By Patience H. White MD, MA, Rowland W. Chang MD, MPH (auth.), John H. Klippel MD, John H. Stone MD, MPH, Leslie J. Crofford MD, Patience H. White MD, MA (eds.)
One of the main prestigious, finished texts on arthritis and similar ailments, together with osteoarthritis, rheumatoid arthritis, osteoporosis, lupus and a couple of hundred others.
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Additional info for Primer on the Rheumatic Diseases
Sample text
Although a rare patient with crystal-induced arthropathy, RA, or even a seronegative arthropathy may have a WBC count greater than 100,000 cells/mm3, such patients should be treated empirically for a septic joint until microbiologic data exclude infection. A WBC count of less than 100,000 cells/mm3 does not preclude the possibility of infection. Patients with CHAPTER 2 • EVALUATION OF THE PATIENT chronic inflammatory arthritides due to RA, SLE, or psoriatic arthritis have an increased risk of joint sepsis secondary to both the structural joint damage caused by chronic inflammation and the immunosuppressive effects of many of the drugs used to treat those diseases.
Swelling in the ankle area eliminates the normal contours associated with the malleoli. The joint line of the ankle is palpated anteriorly (Figure 2A-5). Boggy swelling and tenderness in this area are typical of ankle synovitis. Tenderness and swelling posteriorly at the insertion of the Achilles tendon usually indicates enthesitis, although this can also result from bursitis of the retrocalcaneal bursa. Tenderness in the heel region can indicate plantar fasciitis, another enthesitis associated with spondylarthropathies but also common in overuse injuries and arch abnormalities.
Although many clinicians apply ethyl chloride to the skin before injecting the anesthesia, others believe this practice is cumbersome and results in no clinically significant additional anesthesia. After the periarticular tissues have been anesthetized, a 20- or 22-gauge needle can be used to aspirate small- to medium-sized joints. An 18- or 19-gauge needle should be used for aspirating large joints or joints suspected of infections, intra-articular blood, or viscous, loculated fluid. Small syringes are easier to manipulate and provide greater suction than large syringes, but must be changed frequently when aspirating large joints with copious amounts of SF.