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Rheumatology
Y2S1B1
| Orthopaedic Disease | Features |
|---|---|
| RA | symmetric joint pattern; MCPs and PIPs...rarely distal joints; synovial membranes; inflammatory; extra-articular features |
| OA | weight bearing joints; asymmetric; DIPs |
| Pannus | chronic inflammatory tissue that erodes/invades joint |
| Essentials of Dx of Ankylosing Spondylitis | Chronic LB pain (worse in am); restriction of back/chest motion; inflammatory eye disease, SIJ abnormalities; elev. ESR; RF neg; HLA-B27; peripheral arthritis |
| Essentials of Dx of Rheumatoid Arthritis | insidious onset in sm joints; x-rays joint erosions/narrowing; RF+; extra-articular manifestations (Rhematoid nodules, Sjogren's, Felty's, vasculitis, rheumatoid lung, cardiac disease, neuromyopathy, inflammatory eye disease, osteoporosis) |
| Schirmer's Test | detect tear production in pts with autoimmune disease involving exocrine glands (salivary/lacrimal); Sjogren's Syndrome |
| Rheumatoid nodules | 100% RF+ |
| Schober's Test | used for ankylosing spondylitis for measuring restriction of motion of lumbar spine |
| Essentials of Dx of Psoriatic Arthritis | Psoriasis precedes arthritis in 80%; asymmetric arthritis w/sausage digits incl DIP joints; RF neg; SIJ involvement w/ankylosis; x-ray (osteolysis, pencil-in-cup deformity, lack of osteoporosis); enthesopathy (at soft tissue attachment to bone/joint) |
| "Classic" Psoriatic Arthritis | DIP arthritis with nail change |
| "Common" Psoriatic Arthritis | asymmetric oligoarthritis |
| Essentials of Dx of Reactive/Reiter's Arthritis | 50-80% HLA-B27+; oligoarthritis; conjunctivitis; urethritis; mouth ulcers; usually follows dysentery or and STD |
| Essentials of Dx of Septic Arthritis | Sudden acute onset of MONOARTHRITIS (lg WB joints/wrist); compromised pts - IVDA/preexisting arthritis; infections in body (N.gonorrhea, S.aureus, S.pyogenes, G-bacilli (e.coli, salmonella, pseudomonas), Hemophilus); no dermatitis or tenosynovitis |
| Class I Joint Effusion | Class I: normal/OA; String sign = string; normal viscosity |
| Class II Joint Effusion | relatively high WBC count; INFLAMMATORY; fluid behaves like water (broken down hyluronic acid); not viscous |
| Class III Joint Effusion | precipitate forms; SEPTIC |
| Hemorrhagic Joint Effusion | sickle cell disease or trauma |
| Synovial Fluid Analysis | 1. Gram Stain!! 2. Culture!! |
| Essentials of Dx of Gonococcal Septic Arthritis | Young Healthy Women; Sexually active; Migratory polyarthralgias; Characteristic skin lesion/rash; TENOSYNOVITIS; negative blood/synovial cultures |
| Normal Synovial Fluid | clear; <1mL; high viscosity; <200 WBCs; <25% PMN cells |
| Osteoarthritic Synovial Fluid | clear; 1-10mL; high viscosity; 200-10,000 WBCs; <50% PMN cells |
| Rheumatic/Inflammatory Arthritic Synovial Fluid | opaque; 5-50mL; low viscosity; 5,000-75,000 WBCs; >50% PMN cells |
| Septic Arthritic Synovial Fluid | opaque; 5-50mL; low viscosity; >50,000 WBCs; >75% PMN cells |
| Spinal Septic Arthritis (Discitis) | chronic unrelenting back pain/fever/local tenderness in THORACOLUMBAR region; infx crosses joint space like (unlike malignancy); TB infx--> POTT'S Disease in T10-L2 |
| Hepatitis A associated musculoskeletal syndromes | transient arthralgias |
| HBV-associated musculoskeletal syndromes | abrupt, symm, severe polyarthritis in prodrome; migradory or additive; variety of rashes; cryoglobulinemia; 1% develop PAN |
| HCV-associated musculoskeletal syndromes | acute arthritis is RARE!!; Sjogren's syndrome |
| Lyme Disease | Borrelia burgdorferi |
| Stage 1 Lyme Disease | erythema chronica migrans; flu-like symptoms |
| Stage 2 Lyme Disease | systemic symptoms; cardiac/neurologic symptoms (Bell's Palsy); attacks of arthritis (50%) |
| Stage 3 Lyme Disease | chronic arthritis (like RA); endarteritis; chronic CNS infection |
| Dx of Lyme Disease | IgM - actue and IgG - chronic; ELISA and confirmatory western blot |
| Tx of Lyme Disease | early/acute - antibiotics; Chronic - IV antibiotic and synovectomy |
| Jones Criteria for Rheumatic Fever Dx | Dx requires 2 major or 1 major/2minor, plus evidence of recent strep (GAS) infx |
