GP Rheumatology Flashcards
A 42-year old woman presents to her GP with ongoing fatigue. Her symptoms do not seem to get better with rest and have caused her to reduce her hours at work. She has had extensive investigations which have all been unremarkable. Possible diagnosis?
Chronic fatigue syndrome
What are the features of fatigue which occurs in chronic fatigue syndrome?
- Not the result of exertion
- Does not improve with a reduction in activity or rest
- Cannot be explained by any other medical condition
Signs of chronic fatigue syndrome
None
CFS is considered a diagnosis of exclusion and physical examination will be unremarkable
Symptoms of chronic fatigue syndrome
Severe fatigue often with the following features:
* New or a specific onset (that is, it is not lifelong)
* Persistent and/or recurrent
* Unexplained by other conditions
* Has resulted in a substantial reduction in activity
* Characterised by** post-exertional malaise and/or fatigue** (typically delayed, for example by at least 24 hours, with slow recovery over several days)
Others:
* Sleep disturbance
* Muscle or joint pain (without inflammation)
* Palpitations (in the absence of cardiovascular disease)
* Headaches
* Cognitive dysfunction (e.g. difficulty concentrating)
* Painful lymph nodes without pathological enlargement
Investigations for chronic fatigue syndrome
CFS is recognised on clinical grounds alone
Primary investigations: to assess for an underlying cause
- FBC : e.g. anaemia or infection
- CRP/ESR : to investigate for an inflammatory cause
- Thyroid function tests : e.g. hypothyroidism
- Liver function tests : e.g. chronic liver disease
- Urea and electrolytes : e.g. chronic kidney disease
- Blood glucose or HbA1c : e.g. diabetes mellitus
- Coeliac serology : e.g. coeliac disease
Management for chronic fatigue syndrome
First-line:
* Education
* Rest strategies
* Graded exercise therapy
* Cognitive behavioural therapy
Second-line:
* Pain management clinic
* Low-dose tricyclic antidepressant
Complications of chronic fatigue syndrome
- Social impact
- Reduced quality of life
- Increased risk of depression + aniety
- Increased mortality risk
A 53-year-old cleaner presents to her GP with a tender, swollen right knee. She believes this has been aggravated lately at work as she often works on her knees for long periods of time. On examination, her right knee is swollen and tender to palpate with reduced range of movement. She is otherwise well and there is no associated skin change. Possible diagnosis?
Bursitis
What is bursitis?
Bursitis = inflammation of the synovium-lined, sac-like structures (bursa) found throughout the body - usually between bones, muscles, tendons or ligaments
Pathophysiology of bursitis
- The exact pathophysiology = unknown but the bursa appears to become inflamed as a result of a trigger , e.g. repeated pressure → fills with synovial fluid
- Pain is experienced as the inflamed bursa = compressed against surrounding structures e.g. bone or muscle
Common locations for bursitis
- Prepatellar bursitis
- Infrapatellar bursitis
- Anserine bursitis
- Olecranon bursitis
- Trochanteric bursitis
- Subacromial bursitis
- Retrocalcaneal bursitis
Risk factors for bursitis
- Occupation causing repeated mechanical stress on a bursa: ‘clergymans ’(infrapatellar bursitis) knee from praying, ‘housemaids knee’ (prepatellar bursitis)
-
Autoimmune conditions: rheumatoid arthritis , psoriatic arthritis
Gout or pseudogout - Hip osteoarthritis: trochanteric bursitis
- Penetrative injury: introducing infection
- Abnormal gait: mechanics may induce trochanteric bursitis
- Low-riding shoes: excessive heel pressure can cause retrocalcaneal bursitis
Clinical features of bursitis
Signs:
* Tenderness on palpation
* Altered gait (lower limb bursitis’)
* Erythema (if septic bursitis)
Symptoms:
* Pain (at a particular bursa site)
* Reduced range of movement
* Swelling
Investigations for bursitis
Bursitis = clinical diagnosis
Investigations to consider:
* FBC: leucocytosis in septic bursitis
* CRP: raised in the context of infection
* Fluid aspiration culture: WCC count lower than septic arthritis <20,000 mm^3
* Fluid aspiration for crystals: monosodium urate crystals in gout , calcium pyrophosphate in pseudogout
* Plain x-ray: usually normal, may show underlying osteoarthritis
* MRI: soft tissue swelling and fluid filled bursa
Management for non-septic bursitis
First line:
* Conservative management: rest, ice, compression
* Simple analgesia: paracetamol, ibuprofen
Second line:
* Corticosteroid injection
Third line:
* Surgery: bursectomy
