A. Ask the medical history.
1, age, gender: rheumatoid arthritis: mostly occurs in 8 to 18 years old and more women than men, more than 25 years old with stable disease rarely active. Ankylosing spondylitis: mostly occurs in the 10 to 40 years old, more men than women, the ratio of 5 to 10: 1, male symptoms heavy, fast progress. Osteoarthritis: mostly occurs in people over 45 years old, the age can be earlier for those with more physical activity, and the incidence is higher in women than in men. Rheumatic polymyalgia and giant cell arteritis are seen in older people over 50 years of age. Gout: mainly seen in middle-aged and elderly men and a few postmenopausal women, gout does not occur in premenopausal women.
2.Onset: acute arthralgia is mostly seen in gout, septic arthritis, Leiter’s syndrome, iatrogenic rheumatism, with acute onset and severe pain. Chronic arthralgia: mostly seen in osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, systemic lupus erythematosus, etc., with slow onset and gradually increasing pain.
3, family history: ankylosing spondylitis mostly has a family history.
4, concomitant symptoms: 70% of patients with osteoarthritis between the distal joints appear typical Herbden nodes; rheumatoid arthritis 20% to 30% of patients can have rheumatoid nodules, mainly distributed in the elbow, finger joint extensor, occipital prominence, gastrocnemius tendon. Patients with gout may have gout stones, mainly in the auricle, joints and peri-articular, kidneys, and a few in the aorta, heart valves, and myocardium. Circumscribed erythema, subcutaneous nodules suggest rheumatic fever, subcutaneous nodules are small painless nodules, mostly occurring in the joint extension, mainly at the elbow, wrist, occipital or thoracolumbar spine, not adhering to the skin, no redness or swelling on the surface, mostly appearing at the same time as heart inflammation, and should be distinguished from rheumatoid nodules.
5, whether the joint pain is symmetrical: recurrent crystalline arthritis, infectious arthritis, seronegative spondyloarthropathy is mostly asymmetric, single joint involvement, rheumatoid arthritis is mostly symmetrical, multi-joint involvement.
6, drug response situation: aspirin for rheumatic fever, colchicine for pain phoenix has a special effect, has a dual significance of treatment, diagnosis.
7, arthritis is part of the performance of a disease: polymyositis dermatomyositis, systemic lupus erythematosus, leukoarthritis, psoriatic arthritis, etc. For women of childbearing age with first-episode monoarticular or asymmetric polyarthritis with fever or rash, etc., the possibility of SLE should be noted.
Second, common arthritis.
1. Rheumatoid arthritis: The basic pathological change is synovitis, where abnormal proliferation of synovial membrane forms villi-like protrusions into the joint cavity, invading the articular cartilage, subchondral bone, ligaments, tendons and other tissues, causing destruction of articular cartilage, bone and joint capsule, and eventually joint deformity and loss of function. All joints in the body can be involved, but the proximal interphalangeal joints, metacarpophalangeal joints, wrist joints, metatarsophalangeal joints, knee joints, ankle joints and elbow joints are more likely to be involved, while the thumb, distal interphalangeal joints, sacroiliac joints and thoracolumbar spine are rarely involved, and only in individual patients with severe disease. Rheumatoid factor can be positive or negative, and can be accompanied by fever, malaise and other systemic symptoms.
2, seronegative spondyloarthropathies: refers to a group of rheumatoid factor-negative diseases with similar characteristics, including ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, Reiter’s syndrome, reactive arthritis. The pathological changes are tendon, ligament, fascia and bone connection attachment point inflammation, there is a tendency of family aggregation, and is closely related to HLA-B27, the positive rate is 50% to 95%, all can affect the spine and sacroiliac joints, but the early symptoms are often manifested as asymmetric lower limb arthralgia, heel pain, foot pain. CT of sacroiliac joint or X-ray orthopantomograph can be done to understand the presence of sacroiliac arthritis and HLA-B27 positivity. Look for related symptoms, abdominal discharge, urethritis, conjunctivitis, iritis, etc.
3, osteoarthritis: pathological changes are degeneration of articular cartilage, osteophytes, bone superfluous formation. It is a local disease, susceptible joints are distal interphalangeal joints, knee joints, hip joints, the first metatarsophalangeal joints, cervical and lumbar spine, but not invade the wrist joint, ankle joint, pain is aggravated after activity and reduced at rest, not accompanied by fever, normal blood sedimentation, rheumatoid factor negative, may have stiffness, occurring after rest and start activity, usually less than 30 minutes.
4, gout: is a group of diseases caused by disorders of purine metabolism resulting in increased blood uric acid, blood uric acid > 600-700, most often invades the first metatarsophalangeal joint, but also the ankle, knee, elbow, wrist and finger joints, mostly asymmetric single joint, shoulder, hip and spine joints are rare.
5, juvenile chronic arthritis is also known as juvenile rheumatoid arthritis: age of onset <16 years, disease duration >6 weeks, invasion of single or multiple joints, according to the initial onset of 6 months, can be divided into three types, polyarthritic type: ≥5 joints; less arthritic type: ≤4 joints; systemic type: arthritis and intermittent fever. Polyarthritis type: the incidence is higher in girls than in boys, and all joints can be involved, but mainly the small joints of the fingers and toes are involved, usually starting with the large joints and gradually involving the small joints, which can cause stiffness and deformation of the joints. The rate of rheumatoid factor positivity is 25%. Type I: more girls than boys, with knee, ankle and elbow joints as the prevalent sites, which can be recurrent but rarely leave serious dysfunction. type II: more boys, with the major joints of the lower extremities predominantly affected, with the age of onset generally above 8 years old and HLA-B27 positive rate accounting for 75%. The systemic type, also known as juvenile Still disease, can involve both large and small joints and may appear at the onset or several months after the onset. Patients are febrile, with flaccid fever and a rash that may appear on and off with the fever. The lymph nodes of the liver and spleen are enlarged and the liver function is mildly abnormal. 50% of patients may develop pericarditis and myocarditis.
Examination
1, physical examination: “4” test, Schober test, positive occipital wall distance test are indicative of seronegative spondylolisthesis. Positive knee friction sensation suggests osteoarthritis.
2, laboratory tests: all patients should check the three major routine;
Blood sedimentation: increased – suggests inflammatory arthritis, such as rheumatoid arthritis, rheumatoid arthritis, AS, JRA, etc.;
Normal – gout, osteoarthritis
CRP: acute r-phase reactants, increased seen in inflammatory arthritis, rheumatoid arthritis, ankylosing spondylitis, etc., associated with rheumatoid off disease activity.
RF: RA positive rate is 70%; while SS positive rate is greater than 70%.
Anti-O: increased only reacts to having had streptococcal infection, not necessarily rheumatoid arthritis, and needs to be diagnosed in conjunction with clinical symptoms.
ENA antibody profile and complement have diagnostic significance for SLE, SS, PM/DM, SSc, and mixed connective tissue disease.