approach to the patient
approach to the patient
- carefully assess active and passive range of motion in all joints and evaluate for the presence of pain, tenderness, swelling, deformity and joint effusion.
- A history, taken carefully, can often lead to a diagnosis.
- Joints that are stiff for more than 1hour each morning are usually inflamed – think of rheumatoid arthritis.
- Pain: Where, localized or generalized, constant, intermittent or episodic, aggravating or precipitating factors, any associated neurological features.
- Spinal stiffness and pain which is much worse in the morning may indicate ankylosing spondylitis, especially in young.
- Shoulder and pelvic girdle stiffness and pain, which are worse in the morning in a patient over 55 years, may be polymyalgia rheumatica.
Gout, reactive arthritis and ankylosing spondylitis are more common in men.
Rheumatoid arthritis and other connective tissue diseases are more common in women.
Normochromic, normocytic anaemia
chronic inflammatory diseases
Hypochromic, microcytic anaemia
due to non-steroidal anti-inflammatory drugs (NSAID) induced gastrointestinal bleeding.
- White cell count
is seen in bacterial infection, (septic arthritis)
it also occurs with corticosteroid treatment
occurs with viral illnesses or active systemic lupus
Thrombocythaemia occurs with chronic inflammation.
Thrombocytopenia is seen in drug-induced bone marrow suppression and in SLE.
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
An increase reflects inflammatory disease.
- Protein electrophoretic strip and urinary Bence Jones protein to exclude myeloma as a cause of a raised ESR
- Serum uric acid – for gout.
- Antistreptolysin –O titre – in rheumatic fever.
- antibodies - usually IgM against IgG, and are detected in 70- 80% of patients with rheumatoid arthritis but are not diagnostic.
- RFs are detected in many autoimmune rheumatic disorders.
- Conditions in which rheumatoid factor is found in the serum
rheumatoid arthritis 70%
systemic lupus 25%
sjögren syndrome 90%
systemic sclerosis 30%
polymyositis/ dermatomiositis 50%
relatives of patients with RA
- Rheumatic diseases may involve any organ system:
uveitis (juvenile arthritis, ankylosing spondylitis)
conjunctivitis (Reiter’s syndrome)
oral ulcers (SLE, Behcet’s syndrome)
lymphadenopathy (SLE, Sjogren syndrome)
cutaneous lesions (psoriasis, scleroderma, vasculitis)
interstitial fibrosis - scleroderma, myositis
hepatosplenomegaly - SLE, rheumatoid arthritis
aortic insufficiency -SLE, ankylosing spondylitis
neuropathy - vasculitis, SLE
- Nonarticular soft tissue disorders
- Rheumatoid disorders represent 20-30 % of the workload of the primary care physician.
- most common rheumatic diseases:
-Osteoarthritis (OA) - degenerative arthritis, most common cause of long-term disability in most populations. characterized by progressive loss of articular cartilage with associated remodeling of subchondral bone.
-Rheumatoid arthritis(RA)–is the most common inflammatory arthritis, and is an important cause of disability, morbidity and mortality. RA causes early joint damage and functional limitation.
Diuretics may cause gout in men and older women.
Hormone replacement therapy or the oral contraceptive pill may precipitate systemic lupus.
Steroids can cause avascular necrosis.
- Family history:
Osteoarthritis may be familial.
Seronegative spondyloarthropathies is seen in families with a history of arthritis, psoriasis, ankylosing spondylitis, iritis or inflammatory bowel disease.
Autoimmunity has a familial tendency.
- Connective tissue disease:
2.Lupus erythematosus disseminatus
4.Idiopathic inflammatory myopathies
- Seronegative spondyloarthropathies:
4.Reactive arthritis (Reiter’ssyndrome)
- Antinuclear antibodies: used as a screening test for SLE, but low titres occur in RA and chronic infections and in normal individuals, especially the elderly.
- Conditions in which serum antinuclear antibodies are found:
systemic lupus 95% systemic sclerosis 70%
sjogren syndrome 80% polymiositis and dermatomiositis 40%
rheumatoid arthritis 30%
autoimmune hepatitis 100% drug-induced lupus 95%
myasthenia gravis 50% fibrosing alveolitis 30%
diabetes mellitus 25% infectious mononucleosis 5-10%
normal population8 %