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1

3 stages of Primary Gout

1) Hyperuricemia
2) Acute Gouty Arthritis
3) Chronic Tophaceous Gout

2

-Deposits of urate crystals under skin
-Other major organs (renal)
-Kidney stone formation
-3-40 years after acute episode
-Uncommon in US

Chronic Tophaceous Gout

3

-Sodium urate deposited in synovium
-Excruciating pain
-Inflammation in small joints, usually great toe (podagra)

Acute Gouty Arthritis

4

Most common inflammatory arthritis in older adults

Gout

5

-May be genetic X-linked
-Inborn errors of purine metabolism
-Production of uric acid exceeds excretion

Primary Gout

6

-Excessive uric acid in the blood caused by another dz
(Renal insufficiency, crash diets, diuretics, chemo)

Secondary Gout

7

Allopurinol pt instructions

Take after meals with a glass of water to prevent GI distress

8

DOC for Gout

Allopurinol

9

What can cause a gout attack?

Alcohol and starvation diets

10

Diet instructions for gout

Increase alkaline ash foods (to increase pH) such as citrus fruits, juices, dairy products

11

How to treat Polymyositis

-High dose steroids
-Immunosuppressive agents
-Monitor nutrition for swallowing problems

12

What is Polymyositis coupled w/ a rash?

Dermatomyositis

13

What type of rash w/ Dermatomyositis?

Heliotrope rash (iliac) & periorbital edema

14

What Dz?
-Mostly men
-Involves every body system
-Renal and cardiac problems: leading cause of death

Polyarteritis nodosa

15

What Dz?
Most common form of vasculitis
Skin lesions as an allergic response

Hypersensitivity vasculitis

16

What Dz?
-Japanese women in 20s
-Aortic arch syndrome
-Cerebral ischemia
-Visual changes, syncope, vertigo

Takayasu’s arteritis

17

DOC for vasculitis dzs?

Steroid therapy (prednisone)

18

First symptoms of systemic Necrotizing Dzs?

Arteritis, ischemia

19

DOC for Temporal Arteritis

-Corticosteroids URGENTLY
-Calcium and Vitamin D for prevention of osteoporosis

20

What Dz?
-20% of patients with PMR
-Systemic affecting large and mid size arteries

Temporal Arteritis

21

Women over 50 report declining vision, probably have?

Polymyalgia rheumatica (PMR)

22

What Dz?
-Stiffness, weakness, aching
-Low grade fever, arthralgias, stiffness, fatigue, weight loss
-Neck, shoulder, hip joints most affected

Polymyalgia rheumatica (PMR)

23

What Dz?Exact cause unknown
-Genetic risk: HLA-B27 alleles
Affects vertebral column, spinal deformities
-White men

Ankylosing Spondylitis

24

What Dz?
-Genetic association: HLA-B27 antigens
-Mostly young white men
-From exposure to STD or Intestinal infection

Reiter's Syndrome

25

Reiter's Syndrome Triad of Symptoms

1. Arthritis
2. Conjunctivitis
3. Urethritis
*May also experience balantitis circinata (inflammation around penis)

26

What Dz?
-Autosomal dominant
-Abnormalities of skeletal, ocular, cardiopulmonary & CNS
-Excessively tall, scoliosis, funneled chest
-Decreased visual acuity or glaucoma
-Hyperextensibility of joints
-Elongated hands and feet

Marfan Syndrome

27

Why do most deaths from Marfan Syndrome occur?

-Cardio problems (usually in 30s)
-Mitral valve prolapse
-Mitral valve regurgitation
-Aortic aneurysm rupture

28

Treatment of Marfan Syndrome?

-Palliative (deal w/ symptoms, not cause)
-Monitor CV status
-CV medications
-Orthopedic surgery

29

What Dz?
-Systemic infectious disease
-Borrelia burgdorferi spirochete
-Bite of infected deer tick
-Most common vector borne disease in US

Lyme Dz

30

Stage 1 Lyme Dz

-Localized, flu-like symptoms
-Round or oval, flat or slightly raised rash
-Pain and stiffness in muscles and joints
-Bull’s-eye lesion
-Symptoms usually 7-14 days after bite
-With treatment (ABX), no symptoms 4-5 weeks

31

Stage 2 Lyme Dz

-Early disseminated (spread), 2-12 weeks after bite
-Pt may develop carditis, dysrhythmias, dyspnea, dizziness, palpitations, CNS disorders, Meningitis, facial paralysis, peripheral neuritis

32

Treatment of Stage 2 Lyme Dz

IV antibiotics for 30 days

33

Stage 3 Lyme Dz

Chronic persistent
Arthritis
Chronic fatigue
Memory and thinking problems
Months to years after bite

34

What Dz?
-Mimics gout
-Deposited crystals are calcium pyrophosphate
-Crystals migrate to cartilage
-Older hospitalized males
-Highest in men with metastatic cancer

Pseudogout

35

What Dz?
-30% of people with psoriasis
-30-50 years of age
-Genetic, environmental, infectious agents, immune system dysfunction
-Early morning stiffness, neck and back pain
-Fingernail and toenail lifting

