Presentation

Differential diagnosis

Comments

Action

Acute Single Joint

Septic arthritis

Acute hot red joint. Usually very painful. Patient generally unwell, usually with fever.

Septic prosthesis may be clinically silent (ref orthopedics).

Immunosuppression will mask some signs

Need urgent aspiration of the joint for microscopy

Urgent referral to ER within 24 hrs. Please phone if patient needs to be seen in clinic

Gout,

pseudogout

Difficult to distinguish from sepsis if no previous history of gout. Aspiration to show crystals is the definitive diagnostic test.

The “typical” pseudogout patient would be an elderly woman with a hot red wrist or knee. After diagnosis rest, NSAIDs (if justified by GI risk) and joint injection are options. Colchicine works for gout but is poorly tolerated by most patients.

Remember a normal uric acid does not exclude gout and a raised uric acid is very common.

Remember that with allopurinol you aim to get the uric acid below 350, but even when you achieve this the patient may have further attacks for a year or two

Urgent referral if possibility of sepsis

Reactive arthritis psoriatic arthritis

These patients may have a monoarthritis or oligoarthritis. Joints show clinical signs of inflammation, but redness is uncommon.

Ask about inflammatory bowel disease, iritis, psoriasis and sexual history.

Semi urgent referral for actively inflamed joints

Investigations prior to referral;

CBC, U&E, LFT, CRP

Rarely;

haemarthrosis, avascular necrosis

sarcoidosis

Sub-Acute Single/Few Joint(s

Osteoarthritis;

This is a clinical diagnosis which is based on the history and examination.

Generally these patients need education and encouragement towards self management.

Referral is rarely useful in terms of improving patient outcome, though physiotherapy and occupational therapy assessment can help greatly..

Refer patients where there is diagnostic doubt, or where intra articular injection might help.

Gout

Acute gout is discussed above. Chronic gout e.g. recurrent acute attacks, tophaceous gout may be an indication for allopurinol. Patients will continue to get attacks of acute gout for several months after starting allopurinol and may abandon therapy if not warned.

Refer patients where there is difficulty controlling the disease or diagnostic uncertainty.

Inflammatory Polyarthritis

Rheumatoid arthritis

This is a predominantly clinical diagnosis based on the present of persistent (i.e. >6 weeks) symmetrical synovitis , morning stiffness, malaise.

Rheumatoid factor is not a helpful diagnostic test and should only be used to assess prognosis. False positives are common.

Anti CCP antibodies are highly specific (95-98%) for RA.

We will be reserving clinic slots every week for assessment of patients with possible early RA and if the referral is clearly marked they will be seen quickly.

It is generally helpful not to start steroids before discussion with the rheumatologist

All potential new RA cases should be referred urgently for assessment

Investigations helpful prior to referral include;

CBC,

U&E, LFT

CRP

Anti CCP

Flare of RA

Patients with active RA may flare following infections or without an obvious trigger. Generally it is reasonable to wait a few weeks to see if thing return to normal rather than rushing to change the DMARD dose etc.

For persistent flares depomedrol 80 mg im may settle things down prior to referral for urgent review

Reactive arthritis

See comments above

SLE / CT diseases

Refer to other Division members

Post viral

A history of infection is not always obvious, and distinguishing from rheumatoid arthritis is notoriously unreliable. It is reasonable to treat a patient with an inflammatory arthritis symptomatically with NSAIDs for a few weeks to see if it is self-limiting. Steroids can confuse the diagnostic picture and are usually best avoided.

Phone to discuss this group if worried.

Periarticular /Soft Tissue Rheumatism

Subacromial bursitis

Patients may benefit from injection therapy or a multi-professional approach for persistent soft tissue problems.

We will be running a soft tissue clinic for regional rheumatology problems such as these; please clearly mark referrals if intended for this clinic (including OA / RA where a single injection is requested)

Currently outside our scope of practice until waiting times improve

Plantar fasciitis

Trochanteric bursitis

Tennis elbow

etc