M1 estrategia diagnóstica
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Transcript of 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
3
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
Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
6
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
Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
6
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.
Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
8
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
Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
11
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 lupus erythematosus
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
Systemic lupus erythematosus
Rheumatoid arthritis
Reactive arthritis
Ankylosing spondylitis
Behçet’s disease and other vasculitis
Serositis
Connective tissue diseases
Rheumatoid arthritis
Raynaud’s phenomenon Idiopathic Raynaud’s phenomenon
Systemic sclerosis
Systemic lupus erythematosus
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
Systemic lupus erythematosus
Vasculitis
Síndromes Pediatricos
Patrones articulares
Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
14
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
Eular On-line Course on Rheumatic Diseases – module n°1 Prof. José da Silva, Prof. Karen Lisbeth Faarvang, Dr. Catia Duarte
14
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