G1P1 MOTHER

67 Y/O, MARRIED, FILIPINO

PATIENT LOM, MALE

 ROMAN CATHOLIC

67 Y/O, MARRIED, FILIPINO

PATIENT LOM, MALE

 JULY 8, 1953, QUEZON CITY

ROMAN CATHOLIC

67 Y/O, MARRIED, FILIPINO

PATIENT LOM, MALE

“
PAIN AT THE LEFT KNEE FOR 8
YEARS
“
 8 years prior to consult 2 months prior to consult Hours prior to admission

Pain is reduced to 2/10.

He also have similar
Patients develop pain on complaint at his right knee,
the left knee which is but it is milder compared to
insidious in onset. the left knee.
Pain increases to the
The pain is pricking in score of 7/10. no morning stiffness, no
nature with pain score of history of trauma or fall, no
Associated with limited fever, no knee swelling, and
3/10, no radiation, which range movement of the locking.
aggravated by walking
knee He was currently admitted
and climbing stairs, and
relieved by rest for left TKR surgery.
Upon admission, x-ray of the
left knee was taken,
analgesic was given.
General Survey: (-) weight loss, (-) fever, (-) malaise
Skin: (-) excessive sweating, (-) jaundice, (-) cyanosis
Eyes: (-) pain, (-) blurring of vision, (-) excessive lacrimation, (-) photophobia
Ears: (-) pain, (-) deafness, (-) tinnitus, (-) discharge
Nose: (-) change in smell, (-) epistaxis, (-) nasal obstruction, (-) pain around
paranasal sinuses
Mouth and Throat: (-) Gum bleeding, (-) disturbances in taste, (-) sore throat, (-)
hoarseness, (-) dysphagia
Neck: (-) limitation of movement, (-) pain
Respiratory System: (-) hemoptysis, (-) shortness of breath, (-) orthopnea
Gastrointestinal System: (-) constipation, (-) melena, (-) diarrhea, (-) vomiting
Extremities: (-) swelling of joints, (-) limitation of movement, (+) Left knee
joint pain
Neurologic: (-) paralysis, (-) speech disorder, (-) sensory deficit
Hematologic: (-) bleeding tendencies, (-) pallor, (-) easy bruising
Endocrine System: (-) heat intolerance, (-) polyphagia, (-) polyuria, (-)
polydipsia
PAST MEDICAL HISTORY
• Hypertension for 8 years
• T. Amlodipine 10mg OD
• No Diabetes Mellitus, Ischemic Heart
disease, Tuberculosis, Bronchial asthma
FAMILY HISTORY
• His Father has Hypertension
• No family history of arthritis,
malignancy, diabetes mellitus,
ischemic heart disease
PAST SURGICAL HISTORY
• No significant past surgical
history
PERSONAL AND SOCIAL HISTORY
• Sleep is not disturbed
• No loss of appetite and loss of weight
• Normal bowel and bladder habit
• Non smoker, non alcoholic
• No known drug or food allergy
• Married and blessed with 5 children
• Live with his wife and son
• Previously worked as a hard labor in
construction yard for 10 years
• Financially stable- supported by his son.
Patient is lying comfortably in semi-
recumbent position, alert and
cooperative. He is moderately built
and well nourished.
BMI: 31.4 (Obese)
Vital signs were stable:
PR- 70 bpm, regular rhythm,
normal volume and character
BP- 140/90 mmHg
RR- 18 breaths/min
T- 37 deg C
• Skin/Cutaneous: warm, moist skin, (-) jaundice, (-) cyanosis
• Head: Symmetrical head, no lesions, no masses, no
tenderness
• Eyes: pink palpebral conjunctivae, anicteric sclerae,
transparent cornea, lens are clear; iris are black with regular
contours, pupils are 2-3 mm equally reactive to light and
accommodation.
• Ears: Auricles are symmetrical and non-tender; auditory
canals are patent, no discharge; tympanic membrane is pearly
white, with visible cone of light.
• Nose and Sinuses: septum midline, turbinates are not
congested, no discharge, no tenderness over the frontal and
maxillary sinuses.
• Mouth and Throat: lips and buccal mucosa are pink and moist,
