johan van rensburg - learning - homelearning.ufs.ac.za/internal_medicine_on/resources/3... ·...
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Johan van Rensburg
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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?
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General algorithm
Inflammatory Degenerative
Joints
Local/Regional Generalized
Muscles/Soft tissues
What tipe of metabolic disease? Osteoporosis?
Bone
Are the symptom's from his/her joints, muscles/soft tissues or bone?
Is it likely to be a musculoskeletal problem?
Pain and Stiffness
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Arthritis
Degenerative
Osteoartritis
InflammatoryRheumatoid arthritis
Seronegative spondiloarthropaties
GoutSeptic
Lower back pain
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History most importantAge, gender, nationalityFamily history?Precipitating factors?
Drugs, Diet, Infections, Work, Play, Injuries, Habits etc.
How many joints?Type of pain?1. Referred2. Mechanical3. Inflammatory
Pattern of joint involvement?1. Symmetrical2. Asymmetrical3. Involvement of Hands4. Involvement of back and SI-Joints5. 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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ExaminationGeneral and systemicNeurological examination important in referred pain and back problemsJoints
Look (Be observant)Feel
Tenderness, swelling and warmthJoint outlineStabilityPressure for soft tissue structures and fibromyalgia
MoveActive
Exclude referred painLocalize to joint area
PassiveROMCapsular pattern (joint capsule and synovium)Non-capsular (soft tissue and Internal/degenerative abnormalities)
Movement against resistanceMuscles (strength and tendons)Ligaments and joint stability
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Non-inflammatory(soft tissue rheumatism)
Regional/localized
Myofacialsyndrome
Generalized
Fibromyalgia
Inflammatory(soft tissue rheumatism)
BursitisTenosynovitisEnthesopathy
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TraumaAcute
Chronic
Due to underlying arthritis
Periarticular calcific deposits
Microcrystal deposits
Anxiety
Depression
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LocalizedBursitis
Ganglion
Rotator cuff syndrome
Dupuytran’s contracture
Enthesitis
Tenosynovitis
Adhesive capsulitis
Nerve entrapment syndromes
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GeneralizedFibromyalgia
Chronic fatigue syndrome
Myofacial pain syndrome
Psychogenic rheumatism
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Localized pain and swelling
Associated conditionsRA
Gout
Infections
Repetitive trauma
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Inflammation of synovial tendon sheath
CausesPart of a systemic disorder, e.g. RA
Infections TB
Leprosy
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Inflammation at site of insertion of a tendon into the bone
Very characteristic of seronegativespondyloarthropathy e.g. Reiter’s syndrome
Other causesGout
Sports injuries
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More than 90% of shoulder painExtra-capsular (soft tissue)
Majority of painful non-traumatic conditionsTendinitis of rotator cuff
DiagnosesGood history
Clinical Examination (non-capsular pattern and impairment of active & resisted movements)
Radiology
MRI
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Lateral & medial
Epicondilitis
Olecranon bursitis
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Carpal tunnel syndrome
Dupuytran’s contracture
De Quervain’s tenosynovitis
Ganglion
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CausesOA
RA
Psoriatic arthritis
HA deposition disease
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Bursitis
Enthesitis
Ligament strain
Calcific periarthritis
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Achillis tendinitis
Peritendinitis
Plantar faciitis
Bursitis around calcaneous
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Especially with Ankylosing spondylitis
Reactive arthritis
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GeneralizedSoft tissue rheumatism
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Chronic pain affecting the neck and arm regionOccurring in activities requiring control of posture, often of a repetitive nature,
Psychological factors contribute
Clinicalchronic 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
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Common
Otherwise healthy individualsarticular symptoms
hypermobility
Complicationsmuscle & ligament tears
traumatic & degenarative changes of joints
recurrent dislocations
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Chronic musculoskeletal syndrome
Characterizeddiffuse pain
tender points
No synovitis or myositis.
