Clinical Approach to Patient with Joint Pain I and II Flashcards Preview

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Flashcards in Clinical Approach to Patient with Joint Pain I and II Deck (38):
1

1. What is the most common location of arthritis?
2. What % of adults have some form of self-reported MD diagnosed arthritis?

1. back and spine
2. 22%

2

1. What are some general clinical characteristics of arthritis?
2. What is it called if its inflammatory?
3. How is the disease defined?
4. What are findings are important?

1. Pain and stiffness in a joint
2. synovitis
3. distribution and chronology
4. presence of extra-articular findings are important

3

Acute Monoarticular Arthritis
1. Time course
2. Etiologies (6)

1. about 7 days or fewer in duration; can go out to 14
2. Septic (most urgent to diagnose)
3. Crystal induced (most common, not urgent)
4. Trauma
5. Hemorrhage- may not be obvious; check for anticoagulants
6. Mechanical (occupation/weight)
7. Atypical polyarticular

4

Acute Monoarticular Arthritis
Extra-artciular clues in Sepsis (4)
5. What can also cause inflammation?

1. fever and shaking chills
2. Cutaneous clues
3. Tophi
4. Mucosal involvement
5. Gout

5

Synovial Fluid analysis in acute monoarticular arthritis
1. How important is it?
2. What does it mean if there are 200 WBCs?
3. What does it mean if there are 2000 WBCs and 25% or fewer are PMNs?
4, What does it mean if there are 2000 WBCs and 50% or greater PMNs?
5. Other tests that can be done

1. VERY, single most important test for making correct diagnosis
2. fluid is normal
3. non-inflammatory
4. may be inflammatory
5. Gram stain, culture, crystals

6

What kind of crystals can cause gout? What does each look like under microscope (2)

1. Sodium Urate crystals: needle shaped that may be w/in neutrophil; changes from blue --> yellow on polarized microscopy
2. Calcium pyrophosphate: blunt ended crystal with weak positive birefringence

7

What tests are not that helpful?

1. Radiology- can show demineralization, both gout and sepsis do this
2. Bloodwork (NEVER a substitute for SF);
Uric acid- doesn't correlate with presence of gout
Leukocytosis- can be in gout and sepsis
Blood cultures- can show sepsis

8

Gout incidence
1. Which gender tends to have more gout?
2. When does the other gender catch up?
3. why?

1. males
2. females approach male incidence after menopause,
3. estrogen promotes urate excretion in the urine

9

Gout Mechanism/ Pathogenesis
1. How is IL-1 upregulated?
2. What does IL-1 do?

1. uric acid crystals are ingested by macrophages, which release IL-1
2. recruits neutrophils

10

Gout Therapy
1. Why isn't Colchicine used?
2. Natural course of disease
3. NSAIDs aren't used much. why?
4. Short term
5. Long term treatment & mechanism

1. Side effect is diarrhea, which is bad with gout
2. self-limited
3. decrease renal function, so you excrete less uric acid
4. large dose corticosteroids
5. Allopurinol- inhibits Xanthine Oxidase

11

Chronic Monoarticular Arthritis
1. Time duration
2. Differential Diagnosis

1. about 2 months
2. Degenerative Joint Disease (Osteoarthritis)
3. Mechanical Internal Derangement (like a meniscus tear)
4. Chronic infection
5. Joint Neoplasm (rare)
6. Pigmented Villonodular synovitis
7. Rheumatoid arthritis (rare)
8. Idiopathic

12

Synovial Biopsy in Chronic Monoarticular Arthritis
1. How does it compare to Synovial Fluid?
2. What does it help ID/rule out? (4)

1. usually not better than it, good for some things
2. Neoplasm
Infection (especially fungal)
Pigmented Villonodular synovitis
Sarcoidosis

