Rheumatology/Anemia Flashcards
Fibromyalgia is a ___ condition of _______
Cause?
chronic condition of connective tissue
unknown cause- infx stress
Symptoms of fibromyalgia
Associated sx
Widespread persistent pain (stiff, rore, throbbing, numb, burning) “flu”
Associated: IBS, HA, fatigue, sleep disturbance, depression/anxiety
Fibromyalgia dx based on
dx criteria
History, PE
tenderness 11 of 18 pts for at least 3 months
Tx fibromyalgia
TCAs first line (amitriptylline)
SSRI SNRI
Anticonvulsant
Rheumatoid arthritis
How do deformities present?
Symmetrical
Starts with small joints hands/feet moves to larger joints
Rheumatoid arthritis risk factors
female, smoker, stress, human leukocyte gene
rheumatoid arthritis dx symptoms
- morning stiffness>1 hr
- swelling in three or more joints
- swelling in wrist, hand, finger
- swelling on both sides of body
- x 6 weeks
rheumatoid arthritis labs
rheumatoid factor (present in most), anti-citrullinated peptide/protein antibody test (more specific)
ESR, CRP elevated
Synovial fluid
CBC- anemia and thrombocytosis
deformities seen with rheumatoid arthritis
History: starts with rheumatoid nodules then joint deformities
- ulnar deviation of MCP joints
- swan neck deformity- joint of finger tip points into palm, joint closest to palm bends away (DIP flexion, PIP hyperextension)
- boutenniere deformities- opposite of above, DIP hyperextension, DIP hyperextension
tx rheumatoid arthritis
DMARDs - hydroxychloroquine, plaquenil, leflunomide
Sulfasalazine- se low sperm count
Methotrexate- zostavax not to be given until 4 weeks after stopping, do not start within 2-4 weeks of receiving zostavax
Biological DMARDS- humira, cimzia, enbrel, simponi, remicade
PT: relieve pain (NSAIDS/systemic steroids), reduce inflammation, preserve joint, reduce CV risk
Osteoarthritis is a ____ disease of ____ and ____
sx
Degenerative disease of joint cartilage and bone
Pain stiffness (hip, knee, hands) decreased ROM, swelling, crepitus, joint enlargement and instability
Most common chronic condition of joints
osteoarthritis
risk factors osteoarthritis
joint overuse, age, gender (women), obese, genetics, race (asian less likely)
Dx osteo arthritis
PE:
Radiology:
Dx: Subjective and visual inspection
Trendelenberg test- stand on one foot, pelvis points down to unaffected side (gluteal weakness)
Heberdens nodes
Xray- shows osteophytes, joint space narrowing, subchondral sclerosis, cysts
MRI- not necessary, may show early stages of defects
U/S- shows synovial inflammation, effusion
Treatment osteoarthritis
Mild
Mod
Mild- exercise, splint, weight loss (5-10% in 6 months recommended), NSAIDS, capsaicin
Mod- intraarticular steroids, duloxetine, orthopedics, diclofenac gel or drops
Lyme pathogen?
Most common ____ ____ disease
Borrelia burgdorferi
Most common vector-borne disease
lyme- tick must feed for?
24-48 hours
Lyme
pt presentation in three stages
Early localized (3-30 days): skin lesion (erythema migrans), with or without symptoms
Early disseminated (weeks-months): multiple lesions, skin, heart, musculoskeletal, nervous system changes, persistent fatigue
Late (months-years): arthritis (especially monoarticular arthralgia in knee) + neuro (encephalopathy, polyneuropathy)
Lyme dx
serology, when does it show?
-
Dx: lyme antibody through serological testing- may not show for one month and may be positive indefinitely
ELISA (enzyme linked immunosorbent assay) with B burgdorferi antigens
IgM: within first few weeks
IgG: within one month
Immuno blot (Western blot) CONFIRM specificity
IgM 2-3 bands +
IgG 5-10 bands +
Lyme tx (meds) med in pregnancy: Resolves within? Pain/fatigue persist for? Symptoms longer than 6 months called?
Tx: early disease- doxycycline, amoxicillin, cefuroxime 2-3 weeks
Pregnancy: amoxicillin 2-3 weeks
Jarisch-herxheimer reaction- transient rx, worsening sx (antigens released from dying organisms)
If tx early with abx resolves within 20 days
Pain and fatigue may persist for weeks to months (resolve by 6 months)
Symptoms longer than 6 months is called “post-lyme disease”- difficult to treat
Anemia definition
Is anemia a disease?
