Review Article. Appraoch to Patients with Polyarticular Symptoms. Introduction. Raymond WS Wong
|
|
- Gary Preston
- 6 years ago
- Views:
Transcription
1 Review Article Appraoch to Patients with Polyarticular Symptoms Raymond WS Wong Abstract: Keywords: Polyarticular symptoms represent the most common symptom complex resulting in referral to a rheumatologist for consultation. They are not caused only by lesions in the joints but also by a list of other possible pathologies. The approach to patients with polyarticular symptoms is not fundamentally different from the approach to patients with any other medical problem. With a careful history, a good physical examination and appropriate laboratory tests and radiographs, the rheumatologist is very often able to establish eventually the correct diagnosis and institute appropriate therapy. Acute polyarthritis, chronic polyarthritis, inflammatory, non-inflammatory Introduction Chronic pain in and around multiple joints is the most common symptom complex resulting in referral to a rheumatologist for consultation, amounting to 58% in a personal series. This is in accord with the experience of others. The evaluation of chronic polyarthritis is not only the most common intellectual exercise facing the rheumatologist but also one of the most rewarding. Polyarticular symptoms are not caused only by lesions in the joints but also by a list of other possible pathologies as listed in Table 1. Table 1. Differential diagnosis of polyarticular symptoms Polyarthralgia / Polyarthritis Tendonitis and related disorders Fibrositis Muscular disorders Neuropathies Primary bone disease Functional / Psychogenic Unknown origin These problems can be classified into one of the four broad categories: inflammatory, degenerative-metabolic, functional (including neurotic), or of unknown origin. This classification does not deny the existence of an inflammatory component in a degenerative disorder or a degenerative component of inflammatory arthritides. There may be an organic component even in those syndromes listed as 'psychogenic'. Conversely, there is often a functional component to most organic illnesses. The 'unknown' category is important because of the tendency by many clinicians to 'force' a given patient's musculoskeletal complaints into a diagnostic pigeonhole. New syndromes and subsets of old ones are constantly being recognized. Polyarthralgia is defined as pain in 5 or more joints without demonstrable inflammation by physical examination. Polyarthritis is definite inflammation of 5 or more joints demonstrated by physical examination. A patient with 2 to 4 involved joints is said to have pauci- or oligo- articular arthritis. Chronic polyarthritis can be arbitrarily defined as symptoms persisting in the joints for more than 6 weeks. Diseases commonly presenting with acute and chronic polyarthritis are listed in Table 2. DEPARTMENT OF MEDICINE, QUEEN MARY HOSPITAL, 102 POKFULAM ROAD, POKFULAM, HONG KONG SAR Raymond WS Wong FRCP, FHKAM(Medicine) Correspondence to: Raymond WS Wong The approach to patients with polyarticular symptoms is not fundamentally different from the approach to patients with any other medical problem. With a careful history, a good physical examination, and appropriate laboratory tests and radiographs, a physician can establish the diagnosis and begin appropriated therapy in almost all cases. 20 Hong Kong Bulletin on Rheumatic Diseases
2 WONG Table 2. Diseases commonly presenting with acute and chronic polyarticular Diseases commonly presenting with acute polyarticular symptoms Inflammatory conditions Infection Rheumatoid arthritis Gonococcal Systemic lupus erythematosus Meningococcal Reiter's syndrome Lyme's disease Psoriatic arthritis Acute rheumatic fever Polyarticular gout Bacterial endocarditis Viral (esp. rubella, hepatitis B, parvovirus, Epstein-Barr, HIV) Diseases commonly presenting with chronic (persisting >6 weeks) polyarticular symptoms Inflammatory Non-inflammatory Rheumatoid arthritis Osteoarthritis Systemic lupus erythematosus Fibromyalgia Progressive systemic sclerosis Benign hypermobility syndrome Polymyositis Reiter's syndrome Psoriatic arthritis Enteropathic arthritis Polyarticular gout Calcium pyrophosphate deposition (CPPD) disease Vasculitis Polymyalgia rheumatica History Taking The clinical history is by far the most important diagnostic tool in the evaluation of polyarticular disorders. A number of items deserve special attention. One should direct attention to the temporal pattern of the joint involvement. Three distinct patterns are recognized. The additive pattern is used to describe a clinical syndrome which tends to add on features as it flares and to substract these features in a similar manner as it becomes quiescent. This type of pattern is nonspecific and is characteristically seen in rheumatoid arthritis, lupus erythematosus, post-rubella arthritis, and spondylitis. The term migratory polyarthritis should be restricted to describe those situations in which initially inflammed joints totally remit while, simultaneously, other joints become actively inflammed. This pattern is quite unique and strongly suggestive of either acute rheumatic fever or gonococcal arthritis. The palindromic or intermittent pattern describes those conditions associated with repetitive attacks of polyarticular synovitis which completely remit without sequelae or spread to other joints. Typical examples would be gout and rheumatoid arthritis with palindromic onset. Distribution of joint involvement is also helpful in the differential diagnosis of polyarthritis. Different diseases characteristically affect different joints. Knowledge of the typical joints involved in each disease is a cornerstone of diagnosis in polyarthritis. In practice, knowledge of which joints are spared in each form of arthritis is also quite useful. Tables 3 & 4 list out some of the common examples. Accordingly, deformities of elbows, wrists or MCPs are not just due to 'wear and tear' but to a synovitic process. Similarly, low back pain in a patient with RA is usually caused by another cause and a patient with polyarticular pain involving the jaws and the hips is not suffering from gout. Specific joint symptoms should also be asked for and would prove fruitful. These include early morning stiffness, locking, giving way and the pattern of therapeutic response. Early morning stiffness refers to the amount of time it takes for Volume 2, No. 1, July