13

Acute Polyarthritis
1. How many joints?
2. How long?
3. Differential Diagnosis

1. more than 4
2. less than 8 weeks duration
3. Acute Rheumatic Fever
Gonococcal arthritis
Post-viral arthritis (common)
Lyme arthritis
Immune complex arthritis

14

Parvovirus
1. Which adult population is at risk?
2. What causes arthritis?
3. Disease course

1. People exposed to little kids (elementary school teachers)
2. Ab cross-reactivity (?)
3. usually self-limited

15

How can you differentiate between these 3 causes of acute polyarthritis?
1. Rheumatic fever
2. Borrelia
3. Gonococcal

1. true migratory arthritis, unique skin lesion (only present in 10%)
2. Geography, season, and unique skin lesion (erythema migrans; 90-95% will have it)
3. skin lesions

16

Diagnosis of Acute Polyarthritis
1. Acute Rheumatic Fever
2. Gonococcal
3. Borrelia
4. Parvovirus

1. ASO- strep Ag; DNAase- other serum Ag;
2. culture appropriate sites (oral, ano-rectal, cervix, urethra); can appear near period or 1st trimester
3. Elisa for screening (+ test doesn't make dx); PCR for confimation
4. IgM titer (shows pt having acute parvo)

17

Pathogenesis of GC arthritis
1. Which joints are affected initially?
2. What happens next?
3. What kind of lesions are common?
4. When does it occur? why?
5. What predisposes people to repeated bouts of the syndrome?

1. knees, ankles, wrists, fingers; multiple, bilateral, symmetrical
2. culminates in 1 or 2 joints as disease progresses
3. skin lesions
4. perimenstraul time frame or during pregnancy; driven by progesterone?
5. late complement deficiencies; some GC subtypes have an increased propensity to cause the syndrome

18

Chronic Polyarthritis
1. How many joints?
2. For how long?
3. What is usually the diagnosis?

1. more than 4
2. at least 2 months
3. Rheumatoid arthritis

19

Features of Rheumatoid Arthritis (4)
5. What drives the disease?

1. AM stiffness
2. soft tissue swelling
3. Systemic manifestations (fatigue)
4. Symmetrical Joint Involvement (bilateral; small, medium, large joints)
5. cytokines

20

Epidemiology of RA
1. What countries get it?
2. Racial groups?
3. Which gender gets it more often?
4. Prevalence
5. What does it do to life expectancy?
6. What is happening to risk of getting it?

1. worldwide
2. slightly increased in Europeans and Asians, but all get it
3. women
4. 1 %
5. cuts it by 3-5 years
6. increasing

21

1. How does RA destroy hand function?
2. Which joints are affected in the hand?
3. Which other joints in the body are affected?
4. Which area is notably not affected?

1. erodes ligaments
2. PIP and MCP; NEVER affects Distal interphalangeal joints; if DIP is involved; it's not RA
3. cervical, shoulder, elbow, wrist, knee, ankle, foot joints
4. lumosacral spine/area NEVER involved

22

Extra-articular manifestations of RA (6)

1. Nodules- becoming rare
2. anemia- chronic inflammation shuts down Fe utilization
3. Episcleritis
4. Neuropathy- distal, peripheral
5. Serositis- pleural, common
6. Vasculitis- lower extremity

23

RA Diagnosis
1. What kind of dx?
2. What is usually not diagnostic?
3. What new tech is very helpful
4. What is seen in synovial fluid

1. clinical
2. routine blood work (ESR, CRP, RF, CBC); if all are negative, pt usually won't have RA, but they don't narrow it down
3. ACPA- citrullinated peptide antibodies- shows inflammation and auto-antigenicity; 80-85% specificity
4. inflammatory, low glucose, nonspecific

24

What are some Genetic (2) and Environmental Factors (4) that contribute to RA?

