57. Joint Disorder (26%) Flashcards

Question

Name redflags of joint pain (6)

Answer 1

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

Answer 2

* 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)

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

* CBC * LFT * ESR/CRP * ANA, RF, Anti-CCP * (HLA)-B27 * Coags (in hemarthrosis)

Answer 8

* 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

Answer 9

* 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

Answer 10

* 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

Answer 11

* 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

Answer 12

* 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)

Answer 13

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)

Answer 14

* 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

Answer 15

* 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)

Answer 16

Allopurinol

Answer 17

* ≥ 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

Answer 18

* 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

Answer 19

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)

Answer 20

* 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

Answer 21

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

Answer 22

* **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

Answer 23

* **Methotrexate** * Leflunomide * Sulfasalazine * Hydroxychloroquine * Cyclosporine * Azathioprine