A very common exam question in undergraduate exam up to MRCP PACES.
Sing the song before you go into the exam hall and you'll be confident coz they are almost the same. Don't be over confident though coz the examiner is like the 'Joker' in Batman - you need to outsmart him, he is not that straight forwaard. You have to be the DARK KNIGHT !!
This patient has bilateral symmetrical deforming arthropathy involving the MCP/PIP joints but sparing the DIP joints.
There is Z deformity of the thumb, boutonnière's deformity and swan neck deformity
Tinel sign is positive suggesting carpal tunnel syndrome.
There is also limited movement of thumb abduction and opponens.
There are no nail changes or rashes to suggest RA like psoriatic arthropathy.
There is Rh nodules.
Functinally she can still write and unbutton her shirt.
There is no evidence of episcleritis/scleritis/scleromalacia perforans and the lungs are clear(rule out Rh lung). I would like to examine the abdomen for splenomegaly in Felty's syndrome or hepatosplenomegaly in amyloidosis.
My diagnosis is that this patient has RA and it is inactive as there joint swellings are hard suggesting subluxation and the joints are not warm of tender.
Questions :
What are the causes of anaemia in RA ?
What are the poor prognosis factors ?
How would you investigate this patient ?
What are the options of treatment ?
5 comments:
This is your student from Indonesia. I'll try to answer your questions in here. Please review and comment, thank you!
1. -RA is a chronic disease, anemia in RA is due to that.
- may be due to folate deficiency
- Felty's syndrome
- NSAIDs may cause iron deficiency anemia.
2. Poor prognostic factors in RA are:
a. systemic features: weight loss, extra-articular manifestations such as peripheral neuropathy, anemia,scleritis,GI problems, pleural effusion, fibrosis in lungs, cardiovascular problems, Sjogren's syndrome, Felty's syndrome,Infections due to immunosuppresive drugs in treatment.
b. rheumatoid nodules
c. presence of rheumatoid factor
d. early bone erosion.
3. how to investigate RA? -
a. history of pain and swollen joins, morning stiffness,
b. hand examination - look for deformities, signs, test grip, movements, elbow look for rh nodules,
c. lab: ESR (look for inflammation activity, increased if there is inflammation activity)
-FBC (look for anemia, thrombocytosis)
-immunologic factor - RF
d. radiology - xray, MRI
i missed the 4th question in the earlier post.
4. how to treat RA patient:
a. DMARDS - methotrexate, sulfasalazine, hydroxychloroquine, chloroquine,azatriopine,cyclosporinA
b. Leflunomide
c. analgesic for the pain - codeine, opiates
d. surgery
options of treatment in RA :
1. non pharmacologic - physiotherapy, physical therapy, occupational therapy
2. pharmacologic - DMARDS, NSAID (aspirin, ibuprofen), Glucocorticoids (prednisone), TNF-alpha, analgesic
3. surgery
Good.
Prednisolone is now used as a bridging therapy. Your DMARDS also include the Leflunamide and TNF alpha.
MRCP students must be confident and cool before attending their exams. Questions are asked deeply about the various types of diseases in subjects such as radiology,neurology, bilateral symmetrical deforming arthropathy, rheumatology and so on.
"Rheumatoid arthritis" disease shows usual symptom such as joint pain, chest pain, dry mouth ,etc.
MRCP Courses UK
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