SlideShare a Scribd company logo
1 of 52
JOINT PAIN
DR.RISHIKESAN K.V
SPECIALIST PHYSICIAN
VENNIYIL MEDICAL CENTRE
SHARJAH
ANATOMY
LET’S REVIEW THE ANATOMY OF THE
SYNOVIAL JOINTS.
SYNOVIAL MEMBRANE LINES THE JOINT
CAVITY.
IT SECRETES THE SYNOVIAL FLUID AND
REDUCES THE FRICTION BETWEEN THE BONES
SYNOVIAL FLUID IS AN ULTRAFILTRATE OF
THE PLASMA.
IT IS GOING TO BE REFLECTIVE OF WHAT IS
HAPPENING INSIDE THE PLASMA.
IF THERE IS ANY SYSTEMIC INFLAMMATORY
DISEASE SYNOVITIS AND HENCE ARTHRITIS IS
A POSSIBLE SYMPTOM
DEFINITION : ARTHRITIS Vs. ARTHRALGIA
• MAJOR CAUSE OF MORBIDITY AND MORTALITY
PARTICULARLY IN OLDER POPULATION
• ARTHRALGIA MAY BE A REFERRED PAIN FROM MUSCLES
,TENDONS,BONES
• ARTHRITIS IS A SPECIFIC PATHOLOGIC PROCESS OF
INFLAMMATION OF JOINT STRUCTURE . MAY BE AUTO
IMMUNE,INFECTIOUS OR TRAUMATIC AND WHAT ELSE.
• VIRTUALLY IMPOSSIBLE TO DIFFERENTIATE THE TWO
WITHOUT AT LEAST A PHYSICAL EXAM
DIFFERENTIAL DIAGNOSIS
TRAUMA : SPRAIN ,STRAIN,FRACTURE ,DISLOCATION,TENDONITIS ,TEAR OF
TENDON ,LIGAMENTS,MENISCUS
INFECTIONS : GONOCOCCAL, NON GONOCOCCAL, LYME DISEASE, TB, VIRAL
FUNGAL
CRYSTAL: GOUT,PSEUDOGOUT
DEGENERATIVE: OA
MALIGNANCY: SOLID TUMOR METASTASIS, LYMPHOMA, LEUKAEMIA,
OSTEOSARCOMA, OSTEOCHONDROMA
RHEUMATIC: RA, SLE, REITERS, PSORIATIC, ANK SPONDYLITIS, AC.RHEUMATIC
FEVER, SJOGRENS
OTHERS : A HUGE WIDE LIST OF POSSIBLE CAUSES FOR JOINT PAIN
DIFFERENTIAL DIAGNOSIS
• TRAUMA : SPRAIN ,STRAIN,FRACTURE ,DISLOCATION,TENDONITIS ,TEAR OF TENDON
,LIGAMENTS,MENISCUS
• INFECTIONS : GONOCOCCAL,NON GONOCOCCAL,LYME DISEASE,TB,VIRAL FUNGAL
• CRYSTAL: GOUT,PSEUDOGOUT
• DEGENERATIVE: OA
• MALIGNANCY: SOLID TUMOR
METASTASIS,LYMPHOMA,LEUKAEMIA,OSTEOSARCOMA,OSTEOCHONDROMA
• RHEUMATIC: RA,SLE,REITERS,PSORIATIC,ANK SPONDYLITIS,ACUTE RHEUMATIC
FEVER,SJOGRENS
• OTHERS
• WE HAVE GOT A HUGE WIDE WIDE LIST OF POSSIBLE CAUSES FOR JOINT PAIN
HERE MORE THAN EVER, IT IS ESSENTIAL TO HAVE A
GOOD HISTORY AND PHYSICAL EXAM INORDER TO
MAKE A PROPER DIAGNOSIS
TAKING A GOOD HISTORY
SLICE
SYSTEMIC : ANY SYSTEMIC SYMPTOMS THAT ACCOMPANY THE JOINT PAIN
LIKE FEVER,CHILLS ,RASH,FATIGUE,WEIGHT LOSS
LOCATION: WHICH JOINT / JOINTS SORE? SINGLE, SOME ,MULTIPLE. IF
MULTIPLE SYMMETRICAL OR ASYMMETRICAL IN DISTRIBUTION
INFLAMMATION: IS THE AFFECTED JOINT INFLAMMED?
CHRONICITY: RECENT ONSET/ACUTE, INSIDIOUS ONSET/MORE
CHRONIC.DOES THE PAIN COME AND GO OR PERSISTENT.WHAT TIME OF THE
DAY PAIN WORSE?
EVIDENCE OF TRAUMA
SLICE
SYSTEMIC SYMPTOMS
FEVER: GOUT,RA, INFECTIOUS
ARTHRITIS (ESPECIALLY WITH
CHILLS.)
RASH: VASCULITIS LIKE CHURG
STRAUSS, WEGENERS, PSORIATIC
FATIGUE : RA,SLE ,PMR ANY
CHRONIC FORM OF ARTHRITIS.
DISTRIBUTION / LOCATION
DIP JOINTS - PSORIATIC.
MTP ,PROX.IP JOINTS -RA
INFLAMMATION :
SEPTIC, GOUT, Rheumatoid
Arthritis
CHRONICITY:
ACUTE - INFECTIOUS, GOUT
HAND ARTHRITIS
LOCATION: ASK THESE QNs
WHICH JOINT / JOINTS SORE?
IS IT SINGLE ?
SOME ?
MULTIPLE?
IF MULTIPLE , SYMMETRICAL OR
ASYMMETRICAL IN
DISTRIBUTION?
SLICE THE OSTEOARTHRITIS
Systemic : Primary OA is not associated with any systemic symptoms
Location : Hands (wrists, MCPs, PIPs, DIPs) and weight bearing joints
(hips, knees) primarily. Not necessarily symmetrical.
Inflammation : Joints are not externally inflamed.
Chronicity : Chronic and progressive. Insidious onset. Worsens with
activity, pain improves with rest.
Evidence of trauma : May occur secondary to trauma to a specific
joint. But primary OA is not associated with trauma
SLICE- ing RHEUMATOID ARTHRITIS
•Systemic: YES MOST OF THEM HAVING SYSTEMIC SYMPTOMS:
FATIGUE , MALAISE,WEAKNESS,LOW GRADE FEVER,WEIGHT LOSS
•Location :HAND ARTHRITIS, NOT IN DIPs. ALSO AFFECTS
SHOULDERS,KNEES,HIP. BUT NO LBP. SYMMETRIC
•Inflammation. VERY PROMINENT,WARM ERYTHEMIC JOINTS
•Chronicity: CHRONIC,INSIDIOUS, PROGRESSIVE,PAIN WORST IN
THE MORNING
•Evidence of trauma: NO TRAUMA INVOLVED
EXTRA ARTICULAR SYMPTOMS
SEPTIC ATHRITIS : FEVER,CHILLS,NAUSEA,RASH (ERYTHEMA MIGRANS IN LYME
DISEASE)
MALIGNANCY : PALLOR,EASY BRUISING,INFECTION ELSEWHERE.
RHEUMATOLOGIC OR AUTOIMMUNE : ALL MAY INCLUDE FEVER,WEIGHT LOSS
REITER’S SYNDROME : URETHRITIS, H/O CHLAMYDIAL INFECTIONS, ENTERITIS,
CONJUNCTIVAL INFECTION, CONJUNCTIVITIS.
PSORIATIC ARTHRITIS : PSORIASIS, SAUSAGE DIGITS,NAIL ABNORMALITIES
SLE : MALAR RASHES,RENAL INSUFFICIENCY
ANKYLOSING SPONDYLITIS : ENTHESITIS,RASHES
SJOGRENS SYNDROME : DRY EYES,DRY MOUTH
WEGENERS : CHRONIC URI, LRTI, RENAL INSUFFICIENCY
WHAT NEVER HAS EXTRA ARTICULAR
SYMPTOMS?
OSTEOARTHRITIS ! THE MOST COMMON FORM OF
CHRONIC ARTHRITIS.
IT IS STRICTLY LIMITED TO THE JOINTS.
IT IS THE DEGENERATIVE DISEASE OF THE JOINTS
ACUTE MONOARTHRITIS
CRYSTAL INDUCED ACUTE
MONOARTICULAR ARTHRITIS
SEVERE INFLAMMATION
CRYSTALS POSITIVE
ACUTE MONOARTHROPATHY
<50000 CELLS/ MICROLITRE IN
SYNOVIAL FLUID
CULTURE NEGATIVE
SEPTIC ARTHRITIS
ACUTE MONOARTHROPATHY
SEVERE INFLAMMATION
NO CRYSTALS
>50000 CELLS IN SYNOVIAL
FLUID
CULTURE POSITIVE
VIRAL ARTHROPATHY Vs. SYMMETRICAL
ARTHROPATHY
VIRAL ARTHROPATHY
• SYMMETRIC ARTHROPATHY
• NO SIGNIFICANT INFLAMMATION
• NO RASH OR RENAL FAILURE
• NO PULMONARY INVOLEMENT
• IgM TITRES HIGH FOR SPECIFIC
VIRUSES
• LOOK FOR HEPATITIS PANEL
• IgM PARVOVIRUS TITRES
• EPSTEIN BARR VIRUS TITRES
