Rheumatology Sheet from Rheumatology Department, Faculty of Medicine, Zagazig University, Egypt. Disclaimer : not my slide. Just uploading for my personal use..

1. Dr. Marwa Hany

2. • To understand what are rheumatic diseases & what
are the different types
• To be able to take detailed history from a patient with
rheumatological disease
• To be able to interpret collected information in the sheet
• To understand the importance of early and appropriate
care of patients with rheumatic diseases

3. • What is a rheumatic disease ?
• What is the classification ?
• What are the different types ?

4. A Rheumatic Disease is …..
a disease of the Musculoskeletal System

5. Classification
Inflammatory Diseases
Mechanical/ Degenerative Diseases

6. Rheumatic diseases
Rheumatoid Arthritis &
its varients:
Sjogren’s disease,
Felty disease,
Palindromic Rheumatism
Connective tissue
diseases
SLE
Scleroderma
Polymyositis
Dermatomyositis
Mechanical
/Degenerative
Osteoarthritis
Disc prolapse
Spondylolisthesis
Others:
Crystal induced (Gout)
Endocrine associated
Blood disorders associated
Malignancy associated
Seronegative
Arthropathies
Ankylosing Spondylitis
Psoriatic arthropathy
Reactive arthritis (Reiter)
IBD associated arthropathies

7. Joint Nomencalture

8. • Personal History
• Complaint
• Present History
• Gynacologic & Obstetric
• Past History
• Family History

9. Personal History
 Name:
to be familiar with the patient
 Sex:
SLE
RA
AS
SLE & RA are more common in females, while
Ankylosing spondylitis is more common in males

10.  Age:
SLE is common in childbearing period,
osteoporosis is common after menopause,
osteoarthritis is more common above 50 yrs,
RA is common between 40-60 yrs

11.  Occupation:
Disc prolapse is common in labourers, surgeons & drivers,
Scleroderma is common in workers in silica industries,
Raynaud’ s phenomena is common with use of vibrating
tools

12.  Marital status & Offspings: for selection of different
drugs since that some drugs affect ovarian & testicular
function like cyclophosphamide

13.  Special habits:
In disc prolapse smoking worsens disc perfusion & also
coughing associated with smoking increases the
symptoms,
In RA smoking induces the production of rheumatoid
factor & anti-CCP

14. Complaint
Write it in patient’s own words
 Pain
 Pain & swelling
 Limitation of movement
 Deformity

15. Present History
Analysis of the patient’s complaint:
• Onset, Course, Duration
• Number of joints affected
• Distribution of joint involvement
• Symptoms increase by & decrease by
• Associated symptoms

16.  Onset:
Acute onset may occur in traumatic, inflammatory &
infectious arthropathies.
Gradual onset may occur in some inflammatory &
degenerative conditions like RA and OA

17.  Course:
Progressive/additive course: symptoms occur in some joints
and persists with subsequent involvement of other joints as in
RA & SLE.
Regressive course: symptoms are self limited as is viral arthritis .
Intermittent course: repetitive attacks of arthritis with complete
remission inbetween attacks as in gout
Migratory course: symptoms occur in some joints for a few days
then disappear to appear in other joints as in rheumatic fever

18.  Number of joints affected:
Monoarticular affection involvement of
one joint as in traumatic, septic & crystal
arthropathies
Oligoarticular affection involvement of
4 joints or less as in seronegative
arthropathies
Polyarticular affection involvement of
more than 4 joints as in RA

19.  Distribution of joint affection:
Small joints of the hands & feet are
commonly involved in RA
Large weight bearing joints like
knees & hips are affected in OA
Axial and large girdle joints like
shoulders & hips are affected in AS

20.  Symptoms increase or decrease by:
Inflammatory conditions symptoms are increased by
rest & relieved by movement, while in
Degenerative/ Mechanical conditions symptoms are
increased by movement & relieved by rest

21.  Erythema & warmth: its site and its relation to joint
(erythema & warmth are more marked in septic
arthritis, and in crystal arthropathies but may occur
with others)

22.  Morning stiffness : inability to move joints through
available range of motion marked in the early
morning improving with moving the joint
( morning stiffness > 1 hr occurs in RA, morning
stiffness less than 30 min occurs in OA )
 Inactivity stiffness : gelling of the joint after a small
period of inactivity ( as in OA )

