This action might not be possible to undo. Are you sure you want to continue?
Dr./ Abdel Azeim Alhefny,
IDIAL GUID TO
HISTORY TAKING & CLINICAL EXAMINATION
WITH 22 CASES
Dr./ Abdel Azeim Al-Hefny. MD
Prof. Internal Medicine, Rheumatology, Allergy & Immunology. Ain Shams University
Reumatology Sheet MD.
Dr./ Abdel Azeim Alhefny,
Ten Golden Rules In Rheumatology:1. A good history & physical examination, with good idea about the musculoskeletal anatomy is very important for diagnosis; You must examine the patient!! 2. Don’t order a lab test unless you know why & what you will do if it is abnormal? 3. Acute monoarthritis = joint aspiration to exclude septic & crystalinduced arthritis. 4. Chronic monoarthritis > 8 weeks of unknown cause needs synovial biopsy. 5. Gout does not occur in premenopausal females or in joints close to spine. 6. Most shoulder pain is periarticular (bursitis, tendonitis..), most LBP. is nonsurgical. 7. OA in (MCP, wrist, elbow, shoulder, ankle) joints ---- exclude 1ry cause eg. Metabolic dis. st 8. 1ry fibromialgia does not occur > 55ys. for 1 time, nor with abnormal laboratory results. 9. Not all pts. With +ve RF=RA, nor +ve. ANA = SLE . 10.Fever or multisystem complaints, in Rhc. Pt., rule out infection & other non-Rhc. causes as a 1ry. (Infections cause death in Rhc. pt. more than the 1ry dis. does). Remember nothing is 100%
Reumatology Sheet MD.
Dr./ Abdel Azeim Alhefny,
Synovial (diarthrotic) Joints. These are freely mobile joints in which there is a joint cavity between the articulating bones. These are the commonest joints in the body.
Reumatology Sheet MD.
Dr./ Abdel Azeim Alhefny,
Rheumatism: 1st. introduced in 1642 when they realized that arthritis could be a systemic disease. It was an obsolete term for ARF. Now it is defined as various abnormal conditions marked by recurrent pain, stiffness & other manifestations of articular origin in joints, back, or muscles. Rheumatology: Rheuma= substance that flows- from brain to various parts of the body causing chr. illness (1st. century AD). Or medical science dealing with diseases/abnormalities in the musculoskeletal syst. Arthropathy =A term meaning 'joint disorder'. This can be arthritis or arthralgia and is often used when the nature of the joint disorder is uncertain. Arthritis= A term referring to inflammation of a joint or joints. (The suffix '-itis' means inflammation). There is usually visible evidence of inflammation (objective abnormality) such as Joint pain, stiffness, tenderness, redness, hotness, swelling & limited movement. While if the patient only experienced pain without obvious abnormality; it is called
Arthralgia= (subjective=Joint pain without signs of inflammation). Inflammation= Tissue reaction to injury. It may be acute (as in a burn or in gouty arthritis) or chronic (as in rheumatoid arthritis or chronic infections such as tuberculosis). Cartilage= A white semiopaque nonvascular connective tissue. There are two types. Hyaline cartilage is the very smooth 'gristle' that covers the articulating surfaces of bones that form the joint. Fibrocartilage is the type that is found in the menisci in the knee for example. Capsule= The thick membrane that joins bones making up a joint. It also isolates the joint cavity from surrounding tissue. Enthesis= The anatomical site of attachment of ligament, tendon, joint capsule or fascia to bone. Enthesitis= inflammation of enthesis.
Reumatology Sheet MD.
Dr./ Abdel Azeim Alhefny,
Tendon= A band of fibrous tissue by which muscle is attached to bone. Tendenitis= inflammation of tendon, Tenosynovitis= inflammation of tendon sheath. Ligament= A band of tough tissue which restrains joint movement and confers stability on a joint. There is a high collagen content Sprain = stretch or sprain of the ligament. Synovium= A thin membrane (normally one cell thick) which is found within the joint capsule. It produces synovial fluid which lubricates and nourishes the joint cartilage. It becomes inflamed and thickened (synovitis) in inflammatory arthritis such as rheumatoid disease.
Joint effusion =Accumulation of fluid in a joint.
Bursa= A fluid-filled sac. They are found between tissue planes where shearing forces may act - e.g. at the knee and elbow. They are lined by synovium and contain synovial fluid - like the joint. Bursitis occurs when they are inflamed. eg: prepatellar bursitis. (Housemaid's knee). Monoarthritis= one joint inflamed. Oligo/Pauci-arthritis= 2-4 joints or small joint groups eg: wrist. Polyarthritis= > 4 joints (or groups) inflamed. Spondylitis=Inflammation of axial vertebrae & related structures (discs & ligaments). Myopathy:Disease/Abnormality of the muscles. Myositis (polymyositis):
Inflammatory disease of the muscle (skeletal/ striated muscle). Vasculitis, arteritis: Necrosis and inflammation of blood vessel wall. This results in clinical manifestations due to interference with blood supply to those organs.
Subluxation: malalignment of a joint; so that articulating surfaces incompletely approximate each other. Dislocation: Abnormal displacement of articulating surfaces (not in contact).
most commonly on the elbow on the extensor surface. This may give rise to low back or buttock pain. Ganglion = A soft tissue swelling which arises in relation to a tendon. Sacroiliitis =Inflammation of the sacroiliac joints at the base of the spine./ Abdel Azeim Alhefny. This may result in new bone formation Onycholysis =A nail abnormality seen in psoriasis. bony hypertrophy. It occurs particularly in HLA B27-related conditions such as ankylosing spondylitis Haemarthrosis = A collection of blood within a joint. They occur in approximately 20% of patients with rheumatoid arthritis. fixed resistance by tonic mus. malalignment of articulating joint. Rheumatoid factors may be found in all immunoglobulin classes but the rheumatoid factor test detects IgM-RF. A swelling of the dorsal tendon sheath at the wrist is sometimes mistakenly referred to as a ganglion. spasm (reversible) or fibrosis of periarticular structure (permanent).Reumatology Sheet MD. ROM= Range of motion: The arc of measurable movement through which the joint moves in a single plane. Sometimes attached to deeper structures. or damage to periarticular supporting structures. Contracture: Loss of full movement dt. Rheumatoid factor=An immunoglobulin directed against the Fc portion of IgG. Some conventionally 'seronegative' patients(20%) may have rheumatoid factors of other Ig classes & +ve CCP. Rheumatoid nodules = subcutaneous soft tissue swellings which may vary inconsistency from very soft to moderately hard. Dr. It is usually firm and relatively small. It may be accompanied by pitting of the nail. Deformity: Abnormal shape or size dt. (6) . Flexor tendons and the median nerve traverse the carpal tunnel Periostitis =Inflammation involving the periosteum. Carpal tunnel = The space at the flexor aspect of the wrist bounded by the carpal bones and the flexor retinaculum.
