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Clinical Medicine: Rheumatology

Inflammatory disease polyarticular? 2 possibilities...how do you distinguish physically? RA and SLE. RA more likely to be swollen, tender, red than Lupus.
Non-inflammatory and monoarticular osteoarthritis
What disease is abrupt, as in go to bed fine and wake up w/ problems? Gout
swelling/tenderness surrounding joint; warm, tense, swollen; limited ROM in all planes Articular (w/in joint)
Pain in one plane of movement; tenderness on one side of joint; pain with active ROM > passive ROM Periarticular: bursitis, tendinitis, cellulitis
Extra-articular signs: heart murmur or roth spot SBE (bacterial endocarditis)
DD for first metatarsal phalangeal gout, osteoarthritis
DD for metacarpal-phalangeal or wrist RA, SLE
DD for distal interphalangeal osteoarthritis, psoriatic
Nodes in proximal phalangeal joints Bouchard's
Nodes in distal phalangeal joints Heberden's
What type of anemia would be with inflammatory or chronic disease? normocytic normochromic
Type of anemia in SLE? hemolytic anemia
Type of anemia in scleroderma? microangiopathic hemolytic anemia
What is the actual mechanism of an increased Sed Rate? Increased fibrinogen w/ inflammatory process, as it takes sedimentation longer to settle down. Can also have increased immunoglobulins.
Other than the Sed rate, what else rises during an inflammatory process? CRP- acute phase protein
Way to tell the difference between anemia of chronic disease and iron deficiency? Serum ferritin elevated in CD, low in Fe deficiency
Anemia w/ elevated LDH and bilirubin w/ schistocytes on peripheral smear microangiopathic hemolytic anemia
What lab test is specific for Rheumatoid arthritis? anti-CCP
What lab test is specific for Lupus? anti-double stranded DNA antibody; technically, the anti-Smith is the most specific, but recall it is not very sensitive
T/F: Increased uric acid doesn't mean gout and normal level doesn't exclude gout True
How to definitively Dx crystal induced arthritis? What else requires this method for a definitive Dx? arthocentesis; infectious arthritis
T/F: Ultrasound-guided injection best for knee False, best for shoulders and ankles
Monosodium urate crystals indicate: What shape, color, birefringement? gout, yellow and needle shaped, negatively birefringent
What can give a specific Dx in analysis of synovial fluid? gram stains
WBCs/mm3 to consider inflammatory vs non-inflammatory? Septic? >2,000 inflammatory or <2,000 noninflammatory. Septic= >100,000.
What are examples of non-inflammatory, inflammatory and septic diseases? Non: Osteoarthritis, viral; Inflammatory: RA, gout, psuedogout, reactive arthritis; Septic: Pyrogenic bacterial infections
Fat droplets in synovial fluid indicate: bone fracture involving marrow space
Calcium pyrophosphate dihydrate crystals indicate: What shape, birefringement, color? pseudogout; blue and rhomboidal or rectangular, and positive birefringement
Birefringence: describes optical properties of crystals. Ex: some are "direction dependent" and behave differently w/ light from different directions, VARYING COLORS
Effusion hemorrhagic? Consider: (4) 1)trauma/mechanical derangement, 2) coagulopathy, 3) neuropathic arthropathy, 4) traumatic tap
4 causes of neuropathic arthropathy 1) charcot joint 2) progressive degeneration of wt bearing joint 3) any condition w/ decreased peripheral sensation 4) DM
1) Neuropathic arthopathy 2) Osteoarthritis (OA) 3) Malignancy 4) Fracture 5) internal derangement 6) hemarthrosis 7) Fracture 8) Hemochromatosis Non-inflammatory causes of monoarthritis
Crystal induced or infectious are inflammatory causes of monoarthritis
Biggest risk factors for septic arthritis (4) 1) any diseased or prosthetic joint 2) poorly controlled DM 3) Recent joint surgery 4) Chronic illnesses
3 biggest causes for septic arthritis 1) infection seeding joint from extra-articular source (pyelo, cellulitis etc) 2) Orthopedic surgical procedures or trauma 3) Direct inoculation of pathogen into joint (animal bite/nail puncture)
T/F: Low counts of WBCs in immunocompromised excludes septic arthritis False, immunocompromised can still have septic arthritis
Septic arthritis and gram negative diplococci of effusion Gonnococci (GC)
T/F: Glucose and protein levels in fluid are not sensitive or specific True
ABX for septic arthritis? Start broad, then narrow once Cx returned. If gonococcus, Ceftriaxone.
