Msk Week 4 Objective 10

Front 1

What are the features of inflammatory arthritis, and what history questions do you need to ask regarding these features?

Back 1

-prolonged am stiffness
-pain is worse with inactivity, better with activity
-can have night pain

-(N.B. non-inflammatory arthritis (OA) has inactivity stiffness, but it only lasts a few minutes; aggravated by activity, alleviated with rest)

Front 2

How can you categorize rheumatic disease?

Back 2

1. seropositive
2. seronegative
3. crystal-induced
4. septic/infectious

Front 3

How can seropositive rheumatic disease be sub-classified?

Back 3

1. Connective Tissue Disease
- RA
- SLE
- scleroderma
- Sjögren's
- MCTD
- polymyositis/dermatomyositis
- anti-phospholipid antibody syndrome

2. Vasculitides
-Polyarteritis nodosa (PAN)
-Microscopic polyangitis
-Wegener's granulomatosis
-cutaneous vasculitis
-Giant cell arteritis (Temporal arteritis)

Front 4

What are the seronegative rheumatic diseases?

Back 4

1. Ankylosing spondylitis
2. Reactive arthritis
3. Psoriatic arthritis
4. IBD

Front 5

How can articular rheumatism be distinguished from non-articular?

Back 5

Non-articular has soft tissue pain.

ie. Fibromyalgia = generalized soft tissue tenderness
-require pain in 11/18 tender points; distributed in all 4 quadrants

Myofascial pain syndrome = localized soft tissue pain
-trigger points

Front 6

What sort of arthritis will have a history of very acute onset (ie. hours)?

Back 6

-gout
-infectious

Front 7

What sort of arthritis will have a history of subactue onset (ie. days)?

Back 7

-pseudogout
-infectious

Front 8

What sort of arthritis has an insidious onset(months)?

Back 8

-degenerative
-inflammatory

Front 9

What is your Ddx for mono-articular arthritis?

Back 9

1. infectious
-bacterial
-mycobacterial
-fungal
-viral
-spirochaetes (Lyme)

2. Crystal-induced
-gout
-pseudogout (CPPD)
-hydroxyapatite

3. hemarthrosis
-trauma/fracture
-anti-coagulants
-bleeding diatheses (tendencies)

4. Tumor (neoplasms are rare in articular disease)

5. Inflammatory disease

6. Degenerative disease

(N.B. acute monoarthritis is INFECTIOUS until proven otherwise!! also note, that WBC and synovial fluid analysis may be misleading)

Front 10

What is your Ddx for poly-articular arthritis?

Back 10

1. Infectious
-Lyme disease (rare in BC)
-SBE
-Gonococcus
-Viral (EBV, Parvovirus)
2. Post-infectious
-Rheumatic fever (Strep)
-Reactive arthritis (Chlamydia)
-Enteric infections
3. Inflammatory disease

Front 11

What kinds of arthritis are characterized by an intermittent history of symptoms (with complete remission)?

Back 11

gout

Front 12

What sort of arthritis is characterized by gradual progressions with acute exacerbations?

Back 12

pseudogout

Front 13

What sort of arthritis waxes and wanes with slow progression over time?

Back 13

RA

Front 14

What signs of inflammatory arthritis may be present on physical exam?

Back 14

rubor
tumor
calor
dolor
(functio lessae)

Front 15

Which rheumatic diseases have a symmetrical pattern of joint involvement?

Back 15

-RA
-SLE
-symmetric psoriatic arthritis (one of five variants of psoriatic)

Front 16

Which rheumatic diseases have an asymmetrical pattern of joint involvement?

Back 16

-gout
-pseudo-gout
-septic
-reactive
-most psoriatic

Front 17

Which joints are usually involved in RA?

Back 17

-MCP and PIPs
-NOT DIP!!
-wrists
-elbows
-shoulders
-hips
-knees
-ankles
-MTPs

Front 18

What sort of abnormalities can you see in the hands of people with poorly controlled RA?

