Snw's Internal Medicine- Rheum Review (Usmle Step 3)

Front 1

Morning stiffness duration

Back 1

<15 min --> degenerative (eg osteoarthritis)

>30 min --> inflammatory

inflammatory conditions improve with usage so stiffness goes away during the day

Front 2

SLE presentation

Back 2

look for joint pain and rash

malar rash

photosensitivity rash

discoid rash

Front 3

Inflammatory conditions that cause low back pain

Back 3

1) ankylosing spondylitis

2) psoriatic arthritis

3) reactive arthritis

4) IBD

Front 4

Rheumatoid arthritis physical exam findings

Back 4

symmetric joint pain with distal interphalangeal joints unaffected

rheumatoid nodules --> nodules on extensor surface that are non-tender and rubbery

Front 5

Criteria for RA

Back 5

number of joints affected --> with 10 joints & 1 being a small joint, u get dx

elevated ESR

duration of Sxs >6 weeks

Front 6

Cytokines involved in RA

Back 6

TNF-a --> causes malaise, fatigue, and weight loss & leads to excessive bone erosions & cartilage damage

IL-1 --> local swelling & erythema

IL-6 --> up-regulates hepcidin that leads to iron sequestration and anemia of chronic dz

Front 7

Tx of RA

Back 7

start with NSAID or corticosteroid PLUS methotrexate

methotrexate takes ~6 months to start showing an effect

with MTX --> follow CBC & LFTs, if AST/ALT starts increasing, d/c immediately

MTX may cause flare-ups in process

Front 8

Chronic RA joint deformity

Back 8

ulnar deviation of digits

radial deviation of wrists

Front 9

RA risk factors

Back 9

HLA-DR1, DR4, DR14

MHC I --> HLA-A, B, C

MHC II --> HLA-D (subtypes are P, Q, R)

smoking is strongly assoc with RA

environmental and hormonal factors

Front 10

Rheumatoid factor vs anti-cyclic citrullinated peptide

Back 10

anti-cyclic citrullinated peptide is more specific than RF

neither are necessary nor sufficient

Front 11

Felty syndrome

Back 11

RA

splenomegaly

granulocytopenia

Front 12

Caplan syndrome

Back 12

RA

restrictive lung dz bc of lung nodules

Front 13

TNF-a inhibitors

Back 13

etanercept

infliximab

adalimumab

golimumab

certolizumab

use in combination with MTX if MTX doesnt work

have to get PPD prior to starting on TNF-a inhibitors

Front 14

TNF-a inhibitor failure

Back 14

if TNF-a inhibitors dont work then with MTX, try:

abatacept --> assoc with lymphoma, lung ca, & COPD exacerbation

OR

rituximab

Front 15

Acute joint pain ddx

Back 15

1) gout --> uric acid crystals

2) pseudogout --> calcium pyrophosphate crystals

3) septic arthritis

4) trauma

Front 16

Joint aspiration WBC count

Back 16

<5000 --> non-inflammatory

5000-50,000 --> inflammatory

>50000 --> septic

Front 17

XRay finding in pseudogout

Back 17

chondrocalcinosis

Front 18

Septic or gonococcal arthritis

Back 18

assoc with fever & leukocytosis

gonococcal --> migratory polyarthritis

Staph is most common cause of septic arthritis

Front 19

Tx of gout

Back 19

Acute tx:

NSAIDs (eg indomethacin) or colchicine until pain is no longer present

if above doesnt work, can try glucocorticoids orally or intra-articular injection

Long-term tx:

allopurinol (first line) or febuxostat

do not start allopurinol in acute setting bc it can make it worse but if already taking, then no need to d/c

Front 20

Precipitating factors for gout

Back 20

excessive etoh ingestion

trauma, surgery

infection

steroid w/d

medications (eg hydrochlorothiazide, furosemide, pyrazinamide, ethambutol)

serious medical illness

Front 21

Gout microscopy findings

Back 21

needle shaped negative birefringent crystals under polarized light microscopy

Front 22

Goal of chronic tx of gout

Back 22

decrease uric acid level to <6mg/dL

usually life long tx

start urate-lowering therapy AFTER acute phase

allopurinol is first line

probenecid is for those who have high serum uric acid with low urine uric acid --> but contraindicated in pts with renal insufficiency and nephrolithiasis

