Approach Patient with

Introduction Chronic : common causes  Causes include various self-limited A. Non-inflammatory illness and disabling and life-  threatening.  Mechanical derangement.  Musculoskeletal emergencies  Osteonecrosis. (infection, sepsis, compartment  Neuropathic . syndrome…).  Reflex Sympathetic Dystrophy (RSD).  Adjacent Bone lesion (Tumor, A careful history and physical examination Infection) are the most important tools. B. Inflammatory. Laboratorytesting and imaging studies  Infectious (TB, Fungal, Lyme disease). provide definitive answers in only a few  Crystal arthritis. instances.  RA.  Juvenile chronic arthritis. Many chronic polyarticular diseases require  . months or years to diagnose (delayed extra-  HemophilicArthropathy. articular, lab and radiographic findings)  Synovial neoplasms.  Pigmented History Taking Acute polyarthritis: common causes Is it Arthritis or ? A. Infection-related Common causes of arthralgia  Bacterial species  Fibromyalgia  Neisseria species  Bursitis  Lyme disease.  Tendinitis  .  Hypothyroidism  AIDS  Neuropathic pain  Viral arthritis  Metabolic B. Non-infectious causes.  Depression  RA.  Juvenile chronic arthritis. Number of joints and Acuteness of  Other Connective Tissuediseases. symptoms  Spondyloarthropathy. Acute monoarthritis: common causes  and pseudogout. A. Inflammatory.  Henoch-Schonleinpurpura.  Crystal arthritis.  Sickle-cell Arthropathy.  Septic  Hypertrophic osteoarthropathy.  Spondyloarthropathy.  Sarcoidosis  Palindrome Rheumatism  Leukemia.  (RA). Intermittent arthritis: common causes  Juvenile chronic arthritis.   Sarcoid arthritis Mechanical  B. Non-inflammatory Loose Bodies disease  Trauma o Partial tears  Sickle-cell Arthropathy. o Ligament laxity  Osteonecrosis.  Crystals o Gout  Any Age group= , o Pseudogout Enteropathic arthritis o Hydroxyapatite Sex  Infection o Lyme disease.  >Female:SLE, RA, OA, Systemic o Whipple’s disease sclerosis, PMR.   Male=Female:Psoriatic arthritis,  Intermittent Hydroarthrosis Pseudogout, Enteropathic arthritis.  EpisodicRA  >Male: Gout, Ankylosisspodylitis,  Familial Mediterranean Fever. .  Sarcoidosis Distribution of joint involvement Chronic polyarthritis: common causes  Symmetrical: RA, psoriatic A. (RA-  Osteoarthritis like), 1ry OA, SS  Rheumatoid arthritis (RA).  Asymmetric: LL>UL: Sero –  Juvenile chronic arthritis. vearthropathy, gout  Other Connective Tissuediseases.  Large joints: OA, Reactive  Spondyloarthropathy.  PIP or DIP, MCP and PIP: RA, SLE  Chronic crystal arthritis.  DIP: psoriasis, gout, 1ry OA  Hypertrophic osteoarthropathy.  1st MTP= Gout, OA  Hypothyroidism.  Spine= OA, Ankylosisspodylitis,  Metabolic and infiltrative bone and Psoriatic arthritis, Reactive arthritis joint diseases.  Shoulder= PMR Temporal pattern of joint involvement in Pain character polyarthritis  Aggravated by motion= Mechanical  Migratory pattern:Arthritis in certain  Relieved by motion= Inflammatory. joints remit to reappear in other Duration joints e.g Rheumatic fever, Gonococcal arthritis, Viral Arthritis,  <6 wks= viral arthris, systemic Acute Leukemia rheumatic diseases  Additive pattern: Arthritis persists,  >6 wks=systemic rheumac diseases with subsequent involvement of Associated Symptoms other joints e.g RA, SLE.  Morning sffness: >1hr= RA, PMR,  Intermittent pattern: Repetitive Inflammatory, < 30 min= OA attacksof acute polyarthritis with  Multi-system involvement= Systemic complete remissionbetween attacks rheumatic diseases. e.g RA, polyarticular gout, sarcoid  Fever= infection, reactive arthritis, arthritis, Reiter’s syndrome & RA, SLE, Crystal induced arthritis… psoriatic arthritis. Past Medical history:Trauma, fracture, Age surgical procedures…  <30= SLE, Ankylosing spodylis, Medication list:Drug induced lupus, diuretics Reactive Arthritis. inducing gout.  30-50= RA, Systemic sclerosis, Gout. Physical Examination  >50= OA, Pseudogout, PMR Inspect for: o TB arthritis.  Skin manifestations: SLE, Psoriasis, o Fungal arthritis. Dermatomyositis, sarcoidosis, Behcet, Systemic Examination Rheumatic fever, Cryoglobulinemia, HSP, Still’s disease.  Nervous System: SLE, Behcet,  Subcutaneous nodules: RA, RHD, Gout vasculitis (tophi),1ry OA  Lung and pleura: RA,SLE, SS, PM,  Parotid enlargement: Sjogren’s  Lung: Sarcoidosis, Vasculitis.  Mucocutaneous:  Peri- and myocardium: RA,SLE, SS, o Oral ulcer: Reiter’s, Behcet, SLE PM. o genital ulcer: Reiter’s, Behcet  Heart valve: Rheum fever, RA, SLE,  Nail changes: Psoriasis Reiter’s S.  Eye: RA, AS, Reiter’s, Behcet,  Kidney: SLE, vasculitis, Polyarticular Sarcoidosis gout.  Nose: Wegner’s granulomatosis,  GIT: Reiter’s, IBD, SS. .  Liver: HCV, SS, IBD, sarcoidosis.  Ear: Relapsing polychondritis. Joints examination Laboratory Studies  Soft tissue swelling, warm,  Can be misleading. effusion…= .  Basic: CBC, Urinalysis, RFT, LFT.  Acute phase reactant: ESR, CRP.  Normal passive motion with limited  active motion= bursitis, tendinitis, Uric acid concentration= Gout muscle injury.  CK:PM/DM , hypothyroidism  Ca+² ,P +³:endocrinal, metabolic  Limited passive and active motion =  Antibody tests: Synovitis o ANA= SLE  Erythematous Joint o Anti-dsDNA= SLE o Gout, o Anti-native DNA, anti-Sm= SLE o RF= RA o . o Anti-CCP antibody=RA o Rheumatic fever  Hepatitis B and C o Leukemia  Salmonella, brucella Serology: ReA,  Parvovirus serology o RSD  Rheumatoid Factor  Deformity o Rheumatoid Arthritis o RA o Connective tissue diseases o Psoriasis o Viral infection o SS-Sclerodactyly (flexion contof o Leishmaniasis fingers) o Leprosy o SLE- JaccoudArthropathy. o o Sickle cell disease o Sarcoidosis  Associated Tenosynovitis o Liver diseases o RA, o Subacute bacterial endocarditis o Gout, o Reiter’s syndrome, Imaging Studies o Gonococcal arthritis.  X-ray: o OARAChronic Gout o RSD o . Synovial Fluid Analysis  MRI: Indications o Ankylosing spondylitis.Internal 1. Infecon derangement, 2. Crystal induced arthris o ,, 3. (traumac, pigmented o Pigmented villonodular synovitis. villnodular synovitis).  Bone scan: 4. Differenanginflammatory from non- inflammatory arthritis (WBCs count) o .