What organ system is involved? What is the pathology? What is the possible etiology?

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1 Johan van Rensburg

2 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?

3 General algorithm Pain and Stiffness Is it likely to be a musculoskeletal problem? Are the symptom's from his/her joints, muscles/soft tissues or bone? Joints Muscles/Soft tissues Inflammatory Degenerative Local/Regional Generalized Bone What tipe of metabolic disease? Osteoporosis?

4 Arthritis Degenerative Osteoartritis Inflammatory Rheumatoid arthritis Seronegative spondiloarthropaties Gout Septic Lower back pain

5 History most important Age, gender, nationality Family history? Precipitating factors? Drugs, Diet, Infections, Work, Play, Injuries, Habits etc. How many joints? Type of pain? 1. Referred 2. Mechanical 3. Inflammatory Pattern of joint involvement? 1. Symmetrical 2. Asymmetrical 3. Involvement of Hands 4. Involvement of back and SI-Joints 5. Soft tissue, enthesopathy, synovial joints and structures, cartilage disease Pain/disease? Onset, severity, temporal pattern, associated features, duration Functional status? Never forget to ask for complications of disease and medication

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18 Examination General and systemic Neurological examination important in referred pain and back problems Joints Look (Be observant) Feel Tenderness, swelling and warmth Joint outline Stability Pressure for soft tissue structures and fibromyalgia Move Active Exclude referred pain Localize to joint area Passive ROM Capsular pattern (joint capsule and synovium) Non-capsular (soft tissue and Internal/degenerative abnormalities) Movement against resistance Muscles (strength and tendons) Ligaments and joint stability

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20 Non-inflammatory (soft tissue rheumatism) Inflammatory (soft tissue rheumatism) Regional/ localized Myofacial syndrome Generalized Fibromyalgia Bursitis Tenosynovitis Enthesopathy

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22 Trauma Acute Chronic Due to underlying arthritis Periarticular calcific deposits Microcrystal deposits Anxiety Depression

23 Localized Bursitis Ganglion Rotator cuff syndrome Dupuytran s contracture Enthesitis Tenosynovitis Adhesive capsulitis Nerve entrapment syndromes

24 Generalized Fibromyalgia Chronic fatigue syndrome Myofacial pain syndrome Psychogenic rheumatism

25 Localized pain and swelling Associated conditions RA Gout Infections Repetitive trauma

26 Inflammation of synovial tendon sheath Causes Part of a systemic disorder, e.g. RA Infections TB Leprosy

27 Inflammation at site of insertion of a tendon into the bone Very characteristic of seronegative spondyloarthropathy e.g. Reiter s syndrome Other causes Gout Sports injuries

28 More than 90% of shoulder pain Extra-capsular (soft tissue) Majority of painful non-traumatic conditions Tendinitis of rotator cuff Diagnoses Good history Clinical Examination (non-capsular pattern and impairment of active & resisted movements) Radiology MRI

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33 Lateral & medial Epicondilitis Olecranon bursitis

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38 Carpal tunnel syndrome Dupuytran s contracture De Quervain s tenosynovitis Ganglion

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40 Causes OA RA Psoriatic arthritis HA deposition disease

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42 Bursitis Enthesitis Ligament strain Calcific periarthritis

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45 Achillis tendinitis Peritendinitis Plantar faciitis Bursitis around calcaneous

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47 Especially with Ankylosing spondylitis Reactive arthritis

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49 Generalized Soft tissue rheumatism

50 Chronic pain affecting the neck and arm region Occurring in activities requiring control of posture, often of a repetitive nature, Psychological factors contribute Clinical chronic pain in neck, chest wall, arm, hand impairment of work performance variable upper limb swellings poor grip strength taut proximal muscles poor sleep patterns often mood changes often mild sympathetic dystrophy

51 Common Otherwise healthy individuals articular symptoms hypermobility Complications muscle & ligament tears traumatic & degenarative changes of joints recurrent dislocations

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53 Chronic musculoskeletal syndrome Characterized diffuse pain tender points No synovitis or myositis.

54 Intolerance of discomforts Palpitation Medication Cold Ischeamia Movement Light Noise Heat Exercise

55 Unrevealing Laboratory and Radiological negative

56 Eighty to ninety percent of patients are women Peak age is years

57 Generalized chronic musculoskeletal pain Diffuse tenderness at discrete anatomic locations termed tender points

58 Diagnostic utility but not essential for classification of fibromyalgia Fatigue Sleep disturbances Headaches Irritable bowel syndrome Paresthesias Raynaud s-like symptoms Depression and anxiety

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60 Inflammatory vs. Noninflamatory Acute vs. Chronic Temporal pattern of joint involvement Distribution of joint involvement Age of patient Sex of patient Systemic involvement

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62 Morning stiffness >1 hr Fatigue Profound Activity Improves symptoms Rest Worsens symptoms Systemic involvement Yes Swelling, warmth, erythema, tenderness, loss of function Morning stiffness <30 min Fatigue Minimal Activity Worsens symptoms Rest Improves symptoms Systemic involvement No

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64 Infection Gonococcal Meningococcal Acute rheumatic fever Bacterial endocarditis Viral(esp.. rubella, hepatitis B, parvovirus, Epstein-Barr, HIV) Other inflammatory Rheumatoid arthritis Juvenile chronic arthritis SLE Reiter s syndrome Psoriatic arthritis Polyarticular gout Sarcoid arthritis Serum sickness

