Rheumatology shorts Flashcards
Hand exam
-Salient
-General inspection
-Look
-Feel and Move
-Function
-Other
Salient:
- diagnosis
- disease activity
- function
- extra-articular features
- treatment
GENERAL INSPECTION:
-cushingoid, weight, iritis, scleritis etc
-other joint disease
-gait aids
LOOK:
-Dorsal aspect:
. Wrist- skin (scars, redness, atrophy, rash, scleroderma with sclerodactyly), swelling (distribution), deformity, muscle wasting.
. MCP- deformity (ulnar deviation, volar subluxation)
. PIP/DIP- deformity (swan neck, boutenniere, Z-thumb, sausage-saged)
. Nails (psoriatic changes- pitting, ridging, onycholysis, hyperkeratosis, discoloration, splinter haemorrhage/periungal infarct = vasculitis, clubbing).
. Psoriatic rash (extensor surface joints, scalp and peri-umbilicus, dactylitis, pitting or onycholysis)
-Palmar aspect:
. Skin- scars, palmar erythema, pale palmar creases, discolouration
. Small muscle wasting
FEEL and MOVE PASSIVELY:
-Wrist (synovitis, effusions, range of movement, crepitus, ulnar styloid tenderness)
-MCP (subluxation)
-PIP/DIP (palmar tendon crepitus, subluxation / deformity)
-Carpal tunnel syndrome tests
. ?Active synovitis (boggy tenderness or effusions)
. Restricted movement
HAND FUNCTION:
-Grip strength
-Opposition strength
-Key grip
-Practical ability
-Peripheral nerves (intact on brief screen)
OTHER:
-Other joints
. Elbows (subcutaneous nodules, psoriatic rash)
. Feet (enthesitis with psoriasis)
. Cervical spine (decreased ROM)
. Axial involvement (schober’s, occiput to wall, sacroilitis)
-Signs of systemic disease or steroid complications (cushingoid appearance, bruising, skin atrophy, cataracts, proximal myopathy ?injection marks to suggest biological use).
Rheumatoid arthritis
-stiffness >30min mane
-ulnar deviation
-wasting
-swan neck / boutennaires / z-thumb deformity, non-correctible
-subluxation of MCP / ulnar
-Extra-articular features: CAR PIPES
-XR: LOSED
Extra-articular features:
Cervical myelopathy OR peripheral nerve entrapment (atlantoaxial joint)
Anaemia, Vasculitis, AR
RA nodules
Pericarditis, parotitis, mouth ulcers
ILD/interstitial nephritis
Pleural effusion
Episcleritis
Splenomegaly
XR RA (LOSED)
Loss of joint space
Osteopaenia (juxta-articular)
Soft tisssue swelling
Erosions (marginal/bony erosions)
Deformities
Osteoarthritis:
PIP, DIP and 1st CMC
Herbedens (DIP) and Bouchards (PIP)
Knees, hips
OA: Hand XR LOSS
(also haemochromatosis = 2nd and 3rd MCP)
OA (LOSS)
Loss of joint space
Osteophyte
Subchondral cyst
Subchondral sclerosis
Scleroderma exam
Complete- vital signs, resp/cardiac exam
. Limited- face + peripheral skin thickening, PAH.
. Diffuse- diffuse skin involvement, ILD and renal.
General inspection: scleroderma facies, portal O2 (IWOB), pallor.
Hand exam (contraction deformity fingers with- )
- Sclerodactyly extending to ?mid-forearm
- Calcinosis
- Raynauds, finger pulp atrophy (ulceration, cold)
- Telangiectasia
FUNCTION
-grip strength
-pincer grip
-opposition grip
-button/jar lid
OTHER
-Peripheries: calcification elbow, extensor surface arms
-Joints: shoulders, elbows, knees, ankles
-Face: decreased mouth opening, unable to close eyes, telangiectasia, dry eyes/mouth, alopecia
-Chest: skin thickening, decreased chest expansion, fine crackles, pulmonary HTN (RV heave, loud P2)
-Abdo: hepatomegaly (primary biliary cirrhosis)
-Legs: skin tethering and ulceration
Complications of scleroderma-
ARMS-
-HTN, fistula secondary to ESKD (renal)
-proximal myopathy
CHEST-
-pulmonary HTN
-pulmonary fibrosis
-cor pulmonale
-PEG/stoma suggesting esophageal dysmotility
Summary: limited diffuse scleroderma complicated by ILD, pulmonary HTN, HTN complications.
DDx: mixed connective tissue disease, GVHD, nephrogenic systemic fibrosis
Ix:
Diffuse
. Scl-70 = DcSSc
. Topoisomerase-1 ab= ILD, renal, serositis
. RNA polymerase III (severe skin, GAVE, renal crisis)
Limited-
. anti-centromere = LcSSc (PAH, CREST)
anti-U1RNP = MCTD
anti-PM/Scl = myositis overlap
Complications:
. Renal (UEC, urine)
. Pulmonary HTN (PFT, ECG, TTE)
. ILD (PFTs, HRCT)
. GORD, dysmotility = GI Ix (gastroscopy, esophageal manometry)
Note GAVE= gastric natural vascular ectasia (IDA, anaemia, GI bleeding).
