Approach to Arthritis

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

Arthritis Approach 1

Arthritis Approach 2

 


Joint aspiration and synovial fluid analysis:

  • 3 C’s (cell count, crystals, cultures) + Gram stain

Arthritis Approach 3

Arthritis Approach 4


Download the PDF version: here


References:

  • Davidson’s Principles and Practice of Medicine
  • Toronto notes

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