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39 Cards in this Set
- Front
- Back
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autoimmune disease |
pathologic condition caused by an adaptive autoimmune response
an immune response is directed against an antigen within the body of the host - could be induce by a foreign or self antigen - usually involves a T- cell and B-cell response
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arthralgia |
joint pain symptom of injury, infection, illness (in particular arthritis) or an allergic reaction to a medication |
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difference between arthralgia and arthritis |
arthralgia: noninflammatory condition arthritis: inflammatory condition |
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sensitivity |
proportion of patients with a disease who have a positive test result
*independent of prevalence |
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specificity |
proportion of patients without the disease who have a negative test result
*independent of prevalence |
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predictive value |
likelihood of disease or non-disease based on a positive or negative test result
* affected by disease prevalence |
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high positive predictive value high negative predictive value |
- patient with a positive result probably has the disease in question - patient with a negative result most likely does not have the disease in question |
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t/f: rarely is a test useful as both a diagnostic and evaluative tool |
true: evaluative tests are used to monitor disease overtime
testing for autoimmune antibodies should be done selectively and only when suspicion is high |
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antibody tests for specific autoimmune diseases SLE
Drug induced SLE |
SLE: - anti (ds) DNA (tests for abnormal cells in bone marrow of SLE patients) - anti smith Ag
drug induced SLE: - anti- histone |
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antibody tests for specific autoimmune diseases CREST syndrome |
anticentromere |
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antibody tests for specific autoimmune diseases mixed disease scleroderma |
anti RNP (ribonucleo protein) anti SCL 70 |
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antibody tests for specific autoimmune diseases dermatomyositis sjorgen's syndrome wegener's granulomatosis |
anti jo1 anti ro, anti la ANCA |
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joint fluid analysis (parameters to facilitate diagnosis) |
differentiate based on joint fluid WBC per mm red fluid >> hemorrhagic (trauma, tumor, coagulopathy) % polymorphonuclear leukocytes (PMNs) crustal analysis gram staining & culture arthocentesis if infection is suspected warfarin is not contraindicated experienced rheumatologist |
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joint fluid analysis (parameters to facilitate diagnosis) WBC per mm |
< 2,000 >> non- inflammatory (OA, viral infection) > 2,000 - 10,000 >> inflammatory (gout, pseudogout) > 100,000 >> septic (even <100,000 with fever consider septic unless proven otherwise) |
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acute arthritis |
"acute" less than 6 weeks duration "arthritis" inflammation localized in the articular structure, swelling (synovitis and/or effusion), warmth, discomfort, redness - distinct from arthralgia, peri-arthritis, tendinitis, bursitis, etc
acute or sub acute onset joint symptoms are not frequently serious and are often self limitied |
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MSK emergencies |
- infection: septic arthritis, septic emboli, osteomyelitits - fracture - operable full/partial tendon/ ligament tears - compartment syndrome - entrapment neuropathy/ mononeuritis multiplex - myelopathy/myelitis - primary or secondary bone tumors - vascular: DVT or arterial insufficiency |
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goals for the initial eval of joint complaints |
- distinguished articular vs. non-articular complaint - determine inflammatory vs. noninflammatory features - identify and triage MS emergencies appropriately - assess whether history, current symptoms and exam are consistent with a specific systemic rheumatic disease - obtain appropriate testing - establish short term and long term plan, know when to refer |
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acute monoarthritis |
- if there's a bacterial infection >> it may cause rapid joint destruction and eventual sepsis - septic arthritis: hematogenous seeding of synovium; can be extension from site trauma or osteomyelitis - distinguish between inflammatory (infectious vs noninfections) vs non inflammatory causes of monoarticular arthritis |
