Joint pain Flashcards
List some extra-articular features you would look for in joint pain
Nail changes Rash - malar rash, psoriatic rash, discoid rash ILD on resp exam - clubbing and crackles Infections Enteropathy - diarrhoea Uveitis/iritis - painful, dry, red eyes Back pain/stiffness Mouth ulcers and dry mouth Raynaud's Gouty tophi
What features of joint pain may indicate an inflammatory cause?
Swelling, exercise and heat improve stiffness
What is the biggest differential to rule out in joint pain?
Septic arthritis
What investigations would you do for septic arthritis?
Joint aspiration and blood cultures
What is the management of septic arthritis?
Broad spectrum IV antibiotics
Joint washout in theatre
How long must symptoms be present for before a diagnosis of rheumatoid arthritis can be made?
6 weeks
Describe the common presentation of rheumatoid arthritis
Symmetrical polyarthritis that typically causes synovitis in small joints - particularly the hands and feet - although larger joints can be affected
Morning stiffness >1hour, along with pain that is improved by exercise
Describe the common presentation of seronegative spondyloarthropathy
Asymmetrical oligoarthritis affecting large joints - the spine is frequently affected with sacroiliitis and enthesitis
Morning stiffness >1hour, along with pain that improves with exercise
History of psoriasis, bowel disorders or recent infection
What is enthesitis?
Inflammation where the tendon/ligament attaches to bone
Describe the common presentation of systemic lupus erythematosus
Arthralgia and/or symmetrical small joint polyarthritis (non-erosive)
Typically affects non-Caucasian females with age of onset in young adulthood
Common features - oral ulcers, dry eyes, dry mouth, Raynaud’s phenomenon, discoid rash, malar rash, photosensitivity and general malaise
Describe the common presentation of osteoarthritis
Pain in older adults that is worse with exercise and partially relieved by rest
Symmetrical oligo or polyarthritis that commonly affects the hips, knees and hands
History of previous injury to joint and or obesity
Describe the common presentation of gout
Joint pain, oedema and erythema that develops acutely (classically overnight)
Usually a large joint monoarthritis, but can affect any joint and be polyarticular
History of excess alcohol and red meat consumption, hypertension, renal failure, diuretics and male
Describe the common presentation of fibromyalgia
Myalgia can be reproduced over specific trigger points without joint involvement
Patient may complain of swelling despite objectively no swelling being present
Associated with IBS and depression
Describe the common presentation of septic arthritis
An acutely hot, very painful, swollen joint in an unwell patient with fever
May be a history of immunosuppression
Trauma
Unilateral swollen joint with local tenderness and preceding history of injury
What blood test should be ordered if suspecting gout?
Serum urate
When should joint aspiration and synovial fluid analysis be performed?
When suspecting septic arthritis, gout or pseudogout
Describe the management of osteoarthritis
Exercise, weight loss, regular analgesia and monitoring
Describe the management of rheumatoid arthritis
Early DMARDs (methotrexate)
Anti-TNF therapy if DMARDs fail
IM steroids for acute flares - methylprednisolone
Describe the management of gout
Treat acute attacks with NSAIDs
Prophylaxis with allopurinol
Describe the management of seronegative spondyloarthropathy
NSAIDs, DMARDs and anti-TNF therapy
Describe the management of SLE
Hydroxychloroquine for mild symptoms
Steroids and DMARDs for joint disease
High dose steroids and potent immunosuppressants for end-organ disease
Describe the management for fibromyalgia
Patient education
Amitriptyline is currently first line medication