3 APPROACH TO POLYARTICULAR SYMPTOMS Table 3. Specific joint involvement in polyarthritis Joints involved Common with Not seen in Temporomandibular Rheumatoid arthritis, juvenile rheumatoid arthritis, psoriasis Gout, myalgias Elbows, wrists, Any synovitis Osteoarthritis metacarpophalangeals Hips Nonspecific Gout Ankles (only) Erythema nodosum Cricoarytenoid Rheumatoid arthritis All other Talonavicular Rheumatoid arthritis Cervical spine Rheumatoid arthritis, juvenile rheumatoid arthritis, psoriasis, Gout, gonococcal osteoarthritis, spondylitis, myalgias Thoracolumbar spine Spondylitis : Gout Ankylosing spondylitis Rheumatoid arthritis Psoriasis Reiter's syndrome Inflammatory bowel disease Table 4. Distribution of joint involvement in polyarthritis Disease Joints commonly involved Joints commonly spared Osteoarthritis First CMC, DIP, PIP, cervical spine, MCP, wrist, elbow, glenohumeral, ankle, thoracolumbar spine, hip, knee, first MTP, toe IP tarsal Rheumatoid arthritis Wrist, MCP, PIP, elbow, glenohumeral, cervical DIP, thoracolumbar spine spine, hip, knee, ankle, tarsal, MTP Polyarticular gout First MTP, instep, heel, ankle, knee Axial Gonococcal arthritis Knee, wrist, ankle, hand IP Axial Lyme arthritis Knee, shoulder, wrist, elbow Axial patients to 'limber up' after arising in the morning. Significant morning stiffness lasting for more than one hour tends to differentiate the chronic inflammatory process from other disorders. Its duration tends to parallel the severity of the synovitis. Its duration serves as a useful parameter in evaluating the effectiveness of anti-inflammatory therapy. Symptom of 'giving way' without warning usually suggests an unstable joint with muscle weakness whereas 'giving way' as a result of pain would mean meniscus tear or presence of loose bodies. Symptom of locking is said to be present when the patient is unable to take a joint smoothly through its complete range of motion. It may be due to internal derangement such as cartilage tear or extraarticular soft tissue blockage such as trigger finger. Pattern of therapeutic response is also frequently useful in the differential diagnosis. The typical example would be seen in the highly specific dramatic response of acute rheumatic fever to aspirin. Another situation is the rapid and dramatic response of polymyalgia rheumatica to prednisolone at a dose of 10 to 20 mg per day. Although colchicine is meant to be specific to treat gouty symptoms, it is also worth remembering that a sizable proportion of gouty attacks do not respond. Conversely, a patient with pseudogout may respond to colchicine. Again, although steroid is not recommended as the first line treatment, prednisone dose of about 20 mg per day will usually and invariably abort the synovitic features of SLE and RA completely but often will have little effect on the synovitis of the spondyloarthropathies. Another useful practical point to remember is that indocid is usually 22 Hong Kong Bulletin on Rheumatic Diseases
4 WONG dramatically more effective than other NSAIDs in gout and spondyloarthropathies. Systemic symptoms such as fever, night sweats and weight loss should be sought specifically and, when possible, quantified. Patients, unless asked, somehow often do not perceive relationships between joint pain and these symptoms. Presence of such features should prompt a thorough search for more sinister pathologies including infections, systemic rheumatic diseases or even malignancies. Rheumatic disease systems review is equally important. Thus, in addition to systemic symptoms, patients must be asked specifically about conditions associated with various forms of arthritis, including rash (photosensitive, psoriatic, purpuric, or petechial), areas of alopecia, Raynaud's phenomenon, sicca syndrome, uveitis, scleritis, oral and genital ulcers, urethritis or cervicitis, symptoms of inflammatory bowel disease, and pleuropericardial symptoms. In addition to asking about any type of arthritis in the family, one should inquire about a family history of any associated condition, such as psoriasis, uveitis, or inflammatory bowel disease. In patients suspected of having ankylosing spondylitis, it is important to obtain the history of any family members with chronic back pain and then to attempt to determine the nature of that condition. Differentiating features in the symptomatology among the different categories of polyarticular symptoms are summarized in Table 5. Physical Examination Both comprehensive musculoskeletal examination and complete systemic examination are essential. Each joint should be examined for warmth, synovial thickening, effusions, crepitation, deformity, and tenderness. Both active and passive range of motion should be tested. The spinal examination should include the range of motion of the cervical and lumbar regions, chest expansion, tenderness of the spinous processes and sacroiliac joints, abnormal curves and muscle spasms. Particular attention is given to sites about which the patient specifically complains or those having abnormalities of which the patient is often unaware. Each clinician should develop a standard, disciplined routine examination of the musculoskeletal system as for the abdominal and chest examination. The approach may differ among individual physicians, but it should be the same for a given clinician each time they lay hands on a patient. Typical joint deformities would alert one to the diagnosis of a specific collagen vascular problem, the classical example Table 5. Symptoms useful in differential diagnosis of polyarthritis Symptoms Degenerative Inflammatory Psychogenic Stiffness (duration) Few minutes; "gelling" after Hours (often); most pronounced Little or no variation in intensity prolonged rest after rest with rest or activity Pain Follows activity; relieved by rest Even at rest; nocturnal pain Little or no variation in intensity Flares not seen May interfere with sleep with rest or activity Variable course Flares common Progressively worsening course Often favorable response to medical therapy Weakness Present, usually localized and not Often pronounced Often a complaint; severe "neurasthenia" Fatigue Not usual Often severe with onset in early Often in mornings on arising afternoon Emotional depression Not usual Common; coincides with fatigue; often Often present and lability disappears if disease remits Volume 2, No. 1, July
