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Rheumatology > aPPROACH TO JJOINT PAIN? > Flashcards

aPPROACH TO JJOINT PAIN? Flashcards

1
Q

What is non- articular pain? What are examples of non- articular pain?

A
  • Pain only in certain movements
  • Tender at a specific point
Examples
• Referred pain
• Soft tissue (bursitis, tendonitis)
• Neuropathic
• Periarticular (MSK)
• Ischaemic pain
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2
Q

What is articular pain?

A
  • Pain in all range of movements

* Tender along entire joint line

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3
Q

What are the features of inflammatory pain?

A
  • Morning stiffness >1hr (>30min is also diagnostic!!)
  • Worse early morning or night
  • Better with movement
  • Warmth, redness, swelling (though may also be present in mechanical)
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4
Q

What are the differentials for mechanical pain?

A

OA (hand/hip/spine)

Trauma

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5
Q

What are the differentials of inflammatory polyarthritis (>5)?

A

Symmetrical

  • RA
  • Psoriatic arthritis
  • SLE
  • Mixed CTD

Asymmetrical

  • Psoriatic arthritis
  • Reactive arthritis
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6
Q

What are the differentials of inflammatory oligoarthritis (<5)?

A

Essentially PAIR

  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Enteropathic arthritis
  • Reactive arthritis
  • Disseminated gonococcal
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7
Q

What are the differentials for Monoarthritis?

A
  • Gout
  • Pseudogout
  • Septic arthritis
  • Reactive arthritis (rarer
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8
Q

What are the differentials for migratory polyarthritis?

A
  • Henoch Schonlein Purpura – ROJAK (palpable purpura & oedema in dependent areas, joint pain, abdo pain, kidney injury
  • Acute Rheumatic Fever – JONES (joint pain, myocarditis, Subcutaneous nodules, Erythema Marginatum, Chorea)
  • Disseminated Gonococcal Arthritis
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9
Q

What is the history to elicit for gout?

  • Joint distribution
  • Demographics
  • PC
  • PMH
  • Complications
  • Aetiology
A

Joint distribution: 1st MTPJ, Ankle, Knee (or in jt w OA)

Demographics: middle-aged male patient

PC

  • Max pain peak within 12- 24 hours- MUST ASK
  • Intermittent (ddx is palindromic RA)
  • Triggers (eg seafood buffet, read meats, alcohol, change in meds / diuretic use)
  • Typical hx: went to sleep fine, woke up w excruciating pain

PMH

  • Gout Hx
  • Predisposing factor: *Metabolic syndrome

Complications – AKI (frothy/ blood urine, lethargy); Renal Stones

Aetiology – Cancer due to TLS (LOW, LOA, infections, anaemia, fever)

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10
Q

What is the history to elicit for pseudo gout?

  • Joint distribution
  • Demographics
  • PMH
A
  • Joint distribution: Knee, wrists
  • Demographics: elderly woman
  • History of OA
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11
Q

What is the history to elicit for septic arthritis?

  • Joint distribution
  • Demographics
  • PC
  • Risk factors
A

Joint distribution: knee, hips

Demographics: very young or old (seen commonly in children/ elderly)

Orthopaedic Emergency, Severe Pain in ALL ROM, a/w fever +/- systemic toxicity

Risk Factors (To Elicit!)

  • Skin trauma
  • History of bacteraemia / penetrating ‘injury’ (eg IA injection, jt aspirate, acupuncture)/nearby OM / IVDU
  • Chronic joint injury (eg gout, OA, RA)/prosthetic joint
  • Immunocompromised
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12
Q

What is the history to elicit for rheumatoid arthritis?

  • Joint distribution
  • Joint deformities
  • PC
A

Classically bilat symmetrical deforming peripheral polyarthritis

Joint distribution – wrists, MCPJ, PIPJ (ALWAYS DIPJ sparing, but note possibility of concurrent OA esp in older pts

Possible deforming arthropathy – swan neck, boutonniere, Z thumb, ulnar subluxation, wrist dorsal subluxation

Extra-articular features: Just remember to ask for 1) MM 2) AA Subluxation 3) Incompetent Valves 4) Sicca

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13
Q

What is the history to elicit for ankylosing spondylitis?

