How to Summary Record. Anatomical Site Code. Anatomical Site Code. Chapter XIII M00-M99 Musculoskeletal System & Connective Tissue.

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1 How to Summary Record What Where When Infection Region Congenital Inflammation Level Infant Degeneration Medial/Lateral Juvenile Chapter XIII M00-M99 Musculoskeletal System & Connective Tissue Traumatic Nontraumatic Post-traumatic Post-procedural Anterior/Posterior Unilateral/Bilateral Adult Primary Secondary Recurrent นพ.บ ก เจ ญ ล ก มงาน ลยกรรม รพ.สวรร ประชา ก นครสวรร 1 2 Anatomical Site Code Anatomical Site Code General 1 Shoulder region 2 Upper arm clavicle, scapula, shoulder joint humerus, elbow joint 3 Forearm 4 Hand radius, ulna, wrist joint carpus, finger, metacapus 5 Pelvic and thigh 6 Lower leg buttock, femur, hip joint, pelvis fibula, knee joint, tibia 7 Ankle and foot 8 Other ankle joint, metatarsus, tarsus, toe head, neck, ribs, skull, spine, trunk 0 Multiple sites 9 Site unspecified Dorsopathies [for spine, M40] 1 Occipito-alanto-axial region 2 Cervical region 3 Cervicothoracic region 4 Thoracic region 5 Thoracolumbar region 6 Lumbar region 7 Lumbosacral region 8 Sacral and sacrococcygeal region 0 Multiple sites in spine 9 Site unspecified Knee [M23] 1 Anterior cruciate ligament Anterior horn of medial meniscus 2 Posterior cruciate ligament Posterior horn of medial meniscus 3 Medial collateral ligament Other and unspecified of medial meniscus 4 Lateral collateral ligament Anterior horn of lateral meniscus 5 Posterior horn of lateral meniscus 6 Other and unspecified lateral meniscus 7 Capsular ligament 9 Site unspecified 3 4

2 Anatomical Site Code Systemic Lupus Erythematosus autoantibodies against self antigens and formation of immune complexes Biomechanical lesions [M99] 0 Head region occipitocervical 1 Cervical region cervicothoracic 2 Thoracic region thoracolumbar 3 Lumbar region lumbosacral 4 Sacral region sacrococcygeal, sacroiliac 5 Pelvic region hip, pubic 6 Lower extremity 7 Upper extremity acromioclavicular, sternoclavicular 8 Rib cage costochondral, costovertebral, sternochondral 9 Abdomen and other เกณ จ ยของ สปสช กร เ นการ จ ยห ก กษณะทางค ก 4 ใน 11 อ : Malar rash : Discoid rash : Photosensitivity : Oral ulcers : Arthritis : Serositis : Renal disorder : Neurologic disorder : Hematologic disorder : Immunologic disorder : Antinuclear antibodies (ANA) กร เ นการ จ ย วม การ น กโดยแพท และ การ กษา

3 Clinical Criteria Systemic Lupus Erythematosus Clinical Criteria Synovitis Serositis Renal Neurologic Details - Swelling or effusion - OR tenderness at least 30 minutes of morning stiffness - Typical pleurisy >1 day OR pleural effusion OR pleural rub - Typical pericardial pain >1 day OR pericardial effusion OR pericardial rub OR pericarditis by EKG - 24-hour urine protein 500 mg OR red blood cell casts - Seizures, psychosis, mononeuritis multiplex, myelitis, peripheral or cranial neuropathy, acute confusional state All in the absence of other known causes การ กษา น บความ นแรงของโรค Fever: paracetamol, NSIADs Cutaneous: topical steroids + chloroquin Arthritis: NSAIDs + chloroquin Serositis: NSAIDs or prednisolone Myositis: prednisolone Life threatening disease: high dose steroids, immunosuppressive agents [cyclophosphamide, azathioprine, chlorambucil, methotrexate, mycophenolatem cyclosporin, tracolimus] 9 10 Lupus Nephritis อยละ 16 เ นอาการำของ SLE ก า อยละ 50 พบภาวะไต กเสบตลอดระยะเวลาของโรค Clinical Classification Mild - Proteinuria <1 g/24 hr. - Serum creatinine <1.5 mg% Moderate - Proteinuria >1 g/24 hr. - Serum creatinine <1.5 mg% Severe - Proteinuria >1 g/24 hr. - Serum creatinine >1.5 mg% WHO classification and Treatment - class I, II - no specific treatment - class II, III, IV, V - steroids - immunosuppressive agents - class IV, V - immunosuppressive agents - steriods 11 All are N08.5* Class I: Minimal mesangial lupus glomerulonephritis (LGN) Class II: Mesangial proliferative LGN Class III: Focal LGN (<50% glomeruli) Class IV: Diffuse LGN (>50% glomeruli) Class IV: Membranous LGN Class VI: Advanced sclerotic LGN (90% sclerotic glomeruli) 12

