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Medicine II: Rheumatology > Orientation to Rheumatology > Flashcards

Orientation to Rheumatology Flashcards

1
Q

Spectrum of Diseases treated by a Rheumatologist

A

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

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2
Q

Fibromyalgia

A

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

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3
Q

Symptoms of Fibromyalgia

A
  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”).
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4
Q

Diagnosis of Fibromyalgia

A

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

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5
Q

Management of Fibromyalgia

A

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.

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6
Q

Physical Examination of a Rheum Patient

A
  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
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7
Q

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

A

True

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8
Q

Foreign (non-self) Antigen Response

A

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

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9
Q

Self Antigen Response

A

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

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10
Q

Autoimmunity

A

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

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11
Q

Hypotheses Concerning Autoimmunity:

A
  1. Molecular mimicry, 2. Lymphocyte activation after certain infections, 3. Impaired immune regulation, 4. Exposure of sequestered antigens
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12
Q

Molecular Mimicry

A

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

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13
Q

Impaired immune regulation

A

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

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14
Q

Exposure of sequestered antigens

A

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

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15
Q

Alloimmunity

A

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

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16
Q

PE of Fibromyalgia

A

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

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17
Q

Risk Factors of Fibromyalgia (8)

A

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

18
Q

Pain Syndrome

A

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

19
Q

More associated symptoms of Fibromyalgia

A

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

20
Q

Clinical Presentation of FMS

A

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

21
Q

Distribution of Potential Contributing factors:

A

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

22
Q

Labs and Imaging for FMS

A

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

23
Q

Rules for Rheum Patient (10)

A
  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%!!!!!!
24
Q

History of Articular Symptoms:

A

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

25
Q

History of Extra-Articular Symptoms of FMS

A

IBS, irritable bladder syndrome, depression, vague parasthesias

26
Q

Treatment History:

A

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

27
Q

Past history:

A

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

28
Q

Social History:

A

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.

29
Q

Family History:

A

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.

30
Q

Joint Examination

A
  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
31
Q

Joint Examination in an inflammatory condition

A

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

32
Q

Ddx based of History and Exam

A

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

33
Q

Inflammation is not present:

A
  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).
34
Q

Inflammation for > 6 weeks – count joints:

A

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

35
Q

Duration < 6 weeks =

A

ACUTE

36
Q

Duration > 6 weeks =

A

CHRONIC

37
Q

Cardiovascular manifestations of autoimmune disorders

A

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

38
Q

Abdominal manifestations of autoimmune disorders

A

Tenderness with vasculitis, Organomegaly

39
Q

What defines pain as being widespread?

A

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

40
Q

Inflammation is present for < 6weeks:

A

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

41
Q

Inflammation for > 6 weeks – count joints:

A

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

42
Q

Clinicians Role

A
  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.

Medicine II: Rheumatology (9 decks)

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