Week 3 - MSK and Minor illness Flashcards
What is ‘synovitis’ and give 3 examples of conditions where it occurs
Synovitis is inflammation of the synovial membrane of a joint
Indicates an inflammatory process
Conditions with synovitis:
1. RA
2. Gout
3. OA (degenerative process has caused some inflammation)
What is ‘joint stiffness’ and what is its significance in rheumatoid arthritis
Stiffness is slowness or difficulty moving one or more joints
Rheumatoid arthritis has joint stiffness that is generalised and last for > 30 minutes in the morning
List some of the risks to using the WHO pain ladder in MSK conditions
- Risks of side-effects of prolonged regular use of analgesics
- Risk of addiction to opiates
- Risk of avoiding/neglecting non-pharmacological options e.g. physiotherapy
List some mechanical symptoms of the knee
Joint clicking
Joint locking
Joint giving way
Joint crunching (OA)
Outline bursitis and joint effusion in the knee
Outline how you can differentiate bursitis from joint effusion
Bursitis is inflammation and swelling of the bursa of the knee
Joint effusion is excess fluid in the joint capsule itself
Differentiate bursitis from joint effusion due to the bursitis being an isolated and localised swelling the region of a known bursa (e.g. popliteal bursa) vs generalised swelling in joint effusion (would have a positive patella tap)
List pathologies of hip pain that would tend to produce pain in the anterior, lateral and posterior hip area?
Anterior (to groin) hip pain = ‘true’ hip pain e.g. from osteoarthritis
Lateral hip pain = trochanteric bursitis
Posterior pain = lumbosacral spine or gluteal muscles
What are the clinical features of plantar fasciitis and metatarsalgia?
Plantar fasciitis:
- Tenderness on over insertion of the plantar fascia into the calcaneum
- Tends to occur in people who spend a lot of the day on their feet
- Pain is worst first few steps of the day, then again at night
Metatarsalgia:
- General term for pain over metatarsal bones in the foot
- Can have many causes! e.g. Morton’s neuroma
In metatarsalgia, what would make you suspect a Morton’s neuroma?
Pain and tenderness over the interdigital space where the neuroma is located
What are the clinical features of gout?
Which joint(s) are most often affected?
Clinical features:
- Sudden onset of severe pain
- Erythema, swelling, warmth and tenderness of affected joint
- Reduced ROM
Joints affected:
- Generally affects one joint, however can have multiple joint involvement
- Most commonly affects the big toe, but can also affect feet, ankles, knees and elbows
What are the management options for an acute episode of gout? What preventative treatment may be given?
Acute episode management:
- Analgesia
- Colchicine / high dose NSAIDs / short course of oral steroid
- May want to do a joint aspiration if suspecting septic arthritis
Preventative management:
- Allopurinol or other urate-lowering therapy (xanthine oxidase inhibitor)
List some common causes of primary back pain
- Musculoligamentous injury (lumbosacral strain)
- Spondylosis (degenerative arthritis of the spine)
- Rheumatic e.g. ankylosing spondylitis
- Intervertebral disc herniation (slipped disc)
- Anatomical abnormalities e.g. scoliosis or spondylolisthesis
- Spinal stenosis
- Compression fracture of vertebral body (traumatic compression / osteoporosis compression fracture / metastatic cancer)
Outline musculoligamentous back injuries (lumbosacral strain)
- What causes it
- Time period for development
- Time period for recovery
Musculoligamentous injury (lumbosacral strain)
- Occurs on strenuous activity or twisting activities e.g. lifting heavy boxes or tennis
- However can sometimes be from more subtle activities e.g. falling asleep funny
- Often develops acutely
- Resolves over days / weeks
List some systemic diseases that can cause back pain
Infection
- Epidural abscess
- Osteomyelitis (vertebrae)
- Discitis (intervertebral disc)
Metastases (from: lung, prostate, breast, renal, thyroid)
Inflammatory back pain (HLA-B27 diseases):
- Ankylosing spondylitis (axial)
- Psoriatic / reactive / enteropathic arthritis (peripheral)
List some non-MSK causes of referred / radiating pain that can present with back pain (think organs that can cause referred pain)
Aorta:
- Dissection
