Rheumatology Flashcards Preview

USMLE Step 3 > Rheumatology > Flashcards

Flashcards in Rheumatology Deck (187):
1

- women greater than 50 yoa
- joint pain
- MORNING stiffness; SYMMETRICAL, multiple joints of hands, LASTS MORE THAN 1 HOUR
- symptomatic episodes last for at least 6 weeks

rheumatoid arthritis

2

how is rheumatoid arthritis (RA) defined?

4 or more of the following:

1. morning stiffness more than 1 hour
2. wrist and finger involvement
3. swelling of at least 3 joints
4. SYMMETRIC involvement
5. rheumatoid nodules
6. XR showing erosions
7. POSITIVE RF, or anti-CCP Ab
8. elevated CRP, or ESR
9. synovitis

3

cardiac findings in RA

- pericarditis
- valvular disease

4

pulmonary findings in RA

- pleural effusion with VERY LOW glucose level
- lung nodules

5

hematological findings in RA

anemia with NORMAL MCV

6

neurological findings in RA

mononeuritis multiplex

7

dermatological findings in RA

nodules

8

Felty's syndrome

1. RA
2. splenomegaly
3. neutropenia

9

joint findings in RA

- MCP (metacarpophalangeal) swelling and pain
- Boutonniere deformity
- swan neck deformity
- Baker's cyst
- C1/C2 cervical spine subluxation

10

Boutonniere deformity

PIP flexion with DIP hyperextension

11

swan neck deformity

PIP extension with DIP flexion

12

Baker's cyst

outpocketing of synovium at back of knee

13

treatment for RA

NSAIDs with DMARD

(disease-modifying antirheumatic drug)

14

which joint is SPARED in RA?

sacroiliac joint

15

what should be started to eliminate XR abnormalities in RA?

DMARDs

16

BEST INITIAL DMARD to start in RA

methotrexate

17

adverse effects of methotrexate

- bone marrow suppression
- pneumonitis
- liver disease

18

name the DMARDs

- methotrexate
- biological agents (infliximab, adalimumab, etanercept)
- hydroxychloroquine
- sulfasalazine

19

name the alternate DMARDs

- rituximab
- anakinra
- tocilizumab
- leflunomide
- abatacept
- gold salts

20

MOA of rituximab

anti-CD20 Ab

21

MOA of anakinra

IL-1 receptor antagonist

22

MOA of tocilizumab

IL-6 receptor antagonist

23

MOA of leflunomide

pyrimidine antagonist (similar to methotrexate)

24

MOA of abatacept

inhibits T-cell activation

25

MOA of biological agents (infliximab, adalimumab, etanercept)

block TNF-a

26

what could be added if methotrexate alone fails?

biological agents (infliximab, adalimumab, etanercept)

27

patient being treated with hydroxychloroquine, should get?

regular eye exams

28

adverse effect of sulfasalazine

bone marrow suppression

29

adverse effect of gold salts

nephrotic syndrome

30

what is the role of steroids in RA?

- BRIDGE to DMARD therapy
- to treat acutely ill pt with severe inflammation

31

name the seronegative spondyloarthropathies (4)

1. ankylosing spondylitis
2. reactive arthritis
3. psoriatic arthritis
4. juvenile rheumatoid arthritis

32

characteristics of seronegative spondyloarthropathies

- RF NEGATIVE
- predilection for SPINE
- sacroiliac joint INVOLVEMENT
- association with HLA-B27

33

- young male, less than 40 yoa
- back stiffness, worse at NIGHT, relieved by LEANING FORWARD
- kyphosis = diminished chest expansion

ankylosing spondylitis

34

rare findings in ankylosing spondylitis

- uveitis
- aortitis
- restrictive lung disease

35

best INITIAL test for ankylosing spondylitis

CXR

36

MOST ACCURATE test for ankylosing spondylitis

MRI of SI joint

37

treatment for ankylosing spondylitis

- NSAIDs
- biological agents (infliximab/adalimumab)
- sulfasalazine

38

- asymmetric arthritis with h/o URETHRITIS, or GI INFECTION
- fever
- fatigue
- weight loss
- circinate balanitis
- conjunctivitis
- keratoderma blenorrhagicum

reactive arthritis

39

diagnostic triad for reactive arthritis

1. knee (joint)
2. pee (urinary)
3. see (eye)

