Rheumatoid-auto immune disorder
Character-crampy, throbbing, etc
Quantity- scale of 1-10
Course- onset, duration, progression
Setting- repetitive activity, rest
Associated manifestations-local, constitutional, emotional
Weak muscles and joints
Congenital musculoskeletal disorders
Morning stiffness, or stiffness after prolonged immobility
Crepitus & occasional joint effusions
Grating or catching sensation with movement
cervical & lumbar spine
Palpate for crepitus, warmth, edema, & tenderness
Observe muscles for atrophy
Evaluate joint stability
Vascular dx like vasculitits
Can see progression
Narrowed joint space
Sclerosis of subchondral bone
Lessen weight bearing
Community support groups
Assistive devices-canes, jar openers, scooters
Analgesics-treat only the pain
Topicals-temprorry relief of pain or swelling
Injectables-aim to replace joint fluid
Steroid injection- used with signs of inflammation, effusion or substantial pain
Can surgically repair or replace damaged joints, but they must commit to rehabbing the joint
CBC, CMP, hemoccult if on NSAIDs
LFT’s if on Tylenol
Return to office if no response to tx within 4-6wks, or with flare-up
Adhesions & cysts can develop
Arthritis to ?3 joints
Arthritis of hand joints
Serum rheumatoid factor
Interstitial lung fibrosis
Acute rheumatic fever
Ulcerative colitis or Crohn’s disease
Synovial fluid analysis
Could also get ANA, CH50, immunoglobulins, CRP
Early referral for PT/OT
These drugs work slowly to modify the course of the disease. Methotrexate is the most common, but there are about 12 in all.
Combo of other drugs- analgesics, antidepressants, etc
Etanercept – Enbrel
Infliximab – Remicade
Adalimumab – Humira blocks TNF-a
Anakinra – Kineret blocks interlukin-1
Etanercept – Enbrel blocks TNF-a
Infliximab – Remicade blocks TNF-a
Rituximab – Rituxan blocks B cells
GI: N, diarrhea, abd cramping, oral ulcerations
Immune: immunocompromised, risk of Ca
Renal: proteinuria, increased creatinine
Blood: thrombocytopenia, leukopenia, elevated LFT’s
All but 1 are injections
Maintain ideal body weight
Be sure lab work is being done & monitored
Goal is to control condition, maintain/improve function, prevent deformities, psychosocial support, pt education, self-mgmgt
Caused by genetic, viral
Treatment is similar to RA
Chronic inflammatory disease causing pain and inflammation to the joints between vertebrae & pelvis. Eventually causes fusion to the spine.
Will see involvement in the spine, sacroiliac, & a distal asymmetric pattern.
Usually affects ?5 of the same joints on both sides of the body.
Usually involve ?5 joints, & they’re often red and tender.
Usually caused by a UTI or STD.
Symptoms usually come & go, and disappear within 12 months.
Systemic scleroderma- skin & internal organs
Seen more commonly in children.
R- Raynaud phenomenon
E- esophageal dysmotility
Immunosupressant meds may reduce scleroderma symptoms.
Most often in pt’s >60yo
Related to giant cell arteritis (Temporal arteritis)
Symptoms begin quickly, ?2 wks
Most notable characteristic is skeletal muscle weakness. May have dysphagia, dyspnea, aspiration.
More common in blacks. More common in women.
Remission is rare.
Will have elevated CPK, abnormal EMG
Articular cartilage loss
Nerve irritation or compression
Bone fracture or spur
Stretched or torn tissue
Reflex sympathetic dystrophy
Low cervical (bilat)
Second rib (bilat)
Lateral epicondyle (bilat)
Greater trochanter (bilat)
Pain in 11 of 18 tender points on digital palpation
Antidepressants- amitryptyline, fluoxetine, duloxetine, milnacipran
Lido injection to tender points
St. John’s wort
Can develop as a result from drugs like salicylates, diuretics, ETOH, or nicotinic acid.
Can be from a diet high in purines like anchovies, organ meats, liver, spinach, mushrooms, asparagus, oatmeal, cocoa, or sweetbreads.
Rare in women until menopause
Pain usually peaks within 24-36 hrs
Chronic gouty neuropathy
Acute uric nephropathy
Family hx (for primary gout)
#, duration & characteristics of attacks
Associated symptoms for chronic gout
Bursitis secondary to a bunion
Because there is no build up of uric acid
Gold standard, but painful & not required!
ESR & WBC’s will be elevated during acute attack
RF to rule out RA
Consider 24h urine to measure uric acid excretion
Colchicine (Colcrys) 1.2 at 1st sign of attack, then 0.6qh, 1.2q2h, or 0.6q2-3h until relief.
