MUSCO 01 Introduction肌肉骨骼系统ppt课件.ppt

INTRODUCTION TO MUSCULOSKELETAL,DR TIMOTHY SONG CTCM,Definition: Rheumatologic (or Rheumatic) Disease: diseases characterized by pain and inflammation in joints and connective tissues, often referred to as “collagen-vascular diseases”.,Diversity of Rheumatologic Diseases: Common and Uncommon Diseases Involving Inflammatory and Immune Responses,Inflammatory Diseases (innate immunity) Osteoarthritis* Gout* Pseudogout Immunologically-Mediated Diseases (adaptive immunity) Rheumatoid Arthritis* Systemic Lupus Erythematosus* Spondyloarthropathies* Ankylosing spondylitis Reactive Arthritis (Reiters Syndrome) Psoriatic Arthritis Spondylitis associated with IBD Sjogrens Syndrome Polymositis/Dematomyositis Lyme Disease Rheumatic Fever Behcets Syndrome Systemic Sclerosis (Scleroderma) Wegeners Granulomatosis Giant Cell Arteritis*,Introduction to Rheumatology: Historical Perspective,The Painters Family Jacob Jordaens (1593-1678),Evidence of: Rheumatoid Arthritis,The Virgin with Canon van Der Paele, 1436 Jan van Eyck (1385-1440),Evidence of: Temporal (Giant Cell) Arteritis,Musculoskeletal Complaint,Initial Rheumatic History and Physical Exam to Determine: 1. Is it articular 2. Is it acute or chronic? 3. Is inflammation present? 4. How many/which joints are involved? 5. Are there RED FLAGS?,Joint Pain,Joint Swelling,Diffuse/Systemic Sxs,Goals of Assessment,Identify “Red Flag” conditions Conditions with sufficient morbidity/mortality to warrant an expedited diagnosis Make a timely diagnosis Common conditions occur commonly Many SkM conditions are self-limiting Some conditions require serial evaluation over time to make a Dx Provide relief, reassurance and plan for evaluation and treatment,RED FLAG CONDITIONS,FRACTURE INFECTION ORGAN INVOLVEMENT,Articular vs. Periarticular,Finding ARTICULAR PERIARTICULAR Pain Diffuse, deep “point“ tenderness ROM Pain Active+passive Active motion in all planes in few planes Swelling Common Uncommon,Peri-/Non-articular Pain,Fibromyalgia Fracture Bursitis, Tendinitis, Enthesitis, Periostitis Carpal tunnel syndrome Polymyalgia rheumatica Sickle Cell Crisis Raynauds phenomenon Reflex sympathetic dystrophy Myxedema,Inflammatory vs Noninflammatory,Formulating a Differential Dx,Mono/Oligo vs Polyarticular,Less than 4 joints Osteoarthritis Fracture Osteonecrosis Gout or Pseudogout Septic arthritis Lyme disease Reactive arthrtis Tuberculous/Fungal arthritis Sarcoidosis,4 or more joints Osteoarthritis Rheumatoid arthritis Psoriatic arthritis Viral arthritis Serum Sickness Juvenile arthritis SLE/PSS/MCTD,History: Clues to Diagnosis,Age Young: JRA, SLE, Reiters, GC arthritis Middle: Fibromyalgia, tendinitis, bursitis, LBP RA Elderly: OA, crystals, PMR, septic, osteoporosis Sex Males: Gout, AS, Reiters syndrome Females: Fibrositis, RA, SLE, osteoarthritis Race White: PMR, GCA and Wegeners Black: SLE, sarcoidosis Asian: RA, SLE, Takayasus arteritis, Behcets,Rheumatic Review of Systems,Constitutional: fever, wt loss, fatigue Ocular: blurred vision, diplopia, conjunctivitis, dry eyes Oral: dental caries, ulcers, dysphagia, dry mouth GI: hx ulcers, Abd pain, change in BM, melena, jaundice Pulm: SOB, DOE, hemoptysis, wheezing CVS: angina/CP, arrhythmia, HTN, Raynauds Skin: photosensitivity, alopecia, nails, rash CNS: HA, Sz, weakness, paraesthesias Reproductive: sexual dysfunction, promiscuity, genital lesions, miscarriages, impotence SkM: joint pain/swelling, stiffness, ROM/function, nodules,Rheumatic Review of Systems,Fever/Constitutional: septic arthritis, vasculitis, Stills disease Ocular: Reiters, Behcets, Sjogrens, Cataracts (steroids) Oral: Sjogrens, Lupus, GC, myositis, drugs GI: Reactive arthritis, IBD, hepatitis, Polyarteritis, Scleroderma Pulm: SLE, RA lung, Churg-Strauss, Wegeners, Scleroderma CVS: Vasculitis, PSS, Raynauds, antiphospholipid syndrome Skin: SLE, psoriatic, vasculitis, Kawasaki syndrome CNS: lupus carpal tunnel, antiphospholipid, vasculitis GYN/GU: antiphospholipid, SLE, Reiters, Behcets, CTX Musculoskeletal: Gout, RA, OA, fibromyalgia, fracture,Onset & Chronology,Acute: Fracture, septic arthritis, gout, rheumatic fever, Reiters syndrome Chronic: OA, RA, SLE, psoriatic arthritis, fibromyalgia Intermittent: gout, pseudogout, Lyme, palindromic rheumatism, Behcets, Familial Mediterranean Fever Additive: OA, RA, Reiters syndrome, psoriatic Migratory: Viral arthritis (hepatitis B), rheumatic fever, GC arthritis, SLE,Location,Musculoskeletal Complaint,Initial Rheumatic History and Physical Exam to Determine: 1. Is it articular 2. Is it acute or chronic? 