Usmle World Rheumatology

Front 1

What is the most common cause of prosthetic joint septic arthritis?

Back 1

Staph aureus (after staph, 2nd MCC is strep in non-gonococcal arthritsi)

Front 2

How does septic arthritis present?

Back 2

Acute onset of painful, swollen joint with limited ROM and fever. But, crystal-induced arthritis can present similarly, so need synovial fluid for dx. WBC of 10,000-50,000 can be found in crystal-induced arthritis, whereas 50,000-150,000 stromgly suggestive of septic arthritis. Also, fever higher in septic.

Front 3

What is the MCC of septic arthritis in young, sexually active individuals? How present?

Back 3

Neisseria gonorrhea. Purulent arthritis affecting one or more joints or as polyarthritis assoc with tenosynovitis and skin rash

Front 4

What is reactive arthritis often linked to and what is the triad?

Back 4

GU infection with Chlamydia. Triad of arthritis, conjunctivitis, urethritis

Front 5

What does Borrelia burgdorferi cause?

Back 5

Lyme disease. Can cause arthritis, facial palsy, cardiac conduction abmoralities

Front 6

What joint problems can TB and Blastomycosis cause?

Back 6

Both can cause arhtirits, but far less common than bacterial arthritis and are less virulent and acute and with lower synovial WBC count than bacterial arthritis

Front 7

Who does Salmonella and other gram neg enteric pathogens cause septic arthritis in?

Back 7

Immunocompromised, elderly

Front 8

What is the most common cause of genearlized MSK pain in women 20-55yo?

Back 8

Fibromyalgia

Front 9

How is diagnosis of fibromyalgia made and what are common sites?

Back 9

Widespread MSK pain and excessive tenderness to palpation of at least 11 of 18 predefined soft tissue locations during PE - sites include upper quadrants of butt and medial aspects of knee, SCM, trapezius. Will have absence of joint swelling and worsening with exercise. Pain but no weakness. Also common to have fatigue, IBS, depression. No inflammation, joint swelling, or weakness and no abnormalitites on labs

Front 10

How can differentiate pts with seronegative spondyloarthropathies vs fibromyalgia?

Back 10

Seroneg: Neg RF but elevated ESR. Pain improves with exercise (vs fibromyalgia)

Front 11

Who is polymyalgia rheumatica most common in? S/S? Labs?

Back 11

Women and pts >50yo. Present with pain and stiffness of shoulders and pelvic girdle. ESR almost always elevatd. Commonly assoc with temporal arteritis

Front 12

What are s/s of polymyositis? Lbbs?

Back 12

Symmetric proximal muscle weakness and mild pain. Elevation of CK and inflammation of muscle fibers

Front 13

What are risk factors for rheumatoid arthritis? How present?

Back 13

Female gender, middle age are risk factors. Swelling of wrist and hand joints (MCP, PIP), morning stiffness, elevated RF and ESR are common

Front 14

Who is Sjogrens most common in. What are clinical findings? How is diagnosis made?

Back 14

Autoimmune, most common in women in 5th-6th decade of life. Clinical findings: keratoconjunctivitis sicca (xerophthalmia, dry eyes) and xerostomia (dry mouth). Due to antimicrobial and lubricating properties of normal saliva, pts will have inc dental caries and complain of difficulty swallowing. Lymphocytic infiltration of salivary glands causes enlargement and firmness to palpation of these glands. Dx: subjective and objective evidence of dry mouth and eyes in presence of either histologic evidenc of lymphocytic infiltration of salivary gland sor serum autoAb directed against SSA (Ro) and/or SSB (La)

Front 15

When are antimitochondrial Ab positive?

Back 15

Primary biliary cirrhosis (autoimmune diseas characterized clinically by progressive jaundice, varices, and other signs of cirrhosis)

Front 16

What is Barrett esophagus?

Back 16

Metaplasia of esophagel squamous epithielium to columnar epithelium; is a precursor of esophageal adenocarcinoma

Front 17

What is the MCC of lumbar spinal stenosis aka neuropathic claudication? What are s/s, how differentiate from PVD, and how make dx?

Back 17

DJD is MCC; results from any condition that narrows the spinal canal and compresses nerve roots, most commonly seen in middle-aged and elderly adults Exacerbation of leg symptoms with walking (similar to PVD) but unlike PVD, the symptoms are positional and remain while standing still and is better when walking uphill and sitting. Pain relieved by flexion of spine (widenes spinal canal). Can see weakness, sensory loss, numbness/tingling, discomfort of legs; neuro normal and only 10% have positive straight leg test. Dx: clinical history and classic findings on spinal MRI (bony anatomy, neural structures, soft tissue)

Front 18

What are ankle-brachial index used for?

Back 18

To evaluate for PVD

Front 19

How does PVD present?

Back 19

Leg and butt pain worse with activity and relieved by rest. Pulses decreased

Front 20

What does ankylosing spondylitis present as?

Back 20

Young amles (15-30yo with lower back pain with limited spinal mobility. Improvement with exercise. +HLA-B27

Front 21

What are the 2 most common forms of inflammatory mypoathy? When do they occur and in what gender more commmonly? How do they present and how to distinguish from other causes of myositis? How dx and tx?

Back 21

Polymyositis and dermatomyositis. Present with proximal muscle weakness (gradual onset), +ESR and CK, dx with muscle bx. MC in 40-50yo F>M. Similar presentaiton sin drug-induced myoatphy (caused by statins, antipsychotics, alcohol), hypothyroid myopathy, muscular dystrophy, MG. +ESR and +CK are supportive of inflammatory myositis. Tx with high dose steroids

Front 22

When is Colchicine used?

Back 22

Acute flares of gouty arthritis. Inhibits Neutrophil activity

Front 23

What is indomethacin?

Back 23

Potent NSAID

Front 24

What is Riluzole?

Back 24

Used to slow progression of ALS (progressive weakness of arms, legs, CN with a mix of UMN and LMN signs)

Front 25

What can TCAs do for pain?

Back 25

Dec pain in fibromyalgia (do nothing for muscle weakness)

Front 26

What is pyridostigmine?

Back 26

Anticholinesterase used to treat MG. Most pts with MG have facial and ocular muscle weakness

Front 27

What is the most common cause of asymptomatic elevation of alkaline phosphatase in elderly pt?

Back 27

Pagets disease of bone (osteitis deformans) - typically asymptomatic at time of dx and dx made incidentally with isolated elevated alk phos on routine lab testing

Front 28

What are causes of inc alk phos?

Back 28

MC seen in hepatobiliary disorders or disease of bone causing inc bone turnover. MC is Pagets disease.

Front 29

What are most commonly affected bones in Pagets disease? What are complications?

Back 29

Skull, clavicles, pelvis and long bones. Pahtologic fractures, pain, osteosarcoma, neuro symptoms are complications.

Front 30

What is PSA usually in prostate cancer?

Back 30

>4.

Front 31

In pts with bone mets, what will be lab changes? Presenting s/s?

Back 31

Inc alk phos but will also have hyperCa due to bone resorption. Will also have bane and osteoblastic lesions on x-ray.

Front 32

What are s/s of multiple myeloma?

Back 32

Bone pain, hyperCa due to osteolysis. Monoclonal Ig proteins in serum and urine. Weakness, fatigue, wt loss, renal disease, amyloidosis not uncommon.

Front 33

What are SE of statins?

Back 33

Inc AST, ALT. Rhabdo leading to myoglobinuria and renal failure

Front 34

What are LFT changes in alcoholic liver disease?

Back 34

Inc in AST and ALT but 2:1 AST:ALT

Front 35

How does viral arthritis present? What is MCC?

Back 35

Acute onset of polyarticular and symmetric arthrits that resolves within 2 months. MCC: Parvovirus B19, esp in adults with frequent contact with children, such as daycare workers. Parvo B19 common involves MCP, PIP, wrisk joints and "slapped cheek" appearance is rare in adults

Front 36

How can tell the difference between rheumatoid arthrits and viral arthritis?

Back 36

Rheumatoid: MCP, PIP, wrist (same as viral from Parvo B19). But, viral is more acute onset with morning stiffness <30min and lack of joint swelling or systemic symptoms. Rheumatoid needs to be present for at least 6 weeks to diagnost, morning stiffness >30min, and usually systemic signs

Front 37

What are s/s of SLE?

Back 37

arthritis, rash, hematologic abnormalities, renal disease, fever, wt loss, inc ESR

Front 38

Where does psoriatic arthritis usually affect and what does it look like?

Back 38

DIP joints. Dactylitis ("sausage digit"), nail findings, psoriasis of skin are characteristic

Front 39

How does acute rheumatic fever present?

Back 39

Polyarthritis, carditis, chorea, erythema marginatum, subcutaneous nodules. Arthritis is often migratory in nature and usually first affects the joints of the lower extremities

Front 40

How can gonococcal septic arthritis present?

Back 40

1 of 2 way: asymmetric polyarthritis (often assoc with tenosynovitis and skin rash) or as an isolated purulent arthritis affecting one or few joints

Front 41

What is purulent arthritis in sexually active pt until proven otherwise?

Back 41

Gonococcal arthritis

Front 42

How dx gonococcal arhtriits?

Back 42

Gram stain of synovial fluid, blood, cultures, urethral cultures.

Front 43

When does acute rheumatic fever occur after pharyngitis? What is the organism? What are s/s?

Back 43

2-4 weeks after paryngitis by Group A strep. Symptoms: migratory arthritis of large joints, erythema marginatum rash, subcutaneous nodules, carditis, Sydenham chorea

Front 44

When do symptoms of acute HIV infection tend to present and what are the s/s?

Back 44

2-4 weeks after exposure to virus. Symptoms: non-specific and include fever, arthralgias, sore throat, LAD, mucocutaneous lesions, diarrhea, wt loss

Front 45

How does crystal-induced arthritis usually present and what does tap show?

Back 45

Warm, painful, swollen joint accompanied by low-grade fever. Joint tap: WBC of 10,000-50,000 and characteristic crystals under polarized light

Front 46

What are s/s of infective endocarditis?

Back 46

Fever, new murmur, Osler's nodes (nodules on finger and toe pads), Roth's spots (retinal hemorrhages), and Janeway lesions (small hemorrhages on extremities)

Front 47

What are causes of reactive arthritis and what is presentation?

Back 47

GU infection with Chlaymdia or by certain GI infections. Presents with triad of arthritis, conjunctivitis, urethritis

Front 48

SLE - who is at most risk. What are s/s. What labs are specific?

Back 48

Women in 20s and 30s at highest risk. S/S: malar "butteryfly" rash, arthritis, painless oral ulcers, renal disease. Positive anti-DS DNA is very specific.

Front 49

What is one of the leading causes of M/M in SLE? How should you base treatment?

Back 49

Renal disease (40-75% of pts). Spetrum is wide. Need to do renal bx in pts with lupus nephritis bc different forms have different treatments. In addition, initial bx provides baseline histology against which future biopsies may be compared to monitor disease progression - if delay renal bx, may adversely affect outcome

Front 50

What are red flags for lower back paind and what might they suggest?

Back 50

Red flags: >50yo, previous hx of cancer, unexplained wt loss, pain >1mo duration, nighttime pain causing difficulty with sleep, no response to previous therapy, neurologic symptoms, fever, lack of exacerbation with movement or palpation. May suggest systemic disorder, herniated disk, or bony abnormality such as lytic lesions and compression fractures

Front 51

What does pain to palpation of vertebra on exam suggest?

