Rheumatology Clinical Round With Focus on systemic lupus erythematosus By Dr. Usama Ragab Youssif

1. Email: usamaragab@medicine.zu.edu.eg
Slideshare: https://www.slideshare.net/dr4spring/
Mobile: 00201000035863

2. Intro

3. Joint
• Synovial membrane is away
from articular cartilage.
• Any affection to articular
cartilage → deformity.
• Rheumatoid arthritis is erosive
→ deformity.
• SLE is non erosive → no
deformity

4. Types of joints
Peripheral joints Axial joints Special joints
Big: Wrist, elbow,
shoulder, hip, knee,
ankle
Cervical
Thoracic
Lumbar
TMJ
SIJ
Small: hands and feet

5. Classification of joint problems
According to number of
joints
According to onset &
duration
According to
etiology
Monoarthritis: 1 joint
Oligoarthritis: 2-4 joints
weeks
Polyarthritis: > 4 joints
Acute: lasting less
than 6 weeks
Chronic: lasting more
than 6weeks
Mechanical
“degenerative”: OA
Inflammatory: RA

6. Pattern of joint
involvement
• symmetrical vs. asymmetrical
• small vs. large
• mono-, oligo- vs. polyarticular
• axial vs. peripheral

7. Characteristics of Joint Involvement
Pain, swelling, loss of function of joint
Inflammatory arthritis characteristics Non-inflammatory/degenerative or
mechanical arthritis characteristics
• morning stiffness (> 1 hour)
• aggravated by rest, ameliorated by
activity
• signs of acute inflammation: rubor
(red), tumour (swelling), calor
(hot), dolor (pain)
• no or minimal morning stiffness (<
30 minutes)
• aggravated by use, ameliorated by
rest
• More at night

8. Criteria of the activity
of the disease
clinically
1. Swelling
2. Tenderness
3. Erythema
4. Warm
If redness and hotness are
prominent, they may indicate
arthritis

9. Joint involvement may be articular or extra-
articular
Articular Non articular
Tender joint Tenderness outside joint lines
Disturbed active &passive
movement
Passive movement is better than
active
Deformity No deformity e.g., bursitis &
tendonitis

10. Small joints of the
hand in relation to
arthritis
• DIP: distal interphalangeal
joints
• PIP: proximal interphalangeal
joints
• MCP: metacarpophalangeal
joints
• 1st CMC: 1st carpometacarpal
joint

11. Before start, why I need this intro?
Ask about peripheral joints (UL & LL) for pain, swelling, hotness,
and redness, limitation of movement (stiffness) or deformity.
Ask about
Ask about axial joints (cervical & lumbar) as regard pain or
limitation of movement
Ask about
Ask about extraarticular manifestations
Ask about

12. Patterns of joint involvement in
different forms of polyarthritis

13. Activities of Daily Living and Limitations
• gross motor – walking, stairs, toileting
• fine motor – dressing (buttons, zippers), grooming, eating, grip
• functional capacity classification
Class I: no restrictions
Class II: moderate restriction; able to perform activities of usual
occupation/self-care
Class III: marked restriction; can’t perform activities of usual
occupation/self-care
Class IV: incapacitation, confinement to bed/chair

14. History Taking

15. General History: components
Personal History
Chief Complaint + Duration
History of present illness
History of past illness
Family History

16. Personal
History

17. Personal History (NAS OMMRHH)
Name Age Sex Occupation
Marital status
Menstrual
history
Residence
Habits of
medical
importance
Handedness

18. Age & Sex
• Child: Still's disease & rheumatic fever
• Middle age: gout, rheumatoid, SLE
• Old age: osteoarthrosis
• Females: RA & SLE
• Males: ankylosing spondylitis & Reiter’s
syndrome

19. Occupation
CARRYING HEAVY OBJECTS WORK IN GYM

20. Complaint

21. Chief Complaint + Duration
The most
distressing
Concise In patient
own word
Describe the
duration

22. Example
Pain in both hands 2 month ago
Limb swelling 3 days before
Disturbance of function

23. The history may expand to include
Joints
• Pain
• Swelling
• Morning stiffness
• Loss of function
Back pain Limb pain
Eyes
• Dry eyes and mouth
• Red eyes
Raynaud’s
phenomenon
Systemic and other
symptoms
• Rash, fever, fatigue, weight
loss, diarrhoea, mucosal
ulcers

24. Present
History

25. History of
Present Illness
1. Pain
2. Swelling
3. Deformities
4. Weakness
5. Disturbance of function =
associated non articular
symptoms = Systemic
manifestations = Symptoms
of other systems
6. Investigations & Treatments

26. Pain + Swelling = arthritis
• Arthralgia refers to joint pain without swelling, whereas arthritis
means both pain and swelling.

