Differential diagnosis

Dr. Ioana Saulescu

Musculoskeletal

complaints = among the

most common

problems in clinical

medicine

All physicians have to

be able to recognize

this disorders.

Musculoskeletal disorders

The patient history and physical examination

= basis of diagnosis

Signs and symptoms of joint and extra-articular features

Why is it so important?

Sometimes, it is very easy to establish the

diagnosis!

Six main types of a rheumatic complaint

Inflammatory musculoskeletal disease

Mechanical joint or periarticular disorder

Bone disorder

Non-rheumatic disease (from distance-referred pain)

Functional disorder

Disorder of unknown cause

Symptoms of a musculoskeletal problem

Pain

Stiffness

Swelling

Weakness

Loss of function

Fatigue and malaise

Depression and fear

Sleep disturbance

Symptoms of

systemic disease

A lot of questions for the clinician!

Pain -the most common cause of presentation

Inflammatory pain

Mechanical pain

Neuralgic pain

Bone pain

Referred pain

Establish a pattern for the pain!

Inflammatory joint pain:pain in the

morning, at rest, ameliorated by use

Inflammatory /

infective disorder

Mechanical joint pain: pain related

to joint use, ameliorated by rest

Degenerative

disease

Neuralgic pain:diffuse pain and

parehestesia in dermatome

Root or peripheral

nerve compression

Bone pain:pain at rest , at night, but

also with use

Tumor, Paget

disease, Fracture

Referred pain: pain unaffected by

local movement.

From the distance

Stiffness

How long does it take you before you are moving as well as you are going to move for

the day?

MORNING STIFFNESS

Questions about stiffness

What joints or muscle does it affect?

When during the day?

How long does it last?

What makes it worse?

What improves it?

Swelling and deformity

Did it follow an injury?

Did it appear rapidly or

slowly?

Does it come and go?

Is it gradually enlarging

or progressing?

Is it painful?

Joint or periarthicular structure

Effusion,

Synovial proliferation

Bony growth

IMAGING!

Weakness

Of limbs or of the whole body

Muscle disorder or neuropathy

# general fatigue, depression, fibromyalgia.

Other important issues to asses

Is the problem mono/oligo or poliarthicular , symetric or asymetric?

Is it an acute, subacute or chronic problem? Is it progressive or recurrent problem?

Is there evidence of a systemic proces?

Is there a family history of a similar or related disorder?

Location and symetry(1)

Sometimes the most important clue in identifying the cause!

Specific arthropaties =predilection for specific joint areas.

Wrists and PIP of the hands and feet= rheumatoid arthritis,

DIP of the hands and feet=psoriatic /osteoarthritis ,

Big joints and spine=seronegative spondilarthritis,

Great toe: gout.

Do not forget SYMMETRY.

Onset and chronology

Acute onset, in hours/several days= attacks

of gout or septic arthrithis,

Subacute onset, in weeks/less than 3

month= majority of the rheumatic disease,

Chronic onset, over 3 month / years =

fibromyalgia.

Persistent or recurrent.

Monoarticular joint disease(1)

Prompt evaluation to rule out

infections/malignancy

Inflamatory/infectious disease

Mechanical or infiltrative disorders

Anthibiotherapy until exclusion of septic arthrtis

Acute/chronic monoarticular joint disease(2)

Crystal induced arthritis,

Septic arthritis,

More rare: systemic disease presenting with

monoarticular involvement,

Malignancy, benign tumor.

You must distinguish between

articular and periarticular problem

Polyarticular joint disease

Inflamatory/non-inflamatory disease,

Acute/chronic,

Oligoarticular/poliarticular,

Symetric/asymetric,

With/without axial involvement.

Establish pattern, range of motion,

signs of inflammation.

Pattern of joint involvement

Additive: most common, least specific,

Migratory: most characteristic of rheumatic

fever, Lyme disease, leukemia,

Intermitent (repetitive): crystal induced

disease, RA, SLE, sarcoidosis.

The hand

Osteoarthritis of the hand

Mechanical complain,

DIP involvement Heberden nodes, PIP involvement

Bouchard nodes

Deviation of the phalanges without a pattern,

Erosive arthrosis.

Rheumatoid arthritis of the hands

Inflamator disease,

Symmetrical pattern,

without involving DIP,

Fusiform swelling of the

PIP,

Swan neck deformity,

boutonniere deformity,

Atrophy of the

muscules.

Seronegative spondilarthrities

Psoriatic arthritis

Involvement of DIP,

Asymmetrical

oligoarthritis or

symmetrical poliarthritis

Dactilitis.

Reactive arthritis

Rare involvement of the

hand,

Dactilitis,

Keratodermia

blenoragicum.

Cristal induced arthritis

Condrocalcinosis

Often associated with

OA.

Gout

Usually in chronic

disease,

Tophi.

Systemic sclerosis

Sclerodactyly,

Raynaud syndrome

Telangiectasias,

Digital ulcers.

SLE

Non- erosive,

symmetrical arthritis,

Jaccoud arthropaties.

Septic arthritis

Gonococal septic arthritis =

mono/oligoarthritis, tenosinovitis,

Non-gonococal septic arthritis =

monoarticular

Viral arthritis = parvovirus B19, HBV.

Elbow

periarthicular

involvement: olecranon

bursitis, epicondylitis,

swelling in lateral

process: synovitis.

Olecranon bursitis

Posttrauma,

Non-septic etiology:

RA, cristal induced,

Septic etiology:

especially in

immunosupression.

The shoulder(1)

Proper examination:

begin with visualization of the girdle area.

From the front and from the back

Includes sternoclavicular, glenohumeral,

acromioclavicular joints

The shoulder(2)

Notice the asymmetry,

Muscle atrophy: chronic disorder, like RA,

Sinovitis: visible when the effusion is large,

Active and pasive mobility.

Polymyositis, polymyalgia, fibromyalgia

The knee

Osteoarthritis

Rheumatoid arthritis

Cristal induced

arthritis.

The foot

RA

Symmetrical distribution

of all small joints,

Plantar blisters

Psoriatic arthritis

Asymmetry,

dactilitis.

Reactive arthritis

Mono/oligoarthritis

Asymmetry,

Dactilitis

Entesitis

Nodous erythema:

yersinia,

Gout

Acute: I phalang,

Chronic disorder: tophy.

The hip

The spine

As a whole and on region

Mechanical, inflamatory, septic, malignancy

The spine

Axial alone,

Axial and peripheral.

Sometimes mixed complaints.

Seronegative spondilarthritis

Inflamatory complain

Usually young, male patients

Ask for family history

Look for genetic linkage

Infectious trigger: genito-urinary or enteric

Response to NSAID

Older patients

Osteoporosis

Metastasis

Spondilosis

Pay attention

An old disease may be complicated by a new

one!

One patient may have different complaint!

Make the right exam and choose the proper

treatment!