no ulcers, no exudates, non-hyperemic tonsils.
• Neck: supple, symmetrical, no neck vein engorgement, no mass, trachea in
midline, soft, no palpable lymph nodes
• Respiratory: Symmetrical chest expansion, no lagging, vesicular breath
sounds, no wheezes and rales
• Cardiovascular: Adynamic precordium, apex beat is at the 5th LICS MCL,
normal rate, regular rhythm, no heaves, no thrills, no murmurs
• Abdomen: flabby, normoactive bowel sounds, soft, no palpable mass, liver
span 9cm, non palpable spleen, no CVA tenderness, tympanitic in all
quadrants
• Extremities: No gross deformities, full and equal pulses on all extremities,
CRT <2secs, no edema
Standing Position Supine Position
• Anterior • Anterior
Both hip extended and adducted, Attitude
knee and ankle at neutral position Hips: Both are flexed at 30 deg
There is genu varus deformity of the Knees: Both are flexed at 5 deg
left leg Ankles: Both are at neutral
There is muscle wasting at the left position
thigh and left calf There is muscle wasting at the left
There is apparent shortening of the thigh and left calf
left lower limb There is apparent shortening of the
There is no scars, no swelling left lower limb
• Lateral There is no deformity of the left leg
There is no deformity, scars or There is no scars, no swelling
swelling • Lateral
• Posterior There is no deformity, scars or
There is no swelling on the popliteal swelling
fossa, no scars.
• Gait
Antalgic gait
• There’s local rise in temperature
• There’s tenderness over the medial joint line of the left knee
• Crepitus is felt upon moving the left knee joint
NEUROVASCULAR EXAMINATION
• Peripheral pulse: CRT <2s, distal
pulsations felt on both sides
(dorsalis pedis artery and
posterior tibial artery)
NEUROLOGICAL EXAMINATION
• Sensory examination is intact
on both sides of the lower limb
• Motor examination: Patient
able to dorsiflexion and
plantarflexion for left ankle
joint.
LEFT KNEE X-RAY OF
THE PATIENT
Hb 127 g/L 120.0-150.0 FULL BLOOD COUNT
RBC 4.44 10^12/L 3.80-4.80
HCT 38.3 % 36.0-46.0
MCV 86 Fl 83-101
OTHER LABS.
MCH 28.7 Pg 27.0-32.0
• ESR: 45 mm/hr (0-12)
MCHC 33.2 g/dl 31.5-34.5 • CRP: 7.2 MG/ML
Platelets 236 10^9/L 150-410 (<5.0)
WBC 8.1 10^9/L 4.0-10.0
Lymphocytes % 34.6 % 20.0-40-0
Neutrophil % 52.3 % 40.0-80.0
Monocytes % 10.4 % 2.0-10.0
Eosinophil % 1.9 % 1.0-6.0
Basophil % 0.8 % <1-2
q 67 years old
q Male
q Obese patient
q Pain at left knee for 8 years (long duration)
q Works as a hard labor in construction yard for 10 years
q No history of trauma or fall
q No fever, inflammation of the knee
CASE DIFFERENTIALS
Salient Features
67 years old
Male
Obese patient
Pain at left knee for 8 years (long
duration
Works as a hard labor in
construction yard for 10 years
No history of trauma or fall
No fever, inflammation of the knee
Rule in Rule out
67 years old Gout commonly involves the foot,
Male especially the first
Pain at left knee metatarsophalangeal (MTP) joint,
and pseudogout, the wrist and
knee, although either condition
may affect almost any joint.
No history of trauma or fall
Salient Features
67 years old
Male
Obese patient
Pain at left knee for 8 years (long
duration
Works as a hard labor in
construction yard for 10 years
No history of trauma or fall
No fever, inflammation of the knee
Rule in Rule out
67 years old RA usually causes a symmetric
Obese patient small joint polyarthritis in the
Pain at left knee hands, particularly affecting the
metacarpophalangeal joints and
sparing the distal interphalangeal
joints.
No fever, inflammation of the knee
Salient Features Rule in Rule out

