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