Common Rheumatological Presentations: Joint Pain Flashcards
Key questions to explore in PC
Pain - SOCRATES
Rashes, skin, nail changes => more inflammatory
Immune => systemic symptoms?
Stiffness pattern
-prolonged in morning, improves with mv => inflammatory
-short in morning, worsens with mv => OA
Differentiate between inflammatory and non inflammatory joint issues
Possible differentials
Degenerative
-OA
Inflammatory
- RA
- PsA
- gout, pseudo
Infectious
- septic
- reactive
AI
- lupus
- enteropathic
Rheumatoid arthritis
- core features
- risk factors
- investigations
- management
Risk factors
-FHx
Symmetrical hot PIP, MCP swelling, prolonged morning stiffness improved with use
Onset - weeks, months
Late disease => finger, joint deformation
Systemically unwell
Investigations
-RF, anti CCP
-high CRP
Xray - LESS
Management
Acute - NSAIDs or CS
Maintain - methotrexate
Osteoarthritis
- core features
- risk factors
- investigations
- management
Risk factors
- overweight
- age
Core features
DIP asymmetrical cold swelling, reduced morning stiffness worsened with use
Onset - years
Restricted mv
Investigations
Xray - LOSS
Management
Lifestyle - exercise, weight loss
Analgesia - paracetamol => NSAIDS+PPI => capsaicin cream => opioids+laxatives
Last line - joint replacement
Septic arthritis
- core features
- risk factors
- investigations
- management
ACUTE RED, PAINFUL, SWOLLEN, STIFF JOINT => ASSUME SA UNLESS PROVEN OTHERWISE
Systemically unwell
Risk factors
- joint trauma
- STI
- IC, IVDU, sickle cell
Joint aspiration and culture - confirm infection in joint
Blood, sputum, urine culture - find causative organism
Broad spec empirical ABx until cause found
-most commonly Saureus (fluclox)
Gout vs pseudogout
- core features
- risk factors
- investigations
- management
ACUTE RED PAINFUL SWOLLEN, STIFF JOINT
Gout - BIG TOE, ankles, fingers, wrists Risk factors -red meat, shellfish, alcohol -overweight older male -ACEi, ARB, thiazides -cytotoxics, blood cancers
Investigations - negatively birefringent needle crystals
Managament
Acute - NSAIDs => colchicine => CS
-Maintain - allopurinol
Pseudogout - KNEE, hip, elbow, shoulders
Risk factors
-age
-high Ca/PTH, low Mg/hypothyroid
Investigations - positively birefringent rhomboid crystals
Management
Acute - NSAIDs => colchicine => CS
-Maintain - cool, rest, weight loss
Psoriatic arthritis
- core features
- risk factors
- investigations
- management
Risk factors
- FHx
- psoriasis
Core features
Multiple sausage fingers with RROM, prolonged morning stiffness and pain improved with use
Psoriatic plaques on ext surfaces
Nail changes - onycholysis, salmon plaques
TIREDNESS
Investigations - Xray
- erosive + proliferation of bone
- enthesitis, dactylitis
- pencil in cup
- sacroilitis
Management
Pain - NSAIDs
Maintain - methotrexate
SLE
- core features
- risk factors
- investigations
- management
Risk factors
-FHx
Core features
Systemically unwell - FATIGUE
Systemic symptoms - joints, skin rashes worse in sunlight, myalgia, mouth ulcers, alopecia, lungs, heart, kidney (ASK ABOUT FOAMY URINE)
Investigations
Bloods - high ESR/ANA, low C34/CRP
Management
Acute - NSAIDs
Maintain - HCQ
Reactive
- core features
- risk factors
- investigations
- management
Risk factors
-recent STI, food poisoning
Core features
SA-like
Can’t pee (urethritis), can’t see (uveitis), can’t climb a tree (enthesitis, dactylitis, rash on foot)
Systemically unwell
Investigations - sterile joint aspiration
Xray - enthesitis, dactylitis
Urine culture
Management
Acute - NSAIDs
ABx for bacterial infection
Maintain - sulfa/metho
Key questions to ask in systemic review
Systemic - fevers, nightsweats, fatigue, weight loss?
GI
- recent N+V
- abdo pain
- diarrhoea?
- signs of IBD
GU
- sexually active?
- changes in urine/bowel? => foamy urine, dysuria?
CP
-cough, SOB, chest pain
Neuropsych
- low mood?
- seizures, memory, concentration
Ankylosing spondylitis
- core features
- risk factors
- investigations
- management
Risk factors
- FHx
- young male
Core features
Back pain, prolonged morning stiffness, RROI and pain improved with movement
Investigations - calcification of spine, sacroilitis => bamboo spine
High CRP, ESR
Management
Analgesia and flares - NSAIDs
Maintenance - sulfa
