Examination and taking medical history from rheumatology patient

This is a guide for rheumatologists illustrating how to take history from and examine a patient with musculo-skeletal (Rheumatology ) complaint .
the steps of examination are summarized at the end of the article in figures to make it more easy for a clinician and in order not miss any piece of information .

How to take History from rheumatology patient :

1- Ask about peripheral joints (UL & LL) for pain, swelling, hotness, redness, limitation of movement (stiffness) or deformity.
2- Ask about axial joints (cervical & lumbar) as regard pain or limitation of movement.
• Ask about weakness either a primary or secondary muscle abnormality.
• Ask about the duration and severity of early morning stiffness.

3- Ask about extraarticular manifestations for example
-CVS   : chest pain, dyspnea
- Chest : dyspnea, wheezy chest
- L.N    : swelling (cervical, axilla)
-Skin     : rash
- Eye     : redness
-Kidney : puffines , hypertension .

How to examine  rheumatology patient ?

Using the GALS screen (see the figures)
1- Inspection of gait for symmetry and smoothness of movement .

2- Peripheral joints (UL, LL or Arm, Leg).

  - Inspection: swelling, deformity, wasting of muscle or skin changes, erythema or vasculitic rash.
  - Inspection during movement : is important to observe restriction, hypermobility or pain on usage.

  - Palpation  :  feel and move the joint, this reveal warmth, tenderness, crepitus, swelling or stability .
  - Evaluation of muscle function.

D.D of Swellings of joints (by palpation ).
a- Hard bony swelling.
b- Effusion demonstrated by patellar tap in knee.
c- Synovial thickening or synovitis ;  firm non fluctant.


3- Axialjoints  (spine) for pain & limitation.

Cervical segments :  flexion & extension, lateral flexion.
Lumbar egments   :  flexion & extension, lateral flexion.

4- Other Systems (extra articular manifestations)

 - Heart for pericarditis, myocarditis and valve lesions.
 - Lung for pleurisy and I.P.F
 - Liver, spleen, L.N for enlargement.
 - Skin for rash (purpuric eruption) e.g vasculitis.
 - Eye for redness .
Renal: hypertension, puffiness.

Sequence of GALS screening examination





CONCLUSION

The clinician should be able to answer the following questions :

1- Is there is arthropathy or not?
 the normal joints should be asymptomatic, look normal, assume a normal resting position and move smoothly through their range of movement .

2- Is the arthropathy peripheral, axial or both?

3- Is the arthropathy affecting small or big joints, symmetrical or asymmetrical?

4- Is the arthropathy is mono, pauci, or polyarticular?

5- Is the arthropathy erosive or non erosive?

6- Is the condition acute or chronic, inflammatory or non-inflammatory?

7- What about the extra articular manifestations (is the condition limited to the musculo-skeletal system or it is a systemic process)?

8- Is there is a family history of a similar process?

Inflammatory arthropathy is characterized by pain at rest, morning stiffness and improvement with .activity. In osteoarthritis and non arthritic musculoskeletal problems, pain is generally not present at rest and is precipitated by activity .

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