BCC / Clinical Consultation NLT

RHEUMATOLOGY
1) Arthritis
- OA – Joint pain / Disease + Knee pain - e.g. Obesity, Acromegaly
- RA – Joint pain / CT$ / SOB / Red eye / Cushing $
- Gout – Joint pain / Foot swelling (Tophi)
- Psoriatic arthropathy – Joint pain / Skin lesion / Cushing $
- Ankylosing spondylitis – Back pain or stiffness / Limitation of movement / SOB
- Sarcoidosis – Joint pain / Skin rash / Hypercalcaemia / SOB
- Haemophilia – Shoulder pain
2) Connective tissue disease
- SLE – Skin rash / Joint pain / Fatigue or unwell / Weight loss / SOB / APL$
- Systemic sclerosis – Skin / Joint pain / Hand pain / Swallowing problem / SOB
- MCTD – Chest pain
- Sjogren’s – Dry eye with reduced vision
- PM – Proximal myopathy
- DM – Skin rash / Proximal myopathy
3) Vasculitis
- Tarkayasu arteritis – Hypertension / Arm weakness / Fatigue / Yound stroke
- Giant cell arteritis – Headache / Visual loss
- Wegener’s – Haemoptysis / Haematuria / Epistasis
- Behcet’s – Oral & genital ulcers / Eye – blurred vision or diplopia / Leg swelling (DVT)
4) Metabolic bone disease
- Paget’s disease – Hearing loss + Raised alkaline phosphatase
- Osteoporosis – Back pain in menopausal lady
5) Other collagen disease
- Marfan’s $ - Tall stature / Chest pain / Recurrent pneumothorax / Vision problem / SOB
- HHT – Epistaxis / SOB
- Polymyalgia rheumatica – Fatigue / Muscle pain or stiffness

APPROACH
1) Hand pain / Leg pain
2) Back pain
3) Shoulder pain
4) Knee pain
5) Joint pain
6) Fatigue
7) Tall stature
8) Reno-pulmonary syndrome

APPROACH TO RHEUMATOLOGY PROBLEMS

- Introduction
- Look at a glance to patient for spot diagnosis
- Focus history
- C/O
- SOCRATES / Asso: - joints, muscles, bone, skin & nails
- Background history – Past, Drug, Family, Personal
- Focus examination
- Primary site - *Joint
- Others - Face
Limbs – Look (*joints, muscles, skin, nails), Feel, Move, Measure/Function, Neuro, Vascular
Relevant system
- Concern
BCC / Clinical Consultation NLT
PAIN
- Bone
- Joint
- Muscles and Soft tissue
- Vascular
- Neuro

CAUSES OF HAND PAIN / LEG PAIN

- Joint pain
- Neurogenic pain - Entrapment – CT$ / Pregnancy (melalgia parasthesia)
- Peripheral neuropathy
- Root pain – PID / Malignancy
- Vascular pain – Raynauld’s phenomenon / Claudication pain
- Other – Restless leg $

CAUSES OF CARPAL TUNNEL $ - Famous median traps

- Myxoedema;
- Enforced flexion (eg in a Colles’ splint);
- Diabetic neuropathy;
- Idiopathic;
- Acromegaly;
- Neoplasms (eg myeloma);
- benign Tumours (lipomas, ganglia);
- Rheumatoid arthritis;
- Amyloidosis and Chronic dialysis
- Pregnancy/Premenstrual oedema;
- Sarcoidosis.
- Obesity

CAUSES OF RAYNAULD’S PHENOMENON

- CTD: Systemic sclerosis, SLE, MCTD, rheumatoid arthritis, dermatomyositis/polymyositis.
- Occupational: Using vibrating tools.
- Obstructive: Thoracic outlet obstruction, Buerger’s disease, Atheroma.
- Blood: Thrombocytosis, cold agglutinin disease, polycythaemia rubra vera, monoclonal gammopathies.
- Drugs: Beta-blockers, Ergot
- Others: Hypothyroidism

CAUSES OF BACK PAIN

Bone
- Malignancy – multiple myeloma or secondary
- Osteoporotic #
- Paget’s disease (pelvic pain)
- Infection – TB spine / Discitis
- Trauma
Joint
- Ankylosing spondylitis and Seronegative spondyloarthopathy
- OA (Lumbar spondylosis)
Neuro
- PID
Muscle pain
BCC / Clinical Consultation NLT

CAUSES OF JOINT PAIN

Arthritis - OA / RA / Seronegative / Gout / Pseudogout / Septic / Sarcoidosis
CTD
Vasculitis AND PMR

CAUSES OF SHOULDER PAIN

- Joint – OA, RA, Haemophilia, Adhesive capsulitis, Trauma
- Muscle – PMR, Hypothyroid
- Bone – Malignancy
- Nerve – Referred pain
- Vascular – Avascular necrosis

CAUSES OF KNEE PAIN

- OA / Reactive / Pseudogout / Gout / Septic / Haemophilia

CAUSES OF FATIGUE / LETHARGY

1) Endocrine
- Hypothyroid
- Cushing’s $
- Addison’s disease
- Hypopituitarism
- DM
2) Rheumatology
- CTD
- Vasculitis - Takayasu
- PMR
3) Anaemia
4) Malignancy
5) Chronic illness / infection
6) Chronic fatigue $ / Depression
7) Others – MG, PBC, OSA, Pregnancy

CAUSES OF TALL STATURE

Differential diagnosis of a marianoid habitus is:
(a) Marian's syndrome
(b) Homocystinuria
(c) MEN2b
Differential diagnosis for gynaecomastia and tall stature include:
(a) Klinefelter's syndrome (most common)
(b) Thyrotoxicosis
(c) Acromegaly

CAUSES OF RENO-PULMONARY SYNDROME

- Wegener’s granulomatois
- Microscopic polyangitis
- Goodpasture’s $
- Other vasculitis – Primary
Secondary