Diagnosis and Investigations Flashcards by Emily Ride

Questions to ask re swollen and painful hands?

When did your symptoms start and have they built up gradually?
Do they vary throughout the day?
When are at they at their worst and how do they respond to activity and time of day?
Do your joints ever feel stiff, for example in the morning?
Any constitutional symptoms i.e. fever, night sweats or weight loss?
Any skin rashes, change in bowel habit or dry or watery eyes?
Do joint problems run in your family?

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Types of Inflammatory Arthritis

CTD
Vasculitis
Seropositive Spondlyoarthritis
Seronegative Spondlyoarthritis

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How does IA present?

Insidiously
<30 mins morning stiffness
Improves with exercise and as the day goes on
If multisystem or constitutional sx, expect CTD
If other symptoms such as bowel habit or eye involvement consider Seronegative

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How does RA present?

As with IA but expect strong family hx

Symmetrical small joint polyarthritis

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What is non inflammatory arthritis?

Osteoarthritis

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How does OA present?

No morning stiffness, or morning stiffness lasting <30 mins
Worse with exercise and better with rest
Ageing pt

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How does Septic Arthritis present?

Asymmetrical monoarthritis
Associated fever and infective sx
Acute hx over hours or days
Pt feels generally unwell

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What are the types of crystal arthritis?

Gout

Pseudogout

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How can you differentiate between gout and pseudogout?

Gout: Negatively bifringent needles
Pseudogout: Positively bifringent rhomboids
Gout more likely in pattern - MTP - Ankle - Knee
Pseudogout more likely in larger joint and in patient with underlying OA

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What are the risk factors for gout?

Male
Age >45
Taking thiazide diuretics
Consume large amount of alcohol
Diet high in purines i.e. meat, oily fish, marmite
High BMI
Family Hx

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How does crystal arthritis present?

Acute onset

acutely painful and unable to weight bear on affected joint

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What is Sjogren’s Syndrome?

Goes often alongside CTD/RA

Dry eyes and mouth

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What is reactive arthritis?

Presents after an infection such as food poisoning or STI
Affects younger patients
Asymmetric oligoarthritis

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What do you do if you suspect someone has RA?

Provide simple analgesia for pain relief

Refer urgently to Rheumatology

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What investigations would you do in someone who has RA?

Baseline FBC, LFT, U&E
ESR/CRP - markers of inflammation
TFT - if abnormal can present with joint pain
Rheumatoid Factor and anti-CCP - suggest RA
ANA - suggest CTD
X-Rays of hands and feet - may see RA changes

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What would you see on an X-Ray of a patient with RA?

Soft tissue swelling
Loss of joint space
Intra-articular erosions
Periarticular osteopenia

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How do you diagnose RA?

Using the American College of Rheumatologist guidelines

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Which areas are looked at in the diagnosis of RA?

Number of joints involved - at least 1 must be a small joint
Serology - RF or anti-CCP
Acute phase reactants - CRP or ESR
Duration of symptoms >6 weeks

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How do we monitor disease activity in RA?

Disease Activity Score - DAS
Calculated after looking at number of tender joints, number of swollen joints, global assessment of disease activity from 0-100, and ESR/CRP measurement.

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When would you use USS in a patient with joint swelling?

If there is clinical suspicion about whether or not swelling is present. USS can identify synovitis and joint effusion as well as bone erosions very sensitively.

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How common are extra-articular manifestations of RA?

40% of patients with RA have extra-articular manifestations i.e. dry mouth, lung problems, heart problems, vasculitis, Felty’s syndrome, eye problems

What is Felty’s Syndrome?

RA
Splenomegaly
Neutropenia

What eye problems do people with RA suffer from?

Scleritis

Episcleritis

Differentials for a single hot, swollen joint?

Gout
Pseudogout
Reactive Arthritis
Septic Arthritis
Psoriatic Arthritis
Haemarthrosis

What investigations would you do in someone presenting with a hot swollen joint?

FBC and CRP - infection U&E - any renal disease LFT - alcohol damage Blood cultures - sepsis Joint aspirate and send for culture, microscopy and gram stain Basic observations - systemically well or unwell X Ray joint - look for classical changes

What are the differences on microscopy between gout and pseudogout?

