Professor Rajibul Alam Sir Ward Note

Professor Rajibul Alam Lectures
RHEUMATOLOGY LECTURE
First question
Is it arthritis or arthralgia?
if arthritis there features of inflammation that is joint is red, hot
Second question
Is it mechanical or inflammatory?
• Early morning stiffness
• Worsening of symptoms with inactivity
• সকালবেলা হাত পা জাম থাবক।
• রাবত ঘুম ভাবে
• আবে, আবে শুরু অবেকদিে যােত।
• If patient take take antiinflammatory drug the above sign symptoms are absent
Third question
Associations of other symptoms
• Red eye- uveitis
• Low back pain(ককামবর েযথা)- ankylosing spondylitis
• Oral ulceration + polyarthritis- SLE
• Diarrhoea,dysentery then arthritis develope-Reactive arthritis
• H/O sexual exposure - Gonococcal arthritis
• Butterfly rash + arthritis - SLE
• Carditis + arthritis - RA
Fourth question
What is the Pattern of arthritis?
o Mono/ Oligo/ Polyarthritis
o Migrating/ Nonmigrating
o Number of joint involve
o Low back pain
Monoarthritis
Infective- high fever, DM
Gonococcal- H/O exposure + urethral discharge
Gout - metattarsophalngeal joint
Tubercular- systemic features of tuberculosis
Reactive- diarrhoea, dysentery history
Oligoarthritis
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Polyaryhritis
Symmetrical involvement of MP and PIP joint of both hand- Rheumatoid Arthritis
Oral ulceration + butterfly rash + Alopecia + H/O abortion - SLE
Polyarthritis + LBP - Ankylosing spondylitis
Symmetrical Asymmetrical
SLE Ankylosing Spondylitis
RA Psoriatic Arthritis
Reactive arthritis
Important Information
• CRP normal in SLE but increase in RA
• ANA important for diagnoses of SLE
• Usually Rubor absent in RA if occur usually septic
• Muscle wasting present in RA not in RF
BLEEDING DISORDER LECTURES
When to suspect
• Spontaneous bleeding
• Excessive bleeding following surgery, trauma
• Bleeding from multiple site
# Recurrent bleeding from single site suggest local structural abnormalities.
Platelet
Primary - ITP
Secondary - Given below
Produce at bone marrow

So bone marrow failure cause platelet deficiency e.g.
1. Leukaemia
2. Aplastic anemia
3. Other cause of marrow suppression
Circulate at blood
Destruction in blood cause platelet deficiency e.g.
1. Drug
2. Systemic lupus erythematosus
Destruct at spleen
Hypersplenism causes platelet deficiency e.g.
1. Malaria
2. Kala-azar
Vascular cause
• Henoch- Schonlein- purpura
• Scurvy
• Senile purpura
• Dengue
Coagulation Factor
Cause
Genetic
early age of onset( hemophilia)
Acquired
Liver disease
DIC
Anticoagulant
Character Of Bleeding
Platelet and Vessel Disorder Coagulation factor deficiency

Superficial bleeding Internal bleeding
• petechiae, purpura • Bleeding into muscle, joint
• Prolonged bleeding from superficial cut • Large bruise, ecchymoses
• Epistaxis, gum bleeding • Retroperitoneal, Intracranial hemorrhage
• GIT hemorrhage, menorrhagia
Investigation
Trait BT Tourniquet test APTT

Platelet increase positve normal
Vessel normal /increase positive / negativbe normal
Coagulation factor normal Negative increase
Tourniquet Test
- remember 2.5 - 5- 10
5 minute press by BP calf at pressure between systole and diastole
2.5 cm area - within 2.5 cm area
10 number - more than 10 petechiae within 2.5 cm area
Some Information
# Always think about association
That is a patient of meningitis develop rash - so this rash is due to meningococcal septicaemia not due
to bleeding disorder.
# If anaemia + bleeding it is never ITP
# If CBC normal it signify that patients Bone marrow is normal.
Some Important Table of bleeding disorder
Trait ITP Hemophilia

Age 15 to 50 years Infant, child
Sex Female Male
Family history Usually not found found in 2/3 rd case
Bleeding type Superficial Internal bleeding
Trait ITP Dengue
Duration Usually Short duration
Associations No anaemia, neutropenia organomegaly, Fever, backache, arthralgia
previous history of excessive bleeding, Pain on eye movement
petechiae, purpura lacrimation, generalized pain
Trait ITP APLASTIC ANAEMIA LEUKAEMIA

Anaemia Absent Severe Severe /moderate
Fever Absent Present present
Organomegaly Absent Absent Present
Lymphadenopathy Absent Absent Present
Bony tenderness Absent Absent Present
Trait VESSEL PLATELET COAGULATION Factor

