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Med School Year 2 Flash Cards > Monoarticular Arthritis Clinical > Flashcards

Monoarticular Arthritis Clinical Flashcards

1
Q

Most common causes of acute monoarticular arthritis (three)

A

crystals, trauma, infection

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2
Q

infections in monoarticular arthritis

A

gonococcal, nongonoccal, lyme diseae, mycobacterial/viral/fungal

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3
Q

inflammatory causes of monoarticular arthritis

A

RA, seronegative spondyloarthropathies, SLE, sarcoidosis, reactive arthritis

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4
Q

hot or swollen joints usually means

A

infection

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5
Q

constitutional symptoms (fever, weight loss, malaises) usually means

A

infection

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6
Q

weakness in monoarticular arthritis usually means

A

compartment syndrome or acute myelopathy

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7
Q

burning pain, numbness, paresthesia suggests _____ (3 things) in monoarticular arthritis

A

myelopathy, radiculopathy, neuropathy

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8
Q

risk factors for septic arthritis

A

prosthetic hip or knee joint, skin infection, joint surgery, rheumatoid arthritis, age >80, DM

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9
Q

symptoms of worse with immobility usually means

A

inflammatory arthritis (esp if lasting more than one hour –> RA or polymyalgia rheumatica)

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10
Q

symptoms aggravated by motion and weight bearing and relieve by rest usually means

A

OA

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11
Q

antecedent trauma can point towards this kind of diagnosis

A

fracture, meniscal tear, hemathrosis

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12
Q

systemic complaints: chills, malaise, fever are more seen in

A

infectious (high grade fever more than low grade fever because low grade can be seen in crystals)

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13
Q

GI or GU complaints, recent sexual exposure suggest

A

infectious portals or entry or seronegative spondyloarthropathy (reactive arthritis, psoriasis, IBD)

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14
Q

recent travel to endemic regions suggests

A

infection (Lyme disease, mycobacerial and parasitic)

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15
Q

synovitis symptoms are

A

soft tissue swelling, warmth over a joint, joint effusion

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16
Q

reduced active range of motion with preserved passive range of motion suggests

A

soft tissue disorders - bursitis, tendinitis, or muscle injury

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17
Q

both active and passive ROM decreased suggests

A

soft tissue contracture, synovitis, structural abnormality

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18
Q

fever is seen in these types of rheumatic illnesses

A

infectious, posinfections, reactive, RA, Still’s, systemic rheumatic illness (SLE/vasculitis), crystal induced, cancer, sarcoidosis

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19
Q

sudden onset of pain in seconds/minutes

A

fracture, internal derangment, trauma, loose body

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20
Q

onset of pain over several hours or days

A

infection, crystals, inflammatory

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21
Q

insidious onset of pain over days to weeks

A

indolent infection, OA, infiltrative, tumor

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22
Q

previous acute attacks in any joint with spontaneous resolution

A

crystal depo disease, other inflammatory arthritic

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23
Q

IVDA or immunosuppression

A

septic arthritis

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24
Q

previous prolonged corticosteroid therapy

A

infection, AVN

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25
Q

coaguloapthy or anticoag use

A

hemarthrosis

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26
Q

urethritis, conjunctivitis, diarrhea, rash

A

reactive arthritsi

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27
Q

psoriatic patches or nail changes (pitting)

A

psoriatic arthritis

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28
Q

diuretic use, tophi, renal stones, alcoholic binges

A

gout

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29
Q

eye inflammation, low back pain

A

ankylosing spondylitis

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30
Q

young adulthood, migratory polyarthralgias, inflammation of the tendon sheaths of hands and feet, dermatitis

A

gonoccocal arthritis

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31
Q

hilar adenopathy, erythema nodosum

A

sarcoidosis

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32
Q

most common test in monoarticular arthritis

A

synovial fluid analysis - arthrocentesis; ATTEMPTED IN ALL PATIENTS WHO HAVE AN EFFUSION OR SIGNS SUGGESTING INFLAMMATION WITHIN THE JOINT

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33
Q

septic arthritis synovial fluid looks like:

