rheumatology - a case based training session.ppt

Rheumatology

1. 19/06/2024Dr Andrew Mowat
1
Rheumatology in GP
A Case-based Training
Session

2. 19/06/2024Dr Andrew Mowat
2
Introduction
The Primary Care Presentation of
Rheumatological Disease
Improve problem-solving in the
Rheumatological patient
Stimulate further interest in
Rheumatology
So what do we know already?

3. 19/06/2024Dr Andrew Mowat
3
Cases
The patient with acute monoarthritis
The patient with chronic
polyarthralgia
The patient with myalgia
The patient with vascular problems
The patient with localised syndrome

4. 19/06/2024Dr Andrew Mowat
4
Overview
More than 25 million people in UK
suffer some kind of musculoskeletal
complaint
2/3 female and >65
9.6% of certificated incapacity

5. 19/06/2024Dr Andrew Mowat
5
Case One: Monoarthritis
A 46-year old man
presents with a
sudden onset of
pain, redness and
swelling of the Rt
knee. He cannot
recollect any
injury, and has
never had it
before.

6. 19/06/2024Dr Andrew Mowat
6
Case One: Discussion
Differential Diagnoses
–Septic Arthritis
–Gout
–Pseudogout (Pyrophosphate)
–Haemarthrosis
–Palindromic Rheumatism
–Reiter’s syndrome

7. 19/06/2024Dr Andrew Mowat
7
Case One: Management
History/Examination
Biochemistry
FBC/ESR/U&E/uric acid
Serology
Synovial fluid
Radiology
Drug Treatment
Physiotherapy
Referral

8. 19/06/2024Dr Andrew Mowat
8
Acute Gout
Podagra
–Gout or Lead poisoning?
NSAID or Colchicine?
–Indomethacin
–Azapropazone
Long-term Rx
–Allopurinol
–Lifestyle

9. 19/06/2024Dr Andrew Mowat
9
Case Two: Polyarthralgia
A 35-year-old woman
comes to see you
because her hands have
been getting increasingly
painful for the past few
months. She is worried
because her mother has
arthritis –she is not
sure what type –and she
fears for her job as a
seamstress.

10. 19/06/2024Dr Andrew Mowat
10
Case Two: Discussion
Differential Diagnosis
–Rheumatoid Arthritis
–Seronegative Arthropathies
–SLE
–Postviral Arthritis
–Generalised OA
–Streptococcal Arthritis
–(Juvenile Chronic Arthritis)

11. 19/06/2024Dr Andrew Mowat
11
Polyarthropathy and Age
Age Males Females
Young Reactive ArthritisSLE
Ankylosing
Spondylitis
Rheumatoid Arthritis
Psoriatic Arthropathy
Enteropathic Arthropathy
Middle Age Gout Rheumatoid Arthritis
Sicca Syndrome
Generalised Osteoarthritis
Elderly Polymyalgia Rheumatica
Pseudogout, Malignancy

12. 19/06/2024Dr Andrew Mowat
12
Case Two: Management
History/Examination
Family History (RA, AS, SLE)
Blood Investigations
–FBC, ESR/CRP, urate, Autoantibodies
Radiology
–OA (narrowing, sclerosis, osteophyte)
–RA (erosions >6/12)
–AS (ankyloses), Pseudogout (chondrocalcinosis)

13. 19/06/2024Dr Andrew Mowat
13
Rheumatoid Arthritis
ARA Criteria
–Morning Stiffness: >1h, >6w
–Arthritis 3 areas
–Arthritis hand joints:wrist, MCP, PIP
–Symmetrical Arthritis
–Rheumatoid Nodules
–Rheumatoid Factor
–Radiographic changes:wrists & hands

14. 19/06/2024Dr Andrew Mowat
14
Case Two: Treatment Options
Simple Analgesics
NSAID
Second-line drugs
Gold, Penicillamine, Sulphasalazine,
Chloroquine
Steroid therapy
Therapy: Physio/OT/Hydro

15. 19/06/2024Dr Andrew Mowat
15
Case Three: Myalgia
A 65-year old lady presents with
a 6 month history of persistent
muscle pain in both arms, back,
and both legs. She complains of
overwhelming tiredness.

16. 19/06/2024Dr Andrew Mowat
16
Case Three: Discussion
Differential Diagnosis
–Fibromyalgia Syndrome (Muscular
Rheumatism)
–Polymyalgia Rheumatica
–Polymyositis
inflammatory
iatrogenic (steroids, statins)
autoimmune (PAN, SLE)
–?Hypothyroidism

17. 19/06/2024Dr Andrew Mowat
17
Case Three: Management
Simple Analgesia
Exercise Therapy
Physiotherapy/Hydrotherapy
Positive Feedback
Alternative modalities
Drug Rx
–Amitriptyline, SSRI
–co-analgesics (Gabapentin etc)

18. 19/06/2024Dr Andrew Mowat
18
Fibromyalgia Syndrome
Polymyalgia
–widespread pain for > 3
months
–pain in 11 or more sites
–above and below waist &
both sides of body
Fatigue
Unrefreshing Sleep
Chronic Headache
Irritable Bowel

19. 19/06/2024Dr Andrew Mowat
19
Case Four
A 25-year-old woman is found, at
routine well-woman testing, to have
proteinuria. She has no renal
symptoms, but admits to a history of
fatigue, intermittent but progressive
joint pains, and painful fingers and
toes, particularly when cold.

20. 19/06/2024Dr Andrew Mowat
20
Case Four: Discussion
Assessment:
–Clinical Suspicion
–Laboratory Investigation
White cells (PAN) & Eosinophils
ESR/CRP
Immunological
–Lupus Anticoagulant, anti-DNA, ANCA
–Tissue diagnosis

21. 19/06/2024Dr Andrew Mowat
21
Case Four: Vasculitis
Skin 92% nail infacts, ulcers
Nodules 87% rheumatoid nodules
Systemic 83% weight loss, liver/spleen
CNS 44% sensorimotor
Lung 39% alveolitis, pleurisy
Heart 36% pericarditis
Kidney 20% haematuria, proteinuria
Eye 19% episcleritis
Gut 10% colitis

22. 19/06/2024Dr Andrew Mowat
22
Classification of Vasculitis
Systemic Necrotising Arteritis
–Polyarteritis Nodosa type
–Granulomatosis
Small Vessel Vasculitis
–SLE, Henoch-Schonlein Purpura etc
Giant Cell Arteritis
–Temporal Arteritis, Aortitis etc

23. 19/06/2024Dr Andrew Mowat
23
Case Five: Localised Syndromes
Frozen Shoulder
Tennis & Golfer’s elbow
Carpal Tunnel Syndrome
Plantar Fasciitis
Tendinitis
Bursitis

24. 19/06/2024Dr Andrew Mowat
24
Summary
Know the common conditions
Become familiar with what you know
Be prepared to refer what you don’t
recognise
Ask advice from colleagues
Use time as an aid to diagnosis

25. 19/06/2024Dr Andrew Mowat
25
Where to Get More
Information
The New Medicine: Rheumatology
(MTP)
Collected Reports on the Rheumatic
Diseases (ARC)
Primary Care Rheumatology Society