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Approach to Joint pain_Dr Manoj.pptxnepal civil
- 1. Approach to Joint pain Dr Manoj Khadka FCPS resident
- 5. • Stepwise history • Physical examinatioin • Lab investigations
- 6. Step - 1 Articular and Extra-articular Anatomic structure: Painful site: Painful site: Pain on movement: Swelling Crepitus Diffuse, deep tenderness Point tenderness Active and passive Active only Common Uncommon
- 7. Step - 2 Arthralgia or Arthritis • Arthralgia-SYMPTOM • Joint pain withouts obvious inflammation • Non specific • Non rheumatological conditions like haematoligical diseases’ post viral fever’ hypothyroidism, statins use • Arthritis-DIAGNOSIS • demonstrable features of joint inflammation(joint swelling, redness, joint tenderness) • Increased temperature • Rheumatological conditions like RA, SLE
- 8. Step - 3 Arthritis Inflammatory or Non-inflammatory
- 9. Recognizing inflammation in the Joint History (80% diagnostic) • Significant early morning stiffness IMPROVING with activity • Constitutional symptoms (weight loss and loss of appetite) • Low grade Fever and night sweats • Fatigue Examination (15% diagnostic) • Inflammed Joint(erythematous and indurated appearance) Lab (5% diagnostic) • High ESR, CRP, Platelet • NN anemia NOT specific for inflammation • Hard bony swelling • Tenderness due to structural damage deformity • Functional incapitation
- 10. Step - 4 Duration Acute <6 weeks Chronic >6weeks(detailed Evaluation needed) Onset of symptoms Abrupt (Min-Hrs) Insidious (weeks- months) • RA • OA • Trauma • Crystal Arthropathy • Infection
- 11. Step - 5 How many joints are affected?
- 13. Rheumatoid arthritis Reactive arthritis Ankylosing spondylitis
- 14. Psoriatic arthritis Inflammatory OA of Hand
- 15. Pattern-sequence wise Intermittent arthritis -episodic and patient may be totally asymptomatic in between the episodes (gout behcets syndrome reactive arthritis palindromic rheumatism Additive arthritis -one or more joints are involved with time (RA SpA Psoriasis OA) Migratory polyarthritis -pain and swellinfg in a specific joint starts rapidly and subsides in 24 -36 hrs,arthritis then Picks up new joints (rheumatic fever gonococcal arthritis and viral diseases)
- 16. Symmetry vs Asymmetry Step - 7
- 17. Step - 8 Extra-articular manifestation
- 18. Fever with arthritis • SLE • Viral arthritis • Vasculitis • Rheumatic Fever • AOSD • Brucellosis
- 19. Raynaud’s phenomenon • Scleroderma (commonest) • SLE • RA • Sjogrens • Myositis
- 20. Oral ulcer Painless • SLE • Reactive arthritis • Enteropathic Painful • Bechet
- 21. Subcutaneous nodule • OA • Rheumatois nodule • Gout • Multicentric reticulohistiocytosis
- 22. Arthritis with…. Neuropathy • SLE • Vasculitis • Lyme • RA • Amyloidosis • Cryoglobulinemia Pulmonary • AAV(cough, hemoptysis, pleuritis) • SLE (Pleuritis) • Scleroderma (ILD,PAH) • RA (Pleural effussion, pulmonary nodules, ILD)
- 23. Arthritis with…. Renal invovement • SLE • Vasculitis • Sjogren • RA • Amyloidosis • Cryoglobulinemia GI involvement • SLE (intestinal vasculitis) • Scleroderma (GERD, diarrhea, pseudo- obstruction) • Enteropathic (IBD) • PAN (Mesenteric vasculitis)
- 24. Ocular Keratoconjunctivitis sicca • Sjogren syndrome, RA, SLE Uveitis • SpA, Sarcoidosis, Bechet’s, GPA Scleritis • RA, SLE
- 25. Family History • RA • OA • AS • Gout • Psoriasis
- 26. Drug History • Drug induced lupus: Hydralazine, ACE-inhibitor • Arthralgia: Quinolones • Gout: Diurestics • Vasculitis: Allopurinol, Thiazides • Scleroderma: Bleomycin • Osteonecrosis: Glucocorticoid
- 27. History of malignancy Carcinomatous polyarthritis: • Solid organ (Breast, colon, ovarian, lung) • Lymphoproliferative disease RS3PE (Relapsing seronegative symmetric synovitis with pitting edema): • Lymphoma • Myelodysplastic syndrome
- 28. Physical Examination • Inspection • Palpation • Assessment of range of motion
- 31. Investigation • Blood test 1. Hematology: CBC, LFT, RFT 2.Biochemistry: Uric acid, ESR, CRP 3. Immunology: RF, ANA
- 32. Joint Aspiration Arthrocentesis (Synovial Fluid Analysis) • Indicated when there is warm, red joint with effusion, especially when there is no history of trauma • Aspirated synovial fluid should be sent for 3Cs: 1. Cell count 2. Crystals: for Gout and Pseudogout 3. Culture (gram stain): for Septic arthritis
- 33. Diagnostic imaging Indication: • Bony tenderness • Inability to bear weight • Gross deformity • Age Modalities : • Plain flim • USG • CT scan • MRI
- 34. Reference • Clinical Rheumatology- Springer 2019- Rohini Handa • Kelly’s Rheumatology
- 35. Thank you
Editor's Notes
- Before beginning with Joint pain, it is important to know about the MSK pain as it may arise from various tissue other than Joint itself. Paint arising from………
- Head to toe examination is very important as this young female presenting with polyarthritis and fever has alopecia, malar rash and ecchymosis in leg as may be due to vasculitis.
- These features are very common in Seronegative arthritis
- Many rheumatologival disease present with NN anemia, and its important to do other test for drug adjustment