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APPROACH TO A CASE OF ARTHRITIS Dr.S.SRIRAM Prof.Dr.GOWRISHANKAR’S M5 UNIT
HISTORY <ul><li>Joint pain </li></ul><ul><ul><li>inflammatory arthritis. </li></ul></ul><ul><ul><li>noninflammatory arthri...
Inflammatory arthritis <ul><ul><ul><li>characterized by inflammation affecting   </li></ul></ul></ul><ul><ul><ul><ul><li>S...
<ul><li>alterations in the structure or mechanics of the joint.  </li></ul><ul><li>may occur as a result of  </li></ul><ul...
<ul><li>joint tenderness, without abnormalities </li></ul><ul><li>Also includes </li></ul><ul><ul><li>altered pain sensati...
Symptoms of joint disease <ul><li>Pain   </li></ul><ul><ul><li>inflammatory joint disease </li></ul></ul><ul><ul><ul><li>p...
<ul><li>Stiffness  </li></ul><ul><li>sensation of tightness when attempting to move joints after a period of inactivity </...
<ul><li>Swelling   </li></ul><ul><li>inflammatory arthritis </li></ul><ul><ul><ul><li>synovial hypertrophy </li></ul></ul>...
<ul><li>Limitation of motion  </li></ul><ul><li>structural damage  </li></ul><ul><li>Inflammation </li></ul><ul><li>contra...
<ul><li>Weakness  </li></ul><ul><li>result of disuse atrophy  </li></ul><ul><li>Weakness with pain  </li></ul><ul><ul><ul>...
<ul><li>Fatigue  </li></ul><ul><li>inflammatory polyarthritis </li></ul><ul><ul><ul><li>noted in the afternoon or early ev...
<ul><li>Temporal pattern of arthritis   </li></ul><ul><li>abrupt or insidious.  </li></ul><ul><li>abrupt onset  </li></ul>...
<ul><li>The temporal patterns   </li></ul><ul><ul><ul><li>migratory </li></ul></ul></ul><ul><ul><ul><li>additive or simult...
<ul><li>Number of involved joints  </li></ul><ul><li>Mono arthritis - one joint.  </li></ul><ul><li>Oligo arthritis - 2-4 ...
<ul><li>Symmetry of joint involvement   </li></ul><ul><li>Symmetric arthritis </li></ul><ul><ul><ul><li>involvement of the...
<ul><li>Distribution of affected joints   </li></ul><ul><li>The distal interphalangeal joints of the fingers </li></ul><ul...
<ul><li>Distinctive types of musculoskeletal involvement   </li></ul><ul><li>Spondyloarthropathy </li></ul><ul><ul><ul><li...
<ul><li>Extra-articular manifestations   </li></ul><ul><li>Constitutional symptoms  – </li></ul><ul><ul><ul><li>underlying...
<ul><li>Signs of inflammatory joint disease   </li></ul><ul><li>Synovial hypertrophy   </li></ul><ul><ul><li>most reliable...
<ul><li>Pain throughout the whole range of motion - acutely inflamed joint. </li></ul><ul><li>Pain as the joint is gently ...
<ul><li>Joint tenderness   </li></ul><ul><li>sensitive sign, but not specific for inflammatory arthritides.  </li></ul><ul...
<ul><li>Signs of degenerative or mechanical joint disease   </li></ul><ul><li>Bony overgrowth of the joints (osteophytes)-...
<ul><li>Joint deformity:   </li></ul><ul><ul><li>Restriction of motion </li></ul></ul><ul><ul><li>malalignment of the arti...
<ul><li>Acute monoarthritis   </li></ul><ul><li>Inflammatory   </li></ul><ul><ul><li>Septic Arthritis </li></ul></ul><ul><...
<ul><li>Chronic monoarthritis   </li></ul><ul><li>Inflammatory  </li></ul><ul><ul><li>Chronic infectious arthritis  </li><...
<ul><li>Acute polyarthritis </li></ul><ul><li>Rheumatic fever </li></ul><ul><li>Gonococcal Arthritis  </li></ul><ul><li>Po...
<ul><li>Chronic polyarthritis </li></ul><ul><li>Inflammatory   </li></ul><ul><ul><li>Rheumatoid Arthritis  </li></ul></ul>...
<ul><li>Screening tests for acute polyarthritis  </li></ul><ul><li>Blood cultures  </li></ul><ul><li>Antistreptolysin O ti...
<ul><li>Screening tests for chronic polyarthritis </li></ul><ul><li>Complete blood cell count  </li></ul><ul><li>ESR and C...
