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Flashcards in Rheumatology Deck (75):
1

most common form of arthritis

OA

2

OA in the hands is usually caused by

genetics

3

labs characteristic of OA

ESR<40 mm

4

OA is not found in

the MCP or the wrists

5

OA is found

i. Hands: DIP's, PIP's, 1st C-MC joint
ii. Hips
iii. Knees
iv. Feet: 1st MTP
v. Spine: Cervical and Lumbar

6

vi. Bumps on DIP in OA

Heberden's nodes

7

vii. Bumps on PIP

Bouchard's nodes

8

XR typical of OA

complete loss of joint space, cysts are seen, and bone on bone, extremely sclerotic

osteophytes on XRAY are not necessarily causing acute backpain

9

congenital cause of OA

i. Congenital dysplasia of hip where femur doesn't develop normally

acetabulum is flatter and the joint wears out

10

secondary causes of OA

trauma
congenital
inflammatory disease (RA or Gout)

11

chondrocalcinosis

calcifications of the bone seen in pseudogout

these crystals are seen as invasive and can be targeted on the body

12

OA tx

NSAIDS
Corticosteroid
joint replacement

13

RA clinical features

sxs

morning stiffness

jointpain
swelling
usually seen in symmetrical fashion

soft squishy swelling

If people have RA and have back pain it is not the cause

14

areas affected by RA

o Hands: PIP's, MCP's (Osteoarthritis affects DIP but RA does not)
o Wrists
o Elbows
o Shoulders
o Knees
o Ankles
o Feet: PIP's, MTP's
o Cervical spine (spares the rest of the spine)

15

DIP affected in RA with swan neck

tendons affected not actually the DIP jount

it is the tendon itself that is pulling on the joint

16

why should RA be called rheumatoid disease

it has a lot of systemic effects

i. Pulmonary: pleuritis, interstitial fibrosis, nodules
ii. Cardiac: pericarditis, premature CAD
iii. Hematologic: anemia of chronic disease
iv. Vascular: vasculitis
v. Muscle: muscle wasting
vi. Ocular: Sjögren's syndrome (antibodies to lacrimal gland so pt's don't produce tears or saliva), episcleritis, scleritis, scleromalacia perforans
vii. Constitutional: fatigue, fever, weight loss (very common)

17

Cardiac sxs assoc with

pericarditis, premature CAD

18

pulmonary sxs associated with RA

pleuritis, interstitial fibrosis, nodules

19

PV affects seen with RA

vasculitis

20

ocular impacts of RA

Sjögren's syndrome (antibodies to lacrimal gland so pt's don't produce tears or saliva), episcleritis, scleritis, scleromalacia perforans

21

subcutaneous nodules are seen most commonly where in RA

extensor surface of the elbow

really don't bother people unless they are in pressure areas

greater likelihood of extra articular formations

22

RA dx tests

rheumatoid factor is foumd in 80-85% of people
but only 60% in the first 6 months

CCP is often positive even before pts develop RA but only 50% have it

23

RA dx criteria

morning stiffness lasting longer than an hour
swelling in 3 or more joints
symmetric joint swelling
erosions or decalcification
rhematoid nodules
abnormal serum rheumatoid factor


need to have for longer than 6 weeks to establish and the
this is not

OR
ii. Synovitis is not better explained by "another disease"

24

tx of RA

education is extremely important aspect
NSAIDS-for sxs but not for dz progression
need to use iwht

disease modifying anti rheumatic drugs
DMARDS- hydroxychloroquine, sulfasalazine, methotrexate, leflunomide

corticosteroids can be used while you wait for DMARDS and biologics to work
surgery can be used for reconstruction

25

ACR classification of RA

iii. 6 or more points = definite RA

looking at joint distribution

26

Spondyloarthropathies

often affect the spins and periphery
all can cause inflammation of the spine
but doesn't account for a lot of back pain (2%)

4 major

AS
reactive arthritis and Reiter's
psoriatic arthritis
arthritis of IBD

27

enthesopathy

enthesis is where a tendon or ligament inserts on a bone

28

plantar fascitis

where the plantar fascia attaches to the calcaneous

usually see pain when initially beginning to walk

29

o Mucocutaneous effects of Spondyloarthropathies

- Psoriatic-like skin rashes
- Mucous membrane involvement
o Ocular
- Conjunctivitis
- Uveitis
o Intestinal inflammation
o Aortic insufficiency
o HLA-B27

