Reumatology Sheet Dr.

/ Abdel Azeim Alhefny,

MD.

IDIAL GUID TO

RHEUMATOLOGY
HISTORY TAKING & CLINICAL EXAMINATION

WITH 22 CASES

Dr./ Abdel Azeim Al-Hefny. MD

Prof. Internal Medicine, Rheumatology, Allergy & Immunology.
Ain Shams University

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Rheumatology Sheet

Ten Golden Rules In Rheumatology:-

1. A good history & physical examination, with good idea about the
musculoskeletal anatomy is very important for diagnosis;
You must examine the patient!!
2. Don’t order a lab test unless you know why & what you will do if
it is abnormal?
3. Acute monoarthritis = joint aspiration to exclude septic & crystal-
induced arthritis.
4. Chronic monoarthritis > 8 weeks of unknown cause needs
synovial biopsy.
5. Gout does not occur in premenopausal females or in joints close
to spine.
6. Most shoulder pain is periarticular (bursitis, tendonitis..),
most LBP. is nonsurgical.
7. OA in (MCP, wrist, elbow, shoulder, ankle) joints ---- exclude 1ry
cause eg. Metabolic dis.
8. 1ry fibromialgia does not occur > 55ys. for 1st time, nor with
abnormal laboratory results.
9. Not all pts. With +ve RF=RA, nor +ve. ANA = SLE .
10.Fever or multisystem complaints, in Rhc. Pt., rule out infection &
other non-Rhc. causes as a 1ry.
(Infections cause death in Rhc. pt. more than the 1ry dis. does).

Remember nothing is 100%

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

 Synovial (diarthrotic) Joints. These are freely mobile joints in

which there is a joint cavity between the articulating bones. These
are the commonest joints in the body.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Terminology
Rheumatism:
1st. introduced in 1642 when they realized that arthritis could be a
systemic disease. It was an obsolete term for ARF. Now it is defined as
various abnormal conditions marked by recurrent pain, stiffness &
other manifestations of articular origin in joints, back, or muscles.

Rheumatology: Rheuma= substance that flows- from brain to various

parts of the body causing chr. illness (1st. century AD). Or medical
science dealing with diseases/abnormalities in the musculoskeletal syst.
Arthropathy =A term meaning 'joint disorder'. This can be arthritis or
arthralgia and is often used when the nature of the joint disorder is
uncertain.

Arthritis= A term referring to inflammation of a joint or joints. (The

suffix '-itis' means inflammation). There is usually visible evidence of
inflammation (objective abnormality) such as Joint pain, stiffness,
tenderness, redness, hotness, swelling & limited movement. While if the
patient only experienced pain without obvious abnormality; it is called
Arthralgia= (subjective=Joint pain without signs of inflammation).

Inflammation= Tissue reaction to injury. It may be acute (as in a burn or in

gouty arthritis) or chronic (as in rheumatoid arthritis or chronic infections
such as tuberculosis).

Cartilage= A white semiopaque nonvascular connective tissue. There are

two types. Hyaline cartilage is the very smooth 'gristle' that covers the
articulating surfaces of bones that form the joint. Fibrocartilage is the type
that is found in the menisci in the knee for example.

Capsule= The thick membrane that joins bones making up a joint. It also
isolates the joint cavity from surrounding tissue.

Enthesis= The anatomical site of attachment of ligament, tendon, joint

capsule or fascia to bone. Enthesitis= inflammation of enthesis.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Tendon= A band of fibrous tissue by which muscle is attached to bone.

Tendenitis= inflammation of tendon, Tenosynovitis= inflammation of
tendon sheath.

Ligament= A band of tough tissue which restrains joint movement and

confers stability on a joint. There is a high collagen content Sprain = stretch
or sprain of the ligament.

Synovium= A thin membrane (normally one cell thick) which is found

within the joint capsule. It produces synovial fluid which lubricates and
nourishes the joint cartilage. It becomes inflamed and thickened (synovitis)
in inflammatory arthritis such as rheumatoid disease.

Joint effusion =Accumulation of fluid in a joint.

Bursa= A fluid-filled sac. They are found between tissue planes where
shearing forces may act - e.g. at the knee and elbow. They are lined by
synovium and contain synovial fluid - like the joint. Bursitis occurs when
they are inflamed. eg: prepatellar bursitis. (Housemaid's knee).

Monoarthritis= one joint inflamed. Oligo/Pauci-arthritis= 2-4 joints or

small joint groups eg: wrist. Polyarthritis= > 4 joints (or groups) inflamed.

Spondylitis=Inflammation of axial vertebrae & related structures (discs &

ligaments).

Myopathy:Disease/Abnormality of the muscles. Myositis (polymyositis):

Inflammatory disease of the muscle (skeletal/ striated muscle).

Vasculitis, arteritis: Necrosis and inflammation of blood vessel wall.

This results in clinical manifestations due to interference with blood
supply to those organs.

Subluxation: malalignment of a joint; so that articulating surfaces

incompletely approximate each other.
Dislocation: Abnormal displacement of articulating surfaces (not in
contact).

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Deformity: Abnormal shape or size dt. bony hypertrophy, malalignment of

articulating joint, or damage to periarticular supporting structures.
ROM= Range of motion: The arc of measurable movement through which
the joint moves in a single plane.

Contracture: Loss of full movement dt. fixed resistance by tonic mus.

spasm (reversible) or fibrosis of periarticular structure (permanent).

Rheumatoid factor=An immunoglobulin directed against the Fc portion of IgG.

Rheumatoid factors may be found in all immunoglobulin classes but the
rheumatoid factor test detects IgM-RF. Some conventionally 'seronegative'
patients(20%) may have rheumatoid factors of other Ig classes & +ve CCP.

Rheumatoid nodules = subcutaneous soft tissue swellings which may

vary inconsistency from very soft to moderately hard. Sometimes
attached to deeper structures. They occur in approximately 20% of
patients with rheumatoid arthritis, most commonly on the elbow on the
extensor surface.

