This document provides information on approaching patients with arthritis. It discusses different types of arthritis like osteoarthritis, rheumatoid arthritis, gout, and lupus. For rheumatoid arthritis, it outlines the epidemiology, symptoms, physical exam findings, diagnostic criteria, deformities, extra-articular manifestations, progression, laboratory tests, and prognosis. It also briefly discusses systemic lupus erythematosus. The document emphasizes getting a thorough history and physical exam and considering different possible diagnoses when evaluating a patient with arthritis.

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?