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Rheumatology E-learning
University of Szeged
Department of Rheumatology and Immunology
Case history in rheumatology
History of the presenting musculoskeletalcomplaint Almost always: pain
Exact location
Character
Time of onset/worsening
Exaggerating and easing factors
Functional disturbance
Stiffness
Limited range of motion
In what and to what extent is the patient restricted?
Origin of pain
Joint Inflammatory arthritis
Osteoarthritis
Bone
Soft tissue Tendon, tendon sheath, tendon insertion (enthesis),
bursa
Nerve (neuralgia)
Ischaemia
Referred visceral pain
Character of the pain I.
Pain of articular origin: Associated with the movement of the involved joint
Osteoarthritis (arthrosis): pain at use and movement-initiation E.g. raising from a chair, starting to walk (hip and knee
osteoarthritis)
Lumbar spine pain: exacerbated by lifting, raising from bed or bending down – eases at rest
Inflammatory arthritis: pain worsening at rest Morning stiffness – hands – in rheumatoid arthritis it can be
several hours
Ankylosing spondylitis – worsens at night, the patients is woken up by the pain several times, most intense in the morning, eases during the day
Character of the pain II.
Pain of bony (osseous) origin: Permanent, generally strong, independent of movement Tumour, metastasis, pathologic fracture
Pain of tendons, tendon-sheaths or tendinealinsertions (entheses) Sharp, sudden Triggered by particular types of movement (often of movements
of other joints or areas – e.g. humeral epicondylitis is triggeredby finger movements)
Triggered by direct pressure on the enthesis Pain of nerves (neuralgia)
Tearing, ripping, burning or piercing type Lumbo-ischialgia (sciatica), cervico-brachialgia – the pain is
referred to the corresponding dermatoma, occasionallyassociated with numbness, reduced sensitivity (hypaesthesia), motor deficit or reflex alterations
Entrapment („tunnel”) syndromes – the location corresponds tothe course of the peripheral nerve, pressure of special triggerpoints elicits the pain (Tinel sign)
Further anamnestic data – dysfunction
Hands
Squeezing force is reduced. In more severe cases, the fist closure is impaired
Dressing, buttoning, cutting with knife, opening of bottles, faucets, locks…
Shoulders
Dressing, raising of objects, reaching for objects…
Lower limb
Restriction of walking distance, inability to put on socks, problems with shoes, with squatting…
Further anamnestic data
How many joints hurt you? – Mono-, oligo- orpolyarthritis
Migratory (e.g rheumatic fever), intermittent (e.g. gout) or persistent (e.g rheumatoid arthritis)?
The onset of symptoms: insidious (e.grheumatoid arthritis) or acute (reactive arthritis, gout, trauma)?
Fever? Weight loss? Fatigue? Before the onset of symptoms: infection (e.g.
reactive arthritis, SLE exacerbation), overuse (e-g- soft tissu rheumatism), tick-bite (e.g. Lyme arthritis), travel abroad (tropical infection-associated arthritis)?
Further anamnestic data II.
Further symptoms? Easy sunburning on the face (SLE)? Psoriasis? Other skin symptoms (vasculitis, Reiter’s syndrome)? Dry mouth or eye (Sjögren’s)? Ulcer (aphta) in the mouth (SLE, Behcet)? Eye inflammation(spondyloarthritis, Sjögren’s)? Blanching or blueing of the fingers in response to cold-exposure (=Raynaud’s phenomenon – autoimmune connective tissue diseases)? Abdominal pain, diarrhaea, bloody stools (vasculitis, inflammatory bowel-disease-associated arthritis)? Problems with urine (reactive arthritis)? Stabbing pain in the chest on breathing in (=pleuritis – SLE)? How many steps you can ascend (until dyspnea) (interstitial lungdisease – autoimmune connective tissue diseases)?
Case history – other questions to clarify
Other known illnesses IBD, psoriasis, uveitis, endocrine illness, diabetes, frequent
infections (immune deficiency) Previous illnesses
Thrombosis, stroke (antiphospholipid sy), tumour, urinary stone(hyperuricaemia), fractures (osteoporosis)
Obstetric history Repeated spontaneous abortions (antiphospholipid sy)
Drugs Diuretic (hyperuricaemia), NSAID, intramuscular injection,
corticosteroid (osteoporosis) Social history
Occupation, employment status (soft tissue rheumatism, degenererative spine disease), smoking (rheumatoid arthritis, lung-cancer-associated arthritis), exposure to sunshine (SLE)
Family history Autoimmune disease, psoriasis, young-age musculoskeletal
(inflammatory) illness
Polyarthritis – early rheumatoid arthritis
Physical examination of the joints
Inspection: Swelling
Redness
Deformity
Other discolouration
Palpation Nature of the swelling
○ synovitis = intraarticular balloting fluid = active arthritis → treat!;
○ or periarticular diffuse soft tissue thickening – chronicarthritis ≠ activity sign;
○ or bony enlargement – osteophyte in osteoarthrosis)
Tenderness – exact location helps to identify theorigin of the complaints – joint? tendon? skin? subcutaneous tissue?
