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Rheum 2
Lets talk antibodies
100
A transvaginal ultrasound examination reveals a mass in the adnexa and no evidence of an intrauterine pregnancy. What is the best management?
Ectopic pregnancy
Methotrexate then trend b-hCG
Exam findings for ectopic:
Amenorrhea, unilateral lower abdominal pain, vaginal bleeding, adnexal mass
Also note history of PID, IVF, previous ectopic
100
Repetitive variable decelerations noted on fetal heart tracings suggest?
What about late decels?
Early decels?
variable decelerations= umbilical cord compression
late decelerations = Uteroplacental insufficiency
Early decels→ decrease in HR during a contraction from fetal head compression. Normal progression of labor
100
A 12-year-old boy is brought in to your office by his mother and father. The child has been experiencing swelling of his joints, fevers, and a rash on and off for 7 weeks. What is the most likely diagnosis and management?
Idiopathic Juvenile Rheumatoid Arthritis
Systemic due to fever +rash
Most commonly polyarticular (5+ joints affected)
Clinical diagnosis: labs (ESR, CRP, ANA, can be RF neg or pos)
Treatment: NSAIDS, corticosteroids, methotrexate, biologics.
75-80% remit without serious disability
100
What is the name of the rash associated with Systemic Lupus Erythematosus?
Malar rash on the face
"butterfly" rash
along cheeks and nose but spares nasolabial folds!
100
What is the most specific antibody for SLE?
Anti-smith is most SPECIFIC
200
Choriocarcinomas are malignant placental cancers that are associated with what rare pregnancy complication?
Molar pregnancies
Incomplete and complete moles are considered premalignant because of risk of developing into invasive moles or choriocarcinoma although a rare complication.
200
a 28-year-old P1G0 pregnant female presents for a prenatal visit at 37 weeks. The pregnancy has been unremarkable thus far. Her blood pressure (BP) is 148/94 mm Hg, and her urine dipstick shows +1 proteinuria. What is the recommended management?
Delivery! Because she is 37 weeks. Should also give magnesium for seizure prophylaxis.
Pre-eclampsia→ new onset HTN with proteinuria
eclampsia is HTN+ proteinuria+ seizures
200
a 36-year-old woman who comes to your office with a 6-month history of malaise, paresthesia in both hands, and vague pain in both hands and wrists. She also has felt extremely fatigued. She tells you that the pains in her joints are much worse in the morning and improves throughout the day. She is also noticing pain and swelling in both knees. There is a sensation of bogginess and slight swelling in both wrists and multiple metacarpophalangeal joints. Both knees also feel swollen and boggy. There are no other joint abnormalities, and the rest of the physical examination is normal. Rheumatoid factor and anti-citrullinated peptide antibodies are positive. What is the most important medication to begin asap for best long term outcome?
DMARD!!
Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide
Also biologics→ humira, enbrel, tremfya, taltz
Steroids and NSAIDs to bridge and treat the acute pain but should be tapered once DMARD/biologic is started
200
What joints are affected by psoriatic arthritis?
The arthritis is often asymmetric, and some forms involve the distal interphalangeal joints.
- Inflammation of the flexor tendons of fingers, toes, or both may lead to sausage-shaped deformities (dactylitis), which are not present in patients with rheumatoid arthritis
200
What is the most sensitive antibody for SLE?
Antinuclear antibody- ANA is very sensitive 95% but not very specific= lots of false positive
300
Describe how Rh incompatibility can cause hemolytic disease of the newborn?
Rh negative mom + Rh Positive dad= possible Rh positive fetus
Leads to mother developing anti-Rh antibodies that can pass through placenta and attack fetal RBC in subsequent pregnancies.
Anti-Rho immunoglobulin given at 28 weeks for Rh negative mothers, given again 72 hours after delivery
Any sensitization event→ pROM, placental abruption, etc can cause blood crossing and development of antibodies
300
What ways can you confirm premature rupture of membranes?
>37 weeks gestation. If <37 weeks then Premature PROM
Speculum exam showing fluid pooling in the posterior fornix
Nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - pH > 7.1 means it is positive
Microscope examination - ferning - take a specimen of the fluid put it on a slide and let it air dry will see "fern pattern" crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid)
300
A 45 yo female presents with c/c of "weird fingers." She says her hands usually feel stiff in the morning and look fat, but she knows this is normal because it happens to her mom and sister. Over the years though they have gotten more deformed looking. Given the likeliest dx, which two deformities might you see on PE?
RA!
Boutonniere deformity: flexion at PIP, hyperextension of DIP
Swan neck deformity: flexion at DIP with joint hyperextension at PIP
Involves MCP, PIP, WRIST, knee, MTP, shoulder, and ankle
Symmetric arthritis: swollen, tender and boggy joint
Ulnar deviation at MCP joint
Rheumatoid nodules
300
a 24-year-old male with severe morning back pain and stiffness over the past three months. His pain improves as the day progresses and with exercise. He also complains of photophobia and eye pain with redness. Physical exam shows a stooped posture and diminished anterior flexion of the lumbar spine. Radiography of the lumbar spine shows bilateral sclerotic changes in the sacroiliac area and squaring of the vertebral bodies. What lab findings can help confirm the suspected diagnosis?