Ganglion = A soft tissue swelling which arises in relation to a tendon.

It is usually firm and relatively small. A swelling of the dorsal tendon
sheath at the wrist is sometimes mistakenly referred to as a ganglion.

Carpal tunnel = The space at the flexor aspect of the wrist bounded by
the carpal bones and the flexor retinaculum. Flexor tendons and the
median nerve traverse the carpal tunnel

Periostitis =Inflammation involving the periosteum. This may result in

new bone formation

Onycholysis =A nail abnormality seen in psoriasis. It may be

accompanied by pitting of the nail.

Sacroiliitis =Inflammation of the sacroiliac joints at the base of the

spine. This may give rise to low back or buttock pain. It occurs
particularly in HLA B27-related conditions such as ankylosing
spondylitis
Haemarthrosis = A collection of blood within a joint.
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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Rheumatology history taking

Screening questions in Rheumatology:
Pain, joint swelling & stiffness are the most common symptoms pointing to
the locomotor system; impairment of its function (movement) is the most
important consequence; so, before proceeding in rh. history taking, we ask the
following questions:
1. Have you any pain or stiffness in your muscle, joints or back?
2. Can you dress your self without any difficulty?
3. Can you walk up & down stairs easily?

Personal History

Age:
Young: ARF (5-15), HSP (4), Kawasaki (5)
Middle age: RA (all ages), SLE, PAN (40), RP (20-40), Reiter (20-40yrs.),
Takayasu (15-25), Wegner (40)
Old: OA, Giant Cell Arteritis (GCA>50), Gout (50yrs)

Sex:
F>M M>F M=F

SLE 9:1 Gout (7:1) ARF

RA 3:1 Reiter HSP
Behcet 2:1 AS
Vasculitis 3:1 PAN (2:1)
RP 5:1
GCA 2:1
Takayasu 9:1
Wegner 3:2

Habits:
Addicts---------- viral, infectious arthropathy

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Residency:
Crowded humid damp area: ARF

Occupation:
Vibrating tools, pianist, typist------- RP
Health providers, blood bank staff ------ Viral arthropathy, cryo, vascul.

Past History
Precipitating factors???
Drugs:
Drug-induced Lupus eg.: Hydralazine, Methyl dopa, Procainamide,
Phenytoin, Isoniazid, Chlorpromazine.
BB-------RP.
Lovastatin------Myositis.
L-tryptophan-------Esinophelia-myalgia syndrome.
Infections:
B haemolytic streptococcal A. infection----------ARF
TB
Gonorrhea
Sepsis
Diet:-----------Delayed hypersensitivity reaction------ Arthropathy.
Trauma: Fracture, Haemarthrosis.
Joint Surgery: Open, Laparoscopic, Aspiration:-
Indications, results, & follow up.
Response to previous therapeutic modalities: drug TTT, PT, surgical
corrections----------- clues for diagnosis, effects, side effects, compliance.

Complaint:
Chief symptom & its duration

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

History of the present illness:

If there is any abnormality suspetected we have to proceed for

analysis of symptomatology:-

I- Pain:
 SITE: Where exactly is the pain experienced? (Ask the
patient to point). Site of maximum intensity= localizing pathology.
Diffuse pain, variable, poorly described, or unrelated to anatomical
structures= fibromialgia, malingering, or psychogenic.
 RADIATION: Does the pain radiate elsewhere? = Neuropathy.
 CHARACTER.
 SEVERITY: visual analog scale 1-10 (intolerable pain in pt. doing normal
activities=psychogenic)
 ONSET, COURSE & DURATION, continuous or intermittent?
 FREQUENCY
 DIURNAL VARIATION
 Rest pain = inflammatory (RA).
 Usage pain = mechanical (OA).
 PRECIPITATING-FACTORS, trauma,….
 WHAT Increase, WHAT Decrease
 ASSOCIATED SYMPTOMS, stiffness, redness or swelling
 IMPACT ON GENERAL CONDITION & LIFE STYLE (sleep and
functional capacity -- in relation to work? On normal daily life?
 Associated extra articular symptoms (skin rashes, eye inflammation
etc.).
 PAST HISTORY OF SIMILAR ATTACKS, infections, autoimmune
diseases,… any relevant past medical history?.

II- Stiffness:
Joint tightness d.t. accumulation of inflammatory exudates & edema
fluids--- distention of the periarticular tissues (capsule, tendosynovium,
bursa). After activity; fluids washout from the inflammatory tissues &
stiffness wears off.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

 <1/2 hr. = mechanical.

 >1hr. in the morning, or after a period of rest = inflammatory.
Site: Affecting hands in RA & back in AS.

III- Swelling:
Bony (hard), fluid (+ve fluctuation) or synovial thickening (firm
in consistency).
 Specify & count the swollen joints.
 Diffuse or localized.
 Constant or episodic.
 Duration.
 + Signs of inflammation (pain, hotness, redness & limitation of
movement).

IV- Deformity:
Fixed or correctable?
Characteristic & specific?

V- Movement (Function):
 Normal painless daily activity?
 Painful daily activity?
 Limited movements?
 No movement (ankylosis)?
 Disability (unable to perform ordinary important movements, need for
house hold help) or handicapped (necessitates change of the life style
&/or change or retirement from job)? = severity

VI- Muscle Weakness: distribution, duration & course. Myositis=proximal,

persistent & progressive muscle. weakness.

VII- Sleep disturbance: (organic or psychogenic effects).

VIII- Systemic features (generalized constitutional symptoms)=

systemic disease or paraneoplastic syndrome:
 Low grade fever.
 Easy fatigability.
 Malaise.
 Weight loss. *Night sweets & fever.

