General Practice Guide to Rheumatology

Dr Helen GabathulerMRCP, MRCGPGeneral practitioner and clinical assistant in rheumatology

Aims

• History and Examination• Appropriate Investigations• Management

• Common conditions in general practice• Must Not Miss Diagnoses

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What You Want To Know…

• Is this painful joint(s) a mechanical problem or part of an underlying inflammatory condition?

• Is there anything that I could miss that will seriously harm this patient?

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History Taking

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Presenting Symptoms …

• Pain

• Stiffness

• Joint swelling

• Systemic symptoms

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PAIN

• S Q I T A S

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Stiffness

• Related to activity or rest?• Morning stiffness?• Duration ?

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Joint swelling

• Where and when ?• One or many ?• Symmetrical ?

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Systemic Symptoms

• Fever• Weight loss• Malaise• Rash

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Other Symptoms …

• Respiratory ?• Circulatory ? • Eye ?• Gut ?• Urinary ?• Rashes ?

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• Family history ?

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Important Questions

• FUNCTION• EMPLOYMENT• SOCIAL SUPPORT• Including I C E

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Examination

http://www2.warwick.ac.uk/fac/med/study/ugr/mbchb/misc/oup/version2/

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Investigations ….

• Case dependent

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Management

• Advice and Patient Education• Prescription • Referral - physio, OT, appliances officer,

podiatrist, multidisciplinary back team, secondary care orthopaedics or rheumatology or neurosurgical referrals, social services.

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Common GP Presentations …

• Back Pain• Neck pain• Painful shoulder• Knee pain• Hip pain• Painful hands

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Common Conditions to Recognise in General Practice

• Osteoarthritis• Gout• Polymyalgia rheumatica

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Less Common Conditions

• Rheumatoid arthritis• Ankylosing spondylitis• Systemic lupus erythematosus

Important to diagnose and refer these conditions to rheumatologist EARLY.

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Simple Back Pain

• History - Red Flag Symptoms ?

• Examination - Red Flag Signs ?

• Investigations - avoid !

• Management - activity and regular analgesia

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Red Flags in Back Pain

• Age under 20 or over 55 years • Pain that is constant and often severe

(particularly at night) • Thoracic pain • Past history (carcinoma, steroids, HIV

infection) • Systemically unwell

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• Unexplained weight loss • Widespread or bilateral neurological

symptoms and signs • Structural deformity • Sphincter disturbance • Saddle anaesthesia.

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Lumbar spine X-ray

• Randomised studies in general practice in the UK did not show any benefit in outcome from performing lumbar spine x-rays.

One of the studies found that they have an adverse effect on outcome.

• The dose of radiation from a set of lumbar spine x-rays is 120 times that of a chest x ray.

• The incidence of cancers induced by radiation following x -rays of the lumbar spine may be around 1 in 25 000.

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Magnetic Resonance Imaging• Abnormalities are commonly found on magnetic resonance imaging

scans. A review of eight studies of magnetic resonance imaging in asymptomatic adults found– Bulging discs in 20% to 79% – Herniated discs in 9% to 76% – Degenerative discs in 46% to 91%.

• A randomised controlled trial found no difference in clinical outcome between patients who had a rapid magnetic resonance imaging scan and patients who had an x ray of the lumbar spine.

• Radiographic imaging for chronic non-specific low back pain is not recommended. However, MRI scans are recommended for the investigation of patients who may have malignancy or sepsis as a cause of their pain and for the investigation of radicular symptoms.

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Common Conditions to Recognise in General Practice

• Osteoarthritis• Gout• Polymyalgia rheumatica

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Gout

• Causes intermittent attacks of acute joint pain.

• Due to deposits of monosodium urate crystals in synovial fluid.