Back 51

Spinal infection or possibly lytic lesion of the spine

Front 52

What does positive straight leg test on exam suggest?

Back 52

Herniated disk

Front 53

What is the test of choice to further evaluate back pain in pt with red flag?

Back 53

Plain film looking for lytic lesions or compression fractures. If neg and still high clinical suspicion, get MRI of back or CT scan to evaluate for possible disc disease, cancer, spinal infections.

Front 54

What are the most common cancers to mets to bone?

Back 54

Lung, breast, prostate, renal, multiple myeloma, thyroid

Front 55

When is MRI of back more sensitive than CT?

Back 55

Detection of infection and cancer. Indicated for progressive neurologic deficits, high suspicion of cancer or infection, and symptoms >3mo

Front 56

When should refer back pain pt to ortho or neuro surgeon?

Back 56

Cauda equina syndrome, spinal cord compression, progressive neurologic deficits, or persistent pain after conservative therapy.

Front 57

When should pts on NSAIDs for back pain get imaging?

Back 57

After failing treatment for 2 weeks (earlier if have red flags).

Front 58

Is PT more affective than NSAIDs?

Back 58

PT effective in chronic back pain but not as effective as NSAIDs in treatment of acute lower back pain

Front 59

How does gouty arthritis occur and pts on what therapy are at risk?

Back 59

Results from overproduction or underexcretion of uric acid. Induction chemo results in rapid tumor lysis and releases uric acid into the circulation.

Front 60

How do you prevent and treat gout?

Back 60

Prevention with allopurinol and probenecid (inc urinary excretion of uric acid but 2nd line bc of inc risk of uric acid renal stones). Treat acute attacks with colchicine, NSAIDs, steroids

Front 61

What is the most common presentation of gout?

Back 61

Acute, monoarcticular arthritis affecting 1st metatarsophalangeal joint (podagra).

Front 62

How do you diagnose gout?

Back 62

Definitive dx with joint aspiration with demonstrated needle-shaped, negatively birefringent urate crystals and a WBC count of 2,000-50,000.

Front 63

What is the MOA of allopurinol?

Back 63

Xanthine-oxidase inhibitor -> dec uric acid production

Front 64

What does urine acidification do?

Back 64

Eliminates amphetamines. Will increase gout attacks by increasing uric acid solubility and decreases uric acid renal stone formation.

Front 65

What is N-acetylcysteine used for?

Back 65

Antidote for acetaminophen OD and as a nephroprotective agent to prevent radiocontrast-induced nephropathy

Front 66

What is Mensa and what is it used for?

Back 66

Prevents hemorrhagic cystitis caused by certain chemo agents (cyclophosphamide)

Front 67

What is Behcet's syndrome, who does it occur in, and what are s/s?

Back 67

Multi-systemic inflammatory condition characterized by recurrent oral and genital ulcers and skin lesions. MC seen in Turkish, Asian, and Middle Eastern Population. Combined environmental and hereditary factors play a part in pathogenesis. International criteria for dx: Recurent oral ulcers + 2 of the following: recurrent genital ulcers, eye lesions including anterior uveitits and posterior uveitis, retinal vascularization, skil lesions including erythema nodosum, acneiform nodules and papulopustular lesions, +pathergy test. Some pts have involvement of GI, skeletal, and vascular systems. Tx; steroids offer relief from most symptoms, but no protection for progressoin to dementia or blindness

Front 68

What is erythema nodosum?

Back 68

Red nodules that are tender and warm

Front 69

What should suspect in pts with bilateral ankle arthritis and bilateral hilar adenopathy on CXR?

Back 69

Sarcoidosis

Front 70

Who is sarcoid most common in?

Back 70

Black women in 3rd-4th degades

Front 71

What is the skin lesion of sarcoid?

Back 71

Erythema nodosum

Front 72

What is reactive arthritis?

Back 72

Urethritis, conjunctiviits, and arthritis, as well as mucocutaneous lesions (stomatitis, balanititis, keratoderma blennorrhagicum). Usually follows dysenteric infection or STD (Chlamydia)

Front 73

What does herpes look like?

Back 73

recurrent small grouped vesicles over orolabial and genital areas.

Front 74

What is SLE?

Back 74

Rheumatic disease characterized by auto-Ab directed against self-antigens. Malar rash, arthritis, oral ulcers, other systemic involvement. Clinical course has spontaneous remissions and recurrences

Front 75

How does polymyositis present?

Back 75

inflammatory disease of unknown etiology. Presents initially with slowly progressive proximal muscle weakness of the lower extremities characterized by difficulty ascending and descending stairs or rising from a seated position. The weakness usually progreses over the course of years; an acute presentation is not typical. Proximal arm weakness usually follows leading to complaints of difficulty with combing hair or working with hands overhead. Usually no skin findings (vs dermatomyositis). Muscles of mastication and facial expression are classically spared, but mya develop dysphagia due to involvement of striated muscles of upper pharynx. Weakness is primary complaint, and while muscle tenderness may be present, severe tenderness or tenderness i absence of weakness should lead to consideration of other dx such as PMR.

Front 76

How dx polymyositis?

Back 76

Muscle bx is best diagnostic study. MRI can assist in identifying best place to bx. Bx shows mononuclear infiltrate surrounding necrotic and regenerating muscle fibers. In more advanced disease, an inflammatory infiltrate may be absent and replacement of muscle with fibrotic tissue may be evident.

Front 77

When is MRI of the spine helpful?

Back 77

Identifying conditions that may cause compression of SC or spinal nerve roots such as herniated discs or spinal stenosis.

Front 78

When do you do EEG?

Back 78

Seizures, sleep disorders

Front 79

When is temporal artery bx helpful?

Back 79

Necessary to make dx of temporal arteritis

Front 80

When is LP useful?

Back 80

To dx meningitis, subarachnoid hemorrhage, and inflammatory conditions of CNS such as MS

Front 81

What does x-ray of osteoarthritic knee show?

Back 81

Narrowed joint space, osteophytes, subchondral sclerosis or cysts.

Front 82

What is the biggest risk factor for osteoarthritis?

Back 82

Obesity - wt loss decreases joint pain, increases function, and slow progressoin of disease

Front 83

How do pts with osteoarthritis present?

Back 83

Brief morning stiffness (<30min), exertional joint pain. Usually no symptosm of fever and wt loss

Front 84

What is the most readily modifiable risk factor for osteoarthritis?

Back 84

Weight loss - slows progression and improves joint pain and function. Meds and exercise play a role, but only with temporary relief. PT helps to strengthen muscles and redues pain and improves mobility, but doesn't slow progression of OA

Front 85

What are anti-topoisomerase-I ab for?

Back 85

Systemic sclerosis

Front 86

What are anti-smooth muscle ab for?

Back 86

Autoimmune hepatitis

Front 87

What are anti-neutrophil cytoplasmic Ab for?

Back 87

Granulomatosis with polyangiitis (Wegener's) - a form of granulomatous vasculitis.

Front 88

When is RF classically positive?

Back 88

Rheumatoid arthritis, but can also be inc in SLE, Sjogrens, dermatomyositis, HCV infection, and others

Front 89

What are the manifestations of systemic sclerosis?

Back 89

Heterogeneous condition that can affect every organ system in the body. Skin: skin thickening (begains at acral sites (hands and feeet) with edema that transitions to dermal sclerosis with obliteration of skin appednges (hair follicles and sweat glands) and flexion contractures. Rheumatoid phenom and calcinosis cutis are also commonly observed. The face may take on a "mask-like" appearance due to dermal thickening. CT thickening, the product of myofibroblast proliferation and inc collagen and ground substance production, is the underlying pathogenesis of may features of systemic sclerosis. Involvement of kidneys produces hypertension, and before the advent of ACI, scleroderma renal crisis was the MCC of death in these pts. Pulmonary arterial HTN ulimtately results in RHF. Esophagela and gastric dysmotility causes GERD. Anti-nuclear AutoAb present in all scleroderma pts, anti-topoisomerase-I Ab also.

Front 90

What are the most common complaints of sarcoid pts who present symptomatically?

Back 90

MC: cough, dypsnea, fever, wt loss. WHile lungs are most common involved organ system, the skin (erythema nodosum), eyes, (anterior uveitis), joints (arthritis), and many other organ systems may be affected. CXR: bilateral hilar adenopathy and reticular opacities.

Front 91

What do you see in slit lamp of anterior uveitis?

Back 91

Red eye with leukocytes in anterior chamber

Front 92

What are symptoms of acute HIV infection?

Back 92

Non-specific. Fever, arthralgias, sore throat, LAD, mucocutaneous lesions, diarrhea, wt loss.

Front 93

What part of the eye does histoplasmosis damage?

Back 93

Retina

Front 94

What eye problem can you get with ankylosing spondylitis?

Back 94

Anterior uveitis

Front 95

What are s/s of Hodgkin's lymphoma?

Back 95

Common in young adults . Painless, swollen LN and hilar adenopathy. B symptoms - fever, wt loss.

Front 96

How can you get gout from myeloproliferative disorder?

Back 96

Myeloproliferative disorders are common causes of uric acid overproduction bc they inc catabolism and turnover of purines -> inc in serum uric acid levels

Front 97

What changes does polycythemia vera cause in terms of spleen and pruritis?

Back 97

Splenomegaly, characteristic pruritis with hot baths due to histamine rleae from an inc number of circulating basophils.

Front 98

What is a common arthritis in polycythemia vera pts?

Back 98

Gout (up to 40%)

Front 99

How does CKD cause gout attacks?

Back 99

Decreases the amout of uric acid excreted in the urine

Front 100

What is hemochromatosis (symptoms, cause)?

Back 100

Autosomal recessive iron overload syndrome most often due ot mutation of HFE gene. Symptoms: related to iron accumulation in various organs: hepatic dysfunction progressing to cirrhosis, diabetes, hypogonadism, skin pigmentation, arthritis

Front 101

What is Lesch-Nyhan syndrome?

Back 101

Caused by a genetic deficiency of the enzyme HPRT (hypoxanthine-guanine phosphoribosyl transferase) - characterized by overproduction of uric acid, behavioral problems (esp self-injurious actions), and neurologic disability and is generally diagnosed in chilhood.

Front 102

What are the complications of high Ca in hyperPTH?

Back 102

chondorocalcinosis and CPPD disease (pseudogout) - positively birefringent crystals

Front 103

What type of anemia does pernicious anemia cause?

Back 103

Macrocytic (with neurologic abnormalities)

Front 104

How does portal HTN cause severe pruritis?

Back 104

Inc serum concentrations of bilirubin.

Front 105

When should suspect temporal arteritis?

Back 105

>50yo pt with new headache, jaw claudication, scalp pain, visual loss, or symptoms of PMR. It is a large vessel vasculitis that affects aorta and its cranial arterial branches. Vision loss is one of the msot feared complications of temporal arterities (up to 20% of pts)

Front 106

How treat temporal arteritis?

Back 106

Prompt systemic high dose steroids to lower rate of visual complications and dec likelihood of visual loss in inaffected eye. Note: PMR treated with low-dose steroids.

Front 107

How dx temporal arteriitis?

Back 107

temporal artery bx. ESR will be elevated

Front 108

What is acetazolamide used for?

Back 108

open-angle glaucoma and beneign intracranial HTN

Front 109

How can distinguish gout from pseudogout?

Back 109

Not by history and physical. Need synovial fluid analysis. Pseudogout - rhomnoid, positively birefringent crystals and radiographic evidenc eof chondrocalcinosis. Gout: needle shaped, negatively birefringent crystals.