before proceeding in rh. Dr. RP (20-40).Reumatology Sheet MD. infectious arthropathy (7) . impairment of its function (movement) is the most important consequence. SLE. Rheumatology history taking Screening questions in Rheumatology: Pain.). joint swelling & stiffness are the most common symptoms pointing to the locomotor system.viral. so. Kawasaki (5) Middle age: RA (all ages). Can you dress your self without any difficulty? 3. Takayasu (15-25). Wegner (40) Old: OA. Giant Cell Arteritis (GCA>50). we ask the following questions: 1. HSP (4). joints or back? 2. Reiter (20-40yrs. Gout (50yrs) Sex: F>M M>F Gout (7:1) Reiter AS PAN (2:1) ARF HSP M=F SLE 9:1 RA 3:1 Behcet 2:1 Vasculitis 3:1 RP 5:1 GCA 2:1 Takayasu 9:1 Wegner 3:2 Habits: Addicts---------. Have you any pain or stiffness in your muscle. history taking. PAN (40)./ Abdel Azeim Alhefny. Can you walk up & down stairs easily? Personal History Age: Young: ARF (5-15).
clues for diagnosis. Response to previous therapeutic modalities: drug TTT. Residency: Crowded humid damp area: ARF Occupation: Vibrating tools. Haemarthrosis. typist------. infection----------ARF TB Gonorrhea Sepsis Diet:-----------Delayed hypersensitivity reaction-----. vascul. Aspiration:Indications. blood bank staff -----. Isoniazid. Procainamide. & follow up.RP Health providers. Infections: B haemolytic streptococcal A. cryo. compliance. Joint Surgery: Open. L-tryptophan-------Esinophelia-myalgia syndrome.Arthropathy.: Hydralazine. Methyl dopa. surgical corrections----------. Phenytoin.Viral arthropathy. side effects.Reumatology Sheet MD. Laparoscopic./ Abdel Azeim Alhefny. results. Chlorpromazine. pianist. Trauma: Fracture. Complaint: Chief symptom & its duration (8) . Lovastatin------Myositis. PT. effects. Dr. BB-------RP. Past History Precipitating factors??? Drugs: Drug-induced Lupus eg.
tendosynovium.t.Stiffness: Joint tightness d.… any relevant past medical history?. History of the present illness: If there is any abnormality suspetected we have to proceed for analysis of symptomatology:- I. redness or swelling • IMPACT ON GENERAL CONDITION & LIFE STYLE (sleep and functional capacity -. COURSE & DURATION. variable. poorly described. doing normal activities=psychogenic) • ONSET./ Abdel Azeim Alhefny. WHAT Decrease • ASSOCIATED SYMPTOMS. or unrelated to anatomical structures= fibromialgia. eye inflammation etc. trauma. or psychogenic. autoimmune diseases. Dr.….in relation to work? On normal daily life? • Associated extra articular symptoms (skin rashes. • WHAT Increase. • SEVERITY: visual analog scale 1-10 (intolerable pain in pt. II.distention of the periarticular tissues (capsule. infections. malingering.). • CHARACTER. (9) .Pain: • SITE: Where exactly is the pain experienced? (Ask the patient to point). stiffness. • RADIATION: Does the pain radiate elsewhere? = Neuropathy. • PRECIPITATING-FACTORS. Diffuse pain. accumulation of inflammatory exudates & edema fluids--. fluids washout from the inflammatory tissues & stiffness wears off. bursa). After activity.Reumatology Sheet MD. • Usage pain = mechanical (OA). continuous or intermittent? • FREQUENCY • DIURNAL VARIATION • Rest pain = inflammatory (RA). • PAST HISTORY OF SIMILAR ATTACKS. Site of maximum intensity= localizing pathology. .
Weight loss. need for house hold help) or handicapped (necessitates change of the life style &/or change or retirement from job)? = severity VI. IV. • • • • Specify & count the swollen joints. or after a period of rest = inflammatory. persistent & progressive muscle. VII.Sleep disturbance: (organic or psychogenic effects). Malaise.Swelling: Bony (hard). = mechanical. III.Muscle Weakness: distribution. • + Signs of inflammation (pain. Constant or episodic. (10) ./ Abdel Azeim Alhefny.Deformity: Fixed or correctable? Characteristic & specific? V. VIII. Duration. Dr. weakness. duration & course. in the morning.Reumatology Sheet MD. Site: Affecting hands in RA & back in AS. • >1hr. hotness. redness & limitation of movement). • <1/2 hr. Myositis=proximal. *Night sweets & fever. fluid (+ve fluctuation) or synovial thickening (firm in consistency). Easy fatigability. Diffuse or localized.Systemic features (generalized constitutional symptoms)= systemic disease or paraneoplastic syndrome: • • • • Low grade fever.Movement (Function): • • • • • Normal painless daily activity? Painful daily activity? Limited movements? No movement (ankylosis)? Disability (unable to perform ordinary important movements.
