Rheumatology Flashcards

Question

# Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus Common symptoms of fibromyalgia \*\*\*exam

Answer 1

* Fatigue * Poor sleep * Headaches * Mood disturbances * Allergies * Dizzy * Bowel problems * Cognitive problems “Brain Fog”

Answer 2

* Focus on neuromuscular * Usually no OA, joint deformity * Function is good, able to get to exam table, put coat on , open door * Resistance during PE patient usually gives way * Reflexes normal * Tender points more in women

Answer 3

* A widespread pain index score ≥7 and a symptom severity scale score ≥5 or a widespread pain index score of 3–6, * a symptom severity scale score ≥9 * Symptoms that are present for at least 3 months * The patient does not have another disorder that would explain the pain In practice, however, many clinicians feel that the 1990 ACR criteria did not provide adequate diagnostic guidance

Answer 4

* Rheumatologists: one study showed that some providers used over 60 drugs * Classically: * TCA, SE : weight gain * SSRI * SNRI * Antielpticics * Sedative- hypnotics * “The kitchen sink” * Antidepressants * Sedative hypnotics * Tramadol * Muscle relaxants * Low dose naltrexone

Answer 5

* Pregbalin 2007 ( lyrica) SE: sedation, weight gain, good if there is a sleep issue * Duloxetine 2008 ( cymbalta), biggest bang for the buck , used most, treats pain and depression, nausea, dose slowly, be careful when weaning off , dissociated sense during weaning,( patients often feel they are out of their body, go very slowly * Minaciprin 2009( savella) dose kit, not too popular, tolerance is issue, nausea, headache

Answer 6

* Mind body often overlooked, but patients need the guidance and the tools. * CBT: strong in literature * Coping strategies * Progressive muscle relaxation * Breathing techniques * Mindful meditation * Tai chi or yoga study in NEJM. So it is becoming more accepted, but is it sustainable?

Answer 7

* Combined with education * Supervised , but have patient start up slowly and gradual * Use PT as a way to jump start some exercise * Get them motivated, and improve lifestyle * Walking pool, strength training * Maximize health, see it as an opportunity, remember this is mainly in young pt

Answer 8

* Acupuncture: conflicts in literature may conflict with your own experience and part of EBP * Massage * Manipulation * Magnesium: studies are weak * Malic acid; studies are weak * Chlorella: green algae, super food, some discussion

Answer 9

For fibromyalgia * Yale preventive research study using CAM, naturopaths, IV micronutrient used for a variety of conditions * 12,000 patients, magnesium, B Vitamins , vitamin C, 500 mg at a time ( more than that is only excreted) * IV Micronutrient Therapy * Mg * Calcium gluconate * Pyridoxine * B complex

Answer 10

osteoarthritis

Answer 11

Degeneration of joint starting with degradation of the cartilage and eventually including bone

Answer 12

* 50% of people \>65yrs have x-ray evidence, most w/o symptoms * More common women\> 55 * Risk factors: Obesity, repetitive use, trauma, previous inflammation

Answer 13

Heberden's and Bouchard's nodes

Answer 14

Heberden's nodes: associated with OA

Answer 15

Bouchard's nodes: associated with OA

Answer 16

* Pain: worse after using joint * Stiffness: n\< 1 hour in the morning, severe after immobility * Loss of movement * Restricted ROM * Tenderness * Bony swelling * Soft tissue swelling * Joint crepitus

Answer 17

Endocrinopathies diabetes may be prone to osteoarthritis. Other endocrine problems also may promote development, including acromegaly, hypothyroid, hyperparathyroid, obesity Metabolic dz: e.g., Wilson's

Answer 18

* An i**nherited disorder of copper metabolism** that results in an abnormal accumulation of copper in the body. accumulation of copper begins at birth * symptoms of the disorder do not appear until later in life, between the ages of 6 and 40. * A diagnostic feature of the disease is a _Kayser-Fleischer ring_, a deep copper- colored ring around the edge of the cornea that  represents copper deposits in the eye.

Answer 19

* Weight reduction * Education * Exercise * Physical therapy

Answer 20

* NSAIDs * Acupuncture * Topical creams: i.e.Voltaren gel * Steroid injection * Limbrel (Flavinoid) * Flavocoxid is comprised primarily of the flavonoids such as baicalin and catechin. These or similar ingredients can be found in common foods such as soy, peanuts, cauliflower, kale, apples, apricots, cocoa and green tea. * Synvisc injections * Glucosamine/chondroitin?

