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59 Cards in this Set
- Front
- Back
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joint aspiration in gout? tx?
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- see negatively birefringent, needle-shaped crystals (monosodium urate)
- tx: NSAIDs, indomethacin; however if pt has hx of GI bleed or CRI then give intra-articular corticosteroids |
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tx of gout
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- allopurinol - decreases uric acid production; prevents gout flares
- colchicine: tx acute gout, serious toxicity so not 1st line; avoid in renal failure - indomethacin and NSAIDS: first line tx of gout; avoid in GI bleed and CRI - intraarticular corticosteroids if C/I in the above |
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next step if suspect gout?
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- always do arthrocentesis (not xray)
- r/o infectious process |
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work up if suspect pagets?
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- get Ca and alk phos
- to r/o other causes of increase alk phos get GGT or 5-nucleotidsase (biliary etiology) - |
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hearing loss in Paget's disease
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- very common
- most likely secondary to boney overgrowth - tx w/ bisphos or calcitonin may slow progression but it is otherwise permanent |
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tx of raynaud's?
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dihydropyridine CCB e.g. nifedipine and amlodipine and dilt
- verapamil does not work - if severe can add nitro |
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work up of pt presenting with raynauds
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- first tx with CCB and avoid environmental factors
- if sx persist and other signs of systemic disease (arthralgias, myalgias) then evaluate further with ANA, RF, CBC, C7, UA, complement |
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ankylosing spondylitis
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- back pain with morning stiffness that improves with exercise
- reduced range of forward flexion - can't dx unless presence of sacroiliitis --> get xray of sacroiliac joint - next step is get ANA and RF - should be neg - HLA-B 27 is >90%; absence of this marker makes dx unlikely - monitor disease progression with xray every 3 months or ESR - search for extraarticular manifestations: restrictive lung disease due to fibrosis or limited costovertebral joint motion; uveitis, aortic regurg, MVP, varicocele, IgA nephropathy, cauda equina - pts have normal life expectancy, work normally |
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best antihypertensive to give to pt with risk of gout?
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- ARB e.g. losartan - uricosuric effect
- avoid furosemide and HCTZ (hyperuricemia) |
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reactive arthritis
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aka reiter's syndrome
- usually a preceding GU or GI infection prior to flare - tx infx, exercise, sulfasalazine or methotrexate |
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work up of RA?
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- clinical dx but get RF (only positive in 70-80%) or CCP (anti-cyclic citrullinated peptide for confirmation
- get hand xrays (MCP, PIP), avoid steroids - tx symptomatically with NSAIDs and DMARDs (disease modifying antirheumatic drugs) |
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DMARDS
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- sulfasalazine, methotrexate (first therapy), antimalarials, infliximab
- start immediately early on in the disease even if sx are improving to prevent bony destruction |
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which Ab is very specific for SLE dx?
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- anti-ds DNA
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complications of rhabdo
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- CK > 10,000
- cell breakdown --> hyperK, hyperPhos, hypoCa - renal failure |
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etiology of rhabdo
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- NMS, hypothermia, hypoTH, polymyositis
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tx of rhabdo
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- IV fluids
- followed by alkalinize urine (pH >6) - if hydration doesn't work to correct AKI, then dialysis may be indicated |
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most common cause of acute mono and oligoarthritis in young healthy adults?
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- gonococcal arthritis
- confirm dx with culturing not just joint fluid but must also do mucosal surfaces (urethral, cervical, rectal, oral) |
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unique characteristics of gonococcal cause of arthritis versus other infectious causes of joint disease
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- painful tendons along ankle, toe joints i.e. tenosynovitis
- pustular or vesiculo-pustule skin rash that disappears spontaneously |
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sausage digits
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- spondyloarthritis
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classic pattern of pain seen in rotator cuff tendonitis/tear, impingement syndrome, frozen shoulder?
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- lateral shoulder or deltoid pain, aggravated by reaching or lifting the arms up
- think tear if weakness with external rotation or abduction of shoulder |
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anterior shoulder pain vs posterior shoulder pain vs lateral shoulder pain
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- anterior: acromioclavicular or glenohumeral joint OA, biceps tendonitis
- posterior: referred pain from cervical spine from disc herniation or spinal stenosis - lateral: rotator cuff tendonitis/tear |
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pt with SLE presents with AKI with RBC casts?
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- also see HTN, proteinuria, hematuria, hypo-complementemia, increased anti-DsDNA
- immune complex mediated glomerular injury - renal involvement of SLE --> get renal biopsy before treating b/c type of involvement dictates treatment - type I, II: no tx - type III, IV: immunosuppression with IV methylprednisolone or cyclophos if steroids don't work - monitor the disease with anti-DsDNA and complement levels |
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Anti-DsDNA
Anti-centromere Anti-mitochondrial Anti-Smith Anti-Ro/SSA ANA |
- Anti-DsDNA (subtype of ANA): SLE
- anti-centromere: CREST variant of scleroderma - ANA is positive in SLE but can also be positive in other dz and healthy pts - Anti-mitochondrial: primary biliary sclerosis - Anti-Smith: SLE (specific but not sensitive) - Anti-Ro/SSA: Sjogrens, some SLE (Anti-DsDNA is more specific) |
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tx of SLE
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- low dose prednisone for short term
- hydrochloroquine for arthralgias, serositis, cutaneous sx - cyclophosphamide for more serious sx of SLE e.g nephritis, CNS involvement, vasculitis - methotrexate for significant organ involvement with little response to prednisone - rituximab; however can cause PML |
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young pt with pseudogout (positive birefringment rhomboid crystals), DM, and hepatomegaly?
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- hemochromatosis can cause arthropathy usually in 2nd and 3rd MCP, and knees, ankles, shoulders, morning stiffness
- just pseudogout affects older pts (>65y.o.) |
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which diseases affect which joints?