| Minor Jones Criteria for Rheumatic Fever | prior ARF of RHD, arthralgias, fever, enc ESR and CRP, leukocytosis, prolonged PR |
| Major Jones Criteria for Rheumatic Fever | arthritis, carditis, chorea, erythema marginatum, nodules |
| HIV-Associated Rheumatic Disease | oligoarticular in lower expremities; short lived; spondylarthropathy resembles psoriatic arthritis, Reactive/Reiter's, Enthesopathy; HIV+, but Negative for ANA/RF/anit-Ro/anti-La |
| Diagnostic imaging in bacterial arthritis | x-rays, bone scan, CT (extent of SIJ or SCJ sepsis), MRI anthrography |
| Essentials of Diagnosis for Septic Arthritis | 1. sudden onset of acute monoarticular arthritis in large WB joints; 2. Previous joint damage or IV drug use; 3. Infection; 4. Large joint effusions with WBC >50,000 |
| Hyperuricemia/Gout | a. Mid-age M, 90% d/t underexcretion of uric acid from kidney dysfxn (rather than overproduction), attack d/t sudden change in urate levels; Pain reaches max abruptly and can subside spontaneously in 1wk-2mo; Classically involves only 1 joint (podagra) |
| Calcium pyrophosphate deposition disease | a. Elderly, “pseudogout” of knee, shoulder, wrist, MCPs; linear chondrocalcinosis; Inflammatory, rhomboid weakly birefringent crystals |
| Basic calcium phophate crystal disease | inflammatory arthritis |
| Calcium oxalate crystals | acute arthritis |
| Liquid lipid crystals | acute arthritis |
| Osteoarthritis | Secondary to other articular dx, deg loss of cartilage/bony joint changes, no systemic probs, pain w/activity not at rest (only brief am stiffness), min inflam; Herberden’s nodes - DIP, Bouchard’s nodes - PIP; if pt has acute flare, suggest other Dx! |
| OA findings | b. X-ray (narrow joint space, osteophytes, inc subchondral bone density, bone cysts), normal/cool joint effusions and ESR; Joint proprioception can be destroyed by syphilis or diabetes |
| OA Treatment | a. No cure; pain control, improve function, enhance quality of life; SYNVISC viscosupplementation |
| Diffuse idiopathic skeletal hyperostosis (DISH) | a. subtype of OA; M>F, >50yo, Candle wax appearance of vertebral osteophytes btw 3-4 segments; Preservation of disc space, ligamentous calcification |
| SLE...again | a. Malar rash, discoid rash, pleural effusions, heart problems, lupus nephritis, arthritis, raynauds phenomenon; Uncontrolled autoantibody response to endogenous material instead of external infections |
| Drug-induced SLE | a. If you take pt off drug (hydralazine, procainamide, etc), it goes away; ANA is definitive!, anti-histone |
| Raynaud's phenomenon | a. Color changes: blanching, cyanosis, reactive hypercemia; pain precipitated by emotional/environmental stress; Primary - monotonous pattern in young women; Secondary - irregular capillary patterns |
| Scleroderma/PSS | a. Characterized by multisystem involvement; skin (raynauds and sclerydactyly) renal, cardiac, pulmonary, musculoskeletal, GI); ANA, anti-Scl 70, anti-histone |
| Limited scleroderma/CREST syndrome | a. Calcinosis, raynauds, esophageal constricture, sclerodactyly, telangectasias; Lacks proximal scleroderma |
| Inflammatory muscle disease (polymyositis/dermatomyositis) | a. Symmetric proximal muscle weakness (hip/shoulder), “shawl” sign, Grotton’s patches, heliotope (darkness on eyelid), periungal erythema |
| Sjogren's disease | a. Parotid gland swelling, Keratitis sicca (dry eyes, mouth, vagina); Schirmers test of lacrimal gland fxn, RF, anti-Ro, anti-La |
| Fibromyalgia | a. F 7x>M: 20-50yo, multiple tenderpoints, widespread pain >3months, fatigue, headaches, numbness, elev Substance P; Exercise, antidepressants |
| Henoch-Schoelein Purpura | a. Small vessels; Palpable purpura, kids, serum sickness |
| Essential mixed cryoglobulinemia | a. Small vessels; IgG-IgM complexes with RF activity; sediments with cold; Associated with HBV and HCV |
| Polyarteritis nodosa (PAN) | a. Small-medium vessel; Significant weight loss, livedo reticularis, testicular pain, myalgias, weakness, tenderness, mono/polyneuropathy, hypertension, BUN-kidneys, abnml arteriogram (mesenteric aa) |
| Churg-Strauss Disease | a. Small-medium vessel; Asthma, eosinophilia (in biopsy too), mono/polyneuropathy, pulmonary infiltrates, sinus probs |
