Joint Pain

Rationale

Joint pain is a common problem that can cause considerable dysfunction and disability. To properly evaluate and treat patients with joint pain, the general internist must use a systematic approach.

Prerequisites

Basic courses in anatomy and immunology, and introductory required preclinical course in physical diagnosis

Specific Learning Objectives

1. Knowledge: Students should be able to define and describe:
   1. common presenting symptoms and signs of:
      1. osteoarthritis
      2. rheumatoid arthritis
      3. systemic lupus erythematosus
      4. polymyositis
      5. crystalline arthropathies
      6. scleroderma
      7. carpal tunnel syndrome
      8. herniated disc
      9. aseptic necrosis of the hip
      10. septic arthritis
      11. sarcoidosis
   2. the difference between arthralgia and arthritis
   3. a systematic approach based on an understanding of pathophysiology to classify potential causes of joint pain
   4. key diagnostic criteria for common causes of joint pain
   5. pathophysiology of joint stiffness and pain
   6. immunologic tests to use in the evaluation of patients with joint pain
   7. indications for performing an arthrocentesis
   8. basic types of therapy to use in the treatment of joint pain and side effects associated with each
2. Skills: Students should demonstrate specific skills including:
   1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including:
      1. eliciting features of a patient’s joint pain, including duration, location, severity, timing, debility, exacerbating and remitting factors, associated neurologic symptoms, impact on daily activities, and prior or family history of related problems
      2. determine when in the course of acute arthritis it is necessary to obtain a sexual history and perform a genital exam with appropriate cultures
      3. determining the impact of joint pain on a patient’s activities of daily living
   2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
      1. performing a systematic examination of all joints, and identifying the following abnormal findings:
      2. erythema
      3. swelling
      4. tenderness
      5. effusion
      6. crepitus
      7. decreased or excessive range of motion
      8. Heberden’s nodes
      9. Dupuytren’s contracture
      10. ulnar deviation
      11. tophi
      12. synovial thickening
   3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology:
      1. osteoarthritis
      2. rhematoid arthritis
      3. systemic lupus erythematosus
      4. polymyositis
      5. crystalline arthropathies
      6. scleroderma
      7. carpal tunnel syndrome
      8. herniated disc
      9. aseptic necrosis of the hip
      10. septic arthritis
      11. sarcoidosis
   4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests should include, when appropriate:
         • joint fluid results (Gram’s stain, crystal exam, cell count & differential, and glucose)
         • sedimentation rate
         • rheumatoid factor
         • complement levels
         • antinuclear antibodies
         • uric acid
         • complete blood count
         • plain x-rays
         • radionuclide bone scan
   5. communication skills: Students should be able to explain the results of the evaluation to the patient.
   6. basic and advanced procedure skills: Students should be able to assist
      in:
      1. performing arthrocentesis of the knee after explaining the procedure to the patient
   7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patient including:
      1. select appropriate medications to use for the relief of joint pain
      2. locate information about the cost of alternative medications
      3. determine when to recommend joint immobilization, rest, nonsteroidal antiinflammatory drugs, corticosteroids, antibiotics, assistive devices (cane, walker), and physical therapy
      4. determine when to involve a rheumatologist or surgeon in the management of patients with joint pain
      5. elicit questions from the patient about the management plans
      6. access and utilize appropriate information systems and resources to help delineate issues related to joint pain
3. Attitudes and Professional Behaviors: Students should be able to:
   1. demonstrate sensitivity to the impact of chronic joint pain on a patient’s quality of life and well-being
   2. appreciate the importance of complications secondary to drug administration, to which the geriatric population in particular may be more prone