IX- Extra-articular manifestations & review of systems:

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Skin:
Overlying traumatic/surgical scars or skin discoloration= clue for
diagnosis.
Erythematous joint=sepsis or crystal.
Rash (malar, photosensitivity, = SLE, purpuric eruptions= Vasculitis).
Adherent silver-like plaques = Ps A.
Subcutaneous nodules: RA, SLE, RcF, PAN, Sarcoidosis.
Tophi: Gout.
Alopecia: SLE, SSc
Raynaude’s phenomena (pallor, cyanosis then erythema): SSc, SLE,
RA, PM/DM, Vasc.
Sclerodactyly, digital ulcers & gangrene: SSc.
Palmar erythema: RA (most common pathologic cause>liver c. &
thyrotox.), while pregnancy is the most common physiologic cause.
Keratoderma blenohemorrhageca= Reiter.

Nail changes:
Clubbing: hypertrophic pulmonary osteoarthropathy & fibrosing alveolitis
(in SSc).
Pitting, onycholysis, dystrophy: psoriasis, chronic Reiter’s syn.
Splinter hge.: Vasculitis.

Mouth:
Xerostomia, dysphagia: Sjogren (SS)
Ulcers + genital = Behcet, SLE, Vasculitis (painful) & Reiter (painless).

Eye:
Xerophthalmia: Sjogren (SS) (usually asymptomatic)== Schirmer test
(screening, confirmed by Rose Bengal stain & slit-lamp. D: lip
biopsy).
Conjunctivitis: acute Reiter, SS.
Episcleritis & scleritis: RA, Vasculitis.
Iritis: AS, chr. Reiter.
Iridocyclitis: pausiarticular juvenile chr. arthritis.

Cardiopulmonary:
Dyspnea, chest pain, cough, haemoptysis: pleurisy, pericarditis
(SLE, RA, SSC), vasculitis, pulmonary embolism & infarction, CHF, IHD,
…

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Endocrinal arthropathy:
DM----------Neuropathic or septic arthritis.
Hypothyroidism: carpal tunnel S., & myopathy.
Hyperparathyroidism: pseudogout. Acromegaly: sever OA.
GIT:
Reflux, dysphagia---- SSC.
Abd. Pain, bleeding per rectum, diarrhea,= IBD--AS, Vasculitis.
Jaundice = Viral hepatitis with arthropathy or vasculitis, cryoglobuline.

Genitourinary:
Urithritis (dysuria, dyscharge)—Reiter, Gonorrhea,..
Ulcers--- Reiter, Behcet.

Renal (nephritic, nephrotic):

 Puffiness, smoky urine, HPT, bilateral LL pitting swelling = SLE,
Vasculitis, RA, drugs… amyloidosis.
 Renal colic (stones), nephrocalcinosis= Hyperparathyroidism.

Hematological:
 Anemia, leukopenia, thrombocytopenia = SLE, BM depression by
drugs, hypersplenism in RA.
 DVT, fetal losses= APS.
 Hemochromatosis—sever OA.

CNS:
 Neuropathy, fits, behavioral changes, weakness, TIA, strokes = Lupus
cerebritis, vasculitis.
 Temporal headache = GCA.

Others: HCV, HBV, HIV,…

Family history

Similar condition in the family.

Consanguinity.

Musculoskeletal diseases running in families:

1. RA. 2. Gout. 3. ARF.
4. AS. 5. Seronegative arthropathy (30% in PA).

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

6. OA especially nodal disease of the fingers. 7. Marfan’s syndrome.

**Pt. understanding of the dis., goals of TTT, & psychosocial consequences

must be discussed friendly bet. the pt.& his treating physician.
DD. of Musculoskeletal pain:
I- Articular or Non-articular in origin:
(a) Articular Pain (eg. Arthritis) ==

*Diffuse pain & tenderness allover the joint line.

*Aggravated by both active & passive joint

movement in ROM.

*Generalized joint swelling.

*Limited j. movement in all planes of ROM.

(b) Non-articular (periarticular) pain:==

To be differentiated from regional cellulites, erysipelas, peripheral neuropathy, skin injuries

&/or inflammations.
Diffuse Localized
*Generalized hypermobility. *Localized for periarticular structures
*Fibromyalgia Rheumatica. (ligaments, muscles, tendons, or
bursa).
*Localized swelling, tenderness,
limitation of movement & aggravated
by active movement only in the
direction of the affected structure.

Ex. of localized pain by its origin:

Ligament==

 Localized pain & tenderness at the point of attachment.

 Pain on stretch
 Instability if major tear.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Tendon==

 Localized pain & tenderness at the line of muscle attachment.

 Swollen tendon line.
 Pain on resisted active movement.

Bursa==Localized tenderness & swelling.

 Pain on stretching adjacent structures.

Muscle==

 Pain on active & resistant movement & on stretch of certain muscle.

II- Acute or Chronic onset:

Acute Chronic
Duration <6 weeks >6 weeks
Ex. *Infectious arthritis. *RA.

*Crystal- induced. *Seronegative

Spondyloarthropathy.
*Traumatic.
*OA.
*Reactive (Reiter, ?ARF).
* Chr. Sequences of trauma
or back problems.

III- Inflammatory or Non-inflammatory:

5 cardinal signs of inflammation:

*Swelling (synovial distention).
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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

*Warmth (the back of hand is a sensitive thermometer).

*Erythema (in septic & crystal arthritis + in palindromic RH.,

Reiter, ARF). *Tenderness. *Loss of function (limited ROM).

Clinical markers of disease activity in inflammatory arthritis:

*Duration of MS.

*Night pain.

*Severity of constitutional symptoms.

*Additional joint involvement.

NB. The severity of pain is less important marker of inflammation as it is

too subjected.

Comparison between Inflammatory & Noninflammatory arthritis:

Inflammatory Non-inflammatory
MS  >1hr.  <1/2 hr.
Fatigue  Significant.  Minimal.
Activity  Improve symptoms.  Worsen.
Rest  Worsen  Improve.
Systemic  ++  --
manifestations
ESR, CRP  ++  --
Corticosteroid  Improve  No effect
Ex.  RA.  OA.
 Systemic rheumatic dis.  Traumatic.
(SLE, SSC, Vas.).  Osteonecrosis.
 Infect.: Bact, Viral.  Neuropathic J.
 Crystal.  Metabolic
 Reactive (Reiter, RF). (hemochromatosis),
 Seroneg. (AS,IBD).
 Sarcoidosis, FMF,..  Endocrinal (thyroid,
DM, Acromegaly)

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

IV- Pattern of joint involvement:

(a) Number of affected joints:

* 1 joint = Monoarticular.