Most common gram positive aerobe Staph aureus
Big cause of gram negative bacteria IV drug use (also immuno-compromised more susceptible)
What disease is associated with Spirochetes that we've talked about? Lyme
10% of people with this disease develop arthritis months or years after exposure. Most common area of arthritis? Lyme; arthritis of the knee. Can come with neurologic impairment
Early stages of Lyme? Disseminated? erythema migrans, arthralgia/myalgia, sore throat....DISSEMINATED: skin lesions, facial palsy, meningitis
2 lab tests that have a high specificity for Lyme disease? 1) IgG Western Blot 2) synovial fluid positive w/ PCR (85%)
Txs for early and late/disseminated Lyme disease? Early: 100 mg Doxy BID for 2-4 weeks. Late: Ceftriaxone 2g IV 4 weeks
Sx: new heart murmur, splinter hemorrhages, roth spots, (+) blood Cx Bacterial endocarditis
T/F: Nongonococcal bacterial arthritis: 80-90% are polyarticular False, 80-90% are monoarticular
What is a major general guideline for emprically treating septic arthritis as far as coverage goes? Must treat staph and strep
T/F: Disseminated gonococcal infections, like gonococcal Sx, are more common in males False, more common in females
Manifestations: Purulent monoarthritis, constitutional Sx, hepatitis, myocarditis, endocardtis, meningitis, Rash characterized as macular or papular, pustular, hemorrhagic or necrotic, mostly on distal extremities. Disease? Dermatitis-arthritis syndrome of Disseminated gonococcal infection (DGI)
Describe a DGI skin lesion necrotic, grayish central lesion on erythematous base
Gram stain of gonococcus? negative
What are the 3 stages of prosthetic joint infections and their timelengths? Stage 1: w/in 3 months, usually from time of surgery. Stage 2: 3-24 months. Stage 3: >2 years post surgery, usually caused by ihematogenous spread to abnormal joint surfaces causing joint pain
Hip or knee (most common) monoarticular arthritis lasting weeks to months W/O constitiutional Sx. May have chronic tenosynovitis. Synovial Bx best Dx Tuberculous arthritis
Symmetrical involvement of the small joints of the hands and wrists and the knees. Usually resolves in about a month without joint damage, though some have persistent disease. Also causes "5th disease" (recall what that is?). Parvovirus B19 arthritis. 5th disease is that "slap cheek" rash that children get.
Dx of parvovirus B19? Tx? Immunoglobulins (IgM for present and IgG for past). PCR can be used for immunocompromised (may not have antibody response). Tx: NSAIDs
Typical cause of gout? Mono or polyarticular? overproduction (primary) or under-excretion (secondary) of uric acid; monoarticular
Major causes of acute gouty arthritis? (4) DKA, thiazide diuretics, alcohol, niacin (these all cause functional impairment of tubular transport)
Abrupt onset of severe joint inflammation w/ constitutional Sx. Typically overnight onset. Acute gouty arthritis
T/F: Txs of cellulitis and gout are the same FALSE, you can treat for both if you can't distinguish
2 descriptors of a tophaceous deposit of a PIP joint with gout erythema and desquamation
Tx of acute gouty arthritis? NSAIDs TOC unless CONTRA. Colchicine and corticos also used sometimes.
When is colchicine used acutely for gout? Other times? When steroids and NSAIDs are both CONTRA: as in a person w/ DM and renal failure simultaneously. Most importantly, as long term prophylaxis...initiation of Tx to reduce uric build up
When would you used steroids to treat gout? Perhaps joint injection in pts w/ renal failure (NSAIDs CONTRA). Injections reduce systemic effects
Work-up for gout: Dx gout -> check for DM and renal failure w/ bloodwork and Hx -> give NSAID or steroid -> give something prophylactically to reduce uric acid
Name 4 hyperuricemic meds to avoid between gout attacks 1) thiazides 2) loops 3) niacin 4) low dose ASA
Major, most used drug for reduction of uric acid? One for renal insufficiency? allopurinol; febuxostat
How do you distinguish a tophaceous gout deposit from cartilage nodules in the ear? cartilaginous nodule will blanch out w/ pressure and blend w/ ear
What do we expect to find on XRay after the first gout episode? NOTHING, let's keep it that way!!!
