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
List some differentials for change in bowel habits (mixed constipation and diarrhoea)
- IBS
- Bowel cancer
- Rectal cancer
List some differentials for anal itching
- Lifestyle e.g. poor hygiene, skin changes and irritation
- Haemorrhoids
- Anal fissure
- Thrush (spreading posteriorly)
List some differentials for anal bleeding (fresh red and malaena)
Fresh red:
- Anal fissures
- Haemorrhoids
- IBD (Crohn’s or UC)
- Malignancy
- Diverticular disease
Malaena:
- Upper GI bleed
- Iron tablets (malaena looking)
- Malignancy
List some differentials for anal pain
- Anal fissures
- Haemorrhoids (thrombosed)
- Perianal abscess
- Perianal fissure
- Malignancy
- Cryptitis, ischemia
- Rectocele
- Proctalgia fugax
List the 3 main types of primary headache
Cluster
Tension
Migraine
List the 4 main types of secondary headache
Medication-overuse
Raised ICP e.g. tumour or intracranial haemorrhage
Trigeminal neuralgia
Giant cell arteritis
Tension type headache - state the following:
- Presentation
- Pattern of onset
- Quality of pain
- Severity of pain
- Duration/pattern of headache
- Triggers
- Respond to simple analgesics?
- Associated symptoms
- Clinical findings on examination
- Management
Presentation:
Pattern of onset: generalised, especially frontal and occipital
Quality of pain: tight band, radiates to neck
Severity of pain: mild-moderate
Duration/pattern of headache: recurrent (30min-60min)
Triggers: lack of sleep, stress, poor posture
Respond to simple analgesics? yes
Associated symptoms: none, may have nausea
Clinical findings on examination: normal
Management:
- Generally reassure
- Pain relief but advise on the risk of medication overuse headache (if use > 15 days of month)
- Consider use of Amitriptyline if chronic
Cluster headache - state the following:
- Presentation
- Pattern of onset
- Quality of pain
- Severity of pain
- Duration/pattern of headache
- Triggers
- Respond to simple analgesics?
- Associated symptoms
- Clinical findings on examination
- Management
Presentation:
Pattern of onset: unilateral, around eye
Quality of pain: sharp, stabbing, penetrating
Severity of pain: severe, often at night
Duration/pattern of headache: 15min-3hr clusters, with periods of remission
Triggers: alcohol, smoking, volatile smells, warm temperature, lack of sleep
Respond to simple analgesics? often no, oxygen and triptans
Associated symptoms: ipsilateral autonomic symptoms e.g. red eye, blocked runny nose
Clinical findings on examination: autonomic symptoms during attack
Management:
- Triptans e.g. Sumitriptan and oxygen (acute attacks)
- Verapamil or steroids (preventative)
- Avoid triggers
- Emotional support may be needed
Migraine headache - state the following:
Presentation
- Pattern of onset
- Quality of pain
- Severity of pain
- Duration/pattern of headache
- Triggers
- Respond to simple analgesics?
- Associated symptoms
- Clinical findings on examination
Management
Presentation
- Pattern of onset: unilateral (temporal or frontal)
- Quality of pain: throbbing, pulsating
- Severity of pain: moderate-severe
- Duration/pattern of headache: prolonged headache (4-72hrs)
- Triggers: menstrual cycle, lack of sleep, certain foods
- Respond to simple analgesics? can do, may need additional interventions
- Associated symptoms: aura, photophobia, phonophobia
- Clinical findings on examination: normal
Management:
- In dark room
- Avoid triggers if possible
- Paracetamol or NSAIDs (best taken at start of attack)
- May need Triptan drugs e.g. Sumatriptan
- Prophylaxis with Propranolol or Topiramate if having significant effect on QOL or not responding to treatment
How often does someone have to take regular analgesics to suspect medication-overuse headaches
How does someone with a medication-overuse headache present?
Taking analgesics > 10 days per month
- History of taking analgesics > 10 days per month
- Variable character, dull headaches (tension-like or migraine-like)
- Constant headaches > 15 days per month
List some causes of raised ICP
Causes of raised ICP:
- Brain tumour
- Intracranial haemorrhage
- Aneurysm
- Hydrocephalus
- Meningitis or encephalitis
- Venous sinus thrombosis
Headaches secondary to raised ICP - state the following:
Presentation:
- Pattern of onset
- Quality of pain
- Severity of pain
- Duration/pattern of headache
- Triggers
- Respond to simple analgesics?