Front 110

What type of crystals cause pseudogout?

Back 110

CPPD (calcium pyrophospahte ihydrate crystals)

Front 111

How do attacks of pseudogout often occur?

Back 111

Truama, surgery, medical illness

Front 112

What is the common presentation of pseudogout?

Back 112

Acute pain, swelling, redness, limited motion of affected joint(s). Knee most common (>50%). can also ahve fever, leukocytosis with L shift, and chondrocalcinosis (calcified artericualr cartilage).

Front 113

What is hydroxyapatite and where can see it?

Back 113

Colexed form of Ca found in teeth and bones. It can also exist in cartilage of pts with degenerative osteoarthritis and may be isolated from synovial fluid in such pts

Front 114

What type of crystals do you see in gout?

Back 114

Monosodium urate crystals

Front 115

What is the msot common crystal foudn in renal calculi?

Back 115

Calcium oxalate crystals

Front 116

When are struvite stones found and what are they made of?

Back 116

Magnesium ammonium phosphate crystals. Found in renal calculi of pts with UTI cause by urease-producing organisms (Klebsiella, Proteus)

Front 117

How can distinguish viral arthritis from other types?

Back 117

Symmetric small joint inflammatory arthritis. Tends to resolve within 2mo. Can have +ANA (weakly pos) and +RF. Treatment: NSAIDs for resolution of symptoms. Antivirals un-necessary bc self-limited. Causitive agents: Parvovirus, hepatitis, HIV, mumps, rubella.

Front 118

When does osteoarthritis occur (onset) and do you ahve a fever?

Back 118

No fever bc non-inflammatory. Insidoius onset typically >40yo

Front 119

What type of arthritis can pts with sarcoid have?

Back 119

Polyarthrits - most often in ankles and knees

Front 120

What are the seronegative spondyloarthropathies?

Back 120

Ankylosing spondylitis, reactive arthritis, psoriatic arthritis. Asymmetric arthritis and inflammatory back pain with neg RF

Front 121

How does PMR present?

Back 121

>50yo, inflammatory condition with sore and stiff muscles, esp in neck and shoulders. ESR usually >40, nL ANA

Front 122

What is the classic triad of disseminated gonococcal infection? What other s/s can you have and what is often in the history?

Back 122

Polyarthralgias, tenosynovitis (pain elicited along tendon sheaths), vesiculopustular skin lesions (anywhere from 2-10 and may be dismissed as furuncles or pimples). Fever and chills can be present. Hx of recent unprotected sex with new partner is frequent, while symptoms of symptomatic venereal diases is most often absent.

Front 123

What is the rash and arthritis of Lyme disease?

Back 123

Rash (erythema migrans) occurs early on with bulls eye appearance, while artrhitis (typically monoarticular knee pain) doesn't cocur until months later.

Front 124

What are the skin findings of syphillis?

Back 124

Painless ulcer of genitalia that occurs in primary stage of infection and maculopapular rash of palms and soles in secondary stage

Front 125

What are the s/s of meningococcemia?

Back 125

Petechial rash, high fever, HA, N/V, stiff neck, photophobia.

Front 126

What is erythema marginatum and when do you see it?

Back 126

Raised ring-shaped lesions over trunk and extremities. Seen in acute rheumatic fever ?and others?

Front 127

How does osteoarthritis typically present in hip?

Back 127

>40yo with indolent course - progressive anterior hip pain (can be described as groin pain)exacerbated by walking adn relieved by rest. Morning stiffness/stiffness after prolonged resting is consistent, but morning stiffness lasts <30-60min (as opposed to rheumatoid). Active and passive internal and external rotation is limited and tenderness to palpation and systemic signs are absent. Pain at rest or overnight occurs on in advanced disease. Etiology is progressive mechanical destruction of the articular cartilage leading to bone-to-bone friction and formation of osteophytes.

Front 128

What is th emost common joint disease and what are predisposing factors?

Back 128

Osteoarthritis. Advanced age and obesity, esp for hips and knees

Front 129

What is meralgia paresthetica?

Back 129

Condition where compression of the lateral femoral cutaneous nerve causes lateral hip paresthesia unaffected by motion or palpation.

Front 130

What causes trochanteric bursitis? What are presenting s/s?

Back 130

Caused by friction between the tendons of the gluceus medius and tensor fascia lata over the greater trochanter of teh femur. Pain localized to lateral hip, worsened by palpation. Pain casued by pressure on the lateral hip may interfere with sleeping

Front 131

What is osteonecrosis of the femoral head often assoc with?

Back 131

Chronic corticosteroid use

Front 132

When referred pain from the lumbosacral area causes posterior hip or gluteal pain and when impingement of the lumbar nerve roots causes pain to radiate laterally down the thigh, waht will you see on exam?

Back 132

No limitation of hip mobility but +findings on straight leg raise.

Front 133

What is the most reliable sign for spinal osteomyelitis? What are other features? What is most sensitive test? Who is at inc risk?

Back 133

Most reliable sign: Tenderness to gentle percussion over the spinus process of the involved vertebra. Pain is not relieved by rest. Fever and inc WBC are unreliable. ESR grossly elevated (>100). MRI most sensitive study. Very high index of suspicion in pts with history of IVDA or recent distant site infeciton (ex: UTI).

Front 134

Who is at highest risk for osteomyelitis?

Back 134

IVDA, sickle cell pts, immunocomprmoised

Front 135

What is MC organism in IVDA with osteo?

Back 135

Staph aureus, but gram neg also common.

Front 136

What is tx of spinal osteomyelitis?

Back 136

Long term IV abx with or without surgery

Front 137

What are the s/s of ankylosing spondylitis?

Back 137

Pain and progressive limitation of back motion. Usually max in morning and improve as day goes along

Front 138

How does lumbar disk hernitation present?

Back 138

Acute onset of back pain with or without radiation down a leg. Pts can often recall an inciting event. Worse with activity, improves with rest. Spine not tender to palpation

Front 139

What is the definition of lumbar spinal stenosis? Who is it most common in? How does it present?

Back 139

Narrowing of spinal canal with compression of 1 or more spinal roots. >60yo. Back pain that radiates to butt and thighs. Symptoms worse with walking and lumbar extension and improve with lumbar flexion. Can have numbness and paresthesas. Dx: MRI

Front 140

When do you worry about prostate cancer bone mets?

Back 140

Older age, night pain, urinary symptoms

Front 141

How do vertebral compression fractures present?

Back 141

Local tenderness to palpation, usually in elderly pt with history of osteoporosis

Front 142

What are pts with ankylosing spondylitis for >20 yrs at inc risk for when falling?

Back 142

Vertebral fractures due to dec bone mineral density. Can occur with iminmal trauma so have suspicion if have longstanding AS

Front 143

How does lower back pain of AS present?

Back 143

Insidious, unilateral, intermittent pain that may beocme bilateral with persistent flares. Pain is not typically sudden and severe

Front 144

How does pain of spinal root compression present?

Back 144

Dermatomal distribution with sensory loss, paresthesias, and weakness of muscles innervated by the inolved nerve root

Front 145

What are pts with AS at inc risk for in terms of muscles?

Back 145

Muscle spasms - present with sudden severe back pain that resolves within second to minutes and may recur

Front 146

When can have referred visceral pain to back?

Back 146

Pancreatitis, Abdominal aortic dissection

Front 147

What MCC of bone malignancies?

Back 147

Mets to bone (more common than primary bone cancers)

Front 148

What is the pathophys of secondary amyloidosis and what can it be secondary to?

Back 148

Extracellular deposition of insoluble polymeric proteinf ibrils in tissues and organ with elevated amyloid A. Can be secondary to chronic inflammatory conditions: inflammatory arthritis (RA), chronic infections (bronchiectasis, TB, osteo), IBD, malignancy (lymphoma), vasculitisi

Front 149

What is the clinical presentation, dx, and tx of secondary amyloidosis?

Back 149

Presentation: asymptomatic proteinuria or nephrotic syndrome, CM with heart failure, hepatomegaly, mixed sensory and motor peripheral neuopathy an/dor autonomic neuropathy, visible organ enlargement (ex: macroglossia), bleeding diathesis, waxy thickening, easy bruising of skin. Dx: abd fat pad aspiration bx. Tx: treatment of underlying condition. Colchicine for prevention and tx

Front 150

What is hepatorenal syndrome?

Back 150

Acute renal falure in pts with acute or chronic liver disease and portal HTN. Usually presents in pts with severe liver disease with progressively rising serum Cr and minimal proteinuria (<500mg/day)

Front 151

What is hypertensive nephrosclerosis?

Back 151

Seen in pts with chronic HTN and associated with retinoapthy, LV hypertrophy, progressive renal failure, and mild proteinuria (<1g/day). Kidneys are usually small

Front 152

What is IgA nephropathy?

Back 152

Type of nephritis that typiclaly presents with hematuria on UA. Restricted to kidneys

Front 153

How do pts with PCKD present?

Back 153

Flank pain, hematuria, renal failure, HTN, large palpable kidneys. Can also hve hepatic cysts

Front 154

What does synovial fluid anaylsis of OA reveal?

Back 154

<2000 WBC, no organisms or crystals

Front 155

How does OA present?

Back 155

noninflammatory (no fever), affects hands and weight bearing joints. mild morning stiffness <30min, exacerbated by exercise and relieved by rest. No systemic symptoms. Can have effusions but wont' be hot to touch. Exam: bony crepitus, bony enalrgement, painful/dec ROM are common. X-ray: narrowed joint space with osteophyte formation and subchondral sclerosis/cysts

Front 156

When do you see punched out erosions with rim of cortical bone on x-ray?

Back 156

Gout y arthritis

Front 157

When do you see periarticular osteopenia and joint margin erosions on x-ray?

Back 157

Classic for RA

Front 158

What is cell count in RA?

Back 158

2,000-50,000

Front 159

How does RA present?

Back 159

morning stiffness >30min, systemic symptoms of fever, malaise, wt loss. Joints: wrists, MCP, PIP. Joints warm to touch

Front 160

What will see on x-ray in pts wth infectious arthritis?

Back 160

Normal joint space with soft tissue swelling

Front 161

When do you see calcification of cartilaginous structures on x-ray?

Back 161

(chondrocalcinosis) - see in pseudogout

Front 162

What is the presentation of dermatomyositis and what are they at risk for?

Back 162

Proximal muslce weakness with cutaneous findings - violaceous poikiloderma over various regoins of body. On face, reuptions most often accompanied by periorbital edema and is known as heliotrope sign; on chest and lateral neck, called shawl sign; on knuckles, elbows, and knees it is Gottron's sign. Lichenoid papules overlyoing joints are known as Gottron's papules and are pathopgonominc for DM. At risk for internal malignancies - most common is ovarian, but breast, lung, other female urogenital cancers may occrs as well - essential to have regular age-appropriate cancer screening

Front 163

Who is dermatomyositis mroe common in and what is the Ab test?

Back 163

F:M 6:1. anti-Mi-2 Ab (against helicase)

Front 164

What inflammatory disorders are assoc with aortic aneurysms?

Back 164

Behcet's, Takayasu arteritis, giant cell, ankylosing spondylitis, RA, psoriatic arthritis, relapsing polychondritis, reactive arthritis

Front 165

What autoimmune disease are assoc with renal failure?

