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THE IMPORTANCE OF HISTORY TAKING AND INTERPRETATION IN RHEUMATOLOGY:
History taking is the most important skill needed in rheumatology.
Obtaining a good rheumatology history involves the art of medicine
as much as its science. However, it is very difficult both to teach
and to learn the central art of history taking, which probably
depends more on experience than does any other aspect of medical
practice. When junior physicians complain that patients do not tell
them the same facts as they reveal to the senior consultants, they
are exposing their inability to take a good history. A good history
can be a powerful therapeutic experience for the patient, as well as
provide the physician with some 80% of the diagnostic information
required. History taking involves an initial (patient-centered)
listening phase which is a therapeutic process in itself and a
second (physician-centered) interrogative phase which enables the
physician to sort out the nature of the problem (diagnosis) and
decide on any further course of action that might need to be taken.
The physician needs to learn about the major presenting symptoms,
the chronology of the disorder and its impact on the patient and the
people around the patient, as well as ancillary information such as
past and family history and involvement of other systems. At the
same time, patients must have the opportunity to voice the problems
that matter most to them.
Most physicians think that they are good at communicating with their
patients, but surveys of the patients themselves disagree: all
physicians should be prepared to be critical of their technique when
interviewing patients and to spend more time learning the key skill
involved in communication.
It is important to note that acute symptoms, whether mono- or
polyarticular, may represent musculoskeletal emergencies. Such
emergency conditions include infection (septic arthritis, subacute
bacterial endocarditis, osteomyelitis, necrotizing fasciitis),
systemic vasculitis, acute myelopathy or cervical cord compression,
fracture, deep vein thrombosis, compartment syndromes and tumor.
Delayed diagnosis may lead to permanent disability or death. Thus,
it is very important that these conditions be excluded before
proceeding with evaluation of the major diagnostic possibilities.
What is arthritis:
Arthritis is joint inflammation. Arthritis may involve a single
joint (monoarthritis) or it may involve 2-4 joints (oligoarthritis)
or it may involve more than 4 joints (polyarthritis).
Clinically: Pain in the joint(s) that is accompanied by objective
signs of joint inflammation. The most common sign is swelling
(effusion). Joint pain causes limitation of both active and passive
movements. It is important to differentiate between mechanical and
inflammatory types of pain. Mechanical pain is increased with
activity and is relieved by rest and is not associated with morning
stiffness more than 30 minutes. Inflammatory pain, on the other
hand, is increased with rest and is relieved to some extent by
moderate activity. It is associated with morning stiffness more than
30 minutes.
Redness and hotness of the joint may also be seen in conditions
characterized by pretty aggressive and acute inflammation as septic
arthritis, gout, acute rheumatic fever and palindromic rheumatism.
STEPS IN HISTORY TAKING FROM A PATIENT WITH ARTHRITIS
I. Identifying data:
1. Age and sex
2. Race
3. Residence and occupation
II. Present history:
A. Pattern recognition:
1. Mode of onset
2. Duration of symptoms
3. Number of joints affected
4. Symmetry
5. Regions or joints affected
6. Pattern of sequence of joint involvement
7. Quality and severity of symptoms
8. The setting in which symptoms occurred
9. Factors that aggravate and ameliorate symptoms
10. Associated manifestations
B. Diet, special habits
C. Relevant data from the patient's chart
D. Drugs
III. Past history
IV. Family history
I. IDENTIFYING DATA
I. IDENTIFYING DATA/1. AGE AND SEX
"As a rule, it is important to note that infection can occur in all
age groups of either sex."
CHILDREN:
Some rheumatic diseases may (or may not) start in childhood and
continue to adulthood. In fact, a significant fraction of adults
with rheumatic diseases have the onset of their disease in
childhood. Up to one fifth of all patients with systemic lupus or
dermatomyositis/polymyositis have the onset of their disease before
age 16 years. Other diseases include spondyloarthropathies and
rheumatoid arthritis.
Some rheumatic diseases occur almost exclusively in those under 16
years of age. Included in this category are juvenile rheumatoid
arthritis, acute rheumatic fever and some vasculitides (Henoch
Schonlein purpura and Kawasaki disease).
Certain rheumatic diseases almost never occur in childhood. Included
in this group are gout, calcium pyrophosphate deposition disease (CPPD
disease), polymyalgia rheumatica and primary osteoarthritis.
Many of the rheumatic diseases of childhood have characteristic ages
of onset so that consideration of the age of the child at the onset
of symptoms can be of value in diagnosis. For this purpose, four age
groups can be considered:
The neonatal period: Three rare syndromes occur. These are neonatal
lupus syndromes, neonatal onset multisystem inflammatory disease (NOMID,
also called chronic infantile neurological, cutaneous and articular
syndrome-CINCA) and infantile sarcoidosis. In addition, septic
arthritis may occur in the neonate.
Early childhood (from 1-4 years): early type of oligoarticular
juvenile chronic arthritis, juvenile psoriatic arthritis, Kawasaki
disease and septic arthritis.
Mid childhood (5-11 years): polyarticular juvenile chronic
arthritis, late type of oligoarticular juvenile chronic arthritis
(juvenile ankylosing spondylitis), juvenile dermatomyositis begin to
be seen. Henoch Schonlein purpura and polyarteritis nodosa have
their peak frequencies.
Late childhood (above 11 years) and teenage years: Juvenile
ankylosing spondylitis (in boys) and systemic lupus erythematosus
(in girls) show a marked increase in incidence. The rare vasculitic
syndromes such as Wegener's granulomatosis and Takayasu's arteritis
occur.
Important Notes:
The systemic type of JRA can have its onset at any age during
childhood.
In a child with acute onset of monoarthritis, the initial
differential diagnosis should include:
Infection (septic arthritis and/or osteomyelitis)
Trauma (accidental or non-accidental)
Malignancy (leukemia and neuroblastoma).
In a child with chronic monoarthritis, the differential diagnosis
includes:
1. Oligoarticular JRA
2. A seronegative spondyloarthropathy or one of the related
disorders as coeliac disease (CD) which occurs in mid-late
childhood, monoarthritis may antedate clinical bowel involvement;
diagnosed by antigliadin and anti-endomysium antibodies; it is
recommended that the possibility of CD be considered in any child
with arthritis of unclear origin; gluten-free diet results in
persistent remission of arthritis.