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- DIP and spares MCP: OA, gout, reiters
- PIP, MCP: RA - MCP: hemochromatosis |
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tests for hemochromatosis
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- ferritin (high), transferrin (high), serum iron (high)
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pt s/p viral URI w/ MCP and PIP swelling, mildly +RF?
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- parvovirus
- tx with NSAIDs, self limiting |
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viral arthritis vs rheumatic fever?
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- viral: small joint
- rheumatic: migratory joint involvement |
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pt presents with proximal muscle weakness and decreased DTR... next step?
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- get EMG to confirm myopathy and then get muscle biopsy to determine underlying cause
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most common cause of knee pain in young pts (<45y.o.)?
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- patello-femoral pain syndrome
- etiology: overuse injury e.g. athletes - sx: anterior knee pain provoked by walkin stairs or prolonged sitting - exam: retropatellar pain, crepitation on vigorous right patellar compression - histologic: chondromalacia patellae |
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osgood schlatter
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- epiphysitis of tibial tuberosity
- pts <19y.o. |
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asenine bursitis
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- medial knee pain and local tenderness at medial aspect of knee joint
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painful arc test
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- shoulder pain when arm is abducted 60 -120 degrees
- rotator cuff impingement |
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clinical dx of carpal tunnel is made, what other test can be done to confirm?
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- nerve conduction studies (not MRI) to r/o other causes --> will see slowed conduction from axonal loss
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tx of carpal tunnel?
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- nighttime splinting
- if above doesn't work, then inject steroids - last resort is surgical decompression - NSAIDs don't help |
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symmetrical prox weakness and elevated CPK?
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- ddx dermatomyositis vs polymyositis
- other less likely ddx: drugs, glucocorticoids, hypoTH, malignancy - tx inflammatory myositis with glucocorticoids - will also see increased ferritin |
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most common cause of MI in SLE pts?
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- coronary atherosclerosis
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bilateral pain and morning stiffness involving shoulder, neck, and thighs
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- polymyalgia rheumatica
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polymyositis vs polymyalgia rheumatica
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- polymyositis is usually muscle weakness
- PMR is usually muscle pain - Aldolase and CK r/o polymyositis |
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which test for giant cell arteritis?
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- ESR >40
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pt is on chronic glucocorticoids... what else should they be on?
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- vit D and Ca
- GC decrease intestinal absorption of vit D and Ca and increase Ca excretion in urine and accelerate bone resorption - get bone density scan q1year - can give bisphos if post-menopausal (caution in premenopausal b/c teratogenic) |
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gottron's sign
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eczematous, erythematous, scaly lesion that affects knuckles bilaterally
- sign of dermatomyositis w/ prox muscle weakness with is an AI disease that can be secondary to malignancy if occurs in older men - look for solid tumors e.g. lung ca |
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dry eyes and extensive caries?
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- sjogrens- abnormal tear production and xerostomia
- check anti- Ro/SSA and anti-La/ SSB |
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which cancer is associated with Sjogrens?
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- B cell non-Hodgkin's lymphoma from polyclonal B cell activation in salivary glands (5% risk)
- submandibular lump |
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woman with long hx of steroids use now with limp?
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- osteonecrosis of femoral head aka avascular necrosis or osteochrondritis dissecans
- most sensitive test: MRI for early detection - tx: core decompression, osteotomy, joint replacement, joint replacement if reaches stage 4 - associated with long CS use in hx of SLE, SSC, antiphospholipid ab, chronic renal insufficiency and hemodialysis, truam, gaucher, renal transplant |
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cyclosporin is associated with what joint disease?
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- gout
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gout versus pseudogout in joint presentation?
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- gout: first metatarsophalagneal joint
- pseudogout: nee |
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painless ulcers over glans penis?
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- reiter's syndrome aka reactive arthritis - triggers are GI disease, GC infection
- look for back pain/limited spine movement to dx spondyloarthropathy (do Schober test - measure spine flexion) |
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work up of back pain
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- if no concerning sx then physical therapy and nsaids
- if persists then get ESR/CRP to check for general inflammatory disease and lumbar xray - mri only indicated if suspect tumor, infx, disc herniation, or bac pain >12weeks |
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hemachromatosis
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- liver dysfunction, central hypogonadism, diabetes mellitus, arthropathy, skin pigmentation, arthritis in 2nd and 3rd MCP w/ hooked osteophytes on xray
- fasting transferrin saturation >50% - gold dx: liver biopsy |
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pt with dry eyes and patches in her mouth?
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- sjogren's
- patches are oral candidiasis which is common; also check for dental caries - to screen for xerostomia: do you wake up atnight feeling dry and drink water? |
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heberden vs bouchard's nodules?
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- heberden: swelling of distal interphalangeal joints; in OA
- bouchard: prox interphalangeal joints; in OA and RA |
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70 year old woman on simvastatin with shoulder and pelvic muscle pain and pex with tenderness in muscles of pelvic girdle
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- measure CPK to r/o statin induced myopathy
- check ESR to dx polymyalgia rheumatica |
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shoulder and pelvic muscle pain?
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- polymyalgia rheumatica
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patient with sicca?
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- dry mouth, dry eyes
- do Schirmer test to confirm secratory deficiency - ab workup: Ro- and La- antibodies, RF, ANA |
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pt with diffuse MSK pain without joint swelling or muscle weakness?
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- fibromyalgia
- tenderness to palpation over 11 of 18 predefined areas - r/o other dz that mimic fibromyalgia: CBC, ESR, TSH, CPK |
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proximal muscle weakness?
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- polymyositis- check CPK
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what addictional evaluation should you do with pt with fibromyalgia
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psych! 30% have depression
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