Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
113 Cards in this Set
- Front
- Back
|
Q1 |
Cutaneous manifestations of Ra include Erythema induratum Leg ulcers Palmar erythema Subcutaneous nodules Eccrine hydradenitis
|
|
|
Q2 |
Following are recognized extra articular manifestations of rheumatoid arthritis exceptCaplans syndromePyoderma gangrenosumPhotosensitive rashScleromalacia perforansPeripheral neuropathy |
|
|
Q3 |
Following are poor prognostic factors in RA exceptPersistent synovitisEarly erosive changesExtra articular findingsNegative anti-CCP antibodiesPositive rheumatoid factor |
|
|
Q4 |
A |
|
|
Q5 |
A |
|
|
Q6 |
A |
|
|
Q7 |
A |
|
|
What is RA |
chronic systemic inflammatory disease of unknown cause. |
|
|
What happens pathologically |
An external trigger (eg, cigarette smoking, infection, or trauma) that triggers an autoimmune reaction , leading to synovial hypertrophy and chronic joint inflammation along with the potential for extra-articular manifestations, is theorized to occur in genetically susceptible individual |
|
|
What is the onset like in RA |
onset is insidious, often beginning with fever, malaise, arthralgias, and weakness before progressing to joint inflammation and swelling. 10%) of patients with this disease have an abrupt onset. |
|
|
What is the hallmark feature of RA |
Persistent SYMMETRIC POLYARTHRITIS OF HANDS AND FEET. |
|
|
What are the clinical features of RA |
•Persistent symmetric polyarthritis (synovitis) of hands and feet (hallmark feature) •Progressive articular deterioration •Extra-articular involvement •Difficulty performing activities of daily living (ADLs) •Constitutional symptoms
|
|
|
What are the components of physical examination |
•Upper extremities (metacarpophalangeal joints, wrists, elbows, shoulders)•Lower extremities (ankles, feet, knees, hips)•Cervical spine
|
|
|
What should we look for |
•Stiffness •Tenderness •Pain on motion •Swelling •Deformity •Limitation of motion •Extra-articular manifestations •Rheumatoid nodules
|
|
|
How do you make a diagnosis |
No test results are pathognomonic; instead, the diagnosis is made by using a combination of clinical, laboratory, and imaging features. |
|
|
What are the potentially useful tests in someone suspected of having RA are |
•Erythrocyte sedimentation rate•C-reactive protein level•Complete blood count•Rheumatoid factor assay•Antinuclear antibody assay•Anti−cyclic citrullinated peptide and anti−mutated citrullinated vimentin assays
|
|
|
ESR and CRP |
T |
|
|
CBC |
T |
|
|
RF |
T |
|
|
Anti CAc |
No laboratory test results are pathognomonic for RA, but the presence of anti-cyclic citrullinated protein antibody (ACPA) and rheumatoid factor (RF) is highly specific for this condition. |
|
|
ANA |
T |
|
|
What are the potentially useful imaging studies |
•Radiography (first choice): Hands, wrists, knees, feet, elbows, shoulders, hips, cervical spine, and other joints as indicated•Magnetic resonance imaging: Primarily cervical spine•Ultrasonography of joints: Joints, as well as tendon sheaths, changes and degree of vascularization of the synovial membrane, and even erosions
|
|
|
X-ray |
T |
|
|
MRI |
T |
|
|
USS |
T |
|
|
What are the investigations done in joint aspiration and analysis of synovial fluid |
•Gram stain •Cell count •Culture •Assessment of overall appearance
|
|
|
Gram stain |
T |
|
|
CBC |
T |
|
|
Appearance |
T |
|
|
Management options |
Nonpharmacological Pharmacological |
|
|
Nonpharmacological |
•Heat and cold therapies •Orthotics and splints •Therapeutic exercise.. •Occupational therapy •Adaptive equipment •Joint-protection education •Energy-conservation education
|
|
|
Principles of pharmacological therapy |
DMARDS EARLY is the standard of care To retard disease progression To induce remissions OTHER- supportive |
|
|
What are the DMARDS |
Non biologic Biologic |
|
|
Non biologic DMARDs are |
•Hydroxychloroquine•Azathioprine•Sulfasalazine•Methotrexate•Leflunomide•Cyclosporine•Gold salts•D-penicillamine•Minocycline
|
|
|
Biologic TNF inhibiting DMARDS |
•Etanercept •Infliximab •Adalimumab •Certolizumab •Golimumab
|
|
|
Biologic non TNF inhibitors are |
•Rituximab •Anakinra •Abatacept •Tocilizumab •Sarilumab •Tofacitinib •Baricitinb
|
|
|
What are the problems with DMARDS |
Most are immunosuppressive so have a high risk of infection |
|
|
What are the other drugs used |
•Corticosteroids •Nonsteroidal anti-inflammatory drugs (NSAIDs) •Analgesics
|
|
|
Treatment principals |
•The primary target for treatment of RA should be a state of clinical remission. •While remission should be a clear target, low-disease activity may be an acceptable alternative therapeutic goal, particularly in long-standing disease. •The use of validated composite measures of disease activity, which include joint assessments, is needed in routine clinical practice to guide treatment decisions .••Measures of disease activity must be obtained and documented regularly: as frequently as monthly for patients with high/moderate disease activity or less frequently (such as every 6 mo) for patients in sustained low-disease activity or remission. •Structural changes and functional impairment and comorbidity should be considered when making clinical decisions, in addition to assessing composite measures of disease activity. •Until the desired treatment target is reached, drug therapy should be adjusted at least every 3 mo. •The desired treatment target should be maintained throughout the remaining course of the disease. •The rheumatologist should involve the patient in setting the treatment target and the strategy to reach this target.