What is chondrocalcinosis? presence of calcium containing salts in articular cartilage. NO INFLAMMATION AS SEEN IN PSEUDOGOUT
Tx for Pseudogout? Same as gout! NSAIDs, colchicine, prednisone; colchicine for prophylaxis
T/F: Lupus requires a Bx for Dx False, requires a Bx for severity/staging and Tx direction
Manifestations: rash, photosensitivity, oral ulcers, arthritis, serositis (pleuritic chest pain), kidney disorders, palatine bullae, dermatitis between knuckles Lupus
Anti-double stranded DNA. What other test can ID this disorder w/ very high specificty SLE (Lupus); Anti-Smith is not very sensitive, but very specific. (AKA when it is positive, you are positive, if it isn't, you still may have it)
Screening test for Lupus? ANA test (positive in more than 95%)
What is the complement of Lupus and why? low complement because the complement proteins bind w/ immunoglobulins on cells and facilitate lysis
What biologic false-positive test can occur in people with Lupus? VLDL for syphilis
Txs for mild Lupus (3) 1) NSAIDs, 2) antimalarials (hydroxychloroquine – Plaquenil), and 3) glucocorticoids
Txs for severe Lupus immunosuppresives (methotrexate)
Arthralgias, rash, and serositis being predominate manifestations, NO CNS, nephritis, low complement and anti-double stranded DNA. Tx? Drug Induced Lupus caused by TNF inhibitors, methyldopa, hydralazine, procainamide, minocycline, penicillamine etc. Tx: DISCONTINUE DRUG
Positive antibody test w/ negative lupus test, hypercoagulability, thrombocytopenia. Disease and Tx? Anti-phospholipid Syndrome and life-long anticoagulation w/ Warfarin w/ pts w/ serious complications
Unexplained constitutional Sx. Palpable purpura. Ischemic vascular changes (gangrene, upper extremity claudication, Raynaud’s phenomenon, livedo reticularis) Glomerulonephritis, Myalgia, arthralgia. Abdominal (intestinal angina) or testicular pain Primary Vasculitis: Inflammation in walls of blood vessels
SBE, hep B or C, connective tissue disorders, IBD ard examples of: Secondary forms of vasculitis
3 large vessel vasculitis 1) Giant cell/temporal arteritis 2) Behcet's disease 3) Takayasu artertitis
4 medium vessel vasculitis 1) Polyarteritis nodosa 2) Kawasaki Disease 3) Buerger disease 4) Primary angiitis of CNS
6 small vessel vasculitis (2 categories of 3) Immune complex mediated: 1) Henoch-Schonlein purpura 2) Cutaneous leukocytoclastic angiitis –hypersensitivity 3) Cryoglobulinemia. ANCA positive: 1) Granulomatosis w/polyangiitis 2) Microscopic polyangiitis 3) Churg-Strauss syndrome
Difference between normal and pathological livedo Patho: broad/thicker, interrupted pattern compared to well-connected livedo seen in normal individuals
Young Asian women w/ upper extremity claudication and inflammation of the aorta. 3/6 of Dx criteria (Blank said know these) Takayasu arteritis (large vessel) 1) <40 yo 2) claudication of extremities 3) decreased brachial pulse 4) >10mmHg difference systolic btwn arms 5) Bruits on subclavian/abdominal aorta 6) arteriographic narrowing
Recurrent oral ulceration (aphthous ulcers) plus 2 of the following : recurrent genital ulceration, eye lesions (hypopyon), skin lesions, positive pathergy test. Tx? May also have neurologic lesions, nonerosive arthritis Behcet's Disease (large vessel); Tx: corticosteroids/immunosuppresive therapy
Positive pathergy test: The arm is pricked with a needle and is positive when a small red bump or pustule develops at the site of injury
Hypopyon? layer of pus in the anterior chamber of the eye
Aching pain, very high Sed rate, anemia, morning stiffness. Tx? Dx? Polymyalgia Rheumatica (large vessel); Tx=Dx (low dose corticosteroids (10-20mg). Sed rate w/ lower just in 2 weeks dramatically. Taper dose down to smallest possible.
