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Rheum Clin Med sa

Clinical Medcine

Deposition of uric acid occurs when uric acid is over ____mg/dL 6.8
Pseudogout is due to the deposition of ________ __________. Calcium Pyrophosphate
Causes of hyperuricemia? (3) Underexcretion (90%), overproduction (10%), overconsumption
Gout may be due to an inherited _______ disorder causing overproduction. Enzyme (G6PD, PRPP, HGRPT, etc)
Risk factors for gout Diet high in purines, metabolic syndrome, obesity
Pseudogout is more common in men or women? women
Can be associated with hyperparathyroidism, hemochromatosis, hypomagnesemia, & hypophosphatemia Pseudogout
45 year old male with hx of metabolic syndrome presents complaining of acute onset severe pain & swelling in 1st MTP joint. Dx? Acute Tx? Gout. NSAIDs, Colchicine, steroid injection
Commonly involved joints in gout are?(4) Big toe, mid foot, ankle, knee
Elderly female with swollen & painful knee. XR shows changes consistent with osteoarthritis. Joint aspiration shows cloudy fluid with elevated WBCs and rod-like crystals that are + birifringent. Dx? Tx? Pseudogout; NSAIDs, Colchicine, steroids
24 hour uric acid >800mg in a young patient suggests? Enzymatic Defect
24 hour uric acid >800mg in an elderly patient suggests? Rapid cellular turnover
Gold standard for dx of gout? Monosodium urate crystals (on joint aspirate)
Monosodium urate crystals are _______ birifringent. Negatively
Joint aspirate of painful inflamed joint shows: 7,000 WBC, mostly neutrophils & negative birifringent crystals. Dx? Gout
Joint aspirate of painful inflamed joint shows: Cloudy fluid with 25,000 WBCs (>80% polys) and crystals that are weakly + birifrigent. Dx? Pseudogout
Tophi, soft tissue swelling, and bony changes on XR are suggestive of? Gout
Chondrocalcinosis, uniform joint space loss, subchondral new bone formation, prominent cysts all bilaterally on XRs suggest? Pseudogout
CAN'T LEAP medications that should be avoided in gout patients are: Cyclosporine, Alcohol, Nicotinic Acid, Thiazides, Loop diuretics, Ethambutol, ASA, Pyrazinamide
Medications used to prevent gout attacks after acute phase has passed? Allopurinol, Colchicine (also Probenecid, Losartan, Fenofibrate, Febuxostat, Peglitocase)
Treatment for chronic pseudogout? NSAIDs & Colchicine. Chronic intra-articular joint injections (refractory pts)
MC presenting symptom of JIA? Joint swelling
List the 6 subclasses of JIA discussed: Oligoarthritis, Enthesitis Related Arthritis, Polyarthritis-RF+, Polyarthritis-RF-, Psoriatic Arthritis, Systemic Arthritis
3 year old white female with R knee swelling x8 weeks. Mother reports morning fussiness and limping. ANA+. Abnormal slit lamp exam. Likely diagnosis? Tx? Oligoarthritis; NSAIDs & intra-articular steroid injection
10 year old Native American male presents with swollen ankle and knee. He is tender over tendon/fasciae insertions. HLA-B27+. On later visit, he is found to have back involvement. Likely dx? Tx? Enthesitis Related Arthritis; Anti-TNF-alpha (started early)
Age 10 Hispanic female presents complaining of severe morning stifness, fatigue, malaise, & multiple symmetric painful swollen joints. RF+. Periarticular erosions seen on XR. Likely dx? Tx? Polyarthritis-RF+; MTX, anti-TNF alpha, or Rituximab.
Age 2 white female presents with morning stiffness, symmetric joint swelling to knees, ankles, hands, & feet. TMJ & C-spine also involved. Otherwise healthy. Likely Dx? Tx? Polyarthritis-RF-; MTX, Anti-TNF alpha.
Age 2 white female presents with single swollen toe. Comes back in later with swollen knee. On exam- rash and nail pitting. +HLA-B27 suggests axial involvement. Likely Dx? Psoriatic Arthritis
4 year old female presents with daily spiking fevers up to 106F for the last 2 weeks that correspond with a pale pink rash. Multiple joints are swollen. HSM on exam. Elevated WBC, anemia, elevated ESR & ferritin. Likely Dx? Tx? Systemic Arthritis; Anakinra (limit steroids!!)
