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284 Cards in this Set
- Front
- Back
Rheumatoid arthritis affects mainly ___ membranes of ___ joints.
|
synovial
multiple |
|
Is RA more common in men or women?
|
women 3:1
|
|
What is the usual age of onset for RA?
|
20-40 years
|
|
Is susceptibility of RA genetically determined?
|
yes
|
|
Pathologic findings of RA include ___ synovitis with ___ formation.
|
chronic
pannus |
|
What is fibrous ankylosis?
|
stiffening or fixation of a joint that can be seen in chronic stages of RA
|
|
What is a significant factor in joint damage for RA?
|
inflammation
|
|
What type of nodules are generally seen with RA?
|
subcutaneous (20%)
|
|
What does the prodrome of RA include? (4)
|
malaise
weight loss vague periarticular pain stiffness |
|
What are the S/S of RA?
|
*symmetric joint swelling with stiffness, warmth, tenderness, and pain
|
|
When is stiffness with RA the worst?
|
in the morning (generally greater than 30 mins) and subsides throughout the day
|
|
How is RA differentiated from osteoarthritis?
|
RA
-morning stiffness usually lasts >30 mins (mornings the worst) osteoarthritis -mornings the best (gets worse throughout the day) |
|
What are the most common sites of RA?
|
PIP and MCP joints of the fingers
Wrists Knees Ankles Toes |
|
What is the most destructive element affecting joints in the patient with rheumatoid arthritis?
|
pannus
|
|
Is RA monoarticular?
|
not usually, but can be early in the disease
|
|
Does splenomegaly and lymph node enlargement generally occur with RA?
|
no (few patients have these S/S)
|
|
What are 4 common deformities associated with RA?
|
Ulnar deviation of the fingers
Boutonniere deformity (PIP) “Swan-neck” deformity (DIP) Valgus deformity of the knees |
|
What happens to the skin/muscle with RA?
|
atrophy
|
|
With RA, are the mucous membranes wet or dry?
|
dry
|
|
What are 5 conditions that may be associated with RA?
|
episcleritis
scleromalacia pericarditis pleural disease aortitis (rare late complication that can result in aortic regurg. or rupture) |
|
In what percentage of patients is rheumatoid factor present with RA?
|
75%
|
|
In what percentage of patients is ANA present w/ RA?
|
20%
|
|
Is the sed rate and gamma globulins elevated, normal, or decreased?
|
elevated
|
|
What type of anemia may be present with RA?
|
hypochromic, normocytic
|
|
Is the platelet count with RA elevated, normal, or decreased?
|
elevated
|
|
What is the most sensitive imaging technique done with RA?
|
x-ray (but not sensitive in first 6 months)
|
|
What x-ray changes may appear with RA?
|
-Earliest changes occur in the wrists or feet
-Erosions usually first seen at ulnar styloid |
|
What is included in the non-pharmacologic management of RA?
|
Education
Physical/occupational therapies Systemic rest Articular rest Exercise (joints/muscles/endurance) Heat/Cold assistive devices (hip/knee) splints weight loss |
|
What should a patient w/ RA know about splints?
|
-Night splints for hands/wrists/knee/ankle
-Should be applied for shortest time period needed -Corrective splints for contractures |
|
What is the first line drug used for RA?
|
NSAIDs (analgesic and anti-inflammatory effects)
-can also use selective COX-2 (Celibrex) |
|
What are the most common side effects of NSAIDs with RA?
|
GI side effects (can be serious and lead to death)
-PPI’s sometimes used to decrease GI problems |
|
What are DMARDs?
|
Disease-modifying anti-rheumatic drugs
|
|
When should DMARDs be started?
|
as soon as the diagnosis of RA is certain
|
|
What is the DMARD treatment of choice?
|
Methotrexate (beneficial effect w/in 2-6wks)
|
|
What 2 conditions is Methotrexate contraindicated in?
|
chronic hepatitis
pregnancy |
|
What type of DMARD drugs are given for RA if patient has no response to Methotrexate?
|
tumor necrosis factor inhibitors
-Etanercept (Enbrel, given subq) and Infliximab (Remicade, given IV) |
|
What is the downfall of tumor necrosis factor inhibitors?
|
high cost (more than $10,000 per year)
|
|
Tumor necrosis factor inhibitors work faster than ____ and may become the drug of choice after ___ in the future.
|
Methotrexate
NSAIDs |
|
What is the most common antimalarial DMARD used for RA?
|
Hydroxychloroquine sulfate
|
|
What is the most important potential reaction of Hydroxychloroquine sulfate?
|
pigmentary retinitis, which can lead to visual loss
|
|
When is Hydroxychloroquine sulfate useful for RA?
