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MSK Week 6 > ICL 8.6: Introduction to Rheumatology > Flashcards

ICL 8.6: Introduction to Rheumatology Flashcards

1
Q

what is rheumatology?

A

a subspecialty in Internal Medicine, with a focus on studying autoimmune conditions that cause muscle, skin and joint pain

often, the diseases are multi-system conditions with multiple organ involvement such as SLE

rheumatology also deals with musculoskeletal conditions

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2
Q

what should you ask during an HPI of a suspected rheumatoid disease?

A
  1. mode of onset, severity, quality, alleviating and aggravating factors, etc
  2. sequence of development of different features
  3. duration
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3
Q

which conditions are associated with rheumatoid diseases?

A
  1. psoriasis

2. IBD

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4
Q

what should you look for during a physical exam of a rheumatoid patient?

A
  1. the number of affected joints

mono-articular, oligoarticular, polyarticular

  1. distribution

symmetrical, asymmetrical, axial spine, large joints

  1. joints vs. periarticular structures

proper joint or tendons

  1. any systemic involvement

kidneys, lungs, heart, brain, GI tract, etc.

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5
Q

what questions do you need to get answered while trying to diagnose a rheumatoid condition?

A

Is this a musculoskeletal problem?
Is the condition articular or periarticular?

Is the condition mechanical (arthrosis) or inflammatory?

Does it affect appendicular or axial structures or both?

Is there a disease of another system?

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6
Q

what is articular joint pain?

A

pain is localized to joint line

there is pain with active AND passive range of motion

patient will present with swelling, crepitation, locking, instability or deformity

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7
Q

what is non-articular joint pain?

A

patient will have pain with active but NOT passive ROM

tenderness in adjacent structures

there will also be other physical findings in remote areas

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8
Q

how can you tell if a patient is having joint of periarticular problems?

A

joint = both passive and active motion hurt

periarticular = only passive action will hurt

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9
Q

how can you differentiate between inflammatory and non-inflammatory symptoms?

A

INFLAMMATORY
1. erythema

  1. warmth
  2. swelling
  3. stiffness after prolonged rest, morning sickness –> better with activity
  4. fatigue

NON-INFLAMMATORY
1. pain without swelling

  1. pain is aggravated with activity
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10
Q

what CBC results would indicate a rheumatoid condition? what rheumatoid condition?

A
  1. anemia, thrombocytosis –> inflammation
  2. neutropenia, thrombocytopenia –> Felty’s syndrome
  3. hemolysis, thrombocytopenia –> SLE
  4. elevated ESR, CRP –> inflammation
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11
Q

which rheumatoid condition do CCP antibodies indicate?

A

ACCP = anti-cyclic citrullinated peptide

CCP antibodies are positive in 40% of rheumatoid factor (RF) negative RA patients

CCP is far more specific for RA than RF is but a negative result does not exclude the diagnosis of RA

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12
Q

RF is found in which conditions? what’s its sensitivity?

A
  1. sjogren syndrome (90%)
  2. RA (80%)
  3. IPF (60%)
  4. bacterial endocarditis (40%)
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13
Q

what are the normal and abnormal WBC levels in synovial fluid? which conditions do abnormal WBC counts indicate?

A

WBC <200 = normal

WBC 200-3,000 = OA

WBC 3,000-15,000 = inflammatory condition

WBC >20,000 consider infection and gout

so if someone has arthritis, you need to aspirate the joint so you can get a WBC count or stain

synovial fluid analysis is very helpful, especially to exclude infection and gout

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14
Q

other than a WBC count, what other synovial fluid analysis can you do?

A
  1. crystals

2. gram stain and culture

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15
Q

what does a monosodium urate crystal in synovial fluid look like?

A

spindle = a line

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16
Q

what does a calcium pyrophosphate crystal in synovial fluid look like?

A

rhombus

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17
Q

what is osteoarthritis? what causes it?

A

it’s the degeneration of joint cartilage and the underlying bone, most common from middle age onward

primarily idiopathic from wear and tear

but can also be secondary from trauma or metabolic conditions

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18
Q

what are Heberden’s nodules?

A

bony swelling at DIP joint of the hands seen in osteoarthritis

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19
Q

what is Bouchard’s nodules?

A

bony swelling at PIP joint of the hands seen in osteoarthritis

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20
Q

which parts of the body are commonly effected by osteoarthritis?

A
  1. neck
  2. lumbar spine
  3. fingers = DIP, PIP, and thumb, NOT MCP joints
  4. big toe
21
Q

which two conditions can cause arthritis of the DIP joint?

A
  1. osteoarthris
  2. psoriatic arthritis

OA is non-inflammatory while PA is inflammatory

22
Q

what is fibromyalgia?

A

chronic musculoskeletal pain syndrome of unknown etiology but there’s often an association with stress like trauma, or sexual abuse

presentation is characterized by diffuse pain, tender points, fatigue, and sleep disturbances

patients will have pain NOT localized in the joints; it’s more diffuse and it’s like everywhere hurts

23
Q

what patient population is effected by fibromyalgia?

