• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/208

Click to flip

208 Cards in this Set

  • Front
  • Back
ANA staining pattern for centromere is seen in what?
Limited scleroderma (CREST) and primary biliary cirrhosis
Is dsDNA helpful in drug-induced lupus?
it is absent in drug-induced lupus
What positive marker is seen in MCTD?
anti-U1-RNP
What is the significance of SSA (Ro) and SSB (La) in pregnant women?
Both are passively transferred from mother to baby and can cause neonatal heart block
What is anti-topoisomerase I also known as and what does it signfiy? What is its counterpart?
It is also known as Scl-70, and it is associated with diffuse scleroderma.

Its counterpart is anti-centromere (in limited scleroderma/CREST)
What is anti-synthetase?
Anti-Jo-1, assocaited with myositis but also higher incidence of ILD.
What class of drugs can cause false positives with ANA and its subclasses?
anti-TNF treatment
What ELISA ab is associated with c-ANCA?
anti-PR3 always
What ab is associated with p-ANCA in ELISA testing? What diseases are associated with p-ANCA?
anti-MPO only sometimes

p-ANCA is associated with Churg-Strauss and PAN
Is IBD and other GI diseases anti-MPO+ or anti-MPO-?
negative
What two ANA subtypes are specific for SLE?
anti-dsDNA and anti-Sm
What rheum diseaes (not MPGN and post-strep nephritic syndromes) have low complements?
SLE and vasculitis including rheumatoid arthritis
How are c3 and c4 different in terms of following SLE activity? What about CH50?
C3 is consumed with any activation of complement pathway (classical or alternative).

C4 is consumed with only classical activation (as in SLE).

CH50 measures total hemolytic component of classical pathway.
What is HLA-DR2,3,4 associated with?
DR2 and DR3 are associated with SLE.

DR3 is also seen in Sjogren and polymyositis.

DR4 is associated with severe RA.
What is the incidence of HLA-B27 in healthy whites? What about in RF-negative diseases?
7% (50-90% in PAIR diseases) - psoriatic arthritis, anklyosing spondylitis, iritis/uveitis, reactive arthritis
What is on ddx for 200-2,000 WBC on synovial fluid?
Non-inflammatory -- OA or internal derangement, TB (TB can be <50,000)
What is on ddx for 2,000-50,000 WBC on synovial fluid?
Inflammatory arthropathy (RA), Gout, Pseudogout, TB or fungal infection
What color are gout crystals? CPPD crystals?
both are yellow and blue (thus birefringent), but the important one is the color parallel to the compensator.

gout- yellow; CPPD- blue
In Marfan syndrome, which way are the lenses displaced?
upward
What are angioid streaks on funduscopic exam associated with?
Pseudoxanthoma elasticum (AR collagen d/o, see recurrent UGI bleeds) and Paget disease.
How often is RF+ seen in RA patients?
80% of the time. However sometimes RF can take 2 years to become positive before onset.
What predicts severe course of RA?
High-titer RF, +anti-CCP, +DR4, constitutional sxs, insidious onset, extraarticular disease (eg rheumatoid nodules)
What is the duration of AM stiffness in RA? How about in OA?
In RA, stiffness is one to several hours.

In OA, stiffness is < 30 minutes
Is RA asymmetric or symmetric? One joint or mulitple?
Symmetric and polyarticular
What are diagnostic criteria for RA?
at least 4 of the 7 following:

1) Morning stiffness (>1 hour) x 6 weeks
2) swelling of wrists, MCPs, PIPs x 6 weeks
3) swelling of joints x 6 weeks
4) symmetric joint swelling x 6 weeks
5) rheumatoid nodules
6) erosive synovitis x-ray
7) +RF
What is on ddx for symmetric, polyarticular hand arthritis?
RA, SLE, scleroderma, psoriasis
How does hemochromatosis present as an arthropathy?
MCP and PIP joints, but asymmetric here
What does hoarseness, sore throat possibly indicate in patient with RA?

Jaw pain?
Involvement of cricoarytenoid joint.

