Rheumatoid Arthritis (RA): Presentation (Sx + Deformities)
- Bilateral swollen joints, symmetrical
- Morning stiffness/pain greater than 1 hour
- Joints on hand most affected: MCP and DIP joints
- Deformities: Swan-Neck and Boutonniere
Rheumatoid Arthritis (RA): Diagnosis (Imaging, labs, criteria)
- Need to have at least 3 joints affected for diagnosis
- Xray DOES NOT show narrowing of joint
- Labs: Rheumatoid factor, Anti–cyclic citrullinated peptide (Anti-CCP = more specific), ESR, CRP
Swan-Neck Deformity
Hyperextended PIP joint and flexed DIP joint with hx RA
Boutonniere Deformity
Avulsion at PIP joint (central slip tear), flexed MCP joint, and hyperextended DIP joint with hx RA
Felty Syndrome
Includes rheumatoid arthritis, splenomegaly, and leukopenia (decreased white blood cell count)
Osteoarthritis (OA):
Presentation (Sx + Deformity + Leading cause of..)
- Unilateral swollen joints, asymmetrical
- Joints on hand most affected: PIP and DIP joints
- Heberden’s node = DIP joint
- Leading cause of lower extremity disability in older adults
Osteoarthritis (OA):
Tx + Dx
- Tx: NSAIDs, exercise
- Dx imaging:
o X-rays can show osteophytes, joint space narrowing, subchondral sclerosis, and cysts
o MRI not necessary but can be used to identify OA at earlier stages with cartilage defects and bone marrow lesions
o Ultrasound can detect synovial inflammation, effusion, and osteophytosis
Psoriatic Arthritis:
Signs + Symptoms
- Dactylitis: inflammation of a digit (either finger or toe). The affected fingers and toes swell up into a sausage shape and can become painful.
- Enthesitis: inflammation of the entheses, the sites where tendons or ligaments insert into the bone.
- Psoriatic plaques
- Joints on hand most affected: DIP joints
Psoriatic Arthritis:
Environmental Risk Factors + Tx
- Environmental risk factors for pathogenesis: Bacterial infection, viral infection, trauma
- Tx: NSAIDs
Gout:
Symptoms + Cause
- Common joint affected: MTP joints (big toe)
- High purine foods to avoid: Beer, organ meat, red meat, shellfish
- HCTZ: Exacerbate gout. SEs: hyperuricemia/hyperlipidemia/hyperglycemia
Gout:
Tx / Decrease flare-ups
- Tx: NSAIDs, colchicine, diet change: low purines
- Foods that decrease flare-up: Cherries, coffee, and fatty fish (salmon)
Gout:
Risk Factors / Comorbidity + Dx
- Risk factors/comorbidity: Hypertension, weight, renal function, cardiovascular disease, metabolic syndrome
- Definite diagnosis: Aspiration = Monosodium urate crystals
Baker’s Cyst
Popliteal Cyst
- Pain and swelling behind the knee
Lyme Disease:
Cause + Organism
- Cause: Tick bite
- Organism: Borrelia burgdorferi
Lyme Disease:
Sign + Tx
- Sign: Erythema migrans (EM) rash
- Tx: Doxycycline 100mg BID x 21 days
Lyme Disease:
Three Phases
1) Early localized:
- Appearance of the characteristic skin lesion, erythema migrans
- 3 to 30 days after tick bite
- With or without constitutional symptoms
2) Early disseminated:
- Characterized by multiple EM lesions
- Involvement of skin, heart, musculoskeletal system and nervous system
- Look for persistent fatigue
- Occur weeks to months after infection
3) Late disseminated Lyme disease:
- Associated with intermittent or persistent arthritis involving large joints, especially monoarticular arthralgia most often affecting the knee
- Associated with rare neurologic problems (encephalopathy or polyneuropathy)
- Develops months to a few years after the initial infection
Fibromyalgia:
Type of disorder / Symptoms
- Hypermobility/hyperflexibility disorder = connective tissue disease
- Chronic pain disorder affecting connective tissue. Muscles, tendons and ligaments are excessively irritated causing central sensitization and a heightened perception of pain
- Sx: Fatigue, sleep disturbance, pain
Fibromyalgia:
Diagnosis
- Diagnosis: Physical exam is #1 guide: Tenderness points ~12. Exclude all other diagnoses.
- No specific labs or imaging test to confirm diagnosis – obtaining a good patient history, ROS and physical exam is key!
- Labs are normal!!
Fibromyalgia:
Treatment Plan
- Tx: No cure, need support. Treat comorbidities (mood or sleep disorder)
o Trial with low-dose tricyclic antidepressants or selected antidepressants or anticonvulsants (amitriptyline, nortriptyline). If ineffective, can try SNRI’s and SSRI’s, analgesics
o Exercise program – walking, swimming and biking
Lupus:
Signs and Symptoms
- Butterfly rash, closely resembles rosacea
- Most common complaint: fatigue (>80%)
- Secondary finding that cause cyanosis and erythroderma = Raynaud’s
Lupus:
Labs + End organ damage
- Labs: Antinuclear Antibody (ANA)
- Concern for end organ damage: Kidneys, cardiac, vascular lower extremity, pulmonary
Ehlers Danlos Syndrome:
Disorder Type + Symptoms
- Hypermobility/hyperflexibility syndrome
- Many different types.
- Chief complaint = Pain! No swelling/stiffness/synovitis
