kumar’s chapter 18 x
Rheumatology
how to distinguish mechanical from inflammatory problems
Core skills and knowledge:
Clinical skills for rheumatology:
When taking a muscoskeletal history, you must consider the following:
1. Age: osteoarthritis, poly myalgia rheumatica and giant cell aneritis present
mainly in patients over 50. Autoimmune rheumatic diseases and inflammatory
arthritis? <50 of age
2. Gender: RA, sjorgens, SEE + systemic sclerosis? women. Cost and andylosing
spondylitis! men
3. Ethnicity: SLE? more common in African carriblen people
4. Occupation; if the job invokes heavy use of one port, it can lead to soft tissue
pain and /or oa
Also consider, have the following occurred to the patient?
1. physical trauma
2. psychosocial stress and depression
Then consider the symptoms:
1. Pain: where is it, is it coming from the joints, spine, muscles or bone, and with
local tenderness, could it be referred pain is it constant, intermittent or episodic.
Are there aggravating or precipitating factors? there any associated neurological
features?
2. Stiffness; is it generalised or localised? does it affect the limb girdles or
periphery? is it worse in the morning and relieved by activity? joint stiffness > 30
minutes in the morning = inflammatory arthritis
kumar’s chapter 18 x 1
, 3. Swelling: does it affect one joint or several? mono = trauma, gout, pseudo gout
or sepsis. poly = OA or RA. Is it constant? is there associated inflammation
(redness + heat)
4. Rash, breathlessness, neurological symptoms or blood disorders? might be
things such as RA, SEE or psoriatic arthritis
5. Could a drug be the cause? eg. diuretics may precipitate in older people +
steroids con cause avascular necrosis, have the symptoms responded to
medication?
6. Family history?
Approach to the patient:
observe patients, look for disabilities. Do general and neurological examinations
Anatomy and physiology of the normal joint:
Recall year 1. There are 3 types of joints
1. fibrous + fibro cartilaginous joints: intervertebral discs, sacroiliac joints, public
symphyses' and costochondras joints + skull sutures
2. Synovial joints: see theme 8
juxta articular bone: bone that abuts a joint, highly vascular, compromised of
mineralised collagen enclosed in a thin coating of tougher conceal bone
!! the point at which a tendon or ligament joins a bone = enthuses (enthesis)
Investigation of rheumatic disease:
investigations are usually unnecessary in common musculoskeletal problems
because you can usually tell from the history and examinations. Tests are used to
exclude another condition for reassurance
Useful blood screening tests:
1. full blood count:
kumar’s chapter 18 x 2
, haemoglobin: normochramic, hormocytic anemia suggests chronic
inflammatory and autoimmune diseases. thypochromic, microcytic anemia
suggests iron deficiency sometimes due to NSAIDS' induced oil bleeding
WBC count; neutrophivia = seen in bacterial infection leg. septic aahritis) or
corticosteroid treatment- lymphopenia= viral iunesses or SEE. neutropenia=
ding induced bone marrow suppression. eosinophilia - EGPA
platelets: raised no. Occurs with any chronic inflammation.
thrombocytopenia = drug induced bone marrow suppression and may be
seen in SLE
ESR and CRP: increase = inflammation ( + increased plasma viscosity)
bone and liver biochemistry: raised serum alkaline phosphates may indicate
liver or bone disease. rise in liver enzymes = seen in ding induced toxicity
2. others:
protein electrophoresis (and/or immunofixation)
serum uric acid: for gout
Antistreptolysin O: rheumatic fever
Serum autoantibody studies:
1. Rheumatoid factors (RF): detected in ELISA. They are antibodies (usually lgM
but can be IgE or IgA against the Fc portion of IgG. detected in 70T of those with
ra but it is not Diagnostic because they're also detected in SLE, chronic
infections and asymptotic older people
2. Anti citrullinated peptide antibodies (ACPA)
3. Antinuclear antibodies ANAS
4. Anti double Stranded ON A antibodies
5. Anti extractable nuclear antigen (ENA) antibodies
6. Anti neutrophil cytoplasmic antibodies
7. Anti phospholipid antibodies
8. low complement levels
kumar’s chapter 18 x 3
Rheumatology
how to distinguish mechanical from inflammatory problems
Core skills and knowledge:
Clinical skills for rheumatology:
When taking a muscoskeletal history, you must consider the following:
1. Age: osteoarthritis, poly myalgia rheumatica and giant cell aneritis present
mainly in patients over 50. Autoimmune rheumatic diseases and inflammatory
arthritis? <50 of age
2. Gender: RA, sjorgens, SEE + systemic sclerosis? women. Cost and andylosing
spondylitis! men
3. Ethnicity: SLE? more common in African carriblen people
4. Occupation; if the job invokes heavy use of one port, it can lead to soft tissue
pain and /or oa
Also consider, have the following occurred to the patient?