1. monozygotic concordance: 15-30%; many genes involved
2. having HLA DRB1 and +RF and ACPA; DRB1 is the "shared epitope"
3. smoking- synergistic with DRB1 --> poor prognosis
4. adverse life events precipitate it, suggesting like w/ pit-adrenal axis
5. Gut microbiome
6. Peridontal disease

25

1. Overall Pathogenesis of RA
2. What cytokine may also play a major role?

1. B cells create Ab to some self Ag; activates neutrophils and macrophages --> destruction
2. IL-17 (which suggests IL-23 is present too)

26

RA Treatment
1. What is recommended but not realistic?
2. NSAIDS?
3. Corticosteroids?

1. rest for long time
2. too many side effects, esp in older pts
3. excellent for bridging until Disease Modifying Anti-Rheumatic Drugs take effect; acute suppression

27

Osteoarthritis (DJD)
1. 2 types
2. Causes of the second type

1. Primary and Secondary
2. Trauma
prior inflammatory disease
congenital
metabolic
avascular necrosis (common when pt takes many steroids)
hypermobility

28

DJD
1. Which joints are commonly affected?
2. When are unusual joints involved?
3. What happens?

1. weight bearing joints: 1st MTP, Knee, Hip, Lumbosacral spine, Cervical vertebrae;
2. when a person has an unusual occupation
3. bone on bone -->reactive bone formation

29

Epidemiology of DJD
1. Linear relationship to what 2 things?
2. Geography?
3. How does it vary with race?

1. age and weight; 90% have some evidence of it at 65
2. worldwide
3. gene mutation in black families in the South --> higher incidence of debilitating knee disease

30

Pathogenesis of DJD: what 3 things lead to it?

Mechanical factors
Metabolic factors
Inflammatory Disease

31

1. What are the functions of cartilage (2)
3. Main cartilage cell
4. 4 Main components of Cartilage

1. smooth, low resistance surface for movement
2. compressibility for diffusion of mechanical forces; anything that disturbs weight bearing --> loss of cartilage
3. chondrocytes
4. Water, proteoglycans (compressibility), collagen (tensile strength), chondrocytes (maintain and synthesize cartilage)

32

Chondrocytes
1. what are they
2. What happens when their mechanoreceptor activity is activated?
3. What other cells do they communicate with?

1. sole cell component of cartilage
2. release growth factors, metalloproteinases (degrade cartilage's ability to function normally), and innate inflammatory cytokines
3. osteoblasts

33

Pathogenesis of DJD
1. What is increased?
2. What is decreased?
3. What is altered?
4. What properties of proteoglycan are altered?
5. What do released metalloproteinases do?

1. water
2. functional proteoglycan
3. collagen structure
4. aggregation and biomechanical properties
5. break down matrix and activate innate inflammatory responses

34

1. If obesity/weight is so important in OA, why are NON-weight bearing joints sometimes affected?

1. visceral fat adipocytes secrete adipokines (leptin) that are found in the synovial fluid in OA; these fat cytokines appear to trigger cartilage destruction by activating metalloproteinases, aggrecanases (alter compressibility) and collagenases --> DAMPS(?)

35

Clinical Presentation of DJD
1. When is pain worse?
2. When is pain better?
3. How much morning stiffness?
4. Physical Exam finding
5. Which joints are affected?

1. with weight bearing
2. with rest
3. very little AM stiffness
4. Joint crepitus
5. Cervical, Lumbar Spine, weight bearing joints including 1-MTP and CMC joint of thumb

36

DJD: 1. What lab tests are useful?
2. What imaging tests are useful?

1. none
2. can be misleading; very bad looking knee may not be very painful at all

37

Management of OA (DJD) (6)

1. Education
2. Weight alleviation (won't get better until weight is lost)
3. Physical Therapy (helpful in OA, not very helpful in other diseases)
4. Restrained use of NSAIDs
5. Surgery
6. Alternative therapy- generally not very helpful;

38

What do RA pts often take w/o doctor's recommendation?
How helpful is it?

Chondroitin sulfate
doesn't help, doesn't hurt
costs alot of $$