Approaching the Patient with "Joint Pain" - CRASH! Medical Review Series

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before the video starts, i wana pause and say i love you and respect you so very much. i hope you realize how much you are making medicine easier for me and others. i wish to be like you someday

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Thank you so much for theses videos! they're slightly better than KAPLAN's.. im a final year med student and ive been surviving med school on your videos. Thank you very very much!

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Love every single video of yours. Straight and to the point.

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Thank you so much for all the videos you have made.

[@fatimasuleman1980]

Awesome intro.. thank you so much Dr Paul

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Thank you Dr Bolin, these lectures are really great!

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[@woloabel]

Monday, November 14, 2022. Rheumatology (Arthropathy) or Connective Tissue Pathology Localized to the Joints; Approaching the Patient With Arthralgia ("Joint Pain"): Anatomy and Physiology of Joints: Anatomic Structures of Joints: 1) Bone is the Supportive Connective Tissue of the Body known collectively as the Skeletal System, 2) Ligament is the Connective Tissue And/Or Organic Structure Connecting Bone to Bone; 3) Cartilage is the Solid Tissue Localized to Ends of Bones; 4) Synovial Fluid (SF) is the Ultrafiltrate of Serum (Plasma) having the physiologic utility of Lubrication and/or Facilitation of Motion of Joint by lessening Fiction. The SF is an Ideal Diagnostic Medium For Aetiologic Investigation (Inflammatory Biomarkers [Arthritis, Rheumatoid Arthritis], Metabolic Derangements [Gout, Pseudogout, Uricemia]); 5) Synovial Membrane is the Thin Lining Covering the Joint Cavity, tissue Responsible for the Biosynthesis of Synovial Fluid (Synoviocytes). The Latter Components Collectively are the Anatomy Structure known as the Joint; Pathology of the Joint: 1) Arthritis is a Pathologic Disease Process based on Cellular Infiltration and/or Inflammation Pattern localized to the Joints but not Specific to Causation (Autoimmunity, Trauma (Wear and Tear), Pathogens, Neoplasia, Developmental Congenital Degeneration Mechanism or Other). Inflammation of the Joint can be indicative of a Greater Systemic Inflammatory Disease Process; while 2) Arthralgia is Merely a Symptom of Disease (Indicative also of Systemic Inflammatory Disease) due to 1) Referred Pain from possible Systems of 2) Muscle, 3) Tendon, or 4) Bone. A Physical Examination is First Line Diagnostic Modality for the Differentiation of Arthralgia or An Actual Inflammation of the Joints, otherwise Arthritis. A Good History (Hx) can also be useful but is not Sufficient for an Actual Diagnosis (Aetiology of the Pathology is Variable); Therefore, Joint Pain should be understood as a major source/manifestation of Disability (Functio Laesa) and Morbidity (Chronic Process and Complications), especially in Geriatric Populations. Understandably, Gerontologic understanding is most relevant in this Category of Pathology Study. Possible Aetiology (Ax) in Joint Pain and/or Differential Diagnosis (DDx): 1) Trauma: 1) Sprain, 2) Strain, 3) Fracture, 4) Dislocation, 5) Tendon/Ligament/Meniscus Tear, and 6)Tendonitis); 2) Infection: 1) Gonococcal (Bacteria), 2) Non-Gonococcal Bacterial, 3) Lyme Disease due to Tick-borne Bite Transmission (Borrelia burgdoferi Bacteria), 4) Viral Infection (Parvovirus B19), when