Dr(Lt General) Ved Chaturvedi

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1 Dr(Lt General) Ved Chaturvedi MD.DM Sr Rheumatologist,Sir Ganga Ram Hospital New Delhi President Delhi Rheumatology Association,ex president Indian Rheumatology association ex HOD Rheumatology Research &Referral Army Hospital new Delhi First Rheumatologist in the country >to use new therapy for arthritis called Biologics since 2000 >to establish MSK Ultrasound &Medical Arthroscopy in 2003

2 Early diagnosis of inflammatory Polyarthritis including Rheumatoid Arthritis Dr (Lt General) Ved Chaturvedi, MD, DM SGRH President Delhi Rheumatology Association Dr (Lt General ) Ved Chaturvedi MD.DM

3 Mo ility..pai ful paralysis Ved Chaturvedi. MD, DM

4 1991 :super specialties perceptions Cardiology..ECHO,Angiopla sty Gastro Endoscopy Neurology MRI Endocrine..Hormones

5 Rheumatology Nothing Antibodies..Pathologist Scopes.??

6 Perception of peeping in joint Respect in society Immediate diagnosis Direct patient-doctor relationship

7 MSK Ultrasound

8 Rheumatic diseases.

9 Medicine is a science of uncertainty and an art of probability Sir William Osler

10 Approach to a patient with musculo-skeletal pain. Musculoskeletal Pain Periarticular Non-inlammatory OA,Hypothyroidism Articular Inflammatory

11 Inflammatory Vs Non-inflammatory Arthritis

12 Inflammatory vs. noninflammatory joint diseases crucial because it is a question -Benign vs Non Benign Entirely different management

13 Inflammatory Vs Non-inflammatory Arthritis Inflammatory (History 80 %) worst after rest Improves after exercise Constitutional symptoms Fluctuation in disease activity ESR,CRP High Acute phase reactants High Low hemoglobin

14 Inflammatory Vs Non-inflammatory rheumatic diseases Inflammatory Non-Inflammatory Rheumatic diseases Rheumatic diseases OA, Trauma, hypothyroidism Examples RA, SpA,SLE Morning stiffness >30 min Pain aggravation On resting the joint On moving the joint Spontaneous flares Common Uncommon Acute-phase reactants like ESR,CRP Increased <30 min Normal

15 Acute-phase reactants Rise in platelet count and low hemoglobin

16 Approach to a patient with musculo-skeletal pain. Musculoskeletal Pain Periarticular Articular Non-inflammatory Inflammatory OA Hypothyroidism Monoarthritis Gout Septic / TB arthritis Oligoarthritis Gout SpA Psoriasis Polyarthritis RA SLE Psoriasis

17 Pattern recognition in musculo-skeletal diseases Mode of onset Extra articular features Acute Fever Insidious Mucocutaneous lesions Duration Eye involvements Acute/Self-limiting Chronic Number of affected joints Nodules Sequence of involvment Monoarthritis Intermittent Oligoarthritis Additive Polyarthritis Distribution Symmetrical/Asymmetrical Lower limbs versus upper Small versus large joints Specific joints Migratory

18 Annals of Rheumatic disease : 2015 Oct 1995 Pt Data from Norfolk UK RA Undifferentiated Arthritis Spa Psoriatic Inflammatory OA CTD Sarcoid Malignacy

19 The Physi ia s approa h Diabetic Thyroid Anemia Paraneoplastic (Multiple Myeloma, Leukemia, Lymphoma) Infections

20 The Physi ia s approa h Hyper mobility syndrome Fibromyalgia Depression Viral diseases Neurological disease Primary bone disease Drugs

24 System review : Emphasize Skin Eyes GIT Genito-urinary Renal Symptoms suggestive of involvement of CVS, RS, Hematological or CNS

25 Arthralgia Vs Arthritis

26 Red & Blue method

27 Inflammatory Vs Non-inflammatory Arthritis

28 Inflammatory Arthritis EMS Stiffness & swelling is worst after rest Stiffness gets better with activity Fatique Increase ESR/CRP Hb low

30 Ved Chaturvedi. MD, DM

31 Early Rheumatoid Arthritis: A medical emergency Larry W. Moreland Am J Med 2001;111: Ved Chaturvedi. MD, DM

32 Ved Chaturvedi. MD, DM

33 No Gold standard test RF Anti CCP Ab Anti Carbamylated protein ab

34 )

35 Two prototypes RA Young Females Hand joints Lower limb joints+ Synovial pathology RF SPA Young Males Spinal joints ++++ Ligaments pathology HLA B27

36 Dr Ved Chaturvedi, MD.DM

37 OA Old age Chronic Oligo / Polyarticular Non-inflammatory DIP joint

38 Systemic Connective tissue diseases Young adults Females > Males Chronic Non deforming Arthritis Fever Skin rashes Multiple organ - involvement

40 Rash-Dermatomyositis v/s SLE Dermatomyositis SLE 42 42

41 Heliotrope rash Cutaneous hallmark feature of DM Pruritic, sometimes burning, Violaceous, confluent erythema resembling the color of the heliotrope( a red/purple-colored flower tracking the course of the sun) Characteristic distribution, involving especially the periorbital area

42 Shawl sign Macular rash Posterior neck and shoulders

interphalangeal joints may also occur over the extensor

43 Gottron s papules 1 mm in size Violaceous/pink/dusky red papules located over the dorsal side of metacarpal or interphalangeal joints may also occur over the extensor side of the wrist, elbow or knee joints. pathognomonic of DM

44 Extra-articular features Fever SLE Systemic onset JIA Infective endocarditis AOSD Vasculitis Skin and mucosa involvement SLE Psoriasis Behcet s reactive arthritis Vasculitis Nail changes Psoriasis

45 Extra-articular features Eye SSA Vasculitis Sjogren s syndrome Nodules RA OA Gout Rhemautic fever Erythema nodosum Vasculitis

46 Investigations Hemogram CRP LFT RFT Radiograph chest and affected joints Autoantibodies : RF, CCP, ANA, DsDNA, ENA, Cardiolipin, HLA B27 Blood sugar, T3, T4, TSH. Viral markers Uric Acid & Synovial fluid analysis

47 Synovial Research unit

48 Crystals

49 Histoplasmosis Picture 002.jpg 002.jpg Picture

50 Synovial Chondromatosis Multiple cartilaginous bodies in the synovium

51 Pigmented Villo Nodular Synovitis Golden brown hemosiderin in deep macrophages, giant cells

52 Amyloid Arthritis Amyloid deposits in primary amyloidosis

53 Take Home Lessons: Tools for aki g diag osis Clinical history 80% Physical examination 15% Laboratory investigations 5%how much is In musculoskeletal diseases (MSDs) contributed by each of the above? (ACR - Arthritis Rheum 1996; 39: 1-8) 1. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975;2: Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J 1980;100: Peterson MC, Holbrook JH, Hales DV, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in marking medical diagnoses. West J Med 1992;56: Pryor DB, Shaw L, McCants CB, Lee KL, Mark DB, Harrell FEJr, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118: Castrejón I, McCollum L, Tanriover MD, and Pincus T. Importance of patient history and physical examination in rheumatoid arthritis compared to other chronic diseases: Results of a physician survey. Arthritis Care Res (Hoboken) 2012; 64(8), December 2015 Prof. Anand Malaviya 55

Rheumatology 101 A Pediatrician s Guide

Rheumatology 101 A Pediatrician s Guide Pediatric Staff and Alumni Day 2016 Dawn M. Wahezi, Yonit Sterba, Tamar Rubinstein Disclosures None Pick a Group Group 1 A child with a limp Group 2 ANA To test