CHRONIC
SYMM.ARTHROPATHY
CHRONIC.
SYMMETRIC POLY ARTICULAR.
SIGNICANT INFLAMMATION.
EROSIONS ON XRAY.
POSITIVE RF AND OR ANA.
CONSTITUTIONAL Sx.
EXTRA ARTICULAR MANIFESTATIONS.
LABORATORY WORK UP FOR JOINT PAIN
• IN ANY PATIENT WHO HAS SIGNS OF AN INFLAMMED JOINT,YOU MUST
ORDER A JOINT ASPIRATE
• PATIENTS WITH SIGNS AND SYMPTOMS OF OSTEOARTHRITIS- NO
EXTRAARTICULAR SYMPTOMS,OLDER AGE,ASYMMETRICAL- PLAIN
RADIOGRAPHY IS THE BEST INITIAL TEST,WHILE CT IS MORE ACCURATE
• PATIENTS WITH SIGNS OF AUTO IMMUNE OR RHEUMATOLOGIC DISEASE (
EXTRA ARTICULAR SYMPTOMS) THERE ARE VARIOUS AUTO ANTIBODIES
THAT MAY BE ORDERED CORRESPONDING WITH THE SUSPECTED
SYNDROME.
• THESE Abs. HAVE VARIOUS LEVELS OF SENSITIVITY AND SPECIFICITY
AUTO ANTIBODIES WITH VARIOUS JOINT PAIN
Antinuclear Antibodies (ANA)
Anti-Ro, Anti-La: Sjogren’s
Syndrome
Anti-centromere: CREST
SYNDROME
Anti-Histone: Drug Induced Lupus
Anti- ds DNA, Anti Sm: SLE
Rh. factor(RF),Anti – CCP:
Seen in patients with Rheumatoid
arthritis. However their absence
doesn’t rule out RA
ANCA
c-ANCA: Wegener’s
granulomatosis
P-ANCA: Churg-Strauss syndrome,
poly arteritis nodosa
JOINT ASPIRATION OR ARTHROCENTESIS
JOINT ASPIRATION IS THE
BEST INITIAL DIAGNOSTIC
STEP FOR THE DIAGNOSIS
OF :
GOUT
PSEUDOGOUT AND
SEPTIC ARTHRITIS.
JOINT ASPIRATION OR ARTHROCENTESIS
A RED ,WARM, SWOLLEN,PAINFUL JOINT
POINTS TO:
GOUT
PSEUDOGOUT
SEPTIC ARTHRITIS (FROM VARIOUS
AETIOLOGIES.)
IN THE JOINT ASPIRATION WE LOOK FOR 4Cs
COLOR
CELLS
CRYSTALS , ………… and we get a
CULTURE
OSTEOARTHRITIS
CHRONIC PROGRESSIVE , NON
INFLAMMATORY, IDIOPATHIC
DEGENERATIVE JOINT DISEASE.
CLOSELY RELATED TO AGING PROCESS:
PRIMARY OA
OF COURSE OTHER ARTHROPATHIES CAN
PREDISPOSE TO OA
WEIGHT IS A COMMON CAUSE
MOST COMMONLY AFFECTS THE JOINTS
OF THE HANDS,AS WELL AS WEIGHT
BEARING JOINTS (KNEES,HIPS).
JOINTS OFTEN APPEAR NORMAL,
EXTERNALLY, DECREASED ROM,
CREPITUS.
THE BEST FIRST STEP IN DIAGNOSTIC
EXAMINATION IS XR OF THE AFFECTED
JOINTS.TYPICAL FINDING IS A REDUCTION IN
JOINT SPACE.
OSTEOARTHRITIS
JOINT PAIN IS THE MOST COMMON
SYMPTOM.
NO CONSTITUTIONAL SYMPTOMS.
NODES ON DIPs AND PIPs
ANY LABS SHOULD BE NORMAL
ABNORMALITIES IN LABS ARE NOT
INDICATIVE OF OSTEOARTHRITIS
OSTEOARTHRITIS TREATMENT
ACETAMINOPHEN IS
THE RX OF CHOICE IF
THE PATIENT IS NSAID
SENSITIVE. TOPICAL
CAPSAICIN IS USEFUL
BUT INFERIOR TO
NSAIDs.
Rx. IS
PALLIATIVE.
NSAIDs ARE
THE
MAINSTAY
OF
TREATMENT.
DRY EYES AND DRY MOUTH
AUTO IMMUNE INFLAMMATORY AND
DESTRUCTIVE DISEASE OF THE EXOCRINE
GLAND.
MAJOR SX: DRY EYES,DRYMOUTH AND
PAROITDS ENLARGEMENT
H/o NUMEROUS DENTAL CARIES
1* AND 2* FORMS( SLE ,RA etc)
BX.OF SALIVARY GLANDS SINGLE MOST
ACCURATE TEST: LYMPHOCYTIC
SIALOADENITIS
COMPLICATIONS: NHL, NEONATAL LUPUS
SCHIRMER TEST AND
Anti- Ro /Anti- La
TITRES
SCHIRMER’S TEST
<5 mm IN 5 MINUTE IS A POSITIVE TEST. (NORMAL
15mm)
OFTEN DONE AS A SCREENING TEST
PERHAPS THE BEST INITIAL TEST ALONG WITH ANA IN
ESTABLISHING THE DSIS.
TREATMENT : ARTIFICIAL TEARS,CYCLOSPORINE
OPHTHALMIC. FOR DRY MOUTH: ARTIFICIAL SALIVA,
PILOCARPINE,DENTAL CARE.
BASIC PATIENT EDUCATION: USE OF HUMIDIFIER AT
HOME,VAGINAL LUBRICANTS PRN, SKIN
MOISTURISERS,VIGILANCE FOR PAROTID GLAND
ENLARGEMENT
SERONEGATIVE SPONDYLOARTHROPATHY
A DIVERSE GROUP OF GENERALLY INFLAMMATORY, SYSTEMIC AUTOIMMUNE DISEASE
THAT ARE NEGATIVE FOR RA FACTOR AND ANA.
ALL OF THEM SHARE ONE THING IN COMMON: HLA B 27 ANTIGEN.
HLA B27 IS HIGHLY PREVALENT IN SCANDINAVIANS.NOT ALL OF THEM DEVELOPP
SERO-VE ARTHROPATHY
NEVERTHELESS CLINICALLY DIVERSE: Ankylosing Spondylitis, Psoriatic,
Reactive(Reiter’s)Arthritis, Enteropathic Spondylitis
ANKYLOSING SPONDYLITIS
DISTINCT FROM MOST AUTOIMMUNE DISEASE. IT IS PREDOMINANT IN YOUNG MAN
UNDER THE AGE OF 40!
DSIS BASED ON CLINICAL SYMPTOMS AND ON LUMBAR SPINAL XRAY
CAN’T SEE,CAN’T PEE AND CAN’T DANCE WITH ME
REACTIVE ARTHRITIS OR REITER’S
SYNDROME:
TRIAD OF URETHRITIS - NON
GONOCOCCAL/CHLAMYDIAL
CONJUNCTIVITIS AND
ARTHRITIS
HLA B27 = 70% CASES.
3-10% PROGRESS TO AS.
CAN BE FROM A GI BUG: Yersin & Sal
went to Camp in the Shig.
KERATODERMA BLENORRHAGICA
Lover’s heel
Reiter’s nail
WHAT IS WRONG WITH THIS SPINE?
ANKYLOSING SPONDYLITIS
LUMBAR SPINAL X RAY :SHOWS
FUSION OF LUMBAR SPINAL
PROCESSES: BAMBOO SPINE
PERSISTENT AND CHRONIC REFRACTORY
LBP WHICH IS WORST IN THE MORNING
AND IMPROVES THROUGHOUT THE DAY
BAMBOO SPINE
PATIENTS WILL HAVE A LOSS OF LUMBAR
LORDODSIS.THIS MAY MAKE THE PATIENT
SUSCEPTIBLE TO SPINAL FRACTURES
SYMMETRICAL INFLAMMATORY OLIGOARTHRITIS
PSORIATIC ARTHRITIS IS AN
IMPORTANT SERO -VE
SPONDYLOARTHROPATHY
IT PRESENTS AS SYMMETRICAL
INFLAMMATORY OLIGOARTHRITIS.
IN MOST CASES SKIN
MANIFESTATIONS PRECEDES
ARTHROPATHY.
MILD CASES NEED NSAIDs.
IMMUNOSUPPRESSION FOR
SEVERE CASES
PSORIATIC ARTHRITIS
MORNING ALWAYS HELPS
TO SEE NATURE FRESH AND
RADIANT- Dr.Rishi
RHEUMATOID ARTHRITIS
CHRONIC INFLAMMATORY,SYSTEMIC
DISEASE WITH SEVERE JOINT PAIN
DSIS: BASED ON CLINICAL, IMAGING,AND
LAB CRITERIA.
4 OUT OF 7 CRITERIA.
MORNING STIFFNESS
HAND ARTHRITIS.
SYMMETRIC.
ULNAR DEVIATION OF DIGITS,
BOUTONNIERE DEFORMITY,
RHEUMATOID NODULES,
BAKERS CYST
RF (RHEUMATOID
FACTOR)
RHEUMATOID ARTHRITIS: PHYSICAL EXAM
DIPs ARE NOTABLY EXCLUDED.FINDINGS WILL
