Penn Presby- Rheumatology

Front 1

when does gout have a peak incidence in men

Back 1

50's

Front 2

what is the MC cause of inflammatory arthritis in men over age 30

Back 2

gout; hyperurecemia and deposition of urate crystals cause attacks of inflammatory arthritis (tophi can also tubular and interstitial dz in the kidneys)

Front 3

what is the upper limit of uric acid levels (point at which gout CAN develop)

Back 3

-above 7 mg/dL for men (above 6 for women)
-gout can dvlp at lower levels though

Front 4

why do women have lower normal values of uric acid than men (before menopause)

Back 4

-bc the estrogen levels promote renal excretion of uric acid

Front 5

how is uric acid formed in the body

Back 5

-Hypoxanthine is converted to Xanthine using Xanthine Oxidase
-xanthine is coverted to uric acid using xanthine oxidase

Front 6

what enzyme do humans lack that predispose us to gout

Back 6

-they lack uricase that oxidizes uric acid to allantoin

Front 7

what organ excretes uric acid from the body

Back 7

-kidney
-the rest is oxidize by bacteria in the gut

Front 8

why do urate crystals deposit in the ears and toes

Back 8

-the lower temperatures of the peripheral structures cause the urate crystals to have decreased solubility

Front 9

how does gout look on radiograph

Back 9

-periarticular erosions (may have an overhanging edge or punched out lesion)

Front 10

what are the 4 classifications of gout

Back 10

-primary
-secondary
-overproducer
-unders secretor

Front 11

what is primary gout

Back 11

-uric acid levels are high due to disorders of uric acid metabolism

Front 12

what is secondary gout

Back 12

gout is a minor clinical feature secondary to a number of genetic or acquired diseases

Front 13

what class of gout to most pts with hyperurecemia have (primary, secondary, overproducer, under secretor)

Back 13

-90% are under secretors

Front 14

list some diseases that cause secondary gout

Back 14

-those in which there are excessive rates of cell turnover (myeloproliferative and lymphpproliferative disorders, hemolytic anemias, psoriasis)

Front 15

name a cause of prmary gout

Back 15

-HGPRT deficency (part of Lesch-Nyham syndrome of spasticity, mental retardatiion, self mutilation)

Front 16

name other commonly affected areas of the foot of gout

Back 16

-ankle, tarsal area and knee

Front 17

affected gout joints are red, hot, swollen; what can this be confused with

Back 17

-cellulitis or thrombophlebitis

Front 18

with the exception of arthritis, what is the MC complication of gout

Back 18

-renal disease
-pts can dvlp uric acid kidney stones

Front 19

describe the bony erosions of gout on xray

Back 19

-boney erosions tend to be round with sclerotic margin and have been described as rat bite, cyst like or punched out
-martels sign

Front 20

how can you distinguish gout from other arthrides from radiographs

Back 20

-gout has destructive lesions in the bone that are remote from the articular surface

Front 21

what is Martels sign

Back 21

-gout lesions with overhanging margins

Front 22

what is mandatory for a diagnosis of gout

Back 22

-synovial fluid monosodium urate crystals
-needle shaped with negative befringence (bright yellow)

Front 23

what lab values can be elevated during a gouty attack

Back 23

-synovial fluid leukocytes
-uric acid level (maybe)
-ESR
-WBC

Front 24

treatment of acute gout

Back 24

Colchicine, NSAIDS,

Front 25

Mechanism and dose of colchicine for acute gout

Back 25

-inhibits inflammation, inhibit microtubule formation
-0.5 mg taken hourly until pain reduction, max 8 mg per day

Front 26

what is colchicine given in small incremental doses

Back 26

-to limit GI issues

Front 27

MC NSAID for acute gout

Back 27

-indomethacin

Front 28

Indomethacin dose for acute gout attack

Back 28

50 mg PO tid

Front 29

Tx choices for chronic gout

Back 29

-colchicine, allopurinol, uricosurics (probenicid, sulfinpyrazone)

