Rheumatology (RHM Y-3)

A GUIDE FOR STUDENTS AND FACULTY

2014

SHIFA COLLEGE OF MEDICINE

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ISLAMABAD

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CONTENTS

1. Introduction 3

2. THEME 1 – Pain, Swelling and Deformity in Multiple Joints 4

3. THEME 2 – Pain & Swelling in a Single Joint 9

4. THEME 3 – Elderly Patient with Fracture 10

5. THEME 4 – Patient with Dirty Wound 13

6. Image Gallery 14

7. Resource Material 26

8. List of Persons to Contact 26

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INTRODUCTION

Welcome to the Rheumatology (RHM Y-3) Module!

This module will run for 2 weeks. There are four themes in the module.

Theme 1 is of a patient with multiple joint diseases, Theme 2 is based on a

patient with single joint disease, Theme 3 is based on an elderly patient with

femoral neck fracture and Theme 4 is based on a patient with dirty wound.

You would be learning most topics using clinical vignettes/cases, which are

used to create clinical relevance.

When you look at the time table for this module you would notice that the

mode of instruction is multi-pronged with Problem Based Learning (PBL),

small group discussions (SGD), large group interactive sessions (LGIS),

Creating a Case Activity (CACA) and practicals. Please make it a habit to check

the notice boards everyday for details of these assignments as well as your

group allocation and come prepared to the sessions.

We would be incorporating Evidence Based Medicine in this module and you

would be required to search the latest best evidence available for any topic. It

is important for all of you to inculcate the habit of reading journals so that you

learn to stay up-to-date with the latest innovations in Medical Sciences.

If you want to succeed you will have to take responsibility for yourselves, set

your priorities and spend your time wisely.

Good luck!

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RHEUMATOLOGY (RHM Y-3)

THEME 1 – Pain, Swelling and Deformity in Multiple Joints

Case No. 1: A 35 years old female presents in Foundation OPD with complaints of pain and swelling of multiple joint for 6 weeks.

Presenting Complaint:• Pain and swelling of small joints of hands – 6 weeks.

History of Presenting Complaints:Patient was in usual state of health six weeks back when she started having pain and swelling in small joints of both hands. Her joint stiffness is more pronounced in the morning, when she gets up for prayers and she is unable to knead dough to prepare parathas for breakfast. The stiffness last for 2-3 hours.She also complains of easy fatigability. She consulted a local doctor, who prescribed some tablets for pain but there has no improvement.There is no history of malar rash, photosensitivity, oral ulcers or hair loss.There is no history of sore throat, UTI, chest infection or diarrhea.

Review of Systems:• Cardiovascular: No history of dyspnoea, Orthopnea, chest pain, palpitations, etc.• Respiratory: No history of cough, sputum, fever, chest tightness and discomfort.• Gastrointestinal: No history of nausea, vomiting, abdominal pain, diarrhea, difficulty

in swallowing or moth ulcers. • Genital/ Reproductive: Regular menstrual cycle.• Urinary: No history of burning micturition, increase in frequency or suprapubic

discomfort.• Endocrine: No history of polyuria, polydypsia, increase or loss of weight, dry skin.• Neurological: No history of fits, focal weakness, visual or auditory problems, or

movement disorder.• Psychiatric: No history of depression, anxiety or psychotic symptoms

Past History: No significant medical and surgical past history

Drug History/Allergies: None known. Family History: Mother had similar joint problem at the age of 40.

Personal History: Non-smoker, non-addict. Normal sleep pattern. Normal appetite and bowel habit.

Obstetrical History

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Regular cycle 7/28.5 live births. All born in hospital with normal uneventful deliveries. No history of abortion, IVD or still birth.

Socio-Economic History:Married, having 5 children; the youngest is of 2 months old.Housewife, husband is a clerk.Living in a 3-room house.

GENERAL PHYSICAL EXAMINATION:A young lady, well oriented in time, place and person.Height: 5 ft 2 inchesWeight: 55 Kg No signs of pallor, jaundice, malar rash, alopecia, or mouth ulcers.

Vital Signs: Pulse: 86 bpmBP: 110/70 mmHg Respiratory Rate: 18/minTemperature: 98.30 F SYSTEMIC EXAMINATION:Musculoskeletal System: GALS (Gait, Arm, Leg, Spine)• GAIT: Normal • ARM: Examination of Hands:

Swelling of proximal inter-phalangeal (PIP) and metacarpophalengeal (MCP) joints of both hands. No Muscle wasting & visible deformity. (LOOK)

On palpation, PIP & MCP are warm and tender. There is no subcutaneous nodule and sensory loss. (FEEL)

She is unable to make a fist. (MOVE)Examination of Wrist, Elbow, Shoulder: Normal

• LEG (Hip, Knee and Ankle Joints): Normal• SPINE: Normal

Respiratory System: Chest normal in shape & expansion. On palpation, chest movement is bilaterally equal with normal tactile fremitus. On auscultation, there is bilateral normal vesicular breathing.

