Approach to Joint pain_Dr Manoj.pptxnepal civil

ppt civil service hospital nepal

1. Approach to Joint pain Dr Manoj Khadka FCPS resident

2. Stepwise history Physical examinatioin Lab investigations

3. Step - 1 Articular and Extra-articular Anatomic structure : Painful site: Painful site: Pain on movement: Swelling Crepitus Diffuse, deep tenderness Point tenderness Active and passive Active only Common Uncommon

4. Step - 2 Arthralgia or Arthritis Arthralgia -SYMPTOM Joint pain withouts obvious inflammation Non specific Non rheumatological conditions like haematoligical diseases’ post viral fever’ hypothyroidism, statins use Arthritis- DIAGNOSIS demonstrable features of joint inflammation(joint swelling, redness, joint tenderness) Increased temperature Rheumatological conditions like RA, SLE

5. Step - 3 Arthritis Inflammatory or Non-inflammatory

6. Recognizing inflammation in the Joint History (80% diagnostic) Significant early morning stiffness IMPROVING with activity Constitutional symptoms (weight loss and loss of appetite) Low grade Fever and night sweats Fatigue Examination (15% diagnostic) Inflammed Joint(erythematous and indurated appearance) Lab (5% diagnostic) High ESR, CRP, Platelet NN anemia NOT specific for inflammation Hard bony swelling Tenderness due to structural damage deformity Functional incapitation

7. Step - 4 Duration Acute <6 weeks Chronic >6weeks(detailed Evaluation needed) Onset of symptoms Abrupt (Min- Hrs ) Insidious (weeks- months) RA OA Trauma Crystal Arthropathy Infection

8. Step - 5 How many joints are affected?

9. Step - 6 Pattern- locationwise

10. Rheumatoid arthritis Reactive arthritis Ankylosing spondylitis

11. Psoriatic arthritis Inflammatory OA of Hand

12. Pattern-sequence wise Intermittent arthritis -episodic and patient may be totally asymptomatic in between the episodes (gout behcets syndrome reactive arthritis palindromic rheumatism Additive arthritis -one or more joints are involved with time (RA SpA Psoriasis OA) Migratory polyarthritis -pain and swellinfg in a specific joint starts rapidly and subsides in 24 -36 hrs,arthritis then Picks up new joints (rheumatic fever gonococcal arthritis and viral diseases)

13. Symmetry vs Asymmetry Step - 7

14. Step - 8 Extra-articular manifestation

15. Fever with arthritis SLE Viral arthritis Vasculitis Rheumatic Fever AOSD Brucellosis

16. Raynaud’s phenomenon Scleroderma (commonest) SLE RA Sjogrens Myositis

17. Oral ulcer Painless SLE Reactive arthritis Enteropathic Painful Bechet

18. Subcutaneous nodule OA Rheumatois nodule Gout Multicentric reticulohistiocytosis

19. Arthritis with…. Neuropathy SLE Vasculitis Lyme RA Amyloidosis Cryoglobulinemia Pulmonary AAV(cough, hemoptysis , pleuritis ) SLE ( Pleuritis ) Scleroderma (ILD,PAH) RA (Pleural effussion , pulmonary nodules , ILD )

20. Arthritis with…. Renal invovement SLE Vasculitis Sjogren RA Amyloidosis Cryoglobulinemia GI involvement SLE (intestinal vasculitis ) Scleroderma (GERD, diarrhea, pseudo-obstruction) Enteropathic (IBD) PAN (Mesenteric vasculitis )

21. Ocular Keratoconjunctivitis sicca Sjogren syndrome, RA, SLE Uveitis SpA , Sarcoidosis , Bechet’s , GPA Scleritis RA, SLE

22. Family History RA OA AS Gout Psoriasis

23. Drug History Drug induced lupus: Hydralazine , ACE-inhibitor Arthralgia : Quinolones Gout: Diurestics Vasculitis : Allopurinol , Thiazides Scleroderma: Bleomycin Osteonecrosis : Glucocorticoid

24. History of malignancy Carcinomatous polyarthritis : Solid organ (Breast, colon, ovarian, lung) Lymphoproliferative disease RS3PE (Relapsing seronegative symmetric synovitis with pitting edema): Lymphoma Myelodysplastic syndrome

25. Physical Examination Inspection Palpation Assessment of range of motion

26. Investigation Blood test 1. Hematology: CBC, LFT, RFT 2.Biochemistry: Uric acid, ESR, CRP 3. Immunology: RF, ANA

27. Joint Aspiration Arthrocentesis (Synovial Fluid Analysis) Indicated when there is warm, red joint with effusion, especially when there is no history of trauma Aspirated synovial fluid should be sent for 3C s: C ell count C rystals: for Gout and Pseudogout C ulture (gram stain): for Septic arthritis

28. Diagnostic imaging Indication: Bony tenderness Inability to bear weight Gross deformity Age Modalities : Plain flim USG CT scan MRI

29. Reference Clinical Rheumatology- Springer 2019- Rohini Handa Kelly’s Rheumatology

30. Thank you