QD Clinic - Week 3 Save

This is QD Video brought to you by RheumNow Live. Hi. I'm Jack Cush from RheumNow. I have a case I'm gonna call, what do I have, doc? It's an interesting one in that it's a 59 year old male who, at the end of the summer, we're now here in January, he had a bug bite.

Two weeks later, three weeks later, he started developing arthralgias in his fingers, maybe a wrist. Really nothing else going to go along with that. When you question him further, you find out he lost 40 pounds recently, but he's been dieting and, really changing his life. So is that important? Hard to say.

He has had some night sweats, but not enough to change bed clothes or change the sheets. He doesn't sleep all that great. He went to his family doctor, was given an over the counter medicine. He didn't really want to take nonsteroidal, so he took turmeric over the counter and felt better. Labs were done and he was negative for rheumatoid factor and negative for CCP and he had a normal sed rate.

So I've seen the fellow now twice. My initial visit disclosed that he has an oligoarthralgia in a few finger joints and a wrist and not much else. He's got some periarticular pain but really nothing to write home about. He has no carpal tunnel syndrome or carpal tunnel symptoms. He has a negative Durkan's test if you know what that is.

Look it up on Twitter and RheumNow, you'll find out it's the more specific test for carpal tunnel instead of Tenell's and Phelan's sign, Durkan, D U R K A N. So he has arthralgias and I treated him with a course of steroids. Doesn't hurt to give a blast of steroids for two or three weeks. You know, the literature on acute polyarthritis that presents most of those will go into remission. Most of those will go into remission if you give them a short course of high dose steroids, It might have gone into remission without the steroids.

I gave the fellow twenty milligrams of steroids for two weeks. He stopped, he said he felt better during that, still had some pains, still was taking the turmeric and he comes now back in with some repeat lab tests, which all look just great. So what else would I look for in him? I actually did look for parvovirus B19 IgM antibodies. I did a QuantiFERON in him, he does some foreign travel, his hepatitis serologies were negative, His sed rate was eight.

His CRP was undetectable. His CBC and chem profile were normal. His rheumatoid factor and CCP as I said were negative. What I ordered those unusual tests for rheumatoid, the CAR P antibodies or the fourteen thirty three ADA? No, I don't think so.

He's doing well on very little medicine and the question is, what does he got and how are you gonna manage it? Well, this is my last visit with him because he doesn't have anything. He has sort of intermittent vague pains. He's had more than twelve weeks of symptoms that have been intermittent vague and going nowhere, certainly not escalating and have no physical findings. You have the obligation, especially with someone who has symptoms going on in more than six weeks, certainly more than twelve weeks, to do an evaluation and that's what I did.

Did a laboratory evaluation. I'm not going do an x-ray evaluation. This joint exam is too normal to do that, but I think you're obligated to do an evaluation more than a quick look see and some nonsteroidals. So again persistence, I think is an important indication. Persistence of swelling would clearly change the story but he has no swelling.

And I think it's my obligation to, look for a few other things, swelling, periarticular pain, enthesitis and an abnormal lab. In the absence of those, this is just called arthralgias. I'm gonna quote myself a brilliant quote that I came up with, that I put on Twitter which said, Not all symptoms merit a diagnosis. Some are just evidence of human imperfection. So I told the fellow, take your turmeric, if things get rough, take some more Tylenol, if things persist or get worse, come back and see me.

Pretty simple, but pretty common. QD videos, hopefully useful lessons from the clinic. See you next time. This is QD video brought to you by rheumnow.live. For rheumatologists when the going gets tough, rheumatologists go to RheumNow Live in Fort Worth on 03/22/2324 coming up in a few months.

Check it out. Rheumnow.live. So today's case, a 33 year old Hispanic gal, not seen her in a year because she didn't want to come back because she had no insurance. I told her come see me, she needs to be seen, she's been taking tocilizumab. She's a rheumatoid arthritis patient, chronic symmetric polyarthritis, wrist, elbow, knees, fingers with swelling, AM stiffness, positive rheumatoid factor, previously treated with methotrexate Cimzia during one of her last pregnancies and now she's on Actemra and doing well for the last two years on Tocilizumab subcutaneous injection given every other week.

She's done fine. In the last year she's not seen anyone, not had any labs, she had enough drug to last her a year, now she's back and she's got two requests. One, can I refill her Actemra? She's on a patient assistance program but she just got insurance so maybe your insurance will pay for it. And two, she's pregnant.

No, no, she's not pregnant. She wants to get pregnant. And the question is, what am I going to do about that? And what's my advice to her? So her proposal to me was, I want to get pregnant.

