History & Examination in Rheumatoid Arthritis

Rheumatoid History

1. Presenting complaint
2. Pain: joints, limbs, elsewhere
3. Stiffness, swelling
4. Deformity, Raynaud's
5. Eyes, mouth
6. Systemic
7. Past medical, surgical history
8. Family, social, disability, drug history
Presenting complaint
· What is the problem lately?
Pain: joints
· Site, onset, duration, character, radiation aggravating & relieving factors, severity, associatedsymptoms
· Site: number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
· Timing: acute/ chronic.
· Exacerbating factors: rest, exercise.
Pain: limbs
· Site, onset, duration, character, radiation aggravating & relieving factors, severity, associated
symptoms
· Bone pain.
· Severe pain of sudden onset (vascular disease).
· Nerve entrapment.
· In amputated limb (phantom pain).
Pain: elsewhere
· Site, onset, duration, character, radiation aggravating & relieving factors, severity, associated
symptoms
· Back is common.
· Spinal cord: localize to dermatome.
Stiffness
· Generalized or specific to certain joints.
· Number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
· Worse in morning (RA, other inflammatory).
· Duration before wears off (severity).
Swelling
· Number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
· When first noticed.
· Getting larger or smaller.
Deformity
· Misshapen joints.
· Time course of the deformity.

Raynaud's
· Assess Raynaud's phenomenon (scleroderma).
Eyes, mouth
· Dry eyes, mouth (Sjogren's).
· Red eyes, painful eyes (seronegatives).
· Unilateral loss of visual acuity (seronegatives).
Systemic
· Rash (SLE).
· Fatigue, breathlessness.
· Fever (connective tissue disease).
· Weight loss (dysphagia or malabsorption 2° to scleroderma).
· Abdominal pain, GI bleeding (NSAID s/e).
Past medical, surgical history
· Time of menopause [if applicable].
· Current problem in past.
· Trauma in past.
· Fractures, sprains.
· Infections:
• Gonorrhea [especially if monoarticular, young].
• Staphylococcus
• Streptococcus
• Hepatitis
• TB
• Dysentery
· Gout (gouty arthritis).
· IBD (IBD-associated arthritis).
· Psoriasis (psoriatic arthritis).
· Thyroid problems (osteoporosis).
· Tick bites (Lyme disease) [usu. USA only].
· Arthritis as a child.
· Depression [common in chronic disability].
· Seen a rheumatologist before?.
· Physiotherapy, occupational therapy.
· Joint surgery, bone surgery.
Family history
· The current complaint in parents/ siblings/ children: health, cause of death, age of onset, age of
death.
· Hereditary disease suspected: do a family tree.
· IBD.
· Gout.
· Rheumatoid arthritis.
· Osteoarthritis.
· Seronegatives: PAIR:
• Psoriasis
• Anklyosing
• IBD-associated
• Reiter's

Social history
· Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew] (increases
NSAID risk).
· Alcohol: do you drink. If yes: type, how much, how often (fall risk, increases NSAID risk).
· Present occupation.
· Any other factors that you wish to mention?
Disability
· Who is with you there at home [important for managing daily activities].
· Describe your home: stairs, if apartment what floor, handles (fall risk).
· Difficulties with cooking, dressing, bathing.
· How interrupts life.
· Home aids, utensils, appliances.
Drug history
· Prescriptions currently on [gold, etc], noting side effects.
· Over-the-counters, esp. NSAIDs.
· Steroids.
· Recreational drugs [most rheumatoid pt's are older than this, but may use for pain escape].
· Estrogen replacements [if menopausal], other hormones.
· Calcium supplements.
· Allergies: if allergic to drug, make sure not an allergy, not just a common side-effect.

