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Adult Clinical Medicine > Rheum 1 (OA, Gout, Pseudogout, Fibromyalgia) > Flashcards

Rheum 1 (OA, Gout, Pseudogout, Fibromyalgia) Flashcards

1
Q

Describe the pathogenesis of OA

A
  1. Cartilage loss
  2. Disease of the bone (changes in biomechanics and age)
  3. Inflammation and immunologic (swelling and stiffness)
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2
Q

Types of OA

A
  1. Idiopathic, primary
    - Localized: hands, feet, hips, knees, spine
    - Generalized (3+ joint sites)
  2. Secondary– Areas that you would not except OA due to mechanics alone
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3
Q

Secondary causes of OA

A
  1. Trauma
  2. CPPD (pseudogout)
  3. RA
  4. Gout
  5. DM
  6. Hypothyroidism
  7. Congenital (Hips)
  8. Neuromuscular dz (DM)

**usually asymmetric involvment

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4
Q

Risk Factors for OA

A
  1. Sex: F>M
  2. Age: >45
  3. Obesity
  4. Hereditary
  5. HX of trauma
  6. Metabolic disorders (DM, CPPD)
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5
Q

Defining features of gout

A
  1. Deposition of monosodium urate (MSU) crystals in joint, bone and soft tissue
  2. MSU crystals are NEEDLE shaped
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6
Q

Types of Gout

A
  1. Asymptomatic hyperuricemia
    - All pts w/ gout have hyperuricema but not all hyperuricemas are due to gout
  2. Acute gout –> acute arthritis
  3. Interval (”Intercritical”) gout (cycles)
  4. Chronic gout leads to tophaceous gout
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7
Q

Causes of hyperuricemia that leads to gout

A
  1. overproduction of uric acid–> can cause stones

2. underexcretion of uric acid

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8
Q

Risk factors for gout

A
  1. Trauma or surgery (increase inflammatory response)
  2. Anorexia
  3. Diet (beer, organ meats, shellfish, asparagus, spinach, beans, mushrooms)
  4. Meds (thiazides or loop and allopurinol)
  5. Men and postmeno women
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9
Q

Defining features of pseudogout

A
  1. Deposition of calcium pyrophosphate dihydrate (CPPD) crystals in connective tissues
  2. Rhomboid shaped
  3. Acute attacks induce synovitis
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10
Q

Risk factors for pseudogout

A
  1. Idiopathic
  2. Joint trauma
  3. Surgery
  4. Familial chondrocalcinosis
  5. Hemochromatosis
  6. Hyperparathyroidism (excess Ca2+)
  7. Avg. age 72
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11
Q

Diagnosis of OA is based on the combination of:

A
  1. age
  2. HX
  3. PE Findings
  4. Xray findings

**No labs tell you its OA

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12
Q

Key features of OA

A
  1. OA does not affect all joints equally (asymmetric)
  2. MC joints: Knees, hips, hands, cervical and lumbar spine
  3. LC joints: Elbows, ankles, wrists

Get good Hx (likely secondary to trauma)

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13
Q

Symptoms of OA

A
  1. Pain with use; improvement with rest
  2. Morning stiffness <30 minutes
  3. Decreased range of motion
  4. Lack of systemic symptoms
  5. Stiffness after prolonged immobility (gelling)
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14
Q

PE findings of OA

A
  1. Localized tenderness to the joint
  2. Bony enlargement
  3. Crepitus
  4. Patella femoral pain
  5. Restricted range of motion
  6. +/- Swelling
  7. specific joint signs
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15
Q 
What are specific joint signs for OA in:
Hands
Knees
Toes
Spine
A
  1. Hands: Heberden’s and Bouchard’s nodes
    - shelf sign at 1st CMC joint
  2. Knees: genu varum/valgum
  3. Toes: hallux valgus
  4. Spine: C and L decreased ROM
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16
Q

