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00 a rectal examination to check the anal sphincter tone and prostate gland in men. Check sensation in the 'saddle' area (LD-rr). 31 NEW MEDICINE Central nervous system Lower motor neuron defects in the legs may indicate pressure on a nerve root. Upper motor neuron findings cannot be produced by a lumbar lesion and indicate pathology higher up in the spine. The lower limbs and buttocks should be tested for power, sensation and reflex changes. If abnormalities are detected a rectal examination should be done.

The joints must be palpated for points of tenderness and the presence of an effusion (CP-I ). Marked increase in the temperature and redness suggests: • infectious arthritis (CP-43) • gout (CP-38) • pseudogout (pyrophosphate arthropathy) 23 NEW MEDICINE Pattern of attacks Different diseases produce different patterns of joint involvement. The physician should note in particular the mode of onset, the duration of symptoms and the nature of any remissions. Recurrent, short, well-defined attacks are typical of gout.

Occasionally it is seen in peripheral joint involvement with seronegative arthropathy. Reiter's syndrome may produce an acute, rapid onset monoarthritis. Acute, rapid onset, progressive In patients with acute, rapid on set monoarthritis with progression of symptoms and deterioration of joint function, the provisional diagnosis must be infectious arthritis. Consider surgery, penetrating trauma, joint aspiration or infections e1sewhere in the hody as possihle sources. 24 In an acute, post-traumatic arthritis there is the rapid onset of local joint symptoms following injury as the result of either haemarthrosis or a traumatic effusion.

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