Ch363-approach to MSK diseases Flashcards
در بیماری های روماتولوژی رد فلگ های تشخیص چیان 5؟
چه علایمی میبینیم که به اینا شک میکنیم؟
There are several urgent conditions that must be diagnosed promptly to avoid significant morbid or mortal sequelae. These “red flag” diagnoses include septic arthritis, acute crystal-induced arthritis (e.g., gout), and fracture.
Each may be suspected by its acute onset and monarticular or focal musculoskeletal pain.
1-gout 2-septic arthritis 3-Fracture 4-vascular ischaemia 5-carpal tunnel syndrome
در بیماری که با شکایت اسکلتی عصلنی اومده goal های ما در ارزیابی ش چیه؟ 4
Accurate diagnosis
Timely provision of therapy
Avoidance of unnecessary diagnostic testing
Identification of acute, focal/monarticular “red flag” conditions
در بیماری که با شکایت اسکلتی عصلنی اومده مراحل اپروچ ما در ارزیابی ش چیه؟ 7
Determine the chronology (acute vs chronic)
Determine the nature of the pathologic process (inflammatory vs noninflammatory)
Determine the extent of involvement (monarticular, polyarticular, focal, widespread)
Anatomic localization of complaint (articular vs nonarticular)
Consider the most common disorders first
Consider the need for diagnostic testing
Formulate a differential diagnosis
حداکثر زمانی که میطوله تا علایم و یافته های یه بیماری msk جوری باشه که به یه recognizable diagnostic entity
برسیم؟
Many musculoskeletal disorders resemble each other at the outset, and some may take weeks or months (but not years) to evolve into a recognizable diagnostic entity.
This consideration should temper the desire to establish a definitive diagnosis at the first encounter.
علل مختلفanckle pain?
6
ankle pain can result from a variety of pathologic conditions involving disparate anatomic structures, including :
1-gouty arthritis,
2-calcaneal fracture,
3-Achilles tendinitis,
4-plantar fasciitis,
5- cellulitis,
6-and peripheral or entrapment neuropathy.
What are articular and periarticular structures?
Articular structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxtaarticular bone.
Nonarticular (or periarticular) structures, such as supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin, may be involved in.
بیماری هایNon-articular بیشتر مسول شکایت های MSK اند یا آرتیکولار؟
Although musculoskeletal complaints are often ascribed to the joints, nonarticular disorders more frequently underlie such complaints.
علائم Characteristic بیماری های آرتیکولار ؟ ۷
Articular disorders may be characterized by
1-deep or diffuse pain,
2-pain or limited range of motion on active and passive movement,
3-and swelling (caused by synovial proliferation, effusion, or bony enlargement),
4- crepitation,
5-instability,
6- “locking,”
7- deformity.
علائم Characteristic بیماری های نان آرتیکولار ؟
1-nonarticular disorders tend to be painful on active, but not passive (or assisted), range of motion.
2-Periarticular conditions often demonstrate point or focal tenderness in regions adjacent to articular structures, may radiate or be elicited with a specific movement or position, and have physical findings remote from the joint capsule.
3-Moreover, nonarticular disorders seldom demonstrate swelling, crepitus, instability, or deformity of the joint itself.
انیولوژی های بیماری های التهابی مفصل؟ 5
Inflammatory disorders may be:
1-infectious (Neisseria gonorrhoeae or Mycobacterium tuberculosis),
2-crystal-induced (gout, pseudogout),
3-immune-related (rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]),
4- reactive (rheumatic fever, reactive arthritis),
5-or idiopathic.
What are the four cardinal signs of inflammation which inflammatory disorders may be identified by any of them?
Inflammatory disorders may be identified by any of the four cardinal signs of inflammation (erythema, warmth, pain, or swelling)
در افتراق التهابی از غیر التهابی، علایم سیستمیک التهاب کدامن؟
fatigue
fever
rash
weight loss
در مورد fatigue: اختصاصی نیست
در افتراق التهابی از غیر التهابی، چه یافته هایی در وورک اپ ها به نفع التهاب اند؟ 4
elevated erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP],
thrombocytosis
anemia of chronic disease
hypoalbuminemia
کدام علامته ک به طور شایع در بیماری های مزمن مفصلی وجود داره؟
چه فرقی در التهابی و غ التهابی داره؟
Articular stiffness commonly accompanies chronic musculoskeletal disorders.
