Clinical Medcine
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| Deposition of uric acid occurs when uric acid is over ____mg/dL | 6.8
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| Pseudogout is due to the deposition of ________ __________. | Calcium Pyrophosphate
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| Causes of hyperuricemia? (3) | Underexcretion (90%), overproduction (10%), overconsumption
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| Gout may be due to an inherited _______ disorder causing overproduction. | Enzyme (G6PD, PRPP, HGRPT, etc)
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| Risk factors for gout | Diet high in purines, metabolic syndrome, obesity
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| Pseudogout is more common in men or women? | women
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| Can be associated with hyperparathyroidism, hemochromatosis, hypomagnesemia, & hypophosphatemia | Pseudogout
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| 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
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| Commonly involved joints in gout are?(4) | Big toe, mid foot, ankle, knee
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| 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
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| 24 hour uric acid >800mg in a young patient suggests? | Enzymatic Defect
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| 24 hour uric acid >800mg in an elderly patient suggests? | Rapid cellular turnover
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| Gold standard for dx of gout? | Monosodium urate crystals (on joint aspirate)
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| Monosodium urate crystals are _______ birifringent. | Negatively
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| Joint aspirate of painful inflamed joint shows: 7,000 WBC, mostly neutrophils & negative birifringent crystals. Dx? | Gout
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| Joint aspirate of painful inflamed joint shows: Cloudy fluid with 25,000 WBCs (>80% polys) and crystals that are weakly + birifrigent. Dx? | Pseudogout
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| Tophi, soft tissue swelling, and bony changes on XR are suggestive of? | Gout
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| Chondrocalcinosis, uniform joint space loss, subchondral new bone formation, prominent cysts all bilaterally on XRs suggest? | Pseudogout
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| CAN'T LEAP medications that should be avoided in gout patients are: | Cyclosporine, Alcohol, Nicotinic Acid, Thiazides, Loop diuretics, Ethambutol, ASA, Pyrazinamide
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| Medications used to prevent gout attacks after acute phase has passed? | Allopurinol, Colchicine (also Probenecid, Losartan, Fenofibrate, Febuxostat, Peglitocase)
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| Treatment for chronic pseudogout? | NSAIDs & Colchicine. Chronic intra-articular joint injections (refractory pts)
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| MC presenting symptom of JIA? | Joint swelling
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| List the 6 subclasses of JIA discussed: | Oligoarthritis, Enthesitis Related Arthritis, Polyarthritis-RF+, Polyarthritis-RF-, Psoriatic Arthritis, Systemic Arthritis
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| 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
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| 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)
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| 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.
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| 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.
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| 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
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| 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!!)
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| Pauciarthritis = <__ joints involved | 5
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| Polyarthritis = >__ joints involved | 5
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| List 2 eye manifestations associated with JIA | Chronic uveitis & Acute uveitis
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| Normal CBC but persistent fevers in established systemic onset JIA. Suspect? | Macrophage Activation Syndrome
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| Most benign form of JIA? | Oligoarthritis
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| Acute uveitis is typically associated with which type of JIA? | Enthesitis Related Arthritis
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| Chronic Uveitis is seen with which 3 types of JIA? | Oligoarthritis, Psoriatic Arthritis, Polyarthritis-RF-
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| Pericarditis is associated with which type of JIA? | Systemic onset
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| Lupus is most common in which race? | African Americans (also African Caribbean, Hispanic, & Asian)
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| 22% of lupus is diagnosed between ages __-__ | 15-45
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| Pathogenesis of SLE: ______ susceptibility-->____ of tolerance --> _________ phase --> _______ phase. | genetic, loss, expansion, injury
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| 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
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| Patient must have __/11 criteria to meet diagnostic criteria for SLE. | 4
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| MC presenting sx of SLE? | Arthalgia & arthritis
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| Arthritis that is symmetrical, involves hands, wrists, knees, and is non-erosive or destructive is most likely due to? | SLE
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| Symptoms that are classified under serositis that are associated with SLE? | Pericarditis, Pleuritis
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| Renal symptoms associated with SLE? | Proteinuria, cellular casts, GN
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| Neurologic disorders associated with SLE? | Seizures, psychosis
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| Hematologic symptoms associated with SLE? | Leukopenia, Lymphopenia, Hemolytic anemia, Thrombocytopenia
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| Immunologic abnormalities associated with SLE? | Anti-phospholipid antibody, anti-DNA, anti-Sm, false+ syphilis test
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| Standard of care for SLE pharmacologic treatment, including cutaneous manifestations? | Hydroxychloroquine
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| Commonly prescribed adjunct medications in SLE to help with symptomatic relief? | Steroids, NSAIDs, low-dose ASA (to prevent thrombotic events)
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| Neurologic lupus, lupus nephritis, or vasculitis of internal organs should be treated with? | Cyclophosphamide
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| Photosensitive red rash to cheeks & chin with confluent erythema and induration that spares nasolabial folds is? | ACLE (Acute cutaneous lupus erythematosus)
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| % of people with ACLE that have systemic lupus? | 100%
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| 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)
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| % of people with SCLE that develop systemic lupus? | 50%
