unit 3: rheum Flashcards
1
Q
what color is non-inflammatory synovial fluid?
A
clear
2
Q
what color is mild inflammatory synovial fluid?
A
translucent
3
Q
what color is purulent synovial fluid?
A
opaque
4
Q
true or false: when aspirating a knee it is ok to insert needle thru an area of cellulitis or other skin disorder?
A
false…. you dont want to introduce bacteria from outside.
5
Q
your pt is on coumadin and you want to aspirate their joint… what do you check? what are the parameters? what gauge do you use?
A
- INR
- MUST BE LESS THAN 3
- small gauge (like 22g)
6
Q
true or false: joint aspiration falls under the APRN’s scope of practice
A
*trick question- varies by state
7
Q
wbc count of normal synovial fluid?
A
<2k
*would indicate non-inflammatory condition
8
Q
wbc count of inflammatory synovial fluid?
A
2k-75k
9
Q
wbc count of purulent synovial fluid?
A
100k
10
Q
true or false: bloody joint effusions are usually caused by traumatic aspiration
A
TRUE
11
Q
3 clues to help you dx rheum:
- +/- _______
- # of ______ involved
- _______ of joint involved
A
- absence or presence of inflammation
- number of joints involved
- site of joint involved
12
Q
if inflammation is present what 3 diseases should you consider?
A
- RA
- SLE
- gout
13
Q
if inflammation is absent what disease should you consider?
A
OA
14
Q
monoarticular joint involvement… what 5 diseases should you consider?
A
- gout
- trauma
- septic arthritis
- lyme
- OA
Get LOST
gout, lyme, OA, SA, trauma
15
Q
oligoarticular involvement means what?
A
2-4 joints
16
Q
polyarticular means what?
A
5+ joints
17
Q
oligoarticular involvement…. what 2 diseases should you consider?
A
- Reactive arthritis
2. psoriatic arthritis
18
Q
polyarticular involvement… what 2 diseases should you consider?
A
- RA
2. SLE
19
Q
distal interphalangeal (DIP) joint site… what 2 diseases?
A
- OA
2. PA
20
Q
metocarpophalangeal and wrist involvement… what 2 diseases?
A
- RA
2. SLE
21
Q
first metatarsal phalangeal… what 2 diseases?
A
- OA
2. gout
22
Q
OA def: ________ of the cartilage and ______ of the bone
A
- degeneration of the cartilage
* hypertrophy of the bone
23
Q
______ is the most common form of joint disease
A
OA
24
Q
OA is more common in women or men?
A
women
25
OA usually flares ______ (#) joint at a time
1
26
onset of OA is abrupt or insidious?
insidious, gradual
27
what do you expect ESR and synovial fluid to show in a pt with OA?
* ESR IS NOT ELEVATED
| * syn fluid NON INFLAM
28
2 radiologic findings with OA?
* narrowing of joint space
| * osteophyte formation
29
2 ways to prevent OA
1. weight reduction
| 2. normal vitamin D levels
30
first line treatment for OA?
tylenol
31
is exercise indicated in the treatment of OA?
YES, regular exercise
32
do splints and compression gloves help in treatment of OA?
YES
33
______ is the most common cause of gastric ulcer, perf, and hemmorhage (for the sake of this chapter...)
NSAIDS
34
what should you use to reduce risk of GIB in pts taking nsaids?
PPI
35
NSAIDS should be administered cautiously in what groups? (5)
* over 70
* anticoagulated
* taking corticosteroids
* hx of PUD
* hx alcoholism (dec. clotting times due to liver dysfunx)
36
how many times a year can you give your pt intra articular steroid injections?
NO MORE THAN 4
37
injections of the _____ are not recommended for OA
hand
38
hip and knee replacements are a good choice for OA pts w what restriction
those who have ambulation restrictions
39
gouty arthritis is ideopathic or hereditary?
hereditary
40
gouty arthritis more common in men or women?
men
41
gouty arthritis more common in men over ______y
30
42
gouty arthritis acute or gradual onset?
acute
43
gouty arthritis mono, oligo, or poly articular?
