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Prof. Dr/ Abdel Azeim AlhefnyProf. of Internal Medicine, Rheumatology & Immunology
Director of Rheumatology unitAin Shams University
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Introduction
The objectives of performing a
musculoskeletal examination are:
1) To make an accurate diagnosis
2) To assess the severity and complications
of the condition
3) To construct a management plan
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Ten Golden Rules In Rheumatology
1. A good history & physical examination, with good idea about the musculoskeletal anatomy is very important for diagnosis;
You must examine the patient!!
2. Don’t order a lab test unless you know why & what you will do if it is abnormal?
3. Acute monoarthritis = 1joint inflam. <6w; joint aspiration to exclude septic & crystal- induced arthritis.
4. Chronic monoarthritis > 6 weeks of unknown cause;== synovial biopsy.
5. Gout does not occur in premenopausal females or in j. close to spine.
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6. Most shoulder pain is periarticular (bursitis, tendonitis..), most LBP. is nonsurgical
7. OA in (MCP, wrist, elbow, shoulder, ankle) joints ----exclude 1ry cause eg. Metabolic dis.
8. 1ry fibromialgia does not occur > 55ys. for 1st time, nor with abnormal laboratory results.
9. Not all pts. With +ve RF have RA, nor +ve. ANA have SLE .
10. Fever or multisystem complaints, in Rhc. Pt., rule out infection & other non-Rhc. Causes (Infections cause death in Rhc. pt. more than the 1ry dis. does).
Remember nothing is 100%
Ten Golden Rules In Rheumatology
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Clinical evaluation of the Patient with Rheumatic Disease
3 simple screening questions
1) Have you any pain or stiffness in your muscles,
joints or back?
2) Can you dress your self completely without any
difficulty?
3) Can you walk up and down stairs without any
difficulty?
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If the answer to any question is positive , detailed history must be obtained…Ask about:
1) Pain: Site, radiation, severity, in usage? at rest? at night?
2) Stiffness: subjective feeling of inability to move freely,
duration of early morning stiffness ?
3) Swelling: fluid (effusion) or soft tissue (synovitis) or bone.
which joint? constant or episodic? duration?.
4) Systemic illness: Fever, malaise, fatigue, loss of weight
5) Extraarticular manifestations: Loss of hair, photosensitivity,
dryness of mucous membranes, mouth ulcers, red eyes,
Raynaud's phenomenon, symptoms referable to other
systems.
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Patterns of pain
Degenerative joint pain: pain on joint use, stiffness after
inactivity, pain at end of day after Use (osteoarthritis)
Inflammatory joint pain: pain and prolonged stiffness in the
morning, at rest, and with use (Inflammatory arthritis)
Mechanical joint pain: pain related to joint use only
(unstable joint)
Bone pain: pain at rest and at night (Tumor, Paget’s, fracture)
Neuropathic :diffuse pain and paresthesia in dermatome,
worsened by specific activity (root or peripheral nerve
compression)
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A diagnostic approach to the Patient with Rheumatic Disease
Pearl ! : The diagnosis of many rheumatic diseases
is based mainly on clinical grounds
• Firstly: answer the following questions about thenature of the disease:
I. Articular or non-articular?
II. Acute or chronic?
III. Inflammatory or non-inflammatory?
IV. Pattern of joint involvement.
V Extraarticular features.
• Lastly: Order investigations that help to confirm your clinical impression or to sort out your differential diagnosis.
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I. Articular or Nonarticular ?
• Articular pain is localized to a specific joint, both
passive and active Range Of Motion (ROM) arerestricted in all planes.
• Nonarticular pain originates from periarticular
structures (tendon or bursa), only active ROM isrestricted in the plane of involved structure.
• Diffuse nonarticular conditions: generalized
hypermobility and fibromyalgia (diffuse aches
and pain)
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II. Acute or chronic?
• Acute musculoskeletal disorders are defined asthose of <6 weeks duration:
1) viral arthritis 2) gout 3) reactive arthritis
• Chronic MSK disorders are defined as thoselasting > 6 weeks: non-inflammatory(osteoarthritis) and inflammatory (rheumatoidarthritis).
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III. Inflammatory or non-inflammatory ?
Inflammatory disorders identified by:
• Rest pain partially improved by activity
• Local cardinal signs of inflammation (redness,
hotness, pain, swelling and limited movement).
• Prolonged morning stiffness >1 hour.
• Systemic symptoms (fatigue, fever, weight loss)
• Elevated ESR, CRP.
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Inflammatory Non-inflammatory
MS >1hr. <1/2 hr.
Fatigue Significant. Minimal.
Activity Improve symptoms. Worsen.
Rest Worsen Improve.
Systemic
manifestatio
ns
+ + - -
ESR, CRP + + - -
Corticosteroi
d
Improve No effect
Ex. RA.
