GENERAL GENERAL CO CONC NCEP EPTS TS IN RH IN - - PowerPoint PPT Presentation

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GENERAL GENERAL CO CONC NCEP EPTS TS IN RH IN RHEUMA EUMATOL OLOG OGY Dr. Sahar Abd Elrahman WHY EVEN CARE? 2002 CDC reported arthritis as the leading cause of disability in the US.

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SLIDE 1

ميحرلا نمحرلا اللو مسب

GENERAL GENERAL CO CONC NCEP EPTS TS IN RH IN RHEUMA EUMATOL OLOG OGY

  • Dr. Sahar Abd Elrahman
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SLIDE 2

WHY EVEN CARE?

2002 CDC reported arthritis as the leading

cause of disability in the US.

55.4 million have chronic joint symptoms

lasting for more than 3 months

21.5 million have not seen a physician

Center for Disease Control and Prevention. MMWR 2004;53:383-6. Center for Disease Control and Prevention. MMWR 2004;53:388.

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SLIDE 3

2 million have activity limitations 25% will be unable to work within 7

years of disease onset

Direct and indirect costs are estimated

at 1% of the US gross domestic product = $86.2 billion

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SLIDE 4

Musculoskeletal Complaint Initial Rheumatic History and Physical Exam to Determine:

  • 1. Is it articular
  • 2. Is it acute or chronic?
  • 3. Is inflammation present?
  • 4. How many/which joints are involved?
  • 5. Are there RED FLAGS?

Joint Pain Joint Swelling Diffuse/Systemic Sxs

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SLIDE 5

GOALS OF ASSESSMENT

Identify “Red Flag” conditions Conditions with sufficient morbidity/mortality

to warrant an expedited diagnosis

Make a timely diagnosis Common conditions occur commonly Some conditions require serial evaluation over

time to make a Dx

Provide relief, reassurance and plan for evaluation

and treatment

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SLIDE 6

RED FLAG CONDITIONS

 FRACTURE  INFECTION  ORGAN INVOLVEMENT

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SLIDE 7

ARTICULAR

  • VS. PERIARTICULAR

Finding

ARTICULAR PERIARTICULAR Pain Diffuse, deep "point" tenderness ROM Pain Active+passive Active motion in all planes in few planes Swelling Common Uncommon

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SLIDE 8

ARTICULAR

  • VS. PERIARTICULAR

Finding ARTICULAR PERIARTICULAR

Pain Diffuse, deep tenderness "point" ROM Pain Active+passive in all planes Active motion in few planes Swelling Common Uncommon

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SLIDE 9

INFLAMMATORY VS NONINFLAMMATORY

Feature Inflammatory Noninflammatory Pain (worse when?) Yes (morning) Yes (night) Swelling Soft Tissue (+ effusion) Bony Erythema Sometimes Present Absent Warmth Sometimes Present Absent Morning Stiffness Prominent ( > 1 hr.) Minor ( < 45 min.) Systemic Features+ Sometimes Present Absent Elevated ESR or CRP* Frequent Uncommon Synovial Fluid WBC WBC > 2,000 /mm3 WBC < 2,000 /mm3 Examples Septic arthritis, RA, Gout, Polymyalgia rheumatica Osteoarthritis, Adhesive Capsulitis,Osteonecrosis + fever, rash, weight loss, anorexia, anemia * ESR: erythrocyte sedimentation rate; CRP: C-reactive protein

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SLIDE 10

FORMULATING A DIFFERENTIAL DX

Condition Articular Nonarticular Inflammatory Septic Gout Rheumatoid arthritis Psoriatic arthritis Bursitis Enthesitis PMR Polymyositis Noninflammat

  • ry

Osteoarthritis Charcot Joint Fibromyalgia Carpal tunnel fracture

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SLIDE 11

ONSET & CHRONOLOGY

Acute: Fracture, septic arthritis, gout,

rheumatic fever, Reiter's syndrome

Chronic: OA, RA, SLE, psoriatic arthritis,

fibromyalgia

Intermittent: gout, pseudogout,

palindromic rheumatism, Behcet's, Familial Mediterranean Fever

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SLIDE 12

Additive: OA, RA, Reiter's syndrome,

psoriatic

Migratory:Viral arthritis (hepatitis B),

rheumatic fever, GC arthritis, SLE

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SLIDE 13

Location

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SLIDE 14

ARTHRITIS

Swelli

elling ng : : 2 p

Ten

ende derne ness ss : T : T

War

armth mth : : 1 p

Lim

imit itati tion

  • n of
  • f Motion

Motion : : 1 p

Red

edne ness ss : : 1 1 P

Arthriti

thritis s > T T + + 2 2 p

Gener eneral al Concept

  • ncepts
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SLIDE 15

MONO/OLIGO VS POLYARTICULAR

Less than 4 joints

Osteoarthritis Gout or Pseudogout Septic arthritis Reactive arthrtis Tuberculous/Fungal

arthritis 4 or more joints

 Osteoarthritis  Rheumatoid

arthritis

 Psoriatic arthritis  Viral arthritis  Juvenile arthritis  SLE/MCTD

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SLIDE 16

Musculoskeletal Complaint

Initial Rheumatic History and Physical Exam to Determine:

  • 1. Is it articular
  • 2. Is it acute or chronic?
  • 3. Is inflammation present?
  • 4. How many/which joints are involved?

