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CPCP > Year 2 - Week 5 - Stiff Hands > Flashcards

Year 2 - Week 5 - Stiff Hands Flashcards

1
Q

Pain and stiff joints in hands, especially in the morning. What are the possible diagnoses?

A

Osteoarthritis
Rheumatoid arthritis
Peripheral spondyloarthropathy
Haemochromatosis

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2
Q

What symptoms can present with RA?

A

Symmetrical inflammation of the small joints of hands and feet
Pain - worse at rest or inactivity
Often morning stiffness - worse for first 30-60mins
Boggy swelling around the joints

Can get nocturnal pain, acute or subacute onset
Systemic features - malaise, fatigue, fever
Can be FHx

Ulnar deviation often associated with later progression of the disease

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3
Q

What symptom is usually associated with psoratic arthritis?

A

Hx of psoriasis

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4
Q

If you suspect a P has RA - what should you do?

A

Persistent synovitis of unknown cause - Refer to rheumatology for evaluation within 3 weeks

Refer urgently (3 days) - if small joints of hand/feet are affected, more than one joint is affected, or the P has waited more than 3 months since the onset of symptoms to seek medical advice.

Also do bloods.

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5
Q

What blood tests should you perform for RA?

A

FBC
Inflammatory markers - CRP & ESR
Rheumatoid factor
Poss anti-CCP
U&E
LFTs

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6
Q

Why is it good to check liver and kidney function in a possible diagnosis of RA?

A

To get baseline values of how they are performing before drugs for RA are started - which can affect the liver and kidney function.

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7
Q

What is the goal of secondary care for RA?

A

Achieve remission or, if not possible, to minimise disease activity

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8
Q

What is first line treatement for RA?

A

DMARDs - disease modifiying anti-rheumatic drugs

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9
Q

Name two conventional DMARD drugs

A

Methotrexate
Sulphasalazine

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10
Q

What treatment is given if Ps do not respond to DMARDs adequately?

A

Biological DMARDs (Biologics)

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11
Q

Once a patient is started on DMARDs and is considered stable - they can be transferred back to GP for routine care - what is this called?

A

Shared Care Agreement

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12
Q

What are the benefits of shared care agreements?

A

Reduce burden on secondary care
Help Ps be more active in their own care

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13
Q

What do shared care agreements outline?

A

What monitoring is required
What to do if abnormal results are received
What side effects to monitor for
When to stop/withhold treatment

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14
Q

What is it called when Ps experience symptoms even though they have been in remission?

A

Flare

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15
Q

What drugs are used to manage flares?

A

NSAIDs
Corticosteriods (oral or intra-articular)

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16
Q

Which vaccinations should RA Ps be offered?

A

Influenze
Pneuomcoccal
High risk - also Hep B

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17
Q

Can Ps with RA have live vaccinations?

A

No (except shingles - this may be ok)

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18
Q

What is the risk of CVD compared to general pop for Ps with RA?

A

1.5x higher

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19
Q

Which scoring system assessed CVD risk?

A

QRISK scoring system

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20
Q

For RA Ps - which RF put them at greater risk of developing CVD?

A

Had RA for 10+ years
Have extra-articular manifestations
Are RF or anti-CCP positive
Used corticosteriods or NSAIDs

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21
Q

What is the link between RA and skin cancer?

A

Ps with Ra - inc risk (x2 of gen pop) of developing SCC and 1.2x risk of BCC

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22
Q

Which skin cancer risk increases if Ps take anti-TNF meds?

A

Greater risk of SCC (not BCC)

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23
Q

What is the link between RA and mental health?

A

Approx 40% of Ps with RA get depression and 20% anxiety

Ps with these symptoms are more likely to have worse disease control

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24
Q

What should be discussed at annual review with RA patients?

A
  • Flares
  • Vaccinations
  • CV Risk
  • Mental Health
  • Skin Cancer review
  • Drug concordance
  • Side Effects
  • Monitoring
  • Risk of osteoporosis
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25
Q

What is spondyloarthritis?

A

Another inflammatory arthritis - less common

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26
Q

What are the symptoms of spondyloarthritis?

