MSK and Autoimmune Flashcards
Sprains Strains osteoarthritis fractures mechanical back pain fibromyalgia osteoporosis
non inflammatory conditions
Tx for noninflammatory conditions
NASIDs, Tylenol, RICE
if needed PT, Ortho, nurosurg
Ankylosing spondylitis Psoriatic arthritis reactive arthritis RA IBD-assc/ arthritis SLE Raynauds PMR GCS Vasculitis
Inflammatory and autoimmune
Tx for Inflammatory and autoimmune conditions
CS, DMARDs, biologics
rheum, sometimes ortho
Septic Arthritis
Osteomyelitis
gout
inflammatory but not autoimmune conditions
Tx for inflammatory but not autoimmune conditions
treat etiology, bacteria/virus, uric acid
ID, ortho; gout = pcp
M>F; 30-45yo; genetic
Patho: inflammation of ligaments and tendons at bone insertions and new bone formation
Ankylosing Spondylitis
Chronic back pain and stiffness (pelvis and low back), buttocks and hip pain. Insidious and chronic w/ exacerbations and remissions. Improves with exercise and worsens with inactivity. Sleep disturbance (getting up to walk off pain). Pain worse in the morning*.
Eventually, asymmetric joint involvement of lower limbs.
Ankylosing Spondylitis
PE and Diag for Ankylosing Spondylitis
loss of lumbar lordosis. Muscle spasms of paraspinal muscles. Modified schober flexion test and Moll lateral flexion test (spinal ROM). Heart murmur, AV insufficiency, red eye (uveitis/iritis)
Diag: CBC, CMP, ESR, CRP, RF(-), ANA(-), lyme, x-ray (may be normal early), MRI (detects earlier disease) HLAB27
Tx for for Ankylosing Spondylitis
Active and Stable AS 1st: NSAIDs Begin while awaiting referral TNFI Biologics Physical Therapy Glucocorticoids not recommended Regular lifelong Exercise
Children with _______ are at high risk of developing osteosarcoma, small cell lung cancer, and synovial sarcoma as adult
retinoblastoma
Pain that is noticed________indicates malignant bone tumor
more at night
most common primary bone CA, M >F, 12-24yo, temperate climates, african americans. 75% in femur or tibia. RF hx of radiation.
Osteosarcoma
2nd most common bone tumor ; usually in leg bones, palpable mass
Ewings sarcoma
kids or teens; hard, fixed lesion/mass on bone= BENIGN Tumor
Most often found in 20s, asymptomatic, only remove if pain or deforminity
Osteochondroma
+ Bone biopsy for Multiple myeloma proves the diagnosis
Bence Jones proteins, M-spike
Diag for possoble bone cancer?
Xray. CBC, ESR, CRP
plasma cell malignancy
- fatigue, bone pain, fractures, weakness
high urine calcium
Multiple Myeloma
Labs and Dx for Multiple Myeloma
CBC, CMP, SPEP, UPEP, bence Jones proteins
SPEP separates all the proteins in the blood according to their electrical charge. Urine protein electrophoresis, or UPEP, does the same thing for proteins in the urine.