Jaw pain- TMJ may be affected
What is the most common single joint to be initially involved in RA?
Knee.
What is pseudo-phlebitis and in whom should it be suspected?
Ruptured Baker cyst -- suspect in patient with inflammatory knee arthritis with swollen calf
What kind of xray is needed to look for C1-C2 subluxation in RA? What doe they present with?
Lateral flexion and extension c-spine xrays

They can present with headaches at base of skull and radiate to scalp. +/- nonspecific sxs like tingling, dizziness
What is management of asymptomatic C1-C2 subluxation? What if it is causing headaches?
nothing -- no surgical fusion. Treat headaches with NSAIDs. Wait until symptomatic with myelopathy before doing surgical fusion..
What is the disease burden of RA on the rest of the spine?
The thoracic, lumbar and sacral spine and SI joints are spared in RA. No lumbar pain (unlike ankylosing spondylitis and psoriatic arthritis).
What is the associated between cardiovascular disease and RA?
3x risk of CAD. also increased risks of pericarditis, myocarditis, and rheumatoid nodules on valves
What type of amyloid renal disease is associated with RA? What else is it seen in?
AA (also seen in skin pop drug users)
What is Caplan syndrome?
Dust-mining pneumoconiosis with new ILD and intrapulmonary rheumatoid nodules
What to suspect with necrosis + ulceration over malleoli?
Vasculitis that can be associated with RA.
What are neurologic manifestations of RA?
Mononeuritis multiplex - can manifest as foot or wrist drop. Also cervical myelopathy, carpal tunnel syndrome.
What is Felty syndrome? How do you manage it?
Triad of RA, splenomegaly and neutropenia.

Manage Felty syndrome with MTX, cyclosporine, steroids, GCSF +/- splenectomy
What is large granular lymphocyte (LGL) syndrome? Difference in management?
LGL syndrome is neutropenia, splenomegaly. Different from Felty syndrome because less associated with RA and tends to progress to leukemia.

Splenectomy does not work as well.
What determines if a patient with RA should receive a DMARD like MTX?
Treat early and aggressive with DMARDs if you predict they will go on to erosive disease:

constitutional sxs
rheumatoid nodules
vasculitis
extraarticular manifestations
high ESR, high RF, xray, DR4, ? anti-CCP
Celecoxib's main side effect is what? Is it dose-dependent?
COX-2 inhibitors increase risk for CV events, in a dose-dependent manner.
What is the interaction between NSAID's and lithium? NSAIDs and oral hypoglycemics?
Lithium levels can increase in setting of NSAIDs.

ASA in particular decreases breakdown of oral hypoglycemics.
What are absolute contraindications for MTX?
-renal disease
-liver disease, including HBV, HCV, alcohol
-Pregnancy.
What medication should be given with MTX? What are side effects of MTX?
Folate, to prevent marrow suppression.

Side effects- alopecia, GI, BM suppression, renal failure, pneumonitis (like with penicillamine and gold)
In a patient on MTX who is developing dyspnea, what should you order?
PFT's - look at DLCO, for evidence of pneumonitis
What are other DMARDs for RA? When are they used? When not to use/important side effects?
Leuflonomide- only for RA, second line therapy (don't use in hepatitis, pregnancy). risk of cytopenia.

Plaquenil- don't use in psoriasis (can worsen rash), risk of myopathy

Sulfasalazine- side effects are GI, reversible oligospermia, cytopenias
What about gold (side effects?), penicillamine?
Gold- IM injection can cause pruitis, stomatitis, proteinuria, leukopenia, pneuominitis (stop the drug if any of these sxs are severe).

Penicillamine- similar to gold
What are anti-TNF drugs used for?
RA, psoriasis, anklyosing spondylitis, and IBD
How are anti-TNF drugs (eg etanercept, infliximab/remicade, adalimumab/humira) best employed in RA?
Etanercept, Humira, Remicade are most beneficial when combined with MTX.
What are side effects of rituxan?
Stephens-Johnson syndrome/TEN, PML, TLS, infusion rxns including bronchospasm, ARDS, MI
What vaccicine should not be given to patients on biologics (eg humira/adalimumab), etanercept, remicade/infliximab)?
Live-virus vaccines including varicella and MMR should not be given to patients on anti-TNF
What is the most common side effect of biologics? Also what other disease can they show signs of bringing about?
The most common side effect is increased URI's.

