Rheum Flashcards
1
Q
Define Sensitivity
Define Specificity
What is a good example of one of these types of tests
What is a good examples of these tests
A
Probability of correctly Dx PT w/ Dz
Probability of correctly r/o Dz in PTs w/out a Dz
Sen: ANA lupus
Spec: Anti-dsDNA lupus
2
Q
What process causes the formation of acute phase responses?
What result is significant
When are ESR values more useful?
A
IL-6, cytokines stimulate liver to synthesize proteins
> 100= Ca, infection, renal/autoimmune dz
Normal (sensitivity test)
3
Q
What are two presentations that may be normal variants with an increased ESR
When do ESRs have minimal use?
A
Obesity
Pregnancy
Nephrotic syndromes
End stage RDz
4
Q
What lab result is better than ESR for inflammation/infection indications?
What is an example when a CRP result would be necessary and vital?
CRP is particularly good for tracking ? Dzs
A
CRP- better when accuracy is vital
Steroid tapers
GCA, RA
5
Q
What are three Dzs that would have a minimal or no CRP elevation?
There is no elevated CRP in Lupus unless ? is present
? Dx can have an elevated CRP w/out any inflammation
A
Poly/Dermatomyositis
Scleroderma
Serositis, Synovitis
Renal failure
6
Q
What are 3 examples of acute phase reactants?
Which one was used to track progression of COVID?
Define Complement System and number of proteins
A
Ferritin Fibrinogen Platelet
Ferritin, D-dimer
Aids immune system w/ inflammatory/immune response; >30 proteins
7
Q
What are the functions of the complement system?
What are the 3 pathways of the Complement System
A
Chemotaxis Opsonization Ab response Leukocyte activation Cell lysis Clearing apoptotic cells
Classic Alternative
Mannose binding Lectin
8
Q
Complement system tends to be reduced in chronic autoimmune and inflammatory states such as ?
These Complement measurements are usually used to monitor ? via ? results
Which part of the system screens for deficiency of the classical pathway?
A
Cryoglobinemia Serum sickness SLE Vasculitis Glomerlonephritis Subacute endocarditis
SLE w/ C3, C4
CH50- total deficiency= complete deficit early in cascade
9
Q
Although rare, a complete deficiency of C3 is seen in ? PTs
ANA can detect autoantibodies against ?
A
Peds w/ recurrent pyogenic organisms
Histones, DNA, RNP via fluorescence microscopy
10
Q
What are ANA Titers indicative of
What test is 97% specific for SLE and is rarely present in other conditions or healthy PTs
This result does not appear in drug induced lupus except for ?
A
High Sen, Low Spec:
>1:160- Pos
<1:80- Neg
Anti-dsDNA
Penicillamine
Minocycline
Antitumor necrosis factors
11
Q
When is the indication to order an Anti-dsDNA
Define an Anti-Smith (Sm)
Define an Anti-U1-RNP
A
DDx of SLE and pos ANA
Abs recognize nuclear proteins that bind to RNA; specific for SLE
Abs recognize complex proteins and nuclear RNA in SLE, MCTDz
12
Q
When are Anti-Sm and Anti-U1-RNP tests ordered
When are Anti-Ro (SS-A) or Anti-La (SS-B) ordered
When would these be ordered after a negative ANA
A
Concern of Mixed CT Dz
Primary concern for SLE or Sjogrens
Suspected subacute cutaneous lupus or PTs w/ recurrent photosensitive rashes
13
Q
Mother of children w/ neonatal cutaneous lupus and congenital heart blocks may be ASx but need to be tested for ?
This also needs to be ordered for ? female PTs
A
SLE or Sjogrens
PTs w/ SLE and considering pregnancy
14
Q
Anticentromere Abs occur in ?
What type of test is Anticentromere Abs
Rheumatoid factor is an Ab directed against ?
A
Scleroderma, CREST
98% specific
Fc region of IgG
15
Q
Detection of IgM Rheumatoid Factor titers mean ?
Define Sero-Negative RA
A
> 1:40= latex fixation
20 or more= nephelometry
Ab against IgM
16
Q
What non-RA conditions can have a positive RF?
A
Cryoglubulinemia Hep B/C Elderly PTs SLE/Sjogrens Sarcoidosis Primary biliary cirrhosis Malignancy
17
Q
Define Anti-CCP Ab
What is Anti-CCP Ab as strong predictor for?
What combo of lab results is nearly 100% indicative PT will develop RA?
A
Anti-Cyclic Citrullinated peptide Ab; rules RA in earlier than RF in true RA
RA progresstion, joint erosion in PTs w/ early onset, undifferentiated inflammatory arthritis
+ RF and Anti-CCP
18
Q
What is encompassed in Anti-Neutrophilic Cytoplasmic Ab lab tests
These are highly specific but need ? test to confirm a ? Dx
A
Proteinase-3: GPA
Myloperoxidase- EGP, MPA
Biopsy for GPA Dx
19
Q
Proteinase 3 is to ?
Myloperoxidase is to ?
A
Cytoplasmic
Perinuclear
20
Q
Other autoantibodies that are associated w/ ?:
Scl 70 Anti-centromere Anti-Jo-1 Anti-Mi-2 Anti-Histone
A
Scl: diffuse scleroderma
AC: limited scleroderma/CREST
AJ: dermatomyositis and polymyositis
AM: dermatomyositis
AH: drug induced lupus
21
Q
Antiphospholipid Abs are AKA ?
What are these Abs associated w/
These contribute to the acceleration of ? and are ordered during ? work up
A
Lupus anticoagulant
Antiphospholipid syndrome- A/V thrombus
Possible SLE
Atherosclerosis
Hypercoagulable
22
Q
Synovial fluid analysis is performed to exclude what three Dxs
Do not perform this procedure if ?
These results are not usefule for ?
A
Monoarthritis
Infections
Crystal induced arthritis
Bleeding risk
Overlying cellulitis/rash
Polyarthritis
23
Q
What are the tests included when ordering synovial fluid analysis?
What does it mean if results come back w/ <2K cells, >2K cells or hemorrhagic?
A
Gram stain Culture Cell count w/ diff Polarized microscopy Glucose/LDH/protein
<2K: OA >2K: +crystal= pseudo/gout - culture= RA AS PsA SLE \+ Gram/Culture= SA Hem: Tumor TB Trauma
24
Q
What lab tests would be useful for monitoring SLE and are AKA the “Five fingers of Lupus?
What one would not be useful?
A
Chemistry UA CBC Complement AutoAb (ds DNA) ((ESR C3 C4 Anti-ds DNA))
ANA
25
Pt w/ back stiffness, blurred vision, photophobia and uveititis needs ? lab ordered?