- Associated symptoms
Management
Presentation:
- Pattern of onset: gradual, worsening progression
- Quality of pain: dull and variable
- Severity of pain: mild
- Duration/pattern of headache: progressive, but worse in mornings
- Triggers: leaning forward, straining or valsalva maneuver
- Respond to simple analgesics? yes in early stages
- Associated symptoms: red flag symptoms, N&V, focal neurological symptoms, visual changes
Management:
- Further investigations to cause
- Treat the underlying cause
Headaches secondary to trigeminal neuralgia - state the following:
Presentation:
- Pattern of onset
- Quality of pain
- Severity of pain
- Duration/pattern of headache
- Triggers
- Respond to simple analgesics?
- Associated symptoms
Management
Presentation:
- Pattern of onset: random
- Quality of pain: sharp, stabbing, electric shock
- Severity of pain: severe
- Duration/pattern of headache: brief episodes (seconds-mins)
- Triggers: light touch, eating, cold wind, brushing hair
- Respond to simple analgesics? no, difficult to treat
- Associated symptoms: tingling, numbness, pain in cranial nerve 5 distribution
Management:
- Can give Carbamazepine
List some differential diagnoses for a patient that presents with ‘blackouts’
Cardiovascular:
- AF
- Arrythmias
- Aortic stenosis
- Vasovagal
- Orthostatic hypotension
- Stroke / TIA
Neurological:
- Parkinson’s
- Epilepsy
Infection:
- UTI
- Meningitis
Metabolic:
- Hypoglycaemic event
Outline the difference between a strain and a sprain
A strain: stretch or tear of muscle fibres or tendon
A sprain: stretch or tear of a ligament
Outline the Ottawa rules for referring an ankle injury for an x-ray
- Tenderness over either malleolus
PLUS either:
- Inability to bear weight
- Bone tenderness along the proximal 6 cm to lateral malleolus or medial malleolus
Outline the Ottawa rules for referring a foot injury for an x-ray
- Pain in the midfoot
PLUS either
- Inability to bear weight
- Tenderness at the base of the 5th metatarsal
- Tenderness of the navicular
Outline the Ottawa rules for referring a knee injury for an x-ray
Any of the following:
- Inability to bear weight
- Inability to flex the knee to 90 degrees
- > 55 years
- Tenderness at the head of the fibula
- Tenderness of the patella
Outline the Ottawa rules for referring a wrist injury injury for an x-ray
- Pain / tenderness over the scaphoid bone
Acne vulgaris (skin conditions) - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Common inflammatory disease that peaks in adolescence
- Presence of non-inflammatory comedones and inflammatory papules, pustules, nodules, and cysts
Presentation:
- Comedones, papules, pustules, nodules and scarring
- Skin tenderness
Management:
Depends on type of acne
Comedonal: mainly topical retinoid
Mild inflammatory: topical retinoid plus topical antibiotic
Molluscum contagiosum - state the following:
- Pathophysiology
- Presentation
- Contagious?
- Management
Pathophysiology:
- Common viral infection of the skin mainly affecting children, caused by Poxvirus
- Normally resolves within a few months, but can > 18 months
Presentation:
- Several - many firm, skin-coloured or pink-red, dome-shaped spots with a depressed centre
Contagious?
