There is ±bilateral ±symmetrical deforming polyarthropathy affecting the …..

Rheumatoid arthritis: wrist joint, metacarpal pharyngeal joint, proximal intralaryngeal joint with
sparing distal intralaryngeal joint, with normal nail
Osteoarthritis: just involved distal intralaryngeal joint
psoriatic arthritis: affect nail

Involved distal intralaryngeal joint: osteoarthritis, psoriatic arthritis, gout arthritis, SLE
One joint: gout arthritis, septic arthritis, hemarthrosis, pseudogout
Poly(equal or more than 5joint): RA, SLE, osteoarthritis, psoriatic arthritis
Remember: case is mainly RA

 Inspection
Skin
• Skin rash
• Hypo/ hyperpigmentation
• Scratch mark: present with autoimmune disease
• Ecchymosis: present with bleeding tendency
• Itching, Surgical scar

Muscle wasting: present in

• AR: due to disuse atrophy + carpal tunnel syndrome (median nerve), present with
o Dorsal guttering: muscles are sinking between joint
o Thenar, hypothenar wasting
• Posterior arm wasting: mononeuritis multiplex (ulner and radial): vasa nervosa vasculitis →
infarction → nerve death → muscle paralysis

Joint deformity
• AR
o Ulner deviation: subluxation (partial dislocation of joint) of rest joint
o Boutonniere sign (button hole appearance)
o Swan neck appearance: over distension MP joint, flexion at proximal IP joint
o Z deformity: in thumb
• OA
o Heberden’s node
o Bouchard’s node
• CREST syndrome
o calcinosis (differ from Gouty tophi)
• psoriasis
o telescopic sign: hand bone engaging each other in joint
• Wrist edema, MP joint edema
Nail: psoriasis
• pitting
• Ridging
• Brown & dark discoloration
• Onycholysis: separation of nail bed

Palm
• Pallor, cause of anemia in patient with RA are:
o Normochromic normocytic: anemia of chronic disease
o Microcytic hypochromic: iron deficiency anemia: due to excessive use of NSAID, with
bleeding in GIT, renal failure associated with RA
o macrocytic macrocosmic anemia: due to excessive use of antifolate
o autoimmune hemolytic anemia
• bluish (cyanosis): association with cryptogenic fibrosing alveolitis fibrosing alveolitis
• yellow (jaundice): autoimmune hepatitis, drug induce hepatitis (methotrexate)
• digital infarct: associated with vasculitis
• palmer erythema: Ra + Hepatocellular failure

 palpation
1. temperature: hotness indicate inflammation
2. tenderness: ask about pain
3. wrist effusion (accumulation of fluid in synovial space)
a. do fluctuation test for effusion
b. it is due to traumatic or non-traumatic (infection: TB, crystal deposition gout,
pseudogout)
c. investigated by joint aspiration
4. muscles bulk: test for corrective deformity
a. correctable → rheumatoid hand is excluded, it is Jaccods (mostly SLE)
b. non correctable → RA
5. joints subluxation: joint is very lax
6. hand function:
a. Pencing sign: Hand catch coin by finger
b. ceiling sign: move hand against stretch resistance hand
c. prayer and reverse-player sign
d. buttoning and unbuttoning
e. hand grip : patient cannot fitting his hand around glass by all finger
7. test for carpal tunnel syndrome (median nerve affects lateral half hand)
a. Tinel’s sign: taping on mid transverse carpel ligament
→ shooting pain lateral
b. Tinel’s sign is due to: RA, hypothyroidism, DM, acromegaly
8. sensation by cotton
flexor of forearm for: Rheumatoid nodule, psoriatic plaque(silver in color), Hypo/
hyperpigmentation, Scratch mark

proximal myopathy: raise your shoulder

I would like to complete my examination by examine:

• rest of joint: elbow, lower limb joint for subluxation
• Percuss over back for: tenderness
• Reflux of tendon to detect hyperreflexia: to exclude atlantoaxial subluxation (spinal cord
compression)
• Eye → scleritis, episcleritis, conjunctivitis, keratoconjunctivitis sicca, keratomalacia, pallor,
jaundice
• Mouth → oral ulceration (SLE), cyanosis
• CHEST → pleurisy, malar flush (SLE), lung fibrosis (fine crepitation)
o RA= pleural & pericardial effusion, lung fibrosis, fibrosing alveolitis, bronchiectasis,
caplan syndrome (rheumatoid nodule within lung tissue),, endo/epi/myo carditis
• Abdomen → hepatomegaly(autoimmune),
o RA = splenomegaly (felty’s syndrome= splenomegaly+ pancytopenia+ RA)
o SLE= ascites(polyserositis)
• Dipstick urine for → microscopic proteinuria (nephrotic syndrome due to 2ry amyloidosis)

 Investigation (RA) :
1. General → CBC, ESR,RFT, LFT
• RFT : nephrotic syndrome, amyloidosis, drug (NSAID)
2. Imaging:
• Joint X-ray → osteopenia, bone erosion, widening of joint space, soft tissue edema with
soft effusion
• Chest X-ray → Do to prevent methotrexate inducing lung fibrosis in future
• Echocardiography
• Abdominal Ultrasound
3. Rheumatoid factor, Anti-CCP antibody, antinuclear antibody
4. ANA Profile → to exclude SLE
5. Hb 𝑨𝟏 𝑪 → because steroid induce DM

 Treatment (RA) :
1. Pain killer
a. Steroid (to relieve sign of inflammation) → prednisolone
b. NSAID (+proton pump inhibitor) → indomethacin, paracetamol, ibuprofen
2. DMARD (disease modified antirheumatic drug)
a. Non-biologic → methotrexate, gold, penicillamine
b. Biologic (need screen for TB) → TNF-𝛼(infliximab)
cyclophosphamide, hydroxychloroquine, sulphalazine,
 Introduce yourself and take permission
‫ه أكشف على يدك لو ممكن‬/ ‫ داير‬، ‫ة بكلريوس‬/‫ طالب‬............................ ‫ أنا‬، ‫السالم عليكم‬
 Inspection
start with dorsum hand and resting in below
Uni - Mono
lateral Symmetrical Oligo arthropathy
bi A poly
Affecting (joint effect) (with “RA”/ without sparing of distal intralaryngeal joint “OA, SLE, GA”
 Nail change:
• onycholysis, splinter hemorrhage due to vasculitis
• nail pitting due to psoriatic arthritis
Joint deformity (SND, PD, ZSD, ulnar deviation)
Nodules (HN, PN, wrist edema)
Guttering sign
Skin change (surgical scar, hypo/ hyperpigmentation, skin rash)
:‫أقلب اليد‬
 Palm (paler, jaundice, peripheral cyanosis, thenar/ hypothenar muscle wasting, dupuytren’s
contracture, digital infarction) confirm wrist edema
 Palpation:
Joint examination (hotness, redness, tenderness, effusion, subluxation)
Muscle bulging, dorsal confirm effusion.
Hand function (grip, pencing, prayer, reversal prayer sign)
Sensation ‫اوعى تنسوه‬
 Percussion:
wrist for carpal tunnel syndrome (tunnel sign) ‫ أنا حأضربك ضربه بسيطه لو حسيت بكهربا كلمني‬:‫بسأل المريض‬
‫وبعاين لعيونه عشان أشوف األلم‬
 Dorsum of forearm ‫نهاية اليد‬
‫بسأل تاني من األلم‬
‫بشوف بعيوني‬
Rheumatoid nodule, psoratic plaque, skin rash, hypo/ hyperpigmentation.
‫بهبش باليد بتأكد من‬
Rheumatoid nodule, psoriatic plaque.