3. In addition, a number of uncommon disorders should also be
included as intra-articular hemangiomas, synovial chondromatosis,
villonodular synovitis, lipomatosis arborescens, osteoid osteomas,
osteochondritis disssecans (especially at the knee) and discoid
meniscus.
Influence of sex in children:
The most striking differential sex ratios are seen in the
predominance of juvenile ankylosing spondylitis (spondyloarthropathis
in general) in boys and of systemic lupus in girls although in the
later disease, the ratio is closer to unity in the very young.
Oligoarticular juvenile chronic arthritis, especially when
accompanied by uveitis, is much more common in girls than in boys.
Vasculitides are more common in boys than in girls.
Systemic onset juvenile chronic arthritis occurs with equal
frequency in both sexes.
YOUNG AND MIDDLE-AGED ADULTS:
Men aged 25-50: Reiter's, ankylosing, gonococcal arthritis, gout,
internal derangement, osteoarthritis, hemochromatosis.
Women aged 25-50: Systemic lupus, rheumatoid arthritis, fibromyalgia,
benign hypermobile syndrome, osteoarthritis.
OLDER ADULTS:
There are diseases that are not seen as new onset disease among
older people. These include Reiter's disease, Still's disease and
ankylosing spondylitis. By contrast, there are diseases that occur
almost exclusively in the older population. These include primary
osteoarthritis, polymyalgia rheumatica, giant cell arteritis,
Sjogren's syndrome and CPPD disease.
Equally important in geriatric rheumatology is the fact that
musculoskeletal symptoms occurring in the older age group may
reflect a wide variety of conditions, many of them with serious
implications which are not usually regarded as falling within the
constellation of rheumatic disease. Examples include carcinomatosis,
multiple myeloma, hyperthyroidism, myxedema and a variety of
neurological entities including Parkinson's disease and Alzheimer's
disease. Differential diagnosis requires a broad understanding of
many aspects of clinical medicine including ones that fall outside
the frame of reference of traditional rheumatology.
Diseases that are more common in males:
Ankylosing spondylitis
Churg Strauss: 15-70 years, mean 38 years. Males twice as common as
females.
Gout
Pancreatic arthropathy
Polyarteritis nodosa: Males twice as common as females.
Primary amyloidosis: middle age and elderly, mean age at diagnosis
55 years. More in men. More in whites.
Reiter's disease: young men: the most common cause of inflammatory
arthritis of the lower extremities in young men. Twenty times more
frequent in men.
Rheumatoid vasculitis: middle-aged male with a long standing RA.
Wegener's granulomatosis: 3 months-75 years, peak 30s-40s. Slight
male predominance.
Whipple's: middle aged whites, may be familial. More in men.
Diseases that are more common in females:
By pass arthritis dermatitis: within 1 year of the operation. Three
times more common in women.
Collagenous colitis: mid fifties. More in women.
Felty's syndrome: in whites who have had RA for more than 10 years.
Two thirds are women.
Henoch Schonlein purpura: More in winter and early spring. 4-11
years, any age.
Hypocomplementemic vasculitis: young adults
Mixed connective tissue disease
Mixed cryoglobulinemia: Middle age. More in women.
Multicentric reticulohistocytosis: 11-71 years, mean age 30 years.
Slight female predominance.
Rheumatoid arthritis: 3 times more common in females
Sjogren's syndrome
Systemic lupus erythematosus
Systemic sclerosis
Takayasu arteritis: 10-30 years, children and young women.
Temporal arteritis: 50 years and above, mean age 70 years. Females
twice as common as males.
Examples of diseases that show an equal sex distribution include
psoriatic arthritis.
I. IDENTIFYING DATA/2. RACE
Whites: Ankylosing spondylitis, Whipple's disease.
Blacks: Sickle cell disease
I. IDENTIFYING DATA/3. RESIDENCE AND OCCUPATION
These are more likely to be related to infectious diseases
(reference here is made to residents of Middle East).
Residence in Fayoum (Egypt): leprosy
Residence in Saudia Arabia should raise the suspicion of Medina worm
infection.
A farmer or gardener exposed to soil may have sporotrichosis.
Butchers and farmers may get infected with Coxiella Burnetti (Q
fever), brucella.
II. PRESENT HISTORY
II. PRESENT HISTORY/A. PATTERN RECOGNITION
A. PATTERN RECOGNITION
1. Mode of onset
2. Duration of symptoms
3. Number of joints affected
4. Symmetry
5. Regions or joints affected
6. Pattern of sequence of joint involvement
7. Quality and severity of symptoms
8. The setting in which symptoms occurred
9. Factors that aggravate and ameliorate symptoms
10. Associated manifestations
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/1. MODE OF ONSET
Hyperacute onset of pain with peak intensity reached within seconds
to minutes:
Fracture, internal derangement.
Acute onset of pain with peak intensity reached within hours to a
few days:
Bacterial arthritis, viral arthritis (e.g. parvovirus 19 and
rubella), acute rheumatic fever, reactive arthritis, palindromic
rheumatism, crystal-induced arthritis (the best example being
nocturnal attacks of gout), elderly onset RA (acute monoarthritis of
the large joints with slow and incomplete remissions)
Insidious onset of pain with peak intensity reached gradually over
several weeks to months:
Juvenile rheumatoid arthritis (oligo and polyarticular types),
rheumatoid arthritis, osteoarthritis, psoriatic arthritis,
hypertrophic osteoarthropathy, mycobacterial and fungal arthritis,
most cases of neuropathic arthropathy (Charcot's joints), tumors,
infiltrative diseases.
Note:
It is important to note that variations may occur and the same
disorder may have a sudden onset in some patients and a gradual
onset in others. Rheumatoid arthritis, for example, may present as
an acute polyarthritis (especially in the elderly) and psoriatic
arthropathy as an acute monoarthritis resembling gout, whereas in
most cases both disorders begin insidiously.
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/2. DURATION OF SYMPTOMS
Self-limiting disorders are those disorders in which the arthritis
lasts less than 4-6 weeks.
In self-limiting arthritic disorders, the duration of symptoms and
signs may be a valuable discriminating feature.
Examples:
Episodes of palindromic rheumatism disappear within hours to several
days.
Attacks of rheumatic fever arthritis never last more than 5-6 days
in any individual joint.
