Rheumatologic Cases Discussion - Continuing Medical Education

1. Nurse Practitioner OutreachWrap up Janet Pope MD MPH FRCPC

2. Objectives • To reinforce learnings of the course • To present cases of common rheumatologic problems • To discuss the next steps and ongoing CME

3. Facts • Targeting outcomes makes better disease control • Similar to • HTN • DM • Lipids • Thus we need novel ways to care for our area

4. Case 1 • 49 year old man who works in construction • Complaining of back pain, worse with activity, radiating down his right posterior leg • What is this? • What would you do?

5. Mechanical back pain • If less than 6 weeks of duration and no red flags • No investigations are necessary • If back pain persists, there may be a role for team management

6. Case 2 • 55 year old woman previously well • She has swollen knuckles of both hands, feet feel in the morning like she is walking on pebbles • It has been going on now for 6 weeks • You do labs and she is RF positive (120), ESR 66 • What is the most likely diagnosis?

7. Case 2 • She likely has RA • What would you do?

8. Case 2 • Urgent consult to rheumatology • State: I suspect early RA • Refer to OT/PT or TAS for education, splinting, orthodics • Consider starting prednisone and/or NSAIDs • Consider DMARDs

9. Case 3 • 42 year old woman who complains of joint pain and total body pain • She has no swollen joints and says her fingers feel puffy and hurt all over • She has poor sleep, she is a bit depressed • Her CBC, ESR, TSH are normal • You refer her to rheumatology and they reject the referral

10. Case 3 • What is the most likely diagnosis? • What can you do to manage her?

11. Case 3 • Fibromyalgia • Education • Exercise • Amitryptylline,Gabapentin / Pregabalin, Duloxetine • Who can you refer her to?

12. Case 4 • 84 year old woman with sudden onset of severe stiffness and pain in her shoulders and hips and buttock • Otherwise well. No meds, no allergies • Lives independently but now problems getting dressed. • What else would you ask? • General exam – unremarkable • What do you order?

13. Ask patient about • Temporal arteritis symptoms • HA, scalp tenderness, visual problems, jaw claudication, tongue pain, weight loss, fever Fracture history Diabetes Other medical problems Order CBC, ESR, (CRP), diff AST/ALT, Creatinine, glucose, ?RF, ?BMD

14. PMR Treatment • Ex. 15-20 mg prednisone OD • Reassess patient in a few days • She should be back to her baseline (normal or nearly by 72 hrs) • If she is only 50% better, you don’t have the correct diagnosis

15. Case 5 • 42 year old woman • Otherwise well usually does not go to health professionals as she was been well • Complains of awakening at night when she rolls in her ‘hips’ • Pain is at the lateral side of the hip, well localized to greater trochanter • There is no swelling or warmth but point tenderness to deep palpation on one spot (size of a quarter) on the greater trochanter • ROM of normal of hip

16. Case • What is the diagnosis? • How do you treat it?

17. Case • What is the diagnosis? • Greater trochanteric bursitis • How do you treat it? • Inject the greater trochanter with steroids (ex depomedrol) and lidocane • Try physiotherapy • NO INVESTIGATIONS ARE NECESSARY

18. Case 6 • 56 year old man, works in construction • C/O pain below right shoulder • Unable to lift arm laterally fully over head • Pain is a bit better on days off but often sore at night in his upper arm • Pain never goes as low as the elbow • It does not go to his lateral neck

19. Case • What is the diagnosis? • How do you treat it?

20. Case 6 • What is the diagnosis? • He could have • Rotator cuff tendonitis • Impingement • Partially frozen shoulder • How do you treat it? • Injection • Analgesics • Exercises, and rest, therapy (ROM, ultrasound) • NO INVESTIGATIONS ARE NECESSARY • Unless if it does not improve at all over months of treatment

21. Case 7 • 54 year old woman with pain in many fingers on dominant hand especially • PIPs and DIPs are stiff and swollen • She has 30 minutes of stiffness, no redness but swelling and warmth are noted • What is the most likely diagnosis? • What tests would you order (if any)? • How would you treat it?