Back 165

SLE, scleroderma, Goodpasture, relapsing polychondirits, Wegeners (granulomatosis with polyangiitis)

Front 166

What inflammatory disease are assoc with alveolar homoerrhage?

Back 166

Goodpastures, Wegeners, polyarteritis, Churg-Strauss, Behcets, anti-PL Ab syndrome

Front 167

What inflammatory/depositional disease are assoc with carpal tunnel syndrome?

Back 167

Rheumatoid arthritis, sarcoidosis, amyloidosis.

Front 168

What autoimmune diseaseas are assoc with sudden visual loss?

Back 168

Temporal arteritis and rarely SLE

Front 169

What meds are effective in fibromyalgia?

Back 169

Amytriptyline and cyclobenzaprine - they can inc amt of restorative phase 4 sleep. In pts with depression as well, can also give SSRIs

Front 170

What joint problems is methotrexate used for?

Back 170

inflammatory arthritides such as RA or psoriatic arthritis

Front 171

What is a vessel complication of giant cell/temporal arteritis? How can prevent?

Back 171

Aortic aneurysms bc of involvement of branches of aorta. Pts should be followed with serial CXR

Front 172

What are s/s of giant cell arteritis?

Back 172

HA, jaw claudication, muscle fatigue, visual disturbance, scalp tenderness on exam, dec temporal artery pulse. ESR >50.

Front 173

What is the MC form of leukemia in older pts?

Back 173

CLL. Insidious onset.

Front 174

What is the MCC of hypothyroid?

Back 174

Chronic lymphocytic thyroiditis (Hashimotos).

Front 175

Does radiation to thyroid region predipose to development of hypothyroid?

Back 175

Yes

Front 176

Who is ulcerative colitis more common in?

Back 176

Jews, +Fhx

Front 177

What are teh important causes of membranous glomerulonephritis?

Back 177

Hep B and C, syphilis, gold, penicillamine, SLE< RA. Many pts have no predisposing factors

Front 178

What are tophi?

Back 178

Collecions of urate cyrstals which form firm, yellowish nodules at the sites of involved joints in pts with chronic gout.

Front 179

What is the MCC of septic arthritis?

Back 179

Staph aureus

Front 180

Is RA symmetric?

Back 180

Yes

Front 181

When do you see Heberden nodes?

Back 181

DIP joints in osteoarthritis. They form from calcified cartilagenious spurs

Front 182

What accounts for the MSK complaints in reactive arthritis?

Back 182

Lower extremity oligoarhtirits and enthesopathy (inflammation at gendon and ligament insertions)

Front 183

What causes rotator cuff injuries? What s/s are suggestive? What should use for diagnosis?

Back 183

Can result from chronic rotator cuff tendonitis and should trauma. Shoulder pain and weakness when lifting arm above head is suggestive of rotator cuff pathology. Also, lying on affected side hurts. Limitation of mid-arc abduction and external rotation are common findings on exam. Lidocaine injection will improve rotator cuff tendonitis, but not rotator cuff tear. MRI is excellent for visualizing soft tissue structures and is study of choice for diagnosing rotator cuff tears.

Front 184

What is classic presentation for how tore rotator cuff?

Back 184

Fall on an outstreatched arm.

Front 185

How is x-ray helpful in shoulder injuries?

Back 185

inexpensive way to diagnose fractures, dislocations, and calcific tendonitis, but can't do soft tissue

Front 186

How does multiple myeloma present?

Back 186

pain in spine, ribs, back. Can be accompanied by hyperCa and anemia. dx: BM biopsy

Front 187

What are bone scans used for?

Back 187

Diagnosing osteomyelitis, fractures, metastatic disease.

Front 188

Describe the joint mainfestations of SLE

Back 188

<90% of pts have joint involvement, most commonly affecting the hands or knee. It is a migratory arthritis taht is often disproportionate to objective physical findings Joint pain is common, but the arthritis induced by SLE is considered non-deforming.

Front 189

What are common presentations of SLE?

Back 189

Low-grade fever, weakness, wt loss, rash (malar butterfly, annular, disoid), arthralgias/arthritis, proteinuria, hematologic abnormalities. Inc ESR (nonspecific but suggests systemic inflammation consistent with SLE).

Front 190

When do you see subluxation of cervical vertebrae and tendon damage in hands?

Back 190

Rheumatoid arthritis

Front 191

When do you see cartilage degradation?

Back 191

Osteoarthritis. Advanced age and obesity, esp for hips and knees

Front 192

When do you see distal phalangeal respotion?

Back 192

Prominent in arthritis mutilans variant of psoriatic arthritis leading to classic "pencil-in-cup"deformities

Front 193

Describe the presentation of PMR

Back 193

Pain and stiffness in neck, shoulders, and pelvic girdle in pts >50yo with elevated ESR and morning stiffness lasting >1hr. PE: unremarkable with denying of tenderness with active or passive mortion. No signs of joint inflammation.

Front 194

What is treatment for PMR not assoc with giant cell arteritis?

Back 194

Low dose prednisone (high dose if also have giant cell)

Front 195

What are features of giant cell arteritis?

Back 195

Headache, jaw-claudication, visual changes, abnoramlities of temporal artery, constitiutional symptoms

Front 196

When do you see positive ANA?

Back 196

SLE, drug-induced lupus, RA, mixed CT disorders, polymyositis, other autoimmune conditions

Front 197

What are important non-medication measures to prevent future attacks of acute gouty arthritis?

Back 197

Alcohol cessation, low purine diet. Ethanol -> lactate - lactate competes with urate for renal excretion -> accumulation of urate in body. Also, avoid drugs such as diuretics and pyrazinamide

Front 198

What is treatment of acute attack of gout?

Back 198

NSAIDs (DOC), colchicine, or steroids

Front 199

What is the pathogenesis of spinal stenosis?

Back 199

combo of 2 factors: enlarging osteophytes at faget joints and hypertrophy of ligamentum flavum

Front 200

What does iliac artery atheroscelrosis cause?

Back 200

Claudication in butt and thighs. Typically pain relieved by rest, exacerbated by activity. No positional component like in spinal stenosis

Front 201

How does lumbar disk hernitation present?

Back 201

Acute onset back pain w/ or w/o radiation down 1 leg. Usually recall inciting event. Pain may radiate and may be assoc with neurologic symptoms. Lumbar flexion, sitting makes the pain worse

Front 202

What is spina bifida occulta?

Back 202

Congenital defct of vertebral arch that doesn't involve protrusion of the cord or dura. Typically asymptomatic and dx as incidental radiographic finding

Front 203

How does mets to vertebrae present?

Back 203

Pain that is chronic, dull, worse at night, chnages little with activity, nonradiating

Front 204

What causes Pagets disease?

Back 204

Disorder of inc bone turnover - Osteoclast dysfunction leads to inc bone breakdown and compensaotry inc in bone formation which results in a "mosaic" pattern of lamellar bone, inc alk phos level, and x-ray findings like femoral bowing. Joint and bone pain, skeletal deformities, and hearing loss are common symptoms. Often asympatomic and only identified incidentally on x-ray or with elevated alk phos. Enlarging cranial bones can lead to inc hat size or entraped CN 8 -> hearing loss

Front 205

When do you see osteoblast dysfunction?

Back 205

Diabetes, osteoporosis (pagets is osteoclast dysfunction)

Front 206

When do you see overproduction of calcitriol (active form of vit D)?

Back 206

Granulomatous disease (sarcoid, TB). May have hypercalciuria and hyperCa as well

Front 207

What are s/s of hyperPTH?

Back 207

kidney stones, abd pian, malasie, osteoporotic bone changes

Front 208

What are changes in calcium absorption in pts with GI disease like celiac?

Back 208

Require higher intake of Ca and vit D to prevent osteoporotic bone changes

Front 209

How do you treat symptomatic sarcoidosis?

Back 209

Corticosteroids. No tx if asymptoamtic bc of high rate of spontaneous remission

Front 210

What are manifestations of sarcoidosis?

Back 210

Lung involvement - cough, dyspnea, x-ray which shows hilar/paratracheal adenopathy with or whitout reticulonodular infiltrates and bx which show noncaseating granulomas. Erythema nodosum, anteiror uveitis, acute polyarthritis. May have high ACE level

Front 211

When is hydroxychloroquine used?

Back 211

Malaria prophylaxis and to treat acute malaria, RA, and SLE

Front 212

What is infliximab and when is it used?

Back 212

TNF-alpha blocker approved to treat IBD, AS, and RA

Front 213

What is itraconazole used to treat?

Back 213

Histompalsmosis (bx shows yeast)

Front 214

When is cyclophosphamide used?

Back 214

SLE with renal involvement and as a chemo drug

Front 215

What are INH and rifampin used for?

Back 215

4-drug regimen for active TB

Front 216

What is erythema nodosum? When do you see it?

Back 216

Painful, subcutaneous, pretibial nodules . Can be a symptom of a more serious disease process including sarcoid, TB, histoplasmosis, recent strep infection, IBD.

Front 217

What is the MCC of erythema nodosum?

Back 217

Recent strep infeciton

Front 218

What is the initail workup for erythema nodosum?

Back 218

Symptom guided, includes CXR (for sarcoidosis, TB), PPD skin testing, ASO titer (for recent strep infection)

Front 219

How does RA present?

Back 219

Progressive and symmetric involvement of peripheral joints. Common sites of early involvement include MCP and PIP joints of fingers, metatarsal joints of toes, and wristk joinst. MC affects the cervical spine joints in the axial skeleton and can cause spinal subluxation and spinal cord compression

Front 220

What are the symptoms and exam of RA?

Back 220

Symptoms: indisious onset, multiple joint pain with stiffness and swelling, morning stiffness lasting hours, improves with activity, small joints (PIP, MCP, MTP) commonly involved, monoarthritis (ex: knees, elbows) can also occur later, SPARES DIP joint, unlike OA. Exam: affected joints are tender to the touch, swollen, with limited range of motion, tenosynovitis of the plams -> "trigger finger", Rheumatoid nodules (esp on elbows), cervical joint involvement can lead to spine subluxation -> spinal cord compression.

Front 221

What are the lab/imaging study findings in RA?

Back 221

Positive anti-CCP testing (diagnostic testing, High IgM Rheumatoid factor, high CRP and ESR correlates with disease activity, x-ray show soft-tissue swelling, joint space narrowing, and bony erosions

Front 222

Who is RA more common in?

Back 222

F:M 2-3:1. Peak age 50-75yo

Front 223

What is a sensitive sign of early disease on RA?

Back 223

Reduced grip strength - can occur occasionally and is a sensitive sign of early disease

Front 224

How do pts with RA with cervical spine involvement present?

Back 224

neck pain, stiffness, radicular pain in the upper exremity. Subluxation of the SC compression can present with hyperreflexia or upgoing toes on Babinski

Front 225

What part of the spine is the most common site of disc herniation and spinal stenosis?

Back 225

Lumbar spine

Front 226

What types of arthritis cause sacroiliac involvement?

Back 226

Sernoneg spondyloparthropaities (AS, reactive arthritis, psoriatic arthritis)

Front 227

What is the approach to pts with acute "mechanical" back pain (and what does that mean) without significant neurologic deficit?

Back 227

Conservative approach for 4-6 weeks - this includes early mobilization, muscle relaxants, NSAIDs. Bed rest, exercise, and PT are not shown to be helpful. If pain continues after 4-6 weeks of conservative management or progressive neurologic deficit evolves, high-resolution diagnotic modalities are usually employed - MRI and CT with or without contrast myelography. mechanical back pain - ex could be positive straight leg test that suggests disk herniation but with no neurologic deficit and perianal area is intact

Front 228

When is emergent surgical decompression indicated in back pain?

