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Phase 2 Erin Whyte Jamie McConnell

Phase 2 Erin Whyte Jamie McConnell. Rheumatology. The Peer Teaching Society is not liable for false or misleading information…. aims. The Peer Teaching Society is not liable for false or misleading information…. Rheumatological History. Patient Demographics Sex, Age Ethnicity

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Phase 2 Erin Whyte Jamie McConnell

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  1. Phase 2 Erin Whyte Jamie McConnell Rheumatology The Peer Teaching Society is not liable for false or misleading information…

  2. aims The Peer Teaching Society is not liable for false or misleading information…

  3. Rheumatological History Patient Demographics Sex, Age Ethnicity Handedness Occupation Associated Symptoms Rashes, photosensitivity, psoriasis, changes in skin pigmentation, Raynaud’s phenomenon, alopecia, dry or red eyes, dry mouth, ulcers (oral, nasal, genitals), dysphagia, dyspnoea, loss of sensation/pins and needles, myalgia, muscle weakness, headaches/migraines, cognitive disturbance, depression, seizures, fever, weight loss, change in bowel habit Joints General - how many, which (large/small/both/weight-bearing), symmetry Pain - SOCRATES, night pain? pain now? rest/movement? analgesia tried? Stiffness - when, where, how long does it last? Swelling - when, where, how long does it last? relation to activity? Deformity - where, for how long, speed of progression? The Peer Teaching Society is not liable for false or misleading information…

  4. Rheumatological History Additional Points Flares - frequency, severity (hospitalisation?), what exactly happened and which body part was affected? Functional disability - ADLs eg cooking (opening jars?), dressing (buttons?), overhead activities, walking distances, stairs Previous treatments - what? duration? effectiveness? PMH Any condition relating to the presenting complaint Psoriasis, IBD, IBS, hypertension, gout, recurrent infections, trauma, miscarriage, PE, DVT, blood transfusions, tattoos, STIs, travel history, cardiorespiratory conditions, GI conditions, GU conditions, medication history (including OTC, illicit drugs), allergies Family and Social History Arthritis (type, age of onset), IBD, psoriasis, gout, Marfan syndrome, Ehlers-Danlos syndrome, ankylosing spondylitis Home circumstances, type of property, adaptations, co-inhabitants and relationship Smoking, alcohol (past and present), recent stressful events, ability to relax/sleep, sexual history The Peer Teaching Society is not liable for false or misleading information…

  5. Rheumatological History - inflammatory or not? • Inflammatory symptoms are - • Stiffness Worse in the early morning or after a period of inactivity - progressively easing as the day goes on • Pain present at rest as well as on movement • Examination - • Overlying skin warm and red • Tenderness across the joint line • Swelling • Pain The Peer Teaching Society is not liable for false or misleading information…

  6. Osteoarthritis • 1/4 >65 have symptomatic hip or knee OA, 70% >70 = radiological change • Risk factors - increasing age, female sex (knee), joint injury, obesity, strenuous occupation • Joint pain usually related to use - also stiffness, reduced RoM, deformity and instability • Heberden and Bouchard nodes • Most commonly affected joints = hips, knee, spine, 1st MCPJ, DIP, PIP The Peer Teaching Society is not liable for false or misleading information…

  7. The Peer Teaching Society is not liable for false or misleading information…

  8. Osteoarthritis - x-ray • Osteophyte • Joint space narrowing • Subchondral Sclerosis • Subchondral Cysts The Peer Teaching Society is not liable for false or misleading information…

  9. Osteoarthritis - management Text • Patient education and lifestyle measures - weight loss etc • PT, OT • Supportive aids e.g. supports and braces • Paracetamol and topical NSAIDs first line • NSAIDs second line (+PPI) • Opioids • Intra-articular steroids • Surgery - arthroscopy The Peer Teaching Society is not liable for false or misleading information…

  10. Crystal Arthropathy - Gout Text • Male 40-50 years, dietary purine intake, alcohol, diuretics • Classically mono-arthritis (50% 1st MTPJ) • Severe pain, swelling, tenderness (duvet on foot) • Chronic gout - tophi • Uric acid - negatively birefringent needle shaped crystals on aspirate • Acute attack - NSAIDs, colchicine, intra-articular steroids • Prophylaxis - Allopurinal (not during acute attack - prolongs symptoms) The Peer Teaching Society is not liable for false or misleading information…

