Rheumatology Lec 3

Question 1

Define fibromyalgia.

Answer 1

Fibromyalgia is a chronic disorder characterized by widespread pain, tenderness and stiffness of muscles and connective tissue structures. It is accompanied by fatigue, headaches, sleep disturbances.
Several co-morbidities. Sensitization of the central nervous system.

Question 2

Describe the epidemiology of fibromyalgia.

Answer 2

It is more prevalent in women, three times more. The prevalence increases with age. It typically develops between age 25 and 55. Often have other co-morbidities. 67% has musculoskeletal disorders.

Question 3

What are some of the risk factors for fibromyalgia?

Answer 3

Exact etiology is unknown. Risk factors: Heredity; Stressful or traumatic events; bodily injury; infection; disease.

Question 4

What are some of the clinical presentations of fibromyalgia?

Answer 4

Morning stiffness
Tingling/numbness in hands and feet
Headaches/migraines
Thinking and memory abnormalities
Painful menstrual periods
Fatigue
Trouble sleeping
Jaw pain
Abnormal muscle pain and malaise after exercise
Dizziness
Skin and chemical sensitivities
Deep, aching, throbbing, shooting, radiating, stabbing pain
Depression.

Question 5

What are some of the historical aspects needed for diagnosing fibromyalgia?

Answer 5

Chronic widespread pain with tenderness at 11 of the 18 specific tender points. Chronic widespread pain lasts at least three months, axial skeleton, left and right sides, above and below waist.

Question 6

What are other aspect that form part of the diagnosis of fibromyalgia?

Answer 6

Physical examination.

Tender points according to American College of Rheumatology (ACR), at least 11 of the 18 points.

Question 7

Describe the general management strategies for fibromyalgia.

Answer 7

Minimize stress
Deep breathing exercises
Relaxing techniques and massages
Nutrition
Exercise
Sleep

Question 8

What are some of the medications used to manage fibromyalgia?

Answer 8

Amitryptline
Pregabalin
Gabapentin
Tramadol

Question 9

What are other treatment/management strategies that could be used for fibromyalgia?

Answer 9

Psychotherapy
Physiotherapy
Acupuncture
Massage
OT

Question 10

What is gout?

Answer 10

Gout is a chronic heterogenous disorder of urate metabolism.

Question 11

What are some of the characteristics of gout?

Answer 11

Hyperuricemia.
Deposition of monosodium urate monohydrate crystals in joints and periarticular tissues.
Recurrent attacks of acute synovitis, typically monoarticular.
Chronic destruction of cartilage.
Interstitial deposition of urate crystals in the kidney.

Question 12

What are the different classifications of gout?

Answer 12

Primary gout, 95%(mostly due to hyperuricemia due to under-excretion of uric acid.
Secondary (other causes)

Question 13

Describe the epidemiology of gout.

Answer 13

Most common in middle age men. Common is menopausal women. Can run in families.

Question 14

What are the predisposing factors for gout?

Answer 14

Genetic
Cancers and blood disorders
Alcohol abuse
Obesity
High intake of purine containing foods.
Caffeine
Lead poisoning
Radiation treatment
Hypothyroidism
Age
Duration of hyperuricemia
Starvation
Renal failure
Some drugs
Trauma 
Infection

Question 15

What are some of the triggers for gout?

Answer 15

Injury
Surgery
Consumption of large quantities of alcohol and purine rich foods.
Fatigue
Emotional stress
Illness

Question 16

What are some of the signs and symptoms of gout?

Answer 16

1-2 joints affected at a time.
Cooler joints affected more commonly (urate crystals form at cool temperatures)
Podagra (pain in the metatarsophalangeal join)
Common joints (ball of big toe, feet, ankles, wrists, elbows)

Question 17

What are the Hallmarks of gout?

Answer 17

Usually elevation of serum uric acid.
Recurrent attacks
Bone and joint destruction
Aggregates or uric acid crystals
Kidney disease and stones.

Question 18

What is the clinical presentation of gout?

Answer 18

Asymptomatic hyperuricemia
Acute gouty arthritis
Intercritical gout-intervals between attacks of gouty arthritis are referred to as intercritical periods.
Chronic gouty arthritis.

Question 19

What are the signs of acute gout?

Answer 19

Suddenly appears in 12-24 hours, usually overnight.
Skin is red-purplish, tight and shiny.
Joint is painful, swollen and warm.
Throbbing, crushing or excruciating pain.
Recurrent attacks develop.
Fever, chills, general sick feeling.
Rapid heartbeat.

Question 20

What are the signs of chronic gout?

Answer 20

Progressive joint damage.
More frequent attacks.
Crippling deformity.
Disability.
Restricted joint motion.
Joint pain most of the time.
Hard lumps of urate crystals.

Question 21

Describe tophi.

Advanced chronic tophaceous gout.

