Approach to Pateint With Arthritis

8/14/2019 Approach to Pateint With Arthritis

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Approach patient with

ARTHRITIS

DR. MOHAMMED O. AL-RUKBAN

Assistant Professor

Department of Family and Community Medicine

College of MedicineKing Saud University


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Normal Joint..


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Introduction..

Causes include various self-limited

illness and disabling and life-

threatening.

Is it Arthritis or Arthralgia?

Musculoskeletal emergencies

(infection, sepsis, compartment

syndrome).


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Arthralgia..

Fibromyalgia

Bursitis

Tendinitis Hypothyroidism

Neuropathic pain

Metabolic bone disease Depression


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Monoarthritis..

Trauma Infection:

DGI Skin lesion.

Nongonococcal bacterial infections: large joints.

Mycobacterial and fungal infection.

Crystal induced arthritis Monosodium Urate crystals (MPJ)

Ca pyrophosphate dihydrate crystals (knee)

Lyme disease

Systemic Rheumatoid diseases: Seronegative spodyloarthropathy (Reactive arthritis, psoriatic

arthritis, Inflammatory BD..)

Sarcoid periarthritis

RA

Osteoarthritis


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Polyarthritis..

Rheumatoid Arthritis

Systemic lupus Erythrematosus

Viral arthritis Reiters disease

Psoriatic arthritis

Reactive arthritis


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Migratory Arthritis..

Differential diagnosis:

Rheumatic fever

Gonococcemia

Meningococcemia

Viral Arthritis

SLE

Acute Leukemia


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Rheumatic Fever..

Majer Criteria:1- Carditis 2-Polyarthritis 3- Chorea

4-Erythema Marginatum 5- Subcutaneous nodules

Minor criteria:

1-Arthralgia 2-Ferver 3-Acute phase reactant

(ESR, CRP).4-Prolong PR interval 5-Evidence of group A

streotococcal infection (AST, Throat culture)


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History.. Age

50=OA, Pseudogout, PMR

Any Age group=Psoriatic arthritis,

Enteropathic arthritis


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History.. Sex

>Female:

SLE, RA, OA, Systemic sclerosis,Ankylosis spodylitis, PMR.

Male=Female:

Psoriatic arthritis, Enteropathicarthritis Pseudogout.

>Male: Gout, Reactive Arthritis.


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History.. Sx

Site:

Symmetrical= RA, SLE, Systemic sclerosis

Asymmetrical=OA

Large joints=OA DIP= OA, Psoriatic arthritis

MCP, PIP= RA, SLE

1stMTP= Gout, OA

Spine= OA, Ankylosis spodylitis, Psoriatic arthritis,

Reactive arthritis

Shoulder= PMR


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History.. Sx

Pain character: Aggravated by motion= Mechanical

Relieved by motion= Inflammatory.

Duration: 6 wks=systemic rheumatic diseases

Associated Sx: Morning stiffness: >1hr= RA, PMR, Inflammatory

>30 min= OA


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History.. Sx

Associated Sx:

Multi-system involvement= Systemic

rheumatic diseases.

Past Medical history:

Trauma, fracture, surgical procedures

Medication list:

Drug induced lupus.

Diuretics.


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Phy. Examination..

Joint:

Soft tissue swelling, warm, effusion=

Inflammation.

Inflammation signs extended= septic

arthritis, crystal induced arthritis, fracture.

Passive motion (N), active()= bursitis,

tendinitis, muscle injury. Passive motion (), active()= Synovitis


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Phy. Examination..

General Examination:

LAP, parotid enlargement, oral ulceration, heart

murmurs, pericardial or pleural friction rubs,

crackle= systemic disease. Fever= infection, reactive arthritis, RA, SLE,

Crystal induced arthritis

Subcutaneous nodules= RA, RHD, Gout (tophi)

Skin manifestations= psoriasis, RA, SLE Eye disease (keratoconjunctivitis sicca, uveitis.

Conjunctivitis, episcleritis)


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Laboratory Studies..

Can be misleading.

Basic: CBC, Urinalysis, U&E, LFT.

Acute phase reactant: ESR, CRP.

Antibody tests:

ANA= SLE

Anti-dsDNA= SLE

Anti-native DNA, anti-Sm= SLE RF= RA

Anti-CCP antibody=RA


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Rheumatoid Factor..

Rheumatoid Arthritis

Connective tissue diseases

Viral infection

Leishmaniasis Leprosy

Tuberculosis

Sarcoidosis

Liver diseases

Subacute bacterial endocarditis


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Laboratory Studies..

Uric acid concentration= Gout

Synovial fluid analysis= infection,

crystal induced arthritis,inflammatory..

Hepatitis B and C

Parvovirus serology


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Imaging Studies..

X-ray:

RA

Chronic Gout

OA

Ankylosing spondylosis.

MRI:

Ankylosing spondylosis.


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Rheumatoid Arthritis..

Epidemiology:

The world wide incidence of RA is

approximately 3 cases per 10,000

population and the prevalence rate isapproximately 1%


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Rheumatoid Arthritis..


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History..

Malaise

fever

fatigue weight loss

myalgias

difficulty performing activities of dailyliving


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Examination..

Joint affected

swelling

tenderness

warmth

decreased range of motion

Atrophy of the interosseous

muscles

deformities


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Diagnosis..

Morning stiffness

Arthritis of 3 or more joint areas

Arthritis of hand joints of at least one area

swollen in a wrist, MCP, or PIP joint

Symmetric arthritis

Rheumatoid nodules

Serum RF Radiographic changes typical of RA


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Deformities..


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Extra-articular manifestations..

Rheumatoid nodule

Cardiovascular

Pulmonary

GI & Renal Hematological

Skin

Vasculitis

Neurological

Ocular


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Progression of RA..

Stage 1:

- no destructive changes.

- Osteoporosis.

Stage 2:- periarticular osteoporosis w/wo slight

subchondral bone destruction.

- joint mobility limit but no destruction.

- adjacent muscle atrophy.

- extra-articular soft tissue lesions.


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Progression of RA..

Stage 3- cartilage and bone destruction in addition to

periarticular osteoporosis.

- joint deformity w/wo fibrous or bony ankylosis.

- extensive muscle atrophy.

- extra-articular soft tissue lesions.

Stage 4- criteria of stage 3.

- fibrous or bony ankylosis.


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Laboratory ..

Hematologic parameters

Anaemia

Thrombocytosis

Serum iron & IBC Serum globuline

ALP

Acute phase reactant Immunological parameters

Synovial fluid analysis


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Prognosis..

40 % of patient become disabled after

10 years.

Persistent active cases more than 1

year likely to lead to joint deformities.

Periods of activity cases have better

prognosis.

Mortality rate 2.5 times than general

population


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Systemic Lupus Erythrematosis

Malar rash

Discoid rash

Photosensitivity

Oral ulcers

Arthritis

Serositis

Renal disease (proteinuria, cellular cast)

Neurologic disease (seizure, psychosis)

Hematologic disease

Immunologic abnormalities

ANA


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Summary..

Use of time.

In one study:60% of patients with early

synovitis diagnosed as:

Rheumatoid Arthritis. Spondyloarthropathy.

20% had a self limited arthritis.

20% unclassifiable with good prognosis. In another study:36% unclassifiable

When to refer?

Approach to Pateint With Arthritis

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