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NP 730 Diagnostic Measures > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Rheumatology

A
  • Study of rheumatism, including MSK disease, arthritis + systemic autoimmune conditions
    • Study of joints, MM, and ligament problems
    • DX joint pain
  • Autoimmune conditions resulting in inflammation in areas of body where it’s not needed
    • Maladaptive inflammatory response
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2
Q

Which parts of the body do rheumatic conditions affect?

A
  • Typically affect joints, muscles, and bones
  • May also affect eyes, skin, nervous system, and internal organs (systemically)
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3
Q

Common Rheumatologic characteristics

A
  • Localized pain
    • Diffuse mm/joint pain
  • Stiffness, swelling and tenderness in joints and MMs
  • Redness and warmth in joints and MMs
  • Reduced mobility and ROM in specific joints and MMs
  • Systemic s/s: fever, rashes, fatigue, etc
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4
Q

Rheumatologic testing: Challenges

What is rheumatologic testing centered on

A
  • Few if any rheumatologic serologies track exactly with disease
    • Can be (+) years before disease manifests
    • Disease can occur despite autoAb being absent
      • (+) serologic test but may not have signs; test C-reactive protein too
  • Knowledge of underlying disease and a thorough history and physical examination
    • Clinical references
    • Curbside referrals
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5
Q

Signs of inflammatory arthritis

Think OLDCART

A
  • Onset: ACUTE
  • Location: Symmetric (BL) with SAME ONSET
  • Duration: over weeks or months
  • Characteristics: Prolonged morning stiffness…See last slide (characteristics)
    • Systemic s/s
    • PAIN + SWELLING + WARMTH
    • No trauma - spontaneous
  • Aggravating: Getting up in AM
  • Relieving: gets better with movement or rest after AM
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6
Q

Osteoarthritis VS. Rheumatologic arthritis

A
  • Osteoarthritis - managed in primary care setting → ortho surgeon
    • Happens later in life > 50 y.o.
    • UL = if BL → different onset each side
    • Insidious onset, gradual
    • Effects bigger joints - knees, hips, shoulders
    • Pain from wear and tear on joints (mechanical issue ) - BONE on BONE
  • Rheumatologic Arthritis
    • Extra-articular s/s: outside of joints, weight loss, fatigue, fever, rash
      • Inflammation s/s in synovial membrane
    • Stiffness lasting long in AM ( > 1hr/30m)
    • More RA in smaller joints
    • BL - same onset
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7
Q

Xray imaging of OA vs RA

A
  • X-ray imaging RA
    • Normal in early stages of disease
    • Soft tissue swelling and periarticular osteopenia/osteoporosis
    • Joint erosion - ill-defined
    • Jont space narrowing
  • Can use MRI for ID erosions (NOT ROUTINE TEST)
  • X-ray imaging OA
    • Osteophytes or bone spurs in joints
    • Joint space narrowing
    • Subchondral sclerosis cysts
    • DEXA scan to Dx
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8
Q

Rheumatological conditions differentials

A
  • Rheumatoid arthritis
  • Systemic Lupus Erythematous (SLE)
  • Sjodren’s Syndrome
  • Psoriatic Arthritis
  • Polymyalgia Rheumatica (PMR)
  • Spondyloarthritis
  • Crystal Arthropathy (Cout/CCD)
  • Infection
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9
Q

Gout: Etiology

A
  • Due to buildup of uric acid or calcium crystals
  • M > W
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10
Q

Meds associated with causing gout

A

Diuretics (pts w/HF on this)

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11
Q

Gout characteristics

A
  • Usually affects one joint at a time
    • MOST COMMON JOINT AFFECTED: BIG TOE
    • 2nd most commonly effected: knee
    • Asymmetrical soft-tissue swelling
  • Causes swollen, hot, red, painful joint
    • Painful to light touch
  • ACUTE - usually w/in 24hrs of onset
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12
Q

Gout lab testing

Definitive dx?

A
  • Uric acid level
  • Joint aspiration most diagnostic!
    • Aspirating effected joint during attack and finding monosodium urate crystals in fluid
    • Culture → rule out infection
  • 24-hr urine test, neutrophilia, elevated ESR and CRP
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13
Q

Questions to ask if patient has signs of inflammatory arthritis

A
  • How old are they?
  • Location of pain?
  • How long have the symptoms been present
  • Other systemic symptoms?
  • Symptoms acute or self-limiting
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14
Q

Purpose of ultrasound in inflammatory arthritis

A

Can show inflammatory + structural changes in joints and tendons

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15
Q

RA imaging

A

Ultrasound

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16
Q

Giant Cell arteritis

Diagnosis s/s

A
  • DO NOT MISS → can lead to BLINDNESS
  • Vasculitis
  • Associated w/PMR; > 50
  • UNL H/A w/visual difficulty
  • Jaw pain
  • Scalp tenderness
  • Systemic s/s: mild fever, fatigue, loss of appetite, wt. loss in limbs, worse s/s in AM
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17
Q

Giant Cell Arteritis Labs

Diagnostic test?

