_—— rT Clinical Internal Medicine On Rheumatology New_Bdition_2019_7029 Scanne d with CamScannerNo Contents / I Fmamine hand of Rheumatoid ara. _ BeExamine Ret of: Rhevngto 3. Examine Knee | 3 —— 7 fe* ‘Examine head ana neck of SLE- 4 Ege ins lerosi 6 Examine Hand in-systemic sclerosis 7 Igspect bak £ Pepfornn@ceiprigowgllfieste $ Exaniine lumbar spine ¢@ Examine sacr oiliac joint An kylosing examination in details 3 > Important OSCE Questions on --” Rheumatology with answers Scanned with CamScannerExamine Hand of Rheumatoid arthritis *” | #Technique: the pationt and stand on his right side (0.5 mark) xplain the procedure to the paticnt (0,8 mark) 3) Inspection \ 1 Skin: color, nadutes (1 mark) elling s & Delormities (1 mark) Aatus and power CL mark) 4) Palpation O Temperature (1 mark) O Swelling (1 mark) © Tenderness (0.5 mark) O Abnormal sounds (0.5 mark) 5) Movements 2 marks 0 Make fist O Grip O Pinch O Prayer #Comment: A. Inspection 1) Skin > palmar, efsthema, thin trophic skin, dilated veins, nodules, purpura, digital ulcers 2) Swelling-> PIP joint & MCP joint & Wrist joint 3) Deformities OG Ulnar deviation at MCP joint © Radial deviation at wrist O Zig - Zag hand (both ulnar deviation at MCP joint and radius deviation present at wrist at same time) © Swan neck > flexion of distal interphalangeal joint and extensi of proximal interphalangeal joint © Boutonniere sign > extension of DIP joint and flexion of PIP j GZ- shaped thumb Scanned with CamScanneroo “alg Shoal Chaal 4) a O Trigger fir Jia al y a il a at O Caput ulna = aio ( alla yA Piano sign ~ When you press on caput! ulné 1, it will be depressed then, rel , ley Again asa piano ys ni Due to sublaxation of ulna small muscles wasting i P muscles = due to RA & Contieasteroid & denervation of muscles ~ muscle affected > interossei (al supplied by deep branch of Ulnar nerve & their action: flex MCP and extend IP joints and thus help in Writing) & Thenar and hypothenar muscles B. Palpation 1) Temperature > denote active inflar 2) Tenderness > squeeze for MCP join present 3) Swelling of joints Jaais JS se BES 4) Crepitus > put your palm on joint while crepitus underneath it C. Movement . 1) Make fist > instruct patient to make a fist which mean all fingers are closed so that terminal phalanges are hidden in palm and thumb eros rstyloid process ammation if increased { > denote active inflammatig, it is inaction, you will fa them 2) Grip > instruct the patient not to let your fingers out of his hands by tightly closing on them : — 3) Pinch > instruct the patient to encompass your index with his thumb and index and let your release it leit U) Slats dat jue 3 plo dex 4) Prayer sign > instruct the patient to put both palms face to face, dorsiflex his wrists as much as he can 5) Reverse prayer sign > instruct the patient to put both palm back to back, and flex his wrists as much as he can 6) Fallen’s test > ask patient to niaintain reversed prayer position for}! seconds > tingling or numbness (carpal tunnel syndrome) 7) Tinnel test > tap on flexor retinaculum > numbness — ~ —_— Scanned with CamScannerExamine Feet of rheumatoid arthritix | A. With patient s ing 1) Deformity of ankle (valgus) 2) Longitudinal arch (flat foot) B. Inspection 1) Skin > erythema and sears 2) Swelling > ankle & PIP & MTP 3) Callositics, muscle wasting, nail changes 4) Deformilies - Hallux valgus > deviation of big toe away from midline - Deviation of other toes towards the midline ~ - Loss of plantar arch (flat foot) - Hammer Toe - Claw Toe C. Palpation 1) Temperature 