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Transcripts-7/17/00
Tests and Diagnostic Procedures with Barry
Waters, M.D.
InsightHostKJ> Tonights topic is Tests and Diagnostic Procedures
InsightHostKJ> Dr Waters what one test do you feel is most vaulable in dealing with rheumatic diseases?
DrWaters> There is no single test. The most important thing is how the patient feels. So I guess the most important test is the doctor's hearing test.
InsightHostKJ> Good answer Dr Waters!
Jeff> The gp put me on prednisone right away....will the effect my first visit in any way
Usually if at all possible it's best to see rheumatologist before prednisone. That's why we always see new patients right away if joints swollen or a lot of pain.
Guest8> While pregnant my hands, wrists and arms went numb. It's been 3 years since I had my baby and I still have problems.
Guest8> Recently, I've had a lot of pain with it and can't seem to pick things up. I'm wondering if I go in to see the doctor how much poking and prodding he will do.
DrWaters> And what does the neurologist say?
Guest8> I mean to determine whether this could be arthritis.
DrWaters> Arthritis does not cause numbness.
Guest8> I don't have numbness anymore. Just the pain.
Guest8> Numbness was only when I was pregnant. This doesn't feel exactly the same, it just hurts.
DrWaters> You see why the patient history is so important, you already confused the doctor.
Guest8> I'm sorry. I believe that this started out when I was pregnant three years ago. The symptoms come and to though. But recently, there's just a lot of pain.
DrWaters> What's wrong with being poked and prodded?
Guest8> LOL, it all depends on what the poking and prodding is being done with. I guess what I'm asking is the testing with a lot of needles??
Guest8> I saw something about blood tests and am wondering what kind of things show up that determine arthritis.
DrWaters> The doctor needs to hear when your hands hurt, if you are stiff, what other symptoms you have, etc. He needs to look at your skin and joints, etc. It may or may not be necessary to get lab or xrays. You can't be diagnosed in a Chat room!
Guest8> I understand that thank you. I'm was just asking!
Guest33> When I first went to the doctor for pain and swelling in the feet, I had an elevated sed rate. Now after pred and NSAIDS, it is at 4, although I still have a lot of visible swelling. Is this because of the medications?
DrWaters> Yes, and that's a perfect example of why we follow the patients symptoms and not the sed rate. It's OK to get saed rate initially, but it's pretty useless for follow-up decisions.
deb> you mentioned psoriasas{sp?} in the skin exam. I'm not sure of the correlation?
deb> what do they check the nails for?
DrWaters> Psoriatic arthritis is one of the most common types of inflammatory arthritis, as common as RA, and often as severe. Only way to diagnose it is by looking at the nails, skin and joints. Lab dosen't help and xrays help only in advanced cases.
DrWaters> Psoriasis is often present ONLY in the nails.
Jeff> So....the RF doesn't mean much either. Mine was 365
deb> thanks
DrWaters> In psoriatic arthritis the RF is negative. RA is such a striking disease that usually the RF only helps confirm an already obvious diagnosis.
DrWaters> Jeff first. 365 is very high. If you have multiple swollen joints, about symmetric on both sides of body, AM stiffness and such a high RF you almost certainly have RA. Ask for methotrexate if your RD seems dumb.
Jeff> how do they feel about the patient asking for spcial drugs
Jeff> or trying to dictaite treament
DrWaters> Jeff, if doctor gets mad you can always pretend you were joking. Plus, it's a good way to at least test if the doctor is interested in you as an individual and respects your opinion. You're allowed to be wrong, you didn'y go to medical school.
Melanie> Bone density test? When is it recommended and how often should it be repeated?
DrWaters> Now Melanie, good question. Very contoversial. I recommend it for all post menopausal women not on estrogen and for patients on prednisone. Cut-off is supposed to be 7.5 mg daily or more but I use 5 mg as cut-off. Usually, except in patients on HIGH dose steroids (>20 mg daily) not useful to check more often then every 2 years.
Guest33> I have had some minimal erosion show up on x-rays a year ago. I have not had them taken since then. How often do you recommend x-rays be taken of active joints?
DrWaters> 33, that's a good ? too. Personally, I rarely follow xrays. I'm in the minority on this. It's not like we have a million treatments to choose from. If there is pain or stiffness or swelling I try new or more, if patient feels and looks great, who cares about the xrays.
InsightHostKJ> Dr Waters I vote you become a traveling doctor and take care off all of us
Jeff> there ya go
Cindy> I 2nd that KJ
Guest33> What if the patient looks and feels great but stil has some stubborn joints?
DrWaters> 33 - usually try to inject those. Or maybe fiddle with medications. Depends how much they bother you. Don't you agree that's ultimately more practical then xray.
Guest33> Yes, thank you!
TEXAS> HAVE RF OF 189, CRP OF 8....SOMETIMES VERY ILL ASIDE FROM ra symptoms. am i morphing into lupus
DrWaters> If all I know if someone is "ill" how do I know they have lupus? Most people who are ill have colds.
Dale> Perhaps someone has already asked this, but if not, is there any way to definitely diagnos RA if it does not show up in bloodwork?
DrWaters> Yes and no. If someone has a symmetric polyarthritis and rheumatoid nodules they definitly have RA even if RF negative. If a symmetric polyarthritis and no psoriasis or bowel problems, probably have RA even if RF -, but Dx more iffy.
christinemj> MY RD has been hesistant to diagnosis me with RA. Most recently he is using predisone as a "trial and error". I have had a positive reponse to the pred., and am now weaning off. He has stated that we will try Plaquenil next, if the pain returns after the pred. wean. I am questioning his motives - since I hurt in the meantime - and am wondering if this is a "normally accepted practice."