27. 1- Pain
OCD
Site
Type: morning stiffness and its duration
Precipitating factor
What ↑ what ↓
Diurnal variation
Functional disability

28. 1- Pain
Onset:
• Gradual : rheumatoid arthritis , SLE
• Acute : gout & rheumatic fever
Course:
• Progressive: osteoarthritis
• Regressive: Rheumatic fever
• Remittent: rheumatoid & chronic gout
Duration:
• Long: rheumatoid arthritis, SLE
• Short: acute gout & rheumatic fever

29. Onset/Duration
acute (hours): e.g., gout, infectious, rheumatic fever
subacute (days): e.g., pseudogout, infectious
insidious (months): e.g., degenerative, inflammatory
Follow infection and occur in prodromes: e.g., diarrhea, infection

30. Course
Intermittent with periods of complete remission
(e.g., gout in intercritical periods).
Gradual progression over time with acute
exacerbations (e.g., pseudogout).
Wax and wane with slow progression over time
(e.g., RA).

31. 1- Pain (cont.)
• Site: spine lesion may cause radicular pain
• Radiation: in nerve compression
• Type: morning stiffness & duration: in rheumatoid arthritis more than
1 hour
• Precipitating factors:
Diuretics & diet: precipitate gout
Throat infection: precipitate rheumatic fever

32. 1- Pain (cont.)
Aggravating & relieving factors:
• Inflammatory arthritis (RA): ↑ by rest & ↓ by activity
• Mechanical arthritis (osteoarthrosis) : ↓ by rest & ↑ by activity
Diurnal variation:
• Inflammatory arthritis: ↑ in morning & ↓ by end of day
• Mechanical arthritis: ↓ in morning & ↑ by end of day
Functional disability: ability to work

33. 1- Pain (cont.)
A history of several years
of pain with a normal
examination suggests
fibromyalgia.
A history of several weeks
of pain, early-morning
pain, stiffness and loss of
function suggest
rheumatoid arthritis.

34. Don’t forget, Determine which
component is painful
The joint (arthralgia)
The muscle (myalgia)

35. Causes of
joint pain

36. Causes of
muscle pain

37. 2- Swelling
Limb swelling
Episodic arthritis
(signs of
inflammation):
describe frequency &
duration
SC nodules
(extra-articular
manifestation)

38. The onset and time course is a clue for diagnosis
• Rapid (<30 minutes), severe swelling suggests a hemarthrosis. This occurs
when vascular structures such as bone or ligament are injured and is worse
in the presence of anticoagulants or bleeding disorders.
• Swelling over hours or days suggests traumatic effusion, such as with a
meniscal tear or articular cartilage abrasion.
• Septic arthritis develops over hours-days with pain, marked swelling,
tenderness, redness and extreme reluctance to move the joint actively or
passively.
• Crystal-induced arthritis (gout or pseudogout) can mimic septic arthritis. It
commonly starts overnight or early in the morning due to the rise in serum
uric acid following the evening meal.

39. 3- Deformities
Pattern of affection:
•Monoarticular: suppurative arthritis &
hemarthrosis, gout (recurrent in big toe)
•Polyarticular: rheumatoid arthritis, SLE
•Oligoarticular: osteoarthrosis
•Fleeting: rheumatic arthritis

40. 4- Weakness
• Weakness results from neurological, muscle or joint disease.
• Joint disorders cause weakness, either through
inhibition of function by pain.
disruption of the joint or its supporting structures.
nerve entrapment e.g. carpal tunnel syndrome
• Muscle affection may occur in inflammatory arthritis

41. 5- Associated non articular symptoms
1. weight loss, low grade fever: high-spiking fevers in the evening,
accompanied by a rash, occur in adult-onset Still’s disease
2. Ocular manifestations: red eye
3. Cardiac symptoms, chest symptoms, GIT symptoms, renal symptoms
(nephrotic syndrome)
4. Anemia symptoms
5. Rash: SLE, progressive systemic sclerosis, dermatomyositis
6. Photosensitivity: SLE
7. Abdominal pain & fever: Familial Mediterranean Fever
8. Headache, jaw pain on chewing : features of temporal arteritis

42. Connective tissue disease may present with multiple
extra-articular features
• Raynaud’s phenomenon.
• Sicca symptoms (dryness of mouth and eyes).
• Rashes.
• Respiratory problems, including dyspnoea or pleural pain associated
with RA or connective tissue disease.
• GI problems, including
dysphagia in systemic sclerosis.
abdominal pain, diarrhoea, bloody stool and mouth ulcers: may
suggest arthritis associated with inflammatory bowel disease (IBD).