Early episodes of monoarticular gout tend to subside spontaneously
after 3-10 days and resolution is complete.
Acute or subacute attacks of CPPD disease (pseudogout) may last from
2-3 days to 3-4 weeks.
Chronic disorders are those disorders where the arthritis lasts
longer than 6 weeks.
A. PATTERN RECOGNITION/3. NUMBER OF JOINTS AFFECTED
THE CLINICAL PATTERN MAY BE MONOARTICULAR, POLYARTICULAR OR
OLIGOARTICULAR.
MONOARTHRITIS: This is the involvement of a single joint. Although
almost any individual arthropathy may begin as monoarthritis, the
initial pattern of some disorders is characteristically
monoarticular regardless of the subsequent course.
Chronic monoarthritis is often the presenting feature of a variety
of joint disorders. Histologic elucidation may be necessary to make
the correct diagnosis. In a substantial number of patients, however,
the cause remains undetermined.
CAUSES OF MONOARTHRITIS: With rare exceptions, any disorder is
capable of presenting initially as monoarthritis.
Diseases that are usually monoarticular:
Congenital: Congenital hip dysplasia
Traumatic: Internal derangement, stress fracture with effusion in
adjacent joint, osteochondritis dissecans, loose body, slipped
capital femoral epiphysis
Inflammatory: Pauciarticular JRA, palindromic rheumatism,
crystal-induced, sometimes seronegative spondyloarthropathies
Infectious: bacterial, fungal, TB, viral (AIDS), osteomyelitis
(sympathetic effusion).
Neoplastic: Osteoid osteoma, Synovial osteochondromatosis, pigmented
villonodular synovitis (PVNS), synovioma, osteogenic sarcoma,
neuroblastoma, metastasis, leukemia, lymphoma.
Infiltrative: one type of chronic sarcoidosis
Miscellaneous: Acute coagulopathy, hemoglobinopathy, osteonecrosis,
Paget's involving joint, neuropathic, reflex sympathetic dystrophy,
intermittent hydrathrosis, neurofibromatosis, pancreatic fat
necrosis, familial Mediterranean fever (FMF), foreign body synovitis,
sea urchin spine synovitis, plant thorn synovitis, Gaucher's
disease, transient osteoporosis
Notes:
Single red hot joint in RA: Owing to the frequency of the underlying
disease, it should be remembered that the uncommon occurrence of a
red hot joint in the context of RA may be due to superimposed septic
arthritis and not to the disease process itself.
Monoarthritis in SLE: The occurrence of monoarthritis in a patient
with SLE suggests infection or osteonecrosis.
Hemoglobinopathies (sickle cell arthritis): Arthritic pain, swelling
and effusion may be related to periarticular infarction or gouty
arthritis. The arthritis usually responds to nonsteroidal
anti-inflammatory drugs. Bone infarction and osteonecrosis may
occur. Excruciating pain due to bone infarction, the hand-foot
syndrome or dactylitis, is the most common initial symptoms of
sickle cell disease, occurring in 40 percent of patients overall and
50 percent of children who became symptomatic before age two. It is
important to distinguish this syndrome, which resolves
spontaneously, from osteomyelitis with nuclear medicine scintigraphy
or magnetic resonance imaging (MRI). Osteomyelitis: There is an
increased incidence of osteomyelitis in patients with sickle cell
anemia resulting from infection of infarcted bone.
Paget's disease: Pain may arise either directly from a pagetic
lesion or, more often, from complications indirectly caused by the
abnormal bone, including degenerative arthritis, nerve impingement,
or osteosarcoma.
OLIGOARTHRITIS: This is the involvement of 2 to 4 joints.
In general, some of the rheumatic disorders manifesting as
monoarthritis may also be oligoarticular. Example: oligoarticular
JRA and Coagulopathy. At the same time, many of the rheumatic
disorders manifesting as polyarthritis may also be oligoarticular
Despite this overlap, there are instances in which involvement of
two or three joints rather than one may significantly narrow the
diagnostic spectrum.
Example 1: lower limb oligoarthritis especially of the knees and
ankles in an asymmetric fashion is reminiscent of reactive
arthritis.
Example 2: an asymmetric oligoarthritis affecting DIP and PIP and
MCP joints characterizes a common subgroup of patients with
psoriatic arthropathy.
POLYARTHRITIS: This is the involvement of more than 4 joints. A wide
variety of inflammatory and non-inflammatory disorders, both common
and uncommon may present as polyarthritis. Examples include:
Diseases that are often polyarticular:
Inflammatory: Rheumatoid arthritis, JRA (polyarticular and Still's),
adult Still's, Sjogren's, SLE and other CT diseases, seronegative
spondyloarthropathies and related disorders, calcium pyrophosphate
deposition disease, ca oxalate deposition disease, Vasculitides (Henoch
Shonlein Purpura, Bechet's, PAN, Wegner's, Takayasu, temporal
arteritis, PMR), Pseudovasculitic syndromes (MCES, SABE), Erythema
nodosum, pyoderma gangrenosum, serum sickness (HBV, Rubella),
relapsing polychondritis.
Infectious: bacterial (neisserial gonorrhea, brucellosis, mycoplasma),
viral (Parvovirus, AIDS), Lyme disease, spirochetal (leprosy),
fungal (candida in immunocompromised subjects)
Neoplastic: Paraneoplastic syndromes (HPO, carcinoma polyarthritis
and Jaccoud's arthropathy), metastasis, leukemia, lymphoma
Infiltrative: Sarcoidosis, Chondrocalcinosis-like syndromes (Hemochromatosis,
Ochronosis, Wilson's), amyloidosis with MM, Gaucher's disease
Miscellaneous:
Degenerative: Osteoarthritis, DISH
Years of build up: Dialysis arthropathy, chronic articular
hemorrhage (Coagulopathy)
Endocrinal: hyperparathyroidism, hypothyroidism, acromegaly
Metabolic: Hyperlipidemias types II & IV
Bone diseases: multiple epiphyseal dysplasia
Skin conditions: acne fulminans, Sweet's syndrome, angioedema
Drug-related: pseudorheumatism, anthracyclines, penicillamine
MRH, HPO, FMF, Immunodeficiency syndromes, Sea urchin spine
synovitis
Notes:
Arthritis in Bechet's: A nonerosive, asymmetric, usually
nondeforming oligoarthritis occurs in about one-half of patients
with Behcet's disease, particularly during exacerbations of illness.
