RA, OA Flashcards
pt with virus like sx, morning stiffness for 2 hours that improves with movement, symmetric ulnar deviation, redness warmth, pain at hand, metatarsal and hip joints. Dx? work up?
dx: RA
* four criteria must be present for 6 wk (morning stiffness at least 1 hr, 3 or more areas arthritis, arthritis of hand joints, symmetric arthritis, rheum nodules, Rf factor, radiographic changes ie erosion)
work up: NO ONE test pathognomonic, elevated ESR or CRP, CBC showing anemia of chronic disease, Rf titer, anti CCP antibody (detects early RA), xray revealing bone erosion, joint space narrowing, joint aspiration (gram stain and cell count)
etiology of RA
*systemic autoimmune destruction of cartilage and bone; inappropriate activation of T lymphocytes; more rapid onset than OA and more common in females than males (3:1)
Joint locations affected by RA
- hand: ulnar dev MCP, boutonniere deformity or PIP, swan deformity DIP, muscle atrophy
- wrist: ulnar deviation, loss extension
- feet: eroded metatarsal head –> subluxation, hallux valgus (bunion)
- hips: flexion contractures
- knee: effusions, bakers cyst in popliteal fossa, loss extneions, contractures, gait
- C spine: in prolonged disease, occipital HA, decreased ROM, neuro sx
LAB: ESR (sed rate) in RA
an inflammatory marker - will be elevated, not specific, but is sensitive
LAB: CRP in RA
inflam marker (more sensitive than ESR); will be elevated.
LAB: Rf titer and anti CCP tests for RA
present in 80% pt that have RA but neg Rf doesn’t r/o RA dx *if positive, worse prognosis
can detect early RA (highly specific). A positive anti CCP can dx RA even if Rf is neg; more expensive test
Medication tx for RA
- NSAIDS (Cox II inhibitor ie CELEBREX if GI concern) 2-4 wk
- leave corticosteroid injections for rheumatologist
- -> HPA axis suppression, wt gain, osteoporosis (not more than 3x/yr) - Leave DMARDS for rheumatologist
* hydroxychloroquine, plaquenil (risk of macular damage)
* Methotrexate (risk: cytotoxic, hepatic fibrosis, pulmonary infiltrates - monitor CBC/liver)
* sulfasalazine (risk myelosuppression, monitor CBC, liver ,kidney, allergies)
* azothioprine (imuran)
* gold salts, penicillamine (rarely use) - Anticytokine therapy (enbrel, humira): leave for Rheum bc skin infection, cancer risk *inhibits cytokine TNF alpha,
Radiologic findings RA
SOFT TISSUE swelling around joint, periarticular osteopenia, narrowing joint space, subluxation/dislocation, bone erosion
Goal of RA tx? non medication management?
GOAL: min inflammatory signs/sx, halt joint erosion, maintain strength/mobility
Management: exercise, ntr counseling, massage, rest periods, moist heat, PT, stress reduction
ddx associated with RA?
include all systemic diseases, fibromyalgia
*note: other manifestations such as pulmonary or cardiac often present in RA
An obese, elderly pt complains of joint stiffness that is bad at night and with activity that has slowly gotten worse over the months/years. Dx? common presentations?
dx: OA
presentations:
hands: heberdens nodes DIP, Bouchards PIP
Knee: crepitus, reduced ROM, bony remodling
HIP: unilateral pain at first then bilateral
Spine: lower CS, all LS “degenerative disc disease” –> thin and inflexible discs and osteophytes (spinal stenosis)
Dx and Treatment for slow onset disease involving degeneration of articular cartilage and hypertrophy of bone at articular margins (osteophytes)
Dx: OA (xray best for dx)
Tx: goal to maintain strength, movement, limit joint trauma; non weight bearing exercise, meds (NSAID specifically tylenol first line, PIP or H2 blocker to protect stomach, tiramcinolone injection intra articular maybe, narcotics sparingly, capsaicin cream)
Other: PT/OT, raised seat, cane, brace, surgery (joint fusion), joint replacement
radiology findings for OA
joint space narrowing, osteophyte formation, lipping marginal bone, *no joint obliteration as in RA
what is the reason for the pain and neurological sx associated with spine degeneration in OA
disc space narrows (degenerative disc disease) as discs become thin/inflexible and form osteophytes. This leads to nerve compression which causes the pain and neuro sx
fibromyalgia - who, what, where, why
who: women 20-55 most common
what: soft tissue disorder affecting muscles, tendons, ligaments (not inflammatory), fatigue
where: diffuse, AXIAL pain (neck, chest wall, middle back, arms, lower back, legs) usually bilateral
* chronic, varier intensity, swelling sensation when none, muscle vs joint pain confusion
why: not known, 50% after traumatic event
