general practice guide to rheumatology
Download
Skip this Video
Download Presentation
General Practice Guide to Rheumatology

Loading in 2 Seconds...

play fullscreen
1 / 85

General Practice Guide to Rheumatology - PowerPoint PPT Presentation


  • 658 Views
  • Uploaded on

General Practice Guide to Rheumatology. Dr Helen Gabathuler MRCP, MRCGP General practitioner and clinical assistant in rheumatology . Aims. History and Examination Appropriate Investigations Management Common conditions in general practice Must Not Miss Diagnoses.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'General Practice Guide to Rheumatology' - Melvin


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
general practice guide to rheumatology

General Practice Guide to Rheumatology

Dr Helen Gabathuler

MRCP, MRCGP

General practitioner and clinical assistant in rheumatology

slide2
Aims
  • History and Examination
  • Appropriate Investigations
  • Management
  • Common conditions in general practice
  • Must Not Miss Diagnoses
what you want to know
What You Want To Know…
  • Is this painful joint(s) a mechanical problem or part of an underlying inflammatory condition?
  • Is there anything that I could miss that will seriously harm this patient?
presenting symptoms
Presenting Symptoms …
  • Pain
  • Stiffness
  • Joint swelling
  • Systemic symptoms
slide6
PAIN
  • S Q I T A S
stiffness
Stiffness
  • Related to activity or rest?
  • Morning stiffness?
  • Duration ?
joint swelling
Joint swelling
  • Where and when ?
  • One or many ?
  • Symmetrical ?
systemic symptoms
Systemic Symptoms
  • Fever
  • Weight loss
  • Malaise
  • Rash
other symptoms
Other Symptoms …
  • Respiratory ?
  • Circulatory ?
  • Eye ?
  • Gut ?
  • Urinary ?
  • Rashes ?
important questions
Important Questions
  • FUNCTION
  • EMPLOYMENT
  • SOCIAL SUPPORT
  • Including I C E
examination
Examination

http://www2.warwick.ac.uk/fac/med/study/ugr/mbchb/misc/oup/version2/

investigations
Investigations ….
  • Case dependent
management
Management
  • Advice and Patient Education
  • Prescription
  • Referral - physio, OT, appliances officer, podiatrist, multidisciplinary back team, secondary care orthopaedics or rheumatology or neurosurgical referrals, social services.
common gp presentations
Common GP Presentations …
  • Back Pain
  • Neck pain
  • Painful shoulder
  • Knee pain
  • Hip pain
  • Painful hands
common conditions to recognise in general practice
Common Conditions to Recognise in General Practice
  • Osteoarthritis
  • Gout
  • Polymyalgia rheumatica
less common conditions
Less Common Conditions
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Systemic lupus erythematosus

Important to diagnose and refer these conditions to rheumatologist EARLY.

simple back pain
Simple Back Pain
  • History - Red Flag Symptoms ?
  • Examination - Red Flag Signs ?
  • Investigations - avoid !
  • Management - activity and regular analgesia
red flags in back pain
Red Flags in Back Pain
  • Age under 20 or over 55 years
  • Pain that is constant and often severe (particularly at night)
  • Thoracic pain
  • Past history (carcinoma, steroids, HIV infection)
  • Systemically unwell
slide21

Unexplained weight loss

  • Widespread or bilateral neurological symptoms and signs
  • Structural deformity
  • Sphincter disturbance
  • Saddle anaesthesia.
lumbar spine x ray
Lumbar spine X-ray
  • Randomised studies in general practice in the UK did not show any benefit in outcome from performing lumbar spine x-rays. One of the studies found that they have an adverse effect on outcome.
  • The dose of radiation from a set of lumbar spine x-rays is 120 times that of a chest x ray.
  • The incidence of cancers induced by radiation following x -rays of the lumbar spine may be around 1 in 25 000.
magnetic resonance imaging
Magnetic Resonance Imaging
  • Abnormalities are commonly found on magnetic resonance imaging scans. A review of eight studies of magnetic resonance imaging in asymptomatic adults found
    • Bulging discs in 20% to 79%
    • Herniated discs in 9% to 76%
    • Degenerative discs in 46% to 91%.
  • A randomised controlled trial found no difference in clinical outcome between patients who had a rapid magnetic resonance imaging scan and patients who had an x ray of the lumbar spine.
  • Radiographic imaging for chronic non-specific low back pain is not recommended. However, MRI scans are recommended for the investigation of patients who may have malignancy or sepsis as a cause of their pain and for the investigation of radicular symptoms.
common conditions to recognise in general practice25
Common Conditions to Recognise in General Practice
  • Osteoarthritis
  • Gout
  • Polymyalgia rheumatica
slide26
Gout
  • Causes intermittent attacks of acute joint pain.
  • Due to deposits of monosodium urate crystals in synovial fluid.
  • Related to raised serum uric acid levels
slide27