- Aneurysm
Pancreas:
- Pancreatitis / pancreatic pseudocyst
Kidney:
- Pyelonephritis
- Perinephric abscess
- Nephrolithiasis
Retroperitoneal haemorrhage
List some general red flags for back pain (TUNA FISH)
TUNA FISH mnemonic
Trauma
Unexplained weight loss
Neurological symptoms
Age > 50
Fever
IV drug use
Steroid use
Hx of cancer
List some red flags for back pain for:
- Cancer
- Infection
- Cauda equina syndrome
Cancer:
- Age > 50
- History of cancer
- Unexplained weight loss
- Failure to improve with conservative therapy
Infection e.g. epidural abscess / osteomyelitis / discitis
- Fever
- Immunosuppression
- Focal midline tenderness
- Known or suspected bacteraemia
- Indwelling venous catheter e.g. Pick line
- IV drug use
Cauda equina syndrome:
- Urinary incontinence
- Faecal incontinence
- Saddle anaesthesia
- Erectile dysfunction
- Bilateral sciatica
Lumbosacral strain (back pain) - state the following:
- Pathophysiology
- Description of pain
- Age of onset
- Findings on examination
- Relevant imaging
- How long until recovery
Pathophysiology:
- Muscular or ligamentous injury
- Secondary to physical activity (generally strenuous or unusual activity)
Description of pain:
- Fairly acute onset
- Worse on movement
- Relieved on rest
Age of onset:
- Any age
Findings on examination:
- If tenderness is present, not usually over vertebral bodies themselves (paravertebral tenderness)
- No neurological findings
Relevant imaging:
- No relevant imaging / tests
How long until recovery:
- 90% will recover in 1-2 weeks
- 10% may take up to 3 months to recover
Lumbar disc herniation (back pain) - state the following:
- Pathophysiology
- Risk factors
- Description of pain
- Age of onset
- Findings on examination
- Relevant imaging
Pathophysiology:
- Combination of increased inflammatory cytokines and mechanical compression
- Leads to herniation of the intervertebral disc (most commonly paracentral herniation) leading to compression of a specific nerve root and focal neurological symptoms
Risk factors:
- Obesity
- Male
- Occupation / poor posture
- Smoking
Description of pain:
- Acute onset
- Focal neurological symptoms in a dermatome / myotome
- Pain radiates to one leg (unilateral sciatica)
- Worse with sitting
- Improves on back extension
Age of onset:
- Any age
- Mostly 30-55
Findings on examination:
- Reduced sensation in dermatome
- Weakness in myotome
- Hyporeflexia in patella tendon or at ankle
- Abnormal straight leg raise
Relevant imaging:
- MRI can confirm diagnosis (not always needed)
Spinal stenosis (back pain) - state the following:
- Pathophysiology
- Description of pain
- Age of onset
- Findings on examination
- Relevant imaging
Pathophysiology:
- Narrowing of central canal or foramen
- Secondary to either spondylosis or spondylolisthesis
Description of pain:
- Neurological symptoms across multiple dermatomes / myotomes
- Pain in legs worse than back pain
- Better on flexion spine / sitting
- Worse on prolonged standing or walking
Age of onset:
- > 55 (mostly > 70)
Findings on examination:
- Symptoms recreated on bending backwards (spine extension)
- Positive neurological symptoms across multiple dermatomes / myotomes
Relevant imaging:
- MRI to confirm diagnosis, or to rule out sinister pathologies
Inflammatory back pain (back pain) - state the following:
- Pathophysiology
- Description of pain
- Age of onset
- Findings on examination
- Relevant imaging
Pathophysiology:
Inflammatory conditions associated with HLA-B27:
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
Description of pain:
- Pain worse in morning (early morning pain and stiffness > 30 mins), better as day goes on
- Pain improves with movement
- May have other symptoms e.g. arthritis in other joints, psoriasis, uveitis, IBD
Age of onset:
- < 40
Findings on examination:
- May have reduced ROM of back
- May have +ve Schober’s test
- May have articular findings
- May have extra-articular findings e.g. uveitis
Relevant imaging:
- Plain x-ray of sacroiliac joints
- MRI if plain x-ray unremarkable
Vertebral compression fracture (back pain) - state the following:
- Pathophysiology
- Risk factors
- Description of pain
- Age of onset
- Findings on examination
- Relevant imaging
Pathophysiology:
- Fracture of vertebral body(s), significant cases may have bursting of vertebral body