PM/DM. chr. SS. cyanosis then erythema): SSc. Vasculitis (painful) & Reiter (painless). pulmonary embolism & infarction. while pregnancy is the most common physiologic cause. Sclerodactyly. digital ulcers & gangrene: SSc. Tophi: Gout. IHD. Keratoderma blenohemorrhageca= Reiter. purpuric eruptions= Vasculitis).Extra-articular manifestations & review of systems: Skin: Overlying traumatic/surgical scars or skin discoloration= clue for diagnosis. vasculitis.). confirmed by Rose Bengal stain & slit-lamp. SSC). Vasculitis. Alopecia: SLE. pericarditis (SLE. Eye: Xerophthalmia: Sjogren (SS) (usually asymptomatic)== Schirmer test (screening. Subcutaneous nodules: RA./ Abdel Azeim Alhefny. RA. Conjunctivitis: acute Reiter. dysphagia: Sjogren (SS) Ulcers + genital = Behcet. arthritis. CHF. haemoptysis: pleurisy. Splinter hge. Palmar erythema: RA (most common pathologic cause>liver c. Pitting. Iritis: AS. Adherent silver-like plaques = Ps A. Nail changes: Clubbing: hypertrophic pulmonary osteoarthropathy & fibrosing alveolitis (in SSc). Sarcoidosis. SLE. Episcleritis & scleritis: RA. & thyrotox. Rash (malar.Reumatology Sheet MD. Cardiopulmonary: Dyspnea. D: lip biopsy). Erythematous joint=sepsis or crystal. onycholysis.: Vasculitis. chronic Reiter’s syn. RcF. = SLE. Mouth: Xerostomia. photosensitivity. cough. … (11) . chest pain. Dr. SSc Raynaude’s phenomena (pallor. IX. Vasc. dystrophy: psoriasis. Reiter. Iridocyclitis: pausiarticular juvenile chr. SLE. PAN. SLE. RA.
GIT: Reflux. dysphagia---. • Temporal headache = GCA. Dr. HBV. Musculoskeletal diseases running in families: (12) . Abd. fetal losses= APS. Hypothyroidism: carpal tunnel S. Gonorrhea./ Abdel Azeim Alhefny. bilateral LL pitting swelling = SLE. behavioral changes. RA. leukopenia... Hyperparathyroidism: pseudogout. drugs… amyloidosis. Vasculitis. & myopathy. CNS: • Neuropathy. nephrocalcinosis= Hyperparathyroidism.… Family history Similar condition in the family. Others: HCV. dyscharge)—Reiter. Genitourinary: Urithritis (dysuria. • Renal colic (stones). Ulcers--. Behcet. TIA. Jaundice = Viral hepatitis with arthropathy or vasculitis.Reumatology Sheet MD. Pain. BM depression by drugs. smoky urine. hypersplenism in RA. strokes = Lupus cerebritis. nephrotic): • Puffiness. Vasculitis. fits.Reiter. bleeding per rectum. Acromegaly: sever OA. vasculitis. • DVT. Hematological: • Anemia. HIV. weakness. HPT.= IBD--AS. diarrhea. • Hemochromatosis—sever OA. Consanguinity.SSC. cryoglobuline. thrombocytopenia = SLE.. Renal (nephritic. Endocrinal arthropathy: DM----------Neuropathic or septic arthritis.
• Pain on stretch (13) . OA especially nodal disease of the fingers. AS. Marfan’s syndrome. Dr. of Musculoskeletal pain: I. Seronegative arthropathy (30% in PA). *Localized swelling. Arthritis) == *Diffuse pain & tenderness allover the joint line. Localized *Localized for periarticular structures (ligaments. & psychosocial consequences must be discussed friendly bet.Articular or Non-articular in origin: (a) Articular Pain (eg. limitation of movement & aggravated by active movement only in the direction of the affected structure. 4.. (b) Non-articular (periarticular) pain:== To be differentiated from regional cellulites.Reumatology Sheet MD. 2. goals of TTT./ Abdel Azeim Alhefny. 6. Gout. Diffuse *Generalized hypermobility. understanding of the dis. skin injuries &/or inflammations. the pt. RA. or bursa). **Pt. 7. of localized pain by its origin: Ligament== • Localized pain & tenderness at the point of attachment. ARF. 5. *Aggravated by both movement in ROM. Ex. erysipelas. active & passive joint *Generalized joint swelling. movement in all planes of ROM. peripheral neuropathy. *Fibromyalgia Rheumatica. tenderness. *Limited j. DD. 1. tendons. 3. muscles.& his treating physician.
Acute <6 weeks *Infectious arthritis./ Abdel Azeim Alhefny. II. ?ARF).induced. *Seronegative Spondyloarthropathy. • Pain on stretching adjacent structures. Dr. • Pain on resisted active movement.Inflammatory or Non-inflammatory: (14) .Reumatology Sheet MD. *RA. *Traumatic. Chronic >6 weeks III. *OA. *Crystal. Muscle== • Pain on active & resistant movement & on stretch of certain muscle. • Swollen tendon line. Tendon== • Localized pain & tenderness at the line of muscle attachment. *Reactive (Reiter. Sequences of trauma or back problems.Acute or Chronic onset: Duration Ex. Bursa==Localized tenderness & swelling. • Instability if major tear. * Chr.
Worsen ++ ++ Improve RA. Neuropathic J. ARF).. Osteonecrosis.). *Warmth (the back of hand is a sensitive thermometer). Improve. <1/2 hr. Dr. NB. 5 cardinal signs of inflammation: *Swelling (synovial distention). Improve symptoms. Crystal. Clinical markers of disease activity in inflammatory arthritis: *Duration of MS. The severity of pain is less important marker of inflammation as it is too subjected. *Severity of constitutional symptoms. *Erythema (in septic & crystal arthritis + in palindromic RH. --No effect OA. Systemic rheumatic dis. *Tenderness./ Abdel Azeim Alhefny. CRP Corticosteroid Ex. Reiter. SSC. Minimal.Reumatology Sheet MD. Traumatic. Comparison between Inflammatory & Noninflammatory arthritis: Inflammatory MS Fatigue Activity Rest Systemic manifestations ESR. *Night pain. Infect. *Loss of function (limited ROM). Significant. • • • • • • • • • • • Non-inflammatory • • • • • • • • • • • • >1hr. Metabolic (15) . *Additional joint involvement.: Bact. Viral. (SLE. Vas. Worsen.
