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By E. Tangach. Ohio University.

Structural damage → cartilage loss and erosion of the periarticular bone Hand and Wrist Deformities Boutonnière Deformity (Calliet best diovan 160mg, 1982) (Figure 3–1) Mechanism Weakness or rupture of the terminal portion of the extensor hood (tendon or central slip) buy 40 mg diovan with visa, which holds the lateral bands in place The lateral bands slip downward (or sublux) to the axis of the PIP joint turning them into flexors The PIP then protrudes through the split tendon as if it were a button hole (boutonnière = button hole) The distal phalanx hyperextends RHEUMATOLOGY 85 Result Flexion of the PIP Hyperextension of the DIP Hyperextension of the MCP Note: Positioning of the finger as if you were buttoning a button Orthotic Tripoint finger splint FIGURE 3–1. Boutonnière Deformity Swan Neck Deformity (Calliet, 1982) (Figure 3–2) Mechanism Contracture of the intrinsic and deep flexor muscles and tendons of the fingers Result Flexion contracture of the MCP Hyperextension of the PIP Flexion of the DIP Orthotic Swan neck ring splint FIGURE 3–2. Swan Neck Deformity 86 RHEUMATOLOGY Ulnar Deviation of the Fingers (Calliet, 1982) Mechanism Weakening of the extensor carpi ulnaris (ECU), ulnar and radial collateral ligament Wrist deviates radially Increases the torque of the stronger ulnar finger flexors Flexor/extensor mismatch deviates the fingers in the ulnar direction as the patient tries to extend the joint Result Ulnar deviation is due to the pull of the long finger flexors Orthotic Ulnar deviation splint Tenosynovitis of the Flexor Tendon Sheath One of the most common manifestation of the hands in RA Can be a major cause of hand weakness Result Diffuse swelling of the volar surfaces of the phalanges between the joints with palpable grating of the flexor tendon sheath May be confused with deQuervain’s disease DeQuervain’s disease Tenosynovitis of the extensor pollicis brevis (EPB) and abductor pollicis longus tendon (APL) Thickening of the tendon sheath results in tenosynovitis and inflammation Pain over the tendons on the radial wrist EPB and APL Test: Finkelstein Test (Figure 3–3) Full flexion of the thumb into the palm followed by ulnar deviation of the wrist will produce pain and is diagnostic for deQuervain’s tenosynovitis FIGURE 3–3. Finkelstein’s Test: Full flexion of the thumb into the palm will produce pain when the wrist is deviated in the ulnar direction. Rosemont, Illinois: American Academy of Orthopaedic Surgeons, 1997, with permission. RHEUMATOLOGY 87 Carpal Bones Rotate in Zig-Zag Pattern Mechanism Ligament laxity Radial deviation of the wrist Ulnar styloid rotates dorsally Carpal bones rotate – Proximal row: volarly – Distal row: dorsally Result Zig-zag pattern Floating Ulnar Head (Piano-Key Sign, Think of the Black Keys) Mechanism Proliferating synovium leads to rupture or destruction of the ulnar collateral ligament Result The ulnar head raises up to the dorsal wrist Easily compressible elevated ulnar styloid Ulnar head floats Resorptive Arthropathy Mechanism Digits are shortened and phalanges appear retracted with skin folds Result Telescoping appearance of the digits Most serious arthritic involvement Pseudobenediction Sign Mechanism Stretched radioulnar ligaments allow the ulna to drift upward Extensor tendons of the fourth and fifth digit are subject to abrasion from rubbing on the sharp elevated ulnar styloid Result Extensor tendon rupture Inability to fully extend the fourth and fifth digit Cervical Spine Atlantoaxial Joint Subluxations → Most Common are Anterior Subluxations Instability – Odontoid or Atlas can erode – With flexion, the Atlantoaxial (AA) space should not increase significantly: any space larger than 2. The MCP is thought to be the primary site of RA and inflammation can lead to weakening of joint supporting structures. Insidious Onset Surgical Options Synovectomy Arthroplasty Arthrodesis Tendon repairs TABLE 3–1. Treatment Options for Rheumatoid Arthritis (Verhoeven, 1998) Poor Prognostic Disease Stage Features Treatment Medications 1. Compliance antirheumatic drug (DMARD) Hydroxychloroquine Sulfasalazine Oral gold Moderately (+) 1. Compliance Weekly oral or parental methotrexate May add a second DMARD 3. Corticosteroids PT = Physical Therapy OT = Occupational Therapy NSAID = non-steroidal anti-inflammatory drugs DMARD = disease modifying anti-rheumatic drug RHEUMATOLOGY 93 TABLE 3–2. Drugs Used in Rheumatoid Arthritis and Common Side Effects (Gerber, Hicks, 1995) DMARDs General (Disease Modifying Degree of Anti-rheumatic Drugs) Toxic Profile Toxicity Hydroxychloroquine Macular damage Safer Sulfasalazine Myelosuppression, gastrointestional (GI) distrubances Safer Auranofin GI disturbances, diarrhea, nausea, vomiting, anorexia, rash pruritus, conjunctivitis, stomatitis, anemia, thrombocytopenia, proteinuria, elevated liver enzymes Safer Methotrexate Stomatitis, myelosuppression, hepatic fibrosis, cirrhosis, pulmonary involvement, worsens rheumatoid nodules More toxic Cyclosporine Renal dysfunction, tremor, hirsutism, hypertension, gum dysplasia More toxic Gold, Intramuscular, Myelosuppression, renal → proteinuria Oral Diarrhea (#1, oral), Rash (#1, Intramuscular) More toxic Azathioprine Myelosuppression, hepatotoxicity, lymphoproliferative disorders More toxic D-Penicillamine Oral ulcers, bone marrow suppression induction of autoimmune disease, proteinuria More toxic Chlorambucil Bone marrow suppression, GI disturbances, nausea, vomiting, diarrhea, oral ulceration, central nervous system (CNS) dis- turbances, tremors, confusion, seizures, skin hypersensitivity, pulmonary fibrosis, hepatotoxicity, drug fever peripheral neuropathy, infertility, leukemia and 2˚ malignancies Very toxic Cyclophosphamide Carcinogenesis, impairment of fertility, mutagenesis, GI disturbances, nausea, vomiting, anorexia, alopecia, leukopenia, thrombocytopenia, anemia, cystitis, urinary bladder fibrosis, interstitial pulmonary fibrosis, anaphylactic reaction Very toxic Other Drugs for the Treatment of Rheumatoid Arthritis Toxic Profile ASA, NSAID GI ulceration and bleeding Therapeutic levels for ASA 15 mg/dl–25 mg/dl Toxic > 30 mg/dl Corticosteroids Hyperglycemia, inhibits immune response, osteoporosis, peptic ulcer disease, emotional liability 94 RHEUMATOLOGY OSTEOARTHRITIS (OA) DEFINITION A noninflammatory progressive disorder of the joints leading to deterioration of the articular cartilage and new bone formation at the joint surfaces and margins Disease of the cartilage initially, not bone PREVALENCE Most common form of arthritis and the second most common form of disability in the United States Prevalence increases with age: approximately 70% population > 65 years old have radio- graphic evidence of osteoarthritis (Lane, 1997) Increase in occupations with repetitive trauma Male:female ratio is equal between the ages of 45–55. Because of this, it is suggested that spondyloarthropathies in children include another syndrome, Seronegative Enthesopathy and Arthropathy (SEA) SEA Syndrome – (–) RF – (–) ANA – Enthesitis and either arthritis or arthralgia RHEUMATOLOGY 101 TABLE 3–4. Key Points of Juvenile Arthritides JUVENILE RHEUMATOID ARTHRITIS SYSTEMIC JUVENILE Multisystemic POLYARTICULAR SPONDYLO- Involvement Many joints PAUCIARTICULAR ARTHROPATHIES RF(–) (~98%) RF(–) (90–95%) RF(–) (> 98%) Ankylosing Still’s Disease No extraarticular 1–4 joint involvement Spondylosis (AS) High fever manifestations of Few systemic effects Reiter’s Rheum.

