Differential diagnosis:

EXAMINATION

Rheumatological examination includes a thorough general examination and systemic examination along

with examination of locomotor system.

General Examination

Patient

Conscious

Oriented

Cooperative

Obeying commands

Body Mass Index (BMI)

Weight (in kg)/Height2

(in meters)

Grading according to WHO for Southeast Asian countries

Vitals

Pulse

Rate

Rhythm

Volume

Character

Vessel wall thickening

Radio-radial delay and radio-femoral delay

Peripheral pulses

Blood pressure

Right arm

Left arm

Both lower limbs

Respiration

Rate

Abdominothoracic (male) or thoracoabdominal (female)

Usage of accessory muscles

Jugular venous pulse

Waveform

Jugular venous pressure

__ cm of blood above sternal angle (+ 5 cm water)

Temperature ____ degree of Celsius or Fahrenheit measured at ______ site.

Physical Examination

Pallor

Icterus

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Cyanosis

Clubbing

Lymphadenopathy [systemic lupus erythematosus (SLE) and Still’s disease)

Edema

Other head to toe

Skin

Nails

Oral cavity

Mucous membrane

Eyes

Locomotor System Examination

Rapid screening of the locomotor system can be done by GALS screen (Gait-Arms-Legs-Spine). With

the patient undressed, observe the patient from front, back, and sides. Observe his gait, check his arms

(inspect and palpate), check his legs (inspect and palpate), and check his spine (inspect and palpate).

Examination of the Individual Joints

[Regional Examination of Musculoskeletal System (REMS)]

We have 14 joint areas in the body on either side namely:

Proximal and distal interphalangeal joints

Metacarpophalangeal joints

Carpometacarpal joints of thumb

Wrist joint

Elbow joint

Shoulder joint

Acromioclavicular joint

Sternoclavicular joint

Temporomandibular joint

Hip joint

Knee joint

Ankle joint

Subtalar joint

Small joints of foot including midtarsal, metatarsophalangeal, and interphalangeal joints.

Each of the joints is examined under the following headings:

Inspection: Look for swelling, skin, and deformity

Palpation

Look for tenderness and warmth

Palpate for synovial thickening

Look for crepitus (crepitus can also be auscultated) (Fine crepitus—synovitis or bursitis; Coarse

crepitus—cartilage or bone damage)

Look for range of movement of joint (both active and passive movements)

Example: At knee joint there is swelling on inspection and on palpation synovial thickening present,

warmth and tenderness present, crepitus felt. The range of movement is painful and restricted in both

active and passive movement at the joint. Also examine the tendons, bursae, ligaments, synovium,

and muscles around the joint.

Examination of Spine

Look for the curvature of the spine. Normally there is cervical lordosis, thoracic kyphosis, lumbar

lordosis, and sacral kyphosis. List if any deformities present.

Movements of the spine

Cervical spine Rotation

Flexion

Extension

Lateral bending

Thoracolumbar spine Flexion

Extension

Lateral bending

Rotation

Schober’s test

Straight leg raising test

Sacroiliac joint Direct pressure

Patrick’s test

Gaenslen’s test

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B. DIAGNOSIS FORMAT

Based on chronicity

Acute/chronic

Based on symmetry

Symmetrical/nonsymmetrical

Based on inflammation

Inflammatory/noninflammatory

Based on number of joints involved

Mono/oligo/polyarthritis

Associated features

With/without deformities

With/without axial spine involvement

With systemic manifestations in the form (Pleural effusion, anemia, uveitis, etc.)

Disease severity

DAS28

Simplified and clinical disease activity indices (SDAI and CDAI)

Rheumatoid arthritis severity scale (RASS)

EXAMPLES

Example 1

Chronic symmetrical inflammatory polyarthritis with swan neck deformity of fingers, with no axial spine

involvement, with systemic features in the form of anemia and interstitial lung disease—I would like to

consider diagnosis of rheumatoid arthritis.

CDAI score 7

Example 2

Chronic recurrent inflammatory monoarthritis involving right first MTP joint with deformities, without axial

spine involvement or systemic manifestations—I would like to consider diagnosis of gout.

