Joint Pain And Swelling - Bryan Health
Joint Pain And Swelling
Common Rheumatologic Concerns
ROBERT VALENTE MD ARTHRITIS CENTER OF NEBRASKA LINCOLN, NE
I have no financial disclosures or conflicts of interest to report
1/3rd of All Primary Care Visits Involve a Musculoskeletal Complaint. Do You See Patients with Joint and Muscle Aches and Pains?
DPAOTIYEONUTSA? LWAYS FEEL COMFORTABLE TRIAGING THESE
Common Arthritis Questions
? Is it inflammatory arthritis ?
? Distinguishing RA from OA
? What does this + ANA mean?
? Distinguishing CTD from chronic pain and fibromyalgia
Case 1
DISTINGUISHING INFLAMMATORY ARTHRITIS FROM OSTEOARTHRITIS
Case 1: The Reluctant Contractor
67 yo Male Contractor ? Pcrhervoinoiucsphlax notfaLrBfPa,snceiitcisk pain ? 2woyrnsdpererfvuilo. us, pneumonia, Rx included prednisone. Joints felt ? 2g+etyorsuotfopfoblyeadrthralgia, 3 ibuprofen QID, otherwise too stiff to ? NiRrneaofclyaeFnm/naCtmu/indSaf,ste.niocNontoi,wophntlx.eloSusTrsDi.sy,N,kSoidOnraBe,syhCsootorunsguehns, osoerrngGsoiItuidvtii.tsytNr,eonsosh.xdNoryof ecnyauenmsc,beenry,eess, ? Dad with seropositive RA ? Pain score 6, AM stiff 10 min
What features of the Patient History suggest inflammatory polyarthritis?
A. 10 min of morning stiffness B. Hx of Back pain and plantar fasciitis? C. Trial of prednisone made everything better D. Needs 12 ibuprofen a day, or too stiff to get out of bed
and dad had rheumatoid arthritis
DDx of Polyarticular Pain
? Polyarthritis: Chronic and Acute (viral)
? Reactive arthritis
? Fibromyalgia
? Multiple site Bursitis/Tendonitis
? Hypothyroidism
? Metastasis
? Depression ? Neuropathic pain
"The evaluation of the adult with polyarticular pain" Shmerling RH, ed Wolters Kluwer, May 2018
? Mimeptearbfeoclicta/)inherited bone diseases (osteomalacia, osteogenesis
Case 1
Physical Exam
? Rapid 3 = 7.5
?
Moderate OA hands, 1st and j3ordintMs,CLPkSn,e1est, BCPMFCjos,inAtsC, toes
? BdiylasftuenracltRioontator cuff
? Ndiogrimts al Achilles, No sausage
? Ntoofrlmooarl dL-isstpainnecem2otiniocnh(efsin)ger
? 17 swollen, 20 tender joints
Can you tell if a joint is swollen? ? Yes ? No
Case 1
LAB AND X-RAY RESULTS
? Normal: CBC, ESR, CRP, Chemistries, urine
? -RF, -CCP, - ANA ? X-ray hands C/W
osteoarthritis, Moderate (nodal pattern)
Rheumatoid Arthritis: Radiographic Abnormalities
? Soft tissue swelling ? Symmetric joint involvement ? Peri-articular osteoporosis ? Symmetric joint space
narrowing ? Marginal erosions ? Deformity ? Fibrous ankylosis
Question
Does this 67 yo Male Contractor have inflammatory Arthritis?
A. Yes B. No
The Case for Inflammatory Arthritis
? SX > 6 weeks ? Prolonged AM stiffness ? SX better with ibuprofen ? + family hx of Sero+ RA ? 17 Swollen joints on PE
The Case Against Inflammatory Arthritis
? Patient is 67 yo, and a laborer with lots of OA ? No CTD disease features ? No inflammatory bowel sx ? No psoriasis ? No STD risks, no Gout/stone ? Normal ESR, CRP ? Negative ANA, RF, CCP ? X-rays show osteoarthritis without erosions, Ca++, etc
Does Negative RF, CCP, Normal ESR Affect Your Decision
A. YES B. NO
The Key: SYNOVITIS
Rheumatoid Arthritis
Osteoarthritis
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