DEPEND ON PROGRESSION AND CHRONICITY
DEFORMITIES AND DISABILITIES
EXTRA ARTICULAR MANIFESTATION
FELTY’s SYNDROME:
TRIAD OF *RA,
*NEUTROPAENIA,
*SPLENOMEGALY.
ANY INFECTION WITH
FELTY’s SYNDROME
SHOULD BE TREATED
INPATIENT WITH IV
ANTIBIOTICS COVERING
GRAM +, GRAM –, AND
GNR.
ATALANTO AXIAL
DISLOCATION: DON’T
SEE CHIROPRACTIONERS
TREATMENT
MAINSTAY OF TREATMENT METHOTREXATE
WITH OR WITHOUT A BIOLOGIC TNF ALPHA
INHIBITORS WHICH GRATELY INHIBIT
GENERAL INFLAMATION.
INFLIXIMAB (Remicade)
ETANERCEPT(Enbrel)
ADALIMUMAB (Humira)
NEWLY DIAGNOSED PATIENTS MAY BE
TREATED WITH PREDNISOLONE TO BRIDGE
OVER AS THE BIOLOGICS AND MTX. TAKE
EFFECT
IDENTIFY THE CELEBRITY
A 23 YEAR OLD WOMAN PRESENTS WITH
GENERALISED JOINT PAIN. YOU
IMMEDIATELY NOTICE ERYTHEMA OVER HER
CHEEKS.
PE: OTHERWISE UNREMARKABLE. ON
LEVATERACITAM AND PHENYTOIN FOR PAST
MEDICAL HISTORY OF EPILEPSY. CBC AND CMP
ARE DRAWN. UNREMARKABLE BUT FOR Hb
10.5GM, HCT 31,TLC 3500, PLT 250000.
WHAT IS THE BEST NEXT STEP IN THE
MANAGEMENT OF THIS PATIENT?
Ans: ANA, Anti-ds DNA AND Anti-Sm TITRES
She has undergone a course of
chemotherapy after being
diagnosed with lupus, a condition
affecting the immune system.
IDENTIFY THE CELEBRITY
OVERVIEW OF SLE
CHRONIC IDIOPATHIC INFLAMMATORY
MULTISYSTEMIC DISEASE.
ARTHRITIS IS ONE OF A MYRIAD OF POSSIBLE
SYMPTOMS AND PRESENTATIONS.
WOMEN ARE AFFECTED MORE THAN MEN BY A
RATIO 9:1
CLASSIC TRIAD: FEVER, RASH (MALAR,
DISCOID, PHOTO SENSITIVE) AND
ARTHRALGIA.
DSIS :
BASED ON CRITERIA AND
SUPPORTED BY LABORATORY
EVIDENCE
S O A P B R A I N M.D
SOAP BRAIN MD: DIAGNOSTIC CRITERIA SLE
SEROSITIS
ORAL ULCERS
ARTHRITIS
PHOTOSENSITIVITY
BLOOD DISORDERS
RENAL
4 OF THESE CRITERIA IS 95%
SPECIFIC AND 85% SENSITIVE
ANA
IMMUNOLOGICAL
PHENOMENA (Anti-ds
DNA, Anti-Sm)
NEUROLOGICAL
SYMPTOMS
MALAR RASH
DISCOID RASH
NEONATAL LUPUS
A 23 YEAR OLD WOMAN WITH
POLYARTHRALGIA HAVING POSITIVE
Anti - ds DNA AND Anti-Sm
antibodies IS DIAGNOSED TO HAVE
SLE.
SHE IS STABLE ON METHOTREXATE. 3
YEARS LATER SHE PRESENTED TO
YOUR OFFICE AT 2 MONTHS
GESTATION.
WHICH OF THE FOLLOWING LABS
WOULD YOU BE MOST INTERESTED IN
ORDERING? WHY?
ALL SLE WOMEN SHOULD BE SCREENED FOR Anti-
Ro ANTIBODY DURING EARLY PREGNANCY.BABIES
BORN TO Ro +VE MOTHERS ARE AT THE RISK FOR
NEONATAL LUPUS.THIS TYPICALLY MANIFESTS
AS CHB
A LADY WITH CORPORALGIA
AMITRYPTILINE.
“FEELING OF HURTING ALL OVER, ALWAYS
HAVING THE FLU”
PAIN ELLICITABLE FROM CHARACTERISTIC
PRESSURE POINTS.
DSIS: ENTIRELY CLINICAL
FIBROMYALGIA
CHRONIC , NON INFLAMMATORY
”PAIN PROCESSING “ DISORDER OF
UKNOWN AETIOLOGY.
IT IS A PHYSICAL DISORDER WITH
HEAVY PSYCHIATRIC OVERTONES.
A SYNDROME OF WIDESPREAD PAIN
STIFFNESS, FATIGUE, DISRUPTED SLEEP
OFTEN ACCOMPANIED BY , MOOD OR
ANXIETY DISTURBANCES ; OTHER
SOMATIC DISORDERS ( OVERACTIVE
BLADDER, IBS)
WOMEN AFFECTED MORE BY A RATIO
OF 9:1
INCREASED INCIDENCE IN PATIENTS
SUFFERING,FROM PTSD AND
AUTOIMMUNE DISEASES.
THE MOST COMMON DRUG USED IS
A TCA (AMITRYPTILINE).
RECENTLY GABAPENTINE AND
PREGABALIN HAVE BEEN USED.
NSAIDs AND OPIOIDs NEVER,NEVER
CRYSTAL ARTHROPATHY
NEEDLE SHAPED CRYSTALS OF URIC ACID
THE BEST INITIAL DIAGNOSTIC TEST IS
SYNOVIAL FLUID ANALYSIS.
REMEMBER TO ASPIRATE A JOINT IN
APATIENT WITH MONOARTICULAR ARTHRITIS
EVEN IF THERE IS A HISTORY OF PRE EXISTING
GOUT
GOUT
MOST COMMONLY FIRST OCCURS IN THE BIG TOE
MAY BE POLYARTICULAR AFFECTING ANKLE KNEE , PIPs, DIPs
PRESENTS WITH EXCRUCIATING MONOARTICULAR JOINT PAIN (
MAY WAKE THE PATIENT UP).
ARTHROCENTESIS SHOWS NEEDLE SHAPED NEGATIVELY
BIREFRINGENT CRYSTALS.
THE BEST INITIAL STEP IN THERAPY IS NSAIDs.
WE TREAT THE PAIN FIRST. ULT ONCE ACUTE ATTACK IS OVER
ULTs ONLY FOR CHRONIC GOUT TO PREVENT FURTHER ATTACKS
USE ALLOPURINOL OR FEBUXOSTAT
GOUT AND SERUM URIC ACID
PATIENTS WITH MULTIPLE GOUT ATTACKS
SHOULD UNDERGO A 24 HOUR URINE URIC ACID
ESTIMATION. IF THEY ARE FOUND TO BE UNDER
SECRETORS THEY ARE CANDIDATES FOR THERAPY
WITH URICOSURIC AGENTS LIKE PROBENECID
DONOT FALL FOR THE TRAP OF ORDERING
SERUM URIC ACID LEVEL .
THEY DONOT CORRESPOND TO GOUT
ATTACK
IF PREVENTIVE TREATMENT IS NOT INITIATED
AND GOUTY ARTHRITIS RECURS FREQUENTLY
THEN EROSION AND DESTRUCTION OF THE
JOINT MAY OCCUR
PSEUDOGOUT
PSEUDOGOUT; ACUTE OR CHRONIC
ALWYS LOOK FOR SYSTEMIC DISEASES
TENDS TO OCCUR IN
OLDER PATIENTS WITH PRE EXISTING
JOINT DISEASE AND IN PATIENTS
WITH METABOLIC OR ELECCCTROLYTE DISORDERS
LIKE: HYPERPARATHYROIDISM,HAEMOCHROMATOSIS,
HYPOPHOSPHATAEMIA,HYPOMAGNESAEMIA
ALMOST IDENTICAL TO GOUT
THE BEST INITIAL DIAGNOSTIC TEST IS
ARTHROCENTESIS
RHOMBOID /RECTANGULAR POSITIVELY
BIREFRINGENT CRYSTALS
TEMPORAL ARTERITIS
Answer: ESR
QUESTION
TEMPORAL ARTERITIS AND PMR
PREDNISOLONE IS THE DRUG OF CHOICE.
THIS PATIENT IS AT THE RISK OF
DEVELOPING PMR
QUESTION
TAKE HOME MESSAGE
RHEUMATOLOGY IS ONE OF THE MORE ARCANE MEDICAL
DISCIPLINES.
IT CAN OFTEN BE CONFOUNDING FOR NEW INITIATES
JOINT PAIN IS THE HALL MARK SYMPTOM OF CLINICAL RHEUMATOLOGY .
A DETAILED HISTORY,
PHYSICAL EXAMINATION ,
AND ANALYSIS OF SLICE DATA IS SUFFICIENT TO REACH A PROBABLE
DIAGNOSIS.
A MIX OF STRONG CLINICAL SKILLS,
PATTERN MATCHING TECHNIQUES AND KEY CLUES OFTEN ALLOWS RAPID AND
ACCURATE DIAGNOSIS
THANK YOU…………