Biologics can cause development of ANA and anti-dsDNA.
What drug interaction is important with azathioprine?
Allopurinol (AZA is metabolized by xanthine oxidase which is suppressed by allopurinol). Dose reduce AZA in patients on allopurinol.
What is the presentation of seronegative spondyloarthropathies?
Predilection for spine, SI joints, and entheses (where muscle inserts into bone). Asymmetric, usually lower extremities.
What is an example of enthesis?
Sausage digit (not seen in RA)
What is the combination of sausage digit plus pitted nails typical of?
psoriasis
Is HLA-B27 good for diagnosing seronegative spondyloarthropathy?
No- because 7% of the population has it anyway.
What decreases pain in ankylosing spondylitis?
Exercise always decreases pain
What cardiovascular problem can be seen in ankylosing spondylitis?
Aortitis -- presenting as AI, heart bock, or CHF
What lung problem is seen in ankylosing spondylitis? What can complicate it?
Apical pulmonary fibrosis - pathognomonic.

Can be complicated by cavity/fungas ball.
What are common causes of reactive spondyloarthropathy (ie Reiter)?
GU infections from Chlamydia or Ureaplasma

GI infections from salmonella, shigella, yersinia, campylobacter
Are long-term abx helpful in reactive arthritis if source is found?
No - just give normal course.
What should be excluded in patient before diagnosing with ankylosing spondylitis?
IBD -- may have IBD arthropathy, and psoriasis
How does IBD arthropathy correlate with GI disease activity?

How do you treat it?
Can either be dependent or independent of bowel disease activity.

Treat it with therapy for bowel disease such as sulfasalazine. Can also use MTX, anti-TNF.
What predicts psoriatic arthritis in patients who have psoriasis?
Nail abnormalities (pitting, onycholysis, 'oil spots')
What is psoriatic arthritis' presentation in severe cases? What joints are usually affected?
Worst case called arthritis mutilans (resorption of joints).

Sacroiliitis and DIP joints (unlike RA, hemochromatosis)
What is ddx for diseases affect MCP's? PIP's? DIP's?
MCP: RA, hemochromatosis, SLE

PIP: OA (Bouchard node), RA, SLE

DIP: OA (Heberden node), psoriatic arthritis
What should patients with psoriatic arthritis not be treated with?

What non-rheumatologic med should be avoided in psoriatic arthritis?
anti-TNF agents and plaquenil- get a rash

beta-blocker should be avoided (exacerbates psoriasis).
What are sausage-shaped digits seen in?
entheses in reactive arthritis

also in psoriatic arthritis
What is usual age of onset for ankylosing spondylitis?
Young adulthood
Is chondrocalcinosis (calcium in cartilage) seen in OA?
No it is not
What is the typical age of onset for RA? Men or women?
40-50 years old, more in women
Is OA symmetric or asymmetric?
asymmetric
Where is hip pain in hip OA?
Usually in groin area (not lateral thigh), can have radiation to knee
Glucosamine + chondroitin = helpful in OA?
No difference according to RCT's.
What to medications are relatively contraindicated in patient with gout?
HCTZ and niacin (nicotinic acid)
What specifically needs to be seen on joint aspirate to dx gout?
Intracellular cyrstals (must be intracellular).
What is the goal for allopurinol in gout?
Uric acid level should be 5-6
What should you warn a patient when starting allopurinol in an asymptomatic patient?
It can precipitate a gouty attack
What is a new alternative to allopurinol? What is an advantage?
Febuxostat, with this you don't have to renally dose
What is the relationship between ASA and gout?
Low-dose ASA blocks urate excretion.

High-dose ASA causes uric acid exretion (similar to probenecid).
What is the relationship between gout and women?
Premenopausal women rarely get it.

Postmenopausal women may present with polyarticular gout that mimics RA (but is gout).
What is the relationship between gout and RA? Gout and joint infection?
They never coexist
What is chondrocalcinosis seen in?
pseudogout (CPPD)
Who gets CPPD? What are RF for developing it?
Patients with OA/trauma and older than 60yo.

In CPPD in younger patients -- think about predisposing conditions including:
-primary hyperPTH -hypothyroidism -hemochromatosis
If a patient presents with wrist synovitis, what is first on the ddx?
CPPD - not OA (OA rarely affects wrists). same with MCP's, elbows, ankles.
What is hydroxyapatite arthropathy (HAA)? What population of patients gets it and what do they present with?

