Rheumatology

Musculoskeletal problems are common and usually short-lived and self-limiting. They account for about one in five consultations in primary care. Recognition and early treatment of rheumatic conditions help reduce the incidence of chronic pain disorders in non-inflammatory conditions and allow early referral for specialist care in inflammatory arthritis to achieve better symptom control and prevention of long-term joint damage. Pain, stiffness and swelling are the most common presenting symptoms of joint disease and may be localized to a single joint or affect many joints.

THE NORMAL JOINT

There are three types of joints - fibrous, fibrocartilaginous and synovial. Fibrous and fibrocartilaginous joints include the intervertebral discs, the sacroiliac joints, the pubic symphysis and the costochondral joints. Synovial joints include the ball-and-socket joints (e.g. the hip) and the hinge joints (e.g. interphalangeal). In synovial joints the opposed cartilaginous articular surfaces move painlessly over each other, stability is maintained during use and the load is distributed across the surface of the joint (Fig. 7.1).

MUSCULOSKELETAL SYMPTOMS

Arthralgia describes joint pains when the joint appears normal on examination.

Arthritis is the term used when there is objective evidence of joint inflam-mation (swelling, deformity or an effusion).

In a patient presenting with joint pains, the history and examination must assess the distribution of joints affected (symmetrical?, axial or peripheral?), the presence of morning stiffness (>30 minutes in inflammatory arthro-pathies), aggravating and relieving factors, past medical history and family history. Table 7.1 lists the likely causes of joint pains based on the age and sex of the patient.

Fig. 7.1 Anatomy and physiology of a normal synovial joint

Table 7.1 Differential diagnosis of polyarticular arthritis in adults in the UK
Age Predominantly
males
  Predominantly
females
Young Reactive arthritis   Systemic lupus
erythematosus
  Ankylosing
spondylitis
  Rheumatoid arthritis
      Sjögren’s syndrome
    Psoriatic arthropathy
Enteropathic
arthropathy
 
Middle age Gout Osteoarthritis Rheumatoid arthritis
Elderly   Osteoarthritis
Polymyalgia
rheumatica
Pseudogout
 
Any age: Lyme disease, endocarditis, acute hepatitis B infection, human immunodeficiency virus infection, parvovirus.
Uncommon arthropathies: Malignancy (hypertrophic pulmonary osteoarthropathy), rheumatic fever, Henoch–Schönlein purpura, Behçet’s syndrome.

Pain in or around a single joint may arise from the joint itself (articular problem) or from structures surrounding the joint (periarticular problem). Enthesitis (inflammation at the site of attachment of ligaments, tendons and joint capsules), bursitis and tendinitis are all causes of periarticular pain. Pain arising from the joint may be the result of a mechanical problem (e.g. torn meniscus) or an inflammatory problem.

The causes of a large-joint monoarthritis include osteoarthritis, gout, pseudogout, trauma, septic arthritis (p. 296). Disseminated gonococcal infec-tion is a common cause of acute non-traumatic monoarthritis or oligoarthritis in young adults. Less common causes are rheumatoid arthritis (RA), the spondyloarthropathies, tuberculous infection and haemarthrosis (e.g. in haemophilia, or on warfarin). Acute monoarthritis requires urgent investiga-tion and treatment (p. 298). The key investigation is synovial fluid aspiration with Gram stain and culture and analysis for crystals in gout and pseudogout.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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