Approach to a Rheumatologic Patient:

History, Physical Examination and

Laboratory Studies

Tahir Khan, M.D., FACP, FACR

Consultant Rheumatologist
Mafraq Hospital
 Common Complaints
Pain
Stiffness

Locking

Swelling

Fatigue

Cracking and clicking of joints

 History
Acute or chronic
Migratory, additive, or intermittent
Is the process articular or non articular
If articular, whether inflammatory or non-
inflammatory (jt. Swelling, stiffness, decreased
ROM)
Addition clues like age, joint distribution,
symmetry, extra-articular.
Other medical illnesses
FH
Physical Examination
 Question
74 year old male with history of NHL presents
with pain and swelling of his hands for 3 weeks.
He noticed swelling of her feet as well. He is
unable to close his hands or make his fists and it
takes him 2-3 hours to feel slight better daily. He
denied any other symptoms. MSK exam reveal
soft tissue swelling of her dorsum hands and feet.
He has synovitis of his 2-5 MCPs, PIPs with in his
bilateral MCPs. Labs done by his PCP reveal
negative RF, CCP, What is the most likely
diagnosis.
 Question (continued)
What is the most likely diagnosis?
A) Rheumatoid arthritis

B) Polymyalgia rheumatica

C) Lofgrens syndrome

D) Remitting seronegative
symmetrical synovitis with pitting
edema (RS3PE)
E) Recurrence of NHL
 Physical Examination
Vitals: Fever, tachycardia (pericarditis, anemia),
tachypnea, hypertension (systemic process),
weight, height (loss of 2 cm = new vertebral
fracture).
Head and Neck: Alopecia, ocular inflammation
(think SpA), oral ulcers (painless with reactive
arthritis, painful with enteropathic arthritis),
nasal ulcerations, discharge or bleeding
(vasculitis-GPA), malar rash, telangectasia,
lymphadenopathy, parotid or salivary gland
enlargement, dry mouth, dental carries, thyroid,
scalp tenderness.
 Physical Examination
Head & Neck: Scalp tenderness, ear cartilage.
Chest: Tachypnea, crackles (ILD with
rheumatic diseases), wheezing, pleural
effusions (SLE or RA), chest expansion.
CVS: Murmurs (RF, endocarditis), rubs
(SLE,RA), loss of pulses, asymmetrical BP,
bruits (think large vessel vasculitis).
Skin and Nails: Psoriasis, rashes (think SLE),
periungual erythema (think CTD), livedo
reticularis (think SLE with APS, or vasculitis).
 Physical Examination
Skin and Nails: Photosensitivity, Erythema
nodosum (think enteropathic arthritis,
sarcoid), erythema migrans (lyme),
telangiectasia (think CREST, scleroderma),
pustular skin lesions (think disseminated
gonococcal infection), nodules (RA, tophi),
subcutaneous calcifications, lesions on palms
and soles (pustular psoriasis or
keratoderma=reactive), lesions on glans
penis (think circinate balanitis=reactive),
gottrons plaques (DM dermatomyositis ),
Heliotrope (DM), Shawl sign, Tethered skin,
Raynauds.
 Physical Examination
Skin and Nails: Desquamation
palms/strawberry tongue (Kawasakis).
Abdomen: Tenderness (Behcets, HSP, SLE,
PAN), Look for masses, organomegaly, bruits.
Neurologic: Neuropathy (vasculitis), carpal
tunnel syndrome (RA, pregnancy,
hypothyroidism, amyloidosis), CNS
abnormalities like encephahopathy (SLE).
 MSK Examination
Goal: Whether joint is normal or abnormal
If abnormal, is it inflammatory or
degenerative joint disease.
Joint swelling (fluid, hypertrophied synovium
or from bony enlargement)
Examine all joints using the same approach:
Inspection
Palpation
Range of motion
Special tests
 Wrist Examination
Tinel sign: Tap over the median nerve lateral to
Palmaris longus tendon whilst extending the
wrist.
Phalens test: Flexion of the wrists produces
aggravation of carpal tunnel symptoms.
Shoulder Examination
 Cervical Spine
Lateral rotation should allow 60-90 degrees.
Flexion should allow 60-90 degrees and lateral
flexion 30-60 degrees.
 Thoracic Spine
The thoracic spine allows 45 75 degrees of
rotation.
Chest expansion should be greater than 4 cm.
 Sacroiliac Joint
Palpate the joint itself, or apply lateral
compression of the pelvis.
Faber (Flexion, abduction, and external rotation
with force).
Hip Joint
Knee Joint
Trigger Point Examination
 Special Tests
Gowers sign: Patient attempts to rise from a
chair by climbing up legs with his hands
Use an ophthalmoscope or otoscope to see
red dots or lines at periungual areas, look for
superficial dilated capillaries, drop out of
capillaries with dilatation and hypertrophy of
remaining vessels.
Special Tests
Persons with
Sjogrens moisten
less than 5 mm in
5 minutes.
Laboratory Studies in
Rheumatic Diseases
 DO WE NEED LABS?
Most Rheumatic conditions are
diagnosed clinically.
 Acute Polyathritis
ANA, RF
Hepatitis panel, brucella titers

Parvovirus B-19( IgG, IgM*)

ASO titer

HIV, ACE (Ankles), ANCAs.

Blood cultures (septic arthritis,

reactive, migratory arthritis in DGI)

 Chronic Polyarthritis
CBC
ESR, CRP

ANA

RF, Anti-CCP antibody

CMP

S. uric acid

ANCA

TSH, Ferritin, transferrin

Urine analysis
 Synovial Fluid Analysis
Most CTD have Class II inflammatory SF-
yellow/ white
- transparent/ opaque
- variable viscosity and mucin clot
- WBC count 2000- 100,000
- > 50% PMNs
- Culture -ve
- Indolent/ low virulent infections may
coexist.
- Cholesterol (chronic), steroid
(injected) and other crystals.
 ENAs
Antigens extracted from rabbit, calf
thymus, or human spleen. Antibodies
react with nucleic acid binding
proteins.
ENA- 4 : Anti-SSA & SSB- linked

Anti-Sm & RNP- linked

ENA- 6: Above + Anti-Scl70 & Jo-1
 Anti- cardiolipin Antibodies
Check in lupus patient, if Hx of DVT, arterial
thrombosis, stroke, miscarriages.
TESTS: ACLA *: IgG, IgM, IgA (moderate to
high titers - ELISA
Lupus anticoagulant*- 20%- specific-
functional assay
(prolonged PTT, RVVT, Kaolin clotting
time)
(B2GP2 or prothrombin)- not corrected
in APLA syndrome by adding normal serum,
corrects in clotting factor deficiency.
(phospholipid addition corrects it)
Anti- B2GP1 AB (co-factor) more
specific.
Repeat in 8-10 weeks to confirm
Monosodium urate crystals

Crystal examination
 CPPD
Chondrocalcinosis or
Pseudogout
Weakly + birefringent rectangular crystals
on polarized microscopy.
SF type II inflamm.
Remember list of disease associations:
Hyperparathyroidism, Hemochromatosis,
hypomagnesemia and phosphatasia,
ochronosis, Wilsons, DM, OA, acromegaly
etc.)
CPPD crystals

Crystal examination
 SLE Disease Monitoring Labs
?
 Questions
THANK YOU!