2. Bases del razonamiento clínico
• Conocimiento
• Habilidad (velocidad y agilidad)
• Establecimiento de mapas mentales
– Experto
– Novato
• Pensamiento no analítico
– Patrones
3. Paciente
• “La rodilla me dolió mucho anoche. El dolor
me despertó. Cuando me fuí a dormir estaba
bien. Ahora está inflamada. Es el peor dolor
que he tenido. He tenido problemas similares
en la misma rodilla, una vez hace 9 meses, la
otra hace dos años. No me ha molestado
excepto en esas dos ocasiones.”
4. Novato
• Masculino de 54 años con dolor en la rodilla.
Inició anoche. No refiere trauma previo. A la
exploración sus signos vitales son normales. La
rodilla se encuentra inflamada, eritematosa y
dolorosa a la palpación. Le duele mucho al
explorar el rango de movimiento. Ha
presentado este problema en dos ocasiones
previas.
5. Experto
• Masculino de 54 años con artritis aguda de la
rodilla derecha que lo despertó. Niega
antecedentes y se refiere asintomático al
acostarse. Tiene el antecedente de dos
episodios similares de dolor hace 9 meses y
dos años con periodos libres de dolor entre
ellos. Hoy se encuentra afebril. Su rodilla está
inflamada, dolorosa a la palpación y
eritematosa.
6. Diferencias
• No hay estructura definida en la presentación
novata
• El experto generó una representación del
problema e impresión diagnóstica
• Guía subsecuente
• Transformación a términos clínicos
• Una sola frase “Monoartritis aguda recurrente
en un hombre adulto”
7. Abordaje en dos pasos
• Mapa mental no analítico
• Basado en evidencia y experiencia
• Dos mapas:
– Mapas creados mediante el conocimiento de una
enfermedad
– Mapa generado al revisar a un paciente
8. Tipos de diagnóstico
Diagnóstico
Sindromático
Diagnóstico
Nosológico
Diagnóstico
Etiológico
9. 3
I- MAIN SYNDROMES
The aim of our first step is to establish the main syndrome which is most representative of our patients’
clinical picture (pattern recognition). The main syndromes proposed below represent our diagnostic strategy,
matured and revised over the years. Other experts may identify other operating patterns deemed useful for
their clinical practice.
Figure 1 - Main rheumatological syndromes5
4 Reumatologia Prática. JAP da Silva. Diagnosteo, Publishers. Coimbra. Portugal. 2004.
5 Published under permission. Diagnósteo, Publishers. Coimbra, Portugal.
10. Síndromes regionales
• Dolor en una área específica
– Periarticular
– Articular
– Neurogénico
– Referido
11. 6
Table n°1 - Distinctive features of regional syndromes
Periarticular
Pain
Articular pain Neurogenic
pain
Referred Pain
Enquiry Selective painful
movements
All joint
movements are
painful
Disaestesic.
Aggravated by
compression of
nerve or
mobilization of
the spine
Unrelated to
movement.
“Visceral” timing
Pain on
motion
Active> passive.
Selected motions
Active ~ passive
Several
directions
Normal. If root
pain: Pain on
motion of the
affected spine
segment
Normal
Range of
Motion
Active motion can
be limited by
pain. Passive
motion: full
Can be limited in
active and
passive motion
Normal Normal
Resisted
mobilization
Pain on specific
manoeuvres
No effect No effect No effect
Local
Palpation
Pain upon
affected structure
Possible:
Crepitus,
swelling, effusion,
heat.
Pain along joint
margin
Normal Normal
Neurological
examination
Normal Normal May be
abnormal
Normal
12. Eular On-line Course on Rheumatic Diseases – module n°1
Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
Figure 2 - Most common sites and origins of referred pain
Table n°1 - Distinctive features of regional syndromes
Periarticular
Pain
Articular pain Neurogenic
pain
Referred Pain
Enquiry Selective painful
movements
All joint
movements are
painful
Disaestesic.
Aggravated by
compression of
nerve or
mobilization of
the spine
Unrelated to
movement.
“Visceral” timing
13. Síndrome de dolor generalizado
• Difuso
• Fibromialgia
– Dolor generalizado, migratorio asociado a ejercicio
– Cefalea, ansiedad, trastornos del sueño
– Diferentes patrones
• Diagnóstico diferencial adecuado
– AR
– LES
Sjögren
– Polimialgia reumática
– EA
– Polimiositis
– Hipotiroidismo
– Hipoparatiroidismo
14. Lumbalgia y cervicalgia
• Anatomicamente complejas
• Estudios de imágen
• Mec´nico vs. inflamatorio
• Signos de alarma
• Condiciones musculares, neurológicas, etc.
15. Eular On-line Course on Rheumatic Diseases – module n°1
Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
Table n°2 - Common causes of low back pain, suggestive manifestations and alarm signals.
“Red Flags”
Back pain with inflammatory rhythm
Localized pain
Nocturnal pain
Visceral or constitutional symptoms
Onset before age 30 or after 50
Pain at movement in all directions
History of neoplasm
Risk or evidence of osteoporosis
Neurological manifestations
Sacroiliitis
Spondylodiscitis
Metastases
Osteoporotic fracture
Neurogenic pain
Referred pain
Interspinous ligamentitis
“No Red flags” Acute mechanical low back pain
Chronic mechanical low back pain
Fibromyalgia
Reasoning regarding neck pain follows a similar rationale.