MONO
44
usual site of gouty arthritis?
MTP
| first metaphalangeal joint
45
hyperuricemia is associated with what level of uric acid?
>6.8
46
pts with gout are at increased risk for what other undesired condition?
kidney stones. check for them
47
uric acid kidney stones are common in 5-10% of pts with uric acid level >?
13
48
another name for the MTP joint when gouty is?
podagra
49
true or false. during an acute gout attack, the WBC count is elevated
TRUE
50
pts with gout have a higher INCIDENCE of what 5 other DIAGNOSES/disease processes (think of vessel inflammation related dx and you'll 4 of them.... the 4th one is partially a consequence of the remaining dx)
* HTN
* DM
* CKD
* atherosclerosis
* hyperTRIGS
51
2 options for gouty arthritis treatment include?
* NSAIDS
| * colchicine
52
what is the two step loading dose treatment with colchicine?
* 1.2mg NOW
| * 0.6mg one hour later
53
2 NSAID treatments for gouty arthritis
* naprosyn 500mg BID
| * indomethicin 25-50mg q8h
54
undesirable side effect of colchicine?
diarrhea
55
1. allopurinol starting dose?
2. titrate up every _____ weeks?
3. usual dose to decrease symptoms?
4. max dose?
1. 100mg daily
2. 2-5w
3. 300mg
4. 800mg daily
56
allopurinol and what drug (abx) causes a rash in approx 20% of pts?
ampicillin
57
use allopurinol cautiously in pts with _______
CKD
58
true or false: allopurinol and colchicine may be taken concurrently?
FALSSSSSSSSE
| *colcrys loading for acute attack... allo for prevention
59
all meats are high or low purine?
HIGH
60
organ meats are high or low purine?
HIGH
61
seafood is high or low purine?
HIGH
62
sadly.... what alcoholic bev is high purine?
BEEEEER (and all alc) but esp beer due to the YEAST
63
other foods high in purine: all veg with one grain
| BLOP, SCAM
BLOP: beans, peas, lentils, oatmeal
SCAM: spinach, cauliflower, asparagus, mushroom
64
teach wants us to know high fructose corn syrup is risk factor food for?
gouty arthritis
65
thiazide and loop diuretics are contraindicated in gout bc??
*inhibit renal secretion of uric acid
66
what supplement commonly used as an alternative to statins can raise serum uric acid levels?
niacin
67
corticosteroid dose for gout? if using...
prednisone 30-40mg daily for 2-5d then taper
68
physicain may initiate urate-lowering therapy when pt has had ______+ gout attacks in one year
2
69
goal of urate lowering theraoy is maintain serum uric acid at or below??
6mg/dL
70
recheck uric acid levels about _____ weeks after initiation
4. she keeps saying shell check her pts around a month of treatment...
71
RA morning stiffness lasts longer than _____min
30
72
palmar erythema is a hallmark of which disorder?
RA..... palmAR
73
name 4 extra-articular manifestations of RA... remember its an INFLAM process...
1. subcu nodules
2. interstitial lung disease
3. pericarditis
4. vasculitis
74
most common cause of MORTALITY in pts with RA...
CVD... due to chronic inflam
75
multiple joints are involved with swelling, tenderness, and pain.... which one?
RA
76
____% of RA pts have subcu nodules... these may also be found in other tissues such as....
* 20%
* lungs
* sclera
* other tissue
77
dryness of eyes, mouth, and mucous membranes is AW what disorder other than sjogrens?
RA
78
when and only when may you draw an ANTI CCP antibody on your pt?
only after a positive RA factor. if RA negative then its not RA....
79
what lab test is most specific for RA?
Anti CCP antibodies
80
in RA... are ESR and CRP levels elevated?
