CMN 574 Unit 2 Exam With Verified Solutions
How to evaluate the patient with arthritis. -Answer Joint pattern
-Inflammation?
-Number of joints involved?
-Specific joints involved?
Extra-articular features present or absent?
-Fever
-Rash
-Nodules
Synovial fluid analysis -Answer Most joints are easily aspirated
Aspirating needle should never be passed through cellulitis or any type of skin disorder
A smaller gauge needle can be used for INR < 3.0
Clarity of the fluid
Non-inflammatory fluid is clear
Mild inflammatory fluid is translucent
Purulent fluid is opaque
Normal fluid-200 WBC
Non-inflammatory fluid-WBC < 2K
Inflammatory fluid-WBC 2K-75K
Purulent fluid-WBC 100K
Bleeding disorders or a traumatic aspiration can cause a bloody appearance.
Osteoarthritis diagnosis - Answer The most common form of joint disease
,Develops in men more than women
Degeneration of the cartilage and by hypertrophy of bone
Obesity is a risk factor
Osteoarthritis Prevention & Treatment - Answer Prevention
Weight reduction and normal Vitamin D levels
Treatment
Splinting of the hands
Weight loss
Exercise regularly
Acetaminophen is first line treatment for mild osteoarthritis
NSAIDS
Injections and Surgery
Non-steroidal Anti-Inflammatory Drugs (NSAIDS) for arthritis - Answer -Gastric ulcer,
perforation, and GI hemorrhage are the most serious complications of NSIADS usage
-Proton Pump inhibitors should be used in conjunction with NSAIDS use to reduce the
risk of GI bleeding
-Use cautiously in patients > age 70, on anticoagulant therapy, taking corticosteroids,
history of peptic ulcer disease and alcoholism. -
Intra-articular Injections & Surgery - Answer Triamcinolone 20-40mg to the knee or hip
may be given 4 times a year
Injections not indicated for osteoarthritis of the hand
Total hip and knee replacements are a good choice of treatment for patients with
ambulation limitations secondary to pain from osteoarthritis
Gouty Arthritis - Answer -Hereditary, men over 30 years of age
-Acute onset
,-Usually monoarticular joint involvement
-Involves first metaphalangeal(MTP) joint
-Hyperuricemia-serum uric acid level > 6.8
*Uric acid nephrolithiasis is common in 5-10% of the patients with uric acid level >
13mg/dL.
MTP joint of the great toe is the most susceptible joint - podagra
During an acute attack the WBC count is elevated
Patients with gout have an increased incidence of HTN, DM, CKD, Hypertriglyceridemia
and atherosclerosis
Gouty Arthritis Treatment - Answer -Great response to oral NSAIDS
Naprosyn 500 mg BID
Indomethacin 25-50 mg every 8 hours (tough on stomach)
-Colchicine: Loading dose 1.2 mg followed by 0.6 mg one hour later then 0.6 mg QD or
BID for prophylaxis
Xanthine Oxidase Inhibitors-decrease Plasma uric acid levels by inhibiting the final
enzymatic steps of uric acid production Allopurinol-100 mg PO QD and can be titrate up
every 2-5 weeks. The usual dose to decrease symptoms is 300 mg PO QD with a max
dose of 800 mg PO QD. Use cautiously with CKD patients and will cause a rash in 20% of
patients taking this drug with Ampicillin
Febuxostat-40 mg PO QD and if target acid level is not obtained my be increased to 80
mg PO QD then to 120 mg PO QD
Corticosteroids: Prednisone 40-60 mg QD for 2-5 days and then taper off
Avoid excessive alcohol especially beer, low & high purine foods (organ meats, yeast,
seafood), high fructose corn syrup. Table 20-5.
-Avoid thiazide or loop diuretics that will inhibit renal excretion. Niacin can increase
serum uric acid levels
-The clinician will institute urate-lowering therapy when the patient is experiencing 2 or
more gout attacks a year.
- minimum goal of urate-lowering therapy is to maintain the serum uric acid level at or
below 6mg/dl.
, Rheumatoid arthritis - Definition - Answer Chronic systemic inflammatory disease with
an insidious onset and c/o morning stiffness > 30 minutes
Palmar erythema
Small joints in the hands and the feet with deformity
Extra-articular manifestations including subcutaneous nodules, ILD, pericarditis, and
vasculitis
The most common cause of mortality is cardiovascular disease
RA clinical findings - Answer Many joints are involved with swelling, tenderness, and
pain
20% of RA patients have subcutaneous nodules which are usually seen over bony
prominences. Nodules may also be seen in the lungs, sclera and other tissue.
Dryness of eyes, mouth and mucous membranes
ILD, pericarditis, and small vessel vasculitis can develop
Anti-CCP (Anti-cyclic Citrullinated Peptide) antibodies are the most specific blood test
for RA.
ESR and levels of C-reactive protein are typically elevated.
Platelet count if often elevated
40% of deaths in patients with RA is due to cardiovascular disease from small vessel
vasculitis
Disease -Modifying Anti-Rheumatic Drugs (DMARDs) - Answer Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Gold salts
Azathioprine
cyclosporine
How to evaluate the patient with arthritis. -Answer Joint pattern
-Inflammation?
