Transcript Slide 1

Locomotor system
Dr : BASMA EL-HABBASH
Rheumatology unit
Tripoli Medical Center
Approach to painful joints
Locomotor system
History
Joints:-Pain:- Site:- symmetrical or not.
- Duration of symptoms
- Onset of symptoms:-- Sudden.
- Gradual
- Pattern:- ( course ) e.g. fleeting, additive, progressive,
stationary, intermittent.
- Severity.
- Character.
- Aggravating & relieving factors.
Associating symptoms:• Swelling
• Redness.
• Restriction of movement
• Stiffness:- Morning.
- Site.
- Duration.
- At which condition.
Muscles:- Muscle pain.
- Muscle weakness: Site:- proximal or distal
- Duration of symptoms.
- Diurnal variation.
- Associated symptoms
e.g. rash over the knuckles
Symptoms of proximal myopathy :-Difficulty in arising from setting position.
-Difficulty in climbing stair.
-Difficulty in combing hair.
-Difficulty in lifting objects above the level of
head.
Symptoms related to back pain :1- Site.
2- severity.
3- Associated symptoms:- stiffness after a period
of rest, numbness.
4- Aggravating factor:- eg movement.
5- Associated pain in sacroiliac joints.
6- Previous H/O of trauma or fall down.
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Review of rheumatological features :Hair loss.
Eye: - redness , decreased vision , dryness.
Malar rash.
Photosensitivity.
Mouth ulcers.
Mouth dryness.
Raynaud’s phenomena.
Genital ulcers.
Case history
- 41 years old female, presented to rheumatology
OPD complaining of symmetrical small hand
joints pain of 2 months duration.
* Gradual fixed severe joint pain involving MCP
&PIP joints of both hands of 2 months duration
interfering with her sleep and daily activities
associated with swelling & morning stiffness of
2 hours duration of the above mentioned joints.
* She has no muscle pain or weakness.
She has no hair loss, eye symptoms, malar
rash, photosensitivity, mouth ulcers,
Raynaund’s phenomena or genital ulcers.
Important point:1-middle aged female
2-symmetrical involvement.
3-small hand joints involvement.
4-long duration means chronic disease.
5-morning stiffness > 1 hours.
6- no other rheumatological features.
Diagnosis Rheumatoid arthritis
Case report
28 years old female patient, was referred to
Rheumatology OPD, complaining of pain and
swelling affecting both wrists and both knees of 2
months duration. The pain started gradually and
become more sever in the last 2 weeks interfering
with her sleep and daily activities, increased by
movement and relieved by rest
What do you want to ask more ?
Morning stiffness: No.
Other joint involvement: No.
Associated redness: No.
Associated restriction of movement: yes, she can
not walk or move her hands normally because of
pain and swelling.
What is the diagnosis?
• D/D:1- Rheumatoid arthritis.
2- SLE.
3- Behcet’s disease.
4- IBD with exra-articular manifestations.
5- Reactive arthritis.
6- Psoriatic arthritis.
7- Ankylosing spondilitis.
Review of locomotor system:►Negative apart from recurrent oral ulcers (4 times in
the last 6 months).
►It was painless occurred on the tongue and inner
aspect of the cheeks.
What is the diagnosis?
D/D:1- SLE.
2- Behcet’s disease.
3- IBD with extra-articular features.
4- Reactive arthritis.
►No genital ulcers, No eye symptoms of
previous attacks of anterior or posterior uvietis.
►No H/O diarrhea, blood or mucous in the stool
or wt loss in the previous period.
►No H/O conjunctivitis, urethritis or previous
attack of gastroentritis or G.U.T infection in the
period before joint pain.
SLE is the probable clinical diagnosis
Investigations
1- CBC:- leukopenia and lymphopenia.
2- CXR:- normal.
3- ECG:- normal.
4- U/E/C:- normal.
5- Urine R/E:- normal.
6- 24 hrs collection of urine for protein: normal.
7- VDRL:- was positive.
8- U/S abdomen:- mild hepatosplenomegaly.
9- ANA was positive.
10- Anti-DNA antibodies were negative.
So the patient has :1- Arthritis.
2- recurrent oral ulcers.
3- hematological manifestations:- leukopenia
and lymphopenia.
4- Positive VDRL.
5- Positive ANA.
6- other features:- hepatosplenomegaly.