MRCP General and Rheumatology tutorial.pptx

Preparation for rheumatology station

1. MRCP tutorial By Dr.Sumreen Sarfaraz Rheumatology SPR

2. Introduction 1 Wash your hands and don PPE if appropriate 2 Introduce yourself to the patient including your name and role 3 Confirm the patient's name and date of birth 4 Briefly explain what the examination will involve using patient-friendly language 5 Gain consent to proceed with the examination 6 Adequately expose the hands, wrists and elbows 7 Position the patient sitting with their hands on a pillow 8 Ask if the patient has any pain before proceeding 9 Gather equipment

3. Look 10 Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology 11 Inspect the dorsum of the hands for abnormalities 12 Inspect the palms of the hands and elbows for abnormalities.

4. Feel 13 Assess and compare the temperature of the wrists and small joints of the hands 14 Palpate the radial and ulnar pulse 15 Palpate the thenar and hypothenar muscle bulk 16 Palpate for evidence of palmar thickening 17 Assess median nerve sensation 18 Assess ulnar nerve sensation 19 Assess radial nerve sensation 20 Perform MCP joint squeeze 21 Bimanually palpate the joints of the hand (MCPJ/PIPJ/DIPJ/CMCJ) 22 Palpate the anatomical snuffbox 23 Bimanually palpate the wrist joints 24 Palpate the ulnar border of the forearm and elbow joint

5. Move 25 Assess active finger extension 26 Assess active finger flexion 27 Assess active wrist extension 28 Assess active wrist flexion 29 Assess wrist/finger extension against resistance (radial nerve) 30 Assess index finger ABduction against resistance (ulnar nerve) 31 Assess thumb ABduction against resistance (median nerve) Function 32 Assess power grip 33 Assess pincer grip 34 Assess picking up a small object

6. Special tests 35 Perform Tinel’s test 36 Perform Phalen’s test To complete the examination… 37 Explain to the patient that the examination is now finished 38 Thank the patient for their time 39 Dispose of PPE appropriately and wash your hands 40 Summarise your findings 41 Suggest further assessments and investigations (e.g. neurovascular examination of both upper limbs, examination of the elbow joint and further imaging)

7. Rheumatoid arthritis Symmetrical deforming arthropathy PIP, MCP involvement Sparing of DIP Spindling of fingers Ulnar deviation Deformities ? Palmer erythema Wasting of small muscles of hands ?trigger finger

8. Rheumatoid Hands

9. Questions Diagnostic criteria

10. management General measures Patient education, physiotherapy, occupational therapy, vaccination, Bone protection Pharmacological Treatment NSAIDS CORTICOSTEROIDS DMARDS: sulphasalazine , methotrexate, leflunamide Biological Therapy :anti TNF, IL-1, IL-6 inhibitors, B cell depleting mono clonal antibodies

11. Questions RA cont Serological marker Poor prognostic factors : 1- +test for RA , anti CCP 2- early radiographic evidence of erosive disease 3- impaired functional status 4- persistent disease activity Causes of Anaemia other conditions associated with +RF Sjogren’s syndrome , SLE, Chronic bacterial infection, malignancy, cryoglobulinaemia Other organs affected : eyes, lungs, kidney, immunity, cardiovascular, haematological

12. Psoriatic arthritis Asymmetrical arthropathy DIP involvement , dactylitis , ethesitis Nail pitting, onycholysis , transverse ridging Well defined erythematous plaque with slivery white scales over extensor surfaces

13. Patterns of Joint Involvements in Psoriatic arthropathy

14. Gouty arthritis Asymmetrical deformity and swelling Presence of tophi Olecranon Bursa

15. Questions d/d of single inflamed joint: septic arthritis, gout , mycobacterial, OM, osteoarthris Diagnosis : History : onset, fever, trauma, distribution, associated features, recent travel, predisposing factors joint aspiration : Gout/ pseudogout Blood culture ?role of serum uric acid Management: Rest, rehydration, NSAIDS (Colchicine), IA steroid injection Recurrent gout, topaceous gout , presence of risk factor require long term urate lowering therapy : allopurinol , febuxostat

16. various skin manifestations

17. Scleroderma related hand changes

18. Thank you and best of luck for exam