Monoarticular Arthritis Clinical Flashcards Preview

Med School Year 2 Flash Cards > Monoarticular Arthritis Clinical > Flashcards

Flashcards in Monoarticular Arthritis Clinical Deck (107):
1

Most common causes of acute monoarticular arthritis (three)

crystals, trauma, infection

2

infections in monoarticular arthritis

gonococcal, nongonoccal, lyme diseae, mycobacterial/viral/fungal

3

inflammatory causes of monoarticular arthritis

RA, seronegative spondyloarthropathies, SLE, sarcoidosis, reactive arthritis

4

hot or swollen joints usually means

infection

5

constitutional symptoms (fever, weight loss, malaises) usually means

infection

6

weakness in monoarticular arthritis usually means

compartment syndrome or acute myelopathy

7

burning pain, numbness, paresthesia suggests _____ (3 things) in monoarticular arthritis

myelopathy, radiculopathy, neuropathy

8

risk factors for septic arthritis

prosthetic hip or knee joint, skin infection, joint surgery, rheumatoid arthritis, age >80, DM

9

symptoms of worse with immobility usually means

inflammatory arthritis (esp if lasting more than one hour --> RA or polymyalgia rheumatica)

10

symptoms aggravated by motion and weight bearing and relieve by rest usually means

OA

11

antecedent trauma can point towards this kind of diagnosis

fracture, meniscal tear, hemathrosis

12

systemic complaints: chills, malaise, fever are more seen in

infectious (high grade fever more than low grade fever because low grade can be seen in crystals)

13

GI or GU complaints, recent sexual exposure suggest

infectious portals or entry or seronegative spondyloarthropathy (reactive arthritis, psoriasis, IBD)

14

recent travel to endemic regions suggests

infection (Lyme disease, mycobacerial and parasitic)

15

synovitis symptoms are

soft tissue swelling, warmth over a joint, joint effusion

16

reduced active range of motion with preserved passive range of motion suggests

soft tissue disorders - bursitis, tendinitis, or muscle injury

17

both active and passive ROM decreased suggests

soft tissue contracture, synovitis, structural abnormality

18

fever is seen in these types of rheumatic illnesses

infectious, posinfections, reactive, RA, Still's, systemic rheumatic illness (SLE/vasculitis), crystal induced, cancer, sarcoidosis

19

sudden onset of pain in seconds/minutes

fracture, internal derangment, trauma, loose body

20

onset of pain over several hours or days

infection, crystals, inflammatory

21

insidious onset of pain over days to weeks

indolent infection, OA, infiltrative, tumor

22

previous acute attacks in any joint with spontaneous resolution

crystal depo disease, other inflammatory arthritic

23

IVDA or immunosuppression

septic arthritis

24

previous prolonged corticosteroid therapy

infection, AVN

25

coaguloapthy or anticoag use

hemarthrosis

26

urethritis, conjunctivitis, diarrhea, rash

reactive arthritsi

27

psoriatic patches or nail changes (pitting)

psoriatic arthritis

28

diuretic use, tophi, renal stones, alcoholic binges

gout

29

eye inflammation, low back pain

ankylosing spondylitis

30

young adulthood, migratory polyarthralgias, inflammation of the tendon sheaths of hands and feet, dermatitis

gonoccocal arthritis

31

hilar adenopathy, erythema nodosum

sarcoidosis

32

most common test in monoarticular arthritis

synovial fluid analysis - arthrocentesis; ATTEMPTED IN ALL PATIENTS WHO HAVE AN EFFUSION OR SIGNS SUGGESTING INFLAMMATION WITHIN THE JOINT

33

septic arthritis synovial fluid looks like:

>100,000 WBC with greater than 75% PMN, also should get a culture on preservative-free choclate agar plates, reduction in glucose and elevation in LDH are also consistent with bacterial infection

34

noninflammatory fluids look like:

fewer than 2000 WBC, less than 75% PMN

35

crystalline arthritis fluid looks like:

MSU in gout, intracellular crystal within in the PMN; calcium pyrophosphate crystals in pseudogout

36

bloody synovial fluid with no trauma you should order these tests

PT, PTT, platelet count, bleeding time

37

ESR and CRP indicated this kind of arthritis

inflammatory

38

ANA is sensitive for

SLE

39

RF is used for

RA but limited diagnostic value (esp in monoarthritis)

40

Anti-CCP used for

RA, more specific than RF

41

indications for synovial biopsy

refractory monoarthritis, suspicions of atypical infectious agent, intraarticular tumors; performed using arthroscope or Parker pearson technique

42

Bacterial arthritis risk factors

age >80*, DM, malignancy, immunosuprressive drugs, RA*, joint replacement/hardware*, high risk sexual behavior
*indicate increase likelihood of poor outcome

43

Bacterial arthritis onset, pain level, presents as, other sx

acute onset, severe pain, inability to weight bear, fever/chills/malaise

44

Bacterial arthritis PE

erythematous, swollen, warm, TTP, pain with AROM/PROM, splinter hemorrhages/ Janeway's lesions/Osler's nodes on hands and feet --> endocarditis may be present if these are present; other sources of infection: GU, respiratory, skin, GI

