Rheumatology

1. Rheumatology Examining for Finals Tutor name

2. TuBS attendance • https://tutorialbooking.com/

3. Session overview • Common rheumatological conditions for the OSCE • How to present your findings • Overview of clinical signs/dermatology • Case presentations and viva questions

4. What is the purpose of an OSCE? “This station tests a student’s ability to perform an appropriate focussed physical examination, demonstrating consideration for the patient, and to report back succinctly describing the relevant findings. It also tests a student’s clinical judgement i.e. the ability to decide the differential diagnosis, choose investigations and formulate a management plan.”

5. Presenting your findings • What were you asked to do? • What were your key positive findings? • What were the important negative findings? • What does this mean? • How would you complete your examination, and what investigations would you do?

6. What xray changes do you see in rheumatoid arthritis? • Subluxation • Soft tissue swelling • Erosions • Deformities • Peri-articular osteoporosis • Loss of joint space

7. Rheumatoid Arthritis What is the definition? Symmetrical deforming polyarthritis What % of people with RA are seronegative? ~30% What is rheumatoid factor? Autoantibody, IgM against IgG What are the features of active synovitis? Redness, swelling, pain What causes the deformity? Rheumatoid tenosynovitis

8. Extra-articular features on RA What are the extra-articular features of RA? Eyes and mouth – scleritis, episcleritis, sjogrens syndrome Lungs - pulmonary fibrosis/nodules/effusions Heart - pericarditis/effusion, myocarditis Kidneys – amyloid, mesangial glomerulonephritis Haem - Felty’s syndrome, anaemia Skin – nodules, ulcers, Neuro – mononeuritis multiplex, neuropathy, atlanto-axial subluxation Are seronegative more or less likely to have extra articular features? Less likely Why might you order a lateral cervical spine xray pre-operatively in patients with RA? atlanto-axial subluxation

9. What are the 5 presentations of Psoriatic Arthritis -Asymmetrical Oligoarthritis -DIP disease only -symmetrical polyarthropathy (like RA) -Arthritis Mutilans -Sacroilitis

10. What are the causes of an acutely Swollen Joint Gout Pseudogout Reactive arthritis Septic arthritis Haemarthrosis

11. What are the causes of an acutely Swollen Joint What investigations should you do? What other symptoms can be associated with reactive arthritis? Conjunctivitis, rash, balanitis

12. Case 1

13. Look • Hard irregular nodules on elbows • Scar over first right MCP joint

14. Case 1 - feel • Cool joints • No effusion

15. Case 1 - move • Has difficulty in extending little finger on right • Problems with flexion of fingers • Difficulty with finger abduction on left • Difficulty holding thumb in abduction against force on left

16. Case 1 - function • Has difficulty doing up small buttons • On direct questioning, she can use a knife and fork

17. Case 1 - neurovascular status • Intact radial pulses • CRT <2s • Reduced sensation over left thumb and index and middle fingers Please present your findings.

18. Would you like to present your findings? • Chronic • Symmetrical • Polyarthropathy • Joints affected • Active/inactive • Seropositive/negative • Movement • Function • Complications – carpal tunnel syndrome • Treatments – joint replacement

19. Case 2

22. Case 2 - feel • Joints are cool • Fingers are cool • No swelling • No tenderness

23. Case 2 - move • Fixed flexion deformities of all fingers • Unable to make tight fist • 4+/5 strength, when not limited by deformities • Sensation is normal • Unable to do up small buttons

24. Case 2 • How would you complete your examination? • Would you like to present your findings?

25. What are the patterns of systemic sclerosis? • Limited cutaneous scleroderma (CREST) • skin only affected at face, hands & feet • Diffuse scleroderma – systemic sclerosis • skin of trunk and extremities all affected • Scleroderma without cutaneous features • skin not affected, but systemic manifestations occur

26. Case 3

27. Please present your findings.

28. Differential for Raynaud’s Phenomenon • Reflex – • Raynaud’s disease (i.e. idiopathic), vibrating machinery injury, cervical spondylosis • CTDs – • scleroderma, mixed CTD, SLE, PAN, RA, polymyositis • Arterial disease – • embolism or thrombosis, Buerger’s disease (thromboangiitis obliterans), Trauma • Haematological – • polycythaemia, leukaemia, dysproteinaemia, cold agglutinin disease (IgM  agglutination of RBCs at low temp) • Poisons – • drugs (β-blockers, ergotamine), vinyl chloride

29. Case 4

31. Case 4 • Tender in DIP joints • Decreased range of movement • Some weakness globally in small muscles of hands • Problems doing up buttons Please present your findings.

32. Case 5

35. Case 5 - feel and move • All digits are tender and swollen • Cannot distinguish joint swelling from digit swelling • Tender • Movement and function is intact, limited by pain only • Sensation, peripheral pulses normal Please present your findings.

36. What are the patterns of arthritis in psoriatic arthropathy? • Arthritis mutilans (pencil in cup deformity, telescoping of digits – 3% pts) • Asymmetric oligo-arthritis • RA-like – symmetrical polyarthritis • Ank-spond-like – sacro-iliitis • OA-like – distal arthritis involving DIPJ

37. DIP joints (nails commonly involved) Arthritis mutilans – characterised by resorption of phalanges

38. Pencil in cup deformity

39. Case 6

40. Please present your findings.

41. Diagnostic criteria for SLE 4/11 by American College of Rheumatology Discoid rash Renal – proteinuria/casts Oral ulcers ANA Photosensitivity Serositis – pleuritis, pericarditis Arthritis – 2+ joints Haematological (haemolytic Malar rash anaemia, low WCC/Plts) Immunological markers (anti dsDNA, smooth muscle, antiphospholipid Ab) Neurological changes (seizures, psychosis) (Elevated ESR – not a criterion, but used in monitoring)

42. General – cushingoid, mental state (lupus psychosis) Hands Raynaud’s phenomenon Atrophic skin, bruising (steroids/thrombocytopenia) Rashes – discoid, vasculitic Splinter haemorrhages Palmar erythema Arthropathy Arms Livedoreticularis, purpura Proximal myopathy (active disease/steroids) Face Malar/discoid/photosensitive rash Scalp alopecia Eyes – pallor (anaemia), scleritis Mouth – oral ulceration, dry (Sjogren’s) Cervical adenopathy CV – Pulmonary HTN corpulmonale, pericarditis Respiratory – pleural effusion, pulmonary fibrosis, collapse, infection Abdo - hepatosplenomegaly Legs Peripheral oedema secondary to nephrotic syndrome, steroid use Proximal myopathy, neuropathy, mononeuritis multiplex, cerebellar ataxia Other Obs – BP (HTN), temperature Urine dip (proteinuria) Clinical features of SLE

43. Case 7

45. Case 7 • Can move joints back into position – present.

46. Jaccoud’s arthropathy • Chronic deforming synovitis • Characterized by ulnar deviation of the second to fifth fingers and subluxation of the metacarpophalangeal (MCP) joints, which are voluntarily correctable by the patients. • Affects up to 50% SLE pts

47. Dermatology Present what you see!

48. Case 8 Present what you see

49. Case 8 Discoid lupus – note scarring, alopecia, hyperpigmentation, discoid plaques

50. Case 9 Present what you see