SIU School of Medicine

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Department of Internal Medicine

Joint Pain

Knowledge

Students should be able to define and describe:

  • common presenting symptoms and signs of:
    • osteoarthritis
    • rheumatoid arthritis
    • systemic lupus erythematosus
    • polymyositis
    • crystalline arthropathies (gout, pseudogout)
    • scleroderma
    • carpal tunnel syndrome
    • septic arthritis
    • osteoporosis
    • seronegative spondyloarthropathies (ankylosing spondylitis, etc.)
    • Raynaud’s phenomenon
    • bursitis and tendonitis
    • Wegener’s granulomatosis
    • polyarteritis nodosa
    • temporal arteritis
    • polymyalgia rheumatica
    • fibromyalgia
  • the difference between arthralgia and arthritis
  • how to determine whether a problem is articular or extra-articular
  • a systematic approach to joint problems that is based on an understanding of pathophysiology with the ability to classify potential causes of joint pain, such as inflammatory vs non-inflammatory
  • key diagnostic criteria for common causes of joint pain
  • the use and limitations of tests used to evaluate patients with joint pain, including:
    • routine tests (CBC, CMP, urinalysis, etc)
    • serology (ANA, RF, etc)
    • x-rays
    • synovial fluid analysis
  • indications for performing an arthrocentesis
  • the appropriate use and complications of
    • aspirin and non-steroidal anti-inflammatory medications (NSAIDS)
    • acetaminophen and other analgesics
    • corticosteroids
    • disease-modifying drugs (DMARDS)
    • urate lowering agents
    • bisphosphonates
    • steroid injections

Skills

Students should demonstrate specific skills, including:

  • History-Taking Skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including:
    • eliciting features of a patient’s joint pain, including:
      • duration
      • location
      • severity
      • symptoms of inflammation
      • exacerbating and remitting factors
      • associated neurological symptoms
      • prior or family history of related problems
    • determining the appropriate extra-articular symptoms associated with the various rheumatic disorders.
    • determining the impact of joint pain on a patient’s activities of daily living

  • Physical Exam Skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
    • performing a systematic examination of all joints and identifying abnormal findings:
      • erythema
      • warmth
      • swelling
      • tenderness
      • effusions and synovial thickening
      • crepitus
      • decreased or excessive range of motion
      • Dupuytren’s contracture
      • nodules (rheumatoid, tophi, etc.)
      • spine and joint deformity (varus and valgus deformities, Bouchard’s and Heberden’s nodes, kyphosis, etc)
      • tender points
    • skin rash including:
      • livedo reticularis
      • psoriasis
      • keratoderma blennorrhagicum
      • malar rash
      • palpable purpura
      • erythema chonica migrans
      • sclerodactlyly
    • multisystem exam to look for extra-articular signs

  • Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis in the following scenarios:
    • acute monoarticular arthritis
    • acute polyarticular arthritis
    • chronic monoarticular arthritis
    • chronic polyarticular arthritis
    • intermittent arthritis
    • myalgias
    • low back pain

  • Laboratory Interpretation: Students should understand both the use and misuse of lab tests for rheumatic disorders. They should not only understand their sensitivity and specificity, they should be able to interpret these tests in the context of the clinical scenario and know when it is appropriate to order or not to order these tests. They should understand why ordering “rheumatoid panels” is not recommended.
    • Standard lab tests (CBC, CMP, urinalysis, etc.)
    • sedimentation rate
    • uric acid
    • rheumatoid factor (RF)
    • anti-nuclear antibody (ANA)
    • complement levels
    • extractable nuclear antibodies:
      • anti-dsDNA
      • Smith (Sm)
      • SS-A/Ro
      • SS-B/La
      • RNP
      • SCL-70 and anti-centromere antibody
    • cANCA and pANCA
    • Lyme serology
    • synovial fluid analysis, including crystal identification
    • plain x-rays
    • bone densitometry (DEXA)
    • MRI
  • Basic and Advanced Procedure Skills: Students should be able to assist in performing arthrocentesis of the knee after explaining the procedure to the patient.
  • Management Skills: Students should be able to develop a comprehensive management plan that is appropriate for the patient’s diagnosis. Such a plan may include:
    • patient education
    • the appropriate use of
      • aspirin and non-steroidal anti-inflammatory medications (NSAIDS)
      • acetaminophen and other analgesics
      • corticosteroids
      • disease-modifying drugs (DMARDS)
      • urate lowering agents
      • bisphosphonates
      • the appropriate use of injections
      • prescribing exercise, modalities, and pacing
      • the appropriate use of splinting and assistive devices
      • the appropriate use of physical therapy and occupational therapy
      • determining when to involve a rheumatologist or surgeon

Attitudes and Professional Behaviors

Students should be able to:

  • demonstrate sensitivity to the impact of chronic joint pain or a chronic rheumatologic disease on a patient’s quality of life and well-being.
  • understand how to care for patients you cannot cure.

Resources

  • Internal Medicine Clerkship Guide. Paauw, et al, Mosby 2003. pp148-159 and 465-486.
  • Primer on the Rheumatic Diseases. Edition 12. Published by the Arthritis Foundation. Chapters 7, 8, 9, 13, 15 and 17 (for loan in the Clerkship Office)
  • Clerkship Seminar, “Joint Pain:, Mark Francis, MD
  • “The Management of Gout”, Emmerson, Bryan, MD, PHD, The New England Journal of Medicine, February 15, 1996, Volume 334, Number 7, 445-451
  • “Rational Use of New and Existing Disease-Modifying Agents in Rheumatoid Arthritis”, Kremer, Joel, MD, Annals of Internal Medicine, April 17, 2001, Volume 134, Number 8, 695-706
  • Moskowitz RW. Clinical Rheumatology: A Problem-Oriented Approach to Diagnosis and Management. Lea & Febiger 1982.
  • Richie AM and Francis ML. Diagnostic approach to polyarticular joint pain. American Journal of Family Practice. 68: 1151-1160. 2003.
  • ACP/ASIM videotape "Arthrocentesis and Joint Injection" (for loan in the clerkship office.

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