SM 220 Approach to Joint Pain

Question 1

What are the 5 general aspects of managing a patient who presents with joint pain?

Answer 1

History
Physical Exam
Laboratory Assessment
Arthrocentesis/Synovial Fluid Analysis
Imaging

Question 2

What general questions should be asked in a history for joint pain?

Answer 2

Which joints hurt and for how long?
Inflammatory vs MSK damage?
Family History?
Systemic process?

Question 3

What two factors characterize joint pain physically?

Answer 3

Location and symmetry

Question 4

List 3 diseases that classically present as symmetric inflammatory joint pain?

Answer 4

Rheumatoid Arthritis
HIV Arthritis
Systemic Rheumatic Disease

Question 5

List 3 diseases that classically present as asymmetric inflammatory joint pain?

Answer 5

Psoriatic Arthritis
Arthritis of IBD
Lyme Disease

Question 6

Does bone remodeling suggest chronic or acute disease?

Answer 6

Chronic b/c bone remodelling takes a long time

Question 7

Does inflammation suggest chronic or acute disease?

Answer 7

Acute b/c inflammation is generally recent

Question 8

What are general characteristics of inflammatory joint pain?

Answer 8

Stiffness lasts longer than 1 hour
Improves with activity + worse with rest
Responds to steroid

Question 9

What are general characteristics of non-inflammatory joint pain?

Answer 9

Stiffness lasts less than 30 min
Worse with activity + improve with rest
Does not respond to steroid

Question 10

What are constitutional symptoms and do they suggest inflammatory or non-inflammatory joint pain?

Answer 10

Constitutional symptoms include fever, weight loss, anorexia, and fatigue

Suggest inflammatory joint pain

Question 11

Is Rheumatoid Arthritis associated with ILD?

Answer 11

Yes

Question 12

What are Dactylitis?

Answer 12

Swollen toes

Question 13

What should a physical exam of joint pain involve?

Answer 13

Inspect
Palpate
Range of motion
Strength

Question 14

What should a physical exam cover?

Answer 14

Hand/wrist
Elbow
Knee
Spine
Hip
Ankle/feet

Question 15

What laboratory tests could be ordered in a rheumatologic workup?

Answer 15

ESR and CRP

Question 16

How is Erythrocyte Sedimentation Rate diagnositic?

Answer 16

It isn’t, but it does suggest things

Low ESR = CHF, sickle cell
High ESR = Diabetes, End stage renal disease, pregnancy

Question 17

What can artificially raise ESR?

Answer 17

Age and obesity, also higher in women

Question 18

Do men or women have a higher ESR?

Answer 18

Women have a higher ESR

Question 19

How is ESR determined?`

Answer 19

Draw blood, add sodium citrate, let the blood sit for an hour and the RBC’s will crash out

ESR = height difference from top of tube to precipitate

Question 20

What are ESR and CRP markers of?

Answer 20

Inflammation

Question 21

Which is more variable, ESR or CRP?

Answer 21

ESR varies more

Question 22

Which is more sensitive, ESR or CRP?

Answer 22

CRP is more sensitive

Question 23

Which is effected by age and gender, ESR or CRP?

Answer 23

Both ESR and CRP are affected by age and gender

Question 24

What diseases can a high ESR suggest?

Answer 24

Heart Disease, infection, malignancy, diabetes

Question 25

Can a rheumatologic diagnosis be made on laboratory assessment alone?

Answer 25

Nope

Question 26

What is Rheumatoid Factor?

Answer 26

An antibody that binds to the constant region of Ig

Question 27

What can a positive RF test suggest?

Answer 27

Rheumatoid Factor+ suggests Rheumatoid Arthritis, sarcoid, malignancy

Question 28

What is an anti-CCP?

Answer 28

A test specific for Rheumatoid Arthritis

Question 29

What 2 tests generally point to RA?

Answer 29

Anti-CCP and RF positive

Question 30

What is an ANA?

Answer 30

An anti-nuclear antibody that suggests autoimmune disease, possibly Lupus

Question 31

What is an ANCA?

Answer 31

A test for systemic vasculitis

Question 32

Which tests can be trended over time for improvement?

Answer 32

CRP and ESR can be trended RF, antt-CCP, ANA, and ANCA cannot

Question 33

What is an Arhtrocentesis?

Answer 33

An analysis of joint fluid

Question 34

What is a normal Arthrocentesis?

Answer 34

Clear serum, 0-200 WBC's and < 10% PMNs

Question 35

What is a Group 1 Arthrocentesis?

Answer 35

Non-inflammatory Clear to slightly turbid, 200-2000 WBC's and < 20% PMN's

Question 36

What is a Group 2 Arthrocentesis?

Answer 36

Inflammatory Slightly turbid, 2000-50000 WBC's and 20% - 75% PMN's

Question 37

What is a Group 3 Arthrocentesis?

Answer 37

Pyarthrosis Turbid to very turbid, 50-100,000 WBC's and 75%+ PMN's

Question 38

Which group of Arthrocentesis indicates inflammation?

Answer 38

Group 2

Question 39

What can be seen on synovial fluid?

Answer 39

Crystals, which indicate Gout or Pseudogout

Question 40

When is imaging done in a Rheumatologic workup?

Answer 40

Not always done, typically after a diagnosis was made

Question 41

What is MRI good for visualizing?

Answer 41

Tears and tendonopathies

Question 42

Pros and cons of MRI?

Answer 42

Better for soft tissue and no radiation Expensive and can't have implant

Question 43

What is the first line imaging modality in rheumatology?

Answer 43

Non-constrast CT

Question 44

What is Ultrasound good for visualizing?

Answer 44

Gout and tendonitis

Question 45

Pros and cons of Ultrasound?

Answer 45

Cheap and no radiation User skill dependent and can't see deep tissue well