3. Is inflammation present? 4. How many/which joints are involved?,Is it Articular?,Is Complaint 6 wks Duration?,Nonarticular Condition Trauma/Fracture Fibromyalgia Polymyalgia Rheumatica Bursitis Tendinitis,Chronic,Acute,Acute Arthritis Infectious Arthritis Gout Pseudogout Reiters Syndrome Initial Presentation of Chronic Arthritis,Is Inflammation Present? 1. Is there prolonged AM stiffness? 2. Is there soft tissue swelling? 3. Are there systemic symptoms? 4. Is the ESR or CRP elevated?,Chronic Inflammatory Arthritis,Chronic Noninflammatory Arthritis,How Many Joints Involved?,Chronic Inflammatory Mono/oligoarthritis Consider: Indolent infection Psoriatic Arthritis Reiters Syndrome Pauciarticular JA,Are DIP, CMC, Hip or Knee Involved?,Unlikely to be Osteoarthritis Consider: Osteonecrosis Charcot Arthritis,Osteoarthritis,Chronic Inflammatory Polyarthritis,Is it Symmetric?,Are PIP, MCP or MTP Joints Involved?,Consider: SLE Scleroderma Polymyositis,Consider: Psoriatic Arthritis Reiters Syndrome,Rheumatoid Arthritis,Yes,No,Yes,Yes,No,No,No,Yes,Yes,No,No,Yes,4,4+,Adapted from J. Cush, MD,Know It When You See It,Hard bony enlargements Heberdens nodes at the DIP joints Bouchards nodes at the PIP joints Often have “squared” first CMC joint due to osteophytes at that joint,Osteoarthritis,Know It When You See It,Soft synovial swelling Synovitis and volar subluxation at the MCP joints Synovitis of the wrists Synovitis of the PIP joints with early swan neck deformities,Rheumatoid arthritis,Rheumatoid Arthritis: Late Stages,Deformities Nodules Tendon Rupture,Know It When You See It,Jaccouds Deformity of SLE,Often associated with: Inflammatory eye disease Balanitis, oral ulceration, or keratoderma Enthesopathy Sacroiliitis,Know It When You See It,Seronegative asymmetric arthritis,Know It When You See It,Inflammation of the DIP joints Sausage fingers Joint involvement shows radial pattern Nail changes Psoriatic patches Arthritis may start before the skin,Psoriatic arthritis,Know It When You See It,May look like psoriasis or syphilis Can occur in patches or as sterile pustules,Keratoderma blennorrhagica in Reiters syndrome,Know It When You See It,“Butterfly”/Malar rash Involves cheeks, spares nasolabial fold,Systemic lupus erythematosus,Know It When You See It,Both have periungual erythema,Interarticular dermatitis of SLE,Dermatomyositis,Know It When You See It,Periungual changes Seen in lupus erythematosus, dermatomyositis, and scleroderma Thickening of capillary loops Dropout of capillary loops Hemorrhage in the nail fold may also be present,Know It When You See It,“Mantle” aka “Shawl” Sign of Dermatomyositis,Know It When You See It,Not usually associated with systemic disease,Linear scleroderma,Know It When You See It,Appears in a broad- based interrupted pattern in systemic vasculitis, including SLE May occur as a fine, connected, lacy pattern in normals,Livedo reticularis,Know It When You See It,Can be 1o or 2o Stress/cold can trigger Keep extremities and body warm,Raynauds phenomenon,Know It When You See It,Characteristic of dermal vasculitis,Palpable purpura,Relapsing polychondritis May also occur in Wegeners granulomatosis and syphilis,Know It When You See It,Saddle nose deformity,Know It When You See It,Relapsing polychondritis,Left: Ear changes with inflammation in the cartilage and swelling,Right: Loss of ear cartilage in late stages,Relapsing Polychondritis,Know It When You See It,Tophi appear rather late in gout Prick the tophus with a needle. Put the drop of material on a slide,Gout,Know It When You See It,Polarizer,Gout (Uric Acid),Pseudogout CPPD),Usually a few lesions Usually found on the extremities,Know It When You See It,Skin pustule with