Site of bleeding Superficial Superficial Internal
Family history Usually absent Usually absent Usually present
Test BT, TT may positive BT, TT positive APTT Positive
APTT normal APTT normal BT, TT normal
ANAEMIA LLECTURES
Question
Is it anaemia
Type
Cause
Classification
Posthemorrhagic
Dyshemopoetic
Hemolytic
Dyshemopoetic
Deficiency
a. Fe
b. vit- B 12
c. Folic acid
d. Protein
Bone marrow failure

a. Aplastic anaemia
b. Leukaemia
c. Multiple Myelomma
Chronic disease
a. Chronic kidney disease
b. Hypothyroidism
Hemolytic
Congenital
a. Childhood anaemia, jaundice
b. Blood transfusion history
Acquired
History
Chronic bleeding
GIT- hematemesis, melaena
Genitourinary system - menorrhagia
Diet - strict vegetarian
Gastrectomy
Table on Important Information ( on examination site findings)
Site Features Cause

Eye anaemia + jaundice Hemolytic anaemia
anaemia + subconjunctival bleeding Aplastic anaemia
Leukaemia
Mouth Glossitis Vit B 12 deficiency
Nail Koilonychia Fe deficiency
Leuconychia Protein deficiency
Skin Bleeding, bony tenderness Leukaemia
Metastases
Multiple myeloma
Abdomen anaemia + splenomegaly Hemolytic anaemia
Leukaemia
anaemia + hepatomegaly Consistency hard - malignancy
soft.- cirrhosis
anaemia.+ lymphadenopathy Leukaemia
Malignancy
anaemia + tender hepatomegaly Anaemic heart failure
anaemia+ abdominal mass Malignancy
Blood film
Trait Example with explanation

Microcytic IDA- Target cell pproportionate to severity
Hypochromic anaemia Thalassemia - Target cell disproportionate to severity that is excess
number of target cell presents than severity
Normocytic Blood loss
Normochromic anaemia Aplastic anaemia(features of bone marrow failure)
Meatastases
Macrocytic anaemia Megaloblastic
Vit B12, Folic acid
Normoblastic
CLD, Hypothyroidism
Fragmented In hemolytic anaemia
Spherocyte Autoimmune hemolytic anaemia
Reticulocyte count increase in all type of hemolytic anaemia
Neurology
Common Etiology
❖ Infection - here fever present
❖ Vascular - develop very suddenly
❖ Demyelination - develop over several days
❖ Neoplastic - Over weeks
❖ Degenerative - slow progression over year
Symptoms of different part of nervous system when different disease involved

them
Cerebral cortex
Hemiparesis (For example when hemiparesis sudden it is vascular, gradual may be neoplstic or
due to demyelanating lesion)
Hemiplegia
Convulsion
Extrapyramidal systems
Symptoms Patient complaints

Tremor Appearance of involuntary movements
Rigidity Disturbance of voluntary movement
Rigidity also caused by drug (antipsychotic)

Cerebellum
Vertigo
Nystagmus
Intentional tremor
For example when a patient complain above symptoms, if it is sudden vascular, fever present
it is infectious, gradual it is degenerative.............
A patient has prolong fever+ weight loss+ cerebellar sign + night sweat diagnosis is cerebellar
TB
Raised ICP
Headache
Vomiting
Papilloedema
Any SOL ( tumor, abscess, hematoma) can cause raised ICP
Meninges
Neck rigidity
Kering sign
fever
Meningism ( neck stiffness + photophobia+ headache)
Above symptoms also present in SAH but in SAH fever absent.
Brain stem Spinal cord
All the sign, symptoms are same but in case of brain stem cranial nerves also involved.
Lesion type Common locations

Hemiplegia Usually in internal capsule, brain stem (in that case cranial narve involved)
Monoplegia Usually lesion in cortical region
Quadriplegia Usually cervical region of spinal cord
Above C5 - quadriplegia
C5 to T1 - In upper limb lower motor neuron type
In lower limb, upper motor neuron type
Peripheral Nerves (peripheral neuropathy)
▪ Sensory loss
▪ Lower motor types lesion
Cause of peripheral neuropathy
• Diabetes
• Drug
• Deficiency
Difference between myopathy vs neuropathy
Myopathy Neuropathy
Only wasting at initial phase Wasting present
Jerk present Jerk absent
No sensory loss Sensory loss present
Proximal symmetrical involvement Distal asymmetrical involvement
Some Information
❖ If jerk normal never neuropathy
❖ In peripheral neuropathy motor, sensory, jerk are lost. But in all case of peripheral
neuropathy these three features may not present simultaneously.
❖ Spinal shock - lesion detect by plantar response (extensor in UMNL)
Origin of cranial nerve

3,4- midbrain
5 to 8 - pons
9 to 12- Medulla
Triad of pontine hemorrhage
Hyperpyrexia
Pinpoint pupil
Paralysis

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Professor Rajibul Alam Lectures

# Recurrent bleeding from single site suggest local structural abnormalities.

Produce at bone marrow

Platelet and Vessel Disorder Coagulation factor deficiency

Trait BT Tourniquet test APTT

Some Important Table of bleeding disorder

Trait ITP Hemophilia

Trait ITP APLASTIC ANAEMIA LEUKAEMIA

Trait VESSEL PLATELET COAGULATION Factor

Bone marrow failure

Table on Important Information ( on examination site findings)

Site Features Cause

Trait Example with explanation

Symptoms of different part of nervous system when different disease involved

Symptoms Patient complaints

Rigidity also caused by drug (antipsychotic)

Lesion type Common locations

Difference between myopathy vs neuropathy

Origin of cranial nerve

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