Back 228

In cases of significant or rapidly progressive neurologic deficit (foot drop, weakness of the legs)

Front 229

When is plain roentgenogram used?

Back 229

Pts with osteoporosis and possible vertebral crush fractures.

Front 230

What are s/s of UC and what arthritis can it be related to?

Back 230

Acute onset bloody diarrhea, anemia, neg stool cultures. Typically presents in pts during 2nd-3rd decade, presenting symptom of UC often bloody diarreha, lower abd pain, tenesmus. Common extracolonic manifestations include skin findings, erythema nodosum, pyoderma gangrenosum, episcleritis, arthirits, cholangitis. P-ANCA positive in UC. IBD may occur in assoc wtih inflammatory arthritis - anklyosis spondylitis and IBD are both assoc with HLA-B27 and may occur in association with one another. Both can also be assoc with positive p-ANCA despite absence of vasculitis in both conditions

Front 231

What GI infections can cause reactive arthritis?

Back 231

Shigella, Salmonella, Yersinia, Campylobacter, or C. diff. Reactive arhtiris - uerthritis, conjunctiviits/uveitis, arthritis, maalise, and characteristic cutaneous findings (keratoderma blennoffhagica and balantitis circinata)

Front 232

What does infection with Tropheryma whippelii cause?

Back 232

Whipple disease - a protean disease characterized most commonly by chronic malabsorptive diarrhea, wt loss, migratory non-deforming arthritis, LAD, and low-grade fever

Front 233

What does infection by protozoan Giardia lamblia cause?

Back 233

Frothy, foul-smelling steatorrhea due to malabsorption casued by the infecting organism. Not bloody diarrhea

Front 234

What is cellulitis? What are risk factors? How does it present and waht are the most common infectious agents?

Back 234

Infection of skin and subcutaenous tissue. Predisopsing - obesity, venous insufficiency, disruption of cutaneous barrier (ex: due to concominent infection, trauma, etc), and previous cellulitis. Presentation: red, edematous skin that is hot to touch. Can also have fever, lymphangitis, and regional LAD. MCC: group A srep and staph aureus

Front 235

What is MCC of arterial thrombus of popliteal artery?

Back 235

Atherosclerotic plaque rupture. MC in older pts and presents with acute pain, pallor, paresthesias, pulselessness.

Front 236

How are DVT and cellulitis different?

Back 236

Similar fndings of swelling of calf, low-grade fever, erythema, warmth but fever typically doesn't excssed 38.5 in DVT and no regional LAD

Front 237

What is necrotizing fasciitis and how does it present?

Back 237

INfection of skin that spreads to fascia. Commonly see skin necrosis, bullae, crepitus, and severe systemic illness

Front 238

What does a ruptured Baker's cyst cause?

Back 238

Pseudothrombophlebitis syndrome - swelling seen in posterior calf, just below the knee. Fluid from the cyst may also lead down inner leg, resulting in a hematoma over the medial malleolus known as "crescent sign".

Front 239

What is Erysipeloid?

Back 239

Occupational disease caued by ERysipelothrix rhusiopathiae. Typically affects fingers and hands

Front 240

What is "blue toe syndrome"

Back 240

Emboli to the pedal circulation cause cyanotic and painful toes with intact pulses - common presentation of catheter-induced atherolmbolism (which results from dislodgement of cholesterol plaques from the aortic root)

Front 241

What is one of hte more common complcations of cardiac catheterization?

Back 241

Atheroembolism (.6-1.4%) - dislodged palques may embolize to the cerebral, GI, renal, and cutaneous circulation and cause local iscehmia and organ dysfunction. "blue toe syndrome" results from emboli to small pedal vessels and is characterized by intact pulses and cyanotic toes; can be accompanied by livedo reticularis (the result of ischemic lessions in the lower legs).

Front 242

Where is distribution of cyanosis from R->L shunts?

Back 242

toes, fingers and lips (not just one)

Front 243

What is the most common cause of acute back pain? What is the typical clinical scenario? How manage?

Back 243

Lumbosacral strain. Typical clinical scenario includes acute onset of the back pain after physical exertion, absence of radiation, presence of paravertebral tenderness, neg straight-leg raising test, and normal neurologic examination. Tx: NSAIDs, early moblization

Front 244

How does herniated disc present?

Back 244

Acute pain that radiates to thighs and typically below the knee. Straight leg test positive

Front 245

How does compression fracture of vertebrae present?

Back 245

Acute intense pain, local spinal tenderness. Predisposing factors are obvious - post-menopausal or senile osteoporosis, steroid treatment

Front 246

What are systemic effects of ankylosing spondylitis?

Back 246

Fatigue, uveitis, pulmonary disase - pulmonary symptoms result form fusion of the costovertebral joints resulting in chest wall motion restriction and restrictive pattern on PFT testing.

Front 247

What are PFT results in restrictive lung disease?

Back 247

Both FEV1 and FVC are decreased (<80% predicted), but normal FEV1/FVC (>80%).

Front 248

What are causes of restrictive lung diseases?

Back 248

Interstitial lung disease, neuromuscualr disease, alveolar edema, pleural fibrosis, and chest wall abnormalities.

Front 249

What can cause pulmonary fibrosis?

Back 249

It is a form of restrictive lung disease - can result from systemic diseases such as RA or scleroderma, cigarette smoking, and meds such as bleomycin. Can also be idiopathic.

Front 250

How does pulmonary HTN present?

Back 250

Exertional dyspnea, angina, signs of RHF

Front 251

What is the most sensitive test for identification of vertebral osteomyelitis?

Back 251

MRI - excellent for soft tissues and will also reveal whethere there is any abscess or cord compression. Blood cultures are also important for diagnosis bc they allow for directed antibiotic therapy. Bone scan has similar sensitivity to MRI in diagnosis of vertebral osteomyelitis, but ahs inferior specificity - also, doesn't allow for epidrual abscess and SC compression screening

Front 252

How does vertebral osetomyelitis usually occur and where? What are labs and s/s?

Back 252

Usually hematogenous. Lumbar area most commonly affected. Back pain accompanied by low-grade feve and elevated ESR is typical presentation. HIgh-grade fever and chills are uncommon. PE: local tenderness on percussion over affected vertebrae and paravertberal muscular spasm. Early dx very important bc epidural abascess and SC compression may develop if treaetment is delayed

Front 253

Do plain x-rays show acute osteomyelitis?

Back 253

usually not, but may show chronic.

Front 254

What is RA?

Back 254

Chronic, systemic inflammatory disease with progressive erosion of bone and cartilage and significant joint destruction and deformity. Pts typically present with joint findings (ex: pain, stiffness, swelling), morning stiffness, involvement of PIP and MCP joints, and radiologic evidence of erosions and/or periarticular osteopenia.

Front 255

What are the treatment goals in RA?

Back 255

Induce and maintain early remission, control synovitis, and prevent progression of joint damage

Front 256

What is the algorithm for RA treatment?

Back 256

Start on DMARD (disease modifying antirheumatic agents) ASAP bc joint damage begins early in course. NSAIDs and COX2 inhibitors (ex: celecoxib) are adjunct therapy for symptomatic relief, but don't reduce disease progression. Can also give steroids to relieve symptoms and give short-term radiographic progression, but not effective in preventing joint destruction and can result in generalized bone loss. The DMARDs includ nonbiologics (methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine) and biologics (etanercept, infliximab, adalimumab, tocilizumab, rituximab). Methotrexate is the preferred initial DMARD in pts with mod-severe active RA due to its efficacy and long-term safety profile. pts who don't respond to MTX after 6mo may require biologic DMARD such as TNFa inhibitors (etanercept, infliximab) as step-up therapy

Front 257

What are SE of methotrexate?

Back 257

Pts should be tested for HEP C and B and TB before starting therapy. Don't use in pts who are pregnant or planning to become pregnant in near future and those with renal insufficiency, liver disease, or excessive alcohol intake.

Front 258

What is azathioprine and what is its role in RA?

Back 258

Immunosuppressive. Can be used to treat RA, but not as efficacious as other DMARDs and is assoc with significant hematologic and GI toxicity

Front 259

What is cyclophosphamide, what is it used for, and what are the seirous SE?

Back 259

Alkylating agent, used as immunosuppressant in SLE, vasculitis, and certain cancers. In SLE, reserved for pts with significant renal or CNS problems. Many SE - serious ones are acute hemorrhagic cystitis, bladder carcinoma, sterility, and myelosuppression. Hemorrhagic cystitis and bladder cacner are caused by acrolein, a bladder-toxic metabolic of cyclophosphamide. Drinking lots of fluids, voiding freqeuntly, and taking mensa are helpful in preventing these complications

Front 260

What drugs can casue cochlear dysfunction?

Back 260

Cisplatin, carboplatin, aminoglycosides

Front 261

What are cisplatin and carboplatin used to treat?

Back 261

Testicular, ovarian, and bladder cancers

Front 262

What drugs cause optic neuritis?

Back 262

Ethambutol and hydroxychloroquine

Front 263

What are the toxic causes of peripheral neuropathy?

Back 263

Phenytoin, Isoniazid, vincristine, heavy metals, chronic alcoholism

Front 264

What drugs can cause digital vasospasm (Raynauds phenomena)

Back 264

BB, ergotamine

Front 265

What durgs can cause thyroid dysfunctoin?

Back 265

Amiodarone, Lithium

Front 266

What arhritis can cyclosporine cause?

Back 266

Gout

Front 267

What is the main mechanism of kidney damage in SLE pts?

Back 267

Immune-complex mediated (IC circulate in blood and are deposited in renal glomeruli causing their damage via several mechanisms - one is complement activation -> low C3 in SLE and post-strep (IC-mediated diseases)

Front 268

What disease has IgE-mediated reaction in kidneys as mechanism for injury?

Back 268

Allergic interstiital nephritis (ex: methicillin-induced interstitial nephritis)

Front 269

What is the mechanism of kidney injury in Goodpasture's syndrome?

Back 269

Cytotoxic Ab

Front 270

How does anserine bursitis present? Tx?

Back 270

Sharply localized pain over the anteromedial part of the tibieal plateau just below the joint line of the knee. Valgus stress test fails to reproduce pain, thereby ruling out damage to the MCL. The anserine bursa is located anteromedially over the tibial plateau just below the joint line of the knee. Inflammation can be the result of abnormal jati, overuse, or trauma. Pain often prsent overnight as pressure from the knees making contact with one another while pt lies on their side exacerbates the pain. x-ray is normal. Tx: rest, ice, maneuvers to reduce pressure on bursa. steroid injections into bursa are also helpful.

Front 271

How does prepatellar bursitis present?

Back 271

Pain and swelling directly over tibia. Exam: cystic swelling over patella with variable signs of inflammation. MCC: trauma

Front 272

How does MCL injury present?

Back 272

Pain along medial joint line, aggravated by walking. Caused by valgus stress applied to lateral aspect of the knee when it is partially flexed. Aggrevated by valgus stress testing

Front 273

How does medial compartent osteoarthritis present? What does x-ray show?

Back 273

Pain of medial joint line typically in >40yo. Also have morning stiffness of <30min, crepitus and bony tenderness on exam. X-ray of knee shows narrowing of joint space and osteophyte formation. Can be accompanied by anserine bursitis due to chronic gait abnormality caused by the arthritic pain

Front 274

How does palletofemoral syndrome present?

