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level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
AM pain/stiffnes > 30 mi for at least 6 wk, fatigue, wt loss, anorexia, fever Affects bilateral small joint MCP and PIP. Rheumatoid nodule, knee involvment , C spine subluxation'What are the sx and sign of Rheumatoid Arthritis?
Anti CCP, sed rate, CRP, RF, CBC and CMP Xray of involved joint (RF may be - initially, can take up to 2 years to show)How do you dx RA?
Cardiac: Increase risk of AS, pericarditis, myocarditis, valve nodule Lung: Pleurisy with effusion diffuse Interstitial fibrosis Renal : Amyloid renal dz Blood: anemia of chronic dz and neutropenia Vasculitis: Synovial inflammation Nerve: Mononeuritis multiples with foot and wrist drop Skin: rheumatoid noduleWhat are the extra articular manifestation of RA?
RA, splenomegaly and neutropeniaWhat is Felty Syndrome?
NSAIDS: Iburofen or COX-2 Inhibitors ( do not affect platelet) Steroids: Low dose < 10 taper over a month or low dose 2.5-5 mg chronic. ( Do not alter course of disease)What is the First line treatment of RA?
DMARDS: Disease modifying anti rheumatic drugs ( Sulfasalazine or hydroxychloroquine, MTX) Biologics: Infliximab ( Remicade) etanercept ( Enbrel) leflumonide ( Arava) , Anakinra (Kineret) $$$ 40/dWhat is second line for treatment of RA?
Block activity of TNF. Work best when given along with MTX. Halt and heal erosive changes.How do Biologics work?
Infection, esp. reactivation of TB. Screen all pt with PPD and CXR. Hep B and C Vaccinate for pneumococcal, Zoster, Flu, Hep B.What are the side effects of Biologics?
Use for aggressive dz. Contra: Renal, liver dz and ETOH. SE: Nausea, stomatitis, diarrhea and bone marrow depression and idiosyncratic pneumonitis ( 2-6% ) Give with folic acid. Monitor LFT, CBC, and renal function Q2 mo.What are SE of MTX?
Retinopathy: Check eye exam yearly Renal: Check renal function.What are the SE of Hydroxycholoquine.
Bone marrow depression: Check CBC Oligospermia and liver dz.What are the SE of Sulfasalazine?
Hands: DIP ( Heberdon's node) and PIP ( Bouchard nodes) Spine, hips, knees.Which joints are most affected in OA?
Joint space narrowing, osteophytes, subchondral bone sclerosis, and pseudocyst.What are the xray findings in OA?
Tylenol, Topical analgesics: Capsasin, DMSO, Methsalycilate, Voltaren, Mucopolysaccaride injection. and Exercise.What is the treatment of OA?
Joint swelling 50% initially in first MTP joint ( Podagra) Swelling may extend beyond foot and involve lower leg.What are the sx of gout?
Decrease renal excretion of Uric acid. Serum UA elevated > 9 Secondary causes : ETOH, low dose salicylate and thiazide diuretics and ACE. Diet: HFC, shellfish, meat and ETOHWhat causes gout?
NSAIDS : Naproxen 500 mg bid Indomethacin 50 mg tid x 5-7 days. Steroid in Elderly: Prednisone 30-50 mg x 7-10 days.How do you treat acute gout?
After acute attack subsided. If at least 2 flares/ year, tops or nephrolitiasis. Start allopurinol for uric acid elevation, but wait until acute attack subsided. Continue NSAID for 3 mo to prevent attack. Can determine if overproducing UA by checking a 24 urine uric acid level. > 750 indicates overproduction and allopurinol would be indicated. Do not treat asymptomatic elevated UA.When do you start allopurinol?
Poly arthritis of the hands, knees and wrist.What is pseudo gout?
Calcium pyrophosphate crystals, Causes chonedrocalcinosis, calcium in the cartilage on xray.What causes Pseudogout?
Joint aspiration showing rhomboid positive bifringence.How do you dx pseudo gout?
Hemochromatosis and hyperparathyroid. Cause increase in phosphate and trauma causes precipitation of crystals.What conditions predispose to pseudo gout?
Intra articular steroid injection, NSAIDS, Oral steroid.How do you treat pseudo gout?
Non inflammatory disorder related to neurotransmitter dysfunction. Centralized pain disorder with pain amplification.Fibromyalgia: What causes it?
