Consultation Flashcards
What features in history would be inkeeping with pericarditis?
- Pleuritic chest pain
- Positional - relieved by sitting forwards, worse lying back
- Prodromal viral illness - cough, sore throat, fatigue, low-grade fever
- Associated symptoms: palpitations, SOB, dizziness, syncope
- Causes: viral, HIV/TB, uraemia, cancer, autoimmune disease e.g. RA, Lupus, previous trauma/cardiac surgery/MI (Dressler’s)
What are the DDx of pericarditis?
- Pneumonia
- PE
- MI
What findings on examination would be in-keeping with pericarditis?
- Pericardial rub - sounds ‘squeaky’ like walking in fresh snow
- If tamponade: Beck’s triad of hypotension, elevated JVP and muffled heart sounds. Tachycardia to maintain CO is also an early sign
- Pulsus paradoxus: SBP drops >10mmHg on inspiration
- Kussmaul’s sign - elevated JVP on inspiration
- Signs of an underlying cause e.g. rheumatoid hands
What are some underlying causes of acute monoarticular pain and swelling?
- Trauma
- Infective arthritis
- Inflammation (e.g. crystal arthritis like gout and pseudogout, reactive arthritis and acute sarcoidosis)
- Haemarthrosis (bleeding into the joint cavity secondary to trauma or bleeding disorders)
- Degenerative (flare of osteoarthritis)
How do you differentiate between articular and peri-articular problem with the joints?
Articular Problem:
- Global restriction of joint movements (e.g. global restriction of shoulder movements in gleno-humeral joint disease)
- Active and passive movements are equally restricted
- Swelling of the entire joint (e.g. filling of the parapatellar gutters and suprapatellar pouch with knee effusion)
Peri-articular Problem:
- Restriction of movements in only a certain plane (e.g. restriction of abduction alone in supraspinatus tendinitis)
- Greater restriction in active range of movements
- Localised swelling (e.g. anterior swelling over the lower half of the patella in pre-patellar bursitis)
What investigations should be requested in a patient with acute monoarthritis?
- Bloods including FBC, U&Es, LFTs, CRP, Uric acid
- Blood cultures in those with suspected septic arthritis
- Synovial fluid analysis and culture
- No need to request a plain radiograph unless there is preceding trauma or suspicion of pseudogout
- USS of the knee may be useful for USS guided aspiration in difficult cases.
Outline the pathology of Osteoarthritis
Characterised by degeneration of articular cartilage and bone remodelling. The primary event in OA is breakdown of articular cartilage, which usually occurs at the central load-bearing portion of the joint. It is NOT due to preceding synovitis (unlike in RA, because of synovial hypertrophy and release of cytokines). The breakdown of cartilage can be visualised on plain radiographs as loss of joint space.
Bone remodelling leads to thickening of subchondral bone (seen as sub-chondral sclerosis on XR), formation of bone cysts and growth of osteophytes at articular margins. The clinical effects of osteophytes depend on the site of formation. Osteophytes that form in the hands usually don’t cause symptoms, while those in the acromioclavicular joint could press on the rotator cuff and present with shoulder impingement, and those that form around the vertebrae could cause nerve root compression or spinal stenosis.
The breakdown products of cartilage may cause synovitis (as a secondary event) and expansion of the joint may stretch the surrounding ligaments, tendons or bursae, causing pain.
What views of radiograph would you get for a patient with suspected knee OA?
- Anteroposterior
- Lateral
- Sky-line view
What symptoms must be enquired about if a patient has a history in-keeping with PMR?
Symptoms related to GCA:
- Headache
- Visual symptoms
- Jaw claudication
- Scalp tenderness i.e. when combs hair
What rare complications can arise as a result of GCA?
- Stroke (due to involvement of cerebral blood vessels)
- Aortic aneurysm or dissection (due to involvement of the aorta)
What would be the key points of examination in a patient presenting with ?GCA
- Vital signs
- Palpate temporal arteries, checking for thickening, tenderness and reduced pulsation
- Record visual acuity in both eyes separately, especially if there are visual complaints
- Examine hips and shoulders to check range of movements (PMR)
How should a patient with suspected GCA be investigated?