Jaw claudication, temporal HA, temporal artery thickening, vision loss/diplopia, wt loss/fever, very high sed rate. Tx: Giant Cell (temporal) arteritis (large vessel): Histiocytic lymphocytic multi-nucleated giant cell infiltration of the walls of medium sized and large arteries originating from the aortic arch. Tx: 60 mg prednisone and taper down.
T/F: you can miss giant cell arteritis w/ a Bx True...can occur in skip lesions. Start on prednisone w/ high index of suspicion and see if vision improves.
1) wt loss >4 kg 2) livedo reticularis 3) testicular tenderness 4) myalgias 5) mononeuropathy 6) diastolic HTN (>90) 7) elevated Hep B 8) Arteriographic abnormality 9) elevated BUN creatinine 10) Bx of artery containing. Polyartertis nodosa; (medium vessel)
Most IDable manifestations of polyarteris nodosa (medium vessel). Tx? 1) Wt loss 2) Livedo reticularis 3) Testicular tenderness 5) mononeuropathy 8) Hep B virus 10) Bx; Tx: high dose corticos and immunosuppresives
Strawberry tongue in Peds pts w/ inflammation of eyes and changes in hands. Muco-cutaneous-lymph node syndrome in mostly <4 yo. Tx? Kawasaki Disease; Tx: Immunoglobulins are preferred.
Limited vasculitis in distal vessels. Found in SMOKERS. Tx? Thromboangiitis Obliterans (medium vessel); Cessation of smoking
Vasculitis limited to brain and spinal cord. Abnormal MRI. Dx: angiographic findings + positive brain Bx. Tx? Primary angiitis of CNS (medium vessel); Tx: corticosteroids
What are the 4 possible (2 required) criteria for these Sx: 1) abd pain 2) renal disease 3) palpable purpura 4) arthritis/arthralgias. Tx? Henoch Schonlein Purpura (small vessel); 1) Age < 20 (primarily male children) 2) Bowel angina 3) Granulocytes 4) palpable purpura; Tx: self-limiting w/in 1-6 weeks, steroids can help.
Palpable purpura hallmark, constitutional Sx, residual post-inflammatory hyperpigmentation, urticaria, edema,glomerulonephritis. Tx? Cutaneous small-vessel vasculitis (small vessel); Tx: non-aggressive, rest/elevation of the legs
Positive serum test for ___globulins and low C4 complement. Reversible precipitation at body temps <37 celcius. Most common underlying cause? Cryoglbulinemia (small vessel); Hep C most common underlying cause
Vasculitis, respiratory infiltrates/pulmonary nodules, glomerulonephritis, sinus problems. C-ANCA positive. Saddle-nose deformity Dx require Bx? Granulomatosis w/ polyangiitis (Wegener's Granulomatosis) (small vessels); Dx requires Bx.
Eosinophilia, skin rash, eosinophilic necrosis, transient pulmonary infiltrates, mono/poly neuropathy. p-ANCA positive. Tx? Bx for Dx? Churg-Strauss Syndrome (small vessels); Tx: Steroids; Bx for Dx.
Most common cause of pulmonary-renal syndrome, NO sinus involvement, vasculitic neuropathy, postive p-ANCA. Bx for Dx? Microscopic polyangiitis (like Wegner's) (small vessels); Bx for Dx.
Average life expectancy shortened, 2x likely to have a MI/CVA, average lifetime earnings loss=50%. Will not be able to work 8-10 years after disease onset...what is the disease? Rheumatoid arthritis
What is in common with these disease? 1) Infx diseases (HIV, viral hep, SBE), 2) atrial myxoma 3) paraneoplastic syndromes 4) cholesterol emboli syndromes 5) Toxic drug effects (ergots, cocaine, amphetamines) Diseases that present like vasculitic syndromes
What would make us consider vasculitis mimics over vasculitis? (8) 1) heart murmur 2) necrosis of lower extremity digits 3) splinter hemorrhages 4) liver dysfn 5) drug use 6) high-risk sexual activity 7) prior dx of neoplastic disease 8) unusually high fever
11 factors for poor prognosis of RA. Name just a few (he wanted us to star this slide) >20 swollen joints, high RF titer, elevated anti-CCP, sed rate, CRP, late Tx, joint erosions, nodules, smoking, poor fn status, socioeconomic characteristics
Morning stiffness lasting AN HOUR +, swelling of 3+ joint areas including wrist/hand (Swan-neck and boutonniere), systemic arthritis, nodules, "cock-up toe", ^RF, erosions on radiogaphs (need 4/7 for Dx). Can have Felty's and interstitial lung disease Acute rheumatoid arthritis
Felty's syndrome splenomegaly and neutropenia
What is the first kind of swelling you see on RA xray? Periarticular swelling
Mild management for RA? Severe disease? Mild: NSAIDs and DMARDs; Severe: NSAIDS, methotrexate, biologics
<16 yo, duration of arthritis>6 weeks, asymmetric pattern, Still's disease (what is Still's?). No labs for disease. Juvenile Rheumatoid Arthritis; Stills: sore throat, rash, fever pattern with WBC>40k and ELEVATED ferritin level
Asymmetrical arthritis predates skin lesions, nail dystrophy, sausage digits/dactylitis (CARDINAL), enthesitis, tenosynovitis. Tx? Psoratic arthritis; Tx: NSAIDs for mild, MTX or anti-TNF for moderate.
