Rheumatologische Anamnese, Untersuchung und Untersuchungen

Rheumatologische Erkrankungen können sich mit einer Vielzahl von Symptomen präsentieren und mit Symptomen und Anzeichen verbunden sein, die jedes Körperorgan oder System betreffen. Es ist wichtig, die Ursache der Symptome schnell festzustellen - sowohl bei akuten Erkrankungen (insbesondere um eine frühzeitige Behandlung zu ermöglichen septische Arthritis) and for chronic conditions (e.g. to enable the benefit of early treatment of rheumatoid arthritis (RA)). Rheumatological disease may cause severe functional difficulties as well as pain and so a thorough functional assessment is essential.

Anamnese

Symptome

• Ask about the site of pain and stiffness. Is there a pattern? Stiffness may be due to mechanical dysfunction or local inflammation of a joint, or a combination of both.

• What are the distribution and timing of symptoms? How is the patient affected?

• Osteoarthritis: morning stiffness is common, but typically resolves within half an hour of waking (although prolonged morning stiffness can still be seen in OA)¹; pain is typically worse at the end of the day and after activity, and may be relieved by rest.

• Schmerzen bei entzündlicher Arthritis (z.B., RA) tends to be worse after rest, particularly in the mornings, and is often accompanied by stiffness. Symptoms tend to be bilateral in inflammatory arthritis with smaller joints, such as those of the hands and feet, being affected first. The pain tends to improve with activity.

• Rheumatische Erkrankungen, die die Gelenke betreffen, verursachen oft ausstrahlende Schmerzen - z.B., cervical spondylosis als Schulterschmerzen präsentierend.

• Ein älterer Patient, der über starke Schmerzen in beiden Schultern oder Steifheit des Beckengürtels am frühen Morgen klagt, deutet darauf hin Polymyalgia rheumatica.

• Loss of function:

  • This is often caused by a combination of muscle weakness, pain, mechanical factors such as tendon and joint impairment and damage to the nerve supply.

  • From the patient's point of view, they may describe a joint as 'giving way' or simply 'feeling weak'.

  • It may be useful to gain some idea of the patient's disabilities by asking about mobility, including stairs, personal care such as feeding, washing and dressing, shopping and cooking.

Other relevant history

• Prodromal symptoms and events:

  • Akute rheumatische Erkrankung kann auf Ereignisse wie Infektionen der oberen Atemwege, Durchfall, Harnwegsinfektion, Insektenstiche (z.B., Lyme-Borreliose) and vaccinations.

• Medikation:

  • Some drugs (eg, hydralazine) are a potential cause of joint problems.

• Past history:

  • Ask if there have there been any previous attacks of the symptoms diagnosed in the past.

  • Fragen Sie, ob es eine andere relevante Vorgeschichte gibt - z. B. Psoriasis, entzündliche Darmerkrankung oder eine Vorgeschichte oder ein Risiko für sexuell übertragbare Infektion.

• Family history: eg, inflammatory arthritis, psoriasis.

• Mental health:

  • Many ill effects are aggravated by anxiety or depression.

  • Disability, pain and social isolation may well lead to depression.

• Social support:

  • Der Patient benötigt möglicherweise soziale Unterstützung, insbesondere wenn er allein lebt, sozial isoliert ist und keine nahestehende Betreuungsperson hat.

Untersuchung

Allgemein

• Look at the whole patient. Check the temperature. If the patient appears ill, consider septic arthritis.

• Note whether there is any asymmetry of colour, deformity, swelling, function or muscle wasting. When checking individual joints look for heat, swelling, deformity and limitation of movement from pain or contracture.

• Joint swelling may be due to inflammation of the synovial lining, increase in synovial fluid, hypertrophy of the bone or swelling of the structures surrounding the joint.

• General examination may reveal associated features such as skin or eye involvement, or disorders of the respiratory, cardiovascular, abdominal or neurological systems.

• Check both passive and active range of joint movements.

Upper limbs

• Shoulder examination: test glenohumeral, acromioclavicular and sternoclavicular joints by placing both hands down by the sides with elbows straight in full extension, then placing both hands behind head and pushing elbows back.

• To detect swelling or deformity of the hands, examine them palms down with fingers straight.

• Assess pronation, supination and grip, and dexterity by placing the tip of each finger on the tip of the thumb.

• Pain experienced when second to fifth metacarpals are squeezed suggests synovitis.

Lower limbs

• With the patient in a standing position: observe the patient to check for deformity of the upper leg, lower leg or foot. Check that the quadriceps bulk is normal.

• Gait: observe the patient walking, turning, and walking back. Look for smoothness and symmetry of the arm, leg, and pelvic movements, ability to turn quickly, and length of stride.

• Knee assessment and hip examination: with the patient on the couch, flex each hip and knee while holding the knee to check movement and for knee crepitus. Check for internal and external rotation of the hip.

• Examine each knee for joint effusion:

  • Stroke upwards over the medial side of the knee and downwards over the lateral side.