- h/o Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter

40

treatment for reactive arthritis

reactive arthritis

41

- h/o psoriasis
- sacroiliac spine involvement
- nail pitting
- DIP involvement
- dactylitis ("sausage-shaped" digits)
- enthesis (inflammation of tendon insertion sites)

psoriatic arthritis

42

diagnostic test for psoriatic arthritis

NONE

43

best INITIAL treatment for psoriatic arthritis

NSAIDs

44

treatment for RESISTANT psoriatic arthritis

methotrexate

45

other treatment for psoriatic arthritis

infliximab

46

- fever
- salmon-colored rash
- polyarthritis
- lymphadenopathy
- myalgias
- hepatosplenomegaly
- elevated transaminases

juvenile rheumatoid arthritis (JRA)

47

diagnostic test for JRA

NONE

48

characteristic diagnostic tests for JRA

- very high ferritin
- elevated WBCs
- NEGATIVE RF
- NEGATIVE ANA

49

treatment for JRA

NSAIDs

50

treatment for JRA unresponsive to NSAIDs

steroids

51

treatment for JRA with persistent symptoms

methotrexate, or anti-TNF medications

52

- diarrhea
- fat malabsorption
- weight loss

whipple disease

53

MOST COMMON PRESENTING SYMPTOM OF WHIPPLE DISEASE

JOINT PAIN

54

MOST SPECIFIC test for whipple disease

bowel biopsy showing PAS positive organisms

55

- morning stiffness LESS THAN 30 MINUTES
- CREPITUS on moving joints
- DIP joints

osteoarthritis (OA)

56

name of DIP osteophytes in OA

Heberden's nodes

57

name of PIP osteophytes in OA

Bouchard's nodes

58

best INITIAL test for OA

joint XR

59

diagnostic tests that should be ordered for OA

- ANA
- ESR
- RF
- anti-CCP Ab

60

treatment for OA

acetaminophen

61

how many criteria for systemic lupus erythematosus (SLE) are there, and how are needed to confirm the diagnosis?

- 11
- 4 NEEDED TO CONFIRM DIAGNOSIS

62

diagnostic criteria for SLE

1. malar rash
2. discoid rash
3. photosensitivity rash
4. oral ulcers
5. arthritis
6. serositis
7. kidney d/o
8. neurological d/o (seizures/psychosis)
9. blood d/o (anemia/leukopenia/lymphopenia/thrombocytopenia)
10. anti-DNA, anti-Smith, or anti-phospholipid Abs
11. ANA

63

best INITIAL test for SLE

ANA

64

MOST SPECIFIC test for SLE

anti-dsDNA Ab, or anti-Smith Ab

65

what is the best to follow the severity of a lupus flare-up?

complement levels (drop), and anti-dsDNA Ab (rise)

66

the presence of anti-Ro, or anti-SSA Abs is a risk for development of?

heart block

67

joint XR finding in SLE

normal

68

type of anemia in SLE

ACD is more common than hemolysis

69

only test MORE specific for lupus than anti-dsDNA Ab

anti-Smith Ab

70

other findings in SLE NOT part of diagnostic criteria

- fatigue
- hair loss
- antiphospholipid syndrome
- elevated sedimentation rate

71

treatment for ACUTE FLARE in SLE

steroids

72

treatment for joint pain in SLE

NSAIDs

73

treatment for rash and joint pain NOT responding to NSAIDs

hydroxychloroquinolone

74

treatment for SEVERE DISEASE UPON CESSATION OF STEROIDS for SLE

- belimumab
- azathioprine
- cyclophosphamide

75

MOA of belimumab

inhibits B cells

76

treatment for nephritis in SLE

- steroids and mycophenolate, OR
- steroids and cyclophosphamide

77

MOA of mycophenolate

inhibits B- and T-lymphocyte proliferation

78

MOA of cyclophosphamide

alkylates and crosslinks DNA

79

MCC's of drug-induced lupus

- hydralazine
- procainamide
- isoniazid

80

drug-induced lupus ALWAYS has

- anti-HISTONE Ab
- POSITIVE ANA

81

drug-induced lupus NEVER has

renal, or CNS involvement

82

complement level, and anti-dsDNA Ab are what in drug-induced lupus?

