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 ID: 390816
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Slide1
Rheumatology Revision
Clare Hunt FY2Slide2
The plan
Overview of Osteoarthritis and Rheumatoid arthritis
Case scenarios 1 and 2
Symptoms and signs
Clinical findings
Epidemiology/ Risk factors
Management Slide3
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
Slide4
History
M
ostly 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.Slide5
Differential Diagnoses?Slide6
continued
What might you find on examination?
What are you looking for?Slide7
LOOK
FEEL
MOVESlide8
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 discomfortSlide9
What are your differential diagnoses?
Osteoarthritis
Rheumatoid arthritisSlide10
What investigations would you like?
Bloods – ESR?
X-ray
What x-ray changes would you expect?Slide11
Joint space narrowing
Subchondral sclerosis
Osteophytes
May be none… or….
May also get
subchondral
cysts in late/severe OA.
Z-deformitySlide12
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.jpgSlide13
Osteoarthritis in general
Weight bearing joints – knees, hips
Use – shoulders, hands
Spine (especially C-spine)Slide14
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 arthritisSlide15
Management
Lifestyle changes – weight loss
NSAIDS
Intra-articular steroid injections
Surgery Slide16
Summary of OA
Degenerative disease of increasing age
Mainly weight-bearing/high use joints
Pain, swelling, stiffness – evening > morning
Management – lifestyle, symptom control, surgerySlide17Slide18
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?Slide19
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 Slide20
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 painfulSlide21
Differential diagnoses?
Rheumatoid arthritis
Septic arthritis
Gout
Osteoarthritis
SLE
Psoriatic arthritisSlide22
What is Rheumatoid arthritis?
Definition
“a multisystem autoimmune inflammatory condition that typically affects the small joints of the hands and feet”Slide23
Symptoms and signs
Differentiate OA from RA
Worse in morning
Morning stiffness
Small joints of hand
Symmetrical
MCPs and PIPs > DIPsSlide24
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.jpgSlide25
Other bony features?
C- spine
Cervical subluxation
Neck painAtlanto-axial instability
Feet
Subluxation of metatarsal heads
Claw toesSlide26
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 Slide27
Extra-articular
manifestationsSlide28
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
syndromeSlide29
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?Slide30
SO WHAT ARE YOU GOING TO
DO FOR HER?
Investigations
Bloods
FBC, U+E, LFTs, ESR, CRP, RF, anti-CCP
Imaging
X-ray findings
?Slide31
Soft tissue swelling
Deformity
Loss of joint space
Bony erosion
Periarticular osteopaenia
“Pencil in cup” deformitySlide32
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 decompressionSlide33
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 analysisSlide34
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 infectionSlide35
SummarySlide36
MULTIDISCIPLINARY APPROACH!