T2 - Rheum

Question 1

3 types of rheumatology disorders:

Answer 1

Autoimmune (Multisystem, joint involvement)
MSK = non-traumatic
Chronic Pain (MSK, no discernible other pathology)

Question 2

Eosinophils are elevated in _____ (3)

Answer 2

Worms, wheezes (allergies) and weird diseases

Question 3

Some DDx to consider with Rheumatology

Answer 3

Carpal tunnel syndrome, Fibromylagia, osteoporosis, gout, SLE, Lyme disease, Osteoarthritis, Paget’s disease, PMR, psoriatic arthritis, rheumatoid arthritis, Sjögren’s syndrome, vasculitis.

Question 4

Inflammatory:
Joint redness/warmth (+ or -)
Pain response to activity (improves or worsens)
Stiffness response to activity (minimal or improves)
AM stiffness (prolonged or minimal)

Answer 4

Inflammatory:
+ joint redness/warmth
Pain and stiffness improves with activity
Prolonged AM stiffness?
Non inflammatory is the opposite.

Question 5

What are some red flags of Rheumatoid diseases?

Answer 5

Sudden onset, worsening with tx, systemic symptoms (esp fever), joint pain AND sx in other body systems, recent trauma, unwillingness to bear weight, bone pain.

Question 6

_____ lab test can be helpful in determining Rheumatoid arthritis

Answer 6

anti-CCP (cyclic citrulllinated peptide)

Question 7

What are two examples of acute phase reactants? What can they tell us about inflammation?

Answer 7

ESR + CRP
they increase or decrease by at least 25% in response to inflammation.
Sensitive to inflammation but poor specificity.

Question 8

T/F: if your ANA is negative then you don’t have lupus.

Answer 8

True. 99.9%.
POs ANA is not specific to Lupus, may have other AI disorder or be completely healthy.

Question 9

What can give you a false positive ANA?

Answer 9

age >65, cancer, medications, viral infx, long-term infection.

Question 10

For rheumatic disease, be on the lookout for diagnoses that could be symptoms such as:

Answer 10

Seizure, HA, migraines, gastroenteritis, etc.

Question 11

If you are thinking autoimmune disease, then do a _______ titer too!

Answer 11

Lyme- Lyme is vastly under diagnosed.

Question 12

What is a classic radiograph finding for OA?

Answer 12

Osteophyte formation. Also asymmetric joint space narrowing, subchondral sclerosis

Question 13

Classic RA radiograph findings

Answer 13

Soft tissue swelling, joint effusion, OP, joint space narrowing, erosions, subluxation, swan neck deformity

Question 14

Classic gout radiograph findings

Answer 14

Joint effusion, eccentric erosions “punched-out”, lyric lesions

Question 15

Osteoarthritis is degeneration of ______
Ankylosing spondylitis is _____
Rheumatoid arthritis affects______
Gout affects________
Osteonecrosis affects_______

Answer 15

Cartilage
Enthuses enthesopathy
Synovial membrane/synovitis
Joint space
Bony end plate.

Question 16

Draw rheum slide 35 in Free form.

Question 17

3 things needed for autoimmunity to occur:

Answer 17

“Stupid-Ts” who can’t recognize self from non-self
Bad jeans make one more susceptible to stupid Ts
Inflammation from infx or trauma.

Question 18

If your patient has joint pain or stiffness that is prolonged in the morning, malaise, myalgia, weight loss, and nodules over extensor surfaces, what are you suspecting?

Answer 18

RA.

Question 19

EULAR classification criteria for RA

Answer 19

> =6 = definite RA.
Joint distribution (1 large joint, 2-10lg joints, 1-3 sml joints, 4-10 sml joints, >10 joints (at least 1 small joint)
Serology - neg RF and neg ACPA, low POs RF OR low POs ACPA, high POs RF OR high POs ACPA
Symptom duration - <6weeks, >=6weeks
acute phase reactants - normal CRP AND normal ESR, abnormal CRP OR abnormal ESR

Question 20

Your patient has 2-10 large joints affected, a low positive RF, symptoms that last >6 weeks and a normal CRP and ESR. What is their ACR/EULAR score? Do they have RA?

