Year 2 - Week 5 - Stiff Hands Flashcards by Charlotte Humphries

Pain and stiff joints in hands, especially in the morning. What are the possible diagnoses?

Osteoarthritis
Rheumatoid arthritis
Peripheral spondyloarthropathy
Haemochromatosis

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What symptoms can present with RA?

Symmetrical inflammation of the small joints of hands and feet
Pain - worse at rest or inactivity
Often morning stiffness - worse for first 30-60mins
Boggy swelling around the joints

Can get nocturnal pain, acute or subacute onset
Systemic features - malaise, fatigue, fever
Can be FHx

Ulnar deviation often associated with later progression of the disease

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What symptom is usually associated with psoratic arthritis?

Hx of psoriasis

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If you suspect a P has RA - what should you do?

Persistent synovitis of unknown cause - Refer to rheumatology for evaluation within 3 weeks

Refer urgently (3 days) - if small joints of hand/feet are affected, more than one joint is affected, or the P has waited more than 3 months since the onset of symptoms to seek medical advice.

Also do bloods.

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What blood tests should you perform for RA?

FBC
Inflammatory markers - CRP & ESR
Rheumatoid factor
Poss anti-CCP
U&E
LFTs

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Why is it good to check liver and kidney function in a possible diagnosis of RA?

To get baseline values of how they are performing before drugs for RA are started - which can affect the liver and kidney function.

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What is the goal of secondary care for RA?

Achieve remission or, if not possible, to minimise disease activity

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What is first line treatement for RA?

DMARDs - disease modifiying anti-rheumatic drugs

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Name two conventional DMARD drugs

Methotrexate
Sulphasalazine

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What treatment is given if Ps do not respond to DMARDs adequately?

Biological DMARDs (Biologics)

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Once a patient is started on DMARDs and is considered stable - they can be transferred back to GP for routine care - what is this called?

Shared Care Agreement

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What are the benefits of shared care agreements?

Reduce burden on secondary care
Help Ps be more active in their own care

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What do shared care agreements outline?

What monitoring is required
What to do if abnormal results are received
What side effects to monitor for
When to stop/withhold treatment

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What is it called when Ps experience symptoms even though they have been in remission?

Flare

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What drugs are used to manage flares?

NSAIDs
Corticosteriods (oral or intra-articular)

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Which vaccinations should RA Ps be offered?

Influenze
Pneuomcoccal
High risk - also Hep B

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Can Ps with RA have live vaccinations?

No (except shingles - this may be ok)

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What is the risk of CVD compared to general pop for Ps with RA?

1.5x higher

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Which scoring system assessed CVD risk?

QRISK scoring system

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For RA Ps - which RF put them at greater risk of developing CVD?

Had RA for 10+ years
Have extra-articular manifestations
Are RF or anti-CCP positive
Used corticosteriods or NSAIDs

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What is the link between RA and skin cancer?

Ps with Ra - inc risk (x2 of gen pop) of developing SCC and 1.2x risk of BCC

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Which skin cancer risk increases if Ps take anti-TNF meds?

Greater risk of SCC (not BCC)

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What is the link between RA and mental health?

Approx 40% of Ps with RA get depression and 20% anxiety

Ps with these symptoms are more likely to have worse disease control

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What should be discussed at annual review with RA patients?

Flares
Vaccinations
CV Risk
Mental Health
Skin Cancer review
Drug concordance
Side Effects
Monitoring
Risk of osteoporosis

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What is spondyloarthritis?

Another inflammatory arthritis - less common

What are the symptoms of spondyloarthritis?

Axial symptoms - inflammatory back pain Peripheral symptoms - psoratic arthrtisi, reactive arthritis, enteropathic arthritis

What are the extra-articular manifestations of SA?

Uveitis Psoriasis Enthesitis Dactylitis

Which gene is SA linked to?

HLA-B27

How many joints does psoratic arthritis affect?

Can be one (monoarthritis) Can be a few (polyarthritis)

How many joints does psoratic arthritis affect?

Can be one (monoarthritis) Can be a few (polyarthritis)

What percentage of Ps with psoratic arthtiris have Hx of skin psoriasis?

80%

What percentage of Ps with skin psoriasis will develop psoraiatic arthritis?

20-30%

What are psoriatic nail changes?

Pitting Onchyolysis

What percentage of Ps with psoriatic arthritis will have nail changes?

90%

What does ethesitis affect?

The Achilles tendon & plantar fascia

What does ethesitis affect?

The Achilles tendon & plantar fascia

What can psoriatic arthritis cause in the eye?

Conjunctivitis Uveitis

What should all Ps with skin psoriasis have each year?

Annual screen for psoriatic arthritis

What is used to screen for psoriatic arthritis?

PEST Screening Questionnaire (Psoriasis Epidemiology Screening Tool)

On the PEST tool - how many questions do you have to answer yes to in order that it is likely you have psoriatic arthritis?

3 or more

What does reactive arthritis usually present as?

Monoarthritis or a knee or ankle, or axial spondyloarthritis

What are both psoriatic arthritis and reactive arthritis associated with in terms of fingers or toes?

Dactylitis (sausage fingers/toes)

When does Reactive Arthritis usually occur? Which infections usually pre-empt it?

