Rheumatologic Conditions

1. Rheumatologic Conditions Beatriz Y. Hanaoka, M.D. Division of Rheumatology April 20, 2011

2. 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?

3. 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

4. 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.

5. 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.

6. Case #1

7. Feel: warmth Testing for warmth using the back of the hand. 

8. Case #1

9. Case #1

10. Case #1

11. Case #1

12. What does this patient have?

13. Case #1 • Rheumatoid arthritis • Secondary Sjogren’s syndrome • Secondary Raynaud’s phenomenon

15. Look: swelling Synovial thickening Joint effusion Bony enlargement Combination

16. Common deformities of the hands

17. Hand deformities in RA

18. Look: wasting

19. 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.

20. Case #2

21. Case #2

22. Case #2

24. Seronegative Spondyloarthropathies • Ankylosingspondylitis • 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, erythemanodosum)

25. Common deformities of the spine

26. What spinal deformity is this?

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

28. 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.

29. Case #3

30. Look: skin Redness as seen in gout. This is a valuable indicator of the intensity of underlying joint inflammation

31. Case #3

32. Case #3

33. What is the diagnosis?

34. What is the pattern of the arthritis distribution?

35. What is the diagnosis?

36. Regional examination of the MSK

37. Hand and Wrist Video

38. Elbow Video

39. Shoulder Video

40. Spine Video

41. Hip Video

42. Knee Video

43. Ankle and Foot Video

44. 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?

45. Questions?

47. Cervical spine

48. Temporomandibular joint

49. Dorsal spine

50. Hand