5 APPROACH TO POLYARTICULAR SYMPTOMS being rheumatoid arthritis. However, one should also be careful of not jumping to conclusion on spotting a specific physical sign. For instance, swan neck deformity does not equate the diagnosis of rheumatoid arthritis. As listed in Table 6, there are many other conditions which can be associated with swan neck deformity. A good physical examination would enable one to differentiate among various kinds of polyarthritis. Relevant useful signs are summarized in Table 7. Lesions of other organ systems should be carefully sought for. Dermatological manifestations often give tell tale clues to the underlying causes of polyarthritis. Notable examples are butterfly rash in SLE, tightness of skin in scleroderma, and heliotropic rash on eyelids in dermatomyositis. It is easy to miss small patches of psoriasis especially if they are located in the more occult areas such as the perianal and inframammary regions. Subtle nail changes should also be watched out for. The genital area is often omitted during routine examination to avoid causing embarrassment to the patient. However, in selected patients, this may reveal the genital ulcers of Behcet's disease or circinate balanitis in patients with Reiter's syndrome. The physician should provide adequate explanation and obtain consent from the patient before proceeding with the examination in an appropriate clinical environment. Investigations Non specific tests of inflammation may help to differentiate between inflammatory and non-inflammatory causes for the polyarticular symptoms. These tests include complete blood counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum albumin/globulin (A/G) ratio. Anemia, leucocytosis, thrombocytosis, raised ESR and CRP, reversed A/G ratio are all indicative of the presence of an underlying active inflammation. Checking for autoantibody profile may be helpful in specific diseases. Autoantibodies may have a role in diagnosis, in predicting patterns of disease expression and prognosis and in assessing disease activity. These tests must be ordered wisely because the background false positive rate can be quite high. For example, a positive rheumatoid factor may be more helpful in young persons, in whom background positivity is low whereas a negative result is not helpful in individual cases. On the other hand, a high titre of antinuclear antibody is suggestive of a rheumatic disease and a negative test virtually rules out active systemic lupus. If obtainable and when indicated, synovial fluid should be examined. The primary benefit of synovial fluid examination is to differentiate among non inflammatory, inflammatory and infective arthritis. Table 6. Disorders associated with swan neck deformity Rheumatologic diseases Rheumatoid arthritis Systemic lupus erythematosus Postrheumatic fever (Jaccoud arthropathy) Psoriatic arthritis Gout Polymyositis Table 7. Signs useful in differential diagnosis of polyarthritis Signs Degenerative Inflammatory Psychogenic Tenderness localized Usually present Almost always; the most sensitive Tender "all over', "touch-me-not over afflicted joint indication of inflammation attitude"; tendency to push away or to grasp the examining hand Swelling Effusion common; little synovial Effusion common; often synovial None reaction proliferation and thickening Heat and erythema (skin) Unusual but may occur More common None Crepitus Coarse to medium Medium to fine None, except with coexistent arthritis Bony spurs Common Sometimes found, usually with None, except with coexistent antecedent osteoarthritis osteoarthritis 24 Hong Kong Bulletin on Rheumatic Diseases
6 WONG In many cases, properly chosen radiological investigations are virtually diagnostic or eliminate certain diseases from further consideration. Imaging techniques for evaluation of polyarticular symptoms include conventional radiography, radionuclide joint imaging, arthrography, quantitative bone mineral analysis, computed tomography (CT) and magnetic resonance imaging (MRI). In addition to being diagnostically helpful, radiological assessment may also help to monitor disease progress and treatment response as well as to delineate systemic complications of the underlying rheumatic disease. Conclusion Polyarticular symptom is the most common indication for rheumatologic consultation. It represents a challenge to the skills and experience of the rheumatologist. It is soothing to note that by careful history taking and physical examination along with relevant investigations, the rheumatologist is very often able to establish eventually the correct diagnosis and institute appropriate therapy. Further Readings 1. Maddison PJ, Isenberg DA, Woo P, Glass DN (eds). Oxford Textbook of Rheumatology. Oxford University Press 1998, pp & Ruddy S, Harris ED Jr, Sledge CB (eds). Textbook of Rheumatology. W. B. Saunders Company 2001, pp Koopman WJ (ed). Arthritis and allied conditions. Williams & Wilkins 2001, pp West SG. Rheumatology secrets. Hanley & Belfus, inc. 1997, pp Volume 2, No. 1, July
How do polyarthritis, polyarthralgias, and diffuse aches and pains differ?
Approach to the patient with polyarthritis How do polyarthritis, polyarthralgias, and diffuse aches and pains differ? Polyarthritis is definite inflammation (swelling, tenderness, warmth) of more than
More informationWhat organ system is involved? What is the pathology? What is the possible etiology?
Johan van Rensburg What organ system is involved? What is the pathology? What is the possible etiology? Genetic Environmental What are the possible complications? How is the patient s functioning impaired?
