M1 estrategia diagnóstica

Estrategias Diagnósticas en Reumatología

Dr. Daniel Xibillé Friedmann, MSc

Bases del razonamiento clínico

• Conocimiento

• Habilidad (velocidad y agilidad)

• Establecimiento de mapas mentales

– Experto

– Novato

• Pensamiento no analítico

– Patrones

Paciente

• “La rodilla me dolió mucho anoche. El dolor me despertó. Cuando me fuí a dormir estababien. Ahora está inflamada. Es el peor dolor que he tenido. He tenido problemas similaresen la misma rodilla, una vez hace 9 meses, la otra hace dos años. No me ha molestadoexcepto en esas dos ocasiones.”

Novato

• Masculino de 54 años con dolor en la rodilla. Inició anoche. No refiere trauma previo. A la exploración sus signos vitales son normales. La rodilla se encuentra inflamada, eritematosa y dolorosa a la palpación. Le duele mucho al explorar el rango de movimiento. Ha presentado este problema en dos ocasionesprevias.

Experto

• Masculino de 54 años con artritis aguda de la rodilla derecha que lo despertó. Niegaantecedentes y se refiere asintomático al acostarse. Tiene el antecedente de dos episodios similares de dolor hace 9 meses y dos años con periodos libres de dolor entre ellos. Hoy se encuentra afebril. Su rodilla estáinflamada, dolorosa a la palpación y eritematosa.

Diferencias

• No hay estructura definida en la presentaciónnovata

• El experto generó una representación del problema e impresión diagnóstica

• Guía subsecuente

• Transformación a términos clínicos

• Una sola frase “Monoartritis aguda recurrenteen un hombre adulto”

Abordaje en dos pasos

• Mapa mental no analítico

• Basado en evidencia y experiencia

• Dos mapas:

– Mapas creados mediante el conocimiento de unaenfermedad

– Mapa generado al revisar a un paciente

Tipos de diagnóstico

DiagnósticoSindromático

DiagnósticoNosológico

DiagnósticoEtiológico

Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte

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We propose a “two-step approach to diagnosis”4. The first step aims to define the generic type of pathology,

that is, to set a main syndrome. Using the travel analogy we could say that these main syndromes are

“neighbourhoods” in rheumatology town. Step two involves a more detailed investigation which is adapted to

each syndrome and aims to differentiate between potential causes of that syndrome, thus making a final

differential diagnosis.

This approach allows us to identify precisely the main defining characteristics of each main syndrome and the

most important clues to differentiate between similar conditions and evaluate their severity. This is what finally

really matters for your clinical decisions. These should, obviously, be the guides and focus of our strategic

questioning and examination. The practicing clinician should be as precise and detailed as possible on

aspects that should matter to his reasoning and decision while trying to be economic and fast on dismissing

“background noise”.

Hopefully, this will help the reader to build and maintain a faster and reliable map for clinical expertise in

rheumatology.

I- MAIN SYNDROMES

The aim of our first step is to establish the main syndrome which is most representative of our patients’

clinical picture (pattern recognition). The main syndromes proposed below represent our diagnostic strategy,

matured and revised over the years. Other experts may identify other operating patterns deemed useful for

their clinical practice.

Figure 1 - Main rheumatological syndromes5

4 Reumatologia Prática. JAP da Silva. Diagnosteo, Publishers. Coimbra. Portugal. 2004. 5 Published under permission. Diagnósteo, Publishers. Coimbra, Portugal.

Síndromes regionales

• Dolor en una área específica

– Periarticular

– Articular

– Neurogénico

– Referido


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Figure 2 - Most common sites and origins of referred pain

Table n°1 - Distinctive features of regional syndromes

Periarticular

Pain

Articular pain Neurogenic

pain

Referred Pain

Enquiry Selective painful

movements

All joint

movements are

painful

Disaestesic.

Aggravated by

compression of

nerve or

mobilization of

the spine

Unrelated to

movement.

“Visceral” timing

Pain on

motion

Active> passive.

Selected motions

Active ~ passive

Several

directions

Normal. If root

pain: Pain on

motion of the

affected spine

segment

Normal

Range of

Motion

Active motion can

be limited by

pain. Passive

motion: full

Can be limited in

active and

passive motion

Normal Normal

Resisted

mobilization

Pain on specific

manoeuvres

No effect No effect No effect

Local

Palpation

Pain upon

affected structure

Possible:

Crepitus,

swelling, effusion,

heat.

