Management of monoarticular joint swelling

Management of monoarticular joint swelling

MANGAGENT OF MONOARTICULAR SWELLING:
1.FIRST STEP XRAY
2.BEST STEP ARTHEROCENTESIS
3.NEXT STEP LOOK AT SYNOVIAL FLUID--# OF WHITE CELLS
4. white cells 25-50K=OSTEOARTHERITIS
wHITE cELLS 50-75k=GOUT/PSEUDOGOUT
White Cells More then 75k=Septic Joint
5. SEPTIC JOINT----ADMIT+ Empiric Abx coverage with IV CEFTRIAXONE+IV VANCOMYCIN for MRSA
positive
6. GOUT/PSEUDIGOUT---Outpatient if vitals stabe---Treat wtih INDOMETHACIN 50MG Q8hrs PRN.
PROPHYLAXIS---URINE URIC ACID>900 GIVE ALLOPURINOL
---urine uric acid<700 GIVE PROBENECID
ALWAYS GIVE COLCHICINE.6 BID Prior to prophylaxis.
ALWAYS START PROPHYLAXIS 2 WEEKS AFTER ACUTE EPISODE.
7. OSTEOARTHRITIS: Diagnostic clue= WEIGHT BEARING JOINT, OVERUSE,OBESITY,
XRAY---OSTEOPHYTES,MANAGEMENT---NSAIDS AND BED REST 1-3 DAYS.NOT MORE THEN 3
DAYS---this fact is based on a study that USMLE 3 wants us to know. Therefore remember 1-3 days max bed rest!

**A 24-year-old woman presents to the emergency department with a severe, throbbing headache of the right supraorbital area for the past hour. She also complains of nausea and photophobia. She has had similar attacks in the past, often brought on by menstruation. About 45 min ago she took 400 mg of ibuprofen. Which of the following would be the best therapeutic choice at this time?

A: Meperidine, 50 mg intramuscularly
B: Codeine, 60 mg orally
C: Naproxen, 750 mg orally
D: Sumatriptan, 6 mg subcutaneously
E: Verapamil, 300 mg orally

The answer is D
While the pathophysiology of migraine remains unclear, electrical stimulation of midline dorsal raphe in the brainstem leads to characteristic pain. Pharmacologically, serotonin-mediated neurotransmission appears to be critical in the generation of migrainous pain. Sumatriptan and dihydroergotamine both work by blocking 5-hydroxytryptamine receptors (type I, especially the D subtype). While nonsteroidal anti-inflammatory agents such as ibuprofen and naproxen are helpful in patients with mild to moderate migraine, presumably by reducing inflammatory stimuli from cyclooxygenase inhibition leading to reduced prostaglandin generation, the patient in the question has too severe an attack to benefit from the additional use of this class of agents. Also, the use of narcotic analgesics as a primary therapy is no longer recommended; sumatriptan will relieve a migraine headache in approximately 75 percent of patients within 1 h of treatment. Unfortunately, because of its short half-life (with either oral or subcutaneous administration), headache recurs in up to one-third of patients. Sumatriptan-associated side effects are usually mild to moderate and highly reversible; they include reactions at the injection site, flushing sensations, and neck pain or stiffness. Although up to 5 percent of patients treated with sumatriptan experience chest tightness or pressure, myocardial ischemia is exceedingly rare. Nonetheless, this drug should not be given to those with a history of myocardial infarction, ischemic heart disease, or Prinzmetal's angina. Both beta-adrenergic antagonists and calcium channel blocking drugs are effective prophylactic agents.

**A couple in their 50s comes to your office for a consultation. The man says his back has been hurting lately. When you examine him, you find only a mild case of muscle strain. His wife insists that it must be more serious than that because it has prevented them from having sex over the last 2 months. Upon further questioning, you discover that 2 months earlier the man was impotent for the first time in his life after they had gone to a wedding party and consumed large amounts of food and more than their usual share of alcohol. His wife says that he appeared 'quite frisky' at the party, but he could not achieve an erection later than night. Since then, he has avoided sex, citing his bad back as the cause. His wife is concerned about his back; she also states that there were many young and attractive women at the party that night, and she wonders if he no longer finds her attractive.

