What are the 6 key features to consider in diagnosing arthritis?
How do you determine if a musculoskeletal complaint is articular or non-articular?
A good history. Physical exam: Articular = painful and limited ROM with active and passive motion. Non-articular = painful and limited active ROM but full, unlimited passive ROM.
A patient comes to see you complaining of elbow pain. There was no trauma to induce injury and physical exam reveals warm and tender skin. Will this patient have pain during passive ROM?
No. This is a non-articular injury to the bursa.
What is a unique symptom that can lead you to diagnosis of fibromyalgia?
Specific tender points in the muscle.
What determines if a patient is suffering from acute or chronic appendicular arthritis?
Greater than or less than 6 weeks
What are the important things to consider in acute arthritis?
#1: septic arthritis, then gout, pseudo gout, reactive arthritis and initial presentation of any chronic arthritis
What do you need to ask if you are trying to differentiate a chronic arthritis from inflammatory vs. non-inflammatory?
What are the important things to consider in chronic arthritis?
What things can you ask to determine if you are determining if chronic arthritis is due to a systemic pathology?
A patient with arthritis in his great toe for 20+ years comes to see you complaining of increased pain in the knees now. He also has these lesions on his ears. What is your diagnosis?
A patient comes to see you suffering from polyarthritis in the MCPs and PIPs. You also see this on his elbow. What is your diagnosis?
This woman came to see you with a symmetric polyarthrits with a malar rash and non painful ulcers on the roof of her mouth. What is your diagnosis?
How do you determine if an arthritic condition is inflammatory?
Morning joint stiffness > 1 hour. Pain at rest. Red, swollen, warm, inflamed. Improves with exercise. Constitutional symptoms.
Which of these is inflammatory?
The patient on the left. Note MCP deformities and soft, warm, tender nodules indicating rheumatoid arthritis. The patient on the right has DIP involvement typical of non-inflammatory osteoarthritis.
What different patterns are followed by arthritic conditions?
Additive (spreads from joint to joint), Migratory (moves from one place to another) and Intermittent (comes on goes)
A 27 year old soldier comes to see you with knee pain that has moved from his wrist to his foot and arrived at his knee. What might this patient have?
What conditions do you need to keep in mind when working with a migratory arthritis?
What conditions do you need to keep in mind when working with an intermittent arthritis?
What key feature strongly suggests rheumatoid arthritis in the hands?
How do you think differently about a diagnosis for a swollen knee in elderly people vs. young people?
Older people = OA and gout. Younger people = septic arthritis and rheumatoid arthritis
What are the categories you consider when diagnosing a mono arthritic process?
Chronic and Acute
What is every mono arthritis until it's not? How do you determine this?
A septic arthritis. You rule it out by aspirating the joint and culturing/gram stain for bacteria
What levels in a CBC tell you if the patient has an inflammatory or non-inflammatory condition?
If you can't read text through the fluid it may be inflammatory.
Polarized light microscopy of synovial fluid shows long, needle-like birefringent crystals. What is the condition?
Polarized light microscopy of synovial fluid shows a stubby boxcar which is parallel and yellow. What is the condition?
What tests do you consider to rule in an acute arthritis?
Radiographs (to look for fracture and infection), arthrocentesis and blood work (WBC, ESR to look for inflammatory process)
How does your differential change if arthritis is chronic? What tests do you do?
A 65 year old female with a 3 year history of swelling in the DIPs and PIPs with worsening deformities. Additionally he notes "gelling" phenomenon in the knee that gets better after walking around a little bit. On physical exam you not Heberden's and Bouchard's nodes bilaterally and CMC "squaring" of the joints. What is your differential diagnosis?
Osteoarthritis, crystal-induced (pseudo gout), Hereditary metabolic disease (that lead to pseudo gout), endocrine, hematologic, hypertrophic osteoarthropathy
What are the clinical features of osteoarthritis?
What joints are often affected by osteoarthritis?
Pathology in what joints make you wonder if there is a secondary condition underlying osteoarithrits?
What is the only lab that will have a significant finding with osteoarthritis?
Synovial fluid aspiration. It will have a WBC around 500-1000.
What are the ABCDES of radiographic imaging of osteoarthritis?
An elderly male comes to see you with intermittent bouts of arthritis beginning 4 years ago that lasts 4-7 days. Arthritis has moved from left knee to right knee to wrist. What do you expect to see in his lab values?
This sounds like an inflammatory arthritis, thus his WBC in the synovium should be elevated (anything > 30,000 can play into your diagnosis)
What is your differential for acute inflammatory mono arthritic conditions?
An elderly male comes to see you with intermittent bouts of arthritis beginning 4 years ago that lasts 4-7 days. Arthritis has moved from left knee to right knee to wrist. You decide that this presentation is acute. What is causing this patient's symptoms?
Calcium pyrophosphate dihydrate (CPPD) deposition in chondrocalcinosis (asymptomatic = lanthanic CPPD) and pseudo gout (symptomatic)
What makes you think this patient has something other than osteoarthritis?
Arthritis at the metacarpal joints. This will only be osteoarthritis if the person is a boxer or something. This patient has CPPD.
What underlying diseases can cause pseudo gout?
What joints are often affected in gout?
Cooler joints of the body
What joints are often affected in CPPD?
What do you know about your patient's condition if you see these crystals on your polarizer?
Acute pseudogout or gout
What are the differences between pseudo gout and gout crystals?
What are the ABCDES of CPPD radiographic analysis?
What treatments can you consider for CPPD?
An 18 year old female comes to see your with hand swelling in PIPs and MCPs for the last 15 months. More recently it has moved to her wrist. She has 1-2 hours of morning stiffness and ill-defined back pain. Physical exam reveals scaly, erythematous rash on elbows, scalp and behind ears. What are some of the things to consider in your differential diagnosis?
You also need to consider HIV in young people
How do joint and skin disease relate in psoriatic arthritis vs. juvenile rheumatoid arthritis?
In kids the skin condition precedes the joint condition. In adults the joint condition often precedes the skin condition.
What additional changes are seen in psoriatic arthritis?
What are some key factors in differentiating psoriatic arthritis from rheumatoid arthritis?
What are the ABCDES of psoriatic arthritis radiographs?
How do you treat psoriatic arthritis?
Immunosuppressive agents and anti-TNF-alpha drugs
What different symptoms help you differ ankylosing spondylitis, reactive arthritis, psoriatic arthritis and inflammatory bowel disease from one another?
Where does ankylosing spondylitis tend to generate inflammation? What genetic component do they tend to have?
Tendon origins and insertions. They tend to involve HLA B27