PT w/ suspected SLE from Sxs/PE needs ? test ordered w/ ANA for confirmation
HLA-B27- Ankl Spondyl
Anti-Smith Ab and,
Anti-ds DNA
26
# Define Seronegative Spondyloarthropathy
This group is referred to as such based on the absence of ?
What are the 4 conditions within this category
Dzs characterized by inflammation of:
Uveitis Sacroiliitis Enthesitis Spondylitis
No RF or Abs associated w/ conditions
Psoriatic arthritis
Ankylosing spondylitis
IBS associated arthritis
Reactive arthritis
27
What is the epidemiology of Ankylosing Spondylitiis
What PT populations are at increased risk for developing this?
White M, possible Native American/Eskimo, w/ HLA-B27 w/ insidious onset in late teen/early 20s
1st degree relative w/ AS
28
How does Ankylosing Spondylitis present
What condition is rarely seen in PTs w/ Ankylosing Spondylitis
What are extra-articular manifestations that may be seen in Ankylosing Spondylitis
Worse w/ rest, pain at night
Abnormal FABER/Schober
Transient peripheral arthritis- hip, shoulder, knee
Cauda Equina
Ant uveritis- presenting Sx
AV blocks- MC 1*
29
What will be seen on lab results in PTs w/ suspected Ankylosing Spondyltitis
What causes the 'bamboo spine' appearance?
Inc ESR
Anemia
+ HLA-B27 90%
Syndesmophytes- bony growth from in ligament, leads to vertebral fusion
30
PT is Dx w/ Ankylosing Spond if one clinical and one radiological parameter including ?
What are the 4 grades for classifying Ankylosing Spondylitis
```
Low back pain/stiff x 3mon
Dec lumbar movement
Limited 4th ICS expansion
Sacroiliitis- unilateral 3-4
Bilateral grade 2-4
```
1: Irregular SI/facets
2: Erosion, sclerosis
3: Erosion, sclerosis w/ widening SI joints
4: ankylosis of both SI joints
31
How is Ankylosing spondylitis Tx
First line- NSAIDs
DMARDs: Early dz w/ peripheral joint involvement- Sulfasalazine
TNF-I: Etanercept I/A/G-umab (PT refractory/two NSAID trials)
32
? Ankylosing Spondylitis presentation has a worse prognosis
What environmental factor has large prevalence w/ AS back pain?
What is the phrase for Reactive Arthritis due to their post-infectious triad these presentation of ?
Hip dz <2yrs of onset
Tobacco cessation
Conjunctivitis- cant see
Arthritis- cant bend knees
Urethritis- cant pee
33
What are the essentials of Dx for Reactive Arthiritis
Where in the body/how do these cases present
Inflammatory arthritis triggered by GI/GU infection
Dactylitis
Oligoarthritis- MC in LE
Mucocutaneous lesion- variable
Enthesitis
34
? is the MC cause of inflammatory arthritis in young men
How does gender ratio differ for reactive arthritis epidemiology
What would be seen on joint fluid analysis?
Reactive arthritis
STI: M>F, chlamydia
Enteric: M>F,
Campylobacter Salmonella Dysentery Yersinia Ecoli Shigella
Bacterial Ags, not organisms
35
How long after infection does it take for Sxs to present and where
Reactive arthritis frequently has ? common recurrence and ? if frequent recurrence
? is the prominent feature of reactive arthritis and where/how is it seen on PE
<28d after Dysentery/Chlamydia
LE: knees, ankle, feet
Common: joint arthritis
Frequent= spondyl/sacroiitis
Enthesitis- Plantar fascia Achilles Pelvis w/ warm TTP
36
What causes Dactylitis in Reactive Arthritis
Dactylitis is a feature of spondyloarthropathies usually seen in ?
What are the three mucocutaneous features of Reactive Arthritis
Sausage digit- toe*/finger synovitis and enthesitis
Reactive/Psoriatic arthritis
Circinate balanitis- characteristic; painful inflammatory lesion of glans/shaft
Keratoderma blennorrhagica- papular waxy rash on palms/soles
Aphthous ulcer- shallow painless on mucosa
37
What microbes are tested for in STI etiology of Reactive Arthritis
What microbes are tested for GI etiologies
G/C, HIV
Salmonella Shigella Yersinia
Campylobacter
38
How is Reactive Arthritis Tx
What meds are considered if PT fails initial medical therapy
What part of Reactive Arthritis may relapse years later?
Ibuprofen: first line
Injections- peripheral joints
Systemic steroids- axial Sxs
Sulfasalazine or Methotrexate
Urethritis Uveitis Arthralgia
39
# Define Psoriatic Arthritis
What would be seen on PE
In almost all cases ? precedes that arthritis
Chronic inflammation of skin/nail w/ DIP arthritis
Dactylitis- MC in toes
Nail dystrophy- characteristic
Psoriasis
40
What are the 5 patterns of Psoriatic Arthritis
DIP- distinguishes from RA
Arthritis mutilans
Psoriatic spondylitis
Asymmetric oligo- hand/feet (MC)
Symmetric polya- mimics RA
41
What will be seen on Psoriatic Arthritis x-rays?
How is Psoriatic Arthritis Tx
The use of ? med in psoriatic arthritis can precipitate severe flare ups
DIP w/ arthritis mutulans
MCP MTP Phalange- periostitis
NSAIDs- first step/mild case
DMARDs- second line: Methotrexate, Sulfasalazine
TNF inhibitors-
CAGI-umab/Etanercept
Systemic glucocorticoids w/ Rheum/Derm supervision
42
What is the difference in quality of arthritis between PA and RA
Define Enteropathic Arthritis
What are the two types of Enteropathic Arthritis
Less in PA than RA
Arthritis associated w/ Crohns>UC
Peripheral- acute, early; MC- knee
Flare ups parallel IBD severity
Spondylitis- indistinguishable from AS based on Sx/X-ray
Severity differs from IBD
43
How is Enteropathic Arthritis Tx
What needs to be avoided in these PTs
What is the prognosis for PTs Dx w/ Enteropathic Arthritis
Tx IBD
Persistent- Sulfasalazine
Sulfa failure- Anti-TNF
NSAID- exacerbates IBD
Excellent for arthritis
Poor for IBDz
44
# Define Rheumatoid Arthritis
What part of the body does it cause destruction in?
This form of arthritis is the MC ?
Chronic systemic inflammatory dz targeting synovium
Juxta-articular erosion
Inflammatory arthritis in 1% of world population
45
What age prevalence does RA affect the most?
PTs w/ RA are at risk for ?
