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Year 3 > Acute join pain (oxford clin cases) > Flashcards

Acute join pain (oxford clin cases) Flashcards

1
Q

In an acutely painful joint what diagnosis must you exclude because it is a medical emergency?

A

Septic arthritis

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2
Q

What are articular causes of joint pain in one joint (ie monorthritis)

A

Septic arthritis
Trauma
Gout
Pseudogout

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3
Q

What are periarticular causes of joint pain in one joint (ie monorthritis)

A

Ligment injury
Tendinitis
Bursitis

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4
Q

What type of pain is likely with an acute joint if its worse on movement and better with rest?

A

Non inflammatory

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5
Q

What are some common diagnoses for joint pain if the pain comes on acutely?

A

Septic arthritis
Gout/pseudogout
Trauma

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6
Q

What are some common diagnoses for joint pain if the pain comes on insidiously?

A

Tendonitis

Bursitis

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7
Q

What are common risk factors for gout?

A 
Being on thiazide diuretics
Recent heavy alcohol intake
Chronic renal failure and renal stones
Chemotherapy 
Previous gout
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8
Q

What are some common risk factors for septic arthritis?

A 
Being immunocompromised (diabetes, HIV, steroid use)
Prosthetic limbs
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9
Q

What does joint pain involving multiple joints sequentially indicate is the diagnosis?

A

Rheumatic fever

Gonococcus

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10
Q

What does joint pain involving multiple joints simultaneously indicate is the diagnosis?

A

Rheumatoid arthritis

Psoriatic arthritis

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11
Q

What drugs might predispose someone to gout?

A

Thiazide diuretics
Low dose aspirin
Ciclosporin

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12
Q

What drug predisposes someone to osteoporosis?

A

Steroids

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13
Q

What questions would you ask in the history when someone presents with acute joint pain? Explain why you’d ask them

A

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

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14
Q

How are articular conditions likely to present?

A

With diffuse swelling over the whole joint which will be red, hot and tender. Pain will be present during both passive and active movement

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15
Q

How are periarticular conditions likely to present?

A

There will be a focal point of swelling eg the tendon or the bursa
Pain will be worse on active movement

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16
Q

What do articular and periarticular mean?

A 
Articular= to do with the joint
Periarticular= around the joint
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17
Q

What are tophi and what are they a sign of?

A

They are deposits of urate crystals, they can break through the skin
They are a sign of chronic gout

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18
Q

What are some signs of psoriasis or psoriatic arthritis that are found on the nails?

A

Onycholysis
Subungal hyperkeratosis
Pitting

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19
Q

What is uveitis and when is it seen?

A

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

20
Q

What sign may be seen in the mouth in IBD (especially Crohn’s)?

A

Ulcers

21
Q

What non articular features may you find on examination in someone with a condition causing acute monoarticular pain? Explain why they would be seen

A

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)

22
Q

What investigation is done to rule out septic arthritis?

A

Athrocentesis

23
Q

What is tested in the lab when an arthrocentesis sample is sent there?

A

Culture- takes a few days
Microscopy- cell count and crystals
Gram stain

24
Q

What type of crystal is found in gout?

A

Urate

25
Q

What type of crystal is found in pseudogout?

A

Calcium pyrophosphate

26
Q

What shape and birefringent are crystals in gout?

A

Needle shaped

Negatively birefringent

27
Q

What shape and birefringent are crystals in pseudogout?

A

Rhomboid shaped

Positively birifringent

28
Q

What characteristics will arthrocentesis in someone with infection have?

A

It will be cloudy
High WCC
High neutrophils
Bacteria visible

29
Q

What does blood on arthrocentesis suggest?

A

Trauma or fracture

30
Q

What does fat on arthrocentesis suggest? Why?

A

Fracture- the fat comes from the bone marrow

31
Q

What investigations might you do for someone who presents with acute joint pain? Explain why you would do each one

A

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

32
Q

In gout what type of cells in athroentesis make up most of the WCC when someone has gout?

A

Polymorphonuclear cells (PMNs)

33
Q

What joints are most commonly affected in gout?

A

Most common= big toe

Next most common= knee

34
Q

How is acute gout managed?

A

First line colchicine
NSAIDs alongside colchicine
Corticosteroid injections

35
Q

In whom is colchicine contraindicated?

A

Patients with renal or hepatic impairment

36
Q

In whom are NSAIDs contraindicated?

A

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)

37
Q

What medication is contraindicated in gout and why? When might patients still take it?

A

Aspirin because it reduces urate excretion

Patients may still take it if the cardiovascular risk outweighs the treatment for gout

38
Q

What methods are used to combat chronic gout?

A

Decrease urate production
Increase urate excretion
Increase urate degeneration

These can all be done with different medications

39
Q

What might precede septic arthritis and why?

A

Trauma to the area

It may be a route of infection

40
Q

What might aspirate look like from a joint when someone has septic arthritis?

A

Yellow and turbid (like pus)

41
Q

What should you immediately do in terms of treatment if you suspect a patient has septic arthritis

A

Start broad spectrum antibiotics and analgesia

42
Q

On what movements will a patient with bicipital tendonitis have pain?

A

Shoulder flexion
Elbow flexion
Supination

43
Q

What is reiter’s syndrome?

A

Reactive arthritis that usually follows gastroenteritis or a STI

44
Q

What triad of symptoms indicates Reiter’s syndrome and how do you remember it?

A

Can’t see, can’t pee, can’t climb up a tree
Uveitis
Urethritis
Arthritis

45
Q

What are features of osetoarthritis on xray and how do you remember them?

A 
LOSS:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
46
Q

What is the most common causative agent of septic arthritis?

A

Staphylococcus aureus

Year 3 (104 decks)

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