2009年现代疾病诊断和治疗骨关节炎章.docVIP

Note: Large images and tables on this page may necessitate printing in landscape mode.Copyright ? The McGraw-Hill Companies.??All rights reserved.CURRENT Medical Dx Tx??Chapter 20. Musculoskeletal Immunologic Disorders? Diagnosis Evaluation of Musculoskeletal Disorders Examination of the Patient In the patient with arthritis, the two clinical clues most helpful for diagnosis are the joint pattern and the presence or absence of extra-articular manifestations. The joint pattern is defined by the answers to three questions: (1) Is inflammation present? (2) How many joints are involved? and (3) What joints are affected? Joint inflammation is manifested by redness, warmth, swelling, and morning stiffness of at least 30 minutes duration. Both the number of affected joints and the specific sites of involvement affect the differential diagnosis (Table 20–1). Some diseases—gout, for example—are characteristically monarticular, whereas other diseases, such as rheumatoid arthritis, are chiefly polyarticular. The location of joint involvement can also be distinctive. Only two diseases frequently cause prominent involvement of the distal interphalangeal (DIP) joint: osteoarthritis and psoriatic arthritis. Extra-articular manifestations such as fever (eg, gout, Still disease, endocarditis), rash (eg, systemic lupus erythematosus, psoriatic arthritis, Still disease), nodules (eg, rheumatoid arthritis, gout), or neuropathy (eg, polyarteritis nodosa, Wegener granulomatosis) narrow the differential diagnosis further. Table 20–1.?Diagnostic value of the joint pattern. Characteristic Status Representative Disease Inflammation Present Rheumatoid arthritis, systemic lupus erythematosus, gout Absent Osteoarthritis Number of involved joints Monarticular Gout, trauma, septic arthritis, Lyme disease, osteoarthritis Oligoarticular (2–4 joints) Reiter disease, psoriatic arthritis, inflammatory bowel disease Polyarticular ( 5 joints) Rheumatoid arthritis, systemic lupus erythematosus