![History of Present illness
1.Speed of onset. For example, crystal synovitis develops very rapidly, often
reaching maximum severity with extreme pain within just 2-12 hours, whereas sepsis
is more sub acute and continues to progress until treated.
Many inflammatory joint disorders have chronic beginning.
2.The previous infections or other provoking factors (a trauma, stress, labor,
overcooling, sunlight, the use of alcohol or intake a fat food, starvation, etc.).
3.Clinical course. The chronic inflammatory joint disorders are usually life-long, with
intermittent exacerbations and remissions.
Some patients have mild disease; in others it is more severe.
Some diseases have progressive character. Each exacerbation of disease involves
new joins while in the affected joints the pathologic process continues. At other
diseases the localization of a joint inflammation varies.
4.Previous investigations and treatment; them results
Life history
[past medical history; current health status; family history: psychosocial history]
Environmental hazards, at home, school, and workplace;
the occurrence of Inflammatory joint disorders in members of their family;
allergies.](https://image.slidesharecdn.com/lect1-therapy-220924135237-86cde98b/85/lect-1-therapy-pdf-4-320.jpg)
lect 1-therapy.pdf
- 1. Joint inflammation syndrome (JIS) Inflamed membrane and swollen joint Eroded cartliage and narrowed joint space
- 2. History Complaints Joint pain The additional information. Arthralgia is joint pain with no abnormal examination findings. The concept ofarthritis includes other pathological signs. If the patient complains of a joint pain, ask him to specify a place where he feels the joint pains. Let him to tell about character and intensity of pains, about precipitating and relieving factors. The character and intensity of a joint pain depend on both the expression of the inflammation and the nature of disorder. Dull or sharp joint pains, which worsen after rest, and are relived by movements (rest pains), are typical for JIS. Joint pains are most marked in the early morning and after inactivity. 2 1. If there is the joint damage the usage pain may be present too. The patient can note the occurrence of the swelling of the joint or its deformity; the deviation of the fingers. Also the patient frequently mentions presence of limitation of the function of joints.
- 3. Non-specific symptoms of systemic llness (reflecting acute phase response) Fever Sweats and chills, particularly at night Weight loss, t reduction in appetite Fatigability, poor concentration
- 4. History of Present illness 1.Speed of onset. For example, crystal synovitis develops very rapidly, often reaching maximum severity with extreme pain within just 2-12 hours, whereas sepsis is more sub acute and continues to progress until treated. Many inflammatory joint disorders have chronic beginning. 2.The previous infections or other provoking factors (a trauma, stress, labor, overcooling, sunlight, the use of alcohol or intake a fat food, starvation, etc.). 3.Clinical course. The chronic inflammatory joint disorders are usually life-long, with intermittent exacerbations and remissions. Some patients have mild disease; in others it is more severe. Some diseases have progressive character. Each exacerbation of disease involves new joins while in the affected joints the pathologic process continues. At other diseases the localization of a joint inflammation varies. 4.Previous investigations and treatment; them results Life history [past medical history; current health status; family history: psychosocial history] Environmental hazards, at home, school, and workplace; the occurrence of Inflammatory joint disorders in members of their family; allergies.
- 5. Physical Examination Inspection of gait Antalgic gait. Jerky asymmetric gaitwith less time weight-bearing on painfulleg. Ifthe patient feels acute pain in the metotarsophalangeal joints he can support on the heel only. Attitude of the extremities (held in "loose-pack" position) Inspection of involved joints at rest The character and intensity of joint disorders are correlated with the amount of inflammatory activityand nature of disease. Redness of the overlyingskin Swelling due to the synovitis, effusion
- 6. Deformityofjoint.It is the permanent change of the joint shape due to: Boutonniere deformity 1. the proliferativeor sclerotic process in ether synovial membrane or soft tissue, 2.new bone formation, 3.the bone destruction, Swan neck deformity 4.the fibrous or bony ankylosis, 5.damages of the periarticular structures, 6.subluxations. Deviations of fingers. These are deviations of axes of jointed bones from normal position. For example, the patients with Rheumatoid arthritis have the deviation ofaxes of all fingers in one direction (ulnardeviation of fingers)
- 7. There are the deviations of fingers axes in different directions in the patients with Psoriasis arthropathy or Gout. Palpation of involved joints at rest Increased warmth (e.g. synovitis) Tenderness (Overjoint line) -Swelling: fluid (fiuctuant), Soft tissue (soft, non-fluctuant)
- 8. If you suspect a small amount offluid in the knee jointlook for a Bulge Sine 1.With the ball of your handmilkthemedial aspect of the knee firmly upward two or three times to displace any fluid. 2. Then press or tap the knee just behind the lateral margin of the patella. 3. Watch for a bulge of returning fluid in the hollowmedial to the patella.
