RHEUM Flashcards
What are the 3 screening questions for musculo-skeletal disease?
1 Are you free of any pain or stiffness in your joints, muscles or back?
2 Can you dress yourself without too much difficulty?
3 Can you manage walking up and down stairs?
If yes to all 3, serious inflammatory muscle/joint disease is unlikely.
What bloods should you do to investigate rheumatological disease?
FBC, ESR, urate, U&E, CRP. Blood culture for septic arthritis. Consider rheumatoid factor, anti-CCP, ANA, other autoantibodies , and HLA B27 —as guided by presentation. Consider causes of reactive arthritis , eg viral serology, urine chlamydia PCR, hepatitis and HIV serology if risk factors are present.
X-ray features of osteoarthritis
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
X-ray features of RA
Juxta articular ostopenia
Soft tissue swelling
Joint deformity
Loss of joint space
X-ray features of gout (1st MTPJ).
Peri-articular erosions
Normal joint space
Soft tissue swelling
Back pain: red flags
Aged <20yrs or >55yrs old
Acute onset in elderly people
Constant or progressive pain Nocturnal pain
Worse pain on being supine Fever, night sweats, weight loss History of malignancy Abdominal mass
Thoracic back pain Morning stiffness
Bilateral or alternating leg pain Neurological disturbance (incl sciatica) Sphincter disturbance
Current or recent infection
Immunosuppression, eg steroids/HIV
Leg claudication or exercise-related leg weakness/numbness (spinal stenosis)
Clinical tests for sacroiliitis?
direct pressure, lateral compression, sacroiliac stretch test (pain on adduction of the hip, with the hip and knee flexed).
Most likely cause of back pain in 15-30 yo px
Prolapsed disc, trauma, fractures, ankylosing spondylitis , spondylolisthesis (a forward shift of one vertebra over another, which is congenital or due to trauma), pregnancy.
Most likely cause of back pain in 30-50 yo
Degenerative spinal disease, prolapsed disc, malignancy (primary or secondary from lung, breast, prostate, thyroid or kidney ca).
Most likely cause of back pain >50yo
Degenerative, osteoporotic vertebral collapse, Paget’s , malignancy, myeloma, spinal stenosis.
Back pain Ix
FBC, ESR and CRP (myeloma, infection, tumour), U&E, ALP (Paget’s), serum/urine electrophoresis (myeloma), PSA.
X-rays can exclude bony abnormality but are generally not indicated.
MRI is the image of choice and can detect disc prolapse, cord compression, cancer, infection or inflammation (eg sacroiliitis).
OA Sx
tenderness, derangement and bony swelling (Heberden’s nodes at DIP, Bouchard’s nodes at PIP), reduced range of movement and mild synovitis
OA symptoms
Localized disease (usually knee or hip): pain on movement and crepitus, worse at end of day; background pain at rest; joint gelling—stiffness after rest up to ~30min; joint instability. Generalized disease (primary OA): with Heberden’s nodes (‘nodal OA’, seen mainly in post-menopausal women), commonly affected joints are the DIP joints, thumb carpo-metacarpal joints and the knees.
OA Mx
Conservative:
•Exercise to improve local muscle strength and general aerobic fitness (irrespective of age, severity or comorbidity).
•Weight loss if overweight
•Use a multi- disciplinary approach, including physiotherapists and occupational therapists.
•Try heat or cold packs at the site of pain
•Walking aids
•Stretching/manipulation
Medical:
•Regular paracetamol ± topical NSAIDS. If ineffective use codeine or short-term oral NSAID (+PPI)
•Topical capsaicin (derived from chillies)
•Intra-articular steroid injections temporarily relieve pain in severe symptoms.
•Intra-articular hyaluronic acid injections (visco supplementation) are as effective as NSAIDS or steroid injection, but are much more expensive.
•TENS
•Glucosamine and chondroitin products are not recommended
Surgical:
•Joint replacement (hips, or knees) is the best way to deal with severe OA that has a substantial impact on quality of life.
What is an emergency you MUST consider when presented with an acute joint?
Consider septic arthritis in any acutely inflamed joint, as it can destroy a joint in under 24h. Inflammation may be less overt if immunocompromised (eg from medication) or if there is underlying joint disease. The knee is affected in >50% cases
Septic arthritis RF
- Pre-existing joint disease (especially rheumatoid arthritis)
- Diabetes mellitus
- Immunosuppression
- Chronic renal failure
- Recent joint surgery
- Prosthetic joints (where infection is particularly difficult to treat)
- IV drug abuse
- Age >80yrs
Septic arthritis Ix
Urgent joint aspiration for synovial fluid microscopy and culture is the key investigation as plain radiographs and CRP may be normal. The main differential diagnoses are the crystal arthropathies. Blood cultures may be helpful for guiding antibiotic choice later.
Ask yourself “How did the organism get there?” Is there immunosuppression, or another focus of infection, eg from indwelling IV lines, infected skin, or pneumonia (present in up to 50% of those with pneumococcal arthritis)
Common causative organisms for septic arthritis
- Staph. Aureus
- Streptococci
- Neisseria gonococcus
- Gram –ve bacilli.
Management of septic arthritis
- If in doubt start empirical IV antibiotics (after aspiration) until sensitivities are known.
- Follow local guidelines for antibiotic choice.
- If HIV +ve, look for atypical mycobacteria and fungi.
- Antibiotics are required for a prolonged period but there is no consensus on which route or for how long they should be continued (eg ~2 weeks IV, then 2–4 weeks PO)—ask a microbiologist.
- Ask for orthopaedic advice for consideration of arthrocentesis, lavage and debridement, especially if there is a prosthetic joint involved.
- This may be done arthroscopically (eg for knee) or open under GA (eg for hip; this allows for biopsy— helpful in TB).
- Splint for ≤48h, give adequate analgesia and consider physiotherapy.
What antibiotics are given for septic arthritis?
Consider flucloxacillin 1g/6h IV (clindamycin if penicillin allergic)
•Vancomycin 1g/12h IV if MRSA (or history of MRSA); or
•Cefotaxime 1g/8h IV if gonococcal or Gram –ve organisms suspected
NSAIDs SE
GI bleeding (!gastrointestinal damage may occur without dyspeptic symptoms) and renal impairment
When are NSAIDs contraindicated?
severe cardiac failure
When on NSAIDs, what factors increase side effects?
- prolonged use
- ^age
- Polypharmacy
- history of peptic ulcers and renal impairment (review before and after starting therapy)
Which NSAID has the lowest GI risk?
Ibuprofen