CVS: Apex beat in left 5th intercostals space along mid-clavicular line, no palpable thrills or murmurs. On auscultation S1& S2, no added heart sounds.

GIT: Abdomen soft, non-tender. No visceromgaly or evidence of free fluid. Bowel sounds audible.

CNS:

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No cognitive, sensory, motor or movement abnormality.Case No. 2: A 30 years old female presented to Foundation OPD

Presenting Complaints:1. Fever for 2 months.2. Pain in small joints of hand for 4 weeks.3. Right sided chest pain for 1 week.

History of Presenting Complaint:Patient was in usual state of health 2 months back when she developed malaise and easy fatigability. Fever was undocumented, low grade, continuous, without chills and rigors.Patient also developed pain in the small joints of hands for the last 4 weeks, which is progressively worsening. She also gives history of morning stiffness, which lasts for about half an hour. There is no history of swelling of joints.Patient also complains of pain in the right lower chest for last 1 week. It was sudden in onset, non-radiating and has progressively worsened. It aggravates on deep inspiration. There is no H/O cough, sputum, dyspnea, orthopnea or paroxysmal nocturnal dyspnea (PND). Patient also gives history of intermittent painful bluish discoloration of fingers. Such episodes occur while exposure to cold water (while washing clothes, etc) and within an hour after warming the hands. There is a history of malar rash, which exacerbate on exposure to sunlight (photosensitivity). She has developed oral ulcers, redness in eyes and hair fall.The local doctor has given her pain killers; she is using these for the last 10 days but without any relief.

Systemic Review:• Cardiovascular: No history of dyspnoea, Orthopnea, PND, chest pain, palpitations etc.• Respiratory: No history of cough, sputum, fever, chest tightness and discomfort.• Gastrointestinal: No history of nausea, vomiting, abdominal pain, diarrhea, difficulty

in swallowing or moth ulcers. • Genital/ Reproductive: Regular menstrual cycle.• Urinary: No history of burning micturation, increase in frequency or suprapubic

discomfort.• Endocrine: No history of polyuria, polydypsia, thyroid dysfunction, increase or loss of

weight, dry skin.• Neurological: No history of fits, focal weakness, visual or auditory problems, or

movement disorder.• Psychiatric: No history of depression, anxiety or psychotic symptoms.

Past History:No significant medical and surgical past history

Drug History/Allergies: Not known. Family History: Mother is diabetic. No H/O joint pains.

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Personal History: Non-smoker, non-addict. Normal sleep pattern. Normal appetite and bowel habit.

Obstetric History: Regular cycle 7/28.One live issue, born in hospital with normal uneventful delivery. History of abortion twice, in first trimester. One IUD.

Socio-Economic History:Married, having 1 child of 8 years.Housewife, husband is a businessman.Living in a 3 bed room house.

GENERAL PHYSICAL EXAMINATION:A young lady well oriented in time, place and person.Height: 5 ft 4 inchesWeight: 55 Kg No signs of pallor or jaundice.

Vital Signs: Pulse: 86 bpmBP: 130/90 mmHg Resp Rate: 18/minTemperature: 1000 F

SYSTEMIC EXAMINATION:Musculoskeletal System: GALS (Gait, Arm, Leg, Spine)• GAIT: Normal • ARM: Examination of Hands:

Proximal inter-phalangeal (PIP) and metacarpophalengeal (MCP) joints of both hands are normal. No muscle wasting or visible deformity. (LOOK)

On palpation PIP & MCP are tender. There is no subcutaneous nodule and sensory loss. (FEEL)

Hand movements are normal. (MOVE)Examination of Wrist, Elbow, Shoulder: Normal

• LEG (Hip, Knee and Ankle Joints): Normal• SPINE: Normal

Respiratory System: Chest normal in shape & expansion. On palpation, right lower chest is tender. Chest movement is bilaterally equal with normal tactile fremitus and vocal resonance. Normal vesicular breathing bilaterally with no added sounds.

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CVS: Apex beat in left 5th intercostal space along mid-clavicular line, no palpable thrills or murmurs. On auscultation S1& S2, no added heart sounds.

GIT: Abdomen soft, non-tender. No visceromegaly or evidence of free fluid. Bowel sounds audible.

CNS: No cognitive, sensory, motor or movement abnormality.