|
mild disease
also has a low toxicity |
|
When are corticosteroids used for RA?
|
-Immediate and dramatic anti-inflammatory effect
-May be able to slow rate of bony destruction **Not good long-term medication -Intra-articular steroids may be beneficial, can be used 4 times per year |
|
What may Sulfasalazine cause?
|
Second line agent that may cause neutropenia or thrombocytopenia
|
|
Which DMARD is a pyrimidine synthesis inhibitor?
|
Leflunomide
|
|
Leflunomide can be used alone or with ___.
|
Methotrexate
|
|
What is the downfall of using Lefludomide for RA?
|
drug is carcinogenic, teratogenic
|
|
Is Azathioprine (Imuran) mainly effective for mild or severe RA?
|
severe
|
|
What can Azathioprine (Imuran) cause?
|
immunosuppression
|
|
Is Minocycline used in mild or severe cases of RA?
|
early, mild cases (few side effects)
|
|
When is combination therapy used for RA?
|
when fail to respond to single agents
|
|
What are the DMARDs that can be used for RA?
|
-Methotrexate
-tumor necrosis factor inhibitor (Etanercept, Infliximab) -antimalarials (hydroxychloroquine sulfate) -corticosteroids (ex. prednisone) -Sulfasalazine -Leflunomide -Azathiprine -Minocycline -Gold salts & Penicillamine (now rarely used) -combo. therapy |
|
Can surgical measure be used to correct deformities with RA?
|
yes
|
|
How many years early do patients with RA generally die?
|
10-15 years earlier
|
|
What are the most common causes of death with RA?
|
infection, heart disease, respiratory failure, renal failure and GI disease
|
|
Is ankylosing spondylitis more common in men or women?
|
men
|
|
Does ankylosing spondylitis generally have a young or elderly onset?
|
young
|
|
Where is the pain with ankylosing spondylitis?
|
chronic, low back pain
|
|
What are the progressive limitations with ankylosing spondylitis?
|
back motion and chest expansion
|
|
Where are diagnostic x-ray changes seen with ankylosing spondylitis?
|
sacroiliac joint
|
|
What type of eye condition may show up with RA?
|
anterior uveitis (20-25%)
|
|
What do the labs for ankylosing spondylitis show?
|
elevated sed rate
negative RF HLA-B27 positive (genetic) |
|
Does ankylosing spondylitis have an acute or gradual onset?
|
gradual
|
|
Where may ankylosing spondylitis radiate?
|
down thighs
|
|
What type of condition is "bamboo spine" associated with?
|
ankylosing spondylitis
|
|
What happens with spondylitic heart disease?
|
AV conduction defects
Aortic insufficiency |
|
With ankylosing spondylitis, what may occur with the upper lobes of the lungs?
|
pulmonary fibrosis
|
|
Are constitutional symptoms usually present with ankylosing spondylitis?
|
no
|
|
How is ankylosing spondylitis treated?
|
Postural/breathing exercises
NSAIDS Physical therapy |
|
Which NSAID is thought to be the most effective for ankylosing spondylitis?
|
Indocin (Indomethacin)
|
|
What 3 meds. can be used for ankylosing spondylitis?
|
Indocin (indomethacin)
Sulfasalazine Tumor necrosis factor inhibitors (for refractory symptoms) |
|
What is the prognosis for ankylosing spondylitis?
|
-Almost all patients have long term symptoms
-Rarely there is long term remission |
|
What percentage of patients with ankylosing spondylitis will have work disability after 10 years?
|
10%
|
|
When is the worst prognosis seen with ankylosing spondylitis?
|
if hip disease develops within the first 2 years of disease onset
|
|
Psoriasis precedes ___ in 80% of cases.
|
arthritis
|
|
Is psoriatic arthritis symmetric or asymmetric?
|
asymmetric
|
|
What joint may be involved w/ psoriatic arthritis?
|
sacroiliac joint
|
|
What type of appearance do the finger and toes have with psoriatic arthritis?
|
"sausage"
|
|
Psoriatic arthritis is at least ___ times more common in patients with severe skin disease.
|
5
|
|
What may happen to the nails with psoriatic arthritis?
|
nail pitting
|
|
What do the labs for psoriatic arthritis show?
|
elevated sed rate
RF negative uric acid levels may be high |
|
What is the most helpful imaging modality for psoriatic arthritis?
|
x-rays
|
|
What may show up on x-ray of psoriatic arthritis?
|
-Marginal erosions of bone
-Irregular destruction of joints and bone -“Sharpened pencil” appearance of phalanges -Fluffy periosteal new bone -Paravertebral ossification |
|
How is the paravertebral ossification of psoriatic arthritis different from ankylosing spondylitis?