2) Swelling 3) Tenderness > squeeze for joints, tendon Achilles 4) Nodules , D. Movement 1) Ankle > dorsiflexion, prantar flexion 2) Foot > inversion, eversion at subtalar joint | 3) Toes > de~*Aexion and plantar flexion | Examine Knee | A. Inspection _L) Skin > erythema, scar, sinuses 2) Muscles > muscle wasting (Quadriceps muscle) 3) Joint > swelling - Pre - patellar bursa - Bacl er cyst in popliteal fossa - Knee effusion (DD > House maid knee , cellulitis, R.A) Scanned with CamScannerA) Joint > Deformity (an standing) - Gent valu (knoek knee) - Gent varum (Baw le ~ Flexion deformity B. Palpation 1) Temperature 2) Tenderness 3) Swelling > Joint we C. Tests used to detect fuid in knee foi U 1) Patellar tap > empty suprapatellar m of ind patells > press -lown briskly will fusion po 2) Bulge sign > for smaller volume ¢ rich & stroke over the hollow g, 3) Ripple test > empty suprapatellar pn he opposite hollow and feel side of patella & Watch the filling of the intil you reach upper edg,. {ex > tapping sensation a7 / i i /t ol fosss for backer test : alpate popliteal fossa > for oo. — © Crenitee 3 feeling the joint with hand while joint is moved passively other hand , oo. ¥. Movement ~> flexion and extension of knee joint Scanned with CamScanner#Iimportant OSCE Notes 1) How to differentiate between backer cyst and DVT > By Duplex U/S and MRI | 2) Causes of joint effusion | > Rheumatoid arthritis > Osteoarthritis 3) Crepitus present in > Osteoarthritis 4) Limited movement seen in > R.A, Osteoarthritis, meniscal tear Examine head and neck in SLE A. Head 1) General look > Cushinoid due to corticosterpids treatment 2) Scalp hair > Alopecia (hair loss) : - Diffuse Hair loss > reversible after disease activity controlled - Discoid (patchy) hair loss > i irrever sible (cicatricial) 3) Skin c - Malar rash (butterfly if involve nasal bridge) > fixed erythema, flat or raised sparing nasolabial fold ‘ity (abnormal reaction to sunlight) aangiectasia, pigmentation ve brow > loss of outer 1/3 (associated autoimmune hypothyroidism) elid > Pully (lupus nephritis) ve > associated sjogren syndrome 5) Nose > epistaxi: 6) Oral cavity > painless oral ulcers (if painful > 2ry infected due to candida infection and immunosuppression drugs) B. Neck 1) Lymphadenopathy 2) Congested neck veins 3) Goiter > autoimmune hashimoto thyroiditis or Grave’s disease Scanned with CamScannerrole sclerosis 1) Greet the patieatand stind on his rieht side 2) Pyphiin the procedure to patient 3) General look => younger than her ape 1) Sealp hair > hairloss (alopecia >) Skin loss of forehead wrinkles = creases ~stretched, shiny, adherent to subcutaneous tissue (loss oF f expression) ~ Tek tneiectsia Oy Nose 3 raking) > Pinched nose with narrow elongated nostril (beak 7) Mouth Vertical furrews around mouth fish like mouth sina oral opening k patient to open her mouth > Gum atrophy, prominent teeth, then alc ) Bye > pully evelid, dry eve mie > sel resis 1) Greet the patient and st stand on hi rights 2) Explain the procedure to patient — 3) Inspection Skin ~ stretched. shiny, adherent to under ~ Raynaud's phenomenon - Telangi af syst ving structure ~ Selerodactyty - Hlesion deformity of fingers Shortening ‘phalans _ Scanned with CamScanner alt and pepper appearance + diffuse tanning of- Digital pitting sc ~ Digital uleers : Whe Shychomyeosis Dp Paluition S$ muscle wasting GO Skin - firm (hard in calcinosis) - Tightly adherent (tethered, taut) - Cold in {temperature (Raynaud’s phenomenon) - Dry skin 5) Movement > limited (Active and passive) - unable