653MGA PANGUTANA:

What is the unrecalled intra-articular It was Methylprednisolone, a corticosteroid used to ease the
ing given to the px? pain of the patient by reducing the swelling and redness on
the involved area.

Why Ensure Gold was prescribed to Ensure Gold is a low-fat milk with a good source of Ca, Vitamin
your px D and Protein to prevent the progression of osteoarthritis,
since the intraarticular injection of methylprednisolone may
increase the risk of osteoporosis among patients.

Does the history of OCP use influence Yes, according to Zhang et al. The KORA F4 Study, suggest that
your SUA levels? early menarche, postmenopausal and Hx of OCP use can
independently influence the level of SUA of the patient

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302793/

Common Dance Injuries

The most common dance injuries occur due to overuse of

joints and muscles or overuse injuries that mostly involve
ankle, leg, foot, or lower back.
Some common dance injuries:
1. Knee injuries: patellofemoral pain syndromes
2. Hips: snapping hip
3. Shin splints: pain and tenderness felt along the shin
What are the phases of acute gout
What are the risk factors for septic
arthritis and what was present in
your patient?
normal findings in synovial fluid
The risk factors for septic arthritis in adults include older age,
diabetes mellitus, rheumatoid arthritis, recent joint surgery,
joint prosthesis, previous intra-articular injection, skin
infections, and cutaneous ulcers. Based on the history of our
patient, she had a previous intra-articular injection 3 weeks
prior that could have put her at risk of developing septic
arthritis.
https://www.ncbi.nlm.nih.gov/books/NBK538176/
● Fluid volume: Joints and bursae normally contain very
small amounts of synovial fluid—sometimes less than
1 mL,1 depending on the size of the joint. Viscosity:
Normal synovial fluid is viscous and often compared
to egg whites. Inflammation may cause synovial fluid
to be less viscous.
● Color and clarity: Normal synovial fluid is clear and
colorless or straw-colored.
● A white blood cell count: normal is less than 200
cells/uL
● Red blood cell counts may be high after a traumatic
injury and slightly elevated in patients with
osteoarthritis. They may also be present if the patient
has a bleeding disorder, such as hemophilia.
● Glucose levels that are lower than normal may
indicate infection.
● Lactate dehydrogenase (LDH), an enzyme normally
found in synovial fluid, might be at elevated levels in
people who have rheumatoid arthritis, infectious
arthritis, or gout.

how does septic arthritis cause
osteomyelitis
non pharmacologic management/
patient education for patients with
gout
● Protein levels that are higher than normal may
indicate an infection.
https://www.arthritis-health.com/treatment/joint-aspiration/
diagnosis-through-synovial-fluid-analysis#:~:text=Normal%20s
ynovial%20fluid%20is%20clear,indicate%20the%20presence%
20of%20blood.
Infection in the joint (septic arthritis) triggers inflammatory
cytokines and cells. This causes inflammation in the affected
joint thus called arthritis. Several common cytokines have
osteolytic properties, and phagocytes produce toxic oxygen
radicals and proteolytic enzymes that can harm host cells. The
inflammatory response leads to an increase in intraosseous
pressure, which impairs blood flow and leads to ischemic
necrosis. This dead bone, known as a sequestrum, can act as a
non-living surface for biofilm attachment, allowing bacteria to
adopt a lower metabolic rate and to survive in an
environment with lower oxygen tension.. Poor blood flow as
well as biofilm make it difficult for antimicrobial agents and
host immune cells to access the bacteria.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696389/
Avoid purine rich food such as
- In addition to animal-based foods such as meat and
seafood, other sources of purines that can increase
uric acid levels include alcohol and foods high in
fructose, which is a type of simple sugar present in
fruit and honey.
- Red meat, organi meat, seafood, alcoholic drinks
When people eat foods high in fructose, it can lead to a
depletion of adenosine triphosphate. This, in turn, can lead to
the overproduction of uric acid.
- Soda drinks, juices
Diets that include the following foods may contribute to lower
 uric acid levels:

