- Podagra (Classic) - joint swelling (1 joint) - EXTREMELY TENDER - REDNESS - at night, awakens from sleep

- monoarticular arthritis, TTP - skin warm, tense, dusky red - CHRONIC: TOPHI - Functional loss (Functio laesa)

Gout, Raynaud's, Fibromyalgia Flashcards by Elisabeth Silver

what does gout result from?

deposition of uric acid crystals in joints, tissues (tophi) and fluids w/in the body/joints

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what is uric acid a metabolic product of?

metabolism of purines

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is hyperuricemia the SAME as gout?

NO!!!

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does asymptomatic hyperuricemia need to be treated?

NO!!!

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whats the MOST COMMON arthropathy in the US?

Gout

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what comorbidities is gout seen with?

obesity, HTN, DM, hyperlipidemia

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gout can increase risk for having what?

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what is the biggest problem with gout?

underexcretion

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causes of under excretion of uric acid?

genetics (primary hyperuricemia)

dehydration

renal disorders (renal insufficiency or decr GFR)

low dose ASA, thiazides, B-blockers, nicotinic acid

Lead nephropathy

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non-modifiable risk factors of gout?

male, AA, advanced age, Pacific islanders

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modifiable risk factor of gout?

alcohol and high purine food ingestion, obesity, HTN, diuretic use (HCTZ)

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classic presentation of gout?

Podagra

-PAIN OUT OF PROPORTION IN BIG TOE (can’t walk or put sheet over it)

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sx’s of gout

Podagra (Classic)
joint swelling (1 joint)
EXTREMELY TENDER
REDNESS
at night, awakens from sleep

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what joints does gout occur in?

feet, ankles, knees

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renal sx’s of gout?

uric acid stones, gouty nephritis (interstitial deposits)

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PE of gout

monoarticular arthritis, TTP
skin warm, tense, dusky red
CHRONIC: TOPHI
Functional loss (Functio laesa)

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dx of gout

ARTHROCENTESIS

NEGATIVE BIREFRINGENCE

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what do you see on arthrocentesis that is DIAGNOSTIC for gout?

Intracellular uric acid crystals

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24hour urine for underexcreters for gout will be what level?

normal level

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24hour urine for overproducers for gout will be what level?

elevated level

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what will be the uric acid level for someone with gout? is it diagnostic?

uric acid >6.8 (elevated)

NOT DIAGNOSTIC

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4 categories for gout tx

anti-inflammatory for ACUTE ATTACK

anti-inflammatory PPX for prevention of recurrences

anti-hyperuricemia (urate-lowering) therapy for PREVENTION and REVERSAL OF THE CONSEQUENCES of rate crystal deposition

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FIRST LINE tx for gout? when do you initiate therapy?

NSAIDs - initiate w/in 24hrs

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which NSAID works best for gout?

Indomethacin

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SECOND LINE tx for gout?

Colchicine

THIRD LINE tx for gout?

Corticosteroids (r/o infection first)

when do you start chronic tx for gout after an acute attack?

2-4 weeks after acute attack, start tx after recheck for uric acid level

what fruit reduces gout attacks?

cherries

what is pseudogout? more/less common than gout?

chondrocalcinosis | -less common than gout

deposition of what in pseudogout?

Ca pyrophosphate hydrate (CPPD) deposition

where does pseudogout mostly occur in the body? age?

knee age >60 y/o

pseudogout risk factors?

hypercalcemia

sx's of pseudogout?

acute, can be asx's MONOARTICULAR can resolve on own

pseudogout often co-exists with what disease?

what sx is possible in pseudogout that ISN'T in gout?

fever

dx of pseudogout?

POSITIVE BIREFRINGENCE, rhomboid crystals elevated ESR and CRP

PE of pseudogout

red, warm, tender, swollen, asx's valgus deformity of knees highly suggestive of underlying CPPD

what deformity is knees is highly suggestive of underlying CPPD?

valgus deformity

dx criteria for CPPD?

- CPPD crystals | - Synovial fluid CPPD crystal deposition

what is DIAGNOSTIC for pseudogout?

radiographic findings of joint cartilage calcified and calcium deposits in joint spaces

x-rays for pseudogout?