YES, its inflammatory process
81
in RA is the platelet count elevated or decreased?
elevated
82
____% of deaths in pts w RA is attributed to ______ due to _______ (3 words)
* 40%
* CVD
* small vessel vasculitis
83
initial labs to be drawn on someone you suspect to have RA? 7, maybe 8... not a trick question
```
CBC
CMP
TSH
ESR
ANA
RA factor
uric acid
maybe CRP
(CC TEARum)
```
84
methotrexate was initially used as a ______ drug
cancer, chemo
85
treatment of RA and similar diseases requires high or low doses of methotrexate to be effective?
*lower
86
methotrexate works to decrease ______ and limit ________
* inflam
| * joint damage
87
how often is methotrexate taken?
weekly
88
true of false: methotrexate comes in pill, liquid, and injection form
*true
89
tell me the lab monitoring for methotrexate. what and when
* CBC, CMP
* baseline
* q4-6w for first 3mo
* then q8-12w
90
what blood abnormality does methotrexate cause?
*pancytopenia
| =low count of reds, whites, and platelets (yes I had to google the def lol)
91
methotrexate can cause ______ and ______ failure (hint... this is why we draw a CMP)...
* liver
| * renal
92
other side effects of methotrexate include _____ upset and ____ sores
* GI
| * mouth
93
what other medication is required when prescribing methotrexate? and what is the dose?
* FOLIC ACID
| * 1mg PO daily
94
when you read FOLIC ACID..... what medication are you supposed to remember?
* methotrexate.
| * PTS MUST BE ON SUPPL
95
can methotrexate be combined with other DMARDs?
yes
96
what is the starting dose of methotrexate? (assuming your pt cant get to rheum)
7. 5mg
| * start low and try to maintain low dose
97
what allergy to you think you might want to look out for when prescribing SULFAsalazine?
*sulfa allergy lol
98
what is the other name for sulfasalazine?
azulfidine
99
other than RA what else is sulfasalazine indicated for?
1. ankylosing spondylitis
(AS >> sulfASalazine)
2. IBD (crohn's/UC)
(sulfasalazIne) or (azUlfidine)
100
2 sensory side effects of sulfasalazine, 1 blood one, 1 weird one
*nausea/vom
*photosensitivity
*cytopenia
(one or more blood counts down)
*MAY TINT BODILY FLUIDS ORANGE AND IT STAINS AND DOESNT WASH OUT
101
whats the weird side effect of sulfasalazine?
* may tint Sweat, tears, urine, etc... and it Stains.....
| * S's... think of SulfaSalazine
102
can sulfasalazine be used with other Dmards?
YES
103
how often is sulfasalazine taken?
BID (two S's)
104
whats the other name for hydroxychloroquine?
plaquenil
105
What was plaquenil originally developed for?
malaria
106
what do we use plaquenil for?
SLE
107
what is THE BIG side effect of plauenil?
*retinal damage in higher doses
108
remember the BIG SIDE EFFECT of plaquenil?...... therefore what evaluation do we require before initiating treatment and then YEARLY after?
* SE = retinal damage (in higher doses)
| * opthalmology
109
teach wants us to know plaquenil is not approved to treat _______
covid 19
110
plaquenil can exacerbate what cardiac condition?
CHF. can possibly cause cardiac tamponade
111
plaquenil can possible cause what arrythmia?
*tamponade
| think of it as a topping like red pepper tapenade... "a little plaquinil tamponade please"
112
due to one of the side effects of leflunomide (arava)... what must you screen for prior to intiation?
* elevated LFTs
| * screen for hepatitis (bc how could you know once you start them on the med...)
113
what labs do you need to monitor leflunomide (arava)
* CBC (causes pancytopenia)
| * CMP (monitor LFTS/renal)
114
side effects of azathioprine (imuran)
*N/V
*anorexic effect
*leukopenia
*elevated LFTs
(NALE. thats why we NALED it to the wall and use the newer stuff now)
115
_____ salts (medication for RA) is not commonly used anymore
*gold
116
85% of pts with SLE are ____ what age/gender?
young women
117
the classic butterfly malar rash only occurs in _____% of pts
50%
118
in SLE _______ will be positive on labs along with _______
* ANA
| * anemia
119
HIM are the most common drugs to cause SLE. what are they?
