Approach for Diagnosis of Arthritis 1. Demograph Demographic ic data 2. Articu Articula larr disea disease se or non-artic non-articula ularr disease disease 3. Clini Clinical cal data data Paijit Asavatana Asavatanabodee bodee
Articular icular fea feature tures s Art
Rheumatic Disease Unit
Extra-articu Extra-articular lar
features
Phramongkutklao Hospital
Demographic Characteristics and Diagnosis Diagnosis of Articular Compl Complaints aints 40 years
TK, SLE, SSc
> 40 years
RA, OA, GCA
≤
Associated or prior events
Triggering events
Aggravating factors
Personal history
Family history
Drug history
Age of onset ≤
40 years
> 40 years
RD, AS
Gout
Articular Articular diseases diseases or Peri-arti Peri-articula cularr diseases diseases
Traumatic arthritis
Olecranon bursitis
Cellulitis
Prepatellar Bursitis
Anserinus bursitis
Osgood Schlatter disease
De Quervain tenosynovitis
Symptoms and physical signs
Articular Pathology (eg. arthritis, OA)
Peri-articular Pathology (bursitis, tendinitis)
Non-rheumatic Pathology (eg. referred pain)
Pain / discomfort
Around joint Localized plane boundary, after with use prolonged inactivity
Diffuse, beyond joint boundary without activity relation
Stiffness
Often, > 15 min duration
±
, brief duration
None
Signs of inflammation
Around joint boundary
Localized / linear plane
None
Crepitus Crepitus / locking / stability
Often (internal derangement, loose body)
Unusual, except rotator cuff tendinitis, FTS
None
Limited ROM
All direction, active = passive (with pain)
Some direction, active < passive (with pain)
Free ROM without pain
Deformity
Common if joint destruction, irreducible
Uncommon, reducible
None
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Pattern of Joint Involvement and Diagnosis of Articular Complaints
Int.derangement, OA, Osteonecrosis
Acute migratory
Rheumatic fever, GC arthritis
Chronic additive
SpA (RD, ReA, ReA, PsA), RA
Destructive
RA, OA
Non-destructive
CNTD, malignancy, Still’s, metabolic dis.
Symmetry Chronic Asymmetry
Acute inflammatory Mono-
SpA (RD, PsA), chronic crystal arthropathy
Trauma, hemarthrosis, gout, pseudogout, bact. infection, tumor Diagnosis
1.
History
6. Serology
7. Hist Histol olog ogy y
8. Special lab tests
3. Routine lab 4. Synovial fluid analysis 5. Bone / joint radiograph
Infection (TB, fungus), Monoarticular
RA, SpA, amyloidosis, Chronic inflam.
History
2. Physical examination 3. Routine lab 4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology (RF, HLA B27)
7. Histology 8. Special lab tests (PCR, MRI, arthroscope, special C/S orstaining)
RA, SpA, amyloidosis, Chronic inflam.
Pigmented villonodular synovitis
TB arthritis
Rheumatoid arthritis Rheumatoid nodule
MiliaryTB
Monoarticular
Pigmented villonodular villonodular synovitis
Diagnosis 1.
Infection (TB, fungus), Monoarticular
Monitoring
2. Physical examination
Traumatic arthritis
Viral arthritis, BE, pseudogout, elderly gout, drug-induced arthritis
Acute Poly(> 4 joints)
Acute hemarthrosis
Non-bact infection, PVNS, PVNS, RA, SpA
Inflam Chronic Noninflam
Oligo(2-4 joints)
Mono-
Trauma, crystal, bact.infection, tumor
Acute inflammatory Mono-
Trauma, hemarthrosis, gout, pseudogout, bact. infection, tumor
Acute inflammatory
Acid fast stain
Chronic non-inflam.
Osteoarthritis, internal derangement, osteonecrosis
Monitoring
Osteoarthritis
Osteonecrosis
Apley’s Apley’s test
Godfrey's drop back test
Lateral instability test
Drawer’s test
Mc Murray’s test
2
Monoarticular
Chronic non-inflam.