What is seen on fluid analysis? Imaging?
HAA is calcium apatite deposition disease.

Elderly patients who have very destructive arthropathy of shoulders (Milwaukee Shoulder), hips, knees, hands.

Synovial fluid is noninflammatory and no visible crystals. But there are HAA crystals only seen with EM or special staining using alizarin red. nonbirefringent.

Imaging shows clacification +/- erosions
How do you treat HAA?
Same as CPPD (joint aspiration, NSAIDs, steroids)
What is the usual cause of septic joint in RA patients? Young adults? Sickle cell? Noninflammatory fluid/indolent? IV drug users?
RA patients- S aureus

Young adults- N gonorrhoea

Sickle cell- Salmonella, pneumococcus

Noninflammatory fluid/indolent- mycobacteria, fungus

IV drug users- Staph, Strep, Pseuodomonas/GNR
What is concerning with 'loosening of prosthesis' joint?

What should you suspect in patient presenting with sterno
Loosening of joint prosthesis is worrisome for S aureus or CONS infection

SC or sacroiliac synovitis is suspicious for patient using IV drugs
What are risk factors for disseminated gonorrhea?

How does it present?

What will fluid analysis show?
Pregnancy and menstruation

Fever, migratory polyarthritis, tenosynovitis, dermatitis (red papules/pustules)

Fluid analysis can show only mild inflammation (WBC 10,000-20,000!) and sterile cultures. Blood is commonly seen.
How should you test for gonococcal arthritis specifically?
Direct plating of fluid on Thayer-Martin (chocolate) agar and PCR if possible.
How does Whipple disease present and over what period of time?
It causes palindromic rheumatism (intermittent, inflammatory arthropathy), recurrent diarrhea -- over years

Also, constitutional symptoms, LAD, hyperpigmentation, memorry loss 2/2 progressive dementia.
What is the etiology of and how do you treat Whipple disease? Prognosis after treatment?
Bacteria is Tropheryma whippleii.

Treat with bactrim x 1 year but recurrences are common.
How does TB arthritis present and over what time period?

Joint fluid analysis? How do you dx?
Mildly symptomatic, chronic knee effusion over years

Joinf fluid is mildly inflammatory (20,000 WBCs). AFB cx's, but like pleural TB biopsy of synovium is best, and TB PCR if available.
How do you treat TB arthritis?
Same as active TB (IREZ x 2 months, IR x 4 months)
What causes aseptic arthritis and how does it present?
Aseptic arthritis is caused most often by parvovirus B19 (but also other virues including Rubella, mumps, acute HBV, chronic HCV), and presents similar to RA.
What should you suspect in a patient who is coming in with hand arthritis and 1-2 weeks ago had exposure to sick kids?
Parvovirus aseptic arthritis.
What is a typical presentation of acute rheumatic fever?
Fever and polyarthritis - and look for chorea, erythema marginatum, nodules, evidence of carditis
What is on the ddx for aseptic arthritis (Non bacterial)?
reactive arthritis
How long after the tick bite does Lyme arthritis begin and in how many of untreated patients?
Occurs a few months afterwards in 50% of untreated patients
What is Lyme arthritis' presentation? Prognosis?
asymmetric, only 1 or small number of large joints.

prognosis- can be intermittent over years
How do you dx Lyme arthritis?
serum ELISA test looking for anti-Borrelia burgdorferi IgG.

if positive, order confirmatory Western blot. (false positives with SLE, RA, RMSF, normal)

if possible, send joint fluid for PCR
How do you treat Lyme arthritis?
Give abx to treat Lyme disease -- then stop treatment (and give NSAIDs afterwards for pain)
What should you suspect as dx in patient who has a rash that appears with fever and disappears at defervescence?
Adult Still disease
How do you treat Adult Still Disease?
Same as RA (unless liver is involved)- then use MTX, NSAIDs, and sulfasalazine with caution.
What disease should you suspect with synovitis of 2nd and 3rd MCP's? What would you see on joint fluid analysis?
Hemochromatosis

Joint fluid analysis is noninflammatory (unlike in RA which could also affect MCPs)
What disease does hemochromatosis arthritis present like clinically? Does hemochromatosis arthritis affect small or large joints initially?
RA - morning stiffness < 30 minutes

small joints initially (2nd and 3rd MCP's usually) -- then big joints
What crystal arthropathy is associated with hemochromatosis?
CPPD - can see weakly positive birefringent crystals and chondrocalcinosis
How do you treat arhtropathy of hemochromatosis?
Phlebotomy does not help.

