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NURS 502 > Exam 3 - Rheumatology > Flashcards

Exam 3 - Rheumatology Flashcards

1
Q

What is fibromyalgia?

A

Disorder included with rheumatologic conditions - characterized by symptoms of widespread MS pain, fatigue, nonrestorative sleep, depression, HA, GI complaints (e.g. IBS)

  • More than 3 months of MSK pain
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2
Q

Fibromyalgia diagnostic considerations

A
  • Must meet report of pain survey in 19 areas as well as severity of symptoms → replaced tender point examination
  • More common in females, ages 40-50 years
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3
Q

American College of Rheumatology criteria for diagnosing fibromyalgia

A
  • WPI >7 and SSS score >5 OR WPI of 4-6 and SSS score >9
  • Generalized pain (in at least 4-5 regions)
  • Symptoms present for longer than 3 months
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4
Q

Fibromyalgia clinical presentation

A
  • Persistent widespread pain
  • Chronic fatigue
  • Somatic complaints → non restorative sleep, cognitive difficulties, auditory/vestibular/ocular complaints, chronic rhinitis or “allergies”, migraines, palpitations, IBS, subjective sense of joint swelling, mood disorders
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5
Q

Fibromyalgia physical examination findings

A
  • Normal muscle strength
  • No evidence of synovitis or soft tissue inflammation
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6
Q

Are labs indicated for the diagnosis of fibromyalgia?

A
  • CBC, chem profile, TSH, ESR, CRP to exclude other disorders
    • ANA, rheumatoid factor, anti-citrullinated protein antibody (ACPA) only in setting of synovitis, lupus, or RA
  • Sleep study for OSA
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7
Q

Can fibromyalgia be diagnosed back on history and physical examination alone?

A

Yes, but want to exclude other causes first

  • Patient report of widespread pain present in up to 19 + fatigue + disordered sleep for >3 months
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8
Q

Non pharmacological management of fibromyalgia

A
  • CBT
  • Exercise (to combat muscle wasting)
  • Acupuncture
  • Massage
  • Chiropractor
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9
Q

Pharmacological management of fibromyalgia

A
  • TCAs (amitriptyline, cyclobenzaprine)
  • SNRIs (duloxetine and milnacipran)
  • Gabapentin (Neurontin) and pregabalin (Lyrica) for pain
  • Tylenol
  • Opioids ONLY after all other meds and therapies failed
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10
Q

What are the four stages of a gout attack?

A
  • Asymptomatic hyperuricemia → elevated serum urate but no acute attacks, crystals may deposit in joints and cause asymptomatic damage
  • Acute gout attacks → activation of inflammatory response leading to intense pain, swelling, redness, warmth
  • Intercritical gout (intervals between acute attacks)
  • Chronic tophaceous gout → due to uncontrolled hyperuricemia
    • Firm swelling most commonly found on digits of hands and feet, and olecranon bursa
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11
Q

Risk factors for gout

A
  • Use of diuretics or low dose aspirin use
  • Obesity
  • CKD
  • Metabolic syndrome
  • Advanced age
  • Local trauma
  • Binges of alcohol
  • Overeating/fasting
  • Newly initiated urate-lowering therapy
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12
Q

How does gout appear in men vs women?

A
  • Recurrent episodes of painful monoarthritis in men
  • Oligoarticular arthritis (4 or fewer joints) in postmenopausal women and men with subsequent flares
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13
Q

Acute gout clinical presentation

A
  • Rapid onset (pain peak within 2-4 hours) and increasing pain
  • First attack at night and patient wakes up from sleep
  • Tenderness, warmth, redness, swelling, decreased ROM in affected joint (usually in first MTP)
  • Heberden’s nodes
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14
Q

Gout diagnostic studies

A

Confirmed with needle aspiration → MSU crystals in synovial fluid or tophi aspiration

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15
Q

What are the goals of gout management?