Osteoarthritis, internal derangement, osteonecrosis Diagnosis
3. Routine lab
History
4. Synovial Synovial fluid analysis analysis
5. Bone / joint radiograph
7. Histology
8. Special lab tests (MRI, arthroscope, etc.)
Acute (migratory)
Septic vasculitis
Asymmetrical arthritis
Splinter hge
Rheumatic fever, septic arthritis (GC, non-GC), BE
OligoUrethritis
History
2. PE (articular (articular & extra-articul extra-articular) ar) 3. Routine lab 4. Synovi Synovial al fluid analy analysis sis 5. Bone / joint radiograph
±
Subacute-chronic additive Balanitis
7. Histology
8. Special lab tests
Keratoderma blennorhagica
Psoriasis
Conjunctivitis
Anterior uveitis Psoriatic nail
Dactylitis
Guttage psoriasis
Acute Subacute-chronic additive
SpA (RD (RD,, ReA, PsA) PsA) RA
6. Serology (ASO titer)
Oligo-
Roth spot
Gram’s stain
Septic vasculitis
Diagnosis Monitoring 1.
Septic vasculitis
6. Serology
Oligo-
Rheumatic fever, septic arthritis (GC, non-GC), BE
Monitoring
2. Extra-articul Extra-articular ar manifestation manifestation
1.
Acute (migratory) Oligo-
SpA (RD, ReA, ReA, PsA) PsA) RA
Poly-
(usually symmetrical)
Viral
arthritis (Rubella, parvovirus, HVB, HVC, HIV, CMV, etc), bact. endocarditis Elderly gout, pseudogout (pseudo-RA) Drug-induced arthropathy
Diagnosis Monitoring 1.
History
2. PE (articu (articular lar & extraextra-arti articul cular) ar) 3. Routine lab 4. Synovial Synovial fluid analysis analysis (for exclusion of crystal / infection)
5. Bone / joint radiograph
Slapped cheek in Fifth disease
Symmetrical polyarthritis
Rubella rash
Pseudo-RA in pseudogout
6. Serology (RF, HLA B27)
7. Histology
±
8. Special lab tests
Elderly gout in OA hand
3
Viral
arthritis (Rubella, mumps, HVB, HVC, HIV, CMV, etc), bact. endocarditis Elderly gout, pseudogout Drug-induced arthropathy
Acute Poly-
PolyChronic
Destructive
RA, OA
Nondestructive
CNTD, vasculitis Still’s, malignancy, metabolic dis.
Symmetry
Severe RA
Diagnosis
Monitoring
4. Synovi Synovial al fluid analy analysis sis (crystal)
5. Bone / joint radiograph
±
6. Serology (viral studies)
7. Histology
8. Special lab tests (anti-histone Ab)
±
1. History 2. PE (articular (articular & extra-articul extra-articular) ar) 3. Routine lab
PolyChronic
Destructive
RA, OA
Nondestructive
CNTD, vasculitis Still’s, malignancy, metabolic dis.
Symmetry
Diagnosis 1. History 2. PE (articular (articular & extra-articul extra-articular) ar) 3. Routine lab (CBC, U/A, ESR) 4. Synovial Synovial fluid analysis analysis
5.
Bone / joint radiograph
6.
Serology (ANA, RF)
7. Histology (Tissue biopsy) 8. Special lab tests (TFT, PTH, search for occult malignacy)
PolyChronic Asymmetry Psoriasis
Severe OA
Jaccoud’s arthropathy
Rheumatoid arthritis
Osteoarthritis
Adult
Gottron Gottr on rash in DM
SLE rash
Juvenile
Osteoarthritis
Adult
Juvenile
Monitoring
Rare in OA: Shoulder, elbow, ulnar
side of wrists, ankles, 2nd-5th MCP
and 2nd-5th MTP joints
Rare in RA: T-L spine
RD, PsA, (RA) Chronic gout Pseudogout
PolyChronic Asymmetry
Gout
RD, PsA, (RA) Chronic gout Pseudogout Diagnosis
1. History 2. PE (articular (articular & extra-articula extra-articular) r) 3. Routine lab Arthritis mutilans
Rheumatoid arthritis
Tophaceou Toph aceous s gout
4. Synovial Synovial fluid analysis analysis
5.
Bone / joint radiograph
6. Serology (RF) 7. Histology 8. Special lab tests
Monitoring
4
Psoriatic arthritis
Saturnine Saturnine gout (Ancient Rome)
Distinctive clinical features 1. Asymme Asymmetri trical cal polyart polyarthri hritis tis 2. Predominanc Predominancee of DIP joint involvement involvement 3. Tenosy Tenosynov noviti itiss (sausage (sausage digit digit)) 4. Psoria Psoriatic tic skin skin or or nail nail lesion lesionss
Saturn was a demonic god who ate his own children. The Romans noticed similarities between symptoms of gout (caused by lead poisoning) and the irritable god, and named the disease after him. Saturnine gout = moonshine gout Gout in chronic lead poisoning : Consumption of moonshine whiskey contaminating lead.
