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MC II Exam 2 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What is the definition of rheumatoid arthritis?

A

Chronic, systemic, inflammatory autoimmune disease of unknown etiology

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2
Q

What is the distinctive feature of rheumatoid arthritis?

A

Chronic, symmetric, and erosive synovitis of peripheral joints

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3
Q

What are possible negative effects of untreated rheumatoid arthritis?

A

joint destruction, deformity, disability, and premature death

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4
Q

What is Phase 1 of RA?

A

Genetic risk - individual has genes that give one susceptibility to RA

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5
Q

What is Phase 2 of RA?

A

Preclinical Autoimmunity, brought on by an unknown environmental event

RF and/or anti-CCP may be present, also possibly autoreactive T cells

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6
Q

What is Phase 3 of RA?

A

Clinical disease - Clinical signs and symptoms

RF, anti-CCP, Radiographic changes,?Pathogenic T cells

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7
Q

What are possible RA antigens?

A

Viruses: retroviruses, EBV, parvovirus
Mycoplasma
Heat shock proteins, cartilage antigens, citrullinated peptides

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8
Q

What is the pathophysiology of RA (simplified from slides)?

A

Unknown antigen activates/injures synovium
Synovial inflammation and hypertrophy
Systemic symptoms
Cartilage and bone destruction

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9
Q

What is pannus?

A

Inflamed synovium

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10
Q

What are the categories for the ACR criteria for RA?

A

Joint Involvement
Serology
Acute Phase Reactants
Duration of Symptoms

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11
Q

What is the threshold score for definite RA according to the ACR criteria for RA?

A

> = 6/10, definite RA

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12
Q

How is joint involvement scored on the ACR criteria for RA?

A

1 large joint (0)
2-10 large joints (1)
1-3 small joints with or without large joints (2)
4-10 small joints with or without large joints (3)
>10 joints with at least 1 small joint (5)

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13
Q

How is serology scored on the ACR criteria for RA?

A

Negative RF and negative ACPA (0)
Low-positive RF or low-positive ACPA (2)
High-positive RF or high-positive ACPA (3)

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14
Q

How is “Acute Phase Reactants” scored on the ACR criteria for RA?

A

Normal CRP and normal ESR (0)

Abnormal CRP or abnormal ESR (1)

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15
Q

How is duration of sx scored on the ACR criteria for RA?

A

< 6 weeks (0); ≥ 6 weeks (1)

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16
Q

What are the tests on the Screening Tool for Inflammatory Arthritis (RA) in Primary Care?

A

Significant discomfort with squeezing the MCP and MTP joints
Presence of 3 or more swollen joints
More than 1 hour of morning stiffness

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17
Q

What are important elements of the history in the initial evaluation of a patient with RA?

A 
Degree of joint pain
Duration of morning stiffness
Presence or absence of fatigue
Limitation of function: mobility, personal care, special hand functions, work and recreation
Poor sleep patterns
Weight loss
18
Q

What are important elements of the physical exam in the initial evaluation of a patient with RA?

A 
Joint count of actively inflamed joints
Mechanical joint problems:
Loss of motion
Crepitus
Instability
Malalignment
Deformity
19
Q

What are possible extraarticular manifestations in RA

A 
Rheumatoid nodules
Sjögren’s syndrome
Episcleritis or scleritis
Interstitial lung disease
Pericardial disease
Systemic vasculitis
Felty’s syndrome
20
Q

What are important laboratory and radiology tests in the initial evaluation of a patient with RA?

A 
Rheumatoid factor: IgM against Fc of IgG
Anti-CCP
ESR or CRP
CBC, electrolytes, creatinine
Liver injury tests (LFTs)
Synovial fluid analysis
Urinalysis
Stool guaiacs
Radiographs of hands and/or feet
21
Q

Which is more specific to RA, RF or anti-CCP?

A

Anti-CCP?

22
Q

True or false, the presence of RF with anti-CCP are associated with a higher probability of joint damage and disability

A

True

23
Q

What are poor prognostic indicators for an individual with RA?

A

Earlier age at onset; female sex
Polyarticular synovitis (>13 joints)
High titer rheumatoid factor and/or anti-CCP
Elevated ESR or CRP level
Erosions or cartilage loss on x-ray (in < 1 yr)
HLA-DR4 or “shared epitope”
Poor functional status (HAQ >1 at 1 yr disease)
Extraarticular manifestations: rheumatoid nodules, scleritis, ILD, pericarditis, vasculitis

24
Q

In an individual with RA, how can the C spine become involved?

