approach to arthritis patient
TRANSCRIPT
Approach to Arthritis patient
Dr. Ashish GohiyaAssistant Professor
Department of Orthopaedics
Gandhi Medical College, Bhopal
Goal
• To formulate differential diagnosis.
• Lead to accurate diagnosis.
• Timely therapy.
• Avoid excessive diagnostic test & unnecessary treatment.
Whether the problem is
• 1. Articular or Nonarticular.
• 2. Inflammatory or Non inflammatory.
• 3. Acute or Chronic.
• 4. Localized (Mono, Oligo) Widespread (Poly)
Systemic.
Articular
• Articular cartilage, synovium, synovial fluid, I/A ligaments, joint capsule.
• Pain & limited ROM on active and Passive Movements.
• Crepitations.
• Instability.
• Locking .
Non Articular
• Muscle, tendon, ligaments, bursa, fascia, bone nerve, vessels, skin.
• Pain on active but not on passive movement.
• Focal tenderness distant from articular site.
• No Crepitus, instability, locking.
Inflammatory
• Causes –Infectious (Septic, TB)
–Crystal induced (Gout, Pseudogout)
–Immune related (RA, SLE)
–Reactive (Rheumatic fever,Reiters syndrome)
–Idiopathic
• Signs of inflammation–Erythema, warmth, pain, swelling.
• Systemic symptoms–Morning stiffness,fatigue,fever,wt. loss.
• Lab evidence –Increased ESR, Increased CRP.
Non Inflammatory
• Causes –Trauma (rotator cuff tear, meniscus tear)
–Ineffective repair (Osteoarthritis)
–Cellular overgrowth (Pig. Villonodular synovitis)
–Pain amplification (fibromyalgia)
• Pain without swelling & warmth.
• No inflammatory signs.
• No lab findings.
Clinical
• Age : • SLE , RF, RS – young.• OA – old
• Sex• AS, RS – Male• RA, Fibromyalgia – Female
• Race
• Family • AS, Gout, RA.
Chronology • Onset
– Acute – Septic arthritis, gout– Insidious – RA, OA
• Evolution – Chronic – OA– Intermittent – Gout– Migratory – RF, Viral Arthritis/gonococcal– Additive – RA, – Acute – Infection, Crystal
< 6wk Acute , > 6wk Chronic
No. of Joints affected
• Monoarticular(1or2)
• Oligoarticular(2or3)
• Polyarticular (>3)
Monoarticular
• Septic arthritis• TB arthritis• Gout & other crystal deposition disease• Seronegative spondyloarthropathy• Tumors• Trauma• Hemophilia• Monoarticular presentation of polyarticular
disease.
Oligoarticular
• Gout
• Juvenile rheumatoid arthritis (JRA)
• Psoriasis
• Seronegative spondyloarthropathy
Polyarticular
• Rheumatoid arthritis
• SLE
• Psoriasis
• JRA
• Reiters syndrome
Distribution of joints
• Symmetrical – RA , Psoriasis
• Non symmetrical – spondyloarthropathy, gout
• Upper limb – RA
• Lower limb – RS, Gout.
• Axial skeleton – OA, AS
Systemic
• Fever – SLE, Infection
• Rash – SLE, RS
• Myalgia/ weakness – poymyositis
• Morning stiffness – inflammatory arthritis
• Other system involvement
Physical Examination
• Warmth, Erythema, Swelling.
• Articular / Periarticular swelling
• Jt instability
• Jt volume – flexion deformity
• ROM – Active & passive
– Contracture, deformity
– crepitations
Investigations
• CBP, TLC, DLC
• Acute phase reactants– ESR, CRP (diff. b/w inf & non inf)
• S. Uric acid
• Rheumatoid factor
• ANA
• Complement level
• ASO
• Synovial fluid (acute monoarthritis)
Poor predictive value, Costly
Imaging
• X- ray
• USG
• Radionuclide scintigraphy– Metabolic status– Extent of musculoskeletal system
• CT Scan – In accessible sites
• MRI– Bone marrow involvement– Soft tissue involement