- Mostly secondary to osteoporosis (pathological fragility fracture)
Risk factors:
- Female
- Post-menopausal
- Known osteoporosis
- Trauma
- Bone metastases
Description of pain:
Can be quite variable depending on location
- Acute onset
- Pain is non-radiating
- Pain can be aching or stabbing in quality
- Pain worse on movement
Age of onset:
- > 70
Findings on examination:
- Midline point tenderness at affected specific vertebral body
- Kyphosis may suggest previous compression fractures
Relevant imaging:
- Plain x-ray of suspected affected vertebral body / surrounding joints
Bursitis - state the following:
- Pathophysiology
- Presentation
- Findings on examination
- Any investigations
- Management
Pathophysiology:
- Acute or chronic inflammation of a bursa
- Thickening and proliferation of the synovial lining
- Generally caused by repetitive stress, infection, autoimmune disease, or trauma (has history of risk factors)
Presentation:
- Pain at site of bursa
- Visible localised swelling
Findings on examination:
- Fluctuant well localised swelling
- Tenderness to palpation at site of bursa
- Decreased active ROM
Suspect septic bursitis if warmth, erythema and swelling of affected bursa
Investigations:
- Mostly a clinical diagnosis
Consider the following to rule out other conditions if suspected
- Joint aspiration
- X-ray of affected region
- MRI
Management:
- Analgesia
- Modified physical activity
- Rest
- Corticosteroid injections are reserved for those cases that do not respond to conservative management
- Bursal excision is a last resort.
Tendonitis - state the following:
- Pathophysiology
- Presentation
- Findings on examination
- Any investigations
- Management
Pathophysiology:
- Inflammation of a specific tendon
- Can be secondary to repetitive use and microtrauma, or secondary to injury
Presentation:
- Pain over a tendon
- Pain worse on movement
- Reduced ROM
- As it progresses, may have swelling with warmth or erythema
Findings on examination:
- Tenderness over affected tendon
- Mild swelling or erythema
Investigations:
- Mostly a clinical diagnosis
If suspect tendon rupture or fracture - refer to secondary care for x-ray / ultrasound / MRI
Management:
Conservative
- Analgesia (NSAIDs or Paracetamol)
- Ice
- Support e.g. wrist brace and modified activity of affected tendon
If severe
- Steroid injections for short-term pain relief (this cannot
- Shockwave therapy for assistance healing
- Surgery to repair ruptured tendon
Explain how you would differentiate between osteoarthritis, inflammatory arthritis (including rheumatoid arthritis) and crystal deposition disorders (e.g. gout)
OA:
- Worse at the end of the day
- Better with rest
- Worse with movement
- Associated crepitus
- Presence of risk factors for OA
RA / inflammatory:
- Worse at start of day (early morning pain and stiffness lasting > 30 mins)
- Better with movement
- Worse with rest
- Presence of risk factors for inflammatory disorders
Crystal deposition:
- Generally sudden and severe onset
- Usually monoarthritis (more can be affected) of common sites e.g. big toe, ankle, knee, elbow
- Presence of risk factors for gout
List some points of advice for patients with self-limiting illnesses
- Why prescribing antimicrobials may not be appropriate, including benefits and harms
- Alternative options to prescribing antimicrobials
- How long they should expect the symptoms to last
- Safety netting: what they should do if their condition gets worse
- If applicable, how to minimise spreading the infection to others e.g. good hand hygiene
List some advice for the common cold (self-limiting condition)
- Symptoms typically peak at 1–3 days and last 7–10 days, however they occasionally persist for up to 3 weeks
- If symptoms don’t improve after 3 weeks, contact the surgery for a follow up
Safety netting advice:
- Symptoms that worsen or fail to improve
- Fever greater than 38.5 C, lasting more than three days
- Fever returning after a fever-free period
- Shortness of breath or wheezing (difficulty breathing)
Upper respiratory tract infections - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Upper respiratory tract infections (viral and bacterial) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Direct invasion of the upper airway mucosa by by a variety of bacteria or viruses
