MUSCO 01 Introduction肌肉骨骼系统ppt课件.ppt

INTRODUCTIONTOMUSCULOSKELETAL DRTIMOTHYSONGCTCM Definition Rheumatologic orRheumatic Disease diseasescharacterizedbypainandinflammationinjointsandconnectivetissues oftenreferredtoas collagen vasculardiseases DiversityofRheumatologicDiseases CommonandUncommonDiseasesInvolvingInflammatoryandImmuneResponses InflammatoryDiseases innateimmunity Osteoarthritis Gout PseudogoutImmunologically MediatedDiseases adaptiveimmunity RheumatoidArthritis SystemicLupusErythematosus Spondyloarthropathies AnkylosingspondylitisReactiveArthritis Reiter sSyndrome PsoriaticArthritisSpondylitisassociatedwithIBDSjogren sSyndromePolymositis DematomyositisLymeDiseaseRheumaticFeverBehcet sSyndromeSystemicSclerosis Scleroderma Wegener sGranulomatosisGiantCellArteritis IntroductiontoRheumatology HistoricalPerspective ThePainter sFamilyJacobJordaens 1593 1678 Evidenceof RheumatoidArthritis TheVirginwithCanonvanDerPaele 1436JanvanEyck 1385 1440 Evidenceof Temporal GiantCell Arteritis MusculoskeletalComplaint InitialRheumaticHistoryandPhysicalExamtoDetermine 1 Isitarticular2 Isitacuteorchronic 3 Isinflammationpresent 4 Howmany whichjointsareinvolved 5 ArethereREDFLAGS JointPain JointSwelling Diffuse SystemicSxs GoalsofAssessment Identify RedFlag conditionsConditionswithsufficientmorbidity mortalitytowarrantanexpediteddiagnosisMakeatimelydiagnosisCommonconditionsoccurcommonlyManySkMconditionsareself limitingSomeconditionsrequireserialevaluationovertimetomakeaDxProviderelief reassuranceandplanforevaluationandtreatment REDFLAGCONDITIONS FRACTUREINFECTIONORGANINVOLVEMENT Articularvs Periarticular FindingARTICULARPERIARTICULARPainDiffuse deep point tendernessROMPainActive passiveActivemotioninallplanesinfewplanesSwellingCommonUncommon Peri Non articularPain FibromyalgiaFractureBursitis Tendinitis Enthesitis PeriostitisCarpaltunnelsyndromePolymyalgiarheumaticaSickleCellCrisisRaynaud sphenomenonReflexsympatheticdystrophyMyxedema InflammatoryvsNoninflammatory FormulatingaDifferentialDx Mono OligovsPolyarticular Lessthan4jointsOsteoarthritisFractureOsteonecrosisGoutorPseudogoutSepticarthritisLymediseaseReactivearthrtisTuberculous FungalarthritisSarcoidosis 4ormorejointsOsteoarthritisRheumatoidarthritisPsoriaticarthritisViralarthritisSerumSicknessJuvenilearthritisSLE PSS MCTD History CluestoDiagnosis AgeYoung JRA SLE Reiter s GCarthritisMiddle Fibromyalgia tendinitis bursitis LBPRAElderly OA crystals PMR septic osteoporosisSexMales Gout AS Reiter ssyndromeFemales Fibrositis RA SLE osteoarthritisRaceWhite PMR GCAandWegener sBlack SLE sarcoidosisAsian RA SLE Takayasu sarteritis Behcet s RheumaticReviewofSystems Constitutional fever wtloss fatigueOcular blurredvision diplopia conjunctivitis dryeyesOral dentalcaries ulcers dysphagia drymouthGI hxulcers Abdpain changeinBM melena jaundicePulm SOB DOE hemoptysis wheezingCVS angina CP arrhythmia HTN RaynaudsSkin photosensitivity alopecia nails rashCNS HA Sz weakness paraesthesiasReproductive sexualdysfunction promiscuity genitallesions miscarriages impotenceSkM jointpain swelling stiffness ROM function nodules RheumaticReviewofSystems Fever Constitutional septicarthritis vasculitis Still sdiseaseOcular Reiters Behcets Sjogrens Cataracts steroids Oral Sjogrens Lupus GC myositis drugsGI Reactivearthritis IBD hepatitis Polyarteritis SclerodermaPulm SLE RAlung Churg Strauss Wegeners SclerodermaCVS Vasculitis PSS Raynauds antiphospholipidsyndromeSkin SLE psoriatic vasculitis KawasakisyndromeCNS lupuscarpaltunnel antiphospholipid vasculitisGYN GU antiphospholipid SLE Reiters Behcets CTXMusculoskeletal Gout RA OA