• Related to raised serum uric acid levels

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Presenting complaint – painful, swollen joint (usually big toe) On examination - hot, red, tender, swollen joint

Most important differential diagnosis is infection

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Investigations

• Raised serum urate > 420umol/l• Synovial fluid with negatively

birefringent crytals when viewed under polarised light

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Management

• Treatment acute gout

• Prevention recurrent attacks

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Treatment Acute Gout

• Non-steroidal inflammatory drugs

• Colchicine if contra-indications to NSAIDs

• Review causes ? increased production purines ? reduced renal excretion uric acid

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Increased production purines ……

• Dietary intake - meats, seafood, beans, yeast

• Haematological causes - Chronic Haemolytic anaemia, CML

• Alcohol

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Reduced renal excretion urate…• Drugs - loop and thiazide diuretics aspirin• Kidney disease• Diabetic ketoacidosis• Starvation

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Prevention recurrent attacks

• Treat underlying causes• Allopurinol Reduces urate concentrations in urine and

blood. Do not start during acute attack Always cover with nsaid or colchicine to

prevent gout being precipitated for 3/12 Beware itchy rash – 2%

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Osteoarthritis

• Commonest form of arthritis• Detectable radiologically in > 80% patients

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Osteoarthritis was described by Solomon as

A chronic disorder characterized by softening and disintegration of articular cartilage, with reactive phenomena such as vascular congestion and osteoblastic activity in the subarticular bone, new growth of cartilage and bone (osteophytes) at the joint margins, and capsular fibrosis.

Osteoarthritis is not accompanied by any systemic illness, and although there are sometimes signs of inflammation, it is not primarily an inflammatory disorder.

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Pathological findings in OA include cartilage loss and reactive bone formation.

Incidence increases with age, weight, in women>men over 50 yrs, positive family history, trauma to joint.

Can be idiopathic or secondary OA.Commonest joints affected are hands, hips,

knees and spine.

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Symptoms ….

• Joint Pain - related to use• Rest Stiffness < 30 minutes

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Signs• Tenderness to palpation of joint• Bony thickening• Small effusions• Crepitus• Deformity and restricted movement joint• Muscle wasting• Generalised or localised arthritis ?• Heberdens and Bouchards nodes in hands ?

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Management of OA

• Weight reduction• Exercise to improve specific muscle

strength• Exercise to improve aerobic fitness• Pain Control

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Pain Control in OA

• Paracetamol• Topical NSAIDs • Paracetamol/codeine• NSAIDs - but beware use in elderly - consider co-prescribing PPI• TENs machine

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• Social support

• Aids and appliances

• Intra-articular corticosteroid injection if pain severe

• Surgery - prosthetic joint replacement

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Polymyalgia Rheumatica

• Incidence in elderly of 1.5% W>M • Clinical diagnosis• Overlap with temporal arteritis

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Symptoms

• Pain and stiffness in neck, shoulder and pelvic girdles• Severe morning stiffness – cannot get out of bed !• Bilateral and symmetrical symptoms• Low grade systemic symptoms• Rapid response to small dose prednisolone

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Investigations

• Raised plasma viscosity• Investigations to exclude differential

diagnoses all negative including immunoglobulins, urinary bence

jones protein, rheumatoid factor, thyroid function, CK, CXR

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Management

• Prednisolone 10-20mg daily for 1 month• Aim to reduce to 7.5mg within 6 monthes• Protect bones with biphosponate whilst on

prednisolone• Refer to rheumatologist if unable to

adequately reduce prednisolone to consider MTX.

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Rheumatoid Arthritis

• Commonest disorder of connective tissues.

• 1-3% population prevalence. W>M• Genetic predisposition

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Symptoms• Pain • Swelling• Significant morning stiffness of joints• Symmetrical polyarthritis• Systemic symptoms

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On examination• Symmetrical synovitis of joints especially small

joints.• Long-standing hand changes .. ulnar deviation fingers, z deformity thumb,

swan neck and boutonnière deformities.• Cervical spine arthritis causing subluxation

and cord compression.• Bakers cyst

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Non- articular manifestations

• Rheumatoid nodules• Eye complications – dry eyes (sjogren’s

syndrome); episcleritis.• Neurological complications – peripheral nerve

entrapment eg carpal tunnel s.; peripheral neuropathy; cervical spine compression.

