1
Q
What is the most important part of an evaluation of a patient with suspected rheumatic disease?
A
A careful and detailed history and physical exam
2
Q
What is the likely presentation of a simple partial seizure?
A
- No impairment of consciousness
- Focal myoclonus of a limb, hand or face
- Rising epigastric sensation
- Deja-vu
3
Q
Which type of ischemic stroke is more common in long-standing diabetes and hypertension patients?
A
Small vessel - lacunar infarction strokes
4
Q
Which labs to order when systemic lupus erythematosus is suspected?
A
- CBC
- ANA
- UA
(if normal, SLE excluded)
5
Q
Drug-related lupus is usually characterized by fever, hematologic abnormalities, and 80% of patients will complain of this symptom …
A
Arthralgias
6
Q
Nonpharmacologic treatments for osteoporosis
A
- Smoking cessation
- Exercise
- Alcohol moderation
- Increased dietary calcium and vitamin D
7
Q
Treatment for dermatomyositis/polymyositis
A
- Glucocorticoids mainstay of therapy (prednisone)
- Methotrexate
- Skin protection (photosensitivity)
8
Q
Define scleroderma
A
Disease characterized by deposition of fibrous connective tissue in the skin and other tissues.
May be systemic or localized.
9
Q
What is the gelling phenomenon?
A
Morning stiffness with inflammatory arthritis such as SLE or RA that lasts more than 30 minutes
10
Q
What type of pleural effusion is likely to be seen as a complication of rheumatoid arthritis?
A
- Exudative
- Low glucose and pH
11
Q
Diagnostic tests for epilepsy
A
- Careful history and neurologic exam essential
- Electroencephalography (EEG) - best if patient is sleep deprived
- Brain MRI with seizure protocol (CT less sensitive than MRI)
12
Q
What GI complications are associated with scleroderma?
A
- Esophageal hypomotility in 90% (causes GERD)
- Diverticula of the colon
13
Q
In a patient who is suspected to be showing early stroke signs, will their eyes likely point towards or away from the side of the clot/lesion?
A
Eyes towards lesion
14
Q
Which subset of lupus is the most common form of chronic skin disease and causes non-photosensitive, scarring lesions?
A
Discoid lupus erythematosus
15
Q
What is the most common presenting symptom of systemic lupus erythematosus?
A
Arthralgias (90%)
16
Q
Define systemic lupus erythematosus
A
A chronic autoimmune illness characterized by autoantibodies directed at nuclear antigens causing a variety of symptoms, including rash, arthritis, leukopenia and thrombocytopenia, alopecia, fever, nephritis, and neurologic disease
17
Q
How many of the diagnostic criteria are required to diagnose a patient with systemic lupus erythematosus?
A
Four or more
18
Q
Risk factors for rheumatic diseases
A
- Female
- Age
- Lower education level
- Sedentary lifestyle
- High BMI
- Smoking (RA)
19
Q
What does GFAST/BEFAST stand for and what is it used for?
A
- Gaze/Balance + Eyes
- Facial droop
- Arm drift
- Speech
- Time to call 911
Early stroke detection tool
20
Q
Risk factors for osteoporosis
A
- Female
- Age
- Postmenopausal status
- White or Asian
- Low BMI
21
Q
Due to the risk of cardiovascular disease in rheumatoid arthritis, patients should be given this medication which lowers blood sugar
A
Hydroxychloroquine
22
Q
If a calcium metabolism problem is suspected as the cause of a patient’s low bone mineral density you should check these two lab values
A
- PTH
- Vitamin D (25-hydroxy OH)
23
Q
Which rheumatic disease requires a patient to have neck flexion and extension films checked before being intubated for surgery?
A
Rheumatoid arthritis in the cervical spine
24
Q
Which condition is associated with microstomia?
A
- Microstomia = small mouth
- Associated with scleroderma due to tightening of skin on face
25
Treatment for subarachnoid hemorrhage
- Localize aneurysm and clip
- Gently lower BP to <140 mm Hg
- Elevate head of bed
26
What is the most frequent cause of death in patients with scleroderma?
Lung disease
27
Define a transient ischemic attack
A sudden vascular-related neurologic deficit *without* evidence of infarction that resolves completely within 24 hours
28
Diagnostic tests for dermatomyositis/polymyositis
- Muscle biopsy
- Muscle enzymes (creatine kinase)
- Autoantibodies (nuclear and cytoplasmic)
29
After a negative non-contrast CT in a patient with a suspected subarachnoid hemorrhage, what is the next best diagnostic test?
