1. Clinical Skill (1) Dr.Islam M A Salih Ass.Prof.internal medicine

2. Objectives At the end of the clinical session the students should be able to: a. Recognize the chief complaints of patient with musculoskeletal disease. b. Take history of present illness, past medical, family and social history and drug history from a patient.

3. Anatomy Joint structure

4. Symptoms and definitions 1- Pain: Site Onset Character Radiation Alleviating factors/associated symptoms Timing (frequency, duration and periodicity of symptoms) Timing (frequency, duration and periodicity of symptoms) Exacerbating factors Severity

5. Symptoms and definitions 2 - Stiffness 3- Swelling 4- Erythema (redness) and warmth 5- Weakness 6- Locking and triggering 7- Extra-articular features

6. Symptoms and definitions Determine whether the pain originates from a joint (arthralgia), muscle (myalgia) or other soft tissue. The site may be well localised and suggest the diagnosis, e.g. the first metatarsophalangeal joint in gout several joints suggesting an inflammatory arthritis.

7. Common causes of arthralgia (joint pain) - Generalised : - Infective Viral, e.g. rubella, parvovirus B19, mumps, hepatitis B Bacterial, e.g. staphylococci, tuberculosis Fungal - Postinfective Rheumatic fever, reactive arthritis - Inflammatory Rheumatoid arthritis, systemic lupus erythematosus (SLE), ankylosing spondylitis, systemic sclerosis - Degenerative Osteoarthritis

8. Common causes of arthralgia (joint pain) - Tumour Primary, e.g. osteosarcoma, chondrosarcoma Metastatic, e.g. from lung, breast, prostate Systemic tumour effects, e.g. hypertrophic pulmonary osteoarthropathy - Crystal formation Gout - Trauma, e.g. road traffic accidents - Others Chronic pain disorders, e.g. fibromyalgia Benign joint hypermobility syndrome

9. How many joints are involved One joint is a monoarthritis 2–4 joints, oligoarthritis >4 is polyarthritis

10. Differential diagnosis of monoarthritis, oligoarthritis and polyarthritis ExamplesType Staphylococcus aureusInfectiveMonoarthritis HaemarthrosisTraumatic Bleeding diathesis Post-traumatic Osteoarthritis Crystal arthropathies: gout Rheumatoid arthritis Degenerative Metabolic Inflammatory polyarthritis presenting as monoarthritis

11. Differential diagnosis of monoarthritis, oligoarthritis and polyarthritis ExamplesType Bacterial endocarditisInfective Oligoarthritis Osteoarthritis Sarcoidosis,reactive arthritis Degenerative Inflammatory

12. Differential diagnosis of monoarthritis, oligoarthritis and polyarthritis ExamplesType Bacterial: Lyme disease Viral: rubella, mumps, glandular fever InfectivePolyarthritis Rheumatic fever Osteoarthritis: nodal with Heberden'snodes Haemochromatosis, gout Rheumatoid arthritis, SLE, psoriatic arthritis Post-infective Degenerative Metabolic Inflammatory

13. Are the small or large joints of the arms or legs affected? Different patterns of joint involvement help the differential diagnosis

15. It may be difficult to determine the source of referred pain Perceived atSite of pathology Cervical spine OcciputC1,2 Interscapular regionC3, 4 Tip of shoulder, upper outer aspect of arm C5 Interscapular region or the radial fingers and thumb C6, 7 Ulnar side of the forearm, ring and little fingers C8 Chest Thoracic spine

17. Onset Pain from traumatic injury is usually immediate. Pain from inflammatory arthritis can develop over 24 hours, or more insidiously. Crystal arthritis (gout ) causes acute, sometimes extreme pain which develops quickly, often overnight. Joint sepsis causes pain that develops over a day or two.

18. Character Bone pain is penetrating, deep or boring, and is characteristically worse at night. Generalised bony conditions, such as osteomalacia, usually cause diffuse pain.

19. Muscle pain is often described as ‘stiffness’ and is poorly localised, deep and aggravated by use of the affected muscle(s). It is associated with muscle weakness in some conditions, e.g. polymyositis. Partial muscle tears are painful; complete rupture may be less so.

20. Causes of muscle pain (myalgia) Viral: Coxsackie, cytomegalovirus Bacterial: Streptococcus pneumoniae Parasitic: Schistosomiasis Infective Tears, haematoma, rhabdomyolysisTraumatic Polymyalgia rheumatica, myositis, dermatomyositis Inflammatory e.g. Alcohol withdrawal, statins, triptans Drugs Hypothyroidism, hyperthyroidism, Addison's disease, vitamin D deficiency Metabolic Neuropathic

21. Charcot join Neurological involvement in diabetes mellitus, leprosy, syringomyelia and syphilis (tabes dorsalis) may cause loss of joint sensation, so pain is less than expected from examination. In these conditions, even grossly abnormal joints may be painfree

22. Radiation Pain from nerve compression radiates to the distribution of that nerve, e.g. lower leg pain in prolapsed intervertebral disc or hand pain in carpal tunnel syndrome. Neck pain radiates to the shoulder or over the top of the head. Hip pain is usually felt in the groin, but may radiate to the thigh or knee

23. Alleviating factors/associated symptoms Pain caused by a mechanical problem is worse on movement and eases with rest. Pain due to inflammation is worse first thing in the morning and eases with movement. Pain from a septic joint is present both at rest and with movement

24. Timing (frequency, duration and periodicity of symptoms) A history of several years of pain with a normal examination suggests chronic pain syndrome. A history of several weeks of pain, early-morning stiffness and loss of function is likely to be an inflammatory arthritis.