A

1) treat acute attacks
2) lowering of total body uric acid pool to prevent tissue deposition of MSU crystals
3) anti-inflammatory prophylaxis to prevent further acute attacks

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16
Q

Non pharmacologic management of gout

A
  • Avoid diuretics
  • Control weight
  • Limit alcohol consumption
  • Consume low fat dairy products, cherry juice concentrate
  • DASH diet
  • Topical ice
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17
Q

Pharmacologic management of acute gout attacks

A
  • NSAIDs and oral corticosteroids for initial treatment (corticosteroids preferred of CrCl <50, on anticoagulant therapy, or hepatic dysfunction)
  • Colchicine should be used within 36 hours of onset of acute attack
    • NOT used if GFR is <50
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18
Q

Pharmacologic management of chronic gout attacks

A
  • Urate lowering therapy (ULT) should be started 4-8 weeks after attack is resolved
    • Xanthine oxidase inhibitors (allopurinol, febuxostat)
    • Uricosuric agents (probenecid, lesinurad)
    • Recombinant uricase (pegloticase)
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19
Q

What is considered chronic gout?

A

Patients who have 2+ gout attacks a year

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20
Q

True/false: There is an increase in acute attacks after ULT therapy initiation for gout

A

True - due to inflammation caused by changes in the chemical and/or physical state of preexisting MSU crystals

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21
Q

What medication should be prescribed to patients prophylactically for patients starting ULT therapy for gout?

A
  • Give prophylactic low dose anti inflammatory treatment when initiating patient on ULT → e.g. colchicine
    • Alternative → NSAIDs
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22
Q

What are the three types of treatment for gout?

A
  • Medications to control attacks of joint pain (NSAIDs, colchicine, corticosteroids)
  • Prophylaxis (colchicine, NSAIDs)
  • Medications to lower uric acid levels (allopurinol, febuxostat)
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23
Q

OA risk factors

A
  • Female (middle age and older)
  • Obesity
  • Prior trauma
  • Genetics
  • Repetitive activities
  • Metabolic disorders
  • Neurologic disease
  • Hematologic conditions
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24
Q

OA vs RA

A
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25
Q

OA clinical presentation (history)

A
  • Insidious, progressive pain/stiffness of one or more joints
  • Symptoms common after waking up (duration <1 hour)
  • Pain with weight bearing activities
  • Crepitus, swelling, joint deformity, gradual loss of motion
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26
Q

OA physical examination findings

A
  • If cervical or lumbar spine spine is involved, neuropathy and radiculopathy → groin/butt pain causes patient to “favor” the hip → Trendelenburg gait
  • Heberden nodes (distal) and Bouchard nodes (proximal)
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27
Q

OA diagnostic studies

A

X-ray (will see radiographic changes as disease progresses)

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28
Q

Pharmacological management of OA

  • Pills
A
  • Acetaminophen → first line
  • Tramadol for moderate to severe pain
  • NSAIDs (may be given with H2 blockers or PPIs to reduce GI intolerance)
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29
Q

Pharmacological management for OA

  • Injectables
A
  • Hyaluronan injections for mild to moderate OA (improves fluid viscosity)
  • Intra articular corticosteroid injections → not recommended more often than every 3-4 months
30
Q

Non pharmacological management of OA

A
  • Exercise
  • Locally applied heat, ice
  • Warm baths
  • Custom orthotics
  • Weight reduction
31
Q

What is poly myalgia rheumatica (PMR)?

A

Treatable, chronic systemic inflammatory condition of unknown cause most often in older adults

  • Does not occur in adults younger than 50 years
32
Q

PMR clinical manifestations

A
  • Stiffness/aching of shoulder girdle, pelvic girdle, neck
  • Pain worse at night and can radiate to elbows and knees (can have morning stiffness >1 hour)
  • Low grade fever, depression, fatigue, malaise, weight loss
33
Q

How is PMR different from RA?

A

Inflammatory arthritis of knees and wrists

  • Asymmetric, self limiting, responsive to systemic corticosteroids
34
Q

PMR physical examination findings

A
  • Painful active ROM of shoulder and hips
  • No signs of synovitis
35
Q

American College of Rheumatology diagnostic criteria for PMR

A
  • Patient 50+ years with new onset bilateral shoulder pain
  • Elevated ESR and/or CRP
  • Negative RF and anti-CCP
  • Morning stiffness >45 minutes
  • New hip pain in the absence of peripheral synovitis
36
Q

PMR lab studies to rule out other inflammatory diseases

A
  • CBC, ESR, CRP, CMP, LFTs, serum protein electrophoresis, RF and anti-CCP, UA, TSH
  • Chest x-ray
37
Q

PMR management/treatment

A
  • Referral to rheumatologist
  • Referral to ophthalmologist or plastic surgeon with any sign of temporal arteritis
  • Systemic corticosteroids (low dose prednisone)
    • Consider bone protective measures for patients with chronic PMR and require lifelong corticosteroids
38
Q

What is the most significant complication of PMR?