fibromyalgia fracture Onset Chronology Acute Fracture septicarthritis gout rheumaticfever Reiter ssyndromeChronic OA RA SLE psoriaticarthritis fibromyalgiaIntermittent gout pseudogout Lyme palindromicrheumatism Behcet s FamilialMediterraneanFeverAdditive OA RA Reiter ssyndrome psoriaticMigratory Viralarthritis hepatitisB rheumaticfever GCarthritis SLE Location MusculoskeletalComplaint InitialRheumaticHistoryandPhysicalExamtoDetermine 1 Isitarticular2 Isitacuteorchronic 3 Isinflammationpresent 4 Howmany whichjointsareinvolved IsitArticular IsComplaint 6wksDuration NonarticularConditionTrauma FractureFibromyalgiaPolymyalgiaRheumaticaBursitisTendinitis Chronic Acute AcuteArthritisInfectiousArthritisGoutPseudogoutReiter sSyndromeInitialPresentationofChronicArthritis IsInflammationPresent 1 IsthereprolongedAMstiffness 2 Istheresofttissueswelling 3 Aretheresystemicsymptoms 4 IstheESRorCRPelevated ChronicInflammatoryArthritis ChronicNoninflammatoryArthritis HowManyJointsInvolved ChronicInflammatoryMono oligoarthritisConsider IndolentinfectionPsoriaticArthritisReiter sSyndromePauciarticularJA AreDIP CMC HiporKneeInvolved UnlikelytobeOsteoarthritisConsider OsteonecrosisCharcotArthritis Osteoarthritis ChronicInflammatoryPolyarthritis IsitSymmetric ArePIP MCPorMTPJointsInvolved Consider SLESclerodermaPolymyositis Consider PsoriaticArthritisReiter sSyndrome RheumatoidArthritis Yes No Yes Yes No No No Yes Yes No No Yes 4 4 AdaptedfromJ Cush MD KnowItWhenYouSeeIt HardbonyenlargementsHeberden snodesattheDIPjointsBouchard snodesatthePIPjointsOftenhave squared firstCMCjointduetoosteophytesatthatjoint Osteoarthritis KnowItWhenYouSeeIt SoftsynovialswellingSynovitisandvolarsubluxationattheMCPjointsSynovitisofthewristsSynovitisofthePIPjointswithearlyswanneckdeformities Rheumatoidarthritis RheumatoidArthritis LateStages DeformitiesNodulesTendonRupture KnowItWhenYouSeeIt Jaccoud sDeformityofSLE Oftenassociatedwith InflammatoryeyediseaseBalanitis oralulceration orkeratodermaEnthesopathySacroiliitis KnowItWhenYouSeeIt Seronegativeasymmetricarthritis KnowItWhenYouSeeIt InflammationoftheDIPjointsSausagefingersJointinvolvementshowsradialpatternNailchangesPsoriaticpatchesArthritismaystartbeforetheskin Psoriaticarthritis KnowItWhenYouSeeIt MaylooklikepsoriasisorsyphilisCanoccurinpatchesorassterilepustules KeratodermablennorrhagicainReiter ssyndrome KnowItWhenYouSeeIt Butterfly MalarrashInvolvescheeks sparesnasolabialfold Systemiclupuserythematosus KnowItWhenYouSeeIt Bothhaveperiungualerythema InterarticulardermatitisofSLE Dermatomyositis KnowItWhenYouSeeIt PeriungualchangesSeeninlupuserythematosus dermatomyositis andsclerodermaThickeningofcapillaryloopsDropoutofcapillaryloopsHemorrhageinthenailfoldmayalsobepresent KnowItWhenYouSeeIt Mantle aka Shawl SignofDermatomyositis KnowItWhenYouSeeIt Notusuallyassociatedwithsystemicdisease Linearscleroderma KnowItWhenYouSeeIt Appearsinabroad basedinterruptedpatterninsystemicvasculitis includingSLEMayoccurasafine connected lacypatterninnormals Livedoreticularis KnowItWhenYouSeeIt Canbe1oor2oStress coldcantriggerKeepextremitiesandbodywarm Raynaud sphenomenon KnowItWhenYouSeeIt Characteristicofdermalvasculitis Palpablepurpura RelapsingpolychondritisMayalsooccurinWegener sgranulomatosisandsyphilis KnowItWhenYouSeeIt Saddlenosedeformity KnowItWhenYouSeeIt Relapsingpolychondritis Left Earchangeswithinflammationinthecartilageandswelling Right Lossofearcartilageinlatestages RelapsingPolychondritis KnowItWhenYouSeeIt TophiappearratherlateingoutPrickthetophuswithaneedle Putthedropofmaterialonaslide Gout KnowItWhenYouSeeIt Polarizer Gout