Pauciarthritis = <__ joints involved 5
Polyarthritis = >__ joints involved 5
List 2 eye manifestations associated with JIA Chronic uveitis & Acute uveitis
Normal CBC but persistent fevers in established systemic onset JIA. Suspect? Macrophage Activation Syndrome
Most benign form of JIA? Oligoarthritis
Acute uveitis is typically associated with which type of JIA? Enthesitis Related Arthritis
Chronic Uveitis is seen with which 3 types of JIA? Oligoarthritis, Psoriatic Arthritis, Polyarthritis-RF-
Pericarditis is associated with which type of JIA? Systemic onset
Lupus is most common in which race? African Americans (also African Caribbean, Hispanic, & Asian)
22% of lupus is diagnosed between ages __-__ 15-45
Pathogenesis of SLE: ______ susceptibility-->____ of tolerance --> _________ phase --> _______ phase. genetic, loss, expansion, injury
List the 11 criteria for classification of SLE: Malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal disorder, neurologic disorder, hematologic disorder, immunologic disorder, ANA
Patient must have __/11 criteria to meet diagnostic criteria for SLE. 4
MC presenting sx of SLE? Arthalgia & arthritis
Arthritis that is symmetrical, involves hands, wrists, knees, and is non-erosive or destructive is most likely due to? SLE
Symptoms that are classified under serositis that are associated with SLE? Pericarditis, Pleuritis
Renal symptoms associated with SLE? Proteinuria, cellular casts, GN
Neurologic disorders associated with SLE? Seizures, psychosis
Hematologic symptoms associated with SLE? Leukopenia, Lymphopenia, Hemolytic anemia, Thrombocytopenia
Immunologic abnormalities associated with SLE? Anti-phospholipid antibody, anti-DNA, anti-Sm, false+ syphilis test
Standard of care for SLE pharmacologic treatment, including cutaneous manifestations? Hydroxychloroquine
Commonly prescribed adjunct medications in SLE to help with symptomatic relief? Steroids, NSAIDs, low-dose ASA (to prevent thrombotic events)
Neurologic lupus, lupus nephritis, or vasculitis of internal organs should be treated with? Cyclophosphamide
Photosensitive red rash to cheeks & chin with confluent erythema and induration that spares nasolabial folds is? ACLE (Acute cutaneous lupus erythematosus)
% of people with ACLE that have systemic lupus? 100%
Photosensitive rash of polycylic regions that have a central clearing and a colored scale. Appears similar to psoriasis or ringworm. What is this? SCLE (Sub-acute Cutaneous Lupus Erythematosus)
% of people with SCLE that develop systemic lupus? 50%
Patient presents with lesions on ear, face, & scalp. Lesions have atrophic center with active border. Scalp lesions have surrounding alopecia. What is this? DLE (Discoid Lupus Erythematosus)
What % of patients with DLE develop systemic lupus? 30%
____C3/C4 levels are associated with SLE. Low
Only way to confirm lupus nephritis? Renal biopsy
Most common class of lupus nephritis in SLE patients? Class IV (Diffuse proliferative GN)
Class of lupus nephritis with worst prognosis? Class IV (Diffuse proliferative GN)
What class of lupus nephritis is this: Normal or minimal change disease? Class I
What class of lupus nephritis is this: Mesangial GN Class II
What class of lupus nephritis is this: Focal proliferative GN Class III
What class of lupus nephritis is this? Diffuse Proliferative GN Class IV
What class of lupus nephritis is this? Membranous GN Class V
% of SLE patients that are women? 90
> or = to __ points on the ACR/EULAR defines RA. 6
Swollen synovium is called ______. Pannus
TNF-alpha, IL-1, & IL-6 are _______ that perpetuate systemic inflammation by stimulating __ &__ cells which continue the inflammatory cascade. Cytokines, B, T
__-cells secrete immunoglobulins, including RF. B
Sx of RA typically last greater than __ weeks. 6
Morning stiffness in RA typically lasts longer than _____. 1 hour
List 3 common joints affected by RA: Wrists, MCPs, PIPs
List 3 common deformities associated with RA: Boutonnierre, Swan Neck,Ulnar deviation
Labs that are typically + in RA? RF (80%), Anti-CCP antibodies (80%), ESR/CRP, ANA (30%)
General workup for RA (excluding diagnostic factors like RF, CCP, etc) (5 items) CBC, renal function, liver panel, CXR, XR of joints affected
Radiographic evidence does not occur until __-__ years after onset. 1-2
__________ at site of synovial attachment, __-__ subluxation, ulnar deviation at MCPs, and flexion/extension contractures are common radiographic findings of RA. Osteopenia, C1-C2
What lab is the most specific for RA? Anti-CCP antibodies
40 year old Caucasian female presents complaining joint pain and swelling to all PIPs, MCPs, both wrists, and MTPs. She has a high + RF, + CCP antibody, and high ESR. She also reports fatigue & mild fevers. Appropriate treatment? Anti-TNF alpha with or without MTX (or combo DMARD therapy)
42 year old female presents complaining of swelling and joint pain in 2nd & 3rd PIPs. She has no other complaints. Moderately high-titer RF, +CCP antibody, and very mildly elevated ESR. Appropriate treatment? DMARD monotherapy (MTX)
Common surgical interventions for RA (4): Joint reconstruction, joint replacement, joint fusion, or synovectomy.
