Stiff Hands

Question 1

What are the 3 common diseases that can cause stiffness of the hands listed in the book chapter?

Answer 1

1 - polymyalgia rheumatica
2 - osteoarthritis
3 - rheumatoid arthritis

Question 2

What is polymyalgia rheumatica?

Answer 2

• autoimmune disease
• pain in lots of muscles
• stiffness in joints

Question 3

In a patient with osteoarthritis, how long do they generally have stiffness for in the morning?

1 - <30 minutes
2 - <60 minutes
3 - <90 minutes
4 - <2 hours

Answer 3

1 - <30 minutes

- longer than this and other causes should be investigated

Question 4

In primary care GP can look for signs of osteoarthritis that can supplement the medical history. The image below shows one common finding in patients with osteoarthritis. What are the things on the fingers of the patient called?

1 - heberden’s and swan neck deformity
2 - heberden’s and bouchards nodes
3 - boutonniere deformity and bouchards nodes
4 - bouchards nodes and swan neck deformity

Answer 4

2 - heberden’s nodes and bouchards nodes

• heberden’s nodes common on distal interphalangeal joint
• bouchards nodes common on proximal interphalangeal joint

Question 5

Although RA can occur at any age, what age does RA incidence peak at?

1 - 20-30 years
2 - >45 years
3 - 50-70 years
4 - >70 years

Answer 5

4 - >70 years

Question 6

Is RA more common in men or women?

Answer 6

• women

- twice as common

Question 7

What joints are commonly affected in RA?

1 - hips, knees and hands
2 - hips, feet and hands
3 - hands, feet, wrists and ankles
4 - knees, ankles and feet

Answer 7

3 - hands, feet, wrists and ankles

- proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the hands

Question 8

In patients with RA, do the affected joints become swollen and warm?

Answer 8

• yes

- in osteoarthritis they do not

Question 9

What causes RA?

Answer 9

• genetic and environmental risk factor combined triggering an autoimmune response
• HLA-DR1 and HLA-DR4 are commonly found genetically in patients with RA

Question 10

What 2 markers of inflammation are often performed by the GP in a patient with suspected RA?

1 - C-reactive protein and creatine kinase
2 - C-reactive protein and IL-6
3 - erythrocyte sedimentation rate and creatine kinase
4 - erythrocyte sedimentation rate and C-reactive protein

Answer 10

4 - erythrocyte sedimentation rate and C-reactive protein

Question 10

What 2 markers of inflammation are often performed by the GP in a patient with suspected RA?

1 - C-reactive protein and creatine kinase
2 - C-reactive protein and IL-6
3 - erythrocyte sedimentation rate and creatine kinase
4 - erythrocyte sedimentation rate and C-reactive protein

Answer 10

4 - erythrocyte sedimentation rate and C-reactive protein

Question 11

What 2 markers are currently the most accurate way of diagnosing RA?

1 - rheumatoid factor and creatine kinase
2 - C-reactive protein and rheumatoid factor
3 - anti cyclic citrullinated peptide rate and creatine kinase
4 - anti cyclic citrullinated peptide and rheumatoid factor

Answer 11

4 - anti cyclic citrullinated peptide and rheumatoid factor

- anti cyclic citrullinated peptide is most sensitive

Question 12

As blood tests are not great at diagnosing RA the GP needs to use other criteria. What are the 3 criteria used by a GP to determine if a patient should be referred to see a rheumatologist?

Answer 12

1 - synovitis in a small joint of the hands of feet
2 - more than 1 joint affected
3 - patient experiencing symptoms for >3 months

Question 13

What is generally the first line treatment of a patient with a confirmed diagnosis of RA?

Answer 13

• disease-modifying anti-rheumatic drugs

- specifically methotrexate

Question 14

How often should patients with RA be reviewed?

1 - weekly
2 - monthly
3 - annually
4 - bi-annually

Answer 14

3 - annually

Question 15

What is the most commonly used method for assessing disease progression and response to medications?

1 - Mini state questionnaire
2 - COG questionnaire
3 - Disease Activity Score 28
4 - Whooley questions

Answer 15

3 - Disease Activity Score 28

Question 16

Due to the long term effect inflammation and prednisolone on bone density, what should be assessed for in patients with RA?

Answer 16

• osteoporosis and risk of fragility fracture

- can request a DEXA scan

Question 17

Disease-modifying anti-rheumatic drugs, specifically methotrexate is the first line for treating RA. Although effective at alleviating symptoms, these drugs can have some serious side effects. Once of these side effects is neutropenia. What is neutropenia?

Answer 17

• low number of neutrophils, part of the WBC count

- causes a reduced immune response

Question 18

In addition to neutropenia, what else must be screened at fortnightly blood tests until stable in RA patients who are taking disease-modifying anti-rheumatic drugs?

Answer 18

• hepatitis

- renal disease

Question 19

Once a patient with RA who is taking disease-modifying anti-rheumatic drugs is stable, who’s responsibility is it to monitor the patient?

Answer 19

• GP

Question 20

In addition to Disease-modifying anti-rheumatic drugs, what other medication can be prescribed that can help slow disease progression and alleviate patients symptoms in RA?

Answer 20

• steroids, specifically prednisolone

- NSAIDs