More Related Content

What's hot

Septic arthritis
Septic arthritisSeptic arthritis
Septic arthritis
group7usmkk
 
Approach To A Patient With Polyarthritis
Approach To A Patient With PolyarthritisApproach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Pramod Mahender
 
Tuberculosis of bones and joints
Tuberculosis of bones and jointsTuberculosis of bones and joints
Tuberculosis of bones and joints
airwave12
 
Septic arthritis
Septic arthritisSeptic arthritis
Septic arthritis
orthoprince
 

What's hot (20)

Septic arthritis
Septic arthritisSeptic arthritis
Septic arthritis
 
Knee examination
Knee examinationKnee examination
Knee examination
 
Spondyloarthropathy
SpondyloarthropathySpondyloarthropathy
Spondyloarthropathy
 
Approach To A Patient With Polyarthritis
Approach To A Patient With PolyarthritisApproach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
 
Clinical approach to Arthritis
Clinical approach to ArthritisClinical approach to Arthritis
Clinical approach to Arthritis
 
X ray changes in different types of arthritis
X  ray changes in different types of arthritisX  ray changes in different types of arthritis
X ray changes in different types of arthritis
 
[Int. med] approach to joint pain from SIMS Lahore
[Int. med] approach to joint pain from SIMS Lahore[Int. med] approach to joint pain from SIMS Lahore
[Int. med] approach to joint pain from SIMS Lahore
 
Osteomyelitis
OsteomyelitisOsteomyelitis
Osteomyelitis
 
Osteoarthritis
OsteoarthritisOsteoarthritis
Osteoarthritis
 
Scleroderma
SclerodermaScleroderma
Scleroderma
 
Seronegative spondyloarthropathy
Seronegative spondyloarthropathySeronegative spondyloarthropathy
Seronegative spondyloarthropathy
 
Osteomyelitis, acute, chronic,multifocal. classification, treatment
Osteomyelitis, acute, chronic,multifocal. classification, treatment Osteomyelitis, acute, chronic,multifocal. classification, treatment
Osteomyelitis, acute, chronic,multifocal. classification, treatment
 
Tuberculosis of bones and joints
Tuberculosis of bones and jointsTuberculosis of bones and joints
Tuberculosis of bones and joints
 
Veeu gangrene ppt 5 th term
Veeu gangrene ppt 5 th termVeeu gangrene ppt 5 th term
Veeu gangrene ppt 5 th term
 
Septic arthritis
Septic arthritisSeptic arthritis
Septic arthritis
 
Primary care approach to joint pain
Primary care approach to joint painPrimary care approach to joint pain
Primary care approach to joint pain
 
Septic arthritis
Septic arthritisSeptic arthritis
Septic arthritis
 
History and examination in orthopedics
History and examination in orthopedicsHistory and examination in orthopedics
History and examination in orthopedics
 
AVASCULAR NECROSIS OF HIP (AVN HIP)
AVASCULAR NECROSIS OF HIP (AVN HIP)AVASCULAR NECROSIS OF HIP (AVN HIP)
AVASCULAR NECROSIS OF HIP (AVN HIP)
 
Psoriatic arthritis
Psoriatic arthritisPsoriatic arthritis
Psoriatic arthritis
 

Viewers also liked (9)

Joint pain
Joint painJoint pain
Joint pain
 
Approach to joint pain in child
Approach to joint pain in childApproach to joint pain in child
Approach to joint pain in child
 
Approach to case of arthritis
Approach to case of arthritisApproach to case of arthritis
Approach to case of arthritis
 
Approach to the patient with arthritis
Approach to the patient with arthritisApproach to the patient with arthritis
Approach to the patient with arthritis
 
Post resuscitation care
Post resuscitation carePost resuscitation care
Post resuscitation care
 
Approach to diagnosis of arthritis
Approach to diagnosis of arthritis Approach to diagnosis of arthritis
Approach to diagnosis of arthritis
 
Polyarthritis (clinical approach)
Polyarthritis (clinical approach)Polyarthritis (clinical approach)
Polyarthritis (clinical approach)
 
Topic review approach_arthritis
Topic review approach_arthritisTopic review approach_arthritis
Topic review approach_arthritis
 
Arthritis
ArthritisArthritis
Arthritis
 

Similar to Joint pain DR.RISHIKESAN K.V

Allergy and autoimmune diseases in dentistry
Allergy and autoimmune diseases in dentistryAllergy and autoimmune diseases in dentistry
Allergy and autoimmune diseases in dentistry
abduladentist
 
management of acute rheumatic fever
management of acute rheumatic fevermanagement of acute rheumatic fever
management of acute rheumatic fever
Basem Enany
 
SYSTEMIC LUPUS ERYTHEMATOSUS.pptx
SYSTEMIC  LUPUS  ERYTHEMATOSUS.pptxSYSTEMIC  LUPUS  ERYTHEMATOSUS.pptx
SYSTEMIC LUPUS ERYTHEMATOSUS.pptx
HariHaran726642
 

Similar to Joint pain DR.RISHIKESAN K.V (20)

Allergy and autoimmune diseases in dentistry
Allergy and autoimmune diseases in dentistryAllergy and autoimmune diseases in dentistry
Allergy and autoimmune diseases in dentistry
 
History taking and examination of nose and pns
History taking and examination of nose and pnsHistory taking and examination of nose and pns
History taking and examination of nose and pns
 
TAEM10:Vascular emergency
TAEM10:Vascular emergencyTAEM10:Vascular emergency
TAEM10:Vascular emergency
 
Acute Rheumatic Fever in children
Acute Rheumatic Fever in childrenAcute Rheumatic Fever in children
Acute Rheumatic Fever in children
 
Ser 2016 acute scrotum 1 dr.amitha
Ser 2016 acute scrotum 1  dr.amithaSer 2016 acute scrotum 1  dr.amitha
Ser 2016 acute scrotum 1 dr.amitha
 
Approach to dyspnoea
Approach to dyspnoeaApproach to dyspnoea
Approach to dyspnoea
 
Osteomylitis
OsteomylitisOsteomylitis
Osteomylitis
 
toxoplasma.pptx
toxoplasma.pptxtoxoplasma.pptx
toxoplasma.pptx
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS
 
Ent in General Practice
Ent in General PracticeEnt in General Practice
Ent in General Practice
 
management of acute rheumatic fever
management of acute rheumatic fevermanagement of acute rheumatic fever
management of acute rheumatic fever
 
Rheumatic fever
Rheumatic feverRheumatic fever
Rheumatic fever
 
Seronegative spondyloarthropathies
Seronegative  spondyloarthropathiesSeronegative  spondyloarthropathies
Seronegative spondyloarthropathies
 
Arthritis episode 1, Rheumatoid Arthritis
Arthritis episode 1, Rheumatoid Arthritis Arthritis episode 1, Rheumatoid Arthritis
Arthritis episode 1, Rheumatoid Arthritis
 
Sarcoidosis
SarcoidosisSarcoidosis
Sarcoidosis
 
rheumatic heart disease and fever INDIA
rheumatic heart disease and fever  INDIA rheumatic heart disease and fever  INDIA
rheumatic heart disease and fever INDIA
 
clinical approach to CHD.pdf
clinical approach to CHD.pdfclinical approach to CHD.pdf
clinical approach to CHD.pdf
 
Clinical approach to congenital heart disease diagnosis
Clinical approach to congenital heart disease diagnosisClinical approach to congenital heart disease diagnosis
Clinical approach to congenital heart disease diagnosis
 
