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Acute Care NP Exam > Rheum > Flashcards

Rheum Flashcards

1
Q

Risk factors for septic arthritis

A

Age >80
Diabetes mellitus
Prosthetic joints
Skin infection
Known abnormal joint (Rheumatoid joint)

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2
Q

What to rule out if you suspect acute monoarthritis

A

Septic until proven otherwise

If possible, hold antibx until fluid sent for culture

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3
Q

Which bacteria is often to blame for septic arthritis

A

Non-gonococcal (Staph, strep) - most common, most have fever

Gonococcal
-Need to have untreated disseminated gonorrhea
-Usually migratory arthritis
-Possible rash/lesion

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4
Q

Clinical management and Treatment of septic arthritis

A

Physical exam
Joint aspiration - send for cell count and diff
Blood cultures
GU cultures - gonorrhea
ESR/CRP
Imaging - XR to rule out fracture

Antibx: Broad spectrum while awaiting culture
-Ceftriaxone and Vanc

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5
Q

Causes of acute gout attack

A

Medical or surgical stress
Dehydration
Excessive ETOH
Changes in medications (particularly diuretics)

Family hx of gout
Males greater risk than females

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6
Q

Clinical presentation of gout attack

A

Attack typically comes on over hours
Acutely painful, red swollen joint
Possibly fever

Only way to diagnose it is through synovial fluid analysis - +crystals
Presence of tophi is also considered diagnostic

Serum uric acid will often be elevated (except during acute attack)

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7
Q

Treatment of acute gout

A

NSAIDs (2-3 days)
Colchicine (however can cause diarrhea and joint pain)
Steroids (PO prednisone or intra-articular)
ACTH
Anakinra

DO NOT START ALLOPURINOL

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8
Q

Considerations when starting Allopurinol

A

Good choice for treating chronic gout
-NEVER START DURING A GOUT ATTACK

Always start in combination with an anti-inflammatory agent
Recheck uric acid every 2-3 weeks and adjust to keep uric acid level less than 6.2

Avoid allopurinol with azathioprine
Avoid allopurinol with amoxicillin

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9
Q

Things to think about when treating someone on Etanercept

A

Entanercept is a more potent immunosuppressant

If treating someone with acute onset pain in a joint, concern that the joint could be infected. Should stop the immunosuppressant

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10
Q

Presentation of Human Parovirus B19 arthritis

A

Contact with someone (usually a child - 5ths disease) with a viral illness that then causes bilateral swelling of the wrists, metacarpophalangeal and proximal interphalangeal joints

Treatment is supportive care

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11
Q

Clinical features of rheumatoid arthritis

A

Polyarthritis (>5 joints)
Symmetrical
Small joint involvement (MCP, PIP, wrists, feet)
Can see ulnar deviation
Inflammatory joint pain (stiff after being sedentary for a bit and then they loosen up)
Worse in the AM but better as the day progresses
6+ weeks of symptoms
More common in women

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12
Q

Diagnostic testing for rheumatoid arthritis

A

Positive rheumatoid factor (RF)
Cyclic citrullinated peptide (CCP)
—More specific
Elevated ESR/CRP
Low Hgb, HCT (Anemia of chronic disease)

XR of hands and feet
Synovial aspirate would show WBC and inflammation

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13
Q

What are common X-ray findings for rheumatoid arthritis

A

Soft tissue swelling
Periarticular osteopenia (dark areas on bone)
Joint space narrowing
Marginal erosion

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14
Q

Treatment for rheumatoid arthritis

A

NSAIDS
Corticosteroids

Classic choice is DMARDs:

Low potency:
-Hydroxychloroquine (Plaquenil) - good for mild disease and safe during pregnancy

Medium potency:
-Methotrexate - once weekly, mouth sores, monitor LFTs
-Leflunomide (Arava)

High potency:
-Biologics and small molecules
—TNF inhibitors - improved when used with DMARDs (methotrexate)
—-Increase risk for infection

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15
Q

Use of Corticosteroids in Rheumatology

A

Useful first line agents
Often used for life threatening problems or when people are disabled by their problems
In some rare cases, (PMR) can be used as monotherapy however usually utilized as adjunct

Mostly safe during pregnancy (at lower doses)

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16
Q

Hydroxychloroquine: Uses, common side effects

A

Anti-malarial drug
Used to treat mild to moderate RA and Lupus

Can cause hyperpigmentation
Rare visual field loss
Well documented safe in pregnancy

