Rheumatology and Musculoskeletal General Things General inspection Cushingoid appearance due to steroid use Signs of weight loss May be a feature of active disease Hands Place the patients hands on the pillow Symmetry for small joint synovitis Signs of advanced disease: Ulnar deviation Volar subluxation of the MCP joints Z deformity of the thumb with swan neck Boutonniere deformity of the fingers Examine the fingernails and periungual areas doe splinter like vasculitis changes and look for wasting of the small muscles of the hand. Palmar erythema Palmar tendon crepitus while the patient extends and flexes their fingers. Look for signs of ulnar nerve palsy: Ulnar nerve entrapment at the elbow Look for carpal tunnel syndrome Wrists Look for synovial thickening Phalen’s tests -> carpal tunnel syndrome Elbows Rheumatoid nodules -> seropositive disease Examine the elbow joint Flexion contractures are common Shoulders and the Axilla Examine for tenderness Limitations of movement Palpate for axillary nodes Enlarged nodes may indicate active disease of joints in the area that they drain. Eyes Redness May indicate dryness of Sjogren’s syndrome Nodular scleritis Elevated white ot purple red lesion -> pathologically a rheumatoid nodule -> surrounded by the intestine redness of the sclera. Occur especially in the superior parts of the sclera and often bilateral Only affect 1% of the patients. Iritis does NOT occur. Scleritis When severe -> scleral thinning -> expose the underlying choroid -> scleromalacia Cataracts Due to steroid s=use Parotids Look for enlargement -> Sjogren’s syndrome Mouth Look for dryness of the mouth. Dental caries -> Sjogren’s syndrome Ulcers relating to drug treatment E.g. methotrexate Temporomandibular joints Feel them for crepitus as the patient opens and shuts their mouth Neck Examine the cervical spine for tenderness Chest Examine the lungs for signs of pleural effusion or pulmonary fibrosis Caplan’s syndrome: presence of rheumatoid nodules in combination with pneumoconiosis. Abdomen Feel for splenomegaly Can occur in up to 10% of patients -> suggests the possibility of Felty’s syndrome. Look for hepatomegaly Feel inguinal lymph nodes Lower limbs Ankles and the feet Seronegative spondylarthritis Do not have anti-CCP unlike RA These overlap pathologically due to association with HLA-B27 There are classified into: Ankylosing spondylitis Reiter’s disease/Reactive arthritis Psoartic arthritis Enteropathy arthritis Ankylosing spondylitis Back and sacroiliac joints: Loss of spinal curvatures: Loss of Lumbar lordosis Loss of Thoracic kyphosis Severe flexion of the lumbar spine -> rare Tenderness of the lumbar vertebra Reduction of movement of the lumbar vertebra Reduction of movement of the lumbar spine in all positions. Measure the occiput wall distance: Serial measurements that show increasing distance -> worsening deformity. Schober’s test: Increased distance between the marks spots less than 5cm. Test the lateral movement of the spine by asking the patient to run hand straight down the side of each leg in turn. This movement is often strictly severe. Legs Achilles tendinitis Plantar fasciitis Signs of cauda equina compression Lowe limb weakness Loss of sphincter control Saddle sensory loss Arthritis of the hips and shoulders. Upper limb: Dactylitis of the hands and toes. Lungs Decreased chest expansion -> less than 5 cm -> apical fibrosis. Heart Signs of aortic regurgitation Eyes Acute iritis -> tend to reoccur -> painful and red eye. Rectal and stool examination Reactive Arthritis Classically follows urethritis or diarrhea with conjunctivitis and arthritis -> usually asymmetrical of large weight bearing joints such as: Hips Knee Ankle Genital region: Urethral discharge Circinate balanitis: Scaly, superficial reddened erosions with well demarcated boarders on glans penis. Prostate Prostatitis Eyes Conjunctivitis – rare Mouth Painless smooth mucosal lesions -> especially the tongue Back Sacroiliac joints -> may be unilaterally involved. Lower limbs More commonly affected Knees, MTP joints, toes Sausage toes Plantar fasciitis Achilles tendinitis Keratoderma blennorrhagica on the sole Non tender reddish-brown macules -> become scaling papules This is indistinguishable from psoriasis; nails thickened, opaque and brittle. Hands Less commonly involved Wrists, MCP joints, proximal IP joints, distal IP, keratoderma blennorrhagica on the palms and nail changes. Cardiovascular