Rheum step2

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Author:
gm1147
ID:
166154
Filename:
Rheum step2
Updated:
2012-08-15 14:01:23
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rheum rheumatology step2
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kaplan
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  1. Hand joints in OA
    • DIP - Heberden nodes- most common
    • PIP - Bouchard nodes
  2. OA tests
    • Normal labs
    • Accurate: Xray
    • Joint space narrowing
    • Osteophytes
    • Dense subchondral bone
    • Bone cysts
  3. Secondary causes of gout
    • Cancer
    • Hemolysis
    • psoriasis
    • Chemo
    • Lesch-Nyhan syndrome
    • Glycogen storage diseases
    • Renal insufficiency
    • Keto or lacticacidosis
    • Thiazides
    • ASA
  4. Gout joint cells
    2k-50k neutrophils
  5. Gout tx
    • Acute: NSAIDS>Colchicine (diarrhea, neutropenia). Steroids if no response or renal insufficiency so cant take nsaids
    • Chronic:Stop thiazides, ASA, and niacin
    • Colchicine
    • Probenecid and sulfinpyrazone - inc extretion. Contraindicated in renal patients, can have hypersensitivity
    • Allopurinol - dec production. can have hypersensitivity, SJS, or TEN
  6. Pseudogout risks
    • Hemochromatosis
    • HyperPTH
    • DM
    • Hypothyroid
    • Wilson
  7. Pseudogout tx
    • Initial: NSAIDs
    • Intraarticular steroids (triamcinolone)
    • Colchicine as ppx for new attacks
  8. L4
    • Dorsiflexion of ankle
    • Knee jerk
    • Inner calf sensation
  9. L5
    • Dorsiflexion of toe
    • No reflex
    • inner forefoot sensation
  10. S1
    • Eversion of foot
    • Ankle jerk
    • Outer foot
  11. Tx of cord compression, epidural abscess, cauda equina, sciatica/herniation
    • Steroids, then MRI, chemo for lymphoma, radiation for solid
    • Steroids, vanc or linesolid, drain
    • Surgery
    • NSAIDsm normal acitivities, steroid injections
  12. Lumbar spinal stenosis presentation, dx, tx
    • old, pain, esp with extension
    • MRI
    • Weight loss, steroid injections, surgical
  13. Fibromyalgia tx
    • amitriptyline
    • milnacipran (SNRI)
    • pregabalin
    • trigger point injections
  14. Carpal tunnel signs
    • Tinel - tapping
    • Phalen - flexion
  15. Carpal tunnel dx, tx
    • PE
    • Accurate: EMG, nerve conduction
    • -Splints, NSAIDs, steroids, surgery
  16. Dupuytren contracture: what, who, tx
    • hyperplasia of palmar fascia
    • contracture of 4th and 5th fingers
    • genetic, etoh, cirrhosis
    • Triamcinolone injuection, surgery
  17. Rotator cuff injury: presentation, test, tx
    • Cant flex or abduct the shoulder, tenderness at insertion of the supraspinatus
    • MRI is accurate
    • NSAIDs, rest, PT, steroids, surgery for complete tears and nonresponsive
  18. Patellofemoral syndrome presentation, tests
    • anterior knee pain, due to trauma, imbalance of quad strength, meniscal tear
    • Worse on stairs, after sitting
    • Crepitus, joint locking, instability
    • Normal xray
  19. RA joints, eyes
    • POP, MCP, wrist, knee, ankle, C1-2
    • episcleritis
  20. RA tests
    • RF
    • anti-CCP
    • Eriosion of joints, osteopenia
    • ESR, CRP
    • Normocytic anemia
  21. RA dx
    • 6+:
    • Joints (up to 5pts)
    • ESR or CRP
    • Longer than 6 weeks
    • RF or anti-CCP
  22. Felty syndrome
    • RA
    • Splenomegaly
    • Neutropenia
  23. Caplan syndrome
    • RA
    • Pneumoconiosis
    • Lung nodules
  24. RA tx
    • NSAIDs, steroids for sx