Herberden Nodes affect ___ joint where as Bouchard’s nodes affect __ joint

A

H: DIPs
B: PIPs

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17
Q

Sx of acute gout arthritis attack

A
  1. SEVERE pain
  2. Redness/swelling in a joint
  3. involves 1st MTP (podagra)- can be in others
  4. Abrupt onset (during night or early morning)
  5. Max sx reached w/in 12-24 hrs
  6. sx resolve in few day sto several weeks - quicker if txed
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18
Q

PE signs of acute gout arthritis attack

A
  1. Edema
  2. erythema/warmth
  3. VERY TENDER
  4. May extend beyond the joint and mimic cellulitis
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19
Q

Describe gout intervals (intercritical)

A

“Between attacks”

Occurs with resolution of the acute attack

If untreated:

  1. Next episode usually occurs within two years
  2. Usually more prolonged, less intervals between flares, more severe
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20
Q

What is Chronic tophaceous

A

Collection of MSU crystals surrounded by grandulomatous inflammation
-develop w/in 10 yrs after onset of gout

*prevented by txing gout

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21
Q

Sx of chronic tophaceous

A
  1. Can come out of the skin and expel a white, chalky material
  2. typically NOT painful
  3. found in joint and skin
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22
Q

Sx of pseudogout

A
  1. mimics gout but less painful** and takes longer to reach intensity
  2. MC Joints: knees, triangular fibrocartilage of wrist
  3. can be seen in elbows, shoulders, ligaments, tendons, bursa
  4. acute attacks of synovitis
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23
Q

PE signs of pseudogout

A
  1. Redness/ warmth,
  2. swelling
  3. limited range of motion and
  4. tenderness in affected joint
  5. Looks like cellulitis!
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24
Q