Acute Monoarthritis:

Inflammatory Noninflammatory
Crystal Traumatic

Bacterial Sickle-Cell Disease

Spondyloarthropathy Osteonecrosis

Palindromic Rheumatism

In cases of erythematious acute monoarthritis, exclude septic or

gouty arth. as a primary cause. Synovial fl. aspiration is diagnostic.

Chronic Monoarthritis:

Inflammatory Noninflammatory
Infectious: TB, Fung, Lyme. OA

Crystal. Osteonecrosis

Spon. A., Hemophilic Neuropathic

Synovial Tum. Adjacent bone lesion (Tum,Inf)

**2-4 joints affected= pausy or oligoarticular.

Ex.: Seronegative , Spondyloarthropatheis (AS, Reiter, PA & IBD)

*** >5 joints affected = Polyarticular. Ex.: RA, SLE.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

V- Distribution of joint involvement:

Symmetrical Asymmetrical
Ex. RA Reiter
SLE
PsA

AS
Peripheral Axial
Ex. RA AS
SLE
PsA (70%-also affects
IPJ--- sausage digits)

Reiter
Small Large
Ex. RA Seronegative
SLE
Reiter

RF

VI- Sequence of joint involvement:

1- Migratory (fleeting) polyarthritis:

Symptoms disappear in the affected joints to reappear in others.
Ex.: ARF., Gonococcal, Viral.
2- Additive
Symptoms persist with addition of new joint inflammation
Ex.: RA.
3- Intermittent
Attacks of remissions & exacerbations in the same joint.
Ex.: Gout.

Rheumatological Examination

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

General Examination
Pulse:
Rapid due to Anemia, fever (ARF or activity, SLE, infections)
Tachycardia out of proportion of fever (1ºc=10 b/m)= myocarditis
Bradycardia (HB), arrhythmia= SSc

Blood Pressure:
HPT = SLE, Vasculitis, SSc, RA + renal, CVS---drugs?
Hypo. = HF, dehydration, bleeding!

Pallor
Activity of CTD (anemia of chronic disease).
Anemia (hemolytic, iron def. bl. loss, aplastic-drugs, ..)

Cyanosis
IPF=SSc, RA (bronchiolitis, fibrosing alveoltis, Caplan’s lung),
Bilateral or extensive pleural effusion= SLE
Pericardial effusion=SLE
Ht. failure

Jaundice
Hemolytic = SLE
Drugs
Viral hepatitis associated with or causing arthritis.
Cryoglobulinemic arthritis in hepatitis pt.,Vasculitis.

Face
Malnutrition =TB, malignancy, sever disease, drugs.
Cushingoid= steroid, endocrinal arthropathy.
Alopecia=SLE, Drugs, SSc
Butter fly rash sparing the nasolabial fold=SLE
Heiotrope rash (puple-erythematous discoloration of upper eye
lid, nasolabial, forehead+ periorbital oedema)= DM.

Eye
Colors
Dry (xerophthalmia)=SS
Cataract: premature, posterior capsular=Steroid, chloroquine.
Puffiness: L. nephritis, NS, Amyloid, Drugs
Mouth

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Dry (xerostomia) = SS
Ulcers (B, R, SLE).

Neck:
Thyroid swelling – autoimmune + SLE, hypothyroid with carpal
tunnel, hypo or hyperthyroid with proximal muscle weakness.
Neck veins: CHF, SLE, NS, Pericaldial, pleural effusion,
LN: RA, Felty, SLE.

Hand
Clubbing: Fibrosing alveolitis in RA, SSc, IBD, hyperthyroid
Nail pitting, loss of luster, splitting= PA.
Onycholysis (separation of distal end from its plate):PA, thyrotox.
Splinter hemorrhage, tender Osler nodes at finger pulps (tender
palpable nodules)& Janeway lesions=palpable purpuric spots on
palm dt. microthrombi—necrotic lesions: RF+ SBE
Sclerodactyly: smooth, shiny, tapered fingers with taut, bound
down skin.

Palmar erythema: RA
Mus wasting: RA (interossei), carpal t. S (thenar).
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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Nodules: RA, ARF.

Tophi: GOUT
Heberden & Bouchard nodes: OA
Gottron’s papules (violaceous & flat erythematous & scally
papules on the extensor aspect of PIP, MCP, elbow, knee, medial
maleoli): PM/DM
Digital ulcers & gangrene: RA, SLE, Vasculitis, SSc
Nail bed infarcts= SLE-Vasculitis, RA, DM, SSc
Telangectasia of nail fold: DM, SLE.
RP: SSc, MCTD.

Mechanics hand= DM

Skin:
Characteristic rash: Butterfly malar, descoid,
photosensitive=SLE
Psoriatic lesions (well-defined, raised itchy erythematosus
plaques covered by a loosely adherent silvery scales) =PA.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Purperic eruptions,
Raised =Vasculitis
Flat=thombocytopenic purpera= SLE,
Felty, drugs (gold, D- penicillamine)
V-sign, Shawl-sign rash=PM/DM

Erythema marginatum (flat or raised annular

erythematous macules or papules
on trunk OR extremities) =ARF
Erythema nodosum (tender erythematous sc.
Nodules on extensor aspects- shins)=
Behcet, IBD, TB, Deep fungal infections,
leprosy, Sarcoidosis, drugs: sulfonamides,
oral contraceptives
SC. Nodules: Firm, non tender & not attached to skin. ARF (0.5
cm over bony prominences of elbows, knuckles, ankles and
occiput, don't ulcerate). RA (up to several cm, on
elbows, t. achilles, scapula, hands, feet, sclera &
myocardium), may ulcerate.
Livedo reticularis: (erythematous netlike deep vascular
discoloration mostly on LL)=Vasculitis, SLE
Telangiectasis: dilated venules, capillaries & arterioles, matte-
oval or polygonal macules 2-7mm on hands, face, lips, oral
GI mucosa- may bleed--anemia.
Thickening of the skin=SSc
Calcinosis: cutaneous deposits of calcium, firm, irreg.,
nontender,1mm-few cm, may inflame,on extensors of
elbows, knees , PIP, finger tips
Vesiculopustular lesions, hemorrhagic papules=gonococcal arthritis.

