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Symptoms > Joint Pain > Flashcards

Joint Pain Flashcards

1
Q

How would you frame the DDx of joint pain?

A

Acute vs. chronic

Inflammatory vs. mechanical

Polyarthritis vs. oligoarthritis vs. monoarthritis

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2
Q

What are the patterns of joint pain?

A
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3
Q

A 14 YO girl has had pain in her fingers & wrists & this has made her clarinet performances more difficult over the last couple months. She has also had tactile fevers, fatigue, mouth sores & erythema of her cheeks for the last month. She thinks her hair is thinning & she has lost 5 lb in 2 wks. She has missed the last week of school.

She is tired appearing. Her eyes seem puffy. There is trace pitting edema of her ankles.

What is your top differential?

A

Systemic Lupus Erythematosus (SLE)

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4
Q

Depression/Chronic Pain Syndrome

How does this present?

What questions should you ask?

A
  • Fatigue, weight loss, missing school, diffuse pain
  • Recent stressors? Disinterest in usual activities? Difficulty sleeping?
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5
Q

EBV Infection

How does this present?

What questions should you ask?

A
  • Fatigue, diffuse pain
  • Sick contacts? Swollen LN? Sore throat?
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6
Q

Rheumatoid Arthritis

How does this present?

What questions should you ask?

A
  • Multiple joint pain, fatigue
  • Persistent swelling/stiffness of joints?
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7
Q

Psoriatic Arthritis

How does this present?

What questions should you ask?

A
  • Multiple joint pain
  • Persistent swelling/stiffness of joints?
  • Rash?
  • Nail abnormalities?
  • FHx of psoriasis?
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8
Q

Inflammatory Bowel Disease

How does this present?

What questions should you ask?

A
  • Multiple joint pain, mouth sores, weight loss, fatigue, hair loss
  • Abdominal pain? Diarrhea? Bloody stools?
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9
Q

Systemic Lupus Erythematosus

How does this present?

What questions should you ask?

A
  • Multiple joint pain, mouth sores, facial rash, fatigue, weight loss, hair loss, missing school
  • Has facial rash been persistent?
  • Photosensitive rashes?
  • Leg swelling?
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10
Q

Common Variable Immune Deficiency

How does this present?

What questions should you ask?

A
  • Multiple joint pain, fatigue, weight loss
  • History of sinopulmonary infections?
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11
Q

What laboratory tests would you do for these?

  • SLE
  • EBV
  • Hypothyroidism
  • Rheumatoid arthritis
  • IBD
  • CVID
A
  • SLE
    • CBC, Cr, UA, ANA, anti-dsDNA, anti-Smith Ab
  • EBV
    • Monospot, EBV titers
  • Hypothyroidism - TSH
  • Rheumatoid arthritis
    • RF, CCP, hand X-rays
  • IBD
    • CBC, ESR, CRP, stool guiaic
  • CVID
    • Immunoglobulin panel, vaccine titers
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12
Q

What are the two main categories of symptoms in Systemic Lupus Erythematosus?

A
  • Mucocutaneous manifestations
  • “-itis”
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13
Q

What are the mucocutaneous manifestations in SLE?

A
  • Oral ulcers - hard palate
  • Malar rash - crosses nasal bridge, spares nasolabial folds
  • Rashes often photosensitive
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14
Q

What are the “-itis”-es of SLE?

A
  • CNS inflammation
    • Cerebritis (seizures, psychosis)
    • Transverse myelitis
  • Nephritis
  • Arthritis
    • Small joints
    • Hands & wrists
  • Serositis
    • Pericarditis
    • Pleuritis
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15
Q

What are the laboratory abnormalities seen in SLE?

A
  • Auto Ab
    • ANA (sensitive but not specific)
    • anti-dsDNA, anti-Smith (specific but not sensitive)
    • Coombs
  • Cytopenia
    • Leukopenia, lymphopenia
    • AIHA, ITP
  • Low complement
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16
Q

If our patient with SLE had normal urine but platelets consistently <20K, what would you treat her with?

A
  • Steroids
  • IVIG
  • Rituximab
    • Belimumab - not typically used for thrombocytopenia, but a related B-cell therapy
17
Q

What is the pathophysiology of SLE nephritis?

How is this manifested in the lab abnormalities?

A

Type III Hypersensitivity

  • (Auto)Ab + (Auto)Ag = immune complex (IC)
  • IC deposit in tissues
  • Deposited IC elicits inflammation including PMN infiltration
  • Inflammation results in tissue damage
  • Labs
    • Immunofluorescence for IgG stains dermal-epidermal junction
    • Lupus Band
18
Q

A 14 YO girl has had pain in her fingers & wrists and this has made her clarinet performances more difficult over the last couple months. She has also had fatigue & mouth sores. On exam you see scaling on the extensor surfaces & nail pitting.

What is the most likely diagnosis?

A

Psoriatic Arthritis

19
Q

What are the patterns of joint involvement in Psoriatic Arthritis?

A
  • DIP predominant arthritis
  • Oligoarticular (typically large joints)
  • Polyarticular
  • Axial involvement (uncommon)
20
Q

What are some other presenting characteristics of Psoriatic Arthritis?

What is the genetic association?

A
  • Enthesitis
  • Dactylitis (“sausage digits”)
  • Can be associated w/ HLA-B27
  • Arthritis can precede onset of psoriasis
21
Q

How does Psoriatic Arthritis present on the skin?

What is the Auspitz sign? Koebner phenomenon?

How does this correlate with arthritis severity?

