02c: Gout Flashcards by Nuna H

Gout is a(n) (X) resulting from (Y) deposition in joints/soft tissues.

X = inflammatory arthritis
Y = monosodium urate crystals

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(X)% of gout occurs due to under-excretion of urate. Typically, how much urate is synthesized and then secreted daily?

X = 90

450/750 mg secreted by kidneys and 300/750 mg secreted by GI tract

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When serum urate concentration exceeds (X), crystals precipitate out and deposit in soft tissue/joints.

X = 6.8 mg/dL

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T/F: Hyperuricemia typically preceeds the first attack by a few months.

False - by 5-10 years

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T/F: Knee is involved in gout, pseudogout, and septic joint arthritis.

True

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Joint pattern in Gout v Pseudogout.

Gout: small/peripheral
Pseudogout: large/axial

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T/F: Tophi are commonly involved in gout, pseudogout, and septic joint arthritis.

False - common in gout, VERY rare in pseudogout, and never occur in septic joint

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Patient presents with fever, leukocytosis, and inflammed knee. He claims it’s been getting progressively worse over the past few days. Which part of history makes you think this is (gout/pseudogout/septic arthritis)?

Septic arthritis;

Onset timing: severe within days (not hours)

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Initial gout attack is (mono/poly)-articular most of the time and involves 1st MTP (X)% of the time.

Mono;

X = 50

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List the triggers for an acute gouty attack.

Minor joint trauma
EtOH
Purine-rich food
Acute illness
Diuretic use
Dehydration

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T/F: Untreated acute gouty attacks will resolve on their own in a few hours.

False in 3-10 days

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Aspiration of joint affected by gout will reveal:

Leukocytosis (50,000-100,000!)

2. Monosodium urate crystals (neg birefringent, needle-like), usually engulfed by PMNs

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T/F: Tissue biopsy is gold standard for gout diagnosis.

False - joint aspiration (with visualization of urate crystals)

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T/F: Hyperuricemia is mandatory for precipitation of gout.

True

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30% of patients have normal serum uric acid during acute gout attack. This may be due to the (X) effect of (Y).

X = uricosuric 
Y = IL-6

Also more free water reabsorption in kidney (ADH release)

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T/F: Gouty arthritis risk is strictly environmental, not genetic.

False - large portion of urate metabolism is inherited

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Tophi are masses of (X). Where are they frequently seen?

X = uric acid crystals

Olecranon bursa, top of ears, over extensor surfaces of joints

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What does the development of tophi in gouty arthritis depend on?

Duration and severity of hyperuricemia (decrease in incidence since anti-hyperuricemic agents have been available)

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T/F: Decision to administer chronic treatment for gout is determined partly by magnitude of hyperuricemia.

False

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Long-term therapy for gout recommended in which scenarios?

Over 2 attacks/yr
Tophi
Uric acid kidney stones
Renal insufficiency

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Goal of chronic gout therapy is to reduce serum urate to (X)

X = under 6 mg/dL

Unless tophi present, then under 5 mg/dL

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Gout: How would you counsel your patient on lifestyle?

Exercise/weight management; avoid purine-rich food, EtOH, fructose-rich/sugary drinks; drink water!

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60 y.o. male patient with history of IV drug use and hypertension continues to have gouty attacks, despite having lost weight and altered diet. What could be going on?

May be on thiazide diuretic for HT (which is a hyperuricemic drug)

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List treatment options for acute gout attack.

NSAIDs
Injection glucocorticoids
Systemic glucocorticoids
Colchicine (low dose)

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Allopurinol mechanism of action.