Front 30

allopurinol dose for chronic gout

Back 30

-300 mg po once or twice a day

Front 31

what drugs can cause gout

Back 31

-salicylates
-diuretics
-TB meds
-warfarin
-nicotinic acid (niacin for high cholesterol)

Front 32

what deposits in the joints with pseudogout

Back 32

-Calcium pyrphosphate dihydrate crystal

Front 33

how can CPPD (calcium pyrophosphate dihydrate crystal disease) be diagnosed

Back 33

-calcium pyrophosphate crystals in the synovial fluid
-needle or rhomboid shape
-positive befringence

Front 34

disease of the nerves that leads to underlying bone and joint abnormalities

Back 34

charcot - neuropathic osteoarthropathy

Front 35

describe the French Theory of charcot

Back 35

-neurovascular theory; damage to nerve centers with an alteration of sympathetic control of blood flow to bones and joints leads to persistent hyperemia and active bone resorption

Front 36

describe the German theory of charcot

Back 36

Neurotramatic theory; extreme progression of degenerative joint disease following loss of proprioception and protective sensation

Front 37

MC causes of Charcot

Back 37

-DM (#1)
-syringomyelia
-tabes dorsalis

Front 38

what is syringomyelia (common cause of charcot)

Back 38

-damage to the spinal cord due to a fluid filled sac

Front 39

clinical presentation of charcot

Back 39

-red, hot swollen joint
-deformed, unstable/hypermobile joint
--decreased sensation
-atrophy of intrinsics
-diminished reflexes
-spontaneous fractures/dislocations
-palpable pulses
-rocker bottom foot
-possible ulcers over dislocated/displaced bony prominences

Front 40

list the 3 stages of charcot development

Back 40

1. acute or developmental
2. coalescence
3. reconstruction

Front 41

describe first stage of charcot

Back 41

-Acute or developmental: joint laxity, subluxation, osteochondral fragments

Front 42

2nd stage of charcot

Back 42

coalescence; absorption of debris and fusion of bony fragments

Front 43

3rd stage of charcot

Back 43

reconstruction: remodelling nad revascularization of bony fragments

Front 44

DDx for charcot

Back 44

-acute septic arthritis
-OM
-CPPD crystal depostion dz
-Osteonecrosis (AVN)
-PVN synovitis
-gout
-psoriatic arthritis
-RA

Front 45

conservative tx for charcot

Back 45

-NWB, compression (jones) cast to control edema, cast immobilize for fractures, long term accomodatve footwear

Front 46

surgical tx for charcot; when and what

Back 46

-not performed in acute phase
-ulcer excision
-exostectomy
-resections
-lisfranc, triple, pantalar arhtrodeses
-amputation

Front 47

a spirochete is a bacteria, which tick carries this spirochete bacteria (Borrellia burgdorferi) that can cause Lyme disease

Back 47

-Ixodid ticks

Front 48

Lyme disease has three stages; early, intermediate and late; what happens in early

Back 48

-early(3-32 d incubation): erythema chronicum migrans occurs at the site of the bite (warm, painless and bullseye)
-low grade fever
-lymphadenopathy

Front 49

Lyme disease has three stages; early, intermediate and late; what happens in intermediate

Back 49

-1-6 months after initial exposure
-arthritis, nerve or cardiac involvement (AV block)

Front 50

Lyme disease has three stages; early, intermediate and late; what happens in late

Back 50

-CNS involvement (encepahalopathy, axonal polyneuropathy)
--arthritis

Front 51

Tx for Lyme Dz

Back 51

Doxycycline 100 mg po bid
**during the inital 24 hours of abx therapy, some pts experience Jarisch-Herxheimer reaction characterized by high fever and worsening of symptoms)

Front 52

Lyme disease is a triphasic illness with stage 1 (intial weeks), stage 2 (weeks to months), stage 3 (months to years)..what are the main symptoms of each stage

Back 52

stage 1: erythema chronicum migrans
stage 2: recurrent skin lesions, neurologic and cardiac abnormalities
stage 3 : arthritis