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“Intolerance of discomforts”PalpitationMedicationColdIscheamiaMovementLightNoiseHeatExercise
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Unrevealing
Laboratory and Radiological negative
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Eighty to ninety percent of patients are women
Peak age is 30–50 years
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Generalized chronic musculoskeletal pain
Diffuse tenderness at discrete anatomic locations termed tender points
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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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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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Morning stiffness>1 hr
FatigueProfound
ActivityImproves symptoms
RestWorsens symptoms
Systemic involvementYes
Swelling, warmth, erythema, tenderness, loss of function
Morning stiffness<30 min
FatigueMinimal
ActivityWorsens symptoms
RestImproves symptoms
Systemic involvementNo
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InfectionGonococcal
Meningococcal
Acute rheumatic fever
Bacterial endocarditis
Viral(esp.. rubella, hepatitis B, parvovirus, Epstein-Barr, HIV)
Other inflammatoryRheumatoid arthritis
Juvenile chronic arthritis
SLE
Reiter’s syndrome
Psoriatic arthritis
Polyarticular gout
Sarcoid arthritis
Serum sickness
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InflammatoryRheumatoid 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
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NoninflammatoryOsteoarthritis
Pseudogout (CPPD)
Polyarticular gout
Paget’s disease
Fibromyalgia
Benign hypermobility syndrome
Hemochromatosis
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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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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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Rheumatoid arthritisCommonly involved
Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP
Commonly sparedDIP, thoracolumbar spine
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OsteoarthritisCommonly involved
First CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, first MTP, toe IP
Commonly sparedMCP, wrist, elbow, glenohumeral, ankle, tarsal
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Jaccoud artrhropathy in SLE
Deformity reduced
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Reiter’s syndromeCommonly involved
Knee, ankle, tarsal, MTP, toe IP, elbow, axial
Gonococcal arthritisCommonly involved
Knee, wrist, ankle, hand IP
Commonly sparedAxial
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Early RA
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Extensor tenosinovitis
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Olecranon bursitis and subcutaneous nodules
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A lot of reasons for pain around the hip area
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Baker’s popliteal sist
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RA feet
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Psoriasis in natal cleft
Mono arhtropathy associated with psoriasis
Clinical Picture
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Symmetric psoriatic polyarthritis resembling RA
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Psoriatic Arthritis
Nail pitting
Skin
Enthesophathy
Dactilitis
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Differential diagnosis1. Gout2. Osteoarthritis3. Rheumatoid arthritis4. Psoriasis
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Young patient with right knee pain and left tennis elbow
Reactive arthritis
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Young lady with swollen and painful left knee
Gonococcal arthritis
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Young boy with proteinuria and acute abdominal pain
Henoch-Schonlein Purpura
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Young lady with abdominal pain, rectal bleeding associated with a painful left ankle and sacro-illiitis
Inflammatory Bowel Disease
Pyoderma Gangrenosum
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These facial and nail bed lesions associated with Raynaud’s phenomenon
Scleroderma
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Painful hands and shoulders as well as mouth ulcera
SLE
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Difficulty in climbing steps and painful upper legs
Dermatomyositis
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Comparing:lupus, dermatomyositis and porphyria
Porphyria
Dermatomyositis
Lupus
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What types of arthritis may be associated with these lesions?
1. Inflammatory bowel disease2. Sarcoidosis3. Rheumatic fever4. Tuberculosis5. SLE
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Young patient with migrating arthritis
Rheumatic Fever
Erythema
marginatum
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RA
Sero-negative Spondyloarthropathies
Sicca syndrome
Corticosteroids
Chloroquin
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Patient with non-erosive arthritis and burning of eyes
Sicca Syndrome
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Painful red eye in rheumatic diseases
Uveitis
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Involving one single jointAcute or Chronic?
Inflammatory or Mechanical?
Articular or extra-articular?
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Septic arthritisCrystal induced arthritis
Gout Pseudogout (CPPD)Hydroxy appatite (HA)Cholesterol
HemarthrosisHemophilliaWarfarin
Trauma / overuseLoose body HIVOsteoarthritis
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Septic Joint
Acute Monoarthritis is a rheumatologic emergency
Infection may destroy a joint in 48 hours
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Infected joint in RA
Back
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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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Trauma and surgery
Medication
Alcohol
Diet
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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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Deposition of uric acid crystals in the tissues (tophi)
After repeated attacks after 11 - 12 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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Special investigations
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Special investigationsSide roomImaging
X-raySonarCTMRIIsotopes
HeamatologyBiochemistrySerologySynovial aspiratesPathology
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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