Case #2 Wrap Up Flashcards
How can you differentiate between articular pain and periarticular pain?
Articular—painful, limited active ROM—painful, limited passive ROMPericarticular—painful, limited active ROM—non-painful, unlimited passive ROM
Classic signs of inflammation
Swelling (tumor)Redness (rubor)Warmth (calor)Pain (dolor)Impaired fxn (functio laesa)
When is something considered chronic?
> 6 weeks
What are ways in which we can/should characterize joint involvement in disease?
Polyarticular vs monoarticularSymmetrical vs assymetricalPeripheral vs axial skeleton
What is the significance of the symmetry of joint involvement in distinguishing joint diseases? (i.e. what diseases present symmetrically vs asymmetrically?)
Symmetrical - RA, SLEAsymmetrical - OA, Reactive arthritis (Reiter’s syndrome)Either - Psoriatic arthritisMigratory - Rheumatic fever
Which diseases are manifested by joints pain at the DIP?
OA, psoriatic, gout, or Reiter’s
Which diseases are manifested by joints pain at the PIP?
RA, OA, SLE
Which diseases are manifested by joints pain at the MCP?
RA, pseudogout, hemochromatosis
Which diseases are manifested by joints pain at the wrist?
common RA, rare OA, pseudo gout, gonococcal
What are some clues that there is a potential musculoskeletal emergencies?
- acute onset2. history of significant trauma3. mono or oligoarticular pain4. hot, red, and/or swollen joint5. fever, weight loss, or malaise6. weakness7. burning pain, numbness, or paresthesias8. claudication
What can a hot, red, and/or swollen joint be a sign of?
gout, pseudogout, or infection
What can fever, weight loss, or malaise be a sign of?
infection or sepsis
What can weakness be a sign of?
acute myelopathy
What can burning pain, numbness, or paresthesias be a sign of?
acute myelopathy, radiculopathy, or neuropathy
What can claudication be a sign of?
peripheral vascular disease
What are some examples of musculoskeletal emergencies?
- septic arthritis2. subacute bacterial endocarditis3. osteomyelitis4. necrotizing fasciitis5. systemic vasculitis6. acute myelopathy7. deep venous thrombosis8. compartment syndrome
What are causes of acute monoarthritis?
infection-bacterial -viralcrystalline-gout (monosodium urate)-pseudogout (calcium pyrophosphate)hemarthrosis-trauma-hemophiliaearly presentation of systemic disease
70% of infectious arthritis in those younger than 40 yo is due to ..
neisseria gonorrhea
What is the most important intervention in acute mono arthritis?What are you looking for?
joint aspirationcell count, gram stain/culture, crustal exam
What are some things to consider when doing an arthrocentesis?
- needle and syringe size2. skin sterilization3. local anesthesia4. comfort of you and patient
What is the most important indication for doing an arthrocentesis?
checking for sepsis
Clinical pearl for arthrocentesis-During arthrocentesis procedure, an important challenge may be to determine ….?-Key points
To determine whether the presence of blood in the aspirated synovial fluid indicated a hemarthrosis or is a result of trauma from the procedure itself–if trauma, blood may remain unmixed with the synovial fluid, appearing as red streaks in an otherwise yellow fluid–if hemarthroses, synovial fluid is generally homogeneously bloody and does not form a clot
What would a normal synovial fluid sample look like?
volume < 3.5 mLTransparentClearHigh viscosityWBC < 200/mm3PMNs < 25%Culture - negativeTotal protein - 1-2 g/dLGlucose - nearly equal to that of blood
What distinguishes a noninflammatory process based upon synovial fluid?
Volume often > 3.5 mLColor is yellowWBC - 200-2000/mm3
What distinguishes an inflammatory process based upon synovial fluid?
Volume often > 3.5 mLTranslucent-opaqueColor - yellow to opalescentLow viscosityWBC - 2000-100000/mm3PMNs > 50%Glucose > 25, lower than blood
Acute gouty arthritis
Sudden onset of pain, warmth, redness, swellingMonoarticular - great toe, ankle, or knew(Podagra “foot trap”)Uric acid blood level is helpful in following the disease-decreased excretion, increased productiondiagnosed by aspiration and crystallography
With birefringence, how do urate crystals appear? calcium phosphate crystals?
Urate crystals appear yellow - therefore they are of negative birefringenceCalcium phophate crystals appear blue - therefore they are of positive birefingence
Historical distinctions between inflammatory and noninflammatory diseases?
inflammatory-symmetric-stiffness > 1 hr-R/C/D/T + FL-improves with exercise-constitutional complaintsnoninflammatory-one or very few joints-stiffness < 30 min-no pain at rest-worsen with exercise-no constitutional complains
Describe fibromyalgia in terms of who gets it, what type of complaints they have, and how many points are involved?
Middle aged women with widespread achiness and fatigue with 11/18 or more tender trigger points
What is the significance of a history of rheumatic fever?
-it can cause arthritis and carditis-heart and joints are more susceptible for future injury in septic illness-must consider septic arthritis-bacterial endocarditis can cause septic emboli of small vessels with joint pain and small infarcts of fingers —fever and heart murmur typically present
What is ruled out by saying no dry mucous membranes?
sjogren’s
What is ruled out by saying no raynaud’s phenomenon?
sclerodermaRASLEpoly/dermatomyositis
What is ruled out by saying no oral ulcerations?
SLEReiter’s
What is ruled out by saying no hx of tick bite/erythemia migraines?
Lyme
What is ruled out by saying no ulcers on fingertips?
vasculitisbacterial endocarditis embolization
What is ruled out by saying no macular rash?
SLE
What is ruled out by saying no dysuria?
