RHEUMATOLOGY

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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??