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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.

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General Practice Guide to Rheumatology


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    1. General Practice Guide to Rheumatology Dr Helen Gabathuler MRCP, MRCGP General practitioner and clinical assistant in rheumatology

    2. Aims • History and Examination • Appropriate Investigations • Management • Common conditions in general practice • Must Not Miss Diagnoses

    3. 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?

    4. History Taking

    5. Presenting Symptoms … • Pain • Stiffness • Joint swelling • Systemic symptoms

    6. PAIN • S Q I T A S

    7. Stiffness • Related to activity or rest? • Morning stiffness? • Duration ?

    8. Joint swelling • Where and when ? • One or many ? • Symmetrical ?

    9. Systemic Symptoms • Fever • Weight loss • Malaise • Rash

    10. Other Symptoms … • Respiratory ? • Circulatory ? • Eye ? • Gut ? • Urinary ? • Rashes ?

    11. Family history ?

    12. Important Questions • FUNCTION • EMPLOYMENT • SOCIAL SUPPORT • Including I C E

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

    14. Investigations …. • Case dependent

    15. 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.

    16. Common GP Presentations … • Back Pain • Neck pain • Painful shoulder • Knee pain • Hip pain • Painful hands

    17. Common Conditions to Recognise in General Practice • Osteoarthritis • Gout • Polymyalgia rheumatica

    18. Less Common Conditions • Rheumatoid arthritis • Ankylosing spondylitis • Systemic lupus erythematosus Important to diagnose and refer these conditions to rheumatologist EARLY.

    19. Simple Back Pain • History - Red Flag Symptoms ? • Examination - Red Flag Signs ? • Investigations - avoid ! • Management - activity and regular analgesia

    20. 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

    21. Unexplained weight loss • Widespread or bilateral neurological symptoms and signs • Structural deformity • Sphincter disturbance • Saddle anaesthesia.

    22. 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.

    23. 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.

    24. Common Conditions to Recognise in General Practice • Osteoarthritis • Gout • Polymyalgia rheumatica

    25. 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

    26. Presenting complaint – painful, swollen joint (usually big toe) On examination - hot, red, tender, swollen joint Most important differential diagnosis is infection

    27. Investigations • Raised serum urate > 420umol/l • Synovial fluid with negatively birefringent crytals when viewed under polarised light

    28. Management • Treatment acute gout • Prevention recurrent attacks

    29. Treatment Acute Gout • Non-steroidal inflammatory drugs • Colchicine if contra-indications to NSAIDs • Review causes ? increased production purines ? reduced renal excretion uric acid

    30. Increased production purines …… • Dietary intake - meats, seafood, beans, yeast • Haematological causes - Chronic Haemolytic anaemia, CML • Alcohol

    31. Reduced renal excretion urate… • Drugs - loop and thiazide diuretics aspirin • Kidney disease • Diabetic ketoacidosis • Starvation

    32. 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%

    33. Osteoarthritis • Commonest form of arthritis • Detectable radiologically in > 80% patients

    34. 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.

    35. 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.

    36. Symptoms …. • Joint Pain - related to use • Rest Stiffness < 30 minutes

    37. 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 ?

    38. Management of OA • Weight reduction • Exercise to improve specific muscle strength • Exercise to improve aerobic fitness • Pain Control

    39. Pain Control in OA • Paracetamol • Topical NSAIDs • Paracetamol/codeine • NSAIDs - but beware use in elderly - consider co-prescribing PPI • TENs machine

    40. Social support • Aids and appliances • Intra-articular corticosteroid injection if pain severe • Surgery - prosthetic joint replacement

    41. Polymyalgia Rheumatica • Incidence in elderly of 1.5% W>M • Clinical diagnosis • Overlap with temporal arteritis

    42. 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

    43. Investigations • Raised plasma viscosity • Investigations to exclude differential diagnoses all negative including immunoglobulins, urinary bence jones protein, rheumatoid factor, thyroid function, CK, CXR

    44. 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.

    45. Rheumatoid Arthritis • Commonest disorder of connective tissues. • 1-3% population prevalence. W>M • Genetic predisposition

    46. Symptoms • Pain • Swelling • Significant morning stiffness of joints • Symmetrical polyarthritis • Systemic symptoms

    47. 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

    48. 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

    49. Cardiac complications – pericarditis; mitral valve d. • Respiratory complications – fibrosing alveolitis; pleural effusion.