exam Flashcards
List 5 sources of pain within the joint /5
From deepest → most superficial:
● Subchondral bone - highly vascularised, high neural input
● Periosteum
● Ligaments (intra-articular)
● Synovium - Secretes and reabsorbs synovial fluid
● Joint capsule
List 4 basic pathophysiologic types of joint disease /4
● Synovitis ● Enthesopathy ● Crystal deposition disease ● Infection ● Structural or mechanical derangement NB: Not mutually exclusive, often coexist
List 4 key events occurring in synovitis /4
Disease characterised by warmth, tenderness and boggy end feel
● Neovascularization
● Infiltration of synovium with inflammatory cells (lymphocytes, plasma cells and macrophages)
● Synovial cell hyperplasia → thickening of synovium
● Invading inflammatory cells + synovial hyperplasia = granulation tissue/pannus formation:
○ Pannus may infiltrate the intra articular bone and cartilage
○ Pannus releases inflammatory substances –> erodes nearby cartilage and bone tissue
Differentiate between OA & RA stiffness /2
● RA Stiffness
○ Upon waking, lasts more than 30-60 minutes
○ Occurs due to inflammation
● OA Stiffness
○ Occurs upon waking or following periods of inactivity, is usually brief (less than 30 minutes)
○ Occurs due to “gelling” = thickening of synovial fluid
List 6 descriptors to help diagnose a painful joint /6
HX Features important to the differential diagnosis
Onset of symptoms
○ Abrupt (minutes-hours) – Trauma, crystal deposition, infection
○ insidious (weeks-months) – Most forms of arthritis eg RA, OA etc
● Duration of symptoms
○ Acute (Ssx present for <6 weeks)
○ Chronic ( Ssx present for >6 weeks)
● Joint involvement
○ Migratory – Inflammation persists for only a few days in each joint (rheumatic fever)
○ Additive – Inflammation persists in involved joints as new ones become infected (eg RA)
○ Intermittent – Remitting and relapsing Ssx, episodic
● Number of joints involved
○ Monoarticular – Single joint involvement
○ Oligoarticular – Involvement of 2-4 joints
○ Polyarticular – Involvement of 5 or more joints
● Symmetry of presentation (distribution?)
○ Asymmetrical – Joint involvement on one side of the body; or different joints involved on each side of the body (eg. OA, PsA, ReA)
○ Symmetrical – When the same joints are involved on either side of the body (eg RA, SLE)
● Distribution
○ Axial – The spine & SIJs
○ Peripheral – Joints of the upper and lower extremities
● Distinctive presentation ○ Enthesitis - Occurs in seronegative spondyloarthropathies ○ Dactylitis ○ Back pain ○ Tendonitis ● Extra articular manifestations ○ Systemic SSX ○ Skin lesions ○ Ocular lesions
Briefly define (mono/oligo/polyarthritis)/1/1/1
● Monoarthritis ○ Arthritis affecting 1 joint ● Oligoarthritis ○ Arthritis affecting 2-4 joints ● Polyarthritis ○ Arthritis affecting 5 or more joints
List 3 constitutional manifestations seen in systemic conditions
● Fever
● Weight Loss
● Fatigue
● Malaise
List 4 conditions that typically have skin lesions and describe the lesion
● Systemic Lupus Erythematosus
○ Malar rash – red, raised butterfly rash over nose and cheeks (maxillary & nasal area)
○ Discoid rash - raised, red, flaky rash; generally on head and face
● Dermatomyositis
○ Gottron’s papules – raised, red papules/macules
○ Heliotrope rash – prominent, violaceous purple/red rash on eyelids
○ Erythematous rash - Raised, dusky (blue/purple), smooth or scaly, pruritic rash that can be found on: forehead, V of neck, chest and back, forearms and lower legs, PIPs and MCPs, medial malleoli
● Systemic Sclerosis
○ Dermal induration due to fibrosis - thickening and firming of skin
● Psoriatic Arthritis
○ Psoriasis (precedes arthritis) - raised, red, flaky and pruritic rash on various parts of the body
● Reactive Arthritis
○ Keratoderma blennorhagica - hyperkeratotic skin lesion on palm of hands and soles of feet (looks like psoriasis)
● RA
○ Haemorrhagic rashes due to vasculitis (petechiae, purpura = small, round, red rashes that are not raised)
List 3 inflammatory arthritides resulting in monoarthritis
● Septic arthritis
● Crystal deposition disease (gout and pseudogout)
● Systemic rheumatic disease manifesting as monoarticular involvement (eg. RA)
● Juvenile Idiopathic Arthritis
● PsA - Unilateral (asymmetrical mono/oligo but presenting mono)
Define CRP
● CRP or C-reactive protein is an acute-phase reactant produced by the liver following release of inflammatory cytokines (including interleukin 1 and 6) when there is tissue damage, autoimmune disease or infection.