Why do these PTs have higher mortality rate?
M: 50-70s
F: 30-40s
Septic arthritis Osteoporosis
Lymphoma, NH/B-cell
CV dz
46
Genetic factors that cause RA mostly involve ?
Associated risks w/ Abs against ?
What are external triggers that could cause RA?
T-cell activation from cytokine signaling
Citrullinated protein epitopes
Citrullination- modified conversion arginine to citrulline
Smoking Infection Periodontitis
47
Since RA has a prevalence in twins, what type is more likely to develop it?
What autoimmune factors play a role in it's development?
Once established in the body, what type of damage does RA cause?
Monozygotic>Dizygotic
RF/Anti-CCP Abs
Activated T/B cells and complement in synovium
Pannus- hypertrophy/inflamed synovium of RA
48
Direct synovial infections by ? microbes can cause RA?
How does RA present
What part of the body does it effect first?
```
Parvovirus B19
Retrovirus
Enteric bacterial infection
Mycoplasma/bacterial
EBV
```
Symmetric polyarthritis w/ insidious onset and strong FamHx component
PIP MCP and MTP
(sero negative- in DIPs)
49
What PE finding is essential for RA Dx
What is the sequence of synovitis involvement of RA
What is the hallmark of RA
Bilateral symmetric hand/wrist arthritis worse in AM
Wrist Knee Elbow Ankle Hip Shoulder
Morning stiffness x hrs
Improve w/ movement
50
What are late complications of RA usually seen in the hands?
Why is the risk for neck involvement w/ RA so important to ID pre-op?
Boutonniere
Ulnar deviation- MCPs
Swan neck deformity
Cord injury w/ intubation
Prevent AAD/C1-2 subluxation
51
Tendon positioning of Swan Neck deformity
Tendon positioning of Boutonniere deformity
Define Felty's Syndrome triad
DIP flexion/bent
PIP hyper extension
DIP hyper extension
PIP flexion
RA Splenomegaly
Luekopenia (neutro) <2000
52
What type of lab results would be seen in PTs w/ RA induced Sjogrens Syndrome?
RA PTs are at increased risk for ? post-op complication
They are also at risk for ? spontaneous infection especially if on ? med
Anti-Ro/La (SSA/SSB) negative
Knee/hip joint infections
Septic arthritis, A-TNFs
53
What are the old criteria used for Dx RA
What is the new criteria used?
```
4 of 7, first 4 x 6wks:
Serum RF
Morning stiffness
Arthritis x 3 joint areas
Symmetric arthritis
Hand arthritis
Rheumatoid nodules
Radiographic changes
```
```
6 out of 9 points across four domains:
Joint involvement-5
Acute phase reactant-1
Serology- 3
Synovitis duration-1
```
54
What type of RA has a better prognosis
Felty's Syndrome must be distinguished from ?
Felty's PTs also have increased ? and ? related to leukopenia
Seronegative RF
Large Granular Lymphocyte Syndrome- indolent leukemia
Bacterial infections
Non-healing ulcers
55
What would be seen on PE of RA PTs
What labs are ordered
What x-rays should be ordered?
Synovitis Nodules Splenomegaly
RF Anti-CCP CBC ESR/CRP
ANA- r/o lupus
Hand/wrist
56
What do lab results for PTs w/ RA look like
When/how often are images needed for these PTs?
What do PTs need to do prior to starting DMARD medical therapy
RF
Anemia- proportional to Dz
Thrombocytosis
Synovial fluid w/ 5-50K WBCs
Onset, Q12mon
Update vaccines:
Zoster Influenza Yellow fever
57
How is RA Tx medically
What drug is the standard of care and approved for monotherapy in RA Tx
What med can be taken w/ monotherapy to reduce s/e?
Two total, DMARD and:
NSAIDs
GCCS- Prednisone bridge x 2-6mons
PPI if >65 and on NSAID
Methotrexate
PO Folate
58
What monitoring is done how often during RA Tx regimes?
What systemic dz needs to be r/o prior to starting Tx
What adverse effects occur during RA Tx
CBC BMP LFT SrCr q2-4wks initial, q12wks
TB Hep B/C HIV
Marrow suppression
Pneumonitis
59
What synthetic DMARDs can be used for Tx for RA
Hydroxychloroquine-
Least toxic/effective as mono
Retinal toxiciity over time
Monitor CBC
Minocycline:
Early seropositive Dz effective
Unknown MOA
Use >2yrs= hyper pigmentation
Sulfasalazine:
Combo w/ Metho/Hydroxy
Monitor: CBC LFT UA BMP
```
Leflunomide:
Comparable to Methotrexate
Teratogenic, hepatic toxicity
TB LFT CBC BP Preg Hepatitis
Use Cholestyramine to eliminate if considering pregnancy
```
60
# Define a DMARD
What are the top four meds and their MOAs
DMARDs must be administered ? routes
Bioengineered by recombinant DNA to target cytokine surface molecules/receptors
Block IL-6: Tocilizumab
Inhibit T-cell- Abatacept
Deplete CD20- Rituximab
Inhibit TNF
SQ/IV infusion
61
All Pts need to be screened for ? prior to beginning a biologic because ?
? are absolute c/is for DMARDs
Biologics are not recommended for PTs w/ solid malignancy or non-melanoma skin Ca Tx <5yrs, Hx of Tx skin melanoma or lymphoproliferative malignancy except for ?
Latent TB
Inc risk for infections
Active/UnTx Latent TB
NYHA Class 3,4 HF or EF<50%- no anti-TNF
Rituximab
62
4 categories of biological DMARDs used for RA Tx
TNF- A inhibitors:
CAGI-mab/Etanercept
IL-1 receptor antagonist-
Anakinra
Other:
Rituximab, inhibits CD20
Tocilizumab, inhibits IL-6
Selective Costimulation mod-
Abatacept, alters T-cell activation
63
Biologic DMARDs inc risk for ? infections
There is a possible increased risk for ?
What lab results is used to correlate Dz activity and Tx efficacy
TB
HF exacerbation
MS flare up
Listeria/Histoplasma
Lymphoma
ESR/CRP
64
Before starting ImmSupp therapy for RA Tx, what screenings are recommended?
How early do RA PTs need to start DMARDs?
? is ubiquitous in PTs w/ RA
TST/Interferon G release
Hep B/C
HIV
At Dx
Osteoporosis
65
+RF test in PTs w/ suspected RA means ?
What joint would not be commonly involved w/ RA?