Answer 21

Tophi is tophaceous nodules that consist of multi-centric depositions or urate crystals and intracellular matrix and foreign body granulomatous reactions. As they enlarge in size, they calcify and can cause pressure symptoms. They are firm, yellow and occasionally discharge a chalky material. Can also occur over eyelids, nasal cartilage, cornea, tongues, vocal cords and penis.

Question 22

In which ways does tophaceous gout manifest in the renal system?

Answer 22

Kidney stones
Urate nephropathy
Uric acid nephropathy

Question 23

What are some of the factors needed to diagnose gout?

Answer 23

Symptoms
Clinical examination of the joint
High serum uric acid levels
Joint aspiration
Joint damage on X-rays and tophi that displaces the bone and produces cysts.

Question 24

What does CPPD stand for, related to gout-type disease?

Answer 24

Pseudogoat Chrondrocalcinosis.

Question 25

What are some of the treatment options for gout?

Answer 25

Diet
Weight loss
Current medications
Add gout medications (acute-NSAIDS, colchicine, steriods; chronic-allopurinol)
PT and OT

Question 26

Describe ankylosing spondylitis (AS).

Answer 26

It is a chronic, multisystem inflammatory condition. A systemic rheumatic disease, and is one of the negative spondyloarthropaties. It affects the joints of the spine as well as the sacroilium joints. Complete fusion results in complete rigidity of the spine (bamboo spine).

Question 27

Describe the epidemiology of ankylosing spondylitis.

Answer 27

Typical young men aged 18-30, more men (3:1), cause is unknow but genetic factors paly a big role. Rheumatoid factor negative.

Question 28

Describe the aetiology of ankylosing spondylitis.

Answer 28

It is idiopathic. Probable factors are genetics.
Possibly bacterias like Klebsiella pneumonia and some other Enterbacterias.
Often predisposed people after exposure to infections.

Question 29

Describe the pathology of ankylosing spondylitis.

Answer 29

Enthesis, the site of ligamentous attachment to bone, is thought to be the primary site of pathology. Enthesitis is associated with prominent oedema of the adjacent bone marrow and is characterized by erosive lesions that undergo calcification.
Sacroilitis is usually one of the first manifestations.
Axial arthritis.
Arthritis of gridle joints.

Question 30

What are some of the symptoms of ankylosing spondylitis?

Answer 30

Pain in sacroiliac and lower back regions.
Permanent dull, worse at rest, in the morning and at night.
Relieved by motion and better in afternoon.
Buttock pain.
Lower back stiffness-in the morning.
Chest pain(mimicires intercostal neuralgia and intercostal myositis, worsens in coughing and deep breathing.
Stiffness and tenderness of back muscles.
Flattening of lumbar lordosis.
Bilateral sacroilitis.
Enthesopathies (pain in the site of ligamentous attachment to bone).
Extra-articular manifestations-usually eyes, bilateral, acute onset for about 2 -3 months.

Question 31

Describe advanced Ankylosing spondylitis.

Answer 31

Pain in different segments of the spine.
Atrophy of back muscles.
Decrease articulation in spine.
Ankylosis of sacroiliac and intervertebral joints.
Cutaneous lesions.
Can get cardiac involvement, lung, urinary and GIT.

Question 32

Describe some of the extra-articular manifestations of ankylosing spondylitis.

Answer 32

Acute anterior uveitis (unilateral uveitis).
Inflammatory bowel disease (asymptomatic ileal and proximal colomic mucosal ulceration).
Psoriasis (associated with more peripheral joint involvement).
Cardiovascular disease (aortic regurge due to cusp retraction; conduction disturbances).
Pulmonary disease (restrictive disease: reduces chest wall/spinal mobility; apical fibrosis with long standing disease)

Question 33

What are some of the tests and measurements used for ankylosing spondylitis?

Answer 33

Cervical mobility.
Thoracic mobility.
Lumbar mobility.
Lab tests-HLA B27
ESR and CRP 
Mild anaemia.

Question 34

What are some of the other tests that can be administered to assess ankylosing spondylitis?

Answer 34

Pelvic compression test.
Fabere test/Patrick’s test.
Gaenslen test

Question 35

What characterized changes do the spinal vertebrae show on X-ray in ankylosing spondylitis?

Answer 35

Sacroiliitis

Question 36

What is the prescribed general treatment for ankylosing spondylitis?

Answer 36

Drug therapy (includes anti-inflammatory drugs, local corticosteroids injection, Disease Modifying Anti-rheumatic Drugs)
Surgery (hip arthroplasty)
Physiotherapy and occupational therapy

Question 37

What are the aims of therapy?

Answer 37

To relieve pain.
Maintain mobility
Prevent and correct deformity
Increased chest expansion and vital capacity
Attention to posture
To maintain and improve physical endurance
Advice to patient, education