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13.03.12 Rheumatology clinic notes

History questions
  • Joint pain
  • Change in hair
  • ELBOWS
  • Rash
  • Raynauds
  • Visual changes
  • Dry mouth or eyes


Seronegative RA

  • RF negative
  • ANA, ESR, CRP may still be abnormal
  • Anti-CCP may be raised
  • Common variant - 30% of patients
  • Need to rely on clinical assessment - Disease activity score


Pregnancy

  • Safe drugs
    • Sulfasalazine
    • Tramadol
    • NSAIDs except in 3rd trimester
  • Sjogren's/SLE
    • Ro antibodies can cross placenta => Heart block
      • => In utero scans + surgery
    • Clotting in placenta => Growth retardation
      • => Anticoagulation


Causes of raised ESR

  • Myeloma
  • Cancer
  • Sjogren's
  • TB
  • Helminths (along with eosinophils)
  • Lupus (do urine dip)



Adult-Onset Still's Disease (AOSD)

  • Adult version of juvenile idiopathic arthritis
  • Systemic inflammatory disease
  • Classic triad:
    • Persistent high spiking fever
    • Joint pain
    • Salmon-colored rash
  • Raised ferritin, but no other abnormalities
  • Prognosis is usually favorable but pulmonary, cardiovascular, and kidney manifestations may occasionally cause severe life-threatening complications
  • Treated first with steroids such as prednisone
  • Diagnosis requires 5 features, with 2 major:
Major criteria Minor criteria
Fever of at least 39C for at least one week Sore throat
Arthralgias or arthritis for at least two weeks Lymphadenopathy
Nonpruritic salmon colored rash (usually over trunk or extremities while febrile) Hepatomegaly or splenomegaly
Leukocytosis ( 10,000/microL or greater), with granulocyte predominance Abnormal liver function tests

Negative tests for antinuclear antibody and rheumatoid factor


McMurray test

  • Rotation test for demonstrating torn cartilage of the knee
    • A tear in the meniscus may cause a pedunculated tag of the meniscus which may become jammed between the joint surfaces
  • Procedure:
    • Knee is held by one hand, which is placed along the joint line
    • Flex to complete flexion while the foot is held by the sole with the other hand
    • Place one hand on the lateral side of the knee to stabilize the joint and provide a valgus stress in order to identify a valgus deformity
    • The other hand rotates the leg externally while extending the knee
    • If pain or a "click" is felt, this constitutes a "positive McMurray test" for a tear in the medial meniscus
    • Likewise the medial knee can be stabilized in a fully flexed position and the leg internally rotated as the leg is extended


Notes

  • Psoriatic arthritis is typically asymetrical
    • Swelling and tenderness of individual joints
    • Frequently presents in a pattern of monoarticular or oligoarticular joint involvement
    • In patients with multiple joints involved, the pattern lacks the symmetry of rheumatoid arthritis
    • Early psoriatic arthritis may involve just a few lower extremity joints, such as the knees
  • PET scan for lymphoma/vasculitis
  • Rheumatoid factor (RF) is found commonly in patients with systemic lupus erythematosus (SLE), and has been associated with a more benign disease course
  • Enthesitis is inflammation of the entheses (sites where tendons or ligaments insert into the bone)
  • 1st generation cephalosporins are great against Gram +ves but rubbish against Gram -ves
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