Jane Avery

Jane Avery

1. Key Information

   • 38 years old
   • Female
   • Aching pain in her fingers
     • Progresses to her wrist
     • The pain tended to ease during the day but it then came back with a vengeance in the morning
     • The pharmacist had recommended some Ibuprofen which helped a lot and she has been taking that regularly for three weeks
   • Single and has no children
   • BP of 132/76
   • BMI of 26
     • Just overweight
   • Nothing significant in her previous medical history
   • Non smoker and occasional drinker

2. GP Appointments

   • Initial GP appointment
     • After talking to Jane the GP makes these notes: 6/52 Hx gradually pain pip & mcp j both hands. 1/52 similar discomfort in both wrists. Early morning stiffness. Relieved by NSAIDs. ? work related.
     • Asks questions to help rule out certain conditions
       • Pain in feet or jaw?
         • Her feet may get similar pain but the jaw is not common in arthritis so could rule it out
       • Pain in your neck?
         • Compression of a cervical nerve root may cause pain in the hands
       • Pins and needles in your hands at night?
         • Neurological pain
       • Do your fingers change colour?
         • Raynaud's syndrome - vasospasm causing vasoconstriction and limiting blood flow to the extremities. Can be painful on reperfusion
       • Family history of joint problems?
         • Certain conditions such as arthritis can run in the family
       • Have you had any skin problems?
         • Psoriasis is linked to rheumatoid arthritis
       • Asks is she's had a cold or upset stomach
         • Infections can be one of the triggers of the auto immune response
     • Jane revealed that she was tired but had been busy recently
     • Hand inspection and palpation
       • There was no visible swelling or redness and the joints did not feel warm
       • They were tender though and there was definite end range discomfort on passive movements of the pip and mcp joints of all the fingers and also of the wrists and distal radio-ulnar joints
     • GP suspects a form of arthritis
   • Follow up (1 month later)
     • Her hands were as bad as ever and she thought the wrists were now actually a bit swollen
     • It was taking her over an hour to loosen her fingers up in the morning before she could start work
     • In the last week she had also had some pain in her feet when walking to the station
     • She had also woken once or twice at night with pins and needles in her right hand and had had to shake it to get it right again
     • More tired than she should be with her current activity levels
     • On examination there was indeed now visible swelling as well as tenderness of the wrists and the range of movement of the finger joints was slightly limited
     • Suspected to be inflammatory arthritis
       • Referred to an arthritis clinic

3. RA Diagnostic Tests

   • Haemoglobin levels
     • Both times, Jane's were low
       • Indicates anaemia which is common in chronic disease such as RA as there is an increase in IL6 levels
       • 11.1 and 10.8
   • Rheumatoid Factor (RF)
     • Released by the tissues if they are being attacked by their own immune system
     • As she is negative both times, it suggests she is not releasing the RF and she is not having an autoimmune reaction
     • The RF test is not that good as 20% of patients will not seroconvert (show as a negative when positive) and 5% will be a false positive
       • Can be used to support a diagnosis but not to make one
   • Anti CCP
     • Found in 60% of RA patients and has a high specificity in RA diagnosis
       • Jane's is high, confirming RA
   • ANA
     • Antinuclear antibodies - Used for lupus diagnosis which is another autoimmune disease
   • CRP
     • C-reactive protein (CRP) is a substance produced by the liver in response to inflammation
       • Jane's levels in the second blood test are high, showing an inflammatory disorder
   • X Rays
     • Jane was requested to have x-rays of the hands, wrists and feet and a chest x ray
       • There was small erosion at the edge of the articular surface on a couple of the MCP joints and there was definitely slight osteopenia around the joints
       • Chest x ray was clear
   • Liver function test
     • To see the effects of RA drugs which can affect the liver function
       • Jane's was fine but she had not started any treatment then