UricAcid PseudogoutCPPD UsuallyafewlesionsUsuallyfoundontheextremities KnowItWhenYouSeeIt Skinpustulewithdisseminatedgonorrhea KnowItWhenYouSeeIt Infection Tapifjoint bursainfectionsuspectedDonottapthroughcellulitis KnowItWhenYouSeeIt Atrueconnective tissuediseaseLeft Hypermobilityofjoints CantouchthumbtovolarsurfaceofforearmRight HyperelasticityofskinAssociatedwithvascularabnormalities Ehlers Danlossyndrome AcropachyRight SofttissueswellingbetweenjointsLeft Periostealnewboneformation KnowItWhenYouSeeIt Hyperthyroidism ShoulderpadsignTheworstcaseyouarelikelytoseePatientalsohasmacroglossiaandpurpura KnowItWhenYouSeeIt Amyloidosis RheumatologicAssessments LABSDONOTMAKEADIAGNOSIS H PDOES Howcanlabsleadyouastray ESR CRP OriginsandassociationsSerologies RF ANA CCP APL ANCA whentodo inwhatOTHERdiseasesaretheypositive Arthrocentesisfordiagnosis RHEUMATOSCREENPLUS CBC differentialChem 20UricacidUrinalysisESRC reactiveproteinRPRCPKAldolaseASOtiterImmunecomplexesTFT sw TSHEBVtiters IgM RFANAENA SSA SSB RNP Sm dsDNA CrithidiaScl 70 Jo 1HistoneAbsRibosomalPAbCoombsC3 C4CH50CryoglobulinsWestNileAb Lupusanticoag CardiolipinAbc ANCAanti PR3 MPOanti GBMSPEPLymetiterHIVChlamydiaAb ParvovirusB19HBV HCV HAVHLAtypingCCPAb CUSHYLABSINC YOURINDECISIONISOURBREADANDBUTTER PresbyterianHosp CheapoScreen ANA RF CBC diff 35 00Chem 20 108 00Urinalysis 30 00ESRorCRP 25 30Uricacid 40 00 238 30 CUSHYLABSINC YOURINDECISIONISOURBREADANDBUTTER FurtherInvestigations Manyconditionsareself limitingConsiderwhen Systemicmanifestations fever wt loss rash etc Trauma doexamorimagingforFracture ligamenttear NeurologicmanifestationsLackofresponsetoobservation symptomaticRx 6weeks AcutePhaseReactants ErythrocyteSedimentationRate nonspecific C ReactiveProtein CRP FibrinogenSerumAmyloidA SAA CeruloplasminComplement C3 C4 HaptoglobinFerritinOtherindicators leukocytosis thrombocytosis hypoalbuminemia anemiaofchronicdisease ESR IntroducedbyFahraeus1918Mechanisms RouleauxformationCharacteristicsofRBCsShearforcesandviscosityofplasmaBridgingforcesofmacromolecules HighMWfibrinogentendstolessenthenegativechargebetweenRBCsandpromotesaggregation Methods WestergrenmethodLowESR Polycythemia Sicklecell hemolyticanemia hemeglobinopathy spherocytosis delay hypofibrinogen hyperviscosity Waldenstroms HighESR Anemia hypercholesterolemia female pregnancy inflammation malignancy nephroticsyndrome ErythrocyteSedimentationRate ExtremeElevationofESR RMEFincher ArchIntMed146 1986 ESR Age M Age 2F Age 10 2 ACPRecommendationsforDiagnosticUseofErythrocyteSedimentationRate TheESRshouldnotbeusedtoscreenasymptomaticpersonsfordiseaseTheESRshouldbeusedselectivelyandinterpretedwithcaution ExtremeelevationoftheESRseldomoccursinpatientswithnoevidenceofseriousdiseaseIfthereisnoimmediateexplanationforanincreasedESR thephysicianshouldrepeatthetestinseveralmonthsratherthansearchforoccultdiseaseTheESRisindicatedforthediagnosisandmonitoringoftemporalarteritisandpolymyalgiarheumaticaIndiagnosingandmonitoringpatientswithrheumatoidarthritis theESRshouldbeusedprinicipallytoresolveconflictingclinicalevidenceTheESRmaybehelpfulinmonitoringpatientswithtreatedHodgkin sdisease Case 28yr oldWFpresentswithsuddenonsetofkneeswellingandpain7daysago Twodayslater kneeresolvedbutbothwristsbegantoswell Onday7 thewristsimprovedbutallPIPswereswollenandtender Byday10ShevisitsherPCPwhoexaminesherandorders RheumatoscreenPlus andXRAYs HesendsherhomeonOTCibuprofen tylenolandVicksVapo Rub shecomplainedofarthritisinPIPs wrists kneesandankles TenosynovitisLwrist AMstiffnesswas4hours Case Day14shereturnstoPCPwithlowgradefever pruriticrashonthetrunkandextremities