Arthritis

Question 1

You have a 30 yr old sexually active male present with sacral pain and for some reason he knows he is positive for HLA-B27. What is in your differential and what one are you leaning towards as a diagnosis?

Answer 1

DDX: ankylosing spondylitis and Reiter’s syndrome(reactive arthritis) Ankylosing spondylitis is more likely d/t cardinal sacral pain is usually point of initial complaint. Reiter’s syndrome will involve one large joint and go away in 3-5 mo.

Question 2

What is osteoarthritis and how is it different from RAs etiology?

Answer 2

OA is non-inflammatory, AKA. all labs will be normal/negative. versus RA is inflammatory and often systemic with labs like ESR/CRP/RF/Anti-CCP positive/elevated.

Question 3

A 37 yr old women presents to clinic with polyarthralgias that are symmetrical. Her labs come back with elevated ESR and CRP, but her RF and ANA are normal. You notice her fingers look like juicy sausages with splitting nails…what do you suspect it is?

Answer 3

Psoriatic arthritis! It mimics RA’s clinical features. RA doesn’t have Dactylitis(sausage fingers) and will have positive RF and ANA.

Question 4

A sir walks into your clinic complaining of knee pain. Upon examination his knee is swollen appearing, red, and hot to the touch and his ROM is normal. What do you think it is?

Answer 4

Cellulitis or bursitis etiology. ROM should be have abnormal dysfunction in septic arthritis(gaurding), crepetis in oa, and limited rom in inflammatory arthritides. ROM intact could indicate an overlying structure.

Question 5

What are the clinical features of osteomyelitis?

Answer 5

Microbial infection to bone, often in DM pts, post surgical or hematogenously spread(children)

Question 6

What is the gold standard for osteomyelitis dx?

Answer 6

MRI

Question 7

What is the most common version of osteomyelitis that you see in primary care settings?

Answer 7

Foot OM- usually DM pts with foot infection- “probe to bone” is a good way to dx

Question 8

How do you tx OM?

Answer 8

ABX 1mo-3mo, surgery may be required if associated with implanted device. If complicated, amputation might be necessary

Question 9

What is septic arthritis and how will it often clinically present?

Answer 9

swollen, red, hot, painful monoarticular, pt is septic appearing with fever and gaurding joint=limited ROM! abrupt onset

Question 10

What is the gold standard for septic arthritis dx?

Answer 10

Synovial fluid analysis- looks like green snot- thick, WBC>50K, +culture, PMN’s 75

Question 11

What labs should you collect in suspected septic arthritis before initiating empiric therapy?

Answer 11

Gram stain, Cell count, crystals- stat, culture and sensitivity, CBC, ESR, CRP

Question 12

How do you tx septic arthritis?

Answer 12

Surgical arthrotomy or arthroscopy with I&D is preferred- scrape out the tissues. IV abx up to 6 weeks of Ceftriaxone or vancomycin

Question 13

What is the most common pathogen found with septic arthritis?

Answer 13

Staph. Aureus(beta-hemolytic), if sexually active could be N.Gonococcus

Question 14

What is the clinical presentation of gout?

Answer 14

abrupt, overnight, severe pain, erythema, swelling, monoarticluar, first MTP often, podagra, low grade fever, “can’t put a sheet over it”

Question 15

What is the pathophysiology of gout?

Answer 15

Altered purine metabolism- either too much or not enough clearance at kidneys

Question 16

What things exacerbate gout or increase uric acid production?

Answer 16

ASPIRIN, diuretics, dehydration, ETOH, diet high in sodas/perservatives/meats

Question 17

What is the gold standard for gout dx?

Answer 17

synovial fluid analysis- urate crystals present-aka.monosodium urate, cloudy appearance

Question 18

Is a serum urate level over 6.8 diagnostic for gout?

Answer 18

nope

Question 19

How do you treat acute gout?

Answer 19

Indomethacin(NSAID), colchicine, corticosteroid injection maybe

Question 20

What is the clinical presentation of pseudogout?

