Lecture 39 March 9th-msk

1DDX: LECTURE 39 – MARCH 9th, 2007 CONDITIONS OF THE MUSCULOSKELELTAL SYSTEM • •

Seronegative means that they don’t contain Rheumatoid factor. Polyarthrides Pathologies will be presented as “what is different” from what has come before. Lots of similarities, learn to DDX.

PSORIATIC ARTHRITIS • Patients have psoriasis and arthritis • “42%” should read “10%” • • • •

Need to know the 3 different types and what differentiates them from each other. MC is Asymmetric inflammatory arthritis (47%) Symmetric starts to look like RA Psoriatic spondylitis starts to look like ankylosing spondylitis

ASYMMETRIC INFLAMMATORY ARTHRITIS • Men and women get more often (RA: female m/c) • People have psoriasis for years first. • PIPs and DIPs are affected (RA doesn’t affect DIP) • Pitting of the nails (not present in RA) • Non-symmetrical (DDX RA) • Eyes are affected. SYMMETRIC ARTHRITIS Arthritis mulitans: very destructive: bone starts to be eaten away. Subcutaneous nodules not present (in 20-30% of RA patients: can look at this, but the absence doesn’t rule out RA) ¼ of patients have + rheumatoid factor PSORIATIC SPONDYLITIS Primary symptom: ½ have spondylitis and ½ have sacroiliitis Not as bad as AS Small percentage develop arthritis mutilans Ensethopathy: irritation to soft tissue components that attach to bone. Diagnosis: • Always think about PsA when you see pt. With psoriasis and arthritis. • **know that they have a high frequency of HLA-B27. • No specific age group, but usually middle-age. Lab findings: • See notes • Will see high ESR and C-reactive protein with all inflammatory conditions. Can use this to track progress of treatment. Pencil in a cup: narrowing of one bone into another.

Opera glass deformity: Energetics: Skin is what we show the world. What isn’t meshing with a patient with a skin pathology? Skin pathologies: always irritating patient, always in their face. DDX LECTURE 39, MARCH 9th, 2007 – PAGE 1

REITER’S SYNDROME Combination of 3 different paths in one. Arthritis, UTI, eye inflammation (conjunctivitis). “Can’t see, can’t pee, can’t dance with me” Seronegative Look at patient’s history. Sexual practices? Travel to location where they may have contracted dysentery.l Prognosis: • Can linger, person can get reinfected if they lead life that puts them at risk.

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These conditions will interfere with blood vessel  aortic regurgitation.

Energetics: • What are you keeping a blind eye to, not looking at in your life? How does this tie in to the rest of their life? • Dr. Loken had a patient with arthritic symptoms, but his main concern was that he was developing so many floaters that he was losing peripheral vision and general vision. Patient convinced that he had STI. Had no partners before 20 year marriage, his wife had no partners. Why does he think he had an STI? • Talk with patient, look at history, there were blanked out areas in his memory. Skipped age 9-16. Had blocked out this part of his life. Had been molested by his older brother when he was about 10. From this incident, thought that he had an STI. He thought he would get an STI from ANY anal sex: not just with an infected person. Decided that he needed to talk to his brother. Second appointment, felt 50% better. Didn’t see patient again. • People don’t just get symptoms for no reason! • Body will say: you don’t have to look at it: closing off vision. • • •

Nurture: what do we use to nurture ourselves? Look for imbalances within this. Often an imbalance in sex. Do they describe a common sensation in the eyes, urinary tract, joints? Is there pain everywhere? Restriction? Constant? Try to link this to their emotional life. Inflammation is yin in nature. If there is inflammation, look for imbalances within yin.

ANKYLOSING SPONDYLITIS (AS) Correlation between IBS and the onset of AS. Will start to get inflammation in SI joint: this may be the first thing that they notice. Spine will fuse over time. Will lock, and will havev to use muscles to keep themselves upright. Spine becomes rigid: bamboo spine Youngest of arthritides: 15-35 years old. White male disease. 90% have HLA-B27 Main symptom is bilateral sacroiliitis. Will have limited expansion through ribs. Affects CV and lungs: chest isn’t expanding the way that it is supposed to. Pressure systems that rely on the space that they have for proper functioning. Grading of ROM 1-4. 4=complete ankylosis. 1=normal Hyperchromic anemia: There is a lot of HB in the cell, but not enough of cells overall. This is a B12 deficiency, not an iron deficiency. Can fuse within a few years. Care: treatment is physiotherapy. Energetics: Getting frozen in your body. Can’t move into next phase of life? High school, college time frame. Lots of change in this period. Core issues? SI joint is a transition between earth and water. What is PARALYZING them from moving forward? Fear? GOUT One of the most painful conditions: some patients can’t stand the feeling of sheets on their toes. DDX LECTURE 39, MARCH 9th, 2007 – PAGE 2

Cascade of inflammatory reactions Comes on very quickly!

Uric acid excreted through renal system, and through stool. Secondary: can develop through drugs, other disorders. 95% male (Like AS). Women more at risk after menopause. Red meat (high in purines), alcohol reduces excretion of purines. Usually the MTP joint of big toe. Can’t assume that this presentation is gout! Deposits of urate crystals (tophi). Get deposits in the helix of the ear. Main lab finding is hyperuricemia. If an aspiration of synovial fluid is done, will find uric acid crystals. Increase in chance of getting uric acid stones. Very painful! Uric acid crystals will start to calcify if they are there long enough. Energetics of gout Look at R or L: Yang or Yin. Ethere toe has to do with internal spirituality. Are you on you path? Are you taking care of yourself? Getting nurturing from diet and lifestyle that you aren’t getting from other areas? Pain: we have pain so that our body can get our attention! Don’t want to constantly take pain killers because we aren’t hearing this message. Have to figure out why you are in pain! Message will get stronger and stronger to get through to you. Address the pain, but look at the underlying reasons that this person is getting pain to begin with. PSEUDOGOUT Deposition of CPDC crystals instead of uric acid crystals. Tends to be a condition of the elderly (DDX gout) As we age, get changes in enzyme production, more likely to get gout. More female dominated (DDX gout) Knee joint is the most commonly affected (DDX gout) Looks a lot like gout, but the location and crystals are different. Diagnosis: Might have hyperuricemia, but they don’t have to. Calcification in areas where there has been inflammation for a while. POLYMYALGIA RHEUMATICA (PR) Elevated ESR, immediate symptom relief from prednizone (caution: this drug causes osteoporosis). Tends to occur in elderly, most get it after 70. Patients don’t usually come in until they are in significant pain. Elderly patients: probably used to some aches and pains in body. Morning stiffness lasts 2-3 hours. Can be bilateral, doesn’t have to be. Can spread into wrists and knees. Temporal arteritis (giant cell arteritis): leads to loss of sight. Supplies the head and eyes with blood. Damage  blindness. Artery is sensitive to light touch.

DDX LECTURE 39, MARCH 9th, 2007 – PAGE 3