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NURP 532 > Week 13 Rheumatology > Flashcards

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
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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
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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
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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
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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
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5
Q

what is the grind test?

A
  • CMC test
    • if pain and crepitus with passive ROM of the thumb
  • specific to OA
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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 >
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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.
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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
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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
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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
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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
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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)
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13
Q

Psoriatic arthritis

A
  • inflammatory arthritis with dermatologic conditions of psoriasis
  • 30-50 yrs old men & women
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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
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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
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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
  • screen hepatitis and TB prior to the initiation of immunosuppressants
  • screen depression.
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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
20
Q

ankylosis spondylitis management

A
  • First line: NSAIDs
  • NO DMARDs
  • non pharm same as psoriatic arthritis
  • heat, massage
  • biologic anti-TNF agents if NSAIDs don’t work
    • etancercept
    • infliximab
    • adalimumab
    • glolimumab
21
Q

most common type of juvenile idiopathic arthritis

A

Oligoarticular

  • onset < 16 yrs old
  • involves < 5 joints (usu knee or ankle)
  • limited ROM
  • systemic: fever
  • persisting 6 weeks or longer
  • pain stiffness of joints
  • morning limp
  • positive ANA
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
23
Q

Juvenile idiopathic arthritis diagnostics

A
  • dx of exclusion
  • HLA B27
  • negative lab markers
  • CBC, ESR, CRP
  • lyme testing
  • LFT
  • at least 1 joint for over 6 wk period and r/o other causes
24
Q

Juvenile idiopathic arthritis management

A
  • Refer
  • if polyarticular arthritis → DMARDs
    • methotrexate, sulfasalizine, and hydrochloroquine
  • Oligoarthritis → NSAID or corticosteroid injection
  • child with poly or oligo → higher risk of uveitis = MORE FREQUENT EYE EXAMS!
  • monitor growth, leg length discrepancy, osteopenia, immunizations
  • PT/OT
25
Q

Polyarticular destructive athritits

A
  • 5 + joints
  • uveitits
  • slow growth, fatigue
    • ANA, mild anemia
    • RF
  • NSAIDs, DMARDs (methotrexate), opthalamology referral, nutrition
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
27
Q

SLE diagnostics

A
  • ANA (anti-nuclear antibodies).
    • 94% positive ANA with lupus
    • high false positives = doesn’t mean + for Lupus & can be elevated for other reasons
  • Antibody testing for double stranded DNA
  • Anti-Smith Antibody
  • Anti-RNP antibody
  • ANti-Ro and anti-La
  • leukopenia/lymphopenia, anemia, thrombocytopenia common
  • proteinuria/hematuria
28
Q

SLE management

A
  • refer → rheumatology, nephrology
  • Educate healthy lifestyle, diet, exercise, sunscreen
  • NSAIDs → joint pain, fever, serositis (monitor)
  • Hydroxychloroquine (Plaquenil) → MK, cutaneous, serosal sx’s
    • reduce organ damage
    • adjunct with antiphospolipid syndrome
    • ophthalmology checks
    • Belimumab
  • Low dose corticosteroids → for skin lesions & joint pain
  • Monitor BP (inc CVD risk), bone health (osteoporosis) → Ca, Vitamin D
  • DMARDs, biologics
  • Antibiotic prophylaxis before dental, GU, invasive procedures (inc risk infective endocarditis)
29
Q

Lupus risk factors

A

women

asian, black, hispanic women

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
30
Q

polymyalgia rheumatica workup

A
  • CBC → anemia, leukocytosis
  • elevated ESR/SED rate to 20%
  • no specific that dx
  • Liver function tests
  • TSH
  • UA
  • RF and/or anti-cyclic citrullinated peptide antibodies
  • ANA negative
31
Q

PMR managment

A
  • low dose oral prednisone daily
    • rapid response in 1 week; taper after 4-8 wks of therapy
  • NO NSAIDS
  • monitor pain, morning stiffness, OP, alternative dx
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
34
Q

Acute gout risk factors & sx’s

A
  • common inflammatory arthritis
  • Risk factors
    • Men
    • Diet high in purines (red meats, sea food, alcohol, fructose)
    • Comorbidities
      • HTN, Obesity, CVD, DM, diuretic use, menopause, renal disease, elevated trigs and LDL
  • Sx’s
    • hyperuricemia
    • sudden gout flares MTP joint (big toe) → podagra
      • painful, warmth, redness, swellings
  • No systemic sx’s
35
Q

4 stages of gout

A
  1. Asymptomatic hyperuricemia
    * Deposit in blood when > 6.8 uric acid
  2. Acute gout
  • Monoarticular (1st toe in joint)
  • Ankle, knees
  • Uncommon in axial joints
  1. Intercritical or interval gout
  • Periods between gout attacks
  • Affect more than 1 joint
  • Attacks longer and more severe
  • Uric acid can persists in joint; joint erosion over time
  1. Chronic tophaceous gout
  • Years
  • Tophi
  • Structural joint damage
  • Bone erosion
  • Disabilitng arthritis
36
Q

majority (80-90%) of those with hyperuricemia

A

never go on to develop gout flare

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
39
Q

Gout management

A
  • NSAID - w/o no comorbidities
    • For early attack first 24 hrs
    • improve in 2-3 days, resolve day 10
  • Oral systemic corticosteroids
    • Taper over 10-14 days to prevent rebound
  • Intra Articular corticosteroids injection
    • 1 time injection
    • Only if it’s 1 or 2 joints
  • Oral Colchicine
    • 2 doses in 1 day
    • Less effective if started > 36- 48 hrs of sx onset
    • Don’t give if GFR < 10
    • Renally dose if GFR < 50
  • continue urate lowering therapy (ULT)
  • Non pharm
    • Weight loss
    • Avoid diuretics
    • DASH diet
    • Avoid fructose
    • Limit purine, carbs
    • increase protein, unseat fats
    • Encourage vegetables and low-fat dairy
    • Limit alcohol
    • Topical ice
40
Q

most therapeutic success of gout attack is

A
  • how soon NSAID therapy started at appropriate dose and duration of therapy
  • resolves 5-8 days of starting
  • but avoid NSAID in PUD, impair renal, liver dz, CHF, anticoagulant therapy, elderly
41
Q

when to start urate lowering therapy?

A
  • Start therapy after 2 + attacks a year or even 1st flare 6-8 wks after flare resolved
  • don’t START ULP during acute attack but if already on, CONTINUE it
  • Start low then tirate up
  • goal: uric acid lvl: < 6
    • check levels SU lvls q 3-6 months
  • Xanthine oxidase inhibitors
    • Allopurinol
    • Febuxostat
  • Probenecid
42
Q

prophylaxis of ULT

A
  • continuous use of anti-inflammatory drugs to prevent gout flares
    • allopurinol AND:
    • low dose oral colchicine or NAID with PPI or low dose prednisone
  • continue prophylaxis until SU value < 6 and no acute attacks for 3-6 months
    • warn discontinuation can cause exacerbation of acute flares

NURP 532 (13 decks)

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