Rheumatology [APPROACH TO JOINT PAIN]

Differential Diagnosis
Rheumatology is essentially the diagnosis and management of
joint pain. It has quite an extensive differential as it could be the Arthritis
primary complaint or the symptomatology that links all disease. Joint Pain
Unfortunately, many of these diseases have a list of associated Acute Chronic
symptoms that have be memorized in order to ascertain the Timing and
correct diagnosis. However, there are some classifications that Toxicity
can help reduce the potential list of diagnoses. The number of Acute Chronic
joints, pattern, and symmetry of joint pain play a huge role.
Septic Arthritis
Usually monoarticular involvement has to do with a disease of Inflammatory
Trauma
that joint, indicating an absence of systemic involvement. It’s Crystal Deposition
often acute. Polyarticular involvement is associated with Reactive Arthritis Rubor, Dolor,
systemic disease. Let’s break it down further. In polyarticular Calor, Tumor
Just 1
disease absence of symmetry means it’s likely degenerative as Inflammatory Osteoarthritis
it reflects the asymmetry of use. If there’s symmetry it indicates
autoimmune. Finally, even paying attention to WHICH joint is Monoarthropathy # of Joints Polyarthropathy
involved can be useful (RA spares the DIP for example). Besides Involved
Indolent Infection Lupus
that, extrarticular manifestations are often unique to a given Rheumatoid Arthritis
diagnosis, though crossover does exist. The important thing is Seronegative
that no one finding is sensitive or specific – it’s the combination “Connective Tissue Dz”
of symptoms that lets the diagnosis comes to light. Using this Single Joint vs Multiple Joints
algorithm may be useful, but it’s the memorization that excels in Septic Osteoarthritis, Lupus, Rheumatoid
Crystals Scleroderma, Myositis, Seronegatives
rheumatology.
Acute vs Chronic
Septic, Trauma, Osteo, Lupus, Rheumatoid, Scleroderma,
Arthrocentesis
Crystal, Reactive Myositis, Seronegatives
If you see a red, hot, swollen joint, the answer on the test will be Isolated vs Systemic Manifestations
Arthrocentesis. The diagnosis can be made without an Septic Seronegative (IBD)
arthocentesis (history of gout that has a gouty flare), but your Crystal Lupus (Face, CNS, Renal, Heart, Lung)
reflex should be to tap the joint. In a normal joint there should Rheumatoid (Nodules, Serositis)
be a bunch of fluid - that’s it. In degenerative disease it’s the Reactive (Oral + Genital Ulcer)
same; the joint is just degraded (neither normal joint or Degenerative vs Inflammatory
Osteoarthritis Everything Else
degenerative joint conditions should have prompted a tap). On the
other end of the spectrum, a septic joint will be full of pus: white,
opaque, LOTS of cells, LOTS of polys. 50,000 is the number to Normal NonInflammatory Inflammatory Sepsis
remember. If there are more than 50,000 WBCs it’s septic, Appearance Clear Clear Yellow, White Opaque
regardless. WBC <2 <2 >2, <50 >50
Polys <25% <25% > 50% > 75%
An inflammatory joint will be somewhere in between; it’ll have Gram/Cx
some cloudy fluid, some cells, and mostly polys. Dz None Osteoarthritis Everything Infectio
Else n
WBC is “thousands”
The presence of staph tells you septic. If septic and no organism,
be cautious of gonorrhea and get a NAAT or chocolate agar Antibody Interpretation Antibody Interpretation
culture. ANA Sensitive Lupus RO + LA Sjogren’s

The presence of crystals clues us in on crystal disease. Histone Specific Drug- CCP Rheumatoid
Inflammatory joint without organisms or crystals means “it’s a Induced Lupus Arthritis
rheumatologic disorder” and little else. ds-DNA Specific Lupus + RF Rheumatoid
Renal Involvement Arthritis
Antibodies Smooth Autoimmune Jo Polymyositis
Memorize them. There’s no good way other than repetition. Muscle Hepatitis
Mitochondrial Primary Biliary
Sorry. They’re mostly non-diagnostic, but they’re another clue. Cirrhosis
Bottom line: there isn’t one test, but rather a combination of Centromere Scleroderma Topoisomerase Systemic
findings (including serology) that leads to diagnosis. (CREST) (Scl-70) Scleroderma

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