Presenting complaint

– painful, swollen joint (usually big toe)

On examination

- hot, red, tender, swollen joint

Most important differential diagnosis is infection

investigations28
Investigations
  • Raised serum urate > 420umol/l
  • Synovial fluid with negatively birefringent crytals when viewed under polarised light
management29
Management
  • Treatment acute gout
  • Prevention recurrent attacks
treatment acute gout
Treatment Acute Gout
  • Non-steroidal inflammatory drugs
  • Colchicine if contra-indications to NSAIDs
  • Review causes

? increased production purines

? reduced renal excretion uric acid

increased production purines
Increased production purines ……
  • Dietary intake - meats, seafood, beans, yeast
  • Haematological causes - Chronic Haemolytic anaemia, CML
  • Alcohol
reduced renal excretion urate
Reduced renal excretion urate…
  • Drugs - loop and thiazide diuretics

aspirin

  • Kidney disease
  • Diabetic ketoacidosis
  • Starvation
prevention recurrent attacks
Prevention recurrent attacks
  • Treat underlying causes
  • Allopurinol

Reduces urate concentrations in urine and blood.

Do not start during acute attack

Always cover with nsaid or colchicine to prevent gout being precipitated for 3/12

Beware itchy rash – 2%

osteoarthritis
Osteoarthritis
  • Commonest form of arthritis
  • Detectable radiologically in > 80% patients
slide35

Osteoarthritis was described by Solomon as

A chronic disorder characterized by softening and disintegration of articular cartilage, with reactive phenomena such as vascular congestion and osteoblastic activity in the subarticular bone, new growth of cartilage and bone (osteophytes) at the joint margins, and capsular fibrosis.

Osteoarthritis is not accompanied by any systemic illness, and although there are sometimes signs of inflammation, it is not primarily an inflammatory disorder.

slide36

Pathological findings in OA include cartilage loss and reactive bone formation.

Incidence increases with age, weight, in women>men over 50 yrs, positive family history, trauma to joint.

Can be idiopathic or secondary OA.

Commonest joints affected are hands, hips, knees and spine.

symptoms
Symptoms ….
  • Joint Pain - related to use
  • Rest Stiffness < 30 minutes
signs
Signs
  • Tenderness to palpation of joint
  • Bony thickening
  • Small effusions
  • Crepitus
  • Deformity and restricted movement joint
  • Muscle wasting
  • Generalised or localised arthritis ?
  • Heberdens and Bouchards nodes in hands ?
management of oa
Management of OA
  • Weight reduction
  • Exercise to improve specific muscle strength
  • Exercise to improve aerobic fitness
  • Pain Control
pain control in oa
Pain Control in OA
  • Paracetamol
  • Topical NSAIDs
  • Paracetamol/codeine
  • NSAIDs - but beware use in elderly

- consider co-prescribing PPI

  • TENs machine
slide41

Social support

  • Aids and appliances
  • Intra-articular corticosteroid injection if pain severe
  • Surgery - prosthetic joint replacement
polymyalgia rheumatica
Polymyalgia Rheumatica
  • Incidence in elderly of 1.5% W>M
  • Clinical diagnosis
  • Overlap with temporal arteritis
symptoms43
Symptoms
  • Pain and stiffness in neck, shoulder and pelvic

girdles

  • Severe morning stiffness – cannot get out of bed !
  • Bilateral and symmetrical symptoms
  • Low grade systemic symptoms
  • Rapid response to small dose prednisolone
investigations44
Investigations
  • Raised plasma viscosity
  • Investigations to exclude differential diagnoses all negative

including immunoglobulins, urinary bence jones protein, rheumatoid factor, thyroid function, CK, CXR

management45
Management
  • Prednisolone 10-20mg daily for 1 month
  • Aim to reduce to 7.5mg within 6 monthes
  • Protect bones with biphosponate whilst on prednisolone
  • Refer to rheumatologist if unable to adequately reduce prednisolone to consider MTX.
rheumatoid arthritis
Rheumatoid Arthritis
  • Commonest disorder of connective tissues.
  • 1-3% population prevalence. W>M
  • Genetic predisposition
symptoms47
Symptoms
  • Pain
  • Swelling
  • Significant morning stiffness of joints
  • Symmetrical polyarthritis
  • Systemic symptoms
on examination
On examination
  • Symmetrical synovitis of joints especially small joints.
  • Long-standing hand changes ..

