Arthritis Diagnosis and History Taking

Arthritis Approach

• Arthritis refers to a group of conditions affecting joints
• Causes pain, swelling, stiffness, and decreased range of motion
• Diagnostic approach includes history, physical examination, laboratory testing, and imaging
• Aims to determine the specific cause and guide treatment

History Taking

• Distinguishes types of arthritis
• Onset and duration: sudden vs gradual onset
  • Acute (less than 6 weeks)
• Pattern of joint involvement:
  • Monoarthritis - one joint
  • Oligoarthritis - 2-4 joints
  • Polyarthritis - more than 5 joints
  • Symmetry of joint involvement is important: Symmetric polyarthritis typical of rheumatoid arthritis (RA), whereas asymmetric involvement suggests osteoarthritis (OA) or psoriatic arthritis.
• Associated symptoms:
  • Morning stiffness - greater than 30 minutes may suggest RA
  • Systemic symptoms like fever, weight loss, or fatigue may suggest systemic disease like RA, lupus, or systemic vasculitis.
• Past medical history: trauma, infection, or autoimmune conditions
• Family history: rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis may suggest genetic predisposition.

Physical Examination

• Inspection: swelling, erythema (redness), deformities
• Palpation: tenderness, warmth, effusion (fluid buildup), synovitis (inflammation of the lining of the joint).
• Range of Motion: passive and active motion assessment
  • Decreased range suggests joint effusion or structural damage
• Joint-specific exam:
  • Small joints (hands, feet) commonly involved in RA
  • Knee or hip osteoarthritis is common
• Systemic findings:
  • Skin changes (rash in lupus, psoriasis), eye involvement (uveitis in ankylosing spondylitis), and oral ulcers (SLE).

Laboratory Investigations

• Tests depend on the suspected diagnosis:
  • CBC (complete blood count): anemia of chronic disease, leukocytosis (increased white blood cell count), or thrombocytosis (increased platelet count) in inflammatory arthritis.
  • Acute Phase Reactants: ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein): elevated in inflammatory arthritis (e.g., RA, SLE, or systemic infection).
  • Rheumatoid Factor (RF) and Anti-CCP: specific markers for rheumatoid arthritis (RA)
  • Antinuclear Antibodies (ANA): positive in SLE, but can also be present in other connective tissue diseases.
  • HLA-B27: associated with ankylosing spondylitis, reactive arthritis, and other spondyloarthropathies.
  • Uric Acid: elevated in gout, but can be normal during acute attacks.
  • Joint Aspiration and Synovial Fluid Analysis: evaluates for septic arthritis, crystals (gout or pseudogout), and inflammatory cells.

Imaging Studies

• X-ray: joint space narrowing, osteophytes in osteoarthritis, erosions in rheumatoid arthritis, or soft tissue swelling.
• Ultrasound: synovitis, effusion, and erosions not visible on X-ray.
• MRI: cartilage, ligaments, and early erosions in rheumatoid arthritis.
• CT Scan: detailed bone evaluation (e.g., in the spine or pelvis for ankylosing spondylitis).

Differential Diagnosis of Arthritis

• Inflammatory arthritis
  • **Rheumatoid arthritis (RA): **chronic, symmetric polyarthritis affecting small joints
  • Ankylosing spondylitis: involves the spine and sacroiliac joints, often in young males
  • Psoriatic arthritis: asymmetric arthritis with skin psoriasis
  • Gout: acute, monoarticular arthritis, commonly in the big toe
  • Systemic Lupus Erythematosus (SLE): arthritis with multi-organ involvement
  • Septic arthritis: monoarthritis caused by infection - requires urgent treatment
• Non-inflammatory arthritis
  • Osteoarthritis (OA): common, degenerative changes in weight-bearing joints
• Crystal-induced arthritis
  • Gout: uric acid crystal deposition
  • Pseudogout: calcium pyrophosphate deposition
• Reactive arthritis: follows infections (gastrointestinal or genitourinary).

Treatment Approach

• Non-pharmacologic Measures
  • Physical therapy, joint protection strategies, and weight loss (osteoarthritis).
  • Exercise programs and occupational therapy to maintain function.
• Pharmacologic Therapy
  • Non-steroidal anti-inflammatory drugs (NSAIDs): first-line for most forms of arthritis.
  • Corticosteroids: acute flares in RA, lupus, or gout.
  • Disease-modifying anti-rheumatic drugs (DMARDs):
    • Methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide are used in RA
  • Biologic agents like TNF inhibitors: RA, ankylosing spondylitis, and psoriatic arthritis.
  • Colchicine: gout and pseudogout flares.

This quiz delves into the diagnostic approach for arthritis, focusing on the importance of history taking. It covers the types of arthritis, patterns of joint involvement, symptom duration, and associated symptoms to help distinguish between different types. Understanding these elements is crucial for effective treatment planning.