RHEUMATOLOGY:

Patient is usually someone who has RA / Lupus / scleroderma

Why/Types of Patients:

Lupus - sclero: cuz they have ulcers, for prostacyclin infusions

RA- outpts (most likely smurift) usually burnt out disease: could be on DMARD/
immunosuppresive agents

Septic Arthritis also a reason, common with ppl with underlying bone disease so
superimposed on RA is v common

Patients could be on Kidney Ward: SLE/Scleroderma may have renal F as well.

Knee Replace/Hip Replace in OA: ask about post op course.

If young and have hip fractures: probs osteoperosis, if less than 65 and surgical
procedure should be thinking early onset osteoperosis & look for RFs - smoking + female
+ long term steroids + poor mobility + poor weight bearing + renal F + CF + asians living in
western countries.

RA:

- patient active or burnt out disease?

> Pain (worse in morn? how long? stiffness ass? stiffness worse in morn, take more than
an hour for it to go away?
> Swelling - worse in PIP? MCP? spare DIP? any warmth ? affecting any function?
difficulty using joints ? always this way? can you feed yourself? can you drive? can you
dress?

- If no to all above - probs burnt out

- so now ask
> when was your last admission/ outpatients and why were you there?
> How often are you getting flames - so in last 2 yrs how many times did you come in to
hospital, how many times did you go to GP?
>how many times did you have to change your meds? high dose steroids? change from
DMARD to biological?

- any previous problems with hands? Joints?

> Any surgical procedures done ( tendon release / joint fusion / joint lavage / joint
replacement / aspiration / release of carpal tunnel )

- extra articular manifestation?

>peripheral neuropathy - do you see neurologist? Pins and needles in your feet hand?
difficulty walking cuz numbness? any ulcer or cuts cuz of numbness? ever told they have
carpal tunnel syndrome? ever had an Xray of back of neck to look for axial subluxation,
any operative procedure
> dry eyes? eye drops? eye man of RA?
> ever told fluid around their heart? ever had to remove fluid from around the heart?
personal history of heart attack or stroke as they are at higher risk when they have RA.
> Have you been told you have pul fibrosis? ever dry cough? (usually those on long term
methotrexate Tx) ever been told they have fluid on their lungs?
> ever told they have a low blood count, taking iron? folate? B12 injxns?
> Increased bleeding tendency? platelets low? ever been told they have a big spleen?
> do they see kidney doc on reg basis? told protein in urine? on any tabs for kidney
disease? on dialysis?

Scleroderma:

Usually starts with Raynauds, this progresses to ulcerations on tips of fingers. sometimes
this heals on own. Patients may have hx of this happening in past.

Eventually they dont heal properly cuz its a vasculitic process -> microaneurysms and
microemboli, this is already in inflamed vessels so theyre narrowed.

All of this leads to ischemia, and because they are constantly inflamed they are poor
healers cuz their body has a lot of cytokines.

They can also get superimposed infection on top. Usually staph or strep.

Eventually ulceration can lead to gangrene, at this stage > amputation.

This patient may be on surge or rheum team. Main thing we use is prostacycline infusion
in order to dilate the vessels, this has unpredictable results. They can also use
phosphodiesterase inhibitor.

Things to Ask:

When did this start? did it happen before? how many fingers are involved? sudden or
gradual? cuz if its gradual more likely that its due to combo of gradual vasculitis and
gradual inflamation of vessels. Wereas if sudden may have larger embolis so treat it like
an acute ischemic limb.

Also worthwhile asking if they can feel it? any pain in it? If theres no feeling it suggests that
they need to amputate it.

Asks the 5 Ps of acute. Were they given infusion to open up arteries? Were they put on
Abxs? did they see a vascular surgeon? are they planning to see one? DONT mention if
someone going to amputate, they might not know, just ask if anyone talked to you about
any operations you might need?

How to distinguish CREST and limited scleroderma?

- CREST - nodules on elbows, hand change color in cold? difficulty swallowing? lost wt?
dyspepsia? reflux? sclerodactyly? noticed any red marks on face? (talengectasia)

- When examining - tight skin above elbows = diffuse, if to elbows and below = limited

- Scleroderma with non cut = osoph dysmotility/ vasculitis / renal disease no skin man
Septic Arthritis:

- unilat, painful, swollen joint with or without of trauma hx, on background of previous
injury/rheumatological condition.
- Hx Pain, swelling , nausea, vom, fever, sweats.
- Then ask rheum stuff as well if they tell you they have background Hx of rheum. Can be
because of an injury if younger, if older think of underlying rheum condition.

SLE:

Patients with lupus are very immunosupressed, so can come in with any type of infection.

Things you need to know about Rheum meds:

Patients usually on Analegesia +/ DMARD +/- Biological

Analgesia usually paracetamol + NSAIDS (naproxen? Difene?)

