Module 3 Endocrine Flashcards
Heberden’s Node
-location
-RA or OA?
-DIP
-OA
Bouchard’s node
-location
-RA or OA?
-PIP
-OA
Differential diagnoses
-if inflammation is present
-if inflammation if absent
-RA, systemic lupus, erythematosus, GOUT
-GOUT
Differential diagnosis
-Monoarticular
-Oligoarticular
-Polyarticular
-gout, trauma, septic arthritis, Lyme disease, osteoarthritis
-reactive arthritis, psoriatic arthritis
-RA, SLE
Differential diagnosis
-site of joint involvement
*DIP
*Metacarpophalangeal, wrists
*first metatarsal phalangeal
-OA, psoriatic arthritis
-RA, SLE
-Gout, OA
OA
-what population is this most common in?
-cause
-onset acute or insidious?
-elevated labs?
-dx
-women
-degeneration of cartilage and hypertrophy of bone
-insidious
-no
-radiology reveals narrowing of joint space and osteophyte formation
OA
-prevention
-treatment
-weight reduction (#1 intervention) and maintaining normal vit D levels
-treat sx: splinting hands, weight loss, regular exercise, acetaminophen is first line tx for mild osteoarthritis, NSAIDS, injections/surgery
When to use Tylenol or NSAIDs for OA treatment
-Tylenol for normal OA
-NSAIDS for severe OA
If using NSAIDS for OA treatment, what should you be thinking about?
GI issues: gastric ulcer, perforation, GI hemorrhage = most common complications of NSAID use
If using NSAIDS, what should also be used in conjunction?
PPI
When should you be cautious in using NSAIDS for OA therapy?
over age 70
on anticoagulant therapy
taking corticosteroids
h/o peptic ulcer disease
alcoholism
OA
-intra-articular injections and surgery
-triamcinolone 20-40mg to knee or hip (given up to 4x a year)
-injections not recommended for hand OA
-total hip and knee replacements as tx for pt with ambulation restrictions d/t pain from OA
Gouty arthritis
-idiopathic or hereditary?
-insidious or acute onset?
-monoarticular or polyarticular joint involvement?
-what lab level is elevated?
-hereditary
-acute
-monoarticular
-hyperuricemia (serum uric acid level > 6.8)
Acute gout
-when uric acid is above ______, uric nephrolithiasis is common
-what is a common area of acute gout?
-is WBC elevated during attack?
-common comorbidities of these patients
-what time of year is occurrence most common?
->13mg/dL
-PODAGRA (MTP joint of great toe)
-yes, WBC elevated
-HTN, DM, CKD, hypertriglyceridemia and atherosclerosis
-summer months
Gouty arthritis
-TX
-NSAIDS
-Colchicine
-Corticosteroids
-urate-lowering therapy
Gouty arthritis: TX
-oral NSAID options
-Naprosyn 500mg BID
-Indomethacin 25-50mg every 8 hours
Gouty arthritis: TX
-Colchicine
-loading dose 1.2mg followed by 0.6mg one hour later; 0.6mg BID for prophylaxis
**treatment for flair, not maintenance
Gouty arthritis: TX
-xanthine oxidase inhibitors
-allopurinol
*cautious in CKD patients; causes rash in 20% of pts taking drug with ampicillin
*DRESS syndrome possible SE –> looks like SJS
-febuxostat
Gouty arthritis: TX
-corticosteroids
-prednisone 30-40mg QD for 2-5 days, then taper off
-avoid excessive alcohol, esp beer, high purine foods, high fructose corn syrup, thiazide or loop diuretics, niacin
In what circumstance is urate-lowering therapy initiated?
When patient has 2 or more gout attacks a year
what is the goal of urate-lowering therapy?
maintain the serum uric acid at or lower than 6mg/dL
RA: most common cause of mortality
cardiovascular disease
RA
-def
-acute or insidious onset?
-how long is morning stiffness?
-chronic systemic inflammatory disease
-insidious
-morning stiffness >30 min
RA
-S/S
-Multiple joints are involved with swelling, tenderness, and pain
-20% of RA patients have subcutaneous nodules which are usually seen over bony prominences
RA
-other comorbidities associated
-interstitial lung disease, small vessel vasculitis, nodules in lungs/sclera/other tissue
RA: clinical findings
-what test is the most specific blood test for RA?
-anti-CCP antibodies
RA: clinical findings
-dx labwork
-RA
-anti-CCP (confirms diagnosis)
RA
-what labs are typically elevated?
