| AM pain/stiffnes > 30 mi for at least 6 wk, fatigue, wt loss, anorexia, fever
Affects bilateral small joint MCP and PIP.
Rheumatoid nodule, knee involvment , C spine subluxation' | What are the sx and sign of Rheumatoid Arthritis? |
| Anti CCP, sed rate, CRP, RF, CBC and CMP
Xray of involved joint
(RF may be - initially, can take up to 2 years to show) | How do you dx RA? |
| Cardiac: Increase risk of AS, pericarditis, myocarditis, valve nodule
Lung: Pleurisy with effusion diffuse Interstitial fibrosis
Renal : Amyloid renal dz
Blood: anemia of chronic dz and neutropenia
Vasculitis: Synovial inflammation
Nerve: Mononeuritis multiples with foot and wrist drop
Skin: rheumatoid nodule | What are the extra articular manifestation of RA? |
| RA, splenomegaly and neutropenia | What is Felty Syndrome? |
| NSAIDS: Iburofen or COX-2 Inhibitors ( do not affect platelet)
Steroids: Low dose < 10 taper over a month or low dose 2.5-5 mg chronic. ( Do not alter course of disease) | What is the First line treatment of RA? |
| DMARDS: Disease modifying anti rheumatic drugs
( Sulfasalazine or hydroxychloroquine, MTX)
Biologics: Infliximab ( Remicade) etanercept ( Enbrel) leflumonide ( Arava) , Anakinra (Kineret) $$$ 40/d | What is second line for treatment of RA? |
| Block activity of TNF. Work best when given along with MTX.
Halt and heal erosive changes. | How do Biologics work? |
| Infection, esp. reactivation of TB. Screen all pt with PPD and CXR.
Hep B and C
Vaccinate for pneumococcal, Zoster, Flu, Hep B. | What are the side effects of Biologics? |
| Use for aggressive dz.
Contra: Renal, liver dz and ETOH.
SE: Nausea, stomatitis, diarrhea and bone marrow depression and idiosyncratic pneumonitis ( 2-6% )
Give with folic acid.
Monitor LFT, CBC, and renal function Q2 mo. | What are SE of MTX? |
| Retinopathy: Check eye exam yearly
Renal: Check renal function. | What are the SE of Hydroxycholoquine. |
| Bone marrow depression: Check CBC
Oligospermia and liver dz. | What are the SE of Sulfasalazine? |
| Hands: DIP ( Heberdon's node) and PIP ( Bouchard nodes)
Spine, hips, knees. | Which joints are most affected in OA? |
| Joint space narrowing, osteophytes, subchondral bone sclerosis, and pseudocyst. | What are the xray findings in OA? |
| Tylenol, Topical analgesics: Capsasin, DMSO, Methsalycilate, Voltaren, Mucopolysaccaride injection. and Exercise. | What is the treatment of OA? |
| Joint swelling 50% initially in first MTP joint ( Podagra)
Swelling may extend beyond foot and involve lower leg. | What are the sx of gout? |
| Decrease renal excretion of Uric acid. Serum UA elevated > 9
Secondary causes : ETOH, low dose salicylate and thiazide diuretics and ACE.
Diet: HFC, shellfish, meat and ETOH | What causes gout? |
| NSAIDS : Naproxen 500 mg bid
Indomethacin 50 mg tid x 5-7 days.
Steroid in Elderly: Prednisone 30-50 mg x 7-10 days. | How do you treat acute gout? |
| After acute attack subsided. If at least 2 flares/ year, tops or nephrolitiasis.
Start allopurinol for uric acid elevation, but wait until acute attack subsided. Continue NSAID for 3 mo to prevent attack.
Can determine if overproducing UA by checking a 24 urine uric acid level. > 750 indicates overproduction and allopurinol would be indicated.
Do not treat asymptomatic elevated UA. | When do you start allopurinol? |
| Poly arthritis of the hands, knees and wrist. | What is pseudo gout? |
| Calcium pyrophosphate crystals,
Causes chonedrocalcinosis, calcium in the cartilage on xray. | What causes Pseudogout? |
| Joint aspiration showing rhomboid positive bifringence. | How do you dx pseudo gout? |
| Hemochromatosis and hyperparathyroid. Cause increase in phosphate and trauma causes precipitation of crystals. | What conditions predispose to pseudo gout? |
| Intra articular steroid injection, NSAIDS, Oral steroid. | How do you treat pseudo gout? |
| Non inflammatory disorder related to neurotransmitter dysfunction. Centralized pain disorder with pain amplification. | Fibromyalgia: What causes it? |
| Mutifocal pain, sleep disturbance and memory problems. Joint and proximal muscle tenderness. Points no longer checked. | What are the symptoms of fibromyalga? |
| Worse: Humid weather, stress , poor sleep
Better: Dry hot weather, relaxation and sleep. | What makes fibromyalgia worse and better? |
| Anxiety, depression, migraine, IBS, PMS, non cardiac CP, restless leg, dysmenorrhea, RA, Lupus. | What are associated conditions with fibromyalgia? |
| Hypothyroid, chronic fatigue, and myofacial pain.