acute-onset polyarticular Sx, 5) Mycobacterial Infection (M. Tuberculosis); and 6) Fungal Infection due to Bastomycosis usually systemic Metastatic dissemination is a rare cause (Blastomyces dermatitidis); 3) Crystal Deposition/Accumulation (Uric Acid or Calcium) are also known as Crystal Arthrapathy: 1) Gout is a Metabolic Disorder (Purine Metabolism) due to Uric Acid Underexcretion (Renopathy) and Deposition Thereafter in the Joints with Monosodium Urate Crystallization End products, and 2) Pseudogout is the Deposition of Calcium Pyrophosphate in the Joints (Arthritis/Arthralgia/Synovitis) with a Spontaneous Acute Attack Therein. Aetiology is Unknown but Risk Factors (RFs: Old Age, Genetics [Hemophilia A/B]) and Associations (Hyperparathyroidism, Gout, Hypothyroidism, Hypophosphatasia [ALPL Gene], Acromegaly [Adenoma]) have been Related; 4) Degenerative Aetiology: 1) Osteoarthritis (OA) is the most Common Cause of Joint Pain (Age, Past Infections, Injury) and Inflammation Therein (usually will not have Extra-articular SSx); 5) Malignancy (Neoplasia of Bone or Metastatic): 1) Solid Tumor Metastasis (Carcinoma) while Malignant Joint Effusion has been Reported in Solid Tumors; 2) Lymphoma is the Neoplasia of Lymphocytes in Circulation or Lymph Node Residency (NHL/DLBCL subtype and Most Aggressive); 3) Leukemia is the Malignancy of the Bone Marrow and affects Hematopoiesis (Blastosis/Blastemia); 4) Osteosarcoma is Mesenchymal Neoplasia of the Osteoblast/Osteocyte Line; and 5) Osteochondroma is Exostosis of Bone known as Osteocartilaginous Exostosis, a benign neoplastic structure and process; and 6) Rheumatic Disease Causation1) Rheumatoid Arthritis (RA) is a Multisystemic Autoimmune Disease usually affecting Wrist and Hands Symmetrically; 2) Reiter's Syndrome is a Complication of a Bacterial Infection or Reactive Arthritis resulting in Inflammatory Multisystemic Symptoms including Joint Pain (SP Gastrointestinal/Genitourinary Infection [Salmonella enteritidis/Chlamydia trachomatis]); 3) Psoriatic Arthritis(PA) is a Complication of the immunopathy of Psoriasis; 4) Systemic Lupus Erythematosus (SLE) is a Multisystemic Autoimmune Disorder slightly described as Connective Tissue Disease (Chronic Infiltrative Disease), such Process can effect Joint Erosion (Joint Pain); 5) Ankylosis Spondylitis is Arthritis Localized to the Spinal Cord leading to the Fusion of Vertebrae (Complication and/or Sequalae of Chronic Inflammation); 6) Acute Rheumatic Fever is a Complication/Sequalae of Pharyngitis (Group A Streptococcus Bacterium or specifically Streptococcus pyogenes) due to possible Autoimmune Mechanism, otherwise Unknown Aetiology; 7) Sjoegren's Syndrome is autoimmune Glandular Inflammation (Salivary and Lacrimal of Chronic Duration); and 7) Other Aetiologic Mechanisms; History Taking. 2) Diagnosis: 1) Laboratory Investigation in Joint Pain: 1) Joint Aspiration (Arthrocentesis) for any Inflammation of the Joint (Arthritis); 2) Radiology: 1) Plain Radiograph (X-Ray Imaging) for any visible Inflammatory Process due to Osteoarthritis (Degenerative Disease) which lacks Extra-articular Signs and Symptoms, Geriatric Subjects (Old Age Association/RF), and Symmetrical Pattern; 2) Computed Tomography (CT) can be more Elucidatory (Greater Accuracy); 3) Serology for Autoantibodies for Rheumatologic Disease (Extra-Articular Signs and Symptoms is the Best Initial Test for Aetiologic Investigation. ANA Titers for Lupus is Sensitive but not Specific (Anti-Smith or Anti-dsDNA are most Specific herein). The Specificity and Sensitivity of Antibody Titers is Variable, and