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What is the primary purpose of serum uric acid in the evaluation of septic arthritis?
What is the typical WBC count in synovial fluid analysis in septic arthritis?
What is the purpose of Gram stain and aerobic and anaerobic bacterial culture in septic arthritis evaluation?
What is the significance of PCR testing in septic arthritis evaluation?
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What is the primary consideration in the management of septic arthritis?
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What is the approximate percentage of cases in which blood cultures are positive in septic arthritis?
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What is the characteristic of non-inflammatory joint pain?
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Which of the following is a common cause of monoarticular joint pain?
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What is the characteristic of inflammatory joint pain?
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Which type of joint is commonly involved in ankylosing spondylitis?
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What is the characteristic of polyarticular joint pain?
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Which of the following is a common cause of polyarticular joint pain?
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What is the importance of evaluating the number and types of joints affected in a patient's history?
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Which of the following is a common cause of oligoarticular joint pain?
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What is the primary purpose of the 2015 ACR-EULAR Gout Classification Criteria?
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What is the gold standard for diagnosing gout?
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What is the characteristic appearance of monosodium urate crystals under microscopy?
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What is the term for the condition characterized by high serum uric acid levels?
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What is the name of the joint commonly affected in gout flares?
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What is the imaging modality shown in the image depicting monosodium urate crystal deposition?
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What is the significance of periarticular erosions in radiography for the diagnosis of Rheumatoid Arthritis?
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What is the minimum score required on the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?
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What is the significance of joint involvement in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?
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What is the significance of acute phase reactants in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?
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What is the significance of duration of symptoms in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?
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What is the significance of serology markers in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?
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What is the primary purpose of complete blood count in the evaluation of septic arthritis?
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What is the significance of a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in septic arthritis?
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What is the primary indication for imaging studies in septic arthritis?
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What is the significance of a positive PCR test in synovial fluid analysis?
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What is the significance of a WBC count of 50,000 WBC/mm3 in synovial fluid analysis?
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What is the primary consideration in the management of septic arthritis?
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What is the sensitivity of an elevated C-reactive protein (>100 mg/L) in diagnosing septic arthritis?
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What is the specificity of an elevated erythrocyte sedimentation rate (>30 mm/h) in diagnosing septic arthritis?
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What is the primary indication for using the 2015 ACR-EULAR Gout Classification Criteria in clinical practice?
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What is the characteristic appearance of monosodium urate crystals under microscopy?
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What is the primary role of serum uric acid levels in the evaluation of gout?
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What is the imaging modality shown in the image depicting monosodium urate crystal deposition?
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What is the characteristic skin finding observed in patients with tophaceous gout?
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What is the gold standard for diagnosing gout?
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What is the primary purpose of joint aspiration in the evaluation of gout?
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What is the name of the joint commonly affected in gout flares?
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What is the characteristic of calcium pyrophosphate dihydrate crystals under birefringent microscopy?
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What is the approximate prevalence of Rheumatoid Arthritis worldwide?
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Which of the following is a genetic predisposition for Rheumatoid Arthritis?
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What is the typical duration of flares in calcium pyrophosphate dihydrate crystal deposition?
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Which of the following is a common feature of Rheumatoid Arthritis?
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What is the percentage of osteoarthritis in people aged 65 and older?
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What is a common feature of osteoarthritis in the hands?
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What is the typical morning stiffness in Rheumatoid Arthritis?
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What is a characteristic of joint pain in osteoarthritis?
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What is the characteristic appearance of affected joints in Rheumatoid Arthritis?
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What is a risk factor for developing osteoarthritis?
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What is the significance of cytokines in Rheumatoid Arthritis?
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What is crepitus typically felt and heard in?
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What is a common feature of osteoarthritis in the joints?
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According to the ACR/EULAR 2010 diagnostic criteria, what is the minimum score required for a diagnosis of Rheumatoid Arthritis?
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What is the significance of periarticular erosions in radiography for the diagnosis of Rheumatoid Arthritis?
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What is the significance of serology markers in the ACR/EULAR 2010 diagnostic criteria for Rheumatoid Arthritis?
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According to the ACR/EULAR 2010 diagnostic criteria, what is the significance of joint involvement in Rheumatoid Arthritis?
