Medical history and physical examination for juvenile rheumatoid arthritis

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The most important steps in diagnosing juvenile rheumatoid arthritis (JRA) are the medical history and physical examination. Your child's health professional may ask some of the following questions:

• How long do symptoms last, both during a single day and over time?
• At what age did symptoms first begin?
• Which joints are affected? How many joints are affected?
• Are the same joints always affected or do symptoms move from one joint to another?
• What is the child's pain like?
• Does the child bear weight on the affected body part? Has the child's physical activity changed? Have you noticed any limping, favoring a limb, avoiding play, or crawling rather than walking?
• How is the child's general health? Has he or she been ill recently? Are whole-body (systemic) symptoms present, such as weight loss, weakness, or decreased appetite?
• Is there a family history of arthritis?
• Did an injury or illness (sore throat, diarrhea, or flu-like symptoms) occur before the symptoms started, or did the symptoms come on slowly over time?
• Has the child been bitten by a tick that may be a carrier of Lyme disease?
• Are there other symptoms (such as fever, fatigue, or rash) that occurred before or with joint symptoms?

The physical examination generally is not painful and includes:

• Checking body temperature, blood pressure, lymph nodes, and joints.
• Examining the heart and lungs with a stethoscope.
• Feeling the abdomen.
• Examining the skin.

A history and physical examination are a routine part of the evaluation of joint pain and stiffness. JRA is diagnosed only after a careful physical examination and medical history.

• Joints affected by JRA are often stiff in the morning and improve as the child uses the joint.
• Children usually bear weight on a joint affected by JRA despite the swelling.
• Joints affected by JRA tend to be less painful than those affected by other conditions, such as infection, injury, or cancer.

During the physical examination, the health professional will note:

• Joint problems, such as swelling, tenderness, or stiffness.
• The number and location of affected joints.
• Whether there are other symptoms (fever, rash, or fatigue).

Using the above information, your health professional may be able to clarify the diagnosis and the type of JRA. In many cases, your child may have symptoms for up to 6 months before the type of arthritis is diagnosed.

Pauciarticular JRA (oligoarthritis) tends to affect the large joints and often affects only one joint, especially the knee. Whole-body (systemic) symptoms (fever, rash, weight loss, fatigue) are rare. Inflammatory eye disease develops in about 20% of children with pauciarticular JRA.¹ This type of eye disease often does not cause symptoms before eye damage occurs.

Polyarticular JRA (polyarthritis) affects many joints and often begins in larger joints (such as the knee or hip), but it may also start in smaller joints (as in the hands and wrists). It may also affect knees, ankles, the neck, and the jaw. Symptoms usually affect the same joint on both sides of the body. Whole-body (systemic) symptoms may also be present. Some children may have small bumps under the skin (rheumatoid nodules), especially at pressure points such as the elbows.

Systemic JRA tends to affect many joints, and the child may have fever spikes and/or a rash for weeks to months before arthritis pain develops. The child may also have whole-body (systemic) symptoms (fatigue, loss of appetite) and enlarged lymph nodes, liver, and spleen.

The diagnosis of juvenile rheumatoid arthritis (JRA) requires ruling out other conditions. Information from the medical history and physical examination is very important to evaluate possible causes of symptoms and to select the best tests to rule out other conditions.

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Citations

1. Wallace CA, Sherry DD (2003). Juvenile rheumatoid arthritis. In CD Rudolph et al., eds., Rudolph's Pediatrics, 21st ed., chap 12.4, pp. 836–840. New York: McGraw-Hill.