  11. Pseudogout Text • Calcium pyrophosphate arthropathy • Increasing age, hyperparathydroidism, diabetes, Wilson’s disease, hypothyroidism • Larger joints - acute, hot, swollen, effusion • Positively birefringent rhomboid shaped crystals on aspiration • NSAIDs, IA steroids The Peer Teaching Society is not liable for false or misleading information…

  12. Crystal Arthropathy Text The Peer Teaching Society is not liable for false or misleading information…

  13. Rheumatoid Arthritis: Pathophysiology Rheumatoid arthritis is a chronic, systemic, inflammatory disease of unknown aetiology that primarily affects the peripheral joints in a symmetrical pattern The Peer Teaching Society is not liable for false or misleading information…

  14. Worldwide prevalence = 1% Peak age of incidence = early 40s Women>Men (though sex ratio varies with age) Genetic factors - familial aggregation and HLA DR4 association Initially small joints affected asymmetrically, eventually symmetrically followed by involvement of larger joints Joint swelling, tenderness, pain and stiffness - particularly in the morning, improving as the day goes on Rheumatoid Arthritis: Joint involvement TMJ 25% C Spine 35% Carpus 80% Glenohumeral 60% MCPs 85% Elbow 70% Hip 25% PIPs 65% Knee 80% Ankle 40% MTPs 80% The Peer Teaching Society is not liable for false or misleading information…

  15. Splinter haemorrhage Rheumatoid Arthritis: Extra-articular manifestations Systemic - fever, anorexia, malaise, weight loss, lethargy Alveolitis → Fibrosis Nodules Pleuritis Pericardial Effusion Episcleritis Scleritis Kerato-conjunctivitis sicca Pericarditis Nodule in conductive tissue → AV block Nodule on valve → murmur Elbow nodules Splenomegaly (1% Felty’s syndrome = splenomegaly + neutropenia + lymphadenopathy) Carpal Tunnel Syndrome Renal disease (secondary to drugs and amyloid) Ischaemic ulceration (vasculitis) Distal symmetrical sensorimotor neuropathy Nodules on achilles tendon

  16. Rheumatoid Arthritis: Hands The Peer Teaching Society is not liable for false or misleading information…

  17. Rheumatoid Arthritis: Diagnosis • Bloods - • ESR • CRP • FBC • Immunology - • RhF - >70%, denotes worse prognosis • anti-CCP (more specific than RhF) • Imaging - • X-rays - SPADES • S - soft tissue swelling • P - periarticular osteoporosis • A - absent osteophytes • D - deformity • E - erosions - usually within 2 years • S - subluxation • (often only tissue swelling at • presentation) • US - early inflammation The Peer Teaching Society is not liable for false or misleading information…

  18. Rheumatoid Arthritis: Management Symptomatic Relief - simple analgesics or NSAIDs (consider PPI) Modification of underlying disease - DMARDs - methotrexate, sulfasalazine, azathrioprine, gold, ciclosporin, antimalarials Adjunctive therapy with corticosteroids - systemic, into affected joints) Biological agents - persistently active disease despite treatment with at least 2 DMARDs (including methotrexate) NICE 2009 - DMARDs asap post-diagnosis (avoid further damage), combination therapy including methotrexate + short term steroids (takes up to 3 months for benefits of DMARDs) The Peer Teaching Society is not liable for false or misleading information…

  19. HLA B27 Seronegative spondyloarthropathies Ankylosing Spondylitis Psoriatic Arthritis Reactive Arthritis Enteropathic Arthritis The Peer Teaching Society is not liable for false or misleading information…

  20. Ankylosing Spondylitis Inflammatory back pain - Young age Significant early morning stiffness (>20 minutes) Improvement on exercise Localised tenderness over sacroiliac joints - alternating buttock pain Pain at night Responds to anti-inflammatory medication • Onset = late teens/early adulthood (<40) • Men>Women (2.5:1) • Insidious onset of inflammatory type back pain in lower back/buttocks and/or thoracic region • Extrasketletal manifestations include aortic regurgitation, upper lobe fibrosis and irits/uveitis The Peer Teaching Society is not liable for false or misleading information…

