R HEUMATOLOGY R EVISION Clare Hunt FY2. The plan Overview of Osteoarthritis and Rheumatoid arthritis...
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R HEUMATOLOGY R EVISION Clare Hunt FY2. The plan Overview of Osteoarthritis and Rheumatoid arthritis Case scenarios 1 and 2 Symptoms and signs Clinical
The plan Overview of Osteoarthritis and Rheumatoid arthritis
Case scenarios 1 and 2 Symptoms and signs Clinical findings
Epidemiology/ Risk factors Management
Slide 3
C ASE 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
Slide 4
H ISTORY 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; doesnt smoke. Retired secretary.
Slide 5
D IFFERENTIAL D IAGNOSES ?
Slide 6
CONTINUED What might you find on examination? What are you
looking for?
Slide 7
LOOK FEEL MOVE
Slide 8
E XAMINATION 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
Slide 9
W HAT ARE YOUR DIFFERENTIAL DIAGNOSES ? Osteoarthritis
Rheumatoid arthritis
Slide 10
W HAT INVESTIGATIONS WOULD YOU LIKE ? Bloods ESR? X-ray What
x-ray changes would you expect?
Slide 11
Joint space narrowing Subchondral sclerosis Osteophytes May be
none or. May also get subchondral cysts in late/severe OA.
Z-deformity
Slide 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
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O STEOARTHRITIS IN GENERAL Weight bearing joints knees, hips
Use shoulders, hands Spine (especially C-spine)
Slide 14
W HO ? > 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
Slide 15
M ANAGEMENT Lifestyle changes weight loss NSAIDS
Intra-articular steroid injections Surgery
Slide 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
Slide 17
Slide 18
C ASE 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?
Slide 19
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;
Slide 20
E XAMINATION 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
W HAT IS R HEUMATOID ARTHRITIS ? Definition a multisystem
autoimmune inflammatory condition that typically affects the small
joints of the hands and feet
Slide 23
S YMPTOMS AND SIGNS Differentiate OA from RA Worse in morning
Morning stiffness Small joints of hand Symmetrical MCPs and PIPs
> DIPs
Slide 24
T YPICAL 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
Slide 25
O THER BONY FEATURES ? C- spine Cervical subluxation Neck pain
Atlanto-axial instability Feet Subluxation of metatarsal heads Claw
toes
Slide 26
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
W HAT 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?
Slide 30
SO WHAT ARE YOU GOING TO DO FOR HER? Investigations Bloods FBC,
U+E, LFTs, ESR, CRP, RF, anti-CCP Imaging X-ray findings?
Slide 31
Soft tissue swelling Deformity Loss of joint space Bony erosion
Periarticular osteopaenia Pencil in cup deformity
Slide 32
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
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
