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Rheumatoid Arthritis Extra-articular Rh Extensor surfaces of the forearms, scalp, sacrum, scapula, Achilles tendon, nodules fingers & toes.Epidemiology May cause trigger finger Usually middle aged, female > males (3:1) Indicates Rh factor + and more aggressive dz Genetics: HLA-DR4 linked Eyes: Episcleritis ScleritisRA Diagnostic Criteria (American Rheumatism Association) Keratoconjunctivitis sicca – look for other signs of Sjögren’s syndrome Dx of RA made when ≥4 criteria are met: (xerostomia, parotid enlargement) Morning stiffness (>1hr) Lungs: Pulmonary fibrosis Arthritis of ≥3 joints ≥6 weeks Pleural effusions Arthritis of hand joints Pleurisy Arthritis is symmetrical Rheumatoid nodules Rheumatoid nodules CVS Peri-/Myo-/Endo-carditis Rheumatoid factor + Pericardial effusion Radiological changes Conduction defects Neuro: Entrapment neuropathies – carpal tunnel syndrome (median n), ulnar n @Typical Presentation elbow, peroneal n. @ knee, post. tibial n. @ ankle Cervical cord compression Chronic inflammatory joint dz, relapsing & remitting course Compression neuropathies Symmetrical deforming peripheral polyarthritis Mononeuritis multiplex Classically swollen, painful and stiff hands & feet, worse in the mornings Peripheral neuropathy Insidious onset, affecting small joints first, progressing to large jt involvement Extra-articular symptoms: Haemato Anaemia – due to chronic dz, folate def, assoc pernicious anaemia, Felty’s o Fever, LOW/LOA, fatigue, myalgia synd. or drugs (NSAIDs, gold) o Others (see extra-articular signs of RA) Felty’s syndrome: RA + splenomegaly + hypersplenism (anaemia, neutropenia Atypical presentations: & thrombocytopenia) + leg ulcers. o Palindromic: relapsing/remitting monoarthritis of large jts Vasculitis Nail-fold infarcts o Persistent Monoarthritis Digital gangrene o Systemic: pericarditis, pleurisy, LOW, constitutional symptoms Leg ulcers/purpura o Acute onset widespread arthritis Skin necrosis Musculo- Ruptured tendons skeletal Muscle weakness & wastingSigns OsteoporosisHand & Joints Tenosynovitis & bursitisHand signs Other joint involvement Others Lymphadenopathy Vasculitis – nail-fold infarct, vasculitic skin lesions Feet Amyloidosis Sausage shaped fingers o Clawing of toes Ulnar deviation of fingers o MTPJ subluxation Swan-neck deformities o Valgus deformity of subtalar Short case Approach to RA Boutonniere deformities jt 1) Comment on hand signs and distribution of arthropathy (ie symmetrical polyarthritis) – Z deformity of the thumbs Large joint involvement highlight sparing of DIPJ and comment if RA is active (presence of jt inflammation) PIPJ & MCPJ swelling (DIPJ usu spared) Atlanto-axial jt subluxation – 2) Test grip & pincer movts Volar subluxation @ MCP jts potential cervical cord 3) Test muscles: Wrist subluxation compression a) abduct thumb (abductor pollicis brevis – median n) Piano-key (prominent radial head) b) abduct fingers (dorsal interossei – ulnar n.) Palmar erythema 4) Test pinprick sensation: st Wasting of 1 dorsal interossei & small muscles a) index finger (median n.) of the hand b) little finger (ulnar n.) Ruptured tendons of the hand 5) Test for carpal tunnel syndrome – Phalen’s test (full flexion for 1 min); Tinel’s sign ↓ ROM (gentle percussion)
6) Rheumatoid nodules – inspect elbows ulcers. (monitor urine for bld & protein & FBC) 7) Functional assessment – writing, buttoning D-penicillamine SE: n/v, rash, proteinuria & nephrotic syndrome, cytopenias (monitor with urinalysis & FBC)Invx May ppt other autoimmune dz (eg SLE, MG)FBC Normocytic normochromic anaemia Corticosteroids For severe dz/exacerbations not responding to other drugs WCC ↓ Use lowest dose possible. Risk of long term SE Pltlets ↑ Rebound dz common on stopping steroids.ESR & CRP ↑ Intra-lesional steroids – useful for treating 1-2 inflamed jts notRh factor + in 80% controlled by systemic Rx, bursitis, tenosynovitis, carpal tunnel also + in Sjögren’s, SLE, mixed CT dz & systemic sclerosis syndrome. Avoid repeated injections esp in large jts.ANA + in 30% Other cytotoxic Azathioprine, cyclophosphamide, cyclosporin AX-ray joints Soft tissue swelling drugs Indication: severe dz with failure of other therapies Juxta-articular osteoporosis Surgery To improve function ↓ jt space Eg synovectomy & decompression of wrist & tendon sheaths, tendon Bony erosion at joint margins repair & transfer, arthrodesis, osteotomy, arthroplasties, jt ± subluxation replacement ± complete carpal destruction Paramedical Regular exercise Jt dislocation services PhysiotherapyX-ray lat C-spine Atlanto-axial subluxation (↑ pre-odontoid gap) Occupational therapy – adaptive aids, orthoses (eg wrist splints), Caution during intubation ADL trainingSynovial analysis Turbid Sjögren’s syndrome Oral hygiene, artificial tears ↓ viscosity Splenectomy for PTs with serious infections Clots Others PT educationDrug safety monitoring FBC Support groups Urinalysis *Drugs causing cytopenias: warn PT to stop med and consult doctor if sore throat devts LFT Creatinine Complications Septic arthritisTreatment AmyloidosisSymptomatic Pain: paracetamol, paracetamol/codeine, NSAIDs (eg aspirin), COX- 2 inhibitors Poor Prognostic Factors NSAIDs (eg diclofenac, indomethacin, ibuprofen) 1) Female ⇒ Beware of GI SE – avoid in PTs with hx of PUD & elderly. Give 2) Old age at onset H2RA or PPI 3) HLA-DR4 ⇒ Other SE – interstitial nephritis, fluid retention, hepatotoxicity 4) Insidious onset Rest joints 5) Systemic features: LOW, extra-articular manifestations of RADMARDs (mono- or combination therapy) 6) Greater number of jts affected 7) Uncontrolled polyarthritisHydroxychloroquine For mild dz 8) Persistent dz activity >12 mths SE: macular pigmentation, retinopathy, rash, nausea, diarrhoea, 9) Rheumatoid nodules hemolytic anaemia, ototoxicity, aggravate psoriasis 10) VasculitisSulphasalazine For moderate dz 11) Rh factor > 1 in 512 SE: SJS, n/v, headache, drug-induced hepatitis & cytopenias 12) Early bone erosions, structural damage/deformity ⇒ Monitor LFT & FBC at 3 & 6 mthsMethotrexate SE: cytopenias, hepatitis (monitor LFT & FBC 6-8 wkly) ⇒ Give with folic acid to reduce GI SE Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY,Lefluonomide SE: as for MTX, + alopecia, diarrhoea, rash o=UCSI University, School of Medicine, KT- Campus, Terengganu, ou=Internal MedicineGold salts Less frequently used now due to better drugs w less SE Group, firstname.lastname@example.org SE: glomerulonephritis, cytopenias, exfoliative dermatitis, mouth Reason: This document is for UCSI year 4 students. Date: 2009.02.24 10:50:03 +0800