WU: Check: CBC sed rate RF, TSK and CPK. | What is the DDX of fibromyalgia? |
| Non pharmacolgogic: Exercise, CBT, Yoga, acupuncture,
TCA ( Amitriptyline 25 mg QHS along with Fluoxetine 20 mg in am
Gabapentin 2/3 dose in pm and 1/3 in am
Pregabalin ( Lyrica) is newest approved by $$$
Tramadol may help.
Cyclobenzaprine 5 mg given 3 hours before bed to minimize grogginess.
Cannabinoids oral better than inhaled.
SNRI: Duloxetine or Effexor | How do you treat fibromyalgia? |
| ankylosing spondylitis
Reiters syndrome
Psoriatic Artharitis
Inflamatory bowel disease | What are the seronegative spondyloarthorpathies |
| Asymmetric polyarhtaritis with involovment of SI joints ( sacroilitis)
and spine.
Back pain > 3 mo with stiffness.
Asssociated sx: Uveitis ( photophobia, lacrimation and pain)
Aortitis presenting as aortic insufficiency. | What are the sx of ankylosing spondylitis? |
| Xray: SI fusion, Bamboo spine
Labs: HLAB27, CRP elevation,
Clinical: Schober test,, pain over SI joint and achilles tendon insertion. | How do you diagnose AS? |
| NSAIDS, DMARDS, and Biologics, intra- articular steroid injection, PT | How do you treat AS? |
| Arthritis with infection elsewhere in the body.
Findings: Sausage digits, Urethritis, conjunctivitis, asymmetric arthritis, skin discoloration of feet. | What is Reiters syndrome? |
| Chlamydia, Ureaplasma, Salmonella, Shigella, Campy and c. diff. | What causes Reiters? |
| Nail pitting, oonycholysis, sausage digits, and severe resorptive degeneration of joint. | What are the hallmarks of Psoriatic Arthritis? |
| B ones: symmetric nonerosive arthritis, Skin: Malar rash and oral ulcers, Lung: Pleuritic chest pain, effusion, pnumonitis, PE, Heart: Pericarditis, , CAD, Valve dz, Kidney: Glomerulonephropathy and RF., Blood:Thrombosis, anemia, leukopenia, CNS: Psychosis, seizure, and stroke | What is the multiorgan invlvement of SLE? |
| Anti-ds DNA and anti-SM Ab
Anticardiolipin and lupus anticoagulants are associateed with thrombosis and fetal loss | How do you diagnose Lupus? |
| NSAIDS and Antimalarial ( hydroxychloroquine) effective for rash and artharitis
Steroid for organ involvement.
Azathioprine and cyclophosphamide for renal and CNS disease | How do you treat Lupus? |
| Stiffness in bilateral shoulder girlds and hand swelling
Associated with temporal artharitis in 20% | PMR sx? |
| Start low dose prednisone 10-20 mg/d and monitor disesase activity with Sed rate. | PMR treatment |
| Unexplained persistent relapsing chronic fatigue not alleviated with rest and causing decrease in function.
Associated with 4 of the following. impaired concentration, sore throat, lymph nodes, muscle pain, multijoint pain, headache, nonrefreshing sleeping post exertional malaise > 24 hours. | What is chronic Fatigue syndrome? |
| Thought to be post infectious, accompainieed by immunologic disturbance and depression.
Causing hypothalamic dysfunction.
No dx test | What causes chronic fatigue? |
| NSAIDS for pain
TCA for mood and sleep
Venlafaxine low dose
CBT and exercise | How do you treat chronic fatigue? |
| Granulomatous disease involving lung, skin cardiac, joint and eyes.
Lung: 90% with sx: bilateral hailar adenopathy presents with cough, dyspnea, chest pain. Skin: Erythema nodosum, Eyes: dry eyes, viousla changes Cardiac: palpitation , syncope, fatigue, fever, wt loss. | What is Sarcoidosis and what are the sx? |
