Clinical approach to RA Flashcards
Definition of RA
A chronic auto immune condition that causes inflammation of the synovial lining of the joints.
- It is an inflammatory arthritis.
- RA tends to be symmetrical
- It affects multiple joints - PIP and MCP
- It’s very common (F>M) and may be associated with joint damage, disability and premature mortality
Classification of RA takes into consideration the following…
- Morning stiffnes/ pain that gets better on movement
- Number of joints involved - Arthritis of 3 or more joint areas
- Which joints are involved? - MCP and PIP (plus maybe wrist and ankle)
- Symmetric arthritis!
- Rheumatoid nodules
- Serum RF and ACP
- Radiographic changes - x-ray erosions or bony de-calcification, USS for synovitis
Which gene often presents in Rheumatoid factor positive patients?
HLA DR4
Typical presentation of RA
Typically presents with a symmetrica, polyarthropathy.
Key symptoms:
- Pain
- Swelling
- Stiffness of a joint
Patients usually complain of pain/stiffness in the small joints of the hands and feet i.e the wrist, ankle, MCP and PIP joints. Can also present with these symptoms in the larger joints.
Onset can be rapid or over months/years.
Associated systemic symptoms:
- Fatigue
- Weight loss
- Muscle ache/weakness
When is the pain caused by RA worse?
It’s worse after rest but improves with activity
How does the pain with RA differ from pain caused by osteoarthritis?
Osteoarthritis is a mechanical problem and so the pain is worse with activity and improves with rest (the opposite of RA)
Which investigations are carried our for RA? (4)
- Rheumatoid factor - if this is negative check anti-CCP antibodies
- Inflammatory markers such as CRP and ESR - suggest liver involvement
- X-ray of hands and feet
- USS - for synovitis
What changes due to RA would you expect to find on an X-ray? (4)
- Joint destruction and deformity
- Soft tissue swelling
- Periarticular osteopenia
- Boney erosions
Symptoms of RA (5)
- Pain
- Stiffness
- Immobility
- Poor function
- Systemic Symptoms
Signs of RA
- Swelling
- Tenderness
- Limitation of Movement
- (Redness)
- (Heat)
What is the DAS28 score?
- A disease severity scoring tool
- It is based on the assessment of 28 joints and points are given for: swollen joints, tender joints, ESR/CRP result
Common joints affected with RA?
- Proximal interphalangeal joints
- Metacarpophalangeal joints
- Wrist and ankle
Signs of RA in the Hands (4)
- Palpation of the synovium around joints when the disease is active will feel boggy due to inflammation/swelling
- Swan hand - flexion at DIP, hyperextension at PIP
- Z shaped deformity to the thumb
- Beutonnieres deformity - hyper-extension at DIP, flexion at PIP
- Ulnar deviation of the fingers at the MCP joints
What is Beutonnieres deformity?
It is a deformed position of the fingers or toes, in which the joint nearest the knuckle (the proximal interphalangeal joint, or PIP) is permanently bent toward the palm while the farthest joint (the distal interphalangeal joint, or DIP) is bent back away (PIP flexion with DIP hyperextension).
When is the prognosis of RA worse?
- Younger onset
- Males
- More joints + organs affected
- Seropositive - Presence of RF and anti-CCP
- Erosion seen on x-ray