A

Axial symptoms - inflammatory back pain
Peripheral symptoms - psoratic arthrtisi, reactive arthritis, enteropathic arthritis

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27
Q

What are the extra-articular manifestations of SA?

A

Uveitis
Psoriasis
Enthesitis
Dactylitis

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28
Q

Which gene is SA linked to?

A

HLA-B27

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29
Q

How many joints does psoratic arthritis affect?

A

Can be one (monoarthritis)
Can be a few (polyarthritis)

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30
Q

How many joints does psoratic arthritis affect?

A

Can be one (monoarthritis)
Can be a few (polyarthritis)

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31
Q

What percentage of Ps with psoratic arthtiris have Hx of skin psoriasis?

A

80%

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32
Q

What percentage of Ps with skin psoriasis will develop psoraiatic arthritis?

A

20-30%

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33
Q

What are psoriatic nail changes?

A

Pitting
Onchyolysis

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34
Q

What percentage of Ps with psoriatic arthritis will have nail changes?

A

90%

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35
Q

What does ethesitis affect?

A

The Achilles tendon & plantar fascia

36
Q

What does ethesitis affect?

A

The Achilles tendon & plantar fascia

37
Q

What can psoriatic arthritis cause in the eye?

A

Conjunctivitis
Uveitis

38
Q

What should all Ps with skin psoriasis have each year?

A

Annual screen for psoriatic arthritis

39
Q

What is used to screen for psoriatic arthritis?

A

PEST Screening Questionnaire (Psoriasis Epidemiology Screening Tool)

40
Q

On the PEST tool - how many questions do you have to answer yes to in order that it is likely you have psoriatic arthritis?

A

3 or more

41
Q

What does reactive arthritis usually present as?

A

Monoarthritis or a knee or ankle, or axial spondyloarthritis

42
Q

What are both psoriatic arthritis and reactive arthritis associated with in terms of fingers or toes?

A

Dactylitis (sausage fingers/toes)

43
Q

When does Reactive Arthritis usually occur?
Which infections usually pre-empt it?

A

1-6 weeks after infection

Usually GI infections (Campylobacter, Salmonella, Shigella) or urogenital (Chlamydia trachmatis, HIV).

44
Q

What are the classical symptoms of reactive arthritis? What are they called?

A

Arthritis
Urethritis
Conjunctivitis
(Cant see, cant pee, cant climb a tree) - called Reiter’s syndrome

However not all Ps have all three.

45
Q

How does enteropathic spondyloarthritis present?

A

Assymetrical oligoarthritis - affecting lower limbs - emerging after onset of IBD

46
Q

Whcih diseases is enteropathic spondyloarthritis more common in?

A

Crohns (more than UC)

47
Q

Which gene is linked to enteropathic spondyloarthritis?

A

HLA-B27

48
Q

What are the symptoms of osteoarthritis?

A

Affects small joints of the hands = pain
Stiffness but normally less pronounced than RA and lasts <1 hour in the morning
Pain / stiffness is exacerbated by activity

49
Q

What is the progression of OA?

A

Normally gradual onset and progressive deterioration - but can get transient inflammatory flares as well.

50
Q

What is the gold standard for diagnosis of osteoarthritis?

A

X-Ray

51
Q

What are the criteria for a diagnosis of OA without X-rays?

A

> 45 years
Activity-related joint pain
No joint stiffness or it lasts <30 mins

52
Q

What are the typical sites affected by OA?

A

Neck
Lower back
Thumb base
Hip
Fingers
Knee
Toe base

53
Q

What is an important differential to consider in place of an OA diagnosis?

A

Inflammatory arthritis

54
Q

What is the main treatment for OA?

A

Exercise and physio

55
Q

There are no disease modifying drug therapies for OA . Which drugs can be used to minimise pain?

A

NSAIDs - oral and topical
Capsaicin (topical)
Paracetamol
Opiods
Prednisolone (oral)

56
Q

Which is more effective in reducing pain in OA - paracetamol or NSAIDs?

A

NSAIDs

57
Q

What drug is the first line treatment for OA?

A

Topical NSAIDs

58
Q

What drug is used when topical NSAIDs are ineffective?