4 SLE Summary Diagnosis ICD-10 SLE M32.9 Arthritis in SLE / Lupus arthritis Pericarditis in SLE / Lupus pericarditis Endocarditis in SLE / Lupus endocarditis Pleuritis in SLE / Lupus pleuritis Nephritis in SLE / Lupus nephritis Myopathy in SLE Encephalitis in SLE / Myelitis in SLE Dementia in SLE M M14.8 M I32.8 M I39.- M J99.1 M N08.5 M G05.8 M G73.7 M F02.8 Drug-induced SLE M32.0 Discoid lupus erythematosus L93.0 Crystal Arthropathies Pseudogout Calcium Pyrophophate Deposition Disease (CPPD) Chondrocalcinosis Hyperuricemia Crystal Arthropathies Monosodium Urate Crystal Monosodium urate (MSU) Calcium pyrophosphate dihydrate (CPPD) Basic calcium phosphate hydroxyapatite (BCP) Calcium oxalate Cholesterol Cysteine/Crystine Disease Acute gout; Chronic tophaceous gout Acute pseudogout, Chronic arthropathy, Chondrocalcinosis Calcific periarthritis; Destructive arthropathy; Soft tissue calcinosis Acute arthritis in renal dialysis Chronic synovial effusion in RA/OA Acute arthritis Hyperuricemia Disorder of purine metabolism : Hyperuricemia : Deposition of uric acid crystals in the tissues Various clinical manifestations include : Acute gouty attack : Chronic tophaceous gout : Renal calculi : Urate nephropathy 15 16

5 Monosodium Urate Acute y Attack Monosodium urate Usually on first metatarsophalangeal joint at night (~70%) : Joint rapidly become swollen, red and tender to touch : Often a systemic reaction with fever and an acute phase reaction : Many MSU crystals in synovial fluid needle shaped, negative birefringent (yellow) NSAIDs, Colchicine, Steroids [intra-articular or systemic] Chronic Tophaceous Monosodium urate Continuous inflammation of many joints with pain and immobility : Mass of irate crystals deposit as chalky material tophi over joints-bony : Urate nephropathy and renal calculi of uric acid Allopurinol, Uricosuric agents [probenecid, sulfinpyrazone] CPPD Common form of crystal arthritis less frequent and less understood Knee and wrist are most affected Often asymptomatic, with only radiographic changes : Chondrocalcinosis Various clinical manifestations include : Acute CPP crystal arthritis (Pseudogout) : Chronic arthritis Calcium pyrophosphate deposition disease Associate predisposing conditions : Hemochromatosis, Hyperparathyroidism, Hypomagnesemia, Hypophosphatasia, Alkaptonuria, Wilson s disease and Increasing age 19 20

6 CPPD Calcium pyrophosphate deposition disease NSAIDs, Intra-articular steroids No long term metabolic management Calcium Oxalate Hydroxyapatite, Tricalcium phosphate, Octacalcium phosphate Often difficult to identify Tend to occur in young females and affects the shoulder, wrist Various clinical manifestations include : Acute calcific arthropahty : Destructive arthropathy Milwaukee shoulder syndrome : Osteoarthritis : Soft tissue calcification Basic calcium phosphate NSAIDs, Intra-articular steroids No long term metabolic management birefringent bipyramidal BCP Hydroxyapatite, Tricalcium phosphate, Octacalcium phosphate Often difficult to identify Tend to occur in young females and affects the shoulder, wrist Various clinical manifestations include : Acute calcific arthropahty : Destructive arthropathy Milwaukee shoulder syndrome : Osteoarthritis : Soft tissue calcification Basic calcium phosphate NSAIDs, Intra-articular steroids No long term metabolic management Gutta Gote = a drop 23 24

