approach to the patient with possible rheumatic disease
TRANSCRIPT
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
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
• “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
SLEVasculitisPM/DMMCTD
ROS - PSORIASIS
Psoriatic arthritis
ROS - RASH
Reactive arthritis
ROS - CONJUNCTIVITIS
Reactive arthritis
ROS - UVEITIS
Behcet’sSNSA’s
ROS - RAYNAUD’S
SclerodermaSLEDM/PMMCTD
ROS – ORO/GEN ULCERS
SLEBehcet’s
ROS - POLYCHONDRITIS
Relapsing polychondritis
ROS - ENTHESOPATHY
SNSA’s
ROS - NODULES
RAGout
ROS
• 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– 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
• 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
OAC-SPINE
OSTEOARTHRITISHIP
OSTEOARTHRITIS
OSTEOARTHRITISAVN
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– 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
• Synovial fluid
• ESR
• RF
• Anti-citrulline
• ANA
• HLA-B27
• Specific autoantibodies
IF NO SYNOVITIS…
• 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– 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
• RA
• Corticosteroids
• NSAID’s
• ASA
• COX-2’s
• PHTN
• Conduction blocks
QUESTIONS
RA & C-SPINE
RA & C-SPINE