    • DMARD - methotrexate, TNF inhibitors (infliximab, etanercept, adalimumab), rituximab, hydroxychloroquine (lone for mild or with MTX, retina toxicity), sulfasalazine (bone marrow, hemolysis with G6P, rash), leflunomide, abatacep
  25. Methotrexate sides
    • Liver
    • bone marrow
    • pulmonary
  26. TNFi
    • infliximab
    • etanercept
    • adalimumab
    • sides: infection, TB
  27. hydroxychloroquine
    • lone for mild RA or with MTX
    • retina toxicity
  28. sulfasalazine
    • bone marrow
    • hemolysis with G6P
    • rash
    • oligospermia
  29. Gold salts
    • DMARD
    • sides of nephrotic syndrome
  30. JRA presentation, labs, tx
    • Spiking fever
    • Rash: with fever, salmon, chest and abdomen
    • Splenomegaly
    • Pericardial effusion
    • Mild joint symptoms
    • Anemia, leukocytosis, normal ANA
    • ASA, NSAIDs, steroids
  31. SLE dx
    • 4+:
    • malar rash, discoid rash, photosensitivity, oral ulcers (alopecia is common but not dx)
    • Arthritis (normal xray)
    • serositis (CP)
    • Membranous glomerulonephritis or other renal disorder
    • Psychosis, sz, stroke
    • Hemolytic anemia, anemia of chronic disease, lymphopenia, leukopenia, thrombocytopenia
    • ANA, Anti-dsDNA, Anti-Sm, false syphilis, LE cell prep
    • Nondx:
    • PNA, alveolar hemorrhage, restrictive lung disease
    • Photophobia, cotton wool sponts on retina, blindness
    • Mesenteric vasculitis, raynaud, APL syndrome
  32. SLE ab
    • ANA - sens
    • Anti-dsDNA - spec, esp in flare
    • Anti-Sm - spec
    • Dec complement, esp in flare
    • Anti-SSA and anti-SSB - more in sjogren
  33. SLE tx
    • Steroids
    • Hydroxychloroquine for mild
    • Renal - cyclophosphamide or mycophenolate
  34. SLE cause of death
    • young- infection
    • old- MI
  35. APL syndrome presentation, tests
    • clots
    • 2+ first trim abortions or 1 2nd trim abortion
    • inc PTT
    • normal PT and INR
    • False positive VDRL or RPR
    • Initial test: mixing study
    • Specific: Russell viper venom test (RVVT)- prolonged and no correction with mixing
  36. CREST syndrome
    • aka limited scleroderma
    • Calcinosis
    • Raynaud
    • Esophageal dysmotility
    • Sclerodactyly
    • Telangectasia
  37. Scleroderma presentation
    • CREST
    • Raynaud
    • skin fibrosis
    • GERD, dysmotility, diverticuli
    • HTN crisis
    • Restrictive lung disease or pulm HTN
    • Myocardial fibrosis, pericarditis, heart block
  38. Scleroderma dx
    • ANA
    • SCL-70/anti-topoisomerase - moste specific
    • Anticentromere - for crest
  39. Scleroderma tx
    • if renal, ACEi
    • PPIs
    • CCB for raynaud
    • Cyclophosphamide for pulm fibrosis
  40. Gottron papules
    scales on back of PIP and MCP joints in dermatomyositis
  41. Dermatomyositis and cancer
    • 25%
    • ovary
    • lung
    • GI
    • lymphoma
  42. Myositis tests
    • Initial: CPK aldolase
    • Accurate: bx
    • Anti-Jo in lung fibrosis
    • ESR, CRP, RF, ANA
  43. Myositis tx
    • Steroids
    • MTX
    • Azathioprine
    • IVIG
    • Mycophenolate
    • Hydroxychloroquine for skin lesions
  44. Sjogren syndrome associations
    • RA
    • SLE
    • Primary biliary cirrhosis
    • Polymyositis
    • Hashimoto thyroiditis
  45. Sjogren manifestaions
    • Dry eye
    • Dry mouth, caries
    • Vascuitis
    • Lung disease
    • Pancreatitis
    • RTA
    • Dyspareunia
    • Lymphoma - most dangerous complication
  46. Sjogren dx
