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Medicine II > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

most common form of arthritis

A

OA

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2
Q

OA in the hands is usually caused by

A

genetics

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3
Q

labs characteristic of OA

A

ESR<40 mm

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4
Q

OA is not found in

A

the MCP or the wrists

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5
Q

OA is found

A

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

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6
Q

vi. Bumps on DIP in OA

A

Heberden’s nodes

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7
Q

vii. Bumps on PIP

A

Bouchard’s nodes

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8
Q

XR typical of OA

A

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

osteophytes on XRAY are not necessarily causing acute backpain

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9
Q

congenital cause of OA

A

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

acetabulum is flatter and the joint wears out

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10
Q

secondary causes of OA

A

trauma
congenital
inflammatory disease (RA or Gout)

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11
Q

chondrocalcinosis

A

calcifications of the bone seen in pseudogout

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

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12
Q

OA tx

A

NSAIDS
Corticosteroid
joint replacement

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13
Q

RA clinical features

sxs

A

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

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14
Q

areas affected by RA

A 
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)
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15
Q

DIP affected in RA with swan neck

A

tendons affected not actually the DIP jount

it is the tendon itself that is pulling on the joint

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16
Q

why should RA be called rheumatoid disease

A

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)

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17
Q

Cardiac sxs assoc with

A

pericarditis, premature CAD

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18
Q

pulmonary sxs associated with RA

A

pleuritis, interstitial fibrosis, nodules

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19
Q

PV affects seen with RA

A

vasculitis

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20
Q

ocular impacts of RA

A

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

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21
Q

subcutaneous nodules are seen most commonly where in RA

A

extensor surface of the elbow

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

greater likelihood of extra articular formations

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22
Q

RA dx tests

A

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

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23
Q

RA dx criteria

A 
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”

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24
Q

tx of RA

A

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

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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

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