1. Locomotor system Dr : BASMA EL-HABBASH Rheumatology unit Tripoli Medical Center

2. Approach to painful joints

3. Locomotor system History Joints:- -Pain:- - Site:- symmetrical or not. - Duration of symptoms - Onset of symptoms:-- Sudden. - Gradual - Pattern:- ( course ) e.g. fleeting, additive, progressive, stationary, intermittent. - Severity. - Character. - Aggravating & relieving factors.

4. Associating symptoms:- Swelling Redness. Restriction of movement Stiffness:- - Morning. - Site. - Duration. - At which condition.

5. Muscles:- - Muscle pain. - Muscle weakness: - Site:- proximal or distal - Duration of symptoms. - Diurnal variation. - Associated symptoms e.g. rash over the knuckles

6. Symptoms of proximal myopathy :- -Difficulty in arising from setting position. -Difficulty in climbing stair. -Difficulty in combing hair. -Difficulty in lifting objects above the level of head.

7. Symptoms related to back pain :- 1- Site. 2- severity. 3- Associated symptoms:- stiffness after a period of rest, numbness. 4- Aggravating factor:- eg movement. 5- Associated pain in sacroiliac joints. 6- Previous H/O of trauma or fall down.

8. Review of rheumatological features :- Hair loss. Eye: - redness, decreased vision, dryness. Malar rash. Photosensitivity. Mouth ulcers. Mouth dryness. Raynaud’s phenomena. Genital ulcers.

9. Case history - 41 years old female, presented to rheumatology OPD complaining of symmetrical small hand joints pain of 2 months duration. * Gradual fixed severe joint pain involving MCP &PIP joints of both hands of 2 months duration interfering with her sleep and daily activities associated with swelling & morning stiffness of 2 hours duration of the above mentioned joints.

10. * She has no muscle pain or weakness. She has no hair loss, eye symptoms, malar rash, photosensitivity, mouth ulcers, Raynaund’s phenomena or genital ulcers.

11. Important point:- 1-middle aged female 2-symmetrical involvement. 3-small hand joints involvement. 4-long duration means chronic disease. 5-morning stiffness > 1 hours. 6- no other rheumatological features. Diagnosis Rheumatoid arthritis

12. Case report 28 years old female patient, was referred to Rheumatology OPD, complaining of pain and swelling affecting both wrists and both knees of 2 months duration. The pain started gradually and become more sever in the last 2 weeks interfering with her sleep and daily activities, increased by movement and relieved by rest What do you want to ask more ?

13. Morning stiffness: No. Other joint involvement: No. Associated redness: No. Associated restriction of movement: yes, she can not walk or move her hands normally because of pain and swelling. What is the diagnosis?

14. D/D:- 1- Rheumatoid arthritis. 2- SLE. 3- Behcet’s disease. 4- IBD with exra-articular manifestations. 5- Reactive arthritis. 6- Psoriatic arthritis. 7- Ankylosing spondilitis.

15. Review of locomotor system:- ►Negative apart from recurrent oral ulcers (4 times in the last 6 months). ►It was painless occurred on the tongue and inner aspect of the cheeks. What is the diagnosis?

16. D/D:- 1- SLE. 2- Behcet’s disease. 3- IBD with extra-articular features. 4- Reactive arthritis.

17. ►No genital ulcers, No eye symptoms of previous attacks of anterior or posterior uvietis. ►No H/O diarrhea, blood or mucous in the stool or wt loss in the previous period. ►No H/O conjunctivitis, urethritis or previous attack of gastroentritis or G.U.T infection in the period before joint pain.

18. SLE is the probable clinical diagnosis

19. Investigations 1- CBC:- leukopenia and lymphopenia. 2- CXR:- normal. 3- ECG:- normal. 4- U/E/C:- normal. 5- Urine R/E:- normal. 6- 24 hrs collection of urine for protein: normal. 7- VDRL:- was positive. 8- U/S abdomen:- mild hepatosplenomegaly. 9- ANA was positive. 10- Anti-DNA antibodies were negative.

20. So the patient has :- 1- Arthritis. 2- recurrent oral ulcers. 3- hematological manifestations:- leukopenia and lymphopenia. 4- Positive VDRL. 5- Positive ANA. 6- other features:- hepatosplenomegaly.