ࡱ> `!=gTR f%H%n XU@xZOh#<#4YFҌd1J KY kl =u"Q13ZaT)z4=5ms{ dX0T@?_d-sf^'V>5IK3C_mt4nB$-!4g0AT>{e蚤%W~y >#i8><߱(9><ʳ(8>|O(%|Yf_aRieZxw c+rױz-u IU+Sal%{fLٶkYxj? ~I~Y8zUgW>K. wk29EkI %;|e__9͂dn_d&shX HM>jda| Kn:}Z!{q%db;O[,vr&+YMpsA^dHxm<jϷ Ȟs|U㟜l :'|VDdD+e5rU#~Io2 Y1GA ,xae l7P^x~ * ǩ5F^cˆpYP?;< ɜ,1FYh~uQGHA23\|XY BϡglwXDYo\,}gVEе^:ZU:*ƼŚj̢S|ƽDlۦq;^ pͬf+ ;3m؍yOh;!9G6j=_:ֻ?hxA#'=KDFܬ|h>of-Gfz 7kX\;x6ZhkRK%mRt4祱 59J|6ۀj):sӼWoZėZ*i w[u%rVyvj){<՞_Z^bOl\zUI^Ə8+iu ]88b?'(pDnԐvJ*k3<5{GybhG{L]ɸVo iH<͂f耬F "uI.̪uу+Zp`ٍ65ݔh+ܹv=mYD}w-z0R{ŧ)ȼD6;7Wt=t:C'CKE&1;n/UUYRY)A̚xXUzyy_-U{ӛ40#-F2ɹ~C ]-}}ZXU*Wlj++6k hk(R%mTp2gnj+K&9>75R%mO1F%}rmV㹶Ks'~'~ė5"i5T>!+FLT=ė5(i5T>^&yV^"okZD 2;ݗe`!6LɉQ!$-"n XUxF}xZoU޼88qi@E+#^VД4z6$hNT8r〸VJ Ŀ@#*!.@Y{,PG潙$tFiD_S}.}  O=%n:˾x ^yV3 m?No2Y2ؾq&gRSKЫl\'6_F':u;s%njfYԩ:xPx?{A}Ճd:Z@E9&Z*mQSBD!}?{ձ\/pTEm"<߱]Pns|xag<`7A|ћOX*pz.(ycI1Bf)1bizd$شUg (&ay7CQ~ͼ*}3XYq,_l`ٳ"[%3)P8^Tv/nTcP#o0 O+Ɔ cr[}z w6_>RB5>a%"e/zyidzVFLR'qVh"’Jzg\Q[3 ?,maJ$ "b{hW"l5ǥTYgX(G3kJ1"YmE{1o9*\Z {d힪N`]@(4aU]D(km=uI6yO+yVrE6&Sk-='i0{!{HFem͇#9 mϽʳ9 3σĜcVGV.U˸r:i]]35fg|rY]u `'F3fUL>4} fK>[:=7o۵ݬj[JX@UZr&Y=į]0}'hw 7ngY<"~yj@?Q޿%)i c{bc92~}FdǞ>}1{ib$2`n{Ox80;+;#+c(p S൐J|át6&V6! >S]/kD(Bk Q6!+FTWʶDgmMx=נ@>J|YBKd3;hiћlerYo2d?#l(6( ) d 70&Document Word.Document.80.Microsoft Word Document0/'Document Word.Document.80.Microsoft Word Document/ 00DTimes New RomanȷȷԳ0 0DGaramond RomanȷȷԳ0 0 DWingdingsRomanȷȷԳ0 00DArialngsRomanȷȷԳ0 0" "   @n?" dd@  @@`` 6#     (>  "!(#>>?2$=gTR f%$2$6LɉQ!$- 0AA@8+,}g42d2d 0 ppp@ <4!d!d\{ȷ f___PPT9Hz40___PPT10 pp? %.Monoarticular Arthritis  ,Management in A&E Dr Lillian Yeh SHO A&E LGI0     Monoarticular arthiritis$  ]Pain Inflammation Isolated joint Any joint disorder can present initially as monoarthritis^Z^P Monoarticular Arthritis  tIdentify an acutely inflammed or infected joint. Septic arthritis Crystal-induced arthropathies (gout, pseudogout) 2Cu> 6  Septic arthiritis Bacterial, tuberculous or fungal Potential for rapid disease progression Classified: Neisseira gonorrhoeae All other organisms0n*W+> A  ,!Desseminated gonococcal arthritis$   gYoung Sexually active Healthy adults Women, esp. pregnant or menstruating, affected more often than menNon gonococcal arthritis  Staph Aureus more common Streptococci spp. E.coli & P.aeruginosa in elderly and IV drug users Haemophilus influenzae in young children Opportunistic organisms in +HIV patientsR   <~   < Nongonococcal Arthritis  Pathogenesis: Hematogenous  impaired host defense mechanisms, indwelling venous catheter, chronic arthritis patients, iv drug users. Direct introduction of organisms: bites, joint injection/aspiration, arthorscopy, prosthetic joint surgery. 0ZZZ>   GoutSodium urate crystals Joints of foot or hand Men affected more than women Hx of food overindulgence, heavy etOH intake, diuretics. Obesity Uric acid nephrolithiasisP?(   Pseudogout Resembles acute gouty monoarthritis Pathogenesis: crystals of calcium pyrophosphate dihydrate develop in cartilages and other connective tissue , 1 4  Other conditionsdPatients who don t appear ill: Rheumatoid arthritis Seronegative spondyloarthopathies Patients with signs of systemic illness: Enteropathic arthritis Systemic autoimmune disease47*3>4 + ' Clinical features - General~Symptoms: Short course of increasing pain Redness Swelling Immobility of a single joint Fever sometimes Other symptoms & signs u Clinical features - GeneralpExamination findings: Swelling Warmth Redness Effusion Pay special attention to temperature, skin & other joints[qHClinical features  Septic arthritisDisseminated gonococcal infection: 25% - 50% single, hot, swollen joint Polyarthralgia or