rheum exam 1

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rheum exam 1
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rheum exam 1
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  1. what is the most common form of arthritis
    osteoarthritis
  2. what is the most abundant body protein
    collagen
  3. what is the important component to nearly every rheum disorder
    inflammation
  4. what are the classic signs of inflammation
    • tumor (swelling)
    • calor (warmth)
    • rubor (erythema)
    • dolor (tenderness)
  5. these are small proteins which mediate and regulate immunity, inflammation, and hematopoiesis
    cytokines
  6. these are proteins that bind to receptors on the cell surface to regulate cellular proliferation and/or differentiation
    growth factors
  7. what antigens are associated with seronegative spondyloarthropathies
    HLA-B27
  8. what antigens are associated with RA
    HLA- DR1; DR4
  9. what antigens are associated with SLE and Sjorgens syndrome
    HLA DR3
  10. what dx procedure should you do for a new, acute, inflammatory monoarthritis
    joint aspiration to exclude infection or crystal arthitis
  11. this is the percentage of pts that have a target dz with positive test results
    sensitivity
  12. this the is percentage of pts without dz with neg test results
    specificity
  13. these are useful as screening tests
    high sensitive tests
  14. these test are useful as diagnostic tests and are most useful when positive
    specificity
  15. the percentage of pts in a given population with a target dz prior to testing is known was what
    prevalence
  16. the number of new diagnoses that have occurred in a specific time interval in a specific population is known as what
    incidence
  17. this is the proportion of pts with positive test results who are correctly diagnosed (have disease and positive test)
    positive predictive value
  18. the probability that the pt doesn't have the disease with a negative test result is known as what
    negative predictive value
  19. for negative predictive value:
    if disease prevalence is low, you have a ___ NPV
    if disease prevalence is ____, you have a ____ NPV
    • high
    • high
  20. for positive predictive value:
    if disease prevalence is ___ you have a low PPV
    if disease prevalence is ___ you have a high PPV
    • low
    • high
  21. an ESR > than ____ generally means cancer, serious infx, renal or autoimmune dz
    100
  22. what complements are useful in monitoring SLE pts
    C3/C4
  23. increased protein in a urinalysis may support the dx of which rheum dz's
    • SLE
    • vasculitis
  24. why would you run a CBC for a rheum d/o
    anemia is common in inflammatory dz's
  25. when is an ANA lab considered positive
    at values > 1:160
  26. what is a highly specific marker for RA (rule it in)
    anti CCP antibodies
  27. which autoantibody is associated with mixed CT dz
    RNP
  28. which autoantibody is associated with diffuse systemic sclerosis
    Scl 70
  29. what autoantibody is associated with CREST syndrome (limited scleroderma)
    centromere
  30. which autoantibody is associated with dermatomyositis and polymyositis
    anti-JO-1
  31. which autoantibody is associated with drug induce lupus
    histone
  32. which autoantibodies are associated with Sjorgens syndrome
    SSA/SSB
  33. this is the most common inflammatory arthritis
    RA
  34. what autoimmune factors are present in RA
    RF's and anti-CCP antibodies
  35. this dz results in joint destruction and pannus formation
    RA
  36. this is an insidious onset with bilateral symmetric hand/wrist arthritis d/o that usually spares DIPs and T/L spine
    RA
  37. what joint deformities are associated with RA
    • ulnar deviation
    • Boutonnierre deformity
    • swan-neck deformity
  38. what do you need to be careful about when intubating pts with RA
    • C1-2 involvement
    • risk spinal cord injury with intubation or other neck manipulations
  39. what is Felty's syndrome triad
    • RA
    • splenomegaly
    • leukopenia (2000 mm3)
  40. what are the criterion for RA and how many must be present in order to be positive
    • morning stiffness (lasting an hr before improvement)
    • arthritis of 3 or more joint areas
    • arthritis of hand joints
    • symmetric joints
    • rheumatoid nodules
    • serum RF
    • radiographic changes

    4 out of 7 must be present
  41. what labs should be drawn for RA
    • RF
    • ESR/CRP
    • CBC
    • Anti-CCP
    • ANA
    • Chem/LFT
  42. what is the tx for RA
    • DMARD (within 3 months after onset): methotrexate
    • prednisone low dose
    • NSAIDS
