History and Examination - Inflammatory Joint Diseases Flashcards
What are groups of rheumatic and musculoskeletal disorders?
Inflammatory joint conditions
Crystal Arthritis
CTDs and other rare RMDs
Metabolic bone disease
Non-inflammatory
Soft tissue and MSK
What are the functions of normal synovium?
Maintenance of intact tissue surface
Lubrication of cartilage
Control of synovial fluid volume and composition
Nutrition of chondrocytes within joints
What are features of a joint which is badly affected by rheumatoid arthritis?
Inflamed synovium spreading across joint surface
Thinning of cartilage
Erosion into corner of bone
Inflamed tendon sheath
How is synovitis investigated?
Joint US
Power doppler
What features does a joint with OA have?
Mild - inflamed synovium, thickened + stretched capsule, osteophytes and thinning cartilage
Severe - osteophyte, bone angulation, no cartilage and tight + thickened capsule
Which joints can help determine diagnosis?
1st CMC, DIP or PIP - OA
MCP/ PIP - RA
Wrist or knee/ elderly - pseudogout/ RA
Monoarthritic/ young - SpA/ reactive
1st MTP/ ankle/ knee/ elbow - gout
What can help with history when asking about stiffness?
Stiffness without joint swelling is unlikely inflammatory
Feature of OA and age related mechanical back pain - length of stiffness generally higher in IA
Constitutional symptoms commoner in IA - malaise, fatigue, weight loss…
What is the difference between inflammatory and mechanical pain?
Inflammatory - worse on rest and better on movement
Mechanical - worse on movement and better on rest
What are some connective tissue disease questions?
Arthralgia instead of arthritis - Raynaud’s phenomenon, photosensitivity, sicca symptoms, mouth ulcers, hair loss and miscarriages
Systemic enquiry is important
What rashes should be looked for on examination?
Psoriasis, erythema nodosum, photosensitive and vasculitic
What is done during feel and move of examination?
GALS screen
Plus extra for hands and feet - PIP tuck, thumb to little finger, wrist and fore/mid/hindfoot
Enthesitic points - epicondylitis/ Achilles/ heel
Joint hypermobility often missed
What is included in joint examination?
Joint swelling, bony/firm (OA), soft tissue/ boggy/ spongy (synovitis), dactylitis sausage finger or toes (think SpA), and pressure on palpation
What are other signs and symptoms to look for apart from joints?
Effusions, LNs, amyloidosis, anaemia, thrombocytosis, peripheral neuropathy, scleritis, fibrosis, splenomegaly, muscle wasting and skin thinning
What investigations are common?
Connective tissue disease - urinalysis and BP essential
Gout - urate levels
Joint fluid analysis - microbiology and cytology
What are some types of spondyloarthritides (SpA)?
Non-radiographic axial, axial, radiographic axial, psoriatic arthritis, reactive arthritis, undifferentiated peripheral and arthritis associated with IBD
What are parameters relevant for diagnosis of spondyloarthropathies?
Inflammatory back pain, good response to NSAIDs, SpA FH, preceding infection, acute anterior uveitis, psoriasis, and UC/ Chron’s
What are parameters relevant for diagnosis of SpA - labs and imaging?
HLA-B27 and elevated acute phase reactants (CRP/ESR)
Imaging - radiographic sacroiliitis and sacroiliitis on MRI
Describe systemic vasculitis
Group of rare autoimmune conditions that cause inflammation of blood vessels
Involves many different organs
Serious adverse outcomes
Early diagnosis and appropriate + effective treatment is important
What are some signs of systemic vasculitis?
Collapse of nose, hearing loss, lung damage, kidney damage, nerve damage, damage to airway, damage to aorta + heart and loss of sight
Which joints are most often affected by OA?
Neck, lower back, hips, base of thumb, ends of fingers, knees, and base of big toe
What is Heberden’s and Bouchard’s node?
Heberden’s - at distal interphalangeal joint
Bouchard’s - proximal interphalangeal joint
Describe fibromyalgia
Centralised pain disorder characterised by severe pain and other somatic symptoms
Widespread pain in multiple regions of body for more than 3 months
What are the symptoms of fibromyalgia?
Intrusive fatigue - physical, cognitive and emotional
Increased sensitivity to sound, light, fluctuations in ambient temp. and widespread pain
Fluctuates in type and severity over time
What are differential diagnosis for fibromyalgia?
Malignancy, rheumatic conditions, endocrine, PMR, drug induced conditions, sleep disorders, neuro disease and depression
