OA / RA / Gout Flashcards
Osteoarthritis commonly effects which joints of the finger?
DIP
Are men or women more commonly effected by osteoarthritis?
Women
Peak incidence rate at 65 y.o.
What co-morbidities increase the risk for developing osteoarthritis?
DM
Hypothyroidism
Gout
Paget’s Disease
T/F: There is no genetic predisposition to osteoarthritis?
False
There is
Heberden’s nodes seen in Osteoarthritis are located at what joints?
DIP
Bouchard’s nodes seen in Osteoarthritis are located at what joints?
PIP
Are there specific laboratory findings for Osteoarthritis?
No
What changes may be seen on XR in a patient with osteoarthritis?
Osteophytes
Joint Space Narrowing
Bony Sclerosis
(Remember, XRs can appear normal early in the disease)
What are SIX non-pharmacological managements of osteoarthritis?
- Patient education about joint mechanics
- Psychosocial Support
- PT / OT
- Weight Loss
- Regular Exercise (Anything from stretching to water aerobics)
- Footwear-orthotics
What is the initial OTC choice for pain management in OA?
What would be an additional option?
Acetaminophen
NSAIDs (Ibuprofen, Naproxen, Celecoxib)
What are risk factors and contraindications for NSAID use?
Ulcer Disease
ASA Use
Renal Impairment
What TWO medications can be given as intra-articular joint injections to help improve pain in osteoarthritis?
Corticosteroids
Hyaluronic Acid
What are THREE surgical procedures indicated for osteoarthritis pain relief?
Arthroscopic Debridement
Osteotomy and Realignment (Typically in the knee)
Total Joint Replacement
Are men or women more likely to be affected by Rhuematoid Arthritis (RA)?
Women
Onset b/w 25 - 55
T/F: Rheumatoid Arthritis is not an autoimmune disease
False
It is
What TWO antibodies can be seen in patient’s serum before clinical presentation of RA?
Rheumatoid Factor
Anti-CCP (cyclic citrulinated protein)
Which human leukocyte antigen can be present in RA?
HLA-DRB1
What are the SIX cardinal signs of inflammation?
Heat Erythema Swelling Pain Loss of Function Stiffness
What joints in the hand does RA most commonly effect?
MCP
PIP
Also the wrist
What joint in the toes does RA commonly effect?
Does it effect the 1st MTP joint like in OA?
2nd-5th MTP joints
No involvement in the 1st MTP
Fever in a patient with RA may indicate the presence of what?
Vasculitis
Other than joint pain, stiffness, and deformity…..
What other symptoms may be present in RA?
Nodules
Eye Involvement
Pulmonary Involvement
Weight Loss
What are the FOUR criteria for RA diagnosis?
They need to have a score of what or higher?
- Number and site of joints involved
- Serological abnormality
- Elevated acute-phase response
- Symptoms duration
Need to score 6 ore higher
Which TWO deformities are seen in patients with RA?
HINT: One can also be seen in OA
Boutonneire Deformity
Swan Neck Deformity
T/F: Symetrical Edema can be seen in the hands of patients with RA
True
Is RA associated with a shorter or normal life expectancy?
Shorter
What pulmonary findings can often be seen on CXR in patients with RA?
Pulmonary Effusion
Nodules
Patients with RA can have an elevated Rheumatoid Factor, but this can also elevated in what other rheumatic disease?
Sjogren’s Syndrome
Which antibody present in early RA is sensitive up to 98%?
This helps to indicate rapid progression.
Anti-CCP antibodies
What are TWO labratory tests the indicate acute inflammation?
ESR
CRP
What class of medications is first line for RA treatment?
Which medication is preferred?
DMARDs
Methotrexate
What medications can be used in combination with methotrexate?
NSAIDs
Biologics
What can be given to help manage acute flares of RA?
Steroids
This arthritic disease typically onset before the age of 16?
Juvenile Idiopathic Arthritis
T/F: Oligoarthritis is the most common presentation of Juvenile Idiopathic Arthritis
True
Typically less than 4 joints are effected
___________ is described as an infection of the bone due to a blood borne pathogen. This can often occur after trauma or infection elsewhere
Osteomyelitis
What risk factors increase the risk for developing osteomyelitis?
Immunocompromised Debilitation Wounds/Ulcers after surgery Prosthetic Joints Children
What is the most common pathogen involved in osteomyelitis in general?
In children?
Neonates?
General: Staph aureus
Children: Group A Strep
Neonates: Group B Strep
What are the symptoms osteomyelitis?
Pain, swelling, and erythema around a joint +/- the acute onset of fever, chills, and malaise with an obvious abscess
Children may refuse to use the infected joint
What is a major complication of osteomyelitis?
Sepsis
What labs can be helpful in working up osteomyelitis?
Imaging?