Treat with tylenol and NSAIDs.
What joint diseases are associated with acromegaly?
Carpal tunnel and CPPD
What should you suspect in a patient who smokes and has clubbing of fingers, and a joint effusion?
Hypertrophic pulmonary osteoarthropathy (HPOA).

-associated with malignancies or familial.
What presentation of joint problems is SLE similar to? How is it different from this?
Similar to RA (symmetric, inflammatory joint fluid)

Nonerosive though, unlike in RA
Besides malar rash and discoid lupus, what other types of rashes are associated with lupus?
subacute cutaneous lupus -- UV light-sensitive psoriatic-like lesions. variety of other rashes too.
What is the CAD risk in patients with SLE?
premature CAD is significant risk in patients with SLE. Younger women with lupus have a 50x increase in MI's than without lupus.
What lab marker in SLE predicts eventual glomerulonephritis?
dsDNA ab's
How do you manage glomerulonephritis of SLE?
Treat focal or diffuse GN with cytotoxics and steroids to prevent ESRD.
In a patient with ANA negative lupus (which is very rare - about 0.10% of lupus pts), what is the management?
Check SSA and SSB - if positive, at risk for child having neonatal lupus/congenital heart block. Could also just be subacute cutaneous lupus.
How do you manage a pregnant woman with APS and hx of recurrent miscarriages?
Treat with lovenox (or regular heparin) plus ASA 81mg together to decrease the incidence of miscarriage.
How do you manage a woman who's had a recent lupus flare and now wishes to become pregnant? what if she has a lupus flare during pregnancy?
If patient had a recent lupus flare, continue steroids.

Treat flare during pregnancy with steroids.
What labs in SLE are associated with worse prognosis? better prognosis?
anti-dsDNA and low complements.

better prognosis- elevated anti-U1-RNP (bc dx may actually be MCTD and not SLE)
What are the diagnostic criteria for SLE?
at least 4 at any point in course of disease (mucocutaneous, organs, labs):

1) mucocutaneous: rash, ulcer

2) organs: joints, serositis (pleurisy/pericarditis), renal (proteinuria), hematologic (any cell line down), neuro

3) labs: dsDNA, antiSm, or +ANA
Is lupus arthritis erosive or nonerosive?
Non-erosive
What proportion of patients with SLE who are on high dose steroids chronically develop AVN?
1/3 of these SLE patients witll develop AVN of knee/hip/humerus.
Is there a mortality benefit to steroids and any other drugs in lupus?
Yes for steroids and cytoxan -- in patients with severe lupus or diffuse or focal GN
What are the most common offending agents causing drug-induced lupus?
Procainamide, hydralazine, chlorpromazine, PTU, phenytoin, anti-TNF drugs
What is the diagnostic test for MCTD?

What is the prognosis in patients with MCTD? How do you manage them?
anti-U1-RNP (and usually negative for dsDNA, smith, SSA, SSB) -- anti-U1-RNP can also sometimes be seen in SLE too

prognosis in MCTD is good, with good response to steroids
What is on the differential for a false positive VDRL/RPR?
Lyme disease
Antiphosphlipid syndrome
What do patients with APS have on labs? How many of them actually have SLE too?
either lupus anticoagulant (prolonged PTT) or anticardiolipin ab/ beta-2 glycoprotein

-50% of patients with APS also have SLE
What should you suspect in a patient with APS who has a heart murmur?
LSE or valvular abnormalities
What labs can be positive in Sjogren's besides SSA (Ro) (50% of time) and SSB (La) (30% of time)?
ANA, RF+
What are patients with Sjogren syndrome at significantly higher risk for?
They have a 40x higher risk of developing lymphoma.
How can you diagnose Sjogren in addition to SSA and SSB?
Biopsy of minor salivary glands
What antibodies should be checked in a patient with suspected to have systemic scleroderma? What kind of prognosis with the ab's?
Systemic scleroderma can be diffuse or limited. Diffuse scleroderma is anti-topoisomerase ab positive (only 30% sensitivity though). Limited scleroderma is anti-centromere positive.