  21. Ankylosing Spondylitis X-ray findings Fusion of vertebral bodies (‘Ankylosing’) - late stage Juxta-articular sclerosis, erosions, widening of sacroiliac joints Syndesmophyte formation, ‘bamboo spine’ The Peer Teaching Society is not liable for false or misleading information…

  22. Ankylosing Spondylitis - management • Physiotherapy • NSAIDs • Methotrexate or sulfasalazine - for peripheral joint arthritis (not axial disease) • Anti-TNFα/biologics - severe/persistent • Topical Corticosteroids (uveitis) • Intra-articular steroids The Peer Teaching Society is not liable for false or misleading information…

  23. Psoriatic Arthritis • Chronic seronegative inflammatory arthritis associated with psoriasis • 10% patients with psoriasis (1.5% UK population) - may develop arthritis prior to psoriasis • Peak age of onset 35-55 years, women>men, western caucasian population • Different patterns of disease - symmetrical polyarthritis (DIP common), asymmetric oligoarthritis, spondylitic pattern, arthritis mutilans, juvenile onset • Additional features - nail changes, ocular invovlement • Differs from RA - RF -ve, anti-CCP -ve, no nodules, less deformity etc The Peer Teaching Society is not liable for false or misleading information…

  24. Psoriasis Red, silver-scaled lesions - predominately extensor surfaces and scalp Nails - pitting, yellowing, onycholysis, leukonychia, transverse ridging The Peer Teaching Society is not liable for false or misleading information…

  25. Reactive Arthritis The Peer Teaching Society is not liable for false or misleading information…

  26. Reactive Arthritis • Sterile arthritis occurring following infection at a distal site • Reiter’s Syndrome (archaic term!) - arthritis, urethritis, conjunctivitis (Can’t see, can’t pee, can’t bend the knee) • Tends to occur 2-4 weeks post-infection, can last several months • Systemic features (including malaise, fatigue, fever) • Ix - Elevated inflammatory markers, RF and ANA -ve, white cells and bacterial antigens on joint aspiration • Mx - Initially rest the joints, then physiotherapy. NSAIDs, steroids (Intra-articular), if causative organism found ?antibiotics, DMARDs if chronic/recurrent The Peer Teaching Society is not liable for false or misleading information…

  27. Enteropathic Arthritis Arthritis associated with IBD The Peer Teaching Society is not liable for false or misleading information…

  28. Systemic Lupus Erythematous SLE is a chronic, autoimmune, inflammatory, multisystem, connective tissue disorder that can affect almost any system in the body The Peer Teaching Society is not liable for false or misleading information…

  29. SLE - epidemiology Aetiology unknown - multiple genetic and environmental factors Classically women, age 20-40 More common in Afro-Caribbean, Asian and Hispanic communities May be drug induced (men>women - tetracyclines, methyldopa etc) The Peer Teaching Society is not liable for false or misleading information…

  30. Malar rash • Photosensitive rash • Discoid rash • Neurological involvement (headaches, especially migraines, psychosis, seizures, depression) • Renal disease (proteinuria, casts) • Serositis (pleuritis, pericarditis) • Mucosal aphthous ulceration • Arthritis • Haematological abnormalities • Immunological abnormalities • ANA positive 4/11 criteria present at any time is required for diagnosis of SLE SLE - diagnostic criteria The Peer Teaching Society is not liable for false or misleading information…

  31. SLE - presentation Malar Rash Discoid Rash The Peer Teaching Society is not liable for false or misleading information…

  32. SLE - investigations • FBC, ESR, CRP • ANA (high sensitivity), anti-dsDNA (high specificity) • 25% RF +VE • Low complement (C3, C4) • Screen for renal disease • Antiphospholipid antibodies if APTT prolonged • CT/MRI - renal/neuro involvement The Peer Teaching Society is not liable for false or misleading information…