Back 274

Common overuse pain syndrome of knee. Presents with peripatellar pain worsened by activity or prolonged sitting (due to sustained flexion) and may also complain of crepitus with motion of the patella

Front 275

What are the 2 main causes of avascular necrosis of bone (osteonecrosis)

Back 275

Chronic steroid use and chornic excessive ingestion of alcohol (>90% combined). Other risk factors: trauma and anti-PL syndrome

Front 276

What is the pathophys of osteonecrosis (aka aseptic necrosis, avascular necrosis, ischemic necrosis, osteochondritis dessicans)?

Back 276

Vasculature in affected bone is disrupted causing bone and BM infarction. Subsequently, the bone is unable to remodel and trabecular thinning occurs ultimately leading to collapse of the affected bone. This progression can take months to years to occur.

Front 277

How do pts with osteonecrosis present? What does immaging show?

Back 277

Progressive pain. If of femoral head (hip), anterior hip pain worsened by activity and relieved by rest with progressive limitation of range of motion. Progression will ultimately cause joint instability and pain at rest. In forst few months, x-ray will foten fail to show it. MRI is most sensitive test.

Front 278

When do you see cartilage degeneration in arthritis?

Back 278

osteoarthritis.

Front 279

How does aortoiliac occlusion (Leriche) present?

Back 279

Low back pain, hip, butt, and thigh claudication accompanied by impotence and atrophy of lower extremities. Femoral pulses are weak and bruit may be heard over iliac and femoral arteries

Front 280

How do pts with SLE present?

Back 280

Black, 20-40yo, women. Systemic manfestations: fatigue, fever, wt loss, non-deforming arthritis, oral ulers, serositis, hematologic abnormalities (anemia, thrombocytopenia, leukopenia), proteinuria, rash. >90% have arthritis - MC affecting MCP and PIP joints of hands (like RA, but it is non-deforming, unlike RA)

Front 281

How does dermatomyositis present?

Back 281

Proximal muscle weakness, rash of shoulders and back, scales on hands.

Front 282

How does sarcoid present?

Back 282

Young, black females. Cough, erythema nodosum. AbnL CXR, hyperCa, high ACE level, non-caseating granulomas on bx

Front 283

Where does neuropathic joint disease most commonly affect?

Back 283

Feet and ankles

Front 284

What are systemic effects of hemochromatosis?

Back 284

Arthropathy of MCP joints, bronzed skin, DM, hepatomegaly, heart failure

Front 285

Where in hand does DJD often affect?

Back 285

DIP joints. X-rays: osteophytes, narrowed joint spaces, subchondral bone cysts. Non-inflammatory, no systemic symptoms

Front 286

How does arthritis of psoriatic arthritis present?

Back 286

DIP joints mostly. Dactylitis (sausage digit) is characteritisc. Can also see nail pitting and psoriatic plaques

Front 287

How does PMR present?

Back 287

Stiffness and pain of shoulders and pelvic girdle. Systemic symptosm fo fever and wt loss are also common.

Front 288

What does x-ray in RA show?

Back 288

Joint space erosions, juxta-articular demineralization, and soft tissue swelling

Front 289

What is the MC cervical radiography finding in cervical spondylosis?

Back 289

Osteophytes, but specificity is low

Front 290

What is cervical spondylosis?

Back 290

affects ~10% of ppl >50yo. History of chronic neck pain is typical. Limited neck rotation and lateral bending due to OA and secondary muscle spasm. Sensory deficit due to osteophyte-induced radiculopathy and isolated sensory abnormalities are assoc with a good prognosis. Typical x-ray findings: bony spurs and sclerotic facet joints. Other findings during cervical spnodylosis may include narrowing of disk spaces and hypertrophic vertebral bodies.

Front 291

When do you see reversed lordotic curve?

Back 291

Severe cervical strain

Front 292

In pt who suspect ankylosing spondylitis by history and PE, what is next step?

Back 292

Confirm with plain film x-ray (demonstrating fused sacroiliac joints and/or bamboo spine). HLA-B27 testing is nonspecific.

Front 293

How does AS typically present?

Back 293

Highest incidence in 2nd-3rd decades of life, M:F 2:1. Should investigate in any young pt with progressive lower back pain and spinal stiffness >3mo duration. Morning stiffness often >30min, typically pain improves with exercise. Dec lumbar spinal mobility and tenderness over sacroiliac joints common. X-ray of sacroliiac joints confirms dx in setting of suggestive history and physical

Front 294

What is best test for sacroiliitis?

Back 294

MRI

Front 295

What is the most common extraarticular manifestation of ankylosing spondylitis?

Back 295

Anterior uveitis - presents with monocular pain, blurring, photophobia

Front 296

When do you see positive Anti-DS DNA Ab?

Back 296

SLE

Front 297

When do you see glutamic decarboxylase Ab?

Back 297

Type I DM (70% positive at time of dx)

Front 298

What Ab are seen in myasthenia gravis?

Back 298

Acetylcholine receptor Ab

Front 299

How does chronic fatigue syndrome differ from fibromyalgia?

Back 299

similar, but in CFS mostly extreme fatigue and not body aches and no trigger points. Need symptoms for >6mo to dx CFS

Front 300

Does PMR have stiffness, pain, or weakness?

Back 300

Mostly stiffness rather than weakness or pain

Front 301

Does polymyositis present with stiffness, weakness, or pain?

Back 301

Mostly weakness

Front 302

What is the cause of neurogenic nephroatphy and how does it present? What does X-ray show? How manage?

Back 302

Aaka Charcot's joint; due to diabetic neuropathy. Starts with dec pain, proprioception, and temperature perception which can occur due to DM, peripheral nerve damage, syringomyelia, spinal cord injury, B12 def, or tabes dorsalis. As normal neurologic input is lots, pts unknowingly traumatize their weight bearing joints -> secondary degenerative joint disease, joint deformation, and functional limitation. X-rays: loss of cartilage, osteophyte development, and loose bodies. Associated pain is typiclaly mild. Management: treat underlying disease nd provide mechanical devices (ex: special shoes) to assist in weight bearing and to dec further trauma.

Front 303

What do x-rays of chronic gout show?

Back 303

Punched out erosions with overhanging rim of cortical bone known as a "rat bite" lesion

Front 304

Where does avascular necrosis commonly affect?

Back 304

Proximal and distal femur. Pain is hte main symptom

Front 305

What is the hallmark of osteoporosis?

Back 305

Bone demineralization -> predisposes to pathologic fracutres, esp in hip and vertebrae, but doesn't itself cause joint destruction

Front 306

What will x-ray of bacterial arthritis show?

Back 306

Joint destruction but no osteophytes or loose bodies

Front 307

What should suspct in lower back pain in pts with history of malignancy?

Back 307

Bone mets - tumors to bone typically cause constant progressive pain that is worsened at rest, worse at night. MC tumors to mets to bone are lung, breast, prostate, thyroid, kidney

Front 308

How does lumbar strain present?

Back 308

usually following twisting of the back while lifting heavy weights. Typically exacerbated by activity and relieved by rest, usually no point tenderness.

Front 309

How does iliac artery thrombosis present?

Back 309

Lower back pain assoc with claudication of hip muscles and possibly impotence

Front 310

What is the classic finding of AS?

Back 310

Lower back pain that is worse in morning and graually improves through day. Results in progressive limitation of back motion and chest expansion. Assoc findings includ arthritis of peripheral joints and anteior uveitis. X-ray of pelvis: changes in sacroiliac joint consistent with sacroilitis. High ESR, neg RF, +HLA-B27

Front 311

What is the mechanism of back pain in AS?

Back 311

Apophyseal joint arthritis

Front 312

What can cause nerve root demyelination?

Back 312

Can be caused by many things - including immune-mediated (Guliian-Barre), toxin or med-induced, metabolic, hereditary, or infectious. Cause neurologic abnormalities specific to the affected nerves

Front 313

What 2 conditions are caused by problems with bone mineralization?

Back 313

Osteoporosis and osteomalacia - can both present with pathologic fractures

Front 314

What is MOA of MTX?

Back 314

Inhibits dihydrofolate reductase

Front 315

What are SE of methotrexate?

Back 315

Macrocytic anemia (common), nausea, stomatitis, rash, hepatotoxicity, interstitial lung dsiease, alopecia, fever. Can eventually develp pancytopenia. Shoudl get routine peripheral blood counts q3mo. Can alleviate some of SE with supplemental folic acid without changing efficacy of MTX

Front 316

What are SE of hydroxycholoquine?

Back 316

GI disress, visual disturbances, hemolysis in G6PD def

Front 317

What are SE of cyclosporine?

Back 317

(used after tx to prevent organ rejection). Predisposes to viral infections and lymphoma and can be nephrotoxic

Front 318

What are SE of azathioprine?

Back 318

Pancreatitis, liver toxicity, dose-dependent BM suppression

Front 319

What causes subacromial bursitis and how does it present? What does PE show?

Back 319

Result of repetitive overhead motions. Pain with active ROM of shoulder, passive internal rotation and fwd flexion at the shoulder (neer impingement sign) and no signs of deltoid atrophy

Front 320

How does tear of proximal end of long head of biceps occur and how present?

Back 320

Assoc with rotator cuff injury and typcailly occurs during forceful flexion of the arm. PE: prominent bulge in midportion of upper arm

Front 321

What does tennis elbow cause?

Back 321

Nagging pain over lateral epicondyle

Front 322

What does palsy of axillary nerve cause?

Back 322

Paralysis and ultimately denervaion of deltoid and teres minor

Front 323

What are 3 neuromuscular paraneoplastic syndromes, what are their involved sites, and what are their clinical features?

Back 323

1. Myasthenia gravis: ACh-R in post-synaptic membrane. Features: fluctuating muscle weakness - ocular (ptosis, diplopia), bulbar (dysphagia, dysarthria), facial, neck, limb muscles. 2. Lambert-Eaton syndrome: Post-synaptic membrane V-gated Ca channels. Features: proximal muscle weakness, autonomic dysfunction (ex: dry mouth), CN involvement (ex: ptosis), DEC/ABSENT DEEP TENDON REFLEXES. 3. Dermatomyositis/ polymyositis: muscle fiber injury. Features: symmetric and more proximal muscle weakness, interstitial lung dsiease, esophageal dysmotility, Raynaud's phenomena, polyarthritis, SKIN FINDINGS in dermato (Grotton's papules, heliotrope rash)

Front 324

What are paraneoplastic syndromes?

Back 324

Not related to cancer's invasion - most commonly seen in cancers of lung, breast, ovaries, lymphomas. Symptoms typically reseble those of endocrine, metabolic, hematologic, or neuromuscular disorders

Front 325

How to dx polymyositis/dermatomyositis?

Back 325

Muscle bx

Front 326

In pts with peripheral nerve involvement, what are s/s?

Back 326

Sensory and/or motor abnormaliteis and abnormal reflexes

Front 327

How does MG present?

Back 327

Due to AutoAb against ACH-R in postsynaptic membrane. Flucating ocular (ptosis, diploplia), facial, and/or bulbar muscle weakness that becomes worse with repeititve tasks

Front 328

How does Lamber-Eaton syndrom present?

Back 328

Ab targeted against presynatpic membrane (vs MG which is postsynaptic). Can present with proximal muscle weakness, but usually have other autonomic dysufnction (dry mouth, erectile dysf) and absent/diminished deep tendon reflexes. Repeat isometric contraction can lead to temporary improvement of muscle weakness and reappearance of absent DTRs.