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17
Q

Methotrexate: Uses and considerations

A

Cornerstone of treatment in moderate to Severe RA
Also used in lupus, psoriatic arthritis, myositis, vasculitis
Given once weekly PO or SC
Onset is 4-8 weeks

Can cause painful oral mucosal ulcers
- Folic acid given for side effects
Can cause LFT elevation

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18
Q

Sulfasalazine: Uses and considerations

A

Used to treat mild-moderate RA and psoriatic arthritis

Side effects: Rash, granulocytopenia, nausea, abd bloating

19
Q

Mycophenolate (Cellcept): Uses and considerations

A

Used in lupus nephritis (induction and maintenance) and ANCA positive vasculitidies

Side effects: Increase in infection, malignancy, teratogenic

Better tolerated than cytoxan for lupus

20
Q

Cyclophophosphamide (Cytoxan)

A

Used in life threatening lupus (proliferative nephritis, CNS involvement)

Very toxic: increased risk for malignancy, infection, teratogenic
Can cause sterility

21
Q

Anti TNF alpha antagonist (TNFs): Uses and considerations

A

Etanercept, Infliximab, Adalimumab

Approved for use in RA, spondyloarthropathies, psoriasis, Crohn’s, UC

Inhibits structural damage from RA
Improves efficacy when co-administered with traditional DMARDs - methotrexate

Risks:
Opportunistic infections
Autoimmune phenomenon: Lupus-like syndrome
Exacerbation of MS
Malignancy: Lymphoma

22
Q

JAK kinase inhibitors: Uses and considerations

A

Tofacitinib (Xeljanz)
Upadacitnib (RInvoq)
Baricitinib (Olumiant)

Approved for all the same things as TNFs but should only start these if you have failed TNFs

23
Q

Diagnostic testing for lupus

A

ANA
-Seen in 95% of those with SLE
-Not specific for SLE
-Once it is found to be positive, no need to ever check it again
-Not positive until 1:160

Anti dsDNA
-Seen in 60% of those with SLE
-Highly specific for SLE
Anti Sm (Smith)
-Highly specific for SLE

C3 and C4
-Compliment cascade in lupus resulting in low C3 and C4

Anemia, leukopenia and thrombocytopenia often present

24
Q

Clinical presentation of Lupus

A

Usually seen in women of childbearing age
-Constitutional symptoms, fever, weight loss, malaise, severe fatigue
-Skin rash and/or stomatitis (oral ulcers)
-Arthritis
—Usually in hands, wrists, knees
—Does not cause joint destruction
-Renal disease
-Cytopenias

25
Q

Treatment of Lupus

A

Hydroxychloroquine - main treatment

Corticosteroids
Methotrexate
Cellcept

26
Q

Scleroderma presentation
2 forms

A

Connective Tissue Disease

Thickening of the skin caused by accumulation of connected tissue
Inflammation and fibrosis

Limited Cutaneous systemic sclerosis
-Skin thickening distal to the elbows and knees
-Can involve peri-oral skin thickening (pursed lips)
-Less organ involvement
-Isolated pulmonary hypertension can occur
-Part of CREST syndrome

Diffuse cutaneous systemic sclerosis
-Skin thickening proximal to the elbows and knees, involving truck
-More likely to have organ involvement
-Pulmonary fibrosis and renal crisis are more common

27
Q

CREST Syndrome

A

Part of Limited cutaneous system sclerosis

Calcinosis - calcium deposits in the skin
Raynauds Phenomenon
Esophageal dysfunction - GERD, decreased motility
Sclerodactyly - thickening and tightening of the skin on the fingers and hands
Telangiectasias - dilation of capillaries causing red marks on surface of skin

28
Q

What is a lethal complication of scleroderma

A

interstitial lung disease
Isolated pulmonary hypertension
Scleroderma Renal Crisis

29
Q

What is a rheumatological emergency?