ulnar deviation fingers, z deformity thumb, swan neck and boutonnière deformities.

  • Cervical spine arthritis causing subluxation and cord compression.
  • Bakers cyst
non articular manifestations
Non- articular manifestations
  • Rheumatoid nodules
  • Eye complications – dry eyes (sjogren’s syndrome); episcleritis.
  • Neurological complications – peripheral nerve entrapment eg carpal tunnel s.; peripheral neuropathy; cervical spine compression.
  • Vasculitis rash
slide50

Cardiac complications – pericarditis; mitral valve d.

  • Respiratory complications – fibrosing alveolitis; pleural effusion.
investigations51
Investigations
  • FBC and plasma viscosity
  • Kidney and liver function
  • Rheumatoid factor
  • ANA
  • Urinanalysis
  • Xrays hands and feet – but normal initially, develop erosions over 3yrs
management52
Management
  • Refer for disease-modifying therapy EARLY, as this will prevent disease progression and joint damage.
  • Refer OT and physio.
  • Support and information.
ankylosing spondylitis
Ankylosing Spondylitis
  • Inflammatory arthritis
  • HLA B27 positive spondyloarthropathy
  • m > f young adults
  • Presenting complaint of spinal stiffness aggravated by rest and back pain.
  • O/E reduced movement lower spine on forward flexion by < 4cm
  • Eventually develop ankylosis / fusion of whole spine and marked disabilty.
  • Refer early ……..
do not miss
DO NOT MISS
  • Cauda Equina Syndrome
  • Temporal or Giant Cell Arteritis
temporal giant cell arteritis
Temporal/Giant Cell Arteritis
  • Overlaps with PMR
  • Risk sudden blindness if missed !
  • Presentation includes fatigue, headaches, scalp tenderness, jaw claudication +/- PMR
  • O/E temporal arteries are thickened,nodular, tender, with absent pulsation
  • Visual symptoms include visual loss, diplopia, or amauriasis fugax
cauda equina sydrome
Cauda Equina Sydrome
  • Neurosurgical emergency
  • Misdiagnosed patients can be left wheelchair-bound with double incontinence…
  • Presenting symptoms include

Leg weakness bilat

Sensory disturbance perineal – saddle anaesthesia

Urinary and faecal disturbance ,progressing to incontinence

slide57

O/ELMN weakness legs

Sensory loss perineal area, buttocks,

back of thighs

Loss of perianal tone - need PR !