A

> 100,000 WBC with greater than 75% PMN, also should get a culture on preservative-free choclate agar plates, reduction in glucose and elevation in LDH are also consistent with bacterial infection

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34
Q

noninflammatory fluids look like:

A

fewer than 2000 WBC, less than 75% PMN

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35
Q

crystalline arthritis fluid looks like:

A

MSU in gout, intracellular crystal within in the PMN; calcium pyrophosphate crystals in pseudogout

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36
Q

bloody synovial fluid with no trauma you should order these tests

A

PT, PTT, platelet count, bleeding time

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37
Q

ESR and CRP indicated this kind of arthritis

A

inflammatory

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38
Q

ANA is sensitive for

A

SLE

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39
Q

RF is used for

A

RA but limited diagnostic value (esp in monoarthritis)

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40
Q

Anti-CCP used for

A

RA, more specific than RF

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41
Q

indications for synovial biopsy

A

refractory monoarthritis, suspicions of atypical infectious agent, intraarticular tumors; performed using arthroscope or Parker pearson technique

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42
Q

Bacterial arthritis risk factors

A

age >80, DM, malignancy, immunosuprressive drugs, RA, joint replacement/hardware*, high risk sexual behavior
*indicate increase likelihood of poor outcome

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43
Q

Bacterial arthritis onset, pain level, presents as, other sx

A

acute onset, severe pain, inability to weight bear, fever/chills/malaise

44
Q

Bacterial arthritis PE

A

erythematous, swollen, warm, TTP, pain with AROM/PROM, splinter hemorrhages/ Janeway’s lesions/Osler’s nodes on hands and feet –> endocarditis may be present if these are present; other sources of infection: GU, respiratory, skin, GI

45
Q

Bacterial arthritis imaging findings and what type of imaging used

A

effusion, soft tissue swelling, underlying arthritis (associated with poor outcome); MRI/CT/bone scan reserved for osteomyletits suspicion

46
Q

Bacterial arthritis lab data

A

Joint fluid: culture, Gram stain, cell count, crystal eval; cell count exceed 50,000 (less with immunocompromised) with >75% PMN

47
Q

MC pathogens in Bacterial arthritis and do you need a positive Gram to confirm?

A

staphylococci, streptococci, gram neg bacilli, mycobacteria, neisseria gonorrhea; absence of organisms on Gram’s stain does no rule out bacterial arthrtitis (gonococcal)

48
Q

if bacterial arthritis involves prosthetic joint you should

A

call an orthopedic consult

49
Q

when do you start antibiotics for Bacterial arthritis and how?

A

preferred: diagnosis made before starting antibiotics BUT dont delay treatment if synovial fluid is hard to obtain –> admit to hospital for empiric broad coverage IV antibiotic therapy for gram-positive organisms

50
Q

MRSA is considered in Bacterial arthritis when

A

there is a high risk patient or present in the community

51
Q

orthopedics should be consulted immediate for this in Bacterial arthritis

A

open drainage of the join, but if not indicated then can use closed drainage of daily needle aspiration until all fluid gone

52
Q

how long should parenteral antibiotics be continued after drainage completed in Bacterial arthritis

A

minimum of 2 weeks

53
Q

how do you treat viral arthritis

A

self limited monoarthritis

54
Q

lyme disease is caused by ____ in this region of the US

A

borrelia burgdorferi carried by deer tick Ixodes scapularis in the Northeast and central northern US

55
Q

Lyme disease presents with these lesions

A

target lesions or erythema chronicum migrans (ECM), or monoarthritis of the knee (late presentation)

56
Q

Lyme disease PE and imaging

A

erythematous swollen joint with pain on PROM and AROM

imaging: effusion but in chronic can show osteoporosis, loss of cartilage, periarticular erosions

57
Q

Lyme disease synovial fluid

A

WBC 500 to 50,000; Lyme disease PCR because B. burgdorferi is rarely cultured

58
Q

Lyme disease treatment

A

doxycycline twice a day but if contraindicated then amoxicillin three times a day for 28 days

