Rheumatology

Question 1

3 mechanisms of under excretion that can cause Gout?

Answer 1

• Renal insufficiency
• Ketoacidosis or Lactic acidosis
• Thiazides & aspirin

Question 2

Lab tests in Osteoarthritis?

Answer 2

Normal

x-rays are where to find the pathology

Question 3

OA - Tx?

Answer 3

1. Weight loss & moderate exercise
2. Acetaminophen

(NSAIDS are secondary to acetaminophen b/c of side effects – GI bleeding)

Question 4

What to look for in Synovial fluid of Acute Gout attack?

Answer 4

Elevated:

• Uric acid levels
• ESR
• WBCs

Question 5

Gout – x-ray findings?

Answer 5

Normal in early disease, erosions of cortical bone appear later on

Question 6

Gout – best initial Tx in acute attacks?

Answer 6

1. NSAIDS
2. Corticosteroid injection IF no response or contraindication to NSAIDS
3. Colchicine (only if cannot use NSAIDs or Steroids)

Question 7

Gout – chronic Tx?

Answer 7

1. Lifestyle mods (no alc, weight loss, decrease high purine foods like meat & seafood)
2. Stop Thiazides, aspirin, & niacin. Use Losartan for HTN
3. Colchicine
4. Allopurinol (dec’s prod of uric acid)
   - - Febuxostat if allopurinol is c/i’d (XO inhibitor)
5. Pegloticase (dissolves uric acid)
6. Probenecid & Sulfinpyrazone (increase excretion of uric acid in kidney – rarely used)

Question 8

Safe drug used to treat Gout if pt has Renal injury?

Answer 8

Allopurinol

Question 9

Allopurinol isn’t used for acute gout attacks.

If patient is already taking it, do you stop or continue its use during acute attacks?

Answer 9

Continue

Question 10

Best drug to treat HTN in patient w/ Gout?

Answer 10

Losartan

lowers uric acid

Question 11

Calcium Pyrophosphate Deposition Disease – most common risk factors?

Answer 11

Hemochromatosis & Hyperparathyroidism

also ass’d w/ Diabetes, Hypothyroidism, & Wilson Disease

Question 12

Gout vs. CPPD – joints involved?

Answer 12

Gout – big toe MCP

CPPD – knee & wrist
also CPPD differs from OA in that DIP & PIP are not involved

Question 13

CPPD – best diagnostic test?

Answer 13

Arthrocentesis – cannot confirm CPPD Dx w/out joint aspiration

(positively birefringent rhomboid-shaped crystals)

Question 14

Joint disease Synovial fluid w/ < 200 WBCs?

Answer 14

DJD

also x-ray w/ osteophytes, joint space narrowing, subchondral calcification, & bone cysts

Question 15

Joint disease w/ Synovial fluid WBCs btwn 2,000 - 5,000?

Answer 15

• Gout (negatively birefringent crystals)
• CPPD (positively birefringent crystals)
• Rheumatoid arthritis (anti-cyclic citrullinated peptide)

Question 16

Joint disease w/ Synovial fluid WBCs > 50,000?

Answer 16

Septic Arthritis

Question 17

CPPD – best initial Tx?

Answer 17

1. NSAIDS

2. Intraarticular steroids – Triamcinolone or Colchicine (only if NSAIDS aren’t effective)

Question 18

CPPD – prophylactic Tx between attacks?

Answer 18

Colchicine

helps prevent subsequent attacks

Question 19

Point tenderness at spine w/ percussion of vertebra is highly suggestive of what?

Answer 19

Cord compression

i.e. malignancy, epidural abscess

Question 20

Epidural abscess – most common organism?

Answer 20

Staph aureus

Question 21

Epidural abscess presentation vs. Cord compression from malignancy?

Answer 21

Same, except Epidural abscess has high fever & markedly elevated ESR

Question 22

How to exclude Sciatica (disc herniation) on diff. Dx?

Answer 22

Straight leg raise – above 60 degrees, causes pain going into buttock & BELOW the knee

• 50% specificity & 95% sensitivity (helps RULE OUT sciatica)

Question 23

L4 – motor deficit, reflex affected, & sensory area affected?

Answer 23

M - Dorsiflexion of foot
R - Knee jerk
S - Inner calf

Question 24

L5 – motor deficit, reflex affected, & sensory area affected?

Answer 24

M - Dorsiflexion of toe
R - None
S - Inner forefoot

Question 25

S1 -- motor deficit, reflex affected, & sensory area affected?

Answer 25

M - Eversion of foot R - Ankle jerk S - Outer foot

Question 26

Low back pain w/ positive SLR -- is MRI indicated?

Answer 26

No MRI | only indicated if severe or progressive neuro deficits are described, such as paralysis, weakness, etc.