What can I do? Do I have to stop? Do I have to go back on that other medicine? Do I have to be on no medicine? And we went through this once before with her, but we're going to go through it again.

I think the first teaching point here is that if you have women of childbearing potential, every visit should clearly spell out what their intentions are for future pregnancy. If they're on birth control or they're, otherwise unable to conceive, then you don't have to have this question. But all too frequently we don't discuss it and we should. What are your intentions as far as future pregnancy? I don't want any more pregnancies doc.

Well then you can advise them on what the safe forms of contraception may be. If you don't know that information, the ACR has a reproductive health guidelines group that actually met all last year, I was a part of it, and it's going to be a great publication coming up in the next few months. It's going be a three parter and it's going to give guidelines for management of patients with rheumatic disease with regard to pregnancy, breastfeeding, lactation and other reproductive health issues including contraception. Look for that publication. It is going to be dense with useful information and I think it should be actually a course taught by the people who are running that and that includes, Lisa Sammartino, from Hospital for Special Surgery is leading the effort, for the ACR.

So what did I do with this patient? I told her, yes, you can get pregnant. No, you don't have to change medicine. You're on Actemra, you're doing well. Number one rule of getting pregnant is to be a healthy mom so you can make a healthy baby.

And that can be accomplished, on no medicine if the patient's in remission. It can be accomplished with a D VAR and safe DMARs that you can get pregnant on include hydroxychloroquine and sulfasalazine and gold and not methotrexate, not leflunomide, even cyclosporine and whatnot. Most dangerous drug, is not methotrexate and not leflunomide but is fact mycophenolate. Mycophenolate is a clear cut teratogen, way more than methotrexate or leflinamide. Do not get pregnant, planned pregnancy on mycophenolate.

You can get pregnant on a TNF inhibitor. I mean there's a ton of data regarding that but there are other, and of course, you know, used to be a Class B pregnancy risk and some of the other biologics Class C pregnancy risks like, prednisone, but prednisone is the most dangerous drug we use. Peter Merkel said it, right, and I tweeted it, incredibly popular tweet. Prednisone is the most wonderful drug we have and the most dangerous drug we have. Trying to get pregnant with prednisone is foolish and should not be done.

This lady is doing great on Actemra. There's no negative signals in the few 100 patients thus far reported on Actemra, she's told by me to go ahead and get pregnant, and if she does I'll report it to the company and blah blah blah, but she's not pregnant now so don't write me up. And then if she does get pregnant, she could actually stop the drug, because her past pregnancy is she did very, very well, during the pregnancy off of biologic therapy. She may well repeat that, you know, not all RA patients do fabulous, when they get pregnant. So that's the plan.

Again, would have told her same thing had she been on, let me think about this, Tocilizumab, yes, any TNF inhibitor, yes, Abitacid, yes, rituximab, yes, long half life so you know, I don't want them to get pregnant when they just got the infusion but that's probably okay. There's not enough known about the JAK inhibitors yet, thus far, it doesn't seem like there's a negative signal there. There's been actually a publication on this so I think a little more time. Again, they call whenever I'm recording. This is interesting.

But forget about Xeljanz right now would be my suggestion and maybe ask me next year or ask the other mavens in pregnancy about what they think about using tofacitinib or even baricitinib in women who want to get pregnant. So that's today's lesson. Tune in for more lessons from the clinic. See you. Hi, this is QD Video brought to you by RoomNow.

Live. You know at RoomNow live we're going to have a tremendous amount of interaction time. This is a two day meeting. There's gonna be somewhere between three and a half and four hours of q and a with the faculty, and that's not even counting the q and a is gonna go on at the end of their talks. It's gonna be very different.

You'll see. Read up on it. Today's case is entitled The No Show. This is a nice gal who I've known for maybe fifteen years. She came to me in her, 20s and, she has Behcet's.

She's an African American female who's had Behcet's diagnosed based on recurrent painful oral ulcerations, genital ulcerations, rarely rectal ulcerations. She's had occasional abdominal pain and conjunctivitis, had polyarthralgias, occasionally a swollen joint, occasionally low grade fever. She responds well to high dose steroids, big surprise, and really nothing else. She's been tried in the past on hydroxychloroquine, colchicine, acyclovir, azathioprine, methotrexate, Enbrel, Humira, vitamin A, and tetracycline. Again, when nothing works, she'll try almost anything for people having recurrent severe ulcerations.

So that isn't really the problem in this gal. She does really well. She I've taught her not to self medicate herself with prednisone. And, when she gets into trouble, she does call us and we manage her. The problem has been for her coming to clinic.