A

Scleroderma Renal Crisis
-Abruptly develops severe hypertension

Plus one of the following:
-Increase in creatinine by >50% over baseline or >120% Upper limit of normal
-Proteinuria >2+
-Hematuria >2+ or >10 rbc on UA
-Thrombocytopenia <100,000
-Hemolysis

Can cause headache, seizure, LV failure, encephalopathy

30
Q

Treatment of Scloerderma Renal Crisis

A

Initiation of ACE-I (captopril) and continuation on life long ACE-I

Of note, ACI-I do not prevent scleroderma renal crisis

31
Q

Treatment of Scleroderma

A

No treatment that will treat all sxs
Mostly focused on symptom management

If stable - treat symptoms

If unstable
-Methotrexate
-Mycophenolate mofetil (Cellcept)

32
Q

Giant Cell Arteritis vs Polymyalgia Rheumatica

A

GCA:
-Age of onset >50 - incidence increases with age
-Female>male
-Vision loss - can be perminent
-Amourosis fugax - monocular curtain falling into vision
-Headache
-Scalp tenderness
-Jaw claudication - lot of pain in jaw when chewing
-Fever
-Weight loss

PMR:
-Age of onset >50
-Female >male
-Pain in shoulder and hip girdle
-Stiffness
-Weight loss
-Malaise
-2-3 times more common

33
Q

Diagnostics of GCA

A

Palpation of temporal arteries

-ESR/CRP - elevated
-Normochromic/hypochromic anemia
-Elevated platelets
-Normal WBC

GOLD STANDARD: Temporal artery biopsy

Can also get a temporal artery ultrasound or PET-CT Chest

34
Q

Diagnostics of Polymyalgia Rheumatica

A

Largely a clinical diagnosis
-ESR/CRP elevated

-Give low dose steroids, usually better in just two days

35
Q

Treatment of GCA and PMR

A

GCA:
-high dose steroids (1mg/kg)
-Start if suspicious
-Taper once sxs resolve
-Tocilizamab (Actemra) is helpful
-ASA

PMR:
Low dose steroids (10-20mg starting dose)
May need prolonged low dose steroids
Generally can taper off in 12-18 months

36
Q

Clinical presentation of polyarteritis nodosa

A

Systemic complaints: Weight loss, fatigue, arthralgias
Renal vasculitis
GI: Mesenteric ischemia, liver involvement - n/v/d/hematochezia
Peripheral nervous system: Mononeuritis multiplex
Derm: Livedo reticularis, skin ulcers, erythematous nodules, ischemia
Other: Coronaries, testicles, ovary, breast, eye

37
Q

Treatment of polyarteritis nodosa

A

Glucocorticoids: key compenent
-IV pulse of solumedrol in mild cases
-Cyclosphosphamide in more severe cases

38
Q

Difference in clinical features of Granulomatosis Polyangiitis (GPA) and Microscopic polyangiitis (MPA)

A

GPA:
-ANCA positive
-Histology: GRANULOMATOUS INFLAMMATION
-ENT - chronic sinusitis, hearing loss
-Skin - cutaneous vasculitis

MPA:
-ANCA Positive
-Histology: No granulomatous inflammation
-ENT - not usually involved
-Neurologic: Vasculitic neuropathies common

39
Q

Clinical presentation of Churg-Strauss Syndrome

A

Eosinophilic infiltrates/vasculitis: granulomas with eosinophil necrosis

ENT - nasal polyps, allergic rhinitis, conductive hearing
Eyes - Occassional inflammatory eye disease
Lung: Adult onset asthma
Renal: Segmental necrotizing glomerulonephritis
Cardiac: CHF
Neurologic: Vasculitis neuropathy prominent

40
Q

What is the pathology of osteoarthritis?

A

Degenerative joint disease with slow destruction of the articular cartilage
Usually asymmetrical
Affects both men and women equally
Primarily occurs on the weight bearing joints (knees, hips), fingers, hands, wrists

41
Q

Clinical presentation of osteoarthritis

A

Swelling and edema but no redness or heat to joints
Asymmetric joint involvement
Heberden’s nodes - DIPs (H is distal in the alphabet)
Bouchard’s Nodes - PIPs (B is proximal in the alphabet)
Pain and stiffness is better in the AM and becomes worse as the day progresses
–Aggravated by activity and relieved by rest
Limited ROM

42
Q

Diagnostics for osteoarthritis: Labs and imaging

A

No real labs
Sinovial fluid is clear/yellow
X-ray shows narrowing of the joint space, osteophytes, juxta-articular sclerosis

43
Q

Treatment of Osteoarthritis

A

ASA
Acetaminophen
NSAIDs
Cox 2 inhibitors (Celebrex)

Use of cane (put cane in OPPOSITE hand of affected leg)
Physical therapy
Refer for joint replacement

44
Q

What is sarcopenia

A

Decreased muscle mass and strength
Seen in the elderly

Acute Care NP Exam (22 decks)

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