|
no paravertebral ossification in the anterior aspect of the spine with psoriatic arthritis
|
|
How is psoriatic arthritis treated?
|
-Symptomatic treatment
-NSAIDS for mild cases -Corticosteroids less effective -Methotrexate may be helpful in resistant cases -Tumor necrosis factor inhibitors for disease refractory to methotrexate -PUVA therapy may be helpful |
|
What type of arthritis was formerly known as Reiter's Syndrome?
|
reactive arthritis
|
|
What does the clinical tetrad for reactive arthritis include?
|
urethritis
conjunctivitis (sometimes uveitis) mucocutaneous lesions aseptic arthritis |
|
Who is reactive arthritis most common in?
|
young men
|
|
What percentage of patients with reactive arthritis are HLA-B27 positive?
|
50-80%
|
|
What does reactive arthritis often follow?
|
dysentery (male=female) or STD (males>females 9:1)
|
|
What types of "bugs" can cause dysentery which can lead to reactive arthritis? (4)
|
shigella, salmonella, yersinia, campylobacter
|
|
What types of "bugs" can cause a STD which can lead to reactive arthritis? (2)
|
chlamydia or Ureasplasma urealyticum
|
|
Are the affected joint cultures of reactive arthritis positive or negative?
|
negative
|
|
Is reactive arthritis commonly symmetric or asymmetric?
|
asymmetric
|
|
What joints does reactive arthritis commonly affect?
|
large weight-bearing joints (knee or ankle)
sacroiliitis in 20% of patients |
|
What are the S/S of reactive arthritis?
|
-Systemic symptoms may include fever and weight loss
-Mucocutaneous lesions (balanitis, stomatitis) -Fingernails may pit like psoriatic arthritis -May see “sausage” fingers and toes -Carditis and aortic regurgitation |
|
How is reactive arthritis treated?
|
-NSAIDS are mainstay of treatment
-Antibiotics at time of initial STD may prevent development of reactive arthritis -Tetracycline for 3 months can reduce duration of symptoms for reactive arthritis caused by chlamydia -Tumor necrosis factor inhibitors for refractory cases |
|
What 3 rheumatology conditions have sacro-iliac joint association?
|
ankylosing spondylitis
psoriatic arthritis reactive arthritis |
|
What 2 rheumatology conditions have asymmetric joint involvement?
|
psoriatic arthritis
reactive arthritis |
|
What 2 conditions may "sausage" fingers and toes appear?
|
psoriatic arthritis
reactive arthritis |
|
What is SLE?
|
systemic lupus erythematosis aka Lupus
|
|
Who does SLE most commonly affect?
|
young women
|
|
Where does the rash with SLE generally appear?
|
over sun-exposed areas
|
|
What percentage of patients with SLE have joint symptoms?
|
90%
|
|
Is hemoglobin, WBCs, and platelets increased or decreased with SLE?
|
decreased
|
|
What are the 2 major causes of morbidity with SLE?
|
CNS involvement and glomerulonephritis
|
|
How often is ANA positive with SLE?
|
*100%*
|
|
What type of disorder is SLE?
|
inflammatory autoimmune disorder
|
|
What happens to the antigen-antibody complexes with SLE?
|
they become trapped in capillaries
|
|
What happens to the host cells with SLE?
|
*Autoantibody-mediated destruction
|
|
Does SLE have a hereditary link?
|
yes
|
|
During what stage of a woman is SLE more common?
|
after menarche and before menopause
|
|
What must SLE be differentiated from?
|
drug-induced lupus-like syndrome
|
|
What are the 3 most common drugs that can cause drug-induced lupus-like syndrome?
|
Procainamide
Hydralazine Isoniazid |
|
What are 4 ways that drug-induced lupus-like syndrome can be differentiated from SLE?
|
-Sex ratio is nearly equal
-Not usually CNS features or nephritis -No antibodies to native DNA -Clinical features and lab abnormalities usually revert to normal when drug is withdrawn |
|
What is the diagnostic criteria for SLE? (4 of 11)
|
SOAP BRAIN MD
Serositis Oral ulcers Arthritis Photosensitivity Blood changes (hematologic) Renal involvement ANA (positive 100%) Immunological changes Neurological signs Malar rash Discoid lupus/rash |
|
What are the diagnostic criteria associated with renal disease with SLE?
|
> 0.5 g/day proteinuria, OR
3+ dipstick proteinuria, OR Cellular casts |
|
What are the immunologic abnormalties that are included in the diagnostic criteria for SLE? (4)
|
Positive LE cell preparation, OR
Antibody to native DNA, OR Antibody to Sm, OR False-positive serologic test for syphilis |
|
What are the systemic S/S of SLE?