NORMAL

83

- women (9:1 female predominance)
- dry eyes
- dry mouth
- "sand under eyelids"
- loss of taste and smell
- loss of teeth at an early age

Sjogren's syndrome

84

MOST ACCURATE test for Sjogren's syndrome

lip biopsy

85

other diagnostic test for Sjogren's syndrome

Schirmer test (paper held to eye to test lacrimation)

86

serologic testing for Sjogren's syndrome

- ANA (95% +)
- RF (70% +)
- anti-Ro/SSA Ab (50-65% +, but specific)
- anti-La/SSB Ab (30-65% +, but specific)

87

treatment for Sjogren's syndrome

- pilocarpine
- cevimeline

(keep eyes and mouth moist)

88

MOA of pilocarpine, and cevimeline

increase acetylcholine

(cevimeline is specific to salivary glands)

89

- woman with tight, fibrous thickening of skin
- tight, immobile fingers (sclerodactyly)
- Raynaud's phenomenon
- digital ulceration
- joint pain (mild and symmetrical)

scleroderma (systemic sclerosis)

90

lung involvement in scleroderma

fibrosis and pulmonary hypertension

(leading cause of death)

91

GI involvement in scleroderma

- esophageal dysmotility
- PBC (primary biliary cholangitis in 15% of patients)

92

heart involvement in scleroderma

restrictive cardiomyopathy

93

renal involvement in scleroderma

may lead to malignant hypertension

94

diagnostic test for scleroderma (systemic sclerosis)

- NO single diagnostic test
- ANA
- anti-topoisomerase Ab (anti-Scl 70)

95

treatment for scleroderma

NO treatment (no treatment is effective in stopping it)

96

treatment for renal involvement and HTN in scleroderma

ACEI

97

treatment for pulmonary HTN in scleroderma

- bosentan (endothelin antagonist)
- prostacyclin analogs
- sildenafil

98

treatment for Raynaud's phenomenon in scleroderma

CCB

99

treatment for GERD in scleroderma

PPI

100

treatment for lung fibrosis

cyclophosphamide

101

CREST syndrome (limited scleroderma)

- Calcinosis of fingers
- Raynaud's
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia

102

diagnostic testing for CREST syndrome

anti-centromere Ab

103

thickened skin that looks like scleroderma, WITHOUT:

- hand involvement
- Raynaud's
- heart, lung, or kidney involvement
- MARKED EOSINOPHILIA
- "orange peel" (peau d'orange)
- symptoms are worse with exercise

eosinophilic fasciitis

104

treatment for eosinophilic fasciitis

steroids

105

- cannot get up from seated position
- muscle pain and tenderness
- PROXIMAL muscle weakness
- signs of muscle inflammation

polymyositis

106

- muscle pain and tenderness
- PROXIMAL muscle weakness

PLUS

- Gottron's papules (metacarpophalangeal joint surfaces)
- heliotrope rash (periorbital purplish rash)
- Shawl sign (shoulder/neck erythema)

dermatomyositis

107

tests for polymyositis and dermatomyositis

CPK and aldolase

108

MOST ACCURATE test for polymyositis and dermatomyositis

muscle biopsy

109

the presence of anti-Jo 1 Abs is a risk for development of?

interstitial lung disease

110

MC serious complication of PM/DM

malignancy

111

treatment for PM/DM

steroids

112

- women, with muscle aches and stiffness with TRIGGER POINTS on palpation and nonrefreshing sleep
- depression, and anxiety

fibromyalgia

113

blood tests for fibromyalgia

ALL NORMAL

114

what objective evidence is there for fibromyalgia?

