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Rheumatology USMLE Step 3 > Section 5: Inflamed Joints > Flashcards

Section 5: Inflamed Joints Flashcards

1
Q

What is the synovial fluid cell count in

Normal

Inflammatory

Infections

A

< 2,000

2,000 - 50,000

> 50,000

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2
Q

Factors that precipitate gouty attacks

A
  • Binge drinking of alcohol
  • Thiazides
  • Nicotinic acid

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4713-4726). . Kindle Edition.

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3
Q

Gout:

Best initial test

Most accurate test

A
  • Arthrocentesis (aspiration of joint fluid)
  • Polarized light examination of the fluid will show negatively birefringent needles

Gout = Negative birefringence

Pseudogout = Positive birefringence

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4713-4726). . Kindle Edition.

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4
Q

In the CCS, list tests to order for gout or inflammed joint

A
  • Joint fluid examination for cell count, culture, and protein level
  • Serum uric acid level: However, do not rely on uric acid level to make an accurate diagnosis
  • X-ray of the toe: May show “punched-out” lesions
  • Extremity examination for tophi

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4713-4726). . Kindle Edition.

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5
Q

Gout

Best initial Rx for acute gout

Alternative Rx if BIRx fails

A

NSAIDs

If there is insufficient response or a contraindication to NSAIDs, use steroids to treat acute gouty attacks

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4727-4761). . Kindle Edition.

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6
Q

When to use colchicine in Rx of gout?

A

Colchicine is useful under the following conditions:

  • In the first 24 hours of an attack
  • When there is a contraindication to the use of NSAIDs, such as renal insufficiency
  • As part of preventive therapy to decrease the risk of a gouty attack
  • Treat gout with colchicine only if NSAIDs and steroids cannot be used

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4727-4761). . Kindle Edition.

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7
Q

Adverse effects of colchicine

A
  • Nausea and diarrhea
  • Bone marrow suppression

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4727-4761). . Kindle Edition.

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8
Q

List the ways to prevent gout

A
  • Febuxostat is an alternative to allopurinol. Prevention: –
  • Allopurinol, probenecid, and sulfinpyrazone lower the level of uric acid. Allopurinol has the following adverse effects: rash, allergic interstitial nephritis, and hemolysis
  • Weight loss
  • Avoiding alcohol

Febuxostat is a xanthine oxidase inhibitor that markedly lowers uric acid levels. Febuxostat is the answer when the patient is intolerant of allopurinol

Uricase (rasburicase and pegloticase) are benign drugs to break down uric acid. Use if allopurinol or febuxostat is not enough

Do not start allopurinol during an acute attack of gout

Rasburicase and pegloticase break down uric acid to allantoin. Use if allopurinol and febuxostat are not enough

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4727-4761). . Kindle Edition.

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9
Q
  1. Synovial fluid finding in pseudogout
  2. Rx of Pseudogout
  3. Acute management of pseudogout
A
  1. Positively birefringent rhomboid-shaped crystals
  2. NSAIDS are the best initial therapy. Colchicine is used but is not as effective.
  3. Acute management is the same as gout: NSAIDs or steroids

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4769-4798). . Kindle Edition.

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10
Q

Septic Arthritis

The more abnormal the joint, the more likely a patient is to have septic arthritis: prosthetic joint > rheumatoid arthritis > osteoarthritis > normal joint.

Any arthritic joint or prosthetic joint is a risk factor for septic arthritis

List the CF of septic arthritis

A

Swollen, red, immobile, tender joint

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4769-4798). . Kindle Edition.

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11
Q

Causative organisms of septic arthritis

A
  • Disseminated gonorrhea is diagnosed by culture of: • Joint fluid (50 percent positive) • Pharynx (10– 20 percent positive) • Rectum (10– 20 percent positive) • Urethra (10– 20 percent positive) • Cervix (20– 30 percent positive)
  • Staphylococcus aureus (40 percent)
  • Streptococcus (30 percent)
  • Gram-negative bacilli (20 percent)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4769-4798). . Kindle Edition.

