Ebook Harrison''s rheumatology (3rd edition): Part 2
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Ebook Harrison''s rheumatology (3rd edition): Part 2
SECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2uloskeletal complaints account for >315 million outpatient visits per year and nearly 20% of all outpa lienl visits in the United Stales, rhe Centers for Disease Control and Prevention estimate that 22% (46 million) of the U.S. population has physician diagnosed arthri lis and 19 million have signif Ebook Harrison''s rheumatology (3rd edition): Part 2icant functional limitation. While many patients will have self limited conditions requiring minimal evaluation and only symptomatic therapy and reassEbook Harrison''s rheumatology (3rd edition): Part 2
urance, specific musculoskeletal presentations or their persistence may herald a more serious condition that requires further evaluation or lab oratorSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2nosis and timely therapy, while avoiding excessive diagnostic testing and unnecessary treatment (Table 18-1). There are several urgent conditions that must be diagnosed promptly to avoid significant morbid or mortal sequelae. These “red flag” diagnoses include septic arthritis, acute crystal-induced Ebook Harrison''s rheumatology (3rd edition): Part 2 arthritis (c.g., gout), and fracture. Each may beTABLE 18-1EVALUATION OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTSGoalsAccurate diagnosisTimely provisEbook Harrison''s rheumatology (3rd edition): Part 2
ion of therapyAvoidance of unnecessary diagnostic testingApproachAnatomic localization of complaint (articular vs. nonarticular)Determination of the nSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2spread)Determination of chronology (acute vs. chronic) Consider the most common disorders first Formulation of a differential diagnosissuspected by its acute onset and monarticular or focal musculoskeletal pain (sec Liter in chapter).Individuals with musculoskeletal complaints should be evaluated wi Ebook Harrison''s rheumatology (3rd edition): Part 2th a thorough history, a comprehensive physical and musculoskeletal examination, and, if appropriate, laboratory testing. The initial encounter shouldEbook Harrison''s rheumatology (3rd edition): Part 2
determine whether the musculoskeletal complaint signals a red Hag condition (septic arthritis, gout, or fracture) or not. The evaluation should proceSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2tion, and (4) kưalixấì (monar-Ikular) or widespread (polyarliadar) in distribution.With such an approach and an understanding oi the pathophysiologic processes, rhe musculoskeletal com plaint or presentation can be characterized (e.g.. acute inflammatory monarlhrilis or a chronic noninflammatory, no Ebook Harrison''s rheumatology (3rd edition): Part 2narticular widespread pain) to narrow the diagnostic possibilities. A diagnosis can be made in the vast majority ol individuals. 1 lowever. some patieEbook Harrison''s rheumatology (3rd edition): Part 2
nts will not fit immediately into an established diagnos tic category. Many musculoskeletal disorders resemble each other at the outset, and some may SECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2agnosis at the first encounter.ARTICULAR VERSUS MONARTICULARThe musculoskeletal evaluation must discriminate the anatomic origin(s) of the patient’s complaint. For example. ankle pain can result from a variety of pathologic conditions involving disparate anatomic structures, including gonococcal art Ebook Harrison''s rheumatology (3rd edition): Part 2hritis, calcaneal fracture, Achilles tendinitis, plantar fasciitis, cellulitis, ami peripheral or entrapment neuropathy. Distinguishing between218httpEbook Harrison''s rheumatology (3rd edition): Part 2
s://khothuvien.coniarticular and nonarticular conditions requires a careful and detailed examination. Articular structures include the synovium, synovSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin, may be involved in the pathologic process. Although musculoskeletal complaints are often ascribed to the joints, nonarticular disorders more frequently underlie such complaints. Distinguishing betw Ebook Harrison''s rheumatology (3rd edition): Part 2een these potential sources of pain may be challenging to the unskilled examiner. Articular disorders may be characterized by deep or diffuse pain, paEbook Harrison''s rheumatology (3rd edition): Part 2