67 years old 67 years old Cannot totally rule out

Male Male
Obese patient Obese patient
Pain at left knee for 8 years (long Pain at left knee
duration Works as a hard labor in
Works as a hard labor in construction yard for 10 years
construction yard for 10 years
No history of trauma or fall
No fever, inflammation of the knee
PRIMARY OSTEOARTHRITIS OF
THE LEFT KNEE
• Osteoarthritis (OA) which is also
known as degenerative joint
disease (DJD):
• Is a progressive disorder of the
joints caused by gradual loss of
cartilage and resulting in the
development of bony spurs and
cysts at the margins of the joints.
q Osteoarthritis is the most common form of arthritis and the most
common joint disease.
q Leading cause of impaired mobility in the elderly
q Characterized by degeneration of articular cartilage
q Leads to fibrillation, fissures, gross ulceration and finally disappearance
of the full thickness of articular cartilage
q By the year 2020, 25% of the adult population or 50 million people in
the United States will be affected by OA
q Cervical spine
q Lumbar spine
q Hip
q Hand, DIP, PIP, 1st IP, 1st MCP, CMC joints
q Knee
q Foot, MTP joints
q Shoulder

q Wrist

q Elbow

q Metacarpophalangeal joints

q TMJ

q Ankle
qJoint capsule

qLigaments

qMuscle

qSensory afferents

qUnderlying bone
q SYSTEMIC q IN THE JOINT q LOADING FACTORS
ENVIRONMENT
• Increasing age • Obesity
• Previous damage
• Female gender • Injurious physical
• Bridging muscle
• Racial/ethic factors activities
weakness
• Genetic susceptibility
• Increasing bone density
• Nutritional factors
• Misalignment
• Proprioceptive
deficiencies
 PRIMARY
• More common than secondary OA
• Cause- unknown
• Common in elders where there is no
previous pathology
• Its mainly due to wear and tear
changes occurring in old ages mainly
in weight bearing joints.
SECONDARY
Due to predisposing cause such as:
• Trauma
• Congenital: Dysplasia
• Infection: Septic arthritis, Brucella,
Tb
• Inflammatory: Rheumatoid Arthritis
• Metabolic: Gout
• Hematologic: Hemophilia
• Endocrine: DM, Hypothyroidism
Osteoarthritis is primarily disease of
cartilage.

IL-1 is potent inflammatory cytokine,

which capable of inducing
chondrocytes and synovial cells to
synthesize Matrix
metalloproteinases. MMPs is
responsible of degradation of
articular cartilage.

In addition, IL-1 inhibits synthesis of

collagen II, proteoglycans and
growth factor B stimulated
chondrocyte proliferation.
• The earliest change in OA Inflammatory process results in: • Synovium: Inflammation,
usually appear in the hyaline • Increase tissue swelling vascular hypertrophy
articular cartilage
• Change in color • Ligaments: tighten on
• Chondrocytes produce
• Cartilage fibrillation concave side of deformity
inflammatory cytokines (IL1-B)
• Cartilage erosion down • Bone: sclerosis, osteophytes
(TNF-a) and other inflammatory
to subchondral bone and subchondral CYST
mediators such as IL-6, IL-8,
PGE2, NO, and BMP-2) • Muscles: atrophy

• Decrease collagen synthesis and

increase degradative proteases
STAGE 1

At earliest of OA,
joints looks like this:
STAGE 2

At osteoarthritis
progresses, it look
like this:
STAGE 3

Advancing
osteoarthritis looks
like this:
STAGE 4

Patients with this

level of OA, usually
have pain most of
the time:
STAGE 5

This is the end stage

of disease. Note that
there is no cartilage
left on the end of the
bone:
• Synovial inflammation
• Joint effusions
• Bone marrow edema
• Capsular stretching
• Anserine bursitis
• Iliotibial band syndrome
Sign and symptoms
• Pain increases with activity and worse at night
• Swelling
• Deformities
• Joint instability
• Loss of function
• Crepitus
• Muscle wasting
q BLOOD TEST q SYNOVIAL FLUID q RADIOGRAPHY

X-rays are indicated to evaluate

No blood test are routinely Examination of the synovial fluid is chronic hand pain and hip pain
more helpful diagnostically than an thought to be due to OA
indicated for workup of patients x-ray
For knee pain, x-ray should be
with OA unless symptoms and obtained if symptoms and signs
Synovial fluid in OA:
signs suggest inflammatory WBC <1000/mm3 are not typical of OA or pain
Clear color persists after inauguration of
arthritis. High viscosity effective treatment
• Erosion

