Musculoskeletal_Medicine Flashcards

1
Q

Compartment syndrome Key Signs & Sx? RFs? Ix? Mx?

A

Classic = 6Ps: pain, pallor, perishingly cold, pulseless, paraesthesia, paralysis (BUT these tend to be more associated with PVD than compartment syndrome)

Typical presentation: tightness in compartment + acute disproportionate pain (worse on stretching) after trauma:

  • Acute is following fracture, soft tissue/reperfusion/thermal injury
  • Chronic (pain on exercise) often in long-distance runners
  • Other early sign = paraesthesia
  • Late signs: pallor, pulseless, paralysis

RFs: Trauma, bleeding disorder (haemophilia), compartment support (tight cast/wrappings), burns, intense muscular activity (long distance runner)

Ix:

  • Compartment differential pressure measurement - within 20-30mmHg = fasciotomy needed
  • +/- serum CK, urine myoglobin (rhabdomyolysis)

Acute Mx: dressing release + morphine

  • 2nd line = complete fasciotomy (open all 4 compartments of lower leg)
  • 3rd line = amputation
  • If rhabdomyolysis —> hydration +/- Na bicarbonate (urine alkalisation) +/- haemodialysis (metabolic acidosis)

Chronic Mx: limit exercise + NSAIDs

  • 2nd line = fasciotomy
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2
Q

Extra-articular manifestations of RA –> what would you also examine after hands?

A

NO HIVE:

  • Nodules - rheumatoid nodules (25%)
  • Osteoporosis (worse by steroids & immobilisation)
  • Heart & haem - pericarditis, anaemia, Felty’s syndrome (RA + splenomegaly + neutropenia)
  • Interstitial - pul fibrosis (& pleural effusions, Caplan’s syndrome - nodules from RA + pneumoconiosis), interstitial nephritis (nephrotic syndrome)
  • Vasculitis (high titre RF)
    • Peripheral neuropathy presenting as mono-neuritis multiplex
      • Other neuro: carpal tunnel, cervical myelopathy
    • Splinter haemorrhages, cutaneous ulcers, distal gangrene
  • Eye pathologies - secondary sjogren’s syndrome (dry eyes, mouth & cough), episcleritis
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3
Q

RA - Def? Presentation? Ix? Mx?

A

Def: AI process causing synovial joint inflammation (synovitis) with destruction of peri-articular structures

Presentation: joint pain @rest, swelling & stiffness in morning

  • Exam:
    • Symmetrical swelling w/ DIP sparing
    • Muscle wasting, ulnar deviation, volar subluxation @MCPs
    • Swan-neck & Boutonnieres’ & Z-thumb deformities
    • NOTE: if nail changes/extensor rash = psoriatic arthritis
  • Extra-articular manifestations of RA = NO HIVE:
    • Nodules - rheumatoid nodules (25%)
    • Osteoporosis (worse by steroids & immobilisation)
    • Heart & Haem - pericarditis, anaemia, Felty’s syndrome (RA + splenomegaly + neutropenia)
    • Interstitial:
      • Pul fibrosis (& pleural effusions, Caplan’s syndrome - nodules from RA + pneumoconiosis)
      • Interstitial nephritis (nephrotic syndrome)
    • Vasculitis (high titre RF)
      • Peripheral neuropathy presenting as mono-neuritis multiplex
      • Other neuro: carpal tunnel, cervical myelopathy
      • Splinter haemorrhages, cutaneous ulcers, distal gangrene
    • Eye pathologies - secondary sjogren’s syndrome (dry eyes, mouth & cough), episcleritis

Ix: anti-RF/CCP, ESR/CRP, X-rays

Mx:

  • Create an end target e.g., remission
  • 1st - Monotherapy with conventional DMARD (methotrexate/sulfasalazine) + bridging pred until Sx resolved
  • Target met?
    • Yes = keep drug regime + lifestyle changes (stay active, healthy diet, weight loss if appropriate, alcohol/smoking)
    • No = titrate cDMARD/trial alternative cDMARD ± dual therapy
  • Target met?
    • Yes = keep drug regime + lifestyle changes
    • No = biological agents if DAS28 score >5.1 (severe burden of disease)
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4
Q

Osteoarthritis - presentation? Ix? Mx?