NONE

115

best INITIAL treatment for fibromyalgia

- milnacipran
- duloxetine
- pregabalin

116

- patient 50 years or older
- profound pain, and stiffness of proximal muscles
- stiffness worse in morning
- elevated ESR

polymyalgia rheumatica (PMR)

117

on presentation, all forms of vasculitis can have

- fatigue, malaise, weight loss
- fever
- skin lesions
- joint pain
- neuropathy (mononeuritis multiplex)

118

common laboratory features in all forms of vasculitis

- normocytic anemia
- elevated ESR
- thrombocytosis

119

MOST ACCURATE test for all forms of vasculitis

biopsy

120

best INITIAL treatment for all forms of vasculitis

steroids

121

if steroids are not effective, what alternate treatment and/or additional treatment can used for all forms of vasculitis

- cyclophosphamide
- azathioprine/6-mercaptopurine
- methotrexate

122

adverse effect of methotrexate

liver, and lung fibrosis

123

PAN features:

- abdominal pain
- renal involvement
- testicular involvement
- pericarditis
- HTN

124

best INITIAL test for PAN

abdominal vessel angiography

125

MOST ACCURATE test for PAN

skin, muscle, or sural nerve biopsy

126

treatment for PAN

prednisone and cyclophosphamide

127

PAN does NOT affect what?

LUNGS

128

is found in 30% of PAN

hepatitis B

129

name the vasculitides (7)

1. polyarteritis nodosa (PAN)
2. Wegener's granulomatosis (granulomatosis with polyangiitis)
3. Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
4. temporal arteritis (giant cell arteritis)
5. Takayasu's arteritis
6. cryoglobulinemia
7. Behcet disease

130

Wegener's granulomatosis (granulomatosis with polyangiitis)

- UPPER AND LOWER respiratory findings
- c-ANCA

131

MOST ACCURATE test for Wegener's granulomatosis (granulomatosis with polyangiitis)

biopsy

132

treatment for Wegener's granulomatosis (granulomatosis with polyangiitis)

prednisone and cyclophosphamide

133

Churg-Strauss (eosinophilic granulomatosis with polyangiitis)

- vasculitis
- EOSINOPHILIA
- ASTHMA

134

MOST ACCURATE test for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)

biopsy

135

treatment for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)

steroids

136

temporal arteritis (giant cell arteritis)

- headache
- jaw claudication
- visual disturbance
- scalp tenderness
- ASSOCIATED WITH POLYMYALGIA RHEUMATICA

137

MOST ACCURATE test for temporal arteritis (giant cell arteritis)

biopsy

138

treatment for temporal arteritis (giant cell arteritis)

steroids

139

- young Asian female
- diminished pulses
- TIA/stroke (from vascular occlusion)

Takayasu's arteritis

140

how is Takayasu's arteritis diagnosed?

aortic arteriography or MRA

141

- ASSOCIATED WITH HEPATITIS C
- renal involvement

cryoglobulinemia

142

treatment if cryoglobulinemia is d/t hepatitis C

interferon and ribavirin

143

- Middle Eastern, or Asian ancestry
- oral AND GENITAL ulcers
- ocular involvement (uveitis, optic neuritis)
- hyperreactivity to needle sticks

Behcet disease

144

MOST ACCURATE test for inflamed joints

joint aspiration

145

best INITIAL test for septic arthritis

CELL COUNT

(gram stain only positive 50-60%)
(can be as few as 20,000, but usually > 50,000-100,000)

146

WBC count in normal joint

less than 2,000

147

WBC count in inflamed joint (gout/pseudogout)

2,000-50,000

148

WBC count in infected joint

more than 50,000

149

- male with sudden onset, severe pain
- toe, or knee (red, swollen, tender)
- at night

gout

150

precipitants of gout attacks

- binge drinking alcohol
- thiazides
- nicotinic acid (niacin)