-Number of joints involved?
-Specific joints involved?
Extra-articular features present or absent?
-Fever
-Rash
-Nodules
Synovial fluid analysis -Answer Most joints are easily aspirated
Aspirating needle should never be passed through cellulitis or any type of skin disorder
A smaller gauge needle can be used for INR < 3.0
Clarity of the fluid
Non-inflammatory fluid is clear
Mild inflammatory fluid is translucent
Purulent fluid is opaque
Normal fluid-200 WBC
Non-inflammatory fluid-WBC < 2K
Inflammatory fluid-WBC 2K-75K
Purulent fluid-WBC 100K
Bleeding disorders or a traumatic aspiration can cause a bloody appearance.
Osteoarthritis diagnosis - Answer The most common form of joint disease
,Develops in men more than women
Degeneration of the cartilage and by hypertrophy of bone
Obesity is a risk factor
Osteoarthritis Prevention & Treatment - Answer Prevention
Weight reduction and normal Vitamin D levels
Treatment
Splinting of the hands
Weight loss
Exercise regularly
Acetaminophen is first line treatment for mild osteoarthritis
NSAIDS
Injections and Surgery
Non-steroidal Anti-Inflammatory Drugs (NSAIDS) for arthritis - Answer -Gastric ulcer,
perforation, and GI hemorrhage are the most serious complications of NSIADS usage
-Proton Pump inhibitors should be used in conjunction with NSAIDS use to reduce the
risk of GI bleeding
-Use cautiously in patients > age 70, on anticoagulant therapy, taking corticosteroids,
history of peptic ulcer disease and alcoholism. -
Intra-articular Injections & Surgery - Answer Triamcinolone 20-40mg to the knee or hip
may be given 4 times a year
Injections not indicated for osteoarthritis of the hand
Total hip and knee replacements are a good choice of treatment for patients with
ambulation limitations secondary to pain from osteoarthritis
Gouty Arthritis - Answer -Hereditary, men over 30 years of age
-Acute onset
,-Usually monoarticular joint involvement
-Involves first metaphalangeal(MTP) joint
-Hyperuricemia-serum uric acid level > 6.8
*Uric acid nephrolithiasis is common in 5-10% of the patients with uric acid level >
13mg/dL.
MTP joint of the great toe is the most susceptible joint - podagra
During an acute attack the WBC count is elevated
Patients with gout have an increased incidence of HTN, DM, CKD, Hypertriglyceridemia
and atherosclerosis
Gouty Arthritis Treatment - Answer -Great response to oral NSAIDS
Naprosyn 500 mg BID
Indomethacin 25-50 mg every 8 hours (tough on stomach)
-Colchicine: Loading dose 1.2 mg followed by 0.6 mg one hour later then 0.6 mg QD or
BID for prophylaxis
Xanthine Oxidase Inhibitors-decrease Plasma uric acid levels by inhibiting the final
enzymatic steps of uric acid production Allopurinol-100 mg PO QD and can be titrate up
every 2-5 weeks. The usual dose to decrease symptoms is 300 mg PO QD with a max
dose of 800 mg PO QD. Use cautiously with CKD patients and will cause a rash in 20% of
patients taking this drug with Ampicillin
Febuxostat-40 mg PO QD and if target acid level is not obtained my be increased to 80
mg PO QD then to 120 mg PO QD
Corticosteroids: Prednisone 40-60 mg QD for 2-5 days and then taper off
Avoid excessive alcohol especially beer, low & high purine foods (organ meats, yeast,
seafood), high fructose corn syrup. Table 20-5.
-Avoid thiazide or loop diuretics that will inhibit renal excretion. Niacin can increase
serum uric acid levels
-The clinician will institute urate-lowering therapy when the patient is experiencing 2 or
more gout attacks a year.
- minimum goal of urate-lowering therapy is to maintain the serum uric acid level at or
below 6mg/dl.
, Rheumatoid arthritis - Definition - Answer Chronic systemic inflammatory disease with
an insidious onset and c/o morning stiffness > 30 minutes
Palmar erythema
Small joints in the hands and the feet with deformity
Extra-articular manifestations including subcutaneous nodules, ILD, pericarditis, and
vasculitis
The most common cause of mortality is cardiovascular disease
RA clinical findings - Answer Many joints are involved with swelling, tenderness, and
pain
20% of RA patients have subcutaneous nodules which are usually seen over bony
prominences. Nodules may also be seen in the lungs, sclera and other tissue.
Dryness of eyes, mouth and mucous membranes
ILD, pericarditis, and small vessel vasculitis can develop
Anti-CCP (Anti-cyclic Citrullinated Peptide) antibodies are the most specific blood test
for RA.
ESR and levels of C-reactive protein are typically elevated.
Platelet count if often elevated
40% of deaths in patients with RA is due to cardiovascular disease from small vessel
vasculitis
Disease -Modifying Anti-Rheumatic Drugs (DMARDs) - Answer Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Gold salts
Azathioprine
cyclosporine