    • TNF- alpha inhibitors: infliximab (rheumicaid), etanercept (embrel), adalimumab (humira)
  43. what must be done before starting an RA pt on biologics
    PPD because it can reactivate TB
  44. individual prognosis for RA is influenced by what
    • RF status
    • genetics/family hx
    • tx complications
    • mgt of coexisting illness
  45. if you do an xray on a pt with suspected RA what might you see
    • joint space narrowing
    • joint erosions
    • juxta-articular osteoporosis
  46. which labs are present in 70-80% of pts with RA
    • RF
    • anti-CCP
  47. what are the extra-articular manifestation of RA
    • pleural effusions
    • subcutaneous nodules
    • pericarditis
    • lymphadenopathy
    • vasculitis
  48. what is the most common form of childhood arthritis
    JRA
  49. what is the age time frame to dx JRA
    <16 yoa
  50. what are the 3 distinct clinical presentation patterns of JRA
    • systemic: 10% of cases, variable joint grp involvement
    • polyarticular: 40% of cases, > or = 5 joint grps involved
    • pauciarticular: 50% of cases, < or = 4 joint grps involved
  51. what are the diagnostic criteria for JRA
    • <16 yoa
    • persistent arthritis of at least 6 weeks duration in one or more joints
    • exclusion of other childhood arthritis
  52. what are the 11 criterion for SLE
    • malar rash
    • discoid rash
    • photosensitivity
    • oral ulcers
    • arthritis
    • serositis
    • renal dz
    • neurologic dz
    • hematologic d/o
    • immunologic abnormalities
    • positive ANA
  53. this is a fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
    malar rash
  54. these are erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring occurs in older lesions
    discoid rash
  55. this is a result of unusual reaction to sunlight; by pt hx or physician observation
    photosensitivity
  56. this is a form of lupus where there are deep brawny induration or subcutaneous nodules that occur under normal or, less often, involved skin; the overlying skin may be erythematous, atrophic, and ulcerated and on healing may leave a depressed scar
    lupus profundus
  57. this type of lupus has raised patches with adherent keratotic scaling and follicular plugging
    discoid lupus
  58. this type of lupus has erythematous scaling plaques that can be mistaken for psoriasis or discoid lupus
    subacute cutaneous lupus
  59. what are the type of serositis's in lupus
    • pleuritis
    • pericarditis
  60. what defines renal disease for lupus
    • > 0.5 g/d proteinuria
    • > or = 3+ dipstick proteinuria
    • cellular casts: RBC, hemoglobin, granular-tubular, or mixed
  61. what are the subcategories of hematologic d/o for lupus
    • hemolytic anemia with reticulocytosis
    • leukopenia <4000
    • lymphopenia <1500
    • thrombocytopenia <100000
  62. what are the immunologic abnormalities associated with lupus
    • antibody to native DNA
    • antibody to Sm
    • false positive RPR test for syphilis confirmed by - FTA
  63. what is the earliest sign of lupus
    synovitis
  64. what is the most common presenting feature of SLE
    arthritis- transient, symmetrical, affecting small joints, seldom deforming, non-erosive
  65. what is the hallmark clinical finding of lupus nephritis
    proteinuria
  66. what labs are done for SLE
    • ANA
    • anti-smith
    • antiphospholipid antibody
  67. what is the tx for SLE
    • NSAIDS
    • hydroxychloroquine (plaquenil)
    • corticosteroids (high dose 40-60mg)
  68. when is antiphospholipid antibody syndrome diagnosed
    when a pt has either a vascular thrombosis or pregnancy morbidity
  69. what is the treatment for antiphospholipid antibody syndrome
    lifelong Coumadin or heparin
  70. what is the difference between limited vs diffuse scleroderma
    • it is determined by the extent of skin involvement
    • limited: symmetrical skin thickening of fingers, distal arms and legs, and face/neck
    • diffuse: same as above plus trunk and proximal aspects of limbs
  71. which scleroderma is associated with SCL-70 positive
    diffuse
  72. which scleroderma is associated with anticentromere positivity
    limited
  73. what does the acronym CREST stand for
    • C= calcinosis cutis
    • R= raynauds phenomenon
    • E= esophageal dysmotility
    • S= sclerodactyly
    • T= telangectasias
  74. episodic exaggerated vasopspasm of the digital arteries, usually associated with exposure to cold temps
    raynauds phenomenon
  75. what is the most frequent cause of scleroderma-related death
    pulmonary (pulmonary HTN)- more common in limited CREST
  76. what autoantibody is associated with mixed CT d/o