● dairy products, such as milk, yogurt, and cottage

cheese
● plant oils, such as olive oil, avocado oil, coconut oil,
and canola oil
● pulses, including beans, peas, and lentils
● vegetables, including mushrooms, asparagus, spinach,
tomatoes, and broccoli
● fruits, especially those with high fiber and low sugar
content, such as cherries, citrus fruits, and berries
● whole grains, including quinoa, barley, buckwheat,
oats, and brown rice
● nuts, such as almonds, cashews, pistachios, walnuts,
and macadamia nuts
● soy products, including tofu, tempeh, and edamame
● lean proteins, such as chicken, turkey, and eggs
● water
● coffee

https://www.medicalnewstoday.com/articles/315732#Meal-pl
ans

Arthrocentesis & Arthrotomy Arthrocentesis - a procedure performed to collect synovial

fluid from the joint spaces for the identification of a disease
process or the relief of painful symptoms. It is used in multiple
disease processes including arthritis, gout, and infectious
processes such as septic arthritis. This procedure is safe
overall with very few complications if performed correctly ,
and only a small number of contraindications exist.
https://www.ncbi.nlm.nih.gov/books/NBK557805/

Arthrotomy - a surgical exploration of a joint, which should

include inspection of the cartilage, intra-articular structures,
joint capsule, and ligaments.

Other joint that can be involved in knee, hip, shoulder, elbow, wrist, and finger
Septic Arthritis

Delayed treatment could lead to chronic osteomyelitis or

permanent joint damage from septic arthritis.

https://www.verywellhealth.com/osteomyelitis-versus-septic-
arthritis-5114424#:~:text=Delayed%20treatment%2C%20on%
20the%20other,joint%20damage%20from%20septic%20arthri

Gold standard for diagnosis
Surgical treatment of Septic Arthritis
Was septic arthritis secondary to
acute arthritis/acute gout?
Did you consider Pseudogout?
Gout vs Pseudogout
tis.
synovial fluid evaluation
Needle aspiration of purulent exudate is the primary method
of drainage. Daily joint aspirations are usually required until
the joint cultures are negative. The knee joint is probably the
joint that is most amenable to repeated aspirations. Most
cases of uncomplicated septic arthritis of the knee can be
treated satisfactorily by means of repeated closed needle
aspirations.
A surgical approach to drainage should be considered in the
following situations:
● If signs of local sepsis do not abate and synovial
fluid analysis does not return to normal within 2
days after treatment
● If the purulent fluid becomes too thick to
aspirate
● If septic arthritis occurs in the setting of
rheumatoid arthritis or another underlying joint
disease
https://emedicine.medscape.com/article/1268369-overview#
a1
no. Acute arthritis or acute gout does not usually lead or
cause septic arthritis. Septic arthritis is usually caused by
infection from trauma, or in relation with the case, it was
caused by the intra articular injection.
Pseudogout was not considered due to the absence of calcium
crystals and the characteristic of the attack of pseudogout.
Pseudogout attacks are also sudden. However, the pain
usually stays the same and can last for days or weeks.
Meanwhile, a gout attack causes sudden, sharp pain that get
worse for up to 12 hours. The symptoms then reduce for
several days. The pain goes away after a week to 10 days. This
characteristic is present in our patient.
https://www.healthline.com/health/pseudogout-vs-gout#sym
ptoms
The best way to differentiate gout from pseudogout is through
joint fluid analysis.
Gout crystals are shaped like a needle and are negatively
birefringent. Pseudogout crystals are rhomboid shaped and
positively birefringent.
 https://www.assh.org/handcare/blog/what-is-the-difference-
between-gout-and-pseudogout#:~:text=Gout%20crystals%20a
re%20shaped%20like,of%20the%20hand%20and%20wrist.

