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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?
Recommended