History and Physical Examination for Rheumatic Disease for MUSC Students

Transcription

1 History and Physical Examination for Rheumatic Disease for MUSC Students

2 Inflammatory vs. non-inflammatory arthritis Inflammatory Prolonged stiffness after rest Stiffness improved with use Warmth Prolonged swelling Non-inflammatory Brief stiffness after rest (gelling) Pain worsened with use Bony enlargement Initial joint effusion

3 Rheumatic Review of Systems Weight loss Fever Rash Hair loss Pleuritic chest pain Dysuria Proximal muscle weakness Eye inflammation Raynaud phenomenon Oral or nasal ulceration

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6 Patterns of Arthritis Polyarticular ( 4( 4 joints) Rheumatoid arthritis Systemic lupus erythematosus Gout (chronic) Psoriatic arthritis Nodal osteoarthritis Oligoarticular (<4 joints, includes monoarticular) Infections TB, Pyogenic (Staph( Staph,, Strep, Gonorrhea, fungal, Crystalline arthritis Acute gout (Monosodium urate crystals) pseudogout (calcium pyrophospate dihdrate crystals) Osteoarthritis (knee, hip) Seronegative spondyloarthropathies Ankylosing spondylitis Reactive arthritis Inflammatory bowel disease arthrtis

7 Patterns of Arthritis Temporal Pattern Migratory (e.g, Gonococcal arthritis, rheumatic fever ) Additive (e.g., Rheumatoid arthritis, psoriatic arthritis) Episodic (e.g.,gout, pseudogout) Quantitative Pattern Polyarticular (e.g., Rheumatoid arthritis, systemic lupus) Oligoarticular (e.g., Reiter s syndrome) Monoarticular (e.g., Septic arthritis, gout) Distribution Pattern Symmetric (e.g., Rheumatoid arthritis, systemic lupus) Asymmetric (e.g., osteoarthritis of knee)

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14 Osteoarthritis (non-inflammatory) Synonyms-- --Degenerative joint disease (DJD), osteoarthrosis Most common cause of disability in USA Age and trauma related Several forms- Nodal Isolated joint

15 Osteoarthritis Pathology=cartilage fragmentation and narrowing, with subsequent bony overgrowth Clinically-Early joint effusion, followed by bony enlargement and deformity

16 Osteoarthritis-Symptoms Little morning stiffness May have gelling (A few seconds of stiffness on first arising from a resting position Pain is typically worse with use of affected joint

17 Osteoarthritis-Signs Joint swelling-- --early in course of disease Limited range of motion Joint line tenderness (particularly at knee) Crepitus ( crunchy sensation under examiner s hand) Excessive bone

18 Osteoarthritis-- --Joint Distribution Present Spine Hips Knees Midfoot Hands DIPs (Heberden) PIPs (Bouchard) First CMC Absent Wrists Elbows Shoulders Hands MCP joints

19 Osteoarthritis of Hands Bouchard s nodes Heberden s nodes

20 Left knee Effusion

21 Signs of Rheumatoid Arthritis Symmetrical, polyarticular, additive arthritis Subcutaneous nodules Unreducable deformity in later stages Eye inflammation

22 Rheumatoid Arthritis Proximal Interphalangeal Swelling

23 Rheumatoid Arthritis

24 Rheumatoid Arthritis

25 Gouty Arthritis Abrupt onset of severe joint inflammation, often at night Subsides over 3 to 10 days 75% of first attacks are in first MTP Initial attacks are monoarticular, can become polyarticular Monosodium urate crystals in synovial fluid Tophi

26 Gout-Acute Arthritis of Ankle and First MTP Joint

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29 TOPHACEOUS GOUT

30 Systemic Lupus Erythematosus (SLE) Mucocutaneous Butterfly malar rash Discoid (scarring) lesions Oral and nasal ulceration Pulmonary Pleural effusions Arthritis Symmetrical, inflammatory, nonerosive

31 SLE-Malar Butterfly Rash

32 SLE-- --Malar Butterfly rash

33 SLE-Discoid Lesions (Scarring)

34 SLE-Oral palatal ulceration

35 SLE-Digital arteritis with infarction

36 Symptoms of Ankylosing Spondylitis (Inflammatory) Morning Back stiffness Loosens with activity Eye pain (anterior uveitis) Family history

37 Signs of Ankylosing Spondylitis Diminished ability to reverse lumbar lordosis-- Schober Test Inability to touch occiput to wall Endstage-- -- hunched over Tenderness on compression of SI joints Flexion, abduction, internal rotation at hip (FABER) Iliac compression

38 Ankylosing Spondylitis-- --Fixed Flexion

39 Ankylosing Spondylitis Inability to reverse lumbar lordosis

40 Reiter s Syndrome (Reactive Arthritis) Typically follows a urogenital or intestinal infection Classic Triad Asymmetric oligoarthritis Conjunctivitis Urethritis Rash

41 Reiter s Syndrome-- --Conjunctivitis

42 Reiter s syndrome Achilles Tendinitis

43 Reiter s Syndrome-- --Keratodermia Blenorrhagicum

44 Reiter s Syndrome-- --Keratodermia Blenorrhagicum

45 Reiter s Syndrome-- --Circinate Balanitis

46 Psoriatic Arthritis (inflammatory) May precede rash in 20% of cases Typical presentations: Distal interphalangeal joints Sausage digits Spondylitis symptoms

47 Psoriatic Arthritis with nail and DIP joint involvement

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50 Psoriasis-- --Nail Pitting

51 Psoriatic Arthritis-- --Sausage toes

52 Scleroderma-Symptoms Symptoms Raynaud phenomenon Skin tightness

53 Scleroderma-- --Physical Findings Skin Thickening Raynaud Phenomenon Telangiectases Flexion contractures at finger joints Calcinosis

54 Raynaud Phenomenon

55 Scleroderma

56 Scleroderma Fingers

57 Dermatomyositis Inflammatory muscle disease Proximal muscle weakness Characteristic rash Often accompanies malignancy

58 Dermatomyositis-- --Rash Heliotrope Gottron s papules V of neck and shawl sign

59 Disseminated Gonorrhea Acute arthritis/dermatitis syndrome Migratory arthritis Migratory tenosynovitis (back of hands, feet) Hemorrhagic and/or pustular skin lesions (most common on palms and soles)

60 Disseminated gonorrhea-- dermatitis

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