to make fist - weak hand grip - Pinch (ring) test > unable - Tests for carpal tunnel syndrome ~. prayer, reversed prayer, tinel, phalen tests ; iS ail dystrophy , clubbing Inspect Back 1) Greet the patient and stand on his right side 2) Explain the procedure to patient 3) Examination, > while sanding (From the back) i. Head posture ii. Cervical spines > prominent C7, cervical lordosis iii. Shoulders > levels and shane iv, “Vertebral column position (nudline or scoliosis) _y.: Paravertebral muscles (wasted or spastic) vi. Scapula vii. Sacral dimples 4) Examination > while standing (from lateral view) i. Spine curvature (scoliosis, loss of lumber lordosis) ii, Spine deformities (kyphosis, head stooping) Scanned with CamScannerll test I> i erform occiput to wall ™ ght side 1) Greet the paticnt and stand on his Mi Fo 2 Pyplal the procedure to patient ! strai 3) The patient stands against wall, remove shoes ane straight bach, 4) Localivation of the oceipul |S) Measure with a tape the distanee fron 1 the occipul to the wal = Questions: | N Whatis the normal for thi . (2) How the test could be utilized? es Examination of lumbar spin | 1) Greet the patient and stand on his right side | 2) Explain the procedure to patient | 3) Inspection > deformity, skin, muscle status | 4) Falpation > tenderness, spinal process (tenderness over intervene. dise or spacing) : 5) Movements > flexion, extension, lateral bending 6) Tests > Schober test, finger to floor test |Excarmine sacroiliac joint | 1) Greet the patient and stand on his right side 2) Explain the procedure to patient 3) Elicited pain by - Direct compression on sacroiliac joint - Pelvic compression with the patient on one side | - Localized tenderness on Posterior superior iliac spine (PSIS) 4) Specific tests - Gaenslen’s lest - Pump handle test - Patrick test fo _- Scanned with CamScannerA. Inspect Back Q) hak VU 6s Curvahres ev : . Ole 2h spine ehfemttes ral in AS. lossg normal? Gy beidosva i “ory gid | gence nile Sth, 7 pasha (E, ~ Kamenthed Rowatic iipphesis ( eth aa®) 2 J ete anata © = tes g Royal fambor lardasea _, abil be ‘ |e Semeratt ewer HOD (linnbee SpincFlaber Siesuld } =. Exaggerated thoracic kyphosis “AS + Hypessn tatien rhe Chaar eg. bn-osth, COPP rofdage + Taume » Aesnegely - Exaggerated lumbar terdoius — Pee sanly , obvily | D Back view — — Heael pasihion > Griad, Stoops 1. Shoulder - leye) ~ equal ot aoi” | \ Shape .- Aocoelecl ot olor exacting | 2. Spine, 7 Prminent Cz Cand tran + | \ pesitien —- midlline | Scoiesia 2 3- $Kin -— Stu G pruvites epesnhion 62. Dist prolapse aise Sign easnnunlvog 4, sk. muollty — murtth waoking Jour Spaom ; cop. ~Posaveateotsl ouactea supaS pads — rluscles aaeewed Seapulr asymmetiical of not ((b3n lw ecet asymimetitcal atool side ) i : 7 . yy pevill pb A A 2 Mid line spine oF scoliosis (acl | yyrull Galli teak) Vy geri a uP A) 3- prominent C7 (GG Grind il 4- winging oi scapula or not (jail serratus ant niuscle 5- any scars present . 5- wasting of paravertebral rrius # Sacral dimples (s gy) Hagel poy Aad GaUSe dt wasting of (Sy yb gle cit paul ged weil) DT, ental y iy!) Volks aS yu from lat view 1- kyphosis esp thoracic vertebrae other causes of kyphosis (aortic stenosis Old age , acromegaly , trauma , hyperinflation of lung - Oronchial asthma and COPD- ) 2- loss of normal cervical lordosis o:her causes of exaggerated lordosis ( pregnancy , obesity ) Examine cérvical vertebraopam Ses TLM y chia gs AES Grell (JL Ga | Que Gey / lilly Dyas Gulf GEN Guay Gall Jy sil eallicll deity GIS jal sist tests for cervical