CM: >3 mos MSK pain (generalized), fatigue, nonrestorative sleep; depression, HAs, IBS. W>M onset 40-50years old
Patho: theories: CNS disorder, disturbances in autonomic endocrine and stress responses. Frequently follows physical or mental trauma, viral illness, or stress
Fibromyalgia & Myofascial pain
Diag for Fibromyalgia & Myofascial pain
done to r/o other causes (CBC, Vit d, TSH, ANA rheumatoid factor) USU WNL
Pharm tx for Fibromyalgia & Myofascial pain
Duloxetine (Cymbalta) SNRI FDA approved for fibromyalgia
TCA (amitriptyline 10mg 2-3hrs before bed)
Gabapentin (neurontin) and pregabalin (Lyrica)
Trazodone (Desyrel) and zolpidem (ambien) for sleep
NSAIDs not shown to be effective
Other tx for Fibromyalgia & Myofascial pain
CBT effective in studies in reducing pain and improving function
Exercise (Aerobic) improves pain, sleep, and depression. Begin low intensity for short durations and increased pain at initiating is common. Gentle stretching and yoga combined with biking, swimming, and/or walking
hyperuricemia (SU > 6.8 mg/dL) causes formation of tophi on earlobes, fingers, toes, and olecranon bursae
CM: recurrent episodes of painful monoarthritis (one joint) in men and oligoarthritis (4 or fewer joints) in postmenopausal women and men is subsequent flares. Flares increase in frequency and severity if untreated. High suspicion if pt has renal disease
Gout
often wakes patient at night with tenderness, warmth, redness, and swelling and decreased ROM. Tophi
1st gout attack
1st metatarsophalangeal joint (big toe) most common, knee, elbow, hands, etc
how to confirm dx of gout
Fine needle aspiration to confirm diagnosis
needle aspiration (presence of MSU crystals in synovial fluid). US with icing (very specific for diagnosis; helpful in needle aspiration). Elevated inflammatory markers, creat, and SU
X-ray: punched out; CT shows crystal deposits
Gout Tx extra knowledge
Avoid diuretics (HCTZ competes with uric acid transporter), control weight, and limit alcohol (beer high in purines which is broken down into uric acid). DASH diet, dairy helps, cherry juice (>4mos).
Tx is lifelong
Acute Gout TX
NSAIDs (unless renal disease, CHF, peptic ulcers, HTN, anticoags) and colchicine (in first 12-24hrs of attack: 1.2mg then 0.6mg in one hour). Dose adjust when GFR<50 and do not use if GFR<10. Corticosteroids if pt can’t use NSAIDs or colchicine (oral, IM, intraarticular)
Chronic Gout Tx
Maintain SU level <6mg/dL.
Oxidase inhibitors: Allopurinol (once daily dosing; start at 50-100mg increase to 800 mg as needed), febuxostat (also once daily, good choice in pts with allopurinol hypersensitivity)
Uricosuric agents: probenecid, lesinurad
Recombinant uricase: pegloticase
If 2 or more attacks in a year, hx CKD, kidney stones, or uric acid >9 start ____
urate-lowering therapy
Diagnostics for Gout
ESR, CRP, Cr, Serum Urate, Xray/ US/ Needle aspiration
management of Gout
- treat acute flare
- lowering of the total body uric acid pool to prevent tissue deposition of MSU crystals
- Anti Inflammatory prophylaxis to prevent acute flares, esp when ULT is started
* dietary change, exercise
Most common cause of Infectious arthritis in the adult
Staph aureus most common cause*
N. gonorrhoeae in sexually active adults <30
Acute onset painful, red, swollen joint warm to the touch. Painful at rest and with ROM/weight bearing Knee and hip most common sites (can be any joint). Fever and rigors may be present but is not specific. Proximal lymph node may be enlarged and tender.
Infectious arthritis in the adult
migratory arthritis (bull’s eye rash). ELISA then confirmation with western blot.
Lyme Disease
Should be suspected if unusual joints are involved (sternoclavicular, sacroiliac, symphysis pubis). MRSA is common pathogen.
