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Pathophysiology of osteoporosis

Key Points ■ Osteoporosis is a systemic skeletal disease characterized by decreased bone strength and increased susceptibility to fractures. The reduction in bone strength is a function of reduced bone mass and abnormal bone quality. Determinants of bone quality include bone microarchitecture, geometry, turnover, mineralization, and osteocyte viability. ■ Peak bone mass is highly heritable, with genes controlling 60% to 85% of the variance at different…

Clinical evaluation and clinical features of osteoporosis

Key Points ■ Osteoporosis is a common disease that affects bone and is associated with increased risk of fragility fractures. ■ Fractures occur most frequently at the spine, hip, and wrist, but fractures related to osteoporosis also occur at other skeletal sites. ■ Short- and long-term consequences of osteoporotic fractures include increased morbidity and mortality, pain, physical impairment, increased cost of medical care, decreased quality of…

Epidemiology and classification of osteoporosis

Key Points ■ Osteoporosis is a systematic skeletal disorder characterized by low bone mass, microarchitectural deterioration of bone tissue, and susceptibility to fracture. It can be divided into primary and secondary forms. ■ The most widely used definition of osteoporosis is that of the World Health Organization: bone mineral density (BMD) 2.5 standard deviations or greater below the young normal mean. ■ Even though BMD and…

Basic calcium phosphate crystal deposition disease

Key Points ■ Calcific periarthritis is characterized by periarticular deposits of calcific material (hydroxyapatite), which may also result in calcific tendinitis or bursitis. ■ In calcific periarthritis, the shoulder is the main site affected, but deposits have been described near many other joints. The deposits are often inert and asymptomatic. ■ Deposits can rupture and cause local acute, crystal-induced inflammation; they may also be associated with…

Calcium pyrophosphate deposition disease (pseudogout)

Key Points ■ Calcium pyrophosphate deposition disease (CPDD) is a common and underrecognized form of arthritis in older adult patients. ■ The clinical presentation of CPDD is broad and ranges from an acute monoarticular inflammatory arthritis to a chronic polyarticular noninflammatory arthritis. ■ CPDD can be sporadic or familial and is associated with several metabolic disorders, including hyperparathyroidism, hemochromatosis, hypophosphatasia, and hypomagnesemia. ■ Accurate diagnosis of…

Management of gout and hyperuricemia

Key Points ■ Therapeutic strategies for gout and hyperuricemia have been subjected to systematic and formal consensus review processes and disseminated in recent guidelines. ■ Management strategies involve distinct but linked arms, with attention to safety and improved quality of life: ■ Antiinflammatory treatment and prophylaxis of gouty arthritis. Treatment options are designed to either prevent acute gout flares or treat active inflammation of acute and…

Clinical features of gout

Key Points ■ An acute gout flare is characterized by abrupt and rapid onset of extreme pain, within 24 hours, starting usually at night or early morning, with resolution within days to weeks. ■ In men the initial flare is usually monoarticular, whereas in postmenopausal women it may be oligo or polyarticular. ■ The most commonly involved joints are the metatarsophalangeal joints, affected in 50% of…

Etiology and pathogenesis of gout

Key Points ■ Gout is a chronic disease of monosodium urate crystal deposition, which typically presents as recurrent episodes of severe, painful inflammatory arthritis. Monosodium urate crystals form from extracellular fluids saturated with urate, the endproduct of human purine metabolism. ■ The gout flare is a severe but self-limited arthritis caused by an inflammatory response to monosodium urate crystals. Repeated gout flares and persistent crystal deposition…

Epidemiology and classification of gout

Key Points ■ In many modern societies, with abundantly available foods and a strong tendency toward a sedentary lifestyle, gout has changed its epidemiology from a “disease of kings” to a “disease of commoners,” coinciding with the global obesity epidemic. ■ Although gout’s cardinal feature is inflammatory arthritis, its underlying cause, hyperuricemia, is considered a manifestation of the metabolic syndrome mediated by insulin resistance and obesity.…

