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5002 Case 9 Cheat Sheet by

Rheumatoid arthritis (RA)


- 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)
- 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
- DTRs UL & LL all 3+ bilaterally
- Flexor plantar response
- AROM Cx: all mildly restricted & painful @ end range
- Gentle PROM: w/ no overpr­essure as AROM
- 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


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
- 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
- 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)
- 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
- 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?
- 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
- 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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