A

Pathogenesis - loss of cartilage + bone remodelling –> inflammation & osteophytes

Presentation: pain worse with activity, crepitus + reduced RoM

  • Hands - DIP & PIP swelling = Heberden’s (DIP) & Bouchard’s nodules (PIP)
    • Common site = base of the thumb (1st carpometacarpal joint)
  • Weight-bearing joints affected e.g. knees
  • NOTE: midline knee scar = total knee replacement –> fixed flexion deformity post-replacement

Ix: XR (2 views e.g. AP & lateral)

  • LOSS: Loss of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts

Mx:

  • Conservative – physio, exercise, weight loss
  • Medical:
    • Analgesia (paracetamol –> topical NSAID –> oral NSAID/opioid)
    • IA CS injection
  • Surgical – arthroplasty (e.g. TJR)
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5
Q

Psoriatic arthritis - Signs? Types? Criteria name? Mx?

A

Signs:

  • Extensor plaques with scales (scalp + behind ears)
  • Nails - pitting, hyperkeratosis, onycholysis
  • Other forms: guttate (drop-like), Koebner phenomenon

Types:

  • Mono/oligoarthritis
  • Spondylitis (back)
  • Asymmetrical polyarthritis (incl DIP-specific)
  • Arthritis mutilans
  • Rheumatoid-like

Criteria name: CASPAR criteria - established inflame arthritis/enthesitis + ≥3 of options

Mx:

  • Conservative:
    • Psoriasis - precipitant avoidance (alcohol, smoking, stress, B-blockers)
    • Exercise & physio for arthritis
  • Medical:
    • Psoriasis:
      • Topical Tx:
        • Topical steroids (hydrocortisone 2.5%/betamethasone 0.05%)
        • Calcipotriol
      • PUVA = Psoralen + UVA phototherapy
  • Arthritis = Methotrexate, anti-TNFs
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6
Q

Assessing osteoporosis risk

A
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7
Q

Osteoporosis Mx? Using bisphosphonates –> jaw pain & swelling?

A

0 to -2.5 DEXA:

  • Conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes
  • Repeat DEXA @2yrs
  • 1st line - Bisphosphonates PO (e.g. alendronic acid) –> if not tolerate can trial Denosumab/Raloxifene/Teriparatide
  • Vit D + Ca replacement (if inadequate sunlight/intake exposure)
  • Review Tx every 3-5yrs

NOTE:

  • If premature menopause –> discuss HRT
  • If on high-dose CS (≥7.5mg OD for ≥3 months) –> consider bisphosphonates for bone protection

Osteonecrosis of the jaw

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8
Q

Septic arthritis - presentation? Mx?

A

Presentation - hot swollen joint with reduced range of motion

Mx: needle aspiration before abx –> fluids for 3Cs & G (cells, culture, crystals, gram stain) –> empirical IV abx (based on aspiration)

  • S. aureus is most common
  • NOTE: if prosthetic joint - biofilm can be created - early (<3m post-surgery)/delayed (>3m) –> more complicated, coag neg staph more common
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9
Q

Ankle fracture rules? Classification? Ix? Mx?

A

Rules = Ottawa rules - for what ankle fractures qualify for an X-ray

  • Ankle XR:
    • Pain over malleolar zone
    • Tenderness along distal 6cm of the posterior edge of tibia/fibula
    • Inability to weight bear
  • Foot XR:
    • Pain over midfoot zone
    • Tenderness at base of 5th metatarsal/navicular bone
    • Inability to weight bear

Classification = Weber classification - location of the fibula fracture in relation to the Syndesmosis (Distal Tibiofibula Syndesmosis - ligament between tibia & fibula)

  • Normal
  • A - fracture distal to the syndesmosis
  • B - fracture @level of the syndesmosis
  • C - Fracture above the syndesmosis
  • If also affecting the medial malleolus = bimalleolar fracture