<ul><li>Screening tests for diffuse arthralgias and myalgias </li></ul><ul><li>ESR and CRP - inflammatory disease, includi...
<ul><li>THANK YOU </li></ul>
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Clinical approach to Arthritis

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Transcript of "Clinical approach to Arthritis"

  1. 1. APPROACH TO A CASE OF ARTHRITIS Dr.S.SRIRAM Prof.Dr.GOWRISHANKAR’S M5 UNIT
  2. 2. HISTORY <ul><li>Joint pain </li></ul><ul><ul><li>inflammatory arthritis. </li></ul></ul><ul><ul><li>noninflammatory arthritis. </li></ul></ul><ul><ul><li>arthralgia. </li></ul></ul>
  3. 3. Inflammatory arthritis <ul><ul><ul><li>characterized by inflammation affecting </li></ul></ul></ul><ul><ul><ul><ul><li>Synovium </li></ul></ul></ul></ul><ul><ul><ul><ul><li>synovial cavity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>entheses. </li></ul></ul></ul></ul>
  4. 4. <ul><li>alterations in the structure or mechanics of the joint. </li></ul><ul><li>may occur as a result of </li></ul><ul><li>(1) cartilage or meniscal damage </li></ul><ul><li>(2) alterations in joint anatomy </li></ul><ul><ul><ul><ul><ul><li>congenital </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>developmental </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>metabolic, </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>past inflammatory diseases . </li></ul></ul></ul></ul></ul>Non inflammatory arthritis.
  5. 5. <ul><li>joint tenderness, without abnormalities </li></ul><ul><li>Also includes </li></ul><ul><ul><li>altered pain sensation (eg, fibromyalgia) </li></ul></ul><ul><ul><li>early rheumatic syndrome (eg, arthralgias of systemic lupus erythematosus [SLE]). </li></ul></ul>Arthralgia.
  6. 6. Symptoms of joint disease <ul><li>Pain </li></ul><ul><ul><li>inflammatory joint disease </li></ul></ul><ul><ul><ul><li>pain is present both at rest and with motion </li></ul></ul></ul><ul><ul><ul><li>worse at the beginning than at the end of usage. </li></ul></ul></ul><ul><ul><li>Noninflammatory </li></ul></ul><ul><ul><ul><li>pain occurs mainly or only during motion and improves quickly with rest </li></ul></ul></ul><ul><ul><li>Pain that arises from small peripheral joints </li></ul></ul><ul><ul><ul><li>more accurately localized than pain arising from larger proximal joints. </li></ul></ul></ul>
  7. 7. <ul><li>Stiffness </li></ul><ul><li>sensation of tightness when attempting to move joints after a period of inactivity </li></ul><ul><li>subsides over time </li></ul><ul><li>inflammatory arthritis </li></ul><ul><ul><ul><li>present upon waking </li></ul></ul></ul><ul><ul><ul><li>typically lasts 30-60 minutes or longer. </li></ul></ul></ul><ul><li>noninflammatory arthritis </li></ul><ul><ul><ul><li>experienced briefly (eg, 15 min) upon waking in the morning </li></ul></ul></ul><ul><ul><ul><li>following periods of inactivity. </li></ul></ul></ul>
  8. 8. <ul><li>Swelling </li></ul><ul><li>inflammatory arthritis </li></ul><ul><ul><ul><li>synovial hypertrophy </li></ul></ul></ul><ul><ul><ul><li>synovial effusion </li></ul></ul></ul><ul><ul><ul><li>inflammation of periarticular structures </li></ul></ul></ul><ul><li>noninflammatory arthritis </li></ul><ul><ul><ul><li>formation of osteophytes </li></ul></ul></ul><ul><ul><ul><li>synovial cysts </li></ul></ul></ul><ul><ul><ul><li>Thickening </li></ul></ul></ul><ul><ul><ul><li>effusions </li></ul></ul></ul>
  9. 9. <ul><li>Limitation of motion </li></ul><ul><li>structural damage </li></ul><ul><li>Inflammation </li></ul><ul><li>contracture of surrounding soft tissues </li></ul>
  10. 10. <ul><li>Weakness </li></ul><ul><li>result of disuse atrophy </li></ul><ul><li>Weakness with pain </li></ul><ul><ul><ul><li>musculoskeletal cause (eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause. </li></ul></ul></ul>
