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102 Cards in this Set

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What is gout?
metabolic disorder/arthritis characterized by uric acid crystals in joints, synovium of tendons, and kidneys
Orthopedics p292, 510
What is the etiology of gout?
excess uric acid → hyperuricemia → formation of crystals:
1. too much uric acid synthesized
2. too little uric acid eliminated by kidneys
Orthopedics p292, 510
What are the risk factors of gout?
men >40y/o
unusual in women until menopause
hypertension
obesity
abnormal kidney function
FH of gout
purine-rich diet
excessive alcohol intake
aspirin
thiazide diuretics
lead poisoning
hemolytic anemia, leukemia, other blood disorders
Orthopedics p292
What is the clinical presentation of gout?
rapid onset
pain, inflammation, erythema, edema, warmth of joint
monoarticular
usually MTP joint of great toe or lower extremity (foot, ankle, knee)
sometimes wrist or elbow
Orthopedics p510
What is the diagnostic work-up of gout?
1. aspirate joint → order cell count, crystals, gram, culture (to R/O infectious arthritis)
2. crystals → urate crystals, needle-shaped, negatively birefringent (shine brightly under polarized light)
3. uric acid → hyperuricemia
4. WBC → mild leukocytosis
5. ESR → elevated
6. radiographs intially normal, may progress to bone erosion
Define tophi.
nodules under skin formed by uric acid deposits
Orthopedics p510
What are the complications of gout?
kidney stones
tophi
bone erosion
Orthopedics p510
What is the treatment for acute gout?
1. NSAIDs → ibuprofen, indomethacin (if younger patient)
2. colchicine
3. if NSAIDs not tolerated → prednisone
4. if oral medications cannot be given → intraarticular cortisone injection
5. rest, elevation, moist heat
Orthopedics p510
What is the prevention for gout?
1. decrease seafood, meat, alcohol
2. increase low-fat dairy
3. change gout-inducing medications if necessary
4. prescribe allopurinol or probenecid
Orthopedics p510
Is gout monoarticular or polyarticular?
monoarticular
*unless uncommon presentation
Orthopedics p510
What are the characteristics of urate crystals associated with gout?
needle-shaped
negatively birefringent
Orthopedics p293
gout at MTP joint of great toe
needle-shaped negatively birefringent uric acid crystals → gout
What is the name for gout affecting the MTP joint of the great toe?
podagra
What must be R/O in suspected gout?
infectious arthritis
cellulitis
Orthopedics p292
Uric acid may be normal during acute attack of gout, true or false?
true
*check uric acid when attack is over
Orthopedics p293
What is the dosing for colchicine?
2 0.5mg tablets initially followed by 1 tablet every hour, up to 12, until symptoms reside or diarrhea ensues
Orthopedics p294
What are the cons of colchicine?
inconvenient dosing
GI side effects → diarrhea
Orthopedics p294
How do you determine whether to prescribe allopurinol or probenecid?
order uric acid 24-hour urine collection:
>800mg/d indicates overproducer → prescribe allopurinol
<800mg/d indicates underexcreter → prescribe probenecid (only if normal renal function, otherwise prescribe allopurinol)
Orthopedics p294
What is another name for pseudogout?
chondrocalcinosis
What is pseudogout?
arthritis characterized by calcium pyrophosphate dihydrate (salt) crystals in joints
What is the etiology of pseudogout?
unknown
A majority of people with hyperuricemia never develop gout, true or false?
true
List types of seronegative spondyloarthropathy.
ankylosing spondylitis
psoriatic arthritis
Reiter's syndrome and other forms of reactive arthritis
IBD-associated arthritis
Orthopedics p164
What are the characteristics of seronegative spondyloarthropathies?
1. affect axial skeleton
2. negative for RF
What is the triad that characterizes Reiter's syndrome?
arthritis
conjunctivitis
nongonococcal urethritis
Orthopedics p167
What is the etiology of Reiter's syndrome?
unknown
possibly induced by enteric (Salmonella) or sexually transmitted infections (Chlamydia)
Orthopedics p167
What is Reiter's syndrome?
type of seronegative spondyloarthropathy
type of reactive arthritis
characterized by triad of arthritis, conjunctivitis, and nongonococcal urethritis
Orthopedics p167
What is the clinical presentation of Reiter's syndrome?
triad of arthritis, conjunctivitis, and nongonoccoal urethritis