* Hydralazine
* Isoniazid
* minocycline
120
pts with SLE should get retinal exams how frequently?
*annually
121
what is the dose range of hydroxychloroquine?
*200-400
122
hypercoagulability with recurrent arterial &/or venous thrombus = what dx?
anti-phospholipid syndrome
123
your pt has 3 or more miscarriages in the first trimester... what should you test her for?
anti-phospholipid syndrome
124
your pt has recurrent fetal loss after first trimester... you should test them for what?
anti-phopholipid syndrome
125
anti-phospholipid syndrome may ONLY be anticoagulated with which med?
coumadin. old trusty. goal INR 2-3
126
distal ischemia of the fingers due to vasconstriction of the arterioles in response to cold or stress.... what dx am I?
raynaud phenomenon
127
raynauds phenomenon mostly affects what areas?
fingers, toes, nose, ears
128
raynauds occurs in _____% of the popn, mostly _______ age/gender
* 2-6%
| * young women
129
pts with raynauds should avoid what class of meds?
sympathomimetics (nasal decongestants, appetite suppressants, stimulants, bronchodilators...)
130
raynauds responds well to what two classes of meds?
* CCBs
| * vasodilators
131
cervical _______ can be performed for severe and frequent attacks of what disorder?
* sympathectomy
| * raynauds
132
diffuse fibrosis of the skin and internal organs..... what dx am I?
scleroderma
133
what are the two categories of scleroderma? and what is the distribution of pts in these cats?
* limited (80%)
| * diffuse (20%)
134
what does CREST stand for in relation to scleroderma?
```
C = calcinosis cutis (calcium deposits on the skin)
R = raynauds
E = esophageal motility disorder
S = sclerodactyly (thickening and tightening of the skin on the hands)
T = telangiectasia (small, widened blood vessels of the skin)
```
135
in limited scleroderma the hardening of the skin is limited to the ______ & ________s
* face
| * hands
136
diffuse scleroderma involves hardening of the skin to the face and hands AND the ______ and _______s
* trunk
| * proximal extremities
137
what does sclerodactyly mean?
thickening and tightening of the skin on the hands
138
what does telangiectasia mean?
small, widened blood vessels of the skin. gotta google this one prob for a visual.
139
what does calcinosis cutis mean?
calcium deposits on the skin
140
symptoms of diffuse scleroderma include _______, weight loss, and malaise
*polyarthralgia
141
symptoms of diffuse scleroderma include poly_______, weight_______, and _______
* polyarthralgia
* weight loss
* malaise
142
a clinical finding of scleroderma is ulcerations around the ________
*finger tips
143
a clinical finding of scleroderma is _______ of the GI tract due to fibrosis
*hypomobility
144
a clinical finding of scleroderma is pulmonary ______
*fibrosis
145
a clinical finding of sclerdoerma is _____ and ______ crisis due to proliferation of the small arteries
* HTN
| * renal
146
due to damage to the renal arteries what clinical finding would you expect on UA in a pt w scleroderma?
*proteinuria
147
scleroderma results in _______ due to the RBC's experiencing trauma as they attempt to pass thru diseased small arteries
*anemia
148
what is the #1 cause of mortality in pts w scleroderma?
* pulmonary fibrosis
| * pulmonary HTN
149
what are 2 other common cause of death in pts w scleroderma?
* CKD
| * HF
150
due to GI hypomotility, pts w scleroderma might suffer from _______. you can rx a PPI to reduce symptoms
* GERD
| * esophagitis
151
low dose _____ can help increase GI motility in pts w scleroderma
*reglan
152
treat pulm fibrosis ST scleroderma with?
albuterol
o2
nebs
153
polymositis is defined as progressive ______ muscle weakness over _____ to _____
* proximal
| * weeks to months
154
polymoysitis does NOT involve the ______ or ______
* face
| * eyes
155
what effect of polymyositis increases pts risk for aspiration?