45

Bacterial arthritis imaging findings and what type of imaging used

effusion, soft tissue swelling, underlying arthritis (associated with poor outcome); MRI/CT/bone scan reserved for osteomyletits suspicion

46

Bacterial arthritis lab data

Joint fluid: culture, Gram stain, cell count, crystal eval; cell count exceed 50,000 (less with immunocompromised) with >75% PMN

47

MC pathogens in Bacterial arthritis and do you need a positive Gram to confirm?

staphylococci, streptococci, gram neg bacilli, mycobacteria, neisseria gonorrhea; absence of organisms on Gram's stain does no rule out bacterial arthrtitis (gonococcal)

48

if bacterial arthritis involves prosthetic joint you should

call an orthopedic consult

49

when do you start antibiotics for Bacterial arthritis and how?

preferred: diagnosis made before starting antibiotics BUT dont delay treatment if synovial fluid is hard to obtain --> admit to hospital for empiric broad coverage IV antibiotic therapy for gram-positive organisms

50

MRSA is considered in Bacterial arthritis when

there is a high risk patient or present in the community

51

orthopedics should be consulted immediate for this in Bacterial arthritis

open drainage of the join, but if not indicated then can use closed drainage of daily needle aspiration until all fluid gone

52

how long should parenteral antibiotics be continued after drainage completed in Bacterial arthritis

minimum of 2 weeks

53

how do you treat viral arthritis

self limited monoarthritis

54

lyme disease is caused by ____ in this region of the US

borrelia burgdorferi carried by deer tick Ixodes scapularis in the Northeast and central northern US

55

Lyme disease presents with these lesions

target lesions or erythema chronicum migrans (ECM), or monoarthritis of the knee (late presentation)

56

Lyme disease PE and imaging

erythematous swollen joint with pain on PROM and AROM

imaging: effusion but in chronic can show osteoporosis, loss of cartilage, periarticular erosions

57

Lyme disease synovial fluid

WBC 500 to 50,000; Lyme disease PCR because B. burgdorferi is rarely cultured

58

Lyme disease treatment

doxycycline twice a day but if contraindicated then amoxicillin three times a day for 28 days

59

patient that engage in high risk sexual behavior are at risk for this arthritis

gonococcal arthritis (N. gonorrhea is MC bacterial arthritis in sexually active young people from 18 to 24)

60

Gonococcal arthritis PE

Initial infection 1 day to 3 months prior, arthritis in UE (wrist/extensors), myalgia, arthralgias, fever, malaise, dermatitis

61

Gonococcal arthritis imaging

soft tissue swelling, effusion

62

Gonococcal arthritis labs

mostly based on Hx and PE because N. gonorrhea is difficult to culture

63

Gonococcal arthritis treatment

admitted to hosptial, IV ceftriaxone (if allergic in fluoroquinolone) then oral cefixime (if allergic in fluoroquinolone)

64

Gonococcal arthritis caused by chlamydia is treated with

azithrymycin

65

CPPD can be initial presentation of these underlying metabolic diseases

hyperparathyroidism, hemochromatosis, sarcoidosis, acromegaly

66

BCP crystals are associated with

long term hemodialysis

67

gout uric acid levels, male vs female, age of presentation, associated conditions, precipitating factors

Uric acid: >7mg/dl in men or 6 in women
Male to female: 7 to 1
Increases with increasing age
Conditions: lead intoxication, hematopoietic malignancy, renal impairment; DM, HTN, obesity, hypothyroid, hyperlipidemia
Precipitating: dietary indiscretions, diuretics, dehydration, discontinue hypouricemic therapy, trauma

68

gout presents as ___ pain of a ____ joint (most commonly the _____ joint)

acute onset of severe pain of a single joint (MTP but also seen in foot, ankle, knee, fingers, elbows, wrists)

69

gout PE of joint (acute and chronic)

erythematous and swollen, warm, painful, tophaceous deposits (longstanding), uric acid deposits on ear/elbow/achilles tendon and fingers/brusa/other joints

70

gout imaging

plain films: effusion for aspiration in acute, periarticular erosions in recurrent

71

gout synovial fluid

synovial fluid: uric acid crystals, needle-shaped that are strongly negatively birefringent as bright yellow needle shaped crystals; WBC 200 to 50,000 (can be higher), purulent, Gram stain and culture to rule out infection

72

acute treatment of gout (1st, 2nd, and 3rd line)

start at very first sign of attack for best results, NSAIDs are first line (max dose for 2 to 3 days), prednisone/colchicine for contraindicated NSAID (renal disease, heart failure, GI bleeds); prednisone is 2nd line; colchicine is third line at first sign of attack (GI side effects and contraindicated in renal insuff)