case 1
CASE1
  • 24 year old male plumber presented with 6 month history of low back pain. No radiation. No neurological, urinary or bowel symptoms. Described stiffness after rest, and when awakens in morning. Takes time to ‘get going ‘in morning after getting out of bed.
  • What is your provisional diagnosis?
  • What else would you like to find out?
  • On further questioning you find out that this has been a recurrent problem for a few years. He has a father with a very bad back, and a cousin. His morning stiffness is lasting up to 2 hours. He has had an episode of uveitis in past when needed to attend eye casualty.
  • Any change in your diagnosis?
  • On examination what would you be looking for?
  • Inspection NAD, palpation reveals tenderness over sacro-iliac joints, schoebers test 3cm of difference in flexion lumbar spine, general reduction in lumbar spine movements. No neurol signs.
  • What investigations would you do?
  • And discuss further management…
case 160
CASE1
  • 24 year old male plumber presented with 6 month history of low back pain. No radiation. No neurological, urinary or bowel symptoms. Described stiffness after rest, and when awakens in morning. Takes time to ‘get going ‘in morning after getting out of bed.
  • What is your provisional diagnosis?
  • What else would you like to find out?
slide61
On further questioning you find out that this has been a recurrent problem for a few years. He has a father with a very bad back, and a cousin. His morning stiffness is lasting up to 2 hours. He has had an episode of uveitis in past when needed to attend eye casualty.
  • Any change in your diagnosis?
  • On examination what would you be looking for?
slide62
Inspection NAD, palpation reveals tenderness over sacro-iliac joints, schoebers test 3cm of difference in flexion lumbar spine, general reduction in lumbar spine movements. No neurol signs.
  • What investigations would you do?
  • And discuss further management…
ankylosing spondylitis63
Ankylosing spondylitis
  • Inflammatory arthritis
  • HLA B27 positive spondyloarthropathy
  • m > f young adults
  • Presenting complaint of spinal stiffness aggravated by rest and back pain.
  • O/E reduced movement lower spine on forward flexion by < 4cm
  • Eventually develop ankylosis / fusion of whole spine and marked disabilty.
  • Refer early ……..
case 2
Case 2
  • A 55 year old lady presents with a 3 month history of painful hands. She appears very anxious. She describes difficulty using her hands and stiffness, as well as some swelling.
  • What are your provisional thoughts on diagnoses?
  • What else would you like to know?
  • On further questioning she describes stiffness after rest, and in morning of up to 45 minutes. She is struggling to do up buttons and play the piano. She is very anxious as her job is a piano teacher. She has noticed her finger joints swelling and cannot get her ring off. She has also had knee pain bilaterally for 6 months with use. Her mother had ‘arthritis’ but she doesn’t know which type.
  • What other symptoms should you ask about? And what other systems should you enquire into?
  • She has no dry eyes, or dry mouth, nor symptoms of Raynaud’s; she has developed a dry cough last 6 weeks, but no pain nor shortness of breath. Weight stable. Non-smoker.
  • What are your differential diagnoses? What would you like to examine?
  • Hands show tender, red, swollen, hot MCPs, and PIP joints. Knees are warm and slightly swollen with positive patellar tap. All other joints NAD. Respiratory examination reveals dullness to percussion at bilateral bases and basal crackles on inspiration.
  • How does this help your differential? What investigations would you do? Discuss further management.
slide65
A 55 year old lady presents with a 3 month history of painful hands. She appears very anxious. She describes difficulty using her hands and stiffness, as well as some swelling.
  • What are your provisional thoughts on diagnoses?
  • What else would you like to know?
slide66
On further questioning she describes stiffness after rest, and in morning of up to 45 minutes. She is struggling to do up buttons and play the piano. She is very anxious as her job is a piano teacher. She has noticed her finger joints swelling and cannot get her ring off. She has also had knee pain bilaterally for 6 months with use. Her mother had ‘arthritis’ but she doesn’t know which type.
  • What other symptoms should you ask about? And what other systems should you enquire into?
slide67

She has no dry eyes, or dry mouth, nor symptoms of Raynaud’s; she has developed a dry cough last 6 weeks, but no pain nor shortness of breath. Weight stable. Non-smoker.

