rheumatoid arthritis Flashcards
in sepsis what factor might prompt you to as for senior urgent review ?
lactate of more than 4mmol/L would make me urgently discuss this case with the on call ITU team and my senior team.
RR>25
Your patient has been started on treatment. What would be essential for you to find out when taking your history?
onset of the symptoms, and symptoms that might point to a source – for example, a cough, diarrhoea or dysuria.
Has the patient had any recent contact history with someone who has been unwell?
Has the patient travelled recently?
Have they previously had any infections or similar admissions?
I would like to know how this is managed and where, as I may need to contact the team after her admission.
Is the patient on any medications, including disease-modifying agents or biologics?
You find out that the patient has been taking methotrexate. What would you include in your differential and what investigations would be important to send or request at your first assessment?
Methotrexate can cause bone marrow suppression
neutropenic sepsis
hepatotoxicity
Methotrexate is excreted renally and therefore an urgent U+Es
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manage this according to local trust antimicrobial guidelines.
, I would like to know if the patient has been taking folic acid regularly. Folic acid is given in combination with methotrexate to reduce the toxic effects of methotrexate.
The patient also has a Stage 1 AKI. The patient has been taking methotrexate for several years and is generally stable.
previously been stable,
possibly secondary to drug interactions and anything that might affect the excretion of methotrexate resulting in elevated drug levels. This is the likely cause of this presentation given the new AKI.
The most common drug interaction which can lead to methotrexate toxicity is with NSAIDs, recent penicillin use or proton pump inhibitor use
parvovirus b 19
bone marrow tutors
What would you do with the methotrexate after admission?
stop the methotrexate during the acute admission
I would liaise with the patient’s Rheumatology team to advise them of the admission and that methotrexate has been stopped. They may want to consider whether restarting the methotrexate is the correct decision or whether another agent would be safer.
You are an IMT 1 in a Rheumatology Clinic. You have been asked to assess Mr Pine, a 72-year-old gentleman who has been referred in by his GP with a history of joint pain in the hands and knees. He has a past medical history of hypertension. He used to work as a plumber but retired 4 years ago.
key question from history
site and onset of the pain
is it getting worst over TIME
chacahrecter of the pain - is it dull or sharp or radiating
any reliving or exacerbating factors (is it worst in the morning , or after exercise
any association with the pain - such as fever vomiting
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is the joint pain symmetrical across both hands and knees
stiffness and pain worst - in the morning
Any history of red, hot joints in combination with the pain
any fever any stiffness
Any recent fatigue/malaise/weight loss
Any fevers or night sweats
rheumatoid - scleritis / uveitis / keratoconjuctivitis sicca
pulmonary fibrosis - sob , pleurisy
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list of current medications and any treatments he may have previously tried for pain. I would like to know his allergy status.
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family history of any joint or musculoskeletal disease
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mpact this is having on Mr Pine. How does it affect his daily living activities?
I would also ask for a detailed alcohol and smoking history.
common joints affected in RA , OA , reactive arthritis , psoriatic arthropthy ?
reactive arthritis - arthritis is typically an asymmetrical oligoarthritis of lower limbs
dactylitis
RA : proximal interphalangeal (PIP) and metacarpophalangeal (MCP)
OA: knees, hips, spine and hands.
psoriatic : symmetric polyarthritis
very similar to rheumatoid arthritis
30-40% of cases, most common type
asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
sacroiliitis
DIP joint disease (10%)
describe any signs you have observed in the attached picture. Please tell us any other signs you would examine for on examination.
is there swelling
any erythema
evidence of tophi
evidence of nail pitting or onycholysis.
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assess if the swelling is hard or boggy,
if there is any heat associated with the joint,
or if there is any tenderness on direct joint palpation
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explore the active movement
getting him to flex and extend at the affected joints.
I would then ask him to complete some functional tasks such as picking up a coin off the table.
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complete a lower limb musculoskeletal exam specifically examining the knees
assessing Mr Pine’s gait.
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check for rheumatoid nodules
psoriatic :
psoriatic skin lesions
periarticular disease - tenosynovitis
nail pitting /onycholysis
reactive :
eye
conjunctivitis (seen in 10-30%)
anterior uveitis
skin
circinate balanitis (painless vesicles on the coronal margin of the prepuce)
keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
osteoarthritis
Heberden’s nodes are a symptom of osteoarthritis (OA) of the hand
investigations for osteoarthritis ?
x ray-
(LOSS)
Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts
investigations for psoriarthritis ?
X-ray
unusual combination of coexistence of erosive changes and new bone formation
periostitis
‘pencil-in-cup’ appearance
Rheumatoid arthritis: diagnosis
RF = rheumatoid factor
ACPA = anti-cyclic citrullinated peptide antibody
CRP ESR
duration more than 6 weeks
What investigations would you consider for this gentleman?
x ray of hands
full blood count, renal function, liver function, CRP, ESR, Rheumatoid factor, anti-CCP, urate and ANA.
The case has been discussed at an MDT and it is felt that there are no identifying inflammatory features on the x ray which are felt to be more consistent with osteoarthritis
how you would share this ?
The mainstay of treatment for osteoarthritis is physical management and pain relief.
we have discussed your images at the Rheumatology MDT and based on that discussion
the pain and swelling in your hands and knees are secondary to what we call osteoarthritis. Have you heard of this before?
Osteoarthritis is a type of degenerative arthritis that is extremely common and is associated with aging.
The good news is this is not an inflammatory type of arthritis, such as rheumatoid arthritis,
Would surgery help me?
Surgery can be a good treatment for osteoarthritis of the large joints, such as the knees. However, physical management undertaken with a physiotherapist would be the first line management. Strengthening muscles helps to support the joints and in many cases can reduce pain. Simple analgesic agents may also be helpful to you and in some cases intra articular injections can help. If the pain is not improving, then I would be happy to refer you to see one of my surgical colleagues.
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do you have any questions
i can provide with a written leaflet should you need to be referral to other information
How would you manage this patient’s pain
first steps in pain management would be reviewing the joint with a physiotherapist or occupational therapist to assess the strength and conditioning of the affected joints
topical NSAIDS
then topical plus oral
and then weak opioids
intra-articular steroid injections may be tried if standard pharmacological treatment is ineffective
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All analgesic options should be used in conjunction with physical therapy and not as an alternative.