I cannot see, I cannot pee, I cannot bend my knee. What is the disease and labs and manifestations (esp most specific) Reactive arthritis; manifestations and labs: HLA B27 not specific but more likely, urethritis, conjunctivitis, KERATODERMA BLENNORRHAGIA (brown vesicular-pustules on bottom of feet)
proximal muscle weakness w/ characteristic rash (mantle and/or heliotrope; Gottron sign. Risk of Ca ^ in first 3-5 years. (What are the most common?) Has autoantibodies. Active inflammation under MRI. How to Dx? Dermatomyositis, Dx: Characteristic Bx findings; Most common cancers: ovarian, breast, melanoma, nasopharyngeal, non-Hodgkin's
Heliotrop rash bilateral on upper lids: violet to reddish purple
Gottron sign: psoriasis looking rash on knuckles
Subacute proximal myopathy in adults. Dx of exclusion; rare "stand-alone" condition. Dx? Polymyositis; Dx: Bx of muscle
Severe weakness w/ very high CK following viral infx, Ca, or statin therapy. Dx? Necrotizing Autoimmune Myositis; Dx: Bx
>50 years of age, early involvement of distal muscles with frequent falls. Abnormal EMG and MRI. Inclusion Body Myositis
Raynaud's, pulmonary hypertension is frequent. Dx? Systemic limited cutaneous sclerosis scleroderma
Rapidly progressive disorder affecting large area of skin and multiple internal organs, especially a renal crisis and reduced ejection fraction. What kind of anemia? What kind of antibodies? Systemic diffuse cutaneous sclerosis scleroderma; Microangiopathic hemolytic anemia; Anti-RNA polymerase III antibodides
What indicator makes Raynaud's secondary (and more pathological)? asymmetric and severe
Pulmonary fibrosis, calcinosis, facial sclerosis, telangiectasias, resorption of terminal digits Additional Sceleroderma manifestations.
Pulmonary Fibrosis Restrictive pattern. Both FFV 1 and FVC would go down. Decreased diffusion capacity
Autoimmune disorder with dry eyes and mouth (keratoconjunctivitis sicca and xerostomia) where 90% are female. Nasal dryness and epistaxis associated. Parotitis, corneal inflammation (Rose Bengal stain), Schirmer test Secondary to RA. Sjogren's or Sicca Syndrome
Disorders w/ Asymmetric oligoarticular peripheral arthritis associated w/ HLA B27 where SPINAL SX improve w/ activity and worsen w/ rest Spondyloarthropathies
Bamboo spine on radiography (ossification of annulus fibrosis), morning stiffness improving w/exercise. What conduction disorder associated? (wide pulse pressure and water hammer pulse) Ankylosing Spondylitis; aortic insufficiency
Malformed and insensate joint with loss of function. What is this called? Neuropathic Arthropathy, or a Charcot joint
Noninflammatory synovial fluid on arthrocentesis w/ morning stiffness, joint pain/tenderness (MONOARTHRITIS) affecting 80% of population by age 65. Disease modifier? Osteoarthritis; no disease modifiers, just Sx Tx
Buttock falls when the patient stands on the opposite foot due to abductor weakness Trendelenburg’s sign
History of widespread musculoskeletal pain for more than 3 months, on both sides of the body, above and below the waist, and axial skeleton; fatigue, young women. Positive labwork? Fibromyalgia; positive low titer ANA but no anti-ccp, anti-dsDNA, anti-smith etc, ESR,
Created by: crward88