rheumatology revision
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Rheumatology Revision. Clare Hunt FY2. The plan. Overview of Osteoarthritis and Rheumatoid arthritis Case scenarios 1 and 2 Symptoms and signs Clinical findings Epidemiology/ Risk factors Management . Case scenario 1. - PowerPoint PPT PresentationTRANSCRIPT
RHEUMATOLOGY REVISIONClare Hunt FY2
The plan Overview of Osteoarthritis and Rheumatoid
arthritis
Case scenarios 1 and 2 Symptoms and signs Clinical findings Epidemiology/ Risk factors Management
CASE SCENARIO 1A 67 year old lady comes to see you complaining of increasing pain in her hands
What do you do? History Examination Management
HISTORY Mostly affects her thumbs but also the small joints of
her fingers.
Pain is worse at the end of the day and after she has been gardening.
Noticed slight swelling of her joints. Pain eased by paracetamol when at its worst.
PMH - Hypertension (amlodipine 5mg.)
No alcohol; doesn’t smoke. Retired secretary.
DIFFERENTIAL DIAGNOSES?
CONTINUED
What might you find on examination?
What are you looking for?
LOOK
FEEL
MOVE
EXAMINATION FINDINGS Hands are not grossly deformed although she
does have a mild Z shaped deformity of the thumb
No skin lesions at her elbows or behind the ears.
Generally tender over all PIPs and DIPs with some hard swellings
She can do up buttons and write her name, although this causes some discomfort
WHAT ARE YOUR DIFFERENTIAL DIAGNOSES?
Osteoarthritis Rheumatoid arthritis
WHAT INVESTIGATIONS WOULD YOU LIKE?
Bloods – ESR? X-ray
What x-ray changes would you expect?
Joint space narrowing
Subchondral sclerosis
Osteophytes
May be none… or….
May also get subchondral cysts in late/severe OA.
Z-deformity
OA OF HANDS Usually as part of nodal osteoarthritis Mainly women > 40s or 50s Usually base of the thumb and DIPs Joints may be swollen and tender
Function usually good Linked with increased risk OA knee. Nodal OA likely to be passed mother to daughter. http://www.arthritisresearchuk.org/arthritis-information/conditions/osteoarthritis/which-joints-are-affected/
hands.aspx#sthash.peJPKKJ0.dpuf http://images.rheumatology.org/image_dir/album75691/md_05-04-0068.jpg
OSTEOARTHRITIS IN GENERAL
Weight bearing joints – knees, hips
Use – shoulders, hands
Spine (especially C-spine)
WHO? > late 40s - “wear and tear” Female Family hx OA Overweight Previous joint injury/operation Physically demanding job – repetitive
movements Joint abnormality eg Perthes’ PMH – gout, Rheumatoid arthritis
MANAGEMENT Lifestyle changes – weight loss NSAIDS Intra-articular steroid injections
Surgery
Summary of OA Degenerative disease of increasing age Mainly weight-bearing/high use joints Pain, swelling, stiffness – evening > morning Management – lifestyle, symptom control,
surgery
CASE SCENARIO 2 A 34 year old lady comes to see you giving
an 8 week history of pain affecting the small joints of her hand.
What do you want to know?
CONTINUED Pain and stiffness worst first thing in the morning Improves after about 1hour General malaise Noticed her hands are slightly swollen
PMH – nil DH – OCP
What else do you want to know? Smokes 10/day; <14units alcohol/week Occupation = Secretary Grandmother had problems with her hands
EXAMINATION What might you find?
Slight swelling over MCP and PIP joints both hands
Tender on palpation
No obvious deformity
What else should you look for/check? Temp 37.5 No skin changes elbows or scalp Right eye slightly red around cornea – not painful
DIFFERENTIAL DIAGNOSES? Rheumatoid arthritis
Septic arthritis Gout Osteoarthritis SLE Psoriatic arthritis
WHAT IS RHEUMATOID ARTHRITIS? Definition
“a multisystem autoimmune inflammatory condition that typically affects the small
joints of the hands and feet”
SYMPTOMS AND SIGNS Differentiate OA from RA
Worse in morning Morning stiffness Small joints of hand Symmetrical MCPs and PIPs > DIPs
TYPICAL HAND SIGNS? Ulnar deviation of fingers DIPs spared Guttering of MCPs Wasting of intrinsic hand muscles Carpal tunnel syndrome
http://www.3pointproducts.com/Portals/30688/images//Boutonnierrelabel.jpghttp://www.3pointproducts.com/Portals/30688/images//SwanNecklabel.jpg
OTHER BONY FEATURES? C- spine
Cervical subluxation Neck pain Atlanto-axial instability
Feet Subluxation of metatarsal heads Claw toes
Diagnostic criteria of RA Diagnosis can be made if these are all
present:
Inflammatory arthritis involving three or more joints.
Positive RF and anti-CCP Raised CRP or ESR Duration of symptoms > six weeks Excluded similar diseases:
Psoriatic arthritis Acute viral polyarthritis Gout/psuedogout SLE
EXTRA-ARTICULAR MANIFESTATIONS
Weight loss, fever, malaise common Skin – Rheumatoid nodules – elbows & forearms
Heart – pericarditis, pericardial effusion Lungs – Rheumatoid nodules, pulmonary fibrosis,
pleural effusion, bronchiectasis
Eyes – episcleritis/scleritis
Neuro – peripheral neuropathy, carpal tunnel syndrome
Felty’s syndrome
WHAT DOES THE PATIENT WANT?
I – what does she think it is?
C – what is she worried/concerned about/how is it affecting them?
E – what does she want from you today?
SO WHAT ARE YOU GOING TO DO FOR HER? Investigations
Bloods FBC, U+E, LFTs, ESR, CRP, RF, anti-CCP
Imaging X-ray findings?
Soft tissue swelling
Deformity
Loss of joint space
Bony erosionPeriarticular
osteopaenia
“Pencil in cup” deformity
Management
Conservative Weight loss, smoking cessation Support - “MDT approach”
Medical Analgesia, steroids, DMARDs, Biologics NICE guidance = early DMARDS
Surgical Joint fusions, joint replacement, carpel tunnel
decompression
DMARDS Methotrexate Sulfasalazine Gold Penicillamine
Side effects? Folic acid suppression, deranged LFTs Myelosuppression; pneumonitis (rare) Nephrotic syndrome (Gold & Penicillamine)
Check baseline U+E, FBC, LFTs & urine
analysis
Biologics (after failure to respond to 2 DMARDS)
Anti-TNF alpha Infliximab, Adalimumab, Etanercept
What test should be done prior to starting biologics?
Side effects Allergic reactions; TB reactivation; increased risk
infection
SUMMARY
MULTIDISCIPLINARY APPROACH!