Methods of Examination

Inquiry

Complaints. Patients with diseases of the bones and muscles and with systemic affections of the connective tissue can produce various com­plaints. These would be commonly pain in the joints, spine, or muscles, hindered movements in the morning, sometimes muscular weakness, and elevated temperature. Symmetrical affections of minor joints of the hands

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and soles, their tender articulation (active and passive) and also tender palpation are characteristic of rheumatoid polyarthritis. Major joints (wrist, knee, elbow, hip) are affected less frequently in this disease. Pain becomes more intense by night, in cold and damp weather. At later periods of the disease, the joints are distinctly disfigured, and their articulation is limited (to ankylosis). A frequent complaint is difficult and limited ar­ticulation and movement in the morning; the movements become easier by the end of the day. Rheumatism and arthrosis deformans are characterized by a distinct tendency to affection mainly of the major joints. In arthrosis deformans, pain develops mainly under load on the affected joint (in walk­ing, stepping on the affected leg). Pain intensifies by the evening as a result of daily exercise. In ankylosing spondyloarthritis (Bekhterev's disease), pain is localized in the spine and the sacrolumbar articulations. Pain develops after a long stay in a fixed position (usually during night sleep). At later stages of the disease when changes in the spine become pronounc­ed, pain becomes permanent; it occurs not only during night but also in physical exertion and during weather changes. Specific changes in the spine of a patient can be revealed by the physician at first sight. In rare cases, the joints are also involved in this disease.

Rheumatoid polyarthritis is characterized by the predominant affection of the major joints and by the "wandering" character of affection: various joints are involved one after another, while pain in the previously affected joint disappears (within a few days or weeks) and articulation is restored. Another specific feature of rheumatoid polyarthritis is that all changes in the affected joints and periarticular tissues disappear and leave no trace after the acute rheumatic process abates.

Acute attacks of pain, mainly in the metatarsophalangeal joints of the great toes (less frequently in other joints), which arise mainly during night and predominantly in the aged and middle-aged males, can be a symptom of gout, the disease in which the purin metabolism is upset.

Thus, if a patient complains of pain and difficult movement of joints, the character of this pain should be studied thoroughly to determine its location, intensity, lenght, effect of exercise and other factors that can pro­voke pain, etc.

Muscular pain also differs in its character. Pain can be disseminated to indicate involvement of the entire muscular tissue. Acute attacks of pain in this or that group of muscles that last for several days (often after exposure to cold) suggest myositis. Pain in the calf muscle during walking (usually in the presence of marked atherosclerosis of the arterial vessels in various organs, in frost-bitten legs, in heavy smokers) is characteristic of stenosing arteries of the lower extremities (due to atherosclerosis, obliterating endar-theritis, and certain other diseases). Pain discontinues when the patient

stops walking (the syndrome of intermittent claudication). The patient would often complain of cold in the legs which makes him wear woolen socks and winter boots even in warm weather. Muscular pain is also a symptom of trichinelliasis, cysticercosis, or myositis of infectious, occupa­tional (chronic exposure to low or high ambient temperature, vibration or other harmful industrial factors), and traumatic origin. It is important to determine localization, intensity, character, and duration of the pain.

Elevated temperature and various skin lesions (petechia, erythema, ur­ticaria, etc.) are frequent symptoms of systemic diseases of the connective tissue, the so-called collagenoses, and also allergoses. A rapidly developing (without apparent cause) local oedema of the skin and subcutaneous tissue is frequent in Quincke's disease (allergic oedema attended by skin itching and burning; this may be caused by food, bacterial or other allergy).

Muscular weakness (hypotonia) develops not only in prolonged rest (immobilized patients with grave diseases) but also in some neurological diseases (myatonia, myasthenia, progressive muscular dystrophy, etc.). Each of these diseases has its special features. Myasthenia, for example, is characterized by pathological muscular fatigue. Contractions of a muscle may first be quite normal, but in repeated movements the muscular force decreases to complete loss of contractile power. After a short rest, the mus­cle again becomes capable of contracting. Muscles lifting the upper eyelid and muscles participating in swallowing and mustication are usually af­fected in the first instance.

