Saturday, January 14, 2017

Rheumatology Hands

That day failed my paces - grrrr

Have to restart the whole cycle of revising again and practicing.

Station 5

History

1.Joint pain and swelling - symmetrical, chronology and extent, ADLs - cooking, dressing, showering, and lastly complications - CTS

2. Early morning stiffness - symmetrical, severity in duration (>60 mins, affecting ADL?)

3.Treatment - previous treatment, tolerability, SEs, complications monitoring.

Examination

Look - Feel - Move

- Symmetrical Deforming Polyarthropathy affecting small joints of the hands, sparing DIPs
- Ulnar deviation of the MCP
- Boutonniere's and swan neck deformity
- Z-thumb

- Piano key ulnar head

- Rheumatoid nodules, elbows/any pressure points

- Surgical scar - CT decompression

- Extraarticular manifestations :
Hematological - pallor, splenomegaly (Felty, with neutropenia)
Skin - nodules, vasculitis, pyoderma gangrenosum
Eye - scleritis (more severe, painful compared to epi-), episcleritis, scleromalacia perforans
CVS - valvular disease, pericarditis, CAD, myocarditis, heart failure
Lungs - pulmonary fibrosis (lower zones), pleural effusion, lung nodules, bronchiolitis obliterans
Renal - amyloidosis
Neuro - peripheral neuropathy, mononeuritis multiplex, compression neuropathies such as cervical myelopathy (atlanto-axial subluxation), CTS, ulnar neuropathy

Function

Power grip
Undo button
Pick up coin

Investigation

Blood test -
Inflammatory markers - ESR, CRP
Blood counts - Anemia of chronic disease, Low WBC in Feltys
Rheumatoid Factor - a/w severe disease, 80% RA has it
Anti CCP - cant do in active TB, very specific

Xray - look for reduced joint space, periarticular osteopenia, erosion, deformity

CXR - pleural effusion, pulmonar nodules , HRCT

Treatment

Multidisciplinary approach involving physiotherapy, OT, dexterity aid and modification of homes
Mainstay pharmacological treatment is DMARDs - MTX, Sulphasalazine, Leflunomide, Hydrochloroquine. Pain management - NSAIDS and COX2 inhibitors
Lastly, Biologics - TNF blockade - infliximab, adalimumab, golimumab

1 comment:

pp said...

Y still so free to blog...