She lives about an hour and a half away. She's missed, and been a no show for four out of her last five visits. And today was the usual visit. We discussed how to manage the one active big ulcer she's got going in her vaginal area, but the big issue was, can I see her again? Do you fire patients from the clinic because they don't come in?

I explained to her it's a problem because she's taking away valuable time from other patients who are waiting to get into the clinic. And in addition, she's turning her absences into my financial loss and really hurts our business model. I have a Twitter poll out right now. You might look at that on Twitter under RheumNow and see how it goes. I ask people, why would you fire a patient?

Would you fire a patient or discontinue their care just for being non compliant with visits or do you need other reasons? There are a lot of reasons. I've asked my partners and both of us are sort of the same ilk. We don't fire people because we don't like them nor because they're difficult. We don't fire people when we don't know what to do with them because it's our job to know what to do with them.

We don't fire them for bad behavior even. I can count on one hand the number of patients I've fired in my whole career. But it's not unreasonable to fire someone for chronic noncompliance to make the point that you're hurting yourself and you're hurting my clinic. Go somewhere else. It's not unreasonable to fire someone for not paying their bills or expecting to get free care without negotiating that with you.

That's kind of insulting as well. There are other reasons, but I don't think it should be personality and again, this is my own personal preference. Again the Hippocratic Oath thing where you sign on for good or for bad how to manage people and just because someone's tough personality wise, schedule wise, intelligence wise, doesn't mean that you can bail out on them. Again, it's your job to be the strong coach and get them through the rocky waters and make them well. So again, Behcet's but the difficult discussion is how to, get them to come back.

And my statement today was no more, second chances. You've had thirty four second chances. In the next two years, the next visit she misses, she'll get a letter saying, I'm so sorry, you're but gonna have to find another doctor. And it would kill me to write it but you have to write it. And she gets it, she's sorry about it, she's got all kinds of reasons why, I don't necessarily need to know reasons why, but it's something again we're not just working on the relationship, we're working on how she is as a patient.

You know, patients don't get a handbook on how to become a patient. Most of their patients come to you, they don't know how to be a patient, which is why the difficulty is often in the first, you know, four or five visits when they may or may not follow your instructions, when they may not fill the prescription, when, you know, the idea is that they might be hurting themselves for fear of what they don't know. But again, it's hard to be a patient, it's hard to learn to be a patient, It's my job to sort of coach them along and make them better. She knows how to be a good patient at this point. She needs a reminder.

That's it for this week. Check out roomnow.live. Welcome to QD video brought to you by roomnow.live, a meeting designed to grow your mind and change your practice. Yes. You'll leave Fort Worth with a really big head.

Today's case is hemoptysis and lupus. Holy moly, what's going on there? 43 year old gal who's I've been taking care of. She's got fairly stable lupus, aches and pains, skin, some serologic stuff, doing well on Plaquenil. Been in a drug study and taken care of by my partner and haven't heard from her in a while, but she called the clinic saying, I'm doing lousy.

I got bad hip pain and my elbow hurts and my foot's kind of sore. What do you want to do with my medicines? And oh, by the way, on Saturday, I coughed up a bunch of blood. What? What have you done about it?

It's now Monday? Two days, three days have passed and nothing? I mean, so you set you get into panic mode because hemoptysis is obviously gonna be serious. We're gonna talk about that. So, of course, we told her, either you go to the emergency room or your PCP or you see us today.

But I'm at work today. So she comes in. We see her. We get a chest X-ray on her. We evaluate her.

All is good. Her lupus is stable. She does not look sick. Chest x-ray was normal. It's a one time event.

I'm probably not gonna know reason why. She coughed up a lot of blood, bright red blood, you know, sort of like a palm full and not sick. Again, sort of, we'll just say that I asked every question in the books. I want to go over though what the differential diagnosis is and the approach is. So the differential, first off, you should know that the greatest worry in lupus is that this is alveolar hemorrhage, which is a dastardly complication of the disease.

It happens to people who happen to be sick, who look sick, who are usually febrile, coughing, shortness of breath, can't get their breath back, have a low PO2, have a white out on chest x-ray, two thirds of them will present with hemoptysis. But at the end of the hospitalization, hopefully the alive end of the hospitalization, a hundred percent will have hemoptysis. Oh, and if it is alveolar hemorrhage, fifty percent mortality. That's why you have to jump into action when you see these patients, even if they don't sound sick on the phone or they don't look sick when you see them, you're obligated to go through these, measures and make these considerations. So we got a chest X-ray.

We did vital signs. We ordered some bloods. We're waiting on the blood, but, she looks really good. I don't think that she has alveolar hemorrhage. Chest X-ray is normal.