vertebrae 1- occipul to wail test . | BE Nid cael lead Gath 8 5U Une 92 ote gl N95 Oe Uae i oll wl G3 a importance : - dernonstrate any cervical vertebrae pathology - used for follow up | MIStinhekarie em cnc ret ” 7 SEP chen Je Be Leth I gal Cussy chest J osly> ily sternum ¥ = sternum pi dally Quid aay call Jy 5% 038 any y Syl oe pw Be SI pds ays shall assy, ; elles Says J} sie 4 : bos gis 0S sey oly js aid ob Al 5d " td aS yap d ya f8) all te ght J Scanned with CamScannerLiled: cdot daogy aks Aly sth oat ss OI Gils gt gfe yr ag. ae kien } ule shoulder ch oad cube ot tests for lumbar verlehren ° ”) Jun ban vortoinie) Sacral uinplow=e on yeatiae band i bath te Al | Ss go gp 15 & Hy th Si we Lb 3 “ MS - we VW kee NMI oat ail y implesal 2 10 uae ceady sely pee J ate 20 ale aw 10 ‘sins plied es 3-finger to floor t FT Dany sally del Gh we sails fA movable joint 2 dais dst testdael Is baat 36 cule: direct pressure on sacroiliac joint ys peal JY Aub JSil antl Jot ot 2 hyper extension Us 11 GG gaensien , gill - 2 hyper flexion 4s Vl PP patrick , pump handle test - 2 other : pelvic compression , pelvic eversion direct pressure on sacroiliac joint, straight !eg raising test alt de tly ipression , pelvic eversion , Gaenslen test tnd Gist Yy tall Gd vy + bilateral joints in PPG pelvic coi - ipsilateral joints in Gill test, pump handle test > contralateral joint in Patrick test Scanned with CamScannersl oo Manca N Ny Aube oe al Wei, FVE gies ply ue gh Lattat Sa! Sag slpesien le ale jee Suot mech 4 (2 La - iy i 6 PTS Wl: | ce non. apiobti os Porat t . Tein \ Direct - \ Pressure on Sacrailige Teiwt: {toate forvanadt Mouch wall by dll \th | Yous otiput on | vam) ES xo ied 7 pes “Bat Ac \) Je Knee extended Heel duchwatt — oS aa Weel = Solem Goensle, 4 1 fat. Scheber eccy taster tert test “Pat te wail test Scanned with CamScanner— oS OO lt——~—SC—S sO coutogde mer Lentle & banana. LAL Sarit beg revising Leak on babl« Ikvs teok Lea Ly, Ley S neave Avot | y Supine LO € POL (Cee Heel Shraj - Oh ree pat U Le, Co by tix Iles buip Passi veby ce seuhit abo indilafa & -¢ fours I 4 yaacl 't fear } | | 1 of mere CT Pain) > | Normeatty So" livitatiga Se Dorsiflenion F te | | ~ ¥ Disc pralapsc” q nave foots | — — ‘a Tension rele ved ley Flexo i of 1Be ICnce - = Scanned with CamScannerms On (important OSCE Question af inflammation finflammation (redness, hots oO il . Swelling, loss of movement ) «ation of movement (only 3) Peti - arthritis 3 joint pain with no fimitaltc n duc to stretch of limitation of active movement in one directo inflammatory structures) . 4) All patients with arthritis have arthralgia 5) Arig Rheumatological diseases a Young age (5 - 15 years) > rheumal 5 itis, S q Middle oe (15 OD eas) > Ankylosing spondylitis, SLE & (5 40 years) -> R.A, Reiter syndrome, GOUT O Elderly > Osteoarthritis 8) Sex in Rheumatological diseases O Female > R.A, SLE, Scleroderma G Male > Ankylosing, Reiter syndrome, GOUT 7) Morning stiffness > subjective feeling of inability to move freely after prolonged immobilization 8) Acute onset of joint pain (minutes, hours, days) > Rheumatic fever, gout, infective, traumatic.” 