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Olson Day one
Clin Med II- OA, RA, FIbromyalgia, Arthritis, Septic
Question | Answer |
---|---|
Chronic widespread pain, not otherwise explained, often w/ fatigue | fibromyalgia |
Syndrome of heightened pain perception | fibromyalgia |
Some syndromes that may lead to sensory amplification | IBS, intersticial pain, TMJ, low back pain, HA’s, many depressive disorders |
Criteria for Fibromyalgia | WIDESPREAD pain for >3 m, 11 of 18 tender points when palpated with enough pressure to blanch upper nail bed |
Main tx of fibromyalgia cycle | exercise! Start small, don’t want to lose fxn |
Is fibromyalgia genetic | No links yet, but it is environmental |
What % of pt’s with sjogren’s syndrome may have fibromyalgia | 50%! |
How do we asses for fibromyalgia | pain w/ tender pts. Fatigue, sleep and its quality, psych: depression w/pain, PA and exercise everyday! |
What methods may be needed to improve sxs of fibromyalgia | tx sleep disturbance, mood disturbance, relaxation training, aerobic exercise training |
Pharm tx | TCAs, SSRIs, SNRIs, AEDs, pain relievers: NO to chronic narcotic, muscle relaxants, sedative hypnotics, dopamine agonists |
Use of tramadol in fibromyalgia tx | bw ASA and narcotics, |
MOI of bone spurs | Underlying bone responds ^production of bone d/t damage of wear and tear→bone spurs or osteophytes |
Main classification of OA | joint space narrowing |
5 common radiographic features of OA | Joint space narrowing, marginal osteophytes, subchondral cysts, bony sclerosis, malalignment |
Common signs of OA | knobby PIP, DIP joints, “squaring” of the CMC thumb joint: thenar muscle wasting, pain related to use, gets worse during the day, morning stiffness, ↓ROM, bony enlargement, crepitus, restricted movement d/t bone remodeling |
RF’s of earlier OA | Female, obesity, heredity for certain joitns, trauma, neuromuscular dysfxn, metabolic disorders: hemochromatosis |
MC OA sites | neck, low back, hips, knees, big toe, fingers |
Non pharm txs for OA | heat, exercises: PT, Bracing, |
Pharm tx | APAP, NSAIDs, tramadol/opiod, CS injection, surgery: replacement |
When do we use the thumb CMC joint brace | depending on the occupation, usually improved pain after 12m use vs 1m use |
Topical NSAIDS | tid, ketoprofen 20% or diclofenac gel 1% |
Tx for varus or valgus OA knees | Unloader knee brace: for young, active pt’s, $600 plus |
When do we use hyluraonic acid injections | AKA synvisc viscosupplement, or lubricant, used when CS injections don’t work. Last step before surgery |
Most effective tx for knee OA | quad strengthening, wt reduction |
Supplement trial for OA | Glucosamine/Chrondroitin, try 3m if no improvement stop, an expensive supplement and varies bw pt’s |
Tylonol and NSAIDs effect what | Tylenol: Liver, NSAIDs: Kidney |
When will benefit seen with capsaicin | 2 wks, must use daily, and it BURNS |
Common strong analgeisics used for OA | Tramadol, propoxyphene, codeine, hydrocodone, oxycodone |
Pharm tx for nonsurgical canidates | morphine and fentanyl patches |
Major cell types involved w/ RA | T lymphocytes, macrophages |
Minor cells in RA pannus | fibroblasts, plasma cells, endothelium, dendritic cells, Neutrophils in synovial fluid |
What is the test for RA | rheumatoid factor, + in first 6m 85% w/ established dz, Anti-CCP? More commonly used test |
What commonly causes a + RA factor | RA, Hep C, genetic factors for genes for RA! |
More specific RA test | CCP antibody, won’t b + w/ Hep C, |
Firm spongy yet squishy joints | synovitis consistent w/ RA |
What joints are NOT effected by RA | DIP, thoracic or lumbar spine, Cervical spine CAN be |
Can you have both RA and OA | yes, can effect different/same joints, get OA with age anyway |
Signs on XR of RA, OA | RA: erosions, bone loss: periarticular osteopenia, less dense around the bone edges, OA: sclerosis, or lightning up near edge of bone |
d/t chronic inflammation, what happens to the MCP joints | Ulnar drift d/t laxity in the ligaments, swelling in MCP and PIP joints |
RF’s for RA | female, heredity, HLA antigen DR-4, environment and traumatic triggers |
Common deformities of the fingers | swan neck deformity and boutiners finger |