Increased uric acid production Primary Specific enzyme defects
Secondary Specific enzyme defects myelo or lymphoprolifer lymphoproliferative ative disorders disorders Infectious mononucleosis Chronic hemoolytic anemia Gaucher's Gaucher's disease disease Severe proliferative psoriasis
Decreased uric acid excretion (90%) Primary Idiopathic (90%) Familial juvenile gouty nephropathy
Secondary Chronic renal disease, kidney injury
Criterion
Male much more than
Sex
female
Down's syndrome Beryllium or lead poisoning
Secondary gout Male = female
Age
Middle aged
Elderly
Acute attacks
Common
Uncommon
Mono-
Poly-
Number of joint involved
Tophi development development Late
Volume depletion, Hypertension Sickle cell anemia, Hypothyroidism
Primary gout
Obesity, hypertension, Associations
hyperlipidaemia, high alcohol intake
Early Renal impairment, osteoarthritis
Cystinuria
Drugs (diuretics, low dose aspirin)
Disease causing shoulder pain Rotator cuff tendinitis
Calcific tendinitis
Rotator cuff rupture
Frozen shoulder (adhesive periarthritis)
Physical Examination Arthritis of shoulder joint
Subacromial or subdeltoid bursitis
Arthritis of Sternoclavicular Sternoclavi cular joint
Shoulder arthritis Bicipital tendinitis
Subluxationof Subluxationof acromioclavicular joint
5
Physical Examination 1
Physical Examination
7
3
2
5 4 Winging of scapula
6. 1. Sub Subacr acromi omial al spa space: ce: Rotator cuff tendinitis / impingement syndrome,
6
rotator cuff tear, calcific tendinitis, subacromial subacromial bursitis)
Posterior Poster ior edge edge of of acromio acromion: n: Rotator cuff tendinitis, rotator cuff tear, calcific tendinitis, tendinitis, subacromial subacromial
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bursitis.
tear. 2. Bic Bicipi ipital tal gro groove ove:: Bicipital tendinitis, biceps tendon subluxation / tear.
7. Su Supr pras ascap capul ular ar no notc tch: h:
3. Acromi Acromioclavi oclavicular cular join joint: t: RA, OA, SpA, septic arthritis.
8
Suprascapula Suprascapularr nerve entrapment entrapment
4. Anter Anterior ior glen glenohumer ohumeral al joint joint:: RA, OA, SpA, pseudogout, septic arthritis,
8. Quadrilateral space: Axillary Axillary nerve entrapment. entrapment.
apatite arthropathy, osteonecrosis, osteonecrosis, glenoid labrum tear, frozen shoulder. shoulder.
5. Stern Sternoclavi oclavicular cular join jointt : SpA, RA, septic arthritis, OA.
Physical Examination
Shrug sign
Painful arc
Empty cane beer test (Supraspinatus)
Trigger points
Drop arm test
Neertest (Impingement (Impingement test)
Lift-off test (Subscapularis)
Hawkins test (Impingement (Impingement test)
Infraspinatus Teresmajor
Speed’s test
Yergason’s Yergason’s test
Taut band
Acromioclavicular pathology
Back pain 1. Non-sp Non-specif ecific ic or or mecha mechanic nical al type type Injury Degeneration Congenital
Biceps tendinitis
Medical back pain Inflammatory diseases Infectious Non-infectious
Non-inflammatory diseases Metabolic bone disease
2. Specif Specific ic type type or or medi medica call type type Inflammation (Infectious, non-infectious) non-infectious) Non-inflammation (Fracture, malignancy)
Malignancy Hematolo Hematologic gic diseases diseases Psychogenic rheumatism Malingering Referred pain
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“Red flags” flags” in low back pain
Age range associated with back pain 20
30
40
50
60
Ankylosing spondylitis
70 years
Inflamm. bowel disease Reiter’s disease Psoriatic spondylitis Herniated nucleus pulposus
Muscle strain Isthmic spondylolisthesis Fibrositis Osteoarthritis Metastases Spinal stenosis
(Agency for Health Care Policy and Research, AHCPR guideline)
1.
