Flashcards in Arthritis-Table 1 Deck (42):
You have a 30 yr old sexually active male present with sacral pain and for some reason he knows he is positive for HLA-B27. What is in your differential and what one are you leaning towards as a diagnosis?
DDX: ankylosing spondylitis and Reiter’s syndrome(reactive arthritis) Ankylosing spondylitis is more likely d/t cardinal sacral pain is usually point of initial complaint. Reiter’s syndrome will involve one large joint and go away in 3-5 mo.
What is osteoarthritis and how is it different from RAs etiology?
OA is non-inflammatory, AKA. all labs will be normal/negative. versus RA is inflammatory and often systemic with labs like ESR/CRP/RF/Anti-CCP positive/elevated.
A 37 yr old women presents to clinic with polyarthralgias that are symmetrical. Her labs come back with elevated ESR and CRP, but her RF and ANA are normal. You notice her fingers look like juicy sausages with splitting nails…what do you suspect it is?
Psoriatic arthritis! It mimics RA’s clinical features. RA doesn’t have Dactylitis(sausage fingers) and will have positive RF and ANA.
A sir walks into your clinic complaining of knee pain. Upon examination his knee is swollen appearing, red, and hot to the touch and his ROM is normal. What do you think it is?
Cellulitis or bursitis etiology. ROM should be have abnormal dysfunction in septic arthritis(gaurding), crepetis in oa, and limited rom in inflammatory arthritides. ROM intact could indicate an overlying structure.
What are the clinical features of osteomyelitis?
Microbial infection to bone, often in DM pts, post surgical or hematogenously spread(children)
What is the gold standard for osteomyelitis dx?
What is the most common version of osteomyelitis that you see in primary care settings?
Foot OM- usually DM pts with foot infection- “probe to bone” is a good way to dx
How do you tx OM?
ABX 1mo-3mo, surgery may be required if associated with implanted device. If complicated, amputation might be necessary
What is septic arthritis and how will it often clinically present?
swollen, red, hot, painful monoarticular, pt is septic appearing with fever and gaurding joint=limited ROM! abrupt onset
What is the gold standard for septic arthritis dx?
Synovial fluid analysis- looks like green snot- thick, WBC>50K, +culture, PMN’s 75
What labs should you collect in suspected septic arthritis before initiating empiric therapy?
Gram stain, Cell count, crystals- stat, culture and sensitivity, CBC, ESR, CRP
How do you tx septic arthritis?
Surgical arthrotomy or arthroscopy with I&D is preferred- scrape out the tissues. IV abx up to 6 weeks of Ceftriaxone or vancomycin
What is the most common pathogen found with septic arthritis?
Staph. Aureus(beta-hemolytic), if sexually active could be N.Gonococcus
What is the clinical presentation of gout?
abrupt, overnight, severe pain, erythema, swelling, monoarticluar, first MTP often, podagra, low grade fever, “can’t put a sheet over it”
What is the pathophysiology of gout?
Altered purine metabolism- either too much or not enough clearance at kidneys
What things exacerbate gout or increase uric acid production?
ASPIRIN, diuretics, dehydration, ETOH, diet high in sodas/perservatives/meats
What is the gold standard for gout dx?
synovial fluid analysis- urate crystals present-aka.monosodium urate, cloudy appearance
Is a serum urate level over 6.8 diagnostic for gout?
How do you treat acute gout?
Indomethacin(NSAID), colchicine, corticosteroid injection maybe
What is the clinical presentation of pseudogout?
Same as gout, except synovial fluid and xray results and pubic symphesis involvement and is Calcium pyrophosphate dehydrate disease
how do you dx pseudogout?
synovial fluid will have calcium pyrophosphate and xray will show CHONDROCALCINOSIS(fine linear calcifications in cartilage of joint)
What is the treatment of acute pseudogout?
Same as acute gout!
What are the clinical features of Reiter’s syndrome(reactive arthritis)?
Abrupt, Asymetical large joint involvement, mucosal ulcers, conjunctivitis, urethritis, oligoarthritis, often male, 18-40 yo, enthesopathy(myofasical pain), keratoderma(hands and feet rash)
How do you dx reiter’s
often will have chlamydia, or gasteroenteritis(shigella), positive HLA-B27(30-80%), ESR/CRP will be elevated.
tx for reactive arthritis?
NSAIDS(indomethacin), ABX if chlamydia, but will not relieve s/sx. Will resolve in 3-5mo
What are the clinical features of Ankylosing spondylitis?
Si joint inflammation, 20-30 yo male, insidious, usually FHX, Uveitis(40%-irritation around iris),60% inflammed colon or ilium, pain will ascend spine overtime
How do you dx AS?
Spondylitis, sacroilitis and syndesmophyte on xray, bamboo spine also(fused vertebra), There are some criteria outlined, but there is no way we need to memorize it.
how do you tx AS?
NSAIDS, PT early, TNF blockers(biologics) like infliximab, etanercept, adamlimumab,
What is the clinical presentation of psoriatic arthritis?
polyarticular symmetric, 90% pitting nails, onset 37 yo, inflammed synovium, sausage finers, arthritis mutilans
How do you dx psoriatic arthritis?
history of psoriasis preceding arthrisit, seronegative(aka.neg. RF and ANA), increased ESR and CRP
What is the prefered treatment for psoriatic arthrisit?
NSAIDS, methotrexate, TNF alpha blockers
What are the clinical features of Rheumatoid arthritis?
Persistent progressive multi system inflammatory disorder with extraarticular manifestations.
How do diagnose Rheumatoid arthritis?
6 or greater of the ACR criteria. Basically it involves positive labs and positive imaging. Labs may include positive RF, Positive Anti-CCP(99%), xray is the best imaging for RA(acticular demineralization, soft tissue swelling in flare ups)
What is your first line treatment, second line and 3rd line treatments for RA?
NSAIDS, DMARDS(hydroxychloroquine, sulfasalazine, methotrexate), Biologics(etanercept, abatacept, rituximab, infliximab, adamimumab.)
What are some of the organ systems affected by RA?
Eyes, heart, kidneys, blood vessels, and rbcs and often has complications of pulmonary effusion and eipiscleritis
What is the hyperplastic joint srtucture eroding into bone and cartilage called in RA?
Pannus by infiltration of the T and B lymphocytes
Osteoporosis is highly associated with OA(T/F)
False, they are inversely related
Osteoporosis is highly associated with RAT/F)?
True, osteoporosis is highly associated with RA
What is Osteoarthritis and its clinical features?
Large asymmetrical often weight bearing joint
How do you dx OA?
Xray- see joint space narrowing, sclerosis, bone cysts, osteophytes, asymmetric joint space narrowing
How do you treat OA?
Alter joint activity with pt, Tylenol is first line, then intraarticular viscosupplementation(Euflexxa, sipartz), weak opioid if refractory