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12
Q

True or False?

CCS Tip: Call an orthopedic surgery consult when you suspect a septic joint. The consultation won’t offer much on the CCS, but it needs to be done

A

True

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13
Q

Diagnostic testing in septic arthritis

A

Best initial test: Tap the joint (arthrocentesis).A finding of > 50,000 white cells is consistent with infection

Gram stain has a 50– 60 percent sensitivity

Most accurate test: Culture is > 90 percent sensitive but is never available when you must make an acute treatment decision

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4769-4798). . Kindle Edition.

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14
Q

Empiric Rx of septic arthritis

A

IV Ceftriaxone + IV vancomycin

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15
Q

Choice of antibiotics against Staph and strep in septic arthritis

A

Oxacillin

Nafcillin

Cefazolin

Penicillin allergy: Anaphylaxis

  • Vancomycin
  • Linezolid
  • Daptomycin
  • Clindamycin

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4799-4846). . Kindle Edition.

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16
Q

Choice of antibiotics against Gram-negative bacilli in septic arthritis

A

Ceftriaxone

Ceftazidime

Gentamicin

Penicillin allergy: Anaphylaxis

  • Aztreonam
  • Fluoroquinolone

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4799-4846). . Kindle Edition.

17
Q

Paget’s Disease of Bone is often asymptomatic.

What are some CF?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4799-4846). . Kindle Edition.

A
  • pain
  • stiffness
  • aching
  • fractures

Soft bones lead to bowing of the tibias. Sarcoma arises in 1 percent of patients. In cases of Paget’s, osteolytic lesions will be found initially. These may be replaced with osteoblastic lesions

if osteolytic, then think Paget’s or osteoporosis; but • if osteoblastic, think about metastatic prostate cancer in the differential diagnosis.

18
Q

Paget’s disease:

Best initial test

Most accurate test

A

Alkaline phosphatase level. It will be elevated

Most accurate test: x-ray

For CCS, also order the following

  • Urinary hydroxyproline
  • Serum calcium level— It will be normal
  • Serum phosphate level— It will be normal
  • Bone scan

Treat with bisphosphonates and calcitonin.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4799-4846). . Kindle Edition.

19
Q

Rx of Paget’s disease

A

Bisphosphonates and calcitonin

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4799-4846). . Kindle Edition.

20
Q

A Baker’s cyst is a posterior herniation of the synovium of the knee. Look for a patient with osteoarthritis or rheumatoid arthritis with a swollen calf. A ruptured Baker’s cyst is a “pseudo-phlebitis.” Unruptured cysts can be palpated.

Test to do

Rx

A

Diagnostic Testing:Exclude a deep vein thrombosis with ultrasound

Treat with NSAIDs and, occasionally, with steroid injection.

21
Q

CF of plantar fascitis

A

Pain on bottom of foot

Very severe in the morning, better with walking a few steps

Stretch the foot and calf

Resolves spontaneously over time

22
Q

CF of tarsal tunnel syndrome

A

Pain on bottom of foot

More painful with more use; like carpal tunnel of the foot; may have numbness of the sole, too

Avoid boots and high heels; may need steroid injection

May need surgical release

23
Q

CF of Morton neuroma

A

Painful burning sensation in the interdigital web space between the 3rd and 4th toes

Tenderness when pressure is applied between the heads of the 3rd and 4th metatarsals

Sharp, intermittent pain radiating into the toes that feels better when shoes are taken off

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4842-4872). . Kindle Edition.

24
Q

Indications for Rx in Paget’s disease

A
  • Bone pain
  • Hypercalcemia of immobilization
  • Neurological deficit
  • High output cardiac failure
  • Preparation for orthopedic surgery
  • Involvement of weight-bearing bones (to prevent deformities)

Paget’s disease of the bone (osteitis deformans) is associated with normal serum calcium and phosphate levels and increased alkaline phosphatase and urinary hydroxyproline levels

Rheumatology USMLE Step 3 (5 decks)

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