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Ankylosis spondylitis hallmark?

sacrolitis

what does ankylosing mean?

fibrosing of the spine.

enthesopathy is what?

inflammation of the enthesis.
the enthesis is where the tendon inserts on the bone

in AS when are sxs worse?

in the AM
better with exercise

Criteria for AS

dx based on LBP sxs >3 months and :
elevated ESR or CRP
+HLA B-27 (not specific)
-symmetrical sacrolitis
-diminished chest excursion
-limited spinal ROM + schober's test (<5 cm sig)
-extra-articular fx - uveitis,aoritis

RA has to be present how long to be RA?

6 weeks

does having HLA b-27 make the dx for AS?

NO. its not speicifc
what makes it? HISTORY. right age group, sacrolitis, lbp hx

Late changes of AS on the xray will show what classic sign?

BAMBOO SIGN

AS travels from ____ to ____ over time

SI joint to elevation

AS patients can't do what?

can't touch their toes. loss of flexibility of the spine due to sclerosis. tests with SCHOBER'S test.

It's not the ____ that is involved but the ______ that fuse in AS

It's not the disc space that is involved but the ligaments that fuse in AS

When there is no give to the spine, as in AS, you worry about what with trauma?

Fracture. increased in these patients.

Whats the best tx for AS?

indocin
its lipid soluble and fast acting

What does work in AS as well other than indocin?

TNF INHIBITORS (ETANERCEPT, INFLIXIMAB, Humera )

Remember no drug restores __________

function

What comes first psoriasis or arthritis ?

psoriasis in 85 perfect of pts

Psoriatic arthritis involves the _________ and has a _______ which helps differentiate it from other arthropathies

spine :) and has a rash.

what is classic of psoriatic arthritis?

oligoarthritis (4 joints or less) and asymmetrical (sausage digits-dactylitis)

Sometimes psoriatic arthritis are like RA but you distinguish how?

skin manifestations and the pattern will show you.

What disease processes worsens PA? Sexually active male with multiple partners with abruput PA and no family history....

HIV. thus we must HIV test patients sexually active with PA.

What nail changes will you see in psoriasis?

onychomycosis and pitting.

What is the classic deformity on the fingers of psoriatic arthropathy?

pencil in cup deformities
due to bone resorption

what drugs do you use for PA?

similar to RA
methotrexate and biologics (TNF inhibitors)

NEVER prescribe what for PA?

oral steroids-- initially does great but as your taper you get erythroderma PA (crisis)

Reiter's syndrome is also known as what?

reactive arthritis

what is reiter's triad?

oligoarthritis
urethritis
conjunctivitis

what is reiter's associated with?

HIV

what lesions with you see in reiters?

keratoderma blenorrhagicom (blisters on feet ) and mucus membranes (balanitis)

can also have nail changes, knee efusion, and inflammation of the Achilles tendon

dx is made based on what?

sxs
triad

in parvovirus b19 patient comes in had child that was sick how do you diagnose

IgM for B-19 and history

Enteropathic arthritis is what

bowel-related arthritis

enteropathic arthropy patients have some ____ problem that presents first

GI

antibodies attack the joint space and its called what?

molecular mimicry- lost immune protection and initial antigen can't tell difference between the disease and the joint.

what are the drugs for enteropathic?

methotrexate, TNF and steroids. CHECK HIV!

at what level does uric acid precipitate and crystallize?

6.8 or greater.

what drugs block the distal convoluted tubule so they don't allow the elimination of uric acid?

thiazide diuretics

DX BY NEGATIVELY(YELLOW) BIREFRINGENT NEEDLE-SHAPED CRYSTALS

Gout

What is a genetic predisposition to gout? what is the enzyme that is lacking?

lesch-nyhan syndrom
HGPRT

what is the classic presentation of Gout?

monoarticulation of the padagra. red and hot. can migrate.

Gold standard for diagnosis gout

must prove the crystal formation, or a tophus contiaining urate crystals.

there has to be have evidence of crystals.

Why can't you use allopurinol or uloric during an acute gout attack?

During an acute attack that is not the time to introduce long term therpy Allopurinol and uloriic which would cause more uric acid out of the tissue and you will worsen their attack

What do you use to treat acute gout attacks?

symptomatic therapy
COLCHICINE
NSAIDs: INDOCIN
STEROIDS: INTRARTICULAR OR ORAL

Chroic gout is treated with?

allopurinol or uloric

What do tophi feel like?

rock hard.

which is more common gout or psuedogout?

psuedogout

what are the key diagnostic characteristics of psuedogout?

CHONDROCALCINOSIS ON X-RAY
POSITIVELY BIREFRINGENT(BLUE) ROD or RHOMBOID-SHAPED CRYSTALS

What is the classic triad of dissemmnated gonococcal infection?