23. Comment as follows:
Condition started….. onset, course, duration,
site & radiation, character, increases by, decreases by,
association with other symptoms ( swelling,
limitation, warmth, erythema, morning/ inactivity
stiffness)

24.  Arthralgia is defined as pain without
other signs of inflammation
 Arthritis is defined as inflammation
of the joint where pain is also
associated with other signs of
inflammation like swelling, limitation
of movement, warmth & erythema

25. Extra-articular features:
 Fever, weight loss, myalgias,
arthralgias: may occur with
inflammatory arthropathies like
SLE, infectious arthropathies,
and in vasculitis

26.  Photosensitivity, falling of hair, oral ulcers, skin
rash: as in SLE
 Subcutaneous nodules, dryness of eye & mouth,
lymphadenopathy: in RA patients and variants like
Sjogren’s and Felty’s
 Genital ulcers, heel pain, preceding dysuria or
diarhea, scaly skin lesions, bowel complaint as in
seronegative arthropathies

27. Systemic review:
 Symptoms suggestive of cardiac affection; chest pain,
exertional dysnea, palpitation( valvular disease may occur in
rheumatic fever, RA, Ankylosing spondylitis, while
pericardial effusions & pericarditis may occur in SLE )
 Symptoms suggestive of pulmonary affection; dysnea,
cough, sputum, chest pain, heamoptysis ( interstitial lung
fibrosis occurs in scleroderma & methotrexate use in RA,
apical lung fibrosis in AS, pleurisy& pleural effusion in SLE)

28.  Symptoms suggestive of urologic affection; dysuria,
heamaturia, loin pain ( Glomerulonephritis in SLE &
vasculitis)
 Symptoms suggestive of neurologic affection; motor
weakness, parasthesia, sensory loss, sphincteric
disturbance ( as in disc prolapse), coma, convulsions,
persisting headache not responding to analgesics,
hemiparesis ( as in SLE)

29.  Symptoms suggestive of GIT affection; nausea,
vomiting, diarhea, abdominal pain, melena,
constipation ( inflammatory bowel associated
arthropathies, pancreatitis in SLE, mesenteric
vascular occlusion in vasculitis)

30. Gynecological &Obstetric History
 RA tends to go into remission in pregnancy, while SLE
flares in pregnancy
 Fetal losses may occur in SLE pts with APA syndrome
 Menstrual irregularities may be associated with drug
intake like corticosteroids & cyclophosphamide
 Some drugs used for rheumatic diseases are
contraindicated in pregnant & lactating females

31. Past History
 Trauma: may precede disc prolapse, traumatic arthritis,
ligament sprains
 Diabetes mellitus: increased incidence of carpal tunnel
syndrome, shoulder periarthritis, limited mobility of hand
joints
 Hypertension: either primary or secondary due to steroid
use, renal disease due to SLE 0r vasculitis
 Drug intake: Drug- induced lupus, drug-drug interactions

32.  Endocrinal disorders; hyper/hypothyroidism,
hypo/hyperparathyroidism, acromegally and cushing all
are associated with many musculoskeletal conditions
 Hematologic diseases; hemophilia may be associated
with hemophilic arthropathy & muscle hematoma
 Malignancies: metastasis to joints, paraneoplastic
conditions

33. Family History
 Similar conditions: increased risk of development
of RA & SLE & JIA in first degree relatives
 Related conditions: history of psoriases,
inflammatory bowel disease, ankylosing spondylitis
in relatives ( seronegative arthropathies)

34. • General Examination
• Local Examination

35. General Examination
 Patient appears mildly/moderately or severely ill, lying
comfortable in bed, cooperative/un, of average body
built/ overweight/ underweight
 Vital signs:
Blp, pulse, temp, resp rate

36. Regions:
 Head: hair ( alopecia), face ( cushiongoid, malar rash),
eyebrows ( lost outer third), mouth ( oral ulcers, limited
mouth aperture), nose ( nasal ulcers), eye (red)

37.  Neck: lymphadenopathy, thyroid swelling
 Upper limb: pallor, cyanosis, erythema, tremors, rash
 Lower limb: oedema, cyanosis/gangrene, leg ulcers

38. Local Examination
 Inspection : swelling, muscle wasting, deformity, skin
changes (rash, scars)
 Palpation: tenderness, temperature, crepitus, synovial
thickening, confirm nature of swelling
 ROM: Active, Passive
 Special Tests: specific for each region