Ix: AP, lateral & oblique ankle X-ray

  • CT (distal tibia & hindfoot) - comminuted fracture
  • MRI - ankle ligaments & tendons

Mx: depends on Weber classification & level of displacement

  • No to all Ottawa rules = conservative Mx: RICE – rest, immobilisation, compression, elevation
  • Unimalleolar:
    • No evidence of ligamentous injury on X-ray –> discharge w/ cast + fracture clinic follow-up X-rays
    • Evidence = UNSTABLE
  • Bimalleolar/unstable –> closed reduction (if joint dislocated on X-ray) –> refer for surgical fixation
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10
Q

Ankle fracture X-ray

A
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12
Q

Gout - presentation? Ix? Mx?

A

Presentation: 1st MTP joint, monoarticular (can be poly)

Ix: Bloods (FBC, CRP, Urate), X-ray (errosive)

Mx:

  • Acute:
    • NSAIDs
    • Colchicine
    • Oral Pred (5 days), steroid joint injection
  • Chronic:
    • Dietary advice - low purine, weight loss
    • Xanthine oxidase inhibitor e.g. allopurinol/febuxostat
    • Consider - uricosuric agents e.g. sulphinpyrazone, probenicid, benzbromarone
    • (NOTE: Rasburicase - tumour lysis syndromes)
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13
Q

Ankylosing Spondylitis is a type of what? Ix? Mx?

A

Axial spondylitis

Ix:

  • Spinal exam: Schober’s test - gross restriction <3cm (should be 8-10cm)
  • X-ray:
    • Sacroiliitis
    • Sclerosis
    • Erosive damage
    • Widening joint space
    • (Fusion)
  • MRI scan whole spine & sacroiliac joints - detect pre-radiographic axial spondylitis
    • Sacroiliitis
    • Shiny corners (Romanus lesions)

Mx:

  • Analgesics + NSAIDs
  • TNF-alpha blocker (or IL-17 blocker)
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14
Q

Systemic sclerosis (scleroderma) - def? Subsets? Presentation? Ix? Raynaud’s Mx?

A

Def: multisystem disease - inflammation, vascular abn, fibrosis

Presentation: digital ulcers, tight skin around hands/mouth

Subsets:

  • Limited cutaneous SS (CREST) - skin changes limited to forearm/calf/distal/peri-oral area
  • Diffuse cutaneous SS - more extensive, upper arms, legs, trunk

Presentation:

  • Swelling of hands & feet, Reynaud’s phenomenon, skin thickening
  • Heartburn/reflux/dysphagia, bloating
  • Arthralgia/myalgia
  • Dyspnoea & dry crackles (pul fibrosis, pul HTN)
  • Scleroderma renal crisis (renal failure, marked HTN)

Ix:

  • Bedside: ECG, urine dip, pulmonary function tests (pul fibrosis)
  • Bloods:
    • FBC, U&E, LFTs, CRP/ESR,
    • Abs: ANA (also in SLE, AI hep), anti-centromere (limited cutaneous), SCL-70 aka topoisomerase (diffuse cutaneous)
  • Imaging: CXR, Echo, barium swallow

Mx:

  • Specialist MDT
  • Conservative: smoking cessation, emollients, avoid cold/gloves (Raynaud’s), physio, OT
  • Medical:
    • CCB (nifedipine) for Raynaud’s
    • Omeprazole, prokinetic (domperidone) for GI Sx
    • Analgesia (for joint pain)
    • ACEi (for HTN)
    • Steroids + IS (methotrexate) –> if diffuse disease/complications (pul fibrosis)
  • Scleroderma renal crisis - ACEi + renal dialysis/transplant
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15
Q

GCA - Presentation? Ix? Mx?

A

GCA is most common primary vasculitis

Presentation: headache, scalp pain/tenderness, aching & stiffness, jaw/limb claudication

  • Loss of vision - can have amaurosis fugax, blindness if vision not treated within hrs
  • Commonly associated with polymyalgia rheumatica (PMR)

Ix:

  • ESR & CRP
  • USS temporal artery –> bilateral temporal artery biopsies - up to 2wks after high-dose steroids

Mx: prednisolone, if visual Sx consider IV methylprednisolone

  • If persistent active/relapsing - IL-6 receptor blocker (Tocilizumab)
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16
Q

Neck of femur anatomy? Breakdown?

