Rheum 1
A 27 y/o man suffers from chronic, progressive pain in his back, neck, and sacroiliac joints that is worse at night and improves with exercise. Lateral spine xrays show squaring of the vertebral bodies, and he has already been counseled on the hyperkyphosis and postural abnormalities he may face down the road. What lab test is most associated with this diagnosis?
HLA B27
A 35 y/o man presents to his PCP with complaints of reoccuring pain in his big toe so much so that he can't wear a shoe. Fluid is aspirated from the joint and reveals needle-shaped urate crystals. What is the best maintenance therapy?
Allopurinol
What rheum conditions are associated with HLA-B27
Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD.
What pathogen is most associated with reactive arthritis?
Chlamydia trachomatis
You just diagnosed a pt with Polymyalgia rheumatica. What is the best initial treatment?
Prednisone
A 56 y/o pt presents with complaints of morning stiffness, joint pain, and joint swelling of the MCP and PIP joints of the hands. What xray findings would one expect to see on work up of a patient with these findings?
joint space narrowing, periarticular osteopenia, and bony erosions
What rheum condition is assoc with HLA-DR4?
RA
A 62-year-old male who you have followed for hypertension for several years presents with complaints of worsening fatigue and aching in his back, shoulders, and neck. He notes 3 months of symptoms unresponsive to acetaminophen.
Further history reveals that your patient has experienced stiffness of the neck and shoulders each morning for over 30 minutes. He occasionally has difficulty getting out of bed due to pain. Vital signs are within normal limits. There is no evidence of synovitis of the hands, wrists, or elbows. Active range of motion in the neck and shoulders is slow but full. There is tenderness to palpation of the shoulders, upper back, and neck, but no apparent muscle atrophy.
What is the most likely diagnosis and what lab test would most support your diagnosis?
Polymyalgia rheumatica. ESR/CRP.
A 35-year-old man with hypertension presents with the sudden onset of right big toe pain. He denies trauma of the foot. On examination, he is noted to have a swollen, red, and tender base of the right great toe. What is the best treatment at this time for the probable condition?
Indomethacin or colchicine
25 y/o female c/o frontal headaches on and off over the last year and slowly worsening fatigue. She has had generalized joint pain and siffness x 2-3mo. On PE, you note a thin female. VS normal. Skin: erythema of the malar eminences and nose. Cardio: + friction rub. MSK: ttp of both knees with small effusion of left knee. Incomplete grip of left hand. Remainder of exam normal. What lab(s) are most specific for this diagnosis?
Anti-dsDNA and Anti-Sm
Anti-Jo 1, Anti-SRP, and Anti-Mi-2 are seen with?
Polymyositis/Dermatomyositis
A 56-year-old woman presents to the office complaining of gradually progressive, nonpainful enlargement of the terminal joint on her left hand over a 9-month period. She has some stiffness with typing, usually in the afternoons. She also reports pain in her right knee, which occasionally “locks up.” The right knee hurts more after long walks. On examination, her blood pressure is 130/85 mm Hg, heart rate is 80 beats per minute (bpm), height is 5’8”, and weight is 285 lb with a body mass index (BMI) of 43.3 kg/m2. Examination reveals only a nontender enlargement of her left distal interphalangeal (DIP) joint, and the right knee is noted to have crepitus and slightly decreased range of motion (ROM). Those joints were not red or swollen. What would be the best next step in the eval of this patient?
ESR and xrays of hand and knee
3. A 56-year-old woman comes to the primary care office due to joint pain and generalized stiffness x two months. She denies any history of trauma or illness. Pain was initially in the metacarpophalangeal joints of both hands with swelling but no redness. Physical examination shows no joint deformities, fever, skin rashes, or nodules. Laboratory analysis reveals an elevated sedimentation rate. X-rays of the hands reveal soft-tissue swelling, periarticular osteopenia, and marginal bone erosions. What is the most likely diagnosis?
RA
What are the 3 most common sx of SLE?
