Case 19 Rheumatoid Arthritis


Case 19
Rheumatoid Arthritis
Clinical Examination

Introduction ownself
Exposure – Upto Umbilicus 
Hand scrubbing
Look- Standing Patient

Comment on Cervical Collar
Attitude of the limb
Alignment       -           Front    Head at Centre
 Both shoulders are leveled,
                                                Chest is symmetric on both the sides
                                    No wasting of muscles on chest , shoulder ,arm , forearm                                                     , thenar and hypothenar muscles with normal overlying skin

                                    Side       Normal cervical lordosis
                                                  Maintained deltoid contour , elbows extended ,
                                    Back               
  Spinal curvature is maintained with no kyphoscoliosis
  Normal overlying skin on back with no dimpling , tuft of hair
      and swelling
 No wasting of muscles on supr and intraspinatus fossa ,shoulder               and dorsal surface of arm , forearm and hands

Gait                                         Normal / Stooped wide based gait /frequent fall or early shuffling
Ask Patient to Sit
Neck ROM –                          Decreased ROM
Lumbar                                    Decreased ROM
Spurling sign + -                      Hyperextension + Lateral rotation towards affected side + gentle           compression – if illicits Pain – s/o Radiculopathy
Shoulder Abduction sign        + , Relief of pain with hands putting on head with shoulder abducted.
Hoffman’s Reflex                   Reflex – thumb and other fingers extend with sudden long finger DIP joint extension
Scapulohumeral Reflex           Taping spine of scapula illicits a brisk scapular elevation and abduction of humerus .
Reverse Asymmetric Jerk       Biceps / Supinator
Inverted Radial Reflex           During testing Brachioradialis reflex , the response is reciprocal spastic contracture of fingers.
Lhermitte’s Sign                     Neck – Flexion leads to burning sensation involving upper and lower extremities and trunk.
Finger Escape Sign                 In making a grip , 2 ulnar digits drift out.
                                                In grip and release test , patient unable to form a fist and release all digits within 10 seconds period
Neurovascular Examination
UE – C 5 – T 1
LE – l2 – S 5
Spasticity / Clonus
Sensation – including joint position which is maintained
Power

Reflexes – Knee and Ankle – Brisk bilaterally
                  Plantar reflex upgoing
Sitting   -                                 Upper Extremity Examination /Lower Extremity
                
Look –                                     Skin
                                                Muscle Wasting

Feel –                                      Temperature
                        Tenderness
                        Lymph Nodes


Move                                       Shoulder / Elbow / Wrist and Hands
Hip / Knee / Ankle / Toes                   



In case of Myelopathy spasticity , clonus , brisk reflexes , plantar upgoing.
Cervical Radiculopathy has LMN type presentation



C- Spine
1)Chamberlain Line – Posterior edge of hard palate to posterior border of foramen magnum
Odontoid is 5 mm above this leads to Basilar Imression leading to Brainstem and Spinal Cord compression
2)Mc Gregor Line – Posterior edge of hard palate to most caudal portion of occipital curve
 4.5 mm above this suggest Basilar Impression
3) Mc Rae line –Determines AP dimension of foramen magnum and is drawn from anterior lip to posterior lip. In normal patients odontoid tip falls below this line.
4)Ranawat Lines – Perpendicular distance between centre  of sclerotic ring of C2 and line drawn along axis of C 1 .
            Normal 15 mm.

Ranwat Classification
I – Subjective paresthesia
II – Subjective findings UMN
III-Subjective findings UMN

Other Investigations
MRI

Management
Surgery – Spinal Surgery Consultation
                        Pain , instability , Neurological Symptoms



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