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