Examination in Rheumatoid

1-Knee Examintion:
1- Inspection:* While lying: swelling, scars, redness, muscle waisting.
* Standing: valgus, varus, post aspect for bakers cyst
* While walking: limping to the side of the problem.
2- Palpation:[/LEFT]* Temprature
* Effusion
* Patellofemoral compartment (push the patella and press)
3- Movement:
* Range of movement
* Pain while moving
* Stability: ant and post cruciate ligaments , lateral and medial collateral ligaments.
**********************

2- Spine Examination:
1- Inspection:
At rest: for deformities.
While moving: rotation , lateral flexion, ant and post flexion.
cervical spine is always examined while the patient is sitting BUT lumbosacral spine is examined while the patient is standing.
2- Palpation:
palpate paraspinal muscles and spine for tenderness.
Every time you Examine the spine U should perform a full neuro-exam for the lower limbs.

# Special examination in the spine:

1- Lumbosacral spine:

straight leg raising test ( Thomson's test):
while the patient is lying in the supine position. In normal individuals maximum stretch is at 70 degrees in patients with lumbosacral involvement nerve root stretches at 30 degrees and patient feels the pain.

2- Sacroiliac joint:
sacroilitis occrs in: seronegative arthrits such as Ankylosing spondylitis, or inflammatory bowel disease.

Manouvers to stress the sacroiliac joint:
pain is felt in the joint in the following cases:

1- open a book:
while the patient lying supine hold his both iliac bones and press on them as if U R opening a book.

2- lateral position ( close the book):
while the patient is lying on his lateral postion press the iliac bone as if U R closing a book.

3- Faber test ( Patrik test)
faber stands for
F: flexion
Ab: abduction
ER: External Rotation
all these movement at the hip joint.
******************
3- Hand:

1- Inspection:
At rest:
1- finger tips for pitting scars in scleroderma
2- nails for pitting nails in psoriasis, psoriatic changes, clubbing, splinter hemorrage...... etc.
3-muscles for wasting
4- skin for scaling, loss of hair, discoloration, atrophy.... etc
5- deformities

While moving:
for range the movement
for painful movement
ask the patient to flex his fingers extend them, make a fist.
opposition, adduction, abduction, extension and flexion of the thumb.
extension and flexion of the wrist joint.

Examine for carpal tunnel syndrome:
tap along the distribution of the median nerve.
phalen's test:
ask the patient to dorsiflex his both wrists
if positive patient will feel tingling along the distribution of the nerve.

2- Palpation:
palpate each interphalengeal joint medially lateraly anteriorly and posteriorly and passively flex and extend each joint looking for tenderness and effusion.

palpate each carpophalengeal joint and flex and extend each joint again looking for tenderness and effusion.

again palpate the wrist joint in the middle and extend and flex the joint looking for tenderness and effusion

Varicose veins examination

Varicose veins examination

Taking a history

You should take a full history from any person presenting with varicose veins, bearing in mind that pelvic masses, trauma, and previous deep venous thrombosis are recognised causes. You should ask about if they have aching leg pain; if their legs fatigue easily or feel heavy; and if there is any swelling. All of these symptoms become worse as the day progresses especially with long periods of standing. In severe cases, people may describe acute, bursting pain on walking that is relieved by rest and leg elevation. This is called venous claudication. People with severe venous hypertension may complain of skin changes including venous eczema and ulceration, classically in the gaiter region of the lower leg. You should also ask about any previous treatments. For some people, cosmetic issues may be the most important, but you should remember that some people with symptoms might have few visible varicose veins.

Examination

Inspection

You should start the examination by inspecting the patient standing--if he or she is able to stand--with both legs appropriately exposed to the groin. If varicose veins seem present then gently press on the affected areas, release, and watch the varicosities refill. By doing this, you are simply confirming that the areas are vascular. Consider whether the affected areas are warmer than the surrounding skin by using the back of your hand. Next try to see if the varicosities follow the long or short saphenous vein distribution. Varicosities in the short saphenous vein are seen only below the knee and are usually at the back and to the outer edge of the leg (posterolateral). Long saphenous varicosities may be found along the length of the leg, usually on the medial aspect. Some people have a large accessory vein on the back (posterior) part of the thigh, which may become varicose. This is the accessory vein of Giacomini.

