GP- MSK and rheumatology Flashcards
Risk factor for OA
obesity, age, occupation, trauma, being female and family history.
definition and pathophysiology of OA
“wear and tear” in the joints.
It occurs in the synovial joints and results from genetic factors, overuse and injury.
Osteoarthritis is thought to result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint
Commonly Affected Joints OA
Hips
Knees
Distal interphalangeal (DIP) joints in the hands
Carpometacarpal (CMC) joint at the base of the thumb
Lumbar spine
Cervical spine (cervical spondylosis)
X ray changes on OA
OA presentation and general signs
OA signs in the hands
TOM TIP: Patients may present with referred pain, particularly in the adjacent joints. For example, consider osteoarthritis in the hip in patients presenting with lower back or knee pain.
- OA NICE diagnosis criteria
The NICE guidelines (2022) suggest that a diagnosis can be made without any investigations if the patient is over 45, has typical pain associated with activity and has no morning stiffness (or stiffness lasting under 30 minutes).
OA management
Chronic fatigue syndrome definition
Diagnosed after at least 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms
Chronic fatigue syndrome epidemiology
Epidemiology
more common in females
past psychiatric history has not been shown to be a risk factor
Chronic fatigue syndrome features
Fatigue is the central feature, other recognised features include
* sleep problems, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle
* muscle and/or joint pains
* headaches
* painful lymph nodes without enlargement
* sore throat
* cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding
* physical or mental exertion makes symptoms worse
* general malaise or ‘flu-like’ symptoms
* dizziness
* nausea
* palpitations
Chronic fatigue syndrome investigations
Investigation
NICE guidelines suggest carrying out a large number of screening blood tests to exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening, HbA1C and also urinalysis
Chronic fatigue syndrome diagnosis
Diagnosis
NICE publish diagnostic criteria NICE
a diagnosis is typically made if the symptoms persist for 3 months
Chronic fatigue syndrome management
Fibromyalgia definition
Fibromyalgia is a chronic, complex, and widespread pain syndrome. Patients experience body pain that occurs on both sides, front and back, and above and below the diaphragm for a duration of at least three months. This pain is often accompanied by fatigue, mood disturbances, and sleep issues.
Fibromyalgia epidemiology
women are around 5 times more likely to be affected
typically presents between 30-50 years old
Fibromyalgia features
The cardinal symptom of fibromyalgia is chronic, widespread body pain, often described as a constant dull ache. This is accompanied by:
- Fatigue, often waking up tired despite sufficient sleep
- Cognitive disturbances, such as problems with focus and memory, known as ““fibro fog””
- Mood disorders, particularly depression and anxiety
- Sleep disturbances, including insomnia
- headaches and dizziness
Fibromyalgia differentials
- Rheumatoid arthritis: Characterized by joint pain, swelling, and redness
- Chronic fatigue syndrome: Marked by severe, unexplained fatigue
- Lupus: Presents with rash, joint pain, and kidney problems
- Hypothyroidism: Accompanied by weight gain, constipation, and cold sensitivity
Fibromyalgia diagnosis and investigations
Diagnosis of fibromyalgia is primarily clinical, based on the patient’s history and physical examination. The American College of Rheumatology (ACR) criteria, which include widespread pain for at least three months and tenderness at 11 or more of the 18 specific tender points, are commonly used.
Fibromyalgia management
another term for low back pain
Lumbago is another term for low back pain
majority of patients who do not have a specific disease causing their lower back pain, have what type of back pain?
Non-specific or mechanical lower back pain
Another term for lower back pain
lumbago
Acute low back pain should improve within …
Acute low back pain should improve within 1-2 weeks
How long does recovery for sciatica take ?
Recovery can take longer (4-6 weeks) for sciatica.
There are several challenges with managing patients with lower back pain:
Identifying serious underlying pathology
Speeding up recovery
Reducing the risk of chronic lower back pain
Managing symptoms in chronic lower back pain
The causes of mechanical back pain include:
- Muscle or ligament sprain
- Facet joint dysfunction
- Sacroiliac joint dysfunction
- Herniated disc
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Scoliosis (curved spine)
- Degenerative changes (arthritis) affecting the discs and facet joints
The causes of neck pain include:
Muscle or ligament strain (e.g., poor posture or repetitive activities)
Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)
Whiplash (typically after a road traffic accident)
Cervical spondylosis (degenerative changes to the vertebrae)
Red flag causes of back pain
- Spinal fracture (e.g., major trauma)
- Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs)
- Spinal stenosis (e.g., intermittent neurogenic claudication)
- Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)
- Spinal infection (e.g., fever or a history of IV drug use)
list of abdominal or thoracic conditions that can cause back pain,
Pneumonia
Ruptured aortic aneurysms
Kidney stones
Pyelonephritis
Pancreatitis
Prostatitis
Pelvic inflammatory disease
Endometriosis
red flags for lower back pain
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
The main causes of sciatica are
The main causes of sciatica are lumbosacral nerve root compression by:
- Herniated disc
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Spinal stenosis
Sciatica nerve supplies which body part and what symptoms does it cause when it is affected?
red flag for cauda equina syndrome.