More informationUnderstanding Rheumatoid Arthritis
Understanding Rheumatoid Arthritis Understanding Rheumatoid Arthritis What Is Rheumatoid Arthritis? 1,2 Rheumatoid arthritis (RA) is a chronic autoimmune disease. It causes joints to swell and can result
More informationPatient #1. Rheumatoid Arthritis. Rheumatoid Arthritis. 45 y/o female Morning stiffness in her joints >1 hour
Patient #1 Rheumatoid Arthritis Essentials For The Family Medicine Physician 45 y/o female Morning stiffness in her joints >1 hour Hands, Wrists, Knees, Ankles, Feet Polyarticular, symmetrical swelling
More informationObjectives. Joint Pain. Case 1. Rheumatology for the Primary MD (Not just your grandmother s disease) 12/4/2010
Objectives Rheumatology for the Primary MD (Not just your grandmother s disease) Identify when it is appropriate to refer for rheumatologic evaluation Autoimmune/ Inflammatory v. noninflammatory disease
More informationRHEUMATOLOGY OVERVIEW. Carmelita J. Colbert, MD Assistant Professor of Medicine Division of Rheumatology Loyola University Medical Center
RHEUMATOLOGY OVERVIEW Carmelita J. Colbert, MD Assistant Professor of Medicine Division of Rheumatology Loyola University Medical Center What is Rheumatology? Medical science devoted to the rheumatic diseases
More informationJeopardy. What s the rash? $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400
Jeopardy Antibodies & more antibodies Aching joints What s the rash? Potpourri Image Challenge $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500
More information2/23/18. Disclosures. Rheumatic Diseases of Childhood. Making Room for Rheumatology. I have nothing to disclose. James J.
Making Room for Rheumatology James J. Nocton, MD Disclosures I have nothing to disclose Rheumatic Diseases of Childhood Juvenile Idiopathic Arthritis (JIA) Systemic Lupus Erythematosus (SLE) Juvenile Dermatomyositis
More informationJoint Injuries and Disorders
Joint Injuries and Disorders Introduction A joint is where two or more bones come together. Your joints include the knees, hips, elbows and shoulders. There are many types of joint disorders, including
More informationKelley's Textbook of Rheumatology. 2 Volume Set. Text with Internet Access Code for Premium Consult Edition
Kelley's Textbook of Rheumatology. 2 Volume Set. Text with Internet Access Code for Premium Consult Edition Firestein, G ISBN-13: 9781437717389 Table of Contents VOLUME I STRUCTURE AND FUNCTION OF BONE,
More informationPhysical examination of the musculosceletal- and nervous system. Pánczél Pál dr.
Physical examination of the musculosceletal- and nervous system in the practice of internal medicine. Pánczél Pál dr. Bursae = sacks of the synovial membrane fulfilled with synovium. Localised between
More informationAPPROACH TO PATIENTS WITH POLYARTHRALGIA
APPROACH TO PATIENTS WITH POLYARTHRALGIA Scott Vogelgesang, MD Division of Immunology University of Iowa No conflicts of interest DEFINITIONS Arthralgia joint pain with no evidence of inflammation Arthritis
More informationEssential Rheumatology. Dr Ellen Bruce Consultant Rheumatologist CMFT
Essential Rheumatology Dr Ellen Bruce Consultant Rheumatologist CMFT Saving the best for last! Apparently people recall best the first and last thing they re told. Far too difficult to include everything.
More informationApproach to Arthritis
Approach to Arthritis Dr. V. Krishnamurthy M. D., D. M. (Rheumatology) Rheumatologist, Chennai Meenakshi Multispecialty Hospital Rheumatologist, Meenakshi Academy of Higher Education (MAHER), Apollo Specialty
More informationJoint Disorders. Musculoskeletal Disorders (Part B-2) Module 7 -Chapter 10. Overview Disorders of the Muscular System Disorders of the Skeletal System
Musculoskeletal Disorders (Part B-2) Module 7 -Chapter 10 Overview Disorders of the Muscular System Disorders of the Skeletal System Susie Turner, MD 1/9/13 Joint Disorders Arthritis Inflammation of Joint
More informationMary Derlacki, FNP. No financial relationships to disclose. Office Rheumatology for the Nurse Practitioner. Rheumatoid Arthritis
Office Rheumatology for the Nurse Practitioner Mary Derlacki, FNP Drs. Cassell and Boren Eugene, OR 541-687-0816 mderlacki@comcast.net No financial relationships to disclose Rheumatoid Arthritis 1% of
More informationHistory Taking and the Musculoskeletal Examination
History Taking and the Musculoskeletal Examination Introduction A thorough rheumatologic assessment is performed within the context of a good general evaluation of the patient. The patient should be undressed
More informationArticular disease of the hand - the target joint approach
Articular disease of the hand - the target joint approach Poster No.: C-1817 Congress: ECR 2016 Type: Educational Exhibit Authors: R. R. Domingues Madaleno 1, A. P. Pissarra 1, I. Abreu 2, A. Canelas 1,
More informationMusculoskeletal Referral Guidelines
Musculoskeletal Referral Guidelines Introduction These guidelines have been developed to provide an integrated musculoskeletal service. They are based on reasonable clinical practice and will initially
More informationThe Joints are Painful & Swollen: Do I give Steroids? Dr Tom Kennedy
The Joints are Painful & Swollen: Do I give Steroids? Dr Tom Kennedy Learning Objectives When to use an acute rheumatology service Appropriate use of steroids by condition Injection or Oral or Intramuscular
More informationRheumatoid Arthritis. Rheumatoid Arthritis. RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling. Rheumatic Diseases
RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Rheumatic Diseases The prevalence of rheumatoid arthritis in most Caucasian populations approaches 1% among adults 18 and over and
More informationREFERRAL GUIDELINES: RHEUMATOLOGY
Outpatient Page 1 1 REFERRAL GUIDELINES: RHEUMATOLOGY Date of birth Demographic Contact details (including mobile phone) Clinical Reason for referral Duration of symptoms Essential Referral Content Referring
More informationSystemic forms of stiffness
Systemic forms of stiffness ANNA LITWIC CONSULTANT RHEUMATOLOGIST SALISBURY DISTRICT HOSPITAL CLINICAL RESEARCH FELLOW MRC LIFECOURSE EPIDEMIOLOGY UNIT Overview Rheumatoid arthritis Know it when you see
More informationEtiology: Pathogenesis Clinical manifestation Investigation Treatment Prognosis
Etiology: Pathogenesis Clinical manifestation Investigation Treatment Prognosis JIA is the most common rheumatic disease in childhood and a major cause of chronic disability. Etiology: Unknown, but may
More informationRheumatology Cases for the Internist
Rheumatology Cases for the Internist Marc C. Hochberg, MD, MPH Professor of Medicine Head, Division of Rheumatology and Clinical Immunology Vice Chair, Department of Medicine University of Maryland School
More informationCase reports CASE 1. A 67-year-old white man had back pain since the age. our clinic several years later with progressive symptoms.