Labs:
CBC
ESR
CRP
Blood Cultures
Imaging:
XR
MRI / CT
Bone Scan (Avoid due to radiation)
T/F: Osteomyelitis can be managed outpatient
False
Osteomyelitis patients will require treatment with what until they become afebrile?
After that what should they be treated with?
IV ABx until afebrile
Then 6 weeks of PO ABx until ESR/CRP are normal
If there is an abscess present in osteomyelitis……
How would it be managed?
Surgical Debridement
Reiter Syndrome is also considered an ________ arthritis
Reactive Arthritis
Reiter Syndrome typical follows an episode of what?
Acute bacterial GI infection, STI, or UTI
What is the most common organism involved in reiter syndrome?
Chlamydia Trachomatis
Why do they describe the signs and symptoms of Reiter Syndrome as “Cant see, Can’t Pee, Can’t Climb a Tree”?
Can’t See: Uveitis
Can’t Pee: Cervicitis/Urethritis
Can’t Climb a Tree: Arthritis
T/F: Signs and Sx of Reiter Syndrome typically spontaneously resolve
True
60 - 80% of Reiter Syndrome patients will be positive for what gene?
HLA-B27
Other then a CBC…
What labs should be tested when working up Reiter Syndrome?
STI
Urine Analysis
Stool Culture
Would you expect the synovial fluid in a patient with Reiter Syndrome to show signs of infection?
No
But there will be inflammatory markers
Although no treatment is required for treatment of Reiter Syndrome…..
What can be done to manage this condition?
Treat Underlying Cause and Subsequent Infections
NSAIDs
PT during Recovery
How does psoriatic arthritis typically present?
Nail pitting, yellowing, keratosis DIP involvement Oligoarthropathy "Sausage" like appearance to fingers and toes Psoriasis of the skin
Would Rheumatoid Factor be present in a patient with Psoriatic Arthritis?
No
What unique radiographic finding is evident in psoriatic arthritis?
“Pencil-in-cup-Deformity”
When treating Psoriatic Arthritis, why should steroids be avoided?
They may exacerbate the psoriasis and are not effective for this type of arthritis
How is psoriatic arthritis managed pharmacologically?
NSAIDs
Methotrexate
(Can give Anti-TNFs or Cyclosporine, but typically only when unresponsive)
What is the name of the criteria used to diagnosis and classify Psoriatic Arthritis?
CASPAR
Which joints/bones does ankylosing spondylitis effect?
Spine
SI Joint
Are men or women more likely to be effected by Ankylosing Spondylitis?
Men
How does ankylosing Spondylitis typical present?
Slow onset…..
Intermittent low back pain
Increasing stiffness in the morning
Gradual Loss of motion
Increased Kyphosis
What long term complications are associated with ankylosing spondylitis?
Heart Disease
Pulmonary Fibrosis
What extra articular manifestation is common in ankylosing spondylitis?
Uveitis
Which gene is present in up to 90%of ankylosing spondylitis patients?
HLA-B27
Ankylosing Spondylitis on XR often shows erosion of SI joints and akylosis of the spine.
This is referred to as ___________ spine
Bamboo Spine
What is the primary treatment goal of Ankylosing Spondylitis?
What is the first line medczation?
Second line medications?
Primary Goal: Conserve ROM and Mobility
First-Line: NSAIDs
Second-Line: Ant-TNFs (Humira)
Is infectious arthritis typically polyarticular or monoarticular?
Monoarticular
Which joints are most commonly effected in infectious arthritis?
Knee
Hip
Shoulder
Ankle
In infants, what is the most commonly infected joint?
Hips
Is infectious arthritis considered a medical emergency?
Yes
Is a prosthetic joint gets infected, what most likely will occur?
Removal of the prosthesis
What is the most common, NON-gonoccocal septic arthritis?
Staph aureus
In sexually active adults and teens what is the most common pathogen in monoarticular arthritis?
Nisseria gonorrhea
A 22 y.o. male presents to the ED with right knee pain. He noted that he woke up this morning and his right knee was swollen, warm, and very tender. He was unable to bear weight without pain as well. He denied any injuries or trauma to the knee in the last month. He did note he felt chilly in his room this morning, but never measured his temperature. On examination, he is febrile and tachycardic. His right knee is grossly edematous when compared to the left and there is warmth, erythema, and diffuse tenderness. He has limited passive ROM secondary to pain in the knee. His examination is otherwise unremarkable.
Interestingly, you see that this patient was treated for a STI in the ED two days ago.
What is you suspected diagnosis and what organism may be responsible?
Infectious Arthritis
N. gonorrhea
A 22 y.o. male presents to the ED with right knee pain. He noted that he woke up this morning and his right knee was swollen, warm, and very tender. He was unable to bear weight without pain as well. He denied any injuries or trauma to the knee in the last month. He did note he felt chilly in his room this morning, but never measured his temperature. On examination, he is febrile and tachycardic. His right knee is grossly edematous when compared to the left and there is warmth, erythema, and diffuse tenderness. He has limited passive ROM secondary to pain in the knee. His examination is otherwise unremarkable. You suspect there may be an infection in his right knee.
