SM_220a: Approach to Joint Pain

Question 1

The approach to joint pain in rheumatology involves _____, _____, _____, _____, and _____

Answer 1

The approach to joint pain in rheumatology involves history, physical exam, laboratory assessment, arthrocentesis/synovial fluid analysis, imaging

Question 2

_______ has polyarticular inflammatory joint pain

Answer 2

Rheumatoid arthritis has polyarticular inflammatory joint pain

Question 3

In assessing joint pain, history involves asking about _____, _____, _____, and _____

Answer 3

In assessing joint pain, history involves asking about location and symmetry, onset and chronology, inflammatory vs other joint pain, and systemic and extra-articular features

Question 4

______, ______, and ______ have asymmetric oligarticular inflammatory joint pain

Answer 4

Psoriatic arthritis, crystalline arthritis (gout), and gonorrhea/chlamydia related arthritis have asymmetric oligarticular inflammatory joint pain

Question 5

Describe inflammatory joint pain

Answer 5

Inflammatory joint pain

• Stiffness lasting > 1 hour in the morning or after period immobility
• Symptoms can improve with activity
• Symptoms worse with rest
• Symptoms respond to steroid

(rheumatoid arthritis, spondyloarthropathies such as ankylosing spondylitis, inflammatory arthritis in connective tissue disease)

Question 6

_____ joint pain improves with activity

Answer 6

Inflammatory joint pain improves with activity

Question 7

_____ joint pain responds to steroids

Answer 7

Inflammatory joint pain responds to steroids

Question 8

Describe systemic and extra-articular features someone with joint pain might have

Answer 8

Systemic and extra-articular features associated with joint pain

• Constitutional symptoms: fever, weight loss, anorexia, fatigue
• Rash
• Inflammatory eye disease
• Raynaud’s
• Enthesitis
• Dactylitis
• IBD

Question 9

Relevant family history for joint pain includes _____, _____, and _____

Answer 9

Relevant family history for joint pain includes HLA B27 associated conditions, rheumatoid arthritis, systemic autoimmune disease

(IBD, ankylosing spondylitis, psoriatic arthritis are HLA B27 associated)

Question 10

Physical exam for joint pain includes _____, _____, _____, and _____

Answer 10

Physical exam for joint pain includes inspection, palpation, range of motion, and strength

Question 11

Lab assessment of joint pain includes _____, _____, and _____

Answer 11

Lab assessment of joint pain includes erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor / anti-cyclic citrullinated peptide / ANA / ANCA

Question 12

Describe erythrocyte sedimentation rate

Answer 12

Erythrocyte sedimentation: non-specific marker of inflammation

• Increases with age
• Can be higher in women
• Increased in diabetes, ESRD, and pregnancy
• Lowered by CHF, and sickled erythrocytes

Question 13

Describe C-reactive protein

Answer 13

C-reactive protein: non-specific marker of inflammation

• Levels change more quickly than ESR: more sensitive
• Less variable than ESR
• Affected by age and gender
• Can be increased by heart disease, infection, malignancy, obesity, diabetes, and smoking

Question 14

Rheumatoid factor is _____ but often associated with _____

Answer 14

Rheumatoid factor is non-specific but often associated with rheumatoid arthritis

Question 15

Anti-cyclic citrullinated peptide is associated with _____

Answer 15

Anti-cyclic citrullinated peptide is associated with rheumatoid arthritis

Question 16

ANA is associated with _____ but can occur in _____

Answer 16

ANA is associated with autoimmune disease but can occur in the healthy population

Question 17

ANCA is associated with _____

Answer 17

ANCA is associated with systemic vasculitis

Question 18

In arthrocentesis / synovial fluid analysis, as the WBC count increases, fluid becomes ______

Answer 18

In arthrocentesis / synovial fluid analysis, as the WBC count increases, fluid becomes less clear (more turbid)

Question 19

Cell count of 30,000 on arthrocentesis / synovial fluid analysis indicates _____

Answer 19

Cell count of 30,000 on arthrocentesis / synovial fluid analysis indicates inflammatory arthritis

Question 20

Turbidity and cell count over 50,000 on arthrocentesis / synovial fluid analysis indicates ______

Answer 20

Turbidity and cell count over 50,000 on arthrocentesis / synovial fluid analysis indicates infection

Question 21

Crystals on arthrocentesis / synovial fluid analysis indicate _____ or _____

Answer 21

Crystals on arthrocentesis / synovial fluid analysis indicate gout or pseudogout

Question 22

Plain radiograph is used to assess _____

Answer 22

Plain radiograph is used to assess progression of rheumatoid arthritis

Question 23

In terms of joint pain, MRI is best at looking at _____ and assessing _____

Answer 23

In terms of joint pain, MRI is best at looking at soft tissue and assessing torn rotator cuffs

(also looking for inflammatory arthritis not seen on x-ray)