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Probability diagnosis

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Osteoarthritis

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Viral polyarthritis (e.g. hepatitis, parvovirus)

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Serious disorders not to be missed

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Infection:

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  • rheumatic fever

  • endocarditis

  • tuberculosis

  • brucellosis

  • pyogenic (septic) arthritis: gonococcus, Staphylococcus, Kingella kingae

  • HIV arthropathy

  • dengue fever

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Cancer:

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  • bronchogenic carcinoma

  • leukaemia/lymphoma

  • secondary malignancy

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Other:

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  • rheumatoid arthritis (RA)

  • connective tissue disorders: SLE, scleroderma, polymyositis and dermatomyositis, other

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Pitfalls (often missed)

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Spondyloarthropathies (e.g. psoriasis)

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Fibromyalgia syndrome

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Polymyalgia rheumatica

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Crystal deposition:

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  • gout

  • pyrophosphate (pseudogout)

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Haemarthrosis

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Dengue fever

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Lyme disease

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Ross River virus

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Avascular necrosis

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Rarities:

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  • other vasculitides (e.g. polyarteritis nodosa)

  • haemochromatosis

  • sarcoidosis

  • Whipple disease

  • hyperparathyroidism

  • familial Mediterranean fever

  • amyloidosis

  • pigmented villonodular synovitis

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Masquerades checklist

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Depression

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Diabetes (?arthropathy)

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Drugs: uncommon but some implemented

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Thyroid disorder

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Spinal dysfunction (spondyloarthropathies)

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Is the patient trying to tell me something?

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Always a consideration with pain.

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Psychogenic factors aggravate chronic arthritic conditions.

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Key history

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There is such a multitude of causes of arthralgia that a skilful history to cover many angles is required. Note the pattern of joint involvement (monoarticular or polyarticular), immediate and more recent history, family history and drug use.

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   Enquire whether the joint pain is acute or insidious and confined to specific joints or fleeting as in rheumatic fever.

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Key examination

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A systematic examination of the affected joint or joints should look for signs of inflammation, deformity, swelling and limitation of movement.

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   Searching for associated systemic disease such as connective tissue disorders and infection demands examination of the chest, heart and abdomen.

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Key investigations

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  • FBE

  • EBR & CRP

  • Uric acid

  • Urine analysis

  • Joint X-rays

  • Synovial fluid analysis and culture

  • RA factor

  • Autoantibodies (ANA, dsDNA, ENA), anti-CCP antibody (for RA)

  • Other tests according to findings of tests for infection (e.g. specific serology, blood culture)

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Diagnostic tips

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  • The commonest cause of arthritis is osteoarthritis (OA).

  • Other causes of monoarthritis include crystal deposition disease, sepsis, trauma and spondyloarthritis.

  • The pain of inflammatory disease is worse at rest and improved by activity.

  • There should be no systemic manifestations with OA.

  • With polyarthritis (usually PIPs) and rash consider viral arthritis or a drug reaction.

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