The arthritis most commonly affects the medium and large joints,
including the knee, ankle, and wrist; inflammation is evident on
synovial fluid and biopsy specimens. Pseudopodagra has also been
described in these patients. Sacroiliitis may occur, particularly in
patients with HLA-B27).
Temporal arteritis: Musculoskeletal symptoms, in addition to those
of PMR, have been observed in patients with GCA. In a cohort of 128
patients, for example, peripheral synovitis, distal extremity
swelling with pitting edema, swelling without pitting edema,
tenosynovitis, and carpal tunnel syndrome developed in 23, 13, 5, 6,
and 2 patients, respectively. The onset of most symptoms occurred
within two years of the initial diagnosis.
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/4. SYMMETRY
Symmetrical arthritis: occurs in rheumatoid arthritis that happens
to be the classic example of symmetric arthritis. However, symmetry
is not necessarily strict in the hands: the same MCP or PIP joint
may not be equally affected in both extremities of RA patients
especially in early disease.
Other examples of symmetrical arthritis include:
Inflammatory:
From the RA family: JRA (systemic and polyarticular types), Adult
onset Still's disease, Sjogren's
Other CT diseases: SLE, MCTD, SSc, PM/DM, Adult onset rheumatic
fever, Polymyalgia rheumatica
Erosive inflammatory osteoarthritis, CPPD disease (pseudo-RA type),
Milwaukee shoulder
Infectious:
Viral arthritis especially parvovirus arthritis, Lyme disease
Infiltrative:
Sarcoid arthritis (acute type), Amyloid arthropathy, Hemochromatosis
arthropathy
Neoplastic:
Jaccoud's arthritis, Hypertorphic osteoarthropathy
Endocrinal:
Myxedematous arthropathy
Asymmetrical arthritis:
Inflammatory:
Seronegatives (e.g. reactive arthritis, oligoarticular psoriatic
arthritis)
From the RA family: pauciarticular juvenile rheumatoid arthritis,
palindromic rheumatism
Oligoarticular or polyarticular gout, CPPD disease (pseudogout type)
Infectious:
bacterial arthritis and bacterial endocarditis.
Notes:
Every patient with a symmetric disorder may have an initial
asymmetric phase.
Most asymmetric arthritides may be or are characteristically
initially monoarticular.
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/5. REGIONS OR JOINTS AFFECTED
Axial involvement:
Axial structures include, apart from the spine,
centrally located joints such as the sacroiliac, sternoclavicular,
manubriosternal and the rest of the chest wall and sometimes
shoulders and hips. In the presence of peripheral arthritis, one of
the most important clues is to determine whether there is
concomitant axial involvement or not. While some rheumatic disorders
rarely affect the axial segments, a combined pattern is often seen
in others.
Examples:
Inflammatory:
Seronegative spondyloarthropathies.
Polyarticular and systemic onset JRA as well as adult onset Still's
disease that commonly affect the apophyseal joints of the cervical
spine in addition to peripheral joints.
Rheumatoid arthritis: involvement of the cervical spine structures
is common, whereas the dorsal and lumbar segments are spared.
Persistent pain in these areas should raise the suspicion of
insufficiency fractures of the spine, sacrum or iliac bones.
Tuberculosis: affects the spine in addition to large peripheral
joints as knees and hips. Midtarsal joints' involvement has been
reported.
The SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and
osteitis).
Non-inflammatory:
Degenerative:
Osteoarthritis of the spine that often coexists with appendicular
involvement.
Diffuse idiopathic skeletal hyperostosis.
Endocrinal:
Acromegalic arthropathy: Hypermobility of the spine. Also,
involvement of large and small peripheral joints may occur in as
many as 75% of patients. It may be monoarticular or polyarticular.
The knees, shoulders, hips, or hands are more commonly affected; the
elbows and ankles are involved less frequently.
Infiltrative:
Ochronosis
Miscellaneous:
Spondyloepiphyseal dysplasia.
Peripheral involvement:
Affection of certain joints is closely
associated with the early phases of certain diseases. Consequently,
their involvement often facilitates the diagnostic process.
Joints commonly involved and commonly spared in selected
rheumatic diseases:
Rheumatoid arthritis:
Involved: Wrist, MCP, PIP, elbow, glenohumeral,
cervical spine, hip, knee, ankle, tarsal, MTP.
Spared: Thoracolumbar spine
Osteoarthritis:
Involved: First CMC, PIP, DIP, Cervical spine, thoracolumbar
spine,
hip, knee, First MTP, toe IPs.
Spared: MCP, Wrist, elbow, glenohumeral,
ankle, tarsal
Reiter's disease:
Involved: Knee, ankle, tarsal, MTP, toe IPs, elbow, axial
Psoriatic arthritis:
Involved: Knee, ankle, MTP, toe IPs, wrist, MCP, PIP, DIP,
axial
Enteropathic arthritis:
Involved: knee, ankle, elbow, shoulder, MCP, PIP,
wrist, axial
Sarcoidosis:
Involved: Ankle, knee
Hemochromatosis:
Involved: MCP, wrist, knee, hip, feet, shoulder
Spared: Axial
Polyarticular gout:
Involved: First MTP, instep, heel, ankle, knee
CPPD:
Involved: Knee, wrist, shoulder, ankle, MCP, PIP, DIP,
hip, elbow.
Spared: Axial
Gonococcal arthritis:
Involved: Knee, wrist, ankle, PIP, DIP
Spared: Axial
Sporotrichosis:
Involved: Hand
IV drug users:
Involved: Septic Sternoclavicular arthritis
Other examples:
1. Hypothyroidism: Myxedema arthropathy occurs in one third of
hypothyroid patients. The arthritis is usually bilateral, most often
affecting the knees; the ankles, metacarpophalangeal joints, and
small joints of the hands and feet are less frequently involved. The
increased intra-articular viscid fluid is reflected in a sluggish
"bulge" sign.
