T2 - Rheum Flashcards
3 types of rheumatology disorders:
Autoimmune (Multisystem, joint involvement)
MSK = non-traumatic
Chronic Pain (MSK, no discernible other pathology)
Eosinophils are elevated in _____ (3)
Worms, wheezes (allergies) and weird diseases
Some DDx to consider with Rheumatology
Carpal tunnel syndrome, Fibromylagia, osteoporosis, gout, SLE, Lyme disease, Osteoarthritis, Paget’s disease, PMR, psoriatic arthritis, rheumatoid arthritis, Sjögren’s syndrome, vasculitis.
Inflammatory:
Joint redness/warmth (+ or -)
Pain response to activity (improves or worsens)
Stiffness response to activity (minimal or improves)
AM stiffness (prolonged or minimal)
Inflammatory:
+ joint redness/warmth
Pain and stiffness improves with activity
Prolonged AM stiffness?
Non inflammatory is the opposite.
What are some red flags of Rheumatoid diseases?
Sudden onset, worsening with tx, systemic symptoms (esp fever), joint pain AND sx in other body systems, recent trauma, unwillingness to bear weight, bone pain.
_____ lab test can be helpful in determining Rheumatoid arthritis
anti-CCP (cyclic citrulllinated peptide)
What are two examples of acute phase reactants? What can they tell us about inflammation?
ESR + CRP
they increase or decrease by at least 25% in response to inflammation.
Sensitive to inflammation but poor specificity.
T/F: if your ANA is negative then you don’t have lupus.
True. 99.9%.
POs ANA is not specific to Lupus, may have other AI disorder or be completely healthy.
What can give you a false positive ANA?
age >65, cancer, medications, viral infx, long-term infection.
For rheumatic disease, be on the lookout for diagnoses that could be symptoms such as:
Seizure, HA, migraines, gastroenteritis, etc.
If you are thinking autoimmune disease, then do a _______ titer too!
Lyme- Lyme is vastly under diagnosed.
What is a classic radiograph finding for OA?
Osteophyte formation. Also asymmetric joint space narrowing, subchondral sclerosis
Classic RA radiograph findings
Soft tissue swelling, joint effusion, OP, joint space narrowing, erosions, subluxation, swan neck deformity
Classic gout radiograph findings
Joint effusion, eccentric erosions “punched-out”, lyric lesions
Osteoarthritis is degeneration of ______
Ankylosing spondylitis is _____
Rheumatoid arthritis affects______
Gout affects________
Osteonecrosis affects_______
Cartilage
Enthuses enthesopathy
Synovial membrane/synovitis
Joint space
Bony end plate.
Draw rheum slide 35 in Free form.
3 things needed for autoimmunity to occur:
“Stupid-Ts” who can’t recognize self from non-self
Bad jeans make one more susceptible to stupid Ts
Inflammation from infx or trauma.
If your patient has joint pain or stiffness that is prolonged in the morning, malaise, myalgia, weight loss, and nodules over extensor surfaces, what are you suspecting?
RA.
EULAR classification criteria for RA
> =6 = definite RA.
Joint distribution (1 large joint, 2-10lg joints, 1-3 sml joints, 4-10 sml joints, >10 joints (at least 1 small joint)
Serology - neg RF and neg ACPA, low POs RF OR low POs ACPA, high POs RF OR high POs ACPA
Symptom duration - <6weeks, >=6weeks
acute phase reactants - normal CRP AND normal ESR, abnormal CRP OR abnormal ESR
Your patient has 2-10 large joints affected, a low positive RF, symptoms that last >6 weeks and a normal CRP and ESR. What is their ACR/EULAR score? Do they have RA?
4
No - they need to be >=6 to be definite. Doesn’t mean they don’t haven RA, you might need to keep scoring or look at other DDx.
Start RA patient on __________ monotherapy. If this doesn’t work, then add ______, _____, _____ or ______
DMARD
Combo DMARDS, TNF +/- MTX or non-TNF biologic+/- MTX.
Acute gout tx_______, chronic gout prevention tx _______
Colchicine
Allopurinol
Gout triggers:
Diet, alcohol, fructose, purines.
Your patient c/o asymmetric joint px that worsens with activity but minimal morning stiffness. They have bunions. What do you suspect?
OA.
Your patient has a photosensitive rash, fever, fatigue, arthralgia, Raynaud’s phenomenon and recorrent miscarriage. Upon exam you note slope is, anemia, and arthritis. What do you suspect.?
SLE
SLE is more common in ______ (8:1) and more severe in _____
Women
Women of color
What diagnostics do you want to do for lupus?
CBC, CMP, ESR/CRP, UA, ANA, RF.
Image: x-ray affected joints, echo cardiac, renal US and MRI.
According to the ACR/SLICC criteria, you must have______ to qualify as SLE
4/11 or 4/17 positive OR biopsy confirmed lupus nephritis.
Avoid what in SLE?
Sulfas and minocycline.
Patients with SLE are immunosuppressed and high risk for cancer. What dose this mean?
No live vaccines, more frequent cancer screenings, dental prophylaxis.
SLE treated with
Antimalarial (plaquenil) for skin manifestations and MSK complaints. They also prevent major damage to kidneys and CNS over the long term.
Glucocorticoid steroids.
Immunosuppressants are reserved for patients with significant organ involvement and had inadequate response to glucocorticoids.
Treat fibromyalgia with _____ and _____
CAM, PMH, supportive yoga, CBT, tai chi
Antidepressants and anticonvulsants.
Inflammatory vs non-inflammatory:
RA, SLE, Fibromyalgia, OA
Inflamm= RA and SLE
What different symptoms would you have from Fibromyalgia compared to OA, RA or SLE?
OA = joint pain, no constitutional
RA = joint pain and swelling, malaise
SLE = vague, evolving, multisystem
Fibro = HA, cognitive and mood alteration
What is PMR?
Polymyalgia Rheumatica
Age >50, proximal pain, acute onset, symmetrical aching stiffness (shoulders, hip,neck and torso), AM stiffness >45min, difficulty with ADLs, depression and anorexia.
Signs of PMR - exam and lab
Low grade Fever, wt loss
RF, ANA, anti-CCP usually negative
MARKED increase in CRP/ESR.
What does insidious onset mean?
Can’t point to a specific time that it started.
What score is needed to safely make a dx of PMR?
5 and over.
Scoring criteria for PMR algorithm
Morning stiffness >45 mins = 2
Hip pain with limited ROM = 1
Normal RF or ACPA = 2
Absence of other joint pain = 1
US: 1 shoulder with subdeltoid bursitis or biceps tenosynovitis and/or glenohumoral synovitis AND at least 1 hip with synovitis and/or trochanter if bursitis = 1
Both shoulders with subdeltoid bursitis, biceps tenosynovitis or glenohumoral synovitis =1
PMR pharm management
NSAIDS, glucocorticoids with taping, MTX, biologics,
Balance between rest and activity, nutrition, PT/OT, sleep.