  11. 11. <ul><li>Fatigue </li></ul><ul><li>inflammatory polyarthritis </li></ul><ul><ul><ul><li>noted in the afternoon or early evening. </li></ul></ul></ul><ul><li>psychogenic disorders </li></ul><ul><ul><ul><li>upon arising in the morning </li></ul></ul></ul><ul><ul><ul><li>related to anxiety, muscle tension, and poor sleep. </li></ul></ul></ul>
  12. 12. <ul><li>Temporal pattern of arthritis </li></ul><ul><li>abrupt or insidious. </li></ul><ul><li>abrupt onset </li></ul><ul><ul><ul><li>symptoms develop over minutes to hours </li></ul></ul></ul><ul><ul><ul><li>occur in trauma, crystalline synovitis, or infection. </li></ul></ul></ul><ul><li>insidious pattern </li></ul><ul><ul><ul><li>symptoms develop over weeks to months </li></ul></ul></ul><ul><ul><ul><li>rheumatoid arthritis (RA) and osteoarthritis. </li></ul></ul></ul><ul><li>Duration of symptoms </li></ul><ul><ul><ul><li>Acute <6 weeks in duration; </li></ul></ul></ul><ul><ul><ul><li>chronic is 6 or more weeks in duration. </li></ul></ul></ul>
  13. 13. <ul><li>The temporal patterns </li></ul><ul><ul><ul><li>migratory </li></ul></ul></ul><ul><ul><ul><li>additive or simultaneous </li></ul></ul></ul><ul><ul><ul><li>intermittent. </li></ul></ul></ul><ul><li>migratory pattern </li></ul><ul><ul><ul><li>inflammation for only a few days in each joint (eg, acute rheumatic fever, disseminated gonococcal infection). </li></ul></ul></ul><ul><li>additive or simultaneous pattern </li></ul><ul><ul><ul><li>inflammation persists in involved joints as new ones become affected. </li></ul></ul></ul><ul><li>intermittent pattern </li></ul><ul><ul><ul><li>episodic involvement occurs, with intervening periods free of joint symptoms (eg, gout, pseudogout, Lyme arthritis). </li></ul></ul></ul>
  14. 14. <ul><li>Number of involved joints </li></ul><ul><li>Mono arthritis - one joint. </li></ul><ul><li>Oligo arthritis - 2-4 joints. </li></ul><ul><li>Poly arthritis -5 or more joints. </li></ul>
  15. 15. <ul><li>Symmetry of joint involvement </li></ul><ul><li>Symmetric arthritis </li></ul><ul><ul><ul><li>involvement of the same joints on each side of the body. </li></ul></ul></ul><ul><ul><ul><li>RA and SLE. </li></ul></ul></ul><ul><li>Asymmetric arthritis </li></ul><ul><ul><ul><li>psoriatic arthritis, reactive arthritis (Reiter syndrome), and Lyme arthritis. </li></ul></ul></ul>
  16. 16. <ul><li>Distribution of affected joints </li></ul><ul><li>The distal interphalangeal joints of the fingers </li></ul><ul><ul><ul><li>involved in psoriatic arthritis, gout, or osteoarthritis </li></ul></ul></ul><ul><ul><ul><li>spared in RA. </li></ul></ul></ul><ul><li>Joints of the lumbar spine </li></ul><ul><ul><ul><li>involved in ankylosing spondylitis </li></ul></ul></ul><ul><ul><ul><li>spared in RA. </li></ul></ul></ul>
  17. 17. <ul><li>Distinctive types of musculoskeletal involvement </li></ul><ul><li>Spondyloarthropathy </li></ul><ul><ul><ul><li>involves entheses, </li></ul></ul></ul><ul><ul><ul><li>dactylitis (sausage digits) </li></ul></ul></ul><ul><ul><ul><li>tendonitis </li></ul></ul></ul><ul><ul><ul><li>back pain (sacroiliitis and vertebral disc insertions). </li></ul></ul></ul><ul><li>Gout </li></ul><ul><ul><ul><li>involves tendon sheaths and bursae </li></ul></ul></ul><ul><ul><ul><li>superficial inflammation. </li></ul></ul></ul>
  18. 18. <ul><li>Extra-articular manifestations </li></ul><ul><li>Constitutional symptoms – </li></ul><ul><ul><ul><li>underlying systemic disorder. </li></ul></ul></ul><ul><ul><ul><li>include fatigue, malaise, and weight loss. </li></ul></ul></ul><ul><li>Skin lesions </li></ul><ul><ul><ul><li>SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura, and erythema nodosum. </li></ul></ul></ul><ul><li>Ocular symptoms or signs </li></ul><ul><ul><ul><li>Episcleritis and scleritis -RA or Wegener granulomatosis </li></ul></ul></ul><ul><ul><ul><li>anterior uveitis - ankylosing spondylitis, </li></ul></ul></ul><ul><ul><ul><li>iridocyclitis - juvenile RA </li></ul></ul></ul><ul><ul><ul><li>Conjunctivitis -reactive arthritis </li></ul></ul></ul>
