approach to the patient with possible rheumatic disease
TRANSCRIPT
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APPROACH TO THE PATIENT WITH POSSIBLE
RHEUMATIC DISEASE
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INTRODUCTION
PATIENT• 1/7 visits are for a
MSK complaint• Patient wants relief• Patient wants an
explanation
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 ??
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OVERVIEW OF TALK
• “Rheum Hx” • “Rheum ROS”• Focused PE• Laboratory evaluation• Imaging • Pattern Recognition• The Elderly• Management• Perioperative Care
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NOT COVERED
• Individual disease states
• Autoantibody testing
• Specific treatment modalities
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THE RHEUMATOLOGIC HISTORY
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JOINT PATTERN
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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]
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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
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ENTHESOPATHY
SNSA’s:- Reiter’s- AS- Psoriatic- IBD
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REITER’S SYNDROME
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The “Five” Minute Rheumatologic Review of
Systems (ROS)
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ROS - RASH
Acute Cutaneous Lupus Discoid Lupus
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ROS - RASH
Dermatomyositis Heliotrope rash
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ROS - RASH
Palpable purpura - HSP
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ROS - RASH
Livedo reticularis – APLA Syndrome
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ROS - ALOPECIA
SLE
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ROS - PERIUNGUAL CHANGES
SLEVasculitisPM/DMMCTD
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ROS - PSORIASIS
Psoriatic arthritis
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ROS - RASH
Reactive arthritis
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ROS - CONJUNCTIVITIS
Reactive arthritis
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ROS - UVEITIS
Behcet’sSNSA’s
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ROS - RAYNAUD’S
SclerodermaSLEDM/PMMCTD
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ROS – ORO/GEN ULCERS
SLEBehcet’s
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ROS - POLYCHONDRITIS
Relapsing polychondritis
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ROS - ENTHESOPATHY
SNSA’s
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ROS - NODULES
RAGout
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ROS
• IBD symptoms
• infectious diarrhea or STD sx
• photosensitivity
• hypercoagulable event
• heme/renal/CNS or PNS disease
• sicca
• pleuropericarditis
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AGE
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AGE
• 1-15 yo– JCA– Still’s– ARF
• 20-45 yo– SLE / RA– SNSA’s– PM/DM– DGI– vasculitis
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AGE
• 45-60 yo– Crystalline (MSU)– OA– Sjogren’s
• 65 +– PMR– GCA– Crystalline (CPPD, MSU, others)
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GENDER
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GENDER
MEN- MSU crystals- OA of knees- AS- Reactive (Reiter’s)
WOMEN- RA- SLE- Sjogren’s- OA of fingers
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FAMILY HISTORY
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FAMILY HISTORY
• Nodal osteoarthritis
• SLE
• RA
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PATTERN OF ONSET
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PATTERN RECOGNITION
• Acute
• Indolent
• Brief and relapsing
• Migratory
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PATTERN RECOGNITION ACUTE
Parvovirus infection
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PATTERN RECOGNITION ACUTE
Sarcoid / Lofgren’s Syndrome
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PATTERN RECOGNITION INDOLENT
Rheumatoid arthritis
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PATTERN RECOGNITION BRIEF & RELAPSING
SLE
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PATTERN RECOGNITION MIGRATORY
Acute Rheumatic Fever
Disseminated GC
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The “Five” Minute Rheumatologic Examination
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PE – LOOK FOR SIGNS OF SYSEMTIC DISEASE
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“FOCUSED” FIVE MINUTE EXAM
• alopecia• nasal / genital / oral
ulcers• rash• synovitis – joint
inflammation• cutaneous vasculitis• adenopathy / HSM
• enthesitis• dactylitis• xerostomia• mononeuritis
multiplex• pleuropericarditis
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PE - RASH
Keratodermia blenorrahgica – Reactive arthritis
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PE - RASH
Circinate balanitis - Reactive arthritis
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PE - RASH
ECM - Lyme
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PE - RASH
Gottron’s papules - DM
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PE - VASCULITIS
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PE - PERIUNGUAL CHANGES
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PE - PERIUNGUAL CHANGES
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PE - LOCATION
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LOCATION
• OA
• RA / SLE
• SNSA
• CRYSTALLINE
• PERIARTICULAR
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OAC-SPINE
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OSTEOARTHRITISHIP
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OSTEOARTHRITIS
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OSTEOARTHRITISAVN
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OSTEOARTHRITIS
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OA
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OA
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SNSA
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SNSA - ANKYLOSING SPONDYLITIS
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SNSA - AS
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CRYSTALLINE ARTHRITIS
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GOUT
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PE – JOINT EXAMINATION
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PE – JOINT EXAMINATION
• Synovitis
• Soft tissue
• Crepitus
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SYNOVITIS OR BONY OVERGROWTH ?
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LABORATORY
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LABORATORY TESTING
• NO “screening test” for presence of a rheumatic disease– 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!
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LABORATORY TESTING
• Synovial fluid
• ESR
• RF
• Anti-citrulline
• ANA
• HLA-B27
• Specific autoantibodies
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IF NO SYNOVITIS…
• LFT’s
• TSH
• Hep serologies
• Ca, PO4, albumin
• Alk phos
• Ferritin, Iron, TIBC
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IMAGING STUDIES
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IMAGING STUDIES
• Plain films
• Bone scan
• MRI
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CLINICAL SYNDROMES
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CLINICAL SYNDROMES
• Monoarthritis / Oligoarthritis
• Polyarthritis– Symmetric and brief– Symmetric and sustained– Asymmetric and migratory– Asymmetric and spondylitic
• Arthralgia and/or Myalgia w/o Synovitis
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FIBROMYALGIA
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APPROACH TO ELDERLY PATIENTS
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APPROACH TO ELDERLY
• PMR
• GCA
• Crystalline
• DJD
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PMR
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GIANT CELL ARTERITIS
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CPPD
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MANAGEMENT
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MANAGEMENT
• Educate
• Adapt
• “Autoimmunity as allergy”
• Complementary treatments
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PERIOPERATIVE MANAGEMENT
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PERIOPERATIVE MANAGEMENT
• RA
• Corticosteroids
• NSAID’s
• ASA
• COX-2’s
• PHTN
• Conduction blocks
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QUESTIONS
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RA & C-SPINE
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RA & C-SPINE