Joint pain (Reactive arthritis)

35 year old gentleman has come back from a trip from Bali with complaints of severe Low back pain, hand, and leg pains and red eyes. How would you approach this?

Answer

I would start by getting a focused history if the patient is able to give a brief history and ask about the speed of onset of symptoms and other associated rheumatological symptoms such as rashes, diarrhea, presence of nodules, mouth or genital ulcers. I would specifically ask about the pattern of joint involvement, symptoms of morning stiffness, symptoms of active inflammation of the joints. I would also ask about significant past medical history and also ask for significant risk factors specifically smoking history. I would also enquire about family history and sexual history. After this I would go on to do a focussed assessment using A to E approach.

• Airway: I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct I would be really worried and seek the help of the critical care team after my assessment.
• Breathing: I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing I’ll start the patient on supplemental oxygen therapy ensuring he is on scale 2 of oxygen. I would also get an ABG for this patient to see what the ph, Po2 , pco2 and hcO3 and lactate.
• Circulation: I would look at the observations specifically the BP, heart rate and CRT. If there is evidence of hypotension or tachycardia I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotension despite the first fluid challenge I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient.
• Disability: I would check the patients blood glucose, temperature and do a focused neurological assessment that includes GCS. Specifically if the GCS is less than 8 or if there is a focal neurological deficits I would be concerned and investigate this further.
• Exposure: I would expose the affected joints and do a focused GALS locomotor exam specifically looking for the pattern of joint involvement and the symmetry of signs. I would also be looking for mouth ulcers, genital ulcers and psoriatic skin rashes.

Question

At this point, interrupt the candidate and give the following information. The patient had about of diarrhea in Indonesia. He was admitted briefly to a local hospital and his symptoms started upon arrival. He has evidence of conjunctivitis, sacroiliitis and swelling Of his small joints in the arms and legs. What would you do next?

Answer

Based on the presenting symptoms and signs, I would be suspicious of This gentleman having reactive arthritis. I would start off by sending blood for the patient specifically ESR and CRP. I would also send septic screening and stool samples for culture. I would also get x-ray of his low back to look for any signs of severe inflammation.

The management is largely supportive and would ensure that the patient is on adequate Analgesia and anti-inflammatory medications. I would inform my senior about this patient and refer this patient to the rheumatology team.