Joint Pain

Question 1

Substances that can exacerbate gout

Answer 1

large meal with purines (red meat, liver, nuts, seafood)
increase in alcohol consumption
THIAZIDE diuertics, loop diuretics
chemotherapeutic agents

Question 2

How to diagnose goat

Answer 2

joint aspirate!

polarizing microscopy of fluid must reveal monosodiumurate (MSU) crystals that have strong NEGATIVE BIREFRINGENCE

Question 3

Difference between gout and septic joint

Answer 3

WBC in aspirate is normal value for gout, but elevated in septic joint (avg 100,000) with 90% neutrophil dominance

Question 4

gouty arthritis

Answer 4

excess uric acid which leads to crystal deposition in joints

Question 5

Difference between gout and PSEUDOgoat

Answer 5

gout - MSU crystals that have negative birefringence

pseudogout - calcium pyrophosphate dehydrate CPPD crystals that are POSITIVE berefringence

Question 6

Ddx to consider for nontraumatic swollen joint

Answer 6

gout, (or any crystal induced arthritis), infectious arthritis, osteoarthritis, rheumatoid arthritis

Question 7

Typical first episode of gout

Answer 7

swelling and pain, usually of one joint, accompanied by erythema and warmth…can be easily confused with cellulitis

Question 8

Classically, a gout attack usually involves _______ joint of ______ toe called _______

Answer 8

metatarsophalangeal joint of first toe, called podagra

Question 9

T/F: Uric acid level is always elevated during a gout attack

Answer 9

FALSE. may be normal/low

Question 10

Radiographic changes in the joint can show

Answer 10

cystic changes in the joint surface, punched out lesions and soft-tissue calcifications (non specific)

Question 11

An infection usually involves __#___ joint(s) if bacterial in origin

Answer 11

1

Question 12

What kinds of organisms can invade joints?

Answer 12

bacteria (i.e. gonoccal infections), fungi, mycobacteria

Question 13

3 ways microbes can inject joints

Answer 13

1. direct penetration (surgery, bite, trauma)
2. hematogenous spread from distant infection
3. extension from nearby infected joint

Question 14

How to evaluate joint suspicious for infection

Answer 14

• arthrocentesis and examination of synovial fluid
• blood culture, Gram stain and culture
• CBC, ESR

Question 15

Risk factors for infectious arthritis

Answer 15

alcoholism, DM, HIV, malignancy, hemodialysis (HD), IV drugs, chronic med conditions

Question 16

ROM for septic joint

Answer 16

VERY LIMITED due to pain; will also have joint effusion and fever

Question 17

Typical presentation of osteoarthritis

Answer 17

Elderly, obese (>65) dull, deep, achey pain.

gradual onset, made worse with activity and better with rest; pain constant in later stages

Question 18

What can be felt on physical exam for osteoarthritis

Answer 18

crepitus with passive ROM

Question 19

How do xrays look for osteoarthritis

Answer 19

initially NORMAL then slowly gets bone sclerosis, subchondral cysts, and OSTEOPHYTES (not present in RA)

Question 20

Which joints does RA typically affect most commonly

Answer 20

joints of hands (PIP, MCP) and wrists!!!

also can affect any other joints

Question 21

Symptoms of RA

Answer 21

• MORNING STIFFNESS, improves as day progresses
• fever, fatigue
• C1-C2 subluxation
• subcutaneous rheumatoid nodules over extensor surfaces (PATHGNMONIC)

Question 22

Abnormal labs in RA

Answer 22

• positive rheumatoid factor RF, positive anti-CCP
• elevated ESR and CRP
• anemia
• thrombocytosis and low albumin

Question 23

RA affects which part of the joint

Answer 23

the synovium (synovitis)

Question 24

Acute treatment of gout attack

Answer 24

colchicines, NSAIDS, and glucocorticoids, ice packs

Question 25

Maintenance therapy for gout

Answer 25

allopurinol (decreases uric acid production)

probenecid (increases excretion of uric acid)

Question 26

Treatment for septic arthritis

Answer 26

IV antibiotics and surgery for drainage of infected joint (usu vanc, but do culture to know what you’re dealing with)

Question 27

First line agent for RA treatment

Answer 27

DMARD (disease modifying antirheumatic drugs)

METHOTREXATE AND SULFASALZINE

Question 28

When to do surgery for joint disease

Answer 28

last resort when medication and physical therapy fail

Question 29

What can be used as adjunct to DMARD for RA

Answer 29

NSAIDS, short term corticosteroids, topical analgesics, physical/occupational therapy, mobility exercises, weight loss

Question 30

ACR/EULAR criteria for dx of RA

Answer 30

• joint involvement
• positive serology (CCP/RF elevated)
• positive acute phase reactants (elevated CRP and ESR)
• duration of symptoms > 6 weeks