Back 18

-ulnar deviation (due to loss of ligamentous support)
-swan neck deformity
-boutonnière deformity

Front 19

What would you notice in the radiography of someone with RA vs. someone with OA?

Back 19

RA = subtractive

-erosions/bites OR juxta-articular osteopenia
-diffuse narrowing of joint space
-in knee: affects lateral compartment leading to valgus deformity
-in hip: diffuse hip jnt narrowing leading to acetabular protrusion

OA = additive

-osteophytes
-subchondral sclerosis
-in knee: affects medial compartment leading to varus deformity
-in hip: narrowing is in weight-bearing area (superolateral)

Front 20

When is it important to take a synovial aspirate?

Back 20

-in mono-articular arthritis

Front 21

What categorization of synovial fluid would an OA joint have?

Back 21

Type I

Front 22

Type II synovial fluid is associated with what kind of arthritis?

Back 22

Inflammatory

Front 23

When would you see a type III and type IV fluid?

Back 23

III: septic (may also be type II)

IV: hemarthrosis

Front 24

What is important to inspect for in the peripheral joints?

Back 24

SEADS

1. Swelling
2. Erythema
3. Atrophy of muscles
4. Deformities
5. Skin changes

Front 25

What are you palpating for in the peripheral joints?

Back 25

-warmth
-joint line tenderness
-bone, tendon, cartilage tenderness
-effusion
-crepitus
-laxity/instability

Front 26

What is it important to inspect for in the axial skeleton?

Back 26

-posture
-alignment: kyphosis, lordosis, scoliosis

Front 27

Which seronegative condition especially affects the spine, and what is its salient sign?

Back 27

-ankylosing spondylitis

-sacroiliitis

Front 28

What is it important to palpate for in the axial spine?

Back 28

-muscle spasm
-bony and soft tissue tenderness

Front 29

What should you always ask about in a ROS if you suspect SLE?

Back 29

1. cutaneous symptoms
-Malar rash
-photosensitivity rash
-maculopapular rash

2. Mouth ulcers

3. Alopecia

4. Raynaud's

5. Sicca sx
-xerostomia
-keratoconjunctivitis sicca

Front 30

Which arthritides involve the DIPs?

Back 30

-psoriatic
-OA

NEVER RA!

Front 31

If you suspect inflammatory arthritis, what condition must you ALWAYS ask about in ROS?

Back 31

psoriasis!!

Front 32

What questions would you include in your ROS if you suspected a seronegative spondyloarthropathy?

Back 32

1. Redness and/or dryness of eyes (iritis, conjunctivitis)

2. Psoriasis

3. IBD sx (melena, rectal bleeding, pain/cramping, bloating, flatulence, etc)

4. Recent travel and dysentery (bloody, mucousy diarrhea)

5. pain on urination, dyspareunia (cervicitis, urethritis)

Front 33

What are basic hematological and biochemical tests to include in a rheumatology work-up?

Back 33

1. CBC with Diff
2. Hb
3. Creatinine (BUN)
4. Acute phase reactants: ESR, CRP, C3, C4, albumin,
5. AST/ALT
6. Urinalysis
7. Uric acid
8. Creatinine Kinase

Front 34

ESR has a poor PPV and a good NPV. True or False?

Back 34

True: ESR is overly sensitive but non-specific, therefore has a poor PPV

-has a good NPV

Front 35

You may find various anemias in rheumatic diseases. True or false?

Back 35

True.

Can see anemia of chronic disease with long-standing RA and other chronic conditions.

Can see iron-defiency anemia from use of NSAIDS in tx of rheumatic disease.

Can see a hemolytic anemia in SLE.

Front 36

In SLE, WBC is low. True or false?

Back 36

True. SLE is associated with a lymphocytopenia.

Front 37

When might you see a pancytopenia in rheumatic disease?

Back 37

Associated with drug treatment

eg. methotrexate, sulfasalazine, azathioprine, etc.