A
  • ESR negative → rule this out
  • GOLD STANDARD DX TEST: temporal artery biopsy (not true dx)
    • Part of artery may not be inflamed, can biopsy wrong part
  • CRP elevated in acute phase
  • U/S
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18
Q

Giant Cell Arteritis

Treatment

A

High dose and long-term prednisone

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19
Q

Psoriatic arthritis

Lab reading

A
  • MRI - early dx
  • Can differentiate btwn synovitis (synovial membrane) and (enthesitis) inflammation where tendons + ligaments
  • Rheumatoid factor (-) + 40% pts w/elevated ESR
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20
Q

Rheumatologic Laboratory work-up in Primary Care

A
  • ESR, CRP
  • ANA
    • sub-serologies
  • RF
  • CCP
  • Uric acid
21
Q

Non-rheum etiologies

A
  • Lyme
  • Viruses
    • Parovirus
    • Hepatitis C
    • HIV
  • Osteoarthritis
  • Neuropathy
  • Medications
22
Q

Inflammatory Labs: ESR

A
  • Measured by how fast RBCs settle to bottom of a test tube (60m)
    • In presence of increased acute phase reactants (proteins), RBCs settle faster
  • Non-specific
  • NOT DIAGNOSTIC - normal ESR does not rule out disease
  • Less reliable in acute s/s than CRP
23
Q

Inflammatory labs: CRP

A
  • Acute phase reactant - protein made by liver released into blood w/in few hrs of tissue injury/infection
  • Can elevate in rheumatic, malignant, infectious and allergic conditions
  • GCA - elevated in acute phase
24
Q

Are ESR and CRP measured in tandem?

A

YES

Follow disease activity + response to meds (want levels back in range)

Both are non-specific and non-diagnostic on their own

25
Q

Autoimmune labs: RF

A
  • IgM protein produced in several inflammatory and autoimmune processes
  • Elevated in
    • Sjrogen’s
    • RA
    • Chronic infections Hep C, TB
    • SLE
    • Vasculitis (not specific to RA)
26
Q

Autoimmune labs: CCP

A
  • Peptide formed during metabolism of arginine
  • In RA this metabolism happens more quickly causing increased levels of Citrulline triggering an immune reponse
  • More specific than RF for RA
  • Correlates w/errosive disease
27
Q

If you suspect RA, which two labs should you check?

A

RF + CCP = 90% sensitive

If positive → most likely RA

28
Q

Elevated RF + (-) CCP →

A

less likely RA

29
Q

Autoimmune Labs: ANA

What is it; diseases associated; S+S

A
  • If (+) → most likely have RA
    • But there can be false positives
  • Group of antibodies produced in autoimmune disease states
  • Associated w/several autoimmune disorders: SLE, drug induced lupus, Sjrogen’s, Scleroderma, Mixed connective tissue disease
  • Can be negative in early stages of disease
  • Low specificity, highly sensitive in presence of SLE, false positives and borderline tests possibility
30
Q

If ANA not detectable in 1:40 first mix

A

NEGATIVE RESULT

31
Q

IF ANA 1:40 mix positive

A

larger the bottom number → more (+) the test

aka more parts needed to dilute substance

32
Q

Lupus

4 types

A
  • Chronic autoimmune disorder that can affect multiple body systems
    • Skin, MSK, renal, neuro, heme, CV, pulmonary, reproductive
      • Skin: mallar/butterfly rash, specific
  • Types
    • Systemic
    • Cutaneous
    • Drug-induced - s/s similar to SLE but rarely affects major organs
    • Neonatal
33
Q

Systemic Lupus Erythematous

S/s

A
  • Most common
  • Difficult to diagnose
  • Nonspecific s/s: fatigue, weight loss, fever, joint and mm aches (constitutional symptoms)
  • Less common - rash, photosensitivity, pleuritic chest pain, Reynaud’s, mouth sores
34
Q

If you suspect it’s lupus, which test do you order first?