59
Q

patient that engage in high risk sexual behavior are at risk for this arthritis

A

gonococcal arthritis (N. gonorrhea is MC bacterial arthritis in sexually active young people from 18 to 24)

60
Q

Gonococcal arthritis PE

A

Initial infection 1 day to 3 months prior, arthritis in UE (wrist/extensors), myalgia, arthralgias, fever, malaise, dermatitis

61
Q

Gonococcal arthritis imaging

A

soft tissue swelling, effusion

62
Q

Gonococcal arthritis labs

A

mostly based on Hx and PE because N. gonorrhea is difficult to culture

63
Q

Gonococcal arthritis treatment

A

admitted to hosptial, IV ceftriaxone (if allergic in fluoroquinolone) then oral cefixime (if allergic in fluoroquinolone)

64
Q

Gonococcal arthritis caused by chlamydia is treated with

A

azithrymycin

65
Q

CPPD can be initial presentation of these underlying metabolic diseases

A

hyperparathyroidism, hemochromatosis, sarcoidosis, acromegaly

66
Q

BCP crystals are associated with

A

long term hemodialysis

67
Q

gout uric acid levels, male vs female, age of presentation, associated conditions, precipitating factors

A

Uric acid: >7mg/dl in men or 6 in women
Male to female: 7 to 1
Increases with increasing age
Conditions: lead intoxication, hematopoietic malignancy, renal impairment; DM, HTN, obesity, hypothyroid, hyperlipidemia
Precipitating: dietary indiscretions, diuretics, dehydration, discontinue hypouricemic therapy, trauma

68
Q

gout presents as ___ pain of a ____ joint (most commonly the _____ joint)

A

acute onset of severe pain of a single joint (MTP but also seen in foot, ankle, knee, fingers, elbows, wrists)

69
Q

gout PE of joint (acute and chronic)

A

erythematous and swollen, warm, painful, tophaceous deposits (longstanding), uric acid deposits on ear/elbow/achilles tendon and fingers/brusa/other joints

70
Q

gout imaging

A

plain films: effusion for aspiration in acute, periarticular erosions in recurrent

71
Q

gout synovial fluid

A

synovial fluid: uric acid crystals, needle-shaped that are strongly negatively birefringent as bright yellow needle shaped crystals; WBC 200 to 50,000 (can be higher), purulent, Gram stain and culture to rule out infection

72
Q

acute treatment of gout (1st, 2nd, and 3rd line)

A

start at very first sign of attack for best results, NSAIDs are first line (max dose for 2 to 3 days), prednisone/colchicine for contraindicated NSAID (renal disease, heart failure, GI bleeds); prednisone is 2nd line; colchicine is third line at first sign of attack (GI side effects and contraindicated in renal insuff)

73
Q

long term chronic gout treatment (for what kind of patients, goals of treatment, when to start tx)

A

long term prophylaxis for pt with recurrent gout attacks, uric acid kidney sotones, tophaceous gout
want to lower urate less than 6 gm
can’t start until sx free of (NSAID prophylaxis can be given to prevent acute attack from starting urate lowering drug)

74
Q

long term chronic gout treatment drug types and side effects

A

uricosurics (probenecid and sulfinpyrazone –> younger patients who underexcrete uric acid, SE: urolithaisis, acute gout flare) and xanthine oxidase inhibitors (allopurinol –> can be used in renal insuff, SE - hypersensitivity reaction)

75
Q

CPPD presentation

A

similar to gout, disability of single joint, erythematous and swollen, TTP

76
Q

MC joints in CPPD

A

ankles, knees, wrists, shoulders, MCP

77
Q

CPPD imaging findings

A

Chondrocalcinosis - linear calcification or cartilage (esp in fibrocartilage) in the menisci, pubis, hips, discs, wrist

78
Q

CPPD synovial fluid

A

rhomboid shaped calcium pyrophosphate dihydrate crystals weakly positively birefringent, culture and Gram to exclude infection

79
Q

CPPD treatment

A

high dose NSAID, colchicine is not as effective, prednisone will relieve attack

80
Q

BCP is also called and presents like

A

calcific periarthritis, tendoitis or bursitis

presents like gout with deposits of BCP rupturing into soft tissue –> acute pain, swelling, erythema, warmth

