UWorld 2 Flashcards
(53 cards)
Behcet Disease
Epi - young adults, Turkish, Middle Eastern or Asian descent
Clinical
1) Recurrent, painful oral aphthous ulcers
2) Genital ulcers
3) Eye lesions (uveitis)
4) Skin lesions (EN, acneiform lesions)
5) Thrombosis (high risk of vasculitis)
Evaluation - dx is usually clinical. Bx not really needed.
1) Pathergy - exaggerated skin ulceration with minor trauma (needlestick)
2) Bx - nonspecific vasculitis of different sized vessels
What kind of anemia does MTX cause?
Macrocytic
Can also cause pancytopenia. Do routine peripheral blood counts every 3 months.
Pseudogout
Hyperparathyroidism with chronic hyperCa can cause it, presenting as acute, painful monoarthritis. Diagnostic findings include calcification of the articular cartilage*** (chondrocalcinosis) on XR and rhomboid-shaped positively birefringent calcium pyrophosphate crystals in synovial fluid.
Can also be associated with hypothyroidism and hemochromatosis.
Disseminated gonococcal infection overview
Clinical pres
1) Purulent arthritis without skin lesions OR
Triad of:
1) Tenosynovitis (wrist, ankles, fingers, knees)
2) Dermatitis (pustules, macules, papules, bullae)
3) Migratory asymmetric polyarthralgia without purulent arthritis
Diagnosis
1) BCx (2 sets) but may be negative
2) Synovial fluid analysis may show up to 50k cells/mm (a bit lower than other septic arthritis)
3) Urethral, cervical, pharyngeal or rectal cultures
4) Recommend HIV and syphilis screen
5) Recurrent DGI - check terminal complement activity (C5-9)
6) Dx is confirmed by NAATs as well
Tx
1) IV ceftriaxone 1g/day for 7-14d, switch to PO (cefixime) when clinically improved
2) Joint drainage for purulent arthritis
3) Empiric azithromycin (single 1g dose) OR doxycycline for 7d for concomitant chlamydial infection
4) Treat sexual partners*
Note: purulent arthritis in sexually active person is gonococcal until proven otherwise.
4 types of results for synovial fluid analysis
Normal
1) Appearance - clear
2) WBC - less than 200
3) PMNs - less than 25%
Noninflammatory (OA)
1) Appearance - clear
2) WBC - 200-2000
3) PMNs - 25%
Inflammatory (crystals, RA)
1) Appearance - translucent or opaque
2) WBC - 2000-100,000
3) PMNs - Often greater than 50%
Septic joint
1) Appearance - Opaque
2) WBC - 50-150k
3) PMNs - more than 80-90%
Primary Raynaud’s phenomenon
Etiology - no underlying cause
Clinical pres
1) Usually women age less than 30*
2) No tissue injury*
3) Negative ANA and ESR
Management
1) Avoid aggravating factors (cold, emotional stress)
2) CCB for persistent symptoms (esp dihydropyridine like nifedipine and amlodipine)
Some say B blockers may make condition worse
Secondary Raynaud’s
Etiology
1) Connective tissue diseases
2) Occlusive vascular conditions
3) Sympathomimetic drugs
4) Vibrating tools
5) Hyperviscosity syndromes
6) Nicotine
Clinical
1) Usually men over 40
2) Symptoms of underlying disease
3) Tissue injury* or digital ulcers
4) Abnormal nail fold capillary exam
Management
1) Evaluate and treat underlying disorder
2) CCB* for persistent symptoms, aspirin* for patients at risk for digital ulceration
Tx of pseudogout
Intrarticular glucocorticoids, NSAIDs, Colchicine
OA
Risk factors
1) Age over 50
2) Obesity
3) Prior joint injury
History
1) Chronic, insidious symptoms
2) Minimal/no morning stiffness
PE
1) Knees/hips, DIP joints, cervical/lumbar spine
2) Hard, bony enlargement of joints
3) Crepitus with movement
Radiology
1) XR - narrowed joint space, osteophytes, subchondral sclerosis
This is the most common joint disorder seen in clinical medicine.
Pes anserinus pain syndrome (Anserine Bursitis)
Localized pain and tenderness over the anteromedial tibia, just below the joint line. Pain is exacerbated by pressure from the opposite knee while lying on the side.
Iliotibial band syndrome
Common overuse injury characterized by poorly localized pain at the lateral knee.
Exam shows tenderness at the lateral femoral condyle during flexion and extension
LCL injury
Follows blow to medial aspect of knee.