polyarthritis Fever, dematitis & tenosynovitis are the most common findings on initial examination Small papules on the trunk or extremities#b 1   _hClinical features  Nongonococal bacterial arthritis }Febrile 80% - 90% present with monoarthritis Knee in adults Hip in children Shoulder, wrist, interphalangeal and elbow joints, 1Clinical features - Gout~Sudden onset, often at night Within hours  visibly inflammed - exquisitely tender Swelling  related to synovial effusion & periarticular edema Pyrexia up to 39.4 >>/QP4 F   Clinical features - GoutTypically joints of the foot First MTP joint (podagra) Involvement of tendon sheaths & bursae, especially over the olecrenon or patella Tophi Lasts afew days to afew weeks even without Rx Other joints of the body may become involved in chronically untreated hyperuricaemic patients."   ] Clinical features - Pseudogout Attack reach full intensity within 12-36 hrs Lasts up to 10 days but may persist for months or occur in clusters. Findings consistent with acute synovitis and fever Knee joint Differential diagnosis`Always exclude septic arthritis Periarticular problem e.g. bursitis, tendinitis, soft tissue infection, bone disease Bone pain from Paget s disease, malignancy or osteomyelitisP  5 Differential diagnosis Non inflammatory Structural joint problems  trauma, overuse, loose body, neuropathic joint etc Hemarthrosis  anticoagulants, bleeding disorder Osteoarthritis Congential disorders  slipped femoral epiphysis, congental dysplasia of the hip, " bK  4 (    When a single joint is persistently inflamed (>4 weeks), need to consider infection with a slow growing organisms such as Mycobacterium tuberculosis, atypical mycobacteria or fungi, esp in immunocompromised patients.&zE>   Work-upBloods FBC, CRP, PV, glucose, Uric acid, calcium Gout patients may not have hyperuricaemia Most pseudogout patients do not have hypercalcaemia Blood culture Gonococcal arthritis need STD swabs: 80% +ve,.bL   Work-upX-rays usually are obtained to rule out fracture and bone disease and to assess for findings consistent with specific forms of arthritisWork-up$Joint aspiration WBC count, glucose and protein levels, viscosity, crystals, gram stain and culture In disseminated gonococcal arthritis, N. gonorrhoeae is cultured in less than 50% of purulent joints In nongonococcal bacterial arthritis, causative organism is cultured approx 90% of the time6>t  4 LSynovial fluid characteristics(Work-upAspirate of gouty joint: Needle like crystals. Negatively birefringent. Aspirate of pseudogout joint: Rhomboid shaped crystals. Weakly positive birefringent.409>;  3 8Treatment  Septic arthritisAntibiotics iv. Drainage  closed needle joint aspiration - Open drainage for hips Immobilisation & physio as soon as pain improves Prosthetic joints need to be removed. 4:/WzA$Empiric Therapy for septic arthritis%%$:Treatment  gout & pseudogout Crutches to help mobilisation Oral NSAIDS +/- codeine phosphate preps But NO aspirin Colchicine for gout  frequently causes D&V Prednisolone  60mg initially and tapered over 7 days Allopurinol to treat hyperuricaemia after remission of acute attackVFFPU " *  !(%*  Thank you!  ` 3` ff>>\fg` J*T333` QYmx~3ft` \ғhEy`` cb^DDf`Y˵W` sg7xGr` K%ޯd{mG/` 33f>?" dd@,?nFd@    @ `  n?" dd@   @@``PR    @ ` `<p>> q(    6{ b ` { I* "  #" `  6{ ` ` { K*""  #" `xT ~  ~"\ {  {"  c BB CDEFd @ bb   H   T W6Vw}\gFQ6<1++11 1L b6xQrq 6\}N   - c    0 A Q g     S    6N KawF bFy0 a*ly7lE;uz  B | a F 0 ! 1 < B < & l L 0  @`T "  c |BC+DEFyd @ ==gL6cI}\eA& w6m!W<! &<W!r6W}F6\}>68QNlX^XH8+Sgg|@`Jo 5 "J   B! 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