Lumbar puncture - check for RBCs in CSF
30
What condition can cause osteoarthritic changes at the MCP joints of the fingers?
Calcium pyrophosphate deposition (pseudogout)
31
Is an absence seizure classified as a focal or generalized seizure?
Generalized seizure
32
Which medications can cause drug-related lupus?
- Procainamide
- Hydralazine
- Penicillamine
- Minocycline
33
Which antibodies are you most likely to see in a patient with systemic lupus erythematosus?
Antinuclear (in almost all and primarily to double-stranded DNA)
34
What symptoms would you expect to see in a patient with a stroke in their anterior cerebral artery?
- Contralateral leg weakness
- Incontinence
35
How do bisphosphonates work to treat osteoporosis?
Kill osteoclasts
36
How would an epidural hematoma appear on CT scan?
Convex/lens shaped pattern around MMA area
37
What is sclerodactyly?
- Hallmark symptom of scleroderma
- Thickening and tightening of skin on fingers and hands
38
What is the gold standard diagnostic lab test for systemic lupus erythematosus?
ANA pattern immunofluorescence
(peripheral/rim almost exclusively seen in SLE)
39
What is the most sensitive blood test for inflammation?
SPEP (serum protein electrophoresis)
40
Define scleroderma
Disease characterized by deposition of connective tissue in the skin and other tissues. Can be systemic or localized
41
Which joints can be affected by osteoarthritis, but never by rheumatoid arthritis?
- Thoracic and lumbar spine
- DIP
42
How can scleroderma lead to malignant hypertension?
Lupus nephritis -> Kidney dysfunction -> Renal crisis -> Uncontrolled hypertension
43
This type of seizure is most commonly seen in children, lasts 1-2 minutes, and typically is not associated with epilepsy
Febrile seizures
44
What is the most common cause of hemorrhagic stroke?
Hypertension
45
Treatment for "overlap syndromes"
Corticosteroids/immunosuppresion
46
Recurrent, similar strokes in the same vascular territory suggest this cause
Large vessel atherothromboembolism
47
What are the common pathophysiologies of scleroderma?
- Progressive fibrosis
- Vascular abnormalities
- Inflammation
- Collagen deposits
48
Define a stroke
A sudden neurologic deficit caused by either ischemia (87%) or hemorrhage (13%)
49
Treatment for systemic lupus erythematosus
- Avoid sun exposure/use sunscreen
- NSAIDs (naproxen) for pain and fever
- Hydroxychloroquine for inflammatory rashes
- Prednisone/immunosuppression therapy if severe
- Mycophenolate motefil and cyclophosphamide first line for lupus nephritis
50
Which condition can cause Jaccoud's arthropathy and what is it?
- Systemic lupus erythematosus
- Deformity of hand, ulnar deviation of the fingers, without bone destruction
51
Which medications can lower the seizure threshold?
- Bupropion
- Tramadol
- Antibiotics: fluoroquinolones, carbapenems, cefepime
52
What is the likely presentation of a tonic-clonic seizure?
- Often preceded by aura
- Loss of consciousness
- Apnea
- Violent contractions of the muscles of the trunk and extremities
- Postictal state occurs
53
Which condition is characterized by symmetrical proximal muscle weakness in extremities, accompanied by a characteristic skin rash?
Dermatomyositis
54
Which joints can be affected by rheumatoid arthritis, but never by osteoarthritis?
- MCPs
- Elbows
- MTPs + TMTs
- Wrist
- Shoulder (?)
55
What symptoms would you expect to see in a patient with a stroke in their vertebral artery?
- Crossed facial sensory and body motor signs
- Facial numbness and weakness
- Vertigo, nausea, vomiting
56
Recurrent, widespread vascular injury is the pathological hallmark of this disease
Systemic lupus erythematosus
57
Side effects of rheumatoid arthritis treatment
DMARDs, biologics, and prednisone can all lead to increased infection risk
58
What is the first imaging method that should be used in the analysis of a stroke patient?
Non-contrast CT of the head
59
What is most often the initial manifestation of generalized scleroderma?
Raynaud's phenomenon
60
Where are rheumatoid nodules likely to be seen?
At pressure points:
- Forearm
- Achilles
- Sacrum/spine
61
Diagnostic criteria for osteoporosis
- DEXA scan for T/Z scores
- T score <-2.5 is diagnostic
OR
- T score -1 to -2.5 with FRAX risk of 3%+ for hip or 20%+ for other fracture
62
Symptoms of subarachnoid hemorrhage
- Severe, thunderclap headache
- Rapid onset
- Photophobia
- Decreased consciousness
63
Which vaccinations are recommended for patients on immunosuppressive therapy for rheumatoid arthritis?
