Presentation on theme: "25/04/2014 Dr Andrew Mowat 1 Rheumatology in GP A Case-based Training Session."— Presentation transcript:
25/04/2014 Dr Andrew Mowat 1 Rheumatology in GP A Case-based Training Session
25/04/2014 Dr 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?
25/04/2014 Dr 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
25/04/2014 Dr 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
25/04/2014 Dr 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.
25/04/2014 Dr Andrew Mowat 6 Case One: Discussion Differential Diagnoses –Septic Arthritis –Gout –Pseudogout (Pyrophosphate) –Haemarthrosis –Palindromic Rheumatism –Reiters syndrome
25/04/2014 Dr Andrew Mowat 7 Case One: Management History/Examination Biochemistry FBC/ESR/U&E/uric acid Serology Synovial fluid Radiology Drug Treatment Physiotherapy Referral
25/04/2014 Dr Andrew Mowat 8 Acute Gout Podagra –Gout or Lead poisoning? NSAID or Colchicine? –Indomethacin –Azapropazone Long-term Rx –Allopurinol –Lifestyle
25/04/2014 Dr 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.
25/04/2014 Dr Andrew Mowat 10 Case Two: Discussion Differential Diagnosis –Rheumatoid Arthritis –Seronegative Arthropathies –SLE –Postviral Arthritis –Generalised OA –Streptococcal Arthritis –(Juvenile Chronic Arthritis)
25/04/2014 Dr Andrew Mowat 11 Polyarthropathy and Age AgeMalesFemales YoungReactive ArthritisSLE Ankylosing Spondylitis Rheumatoid Arthritis Psoriatic Arthropathy Enteropathic Arthropathy Middle AgeGoutRheumatoid Arthritis Sicca Syndrome Generalised Osteoarthritis ElderlyPolymyalgia Rheumatica Pseudogout, Malignancy
25/04/2014 Dr 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)
25/04/2014 Dr 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
25/04/2014 Dr Andrew Mowat 14 Case Two: Treatment Options Simple Analgesics NSAID Second-line drugs Gold, Penicillamine, Sulphasalazine, Chloroquine Steroid therapy Therapy: Physio/OT/Hydro
25/04/2014 Dr 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.
25/04/2014 Dr Andrew Mowat 16 Case Three: Discussion Differential Diagnosis –Fibromyalgia Syndrome (Muscular Rheumatism) –Polymyalgia Rheumatica –Polymyositis inflammatory iatrogenic (steroids, statins) autoimmune (PAN, SLE) –?Hypothyroidism
25/04/2014 Dr Andrew Mowat 17 Case Three: Management Simple Analgesia Exercise Therapy Physiotherapy/Hydrotherapy Positive Feedback Alternative modalities Drug Rx –Amitriptyline, SSRI –co-analgesics (Gabapentin etc)
25/04/2014 Dr 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
25/04/2014 Dr 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.
25/04/2014 Dr 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
25/04/2014 Dr Andrew Mowat 21 Case Four: Vasculitis Skin92%nail infacts, ulcers Nodules87%rheumatoid nodules Systemic83%weight loss, liver/spleen CNS44%sensorimotor Lung39%alveolitis, pleurisy Heart36%pericarditis Kidney20%haematuria, proteinuria Eye19%episcleritis Gut10%colitis
25/04/2014 Dr 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
25/04/2014 Dr Andrew Mowat 23 Case Five: Localised Syndromes Frozen Shoulder Tennis & Golfers elbow Carpal Tunnel Syndrome Plantar Fasciitis Tendinitis Bursitis
25/04/2014 Dr Andrew Mowat 24 Summary Know the common conditions Become familiar with what you know Be prepared to refer what you dont recognise Ask advice from colleagues Use time as an aid to diagnosis
25/04/2014 Dr Andrew Mowat 25 Where to Get More Information The New Medicine: Rheumatology (MTP) Collected Reports on the Rheumatic Diseases (ARC) Primary Care Rheumatology Society