Dr. Ioana Saulescu
complaints = among the
problems in clinical
All physicians have to
be able to recognize
The patient history and physical examination
= basis of diagnosis
Signs and symptoms of joint and extra-articular features
Why is it so important?
Sometimes, it is very easy to establish the
Six main types of a rheumatic complaint
Inflammatory musculoskeletal disease
Mechanical joint or periarticular disorder
Non-rheumatic disease (from distance-referred pain)
Disorder of unknown cause
Symptoms of a musculoskeletal problem
Loss of function
Fatigue and malaise
Depression and fear
A lot of questions for the clinician!
Pain -the most common cause of presentation
Establish a pattern for the pain!
Inflammatory joint pain:pain in the
morning, at rest, ameliorated by use
Mechanical joint pain: pain related
to joint use, ameliorated by rest
Neuralgic pain:diffuse pain and
parehestesia in dermatome
Root or peripheral
Bone pain:pain at rest , at night, but
also with use
Referred pain: pain unaffected by
From the distance
How long does it take you before you are moving as well as you are going to move for
Questions about stiffness
What joints or muscle does it affect?
When during the day?
How long does it last?
What makes it worse?
What improves it?
Swelling and deformity
Did it follow an injury?
Did it appear rapidly or
Does it come and go?
Is it gradually enlarging
Is it painful?
Joint or periarthicular structure
Of limbs or of the whole body
Muscle disorder or neuropathy
# general fatigue, depression, fibromyalgia.
Other important issues to asses
Is the problem mono/oligo or poliarthicular , symetric or asymetric?
Is it an acute, subacute or chronic problem? Is it progressive or recurrent problem?
Is there evidence of a systemic proces?
Is there a family history of a similar or related disorder?
Location and symetry(1)
Sometimes the most important clue in identifying the cause!
Specific arthropaties =predilection for specific joint areas.
Wrists and PIP of the hands and feet= rheumatoid arthritis,
DIP of the hands and feet=psoriatic /osteoarthritis ,
Big joints and spine=seronegative spondilarthritis,
Great toe: gout.
Do not forget SYMMETRY.
Onset and chronology
Acute onset, in hours/several days= attacks
of gout or septic arthrithis,
Subacute onset, in weeks/less than 3
month= majority of the rheumatic disease,
Chronic onset, over 3 month / years =
Persistent or recurrent.
Monoarticular joint disease(1)
Prompt evaluation to rule out
Mechanical or infiltrative disorders
Anthibiotherapy until exclusion of septic arthrtis
Acute/chronic monoarticular joint disease(2)
Crystal induced arthritis,
More rare: systemic disease presenting with
Malignancy, benign tumor.
You must distinguish between
articular and periarticular problem
Polyarticular joint disease
With/without axial involvement.
Establish pattern, range of motion,
signs of inflammation.
Pattern of joint involvement
Additive: most common, least specific,
Migratory: most characteristic of rheumatic
fever, Lyme disease, leukemia,
Intermitent (repetitive): crystal induced
disease, RA, SLE, sarcoidosis.
Osteoarthritis of the hand
DIP involvement Heberden nodes, PIP involvement
Deviation of the phalanges without a pattern,
Rheumatoid arthritis of the hands
without involving DIP,
Fusiform swelling of the
Swan neck deformity,
Atrophy of the
Involvement of DIP,
Rare involvement of the
Cristal induced arthritis
Often associated with
Usually in chronic
Gonococal septic arthritis =
Non-gonococal septic arthritis =
Viral arthritis = parvovirus B19, HBV.
swelling in lateral
RA, cristal induced,
begin with visualization of the girdle area.
From the front and from the back
Includes sternoclavicular, glenohumeral,
Notice the asymmetry,
Muscle atrophy: chronic disorder, like RA,
Sinovitis: visible when the effusion is large,
Active and pasive mobility.
Polymyositis, polymyalgia, fibromyalgia
of all small joints,
Acute: I phalang,
Chronic disorder: tophy.
As a whole and on region
Mechanical, inflamatory, septic, malignancy
Axial and peripheral.
Sometimes mixed complaints.
Usually young, male patients
Ask for family history
Look for genetic linkage
Infectious trigger: genito-urinary or enteric
Response to NSAID
An old disease may be complicated by a new
One patient may have different complaint!
Make the right exam and choose the proper