30

ankylosing spondylitis

why would you suspect it

insidious onset
age under 40 sometimes seen in teens or 20's
usually seen as long standing back pain
morning stiffness and improvement with exercise are crucial

31

dx test for AS

getting an xray
can take up to 6 months so often times we will do an MRI before that

can see sclerosing an irregularity
or fusing


rigid spine see with loss of flexibility

32

what physical exam test can we do for AS

Diminished "Schober's test"

<10cm suggest AS

33

psoriatic arthritis is usually seen

15% of the time arthritis precedes skin disease

does not relate to the severity
can be poly-articular but not as symmetrical as RA
can be squishy warm and red to the touch

psoriatic arthritis CAN affect DIP joint similar to OA
spondylitis
arthritis mutilans

can also see hyperkeratosis and onycholisis
nail pitting-20 or more
sausage digits

34

dx of psoriatic arthritis

pencil in a cup

35

reactive arthritis

follows GUI or infectious diarrhea


if you have just arthritis= reactive

reiter's syndrome is seen with conjunctivitis or urethritis and arthritis

36

Precipitating Organisms of reactive arthritis

Precipitating Organisms --> Shigella, Salmonella, Campylobacter, Yersinia, Chlamydia, Ureaplasma, HIV

37

clinical features of reactive arthritis

unilateral or bilateral

o Oligoarthritis (usually in the LE)
o Sacroiliitis (unilateral or bilateral)
o Spondylitis
o Sausage digits
o Enthesopathy (particularly Achilles tendon)-ligaments attaches onto bone
o Plantar fasciitis
o Conjunctivitis
o Uveitis-inflammation or iris
o Urethritis-pain on urination w/o UTI
o Prostatitis
o Cystitis
o Keratodermia blennorrhagicum- pustule lesions on palms and soles usually in HIV pts with reactive arthritis
o Circinate balanitis-penis lesion
o Oral ulcers
o Aortic insufficiency

onycholysis and hyperkeratosis seen as well similar to psoriatic arthritis

38

if you have a pt with Keratodermia blennorrhagicum

reactive arthritis

test for HIV

39

Circinate balanitis

reactive arthritis
painless lesion of the penis

40

tx of reactive arthritis

DMARDS
methotrexate
leflunomide
apremilast
sulfsalizine
azathhiopine
biologics

41

Crystal-Induced Arthritis-MCC and presentation

MC -Gout

seen in women after menopause
men early on
seen in first MPP joint
self limited (6 months of big toe pain do not have gout)

42

more frequent gout attacks turn into

v. Attacks are self-limited and last 1-2 wks
vi. Attacks become more frequent and polyarticular
vii. Can develop chronic polyarticular polyarthritis

can lead to severe deforming arthritis that looks a lot like RA

43

Tophi

may be present (collection of uric acid)

44

uric acid susceptibility

ix. Uric acid > 6.8

can be falsely low serum level during acute attack because it is being consumed
need to check 2 weeks after the attack

45

ddx for gout

cellulitis
warm red
inflammation
low grade fever and peripheral leukocytosis

46

post gout scalding

can be seen after gout
crackling

47

collections of uric acid

seen in ear and elbow

tophi in the plural
tophus in the singular
collections of uric acid

48

tx of acute gout

naproxen 500mg BID or TID
sulindac 200mg
celecoxib 400mg BID
200 mg BID

avoid indomethacine

can use colchicine

49

chronic tx

need the uric acid below 6

allopurinol
febuxostat
probenecid

50

pseudogout presentation

red hot swollen joint

typically in the wrist we see this as the MCC of wrist swelling
many small joints can be affected
pseudo osteoarthritis form is very common

51

hallmark of pseudogout

chondrocalcinosis

52

pseudogout tx

NSAIDS
Colchicine
corticosteroids

53

rashes seen with lupus

discoid and malar


can have discoid withotu systemic

54

generalized symptoms of lupus

o Fever
o Fatigue
o Weight loss
o Oral ulcers

55

Hematologic Manifestations of lupus

o Leukopenia
o Lymphopenia
o Thrombocytopenia
o Coombs-positive hemolytic anemia
o Hypercoagulable state

56

CNS Manifestations LUS

o Peripheral neuropathy
o Cranial neuropathy
o Mononeuritis multiplex
o Seizures
o Stroke
o Organic brain syndrome (dementia-like picture)
o Headaches
o Depression
o Psychosis

