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Rheumatology in GPRheumatology in GPA Case-based Training Session

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Introduction 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?

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CasesCases

The patient with acute monoarthritis

The patient with chronic polyarthralgia

The patient with myalgiaThe patient with vascular problemsThe patient with localised

syndrome

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Overview Overview

More than 25 million people in UK suffer some kind of musculoskeletal complaint

2/3 female and >659.6% of certificated incapacity

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Case One: MonoarthritisCase 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.

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Case One: DiscussionCase One: Discussion

Differential Diagnoses– Septic Arthritis– Gout– Pseudogout (Pyrophosphate)– Haemarthrosis– Palindromic Rheumatism– Reiter’s syndrome

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Case One: ManagementCase One: Management

History/Examination Biochemistry

FBC/ESR/U&E/uric acid Serology Synovial fluid

Radiology Drug Treatment Physiotherapy Referral

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Acute GoutAcute Gout

Podagra– Gout or Lead poisoning?

NSAID or Colchicine?– Indomethacin– Azapropazone

Long-term Rx– Allopurinol– Lifestyle

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Case Two: PolyarthralgiaCase 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.

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Case Two: DiscussionCase Two: Discussion

Differential Diagnosis– Rheumatoid Arthritis– Seronegative Arthropathies– SLE– Postviral Arthritis– Generalised OA– Streptococcal Arthritis– (Juvenile Chronic Arthritis)

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Polyarthropathy and AgePolyarthropathy and Age

Age Males FemalesYoung Reactive Arthritis SLE

Ankylosing Spondylitis

Rheumatoid Arthritis

Psoriatic Arthropathy

Enteropathic Arthropathy

Middle Age Gout Rheumatoid Arthritis

Sicca Syndrome

Generalised Osteoarthritis

Elderly Polymyalgia Rheumatica

Pseudogout, Malignancy

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Case Two: ManagementCase 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)

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Rheumatoid ArthritisRheumatoid 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

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Case Two: Treatment Case Two: Treatment OptionsOptionsSimple AnalgesicsNSAIDSecond-line drugs

Gold, Penicillamine, Sulphasalazine, Chloroquine

Steroid therapyTherapy: Physio/OT/Hydro

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Case Three: MyalgiaCase 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.

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Case Three: DiscussionCase Three: Discussion

Differential Diagnosis– Fibromyalgia Syndrome (Muscular

Rheumatism)– Polymyalgia Rheumatica– Polymyositis

inflammatory iatrogenic (steroids, statins)autoimmune (PAN, SLE)

– ?Hypothyroidism

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Case Three: ManagementCase Three: Management

Simple AnalgesiaExercise TherapyPhysiotherapy/HydrotherapyPositive FeedbackAlternative modalitiesDrug Rx

– Amitriptyline, SSRI– co-analgesics (Gabapentin etc)

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Fibromyalgia SyndromeFibromyalgia 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

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Case FourCase 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.

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Case Four: DiscussionCase Four: Discussion

Assessment:– Clinical Suspicion– Laboratory Investigation

White cells (PAN) & EosinophilsESR/CRP Immunological

– Lupus Anticoagulant, anti-DNA, ANCA

– Tissue diagnosis

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Case Four: VasculitisCase 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

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Classification of VasculitisClassification of Vasculitis

Systemic Necrotising Arteritis– Polyarteritis Nodosa type– Granulomatosis

Small Vessel Vasculitis– SLE, Henoch-Schonlein Purpura etc

Giant Cell Arteritis– Temporal Arteritis, Aortitis etc

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Case Five: Localised Case Five: Localised SyndromesSyndromes

Frozen ShoulderTennis & Golfer’s elbowCarpal Tunnel SyndromePlantar FasciitisTendinitisBursitis

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SummarySummary

Know the common conditionsBecome familiar with what you

knowBe prepared to refer what you

don’t recogniseAsk advice from colleaguesUse time as an aid to diagnosis

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Where to Get More Where to Get More InformationInformationThe New Medicine: Rheumatology

(MTP)Collected Reports on the

Rheumatic Diseases (ARC)Primary Care Rheumatology

Society