*dysphagia
156
muscle _____ and contractures occur _____ in the polymyositis disease process
* atrophy
| * late
157
which muscle related lab is elevated in polymyositis?
CKMB
158
respiratory muscle weakness in polymyositis can lead to ______ retention and thus ________
* Co2
| * mechanical ventilation
159
are you more likely to see polymyositis or dermatomyositis?
*derm
160
what does "mechanics hands mean and what disorder is it a consequence of?
* hyperkeratosis to radial and palmar aspects of hand
| * dermatomyositis
161
a purplish stain over the eyelid is called? and is a consequence of what disorder?
* heliotrope
| * dermatomyositis
162
what labs are elevated in dermatomyositis that may lead a clinical to misdx?
* liver (ALT & AST)
| * might think its hepatitis
163
the rash AW dermatomyositis is ____ red and appears on the _____ region.... and therefore may be mistaken for SLE rash
* dusky
| * malar
164
what does a "shawl sign" mean and what disorder is it AW?
* dusky red rash extending to neck, back, chest wall, and shoulders
* dermato
165
idiopathic inflammatory myopathies include?
* polymyositis
| * dermatomyositis
166
IIM (idiopathic inflam myopathies) labs: H&H high or low? ESR & CRP high or low? ANA positive or negative?
* H&H low- anemia
* ESR & CRP elevated- inflam
* ANA +
167
what is the only specific test for IIMs
muscle biopsy
168
malignancies are more commonly AW poly or dermato?
dermato
169
pt of asian descent w dermato are more prone to what kind of CA?
*nasopharyngeal
170
"westerner" pts w dermato are more prone to what 3 types of cancer?
* lung
* colorectal
* breast
171
caucasian pts w dermato are more prone to what CA?
*ovarian
172
sjogren syndrome occurs mostly in women around what age?
50
173
pts w sjogren's complain of ______ and ______?
* dry eyes
| * cotton mouth
174
_________ is a condition that results from decreased tear production and is AW the sensation of a grain of sand in the eye
*keratoconjunctivitis
175
dry mouth related to sjogren may cause 4 issues. name them
*difficulty speaking
*dysphagia
*dental caries
*parotid enlargement
(dddp)
176
RA factor will be positive in ____% of pts w sjogrens
70
177
ANA will be positive in ______% of pts w sjogrens
95
178
___ biopsy will reveal lumphoid foci in accessory salivary glands. what disorder is this AW?
LIP
| *sjogrens
179
treatment for sjogrens? think of the symptoms...
* artificial tears
* mouth lubricants
* good oral hygiene to prevent dental caries
180
sjogrns is AW increased incidence of what malignancy?
lymphoma
| *specifically non-hodgkins
181
rhabdo is defined as?
*acute necrosis of skeletal muscle
182
ATN stands for ? and is a result of increased myoglobin in a hypovolemic state and is AW what what dx?
* acute tubular necrosis
| * rhabdo
183
rhabdo is AW what causes?
* immobility
* crush injuries
* hypothermia exposure
* statins if pt has compromised liver or kidney
184
what is the treatment for rhabdo?
aggressive IVF
185
vasculitis is defined as?
*inflammation within the walls of affected blood vessels
186
vasculitis involves arteries, veins or both?
all of the above
187
when you encounter vasculitis, first determine the ____ of the vessels involved. then consider what _____ may be affected?
* size of the vessels- large, med or sm?
| * ORGANS
188
read tbls 20-11
bc she loves tables
189
what type of antibodies are present in vasculitis?
*anti-neutrophil cytoplastic antibodies
190
temporal arteritis is diagnosed thru _______ only
*biopsy
191
3 symptoms of temporal arteritis
* HA
* malaise
* vision changes
192
giant cell (temporal artery) arteritis. what inflammatory marker is elevated? and over what number?
