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Renal - clin med sa2

Clinical Medcine

List the 5 categories of theories regarding the etiology of fibromyalgia. Muscle pathology, Neuroendocrine/ANS, Genetics, Pain perception & processing, Psychosocial
45 year old female presents complaining of morning stiffness, multiple tender MS areas, & fatigue. She reports a history of chronic headaches. No inflammation on exam. Likely Dx? Fibromyalgia
Remember that 25% of patients with autoimmune disorders have co-morbid ___________. Fibromyalgia
List the 5 MC items in the DDx for fibromyalgia that must be ruled out to make diagnosis. Statins, Myasthenia Gravis, RA, Hypothyroidism, Polymyalgia Rheumatica
2 medications that have the strongest evidence of efficacy in treating fibromyalgia? Amitriptyline & Cyclobenzaprine (others - Prozac, Cymbalta, Lyrica)
2 non-pharmacologic therapies to help with fibromyalgia ? Improve sleep, exercise (start low & build slow)
Typical spondyloarthritis patient? (Age, sex) Man under 40 (probably in teens/20s)
HLA-B27 is associated with? Spondyloarthritis
27 year old male presents complaining of prolonged low back morning stiffness and alternating low back pain. XR shows sacroiliitis and syndesmophytes (Bamboo Spine). Dx? Ankylosing Spondylitis
A tape measure is placed b/w 2 pts on the L-spine 10 cm apart while standing. Pt then bends forward completely, and distance is re-measured. If expansion is <10cm, suspect? What is this test called? Ankylosing Spondylitis; Schober Test
Increase in measurement from occiput-to-wall over time can detect changes in spinal curvature associated with? Ankylosing Spondylitis
Most common medication for treatment of early/mild ankylosing spondylitis? NSAIDs (+/-steroid injections)
Sulfasalazine helps with _______arthritis but not ________ arthritis in ankylosing spondylitis. Peripheral, spinal
Most effective treatment for axial & peripheral arthritis in ankylosing spondylitis? Anti-TNF alpha
Reiter's syndrome triad includes: Urethritis, reactive arthritis, conjunctivitis (or uveitis)
Reactive arthritis is most typically associated with what bacterial infection? Chlamydia
Circinate Balanitis & Keratoderma Blennorrhagicum are sx associated with? Reactive Arthritis
________ _________ is the only type of spondyloarthritis that is typically self-limiting. Reactive Arthritis
25 year old male presents complaining swollen, painful knee, pain near Achilles Tendon, low back pain, and psoriatic rash on soles of feet. Reports unprotected sex about 4 weeks ago. Dx? Reactive Arthritis
Arthritis Mutilans may be seen in? Psoriatic Arthritis
Name 3 nail findings associated with psoriatic arthritis: Nail pitting, onycholysis, oil drop sign
XR showing pencil in cup deformity- likely dx? Psoriatic Arthritis
29 year old female presents with joint pain and swelling to R Knee, 3rd PIP, DIP, and a swollen toe. Nail pitting on exam. Likely dx? Psoriatic Arthritis
Uveitis, pulmonary fibrosis, & aortic insufficiency are complications that may occur due to what type of spondyloarthritis? Psoriatic Arthritis
What 2 drugs can help with both the skin & joint manifestations of psoriatic arthritis? MTX & anti-TNF alpha
Erythema Nodosum & Pyoderma Gangrenosum are associated with? Enteropathic Arthritis
28 year old male presents complaining of R knee & L ankle pain & inflammation. He reports frequent mouth ulcers and skin changes that look like bruises. Likely Dx? Enteropathic Arthritis
2 most common meds used to treat enteropathic arthritis? Azathioprine & Mesalamine (+/- anti-TNF)
Complications of this type of spondylitis may include acute ant uveitis, aortic insufficiency, heart block, restrictive lung dz, apical fibrocystic dz, amyloidosis, osteopenia, & cauda equina syndrome Ankylosing Spondylitis
Inflammation with tendon and ligament disruption at site of insertion into bone, frequently causing heel pain. Enthesitis
OA is the destruction of _______ cartilage Articular (Hyaline)
In OA, a(n) __________ in water content occurs first, followed by a(n) _________ in water content later increase, decrease
