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DU PA Arthritis
Duke PA Arthritis
| Question | Answer |
|---|---|
| __ is effective in pain relief for those with OA | exercise |
| formerly called degenerative joint disease | osteoarthritis |
| most common cause of long-term disability in U.S. | OA of the knee |
| __ is the most powerful risk factor for developing osteoarthritis | Age |
| female to male ratio for osteoarthritis risk __:1 | 2 |
| african american to caucasian ratio for osteoarthritis risk __:1 | 2 |
| Type __ finger configuration associated with doubled risk of OA knees, hips, hands | 3 |
| higher __ shows a decreased risk for developing OA | education |
| most affected joints in OA | Knees, hips, base of big toe, base of thumb |
| when OA affects three or more joint groups | generalized OA |
| loss of joint space, subchondral sclerosis, osteophytes, subchondral cysts | characteristics of OA |
| __ can't see chondral erosions | x-rays |
| Knee pain and x-ray osteophyte(s)-- plus --at least one of the following: (age > 50 y.o.morning stiffness(<30 min.), crepitus with motion) | DIAGNOSTIC CRITERIA Knee OA |
| Mechanical pain, Gel phenomenon, Bony enlargement, Decreased ROM, Muscle atrophy | other diagnostic features of knee OA |
| mild signs of __ in osteoarthritis | inflammation |
| most significant way to decrease progression of OA | weight loss |
| __ can improve arthritis symptoms by __% | 15-30 |
| contralateral to painful joint | proper use of a cane |
| __ have questionable effectiveness in treating osteoarthritis of the knee | unloader braces |
| __ is an effective treatment for patello-femoral pain | patellar taping |
| squatting puts __ times your body weight on your knees | 9 |
| running puts __ times your body weight on your knees | 4-7 |
| walking puts __ times your body weight on your knees | 3-4 |
| kneeling, squatting, prolonged standing | things to avoid when you have OA |
| sit in a __ stool if stationary at work if you have OA | high |
| low toilets, low chairs, low beds, bath tubs | things to avoid when you have OA |
| __ relaxed muscles, stimulates blood flow, good for OA | heat |
| __ eases muscle spasms, blocks pain signals for OA | cold |
| only thermal modality to raise hip joint temperature | ultrasound |
| useless thermal modalities for OA | infrared, diathermy |
| __ better for hip OA | bicycle |
| __ better for knee OA | elliptical |
| __ promotes joint preservation | wt-bearing exercise |
| shock absorbers of the joints | periarticular muscles |
| physiologic retirement plan | muscle mass |
| __ helps combat sarcopenia | weight resistance training |
| best done when muscles are warm | stretching |
| jogging, stair-climbers, rowing machines, running and jumping sports | not recommended for patients with OA |
| the go to OTC for OA | acetaminophen |
| if response to acetaminophen is inadequated try low dose | OTC NSAIDS |
| Start low, go slow, skip doses or eliminate __ as soon as possible | NSAID |
| NSAIDS can cause __ | GI bleeds |
| if you must use an NSAID b/c tylenol is inadequate also put the patient on a | proton pump inhibitor |
| acts like a narcotic but is not as addictive | tramadol (Ultram) |
| no real GI advantage after 12-18 months | Clecoxib (Celebrex) |
| no evidence for an increase in cardiovascular events over other NSAIDS | Clecoxib (Celebrex) |
| visco-supplementation | hyaluronic acid |
| shows no slowing of disease progression but does have some pain relieving qualities, and is very safe | Glucosamine, chondroitin |
| no benifit to __ for OA | abrasion chondroplasy |
| autologous chondrocyte implantation | carticel procedure |
| Osteochondral Auto Transplant System | OATS procedure |
| longevity of this surgery is 15-20 years in 90-95% | joint replacement surgery |
| gout is principally a disease of __ | men |
| gout is to a lesser extent a disease of __ | postmenopausal women |
