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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