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Rheumatoid arthritis (RA)
Case
- 64 y.o. male
- Upper neck & suboccipitals
- Onset 8 yrs ago for no apparent reason
- Episodic & fluctuates in severity
- Overall getting worse & more persistent |
-6/10 at worse
- "Sore" & "deep pressure" w/ stiffness
- Worse in the morning & gets bit easier w/ movement / activity after approx. 1hr |
AF: Inactivity
RF: NSAIDs partially improve the pain (paracetamol doesn't help) |
Extras
- Kidney stones
- Currently awaiting hospital investigation for a chronic cough & recurrent bronchitis
- Ibuprofen for current complaint
- Atorvastatin 20mg/day (preventative)
- Sometimes wakes due to pain when it's worst
- Early in the morning (around 4-5am)
- Mother: hypertension from 40 y.o., died from a stroke at 72 y.o.
- Father: died from MI at 65 y.o.
- Brother: hypertension @ 55 y.o.; survived MI @ 60 y.o.
- Imaging revealed RA in hands but no complains of Sx |
Physical Examination Findings
BMI: 26.8
- Pulse: 80
- BP: R - 140/78; L - 138/80 |
Posture / stance
- Upper crossed w/ anterior head carriage |
Reflexes
- DTRs UL & LL all 3+ bilaterally
- Flexor plantar response |
ROM
- AROM Cx: all mildly restricted & painful @ end range
- Gentle PROM: w/ no overpressure as AROM |
TTP
- Upper Cx: U traps, suboccipital & scalenes TTP w/ no referral B |
Supine Cx motion palpation: little less stiff than seated
- Palpation: mid - lower Tx spine stiff but no pain
- Mild oedema R ankle: non pitting, no pain; no other obvious abnormality observed in extremities |
Clinical tests
- Cx specialists: no provocation
- Wall angel test: failed |
Discussion
Working diagnosis
- Rheumatoid arthritis (RA)
→ Most probable cause of inflammatory neck pain in pts' of this age (& also due to it being most common inflammatory arthropathy i.e. prior probability)
- Links w/ non-pitting swelling at the ankle & the respiratory Sx |
Why is this an unusual case?
- Presents w/ neck Sx & denied any Sx in the hands & feet
- Typically involvement of the spine occurs yrs after the onset of Sx in the distal extremities |
Differentials to be considered
- Lung cancer for the respiratory symptoms: based on being a past heavy smoker |
Oedema
- Pitting: cardiovascular
- Non-pitting: joint inflammation or infection |
Learning outcomes
Rheumatoid arthritis
- Chronic systemic inflammatory disease
- Pt w/ RA have an increased risk of developing heart disease
- Usually affects distal extremities, bilaterally & symmetrically
- Associated w/ increased risk of CVD disease, osteoporosis, anaemia & infection
- Peak onset 30-50 y.o.
- Associated w/ anaemia
⏺ Presentations:
- Symmetrical synovitis of small joints of distal extremities
- Pain, swelling, heat & stiffness in affected joints
- Pain worse at rest/inactivity
- Swelling around affected joint
- Early morning stiffness, lasting 1+
- Bumps/nodules under skin (rheumatoid nodules)
⏺ Diagnosis:
- No set tests in primary care
- Blood tests & x-ray to confirm: C-reactive protein, rheumatoid factor, ESR
- Inability to make a fist/flex fingers
- Other inflammatory presentations
- Family Hx of RA
DON'T LET INVESTIGATIONS DELAY REFERRAL FOR SUSPECTED RA
⏺ Management:
- NSAIDs until rheumatological appt.
- During flare ups: rest
- During emission: exercise
- Low-impact activities in remission periods
- Referral to GP
- Exercises for enhancing joint flexibility, muscle strength & managuingother functional impairments |
How to identify inflammatory arthropathy, how to refer & what the further investigations & management would be?
⏺ Identifying:
- Medical Hx & physical exam
- Key features: joint pain, swelling & stiffness; distal extremity joint affected; usually bilateral & symmetrical; worse in morning (improves throughout day); fatigue, malaise, other systemic symptoms; family Hx of inflammatory arthritis
⏺ How to refer?
- Urgent referral
- Written letter to GP for further referral to rheumatologist for investigations
⏺ Further investigations:
- Blood tests: rheumatoid factor - C-reactive protein
- X-ray
⏺ Management:
- NSAIDs
- Glucocorticoids
- Encourage regular exercise in remission periods, rest w/ flare ups
- Exercises fro enhancing joint flexibility, muscle strength & managing other functional impairmens |
Modify physical examinations according to risk
- Avoid Cx manipulation: RA can damage transverse ligament in Cx
- Gentle joint mobility testing
- Postural analysis: address misalignment or bracing posture (take breaks as needed or adjust position to suit pt)
- Neurological testing (e.g. sensory/reflex): may be difficult to perform, modify/remove altogether if not clinically relevant to pt
- Adjust duration & intensity of treatment to suit pt |
Identify risk factors for cardiovascular disease
- Rheumatoid arthritis (RA)
- Increasing age: especially after 55 (F) & 45 (M)
- Gender: males at higher risk
- Family Hx: of heart attacks, strokes, angina
- Hypertension
- Cholesterol levels: Hugh LDL, low HDL
- Smoking
- Diabetes: due to damage to blood vessels & increased inflammation in body
- Obesity/sedentary lifestyle: contribute to high BP, cholesterol, diabetes
- Stress: increase BP & contribute to inflammation |
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