Systemic rheumatic dis.(SLE,
SSC, Vas.).
Infect.: Bact, Viral.
.
Reactive (Reiter, RF).
Seroneg. (AS,IBD).
Sarcoidosis, FMF,..
OA.
Traumatic.
Osteonecrosis.
Neuropathic J.
Metabolic
(hemochromatosis),
Endocrinal (thyroid, DM,
Acromegaly)
Comparison between Inflammatory & Noninflammatory arthritis
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IV. Pattern of joint involvement(pattern recognition)
Sequence of involvement :
1) Migratory polyathritis:Symptoms are present in certain joints for few days and then remit to reappear in other joints.
(Acute rheumatic fever and Viral arthritis)
2) Additive polyarthritis:Symptoms begin in certain joints and persist withsubsequent involvement of other joints.
(rheumatoid arthritis)
3) Intermittent:Repetitive acute attacks with complete remission.
( gout)
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Number of joints involved
• Monoarthritis: one joint involved
Septic arthritis and crystal arthropathy .
• Oligoarthritis: (2-4 joints involved)
e.g. spondyloarthropathies (ankylosingspondylitis, psoriatic arthritis. reactive arthritis and inflammatory bowel disease related arthritis).
• Polyarthritis : more than 4 joints involved.
e.g rheumatoid arthritis
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Distribution of joints
involved
• Symmetrical or asymmetrical
• Axial or peripheral
• Large or small joints
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Symmetrical Asymmetrical
Ex. RA
SLE
Reiter
PsA
AS
Peripheral Axial
Ex. RA
SLE
AS
PsA (70%-also
affects IPJ--- sausage
digits)
Reiter
Small Large
Ex. RA
SLE
Seronegative
Reiter
RF
Distribution of joints
involved
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V. Extraarticular manifestations
Are there extraarticular manifestations that would be
helpful in making the diagnosis of systemic
rheumatic diseases?
• Loss of hair, photosensitivity, dryness of mucous
membranes, mouth ulcers, red eyes, Raynaud's
phenomenon, symptoms and signs referable to other
systems (pulmonary, cardiac, renal, neurological).
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Examination
• Gait Arm Leg Spine (GALS screen) to detect important MSK abnormalities and functional disability.
• Gait:
Observe the patient's gait for rhythm andsymmetry.
Upper limbs:
• Inspection: (Look)
Inspect the hand & upper limb joints for deformity,swelling or other signs of joint disease.
• Palpation: (Feel) Palpate the upper limb joints fortenderness, swelling or increased warmth.
Doherty M et al The “GALS” screen. Ann Rheum Dis 1992;51:1165-1169
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Movement (Move)
• Ask the patient to open and spread the fingers, close the
fingers (power grip), and then to pinch the tip of index finger
and thumb (opposition).
• Ask the patient to put his hands together in the position of
prayer and then to lower the arms keeping the palms together.
This demonstrates the range of extension of the wrists.
• Ask the patient to place the back of his hands together and to
raise the arms upwards. This demonstrates the range of flexion
of wrists.
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Movement (Move)
• Instruct the patient to bend and straighten both elbows
simultaneously (0-150)
• With elbows flexed to 90, turn hands palm up (supination
0-90) and then palms down (pronation 0-90).
• Ask the patient to put both hands behind the head with elbows
pointing laterally (abduction and external rotation),
• then to put the arms down and reach up behind the back (extension,
adduction and internal rotation).
• Compare active with passive movements, if active range limited.
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Lower limbs
• Inspection (look):
Inspect the lower limb joints for deformity, swelling or other sings of rheumatic diseases. Note the presence of muscle wasting or leg length inequality.
• Palpation (feel):
• Palpate the lower limb joints for tenderness, swelling or increased warmth.
• Palpate knee joint for effusion (patellar tap test or balloon sign) and palpate for a popliteal cyst.
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Movement (move)• Rotate the hips with the legs extended using the foot as an
indicator (90 arc of movement).
• With the hip and knee at 90 check the range of internal (30) andexternal rotation (45) of the hip.
(Internal rotation is affected first in disorders of the hip joint)
• Complete hip flexion noting the range (0-120).
• Ask the patient to flex each knee in turn and observe the range of movement (0-150) and any signs of tenderness.
• Ask the patient straightens each knee, place a hand on the knee to feel the crepitus
• Ask the patient to extend (20) and flex (30) each ankle
• Passively evert (10) and invert (20) the subtalar joints with theankles in neutral position.
• Ask the patient to flex and extend the metatarsophalangeal (MTP) joints.
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Spine
• Look: observe the standing patient's spine from behindand the side for abnormal kyphosis or scoliosis .
• Feel: palpate for any points of tenderness over the spine.