Front 23

Gout with renal insufficiency

Back 23

should not get NSAID or colchicine

tx with corticosteroids

Front 24

Best screening test for SLE

Back 24

ANA (<3% of SLE are negative)

if positive:

anti-dsDNA (very specific for SLE) --> may indicate renal involvement

anti-Smith (very specific for SLE)

Anti-Ro/SSA and anti-La/SSB --> assoc with neonatal lupus (heart block)

complement levels are decreased

Front 25

Tx of SLE

Back 25

start on prednisone

other immunosuppressants:

azathioprine

mycophenolate mofetil

MTX

cyclophosphamide --> only for lupus nephritis bc of severe toxicity

for rash --> hydroxychloroquine (but can cause retinitis so need to follow with optho)

Front 26

Clinical criteria for SLE

Back 26

need 4 of 11:

1) malar rash

2) discoid rash

3) photosensitivity

4) oral ulcers

5) arthritis

6) serositis

7) renal involvement

8) neuro d/o

9) hematologic d/o

10) serology

11) positive ANA

Front 27

Discoid lupus rash

Back 27

circular rash with raised rim over scalp and face

disfiguring bc of central atrophy and scarring

only 5% of pts with discoid rash will develop SLE

Front 28

Drug-induced lupus

Back 28

procainamide

hydralazine

isoniazid

methyldopa

p/w ONLY rash and anti-histone antibodies

DOES NOT AFFECT CNS OR KIDNEYS

Front 29

Raynaud's Phenomenon

Back 29

primary or idiopathic:

usually woman 20-40 otherwise normal

secondary:

nearly all pts with scleroderma

collagen vascular dz (eg SLE, polymyositis, RA, Sjogren's)

arterial occulsive dz (eg atherosclerosis)

drugs (b-blocker, ergot derivatives)

if pt p/w Raynaud's phenomenon --> check for ARF, arthritis, anemia, fever

Front 30

Limited scleroderma (CREST)

Back 30

CREST syndrome --> calcinosis, raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia

affects face & skin distal to elbows & knees

high risk of developing pulm HTN

less risk of progressing to interstitial lung dz

anti-centromere Abs

Front 31

Diffuse scleroderma

Back 31

progressive form that affects skin proximal to elbows and knees

diffuse organ involvement affecting lungs (interstitial lung dz) & kidneys

diffuse pulm fibrosis, cardiac involvement, renal dz common

anti-topoisomerase I (Scl-70)

Front 32

Tx of scleroderma

Back 32

MTX

raynaud's --> CCB (eg nifedipine)

renal involvement & HTN --> ACEI (if pt enters renal crisis with scleroderma, increase ACEI)

esophageal dysmotility can lead to reflux -> Barrett's -> adenocarcinoma so tx with PPI

pulm alveolitis leading to interstitial lung dz --> cyclophosphamide

pulm HTN --> phosphodiesterase-5 inhibitors (eg sildenafil), prostacyclin analogs (eg siloprost, epoprostenol, or treprostinil)

Front 33

Osteoarthritis characteristics

Back 33

chronic asymmetric arthritis

oligoarticular arthritis or monoarticular

morning stiffness is <30 mins

no constitutional sxs

Front 34

Tx of osteoarthritis

Back 34

pt education for joint protection and assistive device (eg cane or walker)

diet for weight loss

if above not adequate --> trial of acetaminophen on PRN basis

if still not adequate --> trial of NSAIDs on PRN basis

Front 35

Osteoarthritis pathology

Back 35

target tissue is articular cartilage

failure of cartilage secondary remodeling and hypertrophy of the bone

NOT an inflammatory dz

severity of radiographs NOT related to severity of Sxs

Front 36

Osteoarthritis risk factors

Back 36

age

female

genetics

major joint trauma

repetitive stress

obesity

Front 37

Osteoarthritis XRay

Back 37

osteophytes (spurs) --> Bouchard's nodes (prox interphalangeal joint) or Heberden's nodes (distal phalangeal joint)

eburnation

loss of joint space

Front 38

T score vs Z score on DEXA scan

Back 38

T score:

compares bone density to young population

abnormal if < -2.5 STD below mean (sig risk for osteoporotic fracture)