NOTES

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C. DISCUSSION ON SYMPTOMMATOLOGY AND EXAMINATION

DISCUSSED IN THE FOLLOWING HEADINGS

Sympatomatology

Examination of skin, hands and eyes

Examination pattern of musckuloskeletal system

Examination of upper limbs

Examination of lower limbs

Examination of spine

Examination of other joints

Examination of other systems in rheumatological disorders

Discussion on common rheumatological diseases

Scoring systems

1. SYMPTOMATOLOGY

Arthralgia (subjective): Only pain around the joint

Arthritis (objective): Pain + other signs of inflammation (redness/swelling/increased temperature/loss

of function)

Synovitis: Inflammation of synovial membrane

Tenosynovitis: Inflammation of the tendon sheath

Enthesitis: Inflammation of site of attachment of ligament, tendon or capsule to the periosteum or bone

Myositis: Inflammation of muscle

Arthritis–presentation

Duration Acute (presenting within hours to days)

Chronic (persisting for weeks or longer)

Number of joints involved Monoarticular (only 1 joint)

Oligoarticular/pauciarticular (2–4 joints)

Polyarticular (5 joints or more)

If more than one joint is involved Symmetric (or) asymmetric

Additive (or) migratory

Type Inflammatory or noninflammatory (see below)

Deformities Present (or) absent

Deformities are usually seen in:

Rheumatoid arthritis

Psoriatic arthritis

Osteoarthritis

Reiter’s disease

Chronic gout

Precipitating factors like Sexually transmitted disease (STD)

Infection

Trauma

Alcohol

Diarrhea

Associated features Constitutional symptoms:

Fever, fatigue, and weight loss

Extra-articular manifestations and systemic manifestations

Comorbid conditions

Note: Treatment history should be taken in detail.

Inflammatory Versus Noninflammatory Disease

Features Inflammatory (rheumatoid arthritis) Noninflammatory (osteoarthritis)

Age of onset Usually 20–40 years but may begin at any age Most commonly over 50 years of age

Speed of onset Rapid over weeks to months Slow; over years

Systemic symptoms Fatigue, low-grade fever, anorexia. Extraarticular manifestations: Rheumatoid nodules,

Sjogren’s syndrome, Felty syndrome

No systemic symptoms

Joint affection Symmetrical Asymmetrical

Joint symptoms Painful, swollen, stiff joints, and muscle aches Joints painful without swelling

Joints involved Primarily affects small joints

[metacarpophalangeal (MCP) and proximal

interphalangeal (PIP)] with sparing of dip

Affects large weight bearing joints (hip, knee or the

spine). Affects proximal interphalangeal (PIP) and

distal interphalangeal (DIP) joints

Stiffness Morning stiffness for >1 hour. Stiffness occurs

after periods of rest/inactivity (the so-called “gel

phenomenon”)

Morning stiffness for <30 minutes. Stiffness is

generally mild and occurs after periods of activity

Relation of movement with pain

Movement or mild to moderate activity

decreases pain

Movement increases the pain (worsens with activity)

and improves with rest

Examination of joint Swollen, red, warm, tender, and painful Swollen, cool, and hard on palpation. When severely

inflamed (as in acute gout or septic arthritis), can

have erythema of the overlying skin

Radiological findings Bony erosions, soft-tissue swelling, angular

deformities, periarticular osteopenia

Loss of joint space and damage to articular cartilage,

osteophytes

Rheumatoid factor

(RF) factor and

antinuclear antibody

(ANA)

Positive Negative

Erythrocyte

sedimentation rate

(ESR) and C-reactive

protein

Both are often raised Usually normal but transient elevation of ESR may

occur due to synovitis

White blood cell

(WBC) count in the

synovial fluid

WBC count is >2,000/mm3

in septic arthritis

and not in rheumatoid arthritis

WBC count is <2,000/mm3

Causes of Arthritis

Acute monoarthritis

Inflammatory Crystal disease (e.g. gout), infectious disease, spondyloarthropathy, rheumatoid arthritis

Mechanical Trauma, avascular necrosis

Acute polyarthritis

Infectious Bacterial, human immunodeficiency virus (HIV)

Noninfectious Rheumatoid arthritis, spondyloarthropathy, other connective tissue diseases, crystal (gout), sarcoidosis, malignancy, leukemia, sickle cell anemia