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acute monoarthritis: differential diagnosis |
- infection: bacterial, virus, fungi/spirochetes/mycobacteria - crystal induced arthropathies - trauma - hemarthrosis (impact, tear) - osteonecrosis - gonococcal |
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infectious inflammatory acute monoarthritis gonococcal |
typically sexually active young adults more common in women than men pustules on extremities and trunk - anogential infection, often asymptomatic - work up: reveals + blood culture; sterile joint fluid
these may or may not be present: polyarthralgia (monoarthritis in 50%), fever, tenosynovitiis (es wrist), minimal joint effusion |
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infectious inflammatory acute monoarthritis non gonococcal |
- gram positive anaerobes in most cases (S aureus mostly) - gram negatives 10-20% (e coli, proteus, kiebsiella, very young, elderly, IV drug use, immunocompromised) - anaerobes uncommon, diabetes a risk - prodrome of malaise and fever (fever often mild, only 30-40% with temp above 39 C) - large joint predilection (knees/hips > shoulders > wrist/ankles) - requires aggressive management: serial aspiration to dryness vs. open surgical drainage with lavage, parenteral antibiotics, splinting and physical therapy to prevent contractures & muscle atrophy |
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infectious inflammatory lyme disease |
features depend on phase of disease - early disseminated lyme: poly arthralgia, ELISA may be negative - late lyme weeks to months after primary infection: ELISA + - Mono, oligo, occasionally poly arthritis - tends to be asymmetric, large/medium joint - large effusion in a single knee in most |
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infectious inflammatory other infectious organisms |
mycobacteria infection for immunocompromised patients including HIV, transplant, diabetic, geri, elderly
acute HIV look for acute monoarticular or oligoarticular arthritis |
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noninfectious inflammatory monoarthritis |
- acute gout - pseudogout - immunologic disease: immunologically mediated diseases can present as monoarthritis (RA, reiter's syndrome; ankylosing spondylitis, psoriatic arthritis, arthritis assoc with IBD) - acute trauma: meniscus; fracture extending into joint space; trauma resulting in hemoarthrosis - osteoarthritis: degeneration of hyaline articular cartilage with adjacent bony sclerosis and proliferation (may be painful and inflamed) |
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how do you take a history for monoarthritis |
note the onset, symptoms, location, risk factors, concurrent illness - review for septic cause: abrupt onset (fever/chills); h/o skin lesions; vaginal or urethral discharge; exposure to GC, tick bites, concurrent RA/DM; h/o joint prosthesis, immunosuppression, h/o IV drug use or HIV - acute trauma: h/o periarticular injury; internal derangement, hemarthrosis - prior attacks, ddx of gout, pseudogout more common in elderly - review alcohol use: think ddx gout; trauma, infection - back pain/stiffness: think ddx spondyloarthropathies - in younger patients: ddx reiter's syndrome; ankylosing spondylitis; GC - consider co-morbities: IBD, psoriasis, hypothyroidism; h/o gout - meds: diuretics, antihypertensives, anticonculsants; cholesterol lowering medications can cause msk symptoms - review social hx: work/travel - family hx: connective tissue disease; psoriasis, IBD, gout |
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history timing of symptoms |
- rapid onset vs. slow/insidious rapid: trauma, septic crystalline slow: systemic rheumatic disease or non-inflammatory process (osteoarthritis) - AM vs PM AM: prolonged in systemic rheumatic disease PM: sprain/strain/ non-inflammatory processes - worse with activity or rest worse with activity: tendinitis/bursitis/non-inflammatory processes worse with rest: systemic rheumatic disease - time from no symptoms to maximal intensity rapid: trauma, septic, crystalline
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history confined to joints or interarticular mono vs. oligo vs. polyarticular pattern of joints affected |
- confined to joints or inter- articular localized to joints: arthritis or arthralgia interarticular: diffuse pain syndromes mono vs. oligo vs. polyarticular - polyarticular less likely to be septic arthritis (poly septic arthritis still possible) - monoarticular can still be an early presentation of a systemic rheumatic disease - pattern of joints affected small joint peripheral vs. large joint vs. axial involvement clues to type of systemic rheumatic disease if presentation is polyarticular