Z score:

compares bone density to age-matched population

helpful when considering secondary osteoporosis (eg steroids, warfarin)

Front 39

Osteoporosis w/u

Back 39

x-ray is first test

DEXA scan (gold standard) --> T score < -2.5 means osteoporosis

T score < -1.1 means osteopenia

Front 40

Tx of osteoporosis

Back 40

oral Ca 1.5 g/day

Vit D supplementation

alendronate (bisphosphonate) --> can cause esophagitis

Front 41

Type I osteoporosis

Back 41

disproportionate loss of trabecular bone

assoc with fractures of vertebrae and distal forearms

occurs in middle-aged and postmenopausal women

Front 42

Type II osteoporosis

Back 42

occurs equally in men and woman age >75

assoc with fractures of femoral neck, prox humerus, prox tibia, & pelvis

Front 43

Proximal muscle weakness Ddx

Back 43

1) polymyositis

2) dermatomyositis (can have ocular manifestations)

3) inclusion body myositis (affects both prox & distal muscles)

4) steroid induced myositis

5) fibromyalgia

Front 44

Proximal muscle weakness

Back 44

difficulty combing hair

standing up

climbing stairs

lifting objects

Front 45

Distal muscle weakness

Back 45

buttoning shirt

difficulty writing

standing on tip toes

Front 46

Presentation of different myopathies

Back 46

dermatomyositis --> typical heliotrope rash (patchy purple/reddish rash)

polymyositis --> isolated muscle weakness and no evidence of dermatologic manifestations

inclusion body myositis --> affects both prox and distal muscles & typically affects older men

Front 47

Inflammatory infiltrate in myopathies

Back 47

dermatomyositis --> perimysial inflammatory infiltrate

polymyositis --> endomysial inflammatory infiltrate

inclusion body myositis --> inclusions of amyloid in muscle fibers and diffuse inflammatory infiltrate in muscle cells

Front 48

anti-Jo1 Abs

Back 48

found in dermatomyositis and polymyositis

very specific but not very sensitive so negative test does not r/o dz

ANA, however, are positive in 80% of cases

Front 49

Tx of dermatomyositis

Back 49

high dose corticosteroids until CPK normalizes then gradually taper

in refractory cases, can give MTX or azathioprine

hydroxychloroquine is effective for the rash

Front 50

Cancer and dermatomyositis

Back 50

perform UA (bladder cancer), CXR, colonoscopy, PSA, Pap smear (cervical cancer), and CA-125 (ovarian cancer) in woman

pelvic u/s or CT to exclude ovarian cancer

Front 51

Temporal arteritis with polymyalgia rheumatica

Back 51

new onset of headache in a pt >50

scalp tenderness

jaw claudication

decreased or blurry vision

polymyalgia rheumatica:

hip & shoulder stiffness

prox muscle weakness

Front 52

Temporal arteritis w/u

Back 52

ESR (if elevated & you suspect temporal arteritis, treat immediately)

temporal artery bx (gold standard)

Front 53

Temporal arteritis pathology

Back 53

segmental granulomatous inflammation of the media of lg vessels causing narrowing of the lumen

can lead to possible thrombosis of the affected section of the vessel leading to distal ischemia and necrosis