What are four correct statements about Methotrexate
More severe case of RA,
Anti-CCP is specific
Sacroiliac
Monitor CBC/LFT
C/i w/ active hepatitis
Weekly dose, start 7.5mg
Suppressed marrow
66
SLE has a predilection for ? PT populations
Define SLE
What are the common manifestations of SLE
Female of child bearing age
Autoimmune dz characterized by multi-system involvement and production of autoantibodies
Serositis
Fatigue
Rash, photosensitive
Polyarthritis
67
What issue may occur during SLE flares?
What are the three types of Lupus?
Hypocomplenentemia
Drug-induced Neonatal SLE
68
What are the Lupus specific cutaneous involvements?
What are the Lupus non-specific cutaneous involvements?
ACLE- local/general rash
SCLE- torso/limb, no face; MOST photosensitive
CCLE- discoid plaque on scalp-neck
Livedo reticularis
Bullous Chilblain Periungual
69
Chronic systemic damage from SLE is usually mediated by ?
What causes organ destruction
How are RA and SLE similar
Abs to cells and soluble IgG/phospholipid Ags
Direct Ab binding
Immune complexes
Monozygotic twin prevalence
70
What genes are associated w/ SLE
The presence of ? will precede PTs clinical illness
What are SLE predisposing RFs for women
HLA Type DR2/3- encode complement pathway
Autoantibodies
High FSH/LH
OCP/hormone replacement
Low free androgen
Early menarche
71
What are the environmental factors that place PTs at risk for Lupus
Consider SLE in PTs w/ multisystem Dz and ?
SLE PTs w/ Lupus induced hair loss need ? education
Drug- hydralazine isoniazid procainamide
UV- exacerbates, not trigger
EBV- mimicry
Tobacco- inc anti-dsDNA
Pos ANA
Regrows 6-8wks after Dz activity/or d/c medication
72
11 criteria for SLE
Neuro Dz
Heme d/o
ANA+
Malar rash
Arthritis
Immunologic abnormals (anti-Sm/dsDNA)
Renal Dz
Photosensitivity
Oral ulcer (painless)
Discoid rash- in PO, painful
Serositis
73
When compared to other forms of lupus, SCLE is usually induced by ?
What type of Abs are associated w/ SCLE
What hematological d/os are seen in lupus
Meds- hydrochlorothiazide, terbinafine
Anti-Ro/SSA
Thrombocyto <100K
ACDz
Leuko <4K
Lympho <1500
74
What can SLE PTs develop w/ or w/out a Hx of steroid therapy
? lupus complication can lead to life threatening hemodynamic complications
Define Libman-Sacks Endocarditis
Osteonecrosis
Pericarditis
Mitral/Aortic valve thickening
75
What is a rare cardiovascular manifestation of SLE
What does SLE cause that can exacerbate the above rare manifestation
What parts of the body are MC involved w/ SLE related lymphadenopathy
CADz
Accelerated atherosclerosis
Cervical, Axillary
76
What is the MC pulm manifestation of SLE
What are three rare but life threatening pulmonary manifestation of SLE
What would be seen on PFTs for PTs w/ SLE
Pleural involvement
Alveolar hemorrhage/Lupus pneumonitis
Interstitial lung dz
Vanishing lung syndrome
Restrictive w/ low diffusion
77
What SLE manifestations are most difficult to assess
What test and images will be ordered for any suspected SLE PT w/ neuro involvement
Almost all SLE PTs will have ? but only half will it be clinically significant
Neuro, Central>Peripheral
LP, MRI
Lupus nephritis- develops first 36mon w/ hematuria/proteinuria
78
Why does advancing renal dz make it difficult to track SLE progression
How often are SLE PTs screened because of this
How are these cases classified
Falsely inc ESR/CRP
Q3mon w/ 24hr urine
Renal biopsy
79
SLE can cause ? types of abdominal pain
SLE Lab results would show ?
What lab results will correlate w/ SLE activity but ? is more accurate?
Peritonitis
Pseudo obstruction
Rarely: pancreatitis, mesenteric vasculitis
Chem: HyperK
LFT: Hep/Pancreatitis
UA: hematura proteinuria casts
Correlate: ESR but can also be d/t anemia/Renal failure
Better: complement/ds-DNA
80
What is sensitive but not specific for SLE and which one is spec but not sens?
Anti-dsDNA correlates w/ the development of ?
? Abs are associated w/ development of neonatal lupus and heart blocks?
Sen- ANA
Spec- Anti-smit/ds-DNA
Lupus nephritis
Anti-Ro/La (SSA/SSB)
81
What is a clinical indicator SLE is seen on lab results during flares and used as an indicator?
Female SLE PTs w/ ? anti-phospholipid Abs are at risk for ?
What images will be ordered for SLE Pts
Dec C3 C4 CH50
Lupus anticoagulant
Anti-Cardiolipin AB
Miscarriage
CXR- initial pleuritis
CT- pneumonitis, alverolar hemorrhage, fibrosis
82
What complication screenings may fall to the primary level in SLE PTs
What low, med and high potency meds are used for cutaneous SLE
CAD- HTN/HLD
Vaccine- Flu/PPV-23
Bone- Vit D/Ca
Annual cervical Ca screen
First- low HCN
Limbs/trunk:
Triamcinol/Betamethasone
High- hypertrophic regions-
Clobetasol
Caution: adrenal suppresion
83
What meds are second line agents for acute, SCLE and DLE?
Only use steroids on face for ? and preferably use ? base
? is used for scalp lesions or discoid lupus on scalp?
Tacro/Picrolimus
Retinoids
<2wks, Ointment
Lesions: Steroid lotions
Discoid: triamcinolone injection
84
What med is the TxOC for systemic Lupus due to its ability to tx ? aspects
What is the most feared s/e of this Tx and needs ? steps taken
What are two additional benefits of using this TxoC
Hydroxychloroquine- Cutaneous Arthritis Fatigue Serositis
Retinopathy, baseline and annual eye exams
Anti-thrombotic
Lipid lowering
85
What drug is used for Lupus PTs that don't respond to Hydroxy?
What medication is especially useful for bullous lupus
When/why would systemic CCS be used
Chloroquine
Dapsone
CNS/Nephritis
86
What medication or its alternative is the standard of care for proliferative lupus nephritis
What ImmSupp drugs may be used for lupus as steroid-sparing drugs?
What is the first and second line drug used for associated arthralgia/arthritis
IV Cyclophosphamide qMon
Mycophenolate mofetil
```
Belimumab
Cyclosporine
Rituximab
Azathioprine
Methotrexate
```
NSAIDs
Fail= steroid/HydroxyChlor
87
What meds are used to control HTn and renal complications in Lupus?
Most PTs w/ Lupus end up dying from ? bimodal issues?
