Skills - SDL Rheumo Diagnostics (shared drive copy).docx.pdf

Master of Physician Assistant Practice MPAP 525 – Clinical Skills IV Learning Objectives Topic: Inflammatory and Rheumatologic Disorders Diagnostics Student Directed Learning At the conclusion of this activity and completion of required reading, the student will be able to: 1. Discuss the following...

Master of Physician Assistant Practice MPAP 525 – Clinical Skills IV Learning Objectives Topic: Inflammatory and Rheumatologic Disorders Diagnostics Student Directed Learning At the conclusion of this activity and completion of required reading, the student will be able to: 1. Discuss the following tests utilized to detect the presence of inflammation and the conditions in which these tests would be elevated: a) Sedimentation rate (ESR) 1. ↑ ESR a. Polymyalgia rheumatica b. Temporal arteritis c. RA d. Psoriatic Arthritis e. GWP f. Behcet syndrome g. Takayasu Arteritis b) C-Reactive Protein (CRP) 1. ↑ CRP (more sensitive than ESR) a. RA b. Polymyalgia Rheumatica c. Temporal arteritis d. GWP e. Behcet Syndrome f. Takayasu Arteritis 2. Describe the indications for ordering an Antinuclear Antibody (ANA), the significance of the ANA titer and the common immunofluorescence patterns. a. Indications: Suspicion of SLE or other connective tissue dz b. Titer: i. the higher the titer, the more likely the pt has a connective tissue dz Rev 2/20-JH 1. The titer shoes how many times the the pt’s serum was diluted before ab could no longer be detected (ex: 1:640, diluted 640 times, greater concentration than 1:40) ii. ANA titers can be falsely positive in many autoimmune dz 1. When ANA is positive and SLE or other connective tissue dz is suspected 🡪 more specific testing needed c. Immunofluorescence patterns i. SLE: homogenous/rim pattern ii. Sjorgen syndrome: speckled pattern iii. Scleroderma: nucleolar pattern iv. Limited scleroderma: centromere staining 3. Discuss the indication for ordering the following rheumatologic diagnostic studies and the conditions in which they are most likely to be abnormal: a) Antinuclear antibody (ANA) a. Conditions associated w/ positive ANA i. SLE (positive in 95% of SLE pts) ii. Sjorgen syndrome iii. Dermatomyositis/Polymyositis iv. Mixed connective tissue dz 1. ANA is best initial test v. Scleroderma 1. ANA is best initial test b) Anti-Antiphospholipid antibodies a. APLA c) Anti-double-stranded DNA antibodies a. Hallmark test of SLE b. In some pts, levels will increase during possible flare i. Useful for dz monitoring d) Anti-smith antibodies a. Greatest specificity for SLE, BUT low sensitivity i. (positive test is diagnostic, negative test does not exclude it) e) Antineutrophil cytoplasmic antibodies (ANCA) a. Granulomatosis with polyangiitis i. Only help establish dx when probability of dz is high ii. ANCA should be ordered in pts with pulmonary-renal syndrome, rapidly progressive renal failure, mononeuritis multiplex, or pulmonary hemorrhage (should not be used in pts w routine sinusitis unless vasculitis features are present) f) Rheumatoid factor a. RA b. Cryoglobulinemia Rev 2/20-JH c. Mixed Connective Tissue Dz d. Sjogren Syndrome e. SLE f. Systemic Sclerosis g) Anticyclic citrullinated peptide antibodies (anti-CCP) a. RA i. Anti CCP has better sensitivity and specificity than RF for RA h) Uric acid a. Gout b. Psoriatic Arthritis i) HLA-B27 a. Hallmark test of ankylosing spondylitis (present in 95% of those with dz) b. Also positive in reactive arthritis, psoriatic arthritis, IBD associated arthritis c. Routine testing not advised i. Testing most useful when ankylosing spondylitis is suspected or when an inflammatory disorder of the back, joints, chest, or eyes is suspected 4. Compare and contrast the exam/diagnostic findings and common rheumatologic diseases associated with the following types of joint fluid: a) Normal b) Non-inflammatory i. Normal ESR 1. Osteoarthritis c) Inflammatory i. Increased ESR/CRP 1. RA d) Purulent/septic 1. ↑ WBC a. Bacterial Septic Arthritis b.