AP knee, AP pelvis, PA hands, PA wrist

tx for acute pseudogout?

NSAIDs, colchicine (short-term), steroids (short-term), drain fluid, rest, ice

definition of chronic pseudogout?

>3 attacks/year

FIRST LINE tx for chronic pseudogout?

colchicine is useful with frequent attacks

SECOND LINE tx for chronic pseudogout?

NSAIDs

what is fibromyalgia?

chronic pain d/o widespread pain and allodynia w/multiple tender points

what is allodynia?

pain d/t a stimulus which doesn't normally provoke pain

fibromyalgia is NOT explained by___ Must r/o what first?

any other rheumatic or systemic d/o MUST R/O OTHER D/O'S FIRST!!!

what is fibromyalgia d/t?

increased response to stimulation from amplification or increased signaling in the CNS CENTRAL SENSITIZATION

what gender and age for fibromyalgia?

women 20-50

pts with fibromyalgia have increased incidence of ___

depression, anxiety, HA, IBX, chronic fatigue syndrome, SLE, and RA

what may trigger/activate fibromyalgia sx's?

physical and/or emotional stressors - psychological trauma - psychological distress - sensitization of the pain system

sx's of fibromyalgia?

persistent widespread pain and abnormal tenderness, fatigue, sleep, and autonomic disturbances

imaging for fibromyalgia? is it diagnostic?

NOT DIAGNOSTIC MRI -> increased CNS activity that corresponds to FM subjective pain -increased regional cerebral blood flow with response to pain

describe fibromyalgia pain

widespread pain, multiple tender points Moderate to severe intensity that fluctuates, worse in AM and before bed and with cold, stress, new exercise

other sx's of fibromyalgia besides pain?

fatigue or difficulty sleeping hx of depression psychological and neuropsych sx's (anxiety, mental distress, cognitive dysfunction)

fibromyalgia PE

tender muscles at 11 points NO swelling, NO erythema

fibromyalgia is a diagnosis of ___

exclusion

dx for fibromyalgia?

WBC, Anemia, Vit D level (for fatigue), TSH Sleep study Imaging (MRI, Radiographs)

non-pharmacologic tx of fibromyalgia?

Cognitive behavior techniques -helps with pain, coping skills, relaxation techniques Exercise - based on tolerance, if pain then modify workout (DON'T STOP) - weight reduction w/nutrition counseling

1ST LINE med tx for fibromyalgia?

Tylenol or Tramadol; or Tylenol+Tramadol (Ultracet)

what meds should you NOT use to treat fibromyalgia?

narcotics or steroids

2ND LINE med tx for fibromyalgia? careful with what for these?

TCAs (amitriptyline, nortriptyline) | -careful with them if they have a hx of depression b/c of suicidal ideations

3RD LINE med tx fo fibromyalgia?

SNRIs (duloxetine) SSRIs (fluoxetine, citalopram) Cyclobenzaprine Antiepileptics (Gabapentin)

which meds for fibromyalgia have the best efficacy with fibromyalgia?

TCAs

what is Raynaud's phenomenon precipitated by?

cold exposure or stress

which Raynaud's (primary or secondary) is associated with a cause?

Secondary Raynaud's

Raynaud's is common with people with what diseases?

connective tissue diseases (I.e. scleroderma)

what is CREST syndrome?

Calcinosis, Raynaud's phenomenon, Esophageal Dysmotility, Sclerodactyly and Telangiectasia

what drug may cause Raynaud's?

beta-blockers

PE of Primary Raynaud's?

normal b/w attacks

PE of Secondary Raynaud's?

pits or ulcerations on the fingertips may be present in pt's with scleroderma, CREST syndrome or thromboangiitis obliterans

dx of Raynaud's

based on pts description of attacks in primary Raynaud's vasospastic attacks are precipitated by exposure to cold or emotional stimuli and there is BILATERAL involvement of extremities w/out gangrene

tx for Raynaud's

mild attacks - reassurance for the pt and how to prevent attacks mittens better than gloves AVOID SMOKING B/C VASCOCONSTRICTOR BB's may exaggerate sx's

what is the MOST EFFECTIVE med for tx of Raynaud's?

CCB's (amlodipine and nifedipine)