7 Classification Primary gout 90% Gutta Gote = a drop Abnormality in the enzyme of purine metabolism Secondary gout 10% Renal insufficiency, Diuretic therapy, Multiple myeloma, Carcinoma Stages of y arthritis Asymptomatic hyperuricemia Acute gout / Acute gouty arthritis Interval / Intercritical Chronic tophaceous gout Rich man s disease, Disease of Kings, Unwalkable disease, Podagra Clinical Diagnosis: two of the following criteria : clear history of at least 2 weeks of painful joint swelling with complete resolution within 2 weeks : clear history or observation of podagra : presence of typhus : rapid response to colchicine within 48 hours of treatment initiation Definitive diagnosis : presence of monosodium urate crystals in synovial fluid/tissues New York criteria Rome criteria ACR preliminary criteria Urate crystals in joint fluid, tissue, or tophi OR Two of the following -2 attacks of painful limb swelling and/or abrupt onset with remission in 1-2 weeks -attack involving great toe -presence of typhus -response to colchicine within 48 hours Two of the following -painful joint swelling -abrupt in onset with remission in 1-2 weeks -serum uric acid >7 mg in men, >6 mg in women -presence of a typhus -presence of urate crystals in synovial fluid 27 Urate crystals in joint fluid OR Six of the following ->1 acute arthritis attack -maximum inflammation in one day -monoarthritis attack -redness of joint -pain or swelling of first MTP -unilateral first MTP joint attack -unilateral tarsal joint attack -presence of a typhus -hyperuricemia -asymmetrical swelling within a joint on X-ray -subcortical cysts without erosion on X-ray Asymptomatic Hyperuricemia Hyperuricemia alone does NOT make a diagnosis of gout - uric acid >7 mg/dl in male; >6 mg/sl in female - probability of gout increases with higher uric acid levels - 80% of gouty patients have uric acid <9 mg/dl Asymptomatic hyperuricemia generally requires no treatment 28

8 Asymptomatic Hyperuricemia Impaired Excretion (90%) Increased Production (10%) Chronic kidney disease Drugs: thiazide, aspirin, cyclosporine Insulin resistance Hypertension Lead toxicity Hyperparathyroidism Lactic production: alcohol, starvation G6PD deficiency Diet, Alcohol Lesch Nyhan syndrome (HGPRT deficiency) G6PD deficiency Increased purine turnover Myelproliferative disorders Lymphoma, Leukemia Tumor lysis in chemotherapy Severe psoriasis Paget s disease of bone Pseudogout Calcium pyrophosphate deposition disease Calcium pyrophosphate dihydrate disease Common form of crystal arthritis less frequent and less understood Deposition of CPPD in articular tissues is common in elderly : 10 15% in years, 30 50% in >85 years Knee (most frequently), wrist, shoulder, ankle, elbow, hands Positive birefringent rhomboid shaped crystals HGPRT: hypoxanthine-guanine-phosphoribosyl transferase vs. Pseudogout vs. Pseudogout Polarized Light Microscopy 31 32

9 vs. Pseudogout Crystal Arthropathy - hallux, ankle, knee, hand - younger, male - overhanging edges, pouched out lesion, preservation of joint space Pseudogout - knee, wrist, ankle - older, female - calcification densities in hyaline or fibrocartilage Almost any joint can be affected by either disease! Summary Diagnosis ICD-10 Hyperuricemia E79.0 Primary gout Idiopathic gout Secondary gout Drug-induced gout in renal insufficiency Lead-induced gout Syphilitic gout in Lesh-Nyhan syndrome in sickle cell disorders M10.9- M10.0- M10.0- M10.4- M10.2- M10.3- M10.1- A M14.8 E M14.0 D M Crystal Arthropathy Crystal Arthropathy Summary Diagnosis ICD-10 Summary Diagnosis ICD-10 Urate nephropathy Renal calculi in gout y tophi of heart y tophi of ear Neuropathy due to gout M N08.4 M N22.8 M I43.8 M H62.8 M G99.1 Pseudogout Chondrocalcinosis Secondary chondrocalcinosis Calcium hydroxypatite arthropathy Calcium pyrophosphate dihydrate disease Dicalcium phosphate arthropathy M11.2- M11.0- M11.2- M11.0- M11.8- M11.8- Crystal arthropathy M