|
fever
anorexia malaise weight loss |
|
What is the classic rash that is seen in 50% of SLE patients?
|
butterfly rash
|
|
What are the skin manifestations that may occur with SLE?
|
butterfly rash
discoid lupus periungual erythema splinter hemorrhages alopecia |
|
What type of "phenomenon" may occur with SLE?
|
Raynaud's
-often occurs before other features of the disease |
|
What are the ocular manifestations that may occur with SLE? (4)
|
Conjunctivitis
Photophobia Transient or permanent monocular blindness Cotton wool spots |
|
What may occur in the lungs with SLE? (4)
|
pleurisy
pleural effusion bronchopneumonia pneumonitis |
|
What are the cardiac symptoms that may occur with SLE?
|
*involvement of pericardium
cardiac failure (myocarditis/HTN) cardiac arrhythmias |
|
What may occur with the kidneys in patients with SLE?
|
Glomerulonephritis or interstitial nephritis
|
|
What may occur in the joints of SLE?
|
*joint pain +/- active synovitis
|
|
Is mesenteric vasculitis and neurologic symptoms part of the S/S of SLE?
|
yes
|
|
What do the labs with SLE show?
|
-ANA (sensitive, not specific)
-antibodies to double-stranded DNA & Sm (specific not sensitive) -depressed serum complement -3 types of antiphospholipid antibodies -Anemia -Leukopenia -Thrombocytopenia -Direct Coombs positive -Proteinuria -Hematuria -Hypocomplementemia |
|
What may the 3 types of antiphospholipid antibodies that may show up with SLE cause?
|
-One causes false-positives for syphilis
-Lupus anticoagulant --> risk factor for venous and arterial thrombosis and miscarriage -anticardiolipin antibodies --> affect a serum cofactor, not phospholipids directly |
|
Does SLE show a positive or negative direct Coombs test?
|
positive
|
|
Is SLE curable?
|
no, but it is treatable
|
|
What is the #1 goal of treatment with SLE patients?
|
patient education and emotional support
|
|
What should photosensitive patients with SLE do?
|
limit sun exposure and use sunscreen
|
|
What can be used for a rash with SLE?
|
topical corticosteriods
|
|
What is used for joint pain with SLE?
|
rest
NSAIDs |
|
What type of medication with SLE is used for rashes and joint symptoms that do not respond to NSAIDs?
|
Hydroxychloroquine
|
|
What type of medication might be effective for thrombocytopenia with SLE?
|
Danazol
|
|
What type of medication is used for more serious SLE cases?
|
corticosteroids
-CNS disease may require higher doses -taper to lowest effective dose |
|
What is used for lupus nephritis associated with SLE?
|
immunosuppressant mycophenolate mofetil (CellCept)
|
|
What are all the treatment options for SLE?
|
-patient education & emotional support
-limit sun exposure -topical corticosteroids -Hydroxychloroquine -Danazol -DHEA (side effect may limit use) -corticosteroids -CellCept |
|
What is the course/prognosis of SLE?
|
-Usually a remitting and relapsing course
-10 year survival rates > 85% -5 times increased risk of MI -Outlook is becoming increasingly favorable due to recent advances in therapy |
|
What is scleroderma?
|
autoimmune widespread thickening/hardening of the skin
|
|
Where does scleroderma commonly occur on the body?
|
Areas of increased pigmentation and depigmentation
|
|
What are 2 rheumatology conditions that Raynaud's phenomenon may occur in?
|
SLE
scleroderma |
|
Does scleroderma have a positive or negative ANA?
|
positive
|
|
What is the cause of scleroderma?
|
unknown
|
|
Where does diffuse fibrosis of scleroderma occur?
|
skin
internal organs |
|
*Who does scleroderma more commonly affect?
|
women > men
20s to 40s |
|
What are the 2 forms of scleroderma?
|
Limited (CREST syndrome) – skin fibrosis limited to face and hands
Diffuse – may have tendon friction rubs |
|
What does CREST (which is associated with SLE) stand for?
|
Calcinosis
Raynaud's phenomenon Esophageal dysfunction Sclerodactyly Telangiectasias |
|
Is the kidneys and GI tract involved with limited scleroderma?
|
no involvement of kidneys, but does have involvement of GI tract
|
|
What are the S/S of scleroderma?
|
*dysphagia
*GI hypomotility *pulmonary fibrosis *cardiac involement *scleroderma renal crisis skin changes polyarthralgia Raynaud's phenomenon fever and malaise telangiectasia pigmentation changes fingertip ulceration |
|
How does the skin change with scleroderma?
