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 Loss of function Stiffness Fatigue and malaise Swelling Depression and fear Deformity Sleep disturbance Weakness Symptoms of systemic disease Instability 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: warmth Testing 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 thickening Joint effusion Bony enlargement Combination 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 RF negative Reactive arthritis HLA-B27 Psoriatic arthritis Sacroilitis/ spondylitis IBD arthritis 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: skin Redness 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 Rheumatoid Arthritis Symmetrical Polyarthritis Large/ small Peripheral Upper/ lower Ankylosing Spondylitis Asymmetric al Oligoarthriti Large s Central and peripheral Lower Psoriatic Arthritis Asymmetric al Oligo/ Large/ Polyarthritis small Peripheral Upper/ lower Reacive Arthritis Asymmetric al Oligo/ Large/dacty Peripheral Polyarthritis litis Lower Gout Asymmetric al Mono/ oligoarthriti s Lower/ upper Large/ small Distribution Upper or lower limbs Peripheral 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