43. 6- Joint locking
• ‘Locking’ is an incomplete range of movement at a joint because of
an anatomical block. It may be associated with pain.
• Patients use ‘locking’ to describe various problems, so clarify
exactly what they mean.
• True locking is a block to the normal range of movement caused by
mechanical obstruction, such as torn meniscus, within the joint.
The patient is characteristically able to ‘unlock’ the joint by trick
maneuvers.
• Pseudo locking is a loss of the range of movement due to pain.

44. 7- Related workup and treatment
• medications and dosages, complementary therapies
(e.g., herbals), duration of treatment and effectiveness
• physiotherapy, occupational therapy
• surgical – reconstructive vs. total joint replacement
• ask about the effectiveness of each

45. Past History

46. Past history
Trauma: hemarthrosis, osteoarthrosis
Raynaud's phenomenon (pallor, cyanosis, rubor): progressive systemic sclerosis
Psoriasis: in psoriatic arthritis
History of gonorrhea, TB: may cause reactive arthritis
History of IBD
Treatment history : previous treatment & its efficacy

47. Co-morbid
History
• Diabetes: and its
associated arthritis
• Obesity
• Drugs that may cause or
exacerbate arthritis

48. Family History

49. Family History
Similar
condition in
family
Positive
Consanguinity
OA
RA
Gout
FMF

50. Clinical
examination

51. General
examination =
extra-articular
• Vital signs
• General overview
• Systemic overview.

52. Vital signs
• BP: HTN in PAN, lupus nephritis, scleroderma renal crisis
• Pulse: unequal pulse in Takayasu disease
• RR: tachypnea in lung and pleural affection (SLE, RA, ..)
• Temperature: fever in SLE activity, inflammatory CTD
• O2 SAT: low in lung involvement = lung fibrosis

53. General Overview
• Appearance: look ill or healthy
• Built: underbuilt as constitutional feature
• Color: pallor, jaundice, cyanosis, rashes
• Decubitus: orthopneic in HF
• Exposure of back, breast & genitalia
• Facial expression + ‫فكر‬
• Gait

54. Systemic overview
• Mouth: Ulcers in Behcet’s disease and SLE
• Eye: scleritis in RA
• LNs: Still’s and Feltey’s disease, SLE.
• UL & LL: Nail pitting (psoriasis), LL edema, tender calf
muscles, wasting of small muscles of the hands

63. Local examination
look → feel → move → function

64. Look for
Scar
Swelling
Rash
Muscle Wasting

71. Spine
abnormality

72. Inflamed joint

73. Bursitis

74. Feel For
Temperature
Swellings
Tenderness
Crepitus

77. Move
Full range of
movement
– active and
passive
Restriction
– mild,
moderate
or severe?

79. Planes of
movement in a
joint

80. Function
Functional assessment of
joint: muscle tone &
power

81. Sequence
Inspection = Look
Palpation = feel
Movement = move
Don’t forget general look = function

82. General
Assessment
of Locomotor
System (GALS)
G= Gait
A= Arm
L= Leg
S= Spine

83. Gait

84. Gait
Gait is the pattern that you walk.
Sometimes, an injury or underlying
medical condition can cause an
abnormal gait.
Certain gait abnormalities are
temporary, and others require
lifelong management.

85. Phases of gait

86. To examine
gait, we
need
Intact Nerve: motor & Sensory
Intact Muscles
Intact Cerebellum
Intact musculoskeletal system

87. Antalgic Gait

88. Myopathic
Gait =
Waddling

89. Short limb Gait

90. Arm

91. Leg

92. Spine

93. Systemic lupus

94. Definition
SLE is an autoimmune disease in which the
immune system attacks its own tissues, causing
widespread inflammation and tissue damage in
the affected organs.
It can affect the joints, skin, brain, lungs, kidneys,
and blood vessels.
More than 90% of cases of SLE occur in women,
frequently starting at childbearing age.

95. Articular manifestation
• Distribution: like RA i.e., polyarthritis, bilateral,
symmetrical
• Character: mild
Mild arthralgia (rarely arthritis), myalgia
NO deformities

96. Type of patient
Sex: females
more than
males; 10 : 1
Age: 2nd and
3rd decade

97. Extra-articular manifestations
• Usually severe (kidney)
• NO subcutaneous nodules

98. ACR 1997
criteria

99. SLICC 2012

100. 2019
EULAR/ACR
classification
criteria for
SLE

101. From the
above
criteria

102. Arthritis =
similar to RA =
symmetric
small joint =
NON
Deforming

103. Butterfly rash vs discoid rash

104. Lupus profundus

105. Scarring
alopecia

106. Nail bed infarction + Vascular purpura

107. Raynaud Phenomenon

108. Panniculitis

109. Livedo
reticularis

110. Nephrotic syndrome edema

111. Thanks