|
subcutaneous edema, then thickening and loss of folds
|
|
What are the cardiac abnormalities that may occur with scleroderma?
|
pericarditis
heart block myocardial fibrosis right heart failure |
|
What is calcinosis?
|
calcium deposits in the skin
|
|
What is Raynaud's phenomenon?
|
spasm of blood vessels in response to cold or stress
|
|
What is the esophageal dysfunction that may occur with CREST syndrome associated with limited scleroderma?
|
acid reflux and decrease in motility of esophagus
|
|
What is sclerodactyly?
|
thickening and tightening of the skin on the fingers and hands
|
|
What is telangiectasias?
|
dilation of capillaries causing red marks on surface of skin (like broken spider veins)
|
|
What do the labs for scleroderma show?
|
mild anemia
positive ANA scleroderma antibody (SCL-70) in 33% |
|
How is scleroderma treated?
|
symtomatic/supportive
no known med. will alter disease progress |
|
How is Raynaud's treated with scleroderma?
|
calcium channel blockers, or losartan
|
|
How are the digital ulcers with scleroderma treated?
|
IV iloprost
|
|
How is esophageal reflux with scleroderma treated?
|
PPI
|
|
How is malabsorption associated with scleroderma treated?
|
tetracycline
|
|
How is a renal crisis associated with scleroderma treated?
|
ACE-I
|
|
How is pulmonary fibrosis for scleroderma treated?
|
cyclophosphamide
|
|
What is the percentage of a 9 year survival rate with scleroderma?
|
40%
|
|
What are 2 types of cancer that scleroderma may have an increased risk for?
|
breast and lung cancer
|
|
What are the sicca components of Sjogren's syndrome?
|
*dryness of eyes and dry mouth
|
|
Sjogren's syndrome has an increased incidence of ___.
|
lymphoma
|
|
What is Sjogren's syndrome?
|
-Chronic autoimmune dysfunction of exocrine glands in many areas of the body
-Alone or in association with rheumatoid arthritis or other connective tissue diseases |
|
What is keratoconjunctivitis sicca?
|
associated with Sjogren's syndrome
-Decreased tear production -Lymph and plasma cell infiltration of lacrimal glands |
|
What are the associated conditions that may occur with Sjogren's syndrome?
|
*RA
Lupus Biliary cirrhosis Scleroderma Polymyositis Hashimoto’s thyroiditis Polyarteritis nodosa Idiopathic pulmonary fibrosis |
|
Who does Sjogren's syndrome commonly occur in?
|
women > men (9:1)
greatest incidence from 40-60 years |
|
What are the S/S of Sjogren's syndrome?
|
eye problems
parotid gland enlargement (1/3 of patients) *xerostomia *loss of taste/smell pancreatitis pleuritis obstructive lung disease vasculitis renal tubular acidosis 20% chronic interstitial nephritis |
|
What S/S may occur with the eyes in Sjogren's syndrome patients?
|
ocular burning/itching
*ropy secretions "grain of sand" sensation |
|
What are 3 complications that may occur due to xerostomia associated with Sjogren's syndrome?
|
Difficulty swallowing dry foods
Increased thirst *Increased dental caries |
|
What do the labs for Sjogren's show?
|
RF positive (60-70%)
ANA positive (70%) SS-A and SS-B antibodies |
|
What may SS-A antibodies with Sjogren's syndrome be associated with?
|
more extra-glandular manifestations
|
|
What diagnostic procedures can be done for Sjogren's syndrome?
|
lip biopsy (salivary glands)
parotid gland biopsy *Schirmer test |
|
What are 2 ways that the Schirmer's test for Sjogren's syndrome can be performed?
|
-measure amount of moisture in eye with thin paper strip
-put flourescein drops in eyes and see if when blow nose yellow comes out (shows nasolacrimal duct is working if it does) |
|
What type of medication can be used for Sjogren's syndrome?
|
Pilocarpine (severe xerostomia) OR Cevimiline is alternate
|
|
What type of drugs should be avoided with Sjogren's syndrome?
|
*decongestants and atropinic drugs
-b/c they dry you out even more :( |
|
What type of "therapies" can be used to treat Sjogren's syndrome?
|
Supportive treatment
Artificial tears Hard candies or gums Good oral hygiene |
|
What are the complications of Sjogren's syndrome?
|
-Benign or malignant lymphoproliferation
-Malignant lymphomas (3 – 10%) -Waldenström’s macroglobulinemia |
|
What is Waldenström’s macroglobulinemia?
|
Rare disease featuring a bone marrow tumor of B cells that generates large quantities of a monoclonal antibody
|
|
What S/S increase the risk of lymphoma in Sjogren's syndrome patients?