    anti-U1-RNP
  77. this d/o presents with easy fatigability. poorly defined myalgias, arthralgias, and Raynauds phenomenon
    mixed connective tissue d/o
  78. what 4 clinical features should lead you to think MCTD
    • Raynaud phenomenon and swollen hands or puffy fingers
    • the absence of severe renal and CNS dz
    • more severe arthritis and the insidious onset of pulmonary HTN  differentiate MCTD from SLE and scleroderma
    • autoantibodies whose fine specificity is anti-U1-RNP, esp antibodies to the 70kD protein
  79. these are inflammatory disorders characterized by male predominance before age 40, inflammatory arthritis of spine and/or large peripheral joints, uveitis, absence of autoantibodies in the serum, and has a striking association of HLA B-27
    seronegative spondyloarthropathies
  80. what are the different types of seronegative spondyloarthropathies
    • Psoriatic arthritis
    • Enteropathic arthritis
    • Ankylosing spondylitis
    • Reactive arthritis (Reiters syndrome)
  81. a 23 y/o male presents to the clinic complaining of LBP that does not improve with rest and has pain at night. He states it does improve with exercise but it radiates to his butt. Upon exam you note that he has an abnormal schober and FABER test. what is your provisional dx
    ankylosing spondylitis
  82. for dx ank spine, how long must the back pain be present prior to dx
    > 3 months and age of onset should be <45 yoa
  83. what is the first line treatment for ank spine
    NSAIDS

    • * PT, and exercise (weight loss)
    • * DMARDS (sulfasalazine)
    • * TNF inhibitors (Infliximab, etanercept)
  84. which heart defect is associated with Ank spine
    aortic insufficiency
  85. what is the triad of reactive arthritis
    • postinfectious arthritis
    • urethritis
    • conjunctivitis
  86. what is the most common cause of inflammatory arthritis in young men
    reactive arthritis (Reiter syndrome)
  87. what is the most prominent feature of reactive arthritis
    frequent recurrences with arthritis
  88. what are the 5 patterns of psoriatic arthritis
    • asymmetric oligoarthritis affecting large joints (MC)
    • symmetric polyarthritis
    • fingers (DIP) with nail pitting
    • arthritis mutilans
    • psoriatic spondylitis
  89. what will you see on the radiographs for psoriatic arthritis
    • pencil-in-cup to DIP
    • periostitis in MCP, MTP, phalanges
  90. this type of arthritis is associated with IBD
    enteropathic arthritis
  91. what is the most common cause of inflammatory arthritis in men over 40 yoa
    gout
  92. which type form of gout is more common ( overproducer or underexcretor)
    underexcretor
  93. what joint is most susceptible to gout
    MTP big toe (podagra)
  94. what will a polarized microscopy show for gout
    negatively birefringent and needle-like sodium urate crystals
  95. what will labs show for gout
    • elevated serum uric acid (>7.5 mg/dL)
    • elevated WBC, ESR-acute attack
  96. what will radiographs show with gout
    rat bite lesions in latter disease
  97. what is the treatment for gout
    • NSAIDS
    • colchicine
    • corticosteroids
    • opiates
  98. this medication is FDA approved for acute gout
    colchicine
  99. which medications should be considered with increased frequency or severity of gout attacks of underexcreters
    • probenecid
    • sulfinpyrazone
  100. what are the indications for uricosuric drugs
    24 hr urine uric acid test >1100mg

    *goal maintain serum uric acid level at or below 6mg/dl
  101. calcium salt deposits in cartilage (chondrocalcinosis) that precipitate in a joint and cause painful arthritis is known as what
    pseudogout
  102. what should always be suspected in elderly (>60 yoa) hospitalized pts with new acute monoarthritis
    CPPD (pseudogout)
  103. what will the polarized microscopy show for pseudogout
    calcium pyrophosphate crystals
  104. what will xrays for pseudogout show
    • calcifications- chondrocalcinosis esp in knees
    • signs of degenerative changes
  105. what is the treatment for pseudogout
    • joint aspiration (therapeutic and diagnostic)
    • NSAIDS/COX2 (acute episodes)
    • Corticosteroids
    • colchicine
  106. this is a chronic inflammatory disorder mainly characterized by lymphocytic infiltration of exocrine glands
    sjogrens
  107. sjogrens most frequently affects which glands
    • lacrimal
    • salivary glands
  108. what is the most common clinical finding for sjorgens
    keratcomjunctivitis sicca (K. sicca or xerophthalmia)
  109. what is the secondary most common clinical finding for sjorgens
    xerostomia
  110. what is one of the most common complaints of sjorgens