Physical examination of the joints II.
Motion Active (by the patient) and passive (by the doctor)
○ If active is less than passive: muscle weakness, paresis, tendonrupture
Limitation of range of motion○ Involvement (both inflammatory or degenerative) of the joint itself
○ The extent of limitation correlates somewhat with the severity ofjoint inflammation or damage (e.g. limitation of fist closure withhand small joint and wrist inflammation in rheumatoid arthritis)
○ Contracture : permanent limitation of movement by articularcartilage damage or periarticular fibrosis
Acute gouty attack
Chronic tophaceous gout
Palpation of joints1. Identification of the joint space
(interosseous space)
2. Pression:
if tender: indicates joint pathology
(inflammatory or degenerative)
if balloting fluid is palpated = synovitis = active
arthritis;
Verification of synovitis is also important for
the determination of intraarticular injection site
Reminder
active arthritis: 1. activity
sign of a systemic
disease 2. destroys the
articular cartilage →
treat!
RA vs erosive osteoarthritis
(arthrosis)
Heberden’s
arthrosis
Bouchard’s arthrosis
Arthrosis: bony bulks, not
synovitis, in DIP or PIP joints
(RA: wrist, MCP and PIP are
most often inflamed)
Spinal column
Degenerativeillnesses: Weakening of the
intervertebrate disc○ Dehydration,
degeneration, slowly, proportionally to age -discopathy
○ Abruptly, usually after a sudden inappropriatemovement –protrusion, discherniation
Cervical spondylosis
The connection between the adjacent vertebrae becomes
unstable – dyslocation of the vertebrae
Mechanic irritation– inflammation of the neighbouring soft tissues
Increased muscle tone – myalgia
Wearing-off of the margins of the vertebrae – calcification of the
surrounding bony surfaces - spondylosis
Inflammatory spinal diseases
Spondyloarthritis
Common, chronic, disabling inflammatorydiseases involving the intervertebrate small joints, the intervertebrate discs and ligaments
Ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease-associated arthritis, reactive arthritis, etc.
Key features: pain, restricted movement, progressive bony fusion (ankylosis)
Peripheral involvement (arthritis, enthesitis) is common
www.images.rheumatology.org
Inspection:
Increased
thoracic
kyphosis
Hump
(gibbus)
Case history in spinal pain – points
to clarify Localisation:
Low back (lumbar), neck (and upper shoulder), upper back (thoracic)
Onset: ○ sudden: disc herniation, vertebral compression
○ Insidious: spondyloarthritis, chronic degenerative diseases
Easing and exacerbating factors○ Worst at night and morning, eases during movement = INFLAMMATORY
TYPE PAIN – spondyloarthritis, septic spondylodiscitis
○ Worsens after movement (i.e. work, walk, standing), relieved by rest = MECHANICAL TYPE PAIN – degenerative diseases, vertebralcompression fracture
Refers (radiates) to limbs (= nerve root compression): lumbo-ischialgia, cervico-brachialgia
Neurological deficit (loss of sensation, paresis, urinary or fecalincontinence) – nerve, cauda equina or spinal cord compression
Sciatica – pain due to ischiadic nerve
compression
Laségue test: positive, if an
„electric” sudden linear pain is
elicitated
Hypaesthesia
Motor deficit
Loss of reflexes
L-IV: patella
S-I: Achilles
Physical examination of the spinal column
I.
Inspection: Physiological curves
○ Kyphosis
○ Scoliosis
Fixed
Antalgic
○ Hump (gibbus)
Palpation: Spinosus process tender on knocking: compression fracture,
vertebral abscess
Spastic paravertebral muscles – indicate any pathology at thecorresponding spinal level
Range of motion Neck: ante- retroflexion, lateral flexion, rotation. Occiput to
wall, chin to sternum, ear to shoulder, chin to shoulderdistances
Thoracic: chest expansion in deep inspiration (normal > 5 cm)
Lumbar: anteflexion (next slides), lateral flexion
Decreases in all types of spinal diseases
Helps to localise pathology, to assess severity and progression
Neurological examination Sensation of touch in fingers, toes and proximally –
dermatomes!