A

ANA

35
Q

Complete lupus workup

What if it’s positive? Which other labs

A

ESR, CRP, ANA, RF, CCP

Check ANA subserologies (only if +)

Anti-phospholipid antibodies

Urine protein : Cr ratio

Complements C3 + C4 (low → lupus)

36
Q

Spondyloarthritis (SpA)

types

A
  • Type of arthritis that attacks the spine and in some cases joints of arms and legs
    • Peripheral - more rare
  • Axial
  • Psoriatic arthritis
  • IBD related
  • Reactive
37
Q

Spondyloarthritis (SpA) and types

A
  • Type of arthritis that attacks the spine and in some cases joints of arms and legs
    • Peripheral - more rare
  • Axial
  • Psoriatic arthritis
  • IBD related
  • Reactive
38
Q

Axial Spondyloarthritis (axSpA)

What? Diseases associated?

A
  • Chronic low bakc pain before age of 45 - insidious onset, improvement w/exercise but not with rest, pain at night
    • No incident trauma/accident prior to onset of pain
  • Often associated w/other inflammatory disorders - uveitis, psoriasis, IBD, inflammatory arthritis of other joints
    • Visual issues: uveitis = DO NOT MISS
39
Q

Axial Spondyloarthritis (axSpA)

Diagnosis and assessment

A
  • Diagnosis focuses on differentiating mechanical and inflammatory back pain
  • Early diagnosis is crucial
  • Assessment: NEED 4/5 TO DX
    • Onset < 40 y.o.
    • Insidious onset: no incident of trauma or hx
    • Improvement w/exercise
    • No improvement with rest
    • Pain at night (with improvement getting OOB)
40
Q

Axial Spondyloarthritis

Lab Workup and Imaging

A
  • 1st: ESR/CRP → checking inflammation
  • 2nd: HLA-B27 present in 90% of AS, 50-70% of other syndromes
    • $$$$ test, ALWAYS GET CONSULT 1st (rheumatology)
  • Check radiographs x-rays, MRI
    • Normal in early disease
    • Diagnosis based mainly on ASAS criteria and MRI - see abnormal darkening
41
Q

Viral etiology workup (labs + questions)

When would you do infectious workup?

A
  • Do infectious workup when patient presents with all over joint/body pain
    • Have lived or have traveled to an area that’s endemic to particular infectious diseases
    • Especially if duration of s/s < 6 weeks
  • Check LFTs - ELEVATED abnormal
  • HIV - RFs
  • Parovirus Titres - initially starts as cold/viral illness (ask about exposure to children)
    • Red cheeks in children; adults - overall joint pain
42
Q

What if it’s Lyme? what do you look for?

A
  • Inflammatory arthritis
    • Exposure history, concurrent fever, rash, etc. Associated w/joint pain/inflammation
      • Ticks, brush, woods
    • Low threshold in this area of the country
43
Q

Fibromyalgia workup and s/s

A
  • Widespread, diffuse mm pain w/palpation on trigger points throughout body
      • WPI >/= 7; AND SSS >/= 5 OR
  • WPI 3-6; SSS >/= 9
  • > 3 months duration
  • ESR, CRP, RF, CCP, ANA, xrays
    • ESR and CP NORMAL LEVELS in fibromyalgia
44
Q

WPI chart (not sure if we need to know this)

A

Assessment tool to assess fibromyalgia

45
Q

What else can cause diffuse mm pain (confused w/Fibromyalgia)?

What drug hold to see if mm pain gets better

A

Hypothyroidism, Neuropathy

STATIN → rhabdomyolysis

46
Q

Sjogren’s Syndrome

A
  • Autoimmune disorder that attacks tissue in glands that produce moisture-tear and salivary glands
    • Patients will complain of dry eyes and mouth, also possible dry skin, cough, fatigue, joint pain, swollen parotid glands, vaginal dryness
47
Q

Sjogren’s Syndrome lab workup

A
  • ANA (+)
    • Add specific antibody testing: Anti-Ro/SSA, anti-La/SSB
  • Can do direct testing (Shirmer test in eye, sialometry)
  • Opthamology referral
48
Q

Polymyalgia Rheumatica (PMR)

S/s

A
  • Stiffness/pain at hip and shoulder girdle, often also the neck
    • > 50y.o.; more common > 65, 70s, 80s
    • Strength INTACT - just feel like they can’t lift their arms up, HEAVY/STIFF
    • Associated w/temporal arteritis
  • DON’T MISS GCA!
49
Q

PMR lab workup

A
  • DX: CLINICAL - can be vague on exam
  • ESR/CRP - ALWAYS ELEVATED (ESR > 100 suggestive)
  • Refer/rule out other conditions if negative

NP 730 Diagnostic Measures (11 decks)

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