Dr(Lt General) Ved Chaturvedi MD.DM

Sr Rheumatologist ,Sir Ganga Ram Hospital

New Delhi

• President Delhi Rheumatology Association ,ex president Indian

Rheumatology association ex HOD Rheumatology Research

&Referral Army Hospital new Delhi

• First Rheumatologist in the country

>to use new therapy for arthritis called Biologics since 2000

>to establish MSK Ultrasound &Medical Arthroscopy in 2003

Dr (Lt General) Ved Chaturvedi, MD, DM

SGRH

President Delhi Rheumatology Association

Dr (Lt General ) Ved Chaturvedi MD.DM

Early diagnosis of inflammatory Polyarthritis including Rheumatoid Arthritis

Mo ility…..Pai ful paralysis

Ved Chaturvedi. MD, DM

1991 :super specialties perceptions

Cardiology…..ECHO,Angioplasty

Gastro………Endoscopy

Neurology……MRI Endocrine ..Hormones

Rheumatology Nothing

Antibodies…..Pathologist Scopes…….??

Perception of peeping in joint

Respect in society

Immediate diagnosis

Direct patient-doctor relationship

MSK Ultrasound

2003 2004

Rheumatic diseases…….

Sir William Osler

“Medicine is a science of uncertainty and an art of probability”

Approach to a patient with musculo-skeletal pain. Musculoskeletal Pain

Periarticular Articular

Non-inlammatory Inflammatory

OA ,Hypothyroidism

Inflammatory Vs

Non-inflammatory Arthritis

Inflammatory vs. non-

inflammatory joint diseases

crucial because it is a question -Benign vs Non Benign

Entirely different management

Inflammatory Vs

Non-inflammatory Arthritis Inflammatory (History 80 %)

• worst after rest

• Improves after exercise

• Constitutional symptoms

• Fluctuation in disease activity

• ESR,CRP High

• Acute phase reactants High

• Low hemoglobin

Inflammatory Vs Non-inflammatory rheumatic diseases

Inflammatory

Rheumatic diseases

Non-Inflammatory

Rheumatic diseases

Examples

Morning stiffness

Pain aggravation

Spontaneous flares

Acute-phase reactants like ESR,CRP

RA, SpA,SLE OA, Trauma, hypothyroidism

>30 min <30 min

On resting the joint On moving the joint

Common Uncommon

Increased Normal

Acute-phase reactants

Rise in platelet count and low hemoglobin

Approach to a patient with musculo-skeletal pain.

Musculoskeletal Pain

Periarticular Articular

Non-inflammatory Inflammatory

OA Hypothyroidism

Monoarthritis Oligoarthritis Polyarthritis

Gout Septic / TB arthritis

Gout SpA

Psoriasis

RA SLE

Psoriasis

Mode of onset

Acute

Insidious

Duration

Acute/Self-limiting

Chronic

Number of affected joints

Monoarthritis

Oligoarthritis

Polyarthritis

Distribution

Symmetrical/Asymmetrical

Lower limbs versus upper

Small versus large joints

Specific joints

Extra articular features

Fever

Mucocutaneous lesions

Eye involvements

Nodules

Sequence of involvment

Intermittent

Additive

Migratory

Pattern recognition in musculo-skeletal diseases

Annals of Rheumatic disease : 2015 Oct

1995 Pt

Data from Norfolk UK

RA

Undifferentiated Arthritis

Spa

Psoriatic

Inflammatory OA

CTD

Sarcoid

Malignacy

The Physi ia s approa h

Diabetic

Thyroid

Anemia

Paraneoplastic (Multiple Myeloma, Leukemia, Lymphoma)

Infections

Hyper mobility syndrome

Fibromyalgia

Depression

Viral diseases

Neurological disease

Primary bone disease

Drugs

The Physi ia s approa h

System review : Emphasize Skin

Eyes

GIT

Genito-urinary

Renal

Symptoms suggestive of involvement of – CVS, RS, Hematological or CNS

Arthralgia Vs Arthritis

Red & Blue method

Inflammatory Vs

Non-inflammatory Arthritis

Inflammatory Arthritis

EMS

Stiffness & swelling is worst after rest

Stiffness gets better with activity

Fatique

Increase ESR/CRP

Hb low

Ved Chaturvedi. MD, DM

Early Rheumatoid Arthritis:

A medical emergency

Larry W. Moreland

Am J Med 2001;111:498-500.

