Chapter 26. Rheumatology

• Most diagnoses are based on history and physical exam findings. (see the table below).
• Rheumatic diseases are great masqueraders, mostly mimicking disease processes like infection and malignancy.
• ANA is not specific and should not be utilized as a screening tool unless a specific question needs to be addressed (eg, risk of uveitis in a patient with oligoarticular JIA, patient with suspicion of SLE etc.).

History Elements

• Fever pattern, weight loss, nocturnal pain, bone pain, night sweats, fatigue
• Morning joint stiffness, relieved or exacerbated by rest or activity
• Number and location of joints involved, fixed or migratory, transient or chronic
• Performance of activities of daily living, school absences, decline in school performance
• Trauma
• Exacerbation of symptoms over time (acute versus insidious)
• Travel: including Lyme-endemic areas and foreign travel, exposure to unpasteurized cheese and undercooked pork, exposure risks to TB

Review of System Elements

• Alopecia, dry mouth and/or eyes (sicca syndrome symptoms), visual changes (erythema, decreased vision), periorbital swelling, oral and/or nasal ulcers, difficulty hearing, dysphagia, dysphonia
• Dyspnea, chest pain, chronic cough
• Anorexia, diarrhea/bloody stools, nausea, vomiting, abdominal pain, abdominal distention
• Irregular menses, absence of menses
• Bruising, bleeding, petechiae, purpura
• ↓ UOP, hematuria
• Swelling of extremities or periorbital region
• Memory loss, difficulty with concentration, unusual or psychotic behaviors, sleep hygiene (sleep deprivation vs. rheumatologic process causing difficulty concentrating)

Family History Elements

• Arthritis, IBD, JIA, SLE, psoriasis, fetal losses, IUGR, premature births, preeclampsia, thromboses, strokes, other autoimmune diseases (eg, hypo- or hyperthyroid disease, type I DM, myasthenia gravis, muscular sclerosis); FHx may be ⊝

Physical Exam Elements

• General appearance; vital signs; growth curves for height, weight, BMI
• Skin: presence of rashes, including unusual skin findings (ie, tight, thickened skin); splinter hemorrhages in nail beds and abnormal periungual capillary changes at periungual regions; hair appearance (ie, alopecia)
• HEENT: lacrimal/parotid gland prominence; oral/nasal mucosal membranes for ulcers, erythema, bleeding; dentition; eye examination
• Neck: evaluation for lymphadenopathy and thyromegaly
• Cardiac: attention to murmur, rubs, gallop, arrhythmia, and pulses
• Lungs: routine with special attention to quality and quantity of breaths
• Abdominal: presence of hepatosplenomegaly
• Joint: presence of deformity; pain; erythema; warmth; swelling; effusion; limited range of motion, including neck, low back, and TMJ
• Muscle: bulk, strength, atrophy
• Gait: evaluate for stability, tandem gait, heel and toe walking
• Full neurologic exam