Front 54

Tx of temporal arteritis

Back 54

start prednisone (60mg daily) prior to bx results

follow ESR and taper steroids once ESR normalizes

can develop aortic aneurysm so should be followed

Front 55

Ankylosing spondylitis

Back 55

p/w lower back pain

X-ray shows bamboo spine and b/l sacroiliitis

ESR is elevated

90% are HLA-B27 (on chr 6)

seronegative

Front 56

Tx of ankylosing spondylitis

Back 56

NSAIDs are main stay tx

MTX, sulfasalazine, cyclosporine, azathioprine, retinoic acid derivatives, anti-TNF-a can also be considered

Front 57

Seronegative arthropathies

Back 57

1) ankylosing spondylitis

2) reactive/Reiter arthritis

3) psoriatic arthritis

4) IBD assoc arthritis

absence ANA and RF

involve lower back and sacroiliac joints

extra-articular manifestations include aortic valve, lung parenchyma, the eye (uveitis), and skin

Front 58

Reiter's syndrome

Back 58

following non-gonococcal urethritis --> conjunctivitis and arthritis

can also have mucocutaneous manifestations such as keratoderma blennorrhagica (scraping of palms), circinate balanitis, and oral/genital ulcers

pts with HIV can have a particularly aggressive form especially the mucocutaneous parts that resolve with HAART

Front 59

Livedo reticularis

Back 59

mottled reticulated vascular pattern

lace-like purplish discoloration

Front 60

Polyarteritis nodosa

Back 60

assoc with Hep B

medium sized vasculitis

p/w fever, weight loss, myalgias, arthralgias, cutaneous nodules and livedo reticularis

HTN secondary to renal artery involvement

Will never get glomerulonephritis or lung involvement bc those are with capillaries

dx is suspected with angiography of mesenteric and renal arteries with evidence of aneurysms

bx show segmental transmural necrotizing inflammation forming aneurysms with fibrinoid necrosis

Front 61

Hep B titers

Back 61

HBsAg --> active infection

HBc IgG --> chronic infection

HBeAg --> sign of infectivity & assoc with HCC

Front 62

Hep B drugs

Back 62

entecavir

tenofovir

adefovir

telbivudine

lamivudine

Front 63

Polyarteritis nodosa organ manifestations

Back 63

kidney: renovascular HTN

GI: abdominal pain and melena

skin: cutaneous and livedo reticularis

nervous system: peripheral neuropathies (tingling/numbness) & pain in hands, arms, feet, & legs

Front 64

PAN tx

Back 64

corticosteroids

cyclophosphamide for refractory cases

If HbsAg positive --> treat active Hep B

Front 65

Hepatitis vaccination

Back 65

all Hep B infected individuals should get Hep A vaccine

household contacts should get Hep B vaccine, if they are not immune

any chronic liver pt should get both Hep A & Hep B

Front 66

Small vessel vasculitis

Back 66

Granulomatosis with polyangiitis (Wegener's)

Henoch-Schonlein purpura --> younger pts with abd pain & purpura

Churg-Strauss syndrome --> middle aged p/w new onset asthma & eosinophila

Front 67

ANCA

Back 67

c-ANCA --> anti-proteinase 3 Abs

p-ANCA --> anti-myeloperoxidase

Front 68

p-ANCA / anti-myeloperoxidase positive

Back 68

Churg-Strauss syndrome

Microscopic polyangiitis

Front 69

Granulomatosis with polyangiitis (Wegener's)

Back 69

affects small vessels

p/w palpable purpura

RBC casts in urine

upper respiratory tract complaints

destruction of the cartilage of the nose --> saddle nose deformities

Sxs similar to chronic sinusitis

can also affect eyes --> scleritis, uveitis, & keratitis

c-ANCA/anti-proteinase 3 Ab positive

p-ANCA/anti-myeloperoxidase negative

dx is made via bx

tx with high-dose corticosteroids with cyclophosphamide then taper & d/c cyclo & continue tx with MTX or azathioprine for 18 months

Front 70

Methotrexate monitoring

Back 70

monthly LFTs and CBC (anemia due to folate def)

Front 71

TMP-SMZ ppx

Back 71

any patient on immunosuppression medications should be treated TMP-SMZ for prevention of Pneumocystis jirovecii