- Close direct contact, touching contaminated objects and sexual contact
- Children do NOT need to be kept off school but minimise contact
Management:
- Majority of cases are self-resolving and no treatment is required
- Further steps if unresolving
Psoriasis - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Chronic inflammatory skin disease
- Hyperproliferative disorder of basal cells, leading to erythematous, circumscribed scaly papules and plaques
Presentation:
- Red, inflamed, silvery-white scaly and circumscribed papules and plaques
- Often affects elbows, knees, extensor limbs, and scalp
- May have features of psoriatic arthritis e.g. joint pain
Management:
- Combination: topical steroids / topical vitamin D analogue
- Topical calcineurin inhibitors
Scabies - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Scabies skin infestation caused by mites
- Quite contagious and spread by direct contact
Presentation:
- Multiple firm bumps, usually very itchy which is often worse at night
- Rash over affected area
Management:
- Topical insecticide treatments e.g. Permethrin
- Requires two treatments, one week apart with everyone affected being treated at the same time
Erythema multiforme - state the following:
- Pathophysiology
- 2 categories (seriousness)
- Presentation
- Investigations
- Management
Pathophysiology:
- Hypersensitivity reaction
- Generally associated infections e.g. herpes simplex virus and Mycoplasma pneumoniae (also medications and vaccinations)
2 categories (seriousness)
- Erythema multiforme major
- Erythema multiforme minor
Presentation:
- Target lesions that resemble a bull’s eye
- Usually erupt over 24-48 hours and last for 1-2 weeks
- Usually affects the oral mucosa only (if minor) but can affect multiple areas (if major)
- May have crusting of the lips
Investigations - aim to find underlying cause:
- Herpes simplex virus serology
- Chest x-ray if suspect mycoplasma pneumonia
Management:
- Analgesia
- Adequate hydration
- Topical emollients
- Oral/topical corticosteroids (oral/IV if major)
- Treat underlying cause
Chicken pox (varicella zoster) - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Caused by varicella zoster virus
- Usually presents in childhood and is self-limiting
- Tends to be more severe in adults with a higher risk of developing complications
- Can be reactivated as Shingles
Presentation:
- Generalised pruritic, vesicular rash
- Fever
- Malaise
- Headache
- Sore throat
Management:
- If low-risk, supportive care
- Patients in high-risk categories e.g. pregnant women, immunosuppressed patients, and neonates, should receive treatment with antiviral therapy (oral or IV)
- Individuals should stay isolated until last vesicle has burst (no longer contagious) around 5-6 days after rash begins
Hand-foot-and-mouth disease - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Viral infection that is most commonly caused by a coxsackie virus
- Highly infectious
- Most common in young children (particularly < 10)
Presentation:
- Oral vesicles and ulcers
- Rash and/or vesicles on the hands and feet
- Low-grade fever
Management:
- Infection typically resolves spontaneously within 10-14 days
- Treatment is mainly supportive e.g. analgesia and anti-pyrexic medications
Impetigo - state the following:
- Pathophysiology
- Presentation
- Management (non-bullous and bullous)
Pathophysiology:
- Common bacterial infection of the skin that typically occurs in children: usually Staphylococcus aureusand/orStreptococcus pyogenes
- Bullous and non-bullous forms
Presentation:
- Vesicles (non-bullous impetigo) or bullae (bullous impetigo)
- Yellow crusting
Management:
- Reassure
- Explain good hygiene measures (see next slide)
- Stay away from school / work until lesions are healed, dry and crusted over or 48 hours after initiation of antibiotics (food handlers required by law to inform employers immediately)
Non-bullous
- Localised: Topical Fusidic acid 2% or topical hydrogen peroxide
- Widespread: Topical or oral antibiotic e.g. Flucloxacillin
Bullous
- Oral / IV Flucloxacillin
List some good hygiene advice for individuals with impetigo, including isolation advice for infected individuals
Good hygiene advice:
- Wash affected areas with soap and water
- Wash hands regularly, in particular after touching a patch of impetigo.
