Rheumatoid Disorders Tutorial

Question 1

Case 1 - 45F

12 week history of joint pain - hands and wrists
Prolonged morning stiffness, difficuty taking off her wedding ring
GP prescribed ibuprofen, but symptoms continue to persist

What other questions would you ask in her history?

Answer 1

Any family history of autoimmune disease?

Is it worse on one side than the other?

Any fevers?

Any weight loss?

Any past infections?

Any skin / eye symptoms she has noticed (nodules, eye infection thing etc.)

Any fatigue?

Any PMH of psoriasis?

Question 2

What clinical signs would you look for on examination?

Answer 2

Signs of psoriasis? - psoriasis rash

Any nodules on the skin?

Check temperature?

Swelling / redness/ tenderness at joints?

MSK exam - look (redness / swelling), feel (tenderness), move (restrictions in movement e.g. make a tight fist)

Question 3

What investigations / tests would you order?

Answer 3

Blood tests - inflammatory markers, FBC, rheumatoid factor test

X-ray - may turn up normal due to only 12 weeks of symptoms

USS of hand - detects inflammation more sensitively as X-ray just shows damage due to the inflammation

Question 4

What are the differential diagnoses? Which is most likely?

Answer 4

RA - rheumatoid arthritis = most likely

Other differentials = psoriatic arthritis, OA, reactive arthritis

Question 5

For the most likely differential diagnoses, outline the management plan?

Answer 5

Scans and tests to confirm diagnosis

DMARDs

Physiotherapy - hydrotherapy i.e. swimming so it’s not too weightbearing on the joints

Acute treatment = glucocorticoids e.g. prednisolone

Biologics in the future - if it gets worse

Question 6

Case 2 - 40M
PC = swollen left knee for 5 weeks
Last year his ankle was painful for 4 weeks
HPC = plaque of psoriasis on right knee, otherwise well

What other questions would you ask in his history?

Answer 6

SOCRATES for pain

Any previous infections / travelling? Any diarrhoea and vomitting?

Any STIs? Any pain on passing urine, etc.

Any fever?

Any unintended weight loss?

Any skin / eye changes? (nodules, eye inflammation thing, etc.)

How much is it affecting your daily living?

Question 7

What clinical signs would you look for on examination?

Answer 7

Signs of inflammation - redness, swelling, tenderness, heat

Any other psoriasis plaques?

Test range of motion of joints?

Question 8

What investigations / tests would you order?

Answer 8

Blood tests - RBC, rheumatoid factor, signs of inflammation e.g. raised CRP

Knee aspiration

X-ray

Question 9

What are the differential diagnoses? Which is most likely?

Answer 9

Psoriatic arthritis = most likely

Other differentials = sports injury, reactive arthritis, gout (but this is more acute and starts in the big toe)

Question 10

For the most likely differential diagnoses, outline the management plan?

Answer 10

DMARDS

NSAIDs / omeprazole

Physiotherapy

Inject steroid into knee during aspiration to settle down the inflammation - BUT only if aspirate is clean (i.e. no infection there)