Three root cases of anemia:
Anemia basics: reduced oxygen carrying capacity -not a disease, sx of another issue Poor RBC production RBC destruction Blood loss
Anemia labs Most accurate indicator of anemia? Define: Hgb- Hct- MCV- MCH- RDW- Reticulocyte- Poik- Aniso-
HGB** most accurate, less volume dependent- no sx until below 10
Hgb: oxygen carrying
Hct: proportion blood containing RBC (%)
MCV important- red blood cell size
MCH- color, concentration RBC
RDW- variation in sizes, blood cell lives 120 days, iron deficiency anemia increased
Reticulocyte- baby blood cell, normally lose 1% a day hence normal reticulocyte 1%
Poik- abnormal shape
Aniso- divergent blood cell sizes (correlated with rdw)
MCV<80- micro MCV >100- macro
Anemia often presents_____
asymptomatic
S/S anemia
severe s/s anemia
Exertional dyspnea, fatigue, headache, tachycardia, palpitations,
pallor (skin/conjunctiva), systolic flow murmur
Severe anemia: angina, glossitis, roaring in the ears,
muscle cramps, phagophagia (craving for ice),
pica, spooning/ridging/thinning of nails, cheilitis
s/s pernicious anemia
neurological symptoms- loss of position
/vibration sense, balance, memory (can’t dx dementia without checking B12)
Iron deficiency anemia lab findings
low ferritin (iron stores) **most specific
high- TIBC (“empty baskets that carry iron”
MCH and MHCH decreased
RDW increased
Ferritin- decreased, dx: IDA
Reticulocyte low- body doesn’t have building blocks to make new RBCC
If IDA in male- suspect GI blood loss
Tx iron deficiency anemia
monitoring anemia improvement with lab work shows improvement with 1) 2) 3)
tx until?
Ferrous sulfate- take on empty stomach with OJ
Monitoring: reticulocyte will improve first (body making new RBC), then H+H improved at 6 weeks, finally ferritin
Tx until ferritin normal (12 weeks)
Thalassemia
abnormal production of ___
Minor common in ___
Genetic defect- abnormal hgb production
Minor- most common mediterranean, middle eastern, african, asian
Dx thalassemia
labs
definitive dx
NORMAL RDW and iron studies
Microcytic and hypochromic like IDA (decreased MCV, MCH)
Definitive dx: electrophoresis increased hgbA2
Sideroblastic anemia
disorder of???
how do you get it?
CBC/labs show?
Enzyme d/o- enough iron but cannot incorporate into hgb- lays down in a ring
Hereditary or acquired (ETOH, INH, RA, lymphoma, leukemia)
Increased ferritin and Fe (IRON OVERLOAD)** Peripheral smear- ringed sideroblast*** Hematology for bone marrow aspiration
Anemia of chronic disease
associated with?
CBC/labs?
Tx?
Associated with inflammatory disorders, malignancy, HIV
NORMAL OR HIGH FERRITIN, normal TIBC
Can be microcytic or normocytic, normo or hypochromic
Tx: underlying conditions
Microcytic anemias
IDA
Thalassemia
Sideroblast
Anemia of chronic disease
MCV bw 80-100 (normocytic)- look at ____ next…
increased?
normal?
decreased?
next look at reticulocyte
increased reticulo- hemolytic (sickle cell, G6PD, drug induced, autoimmune) not managed in primary care
normal- metabolic
decreased reticulo- renal, aplastic (ER, 0 reticulo-aplastic)
Lab findings with hemolytic anemia
Size? Color? Reticulocyte? Increased what (2)? decreased what (1)?
Positive _____ test
Normal size and color, INCREASED RETICULOCYTE
Increased LDH and bili
Decreased haptoglobin
Positive coombs test- antibodies against RBC
Metabolic anemias labs
Size?
Reticulocyte?
-
-
NORMAL SIZE NORMAL RETICULOCYTE
Thyroid
Addisons
Pituitary
Renal/aplastic anemias
Size? Reticulocyte?
-
-
NORMAL SIZE DECREASED RETICULOCYTE
Renal failure
Aplastic- Viral illness, drug related, idiopathic
Pancytopenia- reticulocyte 0
Macrocytic anemias
b12 and folate deficiency
Sx b12 deficiency
Atrophic glossitis Stocking/glove neuropathy Memory loss/dementia Depression Irritability Balance problems Loss position/vibration sense ataxia Anorexia Diarrhea Weight loss
Causes b12 deficiency
pernicious anemia
gastric bypass
vegetarian/vegan
B12 anemia lab findings
Size? Color?
Reticulocyte?
Two key elevated values are?
Hypersegmented ______
Oval ______
Tx:
Macrocytic, normochromic
Low reticulocyte
Methynalonate + homocysteine elevated
Antibodies to intrinsic factor in pernicious anemia
Hypersegmented neutrophils, oval macrocytes
Tx: replacement B12 1000 mcg IM daily x 1 wk, weekly for one month, and monthly for life
Folate deficiency:
Two key values are?
Causes:
Methylmanolate (NORMAL) + homocysteine elevated
Dilantin, tegretol, phenobarb, azt, ETOH, dialysis, malabsorption, celiac
Replace 1mg daily