🌸The duration of stiffness may be prolonged (hours) with inflammatory disorders (such as RA or polymyalgia rheumatica) and improves with activity.
🌸By contrast, intermittent stiffness (also known as gel phenomenon) is typical of noninflammatory conditions (such as osteoarthritis [OA]), shorter in duration (<60 min), and is exacerbated by activity.
اتیولوژی بیماری های غ التهابی مفصلی؟
1-Noninflammatory disorders may be related to trauma (rotator cuff tear)
2-repetitive use (bursitis, tendinitis)
3-degeneration or ineffective repair (OA),
4-neoplasm (pigmented villonodular synovitis)
5- pain amplification (fibromyalgia)
Ddx of fatigue? 9
1-Fatigue may be profound with inflammation (as seen in RA and polymyalgia rheumatica)
2-but may also be a consequence of fibromyalgia (a noninflammatory disorder)
3- chronic pain
4-poor sleep
5-depression
6-anemia
7-cardiac failure
8-endocrinopathy
9-malnutrition
What are non-inflammatory disorders characterised by?
Noninflammatory disorders are often characterized by
1-pain without synovial swelling or warmth
2-absence of inflammatory or systemic features
3-daytime, intermittent gel phenomena rather than prolonged morning stiffness
4-and normal (for age) or negative laboratory investigations.
شایع ترین اتیولوژی های Muscular skeletal pain که اول باید اینارو Exclude کنیم بعد بریم سراغ بقیه چیان؟
1-trauma
2-fracture
3-overuse syndromes
4-and fibromyalgia
are among the most common causes of musculoskeletal pain, these should be considered during the initial encounter. If excluded, other frequently occurring disorders should be considered according to the patient’s age.
معیار زمانی برای اکیوت و کرونیک چیه؟
اگر بیش از ۶ هفته طول کشیده باشه کرونیک و اگر زیر ۶ هفته س اکیوته
در اپروچ به بیماری که با Musculoskeletal complaints اومده اگه اکیوت و ارتبکولار بود به چیا شک میکنیم? 6
1-Acute arthritis 2-septic arthritis 3-gout 4-pseudogout 5-reactive arthritis 6- initial presentation of chronic arthritis
در اپروچ به بیماری که با Musculoskeletal complaints اومده و کرونیکه و ما میخوایم بفهمیم التهابی عه یا نه، چجوری میفهمیم؟ 4
1- is there a prolonged morning stiffness?
2-Is there soft tissue swelling?
3-Are there systemic symptoms?
4-Is the ESR or CRP elevated?
اگر جواب بله بود پس التهابیه
در اپروچ به بیماری که با Musculoskeletal complaints اومده ارتبکولاره و کرونیکه، اگه مشخص شد که غیر التهابیه اقدام بعدی ؟
باید بررسی کنیم که ایا DIP, CMC1(carpometacarpal) Hip Or knee joints درگیر شده اند یا نه؛ اگه شدن : OA اگه نشدن: 1-Osteonecrosis 2-charcot arthritis 3-Haemochromatosis
در اپروچ به بیماری که با Musculoskeletal complaints اومده ارتیکولاره و کرونیکه، اگه مشخص شد که التهابیه اقدام بعدی ؟
باید بیینیم چندتا مفصل درگیر شده اند:
🌻اگر بین ۱تا ۳ مفصل باشه:
Chronic inflammatory mono/oligoarthritis:
1-TB
2-fungal infection
3-Psoriatic arthritis
4-Reactive arthritis
5-pauciarticular JIA: Juvenile idiopathic arthritis
🌻اگر بیشتر از ۳ (یعنی ۴تا و بیشتر):
Chronic inflammatory polyarthritis
در بیماری با Chronic inflammatory polyarthritis، چه تشخیص هایی مطرحه و چجوری میرسیم به اینا؟
اول میایم میبینیم که درگیری سیمتریک هست یا نیست: 🌸If yes: Are PIP, MCP, MTP Joints involved? 💓If yes: Rheumatoid arthritis 💓If no: SlE-scleroderma-Polymyositis
🌸If no:
Psoriatic arthritis
reactive arthritis
enteropathic arthritis
بعد از رول اوت اتیولوژی های شایع درد اسکلتی عضلانی چه اتیولوژی هایی رو باید فکر کنیم بهشون؟
🎆those aged <60 years
are commonly affected by repetitive use/strain disorders, gout (men only), RA, spondyloarthritis, and uncommonly, infectious arthritis.
