Immunology: - Response to defend against attacks by "_______ _______". - Immunity is provided by _______ cells. - Immune disorders are classified as what (4) things?

- "foreign invaders" - lymphoid cells - Autoimmune , immunodeficiency, hypersensitivity, and immunoproliferative disorders

Soft Tissue/Joint Pain: - Specific joints affected. - What joints are affected with RA? - What joints are affected with Psoriatic Arthritis?

- RA = wrist and proximal small joints of hands and feet - Psoriatic Arthritis = distal joints of hands and feet

Autoimmune Disorders Overview: - When do autoimmune disorders occur? - Body manufactures _________ directed against the body's own cellular components or specific organs. - What does this result in? - Is the exact cause known?

- Occurs when the immune system fails to distinguish self from non-self and misdirects immune response against body's own tissues. - autoantibodies - Results in abnormal tissue reaction and tissue damage. - Exact cause not well understood.

Fibromyalgia: - What is fibromyalgia? - Is it more common in men or women? - Recent evidence suggests that chronic pain is _______ _______. - The new set of diagnostic criteria to diagnose fibromyalgia focuses on measuring ____________ rather than relying on tender point examination alone. - ___/___ tender points to diagnose as fibromyalgia.

- Noninflammatory condition appearing with generalized MSK pain with associated tenderness to palpation in a large number of specific areas. - Women > Men - CENTRALLY MEDIATED - symptom severity - 11/18

Rheumatoid Arthritis (RA): - _______, _______, _______ disorder. - Is it more common in men or women? - Most common between ages ___-___. - What is the cause? - Affects various organs but predominantly ________ tissues of _______ joints.

- Chronic, systemic, inflammatory disorder. - Women > Men (2-3x) - 20-40 - Unknown cause (support for genetic predisposition) - synovial tissues of synovial joints

- Swelling in 1 or more joints - Early morning stiffness (>1hr) - Recurring pain/tenderness in any joint (MTP, MCP) - Inability to move joint normally - Obvious redness and warmth in joint - Unexplained weight loss, fever, or weakness combined w/ joint pain - Symptoms lasting >2 weeks

RA Referral/Diagnosis: - Why is early referral/diagnosis important in RA? - What are some early inflammatory symptoms of RA? (3)

-Studies show 70-90% of people with RA have SIGNIFICANT JOINT EROSION 2 YEARS AFTER ONSET. 1. ) Significant discomfort with compression of metacarpal and metatarsal joints. 2. ) Presence of 3 or more swollen joints. 3. ) More than 1hr of morning stiffness.

RA Hands/Feet: - ________ pain often first complaint. - ________-____ deformities. - ______ ________ of MCP joint and ulnar deviation. - _____ ______ and __________ deformities may also be present.

- Forefoot pain - Hammer-toe - Volar subluxation - Swan Neck and Boutonniere Deformities

RA Cervical Spine: - _________ may be reported in early onset of disease. - ___-___ laxity secondary to inflammation of ligaments. (Occurs more often _____ in disease) - Could result in _________ _________ with resultant spinal cord compression.

- Neck stiffness - C1-C2 laxity (late in disease) - atlantoaxial subluxation

Week 12- Screening for Immunologic Disease Flashcards by Chance Lee Cauble

PART 1

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Immunology:

Response to defend against attacks by “_______ _______”.
Immunity is provided by _______ cells.
Immune disorders are classified as what (4) things?

“foreign invaders”
lymphoid cells
Autoimmune*, immunodeficiency, hypersensitivity, and immunoproliferative disorders

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What are some questions to ask during the patient interview if immune disorder is suspected?

How long have you had this problem? (chronic and repetitive)
Has the problem gone away then recurred? (cyclical pattern)
Have additional symptoms developed or have other areas become symptomatic over time?

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_________ may be the only risk factor for immunologic disease.