Commonly form on the extensor surfaces of the affected joints | RA nodules subQ or periosteal at pressure pts |
Inflammation where tendons/ligaments insert to bone | enthesitis |
Thickened synovial tissue | pannus: eats away at bone underneath it |
Do joint dz’s kill pt’s | no, the chronic inflammation of other organs kills the pt, chronic inflammation of BV’s: Ht dz |
Associated dz’s with RA | Sjogrens: dry mouth, eyes, Schermer’s test, intersticial lung dz |
Tx RA | Pharm within 3m dx use safest related to aggressiveness of the dz, ↓pain, inflammation, Start NSAID if applicable |
Substitute for NSAIDS | low-dose prednisone (<10mg) but not LONG term: bridging until long term are effective |
What do we need to remember with low dose predinisone tx | prophylactic tx for osteoporosis, ↑blood surgar: diabetics |
Gold std for RA pharm tx | Methotrexate (MTX) |
Can’t tolerate methotrexate use what | leflunomide |
When is TNF elevated | RA, psoriatic arthritis, psoriatic plaques |
The more TNF, the more what | Inflammation |
Monitoring for RA drugs | Liver, lung, blood, kidney testing 4-8wks |
What is gout | build up of uric acid in joints d/t overproduction or underexcreation of uric acid |
Red hot swollen joint d/t uric acid crystals | gout: more painful acutely than RA |
Common places of gout | extremity, unilateral, uni-joint, in cold extremities |
Signs, sxs of gout | acute onset, asymmetric, monoarticular |
Cause of gout | high purine diet or alcohol binge |
MC location of gout | 1st MP joint in foot, |
Can you dx gout from a blood test? | No must aspirate joint and test fluid for crystals |
Swelling of big toe joint | podagra |
Collection of uric acid that comes to the surface of the skin | tophus |
Does gout disfigure for life? | no tx usually makes it all go away |
What is most common w/ cause of Hyperuricemia | overproduction 10%, Underexretaion 90%: usually d/t kidney dz |
How is uric acid formed | end produce of purine metabolism |
Is gout autoimmune? Genetic? | genetic predisposition but not autoimmune |
Dx of gout | synovial fluid high WBC and PMN count w/ polarized microscopy |
Tx acute gout | NSAID, colchicine, predinisone, IA injection |
When do we use allopurinol? | ONLY for chronic tx, lowers uric acid, DO NOT start during an acute attack, will ↑ attack and spread to another joint |
What inhibits PMN migration | colchicine |
When are prednisone usually used | w/ renal insufficiency, and elderly, can exacerbate diabetes |
Non pharm tx | p ted: Beer bad, lower purine diets, meat, fish, diary, maintain hydration, D/C diuretics, wt loss, control BP |
Pseudogout | Chondrocalcinosis: d/t calcium, common in elderly, embedded in cartilage |
Location of pseduogout | shoulders, writs, funky shapes under microscope, |
Difference bw gout and pseudogout | gout: uric acid, pseudogout: Calcium, embedded in cartilage on XR |
Infection in a joint | septic arthritis |
Common ppl who get septic arthritis | RA, DM, immunocomprimised, Trauma, Sepsis, Medical emergency |
Dx of Septic arthritis | aspiration: milky murky, thick, high in WBC (>100,000) in infected joint, culture |
Why is septic arthritis so critical | can cause death in 10-40% |
Back pain and stiffness in adolescence and early adulthood, worsens w/ inactivity, ↑w/ Physical activity | ankylosing spondylitis |
Dx of ankylosing spondylitis | limited lumbar motion, Schobar test: <20cm flexion common in men |
A sausage shaped swelling of finger or toe | dactylitis |
Onset of ankylosing spondylitis | prior to age 40, insidious, longer than 3m, morning stiffness, decrease w/ exercise |
Inflammatory arthritis in DIP joints, asymmetric, sausage digits | psoriatic arthritis |
What is pitting of the nails or onycholysis associated w/ | psoriatic arthritis |
Triad of arthritis, urethritis, conjucivitis | Reactive arthritis or Reiter’s syndrome hx of all of these but not at same time |
Enteropathic arthritis | ulcerative colitis and crohn’s dz |
Tx for spondyloarthropathy dz | exercise, NSAIDS, SI and peripheral joint CS injections |
What is TNF associated w/ | Inflammation, pain, plaque hyperproliferation, joint destruction |