🎆Patients aged >60 years are frequently affected by OA, crystal (gout and pseudogout) arthritis, polymyalgia rheumatica, osteoporotic fracture,
and uncommonly, septic arthritis.
These conditions are between 10 and
100 times more prevalent than other serious autoimmune conditions,
such as SLE, scleroderma, polymyositis, and vasculitis.
کدام بیماری ها هستن که در سنین خاص شایع ترند؟
SLE and reactive arthritis occur more frequently in the young,
whereas fibromyalgia and RA are frequent in middle age
and OA and polymyalgia rheumatica are more prevalent among the elderly.
کدوم بیمعری های MSK در مردها شایع ترند؟ ۳
Gout, spondyloarthritis, and ankylosing spondylitis are more common in men
کدوم بیماری های MSK در سفیدپست ها شایع ترند؟
polymyalgia rheumatica, giant cell arteritis, and granulomatosis with
polyangiitis (GPA; formerly called Wegener’s granulomatosis) commonly affect whites, whereas sarcoidosis and SLE more commonly
affect African Americans.
در کدوم بیماری های MSK ، Familial aggregation شایع اند؟ ۳
یعنی مثلا میبینیم در چند نفر از اعضای خانواذه وجود داره. مثلا بچها مشابه والدین
Familial aggregation is most common with
ankylosing spondylitis, gout, and Heberden’s nodes of OA.
از لحاظ زمانی کدوم بیماری های اسکلتی عضلانی :
شروع ناگهانی؟
پیشرفت تدریحی؟
The onset of disorders such as septic arthritis or gout tends to be abrupt,
whereas OA, RA, and fibromyalgia may have more indolent presentations.
شکایت بیمار در کدوم بیماری های اسکلتی عضلانی : Chronic intermittent migratory additive
The patients’ complaints may evolve differently and be classified as
chronic (OA),
intermittent (crystal or Lyme arthritis)
migratory (rheumatic fever, gonococcal or viral arthritis),
or additive (RA, psoriatic arthritis).
هر کدوم از بیماری های زیر از نظر تعداد مفصلیرکه درگیر میکنند در کدام کتگوری قرار میگیرن؟ Infectious arthritis RA OA Crystal arthritis
monarticular (one joint), oligoarticular or pauciarticular
(two or three joints), or polyarticular (four or more joints).
Although crystal and infectious arthritis are often mono or oligoarticular, OA
and RA are polyarticular disorders.
بیماری های نان ارتیکولار از نظر Distribution چجوری طبقه بندی میشن؟
در هر دسته چه بیماری هایی؟
Nonarticular disorders may be
classified as either focal or widespread.
Complaints secondary to tendinitis or carpal tunnel syndrome are typically focal
whereas weakness and myalgia, caused by polymyositis or fibromyalgia, are more
widespread in their presentation.
کدوم بیماری هان که هم میتونن قرینه و غیرقرینه باشن هم اولیگو و پلی؟ ۲
OA
Psoriatic arthritis
اندام فوقانی و تحتانی هر کدوم بیشتر در کدوم بیماری ها درگیر میشن؟
ستون مهره و اگزیال چطور؟
📒The upper extremities are frequently involved in RA and OA.
📕whereas lower extremity arthritis is characteristic of reactive arthritis and gout at their onset.
📗Involvement of the axial skeleton is common in OA and ankylosing spondylitis but is infrequent in RA, with the notable exception of the cervical spine.