SYSTEMIC LUPUS ERYTHEMATOSUS.pptx
SYSTEMIC  LUPUS  ERYTHEMATOSUS.pptxSYSTEMIC  LUPUS  ERYTHEMATOSUS.pptx
SYSTEMIC LUPUS ERYTHEMATOSUS.pptx
 

More from RISHIKESAN K V

Hypertensive heart disease
Hypertensive heart diseaseHypertensive heart disease
Hypertensive heart disease
RISHIKESAN K V
 
Acute pressure syndromes
Acute pressure syndromesAcute pressure syndromes
Acute pressure syndromes
RISHIKESAN K V
 

More from RISHIKESAN K V (15)

GDM REVISIT
GDM REVISITGDM REVISIT
GDM REVISIT
 
Peptic ulcer and gastritis
Peptic ulcer and gastritisPeptic ulcer and gastritis
Peptic ulcer and gastritis
 
The illusive irritable illness of the intestine
The illusive irritable illness of the intestineThe illusive irritable illness of the intestine
The illusive irritable illness of the intestine
 
What to do after 3x pm
What to do after 3x pmWhat to do after 3x pm
What to do after 3x pm
 
TAMING THE PC YES CANINE
TAMING THE PC YES CANINETAMING THE PC YES CANINE
TAMING THE PC YES CANINE
 
Systemic vasculitis 2016 shj
Systemic vasculitis 2016 shjSystemic vasculitis 2016 shj
Systemic vasculitis 2016 shj
 
Antiviral therapy nov.2015
Antiviral therapy nov.2015Antiviral therapy nov.2015
Antiviral therapy nov.2015
 
Pleural effusion.pptx cme march
Pleural effusion.pptx cme marchPleural effusion.pptx cme march
Pleural effusion.pptx cme march
 
NIDM Vs NIDDM
NIDM Vs NIDDMNIDM Vs NIDDM
NIDM Vs NIDDM
 
The global epidemic and the d lightful vitamin
The global epidemic and the d lightful vitaminThe global epidemic and the d lightful vitamin
The global epidemic and the d lightful vitamin
 
Hypertensive heart disease
Hypertensive heart diseaseHypertensive heart disease
Hypertensive heart disease
 
Acute pressure syndromes
Acute pressure syndromesAcute pressure syndromes
Acute pressure syndromes
 
The Wxyz Of Cardiodiab Risk
The  Wxyz Of Cardiodiab RiskThe  Wxyz Of Cardiodiab Risk
The Wxyz Of Cardiodiab Risk
 
Kiss
KissKiss
Kiss
 
GESTATIONAL DIABETES
GESTATIONAL DIABETESGESTATIONAL DIABETES
GESTATIONAL DIABETES
 

Recently uploaded

تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdfتقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
د حاتم البيطار
 
Abortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAE
Abortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAEAbortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAE
Abortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAE
Abortion pills in Kuwait Cytotec pills in Kuwait
 

Recently uploaded (20)

Top^Clinic ^%[+27785538335__Safe*Abortion Pills For Sale In Soweto
Top^Clinic ^%[+27785538335__Safe*Abortion Pills For Sale In SowetoTop^Clinic ^%[+27785538335__Safe*Abortion Pills For Sale In Soweto
Top^Clinic ^%[+27785538335__Safe*Abortion Pills For Sale In Soweto
 
Session-5-Birthing-Practices-Breastfeeding (1).ppt
Session-5-Birthing-Practices-Breastfeeding (1).pptSession-5-Birthing-Practices-Breastfeeding (1).ppt
Session-5-Birthing-Practices-Breastfeeding (1).ppt
 
Pulse Check Decisions - RRT and Code Blue Workshop
Pulse Check Decisions - RRT and Code Blue WorkshopPulse Check Decisions - RRT and Code Blue Workshop
Pulse Check Decisions - RRT and Code Blue Workshop
 
The 2024 Outlook for Older Adults: Healthcare Consumer Survey
The 2024 Outlook for Older Adults: Healthcare Consumer SurveyThe 2024 Outlook for Older Adults: Healthcare Consumer Survey
The 2024 Outlook for Older Adults: Healthcare Consumer Survey
 
Leadership Style - Code and Rapid Response Workshop
Leadership Style - Code and Rapid Response WorkshopLeadership Style - Code and Rapid Response Workshop
Leadership Style - Code and Rapid Response Workshop
 
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdfتقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
تقرير منظمة الصحة العالمية الخاص بالغذاء د حاتم البيطار.pdf
 
An overview of Muir Wood Adolescent and Family Services teen treatment progra...
An overview of Muir Wood Adolescent and Family Services teen treatment progra...An overview of Muir Wood Adolescent and Family Services teen treatment progra...
An overview of Muir Wood Adolescent and Family Services teen treatment progra...
 
Anthony Edwards We Want Dallas T-shirtsAnthony Edwards We Want Dallas T-shirts
Anthony Edwards We Want Dallas T-shirtsAnthony Edwards We Want Dallas T-shirtsAnthony Edwards We Want Dallas T-shirtsAnthony Edwards We Want Dallas T-shirts
Anthony Edwards We Want Dallas T-shirtsAnthony Edwards We Want Dallas T-shirts
 
Navigating Conflict in PE Using Strengths-Based Approaches
Navigating Conflict in PE Using Strengths-Based ApproachesNavigating Conflict in PE Using Strengths-Based Approaches
Navigating Conflict in PE Using Strengths-Based Approaches
 
Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.
Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.
Botulism/ Clostridium botulinum.ppt prepared by Dr PRINCE C P.
 
Indore 💋 ℂall Girl 9713632684 ℂall Girls in Indore Esℂort serviℂe book now
Indore 💋 ℂall Girl 9713632684 ℂall Girls in Indore Esℂort serviℂe book nowIndore 💋 ℂall Girl 9713632684 ℂall Girls in Indore Esℂort serviℂe book now
Indore 💋 ℂall Girl 9713632684 ℂall Girls in Indore Esℂort serviℂe book now
 
Abortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAE
Abortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAEAbortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAE
Abortion pills in Abu Dhabi ௵+918133066128௹Un_wandted Pregnancy Kit in Dubai UAE
 
Communication disorder and it's management
Communication disorder and it's managementCommunication disorder and it's management
Communication disorder and it's management
 
Etiology for RRT and Code Blue Workshop.
Etiology for RRT and Code Blue Workshop.Etiology for RRT and Code Blue Workshop.
Etiology for RRT and Code Blue Workshop.
 
GENETICS and KIDNEY DISEASES /
GENETICS and KIDNEY DISEASES            /GENETICS and KIDNEY DISEASES            /
GENETICS and KIDNEY DISEASES /
 
Adrenal Function Tests-3.pptxwhfbdqbfwwfjgwngnegenhndngssfb
Adrenal Function Tests-3.pptxwhfbdqbfwwfjgwngnegenhndngssfbAdrenal Function Tests-3.pptxwhfbdqbfwwfjgwngnegenhndngssfb
Adrenal Function Tests-3.pptxwhfbdqbfwwfjgwngnegenhndngssfb
 
POSHAN ABHIYAAN-Poshan 2.0 will concentrate on Maternal Nutrition, Infant and...
POSHAN ABHIYAAN-Poshan 2.0 will concentrate on Maternal Nutrition, Infant and...POSHAN ABHIYAAN-Poshan 2.0 will concentrate on Maternal Nutrition, Infant and...
POSHAN ABHIYAAN-Poshan 2.0 will concentrate on Maternal Nutrition, Infant and...
 
I urgently need a love spell caster to bring back my ex. +27834335081 How can...
I urgently need a love spell caster to bring back my ex. +27834335081 How can...I urgently need a love spell caster to bring back my ex. +27834335081 How can...
I urgently need a love spell caster to bring back my ex. +27834335081 How can...
 
