Chronic Muscle / Bone Flashcards
Fibromyalgia Diagnosis
- Generalized pain, present in at least 4 of 5 regions (this helps to exclude regional pain disorders)
- Symptoms have been present at least 3 mo
- Widespread pain index (WPI) ≥7 (out of 19) and symptom severity scale (SSS) ≥5 (out of 12) OR WPI 4 to 6 and SSS ≥9 (these scales can be found at www.fmnetnews.com)
Fibromyalgia Presentation
Persistant pain + fatigue + normal muscle strength
- Hyperalgia: things that hurt, hurt more (e.g., one pin stick feels like multiple ones; getting bumped with shopping cart feels like hit by a truck)
- Allodynia: things that normally do not hurt, now do (e.g., a hug, a heavy blanket)
- Global sensory hyperresponsiveness: patient is hypersensitive to almost everything (e.g., perfume, light, sounds, medications)
May also have related symptoms like dizziness, tachycardia, bowel/bbladder, hair loss
Fibromyalgia Treatment
Duloxetine (pain + mood), start at 10 to 20 mg qd and may increase to 60 mg (weeks to months)
Duloxetine (pain + mood), start at 10 to 20 mg qd and may increase to 60 mg (weeks to months)
regabalin (pain + sleep + paresthesia), start at 25 mg qd and may increase to 50 to 75 mg bid (weeks to months) with max 225 mg bid
Multi-disciplinary approach is critical to help with pain management, stress, exercise
Gout
clinical syndrome resulting from urate crystals deposited in the tissue, with inflammation and potential destruction of the tissue or joint. All patients with gout will have hyperuricemia at some point, but most people never experience a gout attack.
Hyperuricemia Types
Primary hyperuricemia: no coexisting disease or drug that alters uric acid production or excretion
Secondary hyperuricemia: excessive urate production or diminished renal clearance (see risk factors, later)
Gout Symptoms
- Acute stage: joint effusion—joint is red, warm, and very tender (“even the sheets hurt”); reaches maximum inflammation within 24 hr. There is no fever or leukocytosis.
- Chronic gout: may have large, painless nodules (tophi), especially over the MTP or MCP joint
- May have kidney stone(s)
Gout Diagnosis
- Consider CBC, ESR (if unsure of diagnosis)
- Serum uric acid: not recommended with acute attack; most accurate time for baseline level or monitoring therapy is at least 2 wk after resolution of acute flare
- “Gold standard” is seeing urate crystals in joint fluid aspirate (usually done by a rheumatologist)
Gout Treatment - Acute Flare
Acute Flare
NSAIDs (indomethacin or naproxin) but be wary of contraindications to NSAIDs
Colchicine tid first day, then 4 times per day until pain resolves
Predinsone, taper when symptoms begin to resolve
Gout Treatment - Chronic
After second or third attack, check uric acid levels and consider prophylactic therapy (which is usually continued indefinitely), usually with allopurinol (start at 100mg, increase slowly and watch renal). Start 6 weeks after acute flare resolved.
Give colchicine 0.6 mg 1 to 2 times qd or NSAIDs qd for 6 mo to prevent gout flares
If an acute flare occurs, treat as described previously; if using prednisone, may need to extend taper to 10 to 14 days
Continue urate-lowering therapy during the attack
Uric acid goal is <6 mg/dL; it is recommended to lower the uric acid no more than 1 to 2 mg/dL per month, to reduce risk of a flare
A patient experiences a second gouty flare and the primary care provider decides to begin urate-lowering therapy (ULT).
How should this be prescribed?
Begin ULT with a high-loading dose and gradually decrease
Start ULT in five weeks, along with an anti-inflammatory drug
Suspend ULT during future gouty flares
Start ULT during the current flare for best results
Typically, ULT is begun five to six weeks after a flare and should be given with an anti-inflammatory drug, since the initial period of ULT administration is associated with flares. Beginning therapy with a urate-lowering drug during an acute flare will prolong the flare.
Septic arthritis
manifests with the acute onset of a painful, red, swollen joint that is warm to the touch. An important historical point that helps distinguish septic arthritis from sterile inflammation is that the affected joint is painful at rest as well as with motion and weight bearing.
The most important examination for the diagnosis of septic arthritis is synovial fluid, not only for culture but also for cellular and chemical analysis.
Gonococcal Arthritis
There may be clinical uncertainty about the diagnosis, especially in the context of a wide range of synovial fluid leukocyte counts and negative blood cultures. In this situation, ceftriaxone, 1 g/day IM or IV every 24 hours in addition to a one-time, 1-g dose of azithromycin, can be a valid diagnostic and appropriate therapeutic strategy.
The classic triad of clinical findings in disseminated infection is dermatitis, tenosynovitis, and a migratory polyarthritis.
For coverage of gonococcal arthritis, sexually active young adults should receive ceftriaxone, 1 g intravenously daily for 7 to 10 days in addition to 1 g azithromycin orally as a one-time dose
Most common in younger, sexually active adults
Prosthetic Joint Infection
most patients have joint pain with or without radiographic evidence of loosening of the prosthesis.A minority of patients have fever, joint swelling, or sinus track drainage.A helpful observation is that mechanical problems are painful during motion, weight bearing, and pivoting but are comfortable while at rest. Constant joint pain suggests an infection
Septic Sacroiliitis
ever and low back pain or gluteal region pain that is intensified by ambulation.Focal pain that occurs when shear forces are applied to the sacroiliac joint may indicate septic sacroiliitis,
Because of the complexity of the involved joints and difficult access, these collections need pigtail catheter drainage or surgical debridement.
A patient has marked swelling of a shoulder joint with erythema and severe pain.
The primary care provider suspects a bacterial cause, what should be done?
Synovial fluid culture is the most important exam for diagnosis of septic arthritis.
