Rheumatology Flashcards
What are three comorbidities that usually are seen with fibromyalgia
1) Chronic fatigue syndrome
2) myofascial pain syndrome
3) Psychiatric illness
What are the signs of symptoms of fibromyalgia?
- Pain (≥3 mo, intermittent then persistent)
- Chronic fatigue - non-restorative sleep
- Cognitive dysfunction: poor working memory, verbal
- Somatic Symptoms: IBS, H/A, menstrual pain, TMJ
- Mood disorder: anxiety/depression
- Sexual dysfunction
- PTSD
How is a diagnosis of fibromyalgia made?
history and normal investigations
When considering a diagnosis of fibromyalgia, what are other conditions that are on your differential diagnosis?
- rheumatological disease (SLE, spondyloarthritis, PMR, RA)
- hypothyroidism
- Depression
- Neurologic (MS, neuropathy, myopathy)
- Infectious (Lyme disease, hep C, HIV)
- Meds (statin, aromatase inhibitor, bisphosphonate)
What are some lifestyle modifications that can be done to treat fibromyalgia?
- Education (disease is benign, non-deforming, non-progressing)
- Exercise program (water aerobics, ta chi)
- Support the back and neck
- Cognitive-behavioral therapy
- stress reduction
True or false, non-pharmacological management is more effective than pharmacologic management in treating fibromyalgia
TRUE
What are some pharmacological options for the treatment of fibromyalgia?
- NSAID/acetaminophen
- cyclobenzaprine 1-4mg
- tramadol
- nabilone
- amitriptyline (evidence for sleep restoration)
- SSRI + SNRI (less evidence than TCA)
- gabapentin/pregabalin
What are some referrals you can make when you diagnose someone with fibromyalgia?
- sleep study referral
- psychological consult
What are some investigations that you can obtain when the diagnosis for fibromyalgia is equivocal?
- CBC
- ESR/CRP, CK
- TSH
- ANA
- Sleep Study
What is the primary etiology of Gout?
Serum urate level ≥ 6.8-7
Primary:
- idiopathic renal under excretion (90%)
- idiopathic overproduction
Secondary:
- Dietary Excess
- Under excretion –> renal failure, drugs
What are the risk factors for Gout?
- DM
- Male
- Hyperuricemia
- CKD
- obesity
- CAD
- metabolic syndrome
- dyslipidemia
- Drugs: diuretics, cyclosporine, low dose ASA
- Foods: meat, seafood, alcohol, high sugar soft drinks
What are the signs and symptoms of gout
- often the 1st MTP joint
- acute pain, swelling, erythema, w/ limited joint mobility
- tophi (monosodium urate crystals)
- renal - nephropathy, calculi, acidic urine
What other diagnoses are on your differential for someone who presents with symptoms suggestive of gout?
- OA (inflammatory episodes)
- psoriatic arthritis
- Trauma
- septic arthritis
- RA
- pseudogout
If septic arthritis is still on the differential, what investigation would you perform?
- synovial fluid aspiration for crystals
What are some lifestyle modifications someone can make for the treatment of gout?
- limit purine and high fructose intake
- avoid alcohol
- avoid meats, sardines, shellfish, beans, peas
- consider a diet of <1600kcal /day
- weight loss
- avoid thiazides, consider losartan instea
What are the treatment options for an acute gout attack?
- Ice
- NSAIDs
- colchicine
- corticosteroids (usually if NSAID and colchicine is contraindicated)
What can be given to patients with gout for prophylaxsis?
allopurinol (indefinitely)
When is prophylactic medication for gout indicated?
- ≥1 tophi
- radiographic damage from gout
- ≥ 2 flares/year
- > 1 lifetime flare but <2/year
- first flare, and CKD stage ≥3, SU >535, or urolithiasis
What are some findings on xray of someone who has osteoarthritis
joint narrowing
subchondral sclerosis
subchondral cyst formation
ostephytes
What are risk factors for OA
- family history
- inactivity
- obesity
- muscle weakness
- heavy physical activity
- previous trauma
- reduced proprioception
What are signs and symptoms
- insidious onset
- morning stiffness <30 min, and stiffness after inactivity
- pain alleviated with rest and inactivity
- pain around joints after weight-bearing exercise
- crepitus with motion
- bony enlargement
- limited ROM
What are other diagnosis (ddx) to consider in someone who you think has OA?
- infection
- RA
- malignancy
- fracture
- gout/pseudogout
- bursitis (trochanteric, pes anserine)
- referred pain
What are some red flags in someone with joint pain?
- acute severe pain
- constitutional symptoms (fatigue, night sweats, wt loss)
- Neurogenic pain
- Trauma (?fracture)
- focal/diffuse muscle weakness
- claudication
- night pain
- hot and swollen joint
What are some lifestyle modifications for someone with OA?
- exercise rx
- joint protection
- muscle strengthening
- physiotherapy/rehab
- supportive footwear - shock-absorbing, well fitted, orthotics
- assistive devices - cane, brace, home adaptors
What are the treatments for OA other than lifestyle modifications?
- NSAIDs
- Topical capsaicin, NSAIDs
- acetaminophen
- corticosteroid joint injections
- surgery
When do you refer someone with OA to a specialist?
- inadequate pain control
- presence of night pain
- functional restriction (impaired ADLs, unable to walk w/o pain, threat to pts work/life)
What are some findings on lab investigation of PMR?
- low hgb
- elevated platelets
- increased ESR, CRP
- normal CK
What are the inclusion criteria for PMR?
- age > 50
- duration >2 wks
- abrupt onset
- morning stiffness >45
- bilateral shoulder +/- pelvic girdle pain
- elevated ESR/CRP
How do you treat PMR?
with steroids (prednisone)
15% of patients with PMR develop _____
Giant cell arteritis