Front 38

Under what conditions might you discover a thrombocytopenia?

Back 38

ITP associated with SLE

induced by gold injections for RA

Front 39

When might you find a thrombocytosis?

Back 39

RA (a reactive thrombocytosis)

Front 40

Although ESR has a low PPV, it remains a very important diagnostic test for some conditions. What are they?

Back 40

PMR (polymyalgia rheumatica)

Giant cell arteritis (Temporal arteritis)

-following disease activity and tx (RA, SLE)

Front 41

When should you check RF?

Back 41

In condition of inflammatory polyarthritis.

Front 42

In what conditions might RF be positive?

Back 42

RA
SLE
Sjögren's
Cryoglobulinemia
SBE
Infections
Hep C
Cancer
Aging

Front 43

What %age of patients with new RA will have a positive RF?

Back 43

50%

Front 44

What %age of patients with RA for 1-2 years will have a positive RF?

Back 44

80-85%

Therefore can repeat within a few years

Front 45

When might a CCP be useful?

Back 45

In suspected new RA, if Rf is negative.

(peptide produced in immune cascade of RA)

Front 46

What is it important to monitor in SLE?

Back 46

kidney function

kidney is a common target

Front 47

When would you order an ANA?

Back 47

When you suspect SLE or another Collagen Vascular disease

Front 48

When would you NOT order an ANA?

Back 48

If you suspect fibromyalgia

Front 49

If you get a positive ANA, and feel as though it's significant, what can you proceed with?

Back 49

ordering an ENA

Front 50

The higher the ANA titre the more severe the disease. True or false?

Back 50

True!

Front 51

ANA has a poor PPV and needs to be reserved for the right clinical situation? True or false?

Back 51

True

Front 52

You should follow an ANA or ENA. True or false?

Back 52

False!!

Front 53

When might you order an anti-DNA Ab?

Back 53

-suspected SLE (50% have)

- to follow disease activity as levels change with activity

Front 54

Which labs are important to follow in SLE?

Back 54

-CBC
-Creatinine, urinalysis
-DNA Ab
-C3, C4
-Check BP

-NOT ANA or ENA

Front 55

When would you order a CK?

Back 55

If you suspect polymyositis or dermatomyositis.

Front 56

A 30 year old woman presents to the office with multiple areas of MSK pain of 6 month duration. What are the key questions to ask on history?

Back 56

L- OPQRST AAA

1. ask her to point to location of pain

2. ask about onset: insidious, sudden?

3. ask about precipitating factors: trauma, infection, travel?

4. ask about quality of pain: dull, sharp, diffuse, localized?

5. ask about radiation of pain.

6. get her to rate severity of pain.

7. ask if pain is worse at a certain time during the day.

8. is there anything that particulary aggravates the pain?

9. is there anything that alleviates the pain?

10. what other symptoms are associated with the pain?

for FMS think malaise, fatigue, disturbed sleep, etc.

Front 57

Regarding the same patient as in the previous question. What would you look for when you examine her?

Back 57

1. Joint exam
2. FMS point count
3. lab work:
-CBC with diff
-biochem: Cr, liver enzymes
-ESR/CRP

Front 58

Would you do an RF or ANA in this patient?

Back 58

Depends.

a. If you had a strong clinical suspicions of RA, or other collagen vascular disease, then yes.

b. If you had a strong clinical suspicion of FMS, then no.

Front 59

A 70-year old woman comes to your office complaining of 3 months of pain and stiffness in the shoulder girdle and hip girdle. She feels worse in the morning.

What condition is associated with hip and shoulder girdle pain in elderly patients (>55 years)?

Back 59

Polymyalgia rheumatica

Front 60

What lab value is often very high in this condition?

Back 60

ESR

Front 61

What treatment would you order to confirm your clinical suspicion?

Back 61

Low dose prednisone.

A dx criterion of PMR is that it responds almost immediately to corticosteroids.

Front 62

What other symptoms must you ask about?

