Rheumatology

Question 1

Gout: acute and chronic management

Answer 1

Acute

1) NSAIDs
2. Corticosteroid injection (use when no response to NSAIDS or can’t use 2/2 renal insufficiency)
3) Colchicine (SE: Bone marrow suppression, diarrhea)

Chronic

1) Diet: exercise, no alcohol, no meat/seafood
2) Stop thiazides, lasix, asprin, Anti-TB (PE), niacin (use losartan first for HTN)
3) Colchicine: prevents your 2nd attack
4) Allopurinol: decreases uric acid production. If C/I use Febuxostat (both are xanthine oxidase inhibitors)
5) Pegloticase: dissolves uric acid, increases uric acid metabolism
6) Probenecid and sulfinpyrazone: increase excretion in kidney (uricosuric)

note: for renal injury avoid NSAID, probenecid, sulfinpyrazone. Allopurinol is safe in renal injury

Question 2

“Pseudogout”: Risk Factors and Associated with

Answer 2

Risk Factors:
Hemochromatosis
Hyperparathyroidism

Associated with:
Diabetes
Hypothyroidism
Wilson Disease

Question 3

“Pseudogout”: what joints get hit first

Answer 3

large joints: knee or wrist

DIP and PIP are NOT affected

Question 4

“Pseudogout”: treatment

Answer 4

1) NSAIDs
2) Corticosteroid injection (use when no response to NSAIDS or can’t use 2/2 renal insufficiency)
3) Colchicine prevents next attack (SE: Bone marrow suppression, diarrhea)

Question 5

Epidural Abscess: treatment for MRSA, MSSA, Acute neurologic defects

Answer 5

MRSA: Vanc, Linezolid
MSSA: Oxacillin, Nafcillin, Cefazolin
Acute Neuro Defects: Systemic glucocorticoids

Question 6

Motor Deficit, reflex lost, sensory lost
L4
L5
S1

Answer 6

L4: dorsiflexion foot, knee jerk, inner calf
L5: dorsiflexion toe, none, inner foot
S1: eversion of foot, ankle jerk, outer foot

Question 7

systemic signs A/W: Sjogren

Answer 7

dry eyes (sicca)
parotid enlargement

Question 8

Polyarticular symmetric:

Answer 8

RA
SLE
Viral: EBV, HepB, Parvo B19

Question 9

Monoarticular

Answer 9

OA
Septic Arthritis
Gout

Question 10

Migratory

Answer 10

Lyme
GC
Rheumatic Fever

Question 11

Oligoarticular Asymmetric

Answer 11

Spondyloarthropathies

• Ankylosing spondylitis: bamboo spine, uveitis, aortiis –> aortic regurg
• Reiter syndrome
• Psoriatic Arthritis

OA

Question 12

Contraindications to Joint Aspiration

Answer 12

• Cellulitis (overlying)

- Bleeding Diathesis: patient has a high INR, on warfarin, etc.

Question 13

Diseases with +RF

Answer 13

RA
Subacute Endocarditis
TB
Osteomyelitis

Question 14

p-ANCA

Answer 14

PAN
Churg-Strauss
IBD

Question 15

c-ANCA

Answer 15

Wegener’s

Question 16

Antiphospholipid Abs: findings

Answer 16

• lupus anticoagulant
• Anticardiolipin Abs
• Increased PTT (lab phenomenon)
• false +VDRL
• Hypercoagulable: presents with arterial and venous thrombosis
• spontaneous abortions

Question 17

4H’s of Pseudogout

Answer 17

MC elderly >50yo, pre-existing joint damage

• hemochromatosis
• hyperparathyroidsim
• hypophosphatasia
• hypomagnesemia

Question 18

RA: diagnostic criteria

Answer 18

1. Morning stiffness >1hr for 6wks
2. swelling wrists, MCP, PIP for 6wks
3. Swelling 3 joints for 6 weeks
4. Symmetric joint swelling for 6 weeks
5. Joint erosions on X-Rays
6. RF+
7. Rheumatoid nodules

Question 19

Felty Syndrome

Answer 19

RA
Splenomegaly
Neutropenia

Question 20

Caplan Syndrome

Answer 20

RA
Pneumoconiosis (coal miners lung)
Lung Nodules

Question 21

MC cause of death in RA

Answer 21

Coronary Artery Disease (CAD)

Question 22

MTX: S/E

Answer 22

• Liver Toxicity
• Bone Marrow suppression
• Pulmonary toxicity

need CBC and Liver panel every 3mo for 1st year

Question 23

R/A DMARDs Treatment and S/E

Answer 23

1) MTX (lung, liver, BM)
2) TNFi (TB, PPD)
3) Rituximab (CD20+, infections)
4) Hydroxychloroquine (monotherapy, retinal toxicity
5) Sulfasalazine (Rash, hemolysis G6PD, BM)