Front 53

Inflammatory arthritis is inflammation of the joint lining from an immune system problem or autoimmune disease (versus degenerative arthritis): list some inflammatory arthritis

Back 53

-RA
-lupus
-ankylosing spondylitis
-reiters
-psoriatic arthritis

Front 54

joint pain first thing in the morning or after sitting for awhile

Back 54

-inflammatory arthritis (like RA and Reiters)

Front 55

joint pain at the end of the day

Back 55

destructive arthritis (osteoarthritis)

Front 56

immune system attacks the synovial lining of joints causing inflammation, affecting the small joints in the hands and feet first

Back 56

-RA (synovitis is the inital symptom or sign)

Front 57

what are some articular manifestations of RA

Back 57

-pannus formation
-swan neck
-boutonniere
-hallux valgus
-hammerotes
-fibular/ulnar deviations
-even joint space narrowing

Front 58

how does pannus in RA form and what does it cause

Back 58

-it is the formation of proliferative and invasive granualtion tissue
-the pannus then leads to perisrticular bone and cartilage erosions and destructions

Front 59

what are some extra-articualr manifestations of RA

Back 59

-rheumatoid nodules
-caplans nodes in lung
-vasculitis
-pericarditis
-anemia
-dry eyes and scleritis

Front 60

what is the IPJ flexion deformity in RA called

Back 60

-boutonniere deformity

Front 61

what is IPJ extension deformity in RA called

Back 61

-swan neck

Front 62

if performing sx on an RA pt, what additional preop tests are needed

Back 62

-cervical xray due to C1-C2 dislocations

Front 63

lateral deviation of the digits and erosion of met heads

Back 63

RA

Front 64

what is Felty's syndrome and when is it seen

Back 64

-triad of neutropenia, splenomegaly and RA

Front 65

morning stiffness that lasts at least 1 hour

Back 65

RA

Front 66

to dx a pt with RA, they need to meet 4 of 7 criteria. list the 7

Back 66

1. morning stiffness
2. arthritis of 3 or more joints
3. arthritis of hand joints
4. symmetric arthritis (same joint on opp sides of body)
5. rheumatoid nodules
6. serum rheumatoid factor
7. radiographic changes of hand and wrist (erosions or decalcification near joint)

Front 67

name 3 diseases assoc with RA

Back 67

-sjogrens syndrome
-amylodosis
-feltys syndrome

Front 68

drug therapy for RA

Back 68

-DMARDS (gold salts, plaquenil, methotrexate, TNF inhibitors)
-humira is a TNF inhibitor

Front 69

list 7 special considerations that need to be taken into account if operating on an RA patient

Back 69

1. give them supplemental corticosteroids
2. discontinue aspirin or NSAIDS they are on
3. lateral cervical spine xrays
4. protect the skin during surgery
5. inc risk of infection
6. delayed wound healing
7. DVT prophylaxis

Front 70

why do RA surgical pts need periop corticosteroid supplementation

Back 70

-pts on exogenous steroids may dvlp sudden hypotension during sx stress bc ACTH secretion is supressed
-give hydrocortisone sodium succinate or Solumedrol

Front 71

why do RA surgical pts need to discontinue NSAIDS and aspirin 7 days prior to sx

Back 71

-to prevent bleeding complications
-lab testing should include bleeding time, PT, PTT, serum creatinine adn LFT for pts on longterm aspirin or NSAIDS

Front 72

why should RA surgical pts get lateral cervical xrays

Back 72

-atlantoaxial subluxation (c1-C2) is present in many RA pts
-flexion of nexk during anesthesia can cause nerve damage

Front 73

where are heberdens nodes located and in what disease

Back 73

-osteoarthritis (degenerative arthritis)
-DIPJ

Front 74

where are bouchards nodes located and in what diseae

Back 74

-osteoarthritis
-PIPJ
- Buchareds, base

Front 75

list the radiographic findings of OA

Back 75

-uneven joint space narrowing
-joint mice (loose osseous bodies)
-marginal osteophytes
-subchondral sclerosis
-subchondral bone cysts

