Rheum

Question 1

What are teh non-pharmacological recommendations for the treatment fo FM?

Answer 1

• self-management using a multimodal approach
• Interventions that improve self-efficacy
• CBT even for a short time is useful and can help reduce fear of pain and fear of activity
• participate in a graduated exercise program
• Patients should be informed that there is currently insufficient evidence to support the recommendation of complementary and alternative medicine (CAM) treatments

Question 2

Diagnosis for fibromyalgia?

Answer 2

1. Widespread pain index (WPI) of 7 or greater AND Symptom Severity (SS) Scale of 5 or greater

OR

WPI = 3-6 and SS 9 or greater

2. Symptoms present for at least 3 months
3. No other diagnosis to explain symptoms

Question 3

What are the Widespread pain index areas in FM?

Answer 3

Question 5

What are the associated symptom categories present in FM?

Answer 5

Fatigue (90%)

Non-restorative sleep

Cognitive dysfunction

Mood disorder

Pain-related somatic symptoms

Non-pain related symptoms (ie. sexual dysfunction)

Question 6

What are the three main categories in the Symptom Severity Scale?

Answer 6

Waking unrefreshed

Cognitive Symptoms

Fatigue

Question 7

What are some of the laboratory tests or investigations that you would consider in the work-up of FM?

Answer 7

• CBC
• ESR
• CPR
• CK
• TSH
• ?sleep study
• ?psych evaluation

Question 8

What is on your differential for FM?

Answer 8

• MSK
  
  • RA, ME, inflam spondylarthropathies, SLE, PMR, myositis, myofascial pain
• Neurological
  
  • MS, neuropathies, myopathies
• Endo
  
  • hypothyroidism
• Psych
  
  • MDD
• Infectious
  
  • Lyme disease
  • HIV
  • HepC
• Drug related
  
  • statins
  • aromatase inhibitors
  • bisphosphonates
• Cancer
  
  • Bony mets

Question 9

What are the pharmacological treatments for FM?

Answer 9

• NSAIDs, actemainophen
• Strong opioid use is discouraged
• treatment with a weak opioid such as tramadol, should be reserved for treatment of patients with moderate to severe pain that is unresponsive
• cannabinoids (esp if sleep disturbance)
• TCAs, SNRIs, SSRIs
• Gabapentin, pregabalin
• Only pregabalin and duloxetine have Health Canada approval for treatment of FM

Question 10

What are some factors that predict poor outcome in FM?

Answer 10

• previous childhood adverse/traumatic events
• personality traits such as neuroticism or catastrophizing
• poor internal locus of control
• uncontrolled depression
• extreme depression

Question 12

What is the classification criteria for AS?

Answer 12

• >3m Back pain
• Onset before 45 yrs
• Sacroilitis - on DI + >= 1 SpA features OR HLAB27 + >=2 SpA features
  
  • SpA Features (enthesitis achilles, dactylitis, uveitis, psoriasis, crohns or colitis, good response to NSAIDs, FHx, elevated CRP, arthritis)

Question 13

List 5 symptoms of AS

Answer 13

• Back pain worse in 2nd half of night, or with inactivity
• Pain better with activity/exercise
• Pain better w/ NSAIDs
• Insidious onset
• Alternating buttock pain
• AM stiffness > 1 hr
• Age onset before 40 yrs

Question 14

What are common areas affected in pagets?

Answer 14

• Longe bones
• lumbar spine
• Skull
• Arms
• Pelvis

Question 15

What tests would you order to diagnose Paget’s?

Answer 15

• XR
• Bone scan
• ALP
• Serum Ca2+
• Albumin

Question 16

List 5 presenting symptoms of Paget’s

Answer 16

• Bone pain
• HA
• Neurologic symptoms
  
  • Compression neuropathy
  • Paresthesias (numbness, tingling)
• Pathologic #’s
• Reduced ROM or stiffness
• Arthritis
• Reduced hearing

Question 17

How do you Mx Pagets?

Answer 17

• NSAIDs, Tylenol
• Bisphosphonates
• Calcitonin
• Sx

Question 18

What are people with Paget’s at risk for?

Answer 18

Osteosarcoma (osteogenic sarcoma)

Question 19

Name 5 DMARD Rx

(SHMAL)

Answer 19

• MTX
• Sulfasalazine
• Hydroxychloroquine
• Leflunomide
• Azathioprine (Imuran)

Question 20

Name 3 TNF alpha biologics

Name 3 non-TNF alpha biologics

Answer 20

TNF Alpha Inhibitors Biologics (ACE GI)

• Adalimumab
• Certolizumab pegol
• Etanercept
• Goliumumab
• Infliximab

Non-TNF Alpha Biologics (ART)

• Abatacept
• Rituximab
• Tocilizumab

Question 21

What is NY Criteria grading for Sacroilitis?

Answer 21

• Gr 0 - normal
• Gr 1 - Suspicious - some blurring of margins
• Gr 2 - Minimal Scelrosis
• Gr 3 - Definitie Sclerosis - BL - Severe erosions, widening of joint space
• Gr 4 - Complete ankylosis

Question 22

What blood work would you do for RA work up?

Answer 22

• RF
• Anti CCF
• ESR
• CRP

Question 23

What are symptoms of Giant Cell Arteritis?

Answer 23

• New headache, usually around the temples
  
  • Can occur anywhere, including the front, top and back of the skull
• Fatigue
• Loss of appetite
• Weight loss
• Flu-like feeling
• Jaw Claudication
• Pains in face, tongue, or throat.

Question 24

Work up for GCA?

Answer 24

Temporal Artery Bx

Elevated ESR/CRP

Question 26

What are the presenting symptoms of PMR?

Answer 26

• Shld & Pelvic girdle pain + stiffness (proximal)
  
  • +/- Neck + Back
• Fatigue
• >50-65 yrs
• AM stiffness/pain >1 hr
• Depresion/wt loss
• ESR>30-40 mm/hr or CRP PRO >6mg/L
• Respond well to CST

Question 27

Mx of PMR

Answer 27

• Low dose prednisone - very responsive
• NSAIDs not responsive

Question 28

What are signs/symptoms Ehlors Danlos?

Answer 28

• Skin laxity
• Hypermobility
• Arm span: Ht ratio >1.05
• High/narrow palate
• Dental crowding
• Unexplained striae
• Soft velvety skin
• Arachnodactly (Spider fingers)
• Recurrent abdominal hernias
• Pelvic floor, uterine prolapse
• B/L piezogenic papules of the heel
• MV prolapse
• Aortic root dilatation
• Recurrent daily limb pain
• Chronic widespread pain >3m
• Recurrent joint dislocations