Rheumatology

Question 1

Infection begins in skin, passes through muscle/tendon, reaches bone

Answer 1

Contiguous spread

Question 2

Devitalized bone acting as foreign body =

Answer 2

sequestrum –> chronic drainage, colonization, abx don’t reach bone

Question 3

Risk factors for hematogenous spread

Answer 3

IV drug useIV lines (dialysis, cancer)

Question 4

Presentation of osteomyelitis

Answer 4

Acute: pain, fever, pus, red/hot areaChronic: drainage, non-healing ulcer, probe to bone

Question 5

Metal device contaminated, spreads to bone

Answer 5

Surgical/trauma spread

Question 6

Most common cause of septic arthritis

Answer 6

Bacterial (usually S. aureus but don’t forget Gonococcal)Can also be viral, fungal, mycobacterial

Question 7

Hematogenous likely organisms

Answer 7

Usually one organismUsually S. aureusMay also be Coag - staph, gram - rods

Question 8

Arthrocentesis in septic arthritis will show

Answer 8

High WBC (>50,000), High % neutrophil (>90%), high protein perform crystal analysis to r/o

Question 9

Risk factors for septic arthritis contiguous spread

Answer 9

Cellulitis, abscess, osteomyelitis next to joint, Diabetes

Question 10

Blood infection reaches bone

Answer 10

Hematogenous spread

Question 11

Labs for osteomyelitis

Answer 11

Inflammatory markers, High WBC

Question 12

Risk factors for septic arthritis hematogeneous spread

Answer 12

IV drug useIV lines (dialysis, cancer)Sexual intercourse (gonococcal)

Question 13

Contiguous likely organisms

Answer 13

Usually polymicrobial (travel via skin)Usually S. aureusAlso streptococci, Coag - staph, gram - rods, anaerobes

Question 14

Risk factors for contiguous spread:

Answer 14

uncontrolled diabetesneuropathycallus/foot deformity

Question 15

Polymicrobial bloodstream infections are common in

Answer 15

IV drug users

Question 16

Diagnosing Osteomyelitis:

Answer 16

Labs (ESR, CRP, WBC) + imaging (X-ray or MRI)Bone biopsy for 100%

Question 17

Location of hematogenous osteomyelitis in children

Answer 17

metaphysis in long bones(nutrient artery comes into bone, makes loop –> slow blood stream, few phagocytic cells)

Question 18

Symptoms: pain, fever, pus, red/hot area

Answer 18

osteomyelitis

Question 19

Red, hot, painful joints are characteristic of

Answer 19

SEPTIC arthritis

Question 20

Diagnosing Gonococcal arthritis considers

Answer 20

young adults, polyarthritis, urethral/cervix/throat discharge

Question 21

What is important in treating after wash/drainage and IV antibiotics?

Answer 21

Early ROM exercise for affected joints

Question 22

Osteoarthritis is inflammatory/non-inflammatory

Answer 22

non-inflammatory

Question 23

Tibiofemoral knee presentation

Answer 23

Medial pain (varus), limited flexion, deformity, instability, mechanical catching, stair difficulty

Question 24

Imaging for OA includes

Answer 24

AP pelvis, true later, frog-leg lateral

Question 25

Characterisitic findings of OA include

Answer 25

Subchondral bone hypertrophyCartilage (joint-space) lossOsteophytesSubchondral cysts

Question 26

Pharm used for OA injections

Answer 26

cortisone analoghyaluronate (not recommended)(cannot regrow cartilage)

Question 27

Patellofemoral knee presentation

Answer 27

anterior knee pain, pain ascending stairs (not as bad as tibiofemoral)

Question 28

Nerve responsible for knee pain with hip arthritis

Answer 28

Obturator nerve referred pain

Question 29

Late issues leading to joint replacement revision

Answer 29

OsteolysisLooseningWear

Question 30

Heberden's nodes are on

Answer 30

DIP joint

Question 31

Oral pharm for OA

Answer 31

oral NSAIDs

Question 32

Evaluation of OA may include these labs

Answer 32

Inflammatory labs to r/o inflammatory arthritis, infection

Question 33

Bouchard's nodes are on

Answer 33

PIP joint

Question 34

A medial wedge would be used for

Answer 34

Varus knee moment

Question 35

Fusion might be used in _______ and is effective by _____________

Answer 35

Foot, ankle, spine; eliminating motion

Question 36

A lateral wedge would be used for

Answer 36

Valgus knee moment

Question 37

Physical risks of hip or knee replacement include

Answer 37

Thromboembolitic disease (DVT, PE)Neurovascular injuryBleedingWound healing issuesFracture (intra or post op)Hip: dislocation, limp, HO, LLDKnee: stiffness, laxity, PF problemsCardiopulm: MI, stroke, death

Question 38

Pain and swelling in big toe

Answer 38

Podagra

Question 39

Triggering events in gout attack

Answer 39

TraumaDietary/OH excessDiuretic use/change

Question 40

Risk of gout:

Answer 40

Age, family history, obesity, diabetes, HTN, OH use, acute illness, surgery

Question 41

Calcium pyrophosphase (CPP) crystals are deposited in

Answer 41

articular cartilagemenisci, synovium, periarticular tissues

Question 42

May be used to treat CHRONIC inflammatory CPPD

Answer 42

Hydroxychloroquine, Methotrexate if NSAIDs or Colchisine inadequate

Question 43

Intercritical period in gout is

Answer 43

Asymptomatic periods

Question 44

How likely is another acute gout attack in the first year after a first attack/presentation?