Pain along joint

margin

Normal Normal

Neurological

examination

Normal Normal May be

abnormal

Normal

Síndrome de dolor generalizado

• Difuso• Fibromialgia

– Dolor generalizado, migratorio asociado a ejercicio– Cefalea, ansiedad, trastornos del sueño– Diferentes patrones

• Diagnóstico diferencial adecuado– AR– LES

Sjögren– Polimialgia reumática– EA– Polimiositis– Hipotiroidismo– Hipoparatiroidismo

Lumbalgia y cervicalgia

• Anatomicamente complejas

• Estudios de imágen

• Mec´nico vs. inflamatorio

• Signos de alarma

• Condiciones musculares, neurológicas, etc.


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Table n°2 - Common causes of low back pain, suggestive manifestations and alarm signals.

“Red Flags”

Back pain with inflammatory rhythm

Localized pain

Nocturnal pain

Visceral or constitutional symptoms

Onset before age 30 or after 50

Pain at movement in all directions

History of neoplasm

Risk or evidence of osteoporosis

Neurological manifestations

Sacroiliitis

Spondylodiscitis

Metastases

Osteoporotic fracture

Neurogenic pain

Referred pain

Interspinous ligamentitis

“No Red flags” Acute mechanical low back pain

Chronic mechanical low back pain

Fibromyalgia

Reasoning regarding neck pain follows a similar rationale.

In most cases the pain has a mechanical rhythm. It is triggered by movement and relieved by rest. In adults,

most of these conditions are caused by spondyloarthrosis. In many other cases, particularly in young people,

there is no apparent cause for the pain, and it is thought to be the result of mild articular instability and

irritation of the nerves and muscle bundles leading to painful reflex muscle contractions. Both situations

should be treated conservatively, aiming to relieve the pain and restore function, without any specific

aetiological intervention. In a few cases, the pain may be neurogenic, inflammatory, infectious, neoplastic or

psychogenic in origin. The clues for such special conditions are similar to those described above. The

possibility of referred pain, from the heart, lung apex and shoulder must be kept in mind. Acute

lymphadenopathy, thyroiditis and meningitis represent important non-rheumatic causes of neck pain.

I-4 Articular Syndrome

Arthropathies, ie, diseases affecting the joints are at the heart of rheumatology. Final diagnosis will involve the

identification of a specific disease, the evaluation of its activity, accumulated damage, functional impact and

prognosis.

On the first step we have to recognize that this is an articular syndrome. As described above, this is

suggested by pain that emerges with virtually all movements of the joint (as opposed to selective pain found

in periarticular lesions). Patients can usually locate the pain precisely over the joint(s) involved (as opposed to

muscle or diffuse pain, as in muscle disease or fibromyalgia). On examination, pain has similar intensity with

active and passive mobilization and both can be limited in range (passive motion should not be limited in

purely extra-articular lesions). Palpation will typically cause pain along margins of the joint. The presence of

crepitus, heat, swelling or effusion of the joint will confirm the articular origin of the problem.

On the second step, the most important goal is to evaluate the clues of degenerative versus inflammatory

joint disease. Enquiry and physical examination are critical in this respect.

Degenerative joint disease (osteoarthritis) is typically associated with “mechanical” pain: pain that increases

with repeated use of the joint and is worst at the end of day. Pain intensity decreases during rest, is rarely

present at night and the patient can usually find a pain-free position. Patients can describe that pain increases

again after resting and this may be accompanied by “gelling”, stiffness that subsides in 2-3 minutes. Early

morning stiffness associated with degenerative arthritis ceases in a few minutes (<10).

Síndrome articular

• Dolor localizado, crepitación, aumento de volúmen, calor.

• Mecánico vs. inflamatorio

• Otros síntomas

• Exacerbaciones/remisiones

• Actitudes forzadas

• Fluctuación

Diferencias entre inflamación y dañoarticular

Inflamación Daño

RAM Prolongada Corta

Rigidez a la inmovilidad Prolongada Corta

Calor + -

Dolor a la posición forzada Si No

Inflamación de tejido blando + -

Sinovitis o “derrame” +++ +/-

Crepitación - +++

Deformidad - +/-

Inestabilidad - +/-

Síndrome de “Osteoporosis”

• Factores de riesgo

– Postmenopausia

– Menopausia precoz

– IMC bajo

– Sedentarismo

– Ingesta pobre de lacteos

– Antecedentes familiares o personales de fractura

– Malabsorción, hipogonadismo, hipertiroidismo, hiperparatiroidismo, uso de alcohol, esteroides, etc.