What does CRP tell us that ESR doesn’t
● More sensitive than ESR for evaluating inflammation
● Rises faster than ESR - Can detect/test for disease more acutely
● Better mirrors extent of tissue damage than ESR
● Is independent of factors which raise ESR (size & shape of erythrocytes, other proteins involved)
● Correlates better with disease activity
● Not affected by the administration of steroidal, non steroidal anti inflammatories or immunosuppressants
Define ANAs /2
Which People is it foudn in /1
● Antinuclear antibodies are pathological auto-antibodies which target specific nuclear antigens within the nucleus of a cell. These antibodies are generally present in autoimmune diseases where the immune system targets self tissues.
● Normal people
● People with autoimmune conditions
● People with rheumatic conditions
List 3 conditions it (ANAs) would be elevated?
When is it indicated? (what’s the clinical picture)
● SLE ● SSc/CREST ● Polymyositis (PM) ● Mixed Connective Tissue Disease (MCTD) ● Crohn’s
Indicated
● When the patients clinical picture is consistent with a systemic autoimmune disease (eg presnting with Raynaud’s phenomenon) – SLE, PM, MCTD, Ssc, Sjogren’s syndrome
● ANA testing is particularly useful in the diagnosis of SLE, as nearly all SLE patients have positive ANA test (93% sensitivity, 57% specificity)
name 1 LAB test to Dx each condition and why /6 Muscle Injury AS Myositis Muscle Weakness Muscle Dystrophy Paget's
Muscle injury
● Creatine Kinase - most sensitive indicator for muscle injury. CPK is an intracellular enzyme released into the bloodstream when muscle tissue is damaged.
AS
● HLA B27 - high correlation in those presenting with ankylosing spondylitis (80-90% of patients). Not purely diagnostic, should be considered with radiological findings and clinical presentation.
Myositis
● Myositis Specific Antibodies (MSA) - appear in autoimmune myositis
● Muscle biopsy - extremely valuable in the dx of myositis, however not diagnostic. Should be considered in conjunction with CPK and EMG findings. Skin biopsy should be considered for dermatomyositis.
Muscle weakness
● Muscle biopsy - used to dx mm disease i.e. PM
● Muscle biopsy is gold standard for investigating muscle weakness, allows investigations of infection, connective tissue disease, metabolism and genetic disorders. CPK should be considered along with EMG examination.
Muscle dystrophy
● Creatine kinase and muscle biopsy (when reacted with antibody reagents)
● (ESP FOR DUCHENNES) Early SSx should trigger ordering of CPK levels, persistently high serum alanine and aspartate transaminase levels should be noted. Genetic testing should follow, if no dx can be made. Muscle biopsy will illustrate dystrophic process in selected sample.
Paget’s
● ALP → increased in conditions that cause increased bone turnover and destruction
● Primarily radiological diagnosis, followed by serum ALP. Xray will show degenerative malignancy of paget’s, serum ALP will support radiological findings.qa
List 5 indications for joint aspiration /5
● To establish the dx of infection, crystal-induced arthritis, synovitis or neoplasms involving the joint
● To aid in the dx of gout and pseudogout
● To detect the presence of gonococci, a major cause of joint infection
● To identify cause of joint effusion
● To follow progression of joint disease