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What is the significance of acute phase reactants in the ACR/EULAR 2010 diagnostic criteria for Rheumatoid Arthritis?
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What is the significance of duration of symptoms in the ACR/EULAR 2010 diagnostic criteria for Rheumatoid Arthritis?
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What is the first step in the transition from normouricemia to clinically evident gout?
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Which of the following factors can contribute to the development of hyperuricemia?
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What is the relationship between monosodium urate (MSU) crystal deposition and clinically evident gout?
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What is the clinical manifestation of gout that is characterized by the presence of tophi?
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Which of the following is a risk factor for the development of hyperuricemia?
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What is the relationship between hyperuricemia and clinically evident gout?
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Which of the following factors can contribute to the transition from hyperuricemia to clinically evident gout?
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Which of the following is a significant complication of Rheumatoid Arthritis?
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What is the primary goal of treatment in Rheumatoid Arthritis?
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What is the characteristic of Zain's case that increases the suspicion for Rheumatoid Arthritis?
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What is the consequence of a 12-week delay in treatment in Rheumatoid Arthritis?
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What is the common cause of knee pain that must be considered in Zain's case?
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What is the significance of achieving long-term clinical remission in Rheumatoid Arthritis?
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What is the complication of Rheumatoid Arthritis that increases the risk of coronary artery disease?
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What is the primary purpose of the 2015 ACR-EULAR Gout Classification Criteria?
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What is the characteristic appearance of monosodium urate crystals under microscopy?
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What is the significance of dual-energy CT in the evaluation of gout?
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What is the characteristic skin finding observed in patients with tophaceous gout?
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What is the primary role of joint aspiration in the evaluation of gout?
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What is the gold standard for diagnosing gout?
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What is the primary basis of diagnosing osteoarthritis?
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What is the term for the condition characterized by high serum uric acid levels?
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What is the name of the joint commonly affected in gout flares?
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When is X-ray imaging typically used in the evaluation of osteoarthritis?
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What is the primary role of CT or MRI in the evaluation of osteoarthritis?
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What is the primary indication for ultrasonography in the evaluation of osteoarthritis?
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What is the characteristic radiographic finding in osteoarthritis?
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What is the primary role of laboratory testing in the evaluation of osteoarthritis?
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What is the typical feature of joint destruction in osteoarthritis?
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What is the primary indication for referral for joint replacement in osteoarthritis?
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Study Notes
Septic Arthritis – Evaluation
- Complete blood count: elevated WBC count
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): can be normal, used to monitor therapeutic response when elevated
- Serum uric acid: should not be elevated, used to rule out gout
- Blood cultures: positive in 25-50% of cases
Septic Arthritis – Arthrocentesis