2. Hyperparathyroidism: interphalangeal, metacarpophalangeal,
carpal, and acromioclavicular joints. Bone erosions may occur in
juxta-articular sites in these joints. These lesions can be found in
the absence of subperiosteal resorption, can be symmetric, and can
be associated with morning stiffness, thus mimicking RA. Several
features distinguish parathyroid disorders: (1) the erosions may
have a shaggy appearance; (2) they often occur at the distal
interphalangeal joints and spare the proximal interphalangeal
joints; (3) joint-space narrowing in association with these erosions
is uncommon because parathyroid hormone does not directly induce
inflammatory synovitis or cartilage dissolution; and (4) concurrent
articular calcification is common.
3. Diabetic neuroarthropathy: As a consequence of sensory
neuropathy, severe ar-thropathy with Charcot-like changes develops
in approximately 0.1% of patients with long-standing diabetes. The
tarsometatarsal and metatarsophalangeal joints are by far the most
common sites of involvement. Changes may rarely affect joints above
the ankle. A combination of microfragmentation from trauma, ischemia
from small blood vessel disease, and superimposed infection can
contribute to the clinical and radiographic changes of
neuroarthropathy. All patients with diabetic neuroarthropathy have
peripheral neuropathy. Unstable gait may be seen in diabetic
neuroarthropathy of the tarsometatarsal and metatarsophalangeal
joints. This is because, in advanced disease, the longitudinal arch
of the foot collapses, leading to an unstable gait and a
"rocker-sole" appearance. Ulcerations and plantar callosites occur
over hypoesthetic pressure points.
4. Cushing's syndrome: A polyarthropathy associated with Cushing's
disease has been reported.
5. Hyperlipoproteinemias: Type II homozygous hyperlipoproteinemia:
Large joint migratory polyarthritis. Type II heterozygous
hyperlipoproteinemia: recurrent migratory polyarthritis involving
knees, other large joints and to a lesser extent small joints OR
monoarthritis involving the knee or great toe (NB: fever may
accompany the arthritis). Type IV hyperlipoproteinemia: an
asymmetric oligoarthritis involving small and large joints appearing
in middle aged patients and lasting a few days to weeks.
NB: The arthritis in type II hyperlipoproteinemia resembles that of
rheumatic fever: migratory arthritis / sudden onset / lasts for a
few days (but may last up to 2 weeks) / involved joints can be warm,
erythematous, swollen and tender / no joint damage occurs / patients
have a high ESR and a falsely elevated ASOT and, in some cases,
aortic valvular disease secondary to atherosclerosis / several
attacks occur in a year.
NB: Joint fluid in hyperlipidemic arthritis is non-inflammatory with
few or no crystals.
6. HCV arthritis: wrists and small joints of the hands. It is
sometimes difficult to differentiate from rheumatoid arthritis.
7. HCV-cryoglobulinemic arthritis: an intermittent, mono or
oligoarticular, nondestructive arthritis affecting large and medium
sized joints.
8. Polymyalgia rheumatica: Clinical synovitis is most frequently
noted in the knees, wrists and sternoclavicular joints. Joint
effusions have WBC counts that range between 1000 and 20,000
cells/mm.
9. Hypermobility syndrome: traumatic arthritis, synovitis and
effusions, juvenile episodic synovitis. Also arthrlagias, TMJ
dysfunction.
10. Osteoid osteoma: ankle, subtalar, elbow.
11. Neurofibromatosis: plexiform neurofibromatosis around the ankle
in children may present with a picture very similar to chronic
monoarthritis. Also, osteoid osteoma which, in the author's
experience, has been present in a child with neurofibromatosis may
present as monoarthritis.
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/6. PATTERN OF SEQUENCE OF JOINT INVOLVEMENT
Clinical involvement of joints may follow three major patterns:
additive, migratory and intermittent:
Additive: refers to the involvement of more joints while the
previous joints remain symptomatic. This is a rather non-specific
pattern. Polyarticular osteoarthritis (OA) and rheumatoid arthritis
(RA) are typical examples of this progressive sequence.
Migratory: means that the process ceases or abates in one joint
while simultaneously or immediately after starts in a previously
normal joint.
Examples include:
Inflammatory: Rheumatic fever, Whipple's disease
Infectious: Gonococcal arthritis (associated with tenosynovitis)
Infiltrative: acute sarcoid arthritis (sometimes)
Metabolic: Arthritis of hyperlipoproteinemia
Early Lyme disease
Note: It is important to note that the monoarthritis that some
patients may present with may actually be part of a migratory
disease.
Intermittent: means there is complete remission of symptoms and
signs until the next recurrence in the same or other joint. No
evidence of active disease or residual signs can be detected during
the inter-attack intervals.
Examples include:
Palindromic rheumatism
Intermittent hydrathrosis
Crystal induced arthritis as gout, CPPD (pseudo-gout type)
Familial Mediterranean fever: acute, self-limited large joint
monoarthritis (most often affecting the knee or hip). Rarely, a more
protracted arthritis may occur.
ALSO:
Inflammatory:
From RA family: Adult onset Still's disease may also run a
polycyclic clinical course
CT diseases: Patients with SLE also often show complete resolution
of synovitis (commonly polyarthritis) and follow a discontinuous
pattern of arthropathy.
HCV-cryoglobulinemic arthritis: intermittent non-destructive mono-
or oligoarthritis.
Seronegatives: Reiter's syndrome
Other:
Early phases of erosive inflammatory osteoarthritis
Endocrinal:
Early phase of acromegalic arthropathy. Some patients develop
intermittent painful effusions lasting weeks or months. Less
commonly, patients complain initially of joint pain and morning
stiffness. This presentation, together with the elevated erythrocyte
sedimentation rate seen in some patients, can cause confusion with
rheumatoid arthritis (RA).
Metabolic:
Hyperlipoproteinemia: Recurrent attacks of migratory polyarthritis
in 50% of patients with type II hyperlipoproteinemia heterozygous
type. They are self-limited lasting several days to 2 weeks. The
inflammation may be mild or severe resembling rheumatic fever or
episodes of gout.
Note: In case of intermittent pattern, it is important to inquire
about the location of the previous attacks. For example, previous
acute attacks that resolved spontaneously in the same joint suggest
crystal deposition diseases while previous acute attacks that
resolved spontaneously in other joints suggest palindromic
rheumatism.
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/7. QUALITY AND SEVERITY OF PAIN
Quality of pain:
Burning pain especially at night or pain described as electric
shock-like or shooting: suspect neuropathic origin rather than
arthritis e.g. entrapment.