|
marked parotid enlargement, splenomegaly, vasculitis, anemia, peripheral neuropathy
|
|
What is the prognosis for Sjogren's syndrome?
|
-Usually good prognosis with normal life span
-Prognosis related to types of associated disease -Risk of lymphoma |
|
Who is fibromyalgia most common in?
|
women ages 20 – 50
|
|
What is fibromyalgia?
|
a common rheumatic syndrome
-Chronic widespread musculoskeletal pain syndrome with multiple tender points |
|
What syndrome does fibromyalgia share many features with?
|
chronic fatigue syndrome (CFS)
|
|
What are 3 proposed causes of fibromyalgia?
|
Sleep disorders
Depression Viral infections however, cause is unknown |
|
What are 5 conditions that fibromyalgia is a complication of (has an increased incidence for)?
|
Hypothyroidism
RA Sleep apnea (in men) osteoarthritis lyme disease |
|
What are the 3 components of the immune system overload ("the cup runneth over")?
|
stressful episode
injury lingering illness |
|
What are the associated symptoms with fibromyalgia? (10)
|
Chronic Fatigue Syndrome
Irritable Bowel Syndrome Tension Headache Migraine Headache Primary Dysmenorrhea Restless legs syndrome Periodic limb Movement Disorder Temporomandibular joint pain Myofascial Pain Syndrome |
|
What is the most common symptoms of fibromyalgia?
|
widespread pain throughout the body. It may start in the neck and shoulders and spread over time
-It may vary according to time of day, activity level, weather, sleep patterns and stress |
|
What are the clinical findings with fibromyalgia?
|
-Chronic aching pain and stiffness, often involving the entire body but with prominence of pain around neck, shoulders, low back, and hips
-Fatigue, sleep disorders, subjective numbness, chronic headaches, and irritable bowel symptoms are common |
|
According to the American College of Rheumatology, what does a person have to have in order to be diagnosed with fibromyalgia?
|
condition if there is a history of pain for at least 3 months in at least 11 of 18 specific tender point sites on the body
|
|
What are the "trigger points" of pain produced by palpation with fibromyalgia (PE is otherwise normal)?
|
trapezius
medial fat pad of knee lateral epicondyle of elbow |
|
What may a patient come in and say if the have fibromyalgia?
|
"I hurt all over"
-Widespread musculoskeletal pain |
|
What quadrants are involved with fibromyalgia?
|
Each of 4 body quadrants involved (regional)
-Pain on left and right side of body -Pain above and below waist |
|
Is axial skeleton pain present with fibromyalgia?
|
yes
-Cervical spine -Anterior chest -Thoracic spine -Low back |
|
When is the pain the worse with fibromyalgia?
|
in the morning and at the end of the day
|
|
What labs should be done if fibromyalgia is suspected?
|
TSH
CBC ESR CK sleep study ANA RF |
|
How is fibromyalgia treated?
|
Patient education
Exercise daily Stress reduction Medications Alternative/complimentary medicine |
|
What meds. can be used to treat fibromyalgia? (5)
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TCA
Pregabalin (Lyrica) Amitriptyline (Elavil) Fluoxetine (Prozac) Chlorpromazine (Thorazine) Cyclobenzaprine (Flexeril)q |
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What types of alternative/complimentary medicine can be done for fibromyalgia? (5)
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Chiropractor
Massage Osteopathic Acupressure/acupuncture biofeedback |
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Is fibromyalgia a progressive condition?
|
no
|
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What is the prognosis of fibromyalgia?
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Chronic symptoms
Can resume activities |
|
Is cancer risk greater with polymyositis or dermatomyositis?
|
Dermatomyositis
|
|
What is polymyositis?
|
Inflammation of muscle fibers
Etiology unknown WBCs invade muscles Most commonly trunk/torso Severe weakness Flares and relapses |
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What are the associated diseases with polymyositis?
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Lymphoma
Breast Ca Ovarian Ca Colon Ca SLE Scleroderma RA |
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What is the most common symptom of polymyositis?
|
muscle weakness
|
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What muscles are generally involved with polymyositis?
|
those that are closest to the trunk of the body
|
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What are the S/S of polymyositis?
|
Muscle weakness
Onset – gradual/rapid Muscle atrophy Difficulty getting up from chair, stairs, raising arms over head Muscle ache Muscle pain with palpation Fatigue Weight loss Low-grade fever Skin involvement(dermatomyositis) |
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What is Gottron's sign, which is associated with polymyositis?
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scaly reddish discoloration over the knuckles, elbows and knees
|
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In childhood dermatomyositis, what can develop in the fatty layer of the skin?
