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Rheumatology Revision

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.

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Rheumatology Revision

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  1. Rheumatology Revision Clare Hunt FY2

  2. The plan Overview of Osteoarthritis and Rheumatoid arthritis Case scenarios 1 and 2 Symptoms and signs Clinical findings Epidemiology/ Risk factors Management

  3. Case scenario 1 A 67 year old lady comes to see you complaining of increasing pain in her hands • What do you do? • History • Examination • Management

  4. 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.

  5. Differential Diagnoses?

  6. continued What might you find on examination? What are you looking for?

  7. LOOK • FEEL • MOVE

  8. 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

  9. What are your differential diagnoses? • Osteoarthritis • Rheumatoid arthritis

  10. What investigations would you like? • Bloods – ESR? • X-ray • What x-ray changes would you expect?

  11. May be none… or…. Subchondral sclerosis Joint space narrowing Osteophytes Z-deformity May also get subchondral cysts in late/severe OA.

  12. 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

  13. Osteoarthritis in general • Weight bearing joints – knees, hips • Use – shoulders, hands • Spine (especially C-spine)

  14. 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

  15. Management • Lifestyle changes – weight loss • NSAIDS • Intra-articular steroid injections • Surgery

  16. Summary of OA • Degenerative disease of increasing age • Mainly weight-bearing/high use joints • Pain, swelling, stiffness – evening > morning • Management – lifestyle, symptom control, surgery

  17. 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?

  18. 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

  19. 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

  20. Differential diagnoses? • Rheumatoid arthritis • Septic arthritis • Gout • Osteoarthritis • SLE • Psoriatic arthritis

  21. What is Rheumatoid arthritis? • Definition • “a multisystem autoimmune inflammatory condition that typically affects the small joints of the hands and feet”

  22. Symptoms and signs • Differentiate OA from RA • Worse in morning • Morning stiffness • Small joints of hand • Symmetrical • MCPs and PIPs > DIPs

  23. 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.jpg http://www.3pointproducts.com/Portals/30688/images//SwanNecklabel.jpg

  24. Other bony features? • C- spine • Cervical subluxation • Neck pain • Atlanto-axial instability • Feet • Subluxation of metatarsal heads • Claw toes

  25. 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

  26. Extra-articular manifestations

  27. 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

  28. 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?

  29. SO WHAT ARE YOU GOING TO DO FOR HER? • Investigations • Bloods • FBC, U+E, LFTs, ESR, CRP, RF, anti-CCP • Imaging • X-ray findings?

  30. Loss of joint space Deformity Soft tissue swelling “Pencil in cup” deformity Bony erosion Periarticular osteopaenia

  31. 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

  32. DMARDs Check baseline U+E, FBC, LFTs & urine analysis • Methotrexate • Sulfasalazine • Gold • Penicillamine • Side effects? • Folic acid suppression, deranged LFTs • Myelosuppression; pneumonitis (rare) • Nephrotic syndrome (Gold & Penicillamine)

  33. 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

  34. Summary

  35. MULTIDISCIPLINARY APPROACH!

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