Common DMARDS (steroids / methotrexate)

If on methotrexate - do you take it once a week? Do you get your liver tested? (Normally
first line is methotrexate, however affects fertility so that could be a reason not to start it. )

Indication of biological agents:

1- failure of 2 previous DMARDS

2-if they have high RA titre, very severe symptoms, may commence them 1st line -
however this is an unlicensed indication
3- can also start them if trying to get pregnant)

Common SEs:

NSAID: gastric erosion, gastritis, GI bleed - usually also no PPI

COX 2 ihibitors may demonstrate increased risk of ischemic heart disease (arcoxia)

Methotrexate: liver cirrhosis, anemia as a result of folate deficiency (macrocytic

megaloblastic anemia)

macrocytic = determined by MCV / megaloblastic = blood smear (big cell that has many
nuclei).
Macro with normoblast = thyroid disease / preg/ liver disease / reticulocytosis.
Macro with megaloblast = they are immature cells so it means prematurely released from
bone marrow so B12/folate def and some types of reticulocytosis. Alcohol causes both -
alcohol can cause liver and folate def.

Steroids: have they had a bone scan done? baseline DEXA, if impaired start
bisphosphonates. Follow up bone density if on steroids is 6 months - a year. Blood sugars
norm/high? can get hypergly 2 to steroids so you give them insulin. increased appetite?
mood changes?

Cyclophosphamide: bone marrow supression/increased succeptibility to infection (no need

to know too many details here.
Biological agents: etanercept usually used. main SE: flu like symptoms initially, pain at the
site, bone marrow supression but its less common. Can precipitate symptoms of heart
failure.

ACE inhibitors: important, esp if scleroderma, cuz of renal disease. Prevents renal crises.

Social history: how is this affecting your life, what modifications, are you working? whats
your job? manual labour? are you retired? smoking ? bedroom/bath downstairs? walk in
shower? modified utensil (special fork/knife with grip on them).
RENAL:

- Often inpatients getting dialysis, so can be acute or chronic.

- If outpts usually chronic. This tut will be on chronic Kidney disease.
- Diabetes usually, hypertension or glomerular nephritis ( the glomerulonephritis pts usually
dont know why they have chronic kidney disease) , adult polycystic kidney disease.

When theyre inpt this is because of worsening kidney failure/scheduled dialysis/

complication of dialysis/worked up pre transplant/post transplant.

Pts started on Dialysis:

- Why?
>GFR less than 15 thinking about dialysis, less than 5 absolutely.
>fluid overload
>jump in creatinine
>hyperkalemia, uremia
> jump in BP.

- May have fistula for past 6 months, may have central line already there.

- Main cause of death for patients on dialysis : ischemic heart disease, so important to ask
if previous MI? previous angina? did they have angio? CABG ?

Pts on dialysis, but now here cuz compln:

1- Peritoneal:

- May have stopped working (symptoms return to pt presents to hosp)

- May have infection (skin more common than peritoneal)(if you have one ep of peritonitis
cant have peritoneal dialysis ever again. if two eps of cellulitis cant have peritoneal
dialysis.
- May have effusion problems so resp symptoms

2- Hemodialysis:

- skin/line infections (pull line + treat systemically with IV)

- line obstruction

3- pre transplant patients:

- living related? means it was planned for a while.

- have reg blood tests/immunotyping/patient matching/cardiac screen -echo and stress
test , PFTs if abnorm - V/Q scan/ dental exam + dental carries removal.

4- Post Transplant patients:

-post op Hx: how many days out? just transplant or nephrectomy at same time? GA? do
they know their renal function tests a day after transplant? usually urea & creat fall if
successful, if they have rejection it falls then have a spike 24 hrs after, and this indicates
rejection - u ask this by asking did they biopsy your kidney (this is what you do if you think
rejection)
-any blood transfusions?

-what new meds? usually high dose steroids and immunosuppressive agents

Past med Hx?

What was the cause of chronic kidney disease, if they dont know its usually
glomerulonephritis.

- DM - when diagnosed? sugar level,HbA1c etc diabetes Qs? Kidney/Pancreas transplant?

- Polycystic - HT? UTI? scan of head to look for aneurysm? anyone in the family with this?
- Which complications of kidney disease do they have?
- Hypertension (last BP reading? how many agents are they on? ACE? )
- Anemia ( on epo? B12? Folate? )
- Renal osteodystrophy (low Vit D -> Ca -> high parathyroid -> 2 hyper para -> 3
hyperpara) May be on VitD, phosphate binder, bishosphonates. Ask about their bone
health.
- Any previous transplants? could be on dialysis cuz failed transplant, could have worked
for 10 years, then failed, so not acute rejection. These patients would have previous
fistula (non dom arm) /transplant (RIF) /new transplant (dom arm).

Social Hx:

- what are their dialysis days, what times do they come in? Nights (so can work next day).
usually 3 day a week schedule, how does this affect you?

- those on PD at home usually are on ground floor, have a hospital bed, have all the
equipment at home

Fam Hx:

Polycystic Kid/uncontrolled HT in fam/DM in family?