Paresis – proximal and distal muscles
Reflexes – patellar, Achilles, biceps, triceps, radial
Physical examination of the spinal column
II.
Restricted range of motion of the lumbar
spine in ankylosing spondylitis
https://www.slideshare.net/drdsabat/ankylo
sing-spondylitis-ug-lecture
https://www.slideshare.net/drdsabat/ankylosing-spondylitis-ug-lecture
Physical signs of ankylosing spondylitis
Mennel’s sign - sacroileitisFinger to ground distance
„Alarming signs” in a patient with spinal
pain
The pain is exacerbated by rest – inflammation Permanent pain not related to movement –
vertebral compression, tumour Motor deficit, cauda equina syndrome (bladder
or rectum sphincher dysorder, perinealhypaesthesia) – urgent neurosurgical referral
Nerve root compression sign (Laségue test), dermatomal sensory deficit – disc herniation –neurosurgical referral only if conservativetreatment fails
Other conditions: acute lumbago (low back pain, chronic low back pain, lumboischialgia, uncomplicated disc herniation – no detaileddiagnostic procedures are needed. Advise fewdays of bed-rest, simple analgesic, earlymobilisation, active rehabilitation
Enthesitis
Inflammation of the tendons or their insertion sites
Localisation: Tennis elbow (lateral epicondylitis), golfer’s elbow (medial
epicondylitis)
Rotator cuff tendinitis
Achilles tendinitis
Patella tendinitis
Causes: repetitive overload (sport, work – inappropriaterepeated activities), trauma, direct irritation, systemicillness (rheumatoid arthritis, spondylarthropathy(enthesitis), polymyalgia rheumatica)
Physical finding: tenderness upon direct pressure; thepain is triggered by the blocked action (isometric musclecontraction) of the involved tendon
Lateral epicondylitis of the humerus
(tennis elbow)
Pain in the lateral epicondylar region is provoked by resisted extension of
the hand, i.e. contraction of extensors inserting at the lateral epicondyle
Rotator cuff injury – „middle arch sign”
Supraspinatus muscle tendon or the adjacent
subacromial bursa are inflamed (and not the shoulder
joint inself). Pain is provoked by elevation of the arm,
when the inflamed tissues impinge under the
acromion. The pain is highest at the middle third of the
elevation arch of the arm and at internal rotation of the
shoulder
Plantar fasciitis
Bursitis - gouty olecranon bursitis
Soft, balloting mass. Differentiation from arthritis: The localisation is
consistent with the anatomical place of a bursa, subcutaneous,
easily movable, and the interosseus space (joint) is not palpable.
Trochanteric bursitis
Pain at the hip region, thatincreases when lying on theinvolved side
Hip movements are normal
Direct pressure on the greatertrochanter when the patient lieson the side triggers the pain
Ultrasound or – in case of calcification – X-ray confirmsthe diagnosis
Nerve entrapment syndromes Carpal
tunnel syndrome
Wrist pain radiating to the I-III fingers, causing numbness and sensory dysfunction
In more severe cases: anaesthesia, weakness of the flexion of fingers, thenar atrophy
Neuralgia: burning,
pricking, stabbing
pain with numbness,
needle-and-pin
feeling
Carpal tunnel syndrome– Tinel sign
Pressure on the
compression
site will elicit an
„electric” type
sudden pain
corresponding
to the area
supplied by the
nerve
Cubital tunnel syndrome
Compression of the ulnar
nerve at the medial
aspect of the elbow
Symptom: pain,
numbness, hypaesthesia
in the IV-V. fingers,
weakness of the flexion of
the IV-V. finger
Femoral neuralgia
Femoral nerve laesion, usually inthe femoral canal
Causes: hip osteoarthrosis, lumbarspine deformity, overuse
Symptoms: pain at the anterioraspect of the thigh and the knee, numbness at this region, quadricepsmuscle weakness, abnormal gait, decreased or lost knee jerk reflex
Direct pressure on the femoralnerve is positive
Femoral sign: in prone position: flexion of the knee causes a sharp, neuralgiform pain at the anterioraspect of the thigh
Medial tarsal tunnel syndrome
Compression of the tibialis posterior nerve
Cause: flat foot, valgus deformity or inflammation of the ankle, exostosis, irritation by shoe
Symptoms: pain and numbness in the sole, weakness of plantar muscles (short toe flexors)
Tinel sign