RFs? Presentation? Ix? (incl. fracture type & classification) Mx?

A

NoF anatomy - blood supply:

  • Deep femoral artery (the main branch of the femoral artery) - gives rise to:
    • Medial & lateral circumflex femoral arteries - gives rise to:
      • Retinacular arteries - progress superiorly up to the head of the femur
  • Artery of ligamentum teres - only a very small component of perfusion of the head/neck of the femur
  • NOTE: retrograde blood supply from distal to proximal

NOF anatomy - joint capsule (ligaments surrounding the head of the femur and acetabulum):

  • Intracapsular - fracture within the joint capsule (proximal to the trochanteric line) - high risk of blood supply compromise as retinacular vessels sheared –> Avascular Necrosis (AVN)
  • Extracapsular - fracture outside the joint capsule (distal to the trochanteric line) - less risk of blood supply compromise

RFs: elderly, freq falls, osteoporosis, high impact trauma, post-menopausal women

Presentation: externally rotated + shortened leg

  • Typically old, frail, osteoporosis/malacia

Ix:

  • Examine joints above & below, NV exam of lower limb
  • FBC, U&E, LFTs, CRP, G&S (if NoF - need surgery)
  • Hip XR –> CT/MRI (if normal X-ray but high suspicion)
    • NOTE: NoF fracture Xrays: Shenton line - if not smooth = likely fracture
    • NoF fracture types - based on location:
      • Sub-capital (slightly below the head)
      • Transcervical
      • Basicervical
      • Intertrochanteric
      • Subtrochanteric
    • Garden classification - level of displacement:
      • Stage 1 - incomplete (not all the way through the bone)
      • Stage 2 - complete (but fracture components intact)
      • Stage 3 - complete with some displacement
      • Stage 4 - complete with significant displacement

Mx:

  • Conservative - analgesia
  • Medical - bisphosphonates (bone protection) + Vit D + DEXA
  • Surgical:
    • Subtrochanteric - internal fixation = femoral nail
    • Intertrochanteric – internal fixation = dynamic hip screw (DHS)
    • Intracapsular:
      • Undisplaced (Garden I&II) – cannulated hip screw or DHS
      • Displaced (Garden III & IV) - higher risk of AVN:
        • <55yrs – reduction & fixation w/ screws
        • >65yrs – replace:
          • Fit = THR (HoF & acetabulum replaced)
            • Independent, mobile with ≤1 stick, no cognitive impairment
          • Not fit = hemiarthroplasty (just HoF replaced)
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17
Q

OA X-ray changes

A
18
Q

Wrist fracture - types? Mx?

A

Types:

  • Colles’ fracture - common in A&E, fall on an outstretched hand –> fracture of distal radius, displaced dorsaly (dorsum of the wrist)
  • Smith fracture - fall on flexed wrist, displaced in a palmar direction (palm of the wrist)
  • NOTE: displaced in the direction that is facing upwards (e.g. in Colles’ the dorsal aspect is facing the sky; in Smith’s the palmar aspect is facing the sky)

Mx:

  • Check neurovascular intact
  • Imaging (visualise fracture)
  • Reduction under haematoma block > Hold (e.g. cast) > Rehabilitate
  • NOTE: Smith’s fracture is often more complicated –> surgical intervention
19
Q

RA Hand X-ray findings?

A
  • Joint erosion
  • Periarticular osteopenia
  • Ulnar deviation
  • Z-thumb
  • Swan neck
20
Q

Polymyalgia Rheumatica (PMR) - def? presentation? Associated condition? Dx & Ix? Mx?