4. Rheumatoid Arthritis

   • Chronic autoimmune condition
     • The exact cause is unknown but it is thought to be a type III hypersensitivity reaction involving the HLA DR4 and HLA DR1 genes
   • Signs and symptoms
     • Hands
       • Z deformity
       • Boutonniere's deformity
       • Swan neck deformity
       • Subluxation of the fingers
       • Raynaud's syndrome
     • There is heterogenity of the clinical features where they may appear differently amongst people with different severities
     • Carpal tunnel syndrome in the wrist
     • Joint pain and stiffness
     • Skin
       • Rheumatoid nodules
       • Vasculitis
     • Feet
       • Sublaxation of the toes
       • Hammer toe deformity
     • Pulmonary fibrosis
     • Osteoporosis
     • Athero- sclerosis can be increased in RA
   • Pathogenesis
     • The inflammatory process is characterised by infiltration of inflammatory cells into the joints
       • Leads to proliferation of synoviocytes and destruction of cartilage and bone
     • Symptoms are caused by hyperplasia of the synovial lining cells and extensive infiltration of macrophages, lymphocytes, fibroblasts, and leukocytes in joints, where a variety of cytokines, prostaglandins, and proteolytic enzymes are responsible for the process of the inflammation

5. Treatment for Rheumatoid Arthritis

   • Conservative treatment
     • Patient education
     • Encourage them to do regular exercise
     • Refer to a physiotherapist
     • Assess their activities of daily living
       • Able to button a shirt
       • Able to brush hair
       • Able to write
       • Able to walk up and down stairs
       • Able to carry a bag
   • Surgery
     • Most people with RA never have surgery
       • People with rheumatoid arthritis may elect to have surgery to reduce joint pain and improve everyday function
     • Joint replacements
       • Patients may elect to have joint replacements for large joints such as shoulders, hips, or knees as well as smaller joints in the fingers and toes
       • Involves removing either all or part of a damaged joint and inserting a synthetic replacement
     • Arthrodesis
       • In arthrodesis, the damaged joint is removed and the neighboring bones are fused together
         • Arthrodesis is most commonly used to treat arthritic ankles, toes, wrists, or finger joints, it can also be used to stabilize painful joint(s) in the spine (called spinal fusion)
       • Improves stability but reduces movement
     • Synovectomy
       • During this procedure, the surgeon removes the inflamed synovial tissue around the joint to help reduce the symptoms
   • Antirheumatic drugs
     • Either alleviate symptoms or to modify, slow or halt the disease process (DMARDs)
     • NSAIDs can be prescribed as the first line of treatment to alleviate the pain and some inflammation
     • Corticosteroids
       • Corticosteroids are given to RA patients to reduce inflammation and help regulate autoimmune activity
       • Block the productions of prostaglandins to reduce inflammation and depreess WBC accumulation to reduce the immune activity
       • Given by injection into affected joints
     • DMARDs
       • Immuno- supressants
         • Drugs such as methotrexate supress the immune system to reduce the inflammation but must be meticulously monitored to reduce the chance of severe side effects
       • Gold based drugs
         • Given orally or by an injection and are believed to be the most effective treatment
           • Can have side effects including rashes, digestive problems, kidney problems when on the drug and reduced RBC production, meaning they need regular monitoring
       • Chloroquine
         • Not as effective as gold based drugs and prolonged use at a high dose can cause eye problems
       • Sulfasalazine
         • Slows the progress of mild to moderate RA and has few adverse effects
       • Monoclonal antibodies
         • Target Tissue Necrosis Factor alpha to reduce it's activity but it can initially cause allergy like symptoms

6. Forearm and Hand Anatomy

   • Bones
     • Forearm
       • Radius
       • Ulna
     • Wrist
       • Proximal row (Lateral to medial)
         • 1. Scaphoid
         • 2. Lunate
         • 3. Triquetrium
         • 4. Pisiform
       • Distal row (lateral to medial)
         • 1. Trapezium
           • Articulates with the base of the thumb
         • 2. Trapezoid
         • 3. Capitate
         • 4. Hamate
     • Hand
       • Metacarpals
       • Phalanges
     • Joints
       • Radiocarpal joint between the radius and the proximal row of carpals
       • DIPs and PIPs inbetween the phalanges in the fingers
       • Carpometacarpal joints (CMCs)
         • The first CMC joint is a saddle-shaped, very mobile articulation between the trapezium and the base of the first metacarpal. It allows 40° to 50° of thumb flexion–extension parallel to the plane of the palm and 40° to 70° of adduction–abduction perpendicular to the plane of the palm
       • Metacaropphallangeals between the metacarpal bones and the most proxinal phalanges
   • Muscles
   • Brachial Plexus

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