Family Hx

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Immunologic Disease S/Sx. (7)

Soft tissue/joint pain***
Stiffness***
Swelling***
Generalized weakness***
Constitutional symptoms***
Raynaud’s phenomenon***
Sleep disturbances***

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Soft Tissue/Joint Pain:

Specific joints affected.
What joints are affected with RA?
What joints are affected with Psoriatic Arthritis?

RA = wrist and proximal small joints of hands and feet

- Psoriatic Arthritis = distal joints of hands and feet

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Stiffness:

Marked by prolonged stiffness >_____.
What is the gel phenomenon?

> 1 hour

- Gel phenomenon = Symptoms relieved with activity but recurs after sitting and then attempting to continue activity.

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What would we do if we note a cluster of S/Sx associated with immunologic disease?

Immunologic ROS

- Rheumatologic ROS

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PART 2: IMMUNE SYSTEM PATHOLOGIES

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Immune System Pathologies. (11)

Fibromyalgia
Rheumatoid Arthritis (RA)
Polymyalgia Rheumatica
Scleroderma
Systemic Lupus Erythematosus (SLE)
Ankylosing spondylitis (AS)
Reiter’s syndrome or reactive arthritis (ReA)
Psoriatic arthritis (PsA)
Multiple Sclerosis (MS)
Guillain-Barre Syndrome (GBS)
Myasthenia Gravis (MG)

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Autoimmune Disorders Overview:

When do autoimmune disorders occur?
Body manufactures _________ directed against the body’s own cellular components or specific organs.
What does this result in?
Is the exact cause known?

Occurs when the immune system fails to distinguish self from non-self and misdirects immune response against body’s own tissues.
autoantibodies
Results in abnormal tissue reaction and tissue damage.
Exact cause not well understood.

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Fibromyalgia:

What is fibromyalgia?
Is it more common in men or women?
Recent evidence suggests that chronic pain is _______ _______.
The new set of diagnostic criteria to diagnose fibromyalgia focuses on measuring ____________ rather than relying on tender point examination alone.
___/___ tender points to diagnose as fibromyalgia.

Noninflammatory condition appearing with generalized MSK pain with associated tenderness to palpation in a large number of specific areas.
Women > Men
CENTRALLY MEDIATED
symptom severity
11/18***

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Fibromyalgia S/Sx. (5)

Aches and pains
Stiffness
Swelling in soft tissue
Tender points
Muscle spasms or nodules

-Fatigue, morning stiffness, and sleep disturbances may be present but not necessary for diagnosis.

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Rheumatoid Arthritis (RA):

_______, _______, _______ disorder.
Is it more common in men or women?
Most common between ages ___-___.
What is the cause?
Affects various organs but predominantly ________ tissues of _______ joints.

Chronic, systemic, inflammatory disorder.
Women > Men (2-3x)
20-40
Unknown cause (support for genetic predisposition)
synovial tissues of synovial joints

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RA S/Sx. (7)

Swelling in 1 or more joints
Early morning stiffness (>1hr)
Recurring pain/tenderness in any joint (MTP, MCP)
Inability to move joint normally
Obvious redness and warmth in joint
Unexplained weight loss, fever, or weakness combined w/ joint pain
Symptoms lasting >2 weeks

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What is a mnemonic to remember RA S/Sx?

SERIOUS

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RA Referral/Diagnosis:

Why is early referral/diagnosis important in RA?
What are some early inflammatory symptoms of RA? (3)

-Studies show 70-90% of people with RA have SIGNIFICANT JOINT EROSION 2 YEARS AFTER ONSET.

) Significant discomfort with compression of metacarpal and metatarsal joints.
) Presence of 3 or more swollen joints.
) More than 1hr of morning stiffness.

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RA Hands/Feet:

________ pain often first complaint.
________-____ deformities.
______ ________ of MCP joint and ulnar deviation.
_____ ______ and __________ deformities may also be present.