Tophi (irregular firm nodules on extensor of fingers, forearm, elbow,

achilles & helix of ear, may ulcerate discharging white chalky material
MSUM) + preceded 10 yrs. by acute Gouty arthritis=.

LL:
Oedema= NS, LN, amyloidosis (RA, Drugs), DVT (SLE, APS),
Ulcers: Vasculitis + Still’s, RA, SLE. Or hemolytic anemia.
Ischemia: Vasculitis.
Keratoderma blennorrhagicum =vesicles, pustules, on palms
& soles with thick hyperkeratotic plaques =Reiter

Genitalia:

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Genital & Oral Ulcers = Behcet (on scrotum or labia, may penis
or vagina), Reiter (with circinate balanitis= confluent eroded red
papules on corona & glands penis)

Heart:
Carry Coomb's murmur (Oedema of MV) = ARF
SLE----Libman-Sacks endocarditis=verrucous---post. Leaflet MV
Pericarditis, myocarditis, IHD, systemic, pulmonary HPT = SLE
& Vasculitis
Ankylosing Spondylytis--AR

Chest:
Pleurisy, effusion=SLE, RA VAS.
Pneumonitis, Alveolitis, Caplan's lung = RA
Pulmonary embolism, inf= APS

Abdomen:
Splenomegaly = Felty, JRA
HSM= SLE, RA

CNS:
PN, Lateralization, muscle weakness = Vas, SLE,
Entrapment neuropathy = RA

PM/DM

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Local Examination
Physical examination of the locomotor system is extensive &
complex; so, a brief screening procedure to pick up problems in certain
regions is more appropriate. If an abnormality is detected, more detailed
examination of the affected region can be undertaken.

Normal joint should be:

1. Asymptomatic 2. Looks normal
3. No special resting position 4. Moves smoothly through its ROM

Characteristic findings of inflammatory joint:

Synovitis:
 Most comfortable in neutral position.
 Decreased movements in all planes.
 Stress pain all direction (most sensitive).
 Capsular swelling/effusion (most specific).
 Joint line/capsular tenderness.
 Warmth.
 + Fine cripitus.

Tenosynovitis:
 Joint positioned to decrease tension on tendon.
 Decreased movement in the plan of tendon.
 Selective stress pain.
 Linear swelling & tenderness.
 + Fine cripitus. + triggering.

Mechanical arthritis:
 Abnormal shape (deformed joint).
 Coarse cripitus.
 Decreased movements in all planes.
 + Ligamentous stress pain/instability.
 + Synovitis.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Rheumatologic
Examination

GALS : Screening examination of MSK system.

(Gait, Arms, Legs & Spine)

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MD.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Inspection
 Attitude = Position of the affected area at rest.
 Swelling.
 Deformity.
 Muscle wasting.
 Skin changes over the affected MSK area (erythema,
discoloration or scars). Telangiectasia, rash, or bruising.
 Symmetrical affection of MSK elements.

Palpation
 Warmth = inflammation.
 Tenderness (diffuse or localized).
 Swelling (hard, cystic fluctuation or firm).
 Deformity (correctable or not), dislocation or subluxation.
 Cripitus =audible & palpable during movement (fine, or
coarse).
 Muscle state (normal or atrophied) & muscle power.

Movement
 Active = by the patient
 Passive = by the examiner
 ROM (range of movement)=depends on age, sex & race.
 Stress test (moving joint passively toward its limitation) =
universal=all direct. in synovitis, selective in localized lesions.
 Resisted active movement= test periarticular (ms, tn, en)
*Synovitis= restricted both active & passive movements in
all planes of ROM.
*Myositis, bursitis, tendenitis….= restricted active with
normal passive movements, only in the plane.
 Joint stability.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Functional assessment: self care, ambulation, lifting, grasping, sleep..

Examination of specific joint movements

Ask the patient to do active movements & compare with passive if

limited.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

I) Upper Limbs:
a) Hands=MCP, PIP, DIP J.

Inspect for: skin changes, swelling (Heberden on DIP,

Bouchard on PIP nodes), deformities (Swan neck,
Boutonniere, ulnar deviation & z-shaped thumb) & muscle
wasting.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Palpate for: tenderness, warmth, swelling, muscle bulk & power.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Z-shaped thumb

Movements:
 Open & spread the fingers (extension & abduction).
 Fist=Close all fingers (flex, add.) to reach the palm &
thumb closes over them.
 Grip=pt. maximum strength in grasping 2 fingers of the
examiner.
 Pinch the tips of thumb with index finger.
 Metacarpal squeeze: between the examiner’s thumb &
fingers proximal to metacarpal heads if tender= arthritis.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

b) Wrists=radiocarpal J.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Inspect & palpate for: swellings, warmth & tenderness.

Stress test: to elicit mild tenderness= mild arthritis

Movements: 09VH,W03.WMV
 Prayer position =full extension & dorsiflexion75 ْ .
 Full flexion=planter flexion 70 ْ.
 Ulnar deviation 45 ْ & radial deviation 20 ْ.
 Carpal tunnel syndrome provocation:

Carpal tunnel syndrome =Occurs when the carpal tunnel space is

reduced (e.g. when there is swelling of synovium due to inflammatory
arthritis). The resulting compression of the (median) nerve causes a
sensation of pins and needles and numbness and/or pain in the hand.

1) Tinel's sign =Paraesthesiae in lateral 3 1/2 fingers (mainly in the

middle finger) experienced on percussion over the flexor retinaculum at
the extended wrist.