  19. 19. <ul><li>Signs of inflammatory joint disease </li></ul><ul><li>Synovial hypertrophy </li></ul><ul><ul><li>most reliable sign </li></ul></ul><ul><ul><li>chronic inflammatory arthritis- synovial membrane has a doughy or boggy consistency. </li></ul></ul><ul><li>Joint effusions </li></ul><ul><ul><li>in response to </li></ul></ul><ul><ul><ul><li>synovial inflammation </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>anasarca </li></ul></ul></ul><ul><ul><ul><li>intra-articular hemorrhage (hemarthrosis) </li></ul></ul></ul><ul><ul><ul><li>sympathetic effusion </li></ul></ul></ul><ul><ul><li>detected by fluid ballottement or cross-fluctuation through the synovial cavity. </li></ul></ul>
  20. 20. <ul><li>Pain throughout the whole range of motion - acutely inflamed joint. </li></ul><ul><li>Pain as the joint is gently forced (ie, stressed) towards its limitation of range -synovitis. </li></ul><ul><li>Pain not present throughout the entire range of motion - extra-articular source eg.tendinitis. </li></ul><ul><li>Erythema and warmth </li></ul><ul><li>Erythema of the joint -acute inflammatory forms of arthritis, such as gout, septic arthritis, or acute rheumatic fever. </li></ul><ul><li>Warmth of the joint - inflammatory arthritis </li></ul>
  21. 21. <ul><li>Joint tenderness </li></ul><ul><li>sensitive sign, but not specific for inflammatory arthritides. </li></ul><ul><li>Focal tenderness - focus of inflammation outside the joint, such as tendinitis, osteomyelitis, or fracture. </li></ul>
  22. 22. <ul><li>Signs of degenerative or mechanical joint disease </li></ul><ul><li>Bony overgrowth of the joints (osteophytes)- </li></ul><ul><ul><li>at the distal interphalangeal joints - Heberden nodes, </li></ul></ul><ul><ul><li>at the proximal interphalangeal joints are called Bouchard nodes. </li></ul></ul><ul><li>Limited range of motion: </li></ul><ul><ul><li>intra-articular loose bodies, </li></ul></ul><ul><ul><li>osteophyte formation, or subluxation. </li></ul></ul><ul><li>Crepitus during active or passive range of motion </li></ul>
  23. 23. <ul><li>Joint deformity: </li></ul><ul><ul><li>Restriction of motion </li></ul></ul><ul><ul><li>malalignment of the articulating bones(eg.ulnar deviation of the fingers) </li></ul></ul><ul><ul><li>alteration in the relationship of the two articulating surfaces , such as subluxation </li></ul></ul>
  24. 24. <ul><li>Acute monoarthritis </li></ul><ul><li>Inflammatory </li></ul><ul><ul><li>Septic Arthritis </li></ul></ul><ul><ul><li>Gout and Pseudogout </li></ul></ul><ul><ul><li>Systemic rheumatic disease manifesting as monoarticular involvement </li></ul></ul><ul><li>Noninflammatory </li></ul><ul><ul><li>Juxta-articular fracture </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Hemarthrosis </li></ul></ul><ul><ul><li>Osteonecrosis </li></ul></ul>
  25. 25. <ul><li>Chronic monoarthritis </li></ul><ul><li>Inflammatory </li></ul><ul><ul><li>Chronic infectious arthritis </li></ul></ul><ul><ul><li>Lyme Disease </li></ul></ul><ul><ul><li>Crystalline synovitis </li></ul></ul><ul><ul><li>Pauciarticular juvenile rheumatoid arthritis </li></ul></ul><ul><ul><li>Systemic rheumatic disease presenting with monoarticular involvement </li></ul></ul><ul><li>Noninflammatory </li></ul><ul><ul><li>Osteoarthritis </li></ul></ul><ul><ul><li>Ischemic necrosis </li></ul></ul><ul><ul><li>Hemarthrosis </li></ul></ul><ul><ul><li>Paget disease involving the joint </li></ul></ul><ul><ul><li>Stress Fracture </li></ul></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><ul><li>Osteosarcoma </li></ul></ul><ul><ul><li>Metastatic tumor </li></ul></ul><ul><ul><li>Synovial osteochondromatosis </li></ul></ul>