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hard lumps of calcium deposits
|
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What can heart and lung involvement with polymyositis lead to?
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irregular heart rhythm, heart failure, and shortness of breath
|
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Who is polymyositis more common in?
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females
middle childhood and 20s and elderly (bimodal distribution) |
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Is polymyositis a systemic disease?
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it can be
-it is if it affects other areas of the body |
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What is the typical rash of dermatomyositis?
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dusky, erythematous eruption over the face, perioral regions, neck, shoulders, chest, and arms
|
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What is pathognomonic of dermatomyositis?
|
heliotrope suffusion
around the eyes |
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What is the diagnostic criteria for polymyositis?
|
four or more of the following:
-Proximal muscle weakness (trunk, thighs, shoulders) -Increased serum CPK -Muscle pain on grasping or spontaneously -EMG myogenic changes -Positive anti-Jo1 antibody -Nondestructive arthritis or arthralgia -Pathologic inflammatory signs -Systemic inflammatory signs (Temperature over 37 C at axilla, C-Reactive Protein increased, ESR >20 mm/hour) |
|
How is polymyositis treated?
|
Prevent atrophy/contractures
treat dermatomyositis Prednisone Methotrexate Azathioprine (Imuran) IV immunoglobulin Rituximab (B cell depletion therapy) |
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How is dermatomyositis treated?
|
pruritus management
topical corticosteroid avoid sun exposure |
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What are vasculitis syndromes?
|
Heterogeneous group of disorders characterized by inflammation within the walls of affected blood vessels
|
|
How are vasculitis syndromes classified?
|
by size of vessel
|
|
What 2 conditions can occur with small vessel vasculitis syndrome?
|
Henoch-Schönlein purpura and Wegener’s granulomatosis
|
|
What condition can occur with medium vessel vasculitis syndrome?
|
polyarteritis nodosa
|
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What 2 conditions can occur with large vessel vasculitis syndrome?
|
temporal arteritis
Behçet’s syndrome |
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What is the most common vasculitis seen in children?
|
Henoch-Schönlein Purpura
(also occurs in adults) |
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What are the 4 typical features of Henoch-Schönlein Purpura?
|
Palpable purpura
Abdominal pain Arthritis Hematuria |
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What happens with Henoch-Schönlein Purpura?
|
Leukocytoclastic vasculitis with IgA deposition
|
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Where is the purpura usually located with Henoch-Schönlein Purpura?
|
typically on the lower extremities
|
|
How long does Henoch-Schönlein Purpura usually last?
|
Usually self-limited disease lasting 1-6 weeks
|
|
Who is Henoch-Schönlein Purpura more likely to become chronic in?
|
in adults --> persistent or intermittent purpura
|
|
How is Henoch-Schönlein Purpura treated?
|
Corticosteroids (some pts)
Azathioprinen (renal disease) |
|
What is the (original) triad for Wegener’s granulomatosis?
|
upper respiratory disease
lower respiratory disease GN |
|
When should Wegener’s granulomatosis be suspected?
|
if nasal congestion or sinusitis are refractory to usual treatment
|
|
What is the pathology triad for Wegener’s granulomatosis?
|
small vessel vasculitis
granulomatous inflammation necrosis |
|
Wegener’s granulomatosis is a prototype of ___ associated disease.
|
ANCA (90%)
|
|
Wegener’s granulomatosis is generally fatal within ___ year(s) of diagnosis if not treated.
|
1
|
|
Who is Wegener’s granulomatosis most common in?
|
Men = women
Most common in 30s and 40s |
|
What percentage of patients with Wegener’s granulomatosis present with upper or lower respiratory symptoms or both?
|
90%
|
|
How many months does Wegener’s granulomatosis develop over?
|
4-12 months
|
|
What are the upper respiratory symptoms that may show up with Wegener’s granulomatosis?
|
nasal congestion
sinusitis otitis media mastoiditis gum inflammation stridor |
|
What are the lower respiratory symptoms that may show up with Wegener’s granulomatosis?
|
cough
dyspnea hemoptysis |
|
What are the S/S of Wegener’s granulomatosis?
|
-Migratory oligoarthritis
-Ocular disease -Purpura or other skin lesions -Renal disease -Fever, malaise, weight loss -upper/lower respiratory S/S -Congestion/crusting/ulceration/perforation of nasal septum -“Saddle nose” deformity -Proptosis/ptosis/episcleritis -DVT/PE are common -Microscopic hematuria -Segmental necrotizing GN with crescent formation |
|
What do the labs for Wegener’s granulomatosis show?
