Rheumatology Flashcards
(138 cards)
1
Q
What are the WBC and morning stiffness cutoffs for inflammatory vs non inflammatory pain?
A
> 60 mins and >2k for inflammatory pain
2
Q
What disease association?
ANA
A
SLE
SSc
Sjogren syndrome
titer doesn’t correlate with disease activity
3
Q
What disease association?
Anti Sm
A
SLE
most specific but doesn’t correlate with disease activity
4
Q
What disease association?
Anti-u1-RNP
A
MCTD
5
Q
What disease association?
Anticentromere pattern of ANA
A
CREST; SSc and PH
6
Q
What disease association?
Anti-dsDNA Ab
A
SLE
correlates with disease activity, especially renal
7
Q
What disease association?
Anti smooth muslce AB
A
autoimmune hepatitis
8
Q
What disease association?
Anti La, SSB
A
Sjogren, neonatal SLE
9
Q
What disease association?
Anti SCL-70 Ab
A
SSc and pulmonary fibrosis/diffuse cutaneous SSc
10
Q
What disease association?
antihistone Ab
A
drug induced SLE
11
Q
Anti-Ro / SSA Ab
A
Sjogren syndrome, neonatal heart block, subacute cutaneous lupus
12
Q
What disease association?
c-ANCA/ Anti-PR3 Ab
A
Granulomatosis with polyangiitis
13
Q
What disease association?
p-ANCA / anti-MPO Ab
A
Eosinophilic granulomatosis with polyangiitis
MPA - microscopic polyangiitis
14
Q
What disease association?
Anti-Jo-1 Ab
A
polymyositis and antisynthetase syndrome
15
Q
What disease association?
Anti-CCP Ab
A
RA
16
Q
What are the common features of RA?
A
morning stiffness > 1 hour
pain in PIP, MCP, elbow, wrist, knee, ankle and MTP joints
subcataneous nodules over bony prominences or extensor surfaces
synovitis - soft tissue swelling or effusion
symptoms > 6 weeks
17
Q
What are common lab findings in RA?
A
70% of patients will have positive RF or anti-CCP Ab at time of diagnosis, elevated ESR and CRP, normocytic anemia
18
Q
How can you trend response to therapy in RA
A
Xrays
19
Q
What are common findings on Xray in RA?
A
joint space narrowing
bony erosions
periarticular osteopenia
20
Q
does a negative RF exclude RA?
A
no, can have seronegative RA
don’t be tricked!
21
Q
is a positive RF alone diagnostic of RA?
A
no
don’t be tricked!
22
Q
Do fluctuations in RF mirror disease activity?
A
no
don’t be tricked!
23
Q
If you see systemic arthritis and…
skin rash and leukopenia
What is the diagnosis?
A
SLE
24
Q
If you see systemic arthritis and…
psoriasis or pitted nails
What is the diagnosis?
A
Psoriatic arthritis
25
If you see systemic arthritis and...
day care worker or contact with small children
What is the diagnosis?
Parvo B19 (usually self-limited after 3 months)
26
If you see systemic arthritis and...
2nd and or 3rd MCP and PIP joint arthritis with hook like osteophytes
What is the diagnosis?
hemochromatosis
photo of hook like osteophytes: https://prod-images-static.radiopaedia.org/images/4750489/8bbaca8e62d97ef4b31ba38c3500ea_jumbo.jpg
27
If you see systemic arthritis and...
Raynaud phenomenon and sclerodactyly
What is the diagnosis?
SSc (systemic sclerosis)
28
If you see systemic arthritis and...
proximal muscle weakness
What is the diagnosis?
Polymyositis or dermatomyositis
29
If you see systemic arthritis and...
recent immunizations
What is the diagnosis?
post-rubella immunization arthritis
30
If you see systemic arthritis and...
Tophi with symmetric small joint involvement of the hands and feet
What is the diagnosis?
chronic tophaceous gout
31
If you see this in an RA patient you should think of what diagnosis?
arm parestehsias and hyperreflexia
C1-2 subluxation (increase risk of cord compression with tracheal intubation)
32
If you see this in an RA patient you should think of what diagnosis?
cough, fever, pulmonary infiltrates
BOOP
33
If you see this in an RA patient you should think of what diagnosis?
foot drop or wrist drop
mononeuritis multiplex
34
If you see this in an RA patient you should think of what diagnosis?
hoarseness
cricoarytenoid involvement
35
If you see this in an RA patient you should think of what diagnosis?
multiple basilar pulmonary nodules
Caplan syndrome
pneumoconiosis related to occupational dust, characterized by rapid development of multiple basilar nodules and mild airflow obstruction
36
If you see this in an RA patient you should think of what diagnosis?