1-6 weeks after infection Usually GI infections (Campylobacter, Salmonella, Shigella) or urogenital (Chlamydia trachmatis, HIV).

What are the classical symptoms of reactive arthritis? What are they called?

Arthritis Urethritis Conjunctivitis (Cant see, cant pee, cant climb a tree) - called Reiter's syndrome However not all Ps have all three.

How does enteropathic spondyloarthritis present?

Assymetrical oligoarthritis - affecting lower limbs - emerging after onset of IBD

Whcih diseases is enteropathic spondyloarthritis more common in?

Crohns (more than UC)

Which gene is linked to enteropathic spondyloarthritis?

HLA-B27

What are the symptoms of osteoarthritis?

Affects small joints of the hands = pain Stiffness but normally less pronounced than RA and lasts <1 hour in the morning Pain / stiffness is exacerbated by activity

What is the progression of OA?

Normally gradual onset and progressive deterioration - but can get transient inflammatory flares as well.

What is the gold standard for diagnosis of osteoarthritis?

X-Ray

What are the criteria for a diagnosis of OA without X-rays?

>45 years >Activity-related joint pain >No joint stiffness or it lasts <30 mins

What are the typical sites affected by OA?

Neck Lower back Thumb base Hip Fingers Knee Toe base

What is an important differential to consider in place of an OA diagnosis?

Inflammatory arthritis

What is the main treatment for OA?

Exercise and physio

There are no disease modifying drug therapies for OA . Which drugs can be used to minimise pain?

NSAIDs - oral and topical Capsaicin (topical) Paracetamol Opiods Prednisolone (oral)

Which is more effective in reducing pain in OA - paracetamol or NSAIDs?

NSAIDs

What drug is the first line treatment for OA?

Topical NSAIDs

What drug is used when topical NSAIDs are ineffective?

Oral NSAIDs

What are the potential side effects of oral NSAIDs?

GI, renal, liver and CV toxicity Asthmatic Ps - may reduce FEV Can inc risk of miscarriage and delay labour

What should be prescribed alongside oral NSAIDs?

PPI

What is capsaicin made from? How does it work? What is it used for? What are its side effects?

Chilli peppers Though to disrupt pain signals reaching the brain Knee and hand osteoarthritis SE - can cause skin irritation but no systemic side effects

When should opioids be used in OA?

Generally not recommended. NICE - weak opiods should be used for short-term relief when other treatments are ineffective. Strong opiods should not be used.

How long do intra-articular corticosteriod injections last for? When are they recommended?

2-10 weeks of benefit Recommended when other treatments are infective - to facilitate therapeutic exercise

Name two alternative treatments for OA

Glucosamine Chondroitin

Do glucosamine and chondroitin work?

Little evidence that they are more beneficial than placebo

How is arthritis affected during pregnancy?

Often symptoms improve during pregnancy, but then many experience a flare after birth

Which RA medications are contraindicated during pregnancy?

DMARDs = can be tetrogenic - discuss before getting pregnant Biologics - best to stop during pregnancy

Which arthritis can occur in children?

Juvenile idiopathic arthritis

Is paracetamol recommended for OA?

No - little evidence for its efficacy

Which joints are predominantly affected by OA?

Hips Knees Small joints of the hands

Which lifestyle factor can increase the chances of developing OA?

Obesity

What type of gait do Ps with OA of the hip or knee sometimes have?

Antalgic gait - try to avoid putting pressure on the sensitive area

What nodes of the hands are sometimes seen with OA?

Heberden's nodes - on DIPJ

What is the normal range of movement in the hip for the following? - Flexion - Abduction - Adduction - Internal rotation - External rotation - Extension

Flexion - 110-120 degrees Abduction - 30-50 degrees Adduction - 20-30 degrees Internal rotation - 30-40 degrees External rotation - 40-60 degrees Extension - 10-15 degrees

How long should stiffess in OA last?

Approx 30mins - much longer then start thinking of differentials

Which conservative measures should be told to Ps with OA?

Weight loss and exercise

Which is the first drug to try for pain relief from OA of the hip?

Paracetamol - although efficiacy is doubted

What is the first drug to try for pain relief from OA of knee?

NSAIDs

What are the risks of opioids and codeine?

Can make P drowsy and inc chances of a fall

If a P is on aspirin and has OA - should you prescribe NSAIDs?

No - NSAIDs make aspirin less effective and inc risk of GI bleeding

When should GP refer for joint replacement?

When P's pain cannot be controlled, or their ability to function is persistently affected.

If a P does not want surgery, what other treatments can be suggsted?

Intra-articular injections of corticosteriod

What is the correct length of a walking stick?

From the flexor crease of the wrist to the ground - P must be in shoes and standing straight.

What age is the peak incidence of RA?

What is the ratio of incidence of RA between M and F?

F x2 more likely to get RA than M.

Answer the following questions for both RA and OA. Age of Onset? Joints Affected? Association with Movement? Stiffness?

Age of Onset -> OA = 50s+, RA = any age but peak 70 Joints Affected -> OA = Knees, hips and hands, RA = small joints of hands, feet, wrists and ankles Association with movement -> OA = pain worsens with activity, RA = no association with movement Stiffness -> OA = lasts less than 30 mins, RA = lasts > 30 mins

Year 2 - Week 5 - Stiff Hands Flashcards

(86 cards)