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My Aching Joints!

My Aching Joints!. Jon Roebuck CPT MC WRAMC Rheumatology February 7, 2002. Musculoskeletal Pain. 1 in 7 patient visits to primary care Many benign conditions Some are life threatening Pays to know which is which Arthritis Leading causes of disability and absenteeism.

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My Aching Joints!

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  1. My Aching Joints! Jon Roebuck CPT MC WRAMC Rheumatology February 7, 2002

  2. Musculoskeletal Pain • 1 in 7 patient visits to primary care • Many benign conditions • Some are life threatening • Pays to know which is which • Arthritis • Leading causes of disability and absenteeism

  3. Goals of the Lecture • Classification of joint problem • Inflammatory Vs. Noninflammatory • Acute Vs. chronic • Approach to monoarthritis • Approach to polyarthritis • Rheumatology referral • When to order ANA, RF • Summary of points • Questions

  4. History • Musculoskeletal emergencies • Septic arthritis • Subacute bacterial endocarditis • Osteomyelitis • Necrotizing fasciitis • Systemic vasculitis • Acute myelopathy • Deep venous thrombosis • Compartment syndrome

  5. Red flags • History of significant trauma • Hot, swollen joint • Weakness • Focal • Diffuse • Neurogenic pain • Claudication pain

  6. General history • Joints involved • Chronicity • Exercise • Aggravates or alleviates • AM stiffness • Swollen joints • Rubor, Calor, Dolor, Tumor • Fatigue

  7. Inflammatory Symmetric joint involvement Stiffness > 1hr R/C/D/T Improves with exercise Constitutional complaints Noninflammatory One or very few joints Stiffness <30min No pain at rest Worsen with exercise No constitutional Historical distinctions

  8. Physical Exam • Is it really the joint? • Articular • Painful, limited active ROM • Painful, limited passive ROM • Periarticular • Painful, limited active ROM • Full, unlimited passive ROM

  9. Physical Exam • Now is it inflammatory? • Warmth • Erythema • effusion

  10. Physical Exam • Joints involved • Small joint symmetric • Monoarthritis/oligoarthritis • Swelling observed? • Rashes • Nodules • Mucosal sores • Weakness

  11. Physical ExamRefer these patients! • Skin as a clue to systemic disease • Vasculitis • Psoriasis • Erythema nodosum • Pyoderma gangrenosum • Still’s rash • Malar and discoid lesions • Dermatomyositis

  12. This is bad

  13. Refer this one to us(after the ECHO)

  14. Don’t forget the eyes

  15. This might be bad

  16. Close-upPalpable purpura

  17. Inflammatory Crosses bridge of nose Spares nasolabial fold Classic malar

  18. Bad malar • Same features • Possibly discoid • Secondarily infected

  19. Subtle malar

  20. Classic heliotrope • Periorbital edema • Lilac hue • Specific for dermatomyositis

  21. Most common skin rash Papulosquamous eruption over joints Not as specific as heliotrope Gottren’s papules

  22. Koebner phenomenon

  23. Decision time • Acute monoarthritis • Acute polyarthritis • Symmetric • Chronic mono/pauciarthritis • Chronic polyarthritis

  24. MONARTHRITIS MONARTHRITIS

  25. Infection Bacterial viral Crystalline Hemarthrosis Trauma Hemophilia Pigmented synovitis Early presentation of systemic disease Acute monoarthritis

  26. Most important intervention… Aspiration Cell count Gram stain/culture Crystal exam Acute monoarthritis

  27. Arthrocentesis technique • Considerations • Needle and syringe size • Skin sterilization • Local anesthesia • Comfort of you and patient

  28. Knee • Rheumatology • Medial • anesthesia • Orthopedics • Lateral • Superior • If you only know one joint…

  29. What’s in that joint? • Inflammatory crystals • Gout • Pseudogout • Basic calcium phosphate • Fat • Cholesterol • Junk

  30. Crystal diagnosis • Polarized light microscopy • Bright objects on dark background? • Crystal morphology? • Birefringent? • YAG Vs. ABC

  31. Keep it straight Chondrocalcinosis: XRAY diagnosis = Pseudogout = +

  32. fat Cholesterol Other crystals

  33. Most important intervention… Rheumatology referral Call us On call Doc each day 202 782 6734(5) Acute monoarthritis

  34. Chronic monoarthritis • Rheumatology referral • Atypical infection • Fungal • Mycobacterial • Atypical systemic disease • RA, SLE, SNSA • May need synovial biopsy

  35. POLYARTHRITIS POLYARTHRITIS

  36. Acute or chronic polyarthritis • Careful history and physical exam • Synovitis? • No– your problem • Yes– our problem • Referral. To be helpful • Cbc, esr, crp, RF, ANA, bun/cr, UA, TSH

  37. What to write on the referral • What is it? • Sometimes it’s a differential • Sometimes it’s fairly obvious • Sometimes you have no idea • We may not either

  38. Acute (<6 weeks) Viral Parvo Hepatitis HIV EBV Bacterial Rheumatic fever Post-streptococcus Chronic (>6 weeks) RA SLE Other CTD Chronic sequelae of the acute DX’s Inflammatorysymmetric, small joint

  39. Physical Exam • The entire exam is important • However… • Hands are the gateway to rheumatologic diagnosis

  40. Physical Exam • I mentioned swelling • Synovial • Bony • Big difference, not always so obvious

  41. Noninflammatory

  42. Noninflammatory • Osteoarthritis • Primary • Secondary • Hyperparathyroidism • Hemachromatosis • Acromegaly • Hypo/hyperthyroid

  43. Inflammatory

  44. Fusiform swelling

  45. ACR Criteria for RA • Morning stiffness • >1hr • Arthritis of 3 or more joint areas • Soft tissue swelling or fluid • Arthritis of hands • Wrist, MCP, PIP • Rheumatoid nodules • Subcutaneous nodules over bony prominences • Serum rheumatoid factor • Radiographic changes (4/7 criteria satisfy classification criteria)

  46. Boggy MCPs

  47. Prevent this

  48. And this

  49. How do I prevent deformity? • Early aggressive therapy • Multiple DMARDs • Staunch monitoring of disease and medications • Low threshold to increase therapy • Any evidence of breakthrough disease • RHEUMATOLOGY referral!!

  50. Lupus • Very similar to RA • Rashes and other criteria helpful • Serologic eval

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