History and Physical Examination for Rheumatic Disease for MUSC Students
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
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
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
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)
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
Osteoarthritis Pathology=cartilage fragmentation and narrowing, with subsequent bony overgrowth Clinically-Early joint effusion, followed by bony enlargement and deformity
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
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
Osteoarthritis-- --Joint Distribution Present Spine Hips Knees Midfoot Hands DIPs (Heberden) PIPs (Bouchard) First CMC Absent Wrists Elbows Shoulders Hands MCP joints
Osteoarthritis of Hands Bouchard s nodes Heberden s nodes
Left knee Effusion
Signs of Rheumatoid Arthritis Symmetrical, polyarticular, additive arthritis Subcutaneous nodules Unreducable deformity in later stages Eye inflammation
Rheumatoid Arthritis Proximal Interphalangeal Swelling
Rheumatoid Arthritis
Rheumatoid Arthritis
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
Gout-Acute Arthritis of Ankle and First MTP Joint
TOPHACEOUS GOUT
Systemic Lupus Erythematosus (SLE) Mucocutaneous Butterfly malar rash Discoid (scarring) lesions Oral and nasal ulceration Pulmonary Pleural effusions Arthritis Symmetrical, inflammatory, nonerosive
SLE-Malar Butterfly Rash
SLE-- --Malar Butterfly rash
SLE-Discoid Lesions (Scarring)
SLE-Oral palatal ulceration
SLE-Digital arteritis with infarction
Symptoms of Ankylosing Spondylitis (Inflammatory) Morning Back stiffness Loosens with activity Eye pain (anterior uveitis) Family history
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
Ankylosing Spondylitis-- --Fixed Flexion
Ankylosing Spondylitis Inability to reverse lumbar lordosis
Reiter s Syndrome (Reactive Arthritis) Typically follows a urogenital or intestinal infection Classic Triad Asymmetric oligoarthritis Conjunctivitis Urethritis Rash
Reiter s Syndrome-- --Conjunctivitis
Reiter s syndrome Achilles Tendinitis
Reiter s Syndrome-- --Keratodermia Blenorrhagicum
Reiter s Syndrome-- --Keratodermia Blenorrhagicum
Reiter s Syndrome-- --Circinate Balanitis
Psoriatic Arthritis (inflammatory) May precede rash in 20% of cases Typical presentations: Distal interphalangeal joints Sausage digits Spondylitis symptoms
Psoriatic Arthritis with nail and DIP joint involvement
Psoriasis-- --Nail Pitting
Psoriatic Arthritis-- --Sausage toes
Scleroderma-Symptoms Symptoms Raynaud phenomenon Skin tightness
Scleroderma-- --Physical Findings Skin Thickening Raynaud Phenomenon Telangiectases Flexion contractures at finger joints Calcinosis
Raynaud Phenomenon
Scleroderma
Scleroderma Fingers
Dermatomyositis Inflammatory muscle disease Proximal muscle weakness Characteristic rash Often accompanies malignancy
Dermatomyositis-- --Rash Heliotrope Gottron s papules V of neck and shawl sign
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)
Disseminated gonorrhea-- dermatitis