|
|
|
What are the surgical procedures |
•Synovectomy •Tenosynovectomy •Tendon realignment •Reconstructive surgery or arthroplasty •Arthrodesis
|
|
|
What are the joints involved |
Any joint lined by a synovial membrane But commonly MCP JOINTS WRIST PROXIMAL IP JOINT ELBOW SHO |
|
|
What are the common organs of extracellular involvement |
• Cutaneous • Cardiac • Pulmonary • Renal • Gastrointestinal (GI) • Vascular • Hematologic • Neurologic • Ocular • Cutaneous • Cardiac • Pulmonary • Renal • Gastrointestinal (GI) • Vascular • Hematologic • Neurologic • Ocular |
|
|
What is a clinical remission |
Absence of signs and symptoms of significant inflammatory activity. |
|
|
What influence the targets |
The choice of the (composite) measure of disease activity and the target value should be influenced by comorbidities, patient factors, and drug-related risks. |
|
|
What is the pathophysiology |
An external trigger (eg, cigarette smoking, infection, or trauma) that sets off an autoimmune reaction, leading to synovial hypertrophy and chronic joint inflammation along with the potential for extra-articular manifestations, is theorized to occur in genetically susceptible individuals.Synovial cell hyperplasia and endothelial cell activation are early events in the pathologic process that progresses to uncontrolled inflammation and consequent cartilage and bone destruction. Genetic factors and immune system abnormalities contribute to disease propagation.
|
|
|
What are the immune mechanisms involved |
CD4 T cells, mononuclear phagocytes, fibroblasts, osteoclasts, and neutrophils play major cellular roles in the pathophysiology of RA, whereas B cells produce autoantibodies (ie, rheumatoid factors). Abnormal production of numerous cytokines, chemokines, and other inflammatory mediators has been demonstrated in patients with RA, including the following:•Tumor necrosis factor alpha (TNF-α)•Interleukin (IL)-1•IL-6•IL-8•Transforming growth factor beta (TGF-ß)•Fibroblast growth factor (FGF)•Platelet-derived growth factor (PDGF)
|
|
|
What is the destructive nature like in RA |
inflammation and exuberant proliferation of the synovium (ie, pannus) leads to destruction of various tissues, including cartilage (see the image below), bone, tendons, ligaments, and blood vessels. |
|
|
What is the primary site involved |
Articular structure |
|
|
Q |
Q |
|
|
What are the factors of aetiology |
Genetic, environmental, hormonal, immunologic, and infectious factors may play significant roles. Socioeconomic, psychological, and lifestyle factors (eg, tobacco use, the main environmental risk may influence disease development and outcome. |
|
|
What is the main environmental risk |
Tobacco use |
|
|
What is the place of genetic factors |
Genetic factors account for 50% of the risk for developing RA. Genes other than those of the major histocompatibility complex (MHC) are also involved. |
|
|
What are the infectious agents involved
|
Mycoplasma organisms, Epstein-Barr virus (EBV) rubella virus. |
|
|
Q |
Q |
|
|
Q |
•Occasional reports of flulike disorders preceding the start of arthritis•The inducibility of arthritis in experimental animals with different bacteria or bacterial products (eg, streptococcal cell walls)•The presence of bacterial products, including bacterial RNA, in patients’ joints•The disease-modifying activity of several agents that have antimicrobial effects (eg, gold salts, antimalarial agents,
|
|
|
What are the clues for sex hormone involvement |
More involvements in females with this disease, its amelioration during pregnancy, its recurrence in the early postpartum period, and its reduced incidence in women using oral contraceptives. Hyperprolactinemia may be a risk factor for RA. |
|
|
Q |
Q |
|
|
Who initiates the inflammatory process |
T cells are assumed to play a pivotal role in the initiation of RA, and the key player in this respect is assumed to be the T helper cells ( CD 4) |
|
|
Q |
Q |
|
|
Q |
All of the major immunologic elements play fundamental roles in initiating, propagating, and maintaining the autoimmune process of RA. Aberrant production and regulation of both proinflammatory and anti-inflammatory cytokines and cytokine pathways are found in RA. |
|
|
Q |
T and B cells, antigen-presenting cells (eg, B cells, macrophages, and dendritic cells), and various cytokines. |
|
|
What are the functions of B cells |