On inspection, look for:

- Venous stars (venulectasias). These are bluish vessels that may distend above the skin surface and are usually 1-2 mm in diameter
- Superficial thrombophlebitis, which shows as a red, painful lump
- The brown pigmentation of haemosiderin deposition characteristic of increased venous pressure
- Venous eczema
- Ulceration and scarring from previous ulceration, especially in the gaiter area
- Lipodermatosclerosis; this is caused by chronic venous hypertension when fibrin deposition results in progressive sclerosis of the skin and subcutaneous fat
- Scars from previous vein surgery (look for harvesting of vein grafts for coronary artery bypass grafting).

Locating the saphenofemoral junction

Once you have finished the inspection, ask the patient to lie down and identify the saphenofemoral junction. One good way to do this is by locating the femoral artery--which lies between the anterior superior iliac spine and the pubic tubercle--by feeling for the pulse. The vein is medial to the artery and the saphenofemoral junction about two fingers' breadths below the inguinal ligament.

Next ask the patient to stand if he or she can. You then should place one hand on the varicosities and tap on the saphenofemoral junction. If the saphenofemoral junction is incompetent you may feel a fluid thrill. You can confirm the incompetence with a handheld Doppler ultrasonograph if you put it at the saphenofemoral junction and press on the varicosities. You should be able to hear blood flowing up the vein to the junction and with an incompetent valve at the saphenofemoral junction, you can hear the blood flowing back again.

Trendelenberg test
Again ask the patient to lie down, raise his or her leg, and empty the engorged varicosities. To do this, press on the saphenofemoral junction to occlude it. Then ask the patient to stand up and see if the varicosities refill immediately. If by putting pressure at the saphenofemoral junction the varicose veins are controlled saphenofemoral incompetence is present. If the veins simply refill then there is a leaky perforating vein further down. This is known as the Trendelenberg test.

Tourniquet test
If there is a leaky perforating vein--or as an alternative to the Trendelenberg test--you can do the tourniquet test. For this you ask the patient to lie down and lift the affected leg. By doing this, the veins will empty and you should put on the tourniquet, in turn, to the thigh, the lower thigh, and then below the knee. If the tightened tourniquet controls the varicose veins then the defect is above the tourniquet, if the veins refill then the defect is below. Reflux from venous valvular incompetence accounts for most chronic venous disease.

Once you have diagnosed varicose veins, you should consider the cause (aetiology). You should also do a full abdominal and scrotal examination to rule out intra-abdominal or pelvic pathology and do an arterial examination.

Investigations

You may need to do further investigations to clarify the area of valvular incompetence. This is best done by using Duplex ultrasonography.2 With the patient standing, cuffs are placed on the thigh, calf, and foot. The cuffs are inflated and then rapidly deflated to create retrograde venous blood flow in segments of valvular incompetence. It is possible to map valvular incompetence at the common and superficial femoral, long and short saphenous, popliteal, posterior tibial, and perforator veins.

Treatment
Surgery is indicated in people with saphenofemoral incompetence and in those with significant symptoms such as superficial thrombophlebitis, bleeding from
varicosities, or skin changes. This entails identifying the saphenofemoral junction in the groin and ligating it. The long saphenous vein is then disconnected in the groin and stripped to remove its tributaries. Isolated varicosities in the leg can be removed through small incisions (avulsion).

Sclerotherapy can be effective in treating small varicose veins without reflux. If reflux occurs at the saphenofemoral junction the surgeon should correct this first. Sclerotherapy entails marking varices while the patient is standing and then injecting a sclerosant, such as sodium tetradecylsulfate, into the lumen of larger veins to cause an inflammatory reaction. Compression stockings are worn after sclerotherapy.

Conservative management may include:

- Reassurance and advice
- Weight reduction
- Exercise and avoidance of long periods of sitting or standing
- Elevation of the legs
- Compression stockings may be used to manage chronic venous insufficiency, with the greatest compression at the ankle. However, people with peripheral vascular disease should not wear compression stockings unless an ankle brachial pressure index is satisfactory.