60 year old female patient presents complaining of progressively worsening dull aching knee pain with swelling. Pain improves with rest and is worsened by activity. Dx? OA
Hip OA pain is typically referred to the ______. Groin
Strongest risk factor for developing OA? AGE (due to decrease in chondrocytes & muscle atrophy)
Women typically have ______ rates of OA than men because of ________ defiency higher, estrogen
Biomechanical structures associated with an increased risk of developing OA include: (3 items) Repeated joint stress, trauma, infection
Hemochromatosis, ochronosis, and increased bone mineral density are metabolic processes associated with an increased risk in? OA
Only controllable risk factor for OA? Obesity
Bouchard's nodes affect which joints? PIPs
Heberden's nodes affect which joints? DIPs
Which size joints does OA typically affect? Large
A synovial fluid analysis showing transparent yellow fluid with 1000 WBC, 10% PMNs, and a negative culture is likely due to a(n)________ condition such as ____. Non-inflammatory; OA
Whitening around a joint seen on XR is called? Associated with? Subchondral Sclerosis; OA
Osteophytes, joint space narrowing, chondrocalcinosis, & subchondral cysts are XR findings associated with? OA
Supplements that may help with OA? Glucosamine & Chondroitin
Steroid injections for OA can be given every __ months for 1-2 years before other options should be considered. 3
5 Painful injections given 1 week apart that help with moderate OA by lubricating the joints - AKA? Viscosupplementation
A minimally invasive surgical procedure used in OA to buy time or postpone a definitive procedure? Arthroscopy
A definitive procedure that can provide pain relief in OA but is rarely done because of the obvious limitations it can create. Arthrodesis (Joint fusion)
Most common definitive surgical procedure done in OA that has a limited life span and can't always be done on everyone. Arthroplasty (Joint replacement)
Best weight loss activity for patients with OA? Swimming (non-weight bearing exercise)
Rare, chronic connective tissue disease characterized by hardening of the skin & internal organs including GI tract, lungs, heart, & kidneys. Systemic Sclerosis
Highest prevalence of systemic sclerosis is seen in which ethnicity? Choctaw Native Americans
Type of systemic sclerosis in which 50% have early GI or pulmonary involvement, later onset Raynaud's, dilation & drop out of nail fold capillaries, and anti-Scl70 are present. Diffuse Cutaneous
Type of systemic sclerosis in which skin distal to elbows and knees & the face is involved, Raynaud's precedes skin dz, usually have esophageal & lung involvement, dilated nail fold capillaries, & anti-centromere present. Limited Cutaneous
Type of systemic sclerosis in which there is visceral involvement but no skin changes. Systemic Sclerosis sin Scleroderma
Typical scleroderma patient (sex & age?) Female (3:1) aged 30-50
There may be a possible environmental role to the development of systemic sclerosis because a +_____ was found in many spouses of scleroderma patients. ANA
Pathogenesis of systemic sclerosis: Genetic susceptibility+_______ insult or ___________ trigger & microchimerism (in females) leads to immune & vascular pblms, which leads to ________ activation & growth and eventually fibrosis. viral, environmental, fibroblast
What testing is key in systemic sclerosis patients because of likely pulmonary involvement? PFTs (esp DLCO-diffuse lung capacity of CO)
3 phases of cutaneous disease in systemic sclerosis? Inflammatory edematous, indurative, atrophic
"Watermelon Stomach" is a clinical finding associated with? Diffuse Cutaneous systemic sclerosis
Pulmonary HTN is more common in which type of systemic sclerosis? Limited Cutaneous systemic sclerosis
Interstitial lung disease is more common in which type of systemic sclerosis? Diffuse Cutaneous systemic sclerosis
Useful procedure for looking at nail fold capillaries to help in diagnosing systemic sclerosis? Capillary scope
Limited systemic sclerosis is more typically associated with _____GI disease. Upper