I would like to complete my examination by exam:

Rest of the joint
Eye → scleritis, episcleritis, conjunctivitis, keratoconjunctivitis sicca, keratomalacia, pallor, jaundice
Mouth & parotid → dry mouth, dry mucosa, parotid enlargement (Sjogren syndrome),oral ulcer
due to SLE or side effect of drugs
Neck → atlantoaxial subluxation
Proximal myopathy
Chest → caplan’s syndrome, Apical lung fibrosis (due to methotrexate)
Abdomen → splenomegaly for felty’s syndrome, hepatomegaly due to drug or autoimmune
hepatitis
Back → tenderness
Lower limb → ulcer, edema
 Oral discussion ‫االسئلة اللي ممكن تنسأل باالمتحان‬
What is differential diagnosis??
One joint: gout arthritis, septic arthritis, hemarthrosis, pseudogout
Poly(equal or more than 5joint): RA, SLE, osteoarthritis, psoriatic arthritis

What is the type of anemia and its cause???

o Normochromic normocytic: anemia of chronic disease
o Microcytic hypochromic: iron deficiency anemia: due to excessive use of NSAID, with
bleeding in GIT, renal failure associated with RA
o macrocytic macrocosmic anemia: due to excessive use of antifolate
o autoimmune hemolytic anemia

What is felty’s syndrome???

felty’s syndrome = splenomegaly and neutropenia with Rheumatoid arthritis

What is the cause of hepatomegaly and splenomegaly?

splenomegaly for felty’s syndrome, hepatomegaly due to drug or autoimmune hepatitis.

What is investigation of rheumatoid arthritis??

1. General → CBC, ESR,RFT, LFT
• RFT : nephrotic syndrome, amyloidosis, drug (NSAID)
2. Imaging:
• Joint X-ray → osteopenia, bone erosion, widening of joint space, soft tissue edema with
soft effusion
• Chest X-ray → Do to prevent methotrexate inducing lung fibrosis in future
• Echocardiography
• Abdominal Ultrasound
3. ANA Profile → to exclude SLE
4. Hb 𝑨𝟏 𝑪 → because steroid induce DM
5. Specific investigation: Anti-CCP(anti-cyclic Citrullinated peptide antibody), Rheumatic factor.
What is Investigation specific to SLE??
1. ANA profile
2. Anti-double strand DNA
3. Anti histone antibody(drug induce SLE)

What is class of Management of Rheumatoid arthritis

1. NSAID → relief pain (e.g: aspirin, diclofenac sodium or potassium)
2. Low dose of corticosteroid
3. DMARDS(Disease Modifying Anti Rheumatic Drugs) → methotrexate, sulfasalazine,
hydroxychloroquine, leflunomide, IM gold
4. Immunosuppressive drugs → cyclosporin A, Cyclophosphamide, Azathioprine
5. New drugs(biological agent)
a. TNF- alpha inhibitor → infliximab
b. B cell depletion → rituximab
c. Interleukin 1 → anakinra, interleukin 6 → tocilizumab
d. Disruption of T-cell function → Abatacept
What is the side effect of biological drugs & Rheumatoid drugs???

What is further management of Rheumatoid arthritis if medical treatment failed

• Surgical procedure
• Physiotherapy
• Psychotherapy

Criteria of Rheumatoid arthritis??

Old (4 of 7)
1. Morning stiffness (more than 1 hour for 6week)
2. Swelling of the wrist (metacarpal pharyngeal joint & proximal intralaryngeal joint) for 6week
3. Swelling of 3 joint for 3week(common is small joint)
4. Symmetrical joint swelling for 6week
5. Rheumatoid factor or anti-CCP positive
6. CRP or ESR positive
7. X-ray abnormalities and nodules are not necessary for diagnosis for Rheumatoid arthritis
New (6 of 10): add A-D score

Complication of rheumatoid arthritis?

Rupture of tendon, Rupture of Becker cyst, Joint infection, spinal cord compression (due to
atlantoaxial subluxation, may be damage spinal cord), amyloidosis presenting as nephrotic
syndrome , Complication of drug.

Cause of nodule???
Local vasculitis of the area
Prayer & reversal prayer sign Prayer & reversal prayer sign

nail pitting

Dorsal guttering