Rheumatic Conditions
General competencies
1. Perform diagnostic, therapeutic and rehabilitative examination and treatment
of the rheumatologic patient.
2. Optimize treatment plans
a. Consult rheumatologist and arthritis resources
3. Culturally competent communication to provide understanding of the
diagnosis, treatment and rehabilitation.
4. Identify multidisciplinary needs of rheumatologic patients.
5. Practice a multidisciplinary approach for rheumatologic patients including
a. Mental health professionals
b. Physical therapist
c. Patient self- management skills
6. Provide urgent care or referrals when needed
7. Preventative medicine to decrease disability
a. Recognize and emphasize its importance
b. Physical activity prescriptions
Topic Areas
1. Arthralgia
a. Osteoarthritis (OA)
i. Primary and secondary
b. Rheumatoid arthritis (RA)
i. Manifestations
1. Articular, extra-articular, juvenile
c. Spondyloarthritis
i. Ankylosing spondylitis
ii.
d.
e.
Reiter's disease
iii. Psoriatic arthritis
iv. Arthritis associated with inflammatory bowel disease
Infections
i. Directly causing arthritis
1. Septic Arthritis
ii. Indirectly causing arthritis
1. Acute rheumatic fever, sub-acute bacterial endocarditis, postdysenteric
Crystal-induced arthropathies
2.
i. Gout
ii. Acquired
iii. Calcium pyrophosphate dihydrate (pseudogout)
iv. Hydroxyapatite deposition
f. Neoplasms
g. Drug-induced
Connective tissue disorders
a. Lupus erythematosus (LE)
i. Various presentations
1. Systemic, discoid, drug-induced
b. Scleroderma
i. Various presentations
1. Localized, systemic, drug/toxin-induced
c. Polymyositis and dermatomyositis
i.
3.
ii. Distinguish from drug-induced myositis
d. Sjögren's syndrome (primary and secondary)
e. Polymyalgia rheumatica
f. Antiphospholipid syndrome
Vasculitis
a. Polyarteritis nodosa
b. Microscopic polyangiitis
c.
Hypersensitivity angiitis i.
ii.
d.
Serum sickness
Henoch-Schönlein purpura
Granulomatous arteritis i.
4.
Relationship to connective tissue disorders
Wegener's granulomatosis ii. Giant Cell (temporal) arteritis
e. Kawasaki disease
f. Behcet's disease
Regional rheumatic pain syndromes
a. Bursitis
b. Tendinitis and tendinosis
c. Low back pain
d. Costochondritis
e. Chondromalacia patellae
f. Compression
i. Peripheral entrapment (e.g., carpal tunnel)
ii.
Radiculitis and radiculopathy
iii. Spinal stenosis
5.
g. Raynaud's phenomenon
h. Complex regional pain syndrome
Other
a. Osteopenia and osteoporosis
b. Osteomalacia
c. Paget’s disease
d. Avascular necrosis
e. Relapsing panniculitis (Weber-Christian disease)
f. Erythema nodosum
g. Sarcoidosis
h. Goodpastures disease
i. Adult Still's disease
j. Fibromyalgia and chronic fatigue syndrome
For each topic area
1. Epidemiology
2. Anatomy
3. Pathophysiology/Etiology
4. Risk factors
5. History and physical exam
6. Clinical presentations
7. Diagnostic Tests
8. Diagnostic criteria
9. Differential diagnosis
10. Management
11. Psychosocial implications
Highlighted teaching points
1. Pathophysiology/etiology
a. Immunologic processes that contribute to the pathogenesis of rheumatic
disease
2. Risk Factors
a. For listed rheumatic conditions
b. For poor prognosis
3. History and physical exam
a. Basic elements of a rheumatic assessment
i. Focused history
4.
5.
6.
1. For joint and soft tissue symptoms
1. For screening
ii. A complete musculoskeletal physical examination
iii. Functional assessment
b. Use history and physical (in conjunction with laboratory tests) to
monitor:
i. Disease progression
ii. Treatment efficacy
Diagnostic tests:
a. Laboratory tests
i. Indications and contraindications
b. Joint and bursal aspirations
i. Technique
ii. Interpretation of results
1. Identify crystal, inflammatory or infectious causes
c. Radiographic Tests
i. Order appropriate views of involved joints
ii. Interpretation of results
1. Emphasis on soft tissue changes and early erosive changes
d. Urgent joint conditions (e.g. “the red hot joint”)
i. Recognition
ii. Performing appropriate synovial fluid aspiration and analysis
e. Use of laboratory test (in conjunction with clinical findings) to monitor:
i. Disease progression
ii. Treatment efficacy
iii. Potential side effects of treatment
f. Arthrocentesis
i. Indications
ii. Interpretation
g. Tissue biopsy
i. Indications
ii. Interpretation
h. Indications for arthroscopy
Differential Diagnosis
a. Development of a differential diagnosis based on
i. Pattern of joint and soft tissue involvement such as symmetrical
small joints, non-symmetrical large joints, axial skeleton
Management
a. Treatment of listed rheumatologic conditions
i. Monitoring of the laboratory, physical exam and potential side
7.
effects in collaboration with a rheumatologist
b. Pain control modalities:
i. Oral pharmacologic agents
ii. Physical therapy
iii. Acupuncture
iv. Intra-articular and soft tissue aspirations and injections.
c. Pharmacologic agents: mechanisms, indications, contra-indications, and
side effects
i. Analgesic medications
1. Acetaminophen
2. COX 2 inhibitors
3. Tramadol
4. Narcotics
ii. Disease modifying agents
1. Anti-malarials
2. Sulfasalazine
3. Minocycline
4. Gold salts
iii. Immunosuppressive agents
1. Penicillamine
2. Cytotoxic agents (methotrexate, and biologic agents)
d. Osteoporosis as a side effect of treatment
i. Medications causing osteoporosis
ii. Treatment of osteoporosis in patients with rheumatic conditions
e. Rehabilitation services
i. Joint mobilization
ii. Physical conditioning
iii. Promote function and prevent physical disability
f. Use of multidisciplinary teams:
i. Rheumatologist, physiatrist, physical and occupational therapist,
orthopedic surgeon and mental health provider
g. Complementary therapies
i. Supplements, chiropractic and acupuncture
h. Disability prevention
i. General health maintenance (necessary vaccinations, weight
maintenance, nutrition and exercise counseling, and controlling comorbid medical conditions)
Psychosocial implications
a. Evaluation of limitations in activities of daily living:
i. Effect on social status
ii.
Effect on psychological status
References:
1. American Academy of Family Physicians. (2008). Recommended Curriculum
Guidelines for Family Medicine Residents, Rheumatic Conditions (Reprint No.
278), Leawood, Kansas.