system Aortic regurgitation -> rare Psoriatic Arthritis Monoarticular and asymmetrical oligoarticular arthritis of then hands and the feet. NOTE: sausage shaped digits Most PA are of this type. Symmetrical polyarthritis -> similar to RA but seronegative Distal IP joint involvement with psoriatic nail changes. Arthritis mutilans -> destructive polyarthritis Sacroiliitis with or without peripheral joint involvement. Nails: Pits -> looks like a pin prick in the nail Onycholysis -> nail separation from the bed. Leukonychia Nail plate crumbling/degeneration Oedema Related to inflammation Hand and foot swelling Eyes -> 50% of patients Uveitis Conjunctivitis Enteropathy arthritis There are TWO distinct patterns if involvement of the joints with UC and DC: Peripheral joint disease: Asymmetrical oligoarthritic Usually affects the lower limbs -> especially the knees and ankles. Rare causes a deformity. Sacroiliitis: Clinically indistinguishable from ankylosing spondylitis Gouty Arthritis Begin with feet as in 75% of cases affects the MTP joint of the great tow. Examine the ankles and the knees: Tend to be involved in recurrent attacks. Fingers, wrists and elbows are affected late. Inspect and palpate for gouty tophi. Urate deposits within inflammatory cells surrounding them. Tend to occur: Over the synovial joint Olecranon bursa Extensor surface to the forearm Helix of the ear Infrapatellar and Achilles tendon. Examine for signs of secondary causes of gout: Increase purine turn over due to myeloproliferative disease. Lymphoma Leukemia Decreased renal urate excretion due to renal disease or hypothyroidism. Other features that are common in gout patients: Hypertension DM Ischemic heart disease Calcium pyrophosphate arthritis/Pseudogout Similar to what is described in true gout BUT usually affect larger joints: Especially the knees (mainly) and wrists are involved. In minority of the patients: Hyperparathyroidism True gout Calcium Hydroxyapatite Arthritis Large joint arthritis: Knees and shoulder. More common in the elderly. Osteoarthritis Affects synovial joints. Loss of articular cartilage, new bone formation and changes in the shape of the joints. Brief morning stiffness Less than half an hour. General appearance: Swollen -> bony growth and synovium. Deformity -> Heberden and Bouchard nodes Periarticular muscle weakness. Palpation Normothermic Swelling -> effusion Joint line tenderness Periarticular tenderness. Movement Decrease range of motion. Osteophytes, capsular thickening, synovial hyperplasia and joint effusions -> limit joint movement. Weak movements Crepitus Rheumatoid Arthritis Hands and wrists: MCP + PIP -> swelling, erythema, tenderness, bogging -> synovial thickening. Reduced hand grip Ulnar digits deviation Radial wrist deviation Boutonniere + swan neck deformity MCP subluxation -> slight displacement Subcutaneous nodules. Z thumb. Feet and ankles MTP swelling, erythema and tenderness Plantar subluxation of the metatarsals Elbows, knees and hips -> swelling and tenderness Elbow -> commonly affected with fixed flexion, subcutaneous nodules and synovitis. Joint symptoms appear as: Hot Swollen Painful joints MCP, PIP, MTP and Wrists DIP sparing Symmetrical Morning stiffness -> more than 30 minutes Knee -> shoulder -> elbow -> hip Functional loss from the synovial inflammation Extra-articular manifestations: Constitutional symptoms Cardiac diseases: AF, CAD, HF Dyspnoea: interstitial pneumonitis, pulmonary nodules, pleurisy Eye pain and redness -> keratitis, scleritis, episcleritis Poor vision -> keratoconjunctivitis Rheumatoid nodules on extensor surfaces -> painless Skin changes from vasculitis Eyes: Keratosis Keratoconjunctivitis Episcleritis Scleritis Corneal ulceration Lungs Pleural effusions Pulmonary fibrosis Skin Rheumatoid nodules: Firm, non-tender raised over the olecranon and the hand dorsum. Neurological Nerve entrapment from inflammation Commonly medical nerve -> carpal tunnel syndrome. Osteoporosis Height measurement and compare with previous height measurement Look for inability of the patient when standing straight to touch the wall with the back of the head. Assessment of lumbar fractures: Measure the rib to pelvis distance Have the patient stand away from you with arms extended. Insert fingers between the intercoastal margin and the superior surface of the pelvis in the midaxillary line. Feel for tenderness of the spine. Paraspinal muscle contraction