• Move :• Ask the patient to flex then extend the neck, to look right,
left and then tilt the head sideways aiming to touch each earon the shoulder.
• Ask the patient to try to touch the toes without bending the knees and to tilt sideways from the vertical position to try to touch the sides of the knees.
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Recording examination findings
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CLINICAL
PRESENTATIONS
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Discoid rash
Sub acute Cutaneous Lupus
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Oral ulcers Arthritis (nonerosive)
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Localized alopecia
Wide spread non scaring alopecia
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Vasculitis
Raynaud’s
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Joint Effusion
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Hand deformities
Chronic synovitis and tenosynovitis result in characteristic joint deformities classic for chronic rheumatoid arthritis. Patients may have swan neck deformities, Boutonniere's sign, ulnardeviation, cock-up toes, or hammer toes.
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Hand deformities
Z deformity
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Carpal tunnel syndrome
1) Tinel's sign 2) Phalen's sign
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The Elbow
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The Shoulder
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The Knee
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Foot deformities
Cock-up toes, or hammer toes in RA
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Bones of the foot
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Rheumatoid nodules
•20% of patients have SC rheumatoid nodules, most commonly situated over bony prominences but also observed in the bursae and tendon sheaths. (firm, non-tender, freely mobile)•Nodules are occasionally seen in the lungs, the sclerae, and other tissues. •Nodules correlate with the presence of RF ("seropositivity"), as do most other extra-articularmanifestations.•all patients with rheumatoid nodules are seropositive for RF.
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54
PANcont.
Gangrene
Livedo reticularis
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55
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56
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Behçet's syndromeOral ulcers Genital ulcers
57
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Heberden’s and Bouchard’s Nodes
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Sciops-Medical Division
Heberden’s nodes :Hard or bony swellings which develop in the DIP.Bouchard's nodes: bony growths in the proximal interphalangeal (PIP) joints
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Hallux valgus and cock-up toedeformities, characteristic ofosteoarthritis in the foot.
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Knee deformity in OA
Sciencephoto.com
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Deformities
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Lab. Evaluation
Laboratory tests may play an important role
in the diagnosis of patients with rheumatic
diseases.
Improper use of these tests may result in
misdiagnosis, needless additional testing or
even inappropriate therapy.
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Erythrocyte Sedimentation Rate (ESR)
Range :<15 mm/hr for men
<20mm/hr for women
Age adjusted:
(Males) Age
2
(Females) (Age + 10)
2
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Infections, bacterial (35%) e.g. TB.
Connective tissue diseases (25%)
Malignancy : lymphoma , myeloma (15%)
Other causes (22%)
Unknown (3%).
Markedly elevated ESR (>100mm/hr)
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ESR is used:
To reassure the patient with vague symptoms
and normal examination.
To confirm clinical impression of the presence
of inflammatory disease.
Follow up as a marker of treatment success.
The use of the ESR needs always to be
taken in clinical context
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C-Reactive Protein (CRP)
CRP is produced as an acute-phase reactant by the
liver in response to inflammation.
Elevation occurs within 4 hours of tissue injury with
peaks within 24 -72 hours and falls rapidly once the
stimulus is removed.
More specific than ESR but more costly
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A negative RF does not exclude the
diagnosis of RA.
RA patients with high RF titer tend to have
more severe disease (prognostic value).
Poor correlation with disease activity.
(no use to repeatedly measure the RF).
Clinical use of RF
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Rheumatologic diseases:
Rheumatoid arthritis (70-80%)
Sjogren's syndrome (75-95%)
Mixed connective tissue disease (50-60%)
SLE (15-35%)
Polymyositis (5-10%)
Cryoglobulinemia (40-100%)
Causes of positive RF
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Infections:
Ch. hepatitis, especially hepatitis C (45%)
Bacterial endocarditis
Tuberculosis.
Syphilis.
Leprosy.
HIV infection
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Other conditions:
Healthy aging individuals.
Idiopathic pulmonary fibrosis.
Cirrhosis.
Sarcoidosis.
Neoplasms.
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Cyclic citrullinated peptide antibodies (Anti-CCP) or Anti-citrullinated protein antibody (ACPA)
More recently discovered rheumatoid arthritis specific antibodies with sensitivity similar to RF and a very good specificity.
This test is valuable in confirming the diagnosis of early RA.
Anti-CCP antibodies can predict the development of rheumatoid arthritis.
High titre of anti-CCP are prognostic for erosive disease.
