Rheumatology

Question 1

Hand exam - preparation

Answer 1

Cup and key
Neurotip
Stethoscope (RA / Scleroderma proceed)

Examine hands on a pillow

Question 2

Hand exam - general inspection

Answer 2

Weight, Cushingoid appearance
Scleritis / iritis
Other joint disease

Question 3

Hand exam - skin thickness

Answer 3

scleroderma - diffuse or limited

Question 4

Hand exam - close inspection

Answer 4

Wrists - skin (scars, erythema, atrophy, rash), alignment (deformity), muscles (wasting)
MCP - skin, swelling (distribution), alignment (ulnar deviation, volar subluxation)
PIP and DIP - skin, swelling, deformity (swan necking, boutonnieres, z-deformity)
Nails (psoriatic changes - pitting, onycholysism hyperkeratosis, discolouration)

Question 5

Hand exam - screening movements

Answer 5

1. spread fingers
2. palms up
3. make fist
4. show elbows
5. prayer, reverse prayer

Question 6

Hand exam - feel

Answer 6

Wrist - ulnar styloid, dorsal wrist, snuff box
Thumb - CMC, MCP, interphalyngeal joint
Fingers - MCP, PIP, DIP

If there is deformity or subluxation look to assess if it is reducible / correctable deformity

Question 7

Hand exam - ROM

Answer 7

Wrist - ulna / radial, volar / dorsal movements
Fingers - flexion, assessing crepitus

Question 8

Hand exam - power

Answer 8

Finger extension - extensor digitorum - radial nerve (dorsal interosseous branch)
Finger ABduction - interossei - ulna nerve
Thumb opposition - oppenens policis - median nerve

Question 9

Hand exam - special tests

Answer 9

Phalen’s sign
Tinnells test
Functional test - key in cup

Question 10

Hand exam - elbows

Answer 10

nodules - rheumatoid nodues, gouty tophi, calcinosis

Question 11

Hand exam - proceeds

Answer 11

Scleroderma
- limited: Calcinosis, Raynauds, Sclerodactyly, Telangiectasia, typical facies, oral aperture
- diffuse: more proximal scleroderma, pulmonary hypertension, ILD
RA
- Feet
- ILD
Psoriasis / Seronegative
- psoriatic plaques (elbows, scalp)
- telescoping of joints
- Axial involvement
- Aortic regurgitation
- IBD

Question 12

Monoarthropathy
Oligoarthropathy
Polyarthropathy

Answer 12

Mono - 1
Oligo 2-4
Poly >4

Question 13

Deforming polyarthropathy causes

Answer 13

Rheumatoid arthritis
Seronegative spondyloarthritis - psoriatic, ankylosing spondylitis etc.
Chronic tophaceous gout

Question 14

Where are heberdens and bouchards nodes located?

Answer 14

Heberden - distal
Bouchards - proximal

Question 15

Carpal tunnel causes

Answer 15

Occupational
RA
Hypothyroidism
Acromegaly
Amyloidosis
Gout
Obesity
DM (two-hit)
Pregnancy

Question 16

Back exam - inspection

Answer 16

Deformity, lordosis, kyphosis, scoliosis
Winging of scapula (serratus anterior, long thoracic nerve damage)

Question 17

Back exam - movements

Answer 17

Lumbar - flexion, extension, lateral flexion
Cervical - rotation, flexion / extension, lateral flexion
Thoracic (sit on chair) - rotation

Question 18

Back exam - chest expansion

Answer 18

measure with tape, normal >3cm

Question 19

Back exam - palpation

Answer 19

each vertebrae
paraspinal muscles
SIJ tenderness

Question 20

Back exam - special tests

Answer 20

Modified schober’s test (<5cm indicates limited lumbar flexion)
Wall to occiput distance

Question 21

Rheumatoid Arthritis findings

Answer 21

Cushingoid
Hands- symmetrical small joint synovitis, ulnar deviation and volar subluxation at MCPs, Z-shaped deformity of the thumb, swan neck and boutonnieres deformity
Nails- splinter like vasculitic changes
Muscles of hands - wasting, feel for crepitus of palmar tendons
Nerves - ulnar nerve palsy and median nerve palsy
Eyes - dry eyes - Sjogrens (occurs with RA in 10-15% of cases)
Chest - pericarditis, valve lesions, lungs; effusions, fibrosis, infection, nodules
Abdomen -splenomegaly (felty’s syndrome)

Question 22

Ankylosing spondylitis findings

Answer 22

Back and SIJs - limitation of movements, SIJ pain
Legs - achilles tendinitis, plantar fasciitis
Lungs - decreased chest expansion, apical fibrosis
Heart - AR
Eyes - iritis
Other - signs of IBD, secondary amyloidosis

Question 23

Psoriatic arthritis findings

Answer 23

5 distinct groups of PA
- monoarticular and symmetrical oligoarticular arthritis of hands and feet
- symmetrical polyarthritis
- distal interphalyngeal involvement with nail changes
- arthritis mutilans
- sacroiliitis with or without peripheral involvement

Question 24

SLE findings

Answer 24

General inspection - cushingoid, mental state
Hands - rash, vasculitis, arthropathy
Arms - livedo reticularis, purpura, proximal myopathy
Head - alopecia, scleritis, oral ulcers, malar rash, cranial nerve lesions
Chest - pericarditis, pleural effusion, pulmonary fibrosis
Abdomen - hepatosplenomegaly
Legs - red soles, vasculitis, ulcers ofer the malleoli, proximal myopathy, mononeuritis multiplex

Question 25

Antibodies
- CREST
- Diffuse cutaneous systemic sclerosis
- RA
- SLE
- Synthetase syndrome
- MCTD

Answer 25

Antibodies
- CREST - centromere
- Diffuse cutaneous systemic sclerosis - topoisomerase 1
- RA - RF, CCP
- SLE - ANA, dsDNA, Ro, La
- Synthetase syndrome - Jo-1
- MCTD - U1-RNP