• Vasculitis rash

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• Cardiac complications – pericarditis; mitral valve d.

• Respiratory complications – fibrosing alveolitis; pleural effusion.

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Investigations

• FBC and plasma viscosity• Kidney and liver function• Rheumatoid factor• ANA• Urinanalysis• Xrays hands and feet – but normal initially,

develop erosions over 3yrs

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Management

• Refer for disease-modifying therapy EARLY, as this will prevent disease progression and joint damage.

• Refer OT and physio.• Support and information.

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Ankylosing Spondylitis• Inflammatory arthritis• HLA B27 positive spondyloarthropathy• m > f young adults• Presenting complaint of spinal stiffness aggravated

by rest and back pain.• O/E reduced movement lower spine on forward

flexion by < 4cm• Eventually develop ankylosis / fusion of whole spine

and marked disabilty.• Refer early ……..

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DO NOT MISS

• Cauda Equina Syndrome

• Temporal or Giant Cell Arteritis

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Temporal/Giant Cell Arteritis

• Overlaps with PMR• Risk sudden blindness if missed !• Presentation includes fatigue, headaches,

scalp tenderness, jaw claudication +/- PMR• O/E temporal arteries are thickened,nodular,

tender, with absent pulsation• Visual symptoms include visual loss, diplopia,

or amauriasis fugax

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Cauda Equina Sydrome

• Neurosurgical emergency• Misdiagnosed patients can be left wheelchair-

bound with double incontinence…• Presenting symptoms include Leg weakness bilat Sensory disturbance perineal – saddle

anaesthesia Urinary and faecal disturbance ,progressing to

incontinence56

• O/E LMN weakness legs Sensory loss perineal area, buttocks, back of thighs Loss of perianal tone - need PR !

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Case Histories

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CASE 1• 24 year old male plumber presented with 6 month history of low back pain. No

radiation. No neurological, urinary or bowel symptoms. Described stiffness after rest, and when awakens in morning. Takes time to ‘get going ‘in morning after getting out of bed.

• What is your provisional diagnosis?• What else would you like to find out?

• On further questioning you find out that this has been a recurrent problem for a few years. He has a father with a very bad back, and a cousin. His morning stiffness is lasting up to 2 hours. He has had an episode of uveitis in past when needed to attend eye casualty.

• Any change in your diagnosis?• On examination what would you be looking for?

• Inspection NAD, palpation reveals tenderness over sacro-iliac joints, schoebers test 3cm of difference in flexion lumbar spine, general reduction in lumbar spine movements. No neurol signs.

• What investigations would you do? • And discuss further management…

CASE 1• 24 year old male plumber presented with 6

month history of low back pain. No radiation. No neurological, urinary or bowel symptoms. Described stiffness after rest, and when awakens in morning. Takes time to ‘get going ‘in morning after getting out of bed.

• What is your provisional diagnosis?• What else would you like to find out?

• On further questioning you find out that this has been a recurrent problem for a few years. He has a father with a very bad back, and a cousin. His morning stiffness is lasting up to 2 hours. He has had an episode of uveitis in past when needed to attend eye casualty.

• Any change in your diagnosis?• On examination what would you be looking

for?

• Inspection NAD, palpation reveals tenderness over sacro-iliac joints, schoebers test 3cm of difference in flexion lumbar spine, general reduction in lumbar spine movements. No neurol signs.

• What investigations would you do? • And discuss further management…

Ankylosing spondylitis

• Inflammatory arthritis• HLA B27 positive spondyloarthropathy• m > f young adults• Presenting complaint of spinal stiffness aggravated

by rest and back pain.• O/E reduced movement lower spine on forward

flexion by < 4cm• Eventually develop ankylosis / fusion of whole spine

and marked disabilty.• Refer early ……..