در هر کدام از کوموربیدتی های زیر چه Muscular skeletal consequences ممکنه وجود داشته باشه ک در هیستوری بایذ حواسمون بش باشه؟ DM Renal insufficiency depression or insomnia myeloma cancer osteoporosis using glucocorticoids diuretics chemotherapy
Certain comorbidities may have musculoskeletal consequences. This is especially so for
❤️diabetes mellitus
(carpal tunnel syndrome),
🧡renal insufficiency (gout),
depression or insomnia (fibromyalgia),
💛myeloma (low back pain),
💚cancer (myositis),
💙and osteoporosis (fracture)
💜 when using certain drugs such as
glucocorticoids (osteonecrosis, septic arthritis),
💖diuretics or chemotherapy (gout)
کدوم بیماری های روماتولوژیک با علایم زیر همراهند؟ راش تب ابنورمالیتی های ناخن میالژی
A variety of musculoskeletal disorders may be associated with systemic features such as :
fever (SLE, infection)
rash (SLE, psoriatic arthritis)
nail abnormalities (psoriatic or reactive arthritis)
myalgias (fibromyalgia, statin- or drug-induced myopathy)
weakness (polymyositis, neuropathy)
در کدوم بیماری های روماتو لوژیک درگیری چشم داریم؟ 3
Behçet’s disease
sarcoidosis
spondyloarthritis
در کدوم بیماری های روماتو لوژیک درگیری GI داریم؟ 2
scleroderma
inflammatory bowel disease
در کدوم بیماری های روماتو لوژیک درگیری genitourinary داریم؟ 2
reactive arthritis
gonococcemia
در کدوم بیماری های روماتولوژیک درگیری سبستم عصبی داریم؟
Lyme disease
vasculitis
منظور از Great masqueraders چیه و به چه بیماری هایی گفته میشه؟ 7
syphilis and tuberculosis were labeled as the “great masqueraders” as their protean symptoms and potential for multi-organ involvement may result in delays in diagnosis and treatment.
In the modern era, other serious diagnoses (including lupus, sarcoidosis, vasculitis and lymphoma) have also been labeled as great masqueraders.
7-All of these are either uncommon or rare, and are overshadowed by
the most common masquerader with musculoskeletal complaints—
fibromyalgia.
فیبرومیالژیا چیه؟
Fibromyalgia is a pain amplification disorder unified by sleep disturbance, exaggerated pain and sensitivity
(owing to lowered pain thresholds), and a multiplicity of symptoms
with a paucity of abnormalities on clinical examination or laboratory
testing.
یافته های معاینه در فیزیکال اگزم؟
Tender “trigger points” are often found and include tenderness over the epicondyles, trochanteric bursae, anserine bursae, and muscles (gluteal, trapezius, supraspinatus)
that often are misdiagnosed as other nonarticular conditions.
فیبرومیالژی با چه بیماری هایی mis diagnosedمیشه؟ 4
fibromyalgia is frequently underrecognized or misdiagnosed as :
1-arthritis
2-lupus
3-multiple sclerosis
4-autoimmune disease and etc
What are the comorbidities of fibromyalgia? 13
Fibromyalgia has numerous comorbidities including 1-irritable bowel syndrome, 2-dysmenorrhea, 3-migraine, 4-depression, 5-anxiety, 6-memory loss, 7-non-anatomic paresthesia or dysesthesia, 10-fatigue, 11- myalgias, 12-temporomandibular joint pain, 13-and multiple chemical sensitivities.
چرا تشخیص بیماری های روماتولوژی در افراد مسن یا بالای ۶۵ سال خیلی سخته؟
Musculoskeletal disorders
in elderly patients are often not diagnosed because the signs and symp-
toms may be insidious, overlooked, or overshadowed by comorbidities.
These difficulties are compounded by the diminished reliability of laboratory testing in the elderly, who often manifest nonpathologic abnormal results.
در لب تست هایی ک ار پیرا میگیریم چه ازمایش هایی به صورت نان پاتولوژیک ابنورمال اند و مارو در تشخیص ب اشتباه میندازن؟
For example, the ESR may be misleadingly elevated
and low-titer positive tests for rheumatoid factor (RF)
and antinuclear antibodies (ANAs) may be seen in up to 15% of elderly patients.