Annals of the Rheumatic Diseases, 1982, 41, 574-578 Late-onset peripheral joint disease in ankylosing spondylitis MARC D. COHEN AND WILLIAM W. GINSBURG From the Division ofrheumatology and Internal Medicine,
More informationBY Mrs. K.SHAILAJA., M. PHARM., LECTURER DEPT OF PHARMACY PRACTICE, SRM COLLEGE OF PHARMACY
BY Mrs. K.SHAILAJA., M. PHARM., LECTURER DEPT OF PHARMACY PRACTICE, SRM COLLEGE OF PHARMACY Definition and Risk Factors Idiopathic vs. Secondary OA Clinical Features Diagnosis Radiologic Features ACR OA
More informationRheumatoid Arthritis. Marge Beckman FALU, FLMI Vice President RGA Underwriting Quarterly Underwriting Meeting March 24, 2011
Rheumatoid Arthritis Marge Beckman FALU, FLMI Vice President RGA Underwriting Quarterly Underwriting Meeting March 24, 2011 The security of experience. The power of innovation. www.rgare.com Case Study
More informationThe diagnostic challenge of joint pain part 2
Musculoskeletal 407 The diagnostic challenge of joint pain part 2 Polyarthralgia is a common presentation in primary care. Because chronic arthritides may present abruptly, they need to be considered in
More informationUltrasound in Rheumatology
Arthritis Research UK Primary Care Centre Winner of a Queen s Anniversary Prize For Higher and Further Education 2009 Ultrasound in Rheumatology Alison Hall Consultant MSK Sonographer/Research Fellow Primary
More informationA Patient s Guide to Spondyloarthropathies
A Patient s Guide to Spondyloarthropathies 763 Larkfield Road 2nd Floor Commack, NY 11725 Phone: (631) 462-2225 Fax: (631) 462-2240 DISCLAIMER: The information in this booklet is compiled from a variety
More informationWhen is it Rheumatoid Arthritis When to Refer
When is it Rheumatoid Arthritis When to Refer Nancy A. Brown, DO Spring 2015 When is it Rheumatoid Arthritis When to Refer Learning objectives To review the definition and epidemiology of Rheumatoid Arthritis
More informationJuvenile Spondyloarthritis / Enthesitis Related Arthritis (SpA-ERA)
www.printo.it/pediatric-rheumatology/gb/intro Juvenile Spondyloarthritis / Enthesitis Related Arthritis (SpA-ERA) Version of 2016 1. WHAT IS JUVENILE SPONDYLOARTHRITIS/ENTHESITIS- RELATED ARTHRITIS (SpA-ERA)
More informationwww.fisiokinesiterapia.biz Peak onset between 20 and 30 years Form of spondyloarthritis (cause inflammation around site of ligament insertion into bone) and association with HLA-B27 Prevalence as high
More informationRheumatoid Arthritis
Rheumatoid Arthritis What is rheumatoid arthritis? Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of
More informationDepartment of Paediatrics Clinical Guideline. Guideline for the child with possible arthritis (joint swelling/pain, loss of function)
Department of Paediatrics Clinical Guideline Guideline for the child with possible arthritis (joint swelling/pain, loss of function) Definition: Juvenile Idiopathic Arthritis (JIA) is defined as arthritis
More informationWhere has SARA gone? Prof. David Kane Consultant Rheumatologist Beacon & Tallaght Hospitals. Clinical Professor in Rheumatology Trinity College Dublin
Where has SARA gone? Prof. David Kane Consultant Rheumatologist Beacon & Tallaght Hospitals Clinical Professor in Rheumatology Trinity College Dublin 1 Reactive Arthritis Seronegative Asymmetrical Arthritis
More informationMr. OA: Case Presentation
CLINICAL CASES Case 1: Mr. OA OA Mr. OA: Case Presentation 62-year-old lawyer Mild left knee pain for 3 month, but became worse 1 week ago No swelling 1 week earlier: 2-hour walk in the countryside 2 days
More informationJuvenile Idiopathic Arthritis (JIA)
Juvenile Idiopathic Arthritis (JIA) Kaveh Ardalan, MD, MS Division of Rheumatology Ann & Robert H. Lurie Children s Hospital of Chicago Assistant Professor, Pediatrics and Medical Social Sciences Northwestern
More informationFirst Presentation of Joint Pain
First Presentation of Joint Pain Andrew Harrison Rheumatologist Wellington Regional Rheumatology Unit, HVDHB Bowen Centre, Crofton Downs, Wellington Assoc. Prof. in Medicine, University of Otago Wellington
More informationRheumatology: 1. Is it arthritis?