DrWaters> Absolutely standard. Often we can't tell if patient has inflammatory arthritis or not so we try pred for 2 or 3 weeks and if MUCH better on pred probably has inflam arthritis so then start Plaquenil or other DMARD. If symptoms bad should stay on 5 or 7.5 mg of prednisone for a few months until Plaquenil works.
Donna> Are bowel problems synonymous with RA?
DrWaters> Opposite. Often patients who have inflam arthritis and don't have RA and don't have psoriatic arthritis have inflammatory bowel disease - Crohn's disease or ulceratice colitis.
deb> as a rule of thumb, how long is too long to be on prednisone?
DrWaters> It's probably OK to be on 7.5 mg of pred or less forever, but if patient can do well off it, then they should be off it. But only if doing well. In diabetics, prefer pred only if things terrible off it.
Melanie> I have a neurologist, neurosurgeon, opthalmologist,hand doctor, foot doctor, RD, PCP with labs and x-rays and MRI's at 3 different facilities. Any recommendations on how to pull it all together?
DrWaters> Probably not, medicine has become too complex and specialized.
Melanie> That's what I've learned; was just hoping. lol
Dale> In your opinion, if one has one autoimmune disease are they more likely to develope a second?
DrWaters> Yes, I think that's very true. A weird immune system is a weird immune system. I always say that.
Dale> Thank you...I always knew I was weird! LOL
DrWaters> I meant it as a compliment.
TEXAS> are there any definitive test for fms, and what is the final result of this illness if it is progressive
DrWaters> No tests for FMS, it's purely symptom/exam thing. End result is addiction to arthritis chats.
Guest190> LOL
Cindy> lol
Melanie> lol
InsightHostKJ> LMAO! Ain't that the truth!
TEXAS> thanks, i guess.....lol
Guest30> Do autoimmune diseasesn group togethet, now I'm being tested for 4th disease, others are lupus, sjogren's and autoimmune hearing loss?
DrWaters> Autoimmune diseases group. Sjogren's/RA/Lupus often overlap. Hearing thing less common but well reported.
deb> My daughter has been on 20mgs up to 80mgs due to a dx of bullous pemphagoid. Has been on pred since Jan. Always starts breaking out again when down to 20mgs. I'm scared because of her being on pred so long.
deb> What other specialist can she see besides derm?
DrWaters> Pemphagoid is bad. Have her ask derm if they use methotrexate or immuran or Enbrel. I don't know myself. Make sure she's on Fosamax or Actonel to prevent osteoporosis, too.
DrWaters> Really only derm, and rheum for osteoporosis prevention.
Dale> Do you have any "magic" cure for mouthsores due to MTX?
DrWaters> Dissolve Carafate in water and swish in mouth. Take Leucovorin day after MTX instead of daily folic acid. It's a tough problem. When I get a little canker sore I'm a grouch.
Dale> Thank you. Someone suggested sauerkraut juice, but I haven't tried it.
Dale> How much folic acid can one take per day?
DrWaters> Skeptical about the kraut, but try it if you're not the gassy type. I use 1 mg of folic acid daily for each 3 methotrexate pills weekly.
DrWaters> Dale, have you been tried on leucovorin?
Dale> No I have not.
Dale> I take 2mg folic acid/day
DrWaters> You see, you do need to tell your rheum what to do. Jeff was right.
DrWaters> How much MTX?
Dale> He's slowly getting used to it.
Dale> 20mg
DrWaters> 2 or 3 folic acid would be correct.
Dale> What is the benefit of leucovorin? And what is carafate?
DrWaters> Keep up the good work Dale, our patients are our most important teachers. Of course, in a different sense, but close enough.
Dale> Thank you very much. Please send me the bill! LOL
DrWaters> Leucovorin is a potent blocker of MTX. For some crazy reason if you take lecovorin 12 to 24 hours aftwer MTX the MTX works and side-effects often go away. Very strange. The original article was by a Dr. Jeff Shiroky, if your rheum needs a reference. Carafate is a medicine for stomach ulcers.. In some patients it gets rid of oral ulcers if the dissolve a tab in water and swish it around mouth a few times a day.
DrWaters> Tina, I still have a lot of charts to scribble (which is what my wife calls completeing the charts - she's a pediatrician
DrWaters> So I have to go.
InsightHostKJ> You go right ahead Dr Waters...and thank you so much!
Dale> Thank you, Dr. Waters
InsightHostKJ> I'm sorry about the time confusion!
Guest190> Nite Doctor
Cindy> Thanks
Melanie> Thank you very much - good info.
Guest119> Thank you Dr Waters. Do return.
InsightHostKJ> We always appreciate your time with us!
DrWaters> You know, I used to like computers. Now with this cable modem thing I'm beginning to hate them. I hope all the Cable Modem executives get FMS.
InsightHostRon> ROFLMAO
Cindy> rofl
InsightHostKJ> ROFLMAO and with your luck they will all be your patients!
InsightHostRon> hehehehehe
DrWaters> I take it back, you're right. I hope they get ACNE.
InsightHostKJ> LMAO
Melanie> LOL
deb> lol
InsightHostRon> lol
DrWaters> OK, bye eveyone.
InsightHostKJ> Thanks again Dr!
If you didn't get to ask Dr. Waters a question you can always send it to him
via experts@arthritisinsight.com
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