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Case 2

• A 55 year old lady presents with a 3 month history of painful hands. She appears very anxious. She describes difficulty using her hands and stiffness, as well as some swelling.

• What are your provisional thoughts on diagnoses?• What else would you like to know?

• On further questioning she describes stiffness after rest, and in morning of up to 45 minutes. She is struggling to do up buttons and play the piano. She is very anxious as her job is a piano teacher. She has noticed her finger joints swelling and cannot get her ring off. She has also had knee pain bilaterally for 6 months with use. Her mother had ‘arthritis’ but she doesn’t know which type.

• What other symptoms should you ask about? And what other systems should you enquire into?

• She has no dry eyes, or dry mouth, nor symptoms of Raynaud’s; she has developed a dry cough last 6 weeks, but no pain nor shortness of breath. Weight stable. Non-smoker.

• What are your differential diagnoses? What would you like to examine?

• Hands show tender, red, swollen, hot MCPs, and PIP joints. Knees are warm and slightly swollen with positive patellar tap. All other joints NAD. Respiratory examination reveals dullness to percussion at bilateral bases and basal crackles on inspiration.

• How does this help your differential? What investigations would you do? Discuss further management.

• A 55 year old lady presents with a 3 month history of painful hands. She appears very anxious. She describes difficulty using her hands and stiffness, as well as some swelling.

• What are your provisional thoughts on diagnoses?

• What else would you like to know?

• On further questioning she describes stiffness after rest, and in morning of up to 45 minutes. She is struggling to do up buttons and play the piano. She is very anxious as her job is a piano teacher. She has noticed her finger joints swelling and cannot get her ring off. She has also had knee pain bilaterally for 6 months with use. Her mother had ‘arthritis’ but she doesn’t know which type.

• What other symptoms should you ask about? And what other systems should you enquire into?

• She has no dry eyes, or dry mouth, nor symptoms of Raynaud’s; she has developed a dry cough last 6 weeks, but no pain nor shortness of breath. Weight stable. Non-smoker.

• What are your differential diagnoses? What would you like to examine?

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• Hands show tender, red, swollen, hot MCPs, and PIP joints. Knees are warm and slightly swollen with positive patellar tap. All other joints NAD. Respiratory examination reveals dullness to percussion at bilateral bases and basal crackles on inspiration.

• How does this help your differential? What investigations would you do?

• Discuss further management.

Case 3• A 71 year old lady presents with a 2/12 history of a painful right shoulder. She has also

noticed some discomfort in her left shoulder. She is unable to get her sweater over her head in the morning.

• What are your provisional thoughts on diagnosis?• What else would you like to know?• Other symptoms include flu-like illness 2-3/12 ago from which she never quite recovered,

and aching developing in her buttocks. She is extremely stiff in her shoulders in the morning. No other symptoms of note.

• What other specific symptoms MUST you ask about in this case?• What other questions are warranted?• She has no scalp tenderness, jaw claudication, visual disturbances or headache.• In addition no weight loss, bony pain, joint symptoms, or symptoms related to thyroid

dysfunction.• What would you like to examine?• She shows tenderness in proximal muscles limbs, painful arc bilaterally on examination of

shoulders and hips NAD.• Temporal arteries pulsatile and non-tender.• Do these findings confirm your diagnosis?• What investigations would you do? , and discuss further management…

Case 3

• A 71 year old lady presents with a 2/12 history of a painful right shoulder. She has also noticed some discomfort in her left shoulder. She is unable to get her sweater over her head in the morning.

• What are your provisional thoughts on diagnosis?

• What else would you like to know?

• Other symptoms include flu-like illness 2-3/12 ago from which she never quite recovered, and aching developing in her buttocks. She is extremely stiff in her shoulders in the morning. No other symptoms of note.