Bilateral sciatica is a red flag for cauda equina syndrome.
Things to ask for in the history for lower back pain
the main cancers that metastasise to the bones
TOM TIP: It is worth remembering the main cancers that metastasise to the bones. A history of these in an exam patient presenting with back pain should make you think of possible cauda equina or spinal metastases. You can remember them with the PoRTaBLe mnemonic:
Po – Prostate
R – Renal
Ta – Thyroid
B – Breast
Le – Lung
investigations for lower back pain
Investigations for suspected ankylosing spondylitis are:
- Inflammatory markers (CRP and ESR)
- X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease)
- MRI of the spine (may show bone marrow oedema early in the disease)
Screening tool to stratify the risk of a patient presenting with acute back pain developing chronic back pain
Management of acute lower back pain
Management of sciatica
features of prolapsed disc and the different sites of compression and main features for each site of compression
management of prolapsed disc
similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
* NICE recommend using the same drugs as for back pain without sciatica symptoms i.e. first-line is NSAIDs +/- proton pump inhibitors rather than using neuropathic analgesia (e.g. duloxetine)
if symptoms persist e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate
spinal stenosis vs ankylosing spondylitis vs peripheral arterial disease features and how they cause back pain
Polymyalgia rheumatica (PMR) definition and which group it affects
Polymyalgia rheumatica (PMR) is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. There is a strong association with giant cell arteritis, and the two conditions often occur together.
The cause is not fully understood. There are no relevant antibodies. It is more common in older white patients.
polymyalgia rheumatica symptoms
Patients may have a relatively rapid onset of symptoms over days to weeks. Symptoms should be present for two weeks before a diagnosis is considered. The core symptoms are pain and stiffness of the:
- Shoulders, potentially radiating to the upper arm and elbow
- Pelvic girdle (around the hips), potentially radiating to the thighs
- Neck
The characteristic features of the pain and stiffness are:
- Worse in the morning
- Worse after rest or inactivity
- Interfere with sleep
- Take at least 45 minutes to ease in the morning
- Somewhat improve with activity
Associated features include:
- Systemic symptoms (e.g., weight loss, fatigue and low-grade fever)
- Muscle tenderness
- Carpel tunnel syndrome
- Peripheral oedema
differential diagnosis to polymyalgia rheumatica
The presenting symptoms are not specific to PMR, and there is a long list of differentials, including:
- Osteoarthritis
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Statin-induced myopathy
- Myositis (e.g., polymyositis)
- Cervical spondylosis
- Adhesive capsulitis (frozen shoulder)
- Hyperthyroidism or hypothyroidism
- Osteomalacia
- Fibromyalgia
- Lymphoma or leukaemia
- Myeloma
diagnosis of polymyalgia rheumatica: main investigation results plus investigations to perform before prescribing treatment and additional investigations to consider to rule out other things
polymyalgia rheumatica treatment
Additional management for patients on long-term steroids can be remembered with the… mnemonic:
Additional management for patients on long-term steroids can be remembered with the “Don’t STOP” mnemonic:
RA definition, risk factors
Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation in the synovial lining of the joints, tendon sheaths and bursa. It is a type of inflammatory arthritis. Synovial inflammation is called synovitis. Inflammation of the tendons increases the risk of tendon rupture.
Rheumatoid arthritis tends to affect multiple small joints symmetrically across both sides of the body. This pattern is described as symmetrical polyarthritis.
Rheumatoid arthritis is 2-3 times more common in women than men. It most often develops in middle age but can present at any age. Smoking and obesity are risk factors.
most common gene associated with rheumatoid arthritis is
A family history increases the risk of rheumatoid arthritis (although there is no clear inheritance pattern). The most common gene associated with rheumatoid arthritis is HLA DR4.
two most important antibodies associated with RA to know
The most commonly affected joints in RA are:
Rheumatoid arthritis typically causes symmetrical distal polyarthritis affecting the small joints of the hands and feet. The most commonly affected joints are:
- Metacarpophalangeal (MCP) joints
- Proximal interphalangeal (PIP) joints
- Wrist
- Metatarsophalangeal (MTP) joints (in the foot)
On palpation of the joints, there will be tenderness and synovial thickening, giving them a “boggy” feeling.