|
Slight anemia
mild leukocytosis ANCA (90%) Hematuria with RBC casts Bony sinus erosions Lung granulomas Histology shows vasculitis, granulomatous inflammation, necrosis, acute and chronic inflammation |
|
What does a CXR or CT for Wegener’s granulomatosis show?
|
infiltrates, nodules, masses, and cavities
|
|
How is Wegener’s granulomatosis treated?
|
-Cyclophosphamide (3-6 months)
-Azathioprine or Methotrexate (maintain remission) *Early treatment is crucial |
|
Are TNF inhibitors effective with Wegener’s granulomatosis?
|
no
|
|
What type of HTN is involved with Polyarteritis Nodosa?
|
Renin-mediated
|
|
What is Polyarteritis Nodosa?
|
Necrotizing arteritis of medium sized vessels
|
|
What are 10% of Polyarteritis Nodosa cases caused by?
|
hepatitis B
|
|
What type of onset does Polyarteritis Nodosa have?
|
insidious with fever, malaise and weight loss
|
|
What occurs in the extremities with Polyarteritis Nodosa? (3)
|
arthralgia
myalgia neuropathy |
|
What are the typical skin findings with Polyarteritis Nodosa? (3)
|
livedo reticularis
subcutanous nodules skin ulcers |
|
What can Mesenteric vasculitis associated with Polyarteritis Nodosa cause?
|
acute abdomen
-abdominal pain w/ N/V |
|
What do the labs for Polyarteritis Nodosa show?
|
Slight anemia and leukocytosis
Sed rate usually elevated Assess for hepatitis B |
|
Is there a disease specific serologic test for Polyarteritis Nodosa?
|
no
|
|
What is used to confirm diagnosis for Polyarteritis Nodosa?
|
biopsy and angiography
-Biopsy of involved organ is essential -Angiography may show microaneurysms |
|
How is Polyarteritis Nodosa treated?
|
-High dose corticosteroids
-Cyclophosphamide (lowers mortality/morbidity) patients with Hep B: short course of prednisone followed by lamivudine and plasmapheresis 3 x/week |
|
What is the prognosis for Polyarteritis Nodosa?
|
-5 year survival rate is 20% without treatment
-With treatment, 5 year survival rate is 60 – 90% |
|
Who is Behçet’s Syndrome most common in?
|
Asian, Turkish or Middle Eastern people
|
|
Does Behçet’s Syndrome involve arteries or veins?
|
both
|
|
What is “pathergy” phenomenon (Behçet’s Syndrome)?
|
sterile pustule at site of needle stick
|
|
What is the hallmark of Behçet’s Syndrome?
|
painful aphthous ulceration in the mouth
|
|
What are the S/S of Behçet’s Syndrome?
|
-Recurrent, painful aphthous ulcers of mouth and genitals
-Tender papular lesions that mimic erythema nodosum that tend to ulcerate -Pathergy phenomenon -Nonerosive arthritis of knees and ankles -Uveitis may be severe -Increased thrombotic events -CNS involvement |
|
How may the CNS be involved with Behçet’s Syndrome? (4)
|
Aseptic meningitis
Cranial nerve palsies Seizures Spinal cord lesions |
|
How is Behçet’s Syndrome treated?
|
Corticosteroids
azathioprine Cyclophosphamide (severe ocular/CNS disease) |
|
Are Giant Cell Arteritis & Polymyalgia Rheumatica
a spectrum of the same disease? |
yes
|
|
What is the clinical diagnosis of Polymyalgia Rheumatica based upon?
|
pain and stiffness of the shoulder and pelvic girdle
|
|
What are the S/S of Polymyalgia Rheumatica?
|
-pain and stiffness of the shoulder and pelvic girdle
-Fever, malaise, and weight loss -No muscular weakness |
|
Is the sed. rate increased or decreased with Polymyalgia Rheumatica?
|
elevated > 50
|
|
How is Polymyalgia Rheumatica treated?
|
Prednisone
Methotrexate (some patients) |
|
Are disease flares common with Polymyalgia Rheumatica?
|
yes
|
|
What is one big difference b/t fibromyalgia and chronic fatigue syndrome?
|
-pain is major component with fibromyalgia
-fatigue is major component with chronic fatigue syndrome |
|
With deep palpation of trigger points in fibromyalgia, is the pain localized or does it radiate?
|
stays localized
|
|
Is fibromyaliga unilateral or bilateral?
|
bilateral
|
|
Does fibromyalgia affect the upper or lower body?
|
both
|
|
Is fibromyalgia symmetrical?
|
yes
|
|
Is Henoch-Schonlein purpura blanching or non-blanching?
|
non-blanching (will still be red when pushed on)
|