13.04.08 Rheumatology diagnoses

Mechanical injury

    • Characteristics

      • Clear precipitating injury

      • Worse on movement/better with rest

    • Management

      • Short-term

        • NSAIDs

          • Strong e.g. Indomethacin

        • Compound analgesics

        • Neuropathic painkillers (gabapentin etc)

      • Long-term

        • Core strength/stability: Esp. paraspinals, abdominals, gluteals

Ankylosing spondylitis

    • Presentation

      • Slow onset

      • Worse in the morning

      • Better when moving

    • Investigations

      • Bloods

        • ESR, CRP, Plasma viscosity

        • Anaemia of chronic disease

        • Thrombocytosis

        • Raised alk phos

        • Raised ferritin

        • Low albumin

      • MRI

        • Bone marrow oedema on T2: Lumbar spine/sacroiliac joints

    • Management

      • Strong anti-inflammatories

      • Anti-TNF drugs

      • Low impact, non-weight bearing activities

        • Swim, cycle, cross-train

Gout

    • Risk factors

      • CKD, thiazides, HTN

    • 2 stages

      • Acute attacks

      • Chronic arthritis (stiff hands)

    • Management

      • Titrate uric acid to 300 uM with allopurinol

        • Tophi should dissolve

      • Uricase analogues (pegloticas, rasburicase)

de Quervain's tenosynovitis

    • Presentation

      • New mother - frequent lifting

      • Pain, tenderness, and swelling over the thumb side of the wrist

      • Difficulty gripping

    • Aetiology

      • Tenosynovitis of extensor pollicis brevis and abductor pollicis longus tendons

    • Finkelstein's test

      • Grasp the thumb and sharply ulnar deviate the hand

      • If sharp pain occurs along the distal radius, DeQuervain's tenosynovitis is likely

    • Management

      • Hydrocortisone injection

      • Topical or oral anti-inflammatory (But poor tendon penetration)

      • Splint

Tennis elbow

    • Diagnosis

      • Clinical +/- USS

      • Enthicitis

    • Management

      • Steroid injection (max. once every 3 months)

      • Oral/topical analgesia

      • Behaviour/technique modification

Proximal myopathy

    • Aetiology

      • Endocrine

        • Hypo/hyper -thyroid

        • Cushing's

        • Addison's

      • Inflammatory

        • PMR

      • Genetic

        • Muscular dystrophy (may not present until adulthood)

      • Metabolic

        • Low vitamin D

        • Alcohol

Pathological fracture

    • Primaries

      • Breast

      • Bung

      • Byroid

      • Brostate

      • Bidney

      • + Steroids (Osteoporosis)

    • Investigations

      • MRI of vertebral body

        • Tumour will be obvious, Osteoporosis looks normal

Rheumatoid arthritis

    • Presentation

      • Slow onset

      • Worse in the morning

      • Symmetrical

      • Small joints

    • Differentials

      • Psoriatic arthritis

        • NB has many different mimicking patterns: Ank Spond, OA..

      • Lupus

    • Sjögrens

    • Investigations

      • Standard chronic inflammatory screen

      • RF

      • Anti-CCP

        • Can precede symptoms by many years

        • Very specific

Temporal arteritis

    • Presentation

      • Subacute/acute onset

      • >55 years old

    • Signs

      • Inflammation limited to head + neck

      • Beading of temporal artery (may be palpable)

    • Management

      • Steroids

        • High-dose for GCA (60 mg) / Low-dose for PMR

      • Vitamin D

      • Bone protection

Lupus

    • Typical presentation

      • Jamaican

      • Hair falling out

      • Dry mouth

      • Mouth ulcers

      • Facial rash and scars

      • Serositis

        • Pleura, Pericardium, Peritoneum

      • Fatigue

      • Renal disease

      • Raynaud's

Raynauds

    • Classical/True Raynauds:

      • White initially

        • Spasm of arterioles + venules

      • Dusky blue later

        • Venules relax first

        • Back-flow of deoxygenated blood => Blue colour

      • Very red later

        • Reactive hyperaemia

      • Affects just the digits

        • Palms spared

        • Thumb sometimes spared

    • Raynauds phenomenon

      • Stand-alone

      • Starts in teens

      • Mild

      • Need a big trigger

    • Raynauds disease

      • Raynauds in the context of a disease

        • Scleroderma

        • Lupus

      • Sjögrens

      • Myositides

      • Starts later

      • More serious

      • Requires only a small trigger

      • Always ANA positive

Notes

    • RA and gouty nodules are clinically indistinguishable

      • Except gouty nodules may appear yellow if very superficial

    • Be careful of NSAIDs!

      • Asthma/COPD, Kidneys, GI