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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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