Answer 21

* Arthroscopic lavage and debridement * Osteotomy * Total joint replacement

Answer 22

osteoarthritis

Answer 23

* AKA “Podagra” * Inflammation related to increased urate * (\> 6.0 mg/dL) * overproduction or underexcretion * metabolic disease * familial

Answer 24

* On the rise in USA * Men, 5th decade, (women after menopause) * Alcohol, purines, fructose rich drinks, diuretics, asa, niacin, cyclosporines * myeloproliferative diseases * At least 5% of asymptomatic Americans manifest hyperuricemia at least once as an adult * Not everyone with Hyperuricemia has gout! But everyone with gout has hyperuricemia

Answer 25

* Western diets, sedentary lifestyle, obesity and hypertension, increased use of diuretics and aspirin * modifiable risk factors: lifestyle and dietary factors (obesity, alcohol, fructose, purine-rich fatty food), certain drugs (thiazide and loop diuretics), and disease conditions (hypertension, renal insufficiency, and heart failure), heavy drinking

Answer 26

* \*Needle aspiration of affected joint: r/o infection, gold standard, but not always needed, can use to differentiate from RA * Tophi that contain urate crystals (PE) * X-ray findings * elevated serum uric acid \>6 * Uric acid in flare will be normal * WBC might be elevated

Answer 27

* Patient education * Immobilization * NSAIDs, steroids (intrarticular or oral), Colchicine 1.2mg start, then .6 in one hour then 0.6 mg up to TID, * Indocin (50 mg TID) watch for GI bleed * Later/Maintenance: * Allopurinol (200-600 mg in divided doses) prophylactically ( lifetime) block the final enzyme step in the production of uric acid * OR -- Uloric ( febuxostat) 40-80 mg daily $$ * May need to give prednisone first

Answer 28

* lowering serum uric acid (SUA) levels with the urate-lowering therapies (ULTs) allopurinol or febuxostat. * lifelong * Inadequate dosing /nonadherence/intolerance: often lead to treatment failure. * American College of Rheumatology: TAILOR Tx, target SUA level (traditionally \<6, but may need to be lower in some) * Hyperuricemia in non symptomatic patients need not be treated (\>6)

Answer 29

* Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD) * Acute , gout-like inflammation * CPPD crystals in synovial fluid (not urate crystals)

Answer 30

* Occurs with age * Genetics * History of orthopedic trauma, surgery, anesthesia * Also associated with metabolic disease

Answer 31

nSame as with gout, although less effective.

Answer 32

* Chronic systemic inflammatory disease affecting diarthroidal joints * Most common autoimmune (joint) disease * Over production and over expression of TNF: drives synovial inflammation and joint destruction

Answer 33

* 2.5X more likely in women * Genetic predisposition for certain groups: HLA DR4, Native Americans ,Europe & Asian * 30% concordance rate in monozygotic twins * Not documented until the mid-18th century * Typical onset 55 yrs * In USA, lifetime risk is 3.6% women, 1.7% male

Answer 34

* Symmetrical polyarthritis * Joint swelling ( hands and feet) * Morning stiffness \>1 hour

Answer 35

* Skin: nodules, palpable purpura * Eyes: Scleritis * Lungs: Interstitial fibrosis, pleuritis, , nodules, laryngeal cartilage * Heart: pericarditis * Hematologic: Anemia, RA factor * Neurologic: Atlanto-axial subluxation, single nerve involvement (mononeuritis)

Answer 36

* \>33% become disabled * Decrease in life expectancy 3-5 yrs * Often serious treatment adverse effects from drugs needed to treat * 50% greater risk for MI and HF

Answer 37

* Poor sensitivity and specificity for Early inflammatory arthritis, * Fails to ID early cases. * Effective treatment in early RA delays response. * Erosive joint damage and extra articular disease are late changes that can be prevented

Answer 38

* \*Data driven and consensus driven * \*Assess Joint involvement * \*Auto antibody status * \*Acute phase response * \*Symptom duration * \*Want to determine benefit from starting methotrexate * \*Last phase will summarize all data to arrive at a prediction model and cut off for probability score

