Thread by @PanktiMehta24

Doctor: Where is the pain?

Patient: Pain pain everywhere!

❔How do we approach a patient with multiple joint pains❔

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#polyarthritis #MedTwitter #MedEd #RheumTwitter

1️⃣ Is it polyarthritis?

First, you want to make sure it's polyarthritis - multiple (>4 joints) pain WITH SWELLING

& NOT 🚫

🔹Polyarthralgia⏩ pain WITHOUT swelling
🔹Widespread pain
🔹Myalgia
🔹Bone pain
🔹Neuropathic pain

Let's deal with polyarthritis ⏬

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2️⃣ Is it acute or chronic??

Acute<6 weeks

🔹 Infections- gonococcal, infective endocarditis, rheumatic fever, lyme disease, viral

🔹Elderly RA, ANCA vasculitis, paraneoplastic

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#MedTwitter

Chronic >6 weeks

🔹Rheumatoid arthritis
🔹Lupus, Sjogren's, other systemic rheumatic diseases
🔹Still's disease
🔹CPPD/ sometimes polyarticular gout
🔹Psoriatic arthritis
🔹Osteoarthritis

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3️⃣Temporal pattern
📈📉📊
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4️⃣ What is the nature of the pain?

🔹Inflammatory: pain worse at rest, relieved with activity, with early morning stiffness>30min

🔹Non-inflammatory: pain worse with activity, relieved with rest

This is important to figure out the plausible etiologies!

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5️⃣ Next, what is the joint distribution??

This 📷 has the classic bilateral symmetrical polyarthritis seen in

🔹Rheumatoid arthritis
🔹Lupus
🔹Sjogrens & other systemic rheumatic diseases
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📷 is showing asymmetric polyarthritis seen in

🔹Polyarticular psoriatic arthritis (note the 'ray' sign with involvement of MCPs, PIPs DIPs in a line & asymmetric sacroiliitis)

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🔹 Osteoarthritis pattern with knee, hip, 1st MTP, 1st CMC, PIP, DIP involvement

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6️⃣ Extra articular features

🔹Fever 💭 of infection, lupus, still's disease, autoinflammation

🔹Nodules 💭 of RA, gout, rheumatic fever

🔹Rash 💭 lupus, dermatomyositis, sjogren, still's disease, viral infection, psoriasis

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🔹 Raynaud's 💭 of Scleroderma spectrum, lupus, Sjogren

🔹 Others: sicca, skin thickening, weight loss, anorexia, organ specific symptoms 🫁🫘🫀

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And always remember,

History & clinical examination will give you the diagnosis in most cases.

An arthritis panel will only confuse you & make the lab owner richer 😏

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