dry eyes or mouth
Sjogren's
37
If you see this in an RA patient you should think of what diagnosis?
pleural effusion with low plasma glucose <30mg/dl
rheumatoid pleuritis
38
If you see this in an RA patient you should think of what diagnosis?
pulmonary fibrosis
rheumatoid ILD
39
If you see this in an RA patient you should think of what diagnosis?
skin ulcers, peripheral neuropathy
rheumatoid vasculitis
40
If you see this in an RA patient you should think of what diagnosis?
splenomegaly and granulocytopenia
Felty syndrome
41
If you see this in an RA patient you should think of what diagnosis?
red, painful eye
scleritis or uveitis
42
If you see this in an RA patient you should think of what diagnosis?
HF
rheumatoid disease or anti-TNF therapy
43
All RA patients undergoing general anesthesia should have what test done?
cervical xrays to assess for atlantoaxial subluxation
44
What is the goal of RA treatment?
treat to target with the target being remission or low disease activity
45
What is the treatment for quick symptomatic relief for RA?
NSAIDs and low dose oral and intra-articular glucocorticoids
46
What is the treatment for RA for most patients?
MTX
start immediately if signs of erosive disease
47
What is the treatment for RA in early, mild, non-erosive disease?
HCQ
sulfasalazine
combo therapy with these agents
48
When should you use biologics for RA?
when disease control is not achieved with oral DMARDs
add TNF-a inhibitor to MTX
49
What are common toxicities with TNF-a therapy
pancytopenia
positive ANA associated with SLE like symptoms
demyelinating disorders
50
Should you use combo biologic therapy to treat RA?
No, not recommended
51
What additional meds should all patients with RA receive?
calcium and Vit D supplementation
| bisphosphonates for osteoporosis and DEXA scans
52
Can pregnant patients take MTX or leflunomide?
NO!
don't be tricked!
53
What meds are safe for pregnant patients with RA to take?
hydroxychloroquine and sulfasalazine
54
What are the hallmark features of Sjogren's syndrome
keratoconjunctivitis sicca
xerostomia
salivary gland enlargement
55
What illness are patients with Sjogren syndrome much more likely to get?
B cell lymphoma, specifically large B-cell and MALT lymphoma
56
What is the treatment for: Sjogren syndrome
symptomatic: artificial tears and saliva
57
What are the main features of OA?
joint pain worse with activity
reducted joint motion
crepitus
tenderness along the joint line
bony enlargement. - Heberden and Bouchard nodes
involvement of first CMC joint with squaring of the base of the thumb
58
When should you think of secondary OA?
think of a metabolic cause when OA develops in atypical joints: MCP, shoulder or wrist
59
When should you consider surgery for OA?
when pain doesn't respond to nonsurgical treatment, especially when lifestyle or ADLs are affected
60
What diseases are associated with hypertrophic osteoarthropathy?
lung cancer
chronic pulmonary infections
R to L cardiac shunts
61
What are common characteristics of spondyloarthritis?
inflammatory spine and SI disease
asymmetric inflammation in <4 peripheral joints, usually large joints
- inflammation at the sites of ligament and tendon insertion
- HLA B27
- negative RF and anti-CCP
62
Can HLA-B27 independently confirm or exclude a diagnosis of ankylosing spondylitis or other spondyloarthirtis?
no
63
What is the diagnosis?
patient with nail pitting, joint pain and stiffness
psoriatic arthritis
64
How can you distinguish RA from psoriatic arthritis on exam?
sausage fingers - dactylitis is commonly seen in psoriatic arthritis
65
Explosive onset of psoriatic arthritis should prompt workup for what disease?
HIV infection
66
What is the treatment for psoriatic arthritis
NSAIDs initially
MTX for peripheral joint disease if not responding to NSAIDs, will also treat skin
- TNF-a inhibitor for AXIAL disease unresponsive to MTX, unlike RA, often discontinue MTX once TNF-a inhibitor shows improvement
67
What medications for psoriatic arthritis can exacerbate psoriasis?
NSAIDs
antimalarials
withdrawal from steroids
68
Is there a relationship between the extent of joint disease and skin disease in psoriatic arthritis?
no
don't be tricked!
69
has mtx been shown to reduce progression of joint damage in psoriatic arthritis?
no, only joint pain and control of skin disease
70
What infection is commonly found in patients with reactive arthritis?
HIV
71
What are common manifestations of reactive arthritis?
- monoarthritis or acute asymmetric oligoarthritis (usually in weight bearing joints)
- dactylitis
- enthesopahty of achilless tendon
- sacroiliitis
72
What is the workup for reactive arthritis?
