitis?
steroids (prednisone and glucocorticoids)
A pt presents with upper and lower respiratory involvement, fever, malaise, joint pain and has c-ANCA present most likely suffers from ..
(tx: prednisone and cyclophosphamide)
A pt presents with fatigue, fever, skin lesion, joint pain, neuropathy along with eosinophilia, asthma and possibly p-ANCA or anti-myeloperoxidase most likely suffers from ..
A pt presents with headache, jaw claudication, visual disturbances, scalp tenderness and elevated ESR most likely suffers from...
Temporal arteritis (Giant cell arteritis)
What is the best initial step in management of a pt with suspected temporal arteritis (giant cell arteritis)?
give steroids (then perform tempral artery biopsy)
A young asian pt presents with history of fatigue, weight loss, arthralgia, anemia and increased ESR and develops loss/ decrease of pulses and may have had a stroke/ TIA most likely suffers from ...
What is the most accurate diagnostic test for suspected takayasu's arteritis?
1. aortic arteriography
2. magnetic resonance angiography (MRA)
What disease is associated with cryoglobulinemia?
A pt presents with fatigue, malaise, skin lesions, joint pain, hepatitis C and renal involvement most likely suffers from ...
(presence of cryoglobulins and rheumatoid factor)
What is the treatment for hepatitis C (associated with cryoglobulinemia)?
interferon and ribavirin
A pt of middle eastern/ asian decent presents with oral and genital ulcers, uveitis/ optic neuritis, and hyperreactivity to needlesticks (pathergy) most likely suffers from ...
(tx: prednisone and colchicines)
A man presents with sudden onset of severe toe pain that started at night, the toe is red, swollen and tender, and he has a history of binge drinking/ thiazide use/ nicotinic acid use most likely suffers from ...
What is the best initial test for gout?
arthrocentesis (joint fluid aspiration)
What is the most accurate test for gout?
polarized light exam showing negatively birefringent needles
What are diagnostic tests that can be used to detect gout? (4)
1. athrocentesis (cell count, culture, protein level)
2. serum uric acid
3. X-ray of toe (punched out lesions)
4. extremity exam for tophi
What is the best initial therapy for acute gouty attack?
NSAIDs (use steroids if unresponsive or NSAIDs contraindicated)
When should colchicine be used in gout treatment?
1. within 24 hour of attack
2. and if NSAIDs (renal insufficiency) and steroid can not be used
What are the side effects of colchicine?
3. bone marrow suppression
What is the best preventative treatment for gout?
allopurinol (lowers level of uric acid)
as well as weight loss and avoiding alcohol
What is the next best preventative treatment for gout if patient is intolerant of allopurinol?
febuxostat (xanthine oxidase inhibitor lowers uric acid)
What are the side effects of allopurinol?
2. allergic interstitial nephritis
What is the third line preventative treatment for gout when allopurinol and febuxostat are not enough?
uricase (rasburicase, pegloticase) break down uric acid
What is the reason probenecid and sulfinpyrazone are rarely used as preventative treatment for gout anymore?
increase urinary excretion of uric acid which is problematic in renal insufficiency
(they are never the right answer)
A pt with history of hemochromatosis/ hyperparathyroidism/ acromegaly/ hypothryoidism presents with joint inflammation of the knee and wrist that developed over a period of time most likely suffers from ...
Calcium Pyrophosphate Deposition Disease (Pseudogout)
(tx: NSAIDS or steroids)
What is the most accurate diagnostic test for calcium pyrophosphate deposition disease (pseudogout)?
polarized light exam of fluid showing positively birefringent rhomboid-shaped crystals
A pt presents with a swollen, red, immobile, tender joint and has a history of an arthritic/ prosthetic joint most likely suffers from ...
(Usually Staph > Strep> gram negative rod)
What is the best initial test for septic arthritis?
arthocentesis (joint fluid aspiration) showing > 50,000 WBCs
What is the most accurate diagnostic test for septic arthritis?
culture of joint fluid (too timely)
What is the best initial empiric therapy for septic arthritis?
ceftriaxaone and vancomycin
What other treatment combinations can be used to treat septic arthritis?
1. anti-Staph & Strep (oxacillin, nafcillin, cefazolin) with anti-gram negative (ceftriaxone, ceftazidime, gentamicin)
2. if penicillin allergic: anti Stap & Strep (vancomycin, linezolid, daptomycin, clindamycin) and anti- gram negative (aztreonam, fluoroquinolone)
A pt presents with pain, stiffness, aching, history of fractures and bowing of the tibia with possible sarcoma most likely suffers from...
Paget's Disease of Bone
What is the best initial test for paget's disease of bone?
alkaline phosphatase level (elevated)
What is the most accurate test for paget's disease of bone?
X-ray (osteolytic lesion early; osteoblastic lesions late)
What tests should be order when paget's disease of bone is suspected?
1. alkaline phosphatase
3. urinary hydroxyproline
4. serum calcium level (normal)
5. serum phosphatase level (normal)
6. bone scan
What is the treatment for paget's disease of bone?
bisphosphonates and calcitonin
A pt with history of osteoarthritis/ rheumatoid arthritis presents with swollen calf (posterior herniation of the synovium of the knee) most likely suffers from ...
(if ruptured, pseudo-phlebitis)
What diagnostic test is important to perform in a pt with suspected Baker's cyst?
ultrasound to exclude DVT
What is the treatment for Baker's cyst?
NSAIDs and steroid injection (if needed)
A pt presents with pain on the bottom of the foot that is extremely severe in the morning but gets better with walking a few steps most likely suffers from ..
What is the treatment for plantar fasciitis?
foot and calf stretches
A pt presents with pain on the bottom of the foot that is more painful with use and is associated with sensory deficits (numbness) most likely suffers from ..
Tarsal tunnel syndrome
What is the treatment for tarsal tunnel syndrome?
avoid boots and high heels (use steroid injections or surgery if needed)