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36 Cards in this Set
- Front
- Back
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what is morning stiffness?
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Generalized musculoskeletal stiffness occurring after prolonged immobility is a common manifestation of active inflammatory joint disease. Its pathogenic basis is unknown. The duration of morning stiffness, sometimes referred to as “limbering up time”, frequently reflects the degree of disease activity.
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Does morning stiffness occur in degenerative disease?
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Yes, usually not longer than 30 minutes.
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How do you interpret the non-articular symptoms?
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Symptoms that reflect other organ system involvement hint to the diagnosis and emphasize the systemic nature of many of the inflammatory polyarthropathies.
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what does a history of ocular dryness suggests ?
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presence of Sjögren’s syndrome
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what does a history of loose bowel movements suggest?
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could signify inflammatory bowel disease
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What could the biphasic colour changes of a patients hands suggest?
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the presence of Raynaud’s phenomenon.
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How do you differentiate inflammatory and noninflammatory arthritis from a history?
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aggravating and relieving factors; age, sex and presence of extra-articular features.
inflammatory: >common younger, female>male, morning stiffness >45 min, aggravated by rest, relieved by activity, extra-articular manifestations present. non-inflammatory: older, female = male, morning stiffness <45 min, aggravated by acitivity, relieved by rest, extra-articular manifestations absent |
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how do you clinically assess joint inflammation?
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eliciting joint tenderness or identifying the presence of joint swelling due to increased intra-articular fluid, known as an effusion.
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What is the significance of normal findings in the skin and nails?
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The skin is a common target organ for extra-articular manifestations of several different types of inflammatory arthritis.
nails- common in pts w inflammatory associated psoriasis (psoriatic arthritis) |
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What is enthesitis?
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inflammation at the site of tendon or ligament insertion into bone.
usually found in seronegative arthropathies such as ankylosing spondylitis, psoriatic arthritis and reactive arthritis (also known as Reiter’s syndrome). Clinical examination reveals tenderness at the site of the tendon or ligament insertion on palpation. |
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what is the DDx for chronic (> 6 weeks duration) polyarticular inflammatory arthritis.
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1. Rheumatoid arthritis
2. Connective tissue diseases: systemic lupus erythematosus (SLE), Sjogren’s syndrome, and dermatomyositis. 3. Seronegative spondyloarthropathies: The types of arthritis belonging to this family: a) Ankylosing spondylitis b) Psoriatic arthritis c) Enteropathic arthritis (spondyloarthritis associated with Crohn’s disease or ulcerative colitis) d) Reactive arthritis (formerly known as Reiter’s syndrome) e) Undifferentiated spondyloarthritis. 4. Lyme arthritis: 5. Crystalline arthritis 6. Infectious arthritis 7. Paraneoplastic disease |
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what is rheumatoid arthritis?
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classically presents with symmetric inflammatory arthritis in the small joints of the hands and feet, but can affect almost any synovial joint in the body. It spares the distal interphalangeal (DIP) joints of the hands, the thoracic and lumbar spine.
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what are Seronegative spondyloarthropathies?
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Seronegative spondyloarthropathies: a term used to describe a family of diseases that share several clinical features. The most differentiating feature for these diseases compared with rheumatoid arthritis is involvement of the axial skeleton, with particular predilection for the sacroiliac joints. “seronegative” refers to a negative rheumatoid factor. The arthritis with these disease tends to be asymmetric and oligoarticular (fewer than 5 joints involved) and may be associated with dactylitis (sausage digit) or enthesitis.
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what is lyme arthritis?
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: Lyme arthritis is a late manifestation of Lyme disease and is characterized by intermittent of persistent inflammatory arthritis in a few large joints. Migratory arthralgias without frank arthritis can occur in earlier stages of the disease (early localized or early disseminated Lyme disease). Patients with Lyme disease will have a history of living in/travelling to an endemic area and often give a history of erythema migrans or other early disease manifestations. In Wendy’s case the history of camping should bring up Lyme arthritis as part of the differential diagnosis.
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what is Crystalline arthritis?
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Most common types are gout and pseudogout (CPPD arthropathy). These are usually acute presentations, but can become chronic and polyarticular over time. The diagnosis is confirmed by presence of crystals (urate of calcium pyrophosphate dehydrate crystals respectively) on synovial fluid analysis.
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What are the laboratory features of joint inflammation?
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anemia and thrombocytosis, in the absence of dietary deficiency and blood loss, and an elevated ESR. The latter is usually associated with elevation in acute phase reactants such as CRP.