2) Phalen's sign = The wrist is passively held in flexion for up to a

minute. A positive result is when the patient experiences paraesthesiae
in the fingers, usually predominantly the middle finger.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

c) Elbow=Humeroradial, radioulnar J.:

Inspect & palpate for:-

 olecranon bursitis.
 Synovitis= firm, tender, hot swelling at fossae between
olecranon & medial or lateral epicandyles.
 Subcutaneous nodules & tophi, at or below olecranon.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Movement: 09veb04.wmv
 Bend (flex=0-150ْ) & straighten both elbows (ext=0ْ).
 ْْWith elbows flexed at 90 ْ & fixed to his side (to prevent
shoulder movements) ask pt. to turn palms up (supination
0-90 ْ ) & down (pronation 0-90 ْ ) using thumb as
indicator.
 Resisted active movements:
Lateral epicondylitis & Medial epicondylitis.

d) Shoulders = Glino-humeral, scapulo-thorasic, acromio-

clavicular, sterno-clavicular J.:

Inspect for: skin changes, swelling, deformities& muscle

wasting.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Palpate for: warmth, swelling, tenderness over the anterior

aspect & tip of shoulder, acromio-clavicular, sterno-
clavicular, scapulo-thorasic , muscle bulk, contour & power.

Winging of the scapula due to a palsy of the long thoracic nerve. The
appearance of winging may be exaggerated by asking the patient to hold
the arms out in front of him and especially if they push against something
at the same time. .

Movements: 09vsh05.wmv
(Flexion, extension, abduction, adduction & rotation)

 Pt. put both hands behind the head with elbows pointing
laterally (abd, flx., & ext. rot).
 Hands down, hands behind back & thumb pointing up
marking the highest vertebra pt. can touch by each side
(ext., add. & int. rot.).

Restriction of movements &/or pain in the shoulder may be

due to abnormalities in:

1. Glenohumeral joint: pathology excluded if passive

external rotation not limited.
2. Rotator cuff muscles tendon inflammation=
commonest cause of shoulder pain as arm moves up
through mid arc of abduction (40-120 ْ ). (SITS=
supraspinatus, infraspinatus, teris minor &
subscapularis).

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

3. Acromioclavecular joint-OA---hard swelling &

tenderness with pain in shoulder abduction >120 ْ.
II) Lower limb:
a) Hip joint:
Inspect for: Gait, pelvic tilt-scoliosis, swelling,
deformities & muscle wasting.

Palpate for: warmth, swelling & tenderness.

Measurement:
True leg length=from ASIS—lateral maleolus (to
detect congenital or acquired disorders).
Apparent leg length= Umbilicus –medial maleolus (to
detect scoliosis, pelvic contractures--- pelvic tilt.

Movements:
 Hip flexion 0-120° & extension -10°.
 Internal 25° & external rotation 35° examined while
both hip & knee flexed 90°; using the tibia as indicator
for the angle of rotation.
 Leg roll maneuver: to examine Internal 90° & external
rotation 90°while hip & knee are extended, using foot
as indicator for the angle of rotation.
The last 2 tests are sensitive for hip pathology.
Trendelenberg’s sign: 09v08.wmv
Normally on standing on normal leg, the pelvis tilts to the
same side. On standing on the side of the diseased hip, the pelvis
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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

fails to tilt towards the same side, so, drops to the other
side=weak gluteus medius.

b) Knee

Inspection: Swelling, redness, muscle wasting, & specific deformities:

Genovulgum=knock knees. Genuvarum=bow leg.

Palpation: Swelling (soft, cystic or hard / diffuse, localized), warmth,

tenderness = localized or along joint line = inflammatory. Muscle
wasting / compare thigh circumferences 10cm above the patella.

Signs of knee effusion:

 Patellar tap = for large amount, left hand of examiner

compressing the suprapatellar & parapatellar areas—

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

pushing fluid behind patella, with other hand fingers

push patella against femur –tapping sensation.
 Patellar bulge sign=for small amount, milking effusion
from medial upward & laterally, then tap behind & lateral
to patella observing the medial patellar fossa for refilling,
thumb pressing on patella.

Movements: Flexion & extension (0-150)

Patellofemoral Crepitus: With examiner’s palm on knee during full

flexion & extension. Fine / coarse.

Patellofemoral compression test: push patella against femur while

knee in extension & pt. contracting quadriceps—sever pain &

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

tenderness=patello-femoral pathology.

Stability:
Lachman’s test =integrity of anterior cruciate ligament. Knee flexed
20, femur grasped with lt. hand & pulling tibia forwards with rt. hand.
Collateral ligaments: abduction & adduction (medial & lateral
displacement) stretch between tibia & femur while knee in flexion to
elicit any movement.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Popliteal area: Backer cyst-rupture-DD: DVT 09vkn07.wmv

c) Ankle & foot:

Inspection: synovial soft tissue swelling at both malleoli, DD.
Periarticular oedeme, cellulites & fat pad.

Deformities: Pes planus (flat foot= talar head displaced medially &
plantar-ward), pes cavus (high arch),

 Hallux valgus=lateral displacement of proximal

phalanges on metatarsal heads in RA.
 Cock-up (claw) toe: flexion of IPJ +MTP subluxation.
 Hammer toe: hyper ext. MTP, flex. PIP, hyper ext. DIP.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Palpation:

Tender ankle or MTP=synovitis, tenderness in between metatarsals 3 rd-

4th /2nd-3rd =Morton neuroma, over metatarsals=? march fracture.
Metatarsal compression test=squeeze between examiner’s thumb &
fingers just proximal to metatarsal heads= ?synovitis.