in or limited range of motion on active and passive movement, and swelling (caused by synovial proliferation, effusion, or bony' enlargement), crepitaSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2 motion. Pcriar ticular conditions often demonstrate point or focal ten derness in regions adjacent to articular structures, and have physical findings remote from the joint capsule. Moreover, nonarticular disorders seldom demonstrate swelling, crepi lus. instability, or deformity of the joint itsel Ebook Harrison''s rheumatology (3rd edition): Part 2f.INFLAMMATORY VERSUSNONINFLAMMATORY DISORDERSIn the course of a musculoskeletal evaluation, the examiner should determine the nature of the underlyinEbook Harrison''s rheumatology (3rd edition): Part 2
g pathologic process and whether inflammatory' or non inflammatory findings exist. Inflammatory disorders may be infectious (infection with Nriíícria SECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2us [SLh]). reactive (rheumatic fever, reactive arthritis), or idiopathic. Inflam matory disorders may be identified by any of the four cardinal signs of inflammation (erythema, warmth, pain, or swelling), systemic symptoms (fatigue, fever, rash, weight loss), or laboratory' evidence of inflamma lion Ebook Harrison''s rheumatology (3rd edition): Part 2 (elevated erythrocyte sedimentation rate [ESR] or c reactive protein |CRP|, thrombocytosis, anemia of chronic disease, or hypoalbuminemia). ArticularEbook Harrison''s rheumatology (3rd edition): Part 2
stiff ness commonly accompanies chronic musculoskeletal disorders and can extend beyond the joint. 1 lowever. the severity and duration of stiffness SECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2ged rest, is described as severe, lasts for hours, and may improve with activity or antiinflammatory medications. By contrast, intermittent stiffness (also known as gel phenomenon), associated with noninflammatory conditions (such as osteoarthritis(OA|), is precipitated by brief periods of rest, usu Ebook Harrison''s rheumatology (3rd edition): Part 2ally lasts less than 60 minutes, and IS exacerbated by activity. Fatigue may accompany inflammation (as seen in RA and polymyalgia rhcumatica), but maEbook Harrison''s rheumatology (3rd edition): Part 2
y also be a consequence of fibromyalgia (a noninflammatory disorder), anemia, cardiac failure, endocrinopathy, poor nutrition, chronic pain, poor sleeSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2ective repair (OA), neoplasm (pigmented villonodular synovitis), or pain amplification (fibromyalgia). Noninflammatory disorders are often characterized by pain without synovial swelling or warmth, absence of inflammatory or systemic features, daytime gel phenom ena rather than morning stiffness, an Ebook Harrison''s rheumatology (3rd edition): Part 2d normal (for age) or negative laboratory investigations.Identification of the nature of the underlying process and the site ol the complaint will enaEbook Harrison''s rheumatology (3rd edition): Part 2
ble the examiner to characterize the musculoskeletal presentation (c.g., acute inflammatory' monarthritis, chronic nonin flammatory. Monarticular wideSECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2tion. Figure 18-1 presents an algorithmic approach to the evaluation of patients with musculoskeletal complaints. This approach is remarkably' effective and relics on clinical and historic features, rather than laboratory testing, to diagnose many common rheumatic disorders.The algorithmic approach Ebook Harrison''s rheumatology (3rd edition): Part 2may' be unnecessary in patients with the most commonly encountered ailments; as these can also be considered based on fre quency and characteristic prEbook Harrison''s rheumatology (3rd edition): Part 2
esentations. The most prevalent causes of musculoskeletal complaints are shown in Fig. 18-2. As trauma, fracture, overuse syndromes, and fibromyalgia SECTION IIIDISORDERS OF THE JOINTS AND ADJACENT TISSUESCHAPTER 18APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERSJohn J. Cush ■Peter E. LipskyMuscu Ebook Harrison''s rheumatology (3rd edition): Part 2frequently occurring disorders should be considered according to the patient s age. 1 lence. those younger than 60 years are commonly affected by repetitive use/ strain disorders, gout (men only), R A, spondyloarthritis, and uncommonly, infectious arthritis. Patients over age 60 years are frequently Ebook Harrison''s rheumatology (3rd edition): Part 2 affected by OA, crystal (gout and pscudogouc) arthritis, polymyalgia rheumatica, osteoporotic fracture, and uncommonly, septic arthritis. These condiEbook Harrison''s rheumatology (3rd edition): Part 2
tions are between 10 and 100 times more prevalent than other serious autoimmune conditions, such as systemic lupus erythematosus, scleroderma, polymyoGọi ngay
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