| the prevalence of gout is directly related to the degree of __ | hyperuricemia |
| overall gout occurs in __% of the adult male population | 2-3 |
| the prevalence of gout is __ dependant | age |
| uric acid is the breakdown products of the purines __ | adenine and guanine |
| __ of daily uric acid input comes from dietary sources | 1/3 |
| 2/3 of the excretion of uric acid occurs in the __ | kidneys |
| overall __% of patients with primary gout have increased uric acid production | 10-20 |
| __ of daily uric acid input comes from de-novo purine synthesis | 2/3 |
| __ can lead to uric acid overproduction, and secondary gout | lymphomas, leukemias, disorders of hematopoiesis, wide spread psoriasis |
| clinically the most important stimulus to uric acid production is __ which can dramatically increase de-novo synthesis | alcohol |
| __ can all lead to decreased urate clearance | diuretics, aspirin, dehydration, and acidosis |
| __ has long been associated with gout | lead nephropathy |
| uric acid accumulations | tophi |
| trauma to the __ joint from weight-bearing activities may underlie its predominant involvement | first metatarsophalangeal |
| __ sometimes leads to breakdown of tophi | rapid lowering of uric acid blood levels |
| acute gouty arthritis is characterized by __ | rapid crescendo onset |
| a patient with acute gouty arthritis will go to sleep with no symptoms and __ | is awakened by severe pain, erythema, and swelling in the affected joint |
| __ is the most commonly involved joint in gout | first metatarsophalangeal joint |
| gouty involvment of the first metatarsophalangeal joint | podagra |
| the skin overlying a gouty joint is __ | erythematous and warm |
| after the big toe the other joints most affected by gout in order | instep, heel, ankle, knee, hands, wrists, elbows |
| the acute onset of inflammatory monoarthritis in a joint of the lower extremity particularly in middle aged and older men is likely to be __ | gout |
| __ is common in gout | low grade fever |
| patients with __ usually have a more insidious onset than patients with gout | septic joint disease |
| the joint fluid in gout is __, with more than 10,000 WBC's and >90% PMN's | inflammatory |
| __ are both pathognomonic for and for and essential to the diagnosis of acute gouty arthritis | intracellular, needle shaped, negatively birefringent crystals |
| many patients have __ at the time of acute attack, therefore making serum levels unhelpful | normal blood uric acid levels |
| gout may present as | chronic polyarthritis |
| in contrast to the non-reactive margins in rheumatoid arthritis, x-rays of gout typically show | sclerotic changes at erosive borders |
| RA joint progression in chronological order | wrists, knees, elbows, ankles, hips, shoulders |
| RA joints are usually described as __ | boggy |
| morning stiffness | hall mark symptom of RA |
| with RA symptoms are worse in the __ | am |
| with RA symptoms are worse after __ | prolonged periods of rest |
| to qualify for RA quality morning stiffness, the stiffness has to last at least __ | 1 hour |
| RA usually shows __ involvement | bilateral |
| for a diagnosis of RA there must be at least one | swollen joint in the hand |
| __% of those with RA will never develop serum rheumatoid factor | 30 |
| the criteria for RA must be present for __ weeks, to rule out polyarticular manifestations of infection | 6 |
| ulnar deviation, swan neck deformities, boutonniere deformities | RA articular manifestations |
| feet are affected in __% of patients with longstanding RA | 90 |
| outside of the cervical spine __ usually does not affect the spine | RA |
| usually involves the MCP's, PIP's, and DIP's | RA |
| __ is rare but can occur in patients with longstanding RA | tendon rupture |
| subluxation of the MTP's in RA can lead to a visible __ | callous formation on the ball of the foot |
| no single diagnostic tests confirms __ | RA |
| platelet counts are usually increased in patients with | inflammatory diseases |
