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