  • What are your differential diagnoses? What would you like to examine?
slide68
Hands show tender, red, swollen, hot MCPs, and PIP joints. Knees are warm and slightly swollen with positive patellar tap. All other joints NAD. Respiratory examination reveals dullness to percussion at bilateral bases and basal crackles on inspiration.
  • How does this help your differential? What investigations would you do?
  • Discuss further management.
case 3
Case 3
  • A 71 year old lady presents with a 2/12 history of a painful right shoulder. She has also noticed some discomfort in her left shoulder. She is unable to get her sweater over her head in the morning.
  • What are your provisional thoughts on diagnosis?
  • What else would you like to know?
  • Other symptoms include flu-like illness 2-3/12 ago from which she never quite recovered, and aching developing in her buttocks. She is extremely stiff in her shoulders in the morning. No other symptoms of note.
  • What other specific symptoms MUST you ask about in this case?
  • What other questions are warranted?
  • She has no scalp tenderness, jaw claudication, visual disturbances or headache.
  • In addition no weight loss, bony pain, joint symptoms, or symptoms related to thyroid dysfunction.
  • What would you like to examine?
  • She shows tenderness in proximal muscles limbs, painful arc bilaterally on examination of shoulders and hips NAD.
  • Temporal arteries pulsatile and non-tender.
  • Do these findings confirm your diagnosis?
  • What investigations would you do? , and discuss further management…
case 370
Case 3
  • A 71 year old lady presents with a 2/12 history of a painful right shoulder. She has also noticed some discomfort in her left shoulder. She is unable to get her sweater over her head in the morning.
  • What are your provisional thoughts on diagnosis?
  • What else would you like to know?
slide71
Other symptoms include flu-like illness 2-3/12 ago from which she never quite recovered, and aching developing in her buttocks. She is extremely stiff in her shoulders in the morning. No other symptoms of note.
  • What other specific symptoms MUST you ask about in this case?
  • What other questions are warranted?
slide72
She has no scalp tenderness, jaw claudication, visual disturbances or headache.
  • In addition no weight loss, bony pain, joint symptoms, or symptoms related to thyroid dysfunction.
  • What would you like to examine?
slide73
She shows tenderness in proximal muscles limbs, painful arc bilaterally on examination of shoulders and hips NAD.
  • Temporal arteries pulsatile and non-tender.
  • Do these findings confirm your diagnosis?
  • What investigations would you do? , and discuss further management…
case 4
Case 4
  • A 74 year old man presents with a painful swollen knee. It has developed over the past few days. He has an extensive past medical history and is on multiple medication including furosemide and warfarin.
  • What are your preliminary thoughts on possible diagnoses?
  • What other questions would you ask?
  • He has no history trauma to knee, no previous episodes like this. No systemic symptoms. Knee is stiff and painful constantly. Prior to this had noticed occasional aching in hips with exercise. No other joints affected. Is due an INR check.
  • What are your preliminary differential diagnoses?
  • What would you like to examine?
  • Right knee hot, tender and swollen with an effusion, left knee mild crepitus, both hips slight discomfort with rotation and abduction. No skin bruising generally, apyrexial and well, no evidence gouty tophi.
  • Does this help your differential diagnosis?
  • What investigations and further management would you undertake? What complicating factors will affect this patient’s management?
case 475
Case 4
  • A 74 year old man presents with a painful swollen knee. It has developed over the past few days. He has an extensive past medical history and is on multiple medication including furosemide and warfarin.
  • What are your preliminary thoughts on possible diagnoses?
  • What other questions would you ask?
slide76
He has no history trauma to knee, no previous episodes like this. No systemic symptoms. Knee is stiff and painful constantly. Prior to this had noticed occasional aching in hips with exercise. No other joints affected. Is due an INR check.
  • What are your preliminary differential diagnoses?
  • What would you like to examine?
slide77
Right knee hot, tender and swollen with an effusion, left knee mild crepitus, both hips slight discomfort with rotation and abduction. No skin bruising generally, apyrexial and well, no evidence gouty tophi.
  • Does this help your differential diagnosis?
  • What investigations and further management would you undertake? What complicating factors will affect this patient’s management?
raynaud s phenomena
Raynaud’s Phenomena
  • Episodic colour changes hands/feet

white – blue – red

ischaemia --- stasis ---hyperaemia

  • Primary Raynauds
  • Secondary - scleroderma

- SLE

- myositis

osteoporosis
Osteoporosis
  • Who to screen?
  • Who to treat ?
  • Treatment options ?
diagnosing chronic fatigue syndrome
Diagnosing Chronic Fatigue Syndrome :
  • Fatigue :
    • New or had a specific onset
    • Characterised by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days)
  • One or more of the following symptoms:
    • Difficulty with sleeping, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle
    • Muscle and/or joint pain that is multi-site and without evidence of inflammation
    • Headaches
    • Painful lymph nodes without pathological enlargement
    • Sore throat
    • Cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organising thoughts and information processing
    • Physical or mental exertion makes symptoms worse
    • General malaise or flu-like symptoms
    • Dizziness and/or nausea
    • Palpitations in the absence of identified cardiac pathology.
cfs is a diagnosis of exclusion
CFS is a diagnosis of exclusion.
  • Reconsider the diagnosis if the patient does not suffer from:
  • Post-exercise fatigue
  • Cognitive problems
  • Sleep disturbance
  • Chronic pain
slide85

Birefringence, or double refraction, is the splitting of a ray of light into two rays when it passes through certain types of material, such as calcitecrystals. The two rays, called the ordinary ray and the extraordinary ray, travel at different speeds. Thus the material has two distinct indices of refraction, as measured from different directions.

If split ray of light is rotated clockwise is classified as positive birefringent.

If counterclockwise rotation is classifed as negatively birefringent

ad