57

ocular manifestations LUS

o Conjunctivitis
o Episcleritis
o Sjögren's syndrome
o Central retinal artery occlusion
o Cytoid bodies

58

Cardiac Manifestations of LUS


o Pericarditis
o Myocarditis
o Coronary vasculitis
o Libman-Sacks endocarditis
o Coronary artery disease

59

Pulmonary Manifestations LUS

o Pleuritis
o Pneumonitis
o Interstitial lung disease (pulmonary fibrosis)

60

Renal Manifestations LUS

o Focal proliferative glomerulonephritis
o Diffuse proliferative glomerulonephritis
o Membranous nephritis
o Mesangial nephritis

61

LUS dx

Need 4 out of the 11 to diagnose

malar rash
discoid rash
oral ulcers
photosensitivity
arthritis
serositis
renal disorder
neurologic disorder
hematologic disorder
immunologic disorder
antinuclear

62

ANA test for LUS

VERY nonspecific
99% sensitive; 10% specific

most common dz associated
1. hashimotos
2. RA
3. LUS

63

dx tests for LUS

ii. Anti-ds DNA Ab: Present in 50%; very specific; correlates with disease activity
iii. Anti-Sm: Present in 10-20%; very specific

ANA-nonspecific
iv. Complement C3, C4 correlates with renal disease

64

LUS tx

o Prevention of flares: hydroxychloroquine
o Skin: hydroxychloroquine, topical steroids
o Joint: NSAIDs, hydroxychloroquine
o Renal, CNS: corticosteroids, cyclophosphamide, azathioprine, mycophenolate mofetil
o Hematologic: corticosteroids
o Serositis: NSAIDs, corticosteroids
o Steroid sparing: methotrexate, azathioprine, mycophenolate mofetil or belimumab

65

a. Age > 55
b. Shoulder and hip girdle aches
c. Fatigue, weight loss, fever

Polymyalgia Rheumatica And Giant Cell Arteritis

they exist together in 50% of the cases

66

tx of Polymyalgia Rheumatica And Giant Cell Arteritis

need prednisone

67

new onset headache in an older person

always suspect GCA

68

chronic widespread musculoskeletal pain for ≥ 3 mos.

Fibromyalgia

2. Absence of other systemic condition accounting for pain
3. Multiple tender points at characteristic locations í areas you put small amount of pressure but hurts the pt

69

theory behind fibromyalgia

abnormality of pain processing

70

abnormalities seen in pts with firbomyalgia

Lower levels of normal NT like Epi and Serotonin and substance P. A variety of things can trigger it

71

characteristics features of fibromyalgia

1. Fatigue
2. Sleep disturbances í are you refreshed in the morning when you wake up?
3. Paresthesias, swelling sensations
4. Headache
5. Mood disturbance í depression and anxiety
6. Irritable bowel syndrome í alteration of constipation and diarrhea
7. Tender points í Lower sternomastoid, 2nd costochondral, lateral epicondyle, trochanter, knee, suboccipital, mid upper trapezius, supraspinatus, buttock

72

tx for fibromyalgia

o Exercise: aerobic and stretching
o Education; CBT
o Anticonvulsants: pregabalin, gabapentin
o SNRI: duloxetine, milnacipran
o Analgetics: tramadol
o Hypnotics: amitriptyline, nortriptyline, zolpidem (sleep)

73

ddx of mono-arthritis

o Crystal-induced arthritis
- Gout
- Pseudogout

o Infectious arthritis- do not miss this especially if pt has a fever. need to culture if suspected

o Reactive arthritis
seen in younger people in the LE

o Osteoarthritis
usually doesn't present acutely

o Trauma

74

Oligoarthritis (few joints affected) DDX

o Osteoarthritis
-hard nodes, very common

o Psoriatic arthritis
DIP joints, look for hints of psoriasis

o Reactive arthritis

o Pseudogout
think about this in older pts

o Gout
typically these people have had multiple attacks

o Rheumatoid arthritis

75

Polyarthritis (soft squishy) ddx

o Rheumatoid arthritis
PIP MCP wrist, elbow shoulders
symmetrical

o Osteoarthritis (firm nodule)
look for those hand nodes MCP joints spared (shoulders elbows and ankles are spared)

o Psoriatic arthritis
less symmetricle than RA and seen with DIP

o Pseudogout
o SLE
o Gonococcal arthritis