Exam shows laxity of knee with varus stress
Medial meniscal injury
Occurs with twisting of knee and typically causes acute to subacute symptoms.
May show medial joint line tenderness, but can see a small effusion and painful/limited extension
De Quervain tenosynovitis
Classically affects new mothers who hold their infants with the thumb outstretched (abducted/extended).
Caused by inflammation of abductor pollicis longus and extensor pollicis brevis tendons as they pass through a fibrous sheath at the radial styloid process.
Tenderness can typically be elicited with direct palpation of the radial side of the wrist at the base of the hand.
Finkelstein test, which is conducted by passively stretching the affected tendons by grasping the flexed thumb into the palm with the fingers, elicits pain.
Prevention of future gout attacks
1) Weight loss to achieve BMI less than 25
2) Low fat diet
3) Decreased seafood and red meat intake
4) Protein intake preferably from vegetable and low fat dairy products
5) Avoidance of organ-rich foods (liver and sweetbreads)
6) Avoidance of beet and distilled spirits
7) Avoidance of diuretics when possible
Treatment of gout
For acute attacks, initial treatment can include NSAIDs (indomethacin), glucocorticoids or colchicine.
Urate lowering meds (allopurinol, febuxostat) are indicated for patients with recurrent attacks or complicated disease (tophi, uric acid kidney stones)
For first attack…counsel about lifestyle mods
Inflammation of ligamentous insertions
Enthesitis. Seen in Ankylosing spondylitis and the other spondyloarthropathies (PAIR)
Clinical features of psoriatic arthritis
Arthritis
1) DIP joints
2) Asymmetric oligoarthritis
3) Symmetric polyarthritis similar to RA
4) Arthritis mutilans (deforming and destructing arthritis)
5) Spondyloarthritides (sacroilitis and spondylitis)
Soft tissue and nail involvement
1) Enthesitis (inflammation of tendon insertion site to bone)
2) Dactylitis (sausage digits) of toe or finger
3) Nail pitting and onycholysis
4) Swelling of the hands or feet with pitting edema
Skin lesions
1) Arthritis precedes skin disease in 15% of patients
2) Skin lesions are present but not yet diagnosed in 15% of patients
Tx - NSAIDs, MTX, anti TNF agents
Heberden nodes vs bouchard nodes
Heberden - osteophyte at DIP
Bouchard - osteophyte at PIP
Charcot joint
Due to decreased sensation in lower extremity. Patients unknowingly traumatize the weightbaring joints (ankle), leading to joint degeneration, deformation, and functional limitation.
Most common in patients with diabetic neuropathy and is often seen in association with foot ulcers
Clinical features of dermatomyositis
Muscle weakness
1) Proximal, symmetric
2) Weakness in UE is same as LE
Skin findings
1) Gottron’s papules
2) Heliotrope rash (eye swelling and redness and cheek redness)
Extramuscular findings
1) Interstitial lung disease
2) Dysphagia
3) Myocarditis
Diagnosis
1) High CPK (sometimes 10x over normal), aldolase, LDH
2) Anti-RNP, anti-Jo-1 (anti-synthetase antibody), anti-Mi2 (against helicase)
3) Diagnostic uncertainty - EMG or skin/muscle Bx
Management
1) High dose glucocorticoids plus glucocorticoid sparing agent
2) Screen for malignancy - internal cancers are more common in these patients (more than 15% of adult patients). Most common are ovarian, lung, pancreatic, stomach, colorectal cancers, non-Hodgkin
DEXA screening (Dual Energy XR Absorptiometry Scan)
All women 65 and over. Screening can be considered for younger patients who have other risk factors.
Common features of Sarcoidosis
Epi - young adults and african americans
Clinical
1) Constitutional symptoms
2) Cough, dyspnea and chest pain
3) Extrapulm findings - skin lesions, anterior/posterior uveitis, Lofgren syndrome
Imaging
1) Bilateral hilar adenopathy*
2) Pulmonary reticular infiltrates
Lab
1) HyperCa/Hypercalciuria
2) Elevated serum ACE level
Path
1) Bx shows noncaseating granulomas that stain negative for fungi and acid fast bacilli
Hypercalcemia in sarcoid
Occurs in up to 20% of patients. Mechanism is granulomatous activity of 1-alpha-hydroxylase. This causes increased production of 1,25-dihyroxyvitaminD and increased intestinal absorption of calcium.
Hypercalciuria (up to half of patients) is present more often and can result in kidney stones.