__________________

Examination for a diabetic foot

Examination for a diabetic foot

By inspection:


See the color of the skin( any pigmentation)
Any muscle wasting (motor innervations)
If there is dryness of the skin
Comment on hair distribution
Describe any ulcer (type, if there is any discharge))
Any scars
See if there is any deformity
1-hammer toes
2-hallux valgus
3-charcot joints
if there is any amputation
any infection

by palpation
any tenderness
the temperature
take the pulse
see if there is any sensation loss (sensory innervations))

why the ulcer affect the foot af DM people??
1-arterial insufficiency
2-peripheral neuropathy
3-impaired immunity
4-high glucose level and this a good environment to bacteria to live in

Thyroid Examination

Thyroid Examination

Make the patient sitting, expose the head, neck and upper chest

1- look at the whole patient- sitting still or agitated, looking nervous or slow in his/her movement
- thin or fat
- wasting or fating
- generalized loss of weight or localized wasting to face, shoulder, hand
- is he/she sweaty or feel cold
- myxoedema face
- any hair loss (especially the outer tow thirds of the eyebrows)

2- look at the hand- feel the pulse : Tachycardia  thyrotoxcosis
Bradycardia  myxoedema
Collapsing pulse
- the palms moist, sweaty?
- palmar erythema
- peripheral cyanosis
- pallor
- test for fine tremor (patient hold his/her arms out in front of them, elbow and wrist straight , fingers straight and separated)

3- look at the eye
- lid retraction (upper eyelid is higher than the normal)
- lid lag
- exophthalmos (eyeball is pushed forwards)
- ophthalmoplegia (patient can not look upwards or outwards)
- chemosis (edema of conjunctiva)

4- inspect the neck from the front and either side- surface,
- site,
- Shape (diffuse, nodular. Symmetrical, asymmetrical)
- size,
- color (redness)
- there is any scar for a previous surgery?
- any other swellings
- is there any distended veins?
- look for the position of thyroid cartilage, at center or deviated?
- It moves with the swallowing or not??
- It moves with the protrusion of the tongue or not?
- pemberton's sign

5- palpate the neck from the front
- tenderness,
- temperature
- measure the circumference
- mobility ( relation to surrounding tissues : -muscles
- Skin --tethering
-- fixation
- trachea (at center or deviated)
- carotid artery pulse (is it displaced?)

6- palpate the neck from behind
- ask the patient to swallow while you are palpating
- tenderness, shape, surface, size, consistency, thrill, Pulsatility, borders, mobility, temperature
- determine the lower border of the gland
- Palpate the cervical lymph nodes

7- percussion
To define the lower extent of a swelling that extends below the suprasternal notch

8- auscultation:
For a systolic bruit

-Look for any proximal myopathy
-Check the reflexes

(Note: if you suspect cervical lymphadenopathy, or enlargement of a salivary glands there is another examination for them)

Here is Video

around 20 MB

http://www.etu.sgul.ac.uk/cso/skills...id/thyroid.wmv

Lump History & Examination

Lump History

:

1- When was the lump first noticed? (Duration)

2- What made the patient notice the lump? (First symptom)

3- What are the symptoms related to the lump? (Other symptoms)

4- Has the lump changed since it was first noticed? (Progression)

5- Does the lump ever disappear (persistence)? What makes the lump to reappear?

6- Has the patient ever had any other lumps? (Multiplicity)

7- What does the patient think caused the lump? (Cause)

8- There is loss of body weight?

9- There is recurrence after operation or not?