151

best INITIAL test for gout

arthrocentesis (joint fluid aspiration)

152

MOST ACCURATE test for gout

polarized light exam; shows NEGATIVELY BIREFRINGENT NEEDLES

153

best INITIAL treatment for ACUTE gouty attack

NSAIDs

154

if NSAIDs are insufficient, or CI, what should be used for treatment of ACUTE gouty attack

steroids

155

treatment for ACUTE gouty attack if NSAIDs and steroids cannot be used

colchicine

156

adverse effects of colchicine

- N/V
- bone marrow suppression

157

what medication should NOT be started during an acute gouty attack?

allopurinol

158

management of prevention of gout attacks

- allopurinol
- weight loss and exercise
- febuxostat (if allopurinol is NOT tolerated)
- rasburicase/pegloticase (if allopurinol/febuxostat are not enough)

159

MOA of allopurinol

inhibits xanthine oxidase, decreasing uric acid production

160

adverse effects of allopurinol

- rash
- allergic interstitial nephritis
- hemolysis

161

MOA of febuxostat

inhibits xanthine oxidase

162

MOA of rasburicase/pegloticase

converts uric acid to allantoin, which can be excreted by the kidneys

163

- knee and wrist involvement
- NO toe involvement
- slow onset
- pt does NOT wake up with severe pain
- may have h/o hemochromatosis, hyperparathyroidism, acromegaly, or hypothyroidism

pseudogout

164

arthrocentesis shows what in Pseudogout?

POSITIVELY birefringent RHOMBOID-shaped crystals

165

best INITIAL treatment for pseudogout

NSAIDs

166

acute management for pseudogout if NSAIDs are ineffective

steroids

167

- swollen, red, immobile, tender joint
- arthritic and prosthetic joints are at higher risk

septic arthritis

168

risk of septic arthritis based on abnormality

prosthetic joint > RA > OA > normal joint

169

etiology of septic arthritis

- Staphylococcus aureus (40%)
- Streptococcus (30%)
- GNR (20%)

170

in addition to culturing the joint, in disseminated gonorrhea you must also

PANculture all mucosal surfaces ( oropharynx, rectum, urethra, cervix)

171

best INITIAL test for septic arthritis

arthrocentesis: > 50,000 WBCs

172

MOST ACCURATE test for septic arthritis

culture (> 90% sensitive)

173

empiric treatment for septic arthritis

ceftriaxone and vancomycin

174

- asymptomatic
- may have pain, stiffness, aching, fractures
- bowing of tibias
- sarcoma arises in 1% of patients

Paget's disease of bone

175

if osteoLYTIC lesions, think

Paget's, or OP

176

if osteoBLASTIC lesions, think

metastatic prostate cancer

177

best INITIAL test for Paget's disease

AP level (elevated)

178

MOST ACCURATE test for Paget's disease

XR

179

other tests that should be ordered for Paget's disease

- urinary hydroxyproline
- serum Ca++ level (will be normal)
- serum phosphate level (will be normal)
- bone scan

180

treatment for Paget's disease of bone

bisphosphonates and calcitonin

181

what is a Baker's cyst?

posterior herniation of synovium of knee

182

Baker's cysts are seen in which patients?

OA, or RA with a SWOLLEN CALF

183

diagnostic testing for Baker's cyst

US to EXCLUDE DVT

184

treatment for Baker's cyst

- NSAIDs
- steroid injection if needed

185

- pain on bottom of foot
- very severe in MORNING, better w/ ambulation
- resolves spontaneously over time

plantar fasciitis

186

- pain on bottom of foot
- more painful with use
- may have numbness of sole
- avoid boots/high heels
- may need steroid injection/surgery

tarsal tunnel syndrome

187

- painful burning sensation in INTERDIGITAL WEB SPACE between 3rd and 4th toes
- tenderness
- sharp, intermittent pain radiating toes that improves when shoes are removed

Morton's neuroma