Mike Lowe’s cancer fight lowe strong shirt
Mike Lowe’s cancer fight lowe strong shirtMike Lowe’s cancer fight lowe strong shirt
Mike Lowe’s cancer fight lowe strong shirt
 
Session-3-Promoting-Breastfeeding-During-Pregnancy.ppt
Session-3-Promoting-Breastfeeding-During-Pregnancy.pptSession-3-Promoting-Breastfeeding-During-Pregnancy.ppt
Session-3-Promoting-Breastfeeding-During-Pregnancy.ppt
 

Joint pain DR.RISHIKESAN K.V

  • 1. JOINT PAIN DR.RISHIKESAN K.V SPECIALIST PHYSICIAN VENNIYIL MEDICAL CENTRE SHARJAH
  • 2. ANATOMY LET’S REVIEW THE ANATOMY OF THE SYNOVIAL JOINTS. SYNOVIAL MEMBRANE LINES THE JOINT CAVITY. IT SECRETES THE SYNOVIAL FLUID AND REDUCES THE FRICTION BETWEEN THE BONES SYNOVIAL FLUID IS AN ULTRAFILTRATE OF THE PLASMA. IT IS GOING TO BE REFLECTIVE OF WHAT IS HAPPENING INSIDE THE PLASMA. IF THERE IS ANY SYSTEMIC INFLAMMATORY DISEASE SYNOVITIS AND HENCE ARTHRITIS IS A POSSIBLE SYMPTOM
  • 3. DEFINITION : ARTHRITIS Vs. ARTHRALGIA • MAJOR CAUSE OF MORBIDITY AND MORTALITY PARTICULARLY IN OLDER POPULATION • ARTHRALGIA MAY BE A REFERRED PAIN FROM MUSCLES ,TENDONS,BONES • ARTHRITIS IS A SPECIFIC PATHOLOGIC PROCESS OF INFLAMMATION OF JOINT STRUCTURE . MAY BE AUTO IMMUNE,INFECTIOUS OR TRAUMATIC AND WHAT ELSE. • VIRTUALLY IMPOSSIBLE TO DIFFERENTIATE THE TWO WITHOUT AT LEAST A PHYSICAL EXAM
  • 4. DIFFERENTIAL DIAGNOSIS TRAUMA : SPRAIN ,STRAIN,FRACTURE ,DISLOCATION,TENDONITIS ,TEAR OF TENDON ,LIGAMENTS,MENISCUS INFECTIONS : GONOCOCCAL, NON GONOCOCCAL, LYME DISEASE, TB, VIRAL FUNGAL CRYSTAL: GOUT,PSEUDOGOUT DEGENERATIVE: OA MALIGNANCY: SOLID TUMOR METASTASIS, LYMPHOMA, LEUKAEMIA, OSTEOSARCOMA, OSTEOCHONDROMA RHEUMATIC: RA, SLE, REITERS, PSORIATIC, ANK SPONDYLITIS, AC.RHEUMATIC FEVER, SJOGRENS OTHERS : A HUGE WIDE LIST OF POSSIBLE CAUSES FOR JOINT PAIN
  • 5. DIFFERENTIAL DIAGNOSIS • TRAUMA : SPRAIN ,STRAIN,FRACTURE ,DISLOCATION,TENDONITIS ,TEAR OF TENDON ,LIGAMENTS,MENISCUS • INFECTIONS : GONOCOCCAL,NON GONOCOCCAL,LYME DISEASE,TB,VIRAL FUNGAL • CRYSTAL: GOUT,PSEUDOGOUT • DEGENERATIVE: OA • MALIGNANCY: SOLID TUMOR METASTASIS,LYMPHOMA,LEUKAEMIA,OSTEOSARCOMA,OSTEOCHONDROMA • RHEUMATIC: RA,SLE,REITERS,PSORIATIC,ANK SPONDYLITIS,ACUTE RHEUMATIC FEVER,SJOGRENS • OTHERS • WE HAVE GOT A HUGE WIDE WIDE LIST OF POSSIBLE CAUSES FOR JOINT PAIN HERE MORE THAN EVER, IT IS ESSENTIAL TO HAVE A GOOD HISTORY AND PHYSICAL EXAM INORDER TO MAKE A PROPER DIAGNOSIS
  • 6. TAKING A GOOD HISTORY SLICE SYSTEMIC : ANY SYSTEMIC SYMPTOMS THAT ACCOMPANY THE JOINT PAIN LIKE FEVER,CHILLS ,RASH,FATIGUE,WEIGHT LOSS LOCATION: WHICH JOINT / JOINTS SORE? SINGLE, SOME ,MULTIPLE. IF MULTIPLE SYMMETRICAL OR ASYMMETRICAL IN DISTRIBUTION INFLAMMATION: IS THE AFFECTED JOINT INFLAMMED? CHRONICITY: RECENT ONSET/ACUTE, INSIDIOUS ONSET/MORE CHRONIC.DOES THE PAIN COME AND GO OR PERSISTENT.WHAT TIME OF THE DAY PAIN WORSE? EVIDENCE OF TRAUMA
  • 7. SLICE SYSTEMIC SYMPTOMS FEVER: GOUT,RA, INFECTIOUS ARTHRITIS (ESPECIALLY WITH CHILLS.) RASH: VASCULITIS LIKE CHURG STRAUSS, WEGENERS, PSORIATIC FATIGUE : RA,SLE ,PMR ANY CHRONIC FORM OF ARTHRITIS. DISTRIBUTION / LOCATION DIP JOINTS - PSORIATIC. MTP ,PROX.IP JOINTS -RA INFLAMMATION : SEPTIC, GOUT, Rheumatoid Arthritis CHRONICITY: ACUTE - INFECTIOUS, GOUT
  • 8. HAND ARTHRITIS LOCATION: ASK THESE QNs WHICH JOINT / JOINTS SORE? IS IT SINGLE ? SOME ? MULTIPLE? IF MULTIPLE , SYMMETRICAL OR ASYMMETRICAL IN DISTRIBUTION?
  • 9. SLICE THE OSTEOARTHRITIS Systemic : Primary OA is not associated with any systemic symptoms Location : Hands (wrists, MCPs, PIPs, DIPs) and weight bearing joints (hips, knees) primarily. Not necessarily symmetrical. Inflammation : Joints are not externally inflamed. Chronicity : Chronic and progressive. Insidious onset. Worsens with activity, pain improves with rest. Evidence of trauma : May occur secondary to trauma to a specific joint. But primary OA is not associated with trauma
  • 10. SLICE- ing RHEUMATOID ARTHRITIS •Systemic: YES MOST OF THEM HAVING SYSTEMIC SYMPTOMS: FATIGUE , MALAISE,WEAKNESS,LOW GRADE FEVER,WEIGHT LOSS •Location :HAND ARTHRITIS, NOT IN DIPs. ALSO AFFECTS SHOULDERS,KNEES,HIP. BUT NO LBP. SYMMETRIC •Inflammation. VERY PROMINENT,WARM ERYTHEMIC JOINTS •Chronicity: CHRONIC,INSIDIOUS, PROGRESSIVE,PAIN WORST IN THE MORNING •Evidence of trauma: NO TRAUMA INVOLVED
  • 11. EXTRA ARTICULAR SYMPTOMS SEPTIC ATHRITIS : FEVER,CHILLS,NAUSEA,RASH (ERYTHEMA MIGRANS IN LYME DISEASE) MALIGNANCY : PALLOR,EASY BRUISING,INFECTION ELSEWHERE. RHEUMATOLOGIC OR AUTOIMMUNE : ALL MAY INCLUDE FEVER,WEIGHT LOSS REITER’S SYNDROME : URETHRITIS, H/O CHLAMYDIAL INFECTIONS, ENTERITIS, CONJUNCTIVAL INFECTION, CONJUNCTIVITIS. PSORIATIC ARTHRITIS : PSORIASIS, SAUSAGE DIGITS,NAIL ABNORMALITIES SLE : MALAR RASHES,RENAL INSUFFICIENCY ANKYLOSING SPONDYLITIS : ENTHESITIS,RASHES SJOGRENS SYNDROME : DRY EYES,DRY MOUTH WEGENERS : CHRONIC URI, LRTI, RENAL INSUFFICIENCY
  • 12. WHAT NEVER HAS EXTRA ARTICULAR SYMPTOMS? OSTEOARTHRITIS ! THE MOST COMMON FORM OF CHRONIC ARTHRITIS. IT IS STRICTLY LIMITED TO THE JOINTS. IT IS THE DEGENERATIVE DISEASE OF THE JOINTS
  • 13. ACUTE MONOARTHRITIS CRYSTAL INDUCED ACUTE MONOARTICULAR ARTHRITIS SEVERE INFLAMMATION CRYSTALS POSITIVE ACUTE MONOARTHROPATHY <50000 CELLS/ MICROLITRE IN SYNOVIAL FLUID CULTURE NEGATIVE SEPTIC ARTHRITIS ACUTE MONOARTHROPATHY SEVERE INFLAMMATION NO CRYSTALS >50000 CELLS IN SYNOVIAL FLUID CULTURE POSITIVE