serve as antigen-presenting cells. B cells also produce numerous autoantibodies (eg, RF and ACPA) and secrete cytokines. |
|
|
What is the role of pannus |
Hyperactive and hyperplastic synovial membrane turns into pannus and destroys cartilage and bone . Bone destruction is by activating osteoclasts. |
|
|
Q |
The major difference between RA and other forms of inflammatory arthritis, such as psoriatic arthritis, lies not in their respective cytokine patterns but, rather, in the highly destructive potential of the RA synovial membrane and in the local and systemic autoimmunity. |
|
|
Immune complexes ... what do they do |
autoimmune response conceivably leads to the formation of immune complexes that activate the inflammatory process to a much higher degree than normal. This theory is supported by the much worse prognosis of RA among patients with positive RF results. |
|
|
Q |
Q |
|
|
What |
Women are affected by RA approximately 3 times more often than men are, but sex differences diminish in older age groups. Peak age of onset is between 35-50 |
|
|
What |
Q |
|
|
What decides prognosis |
Time is all that matters EARLIER THE DIAGNOSIS AND TREATMENT BETTER THE OUTCOME Intervention with DMARDs in very early RA (symptom duration < 12 weeks at the time of first treatment) provides the best opportunity for achieving disease remission. |
|
|
What is the general course of the disease |
clinical course of RA is generally one of exacerbations and remissions. Approximately 40% of patients with this disease become disabled after 10 years, but outcomes are highly variable. Some patients experience a relatively self-limited disease, whereas others have a chronic progressive illness. |
|
|
What are the poor prognostic indicators with regards to joint destruction are |
•HLA-DRB1*04/04 genotype •High serum titer of autoantibodies (eg, RF and ACPA) •Extra-articular manifestations •Large number of involved joints •Age younger than 30 years •Female sex •Systemic symptoms •Insidious onset
|
|
|
What are the other laboratory indicators of prognosis |
early radiologic evidence of bony injury, persistent anemia of chronic disease, elevated levels of the C1q component of complement, and the presence of ACPA |
|
|
What do absence and presence of RF say |
the presence of RF in sera has been associated with severe erosive disease so poor prognosis. However, the absence of RF does not necessarily portend a good prognosis. |
|
|
What |
Q |
|
|
What are the manifestations on skin |
Subcutaneous nodules in pressure points- olecranon Vasculitic lesions palpable purpura skin ulceration (eg, leg ulceration). palmar erythema pyoderma gangrenosum may be noted. |
|
|
What are subcutaneous nodules |
Q |
|
|
Which statement about rheumatoid arthritis is true? 1. Disorder is seen in patients over the age of 50 2. Is self-limiting 3. Is associated with significant disability 4. Diagnosis is based on a laboratory test
|
Well done! You answered successfullyTeaching PointsRheumatoid arthritis (RA) is associated with significant disability and cost.RA is a chronic disorder associated with shortened life expectancy.Abnormal serum rheumatoid factor is seen in less than 50 percent of individuals.No single test can make the diagnosis of RA. It requires the combination of clinical features, radiography, and laboratory features. |
|
|
When does radiographically visible damage due to rheumatoid arthritis occur? 1. Within the first 12 months of disease 2. Generally after 3 years of disease 3. Generally after 5 years of disease 4. Anytime |
Well done! You answered successfullyTeaching PointsRadiographic changes help distinguish various etiologies of arthritis.Plain radiographic changes usually take from 4 to 5 years to manifest after the onset of symptoms. Historically, only bone scintigraphy showed earlier changes, but MRI is more sensitive and more specific in diagnosing rheumatoid arthritis and can do so much earlier than plain films.The earliest change is periarticular soft tissue swelling of the wrists or feet.Diagnostic changes on radiographs include fairly uniform joint space narrowing and marginal erosions, primarily involving the MCP joints of the hands and the intercarpal and radiocarpal joints of the wrists. |
|
|
In a patient diagnosed with rheumatoid arthritis, which of the following could be the first drug of choice in treatment that alters the course of the disease? 1. Ibuprofen 2. Methotrexate 3. Aspirin 4. Colchicine |
