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Résidence - FM Learner > 57. Joint Disorder (26%) > Flashcards

57. Joint Disorder (26%) Flashcards

1
Q

In a patient presenting with joint pain, distinguish benign from serious pathology. Name examples of serious pathologies. (2)

A
  • sarcoma
  • septic joint
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2
Q

In a patient presenting with a monoarthropathy, rule out what ?

A

infectious causes. (e.g., sexually transmitted diseases).

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3
Q

In patients presenting with musculoskeletal pain, include referred and visceral sources of pain in the differential diagnosis.

Name some examples (3)

A
  • angina
  • glissement de l’épiphyse fémorale capitale se présentant comme une douleur au genou (dlr référée)
  • neuropathic pain
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4
Q

Describe use of X-ray in ligamentous injuries

A

Clinically diagnose ligamentous injuries. Do NOT do an X-ray examination.

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5
Q

In a patient presenting with joint pain, include systemic conditions in the differential diagnosis.

Name examples

A
  • Granulomatose de Wegener
  • Lupus
  • Ulcerative colitis
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6
Q

In assessing patients with a diagnosed rheumatologic condition, search for disease-related complications.

Name example (1)

A

iritis

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7
Q
A
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8
Q

Differentiate joint vs. soft tissue pain

A
  • Arthritis: Pain on ROM, decreased ROM, swelling, erythema
  • Soft tissue: ROM preserved, tendernes over bursae, tendons, or ligaments
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9
Q

Name DDX Monoarthritis (7)

A
  • Trauma
  • Infection (Septic arthritis)
  • Crystal-induced arthritis
  • Osteoarthritis
  • Systemic (Gonoccocal, non-gonococcal, mycobacterial, fungal, lyme)
  • Mechanical derangement
  • Neoplasm
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10
Q

Hemarthrosis is associated with which conditions ? (3)

A
  • fractures intra-articulaires
  • luxations
  • lésions ligamentaires
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11
Q

Gonoccocal joint infx presents how?

A
  • present as purulent arthritis
  • or a triad of tenosynovitis, vesiculopustular skin lesions, and polyarthralgias
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12
Q

Non gonococcal bacterial joint infections should be suspected in who? (3)

A

in IV drug users, immunocompromised, prosthetic joint

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13
Q

List Crystal-induced arthritis (2)

A

Gout (cristaux d’urate monosodique )
Pseudogout (CPPD)

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14
Q

Name causes of Systemic arthritis (4)

A
  • Spondylarthrite séronégative (Arthrite réactive, Arthrite psoriasique, Arthrite associée aux maladies inflammatoires de l’intestin)
  • Polyarthrite sarcoïde
  • Polyarthrite rhumatoïde
  • Troubles myélodysplasiques et leucémiques
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15
Q

Name redflags of joint pain (6)

A
  • Articulations chaudes/enflées
  • SX B
  • Raideur matinale > 30 minutes
  • Douleur nocturne
  • Faiblesse
  • Neurologique (douleur brûlante, engourdissement ou paresthésie)
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16
Q

Describe history : Joint pain

A
  • Red flags
  • Joint pain (OPQRST)
  • Prior joint pain/similar episodes
  • Systemic arthritis (morning stiffness>1h)
  • Trauma
  • Travel (Lyme)
  • Seronegative spondyloarthritis (GI/GU complaints)
  • Family history
  • PMH (immunosuppression)
  • Habits (IVDU, STI risk)
17
Q

When to suspect : Spondylarthrite séronégative (4)

A

suspect in
* enthésite (l’inflammation des sites d’insertion du tendon, du ligament, de la capsule articulaire ou d’un fascia sur l’os)
* dactylite (inflammation grave des articulations des doigts et des orteils)
* conjonctivite/uvéite
* psoriasis

18
Q

Describe physical exam : Joint pain

A
  • Vitals, temperature (high-grade fever)
  • Soft tissue swelling, warm, effusion
  • Passive/Active ROM
  • Extraarticular : Tophi, Skin changes (Psoriasis, Malar rash, Erythema nodosum), Eye involvement
19
Q

Describe investigations : Joint pain (3)

A
  • Imaging (XR, US, CT, MRI). Consider avoiding imaging in absence of trauma or focal bone pain
  • Joint aspiration
  • Consider labs
20
Q

Describe joint aspirations

A

Gross appearance
Crystal analysis
White cell count and differential
* <2,000/mm3 usually non-inflammatory
* >20,000 suspect septic arthritis

Gram stain and Culture

21
Q

What labs to consider in joint pain : (6)

A
  • CBC
  • LFT
  • ESR/CRP
  • ANA, RF, Anti-CCP
  • (HLA)-B27
  • Coags (in hemarthrosis)
22
Q

Décrire présentation/questionnaire : Fibromyalgie

A
23
Q

Décrire EP : Fibromylagie

A
  • Neurologique : possible de retrouver allodynie, trouble d’équilibre et sensibilité aux 9 paires de points douloureux (pas obligatoire pour poser diagnostic)
  • Articulaire : devrait être normal
  • Tout ce qui est pertinent pour confirmer ou infirmer une autre condition
24
Q

Décrire bilans : Fibromylagie

A
  • Bilan d’exclusion : FSC, CRP, CPK, TSH
  • Maladies chroniques, syndrome métabolique, obésité peuvent augmenté légèrement la CRP
  • CRP > 20 considérer investigation supplémentaire
  • Tout autre investigation doit être justifiée par trouvailles au questionnaire ou à l’examen objectif
25
Q