usually affects young
joints symptoms follow infection 3-4 weeks later
lower extremeties affected
sacroiliitis
heel pain from achilles tendonitis or plantar fasciitis
Orthopedics p167
What is reactive arthritis?
sterile arthritis that develops at a joint as a result of infection distant to the joint
Orthopedics p167
What is the management of Rieter's syndrome?
1. arthritis is self-limiting and resolves in few months
2. symptomatic treatment → NSAIDs
3. if urethritis → tetracycline x 10-14 days
Orthopedics p167
What are the indications for arthrocentesis (joint aspiration)?
to determine if:
inflammatory vs. non-inflammatory
crystal-induced → gout, pseudogout
infectious → infectious arthritis
diagnosis uncertain
What are the contraindications forarthrocentesis (joint aspiration)?
overlying infection (cellulitis, psoriatic plaque) or bacteremia → may introduce infection into joint
severe coagulopathy or warfarin therapy (INR >3.0) → may cause bleeding
Current p729
List types of monarticular inflammatory arthritis.
gout
pseudogout
septic arthritis
List types of oligoarticular inflammatory arthritis.
spondyloarthropathies:
ankylosing spondylitis
psoriatic arthritis
reactive arthritis → Reiter's syndrome
IBD-related arthritis
What is the most common polyarticular inflammatory arthritis?
RA
What disorder does a negative ANA rule out?
SLE
RF and ANA are non-specific tests, true or false?
true
What is psoriatic arthritis?
psoriasis + oligoarticular inflammatory arthritis
Orthopedics p167
What is the etiology of psoriatic arthritis?
complication of psoriasis
occurs in 5-10% of psoriasis
Orthopedics p167
What is the clinical presentation of psoriatic arthritis?
psoriatic lesions preceding arthritis by few years
arthritis involving axial skeleton (sacroiliitis) and peripheral joints (small joints of hands and feet)
oligoarticular
sausage finger
nail pitting and ridging
Orthopedics p167
What is the diagnostic workup of psoriatic arthritis?
HLA-B27 positive if axial involvement
Orthopedics p167
List types of infectious arthropathy.
gonococcal arthritis
nongonococcal bacterial (septic) arthritis
viral arthritis
Lyme disease
What disorder is "bamboo spine" associated with?
ankylosing spondylitis
What is the criteria for prescribing allopurinol for prevention of gout?
serum uric acid >5mg/dL
24 hour urine uric acid >800mg/dL (overproducer)
or <800mg/dL (underexcreter) + impaired renal function
What is the criteria for prescribing probenecid for prevention of gout?
serum uric acid >5mg/dL
24 hour urine uric acid <800mg/d (underexcreter) + normal renal function
Describe the process of purine metabolism (which leads to uric acid formation).
purine → guanosine → guanine→ xanthine → uric acid

xanthine converted to uric acid via xanthine oxidase
*allopurinol acts as xanthine oxidase inhibitor
What is the brand name of allopurinol?
zyloprim
What 2 types of arthritis affect DIP joints?
OA
psoriatic arthritis
Current p729
What 2 types of arthritis may present with nodules?
RA
gout
Current p729
Should glucose and protein be ordered on synovial fluid?
no
Current p729
What are the most common causes of bloody synovial fluid?
trauma
bleeding disorder
iatrogenic → traumatic tap
Current p729
*What are the synovial fluid results for normal, noninflammatory, inflammatory, purulent, and hemorrhagic disorders?
What is the viscosity of normal synovial fluid?
high
Describe the mucin clot test and its interpretation.
1. acetic acid added to synovial fluid
2. if normal, non-inflammatory, or hemorrhagic synovial fluid → clot formation
3. if inflammatory or purulent synovial fluid → poor clot formation → cloudy appearance → may indicate RA, gout, septic arthritis, etc.
What is required for diagnosis of gout, pseudogout, and infectious arthrits?
synovial fluid confirmation
What are the indications for prescribing medication for the prevention of gout? What are the goals?
Indications:
1. frequent attacks
2. tophi
3. kidney stones