Well done! You answered successfullyTeaching PointsNSAIDs are used in rheumatoid arthritis to relieve stiffness and joint pain but do not change disease progression.Disease-modifying antirheumatic drugs should be started.Methotrexate, hydroxychloroquine, and sulfasalazine are often used.Biologic agents such as TNF-alpha and IL-1 are used when first-line agents are not effective. |
|
|
What |
is Are |
|
|
What |
What |
|
|
Which condition is treated with gold salts? 1. Osteoarthritis 2. Rheumatoid arthritis 3. Psoriasis 4. Granulomatosis with polyangiitis
|
Well done! You answered successfullyTeaching PointsGold salts are used to prevent further injury of the joints.Gold salts are taken up by macrophages and inhibit lysosomal activity.Gold salts are used for rheumatoid arthritis when the usual NSAID fails.Gold salts, unfortunately, are not well tolerated. |
|
|
is |
I |
|
|
Which of the following is a disease-modifying agent for treatment of rheumatoid arthritis? 1. Celecoxib 2. Indomethacin 3. Hydroxychloroquine 4. Piroxicam
|
Well done! You answered successfullyTeaching PointsDisease-modifying antirheumatic drugs (DMARDs) are used to treat rheumatoid arthritis by decreasing joint inflammation. DMARDs cannot reverse the joint damage, but they can prevent progression.Immunosuppressants such as methotrexate, hydroxychloroquine, sulfasalazine, cyclosporine, and azathioprine are commonly used.Biologic immunomodulators such as rituximab, infliximab, etanercept, and adalimumab are second line drugs.DMARDS take up to a few months to have effects. NSAIDS are used for acute symptoms but do not modify disease progression. |
|
|
What |
What |
|
|
A female is found to have a deformed finger. The PIP joint appears to be bent towards the palm whereas the DIP joint is bent away and appears hyperextended. She may have what condition? 1. Gout 2. Rheumatoid arthritis 3. Psoriasis 4. Carpal tunnel
|
Well done! You answered successfullyTeaching PointsBoutonniere deformity is a deformed finger seen in rheumatoid arthritis.The deformity is characterized by a permanently hyperflexed PIP joint and hyperextended DIP joint."Boutonniere" is French for button hole, and the deformity looks like a finger slipping through a button hole.The mechanics of the PIP flexion deformity is due to interruption of the central slip of the extensor tendon. This allows the lateral slips to separate and the proximal phalangeal head to pop through the gap (like a finger through a button hole).
|
|
|
What |
What |
|
|
Which is false about acetaminophen use in rheumatoid arthritis? 1. Acetaminophen is a weak prostaglandin inhibitor in peripheral tissues 2. Acetaminophen possesses significant anti-inflammatory effects 3. In low doses, acetaminophen does not cause gastrointestinal upset 4. Hepatotoxicity can occur when high doses are consumed |
Well done! You answered successfullyTeaching PointsAcetaminophen is the preferred drug for mild to moderate pain and for lowering fever. It usually is used when there is no need to take a parenteral pain medication. The drug does not possess significant anti-inflammatory effects.In therapeutic doses, side effects are uncommon; acetaminophen does not cause gastrointestinal upset.However, toxic doses of acetaminophen can saturate normal metabolizing enzymes. The loss of glutathione leads to liver damage and can be fatal within 24 to 48 hours.Acetaminophen has no significant effects on inflammation. It remains the most widely used over the counter pain medication for a variety of pain disorders. |
|
|
What |
What |
|
|
Which is false about gold treatment for rheumatoid arthritis? 1. Intramuscular gold resolves symptoms in less than 4 weeks 2. The mechanism of gold is believed to be inhibition of mitogen-induced lymphocyte proliferation 3. Side effects include bone marrow depression 4. Gold can also be taken orally for treatment of rheumatoid arthritis
|
Well done! You answered successfullyTeaching PointsGold usually is a last resort treatment for individuals who do not respond to conventional rheumatoid medications.Gold can only be taken orally or via an intramuscular injection and needs to be taken for a minimum of 3 to 6 months before any benefit is seen.Side effects of gold include loss of appetite, skin rash, marrow depression, alopecia, diarrhea, and itching.The mode of action of gold is unknown but linked to anti-mitochondrial activity and induced cell apoptosis.
