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NR 508 Week 6 TD, Quiz and Summary.pdf
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NR I508 IWeek I6 ITD, IQuiz Iand ISummaryPART I1:
Jonathon Iis Ia I56 Iyear-old Iretired Iautomobile Imechanic Iwho Ihas Inot Ibeen Ito Ithe Idoctor Iin
Iapproximately I6-7 Iyears. IHe Ipresents Ito Iyour Ioffice Icomplaining Ithat Ithree Iweeks Iago Ihe
Iwas Iawoken Iwith Isevere Ipain Iand Iinflammation Iin Ihis Iknee, Iwhich Ihas Ibeen Iconsistent
Isince Ithat Iinitial Inight. IUpon Iphysical Iexamination Iof Ihis Iknee, Iit Iappears Iswollen Iand
IerythematousIwith Iperiarticular Iinvolvement. IUpon Iphysical Iexamination Iand Ilaboratory
Iresults Iyou Inotice Ithe Ifollowing:
Physical Iexamination:
GEN: Iwell Inourished, Iobese Imale I(310 Ipounds)
VS: IBP I191/112 IHR I75 IRR I15 IT I98.6, IHT I5’8”
EXT: IKnee Ijoint Iinflammation
Laboratory I(fasting):
Na I139 ImEq/L
K I3.8 ImEq/L
Ca I9.1 Img/dL I(9-10) ILow INormal
CL I102 Immol/L I(98-106)
HCO3 I22 ImEq/L
BUN I10 Img/dL
SCr I0.9 Img/dL
Serum IUric IAcid I6.5 Img/dL I(4-8.5) I(>6.5 Ihyperuricemia)
Alb I4.1 Ig/dL I(3.5-5)
Cholesterol I300 Img/dL I(<200) IH
UA: IpH I6.8 I(4.6-8) I, Iuric Iacid I250 Img/24h I(250-750)
What Iproblems Ican Ibe Iidentified Iin Ithis Ipatient? IPlease Iprovide Ia Ilist Iof Idifferential
I diagnoses, I as I well I as I indication I of I your I primary I diagnosis. IWhat Iis Iyour
Ipharmacological Iplan Ifor Iyour Iprimary Idiagnosis Iincluding ItheImedication, Idose, Iand
Imechanism Iof Iaction?
Probs I= IHTN, IObesity, IHigh ICholesterol
Poss IDx I= IPseudogout I(calcium Ipyrophosphate Idz), Imonoarthritis, IsepticIjoint
,Pseudogout. IPseudogout, Ialso Ireferred Ito Ias Iacute Icalcium Ipyrophosphate Icrystal
Iarthritis, Iis Ian Iinflammatory Idisease Iprocess Ithat Ibelongs Ito Ia Iclass Iof Idiseases Icalled
Icalcium Ipyrophosphate Ideposition Idiseases I(CPPDs) I(Rho, IZhu, IZhang, IReginato, I&
IChoi, I2012). IThe Itwo Iprevalent Icrystal-induced Iarthropathies Iare Igout Iand Ipseudogout
I(Rothschild, I2017). ISometimes, Ipseudogout Iand Iits Isymptoms Ican Ibe Iindistinguishable
Ifrom Igout I(Rothschild, I2017). ISymptoms Iof Iboth Idiseases Iinclude Icrippling Ipain Iin IoneIor
Imore Ijoints Ias Iwell Ias Ierythema, Iwarmness, Itenderness, Iand Iswelling I(Rothschild, I2017).
IThese Isymptoms Igenerally Ieffect Ithe Ilarger Ijoints, Isuch Ias Ithe Iknees Iand Iwrists
I(Papadakis I& IMcPhee, I2017). IWhen Ithe Iaffected Ijoint Iis Iexamined Ivia Idiagnostic
Iimaging, Ichondrocalcinosis Iis Ialmost IalwaysIpresent I(Papadakis I& IMcPhee, I2017). IIf Ithe
Ipatient Ipresents Iwith Ithe Isymptoms Iabove Iplus Ia Ifever, Ian Iinfection Iof Ithe Ijoint Ishould Ibe
IinvestigatedI(Rothschild, I2017).
There Iare Isome Istudies Ithat Ican Ibe Iuseful Iin Idiagnosing, Iwhich Iinclude IurineIand Iserum Iuric
Iacid Ilevels I(even Ithough Ithese Ilabs Iare Inot Iconsidered Idiagnostic) Iand Iblood Iwork Isuch Ias
Ia ICBC Ito Ievaluate IWBCs, Ia Icholesterol Ipanel, Ia Irenal Ipanel, Iliver Ienzymes, Iand Iglucose
Ilevels I(Rothschild, I2017).
An Iultrasound Ican Ibe Iused Ito Ivisualize Ithe Ijoint Iand Iexamine Ifor Icrystals, Itophaceous
Imaterials, Iand Ierosions Ithat Ihave Ioverhanging Iedges I(Rothschild,I2017). IHowever, Ithe
Ibest Iway Ito Idistinguish Ibetween Igout Iand Ipseudogout IisIto Iaspirate Ithe Isynovial Ijoint
Ifluid; Icalcium Ipyrophosphate Icrystals Iindicate Ipseudogout Iwhile Imonosodium Iurate
Imonohydrate Icrystals Iindicate Igout I(Rothschild, I2017).