| patients who are RF negative tend to have __ as compared to those who are RF positive | milder disease course |
| acute phase reactants associated with RA | ESR, CRP, thrombocytosis |
| synovial fluid analysis in joints affected with RA show | increased WBC's with predominant neutrophils |
| __ is common in RA, and is usually not fixable. it is not due to a lack in Iron. | mild anemia of chronic disease |
| radiographic joint damage in RA is sometimes referred to as a __ | rat bite |
| on radiograph the joint space narrowing in __ is usually more diffuse | RA |
| Keratoconjunctivitis sicca | dry eyes-extra-articular manifestation of RA |
| Pericarditis, premature atherosclerosis, vasculitis, valve disease, and valve ring nodules | heart-extra-articular manifestation of RA |
| Pleural effusions, interstitial lung disease, bronchiolitis obliterans, rheumatoid nodules, vasculitis | lung-extra-articular manifestation of RA |
| Entrapment neuropathy, cervical myelopathy, mononeuritis multiplex (vasculitis), peripheral neuropathy | neurologic-extra-articular manifestation of RA |
| Anemia, thrombocytosis, lymphadenopathy, Felty's syndrome | hematopoitic-extra-articular manifestation of RA |
| Nodules, fragility, vasculitis, pyoderma gangrenosum | skine-extra-articular manifestation of RA |
| for treatment of RA with evidence of moderate-severe @ diagnosis start with __ | DMARDs |
| adjunct treatment for RA | glucocorticoids, NSAIDs, analgesics, physical, and occupational therapy |
| rare manifestation of RA + splenomegaly, leukopenia and recurrent pulmonary infections | Felty's syndrome |
| rupture of synovial fluid from knee into calf; mimics DVT, cellulitis | Baker's cyst |
| patients with RA have an increased risk for __ | cardiovascular disease, accelerated atherosclerosis, increased rate of malignancy (lymphoma) |
| patients with RA can undergo __ | spontaneous remission |
| estrogen protects against __ | gout |
| peak age for gout in men __ years | 40-50 |
| peak age for gout in women >__ years | 65 |
| decreased renal clearance leading to gout | underexcretion |
| increased renal production of uric acid leading to gout | overproduction |
| __% of cases of gout are due at lest in part to | decreased renal clearance leading to hyperuricemia |
| hyperuricemia and __ are associated | hypertension |
| risk factors for gout | infection, trauma, weight loss (extreme diets), hospitalization, dyslipidemia |
| __ are the 4 stages of gout, there can be decades in between stages | hyperuricemia, acute gout, intercritical gout, chronic gout |
| uric acid levels increase at __ | puberty |
| hyperuricemia is defined as serum uric acid level > __ mg/dL | 6.8 |
| most people with __ don't develop gout | hyperuricemia |
| asymptomatic __ usually doesn't need to be treated | hyperuricemia |
| dusky red is the color of __ | gout |
| usually exquisitely tender (bed sheet sign) | gout |
| may be difficult to distinguish from septic arthritis (similar lab features) | gout |
| Peggy says this is the NSAID of choice for gout | indomethacin |
| Treatment of choice for gout | NSAIDs |
| limit/restrict offending foods, limit ETOH, increase fluid intake, weight loss | lifestyle modifications for gout |
| beef, pork, canned sardines, foods with high yeast content, shellfish, asparagus, cauliflower, mushrooms, spinach | foods high in purines |
| __ should be obtained before initiating therapy for acute gout | 24 hour urinary uric acid measurement |
| __ is very allergenic and associated with severe side effects (bone marrow/liver failure, severe skin rashes) | allopurinol |
| __ prophylaxis in a flair | don't stop |
| fenofibrat, and losartan | have mild uricosuric affects |
| aka interval gout | intercritical gout |
| in gout this manifestation can resemble rheumatoid nodules | tophi |
| CPPD Disease | aka pseudogout |
