Rheum Flashcards
(30 cards)
Extra-articular manifestations
Eyes: episcleritis/scleritis/sicca syndrome (sjogren’s)
Lungs: Rheumatoid lung (ILD, pleural effusion, rheumatoid nodules, Caplan syndrome, obliterative bronchiolitis)
Neuro: mononeuritis multiplex, peripheral neuropathy, Atlanto-axial subluxation, carpal tunnel
Haem: anaemia (all types), felty’s
Skin: vasculitis
Renal - amyloid
Bone - osteoporosis
CVS: Risk v high (3x higher) (stroke, MI, diabetes, hyperlipidaemia), pericarditis
what is RA?
Symmetrical, deforming polyarthritis + extra-articular manifestations
Investigations in a patient with RA
Obs, o2 and temp
Calculate DAS 28
Urine dip
Bloods: FBC, UE, CRP, LFT, COAG, Bone profile, vit D, viral screen, Hba1c, lipids
Antibodies: ANA, anti-CCP, Rf
Imaging
Hand and feet XR, USS, MRI
CXR/CT/lung function if respiratory involement suspected
RA Mx
Conservative
Patient education, OT/PT
STOP SMOKING
CVS risk factor modification
Medical: treat to target using DAS 28 (< 2.6) score
Acute flare: steroids or NSAIDs
Remission:
Initially: DMARDs (MTX, HCQ, sulfasalazine)
If fail 2x DMARDs -> biologics (Anti TNF adalimumab, rituximab, tocilizumab)
Manage osteoporosis
Bone protection
Surgical
Joint replacement, arthrodesis, carpal tunnel release
SE of biologic agents
Opportunistic infections
Reactivation of TB
Malignancy
PML (JC virus)
Steroid counselling advice
Take it first thing in morning so does not disturb sleep
Take it with food
Concurrent PPI prescription
What must you always assess for on examination of a patient with suspected RA
FUNCTIONAL ASSESSMENT:
- Power grip
- Precision grip (write, do up buttons)
- Key grip
RhA ddx
Psoriatic arthritis/ HLA B27 arthropathy
SLE
OA
Gout/pseudogout
What screening needed prior to commencing anti-TNFs?
TB
Hep B
RhA prognosis
In 5 years, 1/3 unable to work
MTX side effects
Neutropenia
Pulmonary toxicity
Hepatitis
systems to examine in RA patients
Skin
Nails
Joints
Neck for atlantoaxial subluxation scar
Lungs for iLD
Abdomen for splenomegaly
Eyes
which joints are not commonly involved in RA?
DIPJs
Hot swollen joints causes (ITCHI)
Infective (septic, reactive)
Trauma: FRacture, bursitis
Crystal arthropathy: gout, pseudogout
Haemarthrosis
Inflammators: RhA, PsA, OA
what do we call an arthritis which occurs 2-3 weeks after infection elsewhere?
reactive arthritis
what do you see on joint aspiration in reactive arthritis?
sterile (ie no bugs) but raised WCC/ pus
symptoms in Reactive arthritis
Eye pain
Lower back pain
Diarrhoea
Dactylitis
Tendonitis (achilles tendonitis, plantar fasciitis)
flaky scales on genitalia or sole (keratosis blennhoragicum)
Reactive arthritis mx
Most self resolve
NSAIDs
If fail, can trial sulphasalazine
If monoarthropathy -> steroid injection
colour change in raynaud’s
white
blue
red
what is important to ask for in occupation in patient with Raynaud’s?
Operating vibrating machinery?
which 3 autoimmune conditions most associated with raynaud’s? (SEcondary)
Scleroderma
Lupus
Sjogren’s
Myositis
Rheumatoid arthritis
Common CTD features to ask about in history?
Mouth ulcers
Hairloss
Photosensitive rashes
Joint pain
Dry eyes/mouth
Raynaud’s
Swallowing difficulty
GORD
Stiffness
Swollen hands
Tight skin
Cough/SOB
Features to look for o/e of patient with Raynaud’s?
Pulses, CRT
Look for digital ulcers/ischaemia
Nails - would want to look at nail fold with capillaroscope
Telangiectasis
Sclerodactyly
Tight, shiny skin (Extent of spread)
Calcinosis
Microstomia
why is it important to comment on presence of digital ulcers in raynaud’s?
changes management as they often need admission for IV prostaglandins