. • (hemochromatosis). exclude septic or gouty arth.Reumatology Sheet MD. Reactive (Reiter. Noninflammatory Traumatic Sickle-Cell Disease Osteonecrosis a) Chronic Monoarthritis: Inflammatory Infectious: TB. SLE. Spon. Hemophilic Synovial Tum. Reiter.. Ex.IBD). FMF. (16) . Acute Monoarthritis: Inflammatory Crystal Bacterial Spondyloarthropathy Palindromic Rheumatism In cases of erythematious acute monoarthritis. as a primary cause. (AS. Seroneg.Inf) Noninflammatory **2-4 joints affected= pausy or oligoarticular.: RA. A. Spondyloarthropatheis (AS. Crystal. Synovial fl. Ex./ Abdel Azeim Alhefny. • • • Dr.: Seronegative . Fung. PA & IBD) *** >5 joints affected = Polyarticular. DM. IV. OA Osteonecrosis Neuropathic Adjacent bone lesion (Tum.Pattern of joint involvement: Number of affected joints: * 1 joint = Monoarticular. aspiration is diagnostic. RF). Acromegaly) Sarcoidosis. Lyme.. Endocrinal (thyroid.
: ARF.Additive Symptoms persist with addition of new joint inflammation Ex.Migratory (fleeting) polyarthritis: Symptoms disappear in the affected joints to reappear in others. Ex. Ex. Gonococcal. . Symmetrical RA SLE Peripheral RA SLE Asymmetrical Reiter PsA AS Axial AS PsA (70%-also affects IPJ--.sausage digits) Reiter Large Seronegative Reiter RF Ex.Sequence of joint involvement: 1. Viral./ Abdel Azeim Alhefny. V.Reumatology Sheet MD.: RA. (17) .Distribution of joint involvement: Ex. Dr. 2. Small RA SLE VI..
infections) Tachycardia out of proportion of fever (1ºc=10 b/m)= myocarditis Bradycardia (HB). bl.Intermittent Attacks of remissions & exacerbations in the same joint. dehydration. nasolabial.Reumatology Sheet MD. SSc. drugs.Vasculitis. SLE. SSc Butter fly rash sparing the nasolabial fold=SLE Heiotrope rash (puple-erythematous discoloration of upper eye lid. Rheumatological Examination General Examination Pulse: Rapid due to Anemia. Cushingoid= steroid. forehead+ periorbital oedema)= DM. Ex. endocrinal arthropathy. = HF../ Abdel Azeim Alhefny.. Face Malnutrition =TB. (18) . bleeding! Pallor Activity of CTD (anemia of chronic disease). Alopecia=SLE. fever (ARF or activity. arrhythmia= SSc Blood Pressure: HPT = SLE. Drugs. Caplan’s lung). sever disease. malignancy. RA (bronchiolitis. loss. failure Jaundice Hemolytic = SLE Drugs Viral hepatitis associated with or causing arthritis. Anemia (hemolytic. RA + renal. aplastic-drugs.) Cyanosis IPF=SSc. Dr. Cryoglobulinemic arthritis in hepatitis pt. CVS---drugs? Hypo. fibrosing alveoltis. Bilateral or extensive pleural effusion= SLE Pericardial effusion=SLE Ht. 3.: Gout. iron def. Vasculitis. .
loss of luster. Neck veins: CHF. (19) . splitting= PA. hypo or hyperthyroid with proximal muscle weakness. tender Osler nodes at finger pulps (tender palpable nodules)& Janeway lesions=palpable purpuric spots on palm dt. SLE. hypothyroid with carpal tunnel. R. Drugs Mouth Dry (xerostomia) = SS Ulcers (B. Dr. SSc. pleural effusion. hyperthyroid Nail pitting.Reumatology Sheet MD. SLE). Neck: Thyroid swelling – autoimmune + SLE. posterior capsular=Steroid. Puffiness: L. Pericaldial. microthrombi—necrotic lesions: RF+ SBE Sclerodactyly: smooth. Splinter hemorrhage. SLE. Hand Clubbing: Fibrosing alveolitis in RA. shiny. IBD. Amyloid. Eye Colors Dry (xerophthalmia)=SS Cataract: premature. Onycholysis (separation of distal end from its plate):PA. chloroquine. thyrotox. bound down skin. LN: RA. nephritis. tapered fingers with taut. NS. NS./ Abdel Azeim Alhefny. Felty.
Nodules: RA. MCP. photosensitive=SLE Psoriatic lesions (well-defined. DM. (20) . medial maleoli): PM/DM Digital ulcers & gangrene: RA. carpal t. Tophi: GOUT Heberden & Bouchard nodes: OA Gottron’s papules (violaceous & flat erythematous & scally papules on the extensor aspect of PIP. knee.Reumatology Sheet MD. Dr. Vasculitis. SSc Nail bed infarcts= SLE-Vasculitis. RP: SSc. S (thenar). ARF. SSc Telangectasia of nail fold: DM. raised itchy erythematosus plaques covered by a loosely adherent silvery scales) =PA. SLE. Palmar erythema: RA Mus wasting: RA (interossei). elbow. MCTD. SLE. RA. descoid./ Abdel Azeim Alhefny. Mechanics hand= DM Skin: Characteristic rash: Butterfly malar.
Livedo reticularis: (erythematous netlike deep vascular discoloration mostly on LL)=Vasculitis. Dr. hemorrhagic papules=gonococcal arthritis. lips. oral GI mucosa.Reumatology Sheet MD.shins)= Behcet. drugs (gold. amyloidosis (RA. IBD. Sarcoidosis. Nodules on extensor aspects.1mm-few cm. non tender & not attached to skin. elbow. APS). may inflame. Raised =Vasculitis Flat=thombocytopenic purpera= SLE. LN. t. Tophi (irregular firm nodules on extensor of fingers./ Abdel Azeim Alhefny. knuckles. don't ulcerate). capillaries & arterioles. drugs: sulfonamides. D.5 cm over bony prominences of elbows. LL: Oedema= NS. Shawl-sign rash=PM/DM Erythema marginatum (flat or raised annular erythematous macules or papules on trunk OR extremities) =ARF Erythema nodosum (tender erythematous sc. Deep fungal infections.. Thickening of the skin=SSc Calcinosis: cutaneous deposits of calcium.penicillamine) V-sign. face. Felty. TB.may bleed--anemia. irreg. knees . achilles & helix of ear. Purperic eruptions.on extensors of elbows. ankles and occiput. by acute Gouty arthritis=. firm. RA (up to several cm. PIP. sclera & myocardium). Nodules: Firm. scapula. feet. DVT (SLE. leprosy. nontender. finger tips Vesiculopustular lesions. oral contraceptives SC. forearm. matteoval or polygonal macules 2-7mm on hands. may ulcerate discharging white chalky material MSUM) + preceded 10 yrs. Drugs). ARF (0. achilles. hands. on elbows. may ulcerate. SLE Telangiectasis: dilated venules. (21) .
