[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;” margin_design_tab_text=””]

Your Role: you are the doctor on duty for the Acute Medical Unit.

You have 10-minutes with each patient. The Examiners will alert you when 6-minutes have elapsed and will stop you after 8-minutes.

In the remaining 2-minutes, one examiner will ask you to report on any abnormal physical signs elicited, your diagnosis or differential diagnoses, and your plan for management (if not already clear from your discussion with the patient).

Scenario

Daisy Plater (71-years)

GP Letter: Please see this lady who has been complaining of back and hand pains.

Please advise on how to investigate and manage

Physiological observations

Respiratory rate / minute: 16

Pulse rate / minute: 82

Systolic blood pressure (mmHg): 148

Diastolic blood pressure (mmHg): 86

Oxygen saturations (%): 98

Temperature: 36.4°

Your task is to:

Assess the problem by means of a brief focused clinical history and a focused relevant physical examination. You do not need to complete the history before carrying out an appropriate examination.

Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for investigation and treatment where appropriate. Respond directly to any specific questions which the patient may have.

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/207101086″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” underline_digit=”no” separator=”yes” digit=”20″ title=”Minutes” text=”Station time”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” separator=”yes” digit=”10″ title=”Minutes” text=”Time for this encounter”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”8″ title=”Minutes” text=”Maximum time to examine your patient”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”2″ title=”Minutes” text=”Minimum time for discussion and questions”][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has swelling of the small joints of the hand, along with nodules on the elbows. She also has a buffalo hump. which is consistent with her prolonged steroid use. This is consistent with her diagnosis of rheumatoid arthritis.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Rheumatoid arthritis is a common and useful station for station 5, as patients have good visual signs as well as a plethora of symptoms. In this case, a diagnosis of rheumatoid arthritis ha already been established, and the patient is experiencing a flare of her disease. However, cases can range from a new diagnosis, through to early management options, exacerbations to complications and side effects. This case touches on a few of these aspects. We will discuss all of the above now.

The diagnosis of rheumatoid arthritis (RA) is well established, as the most common systemic inflammatory arthritis, with a 1% global prevalence. Average age of onset is between 30-50 years of age.

Risk Factors

  • Women > men
  • Older age
  • Positive family history for RA / autoimmune inflammatory disease
  • Active or previous smoking history

Symptoms and Signs

  • Multiple join pain and stiffness (lasting > 1 hour)
  • Smaller joints like proximal interphalangeal joints, metacarpophalangeal joints and wrists more commonly involved
  • Synovitis with boggy swelling
  • Systemic symptoms of fatigue, weight loss and even chronic low-grade fever

A scoring system based upon four broad areas, with a score of 6 and above indicates RA (American College of Rheumatology / European League Against Rheumatism Classification Criteria):

  • Joint Involvement (1 large / 2-10 large / 1-3 small / 4-10 small / > 10 any joins with at least one small)
  • Serology (RF – negative, low positive, high positive)
  • Acute Phase Reactants (CRP and ESR)
  • Duration of Symptoms (over/under 6-weeks)

Investigations

  • Rheumatoid Factor – RF
    • Can be positive or negative (+ in 50-80%)
  • Anti-citrulinated protein Ab – Anti-CCP (sensitivity ofo 95%)
  • Anti-nuclear Ab (positive or negative)
  • CRP and ESR (positive or negative)
    • Can be used to follow disease remission
  • Baseline blood tests (full blood count, renal and liver function, bone profile)

Differential Diagnosis

  • Systemic lupus erythematosus
  • Systemic sclerosis
  • Psoriatic arthritis
  • Polymyalgia rheumatica
  • Temporal arteritis (especially if fever and weight loss is significant)

Also need to consider arthropathy related to other autoimmune systemic conditions such as inflammatory bowel disease.

Systemic Manifestations

  • Cardiovascular
    • atheroscerlosis (up to 3x higher risk)
    • pericarditis
    • vasculitis
  • Ocular
    • scleritis
    • keratoconjunctivitis
  • Bone marrow
    • amyloidosis
    • Felty’s syndrome
  • Neurological
    • neuropathy
    • cervical myelopathy
  • Pulmonary
  • Sjögren’s syndrome

Management

Management requires a multidisciplinary approach between physicians, specialist nurses, pharmacists, physiotherapists, occupational therapists and primary care practitioners.

Initially, steroids were the mainstay of treatment, however, they cause significant side effects and the advent of DMARDs (disease modifying anti rheumatic drugs) has been a game changer for people with RA.

All patients should be encouraged to exercise, as this has been shown to have a beneficial effect on disease progression and disability.

Methotrexate (MTX)

The primary DMARD used is first-line now for RA. It is a non-biologic agent and inhibits dihydrofolate reductase, as such, folic acid supplementation is required to be taken for the entire duration of treatment with methotrexate. It is taken once weekly. Side effects include hepatic damage (from mild reversible transaminitis to rare corrhosis), teratogenesis (hence avoid in women of child-bearing age, alopecia, nausea, diarrhoea and oral ulcers.

Methotrexate has been shown to improve life expectancy in RA as well as reduce radiographic features of the disease. Monotherapy with MTX has been found to be less efficacious than dual therapy with with a biologic agent (such as anti-TNF agents).

Leflunamide

This is an alternative to MTX, if the latter is not tolerated or causes severe complications. It inhibits pyrimadine synthesis and also has teratogenic side effects as well as potentially causing gastrointestinal upset, which are more common than with MTX.

Combination therapy of two or more DMARDs has better outcomes than monotherapy. First and second line treatment is non-biologic therapy with the above or hydroxychloroquine, sulfasalazine or minocycline. If these do not work, biologic agents such as adalimumab or etanercept can be used. Unlike non-biologic agents, combination therapy with 2 or more biologic agents is not recommended due to adverse effects.

Corticosteroids

Corticosteroids are of use for pain control, but due to the side effects from prolonged therapy, should only be used for short-term management. DMARDs are the mainstay of treatment.

Side effects of prolonged steroid use include:

  • Type 2 diabetes
  • Weight gain
  • Hypertension
  • Osteoporosis and fractures
  • Thinning skin with easy bruising
  • Gastrointestinal ulceration
  • Visual disturbance from cataracts or glaucoma
  • Poor sleep
  • Depression

Prognosis

Remission can occur in up to half of patients, but exacerbations, such as in this case, do occur. More severe disease tends to occur with those that are serology positive, with raised inflammatory markers and a higher number of affected joints. Radiological evidence of joint erosion is also a poor sign as is systemic disease.

References

2013 NICE Rheumatoid Arthritis Guidelines

NICE Rheumatoid Arthritis in adults: management

British Society for Rheumatology

Arthritis Research UK[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]””[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]