Week 13 Rheumatology Flashcards
1
Q
osteoarthritis
A
- progressive degenerative joint disease
- degeneration of the hyaline cartilage layers in the joints from repetitive use or repetitive trauma
- increasing thickness in the growth plate.
- mono-articular or poly-articular
- asymmetric
- not a systemic disease
- women
- > 50 yrs, obese
2
Q
OA sx’s
A
- gradual onset of symptoms.
- joint pain, stiffness, swelling, tenderness
- fingers, shoulder, hip, knee, or ankle.
- minimal stiffness in the morning → lasts 30
- no redness or warmth
- functional impairment
- gel phenomenon stiffness (“car” moves better when warmed up)
- Pain worse later in the day and after activity, relieved by rest
3
Q
deformities of OA
A
- in OA
- hard bony swellings
- Heberden nodes in DIP joints
- Bouchard’s nodes in PIP joints
- Changes in carpometacarpal (CMC) joint common - base of thumb
4
Q
OA diagnosis
A
- NO xray except for considering joint replacement [xray normal in early stages]
- mod - severe → xray shows joint space narrowing
- osteophyte
- no lab testing
5
Q
OA management
A
- early OA:
- # 1: acetaminophen
- exercise - aerobic
- educate nature of disease
- physical therapy
- tai chi, stretching
- 2nd line: NSAID
- gi bleeding
- CVD
- mod - severe: tramadol
- joint replacement
- corticosteroids
5
Q
what is the grind test?
A
- CMC test
- if pain and crepitus with passive ROM of the thumb
- specific to OA
6
Q
rheumatoid arthritis (RA)
A
- systemic inflammatory arthritis
- Autoimmune
- Often viral trigger
- Leads to erosions of cartilage and bone → deformity
- increases with age
- Women >
7
Q
RA Sx’s / Exam
A
- bilateral & symmetric
- initially in small joints of hands (MCP, PIP), wrists, small joints of feet
- hips, knees, ankles, shoulders, cervical spine
- Morning stiffness lasting longer than 1 hour = inflammatory
- warmth, tenderness, decrease ROM, boggy swelling
- pain and stiffness worse in the morning & better with activity.
- 1st sx → joint pain/stiffness → then systemic symptoms like fatigue, weight loss, numbness and tingling in the hands.
8
Q
rheumatoid factor lab value for RA
A
- Early on in RA, RF can be negative but after 6 months, can be positive for RF
- RF can be elevated in viral hepatitis, lupus, sjogren’s disease
- CCP antibody has higher sensitivity early on in the dz
- Higher than RF in 3 months
9
Q
deformities of RA
A
- Boutonniere: non reducible flexion of the PIP joint; hyper extension of the DIP joint
- Swan neck deformity: hyper extension of the PIP joint with flexion of the DIP joint.
- Result of synovitis stretching, the rupturing the PIP joint through the central extensive tendon.
- subcutaneous nodules over pressure points
10
Q
RA diagnostics
A
- Inflammatory markers = disease activity
- CBC
- Rheumatoid factor
- ANA is usually negative.
- Anti-cyclic citrullinated peptide and anti-mutated citrullinated vimentin
- more sensitive for detecting/diagnosing RA
- develop earlier in the disease process vs RF
- # 1: X-ray
- show articular erosions, osteopenia, and joint space narrowing.
- soft tissue swelling
- ACR classification
- score 6 out of 10 diagnostic of RA
11
Q
RA management
A
-
Assess/manage cardiovascular risk factors yearly
- Leading cause of death
- Screen for infection (TB, hepatitis before starting treatments)
- Immunizations
- Screen osteoporosis, depression
- Non-pharm
- Ice heat
- PT, OT
- aerobic exercises, muscle strength
- improve QOL and reduce structural joint damage
- once dx → refer to rheumatology
12
Q
RA Treatment
A
- First line: methotrexate (DMARDs)
- Early treatment best
- other meds: leflunomide or sulfasalazine
- 2nd line: Biologic if can’t tolerate the DMARD
- DMARD are teratogenic (counsel conception)
- NSAID caution if hx GI bleeding (use Tylenol instead)
13
Q
Psoriatic arthritis
A
- inflammatory arthritis with dermatologic conditions of psoriasis
- 30-50 yrs old men & women
14
Q
Psoriatic arthritis sx’s
A
- DIP joints
- NO MCP involvement
- usually 5 or more joints affected
- asymmetric
- skin rash before onset of psoriasis
- dactylitis - sausage digits
- uveitis
- Enthesitis - inflammation at site where tendon inserts (Achilles tendon or plantar fascia)
- nail pitting (before rash), onycholysis, cracking
15
Q
psoriatic arthritis diagnostics
A
- if have joint inflammation with no rheumatoid factor + typical psoriatic and nail lesions = Caspar CRITERIA
- 3+ suggestive of PA
- Sed rate
- CRP
- Negative ANA
- Negative rheumatoid factor
- Uric acid
- Lipid profile
- HLA allele
- inflammatory markers elevated
- IgA can be elevated in up to 2/3 of patients.