What is the criteria for PT to have met lupus remission
ACEI/ARB
Early- Infection, SLE
Late- atherosclerosis, Ca
>5yrs w/ no clinical/lab evidence and no Tx
88
What is drug-induced Lupus classically associated with
Which one is associated with Subacute Cutaneous Lupus
```
Anti-TNFs
Chlorpromazine
Hydralazine
Isoniazid
Methyldopa/Minocycline
Procainamide
Interferon Alpha
Quinidine
```
Hydrochlorothiazide
89
How does drug induced lupus present
There is increased risk for poor maternal/fetal outcomes if ? coexists
What is the PATH acronym for Lupus and pregnancy outcomes
Fever Myalgia Polyarthritis Serositis w/ anti-histone Abs
Antiphospholipid syndrome
Active lupus nephritis
```
During first trimester:
Proteinuria
Antiphospolipid syndrome
Thrombocytopenia
HTN
```
90
? contraception is safe for PTs w/ SLE
When can OCPs be used?
? anticoagulants need to be recommended for SLE PTs that are pregnant and have Antiphospholipid Syndrome
Levongestrel IUD
Stable low dz and documented negative antiphospholipid Abs
Heparin, ASA
91
Antiphospholipid Syndrome is a ? d/o and means PTs have ? Abs to phospholipids
What type of anticoagulation issue can PT w/ APS have?
This is usually associated w/ ? cardiac Dx
Acquired, usually w/ SLE-
Anticardiolipid (IgG/IgM)
B2-glycoprotein 1
Prolonged aPTT
Libman Sacks endocarditis
92
How is APS Dx
Antiphospholipid Abs or clinical presence of lupus anticoagulant and,
Vascular thrombosis
Pregnancy morbidity
93
How are APS Tx
What needs to be avoided
All PTs w/ antiphospholipid Abs should have aggressive management of ? three things
Heparin INR goal 2-3
Rivaroxaban
Estrogen contraception
Solo ASA therapy
HTN Cholesterol Smoking
94
# Define Scleroderma
Scleroderma has a strong association w/ ?
When/who is it seen
Heterogenous rheumatic dz w/ thick skin and lung/kidney lesions
Raynaud's Phenomenon
50y/o Choctaw Native American females in OK
95
If AfAm have Scleroderma, there is higher prevalence of ? compared to Caucasians that have ?
PTs w/ Scleroderma usually have 1* relatives w/ ?
What is considered the strongest RF for this Dz
AfAm: younger w/ lung dz
Cau: Milder, limited Dz
```
Thyroiditis
Raynauds
Interstitial lung dz
MS
RA
```
FamHx
96
Rheum Classification of scleroderma includes ? criteria
What are the two classification forms and their associated syndromes
```
Thickened skin proximal to MCP joint or,
Two of:
Bibasilar fibrosis
Digital pitting
Sclerodactyly
```
Systemic- Limited/Crest, Diffuse
Localized- Morphea, Linear
97
What is the difference in location of Diffuse or Local Scleroderma
What is the unique exception to this rule?
? Abs are associated with each of these types?
Limited- below elbow/face, slow
Diffuse- above elbow, rapid
Limited w/ PA-HTN
Limited- Anti-centromerase
Diffuse- Scl-70, anti-RNA polymerase 3
98
What viruses are thought to cause scleroderma?
What is the sub-group of limited scleroderma?
CMV
```
CREST:
Calcinosis cutis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangectasis
```
99
? type of scleroderma has a better prognosis
Where does calcinosis appear
Where does the Telangectasis appear
CREST
Extensor surface of forearm
Palmar hand
100
Scleroderma PTs w/ ? are more likely to develop telangectasis
Skin Morphea is more likely to present in ? type
What is the MC Tx for Raynauds
PHTN
Localized
Cold avoidance
Topical CCBs
101
Pts >30y/o w/ first Raynauds should have ?
What are the two forms of pulmonary issues seen with different types of scleroderma
ANA
Nail capillary exam (primary- normal capillaries, no abs)
Diffuse- inflammatory alveolitis leading to pulmonary fibrosis/interstitial lung dz; in first 4yrs of dz
Limited/CREST- vascular dz leading to PAHTN
Seen w/ long standing dzs; morbidity
102
What is the MC cause of scleroderma related death
What would be seen on PFTs in PTs w/ diffuse sclerdoerma induced interstitial lung dz
What monitoring do these PTs need?
Diffuse scleroderma PHTN
Restrictive pattern
PFTs
Echos
103
What type of upper GI issues do scleroderma PTs have
What lower GI issues can they have?
What renal issue can present in a minority of sclerodermis PTs and how is it Tx
GERD w/ dysphagia
Alternating diarrhea/constipation
Sclerodermal Renal crisis- more common in Diffuse as sudden onset HTN/malignant HTN
Tx w/ Captopril, ACEI
104
What are the 3 high RFs for developing sclerodermal renal crisis
What type of MSK issues is common in diffuse scleroderma
Define Sicca Complex
Early diffuse scleroderma
CSS
RNA Polymerase 3 Abs
Tendon friction rub- ankle knee wrist
Dry eyes/mouth seen in Scleroderma PTs
105
Diffuse Scleroderma will have ? presentations
Rapid onset
Weight loss
Dyspnea w/ exertion
Skin texture change- pain edema pruritis
106
What lab results help confirm clinical Dx of Scleroderma
What two images are ordered for these PTs
How often do they need PFTs
ANA- 95%
Antipoisomerase 1 Abs (Anti-SCL 70)- specific, diffuse
Anticentromere- limited*
Chest CT- activity/severity
EKG/Echo- PHTN screening
Baseline
Q4-12mon
107
When does a Scleroderma PTs PFT suggest PHTN has developed?
What PT education goes w/ Tx goals
What meds are used for Scleroderma to protect internal organs and which ones are avoided?
Isolated reduction of DLCO
Reduction OOP to decline of FVC
No proven medication
Skin worst by 24mon, improves from there
Cyclophosphamide- only one, protects pulmonary; Avoid CCS
108
What meds are given for scleroderma induced GI issues w/ PPIs
What motility agents and ABX are used?
What is the best predictor of prognosis
Metoclopramide
Domperidone
Octerotide- motility
Rotate- Tetracycline Metronidazole
No severe organ invovlement in first 3-5yrs of Dx
109
What are the most frequent Sxs of Scleroderma from most to least?
What is the best lab test to differentiate between diffuse and limited sclerosis?
What lab finding is MC associated w/ scleroderma?
