enthesopathy is what?
inflammation of the enthesis.
the enthesis is where the tendon inserts on the bone
Criteria for AS
dx based on LBP sxs >3 months and :
elevated ESR or CRP
+HLA B-27 (not specific)
-diminished chest excursion
-limited spinal ROM + schober's test (<5 cm sig)
-extra-articular fx - uveitis,aoritis
does having HLA b-27 make the dx for AS?
NO. its not speicifc
what makes it? HISTORY. right age group, sacrolitis, lbp hx
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.
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 is the classic deformity on the fingers of psoriatic arthropathy?
pencil in cup deformities
due to bone resorption
NEVER prescribe what for PA?
oral steroids-- initially does great but as your taper you get erythroderma PA (crisis)
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
in parvovirus b19 patient comes in had child that was sick how do you diagnose
IgM for B-19 and history
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 drugs block the distal convoluted tubule so they don't allow the elimination of uric acid?
What is a genetic predisposition to gout? what is the enzyme that is lacking?
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?
STEROIDS: INTRARTICULAR OR ORAL
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)
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.
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
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?
_________ _________ ________ _________ is a key player in synovial inflammation
tumor necrosis factor alpha
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 are you looking for on XRAY with the hips?
entire acetabular joint narrowed
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 score greater than ____ implies active disease. Less than ____ is well controlled and less than _____ is remission
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?
what is the criteria for JIA?
less than 16 and exclusion of other causes of childhood arthritis. ANA is positive commonly.
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?
Calcium is essential for?
Blood clotting, and many other functions
How are phosphates excreted?
so remember calcium-bowel. phosphate-kidney. don't let her trick you.
When PTH is released what response is then given in response to hypocalcemia?
Osteocytes release calcium stored in the lacunar spaces
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_______
thus a lack of any of these can make u more likely for osteoporosis
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.
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
are biomarkers helpful in diagnosis of osteoperosis?
they are just helpful for monistorying patients treated with antiresoptive agents
what type of exercise should you promote for prevention and tx of osteoperosis
weight bearing and resistance training
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
What are the 5 categories of non articular rheumatism?
tendonitis and bursitis
regional myofascial pain
generalized pain syndromes
Persons with inflammatory syndromes experience pain _______movement and may have signs of __________ and __________
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.
hypothyroidism and polymyagia rheumatica often mimic fibromyalgia. How do you differentiate?
TSH and ESR
What are the 9 trigger points of the body
lower cervical (C5-7)
rhomboid (medial scapula)
lateral condyle of the elbow
medial aspect of the knee
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.
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
Polymyalgia Rheumatica is widespread aching and stiffness that likes what region?
limb girdle muscles in older adults
What is almost diagnostic of PMR?
prompt and complete response to low dose corticosteroids (24 to 48 hrs)
What is the typical complaints of a PMR patient?
pain worse in morning
stiffness after long car rides
difficulty getting dressed in the morning or in a low chair.
how long do you give corticosteroids to PMR patients?
some can stop within a year but most go for 2-3 years.
What is the criteria for joint hypermobility syndrome?
A beighton score of 4/9 or greater (current or historically)
arthralgia for 3 months or longer in 4 or more joints
Beighton criteria gives 2 points if bilateral for the following:
-hyperextension of elbows (10 degrees or more)
-touch passively, the forearm with the thumb, while wrist is in flexion
-passive extension of the 5th finger, more than 90 degrees
-hyperexctension of the knees (10 degrees or more)- genu recurvatum
-touch the floor with the palms, when bending over with knees extended
tendonitis can be caused by suddent intense injury but is most often the result of a reptitive minor injury of the affected area that is reproducible on _______
deep bursae are found where?
between bones and overlapping muscles
i.e. subscromial and illiopsoas bursae
superficial bursae are found where?
between bones and tendons/skins
i.e. olecranon and prepatellar bursae
What are some causes of bursitits?
repetitive use, trauma, infection, or systemic inflammatory disease
Can you see bursitis or tendonitis on xray?
no but it will exclude other joint/bone problems.
blood tests plus MRI and diagnostic u/s are helpful but not required.
On occasion, cortisone shots to the inflamed area (_____________ or ________ ) may be helpful for tendonitis/bursitis
tendon SHEATH or bursa
Thoracic outlet syndrome is defined as what?
compression of the neurovascular structures in the area just above the first rib behind the clavicle.
both tietze syndome and costochondritis are characterized by chest wall tenderness mostly which ribs?
RSD is actually which type of CRPS?
excessive sympathetic reaction of the joints and periarticualr soft tissues to any insult.
what is type 2 CRPS?
causalgia.its from partial nerve injury where the nerve is inflamed or irritated
Patient comes in after stubbing his toe 12 days ago. He describes the pain as burning, shooting and aching. The patient seems to be sweating perfusely. His toe seems to be swollen, cool, blue and damp. He is insensitive to heat and cold. On xray there is no bone break but osteopenia seems to be evident. What does this patient have?what phase?
CRPS phase 2.
bone absorption (move over bone) uses acidophillic cytoplasm to remove old bone and forms puts for laying down new bone
thin sheet like membrane comprised of endo- and epithelial cells.
provides mechanical support, forms a semipermeable filtration barrier (kidney,placenta) regulates cell attachment, migration and differentiation
Fibrocartilage has a ______ _________ feel. and is found where?
pubic symphysis, cranium, rib cage
cannont be seen w/o EM or Alizarin red stain
--> milwakee shoulder (hydroxyapatite crystals in the joint because bone rubbing on bone )
Patient presents with pain worse in the Am, warmth over extremeties, morning stiffness for 2 hours and elevated ESR/CSP. do they have inflammatory or noninflammatory complaints?
where can you have rheumatic signs and symptoms that you wouldn't really expect?
ocular- sicca, visual loss, conjunctivitis
oral-gential ulcers, herpes
Patient is able to move against gravity but not against resistance during muscle strength testing. What level would you grade them?
When do you do arthrocentesis?
any undiagnosed mono- or poly-arthritis with an efusion.
suspected crystalline arthritis
When is arthrocentesis CI?
overlying cellulitis, would, bacteremia
neuropathic joint (charcot joint)
inaccessibel joints (hip, SI, publc symphysis)
lack of response to previous injections
What is a useful formula for age estimation for sed rate?
male/female age in years divided by 2. add 10 to final result in women.
so for me: I'm 23. half of that is 11.5
im a woman so add 10 : 21.5
What is the standard test for RF?
anticcp abs may develop years BEFORE joint symptoms appear
HLA-B27 is classic in who?
young males with low back pain.
found MC in caucasians
genetic marker for dsieases with spondyloarthropathies (AS, Reiter's, psoriatic and enteropathic arthritis)
lyme titer tests for what
antibodies against Borrelia burgdorferi, spirocete that is release by ticks.