Answer 39

Goals: to decrease inflammation, prevent progression, pain, loss of function

Answer 40

Education, PT, OT, SW, swimming

Answer 41

* NSAIDs and COX Iis ( caution on COX Inh) * Methotrexate, other DMARDs * Steroids ( use as bridge treatment) * TNF inhibitors

Answer 42

b. Distal interphalangeal joints and sacroiliac joints pain and stiffness

Answer 43

Four for a Minimum of 6 Weeks * 1. Morning stiffness in and around joint lasting at least 1 hour before maximal improvement * 2. Arthritis of 3 or more of the following joints simultaneously: right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints including soft tissue swelling or fluid * 3. Arthritis of hand joint including swelling of wrist, MCP, or PIP joint * 4. Symmetric involvement of joints on both sides of the body * 5. Rheumatoid nodules over bony prominences, or extensor surfaces or in juxtaarticular regions * 6. Positive abnormal serum rheumatoid factor * 7. Radiographic changes including erosions or bony decalcification localized in or adjacent to the involved joints

Answer 44

. Low-grade fever occasionally occurs (temperature, 37° to 38°C; 99° to 100°F), but a higher fever suggests another illness, and infectious causes must then be considered.

Answer 45

* **intermittent joint inflammation** that can be confused with gout or pseudogout * **proximal muscle pain and tenderness** mimicking polymyalgia rheumatica * **diffuse musculoskeletal pain** seen in fibromyalgia.

Answer 46

d. Fibromyalgia

Answer 47

* Connective tissue diseases **Scleroderma and lupus** * **Fibromyalgia:** Evaluate for trigger points ( although this is controversial) * **Hemochromatosis:** Iron studies and skin coloration changes * **Infectious endocarditis:** Murmurs, high fever, and history of intravenous drug use * **Polyarticular gout:** Joints often erythematous; podagra commonly found; gout and RA rarely coexist, but calcium pyrophosphate deposition disease can accompany RA * **Polymyalgia rheumatica:** Pain in the proximal joints of the extremities only * **Sarcoidosis Granulomas:** hypercalcemia, and x-ray findings * **Seronegative spondyloarthropathies, reactive arthritis**: Asymmetric involvement of the joint and may include the spine. Evaluate for history of psoriasis, Reiter's comorbidities, inflammatory bowel disease. Reactive arthritis can be postinfective, sexually acquired, or related to gastrointestinal disorders * **Still's disease:** Fever, leukocytosis with left shift, sore throat, splenomegaly, liver dysfunction, and/or rash * **Thyroid disease:** Consider TSH

Answer 48

* d. All of the above * DMARDs (MIs, valves, sclerosis – cause arterial vessel inflammation), Traditional and biologic, and glucocorticoids (fluid, sugar) – all increase risk for CVD

Answer 49

cardiovascular disease, malignancy, peptic ulcer disease, and chronic lung disease. On average, the established patient with RA has 2 or more comorbid conditions

Answer 50

* associated with increased cardiovascular risk, and should be avoided. * Prior to glucocorticoid use, RF assessment should include family history of diabetes, PMH hypertension or diabetes * may be associated with adverse effects including body weight changes, infection, osteoporosis, mood or sleep disturbance, and reduced wound healing. * patients should be counseled about potential side effects, the importance of taking the medication only as directed, limiting the dosage and duration of glucocorticoid use, difficulty of discontinuing prednisone in patients with active RA, and dangers of abrupt cessation of the medication after long-term use. * medical alert bracelet should be worn by patients receiving long-term glucocorticoid therapy.

Answer 51

* twice the risk for heart failure when compared with individuals of the same age and sex without RA * cardiovascular health prevention steps are important to improve life expectancy in patients with RA * smoking cessation and reduction of cholesterol intake to minimize cardiovascular risk factors * At risk even after controlling for other RFs

Answer 52

a. X-ray imaging b. Rheumatoid factor (RF) * CRP and ESR more informative. X-rays taken early in the course of RA may show only soft tissue swelling * RF not specific: also detected with lupus, scleroderma, Sjögren's syndrome, neoplastic disease, sarcoidosis, and various viral, parasitic, and bacterial infections & chronic antigenic stimulation (prolonged infection caused by bacterial endocarditis, tuberculosis, cytomegalovirus, or HIV) * A positive test for RF is present in 70% to 90% of patients with RA, and indicates presence of antibodies directed against the Fc portion of immunoglobulin G (IgG). * false positive RF titers may be detected in the serum of apparently normal people, especially those older than 70 years, where prevalence ranges from 10% to 25%. * Patients with RA and a high-titer RF are more likely to have erosive joint disease, extra-articular manifestations of RA, and greater functional disability. In contrast **RF-negative patients with RA may exhibit a milder disease course.**