```
Raynauds
GERD
Skin
Finger swelling
Arthralgia
```
Anticentromere antibodies
+ ANA
110
# Define Sjogren's Syndrome
What is the difference between Primary and Secondary
What is the key feature of a Sjogrens presentation w/ ? subjective Sx/complaint
Chronic inflammatory d/o of lymphocytic infiltration of exocrine glands
P: no other rhem dz
S: associated, RA, systemic sclerosis, SLE
Xerostomia
Keratoconjunctivitis Sicca/xerophthalmia
111
Often PTs have Primary Sjogrens w/ ?
What is the common MSK complaint?
Sjogren's PTs are more likely to develop ? form of Cutaneous Vasculitis if they are ? Pos
Fibromyalgia
Arthralgia
CLV, Ro/SSA+
112
What is the MC cardiovascular manifestation PTs w/ Sjogrens can develop?
What are the two types of pulmonary complications Sjogrens PTs can develop
Since it rarely presents, PTs that have pleurisy may have ?
Raynauds
Bronchial>Interstitial
SLE
113
What GI issue may be associated w/ Sjogrens?
What is the MC Neuro complaint?
What is the MC complaints for the Dz overall?
Sjogrens PTs have a 44x greater risk for developing ?
Primary Biliary Cirrhosis
Peripheral neuropathy
Fatigue
Lymphoma
114
Sjogrens have an association w/ ? thyroid dz or ? Psych d/o
What may be seen on seroogical results in these TPs
What are the MC serological findings?
Subclinical hypothyroid
Dep/Anx
ANA Pos
RF Pos
Anti Ro/La*(SSA/SSB)
Cytopenia- normocytic anemia, leuko/thrombocytopenia
Inc ESR
Hypergammglobulinemia- monoconal IgG
115
How is Sjogrens Dx
What meds can be used for Sx Tx of Dry eyes
What can be done for Sx relief of dry mouth
```
Schirmer test- pos dye stain
Abnormal scintigraphy, sialography, sialometry
Dry eyes/mouth x 3mon
Pos Biopsy
Pos SSA/SSB
```
Topical cyclosporine/glucocorticoids
Pilocarpine Cevimeline Lemon drops
116
What 3 drugs are used for potentially severe scenario Txs
Prognosis w/ Sjogrens is good except for the development of ?
How are inflammatory muscle dzs characterized
Hydroxychloroquine- fatigue/arthralgia
Prednisone- arthritis
Prednisone and Methotrexate- internal organs
Lymphoma
Bilateral proximal muscle weakness over wks/months
117
Dermatomyositis has a significant increased risk for ? two malignancy
Since the etiology is unknown, what would be seen on muscle biopsies of these Dzs
? is pathognemonic for dermatomyositis
Hematologic lymphoma
Malignant tumors
Lymphocytic infiltrates
Perifascular atrophy
Gottron sign
Perifascicular atrophy
118
What is the MC presenting Sx of Dermatomyositis
Define Heliotrope Rash
Define Mechanics Hands
Symmetric prox muscle weakness-
Neck Pelvic Thigh Shoulders
Eyelid rash of red/violet color
Covers areas spared by Lupus, over joints
Cracked skin w/ dirty lines, especially PTs w/ Antisynthetase Syndrome
119
PTs w/ Antisynthetase Syndrome have autoimmune myopathy and ? features
What type of pulmonary involvement do most PTs have
```
One Ab and Two of:
Non-erosive arthritis
Fever
Interstitial lung dz
Raynauds
Mechanic hands
```
Weakness/inflammation=
Interstitial (inflammation) pneumonia
Aspiration (weakness) pneumonia
120
What is the classic presentation of Dermatomyositis
How is it Dx
What Neuro test can help confirm Dx
Proximal muscle weakness
Heliotrope
Gottron Sign
Muscle biopsy
Rash (Dermatomyositis)
Elevated CK Aldolase LDH AST/ALT
Abnormal EMG
121
Inflammatory Muscle Dz related Anti-Jo Abs are more likely to be in ? PTs
What other serological result is likely to be seen
How are suspected Inflammatory Muscle Dzs evaluated in order?
Interstitial lung Dz
+ ANA
Hx/Physical Labs EMG MRI Biopsy
122
During an Inflammatory Muscle work up, why would GGT finding be significant
What are two different MRI findings for Inflammatory Muscle Dz that mean different time frames
Why would this imagine be needed for final Dx
GGT released w/ AST/ALT from liver Dz, not muscle damage
Muscle edema- active inflammation
Fatty infiltration- chronic dz
Site for biopsy- deltoid or biopsy w/ 4/5 strength
123
What is the mainstay of therapy for PTs w/ Inflammatory Muscle Dz
What is the s/e
When is the prognosis of Inflammatory Muscle Dz poor
Prednisone:
1-2mg/kg/day x 28d, taper
Steroid induced myopathy
Underlying malignancy
124
# Define Gout
This is characterized by ?
Gout is more common in men until women reach ? age
Heterogenous metabolic d/o of elevated uric acid
Monoarthritis
Extra-articular complication
Deformity
65
125
What do WBC ranges from synovial fluid analysis correlate to
Gout is the MC ?
Hyperuricemia starts at ? lab level
Norma: <150
Non-inflamm: <3K
Inflamm: >3K
Septic: >50K
Cause of inflammatory arthritis in men >40
6.8mg
126
Gout is caused by what two issues
What are the 3 stages of gout
What leads to bone/cartilage erosion in gout and what are they AKA ?
Under secretion/Over production of uric acid from purine metabolism
1: ASx hyperuricemia, no arthritis
2: acute gouty arthritis, intercritical gout
3: Continuous arthritis w/ attacks, tophi
Chronic inflammatory response Macrophages cytokine/enzymes- Rat Bite lesions
127
What type of kidney issue can develop due to hyperuricemia
This risk doubles at ? level
Nephrolithiasis
>13mg
128
PTs that are over producers are classified as ? and is due to ? enzyme deficiencies
How are under excretors classified?
What drugs can cause gout?
Metabolic classification:
HGP- Lesch Nyhan
G6PD- von Gierkes Dz
Majority, Renal
CANT LEAP
Cyclosporine Alcohol Nicotinic acid
Thiazide diuretic Lasix Ethamutol ASA
Pyrazinamide
129
What is the most susceptible joint to gouty attacks that presents w/ half of first attacks?
What are the next most likely joints to be involved
Almost all gout PTs will have a second attack w/in ?
MTP- podagra
Ankle Knee Wrist Finger Elbow
2yrs
130
What types of extra-articular mainfestations can occur from gout?
