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  1. #1
    IMG SURVIVOR's Avatar
    IMG SURVIVOR is offline Moderator 536 points
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    Arthritis IMG SURVIVOR Style

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    55 Year old lady comes to the ER because of pain in her right knee

    Now before you start with all of your theories and want to jump right away to the Treatment, I will try to go over the BASICS and the steps you have to go before you jump to the treatment.

    Is like reading EKG, you may know allot and you may be able to DX and identify a couple of diseases but if you do not go over the basics first you will miss many DX.

    Back to the case

    There are several questions you MUST ask a patient with Arthritis
    1- Time of onset
    2-Poly or monoarticular
    3-Symmetric or asymmetric
    4-Morning stiffness
    5-Extraarticular signs and symptoms
    6-Past medical History
    7-Medications
    8-Alleviating Factors
    9-Aggravating factors
    10-recent trauma

    There a couple more but for short lets stop here.
    So lets go over these questions with her:

    1- She says that she has always had pain in that knee and that lately was better, but in the past several hours it got worst.

    2-She says is only the right knee

    3- is only the right knee

    4-Less than 15 minutes

    5- She has been urinating a lot lately

    6- Diabetes Type2, Osteoarthritis, Gout and Hypertension

    7- Acetaminophen Gliburide, Hydroclorothiazide.

    8-nothing

    9- Movement make it worst
    10- no recent trauma


    So at this moment do you know what is the DX?
    Lets continue to see if is what you think
    If they ask what is the best next step in management what will you answer?


    Your medstudent ask for uric acid levels and they return normal, so he says to the attending it can't be gout.
    The mean attending looks at the medstudent with a look and says who the ______ tell you to do that test? Besides people might have normal uric acid levels and still have gout and other people might have high levels of uric acid and never develop gout.
    WHERE IS YOUR PGY1( thats you)
    You come and tell the medstudent to remember the relationship between high uric acid and heart problems. Do you Know?

    Now you do a physical exam and finds that The knee is red, swollen, tender and hot.

    You perform an arthrocentesis, remember every time you see the word/ suffix centesis means taking fluid out for example
    pericardiocentesis= taking fluid from the pericardium

    The fluid is cloudy or turbulent( you choose)
    No crystals
    WBC 150,000
    culture is +

    Are you changing your DX now

    The patient has Septic Arthritis
    now what bacteria could it be?

    Remember
    old= staph. and you treat it with Vancomycin or nafcillin
    Young= Gonorrhea and you treat it with Ceftriaxone

    Also remember to aspirate the fluid

    Remember that Gout, Diabetes and Osteoarthritis can predispose you to septic arthritis
    Remember that Hydroclorotiazide can give you Hyper GLUC. Meaning elevated levels of Glycemia, lipids, Uric acid and Calcium
    And that was a distractor


    If this were presented in a test question half way you would had stop reading and get the question wrong, ALWAYS read the ENTIRE story.

    Remember that when you see a monoarticular patient think of this:

    Infection
    Gonococcal
    Nongonococcal= like staph
    Lyme disease

    Crystals disease
    Gout
    pseudogout

    Trauma
    Hemarthrosis
    Osteoarthritis
    Cruciate Ligament or meniscal tear

    I have try to go over the basics of arthritis with this case, it might have a little problem here and there. If you find them please correct it. this is to benefit everybody preparing for the test.
    I LOVE YOU TO
    IMG SURVIVOR
    Last edited by IMG SURVIVOR; 10-26-2007 at 08:13 AM.
    Moderator: USMLE AND Residency Forums.

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    why even bother with the obvious. Just know where you are need it and where you can help the most.

  2. #2
    IMG SURVIVOR's Avatar
    IMG SURVIVOR is offline Moderator 536 points
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    You also could send me a pm about anything you think that needs correction or needs to be add it.
    Moderator: USMLE AND Residency Forums.

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    why even bother with the obvious. Just know where you are need it and where you can help the most.

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