9) Insidious onset of joint pain (weeks, months) > R.A, Osteoarthritis 10) Acute onset joint pain (<6 weeks) > Rheumatic fever 11) Chronic onset joint pain (> 6 weeks) > R.A, SLE, Systemic sclerosis, Osteoarthritis 12) Arthritis + deformity > R.A 13) Arthritis with no deformity > SLE 14) Peripheral joints affection G Small joints of wrist, PIP, MCP > RA G Small joints of DIP > Psoriasis CJ Small joints of 1 MTP > GOUT ___G Large joints > Rheumatic fever, Ankyl 1 but not the reverse juvenile RA ' osing, Reiter, septic arthritis Scanned with CamScannerGon (8) Distal interphalangeal joints (DIP) joints alfected in Poort | Osteoarthritis 16) Symmetric arthritis > R.A, ST Scleroderma 17) ‘mmetri¢ arthritis 3 Sere -ve arthritis (Ankylasiag, Reiter syielon Psoriatic, Osteoarthritis) : 18) Migratory arthritis > Rheumatic fever, gonecoccal arlliritls 19) Additive (simultaneous) arthritis > R.A 20) Intermittent (episodic) arthritis > Gout 21) Pro ive arthritis > Systemic sclerosi Osteoarthritis 22) Regressive arthritis Rheumatic fever, Trauma GOUT. 23) Monoarthritis > one joint affection, occur in Septic art hritis, Trauma 24) Oligo or Pauci arthritis > 2 - 4 joints, occur in Sero -ve as an spondylitis, Reiter syndrome 25) Polyarthritis > > 5 joints, seen in R.A, SLE, 26) Arthritis response to treatment : - Dramatic response > Rheumatic. fever - Improved > R.A, SLE - Little improvement > Anky! 27) Constitutional symptoms (fever, fatigue, weight R.A, Systemic arthritis; Septic arthritis (Not Osteoarthritis) 28) Disease associated with morning sti fines ->1 hour 9 RA - < 30 minutes > Osteoarthritis | 29) Rheumatological diseases with oral or genital ulcers COSLE > Painless (unless 2ry infected) & Recurrent OC Reiter syndrome > Painless O Behcet > Painful 30) Eye affection in Rheumatological diseases O Scleritis, Episcleritis > R.A O Conjunctivitis (red eye, burning sensation) > Reiter syndrome O Uveitis > Ankylosing spondylitis (25%) kylosing Rheumatic fever losing, T.B, Osteoarthritis loss) seen in > SLE, 31)_Differentiate between, Rheumatoid arthritis & Osteoarthritis [ RA O.A Inflammatory Non - inflammatory Scanned with CamScanner34) In treatment of R.A % Methotrexate and lefluonamide are contraindication during pregnancy 5) Tests for muscle power in R.A > make fist, hand grip 6) Clinical signs of activity in SLE 3 3 1 Psychogenic SP hour 32) DD = causes of low back pain GC Inflammatory as ankylosing spondylitis 1 Mechanical as dise prolapse & sciatica G Metabolic > osteoporosis Neoplastic > multiple myeloma (7 Referred > pancreatitis 33) DD between inflammatory and mechanical low back pain 30 minnie: “tet Meta, Inflammatory.as AS M — echanical as Disc prolapse and sciatica | “Morning stiffness Onset Tnsidious Acute Duration > 3 months chronic <3 months acute Exercise Decrease pain Increase pain I Rest Increase pain Decrease pain > 60 minutes Few minutes or absen Maximal pain and stifthess Early in the day Late in the day |_ Response to. NSAIDs Good response Little response = alopecia - fever - weight loss - anorexia Scanned with CamScanneree ne. Rheumatology Dr Yakout 4 mos cs Of arthritis + Splenomepaly - Felty syndrome - Serum sickness syndrome ~ Sjogren syndrome - Thyrotuxicosis 38) Auto antibodies in SLE OANAS Sensitive, not specific OD Anii- ds DNA > less sensitive, more specific (indicator Anti Smith Ab > not sensitive, very specific Anti Ro, la Ab > sjogren syndrome Anti RNP > Mixed Connective tissue discase a Antiphospholipid syndrome > Anticardiolipin (IgG, Ip anticoagulant, AntiB2 glycoprotein + Thrombocytopenia O Decrease C3, C4 > indicator for activity Urine analysis > Proteinuria > 0.5 g/day + casts 39) I symptom of scleroderma > R changes on exposure to cold) | 40) Types of scleroderma - Limited cut: neck fora F), Lupus ‘aynaud’s phenomenon (triple color ‘aneous ~ limited to sites distal to elbow and knee ~ face - - Difluse cutaneous > Widespread on proximal and distal extremities ~ face + trunk +1) Sclerodactyiy means > tight skin over fingers 42) Serological markers for systemic sclerosis : Anti - topoisomerase (anti - scl 70) > in diffuse systemic sclerosis CG Anti - centromere Ab > in limited systemic sclerosis 43) Criteria of low back pain in Ankylosing spondylitis T Insidious onset and slowly progressive course Scanned with CamScannerCBC in RA: ness) or Iror 0 Anemia: normocytic normochromic (chronic illness) n defi anemia (GIT erosions from NSAIDs or steroids) Cieng :aciive disease 6 Thromboc ,tosi Felty syndrome 7 i Definition | Tvind ofa + splenoegaly + lenkopenta (newtropentt + Mixombeytepena) ero ve RA Risk © Longstannliny factors © Subcutaneous nodule © Exta-articular mantestitions Common > Splenomey clinical — | 4 Recurrent infections due to decreased neutrophilic count below 1OOo/muns | | findings © Lymphadenopathy. me fiisk oF NUL | JJasia of the liver, portal hypertension amd varices # Nodular tegenersbve hyper phas Nedul asenitis, elton weight loss non healing uh [iad Ye Nowtropenia, iomiveytepents, anemia (aormeestic nonieclromic) vey tanictiont tes | © Abnoual | fe Re pesive in Fos 7 | | | Trenttne nt ahnent of RAs splenectomy jon of the tibial nerve or its ciated branches as e Tarsal tunnel syndrome: compre. es anierneath the flexor retinaculum at the level of the ankle or distally the nerve pa ad on the tibial nerve Valgus deformity of the ankle put. ESR/CRP sions: Ant eainvest Scanned with CamScannerSs manthe. Coacratl O Chronic duration CF Site 2 Iumbosacral dow back pain) and relieved by exer” 1 Agpravated by 6 CO Good response to NSAIDS | hour CO Associated with muscle slifiness J Occur in male ~ 40 years old 44) Radiological changes in sacroiliac joint it OJ Punched out cro: C1 pseudowidening of j 0 Adjacent sclerosis OJ Bony bridging with compl 45) Radiological changes in spine in AS OJ Romanous sign oO Squaring of vertebral bodics o syndesmophytes (J Bamboo spine CJ Railway 4] VAS sion oint etc loss of joint space ppea rance Scanned with CamScannercor eawrugy_ un TanoUut_A_K_S — Notes on Systemic sclerosis 9 HC sclerosis Cause: 's of death: Interstitial lung fibrosis + renal ei ~ Drug used to prevent renal crisis? ACEL(Dow't use ifthe crisi occurred) already ~ CREST Syndrome: limited cut under the skin) — Raynaud’s (B Esophageal dysmotilit tclangicets lancous SSC + calcinosis 'V spasm in res Y ~ Sclerodactyly a (dilated capillaries ¢: (calcium deposition ponse to coldness or stress) — (thick tight skin of fingers and hand) — ausing red minute spots)” spondyl s umbar vertedrae: Schober test connecting the Wwo dimples ~ draw above ils center or § em below (mo localize dimples — draw line an imaginary line — localize a 10 em point dilied Schober)— ask him to touch is toes — normally, the distance increases > § em - Ext cular manif ations (ANKSPOND) |o Aortic insufficiency, ascending aortitis and conduction defects o Neurologic: atlanto-axia! sublaxation and cauda-equina © Kidney: 2ry amyloidosis © Spine: cervical (racture and spinal stenosis (o Pulmonary: upper lobe fibrosis (DD with TB) and restrictive changes © Ocular: anterior uveitis: most common (25-30%) o tg A nephropathy » Diseitis o Asymptlon (30-60° 0) agesies (NSAIDs) - DMARDs — Anti TNF alpha ¥ eye disease (uveitis = red eye and severe p buming sensation) Scanned with CamScanner~T. Inspect eT hig. Skin eeppavant Vessel Re maselen EERE re 2 hyper Rina” 3- WWlevo$Seous YW 3: ony soink & dehaemily Loulnar deviation of finger ab MCP” 2. Radiol at Rev 5. “LigzZay Sage bond Yer Swan wack: 5. Boulnier- 