Forefoot pain
Hammer-toe
Volar subluxation
Swan Neck and Boutonniere Deformities

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RA Cervical Spine:

_________ may be reported in early onset of disease.
___-___ laxity secondary to inflammation of ligaments. (Occurs more often _____ in disease)
Could result in _________ _________ with resultant spinal cord compression.

Neck stiffness
C1-C2 laxity (late in disease)
atlantoaxial subluxation

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RA Shoulder:
-Chronic synovitis may result in limitations of shoulder ROM, dislocation, or spontaneous tears of the ___________ or ________________.

RA Elbow:
-Destruction or articulation may result in ________ contracture, loss of ________/_______, subluxation or _______ nerve neuropathy.

RA Wrist:
-Frequently affected and may result in _________ muscle atrophy, _______ or __________ (due to volar synovitis).

rotator cuff or adhesive capsulitis
flexion contracture, loss of supination/pronation, subluxation, or ulnar nerve neuropathy
interosseous muscle atrophy, ankylosis or carpal tunnel syndrome

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What are some extraarticular manifestations of RA? (6)

Rheumatoid nodules
Arteritis (inflammation of artery walls)
Neuropathy
Scleritis (inflammation of sclera)
Pericarditis
Splenomegaly

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Diagnosis is made if the patient has __/__ of what criteria?

-4/7

) Morning stiffness
) Arthritis of 3 or more joints
) Arthritis of hands
) Symmetric arthritis
) Rheumatoid nodules
) Serum rheumatoid factor
) Radiographic changes

Polymyalgia Rheumatica:

_______, rheumatic inflammatory disorder with unknown cause.
Occurs almost exclusively in people >___.
Is it more common in men or women?
What patient population is it predominantly in?
Characterized by severe ______ and _________ primarily in the _______ as opposed to the joints.

Systemic
> 50
Women > Men (2x)
Caucasian population
severe aching and stiffness primarily in muscles

Polymyalgia Rheumatica S/Sx. (8)

Muscle pain or aching (proximal muscle groups)***
Stiffness upon arising in the morning or after rest***
Weakness, fatigue, malaise
Low-grade fever, sweats
HA
Weight loss
Depression
Vision changes

Polymyalgia Rheumatica: - Condition is _____-________. - Typically lasts __-__ years. - What is used to suppress inflammation, treat symptoms and provide remission but does not cure? - Important for PTs to be aware of the possibility of _______-_______ osteopenia and _______. - Most pts with this condition do not have lasting effects with medical intervention.

- self-limiting - 2-3 years - oral corticosteroids - steroid-induced osteopenia and DM

Scleroderma: - Chronic _________ disease. - Characterized by _________ and _______ of many body parts including skin, blood vessels, synovium, skeletal muscle, and certain internal organs. - What are the (2) main categories of scleroderma? - Who is it more common in?

- multisystem - inflammation and fibrosis - limited cutaneous scleroderma, diffuse cutaneous scleroderma - young/middle-aged women

Limited Scleroderma: - Characterized by long hx of _________ phenomenon. - Skin thickening is limited to _____. - Esophageal ________ is common.

- Raynaud's phenomenon - limited to hand - esophageal dysmotility

Diffuse Scleroderma: - More _______ onset. - Many constitutional symptoms, arthritis, carpal tunnel and marked swelling of hands and legs. - Wide-spread skin thickening occurs and progresses from ________ to _______. - _____________ problems are common (GI effects and pulmonary fibrosis common, severe life-threatening involvement of heart/kidneys occurs)

- acute onset - from fingers to trunk - internal organ

Limited Cutaneous Scleroderma S/Sx. (5)

- Calcinosis - Raynaud's Phenomenon - Esophageal dysmotility, dysphagia, heartburn - Sclerodactyly (thickening of skin of digits of hands and feets) - Telangiectasia (dilated/broken blood vessels near surface of skin) CREST***

Diffuse Cutaneous Sclerosis S/Sx. (6)

- Raynaud's Phenomenon - Trunk and extremity skin changes - Ulceration of fingers - Polyarthralgia - Flexion contractures of large and small joints - Visceral involvement

Systemic Lupus Erythematosus (SLE): - In family of _________ _______ disease. - Chronic, systemic, inflammatory condition affecting skin, joints, kidneys, heart and blood-forming organs, nervous system and mucous membranes. - What is the most common characteristic of SLE? - What are the (2) primary forms of SLE?