| is a rheumatologic disorder with varied clinical manifestations due to precipitation of calcium pyrophosphate dihydrate crystals in the connective tissues | chondrocalcinosis |
| can mimic RA, OA, or gout when symptomatic | CPPD disease |
| often asymptomatic | CPPD disease |
| may worsen OA when both exist | CPPD disease |
| Calcific tendonititis | frozen shoulder |
| inflammation at sites of attachment of bone to a tendon or ligament | enthesopathies |
| characterized by enthesopathies and involvement of the sacroiliac joints | Spondyloarthropathies |
| Formerly preceded by prefix “seronegative” denoting absence of rheumatoid factor | Spondyloarthropathies |
| association with human leukocyte antigen (HLA) B-27 | Spondyloarthropathies |
| if a patient with a spondyloarthropathy is HLA B-27 positive __ | they are more likely to have eye symptoms, earlier onset, and more axial involvement |
| if a patient with a spondyloarthropathy is HLA B-27 negative __ | they are more likely to have peripheral arthritis, skin and nail manifestations, gut symptoms |
| sites of enthesitis in the spondyloarthropathies | Achilles' tendon, plantar fascia, symphysis pubis, ischium, iliac crest, greater trochanter, finger & toes, anterolateral ribs |
| Ankylosing SpondylitisReactive ArthritisPsoriatic ArthritisEnteropathic ArthritisUndifferentiated Spondyloarthropathy | The Spondyloarthropathies |
| Ankylosing Spondylitis | spondyloarthropathy |
| Reactive Arthritis | spondyloarthropathy |
| Psoriatic Arthritis | spondyloarthropathy |
| Enteropathic Arthritis | spondyloarthropathy |
| insidious onsetworsens with inactivity; improves with exercisepersists greater than 3 monthsam stiffnessoften radiates to buttocks, thighs | inflammatory characteristics of low back pain Enteropathic Arthritis |
| acute onsetworsens with activity; improves with restlast 2-4 weeksno am stiffnessrarely radiates | non-inflammatory characteristics of low back pain Enteropathic Arthritis |
| Bilateral Sacroiliitis makes the diagnosis for | ankylosing spondylitis |
| it can take as long as 10 years for someone with spondylitis to show arthropathy on __ | plain film |
| uveitis, conjunctivitis, sicca symptoms | eye manifestations of spondyloarthropathies |
| AI, conduction delays | cardiac manifestations of spondyloarthropathies |
| IgA nephropathy, amyloidosis | renal manifestations of spondyloarthropathies |
| c-spine fractures or dislocations | neurologic manifestations of spondyloarthropathies |
| occult or overt colitis | GI manifestations of spondyloarthropathies |
| manifestations only in psoriatic arthritis and reactive arthritis | skin manifestations of spondyloarthropathies |
| males with Ankylosing Spondylitis tend to have more | lumbar spine involvement |
| females with Ankylosing Spondylitis, tend to have more peripheral involvement, but when they do have spinal involvment it is | in the c-spine |
| Mark at L5 make a mark 10 cm above that, have the patient bend at the hip. This distance should increase to 15 cm or more in the normal patient | Shober maneuver, tests for ankylosing Spondylitis |
| most people with reactive arthritis are | HLA B-27 positive |
| sausage digits | dactylitis |
| enthesopathiesdactylitisinvolvement of skin & mucous membranesrecovery is usually spontaneous with good prognosischronic cases can occur ( SI joint & axial disease associated with chronicity)susceptibilty associated with HLA B- | Clinical Features of Reactive Arthritis |
| Antibiotics if triggering infection is still presentRestNSAIDsConsider intra-articular corticosteroid injectionsChronic disease: consider DMARDs | Treatment of Reactive Arthritis |
| Association with HLA B-27 is weak (<50%) | Psoriatic Arthritis |
| An inflammatory arthritis found in 20-30% of patients with psoriasisUsually (75% of time) psoriasis precedes joint disease on average of 2 decadesPsoriatic findings may be occult (check scalp, nails, flexural areas)Male: female ratio is 1:1 | Psoriatic Arthritis |