/ Abdel Azeim Alhefny. pulmonary HPT = SLE & Vasculitis Ankylosing Spondylytis--AR Chest: Pleurisy. Lateralization. pustules. Leaflet MV Pericarditis. on palms & soles with thick hyperkeratotic plaques =Reiter Genitalia: Genital & Oral Ulcers = Behcet (on scrotum or labia. Pneumonitis. Caplan's lung = RA Pulmonary embolism. Or hemolytic anemia. RA. systemic. Dr. myocarditis. Ulcers: Vasculitis + Still’s. inf= APS Abdomen: Splenomegaly = Felty. JRA HSM= SLE. IHD. Ischemia: Vasculitis. SLE. Keratoderma blennorrhagicum =vesicles. muscle weakness = Vas. Entrapment neuropathy = RA (22) . Reiter (with circinate balanitis= confluent eroded red papules on corona & glands penis) Heart: Carry Coomb's murmur (Oedema of MV) = ARF SLE----Libman-Sacks endocarditis=verrucous---post. SLE. effusion=SLE.Reumatology Sheet MD. Alveolitis. may penis or vagina). RA CNS: PN. RA VAS.
• Warmth.Reumatology Sheet MD. Moves smoothly through its ROM Characteristic findings of inflammatory joint: Synovitis: • Most comfortable in neutral position./ Abdel Azeim Alhefny. • Decreased movements in all planes. Dr. • Stress pain all direction (most sensitive). • Decreased movement in the plan of tendon. Tenosynovitis: • Joint positioned to decrease tension on tendon. • Selective stress pain. a brief screening procedure to pick up problems in certain regions is more appropriate. • Capsular swelling/effusion (most specific). (23) . Mechanical arthritis: • Abnormal shape (deformed joint). Looks normal 4. more detailed examination of the affected region can be undertaken. PM/DM Local Examination Physical examination of the locomotor system is extensive & complex. No special resting position 2. Asymptomatic 3. Normal joint should be: 1. • + Fine cripitus. • Joint line/capsular tenderness. + triggering. If an abnormality is detected. so. • Linear swelling & tenderness. • + Fine cripitus.
Decreased movements in all planes. Rheumatologic Examination GALS : Screening examination of MSK system. (Gait./ Abdel Azeim Alhefny. Legs & Spine) (24) . Arms. Dr. + Ligamentous stress pain/instability. • • • • Coarse cripitus.Reumatology Sheet MD. + Synovitis.
(25) ./ Abdel Azeim Alhefny. Dr.Reumatology Sheet MD.
tendenitis…. or bruising.Reumatology Sheet MD. en) *Synovitis= restricted both active & passive movements in all planes of ROM. Swelling (hard. Cripitus =audible & palpable during movement (fine. bursitis. sex & race. (26) . • Swelling. or coarse). dislocation or subluxation. Muscle state (normal or atrophied) & muscle power. Dr.= restricted active with normal passive movements. cystic fluctuation or firm). • Symmetrical affection of MSK elements. Telangiectasia./ Abdel Azeim Alhefny. rash. • Palpation • • • • • • Warmth = inflammation. Resisted active movement= test periarticular (ms. tn. in synovitis. Tenderness (diffuse or localized). Stress test (moving joint passively toward its limitation) = universal=all direct. Inspection Attitude = Position of the affected area at rest. Movement • • • • • Active = by the patient Passive = by the examiner ROM (range of movement)=depends on age. selective in localized lesions. *Myositis. • Deformity. discoloration or scars). only in the plane. Deformity (correctable or not). • Muscle wasting. • Skin changes over the affected MSK area (erythema.
(27) . ambulation. grasping. Functional assessment: self care.Reumatology Sheet MD./ Abdel Azeim Alhefny.. Dr. • Joint stability. lifting. Examination of specific joint movements Ask the patient to do active movements & compare with passive if limited. sleep.
(28) . I) Upper Limbs: a) Hands=MCP. Boutonniere. Dr. ulnar deviation & z-shaped thumb) & muscle wasting./ Abdel Azeim Alhefny. swelling (Heberden on DIP. deformities (Swan neck. PIP.Reumatology Sheet MD. Bouchard on PIP nodes). DIP J. Inspect for: skin changes.
Dr./ Abdel Azeim Alhefny. (29) . muscle bulk & power.Reumatology Sheet MD. swelling. Palpate for: tenderness. warmth.
• Metacarpal squeeze: between the examiner’s thumb & fingers proximal to metacarpal heads if tender= arthritis.Reumatology Sheet MD. Pinch the tips of thumb with index finger.) to reach the palm & thumb closes over them./ Abdel Azeim Alhefny. add. Z-shaped thumb • • Movements: Open & spread the fingers (extension & abduction). • Grip=pt. maximum strength in grasping 2 fingers of the examiner. • Fist=Close all fingers (flex. (30) . Dr.
/ Abdel Azeim Alhefny. b) Wrists=radiocarpal J.Reumatology Sheet MD. Dr. (31) .
g.W03. • Full flexion=planter flexion 70 ْ. Inspect & palpate for: swellings.WMV • Prayer position =full extension & dorsiflexion75 ْ . warmth & tenderness./ Abdel Azeim Alhefny. • Carpal tunnel syndrome provocation: Carpal tunnel syndrome =Occurs when the carpal tunnel space is reduced (e. Dr.Reumatology Sheet MD. • Ulnar deviation 45 ْ & radial deviation 20 ْ. The resulting compression of the (median) nerve causes a sensation of pins and needles and numbness and/or pain in the hand. (32) . Stress test: to elicit mild tenderness= mild arthritis Movements: 09VH. 1) Tinel's sign =Paraesthesiae in lateral 3 1/2 fingers (mainly in the middle finger) experienced on percussion over the flexor retinaculum at the extended wrist. when there is swelling of synovium due to inflammatory arthritis).