|
|
|
What |
What |
|
|
Which is false about aspirin use in rheumatoid arthritis? 1. In blood, aspirin is rapidly hydrolyzed to its active metabolite, salicylate 2. Salicylate is bound to albumin, but the binding is saturable 3. At higher doses, aspirin can cause"salicylism," characterized by vomiting, tinnitus, decreased hearing, vertigo, and increased respiration. 4. Aspirin rarely causes gastric upset
|
Well done! You answered successfullyTeaching PointsIn therapeutic doses, the main adverse effects are gastric upset and/or upper gastrointestinal (GI) bleeding.At toxic doses, aspirin can cause salicylate poisoning, a consequence of altered acid-base balance.Salicylate poisoning can result in depressed respiration, hyperthermia, dehydration, coma, renal, and respiratory failure.Individuals who have aspirin-induced GI upset need to take a proton pump inhibitor or misoprostol at the same time.
|
|
|
A female reports symmetrical small joint polyarthritis for 2 weeks. Labs show rheumatoid factor levels at 1:320 (positive is 1:40) and anti-CCP at 58 units (40 to 59 units are considered strongly positive). An antinuclear antibody test is negative. Labs also reveal positive cytomegalovirus and parvovirus IgG, and negative parvovirus IgM. The erythrocyte sedimentation rate is 62 mm/hour. What is the appropriate next step in the management of this patient? 1. Naproxen 500 mg twice a day and follow up in 1 month 2. Methotrexate 12.5 mg a week with liver function tests in 1 month 3. Anti-histone antibodies, anti-DS-DNA, and complement levels 4. Prednisone 60 mg a day and follow up in 2 weeks
|
Well done! You answered successfullyTeaching PointsThe patient has rheumatoid arthritis. Early treatment with double or triple disease-modifying antirheumatic drug (DMARD) therapy is indicated. Methotrexate is considered the first-line therapy, with sulfasalazine being used if methotrexate is contraindicated.Remission or low disease activity is the goal for all patients. Remission should at least be targeted for all patients.With negative antinuclear antibody, anti-histone antibodies, and anti-DS-DNA, complement levels are unlikely to be helpful.Prednisone might be helpful, but 60 mg a day is a high starting dose. |
|
|
patient with symmetrical polyarthritis has a positive rheumatoid factor at 1:320, an erythrocyte sedimentation rate of 58 mm/hour, a C-reactive protein of 1.3 mg/dL, anti-CCP at 58 units (40 to 59 units are considered strongly positive), and subcutaneous nodules at the Achilles tendon. Which of the following would not be an appropriate test? 1. Bilateral hand x-rays 2. Liver and kidney function 3. Complete blood count 4. Serum uric acid
|
Well done! You answered successfullyTeaching PointsFurther evaluation of a patient with rheumatoid arthritis should include CBC, chemistry panel, and hand x-rays.Uric acid levels are important in gout but have little importance in rheumatoid arthritis.There is no test that is pathognomonic for rheumatoid arthritis. The diagnosis is made by using a combination of laboratory data, clinical features, and x-ray images.Bone scanning findings often are done in patients to differentiate inflammatory from noninflammatory features, especially in individuals with minimal swelling. |
|
|
40-year-old female patient is diagnosed with rheumatoid arthritis with a large number of joints involved. She has rheumatoid nodules, pericardial rub, elevated erythrocyte sedimentation rate and C-reactive protein, positive rheumatoid factor, and anti-CCP antibody. The patient has minimal relief with naproxen 500 mg twice a day. What is the appropriate next step in her treatment? 1. Increase naproxen to 500 mg 3 times a day 2. Start prednisone 20 mg a day, hydroxychloroquine 200 mg twice a day, and physical therapy 3. Start prednisone 20 mg a day, hydroxychloroquine 200 mg twice a day, methotrexate, and physical therapy 4. Start prednisone 20 mg a day, hydroxychloroquine 200 mg twice a day, methotrexate, calcium, vitamin D, and physical therapy
|
Well done! You answered successfullyTeaching PointsThe patient has rheumatoid arthritis with multiple poor prognostic indicators, making combination therapy the best choice.Methotrexate is the initial disease-modifying antirheumatic drug (DMARD) of choice.Methotrexate, hydroxychloroquine, and/or sulfasalazine have better outcomes than methotrexate alone.Prednisone is for short-term, immediate symptom relief. |
|
|