81
Q

BCP is MC in this joint

A

shoulder (Milwaukee shoulder syndrome is chronic)

82
Q

BCP imaging

A

calcific deposits in supraspinatus tendon or subdeltoid bursa, degenerative changes of GH and AC joints

83
Q

Joint fluid of BCP

A

serosanguinous or milky white fluid with mononuclear cell, WBC <1000, BCP crystals on electron microscopy

84
Q

BCP treatment

A

NSAID or colchicine, joint aspiration, intraarticular steroid injection; surgery if pain is unremitting

85
Q

Meniscal tears caused by

A

sudden deceleration, change in direction, or landing from jumping

86
Q

Meniscal/ligament tears can present this inflammatory timeline and patient complaint

A

inflammatory response over several hours (if quick then can be hemarthrosis –> ACL TEAR)
pt feels knee giving out, locking/catching, unable to fully extend w/o pain

87
Q

Meniscal/ligament tears PE (provocative test)

A

feel a clunk on full extension
McMurray’s test positive - extends knee from flexed position while externally rotating the foot and palpating the knee medially (feels clunk); lateral meniscus - foot internally rotated during extension.
anterior drawer sign positive if ACL damage
posterior drawer sign positive if PCL damage

88
Q

Meniscal/ligament tears imaging needed

A

plain radiography first for arthritis and loose bodies and then MRI/arthroscopy for meniscal tear

89
Q

Meniscal/ligament tears treatment

A

refer to ortho surgeon (peripheral area can heal without intervention bc blood supply but in the inner will need arthroscopy)

90
Q

occult fracture presents in these populations

A

young adult athletes, osteoporosis, osteomalacia, fibrous dysplasia

91
Q

stress fractures present with trauma - true or false

A

false because repetitive muscular forces or physiologic forces in people with mineralization abnormalities

92
Q

patietns that get stress fractures

A

track and field, dancers, military recruits, menstrual disturbances, eating disorders, metabolic conditions

93
Q

stress fracture PE

A

hot, swollen, painful joint

94
Q

stress fracture imaging and joint fluid

A

radiographs will usually be negative but MRI/bone scans can diagnose and joint fluid will be negative for crystals/organisms

95
Q

what is the first step in treating stress fracture

A

find the underlying cause (DEXA, 25-OH vit D levels, CBC, chemistry, liver)

96
Q

treatment of stress fracture

A

referral to ortho surgeon

97
Q

what should patients with JIA do every 3 months

A

ophthalmologist for asymptomatic uveitis –> blindness

98
Q

most common inflamma arthropathy with monoarthritis

A

reactive arthritis

99
Q

reactive arthritis occurs after

A

diarrheal illness or GU infection

100
Q

bacteria associated with reactive arthritis

A

Enteric: salmonella, higella, clostridium, vibrio, hyersinia. GU: chlamydia

101
Q

typical patient with reactive arthritis

A

20 to 40 yoa, male or female, HLAB27 positive

102
Q

MC joint in ReA

A

knee (also see UE, sacroiliacs, spine)

103
Q

other symptoms of ReA

A

fatigue, morning stiffness, fevers, malaise

104
Q

ReA PE

A

MC knee or other weight bearing, warm/tender/swollen with effusion, dactylitis (sausage fingers), ENTHESITIS, keratoderma blenorrhagicum, circinate balantitis, conjunctivitis

105
Q

ReA imaging (acute and chronic)

A

soft tissue swelling/effusion, asymmetric sacroiliitis, later can present with reactive bone proliferation/fluffy periosteal reaction/erosions

106
Q

ReA labs

A

ESR and CRP elevation, anemia, leukocytosis, inflammatory synovial (WBC 2000 to 50,000) with crystal and culture neg, RF and ANA neg

107
Q

ReA treatment

A

resolution of sx in 3 to 6 months; chlamydia - azithromycin; therapeutic drainage; NSAIDs are mainstay daily; prednisone for more debilitating, HLA B27 and keratoderma blenorrhagicum refer to rheumatologist, ophthalmologist referral

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