  • Patellar tap sign:

    • Spread the thumb and index finger and place web space about six inches above knee joint.

    • Press down and distally (pushing fluid from the suprapatellar pouch into the knee joint).

    • Then press down on the patella, noting any lag before the patella hits the femur and bulging to the side as fluid is displaced, indicating an effusion is present.

• Check the feet for synovitis by squeezing across the metatarsals. Examine for callosities, deformities and high or low arch.

Spine

• Untersuchungen von Nacken und Rücken werden separat behandelt Untersuchung der Wirbelsäule Artikel.

• With the patient standing, check from behind to detect lateral spinal curvature, difference in level of the iliac crests and asymmetry of the paraspinal muscles.

• From the side, check for anteroposterior curvature.

• Tenderness over the mid-point of the supraspinatus tendons indicates the need to check for fibromyalgia.

• Assess all movements of the neck and lower back: check lateral flexion of the cervical spine by asking the patient to place his or her ear on the tip of the shoulder on each side.

• Check lumbar spine and hip flexion by asking the patient to touch their toes with the knees straight.

Hand and foot deformities

• The characteristic features of the hands in patients with RA are subluxation of the metacarpophalangeal joints, radial deviation of the wrist joint and ulnar deviation of the fingers.

• Swan-neck deformity (proximal interphalangeal joint hyperextension with concurrent distal interphalangeal joint flexion) occurs in patients with RA, but may also follow trauma or be congenital.
  

  Swan neck deformity

  

  © By Phoenix119 via Wikimedia Commons

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• Boutonnière deformity (flexion of the proximal interphalangeal joint accompanied by hyperextension of the distal interphalangeal joint) can result from tendon laceration, dislocation, fracture, osteoarthritis or RA.
  

  Boutonniere deformity

  

  © By Alborz Fallah via Wikimedia Commons

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• Heberden's nodes are hard swellings caused by formation of calcific spurs of the articular cartilage which can develop in the distal interphalangeal joints of patients with osteoarthritis.
  

  heberden arthrose

  

  © By Drahreg01 [GFDL (http://www.gnu.org/copyleft/fdl.html] via Wikimedia Commons

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• Bouchard's nodes are hard swellings caused by formation of calcific spurs of the articular cartilage which can develop in the proximal interphalangeal joints of fingers or toes of patients with osteoarthritis. Bouchard's nodes are much less common than Heberden's nodes.

• Mallet finger (flexion deformity of the distal interphalangeal joint preventing extension) results from an extensor tendon rupture or an avulsion fracture of the distal phalanx.

• Dupuytren'sche Kontraktur ist eine fortschreitende Kontraktur der palmaren Faszienbänder, die zu Beugedeformitäten der Finger führt. Die Dupuytren-Kontraktur tritt häufiger bei Männern auf und nimmt nach dem 45. Lebensjahr zu. Die Ursache ist unbekannt, aber sie ist häufiger bei Patienten mit Diabetes, Alkoholismus oder Epilepsie.

Extra-articular findings

• Rheumatoide Knoten sind subkutane Weichteilschwellungen, die am häufigsten bei Patienten mit RA, aber auch bei anderen Krankheiten - z.B., rheumatisches Fieber, Bindegewebserkrankungen, Sarkoidose, Weber-Christian-Krankheit, Gicht und Xanthomatose.

• Nodules are the most common extra-articular feature of RA and are present in up to 30% of patients.²

• In RA the nodules are usually located between the skin and a bony prominence (especially the elbow).

• Rheumatoid nodules may be freely mobile or attached to deep tissues.

• Skin rash:

  • Intermittierende Hautausschläge treten bei rheumatischem Fieber, RA, auf, chronic juvenile idiopathic arthritis, und Bindegewebserkrankungen wie systemischer Lupus erythematodes (SLE).

  • Prüfen auf Psoriasis, which may be hidden from view.

  • Circinate balanitis in reaktive Arthritis kann asymptomatisch sein und wird nicht immer erkannt, daher ist eine spezifische Untersuchung wichtig.

  • Mundgeschwüre kann ein Merkmal der reaktiven Arthritis sein und Morbus Behçet sowie Bindegewebserkrankungen.

  • Sjögren-Syndrom wird eine verursachen dry mouth (xerostomia).

• Raynaud's syndrome: usually bilateral and affects fingers more often than toes.

• Diarrhoea:

  • Transient mild diarrhoea may precipitate a reactive arthritis.

  • Es kann auch auf enteropathische Arthritis hinweisen, die sekundär zu Colitis ulcerosa, Morbus Crohn, Zöliakie oder Morbus Whipple.

• Urethritis: may indicate reactive arthritis.

• Red, gritty eyes:

  • Bindehautentzündung oder Uveitis kann bei reaktiver Arthritis auftreten.

  • Uveitis kann bei anderen Spondyloarthropathien auftreten.

  • Episcleritis (painless), scleritis (painful), and keratoconjunctivitis sicca may occur in rheumatoid and related diseases.