Injection drug use
Dx of Infectious arthritis in the adult
culture and cellular chemical analysis of synovial fluid (joint aspiration)
synovial fluid leukocyte count of >50,000 mm3 → septic until proven otherwise by culture
Blood cultures
Tx of Infectious arthritis in the adult
Send immediately to hospital once suspected
IV ABX
N gonorrhoeae: maculopapular rash and migratory polyarthritis
Tx: ceftriaxone 1g/day (7-10days) PLUS azithromycin 1g once
Prosthetic Joint: removal and 6wks of IV ABX followed by new prosthetic implant
Pain management aa
Drains or daily arthrocentesis
Diagnostics for infectious arthritis in the adult
Referral to ED
CBC, ESR, CRP, Blood cultures, synovial fluid aspirate
persistent arthritis for more than 6 weeks in a child younger than 16 years old
Underlying cause unclear.. HLA Class I and II alleles associated
Juvenile arthritis
Most common type of JA
Four or less joints with persistent disease, usually larger joints
May present with morning limp
Usually ANA positive
Oligoarticular
Juvenile Arthritis in ≥ five or more joints during first 6 months of disease with acute or insidious onset, small and large joints
F>M
May develop rheumatoid vasculitis; resemble adults
Polyarticular
Systemic disease with organ involvement
Rash that comes and goes, joint swelling and effusion, warmth, diminished ROM, uveitis
Usually ANA negative, those with ANA and RF + higher risk for uveitis
DX of exclusion
Still’s disease
<18 yrs
Pain—generally a mild to moderate aching
Joint stiffness—worse in the morning and after rest; arthralgia may occur during the day
Joint effusion and warmth
Younger children may be irritable or have behavioral regression
Nonspecific symptoms include decreased appetite, myalgia, nighttime joint pain, inactivity, and failure to thrive
uveitis
Dx: exclusion Dx (ANA may or may not be positive)
Juvenile arthritis
Tx for Juvenile arthritis
similar to rheumatoid arthritis…
biologics or DMARDS may be helpful
NSAIDS
Refer to Pedi rheumatology
(clark test- downward pressure above knee and ask child to flex thigh; positive if pain)
Chondromalacia patella
aka “runner’s knee.”
Dx for septic joint
synovial fluid and blood cultures.
T-score ≤ -2.5 SD OR T score <-1 and > -2.5 and ≥2% & 10-yr major fracture risk 20% or 3% hip fracture risk
Osteoporosis
estrogen deficiency, aging, RA, glucocorticoid use, current smoker, alcohol use, prior hi, hyperparathyroid, hyperthyroid
p fx, low BMI. First 5-10 yrs after menopause
CM: dowager’s hump (kyphosis of T spine)
Assess fall risk and need for PT
Osteoporosis
Dx for Osteoporosis
Vit D, Ca, PTH, creat, eGFR, TSH → to identify secondary causes. DEXA of hip and lumbar spine (Women over 65, or postmenopausal under 65 with increased risk USPSTF grade B)
Supplement recommendation for prevention of osteoporosis (if needed)
Ca 1000mg daily
Men >70 and Women >50 1200mg/day
Vit D19-70yo: 600IU daily
>70: 800 IU daily (smoe may need up to 2000 IU daily)
Stop smoking, increase sunlight exposure (15 mins w/o sunscreen)
Osteoporosis Tx fractures
Weight training, walking
Tx fractures: review meds
Bisphosphonates: alendronate, risedronate, zoledronic acid
Teriparatide
Denosumab
Prolia- injection; know calcium levels prior to injection
Calcitonin nasal spray- good for pts with compression fractures, helps with pain
Prevention and treatment of postmenopausal osteoporosis:
Alendronate (Fosamax), risedronate (Actonel), ibandronate, and zoledronic acid (Reclast)
Tx for Glucocorticoid-induced osteoporosis and men
: Fosamax, Actonel, or Reclast
USPSTF: no screening
NOA: men at risk and over 75
CI: Barett’s esophagus (risk of cancer); in pts with severe reflux or esophagitis consider infusion or once monthly rather than oral
Can cause osteonecrosis of jaw (small risk) 2 month vacation from medication before invasive dental procedures
Bisphosphonates
Administer on empty stomach with 6-8oz water. Taking with food will eliminate benefit (wait at least 30mins before eating)
SE: stomach upset, rarely esophageal ulceration
Unexplained groin or thigh pain- prompt evaluation for fx
Drug holiday every 5 years for 3-5 years
Bisphosphonates
Who to screen for osteoporosis
All women 65+ no risk factors and women <65 with risk factors (high FRAX score)
Repeat dexa scans Q 2-5 years.
Localized increase in bone turnover and blood flow, breakdown exceeds building and weak, highly vascular bone forms and is prone to deformity and fracture.
CM: often asymptomatic; bone pain worsened with heat and becomes severe with weight bearing. Often misdiagnosed as OA.