Which one of the following factors was the most likely cause of the man's initial impotence?

a. Aging
b. Back pain
c. Fear of failure
d. Alcohol
e. Overeating

D

Excessive consumption of food can suppress libido, but alcohol may cause even greater dulling of sexual responsiveness and an inability to achieve or maintain an erection. Secondary impotence developing in a man in his late 40s or early 50s is associated more often with excessive alcohol consumption than with any other single factor.
The fear of failure, both alcohol-associated and as part of one's expectations about aging, is the most critical factor in older men's withdrawal from sexual activity. Once impotent under any circumstance, men often avoid sex rather than face the ego-shattering experience of repeated inadequacy. Both women and men will benefit from insight into the real reasons for the man's withdrawal, and women should understand that it is not the personal rejection that it may appear to be. Avoiding alcohol may prevent further episodes of impotence, but it will not help reverse the sexual withdrawal that occurs secondarily. Treating the back pain with anything other than a mild analgesic obviously misses the point of the couple's office visit. Finally, encouraging further attempts at coitus may only aggravate the problem. Rather, it is important to explain to the couple that sexual activity need not be equated with coitus, and that their emotional needs can be met with caresses and embraces. This will help to allay the man's performance anxiety and allow a return to potency.

**A 35-year-old white female with a history of headaches complains of joint pains. A review of systems reveals that she also has intolerance to multiple different foods, stomach bloating, rectal pain with defecation, dysmenorrhea, chronic irregular periods, and difficulty swallowing. She denies depressive symptoms or drug abuse. She regularly takes several vitamins and acetaminophen. Her physical examination, WBC count, hemoglobin level, and kidney and liver function tests are normal.

The most likely diagnosis is

a. depression with melancholia
b. somatization disorder
c. ulcerative colitis
d. Lyme disease
e. systemic lupus erythematosus

B

The patient described in this case has four pain symptoms, two gastrointestinal symptoms, one sexual/reproductive symptom, and one pseudoneurologic symptom, all with no apparent cause, and thus meets the diagnosis of somatization disorder.

**A 16-year-old white female comes to your office complaining of sleep disturbances, recurrent nightmares, and early-morning awakenings, after which she is unable to return to sleep. Consequently, she feels tired and weak with lack of energy during the day. Her appetite is poor, and she has lost about 10 lb over the past 2 months. She is concerned about having intermittent abdominal cramps and headaches, and thinks there is something wrong; she appears anxious and sad. Physical examination reveals no abnormalities.

At this point, you should

a. assess the potential risk of suicide
b. prescribe diazepam (Valium)
c. reassure the patient that her physical examination is normal and ask her to return if weight loss continues
d. order an upper gastrointestinal roentgenographic series

A

Depression is almost always accompanied by a number of physical complaints. Sleep disturbances, particularly early morning awakenings, and weight loss of 10 lb or more usually indicate a serious depression. It is most important to assess the potential risk of suicide, a significant associated danger. Diazepam could potentially worsen the depression. Instead of reassurances, exploration of feelings and aggravating factors, as well as close follow-up is indicated. Although an upper gastrointestinal roentgenographic series may be a necessary component of further evaluation, it is a less significant consideration at this point.

**Recurrent spontaneous attacks of anxiety accompanied by somatic symptoms best describes which psychiatric illness?
a. Somatization disorder
b. Post-traumatic stress disorder
c. Panic disorder
d. Generalized anxiety disorder

C

Although anxiety is a prominent symptom in many psychiatric illnesses, recurring spontaneous attacks of anxiety are a hallmark of panic disorder. There is an overlap of symptoms between generalized anxiety disorder and panic disorder, but in generalized anxiety disorder symptoms of anxiety are continually present, rather than occurring in discrete attacks. In post-traumatic stress disorder, the patient experiences highly disturbing memories of a specific emotionally traumatic event. Patients with somatization disorder experience multiple somatic complaints that are often accompanied by anxiety symptoms, but the somatic complaints themselves, rather than the anxiety surrounding them, are the reason for the visit to the physician.

**A 35-year-old white female schoolteacher presents with anxiety, fatigue, and insomnia. The symptoms began after a heart murmur was discovered during an employment physical. An echocardiogram revealed mild mitral valve prolapse. A student recently died suddenly on a school field trip because of undiagnosed idiopathic hypertrophic cardiomyopathy. Now the patient is afraid she will die in a similar manner; she is anxious, sleepless, and fearful of physical activity.

The most appropriate action for the physician to take is to

a. prescribe a benzodiazepine in conjunction with a referral to the mental health clinic for group psychotherapy
b. order a stress test and write an exercise prescription
c. reassure her regarding the benign course of her condition and give her the American Heart Association booklet entitled Mitral Valve Prolapse
d. refer her to a cardiologist for a reassuring second opinion

C

Much of the psychological distress caused by the diagnosis of mitral valve prolapse is related to the lack of information and the fear of heart disease, which is often reinforced by the death of a friend or relative. A clear explanation of mitral valve prolapse, along with printed material, is a powerful aid in relieving the patient's emotional distress. It is important to avoid reinforcing illness behavior with unnecessary testing, prescribing, or referrals to specialists.