Pain described as severe aching sensation: may originate in the
joints
An attack of pain that begins in the middle of the night with a
pricking sensation in the great toe which quickly builds up into an
intolerable burning pain: typical gouty podagra.
Throbbing pain: may be vascular.
Note:
However, neither the adjectives that the patients use to describe
their pain nor their assessment of its severity is generally of
great diagnostic value.
Severity of pain:
Severe pain with joint dysfunction following a minor trauma:
Osteochondritis dissecans
Severe pain with moderate physical findings: SLE, FMF, leukemia.
Mild pain with impressive physical findings: Neuroarthropathy
Extreme description of pain: central pain where there is perception
of pain with no evident external causes. However it is important to
consider that sometimes some individuals or groups of individuals
tend to use these extreme terms out of a sense of frustration or
anxiety or because of ethnic variation and risk being labeled as
neurotic because of them when the presence of organic disease may be
missed
Note:
When history reveals long-standing symptoms in a joint, it is
important to distinguish exacerbations of pre-existing disease (e.g.
worsening of degenerative joint disease with excessive use) from a
second superimposed process (e.g. infection).
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/8. THE SETTING IN WHICH IT OCCURRED
Hospitalized patients: acute gout, pseudogout and infection. These
patients are often middle-aged or elderly, the primary age range for
the crystalline arthropathies, In addition, they often have
hospitalization-related risk factors known to provoke gout or
pseudogout attacks: trauma, surgery, hemorrhage, infection, or
medical stress such as renal failure, myocardial infarction and
stroke. One must also be very careful to exclude infection in these
patients.
Postpartum period: onset or flare of RA.
Penetrating trauma: Infection.
Recent upper respiratory tract infection: Henoch Shonlein purpura,
post streptococcal reactive arthritis (most patients "children" only
have mild pharyngitis by history).
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/9. FACTORS THAT AGGRAVATE OR RELIEVE SYMPTOMS
FACTORS THAT AGGRAVATE SYMPTOMS:
Pain that worsens with activity: mechanical causes or
non-inflammatory causes.
Pain that worsens at night and with rest: inflammatory causes.
Constant severe pain, present throughout the day and night and not
affected by or linked to anything might be due to a bone disorder
but can also be functional.
Pain that increases with limb dependency: Hypertrophic
osteoarthropathy.
Pain that increases with limb elevation: ischemia.
Pain that comes or increases with alcohol: Gout, hypertrophic
osteoarthropathy
FACTORS THAT AMELIORATE SYMPTOMS:
Morning stiffness and gelling that improves with motion:
inflammatory arthritis.
Joint pain that improves with rest: mechanical causes.
Aspirin: dramatically relieves the pain of osteoid osteoma (OO). It
is suggested that synovitis in OO is secondary to prostaglandin
secretion by the tumor.
Limb elevation: Improves the pain of hypertrophic osteoarthropathy.
Examples of inflammatory arthropathies include:
Rheumatoid arthritis and its variants
CT diseases
Seronegative spondyloarthropathies & related disorders as SAPHO
syndrome
Crystal arthritis
Infectious arthritis
Examples of non-inflammatory arthropathies include:
Degenerative and related disorders:
Osteoarthritis
Epiphyseal dysplasia
Familial hypertrophic synovitis (CAC syndrome)
Endocrinal arthropathies:
Hypothyroidism: Myxedema arthropathy (noninflammatory viscous
effusions with leukocytic counts less than 1000/mm3. Inflammation is
neither common nor severe, with minimal pain and tenderness and only
slight warmth and erythema).
Acromegalic arthropathy: proliferation of articular and
periarticular structures, with osteophytosis and degenerative
changes of the articular cartilage.
Hyperparathyroidism
Metabolic:
Hyperlipoproteinemia arthropathy
Infiltrative:
Ochronosis
II. PRESENT HISTORY/
A. PATTERN RECOGNITION/10. ASSOCIATED OTHER MUSCULOSKELETAL MANIFESTATIONS
Presence of redness:
Although redness may occur in any acute arthritis regardless of the
etiology, its presence is more often suggestive of infections as
bacterial and neisserial (which may be preceded by transient
polyarticular disease), crystal arthritis (gout, pseudogout,
hydroxyapatite as acute calcific periarthritis), acute rheumatic
fever, psoriatic arthritis, reactive arthritis and palindromic
rheumatism.
The presence of erythema implies associated periarticular
inflammation.
Sausage digits:
Psoriatic arthritis
Periarthritis:
Acute sarcoidosis: sometimes is a polyperiarthritis rather than
polyarthritis
Hyperlipidemic arthritis is considered to be an inflammatory
periarthritis or peritendinitis
Palindromic rheumatism, sometimes inflammation is beside, rather
than, in the joint.
Hypermobility:
Hypermobility syndrome
Hyperparathyroidism: more prominent in the lumbar spine.
Hypothyroidism: Ligamentous laxity occurs in approximately one third
of patients with myxedema.
Early phase of acromegalic arthropathy. Hypermobility is especially
prominent in the spine. This striking finding may be a key in
distinguishing between this and other spinal disorders. Loss of
motion, on the other hand, characterizes the late phase of the
disease. Palpable dorsal phalangeal ridging just distal to the
proximal interphalangeal joints and pronounced degree of joint
crepitation attributed to cartilaginous thickening and joint
hypermobility may also be seen in acromegalic arthropathy.
Occurrence of skin desquamation when inflammation declines:
Suggests acute gouty monoarthritis.
Puffy hands:
Hypothyroidism
RS3PE (remitting symmetrical seronegative
synovitis with pitting edema)
Thickening of periarticular tissues:
1. Hypothyroidism: myxedema arthropathy
2. Acromegalic arthropathy: Thickened synovium and periarticular
tissues may have a swollen appearance, but effusions are relatively
rare.
Periarticular hyperesthesia:
Type IV hyperlipoproteinemia
Vasculitis (if hyperesthesia is in feet for
example)
Unequal leg girth:
Neurofibromatosis (also associated with pes cavus, spinal bifida).
Muscle cramps:
Hypothyroidism
Acromegaly
Dorsal kyphosis:
Hyperparathyroidism: secondary to ligament laxity (associated with
anterior bowing of the sternum).