6. -2 Rape Ramb Z Trigger Pinger & locked Pinger B- Suaiing oe ob “MCC XS. u Wand of alive ER UTS Te Scanned with CamScanneree Sound“: cathe toils, Sainhsts ft encarta. by Ree Ce, 2 Makuyad of susellings od wes +S lak Mad): anbote» ‘Capa. aulinas = = SPilaive hey SA Qh te at devsun, ef wrist Cystic doighbg : = Wats. an : I ‘hevenant maaetive —o. wt reaver L TPassive - fe Grip hesl. - ite. Oineh <7 3 lint a“ Yen PMayer 7 wy danke fargel fest far MV finned “Jest Phalyr test Hever sed Pyaar Scanned with CamScannerI= Ap ‘echtom. Tenp- SweLiny 5) Testcleram or Fendon ach ly . ankeriey of onkk cepiha © nodub , ‘Mover ankle Flexion Fook...dnversion, eMer Sinn. Perr fatto pen Scanned with CamScannerSe ski in, ce ie. Ata bore. “leformidyokrie-Vollgas ” . Vorun:” Mevemal “Puss g “eit Scanned with CamScannerBastions on 42 Na alieece se ORR QU aunt CCP a : 3 ARs, eye eter Poly cure of 'g mech 5 of. hone. foot Siapt UPC Res bee ues panne tare, hob seiweryss: 4 “He -ad-feek spin op etlantocatials - bos! Ry. .Matiedne| Secs Neodule.: iA, 2, Cousin “ofp edmay ary oe a setiver Raila 4p fegrwndgy edie + eshyyen Ry 6! whe iu “Ash inferesseus ms. . oc Ranh, Je achiow of Dud mime addy abd fo Swan, onekle ag booubwiere sash. 9 CCar nin. Sate Miu “s Menkes te mates bk a clig - asbestos . 2 locked Ginger het ‘ponasinevites : 3- otfax. Savorve “iserge—o SLEs SSC CTS —» prumbuss in. later. 3, 1. Cigar. oo RAL 386, actemgpaly, hypetfy, (14 Scanned with CamScannerod: shaving, rom. eer IS onece. voshasd. Shepp: silos: fanaa. a Pos! SMhina—o : Leate Bar Scars, ‘Pigmantabion. toe She nding Pyare. . \stered,, view KY pheSidy Sco Res > o PX ales Vole S| eta wy Mead Sovopintgencanen + - LH: oCCiput er swell teat Normal =~ iZ- eXariin Quinoa, 4. inspection 6 lefovmity ~ less ‘of lorelosis z Palle Faneler ovr intervertebral. disk Spinal prbcss Scanned with CamScanner3~.. Mevemen} - fa Yeans Jaxon sexbengig babe) bending a ‘scheber me becker B Lagiog hea : fhe vine tows cca) TV). eHamine ‘Satweiluess “sitet Com press. Sacrbiliae. gf pelvic: Compression. “PS. TS she atoning ote ob Pambhendl. e ed qensien . Le qiw's ess Scanned with CamScanner@ @esthion sian Ankylosing. de ankylosing ss sSerszve =a Raves Salen, ReMi. Fendi Leccrflidag Atay Ramla Spiny sccheal pein a4 Ainih.Sepalfy Ye yee Uvita SoM t cy. Mothibns ARs somp ; 8 Mungo aipiGd ior ever Te ida T9 A naghtoj2dy, 24 a #Trtlam Low los Faiy m [nile - : (Pres LS exersiy $s : ems = ShifCiun 2 hg. TYaunta ow loach Fine. ASsste - , : , Tye Yeh Dg exGrsss wh NovWRerning SHoCiu. iB sk eoim ii ; Wh Neir ! TR sant Vive ain fitinaby, 12 @CCipad “be wall Used fer follow UP 42 - Pingur she Pleor. best net Specitic hs path Ff SPina WS cKeaning: . MM HLA Bez mw Sew sve an _ ankylosis, . Behat | pPSutielie euB 18 Cruse of lw back pains ais ANAS ing Se ve. Scanned with CamScanner1, 3.n. eh aming, ays - Sclaw sis. Tnspe chain i eeeag, sim “ef Pech ian’ a “Co lot e Qelb yp appar Le ‘Palangectasia.. Ws; Alors: of. Sots: Nail eg rephy “5~ teSerphion.. of lish helene: 3 “- & defotmidy 7” flenion Saker cht sel HN Mowsis ‘sp allp: . peer Fraynaud s Le plexes Contra chur. ms Shute | [a fests. lol of Sibrsy. f elbow Scanned with CamScannerFi U Lela. gy elengated Ga, ee cheat hd nt Ainge oni SeeubsGnt—-Pronbal “Crease, YPinchad “nse ™ 52 Perstd Lip? 2 fish mouth 1 Seve Vee Qivte blast call io mnain- Libvesis, Pbryesis, Si rsis “Ay pers Limited, chittus jerve lap Liniitted, Oni Gobworare! Aif fun, 4 Sly COR EST = Gddcinesis, Raga, Rx Dy Symphomabic Ry swe x esph, ‘SCleredact, Faluny Scanned with CamScanner