Elevated ESR and positive HLA-B27
Ankylosing spondylitis
Bamboo spine on x-ray
Associated with psoriasis, inflammatory bowel disease, anterior uveitis, and aortic regurgitation
Younger male with low back pain.
Treatment includes NSAIDs, PT, anti-TNF biologics
300
Positive HLA-B27 should make you think of these two diseases?
Ankylosing spondylitis and reactive arthritis
400
A 25yo female who is 12 weeks pregnant presents with sudden abdominal pain and vaginal bleeding. Upon exam you notice the cervical os is open but there doesn't appear to be any passage of fetal tissue. What type of abortion is this?
Inevitable. Open os without passage of fetal tissue. The progression of abortion is unlikely to be stopped.
Can technically do expectant management until 13 weeks gestation- aka wait to see if products pass naturally. Requires serial hCGs to monitor- should normalize 2-3 weeks following passage.
More likely to do D&C, misoprostol
400
A 24-year-old G1P0 presents to her obstetrician’s office for a routine prenatal visit at 32 weeks gestation. At this visit, she feels well and has no complaints. Her pregnancy has been uncomplicated, aside from her Rh negative status, for which she received Rhogam at 28 weeks gestation. Fundal height at 30 centimeters. Bedside ultrasound reveals that the fetus is in transverse lie. The patient states that she prefers to have a vaginal delivery. Which of the following is the best next step in management?
Because she is only 32 weeks right now expectant management is best. Most self correct by 37 weeks. If corrected earlier then risk for resuming breech.
Continue to monitor at each follow up
If still breech at 37 weeks then external cephalic version trial. Ultimately may require a c-section
400
What are some key distinguishing characteristics of OA and RA?
400
a 55-year-old female patient complaining of inability to eat completely due to loss of teeth. Along with that the patient also complains of dryness of mouth for 1 year, and dryness of eyes for 7-8 years. Extraoral examination showed bilateral parotid gland enlargement present on the right and left sides of the parotid region. What medication should be considered for treatment of the suspected diagnosis?
Sjogren's syndrome
Pilocarpine: cholinergic drug that increased lacrimation and salivation (side effects include diaphoresis, flushing, sweating, bradycardia, diarrhea, N/V, incontinence and blurred vision)
Cevimeline: stimulates muscarinic cholinergic receptors
artificial tears
400
What are the two main antibodies in Sjogrens?
Anti-SS-A (Anti-RO. Like row a boat. B/C you're so dry)
Anti-SS-B (Anti-LA)
RF also often present in 70%
500
A G3P0 has a history of two abortions in the second trimester. She is currently 11 weeks gestation and is worried she will have another late miscarriage. What is the likely cause of her previous abortions and what can be done in this pregnancy to help prevent recurrence?
Incompetent cervix- progressive painless effacement and dilation of the cervix without apparent uterine contractions or vaginal bleeding
This patient should be further evaluated for cervical length. cervical length < 25 mm on transvaginal ultrasound or advanced cervical changes on physical examination before 24 weeks of gestation
Given her history a cervical cerclage
500
What is necessary to diagnose gestational diabetes?
Screening at 24-28 weeks in average risk patient. If high risk (previous GDM, overweight, ethnic group, previous macrosomia, etc) then screen at initial OB visit.
24-28 weeks: 1 hr 50g OGTT >130 then pt needs a 3 hr 100g OGTT to diagnose
Positive dx if 100g OGTT meets two:
>95mg fasting
>180 at 1 hr
>155 at 2 hr
>140 at 3 hr
500
Management of SLE depends on disease severity and manifestations. What medication is considered the cornerstone of SLE management?
Bonus: what must be regularly monitored while on this medication?
Hydroxychloroquine (plaquenil)
*Must have bi-annual eye exams because of retinal toxicity
500
a 23-year-old male with redness of the eye as well as discharge. He reports that he experiences pain with urination and stiffness and pain of the knee and ankle. With further questioning, he reports a history of gonorrhea infection that was diagnosed and treated approximately 5 weeks ago. He is otherwise healthy. On physical exam, there is conjunctivitis, asymmetric oligoarthritis, and discharge from the urethral meatus. What is the most likely diagnosis?
Reactive arthritis- autoimmune response to an infection (STI, campylobacter, salmonella)
Classic triad: conjunctivitis, urethritis, and oligoarthritis (can’t see, can’t pee, can’t climb a tree)
80% are HLA-B27 positive
Mostly clinical diagnosis if classic arthritis sxs recent hx of GI or STI infection.
Treatment is with NSAIDs and antibiotic for precipitating infection if still present
500
Most specific antibody for rheumatoid arthritis?
Anti-CCP is way more specific than RF!
RF is very sensitive though.