Nurse Practitioner OutreachWrap up

Janet Pope MD MPH FRCPC

Objectives

1. To reinforce learnings of the course2. To present cases of common rheumatologic

problems3. To discuss the next steps and ongoing CME

Facts

• Targeting outcomes makes better disease control– Similar to

• HTN• DM• Lipids

• Thus we need novel ways to care for our area

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?

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

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?

Case 2

• She likely has RA• What would you do?

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

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

Case 3

• What is the most likely diagnosis?• What can you do to manage her?

Case 3

• Fibromyalgia• Education• Exercise• Amitryptylline,Gabapentin / Pregabalin,

Duloxetine

• Who can you refer her to?

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?

Ask patient about

• Temporal arteritis symptoms– HA, scalp tenderness, visual problems, jaw

claudication, tongue pain, weight loss, feverFracture historyDiabetesOther medical problems

OrderCBC, ESR, (CRP), diffAST/ALT, Creatinine, glucose, ?RF, ?BMD

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

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

Case

• What is the diagnosis?

• How do you treat it?

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

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

Case

• What is the diagnosis?

• How do you treat it?

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

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?

Erosive Hand OA

Bony Enlargement

DIP bony enlargementHeberden’s nodes

PIP bony enlargementBouchard’s nodes

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

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

Case 8

Case 8

Dactylitis

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

• 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

Case 9

• 74 year old woman • CHF for 10 years, CRF (creatinine 135)• Meds

– Ramipril 5mg od– Furosemide 40 mg BID

• 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

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

• 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

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

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

• 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

Labs

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

Anti-Nuclear Antibodiesds-DNA

All ANAs

Important ANAs

ENAs

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

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

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

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