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approach to the patient
approach to the patient
Examination
- 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.
- Gender:
Gout, reactive arthritis and ankylosing spondylitis are more common in men.
Rheumatoid arthritis and other connective tissue diseases are more common in women.
blood test
- Haemoglobin
Normochromic, normocytic anaemia
chronic inflammatory diseases
autoimmune diseases
Hypochromic, microcytic anaemia
due to non-steroidal anti-inflammatory drugs (NSAID) induced gastrointestinal bleeding.
- White cell count
Neutrophilia
is seen in bacterial infection, (septic arthritis)
it also occurs with corticosteroid treatment
Lymphopenia
occurs with viral illnesses or active systemic lupus
- Platelets
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.
Rheumatoid factors
- 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%
viral infections
hepatitis
infectious mononucleosis
chronic infections
normal population
elderly
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
Bursitis
Tendinitis
Fibromyalgia
- Osteoporosis
- Gout
- 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.
- Medication:
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:
1.Rheumatoid arthritis
2.Lupus erythematosus disseminatus
3.Systemic sclerosis
4.Idiopathic inflammatory myopathies
5.Sjőgren syndrome
6.Vasculitis
- Seronegative spondyloarthropathies:
1.Ankylosing spondylitis
2.Psoriatic arthritis
3.Enteropathic arthritis
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 %