Initial podagra attacks have dramatic responses to ? Tx meds
What 3 medications are known for causing gout
Nephrolithiasis
Tophi- finger elbow great toe
Skin desquamation w/ pruritus
NSAID, Colchicine
Niacin
ASA
HCTZ/Lasix
131
How is a definitive Dx of gout made?
PTs having a gout flare will have ? level serum uric acid?
When are these serum levels most important?
Negative birefringent, needle sodium-urate crystals in neutrophils
Low or Norm
Monitoring urate lowering therapy
132
Lab results of an acute gout attack will show elevation in ? 3 things?
How long do PTs need to use medical therapy for gout flares?
What is the level PTs want to keep uric acid at to prevent further attacks
WBC ESR CRP
2-3 days after flares resolve
6mg or less
<5mg if tophi present
133
What drug is used for acute gout attacks and prophylaxis
What medication is used for PTs who are refractory to or c/i to taking NSAIDs or prophylaxis drug
What drugs can be used for injections
Colchicine- 1.2mg first Sx, 0.6mg 1hr later
Max 1.8mg in 60min
Wait 12hrs for prophylaxis (max 1.2mg/day)
CCS- prednisone
Methylpred/Triamcinolone
134
What are the indications PTs w/ gout need urate lowering therapy
What drugs are used for lowering therapy
Tophi
2+ attacks/yr
CDK Stage 2 or worse
Nephrolithiasis
XOIs:
Allopurinol- DOC, rash means stop med
Febuxostat- safe for PTs w/ renal insufficiency/Allopurinol reactions
Uricosurics, only for <65y/o:
Probenecid, if renal function preserved
Inc Methotrexate/Ketorolac to toxic levels
135
What drug is reserved for gout PTs w/ severe cases and abundent tophi?
Destructive arthropathy is rarely seen in PTs that have first gout attack after age ?
Leukocyte count >5K and rhomboid shaped crystal in synovial fluid means ?
Pegloticase
50y/o
Pseudogout (Ca Pyrophosphate Dihydrate Deposition Dz)- weakly positive birefringent
136
What part of the body is pseudogout likely to infect?
This Dx is commonly associated w/ what two Dzs?
Pseudogout is MC associated w/ acute medical illnesses and ? and needs to be considered ?
Knee, Wrist
Hemochromatosis
Hyperparathyroidism
Hypothyroid
Surgeries
Elderly hospitalized PT w/ new acute monoarthritis post-op/ortho/MI
137
How is Pseudogout Tx
What drug is used for resistant cases
Define Vasculitis
NSAIDs/Colchicine
GCSS if intolerant to PO meds
Methotrexate
Heterogenous d/os of inflammation and destruction of vessels
138
What are the MC forms of primary vasculitis
Why are these d/os one of the great Dx challenges of medicine
Vasculitis is associated w/ ? Ab and due to ? infection
GCA
Granulomatosis w/ polyangitis
Microscopic polyangitis
Non-sepcific Sxs
Slowly developing
ANCA, Hep B/C
139
What are the large vessel vasculitis'?
What drives the pathophysiology of these conditions?
What are the medium vessel dzs
Takayasus GCA/PMR Behcet dz
T-cell mediated Ag driven
PAN
Buergers Dz, Thromboangitis Obliterans
Kawasakis Dz- MLNS
140
What are the two categories of small vessel vasculitis
Immune mediated:
Cutaneous (hypersensitive)
HSP
Cryoglobin
ANCA-
GPA (Wegeners)
EGP (Churg Strauss Synd)
Microscopic
141
Behcets Dz is found in ? country
Polyarteritis Nodosa is associated w/ ? infection
In vasculitis what happens when the inflammatory cells invade the vessel?
Turkey
Hep B/C
Fibrinoid necrosis, panmural destruction
142
What is the name of the type of damage that occurs from leukocytes in vasculitis
Since so many vasculitis criteria overlap, what is needed for definitive Dx
Leukocytoclasis
Biopsy/Radiological evidence (tawasakus)
143
# Define Mononeuritis Multiplex
What are the characteristic derm findings?
Vascular neuropathy: peripheral neuropathy due to damage to sciatic/peroneal nerve
Palpable purpura
Urticaria x 24hrs
Punched out ulcers
Livedo Reticularis (precedes ulcers)
144
Half of GCA PTs also have ?
What PE finding is found in a quarter of GCA PTs
What is needed for Dx?
When does the biopsy need to be done by?
Polymyalgia rheumatica- ache/stiff shoulder, neck, hip girdle
Aortic involvement, asymmetric pulses
3 of 5:
>50y/o HA Abnormal artery
ESR elevated Abnormal biopsy
Within 2wks of steroids
145
Why would PMR and GCA Dxs be confused/mixed
What is a differentiator?
Since PMR can mimic GCA and RA stiffness, what med is used for these PTs
15% of PMR have abnormal temporal artery biopsies
No blindness w/ pure PMR
Prednisone 15-20mg/day
146
When does a Dx of PMR need to be reconsidered?
What are two late complications seen in GCA
No improvement after one week on steroid
Thoracic aortic aneurysms
Aortic dissections
147
# Define Tkayasu Arteritis
How does it present
Most PTs respond to ? med
Granulomatos vasculitis of aorta in young Asian women
Bruit Absent pulse Claudication HTN
FOUO
Prednisone +/- Methotrex or Mycophenolate
Relapse is common though
148
Behcet Syndrome is common in ? ethnic backgrounds due to ? gene
What does this type of inflammatory vasculitis involve
What is this conditions hallmark presenting feature
Asian Turkish MidEast 25-35
HLA B51
Both art/vein of all sizes
Painful aphthous ulcers on mouth/genitals
Eye ball pain
Erythema nodosum that ulcerates
149
What Neuro Dz can Behcet syndrome mimic
What two TNF inhibitors are effective for Tx
MS due to white matter involvement
Inflixi/Adalimumab
150
# Define Polyarteritis Nodosa
What part of the body does this Dz spare
What unique constitutional Sx does it present w/
Necrotizing inflammatory vasculitis of medium arteries and muscular arterioles
Venous circulation/capillaries
Post-randial pain (intestinal angina)
151
How is Polyarteritis Nodosa Dx
What would be seen as lacking on lab results?
This Dz can be associated w/ ? infection
Angiogram
Biopsy (lung sparing)
Absent granulomatous inflammation
Hep B
Appears <6mon from infection
152
What PE finding is common w/ Polyarteritis Nodosa
True PAN cases are ? negative
What would be seen on biopsy and angiography results
Mononeuritis multiplex- foot drop
Digital gangrene
ANCA negative
B: fibrinoid necrosis
A: microaneurysms
153
How is Polyarteritis Tx if PT is refractory to GCSS or major organ involvement
Small Vessel vasculitis Dzs include ? structures
How are these broadly classified
Cyclophosphamide
Arteriole
Venule
Capillary
Immune complex mediated
ANCA
154
What are the pathological hallmarks for Henoch-Schonlein Purpura and it's MC?
