Post on 11-Feb-2022
Quick Notes on Age, Sex, and Distribution Specificities
How to make the diagnosis before seeing the patient
Age and Sex Specificities
• Young female: Think RA, SLE, Fibromyalgia
• Older female: Think OA, RA (bimodal presentation, Polymyalgia Rheumatica, Gout (over 50 y/o, gout prevalence in females equal to that in males
• Young male: Think Reactive Arthritis, RA, Gout
• Older male: Think OA, Gout, Pseudogout
Distribution Specificities
• Lower Extremity: HLAB27 related arthritis, gout
• Root Joints: Polymyalgia Rheumatica
• Symmetric Small Joint: RA, SLE
• Axial Pain: HLAB27 related, tumor, infection
• 1st MTP (Podagra): Gout, bunion, Pseudogout, reactive arthritis
Distribution Specificities (continued)
• Unilateral inflamed wrist: Pseudogout (look for calcification in the triangular fibrocartilage)
• 1st CMJs, DIPs, Hips, Knees: Primary OA
Primary Osteoarthritis
• Older males and females
• Distribution: DIPs (Heberden’s nodes), PIPs (Bouchard’s nodes, Hips, Knees (medial compartment initially as opposed to lateral compartment involvement in inflammatory disease)
• Genetically determined
• Most common arthritis in world (40 million in U.S.) No disease modifying therapy available
Secondary Osteoarthritis
• Osteoarthritis in atypical areas
• Primary OA does not occur in the ankles, wrists, MCPs, shoulders (glenohumeral articulation), or elbows.
• Usually crystal induced: Gout, Pseudogout, basic calcium phosphate.
• Radiologic clues: MCP Hooks, chondrocalcinosis, joint space loss without erosions
Look for Associated Metabolic Diseases in Secodary Osteoarthritis
• Pseudogout associated with hemochromatosis, hyperparathyroidism, Wilson’s Disease
• Gout
Diffuse Musculoskeletal Pain Syndrome (AKA Fibromyalgia)
• Diffuse pain involving muscle and joints
• High Prevalence in young female patients presenting to rheumatology office
• Neuropathic pain symptomatology
• Associated with sleep disorder (interruption or non-restful sleep)
• Trigger points on physical exam
• Absence of joint swelling
ACR Preliminary Diagnostic Criteria for Fibromyalgia
• Widespread pain index (WPI) greater than or equal to 7 and symptom severity (SS) scale score greater than or equal to 5 or WPI 3-6 and SS scale score greater than or equal to 9.
• Symptoms have been present at a similar level for at least 3 months
• The patient does not have a disorder that would otherwise explain the pain.
Differential Diagnosis of Fibromyalgia
• RA, SLE, myositis, polymyalgia rheumatica (in older patients)
• Hypothyroidism (common)
• Hepatitis C
• Paraneoplastic disease in older patients
Screening Lab Evaluation for a Patient with Rheumatologic Complaints
• CBC, CMP (metabolic profile), CPK
• UA
• T4, TSH
• RF, anti-CCP, ANA, HLAB27
• Sed rate, CRP
• Hepatitis Panel
Treatment of Osteoarthritis
• NSAIDs (Risk of ulcer, stroke, and MI – Counsel the patient). Chronic use not recommended.
• Analgesics (acetaminophen, tramadol, low dose narcotic analgesics)
• Injection (steroids, hyperviscosity agents)
• Surgery
Treatment of Fibromyalgia
• Low dose tricyclics at hs
• Cyclobenzaprine hs
• Duloxetine
• Lyrica (or neurontin)
• Aerobic exercise
• CPAP in OSA patient