Rheumatology Short Case

Question 1

Back Exam

Answer 1

1. General inspection
2. Look
   - deformity
   - kyphosis
   - loss of lumbar lordosis
3. Feel
   - each vertebral body/muscle
4. Test function
   - finger/floor distance
   - extension
   - lateral flexion
   - rotation
   - modified Schober’s test
   - occiput-to-wall distance
   - spring the ASIS (for active sacroiliac disease)
   - palpate sacroiliac joints
   - in prone position - examine for Achilles tendinitis and plantar fasciitis
5. Examine other joints
   - knees
   - hips
   - shoulders
6. Extra-articular manifestations
   - uveitis
   - decreased chest expansion
   - aortic regurgitation, mitral valve prolapse, conduction defects
   - IBD
   - psoriasis

Question 2

Scleroderma

Answer 2

1. General inspection
   - “bird-like” facies
   - weight loss
   - pallor
2. Hands
   - calcinosis, Raynaud’s (atrophy of distal tissue pulp), sclerodactyly, telangiectasia
   - skin thickening (above or below elbow) - limited skin can also be due to diffuse scleroderma on treatment (softens)
   - dilated capillary loops
   - small joint arthropathy
   - fixed flexion deformity
   - tendon crepitus
   - hand function
3. Arms
   - skin thickening
   - pigmentation
   - vitiligo
   - hair loss
   - proximal myopathy
4. Blood pressure
5. Head
   - alopecia
   - eyes - anaemia, difficulty closing, dryness, loss of eyebrows
   - mouth - puckered, difficulty opening (measure with a tape), dryness
   - pigmentation
   - telangiectasiae
6. Ask about dysphagia
7. Chest
   - Roman breast plate
   - heart - pulmonary hypertension (loud P2, palpable P2, RV heave, elevated JVP - V waves)
   - pericardial effusion
   - lungs - fibrosis
8. Abdomen
   - pulsatile liver
   - faecal overload
   - cachexia
9. Legs
   - skin lesions
   - vasculitis
   - small joint arthropathy
   - patellar crepitus
10. Others
    - urinalysis
    - temperature chart
    - stool exam (steatorrhoea)
    - cancer elsewhere

Antibody

• ANA (anti-centromere pattern - pulmonary HTN)
• ENA (SCL-70 - ILD)
• RNA Polymerase III - renal crisis
• U1RNP - MCTD (main differential)