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Musculoskeletal System > 3 - Rheumatology > Flashcards

3 - Rheumatology Flashcards

1
Q

What types of arthritis are associated with the DIP joint?

A

Heberdens nodes - OA, Psoriatic, Reiters/Reactive

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2
Q

What types of arthritis are associated with teh PIP joint?

A

Buchards nodes - OA, SLE, RA, Psoriatic

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3
Q

What types of arthritis are associated with the MCP joint?

A

RA, Pseudogout, Hemochromatosis, SLE

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4
Q

What types of arthritis are associated with the 1st carpometacarpal joint?

A

OA

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5
Q

What types of arthritis are associated with the wrist?

A

RA, SLE, Pseudogout, Gonococcal, Juvenile

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6
Q

What types of joints are most commonly affected by OA?

A

Weight-bearing joints

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7
Q

Describe the pathology of OA.

A

Cytokines, mechanical trauma and altered genetics initiate degenerative cascade

DJD affects the entire joint structure

Irregularity, erosion & ulceration of the articular cartilage

Osteophyte formation in the joint margins and in the floor of cartilage lesions

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8
Q

What are the classifications of OA?

A

Idiopathic - common in hands, feet, knee, hip, spine. (uncommon in shoulder, TMJ, sacroiliac, ankle and wrists). *generalized idiopathic involves three or more joints.

Secondary - many different pathologic conditions can cause arthritis symptoms/pathology

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9
Q

What are some classic symptoms of osteoarthritis?

A

Night Pain, Morning Stiffness (short duration), Little or no swelling, Usually joint specific

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10
Q

Discuss the course of treatment for osteoarthritis.

A 
Psychological Intervention
Weight Loss
Temp Modalities (acute v chronic)
Exercise
Orthotics/Bracing
ADL modificatoin
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11
Q

Discuss the guidelines for can use in OA patients.

A

Place in hand of contralateral side to affected joint
Advanced with the affected limb while walking
20-degree flexion of the elbow during use
Height should be floor to greater trochanter

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12
Q

Discuss pharmacological interventions available for OA

A

Currently there is no treatment that prevents the progression of joint damage

Goal: Pain relief, Inflammation prevention

Non-narcotic: Acetominophen, NSAIDS, Celebrex (cox-2 inhib) in that order for choices of treatment

Narcotic: Tramadol, codeine, oxycodone (geriatric patients sensitive to narcotics** - increased falls/confusion/constipation)

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13
Q

What are some injections available for treatment of OA?

A

Glucocorticoids, Hyaluronate injection - useful when NSAIDs are contraindicated

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14
Q

Describe the topical agents and nutriceuticals available for treatment of OA?

A

Topical Agents: Capsaicin, NSAIDs (diclofenac), menthol based and salicylate based OTC

Nutriceuticals: Glucosamines, Chondroitin sulfate, Ginger extracts

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15
Q

What is the last resort treatment for OA??

A

Arthroscopy (debridement/lavage)
Osteotomies
Joint Replacements

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16
Q

What genes are associated with RA?

A

HLA-DR4 - human leukocytic antigen

More common in women

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17
Q

Describe the common environmental factors associated with increased RA?

A 
Tobacco
Infection
Stress
Trauma
Northern Hemisphere
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18
Q

What is the classical characteristic formation in the joint seen in RA?

A

Pannus Formation with loss of cartilage

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19
Q

What is the reasoning for Ca2+ supplementation in RA patients?

A

RA patients have synovitis associated symptoms, this pathology increases inflammatory mediators (IL-1, TNF, LTB4) which are known to induce osteopenia in these patients

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20
Q

Describe the laboratory findings in patients with RA

A

Rheumatoid Factor - Autoantibody that binds the Fc portion of IgG (forms immune complexes)

In pts. seronegative for RF, a definitive dx can be helped along with serum anti-ccp antibodies (CONFIRMATORY TEST). Nice because it is positive early in disease process.

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21
Q

Describe the classic clinical symptoms of RA

A 
Morning Stiffness (Longer Duration)
Polyarticular (hands often first affected), generally symmetrical, muscle atrophy, depression, anxiety, weightloss
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22
Q

Describe Palindromic Rheumatoid arthritis.

A

Minority of DX (waxing/waning course of disease)

Begins in one joint, worsens for hours-days, then sequence reverses and eventually resolves

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23
Q

Describe the nodules often associated with RA?

A

Almost always seen in RF+ patients (20-25% overall)

Hard rubbery mass attached to the periosteum, or can be amourphous and mobile too???

24
Q

Describe the hematologic abnormalities seen in RA patients?