Inhibits xanthine oxidase (precursors of urate more quickly excreted and don't cause gout)

(X) gout drug and its major metabolite are converted into riboNT by HGPT, thus inhibiting (Y).

``` X = allopurinol Y = de novo purine synthesis ```

Patient put on chronic therapy for gout (allopurinol). Which other medication should be started for initial (X) months of therapy? Why?

Colchicine X = 4-6 Lowering serum urate paradoxically increase risk of acute flare

T/F: Patients on allopurinolmay be on various doses, depending on amount of urate produced/excreted.

True

Max dose of allopurinol given.

800 mg/day

List allopurinol's most common side effect. And its most dangerous.

Hypersensitivity rash (2%); severe hypersensitivity (life-threatening)

Allopurinol causes significant drug interactions with drugs that are (X). Give an example.

X = cleared by xanthing oxidase (purine analogues) Azathioprine (immunosuppressant)

Provenecid is a(n) (X) agent that has which mechanism of action?

X = uricosuric (anti-hyperuricemic) Increases renal clearance of urate by blocking PCT reabsorption (via URAT1 urate transporter)

Patient on treatment for acute gout has developed uric acid kidney stones. Which drug has he likely been prescribed? What can be done to reduce the reoccurrence?

Probenecid (uricosuric agent); Increase fluid intake and alkalinization of urine

Probenecid is only indicated for gout patients that are (undersecretors/overproducers) of uric acid.

Undersecretors

Colchicine mechanism of action.

Suppresses inflammatory response (chemotaxis, IL-1 release) to crystals in joint tissue

T/F: Colchicine is effective in prophylaxis of acute gouty attack.

True

Common side effects of Colchicine.

Diarrhea and other GI stuff

Pseudogout: (X) crystals deposited in (Y). Will it resolve spontaneously?

X = Ca pyrophosphate dihydrate Y = articular cartilage of joint Yes, over 2 weeks

Pseudogout crystals typically appear (X) shape and (pos/neg) birefrengent.

X = rhomboid | Weakly pos

List some risk factors for pseudogout. Star the most important one(s).

1. Old age* 2. Hyperparathyroidism 3. HypoMg 4. Hemochromatosis

Current treatment for pseudogout (chronic).

None

You suspect patient has carpal tunnel. Which two tests could you do on physical exam?

1. Phalen's test (flex wrist at 90o for 1 min) | 2. Tinel's sign (extend wrist at 90o and tap over carpal tunnel)

T/F: Carpal tunnel is most commonly treated with neutral wrist splint and NSAIDs. It's key to treat/adjust work habits to avoid repetitive injury.

Partly true, BUT NOT NSAIDs (not particularly effective for most cases)

Trigger finger: locking of digit in (flexion/extension) related to thickening of (X) and hypertrophied (Y).

Flexion; X = flexor tendon Y = ligamentous pulley (usually A1)

Injection of collagenase clostridium histolyticum has been shown to markedly improve symptoms of (X) wrist/hand problem.

X= Dupuytren's contracture

T/F: DM is associated with Carpal Tunnel, Trigger Finger, and Dupuytren's Contracture.

True

List the four main causes of olecranon bursitis.

1. RA 2. Gout 3. Infection 4. Trauma (aute/chronic)

Olecranon bursitis: patient is most comfortable (pain-free) in which arm position?

Extension at elbow

Elbow arthritis: lack of discomfort with elbow in which position?

At 45o (joint largest); flexion/extension beyond that is painful

T/F: Patient with olecranon bursitis will likely feel discomfort protonating/supinating arm.

False

T/F: Olecranon bursitis does not always imply infection.

True

Max tenderness directly over ECRL tendon origin at epicondyle makes you suspicious for (X) condition. If max tenderness is a few cm distal to epicondyle, you'd think of (Y) condition.