Answer 53

* early in the course of RA may show only soft tissue swelling, * With progression of disease, narrowing of the joint space is caused by loss of cartilage, * characteristic erosions appear, generally at the point of synovium attachment. * In end-stage RA disease, even large cystic erosions of bone may be seen and bony proliferation may occur.

Answer 54

* c. Anti-cyclic citrullinated peptide-2 (ACPA) assay, RF, CRP, and swollen joints * evidence of **anti-CCP antibodies alone can occur years before disease onset** * no single diagnostic test definitively confirms the diagnosis of RA or predicts the disease course

Answer 55

if the diagnosis is questionable and evidence of inflammation might affect therapeutic decisions

Answer 56

The anti-nuclear antibody (ANA) test is sometimes included in the laboratory workup for RA. Although ANA is positive in 20% to 30% of patients with RA, it is more common in patients with extra-articular manifestations of disease

Answer 57

* a complete blood cell count with differential, RF, and ESR or CRP to assess acute-phase inflammatory response, anti-CCP2 assay * To help direct medication choices, baseline evaluation of renal and hepatic function is also recommended.

Answer 58

b.Disease-modifying anti rheumatic drug (DMARD) therapy early aggressive tx w/DMARDs recommended. (steroids would be used as a bridge – not long-term)

Answer 59

Adalimumab (Humira) and etanercept (Enbrel) are equally effective as tumor necrosis factor (TNF) inhibitors in the treatment of patients with active rheumatoid arthritis ( November 2012 ACR Conference Washington DC)

Answer 60

(rheumatologist starts these) * Tumor necrotizing factor alpha inhibitor * **Screening considerations prior to start: PPD (latent can become active)** * **Hep B titer (anti-TNFs can cause reactivation of infection in carriers of the virus)** * **Avoid live vaccines during TNF therapy** * Monitoring * Risk vs benefits (previous lymphoma risk) new data disputes this concern: no apparent association w/lymphoma, +risk for crohn's, colitis

Answer 61

* Vascular ischemia * White (ischemia) * Blue (Cyanotic) * Red: hyperemia * Treatment: vasodilators, eliminate vasoconstrictors, control disease

Answer 62

* Multiorgan, multisystem, all components of Immune system * Differentiate from cutaneous lupus or drug-induced lupus * Relapsing-remitting

Answer 63

* \>Women 8:1 * Onset ages 15-44, African Americans more than Caucasians * Socioeconomic correlation? * Associated with Raynaud’s phenomenon

Answer 64

* may be related to the lupus treatment, infection * For example, leukopenia is found in 15% to 20% of people with lupus * Thrombocytopenia occurs in 25% to 35% of people with lupus.

Answer 65

(4 or more of 11) 1982 and revisited in 1987 * Malar rash * Discoid rash * Photosensitivity * Oral ulcers * Arthritis * Serositis * Renal disorder * Neurologic disorder * Hematologic disorder * Immunologic disorder (DS DNA, antiphospholipid antibodies) * ANA

Answer 66

* Plaquenil 200 mg daily or BID * NSAIDs * Possibly Methotrexate * TNF alpha inhibitors * Prednisone for flares

Answer 67

acetaminophen (short term nsaids or topical nsaids may be considered, opioids if pain is severe)

Answer 68

* Be careful with **_colchicine_ in CKD** - CrCl \<30 mL/minute: Dosage ↓ not required but may be considered; treatment course should not be repeated more frequently than every 14 days. If someone is receiving it prophylactically don’t also give for flare * **_Allopurinol_**: Dosage reduction of 50% is recommended in renal impairment * No NSAID

Rheumatology Flashcards

Exam: fibromyalgia presenting complaints, OA vs RA joint assessment, OA pain mgmt in elderly, labs to rule in RA, preventatitve screening w/TNF inhibitors, gout tx, 50/50 rule for gout pt w/CKD, Dx Lupus (100 cards)