22. Erosive Hand OABony Enlargement PIP bony enlargement Bouchard’s nodes DIP bony enlargement Heberden’s nodes

23. Erosive Hand Osteoarthritis • Erosive hand OA • How do you treat it? • Non pharmacologic • Education, exercises, hot wax, etc. • Reassurance • Pharmacologic • Tylenol • NSAIDs – po or topical • IA injections – steroids • ? Glucosamine • NO INVESTIGATIONS ARE NECESSARY

24. Case 8 • 50 y.o. man presents to the office with painful, swollen fingers • Intermittent flares over the last year with limited morning stiffness and slight loss of energy • Presents with the following findings: • Psoriasis X years with nail involvement • DIPs swelling and dactylitis, swollen knees

25. Case 8

26. Case 8 Dactylitis

27. What is the most likely diagnosis? • What tests would you order (if any)? • How would you treat it?

28. What is the most likely diagnosis? • Psoriatic arthritis • What tests would you order (if any)? • Xrays, CBC, creatinine, liver tests and Hep B and C serology to safely start methotrexate • How would you treat it? • Methotrexate, NSAIDs, injections of steroids or oral steroids if severe to help until DMARD is effective

29. Case 9 • 74 year old woman • CHF for 10 years, CRF (creatinine 135) • Meds • Ramipril 5mg od • Furosemide 40 mg BID

30. Presented with bilat swelling of several small joints of the hands • Swelling, stiffness, some slight erythema • MCPs, PIPs and DIPs, wrists and knees involved Note tophi White or yellowish deposits under the skin

31. What is the most likely diagnosis? • What tests would you order (if any)? • How would you treat it?

32. What is the most likely diagnosis? • Polyarticular tophaceous gout • What tests would you order (if any)? • Uric acid, urea, Creatinine, AST, ALT • How would you treat it? • Allopurinol chronically, avoid NSAIDs due to elevated creatinine and CHF, colchicine or steroids for acute or chronic flares, avoid diuretic if possible

33. Case 10 • 34 year old woman from Mexico • New onset of • Red rash on the cheeks • Rash on arms and neck and face in the sun • Swollen joints • Frequent sores in mouth • Admitted for pleuricy and elevated creatinine

34. What is the most likely diagnosis? • What tests would you order (if any)? • How would you treat it?

35. What is the most likely diagnosis? • SLE • What tests would you order (if any)? • CBC, urinalysis, Creatinine, ANA • (likely anti-DNA if ANA is positive and ENA and maybe complements) • How would you treat it? • Steroids, renal biopsy if active urinary sediment (blood and protein), Cellcept or cyclophosphamide

36. Labs

37. RF in Rheumatoid Arthritis • In General, NOT USEFUL to make a diagnosis • Found in 30-50% of those with early RA • Found in 70-85% of those with established RA • Conclusion: If you think a patient may have RA but the RF is negative there is still a good chance that they might

38. Anti-Nuclear Antibodies ds-DNA Important ANAs ENAs All ANAs

39. ANA & Lupus • 99% of patients with SLE will have a positive ANA • If the ANA is negative it is extremely unlikely that the patient has lupus

40. Next Steps • Rheumatology Update • June 3, 2011 • SJHC Focus on the Diversity of Rheumatic Diseases The St. Joseph’s 2nd Annual Professional Update Day in Rheumatology

41. Next Steps • Hands on teaching • Grand rounds with MSK physical exam • Preceptorships in London with a rheumatologist and also nurse practitioner • Do you want more webcasts? • Other ideas

42. Conclusions • You have learned about common and serious MSK conditions • You have more skills in history, investigation, diagnosis and treatment • The talks are all recorded and available on our website at SJHC • Thank-you