1. Rheumatology Revision
Clare Hunt FY2

2. The plan Overview of Osteoarthritis and Rheumatoid arthritis
Case scenarios 1 and 2
Symptoms and signs
Clinical findings
Epidemiology/ Risk factors
Management

3. Case scenario 1
A 67 year old lady comes to see you complaining of increasing pain in her hands
What do you do?
History
Examination
Management

4. History
Mostly affects her thumbs but also the small joints of her fingers.
Pain is worse at the end of the day and after she has been gardening.
Noticed slight swelling of her joints. Pain eased by paracetamol when at its worst.
PMH - Hypertension (amlodipine 5mg.)
No alcohol; doesn’t smoke. Retired secretary.

5. Differential Diagnoses?

6. What might you find on examination? What are you looking for?
continued
What might you find on examination? What are you looking for?

7. LOOK
FEEL
MOVE

8. Examination findings
Hands are not grossly deformed although she does have a mild Z shaped deformity of the thumb
No skin lesions at her elbows or behind the ears.
Generally tender over all PIPs and DIPs with some hard swellings
She can do up buttons and write her name, although this causes some discomfort

9. What are your differential diagnoses?
Osteoarthritis
Rheumatoid arthritis

10. What investigations would you like?
Bloods – ESR?
X-ray
What x-ray changes would you expect?

11. May be none… or…. Subchondral sclerosis Joint space narrowing
Osteophytes
Z-deformity
May also get subchondral cysts in late/severe OA.

12. OA of hands Usually as part of nodal osteoarthritis
Mainly women > 40s or 50s
Usually base of the thumb and DIPs
Joints may be swollen and tender
Function usually good
Linked with increased risk OA knee.
Nodal OA likely to be passed mother to daughter.

13. Osteoarthritis in general
Weight bearing joints – knees, hips
Use – shoulders, hands
Spine (especially C-spine)

14. Who? > late 40s - “wear and tear” Female Family hx OA Overweight
Previous joint injury/operation
Physically demanding job – repetitive movements
Joint abnormality eg Perthes’
PMH – gout, Rheumatoid arthritis

15. Management Lifestyle changes – weight loss NSAIDS
Intra-articular steroid injections
Surgery

16. Summary of OA Degenerative disease of increasing age
Mainly weight-bearing/high use joints
Pain, swelling, stiffness – evening > morning
Management – lifestyle, symptom control, surgery

18. Case scenario 2
A 34 year old lady comes to see you giving an 8 week history of pain affecting the small joints of her hand.
What do you want to know?

19. continued Pain and stiffness worst first thing in the morning
Improves after about 1hour
General malaise
Noticed her hands are slightly swollen
PMH – nil
DH – OCP
What else do you want to know?
Smokes 10/day; <14units alcohol/week
Occupation = Secretary
Grandmother had problems with her hands

20. Examination What might you find? What else should you look for/check?
Slight swelling over MCP and PIP joints both hands
Tender on palpation
No obvious deformity
What else should you look for/check?
Temp 37.5
No skin changes elbows or scalp
Right eye slightly red around cornea – not painful

21. Differential diagnoses?
Rheumatoid arthritis
Septic arthritis
Gout
Osteoarthritis
SLE
Psoriatic arthritis

22. What is Rheumatoid arthritis?
Definition
“a multisystem autoimmune inflammatory condition that typically affects the small joints of the hands and feet”

23. Symptoms and signs Differentiate OA from RA Worse in morning
Morning stiffness
Small joints of hand
Symmetrical
MCPs and PIPs > DIPs

24. Typical hand signs? Ulnar deviation of fingers DIPs spared
Guttering of MCPs
Wasting of intrinsic hand muscles
Carpal tunnel syndrome
Boutonniere = button hole = because of tendon injury/damage
Swan neck = because hyperextension of PIP and flexion of DIP = caused by a lax volar plate

25. Other bony features? C- spine Feet Cervical subluxation Neck pain
Atlanto-axial instability
Feet
Subluxation of metatarsal heads
Claw toes

26. Diagnostic criteria of RA
Diagnosis can be made if these are all present:
Inflammatory arthritis involving three or more joints.
Positive RF and anti-CCP
Raised CRP or ESR
Duration of symptoms > six weeks
Excluded similar diseases:
Psoriatic arthritis
Acute viral polyarthritis
Gout/psuedogout
SLE

27. Extra-articular manifestations

28. Weight loss, fever, malaise common
Skin – Rheumatoid nodules – elbows & forearms
Heart – pericarditis, pericardial effusion
Lungs – Rheumatoid nodules, pulmonary fibrosis, pleural effusion, bronchiectasis
Eyes – episcleritis/scleritis
Neuro – peripheral neuropathy, carpal tunnel syndrome
Felty’s syndrome

29. What does the patient want?
I – what does she think it is?
C – what is she worried/concerned about/how is it affecting them?
E – what does she want from you today?
Patient is concerned that she has been late to work recently because of disruption to her morning routine

30. SO WHAT ARE YOU GOING TO DO FOR HER?
Investigations
Bloods
FBC, U+E, LFTs, ESR, CRP, RF, anti-CCP
Imaging
X-ray findings?

31. “Pencil in cup” deformity
Loss of joint space
Deformity
Soft tissue swelling
“Pencil in cup” deformity
Bony erosion
Periarticular osteopaenia

32. Management Conservative Medical Surgical
Weight loss, smoking cessation
Support - “MDT approach”
Medical
Analgesia, steroids, DMARDs, Biologics
NICE guidance = early DMARDS
Surgical
Joint fusions, joint replacement, carpel tunnel decompression

33. Check baseline U+E, FBC, LFTs & urine analysis
DMARDs
Check baseline U+E, FBC, LFTs & urine analysis
Methotrexate
Sulfasalazine
Gold
Penicillamine
Side effects?
Folic acid suppression, deranged LFTs
Myelosuppression; pneumonitis (rare)
Nephrotic syndrome (Gold & Penicillamine)

34. Biologics (after failure to respond to 2 DMARDS)
Anti-TNF alpha
Infliximab, Adalimumab, Etanercept
What test should be done prior to starting biologics?
Side effects
Allergic reactions; TB reactivation; increased risk infection

35. Summary

36. MULTIDISCIPLINARY APPROACH!