These are the impressions of the interview panel noted during an informal & unorganized conversation. Please take these in this background
*In one study in USA about 40 % of patients with family physicians have joint pains as prominent feature.
**If proper understanding & protocol is followed
~lot of unrequired investigations,
~delay in timely diagnosis, where essential (to avoid crippling)
~& use of unnecessary NSAIDs can be avoided.
***Second line drugs like Methotexate & Salazopyrene, for Rheumatoid Artheritis have been proved quite useful, safe & essential.
****Most important period for diagnosis of Rheumatoid Artheritis is first 2 years. When timely intervention can prevent or at least delay crippling. This time is usually missed in Pakistan.This is the time when family physicians should be sensitive to the possibility & importance of their thinking & timely help. Please be ready to pick up cases as early as possible.
*****Use of second line drugs in Pakistan is almost non-existant. Adding to the misery of the patient as this could help in avoiding crippling.
Approach to the patient.
· Most of the diseases are systemic. Adopt a conventional approach of a physician. Rheumatology means Review of Systems.
· 1 Take proper detailed history including all elements like present illness, past illnesses, family history, nature of work etc. Nothing should be missed.
· 2 complete physical examination. Think in terms of from head to Toe, while taking history & doing examination. As systemic diseases are very important, diagnostic symptoms & signs may be present, and patient may ignore considering these as unrelated. For examle
· Hair loss
· Eyes , redness, irritation,lack of tears,etc
· Face ,rash etc
· Skin rash, patches, Problems at exposure to sun.
· Breathlessnes,
· Mouth ulcers
· History of fever is very important. General symptoms like appetite, fever, generalised aches pains must be carefully ellaborated and documented. Weight loss should be noted.
· Morning stiffness of more than one hour duration is very important symptom of inflammation. Stiffness slowly decreases on assuming activity.
· Ascertain the condition of heart, kidneys lungs etc.
· Please remember connective tissue diseases are important consideration for any case of PUO.So many cases of SLE are being treated as Tuberculosis.
· While examining Joints please do note local signs .These are very very important.Expose the most involved joints and note
1. Any redness,
2. Temperature ?hot as compared with other joint
3. How much pain & tenderness
4. What about movement? any limitation
5. Any local swelling, including the nature on inspection, palpation.
· Distribution of Joint involvement is very important, more than many fancy investigations.
· Monoartheritis,
· Poly artheritis
· Large joints ,small joints,
· Proximal interphallangeal Distal inter phallangeal joints
Joint diseases can fall under any of the following groups.
A Connective Tissue Deseases, such as Rheumatoid Arthritis, SLE, & Scleroderma only think of these diseases if continued for more than 6 weeks. Many post-infective arthralgias disappear before this time limit.
B Degenerative e.g Osteoarthritis
C Infective a wide range of infections
D Metabolic like gout, Osteoporosis, & hypothyroidism
F Miscellaneous like Erythema Nodosum.She has seen many typical cases in Pakistan.
While considering the list of Differential Diagnosis, think first which group it can belong to.
*If Generalised sypmtoms specific to inflammation are present in many systems think of Connective tissue diseases. Stiffness after periods of rest, decreasing with assuming activity is very important symptom.
**Stiffness & pain increasing along with the duration of activity is pointing towards degenerative deseases.
*** History of many episodes with complete remissions should lead to think of gout.
Too much emphasis is being placed on investigations. First it is the clinical judgement of the physician, based upon history & physical examination. This carries the preference over the investigations.
Cheap, useful indicator. It can pick up upto 95 % cases of connective tissue diseases, infective diseases & malignancy. Use of steroids may change the picture.
In remaining 5 % CRP must be positive. Its titres are helpful to define diagnosis further. If ESR & CRP are negative then one can forget these 3 groups.
Negative result is being misinterpretted in Pakistan.Rheumatoid Arthritis can still be present in seronegative patients. If your clinical judgement is in favour of Rheumatoid Artheritis, go ahead, and label the patient as such. Do not delay. Help the patient to avoid crippling. RA factor is negative in 60- 70 % of young patients and 25- 30 %of Old patients suffering from Rheumatoid Artheritis.RA facor are positive in 10 % of normal population.
Uric Acid
This is another investigation, which is being
*Overordered.Gout is a desease of postmenopausal women. No need to order it in young female patients. Yes in boys & young adults gout is present.
· Misinterpretted.Hyperuricemia is not gout. Levels higher than 10 mgs/dl are important in long term management.
SLE & investigations
Here again clinical picture and evidence of inflammation in multiple systems is good enough to suspect strongly this syndrome. Investigations can not rule this out. ANA is positive in many conditions. In 90 % of SLE patients, it is positive. Specific are anti ds DNA antibodies. Again it is positive only in 40 % of patients of SLE.It is imperative that lab you are using knows what specific kit it is using for these specific tests.
There are arthralgias associated with acute viral infections. These usually subside withen 3 weeks. Hepatitis C is associated with specific vasculitis, giving rise to purpuric lesions in addition to other syndromes. These can be diagnosed by testing cryoglobulins.
On NSAIDs these are being overprescribed by all levels of Physicians.Another condemnable practice is combining two or more NSAIDs.You gain absolutely no advantage by doing this, other than increasing the toxicity. This group of drugs decreases inflammation...
This is weapon of Allopathy to be used properly by us. Generally these are being prescribed where these are not indicated, are not being used where use is imperative. One thing should be very clear that these are used only to gain some temporary relief in window period while other agents start giving relief. Steroids do not prevent damage.5 mgs of prednesolone is a safe maintenance dose.
This is the weapon, which is being overused without giving any thought whether what it is for. What advantage it will gain for the patient. Steroids are not analgesics. These do not prevent long term damage. It should be used only where signs of local inflammation are present and other agents have failed to give relief or improve movemets. Other wise these are conraindicated. Intraarticular injections are mandatory when local symptoms are not relieved by other measures.
In response to one question she agreed that in Pakistan use of second line drug is virtually non-existent which is very unfortunate. As methorexate & salazopyrine have been used for sufficiently long periods. There are satisfactory protocols for follow up. These are so important & essential in preventing crippling.
Every patient who has ASO titre positive is not suffering from Rheumatic fever. There must be other criteria present for the diagnosis. It is being overprescribed.
She is really very much concerned that so many patients are needlessly on Zyloric for long periods of time. Most of these do not need it. Zyloric should be prescribed only if Uric acid is more than 10mgs/dl, with frequent episodes, and evidence of Urinc acid radioluscent stones. Usually episodes are very infrequent at intervals of years then it is better to treat individual episodes and avoid prophalactic use of Zyloric
On Dietary restrictions.
There is no logic to restrict all kinds of meat, milk or eggs etc in Gout.Only certain kinds of meat with high nuclear to cytopalsmic ratio like liver, kidneys or brain have to be avoided.
NSAIDs are certainly being overused in this condition. So many unnecessary expenses and clinical problems can be avoided by avoiding this group.
Simple Exercise & Paracetamol should be good enough for many patients.
Two Specific Conditions being overlooked.
Fibromyalgia & reactive Artheritis are not being given due importance. These are quite common.
Fibromyalgia (Fibrositis.) Present in women. Severe aches & pains. All investigations are