Rheumatology

Question 1

What are the components of the hand examination?

Answer 1

Gait
Posture
Deformity - pattern of involvement
Difficulty removing clothes

Muscle wasting
Nails
- Psoriasis: pitting, ridging, onycholysis, hyperkeratosis, discolouration
Periungual erythema, rashes
Telangiectasia
Skin:
- Sclerederma, calcinosis
- Erythema (inflammation)
- Rashes (eg psoriasis on extensor surfaces; vasculitis)
- Atrophy (chronic disease)
- Scars (joint replacements or tendon repairs)

Joint deformity
- Subluxation or dislocation
Joint warmth
Joint swelling
- Synovitis vs effusion vs bony
Tenderness
Joint movement - pain, tense effusion, crepitus

Palmar tendon crepitus
Carpal tunnel tests - Tinnel and Phalen

Peripheral nerves

• Opposition, finger abduction, wrist extension
• Pulp of index finger, pulp of pinkie, 1st dorsal interosseous

Function

• Open jar
• Key grip
• Undo buttons

Question 2

What are the components of the RA exam?

Answer 2

Hands:

• Swan neck and Boutonniere’s deformities of the fingers and Z deformities of the thumbs
• Volar subluxation and ulnar deviation at the MCPs
• Volar subluxation and radial deviation at the wrist
• Boggy swelling of the small joints of the hand (excluding DIPs)
• Tendon crepitus and trigger finger
• Extensor tendon rupture of the 4th and 5th fingers
• Raynaud’s phenomenon
• Digital arteritis
• Carpal tunnel syndrome

Upper limbs: Rhematoid nodules

Eyes: Secondary Sjogren’s, scleritis, episcleritis, cataracts (steroids)

Neck and throat: cricoarytenoid RA, atlanto-axial subluxation

Lungs: ILD, pleural effusion, pleuritis

Heart: pericarditis, valve disease from rheumatoid nodules

Renal: drugs, secondary amyloid

Neuro: peripheral neuropathy, mononeuritis multiplex, cord compression (C1/C2 subluxation or nodules), entrapment neuropathies (carpal tunnel)

Haem: chronic disease anaemia, Felty’s syndrome (neutropenia and splenomegaly)

Legs: Ulcers, mononeuritis multiplex, pyoderma gangrenosum

Question 3

What are the clinical manifestations in Sjogren’s Syndrome?

Answer 3

Dry mouth - dental caries, candidiasis, enlarged salivary glands
Dry eyes
Vaginal dryness - dyspareunia

Skin

• Xerosis (dry, scaly skin) - mainly axillary folds and lower extremeties
• Raynaud’s syndrome
• Cutaneous vasculitis - papable purpura (most common), urticaria
• Medium vessel vasculitis (uncommon) - cutaneous ulcers, may mimic PAN or RA vasculitis
• Annular erythema

Musculoskeletal

• Arthralgia (50%) +/- arthritis - symmetric, non-erosive and non-deforming
• Prox muscle weakness
• Fatigue, fibromyalgia

Resp

• Dry cough
• Recurrent bronchiolitis and dyspnoea
• Bronchiectasis
• ILD

Cardiac
- Pericarditis, myocarditis, heart block (all rare)

Gastro

• Dysphagia, nausea, dyspepsia, gastritis
• Coeliac disease
• Deranged LFTs
• PBC, AIH associations

Renal
- Intersitial nephritis

Neuro

• Distal painful sensory neuropathy
• Dorsal column neuropathy with areflexia
• Adies pupil
• Fixed tachycardia, anhydrosis, orthostatic hypotension
• Pure sensory trigeminal neuropathy (V1 spared therefore corneal reflex NAD)
• Mononeuritis multiplex
• Autonomic dysfunction

Haem

• NHL (also RA, SLE, coeliac)
• Leucopenia
• Hypergammaglobulinaemia or hypo (less common)
• Type II cryglobulinaemia

Question 4

What is the DDx for proximal weakness?

Answer 4

Steroids/Cushing's
EtOH
Hypo/hyperthyroidism
Hyperparathyroidism
PMR
Polymyositis/dermatomyositis
Osteomalacia

Question 5

What are the components of the ankylosing spondylitis examination?

Answer 5

Look
- Kyphosis and loss of lumbar lordosis

Feel

• Palpate vertebral bodies for tenderness
• Muscular spasm

Function

• Finger-floor distance
• Back extension
• Lateral flexion and rotation
• Modified Schober’s test at L5 (PSIS) level
• Occiput to wall distance

SI joint
- Spring the ASIS bilaterally

Lower limbs

• Achilles tendonitis
• Plantar fasciitis

Large joints
- Knees, hips and shoulders for arthropathy

Chest

• Decreased lung expansion
• Apical fibrosis
• AR, MR, conduction defects

Eyes
- Anterior uveitis

GI

• Oral ulcers (Crohn’s)
• Abdominal tenderness
• Hapatomegaly (amyloidosis secondary to inflammation)

Question 6

What is involved in the Marfan’s examination?

Answer 6

Upper limbs

• Arachnodactyly and joint hypermobility
• Radio-radial and radio-fermoral delay
• Collapsing pulse
• BP

Face

• Blue sclera
• Iridodonesis
• High arched palate

Chest

• Pectus excavatum or carinatum
• AR, MVP

Spine + proportions

• Kyphoscoliosis and hypermobility
• Arm span:height > 1.05
• Upper:lower segment ratio < 0.85

Abdomen
- Pulsatile liver

Question 7

What are the findings associated with FSH muscular dystrophy?

Answer 7

Weakness of triceps + biceps
Absence of triceps and biceps jerks
Weakness of pectorals and trapezius
Scapular winging
Deltoid hypertrophy
Weakness of sternocleidomastoids
Bilateral ptosis and weakness in eyelid closure
Dysarthria
Beevor sign - upward movement of navel with neck flexion

OSA
High frequency hearing loss
Retinal telangiectasia

Question 8

What are the findings in limb girdle dystrophy?

Answer 8

Hip flexors and gluteals affected first
Early involvement of medial quads and tibialis anterior
Lateral quads and calves hypertrophy

Question 9

Which medications can cause Raynaud’s syndrome?

Answer 9

Beta blockers
Sulphasalazine
Bromocriptine
Bleomycin and vincristine in combination