Parkinsonism

Here is a link to the JAMA Rational clinical exam article for Parkinson's Disease
Here is a link to a CMAJ review article on Parkinson's disease

When examining someone with potential Parkinsonism (in real life, but also consider if relevant on an exam), be sure to consider the "Parkinson plus" syndromes.

"My, that is a cute joint"

ACUTE MONOARTHRITIS

A great advanced discussion today that focused on monoarthritis.

The first step in assessing an "acute joint" is to determine if the process is articular, periarticular or referred.

If it is indeed an acute articular process the differential includes:

Infectious: SEPTIC UNTIL PROVEN OTHERWISE!!!
- a very good general rule, although as we learned today in classic presentations of other diseases, joint tap may be deferred
Crystal Arthropathy: Gout, Pseudogout (CPPD), Hydroxyapatite
Inflammatory
Seropositive arthritis (early RA or SLE)
Seronegative arthritis (psoriatic, Ankylosing spondilitis, IBD, reactive)
Degenerative: Osteoarthritis

Trauma: Hemarthrosis, joint trauma

Extra-articular: Bursitis, cellulits, ruptured Baker’s cyst, tendonitis, etc…

A JAMA rational clinical exam article on septic arthritis is linked here and a CMAJ article on approach to acute monoarthritis is here. Gout is unusual in premenopausal women. An article on acute calcific periarthritis is linked here.

IMAGING
Not always necessary - may be helpful for
1)Trauma
2)Evidence of crystal disease
3)Baseline study (i.e. to follow for development of pathology in future if septic joint, etc.)/to assess for obvious coexisting osteomyelitis.

Antihyperuricemic Treatment
Indications:
Recurrent kidney stones
Gout and renal failure
Tophi
Associate chronic joint changes
Frequent/severe attacks of gout

Options:
Uricosuric agents: - best in uric acid undexcretors (normal urine uric acid with high serum levels). Avoid if renal stones/uric acid nephropathy. Less effective in renal failure.

Xanthine oxidase inhibitor - decrease uric acid synthesis. Good for almost everyone, but need to consider drug interacations and adjusft for comorbidities (renal failure)

• Use minimum dose to achieve effect (follow serum urate levels)
• Azathioprine (Imuran) is mteabolized by xanthine oxidase (decrease Imuran dose by >50% and follow for toxicity)
  

Febuxostat - ?available here soon - xanthine oxidase inhibitor - but not a purine analog

• Not clear what its role will be vs allopurinol, and ongoing safety monitoring will be important to follow (as with any new med)

CONSIDER prophylaxis with colchicine (0.6 mg up to BID if normal CrCl) when initiating/titrating antihyperuricemic drugs - stop once normouricemic for 6 months.

"That's Tight" - How to assess for Aortic Stenosis

We discussed EVAR (Endovascular Aneurysm Repair). A NEJM review can be found here. The precise role for EVAR (rather than open) repair is still debated. 2005 AHA guidleines suggest EVAR of infrarenal AAA could be considered in patients at high risk of complications following open repair and may be considered in those at low or average surgical risk. Longterm monitoring, including imaging, should be performed to ensure late complications do not develop. Several studies have been published since then and EVAR is being more widely used.

We also briefly discussed multiple myeloma. A review in BLOOD was published in 2008. Treatment in this field has evolved rapidly over recent years.

Finally, we discussed the physical exam diagnosis of aortic stenosis. The findings of a paper examining a clinical prediction rule for AS is summarized in the following figure from the article.


Abscence of a murmur over the right clavicle (see article Table 1 for how to auscultate for this) as performend by a staff internist or senior medical resident, effectively rules out moderate to severe AS (usually more important clinically than ruling in AS, as to rule it in a TTE will often be performed).

The JAMA rational clinical exam "Does this patient have an abnormal systolic murmur?" can be found here.