In most cases the pain has a mechanical rhythm. It is triggered by movement and relieved by rest. In adults,
most of these conditions are caused by spondyloarthrosis. In many other cases, particularly in young people,
there is no apparent cause for the pain, and it is thought to be the result of mild articular instability and
irritation of the nerves and muscle bundles leading to painful reflex muscle contractions. Both situations
should be treated conservatively, aiming to relieve the pain and restore function, without any specific
aetiological intervention. In a few cases, the pain may be neurogenic, inflammatory, infectious, neoplastic or
psychogenic in origin. The clues for such special conditions are similar to those described above. The
possibility of referred pain, from the heart, lung apex and shoulder must be kept in mind. Acute
lymphadenopathy, thyroiditis and meningitis represent important non-rheumatic causes of neck pain.
16. Síndrome articular
• Dolor localizado, crepitación, aumento de
volúmen, calor.
• Mecánico vs. inflamatorio
• Otros síntomas
• Exacerbaciones/remisiones
• Actitudes forzadas
• Fluctuación
17. Diferencias entre inflamación y daño
articular
Inflamación Daño
RAM Prolongada Corta
Rigidez a la inmovilidad Prolongada Corta
Calor + -
Dolor a la posición forzada Si No
Inflamación de tejido blando + -
Sinovitis o “derrame” +++ +/-
Crepitación - +++
Deformidad - +/-
Inestabilidad - +/-
18. Síndrome de “Osteoporosis”
• Factores de riesgo
– Postmenopausia
– Menopausia precoz
– IMC bajo
– Sedentarismo
– Ingesta pobre de lacteos
– Antecedentes familiares o personales de fractura
– Malabsorción, hipogonadismo, hipertiroidismo,
hiperparatiroidismo, uso de alcohol, esteroides, etc.
19. Síndrome óseo
• Dolor profundo, difuso, continuo, sin relación
con movimiento
• Nocturno
• Tumores, inflamación periosteo, enfermedad
ósea
• Metástasis (columna, cinturas)
• EF tiende a ser normal
20. Síndrome sistémico
• Puede acompañar a otros síndromes
• Enfermedades de tejido conectivo
• Vasculítis
• Síntomas y signos constitucionales
25. pattern of distribution, 2) how the condition began and how it developed over time; 3) the presence or
absence of inflammatory low back pain; 4) accompanying extra-articular manifestations.
Once you have this information, you may classify the arthritis according to a number of parameters, which will
help you find and support a final diagnosis:
14
Number of joints affected
Monoarthritis: one single joint involved
Oligoarthritis: 2 to 4 joints involved
Polyarthritis: 5 or more joints involved
Acute versus Chronic
Acute: onset in hours or days
Chronic: onset over weeks or months
Additive versus Migratory
Additive: the affected joints are added progressively
Migratory. The inflammatory process flits from one joint to another
Persistent versus Recurrent
Persistent: once it has set, the arthritis persists over the time
Recurrent: episodes or crisis of arthritis separated by symptom-free intervals
predominantly Proximal versus predominantly Distal
Proximal: arthritis mainly involves large joints, i.e, proximal to the wrist or ankle,
and the spine
Distal: the arthritis mainly involves the small joints of the hands and feet, with or
without the wrist and ankle
Symmetrical versus Assymmetrical
Symmetrical: affects approximately the same joint groups of each side of the
body
Asymmetrical: there is no relationship between the joints involved on either side
of the body
With or without inflammatory low back pain
With or without systemic manifestations
26. Eular On-line Course on Rheumatic Diseases – module n°1
Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
Table n°5 - Most common causes of secondary osteoarthritis.
Fracture involving the articular surface Preexisting arthritis
Meniscectomy Axial deviations
Articular instability Aseptic necrosis
Intra-articular loose bodies Chondrocalcinosis
Osteochondritis dissecans
Particularly demanding occupations
Patterns of inflammatory joint disease
The Inflammatory articular syndrome is suggested by pain with “inflammatory rhythm” and confirmed by the
demonstration of joint inflammation (diffuse elastic swelling around the joint with or without redness and heat).
When evaluating a patient with arthritis, it is important to determine: 1) which joints are affected and their
pattern of distribution, 2) how the condition began and how it developed over time; 3) the presence or
absence of inflammatory low back pain; 4) accompanying extra-articular manifestations.
Once you have this information, you may classify the arthritis according to a number of parameters, which will
help you find and support a final diagnosis:
Number of joints affected
Monoarthritis: one single joint involved
Oligoarthritis: 2 to 4 joints involved
Polyarthritis: 5 or more joints involved
Acute versus Chronic
28. Patrones
• Oligo/poliartritis crónica asimétrica
– OA
– AR
– Apso, ARe
– Gota tofacea crónica
• Oligoartritis proximal
– EA seronegativas
• Artritis en la cintura escapular y pélvica
– PMR
29. Patrones
• Oligo/poliartritis aguda + fiebre
– Infecciones virales
– Still
– LES, Behcet, PM, AR
• Dolor inflamatorio en columna vertebral
• EA seronegativas
• Poliartritis con manifestaciones sistémicas
– LES
30. Atención óptima
• Enfoque en problemas relevantes
• Evaluar la validez de la información
• Escuchar al paciente
• Explorar adecuadamente
• Resumir los datos
• Uso sensato de laboratorio y gabinete