(Nielen MMJ , Arthritis Rheum 2004)
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Rheumatoid Factor
Anti CCP
Acute phase reactants (nonspecific)
ESR
CRP
Serological Markers for RA
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ANA immunofluorescent patterns
diffuse
nucleolarspeckled
peripheral
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Condition % ANA-positive SLE 95-98
Healthy relatives of SLE patients 15-25
Rheumatoid arthritis 15-30
Mixed connective tissue disease (MCTD) 95 -100
Progressive systemic sclerosis 95
Polymyositis 80
Sjögren's syndrome 75-90
Cirrhosis (all causes) 15
Autoimmune liver disease (autoimmune hepatitis 60-90
primary biliary cirrhosis
Chronic HCV infection 10 - 30
Normals 3 - 5
Normal elderly (>70 yr.) 20 - 40
Neoplasia 15-25
Medical conditions associated with positive ANA
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Serological Tests to Aid Diagnosis of SLE
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The occurrence of ANCA in different clinical conditions
Systemic vasculitis (AAV.. WG, CCS)
Rheumatological diseases(SLE, RA)
Inflammatory bowel disease
Autoimmune liver diseases
Infectious diseases
Subacute bacterial endocarditis (20%)
Entamoeba hystolytica (C PR3 IN 75%)
Drug-induced vasculitis
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Serum Uric Acid
Hyperuricemia is defined as any level over about 6.8 mg/dL
(the point at which urate's solubility is exceeded)
Hyperuricemia is a common serum abnormality but does
not result in gout without crystal deposition.
Serum uric acid level may be normal with acute gouty
arthritis.
If you see patients who have serum uric acid above the
level of 6.8 mg/dL, search for other cardiovascular risk
factors.
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ASOT (anti streptolysin O test)
All patients should have evidence of a
preceding group A streptococcal infection
and the presence of two major
manifestations or one major and two minor
manifestations.
The diagnosis of acute rheumatic fever
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ASOT vary with age, season, geographical location
and epidemiologic circumstances. Titers of 200- 400
Todd units are common in healthy children who live in
crowded cities as in our country.
One should not diagnose the disease on the basis of
increased titers of streptococcal antibodies alone .
ASOT
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X-ray changes: stages of radiological progression in RA are:
• I) Periarticular osteopenia ,osteoporosis.• II) Loss of articular cartilage (joint space narrowing).• III) Bony erosions, particularly of the MCPs and
ulnar styloid• IV) Subluxation and ankylosis.
• MRI and ultrasound: are recently used with high sensitivity for detection of early changes in RA.
Radiographic findings
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Progressive joint damage in RA
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X Ray hand in RA
showing typical erosions at the thumb (black and white arrows) and middle MCP
joints (black arrow) and at the ulnar styloid (black arrow).
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Rheumatoid arthritis: knee joints
symmetric narrowing of medial and lateral joint spaces that is characteristic of RA
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Radiographic features
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1st CMC
(thumb base)
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Serositis:
• Pleurisy
• pericarditis
CXR : pleurisy
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Pleural and pericardial effusions
(CT chest)
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Rheumatoid lung nodules & pl eff in pt with chronic RA
lung nodules
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cerebral vasculitis
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MRI in RA
Both MRI and ultrasonography are more sensitive than radiographs in detecting bony erosions & soft tissue changes in early RA
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Higher sensitivity than XR for detection of bone erosions in RA
( M. Szkudlarek et al, eular June,2004)
Ultrasonography in RA
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• Arthrocentesis is needed to diagnose superimposed septic arthritis which is a common complication of RA
• Should be considered whenever RA patient has acute monoarthritis exacerbation.
SYNOVIAL FLUID EXAMINATION
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Indications for synovial fluid analysis
1. Suspicion of infection. Gram stain, culture, and WBC count (>50,000/cmm) and differential (PMNs> 75% ).
2. Suspicion of crystal-induced arthritis. polarizing microscopy (birefringent crystals).
3. Suspicion of hemarthrosis. Bloody joint fluid = traumatic arthritis, clotting disorder, and pigmented villonodular synovitis.
4. Differentiating inflammatory from non-inflammatory arthritis (Synovial fluid WBC <2000).
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Musculoskeletal complaint
History & Examination?•Articular or non•Acute or chr.•Inflammatory or non.•Number & distribution
Articular?
Acute or Chronic ?
Chronic>6W.Acute<6 W.
Inflammatory or non-infl.
Acute arthritis:•Infectious•Crystal-induced•Reiter’s•Presentation of Chr. Arth.
1
Non articularFibromyalgia R
Hypermobility S
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Inflammatory or non-inflam.
Chronic inflammatory arthritis= MS>1hr, synovial swelling,
warm, j.tender, syst. manifes., CRP, ESR
Chronic non-inflammatoryarthritis
Affects Wt. Br. J.(H & k)., DIP< CMC
OsteonecrosisCharcotarthritis
OA
>4 J = polyarthritis1-4=mono-oligo AChr. Inf.
PA- RS- PJA Symetrical
PA, RS PIP, MCP, MTP
SLE, SSc, PM RA
2
_+
+-
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