Answer 20

Same as gout, except synovial fluid and xray results and pubic symphesis involvement and is Calcium pyrophosphate dehydrate disease

Question 21

how do you dx pseudogout?

Answer 21

synovial fluid will have calcium pyrophosphate and xray will show CHONDROCALCINOSIS(fine linear calcifications in cartilage of joint)

Question 22

What is the treatment of acute pseudogout?

Answer 22

Same as acute gout!

Question 23

What are the clinical features of Reiter’s syndrome(reactive arthritis)?

Answer 23

Abrupt, Asymetical large joint involvement, mucosal ulcers, conjunctivitis, urethritis, oligoarthritis, often male, 18-40 yo, enthesopathy(myofasical pain), keratoderma(hands and feet rash)

Question 24

How do you dx reiter’s

Answer 24

often will have chlamydia, or gasteroenteritis(shigella), positive HLA-B27(30-80%), ESR/CRP will be elevated.

Question 25

tx for reactive arthritis?

Answer 25

NSAIDS(indomethacin), ABX if chlamydia, but will not relieve s/sx. Will resolve in 3-5mo

Question 26

What are the clinical features of Ankylosing spondylitis?

Answer 26

Si joint inflammation, 20-30 yo male, insidious, usually FHX, Uveitis(40%-irritation around iris),60% inflammed colon or ilium, pain will ascend spine overtime

Question 27

How do you dx AS?

Answer 27

Spondylitis, sacroilitis and syndesmophyte on xray, bamboo spine also(fused vertebra), There are some criteria outlined, but there is no way we need to memorize it.

Question 28

how do you tx AS?

Answer 28

NSAIDS, PT early, TNF blockers(biologics) like infliximab, etanercept, adamlimumab,

Question 29

What is the clinical presentation of psoriatic arthritis?

Answer 29

polyarticular symmetric, 90% pitting nails, onset 37 yo, inflammed synovium, sausage finers, arthritis mutilans

Question 30

How do you dx psoriatic arthritis?

Answer 30

history of psoriasis preceding arthrisit, seronegative(aka.neg. RF and ANA), increased ESR and CRP

Question 31

What is the prefered treatment for psoriatic arthrisit?

Answer 31

NSAIDS, methotrexate, TNF alpha blockers

Question 32

What are the clinical features of Rheumatoid arthritis?

Answer 32

Persistent progressive multi system inflammatory disorder with extraarticular manifestations.

Question 33

How do diagnose Rheumatoid arthritis?

Answer 33

6 or greater of the ACR criteria. Basically it involves positive labs and positive imaging. Labs may include positive RF, Positive Anti-CCP(99%), xray is the best imaging for RA(acticular demineralization, soft tissue swelling in flare ups)

Question 34

What is your first line treatment, second line and 3rd line treatments for RA?

Answer 34

NSAIDS, DMARDS(hydroxychloroquine, sulfasalazine, methotrexate), Biologics(etanercept, abatacept, rituximab, infliximab, adamimumab.)

Question 35

What are some of the organ systems affected by RA?

Answer 35

Eyes, heart, kidneys, blood vessels, and rbcs and often has complications of pulmonary effusion and eipiscleritis

Question 36

What is the hyperplastic joint srtucture eroding into bone and cartilage called in RA?

Answer 36

Pannus by infiltration of the T and B lymphocytes

Question 37

Osteoporosis is highly associated with OA(T/F)

Answer 37

False, they are inversely related

Question 38

Osteoporosis is highly associated with RAT/F)?

Answer 38

True, osteoporosis is highly associated with RA

Question 39

What is Osteoarthritis and its clinical features?

Answer 39

Large asymmetrical often weight bearing joint

Question 40

How do you dx OA?

Answer 40

Xray- see joint space narrowing, sclerosis, bone cysts, osteophytes, asymmetric joint space narrowing

Question 41

How do you treat OA?

Answer 41

Alter joint activity with pt, Tylenol is first line, then intraarticular viscosupplementation(Euflexxa, sipartz), weak opioid if refractory

Question 42

Is arthroscopy shown to be beneficial for knee OA?

Answer 42

NO! not beneficial, but can be beneficial in shoulder and elbow