``` X = lateral epicondylitis (tennis elbow) Y = fibromyalgia ```

Lateral epicondylitis: (X) treatment success rates high for short-term, but (Y) more beneficial for long-term.

``` X = corticosteroid injection Y = physiotherapy ```

Most cases of shoulder pain are due to one of which common disorders? Star the most common of these.

1. Rotator cuff tendonitis*/bursitis 2. Acromioclavicular arthritis 3. Adhesive capsulitis 4. Cervical spine referred pain 5. Glenohumeral arthritis 6. Bicipital tendonitis

90% of the time, rotator cuff tendonitis is a result of injury to (X) structure(s).

X = supraspinatus tendon +/- the overlying subacromial bursa

10% of the time, rotator cuff tendonitis includes injury to (X) structure(s).

X = infraspinatus tendon

Under 5% of the time, rotator cuff tendonitis includes injury to (X) structure(s).

X = subscapularis

Rotator cuff tendonitis: (X) muscle is only involved in cases of high velocity trauma.

X = teres minor

Rotator cuff tendonitis: infraspinatus involved means pain with which motion against resistance?

External rotation

Rotator cuff tendonitis: subscapularis involved means pain with which motion against resistance?

Internal rotation

Patient experiencing pain putting on bra. The arm is doing which motions? Which muscle involved?

Supraspinatus; | Retroflection and internal rotation of arm

Loss of motion in all planes at shoulder should make you think of which condition?

Adhesive capsulitis

Rotator cuff tendonitis: supraspinatus involved means pain with which motion against resistance?

Internal rotation and abduction

Pain with resisted motion makes (strain/tear) more likely. And weakness with resisted motion makes (strain/tear) more likely.

Strian; | Tear

Shoulder pain that occurs at night should make you think of which three conditions?

1. Cervical radiculopathy 2. Adhesive capsulitis 3. Tumor

You suspect patient is experiencing shoulder pain secondary to radicular neck pain. Think of questions you may ask to verify.

1. Radiates past elbow? 2. Worse with neck rotation? 3. "Shooting/burning" pain? 4. Any arm numbness/parasthesias?

Patient complains of inability to raise arm over head. You initially think it could be an issue with (X) muscle, but then you see she has a history of DM. So (Y) condition pops into your head.

``` X = supraspinatus Y = adhesive capsulitis (DM MOST FREQUENT MEDICAL CONDITION ASSOCIATED WITH THIS) ```

T/F: Patients tend to experience progressive/worsening pain with adhesive capsulitis.

False - severe pain/loss of motion initially, then pain abates with ROM still limited

Adhesive capsulitis is a result of:

Tightening/fibrosis of joint capsule

Adhesive capsulitis: how would you treat?

1. PT (CRITICAL) | 2. NSAIDs +/- injections

Pain in anterior shoulder that's reproduced with supination. Which condition on top of your differential? Which resisted motion would you test next?

Biceps tendonitis Forward flexion of elbow

Rotator cuff muscles (elevate/depress) humeral head to counteract (upward/downward) pull of (X) muscle.

Depress; Upward X = delts

Acromioclavicular osteoarthritis: maximal pain is seen when you palpate (X) and with which motion?

X = AC joint directly Cross-body adduction

T/F: Feeling crepitus with shoulder motion would make you think of adhesive capsulitis as potential cause.

False

Spurling's maneuver is used to test for (X). Briefly describe this test.

X = radicular cervical pain (radiating to shoulder) Patient rotates neck to side of pain, then extends neck, then doc pushes down on head; should produce patient's shoulder pain

Patient with lateral thigh pain, exacerbated by climbing stairs and getting up from her seat. You suspect (X) bursitis. If (Y) structure is involved, pain can extend how far down the lateral thigh?

``` X = trochanteric Y = IT band ``` Up to knee, but not beyond

T/F: Less than 10% of patients diagnosed with trochanteric bursitis have actual bursitis.

True - it's a misnomer; usually condition due to glute medius tendonitis or tear

List some predisposing factors for trochanteric bursitis.

1. IT band tightness 2. Lower back degenerative arthritis 3. Leg length discrepancy

Patient with trochanteric bursitis will have pain with which resisted motion?

Abduction and external rotation (remember: glute med usually involved, not true bursitis)

Patient with symptoms of trochanteric bursitis complains also of groin pain. How does this affect/verify your differential?

Likely hip arthritis, not trochanteric bursitis

Patient with symptoms of trochanteric bursitis reveals that pain occasionally radiates to lower leg/foot. How does this affect/verify your differential?

Likely lumbar radiculopathy, not trochanteric bursitis

T/F: Pes Anserine Bursitis, unlike trochanteric bursitis, is a true bursitis.

False - another misnomer; usually tendinosis of Pes Anserine tendons

Muscles that attach to pes anserinus

1. Sartorius 2. Gracillus 3. Semitendinosus

Where is pes anserinus anyway?

Just distal and medial to tibial tuberosity

Pes anserine bursitis: pain with which resisted motion?

Knee flexion with adducted and internally rotated hip