Rheumatoid Arthritis (1) Year 4 Internal Medicine Notes

Rheumatoid Arthritis (1) Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / I MED BEAUTIFUL NOTES / RHEUMATOLOGY -- RHEUMATOID ARTHRITIS\n435 medicine teamwork\n[ Important Notes Extra Editing file ]\n\n lecture objectives:\n⇨ Modes of presentation of Rheumatoid Arthritis\n⇨ Pathology of Rheumatoid Arthritis\n⇨ Investigations and management\n⇨ Differential Diagnosis for pt with polyarthritis\n\n Done By: Rawan Aldhuwayhi & Nouf Altwaijri\nRevised By: Luluh Alzeghayer\nReferences: Doctors’ Slides+Davidson+step up to medicine \n\n Rheumatoid Arthritis(RA) :\nscenario:35 female with multiple symmetrical General Characteristic of RA: small joint pain: first think about RA then SLE \nWhat is it:\n- RA is Systemic chronic inflammatory disease Mainly affects synovial joints,It is a systemic disease\nthat has many extra-articular manifestations.\n- Variable expression:Disease severity is variable some patients have moderate restrictions and are\ncapable of performing activities of daily living, whereas others are confined to a wheelchair or bed. \nEpidemiology:\n- Worldwide distribution:Prevalence about 3%\n- Female:male ratio 3:1\n- Peak age of onset: 25-50 years, it can happen to anyone,There is a juvenile type that occurs in children. \nEtiology:\n- Etiology is uncertain(What we know for sure is that it's autoimmune): It may be caused by an\ninfection or a series of infections(most likely viral), or environmental factor like smoking but genetic\npredisposition is necessary ‘associated with HLA-DR4’.\n\nPathophysiology of RA: \nThe Pathology of RA (RA Can Cause):\nNodules Vasculitis Synovitis\n\n 3 major sites of rheumatoid synovitis:\n(Joints Tendon sheaths Bursae) \nComparison between healthy joint and Rheumatoid Arthritis:\n\n Pannus tissue adheres to\narticular cartilage, and the\ncells within\nthe pannus produce\nproteinases that can destroy\ncartilage.\n\n healthy joint RA Is Characterized by Synovitis leading to formation of (PANNUS)\nThickened synovium, called pannus and this will invade the cartilage, it\nwill be seen on radiology as erosion (invasion of cartilage and bone) \n\n Pathogenesis of RA ‘at cellular level’ \nhighly recommended video(3 min)\n\n Invasion of inflammatory cells, T\ncells, B cells, &plasma cells are\npresent in the synovium and in\nthe fluid. The fluid will be mostly\ncomposed of neutrophils. \nActivation of B cells, T cells,\nproduction of autoantibodies\n(Rheumatoid factor), cytokines,\ninterleukins, TNF - production of\ndestructive enzymes - more\ninflammation\n\n IL-1 and TNF-a Have a Number of Overlapping IL-1 Plays a Pivotal(crucial) Role in the Inflammatory\nProinflammatory Effects: and Destructive Processes of RA\n\n Explanation: IL will lead to the accumulation of different components of the immune\nsystem, activation of monocytes will lead to inflammation, fibroblast proliferation will\nlead to synovial pannus formation (further thickening) chondrocytes will lead to\ncartilage destruction, and osteoclasts will lead to bone resorption (destruction)\n\nSigns and Symptoms: \nJoint inflammation:\n- on symmetrical pattern(both side equally). \n- Signs & symptoms:’signs of inflammation’ warm swollen joints(joint swelling is the most common\nsign),Tender, Pain and morning stiffness(morning stiffness prolonged in RA more than one hour\nwhile in osteoarthritis less than half hour \n\n - Joint Involvement On Presentation Of Ra:\n○ 25% of cases presented with monoarticular(one joint involved): 50% of them have Knee\ninvolvement only, while other 50% have shoulder,wrist,hip, ankle,or elbow involvement.\n○ 75% of cases presented with Polyarticular(more than one joint involved):%60 of them have\nsmall joints of hand & feet involvement only, while other 30% have large joint involvement\nonly, and 10% have BOTH small & large joint involvement.\n\n Joint involvement in RA Classically: symmetrical\npolyarthritis (many joints) but can present with\none or two joints and any joint can be involved\nEXCEPT DIP.\n Examine all the joints, temporal,\nsternoclavicular, any other joint can be involved\n\n Articular features seen in the Rheumatoid Hand\nWrist Metacarpophalangeal Joints Synovitis Prominent ulnar styloid Subluxation1 and collapse of carpus Radial deviation Ulnar Deviation Subluxation Synovitis\n\n Ulnar one at the\nsynovitis Subluxation and Pulling of the tendon metacarpophalangeal\ncollapse of carpus\nleads to radial deviation joints \nProximal Interphalangeal Joints Thumbs\nSynovitis Fixed flexion(boutonniere deformity) Fixed extension(Swan neck ) Z deformity Synovitis\n\n Inflamed synovium\n\n inflammation of PIP joint result in swollen,spindle\nlike finger localized in RA unlike seronegative\nspondyloarthritis the whole digit is swollen\n\nRead them just in case: Articular features seen in Rheumatoid foot: Articular features seen In Knee & popliteal: Hammertoe is a contracture Popliteal (‘Baker’s’) cysts may occur in combination with knee (bending) deformity of one