Transcript Team Management of Patients

Nurse Practitioner Outreach
Wrap up
Janet Pope MD MPH FRCPC
Objectives
1. To reinforce learnings of the course
2. To present cases of common rheumatologic
problems
3. 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
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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, fever
Fracture history
Diabetes
Other medical problems
Order
CBC, ESR, (CRP), diff
AST/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
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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
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What is the diagnosis?
He could have
Rotator cuff tendonitis
Impingement
Partially frozen shoulder
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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
PIP bony enlargement
Bouchard’s nodes
DIP bony enlargement
Heberden’s nodes
Erosive Hand Osteoarthritis
• Erosive hand OA
• How do you treat it?
• Non pharmacologic
– Education, exercises, hot
wax, etc.
– Reassurance
• Pharmacologic
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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?
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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?
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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
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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?
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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 Antibodies
ds-DNA
Important
ANAs
ENAs
All ANAs
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