1. Approach to the Patient

Question 1

Rheumatology: super big picture, wtf do they deal with?

Answer 1

Diseases that affect the joints, also diseases that result from autoimmune processes.

Question 2

Percentage of Americans with arthritic and rheumatologic conditions?

Answer 2

21%

Question 3

What are the most prevalent rheum diseases in America?

Answer 3

• Osteoarthritis (27M)
• Gout (3M)
• Rheumatoid arthritis (2M)
• Juvenile Idiopathic Arthritis (300k)

Question 4

What is the leading cause of work loss? what does AAWL stand for?

Answer 4

Rheumatologic disease.

AAWL = arthritis-attributable work limitation. Kind of like AWOL, but different.

Question 5

what are some of the reasons why spending on arthritis meds doubled between 1998-2004?

Answer 5

• incr in number of patients
• increase in prescriptions per patient

Question 6

diagnosis of rheumatic dz is almost exclusively based on what information?

Answer 6

clinical process of taking a meaningful history and accurate physical exam.
she put this as a Key Concept in the ppt slides.

Question 7

impt clinical features to consider with these diseases?

Answer 7

pain, stiffness, limitation of motion, swelling, weakness, fatigue, loss of function

Question 8

Given that a lot of patients have trouble distinguishing between different types of pain/sensation, what is an impt skill for clinical diagnosis?

Answer 8

pattern recognition. therefore make sure to learn the presentation patterns of common arthropathies.

Question 9

joint assessment: what to consider?

Answer 9

Does it look normal? compare to contralateral side Does it assume a normal resting position? Does it move smoothly through its range of motion?

Question 10

define arthralgia

Answer 10

-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

Question 11

what does ANA stand for?

Answer 11

Anti-Nuclear Antibody. acc to lecture it is an overused test. better to take a good history/exam, then test to confirm

Question 12

define connective tissue

Answer 12

• scaffolding of the body
• diverse set of tissues: blood vessels, bone, cartilage, bursae, tendons, ligaments, skin

Question 13

define vasculitides. what is the typical cause?

Answer 13

• 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

Question 14

define phlebitis

Answer 14

inflammation of veins. subset of vasculitis.

(think phlebotomy = venipuncture)

Question 15

define arteritis

Answer 15

inflammation of arteries. subset of vasculitis.

Question 16

what is synovium? what can occur in autoimmune disease?

Answer 16

lines the joint cavity. nourishes cartilage. with autoimmune dz, can get thickened, can erode into bone at the outskirts of the joint capsule.

Question 17

articular cartilage: covered by synovial membrane?

Answer 17

NO. bathed in synovial fluid, which is enclosed in fibrous capsule.

Question 18

fibrous capsule (aka joint capsule) merges with what externally, and what internally?

Answer 18

• externally: periosteum, tendons, ligaments, fascia
• internally: synovial membrane

Question 19

what structure is just adjacent to (lies right up against) the articular cartilage?

Answer 19

subchondral bone plate

On its other side, articular cartilage is in contact directly with the synovial fluid.

Question 20

define enthesitis

Answer 20

inflammation at attachment of tendon or ligament into muscle or bone. typically seen at achilles, triceps insertion points (+ other places)

Question 21

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?

Answer 21

Inflammatory

-because NSAIDs help, fatigue, time course (6 wks = subacute onset), involvement of multiple joints, stiffness after stillness, morning stiffness

Question 22

Symptoms common to inflammatory disease processes?

Answer 22

morning stiffness > 1hr

significant fatigue

better with activity

worse with rest

systemic symptoms

responsive to steroids

Question 23

Symptoms common to mechanical disease processes?

Answer 23

Morning stiffness < 30 min

minimal fatigue

worse with activity

better with rest

no systemic sxs

not responsive to steroids

Question 24

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?

Answer 24

inflammatory -because of redness/swelling, bad pain, fever. This sounds like gout (acute onset)

Question 25

Red flags/concerning symptoms of joint pain? (6)

Answer 25

• fevers, rigors, wt loss
• no comfortable position
• wakes from sleep
• loss of function
• trauma
• malignancy

Question 26

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?

Answer 26

osteoarthritis -because of prior injury, has bothered him for years, slight swelling, grinding, short morning stiffness.

Question 27

Joint history questions: mnemonic?

Answer 27

C = Character

O = Onset

L = Location

D = Duration

P = Provocative factors

L = Lessens pain?

A = Associated systemic sx

Y = Your family history (most impt)

Question 28

Presentation of bursitis/tendonitis: timeframe? location? how to dx?

Answer 28

Acute or subacute in a single location dx based on PE

Question 29

Disease of cartilage: general points?

• what time of day is the pain?
• what is the progression expected to be?
• are there systemic sx?

Answer 29

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.

Question 30

Disease of synovium: general points?

Answer 30

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

Question 31

monoarthritis means what?

Answer 31

single joint involvement

Question 32

oligoarthritis means what?

Answer 32

a few scattered joints involved

Question 33

axial means what?

Answer 33

spine/shoulders/hips