Is it Articular? Is Complaint > 6 wks Duration? Nonarticular Condition

  • Trauma/Fracture
  • Fibromyalgia
  • Polymyalgia Rheumatica
  • Bursitis
  • Tendinitis

Chronic Acute Acute Arthritis

  • Infectious Arthritis
  • Gout
  • Pseudogout
  • Reiter’s Syndrome
  • Initial Presentation of

Chronic Arthritis Is Inflammation Present?

  • 1. Is there prolonged AM stiffness?
  • 2. Is there soft tissue swelling?
  • 3. Are there systemic symptoms?
  • 4. Is the ESR or CRP elevated?

Chronic Inflammatory Arthritis Chronic Noninflammatory Arthritis How Many Joints Involved? Chronic Inflammatory Mono/oligoarthritis Consider:

  • Indolent infection
  • Psoriatic Arthritis
  • Reiter’s Syndrome
  • Pauciarticular JA

Are DIP, CMC, Hip or Knee Involved? Unlikely to be Osteoarthritis Consider:

  • Osteonecrosis
  • Charcot Arthritis

Osteoarthritis

Chronic Inflammatory Polyarthritis Is it Symmetric? Are PIP, MCP or MTP Joints Involved? Consider:

  • SLE
  • Scleroderma
  • Polymyositis

Consider:

  • Psoriatic Arthritis
  • Reiter’s Syndrome

Rheumatoid Arthritis

Yes No Yes Yes No No No Yes Yes No No Yes

<4 4+ Adapted from J. Cush, MD

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SLIDE 17

KNOW IT WHEN YOU SEE IT

 Hard bony

enlargements

 Heberden’s nodes at

the DIP joints

 Bouchard’s nodes at

the PIP joints

 Often have “squared”

first CMC joint due to

  • steophytes at that

joint

Osteoarthritis

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SLIDE 18

KNOW IT WHEN YOU SEE IT

 Soft synovial

swelling

 Synovitis and volar

subluxation at the MCP joints

 Synovitis of the

wrists

 Synovitis of the PIP

joints with early swan neck deformities

Rheumatoid arthritis

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SLIDE 19

RHEUMATOID ARTHRITIS: LATE STAGES

  • Deformities
  • Nodules
  • Tendon Rupture
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SLIDE 20

KNOW IT WHEN YOU SEE IT

Jaccoud’s Deformity of SLE

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SLIDE 21

Often associated with:

  • Inflammatory eye

disease

  • Balanitis, oral

ulceration, or keratoderma

  • Enthesopathy
  • Sacroiliitis

KNOW IT WHEN YOU SEE IT

Seronegative spondyloarthropathy

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SLIDE 22

KNOW IT WHEN YOU SEE IT

 Inflammation of the DIP

joints

 Sausage fingers  Joint involvement shows

radial pattern

 Nail changes  Psoriatic patches  Arthritis may start before

the skin

Psoriatic arthritis

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SLIDE 23

KNOW IT WHEN YOU SEE IT

 May look like psoriasis

  • r syphilis

 Can occur in patches

  • r as sterile pustules

Keratoderma blennorrhagica in Reiter’s syndrome

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SLIDE 24

KNOW IT WHEN YOU SEE IT

 “Butterfly”/Malar rash  Involves cheeks,

spares nasolabial fold

Systemic lupus erythematosus

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SLIDE 25

KNOW IT WHEN YOU SEE IT

Both have periungual erythema Interarticular dermatitis of SLE

Dermatomyositis

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SLIDE 26

KNOW IT WHEN YOU SEE IT

“Mantle” aka “Shawl” Sign of Dermatomyositis

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SLIDE 27

KNOW IT WHEN YOU SEE IT

 Appears in a broad-

based interrupted pattern in systemic vasculitis, including SLE

 May occur as a fine,

connected, lacy pattern in normals Livedo reticularis

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SLIDE 28

KNOW IT WHEN YOU SEE IT

 Can be 1o or 2o  Stress/cold can trigger  Keep extremities and

body warm Raynaud’s phenomenon

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SLIDE 29

KNOW IT WHEN YOU SEE IT

T

  • phi appear rather late in

gout

Prick the tophus with a

  • needle. Put the drop of

material on a slide

Gout