Síndrome óseo

• Dolor profundo, difuso, continuo, sin relacióncon movimiento

• Nocturno

• Tumores, inflamación periosteo, enfermedadósea

• Metástasis (columna, cinturas)

• EF tiende a ser normal

Síndrome sistémico

• Puede acompañar a otros síndromes

• Enfermedades de tejido conectivo

• Vasculítis

• Síntomas y signos constitucionales


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Table n°3 - Main systemic manifestations associated with rheumatic diseases

Associated diseases (in descending order of frequency)

Constitutional manifestations

Fever

Weight loss

Severe fatigue

Systemic lupus erythematosus

Systemic sclerosis

Rheumatoid arthritis

Mixed connective tissue disease

Vasculitis

Skin manifestations

Photosensitivity

Skin rash

Scleroderma

Purpura

Livedo reticularis

Ulcers

Alopecia

Telangiectasia

Heliotrope

Gottron’s papules


Systemic sclerosis

Dermatomyositis

Mixed connective tissue disease

Overlap syndromes

Vasculitis

Mucosal manifestations

Oral and genital aphthae

Dry eyes and mouth

Red eye

Balanitis

Sjögren’s syndrome



Reactive arthritis

Ankylosing spondylitis

Behçet’s disease and other vasculitis

Serositis

Connective tissue diseases


Raynaud’s phenomenon Idiopathic Raynaud’s phenomenon

Systemic sclerosis


Arterial or venous thrombosis Vasculitis

Antiphospholipid syndrome

Recurrent abortion Antiphospholipid syndrome

Dysphagia Systemic sclerosis

Dyspnea Connective tissue diseases

Lower limb edema,

hypertension

Connective tissue diseases

Lymphadenopathy Connective tissue diseases

Muscular weakness Myositis,

Overlap syndromes

Convulsions

Psychosis

Peripheral neuropathy


Vasculitis

Síndromes Pediatricos

Patrones articulares


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Table n°5 - Most common causes of secondary osteoarthritis.

Patterns of inflammatory joint disease

The Inflammatory articular syndrome is suggested by pain with “inflammatory rhythm” and confirmed by the

demonstration of joint inflammation (diffuse elastic swelling around the joint with or without redness and heat).

When evaluating a patient with arthritis, it is important to determine: 1) which joints are affected and their

pattern of distribution, 2) how the condition began and how it developed over time; 3) the presence or

absence of inflammatory low back pain; 4) accompanying extra-articular manifestations.

Once you have this information, you may classify the arthritis according to a number of parameters, which will

help you find and support a final diagnosis:

Number of joints affected

Monoarthritis: one single joint involved

Oligoarthritis: 2 to 4 joints involved

Polyarthritis: 5 or more joints involved

Acute versus Chronic

Acute: onset in hours or days

Chronic: onset over weeks or months

Additive versus Migratory

Additive: the affected joints are added progressively

Migratory. The inflammatory process flits from one joint to another

Persistent versus Recurrent

Persistent: once it has set, the arthritis persists over the time

Recurrent: episodes or crisis of arthritis separated by symptom-free intervals

predominantly Proximal versus predominantly Distal

Proximal: arthritis mainly involves large joints, i.e, proximal to the wrist or ankle,

and the spine

Distal: the arthritis mainly involves the small joints of the hands and feet, with or

without the wrist and ankle

Symmetrical versus Assymmetrical

Symmetrical: affects approximately the same joint groups of each side of the

body

Asymmetrical: there is no relationship between the joints involved on either side

of the body

With or without inflammatory low back pain

With or without systemic manifestations

Fracture involving the articular surface Preexisting arthritis

Meniscectomy Axial deviations

Articular instability Aseptic necrosis

Intra-articular loose bodies Chondrocalcinosis

Osteochondritis dissecans

Particularly demanding occupations

Patrones

• Monoartritis aguda– Gota

– Artrítis séptica

• Monoartritis crónica– Artritis séptica

– OA/sx regional

– Hidrartrosis

– Osteonecrosis

– Artropatía de Charcot

– Tumores (sinovitis villonodular pigmentada)

Patrones

• Oligo/poliartritis crónica asimétrica– OA

– AR

– Apso, ARe

– Gota tofacea crónica

• Oligoartritis proximal– EA seronegativas

• Artritis en la cintura escapular y pélvica– PMR

Patrones

• Oligo/poliartritis aguda + fiebre

– Infecciones virales

– Still

– LES, Behcet, PM, AR

• Dolor inflamatorio en columna vertebral

• EA seronegativas

• Poliartritis con manifestaciones sistémicas

– LES

Atención óptima

• Enfoque en problemas relevantes

• Evaluar la validez de la información

• Escuchar al paciente

• Explorar adecuadamente

• Resumir los datos

• Uso sensato de laboratorio y gabinete

M1 estrategia diagnóstica

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