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Crystal Arthritides
Rheumatology
| Question | Answer |
|---|---|
| Gout epi | M 40-50 yo; F 65 yo; genetic, environmental |
| Gout risk factors | infxn; trauma; wt loss (esp extreme diets); hosp; dyslipidemia (esp trigs) |
| Causes of hyperuricemia: overproduction | Nutritional (purine consumption, EtOH); hematopoietic, psoriasis, drugs |
| Causes of hyperuricemia: underexcretion | Nutritional (EtOH); renal / vasc; drugs (diuretics); metab / hormones |
| Sx of hyperuricemia | usu asymptomatic / req no tx; look for underlying cause (HTN, metab syn) |
| uric acid levels influenced by: | body habitus, ETOH use, BP, diet & insulin resistance |
| 4 stages of gout | hyperuricemia, acute gout, intercritical, chronic |
| Hyperuricemia = uric acid level: | >6.8 mg/dL (levels inc at puberty; higher in men) |
| High uric acid levels also assoc with: | HTN, metab syn, CAD, CKD |
| Gout: monoarticular manifestn | 1st MTP (podagra)> instep > heel > ankle > knee; LE>UE; very painful; self limiting |
| Gout clinical manifestations | very sudden; affected jt = warm, dusky red, swollen, exquisitely tender; systemic signs possible |
| Gout hard to distinguish from: | septic arthritis |
| Gout: Not useful in dx: | serum uric acid, plain films |
| Gold standard in dx of gout | joint aspirate demonstrating uric acid crystals |
| Tx of choice: acute gout | NSAIDs (indomethacin, celecoxib) |
| Acute gout: other tx | colchicine (esp for prophylaxis); c’steroids (oral, IV, intra-art) for pt who cannot take NSAIDs; |
| Gout tx: never … | start a drug to tx elevated uric acid in midst of acute attack; don’t stop prophylactic tx (if already on it) during acute; tx arthritis first, then hyperuricemia (not both at once) |
| Gout prophylaxis | Lifestyle mods (limit offending foods, ETOH; increased fluid intake; wt loss); Eval for provoking meds (diuretics); aspirin, niacin |
| Indications for gout prophylaxis: | 2 or more attacks/yr; erosive dz on plain film; uric acid nephropathy/ nephrolithiasis; chronic polyarticular gout |
| gout prophylaxis: Pharmacology: | colchicine; uricosurics (probenecid); xanthine oxidase inhibitors (allopurinol, Uloric) |
| uricosurics: MOA | decrease urate reabsorption, promotes excretion |
| xanthine oxidase inhibitors: MOA | decrease serum uric acid levels |
| prior to starting prophylaxis for acute gout: | do 24 hr urinary uric acid (<800mg/d = undersecretion; >800mg/d = overproducer) |
| Acute gout prophylaxis: other | limit (3-12 mo); d/c when pt at goal (<6 mg/dL uric a. x 3-6 mo & no attacks); poss fenofibrate, losartan, vit C |
| genetically engineered uricase = | Krystexxa : reduces uric acid & melts tophi; for severe chronic refractory gout |
| intercritical gout | freq inc w/time in untx’d pts; subsequent attacks: less sudden, polyarticular, slower to resolve |
| Hallmarks of Chronic Tophaceous Gout | destructive polyarticular dz; resemble other forms arthritis; multi tophaceous deposits (tophi) (hands, feet, helix of ear); dev about 12 yr after 1st attack; dir rel to uric a. levels; no pain-free intercritical pd |
| Chronic Tophaceous Gout: tx | probenecid, allopurinol, steroids |
| CPPD Epi | true prevalence unk (F > M); if FH, usu presentation <50 yo |
| CPPD etio | idiopathic or associated with primary dz (hyperPTH, hypothyroid, hemochromatosis, hypophosphatemia) |
| CPPD risk factors | trauma (can be minor), MI, CVA, infxn, surg (knee arthroscopy, ?intra-art hyaluronate) |
| CPPD clin presentation: if sx: | If sx, varies: can mimic RA, OA, gout; post-traumatic hemarthrosis; systemic illness (pseudo-PMR); axial dz (c-spine stenosis) |
| CPPD clin presentation: sudden onset | (sim to gout); systemic sx (fever, chills, inc acute phase reactants); acute poss in setting of chronic arthropathy; may worsen OA when both exist |
| CPPD dx | demo crystals in jt fluid; chondrocalcinosis on plain film; CT, MRI and U/S all detect CPPD; do serum Ca, Mg, PO4, alk phos, ferritin, Fe, TIBC |
| CPPD tx | Tx underlying dz; no spec tx for idiopathic dz; poss: NSAIDs / celecoxib; c’steroids (IV, po, intra-art); LD colchicine; hydroxychloroquine; arthrocentesis |
| BCP crystals have a predilection for: | the shoulder |
| BCP clinical presentations: | calcific tendinitis; Milwaukee shoulder; subacromial bursitis; knee & hip poss; |
| BCP tx | NSAIDS, physical therapy |
| Calcific tendonitis: | 4t/5t decades; DM (esp ins-dept); deposits in rotator cuff; often resolve spont |
| Milwaukee shoulder: | rare arthropathy (usu elderly women); rapid rotator cuff & GHJ destn; assoc w/ lg hematomas, bloody synovial fluid |
| CPPD fx where: | large joints (knee, wrist, elbow); chondrocalcinosis; also MCPs, hips, shoulders, ankles |
Created by:
Abarnard
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