  26. 26. <ul><li>Acute polyarthritis </li></ul><ul><li>Rheumatic fever </li></ul><ul><li>Gonococcal Arthritis </li></ul><ul><li>Polyarticular gout </li></ul><ul><li>Polyarticular pseudogout </li></ul><ul><li>Viral arthritis (eg, hepatitis B infection, parvovirus B-19 infection) </li></ul><ul><li>Bacterial endocarditis </li></ul><ul><li>Rheumatoid Arthritis </li></ul><ul><li>Still disease </li></ul><ul><li>Systemic Lupus Erythematosus </li></ul><ul><li>Reactive Arthritis </li></ul><ul><li>Acute sarcoid arthritis </li></ul><ul><li>Mediterranean Fever, Familial </li></ul><ul><li>Enteropathic Arthropathies </li></ul>
  27. 27. <ul><li>Chronic polyarthritis </li></ul><ul><li>Inflammatory </li></ul><ul><ul><li>Rheumatoid Arthritis </li></ul></ul><ul><ul><li>Systemic Lupus Erythematosus </li></ul></ul><ul><ul><li>Viral arthritis </li></ul></ul><ul><ul><li>Psoriatic Arthritis </li></ul></ul><ul><ul><li>Reactive Arthritis </li></ul></ul><ul><ul><li>Enteropathic Arthropathies </li></ul></ul><ul><ul><li>Behçet Disease </li></ul></ul><ul><ul><li>Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy </li></ul></ul><ul><li>Noninflammatory </li></ul><ul><ul><li>Osteoarthritis </li></ul></ul><ul><ul><li>Traumatic osteoarthritis </li></ul></ul><ul><ul><li>Hemochromatosis </li></ul></ul><ul><ul><li>Ochronosis </li></ul></ul><ul><ul><li>Hypertrophic pulmonary osteoarthropathy </li></ul></ul><ul><ul><li>Amyloidosis </li></ul></ul><ul><ul><li>Acromegaly </li></ul></ul>
  28. 28. <ul><li>Screening tests for acute polyarthritis </li></ul><ul><li>Blood cultures </li></ul><ul><li>Antistreptolysin O titer </li></ul><ul><li>Parvovirus B-19 immunoglobulin G and immunoglobulin M levels </li></ul><ul><li>Hepatitis B serology </li></ul><ul><li>ANA </li></ul><ul><li>Others : HIV test, a rubella titer, an angiotensin-converting enzyme level and chest radiograph, and ANCA </li></ul>
  29. 29. <ul><li>Screening tests for chronic polyarthritis </li></ul><ul><li>Complete blood cell count </li></ul><ul><li>ESR and CRP level </li></ul><ul><li>ANAs </li></ul><ul><li>Rheumatoid factor and CCP antibody </li></ul><ul><li>liver function tests , serum creatinine level </li></ul><ul><li>Serum uric acid level </li></ul><ul><li>Urinalysis </li></ul><ul><li>Others : thyroid-stimulating hormone level, a serum ferritin level, and an iron saturation of serum transferrin. </li></ul>
  30. 30. <ul><li>Screening tests for diffuse arthralgias and myalgias </li></ul><ul><li>ESR and CRP - inflammatory disease, including polymyalgia rheumatica </li></ul><ul><li>Creatine kinase and aldolase level - myositis </li></ul><ul><li>Thyroid testing </li></ul><ul><li>Chemistry profile (ie, calcium, phosphorus, electrolyte, glucose, total protein) - metabolic or endocrine disorders </li></ul><ul><li>Others </li></ul><ul><ul><ul><li>25-hydroxy vitamin D level - osteomalacia </li></ul></ul></ul><ul><ul><ul><li>sacroiliac joint radiography - ankylosing spondylitis, especially in woman <45 y with neck, chest wall, and low back pain), </li></ul></ul></ul><ul><ul><ul><li>HLA-B27 - reactive arthritis, </li></ul></ul></ul><ul><ul><ul><li>hepatitis B and C serology testing, </li></ul></ul></ul><ul><ul><ul><li>serum and urine protein electrophoresis - multiple myeloma </li></ul></ul></ul><ul><ul><ul><li>ANA and rheumatoid factor (if clinical features suggest RA, SLE, or another connective-tissue disease). </li></ul></ul></ul>
  31. 31. <ul><li>THANK YOU </li></ul>
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