Décrire tx : Fibromylagie

A
  • Traitement pharmacologique : approche par symptôme (Antidépresseur 3 cycliques, SNRS ou gabapentinoïdes, Éviter les opiacés et les benzo)
  • Éducation
  • Psychothérapie PRN
  • Exercices physiques et autogestion
  • Référer en ergothérapie, réadaptation interdisciplinaire ou services spécialisés de main d’oeuvre (selon les besoins) PRN
  • Physiothérapie PRN
26
Q

Name a few Diagnostic Differentiators for Wegener’s granulomatosis, lupus, ulcerative colitis

A
27
Q

Name signs/symptoms : Gout

A
  • Acute arthritis -> painful, swelling, erythema, usually lower extremity (most common 1st MTP), limited joint mobility
  • Tophi (monosodium rate crystals) > rate deposit in cartilage / tendon bursa / soft tissue / synovial
  • Renal > nephropathy, calculi, acidic urine
28
Q

Describe investigations : Gout

A
  • Hyperuricemia is NOT diagnostic of acute attack (normal 15-480). Helpful to determine efficacy of prophylaxis
  • Consider synovial fluid aspiration for rate crystals (especially if septic arthritis is still on the differential)
  • Imaging Options (uncertain usefulness in primary care) - when diagnostic testing is necessary, use synovial fluid aspiration especially if septic arthritis is still on the differential (X-rays usually not useful u/s (low quality evidence, Dual energy CT)
29
Q

Describe dx : Gout (4)

A

New York Criteria : >= 2 of the following:
* > or = 2 attack of painful joint swelling with complete resolution within 2 weeks
* Unilateral first MT joint attack (podagral)
* Response to colchicine (major reduction in inflammation within 48 hrs)
* Tophi (proven or suspected)

30
Q

Describe lifestyle tx : Gout (6)

A
  • Limit purine intake + limit high fructose intake
  • Avoid alcohol
  • Avoid meats, sardines, shellfish, beans, peas
  • Consider diet <1600 kcal / day (show to reduce serum uric acid)
  • Weight loss. Given risk factors include HTN / obesity / CAD / DM / dyslipidemia
  • Avoid thiazides, consider losartan instead
31
Q

Describe acute gout tx (4)

A
  • use topical ice as an adjunct treatment
  • NSAID (Naproxen)
  • Colchicine
  • Corticosteroids - if NSAID + colchicine contraindicated (ex. On warfarin), avoid in poor diabetes control, infection (ex. prednisone)
32
Q

Describe urate lowering therapy for gout (1)

A

Allopurinol

33
Q

Which patients should be considered for prophylactic urate lowering therapy ? (5)

A
  • ≥ 1 tophi
  • radiographic damage from gout
  • ≥ 2 flares / year
  • > 1 lifetime flare but <2 / year
  • first flare and CKD stage ≥3, SU >535 umol/L, or urolithiasis
  • Do NOT Rx for first flare w/ none of the above conditions
34
Q

Describe : Rheumatoid Arthritis (4)

A
  • Chronic autoimmune disorder causing (usually symmetrical) erosive synovitis of peripheral joints (small and large), swelling, stiffness, pain
  • Morning stiffness ≥ 1 hour, improves w/ use, worsens w/ rest
  • Joint damage > ⬇️ motion, instability, deformity, crepitus
  • Constitutional symptoms (fatigue, rarely wt loss)
  • Vasculitis
  • Lymphocytic Infiltrates - rheumatoid nodules, pulmonary fibrosis, pleural effusion, pulmonary nodules, pericarditis, Hashimoto’s thyroiditis, hepatosplenomegaly
  • Joint Deformities - Boutonniere, Swan neck, claw toe, hammer toe, mallet toe
35
Q

Name dx criteria : Rheumatoid Arthritis

A

At least 4 of the following:
* Moring stiffness around joints for ≥ 1 hour
* Arthritis ≥ 3 joint areas (soft tissue swelling)
* Arthritis of hand joints (wrist, MCP, PIP)
* Symmetric arthritis. Bilateral involvement PIP, MCP or MTP joints
* Rheumatoid nodules
* Serum rheumatoid factor elevated
* Radiographic changes on hand and wrist views (erosions, decalcification)

36
Q

Name investigations : Rheumatoid Arthritis

A
  • Bloodwork : RF, anti-cyclic citrullinated peptide (anti-CCP), CRP/ESR, FSB (elevated platelets)
  • X-ray (diagnostic erosions rarely seen in disease <3 month, I Consider imaging of hands + feet q6mo in recent onset)
  • Joint aspiration
37
Q

Name Complications of Untreated Rheumatoid Arthritis (6)

A
  • Anemia
  • Scleritis
  • Deformities - hands, frozen shoulders, nodules
  • Pericarditis
  • More Infections
  • ?malignancy (unsure if related to DMARDs)
38
Q

Describe pharmacotx : Rheumatoid Arthritis

A
  • NSAIDS - symptom relief but do NOT alter course of illness. Use lowest effective dose for shortest time possible. Offer a PPI
  • Disease-modifying anti-rheumatic drug (DMARDs) - start ASAP - adjust q3-6mo
  • Corticosteroids (adjunct to the above to manage flares, bridge DMARDs, max 3/yr). Can use as short term bridging when starting a new synthetic DMARD but taper rapidly
  • Gastro protection if >65y/o or history of PUD
39
Q

Name examples DMARDs

A
  • Methotrexate
  • Leflunomide
  • Sulfasalazine
  • Hydroxychloroquine
  • Cyclosporine
  • Azathioprine

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