Dermatitis (sparse necrotic pustules)
Migratory polyarthralgias/polyarthritis
Tenosynovitis

Septic arthritis is usually caused by what?

staph aureus

How do you treat staph aureus caused arthritis?

vancomycin

osteomyelitis if the vertebrae is called what?

pott's disease

If you have a patient with sternoclavicular SI or pubic symphesis osteomylitis what do you ask about?

IV drug use.

On xray what do you suspect to see in osteomyelitis

Periosteal elevation along with bony erosions and destruction of the cortex.

what 3 viruses cause viral arthritis?

Human Parvovirus B-19
Hepatitis B and C
HIV

low grade fever with slapped cheeks on a 8 year old boy. What is this caused by? what do you worry about ?

human parvovirus B-19
that the mom will come in with abrupt symmetrical polyarthritis, malaise and flu-like state

what is the hallmark of erythema chronicum migrans?

erythematous wheal with central clearing

patient went camping sometimes between may and august. They come in with slight flu-like symptoms and a big wheal with central clearing. what do you worry about?

lyme disease

How do you diagnose lyme disease?

ELISA and then confirm with western blot test

in stage 1 of lyme disease what do you treat with?

oral antibiotics

what about in stage 2 or 3?

IV antibiotics

Ra involves imflammation of what?

the synovium
its an inflammatory reaction

in RA bone and cartilage are destoryed how?

pannus formation
(fibrous/scaring)

_________ _________ ________ _________ is a key player in synovial inflammation

tumor necrosis factor alpha

What joints are most commonly affected by RA?

wrist, MCP and PIP

swan neck and boutinerre deformity are seen in which conditions?

RA

Which vertebrae are affected by RA?

C1 and C2

what do you look for in RA patients on cervical xray?

wink sign

Why should you always xray RA patients before surgery?

Anytime you have RA you have to check C1 C2 (flexion and extension views) via x ray due to intubation (hyperextension that compromises the spinal cord)

What manifestations of the knee can be seen in RA?

effusion, baker's cyst, contracture

VALGUS

he lateral side is eating away the knees will knock---RA

VARUS

the medial side is eating away -bow leg--- OA

what are you looking for on XRAY with the hips?

entire acetabular joint narrowed
Acetabulo protrusion

Are hammar toes seen in RA or OA?

RA

what are rheumatoid nodules from?

from immunoglobulins binding together and your immune system that is tryign to encapsulate this and then walking on it. Its like a pebble in your shoe.

Whats the difference between a rheumatoid nodule and an effusion of the elbow when they both look alike?

effusion is fluid
rheumatoid is rubbery.

A DAS28 score measures what?

disease activity of RA

A score greater than ____ implies active disease. Less than ____ is well controlled and less than _____ is remission

5.1
3.2
2.6

The majority of patients with RA have what kind of course/prognosis?

polycyclic with relapses

How much shorter withe life span of an RA patient?

2 years shorter
MC causes of death: infections and cardiovascular disease

Steinbrocker's RA functional classification would rank a patient who can perform self-care but limited in both vocatoinal and avocational acitivities as what class?

class III

What DMARDS is the first line for RA?

methotrexate

What directions should you give to a patient taking methotrexate?

take on an empty stomach

What is tocilizumad (acemra) directed against?

IL-6 receptors. used to treat moderate to severe RA

JIA is seen in patients of what age

less than 16

what is the criteria for JIA?

less than 16 and exclusion of other causes of childhood arthritis. ANA is positive commonly.

in OA what is being attacked?

cartilage

What is the "gelling phenomenon" in OA?

Most common phenomenon seems to be difficulty initiating joint movement after inactivity, epitomized by the problem older people with OA have in getting started after sitting down a while.

What are the nodes that are formed in OA and where are they located?

Herbeden's (DIP)
Bouchards (PIP)

OA has what joints involved?

cervical spine, lumbar spine, hips, knees, pip, DIP, big toe

in OA or RA is the elbow involved?

RA

In OA or RA is the hip involved

OA

What will you see on xray with OA?

bony sclerosis
loss of cartilage
osteophytes

DISH has what kind of appearance grossly?

candle wax dripping down the spine

Unline Spinal Stenosis and lumber arthrosis what is preserved in DISH?

intervertebral disk space

For maximal joint relief what two things can be used together?

glucosamine and CSO4

what joint is most responsive to the Glu/CSO4 combination?

knee with moderate to severe OA pain

Calcium is essential for?

Muscle contraction
Nerve function
Blood clotting, and many other functions

T/F Bones have priority over serum calcium levels.

false.
Serum has priority over bone!

Osteomalacia

bone softening from excessive resorption of Ca+ from extracellular bone matrix

Where is calcium absorbed in the digestive tract?

in duodenum & jejunum (proximal SI)

How is calcium excreted?

75% bowel
25% kidney

How are phosphates excreted?

25% Bowel
75% Kidney

so remember calcium-bowel. phosphate-kidney. don't let her trick you.

