4. Conf 1: Gout, Fibromyalgia Flashcards
What is a very general DDx for monoarticular joint pain (ie, pain in the first MTP)?
trauma, infection/sepsis, crystalline disease (gout, pseudogout), Rheumatoid Arthritis, cellulitis
what symptoms suggest gout?
- sudden episodes of severe joint pain, redness, swelling
- usually reaches peak in 12-24 hrs, self-resolves in 10-14 days
- may awaken patients from sleep
- may be tophi (non-tender)
what are risk factors for gout?
- family history of kidney stones
- obesity
- HTN
- excessive alcohol use
- meds that increase serum urate (diuretics)
what is podagra?
acute inflammation of the first MTP with swelling, erythema, pain (regardless of cause). characteristic of gout (Greek: seizure of the foot)
what is the difference in etiology between gout and pseudogout?
- gout = needle-like crystals, monosodium urate
- pseudogout = rhomboid crystals, calcium pyrophosphate
what are some clinical signs of pseudogout?
- sudden attacks of joint pain, swelling, warmth
- may have fever due to inflammatory reaction
- knee is often affected
what clinical features distinguish gout from RA?
Timing: RA is usually more of a chronic onset.
Distribution: some RA patients present with monoarticular dz, but usually RA is poly-articular and bilateral. hands are usually involved with RA.
Pain: RA is worst in morning, improves with usage.
Systemic sx: RA accompanied by fatigue, low fever, malaise
what clinical features distinguish gout from Psoriatic Arth?
Distribution: PA may be more axial, polyarticular
Joint features: PA may present with podagra or dactylitis (sausage digit). usually PA is less painful
Systemic sx: PA usually has enthesopathy, psoriasis, nail changes or eye inflammation.
what clinical features distinguish gout from Osteo Arth?
Timing: Gout is acute, OA is chronic
OA is non-inflammatory
Pain: OA won’t wake you up at night
Distribution: OA commonly affects the 1st MTP joint, wrists, hips, knees –> bony prominences
OA may have joint deformation, crepitus
what tests should be ordered to evaluate gout?
- aspiration of the joint fluid. culture, crystals
- CBC with diff: WBCs, liver/renal function
- uric acid (tho may be low during attack)
- blood cultures to r/o septic arthritis
- joint xray (trauma)
if you only had one test you could run on a possible gout patient, what would it be?
culture/gram stain joint fluid for sepsis because septic arthritis is an emergency
what is the difference between gout crystals and CPPD (pseudogout) crystals?
- gout: needle shaped, monosodium urate crystals. BRIGHT. yellow along plane of (parallel to) polarized light. blue when perpendicular to the axis of light. very “negatively birefringent”
- pseudogout: rhomboid shaped, dull. BLUE when parallel to polarized light, yellow when perpendicular. “positively birefringent”
(Pic this side is CPPD; other side is gout)
describe xray findings in gout
‘punched out’ erosions at joint margins, sclerosis. not seen until 5 yrs post first attack in untreated patients. soft tissue swelling during acute attack
what can contribute to hyperuricemia?
obesity (associated), low dose aspirin, HCTZ (causing under-excr of uric acid), EtOH use (both underexcretion and overproduction) Fructose consumption causes direct elev.
treatment for acute gout?
- NSAIDs in max doses
- oral colchicine (if started within 12 h). give hourly until relief or GI side effects (diarrhea)
- IM steroids (prednisone)
other diagnoses that are part of the Fibromyalgia Spectrum?
CFS, restless leg, IBS, irritable bladder, chemical sensitivities, primary dysmennorrhea, migraines, periodic limb movement during sleep, tension headaches, TMJ, myofascial pain sx
what is the tenderpoint exam?
To dx fibromyalgia, pts need to have pain in 11/18 areas (tenderpoints).
This exam has been dropped from the official disease criteria, but still used
