Rheumatology Flashcards
Go through the back exam (usually ankylosing spondylitis)
Undressed to underwear and standing
Look
- general: gait aids, etc
- from the back and side
- kyphosis, loss of lumbar lordosis
Feel
- down the spine for tenderness or muscle spasm
- spring the ASIS looking for tenderness at the SIJs
- achilles tendonitis, plantar fasciitis
Function
- finger to floor distance (when trying to touch toes)
- modified schober (mark 5cm below and 10cm above ASIS in midline, get them to touch toes with legs fully straight then re-measure. Difference should be >5cm)
- lateral flexion (heel and back against wall)(difference in finger to floor distance at rest and full lateral flexion on both sides, should be >10cm)
- occiput-wall distance (should be 0)
- chest expansion
Extra-articular
- lungs for apical fibrosis
- heart for AR, MVP
- eyes for uveitis
- GI for amyloid (organomegaly)
- generally for signs of psoriasis which can be axial
Symmetrical Deforming Polyarthropathy
5 causes of a symmetrical deforming polyarthropathy
- DIP sparing
- RA
- SLE
- DIP invovlement
- Psoraitic arthritis
- Osteoarthritis
- Gout
However note - Patients (especially older ones) often have concomitant OA and hence DIP invovlement
Hand exam
- LOOK - general inspection
- general inspection - cushingoid, weight, iritis/scleritis, rashes (psoriatic), other joint disease (RA nodules), gait aids, O2
- overt scleroderma
- hand dance
- LOOK - Hands
- symmetrical deforming polyarthritis
- joint involvememnt ?DIP sparing
- scars
- erythema
- wasting - thenar, hypothenar, interosseous = chronic lack of use
- nail beds - psoriatic nail changes, erythema or abnormal nailbed capillaries, severe raynauds
(IF at this point there is no evidence of the 5 symmetrical deformin PO –> be suspicios and consider doing a neuro screen –> hand out straight supinated, make fist and open) –> move onto neuro exam
- FEEL - palpate each joint, starting at wrist
- skin thickening – map out - Limited vs diffuse?
- Synovitis (briefly!) - boddy swelling, effusions, stress tenderness
- Ulna styloid tenderness
- Cool peripheries
- Tinels test
- Test FUNCTION
- Grip strength, opposition strength (thumb and little finger)
- Functional test – jar and key
- If time - test for SENSATION in median and ulnar distribution
- extra articular manifestations and the extent of the disease
HOW TO PRESENT:
- pattern of disease + Ddx
- disease activity
- fucntional impairment
Hand deformities and their diagnosis
Differentials for small nodules on hands
- RA nodules (more common if on MTx)
- Tophi
- Calcinosis
- other i.e skin cancer
Hand - XRAY interpretation
OA - LOSS
- loss of joint space
- osteophytes
- subchondral cysts
- subchondral sclerosis
RA - LESS
- loss of joint space
- erosions
- soft tissue swelling
- soft bones/osteopenia
Arthritis Mutilans
- Complete joint destruction with telescoping of digits
- 2 causes: PsA (more common) and RA
Scleroderma
Classification by extent of skin involvement at diagnosis not antibodies/other manifestations!!
- Limited cutaneous SSc
- skin distal to elbow/knee, typically assoc with CREST/pulm HTN
- Diffuse cutaneous SSc
- skin prox to elbow/knee, typically assoc with ILD/serositis/renal
- Note: often softens/reduces with treatment/time
- Sine
- visceral disease in the absence of skin disease
Confirm diagnosis
- ANA (anti-centromere pattern)
- ENA (Scl-70 assoc with ILD, U3 RNP and anti Th/To assoc with pulm HTN, U1 RNP assoc with MCTD and pulm HTN)
- Nail fold capillaroscopy
-
Exclude differentials
- X ray hands (no erosions, distal osteo-acrolysis) – calcinosis is radio-opaque on XR
- RF, anti CCP, dsDNA
- ESR, CRP
Assess for end organ complications
- Renal crisis
- Urine dipstick +/- 24 hr urine collection
- ILD
- CXR (Bibasilar reticular-nodular appearance with ILD)
- HRCT (both NSIP and UIP pattern)
- Pulmonary function tests (restrictive pattern with reduced DLCO)
- ABG
- Pulmonary HTN
- ECG (right axis, dominant R wave in V1 and S wave in V5/V6)
- CXR
- ECHO +/-Right heart catheter
- ABG
- 6MWT
- GI dysmotility
- Endoscopy
- Oesophageal manometry for GORD
- Barium follow through for GI dysmotility
- FOBT for small bowel telangiectasia
Go through the knee exam
Both knees and thighs exposed, lying on their back
Look
- general: gait aids, endocrine facies, etc
- quad wasting
- rashes, scars, deformity, swelling
- fixed flexion deformity (inspect knee from side)
Feel
- quad wasting
- tenderness, warmth
- effusion: ballot patella (large effusion) or look for medial bulge on pressing lateral compartment (small effusion)
Move
- passive flexion and extension. Note ROM and crepitus
- test all ligaments. More than 5-10 degrees abnormal
- McMurray’s for meniscal integrity, looking for pain or clicking
- stand and look for baker’s cyst on extension in popliteal fossa
- *Other**
- walk them
- examine other joints or systems depending on findings
- *Don’t forget possibility of haemophilia**
- has prominent periarticular sclerosis on x-ray and may have grossly destroyed joint*
Seronegative sponyloarthropathies
PEAR - assoc HLA-B27, asymmetric oligoarthritis, absence of RF
- Psoriatic spondylitis
- Enteropathic arthritis
- Ankylosing spondylitis
- Reactive arthritis
Carpal Tunnel Syndrome - aetiology
- Idiopathic
- Occupational
- Endocrine
- diabetes
- hypothyroidism
- acromegaly
- Rheumatologic
- RA
- gout
- Other
- pregnancy
- obesity
- amyloidosis
- OM of carpal bones
Rheumatoid Arthritis
After the hands…
- Elbows - nodules,skin changes
- Face - scleritis/epislceritis, anaemia, tophi at ears, any facial psoriasis
- Joints - c-spine, feet, shoulders, hips, knees
- Chest (pleuritism, pleural effusions, ILD, pericarditis)
- Abdo - splenomegaly, hepatosplenomegaly
- Steroid/immunosupression - thin/purpuric skin
- finger pricks/insulin
- proximal myopathy
- kyhosis
- BP
- moon faces, buffalo hump, striae
ANA/ENA rheumatology antibody associations
dsDNA, histone, chromatin, PM/Scl, U1-RNP, Ro, La, centromere, Scl-70/topoisomerase I, RNA-polymerase III, sp100, gp210/6ps, Jo-1