Question 27

Cancer w/ compression - best initial test? | Most accurate

Answer 27

Best initial = X-ray | Most accurate = MRI CT if MRI contraindicated

Question 28

Ankylosing spondylitis -- Best initial test? Most accurate?

Answer 28

Best initial = X-ray | Most accurate = MRI CT if MRI contraindicated

Question 29

Cauda Equina Syndrome -- Best initial test? Most accurate?

Answer 29

Best initial = X-ray | Most accurate = MRI CT if MRI contraindicated

Question 30

Cord compression -- Tx while waiting for MRI results?

Answer 30

Glucocorticoids (to relieve compression)

Question 31

Most likely Dx? | Back pain + pain/numbness of medial calf or foot

Answer 31

Disk herniation (Sciatica) PE findings: - Loss of knee & ankle reflexes - Positive straight leg raise (95% of disk herniations are at L4/L5 or L5/S1)

Question 32

Most likely Dx? | Back pain + Hx of cancer

Answer 32

Cord compression (malignancy) PE findings: Vertebral tenderness, sensory level, hyperreflexia

Question 33

Most likely Dx? | Back pain + Fever & high ESR

Answer 33

Epidural abscess PE Findings: Vertebral tenderness, sensory level, hyperreflexia

Question 34

Most likely Dx? | 30 yr old patient w/ back pain that's better w/ activity & worse w/ rest

Answer 34

Ankylosing Spondylitis (pt < 40yrs.) PE findings: Decreased chest motility

Question 35

Most likely Dx? | Back pain + Bowel & bladder incontinence + Erectile dysfunction

Answer 35

Cauda Equina PE Findings: - Bilateral leg weakness - Saddle area anesthesia

Question 36

Cord Compression -- Tx?

Answer 36

1. Systemic glucocorticoids 2. Chemotherapy (for lymphoma) or Radiation (for solid tumors) 3. Surgical decompression (if 1 & 2 are ineffective)

Question 37

Epidural Abscess -- Tx? Which condition has same Tx?

Answer 37

1. Steroids to control acute neuro deficits 2. Anti-Staph ABX (Vancomycin or Linezolid) given until sensitivity of organism is known - Β-lactam ABX more effective if sensitive-staph is found (Oxacillin, Nafcillin, Cefazolin) - add Gentamicin for synergy w/ Staph 3. Surgical drainage for larger collections of fluid

Question 38

Cauda Equina -- Tx?

Answer 38

Surgical Decompression

Question 39

Disk Herniation (Sciatica) -- Tx?

Answer 39

1. NSAIDs & continue normal daily activity 2. Yoga/PT 3. Steroid injection for rapid & dramatic benefit if 1 & 2 ineffective 4. Surgery is rarely needed (only needed if focal neuro deficits develop or progress)

Question 40

Spinal cord compression -- most important first step?

Answer 40

Steroids urgently to decrease pressure on cord (i.e. Dexamethasone) & prevent paralysis

Question 41

Lumbar Spinal Stenosis -- back position that causes pain?

Answer 41

Extension (cord presses backward against ligamentum flavum)

Question 42

Spinal stenosis -- vascular study results?

Answer 42

Normal | SS can simulate Peripheral Artery Disease, but this distinguishes them

Question 43

Lumbar Spinal Stenosis -- Dx test?

Answer 43

MRI (only test)

Question 44

Lumbar Spinal Stenosis -- Tx?

Answer 44

1. Weight loss & pain meds (NSAIDs, Opiates, Aspirin) are first 2. Steroid injections 3. PT & exercise 4. Surgical correction to dilate spinal canal is needed in 75% of patients

Question 45

Fibromyalgia -- presentation?

Answer 45

Young woman chronic MSK pain & tenderness w/ trigger points of focal tenderness @ trapezius, medial fat pad of knee, & lateral epicondyle

Question 46

Fibromyalgia -- Tx?

Answer 46

Best initial = Amitriptyline Others: - Milnacipran (5HT/NE reuptake inhibitor) - Pregabalin - Trigger point injections w/ anesthetics

Question 47

Carpal Tunnel pain is worse when?

Answer 47

At night | also: sensory Sx occur before motor

Question 48

Carpal Tunnel -- most accurate diagnostic test?

Answer 48

Electromyography & Nerve Conduction studies

Question 49

Carpal Tunnel -- best initial Tx?

Answer 49

1. Wrist splint to immobilize & NSAIDS 2. Steroids 3. Surgery (cut open flexor retinaculum to relieve pressure)

Question 50

What is Dupuytren Contracture?

Answer 50

Hyperplasia of Palmar Fascia leading to nodule formation & contracture of fourth