A

Mild normocytic hypochromic anemia - anemia of chronic disease, correlates with ESR elevation and activity of disease

ESR correlated inversely with hemoglobin levels (inhibited erythropoeisis)

Eosinophilia and Thrombocytosis

25
Describe the pulmonary complications seen in RA patients
``` Effusion Fibrosis Nodules Bronchiolitis Arteritis, with pulm hypertension Reactivation of TB by anti-TNF alpha biologic agents ```
26
Describe the cardiac complications seen in RA patients,
``` Effusion Pericarditis (50%) Myocarditis --- stressed this one Endochonral Inflammation Conduction Deficits --- stressed this one ```
27
What types of cancers are increased in incidence in RA patients?
Lymphomas
28
Describe the possible clinical courses for patients with RA.
3 Forms: Self-Limiting, Persistent Nonerosive, Persistent Erosive. Typically whatever pathway is started, is the pathway the patient will continue to follow.
29
What are the good predictors of RA outcomes?
Initial xray score, and RF+ titers are the best predictors of expected outcome.
30
What is the overall RA dx Criteria (2010 ACR)
Number of Joints Involved Serological Abnormality - RF, anti-ccp, symptom duration greater than 6wks Points assigned to each presenting criteria (minimum of 6 needed to qualify as RA) REVIEW SLIDE FOR POINT ASSIGNMENTS FOR CERTAIN CRITERIA
31
Describe Felty's Syndrome
A triad of RA symptoms: 1. Chronic RA, 2. Splenomegaly, 3. Granulocytopenia Known to progress faster
32
What is the preferred treatment for Felty's syndrome? Describe mechanism, Type of drug, and Side Effects
Methotrexate
33
Describe Sjogrens syndrome
Primary: Dry everything due to autoimmune dysfunction of exocrine glands Secondary: Usually in the presence of RA
34
What lab studies are specific to Sjogren syndrome?
Antibody to SS-A Antibody to SS-B 2/3 ANA+ and RF+
35
Describe treatments for Sjogren syndrome
External Moisture Replacement | Pilocarpine, Cevemiline - stimulate excretions
36
What are the 3 major clinical features (stages) of gout?
Acute gouty arthritis Intercritical (interval) gout Chronic Tophaceous
37
Describe Stage 1 gout.
90% of first attacks happen at big toe Knee second most common Can be polyarticular at first onset in patients with multiple contributing factors Sudden onset - resolves in a few days/wks
38
What is the critical criteria for acute gout?
Point System involves: gender, previous arthritis, onset timing, joint involved, HTN, Serum Uric acid level. (5.88 score required for dx) >8 points = high probability of gout
39
Describe Stage 2 gout
Multiple gouty attacks with intermittent periods 2nd attack generally appears within 2 yrs. Must address the reversible causative factors and try to eliminate Initiate prophylactic/antiuremic treatment
40
Describe Stage 3 gout.
Major factor is the presence of tophi (increase in number with duration of hyperuricemia) Can have tense shiny skin over the joints with tophi that could ulcerate and extrude white pasty urate crystals Erosions with sclerotic margins and thin overlying calcified edges seen on radiograph (can use US, MRI, and CT can
41
Describe the renal complications seen in gout patients.
Nephrolithiasis - kidney stones Elevated serum creatinine Urinary sediment Hyperuricemia duh
42
What is Podagra, with regard to gout?
The commonly seen pathology of gout experienced in the 1st MTP joint
43
Describe the treatment course for gout patients depending on their 24hr urine uric acid levels.
Normal: 600mg/d - goal of treatment is to increase urinary uric acid excretion (use probenecid) High: >600mg/d - goal is to decrease production of uric acid (use allopurinol)
44
Describe treatment pathways for acute and chronic gout patients.
Acute: NSAIDs, Colchicine (inhibit leukocyte entry into joints), Glucocorticoids Chronic: Uricosurics (probenecid - increase excretion), Inhibit uric acid synthesis (allopurinol)
45
What is the first line of treatment of acute gout?
NSAIDS (indomethacin) - look out for GI toxicity
46
What is the second line of treatment of acute gout?
Colchicine - MOA that decreases lactic acid release, maintain higher pH and allow greater uric acid solubility Look out for **GI problems** also because this drug inhibits epithelial regeneration by impeding mitosis due to its effects on the microtubules needed for the splitting phase
47
Describe the first line of treatment for prophylaxis in interval stage gout patients?
Probenicid - uricosurics - increase excretion Hydrate to avoid stones Biggest side-effects are headache and rash Allopurinol - decrease formation
48
How will you try to stop the formation of a urate stone in gout patients/
Alkalinize the urine (calcium citrate or sodium bicarb)
49
Describe the recommended dietary modifications for gout patients/
Decrese red meat, seafood, hard alcohol
50
Describe Calcium Pyrophosphate Dihydrate (CPPD)
PSEUDOGOUT/Chondrocalcinosis Crystals deposited in articular and fibrocartilage Most commonly seen in knee DX/ Weakly birefringement, rhomboid, rod-shaped Radiograph - heavy punctuate and linear calcification in chondral regions
51
Describe (BCP) Basic Calcium Phosphate Crystals
Crystals deposited in periarticular structures Common in rotator cuff and subacromial bursa (old lady can't raise her arm) DX/ Negative birefringement
52
What is milwaukee shoulder/
Bilateral shoulder pain associated with BCP calcifications
53
What is the most common cause of urinary stones?
Calcium Oxalate - may cause arthritic changes, multifactorial etiology
54
FOR GOUT
REVIEW TABLE AT END OF PWRPT
55
Describe the clinical features/symptoms of Fibromyalgia
``` Pain Fatigue Crawling Skin Sensation Sleep Problems Depression/Anxiety ```
56
Describe the common treatment options for patients with fibromyalgia.
``` Go kill yourself Stress reduction Meditation Exercise Acupuncture OMT ```
57
Describe the medications that may be indicated for fibromyalgia.
``` Tricyclic Antidepressants SSRIs Dual reuptake inhibitors (norepi/serotonin) Anticonvulsants (CNS pathway) Analgesics ```

Musculoskeletal System (21 decks)

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