Movements: 09VK,F06.WMV

Ankle & foot=3 groups of joints:

* Tibiotalar=ankle—Plantar flexion 50° & dorsiflexion 20°.
* Subtalar=talocalcaneal j.: Stabilize the ankle or distal leg by
lt. hand & rotate the foot passively by rt = 5° of inversion
or eversion.
* Mid tarsal j.----Stabilize the heel=calcneum by lt. hand &
rotate the forefoot passively by rt. ---inversion 35° &
eversion 20°.
* 1st. MTP – plantar flexion 40° & dorsiflexion 65°.
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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

III) Spine:
Inspection:
Normal cervical & lumbar lordosis (concavity to back) & thoracic
kyphosis (front concavity)

Deformities: scoliosis (lateral deviation of spine), kyphosis

(anterior deviation), lordosis (posterior) & gibbus (kyphosis with
acute angle due to infection/TB or fracture).

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Palpation:
For tenderness, warmth, muscle wasting, bony abnormalities.

Movements:
 Cervical spine: notice any localized or radiating pain/
tenderness or limited mobility on active or passive:
Flexion=75, extension 60, Rt. & Lt. Rotation 80, Rt. & Lt.
bending 45.
 Thoracic spine: Rt. & Lt. rotation at thoracolumbar 45.
Chest expansion = difference bet. full expiration & insp>6cm
 Lumbar spine: Flexion 90, Extension 30, Lateral bending
(to touch sides of knees)15-30.
 Lumbosacral: anterior flexion--- increased distance bet.
D12-L1>7cm.
 Schober test: limited flexion ?AS.
Put a mark at the level of PSIS or lumbosacral j.&
another10 cm above, ask pt. to touch the toes with
extended knees, measure the distance bet. the 2 marks
should be>17cm.
 Finger tips-floor distance <10cm =index for combined
hip & lumbosacral flexion.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

09vsp09.wmv

Nerve Stretch signs

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Sciatic N root compression: L5 & S1, stressed by

1. Straight leg raising with hip flexion (normally to

90), if limited by pain flex knee to allow more hip
flexion, then straighten it if pain = +ve Lasegue
test.
2. Confirmed by flexing knee slightly, dorsiflex ankle
(+ve Bragard test),
3. Pressure over the popliteal fossa may also induces
root irritation (bowstring)

Femoral N roots=L2,3&4, stressed by asking pt. to lie

prone, flexion of knee—pain exacerbated by hip
extension.
Pain worsens after compressing the spine by pressing
on head vertically of standing or sitting pt.

Level of lesion:
L4 root=lost knee reflex & weakness of quadriceps.
L5=weak extensor hallucis longus
S1=lost ankle reflex & weak soleus

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Sacroiliac Joint:

pelvic compression with pt. on his side. Or by compression with

springing of the pelvis while pt. in flat supine position, pushing the 2
ASIP by the 2 examiner’s hands postero-laterally=trying to open the
book. Or by hip flexion & adduction to push knee toward the other
ASIS, iliac fossa. Or by local examination on prone position to elicit
any swelling, warmth, or tenderness.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

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MD.

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Approach to patient with musculoskeletal symptoms

Musculoskeletal complaint

History & Examination?

 Articular or non
 Acute or chr.
 Inflammatory or non.
 No. & distribution

Nonarticular: Articular?
 Traumatic
 Fibromyalgia
Acute or Chronic ?
 Polymyalgia R.
 Bursitis/tendenitis
Chronic>6W.
Acute<6 W.

Acute arthritis:
Inflammatory or noninfl.
 Infectious
 Crystal-induced
 Reiter’s
 Presentation of Chronic non-
Chronic inflammatory
Chr. Arth. arthritis= MS>1hr,
inflammatory
synovial swelling, warm,
arthritis
j.tender, syst. Manifes.,
CRP, ESR

>4 J = polyarthritis
1-4=mono-oligo A
Affects Wt. Br. J.
Chr. Inf.
(H&k)., DIP< CMC
PA- RS- PJA
Symetrical

PIP, MCP,
PA, RS
OA Osteonecrosis MTP
Charcotarthritis

RA
SLE, SSc, PM
Interpretation of Synovial fluid
09Vsum10.WMV

analysis

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

Indications for synovial fluid aspiration:

 Monoarthritis (acute or chronic).
 Joint trauma & effusion.
 Suspicion of joint infection, crystal, or hemarthrosis.
 Acute monoarthritis in pt. with chr. Polyarthritis.

Analyze fluid for:

 Appearance, viscosity.
 WBC count & differential.
 Gram stain, culture & sensitivity. Is the effusion
 Crystal identification by polarized microscopy. hemorrhagic?

Inflammatory or noninflammatory
articular condition? DD:
 Traumatic or
mechanical.
 Coagulopathy.
 Neuropathic.
Is WBC>
2000/cmm?

Noninflammatory: Inflammatory or septic arthritis?

 OA
 Traumatic

Is PMNs>
75%?
Other Inflammatory or septic?
Gram stain & culture essential.
Are crystals present?
Common Presentations Of
WBC>50,000/cmm
Common Rheumatic
? Diseases: Gout or Pseudogout.

1. Acute migratory polyarthritis

Inflammatory? (extremely Septic?
painful) affecting
large joints (knees, ankles, elbows & wrists) in a child (5-15ys.);

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

fever, exertional dyspnea (cardotis), involuntary movements

(chorea-may occur after months), skin erythematous plaques with
rounded borders over trunk (erythema marginatum), sc. nodules,
after a history (18 days)of URTI. (Group A-B-H.
strept.=Rheumatogenic) = . ARF

2. Chronic polyarthritis affecting small joints bilaterally &

symmetrical, with additive sequence in female. Both hands are
almost involved + MS>1hr. deformities, with systemic and extra-
articular effects, nodules, RF, X-R= .
RA

3. Symmetrical polyarthritis/arthralgia affecting peripheral joints in

middle aged female, with FUO, butter fly rash, photosensitivity,
alopecia, oral ulcers, headache (HPT), behavioral changes, +fits,
puffiness/LL swelling, dyspnea, chest pain, pallor, easy fatigue,
peripheral vascular manifestations (ischemia, RP, DVT), smoky
urine = .
SLE

4. Chronic oligoarthritis affecting large axial joints, LBP & morning

back stiffness for >3 months in a male patient, improved by
exercise, unrelieved by rest+ limitation of lumbar spine
movements & chest expansion=AS. If with symptoms & signs of
IBS; = .
enteropathic arthritis

5. Sudden LBP after lifting heavy object or bending with radiation

to lateral leg= disc herniation & sciatica.

