history taking and examination in inflammatory joint disease

functions of synovium

maintenance of intact tissue surface

lubrication of cartilage

control of synovial fluid volume and composition (hyaluronan, lubricin)

nutrition of chondrocytes within joints

features of the history

patient demographics - sex, age

onset and pattern of joint involvement

Associated features/systemic involvement

Impact on function

which joints are affected in which condition

•1st CMC/DIPs/PIPs - osteoarthritis

•MCPs/PIPs  rheumatoid arthritis

•Wrist or knee in elderly  pseudogout/Rheumatoid Arthritis

•Monoarthritis in young  SpA/reactive

•1st MTP/ankle/knee/elbow  Gout

stiffness without joint swelling is unlikely to be

inflammatory

what is stiffness a feature of?

early osteoarthritis and age-related mechanical back pain

length and severity of stiffness is generally higher in which arthritis?

inflammatory arthritis

constitutional symptoms commoner in…

inflammatory arthritis

-malaise, fatigue, weight loss etc

mechanical vs inflammatory pain

•Inflammatory

worse on rest, better on movement

•Mechanical

worse on movement, better on rest

connective tissue disease question

•Important if history is arthralgia rather than arthritis

Raynaud’s phenomenon 

Photosensitivity 

Sicca symptoms

Mouth ulcers

Hair loss

Miscarriages/thromboembolic events (include family history)

ask and look for what type of rashes

•Psoriasis (include family history)

•Erythema nodosum

•Photosensitive

•Vasculitic

GALS screen

gait

arms

legs

spine

other places to feel and move in patients

PIP tuck

Thumb to little finger

Wrist  - prayer position and reverse

Fore/mid/hindfoot

•Enthesitic points

epicondylitis/achilles/heel 

Joint hypermobility often missed

what does this question focus on: Do you have any pain, swelling or stiffness in your muscles, joints or back?

Focuses on the common symptoms of a musculoskeletal problem

what does this question focus on: Can you dress yourself completely without any difficulty?

Focuses on upper limb function.

what does this question focus on: Can you walk up and down stairs without any difficulty?

Focuses on lower limb function.

joint examination findings and associations

•Joint swelling

•Bony/firm = OA

•Soft tissue/boggy/spongy = synovitis

‘like a grape’

look carefully at dips between the MCPJs

•Dactylitis ‘sausage toe or finger’ - think Spondyloarthritis

•Pressure on palpation

Enough to blanch nail beds

investigation for connective tissue disease patient

urinalysis and blood pressure

when is urate more helpful in gout?

in chronic disease

Urate can be low/normal/high in an acute flare

what investigations for joint fluid analysis

sample for microbiology

sample for cytology for polarising microscopy

fibromyalgia

•Centralised pain disorder characterised by severe pain and other somatic symptoms

•Widespread pain in multiple regions of the body for ≥ 3months (regional pain may be reported initially)

•Intrusive fatigue- physical, cognitive +/- emotional

•Increased sensitivity to sound, light, fluctuations in ambient temperature

•Fluctuate in type and severity over time

features of rheumatological examination

Examination of symptomatic joints

Pattern of joint involvement

Associated features and other system involvement

Impact on function