Front 76

excessive and abnormal remodeling of bone that may be caused by a viral infection of osteoclasts

Back 76

Pagets Disease of bone (osteitis deformans)

Front 77

which bones does pagets often effect

Back 77

-axial skeleton (pelvis, sacrum, spine, skull)
-long bones such as femur and tibia

Front 78

there are three phases of pagets

Back 78

1. osteolytic phase
2. mixed phase
3. sclerotic phase- blastic phase

Front 79

how would a long bone with pagets look on xray

Back 79

-increased cortical width
-increased bone length
-coursening of trabeculae
-bone enlargement

Front 80

what are the lab features of pagets

Back 80

-elevated serum alkaline phosphatase (N=44-147)
-increased urinary hydroxyproline (N=50mg/24 hours)

Front 81

pagets tx

Back 81

-biphosphonates
-calcium
-vit D
-calcintonin
-NSAIDS

Front 82

what are the seronegative spondyloarthropathies and why are they called that

Back 82

-group of inflammatory disorders that affect the axial skeleton
-they are sero negative meaning neg for rheumatoid factor
-anklylosing spondylitis
-reiters syndrom
-psoriatic arthritis
-enteropahtic spondylitis (crohns)
-reactive arthritis

Front 83

what is bamboo spine and when is it seen

Back 83

-spinal fusion seen in ankylosing spondylitis

Front 84

what gene is common in seronegative spondyloarthropathies

Back 84

HLA-B27

Front 85

what is the classic triad of reiters

Back 85

-conjunctivitis
-urethritis
-arthritis

Front 86

when does reiters dvlp in a genetically susceptible host (one with HLA-B27)

Back 86

-after a GU or GI infection

Front 87

there are two characteristic lesions associated with reiters

Back 87

-balanitis circinata (ulcers of the glans penis)
-kertoderma blennorrhagicum on soles of feet (clear vesicles on a red base that progress to macules, then small keratotic nodules)

Front 88

soft tissue swelling in IPJ of toes and fingers causing sausage deformities

Back 88

reiters

Front 89

what is the most helpful radiographic characteristic of seronegative spondyloarthropathies that distinguishes it from RA

Back 89

-bone proliferation
(linear or fluffy periosteal proliferation) (periostitis at tendon and ligament attachment to bone-enthesitis) (intra-articular bone formation at sites of osseous erosion)

Front 90

describe the nails in psoriatic arthritis

Back 90

-pitting
-transverse ridges
-subungual hyperkeratosis
-discoloration of nail
-oil spot below the nail

Front 91

psoriatic arthritis is similar to RA in that it is progressive inflammatory arthritis; how does it differ

Back 91

-psoriatic arthritis has underlying psoriasis, dactylitis and abscence of anti-cyclic citrulinated peptide antibodies (anti-CCP is present in RA)

Front 92

resorption of the tufts of the distal phalanges of hands and feet

Back 92

psoriatic arthritis

Front 93

Auspitz sign

Back 93

-bleeding occurs at sites of scale removal in psoriatic arthritis

Front 94

what color is the synovial fluid from joints of psoriatic pts

Back 94

lemon yellow

Front 95

what is the name of the clinical test used for anklosing spondylitis

Back 95

Wright-Schober; to detect the limitation of forward flexion of the lumbar spine

Front 96

what is the radiograph hallmark of ankylosing spondylitis

Back 96

-sacroliliac joint is sacroilitis

Front 97

Back 97

Charcot - midfoot collapse

Front 98

Back 98

Charcot

Front 99

Back 99

Blue and Yellow Gout crystals

Front 100

Back 100

Gout

Front 101

Back 101

Lyme disease- erythema chronicum migrans

Front 102

Back 102

psoriatic arthritis

Front 103

What is this disease and what was done on the left post op?

Back 103

RA - met head arthroplasty

Front 104

Back 104

RA

Front 105

Back 105

Sausage digit or psoriatic arthritis

Front 106

Back 106

swan neck of RA