History & Physical Examination:
1. Articular or non-articular?
– Articular:
- Deep or diffuse pain
- Pain or limited ROM on active and passive movement
- Swelling
- Crepitus (palpableless commonly audible vibratory or crackling sensation elicited w joint motion)
- Instability
- Locking (OA)
- Deformity
– Non-articular:
- Point or focal tenderness in regions adjacent to articular structures
- Painful on active but not passive
- Rarely present w: crepitus, instability, and deformity
2. Inflammation or no inflammation?
– Inflammatory:
- Four cardinal sx of inflammation (redness, warmth, pain, swelling)
- Systemic sx (fever, fatigue, rash, wt loss)
- Lab evidence (↑ESR or CRP, anemia of chronic ds, hypoalbuminemia)
- Morning stiffness; exacerbated by prolonged rest (RA or polymyalgia rheymatica)
– Non-inflammatory:
- No inflammatory, systemic, or lab features
- Intermittent stiffness; exacerbated by activity (OA)
- Related to trauma, repetitive use, degenerative, neoplasm
3. Age:
- Young: SLE and reactive arthritis
- Middle ages: RA and fibromyalgia
- Old: OA and polymyalgia rheumatica
4. Gender:
- Males: Gout, reactive arthritis, and ankylosing spondylitis
- Females: RA, fibromyalgia, SLE
5. Race:
- Whites: Polymyalgia rheumatica, giant cell arteritis, and Wegner’s granulomatosis
- African Americans: SLE and sarcoidosis
6. Onset:
- Abrupt: septic arthritis and gout
- Indolent: OA, RA, and fibromyalgia
7. Duration:
- Acute (<6 wks): infectious, crystal induced, or reactive
- Chronic (>6 wks): non-inflammatory, immunologic (OA, RA), non-articular (fibromyalgia)
8. Extent of articular involvement:
- Mono- or Oligo articular: crystal and infectious arthritis
- Poly articular: RA, SLE, viral (EBV, parvovirus B19)
9. Distribution of joint involvement:
- Migratory: RF, disseminated gonococcal infection, Lyme ds
- RA: spares distal joints!
8. Systemic sx:
- SLE: lung, kidney, skin, CNS, and hematologic manifestations
- Sjögren syndrome: dry eyes mouth and parotid enlargement
- Scleroderma (systemic sclerosis): skin and Raynaud phenomenon
- Wegner granulomatosis: upper resp (sinisutis rhinitis), lower resp (lung nodules and hemoptysis), renal (necrotizing GN) involvement
- OA: absence of systemic sx
9. Associated medical conditions:
- DM: carpal tunnel synd and Charcot’s joint
- Renal insuff: gout
- Psoriasis: psoriatic gout and Spondyloarthritis
- IBD: Spondyloarthritis
- Multiple myeloma: low back pain
- Cancer: myositis
- Osteoporosis: fractures
- Glucocorticoids use: osteonecrosis or septic arthritis
- Diuretics or chemo: gout
Joint aspiration and synovial fluid analysis:
- 3 C’s (cell count, crystals, cultures) + Gram stain
Download the PDF version: here
References:
- Davidson’s Principles and Practice of Medicine
- Toronto notes