* ESR
| * 100
193
temporal arteritis is urgent bc it can cause _____
blindness
194
treatment for temporal arteritis?
*high dose steroids
195
temporal arteritis is urgent and may require admission to ______ until the pt is cleared of ______
* ICU
| * organ involvement
196
giant cell arteritis can lead to _____
*aneurysms
197
in temporal arteritis, ESR returns to normal after about ______ of ______
* one month
| * steroids
198
polymyalgia rheumatica is characterized by?
* many pains
* wide spread
* flu-like s/s
199
_____ (lab) is elevated in polymyalgia rheum
*ESR
200
_______ of chronic disease can also be present in Poly rheum
anemia
201
treatment of poly rheum?
oral prednisone 10-20mg for 6-12mo
202
in poly rheum, when dosing steroids what is the goal?
as low as they can go w symptom control
| *teach says slowly decrease prednisone to 5mg or 2.5mg and then see how they do w/o it
203
polyarteritis nodosa is defined as? what organ does it spare?
* necrotizing arteritis of medium sized vessels
| * LUNGS
204
polyarteritis nodosa is commonly associated with hep ____?
hep B
| *10% of cases
205
labs polyarteritis nodosa: ESR? CRP? ANCA?
* elevated
* elevated
* Negative
206
in polyarteritis angiography will show?
aneurysmal dilations
207
polyartertis is only dx'd by two tests. what are they?
* angiography
| * biopsy
208
treatment for polyarteritis nodosa?
* REFER TO ED if acutely ill
| * high dose corticosteroids- up to 60mg prednisone/day
209
early clues to presence of underlying vasculitis (pre-polyarteritis nodosa)
*mononeuritis multiplex (commonly foot drop) + features of systemic illness
210
s/s polyartertitis nodosa
* fever
* abd pain
* extremity pain
* anemia
211
in psoriatic arthritis _______ precedes arthritis by up to 2y in 80% of pts
psoriasis
212
psoriatic arthritis is symmetrical or asymmetrical? and resembles what other arthritis?
* symmetrical
| * rheumatoid
213
psoriatic arthritis will have an elevated? but a negative?
* ESR
| * rheumatoid factor
214
psoriatic arthritis results in severe deformity of the _____ joints
DIP
215
______ can be added if NSAIDS arent effective for psoriatic arthritis
methotrexate
216
in moderate to severe cases of psoriatic arthritis, what class of meds can be used?
DMARDS
217
nail pitting is a classic sign of which arthritis?
*psoriatic
218
it is essential to do a thorough physical exam for arthritis of new onset to search for what?
psoriasis patch
219
labs of psoriatic arthritis?
* ESR elevated
* HIGH uric acid
* reduced iron stores
220
your pt has psoriatic arthritis. what is your plan?
start NSAIDS and refer to rheum. start methotrexate if needed at 7.5mg weekly
221
acute onset of inflammatory monoarticular arthritis, swelling and pain often in weight bearing joints is indicative of?
septic arthritis
222
WBC of synovial fluid in septc arthrtis is usually over _____? and can be up to____?
* 50k
| * 100k
223
do we encourage or discourage "tapping" of septic arthritis in the hand?
NO MAAM/SIR. DONT FKN DO IT
224
what pathogen is responsible for 50% of septic arthritis cases?
staph aureus
225
septic arthritis.... what test do we get to look for bony erosion?
CT or MRI
226
osteomylitis...
* bone infection
* Ct or MRI will show extension of bone involvement
* elevated ESR
* debride necrotic bone and give IV ABX
227
drug of choice for fibro?
lyrica... check the forum too
228
most common site of osteonecrosis is the?
Proximal and distal femur heads
229
treatment for osteonecrosis?
* vascularized and non vascularized bone grafting procedures.
* total hip replacement is usually needed