Back exam
-Look
-Feel
-Function
-Activity
-Extra-articular manifestations
LOOK:
-undress to underpants and stand up
-deformity (back and side, kyphosis, loss of lumbar lordosis)
-gait aids
FEEL:
-tenderness (spinous processes and facet joints)
-sacroiliac joints (pain = active disease)
MOVE:
-lumbar spine (modified schober’s test was abnormal <5cm flexion)
-extension/lateral flexion were abnormal <10cm
-thoracic spine (decreased ROM rotation, reduced chest expansion)
-cervical spine flexion (decreased ROM 45 degrees), extension, lateral bending (45 degrees) and rotation.
-Occiput to wall test (normal/abnormal)
ACTIVITY:
-spring anterior superior iliac spine (active sacroiliac disease).
-achille’s tendinitis (heel) and plantar fascitis.
-knees, hips and shoulders.
EXTRA-ARTICULAR MANIFESTATIONS:
-Lung: apical fibrosis
-Heart: AR, MVP, Conduction deficits, ICD
-Eyes: uveitis
-Gastrointestinal system: IBD, amyloid (hepatosplenomegaly)
-Psoriasis (scalp) OR reactive arthritis
-Hand/knee/hip: small joint arthralgia (psoriasis)
-Cauda equina compression (back, buttock and leg pain + sensory loss saddle + lower limb weakness + loss of sphincter control)
Complications of immunosuppression-
-steroid complications (cushingoid appearance, bruising, skin atrophy, cataracts or proximal myopathy)
-injection marks secondary to biologics
OTHER INVESTIGATIONS:
-MRI
-Serology: HLA-B27 status
-Inflammatory markers: CRP, ESR, FBE (anaemia), albumin (chronic inflammation)
DDx deforming polyarthropathy (6)
RA
Seronegative arthropathies (psoriatic)
Polyarticular gout (look for tophi) or pseudogout
Primary generalised osteoarthritis (DIP/PIPJ involvement is common)
SLE
Jaccouds arthritis
DDx seronegative spondyloarthropathies (4)
Ankylosing spondylitis
Psoriatic spondylitis
Reactive arthritis (reiter’s syndrome)
Enteropathic arthritis
DDx DIPJ spared (3)
RA, SLE, Jaccouds arthropathy
Note on Jaccouds arthropathy: ligament laxity, chronic non-erosive process in the context of different arthropathy (including SLE, psoriasis, IBD and malignancy).
DDx DIPJ involved
Nodal osteoarthritis
Gout
Psoriatic arthritis
Sausage shaped + telescoping
Psoriatic arthritis
Reactive arthritis
SLE:
-malar, discoid rash with livedo reticularis
-cushingoid features
-hand rash sparing knuckles, symmetrical minimally erosive arthritis, jaccoud arthropathy
-nails: nailfold infarct, dilated capillary loops
-head/neck: alopecia, telangiectasia, mouth ulcers
-eye: scleritis, episcleritis or anaemia
-abdomen: hepatosplenomegaly
-BP: HTN and peripheral oedema ?renal disease
Hand XR: NOSD
Extra-articular manifestations
RASH ON MAIDS (young woman with rash)
-also, SLE classification criteria
Hand XR: NOSD
Non-erosive
Osteopenia / osteoporosis (juxta-articular) +/- osteonecrosis
Soft tissue swelling
Deformity
SLE extra articular manifestations:
Renal (proteinuria, active urine sediment)
Arthritis (>2 joints)
Serositis (pleurisy or pericarditis) OR pulmonary fibrosis
Hematologic (pancytopenia, hepatosplenomegaly)
Oral or nasopharyngeal ulcers
Neurologic (seizures, psychosis)
Malar rash
ANA positive
Immunologic (dsDNA, Smith, false + RPR, LAC, ACLA)
Discoid lupus
Sun-sensitive rash
Gout: Extra-articular manifestations (3)
DDK
Diabetes (and metabolic syndrome with obesity, insulin use)
Diuretics (thiazide, fluid overload)
Kidney disease (high urate level)
Psoriatic arthritis
Clinical features
SPAR
. Stiffness (inactivity) / Swelling / Sausage (dactylitis)
. Pain in joints (small joint arthropathy)
. Axial spine (seronegative spondyloarthritis)
. Rash (scalp, hairline or umbilicus psoriatic plaques).
Gout: Hand XR
TOES
Mx: urate lowering (allopurinol or febuxostat), diet and lifestyle (weight loss, avoid alcohol)
TOES
Soft tissue swelling
Periarticular EROSIONS (“punched-out” (rat-bitten) overhanging edges
SclerOTic margins
Tophi (calcified in renal disease)
Psoriatic arthritis: Hand XR
Other- plantar fasciitis, achilles tendonitis, spondyloarthritis
Joint space narrowing with ankylosis
Fluffy periostitis
Marginal erosisons leading to pencil in cup deformity, telescoping and arthritis mutilans
Distal tuft resorption
Soft tissue swelling
Inclusion body myositis
. epidemiology
. clinical features
. Ix (muscle bx - inclusions in vacuoles, mononuclear infiltrates)
. Older adults (men >50yo)
. Progressive, asymmetric muscle weakness proximal to distal (finger flexors, wrist extensors, quadriceps (ant thigh) + dorsiflexion (ant tibial) )
. dysphagia
