RHEUMATOLOGY Rheumatoid Arthritis: Chronic systemic inflammatory disease.

Peak onset = 4th-5th decade. HLA-DR4 = increased risk and severity of disease. CF = symmetrical swollen, painful and stiff small joints of hands and feet. Worse in the morning. Signs Early:- Inflammation (No joint damage) + joint swelling (MCPs/PIPs, wrist, metatarsals) Later: -Joint damage, deformity. (Ulnar deviation, subluxation, Boutonniere, Swan neck and Z deformities) Investigations: Clinical Diagnosis, check baseline bloods and serum antibodies. X-rays. Management Symptom modifying NSAIDs, Corticosteroids. DMARDs (alleviate sx, dampen inflammation,

slow disease progression.) sulfasalazine (1st line), methotrxate; can take up to 6 months to reach full effect. Osteoarthritis: Commonest joint condition
CF: Localised (Monoarthropy) Pain on movement, crepitus, worse at end of day. Joint gelling - stiffness after rest up to 30mins. Bouchards and Heberdens nodes. Mx: Exercise, Analgesia, weight loss, supportive aids, steroid injections, joint replacement

Septic arthritis
Medical EMERGENCY!! Red, hot + swollen joint. Risk Factors: IVDU, DM, trauma, prosthetic joint House officer role Bloods, cultures, analgesia IV flucloxacillin. Senior aspriation, washout in theatrw Crystal Arthropathies

Gout: inflammatory arthritis with deposition of urate crystals

Males: Females = 10:1. Classically: obese males, alcohol, high purine food. CF: Monoarthritis, typically 1st MTP. Excruciating pain, swelling + redness. Precipitants = Trauma, surgery, starvation, infection Investigations: Bloods (FBC, CRP, serum urate). Dx = JOINT ASPIRATION = Negatively birefringent crystals (polarized light) & neutrophils. Management Acute Mx NSAIDS (not aspirin), colchicine, (steroids). Prevention lifestyle, allopurinol/probenacid.

Pseudogout: Calcium pyrophosphate crystals. Weakly positively birefringent crystals in wrist, knee. Deposition along cartilages = linear chondrocalcinosis. NSAIDs help, often need steroids. Hydroxychloroquine for prophylaxis.

Temporal arteritis/Giant Cell arteritis

CF: Headache severe frontal/occipital, Jaw claudication, Visual disturbance visual loss Systemic symptoms (wt loss, anorexia, fever, sweats, malaise, fatigue and depression). Investigations: CRP, ESR/PV. Temporal artery (TA) biopsy (NB skip lesions). Duplex USS TA Diagnosis: Age >50 years, New headache, TA abnormality ESR >50 mm/hour, Positive TA biopsy Treatment: Steroids (>/= 40mg pred), Aspirin 75mg (+ gastro protection)

Spondyloarthropathies
Ankylosing Spondylitis: Young men, question mark posture. Dx = clinical. Mx = Exercise, NSAIDs, TNF- blockers. Surgery Psoriatic arthritis: Symmetrical polyarthropy. Nail changes. Rx: NSAIDs, methotrexate Reactive arthritis: sterile arthritis 1-4wk after urethritis. (Cant see, cant pee, cant climb a tree)

Autoimmune connective tissue disorders

SLE: Non-specific symptoms, ANA, dsDNA, can be drug induced. Mx different for different systems Systemic sclerosis Limited systemic sclerosis (70%): face, forearms and lower legs up to knees aka CREST (anti-centromere) Diffuse systemic sclerosis (30%): involves also the upper arms, thighs or trunks. Dermatomyositis: related to polymyositis. Affects both skin and muscles - skin rash and symmetrical proximal muscle weakness. Heliotrope rash. Gottron lesions.