HIV
GC
Stool cultures for GI pathogens ifdiarrhea is present
if no pathogen is found, reactive arthritis is usually self-limited
73
What is the diagnosis?
35M with back pain with 2 hours of morning stiffness, worse at night, improves with activity and heat
ankylosing spondylitis
74
What are extra-articular manifestations of ankylosing spondylitis?
```
acute anterior uveitis
aortic valvular regurgitation
aortic aneurysm
cardiac conduction defects
apical pulmonary fibrosis and cavitation
cauda equina syndrome
```
75
A patient with ankylosing spondylitis shows up to the ER after a minor fall with neck pain, what's the next step?
urgent CT C Spine to rule out a fracture
76
What is the treatment for ankylosing spondylitis?
NSAIDs - mainstay of treatment
glucocorticoid injections
TNF-a inhibitors if not responding to NSAIDs
MTX, sulfasalazine and HCQ for peripheral joint disease
Ca and Vit D supplementation for all patinets
77
Should you prescribe MTX, sulfasalazine or HCQ to patients with ankylosing spondylitis for AXIAL pain?
No, they are ineffective, use a TNF-a inhibitor
don't be tricked!
78
What medications are effective at treating IBD associated arthritis?
TNF-a inhibitors infliximab and adalimumab
79
nonscarring alopecia is common in what disease
SLE
80
Subacute cutaneous SLE is commonly a result of what?
drug induced and not related to systemic disease
81
Pain or decreased ROM of hips in a patient with SLE suggests what?
osteonecrosis
82
lung infiltrates in SLE are more likely to be related to SLE lung parenchymal involvement or infection?
infection, parenchymal involvement is rare
83
Patient with a positive ANA and a facial rash that involves the nasolabial folds - is this lupus?
No! malar rash doesn't involve the nasolabial folds
don't be tricked!
84
What antibodies correlate with SLE disease activity?
anti-dsDNA ab
85
What lab findings often accompany SLE flares?
low complement levels
86
What are the common lab findings in drug-induced lupus?
Pos ANA
negative Anti- Smith and anti-dsDNA ab
anti-histone *may* be positive
87
Is an isolated ANA 1:40 to 1:80 likely to be SLE?
no
don't be tricked!
88
Are myalgia, arthralgia and fatigue enough reasons to check an ANA?
no, not according to boards basics!
don't be tricked!
89
should you monitor serial ANA titers in patients with SLE?
no, doesn't correlate with disease activity
don't be tricked!
90
What is the treatment for SLE for arthritis?
NSAIDs and HCQ - keep going with HCQ even if they have quiescent disease in order to prevent flares
91
What is the treatment for photosensitive cutaneous lupus
sun block
topical steroids
HCQ
92
What is the treatment for life-threatening SLE
high dose steroids and cyclophosphamide or mycophenalate mofetil
93
what supplements should patients with SLE be taking?
vit d and Ca
94
What do patients on HCQ require for monitoring?
annual optho exams
don't be tricked!
95
what medications can be used in pregnant patients with SLE?
HCQ
| prednisone
96
What is the treatment for SLE flare with isolated class V nephritis and withOUT kidney dysfunction
in isolated class V lupus nephritis, especially without kidney dysfunction, mycophenolate mofetil is the most appropriate initial immunosuppressive therapy
IF the patient had evidence of kidney dysfunction, they cyclosporine would be be used initially with mycophenolate mofetil as maintenance therapy. Cyclosporine has more side effects
97
What is the primary cause of morbidity and mortlity in patients with systemic sclerosis
pulmonary disease
98
Anti-centromere Ab is associated with what form of systemic sclerosis?
limited cutaneous
99
Anti-Scl-70 Ab is associated with what form of systemic sclerosis?
Diffuse cutaneous systemic sclerosis
100
Is skin tightening without Raynaud's scleroderma?
no, another scleroderma-like condition
101
What is the treatment for scleroderma
nothing systemic is available
do not treat with steroids - can precipitate scleroderma renal crisis
102
What is the main cause of mortality in patients with MCTD
pulmonary HTN
103
Should you use NSAIDs or opiates to treat fibromyalgia?
no
104
What is a common drug trigger of acute gout?
HCTZ
Losartan is a better HTN drug for these patients due to its mild uricosuric effect
105
Do you need a synovial fluid analysis to diagnose gout if the patient presents with podagra?
no
106
Patient with CKD with gout - what long term med is useful
Febuxostat
107
What medication is a contraindication to allopurinol or febuxostat
azathioprine
don't be tricked!