• Bone cyst

• Subchondral Sclerosis

• Osteophytes

• Narrow Joint space

Kellgren and Lawrence Radiographic criteria Assessment
of OA:
GOALs: • Non pharmacologic therapy
• Pharmacologic therapy
• Educate patient about the disease and

management • Patients with mild and intermittent

symptoms may need only non
• Improve function
pharmacotherapy
• Control pain • Patients with ongoing, disabling pain
are likely to need both non
• Alter disease process and its consequence
pharmacotherapy and
pharmacotherapy
NON PHARMACOLOGIC MANAGEMENT PHARMACOLOGIC MANANGEMENT
• Weight loss
• Although nonpharmacologic
• Rest/ avoid unnecessary stress approaches to therapy constitute its
• Physical therapy and Orthoses: Braces, splints, mainstay, pharmacotherapy serves
therapeutic shoes and knee tapping, use of an important adjunctive role in OA
walking stick treatment.
• Exercise: increase muscle strength, symptomatic
relief, joint protection, disability prevention.
Compliance, aerobic vs resistance
• Patient psychosocial and support
• Gout- is a metabolic disease
that most often affects middle
aged to elderly men and
postmenopausal women.
• Results from an increased body
pool of urate with
hyperuricemia
q Synovial fluid analysis

q Joint imaging

q Serum uric acid

q 24h uric acid collection

 • Medical
Non-pharmacologic management
• Adequate hydration
• Increase oral fluid intake
• Avoid diuretics unless befits outweigh
he risks
• Hypouricemic diet (low purine diet,
avoid red meats, alcoholic drinks
especially beer, limit seafood,
sweetened fruit juice/ fructose-
containing food and beverages
• Asymptomatic hyperuricemia
• Indications for urate lowering therapy; serum uric
acid > 11-13 mg/dL. Presence of tophi, arthropathy
on radiography, nephrolithiasis, tumor lysis
syndrome, CKD 2-3
• Acute attacks
• NSAIDS, glucocorticoids, ice compress
• Colchicine unless contraindicated ( renal
insufficiency) colchicine 0.5 mg TID may be given
then decreased to OD after acute attack and
maintained until uric acid <6mg/dL and at least 3
months without gout flare recurrence
• Hypouricemic therapy
• 1-2 weeks after acute attacks
• Uric acid under secretion- treated with uricosuric
drugs (probenecid)
• Uric acid overproduction- treated with xanthine
oxidase inhibitors:
• Allopurinol 100mg/tab PO OD initial dose
• Febuxostat 40mg/tab ½ tab PO OD initial
dose
• Chronic inflammatory disease
of unknown etiology marked
by systemic, peripheral
polyarthritis
• Most common form of
inflammatory polyarthritis
which may result in joint
damage and physical disability
qJoint involvement

qSubcutaneous nodules

qPleuritic/pericarditis

qVasculitis
qDIAGNOSTICS qMANAGEMENT

• Serum markers • NSAIDS

• CBC • Glucocorticoids

• Synovial fluid analysis • DMARDS

• Joint imaging
• Hematogenous route is the most
common route of all age groups
• The knee is the most commonly
involved joint
• Acute bacterial infection typically
involves a single joint or few joints
• Oligoarthritis suggests fungal
infection
q Infants- Group B streptococcus, gram neg enteric bacilli,

staphylococcus aureus

q Young adults- N gonorrhea

q Staphylococcus aureus accounts for most non-gonococcal

isolates in adults of all ages

q Fever

q Moderate to severe pain uniform around joint

q Musculoskeletal joint effusion, muscle spasm, decreased

range of motion
qDIAGNOSTICS qMANAGEMENT
Non pharmacologic
• Acute phase reactants
Repeated arthrocentesis
• CBC Surgical drainage/arthroscopic lavage

• Synovial Fluid analysis indicated for:

Septic hip
• Joint imaging
Concomitant osteomyelitis
• Cultures Prosthetic joint infection
PHARMACOLOGIC MANAGEMENT
THANK YOU
PGI MINOZA
PGI MIGUEL