Acromegaly: dorsal kyphosis is frequently observed, possibly
secondary to the barrel-chest deformity related to rib elongation.
Variable pain in hands and feet (+/-digital clubbing and local signs
of inflammation):
Hypertrophic osteoarthropathy, acquired pachydermoperiostosis
Acromegaly (widening of the distal ungual tufts in acromegaly may
lead to an appearance of the hands similar to that of clubbing) and
thyroid acropachy.
Recurrent traumatic soft tissue injuries or recurrent fractures:
Benign hypermobile syndrome: recurrent bruising, sprains, meniscus
tears, acute or recurrent dislocations/subluxations of the:
shoulder, patella, metacarpophalangeal joint, temporomandibular
joint.
Important Notes:
Systemic versus local nature of disease: It is important to
differentiate systemic from local nature of the disease that is
being dealt with. If there is suspicion of a systemic disease, a
full systematic medical inquiry must be embarked upon and any
significant symptoms or signs noted. Systemic disease is suggested
by the patient looking ill, weight loss, dysnea, fever, neuropathy,
lymphadenopathy, splenomegaly, rash, anemia, raised ESR or CRP and
abnormal urinalysis.
However, even if the problem appears to be localized, one must be
conscious of the fact that systemic diseases (rheumatic and
non-rheumatic) often present with local symptoms. Examples of these
include:
Weight loss and bone pain in multiple myeloma or secondary tumor.
Carpal tunnel syndrome in acromegaly, hypothyroidism and amyloid.
Vasculitis (polyarteritis nodosa) in hepatitis B.
Chronic synovitis with bowel problems in inflammatory bowel disease.
Stiff fingers and shoulder pain in diabetic cheiroarthropathy.
Nevertheless, localized problems may sometimes be multifocal
suggesting a generalized disorder as in case of polytendinitis and
bursitis.
It is important to always be wary of the diagnosis of diffuse or
focal osteoarthritis as the cause of symptoms even when there may be
supporting radiographic evidence. Although this condition may be
present, yet it may not be the predominant cause of symptoms as in
the case of rheumatoid arthritis or gout on top of osteoarthritis.
HEURISTICS IN PATTERN RECOGNITION:
Acute onset of large joint monoarthritis in a young girl should be
considered to be oligoarticular JRA unless there is evidence of
infection.
At any age during childhood and in either sex, a pattern of
scattered, asymmetrical, large and small joint oligoarthritis or
limited polyarthritis suggests the possibility juvenile psoriatic
arthritis.
Oligoarthritis of large joints of the lower extremity in an older
boy suggests a seronegative spondyloarthropathy, most likely
ankylosing spondylitis.
The presence of enthesitis with arthritis indicates the likely
presence of seronegative enthesitis and arthritis syndrome (SEA) and
the probable later development of ankylosing spondylitis.
The onset of polyarthritis in a teenage girl should suggest the
possibility of systemic lupus as well as polyarticular juvenile
rheumatoid arthritis.
Isolated hip joint arthritis may be caused by toxic synovitis,
Legg-Calve Perthe's disease, a slipped capital femoral epiphysis, or
less likely, by chronic inflammatory arthritis, probably ankylosing
spondylitis.
In a child presenting with acute onset of fever and painful
arthritis that is presumed to be septic but with negative cultures,
the possibility of post-streptococcal reactive arthritis should be
considered. The arthritis may be migratory, additive or
monoarthritis.
II. PRESENT HISTORY/
B. DIET, TOBACCO, ALCOHOL, SLEEP PATTERN, OTHER
Cigarette smoking: Beurger's disease, rheumatoid vasculitis (in a
long-standing disease in a middle aged male).
Alcohol: Hyperlipoproteinemia, hyperuricemia that may lead to gout,
osteonecrosis, infection, pancreatic arthropathy (one half to
two-thirds of cases have a history of alcoholism causing
pancreatitis), scurvy (scurvy also occurs in food faddists, infants
fed exclusively on cow's milk formula)
Intravenous drug abuse: Infection.
Goat milk: Brucellosis
Diet containing gluten: arthritis of celiac disease.
Perversion to sweet tasting foods: diabetes mellitus.
Contact with dogs and cats: parasites as visceral larva migrans.
Disturbed sleep pattern: fibromyalgia, functional disorder,
inflammatory disease
II. PRESENT HISTORY/
C. RELEVANT DATA FROM THE PATIENT'S CHART
THESE MAY PROVIDE A CLUE TO THE CAUSE OF THE RHEUMATIC PROBLEMS IN
ONE OF THE FOLLOWING WAYS:
A. RHEUMATIC DISEASE IS CAUSED BY A CONCOMITANT DISORDER:
GENERAL:
Presence of a septic focus: infectious arthritis.
Immunodeficiency: infectious arthritis.
History of any recent GI or urinary tract infection: reactive
arthritis
ENDOCRINE AND METABOLIC:
Diabetes mellitus: infectious arthritis, neuroarthropathy, patients
are more prone to RA, hyperuricemia, scleredema, osteonecrosis,
hyperlipoproteinemia (may lead to monoarthritis for example of the
dorsum of the foot: MTPs). Some clinical features in diabetes
suggest secondary Sjogren's syndrome. Diabetes can cause limited
joint mobility
Type B insulin-resistant diabetes mellitus secondary to
insulin-receptor antibodies: has been associated with multiple
rheumatic complaints suggestive of systemic lupus erythematosus,
Sjogren's syndrome, or progressive systemic sclerosis. In one study,
fourteen such patients developed features of an autoimmune disease;
8 of the 14 met the American Rheumatism Association criteria for
systemic lupus erythematosus, and 4 developed glomerulonephritis
histologically consistent with lupus nephritis. Thus, whenever a
patient has extremely insulin-resistant diabetes mellitus and
features of a systemic rheumatic disease, the possibility of
circulating antibodies to insulin receptors should be considered.
Hyperlipidemia: gout, osteonecrosis in addition to arthritis of
hyperlipidemia.
Atherosclerosis: Multiple cholesterol embolization syndrome
Hemochromatosis: Chondrocalcinosis, infection with Listeria
monocytogenes
Hyperparathyroidism: gout, pseudogout in addition to
hyperparathyroid arthropathy
Hypothyroidism: Hyperlipoproteinemia, hyperuricemia and gout, CPPD,
epiphyseal dysplasia. Also myopathy and myotonia.