- Synovial fluid analysis: WBC count > 50,000 WBC/mm3, differential >90% polymorphonuclear cells
- Gram stain, aerobic and anaerobic bacterial culture
- Borrelia burgdorferi cannot be cultured from synovial fluid; PCR testing if suspecting Lyme arthritis (positive in 85% of patients)
Septic Arthritis – Imaging
- X-ray, ultrasonography, MRI may be considered
Septic Arthritis – Management
- Medical emergency: needs immediate diagnosis and urgent referral for treatment
- Types of joints involved: vertebral, sacroiliac, wrists, carpometacarpals, MCP, PIP, DIP, ankle, MTP, shoulders, elbows, hips, knees
Inflammatory Joint Pain vs. Non-Inflammatory Joint Pain
- Inflammatory joint pain: characterized by redness, swelling, warmth, tenderness, morning stiffness, and worsens with inactivity
- Causes: infection, gout, rheumatoid arthritis, calcium pyrophosphate deposition disease, juvenile RA, systemic lupus erythematosus
- Non-inflammatory joint pain: may or may not present with swelling and tenderness, but other signs are absent; worsens with activity
- Causes: osteoarthritis, trauma, polymyalgia rheumatica, sarcoidosis, spondyloarthritides, reactive arthritis, psoriatic arthritis, ankylosing spondylitis, enteropathic arthritis
History
- Evaluate number and types of joints affected and symmetry if polyarthritis is present
- Onset: sudden vs. gradual
Gout – Evaluation
- Based on clinical diagnosis, classification criteria, and microscopy-based diagnosis of synovial fluid
- 2015 ACR-EULAR Gout Classification Criteria: not meant for diagnosis, but can help inform the clinician; intended for research purposes
- Serum uric acid levels: identify hyperuricaemia
- Gold standard for diagnosis: joint aspiration and microscopy analysis showing presence of monosodium urate crystals
Rheumatoid Arthritis (RA) – Evaluation
- Classification criteria: ACR/EULAR 2010 criteria replaced the 1987 ARA criteria
- Lab findings:
- Radiography: periarticular erosions, osteopenia, joint space narrowing
- Inflammatory markers: ESR, CRP
- Serology markers: RF, ACPA, or both
- Seropositive RA: 75-85% will test positive for RF, ACPA, or both
ACR/EULAR 2010 Diagnostic Criteria for RA
- At least 1 joint with definite clinical synovitis (swelling) not explained by another disease plus 1 of the following:
- Presence of long-standing disease previously satisfying classification criteria
- Presence of ≥ 2 typical periarticular erosions
- Score ≥ 6 on the following criteria:
- Joint involvement (0-5)
- Serology (0-3)
- Acute phase reactants (0-2)
- Duration of symptoms (0-1)
Septic Arthritis – Evaluation
- Complete blood count: elevated WBC count
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): can be normal, but when elevated, used to monitor therapeutic response
- Serum uric acid: should not be elevated, used to rule out gout
- Blood cultures: positive in 25-50% of cases
- Arthrocentesis for synovial fluid analysis: WBC count > 50,000 WBC/mm3, synovial fluid WBC differential > 90% polymorphonuclear cells
- Gram stain, aerobic and anaerobic bacterial culture
- Borrelia burgdorferi cannot be cultured from synovial fluid, PCR testing if suspecting Lyme arthritis (positive in 85% of patients)
- Imaging may be considered: X-ray, ultrasonography, MRI
Septic Arthritis – Management
- Medical emergency: needs immediate diagnosis and urgent referral for treatment
- Physical Exam:
- Fever: sensitivity 46%, specificity 31%
- Serum laboratory values:
- Abnormal peripheral WBC count (>10,000/µL): sensitivity 90%, specificity 36%
- Elevated erythrocyte sedimentation rate (>30 mm/h): sensitivity 95%, specificity 29%
- Elevated C-reactive protein (>100 mg/L): sensitivity 77%, specificity 53%
Gout – Evaluation
- Based on clinical diagnosis, classification criteria, and microscopy-based diagnosis of synovial fluid
- 2015 ACR-EULAR Gout Classification Criteria: not meant for diagnosis, but can help inform the clinician; intended for research purposes
- Serum uric acid levels: to identify hyperuricaemia
- Gold standard for diagnosis: joint aspiration and microscopy analysis showing presence of monosodium urate crystals
- Other tests: ultrasonography, dual-energy CT
Calcium Pyrophosphate Dihydrate Crystal Deposition (Pseudogout)
- Aka pseudogout
- Persons > 65 years old
- Onset: sudden
- Duration: flares lasting days to weeks
- Morning pain or stiffness usually present
- Calcium pyrophosphate dihydrate crystals: polymorphic, weakly positive under birefringent microscopy
Rheumatoid Arthritis (RA)
- 0.5-1% worldwide prevalence
- Higher risk in women (2-3x higher than men), smokers, patients with family history of RA
- Genetic predisposition: HLA-DR1 and HLA-DR4
- Systemic autoimmune inflammatory disease
- Chronic/relapsing destructive synovitis: local inflammation, cartilage destruction, bone erosion
