W3: The Progression and Treatment of Rheumatoid Arthritis Flashcards
What are some key features of inflammatory joint conditions?
Symptoms ease with activity
Early morning stiffness - 1hr minimum
Subacute or acute onset
Systemic upset (lungs, skin, cardiovascular)
Blood tests identifies raised inflammatory markers
What are some key features of non-inflammatory joint conditions?
Symptoms worse with activity
Minor morning stiffness (under 30 minutes)
Usually a gradual onset
No systemic upset
Blood tests are usually normal
What is the pattern of joint involvement in RA?
Mainly affects small and symmetrical synovial joints
Most common: MTPs, MCPs, PIPs.
Then: subtalar, ankle, knee, wrist
Often spares the DIPs (but not always)
How does the joints affected vary by stage of R arthritis?
Early - tends to only affect the small joints
Later - tends to also affect larger joints such as knee and shoulder.
What is the typical new presentation of a patient with rheumatoid arthritis?
Sub acute - 2 to 8 weeks
Pain and stiffness hands, wrist, feet (may also include larger joints)
1 hour morning stiffness
May have joint swelling
Undue fatigue
Difficulty with dexterity such as opening jars or picking up coins
May have more prominent systemic symptoms such as weight loss.
What are some important differentiating features to ask about in a patient that Rheumatoid arthritis is a differential diagnosis?
Skin problem: butterfly rash (SLE), scaly rash (psoriatic arthiritis), rash sign of late stage or extraarticular RA.
Eye problems: grittiness, red eye and blurred vision, acute red eyes - RA inflammation of the sclera
Dry mouth (SLE or RA)
Alopecia (SLE, scorasis, RA))
Raynauds (2ndary cause by RA)
Preceding illness - enviornment factor for RA
Family history - genetic link to conditions
What is the different meaning of monoarthritis, oligoarthritis and polyarthritis?
Mono - one joint (Concern over septic arthritis)
Oligo - two to four joints
Poly - more than four
What is sjorgens syndrome?
Disorder of the immune system - dry eyes, dry mouth, dry skin, tiredness and muscle/joint pain
Often accompanies immune system disorders such as RA and lupus.
What physical signs may be found on a general examination outside the joints in rheuamtoid arthiritis and differential diagnosisi?
Anaemia (paleness)
Lymphadenopathy
Palmar erythema (angiogenesis in hand joints)
Other similar conditoins:
Rashes (butterfly in lupus)
Nail dystrophy ( positive RA tar stain)
Tophi - indicates gout
What features can be found on examination of the joints in rheuamtoid arthiritis?
Articular tenderness
Positive metacarpal squeeze (also feel warm and liquid like)
Soft tissue swelling/effusions (large and squishy)
Functional impairement - grip strength, fist formation, reduce joint mobility.
What is fusiform swelling?
Seen in rheumatoid arthritis
Pink sausage-like swelling of the proximal phalanges of the fingers.
What is the feature of rhematoid arthiritis on the skin?
Rheumatoid nodules
Firm lumps under the skin
Consists of necrotising granulomatous inflammation - formed by immune complexes that have migrated out of the joint
What blood tests should be orders on a patient with potential early rheuamtoid arthiritis?
What tests rule out other conditions?
Full blood count - complication of anaemia
ESR and CRP - inflammatory
Urea and electrolytes - chronic systemic affects of RA can damage kidney function
Liver function test - complication of NSAID and methotrexate treatment
Serum urate - may link to gout
THyroid function and glucose - fatigue, likley to develop hypothyroidism.
Autoantibodies - anti-nuclear, anti-CPP and rheumatoid factor.
How do you calculate sensitivity of a test?
true positives + false negatives
How do you calculate the specificity of a disease?
true negative + false positive
What other health conditions are rheumatoid factor also found in?
4% healthy population
Autoimmune: SLE, Sjorgen syndrome
Chronic infections: TB, syphilis, infective endocarditis
Viral infections: EBV
B cell lymphoproliferative disease
What is the role of anti nuclear antibodies in rheumatoid arhtiris diagnosis?
ANA
Stronger association with SLE and other connective tissue diseases but can be positive in RA.
Hepatic, pulomnary disease, infections and malignancy
Low positive in healhty people.
What is the purpose of a chest x-ray in rheumatoid arthiritis?
Look for RA lung involvement - pleural effusions, lung nodules or fibrosis
Rule out other conditions which may present with joint problems - sarcoidosis, and lung cancer.
What is the purpose of a hands and feet x-ray in rheumatoid arthiritis?
Early changes: soft tissue swelling, juxta-articular osteopenia
Erosions - classical RA feature
Loss of joint space.
What is the purpose of ultrasound imaging in patients with rheumatoid arthritis?
Detect joint erosions
Doppler scan - indicates increased angiogenesis
Detect synovitis and tenosynovitis (fluid and thickening)
What are some of the results of uncontrolled Rheumatoid arthiritis?
Increasing joint damage and deformity
Increasing disability (normally unable to work after 5yrs)
Increased mortality (normally cardiovascular or pulmonary related)
What is the cause of ulnar deviation in rheumatoid arthritis?
What other gross changes does this method cause?
The joint capsule is subject to changes - inflammation and stretching from effusion - lead to weakness
This allows laxity within the joint capsule
Bones can move out of the original articular position - creating bony deformations.
This often presents as ulnar deviation or protruding metatarsal heads.
What are some common extra-articular manifestations of rheumatoid arthritis?
Eyes - dry eyes, episcleritis, scleritis, scleromalacia
Skin - ulcers
Nervous system - carpal tunnel syndrome, peripheral neuropathy, cervical myelopathy
Blood vessels - Vasculitis and premature atherosclerosis
Lungs - pulonary fibrosis, nodules and pleural effusions
Heart - pericarditis, pericardial effusions
Blood - anaemia of chronic disease, thrombocytopenia
What are the key principles of RA treatment?
Control symptoms
Minimise Impact
Minimise joint damage
Maximise function