| Predominant involvement of DIPs, Symmetric polyarthritis clinically indistinguishable from RA (most common), Asymmetric oligoarthritis of small joints ( most characteristic), Arthritis mutilans with sacroilitisAS-type with sacroilitis and spondylitis | 5 types of Psoriatic Arthritis |
| pencil in cup deformity is seen in | psoriatic arthritis |
| NSAIDsCombination of NSAIDS + sulfasalazine work wellMethotrexate can be added in refractory casesOligoarthritis form: amenable to corticosteroid injectionsPhysical therap | Treatment of Psoriatic Arthr |
| outside of arthritis patients with a spondyloarthropathie will most often have | gut symptoms |
| patients with gut diseases (Crohn's) are more likely to have | arthritis symptoms |
| male to female ratio with axial enterophathic arthirits __:1 | 1 |
| GI symptoms and __ are usually temporally related | arthritis flares |
| Extra-articular manifestations of enteropathic arthritis = __ | Extra-intestinal manifestations of IBD |
| Low back pain: could it be sacroiliitis? Do __ test | FABER |
| microbes reach joint usually via __ in infectious arthritis | hematogenous spread |
| __ is a rare cause of infectious arthritis | intra-articular |
| __ is the most commonly affecte joint in infectious arthritis | knee |
| infectious arthritis is usually | monoarticular |
| __ accounts for 2/3 of infectious arthritis cases in patients <40 years in adults | gonococcal arthritis |
| __ are a greater risk for gonococcal arthritis | women |
| syndrome of rash, fever, chills, migratory tenosynovitis of knees, ankles, wrists, feet and hands (~30-60%)~40% have skin lesions: papulovesicular or hemorrhagic, varying size monoarticular process: kneehip, ankle, wrist or elbow | gonococcal arthritis |
| Treatment:patients should be hospitalizedceftriaxone 1gm (IM or IV) q 24 hours until clinical improvementpo cefixime or cefpodoxime for at least one week | gonococcal arthritis |
| __ accounts for most cases of nongonococcal arthritis | S. aureus |
| __% of nongonococcal arthritis cases are monoarticular | 90% |
| order of joints affected by nongonococcal arthritis | knee>hip>shoulder>wrist>elbow |
| moderate to severe pain surrounding jointeffusion, spasm, warmth and erythema commonchills and fever common but may be absent in as many as 20% of affected patients | nongonococcal arthritis |
| Synovial fluid is essential for diagnosis and treatment | nongonococcal arthritis |
| syphilis (rare), lyme disease, M. tuberculosis | other (less common) etiologies of bacterial arthritis |
| usually a chronic monoarticular process, pain and swelling develop in affected joint over months to years | tuberculosis arthritis |
| borrelia burgdorferi carried by Ixodes tick causes | Lyme arthritis |
| reported in nearly all states | lyme arthritis |
| Primarily in northeast from Massachusetts to Maryland and in Wisconsin, Minnesota, California, and Oregon | lyme arthritis |
| __% of patients with Lyme disease who are untreated develop arthritis | 70 |
| most common etiology of viral arthritis | hep B&C, rubella, and parvovirus |
| __ can be confused with RA | parvovirus |
| Predilection for immunocompromised patients - DM, alcoholism, AIDS, post-transplant, corticosteroid therapy, chemotherapy | fungal arthritis |
| gardeners and those occupationally or recreationally exposed to soil | fungal arthritis |
| less common etiologies of fungal arthritis | Aspergillus, Cryptococcus, Pseudallescheria, dematiaceous fungi |
| infection complicates __% of joint replacements | 1-4 |
| most common cause of early prosthetic joint infection | S. epidermidis |
| most common cause of late prosthetic joint infection | S. aureus |
| aggressive debridement and prolonged antibiotic therapy | treatment of early prosthetic joint infection |
| removal of prosthesis and prolonged antibiotic therapy | treatment of late prosthetic joint infection |
Created by:
bwyche
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