MUSCO 01 Introduction肌肉骨骼系統(tǒng)ppt課件

1、.,1,INTRODUCTION TO MUSCULOSKELETAL,DR TIMOTHY SONGCTCM,.,2,Definition: Rheumatologic (or Rheumatic) Disease: diseases characterized by pain and inflammation in joints and connective tissues, often referred to as “collagen-vascular diseases”.,.,3,Diversity of Rheumatologic Diseases: Common and Uncom

2、mon 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

3、 (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*,.,4,Introduction to Rheumatology: Historical Perspective,.

4、,5,The Painters Family Jacob Jordaens (1593-1678),.,6,Evidence of: Rheumatoid Arthritis,.,7,The Virgin with Canon van Der Paele, 1436 Jan van Eyck (1385-1440),.,8,Evidence of: Temporal (Giant Cell) Arteritis,.,9,Musculoskeletal Complaint,Initial Rheumatic History and Physical Exam to Determine: 1. I

5、s 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,.,10,Goals of Assessment,Identify “Red Flag” conditions Conditions with sufficient morbidity/mortality to warrant an exp

6、edited 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,.,11,RED FLAG CONDITIONS,FRACTURE INFECTION ORGAN INVOLVE

7、MENT,.,12,Articular vs. Periarticular,Finding ARTICULAR PERIARTICULAR PainDiffuse, deep point tenderness ROM PainActive+passive Active motion in all planesin few planes SwellingCommon Uncommon,.,13,Peri-/Non-articular Pain,Fibromyalgia Fracture Bursitis, Tendinitis, Enthesitis, Periostitis Carpal tu

8、nnel syndrome Polymyalgia rheumatica Sickle Cell Crisis Raynauds phenomenon Reflex sympathetic dystrophy Myxedema,.,14,Inflammatory vs Noninflammatory,.,15,Formulating a Differential Dx,.,16,Mono/Oligo vs Polyarticular,Less than 4 joints Osteoarthritis Fracture Osteonecrosis Gout or Pseudogout Septi

9、c 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,.,17,History: Clues to Diagnosis,Age Young: JRA, SLE, Reiters, GC arthritis Midd

10、le: 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,.,18,Rheumatic Rev

11、iew 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 S

12、kin: 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,.,19,Rheumatic Review of Systems,Fever/Constitutional: septic arthritis

13、, 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, antiphospholipi

14、d 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,.,20,Onset H&P DOES! How can labs lead you astray? ESR/CRP: Origins and ass

15、ociations Serologies (RF, ANA, CCP, APL, ANCA): when to do & in what OTHER diseases are they positive? Arthrocentesis for diagnosis,.,48,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-

16、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 IN

17、DECISION IS OUR BREAD AND BUTTER”,.,49,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”,.,50,Further Investigations,Many conditions are self-limiting Cons

18、ider 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),.,51,Acute Phase Reactants,Erythrocyte Sedimentation Rate (nonspecific) C-Reactive Protein (CRP

19、) Fibrinogen Serum Amyloid A (SAA) Ceruloplasmin Complement (C3, C4) Haptoglobin Ferritin Other indicators: leukocytosis, thrombocytosis, hypoalbuminemia, anemia of chronic disease,.,52,ESR : Introduced by Fahraeus 1918 Mechanisms: Rouleaux formation Characteristics of RBCs Shear forces and viscosit

20、y 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 (Walden

21、stroms) High ESR: Anemia, hypercholesterolemia, female, pregnancy, inflammation, malignancy,nephrotic syndrome,Erythrocyte Sedimentation Rate,.,53,Extreme Elevation of ESR,RME Fincher, Arch Int Med 146:1986,.,54,ESR & Age,M=Age/2 F=(Age+10)/2,.,55,ACP Recommendations for Diagnostic Use of Erythrocyt

22、e Sedimentation Rate,The ESR should not be used to screen asymptomatic persons for disease The ESR should be used selectively and interpreted with caution.Extreme elevation of the ESR seldom occurs in patients with no evidence of serious disease If there is no immediate explanation for an increased

23、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 prinicipall

24、y to resolve conflicting clinical evidence The ESR may be helpful in monitoring patients with treated Hodgkins disease,.,56,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

25、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 h

26、ours.,.,57,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. Tenosynovitis has resolved. Urticarial lesions over trunk and extensor surface of arms. (+)2 cm nontender, left axillary LN. No malar

27、rash, nodules, acne, or Raynauds phenomena. Investigations?,.,58,Case,WBC = 11.2 H/H = 13.7 / 38.9 MCV = 89 ESR = 123 mm/hr SMA-12 WNL, except albumin = 3.3, AST-67, ALT 77 ANA negative RF 57 IU/ml (nl 30 IU/ ml) C3 173, C4 28, ASO = 151 Todd units Uric Acid = 6.6, CCP Ab neg Normal SPEP, UPEP, TFTs, TSH, Ferritin Others?,.,59,Case,She returns after 1 wk for LN Bx results