MDD Flashcards by Daniel El-Dalil

Gout: Acute and Chronic

Acute: Fast acting NSAID - naproxen. Colchicine if CCF,CKD or chemo. Aspirate and corticosteroid injection aborts attack. Early mobilisation important.

Chronic: Hypouricaemic drugs, allopurinol = xanthine oxidase inhibitors. Uric acid levels measured every month and tried to be kept at the lower end of normal.
Lifestyle advice, reduce alcohol, total calorie/cholesterol, avoid certain foods e.g. offal and spinach.

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Psuedogout

Acute similiar to gout - responds well to joint aspiration.

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Fibromyalgia

Education 
Aerobic exercise - swimming, running 
 - encourages sleep and tries to stop the cycle
Healthy balanced diet 
Low dose amitryptilline - 10-75mg nocte
- many people intolerant 
CBT helpful for coping strategies

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Septic Arthritis/Osteomyelitis

ABCDE resus and sepsis 6 
Admit under orthopaedics 
IV abx after aspiration - 2g fluclox 6hrly
Pain relief 
In-theatre washout (source control)
Early rehab improves outcome

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Osteoarthritis

Education, weight loss, physio, topical NSAIDs and paracetemol for pain 1st line and oral w/ PPI cover 2nd line, supports and walking aids and steroid injection. Finally joint arthroplasty/arthrodesis.

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Osteoporosis

Osteopenia - lifestyle advice - no smoking, alcohol, exercise and incerase calcium intake
Osteoporosis - weekly bisphosphonates - alendronic acid weekly - if cannot tolerate then use risondronate instead. Use with AdCal as adjunct.
HRT can be considered in post-meno women
Testosterone in males with hypo-gonadism
PTH analogue intermittent if all other treatment fails.

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Osteomalacia

Vit D replacement high dose for 4 weeks then maintenance. IV if malnourished and activated if hepatic/renal failure.

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Paget’s disease of the bone

Simple analgesia for pain and bisphosphonates for disease modification.

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Carpal Tunnel.

Rest, physio, NSAIDs, splint in dorsiflexion, steroid injection, decompression surgery.

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De Quervains tenosynovitis

Rest, spica splint, NSAIDs, steroid injection, compartemt release surgery if goes on >6m.

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Base of thumb OA

Rest, NSAIDs, surgical: denervation, trapeziectomy, basal arthroplasty.

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Medial and Lateral epicondylitis

Rest, NSAIDs, physio, clasp splint, surgery if above fails

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Cubital Tunnel

Physio, splint (nocturnal), NSAID and steroid injection. Surgery if progressive and signs of permanent nerve damage.

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Olecranon Bursitis

Ice and compression bandage. Rest, NSAIDs topical/PO. Aspirate, steroid injection.

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Adhesive Capsulitis

NSAIDs, physio, steroid injection if not improved in 2 months. If hasn’t healed in 2y then surgery is an option.

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Chronic rotator cuff tendonitis

NSAIDs, steroid injection if severe. Physio, surgery if impingement = arthroscopic decompression.

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Acute rotator cuff tendonitis

USS/MRI diagnostic

Rest in sling, NSAIDs, steroid inj if severe. Should resolve in 1-3 weeks.

Rotator cuff tear

USS/MRI or arthroscopy is diagnostic.
Acute: heat exercises and local anaesthetic injection to distinguish partial and complete tear. If young - surgery, if old - leave it.

Trochanteric bursitis

Steroid Injection - if total hip replacement then pt. needs to be in laminar flow theatre.
Physio to stretch fascia lata

Chondromalacia Patella

Physio

ACL tear

Sprain/partial tear = physio and self resolves
Complete tear - surgical graft repair for young, older patients with low functional demand can be treated conservatively.

MCL/LCL tear

usually heal by themselves, brace and physio. Almost never need surgery if isolated

Meniscal tear

Arthroscopic repair if young as will progress to secondary OA if not repaired.

Spine Red Flags

Constant progressive pain 
Thoracic spine 
Pain at night 
B sx - fever, wt. loss, night sweats 
History of TB, HIV, prev. malignancy 
Midline tenderness on palpation 
Cauda Equina - bowel/bladder symptoms, saddle anaesthesia, prev. trauma.

Simple/mechanical problem

Be active within limits, pain relief, physio - 90% recover in 6 weeks. Reassess in 6w if pain hasn't settled.

Acute lumbar disc prolapse

Make sure to test myotomes and dermatomes and reflexes!! Bed rest for 2 weeks w/ NSAIDs. Epidural injections, MRI and neurosurgical referral.

Lumbar canal stenosis

Activity modification, physiotherapy. Surgical laminectomy - OA pain will still exist.

Cervical spondylitis/brachial neuropathy/cervical radiculopathy

Hard support collar, rest, analgesia, sedation as necessary. Usually recovers in 6-12 weeks. Consider neurosurgery referral.

Cervical myelopathy

Causes include cervical canal stenosis | Refer to neurosurgery urgently.

Ank Spond

NSAIDs, physio, annual assessment, biologics if no improvement

Cervical disc prolapse

support collar, rest, analgesia, sedation 6-12 weeks, can do root block.

Rheumatoid Arthritis

General Management: When diagnosed Methotrexate combined with one other DMARD sulfasalazine/hydroxychloroquine and also a short course of oral prednisolone. If the above does not control the disease and they still have a disease activity score of over 5.5, can consider biologics.

Ankylosing Spondylitis

Important to catch early to prevent sydesmophyte formation and calcification of joints. Ca lead normal life with good Rx. - Early morning exercise to maintain posture and spinal motility - Slow release NSAIDs to relieve pain at night and in early morning. - Methotrexate can be used for peripheral arthritis TNF-a blockers can be used for all aspects of joint inflammation e.g. infliximab Biologics = TNFa blockers

Reactive Arthritis

NSAID and local corticosteroid injection. If relapse then sulfasalazine is often used (methotrexate and TNF-a blocker can also be used in relapse)

Psoriatic Arthritis

One Joint - full dose NSAIDs +/- corticosteroid injections | More than one joint - treat as per RA, prognosis is better. Methotrexate helps with skin also.

SLE

Avoid sunlight and reduce CV risk factors Monitor for signs of infection (neutropenia) and treat early Mild disease NSAIDs and hydroxychloroquine (skin, arthralgia and fatigue) Severe disease (involving CV/kidney) - prednisolone w/ DMARDs such as azathioprine

APL

Hx of severe thrombosis - warfarin, target INR 3-4 W/out thrombotic Hx - low dose aspirin ad lifestyle advice - avoid prolonged immobilisation and oestrogen containing drugs.

Sjorgren's Syndrome

Artificial tear replacement

Limited cutaneous sclerosis

Digital sympathemectomy remove calcinosis if symptomatic treatment of oesophageal problems

Diffuse cutaneous sclerosis

Immunosuppressant therapy - aim to prevent complications and gradually withdraw as the disease stabilises

Poly/dermatomyositis

prednisolone/DMARDs until myositis is clinically inactive. IVIG therapy may be used in some cases