I n t e r n a l M e d i c i n e CJRebojo & CEveneracion

Rheumatology
INFLAMMATORY vs NON-INFLAMMATORY
Transcribed from Dr. Saguil-Sy’s
Lecture
Clinical Features INFLAMMATORY NON-
Definition INFLAMMATORY
• Rheumatology is a branch of medicine that focuses on the biology,
cause, diagnosis and treatment of a variety of musculoskeletal and Pain Worse When? Yes (Morning) Yes (Night)
other system disorders
• US Data: Swelling Soft Tissue Bony
! 20% of outpatient visits
Erythema Sometimes ABSENT
! 46 million (22%) of population has physician-diagnosed arthritis
PRESENT
! 19 million have significant functional limitation
• Red Flag Diagnosis Warmth Sometimes ABSENT
! F - racture PRESENT
! S - eptic Arthritis
! C - rystal Induced Arthritis Morning Stiffness Prominent (>1hr) Minor (<45 mins)

Goal in Evalution of Patients with Musculoskeletal Complaints Systemic Features Sometimes ABSENT
1. Accurate Diagnosis PRESENT
! Septic Arthritis must be treated w/in 3 days; if not, permanent
damage to cartilage happen Elevated ESR or Frequent Uncommon
2. Timely Therapy CRP
3. Avoid Unnecessary Diagnostic Testing
Synovial WBCs WBCs >2000/mm2 WBCs <2000/mm2
Approach on Evaluatiing Patient with Musculoskeletal Examples • Septic Arthritis • OA
Complaints • Rheumatoid • Adhesive
Answer the Questions: Arthritis Capsulitis
• Is it Acute or Chronic? (Acute = <6 weeks) • Gout
• Is it Inflammatory or Non-inflammatory? • PMR
• How many joints are involved?
"Hip, Elbow, Shoulder, Wrist, Knee # 1 big joint
• Is it Articular or Non-articular? PHYSICAL EXAMINATION
• Are there systemic manifestation?
Goals:
ARTICULAR vs NON-ARTICULAR • Ascertain the structures involved
• Nature of Underlying Pathology
• Functional Consequence of the Process
Clinical Features ARTICULAR PERIARTICULAR • Presence of Extraarticular Manifestation
Anatomic Structures • Synovium • Tendon Parts
• Synovial Fluid • Bursa ! Inspection
• Cartilage • Ligament ! Palpation (Joints are 1’c COOLER than rest of body; if same
• Joint Capsule • Muscle temp = (+) inflammation)
• Bone ! Specific Maneuver
• Fascia • Gel Phenomenon
• Nerve - Upon Waking Up
• Skin - Stiff fingers softened by soaking in warm water
! Imaging
Painful Site • Diffuse, Deep • Focal or “point”
tenderness tenderness JOINT ENLARGEMENT may be due to:
Pain on Movement • Pain on ACTIVE • Pain on ACTIVE
• B - ony Hypertrophy (Hard)
and PASSIVE motion in a few
• S - ynovial Hypertrophy (Doughy)
motion in all planes specific planes
• S - ynovial Effusion (Fluid in Joint)
Physical Examination
Swelling • Common (bony or • UNcommon
soft tissue) ! Identify if inflammation is present
! Count the number of tender joints (0-28)
! Count the number of swollen joints
CLINICAL HISTORY ! Joint Stability
• Palpation
• Patient Profile • Application of Manual Stress
• Chronology ! Subluxation or Dislocation
• Precipitating Factors • Inspection
• Extent or Distribution of Articular Involvment • Palpation
• Co-morbid condition ! Flexion Deformity
• Review of System

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SPECIFIC MANEUVER Diagnostic Imaging

• B - ulge Sign • Plain x-ray
• B - allottement of the Patella • Ultrasonography - Soft Tissue
• B - ursal Effusion: Focal, periarticular fluctuant, sharply defined • Radionucleide Scintigraphy # Metabolic Status; extent and
borders, overlies bony prominence distribution of skeletal involvement
• CT Scan # detailed visualization of axial skeleton
RANGE OF MOTION • MRI # Musculoskeletal structure fine detail; bone marrow soft
• Limitation of ROM is due to effusion, pain, deformity, tissues
contracture
• Contracture due to trauma reflects synovial inflammation ADDITIONAL NOTES FROM CAZZY
• Deformities results from ligamentous destruction, soft tissue • SLE is characterized by:
contracture and ankylosis " Loss of Appetite
" Weight Loss
MUSCLE Mechanism/Strength " Malaise
• Grade 1 = Trace Movement • CRP # is INCREASED if IL is released in cell ($ in SLE)
• Grade 2 = Movement w/ Gravity Eliminated • ESR # affected by many factors
• Grade 3 = Movement Against Gravity a. Age = Old # $ ESR
• Grade 4 = Movement Against Gravity and Resistance b. Pregnancy
• Grade 5 = Normal Strength c. Infection
d. Anemia
HAND Pain
! Finkelstien Test
! Formula:
! Tinel’s Sign
! Female = Age + 10/2
! Phalen’s Sign
! Male = Age/2
! Inspect and Palpate • Synovial Fluid Test
! Most important for those w/ Synovial Fluid Effusion # cell count,
SHOULDER Pain gram staining & crystal studies
• Arise from glenohumeral or acromioclavicular joints, bursa, • Knee Effusion
periarticular soft tissues, cervical spine, intrathoracic lesions, "Accumulates in the suprapattelar pouch # horse-shoe shape
rotator cuff (drop arm test) " Normally, knee has (-) intarticular pressure
" Severe pain is due to fluid in the capsule (highly innervated)
KNEE Pain • Gout # patient should avoid ALCOHOL and SODA
• Aritcular or Periarticular • Chronology:
• Gait !Gout # >35 years old
• Malalignment (genu varum or genu valgum) !Acute Spondylitis # 19 years old
! Bulge Sign (<100 mL) • Aspirin and Ethambutol can induce gouty attack
! McMurray Test # Menisceal Tear • Rheumatoid Arhtritis Joint Affectation # PIP
! Drawer Sign # Cruciate Ligament Examination • Hand Osteoarthritis Joint Affectation # IP (d/t strong genetic
predisposition
HIP Pain • Enthesis = point of attachment of tendon to joint
• Gait • Good String Sign # fluid takes LONG TIME before it hits the
• ROM ground
• Plain in posterior gluteal masculature radiating to the posterolateral
aspect of the thigh (OA of LS spine) E N D (CJRebojo 2013)
• Example:
" Sciatica:
! Impingement of the L4, L5, or S1
! Trochanteric Bursitis = LATERAL aspect of the thigh
! Hip Joint Pain = ANTERIOR; over the inguinal ligament

LABORATORY INVESTIGATION
• CBC, ESR, CRP
• U.A.
• CCP, ASO
• ANA
• RF IgM (autoantibodies against the Fc portion of the IgG
Synovial Fluid Analysis
• Appearance: Clear, Pale Straw Colored
• Viscosity: Good string sign; hyaluronate
• Cell Count: <2000/ul, mononuclear cell
• Crystal Studies
• Gram-stain, Culture and Sensitivity

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