rheumatology teaching session gp st2 year 8/9/10
TRANSCRIPT
Rheumatology teaching session
GP ST2 year
8/9/10
Introductions
Kate Gadsby, Lead Rheumatology educator Dr. Helen Vose, GP trainer from Ashbourne
Overview
Identifying inflammatory arthritis DMARDs & shared care protocol TEA & CAKE! Fibromyalgia
Diagnosing inflammatory arthritis
Leena Patel
ST2
Inflammatory arthritis
Group of autoimmune diseases presenting with joint and systemic features
Progressive condition Causes joint destruction and dysfunction Diagnosis of various types depends on
pattern of joint involvement and certain systemic features
Inflammatory arthritis
Rheumatoid arthritis Psoriatic arthritis Ankylosing spondylitis Reactive arthritis
Important message
Evidence shows earlier detection and intensive treatment slows disease progression and joint destruction
Do not delay referral if inflammatory arthritis is suspected
Quick test
Which symptoms would make you think more of an inflammatory arthritis than a mechanical/degenerative joint disease?
History
Pattern of joint involvement Pattern of stiffness(>30 mins in the morning) Presence of swelling Relationship of symptoms to use Fatigue Associations like psoriasis, uveitis,
inflammatory bowel disease
Examination
Pattern of joint involvement Presence of synovitis (soft, boggy feeling
along joint line) Degree of tenderness ROM of joint Joint deformity
Guess the type of arthritis
Now..
Pick out the signs you can see in the picture that point to that diagnosis
Any other joints commonly affected in this type of arthritis?
What features may you find on an x-ray? Any other systems that may be affected?
What features can you identify?
Now..
Which inflammatory arthritis causes this? Which population group does it affect? What signs may you find on examination?
What’s the diagnosis
Which arthritis associated with the following eye symptoms Scleritis/episcleritis Anterior uveitis Uveitis Conjuctivitis
Recognising a pattern
RA – symmetrical involvement of MCPs & MTPs with swelling, morning stiffness and flare ups
Ankylosing spondylitis- prolonged morning stiffness of spine in young person
BUT not always as straight forward!!! If in doubt, refer for further assessment
Investigations
If history and examination suggests inflammatory arthritis, DON’T wait for results, refer straight away
Blood tests
FBC U&E ESR CRP Rheumatoid factor
Rheumatoid factor
NOT a screening test for RA Used for classification and prognosis Can be raised in other conditions and
infection High false positives Anti-CCP antibodies (more sensitive and
specific for RA)
X-rays
During early stages, normal x-rays therefore don’t rely on them for diagnosis
With time, periarticular osteopenia Bony erosions Joint subluxation
Initial management by GP
NSAID – reduced pain, swelling and inflammation
Simple analgesia – paracetamol, codeine Think of gastric protection in elderly,
dyspepsia symptoms Refer to secondary care early Think about quality of life, refer to OT for
possible aids
Secondary Treatment options
1. Steroids
2. Disease modifying anti-rheumatic drugs (methotrexate, sulfasalazine, gold salts, azathioprine, ciclosporin)
3. Biological therapy ( rituximab, etanercept, infliximab)
4. Surgical options
Key messages
Think of inflammatory arthritis when pt presents with joint pain
Ask appropriate history to confirm this Refer early, don’t wait for results X-rays not useful in early stages Rheumatoid factor not diagnostic
References
www.arthritisresearchuk.org www.rheumatology.org.uk InnovAiT; volume 2; issue 10; october 2009