65 Inflammatory Rheumatoid arthritis Polyarticular Juvenile chronic arthritis SLE Progressive systemic sclerosis Polymyositis Reiter s syndrome Psoriatic arthritis Enteropathic arthritis Polyarticular gout Pseudogout (CPPD) Sarcoid arthritis Vasculitis Polymialgia rheumatica

66 Noninflammatory Osteoarthritis Pseudogout (CPPD) Polyarticular gout Paget s disease Fibromyalgia Benign hypermobility syndrome Hemochromatosis

67 Longstanding arthritis (Chronic) leads to deformity Varus deformities of both knees due to OA of the medial compartment of the knee

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69 Migratory Rheumatic fever Gonococcal arthritis Additive Nonspecific Rheumatoid arthritis SLE Intermittent Rheumatoid arthritis Psoriatic arthritis Reiter s syndrome Palandromic Gout Rheumatoid arthritis

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71 Rheumatoid arthritis Commonly involved Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP Commonly spared DIP, thoracolumbar spine

72 Osteoarthritis Commonly involved First CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, first MTP, toe IP Commonly spared MCP, wrist, elbow, glenohumeral, ankle, tarsal

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80 Jaccoud artrhropathy in SLE Deformity reduced

81 Reiter s syndrome Commonly involved Knee, ankle, tarsal, MTP, toe IP, elbow, axial Gonococcal arthritis Commonly involved Knee, wrist, ankle, hand IP Commonly spared Axial

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85 Early RA

86 Extensor tenosinovitis

87 Olecranon bursitis and subcutaneous nodules

88 A lot of reasons for pain around the hip area

89 Baker s popliteal sist

90 RA feet

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98 Clinical Picture Psoriasis in natal cleft Mono arhtropathy associated with psoriasis

99 Symmetric psoriatic polyarthritis resembling RA

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103 Psoriatic Arthritis Nail pitting Skin Enthesophathy Dactilitis

104 Differential diagnosis 1. Gout 2. Osteoarthritis 3. Rheumatoid arthritis 4. Psoriasis

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106 Young patient with right knee pain and left tennis elbow Reactive arthritis

107 Young lady with swollen and painful left knee Gonococcal arthritis

108 Young boy with proteinuria and acute abdominal pain Henoch-Schonlein Purpura

109 Young lady with abdominal pain, rectal bleeding associated with a painful left ankle and sacro-illiitis Pyoderma Gangrenosum Inflammatory Bowel Disease

110 These facial and nail bed lesions associated with Raynaud s phenomenon Scleroderma

111 Painful hands and shoulders as well as mouth ulcera SLE

112 Difficulty in climbing steps and painful upper legs Dermatomyositis

113 Comparing: lupus, dermatomyositis and porphyria Porphyria Dermatomyositis Lupus

114 What types of arthritis may be associated with these lesions? 1. Inflammatory bowel disease 2. Sarcoidosis 3. Rheumatic fever 4. Tuberculosis 5. SLE

115 Young patient with migrating arthritis Erythema marginatum Rheumatic Fever

116 RA Sero-negative Spondyloarthropathies Sicca syndrome Corticosteroids Chloroquin

117 Patient with non-erosive arthritis and burning of eyes Sicca Syndrome

118 Painful red eye in rheumatic diseases Uveitis

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137 Involving one single joint Acute or Chronic? Inflammatory or Mechanical? Articular or extra-articular?

138 Septic arthritis Crystal induced arthritis Gout Pseudogout (CPPD) Hydroxy appatite (HA) Cholesterol Hemarthrosis Hemophillia Warfarin Trauma / overuse Loose body HIV Osteoarthritis

139 Septic Joint Acute Monoarthritis is a rheumatologic emergency Infection may destroy a joint in 48 hours

140 Infected joint in RA Back

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143 Goes to bed healthy Wakes up sudden monoarthritis ( 85% Podagra) (heel, instep, knee, wrist and hands and elbow -olecranon bursitis) Rigors with severe pain Night spent in torture Joint is red ( ripe tomato ),warm and very tender. After attack skin around the joint often peels off Acute attacks usually pass completely until the next attack Uncontrolled hyperuricaemia may lead to polyarticular gout

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145 Trauma and surgery Medication Alcohol Diet

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147 Family history, as well as a typical history of attacks Typical clinical picture and tophi Elevated serum urate - (may be normal during attacks) Urate crystals in aspiration fluid (as well as tophi) X rays: Punched-out erosions (Rat bitten)

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149 Deposition of uric acid crystals in the tissues (tophi) After repeated attacks after years The tophi occur in The auricles - helix Tendons (hands, achilles tendon and feet) Bursae - especially olecranon bursa The tophi may ulcerate with secretion of pasty material

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153 Special investigations

154 Special investigations Side room Imaging X-ray Sonar CT MRI Isotopes Heamatology Biochemistry Serology Synovial aspirates Pathology Synovial biopsy Reasons for special investigations -Confirm clinical diagnosis -Help with diagnosis -Prognostic -Help determine activity of inflammation -Monitor for complications of disease and drugs

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