If they have alveolar hemorrhage, it's a whiteout, or a patchy whiteout. So you need to distinguish whether her blood that she coughed up is from her upper airways, nasopharynx, trachea, or is it due to an intrapulmonary process on maybe unrelated to her lupus. That would include bronchitis, pneumonia, a pulmonary embolus, TB or a fungal infection. I think these are all possibilities. In lupus, it's going to be usually again, alveolar hemorrhage you worry about, maybe a bad case of pneumonitis with some blood.

Rarely would this be something like vasculitis or drug induced, but you gotta worry and someone on an anticoagulant. You know, the list is long, including heart failure, valvular disease, you know, from my residency days, paragonomyosis. Haven't seen it, still waiting. So again, is it from the lung or above the lung? And the evaluation is, you know, lupus causes usually look sick, meaning they are very short of breath.

They have tachypnea, they have a fever that's usually 103, 104, even higher. And again, when you look at their labs, things change and they have evidence of active lupus. Such is not the case here and that's the good news. But again, I think the lesson here is you need to jump to action when the chief complaint is hemoptysis. Tune in for more QD videos.

Bye. This is QD video brought to you by rheumnow.live, a sixteen hour master class for the next best generation of rheumatologists. Today's case from the clinic is entitled a different kind of case. So this 53 year old gal with rheumatoid arthritis comes in, haven't seen her in, see, months. She's supposed to be on a biologic, and I'm wondering what's the deal?

But you find out quickly the deal is that life has gone wrong. In her case, you know, it could have been a death, a divorce, someone running out on her, abandonment, a major financial issue, a major family issue. These happen and when you identify them, hopefully at the front end of a visit, the visit changes. It's no longer the checklist of what drugs are you taking, let me get this right, what did you do, what's new, what's the new diagnosis, what's the last in imaging that you had, and let's go over your rapid three score parameters and get down a good joint exam and do your monitoring and comorbidity assessments. No, now it's all about the patient.

It's all about the big problem, the big elephant in the room. And it could be a lot of different things. I think what you need to do when this happens is recognize this is not going to be your usual visit. You can get by and do your documentation that you need to do to do a usual kind of visit. And in the beginning, you're going to acknowledge the problem.

At the end, you're going to do the things you need to do like refills and set another appointment. But when a new big thing happens like this in a different kind of visit, what do you do? Number one, you focus on the problem, which means you let them talk. You ask questions like, how did that happen? How did you handle that?

What have you done since? You start to write down a checklist of things that you know are going to be issues for this patient. At the top of the list is taking care of the patient. You know, usually when this happens, life goes to hell in a handbasket and they let everything that's been working for them stop. You know, how they took their medicines, what their diet was, what their exercise was.

They stopped doing those things that were actually keeping them under control. You know, being boring is a great outcome in arthritis care. When this happens, they're no longer boring. Their life is turned upside down. So identifying the things that they need to do to get back to boring, to get back to regular behavior, and taking care of themselves.

You know, at this point they may be taking care of everybody else around them but themselves. Usually what happens is they stop medicines. They stop doing the things they were supposed to do. You check on, are they sleeping? Major issue, often goes undetected.

You check and see if they're anxious or depressed and if they need psychologic or psychiatric care. You have to tell them at this point in the game with what's going on, the best thing they can do is take care of themselves. The second best thing they can do is ask for help. Sometimes they're so overwhelmed managing the disaster that is theirs. They think that they have to do everything and they're embarrassed to ask for help.

That doesn't count with you. You know the patient, they know you, they trust you. You have to encourage them to get help. So you need to find out, are they crashing? With all this stuff going on, are they being compliant?

What's it doing to their disease? What it's doing to their health and what it's doing to their head? So I think it's a really important sort of focus is, are we in good shape here or are we, you know, circling downwards? And that's not a good thing. I think you may have to bring the patient back earlier to do the work you need to do to recheck on them.

But it's really important to have sort of an approach. Number one, listen, focus on the problem, develop a list of things they need to do. Again, most of that's listening, in the end they want you to sort of put it together, be an outsider who's got some perspective. Encourage great sleep, encourage perfect mental health, getting them back to normal. Find out if they're crashing and figure out when they need to come back and don't make it six months or in a year.

People who are concerned about their patient usually want to know what's going on. Maybe it's easier just to call them in two weeks or three weeks to say, How's it going? Did that thing we suggest happen for you? Or, What's been the problem since? Or, What's going good for you now?

Nothing? Okay. Well, again, hope, rules and goals. I keep preaching that. That's what every patient wants.

They don't want the answers. They want you to listen. They want some hope. They need some guidance and basically tell them, you know, how they're going to get there and that they will get there. That's it for QD Video.

Watch the next one. It's probably gonna be better than this one.