Answer 44

60%

Question 45

Allopurinol side effects

Answer 45

Allopurinol hypersensitivity, NVD, marrow suppression, hepatitis, fever, vasculitis, alopecia

Question 46

CPPD is associated with

Answer 46

aging, hyperparathyroidism, hemochromatosis, trauma, hypophos/hypomag

Question 47

Asymptomatic hyperuricemia begins at

Answer 47

Puberty for menMenopause for women

Question 48

Clinical presentation of CPPD

Answer 48

Usually mostly asymptomatic

Question 49

Asymptomatic hyperuricemia is associated with

Answer 49

hypertension, hyperglycemia, obesity, hyperlipidemia, CV disease

Question 50

Tophi =

Answer 50

Aggregated MSU crystalsUsually located on ulnar surface of forearms, tendons, olecranon, ear, joints

Question 51

Options for acute gout therapy

Answer 51

colchicine NSAIDcorticosteroidsjoint injection if no infection

Question 52

Febuxostate

Answer 52

non-competitive xanthine oxidase inhibitor

Question 53

Joints affected by Acute Gout

Answer 53

MTP, instep, ankles, knees, prepaterllar/olecranon bursae

Question 54

Acute gout is usually ______articular

Answer 54

MONOarticular

Question 55

Allopurinal, Febuxostate are...

Answer 55

Xanthine oxidase inhibitors Stop purine metabolism, uric acid doesn't form

Question 56

It is possible for people in an acute attack to have a normal uric acid level

Answer 56

True - 50% will have normal level

Question 57

Acute CPP (pseudogout) presents with

Answer 57

acute/subacute arthritis for several days, monoarthritis (knees, wrists), podagra UNcommon, may follow surg/trauma/illness/diuresis

Question 58

Characteristic Radiology finding of Tophi/Chronic gout

Answer 58

Punched out erosions surrounded by radiodensityJoint space preservation, normal mineralizationLate disease: punched out lesions with overhanging edges

Question 59

Chronic/tophaceous gout is usually _____articular

Answer 59

POLYarticular

Question 60

Side effects include cardiovascular (MI, CVA), elevated liver transaminases, gout flare

Answer 60

Febuxostat

Question 61

Chronic Kidney Disease is probably d/t

Answer 61

precipitation of uric acid crystalshypertensiondiabetesRaising SUA induces glom HTN, fibrosisLowering SUA may slow CKD progression

Question 62

Presumptive Gout Diagnosis

Answer 62

Rapid, severe painPain, erythema, swellingHyperuricemia

Question 63

Chronic Inflammatory CPPD presents as

Answer 63

polyarticular, symmetric arthritis of small joints in hands/feet

Question 64

What happens when phagocytes ingest crystals?

Answer 64

Lysis and inflammatory response

Question 65

mimics DJD

Answer 65

OA with CPP clinical presentation

Question 66

Risk for kidney stones is _______ to uric acid level (SUA)

Answer 66

proportional

Question 67

Colchicine

Answer 67

Inhibits microtubule formation (turn off cytokine cascade, inhibit NLRP3 assembly)

Question 68

What is released with macrophace lysis?

Answer 68

IL-1, IL-18, cytokinesFollowed by neutrophil infiltration

Question 69

Management of Gout

Answer 69

Baseline: Ed, diet, lifestyleLook for secondary hyperuricemia causesAcute therapy (colchicine, NSAID, corticosteroids, joint injection if no infection)

Question 70

Diagnosis of CPPD

Answer 70

Weakly birefringent, Positive birefringents (aligned blue calcium)Rhomboid crystals, intracellular

Question 71

Things that can lead to hyperuricemia

Answer 71

High purine dietAlcohol (beer highest)Fructosecell deathATP -> AMP -> Uric acid

Question 72

XOI alternative

Answer 72

Probenecid

Question 73

Diagnosis of Gout

Answer 73

Demonstrate needle shaped crystal inside cell, Negatively birefringent, Parallel-yellow (plane of polarization)(If the crystal is perpendicular to plane it will be blue)

Question 74

CPPD radiology features

Answer 74

Cartilage calcification (deposition into fibrous/hyaline calcium)Uniform joint space lossNo erosionsKnees > Hands > Symphasis

Question 75

Uricosuric added to XOI if

Answer 75

XOI not tolerated, under 60, normal renal function, no history of stones, more than 2 attacks/year,