24 Differential Diagnosis

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rheumatology differential diagnosis

Text of 24 Differential Diagnosis

  • Differential diagnosis

    Dr. Ioana Saulescu

  • Musculoskeletal

    complaints = among the

    most common

    problems in clinical

    medicine

    All physicians have to

    be able to recognize

    this disorders.

  • Musculoskeletal disorders

    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

    diagnosis!

  • Six main types of a rheumatic complaint

    Inflammatory musculoskeletal disease

    Mechanical joint or periarticular disorder

    Bone disorder

    Non-rheumatic disease (from distance-referred pain)

    Functional disorder

    Disorder of unknown cause

  • Symptoms of a musculoskeletal problem

    Pain

    Stiffness

    Swelling

    Weakness

    Loss of function

    Fatigue and malaise

    Depression and fear

    Sleep disturbance

    Symptoms of

    systemic disease

  • A lot of questions for the clinician!

  • Pain -the most common cause of presentation

    Inflammatory pain

    Mechanical pain

    Neuralgic pain

    Bone pain

    Referred pain

  • Establish a pattern for the pain!

    Inflammatory joint pain:pain in the

    morning, at rest, ameliorated by use

    Inflammatory /

    infective disorder

    Mechanical joint pain: pain related

    to joint use, ameliorated by rest

    Degenerative

    disease

    Neuralgic pain:diffuse pain and

    parehestesia in dermatome

    Root or peripheral

    nerve compression

    Bone pain:pain at rest , at night, but

    also with use

    Tumor, Paget

    disease, Fracture

    Referred pain: pain unaffected by

    local movement.

    From the distance

  • Stiffness

    How long does it take you before you are moving as well as you are going to move for

    the day?

    MORNING STIFFNESS

  • 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

    slowly?

    Does it come and go?

    Is it gradually enlarging

    or progressing?

    Is it painful?

    Joint or periarthicular structure

    Effusion,

    Synovial proliferation

    Bony growth

    IMAGING!

  • Weakness

    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 =

    fibromyalgia.

    Persistent or recurrent.

  • Monoarticular joint disease(1)

    Prompt evaluation to rule out

    infections/malignancy

    Inflamatory/infectious disease

    Mechanical or infiltrative disorders

    Anthibiotherapy until exclusion of septic arthrtis

  • Acute/chronic monoarticular joint disease(2)

    Crystal induced arthritis,

    Septic arthritis,

    More rare: systemic disease presenting with

    monoarticular involvement,

    Malignancy, benign tumor.

    You must distinguish between

    articular and periarticular problem

  • Polyarticular joint disease

    Inflamatory/non-inflamatory disease,

    Acute/chronic,

    Oligoarticular/poliarticular,

    Symetric/asymetric,

    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.

  • The hand

  • Osteoarthritis of the hand

    Mechanical complain,

    DIP involvement Heberden nodes, PIP involvement

    Bouchard nodes

    Deviation of the phalanges without a pattern,

    Erosive arthrosis.

  • Rheumatoid arthritis of the hands

    Inflamator disease,

    Symmetrical pattern,

    without involving DIP,

    Fusiform swelling of the

    PIP,

    Swan neck deformity,

    boutonniere deformity,

    Atrophy of the

    muscules.

  • Seronegative spondilarthrities

    Psoriatic arthritis

    Involvement of DIP,

    Asymmetrical

    oligoarthritis or

    symmetrical poliarthritis

    Dactilitis.

    Reactive arthritis

    Rare involvement of the

    hand,

    Dactilitis,

    Keratodermia

    blenoragicum.

  • Cristal induced arthritis

    Condrocalcinosis

    Often associated with

    OA.

    Gout

    Usually in chronic

    disease,

    Tophi.

  • Systemic sclerosis

    Sclerodactyly,

    Raynaud syndrome

    Telangiectasias,

    Digital ulcers.

  • SLE

    Non- erosive,

    symmetrical arthritis,

    Jaccoud arthropaties.

  • Septic arthritis

    Gonococal septic arthritis =

    mono/oligoarthritis, tenosinovitis,

    Non-gonococal septic arthritis =

    monoarticular

    Viral arthritis = parvovirus B19, HBV.

  • Elbow

    periarthicular

    involvement: olecranon

    bursitis, epicondylitis,

    swelling in lateral

    process: synovitis.

  • Olecranon bursitis

    Posttrauma,

    Non-septic etiology:

    RA, cristal induced,

    Septic etiology:

    especially in

    immunosupression.

  • The shoulder(1)

    Proper examination:

    begin with visualization of the girdle area.

    From the front and from the back

    Includes sternoclavicular, glenohumeral,

    acromioclavicular joints

  • The shoulder(2)

    Notice the asymmetry,

    Muscle atrophy: chronic disorder, like RA,

    Sinovitis: visible when the effusion is large,

    Active and pasive mobility.

    Polymyositis, polymyalgia, fibromyalgia

  • The knee

    Osteoarthritis

    Rheumatoid arthritis

    Cristal induced

    arthritis.

  • The foot

    RA

    Symmetrical distribution

    of all small joints,

    Plantar blisters

    Psoriatic arthritis

    Asymmetry,

    dactilitis.

  • Reactive arthritis

    Mono/oligoarthritis

    Asymmetry,

    Dactilitis

    Entesitis

    Nodous erythema:

    yersinia,

  • Gout

    Acute: I phalang,

    Chronic disorder: tophy.

  • The hip

  • The spine

    As a whole and on region

    Mechanical, inflamatory, septic, malignancy

  • The spine

    Axial alone,

    Axial and peripheral.

    Sometimes mixed complaints.

  • Seronegative spondilarthritis

    Inflamatory complain

    Usually young, male patients

    Ask for family history

    Look for genetic linkage

    Infectious trigger: genito-urinary or enteric

    Response to NSAID

  • Older patients

    Osteoporosis

    Metastasis

    Spondilosis

  • Pay attention

    An old disease may be complicated by a new

    one!

    One patient may have different complaint!

    Make the right exam and choose the proper

    treatment!