TOM TIP: Rheumatoid arthritis very rarely affects the distal interphalangeal joints . Enlarged and painful distal interphalangeal joints are more likely to represent Heberden’s nodes due to osteoarthritis
presentation of RA
What is palindromic rheumatism?
Palindromic rheumatism involves self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling typically affecting only a few joints.
The symptoms last days, then completely resolve. Joints appear normal between episodes.
Rheumatoid factor or anti-CCP antibodies may indicate that it will progress to rheumatoid arthritis.
Hand signs in advanced disease in RA
Atlantoaxial subluxation definition and consequences
Atlantoaxial subluxation occurs in the cervical spine. Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1).
Subluxation can cause spinal cord compression and is an emergency. This needs to be considered when a patient is having a general anaesthetic and requires intubation.
MRI can be used to visualise changes in these areas as part of a pre-operative assessment.
Extra articular manifestations in RA
Investigations and diagnosis of RA including RA classification criteria
RA x ray changes
- Periarticular osteopenia
- Boney erosions
- Soft tissue swelling
- Joint destruction and deformity (in more advanced disease)
- loss of joint space
- Atlantoaxial subluxation
Scoring systems used in RA
Management of RA
Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
What markers in RA are used to the success of treatment
C-reactive protein and DAS28 are used to monitor the success of treatment.
Which DMARD is considered the mildest?
Hydroxychloroquine may be used in mild disease and palindromic rheumatism. It is the “mildest” DMARD.
Examples of cDMARDS
Hydroxychloroquine, azathioprine, ciclosporin, cyclophosphamide and mycophenolate.
Which DMARDS are safe to use during pregnancy
Pregnancy can improve symptoms, but some pregnant women experience a symptom flare.
Hydroxychloroquine and sulfasalazine are considered the safest DMARDs in pregnancy (extra folic acid is required with sulfasalazine).
Methotrexate and leflunomide are very harmful in pregnancy (teratogenic).
Main biologics to remember for the treatment of RA
TOM TIP: The main biologics to remember are adalimumab, infliximab and etanercept (TNF inhibitors), and rituximab (a monoclonal antibody that targets the CD20 proteins on the surface of B cells). They cause immunosuppression, increasing the risk of infection, certain cancers (e.g., skin) and reactivation of latent TB.
Methotrexate MOA and SE
Methotrexate interferes with folate metabolism and suppresses the immune system. It is given once a week. Folic acid 5mg is taken once a week (on a different day to the methotrexate).
Main Side effect: Bone marrow suppression and leukopenia, and highly teratogenic
Leflunomide MOA and main SE
Leflunomide is an immunosuppressant medication that interferes with the production of pyrimidine. Pyrimidine is an important component of RNA and DNA.
main SE : Hypertension and peripheral neuropathy
Sulfasalazine MOA and main SE
Sulfasalazine is an immunosuppressive and anti-inflammatory medication. The exact mechanism is not clear.
Main SE: Orange urine and male infertility (reduces sperm count)
Hydroxychloroquine MOA and main SE
Hydroxychloroquine is traditionally an antimalarial medication. It suppresses the immune system by interfering with Toll-like receptors, disrupting antigen presentation and increasing the pH in the lysosomes of immune cells
Main SE: Retinal toxicity, blue-grey skin pigmentation and hair bleaching
Anti-TNF medications MOA and main SE
Anti-TNF medications: Reactivation of tuberculosis
Rituximab main SE
Rituximab: Night sweats and thrombocytopenia
Topical steroids by potency, SE, and how much you should apply
Finger tip rule
1 finger tip unit (FTU) = 0.5 g, sufficient to treat a skin area about twice that of the flat of an adult hand
most common organisms that causes infection in eczema
Opportunistic bacterial infection of the skin is common in eczema. The breakdown in the skin’s protective barrier allows an entry point for infective organisms. The most common organism is staphylococcus aureus. Treatment is with oral antibiotics, particularly flucloxacillin. More severe cases may require admission and intravenous antibiotics.
examples of think and thick emollients used for eczema
how would you describe the management of eczema to a patient?
Simplified pathophysiology for eczema
The simplified pathophysiology is that eczema is caused by defects in the barrier that the skin provides. Tiny gaps in the skin barrier provide an entrance for irritants, microbes and allergens that create an immune response, resulting in inflammation and the associated symptoms.
Eczema definition and presentation
How does distribution of eczema differ on age of the child
itchy, erythematous rash
repeated scratching may exacerbate affected areas
* in infants the face and trunk are often affected
* in younger children, eczema often occurs on the extensor surfaces
* in older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck
Eczema herpeticum definition and cause
Eczema herpeticum is a viral skin infection caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV). It was previously known as Kaposi varicelliform eruption (don’t confuse this with Kaposi sarcoma, which occurs in late stage HIV). Herpes simplex virus 1 (HSV-1) is the most common causative organism, and may be associated with a coldsore in the patient or a close contact. It usually occurs in a patient with a pre-existing skin condition, such as atopic eczema or dermatitis, where the virus is able to enter the skin and cause an infection.