Gout Iand Ipseudogout Iare Itreated Isimilarly; Iboth Iaim Iat Ireducing Ipain Iand Ipreventing
Iflares Ivia Imedications Iand/or Idecreasing Iurate Ilevels I(Rothschild,I2017). IBefore Imaking Ia
Idecision Ion Ithe Itreatment Iplan, Ithe Iprovider Ineeds IaIbaseline Iof Irenal Ifunctioning, Ito Imake
Isure Ithe Idiagnosis Iis Inot Iseptic Iarthritis, Iand Ito Iknow Iif Ithe Ipatient Ihas Ia Ihistory Iof IGI
Icomplications, Iespecially Ibleeding I(PDR, I2017). IOnce Icrystal Ideposits Iare Iconfirmed,
IreliefIof Ipain Iand Iinflammation Ican Ibe Itreated Iwith INSAIDs, Iadrenocorticotropic
Ihormone I(ACTH), Icolchicine, Ior Ia Icombination Iof Imeds Iincluding Iintraarticular
Iglucocorticoid I(Rothschild, I2017).
For IJonathon, Ihe Iis Iexperiencing Isymptoms Ithat Icould Ibe Ieither Igout Ior Ipseudogout. IBased
Ion Ithe Iinformation Igiven, II Ichose Ipseudogout Ibecause, Ieven Ithough Iuric Iacid Ilevels Iare Inot
Iconsidered Ia Idiagnostic Itool, I his IserumIand Iurine Ilevels Iare Iwithin Inormal Ilimits.
IAssuming Ihe Iis Iafebrile Iand Ithe
, pain Iand Iinflammation Iis Inot Ifrom Ian Iinfection, II Iwould Iaspirate Isome Isynovial Ifluid
Ifrom Ihis Ieffected Iknee Iand Ianalyze Iit Ifor Ispecific Icrystal Iformation. II Iwould Ialso Iorder Ian
Iultrasound Iof Ihis Iknee Ito Ievaluate Ifor Icrystal Ior Itophi Idevelopment. IAssuming Ithe Iresults
Iare Ipositive, II Iwould Imake Isure Ito Ihave Icertain Ilabs Idone, Isuch Ias Ia ICBC Iwith Idiff, ICMP,
Irenal Ipanel, Iand Iliver Ipanel Ifor Ibaseline Iresults. II Iwould Ialso Iinject ITriamcinoloneI40mg
Iwith I1 Ipercent Ilidocaine Iinto Ithe Iintraarticuar Iknee Ispace. II Iwould IalsoIhave Ihim Itake
IIbuprofen I800mg IQ6H Iprn Ifor Ipain Iuntil Ipain Iis Itolerable.
Colchicine I 0.6mg IPO IQD Ior IBID, Ican Ibe Ieffective Iin Ipreventing IrecurrenceIin Iboth
Idiseases, Itherefore Icould Ibe Ianother Itreatment Ioption Iif Ithe Iabove Idoes Inot Iwork
I(Rothschild, I2017).
Triamcinolone Iis Ia Icorticosteroid Ithat Iprovides Ivasoconstrictive, Ianti- Iinflammatory, Iand
Iantipruritic Iproperties I(PDR, I2017). ICorticosteroids Iinduce Ilipocortins, Iwhich Iantagonize
Iphospholipase IA2, Iwhich Iin Iturn IleadsIto Ithe Ibreakdown Iof Ileukocyte Ilysosomal
Imembranes Ito Idischarge Iarachidonic Iacid I(PDR, I2017). IThe Irelease Iof Iarachidonic Iacid
Iinhibits Ithe Irelease Iof Iendogenous Iinflammatory Imediators I(PDR, I2017).
Ibuprofen Iinhibits Iboth ICOX-1 Iand ICOX-2 I(enzymes) Iby Iblocking Iarachidonate Ibinding,
Iwhich Iresults Iin Ianti-inflammatory, Ianalgesic, Iand Iantipyretic Ieffects I(PDR, I2017). IThese
Ienzymes Iaccelerate Ithe Iconversion IofIarachidonic Iacid Ito Iprostaglandin IG2 I(PGG2), Iwhich
Iis Ithe Ifirst Ipart Iof Ithe Iprocess Iin Isynthesizing Iprostaglandins Iand Ithromboxane Iresponsible
Ifor Ithe Irapid Iphysiological Iresponses I(PDR, I2017).
Jonathon Iis Ialso Ihypertensive Iand Ihas Ihigh Icholesterol. II Iwould Idouble IcheckIto Iconfirm Ihis
Iblood Ipressure Iis Ireally I191/112, Iif Iso II Iwould Istart Ihim Ion Ilisinopril I40mg Idaily. II Iwould
Ihave Ihim Ikeep Ia Ilog Iof Ihis IBP Iand Ireturn Iin I1 Iweek Ifor Ifurther Ievaluation. IFor Ihis
Ihyperlipidemia, II Iwould Istart Ihim Ion Iatorvastatin I40 Img Idaily Iat Ibedtime. IJonathon Iwould
Ibe Iinstructed Ito Ibe IalertIfor Isymptoms Iof Imyalgia Ior Imyopathy/rhabdomyolysis. IIf
Isymptoms Ioccur, Ithe Ipatient Imust Istop Ithe Imedicine Iand Icall Ithe Ioffice Iimmediately Iso Ithe
Ipatient Ican Ibe Ievaluated II Iwould Ialso Iencourage Ihim Ito Iadhere Ito Ia Idiet Iand Iexercise
Iprogram, Iwhich Ican Iassist Iin Ilowering Ihis IBP Iand Ihis Icholesterol.
Monoarthritis. IMonoarthritis Iis Ipain Ior Iswelling Ithat Iis Ipresent Iin Ione Ijoint I(Becker,
IDaily, I& IPohlgeers, I2016). IThis Ikind Iof Iissue Ican Ibe Iself Ilimiting ItoIone Ior Itwo Ijoints Ior Iit
Ican Ibecome Ia Isystemic Iproblem, Isuch Ias Ia Iseptic Ijoint I(Becker, IDaily, I& IPohlgeers,
I2016). IArthritis Iis Ithe Iusual Iculprit Iwhen Ithe
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