the Assay thereof has Limitation (Lupus has over 100 Possible Antibodies Ongoing Medical Research Indicates); For Matter of Dx and forming a More Specific Approach to A Proper Diagnosis: 1) History (Hx) is useful for Proper Diagnosis. SLICE: 1) Systemic (Fever, Chills, Fatigue Sx) 2) Location (Anatomy Affected); 3) Inflammation (Pattern of Inflammation Acute, Edematous); 4) Chronicity; 5) Evidence of Trauma (Fracture, Contusion et al); 2) Physical Examination (Px) for building a Presumptive Diagnosis; 1) Extra-articular Symptoms with Particular Arthritides: 1) Autoimmunity/Rheumatologic, Malignancy, and Infection; 2) Infectious Aetiology have Fever, Chills, Nausea, and Rash (Lyme Disease has Erythema Migrans); 3) Malignancy has Pallor (Anemia), Ecchymoses (Easy Bruising because of Low Platelets), and Propensity to Infection Elsewhere (Leukopenia); 4) Rheumatologic/Autoimmune (Fever and Unintended Weight Loss): 1) Rheumatoid Arthritis can have Keratoconjunctivitis Sicca or Dry Eyes; 2) Reiter's Syndrome will proceed Gonococcemia or Enteritis; 3) Psoriatic Arthritis can have a Mimic Onychodysgenic Effect; 4) SLE typically Malar Rash (95% Specific) and Renal Insufficiency (Nephrotic Syndrome/Nephritic Syndrome scenario); 5) Ankylosing Spondylitis will also have Low Back Pain; 6) Sjoegren's Disease Dry Eyes and Mouth; and 7) Wagener's Granulomatosis will Chronic Respiratory Tract Infections (Upper and Lower) along with Renal Insufficiency; The Prevalent Location of the Autoimmunity will however Predominate. Amniocentesis Basis: 1) A Red (Rubor), Swollen (Tumor), Warm (Calor), and Painful (Dolor) Joint is essentially the Hallmarks of Inflammation and Infection is the Usual Reason. However, 1) Gout will have Irritation and Inflammation due to Deposition (Infiltration due to Monosodium Urate Crystallization); 2) Pseudogout the same but due to Calcium Pyrophosphate; and 3) Septic Arthritis will show Bacterial Infiltration Causation within the Synovial Fluid Assessed. Morphological Parameters: 1)Color; 2 Cells (WBCs; Neutrophils or Macrophages/Histiocytes); 3) Crystals for the Other Possible Infiltration Causes; and 4) Culture is essential in determining the Bacterial Agent. Therefore, a Good Start for the latter Pathologic Agents (Aetiology Determination); Antibodies Possible in Various Joint Pain Disorder: 1) Anti-Nuclear Antibodies (ANA): 1) Anti-RO (A Soluble Ribonucleoprotein is 70% Specific/SSA) and Anti-LA (SSB) Antibodies are Cellular Ribonucleoprotein Specific Assessments are for Sjoegren's Syndrome and are Antigens Associated with other Autoimmunity Disorders (Lupus) also: 2) Anti-Centromere Antibodies (ACA) is Specific/Sensitive for CREST Syndrome (Primary Biliary Cholangitis [PBC] Association); 3) Anti-Histone (Various subtypes Possible) is specific for Drug-Induced Lupus (Drug Inducement Association); and 4) Anti-Smith (30% Specificity) and Anti-dsDNA (DNA Antigen serves as the Adaptive Humoral Immune Response Target) are in line with SLE (High Specificity); 2) Rheumatoid Factor (RF) and Anti-Cyclic Citrullinated Peptide (Anti-CCP) is Congruent with RA but not sensitive enough so as to be assured of a Negative Result being Diagnostic of RA; 3) Anti-Neutrophil Cytoplasmic Antibodies (ANCA): 1) Cytoplasmic-Anti-Neutrophil Cytoplasmic Antibody (c-ANCA) is Sensitive and Specific (90%) in Wegener's Granulomatosis (WG) while 2) Perinuclear-Antineutrophil Cytoplasmic Antibodies (p-ANCA) for Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome);......TBC MD Paul W. Bolin. Gross und Der Beste.

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