73

long term chronic gout treatment (for what kind of patients, goals of treatment, when to start tx)

long term prophylaxis for pt with recurrent gout attacks, uric acid kidney sotones, tophaceous gout
want to lower urate less than 6 gm
can't start until sx free of (NSAID prophylaxis can be given to prevent acute attack from starting urate lowering drug)

74

long term chronic gout treatment drug types and side effects

uricosurics (probenecid and sulfinpyrazone --> younger patients who underexcrete uric acid, SE: urolithaisis, acute gout flare) and xanthine oxidase inhibitors (allopurinol --> can be used in renal insuff, SE - hypersensitivity reaction)

75

CPPD presentation

similar to gout, disability of single joint, erythematous and swollen, TTP

76

MC joints in CPPD

ankles, knees, wrists, shoulders, MCP

77

CPPD imaging findings

Chondrocalcinosis - linear calcification or cartilage (esp in fibrocartilage) in the menisci, pubis, hips, discs, wrist

78

CPPD synovial fluid

rhomboid shaped calcium pyrophosphate dihydrate crystals weakly positively birefringent, culture and Gram to exclude infection

79

CPPD treatment

high dose NSAID, colchicine is not as effective, prednisone will relieve attack

80

BCP is also called and presents like

calcific periarthritis, tendoitis or bursitis
presents like gout with deposits of BCP rupturing into soft tissue --> acute pain, swelling, erythema, warmth

81

BCP is MC in this joint

shoulder (Milwaukee shoulder syndrome is chronic)

82

BCP imaging

calcific deposits in supraspinatus tendon or subdeltoid bursa, degenerative changes of GH and AC joints

83

Joint fluid of BCP

serosanguinous or milky white fluid with mononuclear cell, WBC <1000, BCP crystals on electron microscopy

84

BCP treatment

NSAID or colchicine, joint aspiration, intraarticular steroid injection; surgery if pain is unremitting

85

Meniscal tears caused by

sudden deceleration, change in direction, or landing from jumping

86

Meniscal/ligament tears can present this inflammatory timeline and patient complaint

inflammatory response over several hours (if quick then can be hemarthrosis --> ACL TEAR)
pt feels knee giving out, locking/catching, unable to fully extend w/o pain

87

Meniscal/ligament tears PE (provocative test)

feel a clunk on full extension
McMurray's test positive - extends knee from flexed position while externally rotating the foot and palpating the knee medially (feels clunk); lateral meniscus - foot internally rotated during extension.
anterior drawer sign positive if ACL damage
posterior drawer sign positive if PCL damage

88

Meniscal/ligament tears imaging needed

plain radiography first for arthritis and loose bodies and then MRI/arthroscopy for meniscal tear

89

Meniscal/ligament tears treatment

refer to ortho surgeon (peripheral area can heal without intervention bc blood supply but in the inner will need arthroscopy)

90

occult fracture presents in these populations

young adult athletes, osteoporosis, osteomalacia, fibrous dysplasia

91

stress fractures present with trauma - true or false

false because repetitive muscular forces or physiologic forces in people with mineralization abnormalities

92

patietns that get stress fractures

track and field, dancers, military recruits, menstrual disturbances, eating disorders, metabolic conditions

93

stress fracture PE

hot, swollen, painful joint

94

stress fracture imaging and joint fluid

radiographs will usually be negative but MRI/bone scans can diagnose and joint fluid will be negative for crystals/organisms

95

what is the first step in treating stress fracture

find the underlying cause (DEXA, 25-OH vit D levels, CBC, chemistry, liver)

96

treatment of stress fracture

referral to ortho surgeon

97

what should patients with JIA do every 3 months

ophthalmologist for asymptomatic uveitis --> blindness

98

most common inflamma arthropathy with monoarthritis

reactive arthritis

99

reactive arthritis occurs after

diarrheal illness or GU infection

100

bacteria associated with reactive arthritis

Enteric: salmonella, higella, clostridium, vibrio, hyersinia. GU: chlamydia

101

typical patient with reactive arthritis

20 to 40 yoa, male or female, HLAB27 positive

102

MC joint in ReA

knee (also see UE, sacroiliacs, spine)

103

other symptoms of ReA

fatigue, morning stiffness, fevers, malaise

104

ReA PE

MC knee or other weight bearing, warm/tender/swollen with effusion, dactylitis (sausage fingers), ENTHESITIS, keratoderma blenorrhagicum, circinate balantitis, conjunctivitis

105

ReA imaging (acute and chronic)

soft tissue swelling/effusion, asymmetric sacroiliitis, later can present with reactive bone proliferation/fluffy periosteal reaction/erosions

106

ReA labs

ESR and CRP elevation, anemia, leukocytosis, inflammatory synovial (WBC 2000 to 50,000) with crystal and culture neg, RF and ANA neg

107

ReA treatment

resolution of sx in 3 to 6 months; chlamydia - azithromycin; therapeutic drainage; NSAIDs are mainstay daily; prednisone for more debilitating, HLA B27 and keratoderma blenorrhagicum refer to rheumatologist, ophthalmologist referral