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Placement of nasoduode- nal or jejunal tubes is tedious and often not successful buy 40mg diovan fast delivery, and their advantages are dubious purchase diovan 160 mg amex. They should be reserved for use in ventilated patients who are at risk for nosocomial pneumonia. When a nasoduodenal tube is used, it should be com- bined with a nasogastric tube. Ten percent of the enteral feeding is then infused via the nasogastric tube, and the rest via the nasoduodenal tube. In either tube- feeding regimen, the gastric residuals should be checked regularly. Once the residual has been checked, it is then infused back to the stomach to avoid electroly- tic imbalances and alkalosis. If these residuals are more than a 2 h tube feeding infusion rate, the feeding should be stopped and the cause investigated. The most common cause of enteral feeding intolerance is tube malposition, although important causes of intolerance that all physicians should bear in mind are sepsis and multiple organ failure. The enteral feeding should be started on admission and continued until the wounds are 90% healed and the patient can maintain an oral intake of his or her caloric demand. General Treatment 35 Enteral feeding is started on admission and, if absorbed, it is increased until full strength is obtained, ideally in the first 24 h. The hourly absorbed nutrition is subtracted from the total resuscitation hourly fluids the patient is receiving, in order to avoid overloading. When patients are scheduled for surgery, nutrition is stopped 2–4 h before surgery, and the stomach is aspirated prior to the induction of anesthesia. In ventilated patients, enteral nutrition is not stopped but is contin- ued during surgery. Caloric requirements in burn patients should be ideally calculated by means of indirect calorimetric measurement.

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Nuclear medicine is a newer specialty that employs the exploding technology of the past few decades buy diovan 160 mg without a prescription. An even newer specialty is medical genetics order 80 mg diovan with visa, which probes the genetic causes of illnesses and seeks cures in genetic therapies. The other special- ties covered in this chapter are allergy and immunology, dermatol- ogy, emergency medicine, neurology, pathology, physical medicine and rehabilitation, preventive medicine, psychiatry, and radiology. Pediatricians see mostly healthy children, providing well-child care and guidance on prevention of illness. Pediatrics is a specialty that calls for strong interpersonal skills, as pediatricians must deal with children and their parents. It is a demanding branch of medicine that includes long hours and inter- ruptions in the evenings. Pediatric patients respond well to treatment and are often happy and satisfied customers. Children heal faster than adults, and this aspect of pediatrics can be very gratifying. Although most of their work is with healthy children, pediatri- cians do see a variety of disorders. These include throat and respi- ratory infections, communicable diseases, cancer, congenital abnormalities, and developmental and behavioral problems. Pedi- atricians practice mostly in offices, sometimes in private practice and sometimes in alternative settings like health maintenance orga- nizations (HMOs). Like many of the specialties that are contact-intensive rather than procedures-intensive, pediatricians make less money than many of their colleagues.