The calcium pyrophosphate crystals that cause pseudogout

can calcify cartilage. The resulting calcifications, called
chondrocalcinosis, show up on x-rays. X-rays can also show
overall joint damage.
https://www.arthritis-health.com/types/pseudogout-cppd/ps
eudogout-diagnosis

An x-ray of the joint may show the deposition of uric acid

crystals. However, x-rays can be normal even when gout is
present. Experts estimate that chronic gout must be present
for 5 to 10 years before joint changes can be seen on an x-ray.
Most gout cases are diagnosed with a joint fluid analysis. An
accurate diagnosis is important to long-term treatment and
health.

https://www.arthritis-health.com/types/gout/gout-diagnosis

Did you consider Reactive Arthritis? No, due to the absence of prior extraarticular infection.

Reactive arthritis occurs in reaction to an infection by certain

bacteria. Most often, these bacteria are in the genitals
(Chlamydia trachomatis) or the bowel (Campylobacter,
Salmonella, Shigella and Yersinia). Chlamydia most often
transmits by sex.

● Pain and swelling of certain joints, often the knees

and/or ankles
● Swelling and pain at the heels
● Extensive swelling of the toes or fingers
● Persistent low back pain, which tends to be worse
at night or in the morning

Reactive arthritis tends to occur most often in men between

ages 20 and 50. Some patients with reactive arthritis carry a
gene called HLA-B27.

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Dis
eases-Conditions/Reactive-Arthritis
Is gout inherited?
Was the patient hyperuricemic? (it
was not mentioned in the protocol)
Why did you not consider OA? RA?
Difference between OA and RA
What is a tophi
How does hypertension relate to
arthritis
Yes, because serum urate levels and the risk of gout are
influenced by a combination of inherited genetic variants and
the environment. Studies estimate that the heritability of
urate is between 45% to 73%.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452604/#:~
:text=Serum%20urate%20levels%20and%20the,genetic%20va
riants%20and%20the%20environment.
It was not explicitly mentioned in the protocol however after
serum UA test was performed, the physician induced an
intra-articular medication, which could mean that the px may
have an increased UA which caused the patient’s right knee
pain.
OA and RA
- Both of them were not considered due to the absence
of morning stiffness
- For RA, aside from the absence of morning stiffness, it
usually affects joints symmetrically, younger
generation, and usually affects the small joints in
hands and feet
- For OA, it does not usually present
inflammation,which is present in the patient
Tophi are chalky deposits of monosodium urate crystals, in
people with longstanding high levels of uric acid in the
blood, a condition known as hyperuricemia. Tophi are
pathognomonic for the disease gout.
Studies have shown that the presence of hypertension is
independently associated with the risk of incident gout2
through reduced renal blood flow with increased renal and
systemic vascular resistance and decreased renal excretion of
urate.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257215/#:~
:text=Studies%20have%20shown%20that%20the,decreased%
20renal%20excretion%20of%20urate.
High blood pressure is another major risk factor for gout. It
gets complicated, though, because the diuretics taken to

How does dehydration affect arthritis
What triggered the patient’s fever
Gold standard test for osteomyelitis
Gold standard test for septic arthritis
Hypertension and hyperuricemia
lower high blood pressure increase uric acid levels, so the
treatment as well as the disease is associated with gout.
https://www.health.harvard.edu/newsletter_article/all-about-
gout
Hypertension predisposes to gout by reducing renal urate
excretion due to glomerular arteriolar damage and
glomerulosclerosis.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034249/
“The synovial fluid and the cartilage tissue cells need water
to help reduce friction and maintain motion between the
joints,”
The patient’s fever was triggered by the bacterial infection in
the patients joint.
The gold standard for the diagnosis of osteomyelitis is bone
biopsy with histopathologic examination and tissue culture.
When the patient is clinically stable, one should consider
delaying empiric antimicrobial treatment until bone biopsy is
performed.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696389/
Synovial fluid analysis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404712/#:~
:text=Synovial%20fluid%20is%20the%20gold,the%20diagnosis
%20of%20septic%20arthritis.

How are gout and nephrolithiasis
related?
They are cousins. Chareng
People with gout could be at a higher risk of developing uric
acid kidney stones because they have a higher level of uric
acid being excreted by the kidneys, and they have more acidic
urine, which makes the uric acid more likely to form stones,
https://creakyjoints.org/about-arthritis/gout/gout-symptoms/
gout-and-kidney-stones/