-ESR, CRP, platelets
RA
-TX
-DMARDS (disease-modifying anti-rheumatic drugs)
-biologic agents/drugs
-NSAIDS
RA
-common DMARDS
-Methotrexate –> drug of choice; produces a positive effect in 2-6 weeks (take with FA)
-sulfasalazine (need ophthalmology eval prior to initiating therapy)
-hydroxychloroquine (Plaquenil)
-Leflunomide (Arava) (screen for hepatitis prior to initiating tx)
-Cyclosporine
RA: Biologic agent/drugs
-def
-examples
-used with DMARDS?
-created or produced from living organisms or at least contain some part of living organism (wide variety of products made from human, animal, or microorganisms via biotechnology)
*include vaccines, blood, blood components, cells, allergens, genes, tissues, and recombinant proteins
-enbrel, humira, orencia, remicade, xeljanz, cosentyx, stelara
-YES
Systemic lupus erythematosus (SLE):
-men or women are more commonly diagnosed?
-what classic symptom appears in 50% of pts?
-what lab will be positive along with _________?
-women
-butterfly molar rash
-ANA will be positive along with anemia
Systemic lupus erythematosus (SLE):
-sx
-how many criteria need to be met to diagnose SLE?
-What can drug-induced lupus be caused by?
-fever, malaise, anorexia, weight loss, and positive ANA (antinuclear antibodies)
-4 of 11
-minocycline, hydralazine, isoniazid (most common)
Systemic lupus erythematosus (SLE):
-TX
-tailor drug therapy to each patient due to fluctuation of disease
-antimalarials (hydroxychloroquine) may help with joint discomfort and rashes
-corticosteroids can be used for sx relief but always taper down and use the lowest dose that gives relief
Antiphospholipid syndrome
-def
-clinical findings
-Russel viper venom
-hypercoagulability with recurrent arterial and/or venous thrombus
-recurrent fetal loss after first trimester; patients with DVT and/or PE (without dx of CA); embolic CVA
-test on blood that would be positive to indicate anti-phospholipid syndrome
Things to avoid with gout risk
-alcohol
-high purine foods (organ meat, yeast (beer), seafood; beans/peas/lentils/oatmeal/spinach/asparagus/cauliflower/mushrooms
-corn syrup drinks
-avoid loop/thiazide diuretics or niacin
what is the goal serum uric acid level for those at risk for gout?
<6.0mg/dL
Antiphospholipid syndrome:
-what tx is used?
-goal level of important lab?
-lifetime anticoagulant like warfarin
-goal INR 2-3
what is a clue that lupus anticoagulant is present?
prolonged PTT (partial thromboplastin time
how is antiphospholipid syndrome dx?
IgG and IgM anticardiolipin, antibodies beta-2 glycoprotein, and lupus anticoagulant
Raynaud phenomenon
-def
-men or women?
-TX
-referral?
-distal ischemia of the fingers due to vasoconstriction of the arterioles in response to cold or stress; can also affect toes, nose and ears
-women
-wearing mitts, keeping body warm, smoking cessation, avoiding sympathomimetic drugs; responds to CCB and vasodilators (amlodipine); surgically: cervical sympathectomy
-rheumatology referral b/c Raynaud’s syndrome can be early indication of Sjogren’s syndrome
what other disease commonly coincides with antiphospholipid syndrome?
SLE
What surgical procedure can be done for severe and frequent attacks of Raynaud syndrome?
cervical sympathectomy
Scleroderma
-def
-CREST
-diffuse fibrosis of the skin and internal organs
-limited form of scleroderma (80%) have CREST (calcinosis cutis, Raynaud phenomenon, esophageal motility disorder, sclerodactyly, and telangiectasia)
*hardening of skin is limited to face and hands
*diffuse scleroderma (20%) involves hardening of skin to face and hands along with trunk and proximal extremities
Scleroderma
-sx
-diffuse scleroderma: polyarthralgia, weight loss, malaise
Scleroderma
-clinical findings
-ulcerations around finger tips (Raynauds)
-hypomobility of GI tract due to fibrosis
-diffuse pulmonary fibrosis which causes poor diffusing ability
-HTN and renal crisis due to proliferation of the small renal arteries along with proteinuria
-anemia due to trauma to the RBC from diseased small vessels
Scleroderma
-TX
No effective drug to slow progression of disease; treat sx of underlying organ involvement
-lung involvement: pulmonary fibrosis and pulmonary HTN is the #1cause of mortality
-CKD and heart failure are also common causes of death
1 cause of mortality in scleroderma
pulmonary fibrosis/HTN; death
Idiopathic inflammatory myopathies: polymyositis
-def
-what occurs in late disease process?
-what lab is elevated?
-what to watch for…
-progressive proximal muscle weakness over weeks to months; no facial or ocular weakness; dysphagia
-muscle atrophy and contractures
-elevated CK-MB
-watch for respiratory muscle weakness, CO2 retention or hypercapnia and need for mechanical ventilation
Idiopathic inflammatory myopathies: Dermatomyositis
-sx
-what labs are elevated?