پیرا بیشتر مستعد کدوم بیماری های روماتولوژیک اند؟
geriatric patients are particularly prone to 1-OA, osteoporosis, 4-osteoporotic fractures, 2-gout, pseudogout, 3-polymyalgia rheumatica, 5-vasculitis, 6-and drug-induced disorders
به ترتیب شیوع
کدام بیماران روماتولوژیکو ادمیت میکنیم؟
(1) acute onset of inflammatory arthritis (possibly gout or septic arthritis);
(2) undiagnosed systemic or febrile illness;
(3) musculoskeletal trauma;
(4) exacerbation or deterioration of an existing autoimmune disorder (e.g., SLE);
(5) new medical comorbidities (e.g., thrombotic event, lymphoma, infection) arising in patients with an established rheumatic disorder.
Notably, rheumatic patients are seldom if ever admitted because of widespread
pain or serologic abnormalities or for the initiation of new therapies.
Ddx of Acute monoarticular inflammatory arthritis and acute inflammatory polyarthritis?
اقدام بعدی ای که برای تشخیص انجام میدیم در دو این دو دسته چه تفاوتی با هم داره؟
💜Acute monarticular inflammatory arthritis may be a “red flag” condition (e.g., septic arthritis, gout, pseudogout) that will require arthrocentesis and, on occasion, hospitalization if infection is suspected.
💜However, new-onset inflammatory polyarthritis will have a wider
differential diagnosis (e.g., RA, hepatitis-related arthritis, chikungunya
arthritis, serum sickness, drug-induced lupus, polyarticular septic
arthritis) and may require targeted laboratory investigations rather
than synovial fluid analyses.
در بیمار با شکایت روماتولوژیک ک تب داره و Multisystem disorders داره به چیا شک میکنیم؟
Patients with febrile, multisystem disorders will require exclusion of :
1-crystal
2-infectious
3-or neoplastic etiologies
and an evaluation driven by the dominant symptom/finding with the
greatest specificity.
Conditions worthy of consideration may include :
gout or pseudogout, vasculitis (giant cell arteritis in the elderly or polyarteritis nodosa in younger patients), adult-onset Still’s disease, SLE, antiphospholipid antibody syndrome, IgG4-related disease, and sarcoidosis.
Lastly, overly aggressive and unfo-
مهم ترین علت بستری شدن بیماران باPreexisting rheumatic diagnosis چیه؟
It is important to note that when established rheumatic disease patients are admitted to the hospital, it is usually not for a medical problem related to their autoimmune disease, but rather because of either a comorbid condition or complication of drug therapy.
در بیمارانی که Chronic inflammatory disorders دارند ریسک ابتلا ب چه بیماری های دیگه ای زیاده؟ 3
Patients with chronic inflammatory disorders (e.g., RA, SLE, psoriasis) have
an augmented risk of infection, cardiovascular events, and neoplasia.
علل Acute gout در بیماران بستری؟
چجوری خودشو نشون میده ک‌ما بهش شک کنیم؟
Certain conditions, such as acute gout, can be precipitated in hospitalized patients by surgery, dehydration, or medications and should be
considered when hospitalized patients are evaluated for the acute onset
of a musculoskeletal condition.
بازو های معاینه در بیماران روماتولوژی؟
The musculoskeletal examination depends largely on careful inspection, palpation, and a variety of specific physical maneuvers to elicit diagnostic signs.
Although most articulations of the appendicular skeleton can be
examined in this manner, adequate inspection and palpation are not
possible for many axial (e.g., zygapophyseal) and inaccessible (e.g.,
sacroiliac or hip) joints. For such joints, there is a greater reliance on specific maneuvers and imaging for assessment.
در معاینه بیمار رومتولوژیک چجوری میتونیم Level of pain را Quantify کنیم؟
One Standard would be to count the number of tender joints on palpation of 28 easily examined joints
(proximal interphalangeals
[PIPs], metacarpophalangeals [MCPs], wrists, elbows, shoulders, and
knees).
علل True articular swelling ?
نحوه افتراق اینا از هم؟
🍎bony hypertrophy
🍏synovial effusion
or proliferation
Synovial effusion can be distinguished from synovial hypertrophy or bony
hypertrophy by palpation or specific maneuvers.
