Approach_to_pateint_with_Arthritis.ppt

1. Approach patient with
ARTHRITIS
DR. MOHAMMED O. AL-RUKBAN
Assistant Professor
Department of Family and Community Medicine
College of Medicine
King Saud University

2. Normal Joint..

3. Introduction..
 Causes include various self-limited
illness and disabling and life-
threatening.
 Is it Arthritis or Arthralgia?
 Musculoskeletal emergencies
(infection, sepsis, compartment
syndrome…).

4. Arthralgia..
 Fibromyalgia
 Bursitis
 Tendinitis
 Hypothyroidism
 Neuropathic pain
 Metabolic bone disease
 Depression

5. 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

6. Polyarthritis..
 Rheumatoid Arthritis
 Systemic lupus Erythrematosus
 Viral arthritis
 Reiter’s disease
 Psoriatic arthritis
 Reactive arthritis

7. Migratory Arthritis..
 Differential diagnosis:
 Rheumatic fever
 Gonococcemia
 Meningococcemia
 Viral Arthritis
 SLE
 Acute Leukemia

8. 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…)

9. History.. Age
 <30= SLE, Ankylosis spodylitis,
Reactive Arthritis.
 30-50= RA, Systemic sclerosis, Gout.
 >50= OA, Pseudogout, PMR
 Any Age group= Psoriatic arthritis,
Enteropathic arthritis

10. History.. Sex
 >Female:
 SLE, RA, OA, Systemic sclerosis,
Ankylosis spodylitis, PMR.
 Male=Female:
 Psoriatic arthritis, Enteropathic
arthritis Pseudogout.
 >Male:
 Gout, Reactive Arthritis.

11. History.. Sx
 Site:
 Symmetrical= RA, SLE, Systemic sclerosis
 Asymmetrical=OA
 Large joints=OA
 DIP= OA, Psoriatic arthritis
 MCP, PIP= RA, SLE
 1st MTP= Gout, OA
 Spine= OA, Ankylosis spodylitis, Psoriatic arthritis,
Reactive arthritis
 Shoulder= PMR

12. History.. Sx
 Pain character:
 Aggravated by motion= Mechanical
 Relieved by motion= Inflammatory.
 Duration:
 <6 wks= viral arthritis, systemic rheumatic
diseases
 >6 wks=systemic rheumatic diseases
 Associated Sx:
 Morning stiffness: >1hr= RA, PMR, Inflammatory
>30 min= OA

13. History.. Sx
 Associated Sx:
 Multi-system involvement= Systemic
rheumatic diseases.
 Past Medical history:
 Trauma, fracture, surgical procedures…
 Medication list:
 Drug induced lupus.
 Diuretics.

14. 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

15. 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…)

20. 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

21. Rheumatoid Factor..
 Rheumatoid Arthritis
 Connective tissue diseases
 Viral infection
 Leishmaniasis
 Leprosy
 Tuberculosis
 Sarcoidosis
 Liver diseases
 Subacute bacterial endocarditis

22. Laboratory Studies..
 Uric acid concentration= Gout
 Synovial fluid analysis= infection,
crystal induced arthritis, inflammatory..
 Hepatitis B and C
 Parvovirus serology

23. Imaging Studies..
 X-ray:
 RA
 Chronic Gout
 OA
 Ankylosing spondylosis.
 MRI:
 Ankylosing spondylosis.

25. Rheumatoid Arthritis..
 Epidemiology :
 The world wide incidence of RA is
approximately 3 cases per 10,000
population and the prevalence rate is
approximately 1%

26. Rheumatoid Arthritis..

27. History..
 Malaise
 fever
 fatigue
 weight loss
 myalgias
 difficulty performing activities of daily
living

28. Examination..
 Joint affected
 swelling
 tenderness
 warmth
 decreased range of motion
 Atrophy of the interosseous
muscles
 deformities

29. 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

35. Deformities..

38. Extra-articular manifestations..
 Rheumatoid nodule
 Cardiovascular
 Pulmonary
 GI & Renal
 Hematological
 Skin
 Vasculitis
 Neurological
 Ocular

39. 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.

40. 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.

41. Laboratory ..
 Hematologic parameters
 Anaemia
 Thrombocytosis
 ↓ Serum iron & IBC
 ↑ Serum globuline
 ↑ ALP
 ↑ Acute phase reactant
 Immunological parameters
 Synovial fluid analysis

42. 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

43. 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

44. 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?