-what can this dx be mistaken for?
-classic sign
-dusky red rash in malar region and my mimic SLE rash, but usually extends beyond malar area
*shawl sign - rash extends to back
*purplish stain over the eyelids called heliotrope
-liver enzymes elevated (ALT, AST)
-Hepatitis dx
-mechanic’s hands –> hyperkeratosis to radial and palmar aspects of hands
Idiopathic inflammatory myopathies:
-sx
-what lab will be high
-will ANA be positive?
-DX
-TX
-bilateral proximal muscle weakness, causing involuntary movements
-CK will be extremely high with a + ANA
-ANA will be positive
-Muscle biopsy
-corticosteroids (prednisone) and methotrexate
Sjogren syndrome
-what type of disease process?
-SX
-what determines type of Sjogren’s patient has?
-autoimmune
-dry eyes and mouth
-+SS-A or SS-B; will also be +RA factor and +ANA
Sjogren syndrome
-women or men?
-keratoconjunctivitis sicca
-Xerostomia
-dental
-parotid
-women
-grain of sand in eye sensation
-difficulty swallowing/speaking
-rampant dental caries at gum line
-parotid enlargement
Sjogren syndrome
-DX
-TX
-diag occular test (lip biopsy) will reveal lymphoid foci in accessory salivary glands
*ANA, then confirm with DS antiDNA test
-satirical tears, mouth lubricants, good oral hygiene; keep it wet/moist
Rhabdomyolysis
-def
-cause
-what is this associated with?
-acute necrosis of skeletal muscle
-acute tubular necrosis is result caused from increased myoglobin in the hypovolemic state (patient is dry; myoglobin higher = ATNF)
-immobility, crush injuries, hypothermia exposure, use of statins in patient with compromised liver or kidney fx
Rhabdomyolysis
-TX
Aggressive IVF resuscitation
Vasculitis
-def
-involves what structures of the body?
-what is present in lab work?
-inflammation within walls of affected blood vessels
-involves arteries, veins, or both
-Anti-neutrophil cytoplastic antibodies present on lab work
Giant Cell (temporal artery) arteritis)
-common in what age?
-SX
-elevated labs
-Urgent?
->50yrs
-HA, malaise, vision changes
-Elevated ESR (usually >100)
-YES, urgent!! –> can cause blindness
Giant Cell (temporal artery) arteritis
-TX
high dose steroids
-ESR returns to normal after about a month of steroids
-poss ICU admission until cleared of organ involvement
What can giant cell arteritis lead to?
aneurysms
Polymyalgia Rheumatica (PMR)
-SX
-ESR lab value elevated?
-what else is often present along with this disease?
-TX
-many pains - wide-spread aching, flu-like sx
-ESR elevated
-Anemia often present
-oral prednisone (treat 6-12 months)
*go as low as you can go to manage sx
Psoriatic arthritis
-what does psoriatic arthritis precede?
-what does this disease resemble?
-elevated ESR? elevated RA?
-what has a severe deformity in this disease process?
-arthritis
-RA
-elevated ESR, not elevated RA factor
-severe deformity in DIP joints
Psoriatic arthritis
-TX
NSAIDS
-add methotrexate if not effective enough
-DMARDS can be used in moderate to severe cases
Septic arthritis
-acute or chronic?
-monoarticular or polyarticular?
-sx
-synovial fluid
-acute
-monoarticular
-swelling and pain often in weight bearing joints
-WBC is elevated in synovial fluid
Septic arthritis
-associated with?
-common organism responsible?
-DX
-TX
-infection: bacteremia, immunosuppressed and loss of skin integrity
-staphylococcus aureus 50%
-CT/MRI determines if bony erosion is present
-abx appropriate for treating bacteria involved
Acute pyogenic osteomyelitis
-def
-DX
-elevated labs
-TX
-serious infection that is caused from bacteria invading bone; if untreated, can affect adjacent bone
-CT/MRI will reveal extension of bone involvement
-elevated ESR
-debridement of necrotic bone and extended abx therapy (IV first, then oral)
Fibromyalgia
-men or women? (age)
-def
-elevated labs?
-trigger points
-women (20-50)
-generalized chronic aching pain and stiffness, fatigue, numbness, IBS, and sleep disorders
-none
-trigger points of tenderness upon palpation; traps, medial fat pad (knee, lateral epicondyle, elbow)
Fibromyalgia
-TX
-meditation, exercise, amitriptyline (hard to get off amitriptyline)
-no opioids or NSAIDS
Fibromyalgia
-what medication should not be given to manage pain?
Opioids or NSAIDS
Osteonecrosis
-what is the most common site?
-TX
-proximal and distal femur heads; leads to hip or knee pain
-vascularized and non-vascularized bone grafting procedures; total hip replacement if usually needed