25. Timing (frequency, duration and periodicity of symptoms ) ‘ Flitting’ pain starting in one joint and moving to others over a period of days is a feature of rheumatic fever and gonococcal arthritis. If intermittent with resolution between episodes it is likely to be palindromic rheumatism

26. Exacerbating factors exercise.

27. Severity Apart from trauma, the most severe joint pain occurs in septic and crystal arthritis

29. Stiffness Establish what the patient means by stiffness. Is it: restricted range of movement? difficulty moving, but with a normal range? painful movement? localized to a particular joint or more generalized?

30. Swelling Establish : the site, extent time course of any swelling

31. Erythema (redness) and warmth Erythema is common in infective, traumatic and crystal- induced conditions and may be mildly present in inflammatory arthritis. All joints with an inflammatory or infective component will be warm.

32. Weakness Weakness suggests joint, neurological or muscle disease. The problem may be focal or generalised. Weakness due to joint disorders is either from pain inhibiting function or to disruption of the joint or its supporting structures

33. Locking and triggering Locking’ is an incomplete range of movement at a joint because of an anatomical block. It may be associated with pain. True locking is a block to the normal range of movement caused by mechanical obstruction, e.g. a loose body or torn meniscus, within the joint. This prevents the joint from reaching the extremes of normal range.

34. Extra-articular features Patients may present with features of extra-articular disease which they may not connect with musculoskeletal problems. The pattern of the joint condition (a/symmetric, flitting) and extent (mono-, oligo- or polyarthritis) suggests the diagnosis and directs the history.

35. The history Presenting complaint Record the nature and duration of pain using SOCRATES, and of stiffness, swelling, weakness and locking. Instability, deformity, sensory disturbance and loss of function may also be presenting complaints. Obtain an exact account of the mechanism of any injury and subsequent events, e.g. development of swelling.

36. The history Presenting complaint Establish the pattern of joint involvement. Predominant involvement of the small joints of the hands, feet or wrists suggests an inflammatory arthritis, e.g. rheumatoid arthritis or SLE. Medium or large joint swelling is more likely to be degenerative or a seronegative arthritis, e.g. osteoarthritis, psoriatic arthritis or ankylosing spondylitis.

37. Past history past episodes of musculoskeletal involvement. Identify co-morbid factors, e.g. diabetes mellitus, steroid therapy, osteoporosis, fractures, ischaemic heart disease, stroke and obesity.

38. Drug history Possible adverse musculoskeletal effects Drug Myalgia, myositis, myopathySteroids Myalgia, arthralgia, positive antinuclear antibody Statins Myalgia, arthralgia, positive antinuclear antibody Angiotensin-converting enzyme (ACE) inhibitors Osteomalacia, arthralgiaAntiepileptics

39. Family history Inflammatory arthritis is more common if a first-degree relative is affected. Osteoarthritis, osteoporosis and gout are heritable in a variable polygenic fashion. Seronegative spondyloarthritis is more common in patients with HLA B27.

40. Environmental, occupational and social histories current and previous occupations. Is the patient working full- or part-time, on sick leave or receiving benefits? Has the patient had to take time off work because of the condition? If so, is the patient's job at risk?

41. Environmental, occupational and social histories Identify functional difficulties, including ability to hold and use items such as pens, tools and cutlery. How does the condition affect activities of daily living, e.g. washing, dressing and toileting? Can patients use stairs and do they need aids to walk? Ask about functional independence, especially cooking, housework and shopping

42. Environmental, occupational and social histories Some conditions are seen in certain ethnic groups, e.g. sickle cell disease may present with bone and joint pain in African patients. Osteomalacia is more common in Asian patients. Bone and joint tuberculosis is more common in African and Asian patients.

43. sexual history since sexually transmitted disease may be relevant : e.g. reactive arthritis, gonococcal arthritis, human immunodeficiency virus (HIV) infection hepatitis

44. Social factors and musculoskeletal conditions Trauma, gout, myopathy, rhabdomyolysis, neuropathy Alcohol Lung cancer with bony metastases, hypertrophic pulmonary osteoarthropathy, rheumatoid arthritits Smoking Trauma, hepatitis B, HIVDrugs of misuse rickets/osteomalacia (vitamin D), scurvy (vitamin C) Diet Vitamin deficiencies e.g. osteoarthritis, diabetes mellitus and Charcot joint Obesity

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