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HISTORY OF DISEASE
1.
Pai
n.
You should characterize the pain as for any other
pain along the lines of SOCRATES.
Site,onset,character,aggravating
factors,relieving
factors
Pain that worsens with movement and improves
with rest is likely to be non-inammatory.
An acute onset (hours) is consistent with septic
arthritis, gout/pseudogout, and trauma. A more
insidious onset is more common in conditions like
bursitis and tendonitis, where the relevant
anatomical structure becomes inamed with
overuse.
Chronic onset suggests osteoarthritis (note that
some
rheumatologists
prefer
the
term
osteoarthrosis to reect the fact that the
inammation is not the primary pathology).
The severity of pain can usefully be assessed by
asking about joint function for example, can the
patient weight bear?
Associated with swelling
History of night cries(Tb)
History of rest pain
History of morning stiffness(rheumatoid arthritis)
History of easy bruiseability(hemophilia)
2.
Tra
uma.
Sometimes even the slightest of knocks can cause
signicant pain. However, this does not exclude
other diagnoses trauma can precipitate infection
or gout, for example.
Common risk factors for gout. There are many
potential causes of gout, but the more common
ones that you should ask about include use of
thiazide diu- retics, recent heavy alcohol intake,
PHYSICAL EXAMINATION
Conscious
Orientation
Built
Nourishment
GENERAL EXAMINATION
Afebrile
Pallor
Icterus
Cyanosis
Clubbing
Generalized Lymphadenopathy
Pitting pedal edema
VITALS
Heart rate :
BP :
Respiratory Rate :
CVS: s1 s2 heard, No murmurs
RS: Normal vesicular breathing heard over all the lung elds
CNS: No focal neurological decit present
LOCAL
EXAMINATION
Palpation:
f e e l for any eusions;
for tenderness on the bones, ligaments, tendons, or
along the joint line;
for temperature (in case of infection or inammation);
and
for neurovascular status. Checking neurovascular
status is crucial, as a neuropathy or vasculopathy
(either causing the pain or secondary to joint damage)
may rapidly lead to irreversible damage and loss of
function.
Movement: being careful and gentle with the painful
joint,
test the full range of passive and active movement.
Note:
Articular conditions are more likely to present with a
diffusely inamed joint (red, hot, painful) and pain on passive
as well as active motion.
Periarticular conditions tend to have a focal point of
tenderness on palpation (in bursitis this would be over the
bursa; in tendonitis, over the tendon) and pain is usually
much worse on active movement than on passive movement
Following ndings rare in someone presenting with acute joint
pain
Skin:
Tophi: deposits of urate crystals that can be found
anywhere on the body usually around joints and bones. They
are hard lumps that sometimes break through the skin with a
chalky appearance.If present, they suggest chronic gout.
Gouty tophi.
Rheumatoid nodules: subcutaneous nodules,
classically found on elbows and ears, which are
pathognomonic of rheumatoid arthritis.
A variety of rashes are seen in conditions that can
also cause arthritis
e.g.
psorias
is, systemic lupus erythematosus (SLE).
Nails: look for pitting, subungual hyperkeratosis, and
onycholysis all signs of psoriasis, associated with
psoriatic arthritis.
Uveitis (inammation of the middle layer of the eye),
evidenced by a painful red eye with diminished vision, and
sometimes an irregularly shaped pupil. This is often
associated
with
HLA-B27-positive
inammatory
arthropathies.
Mouth ulcers which may be evidence of inammatory
bowel disease (par- ticularly Crohns disease), itself
associated with arthropathy.
Lung signs suggestive of brosis (e.g. clubbing, late
inspiratory crackles), as pulmonary brosis is a
complication sometimes seen in various inammatory
arthropathies.
Do not overly focus on these, as beyond the skin and nail signs
these are relatively rare in someone presenting with acute
joint pain.
PROVISIONAL DIAGNOSIS
articular
Peri articular
Non-articular
Ligament injury
Nerve
Tendonitis
entrapment
Bursitis
Bone malignancy
Fasciitis
Osteomyelitis
Epicondylitis
Neuroma
Gout
Pseudogout
Septic arthritis
Seronegative
Periostitis
spondyloarthropathy
Transient synovitis
First presentation of
chronic mono- or
polyarthritis (e.g.
rheumatoid arthritis)
Sarcoidosis
Amyloidosis
Vasculitis
SLE
Rheumatic fever
SPECIAL INVESTIGATION
If
you suspect rheumatoid disease, you may want to
request rheumatoid factor, anticyclic citrullinated peptide
(anti-CCP) antibodies, antinuclear antibody (ANA), and other
autoantibodies.
Serum urate: Patients who develop gout have often had
hyperuricaemia
for years, although during acute gout their serum urate is
often normal or low. For this reason it should not be ordered
in the acute setting. Also note that asymptomatic
hyperuricaemia is fairly common in the population and thus
a nding of elevated urate is not very helpful in diagnosis.
Imaging:
X- R AY
imaging rarely contributes anything to the diagnosis of nontraumatic, acute monoarthritis. As with serum urate, it may
occasionally be misleading as pathology unrelated to the
acute monoarthritis may be picked up, e.g. osteoarthritis.
However:
Radiographs are useful if there has been trauma as they
identify fractures
and, depending on the site, some effusions (e.g. elbow).
Magnetic resonance imaging (MRI) is the imaging of
choice for soft tissue injuries and other extra-articular
pathology, e.g. osteomyelitis. If you have excluded
intra-articular pathology, MRI can be very helpful.