Transcript The Musculoskeletal Exam

Rheumatologic Conditions
Beatriz Y. Hanaoka, M.D.
Division of Rheumatology
April 20, 2011
Characterization of an MSK problem
 What are the symptoms?
 Site and distribution of symptoms
 Chronology
 Associated symptoms
 Symptom response to health interventions
 Preceding factors
 What is its impact?
Symptoms of an MSK Problem
 Pain
 Loss of function
 Stiffness
 Fatigue and malaise
 Swelling
 Depression and fear
 Deformity
 Sleep disturbance
 Weakness
 Symptoms of systemic
disease
 Instability
MSK exam
 In examining the MSK system, it is important to keep
the concept of function in mind.
 Note any gross abnormalities of mechanical function
with the initial introduction to the patient.
 Continue to observe for such problems throughout the
interview and the examination.
Case #1
 40 yo W who was previously in her normal state of
health.
 She presents with a 4 month history of worsening pain
and swelling involving her 2,3,4 and 5 PIPs bilaterally,
right 2 and 3 MCPs, wrists and feet bilaterally.
 She also endorses “bumps” on the dorsal aspect of her
hands, morning stiffness lasting approximately 2 hours,
dryness in her eyes and mouth and, Raynaud’s
phenomenon.
Case #1
Feel: warmth
Testing for warmth using the back of the hand.
Case #1
Case #1
Case #1
Case #1
What does this patient
have?
Case #1
 Rheumatoid arthritis
 Secondary Sjogren’s syndrome
 Secondary Raynaud’s phenomenon
Look: swelling
Synovial thickening
Joint effusion
Bony enlargement
Combination
Common deformities of the hands
Hand deformities in RA
Look: wasting
Case #2
 35 yo M with a h/o psoriasis for 5 years.
 He endorses a 2 month history of pain and swelling in
his right knee and left second toe, associated with 2
hours of morning stiffness.
 He takes ibuprofen 800 mg as needed for pain with
partial relief.
Case #2
Case #2
Case #2
Seronegative
Spondyloarthropathies
 Ankylosing spondylitis
 RF negative
 Reactive arthritis
 HLA-B27
 Psoriatic arthritis
 Sacroilitis/ spondylitis
 IBD arthritis
 Inflammatory peripheral
arthritis (often asymetrical)
 Extra-articular
manifestations
 Ocular inflammation
 Enthesopathy
 Skin changes (psoriasis,
erythema nodosum)
Common deformities of the spine
What spinal deformity is this?
What spinal deformity is this?
What is the underlying disease?
Case #3
 54 yo M with a history of HTN, DM2 and CRI presenting
with sudden onset pain and swelling in his R 1st MTP
joint that started 2 days ago.
Case #3
Look: skin
Redness as seen in gout.
This is a valuable indicator of the intensity of underlying joint inflammation
Case #3
Case #3
What is the diagnosis?
What is the pattern of the
arthritis distribution?
Diagnosis
Symmetry
No joints
involved
Large or
small
Rheumatoid
Arthritis
Symmetrical Polyarthritis Large/
small
Peripheral
Upper/
lower
Ankylosing
Spondylitis
Asymmetric
al
Oligoarthriti Large
s
Central and
peripheral
Lower
Psoriatic
Arthritis
Asymmetric
al
Oligo/
Large/
Polyarthritis small
Peripheral
Upper/
lower
Reacive
Arthritis
Asymmetric
al
Oligo/
Large/dacty Peripheral
Polyarthritis litis
Lower
Gout
Asymmetric
al
Mono/
oligoarthriti
s
Lower/
upper
Large/
small
Distribution Upper or
lower limbs
Peripheral
What is the diagnosis?
Regional examination of
the MSK
Hand and Wrist Video
Elbow Video
Shoulder Video
Spine Video
Hip Video
Knee Video
Ankle and Foot Video
Conclusion
 What are the symptoms?
 Site and distribution of symptoms
 Chronology
 Other associated symptoms
 Symptom response to health interventions
 Preceding factors
 What is its impact?
Questions?
Cervical spine
Temporomandibular joint
Dorsal spine
Hand
Wrist
Elbow
Shoulder
Hip
Knee
Ankle and Foot