Front 329

How does paraneopalstic myelopathy of SC present?

Back 329

Flaccid or spastic paraplegia or quadriplegia, sensory deficits, and/or urinary or fecal retention/incontinence

Front 330

What other bone problems are pts with RA at risk for?

Back 330

Osteopenia and osteoporosis - most likely due to combined effects of the disease process itself, steroid therapy, female sex, and dec ability to perform weight bearing exercises that prevent osteoporosis

Front 331

What is osteitis fibrosis cystica? What is the casue?

Back 331

Aka Von Recklinhausen dsiease of bone. Osteoclastic resorption of bone leads to replacement with fibrous tissue (brown tumors). HyperPTH is the cause

Front 332

What is the pathophys of paget's disease?

Back 332

Inc bone turnover due to osteoclastic overactivity leading to replacement of lamellar bone with abnormal woven bone

Front 333

What is osteomalacia?

Back 333

Disorder of bone mineralization that causes dec bone density. Vit D def, Ca def, parathyroidectomy and renal tubular acidosis are potential casues

Front 334

What are risk factors for osteosarcoma in adults?

Back 334

Primary malignancy bone tumor. Risk factors: chemo and radiation exposure, as well as Pagets disease

Front 335

Pts with what arthritises are at risk for septic arthritis?

Back 335

RA, pts with joint damage. Esp at risk for staph aureus

Front 336

Should you give steroids in septic arthritis?

Back 336

No due to immunosuppresive action (same with anti-cytokine agents like TNFa inhibitors)

Front 337

How does allopurinol work?

Back 337

Inhibits xanthine oxidase -> dec uric acid production

Front 338

When can absent ankle reflex be normal?

Back 338

Elderly - as part of normal aging process

Front 339

How does vertebral compression fracture often occur?

Back 339

Acute onset of pain, without obvious trauma. It occurs often as a complication of advanced osteoporosis. Local tenderness on PE.

Front 340

What does absent babinski sign suggest?

Back 340

No UMN-type lesion

Front 341

What is Lumbago?

Back 341

usually related to physical strain and not dramatic onset. Usually have paravertebral rather than spinal tenderness

Front 342

What type of back pain do you see in multiple myeloma?

Back 342

Chronic back pain

Front 343

What is a hand complication of hypothyroidism? What is the pathophys?

Back 343

Carpal tunnel syndrome (approx 30%). Pathophys: Deposition of mucopolysaccharide protein complexes within the perineurium and endoneurium of the median nerve. In hypothyroid causing carpal tunnel, CTS is commonly BILATERAL and have MORE SEVERE symptoms than other etiologies. Improves wih thyroid therapy

Front 344

What are clinical features of carpal tunnel?

Back 344

Nocturnal pain, parestehsia in R medial nerve distribution that are worse with flexion of wrist (positive Phalen test).

Front 345

What are some causes of carpal tunnel?

Back 345

Hypothyroid, pregnancy, amyloid fibril deposition (primary and secondary; most common due to amyloid deposition in setting of ESRD or chronic hemodialysis from deposition of beta2 microglobulin), acromegaly (due to soft-tissue enlargement caused by synovial edema and tendon hyperplasia), RA (due to inflammation of tendons and synovial sheath -> inc compartmental pressure)

Front 346

Why do Baker's cysts develop?

Back 346

As a result of excessive fluid production by an inflamed synovium - as in cases of RA, OA, and cartilage tears. The excessive fluid accumulates in the popliteal bursa which expands, creating a tender mass in the popliteal fossa. They occasionally burst and release their contents into the calf, resulting in an apperance similar to a DVT.

Front 347

How does subcutaneous abscess present?

Back 347

In the setting of folliciulitis or an injury to the skin. Tender, indurated, warm to palpation, erythematous.

Front 348

What is the cause of lymphedema?

Back 348

Results from obstruction of lymphatic drainage, as occurs from LN resection or surgical damage to lymphatic vessels.

Front 349

What is the most serious SE of hydroxychloroquine?

Back 349

Retinopathy - need eye exams q6mo

Front 350

How does lateral epicondylitis present?

Back 350

(tennis elbow). Pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle. Results from repeated forceful wrist extension and supination (backhand in tennis, use of screwdriver). Underlying pathophys is degeneration of the extensor carpi radialis brevis tendon near the lateral epicondyle

Front 351

How does rotator cuff injury present?

Back 351

Shoulder pain, weakness, dec ROM. Typically result of impingement of supraspinatus tendon

Front 352

How does radial tunnel syndrome present?

Back 352

Cuases s/s similar to lateral epicondylitis and may occur with it. Tenderness tends to overly the extensor muscle wad and pain elicited on exma by flexing pt's long finger while acively extending fingers and wrists

Front 353

How does posterior interosseous nerve entrapment present?

Back 353

Weakness of extrinsic extensors of hand and fingers.

Front 354

What should consider in pt with fever and back pain, esp those who are immunosuppressed or IVDA?

Back 354

Epidural abscess

Front 355

What is dx TOC for epidural abscess? How treat?

Back 355

MRI of spine. Tx with abx and surgical decompression. Get blood cx before starting abx

Front 356

What are epidural abscesses and how do they present? Who is at risk and what are complications?

Back 356

Enclosed infections of epidural space. Back pain, fever, chills, leukocytosis. Most commonly due to hematogneous spread, tend to occur in IVDA and immunosuppressed. If abscess grows large enough, can cause SC compromised by direct compression and restricted blood flow to the cord -> lower extremity weakness, urinary incontinence.

Front 357

What is EMG helpful for?

Back 357

Distinguishing between nerve and muscle disease

Front 358

Why is LP not used for epidural abscess dx?

Back 358

Bc of theoretical risk of puncturing the abscess and introducing bacteria into CSF

Front 359

How do you distinugish gouty arthritis from pseudogout and septic arthritis?

Back 359

Need synovial fluid analysis - can't do it based on history and exam alone bc all present with acute joint pain, swelling, dec ROM, low-grade fever. Gouty arthritis: WBC of 2,000-50,000 (>50,000 will be septic) with neg gram stain

Front 360

What are bone scans used for?

Back 360

metastatic workups and in evaluating suspected fractures or infections

Front 361

What is arthritis of reactive arhtirits?

Back 361

Asymmetric oligoarthritis

Front 362

Is gout monoarticular or poly?

Back 362

80% mono

Front 363

What are radiographic findings of hemochromatosis-assoc arthroapthy?

Back 363

Squared off bone ends and hook-like osteophytes in the 2nd and 3rd MCP joints

Front 364

What is the gold standard for dx of avascular necrosis of hip? How does it present?

Back 364

MRI (can have normal x-ray in early stages). Progressive hip or groin pain without restriction of motion.

Front 365

What is the pathophys of ischemic necrosis of hip?

Back 365

Ishcemic necrosis of bone with eventual collapse of periarticualr bone and cartilage. Ishcmei bone necrosis is due to compromised blood flow to femoral head that can be truamatic or non-traumatic. Well known causes of non-traumatic avascular (aseptic) necrosis are chronic steroid therapy, alcoholism, and Hb-opathies.

Front 366

How does septic hip differ from avascular necorsis on presentation?

Back 366

Avascualr necrosis wont' have dec ROM or fever/chills/erythema (it is aseptic) - just hip pain.

Front 367

What is De Quervain tenosynovitis?

Back 367

Condition that affects new mothers who hold their infants with the thumb outstretched (abducted/extended). Abductor pollicis longus and extensor pollicis brevis tendons are affected as they pass through a fibrous sheath at the radial styloid process; passive stretch of these tendons elicits pain (Finkelstein test).

Front 368

What is trigger thumb?

Back 368

Results in pain over palmar aspect of 1st MCP joint and locking of the thumb in flexion

Front 369

How do scaphoid fracutres occur and where is pain?

Back 369

During forceful hyperextension of wrist often as a result of fall on outstretched hand. Pain typically localizes to the anatomical snuffbox.

Front 370

What is the presentaiton of flexor carpi radialis tenosynovitis?

Back 370

Pain with radial flexion of the wrist and point tenderness over the trapezium

Front 371

How does psoriatic arthritis present? How tx?

Back 371

DIP joints. Morning stiffness, deformity, dactylititis (sausage digit), and nail involvement. NSAIDs, anti-TNFa agents, and MTX. Systemic steroids are contraindicated.

Front 372

What are classic skin lesions of psoriasis?

Back 372

Well demarkated red plaques with silvery scaling

Front 373

How common is enteropathic arthritis in IBD? How does it present?

Back 373

10-20%. Affects lower extremities and sacroiliac joints and tends to wax and wane with symptoms of IBD.

Front 374

Where do tophi occur?

Back 374

over joints and helix of the ear. They can ulcerate

Front 375

When do you see polyarthritis affecting the ankles and knees?

Back 375

Sarcoidosis.

Front 376

What joint is most commonly affected in hand in OA?

Back 376

DIP. Worse with activity, better with rest. Noninflammatory

Front 377

How should you treat OA?

Back 377

Acetaminophen for mild-moderate (NSAIDs have SE that make them second line -just used for exacerbations)

Front 378

What valvular problem are pts with AS at risk for?

Back 378

AR secondary to scarring of arotic valve cusps

Front 379

What conditions are thoracic artoci aneurysms assoc with?

Back 379

Marfans, Ehlers-Danlos, Syphillis

Front 380

What conditions are oral ulcers assoc with?

Back 380

SLE, Crohns, Behcets disease

Front 381

What is a feared complication of temporal arteritis?

Back 381

Ischemic optic neruopathy - results from vasculiitis of the retinal artery and may cause blindness

Front 382

What is Episcleritis assoc with?

Back 382

RA and IBD

Front 383

What kidney problems can you get with AS?

Back 383

Secondary amyloidosis and IgA nephropathy but rare and only occasionally lead to renal failure

Front 384

What are the Ca, P, alk phos, and urinary hydroxyproline changes in pagets (osteitis deformans)?

Back 384

Normal Ca, P. Inc alk phos and urinary hydroxyproline levels (as well as other elevated urinary markers of bone degradation such ad exoysyridinoline, N-telopeptide, C-telopeptide

Front 385

What are the changes in Ca, P, alk phos in hyper PTH?

Back 385

High Ca, low P, high alk phos

Front 386

When will you see high Ca with normal phosphate and alk phos?

Back 386

Milk-alkali syndrome

Front 387

What is whipple disease, what causes it, what is presentaiotn and how diagnose?

Back 387

Most commonly presents wtih chronic malabsorptive diarrhea (steatorrhea, flatuence, abd distention), protein-losing enteropathy, wt loss, migratory non-deforming arthritis, LAD, low-grade fever. Can also damage eye, CNS, and myocardium. Caused by infection with gram+ bacillus Tropheryma whippelii. Dx: small intestinal bx and PCR - bx shows PAS-positive macrophages in the lamina propria containing non-acid-fast gram + bascilli

Front 388

What does UC look like on bx? Crohns?

Back 388

UC: Acute and chronic inflammation of the mucosa leading to crypt abscess formation. Crohns: full-thickness inflammation with granuloma and lymphoid aggreate formation and skip lesions

Front 389

How does intestinal lymphoma present?

Back 389

Abd pain, wt loss, N/V, distention, occult blood in stool. Histology: diffuse infiltrate by atypical lymphocytes

Front 390

What happens in HIV with MAI infects small intestinal wall?

