Approach to a Patient with Arthritis PDF

Approach to a Patient with Arthritis: Detailed Overview **[Arthritis refers]** to a broad group of conditions that affect the joints, causing pain, swelling, stiffness, and decreased range of motion. The approach to a patient presenting with arthritis involves a thorough history, physical examinati...

Approach to a Patient with Arthritis: Detailed Overview **[Arthritis refers]** to a broad group of conditions that affect the joints, causing pain, swelling, stiffness, and decreased range of motion. The approach to a patient presenting with arthritis involves a thorough history, physical examination, laboratory testing, and imaging to determine the specific cause and guide treatment. 1\. History Taking A detailed history is crucial in distinguishing the type of arthritis. Key aspects include: **[Onset and Duration:]** Sudden vs. gradual onset can help differentiate between inflammatory and non-inflammatory causes. Acute (\6 weeks). **[Pattern of Joint Involvement:]** Monoarthritis (one joint), oligoarthritis (2--4 joints), or polyarthritis (≥5 joints). Symmetry of joint involvement is important: Symmetric polyarthritis is typical of rheumatoid arthritis (RA), whereas asymmetric involvement suggests osteoarthritis (OA) or psoriatic arthritis. **[Associated Symptoms:]** Morning stiffness (\>30 minutes may suggest RA or other inflammatory conditions). Systemic symptoms like fever, weight loss, or fatigue suggest systemic disease like RA, lupus, or systemic vasculitis. **[Past Medical History:]** History of trauma, infection, or other autoimmune conditions. **[Family History:]** A family history of rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis may increase suspicion of genetic predisposition. **[2. Physical Examination]** **[Inspection:]** Look for swelling, erythema, and deformities. **[Palpation:]** Assess for tenderness, warmth, effusion, and synovitis. **Range of Motion:** **[Assess active and passive motion]**. Decreased range may suggest joint effusion or structural damage. **[Joint-specific Exam:]** Small joints (hands, feet) are commonly involved in RA. Knee or hip arthritis is common in osteoarthritis. **[Systemic Findings:]** Check for skin changes (rash in lupus, psoriasis), eye involvement (uveitis in ankylosing spondylitis), and oral ulcers (SLE). 3\. **[Laboratory Investigations]** **[Depending on the suspected diagnosis, relevant tests include:]** CBC: To evaluate for anemia of chronic disease, leukocytosis, or thrombocytosis in inflammatory arthritis. Acute Phase Reactants: ESR (Erythrocyte Sedimentation Rate) and CRP (C-reactive protein) are elevated in inflammatory arthritis (e.g., RA, SLE, or systemic infection). Rheumatoid Factor (RF) and Anti-CCP: Specific markers for rheumatoid arthritis. Antinuclear Antibodies (ANA): Positive in SLE, but can also be positive 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. **[4. Imaging Studies]** X-ray: May reveal joint space narrowing, osteophytes in osteoarthritis, erosions in rheumatoid arthritis, or soft tissue swelling. Ultrasound: Useful to detect synovitis, effusion, and erosions not seen on X-ray. MRI: Preferred for detailed imaging of cartilage, ligaments, and early erosions in rheumatoid arthritis. CT Scan: Used when detailed bone evaluation is needed (e.g., in the spine or pelvis for ankylosing spondylitis). **[5. Differential Diagnosis of Arthritis]** The differential diagnosis is extensive and includes: 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 along with multi-organ involvement. Septic arthritis: Monoarthritis caused by infection, requires urgent treatment. Non-inflammatory arthritis: Osteoarthritis (OA): Most common, characterized by degenerative changes in weight-bearing joints. Crystal-induced arthritis: Gout: Due to uric acid crystal deposition. Pseudogout: Caused by calcium pyrophosphate deposition. Reactive arthritis: Follows infections (gastrointestinal or genitourinary). **[6. Treatment Approach]** The treatment of arthritis depends on the underlying cause: Non-pharmacologic Measures: Physical therapy, joint protection strategies, and weight loss in 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: For 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 are used for RA, ankylosing spondylitis, and psoriatic arthritis. Colchicine: For gout and pseudogout flares. Urate-lowering therapy (e.g., allopurinol): Chronic management of gout. Surgical Intervention: Reserved for severe cases with joint destruction requiring joint replacement or synovectomy. **[7. Follow-Up and Prognosis]** Patients with inflammatory arthritis, particularly RA and SLE, require close follow-up for disease activity monitoring and treatment adjustment. Osteoarthritis is typically managed conservatively, with symptom control being the primary focus.