Rheumatological system

History :

pain & swelling :

- SOCRATES
( radiation is important )
(Acute or chronic )
(they get better or worse --- Rest Rheumatoid Arthritis
exercise osteoarthritis
( single joints osteoarthritis or multiple Rheumatoid Arthritis )
- Remember Arthralgia : pain without swelling .
Arthritis : pain with swelling .

Moring stiffness

- length of time (lasting) for severity

- remember there is also stiffness after inactivity
Morning Rhaumatoid Arthritis
Inactivity Osteoarthritis

Deformity :

-if there has been progressive change in shape of area is more likely significant

 Instability

- Pt words (says) giving way or coming out .

- may due to dislocation : 1-shoulder. 2- knee (patella).
- or may due to muscle weakness or ligaments problem .

Change in sensation

12-

nerve entrapment , injury or ischemic

Ask about :
numbness
paraesthesia (pin or needle )

Back Pain
-SOCRATES
(aggravated by 1-movment 2-coughing 3-straining)
-REMEMBER
musculoskeletal pain : localize & aggravated by movement
spinal nerve root irritation : dermatomal distribution (?)
1234-

-Causes of progressive & unremitting pain :

Osteoporosis
Infiltration carcinoma
Leukemia
Myeloma
-Causes of sudden pain :
1-crush fracture of vertebral body
# in Ankylosing Spondylitis :-over sarcoliac joints
-over lumber spine
-worse at Night
-get better by Activity (help to distinguish )

Ankylosing Spondylitis
is a chronic inflammatory disease of
the axial skeleton with variable
involvement of peripheral joints and
nonarticular structures where
immune mechanisms are thought to
have a key role. It mainly affects
joints in the spine and the sacroiliac
joint in the pelvis, and can cause
eventual fusion of the spine
symptoms : (uveitis), causing
redness, eye pain, floaters and
photophobia

Dissection of Abdominal & thoracic Aorta aneurysm cause back pain .

Limb Pain

Can occur from diease of :

1-musculoskeketol system (causes)
- Trauma
- Inflammation
- polymyositis (aching pain in proximal muscle around shoulder & hip. +
weakness )

- polymyalgia rheumatic (pain & stiffness in shoulder & hip . + age 50 | )

Bone (causes) :
Osteomyelitis
Osteomalacia
Osteoprosis
Tumors

Tender :
-tenosynovitis (local pain)

Osteomalacia:
Bone mass
variable,
Mineralisation
decreases

2- vascular system
Acute Atrial Occlusion
Sever pain , sudden onset , coolness & pallor

Chronic Periperal Vascular disease

Calf pain on exercise & relived by rest
Called also intermittent claudication (*)

Venous Thrombosis
Diffuse aching pain in legs & swelling

Osteoporosis:
Bone mass
reduced,
mineralisation
normal

(* spinal stenosis can cause psudo-claudication pain on walking but relived by

leaning forward .)
Sublaxation
incomplete or partial
3- nervous system
dislocation of a joint or
pain associated with paraesthesia or weakness
organ
Causes :
Mononeuritis multiplex
1 synovial thickening or joint sublaxation
is a painful, asymmetrical,
especially with Rheumatoid Arthritis
asynchronous sensory
2 vasculitis associated with inflammatory arthropathics
lead to diffuse peripheral neuropathy or mononeritis multiplex

and motor peripheral

neuropathy involving
isolated damage to at
least 2 separate nerve
areas

3 chronic Rheumatoid Arthritis

often develop subluxation of the cervical spine at Atlanto-axial Joint
this caused by erosion of transfere ligament around posterior aspect of
odontoid procedd (dens)

4 Injery to peripheral nerve can result in vasomotor changes & sever limb
pain .

4 - skin

Raynouds phenomenon
-

Is an abnormal response of the fingers & toes to COLD .

Fingers turn first to white Blue Red .
Red = pain most severs
White = also severe due to ischemic
Causes
1- Familial
2- Scleroderma (connective tissue diease )
may lead to Digital ulcers (complication)

Dry Eyes & Mouth

Sjigrens syndrome
- Pathology : mucus-secretion glands become infiltrated with lymphocyte &
plasma cells which cause atrophy & fibrosis .
- Very common assocated with Rhaumatoid Arthritis & other connective tissue
diseases
- Effects:
Eyes conjunctivitis & keratitis .
Lung .
Kidney .

Red Eyes
-

Seronegative spondyloarthropathy & Bechcets syndrome (but not

rheumatoid arthritis ).
Complicated by Iritis
Seronegative spondyloarthropathy
Bechcets syndrome
is a rare immune-mediated smallvessel systemic vasculitis that often
presents with mucous membrane
ulceration and ocular problems

Group of multisystem inflammatory disorders

affecting various joints, including the spine, peripheral
joints and periarticular structures
Associated with extraarticular manifestations
There are four major seronegative
spondyloarthropathies:
1-Ankylosing Spondylitis , 2-Reiter's Syndrome , 3Psoriatic Arthritis, 4-Arthritis of Inflammatory Bowel
Disease

Systemic symptoms
Symptoms occurred with Rhaumatological diease :
1- fatigue ( commin with connective tissue diease )
2-weight loss & Diarrhea (scleroderma)
3-mucosal ulcers (SLE)
4-Rash
5-Generlized stiffness (Rhaumatoid Arthritis or scleroderma )
6-Fever (SLE) (infection should always excluded)

Past History

history of tick bite lyme diease

IBD Arthritis
Smoking Rhaumatoid Arthritis

sexual history is important ( Gonorrhea )

Occupational

Social History

Family History
-

Rhaumatoid Arthritis
Gout
Primary osteoarthritis
Heamochromatosis
Serongative sponlyloarthropathy
IBD
Hemophilia

Examation Of The Hand & Wrist

Anatomy

1st : Explain the examination for the patient :

I will see your hands , then I will feel every joint individually , then I will ask
you to do some movement .
2nd: Do you have any pain ?
3rd : Ask the patient to put his hands on pillow to start the inspection .