1. physical trauma
2. psychosocial stress and depression
Then consider the symptoms:
1. Pain: where is it, is it coming from the joints, spine, muscles or bone, and with
local tenderness, could it be referred pain is it constant, intermittent or episodic.
Are there aggravating or precipitating factors? there any associated neurological
features?
2. Stiffness; is it generalised or localised? does it affect the limb girdles or
periphery? is it worse in the morning and relieved by activity? joint stiffness > 30
minutes in the morning = inflammatory arthritis
kumar’s chapter 18 x 1
, 3. Swelling: does it affect one joint or several? mono = trauma, gout, pseudo gout
or sepsis. poly = OA or RA. Is it constant? is there associated inflammation
(redness + heat)
4. Rash, breathlessness, neurological symptoms or blood disorders? might be
things such as RA, SEE or psoriatic arthritis
5. Could a drug be the cause? eg. diuretics may precipitate in older people +
steroids con cause avascular necrosis, have the symptoms responded to
medication?
6. Family history?
Approach to the patient:
observe patients, look for disabilities. Do general and neurological examinations
Anatomy and physiology of the normal joint:
Recall year 1. There are 3 types of joints
1. fibrous + fibro cartilaginous joints: intervertebral discs, sacroiliac joints, public
symphyses' and costochondras joints + skull sutures
2. Synovial joints: see theme 8
juxta articular bone: bone that abuts a joint, highly vascular, compromised of
mineralised collagen enclosed in a thin coating of tougher conceal bone
!! the point at which a tendon or ligament joins a bone = enthuses (enthesis)
Investigation of rheumatic disease:
investigations are usually unnecessary in common musculoskeletal problems
because you can usually tell from the history and examinations. Tests are used to
exclude another condition for reassurance
Useful blood screening tests:
1. full blood count:
kumar’s chapter 18 x 2
, haemoglobin: normochramic, hormocytic anemia suggests chronic
inflammatory and autoimmune diseases. thypochromic, microcytic anemia
suggests iron deficiency sometimes due to NSAIDS' induced oil bleeding
WBC count; neutrophivia = seen in bacterial infection leg. septic aahritis) or
corticosteroid treatment- lymphopenia= viral iunesses or SEE. neutropenia=
ding induced bone marrow suppression. eosinophilia - EGPA
platelets: raised no. Occurs with any chronic inflammation.
thrombocytopenia = drug induced bone marrow suppression and may be
seen in SLE
ESR and CRP: increase = inflammation ( + increased plasma viscosity)
bone and liver biochemistry: raised serum alkaline phosphates may indicate
liver or bone disease. rise in liver enzymes = seen in ding induced toxicity
2. others:
protein electrophoresis (and/or immunofixation)
serum uric acid: for gout
Antistreptolysin O: rheumatic fever
Serum autoantibody studies:
1. Rheumatoid factors (RF): detected in ELISA. They are antibodies (usually lgM
but can be IgE or IgA against the Fc portion of IgG. detected in 70T of those with
ra but it is not Diagnostic because they're also detected in SLE, chronic
infections and asymptotic older people
2. Anti citrullinated peptide antibodies (ACPA)
3. Antinuclear antibodies ANAS
4. Anti double Stranded ON A antibodies
5. Anti extractable nuclear antigen (ENA) antibodies
6. Anti neutrophil cytoplasmic antibodies
7. Anti phospholipid antibodies
8. low complement levels
kumar’s chapter 18 x 3
