1. A Case-based Training Session
Rheumatology in GP
A Case-based Training Session
Dr Andrew Mowat
28/03/2017

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?
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

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.
Dr Andrew Mowat
28/03/2017

6. Case One: Discussion Differential Diagnoses Septic Arthritis Gout
Pseudogout (Pyrophosphate)
Haemarthrosis
Palindromic Rheumatism
Reiter’s syndrome
Dr Andrew Mowat
28/03/2017

7. Case One: Management History/Examination Biochemistry Radiology
FBC/ESR/U&E/uric acid
Serology
Synovial fluid
Radiology
Drug Treatment
Physiotherapy
Referral
Dr Andrew Mowat
28/03/2017

8. Acute Gout Podagra NSAID or Colchicine? Long-term Rx
Gout or Lead poisoning?
NSAID or Colchicine?
Indomethacin
Azapropazone
Long-term Rx
Allopurinol
Lifestyle
Dr Andrew Mowat
28/03/2017

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.
Dr Andrew Mowat
28/03/2017

10. Case Two: Discussion Differential Diagnosis Rheumatoid Arthritis
Seronegative Arthropathies
SLE
Postviral Arthritis
Generalised OA
Streptococcal Arthritis
(Juvenile Chronic Arthritis)
Dr Andrew Mowat
28/03/2017

11. Polyarthropathy and Age
Males
Females
Young
Reactive Arthritis
SLE
Ankylosing Spondylitis
Rheumatoid Arthritis
Psoriatic Arthropathy
Enteropathic Arthropathy
Middle Age
Gout
Sicca Syndrome
Generalised Osteoarthritis
Elderly
Polymyalgia Rheumatica
Pseudogout, Malignancy
Dr Andrew Mowat
28/03/2017

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)
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

14. Case Two: Treatment Options
Simple Analgesics
NSAID
Second-line drugs
Gold, Penicillamine, Sulphasalazine, Chloroquine
Steroid therapy
Therapy: Physio/OT/Hydro
Dr Andrew Mowat
28/03/2017

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.
Dr Andrew Mowat
28/03/2017

16. Case Three: Discussion
Differential Diagnosis
Fibromyalgia Syndrome (Muscular Rheumatism)
Polymyalgia Rheumatica
Polymyositis
inflammatory
iatrogenic (steroids, statins)
autoimmune (PAN, SLE)
?Hypothyroidism
Dr Andrew Mowat
28/03/2017

17. Case Three: Management
Simple Analgesia
Exercise Therapy
Physiotherapy/Hydrotherapy
Positive Feedback
Alternative modalities
Drug Rx
Amitriptyline, SSRI
co-analgesics (Gabapentin etc)
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

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.
Dr Andrew Mowat
28/03/2017

20. Case Four: Discussion Assessment: Clinical Suspicion
Laboratory Investigation
White cells (PAN) & Eosinophils
ESR/CRP
Immunological
Lupus Anticoagulant, anti-DNA, ANCA
Tissue diagnosis
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

23. Case Five: Localised Syndromes
Frozen Shoulder
Tennis & Golfer’s elbow
Carpal Tunnel Syndrome
Plantar Fasciitis
Tendinitis
Bursitis
Dr Andrew Mowat
28/03/2017

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
Dr Andrew Mowat
28/03/2017

25. Where to Get More Information
The New Medicine: Rheumatology (MTP)
Collected Reports on the Rheumatic Diseases (ARC)
Primary Care Rheumatology Society
Dr Andrew Mowat
28/03/2017