What lab findings do you get with OA

A
  • No specific test used for diagnosis
    1. Can get WEIGHT BEARING X-rays (hip, ankles, knees)    **
    2. Lab tests used to rule-out secondary causes of OA (Involve a rheumatologist!)
    3. +/- Synovial fluid
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25
What does synovial fluid analysis look like for OA?
1. Normal viscosity, glucose 2. Minimal elevated WBCs (<2000/mm3) 3. Negative culture 4. Negative crystals Normal cell count, culture. No crystals
26
Common Xray findings w/ OA
1. Joint space narrowing 2. Osteophytes 3. Subchondral cysts 4. Subchondral sclerosis
27
If you see chondrocalcinosis think
Pseudogout *may be causing secondary OA
28
articular cartilage calcification should raise the suspicion of a secondary cause __
pseudogout
29
What labs do you initially order in the evaluation of gout
1. CBC 2. CMP 3. TSH 4. Lipids 5. UA 6. 24 hr urine creatinine and Uric acid 7. Joint aspiration is definitive DX *Don’t use labs by itself to dx gout (not definitive dx--> need aspiration)
30
What are the definitions of hyperuricemia in females and males
Uric acid >6.0 mg/dl in females Uric acid >7.0 mg/dl in males *Urate value may be normal or low (12-43% of patients) during an acute flare (Hyperuricemia can be present in asymptomatic patients
31
What does synovial fluid look like for gout?
Visualization of fluid under polarized light microscopy 1. Negatively birefringent crystals 2. Needle-shaped 3. High WBCs; >80% PMNs
32
Xray findings w/ gout
1. Soft tissue swelling 2. Tophi 3. Bony erosions --> “punched out” with overhanging edges 4. Rat bite erosions*** *Obtain with new diagnosis, worsening symptoms or new patient to you
33
Risk factors for kidney stones w/ gout
1. Increased excretion of uric acid 2. Decrease urine volume (allowing the uric acid to build up) 3. Low urine pH **Need the pt to strain their urine and get the composition of the stone so you know what to tx it with
34
What labs do you order w/ pseudogout
1. Ca2+ 2. phosphate 3. magneisum 4. Alkaline phosphate 5. ferritin 6. iron 7. transferrin 8. TSH 9. Joint aspiration is definitve!
35
What does the synovial fluid look like for pseudogout
1. Weakly positively birefringent crystals 2. Rhomboid or rectangular Gout: Negative, Needles Pseudogout: Positive
36
Xray findings with pseudogout
Chondrocalcinosis Radiographic evidence of calcium crystal deposition in cartilage commonly seen in patients with CPPD but is not absolutely specific for CPPD Appear as linear radiodensity in cartilage
37
Non-pharmacologc Tx of OA
1. Patient Education!!--> cannot stop progression but can slow it down 2. Modifications 3. Weight loss!! 4. Weight-bearing canes 5. Assistive devices (higher toilet seats, door handles, finger grips) 6. Footwear (might need to get them in orthotics) 7. PT and 8. Progressive Exercise
38
What are the ACR guidelines for knee OA tx
1. Nonpharm. measures 2. Acetaminophen (topical iceyhot or intra-articular tx) 3. NSAIDs, COX2 inhibitors 4. nonselective NSAIDS _ misprostol or PPI 5. Nonacetylated salicylates 6. pure analgesics
39
1st Line treatment for OA Peak concentrations  30-60 minutes No specific precautions in the elderly
Acetaminophen *Severe liver disease can affect metabolism Watch for products containing acetaminophen (Vicodin, Percocet, Darvocet, Ultracet)
40
what are intra-articular agents for OA
1. Corticosteroids 2. Hyaluronate/ viscosupplement **make sure it is not septic before injecting
41
Describe different COX meds for OA
1. COX1 specific: LD ASA 2. COX NS: ibuprofen, naproxin, indomethacin 3. COX2 preferential: Etodolac, diclofenca (less $ than COX2 specific) 4. COX2 specific: Celecoxib-- Can use 1st line if documented GI bleed or on warfarin
42
SE of NSAIDs/COXIBs
1. GI 2. kidney and liver 3. rash 4. CV 5. Tinniuts 6. DDI (warfarin)
43
Opioids used for OA
1. Oxycodone 2. Codeine *Use after other interventions tried and failed Contract your patients Monitor with pain level and function
44
Alternative therapies for OA
1. Glucosamine sulfate | 2. Chondrontin sulfate
45
When do you send for surgery for OA
1. Severe pain that: - Awakens the patient at night - Prevents standing for >20-30 minutes 2. Loss of joint function: - Cannot walk more than one block - Had to change ADLs due to inabilities Prognosis: 1/3 get better, 1/3 stay the same, 1/3 get worse
46
TX of acute gout attack
1. NSAIDS--> 1st line Naproxen 500 mg BID Indomethacin 50 mg TID 2. Colchicine 0.6mg TID best if used in 1st 24 hrs 3. GCs- local injectio or systemic prednisone
47
Biggest SE of cholchicine
diarrhea and vomiting *start in a low does and titrate up to help reduce diarrhea
48
Prophylactic meds for Gout
*Do not start these medication until you have complete resolution of the attack 1. Anti-hyperuricemic therapy - Allopurinol 300 mg daily – xanthine oxidase inhibitor - Febuxostat 40-80 mg daily – xanthine oxidase inhibitor (For over producers) - Probenecid 250 mg BID – uricosuric drug (For under producers) *Uric acid level monitoring with therapy
