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- 64 y.o. male
- Upper neck & suboccipitals - Onset 8 yrs ago for no apparent reason - Episodic & fluctuates in severity - Overall getting worse & more persistent |
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-6/10 at worse
- "Sore" & "deep pressure" w/ stiffness - Worse in the morning & gets bit easier w/ movement / activity after approx. 1hr |
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AF: Inactivity
RF: NSAIDs partially improve the pain (paracetamol doesn't help) |
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Extras
- Kidney stones - Currently awaiting hospital investigation for a chronic cough & recurrent bronchitis - Ibuprofen for current complaint - Atorvastatin 20mg/day (preventative) - Sometimes wakes due to pain when it's worst - Early in the morning (around 4-5am) - Mother: hypertension from 40 y.o., died from a stroke at 72 y.o. - Father: died from MI at 65 y.o. - Brother: hypertension @ 55 y.o.; survived MI @ 60 y.o. - Imaging revealed RA in hands but no complains of Sx |
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BMI: 26.8
- Pulse: 80 - BP: R - 140/78; L - 138/80 |
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Posture / stance
- Upper crossed w/ anterior head carriage |
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Reflexes
- DTRs UL & LL all 3+ bilaterally - Flexor plantar response |
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ROM
- AROM Cx: all mildly restricted & painful @ end range - Gentle PROM: w/ no overpressure as AROM |
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TTP
- Upper Cx: U traps, suboccipital & scalenes TTP w/ no referral B |
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Supine Cx motion palpation: little less stiff than seated
- Palpation: mid - lower Tx spine stiff but no pain - Mild oedema R ankle: non pitting, no pain; no other obvious abnormality observed in extremities |
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Clinical tests
- Cx specialists: no provocation - Wall angel test: failed |
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Working diagnosis
- Rheumatoid arthritis (RA) → Most probable cause of inflammatory neck pain in pts' of this age (& also due to it being most common inflammatory arthropathy i.e. prior probability) - Links w/ non-pitting swelling at the ankle & the respiratory Sx |
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Why is this an unusual case?
- Presents w/ neck Sx & denied any Sx in the hands & feet - Typically involvement of the spine occurs yrs after the onset of Sx in the distal extremities |
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Differentials to be considered
- Lung cancer for the respiratory symptoms: based on being a past heavy smoker |
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Oedema
- Pitting: cardiovascular - Non-pitting: joint inflammation or infection |
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Rheumatoid arthritis
- Chronic systemic inflammatory disease - Pt w/ RA have an increased risk of developing heart disease - Usually affects distal extremities, bilaterally & symmetrically - Associated w/ increased risk of CVD disease, osteoporosis, anaemia & infection - Peak onset 30-50 y.o. - Associated w/ anaemia ⏺ Presentations: - Symmetrical synovitis of small joints of distal extremities - Pain, swelling, heat & stiffness in affected joints - Pain worse at rest/inactivity - Swelling around affected joint - Early morning stiffness, lasting 1+ - Bumps/nodules under skin (rheumatoid nodules) ⏺ Diagnosis: - No set tests in primary care - Blood tests & x-ray to confirm: C-reactive protein, rheumatoid factor, ESR - Inability to make a fist/flex fingers - Other inflammatory presentations - Family Hx of RA DON'T LET INVESTIGATIONS DELAY REFERRAL FOR SUSPECTED RA ⏺ Management: - NSAIDs until rheumatological appt. - During flare ups: rest - During emission: exercise - Low-impact activities in remission periods - Referral to GP - Exercises for enhancing joint flexibility, muscle strength & managuingother functional impairments |
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How to identify inflammatory arthropathy, how to refer & what the further investigations & management would be?
⏺ Identifying: - Medical Hx & physical exam - Key features: joint pain, swelling & stiffness; distal extremity joint affected; usually bilateral & symmetrical; worse in morning (improves throughout day); fatigue, malaise, other systemic symptoms; family Hx of inflammatory arthritis ⏺ How to refer? - Urgent referral - Written letter to GP for further referral to rheumatologist for investigations ⏺ Further investigations: - Blood tests: rheumatoid factor - C-reactive protein - X-ray ⏺ Management: - NSAIDs - Glucocorticoids - Encourage regular exercise in remission periods, rest w/ flare ups - Exercises fro enhancing joint flexibility, muscle strength & managing other functional impairmens |
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Modify physical examinations according to risk
- Avoid Cx manipulation: RA can damage transverse ligament in Cx - Gentle joint mobility testing - Postural analysis: address misalignment or bracing posture (take breaks as needed or adjust position to suit pt) - Neurological testing (e.g. sensory/reflex): may be difficult to perform, modify/remove altogether if not clinically relevant to pt - Adjust duration & intensity of treatment to suit pt |
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Identify risk factors for cardiovascular disease
- Rheumatoid arthritis (RA) - Increasing age: especially after 55 (F) & 45 (M) - Gender: males at higher risk - Family Hx: of heart attacks, strokes, angina - Hypertension - Cholesterol levels: Hugh LDL, low HDL - Smoking - Diabetes: due to damage to blood vessels & increased inflammation in body - Obesity/sedentary lifestyle: contribute to high BP, cholesterol, diabetes - Stress: increase BP & contribute to inflammation |
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