Joint pain

Question 1

DDX for joint pain in middle age men

Answer 1

Gout / Pseudogout
Trauma (Ligamen, meniscus, fracture)
Septic Arthritis
RA
OA
Bursitis

Acute: Infxn, Gout, Trauma
Chronic: Arthritis

Question 2

Systemic disease that causes joint paint

Answer 2

RA
SLE
Ankylosing spondylitis 
Crohn's Disease
Reiter's Syndrome (reactive arthritis, ifxn somehwere else)
Lyme's
Rheumatic fever

Question 3

ROS for joint pain

Answer 3

Other joints? Compare symptoms of other items on your DDx!

Gen- F/C, myalgias
Skin- Rashes, tick bite?
ENT- Previous ST (Rheum fever)
CV- Rheum complications
Pulm- Rheum complications
GI- IBD (Crohns can have joint manifestations)
GU- Reiters can have GU spread or gonorrhea can cause septic joint
Neuro- N/T, extremity weakness (r/o neuro dz or neuro abnormalities from lyme)
Heme- Easy bleeding, hemarthrosis?

Important to ask about recent or concurrent illness as viral or post-viral infx’s can cause arthritis.

Question 4

PE for joint pain

Answer 4

Inspect, Palpate, ROM, Strength, +/- Special Test (trauma)

What other body systems should we examine?
Nodes, Heart Lungs

Always remember N/V status

Question 5

Labs / imaging to help with joint pain DDX

Answer 5

Imaging: X-ray Left knee (2 views)

Labs: CBC, Uric Acid Level

Arthrocentesis

Question 6

Crystals diagnostic of gout

Answer 6

Needle shaped, negative birefringence

Question 7

Pharm tx for acute gout

Answer 7

NSAIDs

• Indomethacin 50mg TID
• Naproxen 500mg BID
• Celecoxib 400mg BID

Colchicine 1.2mg PO, then 0.6mg 1 hr later,
then 0/6mg BID

Prednisone 40-60mg PO daily for 5-10 days

Question 8

Colchicine warnings / CI

Answer 8

• Initiate within first 72 hrs of attack
• AE: Abdominal cramping, diarrhea
• CI: severe liver/kidney dz,

Question 9

Prophylaxis for gout

Answer 9

Frequent or disabling attacked, >2/yr
Gout w Renal Insufficiency
Tophaceous deposits

ALLOPURINOL 300mg PO daily

FEBOXUSTAT 40mg PO daily

Question 10

Risk factors for OA

Answer 10

Age
Female
Obesity
Joint injury
Repetitive motion stress

Question 11

Joint mostly affected by OA

Answer 11

Hands
cervical spine
lumbosacral spine
hips
knees
foot, 1st MTP

Question 12

Sx OA

Answer 12

Pain in affected joints, worse w movement

Stiff 15-30 mins after inactivity

Gradual onset/progression

Question 13

PE OA

Answer 13

Heberden’s nodes: DIP (tippy tip!)

Bouchard’s nodes: PIP (middle, less common)

Decreased ROM

Question 14

Labs/imaging for OA

Answer 14

Xray, normal in early dz. Change dont correlate w sx

• loss of cartilage
• Osteophytes

ESR, RF(r/o inflammatory dz)
CBC (r/o ifxn)
Arthrocentesis (evaluate for inflammatory or crystal dz)

Question 15

Non pharm tx for OA

Answer 15

Pt education about joint support / body mechanics

PT/OT for balance and navigation at home/work

Weight reduction!!! Even 5-10% loss helps

Regular exercise

Footwear, orthotics, walkers, canes, etc

Question 16

Pharm tx OA

Answer 16

OTC:
Acetominophen
Ibuprofen / Naproxen

Rx:
COX-1 (Celebrex, black box warning for increased CV risk)

Cymbalta (antidepresseants) for chronic pain

Question 17

Joints affected w RA

Answer 17

SMALL JOINTS:
MCP (Metacarpophalangeal)

PIP (Proximal Interphalangeal)

2nd-5th MTP (Metatarsophalangeal)

Thumb interphalangeal

Wrist

LARGE JOINTS:
Shoulder
Elbow
Hip
Knee
Ankle
C1-C2

Question 18

Sx RA

Answer 18

Pain in affected joints
Stiffness, 1 hour +
Tender, inflammed swelling around joints
Loss of function

General fatigue and aching

Question 19

Systemic sx RA

Answer 19

Eye involvement
Pulm involvement (effusions)
Vasculitis
Weight loss
Fever

Question 20

Serology tests for RA

Answer 20

Rhematoid Factor (RF)

anti-CCP antibody

Question 21

PE findings for RA

Answer 21

Boutonneire deformity (PIP, middle!)

Swan neck deformity (DIP, tip!)

Subluxation
Loss of function

Vasculitis, infarction

Question 22

Pharm Rx for RA

Answer 22

DMARDS:
- Methotrexate, 1st line, asap

NSAIDs, Steroids - adjunctive

Question 23

Non Pharm Rx RA

Answer 23

PT/OT

Social support groups

Regular exercise, sufficient rest

Weight reduction