rheumatology

1. Symptoms and Signs in
Rheumatology
Dr Adentan

2. Outline
• Introduction
• Symptoms of rheumatological diseases
• Examination
• Signs
• Conclusion
• References

3. introduction
• Rheumatology deals with non-traumatic diseases of the
musculoskeletal system as well as the systemic autoimmune diseases
• When someone has or is identified at screening as having a
musculoskeletal problem or autoimmune disease, the aim of
consultation is to fully characterize the problem that the person is
complaining of, to identify the syndrome and then make a clinical
diagnosis or at least offer a differential diagnosis.
• Musculoskeletal conditions are common and can coexist. It should
not be assumed that each symptom relates to a single diagnosis

4. cont
• Characterization of these symptoms helps the physician to
differentiate a rheumatological complaint into one of several
“syndromes”

5. Main Rheumatological Pattern

6. What are the symptoms?
• Symptoms specifically related to musculoskeletal conditions are most
often pain and stiffness, frequently accompanied by loss of function,
which can limit activities and restrict participation. Mobility and
dexterity are most often limited. Nonspecific symptoms may be
present as well. Red flags for potentially serious conditions must be
recognized.

7. SYMPTOMS OF A MUSCULOSKELETAL PROBLEM
Specific symptoms
• Pain
• Stiffness
• Swelling
• Deformity
• Weakness
• Instability
• Loss of function

8. General symptoms
• Fatigue and malaise
• Emotional lability—fear, anxiety, depression
• Sleep disturbance
• Symptoms of systemic diseases

9. Red flags
• Weight loss
• Fever
• Temple headache/pain with scalp tenderness/visual disturbance
• Loss of sensation
• Loss of motor function
• Difficulties with urination or defecation
Other possible symptoms
• Color changes or coldness of digits or limbs
• Altered sensation

10. CHARACTERIZATION OF A MUSCULOSKELETAL
PROBLEM
• What are the symptoms?
• Site and distribution of the symptoms
• Chronology
• Duration
• Associated symptoms
• Preceding illnesses or injuries and other relevant clues
• Response to health interventions
• Its impact on activities, participation, and quality of life

11. Patterns of pains

12. About the pain
• Articular or non-articular?
• Acute or chronic?
• Inflammatory or non-inflammatory?
• Pattern of joint involvement.
• Extra articular features

15. Elbow synovitis is an articular syndrome (note the joint line swelling)
as opposed to olecranon bursitis which is a periarticular lesion.

16. •

17. Differences between inflamed and damaged joints

18. Characterization of arthritis

19. Cont.

20. Main manifestations associated with
rheumatic diseases

21. cont

22. Manifestations associated with different CTD.

23. Cont.

24. Aims of examination
• The aim of examination of the musculoskeletal system is to answer four
• questions:
• Are the findings normal?
• What is the abnormality?
• 3 What is the pattern of distribution?
• 4. What other features are of diagnostic importance?
• These, in combination with the history, should establish the differential
• diagnosis.

25. Clinical signs of musculoskeletal conditions
• ■ Attitude
• ■ Deformity
• ■ Swelling
• ■ Skin changes
• ■ Muscle wasting
• ■ Tenderness
• ■ Restricted movement
• ■ Crepitus
• ■ Warmth
• ■ Muscle weakness
• ■ Instability
• ■ Limited function

29. APPROACH TO MUSCULOSKELETAL EXAMINATION

30. MUSCULOSKELETAL EXAMINATION ( ARM)
• Instruct the patient to bend and straighten both elbows
simultaneously (0-150 )
• With elbows flexed to 90 , turn hands palm up (supination 0-90 )
and then palms down (pronation 0-90 )
• Ask the patient to put both hands behind the head with elbows
pointing laterally (abduction and external rotation)
• then to put the arms down and reach up behind the back (extension,
adduction and internal rotation)
• Compare active with passive movements, if active range limited

32. APPROACH TO MUSCULOSKELETAL EXAMINATION

34. Skin manifestation in systemic lupus
erythromasus
• The manifestation are commonly divided into lupus lesions, vascular
lesions, non vascular and non lupus lesions.
• Patients with SLE and no signs of skin manifestations, comprise the
condition “ lupus sine lupo”
• SLE specific skin manifestation are categorized into three major
clinical subtypes according to disease acuity- acute cutaneous lupus
erythematosus(ACLE), subacute lupus erythematosus(SCLE) and
chronic cutaneous lupus erythematosus(CCLE)
•

35. Cont.
• Malar eruption or ‘butterfly rash’ (erythema and oedema of cheeks,
sparing nasolabial folds) lasting hours to days
• Erythematous papular rash on arms, sometimes forming
large plaques and spreading widely
• Photosensitivity (a rash on all recently sun-exposed skin)

37. cont
• The vascular lesions comprise-livedo reticularis, leg ulcers, urticarial,
angioedema, splinter haemorrhages, skin necrosis, palmer erythema,
erosive oral lesions.
• Non vascular, non lupus lesions includes- non scarring alopecia,
papular mucinosis, calcinosis, aseptic pustular eruption

38. Skin manifestation in dermatomyositis
• Heliotrope rash (a pinkish erythema that involves the periorbital
area), Gottron sign (erythematous squamous plaque located in the
dorsum and lateral part of interphalangeal and MCP joints), Gottron
papules are characteristic skin manifestation of dermamyositis.
• Rashes can also involve the malar area of the face, the posterior side
of the neck and shoulders ( the shawl sign), and the scalp. Patients
may have diffuse erythematosquamous scalp lesions, poikiloderma(
hypo and hyper pigmentation,atrophy telangiectasia) and moderate
alopecia. Lesions on the lateral side side of the thigh- Holster sign
• Patients with anti synthetase syndrome have “mechanic hands”.
Other lesions – Raynaud phenomenon, thrombosis and vasculitis

42. Digital necrosis

43. Skin manifestation in Rheumatoid arthritis
• Dermatologic manifestation in rheumatoid arthritis include palisading
granulomas (rheumatoid nodules involving usually mechanically
stressed area; palisaded neutrophilic granulomatous dermatitis),
rheumatoid vasculitis ( which varies from presence of purpuric
papule, petechial to ulcer and peripheral gangrene.

46. Conclusion
• Making a diagnosis requires integration of the history and findings on
examination with knowledge of the possible causes and results of
appropriate investigations. Pattern recognition plays a key role in
rheumatology.
• It should not be assumed that each symptom or sign relates to a
single diagnosis
• Knowing what is likely at different stages of life in different individuals
and looking for clues throughout the consultation are important.

47. Thank you for listening

48. References