Orientation to Rheumatology

Question 1

Spectrum of Diseases treated by a Rheumatologist

Answer 1

Sooooo Many. Diseases/Disorders Resulting from uncontrolled or misdirected responses between antigens and the immune system.

Question 2

Fibromyalgia

Answer 2

Common chronic condition characterized by persistent, widespread pain and tenderness to palpation at anatomically defined tender points located in soft tissue MS structures.

Question 3

Symptoms of Fibromyalgia

Answer 3

1. Fatigue
2. Depression
3. Anxiety
4. Trouble sleeping
5. Morning stiffness
6. Headaches
7. Painful menstrual periods
8. Tingling or numbness in hands and feet
9. Problems with thinking and memory (sometimes called “fibro fog”).

Question 4

Diagnosis of Fibromyalgia

Answer 4

ACR –Classification Criteria for FMS: 1. History of chronic, widespread pain. 2. Pain in 11 of 18 tender points on digital palpation.

Question 5

Management of Fibromyalgia

Answer 5

The FDA has only approved 3 medications:
Duloxetine (Cymbalta), Milnacipran (Savella), Pregabalin (Lyrica) - developed to treat neuropathic pain (chronic pain caused by damage to the nervous system.

Question 6

Physical Examination of a Rheum Patient

Answer 6

1. General/GALS (Gait, Arms, Legs and Spine), 2. Joint Examination, 3. Differential Diagnosis Based on History and PE, 4. Other Manifestations of Autoimmune Diseases

Question 7

T/F: Rheumatic diseases are the leading cause of disability in persons 65 and older.

Answer 7

True

Question 8

Foreign (non-self) Antigen Response

Answer 8

Can be pathogenic or environmental. Individuals with exaggerated inflammatory responses are referred to as “atopic” (allergic rhinitis, asthma, food allergies..)

Question 9

Self Antigen Response

Answer 9

Inability of immune system to distinguish between self and non-self.

Question 10

Autoimmunity

Answer 10

Hypersensitivity directed at cells within the body viewed as antigens. Activation of B and T lymphocytes can cause acute/chronic inflammation.

Question 11

Hypotheses Concerning Autoimmunity:

Answer 11

1. Molecular mimicry, 2. Lymphocyte activation after certain infections, 3. Impaired immune regulation, 4. Exposure of sequestered antigens

Question 12

Molecular Mimicry

Answer 12

Some antigens of infectious agents so closely resemble a self antigen that Ab or T-cells also recognize self as foreign.

Question 13

Impaired immune regulation

Answer 13

Hyperresponsiveness of B and T lymphocytes – failure to undergo apoptosis after infection as programmed.

Question 14

Exposure of sequestered antigens

Answer 14

Reaction of lymphocytes with tissues not exposed to the immune system during fetal development (MHC)

Question 15

Alloimmunity

Answer 15

Occurs when an individual’s immune system reacts against antigens on the tissues of other members of the same species: ….A. Several neonatal diseases in which the maternal immune system becomes sensitized against fetal antigens that cross the placenta…. B. Transplant rejection and transfusion reactions

Question 16

PE of Fibromyalgia

Answer 16

PE shows normal MS examination with no deformity or synovitis but with widespread tender points in joints, muscles, tendon insertion points (entheses)

Question 17

Risk Factors of Fibromyalgia (8)

Answer 17

1.Women, 2.Middle Aged, 3.Genetic factors, 4.Sleep disorders, 5.Rheumatic diseases, 6.Previous Muscle injury/repetitive stress, 7.Inactivity, 8.Stress and anxiety

Question 18

Pain Syndrome

Answer 18

Hypothesized that the underlying pathophysiology involves how the body processes pain or hypersensitivity to stimuli that normally are not painful.

Question 19

More associated symptoms of Fibromyalgia

Answer 19

A person may have two or more coexisting chronic pain conditions including: IBS, chronic fatigue syndrome, endometriosis, inflammatory bowel disease, interstitial cystitis, TMJ dysfunction.

Question 20

Clinical Presentation of FMS

Answer 20

Clinical presentation: insidious onset of chronic, diffuse poorly localized MS pain accompanied by fatigue and sleep distrubance.

Question 21

Distribution of Potential Contributing factors:

Answer 21

1/3 of patients identify antecedent trauma
1/3 describe a viral prodrome
1/3 describe no clear precipitant

Question 22

Labs and Imaging for FMS

Answer 22

All labs and imaging studies are normal. Can reassure patients by completing routine blood work (CBC, CMP, TSH ESR, RF and ANA).

Question 23

Rules for Rheum Patient (10)

Answer 23

1. H&P
2. Laboratory Tests
3. Joint aspiration is needed for all acute inflammatory monoarticular arthritides (Septic versus Crystal-Induced)
4. Chronic inflammatory arthritides (>6 weeks) w/o diagnosis requires synovial biopsy
5. Gout – Rare in pre-menopausal women and affecting joints close to the spine.
6. Shoulder pain - usually non-articular (due to either bursitis or tendonitis) and LBP is usually non-surgical.
7. S/S of OA in joints not typically affected (ie: MCP, wrist, ankle or shoulder) require evaluation for secondary OA (metabolic disease)
8. Primary Fibromyalgia does not occur for the first time in patients > 55 yo and is unlikely with abnormal lab results.
9. All Rheumatoid Factor (RF) positive patients don’t have Rheumatoid Arthritis and all Antinuclear Antibody (ANA) positive patients don’t have SLE.
10. Infection must be ruled-out in patients with known disease, fever and multi-system complaints.
11. Nothing is 100%!!!!!!

