9 - Rheumatology Histories and Exams Flashcards
What are the main symptoms of rheumatological disease?
- Pain
- Swelling
- Stiffness
- Fatigue
- Weakness
What questions do you need to ask in the history if someone is complaining of pain?
What?
Why?
When?
How bad?
Where?
Who? (patient’s social support, mental health etc)
Why do many patients with arthritis develop chronic pain?
Central sensitisation of pain processing cells in dorsil horn
Pain can come from synovium, joint capsule, subchondral bone, peri-articular muscle
How can you tell if pain is articular or peri-articular in origin?
If peri-articular usually only triggered by certain movements but articular is all movements
e.g Tennis elbow pain is felt on resisted wrist extension
How can the pattern of pain in joints help to make a diagnosis?
Certain rheumatological diseases have characteristics that make them more likely
e.g if the spine is involved not likely to be RA, more likely to be ankylosing spondylitis
What are some causes of acute and chronic monoarthritis?
What are some causes of acute and chronic polyarthritis?
What are the differentials for arthritis of the DIPJs?
- OA (most common cause and often Herbeden’s nodes)
- Psoriatic arthritis (will be nail dystrophy)
When a patient presents complaining of stiffness, what are some questions you need to ask?
Stiffness is a feeling of difficulty moving a joint
- Early morning stiffness? (> or < 30 minutes)
- Generalised or loalised?
- Worse after resting?
When a patient presents with joint swelling, what are some questions you need to ask?
- How rapidly did it come on?
- How long goes the swelling last?
- Does the swelling occur parallel to joint line indicating true joint swelling or does it cross the joint line?
- Is the swelling bony?
- Does the swelling extrude any material?
Fill in this table to distinguish the differences between mechanical and inflammatory diseases.
After taking a history of the presenting complaint, what other areas of the history do you need to explore?
ALWAYS CHECK EXTRAARTICULAR SYMPTOMS
What are constitutional symptoms?
Symptoms that are not disease specific e.g fever, weight loss, fatigue, and lymphadenopathy but can indication underlying inflammatory disease, infection or neoplasia
Common in: AS, Primary vasculitis, GCA
Uncommon in: RA and PsA. SLE has fever but not others
What rheumatological diseases are the following extra articular symptoms and signs associated with?
What rheumatological diseases are the following extra articular symptoms and signs associated with?
What are the basics of an MSK exam?
- Introduction
- GALS
- Look
- Feel
- Move (Active and Passive)
- Special tests
How do you perform a GALS assessment?
- Introduction and gain consent
- Screening questions
- Gait
- Arms
- Legs
- Spine
- Regional exam of a joint if any problem detected
- Thank patient and ask if they need any help dressing
How do the following gaits present?
- Antalgic
- Trendelenberg
- Sensory ataxia
- Cerebellar ataxia
- Hemiplegic
- Festinant
- Waddling
- Psychogenic
How do you perform a hand examination for an OSCE?
- Introduce and gain consent
- Hands on pillow and ask if any pain
- Inspect distal to proximal on dorsum, palmar and elbows. Look at thenar/hypothenar
- Feel
- Move
- Neurovascular
- Function
- Special tests
What would indicate a positive Tinel’s and Phalen’s test?
Test for carpal tunnel syndrome (can be caused by arthritis)
Tinel’s: tap on carpal tunnel with your index and middle finger for 30-60 seconds. If irritation in thumb and radial two figners it is positive for median nerve irritation
Phalen’s: hold wrist in forced flexion for 60 seconds, if symptoms develop then positive
What is the sensory and motor supply of the median nerve to the hand?
Sensory: see image
Motor:
- All anterior forearm except FCU and medial two FDP
- LOAF (lateral two lumbricals, opponens pollicis, APB, FPB)
How would a median nerve palsy present?
- Weakness of thumb opposition and abduction
- Numbness in median nerve distribution (palmar sparing if lesion at wrist)
- Late thenar muscle wasting
(If damage in arm will have weak finger flexion but be able to flex ring and little finger)
What is the sensory and motor supply of the ulnar nerve?
Sensory: see image (not just fingertips on back)
Motor:
- FCU
- Medial FDP
- Interossei and adductor pollicis
How will an ulnar nerve palsy present?
- Wasting of hypothenar
- Numbness in distribution of ulnar nerve
- Froment’s test
- Claw Hand in low lesion