Acut Acute e onset onset in in pati patient entss with with risk factors for osteoporosis
2.
Constant or progressive back pain
3.
Nocturnal pain
4.
Constitutional symptoms: fever, night sweats and weight loss
5.
Morning back stiffness in patients younger patients younger than 20
6.
Progressive bilateral or alternating back pain
7.
Severe or progressive neurological abnormalities
8.
Cauda equi equina na syndr syndrome: ome: saddle anesthesia, bladder dysfunction
9.
Vascular claudication or presence of abdominal of abdominal mass
10. Unable to lie still due to pain 11. Pati Patien ents ts with with risk factors: immunosuppressive state, current or recent infection, malignancy or major trauma
Multiple myeloma
Positive “Red “Red flag” of recent LBP LBP 1. Neurological compromise Saddle anesthesia Sphincter dysfunction Sensory / motor loss of lower limb 2. Fracture Recent trauma Risk factors for osteoporosis Long term use of corticosteroid 3. Infection Fever ± chill, weight loss. Risk factors: HIV, DM, drugs, etc. Recent surgery, dental work, sources of infection Shock of unknown origin 4. Cancer Young (<20) or elderly (>55) History of cancer, (+) S/S of malignancy Unexplained weight loss & nocturnal pain 5. Inflammatory arthritis Family history Nocturnal pain, AM stiffness, arthritis, enthesitis History of uveitis, psoriasis, IBD, etc.
Erythema nodosum
Investigation & Rx. Emergency MRI or CT
Neurosurgical Evaluation
Std.X-rays→Bon Bone e sca scan n CBC, U/A, ESR, CRP, hemo & relevant relevant C/S Bl.chem, Std. X-rays, MRI, bone scintigraphy Routine lab, ESR, CRP, Standard X-rays bone scan, MRI
Non-specific skin sign in autoimmune dis. Septal Sept al panni panniculi culitis tis with without out vascu vasculiti litiss Inflammatory subcutaneous plaques (nodules) on anterior aspect of shins Often accompanied by fever, chills, malaise, leukocytosis leukocytosis and arthritis. arthritis. Dx: Typical lesion and typical location Prognosis: Spontaneous Spontaneous resolve in 3 - 6 wks without ulcerations or scarring.
ESR, CRP, X-rays KUB, lumbar spine and heels Rx. NSAIDs NSAIDs ± DMARDs DMARDs
Erythema nodosum Associated conditions Infections Strept.pharyngitis, Strept.pharyngitis, TB, leprosy, fungus, fungus, Lyme’s disease, leptospirosis, yersinia Drugs Penicillin, sulfonamide, bromides, contraceptive pills Autoimmune diseases: Behcet, SLE Malignancy: RE malignancy Miscellaneous Sarcoidosis, pregnancy, IBD (UC > Crohn) Idiopathic Rx:
NSAIDs, steroids, KI
L o B a w P a c k i n
Size Size of Vess Vessel el Invol Involve veme ment nt in Vasc Vascul uliti itis s Cutaneous Palpable purpura
Post-capillary venules LCV, any type of vasculitis of (medium-sized vessels) in medium and small vessel sized vasculitis. dermis. Less commonly capillaries and arterioles.
LVR
Small arterioles (perpendicular branches in dermis).
PAN, cryoglob, SLE, RA, D/M, APL (Sneddon’s syndrome), lymphoma, TB, syphilis, drug, PRV, IVDU, hypercalcemia, arteriosclerosis. arteriosclerosis.
Nodules
Medium-sized vessels.
PAN, TK, WG, RA, SLE, infection, drug, Behcet’s Behcet’s disease, sarcoid, sarcoid, malignancy, UC
Ulcers Gangrene
Arterioles to small arteries. Medium sized vessels to capillaries.
PAN, CS, WG. Hypersensitivity vasculitis, PAN, CS, WG, cryoglobulinemia.