Pagets Disease
Most commonly affected sites; femur, pelvis, tibia, spine, and skull. Rarely in hands and feet
PE: site warm and tender to touch; increased pulsatility. Bone enlarged or deformed, frontal bossing. Nerve entrapment can cause hearing loss, neuropathies, and cranial nerve palsies. Spinal stenosis can occur.
Pagets Disease
diagnostics for Pagets Disease
Alkaline phosphatase or urinary N-telopeptide cross-links (NTX) bone radiograph can distinguish from malignant bone dx
Tx for Pagets Disease
Refer to endo if unresponsive to tx
Tx: indicated when there is bone or joint pain; lesions in weight-bearing sites, skull involvement, nerve entrapment, or in preparation for surgery
Bisphosphonates
Alendronate (Fosamax) 40mg daily for 6 mos
Risedronate (actonel) 30 mg daily for 2 mos
Calcitonin→ pain remits after 2-3 weeks; not as potent or long lasting
PT, shoe lifts, walkers, canes. Calcium and vitamin D supplementation; swimming, bicycling, and tai chi
pain, stiffness, LROM. Pain worse in the morning and after prolonged activity, relieved by rest. condition of spine can result in neuropathy and radiculopathy. Trendelenburg gait (caused by favoring and hip leading to muscle weakness). Heberden nodes (distal interphalangeal joints) and Bouchard nodes (proximal interphalangeal joints)
Bouchard is before heberden
Osteoarthritis
asymmetric mono or polyarticular
Diag Osteoarthritis
o r/o other conditions. All labs are often normal in OA; x-ray will confirm diag
Tx Osteoarthritis
Acetaminophen - Limit alcohol and other OTC acetaminophen-containing drugs
Tramadol (Ultram): can be given as acetaminophen combination and with NSAIDs
NSAIDs: COX2 selective NSAIDs for pts on warfarin, chronic steroids, or hx of GI bleed.
Increase risk of MI and stroke. Consider adding H2 blockers or PPIs for pts with long term NSAID use
Intra Articular injections:
Hyaluronan: once a week for 3-5 wks
Corticosteroids: no more than every 3-4 mos. Caution in those taking oral steroids or with DM
Topical (NSAID) diclofenac for pts over 75. Lidocaine patches
Exercise, podiatry referral for foot wear, walker/cane as needed, weight management, acupuncture. Evidence supporting glucosamine is lacking (if taking, dosage is 500mg tid for 3-6mos)
Joint replacement
infection of bone
CM: localized pain, erythema, and/or swelling; fever may be present; inability to walk in children indicate impingement
RF: Diabetes, slow healing ulcers
Osteomyelitis
Dx of Osteomyelitis
CBC, CRP, maybe ESR. Blood cultures if febrile. X-ray, if normal or not definitive then MRI. Definitive diagnosis is through bone biopsy, ideally off ABX Ankfor 48hrs
tx of Osteomyelitis
Consult ID for long term ABX management, surgery if vascular insufficiency or need debridement, IR for needle biopsy. Wound care for all
Tx: delay ABX until culture if possible. Common first-line is Vanc plus ceftriaxone; fluoroquinolone if beta-lactam allergy
Often need 6 wks of IV ABX through a PICC
treatable, chronic systemic inflammatory condition of unknown cause
>50 yrs new onset bilateral shoulder pain and/or hip pain with elevated ESR and CRP; morning stiffness lasting longer than 1 hr, 50% have systemic symptoms- fever, depression, fatigue, malaise, weight loss (mimic lymphoma)
Dd: often mistaken for RA: but ___ is non-erosive, asymmetric, self-limiting and highly responsive to corticosteroids
Polymyalgia Rheumatica (PMR)
Dx of Polymyalgia Rheumatica (PMR)
CBC, ESR, CRP, CMP including bun/creat, Ca, and phos; LFTs, serum protein electrophoresis; RA factor and anti-CCP, UA, TSH, CXR
Most show: ↑ESR &CRP, leukocytosis, thrombocytosis, mild normochromic anemia, and hypoalbuminemia
Tx of Polymyalgia Rheumatica (PMR)
Tx: refer to rheumatologist, systemic corticosteroids w improvement expected in 1 week usually long term steroids for 1-2 years
Biggest complication is GCA and need bone protective measures- calcium vit D, bisphosphonates
systemic vasculitis; often occurs w/ PMR; elderly>50; F>M
Patho: transmural inflammation causes occlusion. Can involve carotid arteries and branches, aorta and its branches
Giant Cell Arteritis (GCA)
new-onset HA localized to temporal region, severe, jaw claudication, visual impairment, scalp tenderness, prominent or tender temporal artery, tongue infarct, stroke. Systemic sx (fever, weight loss, anorexia, night sweats, and dry cough often occur)
Giant Cell Arteritis (GCA)
Exam for GCA
PE: palpate temporal arteries, auscultate carotids, examine scalp, BP both arms (vascular stenosis), ocular fundoscopy
Diag for GCA
color doppler US of temporal arteries (inflammatory edema of vessel appears as hypoechoic vascular wall thickening (halo sign)).