Back 62

Sx associated with temporal arteritis: headaches, jaw claudication.

1/3 of PMR is associated with TA.

Front 63

What else is important to consider in the pharmacological tx of PMR?

Back 63

- give a bisphosphonate to prevent corticosteroid associated bone loss.

Front 64

A 65 yo man presents with a history of 5 or so prior attacks of a painful, hot, swollen R 1st MTP joint. He cannot tolerate the bedsheets on his foot when these episodes occur. He has just had cardiac bypass surgery and he presents with a red, hot, swollen L knee and R 1st MTP.

What is your Ddx?

Back 64

REMEMBER!!!

-Septic
-Septic
-Septic
-Septic
-Septic
-Gout
-Pseudo-gout

MUST RULE OUT SEPTIC ARTHRITIS!!!!!!

Front 65

Regarding the previous patient, what is the key diagnostic procedure that you need to perform?

Back 65

joint aspiration

Front 66

If the joint was septic, how would you expect the fluid to look?

Back 66

Like a type II or II fluid.

Type II:
transparent to opaque, >25000 WBCs, >50% PMN's, variable viscosity

Type III: yellow - green with frank pus, opaque, >100,000 WBC's, >75-90% PMN's, decreased viscosity

- would expect culture to be positive

Front 67

If the joint inflammation was due to a crystal arthropathy, how would you expect the synovial fluid to look?

Back 67

Like a type II fluid.

would also expect to see crystal.

Na-monourate has negative birefringence, while CPPD has positive birefringence.

Front 68

What is important to remember about the use of allopurinol in the tx of gout?

Back 68

Do not treat with allopurinol until 3 attacks.

Do not treat an acute attack with allopurinol.

Front 69

How would you manage this patient acutely and over the long-term?

Back 69

1. Treat with NSAIDs
(can use colchicine and corticosteroids too, but both have side effects. Colchicine = diarrhea, cramps)

2. Start using allopurinol (for life) as this patients has had > 3 attacks. MUST wait until this attack subsides first.

Front 70

What side effects do you need to monitor with allopurinol use?

Back 70

Rash
elevated liver enzymes

Front 71

A 32 yo IVDU who shares needles presents to ER with skin lesions over legs and buttocks. He feels feverish and looks unwell.

What is your Ddx?

Back 71

1. SBE!
2. Hep C (+) cryoglobulinemia
3. vasculitis
4. Hep B associated serum sickness

Front 72

What lab work would you propose?

Back 72

1. CBC and diff
2. ESR
3. biochem: Cr and liver enzymes
4. Urinalysis
5. HIV
6. Hep B & C
7. Blood cultures and 2-D echocardiogram (to r/o SBE)


8. ANA
9. RF, cryocrit
10. ANCA, C3, C4
11. IgA (Henoch Schonlein purpura)

Front 73

Blood cultures and 2D echo are normal. Skin lesions persist and he has hematuria with RBC casts along with proteinuria.

What does this signify?

Back 73

Glomerulopathy

Front 74

What would be the next dx test that you would order?

Back 74

Kidney biopsy.

Expect to find pauci-immune glomerulonephritis (associated with the vasculitides)

Front 75

What is your dx and how would you tx the patient?

Back 75

1. Leukocytoclastic vasculitis

2. Tx aggressively with Corticosteroids after definitively ruling out infx.

Front 76

What is the gold standard of diagnosing vasculitis?

Back 76

Biopsy - cutaneous purpura are the simplest to biopsy.

Front 77

A 60 yo man presents with muscle weakness in the upper arms and thighs. He is on LASIX, SIMVASTATIN, and VASOTEC for cardiac issues. On exam he has weakness of the proximal mm's of arms and legs.

What is the key lab test to order?

Back 77

Creatine Kinase (released during muscle damage)

Front 78

How would you manage this patient?

Back 78

Statins associated with polymyositis/dermatomyositis and even in severe cases, rhabdomyolysis. Therefore stop the Statin!