A

Giant cell arteritis → report any new headache, change in vision, scalp tenderness, pain on chewing

39
Q

Giant cell arteritis clinical manifestations

A
  • Involvement of CNs → severe headache (temporal region), jaw claudication, visual impairment, scalp tenderness, prominent or tender temporal artery, tongue infarction, stokes, neuropsychiatric symptoms
40
Q

Giant cell arteritis diagnostic studies

A
  • Color doppler ultrasound of temporal arteries → halo sign
  • Gold standard → unilateral temporal artery biopsy
41
Q

Giant cell arteritis management/treatment

A
  • Prednisone
  • Pulse IV methylprednisolone for visual impairment
  • Adjunctive therapy with steroid sparing agents (e.g. methotrexate)
  • Low dose aspirin
42
Q

What is rheumatoid arthritis?

A

Autoimmune disorder characterized by bilateral symmetrical inflammatory polyarthritis and varying degrees of extra-articular involvement

  • Insidious onset
43
Q

Systemic symptoms of RA

A
  • Weakness
  • Weight loss
  • Malaise
  • Fatigue
  • Anorexia
  • Aching
  • Stiffness
44
Q

Localized symptoms of RA

A
  • Painful, tender, swollen joints
  • Morning stiffness for >1 hour
45
Q

Extra articular symptoms of RA

A
  • Sjogren syndrome (dry eyes and mouth)
  • CV disease
46
Q

RA diagnostic studies

A
  • X-rays
  • Labs → CBC, ESR, CRP, creatinine, hepatic panel, UA, RF, anti-CCP
    • Normocytic, normochromic anemia common
  • Synovial fluid analysis (aspiration)
47
Q

Non pharmacologic management of RA

A
  • PT, OT, psychological interventions, exercise
  • Warm showers in the morning
  • Frequent position changes during sleep to alleviate stiffness
  • Assess CV risk yearly
48
Q

Pharmacologic management of RA

A

DMARDs (methotrexate) + folic acid supplementation, biosimilar medications, NSAIDs, glucocorticoids

49
Q

Clinical manifestations of ankylosing spondylitis

A
  • Chronic back pain and stiffness (in pelvis and lower back) due to involvement of spine or sacroiliac joints
    • Back pain improves with exercise and worsens with inactivity/rest and in the morning
  • Buttock pain; hip pain
  • Deep ache or nagging discomfort
  • Sleep disturbance (wake up to “walk to pain off”)
  • Asymmetric joint arthritis (commonly in lower limbs)
50
Q

Extra articular manifestations of ankylosing spondylitis

A
  • Low grade fever, fatigue, weight loss
  • Acute anterior uveitis → unilateral or unilateral alternating
51
Q

Physical exam findings of ankylosing spondylitis

A
  • Loss of normal lumbar lordosis
  • Decreased spine mobility
52
Q

Ankylosing spondylitis diagnostic studies

A
  • Presence of sacroiliitis on MRI associated with one clinical criterion
    • X-ray may not show changes early on in disease process
    • “Bamboo” spine appearance
53
Q

Referrals for ankylosing spondylitis

A
  • Referral to rheumatology
  • Referral to orthopedic surgeon (for patients who develop hip arthritis), evaluation by cardiologist
  • Periodic ophthalmic monitoring
54
Q

Non pharmacologic management of ankylosing spondylitis

A
  • Perform exercises tailored for AS (PT)
  • Local heat and massage
  • Avoid contact sports (can go swimming)
55
Q

Pharmacologic management of ankylosing spondylitis

A
  • NSAIDs first line therapy
  • DMARDs (methotrexate), TNF agents (etanercept, -umab), IL-17 monoclonal antibodies (secukinumab)
  • Systemic corticosteroids for short term relief (NOT long term)
  • Acetaminophen and muscle relaxants to minimize chance of spine deformity
56
Q