Ved Chaturvedi. MD, DM

Ved Chaturvedi. MD, DM

No Gold standard test

RF

Anti CCP Ab

Anti Carbamylated protein ab

)

Two prototypes

Young Females

Hand joints

Lower limb joints+

Synovial pathology

RF

Young Males

Spinal joints

++++

Ligaments pathology

HLA B27

RA SPA

Dr Ved Chaturvedi, MD.DM vedchaturvedi@hotmail.com

OA Old age

Chronic

Oligo / Polyarticular

Non-inflammatory

DIP joint

Systemic Connective tissue diseases Young adults

Females > Males

Chronic

Non deforming

Arthritis

Fever

Skin rashes

Multiple organ -

involvement

42

Dermatomyositis SLE

42

Rash-Dermatomyositis v/s SLE

Heliotrope rash Cutaneous hallmark

feature of DM Pruritic, sometimes

burning, Violaceous, confluent

erythema resembling the color of the heliotrope( a red/purple-colored flower

tracking the course of the sun)

Characteristic distribution, involving especially the periorbital area

Shawl sign Macular rash

Posterior neck and shoulders

Gottron´s papules 1 mm in size

Violaceous/pink/dusky red papules

located over the dorsal side of metacarpal or

interphalangeal joints

may also occur over the extensor side of the wrist, elbow or knee joints.

pathognomonic of DM

Extra-articular features Fever

SLE Systemic onset JIA Infective endocarditis AOSD Vasculitis

Skin and mucosa involvement

SLE Psoriasis Behcet’s reactive arthritis Vasculitis

Nail changes

Psoriasis

Extra-articular features Eye

SSA

Vasculitis

Sjogren’s syndrome

Nodules

RA

OA

Gout

Rhemautic fever

Erythema nodosum

Vasculitis

Investigations Hemogram

CRP

LFT

RFT

Radiograph chest and affected joints

Autoantibodies : RF, CCP, ANA, DsDNA, ENA, Cardiolipin, HLA B27

Blood sugar, T3, T4, TSH.

Viral markers

Uric Acid & Synovial fluid analysis

Synovial Research unit

Crystals

Picture 002.jpgPicture 002.jpg

Histoplasmosis

Synovial Chondromatosis

Multiple cartilaginous bodies in the synovium

Pigmented Villo Nodular

Synovitis

Golden brown hemosiderin in deep macrophages , giant cells

Amyloid Arthritis

Amyloid deposits in primary amyloidosis

Take Home Lessons:

Tools for aki g diag osis Clinical history -

Physical examination -

Laboratory investigations -

In musculoskeletal diseases (MSDs) how much is contributed by each of the above?

(ACR - Arthritis Rheum 1996; 39: 1-8)

17 December 2015 Prof. Anand Malaviya 55

80%

15%

5%

1. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975;2:486–9. 2. Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J 1980;100:928-31. 3. Peterson MC, Holbrook JH, Hales DV, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in marking medical diagnoses. West J Med 1992;56:163–5. 4. Pryor DB, Shaw L, McCants CB, Lee KL, Mark DB, Harrell FEJr, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118:81–90 5. Castrejón I, McCollum L, Tanriover MD, and Pincus T. Importance of patient history and physical examination in rheumatoid arthritis

compared to other chronic diseases: Results of a physician survey. Arthritis Care Res (Hoboken) 2012; 64(8), 1250-5.