Hyperthyroidism: Thyroid acropachy, periostitis (LATS), myopathy,
myasthenia, periodic paralysis.
Pancreatic disease: pancreatic arthropathy
HEMATOLOGICAL:
Hemoglobinopathy: osteonecrosis, infection.
Bleeding diathesis: Hemarthrosis as in hemophilia.
RENAL:
Renal failure: crystal arthritis, infection.
HEPATIC:
Hepatitis B virus: Polyarteritis nodosa.
Hepatitis C virus: HCV arthritis, cryoglobulinemic arthritis.
Primary biliary cirrhosis: Osteomalacia.
MUSCULOSKELETAL:
Long standing RA: Rheumatoid vasculitis, Felty's syndrome.
B. RHEUMATIC DISEASE IS CAUSED BY THE TREATMENT OF THE DISORDER:
Bronchial asthma: previous treatment with steroids: osteonecrosis.
Hypertension: thiazides: hyperuricemia, hyperlipoproteinemia
Epilepsy: on an anti-epileptic drug (as Epanutin) that can induce
lupus and that can cause osteomalacia
C. RHEUMATIC DISORDER AND A CONCOMITANT DISORDER TOGETHER FORM PART
OF A THIRD DIAGNOSIS:
GENERAL:
Recurrent infections: Felty's syndrome.
Inguinal hernia: cutis laxa.
ENDOCRINE AND METABOLIC:
Atherosclerosis: hyperlipoproteinemia.
Diabetes mellitus: Hemochromatosis.
Gynecomastia: Hemochromatosis, pachydermoperiostiosis, POEMS
Addison's disease: Antiphospholipid syndrome (causing venous
thrombosis of the supra-renal gland).
Nephrogenic diabetes insipidus: Amyloidosis.
Pituitary diabetes insipidus: Wegener's granulomatosis, sarcoidosis,
eosinophilic granuloma, hemochromatosis.
Hypogonadism: Hemochromatosis (causing pituitary dysfunction).
Pancreatic disease: systemic sclerosis, SLE, hyperlipoproteinemia
RESPIRATORY
Chronic sinusitis: Wegener's granulomatosis.
Bronchial asthma: Churg Strauss vasculitis.
Positive tuberculin test: tuberculous arthritis.
CARDIOVASCULAR:
Hypertension: SLE with renal affection, Vasculitis, Paget's,
amyloidosis.
Ischemic heart disease: Vasculitis, hemochromatosis, sarcoidosis,
hyper or hypothyroidism
RENAL:
Renal tubular acidosis: Sjogren's (can cause osteomalacia).
Urinary lithiasis: Gout, Ca oxalate crystal deposition disease,
inflammatory bowel disease, Sjogren's.
HEPATIC:
Primary biliary cirrhosis: CREST
NEUROLOGICAL:
Multiple sclerosis: Occasional co-incident occurrence with AS, with
relapsing polychondritis
Epilepsy: SLE
Pseudodementia: Whipple's disease.
In children: neurodevelopmental disabilities and psychomotor
retardation: scurvy
OTOLARYNGEOLOGICAL:
Hearing troubles: Behcet's disease, Cogan's syndrome, relapsing
polychondritis (causes stenosis of the external auditory canal as
well as vasculitis of the internal auditory artery), hypothyroidism,
acromegaly, Paget's disease, Wegener's
REPRODUCTIVE:
Pelvic inflammatory disease: Reiter's disease.
Menstrual troubles: Menorrhagia: hypothyroidism.
MUSCULOSKELETAL:
Recurrent fractures: osteogenesis imperfecta, Idiopathic juvenile
osteoporosis
II. PRESENT HISTORY/
D. DRUGS
The efficacy of a drug may be a valuable diagnostic clue to
diagnosis as in dramatic response of polymyalgia rheumatica to
steroids.
At the same time, drugs themselves can be the cause of the problem
as in drug-induced lupus.
PAST MEDICATIONS
Anti-tuberculous drugs: tuberculous arthritis
Prolonged courses of corticosteroids: osteonecrosis.
CURRENT MEDICATIONS
Corticosteroids: Infection, osteonecrosis, hyperlipoproteinemia
Immunosuppressives: infection.
Anticoagulants: hemarthrosis.
Start of replacement therapy for hypothyroidism: gout
Thiazides: hyperlipoproteinemia, hyperuricemia.
Epanutin: Osteomalacia, drug-induced lupus.
Oral contraceptives: SLE, deep vein thrombosis, hyperlipidemia
Beta-blockers: hyperlipoproteinemia
Quinolones: Tenosynovitis.
Minocin (for treatment of acne): Drug induced lupus
Isotrenetoin: may cause arthritis (monoarthritis).
Interferon alpha: IFN induced arthritis (IFN may be implicated in
the induction of autoimmune phenomenon).
Anti-thyroid drugs: The administration of antithyroid drugs may be
followed by syndromes resembling either RA or systemic lupus
erythematosus, especially in children
III. PAST HISTORY
ILLNESSES, ACCIDENTS AND INJURIES, OPERATIONS, JOINT OVERUSE OR
DAMAGE
Past history of tuberculosis: Tuberculous arthritis.
Joint prosthesis: infection.
Joint damage or overuse: Traumatic arthritis, Osteoarthritis.
Thyroid disease: hypothyroidism: following treatment of
hyperthyroidism
Intestinal by pass: Bypass arthritis dermatitis, cryoglobulinemia.
An attack of unexplained epilepsy: lupus.
A swollen ankle or knee in childhood in a young man now presenting
with back pain: ankylosing spondylitis.
Hypermobility: FMS, predisposition to OA
Blood transfusion: Hepatitis B infection (rarely presents as a
monoarthritis), Hepatitis C infection.
IV. FAMILY HISTORY
A positive family history of: Rheumatoid arthritis, one of the
seronegative spondyloarthropathies, gout, hemophilia.
Of stroke or myocardial infarction before age 55: Hyperlipidemia.
Heart disease: Hemochromatosis, hyperlipoproteinemia
Hyperlipoproteinemia: Deep vein thrombosis, hyperlipoproteinemic
arthritis.
Neuropathy: Amyloidosis
Fractures: may occur repeatedly in patients with osteogenesis
imperfecta.
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