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| 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)
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| What % of patients with DLE develop systemic lupus? | 30%
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| ____C3/C4 levels are associated with SLE. | Low
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| Only way to confirm lupus nephritis? | Renal biopsy
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| Most common class of lupus nephritis in SLE patients? | Class IV (Diffuse proliferative GN)
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| Class of lupus nephritis with worst prognosis? | Class IV (Diffuse proliferative GN)
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| What class of lupus nephritis is this: Normal or minimal change disease? | Class I
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| What class of lupus nephritis is this: Mesangial GN | Class II
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| What class of lupus nephritis is this: Focal proliferative GN | Class III
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| What class of lupus nephritis is this? Diffuse Proliferative GN | Class IV
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| What class of lupus nephritis is this? Membranous GN | Class V
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| % of SLE patients that are women? | 90
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| > or = to __ points on the ACR/EULAR defines RA. | 6
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| Swollen synovium is called ______. | Pannus
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| TNF-alpha, IL-1, & IL-6 are _______ that perpetuate systemic inflammation by stimulating __ &__ cells which continue the inflammatory cascade. | Cytokines, B, T
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| __-cells secrete immunoglobulins, including RF. | B
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| Sx of RA typically last greater than __ weeks. | 6
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| Morning stiffness in RA typically lasts longer than _____. | 1 hour
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| List 3 common joints affected by RA: | Wrists, MCPs, PIPs
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| List 3 common deformities associated with RA: | Boutonnierre, Swan Neck,Ulnar deviation
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| Labs that are typically + in RA? | RF (80%), Anti-CCP antibodies (80%), ESR/CRP, ANA (30%)
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| General workup for RA (excluding diagnostic factors like RF, CCP, etc) (5 items) | CBC, renal function, liver panel, CXR, XR of joints affected
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| Radiographic evidence does not occur until __-__ years after onset. | 1-2
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| __________ at site of synovial attachment, __-__ subluxation, ulnar deviation at MCPs, and flexion/extension contractures are common radiographic findings of RA. | Osteopenia, C1-C2
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| What lab is the most specific for RA? | Anti-CCP antibodies
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| 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)
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| 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)
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| Common surgical interventions for RA (4): | Joint reconstruction, joint replacement, joint fusion, or synovectomy.
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| Most common age range of presentation with RA? | 40-45
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| 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
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| All patients with vasculitis will have an elevated _____ and evidence of _________. Some may have a +_____. | ESR, ischemia, ANCA
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| If a patient presents with a purpuritic rash, fever, unexplained renal insufficiency & CVA and a +ESR, you should suspect? | Vasculitis
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| Before diagnosing vasculitis you should r/o (4)? | Infectious diseases, paraneoplastic syndrome, atrial myxoma, toxic drug effects.
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| Skin hemorrhages <3mm are called? | Petechiae
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| Skin hemorrhages>1 cm are called? | Ecchymosis
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| What are the 2 main types of small vessel vasculitis? | Wegener's Granulomatosis & Leukocytoclastic Angiitis
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| Saddle nose deformity, erosive sinusitis, & subglottic stenosis are associated with? | Wegerner's
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| 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
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| Induction therapy for Wegener's can include: | Rituximab, steroids, cyclophosphamide
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| Maintenance therapy for Wegener's includes: | MTX or Azathioprine
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| 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
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| Antihistamines are typically used to treat which type of vasculitis? | LCV
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| Medications prescribed for LCV (4)? | Antihistamines, Dapsone, Colchicine, Steroids (for fulminant dz)
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| Name a medium vessel vasculitis | Polyarteritis Nodosa
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| 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
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| 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
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| If a patient has Hep B and is dx with Polyarteritis Nodosa, what is the tx plan? | Antivirals, plasma exchange, Prednisone
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| 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)
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| 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
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| Name a type of large vessel vasculitis | Giant Cell Arteritis
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| A biopsy of giant cell arteritis will show? | Multinucleated Giant Cells
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| Amaurosis Fugax is associated with? | Giant Cell Arteritis
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| Treatment for giant cell arteritis? | High dose steroids, bisphosphonates
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| 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
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| What is the treatment for polymyalgia rheumatica? | Low dose steroids (x1-2 yrs) with bisphosphonates
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| Vasculitis that targets the upper & lower respiratory tracts, kidneys, joints, skin, eyes, nerves, and heart? | Wegener's
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| Type of vasculitis that only affects the skin? | LCV
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| Type of vasculitis that affects the skin, muscles, nerves, GI tract, and kidney? | PAN
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| Type of vasculitis that affects the aorta and its major branches and the extra-cranial branches of the carotid? | GCA
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