Rheumatology for medical students
Dr Kenny Sunmboye
Rheumatology SpR
Clinical Scenario 1
1. A 22yr old university student presented with
painful hand joints with no swelling. She has had
raynauds phenomenon for 3 years. Her hair dresser
has commented about her hair thinning on
occasions. She now presents to clinic with chest pain.
She is awaiting blood tests and immunology tests.
What is the likely diagnosis?
a) Scleroderma
b) Rheumatoid arthritis
c) SLE
d) Fibromyalgia
e) Polymyalgia rheumatica
SLE
Female to male ratio 9:1
Most likely to develop between the ages of
15-55 years
Malar rash
Malar rash
Erysipelas
Mnemonic
A RASH POINts Medical Diagnosis
Malar rash
ANA
Arthralgia/
Renal arthritis
Discoid rash
Oral ulcers
Neurological abnormalities
Immunological abnormalities
Photosensitive rash
Serositis
Haematological abnormalities
4 out of 11= definite SLE
Initial investigations
FBC
Inflammatory markers
Liver Tests
U&E
Dont forget URINALYSIS!
Rheumatological blood tests
ANA (Anti Nuclear Antibodies)
Double stranded DNA
ENAs (Extractable Nuclear Antigens)
Ro
La
Sm
RNP
Jo-1
Complements
C3
C4
Medical treatment
Skin +/- joint involvement: Hydroxychloroquine (HCQ)
Other systems affected or HCQ not controlling skin and
joints: prednisolone, azathioprine, methotrexate,
ciclosporin
Other DMARDs used:
Mycophenolate
Cyclophosphamide
Rituximab
Patient education
Avoid exposure to sunlight
Cautious NSAID use
Monitor for cytopenias
Be vigilant for opportunistic infections
Educate patients with SLE regarding aggressive lipid and
blood pressure goals to minimize the risk of CAD.
Clinical Scenario 2
2. A 57 year old male taxi driver presents with painful fingers.
On examination there is evidence of dactylitis and he is
tender over his DIPs and there is pitting of his nails. His
rheumatoid factor is negative and the rest of his blood tests
are unremarkable.
What is the most likely diagnosis?
a) Rheumatoid arthritis
b) Osteoarthritis
c) SLE
d) Psoriatic arthritis
e) Pseudogout
Nail pitting
Psoriatic arthritis (PsA)
10% of people with psoriasis
60% have psoriasis then PsA
20% have PsA then psoriasis
20% have PsA and psoriasis together
Clinical scenario 3
3. A 65yr old school principal is concerned about pain in both his feet
which have been recurrent for about 4 years. He drinks about 5 units
of beer daily and doesnt smoke. On examination he had tenderness
and slight swelling in both 1st MTP joints. He was also tender in the
midfoot of the left foot with no swelling. His bloods show a urate of
611 (<360) and a rheumatoid factor of 25 (<10).
What is the likely diagnosis?
a) Osteoarthritis
b) Rheumatoid arthritis
c) Gout
d) Pseudogout
e) Polymyalgia rheumatica
History taking for gout
Site, onset and duration
Family Hx
PMHx
Medication
Social Hx
Clinical scenario 4
4. A 77yr old retired GP presents with bilateral shoulder pain and
stiffness for the last 3 weeks. He is usually fit and active but now
struggles with his ADLs. He has developed pain in his jaw when he
starts chewing food. He denies headaches. His blood tests are normal
except for a CRP of 20 (<5)
What is the likely diagnosis?
a) Polymyalgia rheumatica
b) Rheumatoid arthritis
c) Fibromyalgia
d) Giant cell arteritis
e) Bilateral frozen shoulders
Vasculitis Classification
Large Vessel
Takayasu arteritis
Giant Cell arteritis
Medium Vessel
Polyarteritis Nodosa
Kawasaki Disease
Isolated Central Nervous system vasculitis
Small Vessel
Wegeners Granulomatosis
Microscopic polyangiitis
Churg-Strauss syndrome
Henoch-Schonlein purpura
Essential Cryoglobulinemic vasculitis
Hypersensitivity vasculitis (LCV)
Vasculitis 2/2 connective tissue disorder
Vasculitis 2/2 infection
GCA. Typical presentation
Age >50
Caucasians
F:M 2:1
NEW headache usually temporal, not always
Scalp tenderness common
Jaw claudication highly suggestive
May or may not also have PMR symptoms
GCA mnemonic
G. I. A. N.T
Granulomatous Inflammation
Increased CRP/ESR/PV
Temporal tenderness
Age >50 years
New headache
Management
Early treatment prevents blindness
Do not defer treatment to await biopsy
Start at 40 -60 mg prednisolone daily for at least 1
month
(vs. 15 mg for PMR) + PPIs + bone protection
If recent visual loss then iv methyl prednisolone
Dramatic response to headache/stiffness within 1 week
Polymyalgia rheumatica
Age >50
F:M 2:1
Constitutional symptoms
- fever, fatigue, anorexia, weight loss
PMR important points
Pain & stiffness in the pelvic, shoulder girdle and neck
Sudden onset
Symptoms are bilateral & symmetrical
Muscle strength + CK is normal
Prompt dramatic response to steroids
Raised CRP
Clinical scenario 5
5. A 35yr old investment banker has noticed recurrent pain and
swelling in the MCP joints and PIP joints of both his hands over the
last 6 months. He is worried about his symptoms. He is being
investigated for ulcerative colitis. His mother has RA. His
rheumatoid factor is negative and other tests are being awaited.
What is the likely diagnosis?
a) Psoriatic arthritis
b) Gout
c) Rheumatoid arthritis
d) Pseudogout
e) Hand osteoarthritis
Rheumatoid arthritis
Diagnosis is clinical
Usually symmetrical
Affects MCP and PIP joints, DIPJs spared
Start DMARDS early
ACR/EULAR 2010 classification criteria
JOINT DISTRIBUTION (0-5)
1 large joint
2-10 large joints
1-3 small joints (large joints not counted)
4-10 small joints (large joints not counted)
>10 joints (at least one small joint)
SEROLOGY (0-3)
Negative RF AND negative ACPA
Low positive RF OR low positive ACPA
High positive RF OR high positive ACPA
SYMPTOM DURATION (0-1)
<6 weeks
6 weeks
ACUTE PHASE REACTANTS (0-1)
Normal CRP AND normal ESR
Abnormal CRP OR abnormal ESR
Miscellaneous
Mnemonics
Erythema nodosum
Causes of erythema nodosum
n o d o s u m
Microbiologic
al
No cause in
60% of cases
Ulcerative
colitis/IBD
sarcoidosis
Drugs
OCP
Kawasaki Disease
Kranked up temperature (fever) for at least 5
days
Konjunctivitis
Kandy tougue/Krusty lips
Knobbly neck
Knuckles Redden/Koloured Palms
Krackly Skin