  • 14. VIRAL ARTHROPATHY Vs. SYMMETRICAL ARTHROPATHY VIRAL ARTHROPATHY • SYMMETRIC ARTHROPATHY • NO SIGNIFICANT INFLAMMATION • NO RASH OR RENAL FAILURE • NO PULMONARY INVOLEMENT • IgM TITRES HIGH FOR SPECIFIC VIRUSES • LOOK FOR HEPATITIS PANEL • IgM PARVOVIRUS TITRES • EPSTEIN BARR VIRUS TITRES CHRONIC SYMM.ARTHROPATHY CHRONIC. SYMMETRIC POLY ARTICULAR. SIGNICANT INFLAMMATION. EROSIONS ON XRAY. POSITIVE RF AND OR ANA. CONSTITUTIONAL Sx. EXTRA ARTICULAR MANIFESTATIONS.
  • 15. LABORATORY WORK UP FOR JOINT PAIN • IN ANY PATIENT WHO HAS SIGNS OF AN INFLAMMED JOINT,YOU MUST ORDER A JOINT ASPIRATE • PATIENTS WITH SIGNS AND SYMPTOMS OF OSTEOARTHRITIS- NO EXTRAARTICULAR SYMPTOMS,OLDER AGE,ASYMMETRICAL- PLAIN RADIOGRAPHY IS THE BEST INITIAL TEST,WHILE CT IS MORE ACCURATE • PATIENTS WITH SIGNS OF AUTO IMMUNE OR RHEUMATOLOGIC DISEASE ( EXTRA ARTICULAR SYMPTOMS) THERE ARE VARIOUS AUTO ANTIBODIES THAT MAY BE ORDERED CORRESPONDING WITH THE SUSPECTED SYNDROME. • THESE Abs. HAVE VARIOUS LEVELS OF SENSITIVITY AND SPECIFICITY
  • 16. AUTO ANTIBODIES WITH VARIOUS JOINT PAIN Antinuclear Antibodies (ANA) Anti-Ro, Anti-La: Sjogren’s Syndrome Anti-centromere: CREST SYNDROME Anti-Histone: Drug Induced Lupus Anti- ds DNA, Anti Sm: SLE Rh. factor(RF),Anti – CCP: Seen in patients with Rheumatoid arthritis. However their absence doesn’t rule out RA ANCA c-ANCA: Wegener’s granulomatosis P-ANCA: Churg-Strauss syndrome, poly arteritis nodosa
  • 17. JOINT ASPIRATION OR ARTHROCENTESIS JOINT ASPIRATION IS THE BEST INITIAL DIAGNOSTIC STEP FOR THE DIAGNOSIS OF : GOUT PSEUDOGOUT AND SEPTIC ARTHRITIS.
  • 18. JOINT ASPIRATION OR ARTHROCENTESIS A RED ,WARM, SWOLLEN,PAINFUL JOINT POINTS TO: GOUT PSEUDOGOUT SEPTIC ARTHRITIS (FROM VARIOUS AETIOLOGIES.) IN THE JOINT ASPIRATION WE LOOK FOR 4Cs COLOR CELLS CRYSTALS , ………… and we get a CULTURE
  • 19. OSTEOARTHRITIS CHRONIC PROGRESSIVE , NON INFLAMMATORY, IDIOPATHIC DEGENERATIVE JOINT DISEASE. CLOSELY RELATED TO AGING PROCESS: PRIMARY OA OF COURSE OTHER ARTHROPATHIES CAN PREDISPOSE TO OA WEIGHT IS A COMMON CAUSE MOST COMMONLY AFFECTS THE JOINTS OF THE HANDS,AS WELL AS WEIGHT BEARING JOINTS (KNEES,HIPS). JOINTS OFTEN APPEAR NORMAL, EXTERNALLY, DECREASED ROM, CREPITUS. THE BEST FIRST STEP IN DIAGNOSTIC EXAMINATION IS XR OF THE AFFECTED JOINTS.TYPICAL FINDING IS A REDUCTION IN JOINT SPACE.
  • 20. OSTEOARTHRITIS JOINT PAIN IS THE MOST COMMON SYMPTOM. NO CONSTITUTIONAL SYMPTOMS. NODES ON DIPs AND PIPs ANY LABS SHOULD BE NORMAL ABNORMALITIES IN LABS ARE NOT INDICATIVE OF OSTEOARTHRITIS
  • 21. OSTEOARTHRITIS TREATMENT ACETAMINOPHEN IS THE RX OF CHOICE IF THE PATIENT IS NSAID SENSITIVE. TOPICAL CAPSAICIN IS USEFUL BUT INFERIOR TO NSAIDs. Rx. IS PALLIATIVE. NSAIDs ARE THE MAINSTAY OF TREATMENT.
  • 22. DRY EYES AND DRY MOUTH AUTO IMMUNE INFLAMMATORY AND DESTRUCTIVE DISEASE OF THE EXOCRINE GLAND. MAJOR SX: DRY EYES,DRYMOUTH AND PAROITDS ENLARGEMENT H/o NUMEROUS DENTAL CARIES 1* AND 2* FORMS( SLE ,RA etc) BX.OF SALIVARY GLANDS SINGLE MOST ACCURATE TEST: LYMPHOCYTIC SIALOADENITIS COMPLICATIONS: NHL, NEONATAL LUPUS SCHIRMER TEST AND Anti- Ro /Anti- La TITRES
  • 23. SCHIRMER’S TEST <5 mm IN 5 MINUTE IS A POSITIVE TEST. (NORMAL 15mm) OFTEN DONE AS A SCREENING TEST PERHAPS THE BEST INITIAL TEST ALONG WITH ANA IN ESTABLISHING THE DSIS. TREATMENT : ARTIFICIAL TEARS,CYCLOSPORINE OPHTHALMIC. FOR DRY MOUTH: ARTIFICIAL SALIVA, PILOCARPINE,DENTAL CARE. BASIC PATIENT EDUCATION: USE OF HUMIDIFIER AT HOME,VAGINAL LUBRICANTS PRN, SKIN MOISTURISERS,VIGILANCE FOR PAROTID GLAND ENLARGEMENT
  • 24. SERONEGATIVE SPONDYLOARTHROPATHY A DIVERSE GROUP OF GENERALLY INFLAMMATORY, SYSTEMIC AUTOIMMUNE DISEASE THAT ARE NEGATIVE FOR RA FACTOR AND ANA. ALL OF THEM SHARE ONE THING IN COMMON: HLA B 27 ANTIGEN. HLA B27 IS HIGHLY PREVALENT IN SCANDINAVIANS.NOT ALL OF THEM DEVELOPP SERO-VE ARTHROPATHY NEVERTHELESS CLINICALLY DIVERSE: Ankylosing Spondylitis, Psoriatic, Reactive(Reiter’s)Arthritis, Enteropathic Spondylitis ANKYLOSING SPONDYLITIS DISTINCT FROM MOST AUTOIMMUNE DISEASE. IT IS PREDOMINANT IN YOUNG MAN UNDER THE AGE OF 40! DSIS BASED ON CLINICAL SYMPTOMS AND ON LUMBAR SPINAL XRAY
  • 25. CAN’T SEE,CAN’T PEE AND CAN’T DANCE WITH ME REACTIVE ARTHRITIS OR REITER’S SYNDROME: TRIAD OF URETHRITIS - NON GONOCOCCAL/CHLAMYDIAL CONJUNCTIVITIS AND ARTHRITIS HLA B27 = 70% CASES. 3-10% PROGRESS TO AS. CAN BE FROM A GI BUG: Yersin & Sal went to Camp in the Shig. KERATODERMA BLENORRHAGICA Lover’s heel Reiter’s nail
  • 26. WHAT IS WRONG WITH THIS SPINE? ANKYLOSING SPONDYLITIS LUMBAR SPINAL X RAY :SHOWS FUSION OF LUMBAR SPINAL PROCESSES: BAMBOO SPINE PERSISTENT AND CHRONIC REFRACTORY LBP WHICH IS WORST IN THE MORNING AND IMPROVES THROUGHOUT THE DAY
  • 27. BAMBOO SPINE PATIENTS WILL HAVE A LOSS OF LUMBAR LORDODSIS.THIS MAY MAKE THE PATIENT SUSCEPTIBLE TO SPINAL FRACTURES
  • 28. SYMMETRICAL INFLAMMATORY OLIGOARTHRITIS PSORIATIC ARTHRITIS IS AN IMPORTANT SERO -VE SPONDYLOARTHROPATHY IT PRESENTS AS SYMMETRICAL INFLAMMATORY OLIGOARTHRITIS. IN MOST CASES SKIN MANIFESTATIONS PRECEDES ARTHROPATHY. MILD CASES NEED NSAIDs. IMMUNOSUPPRESSION FOR SEVERE CASES
  • 30. MORNING ALWAYS HELPS TO SEE NATURE FRESH AND RADIANT- Dr.Rishi
  • 31.
  • 32. RHEUMATOID ARTHRITIS CHRONIC INFLAMMATORY,SYSTEMIC DISEASE WITH SEVERE JOINT PAIN DSIS: BASED ON CLINICAL, IMAGING,AND LAB CRITERIA. 4 OUT OF 7 CRITERIA. MORNING STIFFNESS HAND ARTHRITIS. SYMMETRIC. ULNAR DEVIATION OF DIGITS, BOUTONNIERE DEFORMITY, RHEUMATOID NODULES, BAKERS CYST RF (RHEUMATOID FACTOR)