Anti-topoisomerase ab is associated with ILD and reduced survival.

Anti-centromere is associated with pulmonary hypertension in limited scleroderma. (You do not see ILD in limited scleroderma)
What are the features of limited scleroderma?
Calcinosis
Raynaud
Esophageal - (lower esophagus)
Sclerodactyly
Telangectasias
What do nailfold capillaries signify in certain patients?
In a patient with scleroderma, the degree of abnormality of the nailfold capillary correlates directly with the severity of scleroderma.
What is a tendon friction rub at a joint (eg elbow) pathognomonic for?
Systemic scleroderma
What do fingertip ulcerations tell you in a patient with Raynaud's?
The Raynaud's is probably associated with an underlying rheumatological disease.
What is the usual cause of death in scleroderma? What used to be the usual cause of death and what changed that?
pulmonary hypertension 2/2 to
1)PAH (limited scleroderma)
2)ILD (diffuse scleroderma)

Scleroderma renal crisis used to be, until ACE inhibitors used in patients with scleroderma (even if in renal failure)
Does renal scrisis present early or late in scleroderma? what are RF's for it?
within the first 5 years. very acute presentation.

RF is prior or current steroid use.
What EGD or colonoscopic finding is pathognomonic for diffuse scleroderma? limited scleroderma?
diffuse scl- wide-mouthed diverticula.

limited scl- EGD shows watermelon stomach with telangectasias

both- esophageal dysmotility and gastroparesis. severe GERD.
What liver complication is associated with scleroderma and how common is it?
primary biliary cirrhosis, in 15%.
What medication should be avoided in scleroderma in all circumstances?
Steroids
What is the natural course and prognosis in diffuse scleroderma? Ho can you predict severity of visceral disease specifically?
Diffuse scleroderma- usually all organs that will be affected are affected in the first 5 years.

The severity of visceral disease can be predicted by the extent of skin disease.
What is the diagnosis in a patient presenting with symptoms of scleroderma without Raynaud's? What exacerbates symptoms?
Eosinophilic fasciitis.

Rigorous exercise can worsen. Can also be 2/2 paraneoplascitc syndrome.
What is seen in eosinophilic fasciitis?
Scleroderma and non-scleroderma like skin changes (peau d'orange induration), but sparing the hands (no Raynaud's).

Also tender, migrating edema of the extremities, or polyarthritis of the hands. You also see a peripheral eosinophilia.

Also nailfold capilliaries are normal.
What is the prognosis in eosinophilic fasciitis?
Can be self-limited but usually require steroids or MTX.
What is the main differentiating symptom between myositis and PMR?
Muscle weakness in myositis (no muscle pain)
What does muscle biopsy show in polymyositis? In dermatomyositis?
In polymyositis it shows CD8 T cells with simultaneous muscle degeneration and regeneration.

In dermatomyositis it shows perivascular inflammation (B cells and CD4 T cells)
What antibody should be tested fr in patients with myositis? What does its positivity portend?
Anti-Jo -- rapidly progressive ILD and mechanic's hands.
What ab portends a good prognosis in dermatomyositis?
anti-Mi2 -- seen in 20% but have good prognosis
What are rates of cancer in PM and DM? Any recommendation to do specific screenings for patients with this?
PM- 10%; DM- 20%.

Nothing more than age-appropriate screening.
How do you treat myositis? What should you do if there is a poor response to treatment?

How do you treat the rash in dermatomyositis?
High-dose steroids (prednisone 60mg or 80mg daily)

Reassess for cancer.

Treat the rash with plaquenil.
What should you suspect in a patient presenting with 'weak handshake'?
Inclusion body myositis - prominent distal weakness
What are RF's for inclusion body myositis?
Drug exposure:
-antimalarials
-steroids
-colchicine
-statins
-cocaine

and alcohol use
How do you diagnoise IBM? What is the prognosis?
you need muscle biopsy (vacuoles and fiber inclusions).

unlike PM and DM, it is more indolent and only minimally responsive to steroids.
What is a risk in a gout patient with renal insufficiency who takes long-term colchicine?
colchicine myopathy/neuropathy -- mimics polymyositis in presentation and with elevated CPK.