- 9. Try to Ballotte a "Floating Patella." Firmly grasp the thighjust above the knee with one hand, thus forcing fluid out of the superior portion of the jointspace between the patella and femur. With the fingers of your other hand, push the patella sharply against the femur. Feel for a palpable tap. Mecto HagaanwBawR Ha HAQKoneHHIK Mecto, pe ouyujaeTca nepetexa-ne xopHOCTH It is useful when large amounts of fluid are present.
- 10. Inspection during movement In the beginning check the range of active movements of joints. In the pathology: Functional restriction (Affected most or allactivemovements) HeiTpanbHoenonaweHwe Paarvóane YnbHapHOe lyveaoe OTBeeHne OTBeNeHMe HetpanbHo nonoxeHwe OICTM KOICTM Cr6awe Stress pain = increasing pain towardsextremes of movement. Universalstress pain (inmost/all directions - synovitis). Pain worsens as the joint moves towards the "tight-pack" positionsbecauseofincreased intracapsularoressure from inflammatory and effusion. In the mid "loose-pack" position, when the capsule is at its slackest, there is no pain. Then compare ranges of active and passive movements in joints. Active and passive movement afected equally
- 11. The additional information. Monoarthritis is situation when one joint is involved. Acute monoarthritis should always to consideration of sepsis and crystals. Monoarthritis can be the presentation of what subsequently evolves into oligo-or polyarthtritis, and atypical presentation of common disease is more prevalent than rare disease. Oligoarthritis is arthritis affecting two, three or four joints orjoint groups (for example, the wrist or midfoot, which have many joint but are counted as a single site). Polyarthritis is involvement of five or more joints or joint group. In determining the cause it is helpful to considerwhether the polyarthritis: is symmetrical or asymmetrical shows predominant or equal involvement for upper and lower limbs shows predominant or equal involvement for large and small joints A Rheumatoid arthrits J iniamnmatorys00a
- 12. Investigations Lab tests The full blood count (anaemia, leukocytosiss or leukopenia) Increased ESR C-reactive protein (CRP)> 6 mg/L; Serum proteins (12-globulin>10,5%; T-globulin>19%); Rheumatoid factor is an antibody directed against a specific region of the Fc fragment of human lgG. One traditional method of detecting IgM rheumatoid factor is to coat latex beads with human IgG ("latex fixation test"). Pathological titer is higher than 1:24. High titer of serum RF is typical for RA, but it is not feature of seronegative spondarthritis. .Serum uric acid (in male with gout >0,42 mmol/L; in female with gout >0,36 mmol/L) and urine uric acid (in gout >3,8 mmol/24hr) Immunological test for antibodies to Brucella; chlamydia; Antistreptolysin O (ASLO); mycobactera tuberculesis Tuberculinskintest;Spectrolux (porfirins); Bacterial swabs from genitaliaformicroscopy; Synovial fluid analysis. This is the pivotalinvestigationto confim the diagrnosis of septic arthritis, crystal-associated arthritis and intra-articular bleeding. With increasing joint inflammation the volume of synovial fluid (SF) increases, the total cell count and proportion of neutrophils rise (causing turbidity), and viscosity lowers (due to proteas degradation of hyaluronate). If you see the frank pus or "pyarthrosis" (very high neutrophil count), SF should be sentfor urgent Gram stain and culture. PCR (real-time) for chlamydia, mycoplasma, and ureaplasma
- 13. Biopsies ofsynovialmembrane (Inflammatory results)
- 14. Imaging Studies Plain radiography. (Soft tissue swelling, decreased bone density (pariarticular osteoporosis), joint-space narrowing, joint erosion, bone cysts, deformity, subluxation, fibrous or bony ankylosis) normal osteoporosis
- 16. CT. Computerized reconstruction of multiple radiographic scan sections gives detailed information on anatomy, especially of bone, allowing three-dimensional visualization of joints.
- 17. Scintigraphy. This readily available technique involves gamma-camera imaging following an intravenous injection of radioisotope, usually 99mTc- bisphosphonate. Early post injection images reflect vascularity and can show, for example, the increased perfusion of inflamed synovium.