Week 5 - Joint pain

Question 1

S.H. is a 58 year old lawyer with severe pain in his hands. “I have very bad joint pain”.

Take a history of this patient.

HPC:
• A 58 year old lawyer has severe pains in his hands. Pain is worse with movement.
• Feels very tired and has no energy over the last few months.
• Mother had arthritis and is very concerned he has arthritis too. She had to take gold and has ‘terrible, terrible side effects.’
• Pain in mainly DI (distal interphalangeal) joints, left middle finger - worst.
• Slowly worsening over the last 6-12 months (progressive).
• Not particularly worse, at night. No previous injuries. No history of Ross River fever, Dengue, Lyme disease.
• Skin rash? Yes has a history of psoriasis (importance?)
• No penile discharge, no history of STIs, no leg ulcers (importance of these in history? - think about pathogenesis).

Answer 1

HPC:
• Site - where is the joint pain? single/multiple joints, uni/bilateral, symmetrical/asymmetrical.
• Onset - when did the pain start?
• Character - describe the nature of the pain.
• Radiation - does the pain radiate anywhere?
• Alleviating factors i.e. movement/rest.
• Timing - experienced it before? How long did it last? Constant or intermittent? Worse at a particular time? i.e. morning/night.
• Exacerbating factors i.e. movement/rest.
• Severity.
• Associated symptoms i.e. eye symptoms, fever, malaise, fatigue, weight loss, extra-articular symptoms (e.g. nodules), pins and needles, spasms (OA, carpal tunnel), skin lesions/rash, deformities.
• Effect on lifestyle.

PMHx:
• Past medical history of arthritis, injuries, MSK injuries/fractures, STIs, psoriasis, arboviral disease?

PSHx:
• Past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, Pneumococcal.

FHx:
• Family history of arthritis, psoriasis?

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

• BMI - 24.5.
• Looks fatigued.
• No iritis or scleritis.
• Nail pitting.
• Patches of psoriasis on scalp.
• Tar staining.
• Normal power and sensation.
• No nodules.
• Dual HS, abdo soft non-tender, no hepatomegaly, chest clear.

Psoriatic arthritis:
• Occurs in 10-40% with psoriasis and can present before skin changes.
• Patterns are:
- Symmetrical polyarthritis (like RA).
- DIP joints.
- Asymmetrical oligoarthritis.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Psoriatic arthritis, may have a component of rheumatoid arthritis.
• DDx:
- Rheumatoid arthritis
- Osteoarthritis
- Gout
- Psoriatic arthritis
- Septic arthritis
- Reactive arthritis
- Carpal tunnel syndrome
- Dengue
- RRV
- ARF
- Barmah Forest
- Trauma
- SLE
- Polymyalgia rheumatica
- Fibromyalgia
- Lyme disease

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC - ACD, increased plts in RA.
• ESR
• CRP
• Rheumatoid factor (RhF).
• Anticyclic citrullinated peptide antibodies (ACPA/anti-CCP).
• X-ray - erosive changes with ‘pencil in cup’ deformity in severe cases.
• USS/MRI - can identify synovitis more accurately and have greater sensitivity in detecting bone erosions than conventional X-rays.

Question 5

What treatment does this patient require?

Answer 5

• NSAIDs
• Sulfasalazine.
• Methotrexate.
• Cyclosporin.
• Anti-TNF agents are also effective.