  • Symptoms
  • Joint distribution
  • Complications
A

Symptoms. joint distribution

  • Ask about back pain: spondylitis
  • Alternating buttock pain: sacroilitis
  • Chest pain/reduced chest expansion +/- dyspnoea: costochondral joints
  • Other joint involvement: hips, shoulders

Complications: 6As

  • Acute anterior uveitis (30%) -> if untreated = permanent dmg and blindness. Severe eye pain, redness, photophobia and blurred vision = EMERGENCY
  • Apical lung fibrosis (aka ILD)
  • AR: early diastolic murmur
  • AV conduction defects: 1st degree AV block
  • Achilles tendinitis, plantar fasciitis: signs of Enthesitis
  • Amyloidosis: infiltrative Dz causing IgA Nephropathy
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14
Q

What are the symptoms to ask for in psoriatic arthritis?

A

5 patterns of joint involvement

  • Spondyloarthropathy (ie Spondylitis, sacroiliitis, enthesitis)
  • Oligoarthritis -> MOST COMMON
  • RA type (ie Symmetrical Polyarthritis).
  • Interphalangeal (distal) arthritis -> affects DIPJ in hands and feet
  • Arthritis mutilans

Skin: Scaly, erythematous rash, dactylitis. Important to check: scalp for rash and dandruff, belly button, buttock cleft

Nail changes – pitting, oncholysis, beau lines etc

May also have eye involvement (anterior uveitis), enthesitis, dactylitis

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15
Q

What are the symptoms to ask for in reactive arthritis/ reiter’s syndrome?

  • joint distribution
  • classic triad
A

Typically, acute asymmetrical Oligoarthritis (knees, hips)

Affects peripheral joints; lower > upper

Occurs 1-4 weeks after GI/GU infection

Classic TRIAD of Reiter’s syndrome

  • Can’t see: Conjunctivitis
  • Can’t pee: Urethritis or cervicitis
  • Can’t climb a tree: arthritis
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16
Q

What are the symptoms to ask for in reactive arthritis/ reiter’s syndrome?

  • past medical hx
  • joint distribution
  • extra GI manifestations
A

History of IBD – bloody mucoid stool, diarrhea, malabsorption

2 patterns of joint involvement

  • Peripheral arthritis; lower > upper
  • Axial Arthritis (ie Ankylosing Spondylitis): sacroilitis or spondylitis

After all, HLA B27 is a/w ankylosing spondylitis

Extra-GI Manifestations include:

  • Skin: erythema nodosum, pyoderma gangrenosum
  • Joint: peripheral / axial (due to a/w Ankylosing Spondylitis)
  • Eye: uveitis etc
  • Liver: hepatitis
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17
Q

What are the symptoms to ask for in reactive arthritis/ reiter’s syndrome?

  • joint distribution
  • other symptoms
  • sex history
A

Typically migratory asymmetrical polyarthritis: affects many joints progressively: ankle -> knee -> wrist -> elbow -> shoulder -> hip

Check for rash: painless skin pustules, urethral discharge, urethritis

18
Q

What are the symptoms to ask for osteoarthritis?

  • joint distribution
  • joint deformities
A

Typically weight bearing joints – knees, hips, C spine, 1st MTPJ, 1st MCPJ, DIP, PIP

Heberden’s nodes, Bouchard’s nodes, thumb squaring

19
Q

Differentials for homogenous antibodies?

A
  • histone: drug induced lupus
  • dsDNA: SLE (95% SEPCIFIC) –> correlates w CNS, renal activity
  • RA, Sjogren’s
20
Q

Differentials for speckled antibodies?

A
  • Ro, la: SLE, Sjogren’s
21
Q

Differentials for nucleolar antibodies?

A
  • Scl- 70: diffuse cutaneous systemic sclerosis (dcSSc)
22
Q

Differentials for centromere antibodies?

A
  • Centromeric: limited cutaneous systemic sclerosis (lcSSc)
  • Anti-Sm: Spef for SLE (but 30% prev)
  • Anti- RNP: MCTD
  • Anti – Jo, Mi-2: Polymyositis, dermatomyositis
23
Q

What are the differentials for positive Rheumatoid Factor?