Chronic monoarthritis

Inflammatory Crystal disease, infectious disease (e.g. tuberculosis, fungal), spondyloarthropathy, rheumatoid arthritis

Noninflammatory Osteoarthritis, avascular necrosis, neuropathic arthropathy, villonodular synovitis

Chronic polyarthritis

Inflammatory Rheumatoid arthritis, spondyloarthropathy, other connective tissue diseases

Mechanical Osteoarthritis

Crystal Gout

Metabolic Infiltrative, metabolic, hypothyroidism

2. EXAMINATION OF SKIN, HANDS, AND EYES

Skin changes in rheumatology

Erythema Septic arthritis

Crystal arthropathy

Palpable purpura (Fig. 7C.1) Vasculitis

Ulcers over skin (Fig. 7C.2) Vasculitis

Rash Systemic lupus erythematosus (SLE) [malar or discoid rash (Fig. 7C.3)]

Vasculitis

Drugs

Stills disease

Violaceous scaly lesions Psoriasis

Keratoderma blennorrhagica

Circinate balanitis

Reiter’s disease

Mucosal ulcers (Fig. 7C.4) Behcet’s disease

SLE

Dryness of skin Sjogren’s disease

Thickened hard skin (Fig. 7C.5) Systemic sclerosis

Scleroderma

Pyoderma gangrenosum Inflammatory bowel disease

Palmar erythema Rheumatoid arthritis

Photosensitivity Development of rash on exposure to sunlight of less than 30 minutes (SLE)

Digital gangrene Raynaud’s and medium vessel vasculitis

Alopecia SLE

Scleroderma

Heliotrope rash and Gottron’s papules Dermatomyositis

Salt and pepper appearance Scleroderma (most prominently on the upper back and chest)

Livedo reticularis (Fig. 7C.6) SLE

Antiphospholipid antibody (APLA) syndrome

Sneddon’s syndrome, Polyarteritis nodosa

Raynaud’s Systemic sclerosis

Vasculitis

Mixed connective tissue disorder

Sclerodactyly Progressive systemic sclerosis

Fig. 7C.1: Palpable purpura over lower legs in Henoch–Schönlein

purpura.

Fig. 7C.4: Mucosal ulcers in SLE.

Fig. 7C.2: Ulcers on the leg in medium vessel vasculitis. Figs. 7C.5A to C: Systemic sclerosis. (A and B) Shiny and

thickened skin of hands and feet; (C) Mask-like face with decreas

oral aperture.

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Fig. 7C.3: Systemic lupus erythematosus with malar rash and

alopecia.

Fig. 7C.6: Livedo reticularis-mottled reticulated vascular patter

that appears as a lace-like purplish discoloration of the skin. It is

to swelling of the venules caused by obstruction of capillaries

Subcutaneous Nodules—differential Diagnosis

Rheumatoid arthritis

Rheumatic fever

Gout

Erythema nodosum*

Sarcoidosis

SLE

Hyperlipidemia.

*Erythema nodosum (Fig. 7C.7)

It is a type of panniculitis characterized by painful reddish nodules in the subcutaneous tissue most

commonly seen on the shin.

Common causes include:

Tuberculosis

Leprosy

Sulfonamides and other drugs

Streptococcal infection

Sarcoidosis

Inflammatory bowel disease.

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e.

Fig. 7C.7: Erythema nodosum.

Nail Changes

Clubbing Fibrosing alveolitis

Hypertrophic

Osteoarthropathy

Pitting and onycholysis (Fig. 7C.8) Psoriasis*

Splinter hemorrhages Vasculitis

*Nail Changes in Psoriasis

Involvement is common and may be observed up to 50% of patients with psoriasis. These include:

“Thimble pitting” of the nail plate;

Distal separation of the nail plate from the nail bed (onycholysis);

Yellow-brown discoloration underneath the nail plate (“oil drop” sign);

Subungual hyperkeratosis; and

Thickening of the nail (onychodystrophy).

For diagnosis of nail involvement: >6 nails should be involved with each nail should have >20 pits.

Fig. 7C.8: Nail changes in psoriasis.

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