Mutifocal pain, sleep disturbance and memory problems. Joint and proximal muscle tenderness. Points no longer checked.What are the symptoms of fibromyalga?
Worse: Humid weather, stress , poor sleep Better: Dry hot weather, relaxation and sleep.What makes fibromyalgia worse and better?
Anxiety, depression, migraine, IBS, PMS, non cardiac CP, restless leg, dysmenorrhea, RA, Lupus.What are associated conditions with fibromyalgia?
Hypothyroid, chronic fatigue, and myofacial pain. WU: Check: CBC sed rate RF, TSK and CPK.What is the DDX of fibromyalgia?
Non pharmacolgogic: Exercise, CBT, Yoga, acupuncture, TCA ( Amitriptyline 25 mg QHS along with Fluoxetine 20 mg in am Gabapentin 2/3 dose in pm and 1/3 in am Pregabalin ( Lyrica) is newest approved by $$$ Tramadol may help. Cyclobenzaprine 5 mg given 3 hours before bed to minimize grogginess. Cannabinoids oral better than inhaled. SNRI: Duloxetine or EffexorHow do you treat fibromyalgia?
ankylosing spondylitis Reiters syndrome Psoriatic Artharitis Inflamatory bowel diseaseWhat are the seronegative spondyloarthorpathies
Asymmetric polyarhtaritis with involovment of SI joints ( sacroilitis) and spine. Back pain > 3 mo with stiffness. Asssociated sx: Uveitis ( photophobia, lacrimation and pain) Aortitis presenting as aortic insufficiency.What are the sx of ankylosing spondylitis?
Xray: SI fusion, Bamboo spine Labs: HLAB27, CRP elevation, Clinical: Schober test,, pain over SI joint and achilles tendon insertion.How do you diagnose AS?
NSAIDS, DMARDS, and Biologics, intra- articular steroid injection, PTHow do you treat AS?
Arthritis with infection elsewhere in the body. Findings: Sausage digits, Urethritis, conjunctivitis, asymmetric arthritis, skin discoloration of feet.What is Reiters syndrome?
Chlamydia, Ureaplasma, Salmonella, Shigella, Campy and c. diff.What causes Reiters?
Nail pitting, oonycholysis, sausage digits, and severe resorptive degeneration of joint.What are the hallmarks of Psoriatic Arthritis?
B ones: symmetric nonerosive arthritis, Skin: Malar rash and oral ulcers, Lung: Pleuritic chest pain, effusion, pnumonitis, PE, Heart: Pericarditis, , CAD, Valve dz, Kidney: Glomerulonephropathy and RF., Blood:Thrombosis, anemia, leukopenia, CNS: Psychosis, seizure, and strokeWhat is the multiorgan invlvement of SLE?
Anti-ds DNA and anti-SM Ab Anticardiolipin and lupus anticoagulants are associateed with thrombosis and fetal lossHow do you diagnose Lupus?
NSAIDS and Antimalarial ( hydroxychloroquine) effective for rash and artharitis Steroid for organ involvement. Azathioprine and cyclophosphamide for renal and CNS diseaseHow do you treat Lupus?
Stiffness in bilateral shoulder girlds and hand swelling Associated with temporal artharitis in 20%PMR sx?
Start low dose prednisone 10-20 mg/d and monitor disesase activity with Sed rate.PMR treatment
Unexplained persistent relapsing chronic fatigue not alleviated with rest and causing decrease in function. Associated with 4 of the following. impaired concentration, sore throat, lymph nodes, muscle pain, multijoint pain, headache, nonrefreshing sleeping post exertional malaise > 24 hours.What is chronic Fatigue syndrome?
Thought to be post infectious, accompainieed by immunologic disturbance and depression. Causing hypothalamic dysfunction. No dx testWhat causes chronic fatigue?
NSAIDS for pain TCA for mood and sleep Venlafaxine low dose CBT and exerciseHow do you treat chronic fatigue?
Granulomatous disease involving lung, skin cardiac, joint and eyes. Lung: 90% with sx: bilateral hailar adenopathy presents with cough, dyspnea, chest pain. Skin: Erythema nodosum, Eyes: dry eyes, viousla changes Cardiac: palpitation , syncope, fatigue, fever, wt loss.What is Sarcoidosis and what are the sx?