Lump Examination

:

A- Local Examination:

1- Look:

Number of lumps

Shape (spherical, hemispheric, pear or kidney shape)

Site and extension

Size

Impulse on cough

Color and texture of overlying skin: (smother and shiny or thick and rough skin, scars,

ulcers, discharging sinuses)

2- Feel:

Temperature

Tenderness

Surface (smooth, irregular, nodular)

Edge (well defined, indistinct)

Consistency (stony hard, firm, rubbery, spongy, soft)

3- Press

:

Pulsatility (expansile pulsation, transmitted pulsation)

Compressibility (disappear on pressure and reappear on release)

Reducibility (reappear only on application of another force: cough)

Fluctuation (the 2 fingers moved apart when middle area pressed)

Fluid thrill: indicates presence of fluid

4- Percussion

(dull, resonant)

5- Move

:

Fixation to skin (pinching the skin)

Mobility (try to move the lump in 2 planes)

Attachment to underlying muscle (ask the patient to tense the muscle)

6- Listen:

(bruit, bowel sounds)

7- Transillumination: indicates

presence of clear fluid

8- Examine Surrounding Tissue:

Draining group of lymph nodes

Sensation in surrounding area

Power of related muscle

Distal effects (swelling, atrophy…)

State of local tissue: arteries (ischemia), nerves (muscle wasting and change in sensation),

lymphatic (edema), bones and joints (erosion).

PERIPHERAL VASCULAR DISEASE History

PERIPHERAL VASCULAR DISEASE

Disorder caused by acute or chronic interruption of blood supply to the limbs usually due to atherosclerosis. Males>Females.

Presentation:

General presentation is of calf pain, brought on by exercise. The pain will generally occur at the same distance walked each time, and then relieved by stopping. This is called ‘Intermittent Claudication’ and the distance walked before needing to stop the ‘Claudication Distance’. The Claudication distance is very important to elicit as it can be used to monitor progression of the diseased vessels. Other symptoms related to claudication are numbness and paraesthesia .

When does the pain start?

How far can you walk before you need to stop?

Does the pain go away when you stop?

Do you ever tried to ‘walk through the pain’?

If a patient is unsure about how far they can walk in meters, then suggest local marks to them, such as can you go as far as your front gate? Can you manage to walk to the shop? Then they will be able to quantify their claudication distance which should be noted for future comparison.

Does the pain ever occur at rest?

This may indicate progression of the disease in those with a known claudication distance or worse, a sudden onset of rest pain may indicate distal embolisation. Rest pain is a continuous pain due to Ischaemia. This pain is very severe aching type pain mainly in the forefoot, it may be relieved by the patient dangling their leg over the side of the bed. Rest pain indicates critical Ischaemia, that is, arterial insufficiency severe enough to threaten the viability of the foot or leg.

Have you noticed any change in the colour of your legs?

Patients may commonly notice their leg looking paler than the other and when they go to put their sock on they may feel it colder too, prompting them to wear two pairs!

Have you noticed any change in the skin on you legs, such as sores that wont heal?

Patient may present due to loss of tissue of their lower limb from prolonged compromise. Quite often a carer may notice a blackened toe, or multiple small areas of discolouration over the distal phalanges- ‘trash foot’, this is due to multiple microemboli from atheromatous plaques more promixmal.

Ask questions regarding the known risk factors for peripheral Vascular Disease.

Do you smoke? How many? For how long?

If the patient used to smoke, find out for how long and again how many per day, as smoking has long lasting and far reaching effects.

Do you have high blood pressure? Are you on any medication for your blood pressure? For how long? When did you last have it checked? Was it normal at that time?

Again the same questions need to be asked about hyperlipidaemia and a family history of same.

Many patients will be on a statin and not know that this is for their cholesterol so ask specifically about each medication, what it is for, and for how long they have been on it.

Are you a diabetic?

The following are essential questions to obtain from all patients with diabetes.

How long have you been a diabetic?

Do you need insulin/injections or are you on diet and exercise alone?

If on insulin/oral hypoglycaemics ask if they have ever had a hypoglycaemic episode, and if so how many.

What is your normal blood suger range, can I see you book?

What was your last HbA1C?

This test is a marker of their glycaemic control over the last 12 weeks.

Do you have any problems with your eyesight? Is this related to your diabetes?

Do you have any kidney problems? Is this related to your diabetes

As diabetes is a systemic diseae and affects all the vasculature especially the small and medium sized vessels, poor eyesight and kidney impairment are an indication of the condition of the bodies’ vasculature albeit not a very precise one!