History and Examination - Inflammatory Joint Diseases

Question 1

What are groups of rheumatic and musculoskeletal disorders?

Answer 1

Inflammatory joint conditions
Crystal Arthritis
CTDs and other rare RMDs
Metabolic bone disease
Non-inflammatory
Soft tissue and MSK

Question 2

What are the functions of normal synovium?

Answer 2

Maintenance of intact tissue surface
Lubrication of cartilage
Control of synovial fluid volume and composition
Nutrition of chondrocytes within joints

Question 3

What are features of a joint which is badly affected by rheumatoid arthritis?

Answer 3

Inflamed synovium spreading across joint surface
Thinning of cartilage
Erosion into corner of bone
Inflamed tendon sheath

Question 4

How is synovitis investigated?

Answer 4

Joint US
Power doppler

Question 5

What features does a joint with OA have?

Answer 5

Mild - inflamed synovium, thickened + stretched capsule, osteophytes and thinning cartilage
Severe - osteophyte, bone angulation, no cartilage and tight + thickened capsule

Question 6

Which joints can help determine diagnosis?

Answer 6

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

Question 7

What can help with history when asking about stiffness?

Answer 7

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…

Question 8

What is the difference between inflammatory and mechanical pain?

Answer 8

Inflammatory - worse on rest and better on movement
Mechanical - worse on movement and better on rest

Question 9

What are some connective tissue disease questions?

Answer 9

Arthralgia instead of arthritis - Raynaud’s phenomenon, photosensitivity, sicca symptoms, mouth ulcers, hair loss and miscarriages
Systemic enquiry is important

Question 10

What rashes should be looked for on examination?

Answer 10

Psoriasis, erythema nodosum, photosensitive and vasculitic

Question 11

What is done during feel and move of examination?

Answer 11

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

Question 12

What is included in joint examination?

Answer 12

Joint swelling, bony/firm (OA), soft tissue/ boggy/ spongy (synovitis), dactylitis sausage finger or toes (think SpA), and pressure on palpation

Question 13

What are other signs and symptoms to look for apart from joints?

Answer 13

Effusions, LNs, amyloidosis, anaemia, thrombocytosis, peripheral neuropathy, scleritis, fibrosis, splenomegaly, muscle wasting and skin thinning

Question 14

What investigations are common?

Answer 14

Connective tissue disease - urinalysis and BP essential
Gout - urate levels
Joint fluid analysis - microbiology and cytology

Question 15

What are some types of spondyloarthritides (SpA)?

Answer 15

Non-radiographic axial, axial, radiographic axial, psoriatic arthritis, reactive arthritis, undifferentiated peripheral and arthritis associated with IBD

Question 16

What are parameters relevant for diagnosis of spondyloarthropathies?

Answer 16

Inflammatory back pain, good response to NSAIDs, SpA FH, preceding infection, acute anterior uveitis, psoriasis, and UC/ Chron’s

Question 17

What are parameters relevant for diagnosis of SpA - labs and imaging?

Answer 17

HLA-B27 and elevated acute phase reactants (CRP/ESR)
Imaging - radiographic sacroiliitis and sacroiliitis on MRI

Question 18

Describe systemic vasculitis

Answer 18

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

Question 19

What are some signs of systemic vasculitis?

Answer 19

Collapse of nose, hearing loss, lung damage, kidney damage, nerve damage, damage to airway, damage to aorta + heart and loss of sight

Question 20

Which joints are most often affected by OA?

Answer 20

Neck, lower back, hips, base of thumb, ends of fingers, knees, and base of big toe

Question 21

What is Heberden’s and Bouchard’s node?

Answer 21

Heberden’s - at distal interphalangeal joint
Bouchard’s - proximal interphalangeal joint

Question 22

Describe fibromyalgia

Answer 22

Centralised pain disorder characterised by severe pain and other somatic symptoms
Widespread pain in multiple regions of body for more than 3 months

Question 23

What are the symptoms of fibromyalgia?

Answer 23

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

Question 24

What are differential diagnosis for fibromyalgia?

Answer 24

Malignancy, rheumatic conditions, endocrine, PMR, drug induced conditions, sleep disorders, neuro disease and depression

Question 25

What are the causes of an actively swollen joint?

Answer 25

Sepsis
Inflammatory - RA, crystal arthropathic condition, seronegative spondyloarthritis and reactive arthritis
Non inflammatory effusion - trauma and degenerative
Hemarthrosis