1. Nurse Practitioner Outreach Wrap up Janet Pope MD MPH FRCPC

2. Objectives 1.To reinforce learnings of the course 2.To present cases of common rheumatologic problems 3.To discuss the next steps and ongoing CME

3. Facts Targeting outcomes makes better disease control – Similar to HTN DM Lipids Thus we need novel ways to care for our area

4. Case 1 49 year old man who works in construction Complaining of back pain, worse with activity, radiating down his right posterior leg What is this? What would you do?

5. Mechanical back pain If less than 6 weeks of duration and no red flags – No investigations are necessary If back pain persists, there may be a role for team management

6. Case 2 55 year old woman previously well She has swollen knuckles of both hands, feet feel in the morning like she is walking on pebbles It has been going on now for 6 weeks You do labs and she is RF positive (120), ESR 66 What is the most likely diagnosis?

7. Case 2 She likely has RA What would you do?

8. Case 2 Urgent consult to rheumatology – State: I suspect early RA Refer to OT/PT or TAS for education, splinting, orthodics Consider starting prednisone and/or NSAIDs Consider DMARDs

9. Case 3 42 year old woman who complains of joint pain and total body pain She has no swollen joints and says her fingers feel puffy and hurt all over She has poor sleep, she is a bit depressed Her CBC, ESR, TSH are normal You refer her to rheumatology and they reject the referral

10. Case 3 What is the most likely diagnosis? What can you do to manage her?

11. Case 3 Fibromyalgia Education Exercise Amitryptylline,Gabapentin / Pregabalin, Duloxetine Who can you refer her to?

12. Case 4 84 year old woman with sudden onset of severe stiffness and pain in her shoulders and hips and buttock Otherwise well. No meds, no allergies Lives independently but now problems getting dressed. What else would you ask? General exam – unremarkable What do you order?

13. Ask patient about Temporal arteritis symptoms – HA, scalp tenderness, visual problems, jaw claudication, tongue pain, weight loss, fever Fracture history Diabetes Other medical problems Order CBC, ESR, (CRP), diff AST/ALT, Creatinine, glucose, ?RF, ?BMD

14. PMR Treatment Ex. 15-20 mg prednisone OD Reassess patient in a few days She should be back to her baseline (normal or nearly by 72 hrs) If she is only 50% better, you don’t have the correct diagnosis

15. Case 5 42 year old woman Otherwise well usually does not go to health professionals as she was been well Complains of awakening at night when she rolls in her ‘hips’ Pain is at the lateral side of the hip, well localized to greater trochanter There is no swelling or warmth but point tenderness to deep palpation on one spot (size of a quarter) on the greater trochanter ROM of normal of hip

16. Case What is the diagnosis? How do you treat it?

17. Case What is the diagnosis? Greater trochanteric bursitis How do you treat it? Inject the greater trochanter with steroids (ex depomedrol) and lidocane Try physiotherapy NO INVESTIGATIONS ARE NECESSARY

18. Case 6 56 year old man, works in construction C/O pain below right shoulder Unable to lift arm laterally fully over head Pain is a bit better on days off but often sore at night in his upper arm Pain never goes as low as the elbow It does not go to his lateral neck

19. Case What is the diagnosis? How do you treat it?

20. Case 6 What is the diagnosis? He could have Rotator cuff tendonitis Impingement Partially frozen shoulder How do you treat it? Injection Analgesics Exercises, and rest, therapy (ROM, ultrasound) NO INVESTIGATIONS ARE NECESSARY Unless if it does not improve at all over months of treatment

21. Case 7 54 year old woman with pain in many fingers on dominant hand especially PIPs and DIPs are stiff and swollen She has 30 minutes of stiffness, no redness but swelling and warmth are noted What is the most likely diagnosis? What tests would you order (if any)? How would you treat it?

22. Erosive Hand OA Bony Enlargement DIP bony enlargement Heberden’s nodes PIP bony enlargement Bouchard’s nodes

23. Erosive Hand Osteoarthritis Erosive hand OA How do you treat it? Non pharmacologic – Education, exercises, hot wax, etc. – Reassurance Pharmacologic – Tylenol – NSAIDs – po or topical – IA injections – steroids – ? Glucosamine NO INVESTIGATIONS ARE NECESSARY

24. Case 8 50 y.o. man presents to the office with painful, swollen fingers Intermittent flares over the last year with limited morning stiffness and slight loss of energy Presents with the following findings: Psoriasis X years with nail involvement DIPs swelling and dactylitis, swollen knees

25. Case 8

26. Dactylitis

27. What is the most likely diagnosis? What tests would you order (if any)? How would you treat it?

28. What is the most likely diagnosis? Psoriatic arthritis What tests would you order (if any)? Xrays, CBC, creatinine, liver tests and Hep B and C serology to safely start methotrexate How would you treat it? Methotrexate, NSAIDs, injections of steroids or oral steroids if severe to help until DMARD is effective

29. Case 9 74 year old woman CHF for 10 years, CRF (creatinine 135) Meds – Ramipril 5mg od – Furosemide 40 mg BID

30. Presented with bilat swelling of several small joints of the hands Swelling, stiffness, some slight erythema MCPs, PIPs and DIPs, wrists and knees involved Note tophi White or yellowish deposits under the skin

31. What is the most likely diagnosis? What tests would you order (if any)? How would you treat it?

32. What is the most likely diagnosis? Polyarticular tophaceous gout What tests would you order (if any)? Uric acid, urea, Creatinine, AST, ALT How would you treat it? Allopurinol chronically, avoid NSAIDs due to elevated creatinine and CHF, colchicine or steroids for acute or chronic flares, avoid diuretic if possible

33. Case 10 34 year old woman from Mexico New onset of – Red rash on the cheeks – Rash on arms and neck and face in the sun – Swollen joints – Frequent sores in mouth – Admitted for pleuricy and elevated creatinine

34. What is the most likely diagnosis? What tests would you order (if any)? How would you treat it?

35. What is the most likely diagnosis? SLE What tests would you order (if any)? CBC, urinalysis, Creatinine, ANA (likely anti-DNA if ANA is positive and ENA and maybe complements) How would you treat it? Steroids, renal biopsy if active urinary sediment (blood and protein), Cellcept or cyclophosphamide

36. Labs

37. RF in Rheumatoid Arthritis In General, NOT USEFUL to make a diagnosis – Found in 30-50% of those with early RA – Found in 70-85% of those with established RA Conclusion: If you think a patient may have RA but the RF is negative there is still a good chance that they might

38. Anti-Nuclear Antibodies ds-DNA All ANAs Important ANAs ENAs

39. ANA & Lupus 99% of patients with SLE will have a positive ANA If the ANA is negative it is extremely unlikely that the patient has lupus

40. Next Steps Rheumatology Update June 3, 2011 SJHC Focus on the Diversity of Rheumatic Diseases The St. Joseph’s 2 nd Annual Professional Update Day in Rheumatology

41. Next Steps Hands on teaching Grand rounds with MSK physical exam Preceptorships in London with a rheumatologist and also nurse practitioner Do you want more webcasts? Other ideas

42. Conclusions You have learned about common and serious MSK conditions You have more skills in history, investigation, diagnosis and treatment The talks are all recorded and available on our website at SJHC Thank-you