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history recent trauma warmth and swelling intensity and quality of symptoms |
- recent trauma possible fracture, sprain, strain, tendon/ligamentous rupture, etc acute attacks of CPPD often preceded by traumas - warmth and swelling hot to touch: septic or crystalline cool: non inflammatory - intensity and quality of symptoms 0-10 pain scale, "touch me not" highest often in septic or crystalline - quality of symptoms stiffness pain: systemic rheumatic diseases vague, deep ache: hyperparathyroidism, osteomalacia, bone lesions (night pain) burning/numbness/tingling: neurogenic claudication: vascular vs. spinal stenosis |
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history symmetry constitutional/prodromal symptoms prior similar episodes |
- symmetry: certain systemic rheumatic disease - constitutional prodromal symptoms: infection or systemic rheumatic diseases, occasionally crystalline - prior similar episodes less likely to be infections intercritical return to complete normally crystalline arthritis |
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history sick contacts, etc specific indicators of systemic rheumatic disease |
- sick contacts, travel, pets/exposures, recent infections, comorbidities, sexual history, IV drug use, immunocompromised state - specific indicators of systemic rheumatic diseases: cutaneous manifestation, swollen glands, raynaud's, oral/nasal ulcers, pleurisy, pericarditis, eye inflammation, nail changes, dry eyes/ mouth, proximal muscle weakness, sinusitis, hearing loss |
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physical exam articular extra articular |
- articular: inspection, range of motion, palpation: warmth, erythema, swelling, effusion, tenderness, deformity, crepitus, stability - extra- articular: multi system exam |
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distinguishing exam features sign: symmetry tendinitis/ bursitis: non inflammatory: systemic rheumatic diseases: |
sign: symmetry tendinitis/ bursitis: uncommon non inflammatory: occasional systemic rheumatic diseases: common |
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distinguishing exam features sign: inflammation tendinitis/ bursitis: non inflammatory: systemic rheumatic diseases: |
distinguishing exam features sign: inflammation tendinitis/ bursitis: over tendon/bursa non inflammatory: unusual systemic rheumatic diseases: common |
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distinguishing exam features sign: tenderness tendinitis/ bursitis: non inflammatory: systemic rheumatic diseases: |
distinguishing exam features sign: tenderness tendinitis/ bursitis: focal non inflammatory: unusual (variable) systemic rheumatic diseases: over entire joint space |
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distinguishing exam features sign: instability tendinitis/ bursitis: non inflammatory: systemic rheumatic diseases: |
distinguishing exam features sign: instability tendinitis/ bursitis: uncommon non inflammatory: occasional systemic rheumatic diseases: uncommon |
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distinguishing exam features sign: locking tendinitis/ bursitis: non inflammatory: systemic rheumatic diseases: |
distinguishing exam features sign: locking tendinitis/ bursitis: unusual expect with tears non inflammatory: possible -- implies loose body or internal derangement systemic rheumatic diseases: uncommon |
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distinguishing exam features sign: mutli- system disease tendinitis/ bursitis: non inflammatory: systemic rheumatic diseases: |
distinguishing exam features sign: mutli- system disease tendinitis/ bursitis: no non inflammatory: no systemic rheumatic diseases: often |
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physical exam arthritis periarticular findings VS skin lesions |
- arthritis: associated with loss of motion, aggravated by motion - periarticular findings (tendinitis, bursitis, cellulitis) ROM of joints likely maintained if periarticular - VS: fever + septic arthritis; +/- low grade then gout; RA - skin lesions: necrotic lesions (GC); splinter hemorrhages (endocarditis >> HIV/IVDA), needle tracks, tophi (gout); RA nodules; pitting of nails (psoriatic) erythema nodosum (scaridosis; IBD); keratoderma blonorhagicum/cirinate balanitis (reiter's syndrome); rashes |
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physical exam eyes: mouth: heart: genitalia: spine: |
physical exam eyes: conjuctivities; iritis, fundi for ssx endocarditis mouth: oral lesions heart: murmurs genitalia: GC urethritis, cervicitis spine: restriction of motion; tenderness (spondylitis) |