- Cytokines (TNF-α, IL-1, IL-6) drive chronic synovial inflammation
Rheumatoid Arthritis (RA) - Clinical Features
- Symmetrical, polyarticular pain and stiffness: most often affecting wrists, PIP, MCP, MTP joints
- Morning stiffness > 1 hour
- Systemic symptoms: fatigue, weight loss, anemia
- Visible boggy swelling caused by synovitis
- Palpable synovial thickening
- Affected joint painful if pressure applied on palpation or with movement
- Advanced disease: ulnar deviation, MCP joint subluxation, swan neck deformity, Boutonniere deformity
- Extra-articular manifestations: accelerated atherosclerosis, pericarditis, keratoconjunctivitis sicca, episcleritis/scleritis, interstitial lung disease, pulmonary nodules, rheumatoid nodules, pleural effusion, vasculitis
Osteoarthritis
- Prevalence increases with age: 7.3% in ages 18-44; 30% in ages 45-64; 50% in ages 65 and older
- Women > men
- Other risk factors: overweight/obese, previous joint injury, family history, frequent bending/squatting, repetitive impact
- Degenerative disorder of articular cartilage associated with hypertrophic bone changes
- Onset: gradual
- Duration: lifelong with flares
- Usually no morning pain or stiffness (or short-lived)
Osteoarthritis – Clinical Features
- Asymmetric joint pain and stiffness: commonly affecting hands, knees, hips, feet, spine
- Joint pain worsened by movement/activity, especially following a period of rest
- Joint swelling and tenderness
- Bony enlargement in prolonged or severe OA
- Pain on range of motion and limitation of range of motion
- Crepitus (typically knee) may be felt and heard
- Bouchard nodes on proximal interphalangeal joint
- Heberden nodes on distal interphalangeal joints
Gout
- Gout occurs in several stages: hyperuricaemia, monosodium urate (MSU) crystal deposition, and clinical manifestations (gout flares, chronic gouty arthritis, and tophaceous gout)
- Factors contributing to the transition from hyperuricaemia to clinically evident gout are not well understood
- Hyperuricaemia can be caused by genetic variants, chronic kidney disease, high body mass index (BMI), medications, and dietary factors
Diagnosis of Gout
- Based on clinical diagnosis, classification criteria, and microscopy-based diagnosis of synovial fluid
- 2015 ACR-EULAR Gout Classification Criteria not meant for diagnosis, but can help inform the clinician; intended for research purposes
- Serum uric acid levels to identify hyperuricaemia
- Joint aspiration and microscopy analysis showing the presence of monosodium urate crystals (identified by needle-like appearance and strong negative birefringence) is the gold standard for diagnosis
- Other tests: ultrasonography, dual-energy CT
Rheumatoid Arthritis (RA)
- Classification criteria: ACR/EULAR 2010 criteria replaced the 1987 ARA criteria
- Lab findings: radiography (periarticular erosions, osteopenia, joint space narrowing), inflammatory markers (ESR, CRP), serology markers (Rheumatoid factor, Anti-citrullinated protein antibodies (ACPA))
- ACR/EULAR 2010 Diagnostic Criteria for RA: at least 1 joint with definite clinical synovitis plus 1 of the following:
- Presence of long-standing disease previously satisfying classification criteria
- Presence of ≥ 2 typical periarticular erosions
- Score ≥ 6 on the following criteria:
- Joint involvement (0-5)
- Serology (0-3)
- Acute phase reactants (0-2)
- Duration of symptoms (0-1)
Management of RA
- Low threshold for referral to rheumatologist
- Goals of treatment:
- Early diagnosis and early initiation of treatment to prevent irreversible joint damage
- Achieve long-term clinical remission
- Optimize quality of life
- Monitor for extra-articular complications
- Complications of RA:
- Osteopenia and osteoporosis → fracture
- Lung manifestations
- Accelerated atherosclerosis → coronary artery disease, peripheral vascular disease
- Increased insulin resistance, diabetes mellitus
- Vasculitis, thromboembolic disease
- Depression
- Anemia of chronic disease
- Felty syndrome (RA, splenomegaly, neutropenia)
Osteoarthritis
- Primarily a clinical diagnosis based on history and physical examination
- Imaging not required in patients with risk factors and typical symptoms
- X-ray can confirm diagnosis and rule out other conditions; helpful before referral for joint replacement
- May see joint space narrowing, osteophyte formation, subchondral sclerosis, and joint destruction on X-ray
- CT or MRI when diagnosis is in doubt or strong suspicion for other etiology
- Laboratory testing not usually required
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Description
This quiz covers the evaluation of septic arthritis, including complete blood count, ESR, CRP, serum uric acid, and arthrocentesis for synovial fluid analysis.