neuropathy (paresthesias) is specific to colchicine myopathy/neuropathy, however
How many points should be evaluated and how many positive points are diagnostic of fibromyalgia?
9 pairs of points (18 points) should be evaluated, and if 11 are positive it is positive for fibromyalgia.
In certain therapies for fibromyalgia (ie, pregabalin, duloxetine, milnacipran SNRI), what adverse effect should you be aware of?
Increased suicidal thoughts
What is the diagnosis in pain syndrome with myalgias and trigger points that are localized, may be related to trauma?
Myofascial pain syndrome
What is the diagnosis in pain syndrome with severe pain, touch sensitivity, usually w hx of trauma- and can develop flexion contractures, osteopenia?
Complex regional pain syndrome (previously called RSD).
What does palpable purpura signify?
vasculitis
In vasculitis what are generalized symptoms that are seen with it?
Constitutional symptoms, fever
How is vasculitis organized?
Large artery (GCA+/-PMR, Takayasu arteritis, and aortitis)

Medium artery (PAN, Churg-Strauss, Wegener, microscopic polyangiitis)

Small artery (leukocytoclastic vasculitis)
What is small artery vasculitis (leukocytoclastic vasculitis) caused by?
Drug reaction (most common), virus, SLE, RA, HSP, cryoglobulinemia
What dose steroids is used to treat GCA?
60mg/day and taper over 1-2 years
What disease does PMR mimic in presentation?
elderly onset RA
How do you treat PMR? What should you do if it is not helping?
low dose prednisone (10-20mg/day) over 1-2 years.

if not helping then think GCA or cancer
Whom does Takaysu arteritis (pulseles disease) affect? How does it present? How do you treat it?
Young Asian women. Can present as FUO, or with claudication or renovascular htn (increased aldosterone).

Treat with steroids +/- CCB's
What disease should be suspected in a patient with multiple, diverse symptoms (chest pain, abdominal pain, and foot drop)?
PAN - pericarditis, mesenteric arteritis, mononeuritis multiplex are possible presentations
How do you diagnose PAN?
Biopsy if any peripheral involvement (including testicles if testicular pain). If no options than do an angiogram.
How do you treat PAN?
treat chronic hep B if present. also prednisone and cytoxan.
What should be biopsied to diagnose Wegener?
Any oral, nasal, or sinus abnormality (even though low yield) bc it is least invasive.
In addition to steroids + cytoxan what other medication should be given to all patients with Wegener's?
Bactrim - because they are at increased risk for PCP
What is microscopic polyangiitis (MPA)? How does it present and how is it diagnosed?
Pulmonary-renal syndrome. presents with necriotizing, crescentic GN. No angiographic changes bc small vessels.

Dx with biopsy and also p-ANCA positive.
What are leukocytoclastic vasculitides? What is found on exam?
Hypersensitivity vasculitides (drug rxn is usual caus).

Classic skin finding is palpable purpura.
How long after drug is started will leukocytoclastic vasculitis develop?
within 10 days of starting drug.
What does HSP present with? What is seen on biopsy?
It presents with crops of papuples on skin from waist down, IgA nephropathy findings on renal biopsy, and abdominal pain/GI bleed -- episodic.

Bx shows IgA ab's.
What renal disease is associated with cryoglobulinemia?
MPGN
What is the presentation for cryoglobulinemia? What is on the ddx for cryoglobulinemia?
Presentation arthralgias, purpura - and visceral/renal involvement (MPGN)

subacute endocarditis, cardiac myxoma emboli, and cholesterol atheroembolism (esp if peripheral eos or hypocomplementemia).
What is relapsing polynchondritis?
Inflammation of cartilate in ear, nose, throat. Can also cause AI. Present with hoarse voice, saddle-shaped deformity of nose, and sweling of ear's cartilage.
Besides aphthous ulcers what else is seen in Behcet disease?
CNS disease (recurrent aseptic meningitis), pulmonary artery aneurysm, and pathergy (hyperreactivity to needle sticks) causing sterile abscesses.
How do you treat Behcet disease?
Treat ulcers with colchicine or pentoxifylline.

More serious dz with steroids, azathioprine.
Which type of diabetes is associated with duputyren/flexion contractures? Also where is thickening of the skin seen in DM?
DM 1 can have contractures.

