Differential diagnosis
Dr. Ioana Saulescu
Musculoskeletal
complaints = among the
most common
problems in clinical
medicine
All physicians have to
be able to recognize
this disorders.
Musculoskeletal disorders
The patient history and physical examination
= basis of diagnosis
Signs and symptoms of joint and extra-articular features
Why is it so important?
Sometimes, it is very easy to establish the
diagnosis!
Six main types of a rheumatic complaint
Inflammatory musculoskeletal disease
Mechanical joint or periarticular disorder
Bone disorder
Non-rheumatic disease (from distance-referred pain)
Functional disorder
Disorder of unknown cause
Symptoms of a musculoskeletal problem
Pain
Stiffness
Swelling
Weakness
Loss of function
Fatigue and malaise
Depression and fear
Sleep disturbance
Symptoms of
systemic disease
A lot of questions for the clinician!
Pain -the most common cause of presentation
Inflammatory pain
Mechanical pain
Neuralgic pain
Bone pain
Referred pain
Establish a pattern for the pain!
Inflammatory joint pain:pain in the
morning, at rest, ameliorated by use
Inflammatory /
infective disorder
Mechanical joint pain: pain related
to joint use, ameliorated by rest
Degenerative
disease
Neuralgic pain:diffuse pain and
parehestesia in dermatome
Root or peripheral
nerve compression
Bone pain:pain at rest , at night, but
also with use
Tumor, Paget
disease, Fracture
Referred pain: pain unaffected by
local movement.
From the distance
Stiffness
How long does it take you before you are moving as well as you are going to move for
the day?
MORNING STIFFNESS
Questions about stiffness
What joints or muscle does it affect?
When during the day?
How long does it last?
What makes it worse?
What improves it?
Swelling and deformity
Did it follow an injury?
Did it appear rapidly or
slowly?
Does it come and go?
Is it gradually enlarging
or progressing?
Is it painful?
Joint or periarthicular structure
Effusion,
Synovial proliferation
Bony growth
IMAGING!
Weakness
Of limbs or of the whole body
Muscle disorder or neuropathy
# general fatigue, depression, fibromyalgia.
Other important issues to asses
Is the problem mono/oligo or poliarthicular , symetric or asymetric?
Is it an acute, subacute or chronic problem? Is it progressive or recurrent problem?
Is there evidence of a systemic proces?
Is there a family history of a similar or related disorder?
Location and symetry(1)
Sometimes the most important clue in identifying the cause!
Specific arthropaties =predilection for specific joint areas.
Wrists and PIP of the hands and feet= rheumatoid arthritis,
DIP of the hands and feet=psoriatic /osteoarthritis ,
Big joints and spine=seronegative spondilarthritis,
Great toe: gout.
Do not forget SYMMETRY.
Onset and chronology
Acute onset, in hours/several days= attacks
of gout or septic arthrithis,
Subacute onset, in weeks/less than 3
month= majority of the rheumatic disease,
Chronic onset, over 3 month / years =
fibromyalgia.
Persistent or recurrent.
Monoarticular joint disease(1)
Prompt evaluation to rule out
infections/malignancy
Inflamatory/infectious disease
Mechanical or infiltrative disorders
Anthibiotherapy until exclusion of septic arthrtis
Acute/chronic monoarticular joint disease(2)
Crystal induced arthritis,
Septic arthritis,
More rare: systemic disease presenting with
monoarticular involvement,
Malignancy, benign tumor.
You must distinguish between
articular and periarticular problem
Polyarticular joint disease
Inflamatory/non-inflamatory disease,
Acute/chronic,
Oligoarticular/poliarticular,
Symetric/asymetric,
With/without axial involvement.
Establish pattern, range of motion,
signs of inflammation.
Pattern of joint involvement
Additive: most common, least specific,
Migratory: most characteristic of rheumatic
fever, Lyme disease, leukemia,
Intermitent (repetitive): crystal induced
disease, RA, SLE, sarcoidosis.
The hand
Osteoarthritis of the hand
Mechanical complain,
DIP involvement Heberden nodes, PIP involvement
Bouchard nodes
Deviation of the phalanges without a pattern,
Erosive arthrosis.
Rheumatoid arthritis of the hands
Inflamator disease,
Symmetrical pattern,
without involving DIP,
Fusiform swelling of the
PIP,
Swan neck deformity,
boutonniere deformity,
Atrophy of the
muscules.
Seronegative spondilarthrities
Psoriatic arthritis
Involvement of DIP,
Asymmetrical
oligoarthritis or
symmetrical poliarthritis
Dactilitis.
Reactive arthritis
Rare involvement of the
hand,
Dactilitis,
Keratodermia
blenoragicum.
Cristal induced arthritis
Condrocalcinosis
Often associated with
OA.
Gout
Usually in chronic
disease,
Tophi.
Systemic sclerosis
Sclerodactyly,
Raynaud syndrome
Telangiectasias,
Digital ulcers.
SLE
Non- erosive,
symmetrical arthritis,
Jaccoud arthropaties.
Septic arthritis
Gonococal septic arthritis =
mono/oligoarthritis, tenosinovitis,
Non-gonococal septic arthritis =
monoarticular
Viral arthritis = parvovirus B19, HBV.
Elbow
periarthicular
involvement: olecranon
bursitis, epicondylitis,
swelling in lateral
process: synovitis.
Olecranon bursitis
Posttrauma,
Non-septic etiology:
RA, cristal induced,
Septic etiology:
especially in
immunosupression.
The shoulder(1)
Proper examination:
begin with visualization of the girdle area.
From the front and from the back
Includes sternoclavicular, glenohumeral,
acromioclavicular joints
The shoulder(2)
Notice the asymmetry,
Muscle atrophy: chronic disorder, like RA,
Sinovitis: visible when the effusion is large,
Active and pasive mobility.
Polymyositis, polymyalgia, fibromyalgia
The knee
Osteoarthritis
Rheumatoid arthritis
Cristal induced
arthritis.
The foot
RA
Symmetrical distribution
of all small joints,
Plantar blisters
Psoriatic arthritis
Asymmetry,
dactilitis.
Reactive arthritis
Mono/oligoarthritis
Asymmetry,
Dactilitis
Entesitis
Nodous erythema:
yersinia,
Gout
Acute: I phalang,
Chronic disorder: tophy.
The hip
The spine
As a whole and on region
Mechanical, inflamatory, septic, malignancy
The spine
Axial alone,
Axial and peripheral.
Sometimes mixed complaints.
Seronegative spondilarthritis
Inflamatory complain
Usually young, male patients
Ask for family history
Look for genetic linkage
Infectious trigger: genito-urinary or enteric
Response to NSAID
Older patients
Osteoporosis
Metastasis
Spondilosis
Pay attention
An old disease may be complicated by a new
one!
One patient may have different complaint!
Make the right exam and choose the proper
treatment!