Answer 20

4
No - they need to be >=6 to be definite. Doesn’t mean they don’t haven RA, you might need to keep scoring or look at other DDx.

Question 21

Start RA patient on __________ monotherapy. If this doesn’t work, then add ______, _____, _____ or ______

Answer 21

DMARD
Combo DMARDS, TNF +/- MTX or non-TNF biologic+/- MTX.

Question 22

Acute gout tx_______, chronic gout prevention tx _______

Answer 22

Colchicine
Allopurinol

Question 23

Gout triggers:

Answer 23

Diet, alcohol, fructose, purines.

Question 24

Your patient c/o asymmetric joint px that worsens with activity but minimal morning stiffness. They have bunions. What do you suspect?

Answer 24

OA.

Question 25

Your patient has a photosensitive rash, fever, fatigue, arthralgia, Raynaud’s phenomenon and recorrent miscarriage. Upon exam you note slope is, anemia, and arthritis. What do you suspect.?

Answer 25

SLE

Question 26

SLE is more common in ______ (8:1) and more severe in _____

Answer 26

Women
Women of color

Question 27

What diagnostics do you want to do for lupus?

Answer 27

CBC, CMP, ESR/CRP, UA, ANA, RF.
Image: x-ray affected joints, echo cardiac, renal US and MRI.

Question 28

According to the ACR/SLICC criteria, you must have______ to qualify as SLE

Answer 28

4/11 or 4/17 positive OR biopsy confirmed lupus nephritis.

Question 29

Avoid what in SLE?

Answer 29

Sulfas and minocycline.

Question 30

Patients with SLE are immunosuppressed and high risk for cancer. What dose this mean?

Answer 30

No live vaccines, more frequent cancer screenings, dental prophylaxis.

Question 31

SLE treated with

Answer 31

Antimalarial (plaquenil) for skin manifestations and MSK complaints. They also prevent major damage to kidneys and CNS over the long term.
Glucocorticoid steroids.
Immunosuppressants are reserved for patients with significant organ involvement and had inadequate response to glucocorticoids.

Question 32

Treat fibromyalgia with _____ and _____

Answer 32

CAM, PMH, supportive yoga, CBT, tai chi
Antidepressants and anticonvulsants.

Question 33

Inflammatory vs non-inflammatory:
RA, SLE, Fibromyalgia, OA

Answer 33

Inflamm= RA and SLE

Question 34

What different symptoms would you have from Fibromyalgia compared to OA, RA or SLE?

Answer 34

OA = joint pain, no constitutional
RA = joint pain and swelling, malaise
SLE = vague, evolving, multisystem
Fibro = HA, cognitive and mood alteration

Question 35

What is PMR?

Answer 35

Polymyalgia Rheumatica

Age >50, proximal pain, acute onset, symmetrical aching stiffness (shoulders, hip,neck and torso), AM stiffness >45min, difficulty with ADLs, depression and anorexia.

Question 36

Signs of PMR - exam and lab

Answer 36

Low grade Fever, wt loss
RF, ANA, anti-CCP usually negative
MARKED increase in CRP/ESR.

Question 37

What does insidious onset mean?

Answer 37

Can’t point to a specific time that it started.

Question 38

What score is needed to safely make a dx of PMR?

Answer 38

5 and over.

Question 39

Scoring criteria for PMR algorithm

Answer 39

Morning stiffness >45 mins = 2
Hip pain with limited ROM = 1
Normal RF or ACPA = 2
Absence of other joint pain = 1
US: 1 shoulder with subdeltoid bursitis or biceps tenosynovitis and/or glenohumoral synovitis AND at least 1 hip with synovitis and/or trochanter if bursitis = 1
Both shoulders with subdeltoid bursitis, biceps tenosynovitis or glenohumoral synovitis =1

Question 40

PMR pharm management

Answer 40

NSAIDS, glucocorticoids with taping, MTX, biologics,

Balance between rest and activity, nutrition, PT/OT, sleep.