Clin Med2 Final Flashcards
What rheum disorders are more common in MEN than women?
GOUT *(until menopause) Ankylosing Spondylitis (2:1)
What dz do men = women?
Psoriatic Arthritis
Presentation of Fibromyalgia?
CHRONIC, DIFFUSE MSK pain w/o obvious pathological cause
Tenter points in ALL 4 quadrants of body (inc. axial skeleton)
Sleep disturbances
Severe fatigue/ exercise intolerance
depression, anxiety
Can an event trigger Fibromyalgia?
Usually no, but sometimes from trauma, emotional trauma, flu/illness, or withdrawl from steroids
What are the Historical requirements of fibromyalgia
Widespread body pain involving at least 3 quadrants
At least 3 mo duration
no other pain cause
What are the cardinal features of fibromyalgia
Chronic widespread pain greater than 3 months
tender points on exam
How do you dx fibromyalgia?
Pain at least 3 months of the:
R AND L sides
Axial skeleton (11/18 tender ponts)
pain at 4 kg
What are inflammatory syndromes?
Gout (MC)
Pseudogout
RA
Spondyloarthropathies
Non Inflamm syndromes
Osteoarthritis (MC)
Fibromyalgia
Tx of fibromyalgia
DO NOT USE SYSTEMIC STEROIDS
non drug tx: exercise, sleep, tx psych stress bc “mind-body” illness
drugs: anti-depressants (duloxetine, cyclobenzaprine)
Pregablin- anti-epileptic
Tramadol- mu-opiod receptor ligand
opioids are rare for pain tx
What diseases are worse with exercise/ as the day goes on?
Fibromyalgia and osteoarthritis
(hey, these are the non-inflamm ones too)
they can have am stiffness less than 30 mins
Worst upon awakening?
RA
PMR
Joint pain in OA?
early- worse w/ exercise
late- pain at rest
Timeframe for inflame am stiffness?
am stiffness greater than 30 minutes
and symptoms improve with activity
What is the #1 drug in the world that tx RA
Methotrexate
What are x-ray findings in RA of the hands and wrists?
symmetrical joint space loss PIP MCP corner erosions (mouse bites) @ small joints may see soft tissue swell
Serologic testing for RA
+ RF plus + anti CCP + characteristic sx (swell, stiff)
means 98% likelihood the pt has RA
Real estate of RA
MCP and PIPs (NOT DIPS)
common in 2nd and 3rd digits, wrist and feet
usually b/L involvement
Real estate of OA
common at base of thumb, DIP and PIP (NOT MCP)
hand (70%), knee, hip and spine
usually unilateral joint involvement
Fibromyalgia associations (not part of dz though)
Dizzy, HA cognitive dysfxn insomnia, severe fatigue autonomic dysfxn exercise intolerance patesthesia depression, anxiety restless legs irritable bladder irritable bowel endocrine imbalance multiple sensitivities
Tx Temporal Arteritis
IMMEDIATELY give HIGH dose of PO corticosteroid (60mg prednisone) to reduce inflamm (before blindness)
PMR presentation
symmetric shoulder girdle pain (MC) neck + pelvic + upper arm + thigh pain no pain during physical exam from palpating wt loss, fever, malaise, difficulty standing + grooming joint ROM: normal, MSK strength: nml soft tissue swelling- knee, wrist, MCP LE edema carpal tunnel Labs: ELEVATED ESR and CRP
Age group PMR
Onset is OVER 50.
Mean age 73
whites females mc too
Lupus Criteria
Malar rash (butterfly) Discoid rash- mild form (arm+ears) Photosensitivity Oral Ulcers Arthritis Serositis Renal d/o Neuro d/o Hematologic d/o immunologic d/o antinuclear antibody
(** you need 4/11 criteria to have SLE, don’t have to be at once**)
DDX malar rash
rosacea dermatitis glucocorticoid-induced atrophy cholasma/melasma bengin flushing
explain the malar rash
(butterfly)- fixed erythema, flat or raised over malaria eminences (cheekbone)
SPARES NASOLABIAL FOLD
(vs rosacea- don’t spare it)
Initial screening for inflamm autoimmune d/o
ANA is the FIRST STEP w/ reflex!!
if + then you get other tests
Patterns
Spekled *SLE
Homogenous/diffuse =MC non specific tho
Rim/peripheral
nucleolar
What are other tests for immunology d/o
anti dsDNA (+ inc. lupus dx) anti Sm antiphospholipid ab (lupus anticoagulant) anti Ro (heart block in SLE pt)
What are lupus clusters?