    fatigue
  111. what are the objective criterion for dx sjorgens
    • ocular sxs
    • oral sxs
    • ocular signs of corneal damage
    • abn salivary gland biopsy
    • test indicating impaired salivary gland function
    • presence of typical autoantibodies (SSA & SSB)
  112. how can you treat dry eyes associated with sjorgen
    • artificial tears
    • punctual occlusion
    • topical cyclosporine
  113. how can you treat dry mouth associated with sjorgen
    • pilocarpine
    • cevimeline
    • meticulous oral hygiene
    • sugar-free gum or candy
  114. inflammatory changes to skeletal muscle broadly characterized by bilateral proximal muscle weakness is what type of d/o
    dermatomyositis and polymyositis
  115. dermatomyocitis and polymyositis has a significant increase for what
    malignancy (dermato >>> the poly)

    * ovarian CA is most commonly associated
  116. what is the most common presenting feature of dermatomyositis and polymyositis
    muscle weakness (proximal muscle grps)
  117. how can you test muscle weakness for dermatomyositis and polymyositis
    chair test/ get up and go

    have pt sit in the chair and have them raise up without the use of the arms
  118. what are the dermatologic findings for dermatomyositis
    • heliotrope rash: deep erythematous or violaceous rash on face, neck, chest, extensor surfaces (classically on eyelids)
    • shawl sign: diffuse, flat erythematous lesion occurring over the chest and shoulders or in a V-shaped distribution over the anterior neck and chest
    • Gottron's sign: erythematous, often scaly eruption that occurs in a symmetric fashion over the MCP and IP joints, can be on elbows/knees like psoriasis
    • Mechanics hands: cracked/rough skin of the tips and lateral aspects of the fingers, resulting in irregular, dirty-appearing lines the resemble those of a manual laborer
  119. what are the major diagnostic criteria for dermato/polymyositis
    • diagnostic muscle biopsy
    • elevated serum muscle enzymes (CK, AST, LDH)
  120. which autoantibodies are associated with dermato/polymyositis
    anti-Jo-1 (most likely in pts with pulmonary involvement)
  121. which labs should be drawn for dermato/polymyositis
    • CBC
    • ESR
    • CMP
    • UA
  122. how are dermato/polymyositis treated
    • corticosteroids (prednisone 40-60mg)
    • steroid sparing agents (methotrexate or azathioprine)
    • intravenous immunoglobulin
  123. a complex chronic syndrome manifested primarily by diffuse pain and fatigue is known as what
    fibromyalgia
  124. fibromyalgia frequently co-exists with what d/os
    • depression
    • IBS
    • chronic fatigue syndrome
  125. a 37 y/o female presents to your clinic c/o aching pain at multiple body locations, stiffness and hurts all over. She also complains of fatigue and sleep issues. She has a hx of IBS and has been seen for HAs. what do you think is her dx
    fibromyalgias
  126. what drugs are FDA approved for fibromyalgia
    • pregabalin (lyrica)
    • duloxetine (Cymbalta)
    • milnacipran (savella)
  127. primary vasculitis is most commonly characterized how
    by size of blood vessel involvement (large, med, small)
  128. what are your large vessel diseases
    • giant cell arteritis (polymyalgia rheumatic)
    • takayasu's arteritis
  129. what are your medium vessel diseases
    • polyarteritis nodosa
    • thromboangiitis obliterans (Buergers dz)
    • kawasakis dz
  130. what are your small vessel diseases
    • immune-complex mediated vasculitides
    • - cutaneous vasculitis (hypersensitivity vasculitis)
    • - henoch-schonlein purpura
    • - cryoglobulinemia
    • ANCA associated vasculitides
    • - granulomatosis with polyangiitis (wegeners)
    • - churg-strauss syndrome
    • - microscopic polyangiitis
  131. what are some characteristic findings associated with vasculiitis
    • palpable purpura
    • livedo reticularis
    • punched out ulcers
    • prolonged (>24 hrs) urticaria
  132. this is the most common type of vasculitis in adults (considered only if age > 50 yoa
    giant cell arteritis
  133. what are classical presentations of giant cell arteritis
    • HA
    • scalp tenderness
    • fevers
    • visual abnormalities
    • jaw claudication
  134. what is the ESR for giant cell arteritis
    very high (80-100)
  135. how is giant cell arteritis dx
    temporal artery biopsy
  136. what is the treatment for giant cell arteritis
    high dose corticosteroids (60mg for 3-4 weeks)
  137. what are the formal osteoporosis prevention measures required for prolonged corticosteroid therapy in giant cell arteritis
    • stop smoking
    • weight-bearing exercise