Clinical basics Rheumatology: 1. Is it arthritis? Stephanie Ensworth Case 1 A 29-year-old woman consults her physician 2 months after the birth of her second child because she woke one morning with pain
More informationAches and Pains in Rheumatology: Is it Fibromyalgia, Osteoarthritis, or Rheumatoid Disease?
Aches and Pains in Rheumatology: Is it Fibromyalgia, Osteoarthritis, or Rheumatoid Disease? SCOTT T ANDERSON, MD, PHD, FACR, CCHP-P CLINICAL PROFESSOR Menu(rotating) DIVISION OF RHEUMATOLOGY, ALLERGY,
More informationDepartment of Paediatrics Clinical Guideline
Department of Paediatrics Clinical Guideline The child and young person with possible arthritis (joint swelling and/or pain, loss of function for >4 weeks) Definition: Juvenile Idiopathic Arthritis (JIA)
More informationARTHRITIS. What Is Arthritis?
There are many types of arthritic processes that can cause joint changes, pain and loss of motion and strength in the hands. Many excellent and detailed resources are available and will be listed under
More informationTypes of osteoarthritis
ARTHRITIS Osteoarthritis is a degenerative joint disease is the most common joint disorder. It is a frequent part of aging and is an important cause of physical disability in persons older than 65 years
More informationCLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION
Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 7/28/2012 Radiology Quiz of the Week # 83 Page 1 CLINICAL PRESENTATION AND RADIOLOGY
More informationThe Johns Hopkins Hospital
The Johns Hopkins Hospital 19901006 2016/03/21-04/20 (rheumatology) (emergecny medicine) (rheumatology consult team) attending Dr. Haque, R2 Dr. Michailidou, fellow Dr. Adler "She is a so interesting case.
More information1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown
Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 43 Caring for Clients with Musculoskeletal Disorders Scoliosis Diagnosed in adolescence More common in
More informationRheumatoid Arthritis
Rheumatoid Arthritis Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly
More information1 Eileen Ginsburg, DNP, FNP-BC, ARNP 10/10/2018
Rheumatology labs: Which to order and what do I do with the results? 1 Eileen Ginsburg, DNP, FNP-BC, ARNP 2 OBJECTIVES: By the end of the lecture you will 1. be able to decide which labs you want to order
More informationJuvenileIdiopathicArthritis. Dr Johan Siebert
JuvenileIdiopathicArthritis Dr Johan Siebert 1 NORMAL DIARTHRODIAL JOINT Synovial is a thin membrane enclosing the joint space The joint space contains fluid that bathes the joint and reduces friction
More informationA CRP B FBC C LFT D blood culture E uric acid
1 A 39 year old lady with rheumatoid arthritis is admitted to hospital with a hot, swollen and painful right knee. Which is the most important blood test? A CRP B FBC C LFT D blood culture E uric acid
More informationDifferential diagnostics in Rheumatology
Differential diagnostics in Rheumatology number of affected joints lengths of duration Acute monoarthritis Chronic monoarthritis Acute polyarthritis Chronic polyarthritis Acute monoarthritis Infective
More informationPhysical diagnosis of musculoskeletal system. Dr. Szathmári Miklós Semmelweis University First Department of Medicine 1. Dec
Physical diagnosis of musculoskeletal system Dr. Szathmári Miklós Semmelweis University First Department of Medicine 1. Dec. 2015. Evaluation of patients with musculoskeletal complaints Anatomic localization
More informationSalisbury Foundation Trust Radiology Department Referral Guidelines for Primary Care: Musculoskeletal Imaging
Salisbury Foundation Trust Radiology Department Referral Guidelines for Primary Care: Musculoskeletal Imaging These guidelines have been issued in conjunction with the Royal College of Radiology referral
More informationRheumatology for the Nurse Practitioner. Mary Derlacki, FNP Eugene Rheumatology
Rheumatology for the Nurse Practitioner Mary Derlacki, FNP Eugene Rheumatology Financial Relationships Amgen Genentech AbbVie IS THIS LUPUS? S.T. is a 45 y/o woman with 9 months of joint pain, fatigue,
More informationArthritis Rheumatism Psoriasis
Arthritis Rheumatism Psoriasis 1 / 6 2 / 6 3 / 6 Arthritis Rheumatism Psoriasis You may think that arthritis is a single condition, but there are many forms of arthritis. Each type can be caused by different
More informationArthritis. that affects the joints.
Arthritis that affects the joints. The word arthritis literally means inflammation of the joints. Though joint inflammation is often a symptom, rather than a specific diagnosis itself, the term arthritis
More informationJUVENILE SPONDYLOARTHROPATHIES
www.pediatric-rheumathology.printo.it JUVENILE SPONDYLOARTHROPATHIES What is it? The juvenile spondyloarthropathies constitute are a group of chronic inflammatory diseases of the joints (arthritis) and
More informationRheumatology Review Update in Internal Medicine COPYRIGHT. Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center.
Rheumatology Review Update in Internal Medicine Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center Boston MA Case #1 True statement(s) regarding etanercept and leflunomide, for the treatment
More informationRheumatology Pearls 1) A detailed history is much more useful in the work up of patients with inflammatory peripheral arthritis than any lab tests.
Rheumatology Pearls 1) A detailed history is much more useful in the work up of patients with inflammatory peripheral arthritis than any lab tests. Features suggestive of an inflammatory arthritis that
More informationUltrasound in Rheumatology
Ultrasound in Rheumatology Alison Hall Consultant MSK Sonographer Research Institute for Primary Care & Health Sciences, Keele University Department of Rheumatology, Cannock Hospital, Royal Wolverhampton
More informationIndex. Note: Page numbers of article titles are in boldface type.