    • Initial: schirmer test - filter paper against eye to measure tears. SSA, SSB
    • accurate: lip or parotid gland bx - lymphoid infiltrate
  47. Sjogren tx
    • Water
    • Pilocarpine and cevimeline
  48. PAN size, associations, presentation, tx
    • Small and medium
    • Chronic Hep B, pANCA
    • Renal, foot drop, stroke, GI, skin. Spares lung
    • Prednisone and cyclophosphamide
  49. PMR labs
    • high ESR
    • normal CRP and aldolase (inc in temporal arteritis)
  50. Wegners presentation, dx
    • Upper and lower resp (unresolving pna), renal insufficiency
    • Also skin, joint, eye
    • cANCA, lung bx>renal bx> skin bx
  51. Churg Strauss presentation, dx
    • Asthma, eosinophilia, renal
    • pANCA, bx
  52. Henoch-Schonlein Purpura: presentation, dx, tx
    • GI pain, bleeding
    • Purpura
    • Arthralgia
    • Hematuria
    • clinical dx, bx for accurate (leukocytoclastic vasculitis)
    • Give steroids if severe but wont reverse renal
  53. Cryoglobulinemia: assoc, presentation, mech, labs, tx
    • HepC, endocarditis, CT disorders
    • Joint pain, glomerulonephritis, purpura, neuropathy
    • IgM immune complexes
    • RF, dec C4
    • Interferon and ribavirin
  54. Cold agglutinins assoc, presentation, tx
    • EBV, mycoplasma, lymphoma
    • Hemolysis
    • Stay warm, rituximab, cyclophosphamide, cyclosporine
  55. Behcet syndrome presentation, tx
    • Asian or middle eastern
    • oral and genital ulcers
    • uveitis, blindness
    • arthritis
    • MS mimick lesions
    • steroids
  56. Pathergy
    • sterile skin pustules from minor trauma like a needle stick
    • assoc with Behcet syndrome
  57. Enthesopathy
    • inflammation of tendon attachment points
    • in seronegative spondyloarthropathies
  58. Ankylosing spondylitis presentation, tests, tx
    • back
    • tendons
    • arthritis
    • AV block
    • Aortic insufficiency
    • Uveitis
    • Initial: SI Xray
    • Accurate: MRI
    • ESR inc
    • Tx: exercise, NSAIDs, antiTNF durgs
  59. Seronegative spongyloarthropathies
    • AnkSpon, psoriatic arthritis, reactive arthritis
    • Young, spine, no RF, tendons, uveitis, HLA-B27
    • No steroids
  60. Psoriatic arthritis dx and tx
    • Intial: xray with pencil in a cup deformity
    • Inc uric acid, inc ESR
    • Tx: NSAIDs, MTX, antiTNF
  61. Reactive arthritis assoc, triad, dx, tx
    • IBD, STI (esp men), GI infection (yersinia, salmonella, campylobacter)
    • Joint pain, uveitis/conjunctivitis, urethritis/balanitis
    • Tap
    • Tx with NSAIDs, salfasalazine
  62. Keratoderma blennorhagicum
    skin lesion looks like pustular psoriasis but is unique to reactive arthritis
  63. DEXA cutoff
    • penia: 1-2.5 T score
    • porosis: 2.5
  64. Raloxifene
    • Substitute for estrogen in osteoporosis
    • reduces breast cancer and LDL
  65. Teriparatide
    • TH analog
    • used in osteoporosis
    • osteosarcomas in rats and hyperCa
  66. Nasal calcitonin
    dec risk of vertebral fractures
  67. Septic arthritis risk
    prosthetic>RA>OA
  68. Septic arthritis bug, empiric tx
    • Staph>Strep>Gram neg rods
    • Ceftriaxone and vanc
    • If prosthetic, remove joint, tx for 6-8wks, replace joint
  69. Gonococcal arthritis: presentation, dx, tx
    • polyarticular
    • tenosynovitis esp in fingers
    • petechial rash
    • more freq during menses
    • If recurrent, test for terminal complement deficiency
    • Cx multiple sites, 30k-50k cells
    • Tx with ceftriaxone

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