- autoimmune rheumatic diseases - butterfly rash across cheeks/nose - discoid lupus, systemic lupus

SLE Risk Factors: - Appears to be result of ___________ disturbance caused by interplay of genetic, hormonal, chemical, and environmental factors. - ___________ factors that may trigger include infections, antibiotics/other medications, exposure to UV (sun) light and extreme physical/emotional stress. - There is a known genetic predisposition but no known gene associated with SLE. - Most common in ___-___ years of age. (can occur at any age) - Are men or women affected more?

- immunoregulatory disturbance - environmental factors - 15-40 years - Women > Men (10-15x)

SLE S/Sx. (12)

-Arthralgia*** -Arthritis*** -Constitutional symptoms (low-grade fever & fatigue) -Skin rash (malar) -Pulmonary involvement -Anemia -Kidney involvement -Sun or light sensitivity -Hair loss -Raynaud's phenomenon -Nervous system involvement Mouth, nose, or vaginal ulcers

Spondyloarthropathy: - Group of __________, _________, _________ rheumatic diseases. - What does it target? - Is it more common in men or women? - What are the (3) main types?

- noninfectious, inflammatory, erosive rheumatic diseases - Targets SI, bony insertion of annulus fibrosis of IV discs and facet joint - Men > Women - ankylosing spondylitis, Reiter's syndrome, Psoriatic arthritis

What are the (3) main types of spondyloarthropathy?

- Ankylosing Spondylitis - Reiter's Syndrome - Psoriatic Arthritis

Ankylosing Spondylitis: - _______, _________ inflammatory disorder of undetermined cause. - Inflammation of fibrous tissue affected insertions of _______/______/_______ into bone resulting in what? - What areas are primarily affected? (3)

- chronic, progressive, inflammatory - ligaments/tendons/capsules, results in fusion over time - SI, spine, and large peripheral joints

Ankylosing Spondylosis Early Stage S/Sx. (5)

- Intermittent LBP*** - Sacroiliitis*** - Spasm of paravertebral muscles*** - Loss of normal lumbar lordosis*** - Painful limitation of cervical joint motion***

Ankylosing Spondylosis Advanced Stage S/Sx. (4)

- Constant LBP*** - Loss of normal lumbar lordosis*** - Ankylosis of SI joints and spine*** - Muscle wasting in shoulder and pelvic girdle***

What are some complications of ankylosing spondylitis? (6)

- Prone to fracture from even minor trauma - Most common fracture site is lower cervical spine - Myelopathy - Spondylodiscitis (erosive & destructive lesions of vertebral bodies) - Cauda-equina syndrome - Spinal stenosis

Reiter's Syndrome: - Characterized by what triad? - Type of ________ arthritis. - Occurs mainly in young adult _____ ages ___-___.

- Triad of arthritis, conjunctivitis, and nonspecific urethritis - reactive arthritis - young adult men ages 20-40

Reiter's Syndrome S/Sx. (11)

- Plantar fasciitis*** - Polyarthritis - SI joint changes - Low back and buttock pain - Small joint involvement - Low-grade fever - Urethritis - Conjunctivitis and iritis, bilaterally - Skin involvement (resembling psoriasis) - May be preceded by bowel infection - Anorexia and weight loss

What are the (3) ways we can differentiate Reiter's Syndrome from Ankylosing Spondylitis?

