Rheumatology History and Examination

Rheumatology – The Painful Joint

Components to be assessed:

1.       History

2.       Examination

History taking

·         General questions

o   Demographics

o   Presentation

o   Underlying malignancy

·         Diagnostic questions

·         Follow up investigations

·         Management

Differential diagnoses to consider

1.       Osteoarthritis

2.       Viral arthritis

3.       Rheumatoid arthritis

4.       Crystal deposition – Gout, Pseudogout

5.       Seronegative spondyloarthropathies:

a.       Reiters/reactive arthritis

b.      Ankylosing spondylitis

c.       Enteropathic arthritis

d.      Psoriatic arthritis

6.       Infective:

a.       Septic arthritis à complication is osteomyelitis: gonococcus, Staphylococcus

b.      Endocarditis

c.       Tuberculosis

7.       Cancer à primary or metastatic

Consider psychogenic factors in chronic pain syndrome e.g. back pain

Consider the presentations of each when taking history

1.       Demographics – M vs F, age, ethnicity

2.       Presentation – monoarthritis vs polyarthritis

3.       Which joint?

4.       Underlying malignancy

5.       Infection – recent illness, history of trauma

6.       Systemic symptoms: fever, lethargy, night sweats, rash, dry eyes and mouth, red eyes

7.       Medications:  diuretics

8.       Family history: rheumatoid arthritis, seronegative spondyloarthropathies

9.       Time course: 

a.       Acute 1-4 hours, intense pain – blood infection, crystals

b.      Subacute 1-2 days and soft – fluid (synovial effusion)

c.       Chronic and bony – osteoarthritis

d.      Chronic and soft/boggy – synovial proliferation

Investigations – according to history

1.       Joint

a.       X-Ray – established disease

b.      Ultrasound – useful in shoulder and hip

c.       Joint aspirate

2.       Systemic

a.       FBC à increased WCC

b.      ESR, CRP à autoimmune conditions

c.       Uric acid

d.      Bone scan

e.      Screening for Connective tissue disorders – Anti-CCP, Rhematoid factor, antinuclear antibodies, dsDNA antibodies

Random antibodies – antinuclear antibody (screening for SLE), dsDNA antibodies, ENA antibodies etc, pretty sure these are not really necessary knowledge, the main ones to remember are the ones for Rheumatoid arthritis

HLAB27 – Should not be used as a screening test

Management basic concepts – hard to make this general for all arthritis

1.       Conservative managements: heat packs

2.       Stop the inflammation and ease pain – Paracetamol sustained release, NSAIDs, Steroids (intraarticular)

3.       Joint aspirate can help alleviate pain in both gout and septic arthritis

4.       Treat the underlying cause

a.       Gout:  allopurinol 6 weeks after attack has ceased; weight reduction, normal diet, avoid purine-rich foods, reduce alcohol intake, fluids, avoid diuretics and salicylates

b.      Infective:  IV antibiotics will be required and joint aspirate

5.        

Examination

Overall principles for all joint examinations:

1.       Look – deformity, wasting

2.       Feel – joint lines, swelling, temperature

3.       Move

a.       Active   -              tell patient to

b.      Passive

c.       Resisted

4.       Measure – this is from Talley and O’Connor (T&C)

5.       Special tests/Function

The following are just skeleton summaries of joint examinations, practice getting the main systematic approach into your mind first as that is more important in an OSCE scenario.  The details will fall into place as you learn the aforementioned potential differential diagnoses. 

The main aetiologies to remember in a rheumatological joint examination are osteoarthritis, rheumatoid arthritis, gout and septic arthritis.

Also, remember to use the terms valgus and varus as these will make you look like a pro!

Shoulder –know this well

Look

Feel – tenderness and swelling, crepitus, joint line, biceps groove

Move – abduction, adduction, flexion, extension, internal rotation, external rotation

Special tests:

        Apley scratch test

        Anterior stability – apprehension test

Findings:

Painful limitation of movement in all directions – intra-articular disease

Painful limitation of movement in one plane – tendonitis

Painless weakness – tendon rupture

Localised tenderness on palpation over groove – biciptal tendonitis

Limited shoulder abduction in middle range – suggestive of rotator cuff problems (supraspinatus, infraspinatus, subscapularis, teres minor)

Remember to examine the neck and axillae in patients with shoulder pain and consider other causes of the shoulder pain such as spinal nerve problems

Elbow – kind of awkward to ask you about for a medicine OSCE but could come up

Hands & Wrist – know this well, abridged summary from T&C to practice with

General inspection

Look at in turn the wrists, MCP joints, PIP and DIP joints

·         Swelling

·         Deformity

·         Muscle wasting

·         Skin overlying

Say what you are looking for and why, this will help you remember it

Feel and move passively in turn the wrists, MCP joints, PP and DIP joints

·         Synovitis

·         Effusions

·         Range of movement

·         Crepitus

·         Temperature, cap refill, peripheral perfusion

Assess neurovascular briefly – median, ulnar, radial light touch

Hand function

·         Grip strength

·         Key grip

·         Opposition strength

·         Practical ability?  Unsure what this is

Look at the elbows for subcutaneous nodules, psoriatic rash etc

Other joints

Signs of systemic disease

Hip – kind of awkward to ask you about for a medicine OSCE but could come up

Knee

Pretty self explanatory

Look – all the usual things, swelling, deformity, quadriceps wasting is important

Feel – Quadriceps wasting, warmth over knee and synovial swelling.  Patellar tap for joint effusion.  Bulge sign used for detecting small effusions

Move – flexion, extension

Test ligaments:

                Collateral ligaments

Cruciate ligaments – anterior and posterior drawer test

Special tests:

Apley’s grinding test – not usually performed

McMurray’s test

Ankle – kind of awkward to ask you about for a medicine OSCE but could come up

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