hot swelling at fossae between olecranon & medial or lateral epicandyles. tender. at or below olecranon. c) Elbow=Humeroradial. (33) ./ Abdel Azeim Alhefny. • Subcutaneous nodules & tophi. • Synovitis= firm. radioulnar J. 2) Phalen's sign = The wrist is passively held in flexion for up to a minute.: Inspect & palpate for:• olecranon bursitis. A positive result is when the patient experiences paraesthesiae in the fingers. usually predominantly the middle finger. Dr.Reumatology Sheet MD.
wmv • Bend (flex=0-150ْ) & straighten both elbows (ext=0ْ). • Resisted active movements: Lateral epicondylitis & Medial epicondylitis.: Inspect for: skin changes. • ْWith elbows flexed at 90 ْ & fixed to his side (to prevent shoulder movements) ask pt. acromioclavicular. swelling./ Abdel Azeim Alhefny. d) Shoulders = Glino-humeral.Reumatology Sheet MD. sterno-clavicular J. Dr. (34) . scapulo-thorasic. to turn palms up (supination 0-90 ْ) & down (pronation 0-90 ْ) using thumb as indicator. Movement: 09veb04. deformities& muscle wasting.
). Movements: 09vsh05. put both hands behind the head with elbows pointing laterally (abd. rot). sternoclavicular./ Abdel Azeim Alhefny. & int. Palpate for: warmth. acromio-clavicular. abduction. • Hands down.Reumatology Sheet MD. scapulo-thorasic . flx.. Dr. extension. adduction & rotation) • Pt. & ext. muscle bulk. hands behind back & thumb pointing up marking the highest vertebra pt. The appearance of winging may be exaggerated by asking the patient to hold the arms out in front of him and especially if they push against something at the same time. can touch by each side (ext. contour & power. rot.wmv (Flexion. tenderness over the anterior aspect & tip of shoulder. Winging of the scapula due to a palsy of the long thoracic nerve. Restriction of movements &/or pain in the shoulder may be (35) . . swelling.. add.
Apparent leg length= Umbilicus –medial maleolus (to detect scoliosis. Glenohumeral joint: pathology excluded if passive external rotation not limited. (SITS= supraspinatus. 2. Acromioclavecular joint-OA---hard swelling & tenderness with pain in shoulder abduction >120 ْ. Dr. Palpate for: warmth./ Abdel Azeim Alhefny. swelling & tenderness.Reumatology Sheet MD. swelling. pelvic tilt-scoliosis. II) Lower limb: Hip joint: Inspect for: Gait.pelvic tilt. • Internal 25° & external rotation 35° examined while (36) . deformities & muscle wasting. teris minor & subscapularis). due to abnormalities in: 1. pelvic contractures--. Rotator cuff muscles tendon inflammation= commonest cause of shoulder pain as arm moves up through mid arc of abduction (40-120 ْ). 3. Measurement: True leg length=from ASIS—lateral maleolus (to detect congenital or acquired disorders). Movements: • Hip flexion 0-120° & extension -10°. infraspinatus.
so.wmv Normally on standing on normal leg.Reumatology Sheet MD. On standing on the side of the diseased hip. Trendelenberg’s sign: 09v08. redness. Genuvarum=bow leg. Dr./ Abdel Azeim Alhefny. (37) . The last 2 tests are sensitive for hip pathology. drops to the other side=weak gluteus medius. the pelvis fails to tilt towards the same side. muscle wasting. using foot as indicator for the angle of rotation. both hip & knee flexed 90°. & specific deformities: Genovulgum=knock knees. the pelvis tilts to the same side. • Leg roll maneuver: to examine Internal 90° & external rotation 90°while hip & knee are extended. using the tibia as indicator for the angle of rotation. Knee Inspection: Swelling.
milking effusion from medial upward & laterally.Reumatology Sheet MD. localized). thumb pressing on patella. tenderness = localized or along joint line = inflammatory. warmth. • Patellar bulge sign=for small amount. Muscle wasting / compare thigh circumferences 10cm above the patella. Movements: Flexion & extension (0-150) (38) . Dr. cystic or hard / diffuse. with other hand fingers push patella against femur –tapping sensation. Signs of knee effusion: • Patellar tap = for large amount. Palpation: Swelling (soft./ Abdel Azeim Alhefny. then tap behind & lateral to patella observing the medial patellar fossa for refilling. left hand of examiner compressing the suprapatellar & parapatellar areas— pushing fluid behind patella.
/ Abdel Azeim Alhefny. (39) . Patellofemoral compression test: push patella against femur while knee in extension & pt. hand & pulling tibia forwards with rt. Collateral ligaments: abduction & adduction (medial & lateral displacement) stretch between tibia & femur while knee in flexion to elicit any movement. femur grasped with lt. contracting quadriceps—sever pain & tenderness=patello-femoral pathology. Fine / coarse. Knee flexed 20. Stability: Lachman’s test =integrity of anterior cruciate ligament. hand.Reumatology Sheet MD. Dr. Patellofemoral Crepitus: With examiner’s palm on knee during full flexion & extension.
cellulites & fat pad. DD. Popliteal area: Backer cyst-rupture-DD: DVT 09vkn07.wmv Ankle & foot: Inspection: synovial soft tissue swelling at both malleoli./ Abdel Azeim Alhefny.Reumatology Sheet MD. Periarticular oedeme. (40) . Dr.
Metatarsal compression test=squeeze between examiner’s thumb & fingers just proximal to metatarsal heads= ?synovitis. MTP. Palpation: Tender ankle or MTP=synovitis. Dr.Reumatology Sheet MD.F06. PIP. over metatarsals=? march fracture. • Hammer toe: hyper ext. • Hallux valgus=lateral displacement of proximal phalanges on metatarsal heads in RA. Deformities: Pes planus (flat foot= talar head displaced medially & plantar-ward). DIP. hyper ext. flex./ Abdel Azeim Alhefny. tenderness in between metatarsals 3rd4th /2nd-3rd =Morton neuroma.WMV (41) . Movements: 09VK. • Cock-up (claw) toe: flexion of IPJ +MTP subluxation. pes cavus (high arch).
