Acute join pain (oxford clin cases) Flashcards
In an acutely painful joint what diagnosis must you exclude because it is a medical emergency?
Septic arthritis
What are articular causes of joint pain in one joint (ie monorthritis)
Septic arthritis
Trauma
Gout
Pseudogout
What are periarticular causes of joint pain in one joint (ie monorthritis)
Ligment injury
Tendinitis
Bursitis
What type of pain is likely with an acute joint if its worse on movement and better with rest?
Non inflammatory
What are some common diagnoses for joint pain if the pain comes on acutely?
Septic arthritis
Gout/pseudogout
Trauma
What are some common diagnoses for joint pain if the pain comes on insidiously?
Tendonitis
Bursitis
What are common risk factors for gout?
Being on thiazide diuretics Recent heavy alcohol intake Chronic renal failure and renal stones Chemotherapy Previous gout
What are some common risk factors for septic arthritis?
Being immunocompromised (diabetes, HIV, steroid use) Prosthetic limbs
What does joint pain involving multiple joints sequentially indicate is the diagnosis?
Rheumatic fever
Gonococcus
What does joint pain involving multiple joints simultaneously indicate is the diagnosis?
Rheumatoid arthritis
Psoriatic arthritis
What drugs might predispose someone to gout?
Thiazide diuretics
Low dose aspirin
Ciclosporin
What drug predisposes someone to osteoporosis?
Steroids
What questions would you ask in the history when someone presents with acute joint pain? Explain why you’d ask them
Was the pain acute?- likely septic arthritis, gout, pseudogout
Is the pain insidious?- likely bursitis and tendonitis
Is the pain chronic?- likely osteoarthritis
Do they have any risk factors for gout?- thiazide diuretics, recent alcohol misuse, renal failure, renal stones, previous episode
Have they had any recent trauma to the knee?
Do they have any risk factors for septic arthritis?- immunocompromised (diabetes, on steroids, HIV) or prosthetic joints
Have they had any recent GI infection?
Are they at risk of any STIs?- gonocccus might present this way
Are other joints involved?- sequentially= gonococcus or rheumatic fever, simultaneously= rheumatoid or psoriatic arthritis
How are articular conditions likely to present?
With diffuse swelling over the whole joint which will be red, hot and tender. Pain will be present during both passive and active movement
How are periarticular conditions likely to present?
There will be a focal point of swelling eg the tendon or the bursa
Pain will be worse on active movement
What do articular and periarticular mean?
Articular= to do with the joint Periarticular= around the joint
What are tophi and what are they a sign of?
They are deposits of urate crystals, they can break through the skin
They are a sign of chronic gout
What are some signs of psoriasis or psoriatic arthritis that are found on the nails?
Onycholysis
Subungal hyperkeratosis
Pitting
What is uveitis and when is it seen?
Swelling of the middle layer of the eye- they eye will be red, painful, have diminished vision and may have an irregularly shaped pupil
It is seen in HLA-27 positive arthropathies
What sign may be seen in the mouth in IBD (especially Crohn’s)?
Ulcers
What non articular features may you find on examination in someone with a condition causing acute monoarticular pain? Explain why they would be seen
Nails- onycholysis, subungal hyperkeratosis, pitting (all= psoriasis/ psoriatic arthritis)
Eyes- uveitis (HLA 27 positive arthropathy)
Mouth- ulcers (IBD, especially Crohn’s which is associated with arthropathy)
Skin- rashes, tophi, rheumatoid nodules
Lungs- signs of fibrosis eg crackles at the end of inspiration, clubbing due to inflammatory arthropathy)
What investigation is done to rule out septic arthritis?
Athrocentesis
What is tested in the lab when an arthrocentesis sample is sent there?
Culture- takes a few days
Microscopy- cell count and crystals
Gram stain
What type of crystal is found in gout?
Urate
What type of crystal is found in pseudogout?
Calcium pyrophosphate
What shape and birefringent are crystals in gout?
Needle shaped
Negatively birefringent
What shape and birefringent are crystals in pseudogout?
Rhomboid shaped
Positively birifringent
What characteristics will arthrocentesis in someone with infection have?
It will be cloudy
High WCC
High neutrophils
Bacteria visible
What does blood on arthrocentesis suggest?
Trauma or fracture
What does fat on arthrocentesis suggest? Why?
Fracture- the fat comes from the bone marrow
What investigations might you do for someone who presents with acute joint pain? Explain why you would do each one
Athrocentesis- first line investigation to make an accurate diagnosis
Bloods:
FBC, ESR, CRP- to check for inflammation
Anti CCP, ANA antibodies/ rheumatoid factor- look for arthropathies
Serum urate- raised in those with chronic gout
Xray of joint- useful in identifying fractures, effusion, necrosis, eroision of joint surfaces, crystals
MRI of joint- useful in visualising soft tissue injury which can’t be seen on x ray
In gout what type of cells in athroentesis make up most of the WCC when someone has gout?
Polymorphonuclear cells (PMNs)
What joints are most commonly affected in gout?
Most common= big toe
Next most common= knee
How is acute gout managed?
First line colchicine
NSAIDs alongside colchicine
Corticosteroid injections
In whom is colchicine contraindicated?
Patients with renal or hepatic impairment
In whom are NSAIDs contraindicated?
Peptic ulcer disease, chronic renal failure, asthmatics (although sometimes asthmatics can tolerate low dose NSAIDs and just need to be warned to look for signs of exacerbation)
What medication is contraindicated in gout and why? When might patients still take it?
Aspirin because it reduces urate excretion
Patients may still take it if the cardiovascular risk outweighs the treatment for gout
What methods are used to combat chronic gout?
Decrease urate production
Increase urate excretion
Increase urate degeneration
These can all be done with different medications
What might precede septic arthritis and why?
Trauma to the area
It may be a route of infection
What might aspirate look like from a joint when someone has septic arthritis?
Yellow and turbid (like pus)
What should you immediately do in terms of treatment if you suspect a patient has septic arthritis
Start broad spectrum antibiotics and analgesia
On what movements will a patient with bicipital tendonitis have pain?
Shoulder flexion
Elbow flexion
Supination
What is reiter’s syndrome?
Reactive arthritis that usually follows gastroenteritis or a STI
What triad of symptoms indicates Reiter’s syndrome and how do you remember it?
Can’t see, can’t pee, can’t climb up a tree
Uveitis
Urethritis
Arthritis
What are features of osetoarthritis on xray and how do you remember them?
LOSS: Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
What is the most common causative agent of septic arthritis?
Staphylococcus aureus