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.

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 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.