• What other specific symptoms MUST you ask about in this case?

• What other questions are warranted?

• She has no scalp tenderness, jaw claudication, visual disturbances or headache.

• In addition no weight loss, bony pain, joint symptoms, or symptoms related to thyroid dysfunction.

• What would you like to examine?

• She shows tenderness in proximal muscles limbs, painful arc bilaterally on examination of shoulders and hips NAD.

• Temporal arteries pulsatile and non-tender.

• Do these findings confirm your diagnosis?• What investigations would you do? , and

discuss further management…

Case 4

• A 74 year old man presents with a painful swollen knee. It has developed over the past few days. He has an extensive past medical history and is on multiple medication including furosemide and warfarin.

• What are your preliminary thoughts on possible diagnoses?• What other questions would you ask?• He has no history trauma to knee, no previous episodes like this. No systemic

symptoms. Knee is stiff and painful constantly. Prior to this had noticed occasional aching in hips with exercise. No other joints affected. Is due an INR check.

• What are your preliminary differential diagnoses?• What would you like to examine?• Right knee hot, tender and swollen with an effusion, left knee mild crepitus, both

hips slight discomfort with rotation and abduction. No skin bruising generally, apyrexial and well, no evidence gouty tophi.

• Does this help your differential diagnosis?• What investigations and further management would you undertake? What

complicating factors will affect this patient’s management?

Case 4

• A 74 year old man presents with a painful swollen knee. It has developed over the past few days. He has an extensive past medical history and is on multiple medication including furosemide and warfarin.

• What are your preliminary thoughts on possible diagnoses?

• What other questions would you ask?

• He has no history trauma to knee, no previous episodes like this. No systemic symptoms. Knee is stiff and painful constantly. Prior to this had noticed occasional aching in hips with exercise. No other joints affected. Is due an INR check.

• What are your preliminary differential diagnoses?

• What would you like to examine?

• Right knee hot, tender and swollen with an effusion, left knee mild crepitus, both hips slight discomfort with rotation and abduction. No skin bruising generally, apyrexial and well, no evidence gouty tophi.

• Does this help your differential diagnosis?• What investigations and further management

would you undertake? What complicating factors will affect this patient’s management?

What are these associated with?

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Raynaud’s Phenomena

• Episodic colour changes hands/feet white – blue – red ischaemia --- stasis ---hyperaemia• Primary Raynauds• Secondary - scleroderma - SLE - myositis

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Osteoporosis

• Who to screen?• Who to treat ?• Treatment options ?

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RCP Guidelines

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Chronic Fatigue SyndromeMyalgo-encephalitis

Fibromyalgia

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Diagnosing Chronic Fatigue Syndrome :• Fatigue :

– New or had a specific onset – Characterised by post-exertional malaise and/or fatigue (typically delayed, for example

by at least 24 hours, with slow recovery over several days) • One or more of the following symptoms:

– Difficulty with sleeping, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle

– Muscle and/or joint pain that is multi-site and without evidence of inflammation – Headaches – Painful lymph nodes without pathological enlargement – Sore throat – Cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of

short-term memory, and difficulties with word-finding, planning/organising thoughts and information processing

– Physical or mental exertion makes symptoms worse – General malaise or flu-like symptoms – Dizziness and/or nausea – Palpitations in the absence of identified cardiac pathology.

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CFS is a diagnosis of exclusion.

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Reconsider the diagnosis if the patient does not suffer from:

• Post-exercise fatigue • Cognitive problems • Sleep disturbance • Chronic pain

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Birefringence, or double refraction, is the splitting of a ray of light into two rays when it passes through certain types of material, such as calcite crystals. The two rays, called the ordinary ray and the extraordinary ray, travel at different speeds. Thus the material has two distinct indices of refraction, as measured from different directions.If split ray of light is rotated clockwise is classified as positive birefringent.If counterclockwise rotation is classifed as negatively birefringent