Index Note: Page numbers of article titles are in boldface type. A Abatacept, for rheumatoid arthritis, 789 Acetaminophen, for low back pain, 735 Acupuncture for fibromyalgia, 753 for low back pain, 738
More informationSeronegative spondyloarthropathies : A Pictorial Review
Seronegative spondyloarthropathies : A Pictorial Review Poster No.: P-0008 Congress: ESSR 2012 Type: Scientific Exhibit Authors: J. Acosta Batlle, B. Palomino Aguado, M. D. Lopez Parra, S. 1 2 3 2 4 1
More informationAUTOIMMUNE DISORDERS IN THE ACUTE SETTING
AUTOIMMUNE DISORDERS IN THE ACUTE SETTING Diagnosis and Treatment Goals Aimee Borazanci, MD BNI Neuroimmunology Objectives Give an update on the causes for admission, clinical features, and outcomes of
More informationApproach to Polyarthritis for the Primary Care Physician
24 Osteopathic Family Physician Volume 10, No. 5 September / October, 2018 Osteopathic Family Physician (2018) 24-31 REVIEW ARTICLE Arielle Freilich, DO, PGY2 & Helaine Larsen, DO Good Samaritan Hospital
More informationA Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH)
A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH) 6565 Fannin Street Houston, TX 77030 Phone: 713-790-3333 DISCLAIMER: The information in this booklet is compiled from a variety of sources.
More informationCLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION
Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 12/01/2012 Radiology Quiz of the Week # 101 Page 1 CLINICAL PRESENTATION AND RADIOLOGY
More information8/29/2012. Outline Juvenile idiopathic arthritis. 1. Classification-ILAR. 1. Classification-clinical diagnosis. 1. JIA classification
Outline Juvenile idiopathic arthritis 1. Classification and symptoms (ILAR-International league of Associations for Rheumatology) 2. Imaging J. Herman Kan, M.D. Section chief, musculoskeletal imaging Edward
More informationFinancial Report. Moving Together
Financial Report 2013 Moving Together Our Purpose To improve the quality of life of people who have, or are at risk of developing musculoskeletal conditions. Our Values Respect and integrity Service and
More informationBIOS222 Pathology and Clinical Science 2 & 3
BIOS222 Pathology and Clinical Science 2 & 3 Session 10 Disorders of Musculoskeletal System 1 Bioscience Department www.endeavour.edu.au Session Learning Outcomes At the end of the session, you should
More informationThe Painful Elbow, Wrist, and Hand. Jennifer R Marks, MD
The Painful Elbow, Wrist, and Hand Jennifer R Marks, MD The Painful Elbow A 44 yo M presents to clinic complaining of a sore elbow What further questions do you have for this patient? What is on your differential
More informationRheumatology Educational Goals & Objectives
Rheumatology Educational Goals & Objectives Musculoskeletal complaints are very common in the practice of primary care. They may reflect overuse or trauma, or be a manifestation of a broad range of musculoskeletal
More informationWhat is Axial Spondyloarthritis?
Physiotherapist Module 2 What is Axial Spondyloarthritis? How does it apply to physiotherapists? Claire Harris, Senior Physiotherapist, London North West Healthcare NHS Trust Susan Gurden, Advanced Physiotherapy
More informationREACTIVE ARTHRITIS ARTHRITIS FOUNDATION
ARTHRITIS FOUNDATION Registered Nonprofit Organisation - No. 002-847 NPO Helpline No: 0861 30 30 30 REACTIVE ARTHRITIS This information leaflet is published by the Arthritis Foundation as part of our continuing
More informationAPPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY
APPLICANT (stamp sticker acceptable) Page 1 Fm SA1620 Etanercept INITIAL APPLICATION - juvenile idiopathic arthritis Applications only from a named specialist rheumatologist. Approvals valid f 6 months.
