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

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 LupusDiscoid Lupus

ROS - RASH DermatomyositisHeliotrope 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 IBD symptoms infectious diarrhea or STD sx photosensitivity hypercoagulable event heme/renal/CNS or PNS disease sicca pleuropericarditis

AGE

1-15 yo –JCA –Still’s –ARF yo –SLE / RA –SNSA’s –PM/DM –DGI –vasculitis

AGE yo –Crystalline (MSU) –OA –Sjogren’s 65 + –PMR –GCA –Crystalline (CPPD, MSU, others)

GENDER

MEN -MSU crystals -OA of knees -AS -Reactive (Reiter’s) WOMEN -RA -SLE -Sjogren’s -OA of fingers

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 - LOCATION

LOCATION OA RA / SLE SNSA CRYSTALLINE PERIARTICULAR

OA C-SPINE

OSTEOARTHRITIS HIP

OSTEOARTHRITIS

OSTEOARTHRITIS AVN

OSTEOARTHRITIS

OA

SNSA

SNSA - ANKYLOSING SPONDYLITIS

SNSA - AS

CRYSTALLINE ARTHRITIS

GOUT

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

Plain films Bone scan MRI

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

Educate Adapt “Autoimmunity as allergy” Complementary treatments

PERIOPERATIVE MANAGEMENT

RA Corticosteroids NSAID’s ASA COX-2’s PHTN Conduction blocks

QUESTIONS

RA & C-SPINE