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:

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