More informationPalindromic rheumatism
1 What is palindromic rheumatism? The term palindromic rheumatism (also known as palindromic arthritis ) describes a form of joint pain that comes and goes in cycles or episodes, generally starting in
More informationPatient with Musculo-skeletal Complaints - Summary
Patient with Musculo-skeletal Complaints - Summary 1. Soft Tissue Rheumatism or Arthritis 2. Arthritis Monoarticular Polyarticular - :- (Asymmetrical) (Symetrical) :- -Crystals, Gout - Infective acute
More informationInflammatory rheumatic diseases
Learning objectives Inflammatory rheumatic diseases Bruce Kidd Barts & The London, Queen Mary, University of London To understand: 1. prevalence and range of the rheumatological s 2. clinical features
More informationJuvenile Chronic Arthritis
Juvenile Chronic Arthritis Dr. Christa Visser MBChB MMed (Med Phys) Diploma Musculoskeletal Medicine (UK), Member Society of Orthopaedic Medicine (UK) Childhood Arthritis JCA/JIA/JRA Remember Acute rheumatic
More informationMSK Module 15 CBC Orthopaedic Surgery. Medical Expert & Scholar Objectives General
MSK Module 15 CBC Orthopaedic Surgery Medical Expert & Scholar Objectives General The following competencies will assist in satisfying the CanMeds objectives for medical expert including scholarship. It
More informationGrowing Pains in Children 1.0 Contact Hour Presented by: CEU Professor
Growing Pains in Children 1.0 Contact Hour Presented by: CEU Professor 7 www.ceuprofessoronline.com Copyright 8 2008 The Magellan Group, LLC All Rights Reserved. Reproduction and distribution of these
More informationDifferential Diagnosis And Tests Of Rheumatoid Arthritis And Its Implication For Physiotherapy
Differential Diagnosis And Tests Of Rheumatoid Arthritis And Its Implication For Physiotherapy Onwunzo Chinelo Nkemdilim Physiotherapy Unit, General Hospital Ekwulobia, Ministry of Health, Awka, Anambra
More informationRheumatoid arthritis and Psoriatic arthritis: a guide for Primary Care. Nina Flavin, MD Rheumatology Confluence Health April 13 th, 2018
Rheumatoid arthritis and Psoriatic arthritis: a guide for Primary Care Nina Flavin, MD Rheumatology Confluence Health April 13 th, 2018 No Disclosures Objectives Recognize early signs of RA/PsA what to
More informationPolymyalgia rheumatica and giant cell arteritis
Polymyalgia rheumatica and giant cell arteritis What is polymyalgia rheumatica? Polymyalgia rheumatica is a rheumatic disorder associated with moderate-to-severe musculoskeletal pain and stiffness in the
More informationSEPTIC ARTHRITIS. Dr Ahmed Husam Al Ahmed Rheumatologist SYRIA. University of Science and technology Hospital Sanaa Yemen 18/Dec/2014
SEPTIC ARTHRITIS Dr Ahmed Husam Al Ahmed Rheumatologist SYRIA University of Science and technology Hospital Sanaa Yemen 18/Dec/2014 Objectives be able to define Septic Arthritis know what factors predispose
More informationExamining the prevalence of rheumatoid arthritis in data from the Clinical Practice Research Datalink
Examining the prevalence of rheumatoid arthritis in data from the Clinical Practice Research Datalink Julian Gardiner, Michael Soljak, Department of Primary Care & Public Health Benjamin Ellis, Arthritis
More informationRheumatoid Arthritis
Rheumatoid Arthritis Introduction Rheumatoid arthritis is a fairly common joint disease that affects up to 2 million Americans. Rheumatoid arthritis is one of the most debilitating forms of arthritis.
More informationManifestations and Presentations of Collagen Vascular Diseases. Joseph LaConti, M.D., Ph.D. Center for Arthritis and Rheumatic Diseases Miami, FL
Manifestations and Presentations of Collagen Vascular Diseases Joseph LaConti, M.D., Ph.D. Center for Arthritis and Rheumatic Diseases Miami, FL June 29, 2018 Disclosures Joseph LaConti, M.D., Ph.D., has
More informationRheumatoid Arthritis. Manish Relan, MD FACP RhMSUS Arthritis & Rheumatology Care Center. Jacksonville, FL (904)
Rheumatoid Arthritis Manish Relan, MD FACP RhMSUS Arthritis & Rheumatology Care Center. Jacksonville, FL (904) 503-6999. 1 Disclosures Speaker Bureau: Abbvie 2 Objectives Better understand the pathophysiology
More informationMissed, Misdiagnosed & Mistreated: De-Mystifying Three Common Rheumatic Diseases
Missed, Misdiagnosed & Mistreated: De-Mystifying Three Common Rheumatic Diseases Cong-Qiu Chu, MD, PhD Assistant Professor of Medicine Oregon Health & Science University and Portland VA Medical Center
More informationDifferential Diagnosis of Polyarthritis/Polyarthralgia
Differential Diagnosis of Polyarthritis/Polyarthralgia Robert P. Friday, M.D., Ph.D. Newton-Wellesley Hospital Rheumatology Mass General Hospital Rheumatology None. Disclosures Polyarthritis Outline 1.
More informationDifferential Diagnosis of Polyarthritis/Polyarthralgia
Differential Diagnosis of Polyarthritis/Polyarthralgia Robert P. Friday, M.D., Ph.D. Newton-Wellesley Hospital Rheumatology Mass General Hospital Rheumatology None. Disclosures Polyarthritis Outline 1.
More information2018 ReachMD Page 1 of 10
Transcript Details This is a transcript of a continuing medical education (CME) activity accessible on the ReachMD network. Additional media formats for the activity and full activity details (including
More informationAdditional File 1. ICD9 Codes for chronic pain related diagnoses Dx Diagnosis Description Codes
Additional File 1. ICD9 Codes for chronic pain related diagnoses Dx Diagnosis Description Dx Diagnosis Description Codes Codes 327.52 Sleep related leg cramps 717 Old bucket handle tear of medial 333.84
More information37 year old male with several year history of back pain
37 year old male with several year history of back pain Inflammatory Low Back Pain Clues onset before the age of 40 years insidious onset, chronic (>3 months) pain morning stiffness for longer than 30
More informationRelation between psoriasis and psoriatic arthritis: A study of 40 patients
2018; 2(4): 43-47 ISSN (P): 2521-3466 ISSN (E): 2521-3474 Clinical Orthopaedics www.orthoresearchjournal.com 2018; 2(4): 43-47 Received: 19-08-2018 Accepted: 23-09-2018 Dr. Hardik Sethi Orthopaedics, Govt.
More informationBones? Did someone say bones? 12/31/2012. W.R Reinus, MD MBA FACR
William R. Reinus, MD MBA FACR Temple University Medical Center Aug 2012 (55) 1 Bones? Did someone say bones? 2 ABC S OF ARTHRITIS Arthritis: By definition, any disease that is jointcentered: Both sides
More informationaxial spondyloarthritis including ankylosing spondylitis
1 What is spondyloarthritis? Spondyloarthritis is a general term that describes a number of types of inflammatory arthritis which share many articular and extra-articular features. Conditions which fall
More information