40-year-old patient is diagnosed with rheumatoid arthritis and started on prednisone 20 mg a day, hydroxychloroquine 200 mg twice a day, methotrexate 10 mg per week, calcium, vitamin D, and physical therapy. The patient follows up 1 month later. A complete blood count and chemistry panel are normal. Which of the following would be most appropriate for the management of this patient? 1. Continue current management with follow-up every 4 months for CBC and a chemistry panel 2. Continue present medications and have the patient follow up for monthly liver function tests and CBC 3. Taper prednisone slowly, continue the other medications and have the patient follow up every 2 months for a chemistry panel and CBC 4. Taper prednisone slowly, continue other medications, have the patient see an ophthalmologist, and return every month for liver function tests and a CBC
|
Well done! You answered successfullyTeaching PointsPrednisone can be tapered when disease-modifying antirheumatic drugs (DMARDs) take effect.DMARDs are given long-term to prevent bone injury in patients with RA.Methotrexate requires liver function tests and a CBC every 8 weeks.Hydroxychloroquine should be monitored with yearly ophthalmologic exams. |
|
|
A patient diagnosed with rheumatoid arthritis 3 months ago is being treated with methotrexate 15 mg per week, hydroxychloroquine 200 mg twice a day, and prednisone, which has been tapered from 20 mg a day to 5 mg a day. Despite some improvement, the patient still has morning stiffness, swelling, and tenderness of several metatarsophalangeal joints. She still cannot open a jar. Which of the following would be most appropriate for this patient? 1. Increase prednisone to 40 mg a day 2. Increase methotrexate to 25 mg a week 3. Increase methotrexate to 25 mg a week and refer the patient to rheumatology 4. Switch from methotrexate to leflunomide 20 mg a dayWell done! You answered |
successfullyTeaching PointsThe patient has continuing inflammation despite two disease-modifying antirheumatic drugs (DMARDs).The patient should see a rheumatologist and is a candidate for a biologic agent.Biologic DMARDs include tumor necrosis factor (TNF) and non-TNF inhibitors.The methotrexate likely has been helpful, so increasing the dose would be reasonable. |
|
|
Which of the following statements about rheumatoid arthritis is true? 1. 75 percent of the joints that will be involved will be involved during the first year 2. Joint replacement can be helpful for patients that develop disabilities 3. Rheumatoid arthritis does not decrease life expectancy 4. Rheumatoid arthritis has a progressive course without remissions
|
Well done! You answered successfullyTeaching PointsAs many as 40 percent of patients have spontaneous remission. Ten percent are long-term, while 30 percent have remission and then exacerbation.Drug remissions are also common.Rheumatoid arthritis decreases life expectancy by up to 10 years.Joint replacements should be used judiciously, as they generally last for 15 years. |
|
|
What |
What |
|
|
What |
What |
|
|
Which of the following statements about rheumatoid arthritis is true? 1. It is seen predominantly in patients more than 60 years of age 2. It is self-limited and resolves over 10 years 3. It is associated with significant disability and cost 4. It is diagnosed on the basis of a laboratory testWell done! You answered |
successfullyTeaching PointsRheumatoid arthritis (RA) is associated with significant disability and cost.RA is a chronic systemic inflammatory disorder whose etiology remains unknown.Triggers include infection, smoking, or trauma which lead to chronic joint inflammation and synovial hypertrophy.The disorder usually affects the small joints and has many extraskeletal manifestations which lead to severe disability. |
|
|
What |
What |
|
|
Ulnar deviation of the metacarpophalangeal (MCP) joint is MOST likely to be seen in patients with which condition? 1. Rheumatoid arthritis 2. Osteoarthritis 3. Colles fracture 4. Psoriasis arthropathy
|
Well done! You answered successfullyTeaching PointsUlnar deviation is most often seen in patients with rheumatoid arthritis when there is MCP joint involvement (a common location for involvement).The fingers often become displaced and move towards the fifth finger.The disorder rarely occurs with osteoarthritis.Ulnar deviation is also seen in lupus (SLE) and psoriatic arthropathy, but much less commonly. Systemic lupus erythematosus involvement can cause what is known as Jaccoud arthropathy. With Jaccoud arthropathy there is prominent ulnar deviation of the MCP joints but no underlying erosions or joint space los |