hand & rotate the forefoot passively by rt. * Subtalar=talocalcaneal j. III) Spine: Inspection: Normal cervical & lumbar lordosis (concavity to back) & thoracic kyphosis (front concavity) Deformities: scoliosis (lateral deviation of spine). * Mid tarsal j./ Abdel Azeim Alhefny. kyphosis (anterior deviation). lordosis (posterior) & gibbus (kyphosis with acute angle due to infection/TB or fracture). MTP – plantar flexion 40° & dorsiflexion 65°. Dr. hand & rotate the foot passively by rt = 5° of inversion or eversion. * 1st. ---inversion 35° & eversion 20°. (42) .Reumatology Sheet MD.----Stabilize the heel=calcneum by lt. Ankle & foot=3 groups of joints: * Tibiotalar=ankle—Plantar flexion 50° & dorsiflexion 20°.: Stabilize the ankle or distal leg by lt.
ask pt.& another10 cm above. & Lt. full expiration & insp>6cm Lumbar spine: Flexion 90. & Lt. extension 60. • Finger tips-floor distance <10cm =index for combined hip & lumbosacral flexion. the 2 marks should be>17cm./ Abdel Azeim Alhefny. • • Movements: • Cervical spine: notice any localized or radiating pain/ tenderness or limited mobility on active or passive: Flexion=75. • Lumbosacral: anterior flexion--. Lateral bending (to touch sides of knees)15-30. to touch the toes with extended knees. Extension 30. Palpation: For tenderness. warmth. muscle wasting. Rt. Chest expansion = difference bet. Rt. Thoracic spine: Rt. bony abnormalities. • Schober test: limited flexion ?AS. rotation at thoracolumbar 45.Reumatology Sheet MD. measure the distance bet. & Lt. Put a mark at the level of PSIS or lumbosacral j. bending 45.increased distance bet. D12-L1>7cm. (43) . Rotation 80. . Dr.
/ Abdel Azeim Alhefny.Reumatology Sheet MD. 09vsp09.wmv Nerve Stretch signs (44) . Dr.
stressed by asking pt. then straighten it if pain = +ve Lasegue test. Confirmed by flexing knee slightly.Reumatology Sheet MD. 2. Pressure over the popliteal fossa may also induces root irritation (bowstring) Femoral N roots=L2. Dr. to lie prone. flexion of knee—pain exacerbated by hip extension.3&4. dorsiflex ankle (+ve Bragard test). Straight leg raising with hip flexion (normally to 90). (45) . stressed by 1. Sciatic N root compression: L5 & S1. 3./ Abdel Azeim Alhefny. if limited by pain flex knee to allow more hip flexion. Pain worsens after compressing the spine by pressing on head vertically of standing or sitting pt.
Level of lesion: L4 root=lost knee reflex & weakness of quadriceps./ Abdel Azeim Alhefny. L5=weak extensor hallucis longus S1=lost ankle reflex & weak soleus . Dr.Reumatology Sheet MD. Sacroiliac Joint: (46) .
Dr. (47) . warmth. pelvic compression with pt.Reumatology Sheet MD. Or by hip flexion & adduction to push knee toward the other ASIS. or tenderness. on his side. Or by local examination on prone position to elicit any swelling. iliac fossa. pushing the 2 ASIP by the 2 examiner’s hands postero-laterally=trying to open the book. in flat supine position./ Abdel Azeim Alhefny. Or by compression with springing of the pelvis while pt.
Reumatology Sheet MD. Dr./ Abdel Azeim Alhefny. (48) .
CRP. & distribution Nonarticular: • Traumatic • Fibromyalgia • Polymyalgia R. • No. Manifes. J..RS. • Bursitis/tendenitis Articular? Acute or Chronic ? Chronic>6W.PJA Symetrical (49) . Br. synovial swelling. Acute arthritis: • Infectious • Crystal-induced • Reiter’s • Presentation of Chr. Inf.. Inflammatory or noninfl. warm. syst. PA. ESR >4 J = polyarthritis Affects Wt. Chronic noninflammatory arthritis Chronic inflammatory arthritis= MS>1hr.tender. (H&k)./ Abdel Azeim Alhefny. Dr. Approach to patient with musculoskeletal symptoms Musculoskeletal complaint History & Examination? • Articular or non • Acute or chr. Arth. Acute<6 W. • Inflammatory or non. DIP< CMC 1-4=mono-oligo A Chr. j.Reumatology Sheet MD.
/ Abdel Azeim Alhefny. MTP RA 09Vsum10. Is the effusion hemorrhagic? Inflammatory or noninflammatory articular condition? DD: • • • Is WBC> 2000/cmm? Traumatic or mechanical.WMV Interpretation of Synovial fluid analysis SLE.000/cmm ? Inflammatory? (50) Gout or Pseudogout. Noninflammatory: • OA • Traumatic Inflammatory or septic arthritis? Other Inflammatory or septic? Gram stain & culture essential. with chr. culture & sensitivity. Analyze fluid for: • Appearance.Reumatology Sheet MD. • Acute monoarthritis in pt. Is PMNs> 75%? Are crystals present? WBC>50. MCP. Neuropathic. • Crystal identification by polarized microscopy. • Joint trauma & effusion. viscosity. or hemarthrosis. OA Osteonecrosis Charcotarthritis PA. • Suspicion of joint infection. • WBC count & differential. RS PIP. Polyarthritis. PM Indications for synovial fluid aspiration: • Monoarthritis (acute or chronic). crystal. Dr. Septic? . Coagulopathy. • Gram stain. SSc.
photosensitivity. improved by exercise. exertional dyspnea (cardotis). alopecia. ARF 2.). smoky urine = . LBP & morning back stiffness for >3 months in a male patient. skin erythematous plaques with rounded borders over trunk (erythema marginatum). X-R= . with systemic and extraarticular effects. DVT). (Group A-B-H.=Rheumatogenic) = . PsA 6. after a history (18 days)of URTI. Both hands are almost involved + MS>1hr. Symmetrical polyarthritis/arthralgia affecting peripheral joints in middle aged female. (51) . If with symptoms & signs of IBS. = . oral ulcers. RA 3. behavioral changes. elbows & wrists) in a child (5-15ys. RF. easy fatigue. dyspnea. Sudden LBP after lifting heavy object or bending with radiation to lateral leg= disc herniation & sciatica. deformities. Common Presentations Of Common Rheumatic Diseases: 1. fever.Reumatology Sheet MD. Acute migratory polyarthritis (extremely painful) affecting large joints (knees. butter fly rash. Chronic oligoarthritis affecting large axial joints. SLE 4. chest pain. small joints (sausage digits) &/ or back (Spondyloarthropathy) with psoriatic skin & nail pitting= . RP. Asymmetrical oligoarthritis affecting large. with FUO. with additive sequence in female. pallor./ Abdel Azeim Alhefny. involuntary movements (choreamay occur after months). puffiness/LL swelling. ankles. nodules. Dr. headache (HPT). sc. Chronic polyarthritis affecting small joints bilaterally & symmetrical. nodules. strept. +fits. enteropathic arthritis 5. peripheral vascular manifestations (ischemia. unrelieved by rest+ limitation of lumbar spine movements & chest expansion=AS.
