Professional Documents
Culture Documents
OBJECTIVES
Evaluation of a patient with joint pain.
Specific symptoms and signs of different pathologies.
Making a provisional diagnosis with respect to history,
examination and investigations.
Target audience: Young doctors and medical students.
EXCLUSIONS:
Detailed discussion of different pathologies and investigations.
Management part.
CASE
TERMS
ARTHRALGIA refers to joint pain. It is a
symptom.
ARTHRITIS refers to inflammation of the joints
and its a diagnosis. Signs of inflammation
include tenderness, redness, swelling, increase
in temperature and decrease/loss of function.
EVALUATION OF JOINT
PAIN/INFLAMMATION
1.
2.
3.
4.
Distribution
Acute v/s chronic
Systemic symptoms
Joint inflammation
Question 1
What
is
the
distribution of joint
involvement
and
how many joints
A.Polyarticular symmetric
B. Monoarticular
C. Migratory
D. Oligoarticular asymmetric
A. POLYARTICULAR SYMMETRIC
Rheumatoid Arthritis (RA)
Systemic lupus erythematosus (SLE)
Viral (Hepatitis B, EBV, Parvovirus B19)
Sjogren syndrome
B. MONOARTICULAR
Osteoarthritis (OA)
Crystal-induced arthritis (gout,
pseudogout)
Septic Arthritis (Gonococcus)
Trauma
Hemarthrosis
C. MIGRATORY
Rheumatic Fever
Disseminated gonococcal infection
Lyme disease
D. OLIGOARTICULAR
ASYMMETRIC
Spondyloarthropathies
(back pain +
peripheral arthritis)
-Ankylosing spondylitis
-Psoriatic arthritis
-Rieter Syndrome
-Enteropathic arthritis
Examples
A 62-year-old man presents with right knee pain.
A 24-year-old woman presents with bilateral wrist,
MCP, PIP joint swelling, and pain.
A 32-year-old man presents with knee swelling after
you had seen him one week ago for left wrist pain and
swelling, which has now resolved.
A 29-year-old man has right knee pain and swelling
and left hip pain.
Question 2
Question 3
SLE:
Question 4
Is there evidence of
joint inflammation?
OA is typically noninflammatory.
Reaching to a diagnosis
History answer all the four questions and ask
for systemic symptoms.
Examination look for signs of inflammation
and systemic examination for specific signs.
Investigations blood tests, radiology and
joint aspiration.
TESTS IN RHEUMATOLOGIC
DISEASES
Joint Aspiration
If there is fluid in
the joint, it needs
analysis
immediately.
The basic tests to
run on the
synovial fluid are
the 3 Cs (cell
count, crystals,
and cultures) and
the Gram stain.
TESTS IN RHEUMATOLOGIC
DISEASES
CBC
UCE
PT
ESR, CRP
RA, Anti-CCP
ANA
ANCA
TESTS IN RHEUMATOLOGIC
DISEASES
TESTS IN RHEUMATOLOGIC
DISEASES
DISCUSS
ION
RHEUMATOID ARTHRITIS
RA is a chronic inflammatory multisystemic disease
with the main target being the synovium. The
hallmark of RA is inflammatory synovitis that
presents in a symmetric distribution. The intense
joint inflammation that occurs has the potential to
destroy cartilage and cause bone erosions and
eventually deform the joint.
Anti-CCP (cyclic citrullinated peptide) is also positive
in RA and carries a very high specificity.
Extraarticular Manifestations
Damage to the ligaments and tendons
Radial deviation of the wrist with ulnar deviation of the
digits
Boutonnire deformity
Swan-neck deformity
Rheumatoid nodules
Initial event caused by focal vasculitis
2030% of patients with RA; usually occur in areas of
mechanical stress (olecranon, occiput, Achilles tendon)
Methotrexate may flare this process
LABORATORY FINDINGS
RF or anti-CCP
Anemia
ESR or C-reactive protein (CRP)
X-rays
Synovial fluid analysis
The End
Thank You!