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10-minute consultation BMJ: first published as 10.1136/bmj.326.7394.859 on 19 April 2003. Downloaded from Polyarthralgia Jo Samanta, Julia Kendall, Ash Samanta

This is part of a A 45 year old woman says she has had in Useful reading her hands, knees, and hips for three months. Her series of symptoms have progressively worsened. Michael L Snaith, ed. ABC of . 2nd ed. occasional London: BMJ Books, 1999 articles on What issues you should cover common Assessment—Is her joint simple arthralgia, Medendium Group. Guidelines: summarising clinical problems in degenerative joint , or an inflammatory guidelines for primary care. www.eguidelines.co.uk primary care , or is it secondary to some other cause? (accessed 7 Jan 2003) History—Ask whether she has had any swelling Department of around the , morning stiffness, nocturnal pain or Rheumatology, Leicester Royal pain at rest, or recent viral or throat . Check x If the diagnosis is rheumatoid or a Infirmary, Leicester for systemic features such as fever, weight loss, or LE1 5WW fatigue. She may have bowel or bladder symptoms, and seronegative inflammatory arthropathy, explain the Jo Samanta nature of the condition and that referral to hospital for clinical research her eyes or skin may be affected. Is there a family assistant history of ? Other features may be specialist assessment, education, and long term support would benefit. Give positive messages: several treatment Julia Kendall prolonged repetitive use of hands; mood changes, general practice altered sleep pattern, or lack of energy; and use of over modalities are available that can slow down disease pro- clinical assistant the counter drugs or complementary treatment. gression; chronic disability and “ending up in a Ash Samanta wheelchair” are now the exception rather than the consultant Examination—Which joints are affected? Check for rheumatologist symmetrical presentation and proximal interphalangeal norm. x Arrange early referral. Meanwhile consider start- Correspondence to: or metacarpophalangeal joint swelling (absence of A Samanta groove between knuckles on making a fist); inflamma- ing a disease modifying antirheumatic drug— ash.samanta@ uhl-tr.nhs.uk tion and range of movement of joints; hand function, sulfasalazine and methotrexate are the most common assessed by grip strength and ability to hold objects or first line treatments. (Chest radiography is advisable The series is edited before methotrexate treatment because of possible by general write; nodules around elbows or shins; nodes at distal practitioners Ann (Heberden’s nodes) or proximal (Bouchard’s nodes) pulmonary side effects.) Remember that these drugs McPherson and require regular haematological and biochemical Deborah Waller interphalangeal joints; and pitting of nails. Be alert to http://www.bmj.com/ monitoring. Liaise with local rheumatologists if in (ann.mcpherson@ risk factors such as overweight, sedentary lifestyle, heavy dphpc.ox.ac.uk) physical work, repetitive work, or previous joint , all doubt. x The BMJ welcomes of which might indicate . Short term use (6-12 weeks) of low dose oral contributions from corticosteroid ( < 7.5 mg prednisolone a day) relieves general symptoms and may slow progression. practitioners to the series What you should do x Arrange follow up in four to six weeks for clinical x If there is no active , consider simple assessment, reinforcement of earlier advice, and evalu- BMJ 2003;326:859 arthralgia. Reassure her and advise her to take ation of home and social circumstances. simpleanalgesics or non-steroidal anti-inflammatory on 26 September 2021 by guest. Protected copyright. drugs (NSAIDs). Consider fibromyalgia if she has more generalised pain and signs of depression. Encourage positive lifestyle changes and ask her to return in four Polyarthralgia: weeks. Simple arthralgia x If features indicate osteoarthritis, reassure her and Main symptom is pain; no clinical features of inflammation in the joints or explain the nature of the problem (wear and tear). morning stiffness; history of intercurrent illness or viral infection Advise or NSAIDs (or both), offer lifestyle Osteoarthritis education, and encourage exercise and weight loss. Pain is usually in large, weight bearing joints, carpometacarpal joint of thumb, or distal interphalangeal joints of the fingers; presence of Refer her for physiotherapy if needed. Heberden’s nodes, ; lifestyle factors such as overweight, sedentary x If swelling and features of inflammation are present, occupation, repetitive use of joints, and history of trauma to affected joints consider an inflammatory arthropathy (the common- may be relevant est cause is rheumatoid arthritis). Consider further Seronegative (non-rheumatoid) arthritis investigations such as a full blood count (for anaemia), Linked with psoriasis, bowel disease (, Crohn’s disease), markers of inflammation (erythrocyte sedimentation bladder symptoms, and anterior uveitis. May occur after rate, plasma viscosity, C reactive protein), rheumatoid (streptococcal throat infection, chlamydial urethritis, or bowel infection with factor, and radiography of the hands. yersinia, salmonella, shigella). Mainly asymmetrical, large joint oligoarticular involvement; possible spinal involvement (sacroiliitis) x In the absence of contraindications start treatment with NSAIDS. Long acting preparations usually offer Rheumatoid arthritis At least four of these signs or symptoms for six weeks: pain and swelling in more sustained control. Consider a cyclo-oxygenase-2 at least three joint areas; symmetrical presentation; early morning joint selective inhibitor, as long term treatment is likely to be stiffness for more than one hour; involvement of metacarpophalangeal needed. Advise her to rest affected joints when they are joints, proximal interphalangeal joints, and wrists; subcutaneous nodules; inflamed. Consider referring her to occupational positive rheumatoid factor; radiological evidence of erosions therapy for splinting and home aids.

BMJ VOLUME 326 19 APRIL 2003 bmj.com 859