Psoriatic arthritis

36

Psoriatic Arthritis Tx

-Manage joint pain and inflammation
-Control skin lesions
-Health teaching similar to skin care for lupus
-Management similar to rheumatoid arthritis

37

What Dz?
-Chronic pain syndrome, not inflammatory
-Arthritis commonly present
-Pain, stiffness, tenderness
-Neck, upper chest, trunk, low back, extremities (trigger points)
-Pain intermittent but worsens with stress, increased activity, weather
-30-50 years of age

Fibromyalgia

38

Precipitating factors of Fibromyalgia

-Chronic fatigue syndrome
-Lyme disease
-Trauma
-Flu-like illness

39

Fibromyalgia Tx

-Antidepressants
-Teach that these drugs cause drowsiness
-Avoid alcohol
-NSAIDS
-Sleep aids
*Be careful with older pts (may cause confusion and orthostatic hypotension)
-Muscle relaxants
-Physical Therapy

40

What Dz?
-Chronic illness w/ fatigue 6 months or longer
-Flu-like symptoms

Chronic Fatigue Syndrome

41

Four of more of what criteria must be met for Chronic Fatigue Syndrome?

-Sore throat
-Substantial impairment in short-term memory or concentration
-Tender lymph nodes
-Muscle pain
-Multiple joint pain with redness or swelling
-Headaches of a new type, pattern, or severity (not familiar to the patient)
-Unrefreshing sleep
-Postexertional malaise lasting over 24 hours

42

Supportive Treatments for Chronic Fatigue Syndrome

-Aches and Pains: NSAIDS
-Sleeplessness and depression: Antidepressants
-Teach: adequate sleep, proper nutrition, regular exercise, stress management, energy conservation, CAM

43

What Dz?
-Symptoms atypical of any one connective tissue disease
-10% of patients with CTD
-2 diseases may overlap at one time
-Systemic lupus erythematosus AND systemic sclerosis
-Rheumatoid arthritis AND SLE

Mixed Connective Tissue Dz

44

What Dz?
"I'm sick of always being sick"

Mixed Connective Tissue Dz

45

What do you assess for Scleroderma?

-Skin: painless pitting edema of hands and fingers, taunt, shiny, wrinkle free, decreased ROM, ulcerations, contractures
-Myocardial fibrosis: EKG changes, dysrhythmias, chest pain
-Vasculitic lesions
-Nailbeds: digit necrosis
Autoamputation
-Renal:malignant HTN, urine output and BP
-Respiratory: pulmonary fibrosis, pulmonary HTN
-Gastrointestinal: ability to swallow

46

Main cause of death in Scleroderma?

Renal

47

Important teaching priorities for SLE

Skin Protection, monitor body temperature

48

SLE leading cause of death?

Renal: Lupus Nephritis

49

Classic sign of exacerbation for SLE

Fever

50

What Dz?
-Affects skin ONLY, round coin-like scarring lesions

Discoid DLE

51

What Dz?
-Alopecia (hair loss), dry, scaly, raised rash on the face (butterfly rash), mouth ulcers
-Autoimmune
-Combination of genetic and environmental factors
-Onset 20-40 years of age
-Women 10 times more than men
-Women of color more often affected

SLE

52

Patho of SLE

-Antinuclear Antibodies (ANA) affect DNA, RNA
-Immune complexes form in serum & organ tissues
-Inflammation, damage, destruction
-Invade organs or vessels (vasculitis)
*Particularly attracted to kidney glomeruli
(leading cause of death)
-Deprives organs/tissues of arterial blood & oxygen

53

Chronic therapy complications of RA

-Diabetes mellitus, infection, fluid/electrolyte imbalances, HTN, Osteoporosis, Glaucoma

54

Teaching for RA

-Take steroids with calcium plus vitamin D
-Rest and ice after injection in single joint

55

DOC for RA

Prednisone

56

Cox-2 inhibitor for RA

-Celebrex
*Cardiovascular WARNING!

57

Pts with MS or TB cannot take what drugs?

BRMs

58

BRMs for RA

etanercept (Enbrel)
Monitor CBC, creatinine, liver panel
infliximab (Remicade)
Infusion reaction: tachycardia, shortness of breath, lightheadedness
adalimumab (Humira)
anakinra (Kineret)
Patients with MS or TB cannot take this drug
abatacept (Orencia)

59

Most pts w/ RA are managed with what initially?

DMARDs

60

DMARDs for RA

-Leflunomide (Arava)
*Hair loss, diarrhea, decreased WBCs/platelets, increased liver enzymes, avoid alcohol, pregnancy not recommended

-Hydroxychloroquine (Plaquenil), Antimalarial drug
*Retinal damage, generally tolerated well, mild stomach discomfort, light-headedness/headache

61

DOC for RA

Methotrexate (MTX) (Rheumatrex)
*Immunosuppressive= decreased WBCs, platelets, elevated liver enzymes/creatinine, pregnancy not recommended, risk for infection, avoid crowds

62

Arthrocentesis

Fluid is drained from a joint, can be done with RA

63

Sjögren's Syndrome

-Dry eyes, dry vagina, dry mouth
-Seen in RA

64

Infectious organism possibly causing RA?

Epstein-Barr virus