A

+ve in 75% of RA

Other AI rheum diseases eg Sjogren’s syndrome (60-80%), SLE (25-50%)

Chronic infection eg chronic hep B, hep C, TB, leprosy

In RhF+ asympt pts, screen for Sjogren’s and chronic hep B

RhF will disappear after infection has been cleared

Low titres of Rh F w mechanical arthritis (esp DIP involv) is due to OA rather than RA

Hence look at clinical features, distribution, XR to determine!

24
Q

What are the differentials for positive Anti-CCP (Anti-cyclic citrullinated peptide)?

A

Potential impt surrogate marker for dx and prognosis in RA

  • May be detected in healthy individuals (1.5-9 years) before onset of clinical RA
  • May predict eventual development into RA from undx inflam arthritis
  • Marker of erosive disease in RA

CCP us a SPECIFIC test for RA hence a positive CCP rules in RA -> think ccP = sPecific

25
Q

What are the differentials for positive ANA (Anti-nuclear antibody)?

A

Useful screening test for AI diseases when clinically indicated

Can be caused by virtually anything, hence most people are ANA +ve! Therefore:

  • ANA is a SENSITIVE test for SLE, hence a negative ANA rules OUT SLE -> think seNsitive = aNa
  • If positive, we will send for ANA profile (anti Ro, La, dsDNA, smith etc)
  • If negative: however 5% of SLE are ANA -ve (these pt usually are anti-Ro / La positive)

Not disease-specific: other causes of ANA + include

  • Healthy individuals: F>M, elderly, relatives of rheum pts
  • Drug-induced: Isoniazid, procainamide, hydralazine
  • Hepatic disease: AI hepatitis, PBC, alcoholic liver disease
  • Malignancy: leukaemia, lymphoma
  • Pulmonary disease: idiopathic fibrosing alveolitis, primary pulmonary HTN
26
Q

What is the disease association with dsDNA? What is the appearance?

A
  • SLE (95% SEPCIFIC): correlates w CNS, renal activity

- homogenous

27
Q

What is the disease association with histone? What is the appearance?

A
  • Drug-induced lupus

- homogenous

28
Q

What is the disease association with Ro, la? What is the appearance?

A
  • Sjogren’s (95%), SLE

- Speckled

29
Q

What is the disease association with Scl-70? What is the appearance?

A
  • Diffuse scleroderma (30%)

- nucleolar

30
Q

What is the disease association with centromeric? What is the appearance?

A
  • Limited scleroderma/CREST (60%)

- centromere

31
Q

What is the disease association with anti- SM? What is the appearance?

A
  • Spef for SLE (but 30% prev)

- centromere

32
Q

What is the disease association with anti- RNP? What is the appearance?

A
  • MCTD

- centromere

33
Q

What is the disease association with anti- Jo, Mi2? What is the appearance?

A
  • Polymyositis, dermatomyositis

- centromere

34
Q

What is the disease association with cANCA?

A

probably Wegener’s granulomatosis (Granulomatosis with polyangiitis)

35
Q

What is the disease association with pANCA?

A

perinuclear staining, anti-MPO (myeloperoxidase): probably idiopathic/pri crescentic GN > MPA (Microscopic Polyangiitis) > Churg-Strauss syndrome

36
Q

What is normal synovial fluid appearance?

A

clear & straw-coloured, contains <200 WBC/mm3 (

37
Q

What is inflammatory synovial fluid appearance?

A

yellow & cloudy, contains >3000 WBC/mm3

38
Q

What is septic synovial fluid appearance?

A

yellow-green, opaque and less viscous, >50,000 WBC/mm3

39
Q

What is haemorrhagic synovial fluid appearance?

A

Red/Rusty/Brown; RBC in aspirate; Trauma /haemophilia /bleeding diathesis

40
Q

What is the appearance of gout under polarised light microscopy?

A

Gout: negatively birefringent, needle-shaped crystals of sodium urate

41
Q

What is the appearance of pseudogout under polarised light microscopy?

A

Pseudogout: weakly positively birefringent, rhomboid-shaped crystals of calcium pyrophosphate

Rheumatology (26 decks)

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