1. ) Presence of urethritis and conjunctivitis. 2. ) Prominent involvement of distal joints. 3. ) Presence of asymmetric radiologic changes in SIJ and spine.

Psoriatic Arthritis (PsA): - ________, _________, erosive, inflammatory arthritis. - Associated with skin disease _________. - Does it affect men or women more? - Can occur at any age but usually ___-___. - Arthritis is usually preceded by _____ condition. - Causes and risk factors are unknown.

- Chronic, recurrent, erosive, inflammatory - skin disease psoriasis - Affects both genders equally - 20-30 - skin condition

Psoriatic Arthritis S/Sx. (6)

- Fever - Fatigue - Polyarthritis - Psoriasis - Sore fingers - Unique clinical features of PsA (DIP joint involvement, nail changes, dactylitis, spondylitis, iritis)

Multiple Sclerosis (MS): - Most common _________ ___________ disease of the CNS. - Affects areas of brain and spinal cord. - Symptoms appear between ___-___ years. - Does it affect men or women more? - __________ increases risk 10x. - 5x more prevalent in ______ climates of NA and EU. - Characterized by _________ _______ lesions that form scars (plaques) scattered in CNS white matter.

- inflammatory demyelinating disease of the CNS - 20-40 - Women > Men (2x) - Family Hx - colder climates - inflammatory demyelinating lesions

MS S/Sx. (16)

Symptoms (highest to lowest occurrence) - Unilateral visual impairment - Paresthesias - Ataxia - Vertigo - Fatigue - Muscle weakness - Bowel/bladder dysfunctions - Speech impairment Signs (highest to lowest occurrence) - Optic neuritis - Nystagmus - Spasticity or hyperreflexia - Babinski’s sign - Absent abdominal reflexes - Dysmetria or intention tremor - Labile or changed mood - Lhermitte’s sign (shock-like sensation in flexion)

Guillain-Barre Syndrome (GBS): - AKA _____ _________ _________ - _____, _______ autoimmune disorder. - Demyelination of _______. - Characterized by abrupt onset of _______. - Not related to race, sex, or age. - Exact cause unknown but frequently occurs after an _______.

- Acute Idiopathic Polyneuritis - acute, acquired - PNS - paralysis - illness

GBS S/Sx. (5)

- Muscular weakness (bilateral, progressing from legs and arms to chest and neck) - Diminished DTR - Paresthesias (w/o loss of sensation) - Fever, malaise - Nausea

Myasthenia Gravis (MG): - Develops when antibodies produced by immune system block receptors in muscles that receive signals of _______. - What does this result in? - What are the two peaks of onset?

- ACh (acetylcholine) - Impaired muscle function - 20-30 years, after 50 years

MG S/Sx. (9)

Muscle fatigue and proximal muscle weakness aggravated by exertion*** - Respiratory failure - Ptosis - Diplopia - Dysarthria - Alteration in voice quality - Dysphagia - Nasal regurgitation - Choking, difficulty in chewing

Clues to Immune System Dysfunction: - Insidious onset of episodic back pain in patient younger than 40 with family history of spondyloarthropathy. (_________) - Joint pain preceded or accompanied by burning and urinary frequency (urethritis) and/or accompanied by eye irritation. (_________) - Joint pain preceded or accompanied by a skin rash or lesions. (___________) - Development of neurological symptoms 1-3 weeks after infection. (___________)

- ankylosing spondylitis - Reiter's syndrome - Psoriatic Arthritis - GBS

Guidelines for immediate medical attention? (3)

- Dusky blue discoloration or erythema with exquisite tenderness in a joint - Evidence of spinal cord compression - Presence of incontinence in pt with AS

Guidelines for MD referral? (3)

- New onset of joint pain within 6 weeks of surgery accompanied by constitutional symptoms. - Symmetric swelling and pain in peripheral joints. - Development of progressive neurologic symptoms within 1-3 weeks of previous infection or recent vaccination.