  • 33. RHEUMATOID ARTHRITIS: PHYSICAL EXAM DIPs ARE NOTABLY EXCLUDED.FINDINGS WILL DEPEND ON PROGRESSION AND CHRONICITY
  • 35. EXTRA ARTICULAR MANIFESTATION FELTY’s SYNDROME: TRIAD OF *RA, *NEUTROPAENIA, *SPLENOMEGALY. ANY INFECTION WITH FELTY’s SYNDROME SHOULD BE TREATED INPATIENT WITH IV ANTIBIOTICS COVERING GRAM +, GRAM –, AND GNR. ATALANTO AXIAL DISLOCATION: DON’T SEE CHIROPRACTIONERS
  • 36. TREATMENT MAINSTAY OF TREATMENT METHOTREXATE WITH OR WITHOUT A BIOLOGIC TNF ALPHA INHIBITORS WHICH GRATELY INHIBIT GENERAL INFLAMATION. INFLIXIMAB (Remicade) ETANERCEPT(Enbrel) ADALIMUMAB (Humira) NEWLY DIAGNOSED PATIENTS MAY BE TREATED WITH PREDNISOLONE TO BRIDGE OVER AS THE BIOLOGICS AND MTX. TAKE EFFECT
  • 37. IDENTIFY THE CELEBRITY A 23 YEAR OLD WOMAN PRESENTS WITH GENERALISED JOINT PAIN. YOU IMMEDIATELY NOTICE ERYTHEMA OVER HER CHEEKS. PE: OTHERWISE UNREMARKABLE. ON LEVATERACITAM AND PHENYTOIN FOR PAST MEDICAL HISTORY OF EPILEPSY. CBC AND CMP ARE DRAWN. UNREMARKABLE BUT FOR Hb 10.5GM, HCT 31,TLC 3500, PLT 250000. WHAT IS THE BEST NEXT STEP IN THE MANAGEMENT OF THIS PATIENT? Ans: ANA, Anti-ds DNA AND Anti-Sm TITRES She has undergone a course of chemotherapy after being diagnosed with lupus, a condition affecting the immune system.
  • 39. OVERVIEW OF SLE CHRONIC IDIOPATHIC INFLAMMATORY MULTISYSTEMIC DISEASE. ARTHRITIS IS ONE OF A MYRIAD OF POSSIBLE SYMPTOMS AND PRESENTATIONS. WOMEN ARE AFFECTED MORE THAN MEN BY A RATIO 9:1 CLASSIC TRIAD: FEVER, RASH (MALAR, DISCOID, PHOTO SENSITIVE) AND ARTHRALGIA. DSIS : BASED ON CRITERIA AND SUPPORTED BY LABORATORY EVIDENCE
  • 40. S O A P B R A I N M.D
  • 41. SOAP BRAIN MD: DIAGNOSTIC CRITERIA SLE SEROSITIS ORAL ULCERS ARTHRITIS PHOTOSENSITIVITY BLOOD DISORDERS RENAL 4 OF THESE CRITERIA IS 95% SPECIFIC AND 85% SENSITIVE ANA IMMUNOLOGICAL PHENOMENA (Anti-ds DNA, Anti-Sm) NEUROLOGICAL SYMPTOMS MALAR RASH DISCOID RASH
  • 42. NEONATAL LUPUS A 23 YEAR OLD WOMAN WITH POLYARTHRALGIA HAVING POSITIVE Anti - ds DNA AND Anti-Sm antibodies IS DIAGNOSED TO HAVE SLE. SHE IS STABLE ON METHOTREXATE. 3 YEARS LATER SHE PRESENTED TO YOUR OFFICE AT 2 MONTHS GESTATION. WHICH OF THE FOLLOWING LABS WOULD YOU BE MOST INTERESTED IN ORDERING? WHY? ALL SLE WOMEN SHOULD BE SCREENED FOR Anti- Ro ANTIBODY DURING EARLY PREGNANCY.BABIES BORN TO Ro +VE MOTHERS ARE AT THE RISK FOR NEONATAL LUPUS.THIS TYPICALLY MANIFESTS AS CHB
  • 43. A LADY WITH CORPORALGIA AMITRYPTILINE. “FEELING OF HURTING ALL OVER, ALWAYS HAVING THE FLU” PAIN ELLICITABLE FROM CHARACTERISTIC PRESSURE POINTS. DSIS: ENTIRELY CLINICAL
  • 44. FIBROMYALGIA CHRONIC , NON INFLAMMATORY ”PAIN PROCESSING “ DISORDER OF UKNOWN AETIOLOGY. IT IS A PHYSICAL DISORDER WITH HEAVY PSYCHIATRIC OVERTONES. A SYNDROME OF WIDESPREAD PAIN STIFFNESS, FATIGUE, DISRUPTED SLEEP OFTEN ACCOMPANIED BY , MOOD OR ANXIETY DISTURBANCES ; OTHER SOMATIC DISORDERS ( OVERACTIVE BLADDER, IBS) WOMEN AFFECTED MORE BY A RATIO OF 9:1 INCREASED INCIDENCE IN PATIENTS SUFFERING,FROM PTSD AND AUTOIMMUNE DISEASES. THE MOST COMMON DRUG USED IS A TCA (AMITRYPTILINE). RECENTLY GABAPENTINE AND PREGABALIN HAVE BEEN USED. NSAIDs AND OPIOIDs NEVER,NEVER
  • 45. CRYSTAL ARTHROPATHY NEEDLE SHAPED CRYSTALS OF URIC ACID THE BEST INITIAL DIAGNOSTIC TEST IS SYNOVIAL FLUID ANALYSIS. REMEMBER TO ASPIRATE A JOINT IN APATIENT WITH MONOARTICULAR ARTHRITIS EVEN IF THERE IS A HISTORY OF PRE EXISTING GOUT
  • 46. GOUT MOST COMMONLY FIRST OCCURS IN THE BIG TOE MAY BE POLYARTICULAR AFFECTING ANKLE KNEE , PIPs, DIPs PRESENTS WITH EXCRUCIATING MONOARTICULAR JOINT PAIN ( MAY WAKE THE PATIENT UP). ARTHROCENTESIS SHOWS NEEDLE SHAPED NEGATIVELY BIREFRINGENT CRYSTALS. THE BEST INITIAL STEP IN THERAPY IS NSAIDs. WE TREAT THE PAIN FIRST. ULT ONCE ACUTE ATTACK IS OVER ULTs ONLY FOR CHRONIC GOUT TO PREVENT FURTHER ATTACKS USE ALLOPURINOL OR FEBUXOSTAT
  • 47. GOUT AND SERUM URIC ACID PATIENTS WITH MULTIPLE GOUT ATTACKS SHOULD UNDERGO A 24 HOUR URINE URIC ACID ESTIMATION. IF THEY ARE FOUND TO BE UNDER SECRETORS THEY ARE CANDIDATES FOR THERAPY WITH URICOSURIC AGENTS LIKE PROBENECID DONOT FALL FOR THE TRAP OF ORDERING SERUM URIC ACID LEVEL . THEY DONOT CORRESPOND TO GOUT ATTACK IF PREVENTIVE TREATMENT IS NOT INITIATED AND GOUTY ARTHRITIS RECURS FREQUENTLY THEN EROSION AND DESTRUCTION OF THE JOINT MAY OCCUR
  • 48. PSEUDOGOUT PSEUDOGOUT; ACUTE OR CHRONIC ALWYS LOOK FOR SYSTEMIC DISEASES TENDS TO OCCUR IN OLDER PATIENTS WITH PRE EXISTING JOINT DISEASE AND IN PATIENTS WITH METABOLIC OR ELECCCTROLYTE DISORDERS LIKE: HYPERPARATHYROIDISM,HAEMOCHROMATOSIS, HYPOPHOSPHATAEMIA,HYPOMAGNESAEMIA ALMOST IDENTICAL TO GOUT THE BEST INITIAL DIAGNOSTIC TEST IS ARTHROCENTESIS RHOMBOID /RECTANGULAR POSITIVELY BIREFRINGENT CRYSTALS
  • 50. TEMPORAL ARTERITIS AND PMR PREDNISOLONE IS THE DRUG OF CHOICE. THIS PATIENT IS AT THE RISK OF DEVELOPING PMR QUESTION
  • 51. TAKE HOME MESSAGE RHEUMATOLOGY IS ONE OF THE MORE ARCANE MEDICAL DISCIPLINES. IT CAN OFTEN BE CONFOUNDING FOR NEW INITIATES JOINT PAIN IS THE HALL MARK SYMPTOM OF CLINICAL RHEUMATOLOGY . A DETAILED HISTORY, PHYSICAL EXAMINATION , AND ANALYSIS OF SLICE DATA IS SUFFICIENT TO REACH A PROBABLE DIAGNOSIS. A MIX OF STRONG CLINICAL SKILLS, PATTERN MATCHING TECHNIQUES AND KEY CLUES OFTEN ALLOWS RAPID AND ACCURATE DIAGNOSIS