Emerging treatments for osteoarthritis

Key Points ■ Therapeutic innovation in the field of osteoarthritis includes both symptomatic (aimed at relieving pain and improving joint function) and structure-modifying treatments (aimed at slowing down joint deterioration). ■ An analysis of the therapies currently under development shows that the intraarticular route is generally favored, even if the systemic route is still being studied with a few compounds. ■ Cell therapy, in particular with…

Management of osteoarthritis

Key Points ■ Osteoarthritis (OA) is the most common form of arthritis, and pain is its most common symptom. ■ The aims of treatment are to reduce pain, improve health-related quality of life, maximize activity, and optimize participation. ■ Management of OA should be tailored to the individual based on shared decision making between the patient and their health care provider(s), considering patient preferences and values,…

Fever

Extreme changes in body temperature in psychiatric inpatients should be a cause for concern. Depending on the working diagnosis and initial treatment, fever can be an early sign of an impending disease process, with accompanying morbidity and mortality. Even temperature elevations that are not extreme, including those to about 100.4°F (38.0°C), warrant timely evaluation. In any patient on antipsychotic medication with an unrevealing fever work-up and…

Nausea and Vomiting

Background Nausea is a subjective sensation of gastric discomfort resulting in aversion to oral intake. This is associated with the behavioral drive to remove the noxious ingestant by vomiting. These two related symptoms are relatively nonspecific and can arise from a variety of causes, including primary gastrointestinal disease, central nervous system disorders, endocrine and metabolic disorders, systemic illness, disorders of the thorax, as well as adverse…

Chest Pain

Phone call Questions 1. What are the patient’s vital signs? Have they changed? 2. Is the patient dyspneic, diaphoretic, or tachypneic? 3. When did the pain begin? How does the patient describe it? How does it relate to eating or position? 4. Does the patient have a history of cardiovascular disease (myocardial infarction [MI], coronary artery disease, angina), cardiac risk factors (e.g., hypertension, hyperlipidemia, smoker), gastroesophageal…

Headache

Headaches are a common complaint on a psychiatric service and may be a symptom of a serious medical condition or a manifestation of a psychiatric disorder such as anxiety or depression. Primarily, headaches have been classified into two categories depending upon the etiology: (1) primary headaches that are recurrent and chronic in nature, and (2) secondary headaches that result from a known central nervous system (CNS)…

Insomnia

Insomnia is often a symptom of another disorder. The key to treating insomnia is to search for the underlying cause. As with any consultation, each patient deserves a complete evaluation and appropriate treatment. It is tempting to quickly prescribe sedating medications for patients complaining of sleeplessness, especially if you are fatigued. Beware of medicating patients for insomnia, however, without first assessing them. This will avoid inappropriate…

Substance Withdrawal

Substance withdrawal is commonly encountered in both psychiatric and medical patients. The psychiatrist on call is asked to evaluate and treat patients who are behaviorally difficult, have comorbid psychiatric diagnoses, suffer clinical stigmata of withdrawal, and/or complain of various subjective discomforts related to the substance(s) from which they are withdrawing. Primary concerns for substance withdrawal include medical and psychiatric stability, and identification of the specific substance(s)…

Intoxication

Substance abuse evaluation is an important component of a thorough psychiatric interview. Our understanding of the neurobiologic mechanisms of addiction has progressed rapidly. Although we now have a more complex understanding of the intricacies of substance use and substance-induced disorders, evaluating and treating an intoxicated patient remain the most challenging situations to the psychiatrist on call. Often intoxicated patients are behaviorally difficult and may present with…

The Pregnant Patient

The psychiatrist on call may be asked to assess and manage the pregnant patient. In managing a peripartum patient, providers must be cognizant that treatment decisions affect both mother and the developing fetus. The on-call psychiatrist must carefully weigh the risks of treatment with psychiatric medications in pregnancy and lactation against the risks of untreated symptoms, which may include agitation, psychosis, mania, severe depression, functional impairments,…

Physical and Sexual Trauma

Victims of trauma may require urgent medical and psychiatric attention. Here, trauma is defined as “exposure to actual or threatened death, serious injury, or sexual violence,” as defined by criterion A for post-traumatic stress and acute stress disorders in Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V). This chapter is a brief guide for the psychiatric consultant on how to provide psychiatric intervention in…