What is the most diagnostic procedure for confirming this diagnosis?
Arthocentresis (Aspiration) of the knee
Always send the aspirate for culture!
Also remember that a CBC, ESR, and CRP are helpful in this case
What are the 4 C’s of synovial fluid analysis?
Color
Clarity
Cell
Crystals
What color is ‘normal’ synovial fluid?
Pale, straw yellow
The presence of sodium urate crystals in synovial fluid would be indicative of what condition?
Gout
A 22 y.o. male presents to the ED with right knee pain. He noted that he woke up this morning and his right knee was swollen, warm, and very tender. He was unable to bear weight without pain as well. He denied any injuries or trauma to the knee in the last month. He did note he felt chilly in his room this morning, but never measured his temperature. On examination, he is febrile and tachycardic. His right knee is grossly edematous when compared to the left and there is warmth, erythema, and diffuse tenderness. He has limited passive ROM secondary to pain in the knee. His examination is otherwise unremarkable. Synovial fluid aspiration confirms infectious arthritis.
What is the recommended treatment for this patient?
IV ABx (Broad spectrum + vancomycin for MRSA)
2-6 weeks of PO ABx following completion of IV ABx or until Sx resolve
increase in serum urate levels leading to gout is almost always a result of what?
Uric Acid Under Excretion and Overproduction
What are some predisposing factors to gout?
High Purine Diet Alcohol Surgery Diuretics Drugs
Alcoholism or Vitamin B12 deficiency would lead to an ________ (under excretion/overproduction) of uric acid?
Overproduction
Renal Insufficiency, Diuretics, or ASA would lead to an ________ (under excretion/overproduction) of uric acid?
Under Excretion
Are deposits of uric acid (Tophi) more likely to effect proximal or distal joints?
Distal (ex: MTP)
T/F: Everyone with hyperuricemia will develop gout
False
A 57 y.o. obese male with a history of Vitamin B12 deficiency and remote alcoholism presents to your office with complaints of foot pain. Around 4 a.m. this morning, he woke up in severe pain. He localized the pain to his big toe on his right foot. He described it as a burning ache saying “it feels like my toe is on fire.” Just the lightest touch from even his bed sheets exacerbated the pain. He stated that he was perfectly fine when he went to bed last night, and he denied any trauma or injuries to the foot recently. He denied any fevers, chills, or weight loss. On examination, his 1st MTP on his right foot is significantly swollen, erythematous, and very warm to the touch. He has exquisite tenderness over the joint to even the lightest touch. He is afebrile and aside from being in significant pain, his exam is unremarkable.
What is the most likely diagnosis and how could this be confirmed?
Gout
Joint aspiration with the presence of….
Needle Shaped Crystals
Negative Bifringence
T/F: Elevated serum uric acid levels is diagnostic of gout
False
it is not diagnostic
What is the time between gout referred to as?
If hyperuricemia is not treated during the above time, what may occur?
Intercritical Stage
If hyperuricemia is not treated then the patient may experience more frequent gout flares
A 57 y.o. obese male with a history of Vitamin B12 deficiency and remote alcoholism presents to your office with complaints of foot pain. Around 4 a.m. this morning, he woke up in severe pain. He localized the pain to his big toe on his right foot. He described it as a burning ache saying “it feels like my toe is on fire.” Just the lightest touch from even his bed sheets exacerbated the pain. He stated that he was perfectly fine when he went to bed last night, and he denied any trauma or injuries to the foot recently. He denied any fevers, chills, or weight loss. On examination, his 1st MTP on his right foot is significantly swollen, erythematous, and very warm to the touch. He has exquisite tenderness over the joint to even the lightest touch. He is afebrile and aside from being in significant pain, his exam is unremarkable. Joint aspiration shows needle shaped crystals with negative bifringence, confirming your suspicion of gout.
What medication can be given to abort the current gout flare?
Colchicine +/- NSAIDs
If you are planning on giving a steroid injection you need to r/o infection first
What medication is recommended for gout prevention?
Allopurinol
What lifestyle modifications can be recommended to prevent gout attacks?
Low protein/fat diet
Avoid EtOH
Control BP
Increase fluid intake
Calcium Pyrophosphate Dehydrate Crystals in synovial fluid would be indicative of what?
Pseudogout
What are common precipitating factors to gout?
Surgery
Illness
Hyperparathyroidism
Hematochromatosis
Where is pseudogout more commonly seen?
Wrists
Knees
2nd & 3rd MCP
Do pseudogout crystals (CPPD) have a negative or positive bifringence?
Positive
Is chondrocalcinosis associated with gout or pseudogout?
Pseudogout