Question 24

Specific Ab’s for lupus

Answer 24

Anti-DS DNA

Anti-SM

Question 25

Dx a SLE flare by finding

Answer 25

C3, C4 decreased | DS DNA elevated

Question 26

Scleroderma vs. CREST (say abbreviation)

Answer 26

``` CREST: Calcinosis Raynaud Esophageal dysmotility Sclerodactyly Telangiectasia ``` Scleroderma: also involves lungs, heart, kidney (sudden hypertensive crisis)

Question 27

Scleroderma: Most-specific test

Answer 27

SCL-70 (anti-topoisomerase)

Question 28

Scleroderma: treatment

Answer 28

MTX Renal crisis: ACE inhibitor (even if high Cr) Esophageal dysmotility: PPI for GERD Raynaud: CCB Pulm Fibrosis: Cyclophosphamide Pulm HTN: bosentan, sildenafil, prostacyclin analogs

Question 29

Polymyositis/Dermatomyositis: - Best initial Test: - Most accurate:

Answer 29

- Best initial Test: CPK, aldolase - Most accurate: muscle biopsy Note: Anti-Jo Ab a/w lung fibrosis

Question 30

Polymyositis/Dermatomyositis: Tx

Answer 30

Steroids, but if steroids don't work - MTX - Azathioprine - IVIG - Mycophenolate - Hydroxychloroquine helps skin lesions

Question 31

Polymyositis/Dermatomyositis: Presentation

Answer 31

- proximal muscle weakness: difficulty getting up from seated position or walking up stairs - Malar - Shawl sign - Heliotrope rash - Gottron papules: PIP and MCP - CA: ovary, lung, GI, lymphoma

Question 32

Sjogren Syndrome: - best initial test: - best initial blood test: - most accurate test: - best initial therapy:

Answer 32

Sjogren Syndrome: - best initial test: Schrimer test - best initial blood test: SS-A and SS-B - most accurate test: lip or parotid biopsy - best initial therapy: water the mouth need to evaluate for lymphoma

Question 33

Behcet Syndrome | -What is "pathergy":

Answer 33

-sterile skin pustules from minor trauma like needle stick

Question 34

Behcet Syndrome: presentation treatment

Answer 34

Presentation: - Asian or middle-eastern person - painful oral and genital ulcers - erythema nodosum-like skin lesions - ocular lesions --> uveitis, blindness - Arthritis - CNS lesions mimicking MS tx: steroids

Question 35

Cryoglobuliinemia - presentation - a/w - treatment

Answer 35

- presentation: palpable purpura, proteinuria, hematuria, arthralgia, hepatosplenomegaly, hypocomplementemia - A/W: Hep C --> decreased C4 - Tx: Interferon, ribavirin, telaprevir or boceprevir steroids are NOT effective Lab tests: +RF, cold precipitable immune complexes

Question 36

Churg-Strauss: - presentation - most accurate test - treatment:

Answer 36

- presentation: asthma, eosinophilia - most accurate test: biopsy - treatment: prednisone, cyclophosphamide

Question 37

Anklyosing Spondlyitis: - best initial test: - Most accurate test: - Treatment

Answer 37

- best initial test: X-Ray sacroiliac joint - Most accurate test: MRI - Treatment: NSAIDs, exercise --> anti-TNF drugs

Question 38

Psoriatic Arthritis - best initial test - treatment

Answer 38

- best initial test: X-ray of joint, pencil-in-cup - Tx: NSAIDs --> MTX --> Anti-TNF STEROIDS ARE WRONG

Question 39

Reactive Arthritis - Cause - Test: - Treatment:

Answer 39

- Cause: IBD, STD, GI infection (Yersinia, Salmonella, Camp) - Test: none, tap joint to r/o septic joint - Treatment: NSAIDs --> Sulfasalazine

Question 40

Osteoporosis - Most accurate - T-score - Treatment

Answer 40

- Most accurate: DEXA - T-score: +2.5 SD - Treatment: Vit D, Ca, Bisphosphonates, ERT, Raloxifene, Teriparatide,Calcitonin

Question 41

Septic Arthritis - best initial and most accurate test: - best initial empiric therapy: - treatment for prosthetic joint:

Answer 41

- best initial and most accurate test: arthrocentesis - best initial empiric therapy: Ceftriaxone, Vanc - treatment for prosthetic joint: remove joint, Rx ABX 6wks, replace joint