- Avoids scratching affected areas
- Avoids sharing towels, face cloths, and other personal care products and thoroughly cleans potentially contaminated toys and play equipment
Isolation advice:
- Stay away from school / work until lesions are healed, dry and crusted over or 48 hours after initiation of antibiotics
- Food handlers required by law to inform employers immediately
Measles - state the following:
- Pathophysiology
- Presentation
- Investigation of choice
- Management
Pathophysiology:
- Caused by measles virus
- Levels are low due to success of MMR vaccine
Presentation:
- Maculopapular rash
- Cough
- Coryza (cold-like symptoms)
- Conjunctivitis
- Pathognomonic Koplik’s spots
Investigation of choice:
- Measles-specific IgM and IgG serology (ELISA)
Management:
- No specific treatment of measles except for supportive care
- Immediately inform Public health england
- Advise to avoid contact with people until mostly recovered (minimum 4 days after rash develops)
Outline some differences in the presentation of chicken pox vs measles
Chicken pox:
- Vesicular rash (raised and fluid filled)
- Usually starts on face, chest and back
- Separate vesicles
Measles:
- Mostly flat red rash
- Usually starts at the head and works down
- Presence of pathognomonic Koplik spots
- More likely to have conjunctivitis
- Rash can merge together as it progresses
Ringworm - state the following:
- Pathophysiology
- Types (areas) of ringworm
- Presentation
- Management
Pathophysiology:
- Superficial fungal infection of hair, skin, and nails
Types (areas) of ringworm:
- Tinea corporis (body)
- Tinea capitis (scalp)
- Tinea barbae (beard)
- Tinea manuum (hands)
- Onychomycosis (nails)
Presentation:
- Erythema
- Scaling skin lesions with central clearing
Management:
- Limited tinea corporis (body) infection can usually be managed with topical antifungals e.g. topical Clotrimazole
- Other types may need oral antifungals
- May need to confirm fungal nail infection with potassium hydroxide microscopy
Scarlet fever - state the following:
- Pathophysiology
- Presentation
- Management
Scarlet fever:
- Exotoxin-mediated infection commonly resulting from group A streptococcus (GAS) infection of the throat or, less commonly, the skin
- Mainly affects children aged 1-10 years
Presentation:
Key triad of
- Sore throat
- Fever
- Scarlatiniform abdominal rash (like sandpaper)
May also have a strawberry tongue or cervical lymphadenopathy and absence of a cough
Mainly a clinical diagnosis
Management:
- Always prescribe antibiotics e.g. Phenoxymethylpenicillin (Penicillin)
Why should antibiotics always be prescribed in scarlett fever?
Reduces the risk of complications such as rheumatic fever and invasive group A streptococcus (GAS) infection
Give 2 other names for slapped cheek syndrome
Fifth disease or Parvovirus B19
Slapped cheek syndrome - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Viral infection caused by Parvovirus B19
- Most common in children
- Once you’ve had the infection, you’re usually immune to it for life, however can be more serious for some people e.g. pregnancy or immunocompromised
Presentation:
- Distinctive bright red rash on both cheeks
- Mild fever
- Coryzal symptoms
- Upset stomach
- General malaise
Management:
- Should be self-resolving unless high-risk
Osteoarthritis - state the following:
- How to explain condition to a patient
- Management options
- Safety netting advice
How to explain a condition to a patient:
- Wear and tear of the cartilage which sits over the surface of most joints
- Leads to bone wearing on bone and can lead to painful and stiff joints
- Most commonly affects the larger, weight bearing joints like the hips and knees
Management options:
Conservative
- Physiotherapy
- Weight loss
- Activity modification
- Joint support or other supportive measures
- Acupuncture or TENS machine
Medical
- Topical NSAIDs
- Oral analgesia: Paracetamol, oral NSAIDs, Tramadol or Duloxetine
- Steroid injections
- Joint replacement
Safety netting advice:
- Acute severe worsening of joint pain (fracture or septic arthritis) then present to A&E
- Worsening over time, present to GP to consideration of treatment escalation
Rheumatoid arthritis - state the following:
- How to explain condition to a patient
- Management options
- What is the recommended follow up period
- Safety netting advice
How to explain condition to a patient:
- Autoimmune condition where the immune system attacks the membrane that produces fluid in the joints
- Causes joints to become stiff, swollen and painful
- Most commonly affects the small joints like those in the hands and feet