|
|
I |
I |
|
|
Which of the following is true regarding rheumatoid arthritis? 1. Constitutional symptoms are uncommon 2. The knee is the most common joint affected 3. Joint damage causes radial deviation of the digits 4. Morning stiffness lasts an hour or more
|
Well done! You answered successfullyTeaching PointsRheumatoid arthritis is characterized by morning stiffness, arthralgia of at least 3 joints, involvement of hand joints, symmetry, and possibly rheumatoid nodules.Joint and tendon damage result in hyperextension and ulnar deviation of the digits and the metacarpophalangeal joint is the most common one affected followed by wrist then PIP joints and knees.Symptoms such as fatigue, weight loss, fevers are common.The first change seen on x-ray is periarticular osteoporosis, and as the disease progresses, cartilaginous and bony destruction is seen. |
|
|
Which of the following is true regarding rheumatoid arthritis? 1. Constitutional symptoms are uncommon 2. The knee is the most common joint affected 3. Joint damage causes radial deviation of the digits 4. Morning stiffness lasts an hour or moreWell done! You answered |
successfullyTeaching PointsRheumatoid arthritis is characterized by morning stiffness, arthralgia of at least 3 joints, involvement of hand joints, symmetry, and possibly rheumatoid nodules.Joint and tendon damage result in hyperextension and ulnar deviation of the digits and the metacarpophalangeal joint is the most common one affected followed by wrist then PIP joints and knees.Symptoms such as fatigue, weight loss, fevers are common.The first change seen on x-ray is periarticular osteoporosis, and as the disease progresses, cartilaginous and bony destruction is seen. |
|
|
Which of the following is not among the signs or symptoms listed by the American College of Rheumatology for the classification of rheumatoid arthritis? 1. Morning stiffness 2. Subcutaneous nodules 3. Asymmetric arthritis 4. Arthritis of one or more hand joints |
Well done! You answered successfullyTeaching PointsCriteria for the diagnosis of rheumatoid arthritis (RA) include morning stiffness, rheumatoid nodules, symmetric arthritis, arthritis of hand joints, positive rheumatoid factor, arthritis of three or more joint areas, and typical radiographic changes.The most common clinical presentation of RA is polyarthritis of the proximal interphalangeal joints, metacarpophalangeal joints, and the wrist.RA with symptom duration of fewer than 6 months is defined as early, and when the symptoms have been present for more than 6 months, it is defined as established.The radiographic finding of erosions is pathognomonic |
|
|
A patient with rheumatoid arthritis complains of shortness of breath. Exam reveals dullness to percussion at the left base. Chest radiograph shows a left pleural effusion. Left lateral radiograph shows it to be free-flowing. Thoracentesis is done. Which of the following is least likely to be found in the pleural fluid? 1. Positive rheumatoid factor 2. Yellow color 3. Elevated lactate dehydrogenase (LDH) 4. Low cholesterol |
Well done! You answered successfullyTeaching PointsThe pleural effusion secondary to rheumatoid arthritis usually is a yellow color exudate and contains a low glucose level.There would be elevated LDH and positive rheumatoid factor.Cholesterol should be elevated as these lesions are exudative and elevated cholesterol, as well as LDH and protein, is a characteristic of exudatesRheumatoid pleural effusions are most common in middle-aged males with a positive rheumatoid factor. |
|
|
70-year-old female with a history of osteoarthritis, diabetes, congestive heart failure, and a significant smoking history presents with a deep, productive cough and fever. Auscultation reveals decreased breath sounds in the left chest. Thoracentesis reveals a fluid with a lactate dehydrogenase of 500 units/L, pH 7.45, and low glucose. She may have which of the following conditions? 1. Mesothelioma 2. Lobar pneumonia 3. Rheumatoid arthritis 4. Cancer |