  33. SLE - management • Patient education - avoiding sunlight, smoking cessation, planning pregnancies etc • CV risk reduction • NSAIDs for symptomatic relief • Steroids and antimalarials • Major organ involvement - immunosuppressive agents (e.g. azathioprine, methotrexate - NOT sulfasalazine (linked to drug-induced)) • Rituximab in severe disease (not licensed) • Plasma exchange - aggressive/life threatening SLE The Peer Teaching Society is not liable for false or misleading information…

  34. Associated with - +ANA, +ACA, PBC Immunosuppressives Symptomatic relief CREST Syndrome Limited cutaneous form of systemic sclerosis Calcinosis Raynaud’s Phenomenon Oesophageal Dysmotility Sclerodactyly Telangiectasia The Peer Teaching Society is not liable for false or misleading information…

  35. Antiphospholipid Syndrome (APS) • CLOT • Clot - arterial/venous thrombosis e.g. stroke, TIA, PE, DVT • Livedo reticularis - cutaneous cyanotic vascularity • Obstetric loss • Thrombocytopenia + prolonged APTT • May be primary or secondary (most commonly to SLE) • Female > Male The Peer Teaching Society is not liable for false or misleading information…

  36. Sjögren’s Syndrome • Chronic autoimmune disease - lymphocytic infiltration of the exocrine glands - • Dry eyes (xeropthalmia) • Dry mouth (xerostomia) • Parotid swelling • Primary or associated with other conditions (RA, SLE, scleroderma) • Ix - include autoantibodies (Anti-Ro, Anti-La, ANA etc) and Schirmer test • Mx - Symptomatic (artificial tears, pliocarpine (artificial saliva)), role for hydroxychloroquine The Peer Teaching Society is not liable for false or misleading information…

  37. Polymyositis and Dermatomyosits • Inflammatory myopathies of unknown aetiology • PM 40-60 years old, DM childhood • Inflammation of muscles (and skin in DM) and vessels that supply them • Subacute onset of proximal arm and leg weakness (rash in DM, face and trunk) • Ix - markers of muscle damage - CK, EMG, biopsy • Steroids - if non-responsive methotrexate, azathioprine, IV Ig (esp DM) The Peer Teaching Society is not liable for false or misleading information…

  38. Fibromyalgia Unknown aetiology Female > Male Chronic widespread pain Fatigue Sleep disturbance Problems with concentration/memory Associated - depression, anxiety, functional bowel disorder Risks - stress Management - CBT, analgesics (pregabalin), antidepressants The Peer Teaching Society is not liable for false or misleading information…

  39. Steroids All steroid effects are due to altered gene transcription Once bound - Blocks transcription of pro- inflammatory markers e.g. PLA2 Promotes transcription of anti- inflammatories Diffuses into nucleus and binds to DNA Cell Nucleus GCR GCR/S complex = transcription factor GCR = glucocorticoid receptor Diffuses into cell as lipid soluble Steroid 39

  40. + other mechanisms - promoted transcription of anti-inflammatory proteins Steroids (cont) PLA2 Formation inhibited by steroids Arachidonic Acid Lipoxygenase COX NSAIDs Prostaglandins Thromboxanes Leukotrienes Clotting Pro-inflammatory Inflammatory mediators The Peer Teaching Society is not liable for false or misleading information…

  41. MSK OSCE Tips... • Ask about pain (all examinations) • Remember the basics - introduce yourself etc • Try to practice on real patients, especially hands • Think what could be combined e.g. c. spine and shoulder (ankle and knee??) • If in doubt, look, feel, move • Know features of inflammatory vs mechanical pain and basic management - may have to explain treatment/disease process • Don’t panic! The Peer Teaching Society is not liable for false or misleading information…

  42. What we haven’t covered... • Osteoporosis • Vasculitis • Osteomalacia • Vertebral Disc Degeneration • Primary/Secondary Bone Tumours, Myeloma • Mechanical Back Pain • Infection - Septic Arthritis, Osteomyelitis The Peer Teaching Society is not liable for false or misleading information…

  43. mda10jrm@sheffield.ac.uk mda10elw@sheffield.ac.uk The Peer Teaching Society is not liable for false or misleading information…

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