- Because a variety of patient diseases including acute bronchitis, the common cold, influenza and respiratory distress syndromes
- Irritation and swelling of the upper airways with associated cough (with no proof of pneumonia or underlying condition)
Presentation:
- Cough and sneezing
- Sore throat
- Runny nose / congestion
- Headache
- Low-grade fever
- Facial pressure
- Malaise
- Myalgia
Investigations:
- Mainly a clinical diagnosis which is self-limiting
- May require a chest x-ray if unsure
Management:
Mainly symptom relief (self-limiting)
- Rest
- Fluid intake
- Analgesia (Paracetamol)
List some differentials for the common cold
- Allergic rhinitis (hay fever)
- Sinusitis
- Tracheobronchitis
- Pneumonia
- Influenza
- Atypical Pneumonia
- Whooping cough
- Epiglottitis
- Tonsillitis / Streptococcal Pharyngitis
- Infectious Mononucleosis (EBV)
UTI - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigations
- Management
Pathophysiology:
- Infection of the urinary tract with bacteria (urethra, bladder or kidneys)
Risk factors:
- Female
- > 65 years / post-menopausal
- Sexual intercourse
- Spermicide use
- Indwelling / long term catheter
- History of UTIs
- Poor bladder emptying
Presentation:
Cystitis
- Suprapubic pain
- Dysuria
- Increased urinary frequency and nocturia
- Cloudy urine
- Low-grade fever
Pyelonephritis
- Flank pain
- Haematuria
- High-grade fever
- Nausea & vomiting
Investigations:
- Urine dipstick
- Urine MC&S
May need further investigations if unresolving
Management:
Antibiotics - Nitrofurantoin and Trimethoprim (depending on local sensitivities)
- Can give back-up abx (3 days) to women with mild uncomplicated symptoms
- Men and pregnant women (7-10 days)
Abscesses - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Painful, walled-off collection of pus
- Generally occurs secondary to a bacterial infection
- Can occur in 2 main ways: skin abscesses and internal abscesses
Presentation:
- Painful swelling
- Fever
- Malaise
Investigations:
- Mainly a clinical diagnosis based on presenting symptoms and examination
Management:
- If small, may resolve spontaneously
- Larger abscesses may need antibiotics and drainage of pus
Candidiasis (thrush) - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Management
Pathophysiology:
- Colonisation by candida albicans yeast
- Caused by an overgrowth of the yeast, normally balanced out by the acidity of lactobacillus bacteria in the vagina
Risk factors:
- Extremes of age
- Immunocompromised / HIV
- Pregnancy
- Diabetes
- Broad-spectrum antibiotics
- Stress
- Dentures (oral)
- Inhaled corticosteroids (oral)
Presentation:
- Itching
- Burning
- White “cottage cheese” discharge
Management:
- Antifungals e.g. Clotrimazole, Nystatin, Fluconazole
GORD - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigations
- Management
Pathophysiology:
- Reflux of the gastric contents into the oesophagus
- Can occur with or without oesophageal erosions
Risk factors:
- Family history of heartburn or GORD
- Obesity
- Hiatus hernia
- Older age
- Smoking
- NSAIDs
- Alcohol
Presentation:
- Heart burn
- Acid reflux
- Dysphagia
- Bloating / early satiety
- Halitosis
Investigations:
- PPI trial for 1-2 months (observe if symptoms are better on PPIs)
- If unresolving, consider further tests e.g. OGD, oesophageal manometry, or barium swallow
Management:
Main goals: control symptoms and prevent complications
Conservative
- Lifestyle modifications e.g. weight loss, smaller meals, avoid triggering food/drink, smoking cessation
Medical
- Offer OTC Gaviscon
- PPI (Omeprazole or Lansoprazole) minimal needed
List some differentials for change in bowel habits (constipation)
- Lifestyle/benign: low fibre diet / lack of mobility / poor toileting
- Haemorrhoids
- Medications e.g. opioids
- Depression
- Abdominal hernia
- Hypothyroidism
- Parkinson’s disease / MS
- Electrolyte imbalances: hypocalcaemia / hypomagnesemia
- Large bowel obstruction
- Adhesions
- Bowel or rectal cancer
List some differentials for change in bowel habits (diarrhoea)
- IBD (Crohn’s or UC)
- IBS
- Coeliac disease
- Lactose intolerance
- Clostridium difficile
- Anxiety
- Gastroenteritis
- Hyperthyroidism
- Medications
- Overflow diarrhoea / bowel or rectal cancer