A
  • Lesions
    • Well-demarcated erythematous lesions w/ silvery scale
    • Auspitz sign - bleeding w/ peeling of scale
    • Koebner phenomenon - rash at sites of trauma
    • Most common distribution w/ plaque psoriasis - extensor surfaces of elbows & knees
  • Severity does not correlated with arthritis severity
  • Nail pitting increases the risk of arthritis
22
Q

How is Psoriatic Arthritis treated?

A
  • NSAIDs (arthritis only)
  • Methotrexate
  • Anti-TNF medications (etanercept, adalimumab, infliximab)
  • Costimulation blockade (CTLA-4 Ig, abatacept)
  • Anti-IL17 (secukinamab)
  • Anti-IL12/23 (ustekinumab)
  • JAK/STAT inhibitors (tofacitinib)
  • PDE-4 inhibitors (apremilast)
23
Q

14 YO female presents w/ a 2 wk history of very painful joints, initially her R knee, then her L wrist, and now her L ankle. She has had hives, and is fatigued. She has had mild dsypnea w/ ambulation. She is tachycardic & has a II/VI holosystolic murmur at the apex radiating to the axilla. Her joint exam is normal except for severe pain w/ ROM of the L ankle w/ mild swelling. She has an urticarial-like rash on her trunk. She had a sore throat about a month ago.

What is the Problem List?

What is the Leading DDx?

A
  • Problem List
    • Migratory polyarthritis
    • Urticarial rash
    • Murmur radiating to axilla (mitral valve)
    • History of sore throat
  • Leading DDx: acute rheumatic fever
24
Q

14 YO female presents w/ a 2 wk history of swelling & stiffness intitially her L knee then progressed to also involve her L wrist, then both wrists w/ stiffness of her fingers. She has had fever, rash & is fatigued. She has swelling, warmth, erythema, tenderness & severe pain w/ ROM of her R knee, L wrist & L ankle. She has small pustules on her hands. She had a sore throat about 1 mo ago.

What is the Problem List?

What is the Leading DDx?

A
  • Problem List
    • Additive polyarthritis (very painful & erythematous)
    • Fever
    • Pustular rash
    • History of sore throat
    • Sexually active
  • Leading DDx: gonococcal arthritis
25
Q

14 YO female who presents w/ a 1 wk history with very painful swollen knees & fingers. She has also had a blotchy rash on her arms & legs. About 2 wks ago, she had a fever & red cheeks. Her little brother was also sick with fever & red cheeks. Her exam reveals swelling & stiffness of her knees & PIPs. She has a lacy erythematous rash on her arms & legs.

What is the Problem List?

What is the Leading DDx?

A
  • Problem List
    • Acute polyarthritis
    • Lacy rash in stocking/glove distribution
    • History of febrile illness
    • Sick contact w/ fever & slapped cheek rash (5th’s disease)
  • Leading DDx: Parvovirus
26
Q

Mr. J is a 54 YO man w/ obesity & recently diagnosed HTN who complains of L knee pain. The pain is so severe he became nauseated & vomited 2X this morning. He feels sweaty & wife reports “color was not good”. He seemed to be breathing rapidly. In the past he has complained of intermittent knee pain in both kenes & feet at night. He just retruned from hunting large game in South Africa & attended his college reunion at Yale 4 months ago.

On exam his skin is cool & clammy. On joint exam he has Hebreden’s nodes, squaring of the base of the thumb, non-tender nodules at olecranon bursa on the R, large warm effusion w/ some patchy redness over L knee.

What diagnostic tests should be performed?

What is the likely diagnosis?

A
  • Aspiration of joint, CBC, basic metabolic panel, pulse oximetry, imaging not necessary
  • Synovial fluid analysis
    • Axis of polarization aligned w/ yellow crystals
  • DDx: Gout
27
Q

What is the pathophysiology of Gout?

A
28
Q

What is the treatment principle of acute gout?

What is the treatment principle of recurrent gout?

What are the treatment options?

A
  • Acute gout: reduce inflammation
    • Colchicine
    • NSAIDs
    • Steroids
  • Recurrent gout: reduce uric acid levels
    • Allopurinol
    • Febuxistat
    • Probenacid
29
Q

What if the synovial fluid looked like this?

A

Calcium Pyrophosphate Deposition Disease (CPPD)

30
Q

What is CPPD?

A
  • Common form of arthritis
  • Affects elderly patients preferentially
  • Clinically heterogenous presentation
    • Can look like gout, OA or RA
  • Difficult to treat
  • Lab: blue perpendicular cystals
  • Hallmark: Chondrocalcinosis
31
Q

What if the synovial fluid looked like this?

A

Septic arthritis

  • Monoinflammatory arthritis that is otherwise unexplained
  • This is a medical urgency
  • Joint needs to be drained
  • Etiology is typically from hematogenous spread
  • Wks of antibiotics are typically necessary
32
Q

If the synovial fluid was inflammatory but gram stain was negative, what would the possibilities be?

A
  • Gonococcal arthritis
    • Wrists & knees
    • Sexually active, W > M
    • Extremely sensitive to therapy
    • Dissemination to skin
    • Hard to recover from joints
  • Lyme arthritis
    • Tick form
    • Not very common
    • Secondary & tertiary phase
    • Erythema migrans
  • Fungus
    • Immunocompromised patients
  • Mycobacteria
33
Q

What if the synovial fluid looked like this?

A

Osteoarthritis

  • Normal looking, non-inflammatory
  • Loss of articular cartilage
  • Bones sclerotic
  • Osteophytes
34
Q

What is knee osteoarthritis?

How does it present?

Treatment?

A
  • The most common form of arthritis in adults
  • “non-inflammatory”
  • Can still cause severe pain
  • Treatment is symptomatic

Symptoms (17 decks)

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