Thoracic kyphosis Lumbar lordosis + scoliosis If the height decreases more than 4 cm in a young adult -> likely to have a prior vertebral fracture. Septic Arthritis Destructive atrophy caused by intra-articular infections. Erythematous and swollen joints. Joints warm on palpation Difficult to palpate joint boarders due to swelling. Limited range of motions. Examine for: Arthropathies in other joints. Track marks from IVDU Vitals Chest capillary refill. Carpal Tunnel Syndrome Findings from History Numbness, pain and paraesthesia in the distribution of the median nerve: Three radial fingers and the radial side of the ring finger. May be an early sign of early RA Symptoms often wake the patient from their sleep. May radiate up to the forearm May involve the fourth and fifth fingers, wrist and palm or dorsum of the hand. If the palm is involved -> probable Typically, worse at night Improves by hand shaking -> flick sign Findings from Physical Examinations Symptoms can be reproduced by gentle percussion over the carpal tunnel while the wrist is in extension. Look for muscle wasting in the distribution of the median nerve. Weakness in thumb abduction and opposition as well as thenar atrophy. Sensory changes in the distribution of the median nerve. Do flick sign and ask if things get better. Tarsal Tunnel Syndrome Compression of the posterior tibial nerve in the fibro-osseous canal formed by the flexor retinaculum and the tarsal bones. Findings from history Burning pain, paraesthesia in the toe, sole of the feet and the heel of the feet. May radiate upwards Patient wakes up from pain at night May be improved or worsened with physical activity. Better with rest and elevation. Muscle atrophy. Findings from Physical examinations Tenderness over the nerve posterior to the medial malleus Positive Tinel’s sign over the tarsal tunnel Motor findings include weakness of the toe flexion and of the intrinsic muscles of the foot. Morton’s Neuroma Caused by compression of one or more of the interdigital plantar nerves by the transverse metatarsal ligaments. Findings from History Burning or aching pain that extends distally from the affected web space to the toes: Most often the third and fourth. Radiates to the two adjacent toes. May describe the feeling as a marble or pebble during weight-bearing activities. Metatarsalgia is non localised ache that spreads across the forefoot involving the area of some or all of the metatarsal heads. Pain may improve with rest. Pain may worsen with: Constrictive footwear Weight bearing activities such as walking and running. Stretching to the toes. Findings from Physical Examination Tenderness between involved metatarsal heads. Painful nodule may be palpable. Fibromyalgia syndrome Chronic functional neurosensory disorder of unknown aetiology. Most commonly affects women who are in their 40s and 50s. Findings from History Variable group of symptoms Widespread musculoskeletal pains and aches. Mostly axial Mostly diffuse Made worse by stress or cold. Chronic fatigue Cognitive symptoms: Forgetting words Difficulty in concentrations. Patient may report all over unresponsive to anti-inflammatory drug treatment. Pain and fatigue combination -> severe limitations. Usually poor sleep patterns. Wakes up unrefreshed and more tired in the morning than during the day. Often intolerance of exercise. Days of exhaustion may follow any amount of exercise. no abnormal pathology has been found in joints, muscles or tendons of these patients. Morning stiffness Headaches Pain at tenderness points Autonomic changes: Xerostomia Xerophthalmia Blurry vision Photophobia Raynaud phenomenon Restless leg syndrome Findings from Physical Examination Test for the characteristic multiple hyperalgesia tender points. These areas may be tender to normal finger pressure in normal people. This response should be obtained in at least 11 out of 18 sites in the upper and lower limbs and no on both sides -> WIDESPREAD AND SYMMERTICAL. Test for hyperalgesia at control sites such as the forehead or distal forearm, where it should be absent. Diagnosis should be made based on the presence of multiple hyperalgesia tender sites (with negative control sites) but this may cause over diagnosis. Current criteria include: 3 months of self-reported pain at any 19 sites Fatigue Waking unrefreshed. Cognitive symptoms Those in bold should be scaled from 0 to 3. Inflammatory and endocrine diseases should be excluded.