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Patient Education
General: Follow body uid precautions (see ID: Hepatitis). Obtain vaccination for hepatitis A and B.
Diet: High carbohydrate diet as tolerated. May need to limit protein to 1 mg/kg per day if hepatic encephalopa-
thy is present.
Medications: Vitamin K 5-10 mg po qd for hypo-prothrominaemia. Lactulose for hepatic encephalopathy
15-30 ml bid/tid (titrate to 3 loose bowel movements per day). Avoid acetaminophen.
Prevention and Hygiene: Pre and post exposure vaccination for hepatitis A and B (see PM: Immunizations).
Household contacts, pre-school children, barracks mates should be vaccinated for Hepatitis A. Good hand
washing and sanitation are mandatory. Avoid promiscuous sexual contact.
Wound Care: Blood and secretions are potentially infectious.
Follow-up Actions
Return evaluation: Acute viral hepatitis usually requires 2-3 months of convalescence to recover. Monitor
symptoms.
Evacuation/Consultation Criteria: Evacuate urgently if signs of encephalopathy, bleeding, easy bruisability,
ascites, peripheral edema, or fever with RUQ abdominal pain. Evacuate more stable jaundiced patients when
possible. Consult with GI specialist early and as needed.
Symptom: Joint Pain
CAPT Robert Johnson, MC, USNIntroduction: Arthritis (joint inflammation) is not only painful, but also causes fear of disability and deformity.
The pain may be localized or diffuse. It may be related to trauma, overuse, degenerative processes or
systemic inflammatory disease. The pain may come from the joint itself, supporting soft tissue structures, or
may be referred from neurovascular structures. Over 120 different conditions have been called “arthritis” but
most musculoskeletal or joint pain can be characterized as either mechanical or inflammatory. Mechanical
processes can usually be treated conservatively with rest, ice, heat, other physical therapy modalities and
rehabilitative exercise. Inflammatory conditions tend to be more chronic, limiting, and require referral for
specialty management. History, physical exam and evolution of the process over time are generally sufficient
to distinguish mechanical from inflammatory disease. Psychosocial stresses may aggravate musculoskeletal
pain. See individual sections on various joint pains (e.g., Ankle Pain, etc.).
Subjective: Symptoms
Joint pain, fever, loss of appetite, fatigue, weight loss, rash, joint stiffness and swelling.
Focused History: Where does it hurt? (pain around a joint, with tenderness in soft tissue is likely muscle,
tendon, ligament or bursa damage) Does it hurt when you move the joint? (joint centered pain, worse with
motion suggests localizes joint process– true arthritis) Did something hit the joint, or did you bend it, twist it
or otherwise traumatize it? (traumatic arthritis) Is there redness, warmth or swelling around a joint or joints?
(seen in infection--cellulitis, septic bursa or septic joint; or inflammatory arthritis like rheumatoid
arthritis) How long does it take you to limber up in the morning to reach your best for the day? (stiffness
resolving in < 1 hr., likely mechanical, e.g., osteoarthritis; > 1 hr. suspect inflammatory disease) Does
the pain get better with exercise? (pain at rest, with stiffness after prolonged immobility, gets better with
exercise--tends to be inflammatory; pain worse with exercise or at the end of the day tends to be mechanical)
How many joints hurt? (more joints, more likely systemic disease) How long have you had pain? (>6
weeks is chronic)
Pearls:
- Symptoms of knee giving way or locking is usually mechanical (cartilage or ligament tear or loose body).
- Complaints of numbness and tingling related to a sore joint are not typical arthritis complaints. Consider
alternate diagnoses. - Red, hot, swollen joint is a septic joint until proven otherwise. Gout and other crystal arthritides can
mimic infection.