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Type Type of Vess Vessel el Invol Involve veme ment nt in Vasc Vasculi uliti tis s
Vasculitis and BV size
GI Abdominal pain or mesenteric ischemia
Small to medium sized arteries
HSP, PAN, CS
Capillaries to medium-sized arteries
HSP, PAN, CS
Glomerulonephritis
Capillaries
MPA, WG, CS, Cryoglobulinemia, Cryoglobulinemia, HSP
Ischemic renal failure
Small to medium sized arteries
PAN, TK (common) CS, WG (less common)
Pulmonary hemorrhage
Capillaries; Less commonly small to medium sized arteries
MPA, WG
Pulmonary infiltrates or cavities
Small to medium sized vasculitis
CS, MPA
Peripheral neuropathies
Small arteries
PAN, CS, WG, cryoglobulinemia
Stroke
Small, medium or large arteries
GCA, SLE
GI bleeding
Primary vasculitis
Renal
Pulmonary
Neurological
Jaw claudication, visual loss, tender
Medium
arteries arteries
Large arteries
Drug-induced hyperuricemia Production / intake
GCA
Chemothrapeuatic agents
temporal A, ↓ temporal A pulsation Absent radial pulses
Small
TK GCA PAN KW WG, CSS, MPA Cryoglob. HSP, cut. LCV
Specific types of primary vasculitis
Clinical Features
Arterioles, capillaries, venules
TK, GCA
Renal excretion ACE inhibitors (except losartan)
Didanosine
Cyclosporin / Tacrolimus
Ethanol
Diazoxide
Hypertension in young female
TK, PAN, WG, MPA
Filgrasim
Diuretics (except triamterene, spinorolactone)
Mononeur Mononeuritis itis multiplex multiplex
PAN, WG, CS
Fructose
Ethambutol / Pyrazinamide
Sinusitis, pulmonary-renal synd.
WG, MPA
Glucocorticoids
Levodopa
Ribavirin / Interferon
Probenecid
Nicotinic acid (>3g/d)
Salicylates (<2g/d)
Asthma
CS
Nicotinic acid (>3g/d)
Testicular tenderness
PAN
Bloody diarrhea, crampy abdomen
HSP. IBD
CAN’T LEAP : Cyclosporin, Alcohol, Nicotinic acid, Thiazides,
Loop diuretics, Ethambutol, Aspirin low dose, Pyrazinamide.
Drug-induced Rheumatic Syndrome
Drug-induced Rheumatic Syndrome Drug-induced Lupus
Carbamazepine
Chlorpromazine
Ethosuximide
Hydralazine
INH
Methyldopa
Aromatic amine Slow or
Acetylation
rapid genotype
Inactive metabolites
Drug-induced Anti-phospholi Anti-phospholipid pid Syndrome
Minocycline
Penicillamine
Chlorothiazide
Oral contraceptive pills
Phenytoin
Chlorpromazine
Phenothiazines
Procainamide
Ethosuxumide
Procainamide
Quinidine
Hydralazine
Quinidine
Sulfasalazine
Interferon-gamma
Quinine sulphate
Drug-induced SCLE: Terbinafine, CCB, etanercept.
8
Drug-induced Rheumatic Syndrome
Anti-nuclear antibodies (Patterns, ANA specificities, Disease association)
Drug-induced ANCA-associated Vasculitis
Homogenous
Hydralazine
PTU
Methimazole
d-Penicillamine
Minocycline
Drug-induced Scleroderma Vinyl
chloride Fosinopril Pentazocine
Histone
Rim
ds-DNA Sm
U1-RNP
Tryptophan Bleomysin Organic solvents High titer
Statins
DIL
Drug-induced arthropathy
Fluoroquinolones, retinoids
Cyclosporin, PZA, ETB.
