1. Approach to the Patient Flashcards
Rheumatology: super big picture, wtf do they deal with?
Diseases that affect the joints, also diseases that result from autoimmune processes.
Percentage of Americans with arthritic and rheumatologic conditions?
21%
What are the most prevalent rheum diseases in America?
- Osteoarthritis (27M)
- Gout (3M)
- Rheumatoid arthritis (2M)
- Juvenile Idiopathic Arthritis (300k)
What is the leading cause of work loss? what does AAWL stand for?
Rheumatologic disease.
AAWL = arthritis-attributable work limitation. Kind of like AWOL, but different.
what are some of the reasons why spending on arthritis meds doubled between 1998-2004?
- incr in number of patients
- increase in prescriptions per patient
diagnosis of rheumatic dz is almost exclusively based on what information?
clinical process of taking a meaningful history and accurate physical exam.
she put this as a Key Concept in the ppt slides.
impt clinical features to consider with these diseases?
pain, stiffness, limitation of motion, swelling, weakness, fatigue, loss of function
Given that a lot of patients have trouble distinguishing between different types of pain/sensation, what is an impt skill for clinical diagnosis?
pattern recognition. therefore make sure to learn the presentation patterns of common arthropathies.
joint assessment: what to consider?
Does it look normal? compare to contralateral side Does it assume a normal resting position? Does it move smoothly through its range of motion?
define arthralgia
-from lect: arthralgia = painful to the patient, but appears normal on imaging -from MeSH: the term “arthralgia” is used for non-inflammatory conditions, and “arthritis” is used for inflammatory conditions -from Wiki: arthralgia = joint pain, symptom of injury, infection, illness, allergic reaction
what does ANA stand for?
Anti-Nuclear Antibody. acc to lecture it is an overused test. better to take a good history/exam, then test to confirm
define connective tissue
- scaffolding of the body
- diverse set of tissues: blood vessels, bone, cartilage, bursae, tendons, ligaments, skin
define vasculitides. what is the typical cause?
- from Wiki: a group of disorders that destroy blood vessels by inflammation. both arteries and veins are affected.
- primarily due to leukocyte migration and resulting damage
define phlebitis
inflammation of veins. subset of vasculitis.
(think phlebotomy = venipuncture)
define arteritis
inflammation of arteries. subset of vasculitis.
what is synovium? what can occur in autoimmune disease?
lines the joint cavity. nourishes cartilage. with autoimmune dz, can get thickened, can erode into bone at the outskirts of the joint capsule.
articular cartilage: covered by synovial membrane?
NO. bathed in synovial fluid, which is enclosed in fibrous capsule.
fibrous capsule (aka joint capsule) merges with what externally, and what internally?
- externally: periosteum, tendons, ligaments, fascia
- internally: synovial membrane
what structure is just adjacent to (lies right up against) the articular cartilage?
subchondral bone plate
On its other side, articular cartilage is in contact directly with the synovial fluid.
define enthesitis
inflammation at attachment of tendon or ligament into muscle or bone. typically seen at achilles, triceps insertion points (+ other places)
Pt with 6 weeks of joint pain that involves wrists, shoulders, hand joints, knees, ankles, feet; stiff in morning but loosens up in a few hours; gets stiff again with extended stillness; extreme fatigue during day; NSAIDs help. Inflammatory pain or non-inflammatory pain?
Inflammatory
-because NSAIDs help, fatigue, time course (6 wks = subacute onset), involvement of multiple joints, stiffness after stillness, morning stiffness
Symptoms common to inflammatory disease processes?
morning stiffness > 1hr
significant fatigue
better with activity
worse with rest
systemic symptoms
responsive to steroids
Symptoms common to mechanical disease processes?
Morning stiffness < 30 min
minimal fatigue
worse with activity
better with rest
no systemic sxs
not responsive to steroids
Patient with red/swollen 1st MTP joint, started this morning, worst pain ever, never had this before, no trauma, slight fever, joint is red/swollen/painful. inflammatory pain or non-inflammatory?
inflammatory -because of redness/swelling, bad pain, fever. This sounds like gout (acute onset)
Red flags/concerning symptoms of joint pain? (6)
- fevers, rigors, wt loss
- no comfortable position
- wakes from sleep
- loss of function
- trauma
- malignancy
Pt with right knee pain, injured it 40 yrs ago, bothers him at times but worse in last 2-3 months, slight swelling, can feel grinding, stiff for 15 min in the morning. Acetaminophen helps. likely to be what?
osteoarthritis -because of prior injury, has bothered him for years, slight swelling, grinding, short morning stiffness.
Joint history questions: mnemonic?
C = Character
O = Onset
L = Location
D = Duration
P = Provocative factors
L = Lessens pain?
A = Associated systemic sx
Y = Your family history (most impt)
Presentation of bursitis/tendonitis: timeframe? location? how to dx?
Acute or subacute in a single location dx based on PE
Disease of cartilage: general points?
- what time of day is the pain?
- what is the progression expected to be?
- are there systemic sx?
degenerative, gradual erosion of cartilage leading to weight bearing on unprotected bone, pain after use of joint. Pain is usually at the end of the day. Few systemic sx.
Disease of synovium: general points?
inflammatory, proliferation of synovial membrane (single cell membrane -> thickened mass). local sx of infection (heat/red/swelling), occasional systemic sx (wt loss, fever, fatigue). joints stiffen with rest esp in morning
monoarthritis means what?
single joint involvement
oligoarthritis means what?
a few scattered joints involved
axial means what?
spine/shoulders/hips
