Keyword by Investigation, Refferal to specialist and writing hospital charts by RA 4/5 (1)

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The diagnosis is based on

Symptoms and medical examinations

  • Arthritis (radiological: / Ultrasound / MRI) detected erosions?
    • Small joints: fingers, wrists, toes, jaws
    • Large joint: Shoulder, elbows, hip knees, ankles
  • High values ​​of ACPA (CCP antibody)
  • High values ​​for CRP and lowering reaction (SR)
  • Symptoms of duration of at least 6 weeks

Disease history

Family load (first degree family = parents, siblings, children)

Joint

  • Acquired joint pain
  • Arthritis The feeling of swelling, especially in fingers (rings no longer fit, reduced grip), toes ("cushions"), wrists and ankles
  • Stiffness in joints, especially in the morning 1-2 hours before it gets better
  • For the function, not necessarily the number of sore and swollen joints is crucial, but if it is essential joints that are affected

Neck Pain

  • Arthritis in atlanto-axial joints

Jaw Pain

  • Arthritis in the jaw joints

Osteoporosis (long-term corticosteroid use)

  • Compression fractures in the columna, other fractures

Symptoms of the internal organs, skin and nervous system

Pulmonary symptoms

  • Dyspnea at physical stress
  • Dry cough

Heart

  • Pericarditis

Skin

  • Rheumatic nodes
  • Eczema
  • Echymoses (corticosteroid induced)
  • Vasculitis (in nail beds or more prevalent rheumatoid vasculitis)

Eyes

Nerves

  • Reduced sensitivity or force in the feet or hands
    • Unilateral or bilateral?
    • Progression?
  • Blood tests

Clinical examination

Swollen joints (arthritis)

  • Spool-shaped swelling in the finger's PIP
  • Swelling over MCP ("knuckles")
  • Tying deficiencies (fingertips do not reach the palm of the hand)
  • Pain on movement to the extremities (wrists, shoulders)
  • Pain on pressure across toes (MTP joint)
  • Increased heat in the skin above the joints (especially knees and ankles)
  • Hydrops ("water") in the knees
  • Reduced extension of elbows
    • Number of degrees missing on full extension
  • Reduced ability to gape (jaw)
    • The number of cm spacing between incisors at maximum gape capability
    • Lower jaw deviation (against the affected side)

Contractions (lack of active and passive extension)

  • Joint deformities (after prolonged illness)
    • Ulnar deviation in the fingers MCP joints
    • Swan neck deformity in fingers
    • Buttonhole deformity in fingers
    • Z-deformity (90-90 position) in thumbs
    • Bajonette position in the wrist (hand backs lowered to the forearm)
    • Feet with width-increased forefoot and sunken MTP joints (pressure points)

Skin

  • Rheumatic nodes
  • Echymoses (corticosteroid induced)
  • Vasculitis (in nail beds or more widespread)

Rheumatoid knots

  • Most often located on the extensor side of elbows, fingers, in the lungs of aCCP positive
  • Methotrexate may increase the number of rheumatoid nodules

Pulmonary abnormalities

  • Pleural fluid / pleurisy
  • Nodules In your lungs
  • Fibrosis
  • NB Treatment with Metotrexate and TNF inhibitors may cause interstitial lung disease (ILD)

Heart

  • Auscultation: Regular rhythm, no rubbing sounds (pericarditis)

Nerves

  • Reduced sensitivity or force in the feet or hands
    • Unilateral or bilateral?

The eye

Radiological examinations

  • Ultrasound or MRI examinations can show early changes in joints
  • X-rays or CT examinations of the lungs can detect lung manifestations
  • The ultrasound of the abdomen should be done if suspected hepato splenomegaly (at Felty syndrome or LGL syndrome)

Blood tests

  • CRP and lowering response (SR) are elevated in most RA patients
  • CCP antibody (ACPA) occurs in most people
    • "Revma factor" is not specific

Consider differential diagnoses

Severe disease progression / poor prognosis

  • High inflammation parameters
  • High number of swollen joints
  • High Values ​​of CCP Antibody (ACPA)
  • Early erosions
  • Poor treatment response to two or more DMARDs
  • RA vasculitis

Referral to specialist

Distribution of function in Oslo. In Oslo there is a distribution of functions within rheumatology. Adult patients with rheumatoid arthritis (RA) should be referred to Diakonhjemmet hospitalwhile connective tissue disorders, systemic vasculitides og children with rheumatic diseases shall be considered by Oslo University Hospital, Rikshospitalet

Norwegian Directorate of Health (Supervisor for referrals)

Follow-up by a specialist

Regular follow-up of a specialist in rheumatic diseases is internationally recommended for active inflammation, progressive disease or when treatment is given with immunosuppressive drugs (DMARDs or biological drugs).

The role of the specialist is to assess disease activity and signs of side effects. One can not expect patients, GPs and other healthcare professionals to have sufficient competence:

  • If the disease has resolved, it is a specialist task to assess whether the drug doses can be reduced or treatment terminated.
  • The specialist can assess whether the drugs have lost their effect over time
  • Younger patients may want to become pregnant. At the forefront, changes in medication are often required
  • Older people often get other diseases and drugs that affect the anti-rheumatic drugs. Overdose or loss of action is then possible. The specialist is aware of this and may change the treatment
  • When the disease is in a stable phase without special medication, there is no need for follow-up by a specialist
  • Internationally approved recommendations for the follow-up have been prepared and published (EULAR recommendations; Smolen JS 2017)

RA disease develops very differently from person to person and the treatment response is also individual. Nevertheless, the course is generally much milder now than before methotrexate and the newer drugs came on the market. This is shown in the fact that the need for joint operations has been greatly reduced among persons with RA.

Rheumatoid arthritis (connective tissue disease)

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