Most common age range of presentation with RA? 40-45
Vasculitic syndromes can occur due to a combination of several mechanisms including ________ predisposition and _________ factors like toxins (silica, abestos, pesticides), drugs (Hydralazine, penicillamine, PTU), or bacterial infections. Genetic, environmental
All patients with vasculitis will have an elevated _____ and evidence of _________. Some may have a +_____. ESR, ischemia, ANCA
If a patient presents with a purpuritic rash, fever, unexplained renal insufficiency & CVA and a +ESR, you should suspect? Vasculitis
Before diagnosing vasculitis you should r/o (4)? Infectious diseases, paraneoplastic syndrome, atrial myxoma, toxic drug effects.
Skin hemorrhages <3mm are called? Petechiae
Skin hemorrhages>1 cm are called? Ecchymosis
What are the 2 main types of small vessel vasculitis? Wegener's Granulomatosis & Leukocytoclastic Angiitis
Saddle nose deformity, erosive sinusitis, & subglottic stenosis are associated with? Wegerner's
55 year old white male presents with saddle nose deformity, erosive sinusitis, palpable purpura, uveitis, and stridor. On CXR - non-caseating granuloma. Renal labs suggest GN. c-ANCA +. Dx? MC induction tx? Wegener's; Rituximab
Induction therapy for Wegener's can include: Rituximab, steroids, cyclophosphamide
Maintenance therapy for Wegener's includes: MTX or Azathioprine
Patient presents with purpura that occurs in crops/waves but is otherwise asymptomatic. What should you get to confirm the dx? What is the most likely dx? Skin biopsy; leukocytoclastic angiitis
Antihistamines are typically used to treat which type of vasculitis? LCV
Medications prescribed for LCV (4)? Antihistamines, Dapsone, Colchicine, Steroids (for fulminant dz)
Name a medium vessel vasculitis Polyarteritis Nodosa
50 year old male presents with fever, fatigue, recent weight loss, vague GI pain, & muscle weakness. On exam- hypertensive & livedo reticularis present. Labs- anemic, high ESR, elevated BUN/Cr, +Hep B. Dx? Polyarteritis Nodosa
A patient must have __/10 of the ACR criteria to diagnose PAN. These include: Wt loss, livedo reticularis, testicular pain, myalgia/weak/polyneuropathy, diastolic BP>90, high BUN/Cr, +HepB, angiographic abnormality, or biopsy showing PMNs. 3
If a patient has Hep B and is dx with Polyarteritis Nodosa, what is the tx plan? Antivirals, plasma exchange, Prednisone
If a patient is diagnosed with polyarteritis nodosa that isn't associated with Hep B, what is the treatment plan? Prednisone, AZA, MTX, cyclophosphamide (if severe)
75 year old White female presents complaining of fever, fatigue, wt loss, a temporal HA, pain with chewing, and changes in vision. ESR is high. What should you order? Likely dx? Biopsy(3-6cm); Giant Cell Arteritis
Name a type of large vessel vasculitis Giant Cell Arteritis
A biopsy of giant cell arteritis will show? Multinucleated Giant Cells
Amaurosis Fugax is associated with? Giant Cell Arteritis
Treatment for giant cell arteritis? High dose steroids, bisphosphonates
70 year old white female smoker presents complaining of fever, fatigue, wt loss, limb girdle pain, and morning stiffness lasting several hours. High ESR. Low dose steroids had a rapid response. Dx? Polymyalgia Rheumatica
What is the treatment for polymyalgia rheumatica? Low dose steroids (x1-2 yrs) with bisphosphonates
Vasculitis that targets the upper & lower respiratory tracts, kidneys, joints, skin, eyes, nerves, and heart? Wegener's
Type of vasculitis that only affects the skin? LCV
Type of vasculitis that affects the skin, muscles, nerves, GI tract, and kidney? PAN
Type of vasculitis that affects the aorta and its major branches and the extra-cranial branches of the carotid? GCA
Created by: duanea00