    • Ca++/vit D supplements
    • bisphosphonate therapy
  138. clinical dx for this d/o is based on severe stiffness and pain in the proximal portions of the upper (shoulders) and lower extremities (hips) with a high ESR
    polymyalgia rheumatica
  139. a 50 y/o pt presents to the clinic c/o bilateral aching and stiffness in the morning that lasts >30min and has been bothering them for at least one month. He states the stiffness is in his neck, shoulders and hips. You did his ESR and it comes back at >40 mm/hr. what is your provisional dx
    polymyalgia rheumatica
  140. how is polymyalgia rheumatic tx
    prompt response when started on low dose prednisone (0-20mg.. usually start on 10mg)
  141. what are the important late complications of giant cell arteritis
    • thoracic aortic aneurysms
    • aortic dissection
  142. this vasculitis affects the upper body great vessels (esp aorta and its major branches), usually presents between ages 10-30, Asian females
    takayasu's arteritis
  143. you have a 15 y/o Asian female that presents to your clinic c/o fatigue, weight loss and a low grade fever. She looks ill, has abnormal pulse exam and unequal BP. You notice on PE she has subclavian bruits and aortic insufficiency, and her labs came back with a high ESR. what is your provisional dx
    takayasi's arteritis
  144. what is the treatment for takayasi's arteritis
    • corticosteroids
    • surgical/revascularization therapy
  145. this is the classic vasculitis and is a necrotizing vasculitis of medium vessels, it is associated with mononeuritis multiplex (footdrop), and has derm findings of palpable purpura, livedo reticularis, skin ulcers/digital gangrene
    polyarteritis nodosa
  146. this vasculitis is obliterative, nonatheromatous, inflammatory vaso-occlusive that primarily affect the lower extremities
    thromboangiitis obliterans (Buergers dz)
  147. this vasculiitis is associated with young (<40 yoa) tobacco users
    thromboangiitis obliterans (buergers dz)
  148. how is thromboangiitis dx
    • biopsy
    • angiogram
  149. what is the treatment for thromboangiitis obliterans
    • smoking cessation
    • surgical intervention as required
  150. prolonged acute febrile illness associated with systemic vasculitis is known as which dz
    Kawasaki's dz
  151. this is a vasculitis that affects primarily the pediatric population usually <5 yoa, they have a fever >5 days with a polymorphous, nonvesicular rash, nonpurulent bilateral conjunctivitis, oral mucosal involvement (strawberry tongue, lip fissures), soft tissue abn of hands/feet, and/or cervical adenopathy >1.5cm
    kawasakis dz
  152. how is kawasakis dz treated
    • high dose ASA
    • intravenous immunoglobulin
  153. what is the classical clinical finding for any type of small vessel vasculitis
    palpable purpura
  154. which vasculitis is known as hypersensitivity vasculitis and is associated with medication exposure
    cutaneous leukocytoclastic vasculitis
  155. this vasculitis is strongly associated with IgA deposition in vessel walls, it is the most common vasculitis in children with most cases occurring before 6 yoa
    henoch-schonlein purpura
  156. this d/o has immunoglobulins (antibodies) that precipitate out of blood at low temperatures
    cryoglobulinemia
  157. this vasculitis is very strongly assoc with hep C
    cryoglobulinemia
  158. what is the triad for cryoglobulinemia
    • purpura
    • arthralgias
    • myalgias
  159. what are your ANCA associated vasculitides
    • granulomatosis with polyangiitis (Wegener)
    • churg-strauss syndrome
    • microscopic polyangiitis
  160. this is a necrotizing vasculitis associated with upper respiratory, lower respiratory, and renal manifestations
    granulomatosis with polyangiitis (wegeners)
  161. a saddle nose deformity is assoc with what vasculiitis
    granulomatosis (wegeners)
  162. what is the tx for wegeners (granulomatosis)
    corticosteroids and cyclophosphamide
  163. this necrotizing vasculitis is associated with allergic rhinitis, asthma and eosinophilia (atopy)
    churg-strauss syndrome
  164. what are the 3 clinical phases of churg-strauss syndrome
    • prodromal phase: characterized by atopic dz, allergic rhinitis, and asthma
    • vasculitic phase: life-threatening systemic vasculitis of the medium and small vessels
    • eosinophilic phase: peripheral blood eosinophilia and eosinophilic infiltration of multiple organs, especially the lung and GI tract
  165. how is churg-strauss dx and what is the tx
    • biopsy
    • P-ANCA

    tx: corticosteroids and cyclophosphamide

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