Renal complication associated with systemic sclerosis? Renal crisis (malignant HTN, microangiopathic hemolytic anemia)
______ _____ _________ have been attempted to treat systemic sclerosis but have a 50% mortality rate Stem cell transplants
Treatment for systemic sclerosis is mostly aimed at controlling ________ and preventing _________. Symptoms, complications
Mainstay for GI sx control in systemic sclerosis? PPIs
BP control in systemic sclerosis is typically with? ACEI
Genetic component in inflammatory myopathies may be ______ than other autoimmune disorders. Less
The seasonal incidence of inflammatory myopathies may suggest a _______ cause. Viral
Criteria that must be met to diagnose polymyositis? Symmetrical proximal muscle weakness (with or without dysphagia/resp muscle involvement), abnormal muscle biopsy, elevated skeletal muscle enzymes, abnormal electromyogram
Criteria that must be met to diagnose dermatomyositis? 3 criteria from PM + skin rash
Dermatomyositis is __-cell mediated. Cellular infiltrate is mostly peri-_______ & peri-________. Primary lesion is in the ______ _______. Infiltrate is mostly B-cells & increased ratio of CD_+ to CD_+ T-cells. B, fascicular, vascular, blood vessels, 4, 8
In polymyositis, the cellular infiltrate is primarily in the _______ with inflammatory cells invading the ______ ______. Increased # of cytotoxic CD+_ T cells Fascicle, muscle fiber, 8
Violaceous papules, plaques over the MCPs, PIPs, & DIPs are called? And they are associated with? Gottron's Papules; Dermatomyositis
Symmetrical macular erythema over bony prominences like the small joints of hands, elbows, knees, & malleoli is called? And is associated with? Gottron's Sign; Dermatomyositis
Violaceous erythema around eyelids often with periorbital edema is called? And is associated with? Heliotrope; dermatomyositis
Dilated capillary loops near the nail cuticle causes? Associated with? Periungual Telangiectasia; Dermatomyositis
Symmetrical macular erythema including tendon streaking on hands, shawl sign, on the V-area of neck, face, scalp, and hips is seen with? Dermatomyositis
Associated features of inflammatory myopathies may include (4 items)? Nonerosive arthropathy, interstitial lung disease, Raynaud's, Mechanic's hands
List the muscle enzymes that may be elevated with inflammatory myopathies (6) CPK, aldolase, LDH, ALT, AST, Troponin
Which muscle enzyme is followed to monitor disease activity in inflammatory myopathies? CPK
Which type of MRI should be done before muscle biopsy to confirm correct area? T2
An EMG of a patient with an inflammatory myopathy would show: ________ insertional activity & spontaneous fibrillations. Abnormally _____ amplitude, short duration polyphasic motor potentials, & bizarre _____ frequency discharges. Increased, low, high
A muscle biopsy should be done on the _______ side that the EMG was done on. Contralateral
What lab(s) tell you the phenotype of a patient's inflammatory myopathy? Myositis specific antibodies
1st medication given to a patient with known inflammatory myopathy?? High dose steroids
Other medications (besides steroids) used to treat inflammatory myopathies? (5 drugs!-MAMIR) MTX, azathioprine, mycophenolate mofetil, IVIG, Rituximab
There is a 17-40x increased risk of _______ CA with dermatomyositis. Ovarian
Which type of inflammatory myopathy has the highest incidence of malignancy? Dermatomyositis
Elderly patient presents complaining of proximal & distal muscle weakness that is asymmetric. Biopsy shows red-rimmed vacuoles inside the muscle cells. Likely Dx? Tx? Inclusion Body Myositis; No proven treatment
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
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 cases are 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 in RA 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 of RA 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
Synovial Fluid analysis shows transparent opalescent fluid with 40,000 WBCs, 60% PMNs, and a negative culture. This is likely due to a(n) ______________ process such as _______. Inflammatory, RA
Created by: duanea00