a high ESR. Acute intermittent attacks of monoarthritis with sever pain. uveitis. telangiectasia. GERD. In any patient over the age of 50 with recent onset of headache. cardiomyopathy. A history of asthma. 14. swelling of 1st MTP=podagra. 8. sc. cercinate balanitis. surgery. knee-exclude septic arthritis (30% polyarticular) after diuretic. peripheral neuropathy. 13. Reduction & inf. alcohol.+ genital ulcer or scare. atopy. calcifications.Reumatology Sheet MD. erythema nodosum. CRD. retinal vasculitis. ankle. sclerodactyly. cardiac and renal troubles= . Recurrent oral ulcers. or anemia ??? The diagnosis of should be considered. digital ulcers/gangrene.1-2days-25g-5mmdepth) =Behcet. flexion contractures in a female with tight skin. joint stiffness. dyspnea. myocardial infarction and hypereosinophilia may suggest Churg-Strauss syndrome (CSS). HSP 12. wt. Gout 11. redness. loss of vision. Dr. dysphagia. SSc 10. cyanosis. allergic rhynitis. Jaw claudication and scalp tenderness. > 3 times in 1yr. progressively repeated attacks of RP. cells in vitreous. papulopustules + pathergy (2mm eryth. Arthritis in large weight bearing joint in obese post menopausal woman pain increasing at night after the day time usage +/Heberden & Bouchard nodes= . Polyarthritis/arthralgia. myalgias. conjunctivitis or uveitis. 7. 1-4w after attack of GI or genitourinary infections= RS. keratoderma blennorragicum & painless mucosal ulcers. cutaneous eruptions. Arthritis/enthesitis. Arthritis. fever (FUO)./ Abdel Azeim Alhefny. pericarditis. GCA (52) . OA 9. palpable purpuric eruptions in LL & abdominal pain + hemoptysis & GI bleeding in a child after upper respiratory tract infection = . urethritis. = . superficial thrombophlebitis.
exanthema of the trunk. Myalgias. Arthralgia. and syncope) occur with bruits. and bowel obstruction or perforation. Orchitis and epididymitis in a male. Coronary artery lesions. carditis with heart murmurs and ECG changes. abdominal pain. colon & breast)= Polymyositis & Dermatomyositis & tenderness at the lateral epicondyl & extensor mus. kidney (hematuria. Cardiomyopathy. hemoptysis). Abdominal pain. intraperitoneal hemorrhage (Rupture of mesenteric aneurysm). 20. arthralgias & Symptoms of vascular insufficiency (claudication. bilateral conjunctival congestion. Myalgias. bleeding. Ht. in young women 15-25yrs. and upper respiratory tract (nasal sinus) should suggest the possibility of WG. 15. heliotrope rash on the upper eye lid. Palpable purpura. proteinuria). LL swelling (nephrotic syndrome) & renal failure (GN). Gottron eruption over PIP & MCP./ Abdel Azeim Alhefny. Peripheral neuropathy. and discrepancies of limb blood pressure (LL>UL). pericarditis). repetitive wrist extension or supination & pronation increased by resisted active wrist extension= Tennis elbow= lateral epicondylitis 16. seizures. Close to it dt. 19. arthralgias. fever. Failure + S & S of malignancy (lung. chest pain. livedo reticularis.Reumatology Sheet MD. "strawberry" tongue. Arthritis. 18. Pain (53) . painful mononeuritis multiplex.= Kawasaki. transient visual disturbances.=Takayasu. peripheral gangrene and skin nodules. 17. dyspnea on exertion (angina or myocardial infarction. vomiting. weak pulses. Involvement Dr. CVA. urticaria. Painful cervical LN. stomach. of the lung (dyspnea. Proximal muscle weakness & tenderness. acute onset of high fever. sudden onset of sever HPT. & diarrhea in child <5yrs. around 40s = PAN.
Rheumatology Secrets. 1998. tender points. Patients present with numbness in the median nerve distribution.oup.Reumatology Sheet MD. WWW. 1995. A guide to physical examination & history taking. Tinel’s and Phalen’s signs may be positive. 21. It may occur in isolation or in association with a connective tissue disease References • • • • • • • • • • • • Atlas Rheumatic diseases Barbara Bates. 2002. Manual of Reumatology & outpatient Orthopedic disorders. Carpal Dr. 2001. diffuse pain (>3months). 1992. 2000. paresthesias & RP = Fibromialgia Rheumatica. hand pain. sleep disturbance. It is usually followed by blue. + MS. 4th ed.com . hypothyroid & acromegalic patients. Davidson's principles & practice of Medicine 19th ed. Chronic Raynaud's phenomenon = Blanching of the extremities on exposure to cold. 22. 2002. Nocturnal paresthesias. and pain radiating to the elbow or shoulder (Valleix phenomenon) can also occur. Rheumatology examination &injection techniques. headache. Harrison's principles of Internal Medicine. Medscape Reumatology Web sites Oxford handbook of Rheumatology. cyanotic discolouration on rewarming. tunnel syndrome (CTS) commonly occurs in diabetic./ Abdel Azeim Alhefny. Up to 15% of all patients with CTS will have diabetes. 2nd. Arthrocentesis NEJM. fatigue. normal lab.wmv musculoskeletal. 6th ed . depression.. Thenar atrophy is a late sign and indicates muscle denerva tion. 2002. 14th ed. anexiety.wmv (54) . ILAR. Ed. EULAR Reumatology Web siteS Kelly's text book rheumatology 6th ed.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.