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1 Inflammatory Arthritis Case 7 : Jayna

2 2 Faculty/Presenter Disclosure with Faculty’s Name:Faculty’s Name:

3 3 Disclosure of Commercial Support. Mitigating potential bias N/A.

4 4 Objectives When working with CPP, you will be able to:  Identify inflammatory versus non-inflammatory signs and symptoms  List 3 assessment tools that may be useful  Conduct a joint count examination  Identity appropriate investigations  Appropriate access of RACE line  Appropriate Self Management

5 5 Sore Hands and Feet Jayna is a 55 year old Lawyer 4 week history of soreness in her hands and feet that is increasing over time. She says the balls of her feet hurt with walking and her hands hurt when she is gripping or squeezing. She has noticed some swelling over her knuckles (MCP’s) and in her fingers (PIP’s). Her past history includes right thumb and left knee osteoarthritis diagnosed 5-7 years ago and controlled with occasional medication, stretching and heat. She is finding it difficult to complete her daily work and home activities.

6 6 What are your Key Questions?  How do you determine if this is osteoarthritis or rheumatoid arthritis?

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8 8 Common Patient History for MSK Complaints

9 9 Joint Pain Questions

10 10 History Jayna states that her pain is constant and present with activity and at rest. She has noticed morning stiffness especially in her hands and it often lasts > 4hours. She rates her pain as 7/10 and has noticed that the joints in her hands and feet are warmer to the touch than usual. She is having some swelling in her hands and feet and describes her hands as little sausages. She feels very fatigued and blames this on stress at work.

11 11 Osteoarthritis comparison to Inflammatory Arthritis

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14 14 Physical Exam  What physical examination techniques would you use? We found: -Positive swollen tender joints -6 left hand ( MCP & PIP) -7 right hand ( thumb, MCP and PIP) -Right foot ( 4 Joints) -Active Range of motion is limited by a feeling of resistance and soft tissue compression

15 15 Pain and Function

16 16 Joint Count

17 17 Differental Diagnosis by Joint Count

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22 22 Management Tools  How would you determine medication type and dose to be appropriate ? We used:  Consider DMARD’s  Screen for medical safety  Progress for symptom relef

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25 25 What is best Management  Ruth-Ann has mild to moderate osteoarthritis likely in the patellar and medial compartments  Her pain is improving but she is hesitant to continue with activity for fear of flaring her symptoms  Best Practice would focus on:  Medications  Rehabilitation and Exercise  Patient Education and Self- Management

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28 28 Medication Advice Starting a DMARD -Hydroxychloroquine 600 mg once daily -Monitor Kidney and Liver function -Adverse Effects -- May cause drowsiness, nausea, or night diarrhea.

29 29 Follow-Up  Monitor and Manage  Swelling  Pain  Function  Enhance Education  Promote Self-Management

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32 32 Goal Setting  Jayna is committed to reducing her stress as she has been told that her BP is borderline for medication.  She has not had a flu shot for 5 years but states that she will take your advice and get one this year.  She has been told that she has osteopenia and wants to continue with walking program.

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34 34 Key Resources for your patients

35 35 Clinical Impression  New onset of Rheumatoid Arthritis symptoms including swelling, stiffness and pain.  Pre-existing thumb OA and Knee OA are stable but add another dimension to the assessment.  The patient is reluctant to start Dmard’s but appreciates the promise of avoiding surgery down the road.  Her fatigue has worsened since her joint swelling bega.

36 36 Key Clinical Information  What are the key criteria for Rheumatoid Osteoarthritis?  Morning Stiffness greater than 30 min.  Constant Pain associated with activity  Recurrent episodes  May lead to bony deformity and decreasing function

37 37 Summary When working with Rheumatoid Arhtritis Osteoarthritis, it is important to: -Identify the differences between inflammatory and non-inflammatory joint disease -Focus on low impart dance type movement -Focus on patient self management for lifestyle factors

38 38 References  Arthritis Resource Guide,  Guidelines and Protocols Advisory Committee 

39 Thank You

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