108
can patients wtih kidney failure take colchicine?
no!
don't be tricked!
109
Patients with CPPD who are less than 50 should be screened for what illnesses?
hemochromatosis
hypomagnesemia
hyperPTH
hypothyroidism
110
Does the absense of chondocalcinosis on x ray rule out CPPD?
no
don't be tricked!
111
What is the treatment for pseudogout?
intra-articular steroids (after infection ruled out with arthrocentesis) if 1-2 joints involved
NSAIDs if multiple joints involved
colchicine if no response to NSAIDs, steroids if can't tolerate those 2 meds
112
What is a hallmark physical exam finding of infectious arthritis?
pain with passive extension of joint or when the joint is held in flexion
113
What is the most common organism identified in infectious arthritis?
staph aureus
gonorrhea in young sexually active individuals
114
Patients with recurrent gonococcal infections should be evaluated for what?
deficiencies in terminal complement components
115
How do you diagnose TB as a cause of infectious arthritis?
synovial biopsy
116
Does the presence of crystals in synovial fluid exclude an infectious process?
no, can have both!
don't be tricked!
117
What is the treatment for infectious arthritis due to gonorrhea?
IV CTX for 7 days + 1g oral azithro x1
do not step down to oral meds without sensies due to increasing resistance patterns
118
If a patient is treated for infectious arthritis with antibiotics and the therapy is unsuccessful what diagnosis should you suspect?
TB
don't be tricked!
119
What is the treatment for: dermatomyositis and polymyositis
1. high dose oral steroids
2. add MTX or azathioprine if refractory dz
3. ritux if refractory to above
*HCQ can help with derm manifestations of dermatomyositis
120
What diagnosis should you suspect in a patient with continue or new onset prox muscle weakness despite normalization of muscle enzyme levels?
steroid induced myopathy
don't be tricked!
121
What lab test should you always check as part of a mypoathy workup?
TSH
don't be tricked!
122
if a patient has muscle pain are they likely to have a myopathy
no
muscle pain = myalgia
dermatoMYOSITIS and polyMYOSITIS refer to inflammation, not pain - so use the name to help you out!
123
how do you diagnose takayasu's
aortography
124
woman with morning stiffness in proximal muscles and hips, normal muscle strength, no tenderness over muscles, normal CK, elevated ESR - what's the diagosis
polymyalgia rheumatica
treat with low dose pred
relapses are common
125
What labs are associated with granulomatosis with polyangiitis
c-ANCA
| Anti PR3
126
What labs are associated with microscopic polyangiitis
p-ANCA
| Anti-MPO Ab
127
What labs are associated with eosinophilic granulomatosis with polyangiitis
p-ANCA
| Anti-MPO Ab
128
What are possible complications of GCA?
aortic aneurysm and aortic dissection
don't be tricked!
129
Does PAN renal disease involve the glomerulus?
no
don't be tricked!
130
Do you need ot have eosinophilia to diagnose eosinophilic granulomatosis with polyangiitis?
Yes!
don't be tricked!
131
What is the treatment for relapsing polychondritis
NSAIDs, colchicine or dapsone
glucocorticoids if severe diseaes
132
recurrent, self limited fevers and abdominal and pleuritic chest pain in man from lebanon with associated rash and arthritis - diagnosis?
familial Mediterranean fever
elevated ESR, CRP
positive amyloid A (AA)
postivie for mediterranean fever gene (MEFV)
133
What is the treatment for familial Mediterranean fever ?
colchicine
134
Patient with daily fever, fatigue, arthralgias and ferritin 2700 - diagnosis and treatment?
Adult onset stills
NSAIDs first line, can also use steroids
if refractory can use MTX, TNF-a inhibitors, or anakinra
135
patient with vasomotor changes, skin chagnes and pain in extremity after surgery - what's the diagnosis and mgmt?
complex regional pain syndrome
Dx: neuropathic pain, autonomic dysfunction, swelling, dystrophy, movement disorder and evidence of altered bone metabolism on bone scan, x ray or MRI
tx: PT, steroids, gabapentin and TCAs, can also use bisphosphonates for PAIN even if no signs of osteoporosis
136
What is a common side effect of topical diclofenac?
skin reactions (rash, itch, and burning) than placebo (rate ratio, 1.14 [95% CI, 0.51-2.55]).
137
What medications are FDA approved for fibromyalgia?
pregabalin
duloxetine
milnacipran
138
bilateral hilar LAD
erythema nodosum
migratory polyarthralgia
What is the diagnosis?
Lofgren syndrome
highly specific for sarcoid. obviates need for tissue biopsy.
high value care