Goals:
1. reduce uric acid <6mg/dL
2. prevent attacks
3. encourage mobilization of tophi
Orthopedics p510
Is OA inflammatory or non-inflammatory?
non-inflammatory
Current p729
What is OA?
degenerative non-inflammatory arthritis characterized by degeneration of cartilage and hypertrophy of bone at articular margins
Current p730
What is the etiology of osteoarthritis?
primary → aging
secondary → trauma, overuse, arthritis, metabolic disease, neurologic disease

hereditary and mechanical factors

risk increased with obesity, competitive contact sports, frequent bending and carrying
Current p730
What is the clinical presentation of OA?
insidious onset
minimal morning stiffness and inflammation
pain with motion, relieved by rest
may affect cervical and lumbar spine, carpometacarpal joint of thumb, PIP, DIP, hip, knee, MTP joint of big toe
no systemic symptoms
crepitus
limited ROM
heberden or bouchard nodes
Current p729
What is the diagnostic workup of OA?
ESR → normal
radiograph → narrowed joint space, osteophytes, dense subchondral bone, bony cysts
Current p729
What is the management of OA?
1. if mild → acetominophen 2.6-4g/d
2. if no response to acetominophen or severe → NSAIDs
3. corticosteroid injections up to 4x per year
4. capsaicin cream 0.025-0.075% 3-4x daily for knee OA
5. if functional impairment (restricts walking or pain at rest) or refractory to treatment → refer to orthopedic specialist → hip or knee replacement surgery
Current p731
What is the prevention of OA?
1. maintain normal vitamin D levels
2. lose weight → decreases risk of OA in weight-bearing joints
Current p731
Does recreational running increase the risk of OA?
no
Current p730
Define Heberden node.
bony enlargement of DIP joint; caused by formation of osteophytes; associated with OA
Current p730
Define Bouchard node.
bony enlargement of PIP joint; caused by formation of osteophytes; associated with OA
Current p730
Heberden node of RT index finger
What disorder are Heberden and Bouchard nodes associated with?
OA
What medications may increase risk of hyperuricemia and gout?
lose dose aspirin
niacin (vitamin B3)
thiazide and loop diuretics
allopurinol → if taken within 2 weeks of attack
Current p734
What is scleroderma?
chronic disorder characterized by diffuse fibrosis of the skin and internal organs
Current p758
Where does gout most commonly occur on initial presentation?
MTP joint of great toe
Orthopedics p510
When should patients start allopurinol or probenecid therapy following acute attack of gout?
2 weeks following attack
*if started earlier, therapy may prolong attack or cause a new one
Orthopedics p294
Which of the following are NSAIDs → aspirin, acetaminophen, ibuprofen?
aspirin and ibuprofen

*acetaminophen is not an anti-inflammatory, but an analgesic and antipyretic
When evaluating suspected arthritis, what should you consider?
1. inflammatory vs noninflammatory
2. number of joints involved
3. specific joints involved
4. extra-articular manifestations → fever (gout), rash (psoriatic arthritis, SLE), nodules (RA, gout), neuropathy (polyarteritis nodosa)
Current p729
What tests should be ordered on synovial fluid?
cell count
crystals if suspected gout or pseudogout
culture if suspected infectious arthritis
Who is most commonly affected by scleroderma?
although the condition is rare, women are 2-3 x more affected than men, presenting in 3rd-5th decade
Curren tp758
What is the etiology of lyme disease?
caused by bacteria Borrelia burgdorferi
transmitted via tick bite
tick carried by mice and deer
found in mid-atlantic, NE, north central regions of united states
Current p1342
What is the clinical manifestation of lyme disease?
history of tick bite with tick present >72 hours

stage 1 → after 1 week → target lesion + flu-like symptoms
stage 2 → weeks to months later → fatigue, HA, stiff neck, skin lesions, neurologic (meningitis, Bell palsy), cardiac
stage 3 → months to years later → arthritis, myalgias

