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RHEUMATOLOGY Dr KM Wilkinson FY1 Medicine MRI 23/11/2007 OUTLINE The rheumatological history Key conditions Case histories/potential stations Question time……….. HISTORY BACKGROUND: AGE/SEX/ETHNICITY HPC Key symptoms PAIN STIFFNESS am/pm?? INACTIVITY TIME SWELLING Distribution of joints involved. One or many? Symmetry? Extra articular manifestations Constitutional upset PMH Ask specifically IBD, psoriasis, recent GI/GU infections. Trauma to joints? FH SH Job/Hobbies/ADL i.e FUNCTIONAL LIMITATIONS PSYCHOLGICAL IMPACT RHEUMATOID DISEASE Inflammatory, symmetrical polyarthropathy Women, 30-60 Small joints of hands, feet, wrists and ankles, C- spine, HLA-DR4 Ix Rh factor (+ve 80%), basic bloods, X-rays of affected joints, ESR (active disease, CRP suggests infection), CXR Can be very acute, aggressive and debilitating Extra-Articular Manifestations of RA SYSTEM PROBLEM SYSTEMIC Fever, WL, fatigue PULMONARY Nodules, fibrosis, effusion Anaemia, Felty’s syndrome, lymphadenopathy, HAEMATOLOGICAL bone marrow suppression from drugs, GI blood loss from NSAIDs CTS, atlanto-axial subluxation, NEUROLOGICAL mononeuritis multiplex/polyneuropathy CARDIAC Effusions, pericardiatis EYES Sjogrens syndrome, scleritis SERONEGATIVE ARTHRITIS 1. Ankylosing 1. No Rh factor spondylitis 2. HLA-B27 3. Asymmetrical, 2. Reactive Arthritis oligoarticular (Reiter’s syndrome) 4. Saro-iliac involvement 5. Extra-articular 3. Enteropathic manifestations arthritis (different to RA)- commonly eyes 4. Psoriatic arthritis (uveitis/conjunctivitis) CRYSTAL ARTHROPATHIES GOUT PSEUDOGOUT Inflammatory monoarthropathy Hurts like hell Like gout, but not…. Old boozy men (also trauma, diuretics, surgery, renal failure etc.) Positively birefringent crystals Negatively birefringent crystals Release of Ca from cartilage into the blood Rxn: NSAIDS/colchicine Less severe Allopurinol (not immediately) NSAIDs/steroids Prophylaxis Repeated attacks tophi (ears, fingers, toes) Connective Tissue Disease SLE, systemic sclerosis and the CREST syndrome Multisystem disorders characterised by: 1. Raynaud’s 2. Photosensitivity 3. Mouth ulcers/hair loss etc 4. Muscle/joint pains SLE • Most common CT disease • ANA almost always +ve • Anti-dsDNA specific for SLE but only present in about 40% (Rh factor/anti cardolipin antibodies as well) • Afro-Caribbean 30 year old woman • HLA-b8 and DR3 associations • Virtually any presentation from pancytopoenia to seizures to psychosis to effusions to arthritis to rashes to Raynaud’s to renal failure……………… ‘Systemic sclerosis’ (endarteritis obliterans fibrosis of skin and internal organs-tend to be a diffuse and debilitating process. No cure) ‘Scleroderma’-skin involvement eg microstomia ‘Crest syndrome’ = more local involvement : Calcinosis Raynaud’s (white then red then blue) Esophageal involvement Sclerodactyly Telangectasia STATION 1 : Examine These Hands…… Easy marks LOOK-Be smooth-describe the back, then the front before you even touch the patient. Use correct terms. Never forget the nails. FEEL - Ask about pain first. Describe each joint, naming it by it’s full name. Boggy swelling? Bony? Functional assessment Examine the elbows/behind the ears Thank the patient. Tell the examiner the diagnosis…… Which will be……… Ulnar drift, Swelling of the MCPs/PIPs- boggy/tender suggests active disease Subluxed MCPs Boutonnieres/swan neck deformities Z-thumb Muscle wasting-intraosseous/thenar eminence CTS scar Dupuytrons Rheumatoid nodules Nail ridging/spooning (anaemia) Or……. Nails-pitting/oncholysis Psoriasis patches on elbows/behind ears Arthritis mutilans DIPs Or…….. Heberden’s/Bouchard’s nodes Bony swelling, not tender Older people Station 2: X-Ray 1. JOINT SPACE NARROWING 2. EROSIONS 3. SUBLUXATION 4. PERI- ARTICULAR OSTEOPOENIA Station 3: Spot Diagnosis Station 3: Spot Diagnosis SLE Sunblock, NSAIDS, chloroquine, steroids/ Immunosuppression for severe flare-ups. Station 5: Another one… Station 5: Another one… ERYTHEMA NODOSUM Raised, red, angry, well circumscribed. Classically on shins ?? Drugs (sulphonomides/OCP) Sarcoid/TB Atypical pneumonia (mycoplasma) Pregnancy Streptococci Station 6: mini history Mr X, a 67 year old man attends your clinic complaining of a moderate headache for 3/7, constant and worse around the temples. He feels quite unwell with it and is running a low grade temperature. On questioning he admits to tingling pain when he is combing his hair and chewing food. You elicit pain and stiffness in his shoulder muscles on examination, which he has noticed over the last few months, typically worst in the mornings. ?????????????????????????????????????????????????????? Station 7: Management of RA MULTIDISCIPLINARY!!! [Physios, OTs, specialist nurses, psychiatry, social support, you name it, we want it….] NSAIDS till rheumatology appt…….Then hit ‘em hard with D-MARDs/biological agents D-MARDS METHOTREXATE (folate antagonist, bad for liver and bone marrow) SULFASALAZINE (GI symptoms, also bad for your liver) AZOTHIOPRIM CHLOROQUINE/HXDROXYCHLOROQUINE etc etc Anti-TNF – watch for opportunistic infection/Ca INFLIXIMAB/ADILUMIBAB (antibodies to to TNF) ENTEROCEPT (soluble TNF receptor) Station 7: Important differentials 1. Septic arthritis!!!!! 2. Haemarthrosis 3. Gout/pseudogout 4. RA flare up 5. OA 6. Septic arthritis…… ANY QUESTIONS??