6. Asymmetrical oligoarthritis affecting large, small joints (sausage

digits) &/ or back (Spondyloarthropathy) with psoriatic skin &
nail pitting= . PsA

7. Arthritis/enthesitis, urethritis, conjunctivitis or uveitis, cercinate

balanitis, keratoderma blennorragicum & painless mucosal ulcers;
1-4w after attack of GI or genitourinary infections= RS.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

8. Arthritis in large weight bearing joint in obese post menopausal

woman pain increasing at night after the day time usage +/-
Heberden & Bouchard nodes= . OA

9. Polyarthritis/arthralgia, joint stiffness, flexion contractures in a

female with tight skin, sclerodactyly, telangiectasia, sc.
calcifications, progressively repeated attacks of RP, digital
ulcers/gangrene, dysphagia, GERD, dyspnea, cyanosis, cardiac
and renal troubles= .
SSc

10. Acute intermittent attacks of monoarthritis with sever pain,

redness, swelling of 1st MTP=podagra, ankle, knee-exclude
septic arthritis (30% polyarticular) after diuretic, alcohol,
surgery, CRD, wt. Reduction & inf. = . Gout

11. Recurrent oral ulcers, > 3 times in 1yr.+ genital ulcer or

scare, uveitis, cells in vitreous, retinal vasculitis, superficial
thrombophlebitis, erythema nodosum, papulopustules + pathergy
(2mm eryth- 1-2days-25g-5mmdepth) =Behcet.

12. Arthritis, palpable purpuric eruptions in LL & abdominal

pain + hemoptysis & GI bleeding in a child after upper
respiratory tract infection = .
HSP

13. A history of asthma, allergic rhynitis, atopy, peripheral

neuropathy, cutaneous eruptions, pericarditis, cardiomyopathy,
myocardial infarction and hypereosinophilia may suggest Churg-
Strauss syndrome (CSS).

14. In any patient over the age of 50 with recent onset of

headache, Jaw claudication and scalp tenderness, loss of vision,
myalgias, fever (FUO), a high ESR, or anemia ??? The diagnosis
of should be considered.
GCA

15. Involvement of the lung (dyspnea, hemoptysis), kidney

(hematuria, proteinuria), and upper respiratory tract (nasal sinus)
should suggest the possibility of WG.

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Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

16. Arthritis, acute onset of high fever, bilateral conjunctival

congestion, "strawberry" tongue. Painful cervical LN, exanthema
of the trunk, carditis with heart murmurs and ECG changes.
Coronary artery lesions, abdominal pain, vomiting, & diarrhea in
child <5yrs.= Kawasaki.

17. Myalgias, arthralgias, fever, sudden onset of sever HPT, LL

swelling (nephrotic syndrome) & renal failure (GN), chest pain,
dyspnea on exertion (angina or myocardial infarction,
pericarditis). Abdominal pain, bleeding, and bowel obstruction or
perforation, intraperitoneal hemorrhage (Rupture of mesenteric
aneurysm). Peripheral neuropathy, painful mononeuritis
multiplex, seizures, CVA. Palpable purpura, urticaria, livedo
reticularis, peripheral gangrene and skin nodules. Orchitis and
epididymitis in a male, around 40s = PAN.

18. Myalgias, arthralgias & Symptoms of vascular insufficiency

(claudication, transient visual disturbances, and syncope) occur
with bruits, weak pulses, and discrepancies of limb blood
pressure (LL>UL), in young women 15-25yrs.=Takayasu.

19. Arthralgia, Proximal muscle weakness & tenderness,

heliotrope rash on the upper eye lid, Gottron eruption over PIP &
MCP. Cardiomyopathy, Ht. Failure + S & S of malignancy (lung,
stomach, colon & breast)= Polymyositis & Dermatomyositis

20. Pain & tenderness at the lateral epicondyl & extensor mus.
Close to it dt. repetitive wrist extension or supination & pronation
increased by resisted active wrist extension= Tennis elbow=
lateral epicondylitis

21. Carpal tunnel syndrome (CTS) commonly occurs in

diabetic, hypothyroid & acromegalic patients. Up to 15% of all
patients with CTS will have diabetes. Patients present with
numbness in the median nerve distribution. Nocturnal

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 Reumatology Sheet Dr./ Abdel Azeim Alhefny,
MD.

paresthesias, hand pain, and pain radiating to the elbow or

shoulder (Valleix phenomenon) can also occur. Tinel’s and
Phalen’s signs may be positive. Thenar atrophy is a late sign and
indicates muscle denerva tion.

22. Chronic diffuse pain (>3months), tender points, normal lab.,

+ MS, fatigue, sleep disturbance, depression, anexiety, headache,
paresthesias & RP = Fibromialgia Rheumatica.

Raynaud's phenomenon =
Blanching of the extremities on exposure to cold. It is usually followed by blue,
cyanotic discolouration on rewarming. It may occur in isolation or in association
with a connective tissue disease

References
 Atlas Rheumatic diseases
 Barbara Bates, A guide to physical examination & history taking, 6th ed , 1995.
 Davidson's principles & practice of Medicine 19th ed. 2002.
 Harrison's principles of Internal Medicine, 14th ed. 1998.
 ILAR, EULAR Reumatology Web siteS
 Kelly's text book rheumatology 6th ed. 2001.
 Manual of Reumatology & outpatient Orthopedic disorders, 4th ed. 2000.
 Medscape Reumatology Web sites
 Oxford handbook of Rheumatology, 2002.
 Rheumatology examination &injection techniques, 1992.
 Rheumatology Secrets, 2nd. Ed. 2002.
 WWW.oup.com

Arthrocentesis NEJM.wmv musculoskeletal.wmv

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