Cutaneous, articular and renal manifestations (MC)
or
CNS, thrombotic and muscular sx (lesser extent)
Myosisitis labs
muscle and liver enzyme vs liver only
elevated levels of serum muscle enzymes bc skeletal muscle inflammation
muscle: CPK, aldolase
muscle and liver: AST LDH
Liver only: ALT
Sjogren’s
chronic systemic autoimmune inflammatory d/o characterize by lympocytic infiltration of endocrine glands
Sjrogens presents
F> M 35-50yo
primary = xerostomia, keratoconjunctivitis sicca, hyposalivation
secondary= primary plus RA, SLE, scleroderma
Target organ of Sjrogens
salivary and lacrimal glands
S/Sx OA
PAIN with increased use stiffness less than 15 to 30 minutes swelling crepitus limited ROM
OA complaints by gender
F: knee and hand
M: hip
Enthesitis
inflammation at insertion of tendon or bone
Synovitis
inflammation of the synovial lining
Disease progression over time non inflamm is ___ vs autoimmune is ____
progression over decades (slow)
autoimmune occur in a year or two
Red Flags of back pain (14)
Age greater than 50 significant trauma neuro deficit unexplained wt loss substance abuse ankylosing spondylitis night pain malignancy hx systemic seroids fever (over 100) persistant pain compensation issues increase pain when recumbent bowel and bladder dysfxn
MC cause of LBP?
Idiopathic
Best way to tx LBP?
AVOID BED REST!!! -old recommendation but NOT anymore
do symptomatic treatment
exercise helps prevent it!
Pharm tx LBP?
anti inflamm tramadol opioids muscle relaxants (methocarbamol) epidural steroid injxn
LBP categories
acute less than 4 wks (pain control)
subacute 4-12 wks (pain control + activity)
chronic greater 3 mo (multidisciplinary)
DDX LBP
Mechanic Rheumatologic Endocrine Neuro/Psych Neoplastic Reffered
Spondyloarthritis is
seronegative (RF -) inflamm arthritis of the spine
what if you untx spondyloarthritis
entire spine can be involved
it may fuse (bamboo) = increase risk spine deformity, fx, and disability
limited flexibility, “squaring” of lumbar and thoracic vertebrae, osteopenia, ossification
what is involved in severe spondy?
HIPS!
may need b/l replacement
Inflamm BP explain
stiffness, worse in morning, improves with exercise not relieved by rest
Non inflamm BP explain
worse as day progresses, worsens with exercise
Spondyloarthritis extra articular
acute anterior uveitis (MC) IBD prostatitis (men) aortic regurgitation arrhythmias, conduction defects or complete heart block
Synovial fluid crystal eval in gout:
monosodium urate- needle shape,
acute attack = intracellular
btwn/late attack = extracellular
Synovial fluid crystal eval in pseudogout:
crystal - calcium pyrophosphate- rhomboid or rectangular shape,
dominant cell is neutrophils
Hyperuricemia presents as
disclaimer: word vomit.
Purines come from same sources, same amounts as gout.
When there is renal compromise, the total body uric acid pool is altered. The miscible urate pool is expanded and “flows over” into an insoluble compromise and slightly more eliminated in the intestines to try to compensate
with uric acid overload, 2 outcomes
** 3/4 people have Asx hyperuricemia
** 1/4 people have GOUT
Characteristic X ray finiding in pseudogout
Punctate linear deposits of CPPD crystals in the menisci and cartilage :
CHONDROCALCINOSIS
(knee + wrist)
pseuo = acute mono-arthritis
Case present Older woman- what can she have? Could be: basic calcium phosphate hydroxyapatite deposition disease
MC in older women
“Milwaukee shoulder”- large non-inflame effusion with glenohumeral instability
(deposits of crystals in cartilage + tendons)
tx with NSAIDS, intra-articular steoids
Temporal arteritis/giant cell arteritis:
MC systemic vasculitis
-vessels above the heart (primary branch of aorta, carotids)
age >50
jaw pain, tongue pain, amarosis fugax
lead to visual loss (ischemic optic neuropathy)
Temporal arteritis gold std test
Temporal artery bx
Henoch-schoenlin purpura
MC children
TRIAD: palpable purpura, abd pain, glomerulonephritis
self limiting
Polyarteritis nodosa (PAN)
VERY rare!!
necrotize medium-small arteries ONLY
associated with HBV
multiple organs but SPARES: lung and glomerulus!
ANCA negative
tissue bx is best for dx
Takayasu’s Arteritis
"pulseless' dz in one wrist- not in other (asymmetrical BP too) renovascular HTN limb claudication MC young females HLA-class 1 MC @ aorta + branches dx with Angiogram!!