Management options:
- Early treatment with DMARDs e.g. Sulfasalazine (mild), Methotrexate (moderate)
- Add biologics
- Consider NSAIDs
- Consider corticosteroids
What is the recommended follow up period:
- Regular follow ups with rheumatology (referral)
- Can use DAS28-ESR to monitor effectiveness of treatment
Safety netting advice:
- Acute severe worsening of joint pain (fracture or septic arthritis) then present to A&E
Mechanical lower back pain - state the following:
- How to explain condition to a patient
- Management options
- What is the recommended follow up period
- Safety netting advice
How to explain condition to a patient:
- Incredibly common, experienced by up to 50% of adults during a lifetime
- Pain in your lower back that generally varies with certain positions or activities and so can comes and go
Management options:
Conservative
- Weight loss
- Physiotherapy
- Activity modification
- Education regarding posture and prevention
- Smoking cessation
- Heat or Cold Packs
Medical
- Topical NSAIDs, Paracetamol or oral NSAIDs
What is the recommended follow up period:
- Usually resolves in a few weeks
- Get back in contact if it doesn’t
Safety netting advice:
Sudden onset of any of the following (cauda equina syndrome)
- Tingling sensation / weakness down both legs
- Loss of sensation in the area normally where you sit on a bike
- Urinary incontinence
- Faecal incontinence
- Erectile dysfunction
Conjunctivitis - state the following:
- Pathophysiology
- Common causes
- Presentation
- Management
Pathophysiology:
- Inflammation of the lining of the eyelids and eyeball (conjunctiva)
Caused by:
- Bacteria or viruses
- Allergic reaction or immunological reactions
- Mechanical irritation
- Medicines e.g. Atropine or Neomycin
Presentation:
- Itchy, gritty eye
- Watery / purulent discharge
- Red eye
- Eyelids stuck together in morning
- Tender preauricular lymphadenopathy
- Presence of risk factors
Management:
Usually resolves without treatment after 1-2 weeks
Supportive:
- Damp cold towel
- Analgesia
- Advise on good hygiene to avoid spreading
- Avoid contact lenses
Bacterial - topical broad spectrum antibiotics e.g. Chloramphenicol and Fuscidic acid
If allergic conjunctivitis - antihistamines (oral or topical) or topical mast-cell stabilisers (chronic seasonal symptoms)
Nappy rash - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Type of irritant contact dermatitis in the area of the body covered by a nappy
- Common in under 2 / anyone wearing a nappy
Presentation:
- Acute onset erythematous rash in nappy area
- Baby seeming uncomfortable or distressed
Management:
Generally conservative
- Frequent nappy changes (every 2 hours, more if there is diarrhoea)
- Periods of nappy-free time
- Application of barrier cream
- Topical antifungal if > 3 days
- Topical corticosteroid if severe or if painful
- Topical antibiotic if secondary bacterial infection
Plantar fasciitis - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology
- Inflammation of the plantar fascia
Presentation:
- Gradual onset of pain on the plantar aspect of the heel
- Tenderness over plantar aspect of heel
- Worse on walking or standing for prolonged periods
Management:
- Rest and ice
- Analgesia e.g. NSAIDs
- Physiotherapy
- Steroid injections (painful and can cause rupture or fat pad atrophy)
Infectious mononucleosis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Infection by the epstein barr virus (human herpes virus 4)
- Usually acquired in childhood but produce more severe symptoms in young adulthood
Presentation:
- Lymphadenopathy
- Fever
- Sore throat
- Fatigue
- Tonsillar enlargement
- Splenomegaly (rare cases splenic rupture)
EBV causes an intensely itchy maculopapular rash in response to Amoxicillin or Cephalosporins
Investigations:
- Test for EBV antibodies (IgM and IgG)
- Heterophile antibodies (test for by Monospot test or Paul-Bunnell test)
Management:
- Usually self-limiting and lasts 2-3 weeks
- Can leave pt with fatigue for several months after infection is cleared
- Avoid alcohol (EBV impacts ability of liver to cope with alcohol)
- Avoid contact sports (splenic rupture)
List some complications of EBV / infectious mononucleosis
- Splenic rupture
- Chronic fatigue
- Glomerulonephritis
- Haemolytic anaemia
- Thrombocytopenia
- EBV infection associated with certain cancers, notable: Burkitt’s lymphoma
Outline common names for infectious mononucleosis
- Epstein barr virus (caused by this)
- Glandular fever
- Kissing disease
Gastroenteritis - state the following:
- Pathophysiology
- Common causes
- Presentation
- Management
Pathophysiology:
- Inflammation of the GI tract (stomach and bowel)