La Scl-70
Ro
+
Drug-induced Myositis
Nucleolar
Speckled
SLE
MCTD
SS
PSS
Overlap syndrome or mixed CNT disease
Mixed Connective Tissue Disease
Use immunofluorescent immunofluorescent assay for staining pattern Use ELISA or immunodiffusion immunodiffusion technique for specific specific Ab test
Pseudogout Pseudogout (CPPD arthropathy) arthropathy)
Clinical combination
PSS
Hand edema Raynaud’s Sclerodactyly Esophageal dysmotility PHT, IPD High titer of Anti-U1-RNP Ab
Arthragia or SLE Arthragia non-deforming arthritis Serositis
RA
Chronic non-infectious destructive inflammatory arthropathy
PM
Myositis
Licked candy
Overhanging
No other autoAbs Anti-Sm Anti-DNA Anti-Ro Anti-La
Gull wing
Spondyloarthropathies
Erlenmeyer fl flask
Pencil in in cu cup (Pestle in in mo mortar)
Pertinent findings (asymmetrical involvement) Juxta-articular osteopenia (less severe) Diffuse joint space narrowing Bone erosions / osteolysis (marginal / subchondral bones) New bone formation • Subchondral bone sclerosis • Peri-articular or marginal bone proliferation • Joint ankylosis (early) Predominance of DIP of DIP joint involvement (Psoriatic arthritis, undiff. SNSA)
9
Secondary AS
Diffuse Idiopathic Skeletal Hyperostosis
DISH
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Bony Proliferation of Spine
10 AS
20 AS
DISH
OA
No SI joint Involvement
SI ankylosis may occur
Pertinent positive finding Flowing of at of at least 4 contiguous large paravertebral bony outgrowths (mug handle-like) Peri-articular calcifications Negative findings (DDx. OA, SNSA) Normal disc space and endplate Normal SI and hip joints No vertebral endplate / subchondral bone changes
Vertebral Verte bral Oste Osteomye omyelitis litis Loss Loss of disc disc space space
Bilateral Sacroiliitis
Unilateral Sacroiliitis
Metastatic malignancy
Destruction Destruction of adjacent vertebral endplates endplates No vertebral sclerosis sclerosis No soft soft tissu tissue e masses masses Staph. aureus is the most most common common causative causative organism
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Osteoporotic Osteoporotic Fracture of of Spine
Metastatic spinal fracture Pertinent findings Soft tissue mass (tumor extension) Normal (or widening) disc space until late Localized (diffuse) osteopenia or osteosclerosis or mixed bone density Stepping and destruction of vertebral endplate Asymmetric collapse of vertebral body Non-homogeneous bone density of collapsed vertebra Loss of pedicle of pedicle or posterior element destruction
Bone / Disc Destruction of Spine
Osteoporoti Osteo porotic c spinal fracture fracture Pertinent findings Generalized osteopenia Widening (or relatively normal) disc space Stepping (irregular surface) of well-defined vertebral endplate Collapse of vertebral body Homogeneous bone density and increased vertical radiodense striations of collapsed vertebra Increased bone density (compact bone + callus)
Normal
Normal renal and liver functions
Low risks for cardiac or GI toxicity
High risks for cardiac or GI toxicity
Taking oral medications
’
Spinal Osteoporotic metastasis fracture
Codfish
Pancake
1.
Soft So ft tis tissu suee sh shad adow ow
2.
Inter Int erve vert rteb ebra rall dis discc spac spacee
3.
Vert Ve rteb ebra rall endp endpla late te
4. Bone texture of vertebral body 5. Pedicle
New drugs and sites of action
Oligo-polyarticularr joint Oligo-polyarticula
Intra-articular steroid injection or NSAIDs or colchicine
Pott s disaease
Wedged
Acute Gout Treatment Acute gouty attack Single joint
Bacterial Spdiscitis
Renal or hepatic disease
Allopurinol
Uricase (uric oxidase) Xanthine Xanthi ne oxidas oxidasee
Oxypurinol Febuxostat
Unable to take oral medications
Solumedral IM,IV 100-150 mg/d x 1-2 days
NSAIDs
Colchicine 0.6 mg x 3
Prednisoone
or
ACTH SC, IM, IV 30-60 mg /day then taper off in 2 wks 25-40 IU q 12 hrs for 1-3 days
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Rheumatology’s Ten Golden Rules 1. Good history and physical examination with knowledge of musculoskel of musculoskeletal etal anatomy anatomy.. 2. Most shoulder pain is per-articular. Most low back pain is non-surgical. 3. Pati Patien ents ts with with acute monarthritis need a synovial analysis for diagnosis. 4. Most Most pat patie ient ntss with with chronic monarthritis need a synovial synov ial biop biopsy sy for diagnosis. 5. Gout rarely occurs in pre-menopausal women or affects spine and joints nearby spine.
Rheumatology’s Ten Golden Rules 6. Patien Patients ts with with uncomm uncommon on sites sites of primary of primary OA need to be evaluated for secondary OA. OA. 7. Pri Primar mary y fibrom fibromyal yalgi gia a rarely initially presents after age of 55 or presents with abnormal lab values. 8. Fever and multi-organ complaints in pts with known systemic rheumatic diseases need to be excluded infection and possibly other causes. 9. Why order a lab test? test? What to do if it comes back abnormal? 10. Most of asympt asymptomat omatic ic persons persons having having positive RF or ANA have neither RA or SLE.
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