Transcript Approach_To_Patient_with_Rheum_Disease

APPROACH TO THE PATIENT
WITH POSSIBLE
RHEUMATIC DISEASE
INTRODUCTION
PATIENT
• 1/7 visits are for a
MSK complaint
• Patient wants relief
• Patient wants an
explanation
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INTERNIST
Is this a systemic
process or a localized
issue
Do I embark on a lab
work-up?
Do I “keep” or “send”
NSAID and film ??
OVERVIEW OF TALK
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“Rheum Hx”
“Rheum ROS”
Focused PE
Laboratory evaluation
Imaging
Pattern Recognition
The Elderly
Management
Perioperative Care
NOT COVERED
• Individual disease states
• Autoantibody testing
• Specific treatment modalities
THE RHEUMATOLOGIC
HISTORY
JOINT PATTERN
JOINT PATTERN
• Location (joint or periarticular structure)
• Presence or absence of inflammation
(synovitis)
• Pain character
• Number of involved joints
– mono
– oligo [up to 4]
– poly [5 and up]
JOINT PATTERN
• Site /distribution of affected joints
– Axial or peripheral
– Symmetric or asymmetric
• Presence or absence of enthesopathy –
suggestive of the SNSA’s (AS, PsA,
Reiter’s/Reactive, IBD associated)
– Dactylitis
– Enthesitis or tendinitis
ENTHESOPATHY
SNSA’s:
- Reiter’s
- AS
- Psoriatic
- IBD
REITER’S SYNDROME
The “Five” Minute
Rheumatologic Review of
Systems (ROS)
ROS - RASH
Acute Cutaneous Lupus
Discoid Lupus
ROS - RASH
Dermatomyositis
Heliotrope rash
ROS - RASH
Palpable purpura - HSP
ROS - RASH
Livedo reticularis – APLA Syndrome
ROS - ALOPECIA
SLE
ROS - PERIUNGUAL
CHANGES
SLE
Vasculitis
PM/DM
MCTD
ROS - PSORIASIS
Psoriatic arthritis
ROS - RASH
Reactive arthritis
ROS - CONJUNCTIVITIS
Reactive arthritis
ROS - UVEITIS
Behcet’s
SNSA’s
ROS - RAYNAUD’S
Scleroderma
SLE
DM/PM
MCTD
ROS – ORO/GEN ULCERS
SLE
Behcet’s
ROS - POLYCHONDRITIS
Relapsing polychondritis
ROS - ENTHESOPATHY
SNSA’s
ROS - NODULES
RA
Gout
ROS
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IBD symptoms
infectious diarrhea or STD sx
photosensitivity
hypercoagulable event
heme/renal/CNS or PNS disease
sicca
pleuropericarditis
AGE
AGE
• 1-15 yo
– JCA
– Still’s
– ARF
• 20-45 yo
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SLE / RA
SNSA’s
PM/DM
DGI
vasculitis
AGE
• 45-60 yo
– Crystalline (MSU)
– OA
– Sjogren’s
• 65 +
– PMR
– GCA
– Crystalline (CPPD, MSU, others)
GENDER
GENDER
MEN
- MSU crystals
- OA of knees
- AS
- Reactive (Reiter’s)
WOMEN
- RA
- SLE
- Sjogren’s
- OA of fingers
FAMILY HISTORY
FAMILY HISTORY
• Nodal osteoarthritis
• SLE
• RA
PATTERN OF ONSET
PATTERN RECOGNITION
• Acute
• Indolent
• Brief and relapsing
• Migratory
PATTERN RECOGNITION
ACUTE
Parvovirus infection
PATTERN RECOGNITION
ACUTE
Sarcoid / Lofgren’s Syndrome
PATTERN RECOGNITION
INDOLENT
Rheumatoid arthritis
PATTERN RECOGNITION
BRIEF & RELAPSING
SLE
PATTERN RECOGNITION
MIGRATORY
Acute Rheumatic Fever
Disseminated GC
The “Five” Minute
Rheumatologic Examination
PE – LOOK FOR SIGNS OF
SYSEMTIC DISEASE
“FOCUSED” FIVE MINUTE
EXAM
• alopecia
• nasal / genital / oral
ulcers
• rash
• synovitis – joint
inflammation
• cutaneous vasculitis
• adenopathy / HSM
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enthesitis
dactylitis
xerostomia
mononeuritis
multiplex
• pleuropericarditis
PE - RASH
Keratodermia blenorrahgica – Reactive arthritis
PE - RASH
Circinate balanitis - Reactive arthritis
PE - RASH
ECM - Lyme
PE - RASH
Gottron’s papules - DM
PE - VASCULITIS
PE - PERIUNGUAL CHANGES
PE - PERIUNGUAL CHANGES
PE - LOCATION
LOCATION
• OA
• RA / SLE
• SNSA
• CRYSTALLINE
• PERIARTICULAR
OA
C-SPINE
OSTEOARTHRITIS
HIP
OSTEOARTHRITIS
OSTEOARTHRITIS
AVN
OSTEOARTHRITIS
OA
OA
SNSA
SNSA - ANKYLOSING
SPONDYLITIS
SNSA - AS
CRYSTALLINE ARTHRITIS
GOUT
PE – JOINT EXAMINATION
PE – JOINT EXAMINATION
• Synovitis
• Soft tissue
• Crepitus
SYNOVITIS OR BONY
OVERGROWTH ?
LABORATORY
LABORATORY TESTING
• NO “screening test” for presence of a rheumatic
disease
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neg ANA “rules out” lupus – sensitive test
pos ANA may mean nothing – nonspecific test
pos C-ANCA “rules in” Wegener’s – specific test
neg C-ANCA may mean nothing – insensitive test
• NEVER order an “arthritis panel”
• Use labs to support or refute a clinical impression
or diagnosis – not to make one!
LABORATORY TESTING
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Synovial fluid
ESR
RF
Anti-citrulline
ANA
HLA-B27
Specific autoantibodies
IF NO SYNOVITIS…
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LFT’s
TSH
Hep serologies
Ca, PO4, albumin
Alk phos
Ferritin, Iron, TIBC
IMAGING STUDIES
IMAGING STUDIES
• Plain films
• Bone scan
• MRI
CLINICAL SYNDROMES
CLINICAL SYNDROMES
• Monoarthritis / Oligoarthritis
• Polyarthritis
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Symmetric and brief
Symmetric and sustained
Asymmetric and migratory
Asymmetric and spondylitic
• Arthralgia and/or Myalgia w/o Synovitis
FIBROMYALGIA
APPROACH TO ELDERLY
PATIENTS
APPROACH TO ELDERLY
• PMR
• GCA
• Crystalline
• DJD
PMR
GIANT CELL ARTERITIS
CPPD
MANAGEMENT
MANAGEMENT
• Educate
• Adapt
• “Autoimmunity as allergy”
• Complementary treatments
PERIOPERATIVE
MANAGEMENT
PERIOPERATIVE
MANAGEMENT
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RA
Corticosteroids
NSAID’s
ASA
COX-2’s
PHTN
Conduction blocks
QUESTIONS
RA & C-SPINE
RA & C-SPINE