There is thickening of skin of fingers (as opposed to proximal to metacarpals in systemic sclerosis).
What are angioid streaks?
Seen in fundi in some patients with Paget disease and also pseudoxanthoma elasticum.
What does Paget disease present with? Labs for diagnosis? What cardiac complication do you need to watch out for? What oncologic complication?

Treatment?
Paget disease presents with hearing loss, low back pain, skull enlargement.

Labs for diagnosis of Paget disease are alk phos and urinary hydroxyproline.

Cardiac complication - high output CHF

Oncologic complication - sarcoma in 1%

Treat with calcitonin, bisphosphonate, or teriparatide.
Does bursitis cause pain with passive motion?

Where does bursitis usually happen?
Very little or none at all

Prepatellar, olecranon, trochanter, and pes anserine (medial and inferior to knee)
How does thoracic outlet syndrome present? Workup?
Pain in shoulder from neck into the arm. +/- paresthesias and weakness.

Workup- CXR to look for cervical ribs, EMG w/nerve conduction studies to see if brachiel plexus is affected.
OA of the shoulder is more common in which shoulder joint?
OA is more common in the AC joint, not the glenohumeral joint.
What kind of joint problems are long-term HD patients are risk for? Which joints?
amyloidosis (beta-2 microglobulin) deposition - especially in shoulder and wrist, causing CTS
What is anterior shoulder pain usually? Lateral shoulder pain?
Anterior- OA
Lateral- RC tear, impingement syndrome, frozen shoulder, cervical radiculopathy
What are the tests for shoulder impingement syndrome?
Neer test- patient attempts to shrug shoulder while you apply downward pressure

Hawkins test- you flex elbow and internally rotate shoulder

Yocum test- while patient touches uninvolved shoulder, life up on the flexed elbow
How does subacromial bursitis present? Ddx?
Pain at rest and with movement, laterally. Middle arc of active abduction is painful, but both extremes are painless (can also see this with partial tear).
If a patient presents with shoulder bursitis features and weakness, what to suspect?
Suspect an RC tear as well as bursitis.
Olecranon bursitis is associated with what systemic diseases?
If not traumatic or septic - think gout, RA
What is the diagnosis in a patient who had trauma to elbow and cannot extend fingers 2/2 pain? What is the physical presentation called?
Supracondylar fracture with brachial artery damage --> compartment syndrome.

Volkmann contracture
What is the name of the test used to diagnose De Quervain Tenosynovitis?
Finkelstein test
What is a Dupuytren contracture?
Finger flexion caused by palmar fascia thickening and contracture. Also see cord-like pands on the surface of the palm.
What is the difference between paronychia and a felon?

Herpetic whitlow?
Paronychia- pus around the cuticle

Felon- infection on the palmar side of the distal phalanx. More severe and requires surgical intervention

Herpetic whitlow presents similarly to paronychia but treated conservatively (I&D will worsen it). Can be anywhere on the fingertips.
How do you work up potential AVN in a hip?
Xray or MRI of both hips (risk of b/l AVN is high even if asymtomatic in the other one).
What is the relationship between obesity and hip OA?
There is none.
Workup for suspected Baker cyst?
U/S to exclude DVT, but no MRI needed.
What to suspect in a young patient presenting with recurrent hemarthrosis (and r/o bleeding disorders)? How to make the diagnosis and how to treat?
Pigmented villonodular synovitis (PVN) - idiopathic, monoarticular, benign, synovial tumor.

Dx with MRI.

Treat with synovectomy or radiation.
Who gets spontaneous osteonecrosis of the knee (SONK)? Management?
Elderly women who have mild trauma. RF's are recurrent knee injections, trauma, SLE. Weight bearing pain on medial aspect of knee with spontaneous resolution.

Conservative treatment.
What should you suspect in a patient with painful, burning paresthesias in the interdigital webbing between the feet? Management?
Morton plantar neuroma - arch support, steroid injection. May need surgery.
What else should be looked for in a patient who presents with plantar fasciitis of feet?
Spondyloarthropathy
What does pain in the SI joint make you suspect?
It is not common - usually 2/2 to spondyloarthropathy (vs OA).

Also can be TB; or infectious sacroiliitis in IV drug user presenting with buttock pain.