Psoriatic arthritis clinical manifestations

A
  • Can occur before, with, or after onset of psoriasis
  • Nail pitting before rash
  • Enthesitis and dactylitis, arthritis mutilans
  • Asymmetric sacroiliitis (in AS it is bilateral)
57
Q

Psoriatic arthritis diagnostic studies

A
  • X-ray of affected joints → subchondral erosions, periostitis, ankylosis
    • Late disease will show whittling and “pencil in cup” appearance
58
Q

Non pharmacologic management of psoriatic arthritis

A
  • Regular exercise (swimming, cycling, walking)
  • Referral to rheumatologist and dermatology
59
Q

Pharmacologic management of psoriatic arthritis

A
  • NSAIDs are first line
  • DMARDs are second line (methotrexate)
  • Anti-TNF agents → etanercept, infliximab, adalimumab, golimumab, certolizumab)
60
Q

Clinical manifestations of SLE

A
  • Early symptoms are nonspecific → fatigue, oral ulcers, joint pain, malaise
  • Malar (butterfly) rash
  • Discoid rash
  • Photosensitivity
  • Arthritis
  • Serositis (pleuritis, pericarditis)
  • Persistent proteinuria, cellular casts
  • Seizures, psychosis; mood changes, depression, migraines, headaches
  • Raynaud phenomenon
61
Q

SLE diagnostic studies

A
  • Elevated ESR, CRP, serum gamma globulins
  • Hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
  • UA, BUN, creatinine, 24 hour urine protein excretion, CrCl
62
Q

Non pharmacologic management of SLE

A
  • Referral to rheumatology at diagnosis; dermatologist, ophthalmologist, nephrologist, cardiologist, orthopedic surgeon, hematologist, OT, PT, nutritionist
    • Visits to gynecologist at shorter intervals (higher risk of HPV and cervical dysplasia)
  • Avoid prolonged sun exposure (wear SPF >30)
63
Q

Pharmacologic management of SLE

A
  • Statins for hyperlipidemia, calcium and vitamin D for osteoporosis
  • Antibiotic prophylaxis before dental procedures
  • NSAIDs
  • PPIs in addition to corticosteroids or aspirin therapy
  • Hydroxychloroquine for MSK, mucocutaneous, and serosal manifestations
64
Q

What is juvenile idiopathic arthritis?

A

Persistent arthritis for more than six weeks in a child younger than 16 years old

65
Q

Clinical manifestations (history) of juvenile idiopathic arthritis

A
  • Arthritis → pain (aching), joint stiffness (worse in the morning and after rest), joint effusion and warmth, younger children may be irritable or have behavioral regression
  • Nonspecific symptoms → decreased appetite, myalgia, nighttime joint pain, inactivity, FTT
66
Q

MSK exam findings for juvenile idiopathic arthritis

A
  • Swelling of joint with effusion or thickening of synovial membrane
  • Heat over inflamed joint and tenderness along joint line
  • Loss of joint ROM and function
  • Observe gait abnormalities (may walk with a limp)
  • Holds affected joint in flexion
67
Q

Physical exam findings for juvenile idiopathic arthritis

A
  • Vision screening
  • Nail pits or onycholysis
  • Ciliary injection
  • Fleeting salmon-color rash that is more prominent on the trunk
68
Q

Juvenile idiopathic arthritis diagnostic studies

A
  • Diagnosis of exclusion
  • Watchful waiting since joint pain must be present for >6 weeks
69
Q

Non pharmacologic management of juvenile idiopathic arthritis

A
  • Referred to pediatric rheumatologist and ophthalmologist
    • High risk for uveitis → slit lamp examination every 3-4 months for four years
  • Physical therapy mainstay of treatment for chronic childhood arthritis
  • Water therapy and using heat or cold to reduce pain and stiffness (e.g. swimming)
70
Q

Pharmacologic management for juvenile idiopathic arthritis

A
  • Aggressive early pharmacological therapy
    • NSAIDs
    • DMARDs (managed by pediatric rheumatologist)
    • Oral glucocorticoids if there has not yet been a prompt response

NURS 502 (43 decks)

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