Weakening of active muscular movements is called paresis, while a complete loss of power to perform movements is known as paralysis.

Paresis and paralysis may affect any muscle or group of muscles in the presence of impaired innervation. Clinicists (internists included) would commonly observe patients with affected innervation of muscles of only one extremity (monoplegia); sometimes both legs are paralysed (paraplegia), or the extremities on one side are only affected (hemiplegia). Tetraplegia (paralysis of all four extremities) occurs in rare cases. Paralysis and paresis can develop due to affection of peripheral nerves, spinal cord (injury, compression, tumour growth, etc.), of certain parts of the brain (in thrombosis of the cerebral vessels, e.g. in atherosclerosis, embolism, or cerebral haemorrhages). Spastic paralysis with subsequent atrophy of the paralysed muscles occurs in affection of the central neuron.

The patient sometimes complains of cold and pale fingers (in rare cases of the ear or nose). This may occur at low ambient temperatures, injuries, and psychic stress. This is attended by pain and hyposensitivity of the skin to pain and temperature variations; this condition may develop after an at­tack of hyperaesthesia. Such attacks are characteristic of Raynaud's

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disease (vasomotor neurosis). This condition is often the first symptom of a grave collagen disease, systemic scleroderma.

Anamnesis. Information concerning the onset and development of the disease should be collected. Many chronic diseases of bones and muscles develop insidiously and progress slowly. The disease becomes apparent on­ly at later periods. Acute vigorous onset is characteristic of rheumatism (often in 2-2.5 weeks following tonsillitis, scarlet fever or acute respiratory infection), some forms of rheumatoid arthritis, and infectious arthritis (caused by brucellosis, dysentery, gonorrhoea, etc.). Acute affec­tion of muscles occurs in myositis, acute paralysis, including paralysis unassociated with injuries. Hemiparesis in patients with atherosclerosis or arterial hypertension of any origin occurs not infrequently. Hemiparesis develops due to thrombosis of the cerebral vessels, cerebral haemorrhages in mitral heart diseases concurrent with cardiac fibrillation and throm-boendocarditis (due to embolism and arterial obstruction) and in some other diseases. Nodular periarteritis (mainly in the young) and systemic lupus erythematosus begin acutely only in rare cases.

In some cases, it is possible to establish the factor that provoked the disease of the joints and systemic affections of the connective tissue. In most cases, these diseases are preceded by an infectious disease or over-cooling of the body; sometimes the disease follows irrational use of medicinal preparations (sulpha drugs, antituberculosis preparations, an­tibiotics, vaccines, sera, etc.), or develops due to perverted hypersensitivity to these preparations.

Anaphylactic shock may develop in patients with acquired or con­genital hypersensitivity to certain medicines given parenteral-ly or when carrying out some tests, e.g. Pirquet, or Mantoux test. Some medicines can cause anaphylactic shock due to a contact with the mucosa (eye conjunctiva, mouth mucosa). But a slow development of an allergic reaction to medicinal preparations (antibiotics, sulpha drugs, butadione, thiamine, procaine, etc.) is more frequent: skin itching, dermatitis, ur­ticaria, fever, arthralgia, myalgia, lymphadenopathy and other types of medicamentous allergy develop in several days. The remarkable advances in pharmacology help control many diseases, but they also bring along some negative effects, e.g. development of the so-called medicamentous diseases. Therefore, when questioning the patient, it is necessary to find out if he took some medicines, and if he did, then for what diseases, and what was the allergic reaction, if any.

A certain (unknown) role belongs to the hereditary predisposition of the patient to certain diseases of the bones and muscles, systemic diseases of the connective tissue, and various allergic affections (bronchial asthma, urticaria, etc.).

Physical Examination