Joint pain/arthritis, rash (malar, discoid), constitutional sx such as fever
22 y/o female c/o swollen hands that are stiff and painful. She complains of multiple joint aches and fatigue despite sleeping well. Her appetite is normal, and she has no GI complaints. Although she has no rash, she complains of itchy hands. On examination, you note that there is diffuse, nonpitting edema on her fingers and hands. She has difficulty making a fist. She has no skin findings. Her CBC is normal. Her ANA is strongly positive.
What is the most likely provisional diagnosis?
Scleroderma
A 52-year-old man complains of bilateral knee pain for about 1 year. He is noted to have a body mass index of 40 kg/m2. What medication would you recommend for this man?
NSAID (OA most likely d/t obesity)
An 80 y/o female pt presents with a 3 day hx of fever, fatigue, headache, jaw pain with chewing, and impaired vision of the the right eye. On PE, the patient reports tenderness over the right temporal artery. What is the most likely diagnosis?
Giant cell arteritis
What is one of the most serious complications of Sjogren Syndrome?
Lymphoma
46 y/o female c/o being dx with fibromyalgia several months ago. She reports having all over pain, all the time, which has been worsening for the last 5 yrs. she takes Tylenol + Codeine for pain usually 4x/day. She doesn't exericise because it hurts too much and drinks 2 liters of Mnt. Dew/day. Her sleep is poor and nonrestroative. How would you like to manage this patient?
Educate on good sleep hygiene, recommend low impact exercise. Could try tricyclic antidepressant such as amitriptyline.
A 52-year-old female presents to your office for an initial visit and complains of mild pain and weakness in her hips and thighs. The symptoms have been present for months. About 2 years ago another doctor diagnosed her with psoriasis because of a rash on her hands and elbows, which has since resolved. Otherwise, she reports being relatively healthy and taking no medications. She is a smoker. She has had no recent health screening. On physical examination, her vitals are normal. She has considerable difficulty getting out of her chair. Her strength is symmetrically diminished in the quadriceps and hip flexors. There are violaceious plaques on her knuckles, elbows and around her eyes. The rest of the examination is unremarkable. What is the most likely diagnosis?
Dermatomyositis
What would you expect to see on polarized light microscopy in a pt with pseudogout?
Positive birefringement, rhomboid shaped crystals (calcium pyrophasphate)
What are the 2 most common drugs that can cause lupus?
Procainamide and hydralazine. Isoniazid and quinidine are fairly common as well.
A 44-year-old woman has a 5-month history of malaise and stiff hands in the morning that improve as the day goes by. She notes that both hands are involved at the wrists. Initial laboratory tests show an elevated ESR and high positive anti-CCP. What medication is most likely to lead to the best long-term disease outcome for this patient?
Methotrexate
62 y/o male c/o chronic fatigue, interrmittent fevers, a weird "rash" to his skin, and arthralgias for the past month. On PE, you note elevated BP, erythematous nodules on his LE, and livedo reticularis. Labs reveal an elevated ESR/CRP, elevated creatinine, and mild anemia. A renal angiogram shows multiple aneurysms and constrictions of the arteries. What medication would you like to start on this pt?
High dose steroids (polyarteritis nodosa)
A 47-year-old woman with a history of chronic asthma presents with numbness and tingling in her hands and feet, with right foot "weakness". She has recently noted increased dyspnea without wheezes, as well as PND, orthopnea and ankle swelling. On physical exam, she has palpable purpura and papular lesions over her elbow. HEENT exam reveals nasal polyps. On lung exam, she is noted to have bibasilar crackles without wheezes, and an S3 gallop is noted on cardiac auscultation. Lower extremity exam reveals 1+ pitting edema. Neurologic exam reveals decreased sensation in both feet, and reduced dorsi-flexion of right foot.
Laboratory studies:
Hemoglobin 12.9 g/dL
Leukocyte count 12,400 /uL (46% neutrophils, 29% eosinophils, 16% lymphocytes, 9% monocytes)
Serum creatinine 1.0 mg/dL
Creatinine kinase normal
p-ANCA negative
Urinalysis trace protein; 0-3 RBC's/hpf
Chest radiograph reveals scattered bilateral nodular infiltrates, cardiac enlargement and vascular congestion
Echocardiogram reveals global hypokinesis with ejection fraction of 4
What vasculitis is most likely?
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss Syndrome)