- X-ray confirms
- erosions, osteolysis, and deformities
- Ultrasound/MRI
16
Q
Psoriatic arthritis management
A
1st line: NSAID but most need 2nd line DMARDs (methotrexate, sulfasalazine, leflunomide, azathioprine)
- Refer → rheumatology and dermatology.
- healthy lifestyle, weight loss, exercise, smoking cessation
- PT and OT
- acupuncture and massage
- screen for comorbidities
- higher risk cardiovascular disease.
- BP; diabetes screen
- higher risk cardiovascular disease.
- screen hepatitis and TB prior to the initiation of immunosuppressants
- screen depression.
17
Q
ankylosing spondylitis
A
- chronic inflammatory condition
- inflamed → bone erosion → spur formation
- fusion of bones in spine = bamboo spine
- Doesn’t affect distal joints (hands or wrists), but CAN affect knees, hips, shoulders
- involves the sacroiliac joint and the spine.
- Peaks 20 and 30
- genetics; positive for the HLA-B27 gene.
18
Q
ankylosis spondylitis sx’s
A
- 1st sx: low back pain/butt pain
- deep aching pain in gluteal area and SI joint
- TMJ, costosternal
- uveititis
- Stooping posture
- decreased chest expansion
- enthesitis
- worse in the morning/night
19
Q
ankylosis spondylitis diagnosis and workup
A
- To dx: pain > 3 months
- sacrolitiis on imaging + 1 or more SpA features or + HLA-B27 + 2 more
- Fever and weight loss
- workup
- CRP and sed rate elevated
- RA negative
- mild anemia (CBC)
- x ray not needed
22
Q
Juvenile idiopathic arthritis on exam
A
- enthesitis
- uveitis
- positive ANA
- can be asymptomatic (TMJ/jaw)
- swelling of joint with effusion
- warmth over inflamed joint, tenderness
- loss of ROM → limp
- nail pits, onycholysis
- fleeting salmon color rash on trunk
- ciliary eye injection → uveitis
26
Q
systemic lupus erythematosus ROS
A
- chronic multi system inflammatory rheumatic disease
- most common symptom: cutaneous, musculoskeletal, and hematologic.
- skin - malaria / butterfly rash over cheeks, spares nasal labial fold
- erythematous lesion on hard palate
- Alopecia
- Joint pain (90%) bilateral (non erosive arthritis)
- kidney involvement first presentation in 15% of patients.
- Chest pain or dyspnea.
- General: fever, anorexia, malaise, weight loss
- Skin: malar/butterfly rash, photosensitivity, alopecia
- Vascular: Raynaud’s phenomenon
- Stress, cold exposure
- Numbness and tingling
- Pale
- MSK: joint pain
- Eye: conjunctivitis, photophobia
- Pulmonary: pleurisy, pleural effusion, pneumonitis
- Cardiac: pericarditis, myocarditis, endocarditis
- Lymph: lymphadenopathy
- Neuro/psych: stroke, neuropathies, depression
- Renal: proteinuria from glomerulonephritis
- GYN: Recurrent Spontaneous Abortion/fetal loss
- Gingivitis, mucosal hemorrhage, erosions, ulcerations
29
Q
polymyalgia rhematica (PMR)
A
- Systemic inflammatory
- caucasian women
- peaks 70-80s
- stiffness that lasts > 1 hr after rest for > 2 weeks
- non erosive, asymmetric, highly responsive to systemic corticosteroids
- aching, painful ROM, stiffness in the bilateral shoulders, neck, and hips (LARGER joints)
- systemic symptoms,
- fever, malaise, or weight loss.
- develop giant cell arteritis
- inflamed arteries
- medical emergency! sudden blindness
32
Q
fibromyalgia risk factors
A
- abnormal pain processing in the nervous system and abnormal stress response access
- Persistent widespread pain;
- chronic fatigue
- deep ache in muscles pain, fatigue, and trouble sleeping
- generalized burning and tingling.
- Risk factors
- Females
- Middle age
- family history.
- Trauma
- Stress on body
- irritable bowel syndrome
33
Q
fibromyalgia work up & management
A
- Lab testing is not needed
- Dx:
- sx’s for least 3 month
- have 11 tender points out of 18
- Use widespread pain index > 7 and sx severity > 5
- no other disorders
- Reassure nothing is being damaged in body; body is sensing pain
- 1st line: exercise
- low impact - swimming
- Pharm
- Amitriptyline, Cyclobenzaprine
- SSRI - fluoxetine, duloxetine
- gabapentin, pregabalin
- trazodone - sleep
- Cognitive Behavioral Therapy
- coping skills
- relaxation
- visual imagery
- Acupuncture
- massage therapy
- group therapy
37
Q
tophi
A
- Subcutaneous nodules
- Monosodium crystals mixed with lipids and proteins
- May not even be seen but be seen on imaging study
- Can also be in MTP and olecranon
- Resolve urate lowering therapy
- large → surgery
38
Q
gout diagnostics
A
- dx: joint needle aspiration of inflamed joint/tophus
- US → double contour sign or rate icing
- criteria: 8 or more = diagnosis of gout
- xray → advanced gout
