Rheumatoid Arthritis Flashcards Preview

Long Case - Rheumatology > Rheumatoid Arthritis > Flashcards

Flashcards in Rheumatoid Arthritis Deck (9)
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1

Presentation of RA?

Systemic inflammatory disease with symmetrical, deforming peripheral polyarthritis. Genetic element in 70% of cases (HLA-DR4)

Articular features:
- Pain, swelling and morning stiffness mostly in small joints but can affect larger joints
- deformity in the chronic setting

Non-articular features:
(more common)
- Secondary sjogren's
- R. nodules
- Anaemia + fatigue
- Fibrosis
- Carpal Tunnel (10%)

(rarer)
- Skin = raynauds, ulcers
- eyes = epi/scleritis, cataracts (from steroids)
- lungs = dyspnea (pleural effusion), pleuritic chest pain
- Heart = pericarditis
- C1/C2 subluxation = hoarness, sore throat, neck pain
- neuro = peripheral neuropathy

Systemic features
- anorexia
- weight loss
- polymyalgia

2

Important Hx elements

Onset
- when was diagnosis made
- how long after Sx was diagnosis made

Current
- symptoms, flares
- main concerns
- functional impairment

3

Examination - hands

General
- Cushingoid features (from steroid use)

Hands
- Dorsum = wrist swelling and radial deviation, dorsum wasting and nodules. MCP swelling, ulnar deviation and subluxation
- Deformity = swan-neck and boutonniere's, Z thumb
- Nails = vasculitic changes (splitting, oncholysis, clubbing, ventral pterygium)
Volar = palmar erythema, carpal tunnel scar, fixed flexion

feel
- temperature, creps, swelling, tenderness, nodules

move
- ROM in all joints

FUNCTION:
- grip strength, key strength, opposition strength, buttom, pen etc

4

Examination other

Face
- eyes for episcleritis, cataracts and pallor
- anlarged parotids in sjogrens
- TMJ crepitus

Neck
- cervical spine tenderness and reduced ROM
- cervical lymphadenopathy

Chest
- Lungs for pulmonary fibrosis or effusion
- pericardial rub or regurg murmur

Abdomen
- hepato/splenomegaly
- inguinal lymph nodes

5

Serology testing

1. Rheumatoid factor in 70% (sensitive, not specific)
2. Anti-CCP in 50% (more specific)

6

Other investigations

FBC
X-ray - (can be normal) = soft tissue swelling, juxta-articular osteopenia, reduced joint space, boney erosion, subluxation
USS + MRI - looking at synovitis more accurately

DAS28 score to monitor disease - 6 monthly
- <2.6 indicates remission
- >5.1 is high level of disease

7

NP management

Education
Regular exercise
PT and OT for aids, splints
Manage CV risk - RA accelerates athersclerosis
measure DAS28

8

P management

DMARDS
1st line = Methotrexate
- Folate inhibitor
- SE of GI intolerance, fatigue, mouth ulcers, abn LFT
- causes myelosuppression
2. Sulfazaline
- prostaglandin inhibition
- N+V, diarrhoea, dizziness, mood changes and hallucinations
3. hydroxychloroquine
- immune suppression (targeted)
- can cause irreversible retinopathy ( check VA)
4. Leflunomide
- diarrhea, HTN, abnormal LFTs, peripheral neuropathy

BIOLOGIC AGENTS
- Anti-TNF inhibitors = Adulimumab and Etanercept
- Sub cut administration
- or Infliximab IV every 8 weeks
- eligibility criteria including no active infection, severe heart failure, malignancy, MS, Hep B, TB

9

Symptomatic relief for RA

Steroids = prednisone
- good in acute flares but should be given by a rheumatologist and not for long term management. Oral or IM

NSAIDs
- good symptomatic relief, but should not be taken long term as DMARDs will fill this role