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What is rheumatoid factor and does its presence confirm the diagnosis of rheumatoid arthritis?
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Rheumatoid factor is a biologic marker seen in approximately 70% patients with rheumatoid arthritis. It is an antibody directed against the Fc portion of immunoglobulin G (IgG). Aside from rheumatoid arthritis, rheumatoid factor is also present in most other connective tissue diseases, some acute and chronic infectious states, and granulomatous diseases in the elderly.
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What is anti-CCP (anti-cyclic citrullinated peptide) antibody?
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The anti-CCP antibody is another biologic marker for rheumatoid arthritis and, to date, is the most specific marker for the rheumatoid arthritis. While not detected in all patients with RA, when the anti-CCP antibody is present, we know that the test also indicates patients at higher risk of joint damage.
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why do a synovial fluid analysis?
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to confirm the presence of joint inflammation and to exclude other possible causes such as infection and crystal disease (i.e. gout, pseudogout).
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what are the 3 C's for synovial fluid?
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cell count and differential
crystal analysis culture and sensitivity. |
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what is inflammatory fluid extract from synovial fluid like?
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Inflammatory fluid is turbid in appearance with a low viscosity, has elevated white cell count and a high percentage of polymorphonuclear cells.
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differentiate inflammatory from non-inflammatory synovial fluid.
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inflammatory: clarity = turbid, yellow, low viscosity, WBC 2000-100000, PMN% > 50, crystals =absent, culture = sterile.
non- inflammatory: slightly turbid, yellow, reduced viscosity, WBC 0-2000, %PMN <30, crystals = absent, culture = sterile normal: clear, yellow, high viscosity, WBC 0-200, %PMN <25, absent crystals, culture sterile. |
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what are the goals of treatment in patients with chronic inflammatory polyarthritis?
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relief of symptoms
preservation of joint integrity maintenance of articular function |
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what are disease modifying anti-rheumatic drugs (DMARDs)?
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DMARDs are a class of medications that modify the disease course by somehow modulating the abnormal immune response underlying the disease.
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how long do DMARDS take to kick in?
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2-4 months before favorable response. unlike NSAIDS which take a few days.
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How would you counsel a patient with regards to taking methotrexate, including potential adverse effects?
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Methotrexate is a common first-line agent for treatment of rheumatoid arthritis
SE: include risk of infection, bone marrow suppression, hepatotoxicity, rashes, oral ulcers, gastrointestinal upset (especially nausea), hair loss and pulmonary toxicity. Female pts: avoid pregnancy. Alcohol use should be avoided because increase in hepatotoxicity. |
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What clinical and laboratory variables would you use to monitor for drug toxicity?
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toxicity = blood work, including CBC and liver enzymes. These are generally done monthly at the initiation of the medication and every 4 – 8 weeks thereafter.
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What clinical and laboratory variables would you use to assess the response to therapy?
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clinical response: decreased pain and stiffness, decreased number of swollen or tender joints
only laboratory features that change with activity of disease are the non-specific acute phase reactants such as ESR and CRP. (rheumatoid factor titre does not change with activity of disease.) |
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What are the typical radiographic features of rheumatoid arthritis?
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periarticular osteopenia
symmetrical joint space loss marginal joint erosions. |
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What are indicators of poor prognosis in rheumatoid arthritis?
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• persistent synovitis
• early erosive disease (demonstrated on x-ray)* • extra-articular findings (including subcutaneous rheumatoid nodules) • high titre rheumatoid factor* • positive serum anti-CCP autoantibodies* • poor functional status • socioeconomic factors • elevated acute phase response (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])* |
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if poor response to methotrexate and poor prognosis factors how would you manage disease?
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options including:
switching her from oral to injectable methotrexate a trial of “triple therapy” (hydroxychloroqine, sulfasalazine, methotrexate), using leflunomide with or without methotrexate or consider one of the biological agents. |
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What else can help to optimize level of function in RA pts. aside from pharmacologics?
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rehabilitation program: range of motion exercise program at home along with local physiotherapy follow-up. occupational therapist to recommend assistive devices to help with activities of daily living such as dressing, opening jars etc. Education about the importance of physiotherapy and encouragement to maintain a level of moderate activity are important.
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how long do hip and knee replacements usually last?
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10-15 years.
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Does shoulder replacement help to reduce intractable pain?
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maybe
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Does shoulder replacement help restore normal range of motion or function?
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No
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done this set!
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yup
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