A

Def: inflammatory rheumatological condition

Presentation: muscle aches and joint stiffness (takes 2-3hrs to loosen up in the morning)

  • Profile: elderly woman (>70yrs)
  • Difficult to rise from seated/prone position
  • Shoulder/hip stiffness & bursitis
  • muscle tenderness & oligoarthritis

Associated with GCA (15-20% have GCA; 40-60% GCA have PMR)

  • GCA is most common primary vasculitis
  • Can have amaurosis fugax, blindness if vision not treated within hrs
  • Ix: bilateral temporal artery biopsies - up to 2wks after high-dose steroids

Dx: clinical + ESR, CRP, FBC (to rule out haem disorders)

Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates)

  • Other: methotrexate + folic acid
21
Q

Tenosynovitis of hand & wrist - def? RFs? Presentation of different types? Ix? Mx?

A

Tenosynovitis def:

  • Involves extrinsic tendons of hand & wrist & corresponding retinacular sheath
  • Characterised as tendon irritation manifesting as pain –> progress to catching and locking when tendon gliding fails.

RFs: insulin-dep DM, pregnancy/lactation, dom-hand involvement

Presentation: location over retinacular sheat, pain increases with motion,

  • Trigger finger:
    • Painful popping on finger flexion/extension (catching of flexor tendon)
    • Palpable nodule @level of metacarpal head in palm
  • De Quervain’s disease:
    • ​Pain, tenderness, swelling localised to radial wrist (1-2cm proximal to radial styloid)
    • Worse on thumb mov/ulnar deviation
    • Finkelstein test (thumb in hand + ulnar deviation –> pain)
  • Intersection syndrome:
    • ​Pain & swelling 4cm proximal to wrist joint ± redness/palpable crepitus
    • Much worse on resisted wrist extension
  • Extensor pollicis longus:
    • Thumb IP mov –> pain @Lister’s tubercle
  • Extensor carpi ulnaris:
    • Ulnar wrist pain
    • Worse with extension/ulnar deviation against resistance
  • Flexor carpi radialis:
    • Pain @palmar wrist crease over scaphoid tubercle + along tendon ± localised swelling/ganglion cyst
    • Worse with resisted wrist flexion, radial deviation

Ix: high-res USS

Mx:

  • NSAID ±splinting
  • CS injection (sheath/compartment): flexor tendon sheath (trigger finger), 1st dorsal compartment (De Quervain’s disease)
  • Surgery (surgical release of compartment)
22
Q

How do you approach an MSK X-ray?

Describing a fracture on XR approach?

A

MSK X-RAY APPROACH:

  • NOTE: likely knee or hip x-ray in the exam

General:

  • Name, DoB ±PC
  • XR - date & time, views (AP/lateral), area of body, rotation, penetration (RI_P_E)
  • NOTE: always do ≥2 views, compare to previous X-rays, look at imaging for joints above and below

ABCS approach: Alignment & joint space, Bone texture, Cortices, Soft tissues

  • Alignment & joint space:
    • Changes suggest –> fracture, subluxation (still touch) or dislocation
    • Displacement - describe the position of fragment distal to fracture site described
    • Joint space:
      • Narrowing due to cartilage loss/calcification (chondrocalcinosis)/new bone (osteophytes)
      • Subchondral sclerosis is increased bone density along joint lines (OA)
  • Bone texture - altered density (subchondral cyst - increased density, OA)/disruption (blurry - osteomyelitis) in trabeculae (inside of bone)/cortex (outer coating)
  • Cortices - trace around outside of each bone
    • Step = possible pathology:
      • Fracture
      • Bony destruction - inf or tumour (primary/secondary)
    • Periosteal reaction (new bone in response to injury/stimuli, appears as pale bone on the outside) - can be only sign of stress/healing fracture, mild osteomyelitis, tumour)
  • Soft tissues - swelling, foreign bodies (lipohaemarthrosis caused by fracture), effusions

DESCRIBE A FRACTURE:

Where - what bone? location (proximal, middle, distal OR epiphysis, metaphysis, diaphysis)? Does it involve articular surface (intra/extra-articular)?