>1 attack/yr: 0.6mg daily
>1 attack/yr that are severe: 0.6 BID or TID
Allopurinol (Zyloprim)-reduces uric acid production
Probenecid (Benemid)-increases renal excretion
Febuxostat (Uloric)-reduces uric acid production
Destructive joint dx as seen on x-ray
Severe hyperuricemia (>10 in females, >13 in males, >15 in renal pts)
Severe uric acid overproduction (urinary uric acid excretion >1100mg/day)
Pts with high tumor burden about to receive cytoxic tx
Reduce ETOH, ASA, purines
Avoid hi fructose corn syrup
Try to drink 3L/day
Acute attack should have follow-up in 4wks
Chronic is individualized, but should have at least yearly uric acid level
Generally separated by >30 days, & 2 different parts of the CNS.
MRI with contrast, during or after 1st attack can show lesions. 2nd MRI @ 3 months later can show new lesions.
Female> Male 2:1
Living in temperate climate -further from Equator
Other autoimmune disorders
Secondary Progressive MS (SPMS)
Primary Progressive MS (PPMS)
Relapsing Progressive MS (RPMS) most severe, least common
Listed from least to most severe, but most to least common
Neuromyelitis Optica (NMO)
Acute Disseminated Encephalomyelitis (ADEM)
Severe relapses involving the spinal cord & optic nerve
Sensory symptoms may ascend to the trunk.
Myelopathy 2ndary to cervical spondylosis
Vit B12 deficiency
Guillian-Barre Syndrome -b/c it ascends
Paralysis- usually in legs
Reflexes, including abdominal
Fundoscopic, EOM, nystagmus
Bilateral hand numbness- useless hand syndrome
Dysethesia in 1 of the above areas
Generalized heat intolerance
RPR, Lyme titer
CSF eval by lumbar puncture
MRI brain & spinal cord
Evoked potential- by EEG or EMG
Treatment is to manage exacerbations
Meds to reduce fatigue
Meds for depression
Meds for bowel/bladder dysfunction
Ampyra to improve walking speed- SE of seizures
Exercise-but don’t run a marathon!
Bee stings (to restore sensation)
Removal of Amalgam dental fillings
# of lesions does NOT correlate with dx progression
Some have normal pregnancies, some get worse with pregnancies, it varies.
Optic neuritis as presenting episode
Sensory symptoms as presenting episode
Little residual disability after each exacerbation
Long inter exacerbation period
Progressive course from onset
Poor recovery from exacerbations
Involvement of cerebellar or motor functions
Discoid lupus erythematosus
Drug-induced jujus erythemstosus
It only affects the skin, usually a circular rash on the face, neck, and scalp.
Age 20 – 45
AA or Asian
Exposure to mercury and silica
Certain meds – chlorpromazine, hydralazine, isoniazid, procanimide
Butterfly rash or discoid rash.
Symptoms appear or worsen with sun exposure.
Leg, nasal, or oropharyngeal ulcers.
Livedo reticularis- pallor from anemia.
Petechiae- from thrombocytopenia.
Seen in SLE
Seen in SLE
Heart murmurs-if endocarditis or valvular thickening or dysfunction.
1. Butterfly rash
2. Discoid rash
4. Oral ulcers
6. Serositis (pleuritis, pericarditis)
7. Renal disorder
8. Neurologic disorder (seizures, psychosis)
9. Hematologic disorders (hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia)
10. Immunologic disorder (+ SLE cell prep, Anti-DNA, Anti-SM, false + STS known to be + for 6 months
11. Abnormal ANA
CBC with Diff.
Platelet count (Coomb’s test if anemia detected).
UA (24h for protein if proteinuria present).
PTT & anticardiolipin antibodies in pt’s with thrombotic events.
CMP to evaluate kidney & liver fx
EKG- eval causes of chest pain.
Echo-screen for significant valvular heart dx (present with 18% of SLE pt’s), detect valvular thickening/dysfunction.
#3 CNS causes
Cardiac: inflammation of heart muscle-myocarditis, endocarditis, pericarditis, coronary vasculitis. Also greatly increases risk of cardio dx and MI’s.
CNS: headaches, dizziness, memory probe, behavior changes, seizures.
Heme-oncological: anemia, bleeding or clotting disorders, vasculitits (inflammation of blood vessels), cancers, esp. Non-Hodgkin’s lymphoma.
Renal: kidney damage/failure.
Immunological: susceptibility to infection d/t dx and tx.
Pregnancy: increased risk of miscarriage, flares, pre-eclampsia, pre-term birth.
1st line tx is NSAID’s and lifestyle changes like diet, avoiding sunlight, smoking cessation, adequate rest, & exercise.
Antimalarials like Plaquenil
Immunosupressants like cytoxan, Imuran, Cellcept, & methotrexate.
Risk increases with dosage and length of use.
Immunosupressives like methotrexate 2.5mg 3x/week (max dosage of 20mg/week)
* Plasmapheresis in combo with immunosupressive agents (for rapidly progressing renal fx or life-threatening vasculitis).
* Azanthioprine maintenance regimen with corticosteroids.
* Anticonvulsants and antipsychotics.
* Headaches treated symptomatically.
Hematology for hematologic probs
Nephrology for significant renal probs