Temporal artery biopsy is gold standard** however, don’t hold off on corticosteroids to obtain.
Tx of GCA
prednisone 1 mg/kg daily (max 60mg daily) for at least one month, then taper gradually.
Will remain on prednisone for 2-3yrs. Methotrexate 10-15 mg/wk reduces needed dose of prednisone and relapse. Low-dose ASA (80-160 mg/day). Most should have improvement of HA in 24-48hrs of corticosteroids
f/u weeks 1, 3, 6, then monthly. Monitor ESR, CRP, glucose, and LFTs
If present with visual complaints, sent to hospital for IV prednisone
Inflammatory arthritis HLA-B27 link Flare or trauma after infection Immune, genetic, and environmental factors Immune mechanism
Psoriatic arthritis
May occur before, with, or after onset of skin disease
Arthritis precedes rash in 15-20%
Nail pitting precedes rash
Tenosynovitis, enthesitis, dactylitis
Arthritis mutilans: destructive form, bone erosion, decreased bone length
Axial disease can occur without sacroiliitis, be asymmetric, skin portions of the spine
Extra-articular: more common in men with axial disease
Uveitis or conjunctivitis, GI, urogenital, heart, arteries
Psoriatic arthritis
Dx for Psoriatic arthritis
CBC w/diff, CMP, ESR, CRP, Rheumatoid factor, cyclic citrullinated peptide
X-rays: subchondral erosions, erosions with enw bone formation, periostitis, ankylosis of joints
Late disease: DIP joints: whittling and pencil in cup apperance
Psoriatic arthritis= ______
Ankylosing spondylitis= _____
Psoriatic arthritis: asymmetric
Ankylosing spondylitis, bilateral
more common in men with axial disease
Uveitis or conjunctivitis, GI, urogenital, heart, arteries
Extra-articular
Mgmt of Psoriatic arthritis:
Regular exercise: low impact
Pharm
NSAIDs first-line
DMARDS: methotrexate, sulfasalazine, leflunomide
anti-TNF agents: biologics
Oral steroids NOT recommended
Phosphodiesterase 4 inhibitor: apremilast
IL12 and 23 inhibitor: ustekinumab
IL 17 inhibitor: secukinumab
Skin flares may correlate with joint flares
Disease manifestations, medication complications of Psoriatic arthritis:
HTN, DM, atherosclerosis, metabolic syndrome, psychiatric disease
Reversible vasospastic disorder affecting fingers and sometimes nose and earlobes
RF: frostbite; autoimmune conditions
Patho: vasospasm causes oxygen loss and color change of fingers.