Types:

1. Simple vs Compound:

  • Simple: closed fracture i.e. only bone involved
  • Compound: open fracture i.e. bone exposed to the external environment - (↑risk of infection → ↑fracture non-union) Open fractures are emergencies and require urgent management with:
    • IV antibiotics
    • Tetanus prophylaxis
    • Wound debridement

2. Subtype:

  • Complete (all the way through the bone)
    • Transverse: perpendicular to long axis of bone
    • Oblique: tangential to long axis of bone
    • Spiral: oblique and rotating around the shaft
    • Comminuted: > 2 fragments –> CT to further assess
    • Impacted: broken ends of bone are jammed together by the force of injury, fracture line is indistinct
    • Linear: parallel to axis of the bone
    • Avulsion: bone attached to tendon/ligament is pulled away from main bone
  • Incomplete (not whole cortex, most common in children):
    • Greenstick: bone bends and cracks, occurs < 10yrs
    • Salter-Harris: growth plate involvement

Displacement - describe the position of distal fragment to body (anterior/posterior)

  • Angulation: change in bone axis (varus/valgus, dorsal/palmar, radial/ulna)
  • Translation: movement of fractured bones away from each other (% of bone width)

OVERALL: 1) Type (simple/compound > subtype) 2) Relevant region, side and name of bone 3) Displacement (& angulation, translation)

  • Example: Simple oblique fracture of the proximal right tibia with posterior displacement
23
Q

Overview of MSK exams

A
24
Q

Giving a differential for MSK - structure? Ix? Mx?

A

DDx: degenerative, infective, inflammatory, traumatic, congenital

Ix: 2 views = AP & lateral views + imaging of joints above and below as well

Mx: conservative, medical, surgical

25
Q

Common findings on knee exam?

A

Meniscal injury - tenderness over joint line (+ McMurray’s)

Gout/pseudogout - swollen, erythematous, tender joint

OA - pain, crepitus, limited RoM

Ligament injury based on special tests/mov

26
Q

Finger deformities in RA - flexion & extension?

A

Swan neck deformity - PIP hyperextension, DIP flexion

Boutonniere’s deformity - PIP flexion, DIP hyperextension

Other signs of RA: Z-thumb, ulnar deviation

27
Q

Dupuytren’s contracture - def? causes? image?

A

Def: hypertrophy & contracture of palmar aponeurosis (fascia retinaculum)

Causes:

  • Idiopathic, age, trauma, familial (AD)
  • Alcoholic liver disease
  • Epilepsy & anti-epileptics (e.g. phenytoin)
28
Q

Joints in the hand? Bones in the wrist?

A

CMCs –> MCPs –> PIPs –> DIPs

Carpal bones: Some Lovers Try Positions That They Can’t Handle

  • Base of wrist (radial to ulnar): Scaphoid, Lunate, Triquetrum, Pisiform
  • CMCs (radial to ulnar): Trapezium (trapezi”thumb”), Trapezoid, Capitate, Hamate
29
Q

Special tests on spine?

A

Schober’s test: gross restriction <3cm = Ankylosing Spondylitis (fusion of sacro-iliac & lower spine)

  • Mark midline between dimples of venus & 10cm above –> ask to touch toes –> measure distance between 2-points
  • Should increase by 8-10

Sciatic stretch test: pain in thigh & buttocks = sciatica (L3-S3 nerve root irritation)

  • Patient supine, straight leg raise while ankle dorsiflexion

Femoral nerve test: pain in thigh & buttocks = L2-4 nerve root irritation

  • Patient prone, extend hip
30
Q

Landmarks on pelvic XR (hip)? How can I see if hip fracture?

A

Look at Shenton’s line (inferior pubic rami) = NoF fracture

31
Q

Fibromyalgia

A

Def: chronic pain syndrome diagnosed by the presence of widespread body pain ≥ 3 months

Presentation:

  • RFs: AI rheum condition (RA, SLE), female
  • Chronic widespread body pain
  • Diffuse tenderness on physical exam
  • Fatigue, memory problems, sleep & mood disturbance

Ix: clinical Dx

  • To exclude other causes: FBC, TFT, ESR/CRP, vit-D, Ab-testing (RF, anti-CCP, ANA)

Mx:

  • 1st - TCA e.g. amitryptiline
  • Non-pharm: education, exercise, CBT ± referral to psych