Rheumatology

Question 1

RA: CFx

Answer 1

GENERAL: ?cushingoid appearance
HANDS: small joint symmetrical polyarthritis, DIP sparring, ulnar deviation, Z deformity of thumb, swan neck deformity, boutonniere deformity, volar subluxation of MCP joints.
ARMS: RA nodules
FACE: redness and dryness of eyes (sjogren’s syndrome in 10%), scleritis, dry mouth.
CHEST: pleural effusion, ILD, pericardial rub, valvular regurg (particularly aortic)
ABDO: splenomegaly (10%, consider Felty’s syndrome), hepatomegaly (MTX)
LL: stocking distribution peripheral neuropathy, cord compression (if atlanticoaxial disease), feet arthropathy, achilles tendon nodules

Other sites: elbows, upper cervical spine, knees, tarsal and metatarsophalangeal joints

Deformities:
Boutonniere = flexion of proximal interphalangeal joint and extension of distal interphalangeal joint of the hand.
Swan neck deformity = hyperextension at proximal interphalangeal joint and flexion at distal interphalangeal joint.
Z-deformity of thumb = hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint

Question 2

Ankylosing Spondylitis: CFx

Answer 2

BACK: loss of lumbar lordosis and thoracic kyphosis, severe flexion deformity of lumbar spine, tenderness of lumbar vertebrae, reduction of movement.
LEGS: achilles tendonitis, plantar fascitis, cauda equina (rare)
LUNGS: decreased chest expansion, apical fibrosis
HEART: aortic regurgitation
EYES: iritis (10%)

Look for signs of assoc IBD

Question 3

Psoriatric arthritis: CFx

Answer 3

Monoarticular and oligoarticular arthritis of the hands and feet.
NAILS: oncholysis, pitting, ridging, hyperkeratosis.
SKIN: rash elbows and behind ears

Question 4

OA: CFx

Answer 4

Symmetrical

Heberden’s nodes (DIP), Bouchard’s nodes (PIP)

Question 5

DDx deforming polyarthropathy

Answer 5

RA
Seronegative spondyloarthropathy (psoriatic arthritis, ankylosing spondylitis, Reiter’s disease)
Chronic tophaceous gout (rarely symmetrical)
Primary generalised OA

Question 6

Sjogren’s syndrome: CFx

Answer 6

EYES: redness and dryness
FACE: parotid enlargement
MOUTH: dryness

Question 7

Gout: CFx

Answer 7

• Non-symmetrical oligo-polyarthropathy
• Metatarsal joint of great toe affected in 75% of cases
• Wrist and knees involved after recurrent attacks
• Palpate gouty tophi; joint synovia, olecranon bursa, extensor surface of forearm, helix of ear and infrapatellar and Achilles tendons

Examine for secondary causes of gout: increased purine turnover due to myeloproliferative disease / lymphoma / leukaemia, decrease urate excretion due to renal disease or hypothyroidism

Question 8

SLE: CFx

Answer 8

GENERAL: cushingoid, weight, mental status
HANDS: vasculitis, rash, non-erosive arthropathy
ARMS: livedo reticularis, purpura, proximal myopathy (disease or steroids)
HEAD: alopecia, scleritis, mouth ulcers, butterfly rash, CN lesions, cervical adenopathy
CHEST: pericarditis, pleural effusion, ILD
ABDOMEN: hepatosplenomegaly
HIPS: aspetic necrosis
LEGS: feet (red soles, small joint synovitis), rash, ulcers over malleoli, proximal myopathy, neuropathy, cerebellar ataxia

OTHER: urine analysis (proteinuria), blood pressure (HT), temp chart

Question 9

Scleroderma: CFx

Answer 9

CREST = calcinonsis, Raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia

GENERAL: bird like facies, weight loss
HANDS: calcinosis, atophy of distal tissue pulp (Raynauds), sclerodactyl, telangiectasia, dilated capillary loops, small joint arthopathy and tendon crepitus, fixed flexion deformity, hand function
BP
ARMS: skin tightening or thickening, pigmentation, vitiligo, hair loss, proximal myopathy
HEAD: alopecia, eyes (anaemia, difficulty with closing), mouth (puckered, difficulty opening), pigmentation, telangictasia, neck muscle wasting and weakness
DYSPHAGIA
CHEST: tight skin, cor pulmonale, pericarditis, failure, ILD
LEGS: skin lesions, vasculitis

Other: urine analysis (proteinuria), temp chart (infection), stool examination (steatorrhoea)