Question 24

History of Articular Symptoms:

Answer 24

Inflammatory vs. Noninflammatory Pain (stiffness) early AM that resolves vs. worsening with activity
Swelling – synovitis vs bursitis vs tendonitis
Loss of Function – Muscle weakness, ROM limitations, erosive joint disease

Question 25

History of Extra-Articular Symptoms of FMS

Answer 25

IBS, irritable bladder syndrome, depression, vague parasthesias

Question 26

Treatment History:

Answer 26

Medications and other therapies, Vaccinations (possible reactive arthralgia/arthritis may follow HBV immunization)

Question 27

Past history:

Answer 27

Previous illnesses, Evaluate previous history of prescribed meds (what and why?), History of Infections, trauma, tick-bites (Lyme Disease – spirochaete or RMSV - rickettsia), transfusion (hepatitis or HIV) and travel – ITTTT

Question 28

Social History:

Answer 28

Effects of work & home life on symptoms. Psychosocial – Is the patient a worrier, stressed, anxious or depressed; any sleeping problems; EtOH and smoking history may be important.

Question 29

Family History:

Answer 29

Any history of arthritis – age of onset? Gout, RA and spondylarthropathies are more likely to be inherited. OA and connective tissue diseases are less likely to be inherited. Spondyloarthropathies present predominantly in young men. SLE predominantly occurs in young women of child-bearing age. Gout predominantly occurs in middle-aged men and post-menopausal women. OA predominantly in the elderly.

Question 30

Joint Examination

Answer 30

1. Look, feel, move, measure, compare. 2. Look for: erythema, scars, rashes, swelling, deformity, subluxation and wasting. 3. Feel for warmth, tenderness, swelling & effusion, crepitus. 4. Move – passive, active and assess stability. 5. Measure – ROM, muscle bulk and spinal deformity

Question 31

Joint Examination in an inflammatory condition

Answer 31

In inflammatory conditions, there is an increase in synovial fluid or other fluids in synovium (like blood or pus)

Question 32

Ddx based of History and Exam

Answer 32

No Inflammation for > 6weeks = Chronic, non-inflammatory – count joints: 1. Mono/Oligoarthritis – OA etc. 2. Polyarthritis – OA and possibly hypothyroidism

Question 33

Inflammation is not present:

Answer 33

1. < 6 weeks and no inflammation (OA, fracture, trauma etc). 2. Inflammation is present for < 6weeks: (MONO/OLIGOARTHRITIS – Septic arthritis, gout, pseudogout, Reiter’s syndrome; POLYARTHRITIS – Septic arthritis, RA, SLE or other connective tissue diseases).

Question 34

Inflammation for > 6 weeks – count joints:

Answer 34

Mono/Oligoarthritis – Indolent infection, gout, pseudogout, psoriatic arthritis, Lyme arthritis, Sarcoidosis. Polyarthritis: PERIPHERAL = RA, SLE or other connective tissue dz, gout, pseudogout. AXIAL = ankylosing spondylitis, IBD, psoriatic arthritis, Reiter’s syndrome

Question 35

Duration < 6 weeks =

Answer 35

ACUTE

Question 36

Duration > 6 weeks =

Answer 36

CHRONIC

Question 37

Cardiovascular manifestations of autoimmune disorders

Answer 37

Murmurs--w/swollen joints in septic arthritis, Bruits--w/ vasculitis, Rubs--w/ systemic inflammatory disease like RA or SLE

Question 38

Abdominal manifestations of autoimmune disorders

Answer 38

Tenderness with vasculitis, Organomegaly

Question 39

What defines pain as being widespread?

Answer 39

pain is considered widespread when present above and below the waist on both sides of the body

Question 40

Inflammation is present for < 6weeks:

Answer 40

Mono/Oligoarthritis – Septic arthritis, gout, pseudogout, Reiter’s syndrome ........... Polyarthritis – Septic arthritis, RA, SLE or other connective tissue diseases.

Question 41

Inflammation for > 6 weeks – count joints:

Answer 41

Mono/Oligoarthritis – Indolent infection, gout, pseudogout, psoriatic arthritis, Lyme arthritis, Sarcoidosis .................... Polyarthritis: PERIPHERAL = RA, SLE or other connective tissue dz, gout, pseudogout; AXIAL = ankylosing spondylitis, IBD, psoriatic arthritis, Reiter’s syndrome

Question 42

Clinicians Role

Answer 42

1. Relieve pain and physical symptoms 2. Attend to psychosocial distress and economic aspects of care 3. Attempt to improve functioning. 4. Medications 5. Physical Therapy 6. Educate patient, family, employer and insurance carriers.