- No live vaccines!
- Flu
- Pneumonia
- Zoster (shingrix, not zostavax = live)
- COVID
- Household members keep vaccines up to date also
64
How many points on the RA classification scale are needed for a definitive diagnosis?
6 or more
65
What physical exam sign and lab test are the best predictors for patients with Raynaud's phenomenon developing scleroderma?
- Abnormal nailfold capillary patterns
- Positive ANA test
66
Target intakes for calcium and vitamin D in the treatment of osteoporosis
- Calcium: 1,200 to 1,500 mg/day
- Vitamin D: 600 to 800 IU/day
67
Scleroderma patients almost always (90%) have this condition seen in the fingers
Raynaud's phenomenon (also sclerodactyly, but Raynaud's more common)
68
What are the five "overlap syndromes"?
- Rheumatoid arthritis
- Dermatomyositis
- Lupus
- Polymyositis
- Sjogren's
69
What is the most common type of generalized seizure?
Convulsions (tonic-clonic)
70
What is the name of the generalized seizure type that causes sudden loss of postural tone and may cause falls?
Atonic seizures
71
If circulating levels of calcium in the blood fall, will PTH secretion rise or fall in response?
- PTH will go up
- PTH increases bone resorption, renal calcium reabsorption, and GI absorption
72
What is (perhaps) the most important diagnostic test in rheumatology?
Synovial fluid analysis
73
Treatment for epidural hematoma
Urgent surgical hematoma evacuation is required
74
Which condition is associated with interarticular dermatitis, A rash between the MCP and PIP knuckles?
Systemic lupus erythematosus
75
Treatment for scleroderma
- No disease modifying treatments
- Manage comorbidities
76
As a rule, characteristic disease of one organ system (kidney, joints, skin) plus a high-titer anti-dsDNA antibody is sufficient to make the diagnosis of ...
Systemic lupus erythematosus
77
Symptoms of rheumatoid arthritis
- Small joints of hands and feet involved first
- Morning stiffness >30 minutes
- Joint swelling, warmth, tenderness, limited ROM
- Symmetrical!
- Cervical spine involvement
- Elbows - nodules on pressure points
- Extra-articular: Fatigue, eyes, lungs, heart
78
This condition causes synovial lining hyperplasia, increased synovial effusions, increased WBCs, and erodes cartilage and bone
Rheumatoid arthritis
79
What is the likely presentation of an absence seizure?
- Not preceded by aura
- Arrest of behavior and blank stare
- Eyelid blinking
80
What is the best lab test to monitor the progression of rheumatoid arthritis?
Anti-citrullinated peptide antibodies (anti-CCP)
81
What is the most common form of chronic inflammatory arthritis?
Rheumatoid arthritis
82
Is rheumatoid arthritis more common in men or women?
3x more common in women
83
You see a middle aged (post-partum) female with symmetrical inflammatory arthritis, what is the most likely diagnosis?
Rheumatoid arthritis
84
What is the best imaging method to determine whether or not a stroke is caused by hemorrhage?
Non-contrast CT
85
Which subset of lupus is known as "ANA negative" lupus and causes photosensitive, non-scarring lesions?
Subacute cutaneous lupus erythematosus
86
What is the leading cause of disability in the US?
Stroke
87
What symptoms would you expect to see in a patient with a stroke in their middle cerebral artery?
- Contralateral hemiparesis and hemisensory deficit (face, arm, leg)
- Aphasia or neglect
- Contralateral visual field defect
- Deviation of gaze
88
Symptoms of systemic lupus erythematosus
- Malaise, arthralgia, myalgia, fever, weight loss
- Facial malar (butterfly pattern) rash across cheeks and nose
- Photosensitivity
- Alopecia
- GI and hepatic (diverticulitis)
- Hematologic (*if no leukopenia, not SLE*)
- Neurologic - headaches common (brain disease, psychosis, neuropathy)
- Renal (1/2 have nephritis)
- Ocular (keratoconjunctivitis sicca)
89
What is the most common hematologic abnormality seen in patients with systemic lupus erythematosus?
Anemia of chronic disease
90
In a patient with systemic lupus erythematosus who has a prolonged PTT or PT, how will supplementing them with normal plasma affect their clotting times?