A

Atlantoaxial (C1-C2) subluxation due to laxity/rupture of the transverse ligament or fracture or erosion of the odontoid process

Symptoms: asymptomatic; cervical/occipital pain; cord impingement

25
Q

True or false, The thoracic, lumbar, and sacral spine are often involved in patients with RA

A

False, usually spared, though can have fx secondary to corticosteroid use

26
Q

True or false, shoulder pathology is common in patients with RA

A

True

Glenohumeral joint and AC joint
Subacromial bursitis
Rotator cuff tendinitis/rupture
Bicipital tendinitis/rupture

27
Q

What is Popeye’s sign?

A

Irregular biceps mm when contracted - result of rupture of long head of biceps tendon

28
Q

What sorts of elbow pathology can occur in patients with RA?

A

Flexion deformities and loss of lateral stability can develop
Entrapment of ulnar nerve or radial nerve (posterior interosseous) due to synovitis
Olecranon bursitis: RA; infection
Extensor surface of forearm: RA nodules

29
Q

What sorts of wrist/hand pathology can occur in patients with RA?

A 
MCP/PIP/wrist synovitis (DIPs spared)
Ulnar drift at the MCPs
Palmar subluxation of the MCPs
Swan-neck deformity
Boutonniere deformity
Tenosynovitis
Flexor tendons: weakness, crepitus, triggering (RA nodules), rupture, carpal tunnel syndrome
Extensor tendons: 3rd, 4th, or 5th tendon rupture due to abrasion by eroded ulnar styloid
30
Q

True or false, the DIPs are often involved in patients with RA

A

False, DIPs spared

31
Q

What sorts of hip pathology can occur in patients with RA?

A

About half of patients with RA have radiographic evidence of hip disease
Protrusio acetabuli: about 5% of patients
Trochanteric, iliopsoas and ischial bursitis
Avascular necrosis of the femoral head (glucocorticoid therapy)

32
Q

What is protrusion acutabuli?

A

Femoral head protruding into pelvis thru acetabulum

33
Q

What sorts of knee pathology can occur in patients with RA?

A

Effusions and synovial thickening
Quadriceps atrophy; loss of full extension
Tricompartment loss of joint space on x-rays
Baker’s (popliteal) cyst:
Posterior herniation of the capsule
One-way valve for synovial fluid from the anterior to the popliteal compartment
Venous compression
Rupture of Baker’s cyst : resembles acute thrombophlebitis (crescent sign under malleoli)

34
Q

What sorts of foot and ankle pathology can occur in patients with RA?

A

MTP synovitis common; ankle synovitis can occur in severe disease; flexor tenosynovitis
MTP subluxation with cock-up deformities, fibular drift, and hallux valgus
Pes planus; posterior tibialis tendon rupture
Valgus deformity of the ankle
Achilles tendon: tendinitis, nodules, rupture
Tarsal tunnel syndrome (medial malleolus)

35
Q

What sorts of head and neck pathology can occur in patients with RA?

A 
TMJ: jaw pain
Cricoarytenoid joints:
 Hoarseness
 Stridor
 Aspiration
Ossicles of the ear: conductive hearing loss
36
Q

Initial tx for RA

A

NSAIDs
Rheumatology, PT/OT, podiatry, orthopedics
Glucocorticoids, possibly
DMARDs

37
Q

Rehab tx for RA

A 
Modalities: heat, cold, TENS, paraffin bath
Joint protection techniques
Range of motion
Isometrics, isotonics, endurance
Orthotics, inserts, splints
Mobility devices
ADL: adaptive/assistive devices
Patient education
38
Q

What sorts of maintenance activities should those with RA be conducting?

A

Osteoporosis:
DEXA scans
Calcium / Vit D: 1500 mg /400-800 U/day
Bisphosphonates
Cardiovascular disease: assess risk / modify
Smoking cessation
Minimizing infection risk (particularly pulmonary infections):

39
Q

True or false, RA is best treated aggressively

A

True

40
Q

True or false, biologics for RA are relatively inexpensive

A

False

MC II Exam 2 (5 decks)

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