Typical presentation of eczema herpeticum
A typical presentation is a patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).
Describe the eczema herpeticum rash
The rash is usually widespread and can affect any area of the body. It is erythematous, painful and sometimes itchy, with vesicles containing pus. The vesicles appear as lots of individual spots containing fluid. After they burst, they leave small punched-out ulcers with a red base.
investigations and treatment of eczema herpeticum
Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.
Treatment is with aciclovir. A mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.
eczema herpeticum complications
Children with eczema herpeticum can be very unwell. When not treated adequately it can be a life threatening condition, particularly in patients that are immunocompromised.
Bacterial superinfection can occur, leading to a more severe illness. This needs treatment with antibiotics.
irritant dermatitis and allergic dermatitis presentation and treatment
Chronic pain diagnosis criteria
Chronic pain can be diagnosed when pain has been present or reoccurs in one or more areas over more than 3 months.
Common areas of chronic pain include:
Some studies suggest up to 50% of the adults in the UK are affected by chronic pain. Common areas of chronic pain include:
- Headaches
- Lower back pain
- Neck pain
- Joint pain (e.g., knees or hips)
The NICE guidelines on chronic pain (April 2021) separates chronic pain into:
- Chronic primary pain – where no underlying condition can adequately explain the pain
- Chronic secondary pain – where an underlying condition can explain the pain
There is a long list of causes of chronic secondary pain that could take up the entire page. A few examples are:
- Osteoarthritis
- Lasting pain after a traumatic injury (e.g., bone fracture)
- Migraines
- Irritable bowel syndrome
- Endometriosis
- Cancer
- Neuropathic pain (e.g., due to diabetes, nerve impingement, multiple sclerosis or post-herpetic neuralgia)
- Complex regional pain syndrome
Biological, psychological and social factors contribute to the persistence of the pain. The physical processes that can lead to chronic pain include:
- Sensitisation of the primary afferent nociceptors by frequent stimulation
- Increased activity of the sympathetic nervous system
- Increased muscle contraction in response to pain
Chronic pain management: including chronic primary pain and chronic secondary pain
The… can be used to assess the characteristics of the pain and the likelihood of neuropathic pain
The DN4 questionnaire can be used to assess the characteristics of the pain and the likelihood of neuropathic pain. Patients are scored out of 10. A score of 4 or more indicates neuropathic pain.
There are four first-line treatments for neuropathic pain:
Amitriptyline – a tricyclic antidepressant
Duloxetine – an SNRI antidepressant
Gabapentin – an anticonvulsant
Pregabalin – an anticonvulsant
NICE recommend using one of these four medications to control neuropathic pain. If it does not help, it can be slowly withdrawn, and an alternative can be tried. All four can be tried in turn. Only one neuropathic medication should be used at a time.
After first line treatments, other options for managing neuropathic pain are:
Other options for managing neuropathic pain are:
- Tramadol ONLY as a rescue for short term control of flares
- Capsaicin cream (chilli pepper cream) for localised areas of pain
- Physiotherapy to maintain strength
- Psychological input to help with understanding and coping
Trigeminal neuralgia pain management
Trigeminal neuralgia is a type of neuropathic pain. However, NICE recommend carbamazepine as the first-line medication for trigeminal neuralgia, and if that does not work to refer to a specialist.
Explain Analgesic pain ladder
common side-effect of the long-term use of analgesic medication
Medical overuse headache is a common side-effect of the long-term use of analgesic medication.
The key side effects of NSAIDs are:
- Gastritis with dyspepsia (indigestion)
- Stomach ulcers
- Exacerbation of asthma
- Hypertension
- Renal impairment
- Coronary artery disease, heart failure and strokes (rarely)
NSAIDs may be inappropriate or contraindicated in patients with:
Asthma
Renal impairment
Heart disease
Uncontrolled hypertension
Stomach ulcers
The key side effects of opioids are:
- Constipation
- Skin itching (pruritus)
- Nausea
- Altered mental state (sedation, cognitive impairment or confusion)
- Respiratory depression (usually only with larger doses in opioid-naive patients)
What is used to reverse the effects of opioids in life-threatening overdose?
Naloxone is used to reverse the effects of opioids in life-threatening overdose (usually due to respiratory depression).
Neuropathic pain cause and typical features
Neuropathic pain is caused by abnormal functioning or damage of the sensory nerves, resulting in pain signals being transmitted to the brain.
Typical features suggestive of neuropathic pain are:
- Burning
- Tingling
- Pins and needles
- Electric shocks
- Loss of sensation to touch of the affected area