49
How do you monitor uric acid level with gout prophylactic tx
*Recommendation is baseline and recheck 2 weeks after starting therapy (Most present during an acute attack with normal uric acid level) -Other option: Get a baseline level after the flare and recheck level 4-6 weeks after therapy; adjust dose and recheck. Once level is <6.0, check on with annual physical or prn to check compliance
50
Tx goal for gout
1. Serum urate concentration of <6.0 mg/dl (lower the serum urate concentration slowly) 2. if tophi present: serum urate concentration of <5.0mg/dl
51
Tx of acute pseudgout attack
1. NSAIDs - Indomethacin 50 mg TID to QID for 1-2 days; taper 2. Colchicine 3. Intraarticular glucocorticoid 4. Systemic glucocorticoid *tx underlying cause if present (hypothyroidism, hemochromotosis, idiopathic)
52
Prophylaxis tx for pseudogout
(>3 attacks/year) | Colchicine 0.6 mg BID
53
Definition of Fibromyalgia
chronic widespread pain disorder for >3 months
54
Most common cause of generalized musculoskeletal pain in women 20-55 years of age 6 times more common in women
Fibromyalgia
55
Describe triggers for fibromyalgia
(unknown etiology) 1. physical and emtional stress 2. infections 3. trauma 4. illness 5. mood 6. sleep 7. possible genetic component
56
Alterations in pain and sensory processing in the CNS “Central Sensitization”**** Increased neurological changes
fibromyalgia Initially thought of as a muscle disease No evidence of abnormalities Muscle pain is due to inactivity and pain
57
Sx of fibromyalgia
**MOST ROS ARE POSITIVE 1. Fatigue 2. widespread MSK pain (pt reports swelling but none present) 3. Chronic, persistent pain w/ varying intensity 4. Pain is worse w/ stress, exertion, weather change Associated symptoms 5. Tingling/numbness 6. burning 7. Dizziness, 8. weakness, 9. poor balance, 10. palpations, 11. night sweats, 12. headaches 13. Multiple medication intolerances
58
What labs should you order w/ fibromyalgia?
1. CBC- anemia 2. ESR 3. Creatinine 4. TSH 5. Glucose 6. Ca2+ 7. phsophorous 8. Creatine kinase 9. UA **All will be normal
59
How do you dx fibromylagia
based on the following 3 criteria being met: 1. Chronic (>3 months) 2. Widespread MSK pain with no disorder that would otherwise explain the pain 3. Widespread Pain Index >7 and Symptom Severity Scale >5 OR Widespread Pain Index 3-6 and Symptom Severity Scale >9 *11/18 tender points (are not required based on the new 2011 ACR Criteria)
60
Describe the widespread pain index (WPI) for fibromyalgia
Note the number areas in which the patient has had pain over the last week (1 point each – max of 19) *need at least 7 for dx **MIDDLE of forehead is NOT one!
61
Describe the symptom severity scale (SSS) for fibromyalgia
the sum of the severity of the 3 symptoms plus the severity of the somatic symptoms in general. Score is between 0-12 (Need at least 5) For each of the 3 symptoms level, indicate the severity over the past week using the scale below: Fatigue (0-3) Waking unrefreshed (0-3) Cognitive symptoms (0-3) ``` 0= no problem 1= slight or mild problem/intermittent 2= moderate, considerable problem 3= severe, pervasive, continuous, life disturbing ```
62
PE signs of fibromyalgia
1. No tissue inflammation or swelling 2. 11/18 tender points (bilateral and symmetrical) * Push hard enough to make the red of your finger tips white * Look for malingering: push on middle of forehead and inside of forearms
63
Describe the pt education for fibromyalgia
1. Real illness--> “not in your head” 2. Is not life-threatening 3. Does not lead to deformities 4. Relationship of neurohormones to fatigue, mood, sleep and pain perception is the basis of treatment--> don’t use narcotics
64
Tx of fibromyalgia
1. Treat underlying cause in addition to pain | 2. Sleep, Mood, Connective Tissue Disease, leg cramps (take Vt. D), restless leg (check for Fe def.
65
Describe the multidisciplinary tx approach to fibromyalgia
1. Pharmacologic agents 2. Psychological: CBT 3. PT: CV exercise*, heat and message
66
What pharmacological agents can be used for fibromyalgia
1. Antidepressants: tricyclic, SSRIs, SNRIs, Wellbutrin 2. Tramadol-acetaminophen 3. Anticonvulsants - Pregabalin (1st medication approved for fibromyalgia) - Gabapentin/neurontin - Lyrica- $$ 4. Trazadone for sleep and mood 5. Flexoril for muscle pain and sleep
67
Compare the systemic sx of fibromyalgia and chronic fatigue
Fibro: NO findings despite sx, 1/18 tender pts CF: 4+ sx--> short term memory loss; sore throat; lymph nodes in axillae or neck; joint pain without swelling; muscle pain; unrefreshed sleep; headaches; malaise >24 hours after exercise **Actual PE Findings

Adult Clinical Medicine (26 decks)

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