- Bloods including FBC, U&Es, LFTs, CRP, ESR, Glucose, HbA1c and vitamin D
- Temporal artery USS - characteristic finding is a ‘non-compressible halo’ caused by oedema around the vessel wall
- Temporal artery biopsy
Outline some specific underlying causes of low back pain.
- Infection
- Malignancy
- Axial spondyloarthropathy
- Vertebral compression fracture
- Prolapse of the intervertebral disc
- Cauda equina syndrome
- Spinal Stenosis
What are the features of Cauda Equina syndrome?
- Retention of urine (most consistent feature)
- Inability to feel urine passing down the urethra
- Loss of anal tone
- Perianal anaesthesia (‘numb bum’)
- Bilateral leg pain
What are the red flag symptoms in patients with back pain?
- Age >50 years
- Hx of malignancy
- Unexplained weight loss
- Unremitting or progressively worsening pain
- Poor response to conservative measures
What are the important risk factors to consider for osteoporosis in men?
- Alcohol
- Steroid use
- Hypogonadism
What diagnosis should be considered in a patient with back pain, previous history of fragility fractures and recurrent infections?
- Multiple Myeloma
What should you look for on examination of a patient presenting with back pain with red flag features?
- Examination of spine
- Look for signs that may suggest cancer - e.g. finger clubbing, lymphnode enlargement, hard liver, splenomegaly and abdominal mass
- Neurological examination of the legs is only indicated in those with radicular or neurological symptoms and could be abbreviated or omitted if pain is confined to the back.
What investigations should be requested in a patient with thoracic back pain with red flag symptoms?
- Plain XRays of thoracic spine
- CXR
- Bloods including FBC, U&Es, LFTs, CRP, Bone Profile, PSA, ESR, Myeloma screen
- Depending on above tests - MRI thoracic spine or CT CAP should be considered
Give an overview of Multiple Myeloma
Plasma cells produce immunoglobulins. There are 5 classes of immunoglobulin: IgG, IgM, IgD, IgA and IgE. Each immunoglobulin molecule consists of two heavy and two light chains. There are 5 types of heavy chain (gamma, miu, delta, alpha and elipson) and two types of light chain (kappa and lambda), Each individual plasma cell produces only one type of immunoglobulin, with any one of 5 heavy chains and one of two light chains.
In multiple myeloma, there is monoclonal proliferation of plasma cells, which results in excess production of one type of immunoglobulin, usually IgG, IgD or IgA. This is different from polyclonal proliferation of plasma cells that occurs in infection or inflammation, where multiple clones of plasma cells produce different types of immunoglobulins.
Screening tests for myeloma (serum protein electrophoresis and serum-free light chains) essentially look for evidence of monoclonal proliferation of plasma cells.
What results can be found in Multiple Myeloma
- High ESR - due to elevated immunoglobulin
- Bone osteolysis because of osteoclast stimulation by myeloma cells
- Hypercalcaemia due to stimulation of osteoclasts, which leads to release of calcium from bones into blood
- Renal impairment - secondary to direct toxic effect of light chains on renal tubules, hypercalcaemia or hyperviscosity
- Pancytopenia - because myeloma cells take up the bone marrow space and reduce the production of normal blood cells.
- Immune paresis - production of one type of immunoglobulin by myeloma cells suppresses the production of other types of immunoglobulin, thus increasing the risk of infection (e.g.suppression of IgA and IgM in patients with IgG myeloma
CRAB - High serum calcium, renal impairment, Anaemia, Bone osteolysis
How is Myeloma diagnosed?
- ‘M’ band on serum protein electrophoresis and/or abnormal kappa/lambda ratio
- Evidence of CRAB
- Immune paresis
- Bone Marrow biopsy
- Serum B2 microglobulin level is useful for prognostication - higher levels = poorer outcome
Name some organic causes of widespread pain.
- Inflammatory arthritis (e.g. Rheumatoid arthritis, seronegative spondyloarthropathy)
- OA
- Autoimmune connective tissue disease (e.g. systemic lupus erythematous, Sjogren’s)
- Osteomalacia
- Thyroid dysfunction
- Statin therapy
- Malignancy
Name some features of fibromyalgia
- Chronic widespread pain, fatigue and non-restorative sleep
- Other functional somatic symptoms, such as chronic headache, functional bowel disturbance and dysmenorrhoea
- Psychological distress, and unhelpful thoughts, emotions and behaviours
- Absence of clear evidence of an organic problem