Essential Rheumatology. Dr Ellen Bruce Consultant Rheumatologist CMFT

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Fay Dixon
6 years ago
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1 Essential Rheumatology Dr Ellen Bruce Consultant Rheumatologist CMFT

2 Saving the best for last! Apparently people recall best the first and last thing they re told. Far too difficult to include everything. Audience participation or Outline- Clinical vignettes with some info after

Joint pain A 25 year old lady Mrs S comes to see you because she has noticed pain in her joints (hands, wrists, shoulders, L knee especially ) for the past 2-3

3 Joint pain A 25 year old lady Mrs S comes to see you because she has noticed pain in her joints (hands, wrists, shoulders, L knee especially ) for the past 2-3 weeks Differential diagnosis What further questions would you want to ask? What features on examination would you look for? What investigations would you order?

4 Joint pain Joint pain Arthritis Metabolic Soft Tissue Rheumatism Inflammatory Arthritis Non inflammatory Arthritis Vitamin D Paget s Osteoporosis Fibromyalgia Regional Pain syndromes

5 Joint pain Feature Inflammatory Mechanical Morning Stiffness > 1 hr <30 min Fatigue Significant Minimal Activity Can improve Can worsen Rest May worsen May improve Systemic Yes No Steroid response Yes No Inflammatory arthritis RA Spondyloarthritis (PsA, AS, Reactive) CTD Crystal

6 RA Chronic symmetrical inflammatory polyarthritis of synovial joints F > M ~ 1% population Extra-articular manifestations

8 RA INVESTIGATIONS Blood XR USS/MRI MANAGEMENT

9 RA INVESTIGATIONS Blood XR USS/MRI Test Specificity Sensitivity RF 74% 75% Anti-CCP 96% 68% MANAGEMENT CH- chronic disease e.g liver, lung R- Rheumatoid O- Other CTDs N- Neoplasms, esp post chemo,rtx I- infections, chronic esp granulomatous C- cryoglobulinaemia, esp HCV assoc

10 RA INVESTIGATIONS Blood XR USS/MRI MANAGEMENT Pain relief (+/-NSAIDS) Disease Education Steroids (short term) DMARDS MDT Involvement Methotrexate -once weekly -monitoring bloods -teratogenic -folic acid co-prescription

Acute swollen joint Mrs J, 89yrs inpatient admitted with confusion and a UTI. She has become unable to put weight on her right leg which was very painful. Her knee is swollen.

11 Acute swollen joint Mrs J, 89yrs inpatient admitted with confusion and a UTI. She has become unable to put weight on her right leg which was very painful. Her knee is swollen. The patient is muddled. Differential diagnosis What further questions would you want to ask? What features on examination would you look for? What investigations would you order?

12 Acute swollen joint Differential Sepsis Gout Pseudogout Investigations Management of each

13 Acute swollen joint Exclude sepsis first Investigations? MANANGEMENT Antibiotics if infection NSAIDs, colchicine, steroids Allopurinol Modifiable risk factors

14 Gout and Pseudogout

Developed a new skin rash and complains of pain in her hands. On examination she has a temperature of 38.

15 Connective Tissue Disease 28 year old lady, previously fit and well. Presented with a fever, cough and pleuritic chest pain. Developed a new skin rash and complains of pain in her hands. On examination she has a temperature of 38.9 C and reduced air entry at the left base. Differential diagnosis What further questions would you want to ask? What features on examination would you look for? What investigations would you order?

16 Connective Tissue Disease Nonspecific symptoms - fever, fatigue, wt loss Photosensitive rash Arthralgia or arthritis Raynaud phenomenon Serositis (pleuritis, pericarditis, peritonitis) Nephritis or nephrotic syndrome Neurologic symptoms Alopecia Oral ulcers Sicca symptoms Myopathy Haematological disorder SLE Sjogren s Systemic Sclerosis MCTD Undifferentiated CTD Polymyositis Dermatomyositis

18 Connective Tissue Disease Antibodies Test Specificity Sensitivity ANA 57% 95% dsdna 97% 57% Antibody Rheumatoid factor Antinuclear antibody dsdna SS-A (Ro) SS-B (La) Smith RNP Jo1 Centromere Topoisomerase (Scl-70) canca (pr3) panca (mpo) Ferritin ACL Correlation RA, SLE, Cryogloblinaemia 99.9% SLE / Correlates with ENA 80% SLE SLE, Sjogren s ***Neonatal heart block*** SLE, Sjogren s SLE (low sensitivity, VERY specific) Mixed connective tissue disease Polymyositis Limited cutaneous scleroderma Scleroderma (esp lung disease) Granulomatosis with polyangitis (WG) Eosinophilic granulomatosis with polyangitis (CS), microscopic polyangiitis Adult onset Still s disease Antiphospholipid syndrome

19 Vasculitis 68 year old presents with a 6 day history of headaches. She describes discomfort when she combs her hair. She has also been struggling to get dressed in the morning. Differential diagnosis What further questions would you want to ask? What features on examination would you look for? What investigations would you order?

20 GCA/Temporal Arteritis Visual involvement = Emergency - High dose iv steroids Temporal artery biopsy (might be negative) Side effects of steroids and drugs to co-prescribe

22 Back Pain Differential diagnosis: Musculoskeletal Disc disease Ankylosing spondylitis (inflammatory) Vertebral fracture Malignancy Referred pain Remember Cauda Equina MDT approach, pain management and burden of disease Feature Mechanical Inflammatory Infiltrative Onset Variable Subacute Inisdious Stiffness >30 min >30 min Minimal Activity Worse Better Persistent Nocturnal pain Mild Moderate Severe Condition Disc/OA AS Cancer, infection

23 Finally Good Luck!

A CRP B FBC C LFT D blood culture E uric acid

1 A 39 year old lady with rheumatoid arthritis is admitted to hospital with a hot, swollen and painful right knee. Which is the most important blood test? A CRP B FBC C LFT D blood culture E uric acid