A

Oral NSAIDs

59
Q

What are the potential side effects of oral NSAIDs?

A

GI, renal, liver and CV toxicity
Asthmatic Ps - may reduce FEV
Can inc risk of miscarriage and delay labour

60
Q

What should be prescribed alongside oral NSAIDs?

A

PPI

61
Q

What is capsaicin made from?
How does it work?
What is it used for?
What are its side effects?

A

Chilli peppers
Though to disrupt pain signals reaching the brain
Knee and hand osteoarthritis
SE - can cause skin irritation but no systemic side effects

62
Q

When should opioids be used in OA?

A

Generally not recommended.
NICE - weak opiods should be used for short-term relief when other treatments are ineffective.
Strong opiods should not be used.

63
Q

How long do intra-articular corticosteriod injections last for?
When are they recommended?

A

2-10 weeks of benefit
Recommended when other treatments are infective - to facilitate therapeutic exercise

64
Q

Name two alternative treatments for OA

A

Glucosamine
Chondroitin

65
Q

Do glucosamine and chondroitin work?

A

Little evidence that they are more beneficial than placebo

66
Q

How is arthritis affected during pregnancy?

A

Often symptoms improve during pregnancy, but then many experience a flare after birth

67
Q

Which RA medications are contraindicated during pregnancy?

A

DMARDs = can be tetrogenic - discuss before getting pregnant
Biologics - best to stop during pregnancy

68
Q

Which arthritis can occur in children?

A

Juvenile idiopathic arthritis

69
Q

Is paracetamol recommended for OA?

A

No - little evidence for its efficacy

70
Q

Which joints are predominantly affected by OA?

A

Hips
Knees
Small joints of the hands

71
Q

Which lifestyle factor can increase the chances of developing OA?

A

Obesity

72
Q

What type of gait do Ps with OA of the hip or knee sometimes have?

A

Antalgic gait - try to avoid putting pressure on the sensitive area

73
Q

What nodes of the hands are sometimes seen with OA?

A

Heberden’s nodes - on DIPJ

74
Q

What is the normal range of movement in the hip for the following?
- Flexion
- Abduction
- Adduction
- Internal rotation
- External rotation
- Extension

A

Flexion - 110-120 degrees
Abduction - 30-50 degrees
Adduction - 20-30 degrees
Internal rotation - 30-40 degrees
External rotation - 40-60 degrees
Extension - 10-15 degrees

75
Q

How long should stiffess in OA last?

A

Approx 30mins - much longer then start thinking of differentials

76
Q

Which conservative measures should be told to Ps with OA?

A

Weight loss and exercise

77
Q

Which is the first drug to try for pain relief from OA of the hip?

A

Paracetamol - although efficiacy is doubted

78
Q

What is the first drug to try for pain relief from OA of knee?

A

NSAIDs

79
Q

What are the risks of opioids and codeine?

A

Can make P drowsy and inc chances of a fall

80
Q

If a P is on aspirin and has OA - should you prescribe NSAIDs?

A

No - NSAIDs make aspirin less effective and inc risk of GI bleeding

81
Q

When should GP refer for joint replacement?

A

When P’s pain cannot be controlled, or their ability to function is persistently affected.

82
Q

If a P does not want surgery, what other treatments can be suggsted?

A

Intra-articular injections of corticosteriod

83
Q

What is the correct length of a walking stick?

A

From the flexor crease of the wrist to the ground - P must be in shoes and standing straight.

84
Q

What age is the peak incidence of RA?

A

70

85
Q

What is the ratio of incidence of RA between M and F?

A

F x2 more likely to get RA than M.

86
Q

Answer the following questions for both RA and OA.

Age of Onset?
Joints Affected?
Association with Movement?
Stiffness?

A

Age of Onset -> OA = 50s+, RA = any age but peak 70
Joints Affected -> OA = Knees, hips and hands, RA = small joints of hands, feet, wrists and ankles
Association with movement -> OA = pain worsens with activity, RA = no association with movement
Stiffness -> OA = lasts less than 30 mins, RA = lasts > 30 mins

CPCP (6 decks)

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