1. APPROACH TO THE PATIENT WITH POSSIBLE RHEUMATIC DISEASE

2. 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 ??

3. OVERVIEW OF TALK “Rheum Hx” “Rheum ROS” Focused PE Laboratory evaluation Imaging Pattern Recognition The Elderly Management Perioperative Care

4. NOT COVERED Individual disease states Autoantibody testing Specific treatment modalities

5. THE RHEUMATOLOGIC HISTORY

6. JOINT PATTERN

7. 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]

8. 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

9. ENTHESOPATHY SNSA’s: - Reiter’s - AS - Psoriatic - IBD

10. REITER’S SYNDROME

11. The “Five” Minute Rheumatologic Review of Systems (ROS)

12. ROS - RASH Acute Cutaneous LupusDiscoid Lupus

13. ROS - RASH DermatomyositisHeliotrope rash

14. ROS - RASH Palpable purpura - HSP

15. ROS - RASH Livedo reticularis – APLA Syndrome

16. ROS - ALOPECIA SLE

17. ROS - PERIUNGUAL CHANGES SLE Vasculitis PM/DM MCTD

18. ROS - PSORIASIS Psoriatic arthritis

19. ROS - RASH Reactive arthritis

20. ROS - CONJUNCTIVITIS Reactive arthritis

21. ROS - UVEITIS Behcet’s SNSA’s

22. ROS - RAYNAUD’S Scleroderma SLE DM/PM MCTD

23. ROS – ORO/GEN ULCERS SLE Behcet’s

24. ROS - POLYCHONDRITIS Relapsing polychondritis

25. ROS - ENTHESOPATHY SNSA’s

26. ROS - NODULES RA Gout

27. ROS IBD symptoms infectious diarrhea or STD sx photosensitivity hypercoagulable event heme/renal/CNS or PNS disease sicca pleuropericarditis

28. AGE

29. 1-15 yo –JCA –Still’s –ARF 20-45 yo –SLE / RA –SNSA’s –PM/DM –DGI –vasculitis

30. AGE 45-60 yo –Crystalline (MSU) –OA –Sjogren’s 65 + –PMR –GCA –Crystalline (CPPD, MSU, others)

31. GENDER

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

33. FAMILY HISTORY

34. Nodal osteoarthritis SLE RA

35. PATTERN OF ONSET

36. PATTERN RECOGNITION Acute Indolent Brief and relapsing Migratory

37. PATTERN RECOGNITION ACUTE Parvovirus infection

38. PATTERN RECOGNITION ACUTE Sarcoid / Lofgren’s Syndrome

39. PATTERN RECOGNITION INDOLENT Rheumatoid arthritis

40. PATTERN RECOGNITION BRIEF & RELAPSING SLE

41. PATTERN RECOGNITION MIGRATORY Acute Rheumatic Fever Disseminated GC

42. The “Five” Minute Rheumatologic Examination

43. PE – LOOK FOR SIGNS OF SYSEMTIC DISEASE

44. “FOCUSED” FIVE MINUTE EXAM alopecia nasal / genital / oral ulcers rash synovitis – joint inflammation cutaneous vasculitis adenopathy / HSM enthesitis dactylitis xerostomia mononeuritis multiplex pleuropericarditis

45. PE - RASH Keratodermia blenorrahgica – Reactive arthritis

46. PE - RASH Circinate balanitis - Reactive arthritis

47. PE - RASH ECM - Lyme

48. PE - RASH Gottron’s papules - DM

49. PE - VASCULITIS

50. PE - PERIUNGUAL CHANGES

52. PE - LOCATION

53. LOCATION OA RA / SLE SNSA CRYSTALLINE PERIARTICULAR

54. OA C-SPINE

55. OSTEOARTHRITIS HIP

56. OSTEOARTHRITIS

57. OSTEOARTHRITIS AVN

58. OSTEOARTHRITIS

59. OA

61. SNSA

62. SNSA - ANKYLOSING SPONDYLITIS

63. SNSA - AS

64. CRYSTALLINE ARTHRITIS

65. GOUT

66. PE – JOINT EXAMINATION

67. Synovitis Soft tissue Crepitus

68. SYNOVITIS OR BONY OVERGROWTH ?

69. LABORATORY

70. 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!

71. LABORATORY TESTING Synovial fluid ESR RF Anti-citrulline ANA HLA-B27 Specific autoantibodies

72. IF NO SYNOVITIS… LFT’s TSH Hep serologies Ca, PO4, albumin Alk phos Ferritin, Iron, TIBC

73. IMAGING STUDIES

74. Plain films Bone scan MRI

75. CLINICAL SYNDROMES

76. Monoarthritis / Oligoarthritis Polyarthritis –Symmetric and brief –Symmetric and sustained –Asymmetric and migratory –Asymmetric and spondylitic Arthralgia and/or Myalgia w/o Synovitis

77. FIBROMYALGIA

78. APPROACH TO ELDERLY PATIENTS

79. APPROACH TO ELDERLY PMR GCA Crystalline DJD

80. PMR

81. GIANT CELL ARTERITIS

82. CPPD

83. MANAGEMENT

84. Educate Adapt “Autoimmunity as allergy” Complementary treatments

85. PERIOPERATIVE MANAGEMENT

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

87. QUESTIONS

89. RA & C-SPINE