Small joint arthritis examination routine
This 62 year old lady is concerned about pain in her fingers which has become more troublesome recently.
Your Task :
is to assess the patient”s condition and problems and address any questions or concerns raised by the patient.
You should assess the problem by means of a relevant history and a relevant physical examination.You donot need to complete the history before carrying out appropriate examination.
You should respond to any questions the patient may have and advise the patient of your probable diagnosis and your plan for investigation and treatment where appropriate.
Approach to the case
History of present Illness
Begin with an open question
I believe you have been having pain in your hands
Can you please elaborate a bit about it
What has been going on
Onset :
How did the problem start
Onset over hours:
Infection
Gout
Trauma
Rheumatoid Arthritis
Onset over weeks :
Inflammatory arthritis
Osteoarthritis
Pseudogout
Duration
How long has the problem been present for
Symptoms lasting more than 6 weeks point to Rheumatoid arthritis.
Symptoms lasting less than 6 weeks may be due to a viral infection.
Progression:
Is it getting worse with time , staying the same
Distribution of symptoms :
One or many joint affected ?
Symmetrical or Assymetrical ?
Large joints or small joints affected ?
Involvement of ligaments or tendon insertion ?
Which joints are more painful ?
Are they painful first thing in the morning ?
Does the pain get worse with movement ?
Does the pain keep you awake at night ?
Associated Factors :
Systemic features:
Is there any associated redness or swelling of the joints
Any fever and chills or fatigue ?
Any weight loss ? These symptoms would be present in sepsis as well as connective tissue disorders.
Rash :
Is there any associated rash?
Rash with arthritis is seen in diseases below :
Psoriasis
SLE ( Malar Rash , photosensitivity )
Infection ( rheumatic Fever , lyme”s Disease , Viral exanthema )
Drug reaction ( NSAID , Gold , Penicillamine , Sulphaslazine )
Vasculitis ( including Vasculitis )
Raynaud”s Phenomenon
Associated Stiffness :
Is there any associated stiffness of the joints when you get up first thing in the morning ?
How long does it take them to keep going ? ie how long does the stiffness last for ?
Morning stiffness lasting for more than one hour is suggestive of Rheumatoid Arthritis
Morning stiffness less than one hour is suggestive of Osteoarthritis.
Alopecia : Would be seen in SLE
Oro-genital ulceration :
This occurs in SLE & Behcet”s Disease
Behcet”s Disease
This occurs following bacterial infection causing urethritis or enteritis
The arthritis is assymetrical and usually affects the lower limbs.
The genital lesions usually include Cicinate balanitis.
Eye involvement :
In RA , scleritis or episcleritis can cause a red eye.
Episcleritis is a painless acute red eye without discharge whereas scleritis causes deep ocular pain.
Dry and gritty eyes are seen in keratoconjunctivitis sicca associated with Sjogren”s Syndrome.
Ask about any associated UTIs as well. Gonococcus can cause UTi associated with septic arthritis.
Functional Assessment Questions :
These are done to determine the level of disability.
Ask if the patient is having difficulty picking up objects of daily use such as a cup or pen.
Any difficulty in buttoning / unbuttoning shirts ?
Can patient dress without any difficulty ?
Can patient walk up and down stairs without any difficulty ?
Any past history of fractures or orthopedic fractures ?
Any family history of Rheumatoid Arthritis and Psoriasis ?
Any Occupational association eg House maid”s knee : caused bu kneeling that causes prepatellar bursitis.
Repetitive joint use can cause : tenosynovitis or tennis elbow,
Medications :
Ask which medication is patient on ?
Any previous use iof NSAIDS,steroids and Disease modifying medications ?
Any side effects of these ?
Any medications in use that can cause SLE such as Procainamide,penicillamine ?
Does the patient have a Social Support ? Does she need carers for help in cooking / daily activities .
Does patient need Occupational therapist”s support and evaluation?
Is the house modified for access.
What are the concerns of the patient ?
Patient asked if she has Rheumatoid Arthritis as her mother had it.
Tell the pateient we need to do more tests in order to arrive at a diagnosis.
Also further clinical examination may be necessary.
Tests include :
Blood Tests
Imaging studies eg X – rays f joints of hand , knees anf feet.
Serum tests
It may not be Rheumatoid Arthritis,
Afterwards we will arrange for a follow up appointment to discuss the results.
Will aim to give her analgesics for pain control.
Also arrangements would be made to provide her support at home / package of care in liaison with IDT / Social sevices and Occupational & Physiotherapist assessments.
Discussion with Examiner :
Which blood Tests would you like to do ?
Full Blood Count
ESR
CRP
ANA : Antinuclear Antibody
Extractable Nuclear Antigens : ENAs
Anti DNA , Sm, RNP Ribo nuclear proteins,Ro , La antibodies
ANCA : Anti Neutrophilic Cytoplasmic Antibodies
Rheumatoid Factor
Anti – CCP Antibodies : Cetrullinated c peptide antibodies.
Serum urate levels
Radiographs of hand , knees and feet.
Differential Diagnosis:
Raynaud”s Disease and Phenomenon
Mixed CT Diseases ( Mixed Conective Tissue Diseases )
Cervical Rib
SLE / Systemic Lupus Erythematosis
Professional / vibrational Injury
Assoiated with CREST Syndrome
Sclerodema
