قالب پاورپوینت پزشکی، فیزیولوژی، ارتوپد، درد و صدمات، آناتومی

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1A 58-year-old woman is evaluated for brief episodes of pain, swelling, and redness in the right wrist lasting 4 days. Over the past 2 years, she has experienced similar episodes in her left wrist and left third metacarpophalangeal joint, which resolved without treatment. On physical examination, vital signs are normal. Joint examination reveals swelling, warmth, and redness of the left wrist, as well as redness and bony enlargement of the left third metacarpophalangeal joint. Other joints are normal. Laboratory studies show normal complete blood count, comprehensive metabolic panel, and serum calcium, magnesium, and thyroid-stimulating hormone levels. Radiographs of the wrist and metacarpophalangeal joints are shown on the next page. Synovial fluid analysis from the left wrist shows a leukocyte count of 30,000/uL (30 x 10%/L) with 90% neutrophils. Polarizing microscopy reveals numerous positively birefringent rhomboid crystals within neutrophils. Synovial fluid Gram stain and culture are negative. Which of the following is the most appropriate laboratory study to perform next? (A) Antinuclear antibodies (B) Erythrocyte sedimentation rate (C) Rheumatoid factor (D) Serum ferritin a by Shaghayegh 

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Clinical Presentation of CPPD Patient Symptoms Physical Exam Swelling, warmth, Recurrent episodes of redness, and bony pain, swelling, and enlargement of affected redness in wrists and joints; other joints MCP joints lasting days, normal. resolving spontaneously. Synovial Fluid Findings Leukocyte count ~30,000/uL with 90% neutrophils; positively birefringent rhomboid crystals confirm CPP. crystals; no infection. ۴ 

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Pathophysiology of CPPD Clinical Impact Crystals trigger inflammation causing acute arthritis resembling gout but with longer attacks and possible systemic symptoms. Chronic CPPD mimics osteoarthritis with polyarticular joint damage, often in atypical locations. Crystal Formation Increased inorganic pyrophosphate in cartilage combines with calcium to form CPP crystals, mainly from ATP breakdown. Mutations in the ANKH gene can elevate pyrophosphate levels, promoting crystal deposition. 

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Radiographic Features of CPPD Chondrocalcinosis Hooked Osteophytes Cartilage calcification visible Characteristic bony in wrist radiographs, a projections at 2nd and 3rd hallmark of CPPD. MCP joints, distinguishing CPP crystal arthritis. Joint Damage Radiographs may show degenerative changes with severe joint involvement in chronic disease. 

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Laboratory Evaluation: Synovial Fluid Analysis Crystal Identification Positively birefringent rhomboid crystals confirm CPPD diagnosis. Leukocyte Count Elevated to 30,000/uL with neutrophil predominance, consistent with acute CPP crystal arthritis. Infection Exclusion Negative Gram stain and culture rule out septic arthritis. ۴ 

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Screening for Secondary Causes of CPPD 1 2 3 Metabolic Disorders to Rule Current Patient Labs Recommended Next Test Out Normal metabolic panel, magnesium, and Serum ferritin and transferrin saturation * Hemochromatosis TSH exclude most causes except to screen for hemochromatosis. + Hyperparathyraidien hemochromatosis. * Hypothyroidism + Hypophosphatasia * Hypomagnesemia 

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Why Serum Ferritin Is the Best Next Test Age Consideration Excluding Other Causes Patient is under 60, so Normal thyroid and secondary causes like metabolic labs make hemochromatosis must be hypothyroidism and other excluded. metabolic disorders unlikely. Screening Efficiency Ferritin and transferrin saturation are sensitive and specific for detecting iron overload in hemochromatosis. 

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Why Other Tests Are Less Appropriate Rheumatoid Factor (RF) Unlikely rheumatoid arthritis due to asymmetrical joint involvement and absence of typical RA features. Erythrocyte Sedimentation Rate (ESR) Nonspecific inflammation marker; does not identify CPPD or secondary causes. Antinuclear Antibodies (ANA) Not indicated; no clinical signs of lupus or autoimmune disease. 

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Summary of Key Clinical and Diagnostic Features Target population ‘A. Symptomatic | 8. Asymptomatic Step1 = ee [' denen ee ۰ ‘1st degree relative of HH Normal <45% and | meng aa 200-200 Step 2 No further iron evaluation Heterozygote C282Y ‘of non-C282Y Ferritin < 1000 & Ferritin > 1000 ۲ 4 nommal ALTIAST elevated ALTIAST Step 3 | Exclude other liver or 1 1 blood diseases. ‘Therapeutic Liver biopsy for HIC Liver biopsy+ phiebotomy | and histopathology Chondrocalcinosis Synovial Fluid Crystals Cartage caleticatlon seen on weet Kays Posvely brat Hooked Osteophytes ‘characterise raslagraphichoaing at MCP jolts 5 3 

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Clinical Takeaways and Next Steps Confirm Diagnosis Use synovial fluid analysis and radiographs to establish CPPD. Screen Secondary Causes Order serum ferritin and transferrin saturation to rule out hemochromatosis in younger patients. Manage Symptoms Initiate NSAIDs, corticosteroids, or colchicine for acute flares; monitor chronic joint damage. 