PTH causes an upregulation of what type of bone cells?

osteoclasts

what controls absorption and deposition of calcium in bone?

vitamin D

when calcium is low what is released?

PTH

When PTH is released what response is then given in response to hypocalcemia?

Osteocytes release calcium stored in the lacunar spaces

what is the active form of vitamin D?

1,25(OH)2 Vit D3

What secretes calcitonin?

thyroid gland C-cells

Osteoperosis is common in who?

white or asian smoking women with a fracture history that are <127 pds that are older and really skinny.

Testosterone, estrogen and progesterone are bone_______

building

thus a lack of any of these can make u more likely for osteoporosis

what is the most serious complication of osteopersosi?

hip fracture

How do we diagnose osteoperosis

The gold standard in detection has been bone mineral density measurement. BMD can detect osteoporosis before a fracture occurs so that treatment to prevent fracture can be initiated. It can also predict future fracture risk and DXA (dual energy x-ray absorptiometry) BMD measurements have the additional advantage of measuring the rate of bone loss. This is helpful when monitoring the effects of therapy.

Patient has a T score of -1.9 how would you classify that?

osteopenic.
-1 to -2.5

osteoperosis is for which range for t scores?

-2.5 or lower.

If a patient has a score of -3.0 and a fx what would you classify them as?

severe osteopersosis.

Who gets a BMD scan?

>65 y/o women
>70 y/o men
youngr postmenopause women and men with one or more risk factors
presence of fragility fx
loss of height >1.5 inches

BMD testing shoudl be every 2 years in these patients:

Estrogen deficient women at risk for osteoporosis
Individuals with vertebral abnormalities
Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy
Individuals with primary hyperparathyroidism
Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy

what does the FRAX tool for?

used by the WHO to determine fracture risk.

are biomarkers helpful in diagnosis of osteoperosis?

NO.
they are just helpful for monistorying patients treated with antiresoptive agents

what is the bioactive from of vitamin D

calcitrol

what type of exercise should you promote for prevention and tx of osteoperosis

weight bearing and resistance training

What are some other things you can teach for your patients?

balance, fall prevention and safety.

What is first line tx for osteopersosis?

bisphosphanates

how do bisphosphanates work?

they cause apoptosis of osteoclasts

if they can't tolerate bisphophanates and are 5 years postmenopausal what should you give

calcitonin. (nasal spray or subcu)

Paget's disease is an upregulation of what cells?

osteoblastas and clasts but in a disproportinate way causing irradic, woven bone

who is pagets common in?

males over 50

What do you commonly see in pagets?

enlarged Skull, tinnitus and bowed legs

What is characteristic with pagets?

salt and pepper pattern on xray.
abnormal alkphos

what is the MC complication of pagets?

osteogenic sarcomas (bone tumors)

bone scan is _______ but not ______ in pagets.

sensitive but not specific

first line for pagets?

bisphosphonates

What are the 5 categories of non articular rheumatism?

tendonitis and bursitis
structural disorders
neurovascular entrapment
regional myofascial pain
generalized pain syndromes

Myofascial pain can manifest in many ways. How does it affect the digestive tract?

IBS

nonarticular rheumatism is most common in persons aged

45-64

Persons with inflammatory syndromes experience pain _______movement and may have signs of __________ and __________

during
swelling
redness

Persons with noninflammatory syndromes experience pain _______movement, during _______.

after
rest

Criteria of fibromyalgia

Chronic widespread pain in all 4 quadants of the body (above and below the waist, left and right sides) >3 months duration.

Fibromyalgia is most common in who?

women

what are the defining characteristics of fibromyalgia?

pain and tenderness

hypothyroidism and polymyagia rheumatica often mimic fibromyalgia. How do you differentiate?

TSH and ESR

What are the 9 trigger points of the body

occipital
lower cervical (C5-7)
trapezius
rhomboid (medial scapula)
pectoralis
lateral condyle of the elbow
sacroiliac
trochenter
medial aspect of the knee

Do you give pain meds to fibromyaglia patients?

NO

What is tx for fibromyaglia?

TCA
SSRI
Antiepileptics but non opoids

Chronic fatigue syndrom is characterized by?

a reduction of atleast 50% of ADLs. without other explanantion for one year or more and accompanied by cognitive difficulties.

usually CFS patients have a _________ ______ which subsides but then the fature continues for a year or more after.

antecedent infection

How do you dx CFS?

its a diagnosis of exclusion

What lab may be low?

ESR (0 to 3 mm/hr)
not increased as there is no inflammation

What will you see on PE of CFS?

crimson crescents purple/crimson discoloration of both anterior tonsillar pillars in the abscence of pharyngitis

shotty adenopathy (neck axilla, inguinal)--> pea sized rubbery mobile nodes

CFS syndrome patients should have rst, moderative activity, and run marathons?

no. rest, moderate activity, no exercise

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