Reiter’s
Ankylosing spondylitis
5% of adults with chronic back pain-inflammatory back pain-buttock pain-“bamboo spine”-hip and shoulder pain-enthiesitis (inflam or sites where tendons attach)-peripheral arthritis-TMJ involvement-dactylitis-constitutional features
What is the classic sign seen when OA affects the DIPs? PIPs?
Heberden’s nodes - they are tenderBouchard’s nodes
What is the ACR Criteria for SLE?
RASH ON MAIDSRenal involvementANASerositisHematologic abnormalitiesOral ulcersNeurologic (seizures/psychosis)Malar rashArthritisImmunologic (Anti Sm or dsDNADiscoid lesionsSun sensitivity
What is the CASPAR criteria used for?What are the components?
Classification Criteria for Psoriatic ArthritisSkin psoriasisNail lesionsDactylitisNegative RFJuxtaarticular bone formation radiography
Reactive arthritis/Reiter’s syndrome-diagnosis-musculoskeletal symptoms-extra-articular manifestations (mnemonic)SEE NOTES FOR MORE ON THIS
diagnosis based upon presence of musculoskeletal and other clinical features in a patient with a preceding or ongoing enteric or GU infection, in whom other causes have been excludedasymmetric oligoarthritis, enthesitis, dactylitis, and inflammatory back pain”can’t see, can’t pee, can’t climb a tree”can also see cutaneous manifestations
What 8 things are typical in terms of presentation of RA?
- insidious onset2. adds joints overtime3. predilection for joint synovia of hands, feet, wrists4. joints become warm and swollen5. morning stiffness > 1 hr6. patients are more often tired and don’t sleep properly7. can result in significant disability very quickly8. 3:1 women(late childbearing years): men (60-80s)
What is found on physical exam of someone with RA?
-decreased grip strength-boxing glove edema-carpal tunnel symptoms-ulnar deviation-extensor tendon rupture-boutonniere or swan neck deformities
What two joints are not usually involved in RA?
- cricoarytenoid joint – causing hoariness – can be involved in up to 25%2. TMJ - arthralgia
What is mean corpuscular volume?
measure of average volume/size of single RBC
How do you calculate MCV?
(Hematocrit (%) x 10) / RBC (million/uL)normal is 90 +/- 9 fL
What is mean corpuscular hemoglobin?
measure of average weight of hgb within a single RBC
How do you calculate MCH?
(Hemoglobin (g/dL) x 10) / RBC (million/uL)
What is mean corpuscular hemoglobin concentration?
measure of average concentration of hgb in the RBC (ration of volume of hgb to the volume of erythrocyte)
How do you calculate MCHC?
(Hemoglobin (g/dL) x 10) / Hematocrit (%)
What are acute phase reactants?
proteins that either increase or decrease 25% during inflammation— ESR— CRP - binds to phosphatidylcholine of damaged cells and foreign pathogens— other: fibrinogen, heptogloin, ferritan, procalcitonin, albumin, transferrinhelpful in distinguishing b/t inflammatory and noninflammatory conditions, but NEVER diagnostic
Which is a more reliable indicator of the acute phase response? Why?What numbers are expected with significant inflammation? RA? infection?
CRP is more reliable than ESRESR may be influenced by abnormal RBC morphology, anemia, or changes in plasma proteinsinflammation > 1 mg/dLRA 2-3 mg/dLinfection > 10 mg/dL
What is rheumatoid factor?
immunoglobulins of IgM, IgG, and IgA directed against Fc portion of IgGincreased in 60-80% of RA patients, specificity is 85%
Aside from RA, when else do we see elevated RF?
Sjogren’sSclerodermaSLEChronic liver diseaseGranulomatous disease
What are anti-cyclic citrullinated peptide antibodies?
produced when environmental stimulus triggers the post-translational amino acid change from an arginine to a citruillinesensitivity 80%, specificity >95%a marker of erosive disease
What are antinuclear antibodies?
autoantibodies directed against cell nucleus structureshighly sensitive, but not specific
What types of pharmacological treatments are used for RA?
- adjective drugs - focus on managing pain (NSAIDs) and reducing inflammation (corticosteriods)2. Non-biologic DMARD therapy - aims at halting or slowing disease progression-methotrexate-hydroxychloroquine3. Biological DMARDs - used with #2 to slow progression-TNFa antagonists
What types of non pharmacological treatments are used for RA?
- physical/exercise therapy2. occupational therapy3. cognitive therapy/relaxation techniques4. nutritional and dietary balance5. surgery
Carpal Tunnel Syndrome-clinical features
pain, numbness, tinglingsymptoms are usually worse at night and can awaken patients from sleepto relieve symptoms, patients often flick their wrists as if shaking down a thermometer - FLICK SIGN
What conservative treatments are there for carpal tunnel?
- ergonomic changes2. wrist splints - best within 30 days of onset3. oral medications— NSAIDs, vitamin B6, diuretics— oral steriods4. Local injection5. ultrasound therapy
Injections for carpal tunnel
needle inserted at 30 degree angle just medial to the palmaris longus tendon
When should you consider surgery for carpal tunnel?
in patients with— symptoms not responding to conservative measures for > 10 mo, > 50 yo— severe nerve entrapment as evidence by nerve conduction studies, thenar atrophy, or motor weakness
What is osteoporosis?
a decrease in bone densityBMI has the strongest relationship to bone density (low body weight at risk!)
What measures should be taken if a women with RA wants to get pregnant?
- stop methotrexate 3 months prior- stop lefunomide 2 months prior- consider that high steroid use in early pregnancy may cause cleft palate - NSAIDs are contraindicated 30 weeks onwards