4th : Inspection :
Skin scars (pervious surgery \ trauma )
Redness (palmr erythema)
Atrpthy
Rash
Nail Psoriatic changes ,
onycholysis
discoloration

Psoriatic changes

onycholysis

Deformity ulnar deviation

Valor subluxation

Thenar \ Hypothenar wasting carpal tunnel syndrome

Dupuytren's contracture Alcoholic liver disease , DM
Swelling
#REMEMBER :
(after that you can inspect the elbow for Rhaumatoid nodules & Psoriatic
plaques .. and palpate for them because may they be subcutaneous)
(if there any abnormality make sure if its symmetrical or not )

5th : Palpation (Feel)

Temperature RA \ septic Arthritis
Thenar \ Hypothenar wasting
Palmar thickness
Radial pulses (atrial occlusion)
Metacarpophalangeal joints (MCP) squeeze
Nerve sensation (Radial , median & ulnar ) (patient should close his eyes)

Palpate the Joints

start with the wrist to the distal joints of the fingers
you palpate for any swelling , fluctuance & tenderness
dont forget to palpate the scaphoid for any tenderness (snuff-box)

6th : Active move

Active wrist extension .
Active wrist flexion .
Active finger flexion & extension .
Move the hands from side to side .

7th : Passive move

passive wrist extension & flexion feel for crepitus
passive finger flexion

8th : Assess the power (Function)

Finger extension with resistance (radial nerve C7 & C8).
Finger abduction with resistance (ulnar nerve = C8 T1).
Thumb abduction with resistance (median nerve =C8 T1).
Power grip ( squeeze my finger ).
Pincer key grip ( squeeze my finger ).
Pick up a small object .
Testing opposition strength .

9th : Special test

Tinels test ( tap over carpal tunnel ) tingling suggest median nerve
compression .

Phalens test flexion of the hand for 30 seconds (+ve of there is

paraesthesiae) for carpal tunnel compression.
10th : Thank the patient
11th : Summery
- in inspection no obvious abnormality (you can say examples).
- in palpation there was no increase in temperature & no tenderness in the
joints of the hand .
- sensation was normal with normal range of movment of the hands .
- To complete my examination I want to examine the elbow and if there any
abnormality I will chick by Radiograph .

The Knee Examination

Anatomy

Exposure should be to the meddle of the thigh (actually to the inginal) .

Position of the patient in the bed = Supine

1st : Inspection :
Walking / gait (niccholas mentioned as the last thing to do )
Quadriceps wasting
Skin changes , scars , deformity , swelling
Varus (bow leg) osteoarthritis
Vagus (knock knee)RA
Fixed flexion deformity - the affected knee will often be flexed

fixed lumps in the line of the joint may be meniscal cysts

Knee effusion is usually seen medial to patella
peripatellar grooves may be an early sign of an effusion
if there is patellar subluxation it will slip laterally during knee flexion

2nd : Palpate feel:

Quadriceps tendon
Warmth
Tenderness
synovial swelling
patellar tap (large effusion)
Bulg\sweep test (smaller effusion)

3rd : Move (active)

Ask the patient to lie supine
flexion
Extension

4th : Move (Passive)

Flexion (135 degree) look for crepitus
Extension ( 5 degree) look for crepitus & hyperextension

Collateral ligaments ( > 5 degree is abnormal)

(.. if its stable repeat with knee flexed to 30 degree)
Cruciate ligaments (>5-10 degree is abnormal )
-Anterior drawer test if its increase indicate anterior cruciate ligamentous laxity
-posterior drawer test indicate posterior cruciate ligamentous laxity
# remember to sit on the patient feet to fix them .. the knee should flexed 90 degree.

Patellar apprehension test (push the patella laterally then flex the knee)
+ve (anxious face indicate dislocation

McMurrays test :
- supine position
- the doctor stands on the side to be tested and holds the ankle
- the docrot other hand sits on the knee (joint line) pushes to apply valgus
force .
- the patients leg is then extended from the flexed position while being
internally and then externally rotated
- the test +ve if there is popping sensation which followed by inability to
extend the knee .
- this test detecting a meniscal tear .

Ask the patient to lie on his abdomen (prone position)

look for a Bakers cyst

Apleys grinding test :

Do flexion of the leg then rotate the leg with pushing inward the knee
tenderness & clicking = +ve test
this test detecting a meniscal damage .
distraction test
similar to Apleys grinding test except here will be pulling outward

After that ask the patient to sit on the edge of the bed or on Chair and then ask him to
stand up without using his hands or you can do squat .

5th : Thank the patient

6th : Summery :
in inspection no obvious abnormality (you can say examples).
in palpation there was no increase in temperature & no tenderness in the
joints of the knee.
normal range of movment of the knee .
To complete my examination I want to examine the joint of above and below ,
if there any abnormality I will chick by Radiograph .

By : Abdulaziz AlHawas