Raynaud’s phenomenon and Disease
White and blue feel numbness, tingling, and cold; red stage feel warmth, burning, and swelling. Attacks triggered by cold exposure, rapid change in temperature, and emotional stress. Episodes last 20mins- hours Sharp demarcation (change in color) where the spasms occur
Raynaud’s phenomenon and Disease
How to dx Raynaud’s phenomenon and Disease
clinical; can use nail fold capillaroscopy to distinguish type. Antinuclear antibody (ANA) to determine association with connective tissue disorder
Primary will have normal nail fold capillaroscopy
Secondary will be abnormal due to systemic affects
How to tx Raynaud’s phenomenon and Disease
environment measures are first line: keep body warm, avoid smoking. Ginkgo biloba may help, fish oil, vit c, acupuncture anecdotally help. Mittens>gloves
Avoid: estrogen, nicotine, beta blockers, and pseudoephedrine, amphetamines
Nifedipine (CCB) → decrease spasms
Hydralazine and prazosin (vasodilators)
Refer to rheumatologist
What score of joint involvement makes dx of Raynaud’s?
greater than or = 6
Causes: STI, dysenteric infection
Organisms: chlamydia, salmonella, shigella, yersinia, campylobacter, e. Coli, c Diff
Sporadic occurrence in young adults, may occur with infection outbreak
Patho: Acute sterile inflammatory arthropathy that follows an infection in which there is no microbial invasion of the synovium or joint space; prior infection is remote from the joint.
Strong association with histocompatibility antigen HLA-B27 in Caucasians
Reactive arthritis
: conjunctivitis, urethritis, arthritis**
May not have a documented prior infection
If history of infection, symptoms may occur 1-6 weeks later
Monoarticular arthritis, or asymmetric oligoarthritis in large joints of LEs
Less common involvement of axial spine and SI joints
Enthesitis, dactylitis
Reactive arthritis
Malaise, fatigue, fever, h/a, weight loss
urethritis, cervicitis, prostatitis, cystitis, and salpingo-oophoritis
Dermatologic: lingual or palatal ulcers;
keratoderma blennorrhagica: painless papulosquamous lesions on palms or soles
Cardiac: valve insufficiency, conduction abnormalities
Disease course usually <6 months
Extra-articular Reactive arthritis
dx Reactive arthritis
CBC with diff, CMP, ESR, CRP, Rheumatoid factor, cyclic citrullinated peptide, X-rays of joints: fluffy Psoriatic arthritis, seronegative RA, Lyme arthritis, septic arthritisperiosteal reaction of new bone formation, Synovial fluid aspiration**
Pharm Tx Reactive arthritis
Antibiotics may be warranted for treatment of the infection that triggered the arthritis
NSAIDs: recommended intial tx for sxs present <6 months
Consider PPI or H2 blocker
Intra-articular steroid injections, systemic glucocorticoids for patients who do not tolerate NSAIDs
DMARDs and biologics: patients with sxs longer than 6 months not responding to NSAIDs
Variable course: sxs usually resolve within 6-12 months, 20% of people develop chronic disease
Non-Pharm Tx Reactive arthritis
PT/OT, Low-impact exercise, Active lifestyle if well controlled
Refer to rheumatology for suspected reactive arthritis
Skin or eye disease: refer to appropriate specialist
Symmetric inflammatory polyarthritis. W>M
CM: insidious onset over weeks-months (small amount have acute onset)
Initial: weight loss, weakness, malaise, fatigue, anorexia, aching, and stiffness. Painful, tender, swollen joints ALL morning (at least 1 hour)
Joints: hands, wrists, toes. Bilateral and symmetric involvement
Rheumatoid Arthritis
check joints for pain, tenderness, swelling, deformity, ROM. Synovial membrane feels thick and boggy. Skin over joint thin, shiny, ruddy
Rheumatoid Arthritis
Dx for Rheumatoid Arthritis
baseline CBC, ESR, CRP, creat, hepatic panel, UA, RF, anti-CCP Ab. Synovial fluid analysis. X-ray (may be normal early on) MRI, US
Tx for Rheumatoid Arthritis
PT/OT, increased risk of CV disease (CV risk estimate multiplied by 1.5 (life span decreased by 10 yrs d/t CV risk). Goal: remission in 3-6mos
DMARDs → Methotrexate (MTX) 20-30 mg/week. Do not give with folic acid supplement d/t hyperhomocysteinemia from MTX. Pregnancy is contraindicated while taking.
