By Dr Irwin Lim, Rheumatologist
Yesterday afternoon, I had the opportunity to speak to 70 General Practice registrars (trainee-GPs) at the Wentwest training facility in Blacktown, a hub in Western Sydney.
It was the post-lunch session. I had 1 hour and 45 minutes.
The brief - An update in Rheumatology.
1 hour and 45 minutes is not enough to update all of Rheumatology.
To fight post-prandial sleepiness and to improve the chance of my messages sticking, I chose a case-based format and prepared 4 patient-based presentations to try and stimulate discussion.
I was relying on discussion, so I coaxed and badgered.
Case 1: Male generation-X'er presenting with a swollen ankle and big toe.
Easy case of gout but what I wanted to highlight was the process of differentiating a mechanical/degenerative cause from an inflammatory cause for arthritis.
What bits of the history help? What should GPs be looking for in the examination to help them work out possible causes? How do we make educated guesses about the probabilities of various diagnoses?
We also had to discuss how to and how NOT to use allopurinol and colchicine, common medications commonly poorly instituted.
Case 2: Older, middle-aged female with swelling in her “knuckles” and wrists, with some symptoms of carpal tunnel syndrome.
Straight-forward case of rheumatoid arthritis. It was nice to hear how the GP registrars approached appropriate investigation. As always, the topic of Methotrexate was brought up and we addressed the common problem of patient reluctance to take this medication.
Not unsurprisingly, the GP registrars knowledge of disease-modifying drugs (DMARD) was not extensive. At least, some had heard about biologic DMARDs although none had actually been involved in the care of a patient on a biologic DMARD.
Pleasingly, there were doctors in the room aware of the need for early treatment and the concept of the window-of-opportunity. I took the chance to hammer than nail a few more times.
Case 3: Male baby boomer presenting with years of tender joints, various tendon problems, a stiff back and not much to see in terms of swelling at the joints.
Made the point that those non-so-subtle nail changes might be helpful. As well as the patch of scaly skin on the scalp.
A case of psoriatic arthritis. A frustrating disease, with the diagnosis so often delayed. We discussed why rheumatic disease diagnoses and treatments are so often delayed.
We discussed advances in understanding how the disease develops, we discussed the difficulties with the labels we currently use for diseases and how many autoimmune diseases can be difficult to work out, confusing and frustrating patients and doctors.
Case 4 was to be about chronic back pain. Many GPs don’t enjoy treating this.
We didn’t get to case 4 due to the level of discussion.
And while it was my voice mainly, there were enough questions and comments, and feedback to make me feel it was a worthwhile session.Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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