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Rheumatoid Arthritis
Rheumatology
| Question | Answer |
|---|---|
| Joints most affected by RA | ankles, wrists, shoulders |
| RA epidemiology | Worldwide: 0.8% adult; US: F 40-50/100,000; M 20-25/100,000; by age 65 M:F = 1:1; Lifelong; 3-5 yr reduction in life exp; Incidence is declining |
| RA pathogenesis | Genetics: both susceptibility & dz severity; HLA-DR 1 and DR4 alleles |
| RA: Poss infectious triggers: | Mycoplasma, Mycobacterium, enteric bacteria; rubella, parvovirus B19, EBV |
| RA: Other poss risks: | tea, high vitamin D intake, silicate exposure |
| RA pathology | trigger; prolif syn macrophages / fibroblasts; lympho invade perivascular space; affected jt vessels occluded, synovium forms pannus (which invades cart & bone); cytokines, proteinases, ILs released; jt destn |
| RA Clinical manifestations: | slow, insidious onset; durations of sx = wks to mos; fatigue, malaise, low-grade fever, wt loss; 10-15% advanced, fulminant sx; joints are typically swollen (boggy) and/or warm; erythema not common |
| RA: pts c/o pain & stiffness: | 2/3 pts c/o pain & stiffness in multiple joints, 1/3 c/o pain and stiffness in one or a few joints |
| RA classic presentation: | small bones of hands/feet most likely to be affected early (PIPs, MCPs, MTPs) |
| RA: progression to larger joints: | wrists, knees, elbows, ankles, hips, shoulders |
| RA: around inflamed joints: | may be atrophy of muscle around inflamed joints |
| RA typical course: | waxing/waning over years with acute episodes involving single or multiple joints |
| RA: Articular manifestations: hands | ulnar devn; swan neck deform (PIP hyperext), boutonniere (PIP hyperflex & DIP hyperext) |
| RA: Articular manifestations: feet | affected in 90% of pts w/ longstanding RA; subluxation of MTP joints leads to callus formation |
| RA: Articular manifestations: wrists | in most pts; radial deviation; inc synovial proliferation leads to median n. compression, tendon rupture |
| RA: Articular manifestations: other joints: | any synovial joint can be affected; TMJ, cricoarytenoid, sternoclavicular joints |
| RA: Articular manifestations: c-spine: | C1-C2 articulation; atlantoaxial subluxation is feared complication (d/t ligamentous laxity induced by synovial prolif) |
| RA atlantoaxial subluxation presenting sxs: | pain radiating up occiput; slowly prog quadriparesis w/ inc sensation in hands; UE paresis triggered by head movements; transient episodes of vert art compression |
| RA: joints most commonly affected | MCP, PIP, wrists, knees, shoulders |
| RA: Labs | no single dx test confirms RA; acute phase reactants (ESR, CRP, thrombocytosis); autoAbs (RF, anti-CCP, ANA); anemia of chronic dz; synovial fluid analysis; inc WBCs, mostly PMNs |
| RF testing | RF result changes over time (some: seroneg RA) (so if neg, sd test periodically later) |
| Lab results: Ro, La, Smith, & RNP: | don’t change over time |
| RA labs: CCP | more specific for RA than RF; 30% RA pts are RF neg; 60% RA pts CCP pos; CCP pos at risk for severe dz |
| RA Imaging: | must ID changes early (avoid irreversible joint damage); sig amt genl skeletal bone lost early in dz |
| RA: prevalence of osteoporosis = | 2x that of general population |
| RA Imaging: early findings: | soft tissue swelling, peri-articular osteopenia, marginal erosions |
| RA Imaging: late findings: | diffuse osteopenia, joint space narrowing, deformities |
| RA Tx: mod-severe dz at dx: | start with DMARDs (combo tx); titrate dose upward as needed; add biologic tx for uncontrolled joint pain, swelling |
| RA Tx: mild dz: | less aggressive DMARDs (hydroxychloroquine, sulfasalazine) |
| RA Tx: adjuncts: | glucocorticoids, NSAIDS, analgesics, PT / occupational tx |
| RA complications: | Inc risk of CV disease: premature, accelerated atherosclerosis 2nd to chronic inflame; Inc rate of malig (usu lymphoma); atlantoaxial subluxation |
| Felty’s syndrome: | rare: RA & splenomegaly, leukopenia & recurrent pulmonary infxn; poss also leg ulcers, vasculitis |
| Baker’s cyst: | rupture of synovial fluid from knee into calf; mimics DVT, cellulitis |
| RA: Predictors of poor prognosis: | low functional score, low SES, inc ESR, CRP, early radiographic changes |
| RA: Plain films show joint damage after: | 2 years of dz duration in 70% of cases |
| RA: MRI scans reveal: | erosive joint damage as early as 4 months |
| RA: Primary care mgmt: | disability; med AE (edema); surveil for infxn, malig, osteoporosis, depression; immunizations; CV risk reduction |
| Joints most affected by RA | ankles, wrists, shoulders |
| RA pathogenesis | Genetics: both susceptibility & dz severity; HLA-DR 1 and DR4 alleles |
| RA: Poss infectious triggers: | Mycoplasma, Mycobacterium, enteric bacteria; rubella, parvovirus B19, EBV |
| RA Clinical manifestations: | slow, insidious onset; sxs wks to mos; fatigue, malaise, low-grade fever, wt loss; joints typically swollen (boggy) and/or warm; erythema uncommon |
| RA classic presentation: | small bones of hands/feet, usu affected early (PIPs, MCPs, MTPs); progression to larger joints (wrists, knees, elbows, ankles, hips, shoulders) |
Created by:
Abarnard
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