Learning Objectives of Multiple Joint Disorders

Student should be able to:

Knowledge • Relate autoimmunity and hypersensitivity reactions (Types II & III) to the disease

process and its management. • Formulate a management plan for patients with joint disorders. • Diagnose a patient with multiple joint diseases (SLE & Rheumatoid Arthritis) on

the basis of clinical history, examination & lab investigations. • Order and interpret appropriate laboratory diagnostic tests for joint diseases (CRP

and autoimmune markers like RA factor, ANA, etc.) • Order and interpret various radio-imaging modalities for joint disorders. • Describe the rationale & mechanism of action of drugs (NSAIDs, DMARDs and

Immunomodulators) used in the management of multiple joint diseases. • Identify adverse effects and interactions between drugs (NSAIDs, DMARDs and

Immunomodulators) used in the management of multiple joint diseases. • Select appropriate drugs (NSAIDs, DMARDs and Immunomodulators) depending

on the disease severity and side effects based on best available evidence. • Describe the role of surgical intervention & rehabilitation programmes in patients

with crippling joint disorders.

Skills• Take a focused history of a patient with joint complaints. • Perform clinical examination of joints. • Recognize findings and interpret their clinical significance.

Attitude• Show empathy and respect for patients with crippling joint disease.

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THEME 2 – Pain & Swelling in a Single Joint

This theme will be delivered by using the approach of “Creating a Case Activity (CACA),” in which students are divided into different groups and prompts pertaining to a particular patient are given to them. Students then themselves synthesize and develop the entire case history by consulting different resources. This will be followed by students’ presentations and discussion of these cases.

Learning Objectives of Single Joint Diseases

Student should be able to:

Knowledge• Relate the pathogenesis of monoarthritis (septic arthritis, osteoarthritis, gout/

pseudogout) with its clinical presentation. • Identify the microorganisms involved in septic arthritis and describe Neisseria

gonorrhoeae.• Order and interpret appropriate diagnostic tests for the relevant joint diseases

(complete blood count, ESR, CRP, uric acid & synovial fluid analysis). • Select appropriate antimicrobial agents used for the treatment of septic arthritis. • Describe the rationale & mechanism of action of drugs used in the management of

gout & pseudogout. • Identify adverse effects and interactions of drugs used in the management of gout

& pseudogout.

Skills• Take a focused history of a patient with joint complaints. • Perform clinical examination of joints. • Recognize findings and interpret their clinical significance. • Write an appropriate prescription.

Attitude• Show empathy and respect for patients with acute joint disease.

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THEME 3 - Elderly Patient with Fracture

Case No. 3: A 69-year old woman presented to the ER

Presenting Complaints:1. Lower backache 15 years2. Fell on the floor Last night

History of Presenting Complaints:Patient was in normal state of health 15 years back when she developed lower backache which was gradual in onset and increased in intensity. Pain also radiated to the right leg. Patient also noticed that her posture has become stooped. It is associated with generalized weakness and easy fatigability. She consulted a local doctor several times, who prescribed some tablets for pain, which relieved her symptoms on and off.She slipped on the wet floor of her washroom and developed severe pain at right hip. Her leg was externally rotated and it was difficult for her to stand up. His son brought her to the ER, where x-ray revealed fracture neck of femur.

Review of Systems:• Respiratory: History of cough with whitish sputum, chest tightness and discomfort. • Cardiovascular: History of dyspnoea, no history of orthopnea, chest pain,

palpitations, etc.• Gastrointestinal: No history of nausea, vomiting, abdominal pain, diarrhea,

difficulty in swallowing or moth ulcers. • Urinary: No history of burning micturition, increase in frequency or suprapubic

discomfort.• Endocrine: No history of polyuria, polydypsia, thyroid dysfunction, increase or loss

of weight, dry skin.• Neurological: No history of fits, focal weakness, visual or auditory problems, or

movement disorder.• Psychiatric: No history of depression, anxiety or psychotic symptoms.

Past History: Not significant medical and surgical history.

Family History: Her elder sister was diagnosed with osteoporosis after a hip fracture two years back.

Drug History/Allergies: She took some unknown medication from a local doctor. No known drug allergies.

Gynecological History: Postmenopausal for last 25 years at the age of 44. Has four children; youngest is 33 years old.

Personal History: Non-smoker, non-addict. Normal sleep pattern.

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Normal appetite and bowel habit.

Socioeconomic History: Husband is a retired government officer.Living in a 4-room house.

GENERAL PHYSICAL EXAMINATION:A thin elderly lady, well oriented in time, place and person.Height: 5 feet 1 inches (previous record shows height 5ft 3 inches)Weight: 48 kg

Vital Signs: Pulse: 90/min BP: 130/90 mm of HgResp Rate: 22/minAfebrile

SYSTEMIC EXAMINATION:Musculoskeletal System: GALS (Gait, Arm, Leg, Spine)• GAIT: Unable to walk• ARM: Normal• LEG: Examination of Hip Joint

Shortening and external rotation of right lower limb (LOOK) Severely tender (FEEL ) Reluctant to move (MOVE)

Other Joints: Normal• SPINE:

Inspection (LOOK): Kyphosis. Palpation (FEEL): Tenderness present at dorsolumbar spine Movement (MOVE): Reluctant to move

Chest: Inspection: Asymmetrical (kyphosis)Expansion: Bilaterally equal but reduced.Percussion: Resonant note.Auscultation: Bilateral prolonged expiration with wheeze.