• Cardiorespiratory:

  • Siehe das separate Rheumatoide Arthritis und die Lunge Artikel.

  • Episodes of pericardial or pleuritic chest pain may indicate connective tissue disease.

  • Musculoskeletal chest pain is a common feature of the spondyloarthropathies.

  • Atemnot kann auf damit verbundene Lungenfibrose oder ein Herzfehler wie Aorteninsuffizienz bei den Spondyloarthropathien.

• Neurologisch:

  • Periphere Neuropathien - z.B. Engpass-Neuropathie (z.B Karpaltunnelsyndrom) - may be an early feature of inflammatory synovitis.

  • Migräne, Depressionen, Demenz oder Schlaganfall kann auf SLE hinweisen, Vaskulitis oder Antiphospholipid-Syndrom.

• Systemische Symptome: Gewichtsverlust, fever and anorexia are present in many types of inflammatory arthritis.

Untersuchungen

Bluttests

Investigations are only useful when requested and interpreted in an appropriate clinical context. Some of the following may be useful, depending on clinical judgement and competence in interpreting the results.

• FBC:

  • Anaemia may be due to chronic disease but be careful to consider blood loss from gastric irritation secondary to NSAIDs or other causes of anaemia.³

  • White cells: possible changes include neutrophilia in septic arthritis, eosinophilia in polyarteritis nodosa, neutropenia in Felty's syndrome and leukopenia in SLE.

  • Platelets may be increased in RA and may be decreased in SLE.

• Acute phase proteins: ESR and CRP are nonspecific indicators of inflammatory activity.

• Uric acid: may be raised in gout, although uric acid levels may be normal during an acute episode of gout, and is therefore best checked after resolution of a flare. Hyperuricaemia is supportive of a gout diagnosis, but not sufficient to make the diagnosis, as asymptomatic hyperuricaemia is also common.

• Renal function: may be renal dysfunction in chronic disease such as gout or connective tissue disorders.

• Autoantibodies: rheumatoid factor may support the diagnosis of RA.⁴ Antikörper gegen zyklische citrullinierte Peptide (CCP) sind spezifischer als der Rheumafaktor bei RA und können bei erosiven Erkrankungen empfindlicher sein.⁵

• Antinuclear antibodies may suggest SLE or other connective tissue disorders.

• Human leukocyte antigen (HLA) B27: increased positivity in ankylosing spondylitis and other spondyloarthropathies.⁶

• Serology (eg, HIV), may be appropriate.

Weitere Untersuchungen

• Urine: proteinuria may be due to nephrotic syndrome associated with connective tissue disease.

• Synovial fluid:

  • White cell count raised in infection.

  • Gram stain (tuberculosis), culture and sensitivities.

  • Crystal identification: urate, calcium pyrophosphate.

• Bildgebung:

  • X-rays: may show distinctive changes, such as in RA, and osteoarthritis. CXR may be indicated for lung involvement in RA, SLE, vasculitis and tuberculosis.

  • Ultrasound: soft tissue abnormalities - eg, synovial cysts.

  • CT scan, MRI: much greater information of bone, joint and soft tissue.

• Arthroscopy:

  • Direct view of joint and synovial fluid.

  • Potential for biopsy and therapeutic procedures.

Empfehlungen des National Institute for Health and Care Excellence (NICE)⁷

• Offer to carry out a blood test for rheumatoid factor in adults with suspected RA who are found to have synovitis on clinical examination.

• Consider measuring anti-cyclic citrullinated peptide (anti-CCP) antibodies in adults with suspected RA if they are negative for rheumatoid factor.

• X-ray the hands and feet in adults with suspected RA and persistent synovitis.

Investigations following diagnosis

As soon as possible after establishing a diagnosis of RA:

• Measure anti-CCP antibodies, unless already measured to inform diagnosis.

• X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis.

• Measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional response to treatment.

• If anti-CCP antibodies are present or there are erosions on X-ray:

  • Weisen Sie die Person darauf hin, dass sie ein erhöhtes Risiko für eine radiologische Progression hat, aber nicht unbedingt ein erhöhtes Risiko für eine schlechte Funktion; und

  • Emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare.

Überweisung

Immediate referral to hospital is advised for:

• Patients in whom septic arthritis is suspected - these should be seen immediately.

• Children with a limp - to exclude septic arthritis, non-accidental injury, slipped capital femoral epiphysis.

Empfohlen von NICE:⁷

• Überweisen Sie jeden Erwachsenen mit Verdacht auf anhaltende Synovitis unbekannter Ursache zur fachärztlichen Beurteilung.

• Dringend überweisen (auch bei normaler Akutphasenreaktion, negativen Anti-CCP-Antikörpern oder Rheumafaktor), wenn eines der folgenden zutrifft:

  • Die kleinen Gelenke der Hände oder Füße sind betroffen.

  • Mehr als ein Gelenk ist betroffen.

  • Es gab eine Verzögerung von drei Monaten oder länger zwischen dem Auftreten der Symptome und der Einholung ärztlichen Rates.