Approach to Arthritis
Diseases of joints
Evaluation
Joint involvement causes painEnsure joint involvement, and
not muscle or bone
Relevant history Age- young-RA, middle age-gout, old-OA Sex- male-SA, gout; female-RA, SLE F/H- may be +ve in SA, gout, RA, OA Onset- acute-gout, trauma, infection;
insidious-RA, OA Evolution- continuous-OA, intermittent-
gout, migratory-rheumatic fever, additive-Reiter’s
Associated symptoms- fever, rash, eye/GIT/GU involvement
Pattern of joint involvement Joints involved- Large-OA, small-RA Axial-SA, appendicular-RA Upper limb-RA, lower limb-gout Number of joints involved Mono- 1- traumatic, infectious Pauci- 2-4- gout, reactive arthritis Poly- >4- RA, SLE Symmetry Symmetrical- OA, RA, SA Asymmetrical- gout, trauma, infectious
Inflammation Causes pain, redness, swelling,
local temperature, ROM Inflammatory arthritides- RA Signs of inflammation Worst in morning Morning stiffness present Non-inflammatory arthritides- OA Pain & ROM Worst as day passes No morning stiffness
Examination
InflammationCrepitus
Range of movementDeformity
Investigation X-ray of involved joint RA- periarticular erosions in hands/feet, soft tissue
swelling OA- decreased joint space, loss of cartilage, osteophytes CBC, ESR, CRP Synovial fluid exam. Colour, protein, glucose WBC, gram stain, culture Crystals- polarised microscope Serology- ASO, RF, ANA CT scan/MRI
Treatment
Based on diagnosisParacetamol & NSAIDs
Physical/Occupational therapy
Low backache
A common problem
Types
Local- steady dull pain, local tenderness
Referred- from viscera- abd./pelvic
Radicular- restricted to territory of root
Protective- muscle spasm
Pain
Location Severity/intensity Onset & progression Character Aggravating & relieving factors Associated symptoms
Examination Inspection- deformity, asymmetry Palpation- tenderness Straight leg raising test or bending
with knees extended to elicit root pain
Costovertebral tenderness Neuro. exam. of lower extremities Abdominal, PR/PV, peripheral vascular
examination
Investigation
CBC, ESR Ca, PO4, alk. phosphatase PSA SPEP Bone-scan X-ray CT scan/MRI
PIVD L4- Pain & sensory loss in ant. thigh/knee DTR- knee absent L5- Pain hip, groin, posterolateral thigh, lateral calf, 1-3 toes Weakness of extensor of big toe Difficulty walking on heel DTR- normal S1- Pain posterior thigh, posterior calf, 4-5 toe Weakness of foot & toe flexors Difficulty walking on toes DTR-ankle absent
Treatment
Initially medical,If not improved- MRI
Surgical based on MRI findings
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