Rheumatologic Conditions

Beatriz Y. Hanaoka, M.D.

Division of Rheumatology

April 20, 2011

Characterization of an MSK problem

What are the symptoms?

Site and distribution of symptoms

Chronology

Associated symptoms

Symptom response to health interventions

Preceding factors

What is its impact?

Symptoms of an MSK Problem

Pain

Stiffness

Swelling

Deformity

Weakness

Instability

Loss of function

Fatigue and malaise

Depression and fear

Sleep disturbance

Symptoms of systemic disease

MSK exam

In examining the MSK system, it is important to keep the concept of function in mind.

Note any gross abnormalities of mechanical function with the initial introduction to the patient.

Continue to observe for such problems throughout the interview and the examination.

Case #1

40 yo W who was previously in her normal state of health.

She presents with a 4 month history of worsening pain and swelling involving her 2,3,4 and 5 PIPs bilaterally, right 2 and 3 MCPs, wrists and feet bilaterally.

She also endorses “bumps” on the dorsal aspect of her hands, morning stiffness lasting approximately 2 hours, dryness in her eyes and mouth and, Raynaud’s phenomenon.

Case #1

Feel: warmthTesting for warmth using the back of the hand. 

Case #1

Case #1

Case #1

Case #1

What does this patient have?

Case #1

Rheumatoid arthritis

Secondary Sjogren’s syndrome

Secondary Raynaud’s phenomenon

Look: swelling

Synovial thickeningJoint effusion

Bony enlargementCombination

Common deformities of the hands

Hand deformities in RA

Look: wasting

Case #2

35 yo M with a h/o psoriasis for 5 years.

He endorses a 2 month history of pain and swelling in his right knee and left second toe, associated with 2 hours of morning stiffness.

He takes ibuprofen 800 mg as needed for pain with partial relief.

Case #2

Case #2

Case #2

Seronegative Spondyloarthropathies

Ankylosing spondylitis

Reactive arthritis

Psoriatic arthritis

IBD arthritis

RF negative

HLA-B27

Sacroilitis/ spondylitis

Inflammatory peripheral arthritis (often asymetrical)

Extra-articular manifestations Ocular inflammation Enthesopathy Skin changes (psoriasis,

erythema nodosum)

Common deformities of the spine

What spinal deformity is this?

What spinal deformity is this?What is the underlying disease?

Case #3

54 yo M with a history of HTN, DM2 and CRI presenting with sudden onset pain and swelling in his R 1st MTP joint that started 2 days ago.

Case #3

Look: skinRedness as seen in gout.

This is a valuable indicator of the intensity of underlying joint inflammation

Case #3

Case #3

What is the diagnosis?

What is the pattern of the arthritis distribution?

Diagnosis Symmetry

No joints involved

Large or small

Distribution

Upper or lower limbs

Rheumatoid Arthritis

Symmetrical

Polyarthritis

Large/ small

Peripheral Upper/ lower

Ankylosing Spondylitis

Asymmetrical

Oligoarthritis

Large Central and peripheral

Lower

Psoriatic Arthritis

Asymmetrical

Oligo/ Polyarthritis

Large/ small

Peripheral Upper/ lower

ReaciveArthritis

Asymmetrical

Oligo/Polyarthritis

Large/dactylitis

Peripheral Lower

Gout Asymmetrical

Mono/ oligoarthritis

Large/ small

Peripheral Lower/ upper

What is the diagnosis?

Regional examination of the MSK

Hand and Wrist Video

Elbow Video

Shoulder Video

Spine Video

Hip Video

Knee Video

Ankle and Foot Video

Conclusion

What are the symptoms?Site and distribution of symptoms

Chronology

Other associated symptoms

Symptom response to health interventions

Preceding factors

What is its impact?

Questions?

Cervical spine

Temporomandibular joint

Dorsal spine

Hand

Wrist

Elbow

Shoulder

Hip

Knee

Ankle and Foot