Common causes:
- Viral: Rotavirus, Norovirus, Adenovirus
- Bacterial: E Coli, Campylobacter, Shigella, Salmonella
Presentation:
- Nausea and vomiting
- Diarrhoea (+/- blood depending on cause)
- Fever
Management:
- Isolate patient, until 48 hrs after condition has completely resolved
- Stool MC&S
- Assess hydration and give oral rehydration solution
List some complications of gastroenteritis
- Lactose intolerance
- IBS
- Reactive arthritis
- Guillain–Barré syndrome
- Toxic megacolon
- Dehydration and hypovolaemia, may lead to an AKI
- Haemolytic uraemic syndrome
Hay fever (allergic rhinitis) - state the following:
- Presentation
- Management
Presentation:
- Itchy, red and swollen eyes
- Runny, blocked and itchy nose
- Sneezing
- Associated family history with atopy
Management:
- Avoid the triggers if possible
- Oral antihistamines (taken prior to exposure)
1. Non-sedating antihistamines e.g. Cetirizine, Fexofenadine
2. Sedating antihistamines e.g. Chlorphenamine (Piriton) and Promethazine
- Can use a nasal anti-histamine or corticosteroid spray e.g. Fluticasone
Outline some common differentials for hip pain in children
- Transient synovitis
- Perthes disease
- Juvenile rheumatoid arthritis
- Slipped capital femoral epiphysis
- Hip dysplasia
Transient synovitis (irritable hip) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Inflammation of synovial lining, leading to transient hip joint effusion
- Often related to a previous viral infection
- Most common cause of limping in children (common in ages 3-10)
Presentation:
- Unilateral hip pain
- Protective limp
- Limited ROM in the affected hip joint
- Sometimes reluctant to weight-bear
- Otherwise well in themselves
Investigations:
- Generally a diagnosis of exclusion, important to exclude septic arthritis of hip
- Bloods for infection: FBC, CRP and ESR
- Hip x-ray (rule out other causes)
Management:
- Rest
- Analgesia (NSAIDs recommended)
Perthes’ disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Interrupted blood supply to the femoral head leading to avascular necrosis
- Self-limiting disease of the femoral head whereby there is necrosis, collapse and compression, repair and finally, remodelling
- Can lead to hip pain and mobility issues later in life
Presentation:
- Hip pain, sometimes referred to the hip and worse on activity (especially abduction and internal rotation)
- Limp
- Limited ROM at the affected hip joint
- Muscle atrophy
Investigations:
- Hip x-ray
- May do a perfusion MRI
Management:
Conservative
- Rest during acute episodes (may be able to do limited activity)
- Avoidance of axial loading (may be unable to walk)
- Analgesia
- More complex management depends on the age of the child (may need surgical containment)
Juvenile rheumatoid arthritis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Rheumatoid arthritis of hip joint in a child (< 16 years old)
Presentation:
- Hip swelling or effusion
- Warmth in the joint
- Painful or limited ROM movement, +/- tenderness
- Morning stiffness in affected hips
Investigations:
- FBC, ESR, CRP
- ANA antibodies
- RF antibodies
- Ultrasound
- Hip x-ray
Management:
- Analgesia e.g. NSAIDs
- DMARD e.g. Methotrexate or biologics therapy
- Consider steroids (intra-articular or oral)
Slipped capital femoral epiphysis - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigations
- Management
Pathophysiology:
- Weakness in the proximal femoral growth plate allows for displacement of the femoral epiphysis
- Most common hip disorder in the adolescent age group
Risk factors:
- Obesity
- Male
- Endocrine disorders such as panhypopituitarism or hypothyroidism
- Period of rapid growth
Presentation:
- Bilateral hip pain
- Protective limp
- Limited ROM in affected hip
- Trendelenburg’s gait
- Obesity present
Investigations:
- Hip x-ray
Management:
- Surgical fixation of epiphyses by a screw
Hip dysplasia - state the following:
- Pathophysiology
- Presentation
- Screening test for newborns
- Investigations
- Management
Pathophysiology:
- Malformed hip joint, where the acetabulum and femoral head do not have good articulation
- Higher risk of subluxation and arthritis later in life
- Most cases are congenital but patients don’t experience symptoms until adulthood
Presentation:
- Reduced ROM in the hip, particularly abduction
- Groin pain that increases with activity
- Limping
- Catching, snapping or popping sensation
- Difficulty sleeping on the hip
Screening test for newborns:
- Barlow and Ortolani hip test
Investigations:
- Ultrasound
- Hip x-ray
Management:
- Orthopaedic referral
- Management depends on age, may need Spica casting
