Conditions Flashcards
Rheumatoid arthritis
What? Where? Symptoms? Investigations? X-Ray signs? Treatment? Classification?
Autoimmune disease, 40-60 yrs
Site: small joints in the hands and the feet
Symptoms: swollen, painful, red joints, stiffness worse in the morning but activity may improve it. Fatigue, lethargy, pyrexia, weight loss, other MSK type presentation (synovitis, tenosynovitis, rheumatoid arthritis, bursitis)
Investigations: CRP and ESR raised, normocytic anaemia, rheumatoid factor and ACPA (anti-citrullinated protein antibody) level.
X-Ray: soft tissue swelling, periarticular osteopenia, juxta-articular erosion, late signs may be narrowed joint space, subluxations and destructive changes.
Treatment: NSAID’s for pain before starting DMARD’s like methotrexate or sulfasalazine, biologics
EULAR Classification: The diagnostic criteria for RA is the EULAR classification which classifies 4 categories and ≥6/10 indicated a definite RA.
Joint Distribution (0-5): 1 large joint = 0 points, 2-10 large joints = 1 point, 1-3 small joints = 2 points, 4-10 small joints = 3 points, >10 joints (at least one small joint) 5 points Serology (0-3): Negative RF AND negative ACPA = 0 points, low positive RF or low positive ACPA = 2 points, high positive RF or high positive ACPA = 3 points Symptom Duration (0-1): <6 weeks = 0 points, ≥6 weeks = 1 point Acute Phase Reactants (0-1): Normal CRP and normal ESR = 0 points, abnormal CRP or abnormal ESR = 1 point
Osteoarthritis
What? Cause? RF? Symptoms? Examination? Differentials? Investigation? X-Ray signs? Management? C, M, S
Leading cause of pain and disability. Progressive loss of articular cartilage and remodelling of the underlying bone.
Cause: degradation or cartilage and remodelling or bone due to the active response of chondrocytes in the articular cartilage and the surrounding tissues. The release of enzymes from the cells breaks down the cartilage. The exposure of the underlying subchondral bone leads to sclerosis, following by remodelling causing osteophytes and subchondral bone cysts. The joint space will be lost over time.
RF: primary due to obesity, age, female or manual labour occupations OR secondary to trauma, infiltrative disease, CT disease
Symptoms: insidious, chronic and gradually worsening pain and stiffness that worsens with activity. Pain may worsen through the day but stiffness tends to improve. This leads to deformity and a reduced range of movement.
Examination: deformity – Bouchard nodes (PIPJ’s) or Heberden nodes (DIPJ’s) in hands and fixed flexion deformity or varus malalignment in the knees. Feel for crepitus. Movement of the joint is reduced and painful.
Differential: septic arthritics, fractures, bursitis, malignancy, rheumatoid arthropaties, HAND (De Quervain’s tenosynovitis, RA, gout), HIP (trochanteric bursitis, radiculopathy, spinal stenosis, iliotibial band syndrome), KNEE (referred hip pain, meniscal or ligament tears, chondromalacia patellae)
Investigations: routine bloods, X-ray
X-Ray: loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis
Management:
Conservation: education, joint protection and strengthening exercises, weight loss. Heat or ice packs, joint supports, physiotherapy.
Medical: analgesics, topical NSAID’s, intra-articular steroid injections which is miced with a local anaesthetics ( can cause initial hourly improvement of symptoms but will cause a steroid flare where symptoms worsen for a couple days)
Surgical: osteotomy, arthrodesis (joint fusion), arthroplasty
Back Pain
Yellow Flags?
Red Flags?
Yellow flags are psychosocial patient factors that although not associated with serious organic pathology nonetheless indicate an increased likelihood of chronic back pain and resultant long term disability
Yellow flags include:
a belief that pain and activity is harmful or severely disabling
fear-avoidance behaviour
sickness behaviours
low mood
social withdrawal
an expectation that passive treatment rather than active participation will help
difficulty at work
Cauda Equina:
- Bilateral Sciatica
- Peri-anal Numbness
- Erectile Dysfunction
- Painless Urinary Retention
- Faecal Incontinence
Infections: Spinal Epidural Abscess, Discitis, Vertebral Osteomyelitis
- fever, tuberculosis, immunocompromised
Spinal Cancer: Prostate mets to lower spine are most common.
- Consider weight loss, night sweats, fatigue,- general red flags
Sciatica
Causes?
Symptoms?
Prevention?
Management?
Causes
Anything which leads to compression of a Sciatic nerve
Slipped Disc
Spinal Stenosis
Spondylolisthesis
Symptoms
Pain which radiates from lower back to your buttock and down the back of the leg (Hallmark symptom)
This can vary from Sharp to burning sensation to excruciating pain
Tingling sensation - Pins and Needles
Weakness
Tends to affect on side only
Risk Factors for Mechanical Back Pain - obesity, poor posture, sedentary lifestyle (desk job) Good Manual Handling Technique - ie lifting heavy objects correctly Staying Active and Healthy Stretch Regularly - especially if working at a desk
General Advice
- encourage to stay active (prolonged bed rest is detrimental to recovery)
- local heat to relieve pain and muscle spasms
Analgesia to Manage Pain
- NSAIDs (ibuprofen or naproxen) along with a PPI
- Codeine +/- paracetamol if NSAID is contraindicated or ineffective
Referrals
- physiotherapist for manual therapy (exercises, mobilisation, massage)
- CBT if patient suffering from psychosocial obstacles to recovery