What tetrad may be seen?
Nearly all cases occur in ? PTs w/ ? rare complication
Vasculitis w/ IgA depositions
MC vasculitis in Peds
Glomerulonephritis Abdominal pain Purpura Arthritis
Peds,
IgA glomerulonephritis in adults
155
HSP can follow viral URIs or ?
? is a mandatory PE finding for Dx Henoch-Schonlein Purpura
How is it Tx
```
EBV
Mycoplasma
Varicella
Parvo
Strep/Staph
```
Palpable purpuric rash
NSAIDs, avoid if Renal Dz
Steroids for arthralgia/GI Sxs
Severe/RF: admit, methylpred or,
Pred w/ Azathioprine/Cyclophos
156
What is a poor prognosis sign for PTs w/ HSP and the silver lining
? is the MC organ involved in Cryoglobin w/ nearly all PTs being _Pos
What causes this organ involvement to start
Perisistent renal involvement
No ESRDz progression
Skin, RF
IgG/IgM Abs from low temps <37*C
Cryoglobulins binds w/ Ag forms, immune complex leading to IC mediated vasculitis
157
What 3 PTs are less likely to survive a Cryoglobulinemia Dx
What type is primarily caused by malignancy and manifests w/ hyperviscosity syndromes
How does Essential/Primary Cryoglobulinemia differ from other cases?
Male >60 w/ renal involvement
Type 1- plasma cell d/os
Non-Hep C
Others associated w/ SLE and Sjogrens
158
What is the classic triad of Cryoglobulinemia?
How is Cryoglobulinemia Tx
What is used for PTs w/ essential cryoglobulinemia
Myalgia Arthralgia Purpura
Harvoni for Hep C w/ Rituximab
Rituximab
159
# Define GPA
What are the hallmarks
When/who does the usually infect
Necrotizing vasculitis w/ respiratory and renal manifestations
Necrosis
Vasculitis
Granulomatous inflammation
White, northern Europeans during 4-5th decade
160
90% of PTs w/ Granulo w/ Poly have ? upper respiratory dz
How is this condition Dx
What type of image can help since most PTs will have ? finding
Nasal involvement
+cANCA highly specific
biopsy
Chest CT, pulm lesions
161
How is Granulo w/ Poly Tx
All PTs should receive ? for prophylaxis
What meds are used for remission agents?
```
Severe:
Rituximab w/ GCSS or
Cyclophosphomide w/ GCSS
Limited:
Methotrexate and GCSS
```
PCP/TMP-SMX
Rituximab
Azathioprine or Methotrex if Cyclophos was used for remission induction
162
What are the 3 hallmarks for Eosinophil Granulo w/ Poly
Half will have EGPA w/ ? Abs
Why is this useful for lab Dx
Systemic vasculitis
Eosinophilia
Asthma, adult onset
ANCA w/ specificity for myeloperoxidase
P-ANCA pattern on fluorescence testing
163
PT Dx w/ EGP should have ? HEENT exam done
What are the 3 clinical phases of this Dz
What is less common in this Dz compared to GPA
Nasal- almost all have allergic rhinitis w/ polyps
Prodromal- allergic dz
Eosinophilic- blood eosinophilia and infiltration
Vasculitic- necrotizing
Less renal involvement
164
What is the MC cardiac manifestation of EGP
What neuro manifestations are seen in more than half of cases?
How is it Dx
CHF
Peripheral neuropathy
Mono multiplex
Biopsy- vascular and extravascular for pANCA
165
How is EGPA Tx
What drug is used for remission induction strategy
GCSS alone
Azathioprine, Methotrexate or Mycophenolate added
Cyclophos for vasculitic neuoropathy, glomerulonephritis or cardiac involvement
Cyclophosph
166
# Define Microscopic Poly
This it the MC cause of ? syndrome
What PE finding is more prominent and unique w/ this form
Renal and Pulm involved systemic vasculitis
Pulm-renal syndrome of alveolar hemorrhage and glomerulonephritis
Hemoptysis
167
How is Microscopic Poly Dx
How is it Tx
What is the drug of choice if PTs cant take/don't respond to the previous Tx regime
Biopsy of lung kidney or skin w/ pANCA pos
Cyclophosph and GCSS
Cyclophosph
168
How is Microscopic Poly maintained in remission
Define Hyperalgia
Define Allodynia
Cyclophos induced, switch to Azathiprine of Methotrexate
Excessive severe pain from noxious stimulus
Pain from innoculous stimulus, inc tenderness to light pressure
169
Fibromyalgia frequently co-exists w/ ? conditions
This Dx needs to be reconsidered if PTs are older than ?
What is believed to be the reason for increased pain in these PTs
Depression IBS Chronic fatigue syndrome
Interstitial cystitis
>55
Glutamate
Substance P
170
Fibromylagia PTs nearly all have ? Sx that's more bothersome than the pain
How many pressure points are needed on exam for Dx
Fatigue
11 out of 18 w/ enough pressure to blanch nails
171
What labs are ordered for fibromylagia work up
What is the most effective Tx
If needed, what meds are used
CBC CMP ESR CK TSH
Non-pharm therapy
```
NSAIDs
Acetaminophen
Amitriptyline at bed
Nortriptyline
Tramadol
```
172
What two med classes need to be avoided when Tx fibromyalgia
What med may be used for Tx that is also beneficial w/ Psych issues
What is the alternate to the above that is cheaper
Steroids
Opioids
Duloxetine
Milnacipran
173
FDA Approved drugs for fibromylagia Tx
How is Rosacea malar rash different from ACLE malar rash?
How is Seborrheic Dermatitis rash different from ACLE rash
Duloxetine- SNRI
Milnacipran- SNRI
Pregabalin- anti-convulsant, GABA analogue
Rosacea- stinging telangiectasis and pustules, worse w/ heat/ETOH
Scaly plaques on nasolabial folds
174
Why are Lupus PTs at increased risk for coagulation issues?
? is the MC manifestation of SLE
Tobacco can cause ? result to be high
Anti=phospholipid Abs-
IgG/IgM anti-cardiolipin
Lupus anticoagulant
Arthritis
anti-DNA
175
What can cause false-pos of syphilis
Takayasu PTs w/ cardiac involvement tend to have ?
SLE
Lyme
AR
Angina from stenosis at coronary artery ostia
176
HSP needs to have what two DDx r/o
GMP
| Microvasvular