Glucocorticoids
NSAIDs
Refer to rheumotologist
hronic multisystem inflammatory rheumatic disease that may cause diverse symptoms, such as fatigue, joint pain, rashes, seizures, edema, and chest pain
women, particularly during the prime childbearing age of 15 to 35 year
damage many organ systems, notably the kidneys, lungs, heart, skin, and brain, and may result in severe disability and even death
SLE
relapses and remissions)
Acute with severe manifestations: arthritis, nephritis, serositis, and vasculitis,
fatigue, arthralgia, rashes sporadically for many years
Butterfly rash
SLE
Dx for SLE? most specific
total ANA test most sensitive test (nonspecific)
Anti-smith and anti-double stranded DNA autoantibodies (specific)
Tx for SLE?
NSAID for pain
1st line Hydroxychloroquine: managing the musculoskeletal, mucocutaneous, and serosal manifestations
Corticosteroids - if failed to respond to hydroxychloroquine/sx relief
topical - discoid and skin lesions
combination of glucocorticoids and intravenous cyclophosphamide: focal (Class III), diffuse (Class IV), and membranous (Class V) lupus nephritis
severe persistent arthritis, methotrexate has been used
Belimumab- adjunctive therapy of autoantibody positive SLE pts with active dx receiving standard tx
Osteoporosis prophylaxis with calcium supplementation and vitamin D is appropriate.
Control BP, get influenza vaccine, polyvalent pneumococcal vaccine
which condition(s) should the use of steroids be avoided?
Ankylosing spondylitis
psoriatic arthritis
septic arthritis
For which condition(s) is the recommendation to only use steroids for a short interval of time?
IBD Arthritis, SLE
For what condition(s) are steroids the drug of choice for treatment?
Giant Cell Arteritis (2-3yrs), Polymyalgia Rheumatica
What testing MUST be completed prior to initiating immunosuppressive treatments?
TB; hep B/C, HIV, pregnancy test also. Vaccinate for Herpes Zoster, MMR before tx; avoid live vaccines during tx
About 50% of patients diagnosed with Giant Cell Arteritis also have
polymyalgia rheumatica
About 1/3 of patients with SLE also have
Raynauds
Dactylitis is most commonly seen with ____
psoriatic arthritis
Pitting fingernails can be a physical finding associated with
Psoriatic arthritis.
When considering differentials, what red flag symptom(s) /condition(s) need to be ruled out immediately?
- septic arthritis
Septic Arthritis (acute onset red/hot/painful joint with AROM and PROM→ ED)
Primary Joints Impacted with RA vs OA
Rheumatoid Arthritis
Proximal Fingers, wrists, toes; Bilateral
Osteoarthritis
Distal Fingers, knees, hips (weight bearing); Asymmetric
RA vs OA Presence of Herberden’s nodes (what are they?)
bony swelling of the distal interphalangeal finger joint
NOT present in RA
Present in OA
RA vs OA Joint characteristics?
RA= Soft, warm, tender
OA= hard and bony
Characteristics of joint stiffness RA vs OA
RA=Worse after resting (prolonged morning stiffness)
OA= worse after effort
Radiologic findings RA vs OA
RA= swelling of the soft tissue, osteoporosis, narrowing of the joint spaces and marginal erosions.
OA= nonuniform joint space loss, osteophyte formation, cyst formation and subchondral sclerosis
Lab findings for RF, anti-CCP Ab, ESR and CRP
RA vs OA
RA= RF (+)
anti-CCP Ab (+)
ESR and CRP ↑
OA= RF (-)
anti-CCP Ab (-)
ESR and CRP normal
. What medication should NEVER be initiated during an acute gout attack, and why?
Diuretics will increase uric acid
Tx for exacerbation of Raynaud’s with hx of SLE
trial of nifedipine 10mg 3 times a day
Pt with bone pain and elevated serum Alk. phos. What test helps distinguish pagets from malignant bone disease?
Bone radiograph