*stages overlap and vary
Current p1342
What is the diagnostic workup of lyme disease?
LYME via ELISA for screening
western blot for confirmation

*though diagnosis clinical (i.e. exposure in endemic area + target lesion) in early stage since LYME often negative
Current p1344
What is the management of lyme disease?
doxycycline
Current p1345
What is the prevention of lyme disease?
avoid endemic areas
cover exposed skin
use repellants
inspect for ticks
200mg doxycycline prophylaxis following tick bite
Current p1345
What do deer ticks look like?
target lesion → lyme disease
What viruses are most commonly associated with arthritis?
parvovirus B19
hepB
hepC
Current p779
What is the etiology of viral arthritis?
parvovirus B19
hepB
hepC
Current p779
What is the clinical presentation of viral arthritis?
parvovirus B19 → acute polyarthritis in adults (slapped cheek fever in children); mimics RA

hepB → polyarthritis, jaundice, urticaria

hepC → chronic polyarthritis, mimics RA
Current p779
What is the diagnostic workup of viral arthritis?
parvovirus B19 → positive IgM antibodies
hepB → positive antigen, elevated serum transaminases
hepC → positive antigen, non-erosive radiographs
Current p779
What is the management of viral arthritis?
if parvovirus B19 → self limiting within several weeks
Current p779
What is the etiology of gonococcal arthritis?
secondary to gonorrhea infection
caused by bacteria neisseria gonorrhea
transmitted via sex
What is the clinical presentation of gonococcal arthritis?
initially → migratory polyarthralgias x 1-4 days involving elbow, wrist, knee or ankle

skin lesions → small necrotic pustules over extremities especially palms/soles

Pattern 1 → tenosynovitis involving wrists, fingers, ankles or toes (60%)
Pattern 2 → purulent monoarthritis involving elbow, wrist, knee or ankle (40%)
Current p778
Who is most commonly affected by gonococcal arthritis?
1. young women → especially during menses or pregnancy
2. homosexual men
Current p778
What is the diagnostic workup of gonococcal arthritis?
CBC
BC

synovial fluid:
cell count 30,000-60,000 cells/mcL
positive gram stain in 25% cases
positive culture in <50% cases

GC/chlam culture → cervical, urethral, rectal, pharyngeal
Current p778
What is the management of gonococcal arthritis?
1. admit to hospital to confirm diagnosis, exclude endocarditis, and start tx
2. 3rd generation cephalosporin → cefriaxone IV x 1-2 days
3. then cefixime PO x 7-10 days
Current p778
What is the etiology of nongonococcal (septic) arthrits)?
Staph aureus (50%)
MRSA
group B strep
gram-negatives (10%) → E. coli and pseudomonas aeruginosa

associated with:
loss of skin integrity → psoriasis, ulcers
infection → endocarditis
damaged or prosthetic joints → RA
immunocompromise → DM, alcoholism, cirrhosis, kidney disease, immunosuppressant therapy)
IV drug use
Current p777
What is the most common cause of septic arthritis?
staph aureus
Current p777
What is the clinical presentation of septic arthritis?
inflammatory monoarticular arthritis
commonly affects knee, hip, wrist, shoulder, or ankle
acute pain, swelling, warmth
worsens over hours
joint effusion
Current p777
What is the diagnostic workup of septic arthritis?
synovial fluid:
cell count >50,000 cells/mcL
differentail >90% PMNs
gram stain
culture

BC positive in 50% of cases
Current p777
What is the management of septic arthritis?
1. hospitalization
2. broad-spectrum antibiotics until culture results (vancomycin if suspected MRSA)
3. narrow-spectrum antibiotics x 6 weeks
4. early orthopedic consult for joint drainage
Current p777
Sausage fingers may indicate?
psoriatic arthritis
reactive arthritis
What are the signs and symptoms of joint inflammation?
morning stiffness ≥30min, erythema, swelling, warmth
Current p729
What percentage of people >40 y/o display radiographic features of OA in weight-bearing joints?
90%
Current p730