Gout - negatively biferingent needles of monosodium urate | Pseudogout - positively biferingent rhomboids of calcium pyrophosphate

What are differentials for an acute exacerbation of knee pain?

``` Septic Arthritis Crystal Arthritis Mechanical disruption I.e. ligaments, meniscus, bursa Rapidly progressive OA Osteonecrosis ```

What are the risk factors for OA?

``` BMI - the main modifiable risk factor Age Female Previous joint injury Intense sporting activity Occupation Muscle strength around the joint Genetic Deformities or malalignment ```

What are the causes of secondary OA?

``` Gout Wilson’s Disease Haemochromatosis Haemoglobinopathies Joint injury or surgery SUFE Perthe’s Disease DDH Hypermobility syndromes Diabetes IA or Septic Arthritis ```

Red flags for hip pain in a child?

Constitutional symptoms - ALL Fever, systemically unwell, hot swollen joint - Septic Arthritis Changeable history, unusual history regarding mechanism of injury - Non accidental Injury High fever, non weight bearing - Osteomyelitis

What areas would you want to examine in a child presenting with hip pain?

Perform a hip exam - may be pain on internal rotation Abdomen including testicles and hernial orifices Knee

Differential Diagnoses for hip pain in a child?

``` Transient Synovitis Perthes Disease Osteosarcoma Lymphoma SUFE JIA Non accidental Injury Septic Arthritis Fracture/Trauma DDH Non MSK causes i.e. testicular torsion ```

Red flags for back pain

``` Age <20 or >50 Night or rest pain Trauma or fracture possibility Thoracic pain Bladder/bowel incontinence or retention Fever, night sweats, weight loss, anorexia IVDU Weakness or numbness in the legs History of Ca ```

What are the most common causes of sciatica pain by age?

<50 - disc prolapse | >50 - spinal stenosis

What investigations should you do in someone presenting with multisystem disease?

``` Observations and examinations Urine dipstick - send it for casts if abnormal FBC, U&E, LFT, CRP, TFT RF, anti-CCP, ANA, ANCA X-ray of any areas which appear abnormal ```

What does a positive p-ANCA indicate?

EGPA

What does a positive c-ANCA indicate?

GPA | Microscopic Polyangiitis

What is the diagnostic criteria for EGPA?

Asthma Eosinophilia Multi-system involvement (>2 organs affected)

What would a CXR show in vasculitis?

GPA - cavities in the lung

What is the most common type of glomerulonephritis associated with vasculitis?

Cresenteric Glomerulonephritis - can present with nephrotic or nephritic syndrome clinically

What are the features of nephrotic syndrome?

Proteinuria, hypoalbuminaemia and oedema

What are the features of nephritic syndrome?

Haematuria, proteinuria, hypertension, oedema, oliguria, uraemia

What is the pattern of inflammatory markers seen in SLE?

ESR raised | CRP normal

What is the significance of extra nuclear antibodies in pregnancy?

Some, such as Ro and La are able to cross the placenta and cause neonatal lupus May be associated with antiphospholipid syndrome

Which antibodies are associated with SLE?

dsDNA Sm Ro

What is the diagnostic criteria for Fibromyalgia?

Sx (pain) last >3 months On both sides of the body and above and below the waist Along the axial spine Difficulty sleeping and poor concentration/memory

Differentials for Fibromyalgia?

SLE Lymphoma or infection Hypothyroidism Addison's Disease

What investigations should you do if you are suspecting fibromyalgia?

``` History and exam including trigger points Widespread pain index score TFTs Vitamin D B12 and Iron studies ESR/CRP Magnesium ```

What are the extra-articular manifestations of Ankylosing Spondylitis?

``` Anterior Uveitis Aortic Regurgitation Osteoporosis AV node block Apical pulmonary fibrosis Achilles Tendonitis Amyloidosis ```

What is the management of AS?

Exercise (non weight bearing such as swimming is ideal) NSAIDs Anti-TNFs if 2 NSAIDs have failed In severe cases total hip replacement can be carried out