CVS: Apex beat in left 5th intercostal space along mid-clavicular line, no palpable thrills or murmurs. On auscultation S1& S2, no added heart sounds.

GIT: Abdomen soft, non-tender. No visceromegaly or evidence of free fluid. Bowel sounds audible.

CNS: No cognitive, sensory, motor or movement abnormality.

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Learning Objectives of Elderly Patient with Fracture

Student should be able to:

Knowledge• Generate a differential diagnosis of age-related bone disease based on

clinical presentation (including osteoporosis, osteopetrosis, rickets & osteomalacia).

• Correlate the signs and symptoms with the underlying age-related bone condition.

• Formulate an evidence based management plan for age-related bone diseases. • Order and interpret appropriate diagnostic tests. • Select appropriate treatment modalities depending on the disease severity and

based on best available evidence. • Identify complications of age-related bone disease.• Elucidate measures to be taken in early life for prevention of age-related bone

disease.• Identify and describe genetic disorders related to bones and joints including

Marfan and Ehlers-Danlos Syndromes.

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THEME 4 - Patient with Dirty Wound

Vignette:

A 13 year old boy cut his knee, when he fell to the ground while playing football in the street. He did not pay any attention to his injury or seek medical help. Five days later, when he tried to get out of bed in the morning, he felt weakness in his legs and found walking difficult. He called his father, who took him to a local clinic. He was seen by a GP, who re-assured the father and sent the boy back after cleaning the wound, which was infected. However, the boy’s conditioned did not improve and the next day he was taken to a hospital. By the time he reached there, he had begun to experience difficulty with speech and muscle spasms. The doctor examined the patient and was concerned by his growing respiratory distress and acute muscle spasms. The physician enquired about the boy’s vaccination history and was informed by the father that the boy had not received any vaccination. The doctor immediately intubated the patient and took counter measures.

Learning Objectives of Patient with Dirty Wound

Student should be able to:

Knowledge• Identify the microorganisms involved in infection of contaminated wounds and

describe Clostridium and Anaerobes. • Describe the pathogenesis, clinical presentation and management of infections

caused by dirty wounds (including gas gangrene, tetanus and osteomyelitis). • Elucidate the methods and applications of sterilization and disinfection in medical

and surgical practice.

Skills• Apply principles of Hospital Infection Control including Standard Precautions.

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IMAGE GALLERY

Rheumatoid Arthritis

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Osteoarthritis

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Gout

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Pseudogout

Calcium pyrophosphate dihydrate crystals extracted from the synovial fluid of a patient with pseudogout viewed under polarised light microscopy.

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Septic arthritis ( Neisseria gonorrhoeae)

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Osteoporosis

Lumbar vertebrae of a normal person (A) and a case of osteoporosis (B)

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Osteomalacia/Ricketts

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Marfan Syndrome

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Ehler-Danlos Syndrome

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Osteomyelitis

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Tetanus

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Gas Gangrene

Clostridium perfringens

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RESOURCE MATERIAL

1. Levinson’s Review of Medical Microbiology & Immunology. 2. Robbins’ Pathologic Basis of Disease.3. Katzung’s Basic and Clinical Pharmacology.4. Kumar & Clark’s Clinical Medicine.5. Macleod’s Clinical Examination.

Note: These books are merely suggestions and you do not have to restrict yourself to them. Make sure to look for the latest Best Available Evidence and also consult other reference books.

PERSONS TO CONTACT

Dr. Rifat Nadeem Ahmad Dr. Samina GhayurAssistant Professor, Pathology Professor, PathologyCourse Director Ext: 3761Ext: 3765 e-mail: sameena.ghayur@yahoo.come-mail: rifatahmad@gmail.com

Dr. Mahwish Majid Bhatti Dr. Ghazala MudassarAssistant Professor, Pathology Assistant Professor, PathologyExt: 3765 Ext: 3768e-mail: mahwish72@yahoo.com e-mail: ghazalamudassir@yahoo.com

Dr. Talat Ahmad Dr. Abida ShaheenProfessor, Pharmacology Assistant Professor, PharmacologyExt: 3403 Ext: 3755e-mail: talatnishat@hotmail.com e-mail: abidashaheen97@yahoo.com

Dr. Fahad Azam Dr. Ahmad OmairAssistant Professor, Pharmacology Assistant Professor, PathologyExt: 3755 Ext: 3768e-mail: fahadazam@gmail.com e-mail: dr.ahmad.omair@gmail.com

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