A

prevalence is 5% with a female to male predominance of 8:1

mean age is 30-60

24
Q

what’s the pathophysiology of fibromyalgia?

A

the normal pain pathway has sensory stimulus that activates sensory receptors in the skin/joint which is then transmitted to the DRG and throughout he spinothalamic tract to the sensory cortex where we get pain but the corticospinal tract decreases this pain

with fibromyalgia there’s an increase of the spinothalamic tract and decrease of the corticospinal tract = increased pain

so there’s Increased release of pain neurotransmitters
glutamate and substance P that leads to increased pain perception

so there’s no problems with the joints or muscles, it’s a neurological problem!

25
Q

what is the clinical presentation of acute monoarthritis?

A

the red-hot joint = pus filled joint

26
Q

what are the causes of acute monoarthritis?

A
  1. bacterial infections

Neisseria, mycobacteria; could also be a virus or lyme disease

  1. could also be crystal induced like from gout, CPPD, or hydroxyapatite
27
Q

what lab test can you do to test for acute monoarthritis?

A

abnormal joint fluid will be not clear, you can’t see through it

normal joint fluid you can see through

28
Q

what is the clinical presentation of septic arthritis?

A

mostly a single joint = wwollen, warm, red and painful joint

but there’s also fever and systemic infection symptoms

can involve knees, hips, shoulders (large)

29
Q

what organism most often causes septic arthritis?

A

staph aureus

30
Q

which patient population is often effected by gonococcal arthritis?

A

sexually active individuals

women, often menstruating/pregnant

31
Q

what is the clinical presentation of gonococcal arthritis?

A
  1. fever
  2. chills
  3. skin lesions
  4. migratory arthritis + tenosynovitis –> persistent monoarthritis
  5. genitourinary disease often asymptomatic
32
Q

what is gout?

A

the buildup of monosodium urate crystals

pain is excruciating

typically effects the first MTP joint of the big tow

33
Q

what type of crystals do you see with gout?

A

monosodium urate crystals = needle-shaped

strongly negative birefringent

crystal presence is diagnostic if MΦ engulfing MSU crystals

34
Q

what is pseudogout?

A

aka CPPD crystals deposition disease = calcium pyrophosphate deposition

clinically indistinguishable from gout

often precipitated by illness or surgery

knee (50%) and wrist, but can be any joint

CPPD disease may be asymptomatic (chondrocalcinosis)

35
Q

what is poly arthritis?

A

effects more than 5 joints

36
Q

what are the temporal patterns of polyarthritis? which causes are associated with each?

A
  1. Migratory pattern:
    Rheumatic fever

Gonococcal (disseminated gonococcemia)

Early phase of Lyme disease

Palindromic rheumatism

  1. Additive pattern
    RA
    SLE
    psoriasis
  2. Intermittent
    Gout
    reactive arthritis
37
Q

what viral infection can cause polyarthritis?

A

parvovirus B19

patients will have abrupt onset of flu-like illness and arthritis following exposure to kids who have slapped cheek symptoms of 5th disease

condition may persist for a few weeks to months

38
Q

what type of arthritis is RA?

A

polyarthritis

it effects like all the joints of the hand except the DIP

39
Q

what type of arthritis is RA?

A

polyarthritis

it effects like all the joints of the hand except the DIP which causes serious hand deformities

40
Q

what is reactive arthritis?

A

an infection-induced systemic disease with inflammatory synovitis from which viable organisms cannot be cultured

patients will present with asymmetric, oligoarticular, knees, ankles, feet (lower extremities)

41
Q

reactive arthritis is associated with what genetic conditions?

A

association with HLA-B27

42
Q

what is the clinical presentation of reactive arthritis?

A
  1. patients will present with asymmetric, oligoarticular, knees, ankles, feet (lower extremities)
  2. enthesitis: inflammation of tendon-bone junction (Achilles tendon, dactylitis)
  3. extraarticular: rashes, nails, eye involvement

so it’s a triad of symptoms! can’t see, can’t pee, can’t climb a tree

43
Q

what is psoriatic arthritis?

A

Dactilytis “sausage fingers” with nail changes

nails look fucked up like super old people cracking thick nails

44
Q

what is SLE?

A

autoimmune disease

patients do not develop erosions but they may have acute inflammatory synovitis RA-like

most patients have arthralgia and photosensitivity

musculoskeletal manifestation 90%

45
Q

what is a marker for SLE?

A

ANA positive in 95%

46
Q

what is rheumatic fever?

A

autoimmune disease preceded by infection often seen in kids

patients can prevent with erythema marginatum = patchy looking hives or subcutaneous nodules

47
Q

A 25 year old woman with malar rash, oral ulcers complain of polyarticular joint pain. What is the dx and best diagnostic test?

A

SLE, check ANA

48
Q

A 35 year old man, with silver scaly skin lesions on the elbows and knees, complain of polyarthralgia. What is the best diagnostic test for this condition?

A

None, this is psoriatic arthritis

the patient has sausage toes and spots on the skin

MSK Week 6 (10 decks)

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