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APPROACH TO THE PATIENT WITH POSSIBLE RHEUMATIC DISEASE

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APPROACH TO THE PATIENT WITH POSSIBLE RHEUMATIC DISEASE

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  1. APPROACH TO THE PATIENT WITH POSSIBLE RHEUMATIC DISEASE

  2. PATIENT 1/7 visits are for a MSK complaint Patient wants relief Patient wants an explanation INTERNIST Is this a systemic process or a localized issue Do I embark on a lab work-up? Do I “keep” or “send” NSAID and film ?? INTRODUCTION

  3. OVERVIEW OF TALK • “Rheum Hx” • “Rheum ROS” • Focused PE • Laboratory evaluation • Imaging • Pattern Recognition • The Elderly • Management • Perioperative Care

  4. NOT COVERED • Individual disease states • Autoantibody testing • Specific treatment modalities

  5. THE RHEUMATOLOGIC HISTORY

  6. JOINT PATTERN

  7. JOINT PATTERN • Location (joint or periarticular structure) • Presence or absence of inflammation (synovitis) • Pain character • Number of involved joints • mono • oligo [up to 4] • poly [5 and up]

  8. JOINT PATTERN • Site /distribution of affected joints • Axial or peripheral • Symmetric or asymmetric • Presence or absence of enthesopathy – suggestive of the SNSA’s (AS, PsA, Reiter’s/Reactive, IBD associated) • Dactylitis • Enthesitis or tendinitis

  9. ENTHESOPATHY - Reiter’s - AS - Psoriatic - IBD SNSA’s:

  10. REITER’S SYNDROME

  11. The “Five” Minute Rheumatologic Review of Systems (ROS)

  12. ROS - RASH Acute Cutaneous Lupus Discoid Lupus

  13. ROS - RASH Dermatomyositis Heliotrope rash

  14. ROS - RASH Palpable purpura - HSP

  15. ROS - RASH Livedo reticularis – APLA Syndrome

  16. ROS - ALOPECIA SLE

  17. ROS - PERIUNGUAL CHANGES SLE Vasculitis PM/DM MCTD

  18. ROS - PSORIASIS Psoriatic arthritis

  19. ROS - RASH Reactive arthritis

  20. ROS - CONJUNCTIVITIS Reactive arthritis

  21. ROS - UVEITIS Behcet’s SNSA’s

  22. ROS - RAYNAUD’S Scleroderma SLE DM/PM MCTD

  23. ROS – ORO/GEN ULCERS SLE Behcet’s

  24. ROS - POLYCHONDRITIS Relapsing polychondritis

  25. ROS - ENTHESOPATHY SNSA’s

  26. ROS - NODULES RA Gout

  27. ROS • IBD symptoms • infectious diarrhea or STD sx • photosensitivity • hypercoagulable event • heme/renal/CNS or PNS disease • sicca • pleuropericarditis

  28. AGE

  29. AGE • 1-15 yo • JCA • Still’s • ARF • 20-45 yo • SLE / RA • SNSA’s • PM/DM • DGI • vasculitis

  30. AGE • 45-60 yo • Crystalline (MSU) • OA • Sjogren’s • 65 + • PMR • GCA • Crystalline (CPPD, MSU, others)

  31. GENDER

  32. MEN MSU crystals OA of knees AS Reactive (Reiter’s) WOMEN RA SLE Sjogren’s OA of fingers GENDER

  33. FAMILY HISTORY

  34. FAMILY HISTORY • Nodal osteoarthritis • SLE • RA

  35. PATTERN OF ONSET

  36. PATTERN RECOGNITION • Acute • Indolent • Brief and relapsing • Migratory

  37. PATTERN RECOGNITION ACUTE Parvovirus infection

  38. PATTERN RECOGNITION ACUTE Sarcoid / Lofgren’s Syndrome

  39. PATTERN RECOGNITION INDOLENT Rheumatoid arthritis

  40. PATTERN RECOGNITION BRIEF & RELAPSING SLE

  41. PATTERN RECOGNITION MIGRATORY Acute Rheumatic Fever Disseminated GC

  42. The “Five” Minute Rheumatologic Examination

  43. PE – LOOK FOR SIGNS OF SYSEMTIC DISEASE

  44. alopecia nasal / genital / oral ulcers rash synovitis – joint inflammation cutaneous vasculitis adenopathy / HSM enthesitis dactylitis xerostomia mononeuritis multiplex pleuropericarditis “FOCUSED” FIVE MINUTE EXAM

  45. PE - RASH Keratodermia blenorrahgica – Reactive arthritis

  46. PE - RASH Circinate balanitis - Reactive arthritis

  47. PE - RASH ECM - Lyme

  48. PE - RASH Gottron’s papules - DM

  49. PE - VASCULITIS

  50. PE - PERIUNGUAL CHANGES