- Normal plasma won't correct
- Lupus patient likely has anti-phospholipid antibodies causing the prolonged clotting times (not a deficiency)
91
Side effects of raloxifene
- Increased DVT risk
- Hot flashes
- Decreased breast cancer (good thing!)
92
Differentiate between these two forms of scleroderma:
- Localized
- Generalized
Localized:
- Plaque-like indurations (morphea)
- Involves the skin, SQ tissue, and muscle
- *No* Raynaud's or visceral symptoms
Generalized:
- Diffuse visceral involvement
- CREST syndrome
93
What is the likely presentation of a complex partial seizure?
- Consciousness is affected
- Arrest of motion and a blank stare
- Automatisms: mouth movements/swallowing, verbal utterances
94
Treatment for osteoporosis
- Bisphosphonates: 3-5 years
- Raloxifene
- Prolia
- Anabolics: Forteo, Tymlos, Evenity
95
Which demographics are most likely to develop systemic lupus erythematosus?
- Women
- 15 to 45
- African-American
96
In which type of generalized seizure is consciousness not affected?
Myoclonus seizures
97
What does "CREST syndrome" relate to?
Symptoms of limited systemic scleroderma
- Calcinosis
- Raynaud phenomenon
- Esophageal involvement
- Sclerodactyly
- Telangiectasias
98
Bony overgrowths in the DIP joints are characteristic of this condition
Osteoarthritis
99
Which medications would a pregnant mother with rheumatoid arthritis need to stop three months before conceiving?
Methotrexate/leflunomide
100
What symptoms would you expect to see in a patient with a stroke in their posterior cerebral artery?
Occipital infarction leads to contralateral visual field loss
101
Which condition is associated with the gullwing sign?
Inflammatory OA
102
What lung complications can arise from scleroderma?
Pulmonary interstitial disease and/or pulmonary hypertension
103
Treatments for rheumatoid arthritis
- Methotrexate (standard of care, leflunomide alternative)
- Hydroxychloroquine, sulfasalazine (MTX + HCQ + SSZ = triple therapy)
- Biologic agents
- Prednisone
104
Treatment of hemorrhagic stroke
- Stop/reverse anticoagulation
- Maintain BP between 140 and 180 mm Hg
- Monitor intracranial pressure
105
Why should bisphosphonate therapy be limited to five years maximum?
- Lack of bone turnover increases fracture risk
- Esophagitis and GI damage
106
Side effects of bisphosphonates
Esophagitis
107
Most common cause of subarachnoid hemmorhage
Traumatic head injury
108
Diagnostic tests for scleroderma
- ANA positive in 85% but not specific
- Topoisomerase, anticentromere, RNA polymerase antibodies more specific
109
This form of calcium supplement causes the *least* constipation
Calcium citrate
110
Definition of epilepsy
Two unprovoked seizures that occur more than 24 hours apart within one year
OR
One unprovoked seizure plus abnormal EEG or brain MRI
111
Ischemic stroke treatment
- Aspirin within 48 hours of onset
- tPA asap (within 4.5 hours)
- Endovascular therapy (surgery) if later
- Permissive hypertension (170 to 200 mm Hg initially)
112
What is the ischemic penumbra?
Tissue around the center of a stroke with impaired blood flow but active metabolism (savable tissue, calculated with CT perfusion mismatch)
113
Symmetrical swelling of the hands and feet, but *not* the DIP joints suggests this condition
Rheumatoid arthritis
114
How can scleroderma lead to kidney failure?
- Collagen deposits in glomeruli block filtration
- Intimal thickening of renal vessels blocks blood flow
115
On evaluating a patient's lab results you see the following:
- Elevated ESR and CRP
- RF positive
- Anti-CCP positive
- Hypocomplimentemia
What is the most likely diagnosis?
Rheumatoid arthritis
116
What is Felty's Syndrome?
RA, leukopenia, and splenomegaly
117
Hypocomplementemia in a patient with systemic lupus erythematosus suggests this complication has developed
Renal disease
118
What is often the first sign of scleroderma in the skin?
Swelling and thickening in the skin of the fingers and hands
119
Common causes of stroke
Embolization due to:
- Atrial fibrillation
- Heart failure
- Atrial myxoma
- Hypertension
- Cigarette smoking
- Sickle cell disease
- Hyper-viscosity syndromes
120
What symptoms would you expect to see in a patient with a stroke in their basilar artery?
- Oculomotor deficits
- Ataxia
Clin Med 2
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