Well done! You answered successfullyTeaching PointsAn exudative effusion, which has a high lactate dehydrogenase, normal pH, and low glucose, is indicative of a rheumatoid effusion (RA).Complement levels have been shown to be significantly lower in the pleural fluid of patients with rheumatic disease as opposed to malignancy.Cigarette smoking is the strongest environmental risk factor associated with rheumatoid arthritis. Studies have shown in anti-citrullinated protein antibody (ACPA) positive individuals, there is an interaction between genes and smoking that increases the risk of RA.A strategic approach is followed when managing rheumatoid arthritis. Disease activity is assessed at regular intervals and treatment is changed as per the disease activity. Disease-modifying antirheumatic drugs (DMARDs) are initiated as soon as the diagnosis of RA is made. Traditional or conventional DMARDs include methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine. Biologic DMARDs include the tumor necrosis factor (TNF) inhibitors adalimumab, etanercept, infliximab, golimumab, and certolizumab. Non-TNF inhibitors are tocilizumab, an interleukin-6 inhibitor, abatacept that inhibits T cell costimulation, and rituximab that is anti B cell. According to the American College of Rheumatology 2015 recommendations, the treatment of early RA with a symptom duration less than 6 months is DMARD monotherapy. Methotrexate is the preferred DMARD. It is recommended to use monotherapy over double or triple therapy. Along with methotrexate, glucocorticoids may be used as bridge therapy, usually for 3 months, while the DMARD becomes effective. If the disease activity remains moderate or high, despite the use of DMARD monotherapy, then use a combination of DMARDs which can be either traditional DMARD, TNF inhibitors, or non-TNF inhibitors. For disease flares, short-term glucocorticoids at the lowest dose for the shortest duration can be used. |
|
|
Which of the following radiological features suggest rheumatoid arthritis? 1. Involucrum 2. Bone sclerosis 3. Bone erosions 4. Cartilage hypertrophyWell done! You answered successfully
|
Teaching PointsBone erosions are consistent with an active inflammatory process. Rheumatoid arthritis has a predilection for the MCP joints and causes marginal bony erosions.Cartilage hypertrophy may be noted in acromegaly.Osteophytes and osteosclerosis are degenerative changes and are common in osteoarthrosis, seen most commonly in the DIP joints of the hand.Involucrum is dead bone, commonly seen in chronic osteomyelitis. |
|
|
Which disease modifying medication is commonly used in rheumatoid arthritis (RA)? 1. Allopurinol 2. Prednisone 3. Ibuprofen 4. Methotrexate
|
Well done! You answered successfullyTeaching PointsDisease modifying antirheumatic drugs (DMARDs) are given long-term to prevent bone injury in patients with RA.They are initiated as soon as the diagnosis is made.Traditional or conventional DMARDs include methotrexate, leflunonamide, sulfasalazine, hydroxychloroquine.Biologic DMARDs include tumor necrosis factor (TNF) and non-TNF inhibitors. |
|
|
earlsQuiz: Arthritis, Rheumatoid (Id:88651)Question 26 of 81Quiz Type:Knowledge QuizzerQuestion Keywords:Arthritis, RheumatoidAnatomical Science:Connective Tissue, MusculoskeletalClinical Science:Treatment MedicalLast Updated:11/11/2018 6:59:47 PMQuestion Author:Scott DulebohnSherry GossmanArticle/Question Editor:Mohammed Al-DhahirEditors in Chief:Full ListHow Other Users Answered:1414%86%AnsweredPercent Choice1862030414Which of the following biologic agents is NOT used in rheumatoid arthritis? 1. Abciximab 2. Adalimumab 3. Infliximab 4. Etanercept
|
Well done! You answered successfullyTeaching PointsBiologic agents can be used as DMARDs.These medications block activity of tumor necrosis factor and delay inflammation.These medications can be used in combination with methotrexate.Abciximab is an anti-platelet agent used as an anticoagulant |
|
|
A patient presents with morning stiffness lasting greater than 45 minutes and associated boggy, tender metacarpal joints in both hands. What is the likely diagnosis? 1. Systemic lupus erythematosus (SLE) 2. Polymyositis 3. Acute rheumatic fever (ARF) 4. Rheumatoid arthritis (RA) |
Well done! You answered successfullyTeaching PointsMorning stiffness greater than 30 minutes, edematous metacarpal joints, symmetric joint involvement, and fatigue are common symptoms of RA.SLE can cause joint pain but is more commonly accompanied by a rash and photosensitivity.Polymyositis causes muscle weakness, not joint pain.ARF related arthritis is usually symmetrical but involves large joints. |