disseminated gonorrhea,Know It When You See It,Infection,Tap if joint/bursa infection suspected Do not tap through cellulitis,Know It When You See It,A true connective-tissue disease Left: Hypermobility of joints. Can touch thumb to volar surface of forearm Right: Hyperelasticity of skin Associated with vascular abnormalities,Ehlers-Danlos syndrome,Acropachy Right: Soft tissue swelling between joints Left: Periosteal new bone formation,Know It When You See It,Hyperthyroidism,Shoulder pad sign The worst case you are likely to see Patient also has macroglossia and purpura,Know It When You See It,Amyloidosis,Rheumatologic Assessments,LABS DO NOT MAKE A DIAGNOSIS; H&P DOES! How can labs lead you astray? ESR/CRP: Origins and associations Serologies (RF, ANA, CCP, APL, ANCA): when to do & in what OTHER diseases are they positive? Arthrocentesis for diagnosis,RHEUMATOSCREEN PLUS,CBC & differential Chem-20 Uric acid Urinalysis ESR C-reactive protein RPR CPK Aldolase ASO titer Immune complexes TFTs w/ TSH EBV titers,IgM- RF ANA ENA (SSA, SSB, RNP, Sm) dsDNA-Crithidia Scl-70, Jo-1 Histone Abs Ribosomal P Ab Coombs C3, C4 CH50 Cryoglobulins West Nile Ab,Lupus anticoag. Cardiolipin Ab c-ANCA anti-PR3, -MPO anti-GBM SPEP Lyme titer HIV Chlamydia Ab. Parvovirus B19 HBV, HCV, HAV HLA typing CCP Ab,CUSHY LABS INC. “YOUR INDECISION IS OUR BREAD AND BUTTER”,Presbyterian Hosp. CheapoScreen,ANA + RF,CBC & diff $35.00 Chem-20 $108.00 Urinalysis $30.00 ESR or CRP $25.30 Uric acid $40.00,$ 238.30,CUSHY LABS INC. “YOUR INDECISION IS OUR BREAD AND BUTTER”,Further Investigations,Many conditions are self-limiting Consider when: Systemic manifestations (fever, wt.loss, rash, etc) Trauma (do exam or imaging for Fracture, ligament tear) Neurologic manifestations Lack of response to observation & symptomatic Rx ( 6 weeks),Acute Phase Reactants,Erythrocyte Sedimentation Rate (nonspecific) C-Reactive Protein (CRP) Fibrinogen Serum Amyloid A (SAA) Ceruloplasmin Complement (C3, C4) Haptoglobin Ferritin Other indicators: leukocytosis, thrombocytosis, hypoalbuminemia, anemia of chronic disease,ESR : Introduced by Fahraeus 1918 Mechanisms: Rouleaux formation Characteristics of RBCs Shear forces and viscosity of plasma Bridging forces of macromolecules. High MW fibrinogen tends to lessen the negative charge between RBCs and promotes aggregation. Methods: Westergren method Low ESR: Polycythemia, Sickle cell, hemolytic anemia, hemeglobinopathy, spherocytosis, delay, hypofibrinogen, hyperviscosity (Waldenstroms) High ESR: Anemia, hypercholesterolemia, female, pregnancy, inflammation, malignancy,nephrotic syndrome,Erythrocyte Sedimentation Rate,Extreme Elevation of ESR,RME Fincher, Arch Int Med 146:1986,ESR & Age,M=Age/2 F=(Age+10)/2,ACP Recommendations for Diagnostic Use of Erythrocyte Sedimentation Rate,The ESR should not be used to screen asymptomatic persons for disease The ESR should be used selectively and interpreted with cautionExtreme elevation of the ESR seldom occurs in patients with no evidence of serious disease If there is no immediate explanation for an increased ESR, the physician should repeat the test in several months rather than search for occult disease The ESR is indicated for the diagnosis and monitoring of temporal arteritis and polymyalgia rheumatica In diagnosing and monitoring patients with rheumatoid arthritis, the ESR should be used prinicipally to resolve conflicting clinical evidence The ESR may be helpful in monitoring patients with treated Hodgkins disease,Case,28 yr. old WF presents with sudden onset of knee swelling and pain 7 days ago. Two days later, knee resolved but both wrists began to swell. On day 7, the wrists improved but all PIPs were swollen and tender. By day 10 She visits her PCP who examines her and orders “Rheumatoscreen Plus” and XRAYs. He sends her home on OTC ibuprofen, tylenol and Vicks Vapo-Rub. she complained of arthritis in PIPs, wrists, knees and ankles. + Tenosynovitis L wrist. AM stiffness was 4 hours.,Case,Day 14 she returns to PCP with low grade fever, pruritic rash on the trunk and extremities. Exam: symmetric polyarthritis in an RA-like distribution. Te