1-A 58-year-old woman is evaluated for brief episodes of pain, swelling, and redness in the right wrist lasting 4 days. Over the past 2 years, she has experienced similar episodes in her left wrist and left third metacarpophalangeal joint, which resolved without treatment. On physical examination, vital signs are normal. Joint examination reveals swelling, warmth, and redness of the left wrist, as well as redness and bony enlargement of the left third metacarpophalangeal joint. Other joints are normal. Laboratory studies show normal complete blood count, comprehensive metabolic panel, and serum calcium, magnesium, and thyroid-stimulating hormone levels. Radiographs of the wrist and metacarpophalangeal joints are shown on the next page. Synovial fluid analysis from the left wrist shows a leukocyte count of 30,000/µL (30 × 10³/L) with 90% neutrophils. Polarizing microscopy reveals numerous positively birefringent rhomboid crystals within neutrophils. Synovial fluid Gram stain and culture are negative. Which of the following is the most appropriate laboratory study to perform next? (A) Antinuclear antibodies (B) Erythrocyte sedimentation rate (C) Rheumatoid factor (D) Serum ferritin by Shaghayegh Clinical Presentation of CPPD Patient Symptoms Physical Exam Swelling, warmth, Recurrent episodes of redness, and bony pain, swelling, and enlargement of affected redness in wrists and joints; other joints MCP joints lasting days, normal. resolving spontaneously. Synovial Fluid Findings Leukocyte count ~30,000/µL with 90% neutrophils; positively birefringent rhomboid crystals confirm CPP crystals; no infection. Pathophysiology of CPPD Crystal Formation Clinical Impact Increased inorganic pyrophosphate in cartilage Crystals trigger inflammation causing acute arthritis combines with calcium to form CPP crystals, mainly resembling gout but with longer attacks and possible from ATP breakdown. systemic symptoms. Mutations in the ANKH gene can elevate Chronic CPPD mimics osteoarthritis with polyarticular pyrophosphate levels, promoting crystal deposition. joint damage, often in atypical locations. Radiographic Features of CPPD Chondrocalcinosis Hooked Osteophytes Cartilage calcification visible Characteristic bony in wrist radiographs, a projections at 2nd and 3rd hallmark of CPPD. MCP joints, distinguishing CPP crystal arthritis. Joint Damage Radiographs may show degenerative changes with severe joint involvement in chronic disease. Laboratory Evaluation: Synovial Fluid Analysis Leukocyte Count Crystal Identification Elevated to 30,000/µL Positively birefringent with neutrophil rhomboid crystals predominance, consistent confirm CPPD diagnosis. with acute CPP crystal arthritis. Infection Exclusion Negative Gram stain and culture rule out septic arthritis. Screening for Secondary Causes of CPPD Metabolic Disorders to Rule Out Current Patient Labs Recommended Next Test Normal metabolic panel, magnesium, and Serum ferritin and transferrin saturation to screen for hemochromatosis. • Hemochromatosis TSH exclude most causes except • Hyperparathyroidism hemochromatosis. • Hypothyroidism • Hypophosphatasia • Hypomagnesemia Why Serum Ferritin Is the Best Next Test Age Consideration Excluding Other Causes Patient is under 60, so Normal thyroid and secondary causes like metabolic labs make hemochromatosis must be hypothyroidism and other excluded. metabolic disorders unlikely. Screening Efficiency Ferritin and transferrin saturation are sensitive and specific for detecting iron overload in hemochromatosis. Why Other Tests Are Less Appropriate Antinuclear Antibodies (ANA) Not indicated; no clinical signs of lupus or autoimmune disease. Erythrocyte Sedimentation Rate (ESR) Rheumatoid Factor (RF) Nonspecific inflammation marker; asymmetrical joint involvement does not identify CPPD or and absence of typical RA features. secondary causes. Unlikely rheumatoid arthritis due to Summary of Key Clinical and Diagnostic Features Chondrocalcinosis Synovial Fluid Crystals Cartilage calcification seen on wrist X-rays. Positively birefringent rhomboid crystals confirm CPPD. Secondary Causes Hooked Osteophytes Characteristic radiographic finding at MCP joints. Screen for hemochromatosis and other metabolic disorders 2 3 in patients under 60. Clinical Takeaways and Next Steps Confirm Diagnosis Use synovial fluid analysis and radiographs to establish CPPD. Screen Secondary Causes Order serum ferritin and transferrin saturation to rule out hemochromatosis in younger patients. Manage Symptoms Initiate NSAIDs, corticosteroids, or colchicine for acute flares; monitor chronic joint damage.