| Wegener's Granulomatosis | a. Small-medium vessel; Oral/nasal inflam, nodules on chest x-ray; Granulomatous inflame on biopsy, C-ANCA, hematauria |
| Takayasu's Arteritis | "Pulseless Disease;" a. Large vessel; <40yo, claudication of extremities…weakness w/walking, dec brachial a pulse, BP difference in arms, subclavian a bruits, abnormal arteriogram |
| Temporal Arteritis | Multi-nuclear giant cell arteritis; a. Large vessel; >50yo, temporal a., ESR>50; Treat aggressively to prevent blindness |
| Erythema Nodosum | panniculitis/fat; a. Sarcoidosis, CT disease, Lupus, Inflam bowel disease, TB, strep infx |
| Behcet's Disease | panniculitis; a. HLA-B5, Japanese, Turkish; Mouth ulcer, arthritis, cut vasculitis, phlebitis, arteritis, meningoencephalitis |
| Relapsing polychondritis | panniculitis; a. Cartilage becomes inflamed and dies; Most common: ear, nose, joints |
| Osteoporosis type-I | spine; a. W, 15-20yrs post-menopausal, trabecular bone fx in distal radius and vertebrae…estrogen is major player |
| Osteoporosis type-II | spine and hip; a. F 2x>M, >70yo; Cortical and trabecular bone fx in hip, pelvis, humerus |
| Osteonecrosis/AVN | ASEPTIC: Alcohol, Steroids-sickle cell-storage diseases, Emboli-fat/cholesterol, Post-radiation necrosis, Trauma, Idiopathic, Connective tissue disease-SLE-Caisson; Symptomatic tx, arthroplasty, joint replacement |
| Osteomyelitis | Infxn, neutrophils, pus, intraosseous pressure, dec flow, necrosis, sequestra; Chonic vs acute: bacteria presence, necrosis, x-ray findings; Babies-staph/strep; Adults-staph; Elderly-G-s; Bone scan sensitive; Prophylax b/f surgery or IV 4-6wks w/debride |
| JRA - Systemic onset | < 5yo, 1+ joints, young onset=poor health (? remission, 1/3 prog arthritis, amyloidosis); Spiking fever, arthritis/algias, adenopathy, myalgia, malaise, hepatosplenomegaly, serositis, hepatitis, anemia, rash |
| JRA - systemic onset tests/Tx | ESR, anemia, leukocytosis (inc PMN), thrombocytosis; Splint, PT, NSAIDs |
| JRA - pauciarticular/oligoarticular type I - Younger group | F>M, <6yo, 4+ joints, good prognosis (remissions, altered growth, eye); ANA; Splint, PT, NSAIDs, eye tx |
| JRA - pauciarticular type II - Older Juvenile Spondylarthropathy | M>F, >9yo, 66% ok (hip, cervical, spondylitis); Lower limbs, enthesopathies (insertion site), iritis, SIJ pain; Shober’s test, HLA-B27; PT, NSAIDs |
| JRA - Pauciarticular Type III - Psoriatic | F>M, ~8yo; Dactylitis, asymmetric, nail pitting, onycholysis, psoriatic rash, family Hx; Ok prognosis can relapse into adulthood (spondylitis, iritis); ESR varies w/number of joints; Splint, PT, NSAIDs, (DMARDs), biologics |
| JRA - Polyarticular RF-Negative | F>M, 5+ joints, variable prognosis; Prayer sign, dec neck/TMJ ROM, flexor tenosynovits, fever, Felty’s; ESR, anemia, leukocytosis, thrombocytosis; Splint, PT, NSAIDs, DMARDs, biologics |
| JRA - Polyarticular RF-Positive | F>M; >8yo, 5+ joints, poor prognosis; Rheum nodules, C1-C2 sublux, amyloidosis; ESR, RF+, HLA-DR4, erosive changes on x-ray; Splint, PT, NSAIDs, DMARDs, biologics, surgery |
| Joints specific to RA | TMJ, SC joint, AC joint, elbow, wrist, MCP, ankles, subtalar joint, MTPs |
| Joints specific to OA | shoulder, lumbar spine, hip, 1st CMC, DIP |
| Diagnostic RA Criteria | stiff in am >1hr in 3+ symm swelling >6wks; neuromyopathy (interosseous m atrophy, C1-C2 sublux, carpal tunnel, bladder fxn, jumping legs, dec motor power); osteoporosis (erosions/osteopenia on x-ray w/joint sp narrow); amyloidosis - death in JRA |
| Remission Criteria for RA | >5 criteria for >2wks; am stiff <15min; no fatigue, joint pain/tenderness; ESR <30M, <20F |
| DMARD | disease modifying anti-rheumatic drug; methotrexate is being replaced by leflunomide |
| anti-TNFalpha | biologic agent for RA; injection site rxn...can activate latent TB!! |
| Growing pains in kids | 6-13 yo; localized pain in calves, thighs and shins...NOT in joints |
| osteoporotic fractures | 40% of F >50 will fx in their lifetime; Bone scan T-scores of >-2.5 |
| Infected Joint Prostheses | 1-5% of joint replacements; insidious onset of pain and loosening; S.aureus, S, epidermidis; prevention via prophylaxis prior to invasive dental, GI or GU procedures |
Created by:
bscaryp