Back 390

fever, malabsorptive diarrhea, weight loss. PAS+ macrophages on bx, but unlike whipples, bacilli are acid fast

Front 391

What happens in chronic tophaceous gout? What is ddx?

Back 391

Urate crystals can be deposited in the skin resulting in the formation of tumors with a chalky white appearance. Ddx of tophi: rheumatoid nodules, calcinosis cutis

Front 392

How does inc uric acid lead to nephrolithiasis?

Back 392

Uric acid crystals form in renal tubules and collecting systems

Front 393

How do thiazides inc risk of gout?

Back 393

hyperuricemic effect resulting from hypovolemia-assoc enhancement of uric acid reabsorption in the proximal tubule

Front 394

What do rheumatoid nodules look like?

Back 394

Classicaly, they are firm, flesh-colored and non-tender. Occur over pressure points such as elbow and extensor surfaces of the proximal ulna.

Front 395

What nodes can you get in severe OA?

Back 395

Heberden and Bouchard nodes - hard, bony nodules over the distal and proximal interphalangeal joints, respectively

Front 396

When do vertebral comrpression fracturs occur?

Back 396

Almost always occur when bone demineralization is present. This occurs in osteomalacia, where inadequate serum Vit D, Ca, or P results in demineralized osteoid. It also occurs in osteoporosis, a condition where bone mineral density is decreased and the bone's microarchitecture is disrupted. Pathologic fractures can occur in either condition

Front 397

How do ligamentous sprains of the back present?

Back 397

Often can be traced to a specific event or action. More painful with movement, feel best in the morning. Pain is perispinal, not on bone

Front 398

When do you see lumbar disk degeneration?

Back 398

Hallmark of lumbar OA. Presents as low back pain in elderly. Worsens as day progresses, relieved with rest.

Front 399

When do you see apophyseal joint arthritis?

Back 399

Hallmark of ankylosing spondylitis. Pain and progressive limitation of back motion. Worse in morning, improves throughout the day (like RA)

Front 400

When can you see nerve root demyelination?

Back 400

Many things - including immune-mediated (Gullian-Barre), toxin or med-induced, metabolic, hereditary, or infectious. WIll have neuro abnormaltieis that correspond to the affective nerve roots. no back pain or tenderness to palpation

Front 401

How do you treat reactive arthritis?

Back 401

NSAIDs are first line. Don't need abx.

Front 402

What is the classic triad of reactive arthritis?

Back 402

Nongonococcal urethritis, asymmetric oligoarthritis, and ocnjunctivities. In addition, mucocutaneous lesions and ethesitis (Achilles tendon pain) are common findings in reactive arthritis. Becuase not all symptoms are always present, there should be high suspicion for reactive arthritis in case of any asymmetric oligoarthritis assoc with urethritis, conjunciviits, or mouth ulcers. Synoival fluid is usually sterile

Front 403

What is chondriotin sulfate used for?

Back 403

Many pts with OA take it - it is a component of the ground substance that composes cartilage . But not definitively shown to help

Front 404

What does Parvovirus B19 cause in terms of arthritis and how dx?

Back 404

Arthritis of MCP, PIP, wrist and ankle joints. Anti-B19 IgM is dx TOC when clinically suspected. Adults working with kids are at inc risk. Adults often dont' have slapped cheek appearance. Symptoms resolve within 2mo. Ab develop 10-15d after infection and usually remain positive for 1-6mo

Front 405

What are common casues of viral arthritis?

Back 405

Parvovirus, hepatitis, HIV, rubella

Front 406

What Ab factors are assoc with RA?

Back 406

RF, anti-CCP

Front 407

How long must sypmtoms be present to be able to dx RA?

Back 407

6mo

Front 408

What tests can you do for SLE?

Back 408

ANA highly sensitive, anti-ds DNA highly specific

Front 409

What are ASO titers used for and what will you see on exam?

Back 409

Recent strep infection, + in acute rheumatic fever (migratory polyarthritis (usually lower extremities first), carditis, chorea, erythema marginatum, subcutaneous nodules)

Front 410

What type of arthritis does hyperPTH predipose to?

Back 410

Pseudogout

Front 411

What are s/s of hyperCa?

Back 411

Consptiation, fatigue, excssive urination, abd pain, urinary stones, AMS, osteoporosis

Front 412

What do struvite crystals look like and when do you see them?

Back 412

Shape of coffin lids. Seen in kidney stones caused by chornic UTI with urease-producing organisms

Front 413

How does fungal arthritis usually present and how common is it?

Back 413

Rare. Monoarthritis of the knee.

Front 414

What is Enthesitis?

Back 414

Condition in which inflammation and pain occur at the site of tendon and ligament attachment to bone and is acommon finding in ankylosing spondylitis. Typical sites: heels, tibial tuberosities, iliac crests.

Front 415

What hand deformities do you see in RA?

Back 415

Ulnar deivation of fingers, swan-neck deformities, boutonniere deformities.

Front 416

When do you see subcutaneous nodules in arthritis?

Back 416

RA, gout. Tend to be painless, slow growing, cocur at pressure points such as olecranon process.

Front 417

How can you help prevent lumbar back strain (relation to lifitn a heavy object, no radicular signs, good response to conservative therapy)?

Back 417

Proper pt education - ex: teaching the proper techniques for bending and lifting objects. Also, strenghtneing muslces with regular exercise, good sleeping posture (dont' sleep on back), dont' do exercises with repetitive twisting and bending. Warm up before exercising

Front 418

What is CREST syndrome?

Back 418

Constellation of findings including Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotlitiy, Sclerodactyly, and Telangiectasias. It is a limited form of systemic sclerosis. Calcinosis cutis: localized dysrophic depoisiton of Ca in the skin and manifests as pink-to-white noduels typically on the upper extremities - can ulcerate and drain chalking maternal. Raynaud phenom: acute bouts of digial ischemia in response to cold, may lead to digial necrosis; fingers typically progress thru white, blue, and hyperemic stages. Esophagel dysmoitlity - classically dysphagia and GERD. Sclerodactyly: fibrosis of the skin of the fingers distal t the MCP joitns resulting in a shiny apperance of the skin and flexion contractures and joint pain. Telangiectasias: "mat-like" patches most commonly on face and palms

Front 419

What type of dysphagia does achalasia cause?

Back 419

both solids and liquids. Barium esophagogram: "birds beak" sign in the distal esophagus

Front 420

How does diffuse esophageal spasm present?

Back 420

Acute and severe retrosternal pain as well as dysphagia due to uncoordinated and/or hypertensive esopahgeal contractions

Front 421

What is Felty syndrome?

Back 421

Splenomegaly with neutorpenia (<2,000) in RA. Granulocytopenia doesnt' occur until symptoms of arthritis have been present for >10yrs. Note: splenomegaly is a common finding in pts with RA without granulocytopenia (not felty's)

Front 422

What are systemic symptoms of RA?

Back 422

Rheumatoid nodules, pulmonary fibrosis and infiltrate, scleritis, and rarely splenomegaly with neutropenia (Felty syndrome)

Front 423

What are common SE of methotrexate?

Back 423

Hepatotoxicity, stomatitis, nausea, abd pain, fever, myelosuppresion

Front 424

How does acute hepatitis present?

Back 424

Dramatic increases in ALT and AST, jaundice, viral prodrome of fever, malaise, N/V

Front 425

What are SE of steroid treatment?

Back 425

Thinning of skin, immunosuppression, hyperglycemia, gastritis, psychosis.

Front 426

What are SE of anti-cytokine agents such as infliximab, etanercept, and adalimumab?

Back 426

Rare SE: predisposition to infection, cytopenia, development of lymphomas

Front 427

How can you help to prevent SE of MTX?

Back 427

Give folic acid (doesn't interfere with effectiveness of MTX)

Front 428

What are the 6 criteria used to establish the diagnosis of OA in the setting of a painful knee?

Back 428

Age >50, bony enlargement, bony tenderness, crepitus, lack of warmth/morning stiffness. If 3+ criteria are met, specificity for OA is 69%

Front 429

Where is OA most common in body?

Back 429

Knee, hip, spine, fingers. Often monoarticular

Front 430

How helpful is uric acid level?

Back 430

Nonspecific

Front 431

What does pain at site of tibial tuberosity indicated?

Back 431

Enthesiits - inflmmation at site of tendon insertion into bone, occurs in spondyloarthropathies such as AS

Front 432

What pts get Bakers cyst (palpable popliteal mass)?

Back 432

RA

Front 433

When do you see rotator cuff tendonitis?

Back 433

Caused by impingement. Most common in middle-aged older pts who perform repetitive arm movements above the head. Presents with pain when lifting arm. Confirmed by Neer test (passive motion above the head causes pain and guarding) - confirms dx

Front 434

How can differentiate rotator cuff tendonitis/impingement from rotator cuff tear and frozen shoulder?

Back 434

Isoalted rotator cuff tendonitis symptoms (dec ROM, pain) will be relieved with injection of lidocaine

Front 435

How do you definitivley dx rotator cuff tendonitis/impingement?

Back 435

MRI

Front 436

How can you get rotator cuff tear. S/S

Back 436

Trauma (ralling on outstretched arm) or as a result of chronic impingement and tendonitis. Often complain of pain reaching and lifting arm over head. Weakness more common in tear than in rotator cuff tendoniitis/impingement. Symptoms don't resolve with lidocaine injeciton (but do with impingement)

Front 437

What is adhesive capsulitis (Frozen Shoulder)?

Back 437

Idiopathic condition of pain and contracture. Presents with inability to lift arm above head. Not improved with lidocaine injection

Front 438

How does cervical radiculopathy present?

Back 438

Pain of neck and arms. Paresthesia of arm present in 80% of patients. Can have weakness of shoulder, elbow, or wrist depending on the cervical roots involved. Movement exacerbates the symptoms.

Front 439

How can you get vascular compression of upper extremities and how does it present?

Back 439

May occur in thoracic outlet syndrome. Most commonly presents with a combo of numbness, weakness, swelling due to compression of the subclavian vessels and lower trunk of the brachial plexus. A weakened radial pulse and reproduction of symptoms with specific arm movements supports the diagnosis.

Front 440

How does dissemintate gonococcemia present?

Back 440

High fever, chills, tenosynovitis, migratory polyarthralgias, and a small number of pustular lesions on the extremities. Routine blood and pustule cultures are typically negative due to teh growth requirements of the organism. Skin lesions are discrete purpuric or pustular lesions with a hemorrhagic component and occasionally central necrosis.

Front 441

What is the MCC of infective endocarditis in IVDA?

Back 441

Staph auresu

Front 442

How do pts with TSS present?

Back 442

Fever, erythroderma/desquamatoin, headache, N/V, myalgias. Blood cultures are neg bc it is a toxin-mediated illness

Front 443

What are the cutaneous manifestations of acute HIV syndrome?

Back 443

Like those of other viral examthems - namely, morbilliform macules.

Front 444

What are the cutaneous manifestations of secondary syphilis?

Back 444

Morbilliform, psoriasiform, or pustular. Condylomata lata typically in anogenital region. Fever, arthralgias.

Front 445

What is the MCC of spinal stenosis?

Back 445

Vertebral DJD

Front 446

How do you dx and treat spinal stenosis?

Back 446

Dx: MRI. Tx: conservative or surgical (laminectomy)

Front 447

How does spinal cord compression as a cause of lower back pain present?

Back 447

Back pain, paralysis, hyperreflexia, urinary and fecal incontninence or urinary retention